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So much. Great. Oh, well, lovely to be here. It's a real privilege to come and speak to you guys. Um, I do know Sharon and I've done, been working with her for a bit as a sort of psychiatry link for Crisis Solution Foundation. She's amazing, isn't she? And it's just a fantastic organization. I am Aileen, I'm a consultant psychiatrist. Um This, I'm, I mainly specialize in psychosis or I've, I've done general psychiatry as well and I work in a university as well looking after student welfare. Um, so, uh traumatic stress disorder isn't something I'm not a specialist in PTSD, but I am all stress disorders. But as a general psychiatrist, this is obviously something I've seen a lot of. So it's slightly um, almost off putting, doing this lecture to this audience because I kind of feel you, you, you are going to know some of you, sadly, you're gonna know, have personal experience of trauma recently and I'll just say at the beginning that um, er, any questions you want to ask, obviously, please do, do feel free to ask me, ask me stuff separately. Um, um I'll put my email in the chat here. Um If there's a question you don't want to ask from other people, which I completely understand and um um I am and, and it's also really important, I'm sure to be aware of sources of support for you guys at the moment, which I'm sure Sharon and Chris Rescue Foundation shared with you. Um Thanks to the, I did, I stepped in, um I think I stepped in on Tuesday so I can't pretend to have completely created these slides from beginning. Um, and many thanks to doctors um boil and, er, Nega Nade who kindly shared their lecture slides with me. So I, um, I very, very much based it on them. Uh. Right. Yeah. Want to move on. Oh, there we go. So the first question and I'm guessing this is something you probably share ha ha had or um, thought about in some lectures before is what is a disorder? It's a really, um, it's a really interesting question I think. And it's not one that's, uh, but so sometimes it's one that psychiatrist think about, I think more than other branches of medicine. And there are good reasons for that because psychiatry in the past over years has been, er, something that made that over nationally and internationally, various um, governments have tried to use and abuse psychiatry to be agents to try and medicalize just normal human conditions or people who are, um, you know, a government, a state might not like we we've got a terrible history about homosexuality, for example, being a classed as a psychiatric disorder in the past. So psychiatry has to be very careful, I think, but we don't medicalize normality. Um, whatever normal is we, we, we're not alone in psychiatry as having that question though. You know, I think sometimes people think it's just psychiatrists who get themselves up in knots about this, but there are lots of um, branches of medicine where, what, where pathological, where the line with something is non pathological. Pathological can be tricky to work out. You know, everyone's got a BP. Where do we make a decision that this high BP or low BP is pathological. There's often a, a sort of um what word am I looking for? There's often grayness around the edges. So, yes, probably more so in psychiatry than in other than other branches of medicine but not, not just um defining. So what is the definition of mental disorder? Well, um we can, we, there are different ways to, to do this. I mean, for something to be a, for something to be a disorder, I guess it makes sense that it has to be uh I if, if everyone has it, it's not a disorder. So it is a deviation from the, the numerical norm in the population. The, the difficult one, I think the one that's the one we have to be really careful of is saying something is a disorder simply because it's not socially acceptable. For example, my, my, my um deputy at the time um of uh being gay. Although times have moved on, especially in UK and Europe about that. We also have to be careful that just being disruptive, being uh break, you know, be being, breaking the law uh uh being drunk. For example, I don't think that most people would count that as a mental dis disorder in itself. No, but one would normally um expect there to be some level of personal dis distress or dysfunction associated with it. So this lecture is uh focusing on anxiety. Um and everyone in this er lecture will know what anxiety is. We have all felt it uh be it. You know, we, everyone, for example, has woken up um before an exam. I have two Children in my house at the moment. Well, teenagers doing exams and I'm watching a lot of anxiety, especially walking into um what we call our um A levels. Um So um so what is it? Well, it's uh it, it, no, no one finds anxiety pleasant. I think it would be fair to say. Um and by somatic sensations, I mean, you can have uh a physical bodily sensations. So it's not just in your mind, it's in your body um whatever the difference between those two are, which is a whole other question, you feel uncertain about the future, there's a degree of threat. Do you get increased sympathetic adrenergic discharges by which, I mean, I know again, you'll all know this, you