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This Mood Stabilizer Problem Can Mimic a Whole New Disorder · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:06
  back
• 0:06
  my
• 0:07
  friends
• 0:07
  to
• 0:07
  another
• 0:07
  episode
• 0:08
  of
• 0:08
  Pearls
• 0:08
  and
• 0:09
  Prep.
• 0:09
  This
• 0:09
  is
• 0:09
  NPC
• 0:10
  here
• 0:10
  your
• 0:10
  preceptor
• 0:11
  in
• 0:11
  your
• 0:11
  pocket,
• 0:11
  your
• 0:11
  go
• 0:12
  to
• 0:12
  place
• 0:12
  for
• 0:12
  pearls
• 0:13
  that
• 0:13
  prep
• 0:13
  you
• 0:14
  to
• 0:14
  practice.
• 0:15
  We
• 0:15
  have
• 0:15
  a
• 0:16
  board
• 0:16
  bombs
• 0:17
  bonanza
• 0:18
  today,
• 0:18
  that's
• 0:19
  one
• 0:19
  question.
• 0:19
  But
• 0:19
  it's
• 0:20
  super
• 0:20
  high
• 0:20
  yield,
• 0:21
  it's
• 0:21
  super
• 0:21
  fascinating,
• 0:22
  it's
• 0:22
  super
• 0:22
  interesting
• 0:23
  and
• 0:24
  we
• 0:24
  are
• 0:24
  going
• 0:25
  to
• 0:25
  get
• 0:25
  right
• 0:25
  to
• 0:26
  it.
• 0:26
  My
• 0:26
  friends,
• 0:27
  without
• 0:27
  further
• 0:27
  ado,
• 0:28
  you
• 0:28
  have
• 0:28
  a
• 0:29
  42
• 0:30
  year
• 0:30
  old
• 0:30
  woman
• 0:31
  named
• 0:32
  Henrietta.
• 0:33
  Now
• 0:33
  she's
• 0:33
  probably
• 0:33
  the
• 0:34
  only
• 0:34
  42
• 0:34
  year
• 0:35
  old
• 0:35
  woman
• 0:35
  named
• 0:35
  Henrietta.
• 0:36
  However,
• 0:36
  she's
• 0:37
  a
• 0:37
  mock
• 0:37
  patient
• 0:38
  and
• 0:39
  she
• 0:39
  has
• 0:39
  bipolar
• 0:40
  2
• 0:40
  disorder.
• 0:40
  She's
• 0:41
  stable
• 0:41
  on
• 0:41
  lithium
• 0:42
  900.
• 0:42
  Her
• 0:43
  level
• 0:43
  is
• 0:43
  0.8
• 0:44
  mil
• 0:45
  equivalents
• 0:45
  per
• 0:45
  liter
• 0:47
  and
• 0:48
  she's
• 0:48
  on
• 0:48
  abilify
• 0:49
  15
• 0:49
  milligrams
• 0:50
  every
• 0:50
  day
• 0:51
  for
• 0:51
  the
• 0:51
  last
• 0:52
  several
• 0:52
  months.
• 0:53
  And
• 0:53
  she's
• 0:53
  here
• 0:54
  for
• 0:54
  a
• 0:54
  routine
• 0:54
  follow
• 0:55
  up.
• 0:55
  Now
• 0:56
  she
• 0:56
  tells
• 0:56
  you
• 0:56
  her
• 0:56
  mood
• 0:56
  is
• 0:57
  the
• 0:57
  best
• 0:57
  it's
• 0:57
  been
• 0:57
  in
• 0:58
  years.
• 0:58
  She's
• 0:58
  really
• 0:59
  not
• 0:59
  depressed.
• 0:59
  There's
• 0:59
  no
• 1:00
  Hypomanic
• 1:00
  episodes
• 1:01
  or
• 1:01
  PHQ
• 1:01
  9
• 1:01
  is
• 1:02
  2,
• 1:02
  which
• 1:03
  is
• 1:03
  great.
• 1:04
  She
• 1:04
  denies
• 1:04
  any
• 1:05
  major
• 1:05
  mood
• 1:05
  symptoms.
• 1:06
  But
• 1:06
  her
• 1:06
  husband
• 1:07
  who's
• 1:07
  with
• 1:07
  her
• 1:08
  kind
• 1:08
  of
• 1:09
  pulls
• 1:09
  you
• 1:09
  aside
• 1:09
  and
• 1:09
  says,
• 1:10
  hey,
• 1:10
  listen,
• 1:10
  for
• 1:10
  the
• 1:10
  last
• 1:11
  three
• 1:11
  months
• 1:11
  Henrietta
• 1:12
  has
• 1:13
  been
• 1:13
  spending
• 1:14
  like
• 1:14
  four
• 1:14
  to
• 1:14
  six
• 1:15
  hours
• 1:15
  every
• 1:15
  night
• 1:16
  playing
• 1:16
  online
• 1:16
  poker.
• 1:17
  Texas
• 1:17
  Hold'.
• 1:18
  Em.
• 1:18
  Okay?
• 1:19
  She's
• 1:19
  opened
• 1:20
  up
• 1:20
  two
• 1:20
  new
• 1:20
  credit
• 1:21
  cards,
• 1:21
  she's
• 1:22
  lost
• 1:22
  like
• 1:22
  12
• 1:22
  grand
• 1:23
  and
• 1:24
  she's
• 1:24
  really
• 1:24
  never
• 1:24
  been
• 1:24
  a
• 1:25
  gambler.
• 1:26
  She's
• 1:26
  telling
• 1:26
  you
• 1:26
  she
• 1:27
  doesn't
• 1:27
  feel
• 1:27
  high,
• 1:27
  her
• 1:28
  sleep
• 1:28
  is
• 1:28
  great,
• 1:29
  her
• 1:29
  mental
• 1:29
  status
• 1:30
  exam
• 1:30
  is
• 1:30
  pretty
• 1:30
  unremarkable.
• 1:31
  She's
• 1:31
  in
• 1:31
  good,
• 1:32
  cheerful
• 1:32
  spirits.
• 1:33
  Not
• 1:33
  like
• 1:34
  hypomanic
• 1:34
  though.
• 1:35
  She's
• 1:35
  organized,
• 1:36
  no
• 1:36
  pressured
• 1:36
  speech
• 1:37
  and
• 1:37
  she's
• 1:37
  not
• 1:37
  grandiose.
• 1:39
  So
• 1:39
  my
• 1:40
  friends,
• 1:40
  what
• 1:40
  is
• 1:40
  your
• 1:40
  next
• 1:41
  most
• 1:41
  appropriate
• 1:43
  best
• 1:43
  step
• 1:43
  here?
• 1:44
  Is
• 1:44
  it
• 1:44
  A,
• 1:45
  increase
• 1:45
  her
• 1:45
  abilify
• 1:46
  to
• 1:46
  20
• 1:46
  milligrams
• 1:47
  to
• 1:47
  address
• 1:48
  her
• 1:49
  emerging
• 1:50
  impulsivity?
• 1:51
  Is
• 1:51
  it
• 1:52
  B,
• 1:53
  add
• 1:53
  Depakote
• 1:54
  for
• 1:54
  impulse
• 1:54
  control
• 1:55
  augmentation?
• 1:56
  Is
• 1:56
  it
• 1:56
  C,
• 1:57
  Discontinu,
• 1:57
  abilify
• 1:58
  and
• 1:58
  reassess.
• 1:59
  Is
• 1:59
  it
• 1:59
  D?
• 2:00
  Obtain
• 2:00
  a
• 2:00
  urine
• 2:01
  drug
• 2:01
  screen
• 2:01
  and
• 2:01
  check
• 2:02
  the
• 2:02
  lithium
• 2:02
  level.
• 2:03
  Or
• 2:03
  is
• 2:04
  it
• 2:04
  E?
