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The Intricacies of Diagnosing Anxiety Disorders · Pearls and Prep

• 0:00
  Foreign
• 0:04
  welcome,
• 0:04
  my
• 0:04
  friends
• 0:05
  to
• 0:05
  another
• 0:05
  episode
• 0:06
  of
• 0:06
  Pearls
• 0:06
  and
• 0:07
  prep
• 0:07
  your
• 0:08
  go
• 0:08
  to
• 0:09
  place
• 0:10
  with
• 0:10
  Pearls
• 0:11
  that
• 0:11
  prep
• 0:11
  you
• 0:12
  to
• 0:12
  practice.
• 0:13
  We
• 0:13
  appreciate
• 0:14
  everyone
• 0:14
  listening
• 0:15
  today.
• 0:15
  A
• 0:15
  lot
• 0:15
  of
• 0:16
  psychiatric
• 0:16
  nurse
• 0:17
  practitioner
• 0:17
  students
• 0:17
  have
• 0:18
  been
• 0:18
  sharing
• 0:18
  this.
• 0:19
  We
• 0:19
  really
• 0:19
  appreciate
• 0:20
  you.
• 0:20
  The
• 0:21
  goal
• 0:21
  here
• 0:21
  is
• 0:21
  to
• 0:22
  introduce
• 0:22
  fun
• 0:23
  case
• 0:23
  studies,
• 0:24
  mock
• 0:24
  case
• 0:24
  studies,
• 0:25
  but
• 0:25
  ones
• 0:26
  that
• 0:26
  also
• 0:26
  prepare
• 0:27
  you
• 0:27
  for
• 0:27
  practice,
• 0:28
  get
• 0:28
  you
• 0:28
  thinking
• 0:29
  in
• 0:29
  the
• 0:29
  world
• 0:29
  of
• 0:29
  diagnostics
• 0:30
  and
• 0:30
  treatment,
• 0:31
  that
• 0:31
  help
• 0:31
  you
• 0:32
  ask
• 0:32
  better
• 0:32
  questions,
• 0:33
  that
• 0:33
  help
• 0:33
  you
• 0:34
  critically
• 0:34
  think
• 0:35
  so
• 0:35
  that
• 0:35
  you
• 0:35
  can
• 0:36
  prepare
• 0:36
  the
• 0:37
  best
• 0:37
  kind
• 0:37
  of
• 0:38
  diagnosis
• 0:38
  which
• 0:39
  will
• 0:39
  lead
• 0:39
  you
• 0:39
  to
• 0:39
  the
• 0:39
  best
• 0:40
  kind
• 0:40
  of
• 0:40
  treatment
• 0:40
  plan.
• 0:41
  Today,
• 0:42
  folks,
• 0:42
  I'd
• 0:42
  like
• 0:43
  you
• 0:43
  to
• 0:43
  meet
• 0:44
  Sarah,
• 0:45
  fake
• 0:45
  patient.
• 0:46
  She's
• 0:46
  not
• 0:46
  a
• 0:46
  real
• 0:47
  patient,
• 0:47
  but
• 0:47
  I
• 0:47
  try
• 0:48
  to
• 0:48
  get
• 0:48
  her
• 0:48
  to
• 0:48
  resemble
• 0:49
  what
• 0:49
  you
• 0:49
  might
• 0:50
  see
• 0:50
  in
• 0:50
  the
• 0:50
  real
• 0:50
  world.
• 0:51
  She's
• 0:51
  coming
• 0:51
  to
• 0:51
  you
• 0:51
  in
• 0:52
  the
• 0:52
  outpatient
• 0:52
  space
• 0:53
  today
• 0:53
  and
• 0:54
  she
• 0:54
  is
• 0:54
  complaining
• 0:55
  of
• 0:56
  falling
• 0:57
  behind
• 0:57
  in
• 0:57
  her
• 0:58
  studies.
• 0:58
  She
• 0:59
  cannot
• 0:59
  focus.
• 1:00
  She
• 1:00
  feels
• 1:01
  so
• 1:01
  overwhelmed
• 1:02
  and
• 1:03
  nervous
• 1:03
  and
• 1:03
  on
• 1:03
  edge.
• 1:04
  She
• 1:04
  feels
• 1:05
  like
• 1:05
  she's
• 1:06
  never
• 1:06
  going
• 1:06
  to
• 1:06
  graduate
• 1:07
  her
• 1:08
  PhD
• 1:08
  program
• 1:09
  in
• 1:09
  medieval
• 1:10
  history.
• 1:11
  I
• 1:11
  couldn't
• 1:11
  understand
• 1:12
  Game
• 1:12
  of
• 1:12
  Thrones.
• 1:12
  There's
• 1:13
  too
• 1:13
  many
• 1:13
  characters,
• 1:14
  too
• 1:14
  many
• 1:14
  rivalries,
• 1:16
  too
• 1:16
  many
• 1:16
  sword
• 1:16
  fights.
• 1:17
  I
• 1:17
  needed
• 1:17
  to
• 1:18
  understand
• 1:18
  it
• 1:18
  more
• 1:19
  and
• 1:19
  I
• 1:20
  couldn't.
• 1:20
  I
• 1:20
  can't
• 1:20
  imagine
• 1:21
  how
• 1:21
  difficult
• 1:21
  medieval
• 1:22
  history
• 1:22
  is,
• 1:22
  but
• 1:23
  that's
• 1:23
  beside
• 1:23
  the
• 1:23
  point.
• 1:24
  Sarah
• 1:24
  needs
• 1:25
  your
• 1:25
  help,
• 1:26
  she
• 1:26
  tells
• 1:26
  you.
• 1:26
  She
• 1:27
  washes
• 1:27
  her
• 1:27
  hands
• 1:28
  daily,
• 1:29
  40
• 1:30
  times
• 1:30
  a
• 1:30
  day.
• 1:30
  Her
• 1:31
  skin
• 1:31
  is
• 1:31
  cracked.
• 1:32
  She
• 1:32
  showers
• 1:32
  a
• 1:33
  very
• 1:33
  long
• 1:33
  time
• 1:34
  as
• 1:35
  well.
• 1:35
  She's
• 1:35
  very
• 1:36
  preoccupied
• 1:36
  with
• 1:37
  germs.
• 1:37
  Her
• 1:37
  main
• 1:37
  concern
• 1:38
  is
• 1:38
  falling
• 1:38
  behind
• 1:39
  and
• 1:39
  not
• 1:39
  doing
• 1:40
  well
• 1:40
  in
• 1:40
  school.
• 1:41
  And
• 1:41
  she's
• 1:41
  reached
• 1:42
  a
• 1:42
  breaking
• 1:42
  point.
• 1:43
  She
• 1:43
  just
• 1:43
  can't
• 1:44
  handle
• 1:44
  it
• 1:44
  anymore.
• 1:45
  She
• 1:46
  also
• 1:46
  reports
• 1:47
  that
• 1:47
  her
• 1:47
  mood
• 1:47
  is
• 1:48
  pretty
• 1:48
  down
• 1:49
  and
• 1:49
  that
• 1:50
  she
• 1:50
  has
• 1:50
  less
• 1:50
  and
• 1:51
  less
• 1:51
  time
• 1:51
  for
• 1:51
  friends
• 1:52
  and
• 1:52
  family.
• 1:53
  And
• 1:53
  she's
• 1:54
  constantly
• 1:54
  worried
• 1:55
  about
• 1:55
  the
• 1:55
  next
• 1:56
  pandemic.
• 1:56
  It's
• 1:57
  always
• 1:57
  on
• 1:57
  her
• 1:57
  mind.
• 1:57
  She's
• 1:58
  frequently
• 1:58
  googling
• 1:59
  potential
• 2:00
  scenarios
• 2:00
  around
• 2:01
  the
• 2:01
  world,
• 2:01
  whether
• 2:01
  it's
• 2:02
  an
• 2:02
  Ebola
• 2:02
  crisis
• 2:03
  or
• 2:03
  a
• 2:03
  pandemic.
• 2:04
  She's
• 2:04
  coming
• 2:04
  to
• 2:05
  you
• 2:05
  for
• 2:05
  assistance
• 2:06
  today.
• 2:07
  She
• 2:08
  has
• 2:08
  never
• 2:09
  been
• 2:09
  on
• 2:09
  psychotropic
• 2:10
  medications
• 2:10
  before.
• 2:11
  She's
• 2:11
  been
• 2:11
  in
• 2:11
  therapy
• 2:12
  and
• 2:12
  counseling
• 2:12
  to
• 2:13
  deal
• 2:13
  with
• 2:13
  with
• 2:13
  her
• 2:14
  anxiety
• 2:15
  and
• 2:15
  learned
• 2:16
  some
• 2:16
  strategies
• 2:16
  with
• 2:16
  the
• 2:17
  school
• 2:17
  counselor,
• 2:17
  all
• 2:18
  of
• 2:18
  which
• 2:18
  have
• 2:18
  been
• 2:18
  moderately
• 2:19
  helpful.
• 2:20
  She
• 2:20
  has
• 2:20
  a
• 2:20
  mother
• 2:21
  with
• 2:21
  generalized
• 2:21
  anxiety
• 2:22
  disorder.
• 2:23
  Beyond
• 2:23
  that,
• 2:23
  no
• 2:23
  major
• 2:24
  history
• 2:24
  of
• 2:25
  family
• 2:25
  mental
• 2:26
  health
• 2:26
  symptoms.
• 2:27
  And
• 2:27
  she
• 2:28
  needs
• 2:28
  your
• 2:28
  help.
• 2:28
  Now,
• 2:29
  you
• 2:30
  look
• 2:30
  at
• 2:30
  this
• 2:31
  on
• 2:31
  its
• 2:32
  surface,
• 2:33
  you
• 2:33
  hear
• 2:33
  a
• 2:34
  patient
• 2:34
  coming
• 2:34
  to
• 2:34
  you
• 2:34
  who
• 2:35
  says
• 2:35
  she's
• 2:35
  falling
• 2:36
  behind
• 2:36
  in
• 2:36
  an
• 2:37
  academic
• 2:37
  setting.
• 2:38
  The
• 2:38
  bias
• 2:38
  that
• 2:39
  you
• 2:39
  may
• 2:39
  have
• 2:39
  right
• 2:39
  off
• 2:40
  the
• 2:40
  bat,
• 2:40
  my
• 2:40
  friends,
• 2:41
  is
• 2:41
  what?
• 2:42
  Adhd,
• 2:43
  right?
• 2:43
  That
• 2:43
  might
• 2:43
  be
• 2:44
  the
• 2:44
  bias
• 2:45
  that
• 2:45
  you
• 2:45
  have.
• 2:46
  But
• 2:46
  I
• 2:46
  would
• 2:46
  caution
• 2:47
  you,
• 2:48
  before
• 2:48
  you
• 2:48
  plant
• 2:49
  your
• 2:49
  flag
• 2:49
  on
• 2:49
  any
• 2:49
  diagnosis,
• 2:50
  make
• 2:50
  sure
• 2:51
  you
• 2:51
  collect
• 2:51
  as
• 2:52
  much
• 2:52
  rich
• 2:52
  information
• 2:53
  as
• 2:53
  possible,
• 2:54
  because
• 2:55
  there
• 2:55
  are
• 2:55
  a
• 2:55
  hundred
• 2:55
  reasons
• 2:56
  that
• 2:57
  a
• 2:57
  patient
• 2:57
  may
• 2:58
  be
• 2:58
  falling
• 2:58
  behind
• 2:58
  in
• 2:59
  school.
