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Exploring the Diagnostic Challenges in Anxiety: Jean Luc's Journey · Pearls and Prep

• 0:00
  Foreign.
• 0:04
  Welcome
• 0:04
  back,
• 0:05
  everybody,
• 0:05
  to
• 0:06
  another
• 0:06
  episode
• 0:07
  of
• 0:07
  Pearls
• 0:07
  and
• 0:08
  Prep.
• 0:08
  NPZ
• 0:09
  here.
• 0:10
  Very
• 0:10
  excited
• 0:11
  to
• 0:11
  chat
• 0:11
  with
• 0:11
  you
• 0:12
  again
• 0:12
  today.
• 0:13
  I'd
• 0:13
  like
• 0:13
  you
• 0:13
  to
• 0:13
  meet
• 0:13
  a
• 0:14
  mock
• 0:14
  patient
• 0:14
  named
• 0:15
  Jean
• 0:15
  Luc.
• 0:16
  Jean
• 0:16
  Luc
• 0:17
  is
• 0:17
  French,
• 0:17
  and
• 0:18
  he's
• 0:18
  coming
• 0:19
  to
• 0:19
  you
• 0:19
  in
• 0:19
  the
• 0:19
  outpatient
• 0:20
  space
• 0:21
  saying
• 0:21
  that
• 0:21
  for
• 0:22
  the
• 0:22
  last
• 0:22
  six
• 0:23
  months,
• 0:23
  his
• 0:24
  sleep
• 0:24
  has
• 0:25
  been
• 0:25
  really
• 0:25
  erratic.
• 0:26
  He's
• 0:26
  super
• 0:27
  tired
• 0:27
  in
• 0:27
  the
• 0:27
  morning.
• 0:28
  He's
• 0:29
  no
• 0:29
  longer
• 0:30
  able
• 0:30
  to
• 0:30
  really
• 0:30
  focus
• 0:31
  at
• 0:32
  his
• 0:32
  job.
• 0:33
  He's
• 0:33
  an
• 0:33
  engineer,
• 0:35
  and
• 0:35
  he
• 0:35
  just
• 0:35
  feels
• 0:36
  like
• 0:36
  something's
• 0:36
  off.
• 0:37
  He
• 0:37
  just
• 0:37
  can't
• 0:38
  sleep.
• 0:38
  And
• 0:39
  he
• 0:39
  wakes
• 0:40
  up
• 0:40
  multiple
• 0:40
  times
• 0:40
  throughout
• 0:41
  the
• 0:41
  night.
• 0:42
  He
• 0:42
  doesn't
• 0:42
  have
• 0:43
  refreshing
• 0:44
  sleep
• 0:45
  at
• 0:45
  all.
• 0:46
  He's
• 0:47
  pretty
• 0:47
  nervous
• 0:48
  throughout
• 0:48
  the
• 0:48
  day,
• 0:49
  too,
• 0:49
  which
• 0:49
  is
• 0:49
  a
• 0:49
  little
• 0:50
  bit
• 0:50
  unusual
• 0:50
  for
• 0:51
  him.
• 0:51
  His
• 0:52
  heart
• 0:52
  is
• 0:52
  kind
• 0:52
  of
• 0:52
  racing
• 0:53
  a
• 0:53
  little
• 0:53
  bit.
• 0:54
  He
• 0:54
  has
• 0:55
  tremors.
• 0:55
  He
• 0:56
  can
• 0:56
  get
• 0:56
  a
• 0:56
  little
• 0:57
  bit
• 0:57
  sweaty
• 0:57
  at
• 0:58
  times,
• 0:58
  and
• 0:58
  he's
• 0:59
  not
• 0:59
  sure
• 0:59
  what
• 0:59
  happened.
• 1:00
  You
• 1:00
  know,
• 1:00
  he's
• 1:00
  only
• 1:01
  25
• 1:01
  years
• 1:01
  old.
• 1:02
  He
• 1:02
  doesn't
• 1:03
  have
• 1:03
  a
• 1:04
  history
• 1:04
  of
• 1:04
  mental
• 1:05
  health
• 1:05
  problems.
• 1:06
  You
• 1:06
  know,
• 1:06
  you
• 1:06
  ask
• 1:07
  him
• 1:07
  a
• 1:07
  bunch
• 1:07
  of
• 1:07
  questions.
• 1:08
  He's
• 1:08
  not
• 1:08
  depressed.
• 1:08
  He's
• 1:09
  never
• 1:09
  been
• 1:09
  depressed.
• 1:10
  He
• 1:11
  has
• 1:11
  a
• 1:11
  mother
• 1:11
  and
• 1:11
  an
• 1:11
  aunt
• 1:12
  with
• 1:12
  generalized
• 1:12
  anxiety
• 1:13
  disorder.
• 1:14
  He
• 1:15
  has
• 1:15
  never
• 1:16
  been
• 1:16
  hospitalized
• 1:17
  psychiatrically.
• 1:19
  His
• 1:19
  urine
• 1:19
  drug
• 1:20
  comes
• 1:20
  back
• 1:20
  clean.
• 1:22
  There's
• 1:22
  no
• 1:22
  issues
• 1:23
  there.
• 1:23
  He
• 1:24
  doesn't
• 1:24
  really
• 1:24
  drink
• 1:24
  alcohol,
• 1:25
  maybe
• 1:25
  one
• 1:25
  to
• 1:26
  two
• 1:26
  drinks
• 1:26
  per
• 1:26
  week
• 1:27
  at
• 1:27
  best.
• 1:29
  And
• 1:29
  he's
• 1:30
  already
• 1:30
  been
• 1:31
  to
• 1:31
  the
• 1:31
  emergency
• 1:31
  room
• 1:32
  before
• 1:33
  because
• 1:33
  he
• 1:33
  had
• 1:33
  severe
• 1:34
  heart
• 1:34
  palpitations.
• 1:35
  And
• 1:35
  he's
• 1:36
  telling
• 1:36
  you
• 1:36
  this
• 1:37
  is
• 1:37
  all
• 1:37
  the
• 1:37
  medical
• 1:38
  has
• 1:38
  been
• 1:38
  ruled
• 1:38
  out.
• 1:38
  Right.
• 1:39
  They
• 1:39
  did
• 1:39
  an
• 1:39
  ekg.
• 1:41
  They
• 1:41
  don't
• 1:41
  feel
• 1:41
  like
• 1:42
  this
• 1:42
  is
• 1:42
  cardiac
• 1:42
  in
• 1:43
  origin.
• 1:43
  And
• 1:43
  so
• 1:43
  he
• 1:43
  comes
• 1:44
  to
• 1:44
  you
• 1:44
  just
• 1:44
  like
• 1:44
  a
• 1:44
  lot
• 1:44
  of
• 1:45
  outpatients
• 1:45
  are
• 1:46
  going
• 1:46
  to
• 1:46
  come
• 1:46
  to
• 1:46
  you
• 1:47
  after
• 1:48
  their
• 1:48
  medical
• 1:49
  issues
• 1:49
  have
• 1:50
  been
• 1:50
  ruled
• 1:50
  out.
• 1:51
  They
• 1:51
  did
• 1:51
  a
• 1:51
  thyroid
• 1:52
  panel.
• 1:53
  Doesn't
• 1:53
  look
• 1:53
  like
• 1:53
  he
• 1:53
  has
• 1:53
  hyperthyroidism.
• 1:54
  You
• 1:55
  always
• 1:55
  have
• 1:55
  to
• 1:55
  rule
• 1:55
  that
• 1:56
  out,
• 1:56
  too.
• 1:56
  When
• 1:56
  you
• 1:57
  have
• 1:57
  a
• 1:57
  patient
• 1:57
  who's
• 1:58
  telling
• 1:58
  you
• 1:58
  they
• 1:58
  have
• 1:59
  tremors
• 1:59
  or
• 1:59
  insomnia
• 2:00
  or
• 2:00
  tachycardia
• 2:01
  or
• 2:01
  heart
• 2:01
  palpitations,
• 2:02
  you
• 2:02
  want
• 2:02
  to
• 2:03
  make
• 2:03
  sure
• 2:03
  that
• 2:04
  that's
• 2:04
  not
• 2:04
  a
• 2:04
  hyperthyroid,
• 2:05
  especially
• 2:05
  if
• 2:05
  they
• 2:06
  have
• 2:06
  anxiety
• 2:06
  or
• 2:07
  something
• 2:07
  to
• 2:07
  that
• 2:07
  nature.
• 2:08
  And
• 2:09
  he's
• 2:09
  not
• 2:09
  telling
• 2:10
  you
• 2:10
  that
• 2:10
  he's
• 2:10
  worried.
• 2:11
  You
• 2:11
  ask
• 2:11
  him,
• 2:11
  and
• 2:11
  he's
• 2:12
  saying,
• 2:12
  hey,
• 2:12
  I'm
• 2:13
  not
• 2:13
  really
• 2:13
  worried
• 2:14
  about
• 2:14
  anything
• 2:14
  that
• 2:15
  I'm
• 2:15
  aware
• 2:15
  of.
• 2:15
  I
• 2:15
  just
• 2:16
  really
• 2:16
  don't
• 2:16
  like
• 2:16
  these
• 2:16
  symptoms.
• 2:17
  They're
• 2:17
  very
• 2:18
  bothersome
• 2:18
  to
• 2:18
  me.
• 2:18
  They're
• 2:19
  interrupting
• 2:19
  my
• 2:19
  sleep.
• 2:20
  And
• 2:20
  again,
• 2:20
  I
• 2:20
  go
• 2:21
  to
• 2:21
  work
• 2:21
  as
• 2:22
  an
• 2:22
  engineer
• 2:22
  in
• 2:22
  the
• 2:23
  mornings,
• 2:23
  and
• 2:23
  I
• 2:23
  can't
• 2:23
  quite
• 2:24
  swing
• 2:24
  it
• 2:24
  like
• 2:24
  I
• 2:24
  used
• 2:25
  to.
• 2:25
  I'm
• 2:25
  falling
• 2:25
  behind.
• 2:26
  I'm
• 2:26
  being
• 2:27
  even
• 2:27
  more
• 2:27
  overwhelmed
• 2:28
  because
• 2:28
  I'm
• 2:28
  falling
• 2:28
  behind
• 2:29
  because
• 2:29
  I'm
• 2:29
  so
• 2:29
  darn
• 2:29
  nervous
• 2:30
  and
• 2:30
  I
• 2:30
  feel
• 2:31
  so
• 2:31
  jittery
• 2:31
  that
• 2:32
  I
• 2:32
  can't
• 2:32
  do
• 2:32
  my
• 2:32
  job.
• 2:33
  So
• 2:34
  what's
• 2:34
  the
• 2:34
  first
• 2:35
  thing
• 2:35
  that
• 2:35
  you
• 2:35
  should
• 2:35
  be
• 2:36
  thinking
• 2:37
  or
• 2:37
  I
• 2:37
  should
• 2:38
  say?
• 2:38
  What
• 2:38
  are
• 2:38
  many
• 2:39
  things
• 2:39
  you
• 2:39
  should
• 2:39
  be
• 2:39
  thinking
• 2:40
  all
• 2:40
  at
• 2:40
  once?
• 2:41
  Which
• 2:41
  is
• 2:42
  more
• 2:42
  realistic
• 2:42
  in
• 2:42
  the
• 2:43
  outpatient
• 2:43
  space?
• 2:44
  When
• 2:44
  you
• 2:44
  hear
• 2:44
  John
• 2:45
  Luke's
• 2:45
  story.
• 2:46
  Now,
• 2:47
  of
• 2:47
  course,
• 2:48
  when
• 2:48
  anybody's
• 2:48
  coming
• 2:49
  to
• 2:49
  you
• 2:50
  with
• 2:50
  sudden
• 2:51
  anxiety
• 2:51
  or
• 2:51
  sudden
• 2:52
  insomnia,
• 2:53
  heart
• 2:53
  palpitations
• 2:54
  and
• 2:55
  all
• 2:55
  the
• 2:55
  medical
• 2:55
  stuff
• 2:56
  has
• 2:56
  been
• 2:56
  ruled
• 2:56
  out,
• 2:57
  you
• 2:58
  gotta
• 2:58
  start
• 2:59
  thinking
• 2:59
  about
• 2:59
  the
• 3:00
  DSM
• 3:00
  5,
• 3:01
  right?
• 3:01
  What
• 3:01
  could
• 3:02
  this
• 3:02
  be?
• 3:02
  Could
• 3:02
  this
• 3:02
  be
• 3:02
  a
• 3:03
  generalized
• 3:03
  anxiety
• 3:03
  disorder?
• 3:04
  Could
• 3:04
  this
• 3:04
  be
• 3:04
  a
• 3:04
  panic
• 3:05
  disorder?
• 3:06
  For
• 3:06
  me
• 3:07
  it's
• 3:07
  very
• 3:07
  important
• 3:08
  right
• 3:08
  off
• 3:08
  the
• 3:08
  bat
• 3:08
  to
• 3:09
  understand
• 3:09
  the
• 3:10
  extent
• 3:10
  by
• 3:10
  which
• 3:11
  this
• 3:11
  is
• 3:11
  psychiatric.
• 3:13
  You
• 3:13
  really
• 3:13
  want
• 3:13
  to
• 3:14
  just
• 3:14
  ask
• 3:14
  Jean
• 3:15
  Luc
• 3:15
  important
• 3:16
  questions.
