With our first pediatric case in the Mind Matters ECHO series, Dr. Carol Wurzel presents on a 13 year old male patient with diagnoses of anxiety, depression, and ADHD. The patient presented in early 2020 (pre-pandemic) with worsening symptoms, including thoughts of self-harm, since the 2021 academic year (school returning to in-person learning).
Following the case presentation and discussion, Vanessa Litoff, PsyD, presents on cognitive-behavioral therapy (CBT) for anxiety management. She discusses principles of CBT and uses panic disorder as an example to understand psychotherapeutic techniques such as cognitive restructuring, breathing skills and mindfulness, and exposure therapy.
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Case Presentation Case Discussion Didactic Presentation Didactic Q&A we will then um you know them out during the discussion phase that way we can proceed with the presentations and keep questions at the end. Okay without further ado I want to um turn the floor over to dr carol gazelle from Westchester Park pediatrics. Um Again dr Marcel really really thrilled that you're presenting our first pediatric case. Um You know we know we hear so much in the news media about behavioral health impacts on Children, particularly in this post covid world that we're living in and um you know really excited to hear about this case. Thank you, Take it away. Thank you for having me. Um I just a little two second background about myself, I've been in practice for 30 years around 30 years. Um I practice most of my practice is in uh most of my time practicing was in Westchester is in Westchester County. Um I practice with a group of four other women and um I've been with this particular practice since 2007. Um and this particular patient well we'll get into it but I've taken care of him since he's a little boy so that's that's me basically. Alright next slide Please. Okay so patient I'm presenting is as I said a patient that I've been taking care of since he's probably around two years old. He's a 13 year old male um again patients in stage two. Um Just you know they it's a family of four. Uh He's the older of two kids. The younger brother is around 11 He's a student, he lives with his parents that's an intact family. Um um and I've been well acquainted with the whole family for many, many years. Um He has basically no past medical history. He doesn't have any, he's not on any current medications and he really has no past psychiatric history as well next slide. Um so, um really this basically has been a completely healthy kid. Um and the mother sort of out of the blue called me early in 2020 pre just pre pandemic. Um She was contacted by the teacher that the teacher was concerned about, some writings that the kid had done in school. Um She also mentioned to me um in that conversation that he's not a kid that has a lot friends. Um he's sort of like kind of a homebody. Um and um, he's um, so, but but this was a little bit surprising to her that the teacher had um, contacted her about this. Um he was very, was very self critical in school. If he didn't do well on a test, he would like, why am I going to school? Why am I, Do you know, why am I even, you know, stupid things like that. Um So, um she called me basically to ask me to refer her to a therapist. Um and um, you know, I gave her the names of several therapists in our area that I feel do a good job with this type of situation and um, then sort of the pandemic hit and you know, um other obviously more press, well not more pressing concerns, but school at school, um school went to remote learning. Um and I really didn't hear again about this situation for at least another year or so. Um in terms of just, you know, family history, the only unusual thing is that a little bit unusual is that the father is a widower. Um He lost, this is the second marriage for the father, the first marriage for the mother. Um Father lost his wife at a young age. They had no Children. And um I uh this this family that this the new wife and the two kids and the husband would um periodically go visit the first wife's family out west. So that's really the only unusual thing in this kid's social history that I that I that I can really pinpoint. Um there's no history of sexual abuse, physical abuse, nothing like that. Uh next slide. Um So I sort of want to skip over that first part. But um so basically it's a kid who presented with um difficulty concentrating feelings of, you know, thoughts of self harm. Uh uh very, very self critical and not very social. So interestingly enough, I didn't hear from this family again until this past winter. Like I want to say november december when the mother called me almost in tears to tell me that he's, you know, this is all happening again. He has no friends, He stays in his room, he's on video games all day long. And Interestingly enough, you know when I saw the kid for his checkup in between in in 2021 I had asked her about all these issues and whether she was keeping up with the therapist and she said no she didn't need the therapist because all the symptoms seemed to have resolved during the pandemic when they were quarantined. Um So um you know, he had some friends that he played video games with online and and so that's kind of always like a red flag for me, like why is a kid doing better when they're socially isolated? You know that's you know, most kids are you know chomping at the bit to go out and they hate remote learning and they don't like to you know they lose focus and they and he actually did better with the remote learning situation. Um So um you know, at this point in my mind, you know there's anxiety, there's depression and the and the reason why the mother contact me is because we can go on to the next slide. Um The the therapist was concerned that this lack of focus was a big problem and he wants he requested that she contact me to get a referral to a developmental pediatrician for you know diagnosis of a. D. H. D. So when I spoke to the mother and I got the full history and I knew the history two years ago I said you know what I really feel like you probably need to see a child psychiatrist because there's multiple diagnoses going on here. Um There there may be need there may be a need for multiple arms of treatment. And um I felt that a child psychiatrist would be most proficient at determining what actually is the problem with this kid and how to address better. So that's the case it is. I have to tell you not an unusual case. Uh We you know I mean if there's any pediatricians and family practitioners that deal with kids on the call they know that this is not unusual at all. This has spiked hugely during the pandemic and um but you know this happens to be a kid that I know really really well. So that's that's my case. Thank you so much. Dr brazil um I believe we have some pediatricians who signed up for today's session. Um hope they were able to make it to the meeting. Um really appreciate you presenting this case again bringing this new perspective into this discussion before I turn it over to folks for questions or you know um comments or suggestions for you. I do want to note that dr raj Vohra is here as well. I hadn't seen her when we were talking earlier and um doctor bora is the vice chair of clinical affairs at Mount Sinai hospital for psychiatry and um makes time in her schedule to join my in matters. Um And so I just want to note that she's here. Um So you know, focus on the hub team as well as other participants at large in the meeting, you know, thoughts, comments, suggestions um for dr Marcel. Um and uh if there are questions that you've typed into the chat, I'll also periodically read those out as well, I can ask a few questions about the case actually. Um Sounds like what you what you described. I think pediatricians and family physicians across right now are dealing with very similar cases. Um you're right, it's not unusual, but it is, you know, it is it is it sort of exactly like you said, like I think what what is the primary, what are you trying to treat and you know, who else do you need? Um in the treatment team, I think almost to sort of support this, you know, otherwise totally healthy child. Maybe I missed that in the presentation. But you said that the first time the mother called you was writings that this kid had, what what what was that? I don't know if you presented that or so it was more of um like I'm so stupid or I got a question wrong on a test or but just the teacher was concerned because this was like a repetitive thing. He really he never hurt himself. He never like physically did anything. It was just kind of like these nebulous saying things like I shouldn't live, I don't deserve to live. I'm not exactly sure if it was that okay specific, but enough for the mother, enough for the mother to call me and say, listen, I'm really worried about this, you know? And then at that time you told them to go see a therapist, but they probably didn't continue. They did they did actually start with somebody. But as I said, like when the pandemic hit and you know, all of a sudden there was no school, there were no social stressors. The kid was better, which kind of always is a red flag for me because I don't like to