 Well hello, here we are, just a little bit of getting connected but we are all good to go with tonight's webinar. Welcome to the approximately 1,400 people who have joined us and we have got very many more people who are watching with others and who will watch the recording I'm sure. So 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 cultures and hopes of Aboriginal and Torres Strait Island, Australia. So I'm Steve Trumbull, I'm Head of Medical Education at the University of Melbourne. I'm a GP by background but with a major interest in medical education which is why I'm here tonight. I do work in remote Aboriginal communities but probably not as much as I wish I could. We're obviously broadcasting during the pandemic, this is no longer a novelty, having webinars as a means of communication, it's no longer a novelty being online at home and particularly after hours. We're conscious that many of you will be distracted from tonight's discussion. If you have family issues and you need to leave then please be assured that the webinar is being recorded and you will be able to watch the recording afterwards so please don't feel stressed if you feel you have to leave us tonight. But we hope you can stay, we've got a wonderful case, a great topic and a great panel so let's get in and have a look. So here's the panel, I won't go through their details because you've had the chance to read about them online. So we'll skip people's bios and just introduce the speakers one by one. First of all is a GP like myself, Dr Caroline Johnson from Victoria. Hi Caroline, how are you? Good thanks Steve, hello. Now as a fellow GP I'm going to ask you, how is it that we know that somebody has seasonal or sorry seasonal or effective disorder, social anxiety disorder rather than just being a fancy label for shyness when that person walks through your door? Well it's really a great tragedy of social anxiety disorder that it often gets mixed up with shyness and that means that access to treatment is delayed. So it takes a little bit of picking out and you've got to be very careful that families or teachers or even sometimes other health professionals don't lead you astray because it really can be quite a disabling condition unlike shyness which is a personality trait that many people learn to live with without too much distress at all. Certainly the case we're looking at tonight, Anne-Marie's got lots going on somatically as well I think we'd have to say that it would be a misdiagnosis in her to case. So we'll talk about that and obviously far away. So also in Victoria like Caroline and I, Wes, it's Catherine Madigan and Catherine Neuropsychologist so welcome. Why is this form of anxiety in particular important to discuss? Well it certainly can have profound effects on people's lives if it's left undiagnosed or misdiagnosed or untreated. People are more likely to be depressed, more likely to be single and if you don't want to be single that's an issue. Sufferers are less likely to be employed, they have a lower overall level of academic attainment. You know they're more likely to drop out of school or university courses and obviously can affect their employment prospects and the kinds of jobs they might do so they'll avoid jobs with social interaction. Certainly not a trivial condition at all so that's why we're focusing on tonight, why I've got such a good turn up of participants and also to welcome Lisa, Lisa Lumpay, you're a psychiatrist up around Newcastle area and you were involved in the development of the College of Psychiatrists practice guidelines for the treatment of panic disorder, social anxiety disorder and also generalized anxiety disorder. Do you see those guidelines being used by practitioners in day to day clinical practice? Look I would hope so because one of the things that we deliberately did when we put together those guidelines to have a section up front which provides key facts in three pages and then academics or people that want to read the nitty gritty of all the references can read the body of the text further along but we really wanted to provide a user friendly summary right up front people can use in day to day practice. Fantastic well great to have that I just need to introduce people now to the webinar platform those of you who've been here before be familiar with it I wanted to put out a few features of it. First of all there's the chat box with the purple button there where you can talk to us through the chat so please make sure you're talking with each other looks like people are getting on board there and explaining where they're from and also some of the things that they're interested in particularly I'll try and keep an eye on that through the night and if things are popping up that you want the panel to address will certainly do that however you can also ask more formal questions when there's the question manager box there and we do have a couple of questions being asked already so we will be also covering often some of the questions that were submitted when you registered for the webinar so please if you have a question that you'd like to ask tonight pop it in the question box which is the blue button there slides and resources the slides that you'll be looking at tonight is available with the light blue button and also the cases there if you haven't had a chance to read it as yet there is a friendly help button which is always good news so click on that if you have anything that you're struggling with and you'll be connected to the conference providers there's also a phone number you can call which I won't read out now but I'll pop it in the chat at some stage so let's now get on with the webinar itself each panelist so we have a GP a psychologist a psychiatrist they will give a short presentation specific to their discipline relating to the case and then there'll be a period of questions and answers and the questions are coming from you the discussion don't know how many answers but discussion will be coming from the panelists so I also wanted to mention the learning objectives for tonight and we as a panel have to make sure that we help you achieve those learning outcomes I'll run through them very quickly the first is identify associations comorbidities and patterns treatment seeking behavior of people who are experiencing social anxiety disorder and already some questions about that have popped up in the question area we'll talk about tips and strategies that can assist someone who's experiencing the disorder and finally we really want to talk about the importance of collaboration and appropriate referrals within the mental health professional network to make sure that people experiencing social anxiety disorder are appropriately supported so that's what it's all about and your evaluation you complete the end will tell us whether we've achieved those outcomes or helped you achieve those outcomes throughout the webinar our first speaker is Caroline Johnson who's going to talk to us from the GP perspective as the case finishes up really Caroline we could see that it would be likely that Anne Marie might present to her doctor her husband David a placement husband has suggested she go along to the doctor for help because he's concerned she's more quiet and anxious than usual her husband's also worried about how much she's drinking lately so she makes a 15-minute appointment and arrives on either Monday morning or Friday afternoon how do you go about assisting her thanks Steve that's a pretty common scenario isn't it for a GP 15 minutes to try and sort out something if I'm lucky I already know Anne Marie pretty well and I know already that you know David's a policeman and Bethany and Joshua and I know them all and so I've got a little bit of background but often with anxiety disorders in general and mental health problems more broadly the real role of the GP is to engage the patient to give them a bit of confidence that actually this is something they can get help for because if they're already embarrassed or particularly if she's already socially anxious it might be quite difficult