Latest / Pearls and Prep / Borderline Personality Disorder and Persistent Depression Can Look IDENTICAL. Until You Ask the Right Questions.

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Borderline Personality Disorder and Persistent Depression Can Look IDENTICAL. Until You Ask the Right Questions. · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:05
  back
• 0:05
  my
• 0:05
  friends
• 0:06
  to
• 0:06
  another
• 0:06
  episode
• 0:07
  of
• 0:07
  Pearls
• 0:07
  and
• 0:08
  Prep
• 0:08
  npz.
• 0:08
  Here,
• 0:09
  your
• 0:09
  preceptor
• 0:10
  in
• 0:10
  your
• 0:10
  pocket,
• 0:10
  your
• 0:11
  go
• 0:11
  to
• 0:11
  place
• 0:11
  for
• 0:12
  pearls
• 0:12
  that
• 0:12
  prep
• 0:13
  you
• 0:13
  to
• 0:13
  practice.
• 0:14
  My
• 0:15
  friends,
• 0:15
  we
• 0:16
  are
• 0:16
  going
• 0:16
  to
• 0:17
  have
• 0:17
  a
• 0:18
  diagnostic
• 0:18
  tug
• 0:19
  of
• 0:19
  war
• 0:19
  today
• 0:19
  between
• 0:20
  persistent
• 0:21
  depressive
• 0:21
  disorder
• 0:22
  and
• 0:22
  borderline
• 0:23
  personality
• 0:24
  disorder.
• 0:25
  Two
• 0:26
  very
• 0:26
  common
• 0:26
  presentations
• 0:27
  you
• 0:27
  will
• 0:28
  see
• 0:28
  in
• 0:28
  your
• 0:28
  practice.
• 0:29
  And
• 0:29
  I
• 0:30
  can
• 0:30
  tell
• 0:30
  you
• 0:30
  right
• 0:30
  now
• 0:31
  that
• 0:31
  at
• 0:32
  first
• 0:32
  glance
• 0:33
  you
• 0:33
  might
• 0:33
  freeze
• 0:34
  and
• 0:34
  have
• 0:35
  no
• 0:35
  clue
• 0:36
  what
• 0:36
  the
• 0:36
  difference
• 0:36
  is.
• 0:37
  Not
• 0:37
  because
• 0:37
  you
• 0:38
  don't
• 0:38
  know
• 0:38
  what
• 0:39
  you
• 0:39
  read
• 0:39
  in
• 0:39
  your
• 0:39
  textbooks,
• 0:40
  but
• 0:40
  because
• 0:41
  these
• 0:42
  presentations
• 0:43
  can
• 0:43
  look
• 0:43
  awfully
• 0:44
  similar
• 0:44
  and
• 0:45
  it
• 0:45
  can
• 0:45
  be
• 0:45
  really
• 0:46
  frightening
• 0:46
  in
• 0:47
  session
• 0:47
  if
• 0:47
  you're
• 0:48
  a
• 0:48
  deer
• 0:48
  in
• 0:48
  headlights
• 0:48
  and
• 0:49
  you
• 0:49
  don't
• 0:49
  know
• 0:50
  how
• 0:50
  to
• 0:50
  proceed
• 0:51
  and
• 0:51
  how
• 0:51
  to
• 0:51
  separate
• 0:52
  the
• 0:52
  wheat
• 0:52
  from
• 0:52
  the
• 0:53
  chaff.
• 0:53
  And
• 0:53
  that's
• 0:53
  what
• 0:53
  we're
• 0:54
  going
• 0:54
  to
• 0:54
  do
• 0:54
  today
• 0:54
  in
• 0:54
  the
• 0:55
  form
• 0:55
  of
• 0:55
  a
• 0:55
  mock
• 0:56
  case
• 0:56
  study.
• 0:57
  You
• 0:57
  have
• 0:58
  a
• 0:58
  34
• 0:58
  year
• 0:59
  old
• 1:00
  patient
• 1:00
  named
• 1:00
  Mara.
• 1:01
  Her
• 1:01
  PCP
• 1:02
  referred
• 1:02
  her
• 1:02
  to
• 1:03
  you.
• 1:03
  She's
• 1:03
  been
• 1:03
  on
• 1:03
  zoloft
• 1:04
  low
• 1:04
  dose
• 1:05
  50mg
• 1:05
  with
• 1:06
  a
• 1:06
  partial
• 1:06
  response
• 1:07
  for
• 1:07
  years.
• 1:09
  The
• 1:09
  PCP
• 1:09
  thinks
• 1:10
  this
• 1:10
  is
• 1:10
  either
• 1:10
  chronic
• 1:11
  depression,
• 1:11
  maybe
• 1:11
  a
• 1:11
  personality
• 1:12
  disorder.
• 1:13
  He's
• 1:14
  telling
• 1:14
  you
• 1:14
  the
• 1:14
  patient
• 1:14
  has
• 1:14
  interpersonal
• 1:15
  difficulties,
• 1:16
  some
• 1:16
  childhood
• 1:16
  trauma
• 1:17
  and
• 1:17
  just
• 1:18
  chronic
• 1:18
  emptiness.
• 1:19
  She's
• 1:19
  not
• 1:20
  responding
• 1:20
  adequately
• 1:21
  to
• 1:21
  Sertraline
• 1:22
  or
• 1:22
  Zola.
• 1:23
  Right.
• 1:23
  And
• 1:24
  he
• 1:24
  wants
• 1:24
  you
• 1:24
  to
• 1:24
  evaluate
• 1:25
  her.
• 1:26
  Okay,
• 1:27
  now
• 1:27
  you've
• 1:27
  already
• 1:28
  been
• 1:28
  teed
• 1:28
  up
• 1:28
  with
• 1:29
  a
• 1:29
  referral
• 1:30
  bias,
• 1:30
  what
• 1:31
  we
• 1:31
  call
• 1:31
  a
• 1:31
  referral
• 1:32
  bias.
• 1:32
  I've
• 1:32
  always
• 1:33
  emphasized
• 1:33
  this
• 1:33
  in
• 1:34
  all
• 1:34
  of
• 1:34
  our
• 1:34
  discussions
• 1:35
  together,
• 1:35
  that
• 1:35
  you
• 1:36
  should
• 1:36
  be
• 1:36
  very
• 1:36
  wary
• 1:37
  anytime
• 1:38
  you
• 1:38
  get
• 1:38
  a
• 1:39
  referral
• 1:40
  or
• 1:40
  a
• 1:40
  report.
• 1:41
  And
• 1:41
  it's
• 1:42
  not
• 1:42
  that
• 1:42
  the
• 1:42
  person
• 1:43
  giving
• 1:43
  it
• 1:43
  to
• 1:43
  you
• 1:43
  is
• 1:44
  bad.
• 1:44
  They're
• 1:44
  normally
• 1:45
  amazing,
• 1:45
  incredible,
• 1:46
  well
• 1:46
  intentioned
• 1:47
  people.
• 1:48
  But
• 1:48
  we
• 1:48
  all
• 1:48
  have
• 1:48
  our
• 1:49
  own
• 1:49
  biases
• 1:50
  and
• 1:50
  when
• 1:50
  we
• 1:50
  hand
• 1:50
  the
• 1:51
  baton
• 1:51
  to
• 1:51
  somebody
• 1:52
  else,
• 1:52
  it
• 1:52
  can
• 1:52
  be
• 1:52
  very
• 1:53
  tempting
• 1:53
  to
• 1:54
  anchor
• 1:55
  yourself
• 1:56
  to
• 1:57
  their
• 1:58
  first
• 1:58
  impression.
• 1:59
  Right?
• 2:00
  So
• 2:01
  it's
• 2:01
  very
• 2:01
  important
• 2:02
  that
• 2:03
  you
• 2:04
  look
• 2:04
  at
• 2:04
  your
• 2:04
  patient
• 2:04
  with
• 2:04
  a
• 2:05
  fresh
• 2:05
  set
• 2:05
  of
• 2:05
  eyes.
• 2:05
  And
• 2:06
  that's
• 2:06
  always
• 2:06
  hard
• 2:06
  to
• 2:06
  do
• 2:07
  because
• 2:07
  you
• 2:08
  do
• 2:08
  have
• 2:08
  to
• 2:08
  get
• 2:08
  a
• 2:08
  glimpse
• 2:09
  of
• 2:09
  their
• 2:09
  history
• 2:09
  to
• 2:10
  have
• 2:10
  some
• 2:10
  context
• 2:10
  to
• 2:10
  make
• 2:11
  sure
• 2:11
  you're
• 2:11
  answering
• 2:11
  the
• 2:11
  right
• 2:12
  questions
• 2:12
  right.
• 2:13
  Especially
• 2:13
  if
• 2:13
  somebody
• 2:13
  has
• 2:14
  a
• 2:14
  really
• 2:14
  extensive
• 2:14
  chart.
• 2:15
  You
• 2:15
  can't
• 2:15
  just
• 2:15
  go
• 2:15
  in
• 2:16
  blind,
• 2:16
  however,
• 2:17
  begs
• 2:18
  the
• 2:18
  question
• 2:18
  about
• 2:19
  whether
• 2:19
  or
• 2:20
  not
• 2:20
  in
• 2:20
  an
• 2:21
  ideal
• 2:21
  world
• 2:21
  it
• 2:22
  would
• 2:22
  be
• 2:22
  good
• 2:22
  to
• 2:22
  go
• 2:22
  in
• 2:23
  a
• 2:23
  little
• 2:23
  more
• 2:23
  blind
• 2:24
  because
• 2:24
  you
• 2:24
  don't
• 2:24
  want
• 2:25
  to
• 2:25
  be
• 2:25
  shaped
• 2:25
  by
• 2:26
  a
• 2:26
  bias
• 2:27
  from
• 2:27
  the
• 2:27
  previous
• 2:28
  provider
• 2:28
  who's
• 2:29
  convinced
• 2:30
  that
• 2:30
  the
• 2:30
  patient
• 2:30
  has
• 2:30
  a
• 2:31
  borderline
• 2:31
  personality
• 2:32
  disorder
• 2:32
  and
• 2:32
  has
• 2:32
  formulated
• 2:33
  all
• 2:34
  of
• 2:34
  their
• 2:34
  questions
• 2:35
  and
• 2:35
  their
• 2:35
  judgments
• 2:36
  based
• 2:36
  on
• 2:36
  that
• 2:37
  and
• 2:37
  impression
• 2:38
  that
• 2:38
  they
• 2:38
  have.
• 2:39
  And
• 2:39
  lo
• 2:39
  and
• 2:39
  behold,
• 2:40
  you
• 2:40
  are
• 2:40
  duplicating
• 2:41
  a
• 2:41
  diagnosis
• 2:42
  that
• 2:42
  may
• 2:42
  or
• 2:42
  may
• 2:43
  not
• 2:43
  be
• 2:43
  false.
• 2:43
  The
• 2:43
  anchoring
• 2:44
  bias
• 2:44
  is
• 2:45
  very
• 2:45
  real
• 2:45
  and
• 2:45
  we
• 2:46
  ought
• 2:46
  to
• 2:46
  challenge
• 2:46
  it
• 2:46
  on
• 2:47
  behalf
• 2:47
  of
• 2:47
  our
• 2:47
  patients.
• 2:48
  So
• 2:48
  we
• 2:48
  get
• 2:49
  the
• 2:49
  right
• 2:49
  call
• 2:50
  now.
• 2:51
  Little
• 2:51
  more
• 2:51
  information
• 2:52
  about
• 2:52
  Mara.
• 2:52
  She's
• 2:53
  on
• 2:53
  time,
• 2:53
  she's
• 2:53
  dressed
• 2:54
  nicely,
• 2:55
  she's
• 2:55
  calmly
• 2:56
  sitting
• 2:56
  calmly
• 2:57
  in
• 2:57
  her
• 2:57
  chair.
• 2:57
  Her
• 2:57
  eye
• 2:58
  contact's
• 2:58
  kind
• 2:58
  of
• 2:59
  flat,
• 3:00
  little
• 3:00
  bit
• 3:00
  monotone.
• 3:01
  No
• 3:01
  dramatic
• 3:02
  affect,
• 3:03
  no
• 3:03
  visible
• 3:04
  distress,
• 3:04
  no
• 3:04
  urgency.
• 3:05
  She's
• 3:05
  filling
• 3:05
  out
• 3:06
  her
• 3:06
  paperwork
• 3:07
  and
• 3:07
  she
• 3:07
  tells
• 3:07
  you,
• 3:07
  I've
• 3:08
  always
• 3:08
  been
• 3:08
  feeling
• 3:08
  this
• 3:08
  empty.
• 3:09
  I
• 3:09
  don't
• 3:09
  really
• 3:09
  know
• 3:09
  what
• 3:09
  happy
• 3:10
  feels
• 3:10
  like.
• 3:10
  I
• 3:10
  just
• 3:11
  think,
• 3:11
  this
• 3:11
  is
• 3:11
  me.
• 3:12
  She
• 3:12
  doesn't
• 3:12
  cry
• 3:13
  when
• 3:13
  she
• 3:13
  says
• 3:13
  that.
• 3:13
  She
• 3:14
  doesn't
• 3:14
  even
• 3:14
  look
• 3:14
  away
• 3:14
  from
• 3:14
  you.
• 3:15
  She
• 3:15
  just
• 3:15
  kind
• 3:15
  of
• 3:15
  states
• 3:16
  it
• 3:16
  like
• 3:16
  somebody's
• 3:17
  talking
• 3:17
  about
• 3:17
  the
• 3:17
  weather
• 3:18
  factually,
• 3:19
  without
• 3:19
  any
• 3:19
  expectation
• 3:20
  that
• 3:20
  anything's
• 3:21
  going
• 3:21
  to
• 3:21
  change.
• 3:22
  And
• 3:23
  so
• 3:23
  this
• 3:24
  is
• 3:24
  just
• 3:24
  sort
• 3:24
  of
• 3:24
  how
• 3:25
  she's
• 3:25
  been
• 3:26
  always
• 3:26
  feeling
• 3:26
  this
• 3:27
  empty.
• 3:27
  Now
• 3:28
  I
• 3:28
  hear
• 3:28
  patients
• 3:28
  say
• 3:29
  that
• 3:29
  a
• 3:29
  lot,
• 3:29
  believe
• 3:29
  it
• 3:29
  or
• 3:30
  not,
• 3:30
  it's
• 3:30
  seems
• 3:31
  to
• 3:31
  be
• 3:31
  a
• 3:31
  common
• 3:31
  quote
• 3:32
  that
• 3:32
  they
• 3:32
  always
• 3:32
  feel
• 3:32
  like
• 3:33
  they're
• 3:33
  empty.
• 3:33
  And
• 3:34
  my
• 3:34
  mind
• 3:34
  immediately
• 3:35
  goes
• 3:35
  to
• 3:35
  borderline.
• 3:36
  My
• 3:36
  mind
• 3:37
  immediately
• 3:37
  goes
• 3:38
  to
• 3:38
  potentially
• 3:39
  a
• 3:39
  depression.
• 3:40
  And
• 3:40
  sometimes
• 3:41
  my
• 3:41
  mind
• 3:41
  will
• 3:41
  go
• 3:41
  to
• 3:41
  ptsd
• 3:42
  because
• 3:42
  in
• 3:43
  PTSD
• 3:43
  there
• 3:44
  is
• 3:44
  just
• 3:44
  this
• 3:45
  pervasive
• 3:45
  lack
• 3:46
  of
• 3:46
  joy
• 3:46
  and
• 3:46
  connectivity
• 3:47
  with
• 3:47
  other
• 3:48
  people.
