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Exploring the Nuances of Bipolar I: Insights from a Mock Patient · Pearls and Prep

• 0:00
  Foreign.
• 0:04
  Welcome
• 0:04
  back
• 0:04
  my
• 0:05
  friends
• 0:05
  to
• 0:05
  another
• 0:06
  episode
• 0:06
  of
• 0:06
  Pearls
• 0:07
  and
• 0:08
  prep
• 0:08
  your
• 0:08
  go
• 0:08
  to
• 0:09
  place
• 0:09
  for
• 0:09
  pearls
• 0:10
  that
• 0:10
  prep
• 0:10
  you
• 0:11
  for
• 0:11
  practice.
• 0:12
  Please
• 0:12
  meet
• 0:13
  our
• 0:13
  mock
• 0:13
  patient
• 0:14
  of
• 0:14
  the
• 0:14
  day,
• 0:14
  Michael.
• 0:15
  Michael
• 0:15
  is
• 0:15
  a
• 0:16
  32
• 0:16
  year
• 0:17
  old
• 0:17
  plumber.
• 0:18
  Michael
• 0:19
  has
• 0:20
  just
• 0:20
  invested
• 0:21
  $15,000
• 0:23
  jumping
• 0:23
  on
• 0:23
  trains,
• 0:24
  planes
• 0:25
  and
• 0:25
  automobiles
• 0:26
  in
• 0:26
  an
• 0:26
  attempt
• 0:26
  to
• 0:27
  find
• 0:27
  Mike
• 0:27
  Tyson
• 0:28
  and
• 0:28
  challenge
• 0:28
  him
• 0:28
  to
• 0:28
  a
• 0:29
  boxing
• 0:29
  match.
• 0:30
  He
• 0:30
  is
• 0:31
  coming
• 0:31
  to
• 0:31
  the
• 0:31
  emergency
• 0:32
  room.
• 0:32
  His
• 0:32
  friends
• 0:33
  were
• 0:33
  concerned
• 0:34
  about
• 0:34
  him
• 0:35
  and
• 0:35
  brought
• 0:35
  him
• 0:36
  to
• 0:36
  the
• 0:36
  emergency
• 0:36
  room
• 0:37
  for
• 0:37
  evaluation.
• 0:38
  Now
• 0:39
  you
• 0:40
  are
• 0:40
  consulting
• 0:41
  on
• 0:41
  this
• 0:41
  case
• 0:42
  after
• 0:43
  medical
• 0:43
  has
• 0:44
  ruled
• 0:44
  out
• 0:44
  a
• 0:44
  lot
• 0:45
  of
• 0:45
  the
• 0:45
  medical
• 0:45
  problems
• 0:46
  that
• 0:46
  this
• 0:46
  could
• 0:47
  manifest
• 0:47
  into.
• 0:48
  They
• 0:48
  want
• 0:49
  your
• 0:49
  psychiatric
• 0:50
  take.
• 0:50
  Now.
• 0:51
  Michael
• 0:52
  has.
• 0:53
  He's
• 0:53
  normally
• 0:53
  pretty
• 0:54
  reserved,
• 0:54
  but
• 0:54
  he
• 0:55
  has
• 0:56
  sort
• 0:56
  of
• 0:56
  morphed
• 0:57
  into
• 0:57
  a
• 0:57
  high
• 0:57
  energy
• 0:58
  kind
• 0:58
  of
• 0:58
  guy.
• 0:59
  He's
• 0:59
  been
• 0:59
  very
• 0:59
  irritable,
• 1:00
  talking
• 1:01
  very
• 1:01
  fast
• 1:02
  about
• 1:02
  his
• 1:03
  brilliant
• 1:03
  world
• 1:04
  changing
• 1:04
  ideas
• 1:05
  as
• 1:05
  his
• 1:05
  friends
• 1:05
  characterize
• 1:06
  it.
• 1:07
  He
• 1:07
  has
• 1:07
  these
• 1:07
  rapid
• 1:08
  fire
• 1:08
  monologues
• 1:09
  and
• 1:10
  he's
• 1:10
  not
• 1:10
  sleeping
• 1:11
  very
• 1:11
  well
• 1:11
  at
• 1:12
  all.
• 1:12
  He
• 1:12
  looks
• 1:12
  pretty
• 1:13
  exhausted
• 1:13
  too.
• 1:15
  And
• 1:15
  he's
• 1:15
  been
• 1:15
  in.
• 1:16
  He's
• 1:16
  had
• 1:16
  this
• 1:17
  creative
• 1:17
  burst.
• 1:18
  You
• 1:18
  dig
• 1:18
  a
• 1:18
  little
• 1:18
  deeper
• 1:19
  and
• 1:19
  you
• 1:19
  find
• 1:19
  out
• 1:20
  that
• 1:20
  Michael
• 1:20
  has
• 1:21
  tried
• 1:21
  Prozac
• 1:22
  in
• 1:22
  the
• 1:22
  past.
• 1:23
  You
• 1:24
  ask
• 1:24
  a
• 1:24
  few
• 1:24
  more
• 1:25
  questions
• 1:26
  and
• 1:26
  realize
• 1:26
  that
• 1:27
  his
• 1:27
  plan
• 1:27
  to
• 1:27
  fight
• 1:27
  Mike
• 1:28
  Tyson
• 1:28
  was
• 1:29
  thought
• 1:30
  out
• 1:30
  to
• 1:30
  a
• 1:31
  large
• 1:31
  extent.
• 1:31
  He
• 1:31
  reached
• 1:32
  out
• 1:32
  to
• 1:32
  hbo,
• 1:33
  Showtime
• 1:33
  and
• 1:33
  Netflix
• 1:34
  to
• 1:34
  propose
• 1:35
  fight
• 1:35
  times
• 1:36
  and
• 1:36
  he
• 1:36
  tried
• 1:36
  to
• 1:36
  contact
• 1:37
  Mike
• 1:37
  Tyson's
• 1:37
  agent.
• 1:38
  He
• 1:38
  bought
• 1:39
  $4,000
• 1:39
  worth
• 1:40
  of
• 1:40
  boxing
• 1:40
  equipment.
• 1:41
  Michael
• 1:42
  tells
• 1:42
  you,
• 1:42
  and
• 1:42
  you've
• 1:43
  corroborated
• 1:44
  this
• 1:44
  with
• 1:44
  his
• 1:44
  good
• 1:45
  friends.
• 1:45
  You've
• 1:45
  even
• 1:46
  called
• 1:46
  his
• 1:46
  mother
• 1:46
  in
• 1:46
  Atlanta
• 1:47
  and
• 1:48
  she
• 1:48
  said
• 1:48
  that
• 1:48
  he
• 1:48
  has
• 1:49
  not
• 1:49
  really
• 1:50
  been
• 1:50
  depressed
• 1:50
  in
• 1:51
  the
• 1:51
  past,
• 1:51
  to
• 1:51
  their
• 1:51
  knowledge.
• 1:52
  Maybe
• 1:53
  some
• 1:53
  episodes
• 1:53
  where
• 1:54
  he
• 1:54
  was
• 1:54
  down,
• 1:55
  but
• 1:55
  it's
• 1:55
  a
• 1:55
  little
• 1:55
  bit
• 1:55
  unclear
• 1:56
  and
• 1:56
  that
• 1:57
  he
• 1:57
  hasn't
• 1:57
  had
• 1:57
  episodes
• 1:58
  like
• 1:58
  this
• 1:58
  in
• 1:58
  the
• 1:58
  past
• 1:59
  either
• 1:59
  where
• 1:59
  he
• 1:59
  was
• 2:00
  really
• 2:01
  revved
• 2:01
  up
• 2:01
  or
• 2:01
  irritable
• 2:02
  or
• 2:02
  coming
• 2:03
  up
• 2:03
  with
• 2:03
  ideas
• 2:03
  that
• 2:04
  are
• 2:04
  a
• 2:04
  little
• 2:04
  bit
• 2:04
  bizarre.
• 2:05
  His
• 2:05
  mother
• 2:06
  does
• 2:06
  share
• 2:06
  with
• 2:06
  you
• 2:07
  that
• 2:07
  her
• 2:07
  sister
• 2:08
  or
• 2:08
  his
• 2:08
  aunt
• 2:08
  has
• 2:09
  a
• 2:09
  diagnosis
• 2:09
  of
• 2:10
  bipolar
• 2:10
  disorder.
• 2:11
  She's
• 2:11
  not
• 2:12
  sure
• 2:12
  which
• 2:12
  type,
• 2:12
  but
• 2:13
  that's
• 2:13
  what
• 2:13
  you
• 2:13
  got
• 2:13
  from
• 2:14
  that.
• 2:14
  You.
• 2:15
  You
• 2:15
  also
• 2:15
  learn
• 2:15
  that
• 2:16
  Michael
• 2:16
  has
• 2:16
  a
• 2:17
  history
• 2:17
  of
• 2:17
  migraines
• 2:18
  and
• 2:19
  drinks
• 2:20
  socially
• 2:20
  one
• 2:21
  to
• 2:21
  two
• 2:21
  times
• 2:22
  per
• 2:22
  week.
• 2:23
  Lately
• 2:23
  he's
• 2:23
  drank
• 2:24
  a
• 2:24
  little
• 2:24
  more
• 2:24
  than
• 2:25
  usual
• 2:25
  to
• 2:25
  calm
• 2:26
  his
• 2:26
  brain
• 2:26
  down.
• 2:26
  He
• 2:27
  states
• 2:27
  he
• 2:28
  has
• 2:28
  not
• 2:28
  used
• 2:28
  any
• 2:29
  illicit
• 2:29
  substances.
• 2:30
  His
• 2:30
  UDS
• 2:30
  is
• 2:31
  negative.
• 2:32
  We
• 2:32
  already
• 2:33
  know
• 2:33
  about
• 2:33
  his
• 2:33
  past
• 2:34
  Prozac
• 2:34
  trial.
• 2:36
  So
• 2:36
  what
• 2:36
  are
• 2:36
  we
• 2:36
  thinking
• 2:37
  about
• 2:37
  Michael
• 2:38
  right
• 2:38
  now?
• 2:38
  These
• 2:39
  are
• 2:39
  the
• 2:39
  questions
• 2:39
  you
• 2:40
  have
• 2:40
  to
• 2:40
  ask
• 2:40
  yourself
• 2:40
  and
• 2:41
  be
• 2:41
  very
• 2:41
  open
• 2:41
  in
• 2:42
  the
• 2:42
  beginning
• 2:42
  to
• 2:43
  any
• 2:43
  kind
• 2:43
  of
• 2:44
  diagnostic
• 2:45
  impression
• 2:46
  that
• 2:46
  you
• 2:47
  can
• 2:47
  come
• 2:47
  up
• 2:47
  with.
• 2:47
  Right?
• 2:48
  I
• 2:48
  mean,
• 2:48
  obviously
• 2:49
  this
• 2:49
  looks
• 2:50
  like
• 2:50
  a
• 2:50
  bipolar
• 2:51
  type
• 2:51
  situation
• 2:52
  and
• 2:52
  it's
• 2:52
  good
• 2:53
  we
• 2:53
  did
• 2:53
  a
• 2:53
  uds
• 2:54
  because
• 2:54
  coming
• 2:55
  to
• 2:55
  the
• 2:55
  er,
• 2:56
  it's
• 2:56
  very
• 2:56
  possible
• 2:57
  that
• 2:57
  this
• 2:58
  was
• 2:59
  drug
• 3:00
  related.
• 3:00
  You
• 3:00
  might
• 3:01
  get
• 3:01
  a
• 3:01
  better
• 3:01
  idea
• 3:01
  of
• 3:01
  that
• 3:02
  just
• 3:02
  by
• 3:02
  talking
• 3:02
  to
• 3:02
  Michael's
• 3:03
  friends,
• 3:03
  because
• 3:04
  his
• 3:04
  friends
• 3:05
  are
• 3:05
  normally
• 3:05
  a
• 3:05
  good
• 3:06
  source
• 3:06
  of
• 3:06
  information.
• 3:07
  They
• 3:07
  can
• 3:07
  point
• 3:07
  you
• 3:07
  in
• 3:07
  the
• 3:07
  right
• 3:08
  direction.
• 3:08
  Oh,
• 3:08
  he
• 3:08
  never
• 3:08
  does
• 3:09
  drugs
• 3:09
  or
• 3:09
  oh
• 3:09
  yeah,
• 3:10
  lately
• 3:10
  he's
• 3:10
  been
• 3:10
  hanging
• 3:10
  out
• 3:11
  with
• 3:11
  the
• 3:11
  wrong
• 3:11
  crowd.
• 3:12
  But
• 3:12
  no,
• 3:12
  he
• 3:13
  has
• 3:13
  not
• 3:13
  been
• 3:13
  on
• 3:13
  drugs.
• 3:14
  So
• 3:14
  that's
• 3:15
  very
• 3:15
  helpful.
• 3:15
  Medical
• 3:16
  has
• 3:16
  kind
• 3:16
  of
• 3:16
  ruled
• 3:16
  this
• 3:16
  stuff
• 3:17
  out.
• 3:17
  So
• 3:18
  he's
• 3:18
  coming
• 3:18
  to
• 3:18
  you
• 3:19
  for
• 3:19
  assistance.
• 3:20
  You
• 3:20
  should
• 3:20
  immediately
• 3:21
  think
• 3:21
  to
• 3:21
  yourself,
• 3:22
  if
• 3:22
  we
• 3:22
  are
• 3:23
  looking
• 3:23
  at
• 3:24
  bipolar
• 3:24
  disorder,
• 3:25
  this
• 3:25
  would
• 3:25
  be
• 3:26
  one
• 3:26
  by
• 3:27
  virtue
• 3:27
  of
• 3:27
  the
• 3:27
  fact
• 3:27
  that
• 3:28
  he
• 3:28
  is
• 3:28
  likely
• 3:29
  to
• 3:29
  be
• 3:29
  hospitalized,
• 3:30
  that
• 3:30
  his
• 3:30
  behavior
• 3:30
  has
• 3:31
  landed
• 3:31
  him
• 3:32
  in
• 3:32
  the
• 3:32
  hospital.
