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CHALLENGE ACCEPTED: Can You Spot the 4 Errors in This Psychiatric Case Study? See if your peers and colleagues can too! · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:06
  back,
• 0:06
  my
• 0:06
  friends
• 0:07
  to
• 0:07
  another
• 0:07
  episode
• 0:08
  of
• 0:08
  Pearls
• 0:08
  n
• 0:09
  Prep.
• 0:09
  This
• 0:10
  is
• 0:10
  NPZ
• 0:11
  here,
• 0:11
  your
• 0:11
  preceptor
• 0:12
  in
• 0:12
  your
• 0:12
  pocket,
• 0:13
  your
• 0:13
  go
• 0:13
  to
• 0:13
  place
• 0:14
  for
• 0:14
  pearls
• 0:15
  that
• 0:15
  prep
• 0:16
  you
• 0:16
  to
• 0:16
  practice.
• 0:17
  All
• 0:17
  right,
• 0:18
  today
• 0:19
  we're
• 0:19
  going
• 0:19
  to
• 0:20
  start
• 0:20
  with
• 0:20
  a
• 0:20
  case
• 0:20
  study.
• 0:21
  And
• 0:22
  there
• 0:22
  are
• 0:22
  going
• 0:23
  to
• 0:23
  be
• 0:23
  four
• 0:24
  errors
• 0:25
  each
• 0:25
  in
• 0:26
  this
• 0:26
  case
• 0:27
  study.
• 0:27
  Four
• 0:27
  things
• 0:28
  that
• 0:29
  should
• 0:29
  have
• 0:29
  and
• 0:30
  could
• 0:30
  have
• 0:30
  gone
• 0:31
  better.
• 0:32
  And
• 0:32
  it
• 0:32
  is
• 0:32
  your
• 0:33
  job,
• 0:33
  my
• 0:33
  friends
• 0:34
  to
• 0:35
  find
• 0:35
  all
• 0:36
  four
• 0:36
  things
• 0:37
  that
• 0:37
  could
• 0:38
  have
• 0:38
  gone
• 0:39
  better
• 0:39
  here.
• 0:40
  Four
• 0:40
  things.
• 0:41
  Four
• 0:41
  no
• 0:42
  no's,
• 0:42
  Four
• 0:42
  whoopsie
• 0:43
  dos.
• 0:44
  And
• 0:44
  if
• 0:44
  you
• 0:44
  need
• 0:45
  to
• 0:45
  pause
• 0:45
  this,
• 0:46
  go
• 0:46
  ahead
• 0:46
  and
• 0:47
  pause
• 0:47
  it
• 0:47
  and
• 0:48
  discuss
• 0:48
  with
• 0:49
  peers
• 0:49
  or
• 0:50
  friend
• 0:51
  or
• 0:51
  your
• 0:51
  grandmother,
• 0:52
  anybody
• 0:52
  really,
• 0:53
  and
• 0:54
  just
• 0:54
  try
• 0:54
  to
• 0:54
  figure
• 0:54
  out
• 0:55
  what
• 0:55
  went
• 0:55
  wrong
• 0:55
  here
• 0:55
  because
• 0:56
  there
• 0:57
  are
• 0:57
  some
• 0:57
  things
• 0:57
  that
• 0:57
  went
• 0:57
  wrong.
• 0:58
  It's
• 0:58
  one
• 0:59
  thing
• 0:59
  to
• 0:59
  just
• 0:59
  hear
• 1:00
  all
• 1:00
  of
• 1:00
  the
• 1:00
  evidence
• 1:01
  based
• 1:01
  pearls,
• 1:02
  which
• 1:02
  are
• 1:03
  fun
• 1:03
  and
• 1:03
  I'd
• 1:03
  like
• 1:03
  to
• 1:04
  nerd
• 1:04
  out
• 1:04
  on
• 1:04
  those,
• 1:05
  but
• 1:05
  it's
• 1:06
  even
• 1:06
  more
• 1:07
  rewarding.
• 1:08
  I
• 1:08
  think
• 1:08
  there's
• 1:08
  something
• 1:08
  in
• 1:09
  the
• 1:09
  brain
• 1:10
  that
• 1:10
  just
• 1:10
  clicks
• 1:11
  when
• 1:11
  something
• 1:12
  first
• 1:13
  is
• 1:13
  shown
• 1:13
  to
• 1:13
  not
• 1:14
  be
• 1:14
  correct
• 1:15
  and
• 1:15
  then
• 1:15
  you
• 1:15
  have
• 1:15
  to
• 1:15
  make
• 1:16
  it
• 1:16
  right.
• 1:17
  It
• 1:17
  was
• 1:17
  kind
• 1:17
  of
• 1:18
  like
• 1:18
  those
• 1:18
  viral
• 1:19
  videos
• 1:20
  where
• 1:20
  you
• 1:20
  see
• 1:21
  somebody's
• 1:21
  garden
• 1:22
  and
• 1:22
  it's
• 1:22
  like
• 1:22
  overtaken
• 1:23
  with
• 1:23
  weeds
• 1:24
  and
• 1:24
  you're
• 1:24
  like,
• 1:24
  oh,
• 1:25
  that
• 1:25
  could
• 1:25
  look
• 1:25
  so
• 1:25
  much
• 1:25
  better.
• 1:26
  That's
• 1:26
  kind
• 1:26
  of
• 1:27
  what
• 1:27
  we're
• 1:27
  doing
• 1:27
  here,
• 1:27
  right?
• 1:27
  It's
• 1:28
  like
• 1:28
  a
• 1:28
  makeover.
• 1:29
  It's
• 1:29
  like,
• 1:29
  here's
• 1:29
  this
• 1:29
  case
• 1:30
  that's
• 1:30
  sloppy
• 1:31
  and
• 1:31
  isn't
• 1:31
  going
• 1:31
  right
• 1:32
  and
• 1:33
  here's
• 1:33
  how
• 1:33
  we
• 1:33
  clean
• 1:33
  it
• 1:34
  up
• 1:34
  and
• 1:34
  here's
• 1:34
  why.
• 1:35
  So
• 1:35
  I
• 1:35
  hope
• 1:35
  you
• 1:36
  really
• 1:36
  enjoy
• 1:36
  this.
• 1:37
  So
• 1:37
  here
• 1:37
  we
• 1:37
  go.
• 1:37
  Okay,
• 1:38
  I'm
• 1:38
  going
• 1:38
  to
• 1:38
  make
• 1:38
  the
• 1:38
  case
• 1:39
  as
• 1:39
  clean
• 1:39
  as
• 1:39
  possible
• 1:40
  so
• 1:41
  that
• 1:41
  you
• 1:41
  can
• 1:41
  identify
• 1:43
  what's
• 1:43
  going
• 1:43
  wrong.
• 1:44
  So
• 1:45
  keep
• 1:45
  track
• 1:45
  of
• 1:46
  the
• 1:46
  details
• 1:46
  here.
• 1:47
  So
• 1:47
  you
• 1:47
  have
• 1:47
  a
• 1:47
  28
• 1:48
  year
• 1:48
  old
• 1:48
  patient
• 1:49
  that
• 1:50
  has
• 1:50
  schizophrenia
• 1:51
  in
• 1:51
  the
• 1:52
  outpatient
• 1:52
  space.
• 1:53
  You
• 1:53
  saw
• 1:54
  this
• 1:54
  patient
• 1:55
  four
• 1:56
  weeks
• 1:56
  ago.
• 1:57
  The
• 1:57
  patient
• 1:58
  has
• 1:58
  auditory
• 1:59
  and
• 1:59
  visual
• 1:59
  hallucinations.
• 2:01
  You
• 2:01
  started
• 2:01
  the
• 2:01
  patient
• 2:02
  on
• 2:02
  a
• 2:02
  bill
• 2:02
  of
• 2:02
  I5
• 2:03
  milligrams
• 2:05
  and
• 2:05
  you
• 2:05
  told
• 2:05
  them
• 2:05
  to
• 2:06
  follow
• 2:06
  up
• 2:06
  with
• 2:06
  you.
• 2:07
  And
• 2:08
  a
• 2:08
  couple
• 2:08
  weeks
• 2:09
  and
• 2:09
  the
• 2:10
  patients
• 2:10
  come
• 2:10
  back
• 2:11
  to
• 2:11
  you
• 2:11
  now
• 2:12
  and
• 2:12
  the
• 2:13
  patient's
• 2:13
  saying,
• 2:14
  hey,
• 2:14
  I
• 2:14
  am
• 2:14
  super
• 2:15
  anxious.
• 2:16
  My
• 2:16
  auditory
• 2:16
  and
• 2:17
  visual
• 2:17
  hallucinations
• 2:18
  have
• 2:18
  not
• 2:18
  gone
• 2:18
  away.
• 2:19
  I'm
• 2:19
  still
• 2:19
  hearing
• 2:19
  voices
• 2:20
  all
• 2:20
  the
• 2:20
  time.
• 2:21
  I'm
• 2:21
  seeing
• 2:21
  shadows
• 2:22
  and
• 2:22
  devils
• 2:22
  and
• 2:23
  I'm
• 2:23
  really
• 2:23
  nervous
• 2:24
  and
• 2:25
  I
• 2:25
  can't
• 2:25
  seem
• 2:26
  to
• 2:26
  just
• 2:26
  sit
• 2:26
  still.
• 2:27
  I'm
• 2:27
  pacing
• 2:27
  everywhere.
