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5 Things You Probably Get Wrong About Adjustment Disorder · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:05
  back
• 0:06
  my
• 0:06
  friends
• 0:06
  to
• 0:06
  another
• 0:07
  episode
• 0:07
  of
• 0:07
  Pearls
• 0:08
  and
• 0:08
  prep
• 0:09
  npz.
• 0:09
  Here
• 0:10
  your
• 0:10
  preceptor
• 0:11
  in
• 0:11
  your
• 0:11
  pocket,
• 0:11
  your
• 0:11
  go
• 0:12
  to
• 0:12
  place
• 0:12
  for
• 0:12
  pearls
• 0:13
  that
• 0:13
  prep
• 0:13
  you
• 0:14
  to
• 0:14
  practice
• 0:15
  today.
• 0:16
  You
• 0:16
  are
• 0:16
  going
• 0:16
  to
• 0:16
  learn
• 0:17
  five
• 0:17
  things
• 0:17
  you
• 0:18
  never
• 0:18
  knew
• 0:18
  about
• 0:18
  adjustment
• 0:19
  disorder.
• 0:20
  And
• 0:20
  I'm
• 0:20
  going
• 0:20
  to
• 0:20
  share
• 0:20
  my
• 0:20
  own
• 0:21
  personal
• 0:21
  perspective
• 0:22
  based
• 0:22
  on
• 0:23
  actual
• 0:23
  practice
• 0:24
  with
• 0:24
  respect
• 0:25
  to
• 0:25
  adjustment
• 0:25
  disorders.
• 0:26
  Things
• 0:26
  I
• 0:26
  think
• 0:26
  you
• 0:27
  should
• 0:27
  know
• 0:27
  and
• 0:27
  not
• 0:28
  underestimate
• 0:28
  things
• 0:29
  and
• 0:29
  just
• 0:29
  be
• 0:29
  super
• 0:30
  prepared
• 0:30
  for
• 0:31
  because
• 0:31
  this
• 0:31
  looks
• 0:32
  like
• 0:32
  a
• 0:33
  mild
• 0:33
  diagnosis
• 0:34
  in
• 0:34
  the
• 0:34
  DSM
• 0:35
  5
• 0:35
  and
• 0:35
  it
• 0:36
  surely
• 0:36
  is
• 0:36
  not
• 0:37
  a
• 0:37
  mild
• 0:37
  diagnosis
• 0:38
  and
• 0:38
  there's
• 0:38
  very
• 0:38
  specific
• 0:39
  reasons
• 0:39
  for
• 0:39
  that.
• 0:40
  This
• 0:40
  looks
• 0:41
  like
• 0:41
  a
• 0:41
  lot
• 0:41
  of
• 0:41
  other
• 0:41
  disorders
• 0:42
  that
• 0:43
  it
• 0:43
  isn't.
• 0:43
  It
• 0:43
  can
• 0:44
  be
• 0:44
  a
• 0:44
  slippery
• 0:44
  one.
• 0:45
  It
• 0:45
  can
• 0:46
  really
• 0:46
  bite
• 0:46
  you
• 0:46
  in
• 0:46
  the
• 0:47
  butt
• 0:47
  if
• 0:47
  you're
• 0:47
  not
• 0:47
  prepared.
• 0:48
  And
• 0:48
  I
• 0:48
  want
• 0:48
  to
• 0:49
  talk
• 0:49
  about
• 0:49
  it.
• 0:50
  And
• 0:50
  before
• 0:50
  we
• 0:50
  do,
• 0:51
  just
• 0:51
  a
• 0:51
  quick
• 0:51
  reminder
• 0:52
  my
• 0:52
  friends
• 0:53
  to
• 0:53
  go
• 0:54
  to
• 0:54
  patreon.com
• 0:56
  pearlsandprep
• 0:57
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• 0:57
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  beautiful
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  sticky
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  psychiatric
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  pearls
• 1:02
  that
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  stick
• 1:03
  with
• 1:03
  you
• 1:03
  and
• 1:03
  empower
• 1:04
  you
• 1:04
  in
• 1:05
  your
• 1:05
  practice,
• 1:06
  that
• 1:06
  really
• 1:06
  help
• 1:06
  you
• 1:07
  understand
• 1:07
  the
• 1:07
  how
• 1:07
  and
• 1:08
  why
• 1:08
  of
• 1:08
  what
• 1:08
  you're
• 1:08
  doing
• 1:08
  and
• 1:09
  differentiate
• 1:09
  you
• 1:10
  from
• 1:10
  a
• 1:11
  good
• 1:11
  to
• 1:11
  a
• 1:11
  great
• 1:12
  clinician,
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  go
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  to
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  patreon.com
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  pearlsandprep
• 1:15
  and
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  become
• 1:16
  a
• 1:16
  Patreon
• 1:16
  member
• 1:16
  today.
• 1:17
  All
• 1:17
  right,
• 1:17
  my
• 1:17
  friends,
• 1:18
  five
• 1:18
  things
• 1:19
  you
• 1:19
  didn't
• 1:19
  know
• 1:19
  about
• 1:19
  adjustment
• 1:20
  disorder.
• 1:20
  Let's
• 1:20
  go.
• 1:21
  So
• 1:22
  first
• 1:22
  I
• 1:23
  want
• 1:23
  to
• 1:23
  talk
• 1:23
  to
• 1:23
  you
• 1:24
  guys
• 1:24
  about
• 1:25
  the
• 1:26
  first
• 1:26
  pearl,
• 1:26
  which
• 1:27
  I
• 1:27
  think
• 1:27
  is
• 1:27
  the
• 1:27
  most
• 1:28
  important
• 1:28
  pearl.
• 1:28
  In
• 1:29
  some
• 1:29
  respects,
• 1:30
  the
• 1:30
  diagnosis
• 1:31
  of
• 1:31
  adjustment
• 1:32
  disorder
• 1:33
  is
• 1:33
  super
• 1:35
  conflated
• 1:36
  in
• 1:36
  this
• 1:37
  field.
• 1:37
  I
• 1:37
  can't
• 1:38
  tell
• 1:38
  you
• 1:38
  how
• 1:38
  many
• 1:39
  times
• 1:39
  I
• 1:39
  have
• 1:39
  seen
• 1:39
  this
• 1:40
  misdiagnosed
• 1:41
  through
• 1:42
  the
• 1:42
  grapevine
• 1:43
  by
• 1:43
  a
• 1:44
  prior
• 1:44
  therapist
• 1:45
  or
• 1:45
  a
• 1:45
  prior
• 1:45
  provider.
• 1:46
  And
• 1:47
  I'm
• 1:47
  not
• 1:47
  blaming
• 1:47
  them.
• 1:47
  I
• 1:48
  know
• 1:48
  we
• 1:48
  all
• 1:48
  see
• 1:49
  different
• 1:49
  angles
• 1:50
  of
• 1:50
  our
• 1:50
  patients,
• 1:51
  different
• 1:51
  snapshots
• 1:52
  in
• 1:53
  time.
• 1:53
  It's
• 1:54
  rarely
• 1:54
  that
• 1:55
  the
• 1:55
  therapist
• 1:56
  just
• 1:56
  didn't
• 1:56
  know
• 1:57
  about
• 1:58
  what
• 1:58
  differentiates
• 1:59
  a,
• 2:00
  an
• 2:00
  adjustment
• 2:00
  disorder
• 2:01
  and
• 2:01
  ptsd.
• 2:02
  Sometimes
• 2:02
  that
• 2:02
  is
• 2:03
  the
• 2:03
  case
• 2:03
  though,
• 2:03
  and
• 2:03
  I
• 2:03
  think
• 2:04
  education
• 2:04
  is
• 2:05
  really
• 2:05
  important
• 2:05
  for
• 2:05
  all
• 2:06
  of
• 2:06
  us
• 2:06
  throughout
• 2:06
  our
• 2:06
  career.
• 2:07
  But
• 2:07
  I,
• 2:08
  I
• 2:08
  see
• 2:09
  this
• 2:09
  so
• 2:10
  frequently
• 2:11
  misdiagnosed
• 2:13
  and
• 2:13
  really
• 2:13
  what
• 2:14
  I
• 2:14
  see
• 2:14
  most
• 2:15
  misdiagnosed
• 2:17
  is
• 2:17
  there
• 2:17
  will
• 2:17
  be
• 2:18
  a
• 2:18
  something
• 2:19
  that
• 2:19
  is
• 2:19
  actually
• 2:20
  an
• 2:20
  adjustment
• 2:20
  disorder,
• 2:21
  but
• 2:22
  it's
• 2:22
  labeled
• 2:22
  as
• 2:22
  ptsd
• 2:24
  and
• 2:24
  that
• 2:25
  is
• 2:25
  problematic,
• 2:26
  right?
• 2:26
  It's
• 2:26
  very
• 2:26
  problematic
• 2:27
  because
• 2:27
  they
• 2:27
  go
• 2:28
  down
• 2:28
  two
• 2:28
  different
• 2:28
  treatment
• 2:29
  rabbit
• 2:29
  holes.
• 2:30
  Adjustment
• 2:31
  disorder
• 2:31
  does
• 2:31
  not
• 2:31
  typically
• 2:32
  respond
• 2:32
  to
• 2:32
  medications
• 2:33
  that
• 2:33
  well.
• 2:34
  The
• 2:34
  thing
• 2:35
  that
• 2:35
  helps
• 2:35
  the
• 2:35
  most
• 2:35
  with
• 2:36
  adjustment
• 2:36
  disorder
• 2:37
  is
• 2:37
  usually
• 2:37
  like
• 2:37
  CBT
• 2:38
  or
• 2:39
  just
• 2:40
  actually
• 2:40
  the
• 2:41
  resolution
• 2:41
  of
• 2:42
  the
• 2:42
  stressor.
• 2:42
  I
• 2:42
  mean,
• 2:42
  there's
• 2:43
  a
• 2:43
  huge
• 2:43
  pearl
• 2:43
  for
• 2:44
  you
• 2:44
  right
• 2:44
  now.
• 2:44
  I
• 2:44
  didn't
• 2:44
  mean
• 2:45
  to
• 2:45
  state
• 2:45
  the
• 2:45
  obvious,
• 2:46
  but
• 2:46
  the
• 2:47
  resolution
• 2:47
  of
• 2:47
  the
• 2:47
  stressor
• 2:48
  is
• 2:48
  the
• 2:49
  single
• 2:49
  most
• 2:49
  important
• 2:50
  part
• 2:50
  of
• 2:51
  resolving
• 2:51
  an
• 2:52
  adjustment
• 2:52
  disorder.
• 2:52
  Now,
• 2:53
  you
• 2:53
  don't
• 2:53
  always
• 2:53
  get
• 2:53
  the
• 2:54
  luxury
• 2:55
  of
• 2:55
  that,
• 2:55
  right?
• 2:55
  If
• 2:55
  somebody
• 2:56
  gets
• 2:56
  dumped
• 2:57
  suddenly
• 2:57
  and
• 2:58
  their
• 2:58
  partner
• 2:58
  never
• 2:59
  talks
• 2:59
  to
• 2:59
  them
• 2:59
  again,
• 2:59
  you're
• 3:00
  not
• 3:00
  going
• 3:00
  to
• 3:00
  get
• 3:00
  a
• 3:00
  resolution
• 3:01
  of
• 3:01
  that
• 3:01
  in
• 3:01
  the
• 3:01
  form
• 3:02
  of
• 3:02
  that
• 3:02
  person
• 3:02
  coming
• 3:03
  back
• 3:03
  or
• 3:03
  they
• 3:04
  got
• 3:04
  fired,
• 3:04
  right?
• 3:05
  They're
• 3:05
  not
• 3:05
  going
• 3:05
  to
• 3:05
  just
• 3:05
  get
• 3:05
  hired
• 3:06
  back.
• 3:07
  So
• 3:07
  the
• 3:07
  resolution
• 3:08
  could
• 3:08
  either
• 3:08
  be,
• 3:10
  you
• 3:10
  know,
• 3:10
  that
• 3:11
  that
• 3:11
  precipitating
• 3:12
  stressor
• 3:13
  is
• 3:14
  fixed,
• 3:15
  right?