• 3:00
  Absolutely.
• 3:00
  It
• 3:00
  could
• 3:01
  be
• 3:01
  adhd,
• 3:02
  but
• 3:02
  it
• 3:02
  could
• 3:02
  also
• 3:03
  be
• 3:03
  that
• 3:03
  they're
• 3:03
  losing
• 3:04
  motivation
• 3:04
  and
• 3:04
  energy
• 3:05
  and
• 3:05
  they're
• 3:05
  a
• 3:06
  little
• 3:06
  bit
• 3:06
  depressed.
• 3:06
  It
• 3:07
  could
• 3:07
  be
• 3:07
  that
• 3:07
  they're
• 3:07
  going
• 3:07
  through
• 3:08
  a
• 3:08
  situational
• 3:08
  adjustment
• 3:09
  related
• 3:09
  stressor.
• 3:10
  Maybe
• 3:10
  a
• 3:10
  major
• 3:11
  breakup
• 3:12
  could
• 3:12
  also
• 3:12
  be
• 3:12
  a
• 3:12
  problem.
• 3:13
  This
• 3:13
  could
• 3:13
  be
• 3:13
  a
• 3:13
  new
• 3:14
  school,
• 3:14
  another
• 3:14
  adjustment
• 3:15
  related
• 3:15
  stressor.
• 3:16
  Maybe
• 3:16
  they
• 3:16
  failed
• 3:17
  out
• 3:17
  of
• 3:17
  their
• 3:17
  last
• 3:17
  school.
• 3:18
  Maybe
• 3:19
  they
• 3:19
  had
• 3:19
  to
• 3:20
  move
• 3:20
  for
• 3:20
  some
• 3:20
  kind
• 3:21
  of
• 3:21
  family
• 3:21
  emergency
• 3:22
  and
• 3:22
  they
• 3:22
  were
• 3:22
  transferred
• 3:22
  to
• 3:23
  the
• 3:23
  school
• 3:23
  and
• 3:23
  they're
• 3:23
  falling
• 3:24
  behind.
• 3:25
  So
• 3:25
  think
• 3:26
  adjustment
• 3:26
  related.
• 3:27
  Right.
• 3:27
  There
• 3:28
  could
• 3:28
  be
• 3:28
  some
• 3:28
  trauma
• 3:29
  from
• 3:29
  the
• 3:29
  past,
• 3:29
  a
• 3:30
  very
• 3:30
  significant
• 3:30
  trauma
• 3:31
  or
• 3:31
  a
• 3:31
  recent
• 3:31
  trauma
• 3:32
  that
• 3:32
  maybe
• 3:33
  she's
• 3:33
  not
• 3:33
  telling
• 3:34
  you
• 3:34
  about.
• 3:34
  That
• 3:35
  deserves
• 3:35
  a
• 3:35
  very
• 3:36
  compassionate,
• 3:36
  trauma
• 3:37
  informed
• 3:37
  approach
• 3:38
  to
• 3:38
  be
• 3:38
  able
• 3:38
  to
• 3:38
  elicit
• 3:39
  that
• 3:39
  out
• 3:39
  of
• 3:39
  Sarah
• 3:40
  and
• 3:40
  understand
• 3:40
  if
• 3:41
  trauma
• 3:41
  is
• 3:41
  a
• 3:41
  huge
• 3:42
  part
• 3:42
  of
• 3:42
  this.
• 3:42
  So
• 3:43
  just
• 3:43
  off
• 3:43
  the
• 3:43
  bat,
• 3:43
  when
• 3:44
  someone
• 3:44
  can't
• 3:44
  concentrate
• 3:45
  and
• 3:45
  they're
• 3:45
  falling
• 3:45
  behind,
• 3:46
  be
• 3:46
  careful
• 3:47
  not
• 3:47
  to
• 3:48
  get
• 3:48
  too
• 3:48
  stuck
• 3:48
  to
• 3:49
  an
• 3:49
  ADHD
• 3:49
  diagnosis.
• 3:50
  If
• 3:51
  this
• 3:51
  was
• 3:51
  a
• 3:51
  police
• 3:52
  station,
• 3:52
  I
• 3:52
  would
• 3:52
  say
• 3:53
  definitely
• 3:53
  don't
• 3:53
  let
• 3:54
  the
• 3:54
  suspect
• 3:54
  leave
• 3:55
  the
• 3:55
  station.
• 3:55
  That
• 3:56
  suspect
• 3:56
  deserves
• 3:57
  a
• 3:57
  lot
• 3:57
  more
• 3:57
  questioning,
• 3:58
  but
• 3:59
  just
• 3:59
  keep
• 4:00
  that
• 4:00
  suspect
• 4:00
  there
• 4:01
  because
• 4:01
  there's
• 4:01
  a
• 4:01
  lot
• 4:01
  of
• 4:01
  other
• 4:02
  suspects.
• 4:02
  And
• 4:03
  lo
• 4:03
  and
• 4:03
  behold,
• 4:04
  the
• 4:04
  more
• 4:04
  you
• 4:04
  ask
• 4:05
  Sarah
• 4:05
  questions,
• 4:06
  the
• 4:06
  more
• 4:06
  other
• 4:06
  features
• 4:07
  of
• 4:07
  her
• 4:07
  diagnosis
• 4:08
  are
• 4:08
  going
• 4:08
  to
• 4:08
  jump
• 4:08
  out
• 4:08
  at
• 4:09
  you
• 4:09
  and
• 4:10
  you
• 4:10
  may
• 4:10
  be
• 4:10
  able
• 4:10
  to
• 4:10
  make
• 4:11
  more
• 4:11
  headway
• 4:11
  and
• 4:11
  get
• 4:12
  to
• 4:12
  a
• 4:12
  suspect
• 4:13
  that
• 4:13
  deserves
• 4:14
  more
• 4:14
  of
• 4:14
  your
• 4:15
  suspicion.
• 4:15
  So
• 4:16
  you're
• 4:16
  definitely
• 4:17
  getting
• 4:17
  some
• 4:18
  OCD
• 4:18
  vibes
• 4:19
  here,
• 4:19
  right?
• 4:19
  She's
• 4:19
  telling
• 4:20
  you
• 4:20
  she's
• 4:21
  showering
• 4:21
  three
• 4:22
  hours
• 4:22
  a
• 4:22
  day.
• 4:23
  She
• 4:23
  washes
• 4:23
  her
• 4:24
  hands
• 4:24
  40
• 4:24
  times
• 4:25
  a
• 4:25
  day.
• 4:25
  Sarah
• 4:26
  also
• 4:26
  shares
• 4:27
  with
• 4:27
  you
• 4:27
  that
• 4:27
  she
• 4:27
  has
• 4:27
  some
• 4:28
  bizarre
• 4:28
  thoughts.
• 4:29
  And
• 4:29
  when
• 4:29
  you
• 4:29
  ask
• 4:29
  her
• 4:30
  about
• 4:30
  her
• 4:30
  bizarre
• 4:30
  thoughts,
• 4:31
  she
• 4:31
  tells
• 4:31
  you
• 4:32
  that
• 4:32
  she
• 4:33
  has
• 4:33
  this
• 4:33
  bizarre
• 4:34
  thought
• 4:34
  of
• 4:34
  a
• 4:34
  rabbit
• 4:35
  licking
• 4:35
  a
• 4:35
  lollipop
• 4:36
  in
• 4:36
  a
• 4:36
  wrestling
• 4:37
  ring.
• 4:38
  That
• 4:38
  is
• 4:38
  very
• 4:39
  bizarre.
• 4:39
  Right?
• 4:39
  I
• 4:40
  don't
• 4:40
  think
• 4:40
  I've
• 4:40
  ever
• 4:40
  heard
• 4:41
  that
• 4:41
  in
• 4:41
  my
• 4:41
  life.
• 4:42
  That's
• 4:42
  what
• 4:42
  Sarah's
• 4:43
  telling
• 4:43
  us
• 4:43
  today.
• 4:43
  In
• 4:44
  the
• 4:44
  outpatient
• 4:44
  space.
• 4:45
  A
• 4:45
  rabbit
• 4:46
  is
• 4:46
  licking
• 4:46
  a
• 4:46
  lollipop
• 4:47
  in
• 4:47
  a
• 4:47
  wrestling
• 4:48
  ring.
• 4:49
  Now,
• 4:50
  you
• 4:50
  all
• 4:50
  might
• 4:50
  want
• 4:50
  to
• 4:51
  call
• 4:51
  me
• 4:51
  and
• 4:51
  check
• 4:51
  on
• 4:51
  me
• 4:52
  for
• 4:52
  having
• 4:52
  that
• 4:52
  bizarre
• 4:52
  thought,
• 4:53
  because
• 4:53
  I
• 4:53
  kind
• 4:53
  of
• 4:53
  made
• 4:53
  that
• 4:54
  up
• 4:54
  for
• 4:54
  this
• 4:54
  podcast
• 4:55
  today.
• 4:55
  But
• 4:56
  these
• 4:56
  kinds
• 4:56
  of
• 4:56
  bizarre
• 4:57
  thoughts
• 4:57
  are
• 4:57
  actually
• 4:58
  not
• 4:58
  uncommon
• 4:58
  in
• 4:59
  ocd.
• 5:00
  These
• 5:00
  patients
• 5:00
  feel
• 5:01
  nobody
• 5:01
  else
• 5:01
  is
• 5:01
  thinking
• 5:02
  at
• 5:03
  the
• 5:03
  time,
• 5:04
  and
• 5:04
  it
• 5:04
  makes
• 5:04
  them
• 5:04
  feel
• 5:05
  very
• 5:05
  alienated.
• 5:06
  It
• 5:06
  makes
• 5:06
  them
• 5:06
  feel
• 5:06
  crazy.
• 5:07
  They'll
• 5:07
  actually
• 5:07
  tell
• 5:08
  you,
• 5:08
  really
• 5:08
  commonly,
• 5:09
  I
• 5:09
  feel
• 5:09
  crazy.
• 5:10
  I
• 5:10
  feel
• 5:10
  like
• 5:10
  I'm
• 5:10
  not
• 5:10
  normal.
• 5:11
  I
• 5:11
  feel
• 5:11
  like
• 5:12
  nobody
• 5:12
  else
• 5:12
  has
• 5:12
  these
• 5:13
  thoughts.
• 5:13
  And
• 5:14
  it.
• 5:14
  And
• 5:14
  so
• 5:15
  it's
• 5:15
  Very
• 5:15
  important
• 5:16
  that
• 5:16
  you
• 5:16
  normalize
• 5:17
  a
• 5:17
  lot
• 5:17
  of
• 5:17
  this,
• 5:17
  right?
• 5:18
  Don't
• 5:18
  go
• 5:18
  overboard
• 5:19
  and
• 5:19
  say,
• 5:19
  oh,
• 5:19
  we're
• 5:19
  all
• 5:20
  thinking
• 5:20
  of
• 5:20
  that
• 5:20
  same
• 5:20
  rabbit.
• 5:22
  Darn
• 5:22
  rabbit's
• 5:23
  always
• 5:23
  licking
• 5:23
  that
• 5:24
  lollipop,
• 5:24
  driving
• 5:25
  us
• 5:25
  crazy.
• 5:25
  Okay?
• 5:26
  That's
• 5:27
  not
• 5:27
  what
• 5:27
  you
• 5:27
  need
• 5:27
  to
• 5:27
  do.
