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These TWO Details Separate OCD from GAD Almost Every Time · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:05
  back,
• 0:06
  my
• 0:06
  friend,
• 0:06
  to
• 0:07
  another
• 0:07
  episode
• 0:08
  of
• 0:08
  Pearls
• 0:08
  and
• 0:09
  prep
• 0:09
  npz.
• 0:10
  Here,
• 0:10
  your
• 0:10
  preceptor
• 0:11
  in
• 0:11
  your
• 0:11
  pocket,
• 0:11
  your
• 0:12
  go
• 0:12
  to
• 0:12
  place
• 0:13
  for
• 0:13
  pearls
• 0:13
  that
• 0:14
  prep
• 0:14
  you
• 0:14
  to
• 0:14
  practice.
• 0:15
  Today
• 0:16
  we
• 0:16
  have
• 0:16
  a
• 0:16
  board
• 0:17
  bomb
• 0:18
  back
• 0:18
  by
• 0:18
  popular
• 0:19
  demand.
• 0:19
  A
• 0:20
  fun
• 0:20
  one,
• 0:20
  a
• 0:21
  juicy
• 0:21
  one.
• 0:21
  This
• 0:21
  one
• 0:21
  is
• 0:22
  dripping
• 0:22
  with
• 0:22
  pearls
• 0:23
  and
• 0:23
  it's
• 0:23
  going
• 0:23
  to
• 0:24
  really
• 0:24
  keep
• 0:24
  you
• 0:24
  at
• 0:25
  the
• 0:25
  edge
• 0:25
  of
• 0:25
  your
• 0:25
  seat
• 0:25
  and
• 0:26
  at
• 0:26
  the
• 0:26
  top
• 0:26
  of
• 0:26
  your
• 0:26
  game
• 0:27
  in
• 0:27
  your
• 0:27
  clinic.
• 0:28
  Okay,
• 0:28
  my
• 0:28
  friends,
• 0:29
  so
• 0:30
  you
• 0:30
  have
• 0:30
  a
• 0:31
  28
• 0:31
  year
• 0:31
  old
• 0:32
  mock
• 0:32
  patient
• 0:33
  named
• 0:33
  Terri.
• 0:34
  Okay?
• 0:35
  She's
• 0:35
  28.
• 0:36
  She
• 0:37
  presents
• 0:37
  to
• 0:37
  you
• 0:38
  after
• 0:38
  three
• 0:39
  years
• 0:39
  of
• 0:39
  treatment
• 0:40
  from
• 0:40
  her
• 0:40
  primary
• 0:40
  care
• 0:41
  provider
• 0:41
  for
• 0:42
  generalized
• 0:42
  anxiety
• 0:43
  disorder.
• 0:43
  Okay?
• 0:44
  She
• 0:44
  has
• 0:44
  these
• 0:44
  persistent,
• 0:45
  really
• 0:46
  intrusive
• 0:46
  images
• 0:47
  of
• 0:47
  stabbing
• 0:48
  her
• 0:48
  grandmother,
• 0:49
  which
• 0:49
  she
• 0:50
  finds
• 0:50
  really
• 0:50
  horrifying,
• 0:51
  really
• 0:52
  ego
• 0:52
  dystonic.
• 0:53
  She's
• 0:53
  never
• 0:53
  harmed
• 0:54
  anyone
• 0:54
  in
• 0:54
  her
• 0:54
  life.
• 0:55
  But
• 0:55
  she
• 0:55
  does
• 0:55
  avoid
• 0:56
  being
• 0:56
  alone
• 0:57
  because
• 0:57
  she
• 0:58
  repeatedly
• 0:59
  asks
• 0:59
  her
• 0:59
  husband's
• 1:00
  for
• 1:00
  husband
• 1:00
  for
• 1:00
  reassurance
• 1:01
  that
• 1:01
  she's
• 1:02
  not
• 1:02
  a
• 1:02
  monster.
• 1:03
  She
• 1:03
  checks
• 1:03
  her
• 1:04
  kitchen
• 1:04
  knives
• 1:04
  multiple
• 1:05
  times
• 1:05
  daily
• 1:06
  to
• 1:06
  confirm
• 1:06
  that
• 1:06
  they're
• 1:07
  locked
• 1:07
  away.
• 1:08
  Now
• 1:08
  she's
• 1:08
  on
• 1:08
  Effexor
• 1:09
  150mg
• 1:10
  every
• 1:10
  day.
• 1:10
  She's
• 1:11
  on
• 1:11
  Klonopin
• 1:12
  1mg
• 1:12
  twice
• 1:13
  a
• 1:13
  day,
• 1:14
  also
• 1:14
  started
• 1:14
  by
• 1:15
  her
• 1:15
  previous
• 1:16
  provider
• 1:16
  who's
• 1:17
  sending
• 1:17
  her
• 1:17
  to
• 1:17
  you.
• 1:18
  She
• 1:18
  says
• 1:19
  the
• 1:19
  meds
• 1:19
  help
• 1:20
  kind
• 1:20
  of
• 1:20
  take
• 1:20
  the
• 1:20
  edge
• 1:20
  off,
• 1:21
  but
• 1:21
  the
• 1:21
  intrusive
• 1:21
  images
• 1:22
  and
• 1:22
  rituals
• 1:22
  are
• 1:23
  persistent.
• 1:24
  They're
• 1:24
  unchanged.
• 1:25
  She
• 1:25
  also
• 1:26
  sees
• 1:26
  her
• 1:26
  therapist
• 1:27
  weekly
• 1:27
  for
• 1:28
  talk
• 1:28
  therapy,
• 1:29
  focused
• 1:30
  really
• 1:30
  on
• 1:30
  like,
• 1:30
  exploring
• 1:31
  unconscious
• 1:32
  roots
• 1:32
  of
• 1:32
  her
• 1:32
  anxiety.
• 1:33
  Now,
• 1:34
  which
• 1:34
  of
• 1:34
  the
• 1:34
  following
• 1:35
  is
• 1:35
  the
• 1:35
  most
• 1:35
  appropriate
• 1:36
  next
• 1:37
  step
• 1:37
  in
• 1:37
  the
• 1:37
  management
• 1:38
  of
• 1:38
  our
• 1:38
  friend
• 1:38
  Terri?
• 1:40
  Is
• 1:40
  it
• 1:40
  a,
• 1:41
  adding
• 1:42
  Risperdal
• 1:43
  0.5mg
• 1:44
  daily
• 1:44
  to
• 1:45
  augment
• 1:46
  her
• 1:46
  Effexor
• 1:47
  regimen?
• 1:48
  Is
• 1:49
  it
• 1:49
  B,
• 1:50
  discontinue
• 1:50
  effexor,
• 1:52
  start
• 1:52
  Prozac
• 1:53
  20mg
• 1:53
  daily
• 1:54
  and
• 1:54
  reassess
• 1:55
  in
• 1:55
  four
• 1:55
  weeks?
• 1:56
  Is
• 1:56
  it
• 1:56
  C,
• 1:57
  discontinue
• 1:58
  Effexor,
• 1:59
  start
• 2:00
  Fluvoxamine
• 2:01
  or
• 2:01
  Luvox,
• 2:02
  titrated
• 2:02
  to
• 2:03
  the
• 2:03
  maximum
• 2:03
  tolerated
• 2:04
  dose,
• 2:05
  tapering
• 2:05
  off
• 2:06
  her
• 2:06
  Klonopin
• 2:07
  and
• 2:07
  referring
• 2:07
  her
• 2:07
  to
• 2:07
  erp.
• 2:09
  Okay,
• 2:10
  is
• 2:11
  it
• 2:11
  D,
• 2:11
  continue
• 2:12
  her
• 2:12
  current
• 2:12
  medications
• 2:13
  and
• 2:13
  refer
• 2:14
  her
• 2:14
  to
• 2:14
  cbt?
• 2:15
  Focus
• 2:16
  on
• 2:16
  cognitive
• 2:16
  restructuring
• 2:17
  of
• 2:17
  her
• 2:17
  intrusive
• 2:18
  thoughts,
• 2:19
  or
• 2:19
  is
• 2:19
  it
• 2:19
  E,
• 2:20
  discontinue
• 2:21
  Effexor,
• 2:22
  start
• 2:23
  Prozac
• 2:25
  titrated
• 2:25
  to
• 2:26
  60
• 2:26
  to
• 2:26
  80
• 2:26
  every
• 2:27
  day.
