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Bruce Fage: [00:00:13] Welcome to PsychED, the Educational Psychiatry Podcast by medical learners for medical learners. If you're returning listener, welcome back. If it's your first time, thanks for checking us out. Today's episode is on Generalised Anxiety Disorder and specifically in part one diagnosis of generalised anxiety disorder. Your host today are Dr. Jordan Bawks, a second year psychiatry resident and myself, Dr. Bruce Fage, a fourth year psychiatry resident at the University of Toronto. We are joined by Dr. Jared Peck, head of ambulatory psychiatric care at Mount Sinai Hospital and assistant professor at the University of Toronto. He's a local expert in cognitive behavioural therapy and a bike safety enthusiast. Dr. Peck was my first outpatient supervisor in PGY two. We worked together for about two months and I learned a lot from working with him. It's great to see you again and to be back at Mount Sinai. Dr. Peck, why don't you start us off by telling us a little bit about yourself?
Dr. Jared Peck: [00:01:08] Thanks, Bruce, and thanks, Jordan, for inviting me to take part in this. It's great that you guys are doing this initiative and happy to help out. I've been working as a staff psychiatrist since 2009 here at Sinai. I enjoy the work. I see a lot of patients with anxiety, depression, as well as psychosis and bipolar disorder. But there tends to be a lot of anxiety that comes through the clinic here. And so I do a lot of my clinical work in that area. As you mentioned. I do cognitive behavioural therapy and I'm a little bit anxious myself. I don't always appear that way, but I can relate to some of what people go through with anxiety disorders. So yeah, that's a little bit about me. I can tell you a lot more about me in a non-professional context, but we'll we'll stick to that.
Bruce Fage: [00:02:03] Well, we appreciate you being here despite your own anxiety. So thanks. And we're happy to work through that. We're going to talk a little bit about the objectives for this episode. So by the end of this episode, you should be able to diagnose and recognise the clinical features of Generalised Anxiety disorder using DSM-5 criteria and appreciate the differential diagnosis and how to conduct assessments to help inform your clinical diagnosis. Dr. Peck, knowing that we may have some non-medical listeners, can you give us a plain language summary of generalised Anxiety disorder to set the frame for today's podcast?
Dr. Jared Peck: [00:02:40] Sure. So generalised anxiety disorder or GAD is essentially the medical term for people that are huge. Worrywarts. Many of us worry worry is not a diagnosis in and of itself, but when it starts to get in the way and cause impairment, that's generalised anxiety disorder. The key though is that it's not just worry. There's a lot of physical manifestations and we'll get, I'm sure, into the specifics of specifics of that when we go through the diagnoses. But in a plain language way, it's those folks that are just out of control worry.
Jordan Bawks: [00:03:19] Do you find it useful for patients or when you're explaining to medical learners to differentiate between normal fear and anxiety and anxiety that becomes a clinical disorder? Like how do we draw that distinction?
Dr. Jared Peck: [00:03:30] Yeah. So it's a good question and I think it's something that I discuss with every patient when we're making the diagnosis, particularly in the psychoeducation part. And frankly, for many of our disorders, right? Like we all have, sadness and sadness is different from depression in the same way. And sadness can be helpful sometimes. I think the big key differentiator between normal fear and anxiety and a disorder is the impact it's having on you. So all three of us have many years of education sitting around this table. We've written lots of exams over time, had presentations, things like that. And if we didn't have some level of anxiety or fear, then we might not have studied and we might not have gotten through some of those hoops that we needed to get through to get here. So and it's not just doctors, it's anyone, right? Anxiety can drive you to do things, and that can be good. However, when that anxiety is out of control or disproportionate with what lies ahead of you, then it can become a problem. And so I think that's really the key and we're jumping ahead. But when we get to the treatment aspect, one of the keys for people when they're learning different ways of thinking about their anxiety is to start to differentiate that when there's something in front of them that they're worrying about or that they're fearful about, kind of pulling back and recognising is this worry that's, quote, pathological or out of control, or is there something that I should be fearful from here? So I think it's a really key step to differentiate between, quote, normal fear and pathological normal fear.
Jordan Bawks: [00:05:22] So what you're saying is that everybody worries. And what really makes the distinction between like a normal anxiety and a clinically relevant anxiety is kind of whether it's adaptive, flexible or useful.
