Anxiety: Generalized Anxiety Disorder

By: Gabriella Phillip

Anxiety is normal as we all worry from time to time about meeting deadlines for work or school, or being on time for a scheduled appointment. However, people with generalized anxiety disorder, or GAD, experience a chronic state of severe worry and tension, often without provocation. People with GAD aren’t usually able to shift their focus from their concerns, even though they are aware that much of their anxiety is unwarranted. These worries can include overthinking plans and solutions, inability to set aside or let go of a worry, or severe difficulty with handling uncertainty. People diagnosed with generalized anxiety disorder undergo persistent, excessive worry that occurs on more days than not for at least six months and show at least 3 symptoms of the disorder.

For patients with GAD, worrying is often accompanied by physical symptoms including headaches, irritability, muscle tension, difficulty sleeping or concentrating, sweating, hot flashes, and restlessness. Generalized anxiety disorder affects around 6.8 million American adults; women are twice as likely as men to be afflicted. Onset age of this disorder can occur at any point in one’s life, but usually begins between childhood and middle age. Generalized anxiety disorder can affect all areas of life including social life, school, work, and family. According to a national survey conducted by the Anxiety Disorders Association, 7 out of 10 people diagnosed with GAD noted that their persistent anxiety has a clear impact on their romantic relationships and two-thirds reported that that this disorder has had a negative effect on their friendships. Generalized anxiety disorders are the most common cause of workplace disability.

Treatment for GAD commonly includes medication, cognitive behavior therapy (CBT), talk therapy (psychotherapy), exposure therapy, and anxiety management; some of these treatments are used simultaneously. There is no single optimal treatment since what works for one patient might not be as effective for another patient. A combination of modalities is usually most effective.

If you or someone you know is struggling with Generalized Anxiety Disorder, Arista Counseling and Psychotherapy can help as we are able to provide a combination of treatments which have proven to be effective. Please contact our psychotherapy offices in New York or New Jersey to talk to one of our licensed professional psychologists, psychiatrists, psychiatric nurse practitioners, or psychotherapists. Contact our Paramus, NJ or Manhattan, NY offices respectively, at (201) 368-3700 or (212) 722-1920 to set up an appointment. For more information, please visit http://www.counselingpsychotherapynjny.com/ .

 

Sources

https://adaa.org/sites/default/files/July%2015%20GAD_adaa.pdf

https://www.psychologytoday.com/us/conditions/generalized-anxiety-disorder

 

PTSD in Refugee and Unaccompanied Children:

By: Luz Melendez

Post-traumatic stress disorder (PTSD) is a disorder that can occur to someone after being exposed to one or more traumatic events. These traumatic events can vary from a natural disaster, war/combat, serious injury, sexual violence, and/or exposure to death threats. After experiencing a trauma there can be an emotional reaction to these events which can include fear, helplessness, and even horror. There may also be distressing memories of the traumatic event which can be recurrent and involuntary. In order to be diagnosed with PTSD, symptoms have to last for more than a month and be persistent. (American Psychiatric Association, 2013).

One population that is less talked about when it comes to PTSD is children, but more specifically refugee or asylum seeking children. The current population of children with PTSD in the U.S. is about 5% and among refugee children in the U.S. it’s about 54%. These children are experiencing hunger, extreme poverty, bombings, abductions, sexual assault, and even witnessing deaths. These stressors can often co-occur making everyday life very difficult for them. The effects of these events are causing developmental regression, clinginess, repetitive play of the trauma/s, anxiety, depression, ACES, and mood changes. One effect that is very important is how the brain is being affected by these traumas. PTSD is developed in two key regions of the brain, the amygdala and the prefrontal cortex. The amygdala reacts too strongly while the prefrontal cortex impedes the ability to regulate a threat response. It’s the perfect storm that leads to hyperarousal, hyper vigilance, and sleep deprivation which are big issues when it comes to children. Children’s brains are growing and developing and these traumas are stunting the global developmental growth of these children’s brains.

Often PTSD in refugee or asylum seeking children, if left untreated/undiagnosed, can and will lead to life long-lasting effects. In the situation these children are in, it’s difficult to not only diagnose them but to properly treat them. Many if not all have witnessed one or more of the stressors mentioned above and these children are out in the world not only having their lives completely change but having their mental health deteriorate. Thankfully some host countries who take in refugees, screen them and try to help them adjust to their now new lives and overcome barriers that come with accessing physical and mental health care. This also includes overcoming the stigma that refugees have of seeking mental health care. Like mentioned before only some host countries do this, others are still fixing their processing of refugees.