• 3:17
  I
• 3:17
  would
• 3:17
  ask
• 3:17
  something
• 3:18
  like
• 3:18
  what
• 3:19
  are
• 3:19
  your
• 3:19
  thoughts
• 3:20
  as
• 3:20
  you
• 3:21
  are
• 3:21
  beginning
• 3:22
  to
• 3:22
  experience
• 3:23
  these
• 3:23
  sensations?
• 3:24
  In
• 3:24
  other
• 3:24
  words,
• 3:24
  are
• 3:25
  you
• 3:25
  worried
• 3:25
  about
• 3:25
  particular
• 3:26
  things
• 3:26
  and
• 3:27
  that
• 3:27
  may
• 3:27
  be
• 3:28
  leading
• 3:28
  to
• 3:29
  these
• 3:29
  physical
• 3:30
  manifestations
• 3:31
  in
• 3:31
  your
• 3:31
  body?
• 3:32
  Right.
• 3:32
  Are
• 3:33
  you
• 3:33
  much
• 3:33
  of
• 3:33
  a
• 3:33
  worrier
• 3:34
  to
• 3:34
  begin
• 3:34
  with?
• 3:35
  How
• 3:35
  do
• 3:35
  you
• 3:35
  normally
• 3:36
  cope
• 3:36
  with
• 3:36
  stress?
• 3:36
  Are
• 3:37
  you
• 3:37
  dealing
• 3:37
  with
• 3:37
  stressors
• 3:38
  more
• 3:39
  recently
• 3:39
  that
• 3:40
  have
• 3:40
  been
• 3:40
  really
• 3:40
  bothering
• 3:41
  you?
• 3:41
  Have
• 3:41
  these
• 3:42
  physical
• 3:42
  symptoms
• 3:43
  correlated
• 3:43
  to
• 3:44
  recent
• 3:44
  stressors?
• 3:45
  You
• 3:45
  know
• 3:46
  what
• 3:46
  stressors
• 3:47
  might
• 3:47
  be
• 3:47
  correlated
• 3:48
  with
• 3:49
  these
• 3:50
  physical
• 3:51
  experiences?
• 3:53
  Again,
• 3:53
  I
• 3:53
  like
• 3:54
  open
• 3:54
  ended
• 3:54
  questions.
• 3:55
  I
• 3:55
  usually
• 3:55
  lead
• 3:56
  off
• 3:56
  with
• 3:56
  questions
• 3:56
  that
• 3:57
  begin
• 3:57
  with
• 3:57
  what
• 3:57
  or
• 3:58
  how.
• 3:58
  That's
• 3:59
  a
• 3:59
  little
• 3:59
  pearl
• 3:59
  for
• 3:59
  you
• 3:59
  today
• 4:00
  to
• 4:00
  tuck
• 4:01
  in
• 4:01
  your
• 4:01
  back
• 4:01
  pocket.
• 4:02
  What
• 4:02
  and
• 4:02
  how
• 4:03
  usually
• 4:03
  open
• 4:04
  up
• 4:04
  to
• 4:04
  open
• 4:05
  ended
• 4:05
  questions.
• 4:06
  Why?
• 4:06
  Questions
• 4:06
  are
• 4:07
  a
• 4:07
  little
• 4:07
  bit
• 4:07
  judgmental.
• 4:09
  So
• 4:10
  try
• 4:10
  to
• 4:10
  think
• 4:10
  of
• 4:11
  what
• 4:12
  and
• 4:12
  how
• 4:13
  questions
• 4:13
  to
• 4:14
  guide
• 4:14
  you
• 4:14
  into
• 4:14
  open
• 4:15
  ended
• 4:15
  questions
• 4:16
  because
• 4:16
  they
• 4:16
  will
• 4:16
  get
• 4:16
  you
• 4:17
  more
• 4:17
  information
• 4:17
  typically.
• 4:18
  Now
• 4:19
  the
• 4:20
  important
• 4:20
  thing
• 4:20
  here
• 4:20
  is
• 4:20
  John
• 4:21
  Luke
• 4:21
  is
• 4:21
  again
• 4:21
  emphasizing
• 4:22
  I
• 4:22
  don't
• 4:23
  really
• 4:23
  feel
• 4:23
  nervous.
• 4:24
  Things
• 4:24
  don't
• 4:24
  really
• 4:24
  bother
• 4:25
  me.
• 4:25
  And
• 4:26
  you
• 4:26
  can
• 4:26
  ask
• 4:26
  him
• 4:26
  in
• 4:27
  that
• 4:27
  in
• 4:27
  many
• 4:27
  different
• 4:27
  ways
• 4:28
  until
• 4:28
  you
• 4:28
  feel
• 4:28
  confident
• 4:29
  that
• 4:30
  you've
• 4:30
  ruled
• 4:30
  out.
• 4:30
  You
• 4:31
  could
• 4:31
  ask
• 4:31
  him.
• 4:31
  Is
• 4:31
  there
• 4:31
  anything
• 4:32
  in
• 4:32
  your
• 4:32
  job
• 4:33
  that
• 4:33
  has
• 4:33
  changed
• 4:34
  recently
• 4:35
  that
• 4:35
  might
• 4:36
  escalate
• 4:36
  your
• 4:37
  sense
• 4:37
  of
• 4:37
  worry
• 4:37
  or
• 4:38
  dread?
• 4:38
  How
• 4:39
  are
• 4:39
  your
• 4:39
  relationships
• 4:40
  as
• 4:40
  of
• 4:40
  late?
• 4:41
  A
• 4:41
  lot
• 4:41
  of
• 4:41
  patients
• 4:42
  are
• 4:42
  going
• 4:42
  to
• 4:42
  be
• 4:42
  able
• 4:42
  to
• 4:43
  tell
• 4:43
  you
• 4:43
  whether
• 4:44
  it's
• 4:44
  through
• 4:44
  their
• 4:44
  preliminary
• 4:45
  intake
• 4:45
  or
• 4:45
  pre
• 4:45
  screen
• 4:46
  before
• 4:46
  they
• 4:46
  see
• 4:46
  you,
• 4:47
  whether
• 4:47
  it's
• 4:47
  the
• 4:47
  first
• 4:47
  thing
• 4:48
  they
• 4:48
  do
• 4:48
  when
• 4:48
  they
• 4:48
  see
• 4:48
  you,
• 4:49
  what
• 4:50
  the
• 4:50
  problem
• 4:51
  might
• 4:51
  be.
• 4:52
  Now
• 4:52
  I'm
• 4:52
  not
• 4:52
  saying
• 4:52
  they're
• 4:53
  going
• 4:53
  to
• 4:53
  tell
• 4:53
  you
• 4:53
  what
• 4:53
  the
• 4:53
  problem
• 4:54
  is.
• 4:54
  That's
• 4:54
  for
• 4:54
  you
• 4:55
  and
• 4:55
  the
• 4:55
  patient
• 4:55
  to
• 4:55
  figure
• 4:56
  out
• 4:57
  when
• 4:57
  you
• 4:57
  open
• 4:57
  the
• 4:57
  floor
• 4:58
  to
• 4:58
  the
• 4:58
  patient
• 4:58
  about
• 4:58
  what
• 4:59
  brings
• 4:59
  them
• 4:59
  here.
• 5:00
  A
• 5:01
  lot
• 5:01
  of
• 5:01
  it
• 5:01
  is
• 5:01
  very
• 5:01
  revealing
• 5:02
  as
• 5:02
  to
• 5:02
  what
• 5:03
  they
• 5:03
  say.
• 5:03
  And
• 5:03
  what's
• 5:04
  even
• 5:04
  more
• 5:04
  revealing
• 5:04
  is
• 5:04
  what
• 5:05
  they
• 5:05
  don't
• 5:05
  say.
• 5:05
  So
• 5:06
  what
• 5:06
  John
• 5:06
  Luke
• 5:06
  told
• 5:07
  us,
• 5:07
  he
• 5:08
  talked
• 5:08
  about
• 5:08
  heart
• 5:08
  palpitations
• 5:09
  and
• 5:09
  tremors
• 5:10
  and
• 5:10
  he
• 5:10
  said
• 5:11
  the
• 5:11
  symptoms
• 5:11
  bother
• 5:12
  him
• 5:12
  and
• 5:12
  make
• 5:12
  it
• 5:12
  hard
• 5:12
  for
• 5:13
  him
• 5:13
  to
• 5:13
  focus.
• 5:13
  Notice
• 5:14
  how
• 5:14
  he
• 5:14
  didn't
• 5:14
  talk
• 5:15
  about
• 5:15
  a
• 5:15
  divorce.
• 5:16
  He
• 5:16
  didn't
• 5:16
  talk
• 5:16
  about,
• 5:17
  oh,
• 5:17
  I'm
• 5:17
  worried
• 5:18
  about,
• 5:19
  you
• 5:19
  know,
• 5:20
  losing
• 5:20
  my
• 5:20
  job.
• 5:21
  I'm
• 5:21
  up
• 5:21
  at
• 5:21
  night
• 5:22
  just
• 5:22
  tossing
• 5:23
  and
• 5:23
  turning
• 5:23
  because
• 5:24
  I'm
• 5:25
  worried
• 5:25
  about
• 5:25
  my
• 5:25
  children
• 5:26
  or
• 5:26
  I'm
• 5:27
  always
• 5:27
  on
• 5:27
  edge
• 5:27
  in
• 5:28
  general
• 5:28
  for
• 5:28
  the
• 5:28
  last
• 5:28
  several
• 5:29
  years.
• 5:29
  And
• 5:29
  it's
• 5:29
  really
• 5:30
  just
• 5:30
  gotten
• 5:30
  worse
• 5:30
  lately.
• 5:32
  He's
• 5:32
  not
• 5:32
  going
• 5:33
  down
• 5:33
  other
• 5:33
  rabbit
• 5:34
  holes
• 5:35
  that
• 5:35
  would
• 5:35
  be
• 5:35
  more
• 5:36
  suggestive
• 5:36
  of
• 5:36
  a
• 5:37
  generalized
• 5:37
  anxiety
• 5:38
  disorder
• 5:38
  where
• 5:38
  your
• 5:38
  worry
• 5:39
  is
• 5:39
  all
• 5:39
  over
• 5:39
  the
• 5:39
  place.
• 5:40
  He
• 5:40
  seems
• 5:40
  to
• 5:41
  be
• 5:42
  squarely
• 5:42
  focused
• 5:43
  on
• 5:43
  the
• 5:43
  physical
• 5:44
  symptoms,
• 5:46
  which
• 5:46
  should
• 5:47
  raise
• 5:47
  some
• 5:47
  flags
• 5:48
  for
• 5:48
  you
• 5:49
  and
• 5:49
  orient
• 5:49
  you
• 5:50
  to
• 5:50
  certain
• 5:50
  diagnoses.
• 5:51
  If
• 5:51
  he
• 5:51
  tells
• 5:51
  you
• 5:51
  he's
• 5:51
  not
• 5:52
  much
• 5:52
  of
• 5:52
  a
• 5:52
  worrier,
• 5:53
  that
• 5:54
  matters.
• 5:54
  Now,
• 5:55
  he
• 5:55
  does
• 5:55
  have
• 5:55
  a
• 5:55
  mother
• 5:55
  and
• 5:56
  an
• 5:56
  aunt
• 5:56
  with
• 5:56
  generalized
• 5:57
  anxiety
• 5:57
  disorder,
• 5:58
  so
• 5:58
  he's
• 5:58
  more
• 5:58
  predisposed
• 5:59
  to
• 5:59
  having
• 6:00
  generalized
• 6:00
  anxiety.
• 6:01
  But
• 6:01
  again,
• 6:01
  patients
• 6:02
  are
• 6:02
  pretty
• 6:02
  aware
• 6:03
  of
• 6:03
  whether
• 6:03
  or
• 6:03
  not
• 6:04
  they
• 6:04
  worry
• 6:04
  over
• 6:04
  the
• 6:04
  course
• 6:05
  of
• 6:05
  their
• 6:05
  lives
• 6:05
  and
• 6:05
  how
• 6:06
  bad
• 6:06
  it
• 6:06
  is.
• 6:07
  In
• 6:07
  my
• 6:07
  experience,
• 6:08
  patients
• 6:08
  who
• 6:08
  have
• 6:09
  generalized
• 6:09
  anxiety
• 6:10
  will
• 6:10
  sign
• 6:11
  the
• 6:11
  dotted
• 6:11
  line
• 6:11
  very
• 6:12
  quickly.
• 6:12
  They
• 6:12
  very
• 6:12
  much
• 6:13
  endorse
• 6:13
  it.
• 6:13
  It's
• 6:14
  feels
• 6:14
  real
• 6:14
  to
• 6:14
  them.
• 6:15
  It's
• 6:15
  the
• 6:15
  daily
• 6:15
  existence.
• 6:16
  They
• 6:16
  worry
• 6:17
  constantly
• 6:17
  about
• 6:18
  worst
• 6:18
  case
• 6:18
  scenarios
• 6:19
  that
• 6:19
  could
• 6:19
  happen.
• 6:19
  Catastrophic
• 6:20
  thoughts,
• 6:21
  Jean
• 6:21
  Luc?
• 6:22
  Not
• 6:22
  the
• 6:22
  case.
• 6:22
  So
• 6:23
  you're
• 6:23
  scratching
• 6:23
  your
• 6:23
  head
• 6:23
  here
• 6:24
  and
• 6:24
  going,
• 6:24
  what
• 6:24
  else
• 6:24
  is
• 6:24
  this?
• 6:25
  Right
• 6:25
  now?
• 6:26
  I
• 6:26
  would
• 6:26
  be
• 6:26
  suspicious
• 6:27
  of
• 6:27
  panic
• 6:27
  attacks.