• 2:04
  Refer
• 2:05
  to
• 2:05
  CBT
• 2:05
  for
• 2:06
  gambling
• 2:06
  disorder
• 2:07
  and
• 2:07
  you
• 2:07
  can
• 2:07
  continue
• 2:08
  the
• 2:08
  current
• 2:08
  regimen.
• 2:09
  I'll
• 2:09
  let
• 2:09
  you
• 2:10
  all
• 2:10
  think
• 2:10
  about
• 2:10
  this
• 2:10
  for
• 2:10
  a
• 2:11
  minute,
• 2:12
  how
• 2:12
  you
• 2:12
  can
• 2:12
  help
• 2:13
  Henrietta.
• 2:14
  You
• 2:14
  can
• 2:14
  pause
• 2:14
  this,
• 2:15
  break
• 2:15
  out
• 2:15
  into
• 2:15
  your
• 2:16
  zoom
• 2:16
  sessions
• 2:18
  and
• 2:18
  I'm
• 2:19
  gonna
• 2:19
  go
• 2:19
  into
• 2:19
  the
• 2:19
  answers
• 2:20
  right
• 2:20
  now.
• 2:20
  But
• 2:21
  you
• 2:21
  know
• 2:21
  how
• 2:21
  I
• 2:21
  like
• 2:21
  to
• 2:22
  do
• 2:22
  this?
• 2:22
  I
• 2:22
  like
• 2:22
  to
• 2:23
  go
• 2:23
  into
• 2:23
  the
• 2:23
  wrong
• 2:23
  answers
• 2:24
  first.
• 2:24
  Okay?
• 2:25
  Okay.
• 2:26
  So
• 2:28
  all
• 2:28
  of
• 2:28
  these
• 2:29
  answers
• 2:29
  sound
• 2:30
  somewhat
• 2:30
  reasonable
• 2:31
  at
• 2:32
  face
• 2:32
  value.
• 2:32
  Okay?
• 2:33
  So
• 2:34
  unlike
• 2:34
  a
• 2:34
  lot
• 2:34
  of
• 2:34
  my
• 2:35
  other
• 2:35
  board
• 2:35
  bombs,
• 2:36
  this
• 2:36
  one
• 2:37
  is
• 2:38
  pretty
• 2:38
  safe.
• 2:39
  If
• 2:39
  you
• 2:39
  wanna
• 2:39
  blurt
• 2:40
  out
• 2:40
  a
• 2:40
  wrong
• 2:40
  answer
• 2:40
  and
• 2:41
  you
• 2:41
  won't
• 2:41
  look
• 2:42
  ridiculous
• 2:43
  doing
• 2:43
  it,
• 2:43
  okay?
• 2:44
  I
• 2:44
  told
• 2:45
  you,
• 2:45
  this
• 2:46
  is
• 2:46
  just
• 2:46
  a
• 2:46
  podcast.
• 2:47
  There's
• 2:47
  no
• 2:47
  corporal
• 2:47
  punishment
• 2:48
  punishment
• 2:49
  here.
• 2:49
  I
• 2:50
  don't
• 2:50
  whip
• 2:50
  out
• 2:50
  a
• 2:50
  ruler
• 2:51
  and
• 2:51
  spank
• 2:51
  your
• 2:51
  tush
• 2:52
  or
• 2:52
  twist
• 2:52
  your
• 2:52
  ear
• 2:53
  or
• 2:54
  make
• 2:54
  you
• 2:54
  stand
• 2:54
  in
• 2:55
  the
• 2:55
  corner,
• 2:56
  bang
• 2:56
  your
• 2:56
  head
• 2:56
  against
• 2:56
  the
• 2:57
  window.
• 2:57
  This
• 2:57
  is
• 2:57
  a
• 2:57
  safe
• 2:58
  place.
• 2:58
  This
• 2:59
  is
• 2:59
  a
• 2:59
  safe
• 2:59
  classroom.
• 3:00
  I
• 3:00
  want
• 3:00
  you
• 3:00
  all
• 3:00
  to
• 3:01
  know
• 3:01
  that.
• 3:01
  I
• 3:01
  want
• 3:02
  you
• 3:02
  all
• 3:02
  to
• 3:02
  feel
• 3:02
  that.
• 3:03
  Okay?
• 3:05
  So
• 3:06
  I
• 3:06
  don't
• 3:07
  like
• 3:07
  some
• 3:07
  of
• 3:07
  these
• 3:07
  answers,
• 3:08
  okay?
• 3:08
  I
• 3:08
  don't
• 3:09
  really
• 3:09
  love
• 3:10
  the
• 3:10
  Depakote
• 3:10
  answer.
• 3:11
  Depakote
• 3:12
  is
• 3:12
  pretty
• 3:13
  good
• 3:13
  for
• 3:13
  impulsivity.
• 3:14
  Does
• 3:14
  have
• 3:14
  some
• 3:14
  evidence
• 3:15
  for
• 3:15
  that.
• 3:16
  But
• 3:16
  I
• 3:16
  don't
• 3:17
  like
• 3:17
  adding
• 3:17
  a
• 3:17
  medication
• 3:18
  if
• 3:19
  we
• 3:19
  know
• 3:20
  that
• 3:20
  the
• 3:20
  principal
• 3:21
  problem
• 3:22
  has
• 3:22
  not
• 3:23
  been
• 3:23
  addressed
• 3:23
  yet.
• 3:24
  Okay?
• 3:25
  And
• 3:26
  I'll
• 3:26
  just
• 3:26
  tell
• 3:26
  you
• 3:26
  straight
• 3:27
  out,
• 3:27
  the
• 3:27
  problem
• 3:28
  here
• 3:28
  is
• 3:28
  her
• 3:28
  Abilify.
• 3:29
  Okay?
• 3:30
  The
• 3:30
  problem
• 3:30
  is
• 3:31
  her
• 3:31
  Abilify.
• 3:32
  And
• 3:32
  so
• 3:32
  adding
• 3:33
  Depakote
• 3:34
  to
• 3:35
  a
• 3:35
  problem
• 3:35
  that
• 3:36
  can
• 3:36
  be
• 3:36
  solved
• 3:36
  by
• 3:37
  lowering
• 3:37
  or
• 3:38
  eliminating
• 3:39
  Abilify
• 3:40
  just
• 3:40
  makes
• 3:40
  no
• 3:41
  sense.
• 3:41
  Please,
• 3:42
  in
• 3:42
  your
• 3:42
  careers,
• 3:43
  never
• 3:43
  add
• 3:44
  something
• 3:45
  when
• 3:45
  something
• 3:45
  can
• 3:45
  be
• 3:46
  subtracted.
• 3:46
  There's
• 3:47
  like
• 3:47
  a
• 3:47
  fancy
• 3:48
  human
• 3:48
  bias
• 3:49
  that
• 3:50
  is
• 3:50
  out
• 3:51
  there.
• 3:51
  It's
• 3:51
  famous.
• 3:51
  I
• 3:52
  don't
• 3:52
  know
• 3:52
  it
• 3:52
  off
• 3:52
  the
• 3:52
  top
• 3:52
  of
• 3:53
  my
• 3:53
  head,
• 3:53
  but
• 3:53
  there's
• 3:53
  a
• 3:53
  fancy
• 3:54
  human
• 3:54
  bias.
• 3:54
  It
• 3:55
  has
• 3:55
  its
• 3:55
  own
• 3:55
  term
• 3:56
  that
• 3:56
  we
• 3:56
  feel
• 3:56
  like
• 3:56
  adding
• 3:57
  is
• 3:58
  always
• 3:58
  the
• 3:58
  solution
• 3:59
  to
• 3:59
  our
• 3:59
  problems.
