 Well, welcome everybody and welcome to tonight's webinar on Identifying and Treating Agriphobia. I think panic disorder might be better for the team on the webinar here. But anyway, it is Agriphobia and we welcome all of the viewers who are watching the recording as well later on. MHPN would like to acknowledge the traditional custodians of the land, seas and waterways across Australia upon which our webinar presenters and participants are located. We wish to pay our respects to the elders past, present and future for the memories, the traditions, the culture and hopes of Aboriginal and Torres Strait Islander Australia. So I'm Steve Trumbull and I'll be facilitating tonight's session. I'm a GP by clinical background and have been involved in health professional education for many years. The other panelist bios were disseminated with the webinar invitation. So the interest of ensuring we cover as much content as possible during the webinar will skip going over the bios in detail. But we are joined tonight by Caroline Johnson. Hello, Caroline. Hi, Steve. Now, Caroline is a fellow GP educator. What's one thing you think it is important for other mental health professionals to know about the GP's role in improving outcomes for people who are experiencing agriphobia? Well, the one thing I would emphasise is continuity of care. So the advantage that we have in general practice of seeing people over time and really helping them stay engaged in treatment and making sure that people get the kind of right dose and duration of therapy they need to recover from a condition like agriphobia. Right. All right. Thank you very much. Can only fully agree as a GP continuity is what it's all about. Peter McEvoy, welcome. Caroline, you've been working with the Centre for Clinical Interventions in Western Australia for a number of years. Can you share a bit more about the work you do with this organisation? Thanks, Steve. I'm really wonderful to be with you. The Centre for Clinical Interventions specialises in the treatment of anxiety disorders, affective disorders, so unipolar depression, bipolar disorder and eating disorders. So we offer cognitive behavioural therapy. And we've been going for over 20 years now. So I've been working there all of that time except for four years at CRUFAD in Sydney in the early to mid-2000s. Great. Thank you. And I'm sure that's where you worked most closely with Lisa Lamp. Now, Lisa, we need to build a shrine to you. You have struggled enormously tonight with getting online, but you're here and we're very glad to have you here appropriately. You've been working with anxiety and OCD disorders for many years. What is it that's kept you engaged in that very challenging area of practice? Look, it's the fact that people get better, that we have treatments that work. I love the collaborative nature of working with people and the fact that I learn from my patients and I can then pass that on to future patients and it's a wonderful circle of people getting better and all of us learning more. Great. There's absolutely no question that feeling that you're achieving something is what keeps us going, doesn't it? So that's wonderful that that motivates you. So we've got a great panel tonight, lots to talk about. We are using a new web player tonight, so I will just ask you to pay attention even if you've heard this bit before, but to interact with the webinar platform and to access the resources, there are a few options you can see there on the screen. To click the Supporting Resources button, you click that View Supporting Resources button under the video panel there. If you want to access the slides, the resources, the survey at the end and also to get technical support should you need it. You can access the chat, which is at the top right. You can see a speech bubble up there and that's where you can click on that to get onto the chat room. As I've mentioned, if you need technical support, you can click the Duck button in the bottom right-hand corner of your screen. We often find the webinar, if the webinar stops for people, it's usually an NBN issue rather than anything else, so please try refreshing your browser and if there's anything you have missed, this webcast is being recorded. Within the chat room, please make sure that you are respectful of other participants and panelists and also keep comments on topic in the chat box. I can see there's lots going on in the chat box about people not being able to hear. You have to turn your volume up manually to be able to hear, so please make sure you've done that. If your screen's frozen, sorry, please reload and you should be able to get back onto us. Crystal's frozen as well. Crystal Lockard. You can't hear me, but if anybody knows Crystal, send her a text. Just reload the URL. Now, enough of that. Tonight, each panelist will give a short discipline a specific presentation which will relate to the case which has been circulated. And then after that, we'll have questions and answers between the panel. The aim and the learning outcomes are displayed. I won't read through them because you can do that yourself, but basically it is all about learning about the co-morbidities and most important thing for tonight, identifying treatments that work. So we'll move in now to the interdisciplinary presentations and we're starting off with poor old Stella and I must say to be one of the more florid case studies we've had in this series of webinars, but I always wanted to be a mills and boom novelist. So there we go. But anyway, plenty to talk about. Let's start with Caroline. Thanks very much. Thank you, Steve. And thank you for having me here tonight. So I'm going to share the GP perspective and I think the first thing that we have to talk about the GP's is, you know, we're the first point of call with respect to the health system. So it's very unlikely that Stella will walk in the door and just want help right away. Like we know from the 2007 National Mental Health Survey that only one third of people who, you know, could benefit from help were actually accessing help. But the most important thing it found is of the two thirds of people who weren't accessing help, 85% of them said they had no need for help. So that's the world of the GP. People come to the GP about something or, you know, somebody else says to the GP they're worried about someone. So it's a very different problem than when someone's already engaged in seeking help. So the questions I have are, you know, what Stella's developmental perspective, you know, is she going to come in with her mum dragging her in or are her friends going to bring her in or is she going to present on her own? How willing is she, given that she's anxious and struggling and staying at home, will she actually get help? And then there's all the other questions around what can happen to engage someone in care. And obviously when people are anxious, you know, it's very hard to kind of reassure them that even though, you know, there's a lot of barriers to accessing care. There's cost, there's appointment availability it's worth accessing care. So the GP's role is often trying to make those barriers minimal. And then also to kind of think about having conversations with people about what's the right kind of therapy for that specific problem. And that's something that can be quite hard to do when there's time limitations, but I think it's really important. And I often tell my GP colleagues to focus on what's the tipping point for the patient. So often, you know, the point will be that their friends say this isn't good enough for their employments at risk. Moving on to assessment. I guess the big thing to recognize here is the next slide please. The GP role is not so much about getting the diagnosis perfect. It's about making sure that you're not missing anything. So certainly in a very brief way, making sure that you're not missing any physical health problems. And GPs have little approaches to that. You know, what's the most likely diagnosis? What are the red flag diagnosis I want to miss? I want to touch on a bit of a few of those things we consider. And then this consideration of, well, does it matter what kind of anxiety Stella has? And I think it