Conditions I Treat

I work with each client as a whole person acknowledging the complexities and uniqueness of each individual and their life experience. Individuals are NOT their diagnosis. Individuals are much more than a “condition” or “set of symptoms”. They are a complex mix of evolving strengths, gifts, talents, challenges, difficulties, and experiences. That complexity is so important to remember when providing treatment. At the same time, it is vital to be accurate in understanding what symptoms, condition(s) a person is experiencing so that an accurate diagnosis can be made. Without that accuracy there is a risk of applying the wrong treatment. Even the best of treatments, when applied to the wrong diagnosis, can result in ineffective results or even worsening of symptoms,

I specialize in the treatment of certain conditions. I have described what some of these conditions are below. I encourage anyone who identifies with any of the descriptions below to remember that you are more and much greater than the symptoms you are experiencing. A diagnosis doesn’t have to define you. A diagnosis just a helpful way to understand and communicate about a set of symptoms and to assure that the correct treatment can be provided. Treatment at its best, is meant to strengthen the whole of who you are, what you want to achieve, and who you want to be.

Obsessive Compulsive Disorder (OCD)

OCD is a chronic and often debilitating mental health condition characterized by the presence of obsessions, compulsions or both. The obsessions are recurrent, persistent, intrusive thoughts, images, or urges that are experienced as unwanted and typically create anxiety and distress. Compulsions are repetitive behaviors or mental thoughts that the person uses to counteract or neutralize the anxiety and distress.

OCD is considered moderately heritable and neurologically based. OCD is experienced on a spectrum from very mild to very severe depending on the individual. OCD affects people of all ages, genders, backgrounds, and ethnicities. About 1 in 40 adults, and 1 in 100 kids/teens experience OCD at some point in their lives. Contrary to what is often heard in public, OCD is not a personality quirk, is not reflection of someone’s character or values, and does not help a person to do something “better”. In fact, the diagnosis of OCD means that the symptoms are causing significant distress, interrupting someone’s functioning and ability to engage in valued activities, and is taking up more than one-hour of every day.

Obsessions

Although the person wants to stop thinking about the thoughts/urges/images, they are often unable to suppress or control them. The most common obsessive themes include: contamination, aggression or harm, sexual or religious taboos, symmetry and order, and doubts about safety or morality. Obsessions are considered “ego-dystonic” meaning they are not what the person wants to think about and do NOT reflect what the person wants to do. Most people will acknowledge that their fear is irrational or illogical despite the fact that they continue to feel very distressed and anxious. As an individual experiences these obsessions, they inherently seek relief. Relief is found (at least temporarily) in completing compulsions that the person feels driven to perform.

Compulsions

Compulsions are most often repetitive and are either not realistically connected to the feared outcome or are excessive. Compulsions can vary considerably from person to person. However, common compulsion include: avoidance, washing, cleaning, checking, arranging, ordering, touching/tapping, seeking reassurance, asking repetitive questions, completing mental rituals or rumination, praying, confessing, reading/researching excessively, and “checking” feelings or body sensations. Compulsions often become rigid and extremely time consuming. People with OCD typically become very anxious and distressed if they are unable to complete their compulsion. In addition, the person with OCD often ends up involving others in completing their compulsions, all in the attempt to keep the obsessions and anxiety/distress at bay.

The OCD Cycle

As relief is typically experienced right after the completion of the compulsion, the compulsion becomes reinforced, and an increasing dependency on the compulsion is formed. Similarly, as the person engages in the compulsion the brain comes to interpret the act of completing of the compulsion as a reinforcement that the obsession/fear is an actual threat. As a result, the person becomes increasingly fearful and distressed about their obsessions and increasingly dependent on completing compulsions. Thus, the cycle of OCD is reinforced and tends to expand and become more consuming over time.

Treatment

Fortunately, there are a number of evidenced based treatments that are available to treat OCD that include cognitive-behavioral approaches and pharmacological treatments. Exposure and Response Prevention (ERP) is an evidence based, first line treatment for OCD. Acceptance and Commitment Therapy (ACT) is an adjunctive treatment that has been shown to enhance the treatment response of ERP. As a specialist with over 20 years in treating OCD, I provide ERP therapy sessions from once per week to multiple times per week depending on the severity of a person’s symptoms. Similarly, I integrate ACT treatment as needed. Treatment can be completed in person at my office, via online teletherapy, off-site, or at a person’s home when it is determined clinically beneficial. Referrals can also be made to psychiatrists who are able to provide pharmacological (medication) treatment for OCD. Often ERP and medication treatment is used together. When clients are participating in pharmacological treatment, collaborating with the involved psychiatrist is important to coordinate best care. For those with more severe symptoms referral to more intensive outpatient, inpatient, or residential programs is available.