 

If you or someone you know is struggling with PTSD, Arista Counseling and Psychotherapy can help. Please contact our psychotherapy offices in New York or New Jersey to talk to one of our licensed professional psychologists, psychiatrists, psychiatric nurse practitioners, or psychotherapists at Arista Counseling & Psychotherapy. Contact our Paramus, NJ or Manhattan, NY offices respectively, at (201) 368-3700 or (212) 722-1920 to set up an appointment. For more information, please visit http://www.counselingpsychotherapynjny.com/ .

 

Reference:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed). Arlington, VA: American Psychiatric Association.

Depression: Difference between Unipolar and Bipolar Depression

By Gabriella Phillip

Eliciting a history of brief periods of improved mood is the key to differentiating between unipolar and bipolar depression. Bipolar spectrum disorders typically begin earlier in life than unipolar depression; the usual sign of bipolar disorder in young children could be depression and/or a combination of depression and states of mania/hypomania. It’s significant to ask the patient how old they were when they first experienced a depressive episode. Men have a higher rate of bipolar disorder than women, but the rates for unipolar depression in men and women are more equal.

Some patients with bipolar spectrum disorder can go from normal to severely depressed technically overnight whereas unipolar depressive episodes tend to occur more gradually. Patients with bipolar spectrum depression tend to experience weight gain and crave carbs, while those with unipolar depression usually experience weight loss or loss of appetite. Patients suffering from bipolar depression tend to show irregular responses to antidepressant monotherapy, including switching into mania. Bipolar spectrum disorder is an inheritable mental illness, so it’s vital to take family history into consideration. While patients diagnosed with unipolar depression usually note that their symptoms fluctuate in a more stable, regular pattern, those with bipolar depression have moods that can vary unpredictably, usually with no cause.

When treating bipolar depression, antidepressants are used in combination with some sort of mood stabilizer. Treatment for unipolar depression can include medication like SSRIs and antidepressants, often in combination with cognitive behavioral therapy (CBT) and psychotherapy. Screening instruments including the Bipolar Spectrum Diagnostic Scale and the Mood Disorders Questionnaire can be effective and helpful tools in differentiating unipolar from bipolar depression.

If you or someone you know is struggling with Bipolar Disorder or Unipolar Depression, Arista Counseling and Psychotherapy can help. Please contact our psychotherapy offices in New York or New Jersey to talk to one of our licensed professional psychologists, psychiatrists, psychiatric nurse practitioners, or psychotherapists at Arista Counseling & Psychotherapy. Contact our Paramus, NJ or Manhattan, NY offices respectively, at (201) 368-3700 or (212) 722-1920 to set up an appointment. For more information, please visit http://www.counselingpsychotherapynjny.com/ .

Sources

https://www.psychiatrictimes.com/special-reports/major-depressive-episode-it-bipolar-i-or-unipolar-depression

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2850601/

https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/unipolar-and-bipolar-depression-different-or-the-same/AE364DFBFFBAF1F66A9294A55120C64E/core-reader

 

 

Depression: Have a Case of the Winter Blues? Understanding Seasonal Affective Disorder

 

By: Keely Fell

Can’t seem to shake the winter blues? Nearly five percent of adults are experiencing symptoms that align with major depressive disorder with recurring seasonal pattern, which is more commonly known as Seasonal Affective Disorder. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), an individual who is experiencing “two major depressive episodes in the last two years” that show relations to the time of year, and experience full remissions at other times they may be experiencing Seasonal Affective Disorder (SAD).

It is also important to understand what is happening in the body and why an individual is experiencing such symptoms. When an individual is experiencing these symptoms, often it can be as a result of the lack of natural light due to the shorter periods of daylight during the winter season. With the lack of light, the human brain slows down the production of serotonin, and increases the production of melatonin which leaves individuals feeling drowsy. Melatonin production increase is caused by darkness, which is why we get sleepy when the sun goes down. The regulation of these chemicals is what helps create your body’s specific circadian rhythm. When this system is affected it can cause a feeling of lethargy and or restlessness.

