Generalized Anxiety Disorder Ageing Emotional Functioning Peer Reviewed Journal
Diagnosis and Direction of Generalized Anxiety Disorder and Panic Disorder in Adults
Am Fam Md. 2015 May i;91(nine):617-624.
Patient information: Meet related handout on anxiety and panic disorders, written past the authors of this article.
This clinical content conforms to AAFP criteria for continuing medical instruction (CME). Run across the CME Quiz Questions.
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Commodity Sections
- Abstract
- Epidemiology, Etiology, and Pathophysiology
- Typical Presentation and Diagnostic Criteria
- Differential Diagnosis and Comorbidity
- Treatment
- Referral and Prevention
- References
Generalized feet disorder (GAD) and panic disorder (PD) are among the most common mental disorders in the Us, and they tin can negatively impact a patient's quality of life and disrupt important activities of daily living. Prove suggests that the rates of missed diagnoses and misdiagnosis of GAD and PD are high, with symptoms oft ascribed to concrete causes. Diagnosing GAD and PD requires a broad differential and circumspection to identify confounding variables and comorbid atmospheric condition. Screening and monitoring tools tin can be used to help make the diagnosis and monitor response to therapy. The GAD-seven and the Severity Measure out for Panic Disorder are free diagnostic tools. Successful outcomes may crave a combination of treatment modalities tailored to the individual patient. Treatment often includes medications such as selective serotonin reuptake inhibitors and/or psychotherapy, both of which are highly constructive. Among psychotherapeutic treatments, cognitive beliefs therapy has been studied widely and has an extensive evidence base of operations. Benzodiazepines are effective in reducing feet symptoms, but their use is limited by risk of abuse and adverse issue profiles. Physical activity tin reduce symptoms of GAD and PD. A number of complementary and alternative treatments are frequently used; all the same, evidence is limited for most. Several common botanicals and supplements can potentiate serotonin syndrome when used in combination with antidepressants. Medication should be continued for 12 months before tapering to prevent relapse.
Generalized anxiety disorder (GAD) and panic disorder (PD) are among the virtually common mental disorders in the United states and are ofttimes encountered by primary care physicians. The hallmark of GAD is excessive, out-of-control worry, and PD is characterized past recurrent and unexpected panic attacks. Both atmospheric condition tin negatively impact a patient'south quality of life and disrupt important activities of daily living. The rates of missed diagnoses and misdiagnosis of GAD and PD are high, with symptoms often ascribed to physical causes.
This article reviews the diagnosis and direction of GAD and PD in adults. Diagnosis and care of children and adolescents with these conditions require special considerations that are beyond the scope of this review.
SORT: KEY RECOMMENDATIONS FOR Practice
| Clinical recommendation | Evidence rating | References |
|---|---|---|
| Physical activeness is a cost-effective treatment for GAD and PD. | B | xvi, 17 |
| Selective serotonin reuptake inhibitors are considered first-line therapy for GAD and PD. | B | 19, 20, 22 |
| To avoid relapse, medication should be connected for 12 months after symptoms ameliorate before tapering. | C | eleven |
| When used in combination with antidepressants, benzodiazepines may speed recovery from anxiety-related symptoms only exercise non improve longer-term outcomes. Because benzodiazepines are associated with tolerance, they should be used only short term during crises. | B | eleven, 28–xxx |
| Psychotherapy can be equally constructive as medication for GAD and PD. Cognitive behavior therapy has the best level of evidence. | A | 11, 37 |
| Successful treatment requires tailoring options to individuals and may often include a combination of modalities. | C | 11, 37, 42 |
Epidemiology, Etiology, and Pathophysiology
- Abstract
- Epidemiology, Etiology, and Pathophysiology
- Typical Presentation and Diagnostic Criteria
- Differential Diagnosis and Comorbidity
- Treatment
- Referral and Prevention
- References