• 5:28
  Okay?
• 5:28
  Don't
• 5:28
  lose
• 5:28
  credibility.
• 5:29
  But
• 5:29
  at
• 5:29
  the
• 5:29
  same
• 5:30
  time,
• 5:30
  normalizing
• 5:31
  these
• 5:32
  thought
• 5:32
  patterns
• 5:32
  by
• 5:33
  saying,
• 5:33
  you
• 5:33
  know,
• 5:33
  Sarah,
• 5:34
  in
• 5:35
  O
• 5:35
  C
• 5:35
  D,
• 5:35
  it's
• 5:36
  very
• 5:36
  common
• 5:37
  that
• 5:38
  people
• 5:38
  will
• 5:38
  say
• 5:39
  they
• 5:39
  have
• 5:39
  thoughts
• 5:40
  that
• 5:40
  maybe
• 5:41
  don't
• 5:41
  resonate
• 5:42
  with
• 5:42
  other
• 5:42
  people
• 5:43
  and
• 5:44
  those
• 5:44
  thoughts
• 5:44
  can
• 5:44
  get
• 5:45
  really
• 5:45
  creative
• 5:45
  and
• 5:46
  they
• 5:46
  can
• 5:46
  seem
• 5:46
  really
• 5:46
  random.
• 5:47
  But
• 5:47
  we
• 5:48
  all
• 5:48
  think
• 5:48
  random
• 5:49
  thoughts
• 5:49
  throughout
• 5:49
  the
• 5:50
  day
• 5:50
  that
• 5:50
  might
• 5:50
  feel
• 5:51
  uncomfortable
• 5:52
  if
• 5:52
  we
• 5:52
  shared
• 5:52
  them
• 5:53
  with
• 5:53
  others.
• 5:53
  And
• 5:53
  this
• 5:54
  is
• 5:54
  even
• 5:54
  more
• 5:54
  common
• 5:55
  in
• 5:55
  ocd,
• 5:56
  right?
• 5:56
  So
• 5:56
  you're
• 5:56
  normalizing
• 5:57
  this,
• 5:57
  and
• 5:57
  by
• 5:58
  normalizing
• 5:58
  it,
• 5:59
  you
• 5:59
  make
• 6:00
  the
• 6:00
  patient
• 6:00
  a
• 6:00
  little
• 6:00
  more
• 6:01
  comfortable
• 6:01
  in
• 6:02
  coming
• 6:02
  forward
• 6:03
  and
• 6:03
  being
• 6:03
  open
• 6:03
  and
• 6:04
  forthright
• 6:04
  about
• 6:04
  their
• 6:04
  symptoms.
• 6:05
  The
• 6:06
  therapeutic
• 6:06
  rapport
• 6:07
  that
• 6:07
  you
• 6:07
  have
• 6:07
  with
• 6:07
  your
• 6:08
  patient,
• 6:08
  right?
• 6:08
  You
• 6:08
  always
• 6:08
  hear
• 6:09
  how
• 6:09
  important
• 6:09
  that
• 6:09
  is.
• 6:10
  So
• 6:10
  often
• 6:10
  it
• 6:11
  becomes
• 6:11
  cliche
• 6:12
  and
• 6:12
  we
• 6:12
  start
• 6:13
  to
• 6:13
  lose
• 6:13
  sight
• 6:14
  of
• 6:14
  why
• 6:14
  it's
• 6:14
  so
• 6:14
  important.
• 6:15
  This
• 6:15
  is
• 6:15
  a
• 6:16
  rank
• 6:16
  and
• 6:16
  file
• 6:17
  reason
• 6:18
  why
• 6:18
  it's
• 6:18
  so
• 6:18
  important,
• 6:19
  right?
• 6:19
  It's
• 6:20
  important
• 6:20
  because
• 6:21
  in
• 6:21
  order
• 6:21
  to
• 6:21
  get
• 6:22
  the
• 6:22
  maximum
• 6:22
  amount
• 6:23
  of
• 6:23
  good
• 6:24
  faith
• 6:24
  information
• 6:24
  out
• 6:25
  of
• 6:25
  your
• 6:25
  patient,
• 6:25
  they
• 6:25
  have
• 6:26
  to
• 6:26
  be
• 6:26
  comfortable
• 6:26
  with
• 6:27
  you.
• 6:27
  They
• 6:27
  also
• 6:27
  have
• 6:28
  to
• 6:28
  feel
• 6:28
  comfortable
• 6:29
  being
• 6:29
  themselves
• 6:30
  around
• 6:30
  you
• 6:31
  and
• 6:31
  sharing
• 6:31
  what
• 6:32
  they're
• 6:32
  going
• 6:32
  through
• 6:33
  with
• 6:33
  you.
• 6:33
  And
• 6:34
  sometimes
• 6:34
  that's
• 6:35
  made
• 6:35
  a
• 6:35
  lot
• 6:35
  easier
• 6:36
  when
• 6:36
  you
• 6:36
  just
• 6:36
  normalize
• 6:38
  the
• 6:38
  way
• 6:38
  you
• 6:38
  talk
• 6:38
  about
• 6:39
  this
• 6:39
  stuff.
• 6:39
  You
• 6:39
  have
• 6:40
  a
• 6:40
  non
• 6:40
  judgmental
• 6:41
  tone,
• 6:41
  you
• 6:41
  have
• 6:41
  a
• 6:41
  compassionate
• 6:42
  tone.
• 6:43
  That's
• 6:43
  what
• 6:43
  you
• 6:43
  want
• 6:44
  to
• 6:44
  practice.
• 6:45
  If
• 6:45
  you're
• 6:45
  kind
• 6:45
  of
• 6:46
  cold
• 6:46
  and
• 6:46
  rough
• 6:46
  around
• 6:47
  the
• 6:47
  edges
• 6:47
  and
• 6:48
  you
• 6:48
  lack
• 6:48
  compassion
• 6:49
  and
• 6:49
  you're
• 6:49
  only
• 6:49
  in
• 6:49
  this
• 6:50
  field
• 6:50
  because
• 6:50
  it
• 6:50
  pays
• 6:51
  well,
• 6:51
  you're
• 6:52
  not
• 6:52
  going
• 6:52
  to
• 6:52
  do
• 6:52
  very
• 6:52
  well
• 6:53
  because
• 6:54
  patients
• 6:54
  detect
• 6:55
  that
• 6:55
  they're
• 6:55
  not
• 6:55
  going
• 6:56
  to
• 6:56
  give
• 6:56
  you
• 6:56
  the
• 6:56
  information
• 6:56
  you
• 6:57
  need
• 6:57
  all
• 6:57
  the
• 6:57
  time
• 6:57
  to
• 6:57
  make
• 6:58
  a
• 6:58
  good
• 6:58
  diagnosis.
• 6:59
  And
• 6:59
  if
• 6:59
  you
• 6:59
  don't
• 6:59
  make
• 6:59
  a
• 7:00
  good
• 7:00
  diagnosis,
• 7:00
  you're
• 7:01
  not
• 7:01
  going
• 7:01
  to
• 7:01
  be
• 7:01
  good
• 7:01
  at
• 7:02
  treating
• 7:02
  them
• 7:02
  and
• 7:02
  they're
• 7:02
  going
• 7:02
  to
• 7:03
  go
• 7:03
  see
• 7:03
  somebody
• 7:03
  else.
• 7:04
  It's
• 7:04
  really
• 7:04
  that
• 7:04
  clear
• 7:04
  and
• 7:05
  that
• 7:05
  that
• 7:05
  simple.
• 7:07
  Now
• 7:07
  Sarah's
• 7:08
  talking
• 7:08
  to
• 7:08
  you
• 7:08
  about
• 7:08
  this
• 7:08
  rabbit
• 7:09
  licking
• 7:09
  a
• 7:09
  lollipop
• 7:10
  in
• 7:10
  a
• 7:10
  wrestling
• 7:10
  ring.
• 7:11
  Now
• 7:11
  that
• 7:11
  is
• 7:11
  bizarre.
• 7:12
  And
• 7:12
  I
• 7:12
  don't
• 7:12
  want
• 7:13
  any
• 7:13
  of
• 7:13
  you
• 7:13
  to
• 7:13
  be
• 7:13
  so
• 7:14
  creeped
• 7:15
  out
• 7:15
  by
• 7:15
  that
• 7:15
  and
• 7:16
  put
• 7:16
  off
• 7:17
  by
• 7:17
  that
• 7:17
  where
• 7:17
  you
• 7:17
  start
• 7:18
  calling
• 7:19
  the
• 7:19
  emergency
• 7:19
  room
• 7:20
  and
• 7:20
  trying
• 7:20
  to
• 7:20
  get
• 7:21
  Sarah
• 7:21
  into
• 7:21
  a
• 7:21
  5150.
• 7:22
  Please
• 7:22
  don't
• 7:23
  do
• 7:23
  that.
• 7:23
  Sit
• 7:23
  there
• 7:24
  patiently
• 7:25
  and
• 7:25
  ask
• 7:25
  some
• 7:25
  follow
• 7:26
  up
• 7:26
  questions,
• 7:26
  right?
• 7:27
  Because
• 7:27
  that
• 7:28
  might
• 7:28
  be
• 7:28
  something
• 7:28
  that
• 7:29
  would
• 7:30
  be
• 7:30
  experienced
• 7:31
  or
• 7:32
  thought
• 7:32
  about
• 7:32
  in
• 7:32
  a
• 7:32
  thought
• 7:33
  disorder.
• 7:33
  Right.
• 7:34
  Keep
• 7:34
  the
• 7:34
  thought
• 7:34
  disorder
• 7:35
  suspect
• 7:35
  at
• 7:35
  the
• 7:36
  police
• 7:36
  station.
• 7:36
  Don't
• 7:38
  let
• 7:38
  thought
• 7:38
  disorder
• 7:39
  get
• 7:39
  out
• 7:39
  of
• 7:39
  your
• 7:39
  differential
• 7:40
  diagnosis
• 7:41
  right
• 7:41
  away.
• 7:41
  So
• 7:41
  I
• 7:41
  would
• 7:41
  say,
• 7:42
  Sarah,
• 7:42
  tell
• 7:42
  me
• 7:43
  a
• 7:43
  little
• 7:43
  bit
• 7:43
  more
• 7:43
  about
• 7:43
  this
• 7:44
  bunny
• 7:44
  rabbit
• 7:44
  in
• 7:45
  the
• 7:45
  wrestling
• 7:45
  ring
• 7:46
  licking
• 7:46
  a
• 7:46
  lollipop.
• 7:47
  Do
• 7:47
  you
• 7:47
  ever
• 7:47
  see
• 7:47
  this
• 7:47
  bunny
• 7:48
  rabbit?
• 7:48
  Does
• 7:48
  this
• 7:49
  bunny
• 7:49
  rabbit
• 7:49
  ever
• 7:49
  talk
• 7:50
  to
• 7:50
  you?
• 7:50
  Oh,
• 7:51
  no,
• 7:51
  no,
• 7:51
  no,
• 7:51
  never.
• 7:52
  Never?
• 7:52
  No,
• 7:52
  no,
• 7:52
  not
• 7:53
  like
• 7:53
  that.
• 7:53
  No.
• 7:53
  I'm
• 7:53
  not
• 7:53
  crazy.
• 7:54
  Right.
• 7:54
  And
• 7:54
  that's
• 7:55
  how
• 7:55
  patients
• 7:55
  will
• 7:55
  actually
• 7:56
  respond
• 7:56
  to
• 7:56
  you
• 7:56
  in
• 7:57
  clinic.