• 3:33
  Right.
• 3:34
  That
• 3:34
  alone
• 3:34
  is
• 3:35
  a
• 3:36
  reason
• 3:36
  to
• 3:36
  diagnose
• 3:37
  bipolar
• 3:37
  I.
• 3:37
  If
• 3:38
  he
• 3:38
  gets
• 3:38
  admitted
• 3:38
  more
• 3:39
  specifically,
• 3:39
  I
• 3:39
  think
• 3:40
  the
• 3:40
  ER
• 3:40
  is
• 3:40
  a
• 3:40
  little
• 3:40
  more
• 3:41
  ambiguous
• 3:42
  until
• 3:42
  you
• 3:42
  can
• 3:42
  really
• 3:42
  rule
• 3:43
  it
• 3:43
  out.
• 3:43
  But
• 3:44
  remember
• 3:45
  that
• 3:45
  diagnosing
• 3:46
  bipolar
• 3:46
  one,
• 3:46
  you
• 3:47
  don't
• 3:47
  even
• 3:47
  need
• 3:47
  a
• 3:47
  depression
• 3:49
  diagnosis.
• 3:49
  If
• 3:50
  he
• 3:50
  has
• 3:50
  never
• 3:50
  had
• 3:50
  depression
• 3:51
  in
• 3:51
  the
• 3:51
  past,
• 3:52
  it
• 3:52
  doesn't
• 3:52
  matter
• 3:52
  if
• 3:53
  he
• 3:53
  gets
• 3:53
  hospitalized
• 3:53
  or
• 3:54
  if
• 3:54
  he's
• 3:54
  psychotic.
• 3:55
  In
• 3:55
  this
• 3:55
  case,
• 3:55
  he
• 3:55
  is
• 3:56
  delusional
• 3:56
  and
• 3:56
  he's
• 3:57
  in
• 3:57
  a
• 3:57
  hospital
• 3:57
  setting.
• 3:58
  That
• 3:58
  would
• 3:58
  be
• 3:58
  grounds
• 3:59
  to
• 3:59
  diagnose
• 4:00
  bipolar
• 4:00
  1
• 4:01
  in
• 4:01
  the
• 4:01
  absence
• 4:02
  of
• 4:02
  any
• 4:02
  kind
• 4:02
  of
• 4:02
  medical
• 4:03
  etiology
• 4:03
  or
• 4:03
  any
• 4:04
  other
• 4:05
  substance
• 4:05
  use,
• 4:06
  which
• 4:06
  again,
• 4:06
  we're
• 4:07
  slowly
• 4:07
  ruling
• 4:08
  out
• 4:08
  here.
• 4:09
  Now
• 4:10
  remember
• 4:10
  also
• 4:10
  that
• 4:11
  if
• 4:11
  hospitalization
• 4:12
  is
• 4:12
  needed,
• 4:12
  the
• 4:13
  one
• 4:13
  week
• 4:13
  duration
• 4:14
  rule
• 4:14
  for
• 4:14
  the
• 4:14
  mania
• 4:15
  is
• 4:15
  waived.
• 4:16
  That
• 4:16
  doesn't
• 4:16
  matter.
• 4:17
  It
• 4:17
  doesn't
• 4:17
  even
• 4:17
  matter
• 4:18
  even
• 4:18
  three
• 4:18
  days.
• 4:19
  It
• 4:19
  doesn't
• 4:20
  matter
• 4:20
  if
• 4:20
  he's
• 4:20
  hospitalized
• 4:21
  and
• 4:21
  psychotic.
• 4:22
  We
• 4:23
  have
• 4:23
  enough
• 4:23
  to
• 4:23
  diagnose
• 4:24
  him
• 4:24
  with
• 4:24
  bipolar
• 4:25
  1.
• 4:25
  Now,
• 4:25
  of
• 4:25
  course
• 4:26
  you
• 4:26
  want
• 4:26
  to
• 4:26
  differentiate
• 4:27
  bipolar
• 4:27
  1
• 4:28
  from
• 4:28
  any
• 4:28
  of
• 4:28
  the
• 4:29
  other
• 4:30
  psychotic
• 4:30
  disorders.
• 4:31
  Are
• 4:31
  you
• 4:31
  looking
• 4:31
  at
• 4:32
  schizophrenia?
• 4:32
  Are
• 4:33
  we
• 4:33
  looking
• 4:33
  at
• 4:33
  delusional
• 4:34
  disorder?
• 4:35
  Are
• 4:35
  we
• 4:35
  looking
• 4:35
  at
• 4:35
  schizoaffective
• 4:36
  disorder?
• 4:37
  These
• 4:37
  are
• 4:37
  all
• 4:37
  diagnoses
• 4:38
  you
• 4:38
  can
• 4:38
  begin
• 4:38
  to
• 4:39
  think
• 4:39
  about
• 4:39
  when
• 4:40
  you
• 4:40
  realize
• 4:41
  that
• 4:41
  a
• 4:41
  patient
• 4:42
  is
• 4:42
  just
• 4:42
  not
• 4:42
  acting
• 4:43
  the
• 4:43
  same,
• 4:43
  that
• 4:44
  his
• 4:44
  friends
• 4:44
  and
• 4:44
  family
• 4:44
  are
• 4:45
  concerned.
• 4:46
  Right?
• 4:46
  So
• 4:47
  those
• 4:47
  are
• 4:47
  the
• 4:47
  things
• 4:47
  you
• 4:47
  want
• 4:48
  to
• 4:48
  ask
• 4:48
  about.
• 4:48
  Now,
• 4:49
  you
• 4:49
  may
• 4:49
  not
• 4:49
  be
• 4:50
  able
• 4:50
  to
• 4:50
  ask
• 4:50
  Michael
• 4:51
  a
• 4:51
  lot
• 4:51
  of
• 4:51
  questions.
• 4:51
  Typically,
• 4:52
  when
• 4:52
  folks
• 4:53
  present
• 4:53
  with
• 4:53
  manic
• 4:54
  behaviors,
• 4:54
  they're
• 4:55
  not
• 4:55
  in
• 4:55
  the
• 4:55
  mental
• 4:56
  state
• 4:56
  to
• 4:56
  be
• 4:56
  good
• 4:56
  historians.
• 4:58
  They
• 4:58
  might
• 4:58
  go
• 4:58
  off
• 4:58
  on
• 4:59
  tangents.
• 4:59
  They
• 4:59
  might
• 4:59
  be
• 5:00
  very
• 5:00
  hard
• 5:01
  to
• 5:01
  interview
• 5:01
  and
• 5:01
  structure.
• 5:03
  So
• 5:03
  you
• 5:03
  may
• 5:04
  need
• 5:04
  to
• 5:04
  get
• 5:05
  your
• 5:05
  interview
• 5:05
  in
• 5:05
  bits
• 5:06
  and
• 5:06
  pieces
• 5:06
  and
• 5:06
  you
• 5:07
  should
• 5:07
  rely
• 5:07
  on
• 5:08
  some
• 5:08
  sort
• 5:08
  of
• 5:09
  collaboration
• 5:10
  with
• 5:10
  others
• 5:11
  as
• 5:11
  needed
• 5:12
  to
• 5:12
  figure
• 5:12
  this
• 5:13
  whole
• 5:13
  thing
• 5:14
  out.
• 5:14
  Now,
• 5:15
  something
• 5:15
  that
• 5:15
  would
• 5:15
  be
• 5:16
  very
• 5:16
  valuable
• 5:16
  to
• 5:17
  understand
• 5:17
  would
• 5:17
  be
• 5:18
  how
• 5:18
  Michael's
• 5:19
  Prozac
• 5:19
  trial
• 5:20
  had
• 5:22
  manifested
• 5:23
  right
• 5:23
  what
• 5:24
  did
• 5:24
  that
• 5:24
  look
• 5:24
  like?
• 5:25
  Did
• 5:25
  that
• 5:25
  involve
• 5:26
  severe
• 5:27
  manic
• 5:27
  adduction?
• 5:28
  Was
• 5:28
  he
• 5:28
  hyperverbal?
• 5:29
  Was
• 5:30
  he
• 5:30
  not
• 5:30
  sleeping
• 5:31
  very
• 5:31
  well?
• 5:31
  He
• 5:31
  had
• 5:31
  surges
• 5:32
  of
• 5:32
  energy?
• 5:32
  Did
• 5:33
  he
• 5:33
  do
• 5:33
  anything
• 5:33
  risky?
• 5:34
  Did
• 5:34
  he
• 5:34
  start
• 5:35
  projects?
• 5:35
  Did
• 5:36
  he
• 5:36
  concern
• 5:36
  people
• 5:37
  around
• 5:37
  him?
• 5:37
  That
• 5:37
  would
• 5:38
  be
• 5:38
  very
• 5:38
  interesting.
• 5:38
  The
• 5:39
  evidence
• 5:39
  shows
• 5:39
  that
• 5:39
  around
• 5:40
  25
• 5:40
  to
• 5:40
  30%
• 5:41
  of
• 5:41
  patients
• 5:41
  with
• 5:41
  bipolar
• 5:42
  disorder
• 5:42
  experienced
• 5:43
  their
• 5:43
  first
• 5:44
  manic
• 5:44
  episode
• 5:45
  after
• 5:45
  antidepressant
• 5:46
  initiation.
• 5:47
  For
• 5:47
  all
• 5:47
  we
• 5:47
  know,
• 5:48
  that's
• 5:48
  not
• 5:48
  what
• 5:48
  happened
• 5:49
  here,
• 5:49
  although
• 5:49
  he
• 5:49
  did
• 5:50
  have
• 5:50
  an
• 5:50
  SSRI
• 5:51
  trial
• 5:52
  in
• 5:52
  the
• 5:52
  past.
• 5:53
  Now,
• 5:53
  also
• 5:54
  remember,
• 5:54
  bipolar
• 5:55
  1
• 5:55
  has
• 5:55
  a
• 5:55
  mean
• 5:56
  diagnostic
• 5:56
  delay
• 5:57
  of
• 5:57
  7
• 5:57
  to
• 5:57
  10
• 5:58
  years,
• 5:58
  and
• 5:59
  70%
• 6:00
  of
• 6:00
  folks
• 6:00
  are
• 6:00
  initially
• 6:01
  misdiagnosed
• 6:01
  with
• 6:02
  major
• 6:02
  depressive
• 6:02
  disorder.
• 6:03
  Now
• 6:03
  that's
• 6:03
  a
• 6:03
  really
• 6:04
  big
• 6:04
  deal,
• 6:04
  right?
• 6:05
  Because
• 6:05
  Michael
• 6:06
  could
• 6:06
  have
• 6:06
  been
• 6:06
  laying
• 6:07
  low.
• 6:07
  Maybe
• 6:07
  he
• 6:07
  had
• 6:08
  some
• 6:08
  sub
• 6:08
  threshold
• 6:09
  depression
• 6:09
  over
• 6:09
  the
• 6:09
  years.
• 6:10
  It
• 6:10
  was
• 6:10
  missed.
• 6:11
  Not
• 6:11
  everybody
• 6:11
  just
• 6:12
  walks
• 6:12
  up
• 6:12
  to
• 6:12
  a
• 6:12
  clinic
• 6:13
  or
• 6:13
  walks
• 6:13
  up
• 6:13
  to
• 6:13
  their
• 6:14
  best
• 6:14
  friends
• 6:14
  and
• 6:14
  says,
• 6:14
  hey,
• 6:15
  I'm
• 6:15
  depressed.
• 6:15
  I've
• 6:16
  been
• 6:16
  down
• 6:16
  or
• 6:16
  sad
• 6:17
  for
• 6:17
  two
• 6:17
  or
• 6:17
  more
• 6:17
  weeks
• 6:17
  in
• 6:18
  a
• 6:18
  row
• 6:18
  where
• 6:18
  I'm
• 6:18
  not
• 6:18
  getting
• 6:19
  pleasure
• 6:19
  out
• 6:19
  of
• 6:19
  things.
• 6:20
  That
• 6:20
  doesn't
• 6:20
  always
• 6:21
  happen.
• 6:22
  So
• 6:22
  Michael
• 6:23
  could
• 6:23
  have
• 6:23
  been
• 6:24
  under
• 6:24
  the
• 6:24
  weather
• 6:24
  for
• 6:25
  quite
• 6:25
  some
• 6:25
  time
• 6:25
  and
• 6:26
  it
• 6:26
  would
• 6:26
  be
• 6:26
  good
• 6:26
  to
• 6:27
  ask
• 6:27
  diagnostic
• 6:28
  and
• 6:28
  clarifying
• 6:28
  questions
• 6:29
  about
• 6:29
  whether
• 6:30
  or
• 6:30
  not
• 6:30
  he
• 6:30
  was
• 6:30
  depressed.
• 6:31
  Even
• 6:31
  if
• 6:31
  he
• 6:31
  says
• 6:31
  he
• 6:32
  was
• 6:32
  not
• 6:32
  depressed,
• 6:33
  it's
• 6:33
  important
• 6:34
  that
• 6:34
  you
• 6:35
  flesh
• 6:35
  that
• 6:36
  out
• 6:36
  more
• 6:36
  diagnostically
• 6:37
  and
• 6:38
  collaborate
• 6:38
  with
• 6:38
  people
• 6:39
  in
• 6:39
  his
• 6:39
  close
• 6:40
  circle
• 6:40
  to
• 6:40
  understand.