• 3:15
  Their
• 3:16
  financial
• 3:16
  situation
• 3:17
  gets
• 3:17
  fixed,
• 3:18
  or
• 3:19
  they
• 3:19
  fail
• 3:19
  an
• 3:20
  exam
• 3:20
  and
• 3:20
  then
• 3:20
  they
• 3:20
  get
• 3:21
  to
• 3:21
  retake
• 3:21
  it
• 3:21
  and
• 3:21
  they
• 3:21
  pass,
• 3:22
  or
• 3:23
  it
• 3:23
  never
• 3:23
  really
• 3:23
  gets
• 3:24
  resolved,
• 3:24
  but
• 3:24
  the
• 3:24
  patient
• 3:25
  can
• 3:25
  resolve
• 3:25
  the
• 3:26
  way
• 3:26
  they
• 3:26
  feel
• 3:26
  about
• 3:26
  it
• 3:27
  and
• 3:27
  hence
• 3:27
  the
• 3:27
  adjustment
• 3:28
  disorder
• 3:28
  can
• 3:28
  get
• 3:28
  resolved.
• 3:29
  But
• 3:29
  there
• 3:29
  is
• 3:30
  no
• 3:30
  substitute.
• 3:30
  And
• 3:31
  I
• 3:31
  tell
• 3:31
  my
• 3:31
  patients
• 3:31
  this
• 3:32
  all
• 3:32
  the
• 3:32
  time,
• 3:32
  there
• 3:32
  is
• 3:32
  no
• 3:33
  substitute
• 3:33
  for
• 3:34
  this
• 3:34
  stressor
• 3:34
  just
• 3:35
  resolving.
• 3:35
  There's
• 3:35
  no
• 3:36
  pill
• 3:36
  I
• 3:36
  have
• 3:37
  that's
• 3:37
  going
• 3:37
  to
• 3:37
  be
• 3:37
  as
• 3:38
  good
• 3:38
  as
• 3:39
  you
• 3:39
  just
• 3:39
  being
• 3:40
  able
• 3:40
  to
• 3:40
  get
• 3:40
  through
• 3:41
  the
• 3:41
  eye
• 3:42
  of
• 3:42
  this
• 3:42
  storm,
• 3:43
  right?
• 3:43
  Because
• 3:43
  it's
• 3:43
  an
• 3:44
  adjustment
• 3:44
  disorder.
• 3:45
  It
• 3:45
  it.
• 3:45
  We're
• 3:45
  not
• 3:46
  targeting
• 3:46
  specific
• 3:48
  neurobiological
• 3:51
  differences
• 3:51
  in
• 3:52
  the
• 3:52
  brain
• 3:52
  per
• 3:52
  se.
• 3:53
  We're
• 3:53
  not
• 3:53
  targeting
• 3:53
  the
• 3:54
  amygdala
• 3:55
  in
• 3:55
  a
• 3:55
  fight
• 3:55
  or
• 3:55
  flight
• 3:56
  response
• 3:56
  like
• 3:56
  ptsd.
• 3:58
  PTSD
• 3:58
  has
• 3:59
  a
• 3:59
  whole
• 4:00
  different
• 4:00
  rabbit
• 4:01
  hole
• 4:01
  of
• 4:01
  treatments
• 4:02
  that
• 4:02
  are
• 4:03
  just
• 4:03
  not
• 4:03
  the
• 4:03
  same
• 4:04
  in
• 4:04
  adjustment
• 4:04
  disorder.
• 4:05
  Right?
• 4:06
  Exposure
• 4:06
  therapy
• 4:08
  and
• 4:09
  EMDR
• 4:10
  is
• 4:10
  just
• 4:10
  a
• 4:10
  whole
• 4:10
  different
• 4:11
  treatment
• 4:12
  algorithm
• 4:12
  that
• 4:13
  we
• 4:13
  don't
• 4:13
  typically
• 4:13
  go
• 4:14
  to
• 4:14
  first
• 4:15
  line
• 4:15
  for
• 4:15
  adjustment
• 4:16
  disorder.
• 4:16
  So
• 4:16
  it's
• 4:17
  really
• 4:17
  important
• 4:17
  we
• 4:18
  don't
• 4:18
  misdiagnose
• 4:19
  this
• 4:19
  stuff.
• 4:20
  And
• 4:20
  what
• 4:20
  I'll
• 4:20
  see
• 4:21
  is
• 4:21
  I'll
• 4:22
  see
• 4:22
  other
• 4:22
  providers
• 4:23
  calling
• 4:24
  this
• 4:24
  PTSD
• 4:25
  when
• 4:25
  it's
• 4:26
  really
• 4:26
  a
• 4:26
  divorce
• 4:27
  or
• 4:27
  a
• 4:28
  job
• 4:28
  loss
• 4:29
  or
• 4:29
  a
• 4:30
  patient
• 4:30
  has
• 4:30
  a
• 4:30
  chronic
• 4:31
  illness
• 4:31
  that's
• 4:32
  really
• 4:33
  a
• 4:33
  problem,
• 4:33
  right?
• 4:33
  A
• 4:33
  sudden
• 4:34
  diagnosis,
• 4:35
  but
• 4:35
  it
• 4:35
  does
• 4:35
  not
• 4:36
  meet
• 4:36
  PTSD
• 4:37
  criterion
• 4:38
  A.
• 4:38
  Trauma,
• 4:39
  which
• 4:39
  is
• 4:39
  very
• 4:40
  specific
• 4:40
  in
• 4:40
  the
• 4:40
  DSM
• 4:41
  5,
• 4:42
  exposure
• 4:43
  to
• 4:43
  an
• 4:44
  actual
• 4:44
  or
• 4:44
  threatened
• 4:45
  death,
• 4:46
  serious
• 4:47
  injury
• 4:47
  or
• 4:47
  sexual
• 4:48
  violence.
• 4:49
  Okay,
• 4:51
  so
• 4:51
  we
• 4:51
  don't
• 4:52
  want
• 4:52
  to
• 4:52
  misdiagnose
• 4:53
  this,
• 4:53
  right?
• 4:53
  It's
• 4:54
  very
• 4:54
  important.
• 4:54
  Now
• 4:55
  this
• 4:55
  is
• 4:55
  where
• 4:55
  it
• 4:55
  gets
• 4:56
  really
• 4:56
  slippery
• 4:56
  and
• 4:56
  confusing.
• 4:57
  But
• 4:57
  in
• 4:57
  adjustment
• 4:58
  disorder,
• 4:59
  they
• 4:59
  could
• 4:59
  actually
• 5:00
  have
• 5:00
  a
• 5:01
  threatened
• 5:01
  death,
• 5:02
  serious
• 5:03
  injury
• 5:03
  or
• 5:04
  sexual
• 5:04
  violence
• 5:04
  and
• 5:05
  not
• 5:05
  meet
• 5:05
  PTSD
• 5:06
  criteria.
• 5:07
  Okay?
• 5:08
  They're
• 5:08
  not
• 5:08
  having
• 5:09
  nightmares
• 5:09
  and
• 5:09
  flashbacks
• 5:10
  and
• 5:10
  all
• 5:10
  those
• 5:10
  things.
• 5:11
  In
• 5:11
  that
• 5:11
  case,
• 5:11
  you
• 5:11
  can
• 5:12
  have
• 5:12
  an
• 5:12
  adjustment
• 5:12
  disorder.
• 5:13
  You
• 5:13
  absolutely
• 5:14
  can
• 5:14
  have
• 5:14
  an
• 5:15
  adjustment
• 5:15
  disorder.
• 5:16
  However,
• 5:17
  the
• 5:17
  opposite
• 5:18
  is
• 5:18
  not
• 5:18
  true.
• 5:18
  What
• 5:19
  we
• 5:19
  just
• 5:19
  talked
• 5:19
  about,
• 5:20
  right?
• 5:20
  You
• 5:21
  cannot
• 5:21
  have
• 5:21
  PTSD
• 5:23
  if
• 5:23
  you
• 5:23
  have,
• 5:24
  if
• 5:24
  you're.
• 5:25
  If
• 5:25
  your
• 5:25
  stressor
• 5:25
  in
• 5:26
  the
• 5:26
  adjustment
• 5:26
  disorder
• 5:27
  is
• 5:27
  not
• 5:27
  criterion
• 5:28
  A.
• 5:28
  And
• 5:28
  again,
• 5:28
  that's
• 5:29
  where
• 5:29
  we
• 5:29
  constantly
• 5:30
  get
• 5:30
  confused.
• 5:31
  I'll
• 5:31
  see
• 5:31
  patients
• 5:32
  diagnosed
• 5:33
  with
• 5:33
  PTSD
• 5:34
  after
• 5:34
  a
• 5:35
  Major
• 5:35
  divorce
• 5:36
  or
• 5:36
  after,
• 5:37
  you
• 5:37
  know,
• 5:37
  their
• 5:37
  parents,
• 5:38
  whether
• 5:38
  it's
• 5:38
  their,
• 5:39
  you
• 5:39
  know,
• 5:39
  they
• 5:40
  divorced
• 5:40
  their
• 5:40
  wife
• 5:41
  or
• 5:41
  they
• 5:41
  had
• 5:42
  a
• 5:42
  major,
• 5:43
  really
• 5:43
  messy
• 5:43
  divorce
• 5:44
  with
• 5:44
  their
• 5:44
  parents.
• 5:45
  Well,
• 5:45
  that's
• 5:45
  not
• 5:46
  PTSD
• 5:46
  unless
• 5:47
  there
• 5:47
  was
• 5:48
  some
• 5:48
  kind
• 5:48
  of
• 5:48
  actual
• 5:49
  or
• 5:49
  threatened
• 5:49
  death,
• 5:50
  serious
• 5:50
  injury,
• 5:50
  sexual
• 5:51
  violence.
• 5:53
  And
• 5:53
  so
• 5:53
  we
• 5:53
  have
• 5:53
  to
• 5:54
  be
• 5:54
  really
• 5:54
  careful
• 5:54
  not
• 5:55
  diagnosing
• 5:55
  these
• 5:56
  folks
• 5:56
  with
• 5:56
  PTSD
• 5:57
  when
• 5:57
  they
• 5:57
  have
• 5:57
  an
• 5:58
  adjustment
• 5:58
  disorder.
• 5:59
  Right.
• 6:00
  If
• 6:00
  they
• 6:00
  had
• 6:01
  a
• 6:01
  really
• 6:01
  bad
• 6:01
  boss
• 6:01
  who
• 6:02
  screamed
• 6:02
  at
• 6:02
  them
• 6:03
  or
• 6:03
  a
• 6:03
  toxic
• 6:04
  work
• 6:04
  environment,
• 6:04
  that
• 6:05
  is
• 6:05
  not
• 6:06
  ptsd.
• 6:07
  Right.
• 6:08
  There
• 6:08
  is
• 6:08
  no
• 6:08
  sexual
• 6:09
  violence
• 6:09
  there,
• 6:10
  presumably.
• 6:10
  Right.
• 6:11
  No
• 6:11
  threatened
• 6:11
  death,
• 6:12
  severe
• 6:12
  bodily
• 6:13
  harm.
• 6:13
  Right.
• 6:14
  We
• 6:14
  have
• 6:14
  to
• 6:14
  be
• 6:15
  really
• 6:15
  careful.
• 6:15
  Now
• 6:16
  if
• 6:16
  their
• 6:16
  occupational
• 6:18
  stressors
• 6:19
  involved
• 6:19
  collecting
• 6:20
  or
• 6:20
  examining
• 6:21
  paraphernalia,
• 6:22
  the
• 6:22
  child
• 6:23
  abuse
• 6:23
  or,
• 6:24
  you
• 6:24
  know,
• 6:25
  death
• 6:25
  or
• 6:25
  dismemberment,
• 6:26
  you
• 6:26
  know,
• 6:27
  you're
• 6:27
  a
• 6:27
  firefighter
• 6:28
  or
• 6:28
  a
• 6:28
  forensic
• 6:29
  investigator
• 6:29
  and
• 6:30
  part
• 6:30
  of
• 6:30
  your
• 6:30
  job
• 6:30
  is
• 6:30
  combing
• 6:31
  through
• 6:31
  human
• 6:31
  remains.