• 7:57
  When
• 7:57
  they
• 7:57
  feel
• 7:58
  this
• 7:58
  is
• 7:58
  just
• 7:58
  a
• 7:58
  bizarre
• 7:59
  thought
• 7:59
  and
• 7:59
  there's
• 7:59
  no
• 8:00
  otherwise
• 8:01
  psychotic
• 8:01
  tinge
• 8:02
  to
• 8:02
  it,
• 8:03
  they
• 8:03
  usually
• 8:03
  are
• 8:03
  the
• 8:03
  ones
• 8:04
  who
• 8:04
  are
• 8:04
  clear.
• 8:04
  Oh,
• 8:04
  no,
• 8:04
  no,
• 8:04
  no.
• 8:05
  God,
• 8:05
  no.
• 8:05
  I
• 8:05
  don't
• 8:05
  hear
• 8:05
  this
• 8:06
  rabbit.
• 8:06
  I
• 8:06
  don't
• 8:06
  see
• 8:06
  this
• 8:06
  rabbit.
• 8:07
  It's
• 8:07
  just
• 8:07
  a
• 8:08
  thought.
• 8:08
  It's
• 8:08
  just
• 8:08
  a
• 8:08
  bizarre
• 8:09
  thought.
• 8:09
  I've
• 8:10
  been
• 8:10
  having
• 8:10
  these
• 8:10
  for
• 8:11
  a
• 8:11
  lot
• 8:11
  of
• 8:11
  my
• 8:11
  life.
• 8:12
  The
• 8:12
  OCD
• 8:12
  onset
• 8:13
  is
• 8:13
  around
• 8:13
  19
• 8:13
  or
• 8:14
  20
• 8:14
  years
• 8:14
  old
• 8:14
  in
• 8:14
  most
• 8:15
  folks.
• 8:15
  And
• 8:16
  so
• 8:16
  patients
• 8:17
  are
• 8:17
  your
• 8:17
  best
• 8:17
  teachers,
• 8:17
  right?
• 8:18
  They're
• 8:18
  often
• 8:18
  going
• 8:18
  to
• 8:18
  tell
• 8:19
  you.
• 8:19
  At
• 8:19
  any
• 8:19
  rate,
• 8:20
  you
• 8:20
  have
• 8:20
  to
• 8:20
  ask
• 8:20
  and
• 8:20
  you
• 8:21
  have
• 8:21
  to
• 8:21
  say,
• 8:21
  is
• 8:21
  this
• 8:21
  bunny
• 8:22
  rabbit
• 8:23
  interfering
• 8:23
  with
• 8:23
  your
• 8:24
  thoughts?
• 8:24
  Is
• 8:24
  this
• 8:24
  bunny
• 8:25
  rabbit
• 8:25
  trying
• 8:26
  to
• 8:26
  communicate
• 8:26
  with
• 8:26
  you?
• 8:27
  Do
• 8:27
  you
• 8:27
  feel
• 8:27
  like
• 8:28
  by
• 8:29
  imagining
• 8:29
  this
• 8:29
  bunny
• 8:30
  rabbit,
• 8:31
  something
• 8:31
  bad
• 8:32
  might
• 8:32
  happen
• 8:32
  to
• 8:32
  you?
• 8:33
  This
• 8:33
  is
• 8:33
  where
• 8:33
  OCD
• 8:34
  gets
• 8:34
  really
• 8:34
  complicated
• 8:35
  at
• 8:35
  times,
• 8:35
  because
• 8:37
  with
• 8:37
  ocd,
• 8:38
  you
• 8:38
  have
• 8:38
  this
• 8:38
  bizarre
• 8:39
  thought
• 8:39
  and
• 8:39
  you
• 8:39
  feel
• 8:40
  like
• 8:40
  you
• 8:40
  have
• 8:40
  to
• 8:40
  neutralize
• 8:41
  it
• 8:41
  or
• 8:41
  something
• 8:42
  bad
• 8:42
  might
• 8:42
  happen.
• 8:43
  It
• 8:43
  can
• 8:43
  very
• 8:44
  well
• 8:44
  look
• 8:44
  like
• 8:45
  psychosis.
• 8:46
  When
• 8:46
  patients
• 8:46
  behave
• 8:47
  that
• 8:47
  way
• 8:47
  or
• 8:47
  when
• 8:47
  they
• 8:48
  think
• 8:48
  that
• 8:48
  way.
• 8:48
  It
• 8:48
  can
• 8:48
  look
• 8:49
  like
• 8:49
  psychosis,
• 8:50
  but
• 8:50
  it
• 8:50
  doesn't
• 8:50
  mean
• 8:50
  it
• 8:51
  is
• 8:51
  psychosis.
• 8:52
  If
• 8:52
  the
• 8:52
  patient
• 8:52
  has
• 8:53
  insight
• 8:54
  into
• 8:54
  the
• 8:54
  fact
• 8:54
  that
• 8:54
  this
• 8:55
  is
• 8:55
  bizarre.
• 8:56
  Right.
• 8:56
  If
• 8:56
  the
• 8:56
  patient
• 8:57
  is
• 8:57
  denying
• 8:57
  hallucinations,
• 8:58
  visual
• 8:59
  or
• 8:59
  auditory
• 8:59
  hallucinations,
• 9:00
  and
• 9:00
  is
• 9:00
  otherwise
• 9:01
  organized,
• 9:02
  there
• 9:02
  are
• 9:02
  no
• 9:03
  derailments
• 9:04
  in
• 9:04
  their
• 9:05
  thought
• 9:05
  process.
• 9:05
  In
• 9:05
  other
• 9:06
  words,
• 9:06
  they're
• 9:06
  talking
• 9:06
  to
• 9:07
  you
• 9:07
  logically
• 9:08
  and
• 9:08
  linearly
• 9:09
  with
• 9:09
  insight
• 9:09
  that
• 9:10
  this
• 9:10
  is
• 9:10
  kind
• 9:10
  of
• 9:10
  bizarre
• 9:11
  and
• 9:11
  unusual.
• 9:11
  You
• 9:12
  know,
• 9:12
  with
• 9:12
  a
• 9:12
  little
• 9:12
  time,
• 9:13
  you'll
• 9:13
  slowly
• 9:13
  understand
• 9:14
  this
• 9:14
  is
• 9:14
  not
• 9:14
  psychosis,
• 9:15
  but
• 9:15
  you
• 9:15
  definitely
• 9:16
  want
• 9:16
  to
• 9:16
  get
• 9:16
  a
• 9:17
  feel
• 9:17
  for
• 9:17
  that.
• 9:17
  And
• 9:18
  that's
• 9:18
  another
• 9:18
  reason
• 9:18
  you
• 9:18
  need
• 9:19
  a
• 9:19
  really
• 9:19
  good
• 9:19
  mental
• 9:19
  status
• 9:20
  exam.
• 9:20
  And
• 9:20
  the
• 9:20
  mental
• 9:21
  status
• 9:21
  status
• 9:21
  exam,
• 9:22
  you
• 9:22
  get
• 9:22
  clues
• 9:23
  to
• 9:23
  help
• 9:24
  confirm
• 9:24
  whether
• 9:24
  or
• 9:24
  not
• 9:25
  this
• 9:25
  patient
• 9:25
  is
• 9:25
  psychotic.
• 9:26
  With
• 9:26
  disorganized
• 9:27
  psychotic
• 9:28
  patients,
• 9:28
  you'll
• 9:29
  often
• 9:29
  see
• 9:29
  they're
• 9:29
  very
• 9:30
  disheveled.
• 9:31
  Sometimes
• 9:31
  they're
• 9:31
  catatonic,
• 9:32
  staring
• 9:33
  off
• 9:33
  into
• 9:33
  space.
• 9:34
  Their
• 9:34
  words
• 9:35
  are
• 9:35
  not
• 9:35
  connected
• 9:36
  logically.
• 9:36
  They
• 9:37
  go
• 9:37
  off
• 9:37
  on
• 9:37
  tangents.
• 9:38
  So
• 9:38
  there's
• 9:39
  a
• 9:39
  lot
• 9:39
  of
• 9:40
  clues.
• 9:40
  It's
• 9:40
  not
• 9:40
  just
• 9:41
  what
• 9:41
  your
• 9:41
  patient
• 9:41
  says.
• 9:42
  You're
• 9:42
  also
• 9:42
  using
• 9:42
  your
• 9:42
  eyes
• 9:43
  as
• 9:43
  well
• 9:43
  as
• 9:43
  your
• 9:43
  ears.
• 9:44
  It's
• 9:44
  a
• 9:44
  Mental
• 9:45
  status
• 9:45
  exam.
• 9:45
  It's
• 9:46
  such
• 9:46
  a
• 9:46
  great
• 9:46
  diagnostic
• 9:48
  instrument
• 9:48
  for
• 9:49
  you
• 9:49
  to
• 9:50
  put
• 9:50
  this
• 9:50
  all
• 9:51
  together.
• 9:51
  Definitely
• 9:52
  lean
• 9:52
  on
• 9:52
  that
• 9:52
  as
• 9:53
  part
• 9:53
  of
• 9:53
  your
• 9:54
  differential,
• 9:55
  sort
• 9:55
  of
• 9:55
  understand
• 9:56
  what
• 9:56
  differentials
• 9:57
  to
• 9:58
  hold
• 9:58
  dear
• 9:58
  to
• 9:58
  your
• 9:59
  heart.
• 9:59
  Use
• 9:59
  your
• 9:59
  mental
• 10:00
  status
• 10:00
  exam
• 10:01
  now.
• 10:01
  The
• 10:01
  patient,
• 10:02
  because
• 10:03
  they're
• 10:03
  telling
• 10:03
  you
• 10:03
  this
• 10:04
  is
• 10:04
  so
• 10:04
  exhausting
• 10:04
  and
• 10:05
  it's
• 10:05
  taking
• 10:05
  up
• 10:05
  a
• 10:05
  lot
• 10:05
  of
• 10:06
  time.
• 10:06
  You
• 10:06
  want
• 10:06
  to
• 10:06
  quantify
• 10:07
  that.
• 10:07
  That's
• 10:07
  one
• 10:07
  of
• 10:07
  the
• 10:07
  important
• 10:08
  things.
• 10:08
  How
• 10:09
  much
• 10:09
  time
• 10:09
  do
• 10:09
  you
• 10:09
  spend
• 10:10
  thinking
• 10:10
  about
• 10:10
  this
• 10:10
  bunny
• 10:11
  rabbit
• 10:11
  licking
• 10:12
  a
• 10:12
  lollipop
• 10:12
  in
• 10:12
  a
• 10:12
  wrestling
• 10:13
  ring?
• 10:13
  How
• 10:14
  much
• 10:14
  time
• 10:14
  do
• 10:14
  you
• 10:14
  spend
• 10:15
  washing
• 10:15
  your
• 10:15
  hands
• 10:16
  every
• 10:16
  day?
• 10:16
  How
• 10:16
  much
• 10:16
  time
• 10:17
  do
• 10:17
  you
• 10:17
  spend
• 10:17
  trying
• 10:18
  to
• 10:18
  avoid
• 10:18
  germs?
• 10:19
  That
• 10:20
  might
• 10:20
  be
• 10:20
  an
• 10:20
  even
• 10:20
  better
• 10:21
  question.