Body Dysmorphic Disorder (BDD)

BDD is a distressing condition in which a person becomes preoccupied about some aspect of their physical appearance. While the flaws that the person is preoccupied with are considered to be minor or within normal variation by others, for the person with BDD, the flaws are very real and noticeable. Similar to OCD, the person with BDD engages in ritualistic, repetitive physical or mental behaviors aimed at reducing their distress and the perceived “flaws” that they see. Individuals who have BDD are not merely vain or “superficial” in terms of “only caring about appearances”. Instead, they are convinced and unable to stop thinking about their belief that their appearance is extremely disfigured or flawed in some way. While there has been little research on BDD, it is believed that both genetic predispositions and environmental factors play a role in its development.

Cycle of BDD

BDD has a self-reinforcing cycle in which excessive preoccupation leads to compulsive rituals that temporarily reduce the feelings of distress. The resulting reduction in distress leads to a reliance on the compulsions. The engagement in the compulsions reinforces to the brain that there is truly something wrong. As this occurs the person with BDD typically becomes increasingly convinced that there is something very flawed about their appearance.

Preoccupations

In individuals with BDD, the preoccupation of the flaws takes up a minimum of at least one hour of the day and is considered very distressing. The distress can become so severe that the person has difficulty engaging in daily life activities. The most common of the preoccupations are of the head or face (i.e. hair, nose, skin, eyes, chin, jaw, neck, face size or shape). However, any part of the body can become an area of concern and focus. Whereas people with OCD tend to have a degree of insight into the illogical nature of their obsessions, people with BDD tend to really believe that their perceptions of themselves is accurate. Despite feedback that their appearance is fine, people with BDD will often think others are just trying to be nice and not being honest with them.

Compulsive Rituals

Individuals with BDD can engage in a variety of different behaviors that commonly include: avoidance of being seen, keeping the “disfigured” aspect of themselves hidden, checking their reflection in mirrors, avoiding their reflection in mirrors, camouflaging their appearance with clothing or makeup, avoiding being seen on camera or video, comparing their appearance to others, seeking reassurance from others, or picking/ scraping their skin or body part in an attempt to “fix” what they see as a disfigurement.

Impact on the Person

BDD occurs on a spectrum of mild to severe. At the severe end it can completely consume a person’s life. Individuals can refuse to leave the house or be seen, unable to go to school, to see friends or family, or go to work. Depression and anxiety often occur with BDD as the person comes to belief that they cannot live their life with their disfigurement.

Treatment

Treatment is available to help individuals who suffer with BDD. However, it is often more difficult for people with BDD to engage in treatment because they do not think they have a psychological disorder. Rather they think they are truly disfigured. As a result, their answer is to seek cosmetic, dermatologic, and dental treatments to “fix” their physical appearance rather than to seek treatment for a psychological disorder.

As a specialist in treating people who suffer from BDD I often utilize motivational techniques and psychoeducation to increase both insight in my clients’ condition and their commitment to the therapeutic process. I utilize cognitive therapy techniques to help clients examine the thoughts and distortions that are reinforcing their distorted perceptions. Exposure and Response Prevention is used to reduce the compulsive behaviors and increase the client’s distress tolerance to their upsetting thoughts and perceptions. Finally, I work with clients on retraining how they look at their reflection/appearance in general, how closely they may get to the mirror, what they say to themselves when looking at their body, and what they focus on when looking at their appearance. My work with clients who struggle with BDD can be a combination of in-person office visits, online teletherapy visits, off-site visits and possibly home visits when clinically beneficial. Referrals are available to psychiatrists for pharmacological (medication) treatment, and to intensive out-patient programs, in-patient programs, and residential treatment centers when needed.