• 6:32
  Absolutely.
• 6:33
  The
• 6:33
  DSM
• 6:33
  has
• 6:34
  a
• 6:34
  very
• 6:34
  special
• 6:37
  way
• 6:37
  to
• 6:37
  diagnose
• 6:38
  that.
• 6:38
  It's
• 6:38
  a,
• 6:38
  it's
• 6:39
  very
• 6:39
  clearly
• 6:40
  a
• 6:40
  criterion,
• 6:40
  a
• 6:41
  PTSD
• 6:41
  trauma.
• 6:42
  Again,
• 6:42
  it
• 6:43
  doesn't
• 6:43
  mean
• 6:43
  they
• 6:43
  have
• 6:43
  ptsd.
• 6:44
  They
• 6:44
  have
• 6:44
  to
• 6:44
  have
• 6:45
  the
• 6:45
  full
• 6:45
  PTSD
• 6:46
  diagnosis,
• 6:46
  right?
• 6:47
  You
• 6:47
  have
• 6:47
  to
• 6:47
  have
• 6:48
  intrusions,
• 6:48
  you
• 6:48
  have
• 6:49
  to
• 6:49
  have
• 6:49
  avoidance,
• 6:50
  you
• 6:50
  have
• 6:51
  to
• 6:51
  have
• 6:51
  negative
• 6:52
  alterations
• 6:52
  in
• 6:52
  mood
• 6:53
  and
• 6:53
  cognition.
• 6:53
  Like
• 6:54
  two
• 6:54
  of
• 6:54
  those
• 6:55
  criteria,
• 6:55
  right?
• 6:56
  Where
• 6:56
  they
• 6:56
  start
• 6:57
  to,
• 6:58
  they're
• 6:58
  not
• 6:58
  able
• 6:58
  to
• 6:58
  engage
• 6:59
  in
• 6:59
  pleasurable
• 6:59
  activities
• 7:00
  as
• 7:00
  easily.
• 7:01
  Their
• 7:01
  emotions
• 7:01
  aren't
• 7:02
  as
• 7:02
  positive.
• 7:02
  They
• 7:02
  see
• 7:02
  the
• 7:03
  world
• 7:03
  in
• 7:03
  a
• 7:04
  dreary
• 7:04
  way.
• 7:05
  They
• 7:05
  feel
• 7:05
  like
• 7:05
  guilt
• 7:06
  or
• 7:06
  horror
• 7:06
  or
• 7:07
  anger
• 7:07
  towards
• 7:08
  the
• 7:08
  world.
• 7:08
  Maybe
• 7:08
  they
• 7:08
  don't
• 7:08
  trust
• 7:09
  the
• 7:09
  world,
• 7:09
  right?
• 7:09
  So
• 7:09
  it's
• 7:10
  a
• 7:10
  constellation
• 7:10
  of
• 7:11
  symptoms.
• 7:11
  You've
• 7:11
  got
• 7:11
  the
• 7:12
  hyper
• 7:12
  vigilance,
• 7:12
  right?
• 7:13
  Hyperarousal
• 7:14
  irritability,
• 7:14
  inability
• 7:15
  to
• 7:15
  concentrate.
• 7:16
  They
• 7:16
  need
• 7:16
  two
• 7:16
  of
• 7:16
  those
• 7:17
  in
• 7:17
  that
• 7:18
  section.
• 7:18
  PTSD
• 7:19
  is
• 7:19
  a
• 7:19
  pretty
• 7:20
  layered
• 7:22
  and
• 7:22
  intricate
• 7:23
  diagnosis.
• 7:24
  It
• 7:24
  really
• 7:25
  is
• 7:25
  if
• 7:25
  you
• 7:25
  look
• 7:25
  at
• 7:25
  it.
• 7:26
  And
• 7:26
  I,
• 7:27
  and
• 7:27
  I
• 7:27
  would
• 7:27
  argue
• 7:28
  it's
• 7:29
  one
• 7:29
  of
• 7:29
  the
• 7:29
  diagnosis
• 7:30
  I
• 7:30
  keep
• 7:30
  going
• 7:31
  back
• 7:31
  to
• 7:31
  in
• 7:31
  the
• 7:31
  DSM
• 7:32
  since
• 7:33
  I've
• 7:33
  graduated.
• 7:33
  You
• 7:34
  know,
• 7:34
  you
• 7:34
  think
• 7:34
  you
• 7:34
  know
• 7:34
  it
• 7:35
  and,
• 7:35
  and
• 7:35
  you've
• 7:36
  really
• 7:36
  got
• 7:36
  to
• 7:36
  memorize
• 7:36
  it.
• 7:37
  You
• 7:37
  know,
• 7:37
  you
• 7:37
  need
• 7:37
  one
• 7:37
  intrusion,
• 7:38
  you
• 7:39
  need
• 7:39
  one
• 7:40
  avoidance
• 7:40
  criteria,
• 7:41
  you
• 7:41
  need
• 7:41
  two
• 7:41
  of
• 7:42
  the
• 7:42
  negative
• 7:42
  alterations
• 7:43
  in
• 7:43
  mood
• 7:43
  and
• 7:43
  cognition,
• 7:44
  you
• 7:44
  need
• 7:44
  two
• 7:44
  of
• 7:44
  the
• 7:44
  hyperarousals,
• 7:46
  and
• 7:46
  you
• 7:46
  need
• 7:46
  a
• 7:46
  proper
• 7:47
  criterion,
• 7:47
  a
• 7:47
  trauma.
• 7:48
  And
• 7:48
  if
• 7:48
  you
• 7:48
  don't
• 7:48
  have
• 7:49
  all
• 7:49
  of
• 7:49
  those
• 7:49
  things,
• 7:49
  you
• 7:50
  don't
• 7:50
  have
• 7:50
  ptsd.
• 7:51
  You
• 7:51
  might
• 7:51
  have
• 7:51
  sub
• 7:52
  threshold
• 7:52
  ptsd,
• 7:53
  right?
• 7:54
  But
• 7:54
  until
• 7:55
  proven
• 7:55
  otherwise,
• 7:56
  you
• 7:56
  really
• 7:56
  have
• 7:56
  an
• 7:56
  adjustment
• 7:57
  disorder.
• 7:57
  If
• 7:58
  they
• 7:58
  have
• 7:59
  even
• 7:59
  like
• 7:59
  a
• 7:59
  near
• 8:00
  drowning
• 8:00
  event
• 8:00
  and
• 8:01
  clear
• 8:01
  criterion,
• 8:02
  a
• 8:02
  near
• 8:02
  death
• 8:02
  experience.
• 8:03
  But
• 8:04
  they
• 8:04
  don't
• 8:04
  have
• 8:04
  the
• 8:05
  nightmares,
• 8:05
  the
• 8:05
  flashbacks.
• 8:06
  They're
• 8:06
  not
• 8:06
  avoiding
• 8:07
  water,
• 8:07
  they're
• 8:08
  not
• 8:08
  having
• 8:08
  nightmares
• 8:09
  about
• 8:09
  Drowning,
• 8:10
  Um,
• 8:10
  they
• 8:10
  don't
• 8:10
  perceive
• 8:11
  the
• 8:11
  world
• 8:11
  as
• 8:11
  unsafe.
• 8:12
  They're.
• 8:12
  They're
• 8:13
  not
• 8:13
  very
• 8:13
  hypervigilant.
• 8:14
  Maybe
• 8:14
  they're
• 8:14
  just
• 8:15
  kind
• 8:15
  of
• 8:15
  shooken
• 8:15
  up
• 8:15
  and
• 8:16
  down.
• 8:16
  But
• 8:17
  they
• 8:17
  don't
• 8:17
  have
• 8:17
  that
• 8:18
  PTSD
• 8:19
  full
• 8:20
  blown
• 8:21
  criteria
• 8:21
  like
• 8:21
  criteria
• 8:22
  met.
• 8:22
  They
• 8:23
  just
• 8:23
  have
• 8:23
  that
• 8:23
  criterion
• 8:24
  A.
• 8:24
  Well,
• 8:24
  guess
• 8:24
  what,
• 8:25
  that's
• 8:25
  not
• 8:25
  PTSD
• 8:26
  then,
• 8:26
  right?
• 8:26
  Even
• 8:27
  though
• 8:27
  it
• 8:27
  screams
• 8:28
  ptsd.
• 8:29
  Oh,
• 8:29
  he
• 8:29
  almost
• 8:29
  drowned.
• 8:30
  This
• 8:30
  is
• 8:30
  so
• 8:30
  traumatic.
• 8:31
  It's
• 8:32
  not
• 8:32
  PTSD
• 8:32
  because
• 8:33
  that
• 8:33
  person
• 8:34
  is
• 8:34
  not
• 8:34
  exhibiting
• 8:35
  the
• 8:36
  intrusions
• 8:36
  and
• 8:36
  avoidance
• 8:37
  that
• 8:37
  are
• 8:38
  hallmarks
• 8:38
  of
• 8:38
  this
• 8:38
  disorder.
• 8:39
  Remember,
• 8:41
  not
• 8:41
  to
• 8:41
  beat
• 8:41
  the
• 8:41
  dead
• 8:42
  horse
• 8:42
  here,
• 8:43
  but
• 8:43
  it's
• 8:44
  not
• 8:44
  enough
• 8:44
  to
• 8:44
  just
• 8:45
  say
• 8:45
  something
• 8:46
  traumatic
• 8:46
  happened
• 8:47
  to
• 8:47
  you,
• 8:48
  because
• 8:49
  first
• 8:49
  of
• 8:49
  all,
• 8:49
  that
• 8:49
  kind
• 8:50
  of
• 8:50
  bastardizes
• 8:50
  the
• 8:51
  word
• 8:51
  traumatic
• 8:51
  because
• 8:52
  maybe
• 8:52
  it
• 8:52
  wasn't
• 8:53
  traumatic
• 8:53
  to
• 8:53
  you.
• 8:54
  It's
• 8:54
  a
• 8:55
  big,
• 8:55
  flashy
• 8:56
  near
• 8:56
  death
• 8:57
  experience.
• 8:57
  And
• 8:57
  you
• 8:58
  know,
• 8:58
  we
• 8:58
  use
• 8:58
  it
• 8:58
  almost
• 8:59
  pejoratively
• 9:00
  as
• 9:00
  like
• 9:00
  old
• 9:00
  trauma.
• 9:01
  But
• 9:01
  if
• 9:01
  that
• 9:01
  patient
• 9:02
  is
• 9:02
  not
• 9:03
  avoiding
• 9:04
  things
• 9:04
  as
• 9:04
  a
• 9:04
  result,
• 9:04
  you
• 9:05
  know,
• 9:05
  they
• 9:05
  get
• 9:05
  in
• 9:05
  a
• 9:05
  car
• 9:05
  accident
• 9:06
  that
• 9:06
  was
• 9:06
  maybe,
• 9:07
  maybe
• 9:08
  could
• 9:08
  have
• 9:08
  been
• 9:08
  deadly.
• 9:09
  Right?
• 9:09
  But
• 9:11
  they
• 9:11
  don't
• 9:11
  avoid
• 9:12
  driving
• 9:12
  the
• 9:12
  next
• 9:13
  few
• 9:13
  months,
• 9:13
  they're
• 9:13
  perfectly
• 9:14
  comfortable
• 9:14
  getting
• 9:15
  back
• 9:15
  into
• 9:15
  the
• 9:15
  car.
• 9:15
  Maybe
• 9:16
  they're
• 9:16
  a
• 9:16
  little
• 9:16
  nervous,
• 9:17
  but
• 9:17
  they're
• 9:17
  getting
• 9:17
  in
• 9:17
  the
• 9:17
  car,
• 9:18
  they're
• 9:18
  driving,
• 9:19
  they're
• 9:19
  commuting
• 9:19
  to
• 9:19
  work
• 9:20
  again,
• 9:20
  they
• 9:20
  don't
• 9:21
  avoid
• 9:21
  driving.