• 2:28
  I'm
• 2:28
  just
• 2:29
  super
• 2:29
  anxious.
• 2:30
  I
• 2:30
  want
• 2:30
  to
• 2:31
  jump
• 2:31
  out
• 2:31
  of
• 2:31
  my
• 2:31
  skin.
• 2:31
  I'm
• 2:32
  so
• 2:32
  anxious.
• 2:33
  These
• 2:34
  hallucinations
• 2:34
  are
• 2:35
  just
• 2:35
  driving
• 2:35
  me
• 2:36
  mad.
• 2:36
  They're
• 2:37
  not
• 2:37
  command
• 2:37
  hallucinations,
• 2:38
  they're
• 2:39
  just
• 2:39
  really
• 2:39
  bothersome,
• 2:41
  self
• 2:41
  critical
• 2:42
  voices.
• 2:43
  And
• 2:43
  again,
• 2:43
  I
• 2:44
  also.
• 2:44
  I'm
• 2:45
  seeing
• 2:45
  shadows
• 2:45
  and
• 2:45
  devils,
• 2:46
  and
• 2:46
  it's
• 2:47
  just
• 2:47
  very
• 2:47
  unsettling.
• 2:48
  And
• 2:48
  I.
• 2:48
  You've
• 2:48
  got
• 2:48
  to
• 2:48
  do
• 2:49
  something
• 2:49
  about
• 2:49
  my
• 2:49
  anxiety.
• 2:50
  The
• 2:50
  patient
• 2:51
  appears
• 2:51
  very
• 2:51
  agitated,
• 2:52
  kind
• 2:53
  of
• 2:53
  shifting
• 2:53
  in
• 2:53
  their
• 2:53
  chair,
• 2:54
  very
• 2:54
  hard
• 2:54
  for
• 2:55
  them
• 2:55
  to
• 2:55
  even
• 2:55
  sit
• 2:55
  still
• 2:56
  because
• 2:56
  they're
• 2:56
  just
• 2:56
  so
• 2:57
  nervous
• 2:57
  and
• 2:57
  anxious.
• 2:58
  Okay?
• 2:59
  And.
• 2:59
  And
• 2:59
  so,
• 3:00
  as
• 3:00
  the
• 3:00
  np,
• 3:01
  what
• 3:02
  you
• 3:02
  do
• 3:03
  is
• 3:04
  you
• 3:05
  decided
• 3:06
  to
• 3:07
  increase
• 3:07
  The
• 3:07
  Abilify
• 3:08
  from
• 3:08
  5
• 3:08
  to
• 3:09
  10
• 3:09
  milligrams
• 3:09
  to
• 3:10
  better
• 3:11
  control
• 3:11
  the
• 3:11
  patient's
• 3:12
  psychotic
• 3:12
  symptoms.
• 3:13
  Okay.
• 3:14
  You
• 3:14
  also
• 3:14
  started
• 3:15
  propranolol
• 3:16
  20
• 3:16
  milligrams
• 3:16
  twice
• 3:17
  a
• 3:17
  day
• 3:18
  because
• 3:18
  you
• 3:18
  noticed
• 3:18
  the
• 3:19
  patient
• 3:19
  had
• 3:19
  a
• 3:19
  hand
• 3:19
  tremor.
• 3:20
  Okay.
• 3:21
  And
• 3:21
  so
• 3:22
  you
• 3:22
  said,
• 3:22
  hey,
• 3:22
  why
• 3:22
  don't
• 3:23
  we
• 3:23
  start
• 3:23
  propranolol?
• 3:24
  Let's
• 3:24
  get
• 3:24
  rid
• 3:24
  of
• 3:24
  that
• 3:24
  hand
• 3:25
  tremor.
• 3:25
  And
• 3:26
  you
• 3:26
  decided,
• 3:26
  okay,
• 3:27
  let's
• 3:27
  just
• 3:27
  follow
• 3:27
  up
• 3:27
  with
• 3:28
  the
• 3:28
  patient
• 3:28
  in
• 3:28
  about
• 3:28
  four
• 3:29
  weeks
• 3:29
  to
• 3:29
  see
• 3:29
  how
• 3:29
  they
• 3:30
  do.
• 3:30
  You
• 3:31
  figured
• 3:31
  that
• 3:31
  this
• 3:32
  would
• 3:32
  be
• 3:32
  a
• 3:32
  really
• 3:32
  good
• 3:33
  idea
• 3:33
  to
• 3:33
  just
• 3:33
  increase
• 3:34
  the
• 3:34
  dose
• 3:34
  to
• 3:35
  potentially
• 3:35
  get
• 3:36
  better
• 3:36
  symptom
• 3:36
  control
• 3:37
  here
• 3:38
  and
• 3:38
  follow
• 3:38
  up
• 3:38
  in
• 3:38
  four
• 3:39
  weeks.
• 3:39
  And
• 3:40
  so
• 3:40
  that's
• 3:40
  what
• 3:40
  you
• 3:40
  did,
• 3:41
  and
• 3:41
  you
• 3:42
  let
• 3:42
  the
• 3:42
  patient
• 3:43
  go,
• 3:43
  and
• 3:43
  the
• 3:43
  patient
• 3:43
  left
• 3:44
  your
• 3:44
  office.
• 3:44
  Now,
• 3:45
  if
• 3:45
  you
• 3:45
  want
• 3:45
  to
• 3:45
  pause
• 3:46
  this
• 3:46
  real
• 3:46
  quick
• 3:47
  for
• 3:47
  all
• 3:47
  the
• 3:47
  things
• 3:48
  I
• 3:48
  just
• 3:48
  told
• 3:48
  you
• 3:48
  about
• 3:49
  this
• 3:49
  case,
• 3:50
  from
• 3:50
  when
• 3:50
  you
• 3:50
  first
• 3:50
  started
• 3:51
  seeing
• 3:51
  the
• 3:51
  patient
• 3:52
  to
• 3:53
  the
• 3:53
  latest
• 3:54
  interventions,
• 3:54
  can
• 3:54
  you
• 3:55
  identify
• 3:55
  four
• 3:56
  errors
• 3:56
  here
• 3:57
  that
• 3:58
  could
• 3:58
  have
• 3:58
  gone
• 3:58
  better
• 3:59
  and
• 3:59
  weren't
• 3:59
  really
• 4:00
  consistent
• 4:00
  with
• 4:00
  the
• 4:00
  evidence?
• 4:01
  Go
• 4:01
  ahead
• 4:01
  and
• 4:01
  pause
• 4:02
  it
• 4:02
  if
• 4:02
  you
• 4:02
  want
• 4:02
  to.
• 4:03
  If
• 4:03
  not.
• 4:03
  Here
• 4:04
  we
• 4:04
  go.
• 4:04
  I'm
• 4:04
  going
• 4:04
  to
• 4:04
  start
• 4:05
  identifying
• 4:05
  the
• 4:05
  errors.
• 4:06
  Okay.
• 4:07
  Well,
• 4:07
  the
• 4:07
  first
• 4:08
  error
• 4:08
  is
• 4:09
  that
• 4:09
  we
• 4:10
  started
• 4:11
  the
• 4:11
  Abilify
• 4:12
  at
• 4:12
  too
• 4:12
  low
• 4:12
  of
• 4:13
  a
• 4:13
  dose.
• 4:13
  Right?
• 4:13
  You
• 4:14
  have
• 4:14
  a
• 4:14
  patient
• 4:14
  who
• 4:14
  has
• 4:14
  schizophrenia.
• 4:15
  Auditory,
• 4:16
  visual
• 4:16
  hallucinations.
• 4:18
  The
• 4:18
  amount
• 4:18
  of
• 4:18
  dopamine
• 4:19
  blockade
• 4:20
  that
• 4:20
  you
• 4:20
  want
• 4:20
  to
• 4:21
  achieve
• 4:21
  is
• 4:21
  not
• 4:22
  likely
• 4:22
  to
• 4:22
  happen
• 4:23
  at
• 4:23
  5
• 4:24
  milligrams.
• 4:25
  It's
• 4:25
  not
• 4:25
  a
• 4:26
  very
• 4:26
  good
• 4:26
  starting
• 4:26
  dose.
• 4:27
  Your
• 4:27
  recommended
• 4:27
  starting
• 4:28
  dose
• 4:28
  for
• 4:29
  schizophrenia
• 4:29
  with
• 4:29
  Abilify
• 4:30
  is
• 4:30
  10
• 4:30
  to
• 4:31
  15
• 4:31
  milligrams
• 4:32
  daily,
• 4:32
  not
• 4:33
  5
• 4:33
  milligrams.
• 4:33
  Now,
• 4:34
  I'll
• 4:34
  be
• 4:34
  honest
• 4:34
  with
• 4:34
  you.
• 4:35
  In
• 4:35
  the
• 4:35
  real
• 4:36
  world,
• 4:36
  that
• 4:37
  is
• 4:37
  definitely
• 4:37
  the
• 4:37
  textbook
• 4:38
  recommendation,
• 4:39
  10
• 4:39
  to
• 4:39
  15.
• 4:40
  In
• 4:40
  the
• 4:40
  real
• 4:40
  world,
• 4:41
  a
• 4:41
  lot
• 4:41
  of
• 4:41
  patients
• 4:41
  can't
• 4:42
  necessarily
• 4:42
  tolerate
• 4:43
  going
• 4:44
  to
• 4:44
  10
• 4:44
  right
• 4:44
  away
• 4:45
  because
• 4:45
  they
• 4:46
  get
• 4:46
  really
• 4:46
  restless.