• 4:00
  And
• 4:00
  so
• 4:00
  often
• 4:00
  in
• 4:00
  psychiatry,
• 4:01
  it's
• 4:01
  actually
• 4:02
  subtraction
• 4:03
  that
• 4:03
  solves
• 4:04
  your
• 4:04
  problems,
• 4:04
  right?
• 4:04
  You
• 4:05
  have
• 4:05
  a
• 4:05
  patient
• 4:06
  who's
• 4:06
  like
• 4:06
  sedated
• 4:07
  and
• 4:07
  has
• 4:07
  brain
• 4:08
  fog
• 4:08
  and
• 4:09
  can't
• 4:09
  think
• 4:09
  very
• 4:09
  clearly.
• 4:10
  And
• 4:10
  here
• 4:10
  you,
• 4:11
  here
• 4:11
  you
• 4:11
  go.
• 4:11
  They
• 4:11
  have
• 4:11
  this
• 4:12
  huge
• 4:12
  anticholinergic
• 4:13
  burden.
• 4:14
  There's
• 4:14
  even
• 4:14
  calculators
• 4:15
  online
• 4:15
  for
• 4:15
  you
• 4:16
  to
• 4:16
  look
• 4:16
  at
• 4:16
  anticholinergic
• 4:17
  burdens.
• 4:17
  And
• 4:18
  you
• 4:18
  added
• 4:18
  like
• 4:19
  methylphenidate
• 4:20
  when
• 4:20
  you
• 4:20
  could
• 4:20
  have
• 4:20
  just
• 4:20
  subtracted
• 4:21
  medications
• 4:22
  that
• 4:22
  maybe
• 4:22
  don't
• 4:22
  even
• 4:23
  play
• 4:23
  a
• 4:23
  role
• 4:24
  in
• 4:24
  their
• 4:24
  recovery
• 4:25
  anymore.
• 4:25
  Maybe
• 4:25
  they
• 4:25
  never
• 4:26
  played
• 4:26
  a
• 4:26
  role.
• 4:26
  Maybe
• 4:26
  if
• 4:27
  you
• 4:27
  asked
• 4:27
  your
• 4:27
  patient,
• 4:28
  they
• 4:28
  would
• 4:28
  tell
• 4:28
  you
• 4:28
  they
• 4:29
  don't
• 4:29
  play
• 4:29
  a
• 4:29
  role.
• 4:30
  And
• 4:30
  so
• 4:30
  subtraction
• 4:32
  is
• 4:32
  oftentimes
• 4:33
  the
• 4:33
  solution,
• 4:34
  my
• 4:34
  friends,
• 4:34
  not
• 4:35
  addition.
• 4:36
  Keep
• 4:36
  that
• 4:36
  in
• 4:36
  mind.
• 4:37
  Abilify
• 4:38
  is
• 4:38
  the
• 4:38
  problem
• 4:38
  here.
• 4:38
  And
• 4:38
  we'll
• 4:39
  go
• 4:39
  into
• 4:39
  that
• 4:39
  in
• 4:39
  a
• 4:39
  moment.
• 4:40
  But
• 4:40
  certainly
• 4:41
  addition
• 4:41
  here
• 4:41
  via
• 4:42
  Depakote
• 4:42
  is
• 4:43
  not
• 4:43
  a
• 4:43
  great
• 4:43
  idea.
• 4:44
  Okay?
• 4:45
  Now,
• 4:45
  she's
• 4:45
  a
• 4:45
  42
• 4:46
  year
• 4:46
  old
• 4:46
  woman,
• 4:47
  may
• 4:47
  or
• 4:47
  may
• 4:47
  not
• 4:47
  be
• 4:47
  childbearing,
• 4:48
  but
• 4:49
  Depakote
• 4:49
  is
• 4:49
  an
• 4:50
  even
• 4:50
  worse
• 4:51
  idea
• 4:51
  if
• 4:51
  we're
• 4:52
  putting
• 4:52
  it
• 4:52
  through
• 4:52
  that
• 4:52
  kind
• 4:52
  of
• 4:53
  a
• 4:53
  filter.
• 4:53
  It's
• 4:54
  kind
• 4:54
  of
• 4:54
  more
• 4:55
  of
• 4:55
  a
• 4:55
  heavy
• 4:55
  duty
• 4:55
  medication.
• 4:56
  I've
• 4:56
  seen
• 4:56
  hair
• 4:57
  loss,
• 4:57
  I've
• 4:57
  seen
• 4:57
  weight
• 4:58
  gain.
• 4:58
  I've
• 4:58
  seen
• 4:58
  a
• 4:59
  lot
• 4:59
  of
• 4:59
  issues
• 4:59
  with
• 4:59
  Depakote.
• 5:00
  It's
• 5:00
  also
• 5:00
  life
• 5:00
  saving.
• 5:01
  It
• 5:01
  can
• 5:01
  be
• 5:01
  great
• 5:01
  in
• 5:02
  rapid
• 5:02
  cycling.
• 5:03
  I'm
• 5:03
  just
• 5:03
  not
• 5:03
  a
• 5:03
  fan
• 5:04
  of
• 5:04
  adding
• 5:04
  a
• 5:04
  heavy
• 5:04
  duty
• 5:05
  medication
• 5:05
  when
• 5:05
  she
• 5:06
  already
• 5:06
  is
• 5:06
  on
• 5:06
  lithium
• 5:07
  and
• 5:07
  she's
• 5:07
  telling
• 5:07
  you,
• 5:08
  hey,
• 5:09
  I'm
• 5:09
  not
• 5:09
  hypomanic.
• 5:10
  Right?
• 5:10
  Everything
• 5:11
  else
• 5:11
  looks
• 5:11
  good.
• 5:11
  Her
• 5:11
  mental
• 5:12
  status
• 5:12
  exam.
• 5:12
  She
• 5:12
  doesn't
• 5:13
  have
• 5:13
  pressure
• 5:13
  speech
• 5:13
  or
• 5:14
  Lithium's
• 5:14
  in
• 5:14
  a
• 5:15
  therapeutic
• 5:15
  level.
• 5:15
  Like,
• 5:16
  why
• 5:16
  would
• 5:16
  we
• 5:17
  add
• 5:17
  a
• 5:17
  mood
• 5:17
  stabilizer
• 5:18
  like
• 5:18
  a.
• 5:19
  Like
• 5:19
  a
• 5:19
  rocket
• 5:20
  launcher
• 5:20
  here
• 5:21
  for
• 5:21
  some
• 5:22
  residual
• 5:22
  impulse
• 5:22
  control,
• 5:23
  especially
• 5:23
  if
• 5:24
  there
• 5:24
  was
• 5:25
  a
• 5:25
  problem
• 5:25
  that
• 5:25
  we
• 5:26
  could
• 5:26
  fix
• 5:26
  with
• 5:26
  subtraction.
• 5:27
  So,
• 5:27
  no,
• 5:28
  we're
• 5:28
  not
• 5:28
  going
• 5:28
  to
• 5:28
  choose
• 5:28
  B.
• 5:29
  We're
• 5:29
  not
• 5:29
  going
• 5:29
  to
• 5:29
  add
• 5:30
  Depakote
• 5:30
  for
• 5:31
  impulse
• 5:32
  control.
• 5:32
  Okay?
• 5:33
  Not
• 5:33
  now.
• 5:34
  If
• 5:34
  this,
• 5:34
  if
• 5:34
  our
• 5:35
  impulsivity
• 5:35
  was
• 5:36
  because
• 5:36
  of
• 5:36
  bipolarity,
• 5:37
  then
• 5:38
  I
• 5:38
  think
• 5:38
  we
• 5:38
  should
• 5:38
  consider
• 5:39
  that
• 5:39
  potentially
• 5:40
  optimize.
• 5:40
  Or
• 5:40
  lithium.