• 2:27
  Continue
• 2:28
  the
• 2:28
  Klonopin
• 2:29
  and
• 2:29
  refer
• 2:29
  for
• 2:29
  psychodynamic
• 2:30
  therapy.
• 2:31
  So
• 2:32
  y'
• 2:32
  all
• 2:32
  can
• 2:32
  get
• 2:32
  into
• 2:32
  your
• 2:33
  breakout
• 2:33
  sessions
• 2:33
  on
• 2:34
  Zoom.
• 2:34
  All
• 2:35
  right,
• 2:35
  I'm
• 2:35
  gonna
• 2:35
  start
• 2:36
  going
• 2:36
  over
• 2:36
  the
• 2:36
  answers
• 2:37
  here.
• 2:37
  Now,
• 2:37
  what
• 2:38
  this
• 2:38
  question
• 2:38
  is
• 2:39
  trying
• 2:39
  to
• 2:39
  tease
• 2:39
  out
• 2:39
  is
• 2:40
  really
• 2:41
  important.
• 2:41
  It's
• 2:42
  trying
• 2:42
  to
• 2:42
  tease
• 2:42
  out
• 2:42
  whether
• 2:43
  you
• 2:43
  Know
• 2:44
  the
• 2:45
  evidence
• 2:46
  based
• 2:47
  therapy,
• 2:47
  the
• 2:48
  guidelines
• 2:48
  for
• 2:49
  ocd.
• 2:50
  And
• 2:50
  some
• 2:50
  of
• 2:50
  these
• 2:51
  should
• 2:51
  jump
• 2:51
  out
• 2:51
  at
• 2:51
  you
• 2:52
  right
• 2:52
  away
• 2:52
  as,
• 2:53
  yes,
• 2:54
  that
• 2:54
  sounds
• 2:54
  like
• 2:54
  what
• 2:54
  we
• 2:55
  need
• 2:55
  to
• 2:55
  do
• 2:55
  in
• 2:55
  ocd.
• 2:56
  And
• 2:56
  no,
• 2:56
  that's
• 2:57
  definitely
• 2:57
  not
• 2:57
  what
• 2:58
  we
• 2:58
  need
• 2:58
  to
• 2:58
  do
• 2:58
  with
• 2:58
  ocd.
• 2:59
  Okay?
• 3:01
  And
• 3:01
  the
• 3:01
  biggest
• 3:02
  thing
• 3:02
  to
• 3:02
  recognize
• 3:03
  here
• 3:03
  is
• 3:03
  that
• 3:03
  OCD
• 3:04
  is
• 3:04
  even
• 3:04
  happening
• 3:04
  in
• 3:04
  the
• 3:05
  first
• 3:05
  place.
• 3:05
  You
• 3:05
  have
• 3:05
  this
• 3:06
  anchoring
• 3:06
  bias
• 3:06
  where
• 3:07
  the
• 3:07
  primary
• 3:07
  care
• 3:08
  provider
• 3:08
  refers
• 3:09
  Terry
• 3:10
  over
• 3:10
  to
• 3:10
  you,
• 3:11
  telling
• 3:11
  you
• 3:12
  that
• 3:12
  Terri
• 3:13
  has
• 3:13
  generalized
• 3:13
  anxiety
• 3:14
  disorder.
• 3:14
  You're
• 3:14
  going
• 3:14
  to
• 3:15
  get
• 3:15
  this
• 3:15
  all
• 3:15
  the
• 3:15
  time.
• 3:16
  We
• 3:16
  talk
• 3:16
  about
• 3:16
  anchoring
• 3:17
  bias
• 3:17
  all
• 3:17
  of
• 3:18
  the
• 3:18
  time
• 3:18
  on
• 3:18
  this
• 3:18
  podcast.
• 3:20
  You're
• 3:20
  going
• 3:20
  to
• 3:20
  be
• 3:20
  get.
• 3:21
  You're
• 3:21
  going
• 3:21
  to
• 3:21
  receive
• 3:22
  a
• 3:22
  diagnosis
• 3:23
  from
• 3:23
  a
• 3:23
  qualified
• 3:24
  professional
• 3:25
  who's
• 3:25
  wonderful
• 3:25
  and
• 3:25
  they
• 3:26
  mean
• 3:26
  well
• 3:26
  and
• 3:26
  they're
• 3:27
  highly
• 3:27
  educated,
• 3:28
  but
• 3:28
  it's
• 3:29
  not
• 3:29
  always
• 3:29
  their
• 3:29
  specialty.
• 3:30
  And
• 3:30
  sometimes
• 3:31
  the
• 3:31
  fast
• 3:32
  heuristic
• 3:33
  for
• 3:33
  them
• 3:33
  is
• 3:34
  to
• 3:34
  slap
• 3:34
  on
• 3:35
  a
• 3:35
  very
• 3:35
  common
• 3:37
  disorder
• 3:37
  in
• 3:38
  the
• 3:38
  DSM
• 3:38
  5
• 3:39
  that
• 3:39
  may
• 3:39
  even
• 3:39
  be
• 3:40
  comorbid
• 3:40
  and
• 3:40
  may
• 3:41
  even
• 3:41
  be
• 3:41
  kind
• 3:41
  of
• 3:41
  accurate,
• 3:42
  but
• 3:42
  it
• 3:42
  might
• 3:43
  not
• 3:43
  be
• 3:43
  the
• 3:44
  principal
• 3:44
  issue
• 3:44
  and
• 3:45
  it
• 3:45
  might
• 3:45
  lack
• 3:45
  the
• 3:45
  specificity
• 3:46
  of
• 3:47
  what
• 3:47
  you
• 3:47
  need
• 3:47
  as
• 3:48
  the
• 3:48
  psychiatric
• 3:48
  prescriber.
• 3:49
  There's
• 3:49
  a
• 3:49
  reason
• 3:49
  he's
• 3:50
  sending
• 3:50
  Terry
• 3:51
  to
• 3:51
  you
• 3:51
  in
• 3:51
  the
• 3:51
  first
• 3:51
  place,
• 3:52
  right?
• 3:52
  Because
• 3:52
  something
• 3:53
  isn't
• 3:53
  perfect.
• 3:54
  And
• 3:54
  so
• 3:54
  you
• 3:54
  want
• 3:54
  to
• 3:55
  question
• 3:55
  right
• 3:56
  away
• 3:56
  whether
• 3:56
  the
• 3:57
  diagnosis
• 3:57
  is
• 3:57
  accurate.
• 3:58
  Not
• 3:58
  because
• 3:58
  we
• 3:58
  want
• 3:58
  to
• 3:59
  be
• 3:59
  antagonistic
• 3:59
  to
• 3:59
  our
• 4:00
  good
• 4:00
  friends
• 4:00
  in
• 4:00
  primary
• 4:01
  care,
• 4:02
  but
• 4:02
  because
• 4:02
  they're
• 4:03
  coming
• 4:03
  to
• 4:03
  you
• 4:03
  for
• 4:03
  a
• 4:03
  reason.
• 4:04
  Something
• 4:04
  isn't
• 4:04
  right
• 4:04
  here.
• 4:05
  Their
• 4:05
  treatment
• 4:05
  isn't
• 4:05
  right.
• 4:06
  Well,
• 4:06
  if
• 4:06
  their
• 4:06
  treatment
• 4:06
  isn't
• 4:07
  right,
• 4:07
  it
• 4:07
  begs
• 4:07
  the
• 4:07
  question,
• 4:08
  is
• 4:08
  their
• 4:08
  diagnosis
• 4:09
  right?
• 4:09
  That's
• 4:09
  sort
• 4:09
  of
• 4:09
  a
• 4:10
  fundamental
• 4:11
  way
• 4:11
  of
• 4:11
  examining
• 4:12
  every
• 4:12
  case
• 4:12
  that
• 4:13
  comes
• 4:13
  your
• 4:13
  way,
• 4:13
  right?
• 4:13
  Is
• 4:14
  the
• 4:14
  dose
• 4:14
  right?
• 4:14
  Is
• 4:15
  the
• 4:15
  adherence
• 4:15
  right?
• 4:16
  Is
• 4:16
  the
• 4:16
  diagnosis
• 4:17
  right?
• 4:17
  Is
• 4:17
  substance
• 4:18
  use
• 4:18
  getting
• 4:18
  in
• 4:19
  the
• 4:19
  way?