The 12-month prevalence for GAD and PD amidst U.S. adults 18 to 64 years of age is 2.ix% and 3.ane%, respectively. In this population, the lifetime prevalence is 7.7% in women and iv.half-dozen% in men for GAD, and is 7.0% in women and 3.3% in men for PD.1
The etiology of GAD is non well understood. At that place are several theoretical models, each with varying degrees of empirical support. An underlying theme to several models is the dysregulation of worry. Emerging bear witness suggests that patients with GAD may experience persistent activation of areas of the brain associated with mental activity and introspective thinking following worry-inducing stimuli.2 Twin studies advise that ecology and genetic factors are likely involved.3
The etiology of PD is also non well understood. The neuroanatomical hypothesis suggests that a genetic-environment interaction is likely responsible. Patients with PD may exhibit irregularities in specific brain structures, altered neuronal processes, and dysfunctional corticolimbic interaction during emotional processing.iv
Typical Presentation and Diagnostic Criteria
- Abstract
- Epidemiology, Etiology, and Pathophysiology
- Typical Presentation and Diagnostic Criteria
- Differential Diagnosis and Comorbidity
- Treatment
- Referral and Prevention
- References
GENERALIZED ANXIETY DISORDER
Patients with GAD typically present with excessive anxiety about ordinary, day-today situations. The anxiety is intrusive, causes distress or functional damage, and often encompasses multiple domains (e.thou., finances, work, wellness). The anxiety is oft associated with physical symptoms, such as sleep disturbance, restlessness, muscle tension, gastrointestinal symptoms, and chronic headaches.5 Diagnostic and Statistical Manual of Mental Disorders, fifth ed, (DSM-5) diagnostic criteria for GAD are listed in Table i.v Some factors associated with GAD include female sex, unmarried condition, lower teaching level, poor health, and presence of life stressors.6 The age of onset is variable, with a median age of 30 years.ane
Table 1.
Diagnostic Criteria for Generalized Feet Disorder
| A. Excessive feet and worry (humble expectation), occurring more than days than not for at to the lowest degree half dozen months, almost a number of events or activities (such as work or school functioning). | |
| B. The individual finds it difficult to control the worry. | |
| C. The feet and worry are associated with iii (or more) of the post-obit six symptoms (with at to the lowest degree some symptoms having been nowadays for more than days than not for the past half-dozen months): | |
| Note: But one item is required in children. | |
| 1. Restlessness or feeling keyed upwards or on edge. | |
| 2. Beingness easily drawn. | |
| iii. Difficulty concentrating or mind going blank. | |
| 4. Irritability. | |
| five. Muscle tension. | |
| 6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep). | |
| D. The anxiety, worry, or concrete symptoms cause clinically significant distress or impairment in social, occupational, or other of import areas of operation. | |
| E. The disturbance is not attributable to the physiological furnishings of a substance (e.yard., a drug of abuse, a medication) or another medical condition (e.one thousand., hyperthyroidism). | |
| F. The disturbance is not better explained by another mental disorder (e.g., feet or worry near having panic attacks in panic disorder, negative evaluation in social feet disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in affliction anxiety disorder, or the content of delusional behavior in schizophrenia or delusional disorder). | |
A number of scales are available to establish diagnosis and appraise severity. The GAD-7 (Table two7) has been validated as a diagnostic tool and a severity assessment calibration, with a score of 10 or more having good diagnostic sensitivity and specificity.viii Greater GAD-7 scores correlate with more functional damage.8 The scale was developed and validated based on DSM-IV criteria, but it remains clinically useful later on publication of the DSM-five because the differences in GAD diagnostic criteria are minimal. The PRO-MIS Emotional Distress–Anxiety–Short Form for adults and the Severity Mensurate for Generalized Anxiety Disorder–Developed, available from the American Psychiatric Association at http://www.psychiatry.org/exercise/dsm/dsm5/online-cess-measures, are intended to aid clinical evaluation of GAD and monitor treatment effectiveness.
Tabular array 2.