• 5:41
  Maybe
• 5:41
  that
• 5:41
  might
• 5:41
  be
• 5:41
  the
• 5:42
  better
• 5:42
  idea
• 5:42
  first.
• 5:43
  But
• 5:43
  no,
• 5:44
  it's
• 5:44
  not
• 5:44
  a
• 5:44
  good
• 5:44
  answer.
• 5:45
  Now,
• 5:45
  should
• 5:45
  we
• 5:45
  do
• 5:46
  option
• 5:46
  D
• 5:46
  and
• 5:46
  obtain
• 5:47
  a
• 5:47
  urine
• 5:47
  drug
• 5:48
  sample,
• 5:48
  check
• 5:48
  the
• 5:48
  lithium
• 5:49
  level?
• 5:50
  Well,
• 5:50
  this
• 5:50
  answer
• 5:51
  is
• 5:52
  pretty
• 5:52
  obviously
• 5:53
  wrong
• 5:53
  because
• 5:53
  we
• 5:53
  already
• 5:53
  have
• 5:54
  a
• 5:54
  lithium
• 5:54
  level,
• 5:54
  so
• 5:55
  why
• 5:55
  do
• 5:55
  we
• 5:55
  need
• 5:55
  to
• 5:55
  check
• 5:55
  it
• 5:55
  again?
• 5:56
  And
• 5:56
  it's
• 5:56
  therapeutic
• 5:57
  at
• 5:57
  0.8,
• 5:58
  she
• 5:58
  has
• 5:58
  no
• 5:59
  manic
• 5:59
  symptoms.
• 6:00
  So
• 6:00
  again,
• 6:00
  I
• 6:00
  don't
• 6:01
  know
• 6:01
  how
• 6:01
  checking
• 6:01
  the
• 6:02
  lithium
• 6:02
  level
• 6:02
  would
• 6:02
  be
• 6:02
  very
• 6:03
  constructive
• 6:03
  here.
• 6:05
  I
• 6:05
  think
• 6:06
  depending
• 6:06
  on
• 6:06
  where
• 6:06
  you
• 6:07
  are
• 6:07
  in
• 6:07
  your
• 6:07
  academic
• 6:07
  journey,
• 6:08
  it
• 6:08
  might
• 6:09
  be
• 6:09
  perfectly
• 6:10
  reasonable
• 6:10
  that
• 6:10
  you
• 6:10
  chose
• 6:11
  this
• 6:11
  answer.
• 6:11
  But
• 6:12
  we
• 6:12
  have
• 6:12
  the
• 6:12
  lithium
• 6:13
  level,
• 6:13
  and
• 6:14
  I
• 6:15
  just
• 6:15
  don't
• 6:15
  think
• 6:15
  we
• 6:16
  need
• 6:16
  to
• 6:16
  get
• 6:16
  another
• 6:16
  lithium
• 6:17
  level.
• 6:17
  That's
• 6:18
  just
• 6:18
  ridiculous.
• 6:19
  She
• 6:20
  has
• 6:20
  no
• 6:20
  manic
• 6:20
  symptoms.
• 6:21
  Her
• 6:21
  sleep
• 6:21
  is
• 6:21
  normal.
• 7:16
  That's
• 7:16
  the
• 7:16
  best
• 7:17
  way.
• 7:17
  I
• 7:17
  usually
• 7:17
  parse
• 7:18
  out.
• 7:18
  If
• 7:18
  somebody's
• 7:18
  having
• 7:18
  like
• 7:19
  a
• 7:19
  resurgence
• 7:19
  of
• 7:19
  mania,
• 7:20
  I
• 7:20
  have
• 7:20
  to
• 7:21
  know
• 7:21
  their
• 7:21
  sleep.
• 7:22
  And
• 7:22
  the
• 7:22
  mental
• 7:22
  status
• 7:23
  exam
• 7:23
  is
• 7:23
  key
• 7:23
  too,
• 7:24
  right?
• 7:24
  I
• 7:24
  can
• 7:24
  tell
• 7:25
  when
• 7:25
  someone
• 7:25
  walks
• 7:25
  in
• 7:26
  my
• 7:26
  office
• 7:26
  and
• 7:26
  I
• 7:26
  can't
• 7:26
  get
• 7:27
  a
• 7:27
  word
• 7:27
  in
• 7:27
  and
• 7:28
  they're
• 7:28
  just
• 7:28
  going
• 7:28
  off.
• 7:29
  It
• 7:29
  feels
• 7:29
  like
• 7:29
  you'll
• 7:30
  never
• 7:30
  get
• 7:30
  to
• 7:30
  talk
• 7:31
  to
• 7:31
  them
• 7:31
  unless
• 7:31
  you
• 7:31
  interrupt
• 7:32
  them,
• 7:32
  which
• 7:32
  is
• 7:32
  very
• 7:33
  uncomfortable
• 7:34
  as
• 7:34
  a
• 7:34
  clinician
• 7:34
  to
• 7:35
  interrupt
• 7:35
  your
• 7:36
  patient.
• 7:36
  It's
• 7:36
  uncomfortable
• 7:37
  to
• 7:37
  interrupt
• 7:37
  anybody.
• 7:38
  But,
• 7:38
  you
• 7:39
  know,
• 7:39
  mental
• 7:39
  status
• 7:39
  exam
• 7:40
  is
• 7:40
  a
• 7:40
  very
• 7:40
  good
• 7:40
  clue
• 7:41
  that
• 7:41
  something's
• 7:41
  off.
• 7:41
  The
• 7:42
  words
• 7:42
  are
• 7:42
  coming
• 7:42
  a
• 7:43
  lot
• 7:43
  faster.
• 7:43
  Kind
• 7:43
  of
• 7:44
  like
• 7:44
  how
• 7:44
  I'm
• 7:44
  talking
• 7:44
  right
• 7:44
  now.
• 7:45
  Normally,
• 7:45
  I've
• 7:46
  never
• 7:46
  gotten
• 7:46
  this
• 7:46
  looked
• 7:47
  at,
• 7:47
  but
• 7:47
  she
• 7:48
  has
• 7:48
  no
• 7:48
  manic
• 7:48
  symptoms
• 7:49
  here
• 7:49
  and
• 7:49
  her
• 7:49
  sleep
• 7:49
  is
• 7:49
  good.
• 7:50
  If
• 7:50
  your
• 7:50
  patient's
• 7:50
  telling
• 7:50
  you
• 7:51
  she's
• 7:51
  edgy,
• 7:51
  she's
• 7:51
  pacing,
• 7:52
  her
• 7:52
  husband's
• 7:52
  saying
• 7:53
  she's
• 7:53
  gambling
• 7:53
  into
• 7:54
  the
• 7:54
  wee
• 7:54
  hours
• 7:54
  of
• 7:54
  the
• 7:54
  night
• 7:55
  and
• 7:55
  she
• 7:55
  wants
• 7:55
  to
• 7:55
  start
• 7:56
  her
• 7:56
  own
• 7:56
  poker
• 7:57
  league,
• 7:57
  then
• 7:57
  absolutely
• 7:58
  I
• 7:58
  would
• 7:58
  be
• 7:58
  Worried
• 7:59
  that
• 7:59
  even
• 7:59
  if
• 8:00
  this
• 8:00
  lithium
• 8:00
  level's
• 8:01
  therapeutic,
• 8:01
  maybe
• 8:01
  it
• 8:01
  could
• 8:02
  be
• 8:02
  bumped
• 8:02
  up.
• 8:02
  I
• 8:02
  would
• 8:02
  think
• 8:03
  all
• 8:03
  of
• 8:03
  those
• 8:03
  things,
• 8:03
  but
• 8:04
  we're
• 8:04
  just
• 8:04
  not
• 8:04
  seeing
• 8:05
  the
• 8:05
  broad
• 8:05
  constellation
• 8:06
  of
• 8:06
  manic
• 8:06
  symptoms
• 8:07
  here.