to even raise the problem so that's the first thing is the patient has to be on side the patient has to have a sense of hope and then you really even though you've only got a short period of time you really do have to tease it out a little bit more to be sure that you're on the right track with the diagnosis and so for my secondary and tertiary care colleagues I think you have to forgive the GP occasionally that they give a more generic diagnosis to the patient is anxious but of course we should be encouraging the GP to dig down a bit deeper and make sure that they're on exploring that a little bit more because obviously there's a lot of comorbidity you can have different types of anxiety or you can have anxiety depression together as everyone here would know well and then the third bit in that 15 minutes is really making sure the patient is safe so we're a webinar now called social anxiety disorder but when the person walks in the door I don't know you know could this patient actually be depressed could they even be suicidal the issue of drinking and the husband encouraging her to come in might actually be a hidden way of something else going on for example intimate partner violence so you can't really just jump to the conclusion that because someone says you're anxious that that's the only thing going on and of course one really important tool to help GPs to kind of do that in a quick and efficient way is to think about the you know the five P's so going more into the presenting problem find a bit more of a history about it go into what predisposing factors and there's a bit in this case study that kind of hints at things like you know she had a critical father and she likes you know hobbies that are you know she can do in isolation these kind of things are interesting but this is this formulation really helps us and particularly early on as a GP you should be looking at protective factors because they are often the things that will help you with the engagement when the going gets tough because to manage an anxiety disorder you often have to face something that's quite difficult to face so you need to be careful there that you've got some idea of the protective factors and you help the patient to bring them up. The next thing that inevitably moves on is the patient saying well I've heard I can get a mental health treatment plan and I must admit in a 15 minute appointment even if someone said they've heard they can see a psychologist I try and slow things down a bit there because I have a you know lots of psychologists I work with and I find some of them are experts in some areas rather than others and I personally find as a GP I get much better results if I match the patient with the right kind of therapist for their particular problem so for example I have some psychologist who are really strong at delivering high fidelity CBT and so if I've got someone who I really think is going to benefit from a traditional CBT intervention I'll send them along if I've got someone who I think there's more interpersonal problems I have different psychologists I use for that so the mental health treatment plan for me is really a tool for engagement so what I do at the end of the 15 minutes as I say to this person I can you know help you to get help but there's a little bit of things I'd like to you to think about I'd like to think what the goals are for you so is the goal really to deal with your social anxiety disorder or is it just to you know get your husband off your back or drink less alcohol because if you don't address the patient's goals you won't get very far and treatment dropout will be high I then ask the patient to think about those goals and write them down I give them an outcome measure in my practice I use the K10 but I think there are other ones you can use but for me it's just one that I know is sensitive to change over time so I get the patient to do that in their own time and bring it back I give them some online resources I'd like them to look at just to prime them to give them confidence that there's help out there and if a patient's ready to I often say look I'd love you to write down your life story just one or two pages even just in dot points just to get a sense of the longitudinal nature of this story you know were you anxious as a child because not all people with social anxiety have it going back to childhood because I do think that can help you with the narrative and the you know the engaging patient this next slide just shows you an example of some of the resources I'd ask a patient to look at so the head to health website which has you know well over 300 online resources for people with all kinds of problems but again it just normalizes it and tells the patient that there's stuff out there that they can read and sometimes that'll prompt the patient to ask other questions that they might not have been comfortable to ask the first time if the symptoms are mild and I've gotten on to the point where I think someone might have a specific diagnosis I'll also refer them to e-mental health interventions my experience in face-to-face practices a lot of patients are a bit reluctant to consider these but when patients like them they're absolutely brilliant they really do make a difference and there's lots of evidence to support their use for the right selected patient at the right time and particularly for my younger patients who are perhaps more IT literate they're really good whether that would be appropriate for Anne-Marie is debatable but I always think it's good to let people know that stuff's out there because they might dip in at a later date and then the last thing I want to talk about is this issue of the mental health review so this is really for all my psychologist colleagues out there I take the review of a mental health plan really seriously it's really frustrating when a patient rocks in six months later with another 15 minute appointment and says I just like another referral and I've heard nothing from the therapist about what's happened or what their formulation is or whether there's anything else in the plan that I could reinforce whereas when I've got a letter back saying the person's come and seen me five or six times four times whatever but this is the work we've done these are the things I'm focusing on that really enables me to use that review to really reinforce the right direction reinforce the protective factors reinforce that it's important to stick with the therapy because we know dealing with social anxiety disorder can be really difficult that's why people often avoid situations that make them feel so uncomfortable so again just to flag item two seven one two is just one step in that process of creating this process where eyes the GP will make sure the person keeps going with therapy or if they fail at that that they will keep coming back and try again in the future when they're ready well it is it's great if you can fit that much into your 15 minutes appointments that explains a lot it's interesting that Kirsty Edwards has asked the question about this that how do you do all that within the 15 minutes and obviously you do engage with the patient I think a lot of people think that they don't see general practice as the continuum or the longitudinal interaction that we always seek it to be and that you're not always starting from a standing start but it is frustrating as you said when you were seen as just a simple referral and there's a temptation there for some GPs to just make it a simple referral rather than engaging so you've obviously got to know Anne-Marie you know that are in a situation you've done your research and you know that really the best possible psychiatrist you've got sorry psychologist you can think of to write the mental health treatment plan two is Catherine so you refer Anne-Marie to Catherine now Catherine what are you going to do when Anne-Marie comes through your door for the first time right okay well I suppose we want her to feel comfortable and obviously we want to get a history but I suppose it's about sort of over asking opening