• 4:19
  All
• 4:19
  of
• 4:19
  these
• 4:19
  things
• 4:20
  need
• 4:20
  to
• 4:20
  be
• 4:21
  at
• 4:21
  the
• 4:21
  top
• 4:21
  of
• 4:22
  your
• 4:22
  mind
• 4:22
  as
• 4:23
  routinely
• 4:23
  as
• 4:23
  possible
• 4:24
  as
• 4:24
  you
• 4:24
  begin
• 4:24
  to
• 4:25
  practice.
• 4:26
  Now,
• 4:26
  what's
• 4:26
  weird
• 4:27
  about
• 4:27
  Terry's
• 4:28
  presentation
• 4:29
  today
• 4:29
  is
• 4:29
  that
• 4:30
  she
• 4:30
  has
• 4:30
  this
• 4:30
  gad
• 4:31
  dia
• 4:31
  diagnosis
• 4:32
  slapped
• 4:32
  on
• 4:32
  her,
• 4:33
  on
• 4:33
  her
• 4:33
  case
• 4:34
  file.
• 4:35
  But
• 4:35
  she's
• 4:36
  really
• 4:36
  describing
• 4:37
  ocd,
• 4:38
  right?
• 4:38
  The
• 4:38
  ego
• 4:38
  dystonic,
• 4:39
  persistent,
• 4:40
  inappropriate,
• 4:40
  intrusive
• 4:41
  images
• 4:42
  stabbing
• 4:42
  her
• 4:43
  grandmother.
• 4:43
  Right?
• 4:43
  These
• 4:43
  are
• 4:44
  violent,
• 4:44
  unwanted
• 4:46
  intrusions
• 4:47
  in
• 4:47
  her
• 4:47
  mind.
• 4:48
  That
• 4:48
  is
• 4:48
  categorically
• 4:49
  different
• 4:49
  than
• 4:50
  generalized
• 4:50
  anxiety
• 4:51
  where
• 4:51
  you
• 4:52
  are
• 4:52
  worried
• 4:52
  about
• 4:52
  actual
• 4:53
  things.
• 4:53
  Your
• 4:54
  budget,
• 4:54
  your
• 4:54
  health,
• 4:55
  you
• 4:55
  know,
• 4:56
  your
• 4:56
  job.
• 4:57
  It
• 4:57
  may
• 4:57
  be
• 4:58
  exaggerated
• 4:58
  worries,
• 4:59
  they
• 4:59
  might
• 4:59
  be
• 4:59
  catastrophic
• 5:00
  worries,
• 5:01
  but
• 5:01
  they
• 5:01
  are
• 5:01
  worried.
• 5:02
  You're
• 5:02
  typically
• 5:02
  worried
• 5:03
  about
• 5:03
  everyday
• 5:04
  things
• 5:04
  that
• 5:04
  are
• 5:05
  real
• 5:05
  and
• 5:05
  could
• 5:06
  go
• 5:06
  wrong.
• 5:07
  But
• 5:07
  this
• 5:07
  is
• 5:08
  different.
• 5:08
  What
• 5:08
  Terry's
• 5:09
  bringing
• 5:09
  to
• 5:09
  you
• 5:09
  is
• 5:09
  this
• 5:10
  ego
• 5:10
  dystonic,
• 5:11
  intrusive
• 5:11
  thought
• 5:12
  that
• 5:12
  is
• 5:12
  you
• 5:13
  violent.
• 5:13
  I
• 5:13
  would
• 5:14
  argue
• 5:14
  it's
• 5:15
  maybe
• 5:15
  not
• 5:15
  as
• 5:16
  bizarre
• 5:16
  as
• 5:16
  it
• 5:16
  is
• 5:16
  violent.
• 5:17
  I
• 5:17
  would
• 5:17
  argue
• 5:17
  it's
• 5:18
  more
• 5:18
  violent
• 5:19
  than
• 5:19
  it
• 5:19
  is
• 5:19
  bizarre.
• 5:20
  But
• 5:20
  again,
• 5:21
  it's
• 5:21
  unwanted.
• 5:22
  And
• 5:22
  so
• 5:22
  you're
• 5:23
  not
• 5:23
  really
• 5:24
  looking
• 5:24
  at
• 5:25
  GAD
• 5:25
  here.
• 5:25
  This
• 5:26
  is
• 5:26
  much
• 5:27
  more
• 5:27
  consistent
• 5:28
  with
• 5:28
  ocd.
• 5:29
  And
• 5:29
  if
• 5:30
  that
• 5:30
  wasn't
• 5:30
  the
• 5:31
  biggest
• 5:31
  tip
• 5:31
  off,
• 5:32
  her
• 5:32
  checking
• 5:32
  the
• 5:32
  kitchen
• 5:33
  knives
• 5:33
  multiple
• 5:34
  times
• 5:34
  a
• 5:34
  day
• 5:35
  is
• 5:35
  the
• 5:35
  compulsion
• 5:36
  associated
• 5:37
  with
• 5:37
  the
• 5:38
  obsession
• 5:38
  and
• 5:39
  her
• 5:39
  way
• 5:39
  of
• 5:39
  trying
• 5:39
  to
• 5:40
  neutralize
• 5:40
  the
• 5:40
  anxiety.
• 5:41
  Oh,
• 5:41
  if
• 5:41
  I
• 5:41
  check
• 5:42
  the
• 5:42
  kitchen
• 5:42
  knives,
• 5:43
  then
• 5:43
  the
• 5:43
  obsessions
• 5:44
  aren't
• 5:45
  as
• 5:45
  frightening
• 5:46
  to
• 5:46
  me
• 5:46
  because
• 5:47
  I
• 5:47
  can't
• 5:47
  do
• 5:47
  harm
• 5:48
  even
• 5:48
  if
• 5:48
  I
• 5:48
  wanted
• 5:49
  to,
• 5:49
  and
• 5:50
  I
• 5:50
  don't
• 5:50
  want
• 5:50
  to.
• 5:51
  But
• 5:51
  the
• 5:51
  compulsion,
• 5:52
  again,
• 5:52
  is
• 5:52
  trying
• 5:52
  to
• 5:53
  extinguish
• 5:53
  the
• 5:53
  obsessional
• 5:54
  anxiety
• 5:54
  here.
• 5:55
  So
• 5:55
  this
• 5:55
  sounds
• 5:56
  very
• 5:57
  pervasive,
• 5:57
  very
• 5:58
  intrusive,
• 5:58
  and
• 5:58
  very
• 5:59
  classic
• 5:59
  of
• 5:59
  an
• 6:00
  obsessional
• 6:01
  compulsive
• 6:02
  pathology
• 6:03
  and
• 6:03
  not
• 6:03
  general
• 6:04
  worry.
• 6:04
  That's
• 6:04
  not
• 6:05
  quite
• 6:05
  the
• 6:05
  flavor
• 6:06
  that
• 6:06
  we
• 6:07
  have
• 6:07
  here.
• 6:07
  So
• 6:07
  I
• 6:07
  think
• 6:08
  it's
• 6:08
  really
• 6:08
  worth
• 6:09
  just
• 6:09
  staring
• 6:10
  that
• 6:10
  right
• 6:10
  in
• 6:10
  its
• 6:11
  eyes
• 6:11
  and
• 6:11
  saying
• 6:12
  this.
• 6:12
  Something's
• 6:12
  not
• 6:12
  right
• 6:13
  here.
• 6:13
  The
• 6:13
  specificity's
• 6:14
  off.
• 6:14
  The
• 6:15
  provider
• 6:15
  got
• 6:15
  the
• 6:15
  anxiety
• 6:16
  right,
• 6:16
  but
• 6:17
  we're
• 6:17
  not
• 6:17
  quite
• 6:17
  in
• 6:18
  the
• 6:18
  right
• 6:18
  direction.
• 6:18
  Now,
• 6:19
  this
• 6:19
  matters,
• 6:19
  right?
• 6:19
  This
• 6:20
  matters
• 6:20
  a
• 6:20
  lot
• 6:20
  because
• 6:21
  it's
• 6:21
  going
• 6:21
  to
• 6:21
  qualitatively
• 6:22
  change
• 6:23
  the
• 6:23
  way
• 6:23
  we
• 6:24
  treat
• 6:24
  this
• 6:24
  patient,
• 6:25
  right?
• 6:25
  The
• 6:26
  dose,
• 6:26
  the
• 6:26
  duration,
• 6:27
  the
• 6:27
  kinds
• 6:28
  of
• 6:28
  medications
• 6:28
  get
• 6:29
  more
• 6:29
  specific,
• 6:29
  the
• 6:29
  kinds
• 6:30
  of
• 6:30
  therapy
• 6:30
  get
• 6:31
  more
• 6:31
  specific.