• 4:47
  They
• 4:47
  have
• 4:47
  aesthesia.
• 4:48
  Right?
• 4:48
  That
• 4:48
  inner
• 4:48
  feeling
• 4:49
  of
• 4:49
  restlessness.
• 4:50
  However,
• 4:50
  your
• 4:51
  plan
• 4:51
  cannot
• 4:52
  be
• 4:52
  to
• 4:52
  just
• 4:52
  start
• 4:52
  the
• 4:53
  patient
• 4:53
  and
• 4:53
  keep
• 4:53
  the
• 4:53
  patient
• 4:54
  at
• 4:54
  5
• 4:54
  milligrams.
• 4:55
  You
• 4:55
  want
• 4:55
  to
• 4:55
  at
• 4:55
  least
• 4:56
  titrate
• 4:56
  up
• 4:56
  to
• 4:57
  10
• 4:57
  milligrams
• 4:58
  as
• 4:58
  expeditiously
• 4:59
  as
• 4:59
  you
• 4:59
  can,
• 5:00
  as
• 5:00
  the
• 5:00
  patient
• 5:01
  can
• 5:01
  tolerate
• 5:01
  it.
• 5:01
  But
• 5:01
  in
• 5:02
  this
• 5:02
  case,
• 5:02
  error
• 5:03
  number
• 5:03
  one
• 5:03
  is
• 5:04
  we
• 5:04
  started
• 5:04
  the
• 5:04
  patient
• 5:04
  on
• 5:05
  Abilify
• 5:06
  and
• 5:06
  we
• 5:06
  started
• 5:07
  them
• 5:07
  too
• 5:07
  low.
• 5:07
  And
• 5:07
  we
• 5:07
  kind
• 5:07
  of
• 5:08
  left
• 5:08
  them
• 5:08
  hanging
• 5:08
  there
• 5:08
  until
• 5:09
  the
• 5:09
  next
• 5:09
  follow
• 5:09
  up.
• 5:10
  Okay.
• 5:10
  That
• 5:11
  delays
• 5:11
  the
• 5:11
  therapeutic
• 5:12
  response.
• 5:13
  We
• 5:13
  always
• 5:13
  want
• 5:14
  to
• 5:14
  be
• 5:14
  very
• 5:14
  careful
• 5:15
  to
• 5:15
  not
• 5:17
  be
• 5:17
  too
• 5:17
  aggressive
• 5:18
  in
• 5:18
  prescribing,
• 5:19
  which
• 5:19
  can
• 5:19
  lead
• 5:19
  to
• 5:20
  side
• 5:20
  effects.
• 5:20
  But
• 5:20
  you
• 5:20
  also
• 5:21
  want
• 5:21
  to
• 5:21
  be
• 5:21
  mindful
• 5:22
  of
• 5:22
  not
• 5:23
  under
• 5:23
  treating.
• 5:23
  Right.
• 5:24
  It's
• 5:24
  a
• 5:24
  seesaw,
• 5:25
  it's
• 5:25
  a
• 5:25
  balance.
• 5:26
  And
• 5:27
  when
• 5:27
  you
• 5:27
  get
• 5:27
  out
• 5:27
  into
• 5:27
  practice,
• 5:28
  it's
• 5:28
  going
• 5:28
  to
• 5:28
  be
• 5:28
  something
• 5:29
  you're
• 5:29
  going
• 5:29
  to
• 5:29
  have
• 5:29
  to
• 5:29
  learn
• 5:30
  and
• 5:30
  get
• 5:30
  comfortable
• 5:31
  with.
• 5:31
  I
• 5:31
  think
• 5:31
  a
• 5:32
  lot
• 5:32
  of
• 5:32
  new
• 5:32
  grads
• 5:32
  go
• 5:33
  out
• 5:33
  there
• 5:33
  and
• 5:33
  they
• 5:33
  go,
• 5:33
  you
• 5:33
  know,
• 5:34
  I
• 5:34
  need
• 5:34
  to
• 5:34
  be
• 5:35
  very
• 5:35
  careful
• 5:35
  with
• 5:35
  side
• 5:35
  effects.
• 5:36
  Of
• 5:36
  course
• 5:36
  you
• 5:36
  do.
• 5:36
  We
• 5:36
  all
• 5:37
  do.
• 5:37
  That
• 5:37
  is
• 5:38
  very
• 5:38
  good
• 5:38
  to
• 5:38
  be
• 5:38
  paranoid
• 5:39
  about
• 5:39
  side
• 5:39
  effects
• 5:40
  throughout
• 5:40
  your
• 5:40
  career.
• 5:41
  But
• 5:41
  you
• 5:41
  should
• 5:41
  be
• 5:42
  equally
• 5:42
  paranoid
• 5:43
  about
• 5:43
  under
• 5:44
  treating
• 5:44
  a
• 5:44
  patient
• 5:45
  who
• 5:45
  now
• 5:45
  is
• 5:45
  hearing
• 5:46
  voices
• 5:46
  that
• 5:46
  are
• 5:47
  degrading.
• 5:47
  God
• 5:48
  forbid
• 5:48
  there
• 5:48
  are
• 5:49
  command
• 5:49
  hallucinations.
• 5:50
  In
• 5:50
  this
• 5:50
  case
• 5:50
  there's
• 5:50
  not
• 5:51
  command
• 5:51
  hallucinations.
• 5:52
  But
• 5:52
  think
• 5:53
  about
• 5:53
  that,
• 5:53
  right?
• 5:53
  It's
• 5:53
  like,
• 5:54
  okay,
• 5:54
  I'm
• 5:54
  trying
• 5:54
  to.
• 5:54
  I
• 5:55
  worried
• 5:55
  about
• 5:56
  maybe
• 5:56
  akaesthesia
• 5:57
  or
• 5:57
  something.
• 5:58
  I'm
• 5:58
  worried
• 5:58
  about
• 5:59
  hand
• 5:59
  tremors.
• 5:59
  But.
• 6:00
  But
• 6:00
  what,
• 6:00
  what
• 6:00
  do
• 6:00
  I
• 6:01
  also
• 6:01
  need
• 6:01
  to
• 6:01
  be
• 6:01
  worried
• 6:01
  about?
• 6:02
  I
• 6:02
  need
• 6:02
  to
• 6:02
  be
• 6:02
  very
• 6:03
  worried
• 6:03
  about
• 6:03
  under
• 6:03
  treating
• 6:04
  someone
• 6:04
  with
• 6:05
  schizophrenia.
• 6:05
  Disproportionately
• 6:06
  high
• 6:07
  suicide
• 6:07
  rates,
• 6:07
  really,
• 6:08
  in
• 6:08
  all
• 6:08
  severe
• 6:09
  mental
• 6:09
  illnesses
• 6:10
  and
• 6:10
  also
• 6:10
  in
• 6:11
  schizophrenia.
• 6:11
  Right.
• 6:12
  So
• 6:12
  there
• 6:12
  are
• 6:12
  acute
• 6:13
  safety
• 6:13
  concerns,
• 6:14
  concerns
• 6:15
  about
• 6:15
  the
• 6:15
  individual
• 6:16
  just
• 6:16
  being
• 6:16
  able
• 6:16
  to
• 6:17
  wake
• 6:17
  up
• 6:17
  every
• 6:17
  day
• 6:18
  and
• 6:18
  take
• 6:18
  a
• 6:18
  shower
• 6:18
  and
• 6:19
  maintain
• 6:19
  employment.
• 6:20
  So
• 6:20
  there's.
• 6:21
  I
• 6:21
  want
• 6:21
  you
• 6:21
  to
• 6:21
  think
• 6:21
  of
• 6:22
  both
• 6:22
  sides
• 6:22
  of
• 6:22
  that
• 6:22
  seesaw.
• 6:23
  So
• 6:23
  error
• 6:23
  one
• 6:24
  for
• 6:24
  sure
• 6:24
  here
• 6:24
  is
• 6:25
  starting
• 6:25
  Abilify
• 6:26
  way
• 6:26
  too
• 6:27
  low.
• 6:28
  Error
• 6:28
  number
• 6:29
  two,
• 6:29
  my
• 6:29
  friends
• 6:30
  and
• 6:30
  oh,
• 6:30
  this
• 6:31
  is
• 6:31
  a
• 6:31
  cardinal
• 6:31
  error
• 6:32
  we
• 6:32
  all
• 6:32
  have
• 6:33
  to
• 6:33
  be
• 6:33
  mindful
• 6:33
  of
• 6:34
  is
• 6:35
  that
• 6:35
  in
• 6:35
  this
• 6:36
  case,
• 6:36
  we
• 6:36
  increased
• 6:37
  the
• 6:38
  Abilify
• 6:39
  to
• 6:39
  10
• 6:39
  milligrams
• 6:40
  because
• 6:40
  we
• 6:41
  interpreted
• 6:41
  the
• 6:41
  patient's
• 6:42
  anxiety
• 6:42
  as
• 6:43
  it
• 6:43
  related
• 6:44
  to
• 6:44
  their
• 6:44
  hallucinations
• 6:45
  and
• 6:46
  to
• 6:46
  their
• 6:46
  auditory
• 6:46
  and
• 6:47
  visual
• 6:47
  hallucinations,
• 6:48
  when
• 6:48
  in
• 6:48
  fact
• 6:49
  they
• 6:49
  were
• 6:49
  probably
• 6:50
  prescribing
• 6:51
  classic
• 6:52
  akaesthesia,
• 6:53
  right?
