Holistic Interventions for OCD

Obsessive Compulsive Disorder (OCD) can be extremely debilitating for some people. It  can limit their opportunities in education and employment and fundamentally reduces enjoyment in life. In this episode holistic clinical psychologist Dr Adrian Lopresti discusses a case whereby using  specific strategies and lifestyle changes brought back hope. An important demonstration for sufferers and carers.

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Doctor Adrian Lopresti is a clinical psychologist in private practice and senior research at Murdoch University in WA. He has over 20 years of clinical experience working with children and adults suffering from a range of mental health conditions. Aside from his broad experience in psychological therapies, he also has completed studies in many of the holistic health disciplines such as nutritional and lifestyle medicine. Doctor Lopresti regularly publishes in peer reviewed and high end impact journals on the effects of diet, nutraceutical sleep and exercise in the treatment and prevention of depression, anxiety and attention Deficit Hyperactivity Disorder. He's completed several clinical trials and is well published. All of his work ties in holistic medicine principles together with psychology. Hi, Adrian, how are you doing? Good, Daniel. Thanks for having me today. Pleasure, mate. What you do is absolutely ground break. I love reading your articles. I've just finished reading one on the effects of humeric or curcumin on the human microbiome, which was fascinating. So I feel a little bit more educated today. Thank you. You also are a regular contributor on another podcast, FX Medicine, and I've noted that you speak to some pretty high end people in their respective medical disciplines on that podcast. That must be so exciting for you to do that each time. Yeah, it's great speaking to different people and just kind of picking their brains and learning every, every time I, you know, do a podcast or whether I'm on one end of this microphone or the other, it's it's a great experience. Today we'll be talking about a patient of yours, a young boy diagnosed with Obsessive Compulsive Disorder. OCDOCD features a pattern of unwanted thoughts and fears known as obsessions. These obsessions lead you to Do repetitive behaviours, also caused compulsions. And these obsessions and compulsions get in the way of daily activities and cause a lot of distress. That is the standard medical description. Do you agree with that? Yeah, I mean it's certainly it's AI mean, it's a it's a fascinating condition and certainly as you mentioned, there's a combination of the obsessions and the obsessions can vary from one patient to another. They can vary quite significantly in terms of what they're they obsess about and then the compulsive behaviours can also vary significantly from one person to the other. So definitely they have had seen quite a few patients with OCD over my experience and the severity can vary from moderate to very severe where it impacts on the daily function, you know significantly. Let's talk about your case. I know that he's a 12 year old male. I don't know much else. Yeah, I mean, actually the first time I saw him was 12. And then I saw and had seen him for several years, actually on and off for several years. He's 17 now. The first time he saw me, he was actually presenting with anxiety and panic attacks. So he was experiencing kind of suffocating. He felt like he was passing out and couldn't breathe and that that impacted on his ability to kind of go to school. He was missing a lot of school. He also had had a lot of somatic symptoms. He, you know, the hypochondria kind of symptoms that people kind of refer to. So he would talk about having a pressure in his head and having a sore head. And so that's where originally started out. It's more panic. And then the somatic symptoms, then missing school and then the OCD symptoms kind of became more prominent as he got older and they came and went over. Over his time different kind of obsessions have appeared and and different compulsions appeared and and then got better and then got worse and so on and so forth. There's always been a long association between OCD and anxiety and I think in the early days OCD is considered to be a sub branch of anxiety, but it's its own condition these days. My understanding is please correct me if I'm wrong, That's correct. However, is it a bit of a chicken and egg situation? Can anxiety lead to OCD and OCD lead to anxiety? Or are they both so separate that some people can have one without the other? Yeah, I mean, people can have one without the other. I mean, I'm not a big diagnostic person. So I mean, OCD is probably what I do. Give them label too, because it helps my clients understand it and it helps with the psycho education. But there's so much overlap with all the different conditions, so many people with generalized anxiety or have OCD or social anxiety and so on and so forth. So there's significant comorbidity and then maybe one comes a bit more prominent than the other. So he originally had the panic symptoms first a bit, were initially more prominent and then the OCD, but I think the OCD was always underlined for him. I did have a look through my notes and I do recall that he was, when he was younger, he was quite obsessed with food and worried that he was going to get food poisoning. And so he was very, very much a picky eater from a very young age and that came and went. But there's often signs like that when you kind of find out about the history that there's some elements of OCD behaviours that that may appear in in young childhood. It seems that OCD is more commonly