does matter because different types of anxiety respond to different types of therapy, but also there's more than just getting the diagnosis right. There's the formulation and thinking about, you know, what are the factors that, again, people talk a bit more about formulation, but recognizing that the GP formulation is often not done in a nice linear way from presentation to end. So there's a lot of information that occur over time. Moving on to the next point, which is the management slide. I guess the big thing to emphasize here is that GPs really work in what I call a dimensional perspective. We don't really wait for someone to cross a categorical diagnostic line before we do stuff. Although a lot of the systems we work in actually require us to. So for example, you're only eligible for a mental health treatment plan if you've got a diagnosis, but most of us in general practice land will be a bit pragmatic about that and say to patients, well, you know, if you're very close to crossing this line, we won't wait until you get sicker. But there are implications for that around the person, you know, having a diagnosis. And in that respect, it's really important to listen to the patient. What do they think is going on? Even if you disagree with what they think is going on, you've got to have a conversation about, you know, what do you think caused the problem and spent a lot of time on having conversations about, you know, what the mental health professionals view is of what causes anxiety and what perpetuates it. Because getting that kind of shared understanding can really help prepare someone for therapy. And then there's, of course, the conversation around what type of therapy. And I'm not going to speak about that a lot now, except to say the GP has a really important role in explaining to people with anxiety disorders that getting help is hard. You know, I often use analogies like, you know, you don't expect someone to suddenly run a marathon if they're not training for it. And to get help for anxiety, you really have to be, you know, prepared to commit to a bit of time and work. And my role as the GP is to sit with you on that journey. So moving on to how will we then work once we hand over the care to other professionals. And I guess the big thing here is GPs do like to know from the health professionals we're referring to what their approach will be. I certainly spent a lot of time when I met someone who says, I had therapy before it didn't help. I say, well, what exactly happened in therapy? Because then I can at least form a view of did they get an evidence-based therapy? Did they get CBT or something else? And so for those of you who often interact with GPs, please remember it's not that helpful to just say to Stella, go and see GP to get a plan. If someone turns up with a 15 minute appointment, you're not going to get a very good quality plan with that approach. So thinking about how you're going to engage, not just with the GP, but also with the patient and the family. And then the last point I guess I want to make, which is my big area of interest, which is the last slide I'm going to talk to is the issue about recovery. And I think, you know, it is true, what Lisa says, treatment for agriphobia does work, but people often have a lot of false starts and it's a difficult thing to do. And I see myself, you know, the GP role, my own role, very much is to save the person. I'm sticking with you on this journey. I want you to come back. If it's not working or you want to drop out of therapy, that's your choice, but come and talk to me about it because this will come and go. You might have a few false starts. And I do think that that ability to monitor someone over time and look out for relapse and talk about relapse signals and finding out, you know, what did you do when treatment didn't help? It's really important in keeping people engaged for the longer term. So I think they're the main points from me, Steve. That's great. Thanks Caroline. Thanks very much indeed. And so you would have probably given a diagnosis, I guess, to Stella in this case and she'd move on if you weren't going to do the counselling yourself to a clinical psychologist or other suitable counsellor. And Pete McEvoy is going to give us that perspective now. Thanks, Pete. Great. Thanks, Steve. I feel like I'm a horrible psychologist. I need to thank Caroline and all the GPs for all the amazing work they do before we see clients in helping to collaborate with the explanatory models and preparing them for therapy, which makes our job a lot easier. So when we first start to see a client, obviously we'll put together a problem list and really try to understand the impacts on the client's life from their problems. So in Stella's case, if there's a history of panic attacks, then understanding their onset, any changes, persistence, frequency and intensity of those attacks. And we'll probably ask Stella to give me a really detailed example of a time when she's experienced a panic attack or in terms of agriphobia, just how she experiences that. I want to be pretty sure that a medical review has been completed and I'm assuming after someone has seen Caroline that that has been completed and I can assume that there are no medical complications and so a psychological formulation of the problems is appropriate. I don't want to assess for co-occurring problems, so depression, social anxiety, and also the temporal relationship between those problems. So did the agriphobia follow the social anxiety or come before and the depression as well? Because that tells us something about the relationship between the problems that Stella's presenting with and also guides what might be the treatment priority. Some of the low hanging fruit may be lifestyle factors that we might want to consider working on as well, but also protective factors that we may want to recruit to support Stella's recovery as we work through therapy. We want to be aware of other interventions, particularly medications. If there are PRM medications like benzodiazepines, then that might really interfere with our progress so we really need to know about that at the outset. And then we want to assess change. So as part of our assessment formulation, we might administer some psychometric measures with some of the beliefs, some of these scales as examples here, that we also want to target and treat and we'll see change in over the course of therapy. Next slide please. We will do an assessment of predisposing factors. We know that anxiety is highly heritable, so it tends to run in families. So there's going to be genetic component most often. Also some environmental factors, so parenting or modelling of coping behaviors with anxiety that we might want to know about and also significant life events. So any early experiences of trauma, separation, deaths of parents, for example. And then temperamental factors. So non-specific, temperamental factor. When I say non-specific, I mean increases risk to a whole range of different mental disorders, things like neuroticism. But in terms of panic disorder and agrophobia, anxiety sensitivity, a few of those physical sensations which may be a fear that physical sensations may lead to a medical catastrophe or a cognitive catastrophe in terms of losing one's mind or social catastrophe. So it may lead to severe negative evaluation. For example, people who believe their anxiety may lead to those things are more likely to develop panic disorder and potentially agrophobia. We can't change one of those predisposing factors that have happened well in the past, but we can work on what's left behind. So some of the beliefs about self, others in the future and coping strategies as examples. Next slide please. Moving on to case formulation. So I often think about the seven P's when I'm formulating. Presenting problem we've already talked about, predisposing factors we've talked about, and then get a sense of precipitating factors. So we can break that into distal precipitants, those factors where there was a significant change in the rate or frequency or intensity of the agrophobia, what was happening around that time for the client, but also on a daily basis, more proximal treatments. What's