• 3:48
  Trauma
• 3:49
  seems
• 3:49
  to
• 3:49
  stifle
• 3:50
  so
• 3:50
  much
• 3:50
  of
• 3:50
  our
• 3:50
  personalities
• 3:51
  and
• 3:51
  our
• 3:51
  ability
• 3:52
  to
• 3:52
  really
• 3:52
  connect
• 3:52
  and
• 3:53
  enjoy.
• 3:53
  So
• 3:54
  anything
• 3:54
  that
• 3:54
  robs
• 3:55
  us
• 3:55
  of
• 3:56
  those
• 3:56
  feelings,
• 3:57
  I
• 3:57
  tend
• 3:57
  to
• 3:57
  kind
• 3:58
  of
• 3:58
  gravitate
• 3:58
  towards
• 3:59
  those
• 3:59
  diagnoses
• 3:59
  just
• 4:00
  in
• 4:00
  my
• 4:00
  head,
• 4:01
  just
• 4:01
  preliminarily
• 4:02
  as
• 4:02
  I
• 4:03
  find
• 4:03
  that
• 4:03
  that's
• 4:04
  kind
• 4:04
  of
• 4:04
  useful.
• 4:05
  But
• 4:06
  the
• 4:06
  key
• 4:06
  here
• 4:06
  is
• 4:06
  when
• 4:06
  the
• 4:06
  patient
• 4:07
  says,
• 4:07
  I've
• 4:07
  always
• 4:08
  been
• 4:08
  feeling
• 4:08
  this
• 4:08
  empty
• 4:09
  thinking
• 4:09
  out
• 4:10
  loud.
• 4:10
  I
• 4:10
  think
• 4:10
  of
• 4:11
  a
• 4:11
  chronic
• 4:11
  condition,
• 4:12
  right?
• 4:12
  I
• 4:12
  think
• 4:12
  of
• 4:13
  a
• 4:13
  persistent
• 4:13
  depressive
• 4:13
  disorder
• 4:14
  because
• 4:14
  that's
• 4:14
  an
• 4:14
  always
• 4:15
  kind
• 4:15
  of
• 4:15
  thing,
• 4:15
  right?
• 4:16
  It's
• 4:16
  at
• 4:16
  least
• 4:17
  years
• 4:17
  with
• 4:18
  no
• 4:18
  two
• 4:18
  month
• 4:19
  period
• 4:20
  of
• 4:21
  any
• 4:21
  breaks
• 4:22
  from
• 4:22
  that
• 4:22
  sense
• 4:23
  of
• 4:23
  depression.
• 4:24
  So
• 4:24
  when
• 4:24
  somebody
• 4:25
  says
• 4:25
  always,
• 4:25
  I'm
• 4:26
  thinking
• 4:26
  again,
• 4:26
  trauma,
• 4:26
  because
• 4:27
  that
• 4:27
  can
• 4:27
  be
• 4:27
  a
• 4:27
  longitudinal
• 4:28
  problem.
• 4:29
  I'm
• 4:29
  thinking
• 4:29
  depression
• 4:30
  that's
• 4:30
  persistent,
• 4:31
  probably
• 4:31
  PDD
• 4:32
  or
• 4:33
  I
• 4:34
  may
• 4:34
  be
• 4:34
  thinking
• 4:35
  of
• 4:35
  especially
• 4:36
  the
• 4:36
  emptiness
• 4:36
  is
• 4:36
  a
• 4:37
  tip
• 4:37
  tip
• 4:37
  off
• 4:38
  for
• 4:38
  borderline
• 4:39
  personality
• 4:40
  disorder
• 4:40
  because
• 4:40
  that
• 4:41
  is
• 4:41
  actually
• 4:41
  one
• 4:41
  of
• 4:42
  the.
• 4:42
  The
• 4:42
  criterion,
• 4:43
  criterion
• 4:43
  7
• 4:44
  is
• 4:44
  chronic
• 4:45
  sense
• 4:45
  of
• 4:46
  emptiness.
• 4:46
  Now,
• 4:47
  just
• 4:47
  like
• 4:47
  any
• 4:47
  other
• 4:47
  diagnosis,
• 4:48
  you
• 4:48
  have
• 4:48
  to
• 4:48
  get
• 4:49
  to
• 4:49
  the
• 4:49
  bottom
• 4:49
  of
• 4:50
  what
• 4:50
  is
• 4:51
  making
• 4:51
  them
• 4:52
  feel
• 4:52
  empty,
• 4:53
  right?
• 4:53
  And
• 4:53
  if
• 4:54
  it's
• 4:54
  because
• 4:54
  they
• 4:54
  don't
• 4:55
  have
• 4:55
  a
• 4:55
  stable
• 4:55
  self
• 4:56
  image
• 4:56
  and
• 4:57
  their
• 4:57
  relationships
• 4:58
  are
• 4:58
  hollow
• 4:58
  and
• 4:59
  unpredictable
• 4:59
  and
• 5:00
  chaotic
• 5:00
  and
• 5:00
  that's
• 5:01
  driving
• 5:01
  a
• 5:01
  sense
• 5:01
  of
• 5:01
  emptiness,
• 5:02
  you
• 5:02
  definitely
• 5:03
  gravitate
• 5:04
  more
• 5:04
  towards
• 5:04
  borderline
• 5:05
  personality.
• 5:06
  If
• 5:06
  they're
• 5:07
  just
• 5:07
  empty
• 5:07
  because
• 5:07
  their
• 5:08
  mood
• 5:08
  is
• 5:08
  empty
• 5:08
  and
• 5:09
  flat
• 5:09
  and
• 5:09
  nothing
• 5:09
  brings
• 5:10
  them
• 5:10
  joy,
• 5:11
  then
• 5:11
  you're
• 5:11
  definitely
• 5:12
  in
• 5:12
  the
• 5:12
  persistent
• 5:13
  depressive
• 5:14
  disorder
• 5:14
  column,
• 5:15
  right?
• 5:15
  Or
• 5:15
  some
• 5:15
  sort
• 5:16
  of
• 5:16
  depressive
• 5:16
  disorder
• 5:17
  column.
• 5:18
  So
• 5:18
  the
• 5:19
  empty
• 5:19
  is
• 5:19
  just
• 5:19
  really
• 5:20
  important
• 5:20
  to
• 5:22
  get
• 5:22
  a
• 5:22
  qualitative
• 5:23
  understanding
• 5:24
  about.
• 5:25
  Okay?
• 5:26
  That
• 5:26
  is
• 5:26
  the
• 5:27
  most
• 5:27
  important
• 5:27
  thing
• 5:28
  because
• 5:28
  in
• 5:28
  borderline
• 5:29
  personality,
• 5:29
  we'll
• 5:30
  call
• 5:30
  it
• 5:30
  BPD
• 5:30
  here,
• 5:31
  chronic
• 5:32
  emptiness
• 5:32
  is
• 5:32
  a
• 5:32
  sense
• 5:33
  of
• 5:33
  kind
• 5:33
  of
• 5:33
  disconnection
• 5:34
  from
• 5:34
  themselves,
• 5:35
  kind
• 5:35
  of
• 5:35
  this
• 5:35
  aching,
• 5:36
  active
• 5:36
  void
• 5:38
  that
• 5:38
  is
• 5:38
  really
• 5:39
  slow
• 5:39
  to
• 5:39
  remit.
• 5:40
  And
• 5:40
  it's
• 5:41
  actually
• 5:41
  very
• 5:42
  correlated
• 5:42
  with
• 5:42
  suicidal
• 5:43
  ideation.
• 5:44
  Okay?
• 5:44
  It's
• 5:44
  this
• 5:45
  chronic
• 5:45
  sense
• 5:45
  of
• 5:46
  emptiness.
• 5:46
  And
• 5:46
  sometimes
• 5:47
  their
• 5:48
  behavior
• 5:49
  that
• 5:50
  they
• 5:50
  will
• 5:50
  exhibit
• 5:50
  the
• 5:51
  impulsivity.
• 5:52
  Changing
• 5:52
  jobs,
• 5:53
  changing
• 5:54
  names,
• 5:54
  changing
• 5:54
  hair
• 5:55
  colors
• 5:55
  is
• 5:56
  often
• 5:56
  a
• 5:57
  way
• 5:57
  to
• 5:57
  feel
• 5:58
  less
• 5:58
  empty.
• 5:59
  So
• 5:59
  they
• 5:59
  will
• 6:00
  act.
• 6:01
  They
• 6:01
  will
• 6:01
  actually
• 6:02
  act.
• 6:02
  It's
• 6:02
  a
• 6:03
  very
• 6:04
  active
• 6:05
  form
• 6:05
  of
• 6:06
  a
• 6:06
  disorder,
• 6:06
  right?
• 6:07
  They're
• 6:07
  acting
• 6:08
  to,
• 6:09
  to
• 6:10
  get
• 6:10
  out
• 6:10
  of
• 6:10
  that
• 6:10
  void.
• 6:11
  They
• 6:12
  are,
• 6:12
  it's.
• 6:12
  It's
• 6:13
  spurring
• 6:14
  action,
• 6:14
  it's
• 6:14
  provoking
• 6:15
  action
• 6:15
  within
• 6:16
  them.
• 6:16
  As
• 6:16
  opposed
• 6:16
  to
• 6:16
  PDD
• 6:17
  or
• 6:17
  persistent
• 6:18
  depressive
• 6:18
  disorder,
• 6:19
  which
• 6:20
  that
• 6:20
  emptiness
• 6:20
  is
• 6:21
  flat
• 6:21
  and
• 6:21
  it's
• 6:22
  not
• 6:22
  really
• 6:22
  backed
• 6:22
  by
• 6:23
  any
• 6:23
  kind
• 6:23
  of
• 6:23
  action
• 6:24
  to
• 6:24
  compensate
• 6:25
  for
• 6:25
  it
• 6:25
  because
• 6:25
  depression
• 6:26
  is
• 6:27
  really
• 6:27
  sapping
• 6:28
  them
• 6:28
  of
• 6:28
  the
• 6:28
  energy
• 6:28
  or
• 6:28
  the
• 6:29
  mood
• 6:29
  to
• 6:29
  initiate
• 6:29
  any
• 6:30
  actions
• 6:30
  at
• 6:30
  all.
• 6:31
  So
• 6:31
  when
• 6:31
  you
• 6:32
  think
• 6:32
  emptiness,
• 6:32
  one
• 6:33
  really
• 6:33
  good
• 6:33
  pearl
• 6:34
  is
• 6:34
  what
• 6:34
  are
• 6:34
  you
• 6:34
  doing
• 6:35
  about
• 6:35
  that
• 6:35
  emptiness?
• 6:36
  Right?
• 6:36
  You
• 6:36
  wanna
• 6:37
  word
• 6:37
  that
• 6:37
  a
• 6:37
  little
• 6:37
  differently
• 6:38
  to
• 6:38
  the
• 6:38
  patient,
• 6:38
  but
• 6:38
  you
• 6:39
  can
• 6:39
  ask
• 6:39
  something
• 6:40
  to
• 6:40
  the
• 6:40
  effect
• 6:40
  of
• 6:41
  when
• 6:41
  you
• 6:41
  feel
• 6:41
  really
• 6:42
  empty,
• 6:43
  what
• 6:43
  comes
• 6:43
  next
• 6:44
  for
• 6:44
  you?
• 6:44
  How
• 6:44
  do
• 6:44
  you
• 6:45
  overcome
• 6:45
  that
• 6:45
  sense
• 6:46
  of
• 6:46
  emptiness?
• 6:46
  Bam.
• 6:47
  If
• 6:47
  someone's
• 6:47
  depressed,
• 6:48
  they're
• 6:48
  probably
• 6:49
  gonna
• 6:49
  give
• 6:49
  you
• 6:49
  an
• 6:49
  answer
• 6:50
  that's
• 6:50
  kind
• 6:50
  of
• 6:50
  like,
• 6:51
  eh,
• 6:52
  that's
• 6:52
  just
• 6:52
  how
• 6:52
  it
• 6:52
  is.
• 6:52
  I
• 6:53
  don't
• 6:53
  know,
• 6:53
  you
• 6:53
  know,
• 6:54
  I'll
• 6:54
  just
• 6:54
  scroll
• 6:54
  on
• 6:55
  my
• 6:55
  phone
• 6:55
  or
• 6:55
  try
• 6:55
  to
• 6:56
  fall
• 6:56
  asleep.
• 6:56
  Right?
• 6:57
  It's
• 6:57
  this
• 6:57
  very
• 6:57
  passive,
• 6:59
  energic,
• 6:59
  just
• 7:00
  not
• 7:00
  a
• 7:00
  lot
• 7:00
  of
• 7:00
  energy,
• 7:01
  motivation
• 7:01
  behind
• 7:02
  that
• 7:02
  answer,
• 7:02
  as
• 7:03
  opposed
• 7:03
  to
• 7:03
  borderline,
• 7:03
  where
• 7:04
  there
• 7:04
  will
• 7:04
  be
• 7:04
  these
• 7:04
  more
• 7:05
  frantic
• 7:05
  theatrical
• 7:06
  displays
• 7:07
  to
• 7:08
  fill
• 7:08
  that
• 7:08
  void.
• 7:09
  And
• 7:09
  it's
• 7:09
  this
• 7:09
  gnawing
• 7:10
  sense
• 7:10
  of
• 7:11
  emptiness
• 7:11
  that
• 7:11
  has
• 7:12
  to
• 7:12
  be
• 7:12
  corrected
• 7:13
  in
• 7:13
  a
• 7:13
  more
• 7:14
  of
• 7:14
  a
• 7:15
  flagrant
• 7:16
  level.
• 7:16
  Okay?
• 7:17
  And
• 7:17
  so
• 7:17
  don't.
• 7:18
  It's
• 7:18
  not
• 7:18
  enough
• 7:19
  to
• 7:19
  just
• 7:19
  assess
• 7:19
  that
• 7:19
  your
• 7:20
  patient's
• 7:20
  empty.
• 7:21
  The
• 7:21
  big
• 7:21
  takeaway
• 7:22
  here
• 7:22
  is
• 7:22
  what
• 7:22
  do
• 7:23
  they
• 7:23
  do
• 7:23
  about
• 7:24
  their
• 7:24
  emptiness?
• 7:25
  Okay?
• 7:25
  And
• 7:25
  in
• 7:26
  pdd,
• 7:26
  it's
• 7:27
  this
• 7:27
  gray,
• 7:28
  flat,
• 7:28
  pervasive
• 7:29
  emptiness
• 7:30
  that
• 7:30
  the
• 7:30
  patient
• 7:31
  can't
• 7:31
  even
• 7:31
  really
• 7:31
  distinguish
• 7:32
  from
• 7:32
  their
• 7:32
  own
• 7:32
  personality.
• 7:33
  Okay?
• 7:34
  And
• 7:35
  so
• 7:36
  that
• 7:36
  is
• 7:36
  a
• 7:36
  really
• 7:37
  good
• 7:37
  way
• 7:38
  for,
• 7:38
  for
• 7:38
  you
• 7:39
  to,
• 7:39
  to.
• 7:40
  To
• 7:40
  figure
• 7:40
  this,
• 7:40
  figure
• 7:41
  out
• 7:41
  the
• 7:41
  difference
• 7:41
  there,
• 7:42
  okay?
• 7:42
  Now
• 7:43
  later
• 7:43
  on
• 7:44
  in
• 7:44
  the
• 7:44
  session,
• 7:45
  you
• 7:45
  learn
• 7:45
  a
• 7:45
  little
• 7:45
  bit
• 7:46
  more
• 7:46
  about
• 7:46
  Mara.