diagnosed in young children or or young adults. Why is that do you think? I'm not sure what the rates of diagnosis are, the prevalence of the children and young adults as opposed to older adults, but often kids will develop OCD and then I suppose it disappears over time. So as I become older it might disappear over time. It might be that also they learn to kind of cope with it differently, so therefore they don't seek intervention. I see there's one way, you know, often you'll freak out because you don't want to engage in behaviours that you know probably going to occur through exposure therapy with with psychological interventions and that's can freak people out. So, so therefore they don't seek intervention as adults but when they're children, it's the parents that will then seek the intervention. And so whether the child wants to or not, they they may go see a psychologist for intervention do parents. Hold back for a long time. Are parents in denial around the condition or they maybe don't understand it? Or do you feel that a lot of parents are straight onto it and straight to the psychologist quite quickly? I think it depends on the severity. So if it's if it's moderate severity, they might hold up for a while because maybe they, you know, they think that people, their child will grow out of it. But if it's significant, if it impacts their ability to go to school and and to function socially, then they're more likely to seek intervention. So it's more that severe in that's probably going to be where parents will seek support for their child. In the case of the lad we're talking about now, can we give him a nickname for the for ease of purpose? Well, let's give him a boring name like John or something. OK, John, good. That's a good name. Sorry to all the John's out there. When John came in, how would you ride him on the scale of OCD? Would you have said that he's the mild, moderate or severe end? I'd say at first it was mild and so when he first came in, I'd say the more prominent was the school avoidance and the panic disorder. So then I provided some intervention for him for that and he got better. And then I think I saw maybe one or two years later and that's when the OCD became a prominent and that's where it was certainly the more more severe range of OCD that was occurring and that was impacting on his his. So she's ability to socialize. He wasn't going to school at all, spending most of his time at home. With the early interventions, while you're working with him for a couple of years, did that involve psychology and counselling services, or was there some change to the diet or the addition of some sort of supplemental herbal medicines or or recommendation to another professional at the same time? The treatment was, it was supposed with with most of the clients I have seen. It was holistic, so it certainly was a psychological intervention. So there was the, I suppose cognitive behaviour type therapy that I was doing to try to identify thoughts and helping to learn, manage his thoughts differently and so forth. And a lot of psycho education that was occurring. So, so there was that. So there was the individual therapy that I was offering. But then I as I explored more and tried to do a good assessment with him, his diet was poor, He was very picky eater. So we tried to incorporate more foods into his diet. He wasn't engaging any exercise, He wasn't socializing. And this all also occurred in the context of, you know, his parents being quite stressed, his dad and his mum. His mum had anxiety, His father was suffering significant stress from work. There was significant marital conflict going on. So, so that also formed part of the intervention service. So it was individual therapy for John and I worked with the parents who work on their own kind of stress management and self-care. And then gradual things like a dietary, you know, improving dietary intake and injury, increasing more foods and fruits and vegetables just because the difficulty was engaging him, trying to increase his physical activity. And when he came back the second time, we did talk also about pharmaceutical medication. Do you feel that the environment, the parents behaviour, the difficulties in the marriage, stress and anxiety in the relationship, financial distress, all these factors have an impact on early age OCD? It has an impact on the likelihood of experiencing a mental health disorder. So whether it be OCD and I'd say there's probably a genetic component to his OCD and whether some physiological factors going on too. But certainly if there's significant stress, significant stress in the home environment, that's going to increase the likelihood of any condition, whether that be OCD or or not. So and he was obviously vulnerable to developing OCD. I could have another child coming in where he might he or she might be experiencing similar environmental stresses. I've never developed OCD, but maybe developed social anxiety or depression or something like that. When John came in to see you, he was 12 years old. Do you feel or do you know if he recognized at that point that he had a problem or did he was he dragged and going, I'm OK, why am I here? Yeah, you're both. So often what happens is that, you know, often I'll see patients who have already seen somebody else for intervention. So he wasn't going to school. So the school psychologist had got involved and he was actually quite traumatized because what actually happened was that he was forced to go to school and that significantly contributed to his anxiety and and so he had a very bad experience with previous interventions. And so I had to really work on developing a good relationship with him