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I couldn't see it on the top. It's a, there's no, oh, there I think that should be it. Now, is that working it now has a little button on the corner saying live. Yes, that's good. Ok, sorry. I'm so sorry. I mean, I think you just have to start from the beginning. Yeah, that's fine. No worries. Um OK. Can everyone hear me now? See me if people could put it in the chart that they can hear us us? All right and see the screen? OK. Yeah. OK. Good. Wonderful. Um OK. Sorry. There's a technical issue. Um So from top, my name is Anna um for a few med students. Um I um here cos I absolutely love my psych placement. I just wanna learn more about it and I think get people interested in it. Um and I'm coming to you from Jersey. Um So the contents of this talk will be the types of anxiety disorders. What defines them, the particular clinical features and how to tell them apart. Um Focusing on generalized anxiety disorder, panic disorder, phobias, obsessive compulsive disorder and posttraumatic stress disorder. I'll also talk about some of the medications that you can give um and some, some things to think about when you're counseling patients about these drugs. Um I'll talk about the principles of CBT some of its pros and cons um along with some other psychological therapies that can be useful. Um at the end, I'll have some exam questions as well and there'll be one closer in. But yeah. Um ok, let's get started. Um ok, so the everything in psychiatry now is based on the ICD 11. So defines anxiety disorders as excessive fear and anxiety. Um The crucial part of this though is that it results in significant distress or impairment in functioning if you look in the ICD 11 for pretty much any psychiatric psychiatric disease, that is the vital factor. Um And also another thing that's really important is that it's not due to another health condition or substance use. Um because there's a lot of things that can mimic anxiety, whether that's physical health or substance or a different mental health condition. Um And it's really, really important to not pigeon hole. Um So you'll see that in the CD 11 a lot as well. Um The things that differentiate the anxiety disorders are the focus of the apprehension and I'll get more into that later. Um Yes. So generalized anxiety disorder, there is no specific focus of anxiety unlike phobias. Um there's just a general kind of chronic worry about lots of different spheres of life. Um There can be panic attacks, but they're more likely to be expected if they kind of come out of the blue, you might consider panic disorder. Um, and you get the sense of the physiological arousal, like the fight or flight where you have a lot of adrenaline pumping. Um, you can feel your heart beating or sweating, you feel nauseous, all these sort of things, um, where your brain is activating to a simu. So it wouldn't normally. Um And it's really worth bearing in mind when a when someone has a chronic physical health condition, um there's a lot of comorbidity with things like heart disease and diabetes and all these things that people live with and um mental health conditions including anxiety and depression. And also people who frequently present to particularly primary care or um ed with somatic symptoms such as gi problems, abdominal pain, headaches, backache, ins, insomnia. Um even in Children, there's um Children are less likely to be able to say like I feel anxious, but they might present with stomachaches that you can't seem to work out why. Um And that's a really important thing to bear in mind. Um So I have a question, um which I think really exemplifies this. So, um a 24 year old female smoker presents a GP practice with six month history of difficulty sleeping, often awake for hours worrying before eventually falling asleep. This is affecting her ability to concentrate at work during the consultation. You notice that she appears agitated and fidgeting throughout looking at her notes, you noticed she has recently presented with a variety of symptoms including abdominal pain and palpitations, which condition is important to rule out in this patient's case before proceeding with the diagnosis of generalized anxiety disorder. So I was wondering if people could put in the chat. Um some ideas of what things you might want to rule out. Um Before you might say that someone is suffering with anxiety. Um whether that's um yeah, different bloods you might take or just conditions you might consider. Um Yeah. Yeah. Absolutely. Hyperthyroidism. So you do um T FT S to check thyroid levels. Absolutely. Um Any other ideas? Yeah, exactly. Other causes of palpitations because you don't want to miss someone's got an arrhythmia or something and you know that there's a whole, you don't want to just say someone's got anxiety and yeah, withdrawal as well. Yeah, like the clinical picture of someone being quite agitated may well be because of that and people might not want to tell you particularly. Um Absolutely. Any more. It is. Oh Carcinoid, that's very um very scientific. I hadn't thought of that. But yeah, you may all be right. Um Any more it is and then I'll go on to the things that I thought of. That's all good. OK. So um yeah, differentials for anxiety um other anxiety disorders, for example, PTSD, you could have the hypervigilance and hyperarousal can look a bit like the anxiety or fight or flight type things, then you can have anxiety about different things which