feel, uh, uh, your pulse might be racing, you might feel shaky, sweaty. That can be, uh, um, you can, you can, you can feel hot, you can feel s all, all, all of the things, we all know what it feels like to be anxious and there's an evolutionary reason for anxiety. Now, you've probably, I don't know if you've heard the Jas Dobson Curb and I don't know if you can see that, but essentially that's performance and that's arousal. And if someone's really, really, really laid back and I, I, my two kids, my son is wandering in completely laid back um every morning and just, how's it, how's your exam gone? He shrugs. I, I have no idea if he um I think he's a bit in the wrong stage of the curve. Well, my daughter is completely stressed and I think it's his stage of the curve. But what we're saying here is that a little bit of anxiety, a little bit of arousal. This is the Ys Dobson Curve, which is very famous psychological experience. Actually, it's an evolutionary advantage and it makes your performance say in an exam better. Um But there's a level at which being too anxious starts reducing your performance. And one of the things we always try to do with um students trying to take it sounds as trying to help them. Not to be there and not, not reach that point. Um But so it's important to say, and I think, excuse me, um Stress, anxiety is entirely normal. You know, if, and, and we've evolved to uh feel stress and anxiety, you know, if you're being chased by a bear just sitting there, smiling at the bear is not a normal response. Um You would run away, you would feel stressed and anxious and run away from the bed. We, we, we, we've evolved to that. What becomes a problem is when either um something in minor, very minor is causing you the same response as if you're being chased by a bear. So, um and you know, then we see this with all sorts of phobias or with general anxiety. So you just feel i irritable, anxious, panicky all the time, even when nothing's going on or of course, something is going on but your, and it's perfectly reasonable to feel anxious. But um um the response is either uh over the top inappropriate or it might be appropriate to a bad situation. But what it's doing is causing a very negative impact on your life. And it's very common primary care, which I mean by GPS in this, this country and similar in other countries. It, it, it's very common for people to present to primary care or GP with, with self-limiting anxiety symptoms. You know, people will say I'm feeling stressed at the moment and, and it's often perfectly reasonable and it often goes and, you know, it's important to just give people sensible advice, try to get enough sleep. Um, if you're not sleeping, try and wake up the same time anyway. So you can get back into decent sleep pattern. Avoid alcohol, drugs. Any, um, um, what we would generally view as negative ways to manage stress, talk to friends. Uh, do exercise. Exercise is a massively important, um, help with stress, which makes sense because if you've got this sort of fight flight adrenergic, I need to run away from a bear going for a run really reduces those symptoms. So exercise is probably one of the best ways to manage stress related disorders if you can feel up to it, you know, I think it's all very well for people to say, oh, do some exercise. If you're really, really stressed, really anxious, really depressed, it is someone's gonna really struggle to manage that. But if you, if, if you people are feeling that they're becoming more anxious, depressed or stressed trying to get them to exercise before it gets too um bad is, is really helpful advice. So as I mentioned, stress is normal. Um a response to stress is being, being anxious if something bad is happening is entirely normal. Um But we do have in our um psychiatric kind of definitions, we can call some acute stress reaction adjustment disorder and posttraumatic stress disorder. And I'm going to go through all of these in this lecture, um important to mention that stress or uh can um cause you if you have got an underlying mental health condition, uh or actually your physical health condition as well, all of these will be, can be worse if you're under a, if you're having a stressful period. Um and um substance misuse, I think is one of the major issues, but all sorts of underlying problems can be get worse. And I would say it says physical injuries, but I should probably have me stresses in the slide. So actually any physical health condition is going to be made most physical health conditions, I'll say any most are going to be made worse by stress. Um In psychiatry, we have, we are quite good at noticing the interaction between stress, anxiety, difficult life situations and your mental health condition. But if you speak to a rheumatologist or a neurologist or a um dermatologist or any, any one looking after people with chronic health conditions, they will all say and people with, with those health conditions will all say yes, of course, when I'm having a stressful time, my multiple sclerosis, my eczema, my psoriasis, my um epilepsy all gets worse just because psychiatry has worked this out doesn't mean that everyone shouldn't be aware of it. Um And I can talk a