• 6:32
  So
• 6:32
  getting
• 6:33
  back
• 6:33
  to
• 6:33
  the
• 6:33
  question,
• 6:33
  do
• 6:34
  we
• 6:34
  add
• 6:34
  Risperdal
• 6:35
  here
• 6:35
  to
• 6:35
  augment
• 6:36
  Venlafaxine
• 6:37
  or
• 6:37
  the
• 6:37
  Effexor
• 6:38
  regimen?
• 6:39
  We
• 6:39
  might
• 6:39
  see
• 6:39
  antipsychotic
• 6:40
  augmentation
• 6:41
  if
• 6:42
  a
• 6:42
  patient
• 6:43
  was
• 6:43
  on
• 6:43
  an
• 6:43
  SSRI
• 6:44
  at
• 6:44
  a
• 6:44
  maximal
• 6:45
  dose
• 6:45
  for
• 6:45
  8
• 6:45
  to
• 6:45
  12
• 6:46
  weeks
• 6:46
  in
• 6:46
  OCD.
• 6:47
  But
• 6:47
  this
• 6:47
  patient
• 6:48
  is
• 6:48
  not
• 6:48
  on
• 6:48
  an
• 6:49
  SSRI
• 6:49
  for
• 6:49
  OCD.
• 6:50
  They're
• 6:50
  on
• 6:51
  an
• 6:51
  S
• 6:51
  N
• 6:51
  R
• 6:52
  I,
• 6:52
  which
• 6:52
  is.
• 6:53
  Doesn't
• 6:54
  have
• 6:54
  the
• 6:54
  evidence
• 6:54
  base
• 6:55
  of
• 6:55
  SSRIs.
• 6:56
  So
• 6:56
  augmenting
• 6:57
  when
• 6:57
  you're
• 6:57
  already
• 6:58
  in
• 6:58
  the
• 6:58
  wrong
• 6:58
  drug
• 6:59
  class
• 6:59
  with
• 6:59
  a
• 7:00
  suboptimal
• 7:00
  regimen
• 7:01
  doesn't
• 7:01
  make
• 7:01
  a
• 7:01
  lot
• 7:01
  of
• 7:02
  sense.
• 7:02
  So
• 7:02
  I
• 7:02
  say
• 7:02
  get
• 7:02
  rid
• 7:03
  of
• 7:03
  Risperidone.
• 7:04
  That
• 7:04
  is
• 7:04
  not
• 7:05
  the
• 7:05
  right
• 7:05
  context.
• 7:06
  It
• 7:06
  might
• 7:06
  work
• 7:06
  in
• 7:07
  a
• 7:07
  different
• 7:07
  scenario
• 7:08
  clinically.
• 7:09
  But
• 7:09
  putting
• 7:10
  the
• 7:10
  cart
• 7:10
  before
• 7:10
  the
• 7:10
  horse?
• 7:11
  Our
• 7:11
  main
• 7:11
  problem
• 7:11
  here
• 7:12
  is
• 7:12
  not
• 7:13
  that
• 7:13
  we're
• 7:13
  not
• 7:13
  augmenting
• 7:14
  with
• 7:14
  Risperdal.
• 7:15
  So
• 7:15
  forget
• 7:15
  option
• 7:16
  A.
• 7:17
  Option
• 7:17
  A
• 7:17
  is
• 7:18
  not
• 7:18
  the
• 7:18
  answer.
• 7:18
  Option
• 7:19
  B,
• 7:19
  do
• 7:19
  we
• 7:20
  discontinue
• 7:20
  effexor,
• 7:21
  start
• 7:21
  Prozac
• 7:22
  20
• 7:22
  milligrams
• 7:23
  daily
• 7:23
  and
• 7:23
  reassess
• 7:23
  in
• 7:24
  four
• 7:24
  weeks?
• 7:25
  Well,
• 7:25
  there's
• 7:25
  two
• 7:25
  issues
• 7:26
  with
• 7:26
  this.
• 7:26
  The
• 7:26
  first
• 7:27
  thing
• 7:27
  is
• 7:27
  that
• 7:28
  Prozac
• 7:29
  20
• 7:29
  is
• 7:29
  not
• 7:29
  going
• 7:30
  to
• 7:30
  do
• 7:30
  anything
• 7:30
  for
• 7:30
  this
• 7:31
  patient
• 7:31
  that's
• 7:31
  not
• 7:31
  an
• 7:32
  OCD
• 7:32
  dose,
• 7:33
  right?
• 7:33
  We
• 7:33
  want
• 7:33
  to
• 7:33
  really
• 7:33
  push
• 7:34
  OCD
• 7:35
  doses
• 7:35
  to
• 7:36
  the
• 7:36
  maximal
• 7:36
  range
• 7:37
  with
• 7:38
  SSRI,
• 7:38
  so
• 7:39
  we're
• 7:39
  talking
• 7:39
  more
• 7:39
  like
• 7:40
  60
• 7:40
  to
• 7:40
  80
• 7:40
  milligrams.
• 7:41
  I've
• 7:41
  seen
• 7:41
  patients
• 7:41
  go
• 7:42
  well
• 7:42
  above
• 7:42
  the
• 7:42
  FDA
• 7:43
  max.
• 7:43
  Of
• 7:43
  course,
• 7:43
  you've
• 7:44
  got
• 7:44
  to
• 7:44
  consult
• 7:45
  your
• 7:45
  guidelines
• 7:45
  patient
• 7:46
  by
• 7:46
  patient.
• 7:47
  Scour
• 7:47
  the
• 7:48
  literature
• 7:48
  for
• 7:48
  that
• 7:48
  one.
• 7:48
  That's
• 7:49
  not
• 7:49
  something
• 7:50
  that
• 7:50
  I
• 7:50
  will
• 7:50
  recommend
• 7:51
  here.
• 7:51
  Okay.
• 7:52
  I'm
• 7:52
  just
• 7:52
  kind
• 7:52
  of
• 7:53
  explaining
• 7:53
  how
• 7:53
  things
• 7:54
  happen
• 7:54
  in
• 7:54
  practice.
• 7:55
  But
• 7:55
  I
• 7:55
  have
• 7:55
  seen
• 7:55
  heroically
• 7:56
  high
• 7:56
  doses
• 7:56
  for
• 7:56
  OCD
• 7:57
  well
• 7:58
  past
• 7:58
  the
• 7:58
  FDA
• 7:59
  maximums
• 8:00
  in
• 8:00
  practice.
• 8:01
  But
• 8:01
  at
• 8:01
  20
• 8:02
  milligrams
• 8:02
  of
• 8:03
  of
• 8:03
  Prozac
• 8:04
  is
• 8:04
  like
• 8:05
  you.
• 8:05
  You
• 8:06
  have
• 8:06
  a
• 8:06
  charging
• 8:06
  rhino
• 8:07
  in
• 8:07
  front
• 8:07
  of
• 8:07
  you
• 8:07
  and
• 8:08
  you're
• 8:08
  trying
• 8:08
  to
• 8:08
  beat
• 8:08
  it
• 8:09
  on
• 8:09
  the
• 8:09
  head
• 8:09
  with
• 8:09
  a
• 8:09
  spatula.
• 8:10
  It's
• 8:10
  just
• 8:10
  not
• 8:10
  going
• 8:10
  to
• 8:10
  happen.
• 8:11
  Okay.
• 8:11
  And
• 8:12
  so
• 8:12
  that's
• 8:12
  not
• 8:12
  a
• 8:12
  really
• 8:13
  good
• 8:13
  idea.
• 8:14
  Also,
• 8:14
  four
• 8:15
  weeks.
• 8:15
  Here
• 8:15
  is
• 8:15
  the
• 8:15
  tip
• 8:16
  off
• 8:16
  again,
• 8:16
  the
• 8:16
  question's
• 8:17
  trying
• 8:17
  to.
• 8:18
  To
• 8:18
  sniff
• 8:19
  out
• 8:19
  whether
• 8:19
  you
• 8:19
  understand
• 8:20
  how
• 8:21
  long
• 8:21
  a
• 8:21
  patient
• 8:21
  needs
• 8:22
  to
• 8:22
  be
• 8:22
  on
• 8:22
  medications
• 8:22
  and
• 8:23
  OCD
• 8:24
  for
• 8:24
  to
• 8:24
  understand
• 8:24
  a
• 8:25
  proper
• 8:25
  response
• 8:26
  and.