hear that. I like to hear that they can't concentrate and they're, you know, playing video games instead of doing school work, because that's a much more normal. I mean that's not good, but it's much more normal. I think it's much more typical. But I know you also said that the mother told you that he's always been like a bit of a warrior. He's a quiet kid. Yes, he's a quiet kid. He's always been a bit of a warrior a little bit, you know, um you know, not many friends, some friends, not many friends, Things like that. And what was this time? The mother's primary concern was that he was now voicing suicidal ideation. No, he was not suicidal something on the no, no, he wasn't suicidal, He was more again with um she really was more concerned about the fact that he really had no social life, he had no friends. Um He was very you know in his room playing video games all day long and you know didn't wasn't concentrating in school properly. Grades were falling a little bit and not really not really functioning well, you know, so to make to make sure I'm understanding that when in school in person he was evidencing this kind of isolation, these issues came to light again. But when Ramo learning at home she said, oh it's it's you know because I I addressed it with her when she came, you know because there was a 2020 visit, there was a 2021 visit and this happened late 2021. So when the 2021 visit happened, I said to her, you know, what's going on with the therapist was we we were seeing a therapist for a little bit but you know things so seems to be better now he plays video games with kids online and at that point that was what kids were doing. So. And you noted self harm thoughts, not self harm behaviors and getting at correct correct. In addition to the self deprecating talk, what types of self harm ideations was he expressing? I think if I recall what she said to me a couple of years ago, I think she said that he was saying that um he wished like he could beat himself up or something like that, you know, things like that. Not specifically like a minute because because I asked, you know, whenever I get a call like that from a parent, I always ask them like is there any issue with like is he saying that he wants to hurt kill himself Because then you have to call the, you know, then you have to get him to an emergency room. That's not, you know, that's different than or hasn't done anything. But he had, it was sort of like kind of like vague at that point. Not very well thought out. Did did he, did the mother ever express that the child had odd behaviors or odd thinking? No, there was no because again, isolation, loss of focus, um worrying can all sort of be in teenagers. A cluster of, you know, 34 different types of, you know, new pathology that can be stemming. And some of it kind of like teasing it apart in the details and families very frequently sometimes. Like tend to see it, but don't tend to see it because again, like you said, if he's in his room all day isolating um not coming, not talking to family as much and the mother might think, oh he's at least he's talking to somebody online, Maybe he's okay. But in your visit with the child, Did you notice I had never struck me personally and all the times that I've seen him that he's odd in terms of his behavior because believe me, I have a lot of kids that I think are you that didn't, he didn't ring any bells, no. And and did his has his, like a BLS like showering, bathing. Not okay. No, that's no. Um and just so you know, it's for like just sort of education like along the way, you know, some of the things that we worry about in kids these age with such things is the possibility of a pro drome right for psychotic episodes. I mean this is h when some of it starts showing up and very frequently these might be just the very first signs of like and frequently a lot of kids, especially in school age in this age. Exactly. I think are getting lost in the idea though. Maybe they're just depressed. Maybe they're you know, A. D. H. D. Focus, but we're sort of missing the whole sort of major diagnosis of psychosis that like at this point acting at this early stage is what makes such a big difference in the treatment. Um And so I kind of like try to encourage, you know, pediatricians and adolescent medicine people to sort of really think of that as like any kind of odd thinking odd behaviors. Um mild paranoia based on like my my classmates don't like me. I don't have any friends because they think I'm weird, You know, all of that sort of sometimes can be the beginnings of a program. Um So while we're looking at all the other diagnosis, I just wanted to sort of throw that out as well. Um and in terms of other than like this isolation, does the mother described panic attacks or like, no, no, no. And the child does either. No, no. I saw somebody else had a hand up to, so I don't want to keep asking all the questions. Thank you know, those are really good questions. I appreciate it. We have several questions for you. Dr brazil in the comments as well. Um if no one else has a question from the hub team right away, I can read some of these questions out. Uh Dr Gilla is asking if he's being bullied in school, if you're aware of. No, I asked that. No. Um Dr kim raj asked do we have a sense of how the child was feeling during the time period when the mother thought he was asymptomatic? I think. So, I have a small kind of subset of kids that have a lot of social anxiety and those are the kids that Unfortunately they tended to do better with the remote learning. They liked it because they didn't have to didn't force them to go into school. It didn't force them, you know, I mean, he's you know, 12, 13 years old. It didn't force them to um you know, pick a friend group or you know those kind of things. So I think I think the family probably thought everything was was okay at that point. Mhm. Um Dr Herrera you had raised a hand. I don't know if you want to ask your question yourself. Yes. Hi thank you so much. I'm carla, I'm a social worker. Um I was just wondering if dr Marcel if you had a chance to explore with the patient where they um picked up this um I guess to put in some self deprecating talk like when was that something that they started doing or how they noticed they started doing it. I know that's like self awareness and asking a preteen might be somewhat challenging. But yeah I don't know that, I don't know that I have really addressed it with the with him in particular. Um I didn't hear anything about this until that call I got from the mother pre I think it was like in January of 2020 around there. Um and you know it was surprising to me because this was sort of like a regular you know one of your regular intact family units that you know I had never heard anything like that before and I actually went back over my notes from previous checkups because I had seen the kid every year since he's like to and um you know other than you know on those P. S. C. Seventeen's that we do the behavioral checklist Um for kids that are under the age of 13. We you know just you know sometimes he worries sometimes he can't concentrate you know but those are very typical answers that I get from a lot of families. So nothing nothing out of the ordinary. Okay. Um And then Dr chung is asking a question you know which is you know sort of key I think you know you've shared the account from the mother's vantage point which she has shared with you. Dr Cheung asks when you talk to the child, what does he tell you? Nothing Like you know not not not much but does he describe any like if you ask him specific questions about focus mood. I don't he doesn't he's not that I don't think it's that he's that self aware about those types of things. Um And the last time I actually um saw him was for I think we're in the winter or the fall of the winter and everything was fine until I got this phone call. So I'm guessing you meet with him when the mom is in the room with you. Yes. Yes. Yes. And you may have touched on this already but any kind of substance use. No nothing. No because that I did address with him. No He's very kind of like I mean just in terms of his physical development. This is a this is like a pre pube it'll very early puberty, 13 year old. It's not like a mid puberty all 13 year old. Not that that it means that he can't be abused, you know? But he's not, I asked him that, you know, while folks are kind of composing other thoughts or questions, you know, I'm struck by the fact that, you know, he his anxiety to to dr vars point, you know, what might it be indicative of that he's not able to articulate yet, right? That that he might be able to tell us if we ask him the question that kind of connects, you know, somehow. But the fact that it's sort of specific to return to school is striking, what is that about? Is there a is there a situational stressor that hasn't yet been explored that sort of sort of notable that pattern? Um But also I, you know, if you were to ask him like, you know, your mom's worried about, you know, you saying she, you know, you're saying these things about how you want to beat yourself up and you know how, you know, you say you're stupid and such, like tell me like what you what does that mean to