Here are some tips and tricks to shaking those winter blues:

  1. Take a few minutes during your day to get outside Whether that’s during your lunch break or walking to pick up the mail, going outside during daylight will increase the serotonin production in your brain.
  2. Light Therapy During the dark winter months, if these symptoms are taking over you can try light therapy. Light therapy allows for the brain to think it’s being exposed to sunlight. People who use light therapy typically invest in a light box (if interested Harvard Health has many they recommend) which delivers around 10,000 lux, compared to a standard sunny day that ranges 50,000 lux or above. They recommend that, you sit in front of the light box for no more than 30 minutes a day. This allows for the brain to regulate its circadian rhythms by allowing the retinas to be stimulated. Light therapy does not work for everyone.
  3. Talk Therapy If these symptoms persist and are affecting your day talk therapy is also affective. Reaching out to a psychologist, psychiatrist, psychiatric nurse practitioner, or psychotherapist to come up with symptom relief is another big way to combat these symptoms. Symptom relief may include the use of antidepressants, or various therapeutic methods.

 

If you or someone you know has Seasonal Affective Disorder or seems to have the symptoms of SAD, and needs help, please contact our psychotherapy offices in New York or New Jersey to talk to one of our licensed professional psychologists, psychiatrists, psychiatric nurse practitioners, or psychotherapists at Arista Counseling & Psychotherapy. Contact our Paramus, NJ or Manhattan, NY offices respectively, at (201) 368-3700 or (212) 722-1920 to set up an appointment. For more information, please visit http://www.counselingpsychotherapynjny.com/ .

Sources:

https://www.nimh.nih.gov/health/topics/seasonal-affective-disorder/index.shtml

https://www.health.harvard.edu/blog/seasonal-affective-disorder-bring-on-the-light-201212215663

https://www.psychiatry.org/patients-families/depression/seasonal-affective-disorder

 

Body Dysmorphic Disorder

By Gabriella Phillip

Body Dysmorphic disorder, or BDD, is a psychiatric disorder in which a person is preoccupied with an imagined or minor physical defect that other people usually don’t notice. BDD has various features that are similar to that of obsessive-compulsive disorders and eating disorders. Patients diagnosed with obsessive-compulsive disorder, or OCD, have distressing thoughts and images that they aren’t able to control. Emotional distress that can result from this can cause a person to perform particular rituals or compulsions. Regarding BDD, the person’s persistent preoccupation with his/her perceived physical defect can lead to ritualistic behaviors including constantly looking in the mirror or skin picking. Similarly to eating disorders, like anorexia nervosa and bulimia nervosa, Body Dysmorphic Disorder involves a concern with body image. However, while eating disorder patients are concerned with body weight, those diagnosed with BDD are worried about a specific area or part of the body.

Body Dysmorphia affects approximately 2% of the general population; however, BDD usually goes undiagnosed so the number of people who actually have the disorder could potentially be much greater. Those with body dysmorphia oftentimes feel a significant amount of shame regarding their perceived flaws which may hinder them from seeking treatment. BDD prevalence differs by gender, as women are reported to have higher rates of this disorder than men. Factors such as living with a pre-existing mental condition like depression or anxiety or experiencing bullying or abuse during childhood or adolescence can increase the risk of Body Dysmorphic Disorder. The typical onset for BDD is between the ages twelve and seventeen, around the time when adolescents go through puberty and certain bodily changes.

Social media platforms like Instagram oftentimes feed us an interminable supply of filtered and unrealistic depictions of different people and their lives. It’s easy to compare yourself to well edited pictures of models, celebrities, and even friends online, making you feel as though you don’t measure up as you are. Also, various forms of bullying like body shaming or slut shaming can occur online and can easily result in distorted body image and low self-esteem. Those with BDD sometimes choose to socially isolate themselves due to high level of shame related to their bodily appearance. While social media doesn’t necessarily cause body dysmorphia, it can serve as a trigger for those already predisposed to the disorder, or could possibly worsen existing symptoms. The main treatments used for BDD are cognitive behavioral therapy (CBT) and antidepressant medication, specifically serotonin reuptake inhibitors (SSRIs). Many patients use therapy and medication simultaneously. These treatments are meant to help reduce obsessive compulsive behaviors, improve stress level management involved in these behaviors, and aid patients in viewing themselves in a more loving and less judgmental light.