• 6:28
  A
• 6:28
  lot
• 6:28
  of
• 6:28
  his
• 6:28
  symptoms
• 6:29
  are
• 6:30
  reminiscent
• 6:30
  of
• 6:31
  panic
• 6:31
  symptoms
• 6:32
  that
• 6:32
  are
• 6:32
  included
• 6:33
  in
• 6:33
  the
• 6:33
  DSM
• 6:34
  5
• 6:34
  criteria
• 6:34
  for
• 6:35
  panic
• 6:35
  disorder.
• 6:36
  He's
• 6:36
  talking
• 6:36
  about
• 6:36
  palpitations,
• 6:37
  he's
• 6:37
  talking
• 6:37
  about
• 6:38
  diaphoresis,
• 6:39
  he's
• 6:39
  talking
• 6:39
  about
• 6:39
  tremors.
• 6:40
  He's
• 6:40
  talking.
• 6:40
  You
• 6:40
  want
• 6:41
  to
• 6:41
  ask
• 6:41
  him
• 6:41
  about
• 6:41
  that,
• 6:42
  right?
• 6:43
  That's
• 6:44
  very
• 6:44
  important.
• 6:44
  You
• 6:45
  could
• 6:45
  ask
• 6:45
  by
• 6:46
  seeing
• 6:47
  what
• 6:47
  other
• 6:47
  symptoms
• 6:48
  might
• 6:48
  be
• 6:48
  clustered
• 6:49
  along
• 6:49
  with
• 6:50
  these
• 6:50
  physical
• 6:50
  manifestations.
• 6:51
  Do
• 6:52
  you
• 6:52
  feel
• 6:52
  like
• 6:52
  you're
• 6:52
  losing
• 6:53
  control?
• 6:53
  Do
• 6:53
  you
• 6:53
  feel
• 6:53
  like
• 6:54
  you're
• 6:54
  going
• 6:54
  crazy?
• 6:55
  Do
• 6:55
  you
• 6:55
  feel
• 6:55
  like
• 6:55
  you're
• 6:56
  about
• 6:56
  to
• 6:56
  die?
• 6:56
  Those
• 6:57
  are
• 6:57
  more
• 6:57
  panic
• 6:57
  type
• 6:58
  symptoms.
• 6:58
  And
• 6:59
  one
• 6:59
  key
• 6:59
  differentiator
• 7:00
  that
• 7:00
  would
• 7:00
  be
• 7:00
  wonderful
• 7:01
  to
• 7:01
  ask
• 7:02
  is
• 7:03
  how
• 7:03
  long
• 7:03
  do
• 7:03
  these
• 7:04
  last?
• 7:04
  How
• 7:04
  long
• 7:04
  do
• 7:05
  these
• 7:05
  uncomfortable
• 7:05
  symptoms
• 7:06
  last?
• 7:06
  He
• 7:06
  might
• 7:06
  tell
• 7:07
  you,
• 7:08
  well,
• 7:08
  they
• 7:08
  only
• 7:08
  last
• 7:09
  two
• 7:09
  or
• 7:10
  three
• 7:10
  minutes
• 7:10
  and
• 7:10
  then
• 7:10
  they
• 7:10
  kind
• 7:11
  of
• 7:11
  ease
• 7:11
  away.
• 7:12
  But
• 7:12
  it's
• 7:12
  so
• 7:12
  terrifying.
• 7:13
  Well,
• 7:13
  if
• 7:13
  that's
• 7:14
  the
• 7:14
  case,
• 7:14
  I
• 7:14
  would
• 7:14
  be
• 7:14
  much
• 7:15
  more
• 7:15
  inclined
• 7:15
  to
• 7:15
  think
• 7:15
  this
• 7:16
  is
• 7:16
  some
• 7:16
  sort
• 7:16
  of
• 7:16
  panic
• 7:17
  disorder
• 7:17
  because
• 7:18
  it's
• 7:18
  just
• 7:18
  several
• 7:18
  minutes.
• 7:19
  It
• 7:19
  peaks,
• 7:20
  then
• 7:20
  it
• 7:20
  kind
• 7:20
  of
• 7:21
  ebbs
• 7:21
  and
• 7:22
  flows,
• 7:22
  you
• 7:22
  know,
• 7:23
  two
• 7:23
  to
• 7:23
  three
• 7:23
  minutes,
• 7:24
  highs
• 7:24
  and
• 7:24
  lows,
• 7:25
  and
• 7:25
  goes
• 7:25
  away.
• 7:26
  And
• 7:26
  then
• 7:26
  he
• 7:26
  maybe
• 7:26
  dreads
• 7:27
  the
• 7:27
  next
• 7:27
  attack.
• 7:27
  But
• 7:28
  John
• 7:28
  Luke
• 7:28
  is
• 7:28
  telling
• 7:29
  you
• 7:29
  no.
• 7:29
  All
• 7:30
  day
• 7:30
  I'm
• 7:30
  feeling
• 7:30
  like
• 7:31
  this
• 7:31
  and
• 7:32
  it's
• 7:32
  just
• 7:32
  so
• 7:32
  uncomfortable
• 7:33
  and
• 7:33
  I
• 7:33
  don't
• 7:33
  understand
• 7:34
  what's
• 7:34
  going
• 7:34
  on.
• 7:34
  Even
• 7:35
  at
• 7:35
  night
• 7:35
  when
• 7:35
  I
• 7:35
  try
• 7:35
  to
• 7:35
  go
• 7:36
  to
• 7:36
  bed,
• 7:36
  I
• 7:37
  can't
• 7:37
  sleep
• 7:37
  very
• 7:37
  easily.
• 7:38
  I
• 7:39
  wake
• 7:39
  up
• 7:39
  in
• 7:39
  the
• 7:39
  middle
• 7:39
  of
• 7:39
  the
• 7:39
  night
• 7:40
  multiple
• 7:40
  times.
• 7:40
  This
• 7:41
  is
• 7:41
  odd,
• 7:41
  right?
• 7:41
  And
• 7:42
  what
• 7:42
  I
• 7:42
  love
• 7:42
  to
• 7:42
  do
• 7:43
  is
• 7:43
  I
• 7:43
  love
• 7:43
  to
• 7:43
  ask
• 7:43
  patients
• 7:44
  when
• 7:44
  they're
• 7:44
  waking
• 7:45
  up
• 7:45
  in
• 7:45
  the
• 7:45
  middle
• 7:45
  of
• 7:45
  the
• 7:45
  night,
• 7:46
  what
• 7:46
  are
• 7:46
  you
• 7:47
  thinking
• 7:47
  about?
• 7:47
  Patients
• 7:48
  who
• 7:49
  deal
• 7:50
  with
• 7:51
  generalized
• 7:51
  worry
• 7:52
  or
• 7:52
  depression.
• 7:53
  They'll
• 7:53
  give
• 7:53
  you
• 7:53
  answers
• 7:54
  that
• 7:54
  sound
• 7:54
  like,
• 7:54
  oh,
• 7:55
  I'm
• 7:55
  just
• 7:55
  worrying
• 7:56
  about
• 7:56
  the
• 7:56
  next
• 7:56
  day.
• 7:56
  Of
• 7:56
  all
• 7:57
  the
• 7:57
  things
• 7:57
  that
• 7:57
  could
• 7:57
  go
• 7:57
  wrong,
• 7:58
  right?
• 7:58
  I'm
• 7:59
  worried
• 7:59
  about
• 7:59
  my
• 7:59
  job,
• 8:00
  I'm
• 8:00
  worried
• 8:00
  about
• 8:00
  my
• 8:00
  finances,
• 8:01
  I'm
• 8:02
  worried
• 8:02
  about
• 8:02
  my
• 8:02
  kids
• 8:03
  and
• 8:03
  how
• 8:03
  they're
• 8:03
  going
• 8:04
  to
• 8:04
  do
• 8:04
  in
• 8:04
  school
• 8:04
  and
• 8:04
  whether
• 8:05
  their
• 8:05
  school
• 8:05
  is
• 8:05
  safe.
• 8:06
  Depression
• 8:07
  might
• 8:07
  be
• 8:07
  more
• 8:07
  ruminative.
• 8:08
  I'm
• 8:08
  regretting
• 8:09
  things
• 8:09
  I've
• 8:09
  done
• 8:09
  in
• 8:09
  the
• 8:09
  past.
• 8:10
  I
• 8:10
  feel
• 8:10
  really
• 8:10
  bad
• 8:11
  and
• 8:11
  guilty
• 8:11
  and
• 8:11
  shameful
• 8:12
  and
• 8:12
  it
• 8:12
  keeps
• 8:12
  me
• 8:12
  up
• 8:12
  thinking
• 8:13
  of
• 8:13
  all
• 8:13
  the
• 8:13
  people
• 8:13
  I've
• 8:14
  wronged.
• 8:14
  That's
• 8:14
  more
• 8:14
  of
• 8:15
  a
• 8:15
  depressive
• 8:15
  answer.
• 8:15
  But
• 8:15
  if
• 8:16
  a
• 8:16
  patient
• 8:16
  can't
• 8:17
  give
• 8:17
  you
• 8:17
  a
• 8:17
  crystallized
• 8:18
  answer
• 8:19
  as
• 8:19
  to
• 8:19
  why
• 8:19
  they're
• 8:20
  waking
• 8:20
  up
• 8:20
  in
• 8:20
  the
• 8:20
  middle
• 8:20
  of
• 8:21
  the
• 8:21
  night,
• 8:21
  or
• 8:21
  if
• 8:21
  it's
• 8:22
  not
• 8:22
  psychological,
• 8:23
  I
• 8:23
  tend
• 8:24
  to
• 8:24
  look
• 8:24
  at
• 8:24
  that
• 8:25
  as
• 8:25
  maybe
• 8:26
  something
• 8:26
  else
• 8:26
  is
• 8:26
  going
• 8:27
  on
• 8:27
  here
• 8:27
  that
• 8:27
  isn't
• 8:27
  purely
• 8:28
  psychiatric,
• 8:29
  especially
• 8:29
  if
• 8:30
  that
• 8:30
  patient
• 8:30
  is
• 8:31
  going
• 8:31
  to
• 8:31
  continue
• 8:32
  to
• 8:32
  point
• 8:32
  to
• 8:32
  their
• 8:33
  physical
• 8:33
  manifestations.
• 8:34
  So
• 8:34
  Jean
• 8:35
  Luc
• 8:35
  is
• 8:35
  telling
• 8:35
  us,
• 8:36
  you
• 8:36
  know,
• 8:36
  I
• 8:36
  just
• 8:37
  wake
• 8:37
  up
• 8:37
  because
• 8:37
  I
• 8:37
  can
• 8:38
  feel
• 8:38
  my
• 8:38
  heart
• 8:38
  beating
• 8:39
  and
• 8:39
  it
• 8:39
  freaks
• 8:40
  me
• 8:40
  out.
• 8:40
  I'm
• 8:41
  shaky.
• 8:41
  I
• 8:42
  just
• 8:42
  can't
• 8:42
  sleep.
• 8:42
  I
• 8:43
  really
• 8:43
  can't
• 8:43
  sleep.
• 8:44
  And
• 8:44
  that's
• 8:45
  when
• 8:45
  you
• 8:45
  have
• 8:45
  to
• 8:46
  pause
• 8:46
  and
• 8:47
  also
• 8:47
  dig
• 8:48
  deep
• 8:48
  and
• 8:48
  make
• 8:48
  sure
• 8:48
  this
• 8:49
  isn't
• 8:49
  mania
• 8:50
  or
• 8:50
  hypomania.
• 8:51
  What
• 8:51
  are
• 8:51
  the
• 8:51
  reasons
• 8:51
  you
• 8:52
  feel
• 8:52
  like
• 8:52
  you
• 8:52
  can't
• 8:52
  sleep?
• 8:53
  What
• 8:53
  are
• 8:53
  you
• 8:54
  doing
• 8:54
  when.
• 8:54
  When
• 8:55
  you
• 8:55
  can't
• 8:55
  sleep?
• 8:55
  What
• 8:55
  types
• 8:56
  of
• 8:56
  activities
• 8:57
  do
• 8:57
  you
• 8:57
  engage
• 8:58
  in
• 8:58
  when
• 8:58
  you
• 8:58
  can't
• 8:58
  sleep?
• 8:59
  That's
• 8:59
  kind
• 8:59
  of
• 8:59
  my
• 8:59
  feeler
• 9:00
  I
• 9:00
  throw
• 9:00
  out
• 9:00
  there
• 9:01
  for
• 9:01
  folks
• 9:01
  who
• 9:02
  might
• 9:02
  be
• 9:02
  hypomanic
• 9:03
  or
• 9:03
  manic.
• 9:03
  What
• 9:04
  kind
• 9:04
  of
• 9:04
  activities
• 9:05
  are
• 9:05
  you
• 9:05
  doing?
• 9:06
  Because
• 9:06
  I
• 9:06
  find
• 9:07
  some
• 9:07
  people
• 9:07
  who
• 9:07
  are
• 9:07
  hypomanic
• 9:08
  or
• 9:08
  manic
• 9:08
  might
• 9:09
  bite
• 9:09
  that
• 9:09
  bait
• 9:09
  and
• 9:09
  say,
• 9:10
  oh,
• 9:10
  I'm
• 9:10
  starting
• 9:10
  projects.
• 9:11
  I'm
• 9:11
  cleaning
• 9:11
  the
• 9:11
  entire
• 9:12
  house.
• 9:12
  I'm
• 9:13
  starting
• 9:13
  a
• 9:13
  soap
• 9:13
  company.