• 7:47
  She
• 7:47
  talks
• 7:47
  about
• 7:47
  feeling
• 7:48
  low
• 7:48
  grade
• 7:48
  sad
• 7:49
  since
• 7:49
  she
• 7:49
  was
• 7:49
  about
• 7:50
  14.
• 7:51
  She
• 7:51
  finished
• 7:51
  college
• 7:52
  but
• 7:52
  had
• 7:52
  to
• 7:52
  force
• 7:52
  herself
• 7:53
  through
• 7:53
  every
• 7:54
  semester.
• 7:54
  She's
• 7:55
  a
• 7:55
  medical
• 7:55
  coder.
• 7:56
  It's
• 7:56
  okay,
• 7:57
  she
• 7:57
  shows
• 7:57
  up
• 7:57
  and
• 7:57
  does
• 7:58
  it.
• 7:58
  She
• 7:58
  says
• 7:58
  now
• 7:59
  she's
• 7:59
  been
• 7:59
  in
• 7:59
  two
• 7:59
  long
• 8:00
  term
• 8:00
  relationships,
• 8:01
  one
• 8:01
  lasting
• 8:01
  five
• 8:01
  years,
• 8:02
  one
• 8:02
  lasting
• 8:02
  three
• 8:02
  years.
• 8:03
  And
• 8:03
  she
• 8:04
  just
• 8:04
  calls
• 8:04
  herself
• 8:04
  boring.
• 8:06
  She
• 8:06
  can't
• 8:06
  really
• 8:06
  remember
• 8:07
  a
• 8:07
  time
• 8:07
  she
• 8:07
  felt
• 8:07
  genuinely
• 8:08
  excited
• 8:08
  about
• 8:08
  anything.
• 8:10
  She
• 8:10
  sleeps
• 8:10
  okay,
• 8:11
  not
• 8:11
  really
• 8:11
  refreshed.
• 8:12
  Her
• 8:12
  appetite's
• 8:12
  fine.
• 8:12
  She
• 8:13
  doesn't
• 8:13
  really
• 8:13
  care
• 8:13
  about
• 8:13
  food,
• 8:15
  no
• 8:15
  substance
• 8:15
  use,
• 8:16
  no
• 8:16
  self
• 8:16
  harm.
• 8:17
  Never
• 8:17
  been
• 8:17
  hospitalized
• 8:18
  psychiatrically.
• 8:19
  She
• 8:20
  says
• 8:20
  her
• 8:20
  boyfriend's
• 8:20
  a
• 8:20
  bit
• 8:21
  hard
• 8:21
  to
• 8:21
  read.
• 8:21
  He's
• 8:23
  boyfriend
• 8:23
  is
• 8:23
  saying
• 8:23
  that
• 8:24
  she
• 8:24
  never
• 8:24
  really
• 8:24
  seems
• 8:24
  happy
• 8:25
  or
• 8:25
  sad
• 8:26
  and
• 8:26
  she
• 8:26
  kind
• 8:26
  of
• 8:27
  agrees
• 8:27
  with
• 8:27
  that.
• 8:27
  She
• 8:28
  has
• 8:28
  a
• 8:28
  couple
• 8:28
  of
• 8:28
  friends,
• 8:29
  but
• 8:29
  she
• 8:30
  doesn't
• 8:30
  really
• 8:30
  reach
• 8:30
  out
• 8:30
  to
• 8:31
  them.
• 8:31
  They
• 8:31
  all
• 8:31
  text
• 8:31
  her
• 8:32
  and
• 8:32
  she
• 8:32
  responds
• 8:33
  on
• 8:33
  occasion,
• 8:34
  but
• 8:34
  it's
• 8:34
  really
• 8:34
  not.
• 8:35
  She
• 8:36
  doesn't
• 8:36
  really
• 8:36
  make
• 8:36
  the
• 8:36
  effort
• 8:37
  very
• 8:37
  often.
• 8:38
  She
• 8:38
  not
• 8:38
  cuz
• 8:39
  she's
• 8:39
  mad
• 8:39
  at
• 8:39
  them.
• 8:39
  She
• 8:40
  just
• 8:40
  doesn't
• 8:40
  really
• 8:40
  feel
• 8:40
  the
• 8:41
  point
• 8:41
  of
• 8:41
  social
• 8:42
  interactions
• 8:43
  more
• 8:43
  broadly.
• 8:44
  And
• 8:45
  she
• 8:45
  denies
• 8:46
  any
• 8:46
  history
• 8:46
  of
• 8:46
  like
• 8:47
  intense
• 8:47
  quick
• 8:48
  relationships
• 8:48
  that
• 8:48
  form
• 8:49
  or
• 8:49
  romantic
• 8:50
  sparks
• 8:51
  and
• 8:51
  big
• 8:51
  romantic
• 8:51
  sparks
• 8:52
  in
• 8:52
  her
• 8:52
  relationships.
• 8:53
  She
• 8:53
  says
• 8:53
  she's
• 8:54
  never
• 8:54
  really
• 8:54
  fallen
• 8:54
  hard
• 8:55
  for
• 8:55
  anyone
• 8:56
  and
• 8:56
  her
• 8:56
  first
• 8:57
  relationship
• 8:57
  kind
• 8:58
  of
• 8:58
  ended
• 8:58
  cuz
• 8:58
  her
• 8:59
  boyfriend
• 8:59
  said
• 8:59
  like
• 9:00
  I'm
• 9:00
  dating
• 9:00
  a
• 9:00
  wall,
• 9:01
  okay.
• 9:01
  And
• 9:01
  she
• 9:02
  didn't
• 9:02
  really
• 9:02
  deny
• 9:02
  that.
• 9:03
  So
• 9:03
  this
• 9:04
  is
• 9:04
  really
• 9:04
  important,
• 9:04
  right?
• 9:06
  It's
• 9:06
  very
• 9:06
  important
• 9:07
  to
• 9:07
  ask
• 9:07
  your
• 9:07
  patients
• 9:08
  how
• 9:08
  are
• 9:08
  your
• 9:08
  relationships?
• 9:09
  How
• 9:09
  would
• 9:10
  you
• 9:10
  describe
• 9:10
  your
• 9:10
  relationships
• 9:11
  to
• 9:11
  me?
• 9:12
  How
• 9:12
  many
• 9:12
  serious
• 9:13
  relationships
• 9:13
  have
• 9:13
  you
• 9:14
  had
• 9:14
  in
• 9:14
  the
• 9:14
  past?
• 9:14
  How
• 9:15
  do
• 9:15
  you
• 9:15
  react
• 9:15
  when
• 9:16
  your
• 9:16
  relationships
• 9:17
  fail
• 9:17
  or
• 9:18
  when
• 9:18
  they
• 9:18
  don't
• 9:18
  go
• 9:18
  as
• 9:19
  planned?
• 9:19
  And
• 9:19
  my
• 9:20
  friends,
• 9:20
  this
• 9:20
  is
• 9:20
  a
• 9:20
  very
• 9:21
  good
• 9:21
  way
• 9:21
  to
• 9:21
  tease
• 9:22
  out
• 9:22
  PDD
• 9:23
  and
• 9:23
  BPD
• 9:25
  because
• 9:25
  the
• 9:25
  folks
• 9:26
  who
• 9:26
  have
• 9:27
  PDD
• 9:28
  are
• 9:28
  gonna
• 9:28
  again
• 9:28
  they're
• 9:29
  gonna
• 9:29
  be
• 9:29
  a
• 9:29
  little
• 9:29
  bit
• 9:30
  apathetic.
• 9:31
  Their
• 9:31
  relationships
• 9:32
  erode
• 9:33
  or
• 9:33
  crumble
• 9:33
  in
• 9:34
  I.
• 9:35
  What
• 9:35
  I
• 9:35
  understand
• 9:36
  as
• 9:37
  a
• 9:37
  kind
• 9:37
  of
• 9:38
  a
• 9:38
  slower.
• 9:38
  It's
• 9:39
  a,
• 9:39
  it's
• 9:39
  a
• 9:39
  slower
• 9:40
  fade,
• 9:41
  right?
• 9:41
  It's
• 9:41
  not
• 9:41
  this
• 9:42
  big
• 9:42
  theatrical
• 9:43
  breakup
• 9:44
  with
• 9:44
  idealization
• 9:45
  and
• 9:45
  devaluation.
• 9:46
  Devaluation
• 9:47
  that
• 9:47
  you
• 9:47
  hear
• 9:48
  where
• 9:48
  you
• 9:49
  know
• 9:49
  this,
• 9:49
  this
• 9:49
  per.
• 9:49
  This
• 9:50
  partner's
• 9:50
  amazing
• 9:51
  one
• 9:51
  minute
• 9:51
  and
• 9:51
  the
• 9:51
  worst
• 9:51
  person
• 9:52
  ever
• 9:52
  the
• 9:52
  next.
• 9:52
  That
• 9:52
  you'd
• 9:53
  kind
• 9:53
  of
• 9:53
  see
• 9:53
  more
• 9:53
  in
• 9:53
  bpd.
• 9:54
  It's
• 9:54
  this
• 9:55
  slow.
• 9:55
  I'm
• 9:56
  not
• 9:56
  really
• 9:56
  reaching
• 9:56
  out.
• 9:57
  I
• 9:57
  don't
• 9:57
  have
• 9:57
  a
• 9:57
  range
• 9:57
  of
• 9:58
  emotions
• 9:58
  and
• 9:59
  therefore
• 9:59
  I'm
• 9:59
  not
• 9:59
  building
• 10:00
  strong
• 10:00
  connections.
• 10:01
  That's
• 10:01
  pdd.
• 10:02
  That
• 10:02
  again,
• 10:03
  the
• 10:03
  lack
• 10:03
  of
• 10:03
  energy
• 10:04
  what
• 10:04
  animates
• 10:04
  PDD
• 10:05
  is
• 10:05
  just
• 10:05
  a
• 10:06
  lack
• 10:06
  of
• 10:06
  closeness
• 10:07
  because
• 10:07
  there's
• 10:07
  not
• 10:07
  a
• 10:07
  lot
• 10:07
  of
• 10:08
  energy,
• 10:08
  there's
• 10:08
  not
• 10:08
  a
• 10:08
  lot
• 10:09
  of
• 10:09
  pleasure.
• 10:09
  And.
• 10:10
  And
• 10:10
  you
• 10:10
  can
• 10:10
  imagine
• 10:10
  it's
• 10:11
  very
• 10:11
  hard
• 10:11
  to
• 10:11
  build
• 10:11
  a
• 10:11
  relationship
• 10:12
  when
• 10:13
  somebody
• 10:13
  is
• 10:14
  not.
• 10:14
  There's
• 10:14
  not
• 10:14
  a
• 10:14
  lot
• 10:15
  of
• 10:15
  energy
• 10:15
  or
• 10:15
  joy
• 10:16
  that's
• 10:17
  instilled
• 10:17
  in
• 10:17
  the
• 10:17
  relationship.
• 10:18
  Right.
• 10:18
  How
• 10:18
  are
• 10:18
  you
• 10:18
  going
• 10:19
  to
• 10:19
  share
• 10:19
  a
• 10:19
  good
• 10:19
  meal
• 10:19
  together
• 10:20
  when
• 10:20
  one
• 10:20
  person
• 10:21
  just
• 10:21
  feels
• 10:21
  emotionally
• 10:22
  flat
• 10:22
  and
• 10:23
  kind
• 10:23
  of
• 10:23
  detached
• 10:24
  for
• 10:24
  the
• 10:24
  entire
• 10:25
  time?
• 10:25
  Partners
• 10:26
  might
• 10:26
  describe
• 10:26
  them
• 10:27
  as
• 10:27
  distant
• 10:27
  or
• 10:27
  cold,
• 10:28
  and
• 10:29
  that
• 10:29
  can
• 10:30
  mimic
• 10:30
  the
• 10:30
  interpersonal
• 10:31
  dysfunction
• 10:31
  of
• 10:32
  bpd.
• 10:32
  But
• 10:33
  notice
• 10:33
  how
• 10:33
  the
• 10:34
  worm
• 10:34
  at
• 10:34
  the
• 10:34
  core,
• 10:35
  as
• 10:35
  I
• 10:35
  describe
• 10:35
  it,
• 10:36
  the
• 10:36
  worm
• 10:36
  at
• 10:36
  the
• 10:36
  core
• 10:37
  there
• 10:37
  is
• 10:37
  not
• 10:38
  a
• 10:38
  frantic,
• 10:40
  a
• 10:40
  means
• 10:40
  to
• 10:40
  frantically
• 10:41
  avoid
• 10:41
  abandonment
• 10:42
  like
• 10:42
  bpd.
• 10:43
  The
• 10:43
  worm
• 10:43
  at
• 10:44
  the
• 10:44
  core
• 10:44
  there
• 10:44
  is
• 10:44
  depression,
• 10:45
  right?
• 10:45
  This
• 10:45
  lack
• 10:46
  of
• 10:46
  emotional
• 10:46
  range
• 10:47
  and
• 10:47
  interest
• 10:48
  and
• 10:48
  motivation
• 10:48
  or
• 10:49
  joy
• 10:49
  in
• 10:49
  life
• 10:50
  that's
• 10:50
  making
• 10:50
  intimacy
• 10:51
  more
• 10:51
  difficult
• 10:52
  to
• 10:52
  obtain
• 10:52
  in
• 10:52
  the
• 10:52
  first
• 10:53
  place.
• 10:53
  Right.
• 10:54
  Do
• 10:54
  you
• 10:54
  see
• 10:54
  how
• 10:54
  that's
• 10:54
  qualitatively
• 10:55
  different
• 10:56
  than
• 10:56
  borderline
• 10:56
  personality
• 10:57
  disorder,
• 10:57
  where
• 10:58
  when
• 10:58
  a
• 10:58
  relationship
• 10:58
  erodes
• 10:59
  or
• 10:59
  if
• 10:59
  there's.
• 11:00
  If
• 11:00
  there's
• 11:00
  conflict
• 11:01
  or
• 11:01
  a
• 11:01
  breakup,
• 11:02
  that
• 11:02
  can
• 11:03
  manifest
• 11:03
  in
• 11:03
  really
• 11:04
  dramatic
• 11:04
  ways
• 11:05
  to
• 11:05
  avoid
• 11:07
  losing
• 11:07
  that
• 11:07
  partner?
• 11:08
  In
• 11:08
  other
• 11:08
  words,
• 11:08
  there's
• 11:09
  this.
• 11:09
  There's
• 11:10
  a
• 11:10
  ton
• 11:10
  of
• 11:10
  passion
• 11:11
  and
• 11:11
  verve
• 11:12
  and
• 11:12
  zest
• 11:13
  and.
• 11:13
  And
• 11:13
  that's
• 11:14
  very
• 11:14
  different
• 11:14
  than
• 11:15
  a
• 11:15
  distant,
• 11:15
  cold,
• 11:15
  kind
• 11:16
  of
• 11:16
  detached
• 11:16
  pdd.
• 11:17
  Right?
• 11:18
  And
• 11:19
  so
• 11:19
  be
• 11:20
  very
• 11:20
  careful
• 11:20
  if
• 11:21
  a
• 11:21
  patient
• 11:21
  has
• 11:21
  interpersonal
• 11:22
  dysfunction,
• 11:23
  because
• 11:23
  again,
• 11:23
  just
• 11:23
  like
• 11:24
  feeling
• 11:24
  empty,
• 11:25
  it's
• 11:25
  not
• 11:25
  enough
• 11:26
  to
• 11:26
  know
• 11:27
  why
• 11:28
  your
• 11:28
  patient
• 11:28
  has
• 11:29
  interpersonal
• 11:29
  dysfunction.