because that's really important. With people with OCD. That therapeutic relationship is absolutely crucial because you may ask them to engage in behaviours that go against the OCD and so they need to really trust you as a as a therapist And so and whether that's engaging in recommending psychological interventions, whether that's recommending dietary changes or exercise or sleep hygiene stuff, you know all of those things they. I think the first thing when working with someone with OCD is the relationship. And trust is quite difficult to earn. It takes a long time. Yeah, particularly when you've got a history where they had a district not a good experience with a previous therapist or, and that became problematic. So I had to work slow with this with Johnny. He comes in and he's got what you've assessed to be a fairly poor diet. Would you mind just running us through what a poor diet is, if you remember, and also how you managed to bring a good diet to somebody that's got mental health issues around food? Well, the job we never got to a good diet. We got to a less diet, so. Everything's everything's relative. I get it. Yeah, so, so it's just not as bad, but it was, it was very restrictive. So he was from memory, he was having just a sandwich. He would have a couple of sandwiches and pizza, Margarita pizza I think was all that he would eat. So it was very restricted. He wasn't having any fruits and vegetables. So we just worked on, you know, even first I remember just trying to get into drink more water. We looked at what fruits and vegetables were safer for him and for him to just start eating those. So it's just really a gradual progression there. I mean the other thing too was in my mind was always thinking about well what supplements could I give him to? What vitamins and herbal ingredients could I give him? But the problem with John and with OCD often is that they become quite anxious taking different and different supplements. And because he because he also had that food poisoning phobia in the past, there was also that worry that if I take these supplements and I remember him taking AB vitamin once again talked about that pressure in his head getting worse so he stopped. So from a supplemental perspective there wasn't a lot I could do. There was all the ideas I had, but the the only thing really he was willing to take initially was magnesium. You changed his diet as best you could, you got to drink more water and and then what happened to the health condition that he came in to see you with and what was the next step? Well, he got, he got better from and then I didn't see he was going to school several days a week and not only seen for about a year or two and then came back again and he had a major kind of relapse and exacerbation in his OCD type symptoms. And this is where the OCD became more prominent. He was worried about going crazy. He was worried about his laptop kind of making him sick and unwell so he wouldn't touch his laptop. He watched a horror movie and he would continually obsess about the scenes from this horror movie and therefore think people were going to break into the house. And those sorts of things was occurring for him. And yeah, and again, this, this pressure in the head, this sword neck, they were also very prominent. And so he would avoid activities that might exacerbate the pain. Yeah, and how old is? How old was he then? So it was about 14 at that stage, so. What did you do to try to help him at that point? Well, they, I mean again. So there, he wasn't going to school at all when I saw him again. And he was really just spending all his day at home on the computer, on the computer, playing games he would spend his late evenings on. I think it was Twitter or whatever it might be, you know, engaging in with other people from around the world.

So he would be staying up till two 3: 15:40

00 AM at night. So his sleep was really, really poor. When you don't have anything to do during the day, that's a really bad ingredient for OCD. The the less you do, the more you have time to focus on these obsessions and the compulsions. So his poor loss, I was just feeding the OCD and the poor sleep was also doing that. So I tried to look at changing some of the sleep routine, tried to increase some of his activity during the day and try to in getting to engaging things other than his OCD. And he did like drawing and then doing those types of things was where we really tried to work through 1st. And then did he go away from you feeling better again? He got better. And then this was also because his symptoms were so bad. When he came back and saw me, he was also on some antidepressants for his OCD. So often that's a treatment for OCDS, your SSRIs and that seemed to help a little bit. But I think that was important just to take the edge off 1 because he was so anxious, the poor guy say so. That was really difficult for him. But you know, he did start doing more things. He started exercising, he started cooking. Those are the things. He wasn't going to school, but Lucy had some activities he was doing to the day that made him feel better. That also made him move away from his or his, move his thinking away from the obsessions, and at least for a while he could have a break by cooking or by engaging some other activity. And then we also started to continue to just continue to try to increase his food variances. There's been a lot of commentary in the medical literature in the last few years around SSRIs which are a class of antidepressants, and I'm just wondering, in a young fellow or female with OCD or anxiety or depression, do SSR is initially cause any issues with them or have you generally found that they have a some