• 9:21
  They're
• 9:22
  not
• 9:22
  having
• 9:22
  nightmares
• 9:22
  of
• 9:23
  being
• 9:23
  in
• 9:23
  car
• 9:23
  accidents.
• 9:24
  Well,
• 9:24
  then
• 9:25
  definitionally,
• 9:26
  it
• 9:26
  wasn't
• 9:26
  really
• 9:27
  traumatizing
• 9:27
  to
• 9:28
  that
• 9:28
  patient.
• 9:29
  Right?
• 9:29
  They
• 9:29
  might
• 9:29
  be
• 9:29
  adjusting
• 9:30
  and
• 9:30
  having
• 9:31
  a
• 9:31
  little
• 9:31
  harder
• 9:31
  time,
• 9:32
  maybe
• 9:32
  they're
• 9:32
  a
• 9:32
  little
• 9:32
  jumpier
• 9:33
  behind
• 9:33
  the
• 9:33
  wheel,
• 9:34
  but
• 9:34
  they're
• 9:34
  otherwise
• 9:34
  going
• 9:35
  to
• 9:35
  work.
• 9:35
  That
• 9:35
  would
• 9:36
  be
• 9:36
  maybe
• 9:36
  more
• 9:37
  of
• 9:37
  an
• 9:37
  adjustment
• 9:37
  disorder.
• 9:38
  You'd
• 9:38
  have
• 9:38
  to
• 9:38
  look
• 9:38
  at
• 9:38
  that
• 9:38
  too,
• 9:39
  because
• 9:39
  adjustment
• 9:40
  disorders
• 9:40
  also
• 9:41
  suggest
• 9:41
  that
• 9:41
  there's
• 9:42
  some
• 9:42
  impairment
• 9:42
  in
• 9:42
  functioning.
• 9:43
  But
• 9:43
  if
• 9:43
  it
• 9:44
  doesn't
• 9:44
  meet
• 9:44
  full
• 9:44
  criteria
• 9:45
  for
• 9:45
  ptsd,
• 9:47
  and
• 9:47
  yet
• 9:47
  it
• 9:47
  was
• 9:47
  a
• 9:48
  near
• 9:48
  death
• 9:48
  experience,
• 9:48
  you
• 9:49
  would
• 9:49
  definitely
• 9:50
  diagnose
• 9:50
  an
• 9:50
  adjustment
• 9:51
  disorder.
• 9:52
  The
• 9:52
  caveat
• 9:52
  though
• 9:53
  is
• 9:53
  six
• 9:54
  months
• 9:54
  later,
• 9:56
  okay,
• 9:57
  six
• 9:57
  months
• 9:58
  later,
• 9:58
  that
• 9:59
  adjustment
• 10:00
  disorder
• 10:00
  no
• 10:01
  longer
• 10:01
  applies.
• 10:57
  Okay,
• 10:57
  so
• 10:58
  let's
• 10:58
  get
• 10:58
  back
• 10:59
  to
• 10:59
  our
• 10:59
  example
• 11:00
  of
• 11:01
  let's
• 11:01
  call
• 11:01
  him
• 11:01
  Henry.
• 11:02
  He
• 11:02
  gets
• 11:02
  in
• 11:02
  a
• 11:02
  car
• 11:03
  accident,
• 11:04
  okay?
• 11:04
  But
• 11:04
  he's
• 11:05
  not
• 11:05
  exhibiting
• 11:05
  the
• 11:05
  full
• 11:06
  PTSD
• 11:06
  constellation.
• 11:07
  He
• 11:07
  would
• 11:07
  have
• 11:07
  an
• 11:07
  adjustment
• 11:08
  disorder.
• 11:08
  And
• 11:08
  you
• 11:08
  can
• 11:09
  diagnose
• 11:09
  adjustment
• 11:09
  disorder
• 11:10
  immediately,
• 11:11
  you
• 11:11
  know,
• 11:11
  as
• 11:11
  opposed
• 11:12
  to
• 11:12
  ptsd.
• 11:12
  You
• 11:12
  gotta
• 11:13
  wait
• 11:13
  a
• 11:13
  month
• 11:13
  before
• 11:13
  you
• 11:13
  adjust,
• 11:14
  before
• 11:14
  you
• 11:14
  diagnose
• 11:15
  that.
• 11:15
  Right.
• 11:16
  Time.
• 11:16
  So
• 11:16
  it's
• 11:16
  an
• 11:16
  adjustment
• 11:17
  disorder
• 11:17
  immediately.
• 11:19
  And
• 11:19
  if
• 11:20
  they
• 11:20
  meet
• 11:20
  full
• 11:20
  criteria
• 11:21
  for
• 11:21
  PTSD
• 11:22
  within
• 11:22
  three
• 11:22
  days,
• 11:23
  you
• 11:23
  can
• 11:23
  do
• 11:23
  an
• 11:23
  acute
• 11:23
  stress
• 11:24
  disorder.
• 11:24
  Right,
• 11:25
  it
• 11:25
  has
• 11:25
  all
• 11:25
  the
• 11:25
  PTSD
• 11:26
  criteria,
• 11:26
  but
• 11:26
  it's
• 11:27
  three
• 11:27
  days
• 11:27
  to
• 11:27
  one
• 11:27
  month.
• 11:28
  Right,
• 11:29
  but
• 11:30
  if
• 11:30
  you
• 11:31
  are
• 11:31
  diagnosing
• 11:32
  an
• 11:32
  adjustment
• 11:32
  disorder
• 11:33
  because
• 11:33
  you're
• 11:33
  going,
• 11:33
  okay,
• 11:33
  Henry's
• 11:34
  still
• 11:34
  driving,
• 11:34
  he's
• 11:35
  not
• 11:35
  having
• 11:35
  nightmares,
• 11:36
  he's
• 11:36
  not
• 11:36
  having
• 11:36
  flashbacks.
• 11:37
  We're
• 11:37
  going
• 11:37
  to
• 11:38
  diagnose
• 11:38
  him
• 11:38
  with
• 11:38
  an
• 11:38
  adjustment
• 11:39
  disorder
• 11:39
  right
• 11:39
  now.
• 11:40
  But
• 11:40
  if
• 11:40
  his
• 11:41
  symptoms
• 11:42
  that
• 11:42
  appear
• 11:42
  to
• 11:42
  be
• 11:43
  kind
• 11:43
  of
• 11:43
  sub
• 11:43
  threshold
• 11:44
  PTSD,
• 11:44
  if
• 11:44
  they're
• 11:45
  persisting
• 11:45
  beyond
• 11:46
  6
• 11:46
  months
• 11:47
  after
• 11:48
  this
• 11:48
  stressor
• 11:49
  ends,
• 11:49
  then
• 11:49
  an
• 11:50
  adjustment
• 11:50
  disorder
• 11:50
  no
• 11:50
  longer
• 11:51
  applies
• 11:51
  and
• 11:51
  you
• 11:52
  might
• 11:52
  actually
• 11:52
  diagnose
• 11:53
  and
• 11:53
  other
• 11:53
  trauma
• 11:54
  and
• 11:54
  stressor
• 11:55
  related
• 11:55
  disorder.
• 11:56
  The
• 11:56
  other
• 11:57
  qualifier
• 11:58
  meaning
• 11:58
  we,
• 11:58
  we
• 11:59
  have
• 11:59
  some
• 11:59
  sort
• 11:59
  of
• 11:59
  trauma
• 12:00
  going
• 12:00
  on
• 12:00
  because
• 12:00
  this
• 12:01
  is
• 12:01
  lasting
• 12:01
  way
• 12:01
  too
• 12:02
  long.
• 12:02
  Okay,
• 12:03
  we're
• 12:03
  not
• 12:03
  really
• 12:03
  confident
• 12:04
  this
• 12:04
  is
• 12:04
  an
• 12:04
  adjustment
• 12:05
  disorder
• 12:05
  anymore.
• 12:06
  And,
• 12:06
  and
• 12:06
  the
• 12:06
  patient
• 12:07
  is
• 12:07
  a
• 12:07
  little
• 12:08
  bit
• 12:08
  jumpy
• 12:09
  in
• 12:09
  cars.
• 12:10
  There
• 12:10
  is
• 12:11
  some
• 12:11
  trauma
• 12:11
  response,
• 12:12
  but
• 12:12
  not
• 12:12
  a
• 12:12
  full
• 12:12
  blown
• 12:13
  one.
• 12:13
  We
• 12:13
  would
• 12:13
  say
• 12:14
  other
• 12:14
  trauma
• 12:14
  and
• 12:15
  stress
• 12:15
  related
• 12:15
  disorder
• 12:16
  because
• 12:16
  after
• 12:16
  that
• 12:17
  six
• 12:17
  months
• 12:17
  is,
• 12:18
  is
• 12:18
  over.
• 12:19
  You
• 12:19
  can't
• 12:20
  do
• 12:20
  a
• 12:20
  diagnosis
• 12:20
  of
• 12:21
  adjustment
• 12:21
  disorder
• 12:22
  anymore.
• 12:22
  Okay.
• 12:23
  But
• 12:23
  the
• 12:24
  greater
• 12:24
  point
• 12:24
  is
• 12:24
  be
• 12:25
  really
• 12:25
  picky,
• 12:25
  my
• 12:26
  friends,
• 12:26
  about
• 12:27
  whether
• 12:27
  or
• 12:27
  not
• 12:27
  this
• 12:28
  is
• 12:28
  a
• 12:28
  criterion,
• 12:29
  a
• 12:29
  trauma
• 12:29
  that's
• 12:30
  going
• 12:30
  to
• 12:30
  help
• 12:30
  you
• 12:30
  understand
• 12:31
  is
• 12:31
  this
• 12:31
  really
• 12:31
  an
• 12:32
  adjustment
• 12:32
  disorder?
• 12:33
  And
• 12:33
  you
• 12:33
  won't
• 12:33
  accidentally
• 12:34
  diagnosis,
• 12:35
  diagnose
• 12:35
  it
• 12:35
  as
• 12:36
  ptsd
• 12:36
  and
• 12:37
  then
• 12:37
  you
• 12:37
  won't
• 12:37
  accidentally
• 12:38
  go
• 12:38
  down
• 12:38
  this
• 12:38
  treatment
• 12:39
  algorithm.
• 12:40
  That
• 12:40
  is
• 12:40
  inappropriate.
• 12:41
  Right.
• 12:41
  Prolonged
• 12:42
  exposure,
• 12:43
  cpt,
• 12:43
  emdr,
• 12:44
  you
• 12:44
  get
• 12:45
  all
• 12:45
  kinds
• 12:45
  of
• 12:45
  disability
• 12:46
  when
• 12:46
  you
• 12:46
  have
• 12:46
  ptsd.
• 12:47
  You
• 12:47
  don't
• 12:47
  want
• 12:47
  to
• 12:48
  mislabel
• 12:49
  that
• 12:49
  it's
• 12:49
  totally
• 12:50
  wrong
• 12:50
  treatment
• 12:51
  path.
• 12:52
  So
• 12:52
  that's
• 12:52
  your
• 12:52
  first
• 12:53
  issue.
• 12:53
  Is
• 12:54
  it
• 12:54
  a
• 12:54
  criterion
• 12:55
  a
• 12:55
  trauma?
• 12:56
  And
• 12:56
  even
• 12:56
  if
• 12:56
  it
• 12:56
  is
• 12:57
  a
• 12:57
  criterion
• 12:57
  a
• 12:57
  trauma,
• 12:58
  it
• 12:58
  still
• 12:58
  could
• 12:58
  be
• 12:58
  an
• 12:58
  adjustment
• 12:59
  disorder.
• 12:59
  So
• 12:59
  you
• 12:59
  got
• 13:00
  to
• 13:00
  make
• 13:00
  sure
• 13:00
  if
• 13:01
  you
• 13:01
  it
• 13:01
  does
• 13:01
  this
• 13:01
  come
• 13:02
  with
• 13:02
  the
• 13:02
  constellation
• 13:03
  of
• 13:03
  PTSD
• 13:03
  symptoms?
• 13:04
  If
• 13:04
  not
• 13:05
  go
• 13:05
  down
• 13:05
  the
• 13:05
  adjustment
• 13:06
  rabbit
• 13:06
  hole.