• 6:53
  That
• 6:53
  subjective
• 6:54
  restlessness.
• 6:55
  And
• 6:55
  here's
• 6:56
  the
• 6:56
  trick
• 6:56
  is
• 6:58
  your
• 6:58
  patients
• 6:58
  are
• 6:58
  gonna
• 6:59
  have
• 6:59
  one
• 7:00
  set
• 7:00
  of
• 7:00
  words
• 7:01
  or
• 7:01
  a
• 7:01
  specific
• 7:02
  language
• 7:02
  to
• 7:02
  describe
• 7:03
  their
• 7:03
  symptoms,
• 7:03
  and
• 7:04
  you're
• 7:04
  gonna
• 7:04
  have
• 7:04
  a
• 7:05
  different
• 7:05
  one.
• 7:05
  A
• 7:05
  lot
• 7:06
  of
• 7:06
  times
• 7:06
  you
• 7:07
  might
• 7:07
  have
• 7:07
  the
• 7:07
  nerdy
• 7:07
  textbook
• 7:08
  definitions
• 7:09
  and
• 7:10
  the
• 7:10
  patients
• 7:10
  are
• 7:11
  gonna
• 7:11
  have
• 7:11
  their
• 7:11
  own
• 7:11
  definitions,
• 7:12
  right?
• 7:12
  A
• 7:12
  patient
• 7:12
  may
• 7:13
  say,
• 7:13
  I'm
• 7:13
  depressed.
• 7:14
  And
• 7:14
  really
• 7:14
  they're
• 7:15
  not
• 7:15
  depressed
• 7:16
  for
• 7:16
  two
• 7:16
  or
• 7:16
  more
• 7:16
  weeks
• 7:17
  in
• 7:17
  a
• 7:17
  clinical
• 7:17
  sense.
• 7:18
  In
• 7:18
  a
• 7:18
  sense
• 7:19
  that,
• 7:20
  that
• 7:20
  they're
• 7:20
  meeting
• 7:21
  a
• 7:21
  definitional
• 7:22
  major
• 7:22
  depressive
• 7:23
  episode.
• 7:24
  They
• 7:24
  might
• 7:24
  say
• 7:25
  they're
• 7:25
  depressed
• 7:26
  and
• 7:26
  what
• 7:26
  they're
• 7:27
  describing
• 7:27
  is
• 7:27
  maybe
• 7:28
  an
• 7:28
  acute
• 7:28
  stressor,
• 7:29
  maybe
• 7:29
  an
• 7:29
  adjustment
• 7:30
  related
• 7:30
  stressor.
• 7:30
  They
• 7:31
  might
• 7:31
  be
• 7:31
  Describing
• 7:32
  a
• 7:32
  temporary
• 7:33
  setback,
• 7:33
  more
• 7:34
  hour
• 7:34
  by
• 7:34
  hour
• 7:34
  mood
• 7:35
  dysregulation.
• 7:35
  That's
• 7:36
  consistent
• 7:36
  with
• 7:36
  a
• 7:36
  personality
• 7:37
  disorder
• 7:37
  or
• 7:38
  something.
• 7:38
  So
• 7:38
  you
• 7:38
  have
• 7:39
  to
• 7:39
  be
• 7:39
  very
• 7:39
  careful
• 7:39
  not
• 7:40
  to
• 7:40
  sign
• 7:40
  the
• 7:40
  dotted
• 7:41
  line
• 7:41
  on
• 7:42
  the
• 7:42
  definitions
• 7:43
  that
• 7:43
  are
• 7:43
  hurled
• 7:44
  at
• 7:44
  you
• 7:45
  in
• 7:45
  your
• 7:45
  practice.
• 7:46
  Because
• 7:47
  patients
• 7:47
  are,
• 7:48
  they're
• 7:48
  amazing
• 7:48
  and
• 7:48
  they
• 7:49
  know
• 7:49
  exactly
• 7:49
  what
• 7:50
  they're
• 7:50
  going
• 7:50
  through,
• 7:50
  but
• 7:50
  they
• 7:50
  may
• 7:50
  not
• 7:51
  have
• 7:51
  the
• 7:51
  exact
• 7:52
  clinical
• 7:52
  verbiage
• 7:53
  that
• 7:54
  is
• 7:54
  consistent
• 7:54
  with
• 7:55
  what
• 7:55
  you
• 7:55
  need
• 7:55
  to
• 7:55
  hear.
• 7:56
  And
• 7:56
  it
• 7:56
  might
• 7:57
  even
• 7:57
  conflict
• 7:57
  with
• 7:57
  the
• 7:58
  actual
• 7:58
  definition
• 7:59
  of
• 7:59
  what's
• 7:59
  happening.
• 7:59
  So
• 8:00
  just
• 8:00
  be
• 8:00
  very
• 8:00
  careful
• 8:01
  about
• 8:01
  where
• 8:01
  you
• 8:01
  sign
• 8:01
  the
• 8:02
  dotted
• 8:02
  line.
• 8:02
  And
• 8:02
  there's
• 8:03
  no
• 8:03
  greater
• 8:03
  example
• 8:04
  of
• 8:04
  that
• 8:04
  than
• 8:05
  with
• 8:05
  akaesthesia,
• 8:06
  because
• 8:06
  there.
• 8:06
  I've
• 8:06
  never
• 8:07
  met
• 8:07
  a
• 8:07
  patient
• 8:08
  who
• 8:08
  comes
• 8:08
  to
• 8:08
  me
• 8:08
  and
• 8:08
  goes
• 8:09
  npz.
• 8:10
  I
• 8:10
  have
• 8:10
  akaesthesia.
• 8:12
  I
• 8:12
  have
• 8:12
  the
• 8:12
  Greek
• 8:13
  word
• 8:13
  for
• 8:13
  subjective
• 8:14
  restlessness
• 8:15
  that
• 8:15
  makes
• 8:15
  me
• 8:15
  feel
• 8:15
  like
• 8:16
  I
• 8:16
  want
• 8:16
  to
• 8:16
  jump
• 8:16
  out
• 8:16
  of
• 8:16
  my
• 8:17
  skin
• 8:17
  and
• 8:17
  I
• 8:17
  can't
• 8:17
  sit
• 8:18
  still
• 8:18
  or
• 8:18
  sit
• 8:18
  in
• 8:18
  a
• 8:18
  chair,
• 8:19
  right?
• 8:19
  And
• 8:20
  they're
• 8:20
  often
• 8:20
  going
• 8:20
  to
• 8:20
  describe
• 8:21
  it
• 8:21
  as,
• 8:21
  I
• 8:21
  feel
• 8:21
  so
• 8:22
  much
• 8:22
  more
• 8:22
  anxious.
• 8:23
  And
• 8:23
  you
• 8:24
  may
• 8:24
  instinctively
• 8:25
  believe
• 8:26
  that
• 8:26
  their
• 8:26
  anxiety
• 8:27
  is
• 8:27
  a
• 8:27
  result
• 8:27
  of
• 8:27
  their
• 8:28
  auditory
• 8:28
  or
• 8:29
  visual
• 8:29
  hallucinations
• 8:29
  that
• 8:30
  are
• 8:30
  getting
• 8:30
  more
• 8:30
  intense,
• 8:31
  they're
• 8:31
  getting
• 8:31
  louder,
• 8:32
  they're
• 8:32
  becoming
• 8:32
  more
• 8:32
  frequent.
• 8:33
  You
• 8:33
  definitely
• 8:33
  need
• 8:34
  to
• 8:34
  ask
• 8:34
  that
• 8:34
  question.
• 8:34
  You
• 8:35
  need
• 8:35
  to
• 8:35
  make
• 8:35
  sure,
• 8:36
  are
• 8:36
  your
• 8:37
  auditory,
• 8:37
  visual
• 8:38
  hallucinations
• 8:38
  getting
• 8:38
  worse?
• 8:39
  Are
• 8:39
  the
• 8:39
  voices
• 8:40
  getting
• 8:40
  more
• 8:40
  intense?
• 9:36
  If
• 9:36
  that's
• 9:36
  the
• 9:36
  case,
• 9:36
  then
• 9:37
  certainly
• 9:38
  you
• 9:38
  may
• 9:38
  go
• 9:38
  the
• 9:38
  route
• 9:39
  where
• 9:39
  you
• 9:39
  increase
• 8:45
  the
• 9:39
  dose
• 9:40
  of
• 9:40
  the
• 9:40
  second
• 9:41
  generation
• 9:41
  antipsychotic.
• 9:42
  But
• 9:43
  I
• 9:43
  would
• 9:44
  really
• 9:44
  pin
• 9:45
  the
• 9:45
  patient
• 9:45
  down
• 9:45
  on
• 9:46
  the
• 9:46
  definition
• 9:47
  of
• 9:47
  what
• 9:47
  they
• 9:47
  are
• 9:47
  going
• 9:48
  through
• 9:48
  and
• 9:49
  make
• 9:49
  them
• 9:49
  flesh
• 9:50
  out
• 9:50
  the
• 9:51
  experience
• 9:52
  that
• 9:52
  they're
• 9:52
  having.
• 9:53
  And
• 9:53
  I
• 9:53
  will
• 9:53
  ask
• 9:54
  the
• 9:54
  patient
• 9:54
  to
• 9:55
  carefully
• 9:56
  and
• 9:56
  slowly
• 9:56
  describe
• 9:57
  what
• 9:57
  anxiety
• 9:58
  looks
• 9:58
  like
• 9:58
  for
• 9:58
  them.