questions and trying to get her to speak so maybe we're not going to get the whole history in the first session but you know like take a couple of sessions to get all the background anyway I like to give people some questionnaires to take home after the first session so I've listed those there so the label we investigate the different social and performance scenarios and their degree of anxiety and avoidance I use David Clark's questionnaire so that will give you a good idea of their safety behaviors negative thoughts they experience in social interactions and how they feel about themselves obviously we need to assess how depressed she is and if there's any risk we need to get an idea of her alcohol intake and whether she's self-medicating quite often these people have some level of perfectionism so it's good to have a look at that and you know check for other conditions such as OCG, CAD and whether they've got any point in these issues so we're going to work with Anne-Marie to come up with a formulation of the factors that are maintaining her social anxiety so obviously a major factor is the avoidance of social interaction and you know she mentions that you know she's done repeated exposure and it gets any better but people don't realise they're engaging in safety behaviours so one of hers obviously is drinking so she's not really going to get the benefit out of you know her exposure if she keeps using alcohol as a crutch for example we also need to get her doing some attention training so that could be another reason why she hasn't improved so people with social anxiety are quite self-focused and they need to do attention training in order to learn how to focus externally. I wouldn't be surprised if she's a bit of a perfectionist so it could be that after a social event she's criticising herself focusing on what didn't go well rather than patting herself on the back so you know the things that she did well so stopping that post-event post-mortem is important and trying to get across the idea to her that it's not about being perfect and it's so okay to make mistakes stuff I forget people's names you know the important things to get there and interact with people. If people are as severely anxious which she tends to be I like to spend most of the sessions actually getting out there and doing some exposure work so I find the easy part is getting people to read manuals or do some of the online programs that Caroline suggested yeah I think people can do the reading but actually pushing them to go out and put the material into practice is the hard part so we might go cafes going to shops and ask questions about products and services. I also encourage people to get involved in support groups so in Victoria we're lucky that there's quite a few not-for-profit support groups and that gives people a supportive place to practice what they're learning in sessions. Group therapy may also be a really good option for people and the opportunity for people to get video feedback and we can encourage people to get involved in hobby and community groups. I find that there's a lot of good on CBT manuals on social anxiety and related topics such as self-esteem, perfectionism and self-compassion. If people have just gotten mild social anxiety I generally encourage them to start off just doing the CBT. If their anxieties may be moderate and they're still finding things a bit difficult maybe they would get any depressants from the GP but if they're very severely depressed and extremely anxious well then I'd certainly be considering going back to GP for some occasion if they're open to that and I think we've only got 10 sessions under a mental health care plan so although people can achieve a lot in 10 sessions if someone is depressed and you know they're not motivated you know it's certainly going to hamper their progress so that needs to be kept in mind and sometimes people will possess the treatment and they're fearful of job interviews and they've got one the next day or they're going to have to give a winning speech in a week so if we have goals that can't be met in such a short time on a frame you know I might refer someone over back to the GP for beta blockers because you know there's not going to be time to address the issues. I must say Catherine you've taken me back to first year medicine in 1979 when beta blockers have just been invented and one of my colleagues took one before and that's me Oral and had to do it all from the reclining position because it's blood pressure dropped but I think what you're suggesting there is that there might be some short-term win and it sounds to me like Amary's using alcohol as her own self-medication there's been questions asked about when you would focus on the alcohol use or the social anxiety disorder in your approach first of all a whole lot of things you could do I suppose in deciding what to do but it sounds like you're in good communication with the referring GP you've referred back to Caroline Caroline's had another assessment and then thought that really the involvement of a psychiatrist would be appropriate at this stage again she has her network of psychiatrists who she uses for different referral reasons we don't refer to specialists we consult with specialists so it's not a sending away it's a team effort and in this situation Caroline seen that least is the most appropriate person to work with as part of the team for the treatment of Anne-Marie so Lisa it's good to have you we have acknowledged that your internet's a little bit wobbly where you are so if we lose you we lose you but we've got you for now and you've got Anne-Marie so what are you going to do as priority one thanks well my best priority is always to clarify the diagnosis and when I'm you know teaching the medical students I always say you know keep them open mind start from scratch and do your own so GP give you a variable amount of referral information you know ranging from I've had a chat from the GP on the phone to you know thanks for seeing this patient they'll tell you what the problem is so it's important to start from scratch so I want to have in my own mind a hypothesis about why this patient developed this problem at this time and I think patients generally want to know that as well so being a psychiatrist I do like to look at the possible antecedents of the problem and the interesting thing about anxiety is there's a very strong genetic vulnerability to anxiety whereas depression is much more environmentally influenced in large measure we inherit an anxiety prone temperament in the family so that's often one of the biggest factors in why the patient get anxiety but there may well be other experiences they've had I also need that to help decide on the most appropriate treatment and we've heard about the importance of formulation I'll certainly echo that because that really is your treatment roadmap based on your diagnostic and treatment formulation important for me to identify comorbidities and again we've heard about the possibility that there might be a comorbid depression that's very important to identify and with Anne Marie we think there may be a hint of an obstetric and public personality style we want to know about that too because it's going to have a bearing on how Anne Marie engages with therapy and with therapists because perfectionism as we've heard could really interfere with treatment because you don't need to be perfect you just need to be good enough to get by and similarly that applied in social situations and I don't want to miss a disorder that better explains the presenting symptoms and perhaps I'll just mention it can be sometimes difficult to distinguish between is this primarily a depression that has made the person very anxious or is it a primary anxiety disorder that has made the person rather depressed and to me the history that's most important while not all anxiety disorders come on in the teens most of them are preceded by being anxious persons who particularly with social anxiety was quite shy maybe always lacking in confidence as it's quite evident from