• 13:06
  Okay,
• 13:07
  the
• 13:07
  second
• 13:07
  pearl
• 13:08
  you
• 13:08
  may
• 13:08
  not
• 13:08
  know
• 13:08
  about
• 13:09
  adjustment
• 13:09
  disorder
• 13:10
  and
• 13:10
  I
• 13:10
  really
• 13:10
  learned
• 13:10
  this
• 13:11
  the
• 13:11
  hard
• 13:11
  way
• 13:11
  in
• 13:12
  practice
• 13:12
  is
• 13:12
  medications
• 13:13
  really
• 13:13
  don't
• 13:14
  work
• 13:14
  that
• 13:14
  well
• 13:14
  for
• 13:14
  this.
• 13:15
  The
• 13:15
  evidence
• 13:15
  is
• 13:16
  pretty
• 13:16
  clear
• 13:16
  about
• 13:16
  that.
• 13:17
  There's
• 13:17
  no
• 13:17
  FDA
• 13:18
  approved
• 13:18
  medications
• 13:19
  for
• 13:19
  an
• 13:19
  adjustment
• 13:20
  disorder.
• 13:21
  The
• 13:22
  evidence
• 13:22
  for
• 13:23
  pharmacotherapy
• 13:24
  is
• 13:24
  pretty
• 13:24
  thin
• 13:24
  out
• 13:25
  there
• 13:25
  as
• 13:26
  it
• 13:26
  relates
• 13:26
  to
• 13:26
  adjustment
• 13:27
  disorder.
• 13:27
  CBT
• 13:28
  is
• 13:28
  a
• 13:28
  lot
• 13:28
  better
• 13:28
  in
• 13:29
  my
• 13:29
  experience,
• 13:30
  having
• 13:30
  the
• 13:30
  patients
• 13:31
  kind
• 13:31
  of
• 13:31
  reframe
• 13:32
  what's
• 13:32
  happened
• 13:32
  to
• 13:32
  them.
• 13:34
  It's
• 13:34
  really
• 13:34
  the
• 13:34
  only
• 13:35
  intervention
• 13:35
  with
• 13:36
  consistent
• 13:36
  randomized
• 13:37
  controlled
• 13:37
  trial
• 13:37
  evidence
• 13:38
  for
• 13:38
  it.
• 13:39
  And
• 13:40
  so
• 13:41
  reframing
• 13:41
  thoughts
• 13:42
  and
• 13:42
  behaviors
• 13:44
  in
• 13:44
  response
• 13:45
  to
• 13:45
  a
• 13:45
  major
• 13:45
  stressor
• 13:46
  is
• 13:46
  probably
• 13:46
  your
• 13:47
  best
• 13:47
  bet.
• 13:48
  Yes.
• 13:49
  You
• 13:49
  know,
• 13:49
  I
• 13:50
  have
• 13:50
  had
• 13:50
  some
• 13:50
  good
• 13:50
  experience
• 13:51
  treating
• 13:51
  around
• 13:52
  this
• 13:53
  via,
• 13:54
  you
• 13:54
  know,
• 13:54
  if
• 13:54
  the
• 13:54
  patient
• 13:55
  can't
• 13:55
  sleep,
• 13:55
  then
• 13:55
  sure,
• 13:56
  maybe
• 13:56
  trying
• 13:56
  them
• 13:56
  on
• 13:57
  trazodone
• 13:58
  or,
• 13:58
  or
• 13:59
  rameltion
• 14:00
  or
• 14:01
  you
• 14:01
  know,
• 14:02
  educating
• 14:02
  them
• 14:02
  on
• 14:02
  sleep
• 14:03
  hygiene.
• 14:04
  Fine,
• 14:05
  fine.
• 14:05
  All
• 14:05
  fair
• 14:05
  game.
• 14:06
  But
• 14:06
  you're
• 14:06
  not
• 14:06
  really
• 14:07
  getting
• 14:07
  to
• 14:07
  the
• 14:07
  core
• 14:08
  problem,
• 14:08
  which
• 14:09
  is
• 14:09
  their
• 14:09
  stressor,
• 14:10
  and
• 14:10
  that
• 14:10
  needs
• 14:11
  to
• 14:11
  resolve.
• 14:11
  Right.
• 14:12
  And
• 14:12
  medications
• 14:13
  just
• 14:13
  don't
• 14:13
  seem
• 14:14
  to
• 14:14
  help
• 14:14
  that.
• 14:14
  And
• 14:15
  in
• 14:15
  fact,
• 14:16
  I'll
• 14:16
  add
• 14:16
  a
• 14:16
  mini
• 14:16
  pearl
• 14:17
  onto
• 14:17
  this
• 14:17
  pearl.
• 14:18
  You
• 14:18
  really.
• 14:19
  I've
• 14:19
  seen.
• 14:19
  I've
• 14:20
  seen
• 14:20
  it
• 14:20
  be
• 14:20
  kind
• 14:21
  of
• 14:21
  problematic
• 14:21
  to
• 14:21
  prescribe
• 14:22
  medications
• 14:22
  because
• 14:23
  now
• 14:23
  you're
• 14:23
  giving
• 14:23
  these
• 14:23
  serotonergic
• 14:24
  medications
• 14:25
  that
• 14:25
  are
• 14:26
  flattening
• 14:26
  affect.
• 14:27
  They're
• 14:28
  flattening
• 14:28
  emotions
• 14:29
  across
• 14:29
  the
• 14:29
  board,
• 14:30
  and
• 14:30
  it's
• 14:31
  really
• 14:31
  kind
• 14:31
  of
• 14:31
  bad.
• 14:31
  I
• 14:32
  mean,
• 14:32
  you're
• 14:32
  kind
• 14:32
  of
• 14:32
  taking
• 14:32
  the
• 14:33
  humanity
• 14:33
  out
• 14:33
  of
• 14:33
  the
• 14:34
  suffering,
• 14:35
  and
• 14:35
  it's
• 14:36
  hard
• 14:36
  to
• 14:36
  explain
• 14:37
  that.
• 14:37
  But
• 14:37
  if
• 14:37
  your
• 14:38
  patients
• 14:38
  coming
• 14:39
  to
• 14:39
  you
• 14:39
  because
• 14:39
  they
• 14:39
  have
• 14:39
  emptiness
• 14:40
  syndrome
• 14:40
  and
• 14:40
  it
• 14:41
  looks
• 14:41
  like
• 14:41
  an
• 14:41
  adjustment
• 14:42
  disorder,
• 14:42
  right.
• 14:42
  Their
• 14:42
  daughter
• 14:43
  just
• 14:43
  went
• 14:43
  off
• 14:43
  to
• 14:43
  college
• 14:45
  or,
• 14:45
  you
• 14:45
  know,
• 14:45
  or
• 14:46
  maybe
• 14:46
  they
• 14:46
  lost
• 14:46
  custody
• 14:47
  of
• 14:47
  their
• 14:47
  daughter.
• 14:48
  It's.
• 14:49
  It
• 14:49
  seems
• 14:49
  it's
• 14:50
  almost
• 14:50
  kind
• 14:50
  of
• 14:51
  wrong
• 14:51
  to
• 14:51
  give
• 14:51
  them
• 14:52
  a
• 14:52
  medication
• 14:52
  if
• 14:52
  it's
• 14:53
  an
• 14:53
  adjustment
• 14:53
  disorder
• 14:54
  that
• 14:54
  just
• 14:55
  blunts
• 14:55
  their
• 14:55
  emotions.
• 14:56
  I
• 14:56
  mean,
• 14:56
  these
• 14:56
  are
• 14:56
  very
• 14:57
  appropriate
• 14:57
  emotions
• 14:58
  to
• 14:58
  sift
• 14:58
  through.
• 14:59
  It's
• 14:59
  important
• 14:59
  that
• 14:59
  they
• 15:00
  go
• 15:00
  through
• 15:00
  this
• 15:00
  with
• 15:00
  cognitive
• 15:01
  behavioral
• 15:02
  therapy,
• 15:02
  and
• 15:03
  they
• 15:03
  can
• 15:03
  kind
• 15:03
  of
• 15:03
  process
• 15:04
  it
• 15:04
  differently.
• 15:04
  But
• 15:05
  I
• 15:05
  wouldn't
• 15:05
  just
• 15:05
  blunt
• 15:06
  the
• 15:06
  emotion.
• 15:06
  It's
• 15:06
  a
• 15:06
  very
• 15:06
  real
• 15:07
  emotion.
• 15:08
  And,
• 15:08
  you
• 15:08
  know,
• 15:09
  every
• 15:09
  patient's
• 15:09
  different.
• 15:10
  You
• 15:10
  know,
• 15:10
  maybe
• 15:10
  don't
• 15:11
  take
• 15:11
  that
• 15:11
  to
• 15:11
  the
• 15:11
  bank
• 15:11
  and,
• 15:12
  you
• 15:12
  know,
• 15:12
  look
• 15:12
  at
• 15:13
  each
• 15:13
  patient
• 15:13
  individually.
• 15:14
  But
• 15:15
  I
• 15:15
  find
• 15:15
  that
• 15:15
  it's
• 15:15
  just
• 15:16
  not
• 15:16
  a
• 15:16
  very
• 15:16
  appropriate
• 15:17
  response.
• 15:17
  And
• 15:17
  the
• 15:18
  evidence,
• 15:18
  of
• 15:18
  course,
• 15:18
  suggests
• 15:19
  it
• 15:19
  isn't.
• 15:20
  Um,
• 15:20
  it's
• 15:20
  not
• 15:21
  very
• 15:21
  effective.
• 15:22
  And
• 15:22
  so
• 15:22
  think
• 15:23
  about
• 15:23
  cbt.
• 15:24
  I
• 15:24
  would
• 15:25
  definitely
• 15:25
  turn
• 15:25
  my
• 15:26
  psychotherapy
• 15:28
  alarm
• 15:28
  on
• 15:29
  or
• 15:29
  radar
• 15:29
  on
• 15:29
  whenever
• 15:30
  I'm
• 15:30
  seeing
• 15:30
  an
• 15:30
  adjustment
• 15:31
  disorder,
• 15:31
  because
• 15:32
  meds
• 15:32
  don't
• 15:33
  seem
• 15:33
  to
• 15:33
  do
• 15:33
  that
• 15:33
  well.
• 15:34
  You'll
• 15:34
  see,
• 15:34
  too,
• 15:34
  if
• 15:35
  you
• 15:35
  end
• 15:35
  up
• 15:35
  prescribing
• 15:35
  them
• 15:36
  because
• 15:36
  you
• 15:36
  have
• 15:37
  a
• 15:37
  hunch
• 15:37
  that
• 15:37
  this
• 15:37
  is
• 15:37
  something
• 15:38
  else,
• 15:39
  but
• 15:39
  it's
• 15:39
  adjustment
• 15:40
  disorder
• 15:40
  if
• 15:40
  they're
• 15:41
  not
• 15:41
  effective.
• 15:41
  You
• 15:42
  may
• 15:42
  be
• 15:43
  correct
• 15:43
  that
• 15:43
  this
• 15:43
  was
• 15:44
  probably
• 15:44
  an
• 15:44
  adjustment
• 15:45
  disorder,
• 15:45
  because
• 15:46
  I
• 15:46
  have
• 15:46
  found
• 15:47
  my
• 15:47
  patients
• 15:47
  don't
• 15:48
  respond
• 15:48
  very
• 15:48
  well
• 15:50
  when
• 15:50
  you
• 15:50
  give
• 15:50
  them
• 15:51
  medications.
• 15:51
  They
• 15:52
  respond
• 15:52
  very
• 15:52
  well
• 15:52
  when
• 15:53
  the
• 15:53
  stressor
• 15:53
  is
• 15:53
  over.
• 15:54
  That's
• 15:55
  what
• 15:55
  they
• 15:55
  respond
• 15:55
  well
• 15:55
  to.
• 15:56
  Okay,
• 15:56
  So
• 15:57
  I
• 15:57
  wouldn't
• 15:57
  be
• 15:57
  reflexive
• 15:58
  here
• 15:58
  and
• 15:58
  just
• 15:59
  prescribe
• 15:59
  an
• 15:59
  ssri.