you? Like how long have you felt that way? I don't I don't know if you were able to help him kind of realize that you're conveying what his mom is telling you, you're back to him and want to hear his perspective and you want to hear from him, You know, a 13 year old wants to feel hard and more than perhaps, you know, someone younger. Um I'm curious what he might say because it's sort of notable that his perspective on it is still a bit out of reach. And also maybe another question to follow up Doctor IRS question is that the mom has expressed these things to you when she calls you, but has she ever verbalized this when you are together in the room? So, you know, in child psychiatry, one of the things that we really specifically asked for is to speak to the child without the parent. Um because a lot of times, you know, they'll share things that they don't want their parents to know about. Um and sometimes that that can show an interesting dynamic, like has the, so is the mother open in talking to you about her concerns in front of the child? Um if not then why? So, and then if that's not ever been brought up in front of the kid at all, why he's here, why you are concerned? Um then it sort of is like, what's going on here? Right? Um the child might be like, wait, why am I being asked these questions or they're talking about me behind my back? Well, I'm not gonna say anything now. Um so I'm just curious as to what did the mother present the stuff in front of him or no, she, this was in a private phone call to me um when the last time I saw them together there was nothing like this brought up. It was interesting. It's interesting because I feel like, you know, I always felt like something was under the surface that had to, you know that it couldn't be perfect but you know, it couldn't have been perfect. But you I mean you can ask and ask and ask and if the parents are telling you and the kid is not and the kids in the room and he's not saying anything to um Well wait a minute mom. You know, I mean I have a lot of fear. I have a lot of patients a little bit older than him that say wait a minute mom, you know like that's not right, you know, let's you know, but but he did not say anything. Yeah, I think that's um right. Like it sounds like that's a piece to take away perhaps that you know, hearing from him, I'm just struck that she won't talk about this with him present. That's sort of really strong. I don't think that she's adverse to talking about it with him present. Um I just think she was in a crisis situation when she called me. So that's really and there's a way to validate that I think you know parents are worried about talking about certain things with their child present perhaps, you know for a variety of reasons um might help to kind of pull all those pieces together with a conversation with everyone together. I note that there's a raised hand Tyree Grant. Hi good evening. Um have a couple of questions. One is um what coping mechanisms have been identified uh from the child? I know this these past couple of years have been a bit challenging and coping mechanisms have been pushed to the brink. But I think some things have become a lot of maladaptive coping mechanisms have become more normalized and I'm just curious to know what mom is seeing as not normal, which may be normal, may not be healthy, but it may be maladaptive and so I just wanna to kind of hear has anything been identified, you know um you know, the although ideally what used to be normal for teenagers to socialize, that's not the norm now. Social isolation is kind of the new norm. Uh and so communication through other mediums and not being direct is kind of what's normal for this generation. So I'm just curious to know uh what you know, what has been identified in terms of him, how he's been coping, how he's been handling, it's it's obvious that there is something social anxiety but how how has he been handling it? I think um curious to hear, I think he's probably playing video games like all the time online, all the, you know, I don't it's not, I don't think he's like a social media kind of kid but I do think that he's probably just, I mean, he probably was um I mean, I think that he coped during the, I think he almost don't want to say thrives because nobody thrives in a socially isolated that situation. But um I think that um he probably had a lot of social anxiety in school in person and when he was remote, I think that kind of reduced his almost reduced his anxiety. So I think that was, I think that's a coping mechanism for him. I don't know if that answers your question, I'm not sure. Um Yeah, somewhat. Yeah, because I heard you mentioned earlier that he did have some sort of peers or is it just presumed that the only peers he has are the ones he's playing remotely. No, he does have some peers. He did have some peers in school. He did have, he does have a few, he did have a few friends in school, at least the first time when i is he is when I I'm sorry, is he engaged in any school activity? The any extracurricular things? I think he does. I think he does the, you know, kind of the routine sports that the kids do, uh softball, baseball, basketball, but again, all those things also went To the wayside during the, during the height of the pandemic. So there wasn't any indoor basketball, there wasn't any stuff like that, but I mean, he's not like the kid who's like the star athlete that's able to like, you know, do 15 travel soccer teams and you know, be happy doing that. That's not the kind of kid. He is my, you know, my other question was around is mom anxious because she never really she never really struck me as an anxious mother. You know, she never really struck me, she's not the kind of, you know, she's not my regular repeater patient that comes every week with a kid with a runny nose or anything. She doesn't, she never struck me that way. And dad, is that around? Yes, Yes, Yes and no, never struck me. I mean, not during visits with me as a particularly anxious family parent do is emotional expression encouraged in the family because Yes. Yeah, I think so. I think so. Okay. Because my experience is that a lot of this is learned behavior. Um and he's probably emulating some somebody in the house. Well, it could it could be the I mean, the father, I don't know as well. So it could be from the father, but the mother is a very warm. Um always struck me as very warm. I mean, she's like a nursery school teacher, she's a very warm. Uh not a very hands off cold kind of person never struck me that way. Okay, It's actually really great questions. I appreciate you asking them and breaking them down into bits like that, Thank you so much. Um and I think your question makes made me think about the question about sort of what is, what is normative for this generation at this point in time in history is a really important question I think as well, You know, I have a 12 year old um and you know what I did at 12 is not what she does at 12, and it's there's a new version of what's healthy I think, and you know, all parents, I think struggle with letting our Children do certain things differently. So I think it's important, particularly the pandemic and the additional pole to finding your social life online, because that's the only way you could maintain a social life to some extent. His kids last year, the year before, my daughter has a friend who has selective mutism barely speaks, can't speak in the school setting, but chats away with friends online and thrives, you know, on the, in the internet space. Um you know, so there's there's relative pieces here and again, I feel this pull to want to hear what this little boy would say himself. Um These are really great questions. There's a question from dr Baskin about how this young man was doing in school over the years and whether he's ever been evaluated for learning difficulties in the past, given his school related social, low self esteem. Um No, this is not, this is a kid that's, you know, regular ed always been, you know, average student never had any school issues until that, you know, until pre just very pre pandemic. And during the pandemic, he actually did pretty well in school. So during the, during the quarantine, when there was no school, he actually did pretty well in school. So it's not your sense that there's something organic sort of around his school related difficulties or is No, although I often find it very difficult myself, not just this particular patient, but with, you know, what's anxiety, what's what's attentional issue? It's very sometimes very hard to make that determination when one can certainly make the other one much worse. So, yeah, so, um just noting the time, you know, I wanted to, you know, I know you you're kind of wondering if he needs to be evaluated by a psychiatrist, He's connected to therapy, although not at the moment, he has been in the past. He is, he is now again, okay. Um, he hasn't been sort of evaluated, hasn't had like a psychological assessment done. So, you know, that's an outstanding question that you had sort of coming into the meeting today. Um, you know, I am um dr chang is asking the same question in the chat about, you know, is there a different way for a child or family