GAD-7 Screening Tool
| Over the last two weeks, how oft have you been bothered past the following problems? | Not at all | Several days | More than half the days | Nigh every day |
|---|---|---|---|---|
| (Utilise "✓" to indicate your answer) | ||||
| ane. Feeling nervous, anxious, or on edge | 0 | one | two | 3 |
| 2. Non being able to finish or control worrying | 0 | 1 | 2 | 3 |
| 3. Worrying too much virtually dissimilar things | 0 | 1 | 2 | three |
| 4. Problem relaxing | 0 | 1 | ii | three |
| 5. Beingness so restless that it is hard to sit down still | 0 | i | ii | iii |
| six. Becoming hands bellyaching or irritable | 0 | i | 2 | 3 |
| 7. Feeling afraid as if something awful might happen | 0 | 1 | 2 | 3 |
| Total score_____ | =___ | +___ | +___ | +___ |
PANIC DISORDER
PD is characterized by episodic, unexpected panic attacks that occur without a clear trigger.5 Panic attacks are defined by the rapid onset of intense fearfulness (typically peaking within about ten minutes) with at least four of the physical and psychological symptoms in the DSM-v diagnostic criteria (Tabular array iii).5 Another requirement for the diagnosis of PD is that the patient worries about further attacks or modifies his or her behavior in maladaptive ways to avert them. The most common concrete symptom accompanying panic attacks is palpitations.ix Although unexpected panic attacks are required for the diagnosis, many patients with PD also have expected panic attacks, occurring in response to a known trigger.9 The Severity Mensurate for Panic Disorder–Adult (http://www.psychiatry.org/File%20Library/Practice/DSM/DSM-v/SeverityMeasureForPanicDisorderAdult.pdf) is an cess scale that can complement the clinical assessment of patients with PD.
Table 3.
Diagnostic Criteria for Panic Disorder
| A. Recurrent unexpected panic attacks. A panic attack is an sharp surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur: | |
| Note: The abrupt surge can occur from a calm land or an anxious state. | |
| 1. Palpitations, pounding middle, or accelerated middle rate. | |
| ii. Sweating. | |
| 3. Trembling or shaking. | |
| 4. Sensations of shortness of jiff or smothering. | |
| 5. Feelings of choking. | |
| 6. Chest pain or discomfort. | |
| 7. Nausea or abdominal distress. | |
| 8. Feeling empty-headed, unsteady, lite-headed, or faint. | |
| 9. Chills or oestrus sensations. | |
| 10. Paresthesias (numbness or tingling sensations). | |
| 11. Derealization (feelings of unreality) or depersonalization (being detached from oneself). | |
| 12. Fear of losing control or "going crazy." | |
| 13. Fright of dying. | |
| Note: Culture-specific symptoms (e.yard., tinnitus, cervix soreness, headache, uncontrollable screaming or crying) may exist seen. Such symptoms should non count equally one of the four required symptoms. | |
| B. At least one of the attacks has been followed past 1 month (or more) of one or both of the following: | |
| i. Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart set on, "going crazy"). | |
| two. A pregnant maladaptive modify in beliefs related to the attacks (e.g., behaviors designed to avoid having panic attacks, such equally abstention of exercise or unfamiliar situations). | |
| C. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or some other medical condition (eastward.m., hyperthyroidism, cardiopulmonary disorders). | |
| D. The disturbance is non better explained by some other mental disorder (e.g., the panic attacks do not occur merely in response to feared social situations, as in social anxiety disorder; in response to confining phobic objects or situations, as in specific phobia; in response to obsessions, as in obsessive-compulsive disorder; in response to reminders of traumatic events, every bit in posttraumatic stress disorder; or in response to separation from zipper figures, equally in separation feet disorder). | |
Differential Diagnosis and Comorbidity
- Abstruse
- Epidemiology, Etiology, and Pathophysiology
- Typical Presentation and Diagnostic Criteria
- Differential Diagnosis and Comorbidity
- Treatment
- Referral and Prevention
- References
When evaluating a patient for a suspected anxiety disorder, it is important to exclude medical conditions with similar presentations (e.g., endocrine conditions such as hyperthyroidism, pheochromocytoma, or hyperparathyroidism; cardiopulmonary weather such equally arrhythmia or obstructive pulmonary diseases; neurologic diseases such equally temporal lobe epilepsy or transient ischemic attacks). Other psychiatric disorders (e.grand., other anxiety disorders, major depressive disorder, bipolar disorder); utilize of substances such as caffeine, albuterol, levothyroxine, or decongestants; or substance withdrawal may also present with like symptoms and should be ruled out.5
Complicating the diagnosis of GAD and PD is that many atmospheric condition in the differential diagnosis are too mutual comorbidities. Additionally, many patients with GAD or PD meet criteria for other psychiatric disorders, including major depressive disorder and social phobia. Evidence suggests that GAD and PD usually occur with at least one other psychiatric disorder, such as mood, anxiety, or substance use disorders.ten When anxiety disorders occur with other conditions, historic, physical, and laboratory findings may be helpful in distinguishing each diagnosis and developing appropriate handling plans.