little bit about the reasons for this later. So for an acute stress disorder, I mean, arguably this is medicalizing um normal human response responses here. But, um, usually, so this, this is when a traumatic event was experienced directly by the person and they get essentially some of the er, um, symptoms that we see in post traumatic longer term stress disorder, but they don't, but very acute, so intrusive thoughts about what happened. Feeling negative, depressed dissociation where it's just where you feel like your body is sort of, you're not part, looking down at yourself, not there. You feel like you're not really in your body and your world, you avoid the situation that causes stress and you feel all the anxiety arousal we were talking about earlier. These, the acute means these usually would self limit and go by themselves. Adjustment disorder is a slightly vague um um term that you will often see used in mental health sometimes when we're not quite sure what else to say, but usually there has to be some, some kind of identifiable stressor. And with this, it's a subjective um um decision about what the stress is. So it, so it might be, it might be something to be individual. This is stressful to other people. You might not find it as stressful. And again, I'd like to say can be very, very subjective. So some people who've got a low threshold for stress, what other people will find that maybe they've lost a job. Well, that is stressful, but most people wouldn't think that was enough to get PTSD. But someone who's vulnerable may develop an adjustment disorder in relationship to it. It may be something that is seen to other people is even much less, something has much less impact in your life. And there are subtypes of adjustment disorder, depressed mood, anxiety disturbances in emotion and conduct. These can be quite dramatic. Um but again, they're usually self-limited, don't usually expect in a few weeks. So the focus and the main focus of this is the longer term posttraumatic stress disorder or posttraumatic stress. Sometimes people call it without using the disorder. And this has been, um, there's been, there were discussions, there were suggestions in ancient times about people coming back from wars, er, with the classic symptoms now that we think of, of PTSD. But there was interesting more, I think, er, since the late 19th century and modern war especially, I think the first World War in 1914 to 1918 was when there's some really, er, er, that's when people really noticed that young men were coming back from the front, very, very changed as an excellent trilogy of books by Pat Barker, um, er, English writer about this. So, based on the initial um, response to this, what was called war neurosis, neurasthenia, shell shell shock and they would come back with a lot of the um, um, symptoms that we now recognize as PTSD sometimes and there'd be, sometimes people would describe them as more physical symptoms. So there'd be an idea that people can't kind of exercise walk as much. But I think increasingly people realized that this was a psychological response to the terrible experiences of war. Uh, Gulf War syndrome was interesting because when people came back from the Gulf at first, lots of people wondered if they'd been exposed to some kind of chemical. Uh, and, uh, there was a lot of, um, in, there was a large amount of research done into establishing it actually, that's not the case. Mhm. Um So what causes PTSD? Well, unlike Adjustment disorder, one would normally expect PTSD for it to be something that is accepted generally as er something that most people would regard as a um a serious event, serious domestic violence wars, serious accident, uh ser abuse sometimes and then 11 terrible interaction, other times can be um um a um uh a more longer a AA a AAA series of events over time, serious bullying can, for example, cause PTSD and there are uh a core symptoms clusters. So there's a re experiencing phenomena. So, flashbacks to the event, um nightmares, images, physical sensations, um hyperarousal phenomena, numbing. You can feel irritable, angry, have poor sleep, poor concentration, avoidance. So you avoid the um um thing that um the thing that happens and you can get cognitive changes, depression, anxiety, suicidal ideas. My um my youngest son, the one who needs the laid back. Um one with his G CS E, he's had a terrible accident, um, a few years ago where he was thrown off the top of a fun fare ride in the park. They haven't put the, um, when he was 12 they haven't put the bar down. Um, and he broke, oh, everything, head legs, arm, everything horrible facial injuries. Um, which is, and he is, I mean, I, I, it was interesting because I, um, I didn't witness it. I went to go and see it afterwards and I was, um, I would have said it was interesting because at the beginning straight afterwards he, you could see he and I, I think he didn't sleep well, he was finding it really di he was in a wheelchair at first and he didn't want to go out of the house and was really, got really scared just being pushed over even small, um, tiny, um, areas and it's, it's really interesting cos um, it, it, it was only a few months, it was a few weeks of that and