• 6:41
  Did
• 6:41
  you
• 6:41
  notice
• 6:41
  seasons
• 6:42
  or
• 6:42
  episodes
• 6:43
  where
• 6:43
  he
• 6:43
  seemed
• 6:44
  more
• 6:44
  down
• 6:44
  for
• 6:45
  several
• 6:45
  weeks
• 6:45
  at
• 6:45
  a
• 6:46
  time,
• 6:46
  more
• 6:46
  withdrawn,
• 6:47
  less
• 6:48
  able
• 6:48
  to
• 6:49
  enjoy
• 6:49
  things
• 6:49
  you
• 6:49
  planned
• 6:50
  together,
• 6:50
  or
• 6:50
  was
• 6:51
  telling
• 6:51
  you
• 6:51
  he
• 6:51
  wasn't
• 6:52
  doing
• 6:52
  so
• 6:52
  well?
• 6:52
  The
• 6:53
  peak
• 6:53
  onset
• 6:53
  of
• 6:53
  bipolar
• 6:54
  1
• 6:54
  is
• 6:55
  18
• 6:55
  to
• 6:55
  22
• 6:56
  years,
• 6:56
  with
• 6:57
  50%
• 6:57
  of
• 6:57
  cases
• 6:58
  occurring
• 6:59
  before
• 6:59
  the
• 6:59
  age
• 6:59
  of
• 7:00
  25.
• 7:01
  That
• 7:01
  doesn't
• 7:02
  mean
• 7:02
  you
• 7:02
  can't
• 7:02
  experience
• 7:02
  it
• 7:03
  later.
• 7:03
  Michael
• 7:04
  is
• 7:04
  32
• 7:04
  years
• 7:04
  old.
• 7:05
  Please
• 7:06
  know
• 7:06
  that
• 7:06
  as
• 7:07
  we
• 7:07
  move
• 7:07
  up
• 7:07
  in
• 7:08
  age
• 7:08
  and
• 7:08
  this
• 7:09
  was
• 7:09
  a
• 7:09
  sudden
• 7:09
  manic
• 7:09
  episode
• 7:10
  in
• 7:10
  his
• 7:10
  40s
• 7:11
  or
• 7:11
  50s
• 7:11
  or
• 7:11
  anything
• 7:12
  over
• 7:12
  the
• 7:12
  age
• 7:12
  of
• 7:12
  35?
• 7:13
  You
• 7:13
  definitely
• 7:14
  want
• 7:14
  to
• 7:14
  be
• 7:14
  more
• 7:14
  suspicious
• 7:15
  of
• 7:15
  a
• 7:15
  medical
• 7:16
  etiology.
• 7:17
  A
• 7:17
  few
• 7:17
  other
• 7:18
  pearls
• 7:18
  that
• 7:18
  you
• 7:19
  can
• 7:19
  branch
• 7:20
  out
• 7:20
  on
• 7:20
  here
• 7:21
  and
• 7:21
  ask
• 7:21
  more
• 7:21
  questions
• 7:22
  about
• 7:22
  Michael's
• 7:23
  aunt,
• 7:24
  presumably
• 7:24
  bipolar.
• 7:26
  And
• 7:26
  you
• 7:26
  know,
• 7:26
  bipolar
• 7:27
  bipolarity
• 7:27
  shows
• 7:28
  a
• 7:28
  79
• 7:28
  to
• 7:29
  93,
• 7:29
  3%
• 7:30
  heritability
• 7:31
  higher
• 7:31
  than
• 7:32
  breast
• 7:32
  cancer
• 7:32
  or
• 7:33
  diabetes.
• 7:34
  So
• 7:35
  that's
• 7:36
  pretty
• 7:36
  significant
• 7:37
  as
• 7:37
  well.
• 7:37
  You
• 7:38
  also
• 7:38
  want
• 7:38
  to
• 7:38
  think
• 7:39
  in
• 7:39
  the
• 7:39
  back
• 7:39
  of
• 7:39
  your
• 7:39
  mind,
• 7:40
  if
• 7:40
  someone
• 7:41
  is
• 7:41
  bipolar,
• 7:43
  what
• 7:43
  might
• 7:43
  they
• 7:43
  be
• 7:44
  doing
• 7:44
  to
• 7:45
  cope
• 7:45
  with
• 7:45
  this?
• 7:45
  Now,
• 7:45
  in
• 7:46
  Michael's
• 7:46
  case,
• 7:46
  this
• 7:46
  seemed
• 7:47
  like
• 7:47
  a
• 7:47
  pretty
• 7:48
  fast
• 7:48
  onset
• 7:49
  coming
• 7:50
  out
• 7:50
  of
• 7:50
  nowhere
• 7:51
  type
• 7:51
  of
• 7:52
  event.
• 7:53
  In
• 7:53
  more
• 7:54
  cases
• 7:54
  than
• 7:54
  not,
• 7:55
  you
• 7:55
  will
• 7:55
  see
• 7:56
  that
• 7:57
  these
• 7:58
  episodes
• 7:59
  tend
• 7:59
  to
• 8:00
  occur
• 8:00
  over
• 8:01
  time,
• 8:02
  right.
• 8:02
  That
• 8:02
  they're
• 8:03
  proceeded
• 8:03
  with
• 8:03
  depressive
• 8:04
  episodes,
• 8:04
  or
• 8:06
  they
• 8:06
  involve
• 8:07
  early
• 8:07
  depression,
• 8:08
  they
• 8:08
  involve
• 8:09
  impulsivity,
• 8:10
  maybe
• 8:10
  suicide
• 8:11
  attempts,
• 8:11
  substance
• 8:12
  use,
• 8:12
  racing
• 8:13
  thoughts,
• 8:13
  a
• 8:14
  cluster
• 8:14
  of
• 8:14
  symptoms
• 8:14
  for
• 8:15
  quite
• 8:15
  some
• 8:15
  time
• 8:16
  that
• 8:16
  had
• 8:17
  bothered
• 8:17
  the
• 8:17
  patient
• 8:17
  and
• 8:18
  may
• 8:18
  then
• 8:18
  eventually
• 8:19
  manifest
• 8:19
  into
• 8:20
  a
• 8:20
  bipolar
• 8:21
  one
• 8:21
  type
• 8:21
  episode.
• 8:22
  Right.
• 8:23
  So
• 8:23
  I
• 8:24
  just
• 8:24
  want
• 8:24
  you
• 8:24
  all
• 8:24
  to
• 8:25
  be
• 8:25
  thinking
• 8:25
  about
• 8:25
  this
• 8:26
  stuff
• 8:27
  and,
• 8:27
  and
• 8:28
  ask
• 8:28
  yourselves,
• 8:28
  what
• 8:29
  else
• 8:29
  should
• 8:29
  I
• 8:29
  be
• 8:30
  thinking
• 8:30
  right
• 8:30
  now?
• 8:31
  Could
• 8:31
  this
• 8:31
  be
• 8:32
  an
• 8:32
  anxiety
• 8:32
  disorder?
• 8:33
  Could
• 8:33
  this
• 8:33
  be
• 8:33
  an
• 8:34
  anxiety
• 8:34
  attack,
• 8:34
  a
• 8:35
  nervous
• 8:35
  breakdown,
• 8:35
  a
• 8:36
  panic
• 8:36
  attack?
• 8:36
  Could
• 8:37
  that
• 8:37
  be
• 8:37
  what
• 8:37
  we're
• 8:37
  looking
• 8:38
  at?
• 8:38
  Well,
• 8:39
  probably
• 8:39
  not,
• 8:40
  although
• 8:40
  it
• 8:40
  could
• 8:40
  be
• 8:41
  comorbid.
• 8:41
  But
• 8:42
  you
• 8:42
  know,
• 8:42
  this
• 8:42
  is
• 8:43
  a
• 8:43
  pretty
• 8:44
  delusional,
• 8:45
  grandiose
• 8:46
  goal,
• 8:46
  right,
• 8:46
  to
• 8:46
  fight
• 8:46
  Mike
• 8:47
  Tyson.
• 8:47
  This
• 8:47
  doesn't
• 8:48
  quite
• 8:48
  fit
• 8:49
  into
• 8:49
  an
• 8:49
  anxiety
• 8:50
  disorder.
• 8:50
  He
• 8:50
  might
• 8:51
  have
• 8:51
  racing
• 8:51
  thoughts,
• 8:51
  he
• 8:52
  might
• 8:52
  be
• 8:52
  on
• 8:52
  edge,
• 8:52
  disheveled,
• 8:53
  nervous
• 8:54
  and
• 8:54
  out
• 8:54
  of
• 8:54
  sorts.
• 8:55
  It's
• 8:55
  very
• 8:56
  possible
• 8:56
  because
• 8:57
  anxiety
• 8:57
  disorders
• 8:58
  coexist
• 8:58
  in
• 8:58
  about
• 8:59
  75%
• 8:59
  of
• 9:00
  bipolar
• 9:00
  patients.
• 9:01
  They
• 9:01
  often
• 9:01
  precede
• 9:02
  mood
• 9:02
  episodes
• 9:03
  by
• 9:03
  years.
• 9:04
  Right.
• 9:04
  But
• 9:04
  we
• 9:05
  shouldn't
• 9:05
  mistake
• 9:05
  that
• 9:05
  for
• 9:06
  the
• 9:06
  root
• 9:06
  of
• 9:07
  what
• 9:07
  brings
• 9:07
  him
• 9:07
  to
• 9:08
  the
• 9:08
  emergency
• 9:08
  room,
• 9:08
  that
• 9:09
  the
• 9:09
  content
• 9:10
  of
• 9:10
  his
• 9:10
  ambition.
• 9:11
  He
• 9:11
  wants
• 9:11
  to
• 9:11
  fight
• 9:11
  Mike
• 9:12
  Tyson
• 9:12
  is
• 9:12
  very
• 9:12
  grandiose.
• 9:13
  It's
• 9:13
  very
• 9:13
  delusional.
• 9:15
  And
• 9:15
  one
• 9:15
  thing
• 9:15
  I
• 9:16
  love
• 9:16
  to
• 9:16
  ask
• 9:16
  patients
• 9:17
  that
• 9:17
  I
• 9:17
  find
• 9:18
  is
• 9:18
  so
• 9:18
  diagnostically
• 9:19
  accurate,
• 9:20
  or
• 9:20
  at
• 9:21
  least
• 9:21
  helpful,
• 9:21
  high
• 9:21
  yield,
• 9:22
  is
• 9:22
  I
• 9:22
  ask
• 9:23
  about
• 9:23
  their
• 9:23
  sleep,
• 9:24
  right?
• 9:24
  It's
• 9:24
  really
• 9:24
  important
• 9:25
  you
• 9:25
  ask
• 9:25
  about
• 9:26
  his
• 9:26
  sleep.
• 9:27
  How
• 9:27
  has
• 9:27
  he
• 9:27
  been
• 9:27
  sleeping
• 9:27
  lately?
• 9:28
  Oftentimes
• 9:29
  you
• 9:29
  can
• 9:29
  get
• 9:29
  that
• 9:30
  out
• 9:30
  of
• 9:30
  a
• 9:30
  patient
• 9:30
  who's
• 9:31
  manic.
• 9:31
  And
• 9:31
  sometimes
• 9:32
  they'll
• 9:32
  proudly
• 9:32
  tell
• 9:33
  you,
• 9:33
  I
• 9:33
  don't
• 9:33
  need
• 9:33
  sleep,
• 9:34
  I
• 9:34
  haven't
• 9:34
  been
• 9:34
  sleeping
• 9:34
  much
• 9:35
  at
• 9:35
  all,
• 9:35
  I
• 9:35
  feel
• 9:35
  great.
• 9:36
  Or
• 9:36
  if
• 9:36
  they're
• 9:36
  more
• 9:37
  irritable
• 9:37
  and
• 9:37
  dysphoric,
• 9:38
  they
• 9:38
  might
• 9:38
  tell
• 9:38
  you,
• 9:38
  well,
• 9:39
  I
• 9:39
  haven't
• 9:39
  slept
• 9:39
  at
• 9:39
  all,
• 9:40
  don't
• 9:40
  talk
• 9:40
  to
• 9:40
  me.
• 9:41
  They
• 9:41
  might
• 9:41
  have
• 9:41
  this
• 9:41
  more
• 9:41
  off
• 9:42
  putting
• 9:42
  attitude
• 9:43
  where
• 9:43
  they're
• 9:43
  just
• 9:43
  really
• 9:43
  disheveled,
• 9:44
  look
• 9:44
  under
• 9:44
  the
• 9:45
  weather
• 9:45
  and
• 9:45
  not
• 9:45
  in
• 9:46
  the
• 9:46
  mood
• 9:46
  to
• 9:46
  engage
• 9:46
  because
• 9:47
  they're
• 9:47
  irritable
• 9:47
  and
• 9:48
  look
• 9:48
  exhausted.
• 9:49
  And
• 9:49
  this
• 9:49
  is
• 9:49
  where
• 9:49
  your
• 9:49
  mental
• 9:50
  status
• 9:50
  exam
• 9:51
  is
• 9:51
  so
• 9:51
  critical,
• 9:52
  because
• 9:52
  you
• 9:52
  will
• 9:53
  often
• 9:53
  find
• 9:53
  a
• 9:53
  patient
• 9:54
  who
• 9:54
  is
• 9:55
  talking
• 9:55
  really
• 9:56
  fast.
• 9:56
  Their
• 9:56
  ideas
• 9:57
  are
• 9:57
  just
• 9:57
  not
• 9:58
  connected
• 9:59
  logically.