Body Focused Repetitive Disorders (BFRB’s)

BFRB’s are a group of conditions in which a person engages in repetitive behaviors (essentially “grooming behaviors” such as picking, pulling, chewing, and biting) that lead to unintentional injury and damage to the body. People who suffer from BFRB’s often feel an intense, uncontrollable urge to engage in the behavior despite knowing that they will dislike the negative consequences that occur.

A complex interplay between genetics, brain structure, temperament, and environmental stress factors are thought to lead to the development of BFRD’s. BFRD’s can affect people of all ages. The most common BFRB’s include hair-pulling, skin-picking, nail-biting, and cheek biting. Other BFRB’s include hair eating, nail-picking, skin-biting, lip-biting, tongue-chewing, and hair-cutting.

Cycle of BFRB’s

Unlike OCD or BDD, the repetitive behaviors in BFRB’s provide a sense of pleasure, relief or enjoyment. This sense of relief/pleasure/enjoyment often becomes a coping mechanism for dealing with other painful feelings a person might be feeling. As the person increasingly uses the repetitive behavior to cope with uncomfortable feelings, a powerful reinforcing cycle of behavior develops. Over time it becomes increasingly difficult to resist picking, pulling, biting etc.., despite the increasing awareness of the damage that is being caused to the body. The damage can include hair loss and balding on some part of the body, painful sores, wounds and scarring on the skin, mouth, lips, and scalp, and damage to nails, cuticles and nailbed. The awareness not only of the resulting damaging physical effects, but also that the behaviors are becoming increasingly difficult to control, leads to a sense of shame, embarrassment and low self-worth. While this awareness may temporarily help a person to refrain from engaging in the behaviors, it is typically short-lived. The dependency to use these behaviors as a coping mechanism is strong and leads to engaging in the behaviors once again.

Impact on the Person

Individuals who are trapped in the cycle of BFRD’s can often experience feelings of depression, anxiety, shame, guilt, and low-self-worth as they struggle to control their urges. BFRD’s can become time-consuming and lead many hours of lost time. The physical consequences of hair loss and wounds on the skin can also lead to medical complications from infection and damage to the body. Issues of self-consciousness, anxiety in social situations, and increased isolation are common as people seek to hide the physical symptoms of their condition.

Treatment

The good news is that both therapeutic and pharmacological treatments are available to treat BFRB’s. In treating clients who struggle with a BFRB, I utilize Habit Reversal Therapy (HRT) which is the primary treatment of choice. Adjunctive treatments include Acceptance and Commitment Therapy and Dialectical Behavior Therapy. While treatment takes commitment, patience, and time individuals can regain a sense of empowerment in learning to utilize alternate healthy coping methods to break the cycle of BFRB’s and to cope with uncomfortable feelings without causing damage to their bodies. When needed referrals for pharmacotherapy (medication treatment) from a psychiatrist can also be provided.

Depression

Depression is a common condition that affects a person’s mood, thinking, perceptions, feelings, and behavior. It is thought to be caused by a number of factors that include one’s biology, brain chemistry, hormones, genetics and environmental/life experiences. Depression is much more than a short bout of feeling down or sad and is not something someone can just “snap out of”. It is a serious condition in which a person experiences symptoms most of the day, nearly every day, for more than two-weeks and interrupts a person’s day-to-day functioning at school and work and in hobbies and personal relationships. As more severe depression can lead to difficulty functioning it often requires therapeutic and pharmacological treatment. Severe depression when left untreated can lead to feelings of suicidality and even suicide attempts. While some people may only have one episode of depression in their lifetime, others can have multiple episodes.

Symptoms

People who suffer from depression often have a loss of interest in normal activities, feel tired with a loss of energy, have feelings of worthlessness and guilt, have difficulty concentrating, making decisions or remembering things, have a change in appetite and sleep, and have thoughts of death and even suicide. In young children depression may also present with sadness, irritability, clinginess, worry, aches and somatic complaints. In teens, symptoms can include, sadness, feelings of worthlessness, poor school performance and attendance, anger, feelings of being misunderstood, use of recreational drugs or alcohol, changes in eating and sleeping habits, self-harm, loss of interest in normal activities, and increased social isolation.