• 8:07
  We're
• 8:07
  seeing
• 8:08
  impulsivity
• 8:09
  that
• 8:09
  seems
• 8:09
  to
• 8:09
  be
• 8:09
  circumscribed
• 8:10
  for
• 8:10
  whatever
• 8:11
  reason
• 8:11
  and
• 8:11
  not
• 8:12
  part
• 8:12
  of
• 8:12
  a
• 8:12
  broader
• 8:13
  decompensation
• 8:14
  of
• 8:14
  mania.
• 8:14
  So
• 8:15
  I'm
• 8:15
  not
• 8:15
  thinking
• 8:16
  that.
• 8:16
  Right.
• 8:16
  I'm
• 8:16
  thinking
• 8:17
  something
• 8:17
  else
• 8:17
  is
• 8:17
  the
• 8:18
  problem
• 8:18
  here.
• 8:18
  So
• 8:18
  a
• 8:19
  uds,
• 8:19
  sure,
• 8:20
  there
• 8:20
  are
• 8:20
  probably
• 8:20
  drugs
• 8:21
  out
• 8:21
  there
• 8:21
  that
• 8:22
  make
• 8:22
  you
• 8:22
  want
• 8:22
  to
• 8:22
  gamble
• 8:23
  compulsively.
• 8:23
  Is
• 8:24
  getting
• 8:24
  a
• 8:24
  UDS
• 8:25
  the
• 8:25
  dumbest
• 8:25
  idea
• 8:25
  in
• 8:25
  the
• 8:26
  world?
• 8:26
  No,
• 8:26
  but
• 8:27
  it
• 8:27
  might
• 8:27
  be
• 8:27
  the
• 8:27
  second
• 8:27
  dumbest
• 8:28
  idea
• 8:28
  in
• 8:28
  the
• 8:28
  world.
• 8:29
  I
• 8:29
  don't
• 8:29
  know.
• 8:29
  It's
• 8:30
  just
• 8:30
  not
• 8:30
  really
• 8:31
  a
• 8:31
  smart
• 8:31
  idea
• 8:32
  because
• 8:32
  there's
• 8:33
  an
• 8:33
  elephant
• 8:33
  in
• 8:33
  this
• 8:33
  room
• 8:34
  and
• 8:34
  we
• 8:34
  know
• 8:34
  the
• 8:34
  elephant
• 8:35
  is
• 8:35
  there
• 8:35
  and
• 8:35
  we
• 8:36
  know
• 8:36
  why
• 8:36
  he's
• 8:36
  there.
• 8:37
  And
• 8:37
  we're
• 8:37
  gonna
• 8:37
  get
• 8:37
  to
• 8:37
  that
• 8:37
  in
• 8:38
  a
• 8:38
  minute.
• 8:38
  Now,
• 8:38
  do
• 8:39
  we
• 8:39
  choose
• 8:39
  option
• 8:39
  E,
• 8:40
  refer
• 8:40
  to
• 8:40
  CBT
• 8:41
  with.
• 8:41
  While
• 8:41
  continuing
• 8:42
  the
• 8:42
  current
• 8:42
  regimen.
• 8:43
  I
• 8:44
  think
• 8:44
  this
• 8:44
  is
• 8:44
  one
• 8:44
  of
• 8:44
  the
• 8:44
  worst
• 8:45
  answers
• 8:45
  on
• 8:45
  here.
• 8:46
  Although
• 8:46
  CBT
• 8:47
  for
• 8:47
  gambling
• 8:48
  disorder
• 8:48
  is
• 8:48
  evidence
• 8:49
  based,
• 8:50
  continuing
• 8:50
  Abilify
• 8:52
  while
• 8:52
  referring
• 8:53
  for
• 8:53
  therapy
• 8:53
  here
• 8:53
  is
• 8:54
  kind
• 8:54
  of
• 8:54
  like
• 8:54
  referring
• 8:55
  someone
• 8:55
  for
• 8:55
  burn
• 8:56
  treatment.
• 8:56
  When
• 8:57
  you
• 8:57
  leave
• 8:57
  their
• 8:57
  hand
• 8:57
  on
• 8:58
  the
• 8:58
  stove,
• 8:58
  it
• 8:58
  just
• 8:58
  doesn't
• 8:59
  really
• 8:59
  make
• 8:59
  sense.
• 9:00
  Like
• 9:00
  take
• 9:00
  their
• 9:00
  hand
• 9:01
  off
• 9:01
  the
• 9:01
  stove.
• 9:01
  Right.
• 9:02
  In
• 9:02
  this
• 9:03
  case,
• 9:03
  it
• 9:03
  would
• 9:03
  be
• 9:03
  the
• 9:03
  Abilify.
• 9:04
  And
• 9:04
  so,
• 9:05
  no,
• 9:05
  I
• 9:05
  think
• 9:05
  cbt,
• 9:06
  you're
• 9:06
  now,
• 9:06
  you're
• 9:06
  giving
• 9:06
  them
• 9:07
  this
• 9:07
  class
• 9:07
  they
• 9:08
  have
• 9:08
  to
• 9:08
  attend
• 9:09
  for
• 9:09
  four
• 9:09
  days
• 9:10
  a
• 9:10
  week.
• 9:10
  And
• 9:11
  it
• 9:11
  just,
• 9:12
  it's
• 9:12
  like,
• 9:12
  what's
• 9:12
  the
• 9:13
  point?
• 9:13
  You
• 9:13
  could
• 9:13
  have
• 9:13
  solved
• 9:13
  this
• 9:14
  a
• 9:14
  lot
• 9:14
  less
• 9:14
  intrusively
• 9:15
  and
• 9:16
  expensively.
• 9:17
  So
• 9:17
  we
• 9:18
  can,
• 9:18
  we
• 9:18
  can
• 9:19
  make
• 9:19
  this
• 9:19
  work.
• 9:19
  So
• 9:20
  that
• 9:20
  leaves
• 9:20
  us
• 9:20
  with
• 9:21
  increasing
• 9:21
  the
• 9:21
  Abilify.
• 9:22
  Do
• 9:22
  we
• 9:22
  want
• 9:22
  to
• 9:22
  increase
• 9:23
  the
• 9:23
  Abilify?
• 9:24
  Well,
• 9:25
  that
• 9:25
  would
• 9:25
  be
• 9:25
  like
• 9:26
  taking
• 9:26
  her
• 9:26
  hand
• 9:26
  off
• 9:27
  of
• 9:27
  the
• 9:27
  stove
• 9:27
  and
• 9:27
  just
• 9:28
  putting
• 9:29
  it
• 9:29
  into
• 9:29
  a
• 9:29
  fireplace.
• 9:30
  I
• 9:30
  don't
• 9:30
  think
• 9:31
  that
• 9:31
  makes
• 9:31
  any
• 9:31
  sense.
• 9:32
  Right.
• 9:32
  This
• 9:33
  is
• 9:33
  a
• 9:33
  trap
• 9:33
  answer.
• 9:33
  And
• 9:34
  I
• 9:34
  think
• 9:34
  this
• 9:34
  answer
• 9:34
  is
• 9:35
  the
• 9:35
  most
• 9:35
  reasonable
• 9:35
  wrong
• 9:36
  answer,
• 9:36
  at
• 9:37
  least
• 9:37
  on
• 9:37
  the
• 9:37
  surface.
• 9:37
  If
• 9:38
  you're
• 9:38
  not.
• 9:38
  If
• 9:38
  you
• 9:38
  don't
• 9:38
  know
• 9:39
  any
• 9:39
  better.
• 9:39
  Right.