• 11:30
  You
• 11:30
  have
• 11:30
  to
• 11:31
  understand
• 11:31
  what
• 11:31
  is
• 11:31
  animating
• 11:32
  that
• 11:33
  dysfunction.
• 11:34
  Just
• 11:34
  like
• 11:34
  everything
• 11:34
  else
• 11:35
  in
• 11:35
  mental
• 11:35
  health,
• 11:35
  you
• 11:35
  have
• 11:36
  to
• 11:36
  go
• 11:36
  to
• 11:36
  the
• 11:36
  root.
• 11:37
  You
• 11:37
  cannot
• 11:37
  be
• 11:37
  satisfied
• 11:38
  with
• 11:38
  just
• 11:38
  superficial
• 11:39
  characterizations
• 11:41
  of
• 11:41
  how
• 11:41
  your
• 11:41
  patient's
• 11:42
  describing
• 11:42
  something
• 11:42
  or
• 11:43
  as
• 11:43
  you
• 11:43
  might
• 11:44
  encode
• 11:44
  something.
• 11:45
  Ask
• 11:45
  yourself
• 11:46
  what
• 11:46
  animates?
• 11:47
  What
• 11:47
  animates
• 11:48
  this
• 11:48
  at
• 11:48
  its
• 11:48
  core?
• 11:49
  Okay?
• 11:50
  And
• 11:50
  so
• 11:50
  relationship
• 11:51
  stability
• 11:52
  is
• 11:52
  one
• 11:52
  of
• 11:52
  the
• 11:52
  key
• 11:53
  ways
• 11:53
  you
• 11:53
  can
• 11:53
  differentiate
• 11:54
  PDD
• 11:55
  and
• 11:55
  bpd,
• 11:55
  Right?
• 11:56
  Mara
• 11:57
  sounds
• 11:58
  more
• 11:58
  emotionally
• 11:58
  unavailable,
• 11:59
  not
• 11:59
  unstable.
• 12:00
  And.
• 12:00
  And
• 12:00
  that's
• 12:01
  really
• 12:01
  the
• 12:01
  key.
• 12:02
  And
• 12:02
  with
• 12:02
  borderline
• 12:03
  personality,
• 12:04
  oftentimes
• 12:05
  you
• 12:05
  will
• 12:05
  see
• 12:05
  and
• 12:06
  hear,
• 12:06
  the
• 12:06
  patient
• 12:07
  will
• 12:07
  admit
• 12:07
  readily
• 12:08
  that
• 12:08
  their
• 12:08
  most
• 12:09
  chaotic
• 12:10
  and
• 12:10
  dysfunctional
• 12:11
  moments
• 12:12
  of
• 12:12
  their
• 12:12
  lives
• 12:13
  surround
• 12:14
  or
• 12:14
  orbit
• 12:14
  around
• 12:15
  the
• 12:16
  conclusion
• 12:17
  of
• 12:17
  a
• 12:17
  relationship
• 12:18
  or
• 12:18
  the.
• 12:19
  The.
• 12:19
  The
• 12:19
  perception
• 12:20
  that
• 12:20
  they
• 12:20
  are
• 12:21
  being
• 12:21
  rejected
• 12:22
  in
• 12:22
  some
• 12:22
  way.
• 12:23
  The
• 12:23
  breakups
• 12:23
  are
• 12:24
  intense,
• 12:24
  chaotic,
• 12:25
  and
• 12:26
  again,
• 12:26
  PDD
• 12:27
  has
• 12:27
  more
• 12:27
  of
• 12:27
  like
• 12:27
  this
• 12:28
  quiet
• 12:28
  erosion
• 12:29
  where
• 12:29
  the
• 12:29
  partner
• 12:30
  feels
• 12:30
  emotionally
• 12:31
  starved
• 12:31
  from
• 12:32
  them.
• 12:32
  So
• 12:32
  that's
• 12:32
  another
• 12:33
  big
• 12:33
  way
• 12:33
  we
• 12:33
  can
• 12:34
  differentiate
• 12:34
  it,
• 12:35
  right?
• 12:35
  Relationship
• 12:36
  stability.
• 12:37
  And
• 12:37
  what
• 12:37
  animates
• 12:38
  that?
• 12:39
  Okay,
• 12:39
  now
• 12:41
  let's
• 12:41
  say
• 12:41
  the
• 12:41
  next
• 12:41
  visit,
• 12:42
  Mara
• 12:42
  comes
• 12:42
  back.
• 12:43
  She's
• 12:43
  tearful.
• 12:43
  When
• 12:44
  she
• 12:44
  talks
• 12:44
  about
• 12:44
  her
• 12:44
  childhood,
• 12:45
  she
• 12:45
  is
• 12:45
  showing
• 12:46
  emotion.
• 12:46
  Her
• 12:46
  dad
• 12:47
  wasn't
• 12:47
  emotionally
• 12:47
  available.
• 12:48
  She
• 12:48
  says
• 12:48
  her
• 12:48
  mom
• 12:49
  was
• 12:49
  critical
• 12:49
  and
• 12:49
  unpredictable.
• 12:51
  She
• 12:51
  learned
• 12:51
  early
• 12:51
  that
• 12:52
  nobody
• 12:52
  cares.
• 12:52
  You
• 12:53
  just
• 12:53
  gotta
• 12:53
  power
• 12:53
  through
• 12:53
  it.
• 12:54
  She
• 12:54
  doesn't
• 12:54
  trust
• 12:55
  a
• 12:55
  lot
• 12:55
  of
• 12:55
  People.
• 12:56
  And
• 12:56
  sometimes
• 12:57
  she
• 12:57
  tests
• 12:57
  her
• 12:57
  boyfriend
• 12:58
  by
• 12:58
  withdrawing
• 12:59
  to
• 12:59
  see
• 12:59
  if
• 12:59
  he'll
• 12:59
  still
• 12:59
  pursue
• 13:00
  her.
• 13:01
  Now,
• 13:02
  she
• 13:02
  also
• 13:02
  says
• 13:02
  in
• 13:03
  college
• 13:03
  she
• 13:03
  went
• 13:03
  through
• 13:03
  a
• 13:04
  phase
• 13:04
  where
• 13:04
  she'd
• 13:04
  go
• 13:04
  home
• 13:05
  with
• 13:05
  guys
• 13:05
  that
• 13:05
  she
• 13:05
  didn't
• 13:06
  know.
• 13:06
  She
• 13:07
  really
• 13:07
  wasn't
• 13:08
  enjoying
• 13:08
  it,
• 13:09
  and
• 13:09
  she
• 13:09
  was
• 13:09
  just
• 13:09
  trying
• 13:10
  to
• 13:10
  feel
• 13:10
  something.
• 13:10
  She
• 13:11
  said
• 13:11
  anything
• 13:11
  at
• 13:11
  all.
• 13:12
  Maybe
• 13:12
  it
• 13:12
  lasted
• 13:13
  a
• 13:13
  semester,
• 13:13
  and
• 13:13
  then
• 13:14
  she
• 13:14
  just
• 13:14
  kind
• 13:14
  of
• 13:14
  stopped
• 13:15
  because
• 13:15
  it
• 13:15
  wasn't
• 13:15
  really
• 13:16
  working
• 13:16
  out.
• 13:16
  Okay.
• 13:17
  So
• 13:17
  she
• 13:18
  stopped
• 13:18
  going
• 13:18
  home
• 13:18
  with
• 13:19
  guys
• 13:19
  randomly.
• 13:20
  And
• 13:21
  she
• 13:21
  kind
• 13:21
  of
• 13:21
  adds
• 13:22
  a
• 13:22
  comment.
• 13:22
  And
• 13:22
  she
• 13:22
  says,
• 13:23
  I
• 13:23
  also
• 13:23
  used
• 13:23
  to
• 13:23
  scratch
• 13:24
  my
• 13:24
  arms
• 13:24
  when
• 13:24
  I
• 13:24
  was
• 13:25
  really
• 13:25
  stressed
• 13:25
  in
• 13:25
  high
• 13:26
  school.
• 13:26
  Not
• 13:26
  really
• 13:26
  deeply,
• 13:27
  but
• 13:27
  just
• 13:27
  to
• 13:27
  feel
• 13:28
  something.
• 13:28
  And
• 13:28
  she
• 13:29
  hasn't
• 13:29
  done
• 13:29
  it
• 13:29
  in
• 13:29
  over
• 13:30
  10
• 13:30
  years.
• 13:31
  Okay.
• 13:31
  She
• 13:31
  talks
• 13:31
  about
• 13:32
  some
• 13:32
  fights
• 13:32
  with
• 13:32
  her
• 13:32
  boyfriend,
• 13:33
  and
• 13:33
  then
• 13:34
  she
• 13:34
  gets
• 13:34
  into
• 13:34
  a
• 13:34
  flash
• 13:35
  of
• 13:35
  rage,
• 13:35
  like
• 13:36
  white
• 13:36
  hot
• 13:36
  rage,
• 13:37
  but
• 13:37
  she
• 13:37
  never
• 13:37
  really
• 13:38
  says
• 13:38
  anything.
• 13:38
  She
• 13:38
  just
• 13:39
  kind
• 13:39
  of
• 13:39
  goes
• 13:39
  quiet
• 13:39
  and
• 13:40
  leaves
• 13:40
  the
• 13:40
  room.
• 13:41
  She's
• 13:41
  scared
• 13:41
  about
• 13:42
  how
• 13:42
  she
• 13:42
  feels,
• 13:43
  but
• 13:43
  she
• 13:43
  kind
• 13:43
  of
• 13:43
  just
• 13:44
  shuts
• 13:44
  down.
• 13:45
  Now,
• 13:45
  this
• 13:45
  is
• 13:45
  challenging,
• 13:46
  my
• 13:46
  friends,
• 13:46
  because
• 13:46
  here
• 13:47
  you
• 13:47
  have
• 13:47
  a
• 13:47
  lot
• 13:47
  of
• 13:48
  big,
• 13:48
  flashy
• 13:48
  diagnostic
• 13:49
  red
• 13:49
  flags
• 13:50
  that
• 13:51
  genuinely
• 13:51
  look
• 13:51
  like
• 13:52
  borderline
• 13:52
  personality
• 13:53
  disorder
• 13:53
  and
• 13:54
  very
• 13:54
  well
• 13:54
  could
• 13:54
  be
• 13:55
  borderline
• 13:55
  traits,
• 13:56
  but
• 13:56
  they're
• 13:57
  not
• 13:57
  quite
• 13:58
  meeting
• 13:58
  that
• 13:59
  criteria
• 13:59
  either.
• 14:00
  Right.
• 14:01
  We
• 14:01
  have
• 14:01
  to
• 14:01
  remember
• 14:02
  that
• 14:02
  a
• 14:02
  lot
• 14:02
  of
• 14:02
  our
• 14:03
  patients
• 14:03
  who
• 14:03
  walk
• 14:03
  into
• 14:03
  our
• 14:04
  clinic
• 14:04
  have
• 14:04
  parent
• 14:04
  parents
• 14:05
  who
• 14:05
  are
• 14:05
  emotionally
• 14:06
  unavailable
• 14:06
  or
• 14:06
  critical
• 14:07
  or
• 14:07
  unpredictable.
• 14:08
  That
• 14:08
  can
• 14:09
  make
• 14:09
  people
• 14:09
  develop
• 14:10
  depressive
• 14:12
  disorders
• 14:12
  over
• 14:13
  time.
• 14:13
  Or
• 14:13
  BPD
• 14:14
  or
• 14:14
  anxiety
• 14:14
  and
• 14:15
  uncertainty
• 14:15
  with
• 14:15
  the
• 14:16
  world.
• 14:16
  Right.
• 14:17
  That
• 14:17
  can,
• 14:17
  depending
• 14:18
  on
• 14:18
  the
• 14:18
  exact
• 14:19
  past
• 14:20
  circumstances,
• 14:21
  relational
• 14:22
  trauma
• 14:23
  and
• 14:23
  just
• 14:23
  general
• 14:23
  avoidance.
• 14:24
  Right.
• 14:24
  That
• 14:24
  can
• 14:25
  just
• 14:25
  mess
• 14:25
  with
• 14:25
  our
• 14:26
  attachment
• 14:27
  styles
• 14:27
  more
• 14:27
  broadly.
• 14:28
  So
• 14:28
  we
• 14:28
  can't
• 14:28
  just
• 14:29
  put
• 14:29
  everyone
• 14:29
  into
• 14:30
  a
• 14:30
  category
• 14:31
  of
• 14:31
  BPD
• 14:32
  if
• 14:32
  their
• 14:32
  parents
• 14:32
  weren't
• 14:33
  available
• 14:33
  or
• 14:33
  predictable.
• 14:34
  So
• 14:34
  that
• 14:34
  can
• 14:34
  be
• 14:34
  a
• 14:34
  red
• 14:35
  herring
• 14:35
  a
• 14:35
  lot.
• 14:35
  You
• 14:35
  have
• 14:36
  to
• 14:36
  get
• 14:36
  more
• 14:36
  specific.
• 14:36
  Right.
• 14:37
  That's
• 14:37
  too
• 14:37
  broad.
• 14:38
  There's
• 14:38
  too
• 14:38
  much
• 14:38
  there.
• 14:39
  Okay.
• 14:40
  Now,
• 14:40
  this
• 14:40
  phase
• 14:41
  where
• 14:42
  she
• 14:42
  was
• 14:42
  trying
• 14:42
  to
• 14:42
  feel
• 14:43
  something
• 14:43
  in
• 14:43
  college
• 14:44
  and
• 14:45
  she
• 14:45
  started
• 14:45
  to
• 14:45
  go
• 14:45
  home
• 14:46
  with
• 14:46
  random
• 14:46
  people,
• 14:47
  that
• 14:47
  definitely
• 14:48
  raises
• 14:48
  some
• 14:48
  eyebrows.
• 14:49
  But
• 14:49
  again,
• 14:49
  my
• 14:50
  friends,
• 14:50
  don't
• 14:50
  get
• 14:50
  too
• 14:51
  caught
• 14:51
  into
• 14:52
  that
• 14:52
  bait
• 14:53
  because
• 14:53
  everyone
• 14:54
  in
• 14:54
  their
• 14:54
  lives
• 14:54
  has
• 14:55
  been
• 14:55
  impulsive
• 14:55
  at
• 14:56
  some
• 14:56
  point.
• 14:56
  And
• 14:57
  if
• 14:57
  we
• 14:57
  focus
• 14:57
  on
• 14:57
  that
• 14:58
  and
• 14:58
  take
• 14:58
  that
• 14:58
  to
• 14:58
  the
• 14:58
  bank
• 14:59
  too
• 14:59
  quickly,
• 14:59
  everyone
• 15:00
  can,
• 15:01
  can.
• 15:01
  Can
• 15:02
  be
• 15:02
  thought
• 15:02
  to
• 15:03
  have
• 15:03
  a
• 15:03
  BPD
• 15:04
  diagnosis.
• 15:05
  The
• 15:05
  question
• 15:05
  is,
• 15:06
  is
• 15:06
  this
• 15:06
  a
• 15:06
  pervasive,
• 15:07
  ingrained
• 15:07
  personality
• 15:08
  trait
• 15:09
  that
• 15:10
  is
• 15:10
  not
• 15:10
  really
• 15:10
  questioned
• 15:11
  by
• 15:11
  the
• 15:11
  patient
• 15:12
  very
• 15:12
  much?
• 15:12
  It
• 15:12
  just
• 15:12
  continues
• 15:13
  to
• 15:13
  happen.
• 15:14
  And
• 15:14
  she
• 15:14
  made
• 15:14
  it
• 15:14
  pretty
• 15:15
  clear.
• 15:15
  Mara
• 15:15
  made
• 15:16
  it
• 15:16
  pretty
• 15:16
  clear.