Treatment

Thankfully Clinical Depression is very treatable through psychotherapy and pharmacotherapy (medication). It is important for someone with depression to feel a connection with others and to be reminded that there is hope and that things can change. As a therapist who treats depression I seek to “walk” with my clients as they participate in treatment toward recovery. The most common effective form of therapeutic treatment is Cognitive Behavioral Therapy (CBT). I incorporate many CBT techniques such as identifying and challenging unhealthy thought patterns and changing unhealthy behavioral patterns that are reinforcing depression. Interpersonal Therapy can be very important in helping someone identify and improve relationships in their life that may be unhealthy and causing pain. Setting small goals, structuring one’s day, increasing social connection and utilizing behavioral activation such as incorporating exercise are also very helpful in addressing the difference facets of depression. Working through painful life events and learning how to express one’s feelings through healthy coping styles is often a part of a person’s recovery. When medication treatment is needed, I provide referrals to and coordinate with treating psychiatrists.

Generalized Anxiety Disorder (GAD)

Individuals with GAD often state that they have persistent feelings of doom and worry that follow them throughout each day. Their worry can be about all kinds of things including money, school, tests, health, family, work, social issues, relationships, life events, and the future. With GAD a person often expects “the worst”. Their worry is very difficult to control and is exaggerated as compared to the actual events that they are worried about. Someone with GAD cannot simply “stop worrying” as they are often told by others. It is not uncommon for people with GAD to also experience headaches, stomachaches and other physical symptoms of distress.

The exact cause of GAD is not known; however, it is believed that family background, biology, life experiences (especially stressful ones) all play a role. While some people with mild GAD may still be able to function and go to school and/or work, enjoy relationships with others, and make and achieve goals, others with more severe symptoms may struggle simply trying to function on a daily basis. People with more severe anxiety often find it difficult to accomplish even small tasks.

Treatment

When treating someone with GAD I use a variety of techniques that address the different facets of the disorder. By teaching clients how to use a variety of tools and addressing the different symptoms of the disorder they are better able to learn how to manage their anxiety and change how they interact with the world.

Cognitive-Behavioral Therapy (CBT) is one of the primary therapeutic treatments for GAD. CBT techniques include identifying and changing unhealthy thoughts, thought patterns and behavioral patterns. Learning relaxation techniques such as Progressive Relaxation as well as breathing techniques (that help to calm the nervous system) can help a person move from being in a constant state of arousal to one of being calm and more relaxed. Mindfulness training can be very effective in helping a person focus on the present moment rather than worrying about future events. Problem-solving training can help a person move from a cycle of circular rumination of worries to actively deciding on how to take steps toward resolution. As with most anxiety disorders, intolerance of the unknown, distress and of risk is common. Acceptance and Commitment Therapy (ACT) is helpful in teaching clients how to accept and tolerate feelings of distress and anxiety while learning they can still go about their lives and attend to the things they can control.

Social Anxiety Disorder (SAD)

Social Anxiety Disorder (SAD) is more than just “shyness”. It is a potentially severe form of anxiety that disrupts a person’s ability to engage in life in the way they otherwise would. People with Social Anxiety Disorder often go years without seeking treatment. It often begins in adolescence and is one of the most common anxiety disorders. It can disrupt a person’s life negatively impacting one’s occupation, ability to meet new people or spend time with friends, attend school, present or speak up in groups or meetings, or achieve goals. People who suffer from SAD often miss out on social and occupational occasions and may spend time isolating and avoiding circumstances where they may have to interact with others.

The primary fear for people with SAD is the fear of being judged, embarrassed, negatively evaluated or rejected in some way. When asked what their fear is, they will often say “being viewed as boring, weird, stupid, dumb or awkward”. In addition, when unable to avoid social situations, people with more severe social anxiety may experience physical symptoms such as rapid heart rate, nausea, sweating, shaking hands, and even panic attacks. Unfortunately, appearing anxious, shaking, trembling, or faltering over ones’ words are some of the very things people with social anxiety fear.

Cycle of Social Anxiety

As with most types of anxiety a typical response is to want to avoid the thing that makes one anxious. And, as with most anxiety disorders the act of avoidance inevitably reinforces the fear by teaching the brain that the feared object, person, thought, feelings etc. is truly something to be feared. As with other disorders, the avoidance (of social situations in this disorder) ultimately reinforces the anxiety and makes it worse. Over time the avoidance and anxiety tends to grow and makes it increasingly difficult for the individual to participate in life.