• 8:26
  And
• 8:27
  at
• 8:27
  what
• 8:27
  dose.
• 8:28
  So
• 8:28
  four
• 8:28
  weeks
• 8:28
  is
• 8:29
  absolutely
• 8:30
  insufficient.
• 8:31
  OCD
• 8:31
  guidelines
• 8:32
  are
• 8:32
  typically
• 8:32
  requiring
• 8:33
  eight
• 8:33
  to
• 8:33
  12
• 8:33
  weeks
• 8:34
  at
• 8:34
  a
• 8:34
  maximal
• 8:35
  tolerated
• 8:35
  dose
• 8:36
  before
• 8:36
  we
• 8:37
  declare
• 8:38
  failure,
• 8:38
  before
• 8:38
  we
• 8:38
  move
• 8:39
  on
• 8:39
  to
• 8:39
  something
• 8:39
  else.
• 8:40
  Right.
• 8:40
  So
• 8:41
  I
• 8:41
  don't
• 8:41
  like
• 8:41
  this
• 8:41
  question.
• 8:42
  It's
• 8:42
  insufficient.
• 8:43
  It's
• 8:43
  weak
• 8:44
  or.
• 8:44
  I
• 8:44
  don't
• 8:44
  like
• 8:44
  this
• 8:44
  choice.
• 8:45
  It's
• 8:45
  insufficient
• 8:45
  in
• 8:46
  weak.
• 8:46
  So
• 8:46
  B
• 8:46
  is
• 8:47
  actually
• 8:47
  wrong.
• 8:48
  Let's
• 8:49
  go
• 8:49
  to
• 8:49
  option
• 8:49
  D
• 8:49
  real
• 8:50
  quick.
• 8:50
  Do
• 8:50
  we
• 8:51
  continue
• 8:51
  these
• 8:51
  current
• 8:52
  meds
• 8:52
  and
• 8:52
  refer
• 8:52
  to
• 8:52
  cbt?
• 8:53
  Focus
• 8:54
  on
• 8:54
  focusing
• 8:55
  on,
• 8:55
  like,
• 8:55
  restructuring
• 8:56
  these
• 8:56
  intrusive
• 8:56
  thoughts.
• 8:57
  And
• 8:57
  that's
• 8:58
  the
• 8:58
  wrong
• 8:58
  answer.
• 8:58
  That
• 8:59
  might
• 8:59
  be
• 8:59
  one
• 8:59
  of
• 8:59
  the
• 8:59
  most
• 9:00
  wrong
• 9:00
  answers.
• 9:01
  Actually.
• 9:02
  This
• 9:02
  is
• 9:02
  not
• 9:03
  a
• 9:03
  good
• 9:03
  idea.
• 9:03
  Number
• 9:03
  one,
• 9:04
  we're
• 9:04
  keeping
• 9:04
  in
• 9:04
  a
• 9:04
  regimen
• 9:05
  that
• 9:05
  isn't
• 9:05
  really
• 9:06
  evidence
• 9:06
  based.
• 9:06
  There's
• 9:07
  not
• 9:07
  a
• 9:07
  lot
• 9:07
  of
• 9:07
  evidence
• 9:08
  for
• 9:08
  SNRIs
• 9:09
  with
• 9:09
  OCD
• 9:09
  or
• 9:10
  benzos.
• 9:10
  Not
• 9:11
  a
• 9:11
  good
• 9:11
  idea.
• 9:11
  Again,
• 9:11
  we
• 9:12
  want
• 9:12
  high
• 9:12
  dose
• 9:12
  SSRIs.
• 9:13
  8
• 9:13
  to
• 9:13
  12
• 9:14
  weeks.
• 9:14
  Sustained
• 9:15
  high,
• 9:15
  maximally
• 9:16
  tolerated
• 9:16
  SSRI
• 9:17
  dose.
• 9:18
  The
• 9:18
  whole.
• 9:18
  The
• 9:19
  whole
• 9:19
  rigmarole
• 9:20
  here
• 9:20
  is
• 9:21
  the
• 9:21
  serotonergic
• 9:23
  piece
• 9:23
  in
• 9:24
  ocd.
• 9:24
  It
• 9:24
  usually
• 9:25
  requires
• 9:25
  higher
• 9:26
  doses.
• 9:27
  Okay,
• 9:28
  so
• 9:28
  keeping
• 9:29
  the
• 9:29
  status
• 9:29
  quo
• 9:29
  and
• 9:30
  just
• 9:30
  adding
• 9:30
  CBT
• 9:31
  is
• 9:31
  not
• 9:31
  gonna
• 9:31
  work.
• 9:31
  In
• 9:32
  fact,
• 9:32
  erp.
• 9:33
  Okay.
• 9:33
  Exposure
• 9:34
  response
• 9:35
  is
• 9:36
  what
• 9:36
  we
• 9:36
  need
• 9:36
  to
• 9:37
  do.
• 9:37
  Not
• 9:38
  C,
• 9:38
  not
• 9:39
  cbt.
• 9:39
  Okay.
• 9:40
  An
• 9:40
  exposure
• 9:41
  response
• 9:42
  is
• 9:43
  much
• 9:44
  more
• 9:45
  specific
• 9:45
  to
• 9:45
  ocd.
• 9:46
  And
• 9:47
  of
• 9:47
  course,
• 9:47
  that's
• 9:48
  extremely
• 9:48
  important
• 9:49
  because
• 9:49
  you
• 9:50
  don't
• 9:50
  want
• 9:50
  to
• 9:50
  just
• 9:50
  restructure
• 9:51
  your
• 9:52
  response
• 9:52
  to
• 9:52
  the
• 9:53
  obsessional
• 9:53
  thoughts
• 9:54
  that
• 9:54
  can
• 9:54
  actually
• 9:54
  feed
• 9:55
  the
• 9:55
  obsessional
• 9:56
  thoughts
• 9:56
  even
• 9:57
  more
• 9:57
  because
• 9:57
  you're
• 9:58
  asking
• 9:58
  for
• 9:58
  reassurance
• 9:59
  and
• 9:59
  you're
• 10:00
  working
• 10:00
  to
• 10:00
  get
• 10:00
  reinsurance
• 10:01
  to
• 10:01
  reassurance
• 10:02
  to
• 10:02
  reframe
• 10:03
  a
• 10:03
  thought
• 10:03
  that's
• 10:03
  disturbing.
• 10:04
  Kind
• 10:04
  of
• 10:04
  feed
• 10:05
  that
• 10:05
  obsessional
• 10:06
  thought
• 10:07
  cycle.
• 10:07
  And
• 10:08
  so
• 10:08
  you
• 10:08
  need
• 10:08
  erp.
• 10:09
  You
• 10:09
  need
• 10:09
  to
• 10:09
  be
• 10:09
  able
• 10:09
  to
• 10:10
  resist
• 10:10
  the
• 10:11
  compulsions
• 10:11
  and
• 10:12
  tolerate
• 10:12
  anxiety
• 10:13
  and
• 10:13
  not
• 10:13
  feel
• 10:13
  compelled
• 10:14
  to
• 10:15
  act
• 10:15
  on
• 10:15
  the
• 10:16
  obsession.
• 10:17
  And
• 10:17
  that's
• 10:17
  why
• 10:17
  ERP
• 10:18
  is
• 10:18
  more
• 10:18
  of
• 10:19
  a
• 10:19
  gold
• 10:19
  standard
• 10:19
  in
• 10:19
  ocd.
• 10:20
  So
• 10:20
  now
• 10:21
  we've
• 10:21
  this,
• 10:21
  this
• 10:22
  choice,
• 10:22
  this
• 10:22
  answer
• 10:23
  choice
• 10:23
  is
• 10:23
  drifting
• 10:24
  not
• 10:24
  only
• 10:24
  from
• 10:25
  the
• 10:25
  fact
• 10:25
  that
• 10:25
  we
• 10:25
  need
• 10:25
  to
• 10:25
  change
• 10:26
  these
• 10:26
  meds
• 10:26
  up,
• 10:26
  but
• 10:27
  now
• 10:27
  we're,
• 10:27
  we're
• 10:28
  orienting
• 10:29
  to
• 10:29
  a
• 10:29
  specific
• 10:30
  kind
• 10:30
  of
• 10:30
  therapy
• 10:31
  that
• 10:31
  may
• 10:31
  even
• 10:31
  be
• 10:31
  counterproductive
• 10:32
  and
• 10:32
  certainly
• 10:33
  is
• 10:33
  not
• 10:33
  the
• 10:33
  gold
• 10:33
  standard.