• 9:59
  What
• 9:59
  does
• 9:59
  this
• 9:59
  anxiety
• 10:00
  look
• 10:00
  like
• 10:00
  for
• 10:00
  you
• 10:01
  when
• 10:01
  you're
• 10:01
  at
• 10:01
  home,
• 10:01
  When
• 10:02
  I'm
• 10:02
  not
• 10:02
  with
• 10:02
  you,
• 10:03
  walk
• 10:03
  me
• 10:03
  through
• 10:03
  what
• 10:04
  it
• 10:04
  looks
• 10:04
  like.
• 10:04
  And
• 10:05
  more
• 10:05
  often
• 10:05
  than
• 10:05
  not,
• 10:06
  when
• 10:06
  it
• 10:06
  comes
• 10:06
  to
• 10:06
  akesthesia,
• 10:07
  it
• 10:07
  will
• 10:07
  be
• 10:08
  very
• 10:08
  physical
• 10:08
  in
• 10:08
  nature.
• 10:09
  They're
• 10:09
  going
• 10:09
  to
• 10:10
  talk
• 10:10
  about
• 10:10
  pacing,
• 10:11
  they're
• 10:11
  going
• 10:11
  to
• 10:11
  talk
• 10:11
  about
• 10:12
  kind
• 10:12
  of
• 10:12
  trembling
• 10:13
  or
• 10:13
  walking
• 10:13
  around
• 10:14
  nervously.
• 10:15
  And
• 10:15
  they'll
• 10:16
  sense
• 10:16
  that
• 10:16
  they
• 10:16
  just,
• 10:16
  they
• 10:17
  never
• 10:17
  feel
• 10:17
  comfortable
• 10:18
  physically.
• 10:18
  They
• 10:18
  just
• 10:18
  want
• 10:19
  to
• 10:19
  jump
• 10:19
  out
• 10:19
  of
• 10:19
  their
• 10:19
  skin.
• 10:20
  It's
• 10:20
  this
• 10:21
  very
• 10:21
  restless
• 10:22
  issue.
• 10:22
  And
• 10:23
  it's
• 10:23
  a
• 10:23
  problem,
• 10:23
  right?
• 10:24
  There's
• 10:24
  like
• 10:24
  increased
• 10:24
  suicide
• 10:25
  rates
• 10:25
  with
• 10:25
  apostasia.
• 10:27
  There's
• 10:27
  a
• 10:27
  lot
• 10:27
  of
• 10:27
  problems
• 10:28
  that
• 10:28
  treatment
• 10:28
  failure,
• 10:29
  treatment
• 10:29
  non,
• 10:29
  non
• 10:30
  adherence,
• 10:31
  it
• 10:31
  can
• 10:31
  really
• 10:31
  torpedo
• 10:32
  your
• 10:32
  boat.
• 10:33
  So
• 10:34
  in
• 10:34
  this
• 10:34
  case,
• 10:35
  we
• 10:35
  did
• 10:36
  the
• 10:36
  worst
• 10:36
  thing
• 10:36
  we
• 10:36
  could
• 10:37
  and
• 10:37
  that
• 10:37
  is
• 10:37
  increase
• 10:38
  the
• 10:39
  antipsychotic
• 10:40
  when
• 10:40
  in
• 10:40
  fact
• 10:41
  that's
• 10:41
  gonna
• 10:41
  worsen
• 10:42
  akesthesia
• 10:42
  because
• 10:43
  we
• 10:43
  didn't
• 10:43
  pin
• 10:43
  the
• 10:43
  patient
• 10:44
  down
• 10:44
  on
• 10:44
  what
• 10:45
  they
• 10:45
  were
• 10:45
  Specifically
• 10:46
  going
• 10:46
  through.
• 10:47
  Okay?
• 10:48
  And
• 10:48
  that's
• 10:48
  the
• 10:48
  key.
• 10:49
  We
• 10:49
  need
• 10:49
  to
• 10:49
  make
• 10:50
  sure.
• 10:50
  Is
• 10:50
  this
• 10:50
  the
• 10:51
  auditory
• 10:51
  visual
• 10:52
  hallucinations
• 10:53
  that
• 10:53
  are
• 10:53
  getting
• 10:53
  worse,
• 10:54
  or
• 10:54
  is
• 10:55
  this
• 10:55
  some
• 10:56
  medication
• 10:56
  side
• 10:56
  effect?
• 10:57
  If
• 10:57
  we
• 10:57
  get
• 10:57
  that
• 10:57
  wrong,
• 10:58
  we're
• 10:58
  gonna
• 10:58
  go
• 10:58
  the
• 10:58
  opposite
• 10:59
  direction
• 10:59
  here.
• 10:59
  Okay?
• 11:00
  So
• 11:00
  that
• 11:00
  was
• 11:00
  Error
• 11:00
  2.
• 11:01
  Error
• 11:01
  2
• 11:02
  is
• 11:02
  not
• 11:02
  identifying
• 11:03
  carefully
• 11:03
  enough
• 11:04
  what
• 11:04
  their
• 11:05
  anxiety
• 11:05
  means.
• 11:06
  If
• 11:06
  you
• 11:07
  misinterpret
• 11:07
  this,
• 11:08
  you
• 11:08
  might
• 11:08
  even
• 11:08
  put
• 11:09
  the
• 11:09
  patient
• 11:09
  on
• 11:09
  a
• 11:09
  benzodiazepine
• 11:10
  or
• 11:10
  an
• 11:11
  SSRI
• 11:11
  if
• 11:12
  you
• 11:12
  take
• 11:12
  them
• 11:13
  at
• 11:13
  face
• 11:13
  value
• 11:13
  for
• 11:14
  the
• 11:14
  fact
• 11:14
  that
• 11:14
  they're
• 11:14
  anxious
• 11:15
  and
• 11:15
  they're
• 11:15
  really
• 11:16
  describing
• 11:16
  this
• 11:16
  physical
• 11:17
  dopamine
• 11:18
  blockade
• 11:19
  and
• 11:19
  not
• 11:20
  the
• 11:20
  need
• 11:20
  for
• 11:21
  a
• 11:21
  benzodiazepine
• 11:22
  or
• 11:22
  an
• 11:22
  ssri.
• 11:23
  So
• 11:23
  with
• 11:23
  the
• 11:23
  wrong
• 11:23
  diagnosis,
• 11:24
  you
• 11:24
  get
• 11:24
  the
• 11:24
  wrong
• 11:25
  treatment,
• 11:25
  then
• 11:25
  you
• 11:25
  get
• 11:25
  polypharmacy,
• 11:26
  then
• 11:26
  you
• 11:26
  get
• 11:27
  medication
• 11:27
  interactions.
• 11:28
  And
• 11:28
  so
• 11:29
  error
• 11:29
  two
• 11:30
  is
• 11:30
  especially
• 11:30
  important
• 11:31
  to
• 11:32
  let
• 11:32
  that
• 11:32
  marinate.
• 11:33
  Now,
• 11:33
  error
• 11:34
  three
• 11:35
  may
• 11:35
  be
• 11:35
  a
• 11:35
  little
• 11:36
  harder
• 11:36
  for
• 11:36
  us
• 11:36
  to
• 11:36
  detect
• 11:37
  here,
• 11:37
  but
• 11:37
  this
• 11:38
  error
• 11:38
  3
• 11:38
  was
• 11:39
  using
• 11:39
  propranolol
• 11:40
  to
• 11:40
  treat
• 11:40
  the
• 11:40
  tremor
• 11:40
  in
• 11:41
  this
• 11:41
  context.
• 11:41
  Now,
• 11:41
  propranolol
• 11:42
  is
• 11:43
  very
• 11:43
  good
• 11:43
  at
• 11:43
  treating
• 11:44
  tremors.
• 11:45
  No
• 11:45
  doubt
• 11:46
  about
• 11:46
  it.
• 11:46
  However,
• 11:47
  it
• 11:47
  wasn't
• 11:47
  the
• 11:48
  most
• 11:49
  effective
• 11:49
  move
• 11:50
  in
• 11:50
  this
• 11:50
  case,
• 11:51
  because
• 11:51
  now
• 11:52
  you're
• 11:52
  really
• 11:52
  just
• 11:52
  masking
• 11:53
  the
• 11:53
  akesthesia
• 11:54
  symptoms
• 11:54
  without
• 11:54
  addressing
• 11:55
  the
• 11:55
  root
• 11:55
  cause.
• 11:55
  And
• 11:56
  the
• 11:56
  root
• 11:56
  cause
• 11:56
  is
• 11:56
  the
• 11:56
  abilify.
• 11:57
  Here
• 11:58
  again,
• 11:58
  propranolol.
• 11:59
  Perfectly
• 11:59
  fine.
• 12:00
  You
• 12:00
  know,
• 12:00
  maybe
• 12:00
  20
• 12:01
  milligrams
• 12:01
  a
• 12:01
  day.
• 12:02
  Fine.
• 12:03
  There's
• 12:04
  other
• 12:04
  ways
• 12:04
  to
• 12:04
  treat
• 12:04
  akesthesia.