triggering the avoidance or the anxiety every day for the client. And then the perpetuating factors, what keeps it going? Well, the cognitive content, the thoughts and the images that the client maybe has gone through their mind about what may occur if they don't avoid these situations. It helps us to establish a differential diagnosis about what might be driving that avoidance. As a clinician, we're aware that attentional biases, interpretation biases and memory biases may all be at play in the session as well. So the client is focusing their attention on the perception of threat that might be interpreting fairly ambiguous information in their environment consistently with their expectations of threat, and therefore they're more likely to remember those examples of negative experiences at the expense of more benign or positive experiences. In terms of avoidance, we obviously want to know a lot about the sort of situations they're avoiding, the ways they're avoiding it, subtle and not so subtle ways, and how much more generalized that's becoming over time. Obviously there are emotions we want to assess and also physiological symptoms of anxiety. Protective factors, as I mentioned before, we want to recruit these during our therapy and use those to really support the client's recovery. Think about potential obstacles to change from the past experience of therapy perhaps or whatever's happening in their life that might interfere with their progress and we need to plan for contingencies around those. And then obviously that all this leads to the treatment plan itself. Next slide please. So here's a formulation, a super formulation we may bring together for STELA based on Clark's cognitive model of a panic disorder and I've adapted it here to taking into consideration some of the features of agrophobia. So we might have a trigger stimulus, an internal stimulus of maybe physical sensations of anxiety or external situations. In STELA's case, crowded, noisy places, social situations, shops, university campuses and she describes buses as co-owned wheels. So a bus is definitely a trigger stimulus. There's some sort of perception of threat in these contexts which leads to that apprehension and the fight-or-flight response. So there will be a lot of psychoeducation around what the fight-or-flight response is and how that manifests for STELA in terms of bodily sensations. How that leads to some sort of catastrophic interpretation of the sensations but also the situations. She talked about being dragged away for torture by her friends and sister, I think, in the case and they're feeling trapped like a rat in a box of no escape. And I want to know if you were continued to be trapped, what then would happen? What are her predictions about that? So to prevent those catastrophes happening, she engages in a lot of avoidance using emergency exits, escaping, avoiding, spending more time at home and all this really serves to maintain the perception of threat and keep the cycle going. So really we want STELA to understand these cycles, see how it explains her past experience, her current experience and how it also presents the change in an altered future that's more positive. Next slide, please. So in terms of the core components of treatment, a lot of psychoeducation during that individualised case formulation mitigates some cognitive restructuring and thought challenging to modify that perception of threat and a lot of that challenging might happen through behavioural experiments where we're setting up experiments where we're directly testing some of her fears and that might involve intrusive exposure to the physical sensations, situational exposure in vivo exposure and while she's doing that really abstaining from any subtle avoidance behaviours because those behaviours are going to stop her from really directly challenging her fears. We may introduce some derousal strategies I don't often use those routinely because they can stop STELA from learning that her anxiety is not dangerous, it's not threatening, it's not going to lead to a catastrophe so it really depends on the function of the derousal strategies. Is it just to dampen down some of the feelings or is it to try and prevent a catastrophe? If it's the latter we really want to not use them when we're doing behavioural experiments and then routinely monitoring her outcome session by session to make sure our treatment is having an impact. Thanks, Steve. Thanks very much indeed, wonderful. So just before we move on to Lisa I just want to remind people to post questions if you have them. There are no questions as yet which is unprecedented. I've just checked the system is working so just remember you've got to put your mouse cursor down to the bottom of the image and hover over the three dots there and then that will show ask a question. You click on that and ask a question so we should be able to answer those when we get to that point in the presentations or in the webinar. So now Lisa thank you very much. Let's hear the psychiatrist perspective. Thank you. I guess generally by the time a patient comes to see a psychiatrist often they're not making the sort of progress that the referring practitioner would have hoped for them to make. So I guess the first thing that we tend to think about is is the diagnosis right? So in this case I would take a close look at the history and there's a few little pointers that maybe we should consider some other things there's a reference to being shy so could this be social anxiety disorder and could that be the primary disorder or could it be a coexisting disorder? Noting that endorsing shyness is really pretty common and particularly in that age group it wouldn't at all be unusual that entering a new social environment like university could cause a transient increase in shyness and social anxiety shyness is also particularly common in younger people and so you know it's not abnormal but I would just be thinking in the back of my mind okay could this be social phobia? Her key concerns appear to be physical symptoms so that certainly makes panic and agriphobia more likely because social phobia is much more about worrying what people are going to think about me and there's a little bit of that but it does look as though physical symptoms are more likely and of course I would be wanting to think could a medical condition or treatment explain these symptoms there's a little hint about alcohol use so I'd certainly be wanting to explore that further and just checking what level and are any other substances involved Next slide so there's a few things to keep in mind diagnostically and first of all panic attacks don't make it panic disorder panic attacks can actually be seen in any anxiety disorder so that of itself is not enough for us to say okay this is a panic disorder I really would want to clarify with Stella what her main fears are so for example is the worst thing to her that somebody might think that she's bullish or looks odd or otherwise negatively evaluates her or is she much more worried about some terrible physical or mental outcome like Peter highlighted in his slide about losing it or being trapped and what would happen if she was trapped what does she fear would happen the associated avoidance certainly makes it phobic so that means that if she's having a panic attacks it would be and the main fear is physical or perhaps going insane then panic disorder and the associated avoidance would make it agriphobia if she's avoiding because of those fears and just noting that age is a very relevant factor when we're making a diagnosis because anxiety disorders usually present for the first time in the teens or 20s is highly unusual for a patient over 40 years to be presenting with anxiety for the first time particularly panic or phobia so that's a bit of a red flag and the two most common things to think about in that case would be is it really a depression with prominent anxiety symptoms or is there in fact some organic cause a medical condition or treatment next we also would think about co-morbidity as again as Pete referred to if you've got one anxiety disorder you're likely to have more we always think about major depression because there are