this story whereas with somebody whose anxiety social anxiety is secondary to a depression I'm much more likely to hear a story like I don't quite know what come over me I'm just not myself I don't normally worry about things but over the past weeks or months things sort of happen so I think it can be quite helpful to keep those things out so in this case as I mentioned I want to be clear about personality style and major depression it's always important to bear in mind that people may have a history of complex trauma which can really complicate therapy and also recovery and clearly we've got some issues around alcohol use in this case as well and the next thing for me is the treatment focus formulation developing a model that I share with the patient to explain why the treatment didn't occur in the first place and perhaps even more importantly given that all of us have anxiety from time to time why in amary's case did this become a disorder why has it kept going and there's an intriguing reference in here case history to the even though she pushes herself to confront social situations it actually seems to be getting worse rather than better but we really want to try and tease out what are the reinforcements for her anxiety so why her symptoms have persisted and it's very important to take account of behavioral responses how do the important people in her life respond to her anxiety what's going on in her environment that might be contributing to the future and I guess in addition to protective factors I think it's really important to identify potential barriers to treatment up front so that you and the patient can work together to try to think about how you're going to address those barriers so we want to share that formulation get the patient important and ask her to share it with important others in her life do they agree what else would they add to that model and then the provision of psychoeducation which is often very well done in general practice and because amary was seen a psychologist who said she will also have had very good quality psychoeducation but I do like to introduce them to the flight or flight model they haven't heard about that before what is social anxiety disorder what causes it what do you need to do to get over it and then really got treatment evidence based treatment options in detail and what CBT what should it look like if you're really getting CBT that show fidelity to what the evidence says work and what about pharmacopsy therapeutic options and really my rule of thumb and in the deco by the clinical practice guideline is if a patient needs medication for more than a few days then it should be an antidepressant so there's a very limited role for bentadazipine and really with beta blockers I would also exercise great caution in using them because they could easily start to be used in a kind of PRN basis and the evidence is very clear that generalized social anxiety disorder beta blockers are not better than placebo I think that there's a tendency for them to be overused sometimes in both special and primary care I'd say and of course it's up to the patient in terms of treatment they prefer and I'll just finish with a couple of diagrams that are actually taken from the clinical guidelines for anxiety and they they take account what typically happens in general practice and GPs do a magnificent job because people walk in the door with some mixture of physical, psychological and probably social and cultural problems and GPs have to kind of work out is this something that's going to get better by itself it's something I need to intervene for so our guidelines recommend obviously a good assessment but then a kind of watchful waiting and give the patient psychoeducation some general advice not to avoid things things don't get better let's have another look at so if symptoms have been or gotten worse then let's look at an initial treatment and basically we recommend that that chosen based on severity of the presenting symptoms so we recommend cognitive behaviour therapy at first line treatment for mild symptoms and by mild we mean symptoms that perhaps are not overly impairing or distressing the moderate level of social anxiety then in fact there's a choice that can be done patient so we recommend mono therapy is usually enough DBT or medication but you could use both if you wanted and as we've heard when it's more severe or when there's a comorbid depression then we would want to combine those two treatments so I guess those are the sorts of things I've been looking at wonderful thank you so much Lisa there were some issues with your microphone so we managed to string the things together we've understood what you said and the the staff are going to talk to you about how we might be able to improve that okay but there are so many questions and I guess we'll focus on Caroline and Catherine first of all people have been asking about what about earlier now we have Anne Marie at 47 what about when she was back at school and the case we've seen a whole lot of things about having a very strict parent being anxious school not feeling comfortable being very sensitive to criticism which seemed to come her way could anything have been done then do you think Caroline or particularly Catherine well we know from research that I think 40 percent of cases start before the age of 10 and I think it's 90 percent of people would start experiencing it before the age of 18 or 31 so certainly if people find that their child is being a bit you know I suppose you know selective mutism not reporting not having friends to play with at school perhaps being hesitant to raise their hand in class you know being anxious about shell and tell you know you would think that the primary teachers would be observing these things and you'd hope that they'd be feeding that back to Karen and I suppose teachers sort of know what's an average performance at school so you would hope that the teacher might refer to the school psychologist or perhaps have a word to the parents about you know whether they think the child needs some assistance and Catherine are there any other therapy types that could be used to backstage rather than going straight to CBT is there anything else that might work well in an adolescent perhaps sorry on an adolescent well yeah when we're talking about here with Anne Marie we've talked about CBT we've talked about medication people are asking questions about maybe other sorts of psychological interventions that might be evidence-based but still useful at this stage if we're still back in the early the early days well I supposing in childhood you know there are good storybook parents can read to children that might be sort of fostering ideas you know consistent with the CBT approach but you know through certain storybooks um there's a psychologist John Maloof at the University of Armadale and he had a shy child and he's actually put resources on the internet so if you type in John Maloof M-A-L-O-U-S shy children he talks about all the things that he did with his young daughter so people might find that helpful we thought okay Caroline can I chip in there Steve yes sure Caroline what did you want to say oh just I think that um one of the great things about being in general practices you often um see parents interacting with their children when they come in for all kinds of things like immunizations or when they've got coughs and colds and it is an opportunity to observe and notice like if you've got a very strict parent or someone who's very harsh and you can sometimes try and role model and say oh you know that's interesting how you cope that way and sometimes you can make some little you know hints to get under people's skin to sort of think about the way they do it and I think this is where um certainly early childhood teachers or kindergarten teachers and these things are really important and I've been very impressed with the kindergarten teachers I know that they often do teach sort of cognitive and behavioral strategies from a very early age and so getting parents to talk about those things