If you or someone you know is struggling with Body Dysmorphic Disorder, Arista Counseling and Psychotherapy can help. Please contact our psychotherapy offices in New York or New Jersey to talk to one of our licensed professional psychologists, psychiatrists, psychiatric nurse practitioners, or psychotherapists at Arista Counseling & Psychotherapy. Contact our Paramus, NJ or Manhattan, NY offices respectively, at (201) 368-3700 or (212) 722-1920 to set up an appointment. For more information, please visit http://www.counselingpsychotherapynjny.com/ .

 

Pain: Chronic Pain is a Fundamental Health Issue

By Gabriella Phillip

According to The International Association for the Study of Pain, pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. When someone is injured, pain sensors immediately send signals to the brain. Although regular pain, like cramps or a headache, can be relieved in a rather short period of time, chronic pain involves the brain receiving pain signals a while after the onset of pain or the original injury.

One in five people live with chronic pain and the frequency of chronic pain increases as we get older. Many elderly people are experiencing pain that oftentimes goes undiagnosed. In addition, research shows that patients with dementia are being severely untreated for their experience with pain. Even though it’s a fundamental human right to have proper access to pain management, most elderly people are receiving quite inadequate care from health facilities, making it harder for them to cope and go about their daily lives with severe chronic pain.

Chronic pain can strongly impact or contribute to the formation of serious mental health issues including anxiety and depression. Current research from Neuroscience Research Australia shows that patients living with chronic pain have lower levels of glutamate, a significant chemical messenger that aids emotional regulation. Therefore, it’s possible for people with chronic pain to undergo certain personality changes like being more tired than usual, feeling unmotivated, or worrying on a more frequent basis than before. Around half of people suffering from chronic pain also have mental health conditions. The daily demands of learning to live with chronic pain can help generate anxiety, depression and other mood disorders.

If you or someone you know is struggling with Chronic Pain and its mental health effects, Arista Counseling and Psychotherapy can help. Please contact our psychotherapy offices in New York or New Jersey to talk to one of our licensed professional psychologists, psychiatrists, psychiatric nurse practitioners, or psychotherapists at Arista Counseling & Psychotherapy. Contact our Paramus, NJ or Manhattan, NY offices respectively, at (201) 368-3700 or (212) 722-1920 to set up an appointment. For more information, please visit http://www.counselingpsychotherapynjny.com/ .

PTSD Researcher Finds Link between Stress and Trauma

By Diana Bae

Rachel Yehuda, PhD, is a distinguished researcher and Director of Traumatic Stress Studies Division at the Icahn School of Medicine of Mount Sinai. She has conducted numerous prominent post-traumatic stress disorder (PTSD) studies and treatment. One of her most well-known studies researched Vietnam War combat veterans with PTSD and found that they had significantly lower cortisol levels than veterans without PTSD. Cortisol is a hormone that controls stress and although it is thought that more cortisol resulted in more stress, Dr. Yehuda showed that that is not the case. Thus, there needs to be a sufficient amount of cortisol to handle stress and reduce the risk of developing trauma. Now, Dr. Yehuda plans to test a drug, oral hydrocortisone, to see whether it can replicate the cortisol naturally produced in the body. If this drug is successful, it may prevent PTSD and other similar disorders.

Arista Psychological and Psychiatric Services understands the problems caused by PTSD and are dedicated to provide proper attention and treatment. If you or someone you know would like to set up an appointment for our counseling services, contact us at our offices in Paramus, NJ (201) 368-3700 or in Manhattan, NY (212) 996-3939. For more information, please visit our website https://www.counselingpsychotherapynjny.com/

Source: Inside, a publication of the Mount Sinai Health System, Issue: November 25 – December 15, 2019;  Picture Source: http:// www. thesuburban.com/life/lifestyles/can-trauma-be-transmitted-intergenerationally-oct-dawson-college-peace-centre/article_ea2d7bb0-b063-11e7-aee3-5b0d013065f7.html, https:// askopinion.com/how-to-deal-with-ptsd-aka-post-traumatic-stress-disorder