• 9:59
  He's
• 10:00
  going
• 10:00
  to
• 10:00
  talk
• 10:00
  about
• 10:00
  fighting
• 10:01
  Mike
• 10:01
  Tyson
• 10:01
  and
• 10:02
  that
• 10:02
  line
• 10:02
  of
• 10:02
  conversation
• 10:03
  will
• 10:03
  quickly
• 10:04
  jump
• 10:04
  to
• 10:04
  developing
• 10:05
  an
• 10:05
  app
• 10:05
  to
• 10:06
  solve
• 10:06
  world
• 10:06
  hunger
• 10:06
  or
• 10:07
  the
• 10:07
  geopolitical
• 10:08
  implications
• 10:08
  of
• 10:08
  organizing
• 10:09
  your
• 10:09
  socks.
• 10:10
  Things
• 10:10
  change
• 10:11
  quickly.
• 10:11
  They
• 10:11
  might
• 10:12
  be
• 10:12
  dressed
• 10:12
  flamboyantly,
• 10:13
  or
• 10:14
  it
• 10:14
  may
• 10:14
  not
• 10:14
  be
• 10:15
  very
• 10:15
  organized
• 10:15
  looking.
• 10:16
  They
• 10:16
  might
• 10:16
  be
• 10:17
  highly
• 10:17
  intrusive.
• 10:17
  They
• 10:18
  might
• 10:18
  ask
• 10:18
  you
• 10:18
  very
• 10:18
  personal
• 10:19
  questions.
• 10:20
  They
• 10:20
  might
• 10:20
  be
• 10:20
  really
• 10:20
  confident,
• 10:21
  they
• 10:21
  might
• 10:22
  be
• 10:22
  very
• 10:22
  irritable.
• 10:23
  So
• 10:23
  mania
• 10:23
  is
• 10:23
  not
• 10:24
  always
• 10:24
  the
• 10:24
  Hollywood
• 10:25
  mania
• 10:25
  where
• 10:25
  people
• 10:25
  are
• 10:26
  happy
• 10:26
  and
• 10:26
  euphoric.
• 10:28
  It
• 10:28
  could
• 10:28
  be
• 10:28
  the
• 10:29
  dysphoria,
• 10:29
  the
• 10:30
  irritability.
• 10:31
  Keep
• 10:31
  that
• 10:31
  in
• 10:32
  mind,
• 10:32
  too,
• 10:33
  and
• 10:33
  assess
• 10:33
  his
• 10:34
  insight.
• 10:34
  Does
• 10:34
  he
• 10:34
  understand
• 10:35
  that
• 10:35
  this
• 10:35
  is
• 10:35
  a
• 10:36
  little
• 10:36
  bit
• 10:36
  beyond
• 10:36
  the
• 10:36
  pale?
• 10:37
  That
• 10:37
  it's
• 10:37
  not
• 10:38
  realistic
• 10:38
  that
• 10:38
  he
• 10:39
  would
• 10:39
  challenge
• 10:39
  Mike
• 10:39
  Tyson
• 10:40
  to
• 10:40
  a
• 10:40
  fight?
• 10:40
  Granted
• 10:41
  that
• 10:41
  Michael's
• 10:42
  not
• 10:42
  a
• 10:42
  boxer
• 10:43
  or
• 10:43
  something
• 10:44
  and
• 10:44
  has
• 10:44
  a
• 10:44
  real
• 10:44
  shot
• 10:45
  at
• 10:45
  it,
• 10:46
  but
• 10:46
  for
• 10:46
  all
• 10:46
  we
• 10:46
  know,
• 10:46
  he's
• 10:47
  not.
• 10:48
  You
• 10:48
  don't
• 10:48
  ask
• 10:48
  him
• 10:48
  directly.
• 10:49
  Do
• 10:49
  you
• 10:49
  have
• 10:49
  insight?
• 10:50
  That's
• 10:50
  not
• 10:50
  how
• 10:50
  mental
• 10:51
  status
• 10:51
  exams
• 10:52
  work.
• 10:52
  You
• 10:52
  can
• 10:53
  infer
• 10:53
  whether
• 10:54
  or
• 10:54
  not
• 10:54
  he
• 10:54
  has
• 10:54
  insight
• 10:55
  into
• 10:55
  the
• 10:55
  severity
• 10:56
  of
• 10:56
  his
• 10:56
  condition,
• 10:57
  how
• 10:57
  reasonable
• 10:57
  or
• 10:58
  unreasonable
• 10:58
  his
• 10:58
  ideas
• 10:59
  might
• 10:59
  be,
• 11:00
  and
• 11:00
  his
• 11:01
  actual
• 11:01
  mental
• 11:02
  state.
• 11:02
  His
• 11:02
  judgment
• 11:03
  is
• 11:03
  impaired
• 11:04
  because
• 11:04
  he's
• 11:04
  trying
• 11:04
  to
• 11:05
  fight
• 11:05
  Mike
• 11:05
  Tyson
• 11:06
  and
• 11:06
  he's
• 11:06
  spending
• 11:06
  thousands
• 11:07
  of
• 11:07
  dollars
• 11:07
  to
• 11:07
  do
• 11:08
  it,
• 11:08
  and
• 11:08
  he's
• 11:08
  not
• 11:08
  really
• 11:08
  a
• 11:09
  boxer.
• 11:09
  I
• 11:09
  do
• 11:09
  like
• 11:10
  to
• 11:10
  ask
• 11:10
  patients
• 11:11
  to
• 11:12
  understand
• 11:12
  how
• 11:13
  tangential
• 11:14
  or
• 11:14
  random
• 11:15
  their
• 11:15
  thoughts
• 11:15
  can
• 11:15
  be
• 11:16
  if
• 11:16
  Michael
• 11:16
  is
• 11:16
  actually
• 11:17
  a
• 11:17
  boxer,
• 11:18
  if
• 11:18
  he's.
• 11:19
  And
• 11:19
  not
• 11:19
  that
• 11:20
  it
• 11:20
  really
• 11:20
  matters.
• 11:20
  I
• 11:20
  mean,
• 11:20
  the
• 11:21
  guy's
• 11:21
  in
• 11:21
  the
• 11:21
  emergency
• 11:22
  room.
• 11:22
  His
• 11:23
  delusion
• 11:23
  is
• 11:24
  pronounced.
• 11:24
  It
• 11:25
  doesn't
• 11:25
  really
• 11:25
  matter
• 11:26
  diagnostically
• 11:26
  for
• 11:27
  you
• 11:27
  to
• 11:27
  know
• 11:27
  that.
• 11:27
  But
• 11:28
  I
• 11:28
  like
• 11:28
  to
• 11:28
  have
• 11:28
  an
• 11:28
  idea
• 11:29
  of
• 11:29
  how
• 11:30
  far
• 11:30
  have
• 11:30
  we
• 11:31
  wandered
• 11:31
  off
• 11:31
  the
• 11:31
  farm
• 11:31
  here,
• 11:32
  right?
• 11:32
  If
• 11:33
  he
• 11:33
  has
• 11:33
  nothing
• 11:33
  to
• 11:34
  do
• 11:34
  with
• 11:34
  boxing,
• 11:34
  if
• 11:35
  he's
• 11:35
  not
• 11:35
  an
• 11:35
  aggressive
• 11:36
  person,
• 11:36
  if
• 11:36
  he's
• 11:36
  a
• 11:36
  passive
• 11:37
  person,
• 11:37
  he
• 11:37
  doesn't
• 11:37
  enjoy
• 11:38
  working
• 11:38
  out.
• 11:39
  It
• 11:39
  just
• 11:39
  speaks
• 11:40
  to
• 11:40
  how
• 11:41
  much
• 11:41
  we've
• 11:41
  wandered
• 11:42
  off
• 11:42
  the
• 11:42
  farm
• 11:42
  and
• 11:42
  involves
• 11:43
  other
• 11:43
  psychodynamic
• 11:44
  implications.
• 11:45
  You
• 11:45
  have
• 11:45
  good
• 11:45
  tools
• 11:46
  and
• 11:46
  instruments
• 11:46
  to
• 11:46
  ask
• 11:47
  more
• 11:47
  pointed
• 11:47
  questions
• 11:48
  here.
• 11:48
  Again,
• 11:49
  you
• 11:49
  might
• 11:49
  have
• 11:49
  to
• 11:49
  corroborate
• 11:50
  with
• 11:50
  his
• 11:50
  family
• 11:51
  about
• 11:52
  what
• 11:52
  exactly
• 11:53
  his
• 11:54
  symptoms
• 11:55
  have
• 11:55
  looked
• 11:55
  like
• 11:55
  over
• 11:56
  time.
• 11:56
  The
• 11:57
  Prozac
• 11:57
  is
• 11:57
  a
• 11:57
  big
• 11:58
  thing
• 11:58
  to
• 11:58
  ask
• 11:58
  about.
• 11:59
  Do
• 11:59
  you
• 11:59
  remember
• 11:59
  when
• 11:59
  Michael
• 12:00
  was
• 12:00
  on
• 12:00
  Prozac?
• 12:01
  Did
• 12:01
  he
• 12:01
  seem
• 12:02
  unusually
• 12:02
  irritable
• 12:03
  or
• 12:03
  agitated?
• 12:04
  Did
• 12:04
  he
• 12:04
  feel
• 12:05
  really
• 12:05
  hyper
• 12:06
  when
• 12:06
  he
• 12:06
  was
• 12:06
  on
• 12:06
  that
• 12:07
  medication?
• 12:07
  You
• 12:08
  could
• 12:08
  maybe
• 12:08
  get
• 12:08
  information
• 12:09
  from
• 12:09
  that.
• 12:09
  You
• 12:10
  could
• 12:10
  maybe
• 12:10
  ask
• 12:10
  him.
• 12:11
  Right?
• 12:11
  Hey,
• 12:11
  do
• 12:11
  you
• 12:11
  remember
• 12:12
  taking
• 12:12
  Prozac?
• 12:12
  How
• 12:12
  did
• 12:13
  that
• 12:13
  make
• 12:13
  you
• 12:13
  feel?
• 12:13
  Oh,
• 12:13
  I
• 12:13
  felt
• 12:14
  great.
• 12:14
  I
• 12:15
  felt
• 12:15
  wonderful.
• 12:15
  I
• 12:15
  felt
• 12:16
  on
• 12:16
  top
• 12:16
  of
• 12:16
  the
• 12:16
  world.
• 12:17
  I
• 12:18
  was
• 12:18
  out
• 12:18
  driving
• 12:18
  late
• 12:19
  at
• 12:19
  night.
• 12:19
  He
• 12:19
  might
• 12:20
  give
• 12:20
  you
• 12:20
  really
• 12:20
  good
• 12:21
  information
• 12:21
  about
• 12:22
  what
• 12:22
  to
• 12:22
  look
• 12:23
  for
• 12:23
  there.
• 12:24
  Now,
• 12:24
  as
• 12:25
  a
• 12:25
  new
• 12:25
  grad,
• 12:26
  as
• 12:26
  an
• 12:26
  NP
• 12:27
  student,
• 12:27
  you
• 12:27
  might
• 12:27
  be
• 12:28
  wondering,
• 12:28
  how
• 12:28
  do
• 12:28
  I
• 12:28
  tell
• 12:28
  the
• 12:29
  difference
• 12:29
  between
• 12:29
  bipolar
• 12:30
  I
• 12:30
  and
• 12:30
  bipolar
• 12:31
  2?
• 12:31
  When
• 12:31
  you're
• 12:32
  assessing
• 12:32
  a
• 12:32
  patient,
• 12:32
  you
• 12:33
  might
• 12:33
  feel
• 12:33
  pressured
• 12:33
  to
• 12:33
  get
• 12:34
  the
• 12:34
  diagnosis
• 12:34
  right
• 12:35
  and
• 12:35
  say,
• 12:35
  what
• 12:35
  am
• 12:35
  I
• 12:35
  looking
• 12:36
  at
• 12:36
  here?
• 12:36
  Am
• 12:37
  I
• 12:37
  looking
• 12:37
  at
• 12:37
  schizophrenia,
• 12:38
  even?
• 12:38
  Those
• 12:39
  are
• 12:39
  questions
• 12:40
  that
• 12:40
  very
• 12:40
  well
• 12:41
  might
• 12:41
  come
• 12:41
  up.
• 12:41
  I
• 12:42
  don't
• 12:42
  mean
• 12:42
  to
• 12:42
  oversimplify
• 12:43
  this
• 12:43
  stuff.
• 12:43
  I
• 12:43
  know
• 12:44
  in
• 12:44
  practice
• 12:44
  it
• 12:45
  can
• 12:45
  be
• 12:45
  Tricky,
• 12:46
  Right?
• 12:46
  But
• 12:46
  if
• 12:47
  we
• 12:47
  think
• 12:47
  about
• 12:47
  this,
• 12:48
  at
• 12:49
  its
• 12:49
  core,
• 12:49
  the
• 12:50
  diagnosis
• 12:50
  becomes
• 12:51
  a
• 12:51
  little
• 12:51
  bit
• 12:52
  easier,
• 12:53
  right?
• 12:53
  Because
• 12:54
  again,
• 12:55
  bipolar
• 12:55
  I
• 12:56
  lends
• 12:56
  you.
• 12:57
  In
• 12:57
  the
• 12:57
  hospital,
• 12:58
  typically
• 12:58
  it's
• 12:59
  extreme.
• 13:00
  It's
• 13:00
  like
• 13:00
  a
• 13:00
  volcanic
• 13:01
  eruption.
• 13:02
  It's
• 13:03
  very
• 13:03
  visible
• 13:04
  and
• 13:04
  it's
• 13:04
  a
• 13:04
  dire
• 13:05
  emergency.
• 13:05
  Bipolar
• 13:06
  two
• 13:07
  is
• 13:07
  nothing
• 13:07
  to
• 13:07
  sneeze
• 13:08
  at
• 13:08
  either.