• 16:00
  Now,
• 16:01
  remember
• 16:01
  one
• 16:01
  thing,
• 16:01
  though,
• 16:02
  my
• 16:02
  friends.
• 16:02
  Diagnostically,
• 16:03
  if
• 16:04
  your
• 16:04
  patient
• 16:04
  does
• 16:05
  meet
• 16:05
  major
• 16:06
  depressive
• 16:07
  disorder
• 16:07
  criteria,
• 16:11
  it
• 16:11
  doesn't
• 16:11
  matter
• 16:12
  if
• 16:12
  they
• 16:12
  just
• 16:13
  had
• 16:13
  a
• 16:13
  stressor
• 16:13
  and
• 16:14
  it
• 16:14
  looks
• 16:14
  and
• 16:14
  smells
• 16:15
  exactly
• 16:16
  like
• 16:16
  an
• 16:16
  adjustment
• 16:17
  disorder.
• 16:17
  That
• 16:17
  doesn't
• 16:17
  matter
• 16:18
  if
• 16:18
  they.
• 16:18
  If
• 16:18
  they
• 16:18
  meet
• 16:19
  criteria
• 16:19
  for
• 16:19
  mdd.
• 16:20
  It's
• 16:20
  mdd,
• 16:21
  period,
• 16:21
  non
• 16:21
  negotiable.
• 16:22
  It
• 16:22
  says
• 16:23
  it
• 16:23
  very
• 16:23
  clearly
• 16:23
  in
• 16:23
  the
• 16:23
  dsm.
• 16:24
  So
• 16:25
  again,
• 16:25
  you
• 16:26
  have
• 16:26
  a
• 16:26
  patient
• 16:26
  who
• 16:26
  just
• 16:27
  got
• 16:27
  fired
• 16:27
  and
• 16:28
  it
• 16:28
  just
• 16:28
  happened
• 16:28
  a
• 16:29
  month
• 16:29
  ago
• 16:29
  and
• 16:29
  they
• 16:29
  can't
• 16:30
  function
• 16:30
  and
• 16:30
  they've
• 16:30
  never
• 16:31
  really
• 16:31
  been
• 16:31
  depressed
• 16:31
  before.
• 16:32
  And
• 16:32
  it's
• 16:33
  clear
• 16:33
  that
• 16:33
  that
• 16:34
  stressor
• 16:35
  was
• 16:35
  the
• 16:35
  opening
• 16:36
  bell
• 16:37
  that
• 16:37
  made
• 16:37
  them,
• 16:38
  made
• 16:39
  it
• 16:39
  difficult
• 16:39
  for
• 16:39
  them
• 16:39
  to
• 16:40
  function.
• 16:40
  Well,
• 16:40
  guess
• 16:40
  what?
• 16:42
  If
• 16:42
  they're
• 16:42
  super
• 16:43
  self
• 16:43
  critical
• 16:43
  and
• 16:43
  they're
• 16:44
  not
• 16:44
  eating
• 16:44
  and
• 16:44
  sleeping
• 16:45
  much
• 16:45
  and
• 16:46
  they're
• 16:46
  thinking
• 16:46
  about
• 16:46
  death
• 16:46
  a
• 16:47
  lot
• 16:47
  and
• 16:47
  they
• 16:48
  have
• 16:48
  anhedonia
• 16:48
  and
• 16:49
  they're
• 16:49
  sad
• 16:49
  and
• 16:49
  down
• 16:50
  and
• 16:50
  depressed.
• 16:50
  Oops,
• 16:50
  that's
• 16:51
  like
• 16:51
  five
• 16:51
  right
• 16:52
  there.
• 16:52
  And
• 16:52
  you
• 16:53
  cannot,
• 16:53
  you
• 16:53
  cannot
• 16:54
  diagnose
• 16:54
  an
• 16:55
  adjustment
• 16:55
  disorder
• 16:56
  there.
• 16:56
  It
• 16:56
  doesn't
• 16:57
  matter
• 16:57
  that
• 16:57
  it,
• 16:58
  it,
• 16:58
  it
• 16:58
  seems,
• 16:58
  it
• 16:59
  screams
• 16:59
  adjustment
• 17:00
  because
• 17:00
  they
• 17:01
  just
• 17:01
  got
• 17:01
  fired
• 17:01
  and
• 17:02
  it's
• 17:02
  like,
• 17:02
  well,
• 17:02
  he's
• 17:02
  never
• 17:02
  been
• 17:03
  depressed.
• 17:03
  Of
• 17:03
  course
• 17:03
  this
• 17:03
  is
• 17:04
  an
• 17:04
  adjustment.
• 17:04
  Of
• 17:04
  course
• 17:04
  the
• 17:05
  firing
• 17:05
  caused
• 17:05
  that.
• 17:06
  Not
• 17:06
  if
• 17:07
  you
• 17:07
  have
• 17:07
  all
• 17:07
  criteria
• 17:08
  for
• 17:08
  mdd,
• 17:08
  then
• 17:09
  it
• 17:09
  is
• 17:09
  mdd.
• 17:10
  Get
• 17:10
  adjustment
• 17:10
  out
• 17:11
  of
• 17:11
  your
• 17:11
  mind.
• 17:12
  Right?
• 17:12
  So
• 17:12
  that's
• 17:12
  another
• 17:12
  pearl.
• 17:13
  And
• 17:13
  this
• 17:13
  is
• 17:13
  why
• 17:14
  this
• 17:14
  can
• 17:14
  be
• 17:14
  so
• 17:14
  misdiagnosed.
• 17:15
  You
• 17:15
  see
• 17:16
  how
• 17:16
  something
• 17:16
  that
• 17:16
  looks
• 17:16
  so
• 17:17
  innocent
• 17:17
  in
• 17:17
  the
• 17:17
  dsm
• 17:18
  adjustment,
• 17:18
  easy.
• 17:19
  You
• 17:19
  just
• 17:19
  got
• 17:20
  fired,
• 17:20
  you
• 17:20
  just
• 17:20
  got
• 17:20
  divorced.
• 17:21
  It's
• 17:21
  an
• 17:21
  adjustment.
• 17:22
  Do
• 17:22
  you
• 17:22
  see
• 17:22
  how
• 17:23
  that
• 17:23
  can
• 17:23
  be
• 17:23
  so
• 17:23
  difficult
• 17:24
  when
• 17:24
  it
• 17:24
  comes
• 17:25
  down
• 17:25
  to
• 17:25
  the
• 17:25
  definitions
• 17:26
  and
• 17:26
  the
• 17:26
  timing?
• 17:26
  It
• 17:27
  can
• 17:27
  get
• 17:27
  really
• 17:27
  difficult.
• 17:28
  Now
• 17:28
  the
• 17:28
  third
• 17:29
  pearl
• 17:29
  that
• 17:29
  crept
• 17:30
  up
• 17:30
  on
• 17:30
  me
• 17:30
  as
• 17:30
  I
• 17:31
  started
• 17:31
  to
• 17:31
  practice
• 17:32
  is
• 17:32
  how
• 17:33
  prevalent
• 17:34
  personality
• 17:34
  disorders
• 17:35
  are
• 17:35
  in
• 17:36
  adjustment
• 17:36
  disorders.
• 17:38
  And
• 17:39
  lo
• 17:39
  and
• 17:40
  behold,
• 17:40
  in
• 17:40
  the
• 17:40
  DSM
• 17:41
  5TR,
• 17:42
  it
• 17:43
  even
• 17:43
  says
• 17:43
  that
• 17:44
  some
• 17:44
  personality
• 17:45
  features
• 17:46
  may
• 17:46
  be
• 17:46
  associated
• 17:46
  with
• 17:47
  a
• 17:47
  vulnerability
• 17:47
  to
• 17:48
  situational
• 17:48
  distress
• 17:49
  that
• 17:49
  may
• 17:50
  resemble
• 17:50
  an
• 17:50
  adjustment
• 17:51
  disorder.
• 17:51
  Now
• 17:52
  I
• 17:52
  won't
• 17:52
  beat
• 17:52
  the
• 17:52
  dead
• 17:52
  horse
• 17:53
  on
• 17:53
  this
• 17:53
  one
• 17:53
  because
• 17:53
  I
• 17:54
  think
• 17:54
  it's
• 17:54
  very
• 17:55
  common.
• 17:55
  It's
• 17:55
  very
• 17:55
  much
• 17:56
  common
• 17:56
  sense
• 17:56
  if
• 17:56
  you
• 17:57
  think
• 17:57
  about
• 17:57
  it,
• 17:57
  right?
• 17:58
  The
• 17:58
  personality
• 17:58
  disorders,
• 18:00
  these
• 18:00
  folks
• 18:00
  have
• 18:01
  a
• 18:01
  very
• 18:01
  difficult
• 18:01
  time
• 18:02
  with
• 18:02
  interpersonal
• 18:03
  relationships
• 18:03
  at
• 18:04
  time
• 18:04
  in
• 18:04
  just
• 18:04
  coping
• 18:05
  and
• 18:06
  emotional
• 18:06
  regulation
• 18:07
  more
• 18:07
  broadly.
• 18:09
  No
• 18:09
  surprise
• 18:09
  that
• 18:09
  cluster
• 18:10
  B,
• 18:10
  especially
• 18:11
  bpd,
• 18:12
  is
• 18:12
  the
• 18:12
  most
• 18:12
  common
• 18:13
  confounder
• 18:13
  here
• 18:13
  with
• 18:14
  adjustment
• 18:14
  disorders
• 18:15
  and
• 18:16
  how
• 18:16
  they
• 18:16
  have
• 18:16
  a
• 18:16
  hard
• 18:16
  time
• 18:17
  regulating.
• 18:17
  So
• 18:17
  you
• 18:18
  can
• 18:18
  imagine
• 18:18
  if
• 18:18
  you're
• 18:18
  going
• 18:19
  into
• 18:19
  this
• 18:19
  with
• 18:20
  a
• 18:20
  lifetime
• 18:21
  struggle
• 18:22
  in
• 18:22
  being
• 18:22
  able
• 18:22
  to
• 18:22
  regulate
• 18:23
  your
• 18:23
  emotions.
• 18:23
  You
• 18:24
  can
• 18:24
  imagine
• 18:24
  how
• 18:25
  you
• 18:26
  are
• 18:26
  way
• 18:26
  more
• 18:26
  predisposed
• 18:27
  to
• 18:27
  getting
• 18:27
  an
• 18:28
  adjustment
• 18:28
  disorder
• 18:29
  or
• 18:29
  developing
• 18:30
  one.
• 18:30
  Right.
• 18:30
  If
• 18:30
  you
• 18:31
  have
• 18:31
  neurotic
• 18:31
  personality
• 18:32
  traits,
• 18:33
  you're
• 18:33
  very
• 18:33
  dependent,
• 18:34
  you're
• 18:34
  very
• 18:34
  avoidant.
• 18:36
  Absolutely.
• 18:36
  That
• 18:36
  opens
• 18:37
  the
• 18:37
  floodgates
• 18:38
  for
• 18:39
  developing
• 18:40
  an
• 18:40
  adjustment
• 18:40
  disorder.
• 18:41
  So
• 18:41
  just
• 18:41
  keep
• 18:41
  that
• 18:42
  in
• 18:42
  mind.
• 18:42
  And
• 18:43
  not
• 18:43
  only
• 18:43
  keep
• 18:44
  it
• 18:44
  in
• 18:44
  mind,
• 18:45
  but
• 18:47
  keep
• 18:47
  this
• 18:48
  pearl
• 18:48
  in
• 18:48
  mind
• 18:48
  that
• 18:48
  about
• 18:49
  56%
• 18:50
  in
• 18:50
  some
• 18:50
  studies
• 18:50
  show
• 18:51
  56%
• 18:52
  of
• 18:52
  your
• 18:53
  patients
• 18:53
  with
• 18:53
  an
• 18:53
  adjustment
• 18:54
  disorder
• 18:54
  has
• 18:55
  had
• 18:55
  a
• 18:55
  likely
• 18:55
  personality
• 18:56
  disorder.