some common genetic vulnerabilities between anxiety and depression or particularly for generalized anxiety disorder but depression does come first in about 33% of cases in panic and agriphobia not much in social anxiety disorder which tends to come first a number of medical conditions which are GP colleagues are very good at checking for so I don't necessarily go into a lot of detail there but just sort of tick the boxes and then we just need to check could it be side with medication possibly for some other medical condition or even psychotropic medication next slide we know some interesting things about the first panic attack so DSM3 or DSM5 now sorry always talks about coming out of the blue and the first attack may seem to come out of the blue and it seems to most often happen when somebody is away from home when they are intoxicated or during substances or when they've recently had an illness or are going through a period of increased stress but thereafter it's pretty rare that they come out of the blue and one of the things that I or a clinical psychologist treating the patient will do is really help them learn what those triggers or cues are next slide it's also interesting to think about when panic attacks occur so there's often a misapprehension in amongst lay people that agriphobia is the fear of the marketplace or the fear of open spaces but really it's the fear of being anywhere where you wouldn't be able to escape or get help if you needed it so people can get panic attacks when they're alone they can get them when they're with friends and family they can get them in their sleep and that tends to be particularly frightening for people but the good news is it responds just as well to my usual treatments so panic attacks can actually occur really in a range of situations not just when people are away from home next slide now the treatment algorithm this was from the RANZ or it should say CPE clinical practice guidelines that's the College of Psychiatrists and these came out in 2018 these steps really are often done by the GP so the GP makes a good global assessment and then because so many conditions in general practice and Carolyn can tell me if I'm right or wrong about this but they often spontaneously resolve so the GP takes a watchful waiting approach but gets the patient to come back if symptoms haven't settled and then we think about initial treatment based on severity next slide and this is what we recommended in the guidelines that the mild anxiety cognitive behaviour therapy is the treatment of choice and medications often not required at all the moderate CBT or medication for both but really we wouldn't recommend both we think that one or the other is probably sufficient and even in moderate cases CBT if the patient can engage with it and get good quality CBT is often sufficient but when we start talking about severe anxiety disorders then we are probably thinking about combining cognitive behaviour therapy and medication and just noting that if a patient is likely to need medication more than a few days then it should be an antidepressant not a benzodiazepine and not a beta blocker and the other key point to keep in mind and for patients to know is it takes a lot longer for anxiety than it does for depression to see a response so at least four to six weeks okay I think that's it, isn't it? It is indeed, thank you so much Lisa that's fabulous and the questions have gone brisk which is great, there's been lots coming in now so we've got plenty to talk about and we'll move into that phase of the webinar now the first question as I promised because she was the first cab off the rank was from Lynette Moodley and Lynette has asked at what point will it be useful to explore the causes of the anxiety or panic in addition to symptom management so when do we go back to look at what's actually maybe underlying this rather than just treating symptoms Lisa looks like you're up and it's hard for Lisa because she's using a Commodore 64 she found in the drawer hard to unmute, there she goes look I just want to I think emphasise what Pete said is that genetic factors are much stronger in anxiety than they are in many other disorders and it's actually uncommon that there will be some cause like a traumatic incident or parenting experiences so I often say to my patients you know you didn't cause your child's anxiety except in so far as they passed on your genes and so it's not something about parenting very often or a traumatic event and I think that's probably good news for parents but where they need to help if they've got anxiety which one or other parent usually do is show how to feel the fear and do it anyway and I guess Pete might want to add something there as well I would agree with everything Lisa said I guess we've talked about a bunch of potential causes of herogrophobia and that's what I would spend some time really trying to understand the content of the perceived threat that she's reporting is it and when it started around the onset what was happening for her to really understand her interpretation of those contexts and that will tell us a lot about how to treat it how to respond to it using the principles that we've been talking about you know if there is a history of trauma you know clients who grew up in very violent households for example then it may be that we target that as well in treatment separately but we weren't necessarily mean we wouldn't also type herogrophobia using the approaches we've been talking about but really that falls out of the assessment the case formulation and that will guide the intervention rather than the other way around and certainly diagnosis is one bit of information but it's by far not the most important everything else in the case formulation is far more important Right, excellent thank you Peter now the next question we've got from Andy Williams who's been active in the chat box and as opposed to her question in the question area and it's actually a really important one it's saying that we don't have anyone with lived experience on the panel primarily and I was just wondering if there is anybody on the panel who could maybe give us some insight into how things might result for Stella so what would she say about her experience if she or another person with lived experience was on the panel I might ask you Caroline because you're sort of in the front line of general practice the next time you see Stella for something else what do you think she'd be saying about her experience? Well I think it's a lovely segue from what Pete and Lisa were talking about before about you know which comes first the trauma or the you know like the genes the trauma everything else what I love about working in general practice with people over time is I notice that they're explanatory models about what's happening changes with time and one of the richest things in general practice is because you see people little pieces as they're going through their therapeutic journey is you could just encourage them to reflect on that and talk about it and so sometimes people really want to focus a lot on the bad things that have happened to them and then your role is to kind of get them you know make sure they feel heard that they've really somebody's really listened because I think that in itself is immensely therapeutic and then maybe over time particularly with a condition like agrophobia of saying well it's all part of the journey is to say well I understand that these things happen to me and I understand the leap between them and this condition that I have or my family history whatever but then there's a kind of a leap they have to make of saying well I now have to do some things kind of separate from that you know I can't just be a victim of my past or my genes or whatever else I have to now do this and that lived experience that's the bit I find most interesting because I think it's really hard for some people it's very unpleasant to do exposure it's very challenging and when the psychologist say to us well no don't give them beta blockers and I think we all accept you know not to give bends or daisopins but it's very tempting to say well here's a little bit of you know beta blocker just to help you