position to make this diagnosis or should we just find a psychiatrist to sort of proceed to the next step and make the diagnosis. I'm curious what folks would suggest. Um, you know, so Dr Rose l can have her main question sort of clearly answered in addition to I hope what's been helpful destruction. So I think based on I guess a lot of the questions that we had and a lot of the answers that you didn't have because of how it seems like the child is not open in talking. Um I do think it would be hard to make a diagnosis um at this juncture, but I do agree that he should be evaluated further by a psychiatrist because it sounds like he's, you know, there needs to be some more and the therapist also should be able to make some diagnosis for sure they are trained to do that as well, at least a preliminary diagnosis, which is why it sounds very odd that he wanted the kids to go to a developmental pediatrician when I having known him and known what the history was felt. And I found it very interesting what you said actually about this being, about, you know, worrying about all these symptoms being like a pre psychotic sort of thing. That so, so I really was very firm with the mom and I said, listen, I really feel like we need a psychiatrist here because we have like five different things going on and you know, who knows what the it's going to end up being. But I felt like they're they're ultimately going to need to have a relationship with somebody because there needs to be, you know, medication evaluation possibly and all Yeah, for sure, for sure. I I do agree and I think it's possible that the therapist maybe and I don't know why he would be suggesting that developmental because I feel like again if the therapist is also seeing something odd and might be thinking of this as a proud room, then a psychiatrist is still a better choice than sending. So one way or the other, I do think he needs to be evaluated by a psychiatrist or you know, like a better trained therapist one way or the other. I I just wanted to mention because as I as I've been listening, there's a part of me that thinks that it could be this kid just has social anxiety, you know, you you hear all the time about people who are introverts and did much, but you know, a lot of adults talk about this, it was so nice not to have to socialize, It was so nice to be able to be home And not have to, you know, do all the crazy things that we do that makes everybody so busy and you know, I keep thinking this this kid, you know, this 13 year old who obviously is anxious and may have within normal limits self esteem issues, you know, and then the pandemic hits and so it's not so comfortable, but on the other hand, he doesn't have to go to school and have all that anxiety. Plus maybe he was surrounded by his family which can feel very protective. So I guess, you know. Yes it does sound like just to make sure that he's not at risk to have him evaluated I guess my other thought is but you know, I'm sure there is a way to do this so that he doesn't feel even more even lower self esteem because he's different than all these other kids that are playing video games and whatever. Um You know, just in case what he's going through is a normal sort of 13 year old with social anxiety who is able to sit in his room and do video games that it it doesn't mean that you know that he's psychiatrically ill or whatever he might think um by his parents taking him off to see a psychiatrist. So there may be ways to talk to the parents about how to approach him with it. Um That's a good suggestion judy I think you know, empowering parents with language about how to communicate around this with the child is often a big gift, you know that one can offer because she's probably mom's probably nervous and anxious about what's happening with her child. And understandably so and perhaps doesn't have the words um dr brody anything that you'd want to add. Thank you dr iron. No not not at all. No I I um my practice is entirely an adult practice. And I I I'm all I can do is listener. I really can. Thank you dr Russell. I hope this was helpful. So your question about you know, should I refer to a psychiatrist? Seems like a resounding? Yes. And I hope some of the other pieces around the family dynamics and exploring that. Um and getting the conversation maybe to include the child a bit more is a useful takeaway for you. Um Thank you everyone for all your incredibly valuable suggestions. Um I want to switch gears now to turn it over to our didactic presentation with Dr Vanessa Lo Tov. Dr Lo Tov presented last month on screening for anxiety um was really really got incredibly good feedback about um all the concrete and tangible um strategies for screening for anxiety that she had shared for those who missed her presentation last month you can see the recording as well as view the slides on our web page which we will link later on in the presentation as well as and it's we also email those around. Um Today, Dr Lo Tov is gonna talk about CBT cognitive behavioral therapy for anxiety and so without further ado I will turn it over to for your much awaited part to presentation and thank you for having me back. So like doctor I mentioned I'm going to be talking about cognitive behavioral therapy for anxiety. I'm going to start with the general principles that guide treatment for anxiety disorders in general. And then I'm going to go through through each of those principles using treatment for panic disorder as an example next slide. So cognitive behavioral therapy involves helping people understand where they think feel and act a certain way so they can become aware of patterns that are keeping them stuck and make changes that are meaningful, it includes helping them understand the situations that trigger anxiety and fear, improving their awareness of the impact this has on their beliefs, emotions and physiological reactions, and also how these reactions influence their behavior. And then over time identifying the actions they can take to make changes that are valuable and meaningful to them. Next. Like before I get into the treatment, I'm going to talk about learning and its impact on the development of anxiety because even though people can have a biological vulnerability to anxiety, their history and experiences can shape their patterns of thinking, feeling and acting. So when I'm working with clients and trying to conceptualize their case, I'm thinking about whether their fears have been influenced by the experiences that they've had throughout their lives and having these conversations with clients can help them make sense of why they're experiencing certain fears and can also build a foundation in the therapy to move forward. I've provided a few case examples that illustrate how a person's fear can impact their anxiety. This is maybe most clearly illustrated by a client with social anxiety who's frequently shamed, rejected or humiliated in their relationships. That can mean with peers or within their family. So in this case, social experiences become associated with getting rejected or humiliated and in turn activate feelings of fear and apprehension. Another example is a client with generalized anxiety who grew up with a loved one who experienced recurrent and chronic illness. That person can become vigilant of any signs or indicators of illness in themselves, which can keep their fear system on alert and also heightens their general baseline level of anxiety. This can also be seen in a client with panic disorder, for instance, whose parent was rushed to the er after having a heart attack in this case, changes in heart rate or chest pain become a signal to them that there's a medical risk or emergency. So that client is clearly pulling from their experience to make sense of their symptoms. However, not everyone with anxiety has had a painful experience that can account for or that contributes to their fear. And anxiety can just develop based on associations that have been made when someone is feeling afraid and then the way they've attached meaning to that experience. An example of this can be seen in a client who faints the first time they get their blood drawn and then becomes fearful of needles, blood and blood draws for them feeling faint becomes associated with fear and feeling out of control, which has the power to activate that fear response the next time the client is faced with getting their blood drawn. This can also happen for a client who has their first panic attack while sitting in a filled lecture hall and then becomes fearful of crowded in close spaces. In this case cloud um crowded spaces become associated with having panic attacks and then avoidance becomes the way to escape. That. This can also be seen in a client with O. C. D. Who experiences a disturbing image after seeing the number six and then becomes fearful of that number. So here the number six becomes associated with experiencing unwanted disturbing images. Which the client becomes motivated to prevent all of these demonstrate the association that gets created between a specific situation or experience and feelings of fear. The past can inform the way clients experience things now and can also help you as a provider understand why they're struggling