he just had nothing, absolutely nothing. I was, I was still really anxious months later but he was absolutely fine to the extent the avoidance phenomena. He came back. Um, oh, no, it was a few, a few, two years ago. Where have you been? And you've been back to the fair, same fair, um, and gone on some rides. Amazing. Um, I'm never, I would, I am never, ever, ever in my life going on a phone phone ride but I think it shows it, that's an example from my life of how, er, you can experience something really terrible and get all of these or you can have, um, or you cannot and it's really quite difficult to predict. Um, whi which ones go from an, a, an acute disorder into a longer term one. Um, and he's fine now. He's absolutely fine. He's got very, he's got no, no long term, um, um, problems at all. Um, so it's a common reaction of normal individuals. Um, usually within six months and it's trauma, you can, um, call it, you can get delayed trauma after, after six months. Um, um, and that's a specific, called delayed PTSD and central to all cases. A situation where the patient felt his life was in danger and some professions exposure to these events is common. Um, so firemen, soldiers, relief workers, um, etcetera. It's interesting because it does say there that, um, the individual felt their life was in danger. But I would have said, and I've seen this with, um, with people who, um, have re, who respond, who have responded. Sometimes I, I have seen patients with PTSD where it wasn't, their life was in danger, but they have witnessed something awful. Um, ok. Um, so the epidemiology whoops, the epidemiology obviously is entirely varies to a large extent from, you know, where you live. Sadly, at the moment in the UK, 3.7% of men in 2014 and 5.1% of women screen positive for PTSD, most likely to be women. No idea why that is the case. Um But I mean, it goes about saying, I guess that there are differences across the world depending on um what's happening in the world and how likely you are to be exposed to trauma. Um And also the way studies are designed and methods of assessment people in the armed forces are, um, interestingly only found to have 4% PTSD, which I find is very strange given that that's lower than the UK general population. And I think, I suspect that they're using a slightly different, um, they've got a higher threshold in their studies in the general population ones. But in, um, when you looked at people in the military personnel, the ones who were in combat roles were twice as likely to report PTS, even ones not in combat roles. Um So there's been 11 of the things about PTSD, I would say that's interesting, um, is that there's been a lot more research into it than other anxiety disorders. And the reason for that is because of its relationship with the military, um, military psychiatrists and governments have funded um, research into PTSD because of the military link. And, um, so we, we do know, I mean, that's not, that's a bit simplistic, it's not just that, but it does mean that there's been, it's, it's a decently researched area of psychiatry. So we know, as I've said that stress causes physiological and psychological reactions. And I talked about how major threatening experience act of it, fight flight and freeze response trauma. Um and it trauma is, it can be, can, it can be not relieved, but it can be relieved at all the levels of the way you behave, how you feel, um how you think and your neuroendocrinology system. And there's some evidence that major threats may even physiologically change your brain and certainly can change the way your brain functions. Um, so there's a sort of physiological side and then there's a psychological side and with classical conditioning, something happens and you have a learned response, this sort of Pavlovian thing. So, um, what happens is you have to give for an example. You were in a, you were in a war though you had gunfire. It was very traumatic, there was gunfire, there's a traumatic experience, you experienced trauma and all the, er, physical and psychological responses to the trauma. And then what happens is you hear things which, um, er, er, are like gunfire, car back firing and a firework produces through a classical conditioning, the same response that you had to the gunfire and the continued um, avoidance or so. And then if you, if you avoid any experience, so if you, if you had initial experience of um, gunfire and had that fear response and then went to a load of firework displays, your body and your mind would learn that fireworks are harmless and that, that noise in itself is harmless. So you would unlearn that response if you avoid fireworks. Um, because you worried about having a response, the response is gonna stay and that's the kind of um method of trying to uh uh un uh of any sort of response to anxiety phobia, which is a gradual exposure. So, you know, with a phobia, if you're very phobic of, I say spiders, you wouldn't, um you wouldn't sit someone down with a big tarantula, you'd talk to them about spiders and then show him pictures of spiders and videos of spiders. And there's a really interesting work on virtual reality where you would be exposed in a virtual world to