things they've noticed that help reduce um stress and worry for children in general I think can really help and that just normalizes the conversation so that then if a child does seem to be more than shy and be unduly anxious or avoiding things it just makes it much easier for people to talk about getting help rather than kind of making it too much of a medical problem I think that's really important because I think it scares parents away if they think their child's got a problem and they're going to end up on some sort of merry-go-round of of medicalization and even medication it's really important to reassure people that there are lots of things that can be done before you get to that point absolutely and this takes us back to the very beginning I guess when we talked about the risk of um medicalizing what might just be shyness it's clearly not in this case lots of questions being asked about other diagnoses and even in the questions that were submitted before the webinar questions about what about autism spectrum disorder high function autism avoidant personality post trauma generalized anxiety disorder Lisa you are putting up a valiant effort by holding a phone to your ear for the next 45 minutes or so we better give you a chance to talk what do you think about the diagnosis is there a risk of us missing some of those other conditions at this stage well I think that's really the reason for a very careful assessment particularly in someone who's not responding the way you've expected them to so I think you know up to now all the steps have been absolutely right we've made the diagnosis of social anxiety disorder GP's referred for a psychologist but let's say you know a patient doesn't seem to be making much progress or whatever and maybe that's when we want to just go back and let's just have another look at things and are we missing something something else certainly with high functioning autism you you can get some social anxiety but normally you will pick up that there is a misreading of social cues and that the person doesn't interact it's not a pure anxiety that's happening in the interaction and there may be some distress around things going wrong but when you explore it it's more around misreading cues and people with social anxiety are generally acutely aware of social cues and if anything they they tend to err on the side of interpreting them as being critical and they're often hyper sensitive to the the needs of others so in practice I don't I think you can tease those apart reasonably well it can be harder to tease out avoidant personality disorder because they can of course coexist and the way I think about it is the person who just has a social anxiety disorder says look if only I could get over my social anxiety problem people would see that I have a lot to offer whereas the person with avoidant personality disorder almost has the reverse problem they actually worry that if they got to know people better then people would see that deep down they don't have anything to offer they're somehow inferior or worthless so they have a often crippling low sense of self-esteem which which is as a therapist it you know your counter-transferences it makes you just terribly sad because you see this really interesting worthwhile very nice person who just has an absolute rock bottom self-esteem and it's their intense fear of rejection that's contributing to their social anxiety so they're going to need much longer term therapy 10 sessions of CBT is unlikely to to cut it for them in terms of trauma again it's unlikely to be just a post-traumatic stress disorder but it may well be excuse me now my voice is going let alone the technology it may well be that this person has a history of complex trauma which is really complicating the picture and I think that is something that we need to be alert forward generally thanks for that and clearly a lot of the questions we had before the webinar were about the impact of this COVID pandemic on people with social anxiety disorder this must be hellishly difficult do any of you want to talk about what you see or what you're seeing at the moment in your practices about people who may have the disorder they're also trying to cope with the impacts of the COVID pandemic which may actually not be all bad but there's a return to society at some stage I suppose does anybody have any comments about that yeah well I can comment on that I've certainly found that people are reporting sort of relapsing and going backwards because they're losing confidence and obviously many people are not going to university or school single people may be living alone they're not having that interaction of work so a lot of people are finding that's very difficult and I think how people are that scared to go out now are only going to the supermarket maybe once a week so I've been encouraging people to try to get out every day go to the supermarket get a takeaway coffee get some takeaway food and just try to have little interactions that are available in terms of you know talking to your shop assistant then the risk is because that's a battle you can do at this point maybe catch up if you've got a friend that lives locally and go for a walk there's not that many avenues that people have learned maybe talk to people on zoom like this works well what about what about you Caroline what do you want to offer I just think it's interesting I've seen some people with social anxiety disorder who think the pandemic is great because they don't have to face their anxiety but I certainly spoke to someone just today who you know really his therapy stall because he can't really do the behavioral experiments that he'd been set up to do by his psychologist and so he's not ready to engage the other thing I find really interesting is some people really want face to face even though you give them the option of video or telephone I mean I'm not so keen on telephone I much prefer video but I kind of assume that patients with social anxiety would prefer telephone to video but interestingly some of them actually said no I really want to come in face to face so we've had to kind of deal with how to do that safely because obviously having people in your room for longer periods of time the height of the pandemic has risks but I think it's just a case by case everybody's a bit different about how they deal with that thanks for that and before you go what about the question from Belinda Mitten Connell who was asking about okay what if you had somebody who you made the diagnosis would you be confident to write on a Centrelink form that they don't have to attend work interviews and things like that are you confident enough in the diagnosis of social anxiety disorder that you could make a statement on a legal document? The answer is it depends but yes I think GPs are well trained to make diagnoses of psychiatric illnesses if we're going down that path but I think one of the problems is as GPs we're often not allowed to on Centrelink do certain things and there's a real problem in the way Centrelink interacts with GPs but I think there are many patients who I think I feel comfortable and the point of having psychologists and psychiatric colleagues is they're the people I refer to when the diagnosis isn't clear but in some cases it's very clear I have whole families of people with social anxiety I treat because it's such a you know strongly genetically inherited condition so I meet one family member and then over a course of maybe three or four or five years I eventually meet other family members who also have social anxiety disorder and I think it's pretty straightforward then to make the diagnosis and I would feel very comfortable in those situations but my framing of it is always is it good for someone to avoid something because they've got social anxiety disorder can we work around and actually help them to not need to avoid things because that's one of the problems with the whole notion of disability that you know sometimes you use as excuse not to challenge yourself to move on and that really means you have to have a