• 18:57
  So
• 18:58
  just
• 18:58
  it's,
• 18:58
  it's
• 18:59
  when
• 18:59
  you
• 18:59
  see
• 18:59
  adjustment,
• 19:00
  your,
• 19:01
  your
• 19:01
  ears
• 19:01
  should
• 19:01
  kind
• 19:02
  of
• 19:02
  perk
• 19:02
  up
• 19:02
  and
• 19:02
  say,
• 19:02
  okay,
• 19:03
  wait
• 19:03
  a
• 19:03
  minute,
• 19:03
  maybe
• 19:04
  I,
• 19:04
  there's
• 19:04
  a
• 19:04
  personality
• 19:05
  component
• 19:05
  I
• 19:05
  can
• 19:05
  also
• 19:06
  diagnose
• 19:06
  here
• 19:06
  that
• 19:06
  I
• 19:07
  don't
• 19:07
  want
• 19:07
  to
• 19:07
  ignore
• 19:07
  that
• 19:08
  might
• 19:08
  respond
• 19:09
  very
• 19:09
  well
• 19:09
  to
• 19:09
  psychotherapy.
• 19:10
  As
• 19:10
  we've
• 19:10
  learned
• 19:11
  before
• 19:11
  in
• 19:11
  previous
• 19:11
  sessions
• 19:12
  or
• 19:13
  episodes
• 19:13
  that
• 19:14
  as
• 19:14
  soon
• 19:14
  as
• 19:15
  personality
• 19:15
  disorders
• 19:16
  enter
• 19:16
  your
• 19:16
  arena,
• 19:16
  think
• 19:17
  psychotherapy
• 19:17
  is
• 19:18
  very
• 19:18
  important.
• 19:18
  Right.
• 19:19
  And,
• 19:19
  and
• 19:20
  so,
• 19:20
  so
• 19:20
  definitely
• 19:21
  adjustment
• 19:22
  disorders
• 19:22
  should
• 19:23
  kind
• 19:23
  of
• 19:23
  open
• 19:23
  the
• 19:23
  floodgates
• 19:24
  for
• 19:24
  a
• 19:24
  personality
• 19:25
  disorder
• 19:25
  assessment
• 19:26
  and
• 19:27
  start
• 19:27
  asking
• 19:27
  those
• 19:28
  questions
• 19:28
  and
• 19:28
  getting
• 19:29
  curious
• 19:29
  about
• 19:30
  how
• 19:30
  your
• 19:30
  patients
• 19:30
  relate
• 19:31
  to
• 19:31
  the
• 19:31
  world.
• 19:31
  Particularly
• 19:32
  if
• 19:32
  this
• 19:32
  is
• 19:32
  an
• 19:33
  adjustment
• 19:33
  disorder
• 19:33
  related
• 19:34
  to
• 19:34
  a
• 19:34
  breakup.
• 19:35
  I
• 19:35
  always
• 19:35
  ask
• 19:35
  my
• 19:36
  patients,
• 19:36
  how
• 19:36
  do
• 19:36
  you
• 19:36
  normal.
• 19:37
  How
• 19:37
  do
• 19:37
  you
• 19:37
  normally
• 19:38
  handle
• 19:39
  a
• 19:39
  breakup?
• 19:40
  Walk
• 19:40
  me
• 19:41
  through
• 19:41
  kind
• 19:41
  of
• 19:41
  the
• 19:41
  toughest
• 19:42
  times
• 19:42
  in
• 19:42
  your
• 19:42
  life.
• 19:43
  Have
• 19:43
  you
• 19:43
  noticed
• 19:43
  that
• 19:43
  they
• 19:44
  revolve
• 19:44
  around
• 19:44
  a
• 19:44
  particular
• 19:45
  pattern?
• 19:46
  And
• 19:46
  some
• 19:46
  might
• 19:47
  say,
• 19:47
  yeah,
• 19:47
  breakups,
• 19:48
  divorces,
• 19:49
  and
• 19:49
  so
• 19:50
  very
• 19:51
  diagnostically
• 19:52
  important
• 19:52
  there.
• 19:53
  Uh,
• 19:53
  now
• 19:54
  the
• 19:54
  fourth
• 19:54
  pearl
• 19:54
  that
• 19:55
  I
• 19:55
  think
• 19:55
  is
• 19:55
  probably,
• 19:57
  I
• 19:57
  already
• 19:57
  said
• 19:57
  this
• 19:58
  once,
• 19:58
  but
• 19:58
  it
• 19:58
  might
• 19:59
  be
• 19:59
  the
• 19:59
  most
• 20:00
  important
• 20:00
  pearl
• 20:01
  here
• 20:02
  is
• 20:02
  that
• 20:02
  there
• 20:03
  is
• 20:03
  a
• 20:03
  very
• 20:03
  suicide,
• 20:04
  a
• 20:04
  very
• 20:04
  serious
• 20:05
  suicide
• 20:05
  risk
• 20:06
  with
• 20:06
  adjustment
• 20:07
  disorders.
• 20:08
  They
• 20:08
  have
• 20:08
  12
• 20:09
  times
• 20:09
  the
• 20:09
  rate
• 20:10
  of
• 20:10
  completed
• 20:10
  suicide
• 20:11
  versus
• 20:11
  the
• 20:11
  general
• 20:11
  population.
• 20:12
  And
• 20:13
  the
• 20:13
  scary
• 20:13
  part
• 20:13
  about
• 20:14
  this
• 20:14
  is
• 20:14
  attempts
• 20:14
  are
• 20:15
  usually
• 20:16
  not
• 20:16
  planned
• 20:17
  like
• 20:17
  in
• 20:17
  depression.
• 20:18
  They
• 20:18
  tend
• 20:18
  to
• 20:18
  be
• 20:18
  more
• 20:19
  impulsive.
• 20:20
  There
• 20:20
  tends
• 20:20
  to
• 20:21
  be
• 20:21
  a
• 20:21
  much
• 20:22
  shorter
• 20:22
  interval
• 20:23
  from
• 20:23
  the
• 20:23
  disorder
• 20:24
  onset
• 20:24
  to
• 20:24
  the
• 20:25
  attempt.
• 20:25
  So
• 20:25
  you
• 20:25
  don't
• 20:25
  always
• 20:26
  have
• 20:26
  the
• 20:26
  luxury
• 20:26
  of
• 20:26
  time
• 20:27
  to
• 20:27
  identify
• 20:28
  this,
• 20:29
  right.
• 20:29
  You've
• 20:29
  seen
• 20:30
  this
• 20:30
  in
• 20:30
  Hollywood
• 20:30
  or
• 20:31
  on
• 20:31
  the
• 20:31
  news
• 20:31
  where,
• 20:31
  you
• 20:32
  know,
• 20:32
  a
• 20:32
  guy
• 20:32
  gets
• 20:33
  life
• 20:33
  in
• 20:33
  prison.
• 20:34
  You
• 20:34
  know,
• 20:34
  he
• 20:35
  spent,
• 20:35
  he
• 20:36
  spent
• 20:36
  his
• 20:36
  whole
• 20:36
  life
• 20:36
  in
• 20:38
  living
• 20:38
  in
• 20:38
  mansions
• 20:39
  and
• 20:39
  rich
• 20:39
  and
• 20:40
  famous,
• 20:40
  and
• 20:40
  then
• 20:40
  he
• 20:40
  gets
• 20:41
  sentenced
• 20:41
  to,
• 20:42
  to
• 20:42
  prison
• 20:43
  and
• 20:43
  then
• 20:43
  he
• 20:43
  kills
• 20:43
  himself.
• 20:44
  Right.
• 20:44
  And
• 20:45
  so,
• 20:46
  and
• 20:46
  it's
• 20:47
  short
• 20:47
  and
• 20:47
  it's
• 20:47
  not
• 20:47
  always
• 20:48
  planned.
• 20:48
  It's
• 20:48
  just
• 20:49
  life
• 20:49
  kind
• 20:49
  of
• 20:49
  crumbles
• 20:50
  quickly
• 20:51
  and
• 20:51
  they
• 20:52
  kill
• 20:52
  themselves.
• 20:53
  And
• 20:53
  so
• 20:55
  I
• 20:55
  would
• 20:55
  say,
• 20:55
  my
• 20:56
  friends,
• 20:56
  this
• 20:56
  is
• 20:56
  a
• 20:56
  very
• 20:56
  important
• 20:57
  pearl
• 20:57
  because
• 20:57
  again,
• 20:58
  when
• 20:58
  we
• 20:58
  think
• 20:58
  adjustment
• 20:59
  disorder,
• 20:59
  we
• 20:59
  think,
• 20:59
  oh,
• 21:00
  that's
• 21:00
  not
• 21:00
  ptsd.
• 21:01
  You
• 21:02
  know,
• 21:02
  that's
• 21:02
  self
• 21:02
  limiting.
• 21:03
  We
• 21:04
  all
• 21:04
  have
• 21:04
  them
• 21:04
  at
• 21:04
  some
• 21:05
  point.
• 21:05
  It's
• 21:06
  not
• 21:06
  so
• 21:06
  bad.
• 21:06
  It's
• 21:07
  not
• 21:07
  major
• 21:07
  depression
• 21:08
  or
• 21:08
  schizophrenia.
• 21:09
  Well,
• 21:10
  we
• 21:10
  need
• 21:10
  to
• 21:10
  be
• 21:11
  very
• 21:11
  careful
• 21:11
  because
• 21:11
  it
• 21:12
  is
• 21:12
  a
• 21:12
  absolute
• 21:13
  serious
• 21:14
  risk
• 21:14
  factor
• 21:15
  for
• 21:15
  suicide.
• 21:17
  Watch
• 21:17
  out
• 21:17
  if
• 21:18
  your
• 21:18
  patient
• 21:18
  is
• 21:18
  a
• 21:18
  drinker,
• 21:19
  if
• 21:19
  they're
• 21:19
  already
• 21:20
  kind
• 21:20
  of
• 21:20
  impulsive,
• 21:21
  and
• 21:21
  again,
• 21:21
  if
• 21:21
  they
• 21:21
  have
• 21:22
  a
• 21:22
  borderline
• 21:23
  traits
• 21:23
  or
• 21:23
  a
• 21:23
  poor
• 21:24
  personality
• 21:24
  disorder,
• 21:25
  watch
• 21:25
  out
• 21:26
  for
• 21:26
  all
• 21:26
  of
• 21:26
  that,
• 21:27
  right?
• 21:27
  Lethal
• 21:28
  means
• 21:28
  restriction
• 21:29
  becomes
• 21:29
  very
• 21:29
  paramount.
• 21:32
  Definitely.
• 21:32
  Just
• 21:32
  be
• 21:33
  very,
• 21:33
  very
• 21:34
  careful
• 21:34
  of
• 21:34
  those
• 21:34
  risk
• 21:35
  amplifiers
• 21:35
  that
• 21:36
  can
• 21:36
  worsen
• 21:36
  their,
• 21:38
  or
• 21:38
  increase
• 21:38
  the
• 21:39
  likelihood
• 21:39
  they
• 21:39
  commit
• 21:39
  Suicide,
• 21:40
  those
• 21:40
  interpersonal
• 21:41
  stressors,
• 21:42
  alcohol
• 21:42
  use,
• 21:43
  if
• 21:43
  they're
• 21:43
  younger.
• 21:45
  Also
• 21:45
  people
• 21:45
  with
• 21:46
  Alex
• 21:46
  thymia,
• 21:46
  they
• 21:47
  have
• 21:47
  difficulty
• 21:47
  identifying
• 21:48
  or
• 21:48
  describing
• 21:49
  their
• 21:49
  feelings.
• 21:50
  That's
• 21:50
  also
• 21:50
  known
• 21:51
  to
• 21:51
  be
• 21:51
  an
• 21:51
  independent
• 21:52
  risk
• 21:52
  factor
• 21:52
  to
• 21:52
  increase
• 21:53
  suicide
• 21:54
  in
• 21:54
  these
• 21:54
  cases.
• 21:56
  So
• 21:56
  now
• 21:56
  you
• 21:56
  have
• 21:56
  kind
• 21:56
  of
• 21:57
  a
• 21:57
  whole
• 21:58
  arsenal
• 21:59
  of
• 21:59
  things
• 21:59
  to
• 21:59
  look
• 21:59
  out
• 22:00
  for.