might classify it as something else. So, anxiety about food, you could tie into anorexia, nervosa. Um anxiety about physical symptoms could be um that, you know, tests come back negative could be somatoform disorder and yes, absolutely. The um hyperthyroidism. Absolutely. Right. Um substance use and not even just like recreational drugs, I mean, and salbutamol can give you like a tremor, things like that. And caffeine obviously, um, substance withdrawal, like alcohol or opioids, um cardiac and lung diseases that someone said, um, you know, someone might be having chest pain or, you know, feel like they're having a heart attack and it might be because they are, um there's also situational anxiety and adjustment disorder. So someone might be going through really anxiety, inducing time in life. Um And it's best to not pathologize that sometimes. Um And yeah, um that can be normal and healthy. It just depends on how long it goes on and how much it impedes in someone's life. Um Yeah. So, yeah, these were the options that came with the, um, the question which I thought were a dead giveaway. Um So I'm gonna put that question out. Um So yeah, is, as can people see the poll? Yeah. Yeah, it seems like people are thinking d yeah, fantastic. We covered it already. Um You know, pheochromocytoma, possibly. Sure, but it's extremely rare um, insomnia also, possibly, but it doesn't seem that I'm, it's not a main feature of history. Um, yeah, Wilson's disease. I never, I have no idea but I don't think. Um, but yeah, and depression is looking less likely. So. Yeah. Fantastic. Um, I'll stop that part. Um, wonderful. Ok. It's hyperthyroidism and it's a really easy thing to rule out. Um, ok. So moving on to panic disorder, um, it's characterized by recurrent panic attacks. So it's rapid onset, intense fear and anxiety um where you have hyperventilation, heart palpitations, nausea, hot flushes, sweating, lots of different physical symptoms. And for panic disorder, at least some of the panic attacks have to be unexpected. Um where you're just going about your life and out of the blue, you have them, you can have anxiety between attacks. But the, the concern has to be about recurrence of the attack and the significance of the symptoms that you might while you're having a heart attack. So the subject of the anxiety is about the panic attacks and that's what makes it panic sort of instead of panic attacks with generalized anxiety if that makes sense. Um It's a bit complicated to differentiate and I'm sure in practice even more complicated to differentiate between the two. But it's the subject of the anxiety, like the main problem being the panic attacks. Um and this can lead to avoidance of whatever is triggering these panic attacks or um yeah, or avoidance of going out because you're worried that you might not be able to predict when they might happen next. And Agoraphobia, which I'll go into later. Um I'm just gonna share my screen um because I have a quick video um and I will and share audio. Ok, this is me 10 years. Can, can people say that? Yeah, we can see inhale good. Awesome. Ok, ago. And the reason this is the most embarrassing day of my life is not that it looks like I've been attacked by a blow dryer and a can of hairspray. No, it's that I am about to freak out on national television. Health news. Now, one of the world's most commonly prescribed medications may be providing a big bonus. Researchers report people who take cholesterol lowering drugs called statins for at least five years may also lower their risk for cancer, but it's too early to prescribe statins slowly for cancer production. At this point. I realize I'm helpless. So I bail right in the middle. Uh, that does it for news. We're gonna go back now to Robin and Charlie. All right. Thanks very much Dan Harris at the news desk with some of the headlines of the morning. I wanna go to Tony Perkins. Now he is once the fear subsided, humiliation rushed in. I knew with rock solid certainty that I had just had a panic attack on national television. So, ok, so let me just start sharing that and take it back to the slides. OK. Yeah, I just wanted to show that because I thought it was interesting that it, it can present so subtly. Um and that it's not always going to be a very dramatic hyperventilation and um someone that's very obviously like it can also be more subtle because people have learn how to manage it, cope with it as best as I can. Um And yeah, from that video, the that man where it's on live television that you, that's like the definition of an unexpected one, I suppose that just completely pops up and can be really debilitating. Um Yeah, so I thought that was interesting. Um So specific phobias um which are anxiety specific to a particular situation or object. Um I'm sure everyone's aware of the common ones. Um but it has to be out of proportion to actual danger. So for example, arachnophobia people don't, people don't like spiders, you know, there there's a possibility that some spiders might harm you, but the is out of proportion to the real risk that you'll be harmed. Um Yeah, shows here as well, some other common ones. So a phobia. Um tryptan fear of dogs, fear of planes, et cetera, et cetera. Um And people either avoid said thing or endure them with intense anxiety and can be really debilitating. Um it can include panic attacks but only in the context of the particular trigger, um which differentiates it again from panic disorder. Um, and