• 15:16
  This
• 15:16
  lasted
• 15:17
  about
• 15:17
  a
• 15:17
  semester
• 15:18
  and
• 15:18
  she
• 15:18
  did
• 15:18
  not
• 15:19
  enjoy
• 15:19
  it.
• 15:19
  She
• 15:20
  just
• 15:20
  wanted
• 15:20
  to
• 15:20
  feel
• 15:20
  something.
• 15:21
  And
• 15:21
  it
• 15:22
  was
• 15:22
  her
• 15:22
  way
• 15:22
  of,
• 15:22
  I
• 15:23
  think
• 15:23
  it
• 15:23
  looks
• 15:23
  like
• 15:24
  not
• 15:24
  being
• 15:24
  depressed.
• 15:25
  Right.
• 15:25
  This
• 15:25
  is
• 15:25
  not
• 15:25
  A
• 15:26
  pervasive
• 15:26
  personality
• 15:27
  trait
• 15:27
  that
• 15:27
  continues
• 15:28
  to
• 15:28
  bring
• 15:28
  her
• 15:28
  to
• 15:28
  therapy.
• 15:29
  Neither
• 15:29
  is
• 15:30
  scratching
• 15:30
  her
• 15:30
  arm.
• 15:31
  She
• 15:31
  said
• 15:31
  it.
• 15:31
  She
• 15:32
  was
• 15:33
  really
• 15:33
  stressed
• 15:33
  in
• 15:33
  high
• 15:34
  school.
• 15:34
  Well,
• 15:34
  that's
• 15:34
  not
• 15:35
  enough
• 15:35
  to
• 15:36
  satisfy
• 15:37
  the
• 15:37
  BPD
• 15:38
  criterion.
• 15:40
  It's
• 15:40
  just
• 15:40
  not
• 15:40
  right.
• 15:40
  You
• 15:41
  scratched
• 15:41
  yourself
• 15:42
  one
• 15:42
  time
• 15:42
  and
• 15:43
  it
• 15:43
  was
• 15:43
  an
• 15:43
  isolated
• 15:44
  issue.
• 15:45
  That's
• 15:46
  not
• 15:46
  really
• 15:47
  good
• 15:48
  enough.
• 15:49
  So
• 15:49
  the
• 15:49
  impulsivity
• 15:50
  has
• 15:50
  to
• 15:50
  exist
• 15:51
  in
• 15:51
  greater
• 15:52
  or
• 15:52
  equal
• 15:52
  to
• 15:52
  two
• 15:53
  areas.
• 15:53
  And
• 15:53
  she
• 15:54
  had.
• 15:54
  Well,
• 15:55
  actually
• 15:56
  in
• 15:56
  self
• 15:56
  harm
• 15:57
  as
• 15:57
  well
• 15:57
  is
• 15:58
  criterion
• 15:58
  five.
• 15:59
  So
• 15:59
  there's
• 15:59
  criterion
• 15:59
  five,
• 16:00
  that's
• 16:00
  recurrent
• 16:01
  self
• 16:01
  harm
• 16:01
  and
• 16:02
  suicidality.
• 16:02
  Criterion
• 16:03
  four
• 16:03
  is
• 16:03
  impulsivity
• 16:04
  in
• 16:04
  two
• 16:04
  areas.
• 16:05
  Well,
• 16:06
  here
• 16:06
  she
• 16:06
  was
• 16:06
  impulsive
• 16:07
  by
• 16:07
  going
• 16:08
  home
• 16:08
  with
• 16:08
  folks
• 16:08
  in
• 16:09
  one
• 16:09
  area
• 16:09
  and
• 16:10
  it
• 16:10
  was
• 16:10
  time
• 16:10
  limited.
• 16:10
  It
• 16:11
  was
• 16:11
  not
• 16:11
  a
• 16:12
  broader
• 16:12
  part
• 16:12
  of
• 16:13
  her
• 16:13
  personality.
• 16:13
  We're
• 16:14
  wondering,
• 16:14
  is
• 16:14
  this
• 16:14
  a
• 16:14
  trait
• 16:15
  or
• 16:15
  a
• 16:15
  state?
• 16:16
  Best
• 16:16
  way
• 16:16
  you
• 16:16
  can
• 16:17
  ever
• 16:17
  differentiate
• 16:17
  something
• 16:18
  like
• 16:19
  a
• 16:19
  BPD
• 16:19
  and
• 16:20
  a
• 16:20
  mood
• 16:20
  disorder
• 16:20
  or
• 16:21
  like
• 16:21
  bipolar.
• 16:21
  Right.
• 16:22
  Is
• 16:22
  it
• 16:22
  a
• 16:22
  trait
• 16:23
  or
• 16:23
  is
• 16:23
  it
• 16:23
  a
• 16:23
  state?
• 16:25
  Okay.
• 16:25
  And
• 16:26
  clearly
• 16:26
  she
• 16:27
  went
• 16:27
  home
• 16:27
  with
• 16:28
  people
• 16:28
  for
• 16:29
  a
• 16:29
  semester.
• 16:29
  It
• 16:30
  was
• 16:30
  a
• 16:30
  phase.
• 16:30
  It
• 16:30
  is
• 16:30
  not
• 16:31
  an
• 16:31
  ingrained
• 16:31
  personality
• 16:32
  behavior
• 16:32
  or
• 16:32
  traitor.
• 16:33
  So
• 16:33
  that
• 16:34
  sounds
• 16:34
  more
• 16:34
  like
• 16:34
  a
• 16:34
  state.
• 16:35
  She
• 16:35
  was
• 16:35
  in
• 16:35
  a
• 16:35
  state
• 16:35
  of
• 16:36
  depression.
• 16:36
  She
• 16:36
  tried
• 16:36
  to
• 16:36
  feel
• 16:37
  something.
• 16:37
  She
• 16:37
  was
• 16:38
  super
• 16:38
  stressed
• 16:38
  in
• 16:38
  high
• 16:38
  school,
• 16:39
  so
• 16:39
  she
• 16:39
  scratched
• 16:39
  herself.
• 16:40
  Does
• 16:40
  she
• 16:40
  scratch
• 16:41
  herself
• 16:41
  all
• 16:42
  of
• 16:42
  the
• 16:42
  time
• 16:42
  or
• 16:42
  frequently
• 16:43
  when
• 16:43
  she
• 16:44
  feels
• 16:44
  dysregulated
• 16:45
  as
• 16:45
  attempt
• 16:45
  to
• 16:45
  regulate
• 16:46
  herself?
• 16:46
  If
• 16:47
  she
• 16:47
  did,
• 16:48
  that
• 16:48
  would
• 16:48
  satisfy
• 16:49
  the
• 16:50
  reoccurrent
• 16:51
  suicidal
• 16:51
  gestures
• 16:52
  or
• 16:52
  self
• 16:52
  harmful
• 16:53
  gestures
• 16:53
  in
• 16:53
  bpd.
• 16:54
  This
• 16:54
  is
• 16:54
  isolated.
• 16:55
  So
• 16:56
  again,
• 16:56
  very
• 16:56
  important
• 16:57
  distinction
• 16:58
  there.
• 16:58
  Right.
• 16:59
  It
• 16:59
  clearly
• 17:00
  says
• 17:00
  in
• 17:00
  criterion
• 17:01
  five
• 17:01
  for
• 17:01
  BPD
• 17:02
  reoccurrent
• 17:03
  self
• 17:03
  harm.
• 17:04
  So
• 17:04
  a
• 17:04
  time
• 17:04
  limited
• 17:05
  adolescent
• 17:06
  moment
• 17:06
  of
• 17:06
  extreme
• 17:07
  frustration
• 17:07
  and
• 17:08
  despair
• 17:08
  does
• 17:09
  not
• 17:09
  necessarily
• 17:10
  mean
• 17:10
  that
• 17:11
  your
• 17:11
  patient
• 17:11
  has
• 17:11
  bpd.
• 17:12
  And
• 17:12
  yet
• 17:13
  it
• 17:13
  is
• 17:13
  encoded
• 17:13
  in
• 17:14
  our
• 17:14
  minds
• 17:14
  when
• 17:14
  we
• 17:15
  see
• 17:15
  it
• 17:15
  in
• 17:15
  a
• 17:15
  chart.
• 17:16
  Oh,
• 17:16
  this
• 17:16
  is
• 17:16
  self
• 17:17
  harm.
• 17:17
  That
• 17:18
  it's.
• 17:18
  It
• 17:19
  almost
• 17:19
  like
• 17:19
  a
• 17:20
  heat
• 17:20
  seeking
• 17:20
  missile
• 17:21
  goes
• 17:21
  to
• 17:21
  bpd.
• 17:21
  It's
• 17:22
  not
• 17:22
  quite
• 17:22
  the
• 17:22
  same.
• 17:23
  Right.
• 17:23
  It's
• 17:24
  just
• 17:24
  not.
• 17:24
  And
• 17:24
  it
• 17:25
  can
• 17:25
  really
• 17:25
  be
• 17:25
  something
• 17:26
  that
• 17:26
  leads
• 17:26
  us
• 17:26
  astray
• 17:27
  and
• 17:27
  puts
• 17:28
  people
• 17:28
  in
• 17:28
  a
• 17:28
  box
• 17:29
  really
• 17:29
  too
• 17:29
  much
• 17:29
  too
• 17:30
  quickly.
• 17:30
  So
• 17:30
  we
• 17:30
  really
• 17:31
  have
• 17:31
  to
• 17:31
  think
• 17:31
  twice
• 17:31
  about
• 17:32
  that.
• 17:32
  Right.
• 17:33
  When
• 17:33
  she
• 17:33
  talked
• 17:33
  about
• 17:33
  being
• 17:34
  Ray
• 17:34
  in
• 17:34
  a.
• 17:35
  In
• 17:35
  a
• 17:35
  flash
• 17:35
  of
• 17:35
  rage,
• 17:36
  of
• 17:36
  course.
• 17:37
  Another
• 17:37
  red
• 17:37
  herring.
• 17:38
  Right?
• 17:38
  It
• 17:38
  looks
• 17:38
  a
• 17:39
  lot
• 17:39
  like
• 17:40
  bpd.
• 17:41
  Okay.
• 17:42
  Because
• 17:42
  there's
• 17:43
  that
• 17:43
  white
• 17:43
  hot
• 17:44
  rage.
• 17:45
  However,
• 17:46
  Mara
• 17:46
  suppressed
• 17:47
  that
• 17:47
  rage.
• 17:47
  Right.
• 17:47
  She
• 17:48
  didn't
• 17:48
  really
• 17:48
  act
• 17:48
  on
• 17:49
  it.
• 17:49
  And
• 17:49
  in
• 17:49
  bpd,
• 17:50
  it's
• 17:51
  normally
• 17:51
  criterion
• 17:52
  eight.
• 17:52
  Right.
• 17:52
  Inappropriate
• 17:53
  intense
• 17:54
  anger
• 17:54
  or
• 17:55
  difficulty
• 17:55
  controlling
• 17:56
  anger.
• 17:56
  So
• 17:56
  these
• 17:56
  are
• 17:56
  like
• 17:57
  displays
• 17:58
  of
• 17:58
  temper,
• 17:58
  Constant
• 17:59
  anger.
• 17:59
  It's
• 17:59
  a
• 17:59
  trait.
• 18:00
  Reoccurring
• 18:00
  fights,
• 18:00
  Reoccurring
• 18:01
  interpersonal
• 18:02
  insta.
• 18:03
  Relationship
• 18:03
  instability.
• 18:04
  Right.
• 18:05
  As
• 18:05
  opposed
• 18:05
  to
• 18:05
  Mara
• 18:06
  here,
• 18:06
  whose
• 18:07
  anger
• 18:07
  sounds
• 18:07
  much
• 18:08
  more
• 18:08
  internalized,
• 18:09
  it's
• 18:09
  much
• 18:09
  more
• 18:09
  controlled.
• 18:10
  She
• 18:10
  doesn't
• 18:10
  externalize
• 18:11
  it.
• 18:11
  She
• 18:11
  doesn't
• 18:11
  dysregulate
• 18:12
  as
• 18:12
  much.
• 18:13
  Mara
• 18:13
  already
• 18:14
  said
• 18:14
  she
• 18:14
  doesn't
• 18:14
  really
• 18:14
  reach
• 18:15
  out
• 18:15
  to
• 18:15
  people.
• 18:15
  It's
• 18:15
  not
• 18:16
  that
• 18:16
  they're
• 18:16
  unstable.
• 18:17
  It's
• 18:17
  not
• 18:17
  that
• 18:17
  she
• 18:17
  has
• 18:18
  relationships
• 18:18
  that
• 18:18
  are
• 18:18
  volcanic
• 18:19
  and
• 18:19
  implode.
• 18:20
  She
• 18:20
  just
• 18:20
  doesn't
• 18:21
  even
• 18:21
  take
• 18:21
  the
• 18:21
  initiative
• 18:22
  to
• 18:22
  begin
• 18:22
  with.
• 18:22
  And
• 18:22
  again,
• 18:23
  if
• 18:23
  you
• 18:23
  get
• 18:23
  to
• 18:24
  the
• 18:24
  core
• 18:24
  of
• 18:24
  the
• 18:24
  problem
• 18:25
  in
• 18:25
  forming
• 18:26
  relationships
• 18:26
  for
• 18:26
  her,
• 18:27
  she's
• 18:27
  not
• 18:27
  engaged
• 18:28
  enough
• 18:29
  with
• 18:29
  bpd.
• 18:30
  There's
• 18:30
  this
• 18:30
  super
• 18:31
  engagement
• 18:31
  at
• 18:31
  times,
• 18:32
  this
• 18:32
  super
• 18:32
  devotion,
• 18:33
  and
• 18:33
  this
• 18:33
  super
• 18:34
  dramatic
• 18:35
  display
• 18:36
  when
• 18:36
  relationships
• 18:37
  don't
• 18:37
  go
• 18:37
  well.
• 18:38
  Because
• 18:38
  again,
• 18:38
  at
• 18:38
  the
• 18:39
  core
• 18:39
  of
• 18:40
  BPD
• 18:40
  is
• 18:40
  the
• 18:41
  frantic
• 18:41
  avoidance
• 18:42
  of
• 18:42
  abandonment.
• 18:43
  That
• 18:43
  is
• 18:44
  the
• 18:44
  key,
• 18:44
  right?
• 18:44
  And
• 18:45
  so
• 18:45
  we
• 18:45
  always
• 18:45
  have
• 18:45
  to
• 18:46
  remember
• 18:46
  what
• 18:46
  is
• 18:46
  the
• 18:46
  center
• 18:47
  of
• 18:47
  gravity
• 18:47
  of
• 18:48
  what
• 18:48
  we're
• 18:48
  looking
• 18:48
  at?
• 18:48
  Depression.
• 18:49
  It's
• 18:49
  this,
• 18:50
  what's
• 18:50
  the
• 18:50
  point
• 18:50
  of
• 18:51
  everything?
• 18:51
  Because
• 18:51
  I'm
• 18:51
  not
• 18:51
  in
• 18:51
  the
• 18:52
  mood
• 18:52
  and
• 18:52
  I
• 18:52
  don't
• 18:52
  enjoy
• 18:53
  anything.
• 18:53
  With
• 18:53
  bpd,
• 18:54
  it's,
• 18:54
  I
• 18:54
  cannot
• 18:55
  be
• 18:55
  abandoned
• 18:56
  or
• 18:56
  betrayed.
• 18:57
  I
• 18:57
  will
• 18:57
  do
• 18:58
  everything
• 18:58
  possible
• 18:58
  to
• 18:59
  not
• 18:59
  feel
• 18:59
  this
• 19:00
  empty
• 19:00
  or
• 19:00
  feel
• 19:01
  betrayed.