• 22:00
  Right.
• 22:01
  And
• 22:01
  I
• 22:01
  would
• 22:01
  just
• 22:02
  screen
• 22:02
  for
• 22:02
  suicidality,
• 22:03
  really.
• 22:03
  Of
• 22:04
  course,
• 22:04
  in
• 22:04
  every
• 22:04
  patient
• 22:05
  you
• 22:05
  see.
• 22:05
  But
• 22:06
  be
• 22:06
  especially
• 22:07
  attentive
• 22:07
  to
• 22:07
  the
• 22:08
  folks
• 22:08
  who,
• 22:08
  who
• 22:09
  have
• 22:09
  adjustment
• 22:09
  disorders.
• 22:10
  Right.
• 22:10
  Very,
• 22:11
  very
• 22:11
  important.
• 22:12
  And,
• 22:13
  you
• 22:13
  know,
• 22:14
  you
• 22:14
  won't
• 22:15
  always
• 22:15
  have
• 22:15
  the
• 22:15
  luxury
• 22:16
  of
• 22:16
  four
• 22:17
  other
• 22:17
  major
• 22:17
  depressive
• 22:18
  episodes
• 22:19
  where
• 22:19
  the
• 22:19
  patient
• 22:20
  had
• 22:20
  one
• 22:20
  attempt
• 22:21
  and
• 22:21
  you
• 22:21
  already
• 22:21
  know
• 22:22
  they're
• 22:22
  high
• 22:22
  risk
• 22:22
  and
• 22:22
  their
• 22:23
  family
• 22:23
  has
• 22:23
  bipolarity
• 22:24
  maybe
• 22:24
  and
• 22:24
  has
• 22:25
  a
• 22:25
  suicide
• 22:25
  risk.
• 22:26
  You
• 22:26
  might
• 22:26
  not
• 22:26
  have
• 22:26
  that.
• 22:27
  Right.
• 22:28
  This
• 22:28
  patient
• 22:28
  might
• 22:28
  have
• 22:29
  no
• 22:29
  family
• 22:29
  history.
• 22:30
  It
• 22:30
  might
• 22:30
  look
• 22:30
  like
• 22:31
  otherwise
• 22:31
  they're
• 22:32
  super
• 22:32
  low
• 22:32
  risk,
• 22:32
  they've
• 22:33
  never
• 22:33
  self
• 22:33
  harmed
• 22:33
  before,
• 22:34
  they
• 22:34
  have
• 22:34
  no
• 22:34
  psychiatric
• 22:35
  history,
• 22:36
  and
• 22:36
  yet
• 22:36
  this
• 22:36
  is
• 22:36
  a
• 22:37
  very
• 22:37
  high
• 22:37
  suicide
• 22:38
  risk
• 22:38
  cohort.
• 22:39
  Okay,
• 22:40
  the
• 22:41
  last
• 22:41
  pearl
• 22:41
  I'll
• 22:42
  leave
• 22:42
  you
• 22:42
  with
• 22:42
  is
• 22:42
  that
• 22:43
  there's
• 22:44
  many
• 22:44
  different
• 22:44
  subtypes
• 22:45
  of
• 22:46
  adjustment
• 22:47
  disorder.
• 22:47
  You
• 22:47
  have
• 22:47
  with
• 22:48
  depressed
• 22:48
  mood,
• 22:48
  with
• 22:48
  anxiety,
• 22:49
  with
• 22:49
  mixed
• 22:50
  anxiety
• 22:50
  and
• 22:50
  depressed
• 22:51
  mood,
• 22:51
  with
• 22:51
  disturbance
• 22:52
  of
• 22:52
  conduct,
• 22:53
  which
• 22:53
  is
• 22:53
  pretty
• 22:53
  interesting
• 22:54
  too.
• 22:54
  I've
• 22:54
  seen
• 22:54
  that.
• 22:56
  I've
• 22:56
  definitely
• 22:57
  seen
• 22:57
  that.
• 22:58
  Where
• 22:58
  patients
• 22:58
  can
• 22:59
  be
• 22:59
  more
• 22:59
  aggressive
• 22:59
  or
• 23:00
  they
• 23:00
  violate
• 23:01
  major
• 23:01
  societal
• 23:02
  norms.
• 23:03
  They
• 23:03
  get
• 23:03
  out
• 23:03
  of
• 23:03
  work
• 23:03
  a
• 23:04
  lot.
• 23:05
  You
• 23:05
  know,
• 23:05
  it's
• 23:05
  not
• 23:05
  malingering
• 23:06
  per
• 23:06
  se,
• 23:06
  but
• 23:06
  they
• 23:06
  just
• 23:07
  have
• 23:08
  a
• 23:08
  difficulty
• 23:10
  kind
• 23:10
  of
• 23:10
  behaving
• 23:11
  more
• 23:11
  broadly.
• 23:11
  It's
• 23:12
  less
• 23:12
  depressed
• 23:12
  and
• 23:12
  anxious,
• 23:13
  but
• 23:13
  it's
• 23:13
  more
• 23:13
  behavioral.
• 23:15
  You
• 23:15
  have
• 23:16
  adjustment
• 23:17
  disorder,
• 23:17
  the
• 23:17
  mixed
• 23:17
  disturbance
• 23:18
  of
• 23:18
  emotions
• 23:18
  and
• 23:19
  conduct.
• 23:19
  And
• 23:19
  then
• 23:20
  you
• 23:20
  have
• 23:20
  an
• 23:20
  unspecified.
• 23:20
  Of
• 23:21
  course.
• 23:22
  And
• 23:22
  remember
• 23:22
  that
• 23:24
  adjustment
• 23:25
  disorder
• 23:25
  can
• 23:26
  absolutely
• 23:26
  evolve
• 23:27
  into
• 23:27
  mdd
• 23:29
  and
• 23:29
  like
• 23:29
  we
• 23:29
  said,
• 23:29
  ptsd.
• 23:30
  Right.
• 23:30
  You
• 23:30
  can
• 23:30
  have
• 23:31
  a
• 23:31
  car
• 23:31
  accident
• 23:32
  where
• 23:32
  they
• 23:32
  are
• 23:32
  not
• 23:33
  meeting
• 23:34
  criteria
• 23:34
  for
• 23:34
  PTSD
• 23:35
  yet,
• 23:35
  and
• 23:35
  then
• 23:35
  they
• 23:35
  do
• 23:36
  later.
• 23:37
  And
• 23:37
  so
• 23:37
  it
• 23:37
  can
• 23:38
  evolve.
• 23:38
  And
• 23:38
  we've
• 23:38
  got
• 23:39
  to
• 23:39
  watch
• 23:39
  this,
• 23:39
  right?
• 23:40
  This
• 23:40
  is
• 23:40
  a,
• 23:40
  this
• 23:40
  is
• 23:40
  definitely
• 23:41
  a
• 23:41
  diagnosis
• 23:42
  that
• 23:42
  you
• 23:42
  watch
• 23:43
  and
• 23:43
  wait.
• 23:43
  And
• 23:44
  you
• 23:44
  gotta
• 23:44
  help,
• 23:45
  of
• 23:45
  course,
• 23:45
  you
• 23:45
  gotta
• 23:45
  treat
• 23:46
  and
• 23:46
  do
• 23:47
  what
• 23:47
  you
• 23:47
  can,
• 23:48
  but
• 23:48
  of
• 23:48
  course
• 23:49
  it
• 23:49
  can
• 23:49
  be
• 23:49
  a
• 23:50
  very,
• 23:50
  very
• 23:51
  big
• 23:51
  deal.
• 23:52
  And
• 23:52
  so
• 23:53
  just
• 23:53
  look
• 23:53
  out
• 23:54
  for
• 23:54
  that
• 23:54
  and.
• 23:55
  All
• 23:56
  right,
• 23:56
  my
• 23:56
  friends,
• 23:56
  well,
• 23:57
  I
• 23:57
  hope
• 23:57
  you
• 23:58
  enjoyed
• 23:58
  this.
• 23:59
  You
• 23:59
  know,
• 24:00
  we
• 24:00
  of
• 24:00
  course
• 24:00
  love
• 24:00
  sharing
• 24:01
  our
• 24:01
  perspectives
• 24:02
  here
• 24:02
  at
• 24:02
  Pearls
• 24:03
  and
• 24:03
  Prep.
• 24:04
  And,
• 24:05
  you
• 24:05
  know,
• 24:05
  one
• 24:06
  last
• 24:06
  thing
• 24:06
  before
• 24:06
  you
• 24:06
  go.
• 24:07
  So,
• 24:08
  you
• 24:08
  know,
• 24:08
  I
• 24:08
  think
• 24:08
  we've
• 24:08
  all
• 24:09
  had
• 24:09
  moments
• 24:09
  in
• 24:10
  clinic
• 24:10
  where
• 24:11
  we
• 24:11
  know
• 24:11
  the
• 24:11
  med
• 24:12
  to
• 24:12
  use,
• 24:12
  but
• 24:13
  maybe
• 24:13
  we
• 24:13
  struggle
• 24:13
  to
• 24:14
  explain
• 24:14
  why
• 24:14
  we're
• 24:14
  using
• 24:15
  it,
• 24:15
  why
• 24:15
  we're
• 24:15
  doing
• 24:16
  a
• 24:16
  switch,
• 24:16
  why
• 24:17
  a
• 24:17
  patient
• 24:17
  is
• 24:17
  sweaty,
• 24:18
  or
• 24:19
  why
• 24:19
  a
• 24:19
  patient
• 24:19
  feels
• 24:20
  emotionally
• 24:20
  blunted
• 24:21
  and,
• 24:21
  and
• 24:21
  how
• 24:21
  it's
• 24:22
  happening.
• 24:22
  Right.
• 24:23
  And
• 24:24
  so
• 24:24
  that's
• 24:24
  really
• 24:25
  the
• 24:25
  difference
• 24:25
  between
• 24:25
  a
• 24:26
  good
• 24:26
  and
• 24:26
  great
• 24:26
  clinician,
• 24:27
  right?
• 24:27
  Knowing
• 24:28
  the
• 24:28
  how
• 24:28
  and
• 24:28
  why
• 24:28
  of
• 24:29
  what
• 24:29
  your
• 24:29
  patient's
• 24:29
  going
• 24:30
  through.
• 24:30
  And
• 24:30
  patients
• 24:30
  smell
• 24:31
  that
• 24:31
  a
• 24:31
  mile
• 24:31
  away.
• 24:32
  And
• 24:32
  that's
• 24:32
  exactly
• 24:33
  why
• 24:33
  we
• 24:34
  built
• 24:34
  this
• 24:34
  Patreon
• 24:35
  Library.
• 24:35
  Right?
• 24:35
  It's
• 24:36
  a
• 24:36
  visual,
• 24:36
  practical,
• 24:37
  psych
• 24:37
  resource
• 24:38
  designed
• 24:38
  to
• 24:39
  make
• 24:39
  this
• 24:39
  stuff
• 24:39
  finally
• 24:40
  stick.
• 24:41
  So
• 24:41
  if
• 24:41
  you
• 24:41
  want
• 24:41
  to
• 24:42
  become
• 24:42
  the
• 24:42
  kind
• 24:42
  of
• 24:43
  clinician
• 24:43
  that
• 24:43
  doesn't
• 24:43
  just
• 24:44
  know
• 24:44
  what
• 24:44
  to
• 24:44
  prescribe,
• 24:45
  but
• 24:45
  can
• 24:45
  confidently
• 24:46
  explain
• 24:46
  why,
• 24:47
  definitely
• 24:47
  join
• 24:48
  us@patreon.com
• 24:49
  Pearls
• 24:50
  and
• 24:50
  prep.
• 24:50
  Thank
• 24:51
  you
• 24:51
  all
• 24:51
  very
• 24:51
  much
• 24:51
  for
• 24:51
  being
• 24:51
  here.
• 24:52
  And
• 24:52
  you
• 24:52
  all
• 24:52
  take
• 24:52
  care.
• 24:53
  Bye.
• 24:53
  Bye.