• 12:05
  And
• 12:05
  if
• 12:05
  you
• 12:06
  become
• 12:06
  a
• 12:06
  Patreon
• 12:06
  member
• 12:07
  by
• 12:07
  going
• 12:07
  into
• 12:08
  our
• 12:08
  show
• 12:08
  notes,
• 12:08
  we
• 12:09
  will
• 12:09
  do
• 12:09
  a
• 12:09
  deeper
• 12:09
  dive
• 12:10
  into
• 12:10
  the
• 12:10
  treatments
• 12:11
  that
• 12:11
  you
• 12:11
  could
• 12:12
  employ
• 12:12
  in
• 12:12
  this
• 12:13
  specific
• 12:13
  case.
• 12:14
  Akastesia,
• 12:15
  I
• 12:15
  highly
• 12:15
  recommend
• 12:16
  you
• 12:16
  become
• 12:16
  members,
• 12:16
  my
• 12:17
  friends.
• 12:17
  There's
• 12:17
  a
• 12:17
  lot
• 12:17
  of
• 12:17
  high
• 12:18
  yield
• 12:18
  pearls
• 12:18
  there.
• 12:18
  It's
• 12:19
  gonna
• 12:19
  save
• 12:19
  you
• 12:19
  tons
• 12:19
  of
• 12:20
  time
• 12:20
  and
• 12:20
  knowledge.
• 12:21
  It's
• 12:21
  becoming
• 12:21
  really
• 12:22
  popular,
• 12:22
  actually,
• 12:22
  our
• 12:23
  Patreon.
• 12:23
  So
• 12:24
  just
• 12:24
  a
• 12:24
  shameless
• 12:25
  plug
• 12:25
  there.
• 12:26
  But,
• 12:26
  my
• 12:26
  friends,
• 12:27
  again,
• 12:28
  not
• 12:28
  a
• 12:28
  bad
• 12:28
  thing
• 12:28
  to
• 12:29
  start
• 12:29
  propranolol.
• 12:30
  But
• 12:30
  in
• 12:30
  this
• 12:30
  context,
• 12:31
  you're
• 12:31
  really
• 12:31
  masking
• 12:32
  the
• 12:32
  symptoms
• 12:32
  and
• 12:33
  you're
• 12:33
  not
• 12:33
  addressing
• 12:33
  the
• 12:33
  underlying
• 12:34
  problem.
• 12:35
  Now,
• 12:35
  I
• 12:36
  will
• 12:36
  say
• 12:36
  that
• 12:37
  adding
• 12:37
  propranolol
• 12:38
  to
• 12:38
  treat
• 12:39
  a
• 12:39
  tremor
• 12:39
  is
• 12:39
  perfectly
• 12:40
  fine.
• 12:40
  If
• 12:40
  the
• 12:40
  patient
• 12:41
  is
• 12:41
  saying,
• 12:41
  hey,
• 12:42
  this
• 12:43
  medication
• 12:43
  is
• 12:43
  great.
• 12:44
  It's
• 12:44
  the
• 12:44
  first
• 12:44
  medication
• 12:45
  in
• 12:45
  ages
• 12:45
  that
• 12:45
  has
• 12:46
  actually
• 12:46
  quieted
• 12:46
  my
• 12:47
  voices.
• 12:47
  I
• 12:48
  feel
• 12:48
  normal
• 12:48
  again.
• 12:48
  I
• 12:49
  feel
• 12:49
  like
• 12:49
  I
• 12:49
  can
• 12:49
  function.
• 12:49
  I
• 12:50
  don't
• 12:50
  want
• 12:50
  to
• 12:50
  get
• 12:50
  off
• 12:50
  of
• 12:50
  it,
• 12:51
  but
• 12:51
  I
• 12:51
  have
• 12:51
  this
• 12:51
  obnoxious
• 12:52
  hand
• 12:52
  tremor
• 12:53
  that
• 12:53
  really
• 12:53
  makes
• 12:54
  it
• 12:54
  hard
• 12:54
  for
• 12:54
  me,
• 12:55
  you
• 12:55
  know,
• 12:55
  to
• 12:55
  sign
• 12:55
  papers
• 12:56
  or
• 12:56
  to
• 12:56
  go
• 12:57
  bowling
• 12:57
  or
• 12:57
  whatever
• 12:57
  it
• 12:58
  is
• 12:58
  that
• 12:58
  they
• 12:58
  need
• 12:58
  to
• 12:58
  do.
• 12:59
  That
• 12:59
  would
• 12:59
  be
• 13:00
  a
• 13:00
  good
• 13:00
  time
• 13:00
  to
• 13:00
  employ
• 13:01
  something
• 13:01
  like
• 13:01
  propranolol
• 13:02
  when
• 13:02
  everything
• 13:02
  else
• 13:03
  is
• 13:03
  Hunky
• 13:03
  dory.
• 13:03
  But
• 13:04
  if
• 13:04
  you're
• 13:04
  already
• 13:04
  not
• 13:05
  controlling
• 13:06
  the
• 13:06
  core
• 13:07
  symptoms
• 13:07
  and
• 13:08
  the
• 13:08
  side
• 13:08
  effects
• 13:08
  are
• 13:08
  really
• 13:09
  overshadowing
• 13:09
  treatment
• 13:10
  early
• 13:10
  on,
• 13:10
  in
• 13:10
  my
• 13:11
  experience,
• 13:11
  I'm
• 13:12
  a
• 13:12
  lot
• 13:12
  pickier
• 13:13
  and
• 13:13
  I
• 13:13
  don't
• 13:13
  just
• 13:14
  treat
• 13:14
  a
• 13:14
  side
• 13:14
  effect
• 13:15
  because
• 13:15
  that's
• 13:16
  kind
• 13:16
  of
• 13:16
  putting
• 13:16
  the
• 13:16
  cart
• 13:16
  before
• 13:17
  the
• 13:17
  horse.
• 13:17
  We
• 13:17
  need
• 13:17
  to
• 13:17
  make
• 13:18
  sure
• 13:18
  that
• 13:18
  the
• 13:18
  treatment
• 13:18
  itself
• 13:19
  is
• 13:19
  in
• 13:19
  a
• 13:19
  therapeutic
• 13:20
  dose
• 13:20
  and
• 13:20
  it's
• 13:20
  working
• 13:21
  and
• 13:21
  it's
• 13:21
  doing
• 13:22
  its
• 13:22
  job
• 13:22
  before
• 13:22
  we
• 13:23
  even
• 13:24
  address
• 13:24
  the
• 13:25
  fact
• 13:25
  that,
• 13:25
  that
• 13:25
  there's
• 13:26
  a
• 13:26
  side
• 13:26
  effect
• 13:26
  to
• 13:26
  cover
• 13:26
  down
• 13:27
  on
• 13:27
  cause.
• 13:27
  Okay,
• 13:27
  great.
• 13:28
  You
• 13:28
  got
• 13:28
  rid
• 13:28
  of
• 13:28
  the,
• 13:29
  the
• 13:29
  tremor,
• 13:29
  but
• 13:30
  the
• 13:30
  patient's
• 13:30
  core
• 13:31
  problems
• 13:33
  have
• 13:33
  still
• 13:33
  not
• 13:33
  been
• 13:34
  addressed.
• 13:34
  So
• 13:34
  again,
• 13:35
  propranolol
• 13:36
  is
• 13:36
  great,
• 13:36
  but
• 13:36
  don't
• 13:37
  mask
• 13:37
  your
• 13:37
  symptom.
• 13:38
  Get,
• 13:38
  you
• 13:38
  know,
• 13:38
  address
• 13:38
  the
• 13:39
  core
• 13:39
  problems
• 13:39
  first
• 13:40
  and
• 13:40
  go
• 13:40
  from
• 13:41
  there.
• 13:43
  All
• 13:43
  right,
• 13:43
  my
• 13:43
  friends,
• 13:44
  now
• 13:44
  the
• 13:44
  last
• 13:44
  error
• 13:45
  was
• 13:45
  a
• 13:45
  little
• 13:45
  more
• 13:46
  subtle
• 13:48
  and
• 13:49
  I
• 13:49
  wonder
• 13:50
  if
• 13:50
  you
• 13:50
  got
• 13:50
  it.
• 13:51
  But
• 13:52
  the
• 13:53
  last
• 13:53
  error
• 13:53
  is
• 13:53
  the
• 13:54
  scheduling.
• 13:54
  Let's
• 13:55
  not
• 13:55
  do
• 13:55
  four
• 13:55
  week
• 13:56
  follow
• 13:56
  ups
• 13:56
  for
• 13:56
  patients
• 13:57
  that
• 13:58
  are
• 13:59
  doing
• 13:59
  some
• 13:59
  kind
• 13:59
  of
• 14:00
  medication
• 14:00
  adjustment
• 14:01
  or
• 14:01
  complaining
• 14:01
  of
• 14:01
  an
• 14:02
  acute
• 14:02
  side
• 14:02
  effect
• 14:02
  like
• 14:02
  this
• 14:03
  and
• 14:03
  they're
• 14:03
  hearing
• 14:03
  voices
• 14:04
  that
• 14:04
  this
• 14:05
  is
• 14:05
  not
• 14:05
  a
• 14:05
  four
• 14:05
  week
• 14:05
  follow
• 14:06
  up.
• 14:06
  Right.