when you've got to do this and so the experience of the person is often this one of knowing that they're being helped but often feeling like they're being abandoned because people are asking them to do things that make them feel worse and I think that's a really important thing in general practice to have those conversations of saying I know that that's part of the journey but it's worth investing the time because I can tell them lots of stories of people I know who have gone through that journey and gotten better but people might want to add to that. Yeah thanks Caroline Firstly I guess I'd say there's no way I would ever ask anyone to do something that they didn't believe would be helpful for them and so the process from the very beginning needs to feel very collaborative and although we bring our expertise in terms of our understanding of theory and research and past clinical practice the client is an expert in their life and their experience and it's a coming together of those expertise that are going to produce the best outcome so if ever a client of mine felt like I was asking them to do something that was terribly uncomfortable for fun or they didn't clearly see how it could help them then I've not done my job well at all so the client needs to understand what they're doing, why they're doing it how it's going to be helpful to them why it's important and if they can't articulate that themselves and understand why it's important for them to do it then we need to take a step back and in terms of the individual lived experience of recovery that is very individual and that needs to be us as clinicians really understanding where the client wants to get to and helping facilitate them to get there it's not our gender it's not so some clients are going to be these panic attacks are just really affecting my life and I really want to be able to do X, Y and Z so there are priorities X, Y and Z that work together to get there now that a lot of the strategies that we're working on in treatment are a means to an amp they may not be the ends themselves but other aspects of the person's quality of life that really they want their coming to therapy for but they need to understand how those means are going to get them there and if they don't we've not done our job well. Can I add something Steve? In my experience anxiety can be quite contagious from a therapist and I think sometimes treating clinicians often medication partly because of their own anxiety you know Pete's absolutely right I want I want my patients to be their own therapists to understand why we would be asking them to do anything difficult and really negotiating it with them but a lot of therapists get anxious about a patient's anxiety and sometimes prescribing I think it's a little bit more to treat the therapist's anxiety than the patient's okay we'll leave that one sitting there because it's a really important point and obviously something we need to be very mindful of but it has actually a couple of you have now mentioned exposure therapy and that was something that came up in the questions that were submitted before the webinar and it's coming up a bit in the chat box as well just wondering Pete did you have any thoughts any more thoughts about exposure therapy and its role in agrophobia? Sure it's where we get the biggest bang for our buck in therapy and traditionally we might have used a mainly behavioural rationale so it's about habituation or just repeatedly going back in the situation to desensitising but really in contemporary practice it's more a cognitive formulation it's about what is your prediction specifically about it might be about your anxiety how intense it's going to get how long it's going to stay up for particularly about how other people respond to you in that situation we really need to isolate very specifically the client's predictions in that situation and set up the circumstances where they can directly test those beliefs and find out once and for all how accurate they are and we know we've done our job well when a client's walking back to the clinic if we've gone out of the clinic to do an exposure shaking their head in disbelief they're just so surprised that their fear did not come true it really maximised what we call the expectancy violation the difference between what they were predicting and what actually happened and that's where the most powerful learning occurs so before I mentioned I rarely use control breathing or relaxation in conjunction with exposure I really would never do it the reason is because it minimises that expectancy violation there's always another explanation for why the client survived the control breathing but in fact if we as therapists believe that anxiety is not dangerous it's not harmful and it's tolerable and actually I go into therapy knowing that my clients are far more capable than they believe themselves to be then really what I need to do is create the circumstances for them to learn that about themselves and maximise that expectancy violation so we don't need to control it we don't need to minimise it we can just actually go and experience and ride the wave come out the other side and learn something about how intense it gets how quickly it passes and how the client is capable of tolerating it some of my biggest wins actually have been when clients have occasionally had panic attacks while we've done exposure exercises and they might have the belief now I've got to go home and rest for the rest of the day and we test that belief I remember a client who wanted to do that and she decided instead to go into uni and test that out came back to me next week and said I could not believe how productive I was that afternoon I thought I'd be shattered and couldn't achieve anything and that was a huge turning point for her the violation of her expectancy was so massive that she was just ran away with it and was doing amazing things so a well-beknown behavioural experiment we can always learn something about the capability of the fear coming through the cost of it if it were to come true and also the client's capability to cope if it comes true so our job is to help the client learn those things about themselves That's great Peter and to lift a quote out of the chat box from Daniel Make the amygdala learns through experience which probably sums up a lot of neuroscience in a few words it's great so thanks very much for your responses too for Lisa's comment on dealing with the counter-transference that we have to be very, very mindful of so plenty to talk about still and I'm actually going to go back to Lisa now because there's been a number of questions that have popped up in the chat and also more formally asking about comorbidities and overlap presentations everything from autistic spectrum disorder alcohol addiction PTSD depression all of those sorts of things and just wondering about how much we I know we've already touched on it but how much do we have to tease apart those comorbidities or do we rank order them in treatment or do we try and take more of an omnibus approach comorbidities are extremely important because they're very common and I think it's important to be aware of them having said that sometimes patients don't disclose all the detail until they trust us better or sometimes they so much accommodated or learn to live with symptoms that doesn't occur to them to mention them so sometimes it's something that we find out over time as we get to know the patient better but it is really important to be aware of other symptom clusters if you like they could be there I'm a little bit cautious about thinking that we have to give a name to them all and diagnose them because in order to help an individual we need that individual's problem list so although I do a diagnostic exercise and I sometimes just have to be aware that there are some symptoms suggestive of PTSD or ASD or whatever it might be without meeting a full hand I'm careful about putting a label that might stick and not be particularly helpful so I'm cautious about making along those diagnoses but in terms of enumerating the problems that they're causing difficulty sleeping social anxiety drinking too much or relying on substances I think that's the