agoraphobia is something that is really interesting. It's, I think it's a bit misunderstood as well where people think you don't want to go outside. But actually it's a phobia towards situations where escape is difficult. So that could be public transport. That could be in a crowd that could be outside your home alone. It's just the fear of the feeling of being trapped, um, which could be different for different people. Um And so people might only be able to leave the house with support person or um yeah, not be able to leave at all. Um um Moving on to obsessive compulsive disorder. Um The So it is really important in order to understand the process behind it really important to understand the difference between obsessions and compulsions. Um So, obsessions being repetitive and persistent thoughts, images or impulses, they can be whatever really, but they have to be intrusive and unwanted. Um And those cause significant anxiety. So, some very common themes are um contamination like germs, micro organisms. Um A common theme can be symmetry. Um A common theme is checking things. That's what the tap was meant to represent. Um Another common theme which is more severe and brings a lot of anxiety with it is um like intrusive sexual thoughts or aggressive thoughts. Um And there's a lot of stigma around that and the patients may experience a lot of anxiety around that which will make their symptoms worse. Um and the difference between that and a compulsion. So the compulsions are repetitive behaviors or mental acts um that you feel driven to perform, to feel a sense of completeness over the obsession, to get it out of your mind, to stop it from bothering you. So the compulsions can be a visible act or it can be something that you do inside your mind. Um For example, there's a very common theme of sort of like religious absolution of like, I feel like I've sinned and then inside people's heads, they will ask for forgiveness a certain amount of times. And that feels like it gives the sense of completeness and takes away the obsessive thought and the anxiety associated with it. And so some examples of compulsions could be cleaning, washing your hands, counting um all sorts of other things. Um It does vary. Um and to talk a bit more about the cycle behind it. So the obsessive thought comes into your head. Um And it, this happens to everyone, like, I think everyone has had things come into your head and you're like, where, where did that come from? That's really weird. I don't actually think that um but the anxiety that it provokes is unbearable um to people with O CD and really, really uncomfortable and you'll do anything to get rid of that. And the only way that you feel able to get rid of that is through this compulsive behavior. Um So there's the two sides of you arguing over what you're going to do next. Um And that provides a sense of temporary relief. But the crucial part is, is that for a diagnosis of a CD, the compulsion, the compulsions have to be very time consuming. Um So you might spend over an hour daily um performing these compulsions. Um And that's what makes it debilitating. Like if you were quite happy, washing your hands for an hour a day, it didn't bother you. That would be a different story. But yeah, so an example of the A CD cycle would be the excessive thought of like you've touched a doorknob and you're contaminated from it. Um That causes you a lot of anxiety. You're worried about your health, you're worried about the health of your family and the compulsive behavior is I need to wash my hands. I need to wash the door up until they feel clean and feeling clean as a very subjective thing. And it, until you feel it feels done and that can take however long it takes. Um, you know, another more extreme example would be the excessive thought of like I'm going to harm my family. Like I That's, yeah, that, that pops into your head. That would give you a lot of anxiety and the compulsive behavior might be that you need to isolate yourself from family or lock yourself away from your family or do something like that, which gives you a small amount of relief, but you have to battle these sorts of time and time again. Um and moving on to posttraumatic stress disorder. So a person when a person experiences trauma, um they might develop symptoms of posttraumatic stress disorder. The triggering event for a diagnosis of post thoracic stress disorder has to be an event that's likely to cause distress in almost anyone. Um So it generally is considered to be yeah, like violence and war abuse, things like this. Um But there there can be really delayed onset trauma. So um posttraumatic stress disorder, so someone might have been abused as a child and then symptoms present a lot later, but typically it's within six months and symptoms need to be present for at least a month and it's, I don't know the ins and outs of this, but I think it's really interesting the um that it's due to the faulty processing of memory in the hippocampus. So it doesn't lay it lay down the memory as a normal memory that's in the past. It, it stores it as something that is present and current um which stops you from being able to move forward. Um and the symptoms, it can cause really intense flashbacks, um vivid dreams, um hyperarousal, um which is a sort of on edge and you're waiting for the thing to happen again and hypervigilance as well, which might manifest as behaviors and like the checking and that things won't happen again. And