• 14:07
  And
• 14:07
  you
• 14:07
  have
• 14:08
  to
• 14:08
  use
• 14:08
  your
• 14:08
  clinical
• 14:08
  judgment,
• 14:09
  of
• 14:09
  course,
• 14:10
  but
• 14:10
  there
• 14:10
  are
• 14:10
  some
• 14:11
  black
• 14:11
  and
• 14:11
  white
• 14:12
  cases,
• 14:12
  more
• 14:13
  or
• 14:13
  less
• 14:13
  speaking
• 14:13
  in
• 14:14
  mental
• 14:14
  health
• 14:15
  and
• 14:15
  when
• 14:15
  your
• 14:15
  patient
• 14:16
  is,
• 14:16
  you
• 14:16
  know,
• 14:16
  acutely
• 14:17
  psychotic
• 14:17
  and
• 14:17
  they
• 14:18
  have
• 14:18
  acute
• 14:18
  side
• 14:18
  effects
• 14:19
  that
• 14:19
  are
• 14:19
  worsening.
• 14:20
  This
• 14:20
  is
• 14:20
  not
• 14:21
  a
• 14:21
  four
• 14:21
  week
• 14:21
  er,
• 14:22
  right?
• 14:22
  This
• 14:22
  is
• 14:22
  just
• 14:23
  not
• 14:23
  a
• 14:23
  four
• 14:23
  week
• 14:23
  er.
• 14:24
  This
• 14:24
  is
• 14:24
  someone
• 14:25
  you
• 14:25
  want
• 14:25
  to
• 14:25
  check
• 14:25
  in
• 14:26
  with
• 14:26
  maybe
• 14:26
  even
• 14:27
  before
• 14:27
  your
• 14:27
  next
• 14:27
  appointment
• 14:28
  with
• 14:28
  a
• 14:28
  T
• 14:28
  con
• 14:29
  you
• 14:30
  want
• 14:30
  to
• 14:30
  see
• 14:30
  them
• 14:30
  in
• 14:30
  clinic
• 14:31
  within
• 14:31
  a
• 14:31
  week
• 14:31
  to
• 14:31
  make
• 14:31
  sure
• 14:32
  that
• 14:33
  whatever
• 14:33
  you
• 14:34
  do
• 14:34
  in
• 14:34
  this
• 14:34
  case
• 14:34
  is
• 14:35
  getting
• 14:35
  better,
• 14:36
  whether
• 14:36
  you
• 14:37
  switch
• 14:37
  the
• 14:38
  medication,
• 14:39
  whether
• 14:39
  you
• 14:39
  treat
• 14:40
  the
• 14:40
  side
• 14:40
  effects.
• 14:41
  That
• 14:41
  is
• 14:42
  definitely
• 14:42
  something
• 14:43
  that
• 14:44
  you
• 14:44
  want
• 14:44
  to
• 14:44
  monitor
• 14:44
  closely
• 14:45
  and
• 14:45
  carefully.
• 14:46
  There's
• 14:46
  many
• 14:46
  dimensions
• 14:47
  to
• 14:48
  looking
• 14:48
  at
• 14:48
  the
• 14:48
  patient
• 14:49
  in
• 14:49
  the
• 14:49
  outpatient
• 14:50
  space.
• 14:50
  There's
• 14:50
  the
• 14:51
  diagnosis
• 14:51
  in
• 14:51
  this
• 14:52
  case,
• 14:52
  making
• 14:52
  sure
• 14:52
  you're
• 14:52
  getting
• 14:53
  to
• 14:53
  the
• 14:53
  root
• 14:53
  problem,
• 14:54
  which
• 14:54
  is
• 14:54
  aesthesia,
• 14:55
  not
• 14:55
  anxiety.
• 14:56
  Looking
• 14:57
  at
• 14:57
  the
• 14:57
  patient's
• 14:57
  potential
• 14:59
  treatments
• 14:59
  to
• 15:00
  address
• 15:00
  that
• 15:00
  root
• 15:00
  problem
• 15:01
  and
• 15:01
  then
• 15:02
  making
• 15:02
  sure
• 15:02
  your
• 15:02
  plan
• 15:03
  is
• 15:03
  consistent
• 15:04
  with
• 15:04
  the
• 15:04
  urgency
• 15:05
  of
• 15:05
  the
• 15:05
  situation.
• 15:06
  So
• 15:06
  all
• 15:07
  of
• 15:07
  those
• 15:07
  things
• 15:07
  have
• 15:07
  to
• 15:07
  be
• 15:09
  very
• 15:09
  precise
• 15:09
  and
• 15:10
  we
• 15:10
  don't
• 15:10
  want
• 15:10
  to
• 15:10
  underestimate
• 15:11
  the
• 15:11
  follow
• 15:11
  up
• 15:11
  cadence.
• 15:12
  It's
• 15:12
  a
• 15:12
  big
• 15:12
  deal
• 15:13
  because
• 15:13
  if
• 15:14
  you
• 15:14
  make
• 15:14
  the
• 15:14
  patient
• 15:14
  hang
• 15:15
  out
• 15:15
  for
• 15:15
  two
• 15:15
  more
• 15:15
  weeks,
• 15:16
  three
• 15:16
  more
• 15:16
  weeks,
• 15:16
  and
• 15:17
  they
• 15:17
  might
• 15:17
  say,
• 15:17
  okay,
• 15:17
  screw
• 15:17
  this,
• 15:18
  I'm
• 15:18
  not
• 15:18
  dealing
• 15:18
  with
• 15:18
  this
• 15:18
  AKA
• 15:19
  Stezia
• 15:19
  anymore,
• 15:20
  I'm
• 15:20
  done.
• 15:22
  I'm
• 15:22
  just
• 15:22
  going
• 15:22
  to
• 15:22
  get
• 15:22
  off
• 15:22
  this
• 15:23
  medication.
• 15:23
  And
• 15:23
  now
• 15:23
  you've
• 15:24
  created
• 15:24
  this
• 15:24
  impression
• 15:25
  with
• 15:25
  this
• 15:25
  patient
• 15:26
  where
• 15:26
  medications
• 15:27
  in
• 15:27
  general
• 15:27
  are
• 15:28
  registered
• 15:28
  or
• 15:28
  encoded
• 15:29
  in
• 15:29
  their
• 15:29
  brain
• 15:29
  as
• 15:30
  harmful.
• 15:31
  And
• 15:31
  they
• 15:32
  just
• 15:32
  never
• 15:32
  want
• 15:32
  to
• 15:33
  go
• 15:33
  the
• 15:33
  med
• 15:33
  route
• 15:33
  again
• 15:34
  because
• 15:34
  they
• 15:34
  can't
• 15:34
  tolerate
• 15:35
  that
• 15:35
  subjectively
• 15:36
  awful
• 15:37
  feeling
• 15:37
  of
• 15:37
  Akaesthesia.
• 15:38
  And
• 15:39
  maybe
• 15:39
  they
• 15:39
  feel
• 15:39
  misunderstood
• 15:40
  by
• 15:40
  you.
• 15:41
  One
• 15:41
  or
• 15:41
  two
• 15:41
  weeks
• 15:42
  more
• 15:43
  of
• 15:43
  waiting
• 15:44
  is
• 15:44
  really
• 15:44
  detrimental.
• 15:45
  And
• 15:45
  for
• 15:46
  you,
• 15:46
  it
• 15:46
  might
• 15:46
  just
• 15:46
  feel
• 15:46
  like
• 15:47
  another
• 15:47
  day
• 15:47
  at
• 15:47
  the
• 15:47
  clinic.
• 15:48
  For
• 15:48
  them,
• 15:48
  it
• 15:48
  might
• 15:48
  be
• 15:49
  a
• 15:49
  really
• 15:49
  torturous
• 15:50
  wait
• 15:50
  period
• 15:51
  that
• 15:51
  defines
• 15:52
  how
• 15:52
  they
• 15:53
  look
• 15:53
  at
• 15:53
  medications
• 15:54
  for
• 15:54
  the
• 15:55
  next
• 15:55
  10
• 15:55
  years.
• 15:56
  And
• 15:56
  that's
• 15:57
  a
• 15:57
  big
• 15:57
  deal
• 15:57
  because
• 15:57
  the
• 15:58
  stakes
• 15:58
  are
• 15:58
  high
• 15:58
  with
• 15:58
  severe
• 15:59
  mental
• 15:59
  illness
• 15:59
  like
• 16:00
  schizophrenia.
• 16:01
  I
• 16:01
  hope
• 16:01
  you
• 16:01
  enjoyed
• 16:02
  this.
• 16:02
  Four
• 16:02
  little
• 16:02
  errors
• 16:03
  here.
• 16:03
  Some
• 16:03
  of
• 16:04
  them
• 16:04
  were
• 16:04
  big.
• 16:04
  These
• 16:04
  are
• 16:04
  ones
• 16:04
  you
• 16:05
  want
• 16:05
  to
• 16:05
  avoid.
• 16:05
  The
• 16:06
  big
• 16:06
  pearls
• 16:06
  here
• 16:07
  are
• 16:07
  be
• 16:07
  very
• 16:08
  picky
• 16:08
  about
• 16:08
  your
• 16:08
  starting
• 16:09
  dose.
• 16:09
  Make
• 16:09
  sure
• 16:09
  you're
• 16:10
  not
• 16:10
  undertreating.
• 16:11
  Make
• 16:11
  sure
• 16:11
  that
• 16:11
  if
• 16:11
  side
• 16:11
  effects
• 16:12
  do
• 16:12
  come
• 16:13
  about,
• 16:13
  you
• 16:13
  have
• 16:13
  an
• 16:13
  understanding
• 16:14
  of
• 16:14
  what
• 16:14
  they
• 16:14
  are,
• 16:14
  how
• 16:15
  to
• 16:15
  define
• 16:15
  them.