• 10:21
  Rather
• 10:21
  than
• 10:22
  washing
• 10:22
  your
• 10:22
  hands,
• 10:23
  because
• 10:23
  I
• 10:23
  wash
• 10:23
  my
• 10:23
  hands
• 10:24
  for
• 10:24
  25
• 10:24
  minutes.
• 10:25
  How
• 10:25
  much
• 10:25
  time
• 10:25
  do
• 10:25
  you
• 10:26
  spend
• 10:26
  trying
• 10:27
  to
• 10:27
  shower?
• 10:27
  Another
• 10:28
  hour
• 10:28
  and
• 10:28
  20
• 10:28
  minutes.
• 10:29
  Don't
• 10:29
  sit
• 10:29
  there.
• 10:29
  This
• 10:30
  is
• 10:30
  an
• 10:30
  algebra
• 10:30
  class,
• 10:31
  okay?
• 10:32
  Don't
• 10:32
  just
• 10:32
  sit
• 10:32
  there
• 10:33
  tallying
• 10:33
  up
• 10:33
  all
• 10:33
  the
• 10:34
  time
• 10:34
  like
• 10:34
  a
• 10:34
  brand
• 10:35
  new
• 10:35
  grad
• 10:36
  fresh
• 10:36
  off
• 10:37
  the
• 10:37
  school
• 10:38
  bus.
• 10:38
  Ask
• 10:38
  an
• 10:39
  umbrella
• 10:39
  question.
• 10:39
  How
• 10:40
  much
• 10:40
  extra
• 10:40
  time
• 10:41
  in
• 10:41
  your
• 10:41
  day
• 10:42
  do
• 10:42
  you
• 10:42
  spend
• 10:42
  avoiding
• 10:43
  germs
• 10:44
  or
• 10:44
  contamination?
• 10:45
  That,
• 10:45
  friends,
• 10:46
  is
• 10:46
  a
• 10:46
  high
• 10:46
  yield
• 10:47
  question.
• 10:47
  And
• 10:48
  if
• 10:48
  they
• 10:48
  say
• 10:48
  2
• 10:48
  hours,
• 10:49
  3
• 10:49
  hours,
• 10:49
  5
• 10:50
  hours,
• 10:50
  you
• 10:50
  have
• 10:51
  exceeded
• 10:51
  the
• 10:52
  DSM
• 10:52
  5tr
• 10:53
  threshold
• 10:54
  of
• 10:54
  1
• 10:54
  hour,
• 10:55
  you
• 10:55
  still
• 10:55
  haven't
• 10:55
  diagnosed
• 10:56
  OCD.
• 10:56
  You've
• 10:57
  got
• 10:57
  to
• 10:57
  work
• 10:57
  at
• 10:57
  that.
• 10:58
  But
• 10:58
  you're
• 10:58
  definitely
• 10:59
  saying,
• 10:59
  okay,
• 11:00
  this
• 11:00
  suspect
• 11:00
  spending
• 11:01
  a
• 11:01
  lot
• 11:01
  more
• 11:01
  time
• 11:02
  in
• 11:02
  the
• 11:02
  slammer
• 11:03
  because
• 11:03
  we're
• 11:03
  not
• 11:04
  willing
• 11:04
  to
• 11:04
  let
• 11:04
  this
• 11:04
  suspect
• 11:05
  go.
• 11:05
  OCD
• 11:06
  looks
• 11:06
  like
• 11:06
  a
• 11:06
  good
• 11:07
  differential.
• 11:07
  Now,
• 11:08
  I
• 11:09
  would
• 11:09
  also
• 11:09
  caution
• 11:10
  you,
• 11:10
  don't
• 11:11
  just
• 11:11
  assume
• 11:11
  this
• 11:12
  patient
• 11:12
  is
• 11:12
  only
• 11:12
  here
• 11:13
  for
• 11:13
  ocd,
• 11:14
  right?
• 11:14
  OCD
• 11:15
  is
• 11:15
  highly
• 11:15
  comorbid,
• 11:16
  particularly
• 11:16
  with
• 11:17
  depression.
• 11:18
  So
• 11:18
  you're
• 11:18
  not
• 11:18
  done.
• 11:19
  When
• 11:19
  you
• 11:19
  start
• 11:19
  asking
• 11:20
  about
• 11:20
  obsessions
• 11:21
  and
• 11:21
  compulsions,
• 11:22
  you've
• 11:22
  got
• 11:22
  to
• 11:23
  go
• 11:23
  on
• 11:23
  to
• 11:24
  where's
• 11:24
  the
• 11:24
  collateral
• 11:25
  damage
• 11:25
  here,
• 11:26
  Right?
• 11:26
  How
• 11:26
  is
• 11:26
  this
• 11:27
  affecting
• 11:27
  your
• 11:27
  mood?
• 11:27
  Lord
• 11:28
  knows.
• 11:28
  Your
• 11:28
  substance
• 11:29
  use.
• 11:29
  Do
• 11:29
  you
• 11:29
  feel
• 11:30
  compelled
• 11:31
  to
• 11:31
  use
• 11:32
  alcohol
• 11:32
  or
• 11:32
  cannabis?
• 11:33
  It
• 11:33
  must
• 11:33
  be
• 11:33
  exhausting
• 11:34
  having
• 11:34
  these
• 11:35
  thoughts
• 11:35
  all
• 11:35
  day.
• 11:35
  How
• 11:36
  do
• 11:36
  you
• 11:36
  cope
• 11:36
  with
• 11:36
  all
• 11:36
  of
• 11:36
  these
• 11:37
  thoughts
• 11:37
  and
• 11:37
  rituals?
• 11:38
  That's
• 11:38
  a
• 11:38
  very
• 11:39
  good
• 11:39
  question.
• 11:39
  Some
• 11:40
  people
• 11:40
  might
• 11:40
  say,
• 11:40
  I
• 11:41
  cope
• 11:41
  with
• 11:41
  yoga.
• 11:42
  I
• 11:42
  drink
• 11:43
  green
• 11:43
  tea,
• 11:43
  matcha,
• 11:44
  whatever.
• 11:45
  Matcha
• 11:45
  powder
• 11:45
  is
• 11:46
  green
• 11:46
  tea
• 11:46
  or
• 11:46
  something,
• 11:47
  okay?
• 11:48
  I
• 11:48
  do
• 11:48
  taekwondo
• 11:49
  or
• 11:50
  I
• 11:50
  drink
• 11:50
  tons
• 11:51
  of
• 11:51
  alcohol.
• 11:51
  That's
• 11:51
  how
• 11:52
  I
• 11:52
  cope
• 11:52
  with
• 11:52
  these
• 11:52
  intrusive
• 11:53
  thoughts.
• 11:53
  I
• 11:54
  smoke
• 11:54
  a
• 11:54
  ton
• 11:54
  of
• 11:54
  cannabis.
• 11:55
  So
• 11:56
  how
• 11:56
  do
• 11:56
  you
• 11:56
  cope
• 11:57
  with
• 11:57
  this
• 11:57
  is
• 11:58
  a
• 11:58
  very
• 11:58
  good
• 11:58
  question.
• 11:59
  But
• 11:59
  I'm
• 12:00
  jumping
• 12:00
  ahead
• 12:00
  of
• 12:00
  myself
• 12:01
  a
• 12:01
  little
• 12:01
  bit
• 12:01
  and
• 12:02
  I'm
• 12:02
  breaking
• 12:02
  my
• 12:02
  own
• 12:03
  rules.
• 12:03
  Because
• 12:03
  what
• 12:03
  I
• 12:03
  always
• 12:04
  tell
• 12:05
  our
• 12:05
  students
• 12:05
  here
• 12:06
  is
• 12:07
  you
• 12:07
  have
• 12:07
  to
• 12:07
  squeeze
• 12:07
  the
• 12:08
  orange.
• 12:08
  I
• 12:08
  can't
• 12:09
  emphasize
• 12:09
  it
• 12:09
  enough.
• 12:09
  I'M
• 12:10
  going
• 12:10
  to
• 12:10
  say
• 12:10
  it
• 12:10
  again.
• 12:11
  Squeeze
• 12:12
  the
• 12:13
  orange,
• 12:14
  okay?
• 12:15
  And
• 12:15
  don't
• 12:16
  you
• 12:16
  go
• 12:16
  on
• 12:16
  to
• 12:16
  the
• 12:17
  next
• 12:17
  orange
• 12:17
  until
• 12:17
  all
• 12:18
  the
• 12:18
  juice
• 12:18
  is
• 12:19
  squeezed
• 12:19
  in
• 12:19
  one
• 12:20
  particular
• 12:20
  orange,
• 12:21
  okay?
• 12:22
  I
• 12:22
  want
• 12:22
  you
• 12:22
  to
• 12:22
  really
• 12:23
  think
• 12:23
  of
• 12:23
  that
• 12:23
  image
• 12:23
  in
• 12:24
  your
• 12:24
  brain.
• 12:24
  Not
• 12:24
  obsessively.
• 12:25
  I
• 12:25
  don't
• 12:25
  want
• 12:26
  you
• 12:26
  to
• 12:26
  think
• 12:26
  about
• 12:26
  it
• 12:26
  as
• 12:26
  you
• 12:27
  sleep.
• 12:27
  I
• 12:27
  want
• 12:28
  you
• 12:28
  to
• 12:28
  think
• 12:29
  of
• 12:29
  this
• 12:29
  concept,
• 12:29
  squeeze
• 12:30
  the
• 12:30
  orange.
• 12:30
  Because
• 12:30
  your
• 12:31
  patient
• 12:31
  is
• 12:32
  going
• 12:32
  to
• 12:32
  come
• 12:32
  to
• 12:32
  you
• 12:33
  with
• 12:33
  really
• 12:34
  important
• 12:34
  the
• 12:35
  material,
• 12:35
  like
• 12:35
  this
• 12:36
  rabbit
• 12:36
  licking
• 12:37
  the
• 12:37
  lollipop
• 12:38
  in
• 12:38
  the
• 12:38
  wrestling
• 12:39
  ring.
• 12:39
  And
• 12:40
  before
• 12:40
  you
• 12:40
  move
• 12:40
  on,
• 12:40
  you've
• 12:41
  got
• 12:41
  to
• 12:41
  ask
• 12:41
  all
• 12:42
  the
• 12:42
  questions
• 12:43
  possible,
• 12:44
  okay?
• 12:44
  That's
• 12:45
  very
• 12:45
  important,
• 12:45
  because
• 12:46
  with
• 12:46
  ocd,
• 12:47
  it's
• 12:47
  not
• 12:47
  always
• 12:47
  bizarre
• 12:48
  thoughts.
• 12:49
  It
• 12:49
  can
• 12:49
  also
• 12:49
  be
• 12:50
  violent,
• 12:50
  intrusive
• 12:51
  thoughts,
• 12:51
  right?
• 12:52
  I
• 12:52
  have
• 12:52
  this
• 12:52
  image
• 12:53
  of
• 12:53
  beating
• 12:53
  up
• 12:54
  my
• 12:54
  grandmother
• 12:54
  every
• 12:54
  day.
• 12:55
  It's
• 12:55
  driving
• 12:55
  me
• 12:55
  crazy.