Treatment

Social anxiety is very treatable. This is important as untreated social anxiety has been linked to higher rates of depression, substance abuse, loneliness and other anxiety disorders. In treating social anxiety, I utilize CBT which is considered the gold standard of treatment for SAD. There are different parts of CBT that each seek to address the different aspects of SAD. Cognitive strategies are used to help individuals challenge the distorted thoughts that perpetuate anxiety and negative self-appraisal. Exposure therapy is used to help individuals face and master their fears in small, manageable steps while practicing social skills and using healthier self-talk and coping skills. Mindfulness is helpful in developing increased awareness of one’s thoughts, feelings, internal experience, and bodily sensations in a more objective and less judgmental manner. Breathing and relaxation techniques help to counteract anxious physiological reactions and increase ones’ ability to remain grounded and “present”. When used together, all these techniques give individuals a chance to not only experience success but also learn that they can tolerate and overcome situations in which they might feel embarrassed or potentially judged. Ultimately, individuals with SAD can engage in and fully participate in life without the previous avoidance, fear and anxiety. When needed referrals to a psychiatrist for pharmacotherapy (medication treatment) is available.

Panic Disorder

Panic attacks are experienced as sudden, very intense feelings of anxiety that are accompanied with a variety of symptoms, many of which are physiological. Those symptoms may include: palpitations, pounding and/or rapid heart rate, sweating, trembling/shaking, feelings of shortness of breath or choking, chest pain, nausea or abdominal distress, dizziness, lightheadedness, numbness or tingling sensations, derealization, fear of losing control or going crazy, and fear of dying. Panic attacks tend to pass fairly quickly, typically reaching a peak within 10 minutes or less and then subsiding. It is not uncommon for people who experience a panic attack to think they are having a medical emergency such as a heart attack and to go to the emergency room.

Panic attacks can occur in the absence of any readily identifiable trigger as well as in the context of another psychological disorder. No matter how they are experienced, they are considered very frightening. The distress caused by the panic attack itself is what typically causes people with Panic Disorder to become most afraid of the panic attack itself. As a result, people with Panic Disorder often become avoidant of experiences or potential triggers that might cause a panic attack to occur again.

Cycle of Social Anxiety

As with most other anxiety disorders, the tendency to avoid having another panic attack reinforces the belief that the experience is intolerable and must be avoided at all cost. The avoidance in turn reinforces the fear of another attack which then leads to more avoidance. As the cycle grows, a person with severe Panic Disorder may avoid school, work, or any other situation in which they fear an attack could happen.

Treatment

Education about what a panic attack is and the fact that it is not dangerous and does not mean the person is “going crazy” is a very helpful and important first step in treatment. As with most other anxiety disorders, Cognitive Behavioral Therapy is the treatment of choice. Learning to identify any triggers for the panic attacks is helpful in developing awareness of and ultimately learning to face the triggers. Since it’s the panic attack itself that is most feared, it is very important that treatment address the symptoms of the panic attack itself. This can be accomplished through interoceptive exposures. Interoceptive exposures are tasks in which a person learns to face and experience the physiological symptoms of a panic attack (such as increased heart rate, difficulty breathing, hot flashes, dizziness etc.) while learning how to tolerate the symptoms. Relaxation and breathing techniques are used to help individuals learn how to manage the physiological symptoms and return their body to a calmer state. Exposure therapy is useful in helping individuals begin to face their feared triggers and situations while managing symptoms and learning how to remain relaxed and calm. Acceptance and Commitment Therapy is a newer therapy that helps people learn to tolerate feeling anxious and remain committed to a value driven goal despite the anxiety. When needed, referral to a psychiatrist for pharmacotherapy (medication treatment) is also available.

Tics/Tourette’s

Tics are sudden movements, twitches, or sounds that are predominantly involuntary or semi-voluntary and occur in a person repeatedly. Most individuals feel an “urge” to tic just prior to the tic, called a premonitory urge. While individuals can sometimes suppress the tic for some time, the tic will typically occur at some point. Movements of the body (facial contortions, arm jerking, eye blinking, hopping, jaw movements, head and shoulder movements etc.) are considered “motor tics”, whereas sounds (words, utterances, throat clearing, sniffing, grunting etc.) are considered “vocal tics”. Tics can range from being mild (in terms of intensity and frequency) to severe. Many mild tics are not very noticeable and aren’t disruptive to a person. Although less common, at the other end of the spectrum tics can become very severe, disruptive, and can lead to physical distress and even injury.