• 14:03
  It
• 14:03
  is
• 14:04
  not
• 14:04
  so
• 14:04
  much
• 14:04
  like
• 14:04
  a
• 14:05
  volcano,
• 14:05
  it's
• 14:06
  more
• 14:06
  like
• 14:06
  a
• 14:06
  forest
• 14:07
  fire
• 13:13
  that
• 14:08
  gets
• 14:09
  out
• 14:09
  of
• 14:09
  control
• 14:09
  with
• 14:10
  time
• 14:10
  and
• 14:10
  it
• 14:11
  can
• 14:11
  be
• 14:11
  extremely
• 14:12
  devastating.
• 14:13
  Right.
• 14:13
  There
• 14:13
  are
• 14:13
  studies
• 14:14
  that
• 14:14
  bipolar
• 14:14
  2
• 14:16
  includes
• 14:16
  a
• 14:17
  higher
• 14:18
  suicide
• 14:18
  rate
• 14:18
  than
• 14:19
  bipolar
• 14:19
  1.
• 14:20
  People
• 14:20
  are
• 14:21
  spending
• 14:21
  more
• 14:21
  time
• 14:22
  in
• 14:22
  depression
• 14:23
  in
• 14:23
  bipolar
• 14:24
  2
• 14:25
  than
• 14:25
  in
• 14:25
  bipolar
• 14:26
  1.
• 14:26
  Some
• 14:26
  studies
• 14:27
  show
• 14:27
  they
• 14:27
  spend
• 14:28
  50%
• 14:28
  more
• 14:29
  time
• 14:29
  in
• 14:29
  depressive
• 14:29
  episodes
• 14:30
  than
• 14:30
  bipolar
• 14:31
  1.
• 14:31
  It's
• 14:31
  very
• 14:32
  complicated
• 14:32
  because
• 14:32
  people
• 14:33
  with
• 14:33
  bipolar
• 14:33
  2
• 14:34
  sometimes
• 14:35
  feel
• 14:35
  so
• 14:35
  good,
• 14:35
  they
• 14:36
  don't
• 14:36
  feel
• 14:36
  like
• 14:36
  they
• 14:36
  need
• 14:36
  treatment.
• 14:37
  A
• 14:37
  lot
• 14:37
  of
• 14:37
  the
• 14:38
  danger
• 14:38
  or
• 14:38
  the
• 14:38
  forest
• 14:38
  fire
• 14:39
  keeps
• 14:39
  ravaging
• 14:40
  where
• 14:41
  an
• 14:41
  individual
• 14:42
  is
• 14:42
  just
• 14:42
  a
• 14:43
  little
• 14:43
  too
• 14:43
  irritable.
• 14:43
  You
• 14:44
  know,
• 14:44
  they
• 14:44
  can't
• 14:44
  hold
• 14:45
  a
• 14:45
  job,
• 14:45
  they,
• 14:46
  they
• 14:46
  can't
• 14:46
  hold
• 14:46
  a
• 14:47
  relationship
• 14:47
  very
• 14:47
  easily,
• 14:48
  or
• 14:48
  they're
• 14:49
  impulsive,
• 14:49
  their
• 14:49
  foot's
• 14:50
  on
• 14:50
  the
• 14:50
  gas
• 14:50
  a
• 14:50
  little
• 14:51
  too
• 14:51
  much,
• 14:51
  they're
• 14:51
  signing
• 14:52
  off
• 14:52
  on
• 14:52
  that
• 14:52
  mortgage
• 14:52
  too
• 14:53
  quickly,
• 14:53
  they're
• 14:53
  moving
• 14:54
  to
• 14:54
  another
• 14:54
  state.
• 14:55
  And
• 14:55
  moving
• 14:55
  to
• 14:55
  another
• 14:56
  state
• 14:56
  doesn't
• 14:56
  sound
• 14:57
  like
• 14:57
  this
• 14:57
  volcanic
• 14:58
  eruption.
• 14:58
  It
• 14:58
  doesn't
• 14:59
  sound
• 14:59
  like
• 14:59
  this
• 14:59
  thing
• 14:59
  you
• 15:00
  have
• 15:00
  to
• 15:00
  stop
• 15:00
  and
• 15:00
  hospitalize
• 15:01
  someone
• 15:01
  for
• 15:02
  at
• 15:02
  the
• 15:02
  same
• 15:02
  time.
• 15:02
  If
• 15:03
  you
• 15:03
  look
• 15:03
  more
• 15:03
  closely,
• 15:04
  it
• 15:04
  could
• 15:04
  be
• 15:05
  a
• 15:05
  little
• 15:05
  too
• 15:05
  impulsive
• 15:06
  and
• 15:07
  it
• 15:07
  can
• 15:08
  eventually
• 15:08
  destroy
• 15:09
  the
• 15:09
  forest
• 15:09
  with
• 15:10
  time.
• 15:10
  Bipolar
• 15:10
  2
• 15:11
  is
• 15:11
  nothing
• 15:11
  to
• 15:11
  sneeze
• 15:11
  at.
• 15:12
  But
• 15:12
  we're
• 15:12
  looking
• 15:12
  at
• 15:12
  the
• 15:13
  difference
• 15:13
  between
• 15:13
  a
• 15:13
  volcanic
• 15:14
  eruption
• 15:14
  and
• 15:15
  a
• 15:15
  forest
• 15:15
  fire.
• 15:16
  Now,
• 15:18
  the
• 15:18
  bipolar
• 15:19
  2
• 15:19
  suicide
• 15:20
  attempt
• 15:20
  rate
• 15:20
  is
• 15:20
  about
• 15:21
  24%.
• 15:21
  The
• 15:22
  evidence
• 15:22
  suggests
• 15:23
  the
• 15:23
  bipolar
• 15:24
  1
• 15:24
  suicide
• 15:25
  rate
• 15:25
  is
• 15:25
  a
• 15:26
  17%
• 15:26
  suicide
• 15:27
  rate.
• 15:28
  That
• 15:28
  is
• 15:28
  an
• 15:28
  estimation
• 15:29
  based
• 15:29
  on
• 15:29
  the
• 15:29
  recent
• 15:30
  evidence.
• 15:30
  That's
• 15:31
  a
• 15:31
  7%
• 15:31
  higher
• 15:32
  suicide
• 15:32
  risk
• 15:33
  with
• 15:33
  bipolar
• 15:34
  2.
• 15:34
  Even
• 15:34
  though
• 15:34
  bipolar
• 15:35
  1
• 15:35
  is
• 15:35
  considered
• 15:36
  the
• 15:36
  more
• 15:36
  severe
• 15:37
  presentation.
• 15:38
  90%
• 15:38
  of
• 15:39
  bipolar
• 15:39
  I
• 15:40
  patients
• 15:40
  require
• 15:40
  hospitalization
• 15:41
  versus
• 15:42
  a
• 15:42
  much
• 15:42
  lower
• 15:43
  percentage,
• 15:43
  somewhere
• 15:44
  in
• 15:44
  the
• 15:44
  neighborhood
• 15:44
  of
• 15:45
  30%
• 15:46
  might
• 15:46
  require
• 15:46
  hospitalization
• 15:47
  for
• 15:47
  bipolar
• 15:48
  2.
• 15:48
  Now
• 15:48
  you
• 15:49
  might
• 15:49
  be
• 15:49
  saying,
• 15:49
  well,
• 15:49
  wait
• 15:50
  a
• 15:50
  minute,
• 15:50
  I
• 15:50
  thought
• 15:50
  only
• 15:50
  bipolar
• 15:51
  1
• 15:52
  is
• 15:52
  the
• 15:52
  hospitalization
• 15:53
  piece.
• 15:53
  That's
• 15:54
  how
• 15:54
  we
• 15:54
  diagnose
• 15:54
  bipolar
• 15:55
  I
• 15:55
  with
• 15:55
  psychosis
• 15:56
  or
• 15:56
  hospitalization
• 15:57
  or
• 15:57
  7
• 15:57
  day
• 15:58
  incidence
• 15:58
  of
• 15:59
  these
• 15:59
  kind
• 15:59
  of
• 15:59
  marked
• 16:00
  changes
• 16:00
  in
• 16:00
  mood.
• 16:01
  And
• 16:01
  you're
• 16:02
  right,
• 16:02
  the
• 16:02
  folks
• 16:02
  who
• 16:02
  get
• 16:03
  hospitalized
• 16:03
  for
• 16:03
  bipolar
• 16:04
  2,
• 16:04
  it
• 16:04
  doesn't
• 16:05
  mean
• 16:05
  they
• 16:05
  have
• 16:05
  to
• 16:05
  be
• 16:05
  manic
• 16:06
  or
• 16:06
  hypomanic.
• 16:07
  They
• 16:07
  could
• 16:07
  be
• 16:07
  severely
• 16:08
  depressed
• 16:09
  and
• 16:09
  suicidal.
• 16:09
  That's
• 16:10
  not
• 16:10
  your
• 16:10
  manic
• 16:11
  state,
• 16:12
  that's
• 16:12
  not
• 16:12
  seven
• 16:12
  days
• 16:13
  of
• 16:13
  mania,
• 16:13
  but
• 16:14
  it
• 16:14
  could
• 16:14
  be
• 16:14
  severe
• 16:14
  depression.
• 16:15
  The
• 16:15
  bipolar
• 16:15
  2
• 16:16
  spends
• 16:17
  a
• 16:17
  lot
• 16:17
  more
• 16:17
  time
• 16:18
  in
• 16:18
  the
• 16:18
  depressive
• 16:19
  state.
• 16:20
  Very
• 16:20
  interesting
• 16:21
  stuff.
• 16:21
  And
• 16:21
  keep
• 16:22
  in
• 16:22
  mind,
• 16:22
  when
• 16:22
  you're
• 16:22
  diagnosing
• 16:23
  bipolar
• 16:23
  2,
• 16:24
  you
• 16:24
  do
• 16:25
  need
• 16:25
  both
• 16:25
  hypomania
• 16:26
  and
• 16:26
  major
• 16:26
  depression.
• 16:27
  If
• 16:27
  all
• 16:27
  you're
• 16:27
  getting
• 16:28
  is
• 16:28
  hypomania,
• 16:29
  remember
• 16:29
  that's
• 16:29
  not
• 16:29
  enough.
• 16:30
  You
• 16:30
  have
• 16:30
  to
• 16:30
  make
• 16:30
  sure
• 16:31
  that
• 16:31
  the
• 16:31
  patient
• 16:31
  also
• 16:32
  has
• 16:33
  depression.
• 16:33
  Now,
• 16:34
  Michael
• 16:35
  here
• 16:35
  in
• 16:35
  the
• 16:35
  hospital,
• 16:36
  he's
• 16:37
  never
• 16:37
  had
• 16:37
  depression,
• 16:38
  at
• 16:38
  least
• 16:38
  none
• 16:38
  that
• 16:38
  we
• 16:39
  can
• 16:39
  definitively
• 16:40
  diagnose.
• 16:40
  We
• 16:40
  don't
• 16:41
  have
• 16:41
  the
• 16:41
  collateral
• 16:41
  to
• 16:41
  do
• 16:41
  it.
• 16:42
  He's
• 16:42
  not
• 16:42
  telling
• 16:42
  us
• 16:43
  if
• 16:43
  he's
• 16:43
  been
• 16:43
  depressed.
• 16:44
  But
• 16:44
  again,
• 16:44
  virtue
• 16:45
  of
• 16:45
  his
• 16:45
  delusion,
• 16:46
  he's
• 16:46
  in
• 16:46
  the
• 16:47
  hospital,
• 16:47
  he's
• 16:47
  disheveled,
• 16:48
  he's
• 16:48
  talking
• 16:48
  fast,
• 16:49
  he
• 16:49
  has
• 16:50
  increased
• 16:50
  goal
• 16:51
  directed
• 16:51
  activity,
• 16:52
  high
• 16:52
  risk
• 16:53
  behaviors,
• 16:53
  spending
• 16:54
  tons
• 16:54
  of
• 16:54
  money.
• 16:55
  He's
• 16:55
  hitting
• 16:55
  all
• 16:55
  the
• 16:56
  wickets.
• 16:56
  We
• 16:56
  don't
• 16:56
  need
• 16:57
  depression
• 16:57
  in
• 16:57
  his
• 16:57
  past.
• 16:58
  We
• 16:58
  can
• 16:59
  diagnose
• 16:59
  bipolar
• 17:00
  one
• 17:00
  again,
• 17:01
  ruling
• 17:01
  out
• 17:01
  all
• 17:02
  of
• 17:02
  the
• 17:02
  other
• 17:03
  potential
• 17:03
  confounders,
• 17:04
  probably
• 17:05
  another
• 17:05
  podcast
• 17:06
  episode.
• 17:06
  But
• 17:07
  the
• 17:08
  schizophrenia,
• 17:09
  right,
• 17:09
  is
• 17:09
  this
• 17:09
  schizophrenia?
• 17:10
  Is
• 17:10
  this
• 17:11
  delusional
• 17:11
  disorder?
• 17:12
  You
• 17:12
  know,
• 17:12
  we
• 17:12
  can
• 17:12
  think
• 17:12
  about
• 17:13
  that
• 17:13
  stuff.
• 17:13
  That's
• 17:14
  good
• 17:14
  to
• 17:14
  think
• 17:14
  about
• 17:14
  that
• 17:15
  stuff,
• 17:15
  right?