way that we can then start to prioritise what an individual's problems are and what ones are causing the most distress and impairment and then think about strategies that we can use so that's where the individualised formulation becomes very important and then as we go along okay if it becomes clear that they make criteria for another diagnosis then we might share that with them because it can be helpful sometimes I mean labels aren't all bad sometimes they help you look for more information or get in touch with support groups for example or us as therapists to think about other treatments that might be helpful I will say it is important to think about trauma history because as has been mentioned exposure can be very confronting so we do need to be mindful of the sorts of things that might be triggering for people but that is all part of a comprehensive assessment and as I say I think gradually putting the pieces together over time Well in the question Sash has actually given us a particular symptom that ties in nicely to Stella going off on her sister's hen's knife which is that again on differentials that your thoughts on avoidance of public places being driven primarily by fear of vomiting induced by anxiety and escape not being possible the consequences judgment of others and embarrassment of being seen vomiting rather than the act of vomiting itself throwing it at the three of you here what would be your first approach if Stella had come with that particular symptom what would you focus on Peter you're nodding or vertically shaking your head I'm not sure which cultural sign you're giving me Yeah look I'm happy to speak to this so the primary perceived threat is what's going to probably guide our diagnostic assessment in this case an important change I guess in DSM-5 was that agriphobia didn't have to be panic disorder didn't have to be present to be able to diagnose agriphobia so that's a really important thing to keep in mind I see detail not already allowed them to be diagnosed separately so the agriphobia that Lisa defined earlier is really agnostic to what the fear actually is other than people being afraid of not being available should they need it so why do they need help that may differ across people is it a fear of falling is it a fear of panic attack is it a fear of something else so that I guess is the first point for example we could be thinking for differential diagnosis of metaphobia that fear of vomiting but there's a social aspect to it in the fear of judgment from others if I were to vomit I guess for differential for that I'll be saying well is the social anxiety generalised beyond just the fear of vomiting is the person more broadly fearful of other people judging them negatively for other reasons as well the symptoms of anxiety might be obvious that they might for short of other people's expectations in some important way or some sort of rejection may ensue because of the way they're behaving so if that's more generalised then I'll be thinking more social anxiety as part of the picture and maybe the vomiting is a consequence of that and then the social judgment but if there's no generalisation of that fear of negative evaluation then I might be thinking more metaphobia as a specific phobia maybe with agrophobia as a fear of going out in case hope isn't available should the person feel unwell and vomit but it could be that the avoidance is really driven again by the metaphobia itself so again your place formulation should address that the other point I would make for my mom from Lisa's point and the question about co-occurring problems we can't take a very trans-diagnostic perspective as well because a little secret is that all anxiety disorders are going to involve some perceived threat some negative thought leading to some emotion of fear and anxiety which leads to some sort of emotion driven behaviour which is some sort of avoidant behaviour which then maintains the perceived threat and that's the cycle we could plug into that simple formulation really any anxiety disorder so what do we want to achieve and how to manage their thoughts more effectively so that they're more balanced and more accurate and more helpful to them we want them to learn that they can cope with those emotions without having to avoid them so the emotions themselves aren't as scary as they used to be and we want them to directly challenge their perceived threats as well by actively confronting those situations and learning that it's less probable, their fears to come true less costly and they can cope better than they thought so if we take those general principles we can apply that to any of those anxiety disorders so in this example I'd say well avoiding a social situation for fear of negative evaluations serving the same function as avoiding a situation for fear of vomiting they're both avoidant functions so if the client can really understand the function of their behaviour they're doing the avoidance for good reasons because they want to protect themselves from threat that's a really important point to validate that they're doing it because it has helped in the past and they believe it's helping them currently if we can help them to understand how those behaviours are actually in the longer term maintaining the problem so it's worthwhile experimenting with dropping them and learning that actually they can cope better it's less probable and less catastrophic than they thought and that can be applied to fear of vomiting fear of negative evaluation or any other fear then they're learning how to generalise those principles across their problems and it's going to be much more efficient and effective way of treating their primary problem but also their co-occurring problems and hopefully leave them less vulnerable to relapse down the track Right, thank you very much and actually I'm going to jump in and ask a question that anybody can respond to because it's got quite a lot of support in the chat box which is about there could be sensory sensitivities going on in Stella's case here and the sorts of things that she is avoiding Caroline, I can see you nodding I mean, presuming she's not vomiting and you're not taking a more physical approach, would you be wondering about autistic spectrum disorder if she was complaining of sensitivities like that? Yes, I mean this is something I certainly think in the last few years it's become easier to have conversations about because our patients are also much more informed about this and whether the pandemic helped people spend enough time on the internet to start asking these questions which I think is a great thing that they're actually questioning it and I have had a few patients who have had sort of physical fears that we thought were anxiety and then they've raised the question themselves is this a sensory problem and I guess the challenge for me as a GP is then often the psychologist they're seeing who's trained in pure CBT says well I don't this isn't really my area of expertise go back to the GP and find someone else and that can be really hard as a GP it is a slightly different thing than just sort of textbook CBT and how am I going to help the person and I do think if psychologists have expertise in this area it would be really good if they highlighted on their website so that we know there are people who are comfortable dealing with those variations because it can be quite challenging for a patient when a therapist says well you've had your dose of CBT and I think you've got something else going on and I can't help and there's a shortage of professionals to help in that area so any sort of advice who's comfortable offering that so that people don't end up just going around around the sort of therapy circles and starting again I think is really important and then from the GP point of view it's about being really compassionate and saying yes this is possible but for most of us in general practice even those of us who are comfortable delivering simple CBT we probably would want some extra help around those for all the things Lisa said about not using labels inappropriately and confusing people more I must say I never wrote the case thinking of Stella as being neurodivergent but it's