sort of benefit from straight away? When it's like for John, I think it was probably beneficial because it was symptoms were so severe whether it made him feel better or or I don't think necessarily made him feel better, but mine feel less worse. And so if it has a kind of a numbing effect then that allows you to do things that it may be previously wouldn't have done. So there is a danger I think certainly SSRI is for people with mild to moderate symptoms. The, you know, the research indicates it's not so, so effective for people with OCD that they are higher doses that generally are given with SSRI. And I've noticed in my experience that it can be beneficial for people with severe OCD. What was the next step in John's treatment? He started cooking and he started to, I'm reluctant to say find a bit of purpose unless you correct me, but he but he started to find a bit of activity in his daily routine. Purpose is the right purpose. That was really what we worked on. He's trying to develop purpose. So I mean that was the the key was you know what, trying to develop some. You know what, what is his goals, what is his dreams? And only I know that he was young, but using that rather than trying to dedicate energy towards reducing OCD, it was also about working towards increasing activity towards areas that he was, that he valued, that gave him meaning, that gave him purpose. And you know, he had a dream of kind of travelling and going overseas and we talked about how to do that and what, you know, what type of job he wanted. And we talked about how, you know what developed some ideas around that and how he would be able to, how he would to achieve that. So it was it's a slow progression, I mean and because often what happens with people though OCD and specifically with John was that he would say the right things but they would not actually put them into practice. So it was often, you know, you go to as a as a practitioner, I had to kind of work with my own frustrations too because if I become frustrated and I, you know, it just causes kind of stalemate so often it was slow. If you come back, say or say, go away and do things for often, set some homework tasks. We developed some homework tasks for him to do, come back and not do them. So OK, let's go to the next step. Let's look at the barriers. What stopped you from doing it? That's kind of that, you know. Let's refine it accordingly. Did you feel at this point in the relationship with John that you had his trust? Yeah, yeah, absolutely. I think that was the reason why he came back that second time around and a third time, you know, he's come back several times as required. Often you can't do all the work in one in one phase, you know, that's kind of different stages that you can do the work. So definitely came back. I think that, you know, he always trusted me. He at one stage he was hospitalized for five days because he had suicide radiation which again probably were OCD top related but an involved repatient for five days. So that really impacted on his trust. So working with me and and having that relationship was was a really positive experience for him I think. In the previous visit, you'd worked on his sleep hygiene, helping him to sleep better. Had that continued to improve? Was he still sleeping, or had he gone back to all sleep patterns? Interestingly, that was probably often that made a trigger to his relapse was because part of his OCD was also OCD or anxiety was the desire to be like to be accepted. And so through Twitter and through his online, because that was his only social interaction. So he would value kind of getting feedback and interacting with people who are all, you know, living in the US and all that type of stuff. So that's why he'll start late. Yeah, we had to continually go back to the sleep project because that was a major trigger to, I think, to his relapse. Did you use any herbs or supplements or medications to assist him in improving his sleep patterns? We it was really some magnesium. At one stage he was prescribed actually between visits but after he stopped seeing me, he had seen the naturopath and they put him on a a combination of Sisyphus Magnolia and passionflower herbal combination. So he was taking that. I don't think he necessarily got much benefit from it and I think we got him on some fish oils at one stage. But and in my head based upon the literature, if you think about the literature with regards to OCD, some of the ingredients that may be beneficial would be high dose, I think high dose Omega threes. There's some research around Nic and acetyl C in acetyl cystine. It's in some research with saffron with OCD. So there's kind of some research here in there with regards to OCD. There's a couple of studies on milk Thistle with OCD too. So they were in my kind of tool kit that I'll hopefully pull out at some stage, but I never really did with him unfortunately. So, so there's really whole different options that people we could consider them in. Unfortunately funds were limited. So we you know in terms of assessments and go, OK, well what's going on physiologically foreign that might be contributing to is is OCD. We weren't able to get to that point apart from some standard blood tests that the GP did. We weren't able to kind of do any major kind of analysis to see what was going on from that perspective. Fish oil and NAC would be typically associated with inflammation of the brain and trying to arrest some of those pathways. Is that the purpose in your mind? Do you feel that there's an association between some sort of inflammatory process going on in the body and the and all the brain and and that's what you're trying to address with these