Tics typically start between ages 5-7, peak at approximately 12 years of age and are present more often in boys. Tics tend to come in waves; they come and go. Sometimes there are patterns and triggers for tics (i.e. stress, anxiety, excitement). Other times there isn’t an identifiable trigger.

It is important to know that many children experience tics at some point during childhood. Experiencing tics doesn’t necessarily mean someone has a tic disorder. Most often the tics are not disruptive, treatment is not needed, and the child grows out of the tics. However, when tics are more severe and occur over the course of a year, either a Tic Disorder or Tourette’s may be diagnosed. Tic disorders and Tourette’s are considered heritable neurological conditions. A Tic Disorder is typically diagnosed when a person experiences only motor tics, or only vocal tics for more than one year. Tourette’s is only diagnosed with someone experiences both motor and vocal tics for more than one year.

How to Determine When Treatment is Needed

Treatment is not always needed or advised for Tics. As mentioned earlier, it is not uncommon for many children to experience some tics during early childhood. Treatment is typically NOT needed when tics: are infrequent and not disruptive, do not bother the child/person, do not interrupt a person’s ability to function in daily life or to achieve life goals, and do not present a physical danger to oneself or to others. In situations where the tic is disruptive, frequent, interrupts daily life, impacts ability to function and achieve life goals, or is a danger to oneself or others then treatment is more likely to be advised. Since tics are most common and intense during childhood, treatment is most often provided to children and young teenagers. However, adults who continue to experience significant tics and want to learn how to manage and minimize the negative effects of the tics on their life can also benefit from treatment.

It is important to note that parents commonly seek treatment for their children when they observe their child experiencing tics. Parents are often worried that the tics will adversely affect their child’s social or interpersonal development. If the tic doesn’t present a physical danger, isn’t bothering the child, and doesn’t get in the way of the child engaging in daily life it is typically recommended not to bring attention to the tic, not mention it to the child (if the child is unaware of the tic), and instead “wait and see” to see if the tic goes away on its own. If the child expresses distress in some way due to the tic or if the tic increases in severity and becomes more disruptive then it can be helpful to seek a professional assessment to see if treatment is recommended.

Impact of Tics/Tourette’s

In severe cases of tics/Tourette’s an individual can experience tics for much of the day and struggle to engage in daily tasks. In those situations, individuals can become increasingly frustrated, self-conscious, anxious, depressed and isolated. Unfortunately, when tics become more disruptive the person with the tics tends to become increasingly anxious and stressed about the thought of having the tics. That anticipatory stress and anxiety in turn tends to make the tics more likely and more intense. For people with loud vocal tics, the disturbing nature of the tic in certain social situations can become agonizing to experience.

Treatment

There are two primary forms of treatment for tics; therapeutic and pharmacologic (medication). The primary therapeutic treatment is called Cognitive Behavioral Intervention for Tics (CBIT). CBIT involves education and increasing awareness of a person’s urge to tic, the motor or vocal tic itself, tic patterns, and triggers. I ask my clients (and often the parents of the child) to log when, where and what types of tics occur throughout the week. This awareness helps to identify the environmental triggers and patterns that most frequently occur during tics as well as the times in which the tics don’t frequently occur. Gathering this information is instrumental in developing how to best treat the tics. During therapeutic sessions I help clients to increase their self-awareness of the premonitory urge to tic. This awareness is important as the intervention for the tic works best when it is used as soon as the urge is felt. Finally, I teach clients how to develop and engage in a “competing behavior” when they feel the urge to tic. A competing behavior is something the person does to make the tic less likely to occur. Often competing behaviors involves engaging the same muscle group (that the tic utilizes) to do something different. For example, someone with a shoulder shrugging tic may be encouraged to purposely pull their shoulders in a downward manner, holding them in that position, until the urge to tic decreases or passes entirely. While it may not be possible to eliminate all tics, it is often possible to help reduce the frequency and severity of the tic, or to “shape” the tic into something less disruptive. A National Institute of Health funded study found that more than half of the people who participate in CBIT have significant reduction in tic severity and improved ability to function.

When needed I can provide referrals to psychiatrists or neurologists for pharmacotherapy (medication treatment). Typically, medication treatment is used in conjunction with CBIT>