Treatment
- Abstruse
- Epidemiology, Etiology, and Pathophysiology
- Typical Presentation and Diagnostic Criteria
- Differential Diagnosis and Comorbidity
- Handling
- Referral and Prevention
- References
Some studies evaluating anxiety treatments appraise not-specific feet-related symptoms rather than the set of symptoms that characterize GAD or PD. When possible, the treatments described in this section will differentiate betwixt GAD and PD; otherwise, treatments refer to feet-related symptoms in general.
Medication or psychotherapy is a reasonable initial treatment selection for GAD and PD.11 Some studies suggest that combining medication and psychotherapy may be more than constructive for patients with moderate to severe symptoms.12 The National Institute for Health and Care Excellence (NICE) guidelines on GAD and PD in adults are a useful review of available evidence; yet, information about self-help and group therapies may accept less utility in the United states of america because of their relative lack of availability.xi
Education
Empathetic listening and education are an important foundation in the treatment of anxiety disorders.eleven Patient education itself can assist reduce anxiety, specially in PD.13 The institution of a therapeutic alliance between the patient and physician is of import to allay fears of interventions and to progress toward treatment.
Mutual lifestyle recommendations that may reduce anxiety-related symptoms include identifying and removing possible triggers (e.k., caffeine, stimulants, nicotine, dietary triggers, stress), and improving slumber quality/quantity and concrete action.
Caffeine tin trigger PD and other types of feet. Those with PD may be more sensitive to caffeine than the full general population because of genetic polymorphisms in adenosine receptors.14 Smoking cessation leads to improved feet scores, with relapse leading to increased anxiety. Many studies show an clan between disordered sleep and anxiety, but causality is unclear.15 In addition to decreased depression and feet, physical activity is associated with improved physical health, life satisfaction, cerebral functioning, and psychological well-being. Physical activeness is a cost-effective approach in the handling of GAD and PD.16,17 Exercising at 60% to 90% of maximal heart rate for 20 minutes 3 times weekly has been shown to decrease anxiety16; yoga is as well effective.18
MEDICATION
Commencement-Line Therapies. A number of medications are available for treating feet (Table 4). Selective serotonin reuptake inhibitors (SSRIs) are generally considered first-line therapy for GAD and PD.nineteen–22 Tricyclic antidepressants (TCAs) are better studied for PD, but are thought to be constructive for both GAD and PD.19,xx In the treatment of PD, TCAs are equally effective as SSRIs, merely adverse effects may limit the use of TCAs in some patients.23 Venlafaxine, extended release, is constructive and well tolerated for GAD and PD, whereas duloxetine (Cymbalta) has been adequately evaluated just for GAD.24 Azapirones, such as buspirone (Buspar), are meliorate than placebo for GAD25 but do not appear to be effective for PD.26 Mixed testify suggests bupropion (Wellbutrin) may have anxiogenic effects for some patients, thus warranting close monitoring if used for treatment of comorbid depression, seasonal affective disorder, or smoking cessation.27 Bupropion is not approved for the treatment of GAD or PD.
Tabular array 4.