• 10:34
  So
• 10:34
  I
• 10:34
  don't
• 10:34
  like
• 10:34
  option
• 10:35
  D
• 10:35
  either.
• 10:36
  Option
• 10:36
  E
• 10:37
  is
• 10:37
  asking
• 10:37
  us
• 10:38
  if
• 10:38
  we
• 10:38
  want
• 10:38
  to
• 10:39
  add
• 10:39
  psychodynamic
• 10:40
  therapy
• 10:41
  and
• 10:41
  push
• 10:42
  Prozac
• 10:42
  to
• 10:43
  60
• 10:43
  to
• 10:43
  80.
• 10:43
  Well,
• 10:44
  the
• 10:44
  Prozac
• 10:45
  dose
• 10:45
  sounds
• 10:45
  pretty
• 10:46
  good
• 10:46
  here,
• 10:46
  but
• 10:47
  you
• 10:48
  know,
• 10:48
  I
• 10:48
  don't
• 10:49
  like
• 10:49
  the
• 10:49
  idea
• 10:49
  that
• 10:49
  we're
• 10:50
  supposed
• 10:50
  to
• 10:50
  continue
• 10:51
  Klonopin.
• 10:52
  That's
• 10:52
  not
• 10:52
  a
• 10:53
  smart,
• 10:53
  that's
• 10:53
  not
• 10:54
  what
• 10:54
  we're
• 10:54
  looking
• 10:55
  for.
• 10:55
  That
• 10:55
  can
• 10:56
  interfere
• 10:56
  with
• 10:57
  ERP
• 10:57
  actually.
• 10:59
  So.
• 10:59
  Wrong,
• 11:00
  wrong,
• 11:00
  wrong.
• 11:00
  And
• 11:01
  psychodynamic
• 11:01
  therapy,
• 11:02
  there's
• 11:03
  really
• 11:03
  no
• 11:03
  evidence
• 11:03
  base
• 11:04
  for
• 11:04
  that
• 11:04
  for
• 11:04
  ocd.
• 11:05
  Again,
• 11:05
  not
• 11:06
  the
• 11:06
  gold
• 11:06
  standard
• 11:07
  approach.
• 11:08
  So
• 11:09
  yeah,
• 11:10
  we
• 11:11
  are
• 11:11
  zeroing
• 11:12
  in
• 11:12
  on
• 11:12
  the
• 11:12
  right
• 11:12
  answer
• 11:13
  then,
• 11:13
  which
• 11:14
  would
• 11:14
  be
• 11:15
  C,
• 11:15
  we're
• 11:16
  going
• 11:16
  to
• 11:16
  discontinue
• 11:17
  Effexor,
• 11:17
  we're
• 11:17
  going
• 11:17
  to
• 11:17
  start
• 11:17
  Luvox,
• 11:18
  titrate
• 11:19
  to
• 11:19
  the
• 11:19
  maximum
• 11:20
  tolerated
• 11:20
  dose,
• 11:21
  taper
• 11:21
  off
• 11:21
  Clonazepam
• 11:22
  or
• 11:22
  Klonopin
• 11:23
  and
• 11:24
  refer
• 11:24
  to
• 11:25
  erp.
• 11:26
  Okay,
• 11:27
  that's
• 11:28
  what
• 11:29
  we
• 11:30
  need
• 11:30
  to
• 11:30
  do.
• 11:31
  So
• 11:32
  and
• 11:32
  that,
• 11:33
  that
• 11:33
  answer
• 11:33
  has
• 11:35
  all
• 11:35
  of
• 11:35
  the,
• 11:36
  the
• 11:36
  juice
• 11:36
  we
• 11:37
  need
• 11:37
  for
• 11:37
  OCD,
• 11:38
  right?
• 11:38
  We
• 11:38
  have
• 11:39
  a
• 11:39
  maximum
• 11:39
  tolerated
• 11:40
  dose,
• 11:40
  eight
• 11:40
  to
• 11:40
  12
• 11:41
  weeks.
• 11:41
  Get
• 11:41
  off
• 11:41
  the
• 11:41
  Klonopin,
• 11:42
  get
• 11:43
  going
• 11:44
  with
• 11:44
  ERP.
• 11:45
  Now
• 11:45
  we
• 11:45
  are
• 11:45
  approaching
• 11:46
  the
• 11:46
  evidence
• 11:47
  base
• 11:48
  and
• 11:48
  I
• 11:48
  think
• 11:48
  that's
• 11:49
  completely
• 11:50
  wonderful
• 11:50
  because
• 11:50
  OCD
• 11:51
  is
• 11:51
  a
• 11:52
  radically
• 11:52
  under
• 11:53
  treated
• 11:53
  or
• 11:54
  I
• 11:54
  could
• 11:54
  even
• 11:54
  say
• 11:55
  untreated
• 11:56
  mental
• 11:57
  health
• 11:57
  issue.
• 11:58
  Actually
• 11:58
  it's
• 11:59
  a
• 11:59
  radical
• 11:59
  minority
• 12:00
  of
• 12:00
  folks
• 12:00
  with
• 12:01
  O
• 12:01
  C,
• 12:01
  D
• 12:02
  are
• 12:02
  even
• 12:03
  ever
• 12:03
  enrolled
• 12:04
  in
• 12:04
  anything
• 12:04
  like
• 12:05
  ERP
• 12:06
  and
• 12:06
  their
• 12:06
  OCD
• 12:07
  is
• 12:07
  usually
• 12:07
  found
• 12:08
  very
• 12:09
  far
• 12:09
  down
• 12:10
  the
• 12:10
  road.
• 12:10
  It's
• 12:10
  not
• 12:10
  diagnosed
• 12:11
  very
• 12:11
  quickly.
• 12:12
  It
• 12:12
  can
• 12:12
  take
• 12:13
  years
• 12:13
  before
• 12:13
  OCD
• 12:14
  is
• 12:14
  properly
• 12:14
  diagnosed.
• 12:15
  It's
• 12:15
  misdiagnosed
• 12:16
  as
• 12:16
  depression
• 12:17
  or
• 12:17
  adhd,
• 12:18
  even
• 12:18
  psychosis
• 12:19
  when
• 12:19
  there's
• 12:19
  violent
• 12:19
  or
• 12:20
  bizarre
• 12:20
  obsessional
• 12:21
  images
• 12:21
  or
• 12:22
  compulsions.
• 12:22
  Right?
• 12:23
  So
• 12:23
  that
• 12:23
  delays
• 12:24
  treatment.
• 12:24
  And
• 12:24
  then
• 12:24
  once
• 12:25
  folks
• 12:26
  are
• 12:26
  even
• 12:26
  diagnosed
• 12:27
  with
• 12:27
  O
• 12:27
  C,
• 12:27
  D,
• 12:28
  only
• 12:28
  5
• 12:29
  to
• 12:29
  10%
• 12:29
  of
• 12:30
  OCD
• 12:30
  patients
• 12:31
  ever
• 12:31
  receive
• 12:32
  therapist
• 12:32
  guided
• 12:33
  ERP.
• 12:34
  And
• 12:35
  yeah,
• 12:35
  that's
• 12:35
  due
• 12:35
  to
• 12:36
  staffing
• 12:37
  shortages,
• 12:37
  lack
• 12:38
  of
• 12:38
  training,
• 12:38
  lack
• 12:39
  of
• 12:39
  available,
• 12:39
  available
• 12:40
  man
• 12:40
  Hours
• 12:40
  and
• 12:41
  insurance
• 12:41
  reimbursement.
• 12:42
  But
• 12:43
  I
• 12:43
  can
• 12:44
  tell
• 12:44
  you
• 12:44
  right
• 12:44
  now
• 12:45
  that
• 12:45
  exposure
• 12:46
  and
• 12:46
  response
• 12:46
  prevention
• 12:47
  is
• 12:48
  gold
• 12:49
  standard.
• 12:49
  High
• 12:49
  dose
• 12:50
  SSRIs,
• 12:50
  8
• 12:51
  to
• 12:51
  12
• 12:51
  weeks
• 12:51
  without
• 12:52
  Klonopin
• 12:53
  straying
• 12:53
  away
• 12:53
  from
• 12:54
  CBT.