• 19:01
  Right?
• 19:02
  Qualitatively
• 19:03
  different
• 19:04
  situations.
• 19:05
  And
• 19:05
  so
• 19:06
  don't
• 19:06
  be
• 19:07
  thrown
• 19:07
  by
• 19:08
  the
• 19:08
  red
• 19:09
  herring.
• 19:09
  Child
• 19:10
  adversity,
• 19:11
  it's,
• 19:12
  you
• 19:12
  know,
• 19:12
  especially
• 19:13
  neglect.
• 19:13
  It's
• 19:13
  strongly
• 19:14
  associated
• 19:14
  with
• 19:15
  bpd,
• 19:15
  but
• 19:15
  also
• 19:15
  chronic
• 19:16
  depression.
• 19:17
  So
• 19:18
  it's
• 19:18
  not
• 19:18
  this
• 19:19
  automatic
• 19:20
  assumption
• 19:20
  that
• 19:21
  because
• 19:21
  she
• 19:21
  had
• 19:21
  childhood
• 19:22
  neglect
• 19:22
  and
• 19:22
  unstable
• 19:23
  caregivers
• 19:23
  that
• 19:24
  she
• 19:24
  has
• 19:24
  some
• 19:24
  borderline
• 19:25
  personality
• 19:25
  disorder.
• 19:26
  It
• 19:26
  very
• 19:27
  well
• 19:27
  may
• 19:27
  not
• 19:28
  be
• 19:28
  the
• 19:28
  case.
• 19:29
  Okay,
• 19:30
  and
• 19:30
  remember
• 19:31
  again
• 19:31
  that
• 19:32
  the
• 19:33
  in
• 19:33
  BPD
• 19:34
  impulsive
• 19:34
  behavior,
• 19:35
  it
• 19:35
  tends
• 19:36
  to
• 19:36
  be
• 19:36
  reoccurrent.
• 19:37
  It
• 19:37
  tends
• 19:37
  to
• 19:37
  span
• 19:38
  multiple
• 19:38
  domains,
• 19:39
  and
• 19:40
  it
• 19:40
  is
• 19:40
  often
• 19:40
  as
• 19:41
  a
• 19:41
  result,
• 19:41
  to
• 19:42
  kind
• 19:42
  of
• 19:43
  address
• 19:43
  that.
• 19:44
  That
• 19:44
  inner
• 19:44
  void,
• 19:45
  that
• 19:45
  emptiness
• 19:46
  or
• 19:47
  maybe
• 19:47
  even
• 19:47
  the.
• 19:48
  The
• 19:49
  abandonment
• 19:49
  that's
• 19:50
  happening.
• 19:50
  The
• 19:51
  impulsive
• 19:51
  behavior
• 19:52
  is
• 19:52
  a
• 19:52
  means
• 19:52
  to
• 19:52
  escape
• 19:53
  that
• 19:54
  and
• 19:54
  to
• 19:54
  kind
• 19:55
  of
• 19:55
  cope
• 19:55
  with
• 19:55
  that.
• 19:56
  So
• 19:56
  always
• 19:56
  ask,
• 19:56
  what
• 19:57
  is
• 19:57
  animating
• 19:58
  this
• 19:58
  impulsivity
• 19:59
  right
• 19:59
  now?
• 19:59
  Is
• 19:59
  it
• 20:00
  to
• 20:00
  feel
• 20:00
  something
• 20:00
  because
• 20:01
  you're
• 20:01
  so
• 20:01
  depressed
• 20:01
  and
• 20:02
  down
• 20:03
  and
• 20:03
  you
• 20:03
  just
• 20:03
  want
• 20:03
  to
• 20:04
  feel,
• 20:04
  or
• 20:05
  is
• 20:05
  this
• 20:05
  because
• 20:05
  you
• 20:05
  are
• 20:06
  reeling
• 20:06
  from
• 20:06
  a
• 20:06
  breakup
• 20:07
  and
• 20:07
  you
• 20:07
  don't
• 20:07
  know
• 20:07
  how
• 20:07
  to
• 20:07
  express
• 20:08
  your
• 20:08
  rage
• 20:08
  in
• 20:08
  any
• 20:09
  other
• 20:09
  way?
• 20:10
  You've
• 20:10
  got
• 20:10
  to
• 20:10
  ask
• 20:10
  the
• 20:11
  patient
• 20:11
  whether
• 20:11
  it's
• 20:11
  sleep
• 20:12
  or
• 20:12
  impulsivity,
• 20:13
  self
• 20:13
  harm.
• 20:14
  You've
• 20:15
  got
• 20:15
  to
• 20:15
  ask
• 20:15
  them
• 20:16
  what
• 20:16
  the
• 20:17
  root
• 20:17
  of
• 20:17
  that
• 20:17
  behavior
• 20:18
  is,
• 20:18
  and
• 20:18
  you
• 20:19
  will
• 20:19
  get
• 20:19
  really
• 20:19
  rich
• 20:20
  answers
• 20:21
  from
• 20:21
  them.
• 20:22
  Now
• 20:23
  with
• 20:24
  bpd,
• 20:25
  okay,
• 20:27
  the
• 20:27
  mental
• 20:27
  status
• 20:28
  exam
• 20:28
  is
• 20:28
  really
• 20:29
  important
• 20:29
  to
• 20:29
  kind
• 20:29
  of
• 20:29
  parse
• 20:30
  out
• 20:30
  the
• 20:30
  difference
• 20:30
  between
• 20:31
  BPD
• 20:31
  and
• 20:31
  pdd.
• 20:32
  Okay?
• 20:33
  When
• 20:34
  we
• 20:34
  ask
• 20:34
  Mara,
• 20:34
  she
• 20:35
  says
• 20:35
  her
• 20:35
  mood
• 20:35
  is
• 20:35
  really
• 20:35
  blah.
• 20:36
  Same
• 20:36
  as
• 20:36
  always,
• 20:38
  right?
• 20:38
  When
• 20:38
  we
• 20:39
  Think
• 20:39
  about
• 20:39
  when
• 20:39
  we.
• 20:39
  When
• 20:40
  we
• 20:40
  take
• 20:40
  note
• 20:41
  on
• 20:41
  her
• 20:41
  thoughts.
• 20:41
  She's
• 20:42
  just
• 20:42
  sort
• 20:42
  of
• 20:42
  hopeless.
• 20:43
  What's
• 20:43
  the
• 20:43
  point?
• 20:44
  Okay,
• 20:45
  she
• 20:45
  has
• 20:45
  fantasies
• 20:46
  of
• 20:46
  just
• 20:46
  starting
• 20:46
  over.
• 20:47
  But
• 20:47
  these
• 20:48
  are
• 20:48
  fantasies.
• 20:48
  They're
• 20:49
  passive,
• 20:49
  right?
• 20:50
  In
• 20:50
  BPD
• 20:51
  they're
• 20:51
  more
• 20:51
  active.
• 20:52
  They're
• 20:52
  changing
• 20:52
  their
• 20:53
  hairstyle.
• 20:53
  Maybe
• 20:54
  they're
• 20:54
  trying
• 20:54
  a
• 20:54
  whole
• 20:54
  new
• 20:55
  group
• 20:55
  of
• 20:55
  friends.
• 20:56
  They're
• 20:57
  changing
• 20:57
  things
• 20:58
  radically
• 20:59
  to
• 21:00
  adjust
• 21:00
  to
• 21:01
  the
• 21:01
  moment,
• 21:01
  to
• 21:01
  not
• 21:01
  feel
• 21:02
  that
• 21:02
  void,
• 21:03
  to
• 21:03
  avoid
• 21:03
  abandonment,
• 21:04
  period.
• 21:05
  And
• 21:05
  again,
• 21:06
  with
• 21:06
  depression,
• 21:06
  you
• 21:07
  have
• 21:07
  this
• 21:07
  gray,
• 21:08
  blah,
• 21:08
  constricted,
• 21:10
  longitudinally
• 21:12
  apathetic
• 21:14
  kind
• 21:14
  of
• 21:15
  low
• 21:15
  energy
• 21:16
  mood
• 21:16
  state,
• 21:17
  right?
• 21:17
  It's
• 21:18
  blah.
• 21:18
  It's
• 21:18
  in
• 21:19
  many
• 21:19
  ways
• 21:19
  the
• 21:19
  opposite
• 21:20
  of
• 21:20
  bpd,
• 21:21
  Even
• 21:21
  though
• 21:21
  it
• 21:21
  looks
• 21:21
  so
• 21:22
  similar
• 21:22
  when
• 21:23
  a
• 21:23
  patient
• 21:23
  is
• 21:23
  complaining
• 21:24
  of
• 21:24
  being
• 21:24
  empty
• 21:24
  all
• 21:25
  the
• 21:25
  time.
• 21:25
  And
• 21:25
  one
• 21:26
  of
• 21:26
  the
• 21:26
  reasons
• 21:26
  this
• 21:26
  gets
• 21:26
  so
• 21:27
  tricky
• 21:27
  is
• 21:27
  because
• 21:27
  both
• 21:28
  bd,
• 21:28
  Both
• 21:29
  P.
• 21:30
  PDD
• 21:30
  and
• 21:31
  BPD
• 21:31
  are
• 21:32
  like
• 21:32
  longitudinal.
• 21:33
  They're
• 21:33
  almost
• 21:33
  traits,
• 21:34
  right?
• 21:34
  With
• 21:35
  an
• 21:35
  MDD
• 21:36
  recurrent,
• 21:36
  moderate
• 21:37
  or
• 21:37
  something,
• 21:37
  right?
• 21:37
  Major
• 21:38
  depressive
• 21:38
  disorder,
• 21:38
  recurrent,
• 21:39
  moderate.
• 21:40
  It's
• 21:40
  pretty
• 21:40
  clear
• 21:41
  to
• 21:41
  the
• 21:41
  patient
• 21:42
  that
• 21:42
  they
• 21:43
  have
• 21:43
  cycles
• 21:43
  where
• 21:43
  they're
• 21:43
  depressed
• 21:44
  and
• 21:44
  they
• 21:44
  have
• 21:44
  cycles
• 21:45
  where
• 21:45
  they're
• 21:45
  enjoying
• 21:45
  art
• 21:46
  again
• 21:46
  or
• 21:47
  working
• 21:47
  on
• 21:47
  cars
• 21:48
  or
• 21:48
  cutting
• 21:48
  hair,
• 21:49
  right?
• 21:49
  That
• 21:50
  it
• 21:50
  just,
• 21:50
  it
• 21:50
  goes
• 21:50
  away
• 21:51
  and
• 21:51
  they
• 21:51
  know
• 21:51
  who
• 21:52
  they
• 21:52
  are
• 21:53
  separate
• 21:53
  from
• 21:53
  their
• 21:54
  cyclical
• 21:54
  depressive
• 21:55
  episodes.
• 21:55
  That's
• 21:55
  not
• 21:56
  the
• 21:56
  case
• 21:56
  with
• 21:56
  pdd.
• 21:57
  Those
• 21:57
  folks
• 21:57
  are
• 21:58
  typically.
• 21:58
  It's
• 21:58
  a
• 21:58
  lot
• 21:58
  harder
• 21:59
  for
• 21:59
  them
• 21:59
  to
• 21:59
  differentiate
• 22:00
  between
• 22:02
  their
• 22:02
  depression
• 22:02
  and
• 22:03
  who
• 22:03
  they
• 22:03
  actually
• 22:03
  are.
• 22:04
  Which
• 22:04
  makes
• 22:04
  you
• 22:05
  even
• 22:05
  more
• 22:05
  confused
• 22:06
  because
• 22:06
  now
• 22:07
  you're
• 22:07
  like,
• 22:07
  wait
• 22:07
  a
• 22:07
  minute,
• 22:07
  is
• 22:07
  this
• 22:08
  a
• 22:08
  personality
• 22:08
  trait?
• 22:09
  And
• 22:09
  if
• 22:09
  it
• 22:09
  is,
• 22:10
  if
• 22:10
  it's
• 22:10
  so
• 22:10
  ingrained
• 22:11
  that
• 22:11
  they
• 22:11
  just
• 22:11
  feel
• 22:11
  this
• 22:11
  is
• 22:12
  who
• 22:12
  they
• 22:12
  are,
• 22:12
  maybe
• 22:13
  I
• 22:13
  am
• 22:13
  looking
• 22:13
  at
• 22:14
  a
• 22:14
  personality
• 22:14
  disturbance
• 22:15
  and
• 22:15
  not
• 22:15
  a
• 22:15
  mood
• 22:15
  disturbance.
• 22:16
  And
• 22:16
  so
• 22:17
  it's
• 22:18
  really
• 22:18
  important
• 22:18
  to
• 22:19
  do
• 22:19
  a
• 22:19
  good
• 22:19
  mental
• 22:20
  status
• 22:20
  examination
• 22:21
  on
• 22:21
  them
• 22:22
  to
• 22:22
  just
• 22:22
  make
• 22:23
  sure
• 22:24
  that,
• 22:24
  you
• 22:25
  know,
• 22:25
  you
• 22:25
  can,
• 22:25
  you
• 22:26
  can
• 22:26
  assess
• 22:26
  the
• 22:26
  difference.
• 22:27
  And
• 22:27
  the
• 22:27
  affect
• 22:27
  is
• 22:28
  very
• 22:28
  important
• 22:28
  too,
• 22:29
  right?
• 22:29
  The
• 22:29
  constricted
• 22:30
  affect.
• 22:31
  No
• 22:31
  rapid
• 22:31
  effective
• 22:32
  shifts
• 22:32
  in
• 22:33
  pdd,
• 22:34
  sometimes
• 22:35
  in
• 22:35
  B
• 22:35
  BPD
• 22:36
  depending
• 22:36
  on
• 22:37
  the
• 22:37
  level
• 22:37
  of
• 22:38
  distress.
• 22:38
  They
• 22:38
  come
• 22:38
  to
• 22:38
  your
• 22:39
  office
• 22:39
  and
• 22:39
  you
• 22:39
  will
• 22:39
  see
• 22:40
  a
• 22:40
  much
• 22:40
  more
• 22:40
  labile
• 22:41
  affect,
• 22:42
  right?
• 22:42
  But
• 22:42
  definitely
• 22:43
  look
• 22:43
  at
• 22:43
  affect
• 22:44
  and
• 22:44
  affect
• 22:44
  is
• 22:45
  a
• 22:45
  clue
• 22:45
  if
• 22:46
  that
• 22:46
  person
• 22:46
  is
• 22:46
  really
• 22:47
  constricted
• 22:47
  in
• 22:48
  gray
• 22:48
  and
• 22:49
  kind
• 22:49
  of
• 22:49
  blah
• 22:49
  and
• 22:49
  not
• 22:50
  reactive
• 22:50
  to
• 22:50
  anything.
• 22:51
  That's
• 22:51
  my
• 22:51
  clue.
• 22:52
  Like
• 22:52
  this.
• 22:52
  This
• 22:53
  has
• 22:53
  kind
• 22:53
  of
• 22:53
  a
• 22:53
  gloomy
• 22:54
  dark
• 22:54
  clouds
• 22:55
  in
• 22:55
  the
• 22:55
  sky.
• 22:55
  It's
• 22:56
  this
• 22:56
  really
• 22:56
  consistently
• 22:57
  gray,
• 22:58
  cloudy.
• 22:59
  Why
• 22:59
  even
• 22:59
  go
• 22:59
  outside
• 23:00
  today,
• 23:00
  right?