Medications for the Treatment of Generalized Anxiety Disorder and Panic Disorder
| Medication | Estimated cost* | |
|---|---|---|
| First line | ||
| Selective serotonin reuptake inhibitors | ||
| Escitalopram (Lexapro) | $25 ($190) | |
| Fluoxetine (Prozac) | $five ($250) | |
| Fluvoxamine for PD | $fifteen (NA) | |
| Paroxetine (Paxil) | $5 ($150) | |
| Sertraline (Zoloft) | $10 ($200) | |
| Serotonin-norepinephrine reuptake inhibitors | ||
| Duloxetine (Cymbalta) for GAD | $50 ($210) | |
| Venlafaxine, extended release (Effexor XR) | $15 ($230) | |
| Azapirone | ||
| Buspirone (Buspar) for GAD | $v ($87) | |
| 2nd line | ||
| Tricyclic antidepressants | ||
| Amitriptyline† | $5 (NA) | |
| Imipramine (Tofranil)‡ | $ten ($265) | |
| Nortriptyline (Pamelor)† | $10 ($725) | |
| Antiepileptics | ||
| Pregabalin (Lyrica)† for GAD | NA ($145) | |
| Antipsychotics | ||
| Quetiapine (Seroquel)† for GAD | $xv ($130) | |
| Hydroxyzine (Vistaril) | $12 ($200) | |
| Third line | ||
| Monoamine oxidase inhibitors§ | ||
| Isocarboxazid (Marplan)† | NA ($130) | |
| Phenelzine (Nardil)† | $20 ($l) | |
| Tranylcypromine (Parnate)† | $l ($185) | |
| Augmentation | ||
| Benzodiazepines|| | ||
| Alprazolam (Xanax) ¶ | $10 ($seventy) | |
| Clonazepam (Klonopin)** | $10 ($lxx) | |
| Diazepam (Valium) for GAD | $10 ($90) | |
| Lorazepam (Ativan)‡ | $10 ($300) | |
Medications should be titrated slowly to decrease the initial activation. Considering of the typical filibuster in onset of action, medications should not be considered ineffective until they are titrated to the high stop of the dose range and connected for at least four weeks. Once symptoms accept improved, medications should be used for 12 months earlier tapering to limit relapse.11 Some patients will crave longer treatment.
Benzodiazepines are constructive in reducing anxiety, but at that place is a dose-response relationship associated with tolerance, sedation, confusion, and increased bloodshed.28 When used in combination with antidepressants, benzodiazepines may speed recovery from anxiety-related symptoms just do non improve longer-term outcomes. The higher risk of dependence and agin outcomes complicates the apply of benzodiazepines.29 NICE guidelines recommend only short-term employ during crises.eleven Benzodiazepines with an intermediate to long onset of action (such as clonazepam [Klonopin]) may take less potential for abuse and less adventure of rebound.30
Second-Line Therapies. Second-line therapies for GAD include pregabalin (Lyrica) and quetiapine (Seroquel), although neither has been evaluated for PD. Pregabalin is more constructive than placebo only not as effective as lorazepam (Ativan) for GAD. Weight proceeds is a common adverse effect of pregabalin. In that location is limited evidence for the use of antipsychotics to treat feet disorders. Although quetiapine seems to be effective for GAD, the agin effect profile is pregnant, including weight gain, diabetes mellitus, and hyperlipidemia.31 Hydroxyzine is considered a second-line treatment for GAD,32 but there are minimal data for its utilize in PD. Its rapid onset tin can be appealing for patients needing immediate relief, and it may exist a more appropriate alternative if benzodiazepines are contraindicated (e.k., in patients with a history of substance corruption). Based on clinical experience, gabapentin (Neurontin) is sometimes prescribed past psychiatrists to treat feet on an every bit-needed basis when benzodiazepines are contraindicated. Of note, the placebo response for medications used to treat GAD and PD is high.13
PSYCHOTHERAPY AND RELAXATION THERAPIES
Psychotherapy includes many different approaches, such as cognitive behavior therapy (CBT) and applied relaxation (Tabular array 5).33,34 CBT may use applied relaxation, exposure therapy, breathing, cognitive restructuring, or instruction. Psychotherapy is equally constructive as medication for GAD and PD.eleven Although existing testify is insufficient to draw conclusions almost many psychotherapeutic interventions, structured CBT interventions have consistently proven effective for the treatment of feet in the chief care setting.34–36 Psychotherapy may be used lone or combined with medication as first-line treatment for PD37 and GAD,11 based on patient preference. Psychotherapy should exist performed weekly for at to the lowest degree eight weeks to assess its effect.
Table 5.