something that would be in your mind all of you I guess when you're meeting somebody with Stella's issues alright so thanks so much for everything that's been said so far there has been quite a lot of quite a few questions asked about other approaches to therapy and as Caroline said some people might not see CBT as always the front line of treatment here but question from Kay about the role of other counsellors in particular school counsellors or counsellors that Stella might have access to educationally at the university just wondering about how perhaps counsellors who are not particularly health professionals might be able to assist Stella with her problem but I would respond there because as a GP we often hear that people are going to see different types of help and so that kind of conducting the orchestra of saying well let's not make let's make sure that different types of help don't confuse each other like if someone's having a dose of CBT then you kind of want them to stick on that path until we've decided whether it's going to help or not but I think so this is where school counsellors could often be really helpful in being that sort of empathic connection therapeutic approaches and certainly not saying why you're trying that it doesn't work because that's not really helpful when someone started something so I'm really grateful if people my experience as a GP people often turn up and say the counsellor said I should just come and see you and get this it's very rare for them to call or leave a message and I'm very grateful when people do I know it can be hard to get hold of GPs and we can find it hard to get hold of school counsellors but having a quick chat about our alignment so that everyone's on the same page and I think school counsellor can be hugely helpful particularly when the family's not so engaged or they're a bit skeptical about the benefits or there's cultural issues that a traditional clinical psychologist might not have grasped so much in individual therapy and I think they do play a role there but I think it has to be a team game not individuals giving unsolicited advice I'm actually, thanks Caroline I'm actually going to go back and fortunately it's also been asked by Lisa oh no sorry by Jess which is about in Lisa's presentation why is the presentation over 40 years of age a red flag what in particular and somebody else asked about menopause obviously a bit later than 40 but we're just curious about why in particular over 40 is a red flag well it's actuarial for example 90% of people are going to get social anxiety disorder we'll have it by 30 so it's just saying when you hear hoof beats, think of horses not the zebras at least in Australia knowing that a particular condition is much more common in a particular age group that's all so it doesn't mean you can't get anxiety for the first time over 40 but it's uncommon so it means that I don't want to miss something just like chest pain isn't it if you're over 40 and you're getting chest pain we're going to look a lot more carefully for a cardiac cause than in a 20 year old presenting with chest pain I mean we're not going to absolutely exclude a cardiac cause but we're going to perhaps really be thinking of a much broader constellation of possibilities so that's all it's just about the age what we know from large scale population surveys about the ages at which people first get their anxiety alright well that's that's useful, ultra is our diagnosis suspicion I guess depending on the person who's in front of us at the time now we've only got time for a couple more questions and there have been a lot after a slow start which is fantastic but this one from Lisa it is Lisa this time I hope it's not you asking this question Lisa because it is if I see a client being prescribed benzos or beta blockers how can I respectfully suggest to the GP that antidepressants are actually the recommended medication I wonder let's see how you would like to be told Caroline yeah so I guess every GP is different I think the majority of GPs who prescribe benzodiazepines and beta blockers are doing it because someone else has given it before and the patient said it's helpful or like Lisa they're anxious they want to reduce distress and they're anxious to do something and do it quickly so I don't think maybe when I was a younger GP there were a lot of benzos being thrown around haphazardly but in my experience it's much more that they've seen a psychiatrist or been given something in ED when they're distressed and then there's this kind of expectation of continuing it so you shouldn't assume because a GP is prescribing it that they also think it's a great choice and I think the best way is when you write back to the GP saying oh you know we had a conversation the patient and I about the limitations of benzodiazepines and beta blockers when you're doing therapy but I know it can be really difficult would love to have a chat with you about your thoughts on this because I certainly I know a lot of the times I've prescribed these drugs it's because it's been continuing from someone else and I have actually said to people these are not a great idea they're not going to cure your anxiety they're just going to make the treatment take longer but you know you've got to temper that also with people's need for immediate relief or the fact that they've had brief relief for some of these medications so I think it is a respectful it is good to be respectful but I think it's also good to not assume that GPs think it's a great idea to be using these drugs and so having more of a collaborative conversation about how can we reduce that in the context of what we're trying to do in therapy would probably be more productive I hope that helps because I think it is intimidating, can't it? Yeah, Pete are you going to say something about that? Yeah, just to reinforce the Caroline that really the conversation for me would be with the client and talk in term about how it fits into their formulation how they're using it and what it's teaching them about their capacity to cope Lisa said before that really would want to make ourselves redundant and help the client to develop their own coping self-efficacy so I have a conversation with them about when you take your benzodiazepine does it help you to feel more or less confident with your ability to cope with your anxiety and if our goal here really is to help you develop that confidence so that you can then manage down the tracks if you don't have your benzodiazepine on you and a lot of clients really don't want to be taking medication for the rest of their life either so you might tap into that motivation and you put it in your formulation as a safety behaviour and avoidant behaviour and help the client understand how in the short term maybe having some impact of obliterating the anxiety symptoms but in the long term undermining their coping self-efficacy so if we're working towards building that and at the same time they're carrying and taking their benzodiazepines then really we're working at very different goals and really there probably isn't much point with this approach so I guess just again handing over to the client to make that decision is building your coping self-efficacy something that you think is important to you or is it kind of continuing to use the benzodiazepines whenever you feel some anxiety and leave the question open for them to answer and if they're answering it actually I've tried this for a long time it's not working then that gives you the opportunity to really undermine the potential benefits of making that change and then I'd write that back into my letter to the GP that that's one of our therapeutic goals as to if not stop using immediately at least start reducing as part of the exposure program. What do you think Lisa? Yeah I think that with both this and the previous question about long counsellors I think something that hasn't quite been mentioned is the patient's right to know what the evidence is so that they can make an informed decision so there's a range of treatments available they have varying levels of evidence as to their likelihood to affect long-term improvements in function and I mean I assume when something's been