this can also cause avoidance of the triggers. Um And posttraumatic stress disorder is very comorbid with substance use disorders as well. Um to try and block out the flashbacks and the calm down the hyperarousal. Um they're very commonly come hand in hand. And yes. Um So that's a summary of the different ones that I've mentioned. Um Then, so I'll go into the treatments that you can have um both generic and specific. Because for anxiety disorders, there can be, there can be a lot of overlap. Then there are some specific ones. Um I've put this diagram on there because I think it's a good reminder of how psychiatric treatment works generally. Um I don't know whether you can see it actually might have to zoom in, in your own computers. But um yeah, so at the bottom of this pyramid is self care and informal community care. So that might be like uh yeah, like support groups or mental health workshops and things like that um that empower people to care for themselves. Um And then going up a level you can present to your GP um and have been managed by your GP for um mental health and this is where the majority of anxiety disorders are managed. Um Where as the I says on the side where, you know, many, there's a lot more people managed in primary care. Um Then once, if your anxiety disorders become more severe, um you might need community mental health services um or service in general hospitals and even more severe um could be like if it was um yeah, complicated by uh risk of self harm or things like that and you are harm. Um It could be yeah longer stay facilities and special services. Um So it's quite a busy slide. Um I'll talk through it. So um I'll start with generalized anxiety disorder at the top in the middle. So firstly, if someone was to present to their GP, um they would be encouraged to um learn more about their condition and they'd have active monitoring if that was appropriate and self help measures. Um I think a lot can be achieved sometimes in low level anxiety. Um One, yeah. Uh People's lifestyles are really um yeah, focuses put on lifestyles. The second line being CBT. Um If people are willing to engage with CBT, then you do that first. Um Because that is going to give people the tools that they need to be there in therapists. Um But if for some reason they don't want to engage with it, they can't engage with it. Um for whatever reason or their anxiety is too much, then they might want to try medication. Um such as sertraline, another SSRI or an SNRI, um It's normally the ones prescribed would be uh sertraline or escitalopram or paroxetine in terms of SSRI S. Um And you could try if the original um sri prescribed wasn't working you could try a different one. If someone's like that to you, it was a bit more um was more severe. You might do both interventions at the same time. Both CBT um could be more, higher intensity CBT. Um So more time spent on it, more weeks of it. Um But if it became more severe, you might want to refer to a specialist and they are very similar principles in terms of panic disorder and phobias um in panic disorder that um is some, some you might consider using imipramine or chlomipramine if someone um has a contraindication to SSRI s. Um and those are TCA sa tricyclic. Um and there are also useful in A CD which I'll get onto. Um and I was looking at the option of phobia and I was looking on the mind website and it was talking about how you can use exposure therapy, hypnotherapy, all these things. Um But I'm not sure of the evidence base for things like that for hypnotherapy anyway. But yeah, um then O CD. So for mild A CD, you'd start with CBT and E RP, which is exposure and response prevention, which I'll get into more later, but it's exactly as the name suggests that you're exposed and you're trying to prevent the response. Um And for OC D, it has to be the combination of the two. that's the gold standard treatment or for as before, if someone can't or doesn't want to engage with psychological therapies, you could try an SRI for moderate A CD. Um, you could start with an SSRI or more intensive psychological therapies and consider clomiPRAMINE TCA. Um, it's, I've seen a lot of exam questions, um, with the answer, what about like someone, um, a vignette of someone with a CD and SRI S hasn't worked and it's asking you what to try next and the answer's coming for me. Um So, yeah, remember that and if it is, then you can refer it on. Um Yeah, uh and PTSD. So there's a really interesting concept where people seem to think that um talking about events after they happen are really helpful. I mean, like in, in healthcare environments, you have um often have debriefs after, you know, something traumatic has happened or in like acute setting. Um But actually the evidence suggests that a single session debriefing could actually make ptsd worse, which I think is really interesting. Um It might be that you just don't have the follow up and the, the cow of it, but it, it could also be that it prevents you from processing it properly or it could be that the people doing the debriefing aren't trained to do it. Um It would be interesting more research on that, I think. Um But PTE S symptoms that occur for less than a month and could be more along the lines of acute stress reaction, which is when there's a big stressor and it's very normal to um have a response to that um for less than a month. So you might try watchful waiting. Um And if patients from the military, they can be seen