• 17:15
  Any
• 17:15
  kind
• 17:15
  of
• 17:16
  psychosis
• 17:16
  or
• 17:16
  mood
• 17:17
  disorder
• 17:17
  should
• 17:18
  be
• 17:18
  thought
• 17:18
  about
• 17:19
  in
• 17:19
  the
• 17:19
  context
• 17:19
  of
• 17:20
  this
• 17:20
  presentation,
• 17:21
  however,
• 17:22
  I
• 17:22
  would
• 17:22
  say
• 17:23
  that
• 17:24
  we
• 17:24
  have
• 17:24
  some
• 17:24
  evidence
• 17:25
  that
• 17:25
  this
• 17:25
  is
• 17:25
  not
• 17:25
  necessarily
• 17:26
  schizophrenia.
• 17:27
  One
• 17:28
  clue
• 17:28
  is
• 17:28
  that
• 17:28
  he
• 17:29
  did
• 17:29
  take
• 17:29
  an
• 17:29
  antidepressant
• 17:30
  in
• 17:30
  the
• 17:30
  past,
• 17:31
  Prozac,
• 17:31
  and
• 17:32
  he
• 17:32
  stopped
• 17:32
  it
• 17:32
  because
• 17:33
  it
• 17:33
  was
• 17:33
  activating.
• 17:34
  We
• 17:34
  also
• 17:34
  have
• 17:35
  evidence
• 17:36
  that
• 17:36
  this
• 17:36
  is
• 17:36
  an
• 17:36
  episodic
• 17:37
  issue
• 17:37
  as
• 17:38
  opposed
• 17:38
  to
• 17:39
  schizophrenia,
• 17:39
  which
• 17:39
  is
• 17:40
  a
• 17:40
  chronic
• 17:40
  deterioration
• 17:41
  in
• 17:41
  functioning
• 17:42
  and
• 17:42
  it's
• 17:42
  inconsistent.
• 17:43
  So
• 17:43
  this
• 17:43
  is.
• 17:44
  Michael's
• 17:45
  presentation
• 17:45
  is
• 17:45
  rather
• 17:46
  inconsistent
• 17:46
  with
• 17:46
  a
• 17:47
  chronic
• 17:47
  deterioration
• 17:48
  in
• 17:48
  functioning.
• 17:49
  The
• 17:49
  psychosis
• 17:50
  in
• 17:50
  schizophrenia
• 17:51
  is
• 17:51
  typically
• 17:51
  more
• 17:51
  persistent
• 17:52
  and
• 17:52
  it
• 17:53
  often
• 17:53
  has
• 17:53
  negative
• 17:53
  symptoms
• 17:54
  and
• 17:54
  cognitive
• 17:54
  deficits,
• 17:55
  which
• 17:55
  just
• 17:55
  don't
• 17:56
  appear
• 17:56
  to
• 17:56
  be
• 17:56
  the
• 17:57
  case
• 17:57
  in
• 17:57
  Michael's
• 17:58
  history.
• 17:58
  Everything
• 17:58
  was
• 17:58
  more
• 17:58
  or
• 17:59
  less
• 17:59
  going
• 17:59
  well
• 17:59
  up
• 18:00
  until
• 18:00
  this
• 18:00
  point,
• 18:01
  but
• 18:01
  it's
• 18:02
  something
• 18:02
  to
• 18:02
  think
• 18:02
  about
• 18:02
  because
• 18:03
  he
• 18:03
  is
• 18:03
  grandiose,
• 18:04
  he
• 18:04
  has
• 18:04
  delusions.
• 18:05
  So
• 18:06
  that
• 18:06
  could
• 18:06
  very
• 18:06
  well
• 18:07
  be
• 18:07
  something
• 18:07
  to
• 18:07
  think
• 18:07
  about
• 18:08
  with
• 18:08
  schizophrenia.
• 18:08
  But
• 18:09
  again,
• 18:09
  I
• 18:09
  would
• 18:09
  urge
• 18:09
  you,
• 18:09
  is
• 18:10
  this
• 18:10
  episodic
• 18:11
  or
• 18:11
  chronic
• 18:12
  deterioration?
• 18:12
  And
• 18:13
  that's
• 18:13
  why
• 18:13
  you
• 18:13
  need
• 18:13
  collateral
• 18:14
  so
• 18:14
  badly.
• 18:15
  We
• 18:15
  talk
• 18:15
  about
• 18:16
  bipolar
• 18:16
  2
• 18:17
  already.
• 18:17
  We
• 18:17
  sort
• 18:17
  of
• 18:18
  drew
• 18:18
  the
• 18:18
  distinction
• 18:19
  there.
• 18:19
  They're
• 18:19
  very
• 18:19
  interesting.
• 18:20
  They're
• 18:20
  very
• 18:20
  important
• 18:21
  as
• 18:22
  well.
• 18:22
  You
• 18:22
  always
• 18:23
  want
• 18:23
  to
• 18:24
  rule
• 18:24
  out
• 18:25
  antidepressant
• 18:25
  induced
• 18:26
  mania.
• 18:27
  He's
• 18:27
  not
• 18:27
  on
• 18:27
  any
• 18:28
  right
• 18:28
  now.
• 18:28
  Prozac
• 18:29
  has
• 18:29
  been
• 18:29
  washed
• 18:30
  out
• 18:30
  of
• 18:30
  his
• 18:30
  system
• 18:31
  long
• 18:31
  ago.
• 18:31
  He
• 18:31
  took
• 18:32
  it,
• 18:32
  you
• 18:32
  know,
• 18:32
  he
• 18:32
  stopped
• 18:33
  at
• 18:33
  eight,
• 18:33
  eight
• 18:33
  months
• 18:34
  ago.
• 18:34
  It
• 18:34
  does
• 18:35
  have
• 18:35
  a
• 18:35
  very
• 18:35
  long
• 18:35
  half
• 18:35
  life
• 18:36
  that
• 18:36
  may
• 18:37
  take
• 18:37
  up
• 18:37
  to
• 18:37
  a
• 18:37
  month
• 18:37
  to
• 18:38
  wash
• 18:38
  out.
• 18:38
  But
• 18:38
  it's
• 18:39
  not
• 18:39
  eight
• 18:39
  months.
• 18:39
  So
• 18:39
  an
• 18:40
  antidepressant
• 18:40
  is
• 18:40
  not
• 18:41
  in
• 18:41
  the
• 18:41
  cards
• 18:41
  here
• 18:41
  because
• 18:41
  UDS
• 18:42
  is
• 18:42
  negative.
• 18:43
  It's
• 18:43
  always
• 18:43
  good
• 18:44
  to
• 18:44
  ask
• 18:44
  about
• 18:44
  any
• 18:44
  other
• 18:44
  supplements
• 18:45
  and
• 18:45
  to
• 18:45
  pop
• 18:46
  up
• 18:46
  on
• 18:46
  UDS
• 18:46
  for
• 18:47
  split
• 18:47
  for
• 18:47
  simplicity
• 18:48
  of
• 18:48
  this
• 18:48
  case.
• 18:49
  That's
• 18:49
  not
• 18:49
  really
• 18:50
  something
• 18:51
  that
• 18:51
  we
• 18:51
  would
• 18:51
  think
• 18:52
  about.
• 18:53
  Definitely
• 18:53
  encourage
• 18:54
  you
• 18:54
  to
• 18:54
  join
• 18:54
  our
• 18:54
  Patreon
• 18:55
  to
• 18:55
  get
• 18:56
  the
• 18:57
  metrics
• 18:57
  and
• 18:57
  rating
• 18:58
  scales
• 18:58
  and
• 18:58
  all
• 18:58
  kinds
• 18:59
  of
• 18:59
  unique
• 18:59
  clinical
• 18:59
  tools
• 19:00
  to
• 19:00
  make
• 19:00
  this
• 19:00
  easier
• 19:01
  and
• 19:01
  more
• 19:01
  fun.
• 19:02
  I
• 19:02
  highly
• 19:02
  recommend
• 19:03
  you
• 19:03
  join
• 19:03
  our
• 19:03
  Patreon
• 19:04
  in
• 19:04
  the
• 19:04
  show
• 19:04
  notes
• 19:05
  to
• 19:05
  access
• 19:05
  those
• 19:06
  materials.
• 19:07
  Now,
• 19:07
  going
• 19:07
  back
• 19:08
  to
• 19:08
  the
• 19:08
  diagnosis
• 19:09
  piece
• 19:09
  of
• 19:09
  bipolar
• 19:10
  one,
• 19:11
  we
• 19:11
  have
• 19:12
  talked
• 19:13
  about
• 19:13
  the
• 19:13
  duration,
• 19:14
  that's
• 19:14
  at
• 19:14
  least
• 19:14
  one
• 19:15
  week,
• 19:16
  nearly
• 19:16
  every
• 19:16
  day
• 19:17
  of
• 19:17
  a
• 19:18
  distinct
• 19:18
  period
• 19:18
  of
• 19:19
  abnormally
• 19:19
  and
• 19:20
  persistently
• 19:20
  elevated
• 19:21
  expansive
• 19:21
  or
• 19:21
  irritable
• 19:22
  mood
• 19:23
  and
• 19:23
  and
• 19:24
  abnormally
• 19:24
  and
• 19:25
  persistent
• 19:25
  increased
• 19:26
  goal
• 19:26
  directed
• 19:26
  activity
• 19:27
  or
• 19:27
  energy.
• 19:28
  So
• 19:28
  we
• 19:28
  hit
• 19:28
  those
• 19:28
  checkboxes.
• 19:29
  But
• 19:29
  remember,
• 19:30
  any
• 19:30
  duration
• 19:30
  is
• 19:31
  okay.
• 19:31
  If
• 19:31
  hospitalization
• 19:32
  is
• 19:32
  necessary
• 19:33
  as
• 19:34
  a
• 19:34
  result
• 19:34
  of
• 19:34
  his
• 19:34
  issue,
• 19:35
  the
• 19:35
  delusions
• 19:35
  would
• 19:36
  lead
• 19:36
  him
• 19:36
  to
• 19:36
  hospitalizations.
• 19:37
  And
• 19:38
  this
• 19:38
  is
• 19:38
  marked
• 19:39
  impairment.
• 19:39
  Right?
• 19:40
  This
• 19:40
  is
• 19:40
  marked
• 19:41
  impairment.
• 19:41
  You
• 19:41
  cannot
• 19:42
  function
• 19:42
  socially,
• 19:43
  occupationally,
• 19:44
  and
• 19:44
  you,
• 19:44
  you
• 19:45
  need
• 19:45
  hospitalization
• 19:46
  to
• 19:46
  prevent
• 19:46
  harming
• 19:47
  yourself
• 19:47
  or
• 19:47
  others.
• 19:48
  In
• 19:48
  this
• 19:48
  case
• 19:48
  harming
• 19:48
  himself
• 19:49
  or
• 19:49
  Mike
• 19:50
  Tyson.
• 19:51
  Now,
• 19:51
  the
• 19:52
  symptom
• 19:52
  count.
• 19:53
  You
• 19:53
  need
• 19:53
  three
• 19:53
  symptoms.
• 19:54
  Four
• 19:54
  if
• 19:54
  the
• 19:54
  mood
• 19:55
  is
• 19:55
  irritable.
• 19:55
  One
• 19:56
  of
• 19:56
  the
• 19:56
  most
• 19:56
  important
• 19:56
  ones
• 19:57
  is
• 19:57
  a
• 19:57
  decreased
• 19:57
  need
• 19:58
  for
• 19:58
  sleep.
• 19:58
  This
• 19:59
  is
• 19:59
  not
• 19:59
  decreased
• 19:59
  sleep.
• 20:00
  That's
• 20:01
  very
• 20:01
  broad
• 20:01
  and
• 20:01
  tricky.
• 20:02
  You're
• 20:02
  gonna
• 20:02
  get
• 20:02
  a
• 20:02
  lot
• 20:02
  of
• 20:03
  false
• 20:03
  positives
• 20:03
  if
• 20:03
  you
• 20:04
  just
• 20:04
  ask
• 20:04
  people
• 20:04
  how
• 20:04
  much
• 20:04
  they're
• 20:05
  sleeping.
• 20:05
  You
• 20:05
  need
• 20:06
  to
• 20:06
  understand
• 20:06
  the
• 20:06
  core
• 20:07
  reason
• 20:07
  behind
• 20:07
  why
• 20:08
  they
• 20:08
  are
• 20:08
  not
• 20:08
  sleeping.
• 20:09
  And
• 20:09
  in
• 20:09
  this
• 20:09
  case
• 20:10
  it's
• 20:10
  because
• 20:10
  he
• 20:10
  has
• 20:10
  so
• 20:11
  much
• 20:11
  energy.
• 20:11
  He
• 20:12
  has
• 20:12
  this
• 20:12
  good
• 20:12
  idea
• 20:13
  that's
• 20:13
  keeping
• 20:13
  him
• 20:13
  up
• 20:14
  all
• 20:14
  night.
• 20:14
  That
• 20:15
  is
• 20:15
  very
• 20:15
  important
• 20:16
  to
• 20:16
  consider.
• 20:17
  It's
• 20:17
  not
• 20:18
  just
• 20:18
  that
• 20:18
  he's
• 20:19
  not
• 20:19
  sleeping.
• 20:20
  We
• 20:20
  cannot
• 20:20
  stop
• 20:21
  there.
• 20:21
  If
• 20:21
  we
• 20:21
  want
• 20:21
  to
• 20:21
  be
• 20:21
  really
• 20:22
  accurate
• 20:22
  in
• 20:22
  our
• 20:23
  diagnoses,
• 20:23
  we
• 20:23
  have
• 20:24
  to
• 20:24
  get
• 20:24
  to
• 20:24
  the
• 20:24
  core.
• 20:25
  He
• 20:25
  is
• 20:25
  too
• 20:27
  excited
• 20:27
  to
• 20:28
  sleep,
• 20:28
  too
• 20:28
  goal
• 20:29
  directed
• 20:29
  to
• 20:29
  sleep,
• 20:30
  and
• 20:31
  thus
• 20:31
  he's
• 20:31
  not
• 20:31
  doing
• 20:31
  it.