• 9:40
  Increasing
• 9:40
  the
• 9:40
  Abilify,
• 9:41
  you
• 9:41
  might
• 9:41
  say,
• 9:41
  well,
• 9:41
  well,
• 9:42
  wait
• 9:42
  a
• 9:42
  minute.
• 9:42
  This
• 9:42
  is
• 9:42
  breakthrough
• 9:43
  impulsivity.
• 9:44
  Let's
• 9:44
  just
• 9:44
  increase
• 9:45
  her
• 9:45
  mood
• 9:45
  stabilizer
• 9:46
  and
• 9:46
  she
• 9:46
  might
• 9:46
  become
• 9:46
  less
• 9:47
  impulsive.
• 9:48
  That
• 9:49
  would
• 9:49
  make
• 9:50
  sense.
• 9:50
  If
• 9:50
  this
• 9:51
  was
• 9:51
  more
• 9:51
  of
• 9:51
  a
• 9:51
  manic
• 9:52
  problem
• 9:52
  where
• 9:53
  she's
• 9:53
  not
• 9:53
  sleeping
• 9:53
  as
• 9:53
  much,
• 9:54
  she's
• 9:54
  more
• 9:54
  agitated,
• 9:55
  and.
• 9:55
  And
• 9:55
  she's
• 9:55
  just
• 9:56
  more
• 9:56
  broadly
• 9:56
  impulsive
• 9:57
  as
• 9:57
  a
• 9:57
  result
• 9:58
  of
• 9:58
  her
• 9:58
  mania
• 9:59
  or
• 9:59
  hypomania,
• 9:59
  then
• 10:00
  yes,
• 10:00
  in
• 10:01
  theory,
• 10:02
  maybe
• 10:02
  more
• 10:03
  of
• 10:03
  a
• 10:03
  D2
• 10:03
  blockade.
• 10:04
  You
• 10:05
  could
• 10:05
  make
• 10:05
  a
• 10:05
  case
• 10:06
  is
• 10:06
  smart.
• 10:07
  Remember
• 10:07
  though,
• 10:08
  Abilify
• 10:08
  is
• 10:08
  a
• 10:09
  partial
• 10:09
  agonist,
• 10:10
  so
• 10:10
  it
• 10:10
  will
• 10:10
  lower
• 10:11
  de.
• 10:11
  It
• 10:11
  will
• 10:12
  increase
• 10:12
  dopamine
• 10:13
  in
• 10:13
  select
• 10:13
  areas.
• 10:14
  It
• 10:14
  will
• 10:14
  also
• 10:14
  decrease
• 10:15
  dopamine
• 10:16
  where
• 10:16
  it's
• 10:16
  excessive
• 10:17
  in
• 10:17
  other
• 10:17
  areas.
• 10:17
  So
• 10:18
  you're
• 10:18
  not
• 10:18
  entirely
• 10:19
  wrong
• 10:19
  if
• 10:20
  this
• 10:20
  was
• 10:21
  part
• 10:21
  of
• 10:21
  a
• 10:21
  broader
• 10:22
  hypomanic
• 10:23
  construct,
• 10:24
  but
• 10:24
  it
• 10:25
  doesn't
• 10:25
  look
• 10:25
  like
• 10:25
  it
• 10:25
  is.
• 10:26
  And
• 10:26
  in
• 10:26
  this
• 10:26
  case,
• 10:26
  you
• 10:26
  would
• 10:27
  probably
• 10:27
  worsen
• 10:28
  this
• 10:28
  issue,
• 10:28
  this
• 10:28
  gambling
• 10:29
  issue,
• 10:29
  if
• 10:29
  you
• 10:30
  increased
• 10:30
  her
• 10:30
  to
• 10:30
  20.
• 10:31
  Because
• 10:31
  gambling
• 10:31
  is
• 10:31
  often
• 10:32
  dose
• 10:32
  related
• 10:33
  and
• 10:33
  caused
• 10:33
  by
• 10:34
  Abilify
• 10:34
  itself.
• 10:35
  The
• 10:35
  FDA
• 10:35
  label
• 10:36
  explicitly
• 10:36
  states
• 10:37
  these
• 10:37
  urges
• 10:37
  are
• 10:38
  reported
• 10:38
  to
• 10:38
  have
• 10:39
  stopped
• 10:39
  when
• 10:39
  the
• 10:39
  dose
• 10:39
  was
• 10:40
  reduced
• 10:40
  or
• 10:40
  the
• 10:40
  medication
• 10:41
  was
• 10:41
  stopped.
• 10:42
  So
• 10:43
  now
• 10:44
  you
• 10:44
  could
• 10:44
  eliminate
• 10:45
  the
• 10:45
  Abilify
• 10:46
  altogether.
• 10:46
  You
• 10:47
  could
• 10:47
  do
• 10:47
  a
• 10:47
  dose
• 10:47
  reduction,
• 10:48
  which
• 10:48
  personally
• 10:48
  for
• 10:48
  me
• 10:49
  is
• 10:49
  a
• 10:50
  little
• 10:50
  bit
• 10:50
  more
• 10:50
  preferable.
• 10:51
  I
• 10:51
  wouldn't
• 10:51
  want
• 10:51
  to
• 10:51
  just
• 10:51
  willy
• 10:52
  nilly
• 10:52
  to
• 10:52
  yank
• 10:52
  somebody
• 10:53
  off
• 10:53
  of
• 10:53
  Abilify
• 10:53
  completely,
• 10:54
  especially
• 10:55
  if
• 10:55
  it
• 10:55
  served
• 10:55
  a
• 10:55
  purpose
• 10:56
  for
• 10:56
  Henrietta.
• 10:57
  I
• 10:57
  would
• 10:57
  kind
• 10:57
  of
• 10:57
  ask
• 10:58
  her,
• 10:58
  what
• 10:58
  role
• 10:58
  has
• 10:58
  Abilify
• 10:59
  played
• 10:59
  in
• 11:00
  your
• 11:00
  recovery
• 11:01
  up
• 11:01
  until
• 11:01
  this
• 11:01
  point?
• 11:02
  And
• 11:02
  she
• 11:03
  might
• 11:03
  say,
• 11:03
  you
• 11:03
  know,
• 11:03
  before
• 11:03
  I
• 11:04
  was
• 11:04
  just
• 11:05
  so
• 11:05
  edgy.
• 11:05
  It's
• 11:05
  really
• 11:06
  helped
• 11:06
  me
• 11:06
  calm
• 11:06
  down,
• 11:07
  it's
• 11:07
  really
• 11:07
  helped
• 11:08
  with
• 11:08
  my
• 11:08
  depression,
• 11:08
  et
• 11:08
  cetera,
• 11:09
  et
• 11:09
  cetera.
• 11:09
  She
• 11:09
  might
• 11:09
  have
• 11:10
  many
• 11:10
  different
• 11:10
  answers
• 11:10
  for
• 11:10
  you.
• 11:11
  But
• 11:11
  if
• 11:11
  it
• 11:11
  has
• 11:12
  been
• 11:12
  beneficial
• 11:12
  and
• 11:13
  it's
• 11:13
  conclusively
• 11:14
  beneficial
• 11:14
  and
• 11:14
  her
• 11:15
  husband
• 11:15
  corroborates
• 11:16
  that,
• 11:16
  I
• 11:16
  would
• 11:16
  be
• 11:17
  wary
• 11:17
  to
• 11:17
  just
• 11:18
  yank
• 11:18
  this
• 11:18
  away
• 11:18
  from
• 11:19
  her
• 11:19
  regimen
• 11:19
  completely.
• 11:20
  But
• 11:20
  without
• 11:20
  a
• 11:21
  doubt,
• 11:21
  we
• 11:21
  need
• 11:21
  a
• 11:21
  dose
• 11:22
  reduction
• 11:22
  here
• 11:22
  because
• 11:23
  this
• 11:23
  is
• 11:23
  iatrogenic.