• 9:14
  I'm
• 9:15
  ordering
• 9:15
  five
• 9:15
  grand
• 9:15
  pianos
• 9:16
  because
• 9:17
  I
• 9:17
  want
• 9:17
  to
• 9:17
  start
• 9:17
  my
• 9:18
  own
• 9:18
  orchestra
• 9:19
  at
• 9:19
  the
• 9:19
  next
• 9:20
  neighborhood
• 9:20
  potluck,
• 9:21
  right?
• 9:21
  You
• 9:21
  can
• 9:21
  get
• 9:21
  some
• 9:22
  really
• 9:23
  tangential,
• 9:24
  grandiose
• 9:25
  ideas
• 9:26
  or
• 9:26
  thought
• 9:26
  patterns
• 9:27
  when
• 9:27
  you
• 9:27
  open
• 9:27
  that
• 9:28
  up.
• 9:28
  But
• 9:28
  for
• 9:28
  Jean
• 9:28
  Luc,
• 9:29
  he's
• 9:30
  not
• 9:30
  endorsing
• 9:30
  those
• 9:31
  things,
• 9:32
  right?
• 9:32
  And
• 9:32
  this
• 9:33
  is
• 9:33
  the
• 9:33
  key,
• 9:33
  my
• 9:33
  friends.
• 9:34
  When
• 9:34
  patients
• 9:35
  tell
• 9:35
  you,
• 9:35
  well,
• 9:35
  I
• 9:36
  just
• 9:36
  wake
• 9:36
  up,
• 9:36
  I
• 9:36
  just
• 9:36
  sit
• 9:37
  there,
• 9:37
  I
• 9:37
  just
• 9:37
  stare
• 9:38
  at
• 9:38
  the
• 9:38
  ceiling.
• 9:38
  I
• 9:38
  get
• 9:38
  that
• 9:39
  answer
• 9:39
  all
• 9:39
  the
• 9:39
  time.
• 9:40
  They
• 9:40
  just
• 9:40
  stare
• 9:40
  at
• 9:41
  the
• 9:41
  ceiling.
• 9:41
  So
• 9:41
  that
• 9:42
  doesn't
• 9:42
  scream
• 9:43
  mania,
• 9:43
  right?
• 9:43
  Manic
• 9:44
  people
• 9:44
  have
• 9:44
  a
• 9:44
  hard
• 9:44
  time
• 9:45
  sitting
• 9:45
  still.
• 9:45
  They'll
• 9:45
  move
• 9:46
  around.
• 9:46
  They
• 9:47
  can't
• 9:47
  sit
• 9:47
  still.
• 9:48
  They're
• 9:48
  talking
• 9:49
  fast.
• 9:49
  They
• 9:50
  might
• 9:50
  be
• 9:50
  again
• 9:50
  starting
• 9:51
  projects,
• 9:52
  engaged
• 9:52
  in
• 9:52
  risky
• 9:53
  activity,
• 9:53
  overspending
• 9:54
  into
• 9:54
  the
• 9:54
  wee
• 9:55
  hours
• 9:55
  at
• 9:55
  night.
• 9:56
  But
• 9:56
  Jean
• 9:57
  Luc
• 9:57
  is
• 9:57
  telling
• 9:57
  you
• 9:57
  he's
• 9:58
  trying
• 9:58
  to
• 9:58
  sleep,
• 9:58
  but
• 9:58
  he's
• 9:59
  just
• 9:59
  kind
• 9:59
  of
• 9:59
  wired.
• 10:00
  When
• 10:00
  you
• 10:00
  hear
• 10:00
  wired,
• 10:01
  you've
• 10:01
  got
• 10:01
  to
• 10:02
  think
• 10:02
  mania.
• 10:02
  But
• 10:03
  once
• 10:03
  you
• 10:03
  establish
• 10:04
  those
• 10:04
  other
• 10:04
  clusters
• 10:05
  and
• 10:05
  the
• 10:05
  grandiosity,
• 10:06
  the
• 10:06
  talking
• 10:07
  fast,
• 10:07
  the
• 10:07
  doing
• 10:08
  risky
• 10:08
  stuff,
• 10:08
  and
• 10:08
  Jean
• 10:09
  Luc
• 10:09
  goes,
• 10:09
  no,
• 10:09
  no,
• 10:10
  none
• 10:10
  of
• 10:10
  that.
• 10:10
  That's
• 10:10
  not
• 10:10
  what
• 10:11
  I'm
• 10:11
  experiencing
• 10:11
  at
• 10:12
  all.
• 10:12
  Now.
• 10:13
  You're
• 10:13
  orbiting
• 10:14
  away
• 10:14
  from
• 10:14
  that.
• 10:15
  And
• 10:15
  he's
• 10:15
  telling
• 10:15
  you,
• 10:15
  I'm
• 10:16
  just
• 10:16
  sitting
• 10:16
  there
• 10:16
  because
• 10:17
  I'm
• 10:17
  shaky.
• 10:18
  I
• 10:18
  have
• 10:18
  palpitations,
• 10:19
  and
• 10:19
  I
• 10:20
  just
• 10:20
  don't
• 10:20
  feel
• 10:20
  myself.
• 10:21
  He's
• 10:21
  not
• 10:21
  worrying.
• 10:21
  There's
• 10:22
  no
• 10:22
  depressive
• 10:22
  rumination.
• 10:23
  So
• 10:23
  now
• 10:23
  you're
• 10:24
  really
• 10:24
  gravitating
• 10:24
  away
• 10:25
  towards
• 10:25
  a
• 10:25
  lot
• 10:26
  of
• 10:26
  the
• 10:26
  psychiatric
• 10:27
  problems,
• 10:27
  right?
• 10:28
  You're
• 10:28
  not
• 10:28
  in
• 10:28
  the
• 10:28
  medical
• 10:28
  realm,
• 10:29
  so
• 10:29
  you're
• 10:29
  getting
• 10:29
  more
• 10:29
  towards,
• 10:30
  is
• 10:30
  this
• 10:30
  maybe
• 10:30
  substance
• 10:31
  induced?
• 10:31
  That's
• 10:32
  always
• 10:32
  important
• 10:32
  to
• 10:33
  ask.
• 10:33
  John
• 10:33
  Luke
• 10:34
  told
• 10:34
  you
• 10:34
  during
• 10:34
  your
• 10:34
  initial
• 10:35
  eval
• 10:36
  that
• 10:37
  he
• 10:37
  gave
• 10:37
  up
• 10:38
  coffee
• 10:38
  eight
• 10:39
  months
• 10:39
  ago.
• 10:39
  He
• 10:39
  only
• 10:39
  drinks
• 10:40
  two
• 10:40
  matchas
• 10:40
  a
• 10:41
  day.
• 10:42
  He's
• 10:42
  not
• 10:42
  a
• 10:42
  coffee
• 10:42
  drinker.
• 10:43
  And
• 10:44
  so
• 10:44
  at
• 10:45
  first
• 10:45
  glance,
• 10:47
  you
• 10:47
  might
• 10:47
  be
• 10:47
  thinking,
• 10:48
  oh,
• 10:48
  well,
• 10:48
  caffeine's
• 10:49
  not
• 10:49
  the
• 10:49
  problem
• 10:49
  here.
• 10:50
  He
• 10:50
  stopped
• 10:50
  drinking
• 10:51
  coffee.
• 10:51
  Here's
• 10:51
  a
• 10:51
  pearl.
• 10:52
  Always
• 10:52
  ask
• 10:52
  a
• 10:52
  patient
• 10:53
  why
• 10:53
  they
• 10:53
  stopped
• 10:53
  a
• 10:54
  substance.
• 10:54
  I
• 10:54
  ask
• 10:55
  them
• 10:55
  that
• 10:55
  because
• 10:56
  usually
• 10:56
  if
• 10:57
  somebody
• 10:57
  is
• 10:57
  intentionally
• 10:58
  stopping
• 10:58
  a
• 10:58
  substance,
• 10:59
  it's
• 10:59
  for
• 10:59
  a
• 10:59
  particular
• 11:00
  reason.
• 11:00
  It
• 11:01
  doesn't
• 11:01
  necessarily
• 11:01
  mean
• 11:02
  that
• 11:02
  they
• 11:02
  had
• 11:03
  some
• 11:03
  severe
• 11:03
  substance
• 11:04
  use
• 11:04
  disorder.
• 11:05
  But
• 11:05
  more
• 11:05
  often
• 11:05
  than
• 11:06
  not,
• 11:06
  they
• 11:06
  stopped
• 11:06
  it
• 11:07
  for
• 11:07
  a
• 11:07
  reason,
• 11:07
  because
• 11:07
  it
• 11:08
  was
• 11:08
  problematic.
• 11:08
  That
• 11:08
  will
• 11:09
  give
• 11:09
  you
• 11:09
  clues
• 11:10
  and
• 11:10
  into
• 11:11
  more
• 11:11
  of
• 11:12
  their
• 11:12
  diagnostic
• 11:12
  picture.
• 11:13
  We
• 11:13
  asked
• 11:14
  John
• 11:14
  Luke,
• 11:14
  well,
• 11:14
  what
• 11:15
  were
• 11:15
  some
• 11:15
  of
• 11:15
  the
• 11:15
  reasons
• 11:15
  that
• 11:16
  led
• 11:16
  you
• 11:16
  to
• 11:16
  stopping
• 11:17
  caffeine?
• 11:18
  He
• 11:18
  told
• 11:18
  you,
• 11:19
  well,
• 11:19
  I'm
• 11:19
  just
• 11:19
  a
• 11:19
  little
• 11:19
  too
• 11:20
  sensitive
• 11:20
  to
• 11:21
  those
• 11:21
  strong
• 11:21
  coffees.
• 11:21
  I
• 11:22
  was
• 11:22
  drinking
• 11:22
  death
• 11:22
  wish
• 11:23
  coffee.
• 11:24
  I
• 11:24
  felt
• 11:24
  really
• 11:25
  unpleasant,
• 11:26
  really
• 11:26
  jittery,
• 11:27
  and
• 11:27
  I
• 11:27
  had
• 11:27
  to
• 11:28
  stop.
• 11:28
  So
• 11:28
  I
• 11:28
  switched
• 11:28
  to
• 11:28
  Matcha.
• 11:29
  Now
• 11:30
  it's
• 11:30
  incumbent
• 11:31
  upon
• 11:31
  all
• 11:31
  of
• 11:31
  us
• 11:32
  to
• 11:32
  be
• 11:32
  familiar
• 11:33
  with
• 11:34
  the
• 11:34
  caffeine
• 11:34
  content
• 11:35
  in
• 11:35
  a
• 11:36
  lot
• 11:36
  of
• 11:36
  these
• 11:37
  beverages.
• 11:37
  And
• 11:37
  there's
• 11:37
  a
• 11:38
  billion
• 11:38
  beverages
• 11:38
  out
• 11:39
  there
• 11:39
  that
• 11:39
  are
• 11:39
  impossible
• 11:40
  to
• 11:40
  keep
• 11:40
  track
• 11:40
  of.
• 11:41
  You
• 11:41
  have
• 11:41
  flavored
• 11:42
  waters
• 11:42
  now
• 11:42
  like
• 11:43
  grapefruit
• 11:43
  water
• 11:44
  with
• 11:45
  alkaline
• 11:46
  this
• 11:46
  and
• 11:46
  that.
• 11:46
  I
• 11:47
  can't
• 11:47
  keep
• 11:47
  track
• 11:47
  of
• 11:47
  all
• 11:48
  of
• 11:48
  it.
• 11:48
  Even
• 11:48
  Coke
• 11:49
  and
• 11:49
  Pepsi
• 11:49
  was
• 11:49
  hard
• 11:49
  enough
• 11:50
  to
• 11:50
  figure
• 11:50
  out.
• 11:51
  Some
• 11:51
  say
• 11:51
  Pepsi
• 11:52
  tastes
• 11:52
  better.
• 11:52
  Usually
• 11:53
  wins
• 11:53
  in
• 11:53
  blind
• 11:54
  taste
• 11:54
  tests.
• 11:55
  That's
• 11:55
  a
• 11:55
  bit
• 11:55
  of
• 11:55
  a
• 11:56
  tangent.
• 11:57
  My
• 11:57
  point
• 11:57
  is
• 11:58
  we
• 11:58
  have
• 11:58
  to
• 11:58
  figure
• 11:58
  this
• 11:59
  out
• 11:59
  because
• 11:59
  the
• 12:00
  caffeine
• 12:00
  content
• 12:01
  is
• 12:01
  very
• 12:01
  sneaky
• 12:02
  in
• 12:02
  a
• 12:02
  whole
• 12:02
  host
• 12:02
  of
• 12:02
  beverages.
• 12:04
  In
• 12:04
  coffee,
• 12:04
  we're
• 12:05
  looking
• 12:05
  at
• 12:05
  maybe
• 12:06
  95,
• 12:06
  100
• 12:07
  milligrams
• 12:08
  of
• 12:08
  caffeine
• 12:08
  in
• 12:08
  an
• 12:09
  eight
• 12:09
  ounce
• 12:09
  cup
• 12:09
  of
• 12:09
  coffee.
• 12:10
  Matcha.
• 12:11
  Lo
• 12:12
  and
• 12:12
  behold,
• 12:12
  that's
• 12:12
  70
• 12:13
  milligrams.
• 12:13
  So
• 12:13
  we'll
• 12:13
  put
• 12:14
  a
• 12:14
  pin
• 12:14
  in
• 12:14
  that
• 12:14
  for
• 12:14
  a
• 12:14
  minute.