Dr. Jared Peck: [00:05:37] Yeah. And I think just one sort of other piece which we're speaking to, but to be more explicit worry is the thinking or cognitive manifestation of fear. And we're all animals that are wired to have a fear response. And people with anxiety disorders and GAD tend to have this faulty alarm system where maybe they misread a cue in their environment or overcall something and interpret it as, you know, being fear. So it sets off their fear system. And when your fear system is inappropriately or prematurely activated, that is when you start to be having pathological anxiety or an anxiety disorder.
Jordan Bawks: [00:06:25] Like, why do you think GAD in particular is something that's important to learn about?
Dr. Jared Peck: [00:06:32] I think for a few reasons. One is people with GAD tend to sort of suffer in silence, so to speak. I think people kind of dismiss anxiety and they just say, well, you know, you're not psychotic or you're not really depressed, but there's a lot of suffering that's going on out there. And if we don't explicitly learn about it or label it, then we could miss it. So I think we want to know to look for it. When we look at utilisation of health care resources, people with anxiety present to their family doctor a lot more often for non-anxious complaints for medical problems. Sometimes it's catastrophic misinterpretation of, you know, physical things. But for people listening to this who are not going to be psychiatrists but are medical students, it's important for them to know that whatever setting they're in, they're going to see people with anxiety and they they have a lot of comorbidity with other psychiatric illnesses as well as physical. And just from a work productivity perspective, we'll probably get into this a bit later. But they tend to miss work. They tend to endure their symptoms for many, many years without treatment. And they often end up fearful of things, so they might end up being unmarried or if they're not identified as having anxiety and it's seen as more just their irritability, it can lead to problems in relationships. So I think there's a variety of really important reasons to to know about it so that we can help ultimately treat people.
Bruce Fage: [00:08:18] So thanks for providing that that context. Can you speak a little bit about the epidemiology of anxiety? What what does this look like from a population trend level? What kind of people get GAD and when do they tend to get it?
Dr. Jared Peck: [00:08:32] Thanks, Bruce. That's a good and important question. It tends to affect women twice as much as it affects men. And it can the onset can be at any point, but there's a bit of a bimodal distribution, often laid out in adolescence. It can kick in, which corresponds to the, you know, kids or adolescents starting to have more responsibility. You know, if you think of junior high school or high school, your day is no longer as constructed and there's more free time and more decisions for you. So a little bit more falling on your shoulders. You can see it in early adulthood as well. Similar type of transition, but really you can also see it later on. Sometimes in older adults with the onset of a chronic physical disease, it can make them feel somewhat helpless and and trigger this. Um, the one-year prevalence tends to be about 3 to 8%, but only 30% of people, right? So that's like one third of people actually get formal psychiatric treatment. And as I mentioned earlier, people most commonly present in their family doctors and they can go go quite a long time until they're referred or even picked up as having anxiety and in the meantime are often presenting with headaches or gastrointestinal illness or quote, a lot of muscle tension, which can can lead to other physical issues that they present with.
Jordan Bawks: [00:10:16] So this is a shout out to all you medical students listening. No matter what field you end up in, your goal is to do better than that 30%. All right. So after these two episodes, you're going to be able to pick up GAD and you're going to be able to at least think about or refer for the appropriate treatments. Now, my understanding of generalised anxiety disorder is that it's generally considered to be like a chronic illness. It's not something that's kind of episodic. It's like you have GAD and without treatment it's probably something that's going to be with you lifelong. Is that a is that an accurate understanding?
Dr. Jared Peck: [00:10:56] So to some degree, yes. So, you know, major recurrent, major depressive disorder, we tend to see people going along doing reasonably well. And then they have these triggered drops. People with GAD have this chronic worry. But we do see these flares like people will cope reasonably or manage with their anxiety, but then something might happen that triggers an intensification. So it's not that it's static in that it's always there at the same level, but I would say it's more chronic just with intensification, which is unfortunately well, fortunately or unfortunately the opportunity for us to intervene, that's when they tend to get referred.
Bruce Fage: [00:11:46] Now, I know that some people listening to this podcast right now might be worrying, Oh, I think this is me. I've been a worrier all my life, so we're going to take a step back and provide you some relief by talking about how we diagnose generalised anxiety disorder from a DSM-5 diagnostic criteria and how it technically and clinically differentiates from normal worry. So as for the DSM-5 a diagnostic criteria, the essential characteristics of GAD are sustained and excessive anxiety and worry, accompanied by either tension or restlessness occurring more days than not, for at least the last six months in a number of different areas, meaning work, school, health, finances. Et cetera. The worry is difficult to control and it is associated with at least three of the following six symptoms restlessness, feeling keyed up or on edge, being easily fatigued, having difficulty concentrating, or finding that your mind goes blank, having irritability, muscle tension or sleep disturbances. Of course, as with most DSM five diagnoses, there are some caveats in that the worry has to cause some sort of functional impairment and is not related to the effects of a medication, an illicit substance or another medical condition.