substances? Yeah, there's some research around OCD, inflammation and even oxidant stress. So there's increased markers. Opposite that is stress in many people with OCD and then you've also got many kids who develop OCD after you know Pandas pictures or something like that. So so inflammation probably plays a role, plays a role for some people with OCD. So we've got to be careful about that blanket rule going on. OCD inflammation, I think it is a driver for some people and so yes, I think that that's the way to go. And look, he was engaging in many pro inflammatory behaviours, so therefore good guy, OK, inflammation probably is a drop, is a contributor or a major driver here for him. And then obviously, the other theory around those CDs neurotransmitters and serotonin in particular, and then whether there's some issues around the HPA access as cortisol might also be a factor too. For the listeners, HPA access is the relationship between the. Hypothalamus, pituitary, adrenal waxes and then they kicked in for a stress response and for people with OCD it might be a hyperactive HBA axis. So too much kind of cortisol released in in response to a stressor or there might be disturbances in its rhythm. So, so he was, he was sleeping late at night, so, you know, go to bed late at night. And so that was going to really impact on his diagonal rhythm of of cortisol. And I mean even there's diurnal rhythm of inflammation, there's a diurnal rhythm of oxidated stress and oxidated markers that change over time too. But so that's why I'm really having that regular routine, regular sleep routine, regular eating routine, those sorts of things are going to be really important to just normalize some of those potential dysregulated hormones that are going on. You mentioned a couple of times you had them on magnesium. What do you see is the role for magnesium in an OCD patient? Well, I mean some magnesium probably, I mean obviously it impacts on scale, magnesium impacts on HPA axis actually it can reduce cortisol. It has, you know, there's been some research around anti-inflammatory effects. There's important cofactor for neurotransmitters. It can be quite calming and and foreign. So. And then there's also the fact that he's eating a very poor diet, probably consuming very little magnesium in his diet. And saying that you could argue that there's a whole bunch of nutrients that he was probably not consuming enough of, but magnesium was one that he was OK about taking. So really, that's first. Like, OK, it might happen. In fact, let's try it and let's see whether it goes. And so he would have it before he goes to bed. The general data behind magnesium and many mental health conditions is outstanding overall. I was reading somewhere that there was an increase in OCD or a surge over the COVID pandemic, something like a 50% increase in diagnosis, 11 author had said. What does that tell us about the condition? What do you think was happening there? Well, the, the, the, the problem that you've got is that there's many behaviours that people can engage in that can feed OCD. And so one of those is if if you're watching the news and you're watching you're focusing on negative news items and negative information and you're just purely focusing on that, then the and then you start researching more and more about it and then you start talking about more, it becomes and become preoccupied with it. And that's just really going to set that driver there to really trigger an OCD episode. Then you've got the fact that, you know, maybe sleep routines were impacted and diets were impacted. And I think there's there's some people, no matter what stress that they're exposed to, they'll never develop OCD. There's a lot of people that will never develop OCD, but if they've got a genetic tendency or a genetic risk to develop OCD, and then you have all those things that was going on. COVID. You know, the the bad news, the lack of social interaction changes in lifestyle and routines, that's it's just going to set up a trigger for OCD and all other conditions. So I suspect the research around depression and anxiety and all the other mental health conditions also increased over time. Absolutely. And and one of the bigger other factors was the absolute drop off the Cliff in in diet. People just tended to eat more rubbish. I mean this is a a guesstimate, but how do you kind of weigh the the the etiology or the the origin of OCD between genetic or epigenetic factors, environment and lifestyle factors? Do you think in that interplay one has more influence or it's just different for every person? Yeah, it is different. I mean, I think what really we need to do as practitioners is, is really just rather than talk about OCD, it's more talk about OCD with this specific person that I'm saying. So they're presenting with. As I mentioned, I'm not a huge fan of diagnosis, but let's say they're presenting with OCD then rather than necessarily A use of literature to help you guide the theories and the information. But ultimately you're dealing with this person sitting in front of you. And so based upon that person sitting in front of you, you're doing a good assessment, will then help you determine the potential drivers of OCD for that specific person. So if they're engaging all the right behaviours, eating a perfect diet, not exercise, you're exercising, not having any stress in their life. I don't know if there's any such individual by the way, but then you're going to look at the genetics is a factor here. And you know, maybe we need to look at from a biological perspective, purely from a biological perspective, but you're eating a poor diet and not sleeping like my clients, then I know that