• 12:56
  Well,
• 12:56
  that's
• 12:57
  a
• 12:57
  good
• 12:57
  sign
• 12:57
  that
• 12:58
  the
• 12:58
  patient
• 12:58
  said
• 12:58
  it's
• 12:59
  driving
• 12:59
  them
• 12:59
  crazy,
• 13:00
  because
• 13:00
  odds
• 13:00
  are
• 13:01
  they
• 13:01
  probably
• 13:01
  don't
• 13:01
  want
• 13:02
  to
• 13:02
  actually
• 13:02
  beat
• 13:02
  up
• 13:03
  their
• 13:03
  grandmother.
• 13:04
  And
• 13:04
  you
• 13:05
  don't
• 13:05
  have
• 13:05
  to
• 13:05
  call
• 13:05
  their
• 13:06
  grandmother
• 13:06
  and
• 13:06
  warn
• 13:06
  them,
• 13:07
  but
• 13:07
  you
• 13:07
  definitely
• 13:08
  want
• 13:08
  to
• 13:08
  make
• 13:08
  sure
• 13:09
  that
• 13:09
  you
• 13:09
  are
• 13:09
  assessing
• 13:10
  whether
• 13:10
  intrusive
• 13:11
  thoughts
• 13:11
  involving
• 13:12
  violence
• 13:13
  have
• 13:13
  any
• 13:13
  intent
• 13:14
  attached
• 13:15
  to
• 13:15
  them.
• 13:16
  It's
• 13:16
  very
• 13:16
  important
• 13:16
  you
• 13:17
  do
• 13:17
  that.
• 13:17
  Right?
• 13:18
  Don't
• 13:18
  let
• 13:18
  that
• 13:18
  off
• 13:18
  your
• 13:19
  hook.
• 13:19
  Because
• 13:20
  a
• 13:20
  lot
• 13:20
  of
• 13:21
  obsessions
• 13:22
  are
• 13:22
  violent
• 13:22
  in
• 13:22
  nature,
• 13:23
  and
• 13:23
  patients
• 13:23
  have
• 13:23
  no
• 13:24
  interest
• 13:24
  whatsoever
• 13:25
  in
• 13:25
  acting
• 13:25
  on
• 13:25
  them
• 13:25
  and
• 13:26
  in
• 13:26
  fact,
• 13:26
  are
• 13:26
  horrified
• 13:27
  by
• 13:27
  the
• 13:27
  idea
• 13:28
  of
• 13:28
  acting
• 13:28
  on
• 13:29
  any
• 13:29
  kind
• 13:29
  of
• 13:29
  violent
• 13:30
  thoughts.
• 13:30
  Right?
• 13:30
  But
• 13:30
  it's
• 13:31
  just
• 13:31
  one
• 13:31
  of
• 13:31
  the
• 13:31
  subtypes
• 13:32
  of
• 13:33
  ocd,
• 13:34
  right,
• 13:34
  where
• 13:35
  you
• 13:35
  have
• 13:35
  contamination
• 13:36
  and
• 13:36
  cleaning
• 13:37
  fears,
• 13:38
  responsibility,
• 13:39
  checking,
• 13:39
  where
• 13:39
  you
• 13:39
  check
• 13:40
  locks
• 13:40
  or
• 13:41
  repeated
• 13:41
  checking
• 13:42
  behaviors,
• 13:43
  you
• 13:43
  have
• 13:43
  forbidden
• 13:44
  thoughts,
• 13:44
  whether
• 13:45
  they
• 13:45
  be
• 13:45
  violent,
• 13:45
  aggressive,
• 13:46
  or
• 13:46
  sexual
• 13:46
  in
• 13:47
  nature.
• 13:48
  And
• 13:48
  you
• 13:48
  have
• 13:48
  symmetry,
• 13:49
  right?
• 13:49
  So
• 13:49
  there's
• 13:49
  many
• 13:50
  variations.
• 13:51
  They
• 13:51
  don't
• 13:51
  all
• 13:51
  come
• 13:52
  separately.
• 13:52
  Sometimes
• 13:53
  they're
• 13:53
  mixed.
• 13:54
  So
• 13:54
  you
• 13:54
  really
• 13:54
  want
• 13:54
  to
• 13:55
  get
• 13:55
  an
• 13:55
  idea.
• 13:56
  You
• 13:56
  know,
• 13:56
  if
• 13:56
  you
• 13:57
  were
• 13:57
  Picasso
• 13:57
  and
• 13:58
  you
• 13:58
  were
• 13:58
  painting
• 13:58
  a
• 13:59
  picture,
• 13:59
  you
• 13:59
  really
• 14:00
  want
• 14:00
  the
• 14:00
  patient,
• 14:01
  you
• 14:01
  and
• 14:01
  the
• 14:01
  patient
• 14:02
  to
• 14:02
  collaborate
• 14:03
  and
• 14:03
  paint
• 14:03
  the
• 14:03
  most
• 14:04
  accurate
• 14:04
  picture
• 14:04
  you
• 14:05
  can
• 14:05
  of
• 14:05
  what
• 14:06
  they're
• 14:06
  coming
• 14:06
  to
• 14:06
  you
• 14:07
  with.
• 14:07
  Now,
• 14:07
  mind
• 14:08
  you
• 14:09
  don't
• 14:09
  spend
• 14:09
  the
• 14:09
  whole
• 14:10
  hour
• 14:10
  on
• 14:10
  this
• 14:10
  either,
• 14:11
  right?
• 14:11
  Because
• 14:12
  you
• 14:12
  are
• 14:13
  in
• 14:13
  the
• 14:13
  outpatient
• 14:14
  space.
• 14:14
  You
• 14:14
  have
• 14:14
  other
• 14:14
  questions
• 14:15
  to
• 14:15
  ask,
• 14:16
  and
• 14:16
  you
• 14:16
  don't
• 14:17
  want
• 14:17
  to
• 14:17
  spend
• 14:17
  every
• 14:17
  minute
• 14:18
  on
• 14:18
  every
• 14:19
  facet
• 14:19
  of
• 14:19
  their
• 14:20
  ocd.
• 14:20
  But
• 14:21
  you
• 14:21
  want
• 14:21
  to
• 14:21
  have
• 14:21
  a
• 14:21
  good
• 14:21
  enough
• 14:22
  idea
• 14:23
  as
• 14:23
  to
• 14:23
  what
• 14:24
  you're
• 14:24
  looking
• 14:24
  at.
• 14:24
  And
• 14:25
  what
• 14:25
  is
• 14:25
  the
• 14:25
  most
• 14:25
  single
• 14:26
  impairing
• 14:27
  issue
• 14:28
  that
• 14:29
  Sarah
• 14:29
  is
• 14:29
  bringing
• 14:30
  to
• 14:30
  you
• 14:30
  right
• 14:30
  now?
• 14:30
  Now,
• 14:31
  she
• 14:31
  mentioned
• 14:31
  to
• 14:31
  you
• 14:32
  she
• 14:32
  can't
• 14:33
  focus.
• 14:33
  And
• 14:33
  it's
• 14:34
  really
• 14:34
  important.
• 14:34
  I
• 14:34
  always
• 14:35
  love
• 14:35
  to
• 14:36
  ask
• 14:37
  a
• 14:37
  patient,
• 14:38
  walk
• 14:38
  me
• 14:39
  through
• 14:40
  what
• 14:40
  you
• 14:40
  believe
• 14:41
  is
• 14:41
  getting
• 14:41
  in
• 14:42
  the
• 14:42
  way
• 14:42
  of
• 14:42
  paying
• 14:43
  attention
• 14:43
  in
• 14:44
  school
• 14:45
  and
• 14:45
  you
• 14:46
  want
• 14:46
  them
• 14:46
  to
• 14:46
  flesh
• 14:46
  that
• 14:46
  out
• 14:47
  for
• 14:47
  you.
• 14:47
  And,
• 14:47
  and
• 14:48
  I'll
• 14:48
  give
• 14:48
  them
• 14:48
  examples
• 14:48
  to
• 14:49
  help
• 14:49
  them
• 14:49
  out.
• 14:49
  Sometimes
• 14:50
  I'll
• 14:50
  say,
• 14:50
  is
• 14:50
  it
• 14:50
  because
• 14:50
  you're
• 14:51
  really
• 14:51
  bored
• 14:51
  and
• 14:51
  the
• 14:51
  subject
• 14:52
  material
• 14:52
  is
• 14:52
  just
• 14:53
  not
• 14:53
  interesting
• 14:53
  and
• 14:53
  you
• 14:53
  find
• 14:54
  yourself
• 14:55
  moving
• 14:55
  on
• 14:55
  to
• 14:55
  other
• 14:56
  topics
• 14:56
  like
• 14:57
  surfing
• 14:58
  the
• 14:58
  web
• 14:58
  during
• 14:58
  the
• 14:58
  lecture?
• 14:59
  Is
• 14:59
  the
• 14:59
  problem
• 14:59
  that
• 15:00
  you're
• 15:00
  so
• 15:00
  nervous
• 15:00
  and
• 15:00
  on
• 15:01
  edge
• 15:01
  that
• 15:02
  you
• 15:02
  just
• 15:02
  can't
• 15:02
  really
• 15:03
  get
• 15:03
  through
• 15:03
  the
• 15:04
  lecture
• 15:04
  because
• 15:04
  you're
• 15:05
  worried
• 15:05
  about
• 15:05
  stuff
• 15:06
  that
• 15:06
  could
• 15:06
  go
• 15:06
  wrong
• 15:06
  in
• 15:07
  your
• 15:07
  home
• 15:07
  or
• 15:07
  personal
• 15:07
  life?
• 15:08
  Is
• 15:08
  the
• 15:09
  problem
• 15:09
  these
• 15:09
  obsessive
• 15:10
  thoughts
• 15:10
  you're
• 15:10
  talking
• 15:11
  about,
• 15:11
  right,
• 15:12
  where
• 15:12
  you're
• 15:13
  thinking
• 15:13
  of
• 15:13
  this
• 15:13
  bunny
• 15:13
  rabbit
• 15:14
  licking
• 15:14
  a
• 15:14
  lollipop
• 15:15
  in
• 15:15
  a
• 15:15
  wrestling
• 15:16
  ring?
• 15:16
  By
• 15:16
  the
• 15:17
  way,
• 15:17
  you
• 15:17
  should
• 15:17
  join
• 15:17
  my
• 15:17
  Patreon.
• 15:18
  I
• 15:18
  have
• 15:18
  a
• 15:18
  beautiful
• 15:19
  slide
• 15:19
  deck
• 15:20
  full
• 15:20
  of
• 15:20
  this
• 15:20
  information
• 15:21
  chalk
• 15:21
  with
• 15:22
  pearls
• 15:22
  and
• 15:23
  the
• 15:23
  image
• 15:23
  of
• 15:24
  a
• 15:24
  bunny
• 15:24
  licking
• 15:25
  a
• 15:25
  lollipop
• 15:26
  in
• 15:26
  a
• 15:26
  wrestling
• 15:26
  ring.
• 15:26
  You
• 15:27
  really
• 15:27
  should
• 15:27
  become
• 15:27
  a
• 15:28
  Patreon
• 15:28
  member
• 15:29
  just
• 15:29
  for
• 15:29
  that
• 15:29
  image.
• 15:30
  It's
• 15:30
  a
• 15:30
  beautiful
• 15:31
  slide
• 15:31
  deck
• 15:31
  full
• 15:31
  of
• 15:31
  Sarah's
• 15:32
  mock
• 15:33
  patient
• 15:33
  case
• 15:33
  with
• 15:34
  tons
• 15:34
  of
• 15:34
  pearls,
• 15:34
  evidence
• 15:35
  based
• 15:36
  screening
• 15:36
  tools
• 15:36
  and
• 15:37
  bonus
• 15:37
  material.