• 12:54
  This
• 12:55
  question
• 12:55
  has
• 12:55
  a
• 12:56
  lot
• 12:56
  of
• 12:56
  juice
• 12:56
  in
• 12:57
  it,
• 12:57
  and
• 12:57
  really
• 12:58
  to
• 12:58
  appreciate
• 12:58
  it
• 12:59
  to
• 12:59
  my
• 12:59
  friends
• 12:59
  is
• 12:59
  you
• 13:00
  gotta
• 13:00
  remember
• 13:00
  that
• 13:01
  the
• 13:02
  pathology
• 13:03
  in
• 13:03
  gad,
• 13:04
  as
• 13:05
  opposed
• 13:05
  to
• 13:06
  ocd,
• 13:07
  it's
• 13:07
  just.
• 13:08
  It's
• 13:08
  just
• 13:09
  different,
• 13:09
  okay?
• 13:10
  In
• 13:11
  gad,
• 13:11
  we're
• 13:11
  really
• 13:12
  looking
• 13:12
  at
• 13:12
  the
• 13:12
  amygdala,
• 13:13
  and
• 13:14
  in
• 13:14
  ocd,
• 13:15
  it's
• 13:15
  the
• 13:16
  CSTC
• 13:17
  loop.
• 13:17
  Okay?
• 13:18
  The
• 13:18
  corticostriato
• 13:19
  thalamo
• 13:19
  cortical
• 13:20
  loop.
• 13:20
  That's
• 13:20
  a
• 13:20
  mouthful,
• 13:21
  right?
• 13:21
  The
• 13:21
  CSTC
• 13:22
  loop.
• 13:23
  And
• 13:23
  so
• 13:23
  we're
• 13:23
  talking
• 13:24
  about
• 13:24
  different
• 13:24
  neurobiology
• 13:25
  between
• 13:25
  these
• 13:25
  two
• 13:26
  pathologies.
• 13:27
  And
• 13:28
  it
• 13:28
  requires
• 13:29
  a
• 13:29
  more
• 13:29
  intense
• 13:30
  foot
• 13:31
  on
• 13:31
  the
• 13:31
  gas,
• 13:32
  more
• 13:32
  pressure
• 13:33
  on
• 13:33
  the
• 13:33
  gas
• 13:33
  as
• 13:33
  it
• 13:34
  relates
• 13:34
  to
• 13:35
  the
• 13:35
  serotonergic
• 13:36
  work
• 13:37
  being
• 13:37
  done
• 13:37
  here,
• 13:38
  okay?
• 13:38
  High
• 13:38
  doses,
• 13:39
  longer
• 13:39
  timeframes
• 13:40
  with
• 13:40
  erp,
• 13:41
  ideally.
• 13:42
  And
• 13:42
  so
• 13:42
  it's
• 13:43
  a
• 13:43
  kind
• 13:43
  of
• 13:43
  a
• 13:43
  different
• 13:43
  pathology,
• 13:44
  right?
• 13:44
  It's
• 13:44
  a
• 13:44
  sensitive
• 13:45
  smoke
• 13:45
  detector
• 13:46
  with
• 13:46
  the
• 13:46
  amygdala.
• 13:48
  And,
• 13:48
  you
• 13:49
  know,
• 13:49
  so
• 13:49
  oftentimes
• 13:50
  benzos
• 13:51
  do
• 13:51
  work
• 13:51
  for
• 13:51
  that,
• 13:52
  okay,
• 13:52
  to
• 13:53
  kind
• 13:53
  of
• 13:53
  cool
• 13:53
  down
• 13:53
  the
• 13:54
  threat
• 13:54
  response.
• 13:54
  But
• 13:55
  you
• 13:55
  have
• 13:55
  this
• 13:55
  habit
• 13:56
  loop
• 13:56
  in
• 13:56
  the
• 13:56
  CSTC
• 13:58
  that
• 13:58
  is
• 13:58
  fundamentally
• 13:59
  different.
• 13:59
  It's
• 13:59
  a
• 14:00
  qualitatively
• 14:00
  different
• 14:01
  experience.
• 14:01
  It's
• 14:02
  a.
• 14:02
  It's
• 14:02
  a
• 14:02
  stuck
• 14:03
  point,
• 14:03
  okay?
• 14:04
  And
• 14:04
  that
• 14:04
  has
• 14:04
  its
• 14:04
  own
• 14:04
  neurobiology.
• 14:05
  So
• 14:05
  that's
• 14:06
  why
• 14:06
  we
• 14:06
  have
• 14:06
  to
• 14:06
  get
• 14:06
  this
• 14:06
  right.
• 14:07
  There
• 14:07
  are
• 14:07
  moments
• 14:08
  in
• 14:08
  psychiatry
• 14:09
  where
• 14:09
  not
• 14:10
  getting
• 14:10
  the
• 14:10
  diagnosis
• 14:11
  perfectly
• 14:11
  right
• 14:12
  is.
• 14:14
  Although
• 14:14
  it's
• 14:14
  ideal,
• 14:14
  if
• 14:15
  we
• 14:15
  do,
• 14:15
  we
• 14:15
  can
• 14:16
  accidentally
• 14:16
  be
• 14:16
  right.
• 14:17
  We've
• 14:17
  talked
• 14:17
  about
• 14:17
  this
• 14:18
  in
• 14:18
  the
• 14:18
  past,
• 14:18
  right?
• 14:18
  If
• 14:18
  you're
• 14:19
  not
• 14:19
  sure
• 14:19
  if
• 14:19
  something
• 14:20
  is
• 14:20
  unipolar
• 14:20
  bipolar
• 14:21
  depression,
• 14:21
  you
• 14:21
  do
• 14:22
  have
• 14:22
  mixed
• 14:22
  features.
• 14:23
  You
• 14:23
  might
• 14:23
  get
• 14:23
  away
• 14:24
  with
• 14:24
  latuda
• 14:25
  as
• 14:25
  a
• 14:25
  hedge,
• 14:26
  right?
• 14:26
  You're
• 14:26
  not
• 14:26
  sure
• 14:26
  if
• 14:27
  it's
• 14:27
  morphing
• 14:27
  into
• 14:27
  bipolar
• 14:28
  2,
• 14:28
  if
• 14:28
  it'll
• 14:28
  ever
• 14:29
  be
• 14:29
  bipolar
• 14:29
  2.
• 14:29
  But
• 14:30
  there's
• 14:30
  enough
• 14:30
  mixed
• 14:30
  features
• 14:31
  that
• 14:31
  makes
• 14:31
  you
• 14:31
  nervous,
• 14:32
  and
• 14:32
  you
• 14:32
  avoid
• 14:33
  antidepressant
• 14:34
  monotherapy.
• 14:34
  You
• 14:35
  might
• 14:35
  get
• 14:35
  away
• 14:35
  with
• 14:36
  not
• 14:36
  being
• 14:36
  able
• 14:36
  to
• 14:36
  know
• 14:37
  that
• 14:37
  declaratively
• 14:38
  because
• 14:39
  you're
• 14:39
  human,
• 14:39
  and
• 14:39
  it's
• 14:39
  not
• 14:39
  always
• 14:40
  possible
• 14:40
  to
• 14:40
  know
• 14:40
  right
• 14:41
  away.
• 14:41
  And
• 14:41
  you
• 14:42
  could
• 14:42
  prescribe
• 14:42
  something
• 14:43
  like
• 14:43
  latuda.
• 14:44
  We
• 14:44
  talked
• 14:44
  about
• 14:44
  the
• 14:44
  RCT
• 14:45
  evidence
• 14:46
  as
• 14:46
  it
• 14:46
  relates
• 14:46
  to
• 14:46
  latuda
• 14:47
  in
• 14:47
  mdd
• 14:47
  mixed
• 14:48
  features.
• 14:48
  However,
• 14:49
  you
• 14:50
  don't
• 14:50
  have
• 14:50
  that
• 14:50
  luxury.
• 14:51
  If
• 14:51
  you
• 14:51
  are,
• 14:53
  you
• 14:53
  are
• 14:53
  thinking
• 14:53
  about
• 14:54
  the
• 14:54
  difference
• 14:54
  between
• 14:54
  GAD
• 14:55
  and
• 14:55
  OCD.
• 14:55
  Again,
• 14:56
  two
• 14:56
  different
• 14:56
  neurobiological
• 14:57
  signatures.
• 14:58
  One
• 14:58
  requires
• 14:59
  high
• 14:59
  dose
• 15:00
  SSRIs,
• 15:01
  one
• 15:01
  requires
• 15:01
  an
• 15:02
  ERP.