with a specific type of fear. Next slide now I'm going to talk about the general principles of cognitive behavioral therapy for anxiety. So the cognitive part of CBT involves psycho education, understanding patterns of anxiety and cognitive restructuring. The first part involves psycho education to the client on the specific anxiety disorder that they experience. This helps the client learn about their diagnosis, what it means for them and what treatment involves. So in the beginning the therapist is teaching the client about their symptoms and also introducing a common language to talk about their experience As part of this, the therapist and client are also learning about the patterns of anxiety that they experienced and initially this starts with understanding the context that anxiety tends to occur in for them. So essentially the triggers to their anxiety and then helping them identify the types of beliefs that contribute to feelings of fear. The last part of cognitive therapy involves cognitive restructuring. Initially this involves naming the anxious thoughts which can be very effective in Externalizing their fears and helping them create some emotional distance. But during this phase of treatment, clients are also learning to evaluate their thoughts and look at them from a different perspective. Next I'm going to talk about the behavioral aspects of treatment which include mindfulness response prevention and establishing and implementing exposures. So the behavioral aspect of CBT involves creating change and the most direct and powerful way to change what we think and how we feel is ultimately to change what we do and that's really what this part of treatment is about. So, during the stage of treatment, clients are gradually confronting their fears through exposures. Usually this starts by coming up with a list of exposures or situations that trigger their anxiety so clients know what to expect and can also see the trajectory for treatment. This part of therapy is done gradually because you want clients to take a risk and face something that's challenging but not something that's going to be unmanageable over time. It also helps clients build a bigger window of tolerance for their anxiety response prevention is a major part of that change. So here clients are intentionally resistant of strategies they've used in the past to get rid of their anxiety and they're resisting them because these strategies unintentionally reinforce their fear and so ultimately prevent them from overcoming it. Mindfulness is another key piece of behavior therapy and is something that's helpful to integrate through throughout the therapy. Mindfulness is a practice that can help clients become aware of their thoughts and emotions in the moment, but also a practice of allowing for them. So, for instance, allowing emotions and feelings of anxiety to be in their body without changing them and accepting them as they are. This is also part of what I'm doing with clients during exposures, so helping clients sit with their body's reaction without trying to change it. I also want to note that even though these interventions are listed in a specific order in this slide and this can be the general progression of treatment. These interventions are often overlapping throughout the therapy. So, for instance, psycho education might be continually integrated as clients are going through exposures in order to reinforce the work that they're doing in the remaining time that we have, I'm gonna use a panic disorder case to help illustrate each of these steps in detail next slide. So, I'm going to talk about treatment specifically for panic disorder. This starts with psycho education about the purpose of cognitive behavioral therapy, which is essentially to teach clients skills to manage their anxiety and their panic. This first part of therapy also gives them an idea about what to expect from treatment. The first few sessions also focus on developing an awareness of the causes and symptoms of their fear to help them understand how their sphere system works and to identify the patterns that they've relied on to reduce their anxiety. The second stage of treatment involves coming into contact with the situations and body sensations that trigger anxiety so that they can overcome it even though that second stage of treatment can sound scary. It's the most the most powerful strategy for overcoming fears and it's important to let clients know that when they start the stage of treatment will be up to them. So the choice essentially to move forward is there's you're just showing them a path that they can take to move through their fears. In these first sessions, clients are also learning about the function of anxiety and panic. So, at some point in all of our lives, we've experienced the feeling of being afraid or felt apprehensive about something and when we experience that sensation, it's our anxiety system, which is essentially our body's alarm system turning on, it's telling us to pay attention to be on alert for something that might go a mess and we stay alive because of that. It helps us survive not only physical threats, but emotional ones too. So our anxiety system actually helps preserve our physical and our emotional well being. But for clients with panic disorder and other anxiety disorders, this internal alarm system becomes over activated and is responding, responding to things that aren't dangerous. A key example of this for clients with panic disorder are the subtle changes in their body, like an increased heart rate or a change in their breathing that become capable of triggering that alarm system because those changes have become a sign that something is wrong, which ultimately escalates fear and the feelings of being out of control and when their fear system is responding to things that aren't actually dangerous or a threat to them. You can start to frame this as an internal false alarm. In treatment, therapists are helping clients understand why their body is reacting that way and also that the physical symptoms of panic are not harmful so that over time they can feel less afraid of their body's reaction. And those conversations essentially get at the fear of fear that's central to panic in this first session. I'm also encouraging clients to read the first few chapters that are in the workbook, mastery of your anxiety and panic, which described the physiology of panic and the panic cycle in more detail in order to supplement and rainforest what was talked about in the session. I'll also encourage clients to read the chapter on the common fears that people with panic attacks experience. So we can discuss which resonated most with them during the next session. That's also a nice segue into talking about how beliefs can influence and drive their fear next slide. So when panic attacks happen without any obvious explanation or trigger, people tend to look inward to understand the causes of their symptoms and when they do that, the normal feelings of fear become misunderstood as a serious problem. For instance, many people misinterpret symptoms of panic as a sign of an underlying medical condition, like a heart attack or stroke. So initially ruling out cardiovascular problems and heart disease is necessary and assures clients that their symptoms are likely a sign of anxiety. However, even after giving clearance by their doctors, these fears can persist and so can be worked through in treatment. Fear of fainting is also common in panic disorder. This can happen because clients misinterpret feeling dizzy or lightheaded as a sign that they're about to faint. Well, it's more likely an indicator that the way their breathing is changing. For instance, they're probably taking shorter quicker breaths and while fainting can happen in panic disorder. It's rare in general fainting is more likely to happen for clients with blood or needle phobias or people who respond to stress with a drop in their blood pressure. People also misinterpret symptoms of panic as a sign that they're losing control of their mind or body when it comes to their mind, you might hear clients say that they feel like they're going crazy or insane. This can be a reflection of how unnerving or distressing it feels for them to have panic attacks so frequently and without an obvious explanation. It can also speak to the lack of control they feel when a panic attack happens. Other times, clients misinterpret symptoms of un reality, like the changes that can happen in their vision or perception as a sign of psychosis. But this is just another way that their anxiety can manifest. Clients can also mistake the strong desire to escape as a sign that they're not in control of their reactions or decisions. So, clients might talk about feeling afraid, they'll lose control of their body and do something embarrassing, for instance, abruptly leaving a restaurant without saying goodbye because a panic attack set in and even though feeling feels sudden and abrupt, they're not losing control, they're actually just making a choice to do what seems necessary for them to feel safe and in control. Again, all of these can be helpful to review with clients in the beginning of treatment so that they can be addressed. But it's also