• 15:38
  Now,
• 15:38
  getting
• 15:39
  right
• 15:39
  back
• 15:39
  to
• 15:39
  Sarah.
• 15:40
  So
• 15:41
  you
• 15:41
  want
• 15:41
  to
• 15:41
  pinpoint
• 15:42
  the
• 15:43
  ground
• 15:43
  zero.
• 15:44
  What
• 15:44
  is
• 15:44
  the
• 15:45
  chief
• 15:46
  obstacle
• 15:47
  that
• 15:47
  competes
• 15:47
  with
• 15:48
  your
• 15:48
  attention?
• 15:48
  Sarah,
• 15:49
  you
• 15:50
  know,
• 15:50
  we've
• 15:50
  talked
• 15:50
  about
• 15:51
  your
• 15:51
  mood
• 15:51
  is
• 15:51
  down.
• 16:46
  We've
• 16:47
  talked
• 16:47
  about
• 16:47
  the
• 16:47
  fact
• 16:47
  that
• 16:48
  you're
• 16:48
  thinking
• 16:48
  of
• 16:48
  very
• 15:54
  bizarre
• 16:49
  thoughts
• 16:50
  and
• 16:50
  you're
• 16:50
  worried
• 16:50
  about
• 16:51
  germs.
• 16:52
  You
• 16:52
  know,
• 16:52
  what
• 16:52
  do
• 16:53
  you
• 16:53
  think
• 16:53
  of
• 16:53
  all
• 16:53
  the
• 16:53
  things
• 16:54
  we've
• 16:54
  talked
• 16:54
  about
• 16:54
  is
• 16:55
  the
• 16:55
  main
• 16:55
  reason
• 16:56
  you
• 16:56
  can't
• 16:57
  focus
• 16:57
  on
• 16:57
  medieval
• 16:58
  studies.
• 16:58
  You're
• 16:58
  falling
• 16:59
  behind.
• 17:00
  Now
• 17:00
  she
• 17:00
  might
• 17:00
  throw
• 17:00
  a
• 17:00
  curveball
• 17:01
  at
• 17:01
  you
• 17:01
  and
• 17:01
  give
• 17:02
  you
• 17:02
  an
• 17:02
  easy
• 17:02
  answer.
• 17:03
  She
• 17:03
  might
• 17:03
  say,
• 17:03
  well,
• 17:04
  you
• 17:04
  know,
• 17:04
  it's
• 17:04
  kind
• 17:04
  of
• 17:05
  because
• 17:05
  I
• 17:05
  actually
• 17:05
  have
• 17:06
  never
• 17:06
  been
• 17:06
  able
• 17:06
  to
• 17:06
  pay
• 17:06
  attention.
• 17:07
  And
• 17:07
  now
• 17:08
  you're
• 17:08
  going
• 17:08
  to
• 17:08
  yourself.
• 17:08
  You're
• 17:09
  going,
• 17:09
  oh,
• 17:09
  do
• 17:10
  I
• 17:10
  go
• 17:11
  down
• 17:11
  the
• 17:12
  ADHD
• 17:13
  rabbit
• 17:13
  hole
• 17:14
  or
• 17:14
  do
• 17:14
  I
• 17:14
  go
• 17:15
  down,
• 17:15
  down
• 17:15
  the
• 17:16
  O
• 17:16
  C
• 17:16
  D
• 17:17
  rabbit
• 17:17
  hole?
• 17:18
  The
• 17:18
  answer
• 17:18
  to
• 17:18
  that,
• 17:19
  in
• 17:19
  my
• 17:19
  view,
• 17:20
  is
• 17:20
  you've
• 17:21
  got
• 17:21
  to
• 17:21
  orient
• 17:21
  yourself
• 17:22
  to
• 17:22
  why
• 17:22
  Sarah
• 17:23
  came
• 17:23
  to
• 17:23
  your
• 17:23
  office
• 17:24
  to
• 17:24
  begin
• 17:24
  with,
• 17:24
  right?
• 17:25
  You
• 17:25
  may
• 17:26
  want
• 17:26
  to
• 17:26
  treat
• 17:26
  her
• 17:26
  adhd,
• 17:27
  you
• 17:27
  may
• 17:28
  want
• 17:28
  to
• 17:28
  treat
• 17:28
  her
• 17:29
  ocd,
• 17:30
  but
• 17:30
  at
• 17:30
  the
• 17:31
  end
• 17:31
  of
• 17:31
  the
• 17:31
  day,
• 17:32
  the
• 17:32
  patient
• 17:32
  is
• 17:32
  there
• 17:33
  for
• 17:33
  a
• 17:33
  specific
• 17:33
  reason
• 17:34
  and
• 17:34
  we
• 17:35
  have
• 17:35
  to
• 17:36
  honor
• 17:37
  her
• 17:37
  visit
• 17:37
  by
• 17:38
  making
• 17:38
  sure
• 17:39
  we
• 17:39
  are
• 17:39
  addressing
• 17:40
  the
• 17:40
  chief
• 17:41
  symptom,
• 17:42
  distress
• 17:42
  and
• 17:43
  impairment.
• 17:44
  Sometimes
• 17:45
  the
• 17:45
  patient
• 17:45
  doesn't
• 17:46
  have
• 17:46
  full
• 17:46
  insight
• 17:46
  into
• 17:46
  what
• 17:47
  that
• 17:47
  is
• 17:47
  or
• 17:47
  the
• 17:47
  interplay.
• 17:48
  And
• 17:49
  it's
• 17:49
  okay
• 17:49
  for
• 17:49
  us
• 17:50
  to
• 17:50
  guide
• 17:50
  that
• 17:51
  and
• 17:51
  figure
• 17:51
  that
• 17:52
  out.
• 17:52
  But
• 17:53
  don't
• 17:53
  just
• 17:53
  treat
• 17:54
  OCD
• 17:55
  if
• 17:55
  she's
• 17:55
  coming
• 17:56
  to
• 17:56
  you
• 17:56
  genuinely,
• 17:57
  because
• 17:57
  the
• 17:57
  ADHD
• 17:58
  is
• 17:58
  The
• 17:58
  worst
• 17:59
  thing.
• 17:59
  And
• 18:00
  lo
• 18:00
  and
• 18:00
  behold,
• 18:00
  you
• 18:00
  do
• 18:01
  a
• 18:01
  full
• 18:01
  ADHD
• 18:01
  workup,
• 18:02
  and
• 18:02
  this
• 18:02
  really
• 18:02
  has
• 18:03
  been
• 18:04
  catastrophic
• 18:05
  and
• 18:05
  destructive.
• 18:06
  And
• 18:06
  she
• 18:06
  also
• 18:07
  has
• 18:07
  ocd.
• 18:08
  This
• 18:08
  might
• 18:08
  sound
• 18:09
  confusing.
• 18:09
  And
• 18:09
  guess
• 18:10
  what?
• 18:10
  Welcome
• 18:10
  to
• 18:11
  psychiatry.
• 18:13
  It's
• 18:13
  not
• 18:13
  always
• 18:14
  simple.
• 18:14
  You
• 18:15
  don't
• 18:15
  always
• 18:15
  get
• 18:15
  this
• 18:16
  clean
• 18:16
  DSM
• 18:17
  5tr,
• 18:17
  OCD
• 18:18
  diagnosis
• 18:18
  with
• 18:19
  nothing
• 18:19
  else
• 18:19
  in
• 18:19
  front
• 18:20
  of
• 18:20
  you.
• 18:20
  What
• 18:21
  actually
• 18:21
  happens
• 18:22
  is
• 18:22
  you
• 18:23
  start
• 18:23
  getting
• 18:23
  plucked
• 18:24
  in
• 18:24
  different
• 18:24
  directions
• 18:25
  during
• 18:25
  your
• 18:25
  interview.
• 18:26
  The
• 18:26
  chief
• 18:27
  reason
• 18:27
  she's
• 18:28
  here
• 18:28
  is
• 18:28
  that
• 18:28
  she's
• 18:28
  falling
• 18:29
  behind.
• 18:30
  And
• 18:30
  if
• 18:30
  you
• 18:31
  can
• 18:31
  get
• 18:31
  to
• 18:31
  the
• 18:31
  core
• 18:32
  answer
• 18:32
  of
• 18:32
  why
• 18:32
  she's
• 18:33
  falling
• 18:33
  behind,
• 18:33
  and
• 18:34
  you
• 18:34
  do
• 18:34
  realize
• 18:35
  that
• 18:35
  it's
• 18:35
  actually
• 18:36
  these
• 18:36
  thoughts
• 18:36
  that
• 18:37
  she's
• 18:37
  so
• 18:37
  preoccupied
• 18:38
  with
• 18:38
  getting
• 18:39
  sick
• 18:39
  or
• 18:40
  having
• 18:40
  germs,
• 18:41
  getting
• 18:41
  contaminated
• 18:42
  with
• 18:42
  germs,
• 18:43
  that
• 18:43
  she
• 18:44
  can't
• 18:44
  focus
• 18:44
  in
• 18:44
  class.
• 18:45
  Now
• 18:45
  you're
• 18:45
  definitely
• 18:46
  in
• 18:46
  the
• 18:46
  ocd.
• 18:48
  OCD
• 18:48
  is
• 18:48
  definitely
• 18:50
  a
• 18:50
  major
• 18:51
  treatment
• 18:52
  target.
• 18:53
  And
• 18:53
  more
• 18:53
  and
• 18:54
  more
• 18:54
  of
• 18:54
  your
• 18:54
  questions
• 18:55
  should
• 18:56
  go
• 18:57
  down
• 18:57
  this
• 18:57
  path
• 18:58
  right
• 18:58
  of
• 18:58
  the
• 18:59
  of
• 18:59
  ocd,
• 18:59
  don't
• 19:00
  ignore
• 19:00
  adhd.
• 19:01
  Definitely
• 19:02
  keep
• 19:02
  it
• 19:02
  there.
• 19:02
  If
• 19:02
  it's
• 19:03
  been
• 19:03
  a
• 19:03
  problem
• 19:03
  before
• 19:04
  the
• 19:04
  age
• 19:04
  of
• 19:04
  12
• 19:05
  and
• 19:05
  she's
• 19:05
  endorsing
• 19:06
  forgetfulness,
• 19:06
  misplacing
• 19:07
  things,
• 19:07
  and
• 19:08
  having
• 19:08
  a
• 19:08
  hard
• 19:08
  time
• 19:09
  listening
• 19:09
  to
• 19:10
  other
• 19:10
  people
• 19:10
  when
• 19:10
  spoken
• 19:11
  to
• 19:11
  directly,
• 19:11
  definitely
• 19:12
  keep
• 19:12
  that
• 19:12
  in
• 19:13
  your
• 19:13
  back
• 19:13
  pocket.
• 19:13
  Remember,
• 19:14
  your
• 19:14
  job
• 19:15
  is
• 19:15
  not
• 19:15
  to
• 19:15
  save
• 19:16
  the
• 19:16
  world
• 19:16
  in
• 19:16
  the
• 19:16
  very
• 19:17
  first
• 19:17
  patient
• 19:17
  encounter.
• 19:18
  You
• 19:18
  couldn't
• 19:18
  do
• 19:18
  it
• 19:18
  if
• 19:19
  you
• 19:19
  tried.