Jordan Bawks: [00:13:06] Okay, so that's generalised anxiety disorder. Why don't we go through that kind of one more time, slightly different language, see if that sticks, because I don't know about you guys, but I find the DSM-5 criteria a lot to absorb in one pass. So basically the core of GAD is that there's this kind of like regular obsessive worry or anxiety. It's there a more days than not. It's been there for at least six months. And this is kind of what differentiates it from other anxiety disorders, but it's kind of generalised. So it's not like I'm specifically worried about dogs every day for six months. It's like, you know, the worry could be around, Am I going to make the bus? Am I going to get fired from my job? Am I do I have a problem with my knee that I need to go to the doctor? So there's kind of this general picture of it and then the worry is difficult to control. I mean, if anyone from the DSM-5 is listening, you know, don't take this the wrong way, but I've always found this a kind of a silly criteria. It's like naturally the worry is hard to control. It's been there for six months and it's interfering with their function. But and then the other the key part of the diagnosis is that there's associated cognitive or physical symptoms. So there's like the irritability. When I think of the cognitive type of symptoms, I think of the the irritability, I think of the difficulty concentrating or the mind. Going blank. And then when I think of kind of the more physical stuff, I think about the restlessness, that kind of physical agitation, inability to relax the the muscle tension, the sleep disturbance, the being easily fatigued.
Bruce Fage: [00:14:46] So, Dr. Peck, in your clinical experience, does this resonate with the kind of patients that you see? Do you pick up a lot of these symptoms?
Dr. Jared Peck: [00:14:57] Yeah, definitely. There's a lot of people we have to be careful because some people label, quote, worrying in a way that they are worrying and thinking about things, but it doesn't necessarily fit into this, which gets into exactly how we tease out what they mean by worry. But it definitely resonates with a lot of folks that I see.
Jordan Bawks: [00:15:23] Now, medical students are always looking for nifty acronyms. What do you guys use to remember the six physical symptoms, that cognitive and physical symptoms? Do you guys have one?
Dr. Jared Peck: [00:15:33] I've never I'm not a huge acronym person. There were a couple of them that I had in med school, but I'm sorry. I can't help you out there.
Jordan Bawks: [00:15:42] Dr. Fage, do you ever?
Bruce Fage: [00:15:43] I find that when you're doing a diagnostic interview, some of the symptoms are similar to what you might see in a major depressive disorder. So you've covered a few of them if you've asked questions about that. So I always just try to remember the muscle tension piece.
Jordan Bawks: [00:15:58] As like a differentiating one.
Bruce Fage: [00:15:59] From when to not forget when you're going through a diagnostic screen.
Jordan Bawks: [00:16:03] Yeah. For those who do like acronyms and I'm kind of a visual guy, so I like to see it spelled out on my page is I'll use TRY ICE. So that's tension, restlessness, insomnia, and then the ice being irritability, concentration, energy. But, you know, it's whatever you need to do to remember them. And if you're a genius like Dr. Park, you can just pull them out from your mind at will. You don't need any acronyms. So, Dr. Peck. Next question, What is your typical screening question for GAD during a general psychiatric assessment?
Dr. Jared Peck: [00:16:44] So I think of it in two ways, which actually might help with not an acronym, but a way of conceptualising remembering. I always think of the sort of cognitive or thinking side of anxiety, which is the worry and then the physical side. And that physical side can take you into panic attacks, which we'll talk about in another point possibly, which isn't GAD versus the kind of more chronic physical stuff. But with I usually start off with an entry into the worry on the cognitive side. So it's usually a pretty simple question. So "Are you a worrier?" Right? Or "do you worry?". And then once you get a yes, you don't check the box, you then move in a little deeper around, "Well, what kinds of things do you worry about? Give me an example. Over the last day or so, what our worries have been going through your mind?" And then if you're getting positives there, then they hit that criteria.
Bruce Fage: [00:17:47] I would agree. I think that using the non-clinical language and describing worry when you're bringing it up with patients is really helpful. And I try to ask about how much it impacts their function and if they feel that their worry is productive or unproductive as well.