helpful for clients to see that these are common fears that people with panic disorder experience, which can also normalize what they're going through as physicians. Your insights and explanations are especially helpful for clients who are experiencing these concerns because there's trust in you as their doctor and their trust in the medicine so clients can leave your office with a better understanding of the differences between the signs and symptoms of certain medical or psychological conditions and symptoms of panic. Next slide to understand the patterns of anxiety that clients experience, I'll ask them to start monitoring their panic attacks between sessions. This includes monitoring their triggers, anxious thoughts, levels of anxiety and avoidance and safety behaviors. I've included an example of a panic attack recording form, which is also in the mastery of anxiety and panic workbook. This is more detailed and also includes a list of the physical sensations clients can experience. The goal of self monitoring is to increase their awareness of their experience. For instance, clients tend to experience panic attacks is unexpected and so this step helps them identify the external or internal triggers that are present, monitoring their anxiety in this way can make their experience more predictable. For instance, they can start to identify when and where it happens in the step, clients are beginning to take a more active role in treatment as they begin to observe their experience. Opposed to feeling like it's just happening to them. You can also shape a more open and curious stance towards their experience and helps them recognize the patterns and the themes that might be present. Next slide, a part of recognizing those patterns and themes includes identifying the anxious thoughts that clients experience as they self monitor week to week there are three types of thoughts that I'm paying attention to with clients as we're reviewing their triggers. The first are the catastrophic or what if thoughts which include the misperceptions that I just spoke about. But it also includes beliefs about anxiety and panic being intolerable and the belief that feelings of anxiety and panic will be never ending. These catastrophic thoughts are the core drivers of panic attacks. The second type of anxious thoughts include worries about judgments from others. These often center around fears about some what someone will think about them if they had a panic attack in front of them. So clients often anticipate that these judgments will be negative. For example, they might believe that any noticeable sign of anxiety will be seen as a weakness or they'll be seen as less than in some way when this is the case, symptoms of panic can be experienced as less acceptable. Which can also lead to internal self doubt or criticism. Having recurrent panic attacks can also influence the beliefs clients have about themselves and their body. For instance, after having repeated panic attacks, clients can start to view their body as their enemy even though their body is doing what it's built to do. Clients can also start to doubt how capable or competent they are to cope, which can lead to more complicated emotions like guilt and shame. So a major part of treatment is addressing these thoughts directly to shape, healthier and more adaptive but still genuine beliefs. Next slide Next I'm going to talk about cognitive restructuring, which is a therapeutic intervention that helps clients challenge the automatic thoughts and beliefs that are reinforcing their anxiety. There are several different tools to do this, but I'm gonna talk about a few that I found most useful when working with panic disorder. The first is perspective taking, which is a tool that helps clients create some cognitive and emotional distance from their experience so they can gain better awareness of how they're thinking about and experience experiencing something. One way to do this is to have clients practice identifying what they expected to happen during a panic attack, which really targets the catastrophic. What if thoughts they experience and then talk about what actually happened. This is also really useful to do during the exposure, the exposure phase of treatment so clients can see themselves overcoming their fear. It also helps to shape their learning and when that happens, the physical symptoms can start to become associated with their bodies normal fight or flight response instead of whatever their internal catastrophic thought is saying, Another way to improve insight is to help clients identify how real or likely their fears seem in the moment. For instance, on a scale from 0 to 100%. When someone's fear system is turned on the strength of their beliefs or believability of their fear is going to be high. So I usually hear clients say that their fear feels at least 80-90% real in the middle of a panic attack, But after a panic attack that goes down significantly, for instance, when they're sitting in my office, whatever their fear is, might feel 10% real at that time. So having these conversations and highlighting the changes in the strength of their beliefs during and after panic attacks can be helpful in improving their emotional insight. Another perspective, taking exercise that's useful is asking clients to imagine what they'd say to close friends or family members if they witnessed them having a panic attack or how they helped them through it. Usually clients express compassion and understanding when thinking about others who are struggling. So this can be helpful for people who are experiencing anxiety about how others might be reacting to them or clients who are viewing themselves harshly because of their panic attacks. If this is well placed and timed, it can help clients develop more empathy and flexibility with their own experience. And lastly, it's important to shape confidence in their ability to cope. This can include problem solving through unwanted experiences. For instance, having a panic attack while they're walking down the aisle on their wedding day or experiencing an unsupportive reaction from a friend because it's not that something unwanted or hard isn't going to happen eventually and we don't need to avoid that, but instead strengthen their ability to get through it next slide next I'm going to focus on, the behavioral aspects of treatment for panic disorder. So sometimes the way people are trying to cope with anxiety actually reinforces it and that's the case with avoidance and safety behaviors. These behaviors essentially tell a person's fear system that what they're feeling isn't okay. So their fear system marks it as a threat and then gets activated the next time that feeling or sensation happens. So even though a client feels relief in the moment, for instance, after they check their pulse, their fears come back and often with more intensity when having conversations with clients about the impact of avoidance and safety behaviors. I also want to normalize this reaction with them because if I was feeling afraid or scared of course I would do something to stop it. It's such a natural reaction to move away from things that feel bad. But unfortunately with panic attacks it works a little differently. And instead of working long term avoidance only works in the moment and over time. The fear or panic it's worst. And since that's the case I tell clients that we just need to change our strategy. Once clients understand the impact of avoidance on anxiety, clinicians can start to encourage response prevention. So in response prevention clients are practicing letting go of the safety behaviors and avoidance strategies that they've used to cope with their anxiety. An example of this would be a client who stops checking their heart rate when they're anxious if this was something they relied on to feel okay. This also marks a shift in treatment because clients are making direct changes and beginning to experiment with their fear. The goal is ultimately to interrupt patterns of behavior that have maintained their symptoms and also create new opportunities for learning to take place. So clients can watch themselves cope and tolerate anxiety even when their heart rate goes up. Next slide. Next, I'm going to talk about breathing skills and mindfulness, which are two behavioral interventions that are useful across the different anxiety disorders. First, I'm gonna talk about breathing skills. So when people feel anxious or panicked, they sometimes hold their breath or start breathing more quickly and when clients are taking quicker and more shallow breaths, it can lean to symptoms of hyperventilation and cause them to feel like they're not getting enough air. It can also cause them to feel dizzy, lightheaded and experience some of the symptoms of unreality, like their vision tunneling. When I am introducing breathing skills, the clients, I'm letting them know that this is meant to help them regulate their breath while allowing for and opening up to the feelings of anxiety that they're feeling. So it's important to note that this is not a method to control for or get rid of their anxiety. There are many different types of breathing exercises and the right ones for clients are just the ones