• 11:24
  This
• 11:24
  is
• 11:24
  something
• 11:25
  that
• 11:25
  is
• 11:25
  caused
• 11:26
  by
• 11:26
  the
• 11:27
  Abilify
• 11:27
  increase
• 11:28
  via
• 11:28
  the
• 11:29
  D2
• 11:29
  and
• 11:29
  D3
• 11:30
  partial
• 11:30
  agonism,
• 11:31
  which
• 11:31
  is
• 11:32
  a
• 11:32
  unique
• 11:33
  risk
• 11:33
  from
• 11:33
  Abilify
• 11:34
  and
• 11:34
  Vraylar,
• 11:35
  also
• 11:35
  known
• 11:35
  as
• 11:35
  Cariprazine.
• 11:36
  These
• 11:36
  are
• 11:37
  atypical
• 11:37
  antipsychotics
• 11:38
  that
• 11:38
  have
• 11:39
  an
• 11:39
  affinity
• 11:39
  for
• 11:39
  partial
• 11:40
  agonism,
• 11:40
  for
• 11:40
  D2,
• 11:41
  D3D.
• 11:41
  It
• 11:42
  manipulates
• 11:42
  the
• 11:43
  reward
• 11:43
  pathways
• 11:44
  in
• 11:44
  our
• 11:44
  brain
• 11:45
  with
• 11:45
  that
• 11:46
  can
• 11:46
  lead
• 11:46
  to
• 11:46
  compulsive
• 11:47
  gambling.
• 11:48
  And.
• 11:48
  And
• 11:48
  so
• 11:49
  watch
• 11:49
  out
• 11:49
  for
• 11:49
  that,
• 11:50
  right?
• 11:50
  It
• 11:50
  can
• 11:50
  lower
• 11:50
  the
• 11:51
  threshold
• 11:51
  by
• 11:51
  which
• 11:51
  we
• 11:52
  want
• 11:52
  to
• 11:52
  compulsively
• 11:52
  gamble
• 11:53
  or
• 11:53
  shop
• 11:54
  or
• 11:55
  do
• 11:55
  other
• 11:55
  impulse.
• 11:56
  So
• 11:56
  it's
• 11:56
  not
• 11:56
  just
• 11:56
  gambling,
• 11:57
  right?
• 11:57
  It
• 11:57
  could
• 11:57
  be
• 11:58
  actually
• 11:59
  many
• 11:59
  different
• 12:00
  things
• 12:00
  at
• 12:01
  once.
• 12:01
  So
• 12:01
  look
• 12:01
  for
• 12:02
  kind
• 12:02
  of
• 12:02
  all
• 12:02
  sorts
• 12:03
  of
• 12:03
  compulsive
• 12:04
  reward
• 12:04
  seeking
• 12:05
  behavior
• 12:05
  in
• 12:05
  vulnerable
• 12:06
  individuals.
• 12:06
  It's
• 12:06
  not
• 12:06
  everybody,
• 12:07
  but
• 12:07
  it's
• 12:08
  definitely
• 12:08
  something
• 12:08
  we
• 12:09
  need
• 12:09
  to
• 12:09
  think
• 12:09
  about.
• 12:10
  So
• 12:10
  the
• 12:10
  answer
• 12:11
  then,
• 12:11
  my
• 12:11
  friends,
• 12:12
  is
• 12:13
  C
• 12:13
  discontinue.
• 12:14
  And
• 12:14
  I
• 12:14
  would
• 12:15
  add
• 12:15
  a
• 12:15
  specifier
• 12:15
  to
• 12:16
  that
• 12:16
  or
• 12:16
  reduce
• 12:16
  the
• 12:17
  Abilify
• 12:17
  dose
• 12:17
  and
• 12:18
  then
• 12:18
  reassess.
• 12:18
  And
• 12:18
  I
• 12:18
  bet
• 12:19
  you
• 12:19
  money
• 12:19
  that
• 12:20
  Henrietta
• 12:20
  is
• 12:20
  going
• 12:20
  to
• 12:20
  be
• 12:21
  gambling
• 12:21
  less,
• 12:21
  if
• 12:22
  at
• 12:22
  all.
• 12:22
  If
• 12:22
  you
• 12:22
  get
• 12:22
  her
• 12:23
  back
• 12:23
  down
• 12:23
  to
• 12:24
  a
• 12:24
  lower
• 12:24
  dose,
• 12:24
  she's
• 12:25
  at
• 12:25
  15
• 12:25
  now,
• 12:25
  so
• 12:26
  maybe
• 12:26
  10
• 12:26
  and
• 12:27
  then
• 12:27
  5.
• 12:27
  Or
• 12:28
  maybe
• 12:28
  you
• 12:28
  have
• 12:28
  to
• 12:28
  discontinue
• 12:29
  it
• 12:29
  altogether,
• 12:30
  depending
• 12:30
  on
• 12:30
  the
• 12:30
  timing.
• 12:31
  But
• 12:31
  the
• 12:31
  big
• 12:31
  takeaways
• 12:32
  here,
• 12:32
  of
• 12:32
  course,
• 12:32
  are
• 12:33
  to
• 12:33
  look
• 12:33
  at
• 12:33
  the
• 12:33
  big
• 12:33
  picture.
• 12:35
  Is
• 12:35
  this
• 12:35
  mania
• 12:35
  or
• 12:36
  hypomania
• 12:36
  getting
• 12:36
  worse
• 12:37
  or
• 12:37
  is
• 12:38
  this
• 12:38
  circumscribed
• 12:39
  to
• 12:39
  gambling?
• 12:40
  Is
• 12:40
  there
• 12:40
  a
• 12:40
  temporal
• 12:41
  relationship
• 12:41
  or
• 12:42
  association
• 12:42
  between
• 12:43
  when
• 12:43
  she
• 12:43
  gambles
• 12:44
  and
• 12:44
  any
• 12:44
  increases
• 12:45
  or
• 12:45
  onboarding
• 12:46
  of
• 12:46
  the
• 12:46
  Abilify?
• 12:47
  Those
• 12:47
  are
• 12:47
  all
• 12:47
  really
• 12:48
  important
• 12:48
  questions
• 12:49
  to
• 12:49
  ask.
• 12:49
  You
• 12:50
  have
• 12:50
  a
• 12:50
  lot
• 12:50
  of
• 12:50
  reassurance
• 12:51
  here
• 12:51
  in
• 12:51
  that
• 12:51
  her
• 12:51
  mental
• 12:51
  status
• 12:52
  exam
• 12:52
  looks
• 12:52
  good.
• 12:53
  You
• 12:53
  have
• 12:53
  reassurance
• 12:54
  that
• 12:54
  her
• 12:54
  lithium
• 12:54
  level
• 12:55
  is
• 12:55
  nice
• 12:55
  and
• 12:56
  therapeutic.
• 12:57
  You
• 12:57
  have
• 12:57
  a
• 12:57
  corroborator
• 12:58
  with
• 12:58
  you.
• 12:58
  You
• 12:59
  have
• 12:59
  collateral
• 12:59
  with
• 12:59
  you,
• 13:00
  with
• 13:00
  her,
• 13:00
  with
• 13:00
  her
• 13:00
  husband,
• 13:01
  who's
• 13:01
  basically
• 13:02
  can
• 13:02
  confirm
• 13:02
  the
• 13:03
  fact
• 13:03
  that,
• 13:03
  you
• 13:03
  know,
• 13:03
  she's
• 13:04
  not.
• 13:04
  She
• 13:04
  doesn't
• 13:04
  have
• 13:04
  pressured
• 13:05
  speech.
• 13:06
  There's
• 13:06
  not
• 13:06
  a
• 13:06
  whole
• 13:06
  lot
• 13:07
  else
• 13:07
  going
• 13:07
  on.