• 20:33
  So
• 20:33
  we
• 20:33
  have
• 20:34
  these
• 20:34
  criteria
• 20:34
  here
• 20:35
  that
• 20:35
  he's
• 20:35
  distractible,
• 20:36
  his
• 20:36
  thoughts
• 20:36
  are
• 20:36
  racing,
• 20:37
  he's
• 20:38
  excessively
• 20:39
  involved
• 20:39
  in
• 20:39
  activities
• 20:40
  that
• 20:40
  have
• 20:40
  high
• 20:40
  potential
• 20:41
  for
• 20:41
  painful
• 20:41
  consequences.
• 20:43
  The
• 20:43
  bipolar
• 20:43
  2
• 20:44
  disorder
• 20:44
  is
• 20:45
  very
• 20:45
  similar
• 20:46
  to
• 20:46
  this,
• 20:46
  except
• 20:47
  for
• 20:47
  the
• 20:47
  fact
• 20:47
  that
• 20:48
  the
• 20:48
  cutoff
• 20:48
  is
• 20:49
  four
• 20:49
  days,
• 20:49
  not
• 20:49
  seven
• 20:50
  days.
• 20:50
  You
• 20:50
  need
• 20:51
  a
• 20:51
  depression
• 20:51
  as
• 20:52
  well
• 20:52
  as
• 20:52
  a
• 20:52
  hypomania.
• 20:53
  And
• 20:53
  it
• 20:53
  is
• 20:54
  not
• 20:54
  severe
• 20:54
  enough
• 20:55
  to
• 20:55
  cause
• 20:55
  marked
• 20:55
  impairment
• 20:56
  in
• 20:56
  social
• 20:56
  or
• 20:57
  occupational
• 20:57
  functioning
• 20:58
  or
• 20:58
  necessitate
• 20:59
  hospitalization.
• 21:00
  If
• 21:00
  there
• 21:00
  are
• 21:00
  psychotic
• 21:01
  features,
• 21:01
  the
• 21:01
  episode
• 21:02
  is
• 21:02
  by
• 21:02
  definition
• 21:03
  manic.
• 21:04
  Those
• 21:04
  are
• 21:04
  key
• 21:05
  distinctions.
• 21:06
  Key
• 21:06
  distinctions.
• 21:07
  One
• 21:07
  involves
• 21:08
  hospitalization,
• 21:09
  marked
• 21:09
  impairment,
• 21:10
  psychosis.
• 21:11
  Right.
• 21:11
  One
• 21:12
  does
• 21:12
  not
• 21:13
  necessarily
• 21:14
  require
• 21:14
  those
• 21:15
  things.
• 21:15
  I
• 21:16
  would
• 21:16
  argue
• 21:16
  it's
• 21:16
  still
• 21:16
  very
• 21:16
  impairing.
• 21:17
  But
• 21:18
  that's
• 21:18
  what
• 21:19
  I
• 21:19
  would
• 21:19
  look
• 21:19
  at.
• 21:20
  Remember,
• 21:20
  psychosis,
• 21:21
  psychotic
• 21:22
  features
• 21:22
  are
• 21:22
  never
• 21:22
  present
• 21:23
  during
• 21:23
  a
• 21:23
  hypomanic
• 21:24
  episode.
• 21:24
  It's
• 21:25
  like
• 21:25
  jumbo
• 21:25
  shrimp.
• 21:26
  It's
• 21:26
  not
• 21:26
  a
• 21:26
  thing.
• 21:27
  So
• 21:28
  get
• 21:28
  that
• 21:28
  out
• 21:28
  of
• 21:28
  your
• 21:29
  heads,
• 21:29
  at
• 21:29
  least
• 21:29
  diagnostically.
• 21:30
  Inter
• 21:30
  for
• 21:31
  your
• 21:31
  boards.
• 21:32
  This
• 21:32
  has
• 21:32
  been
• 21:32
  pretty
• 21:33
  interesting.
• 21:33
  Remember,
• 21:33
  there's
• 21:34
  specifiers
• 21:34
  too.
• 21:35
  Think
• 21:35
  about
• 21:35
  what
• 21:36
  specifiers
• 21:36
  there
• 21:36
  might
• 21:37
  be.
• 21:37
  Right.
• 21:37
  Anxious
• 21:38
  distress,
• 21:38
  mixed
• 21:38
  features,
• 21:39
  melancholic
• 21:40
  features,
• 21:40
  rapid
• 21:40
  cycling.
• 21:41
  The
• 21:41
  rapid
• 21:42
  cycling
• 21:42
  would
• 21:42
  be
• 21:42
  presence
• 21:43
  of
• 21:43
  at
• 21:43
  least
• 21:43
  four
• 21:43
  mood
• 21:44
  episodes.
• 21:44
  That's
• 21:44
  depression,
• 21:45
  manic
• 21:45
  or
• 21:45
  hypomanic
• 21:46
  within
• 21:46
  the
• 21:47
  past
• 21:47
  12
• 21:47
  months.
• 21:48
  Doesn't
• 21:48
  look
• 21:48
  like
• 21:48
  he's
• 21:48
  rapid
• 21:49
  cycling
• 21:49
  here.
• 21:50
  Right.
• 21:50
  He
• 21:51
  might
• 21:51
  have
• 21:51
  anxious
• 21:51
  distress.
• 21:52
  That's
• 21:53
  possible
• 21:53
  if
• 21:54
  he
• 21:54
  has
• 21:54
  two
• 21:54
  anxious
• 21:55
  symptoms
• 21:55
  or
• 21:55
  he's
• 21:57
  feeling
• 21:57
  on
• 21:57
  edge,
• 21:58
  restless,
• 21:58
  difficulty
• 21:59
  controlling
• 21:59
  his
• 22:00
  worry,
• 22:00
  that
• 22:00
  kind
• 22:01
  of
• 22:01
  thing.
• 22:02
  So
• 22:02
  just
• 22:03
  kind
• 22:03
  of
• 22:03
  take
• 22:03
  a
• 22:04
  look
• 22:04
  at
• 22:04
  your
• 22:04
  specifiers.
• 22:06
  Those
• 22:06
  are
• 22:06
  very
• 22:06
  important
• 22:07
  to
• 22:07
  look
• 22:07
  at.
• 22:07
  We
• 22:07
  have
• 22:08
  more
• 22:08
  details.
• 22:08
  If
• 22:09
  you
• 22:09
  become
• 22:09
  a
• 22:09
  Patreon
• 22:10
  member
• 22:10
  and
• 22:10
  get
• 22:11
  our
• 22:11
  slide
• 22:11
  decks
• 22:11
  full
• 22:11
  of
• 22:12
  this
• 22:12
  information,
• 22:12
  it's
• 22:13
  very
• 22:13
  useful.
• 22:13
  I
• 22:13
  highly
• 22:14
  recommend
• 22:14
  it
• 22:14
  for
• 22:14
  your
• 22:14
  practice.
• 22:15
  Let's
• 22:16
  move
• 22:16
  on
• 22:16
  to
• 22:16
  the
• 22:16
  prognostic
• 22:17
  indicators
• 22:17
  for
• 22:17
  bipolar
• 22:18
  disorder.
• 22:18
  Here,
• 22:19
  good
• 22:19
  prognosis
• 22:20
  would
• 22:20
  mean
• 22:21
  good
• 22:21
  treatment
• 22:21
  adherence,
• 22:22
  lack
• 22:22
  of
• 22:22
  early
• 22:23
  childhood
• 22:23
  adversity,
• 22:24
  higher
• 22:24
  age
• 22:24
  of
• 22:25
  onset
• 22:25
  is
• 22:26
  typically
• 22:26
  a
• 22:26
  little
• 22:26
  bit
• 22:27
  more
• 22:27
  favorable.
• 22:28
  Good
• 22:28
  social
• 22:28
  supports,
• 22:29
  an
• 22:29
  absence
• 22:29
  of
• 22:30
  rapid
• 22:30
  cycling
• 22:30
  and
• 22:30
  an
• 22:31
  absence
• 22:31
  of
• 22:31
  personality
• 22:32
  disorders.
• 22:33
  Poor
• 22:33
  prognosis
• 22:34
  factors
• 22:34
  would
• 22:35
  be
• 22:35
  mixed
• 22:35
  episodes
• 22:36
  or
• 22:36
  features
• 22:37
  as
• 22:37
  well
• 22:37
  as
• 22:37
  psychotic
• 22:38
  features
• 22:38
  or
• 22:38
  comorbid
• 22:39
  anxiety,
• 22:40
  substance
• 22:40
  use
• 22:41
  disorder,
• 22:41
  personality
• 22:42
  disorders.
• 22:42
  Those
• 22:43
  are
• 22:43
  definitely
• 22:44
  more
• 22:44
  complicated
• 22:45
  and
• 22:45
  difficult
• 22:46
  to
• 22:46
  treat.
• 22:47
  Remember
• 22:47
  that
• 22:47
  more
• 22:47
  than
• 22:48
  90%
• 22:48
  of
• 22:48
  individuals
• 22:49
  with
• 22:49
  a
• 22:49
  single
• 22:49
  manic
• 22:50
  episode
• 22:50
  will
• 22:50
  go
• 22:51
  on
• 22:51
  to
• 22:51
  have
• 22:51
  another
• 22:51
  mood
• 22:52
  episode.
• 22:53
  That
• 22:53
  is
• 22:53
  also
• 22:53
  very
• 22:54
  important
• 22:54
  in
• 22:55
  this
• 22:55
  case.
• 22:55
  We
• 22:55
  admit
• 22:56
  Michael,
• 22:56
  he
• 22:56
  goes
• 22:56
  to
• 22:56
  the
• 22:57
  hospital
• 22:58
  and
• 22:58
  we
• 22:59
  start
• 22:59
  him
• 22:59
  on
• 23:00
  Zyprexa.
• 23:01
  In
• 23:01
  our
• 23:01
  show
• 23:01
  Notes
• 23:02
  Patreon
• 23:02
  page,
• 23:03
  you're
• 23:03
  going
• 23:03
  to
• 23:03
  get
• 23:03
  a
• 23:03
  really
• 23:03
  good
• 23:04
  deep
• 23:04
  dive
• 23:04
  on
• 23:04
  what
• 23:04
  Zyprexa
• 23:05
  does.
• 23:06
  Why
• 23:06
  it
• 23:06
  might
• 23:07
  be
• 23:07
  ideal.
• 23:07
  Of
• 23:07
  course,
• 23:08
  there's
• 23:08
  many
• 23:08
  different
• 23:09
  agents
• 23:10
  you
• 23:10
  can
• 23:10
  start
• 23:10
  him
• 23:11
  on,
• 23:11
  be
• 23:12
  it
• 23:12
  second
• 23:12
  generation
• 23:13
  antipsychotics
• 23:13
  or
• 23:13
  mood
• 23:14
  stabilizers.
• 23:15
  But
• 23:15
  for
• 23:16
  immediate
• 23:16
  rapid
• 23:17
  antimanic
• 23:18
  activity,
• 23:18
  the
• 23:19
  folks
• 23:19
  in
• 23:19
  the
• 23:19
  hospital
• 23:20
  decided
• 23:20
  to
• 23:20
  start
• 23:21
  him
• 23:21
  on
• 23:22
  Olanzapine,
• 23:22
  also
• 23:23
  known
• 23:23
  as
• 23:23
  Zyprexa.
• 23:24
  The
• 23:25
  chief
• 23:25
  goal
• 23:25
  here
• 23:26
  is
• 23:26
  to
• 23:26
  block
• 23:27
  dopamine
• 23:27
  D2
• 23:28
  receptors.
• 23:28
  And
• 23:29
  it's
• 23:29
  crucial
• 23:29
  for
• 23:29
  those
• 23:30
  antipsychotic
• 23:30
  effects,
• 23:31
  reducing
• 23:32
  his
• 23:32
  positive
• 23:32
  symptoms
• 23:33
  of
• 23:33
  psychosis
• 23:33
  like
• 23:34
  delusions
• 23:34
  and
• 23:34
  hallucinations
• 23:35
  and
• 23:35
  the
• 23:35
  grandiosity
• 23:36
  often
• 23:37
  seen
• 23:37
  in
• 23:37
  mania.
• 23:38
  So
• 23:39
  by
• 23:39
  blocking
• 23:39
  these
• 23:39
  receptors,
• 23:40
  we're
• 23:40
  going
• 23:40
  to
• 23:41
  target
• 23:41
  the
• 23:41
  mesolimbic
• 23:42
  pathway
• 23:42
  and
• 23:43
  it
• 23:43
  tries
• 23:43
  to.
• 23:43
  We're
• 23:44
  going
• 23:44
  to
• 23:44
  try
• 23:44
  to
• 23:44
  normalize
• 23:44
  some
• 23:45
  of
• 23:45
  his
• 23:45
  overactive
• 23:46
  dopaminergic
• 23:47
  activity
• 23:48
  associated
• 23:48
  with
• 23:48
  his
• 23:49
  acute
• 23:50
  mania.
• 23:50
  Now,
• 23:51
  remember
• 23:51
  that
• 23:51
  we're
• 23:51
  also
• 23:51
  blockading
• 23:52
  the
• 23:52
  five
• 23:52
  HT2A
• 23:53
  serotonin
• 23:54
  receptors
• 23:55
  and
• 23:55
  that
• 23:55
  contributes
• 23:56
  a
• 23:56
  little
• 23:56
  bit
• 23:56
  to
• 23:57
  Zyprexa's
• 23:58
  antidepressant
• 23:58
  properties.