• 12:15
  But
• 12:15
  Matcha
• 12:16
  tea
• 12:16
  has
• 12:16
  its
• 12:16
  fair
• 12:17
  share
• 12:17
  of
• 12:17
  caffeine.
• 12:17
  So
• 12:18
  70,
• 12:18
  he
• 12:18
  has
• 12:18
  two,
• 12:19
  that's
• 12:19
  140
• 12:19
  milligrams
• 12:20
  every
• 12:20
  morning.
• 12:21
  Energy
• 12:21
  drinks
• 12:21
  can
• 12:21
  have
• 12:22
  up
• 12:22
  to
• 12:22
  500
• 12:23
  milligrams
• 12:23
  of
• 12:23
  caffeine.
• 12:24
  I
• 12:24
  mean
• 12:24
  that
• 12:24
  is
• 12:24
  like
• 12:24
  a
• 12:24
  panic
• 12:25
  attack
• 12:25
  in
• 12:26
  a
• 12:26
  can.
• 12:27
  So
• 12:27
  we've
• 12:27
  got
• 12:27
  to
• 12:27
  be
• 12:28
  really
• 12:28
  careful
• 12:29
  about
• 12:29
  that.
• 12:30
  Caffeine
• 12:30
  sneaks
• 12:31
  into
• 12:31
  all
• 12:31
  other
• 12:32
  things.
• 12:32
  Dark
• 12:33
  chocolate,
• 12:34
  Coca
• 12:34
  Cola
• 12:35
  iced
• 12:36
  tea.
• 13:31
  Dark
• 13:31
  chocolate
• 13:31
  has
• 13:31
  12
• 12:37
  milligrams
• 13:32
  and
• 13:32
  one
• 13:33
  ounce
• 13:33
  of
• 13:33
  a
• 13:33
  portion
• 13:34
  size.
• 13:34
  If
• 13:34
  you
• 13:34
  have
• 13:35
  five
• 13:35
  or
• 13:35
  six
• 13:35
  ounces
• 13:36
  or
• 13:36
  a
• 13:36
  whole
• 13:36
  bar
• 13:36
  of
• 13:36
  chocolate
• 13:37
  at
• 13:37
  night
• 13:38
  and
• 13:38
  you
• 13:38
  think
• 13:39
  that's
• 13:39
  a
• 13:40
  good
• 13:40
  dessert,
• 13:40
  that's
• 13:41
  fine.
• 13:41
  I
• 13:41
  love
• 13:41
  dark
• 13:41
  chocolate.
• 13:42
  Milk
• 13:42
  is
• 13:43
  better.
• 13:43
  But
• 13:43
  for
• 13:44
  our
• 13:44
  health,
• 13:44
  dark
• 13:44
  chocolate
• 13:45
  could
• 13:45
  also
• 13:45
  interfere
• 13:46
  with
• 13:46
  your
• 13:46
  sleep.
• 13:47
  It's
• 13:47
  like
• 13:47
  taking
• 13:47
  a
• 13:48
  small
• 13:48
  coffee
• 13:48
  right
• 13:48
  before
• 13:49
  sleep.
• 13:50
  And
• 13:50
  that's
• 13:50
  very
• 13:50
  problematic.
• 13:51
  And
• 13:52
  I'll
• 13:52
  tell
• 13:52
  you
• 13:52
  why
• 13:52
  it's
• 13:53
  so
• 13:53
  problematic.
• 13:54
  Because
• 13:54
  number
• 13:55
  one,
• 13:55
  in
• 13:55
  regular
• 13:56
  metabolizers,
• 13:57
  caffeine
• 13:57
  has
• 13:58
  about
• 13:58
  a
• 13:58
  five
• 13:58
  hour
• 13:59
  half
• 13:59
  life,
• 13:59
  meaning
• 14:00
  50%
• 14:00
  of
• 14:01
  the
• 14:01
  caffeine
• 14:01
  will
• 14:02
  be
• 14:02
  eliminated
• 14:02
  from
• 14:03
  your
• 14:03
  system
• 14:03
  within
• 14:04
  about
• 14:04
  five
• 14:04
  hours.
• 14:05
  Now
• 14:06
  in
• 14:06
  people
• 14:06
  who
• 14:07
  are
• 14:07
  slow
• 14:07
  metabolizers,
• 14:08
  many
• 14:09
  of
• 14:09
  whom
• 14:09
  are
• 14:10
  European
• 14:10
  in
• 14:11
  descent,
• 14:11
  we
• 14:11
  think
• 14:12
  about
• 14:12
  10%
• 14:12
  of
• 14:13
  people
• 14:13
  are
• 14:13
  slow
• 14:14
  metabolizers
• 14:14
  of
• 14:14
  caffeine.
• 14:15
  Well,
• 14:15
  that
• 14:15
  half
• 14:16
  life
• 14:16
  can
• 14:16
  jump
• 14:16
  from
• 14:17
  five
• 14:17
  hours
• 14:17
  to,
• 14:18
  to
• 14:19
  ten
• 14:20
  hours
• 14:20
  or
• 14:20
  more.
• 14:21
  Your
• 14:21
  textbooks
• 14:22
  get
• 14:22
  you
• 14:22
  very
• 14:23
  far.
• 14:23
  But
• 14:24
  in
• 14:24
  practice,
• 14:24
  it's
• 14:25
  not
• 14:25
  as
• 14:25
  simple
• 14:25
  as
• 14:26
  caffeine
• 14:26
  has
• 14:26
  a
• 14:26
  half
• 14:27
  life
• 14:27
  of
• 14:27
  5
• 14:28
  hours
• 14:28
  in
• 14:29
  normal
• 14:29
  metabolizers
• 14:30
  and
• 14:30
  10
• 14:30
  hours
• 14:31
  in
• 14:31
  slow
• 14:32
  metabolizers.
• 14:33
  It's
• 14:34
  much
• 14:34
  more
• 14:34
  complicated
• 14:35
  because
• 14:36
  everybody
• 14:36
  metabolizes
• 14:37
  drugs
• 14:38
  differently.
• 14:38
  It's
• 14:39
  not
• 14:39
  as
• 14:39
  simple
• 14:39
  as
• 14:40
  5
• 14:40
  and
• 14:40
  10.
• 14:40
  Some
• 14:41
  might
• 14:41
  be
• 14:41
  metabolizing
• 14:42
  it
• 14:42
  in
• 14:42
  3
• 14:42
  hours
• 14:43
  or
• 14:43
  the
• 14:43
  half
• 14:44
  life
• 14:44
  might
• 14:44
  be
• 14:44
  3
• 14:44
  hours,
• 14:45
  2
• 14:45
  hours
• 14:45
  or
• 14:45
  12
• 14:46
  hours
• 14:46
  or
• 14:46
  16
• 14:46
  hours.
• 14:47
  In
• 14:47
  fact,
• 14:47
  the
• 14:47
  variability
• 14:48
  in
• 14:48
  caffeine
• 14:49
  consumption
• 14:50
  can
• 14:51
  have
• 14:51
  a
• 14:51
  40
• 14:52
  fold
• 14:52
  difference.
• 14:53
  To
• 14:53
  me,
• 14:53
  that
• 14:53
  is
• 14:53
  shocking.
• 14:54
  That
• 14:54
  is
• 14:54
  one
• 14:54
  of
• 14:54
  the
• 14:54
  more
• 14:55
  shocking
• 14:55
  Statistics
• 14:56
  that
• 14:56
  I've
• 14:56
  read
• 14:56
  in
• 14:57
  psychiatry,
• 14:57
  85%
• 14:58
  of
• 14:58
  the
• 14:58
  US
• 14:59
  population
• 14:59
  consumes
• 15:00
  at
• 15:00
  least
• 15:00
  one
• 15:00
  caffeinated
• 15:01
  beverage
• 15:01
  per
• 15:01
  day.
• 15:01
  There
• 15:02
  is
• 15:02
  a
• 15:02
  potential
• 15:03
  40
• 15:03
  fold
• 15:04
  variance
• 15:05
  in
• 15:05
  the
• 15:05
  way
• 15:05
  people
• 15:06
  can
• 15:06
  metabolize
• 15:07
  caffeine.
• 15:08
  While,
• 15:09
  well,
• 15:09
  we
• 15:09
  might
• 15:09
  have
• 15:10
  a
• 15:10
  very
• 15:10
  sneaky
• 15:11
  problem
• 15:12
  and
• 15:12
  a
• 15:12
  unique
• 15:12
  opportunity
• 15:13
  to
• 15:14
  get
• 15:14
  an
• 15:14
  accurate
• 15:14
  caffeine
• 15:15
  count
• 15:15
  from
• 15:16
  patients
• 15:16
  because
• 15:16
  this
• 15:17
  can
• 15:17
  change
• 15:17
  the
• 15:18
  game
• 15:18
  so
• 15:18
  much
• 15:18
  in
• 15:19
  their
• 15:19
  mental
• 15:19
  health
• 15:19
  overall.
• 15:20
  It
• 15:20
  can
• 15:21
  mask
• 15:22
  a
• 15:22
  lot
• 15:22
  of
• 15:23
  symptoms
• 15:23
  out
• 15:23
  there.
• 15:24
  It
• 15:25
  can,
• 15:26
  it
• 15:26
  can
• 15:27
  really
• 15:27
  throw
• 15:27
  a
• 15:28
  monkey
• 15:28
  wrench
• 15:28
  in
• 15:28
  our
• 15:28
  entire,
• 15:29
  in,
• 15:30
  in
• 15:30
  the
• 15:31
  entire
• 15:31
  diagnostic
• 15:32
  picture.
• 15:32
  Why
• 15:33
  is
• 15:33
  that?
• 15:33
  Because,
• 15:34
  well,
• 15:35
  caffeine
• 15:36
  is
• 15:37
  competing
• 15:37
  with
• 15:38
  our
• 15:38
  ability
• 15:38
  to
• 15:38
  sleep,
• 15:39
  as
• 15:39
  you
• 15:39
  know.
• 15:40
  Right.
• 15:40
  It's
• 15:41
  very
• 15:42
  much
• 15:42
  competing
• 15:43
  with
• 15:43
  our
• 15:43
  ability
• 15:44
  to
• 15:44
  sleep.
• 15:44
  Adenosine
• 15:45
  is
• 15:45
  our
• 15:45
  sleep
• 15:46
  pressure
• 15:46
  molecule.
• 15:47
  As
• 15:47
  you
• 15:47
  know,
• 15:47
  caffeine
• 15:48
  directly
• 15:48
  antagonizes
• 15:49
  the
• 15:50
  adenosine
• 15:50
  receptor,
• 15:51
  so
• 15:51
  it
• 15:51
  essentially
• 15:53
  dissolves
• 15:53
  that
• 15:54
  sleep
• 15:54
  pressure
• 15:54
  and
• 15:55
  blocks
• 15:55
  it.
• 15:55
  So
• 15:55
  you
• 15:55
  don't
• 15:56
  feel
• 15:56
  it
• 15:56
  until
• 15:56
  the
• 15:56
  antagonism
• 15:57
  wears
• 15:57
  off
• 15:57
  and
• 15:58
  then
• 15:58
  you
• 15:58
  crash.
• 15:59
  Well,
• 15:59
  that's
• 15:59
  a
• 15:59
  really
• 15:59
  big
• 16:00
  deal.
• 16:01
  So
• 16:01
  you
• 16:02
  might
• 16:02
  be
• 16:02
  awake
• 16:02
  into
• 16:03
  the
• 16:03
  wee
• 16:03
  hours
• 16:04
  thinking
• 16:05
  you're
• 16:05
  fine
• 16:05
  because
• 16:05
  you
• 16:06
  stopped
• 16:06
  your
• 16:06
  caffeine
• 16:07
  at
• 16:08
  1
• 16:08
  o'
• 16:09
  clock
• 16:09
  pm.
• 16:09
  But
• 16:09
  if
• 16:10
  you're
• 16:10
  a
• 16:10
  slow
• 16:10
  metabolizer,
• 16:11
  you
• 16:11
  gotta
• 16:11
  think
• 16:11
  about
• 16:11
  this.
• 16:12
  If
• 16:12
  you've
• 16:12
  had
• 16:12
  two
• 16:12
  matchas
• 16:13
  and
• 16:14
  you
• 16:14
  stopped
• 16:14
  drinking
• 16:15
  it
• 16:15
  around
• 16:15
  1pm,
• 16:17
  140mg,
• 16:19
  you
• 16:19
  know,
• 16:19
  10
• 16:20
  hours
• 16:20
  later,
• 16:20
  maybe
• 16:20
  12
• 16:21
  if
• 16:21
  you're
• 16:21
  a
• 16:21
  really
• 16:21
  poor
• 16:22
  metabolizer,
• 16:22
  that's
• 16:23
  still
• 16:23
  like
• 16:23
  drinking
• 16:24
  one
• 16:24
  matcha
• 16:25
  at
• 16:25
  one
• 16:25
  in
• 16:25
  the
• 16:25
  morning.
• 16:26
  I
• 16:26
  mean,
• 16:26
  who
• 16:27
  could
• 16:27
  sleep
• 16:27
  that
• 16:27
  easily
• 16:28
  by
• 16:29
  drinking
• 16:29
  70
• 16:29
  milligrams
• 16:30
  of
• 16:30
  caffeine
• 16:30
  a
• 16:31
  matcha
• 16:31
  at
• 16:31
  one
• 16:32
  in
• 16:32
  the
• 16:32
  morning?
• 16:32
  Of
• 16:32
  course
• 16:32
  that's
• 16:33
  going
• 16:33
  to
• 16:33
  keep
• 16:33
  you
• 16:33
  up.