spiders to, until you get a real spider. And that's the way to manage anxiety. It's similar when you have a fear response to an active a to something that has um caused you to themselves. Um So you've got the psychological response and then there's the hypothalamic pituitary adrenal axis, which is the body's alarm system. Um Cortisol plays a role, Corzo plays a role in everything. Um And I think Cortisol is 11 of the main reasons we think that you are more likely for example, to become unwell. If you're stressed, everyone knows this, don't they? You get run down, you're stressed, you're more likely to get colds, viruses. And that's because um um high cortisol, um seems to shut off the immune system and you're more like what? So, so, so, so he prolonged, prolonged stress activates hp A symptoms cause derangement of cortisol. And then you're more likely to get unwell. Um And then when the danger is gone, brain reduces production of cortisol, calm it down, we rest and if you're constantly stressed, you're in a constant false alarm, um which can have an impact on all sorts of things as you can probably see from this diagram. So you get, um um um you can get all sorts of uh you can get issues, not only with the kind of the immune system, but also that how you, how you uh uh both how you lay down memories and how you're able to process emotions. It's all very, we don't, we don't know everything about this, but it's all very interesting. The other um relationship which I haven't gone into detail here is between adrenaline and Cortisol and Serotonin, which is partly why we think stress causes anxiety and depression through the serotonergic symptom syndrome. So our brain um is programmed to process memories. But if we try to avoid thinking about the trauma, we don't process the memories leading to further nightmares and intrusive memories leading to further hyperarousal, which leads to more avoidance and weakness, perpetuous vicious cycle, which can go on for many years. Um Laying down the the symptoms of post traumatic stress. And one of the issues. Of course, it, by drinking a lot, which is really common in people who've had this experience, it stops you being able to lay down the noise. So if we're worried about someone who we feel has been through a traumatic event, general screening questions. Have you been exposed to frightening events where you felt you or another person might die or become serious injured? What was your reaction? How did you cope? And I think then you, if you did get a yes and you would go into some more specific questions about the list, you know, nightmares, intrusive memories, um flashbacks, emotional numbness and then into mood questions, sort of standard depression, anxiety. So, um as I said before, as with my son, you get the acute stress reaction which is perfectly um normal and then we think it usually is two up to about 43. It's the first few months where you can lay down the behaviors, the patterns of behaviors where you well in or, or, or, or um thoughts, emotions that turn into traumatic stress. Um um ex experience. So what is complex ptsd? I don't know if anyone's heard of this. It's a, it's something that's kind of been talked about more in the last 10, 15 years. Um And it's when people, it's, it, it, it's a more complicated um pattern both often of um often due to multiple exposures. So for example, domestic abuse, child sexual abuse being in the long term. Um um um Having repeated exposures to stress over a long period of time rather than a one off exposure like my son's accident or an earthquake. Um And it's, there are more, there are extra clusters of symptoms and complex ptsd people, people. Um We see emotional dysregulation. So you might find people who may self harm or um um find it really difficult to cope in relationships, feel, be, be, become, feel negative about themselves. And like I say, have difficult, difficult interpersonal relationships might find difficult, holding down a relationship or, or a job or functioning with colleagues. Um And um it's, it's, it's a very complicated one. This because um emotionally, some people categorize what we would call emotionally unstable personality disorder as complex ptsd versus can, can say not some, there's this quote where people will say they don't ask someone what's wrong with you, but what has happened to you? And it's a debate in psychiatry at the moment as to whether er eu PT emotional personal disorder is actually complex PTSD and that's only what some people in the field think. Um So the difference between the two. So in PTSD, as we talked before, you re experi the event as hyper arousal, you'll avoid the thoughts, feelings placed. Whereas in complex ptsd, it's much more sort of turned into yourself. Um You will again avoid re but you have is much more feeling negative about yourself and, and difficulties in relationships as a result. Um With both using drug and alcohol is common. But I think, I actually, I don't know the stats on whether it's more so in complex ptsd. I suspect it might be, but I'm not sure now. So how do we manage? Both? Patient is exhibits in the, in the first step in complex PD and PTSD is diagnosing and reassuring people that the most