sleeps going to be a major factor for him. But for somebody else it may not be because they sleep perfect. So it just really needs to be personalized. And that's where that bringing assessment comes in, really doing a comprehensive assessment. And also I mentioned earlier this, the context is that he was a young child and he was exhausted, experiencing family stresses and his parents stress. That's something that also practitioners need to be very, very mindful of. Not just working with the individual, so working with the environment that individuals in and and potentially working with the parents and doing some family therapy or referring on and getting them to seek their own support too. How do you measure success in something like this? Do you have in in your brain or is or does the Psychology Association provide some key markers for what you should look at? Is there a tick box system? And how do you apply that theory of success to your patient John? It's a good question. I mean, obviously you can look at, you know, measuring severe change in symptoms, severity over time. Yeah. And you could use different questionnaires. There's a whole range of different questionnaires that you could use for OCD to assess change over time from a symptom point of view. But ultimately, you know, somebody could experience a reduction in their OCD, but the quality of life is no better. So I think ultimately it's about them living are more valued, fulfilling life. And again, have you mentioned that? I don't know, but you know there are many people who have significant OCD that live a very fulfilling life, but their RCD is still significant. And I'll say that they're doing very well. You know, I'd say that I would judge them as as successful. Then you've got other people who their RCD is not so severe and I'm living and because of that, they're letting the OCD rule their life and they're not living a quality, quality life. So I think it's it's, you know, are they engaging in a fulfilling life? What's their social interactions? What do they want out of their life and how close are they now to where they are ideal life would be and how do we help them kind of live a more valued, fulfilling life? And that's my definition of success. It's not necessary a reduction in the severity of the symptoms that often occurs as I become a live, a more fulfilling life, but I think that's where I'm at with with a lot of my a lot of my clients. Yeah. So where was John at last time you saw him? He was last time I spoke, actually I maybe probably about three months ago I had a call from his father, so and he was studying. He was, yeah, still struggling. I certainly the president who was still experiencing anxiety, but he was studying. He was interacting a lot more. He had a part time job so he was doing a a lot better and and yeah, and certainly you know, there's possible that over time I would see him again for booster sessions if required. Well, that's great. What a great outcome. Yeah, it doesn't always work out that way, but I think we got there. Now we we just need one more bit of advice from you. Even if someone's got somebody in the family or someone they know that's been diagnosed with OCD, people say stuff, try to make the situation better. Like don't worry, we all have a little OCD or just relax, don't worry about it, you'll be fine. Oh, it's all in your head. All these sorts of comments which are unlikely to be helpful, I would think. Can you give any advice as to how you would approach somebody that's had a diagnosis with of OCD? Yeah, I mean you made some good points there with some things that you shouldn't say. And then don't worry about it, don't think about it. I mean that would be in actual fact it's the not thinking about it without CD that often makes it worse The more you try not to think about it, the more you do think about it. And the behaviours of compulsions are often there to that they people engaging those compulsions in a way to not think about it. I go OK, if I'm engaging this compulsion I'll stop thinking about it and yes it works for a few minutes so then it reappears again. So certainly not saying don't think about it or don't worry about it. But ultimately look if I think that for a lot of people if if they're there for that person, if they can go out and do things and just have fun, you know, the more the less you focus on OCD the the the less you feed it. And so if you're engaging in some other activity, if you spend a full day with somebody and have a brilliant time, you've had such a laugh and you're so focused on an alternative activity, you can feed OCD for that day. And the the less you feed it, eventually it starts, I suppose is how I kind of think about another time. But and so yeah, have fun, take them out, do things, you know, that's the key. Make them laugh. You know, they're the things that I think is really important as a support for somebody with OCD. No, that is absolutely brilliant. Thank you. Very helpful. Well, I do. What a pleasure and what an honour to speak to you. I'm so grateful for the work you do in the research and the publications. You know, I've been reading your stuff for for many years now. You know, I'm really grateful and and so should the whole holistic medicine industry. Be grateful for the work you do because it's absolutely outstanding. So good on you. Keep it up. I wish you all the best. Thank you. Well, certainly I'll have to say the same thing about you, Daniel. You know, followed a lot of your work and this is all your stuff over the years too. So keep the great work up. All right. Well, the mutual admiration society keeps going. Good. OK. Thanks, matey. Good on you all. Right. Thanks a lot.