• 23:01
  As
• 23:01
  opposed
• 23:02
  to
• 23:02
  let's
• 23:03
  go
• 23:03
  do
• 23:03
  backflips,
• 23:04
  buy
• 23:04
  that
• 23:05
  pot
• 23:05
  of
• 23:05
  gold
• 23:06
  near
• 23:06
  the
• 23:06
  rainbow
• 23:07
  and
• 23:08
  then
• 23:08
  enjoy
• 23:09
  a
• 23:09
  thunderstorm
• 23:10
  and
• 23:10
  a
• 23:10
  tornado,
• 23:10
  right?
• 23:11
  It's
• 23:11
  just
• 23:11
  different.
• 23:12
  It's
• 23:12
  a
• 23:12
  different
• 23:12
  emotional
• 23:13
  tone.
• 23:13
  That
• 23:13
  you
• 23:13
  can
• 23:14
  pick
• 23:14
  up
• 23:14
  on
• 23:15
  without
• 23:15
  words
• 23:15
  or
• 23:16
  without
• 23:16
  as
• 23:16
  many
• 23:16
  words.
• 23:17
  Okay,
• 23:19
  so
• 23:19
  those
• 23:19
  are
• 23:20
  just
• 23:20
  other
• 23:20
  ways
• 23:21
  to
• 23:21
  kind
• 23:22
  of
• 23:22
  look
• 23:22
  at
• 23:22
  this
• 23:23
  self
• 23:23
  harm.
• 23:24
  Again
• 23:24
  it.
• 23:25
  You've
• 23:25
  got
• 23:25
  to
• 23:25
  hunt
• 23:25
  for
• 23:26
  the
• 23:26
  reoccurring
• 23:26
  suicidal
• 23:27
  behaviors,
• 23:27
  gestures
• 23:28
  or
• 23:28
  threats.
• 23:29
  It's
• 23:29
  not
• 23:29
  enough
• 23:29
  to
• 23:30
  just
• 23:30
  take
• 23:30
  a
• 23:30
  one
• 23:30
  off
• 23:31
  and
• 23:31
  assume
• 23:32
  somebody
• 23:32
  has
• 23:32
  bpd.
• 23:33
  But
• 23:34
  in
• 23:34
  Mara's
• 23:35
  case,
• 23:35
  I
• 23:35
  think
• 23:36
  it's
• 23:36
  fair
• 23:36
  to
• 23:36
  say
• 23:36
  she
• 23:37
  has
• 23:37
  pdd.
• 23:38
  And
• 23:38
  you've
• 23:39
  got
• 23:39
  to
• 23:39
  really
• 23:39
  sniff
• 23:39
  that
• 23:40
  out
• 23:40
  from
• 23:40
  temporally
• 23:42
  and
• 23:42
  ask
• 23:42
  her,
• 23:42
  you
• 23:42
  know,
• 23:42
  have
• 23:43
  you
• 23:43
  ever
• 23:43
  had
• 23:43
  a
• 23:43
  two
• 23:43
  month
• 23:44
  period
• 23:44
  where
• 23:44
  you
• 23:44
  didn't
• 23:44
  feel
• 23:45
  like
• 23:45
  this,
• 23:45
  where
• 23:45
  you
• 23:46
  didn't
• 23:46
  feel
• 23:46
  so
• 23:46
  down
• 23:47
  and
• 23:47
  empty?
• 23:47
  And
• 23:48
  my
• 23:48
  patients
• 23:48
  with
• 23:48
  PDD
• 23:49
  will
• 23:49
  be
• 23:49
  like,
• 23:49
  no,
• 23:49
  I've
• 23:50
  been
• 23:50
  like
• 23:50
  this
• 23:50
  all
• 23:50
  the
• 23:50
  time.
• 23:51
  Right?
• 23:51
  I've
• 23:51
  been
• 23:52
  this
• 23:52
  way
• 23:52
  all
• 23:52
  the
• 23:53
  time.
• 23:53
  And
• 23:53
  if
• 23:53
  you
• 23:54
  can
• 23:54
  throw
• 23:54
  in
• 23:54
  questions
• 23:54
  about
• 23:55
  their
• 23:55
  relationships
• 23:56
  and
• 23:56
  how
• 23:56
  they
• 23:56
  deal
• 23:56
  with
• 23:57
  rejection,
• 23:58
  and
• 23:58
  if
• 23:58
  you
• 23:58
  can
• 23:59
  throw
• 23:59
  in
• 24:00
  questions
• 24:00
  about
• 24:01
  what
• 24:01
  they
• 24:01
  do
• 24:02
  when
• 24:02
  they
• 24:02
  have
• 24:02
  a
• 24:02
  void
• 24:03
  to
• 24:03
  fill
• 24:04
  and
• 24:04
  why
• 24:05
  they
• 24:05
  had
• 24:06
  behaved
• 24:06
  impulsively,
• 24:07
  what
• 24:07
  their
• 24:07
  thoughts
• 24:07
  were
• 24:08
  on
• 24:08
  their
• 24:08
  impulsive
• 24:09
  behaviors
• 24:09
  and
• 24:09
  what,
• 24:10
  what
• 24:10
  animated
• 24:11
  that
• 24:11
  you
• 24:11
  will
• 24:11
  get
• 24:12
  really
• 24:12
  close
• 24:12
  to
• 24:13
  separating
• 24:13
  PDD
• 24:14
  and
• 24:15
  bpd.
• 24:15
  And
• 24:16
  don't
• 24:16
  get
• 24:16
  me
• 24:16
  wrong,
• 24:17
  we
• 24:17
  really
• 24:17
  have
• 24:17
  to
• 24:17
  get
• 24:18
  close
• 24:18
  to
• 24:18
  this
• 24:18
  because
• 24:18
  PDD
• 24:19
  involves
• 24:20
  usually
• 24:20
  a
• 24:21
  combination
• 24:21
  of
• 24:21
  antidepressants
• 24:22
  and,
• 24:22
  and
• 24:23
  psychotherapy.
• 24:23
  The
• 24:24
  combination
• 24:24
  is
• 24:24
  critical
• 24:25
  in
• 24:25
  pdd,
• 24:26
  that's
• 24:26
  what
• 24:26
  the
• 24:26
  evidence
• 24:26
  seems
• 24:27
  to
• 24:27
  suggest.
• 25:22
  And
• 25:22
  in
• 25:23
  BPD
• 25:23
  we
• 25:23
  know
• 25:24
  that
• 25:24
  the
• 25:24
  gold
• 25:24
  standard
• 25:25
  psychotherapy
• 25:26
  is
• 25:26
  dbt,
• 25:27
  right.
• 25:27
  To
• 25:28
  specifically
• 25:28
  target
• 25:29
  the
• 25:29
  mood
• 25:30
  instability,
• 25:30
  impulsivity,
• 25:32
  the
• 25:32
  disassociation,
• 25:32
  psycho.
• 25:33
  Like
• 25:33
  that,
• 25:33
  that,
• 25:34
  like
• 25:34
  that,
• 25:34
  like
• 25:35
  that.
• 25:35
  Really
• 25:36
  it's
• 25:36
  a,
• 25:36
  it's
• 25:37
  completely
• 25:37
  different
• 25:37
  treatments
• 25:38
  if
• 25:38
  you
• 25:38
  will.
• 25:38
  So
• 25:38
  you
• 25:38
  really
• 25:38
  don't
• 25:39
  want
• 25:39
  to
• 25:39
  misdiagnose
• 25:40
  Mara
• 25:40
  and,
• 25:41
  and
• 25:42
  suggest
• 25:42
  she
• 25:42
  goes
• 25:42
  to
• 25:43
  does
• 25:43
  DBT
• 25:44
  for
• 25:45
  emotional
• 25:45
  dysregulation,
• 25:46
  which
• 25:46
  she
• 25:46
  doesn't
• 25:47
  really
• 25:47
  have.
• 25:47
  She
• 25:47
  has
• 25:47
  more
• 25:48
  of
• 25:48
  like
• 25:48
  these
• 25:48
  neuro
• 25:48
  vegetative
• 25:49
  depressive
• 25:50
  symptoms
• 25:50
  that
• 25:51
  need
• 25:52
  to
• 25:52
  be
• 25:52
  treated
• 25:52
  with
• 25:53
  therapy
• 25:53
  and
• 25:53
  as
• 25:54
  well
• 25:54
  as
• 25:54
  pharmacotherapy.
• 25:56
  Okay,
• 25:56
  like
• 25:56
  psychotherapy
• 25:57
  and
• 25:58
  pharmacotherapy,
• 25:59
  you
• 25:59
  wanna
• 25:59
  make
• 26:00
  sure
• 26:00
  your
• 26:00
  patient
• 26:00
  doesn't
• 26:00
  have
• 26:01
  double
• 26:01
  depression,
• 26:01
  right?
• 26:02
  Cause
• 26:02
  she
• 26:02
  could
• 26:02
  be
• 26:02
  chronically
• 26:03
  depressed
• 26:03
  for
• 26:03
  two
• 26:04
  years,
• 26:04
  no
• 26:04
  two
• 26:04
  month
• 26:05
  break
• 26:05
  of
• 26:05
  not
• 26:06
  being
• 26:06
  depressed.
• 26:06
  And
• 26:07
  lo
• 26:07
  and
• 26:07
  behold
• 26:07
  she
• 26:08
  has
• 26:08
  an
• 26:08
  acute
• 26:08
  worsening
• 26:09
  of
• 26:09
  symptoms.
• 26:10
  And
• 26:10
  we
• 26:10
  call
• 26:10
  that
• 26:11
  double
• 26:11
  depression.
• 26:11
  When
• 26:12
  more
• 26:14
  major
• 26:14
  depressive
• 26:15
  symptoms
• 26:15
  are
• 26:15
  recruited
• 26:16
  on
• 26:16
  top
• 26:16
  of
• 26:16
  the
• 26:16
  PDD
• 26:17
  symptoms.
• 26:18
  And
• 26:19
  now
• 26:19
  she
• 26:19
  has
• 26:19
  double
• 26:20
  depression.
• 26:20
  So
• 26:20
  she
• 26:21
  has
• 26:21
  this
• 26:21
  chronic
• 26:21
  depression
• 26:22
  with
• 26:22
  a
• 26:23
  superimposed
• 26:24
  worsening
• 26:24
  of
• 26:25
  depression
• 26:25
  that
• 26:26
  now
• 26:26
  includes
• 26:26
  anhedonia,
• 26:27
  worthlessness,
• 26:28
  SI
• 26:29
  and
• 26:29
  psychomotor
• 26:30
  retardation
• 26:31
  or
• 26:31
  agitation.
• 26:32
  Now
• 26:32
  that
• 26:32
  might
• 26:32
  be
• 26:32
  a
• 26:32
  mouthful
• 26:33
  for
• 26:33
  my
• 26:33
  friends,
• 26:33
  but
• 26:34
  if
• 26:34
  you
• 26:34
  join
• 26:34
  our
• 26:35
  Patreon
• 26:35
  page,
• 26:36
  you
• 26:36
  will
• 26:36
  see
• 26:36
  these
• 26:37
  mnemonic
• 26:37
  devices.
• 26:37
  And
• 26:38
  what
• 26:38
  I
• 26:38
  mean
• 26:38
  by
• 26:38
  that
• 26:38
  is
• 26:39
  there's
• 26:39
  the
• 26:39
  PDD
• 26:40
  symptoms
• 26:41
  that
• 26:41
  are
• 26:41
  kind
• 26:41
  of
• 26:42
  low
• 26:42
  grade,
• 26:42
  you
• 26:42
  know,
• 26:42
  like
• 26:43
  low
• 26:43
  energy,
• 26:44
  SAD
• 26:45
  mood,
• 26:46
  sleep
• 26:46
  disturbances,
• 26:47
  eating
• 26:47
  disturbances.
• 26:48
  But
• 26:48
  if
• 26:49
  you
• 26:49
  notice
• 26:49
  double
• 26:49
  depression
• 26:50
  and
• 26:50
  a
• 26:50
  major
• 26:51
  depressive
• 26:51
  disorder
• 26:52
  is
• 26:52
  imposed
• 26:52
  on
• 26:53
  that
• 26:53
  on
• 26:53
  top
• 26:53
  of
• 26:53
  that,
• 26:54
  then
• 26:55
  think
• 26:55
  of
• 26:55
  the
• 26:55
  acronym
• 26:56
  pig.
• 26:57
  A,
• 26:57
  a
• 26:58
  PIG
• 26:58
  with
• 26:58
  si.
• 26:59
  Okay?
• 27:00
  That
• 27:00
  acronym
• 27:00
  is
• 27:01
  gonna
• 27:01
  clue
• 27:01
  you
• 27:01
  in.
• 27:01
  Like,
• 27:01
  wait
• 27:02
  a
• 27:02
  minute,
• 27:02
  what
• 27:02
  other
• 27:02
  symptoms
• 27:03
  do
• 27:03
  I
• 27:03
  need
• 27:03
  to
• 27:03
  look
• 27:03
  for
• 27:03
  here
• 27:04
  on
• 27:04
  top
• 27:04
  of
• 27:04
  the
• 27:04
  persistent
• 27:05
  depression
• 27:05
  that
• 27:06
  would
• 27:06
  indicate
• 27:06
  this
• 27:07
  is
• 27:07
  a
• 27:07
  major
• 27:08
  depression?
• 27:08
  So
• 27:08
  if
• 27:08
  they
• 27:09
  have
• 27:09
  anhedonia
• 27:09
  on
• 27:10
  top
• 27:10
  of
• 27:11
  PDD
• 27:11
  symptoms,
• 27:11
  if
• 27:12
  they
• 27:12
  have
• 27:12
  feelings
• 27:13
  of
• 27:13
  guilt,
• 27:13
  psychomotor
• 27:14
  changes,
• 27:15
  or
• 27:15
  si,
• 27:16
  those
• 27:16
  are
• 27:17
  not
• 27:17
  part
• 27:17
  of
• 27:17
  the
• 27:17
  PDD
• 27:18
  diagnosis.
• 27:20
  They're
• 27:20
  exclusive
• 27:21
  to
• 27:21
  the
• 27:21
  MDD
• 27:22
  diagnosis.
• 27:23
  So
• 27:23
  if
• 27:23
  you
• 27:23
  start
• 27:23
  to
• 27:23
  see
• 27:23
  those
• 27:24
  trickle
• 27:24
  into
• 27:24
  pdd,
• 27:25
  you,
• 27:25
  my
• 27:25
  friends,
• 27:26
  may
• 27:26
  have
• 27:26
  a
• 27:26
  double
• 27:27
  depression
• 27:27
  on
• 27:27
  your
• 27:27
  hands.
• 27:28
  And
• 27:28
  it's
• 27:29
  really
• 27:29
  important.
• 27:29
  We're
• 27:29
  gonna
• 27:30
  go
• 27:30
  into
• 27:30
  this
• 27:30
  in
• 27:30
  a
• 27:30
  separate
• 27:31
  episode
• 27:31
  later
• 27:31
  on,
• 27:32
  but
• 27:32
  it's
• 27:32
  really
• 27:32
  important.
• 27:33
  You
• 27:33
  don't
• 27:33
  just
• 27:34
  treat
• 27:34
  the
• 27:34
  acute
• 27:34
  worsening,
• 27:35
  but
• 27:35
  you
• 27:35
  continue
• 27:36
  to
• 27:36
  treat
• 27:36
  the
• 27:36
  underlying
• 27:37
  depression
• 27:38
  too.
• 27:38
  So
• 27:38
  let's
• 27:39
  wrap
• 27:39
  this
• 27:39
  up,
• 27:39
  my
• 27:39
  friends.