Dr. Jared Peck: [00:18:03] An interesting question that can sometimes confirm it is even asking if they worry about their worry. Right. Because that will take you to them being concerned about it and recognising that their worry is causing a problem.
Jordan Bawks: [00:18:20] And what kinds of things would you look for on a mental status exam when you're with a patient that may kind of direct you into the feeling strongly that there's a generalised anxiety component, or what might you typically see?
Dr. Jared Peck: [00:18:37] Well, so starting off with the appearance, not always, but you'll sometimes have someone who's actually got a little bit of pressured speech, not in a manic sense, but in a sort of anxious sense and sometimes can be a bit overinclusive like wanting to tell you everything, get everything in quickly. They people can be a bit fidgety or, you know, just have that sort of frightened appearance. Sometimes physically, they're not fully curled up in a ball, but you can see that they're nervous, which often settles as you're talking with them. So those are some big things and then themes that you're hearing. Right? You're going to hear the worry coming out. You'll sometimes get some reassurance seeking. They can really present sometimes as almost wanting to please you and make sure they're doing an okay job in the interview or you're just clinical interaction. So I think those are some of the common themes. Things that I see.
Jordan Bawks: [00:19:49] Yeah. For me, that reassurance seeking, that's one to me that if I've been thinking about generalised anxiety disorder, I feel relatively comfortable about the diagnosis. And then at the end, if someone is sort of saying, well, what if, what if I get this side effect? And "What if I do this and what if that?" And when it's like things you thought they were wrapped up and then all these extra questions come up and there's this real reassurance seeking element that to me is something I usually kind of say, "Yeah, I am on the right page here". Like there is definitely an element here where the worry is really significant and I feel pretty confident about GAD.
Bruce Fage: [00:20:28] Dr. Peck, there's some evidence that suggests that the use of standardised scales or questionnaires to help with either screening for mental illness or monitoring treatment response can improve patient outcomes. What do you think about scales in clinical practice, and are there any that you find particularly helpful?
Dr. Jared Peck: [00:20:44] Yes. So scales I think are still underused. Measurement based care is essential in managing all of our disorders. The key is finding the right scale. So GAD-7 is a very quick seven question inventory that can be self-administered that is great for the family doctor's office. Or you could do it before seeing someone in the psychiatrist's office as well. It's fairly easy. Offhand, I don't know the numbers, but scoring it, you can see how someone's doing. You can use it to track symptoms over time. I'm pretty sure it hasn't been validated for monitoring treatment over time. There's a couple of other questionnaires that can be quite helpful. One is the Penn State Worry Questionnaire. That one really captures the cognitive element. So the worry side, and I believe it's not copyright protected so people can find that online and I find that's helpful for tracking treatment over time. Some people use the Beck anxiety inventory. My experience with it is it's more focussed on the physical symptoms. So if someone has GAD with primarily physical symptoms that worry you're going to capture more of the physical symptoms on the buy. So those are three the latter two being ones that you can use to track over time response to treatment.
Jordan Bawks: [00:22:27] Now, keeping in mind that this is something that we plan on covering in our future episodes because we plan to do an episode on most of the major anxiety disorders, I think it's still worth talking about differential diagnosis. And, you know, I know because I've trained with you, Dr. Peck, that your approach to differentiating anxiety disorders is pretty straightforward. You want to walk us through it?
Dr. Jared Peck: [00:22:49] Yeah. So, I mean, the person always has the answer in front of you. We know that comorbidity is the rule, so to speak. When one person has one anxiety disorder, they often have another. But determining whether they have them I think is pretty straight ahead. You can take the question, what if and have a blank that you fill in when you're thinking about what goes through the patient's mind? So if the person has panic disorder, essentially what that is, is people have had a panic attack and they're now fearful of having further panic attacks. And so their fear is, what if I have a panic attack for the person who has social anxiety disorder, the sort of core cognitive construct there that's driving their fear is the fear of being humiliated or embarrassed by others. So what if I become embarrassed or what if I'm rejected in that social situation? What if I make a fool of myself? So some version of that OCD and PTSD are technically not anxiety disorders. We used to conceptualise them that way. PTSD. It's what if I get attacked again or whatever. You know, a horrible trauma has happened to the person and OCD. What if I get these germs? What if I touch that usually related to whatever that intrusive thought is? And then we have our specific phobias, which are, you know, fairly obvious. What if the dog attacks me now, the challenging one or where people get can slip up? Is that in generalised anxiety disorder people worry about any and everything right. So it's not just what if one thing you're going to be getting what if a whole bunch of things but what if it rains like they don't have a rain phobia. So they start to have fears of multiple different things? But I think that's a good basic way. And as I said, the person you're sitting with, if you ask the question about what they worry about, you're going to get this.