very good relationship and be very well well engaged with a patient so they trust you enough to push them out of their comfort zone and that's where Centrelink often doesn't help because Centrelink's often very black and white about either your fit or your not fit which is really not helpful for people who are struggling with trying to you know get a return of function from an anxiety disorder. Any other comments from the panelists? About COVID Steve or? Well yeah about COVID or yeah in particular? Oh look I mean I'd echo what Carolyn said we've seen people where it probably meant that they've engaged with therapy when they might not have otherwise so I think for some people with social anxiety beginnings therapy it removed a lot of the anxiety about actually getting out and coming to appointments and we've had some quite enthusiastic uptake of Kelly Health but then again as Catherine said I think and in fact Carolyn's well then when it comes time to now it's important to go out and start doing your exposure it has created some challenges at that stage but I think at least in social anxiety I think overall it hasn't been entirely a bad thing in terms of us being able to engage people in therapy. Okay thanks and also while I've got two people have been asking about why this might be emerging in Ann Marie at this stage she's 47 this is obviously going on for some time is there anything you can think of that might be triggering for her or the bringing it out? Look I'd just say that it's not emerging now it's something that she's accommodated I think for a long time in her life if you actually read her her history there's lots of things that she hasn't done right through her life because of her social anxiety so she's really been impaired I mean I think her social anxiety has stopped her living the life she might have liked to have lived it may be that she's now become the fact that she's become depressed on top of it or maybe she's just become demoralised because you know like maybe her husband's been doing more social functions so she's been pushing herself more I mean I can't imagine how dispiriting it must be to force yourself to go out and confront situations and find that not only are you not getting better but you seem to be getting worse and I think you know Catherine's people might not realise it but a lot of what Catherine spoke about identifies some of the reasoning for that which is you know when people go home and just play over and over in their mind how how much of a fool they made of themselves then you can understand why instead of having an experience of mastery people get an experience of failure because of of the message they're getting themselves so I think we frequently see exacerbations but what we do know about social anxiety disorder it is it is a chronic disorder of all the anxiety disorders it is one of the least likely to undergo spontaneous remission but it can certainly have periods of relative exacerbation or you know or becoming a bit less less severe thanks later and a few people have been asking about menopause Caroline would you do a workup on Amory at this stage? Yeah so I was just going to throw in there I certainly I certainly think one of the things I find helpful as a GP is to always ask why is this person in the room right now and in my experience periods of transition are common times that people present more with symptoms so in Amory's case that could be just a role transition issue like you know if your children are leaving home and you suddenly do you know your husband's thinking we're going to have more social engagements now and you're not going to be as busy raising the family therefore you know that might be a reason for you know change role transition but then there's also the biological changes that happen in the perimenopause and I certainly find it's very and I personally think it's because at that time your estrogen levels might be dropping you might be getting a regular menstrual cycle you might be getting more aches and pains because of estrogen deficient there's all these biological changes happening in your body and so insomnia for example is really common around the perimenopause 47 I think is a little bit young for that but certainly some women do start experiencing perimenopausal symptoms from their early 40 so I always ask a few questions about that and then I also make sure that we're not missing any other physical causes in my 20 year career I've met a few people who I thought had well established social anxiety disorder who actually had also developed thyrotoxicosis it's not common but it's really embarrassing if you miss other common ones would be making sure someone doesn't have an organic thing like anemia or thyrotoxicosis with regard to perimenopause I don't tend to do a whole lot of tests I rely on the history so if a person's getting irregular periods hot flushes insomnia then I think well that could be an element but I don't think blood tests are actually all that helpful because really your hormone levels depend on the day you do the test and I know a lot of people do push for that but I actually don't think it's that clinically useful it's the history that's more important okay great thanks for that any other comments from the from the group um yeah Lisa here I would just add that um what we know about social anxiety I mean the thing that's always been fascinating to me is obviously you can have a range of symptoms when you get highly anxious from you know from head to toe um but there are patterns in what symptoms bother people the most and in social anxiety it's the symptoms that are most visible to other people so typically sweating shaking and blushing and if you think about menopause menopausal symptoms include flushing um sweating so it you could understand why you might get an exacerbation um around the perimenopause because those sort of symptoms um might spell anxiety to other people um in that person's mind so you know that could be another reason why um it could you could see an exacerbation thanks for that now Carol I'm going to put you on the spot a little bit you're practicing in the leafy green suburbs of Melbourne but there are others who are obviously working in areas without such a supply of therapists as there might be in a city the size of Melbourne or the other capitals I was wondering what the people what the teams think about referring to other people in your area who might not be of a particular disciplinary background but who you know have either lived experience or some other skill sets such as therapy or something that might actually be part of the solution for somebody has anybody had any experience working with other people they know would have a particular benefit for a client well I certainly have not so much though for social anxiety disorder so I certainly have people with more complex mental health conditions who I use the peer workforce which is an emerging workforce but probably more in the group of patients who have more complex mental health issues and I certainly think they're not widely accessible unfortunately but I also work a lot with mental health social workers occupational therapists mental health nurses they all become part of the landscape but if we're sticking to the topic of social anxiety disorder if someone hasn't had an evidence-based treatment for the condition that I've diagnosed them I try and make sure they've at least had that with the understanding that if you have that like if you have say CBT for this with exposure therapy and it doesn't work then I'd start thinking a bit more creatively of have I missed something or is this more complex and needs a broader group the problem for patients is it's expensive so while a lot of GPs will bulk build patients with mental health problems many of our colleagues won't and that's fine that's a understandable you know it's a it's a decision to you know if you're making a living but if you say to a patient well he's three or four other people you could see most patients will balk at the cost and that's very hard for us in general