prescribed that there's a reason why that particular combination might have been prescribed so I am careful when I was younger I probably wasn't that careful but now I'm more experienced and I understand that prescribing decisions can be complex but I do think that one of the important things is to share what the evidence tells us with the patient so that they then are in a better position to make an informed decision and many some patients won't like CBT or they won't want an antidepressant or they they won't want medication at all but at least they then can make an informed decision if they know what the evidence tells us. That's great and I think that conversation is really important I would suggest that maybe in the chat Deborah Fox has summed it up by saying it's team game, clapping hands emoji, well said Dr Caroline a collaborative approach is great which is really what everybody has said getting that collaboration not only between health professionals but with the patients themselves obviously and finding out as a GP getting some support in stopping something that I might not be totally happy with is a really good thing so you feel like you're not alone in that therapeutic relationship. I'm afraid we've come to the end of our question time now but this is the really important bit where we get each of our panellists to summarise a few final words about their approach to people with necrophobia so we'll go through the same order I think and start with Caroline thank you. I'll finish where I started which is remember the value of a continuous relationship with a GP so encouraging people to have that ongoing support if you're working in the community with a GP making sure they understand the advice you've given because the GP can really help you reinforce it because they will be seeing the other person over time and they can certainly also revisit it when there's relapses in the future so I think that's the main thing that collaboration and continuity. Right thank you 30 seconds now we'll go to Pete your final thoughts Look we've come a lot of ground today I think some of the take-homes to me are definitely that collaboration, definitely the client focus, definitely the importance of the comprehensive assessment and case formulation to really drive your treatment plan and using the approaches that are most effective and most efficient based on the evidence and helping to socialize the client to that as Lisa was just saying so that they can make a really informed decision and again just thinking my colleagues for the amazing work they do we're just one psychologists one cog in the wheel and all the work Caroline and her colleagues to really pave the way for us and Lisa and psychiatrists are so critical when we have complex cases to really provide that additional support and the multi-disciplinary team, Pete workers can also be really important in a lot of contexts but also again really focusing on the consumer's priorities and our roles to facilitate them to achieve that Right thank you that's what MHPN is all about the collaborative teamwork so fabulous Lisa your final thoughts Yeah look collaboration communication teamwork and then I'm going to echo something that Caroline said right at the beginning which was not giving up you know that would be one thing I would say with patients too you know I'm going to stick with you until we you know find a way through this thing I think and I think if if treatment doesn't seem to progressing I think a good therapist will try to work out why why is this patient not seem to be getting the benefit that we hoped and expected they would get so all those things and and sticking in there All right well everybody's been exceptionally concise which means I've got a couple of minutes and people are leaving from the chat group I can see but one thing we didn't touch on and it's one thing we agree to talk about before we started the webinar which is about the role of family and that you know for better or worse Stella does have two sisters who are in her life just wondering in a couple of minutes what sort of words would you say to her family in supporting her in being treated with agriphobia what can they do to try and sustain the messaging in the home Pete looks like you're ready or Lisa I'm happy to speak first at the point where Stella and I have worked through her and developed her individualised case formulation so she really understands what's maintaining her problems and also what's most likely to be helpful for modifying those problems and breaking the vicious cycles it'll be great to have a session or two with her family with Stella's consent and I'll chat to Stella before about the sort of things that we want to cover in that session and then I'll be asking Stella to articulate what she needs from them over time and how she wants them to respond when she's feeling anxious and when she's asking for reassurance or being very avoided so the critical thing is that Stella really understands what's maintaining it what needs to change and then she can ask for it in the way the family can understand and respond to and maybe even put down a plan and she'll write down that plan when I feel like this or when I'm doing this I would like you to do this to help support me so everyone's on the same page you've got that in writing and that can change over time absolutely but then the family have clear guidance a clear way of how to help the client the client is also asking for the sort of help that is unlikely to get there back up and then feeling angry and upset because that's not going to get anyone anywhere so that again collaboration because that's a collaboration and bringing the family into the room so that you can have that conversation with them the family may need some of their own individual support because sometimes it's very difficult caring for someone a loved one who's really going through a difficult time so that may be another suggestion that we might make right thanks Pete and you've actually picked up on a comment from Susan Camar which is about making the client their own therapist and recovering the idea of equipping which is stellar with the ability to use her family members to do things that help her just sound so important so I think that's a really good message and probably an excellent one for us to finish on number two daughter's done tacos tonight so finishing early is a bonus but thank you all very much for what you've said it's been absolutely fabulous tonight you've been so generous with your thoughts and I think the audience have really appreciated what you've had to say we do just have a few things to say so please don't leave before we talk about these few things which is about completing the exit survey which is really important getting the feedback we need from you so there is a banner above where we are at the moment or scan the QR code that will pop up at the end of the webinar the recordings available those of you who had trouble connecting or hearing or with the screen freezing there is a there will be a perfect recording online for you to watch in a couple of days and even to share with some of your colleagues if you want to have something to discuss the next webinar is coming up fabulous one tomorrow emerging minds navigating cultural differences culturally responsive practice supporting families so that's tomorrow at 7.15 and that will hopefully touch on a few of the questions we had tonight that I couldn't get to about cross-cultural difficulties and then Wednesday the 10th of April we have no I can't overcoming school refusal again with some fruity case studies there so and also there is a new webinar it's not on the slide you're looking at now which is about and again it's important for tonight supporting the mental health of a neurodivergent person with co-occurring autism and ADHD so that's Wednesday the 26th of June close to the winter solstice still forward to there before I close I'd like to acknowledge the lived experience of people and carers who have lived with mental illness in the past and those who continue to live with mental illness in the present so thank you to everyone for your participation this evening and have a good evening good night