quicker under armed forces services. So that's important to bear in mind. So first line PTSD is trauma focused CBT, um which is really important and I'll talk more about CBT in a bit. Um Also E MTR therapy, which I think is so cool. Um eye movement desensitization and reprocessing therapy, we'll talk a bit more about that later. Um And second line, if you need to take medication for it, then, then the vaccine can work. SSRI S can work and in severe cases, um you might use risperiDONE. Yes, that's that for that side. Um So counseling patients on SSRI S um as you can see, like for medication for anxiety disorders, Sri S take up quite a lot of it. Um And sertraline is normally first line because it's cost effective. There's fewer drug interactions unlike paroxetine, which can interact with all sorts of stuff. Um And it has a limited effect on the QT interval which um escitalopram is quite bad for um a really important thing. And your counseling for SSRI S is that you screen for suicide risk, especially in younger patients. This is AAA very important thing for any psych history really. But um particularly for patients under 30 there's evidence to show that in the first few weeks when you start an SSRI um that it increases your chance of suicidal ideation and self harm. Um So you might want to check in with patients weekly after you prescribe it. Um I know in depression, the mechanism is that it increases energy before it increases mood. Um But I'm not sure how that works with anxiety, but the effect is still the same. Um And then yeah, screening for cardiac history is important. Um because any um any mental health medications that can prolong your PT interval. Um Yes, of course. So I will um we'll put the slides out on me all as well. So, um anything that can prolong your QT interval um can cause torsade point, which is af can, can be a fatal arrhythmia, but it's rare that it's very bad and you do not want that. Um And another thing to be aware of is that SSRI S are contraindicated in mania and in manic depression. Um And so it seems like it would be easy to differentiate these different states, but actually in practice, it can be really hard. And so you need to be sure that you're not um that someone's agitation and restlessness isn't because of hypermania or something like that. Um Yes. Um Also just a note on propranolol, um it can be prescribed um in anxiety but it only affects the physical symptoms. Um It affects the sort of fight or flight response, um which can be helpful. Um It can prevent the increase in anxiety associated with the physical symptoms. Um and it can be if it's something that, you know, will cause anxiety like exam or public speaking. Um It can be helpful as like a pill in the pocket type thing, but it's not, it's not first line medication cos it doesn't really address the psychological face this, so benzodiazepines, um they are quite interesting drugs. There's a lot of caveats to them. You don't want to be prescribing them if you can avoid it. Um There's because they have a lot of um addictive, potential, potential for tolerance for withdrawal. Um They have street value and so they're just, if you can avoid them, then you do. Um and maximum, you want to be prescribing them for 2 to 4 weeks if a patient really needs them and then wean them off slowly. Um and things that you might want to counsel patients about would be um they interact with alcohol a lot. So they both work on the same Gaba receptors and they have a synergistic um action. So they're both sedative, they're both depressants and so they in shock very badly. Um So you do not want to be drinking and taking benzodiazepines, you want to avoid them in frail elderly people. Um They can make you like um add to the sedation and I think they can also give you postural hypertension, which is not good for elderly people um, driving safety. So if it, if any medication makes you sedated, then you need to be careful about driving. Um, and it's a criminal offense to drive on sedating medication if you know that it will, uh, if you don't know already that you'll be fine on it. Um, so, yeah, need to be aware of that. Um, the Benzodiazepines are contraindicated in phobias. So you couldn't go to your GP and ask for Benzodiazepines if you were gonna get on a flight and you have a fear of flying. Um Some patients, particularly when I was on my flight placement in inpatient psychiatric units really wanted Benzodiazepines prescribed for sleeping cos obviously like a psychiatric hospital is a really loud overstimulating place. However, they might make you sleep or feel like you're sleeping, but actually they're, it's unnatural non rem sleep. So it's not particularly restorative. Um and it's just not the same and in some people, it can have paradoxical effect and cause aggression instead of sedation. It's obviously something you want to avoid. Um a note on Z drugs. So Zopiclone, zolpidem, there's another one, I can't remember what it's called. Um They can also be used for insomnia, but they have similar issues with tolerance and don't give you a restful sleep. It's um just the illusion of more sleep it seems. Um Yeah, I know there's been patients asking for Z drugs in the hospital and cos hospitals are also very loud and difficult to sleep in. Um but it's important to resist and especially if patients are gonna go home, see, say that it's not necessary. Um Yeah, so um I have to talk a bit about principles behind CBT. Um It was founded by Aon Beck