Changes to the Brain

 By: Katie Connell

                For a long time, scientists believed that changes to brain structure only occurred during infancy and childhood. By the time one became an adult, it was thought that brain structure would remain largely permanent and that no more changes could occur. However, in the 1960’s, scientists discovered that changes to the adult brain were indeed possible. One thing that verified this were brain changes that occurred to patient’s brains that were damaged in injuries and accidents. Damage that occurred in certain parts of one’s brain resulted in healthier parts taking over. With this discovery came insight into other ways that the brain could be changed, specifically in the realm of psychotherapy. Cognitive Behavioral Therapy (CBT) is a great example of a type of psychotherapy that can lead to long lasting changes to the brain. During a process called synaptic pruning, extra neurons (which transmit information) and synaptic connections (which permit neurons to transmit info) are eliminated to increase the efficiency of neural transmissions. One way this happens is by neurons being used more frequently. Those that aren’t used as much get eliminated, which improves the transmission of information. By repeated exposure and engagement in CBT (including thought shifting techniques and cognitive restructuring), neurons become strengthened, meaning less synapses and better transmission of neurons. Through the use of routine CBT, critical neural networks are able to change how we think and feel.

If you or a person you know is seeking CBT or other forms of therapy, the psychologists, psychiatrists, and therapists at Arista Counseling and Psychiatric Services can help. Please contact the Bergen County, NJ or Manhattan offices at (201) 368-3700 or (212) 722-1920. 

Source:

https://www.verywellmind.com/what-is-brain-plasticity-2794886

 

 

Obsessive Compulsive Disorder

Obsessive Compulsive Disorder

Obsessive Compulsive Disorder

By: Julia Keys

Obsessive Compulsive Disorder (OCD) has been normalized and trivialized in society as a need for everything to be meticulously clean and organized when in reality it is a serious psychological disorder that can cause significant distress for those who have it. Obsessive Compulsive Disorder is characterized by a pattern of uncontrollable reoccurring thoughts, known as obsessions, which can only be remedied by certain behaviors, known as compulsions. People with OCD are commonly depicted as being ultra-neat or afraid of germs, which is true for some people, but the way OCD expresses itself is unique to the individual.

There are several common themes that psychologists have determined when treating patients with Obsessive Compulsive Disorder. One common theme is contamination. This may take on the literal meaning in which an object or place can be perceived as dirty, but it can also mean that contact with a person, place, or object will cause great harm. Checking is another typical behavior. One may check if something is safe or turned off over and over again. Checking can also express itself in the need for constant verbal reassurance, so a person with OCD may ask the same question over and over. People with OCD may be worried that they will suddenly lose control and hurt themselves or someone else. In efforts to qualm these obsessions, one may avoid certain places or people or have plans set in place that could prevent them from acting out these thoughts.

Common obsessions may include, but are not limited to:

  • Fear of germs or contamination
  • Unwanted forbidden or taboo thoughts involving sex, religion, and harm
  • Aggressive thoughts towards others or self
  • Having things symmetrical or in a perfect order

Common compulsions may include, but are not limited to:

  • Excessive cleaning and/or handwashing
  • Ordering and arranging things in a particular, precise way
  • Repeatedly checking on things, such as repeatedly checking to see if the door is locked or that the oven is off
  • Compulsive counting

When reading these lists one might think that these behaviors are relatively typical, however people with OCD spend an excessive amount of time and effort thinking about obsessive thoughts and preforming rituals to control them. A person with OCD may feel brief relief after preforming a compulsion, but they do not feel pleasure from such acts. Obsessions and compulsions are very difficult to control and may result in significant problems in one’s daily life or relationships.

If you or someone you know is struggling OCD, please contact our psychotherapy offices in New York or New Jersey to talk to one of our licensed professional psychologists, psychiatrists, psychiatric nurse practitioners, or psychotherapists at Arista Counseling & Psychotherapy. Contact our Paramus, NJ or Manhattan, NY offices respectively, at (201) 368-3700 or (212) 722-1920 to set up an appointment. For more information, please visit http://www.counselingpsychotherapynjny.com/ .