in my opinion that fit for them. I've included a few examples here, So there's diaphragm breathing which involves taking a slow breath into your stomach so your stomach should expand on your breath in. When clients are taking those shorter and more shallow shallow breaths. When they're anxious, their chest will rise and fall with their breathing. So one way to practice this is actually by placing one hand on their chest and the other on their stomach and as they breathe in and out, only the hand on their stomach should move and clients can use that as a guide when they practice Another breathing exercises 3-3 breathing, which involves breathing in for three seconds, holding for two and then breathing out for three seconds. There's also videos that clients can use to help them paced their breathing, which has an added visual component, for example of an image that expands and contracts and can help clients feel more grounded while they practice mindfulness is another extremely useful intervention and skill for clients to develop mindfulness involves internally slowing down and bringing their awareness to their internal experience. This includes noticing the emotions and physical sensations they have, for instance, their heart beating, the feeling of their chest rising and falling and the tension they might be holding in different places in their body and then allowing for these sensations as they are. This may seem counterintuitive, but tolerating and accepting anxiety instead of fighting, it will help them more easily move through it and improve their sense of control over time. Any amount of practice with these skills is helpful, even if it's only a few minutes to die, even that much can make a difference. Next slide. Next I'm going to talk about exposure therapy, which is the most powerful intervention to treat anxiety disorders like panic. So during exposures, clients are intentionally confronting the situations and the body sensations that trigger their anxiety. So they're essentially facing their fears. But an essential part of this involves allowing for the anxiety and discomfort that they feel instead of fighting it or trying to get rid of it. As clients practice exposures, they're creating new associations with that experience. So there's learning that's taking place and clients can develop a new understanding of their symptoms. For instance, heart racing doesn't mean that their heart is about to stop. They can also learn that they can manage feelings of anxiety as uncomfortable as they can be, and also develop more confidence in their ability to cope with challenges and overcome their fear. There's a few general guidelines to follow when starting exposures first, it's always helpful to ask clients why making this change is important to them. They're putting themselves in a situation that's going to feel uncomfortable, so knowing why they're doing it can increase motivation and willingness. It's also important to give clients the control and choice about when to start, so they can really feel empowered to make that change. Lastly, exposure should be planned and predictable, so clients know what to expect. This includes talking about the level of anxiety they can expect to feel the physical sensations that will come up and the anxious thoughts that will trigger It can also include talking about what you'll do if the exposure is too hard or if they have a panic attack during the exposure, the pace of exposure should also be gradual. So you'll start with triggers that cause lower levels of anxiety first and then work your way up to the harder ones. Next slide, there are a few different types of exposures, imaginable exposures involved creating a story or script to help clients visualize the situation that's causing them anxiety. If clients are hesitant to begin in a receptive exposures, which I'll talk about next imagine ALS can be a good place to start because they usually trigger more manageable levels of anxiety for panic disorder. This can include an imaginable of the first exposure that will do or unimaginable of a panic attack they've had in the past. This gives clients the opportunity to practice tolerating lower levels of anxiety before they start doing exposures that are more difficult in a receptive exposures involve intentionally bringing up the body signs and sensations that generate anxiety so clients can get used to them because the fear of physical symptoms is central to panic. These exposures make a really big impact, setting up a hierarchy for these exposure starts with an initial assessment where clients are asked to go through a series of exercises that recreates the physical sensations that are common in panic. So for instance a client might be um client might be asked to run in place to get their heart rate up, breathe through a straw to recreate the lack of air sensation that comes up during a panic attack or to spend to re create feelings of dizziness. Then after each exercise, clients are asked to rate how anxiety provoking and similar to panic it was and then those ratings are used as a guide to choose a starting and an end point for the exposures. And lastly there are in vivo exposures which involve confronting the real life situations that trigger anxiety for example that could be drinking coffee, going to the gym or going out to dinner with friends and when, when this is connected to something that clients really care about or really value. For instance like strengthening their social connections, it can be especially motivating and meaningful. Next five um this last slide includes a list of resources for patients and physicians. It includes some resources through Mount Sinai for instance Mount Sinai khan and the wellness hub app through the center for stress resilience and personal growth. There's also a list of some common mindfulness apps that clients have found helpful and there's also free CBT worksheets, including some of the ones that were listed on the side today that can help clients as they're monitoring triggers um and also doing exposures and then lastly there's some readings that are I've included in the end which were also on my on the side during the last presentation too, but specific to panic disorder. Okay, that's it. Thank you so much. Um Dr um you know, you packed so much into, you know, a half hour. It's it's really incredible to sort of watch you kind of demystify what psychotherapy for anxiety using CBT looks like and kind of break it down into all these components of it. Um You know, imagine folks there may be folks on the call who either haven't experienced it or didn't know it had all these components. Um I appreciate how you connected each of the components, the interventions to the various aspects of anxiety as well. Um Thank you so much. I'm sure there are questions. Um I'll open up the floor to to focus on the call. That may have questions for dr dr brody. I thank you for your presentation. It was really excellent. What are this patient specific factors that predict a good response to CBT for anxiety? That's a really good question. Um I don't know what the research says about it, but I can I guess maybe like speak to some of my anecdotal experience that I've had with clients. Um I found that building self awareness is a really good indicator of clients who can do well in this? So being able to identify the name, the anxious thoughts they're experiencing, the physical reactions that they have and have an awareness about what it means to sit with and tolerate that. So that distress tolerance piece as well. So the self awareness and distress tolerance are both important factors. There are some clients that it takes a little bit longer to identify some of the anxious thoughts coming up and so that can sometimes make things more difficult because there are, there's obviously an unconscious process happening there. You just can't really um, sometimes it can be hard to target. Also clients with a good support system is always a good indicator to oftentimes we're doing exposures in session. And so clients have kind of that support of therapists with them as their starting. And so sometimes especially as they're starting new exposures, doing those doing that practice on their own at home can be a bit frightening because it's going to be activating their fear system, which is what they're trying to work through. So sometimes just knowing that they have support even at home, even if they're not there with them can be a nice piece of that as well. So I think those are some of the ones that stand out just off the top of my head and also the, that kind of like emotional insight piece to being able to distinguish between like their fear and their thought um follow up question to that, you know, what would you say about sort of the readiness, You talked about the motivation of what they're losing as a result of kind of being having this crippling panic. Um and to the extent that it's more on the severe side and I'm thinking about like combat veterans with crippling panic or PTSD. Um I know we're not talking about PTSD here today but you know um when it's really severe and it's interfering with their life, you could speak to sort of you know, readiness and the motivation piece that you