Possible Behavior Interventions for the Handling of Generalized Anxiety Disorder, Panic Disorder, and Anxiety-Related Symptoms
| Intervention | Comments |
|---|---|
| Cognitive behavior therapy* | This intervention is useful in treating feet disorders. The cognitive portion assists change in thinking patterns that support fears, whereas the beliefs portion often involves training patients to relax securely and helps desensitize patients to anxiety-provoking triggers. |
| To be constructive, therapy must be directed at the patient's specific anxieties and tailored to his or her needs. There are minimal agin effects, except that beliefs desensitization is typically associated with temporary balmy increases in feet.33 | |
| Mindfulness-based stress reduction† | This intervention promotes focused attention on the present, acknowledgment of one's emotional state, and meditation for further stress reduction and relaxation. |
| Key features include moment to moment awareness cultivated with a nonjudgmental attitude, formal meditation techniques, and daily do.34 |
Mindfulness has like effectiveness to traditional CBT or other behavior therapies,38 particularly mindfulness-based stress reduction.39 A meta-analysis of 36 randomized controlled trials on meditation showed that meditative therapies reduce anxiety symptoms, simply most studies looked at anxiety symptoms rather than anxiety disorders.40 Transcendental meditation has similar effectiveness to other relaxation therapies.41
Later a treatment grade, rebound symptoms may occur less often with psychotherapy than with medications. Successful handling requires tailoring options to individuals and may often include a combination of modalities.xi,37,42 Combined treatment with medications and psychotherapy reduces relapse fifty-fifty at two years.43
COMPLEMENTARY AND ALTERNATIVE MEDICINE THERAPIES
Although a number of complementary and alternative products have evidence for treating depression, most lack sufficient bear witness for the treatment of anxiety. Botanicals and supplements sometimes used to treat GAD and PD are listed in Table half dozen. Kava extract is an effective treatment for feet 44; however, case reports of hepatotoxicity have decreased its employ.45 St. John'due south wort, tryptophan, 5-Hydroxytryptophan, and S-adenosyl-l-methionine should be used with circumspection in combination with SSRIs considering of the increased risk of serotonin syndrome.46
Prove indicates that music therapy, aromatherapy, acupuncture, and massage are helpful for anxiety associated with specific disease states, but none have been evaluated specifically for GAD or PD.
Table vi.
Botanicals and Supplements Sometimes Used to Treat Generalized Anxiety Disorder and Panic Disorder
| Therapy | Potential significant adverse effects* |
|---|---|
| Botanicals | |
| Kava (Piper methysticum) | Possible hepatotoxicity, sedation, interference with P450 substrates |
| Lavender oil (Lavandula angustifolia) | Minimal |
| Passionflower (Passiflora incarnata) | Dizziness, sedation, decreased blood force per unit area |
| St. John's wort (Hypericum perforatum)† | Like to serotonin reuptake inhibitors, interference with P450 substrates |
| Valerian (Valeriana officinalis) | Headache, gastrointestinal upset |
| Supplements | |
| five-Hydroxytryptophan† | Gastrointestinal upset, possible eosinophilia-myalgia syndrome |
| Inositol | Nausea, headache |
| l-theanine | May lower claret pressure; may lower effect of stimulant medication |
| l-tryptophan† | Gastrointestinal upset, possible eosinophilia-myalgia syndrome |
| S-adenosyl-l-methionine† | Gastrointestinal upset, mania in patients with bipolar disorder |
| Vitamin B complex | Yellow urine |
Referral and Prevention
- Abstract
- Epidemiology, Etiology, and Pathophysiology
- Typical Presentation and Diagnostic Criteria
- Differential Diagnosis and Comorbidity
- Handling
- Referral and Prevention
- References
For patients with GAD or PD, psychiatric referral may exist indicated if there is poor response to treatment, atypical presentation, or concern for significant comorbid psychiatric illness. There is insufficient evidence to support a concise recommendation on the prevention of PD and GAD in adults.
Information Sources: We searched Essential Evidence Plus, PubMed, and Ovid Medline using the keywords generalized anxiety disorder, panic disorder, diagnosis, handling, medication, epidemiology, etiology, pathophysiology, differential diagnosis, and complementary and alternative medicine. Nosotros searched professional person and authoritative organizations on the topic of anxiety disorders, including the American Psychological Clan, the National Institute of Mental Health, the National Institute for Wellness and Care Excellence, and the Cochrane Collaboration. Search dates: May to July 2014.
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