• 16:34
  I
• 16:34
  know
• 16:34
  some
• 16:35
  of
• 16:35
  you
• 16:35
  out
• 16:35
  there
• 16:35
  are
• 16:35
  heroic
• 16:36
  metabolizers.
• 16:37
  And
• 16:37
  you
• 16:37
  could
• 16:37
  probably
• 16:38
  have
• 16:38
  an
• 16:38
  Irish
• 16:39
  coffee
• 16:39
  at
• 16:40
  midnight
• 16:40
  and
• 16:40
  sleep
• 16:41
  like
• 16:41
  a
• 16:41
  baby.
• 16:41
  I'm
• 16:41
  not
• 16:41
  talking
• 16:42
  about
• 16:42
  you
• 16:42
  guys.
• 16:43
  Bless
• 16:43
  your
• 16:43
  souls.
• 16:44
  I'm
• 16:44
  nothing
• 16:44
  like
• 16:45
  you.
• 16:45
  I'm
• 16:45
  extremely
• 16:45
  sensitive
• 16:46
  to
• 16:46
  caffeine.
• 16:47
  But
• 16:48
  imagine
• 16:48
  how
• 16:48
  difficult
• 16:49
  that
• 16:49
  would
• 16:49
  be.
• 16:49
  So
• 16:49
  now
• 16:49
  you
• 16:50
  have
• 16:50
  a
• 16:50
  patient
• 16:50
  in
• 16:51
  Siri,
• 16:52
  10%
• 16:52
  of
• 16:53
  the
• 16:53
  population,
• 16:53
  85%
• 16:54
  of
• 16:54
  which
• 16:55
  also
• 16:56
  consume
• 16:56
  caffeine.
• 16:57
  So
• 16:58
  you
• 16:58
  have
• 16:58
  a
• 16:58
  wide
• 16:59
  range
• 16:59
  of
• 16:59
  patients
• 17:00
  who
• 17:00
  could
• 17:00
  be
• 17:01
  the
• 17:01
  10%
• 17:01
  of
• 17:02
  slow
• 17:02
  metabolizers
• 17:03
  or
• 17:03
  the
• 17:03
  85%
• 17:04
  of
• 17:04
  people
• 17:04
  who
• 17:05
  consume
• 17:05
  at
• 17:05
  least
• 17:06
  one
• 17:06
  caffeinated
• 17:06
  beverage.
• 17:07
  And
• 17:07
  depending
• 17:07
  on
• 17:07
  the
• 17:07
  timing
• 17:08
  of
• 17:08
  that
• 17:08
  consumption,
• 17:09
  now
• 17:09
  you
• 17:10
  are
• 17:10
  opening
• 17:10
  up
• 17:10
  the
• 17:10
  floodgates
• 17:11
  for
• 17:11
  so
• 17:11
  many
• 17:11
  different
• 17:12
  potential
• 17:12
  psychiatric
• 17:13
  problems.
• 17:14
  What
• 17:14
  does
• 17:15
  caffeine
• 17:15
  do?
• 17:15
  Well,
• 17:16
  for
• 17:16
  starters,
• 17:16
  it
• 17:17
  can
• 17:17
  precipitate
• 17:17
  insomnia.
• 17:18
  It
• 17:19
  leads
• 17:19
  to
• 17:19
  more
• 17:19
  broken
• 17:20
  and
• 17:20
  erratic
• 17:20
  sleep,
• 17:21
  it
• 17:21
  interferes
• 17:22
  with
• 17:22
  slow
• 17:22
  wave
• 17:23
  sleep.
• 17:23
  Which
• 17:23
  allows
• 17:24
  you
• 17:24
  to
• 17:24
  consolidate
• 17:25
  memories
• 17:26
  and
• 17:27
  engage
• 17:27
  in
• 17:27
  brain
• 17:28
  metabolic
• 17:28
  recovery
• 17:29
  and
• 17:29
  the
• 17:30
  repair
• 17:30
  of
• 17:30
  free
• 17:31
  radicals.
• 17:32
  It
• 17:32
  disrupts
• 17:32
  REM
• 17:33
  sleep,
• 17:33
  which
• 17:33
  is
• 17:33
  involved
• 17:34
  in
• 17:34
  emotional
• 17:34
  regulation
• 17:35
  and
• 17:35
  memory
• 17:36
  processing.
• 17:37
  Cognitive
• 17:37
  restoration,
• 17:38
  very
• 17:39
  important
• 17:39
  stuff,
• 17:40
  right?
• 17:40
  So
• 17:40
  your
• 17:40
  patient's
• 17:40
  waking
• 17:41
  up,
• 17:41
  they
• 17:41
  have
• 17:41
  brain
• 17:42
  fog.
• 17:43
  If
• 17:43
  you
• 17:43
  have
• 17:43
  PTSD
• 17:44
  and
• 17:44
  you
• 17:44
  rely
• 17:44
  on
• 17:45
  memory
• 17:45
  consolidation
• 17:46
  or
• 17:46
  you
• 17:46
  rely
• 17:47
  on
• 17:48
  emotional
• 17:49
  regulation
• 17:49
  in
• 17:49
  your
• 17:50
  REM
• 17:50
  cycles,
• 17:50
  caffeine
• 17:51
  now
• 17:51
  is
• 17:51
  getting
• 17:51
  in
• 17:52
  your
• 17:52
  way.
• 17:52
  That's
• 17:53
  a
• 17:53
  huge
• 17:53
  problem
• 17:54
  too.
• 17:54
  It
• 17:54
  undermines
• 17:54
  treat
• 17:55
  your
• 17:55
  ability
• 17:55
  to
• 17:55
  heal
• 17:56
  in
• 17:57
  all
• 17:57
  kinds
• 17:57
  of
• 17:57
  mood
• 17:58
  disorders.
• 17:58
  The
• 17:58
  importance
• 17:59
  of
• 18:00
  getting
• 18:00
  REM
• 18:01
  sleep,
• 18:01
  slow
• 18:01
  wave
• 18:02
  sleep
• 18:02
  so
• 18:03
  that
• 18:03
  your
• 18:03
  body
• 18:03
  can
• 18:03
  repair
• 18:04
  and
• 18:05
  hormones
• 18:05
  can
• 18:06
  realign
• 18:06
  at
• 18:06
  night.
• 18:06
  It's
• 18:07
  a
• 18:07
  very
• 18:07
  big
• 18:08
  deal.
• 18:08
  Your
• 18:09
  sleep
• 18:09
  becomes
• 18:09
  lighter,
• 18:10
  erratic,
• 18:10
  it's
• 18:10
  harder
• 18:10
  to
• 18:11
  fall
• 18:11
  asleep.
• 18:11
  Your
• 18:12
  cortisol
• 18:12
  can
• 18:13
  shoot
• 18:13
  up
• 18:13
  the
• 18:13
  next
• 18:13
  day,
• 18:14
  causing
• 18:14
  weight
• 18:14
  gain.
• 18:15
  Cortisol
• 18:16
  can
• 18:16
  be
• 18:16
  detrimental
• 18:17
  to
• 18:17
  neurotransmitters
• 18:19
  if
• 18:19
  it's
• 18:19
  dysregulated
• 18:20
  over
• 18:20
  time.
• 18:21
  Now
• 18:21
  you're
• 18:21
  playing
• 18:21
  from
• 18:21
  behind
• 18:22
  with
• 18:22
  a
• 18:22
  whole
• 18:22
  host
• 18:22
  of
• 18:23
  mental
• 18:23
  health
• 18:24
  conditions.
• 18:25
  This
• 18:25
  is
• 18:25
  a
• 18:25
  pretty
• 18:25
  big
• 18:26
  deal.
• 18:26
  And
• 18:27
  we
• 18:27
  really
• 18:27
  want
• 18:27
  to
• 18:28
  have
• 18:28
  a
• 18:28
  good
• 18:28
  inventory
• 18:28
  of
• 18:29
  John
• 18:29
  Luke's
• 18:29
  timing.
• 18:30
  Now
• 18:31
  there
• 18:31
  are
• 18:32
  ways
• 18:32
  that
• 18:32
  you
• 18:32
  can
• 18:33
  tell
• 18:33
  whether
• 18:33
  you're
• 18:33
  slow
• 18:34
  or
• 18:35
  fast
• 18:35
  metabol
• 18:36
  metabolizer
• 18:36
  of
• 18:37
  caffeine
• 18:37
  when
• 18:37
  you
• 18:37
  graduate,
• 18:38
  you
• 18:38
  may
• 18:38
  not
• 18:39
  be
• 18:39
  in
• 18:39
  a
• 18:39
  practice
• 18:39
  that
• 18:40
  regularly
• 18:40
  measures
• 18:41
  that,
• 18:41
  so
• 18:41
  don't
• 18:42
  think
• 18:42
  you're
• 18:42
  just
• 18:42
  going
• 18:42
  to
• 18:42
  start
• 18:42
  practicing.
• 18:43
  And
• 18:43
  all
• 18:44
  these
• 18:44
  amazing
• 18:44
  tools
• 18:45
  at
• 18:45
  your
• 18:45
  fingertips
• 18:46
  that
• 18:46
  tell
• 18:46
  you
• 18:46
  if
• 18:47
  your
• 18:47
  patient
• 18:47
  is
• 18:47
  a
• 18:48
  slow
• 18:48
  metabolizer
• 18:49
  of
• 18:49
  caffeine
• 18:50
  or
• 18:50
  not.
• 18:50
  Some
• 18:51
  of
• 18:51
  this
• 18:51
  is
• 18:51
  going
• 18:51
  to
• 18:52
  have
• 18:52
  to
• 18:52
  be
• 18:52
  hashed
• 18:52
  out
• 18:53
  more
• 18:53
  observationally
• 18:54
  over
• 18:55
  time.
• 18:55
  You
• 18:55
  can
• 18:55
  ask
• 18:55
  Jean
• 18:56
  Luc
• 18:56
  and
• 18:56
  he's
• 18:56
  already
• 18:57
  confirmed
• 18:57
  that
• 18:57
  he
• 18:58
  is
• 18:58
  pretty
• 18:58
  sensitive
• 18:58
  to
• 18:59
  caffeine,
• 18:59
  that
• 19:00
  he's
• 19:00
  otherwise
• 19:00
  not
• 19:00
  anxious
• 19:01
  or
• 19:01
  panicky,
• 19:02
  and
• 19:02
  that
• 19:02
  these
• 19:03
  are
• 19:03
  precipitated
• 19:04
  by
• 19:04
  his
• 19:04
  caffeine
• 19:05
  use.
• 19:05
  I
• 19:06
  would
• 19:06
  also
• 19:06
  ask
• 19:06
  him,
• 19:07
  has
• 19:07
  there
• 19:07
  ever
• 19:07
  been
• 19:07
  a
• 19:08
  time
• 19:08
  you
• 19:08
  abstain
• 19:08
  from
• 19:09
  caffeine
• 19:09
  for
• 19:09
  30
• 19:10
  days
• 19:10
  or
• 19:10
  more
• 19:10
  that
• 19:10
  you're
• 19:11
  aware
• 19:11
  of?
• 19:12
  If
• 19:12
  he's
• 19:12
  able
• 19:12
  to
• 19:12
  tell
• 19:12
  you
• 19:12
  that,
• 19:13
  you
• 19:13
  should
• 19:13
  ask
• 19:13
  him
• 19:14
  the
• 19:14
  follow
• 19:14
  up
• 19:14
  question
• 19:14
  of
• 19:15
  how
• 19:15
  often
• 19:15
  were
• 19:16
  these
• 19:16
  symptoms
• 19:17
  bothering
• 19:17
  you
• 19:18
  when
• 19:18
  you
• 19:18
  abstained
• 19:18
  from
• 19:19
  caffeine?
• 19:19
  These
• 19:19
  are
• 19:20
  the
• 19:20
  careful
• 19:20
  questions
• 19:21
  that
• 19:21
  you
• 19:22
  ask
• 19:22
  your
• 19:22
  patients
• 19:23
  to
• 19:23
  sculpt
• 19:23
  out
• 19:25
  better
• 19:25
  clarity
• 19:26
  in
• 19:27
  their
• 19:27
  symptoms.
• 19:27
  And
• 19:28
  slowly
• 19:29
  but
• 19:29
  surely
• 19:29
  you
• 19:30
  might
• 19:30
  get
• 19:30
  to
• 19:30
  a
• 19:31
  pretty
• 19:31
  good
• 19:31
  spot
• 19:32
  where
• 19:32
  he
• 19:32
  says,
• 19:32
  come
• 19:32
  to
• 19:33
  think
• 19:33
  of
• 19:33
  it,
• 19:34
  I
• 19:34
  wasn't
• 19:34
  drinking
• 19:35
  coffee
• 19:35
  at
• 19:35
  all
• 19:35
  until
• 19:36
  I
• 19:36
  was
• 19:36
  25
• 19:36
  and
• 19:36
  I
• 19:37
  never
• 19:37
  had
• 19:37
  these
• 19:37
  symptoms
• 19:38
  and
• 19:38
  I'm
• 19:38
  not
• 19:38
  a
• 19:38
  worrier
• 19:39
  and
• 19:39
  no,
• 19:40
  I
• 19:40
  don't
• 19:40
  dread
• 19:40
  the
• 19:40
  next.
• 19:41
  It's
• 19:41
  not
• 19:41
  really
• 19:42
  like
• 19:42
  that.
• 19:42
  I
• 19:42
  don't
• 19:42
  avoid
• 19:43
  places
• 19:44
  where
• 19:44
  I
• 19:44
  might
• 19:44
  have
• 19:45
  heart
• 19:45
  palpitations
• 19:45
  or
• 19:46
  tremors.