Sources:

https://www.nimh.nih.gov/health/topics/obsessive-compulsive-disorder-ocd/index.shtml

https://www.psychologytoday.com/us/blog/living-ocd/201107/the-many-flavors-ocd

Source for Picture:

https://www.bing.com/images/search?view=detailV2&id=47C5DD3F1D65AD247FE6091E7A61190FA00E0683&thid=OIP.X50wPNnUfEvJHrY8IH6VyQHaFj&mediaurl=http%3A%2F%2Fwww.belmarrahealth.com%2Fwp-content%2Fuploads%2F2016%2F01%2FObsessive-compulsive-disorder-OCD-questionnaire-can-also-help-determine-the-risk-of-depression-and-anxiety.jpg&exph=2475&expw=3300&q=ocd&selectedindex=57&ajaxhist=0&vt=0&eim=1,2,6

 

 

 

Antidepressants: What Happens When You Stop Taking Your Medication

Antidepressants: What Happens When You Stop Taking Your Medication

Antidepressants: What Happens When You Stop Taking Your Medication

By: Julia Keys

Anti-depressant discontinuation syndrome occurs when a person suddenly stops taking their anti-depressants. Sometimes individuals decide to go off of their medication because of side effects such as weight gain, nausea, or sexual dysfunction. Another common reason why individuals stop their medication “cold turkey” is because they may feel as if the medication has changed their personality. Anti-depressants are not meant to change one’s personality, but sometimes they can cause fogginess or fatigue which can make the patient feel “not like themselves” or “out of it”. However, abruptly going off medication can cause symptoms that are more painful and severe than the side effects one might feel on an anti-depressant that is not right for them.

The effects of anti-depressant discontinuation can be felt as early as a couple hours to as late as a couple days after missing a dose depending on the type of anti-depressant. Symptoms are typically ameliorated within six to twenty four hours after taking the missed dose.

Symptoms of Anti-depressant discontinuation syndrome:

  • Nausea
  • Chills
  • Headache
  • Vomiting
  • Problems with balance
  • “brain zaps” or “brain shocks”, the sensation of a jolt of electricity running through the head, neck or limbs
  • Anxiety

Unlike illegal drugs, phasing out of anti-depressants can be a painless process if done correctly. In order to go off of anti-depressants successfully, one must slowly wean themselves off the medication with the help of a psychiatrist or psychiatric nurse practitioner.

Tips to prevent or minimize anti-depressant discontinuation syndrome:

  • NEVER stop taking medication without talking to your doctor
  • Follow your doctor’s directions exactly when going off your meds. If you start to feel any of the symptoms of anti-depressant discontinuation syndrome contact your doctor as soon as possible
  • Set a reminder on your phone or computer to take your medication each day
  • Always keep your medication in the same place
  • Make sure to keep on top of your doctor’s appointments by putting them in a calendar so that you will never run out of medication by accident

If you are struggling with mental health issues and are in need of treatment, do not hesitate to seek help by contacting Arista Counseling & Psychotherapy, located in New York and New Jersey to speak to licensed professional psychologists, psychiatrists, psychiatric nurse practitioners or psychotherapists. To contact the office in Paramus NJ, call (201) 368-3700. To contact the office in Manhattan, call (212) 722-1920. For more information, please visit http://www.counselingpsychotherapynjny.com/ .

Sources:

https://www.aafp.org/afp/2006/0801/p449.html

https://www.aafp.org/afp/2006/0801/p449.html

Source for picture:

https://www.bing.com/images/search?view=detailv2&iss=sbi&form=SBIIRP&sbisrc=ImgDropper&q=imgurl:https%3A%2F%2Ftse4.mm.bing.net%2Fth%3Fid%3DOIP.w1jYI-8qe7WzoyGlc18DmQHaFj%26w%3D259%26h%3D194%26c%3D7%26o%3D5%26dpr%3D1.15%26pid%3D1.7&idpbck=1&selectedindex=0&id=https%3A%2F%2Ftse4.mm.bing.net%2Fth%3Fid%3DOIP.w1jYI-8qe7WzoyGlc18DmQHaFj%26amp%3Bw%3D259%26amp%3Bh%3D194%26amp%3Bc%3D7%26amp%3Bo%3D5%26amp%3Bdpr%3D1.15%26amp%3Bpid%3D1.7&mediaurl=https%3A%2F%2Ftse4.mm.bing.net%2Fth%3Fid%3DOIP.w1jYI-8qe7WzoyGlc18DmQHaFj%26w%3D259%26h%3D194%26c%3D7%26o%3D5%26dpr%3D1.15%26pid%3D1.7&exph=0&expw=0&vt=2&sim=0