• 15:03
  An
• 15:03
  ERP
• 15:03
  path
• 15:04
  versus
• 15:04
  a
• 15:04
  CBT
• 15:05
  path.
• 15:05
  One
• 15:06
  does
• 15:06
  not
• 15:06
  benefit
• 15:06
  from
• 15:07
  benzodiazepines
• 15:08
  or
• 15:09
  like
• 15:09
  antipsychotic
• 15:10
  augmentation
• 15:10
  as,
• 15:11
  as
• 15:11
  readily.
• 15:11
  You
• 15:12
  so,
• 15:12
  so
• 15:12
  really
• 15:13
  different.
• 15:13
  Right?
• 15:14
  And
• 15:14
  you,
• 15:15
  you
• 15:15
  might
• 15:15
  have
• 15:15
  many
• 15:15
  patients
• 15:16
  I
• 15:16
  know
• 15:16
  I've
• 15:16
  had
• 15:16
  tons
• 15:16
  of
• 15:16
  them
• 15:17
  that
• 15:17
  don't
• 15:17
  respond
• 15:18
  very
• 15:18
  easily
• 15:18
  when
• 15:19
  you
• 15:19
  maximize
• 15:19
  an
• 15:19
  SSRI
• 15:20
  dose.
• 15:20
  It's
• 15:21
  very
• 15:21
  hard
• 15:21
  to
• 15:21
  do
• 15:21
  that
• 15:22
  in
• 15:22
  practice.
• 15:23
  You
• 15:23
  have
• 15:24
  sexual
• 15:24
  side
• 15:24
  effects
• 15:25
  and
• 15:25
  emotional
• 15:26
  flattening
• 15:27
  and
• 15:28
  insomnia
• 15:28
  and
• 15:28
  so
• 15:29
  many,
• 15:29
  so
• 15:29
  many
• 15:30
  issues.
• 15:30
  Stumbling
• 15:30
  blocks
• 15:31
  where
• 15:31
  getting
• 15:32
  the
• 15:32
  80
• 15:32
  milligrams
• 15:32
  of
• 15:33
  Prozac
• 15:33
  is
• 15:34
  not
• 15:34
  always
• 15:34
  easy
• 15:35
  or
• 15:35
  viable.
• 15:35
  Getting
• 15:36
  the
• 15:36
  200mg
• 15:37
  of
• 15:37
  Zoloft
• 15:37
  is
• 15:37
  not
• 15:38
  always
• 15:38
  easy
• 15:38
  or
• 15:38
  viable.
• 15:39
  And
• 15:39
  so
• 15:40
  there
• 15:40
  are
• 15:40
  hard
• 15:40
  limitations
• 15:41
  but
• 15:42
  important
• 15:42
  guidelines
• 15:43
  that
• 15:43
  distinguish
• 15:44
  these
• 15:44
  two
• 15:45
  and
• 15:45
  it
• 15:45
  makes
• 15:45
  all
• 15:46
  the
• 15:46
  difference.
• 15:46
  Now,
• 15:46
  my
• 15:46
  friends,
• 15:47
  if
• 15:48
  you've
• 15:48
  been
• 15:48
  enjoying
• 15:48
  this,
• 15:49
  I
• 15:49
  can't
• 15:49
  emphasize
• 15:50
  enough
• 15:51
  that
• 15:52
  you
• 15:53
  don't
• 15:53
  want
• 15:53
  to
• 15:53
  be
• 15:53
  one
• 15:53
  of
• 15:53
  those
• 15:54
  providers
• 15:55
  that
• 15:55
  just
• 15:55
  follows
• 15:56
  algorithms
• 15:56
  and
• 15:57
  prescribes
• 15:57
  and
• 15:58
  just
• 15:58
  slaps
• 15:58
  on
• 15:58
  a
• 15:58
  diagnosis
• 15:59
  because
• 16:00
  it's
• 16:00
  a
• 16:00
  diagnosis.
• 16:00
  If
• 16:01
  you
• 16:01
  want
• 16:01
  to
• 16:01
  know
• 16:01
  the
• 16:01
  how
• 16:02
  and
• 16:02
  the
• 16:02
  why
• 16:02
  and
• 16:02
  be
• 16:03
  empowered
• 16:03
  and
• 16:04
  completely
• 16:04
  transform
• 16:05
  the
• 16:05
  way
• 16:05
  you
• 16:05
  practice
• 16:06
  and,
• 16:07
  and
• 16:08
  improve
• 16:08
  patient
• 16:09
  outcomes,
• 16:09
  I
• 16:10
  highly
• 16:10
  recommend
• 16:10
  if
• 16:11
  there's
• 16:11
  one
• 16:11
  thing
• 16:11
  you
• 16:11
  don't
• 16:12
  forget
• 16:12
  today
• 16:12
  is
• 16:12
  go
• 16:12
  to
• 16:13
  our
• 16:13
  show
• 16:13
  notes
• 16:14
  and
• 16:14
  become
• 16:15
  a
• 16:15
  Patreon
• 16:15
  member.
• 16:16
  I
• 16:17
  don't
• 16:17
  know
• 16:17
  what
• 16:17
  kind
• 16:18
  of
• 16:18
  clinician
• 16:18
  I
• 16:18
  would
• 16:18
  be
• 16:19
  if
• 16:19
  I
• 16:19
  didn't
• 16:19
  have
• 16:20
  the
• 16:20
  Patreon
• 16:20
  library.
• 16:21
  It's
• 16:21
  fun,
• 16:22
  it's
• 16:22
  sticky,
• 16:22
  it's
• 16:23
  memorable.
• 16:23
  I
• 16:24
  wouldn't
• 16:24
  know
• 16:24
  half
• 16:24
  the
• 16:25
  stuff.
• 16:25
  I
• 16:25
  know
• 16:25
  I
• 16:25
  would
• 16:25
  be
• 16:26
  so
• 16:26
  much
• 16:26
  more
• 16:27
  lost
• 16:27
  and
• 16:27
  stuck
• 16:28
  in
• 16:28
  sessions
• 16:28
  and
• 16:28
  imprecise.
• 16:30
  Learning
• 16:30
  doesn't
• 16:30
  end
• 16:31
  in
• 16:31
  school.
• 16:31
  Right.
• 16:32
  And
• 16:32
  so
• 16:32
  I
• 16:32
  highly
• 16:33
  recommend
• 16:33
  if
• 16:33
  you
• 16:33
  want
• 16:34
  to
• 16:34
  transform
• 16:34
  the
• 16:34
  way
• 16:35
  you
• 16:35
  practice
• 16:35
  and,
• 16:36
  and
• 16:36
  be
• 16:36
  that
• 16:36
  provider
• 16:37
  that
• 16:37
  understands
• 16:38
  the
• 16:38
  how
• 16:38
  and
• 16:38
  why,
• 16:38
  patients
• 16:39
  will
• 16:39
  smell
• 16:39
  that
• 16:40
  a
• 16:40
  mile
• 16:40
  away
• 16:41
  and,
• 16:41
  and
• 16:42
  it'll
• 16:42
  exponentially
• 16:43
  help
• 16:43
  you.
• 16:43
  So
• 16:43
  if
• 16:43
  there's
• 16:44
  one
• 16:44
  thing
• 16:44
  you
• 16:45
  don't,
• 16:45
  you
• 16:46
  don't
• 16:46
  forget
• 16:46
  before
• 16:47
  you
• 16:47
  hit
• 16:47
  the
• 16:47
  hay
• 16:47
  tonight
• 16:48
  and
• 16:48
  go
• 16:48
  to
• 16:48
  bed,
• 16:49
  go
• 16:50
  into
• 16:50
  our
• 16:50
  show
• 16:50
  notes
• 16:50
  and
• 16:51
  join
• 16:51
  Patreon
• 16:52
  and
• 16:52
  tell
• 16:52
  your
• 16:52
  friends
• 16:52
  to.
• 16:53
  It
• 16:53
  is
• 16:53
  sticky
• 16:54
  and
• 16:54
  so
• 16:54
  much
• 16:54
  fun.
• 16:55
  All
• 16:55
  right,
• 16:55
  my
• 16:55
  friends,
• 16:55
  with
• 16:56
  that,
• 16:56
  have
• 16:56
  a
• 16:56
  great
• 16:57
  rest
• 16:57
  of
• 16:57
  your
• 16:57
  week.
• 16:58
  Bye
• 16:58
  Bye.