• 19:46
  I
• 19:47
  just
• 19:47
  really
• 19:47
  don't
• 19:47
  like
• 19:48
  these
• 19:48
  symptoms.
• 19:49
  Right.
• 19:49
  Because
• 19:49
  if
• 19:49
  he
• 19:49
  is
• 19:49
  avoiding
• 19:50
  places
• 19:51
  that
• 19:51
  he
• 19:51
  feels
• 19:52
  like
• 19:52
  he
• 19:52
  might
• 19:52
  lose
• 19:53
  control
• 19:53
  or
• 19:53
  have
• 19:53
  heart
• 19:53
  palpitations
• 19:54
  or
• 19:54
  feel
• 19:55
  really
• 19:55
  nervous,
• 19:56
  you
• 19:56
  should
• 19:56
  be
• 19:56
  thinking
• 19:56
  of
• 19:57
  a
• 19:57
  potential
• 19:57
  panic
• 19:58
  disorder
• 19:58
  or
• 19:59
  a
• 19:59
  substance
• 19:59
  induced
• 20:00
  anxiety
• 20:00
  disorder
• 20:01
  if
• 20:01
  this
• 20:01
  is
• 20:01
  starting
• 20:01
  to
• 20:01
  cause
• 20:02
  market
• 20:02
  impairment.
• 20:03
  And
• 20:03
  it,
• 20:03
  it
• 20:04
  sounds
• 20:04
  like
• 20:04
  it
• 20:04
  might
• 20:05
  be
• 20:05
  by
• 20:06
  virtue
• 20:06
  of
• 20:06
  the
• 20:06
  fact
• 20:06
  that
• 20:06
  he's
• 20:06
  impaired
• 20:07
  at
• 20:07
  work.
• 20:08
  My
• 20:08
  point
• 20:08
  here
• 20:08
  is
• 20:09
  you
• 20:09
  do
• 20:09
  want
• 20:09
  to
• 20:10
  keep
• 20:10
  an
• 20:10
  eye
• 20:11
  on
• 20:12
  whether
• 20:12
  or
• 20:12
  not
• 20:13
  he
• 20:13
  does
• 20:14
  have
• 20:14
  panic
• 20:14
  disorder,
• 20:15
  but
• 20:15
  this
• 20:15
  doesn't
• 20:16
  seem
• 20:16
  random.
• 20:16
  As
• 20:17
  required
• 20:17
  in
• 20:18
  a
• 20:18
  DSM
• 20:19
  5
• 20:19
  panic
• 20:20
  disorder
• 20:20
  diagnosis.
• 20:21
  This
• 20:21
  is
• 20:22
  precipitated
• 20:22
  by
• 20:23
  a
• 20:23
  particular
• 20:24
  substance
• 20:25
  that
• 20:25
  you've
• 20:25
  isolated.
• 20:26
  And
• 20:26
  you
• 20:26
  can
• 20:27
  then,
• 20:27
  if
• 20:28
  you
• 20:28
  have
• 20:28
  the
• 20:28
  tools,
• 20:28
  do
• 20:28
  a
• 20:29
  genetic
• 20:29
  test
• 20:29
  to
• 20:29
  see
• 20:29
  if
• 20:30
  he's
• 20:30
  a
• 20:30
  slow
• 20:30
  metabolizer
• 20:31
  of
• 20:31
  caffeine
• 20:32
  at
• 20:32
  CYP1A2.
• 20:34
  Remember
• 20:34
  that
• 20:34
  CYP1A2
• 20:35
  and
• 20:35
  here's
• 20:36
  a
• 20:36
  little
• 20:36
  pearl
• 20:36
  as
• 20:36
  well.
• 20:37
  If
• 20:37
  you
• 20:37
  have
• 20:38
  a
• 20:38
  patient
• 20:38
  on
• 20:38
  Zyprexa
• 20:39
  or
• 20:40
  something
• 20:40
  of
• 20:40
  that
• 20:40
  nature,
• 20:41
  remember
• 20:42
  that
• 20:42
  caffeine
• 20:43
  actually
• 20:43
  competes
• 20:44
  for
• 20:44
  the
• 20:44
  CYP1A2
• 20:46
  receptor
• 20:46
  with
• 20:46
  Zyprexa.
• 20:47
  So
• 20:48
  it
• 20:48
  can
• 20:48
  actually
• 20:49
  elevate
• 20:49
  the
• 20:50
  levels
• 20:50
  of
• 20:50
  Zyprexa
• 20:51
  because
• 20:51
  it's
• 20:52
  competing
• 20:52
  for
• 20:53
  that
• 20:53
  metabolism,
• 20:54
  leading
• 20:54
  to
• 20:54
  more
• 20:54
  weight
• 20:55
  gain,
• 20:55
  leading
• 20:55
  to
• 20:56
  more
• 20:56
  dystonias
• 20:57
  or
• 20:57
  EPS
• 20:58
  symptoms.
• 20:58
  So
• 20:59
  just
• 20:59
  keep
• 20:59
  that
• 20:59
  in
• 20:59
  mind
• 21:00
  that
• 21:00
  this
• 21:00
  is
• 21:00
  not
• 21:00
  as
• 21:00
  simple
• 21:01
  as
• 21:01
  slow
• 21:01
  metabolizer,
• 21:02
  rapid
• 21:02
  metabolizer.
• 21:03
  There
• 21:03
  are
• 21:03
  also
• 21:03
  things
• 21:04
  like
• 21:04
  oral
• 21:05
  contraceptives,
• 21:05
  SSRIs
• 21:07
  and
• 21:08
  you
• 21:08
  know,
• 21:08
  Zyprexa
• 21:09
  that
• 21:10
  can
• 21:10
  compete
• 21:10
  directly
• 21:11
  with
• 21:12
  some
• 21:12
  of
• 21:12
  these
• 21:12
  receptors
• 21:13
  and
• 21:13
  influence
• 21:14
  how
• 21:14
  they
• 21:14
  are
• 21:14
  metabolized.
• 21:16
  Very
• 21:16
  fascinating
• 21:17
  stuff.
• 21:18
  One
• 21:18
  of
• 21:18
  the
• 21:18
  neat
• 21:19
  things
• 21:19
  about
• 21:20
  this,
• 21:20
  and
• 21:20
  I
• 21:21
  encourage
• 21:21
  you
• 21:21
  to
• 21:21
  become
• 21:21
  a
• 21:21
  Patreon
• 21:22
  member,
• 21:22
  my
• 21:22
  friends,
• 21:23
  because
• 21:23
  if
• 21:23
  you
• 21:23
  become
• 21:23
  a
• 21:23
  Patreon
• 21:24
  member,
• 21:24
  you'll
• 21:24
  have
• 21:24
  a
• 21:24
  slide
• 21:25
  deck
• 21:25
  of
• 21:26
  John
• 21:26
  Luke's
• 21:26
  case.
• 21:26
  And
• 21:27
  in
• 21:27
  the
• 21:27
  slide
• 21:27
  deck
• 21:28
  you
• 21:28
  can
• 21:28
  actually
• 21:28
  see
• 21:29
  the
• 21:29
  half
• 21:29
  lives
• 21:30
  and,
• 21:30
  and
• 21:30
  the
• 21:31
  difference
• 21:31
  between
• 21:31
  someone
• 21:32
  who
• 21:32
  metabolizes
• 21:33
  caffeine
• 21:34
  normally
• 21:34
  and
• 21:34
  somebody
• 21:35
  who
• 21:35
  metabolizes
• 21:36
  it
• 21:36
  poorly.
• 21:36
  It's
• 21:37
  really
• 21:37
  shocking.
• 21:38
  Even
• 21:38
  the
• 21:39
  next
• 21:39
  day
• 21:39
  at
• 21:39
  9am
• 21:40
  A
• 21:40
  poor
• 21:40
  metabolizer
• 21:41
  like
• 21:41
  Jean
• 21:41
  Luc
• 21:42
  can
• 21:42
  still
• 21:43
  have
• 21:44
  24
• 21:44
  milligrams
• 21:45
  of
• 21:45
  caffeine
• 21:46
  in
• 21:46
  their
• 21:46
  system
• 21:47
  24
• 21:47
  hours
• 21:48
  later.
• 21:48
  I
• 21:49
  mean,
• 21:49
  that's
• 21:49
  unbelievable
• 21:50
  to
• 21:50
  think
• 21:50
  of
• 21:50
  the
• 21:51
  kind
• 21:51
  of
• 21:51
  interference
• 21:52
  that
• 21:52
  can
• 21:53
  play
• 21:53
  in
• 21:53
  somebody's
• 21:53
  mental
• 21:54
  health.
• 21:54
  Now
• 21:54
  he's
• 21:55
  got
• 21:55
  25
• 21:55
  milligrams
• 21:56
  of
• 21:56
  caffeine
• 21:56
  in
• 21:56
  his
• 21:57
  system
• 21:57
  from
• 21:57
  the
• 21:57
  next
• 21:57
  day.
• 21:58
  And
• 21:58
  even
• 21:58
  though
• 21:58
  he
• 21:59
  had
• 21:59
  a
• 21:59
  matcha
• 21:59
  at
• 22:00
  8am
• 22:00
  the
• 22:01
  last
• 22:01
  day,
• 22:01
  that
• 22:01
  was
• 22:02
  140
• 22:02
  milligrams
• 22:03
  or
• 22:03
  two
• 22:03
  matchas
• 22:04
  that
• 22:04
  were
• 22:04
  140
• 22:04
  milligrams
• 22:05
  total.
• 22:05
  The
• 22:06
  next
• 22:06
  day
• 22:06
  he
• 22:06
  has
• 22:06
  a
• 22:06
  25
• 22:07
  milligram
• 22:08
  of
• 22:08
  caffeine
• 22:08
  still
• 22:09
  in
• 22:09
  his
• 22:09
  system.
• 22:09
  Because
• 22:10
  of
• 22:10
  those
• 22:10
  half
• 22:10
  lives,
• 22:10
  my
• 22:11
  friends,
• 22:11
  the
• 22:11
  half
• 22:11
  life
• 22:11
  of
• 22:11
  10
• 22:12
  hours.
• 22:12
  Every
• 22:13
  10
• 22:13
  hours
• 22:14
  the
• 22:15
  amount
• 22:15
  of
• 22:15
  caffeine
• 22:16
  in
• 22:16
  his
• 22:16
  system
• 22:17
  goes
• 22:17
  down
• 22:17
  by
• 22:18
  50%
• 22:18
  and
• 22:18
  then
• 22:19
  another
• 22:19
  50%
• 22:19
  and
• 22:19
  then
• 22:20
  another
• 22:20
  50%.
• 22:20
  And
• 22:20
  if
• 22:20
  you
• 22:21
  keep
• 22:21
  doing
• 22:21
  the
• 22:21
  math,
• 22:21
  that
• 22:22
  brings
• 22:22
  you
• 22:22
  to
• 22:22
  25mg
• 22:24
  at
• 22:24
  8am
• 22:24
  the
• 22:25
  next
• 22:25
  day,
• 22:25
  as
• 22:26
  opposed
• 22:26
  to
• 22:26
  a
• 22:26
  normal
• 22:26
  metabolizer
• 22:27
  where
• 22:27
  it's
• 22:27
  completely
• 22:28
  out
• 22:28
  of
• 22:28
  his
• 22:28
  system.
• 22:29
  If
• 22:29
  you
• 22:29
  still
• 22:30
  have
• 22:30
  caffeine
• 22:30
  in
• 22:31
  your
• 22:31
  system
• 22:31
  the
• 22:32
  next
• 22:32
  day
• 22:32
  and
• 22:32
  then
• 22:32
  you
• 22:33
  start
• 22:33
  drinking
• 22:33
  again
• 22:34
  because,
• 22:35
  well,
• 22:35
  I'm
• 22:35
  so
• 22:36
  tired
• 22:36
  now,
• 22:36
  I
• 22:36
  didn't
• 22:36
  get
• 22:37
  sleep,
• 22:37
  I
• 22:37
  was
• 22:37
  up
• 22:37
  all
• 22:37
  day,
• 22:38
  so
• 22:38
  I'm
• 22:38
  gonna
• 22:38
  have
• 22:38
  more
• 22:38
  caffeine.
• 22:39
  You
• 22:39
  could
• 22:39
  see
• 22:40
  how
• 22:40
  this
• 22:40
  is
• 22:40
  this
• 22:40
  vicious
• 22:41
  positive
• 22:42
  feedback
• 22:42
  cycle.
• 22:43
  And
• 22:43
  sure
• 22:43
  enough,
• 22:44
  Jean
• 22:44
  Luc
• 22:44
  might
• 22:45
  at
• 22:45
  some
• 22:45
  point
• 22:46
  start
• 22:46
  to
• 22:46
  develop
• 22:47
  a
• 22:47
  full
• 22:47
  blown
• 22:48
  substance
• 22:48
  induced
• 22:49
  anxiety
• 22:49
  disorder
• 22:50
  where
• 22:50
  he
• 22:51
  does
• 22:51
  worry
• 22:52
  and,
• 22:52
  and
• 22:52
  he's
• 22:52
  on
• 22:53
  edge
• 22:53
  most
• 22:53
  days,
• 22:54
  even
• 22:54
  though
• 22:54
  the
• 22:54
  precipitating
• 22:55
  factor
• 22:55
  is
• 22:56
  more
• 22:56
  physical.