• 13:07
  It's
• 13:08
  just
• 13:08
  this.
• 13:09
  And
• 13:09
  so
• 13:09
  I
• 13:10
  think
• 13:10
  the
• 13:10
  answer
• 13:11
  here
• 13:11
  is
• 13:11
  pretty
• 13:11
  cut
• 13:12
  and
• 13:12
  dry.
• 13:12
  Remember,
• 13:13
  it's
• 13:13
  not
• 13:13
  always
• 13:13
  going
• 13:13
  to
• 13:14
  be
• 13:14
  big
• 13:14
  and
• 13:14
  flashy
• 13:15
  like
• 13:15
  gambling.
• 13:15
  There
• 13:16
  might
• 13:16
  be
• 13:16
  increased
• 13:16
  sexual
• 13:17
  urges,
• 13:17
  which
• 13:17
  make
• 13:18
  it
• 13:18
  even
• 13:18
  harder
• 13:18
  to
• 13:19
  figure
• 13:19
  out
• 13:19
  if
• 13:19
  this
• 13:20
  is
• 13:20
  the
• 13:20
  bipolarity
• 13:21
  versus
• 13:21
  the
• 13:22
  D3
• 13:22
  partial
• 13:23
  agonism
• 13:23
  of
• 13:23
  abilifier
• 13:24
  Vailar.
• 13:25
  It
• 13:25
  could
• 13:25
  come
• 13:25
  out
• 13:26
  as
• 13:26
  binge
• 13:26
  eating
• 13:27
  that
• 13:27
  we,
• 13:27
  you
• 13:27
  know,
• 13:28
  so
• 13:28
  just
• 13:28
  keep
• 13:28
  that
• 13:29
  in
• 13:29
  mind.
• 13:29
  Right?
• 13:29
  This
• 13:29
  is
• 13:30
  more,
• 13:30
  it's
• 13:30
  more
• 13:30
  about
• 13:31
  impulsivity
• 13:32
  and
• 13:32
  gambling
• 13:32
  is
• 13:33
  a
• 13:33
  frequent
• 13:33
  one
• 13:33
  in
• 13:34
  the
• 13:34
  literature.
• 13:34
  But
• 13:34
  be
• 13:34
  open
• 13:35
  minded
• 13:35
  to
• 13:35
  all
• 13:35
  of
• 13:35
  that.
• 13:36
  All
• 13:36
  right,
• 13:36
  my
• 13:36
  friends,
• 13:37
  now
• 13:37
  if
• 13:38
  you
• 13:39
  wanted
• 13:40
  a
• 13:40
  beautiful
• 13:41
  full
• 13:42
  clinical
• 13:42
  library
• 13:43
  of
• 13:43
  all
• 13:44
  of
• 13:44
  these
• 13:44
  great
• 13:45
  board
• 13:45
  bombs
• 13:46
  and
• 13:46
  really
• 13:47
  sticky
• 13:47
  ways
• 13:47
  to
• 13:47
  remember
• 13:48
  psychopharmacology,
• 13:49
  the
• 13:49
  one
• 13:50
  thing
• 13:50
  you
• 13:50
  should
• 13:50
  not
• 13:50
  forget
• 13:50
  tonight
• 13:51
  before
• 13:51
  you
• 13:51
  go
• 13:51
  to
• 13:51
  bed,
• 13:52
  go
• 13:52
  to
• 13:52
  our
• 13:52
  show
• 13:52
  notes
• 13:53
  and
• 13:53
  become
• 13:53
  a
• 13:54
  Patreon
• 13:54
  member.
• 13:55
  My
• 13:55
  friends,
• 13:57
  the
• 13:57
  difference
• 13:58
  between
• 13:58
  a
• 13:58
  good,
• 13:58
  clean
• 13:59
  clinician
• 13:59
  and
• 13:59
  a
• 13:59
  great
• 14:00
  clinician,
• 14:00
  the
• 14:01
  difference
• 14:01
  between
• 14:02
  a
• 14:02
  clinician
• 14:03
  that
• 14:03
  just
• 14:03
  follows
• 14:03
  the
• 14:04
  algorithms
• 14:05
  and
• 14:05
  one
• 14:06
  that
• 14:06
  doesn't
• 14:06
  is
• 14:07
  the
• 14:07
  clinicians
• 14:08
  that
• 14:08
  know
• 14:08
  the
• 14:09
  how
• 14:09
  and
• 14:09
  the
• 14:09
  why
• 14:09
  of
• 14:10
  what
• 14:10
  they
• 14:10
  are
• 14:11
  doing.
• 14:11
  My
• 14:11
  friends
• 14:12
  and
• 14:12
  I
• 14:12
  built
• 14:13
  this
• 14:13
  library
• 14:13
  so
• 14:13
  you
• 14:14
  would
• 14:14
  know
• 14:14
  the
• 14:14
  how
• 14:14
  and
• 14:14
  the
• 14:15
  why
• 14:15
  of
• 14:15
  what
• 14:15
  you're
• 14:15
  doing.
• 14:16
  Patients
• 14:16
  can
• 14:16
  smell
• 14:17
  it
• 14:17
  a
• 14:17
  mile
• 14:17
  away.
• 14:18
  They
• 14:18
  trust
• 14:18
  you
• 14:18
  more,
• 14:19
  your
• 14:19
  outcomes
• 14:19
  are
• 14:19
  smoother
• 14:20
  and
• 14:20
  better
• 14:20
  and
• 14:21
  life
• 14:21
  is
• 14:22
  just
• 14:22
  easier.
• 14:22
  I
• 14:23
  genuinely
• 14:24
  terrified
• 14:24
  to
• 14:24
  know
• 14:25
  where
• 14:25
  I
• 14:25
  would
• 14:25
  be
• 14:25
  without
• 14:26
  this
• 14:26
  clinical
• 14:26
  library.
• 14:27
  I
• 14:28
  just
• 14:28
  can't
• 14:29
  even
• 14:29
  imagine
• 14:30
  how
• 14:31
  many
• 14:31
  tools
• 14:31
  I
• 14:31
  would
• 14:32
  not
• 14:32
  have
• 14:32
  and
• 14:32
  the
• 14:32
  knowledge
• 14:33
  I
• 14:33
  would
• 14:33
  not
• 14:33
  have
• 14:34
  without
• 14:34
  this
• 14:34
  library.
• 14:35
  So
• 14:35
  if
• 14:35
  there's
• 14:35
  one
• 14:36
  thing
• 14:36
  you
• 14:36
  don't
• 14:36
  forget,
• 14:36
  head
• 14:37
  over
• 14:37
  to
• 14:37
  the
• 14:37
  show
• 14:37
  notes,
• 14:37
  become
• 14:38
  a
• 14:38
  Patreon
• 14:38
  member,
• 14:39
  join
• 14:39
  us.
• 14:40
  Spread
• 14:40
  the
• 14:40
  word.
• 14:41
  It's
• 14:41
  fun,
• 14:41
  it's
• 14:41
  sticky.
• 14:42
  People
• 14:42
  love
• 14:42
  it,
• 14:43
  and
• 14:43
  we'd
• 14:43
  love
• 14:43
  to
• 14:44
  have
• 14:44
  you
• 14:44
  as
• 14:44
  a
• 14:44
  member.
• 14:44
  Without
• 14:45
  further
• 14:46
  ado,
• 14:46
  thank
• 14:46
  you
• 14:46
  all
• 14:47
  very
• 14:47
  much
• 14:47
  for
• 14:47
  tuning
• 14:47
  in.
• 14:47
  Until
• 14:48
  next
• 14:48
  time,
• 14:48
  here
• 14:48
  on
• 14:49
  Pearls
• 14:49
  and
• 14:49
  Prep,
• 14:50
  thank
• 14:50
  you.