Jordan Bawks: [00:25:12] And as you said, like one of the reasons it's hard is because the rates of co-morbidities are so high. You know, I was looking at a couple of different sources and I saw between 50 to 90% lifetime comorbidity rates and people with generalised anxiety disorder. So very well may be that they have generalised anxiety disorder and panic and or generalised anxiety disorder and depression. And let's take a second to talk about depression specifically because that's one, as Dr. Fage mentioned earlier, there's a lot of overlapping symptoms. So I find that one can be really tough to tease apart. And what's your approach to differentiating generalised anxiety disorder from depression?
Dr. Jared Peck: [00:25:59] Well, I think it can be a challenge, especially because you're seeing people when they've entered into clinical care and as I mentioned earlier, they'll, you know, they might be a flare in their anxiety or it might not be a flare in their anxiety. It might be that this person's going along with GAD for years and then they have a depression because of this comorbidity. So when you're seeing someone and meeting them for the first time and they're depressed, they can have a major depressive episode with anxious. Distress or with panic symptoms. And so it becomes hard. So I think we want to get a really good time course so the individual, you know, might be able to tell you whether their anxiety really started in conjunction with their more recent depressive symptoms or whether it predates it. So that's one key piece, just getting that time course. And if they can't provide it, I think we underuse collateral history from family members. We want to make a plug to make sure we include family members in the care of our patients, even if it's a one-time consultation, you know, those folks around them will be able to give insights so that they can help with the time course. The other piece is, although there's this overlap, when we look at sleep, let's say people who are anxious typically have difficulty falling asleep because they just can't shut their mind down. Sometimes they wake up in the middle of the night worrying about things. People with classic depression can have that initial insomnia, but they often have that early morning awakening. Now, this isn't a complete rule, but you can often differentiate it by that. And so so that's one piece. The content of their worries is important as well because people can use that phrase worry. But what they're really doing is they're looping back on their guilt or about how they're letting people down. And it can be a lot more sort of depression or depressive cognitions. So I think that's another key.
Bruce Fage: [00:28:24] As residents, we often work with people who struggle in some way with substance use, and it's not uncommon that a person might say to us as an explanatory model for why they use substances is that they're medicating, they're self-medicating, they're trying to cope with their anxiety by using substances. Is this something that you come across commonly in your clinical work?
Dr. Jared Peck: [00:28:51] Yeah. So there are many people with anxiety disorders who I see who don't misuse or overuse substances, but there's definitely a subset of people who end up using their substance. Probably the two most common being people using cannabis or alcohol and looking at the alcohol. Start off with people get into just this vicious cycle because they're coming to see you. So it's probably not working out all that well. But what happens with alcohol is once the alcohol is no longer bound to the receptors, we get this rebound anxiety. So although they started off using it with one drink that takes the edge off things and probably did make them feel relaxed in a very biological way initially, it then creates a problem because their tolerance and they're drinking more and then they get these drug opposite effects with the rebound anxiety when it's out of the system. And their attempt at, quote, self-medication turns into a problem in driving their anxiety further.
Bruce Fage: [00:30:07] So it sounds like people may use substances as a coping strategy in the short term, but in the long term, it can actually worsen their symptoms.
Jordan Bawks: [00:30:15] Correct. This is something that we haven't been doing in our previous episodes, but it's always important to think of when you're seeing a patient in front of you who's got a mental health problem, whether there's some kind of general medical condition that's contributing to that problem. The basic blood work for someone with an anxiety disorder problem, the blood work I usually order is like a CBC, a complete blood count, thyroid stimulating hormone, vitamin B, 12. Occasionally, if someone's got like a more panicky picture, like they're talking a lot about chest palpitations, I may order like an EKG or a holter just to rule out, especially if there's a family history or something like that of a cardiac problem. Any other investigations either of you guys would do a screening basis?