• 22:57
  He
• 22:58
  can
• 22:58
  start
• 22:58
  feeling
• 22:58
  super
• 22:59
  anxious,
• 23:00
  he
• 23:00
  can
• 23:00
  have
• 23:00
  panic
• 23:01
  attacks,
• 23:01
  he
• 23:02
  can
• 23:02
  start
• 23:03
  experiencing
• 23:03
  obsessions
• 23:04
  or
• 23:04
  compulsions.
• 23:05
  And
• 23:06
  now
• 23:06
  he's
• 23:07
  not
• 23:07
  sleeping
• 23:07
  enough.
• 23:07
  And
• 23:08
  through
• 23:08
  time
• 23:08
  maybe
• 23:08
  he'll
• 23:09
  develop
• 23:09
  a
• 23:09
  depressive
• 23:09
  disorder.
• 23:10
  A
• 23:11
  lot
• 23:11
  of
• 23:11
  things
• 23:11
  can
• 23:11
  be
• 23:12
  unleashed
• 23:12
  through
• 23:12
  this
• 23:12
  and
• 23:13
  how
• 23:13
  common
• 23:13
  caffeine
• 23:14
  is,
• 23:14
  how
• 23:15
  commonly
• 23:15
  it's
• 23:15
  consumed
• 23:16
  and
• 23:16
  the
• 23:17
  variation
• 23:17
  of
• 23:18
  caffeine
• 23:18
  products
• 23:19
  out
• 23:19
  there
• 23:20
  from
• 23:20
  pre
• 23:20
  workout
• 23:21
  and
• 23:21
  energy
• 23:21
  drinks
• 23:22
  and
• 23:22
  God,
• 23:22
  I
• 23:23
  think
• 23:23
  even
• 23:23
  jelly
• 23:23
  beans
• 23:24
  have
• 23:24
  caffeine.
• 23:24
  You
• 23:25
  might
• 23:25
  want
• 23:25
  to
• 23:25
  fact
• 23:25
  check
• 23:25
  me.
• 23:26
  That's
• 23:26
  why
• 23:26
  I
• 23:27
  would
• 23:27
  love
• 23:27
  if
• 23:27
  you
• 23:27
  emailed
• 23:28
  me.
• 23:28
  I'd
• 23:28
  love
• 23:28
  to
• 23:28
  hear
• 23:29
  your
• 23:29
  feedback
• 23:30
  and
• 23:30
  your
• 23:31
  experience
• 23:31
  about
• 23:32
  caffeine
• 23:32
  and
• 23:33
  what
• 23:33
  you've
• 23:33
  seen
• 23:33
  out
• 23:34
  there
• 23:34
  in
• 23:34
  practice.
• 23:35
  This
• 23:35
  is
• 23:35
  such
• 23:35
  a
• 23:35
  big
• 23:36
  deal
• 23:36
  because
• 23:36
  it's
• 23:36
  so
• 23:37
  ubiquitous.
• 23:37
  Methamphetamines,
• 23:38
  how
• 23:38
  many
• 23:39
  times
• 23:39
  you're
• 23:39
  going
• 23:39
  to
• 23:39
  meet
• 23:39
  someone
• 23:40
  who's
• 23:40
  addicted
• 23:41
  to
• 23:41
  meth?
• 23:41
  I've
• 23:41
  had
• 23:42
  patients
• 23:42
  like
• 23:42
  that,
• 23:42
  but
• 23:43
  it's
• 23:43
  few
• 23:43
  and
• 23:43
  far
• 23:44
  between.
• 23:44
  Caffeine
• 23:45
  is
• 23:45
  80%
• 23:46
  one
• 23:47
  caffeinated
• 23:48
  drink
• 23:48
  or
• 23:49
  more
• 23:49
  in
• 23:49
  the
• 23:49
  United
• 23:50
  States.
• 23:50
  That's
• 23:50
  a
• 23:50
  lot.
• 23:50
  With
• 23:51
  a
• 23:51
  variability
• 23:51
  of
• 23:52
  40
• 23:52
  fold
• 23:53
  metabolism
• 23:54
  variances.
• 23:55
  It's
• 23:56
  a
• 23:56
  really
• 23:56
  big
• 23:56
  deal.
• 23:56
  And
• 23:57
  what
• 23:57
  that
• 23:57
  can
• 23:57
  do
• 23:57
  to
• 23:57
  the
• 23:58
  half
• 23:58
  lives
• 23:58
  depending
• 23:59
  on
• 23:59
  the
• 23:59
  milligrams
• 24:00
  of
• 24:01
  caffeine
• 24:02
  in
• 24:02
  ingested.
• 24:03
  The
• 24:03
  big
• 24:03
  takeaways
• 24:04
  here,
• 24:04
  I
• 24:04
  hope
• 24:04
  for
• 24:05
  all
• 24:05
  of
• 24:05
  you,
• 24:05
  is
• 24:05
  number
• 24:05
  one,
• 24:05
  do
• 24:06
  a
• 24:06
  full
• 24:06
  caffeine
• 24:06
  inventory
• 24:07
  with
• 24:07
  your
• 24:07
  patients.
• 24:08
  Recognize
• 24:09
  that
• 24:09
  when
• 24:09
  you
• 24:09
  disrupt
• 24:10
  sleep
• 24:11
  by
• 24:11
  virtue
• 24:12
  of
• 24:12
  how
• 24:12
  fast
• 24:12
  you
• 24:13
  metabolize
• 24:13
  this
• 24:13
  stuff
• 24:14
  or
• 24:14
  how
• 24:14
  slow
• 24:14
  you
• 24:14
  metabolize
• 24:15
  it,
• 24:15
  so
• 24:16
  so
• 24:16
  many
• 24:16
  things
• 24:16
  can
• 24:16
  go
• 24:17
  wrong.
• 24:17
  Anxiety,
• 24:18
  weight
• 24:19
  gain,
• 24:19
  hormonal
• 24:20
  fluctuations,
• 24:21
  cognitive
• 24:21
  repair,
• 24:23
  deep
• 24:23
  sleep
• 24:23
  rem.
• 24:24
  All
• 24:24
  of
• 24:24
  those
• 24:24
  things
• 24:25
  get
• 24:25
  undermined
• 24:26
  and
• 24:26
  your
• 24:26
  entire
• 24:27
  diagnostic
• 24:27
  clarity
• 24:28
  is
• 24:28
  confused.
• 24:29
  Your
• 24:29
  treatment
• 24:29
  outcomes
• 24:30
  are
• 24:30
  hampered
• 24:30
  a
• 24:30
  little
• 24:31
  bit.
• 24:31
  So
• 24:32
  get
• 24:32
  a
• 24:32
  good
• 24:32
  inventory
• 24:33
  of
• 24:33
  how
• 24:34
  much
• 24:34
  caffeine
• 24:34
  they're
• 24:34
  taking.
• 24:35
  Even
• 24:35
  in
• 24:35
  Midol,
• 24:36
  even
• 24:36
  in
• 24:36
  Excedrin,
• 24:37
  there's
• 24:38
  caffeine
• 24:38
  counts
• 24:39
  that
• 24:39
  are
• 24:39
  kind
• 24:40
  of
• 24:40
  sneaky.
• 24:40
  Think
• 24:41
  about
• 24:41
  all
• 24:41
  the
• 24:41
  other
• 24:41
  things
• 24:42
  that
• 24:42
  might
• 24:42
  influence
• 24:43
  caffeine
• 24:44
  metabolism.
• 24:45
  Add
• 24:45
  that
• 24:45
  to
• 24:45
  the
• 24:46
  mix
• 24:46
  and
• 24:46
  you
• 24:46
  have
• 24:46
  even
• 24:47
  more
• 24:47
  to
• 24:47
  think
• 24:47
  about.
• 24:48
  And
• 24:48
  remember,
• 24:49
  if
• 24:49
  you've
• 24:49
  mistakenly
• 24:50
  labeled
• 24:51
  someone
• 24:51
  or
• 24:51
  diagnosed
• 24:51
  someone
• 24:52
  with
• 24:52
  a
• 24:52
  social
• 24:52
  anxiety
• 24:53
  disorder
• 24:53
  or
• 24:53
  panic
• 24:54
  disorder
• 24:54
  and
• 24:54
  now
• 24:54
  you
• 24:55
  put
• 24:55
  them
• 24:55
  on
• 24:55
  benzodiazepines
• 24:57
  or
• 24:57
  you've
• 24:57
  started
• 24:58
  SSRIs
• 24:58
  or
• 24:58
  you
• 24:59
  do
• 24:59
  something
• 24:59
  else
• 24:59
  that's
• 24:59
  complicated
• 25:00
  and
• 25:00
  you
• 25:00
  didn't
• 25:01
  ask
• 25:01
  this
• 25:01
  question,
• 25:01
  you
• 25:02
  could
• 25:02
  have
• 25:02
  saved
• 25:02
  them
• 25:02
  from
• 25:03
  all
• 25:03
  the
• 25:03
  polypharmacy,
• 25:04
  more
• 25:04
  diagnostic
• 25:05
  side
• 25:05
  effects
• 25:06
  and
• 25:06
  sexual
• 25:06
  dysfunctions.
• 25:07
  You
• 25:07
  could
• 25:07
  have
• 25:07
  saved
• 25:07
  them
• 25:08
  if
• 25:08
  you
• 25:08
  just
• 25:08
  got
• 25:08
  a
• 25:08
  careful
• 25:10
  so
• 25:10
  I
• 25:10
  really
• 25:10
  hope
• 25:10
  you
• 25:11
  enjoyed
• 25:11
  this
• 25:11
  episode,
• 25:11
  my
• 25:12
  friends.
• 25:12
  I
• 25:12
  can't
• 25:12
  emphasize
• 25:13
  enough
• 25:13
  to
• 25:13
  become
• 25:13
  Patreon
• 25:14
  members
• 25:14
  where
• 25:14
  you
• 25:15
  have
• 25:15
  access
• 25:15
  to
• 25:15
  exclusive
• 25:16
  slide
• 25:17
  decks
• 25:17
  with
• 25:18
  high
• 25:18
  yield
• 25:19
  practice
• 25:19
  information,
• 25:20
  pearls,
• 25:21
  research
• 25:21
  articles,
• 25:22
  really
• 25:22
  beautiful
• 25:23
  things
• 25:23
  that
• 25:23
  you
• 25:23
  need
• 25:23
  to
• 25:24
  be
• 25:25
  sharper
• 25:25
  in
• 25:25
  your
• 25:25
  practice.
• 25:26
  You
• 25:26
  also
• 25:27
  will
• 25:27
  have
• 25:27
  access
• 25:27
  to
• 25:28
  a
• 25:29
  private
• 25:29
  podcast
• 25:30
  feed
• 25:30
  with
• 25:30
  more
• 25:30
  mock
• 25:30
  case
• 25:31
  studies
• 25:31
  like
• 25:31
  this
• 25:31
  to
• 25:32
  really
• 25:32
  propel
• 25:32
  your
• 25:32
  practice.
• 25:33
  This
• 25:33
  podcast
• 25:34
  has
• 25:34
  gotten
• 25:34
  very
• 25:34
  big
• 25:35
  very
• 25:35
  quickly,
• 25:36
  particularly
• 25:36
  among
• 25:36
  NP
• 25:37
  students
• 25:38
  as
• 25:38
  this
• 25:38
  is
• 25:38
  geared
• 25:38
  towards
• 25:39
  psych
• 25:39
  NP
• 25:39
  students
• 25:40
  to
• 25:40
  start
• 25:40
  thinking
• 25:41
  more
• 25:41
  critically
• 25:41
  through
• 25:42
  case
• 25:42
  studies.
• 25:43
  I
• 25:43
  find
• 25:43
  that's
• 25:43
  a
• 25:43
  really
• 25:43
  fun
• 25:44
  way
• 25:44
  to
• 25:44
  go
• 25:44
  about
• 25:44
  things
• 25:45
  and
• 25:45
  you
• 25:46
  all
• 25:46
  have
• 25:46
  really
• 25:46
  provided
• 25:47
  great
• 25:47
  feedback.
• 25:47
  Definitely
• 25:48
  email
• 25:48
  me
• 25:49
  if
• 25:49
  you
• 25:49
  have
• 25:49
  questions
• 25:50
  and
• 25:50
  you
• 25:50
  want
• 25:50
  certain
• 25:51
  cases
• 25:51
  to
• 25:51
  get
• 25:52
  looked
• 25:52
  at
• 25:52
  and
• 25:52
  themes
• 25:53
  to
• 25:53
  be
• 25:53
  brought
• 25:53
  up.
• 25:53
  I'd
• 25:54
  love
• 25:54
  to
• 25:54
  teach
• 25:55
  different
• 25:55
  things
• 25:55
  that
• 25:55
  you're
• 25:55
  having
• 25:56
  trouble
• 25:56
  with
• 25:56
  in
• 25:56
  class.
• 25:57
  There's
• 25:57
  a
• 25:57
  whole
• 25:58
  host
• 25:58
  of
• 25:58
  really
• 25:59
  fun
• 25:59
  things
• 25:59
  we're
• 25:59
  going
• 25:59
  to
• 25:59
  go
• 26:00
  over
• 26:00
  in
• 26:00
  the
• 26:00
  future
• 26:00
  as
• 26:00
  well.
• 26:02
  Pleasure
• 26:02
  to
• 26:02
  be
• 26:02
  with
• 26:03
  you.
• 26:03
  Signing
• 26:03
  off
• 26:03
  now.
• 26:04
  Take
• 26:04
  care
• 26:04
  everybody
• 26:05
  and
• 26:05
  bye
• 26:05
  bye.