in the 19 sixties. Um So the concept behind it is that your thoughts, your feelings and behaviors, all interact with each other and also interact with your physical state. So if you focus first on the side without anxiety, you have a situation and you, you have thoughts about the said situation. Um you feel emotions about that you have behaviors and you also feel physically a certain way about it. Um And so all of these interact with each other. So the thought of like, oh this is a really nice dog might make you feel sense of joy. Um And that is a physical feeling in itself and the way that you feel about that would guide your behavior. Um And it all sounds really obvious, but it's, it's a really like foundational model. Um And however, with anxiety or also applies for depression or all the other things that CBT um works for. You've got the, the thoughts about the subject of the anxiety, for example, the dog's going to attack me or I'm having a heart attack, I'm going to die or um things like that, you've got the emotions that the stimulus is bringing out in you, which are more difficult to sort of grasp but not the behaviors. So you might run away, you might seek medical help. You might, um, the quiet, my I, yeah, things like that. Um, but what you might, the thing that you're most likely to experience and take note of is the physical response. So the increasing heart rate, the sweating, the palpitations, the, um, nausea, things like that. So that is the easiest thing to, for people to pick up on. Um So the, the how CBT works is that it wants you to be able to differentiate the thoughts and feelings and behaviors and the physical elements. Um And to be able to realize that they don't all have to come in this big complicated mess that you can tease out the different elements and weaken those connections between. Say, for example, if you can change the thought about the stimulus that may not lead to the same feelings and the same behaviors and the same physical state that you often experience. Um or say, for example, um with the example, with propranolol, you can, you might be able to change the physical state and therefore that might not impact the thoughts and behaviors um and feelings as much so that you, it isn't all compounding on each other if that makes sense. So CBT is fantastic, but it does have its cons as well which we'll get to. Um It's a short course. Um It's, I think I wanna say 10 weeks, but that might be wrong. So, something I should. Um, but it's, it, the goal of it is for you to become your own therapist and become independent in working with your own thoughts and your mind. Um, it doesn't want you to be having therapy for the rest of your life. Um, it wants you to be able to learn from that short course and take those skills into the rest of your life. It works for multiple conditions. Um And that means that certainly for a couple of conditions, even if the diagnosis isn't completely correct, it still might work. Um And that's really good. Um And then for certain other conditions, for example, you can have CBT for eating disorders, um and trauma focused CBT. And so they're slightly altered, but the principles are the same. Um, you can have CBT in person or you can have it online, um which is a really good option for some patients. Say, for example, if you're someone who's agoraphobic, um you might not want to go to a busy, crowded stressful GP surgery or wherever else you might receive CBT. So online could be a really good option. It's meant to equip you with practical strategies um to go about in your life and when you face new things. Um and it also works alongside of medication, which is good because the medication can be what you need to get yourself to engage with therapy. Um And that's what will actually cause the change in your life and allow you to manage your condition going forwards. Um Some of the cons is that the patient's got to be willing to, willing and able to engage with the program. And there's lots of reasons why people might not be able to. Um you know, people might be working really long hours and have families, et cetera, et cetera. Um And therefore people might not be able to. So it might be difficult for people with learning disabilities. Um or you need particularly focused CBT that might be super specialist. Um It needs you to confront your anxiety head on which might be quite intense for some people. Um It's better for mild to moderate um anxiety and something about it is that it very much focuses on the present, it doesn't dig into past traumas. Um or just the bog standard CBT anyway, and that might be helpful for some people, but for people with trauma or for people who are suffering from PTSD, you need to have a form of therapy that unpicks the origins of the anxiety that you're experiencing. Um Otherwise you're not really gonna get anywhere. Um Yeah. So some of the other psychological therapies um Yes, exposure and response prevention. So you have a fear like let's say you start with something that helps you draw a tiny bit closer to the thing that, that scares you and the thing that provokes anxiety um you expose yourself a little bit and with the support of the therapist don't engage in the behaviors that allow you to kind of get rid of the discomfort. Um And you show yourself little by little that you can disrupt the cycle and that you can deal with the anxiety and it will pass. Um And it's really, really effective for O CD. Um AN E MDR I think