Dr. Jared Peck: [00:31:07] So I usually check their renal function as well, not because I think it's driving it, but just if we're going to be initiating medication, you kind of do that up front. I think in your typical person who you think is healthy in front of you, that's suffice. Obviously, if it's someone a little older, you might be doing extended lights or if there's worry about some other illness driving this. You always want to rule out the physical, especially since these folks can present with physical other comorbid illnesses. But you don't want to overdo it, starting to chase things there that aren't there.
Bruce Fage: [00:31:53] Yeah, I think it's that balance, particularly if people with anxiety might be prone to wanting to investigate their medical concerns to an extent where it can become harmful. I think sometimes when I interact with family doctors, they're not really sure how aggressively to pursue somebody's complaint if they haven't found an answer. Sometimes you might consider doing liver function tests as well, because a lot of the medications, if you're going to consider a medication, a lot of them are cleared through the liver. And particularly if somebody has a comorbid alcohol use disorder.
Jordan Bawks: [00:32:33] All right. Let's take a second to review what we've talked about for our learners and also to see if there's anything else any of us want to add. We talked about why generalised anxiety disorder is an important disorder to talk about. We talked about it's being prevalent. We talked about the common presentations to family doctors. We talked about it being undertreated. We talked about the epidemiology, the bimodal distribution, late adolescence, early adulthood, later in life. We talked about its tendency to be a chronic disorder that can have flares that precipitate presentation to treatment centres. We talked about the diagnosis using DSM-5 criteria. Six months of excessive, difficult to control, worry about a variety of different things, accompanied by at least three of six cognitive physical symptoms. We talked about differentiating generalised anxiety disorder from other anxiety disorders by the fact that it's a generalised kind of worry. And we talked about some of the common comorbidities, including depression, alcohol and other substance use disorders. Everything we talked about today sitting here now, any thoughts before we wrap up the episode? [00:33:52] Doctor Packard. Doctor Fage. [00:33:53]
Dr. Jared Peck: [00:33:54] I think you did. You covered it all. The one thing that I think I'd add that I don't think I said earlier is people with GAD don't necessarily worry about different stuff than anyone else. So any of these worries could pass through any of our minds. It's just it's really key to focus on the hard to control part or turning off the worry as that's just a real key point there.
Jordan Bawks: [00:34:22] So maybe not so silly as I made it out to be. We talked about the DSM-5 criteria. All right. [00:34:29] Good to put that in the humble bank for Dr. Bawks over here. Doctor Fage, any last thoughts? [00:34:35]
Bruce Fage: [00:34:36] I mean, I think we can all appreciate that fear and anxiety are a normal part of the human experience, and it's not necessarily the intent to over pathologize somebody who might be experiencing something that's very common. But I think we've tried to elucidate the difference between that and something that actually does become problematic and causes suffering.
Jordan Bawks: [00:34:59] Well, thanks so much for joining us today, Doctor Jared Peck. A pleasure, as always. We'll be bothering you again soon to get you back and talk about the treatment of generalised anxiety disorder. And I did see your slides on cognitive behavioural therapy for generalised anxiety disorder and I'm going to make a pitch to the group that we do a special episode on sort of advanced CBT for generalised anxiety disorder because stuff looks pretty cool. Metacognitive model. Laval Model. Anytime you've got fancy names for something, you know it's going to be good. What do you think?
Dr. Jared Peck: [00:35:33] Well, let's see how this one turns out and how the first treatment one is and we'll go from there.
Jordan Bawks: [00:35:39] Sounds good. Thanks so much, listeners, for joining us back at Psyched. We love to hear your feedback. Give it to us on our website. I believe we have an email address there. You can find us at psychedpodcast.org. You can also check us out on Facebook @Psyched podcast. Give us a like, give us a follow. You can stay up to date on what we're doing. You can give us feedback if you want longer episodes, if you want shorter episodes, if you want to kick the experts off the episodes, you let us know and we will think about doing it. Thanks for tuning in. We hope to have you guys back next time. This episode of Psyched was written and produced by Dr. Jordan Bawks and Dr. Bruce Fage. Our theme song is Working Solutions by Olive Music. We would especially like to thank Dr. Peck once again for making the time to help us out with the episode. This podcast and this episode was made possible by the support from the Department of Psychiatry at the University of Toronto and is produced in affiliation with the Canadian Psychiatric Association. The views expressed in this episode do not necessarily reflect those of the Canadian Psychiatric Association or the Department of Psychiatry at the University of Toronto. I'd also like to offer a big thanks to all of the board members, our staff mentors and the medical students who are affiliated with us and help us out and make these episodes possible. Take care!