• 16:16
  You're
• 16:16
  ensuring
• 16:16
  that
• 16:16
  you
• 16:17
  and
• 16:17
  the
• 16:17
  patient
• 16:17
  are
• 16:17
  carefully
• 16:18
  defining
• 16:19
  the
• 16:19
  exact
• 16:20
  complaints
• 16:21
  that
• 16:21
  are
• 16:21
  coming
• 16:21
  up
• 16:22
  in
• 16:22
  session
• 16:22
  so
• 16:22
  you
• 16:22
  can
• 16:23
  pinpoint
• 16:23
  an
• 16:23
  exact
• 16:24
  treatment
• 16:25
  for
• 16:25
  these
• 16:25
  complaints.
• 16:26
  And
• 16:26
  again,
• 16:27
  making
• 16:27
  sure
• 16:27
  that
• 16:28
  your
• 16:28
  follow
• 16:28
  up
• 16:28
  makes
• 16:29
  sense,
• 16:29
  considering
• 16:30
  the
• 16:30
  severity
• 16:30
  of
• 16:30
  the
• 16:31
  situation.
• 16:32
  If
• 16:32
  you
• 16:32
  all
• 16:32
  become
• 16:33
  Patreon
• 16:33
  members,
• 16:34
  whether
• 16:34
  free
• 16:34
  members
• 16:35
  or
• 16:35
  paid
• 16:35
  members,
• 16:35
  or
• 16:36
  our
• 16:36
  Street
• 16:36
  Tips
• 16:36
  plan,
• 16:37
  or
• 16:37
  our
• 16:37
  Pearls
• 16:37
  plus
• 16:38
  plan,
• 16:38
  I
• 16:38
  highly
• 16:39
  encourage
• 16:39
  it.
• 16:39
  Because
• 16:39
  what
• 16:40
  we're
• 16:40
  going
• 16:40
  to
• 16:40
  do
• 16:40
  is
• 16:41
  a
• 16:41
  little
• 16:41
  after
• 16:41
  hours,
• 16:43
  office
• 16:43
  hours,
• 16:44
  if
• 16:44
  you
• 16:44
  will,
• 16:45
  clinical
• 16:45
  office
• 16:46
  hours.
• 16:46
  We're
• 16:46
  going
• 16:47
  to
• 16:47
  include
• 16:47
  in
• 16:47
  our
• 16:47
  Patreon
• 16:48
  membership
• 16:49
  here
• 16:50
  a
• 16:50
  follow
• 16:50
  up
• 16:50
  to
• 16:50
  this
• 16:51
  case
• 16:51
  study
• 16:52
  and
• 16:52
  we're
• 16:52
  going
• 16:52
  to
• 16:52
  talk
• 16:52
  about
• 16:52
  what
• 16:53
  we
• 16:53
  would
• 16:53
  actually
• 16:53
  do
• 16:53
  for
• 16:54
  this
• 16:54
  patient.
• 16:54
  So
• 16:55
  not
• 16:55
  to
• 16:55
  leave
• 16:55
  you
• 16:55
  all
• 16:56
  on
• 16:56
  a
• 16:56
  cliffhanger,
• 16:56
  but
• 16:57
  that's
• 16:57
  the
• 16:57
  beauty
• 16:57
  of
• 16:57
  being
• 16:58
  Patreon
• 16:58
  members,
• 16:58
  is
• 16:59
  you
• 16:59
  can
• 16:59
  figure
• 16:59
  out,
• 16:59
  what
• 17:00
  did
• 17:00
  we
• 17:00
  do
• 17:00
  for
• 17:00
  this
• 17:00
  patient.
• 17:01
  Sure
• 17:01
  enough,
• 17:02
  you
• 17:02
  will
• 17:02
  be
• 17:02
  surprised.
• 17:03
  There
• 17:03
  is
• 17:03
  more
• 17:03
  recent
• 17:04
  evidence
• 17:04
  that
• 17:04
  shows
• 17:05
  a
• 17:05
  particular
• 17:05
  agent
• 17:06
  is
• 17:06
  really
• 17:06
  good,
• 17:07
  very
• 17:08
  effective,
• 17:08
  and
• 17:09
  most
• 17:09
  importantly,
• 17:10
  very
• 17:10
  tolerable
• 17:11
  to
• 17:11
  treat
• 17:11
  antipsychotic
• 17:12
  induced
• 17:12
  akesthesia.
• 17:13
  And
• 17:13
  I
• 17:13
  don't
• 17:13
  think
• 17:14
  you'll
• 17:14
  guess
• 17:14
  it,
• 17:14
  and
• 17:14
  it
• 17:15
  is
• 17:15
  a
• 17:15
  very,
• 17:15
  very
• 17:16
  good
• 17:17
  treatment
• 17:17
  that
• 17:18
  the
• 17:18
  evidence
• 17:18
  is
• 17:19
  pointing
• 17:19
  to.
• 17:19
  And
• 17:19
  I'll
• 17:20
  throw
• 17:20
  in
• 17:20
  two
• 17:20
  more
• 17:20
  treatments
• 17:21
  that
• 17:21
  we
• 17:21
  can
• 17:22
  pursue,
• 17:22
  one
• 17:22
  of
• 17:22
  which
• 17:23
  we
• 17:23
  talked
• 17:23
  about.
• 17:23
  We
• 17:23
  talked
• 17:23
  about
• 17:24
  propranolol,
• 17:24
  but
• 17:25
  there's
• 17:25
  two
• 17:25
  more
• 17:25
  treatments
• 17:26
  that
• 17:26
  you
• 17:26
  can
• 17:27
  get
• 17:27
  exposed
• 17:27
  to
• 17:28
  if
• 17:28
  you're
• 17:28
  a
• 17:28
  Patreon
• 17:28
  member
• 17:29
  in
• 17:29
  how
• 17:29
  we
• 17:30
  would
• 17:30
  do
• 17:30
  this.
• 17:30
  This
• 17:31
  patient's
• 17:31
  gonna
• 17:31
  stay
• 17:31
  on
• 17:31
  Abilify,
• 17:32
  quite
• 17:32
  honestly.
• 17:33
  So
• 17:33
  in
• 17:34
  our
• 17:34
  Patreon
• 17:34
  membership,
• 17:35
  you
• 17:35
  will
• 17:36
  find
• 17:36
  out
• 17:36
  what
• 17:36
  they
• 17:36
  actually
• 17:37
  switched
• 17:38
  to
• 17:38
  and
• 17:38
  why.
• 17:39
  Because
• 17:39
  we
• 17:39
  have
• 17:39
  to
• 17:39
  be
• 17:40
  very
• 17:40
  careful
• 17:41
  about
• 17:41
  which
• 17:42
  medications
• 17:43
  might
• 17:43
  be
• 17:43
  more
• 17:43
  suitable
• 17:44
  than
• 17:44
  the
• 17:44
  Abilify,
• 17:45
  which
• 17:45
  tends
• 17:46
  to
• 17:46
  cause
• 17:46
  akesthesia
• 17:47
  20%
• 17:47
  of
• 17:48
  the
• 17:48
  time,
• 17:48
  usually
• 17:48
  in
• 17:49
  one
• 17:49
  year.
• 17:49
  It's
• 17:49
  one
• 17:49
  of
• 17:50
  the
• 17:50
  most
• 17:50
  egregious
• 17:50
  offenders
• 17:51
  in
• 17:51
  the
• 17:52
  second
• 17:52
  generation
• 17:52
  antipsychotic
• 17:53
  space.
• 17:53
  Of
• 17:54
  course,
• 17:54
  the
• 17:54
  first
• 17:54
  generations
• 17:55
  are
• 17:55
  much
• 17:55
  more
• 17:56
  egregious
• 17:57
  in
• 17:57
  their
• 17:57
  ability
• 17:57
  to
• 17:58
  cause
• 17:58
  aesthesia.
• 17:59
  They
• 17:59
  block
• 17:59
  more
• 17:59
  dopamine
• 18:00
  2
• 18:00
  receptors,
• 18:01
  as
• 18:01
  you
• 18:01
  know
• 18:02
  from
• 18:02
  your
• 18:02
  textbooks.
• 18:03
  But
• 18:03
  yeah,
• 18:04
  definitely
• 18:04
  encourage
• 18:05
  you
• 18:05
  to
• 18:05
  become
• 18:05
  members,
• 18:05
  because
• 18:06
  we
• 18:06
  are
• 18:06
  going
• 18:06
  to
• 18:06
  go
• 18:06
  over
• 18:07
  what
• 18:07
  actually
• 18:08
  happened
• 18:08
  with
• 18:08
  this
• 18:08
  mock
• 18:09
  patient,
• 18:09
  how
• 18:09
  to
• 18:10
  make
• 18:10
  things
• 18:10
  right,
• 18:10
  and
• 18:10
  with
• 18:11
  what
• 18:11
  agent.
• 18:11
  So
• 18:12
  hang
• 18:12
  on
• 18:12
  for
• 18:12
  that,
• 18:13
  my
• 18:13
  friends.
• 18:13
  We
• 18:13
  appreciate
• 18:14
  all
• 18:14
  your
• 18:14
  support
• 18:14
  out
• 18:15
  there.
• 18:15
  And
• 18:16
  until
• 18:16
  next
• 18:16
  time,
• 18:16
  NPC
• 18:17
  signing
• 18:17
  off.
• 18:18
  Take
• 18:18
  care.
• 18:18
  Good
• 18:19
  luck
• 18:19
  to
• 18:19
  all
• 18:19
  you.
• 18:19
  Bye
• 18:19
  bye.