• 23:59
  Although
• 23:59
  he's
• 23:59
  denying
• 24:01
  that
• 24:01
  he's
• 24:01
  depressed,
• 24:02
  even
• 24:02
  if
• 24:02
  he
• 24:02
  hasn't
• 24:02
  been
• 24:03
  depressed
• 24:03
  before,
• 24:04
  it's
• 24:04
  going
• 24:04
  to
• 24:04
  be
• 24:04
  protective
• 24:05
  for
• 24:05
  him
• 24:05
  in
• 24:05
  the
• 24:05
  future.
• 24:06
  It
• 24:06
  can
• 24:07
  improve
• 24:07
  mood,
• 24:07
  reduce
• 24:08
  agitation
• 24:08
  and
• 24:09
  reduce
• 24:09
  the
• 24:09
  likelihood
• 24:09
  of
• 24:10
  extra
• 24:10
  pyramidal
• 24:11
  symptoms.
• 24:12
  So
• 24:12
  that's
• 24:12
  also
• 24:12
  very
• 24:13
  important.
• 24:13
  Now,
• 24:14
  it
• 24:14
  will
• 24:14
  make
• 24:14
  him
• 24:14
  tired
• 24:15
  because
• 24:15
  it
• 24:15
  blocks
• 24:15
  histamine.
• 24:16
  It'll
• 24:16
  make
• 24:17
  him
• 24:17
  significantly
• 24:17
  sedated,
• 24:18
  but
• 24:19
  that
• 24:19
  can
• 24:19
  be
• 24:19
  highly
• 24:19
  beneficial
• 24:20
  in
• 24:20
  acute
• 24:20
  mania
• 24:21
  for
• 24:22
  calming
• 24:22
  agitation
• 24:22
  and
• 24:23
  promoting
• 24:23
  sleep.
• 24:24
  It
• 24:25
  also
• 24:25
  has
• 24:25
  alpha
• 24:26
  1
• 24:26
  adrenergic
• 24:27
  receptor
• 24:27
  blockade,
• 24:28
  which
• 24:28
  will
• 24:28
  cause
• 24:29
  sedative
• 24:29
  hypotensive
• 24:30
  effects,
• 24:31
  and
• 24:31
  the
• 24:32
  muscarinic
• 24:33
  acetylcholine
• 24:34
  receptor
• 24:34
  blockade,
• 24:34
  M1,
• 24:35
  which
• 24:36
  can
• 24:36
  lead
• 24:36
  to
• 24:36
  dry
• 24:36
  mouth,
• 24:37
  blurred
• 24:38
  vision,
• 24:38
  constipation,
• 24:39
  cognitive
• 24:39
  dulling.
• 24:40
  We're
• 24:40
  going
• 24:40
  to
• 24:41
  start
• 24:41
  him
• 24:41
  at
• 24:41
  10mg
• 24:42
  for
• 24:42
  acute
• 24:42
  mania.
• 24:43
  Target
• 24:43
  between
• 24:44
  10
• 24:45
  and
• 24:45
  20
• 24:45
  daily
• 24:46
  based
• 24:46
  on
• 24:46
  his
• 24:46
  response
• 24:47
  and
• 24:47
  tolerability.
• 24:48
  Look
• 24:49
  out
• 24:49
  for,
• 24:49
  of
• 24:49
  course,
• 24:50
  those
• 24:50
  core
• 24:50
  side
• 24:50
  effects.
• 24:51
  Sedation,
• 24:51
  weight
• 24:52
  gain,
• 24:52
  it's
• 24:52
  a
• 24:52
  huge
• 24:52
  weight
• 24:53
  gainer,
• 24:53
  so
• 24:53
  definitely
• 24:54
  want
• 24:54
  to
• 24:54
  target
• 24:55
  that.
• 24:55
  We
• 24:55
  may
• 24:55
  not
• 24:56
  keep
• 24:56
  him
• 24:57
  on
• 24:57
  Zyprexa
• 24:58
  once
• 24:58
  he
• 24:58
  gets
• 24:58
  discharged
• 24:59
  because
• 24:59
  of
• 24:59
  metabolic
• 25:00
  concerns,
• 25:00
  increased
• 25:01
  blood
• 25:01
  glucose,
• 25:01
  lipids,
• 25:02
  you
• 25:02
  know,
• 25:02
  monitor
• 25:03
  his
• 25:03
  waistline,
• 25:03
  his
• 25:03
  metabolic
• 25:04
  blood
• 25:04
  work
• 25:04
  after
• 25:05
  the,
• 25:05
  after
• 25:05
  the
• 25:05
  fact
• 25:06
  of
• 25:06
  the
• 25:06
  course.
• 25:07
  But
• 25:08
  we
• 25:08
  need
• 25:08
  to
• 25:08
  rapidly
• 25:09
  stabilize
• 25:10
  him
• 25:10
  right
• 25:11
  now.
• 25:11
  That's
• 25:11
  the
• 25:12
  key,
• 25:12
  the
• 25:12
  absolute
• 25:13
  priority.
• 25:14
  Okay,
• 25:15
  so
• 25:15
  a
• 25:16
  lot
• 25:16
  of
• 25:16
  cool
• 25:16
  pearls
• 25:17
  on
• 25:17
  our
• 25:17
  Patreon
• 25:17
  page
• 25:18
  for
• 25:18
  you
• 25:18
  to
• 25:18
  think
• 25:18
  about
• 25:19
  with
• 25:19
  this.
• 25:19
  It's
• 25:20
  very
• 25:21
  exciting
• 25:21
  to
• 25:21
  go
• 25:22
  over
• 25:22
  the
• 25:22
  research
• 25:22
  because
• 25:23
  there's
• 25:23
  so
• 25:23
  much
• 25:23
  more
• 25:24
  that
• 25:24
  meets
• 25:24
  the
• 25:24
  eye
• 25:24
  with
• 25:25
  this
• 25:25
  case.
• 25:26
  And
• 25:26
  I
• 25:26
  highly
• 25:27
  recommend
• 25:27
  you
• 25:28
  look
• 25:28
  at
• 25:28
  this
• 25:28
  case
• 25:28
  more
• 25:29
  closely
• 25:29
  on
• 25:29
  our
• 25:29
  page.
• 25:30
  I
• 25:30
  hope
• 25:30
  you
• 25:31
  learned
• 25:31
  something
• 25:31
  about
• 25:32
  distinguishing
• 25:32
  between
• 25:33
  bipolar
• 25:33
  I
• 25:33
  and
• 25:34
  ii.
• 25:34
  Maybe
• 25:34
  a
• 25:35
  little
• 25:35
  sprinkle
• 25:35
  of
• 25:35
  schizophrenia
• 25:36
  in
• 25:36
  there
• 25:37
  and
• 25:37
  what
• 25:37
  to
• 25:38
  look
• 25:38
  for.
• 25:38
  And
• 25:39
  obviously
• 25:39
  not
• 25:39
  to
• 25:40
  ever
• 25:40
  underest,
• 25:40
  underestimate
• 25:41
  bipolar
• 25:42
  two.
• 25:42
  That's
• 25:42
  a
• 25:42
  wicked.
• 25:43
  That's
• 25:43
  a
• 25:43
  wicked
• 25:44
  illness,
• 25:44
  right?
• 25:44
  Definitely
• 25:45
  not
• 25:45
  fun.
• 25:46
  I
• 25:46
  hope
• 25:46
  you
• 25:46
  learned
• 25:47
  more
• 25:47
  about
• 25:47
  bipolar
• 25:48
  1
• 25:49
  and
• 25:49
  what
• 25:50
  to
• 25:50
  look
• 25:50
  for.
• 25:50
  There
• 25:51
  is
• 25:51
  evidence
• 25:51
  that
• 25:51
  mood
• 25:52
  stabilization
• 25:52
  in
• 25:53
  conjunction
• 25:53
  with
• 25:54
  second
• 25:54
  generation
• 25:55
  antipsychotics
• 25:55
  like
• 25:56
  lithium,
• 25:57
  lamictal
• 25:57
  or
• 25:57
  Depakote
• 25:58
  tend
• 25:58
  to
• 25:59
  be
• 25:59
  more
• 25:59
  efficacious.
• 25:59
  But
• 26:00
  every
• 26:00
  patient's
• 26:00
  a
• 26:00
  little
• 26:01
  bit
• 26:01
  different.
• 26:01
  Every
• 26:02
  side
• 26:02
  effect
• 26:02
  profile
• 26:03
  is
• 26:03
  a
• 26:03
  little
• 26:03
  bit
• 26:03
  different.
• 26:03
  We
• 26:03
  have
• 26:04
  to
• 26:04
  weigh
• 26:04
  the
• 26:04
  pros
• 26:04
  and
• 26:05
  cons
• 26:05
  across
• 26:05
  the
• 26:05
  board.
• 26:06
  And
• 26:06
  of
• 26:06
  course
• 26:07
  you
• 26:07
  want
• 26:07
  to
• 26:07
  transition
• 26:08
  this
• 26:08
  patient
• 26:08
  out
• 26:08
  to
• 26:09
  psychotherapy
• 26:10
  and
• 26:10
  other
• 26:10
  community
• 26:10
  resources
• 26:11
  to
• 26:11
  have
• 26:12
  an
• 26:12
  understanding
• 26:13
  of
• 26:13
  underlying
• 26:14
  stressors
• 26:14
  vulnerabilities
• 26:15
  and
• 26:15
  ways
• 26:16
  we
• 26:16
  can
• 26:16
  prevent
• 26:17
  any
• 26:17
  kind
• 26:17
  of
• 26:17
  major
• 26:18
  unraveling
• 26:19
  in
• 26:19
  the
• 26:19
  future.
• 26:20
  I
• 26:20
  really
• 26:20
  appreciate
• 26:21
  you
• 26:21
  all
• 26:21
  being
• 26:22
  here
• 26:22
  today.
• 26:22
  We
• 26:23
  would
• 26:23
  love
• 26:23
  if
• 26:23
  you
• 26:23
  would
• 26:24
  join
• 26:24
  us.
• 26:25
  Become
• 26:25
  a
• 26:25
  Patreon
• 26:26
  member.
• 26:26
  You're
• 26:27
  going
• 26:27
  to
• 26:27
  get
• 26:27
  beautiful
• 26:27
  slide
• 26:28
  decks
• 26:28
  full
• 26:28
  of
• 26:28
  this
• 26:29
  information.
• 26:29
  You're
• 26:30
  also
• 26:30
  going
• 26:30
  to
• 26:30
  get
• 26:30
  bonus
• 26:31
  case
• 26:31
  studies
• 26:31
  in
• 26:32
  a
• 26:32
  private
• 26:32
  podcast
• 26:33
  feed
• 26:34
  and
• 26:34
  a
• 26:34
  whole
• 26:34
  host
• 26:35
  of
• 26:35
  resources
• 26:36
  with
• 26:36
  fascinating
• 26:37
  research
• 26:37
  breakdowns
• 26:38
  and
• 26:39
  tools,
• 26:39
  clinical
• 26:40
  tools
• 26:40
  to
• 26:40
  boost
• 26:40
  your
• 26:40
  confidence
• 26:41
  and
• 26:41
  impact
• 26:41
  in
• 26:42
  your
• 26:42
  practice.
• 26:42
  Can't
• 26:43
  emphasize
• 26:43
  it
• 26:43
  enough.
• 26:44
  And
• 26:44
  if
• 26:44
  nothing
• 26:44
  else,
• 26:45
  please
• 26:45
  walk
• 26:46
  over
• 26:46
  to
• 26:47
  Apple
• 26:47
  and
• 26:48
  rate
• 26:48
  us
• 26:48
  today.
• 26:49
  Give
• 26:49
  us
• 26:49
  five
• 26:50
  stars
• 26:50
  on
• 26:50
  Apple
• 26:50
  and
• 26:51
  provide
• 26:51
  some
• 26:51
  feedback.
• 26:52
  Share
• 26:52
  with
• 26:52
  your
• 26:52
  friends
• 26:53
  in
• 26:53
  NP
• 26:54
  School
• 26:54
  as
• 26:55
  a
• 26:55
  good
• 26:55
  resource
• 26:56
  to
• 26:56
  get
• 26:56
  you
• 26:56
  all
• 26:56
  prepared
• 26:57
  and
• 26:57
  understand
• 26:57
  what
• 26:57
  it's
• 26:58
  like
• 26:58
  to
• 26:58
  practice
• 26:58
  right
• 26:59
  Cases
• 27:00
  are
• 27:00
  way
• 27:00
  more
• 27:00
  fun
• 27:00
  to
• 27:01
  learn
• 27:01
  from.
• 27:01
  We
• 27:02
  appreciate
• 27:02
  each
• 27:02
  and
• 27:03
  every
• 27:03
  one
• 27:03
  of
• 27:03
  you.
• 27:03
  This
• 27:03
  podcast
• 27:04
  has
• 27:04
  gotten
• 27:04
  very
• 27:05
  big
• 27:05
  very
• 27:05
  fast.
• 27:06
  It's
• 27:06
  been
• 27:07
  spreading
• 27:07
  a
• 27:08
  little
• 27:08
  bit
• 27:08
  like
• 27:08
  wildfire.
• 27:09
  People
• 27:09
  are
• 27:09
  mentioning.
• 27:10
  It's
• 27:10
  been
• 27:10
  very
• 27:10
  useful
• 27:11
  and
• 27:11
  that's
• 27:12
  the
• 27:12
  whole
• 27:12
  point.
• 27:12
  Thank
• 27:13
  you
• 27:13
  all
• 27:13
  very
• 27:13
  much
• 27:13
  and
• 27:14
  signing
• 27:14
  off.
• 27:14
  This
• 27:14
  is
• 27:15
  npz.
• 27:15
  Take
• 27:16
  care.