practice to actually access affordable even in the leaf eastern suburbs when you say to someone that you know you might have to spend a hundred dollars out of pocket to see a psychologist for you know up to 10 visits that's quite a big imposition I would argue that it's a great investment but you have to get people to balance that especially if you're asking them to do something that makes them feel uncomfortable like deal with social anxiety yep no fair comment any other comments from the group before we move on to another question one thing I think quite often when people have young children they can use the children there's a bit of a barrier between them and the world and the children can sort of engage in some of the social interaction and then I mean the children get older and aren't available it's lost you know a major source of company um well it's interesting in Anne-Marie's case of course her children were also her major source of friends through the school and she's obviously lost that connection as well so she's pretty lonely in her in her house isn't she alcohol it's not a suggestion this is the whole thing obviously that alcohol has taken on such a prominence at the moment what do people think about alcohol in somebody with social anxiety disorder is it seen it's used seen more frequently is that chicken or egg what what does the panel think well that is the most likely substance to be abused because alcohol is so socially acceptable if you go along to a social gathering or situation where people are having a drink you can have a drink too it is anxiolytic at least to start with and it's going to look quite normal to to kind of have that drink and so of course and people can start to rely on it so it is interesting that you do find in groups such as Alcoholics Anonymous you have quite often quite high rates of social anxiety disorder in amongst those groups so it it does seem to be a substance that probably is more likely to be used in in problematic ways than say other substances for example most anxious patients don't go around using stimulants at all so we don't see many problems with that but alcohol and if they've been prescribed bento daisopens in some type of prn way then that can become a problem as well which is again why as a general rule we don't like medication use prn for anxiety and because then when people cope with the situation they haven't really mastered it they attribute it to the medication and they're not going to get any sort of extinction of their fear so and alcohol is going to work that way as well thanks for that Catherine back to you a number of people are asking about attention training I must say I'm intrigued by it as well what does that actually involve and how does it help people with social anxiety disorder right all these people go on to YouTube and if you type in attention training you can find a couple of tracks by somebody called Joel Dames D-A-M-E-F and you can also find I think it's the psychologist Adrian Wells talking about attention training and yeah there's quite a lot of information that you can get even on YouTube but perhaps if we explain why attention training because we know that in social anxiety people are too self-focused as as Catherine mentioned before so their attention is often on themselves and constructing a picture in their own minds of how other people are probably seeing them so it's no wonder that that becomes it becomes very hard to maintain a conversation when at the same time you're trying to imagine how you're coming across to other people so part of that attention training is about training people to keep their attention focused externally would that be a fair comment Catherine yeah and I think when people are very self-focused they're so busy trapped in their head worrying about what other people are thinking and paying attention to their anxiety symptoms but I can't actually take on board that perhaps the other person is responding favorably to them so they're then missing out on some social cues that might correct their sort of negative beliefs and assumptions because they're just too tapped into their worries and their physical symptoms. There's quite a few attention training tracks that go for maybe five or ten minutes and you get your client to do maybe ten minutes twice a day I think it's been recommended that they do it maybe for two months and then that gets them much better at listening to other people and if you're intently listening and focusing well that's diverting you from paying attention to your physical symptoms then you need to know what. And I was going to add there's some interesting research that shows that even that one piece of advice to keep their attention focused externally rather than internally has been shown to be very beneficial in terms of overcoming their social anxiety. Sounds fabulous can we do in the last five minutes before we we sum up I just was wondering if we could talk about specific groups about maybe people from different cultures and linguistic backgrounds any thoughts about how have any of you worked with people from different groups like that and if has it changed your approach at all have you observed anything specific I guess. Well you know you need to you need to find out what they're aiming for so what is culturally appropriate interaction that that person is actually you know what are their goals. So I think that's that's the first thing we have to be careful about making assumptions that you know as to what we're aiming for I guess with any treatment or what what the person sees as the problem because obviously there are different cultural norms in terms of different styles of social interaction so that would be and I'd just be I'd explore that with the patient which is something we're doing anyway you know what what is this person's what are their goals. Okay and older people as well anything specific that any of you do with older older people with this condition beyond 47 obviously into the 70s or 80s. Well I generally find that the average age of people that come in is about 30 and that tends to be the age at which people sort of tend to surface for treatment I find it pretty rare that people say 60 or 70 would come in. Yeah I would find it rare for people to surface that 50 I don't get that many they mainly tend to be sort of in that late 20s 30s sort of bracket. And in fact it should raise suspicion that depression is really the primary disorder. It's extremely rare for people to present with our first presentation of anxiety in that older age group but I agree with Catherine I think even really an older person it is unusual for us to see them presenting for treatment for social anxiety for the first time so a loss of confidence a kind of anxiety around people are we missing a depression here. Okay what about the people around Ann Marie and people like her do you have any thoughts about supports for the partners of people with social anxiety disorder or the children of a of a person or the parents of a child or a teenager. Well if it sounds awful but I think it's one of these things we have to be a bit cruel to be kind. One of my brothers he was I don't know if you'd say it's socially anxious but certainly a shy child and I remember when he was maybe kinder or prep my father would not buy he many lollies the milk bar and if he wanted a freddo frog my father would hand him the money and say well if you want it you're going to have to buy yourself so you know he got a lot to do he had a lot of freddo frogs and once he could get that freddo at the milk bar then it was taken up a notch and look my father was not a psychologically minded person so it was just pure exposure and freddo frogs and 20 cent pieces and years later my brother became a politician so you know it goes to show you that if you push you may still be a bit shy but if you get that wish you will succeed but people have to encourage you and you know quite strongly push you out of your comfort zone. I'm sorry Catherine that was a joke and I was going to make and I thought that I wouldn't make it but