• 27:40
  What
• 27:40
  is
• 27:40
  the
• 27:41
  difference
• 27:41
  between
• 27:41
  PDD
• 27:42
  and
• 27:42
  bpd?
• 27:43
  Right,
• 27:44
  you
• 27:44
  have
• 27:45
  emptiness,
• 27:45
  but
• 27:45
  in.
• 27:46
  It's
• 27:46
  flat.
• 27:46
  With
• 27:46
  pdd,
• 27:48
  it's
• 27:48
  just
• 27:49
  their
• 27:49
  emotional
• 27:49
  tone
• 27:50
  is
• 27:50
  very
• 27:50
  flat.
• 27:51
  There's
• 27:51
  not
• 27:51
  a
• 27:51
  lot
• 27:51
  of
• 27:52
  joy
• 27:52
  in
• 27:52
  bpd.
• 27:53
  They
• 27:53
  can
• 27:53
  enjoy
• 27:53
  a
• 27:54
  hell
• 27:54
  of
• 27:54
  a
• 27:54
  lot
• 27:54
  of
• 27:54
  things,
• 27:55
  but
• 27:55
  that
• 27:56
  emptiness
• 27:56
  is
• 27:56
  just
• 27:57
  really
• 27:57
  distressing
• 27:58
  and
• 27:58
  they
• 27:59
  really
• 27:59
  want
• 27:59
  to
• 27:59
  do
• 27:59
  something
• 28:00
  about
• 28:00
  that
• 28:00
  emptiness.
• 28:01
  As
• 28:01
  opposed
• 28:01
  to
• 28:01
  PDD
• 28:02
  where
• 28:02
  it's
• 28:02
  like,
• 28:02
  well,
• 28:02
  I
• 28:03
  don't
• 28:03
  really
• 28:03
  need
• 28:03
  to
• 28:03
  do
• 28:03
  anything
• 28:04
  about
• 28:04
  the
• 28:04
  emptiness.
• 28:04
  Effectively,
• 28:05
  the
• 28:06
  affect
• 28:06
  with
• 28:06
  PDD
• 28:07
  is
• 28:07
  persistent.
• 28:08
  They
• 28:08
  don't
• 28:08
  really
• 28:08
  react
• 28:08
  to
• 28:09
  much.
• 28:09
  They
• 28:09
  could
• 28:09
  win
• 28:09
  the
• 28:10
  lottery.
• 28:10
  They're
• 28:10
  just
• 28:10
  like,
• 28:11
  okay,
• 28:11
  whatever.
• 28:12
  In
• 28:12
  bpd,
• 28:12
  the
• 28:13
  affect
• 28:13
  is
• 28:13
  shifted,
• 28:13
  shifting
• 28:14
  rapidly.
• 28:14
  It's
• 28:15
  really
• 28:15
  reactive.
• 28:15
  Hours
• 28:16
  to
• 28:16
  days
• 28:16
  of
• 28:16
  changes
• 28:17
  in
• 28:17
  mood
• 28:18
  rapidly
• 28:18
  changing,
• 28:19
  not
• 28:20
  very
• 28:20
  steady.
• 28:21
  Relationships
• 28:22
  in
• 28:23
  PDD
• 28:23
  are
• 28:24
  actually
• 28:24
  kind
• 28:24
  of
• 28:24
  stable,
• 28:25
  but
• 28:25
  they're
• 28:25
  just
• 28:25
  an
• 28:25
  emotional
• 28:26
  distance
• 28:26
  because
• 28:27
  people
• 28:27
  are
• 28:27
  flat.
• 28:27
  They're
• 28:28
  disengaged,
• 28:28
  they're
• 28:28
  at
• 28:28
  home,
• 28:29
  they're
• 28:29
  kind
• 28:29
  of
• 28:29
  low
• 28:29
  and
• 28:29
  depressed.
• 28:30
  With
• 28:30
  bpd,
• 28:31
  relationships
• 28:32
  are
• 28:32
  really
• 28:32
  intense.
• 28:32
  They're
• 28:33
  unstable.
• 28:33
  There's.
• 28:34
  I
• 28:34
  love
• 28:34
  him.
• 28:34
  He's
• 28:35
  the
• 28:35
  best
• 28:35
  ever.
• 28:35
  My
• 28:35
  mom's
• 28:36
  the
• 28:36
  greatest
• 28:36
  ever.
• 28:36
  It's
• 28:37
  like
• 28:37
  this
• 28:37
  kind
• 28:37
  of
• 28:38
  seesaw.
• 28:38
  There's
• 28:38
  a
• 28:38
  lot
• 28:38
  of
• 28:39
  sparks
• 28:39
  and,
• 28:40
  and,
• 28:40
  and,
• 28:40
  and
• 28:40
  flames.
• 28:41
  And
• 28:41
  there's
• 28:42
  a
• 28:42
  lot
• 28:42
  more
• 28:42
  to
• 28:43
  look
• 28:43
  at
• 28:43
  there.
• 28:44
  Okay.
• 28:44
  With
• 28:45
  impulsivity,
• 28:46
  again,
• 28:47
  reoccurring
• 28:48
  trait
• 28:48
  based
• 28:49
  impulsivity
• 28:49
  with
• 28:49
  bpd.
• 28:50
  With
• 28:51
  pdd,
• 28:52
  it's
• 28:52
  just
• 28:52
  they're
• 28:53
  a
• 28:53
  little
• 28:53
  more
• 28:53
  inhibited,
• 28:54
  actually.
• 28:54
  They're
• 28:54
  not
• 28:54
  as
• 28:54
  impulsive.
• 28:55
  They're
• 28:55
  a
• 28:55
  little
• 28:55
  more
• 28:56
  constricted,
• 28:56
  withdrawn.
• 28:57
  It's
• 28:57
  not
• 28:58
  a.
• 28:58
  A
• 28:59
  syndrome
• 28:59
  of
• 28:59
  action,
• 29:00
  I
• 29:00
  guess,
• 29:00
  is
• 29:00
  a
• 29:00
  good
• 29:01
  way
• 29:01
  to
• 29:01
  put
• 29:01
  this.
• 29:01
  Right?
• 29:02
  And
• 29:02
  bpd,
• 29:02
  there's
• 29:03
  more
• 29:03
  action,
• 29:03
  there's
• 29:04
  more
• 29:04
  flare,
• 29:04
  there's
• 29:04
  more
• 29:05
  fireworks,
• 29:05
  there's
• 29:05
  just
• 29:06
  more
• 29:06
  movement.
• 29:07
  Pdd,
• 29:07
  you
• 29:07
  don't
• 29:07
  have
• 29:08
  that.
• 29:08
  And
• 29:08
  you
• 29:08
  can
• 29:08
  see
• 29:09
  that
• 29:09
  in
• 29:09
  the
• 29:09
  mse,
• 29:10
  the
• 29:10
  mental
• 29:10
  status
• 29:11
  exam.
• 29:11
  Self
• 29:11
  harm
• 29:12
  is.
• 29:12
  It
• 29:12
  happens
• 29:13
  with
• 29:13
  pdd,
• 29:13
  it's,
• 29:14
  it's
• 29:14
  probably
• 29:15
  a
• 29:15
  little
• 29:15
  more
• 29:15
  on
• 29:15
  the
• 29:15
  rare
• 29:16
  side
• 29:16
  in
• 29:16
  my
• 29:16
  experience,
• 29:17
  but
• 29:17
  it
• 29:18
  can
• 29:18
  happen.
• 29:18
  With
• 29:19
  bpd,
• 29:19
  it
• 29:19
  is
• 29:20
  reoccurrent,
• 29:21
  right?
• 29:21
  It's
• 29:21
  reoccurrent.
• 29:22
  Gestures,
• 29:22
  attempts,
• 29:23
  self
• 29:23
  harm,
• 29:24
  mutilation.
• 29:25
  Right.
• 29:25
  Posturing,
• 29:26
  that
• 29:26
  kind
• 29:26
  of
• 29:26
  thing.
• 29:26
  It's
• 29:27
  more
• 29:27
  ingrained.
• 29:27
  It's
• 29:28
  more
• 29:28
  of
• 29:28
  a
• 29:28
  reoccurring
• 29:29
  pattern.
• 29:29
  Okay.
• 29:30
  Again,
• 29:31
  we
• 29:31
  talked
• 29:31
  a
• 29:31
  little
• 29:31
  bit
• 29:31
  about
• 29:32
  anger.
• 29:32
  How
• 29:32
  in
• 29:32
  pdd,
• 29:33
  it's
• 29:33
  kind
• 29:33
  of
• 29:33
  internal,
• 29:34
  it's
• 29:34
  more
• 29:35
  suppressed.
• 29:35
  And
• 29:35
  bpd,
• 29:36
  it's
• 29:36
  more.
• 29:37
  It's.
• 29:37
  It's
• 29:37
  hard
• 29:37
  to
• 29:38
  control.
• 29:38
  There's
• 29:38
  displays
• 29:39
  of
• 29:39
  it,
• 29:39
  there's
• 29:40
  outbursts
• 29:40
  of
• 29:40
  it.
• 29:40
  It's
• 29:41
  a
• 29:41
  known
• 29:41
  problem.
• 29:41
  It's
• 29:42
  wreaked
• 29:42
  havoc
• 29:42
  on
• 29:42
  relationships.
• 29:44
  Okay.
• 29:45
  And
• 29:45
  that's
• 29:46
  just
• 29:46
  another
• 29:46
  good
• 29:46
  way
• 29:47
  to
• 29:47
  put
• 29:47
  it.
• 29:47
  And
• 29:47
  of
• 29:47
  course,
• 29:47
  the
• 29:48
  treatments
• 29:48
  for
• 29:48
  the
• 29:48
  two
• 29:48
  are
• 29:49
  very
• 29:49
  different.
• 29:49
  There
• 29:50
  is
• 29:50
  not
• 29:50
  as
• 29:50
  much
• 29:51
  of
• 29:51
  an
• 29:51
  evidence
• 29:51
  base
• 29:51
  for
• 29:52
  antidepressants
• 29:52
  in
• 29:53
  bpd.
• 29:54
  You
• 29:54
  may
• 29:55
  treat
• 29:55
  the
• 29:55
  incidental
• 29:56
  symptoms
• 29:56
  that
• 29:56
  are
• 29:57
  coming
• 29:57
  about
• 29:57
  as
• 29:58
  a
• 29:58
  result
• 29:59
  of
• 29:59
  bpd.
• 30:00
  If
• 30:00
  they
• 30:00
  are
• 30:00
  anxious,
• 30:01
  sure,
• 30:01
  you
• 30:01
  can
• 30:01
  kind
• 30:02
  of
• 30:02
  treat
• 30:02
  around
• 30:02
  the
• 30:02
  edges
• 30:03
  and
• 30:03
  reach
• 30:04
  for
• 30:04
  things
• 30:04
  to
• 30:04
  kind
• 30:04
  of
• 30:04
  curtail
• 30:05
  those
• 30:05
  symptoms.
• 30:05
  But
• 30:06
  there
• 30:06
  is
• 30:06
  no
• 30:07
  FDA
• 30:07
  approved
• 30:08
  pharma
• 30:08
  pharmacotherapy
• 30:09
  for
• 30:09
  dbt,
• 30:10
  as
• 30:10
  opposed
• 30:11
  to
• 30:11
  depression,
• 30:11
  which
• 30:12
  there
• 30:12
  are
• 30:12
  FDA
• 30:12
  approvals
• 30:13
  and
• 30:13
  you
• 30:13
  want
• 30:13
  to
• 30:13
  go
• 30:13
  the
• 30:14
  antidepressant
• 30:14
  path.
• 30:15
  I
• 30:15
  hope
• 30:15
  this
• 30:16
  helped
• 30:16
  you.
• 30:16
  My
• 30:16
  friends,
• 30:16
  I
• 30:17
  cannot
• 30:17
  emphasize
• 30:17
  it
• 30:18
  enough.
• 30:18
  If
• 30:18
  there's
• 30:18
  one
• 30:19
  thing
• 30:19
  you
• 30:19
  don't
• 30:20
  forget
• 30:20
  today
• 30:20
  before
• 30:21
  you
• 30:21
  go
• 30:21
  to
• 30:21
  bed,
• 30:22
  remind
• 30:22
  yourself,
• 30:23
  set
• 30:23
  a
• 30:23
  reminder,
• 30:24
  go
• 30:24
  to
• 30:24
  our
• 30:24
  show
• 30:25
  notes
• 30:25
  and
• 30:25
  become
• 30:25
  a
• 30:26
  Patreon
• 30:26
  member.
• 30:26
  Because,
• 30:27
  my
• 30:27
  friends,
• 30:28
  this
• 30:28
  stuff
• 30:29
  is
• 30:30
  made
• 30:30
  very
• 30:30
  simple
• 30:31
  for
• 30:31
  you.
• 30:31
  There's
• 30:31
  a
• 30:31
  full
• 30:32
  clinical
• 30:32
  library
• 30:33
  of
• 30:33
  this
• 30:33
  stuff.
• 30:34
  And
• 30:34
  what
• 30:34
  separates
• 30:35
  the
• 30:35
  good
• 30:35
  and
• 30:35
  the
• 30:36
  great.
• 30:36
  Clinicians
• 30:36
  are
• 30:36
  the
• 30:37
  ones
• 30:37
  who
• 30:37
  simply
• 30:38
  just
• 30:38
  follow
• 30:38
  algorithms
• 30:39
  and
• 30:40
  hit
• 30:40
  prescribe
• 30:41
  and
• 30:41
  the
• 30:42
  ones
• 30:42
  who
• 30:42
  actually
• 30:42
  know
• 30:43
  the
• 30:43
  how
• 30:43
  and
• 30:43
  the
• 30:43
  why
• 30:43
  of
• 30:44
  what
• 30:44
  they're
• 30:44
  doing,
• 30:44
  and
• 30:44
  they
• 30:45
  can
• 30:45
  explain
• 30:45
  it
• 30:45
  to
• 30:45
  their
• 30:46
  patients.
• 30:47
  Patients
• 30:47
  connect
• 30:47
  with
• 30:48
  you
• 30:48
  instantly.
• 30:48
  When
• 30:48
  you
• 30:49
  have
• 30:49
  that
• 30:49
  how
• 30:49
  and
• 30:49
  the
• 30:50
  why
• 30:50
  knowledge,
• 30:50
  they
• 30:51
  trust
• 30:51
  you
• 30:51
  more.
• 30:52
  You
• 30:52
  are
• 30:52
  a
• 30:53
  extremely
• 30:54
  valued
• 30:54
  clinician
• 30:55
  to
• 30:55
  them
• 30:55
  and
• 30:55
  to
• 30:56
  the
• 30:56
  people
• 30:56
  who
• 30:56
  hire
• 30:56
  you.
• 30:57
  I
• 30:57
  can't
• 30:57
  emphasize
• 30:57
  it
• 30:58
  enough
• 30:58
  how
• 30:58
  patreon
• 30:59
  will
• 30:59
  transform
• 31:00
  the
• 31:00
  way
• 31:00
  you
• 31:00
  see
• 31:00
  yourself
• 31:01
  as
• 31:01
  a
• 31:01
  clinician
• 31:01
  and
• 31:02
  transform
• 31:02
  the
• 31:02
  way
• 31:03
  you
• 31:03
  practice
• 31:03
  with
• 31:04
  your
• 31:04
  patient
• 31:04
  outcomes.
• 31:05
  Highly
• 31:05
  recommend
• 31:06
  it.
• 31:06
  Until
• 31:07
  next
• 31:07
  time,
• 31:07
  my
• 31:07
  friends.
• 31:08
  Signing
• 31:08
  off.
• 31:09
  Bye
• 31:09
  Bye.