most will. Um Most people will, um, um, or any stress disorder, actually, most, most will um, go does resolve self time. Most people who've had a terrible stress response and it's important earlier on to get, get in there to make sure that people don't start using damaging and dysfunctional ways to manage your stress and such as, um, like I say, alcohol and drugs and avoidance. Um, Deb breathing is interesting. So, um, many years ago, there was a group of people who were very interested who, who, who, who were real proponents of psychological debriefing. There's been a major trauma, get everyone who's been in the, the train crash or whatever the crash together and debrief them about what's happened. Well, um, and they, to their credit is a randomized controlled trial after I can't remember what trauma it was. But, er, they took a group of people who, um, had, had the trauma and group who didn't. Um, and sorry, got to a group of people who had the trauma and gave some psychological debriefing and some not and followed them up. Um, and after six months, the group who'd had for debriefing were much more likely to have post traumatic stress disorder from s group. We didn't have Debri, which is exactly the opposite of what the group were expecting to find to their credit rather than saying, oh, we didn't have enough of a sample size or there must have been something wrong with our research or there, they, they accepted, but they had found the complete opposite. And it's a really, it was a really brilliant example of where um as medics, we have to be really careful just because something sounds good and make, we think makes sense. And we have a well meaning view that this is, you know, this, we can sometimes be doing harm. It's a, um it's a, it's a really, really important lesson in that paper. Um So be careful in the first steps, I think even well, meaning psychological debriefing can cause more problems. And there's been some, there's been some research since that study to make sure that it should be fairly, it should be fairly low key people shouldn't be forced into it. You need people a bit of time and space. You know, we kind of evolved, I think to have, we know how people respond to trauma and often it's sort of a sort of shock and denial and responses. I'm sure you all know, well, that's evolve for a reason. So don't go Meck about with it too much. Um, we know that but if symptoms persist or if people start using dysfunctional ways to, to, um, to uh cope then that's slightly different. We know that self-help and support groups can help. We know that C BT can help and E MD R, which I'll talk about in a bit in the military. There's quite a lot of interesting um, um, work being done on virtual reality. Um and, er, headsets where people, you can't, you can't put people back in a trauma zone, can you? So if you do it in virtual reality you can. And I've, um um if you're interested, I have um I do know someone who, who's got an expert in virtual reality and PTSD, who I might be able to persuade to come and talk to you if he's an American expert. So I do some work on virtual reality as in my research work. So, um let me know, I can only ask um medication, it's in terms of medication, avoid benzodiazepines cause like alcohol, all that's gonna do is stop you. I mean, you can use Benzos very briefly at the fi, in the first few days, weeks, maybe. Uh especially someone really not sleeping at all, that's fine, but you have to be careful not to cause both dependence and people um using it to avoid laying down the um memories that you need to be able to have. Um and then it's important to make sure that you treat any comorbid diagnosis. So if someone's got depression, um, or if someone has, uh rarely if uh they get psychotic symptoms, then it's important to use medication and treat appropriately and treat. Of course, any physical health condition that might maybe be worsened because of stress. Uh E MD R, I remember when I first came across E MD R, eye movement desensitization processing many years ago. And it, so you, I mean, essentially you, you get the person to er visualize what happened and the um therapist who I think is run against for 22nd. And I remember thinking that sounds absolute baloney. What nonsense is this? And then, yeah, I am, I am a firm proponent of evidence based medicine and the trials suggest that it works. So, what do I know? Um So over the last say 20 years, um E MD R has, has a increase in acceptance is something that can help with um PTSD and I'm not a neuropsychologist. So I don't completely understand how, how it works, but I have been convinced that it works. So uh we've got, I've um only spoke for 40 minutes, but um I'm happy to take some questions now. Uh So the key point is that for PTS that re anyone com responding with anxiety and stress to a traumatic event is entirely normal. Um It's, we diagnose ptsd when the response is uh delayed and oh, might not even say excessive cause a terrible thing happens, you're gonna respond. But if it starts, uh, uh, really interfering with your function, you can have, um, uh, uh, it can be, it can be an, a normal response to a normal event or an abnormal response to a normal event. You