it's actually true I hope he hasn't got diabetes from all those chocolate frogs as well but great story let's now just start moving towards we finished at 8.30 10 minutes to go on this side of the continent I'm just wondering Caroline what do you see is the future for Amory when she comes back to you after having spent time with Catherine and with Lisa and maybe with other peer supports other therapists social work whatever it might be that you're able to find for her do you think she's got a positive way forward? Look I certainly think she's got a much more positive way forward by having sought help but I don't think it's always a quick fix I do find many of these patients come back and say it was too difficult and that's certainly when we have a conversation about medication the good news is I find the patients who are still engaged and are willing to try do respond very well to SSRIs in this situation and sometimes that's the extra step that enables them to re-engage with the therapy that they found too difficult. I don't want to paint that that's what always happens but certainly I think when you're dealing with someone who's older who's had the symptoms for a very long time that can be difficult and then there's always the tension of how much you go into the background of the hypercritical father I could see some questions coming through in the question manager of you know how much of this is dealing with the here and now and the symptoms you've got now versus opening up that can of worms about your background and again some people find one pathway more helpful than the others and therefore sometimes you have to switch therapists midstream you know if they've reached closure with one type of therapy then you have to say well is this something you'd like to explore more and that that is tricky in general practice because again it means a bigger commitment of time and more cost for the patient and there's not always certainty about how much extra benefit they'll get from doing those things and so sometimes people then say well it's easier just to retreat back into my old way of doing things which is to stay more at home and to go out on social engagements less so you really need you need that impetus of I need to change there's something has to be something else in the patient's life that pushes them yeah it's such an important principle not to stick with the one the one treatment but to to change it's appropriate absolutely sorry so who was that that was there's a good story on the internet about the psychologist Albert Ellis so if you google Albert Ellis and dating anxiety when he was 18 or 19 he was cripplingly anxious around women and he also feared public speaking and he fixed both of these social phobias in the space of two months but if you read the story about how much effort he put into it he took 120 women in a month and when I see people I like to show them this article about Albert Ellis because I say you know this man was extremely anxious but look at how hard he worked to get over it so he got a fantastic result in two months but you know I say to people will it be spoke to 120 women in a month when he was fit you full of chatting to women you know that shows you his commitment to getting out of his comfort zone so you know I try to encourage people it's not that you can't do it but how hard are we going to work to get that result and he made that fantastic progress decades ago when we didn't know as much about social anxiety as we do now all he knew was that he had to expose himself to his fears that's all he knew he didn't have the health of the psychologist there weren't all these resources he didn't do any attention training all he knew was he'd have to go and talk to women but he did also he was actually a big fan of stoic philosophy so he also had that philosophy that um it's the way you think about things that make them problematic so he actually combined exposure and thinking I'm going to be lying awake tonight thinking 120 people that's exhausting that's that's not exhausting but it's interesting how amazing it is so that's beautifully a lot of these principles have very ancient roots don't they into solid thinking and philosophy what about you Lisa anything you wanted to finish up on before we we wrap up for the evening and then back to Catherine look it's a very treatable disorder but it's quite a complex disorder because and I think all those little aspects of cognitive training like attention refocusing and not doing what we call post-event processing are terribly important and the reason is this if you have a panic disorder with agriphobia your fear is typically that you're going to have a panic attack and you know drop dead or have a stroke or something so if you can persuade people to you know drive across the harbour bridge or catch an express train or whatever it might be and they arrive alive at the other side then it's clear that their their feared outcome hasn't happened but you see social anxiety social situations are so much more ambiguous we never know for sure what people are thinking so there has to be this I think extra layer of work at deciding that embarrassing yourself is just not the worst thing that can happen to you and you know not being so focused on yourself being prepared to be sort of good enough so I think for a good going social anxiety disorder you probably do need quite sophisticated psychological help to get over it I think and but that is such a good investment because the other thing we know about CBT in particular is that the effects last once you kind of get better you can stay better so I really encourage people to engage in CBT wonderful well thank you all so much for tonight you've really given us a lot to think about the chat box has been vibrant I think it's probably a good way to put it lots of questions we didn't get to but I think we've got two bits and pieces of most of them and hopefully people feel that we've achieved something tonight from the conversation I've certainly learned a massive amount we're now just going to do the wrap up one thing we really do look for and please do complete the exit survey give some feedback on what's been useful tonight there's a survey icon at the top of the screen the top right of the screen click on that very quick survey to fill out or otherwise it'll pop up when we finish the next webinar is going to be held in September I'm sorry no this Wednesday this one coming primary care of course older persons and mental health so please if you can attend the one this Wednesday and then a really important one again the 22nd of September all his topics are just fantastic treating mental health professionals which is one of the great challenges so treating mental health professionals 22nd of September I just wanted to remind you that mental health professional network supports the engagement and ongoing maintenance of practitioner networks where clinicians from different disciplines meet regularly with other mental health practitioners to share tips and resources build local referral pathways and engage in cpd activities like this so due to the current environment most mhpn networks have been postponed although some are organizing zoom meetings so please contact your local coordinator or the central mhpn office so to learn more about joining your local practitioner network and special interest groups contact mhpn or go to the news section of the website you can also indicate your interest in the exit survey which if you haven't pushed that button please push the button or it will pop up at the end so before I close I would like to acknowledge the lived experience of people many of human with us tonight who have lived with mental illness in the past and who continuously with mental illness in the present thank you all the people online thank you to Catherine and Caroline and Lisa for speaking with us this evening and to everybody for participating we now have time to go in the lax with family hopefully all friends ought to have a chat and look after each other stay well and thank you all good night