noted. I can't speak to like the vet population specifically, I think that's probably outside of my scope. But in terms of readiness when clients are really struggling, I do just try to meet them where they're at and I think empathy and validation goes a long way with those clients with with clients in general just being able to acknowledge how difficult and painful it is to be experiencing what they're going through. Of course, that's when clients are in maybe that position. That's also a time where I would um I try to bring in a psychiatrist as well to add the medication piece to make things a little bit easier for them and to kind of have added support, which I think is really nice like adding that bit of structure to to the treatment as a whole and then having kind of a treatment team also support you, the clinician and the client as you move forward. Um but for those clients to talking about the things that that they value in their life, that they want to get back to and using that as kind of like the framework for making some of these changes. And so sometimes it might be the case that you might I might start with things that are more value based when I'm doing exposures opposed to just the introspective exposures for instance, because I want it to be motivating and meaningful for them and if they're really, really struggling, I want that to kind of be at the forefront of our treatment goals. Great, thank you. Dr. Gill is asking about statistical success rates for CBT in 13 year old patients who have generalized anxiety and not panic disorder. I don't know, I'm sorry, you don't treat Children? I don't so I treat mostly older teens and adults, so I'm not sure about the statistics for um for for young young kids, you know, that's fair enough. I would just say that, you know, CBT has been well studied in a variety of populations, including Children. Um you know, there's really sort of robust data out there for CBT for anxiety in particular. Um you know, Happy I'm dr bill if you'd like to send you some you know sort of studies that you can look at as well if that would help other questions for dr liftoff Um there's a raised hand Tyrie Grant, Hi, thank you for the presentation. Um This is more so in regards to um how did you adapt to uh utilizing exposure treatment during, you know, I guess this extensive phase of remote uh tell a ho Yeah, so so in the beginning I was a little apprehensive but honestly as we've as the pandemic has kind of gone on and I think clients and therapists have got used to the video platform. It's actually I think it's I think it's evolved really well and sometimes we can do exposures that we might not normally be able to do in session because some of the triggers happen at home. Um So I've actually seen like a really good um transition between the two. It doesn't seem to to be a detriment to do it by video. In my in my experience. Thank you. That's a good. Really great and relevant question. I appreciate you asking that dr cheung you have a question about primary care physicians using aspects of CBT. Do you want to ask it yourself? Hi, how you doing? Good. I'm just wondering so, you know, it's not practical for a primary doctor just have about a 40 minute 45 minute session into CBT but is there a way for us to take aspects of it over time. Like say there's a person with anxiety and we we can at least explain the framework and say, well today let's talk about one of your triggers and see how you respond to it. Are there ways we can, you know, change the way you respond to it and over time affect change rather than say, oh, you got to see a therapist or anything to deal with. You see any role for family doctors to do that. I do actually, I think there's a few pieces that can potentially borrow that wouldn't necessarily take up maybe so much time. So you still have, have the time you need to address the medical concerns clients are coming in coming in with. I think the first piece, like the psycho education part is something that can be really helpful for clients to hear, especially from physicians actually and talking about, um, the way their fear system is activated and what they can expect when that happens and just normalizing their body's response in general, even though it's triggering this kind of catastrophic reaction in them. So I think that's one piece that's actually really, really helpful and shouldn't be understated because it's very useful and important and something I'm usually kind of talking to clients really throughout treatment is like the psycho ed piece. So that's kind of like reinforcing what they're what they're hearing and what they're learning. The second piece, I think monitor, having themselves monitor triggers is a nice piece because I think come back to you at, for instance, the next visit and talk about maybe the most salient things that they saw or the most salient themes that came up for them. And then in doing some of that you can also externalize some of the kind of like what if anxious thoughts that they're talking about, which does create some emotional distance between um that reaction they're they're having and when that thought is coming up. So I think those pieces are can be really helpful and then the mindfulness piece, I think you can really encourage them to start practicing mindfulness and some of those breathing skills. Those are things that are think really accessible for clients, especially now with all the apps that are out there. And so that's something that you can introduce and then and then also check in with them during follow up visits. So so those are the pieces right now that stand out to me the most thank you doctor. This is a follow on to what dr Cheung was saying. Um in my practice, much more prosaic strategy is I give patients who I think would be good candidates for CBT. I give them David Byrne's book called Feeling Good. Um and it you know, it sets me back somewhere between five and $6 per copy on amazon. And so I give the patients the present and I say to them, read the first three chapters and as often as not because Burns is a superb writer for the general reader. Um they read those first three chapters and kind of the light bulb goes off, then they're motivated to actually pursue treatment with someone, someone who does it now. It doesn't have to be that book. I'm sure there are other resources which would do the same thing that you can you can you can give to the patient, but you know, sometimes just a very clear, accessible written description can really motivate patients to uh see a therapist. I actually agree. Yeah, it's it's such good information for them to be able to have kind of at their fingertips fingertips. It's a nice gift, I would think as well by giving the book dr brody and they read these chapters like, oh my gosh, I'm normal. You know, somebody wrote a book about all this, it must be others because it makes people feel so crazy. So I think that's so helpful. Thank you. You know, I um we're almost at time, but I'm so grateful that we're ending on this note. Um and dr chang really appreciate your question. Just kind of help us bring it home to some extent, because, you know, through a book through kind of opening the framework and discussing what they can expect from therapy. Um I think primary care physicians, Family physicians, pediatricians really, because you have an established relationship with the patient and and trust that they've already given to you, you know, kind of getting that intro um really can be that warm hand off, you know and kind of help them understand As judy said like there's a name for this, there's writing that goes with this, here's a book you can read about it, you know, here's what I know about this disorder as well as how treatment for it can work. Um you know, I can just imagine how much more comfortable a patient would feel going into a psychotherapy appointment for the first time in their life, having that kind of insight provided by someone they trust. Um it's probably invaluable as opposed to I'm not really sure what therapy is call around and you know, you'll figure it out on your own which is just for someone who's already afraid of so many things and things their body is doing. You know it's one more fear they perhaps have to conquer. Um so really appreciate um you know these suggestions. Um I know we're at time and I want to be respectful of folks um you know, thank you, thank you again everybody for as always joining on time, staying for the whole time participating, sharing insights and suggestions for our case presentation and bringing such great questions to our speaker. Special thanks to dr brazeal and dr liftoff for presenting today. Um you know we've been building this community with mind matters. Please keep coming um as I noted in the beginning we do a lot of sort of um deep analysis with the data that we generate from the pre and post survey. So please take the post survey. We really look for those matched responses. Um share that data back with you all at some point when when it's called. Um Thank you. And we will see you next month um Where we the didactic will be focused on medication management for anxiety. Um So have a wonderful evening and we'll see you all in a month. Thank you.