know, what, what's one person's trauma? Is it necessary in animals? This can happen to anyone. It's not a sign of weakness. Um, avoidance of the trauma or anything that reminds you of a trauma is a way to maintain PTSD. And it's really important that people use common sense, coping strategies to manage anxiety. Um There is an overlap of complex PTSD and borderline personality disorder which I think we're trying to as a psychiatric profession understand and in terms of outcome, one third are at sym are symptomatic for more than three years and at risk of secondary problems, uh which can be depression, um relationship problems and alcohol and drugs, which are extremely common as well. Thank you very much. So, now I have space for any questions. Then he wants to either put their hand up or uh put a message in the chat or avo can I elaborate on avoidance phenomena? That's essentially a man. So it depends what you um um what the initial trauma was, but you want to avoid anything that's um makes you uh re relive it and that can be that can be um Yeah, that I, I'm not keen on going on fairgrounds to fair grounds. That's kind of probably all right, one can live without it. Um, if I, um, if I was trying to avoid cars or I was trying to avoid, I can get to the stage where people will be unable to even watch a watch television in case the car comes on or even talk in extremes, even say bad, had a car crash or even talk about cars, then there's, that's avoidance phenomena. Um And uh where it becomes, er, disabling your life, do people with the anxiety have capacity to make decisions? Is that question generally? I mean, you know, anxiety is normal, you know, about the four point capacity test, er, of being able to understand something, weigh, weigh it up, er, er, er, um, make a decision and communicate it. Um, yeah, I mean, you'd have to be pretty anxious not to be able to do that. So certainly people who are a bit anxious all the time, extremely, you're having a panic attack, maybe not. But generally, you know, most people anx anxious and to say that someone doesn't have capacity to make a decision is usually you have to be a, you have to meet that four point test and I'd be surprised if most anx anxious people met it any more questions with anyone. Um doctor, there's another question in the chat and people with anxiety have the capacity to make decisions I just answered that question. Oh, sorry, sorry. Mhm. No, anyone has any other questions? No, if not, you get a 15 minute break before the next one. Um please do. Like I said, I'll put my email. If anyone wants to email me directly, please do. Um and um um if you want me to try and find out about the VR uh lecture, let me know I can ask the um person I know, oh, why Benzodiazepine is contraindicated. Well, because as I said, it stops you laying down memory, it's not, not completely contraindicated. As I said, you can give them for a few days. Um, but they're addictive is the main reason. Um, so in the same way, you wouldn't say to someone why, you know, recommend they start drinking heavily. Uh, they, they have a similar reaction, they're addictive and they, um, um, would stop you. Um, you know, stop your break. If you, if you're, if you're, if you're sedated, you're not gonna be able to, um, um, lay down for memories and work through from you, you're avoiding it and avoidance is one of the ways that you get PTSD. Main problem is they're addictive and if someone's got ptsd, they're going to be much more likely to get addicted to them. What are better alternatives that don't cause addiction. Uh Well, as again, as I said, there, there, there, there, there, there aren't any really apart for, you can treat the, any comorbid um issue like depression anxiety. So use an antidepress, sorry you get, if it's a, if it's a diagnosed depression stroke anxiety disorder, you might be able to use something like a SSRI if you're sure that's what it is. But beyond that, there, there, there is no better medicine. Alternative treatments are essentially psychological. So a mixture of things like health advice and CBD plus MDR. Um um good. That's why, that's why I didn't talk about medicines because there isn't really a role for it. You're more likely to do harm, more harm than good and it's tricky. You've got someone distressed in front of you. They might be wanting Benzo's, but especially my friends with GPS are, they're the ones who are then stuck with, um, use down the line. You know, they can be quite damaging, um, to people. Um, and, and especially in someone with PSD. So you really want to avoid it. I would just say short, very, very short term for sleep. Great. Well, lovely to meet you. Um, um, and I hope to, I may well try and, um, be able to, if, if I get good feedback and come talk about other things. I do quite a lot of leur um, and, uh, I hope you enjoy the rest of your day and the rest of your program patient. Thank you very much, doctor. My pleasure. My pleasure. Have a lovely day. All. Have a great day. Um, before everyone leaves. Please do complete the feedback like I said in the chat. Um and we have our next lecture in approximately 10 minutes on plan preparation. So hopefully you can attend that. Bye. Thank you.