is so cool. Um So the thought behind it is that the bilateral stimulation. So the therapist moves their eyes in front of the person's face. Um And you follow it with your, you follow up with your eyes. Um And the thoughts are that the stimulation between both sides of the brain has an effect on the hippocampus and allows you to reprocess memories that have been wrongly stored. I used to II did a lot of research into this for a presentation for um for my flight placement. I've forgotten it all, but I think it's really cool. Um Yeah. OK. Um Yes. OK. We have a couple more exam questions. Um So 32 year old man presents for several months of worsening low mood and behaviors. He feels he cannot control, he often feels distressed and finds that the only way to obtain some relief is to repeat a certain phrase in his mind. There's no significant past medical history and is physically. Well, there's the magic phrase that always comes up. Um What is the simple and ex symptom, an example of um I'll put the pole up there. It is. Can you see that? Yes, that is. So. Mhm I'll give it a minute. So we have an answer for compulsion and example and an answer for obsession any more. It is. Mhm OK. Um The answer is I'm gonna close the pole. So answer is compulsion. Um I think this question is a good example of the fact that compulsions don't always have to be a physical act. It can be a mental process. Um So repeating a certain phrase in his mind because you have control over that action, even if it is mentally, that makes it a compulsion and it's what is used to um deal with the anxiety and the distress of the. Um yeah, that the patient's feeling. So that's what makes it compulsion. I hope that makes sense. OK. Next question. Um 19 year old student presents describing excessive thoughts that he she will hurt someone. The concerns began when she moved out of her family home to university. She has particular worries about using the communal kitchen in her flat due to concerns that she will harm her flatmates. She, she tends to prepare and eat all her meals during the night. When they're in bed. She's asked to complete a Yale Brown obsessive compulsive scale. Um And her results suggest mild symptoms of OCD given the likely diagnosis. What is the most appropriate treatment option? Stop cold. Yeah, that's not. Oh, we've got some answers. Move up a little bit longer. Ok. That's great. I will place of po, and it was cognitive behavioral therapy. So, mild symptoms very, I mean, they should to be exact, talk about, um, CBT with E RP. Um, because that's what makes it specific for a CD. Um, but that was where you'd start if that wasn't working or the patient wanted to try an SSRI we would do that. And then if that wasn't working, then you'd go to clomiPRAMINE. Um Yeah, going to open the pole for the next question. A 34 year old man confide in you that he experienced childhood, sexual abuse, which of the following features is not a characteristic feature of post traumatic stress disorder. I did open the f didn't I? Yes, I did got one response for a anymore q some responses today. Five. OK. I'm gonna close the pole and the answer is D I'm yes. So lots of inhibitions can be a feature of um quite a few um conditions particularly uh front to temporal dementia. It can be a feature of particular sites of psychosis um or bipolar, particularly mania. Um But let's say posttraumatic stress disorder, um the hyperarousal being the sort of sense of fight or flight that people experience. Um And yes, the emotional numbing nightmares, avoidance, they're all symptoms too. I think this is the last question um that po um so a young couple, couple enters the do the general practice. The wife explains how her partner has been acting out of character, specifically checking on their daughter subtly throughout the day. And even through the night, on average, he would check 10 to 20 times. When asked, he explains that last month, he nearly lost his daughter in the park where it is a scary ordeal and he repeatedly relives what happens in his mind. The husband says that he does not go to the park anymore, feels anxious and has difficulty sleeping. There is no past medical or psychiatric history of note, which of the following is the most likely diagnosis. Pulse open. Good. I don't FD no anyone else. We've got lots of answers for e Awesome. OK. Uh We'll close that. Um And the answer is e so I think for this question, I picked it because it's possible for to confuse some of the compulsions in obsessive compulsive disorder for the like for example, the checking um with the hypervigilance of posttraumatic stress disorder. And I think those things can present quite similarly. Um And especially if they hadn't asked. Um Yeah, when asked, he says that last month, he nearly lost his daughter in the park. I think it's, it's easy to forget that with these exam questions, they will give you these things. Whereas if you're in a consult, consultation with a patient, um they may or may not tell you these things. And so if they haven't asked, you might be going down a different path. Um So yeah, that is the last exam question I believe. Um And that is everything for me. Um We've got some more revision sessions coming up with psych. So, so keep your eyes peeled. They'll be on here or meal as well. Um Thank you so much for coming and for listening. If you have any questions, that's my email address. Um I hope you found it useful and, or interesting. Um Thank you so much. See.