• 19:20
  Sigmund
• 19:20
  Freud
• 19:20
  could
• 19:21
  come
• 19:21
  back
• 19:21
  from
• 19:21
  the
• 19:21
  dead,
• 19:22
  and
• 19:22
  he
• 19:22
  couldn't
• 19:23
  do
• 19:23
  it
• 19:23
  if
• 19:23
  he
• 19:23
  tried.
• 19:23
  But
• 19:24
  my
• 19:24
  point
• 19:25
  is,
• 19:26
  be
• 19:26
  patient,
• 19:27
  because
• 19:28
  this
• 19:28
  patient
• 19:28
  is
• 19:29
  in
• 19:29
  the
• 19:29
  outpatient
• 19:29
  space,
• 19:30
  right?
• 19:31
  They're
• 19:31
  not
• 19:31
  on
• 19:32
  a
• 19:32
  gurney
• 19:32
  in
• 19:32
  the
• 19:32
  emergency
• 19:33
  room.
• 19:33
  Right.
• 19:34
  You're
• 19:34
  not
• 19:34
  hanging
• 19:34
  blood
• 19:35
  for
• 19:36
  someone
• 19:36
  who
• 19:36
  has
• 19:36
  a
• 19:36
  stab
• 19:37
  wound
• 19:37
  in
• 19:37
  their
• 19:37
  neck.
• 19:37
  As
• 19:38
  a
• 19:38
  new
• 19:38
  grad,
• 19:38
  you've
• 19:39
  gotta
• 19:39
  slow
• 19:39
  down
• 19:40
  and
• 19:41
  rest
• 19:41
  assured,
• 19:41
  you
• 19:42
  have
• 19:42
  time
• 19:42
  for
• 19:42
  this.
• 19:43
  If
• 19:43
  you
• 19:43
  can
• 19:43
  orient
• 19:44
  yourself
• 19:44
  even
• 19:45
  close
• 19:45
  to
• 19:45
  their
• 19:45
  core
• 19:46
  diagnoses,
• 19:47
  you're
• 19:47
  doing
• 19:47
  pretty
• 19:47
  darn
• 19:48
  good.
• 19:49
  So
• 19:49
  we've
• 19:49
  gone
• 19:50
  down
• 19:50
  the
• 19:50
  OCD
• 19:51
  rabbit
• 19:51
  hole.
• 19:51
  She's
• 19:52
  told
• 19:52
  us
• 19:52
  it's
• 19:53
  over
• 19:53
  an
• 19:53
  hour.
• 19:53
  It's
• 19:53
  super
• 19:54
  disruptive.
• 19:54
  It
• 19:54
  is
• 19:55
  one
• 19:55
  of
• 19:55
  the
• 19:55
  reasons
• 19:56
  it's
• 19:56
  very
• 19:56
  hard
• 19:56
  for
• 19:56
  her
• 19:57
  to
• 19:57
  focus.
• 19:57
  So
• 19:58
  you're
• 19:58
  getting
• 19:58
  really
• 19:58
  good
• 19:59
  information
• 19:59
  here.
• 19:59
  Obviously.
• 20:00
  Do
• 20:01
  some
• 20:01
  lab
• 20:01
  work.
• 20:02
  If
• 20:02
  you
• 20:02
  join
• 20:03
  in
• 20:03
  my
• 20:03
  Patreon,
• 20:03
  you're
• 20:04
  going
• 20:04
  to
• 20:04
  see
• 20:04
  the
• 20:04
  specific
• 20:05
  labs
• 20:05
  that
• 20:05
  you
• 20:05
  really
• 20:05
  want
• 20:06
  to
• 20:06
  look
• 20:06
  at
• 20:07
  here
• 20:07
  and
• 20:07
  rule
• 20:08
  out.
• 20:08
  Know
• 20:08
  that
• 20:09
  this
• 20:09
  isn't
• 20:10
  any
• 20:10
  kind
• 20:10
  of
• 20:11
  medical
• 20:11
  problem.
• 20:12
  Remember,
• 20:12
  a
• 20:12
  lot
• 20:13
  of
• 20:13
  psychiatry,
• 20:13
  these
• 20:14
  are
• 20:14
  diagnoses
• 20:14
  of
• 20:15
  exclusion.
• 20:15
  So
• 20:16
  you've
• 20:16
  got
• 20:16
  to
• 20:16
  make
• 20:16
  sure
• 20:16
  the
• 20:16
  medical
• 20:17
  stuff
• 20:17
  is
• 20:17
  ruled
• 20:18
  out.
• 20:18
  If
• 20:18
  she's
• 20:18
  telling
• 20:19
  you,
• 20:19
  I've
• 20:19
  had
• 20:19
  these
• 20:19
  obsessive
• 20:20
  thoughts
• 20:20
  for
• 20:20
  nine
• 20:21
  years,
• 20:21
  but
• 20:21
  it's
• 20:21
  just
• 20:21
  gotten
• 20:22
  worse
• 20:22
  and
• 20:22
  worse.
• 20:23
  My
• 20:23
  mother
• 20:23
  has
• 20:23
  severe
• 20:24
  ocd.
• 20:25
  Then
• 20:25
  sure,
• 20:25
  your
• 20:26
  index
• 20:26
  of
• 20:26
  suspicion
• 20:27
  for
• 20:27
  this
• 20:28
  being
• 20:28
  a
• 20:28
  medical
• 20:28
  problem
• 20:29
  as
• 20:29
  its
• 20:29
  primary
• 20:30
  basis
• 20:30
  is
• 20:31
  lowered.
• 20:31
  But
• 20:31
  that's
• 20:32
  not
• 20:32
  to
• 20:32
  say
• 20:32
  that
• 20:32
  there
• 20:33
  isn't
• 20:33
  a
• 20:33
  hyperthyroid
• 20:34
  or
• 20:34
  some
• 20:34
  kind
• 20:34
  of
• 20:34
  B12
• 20:35
  or
• 20:35
  folate
• 20:35
  deficiency
• 20:36
  making
• 20:36
  this
• 20:37
  harder
• 20:37
  for
• 20:37
  the
• 20:37
  patient.
• 20:38
  But
• 20:38
  again,
• 20:38
  I
• 20:39
  don't
• 20:39
  want
• 20:39
  to
• 20:39
  go
• 20:40
  down
• 20:40
  the
• 20:40
  lab
• 20:40
  ratio
• 20:41
  alley
• 20:41
  right
• 20:42
  now,
• 20:42
  but
• 20:43
  I
• 20:43
  want
• 20:43
  you
• 20:43
  to
• 20:43
  just
• 20:43
  start
• 20:44
  thinking
• 20:44
  about
• 20:44
  labs.
• 20:45
  Of
• 20:45
  course.
• 20:45
  And
• 20:45
  all
• 20:46
  of
• 20:46
  your
• 20:46
  diagnosis.
• 20:47
  Now,
• 20:47
  we
• 20:47
  talked
• 20:48
  a
• 20:48
  little
• 20:48
  bit
• 20:48
  about.
• 20:49
  As
• 20:49
  she's
• 20:50
  sharing
• 20:50
  this
• 20:50
  information,
• 20:51
  you
• 20:51
  want
• 20:51
  to
• 20:51
  rule
• 20:51
  out
• 20:52
  that
• 20:52
  this
• 20:52
  isn't
• 20:52
  some
• 20:52
  kind
• 20:53
  of
• 20:53
  delusion
• 20:53
  or
• 20:54
  a
• 20:54
  delusional
• 20:54
  disorder
• 20:55
  is
• 20:55
  usually
• 20:55
  a
• 20:55
  fixed
• 20:56
  false
• 20:56
  belief.
• 20:57
  And
• 20:57
  usually
• 20:57
  the
• 20:57
  patient
• 20:58
  has
• 20:58
  poor
• 20:58
  insight.
• 20:59
  Well,
• 20:59
  that's
• 20:59
  not
• 20:59
  Sarah.
• 21:00
  She
• 21:00
  knows
• 21:00
  these
• 21:00
  are
• 21:00
  bizarre
• 21:01
  thoughts.
• 21:01
  She
• 21:01
  knows
• 21:02
  that
• 21:02
  in
• 21:02
  all
• 21:02
  likelihood
• 21:04
  she's
• 21:04
  not
• 21:04
  going
• 21:04
  to
• 21:05
  be
• 21:05
  infected
• 21:05
  with
• 21:05
  Ebola.
• 21:07
  She
• 21:07
  does
• 21:07
  feel
• 21:07
  compelled
• 21:08
  anyway
• 21:09
  to
• 21:09
  behave
• 21:09
  in
• 21:09
  certain
• 21:10
  ways
• 21:10
  to
• 21:10
  mitigate
• 21:11
  her
• 21:11
  risk.
• 21:12
  But
• 21:12
  that's
• 21:13
  very
• 21:13
  different
• 21:13
  than
• 21:13
  I
• 21:13
  am.
• 21:14
  Sure,
• 21:14
  I
• 21:14
  have
• 21:14
  Ebola
• 21:15
  and
• 21:15
  it's
• 21:15
  in
• 21:15
  my
• 21:16
  coffee.
• 21:16
  Right.
• 21:17
  If
• 21:18
  that's
• 21:18
  what
• 21:19
  you're
• 21:19
  dealing
• 21:19
  with,
• 21:19
  you're
• 21:20
  probably
• 21:20
  dealing
• 21:20
  with
• 21:20
  more
• 21:21
  of
• 21:21
  a
• 21:21
  delusional
• 21:21
  disorder.
• 21:22
  You
• 21:22
  gotta
• 21:22
  go
• 21:22
  down
• 21:22
  the
• 21:22
  schizophrenia
• 21:23
  path.
• 21:24
  But
• 21:24
  she's
• 21:25
  pretty
• 21:25
  clear
• 21:25
  that
• 21:26
  she's
• 21:27
  very
• 21:27
  disturbed
• 21:27
  by
• 21:28
  these
• 21:28
  symptoms.
• 21:28
  She
• 21:28
  would
• 21:28
  rather
• 21:29
  not
• 21:29
  have
• 21:29
  them,
• 21:29
  but
• 21:29
  she
• 21:30
  feels
• 21:30
  compelled.
• 21:31
  Now,
• 21:31
  is
• 21:31
  this
• 21:31
  generalized
• 21:32
  anxiety
• 21:33
  disorder?
• 21:33
  That's
• 21:33
  something
• 21:33
  to
• 21:34
  think
• 21:34
  about.
• 21:34
  Of
• 21:34
  course.
• 21:35
  That's
• 21:35
  very
• 21:35
  comorbid.
• 21:36
  In
• 21:36
  practice,
• 21:37
  my
• 21:37
  friends,
• 21:38
  in
• 21:38
  real
• 21:38
  world
• 21:39
  practice,
• 21:39
  you're
• 21:40
  not
• 21:40
  going
• 21:40
  to
• 21:40
  have
• 21:40
  OCD
• 21:41
  handed
• 21:41
  to
• 21:41
  you
• 21:42
  on
• 21:42
  a
• 21:42
  plate
• 21:43
  like.
• 21:43
  Like
• 21:43
  spaghetti
• 21:44
  and
• 21:44
  meatballs.
• 21:45
  You're
• 21:45
  going
• 21:45
  to
• 21:45
  get
• 21:45
  spaghetti
• 21:46
  and
• 21:46
  meatballs,
• 21:47
  and
• 21:47
  then
• 21:47
  there's
• 21:47
  going
• 21:48
  to
• 21:48
  be
• 21:48
  vanilla
• 21:48
  ice
• 21:48
  cream
• 21:49
  drizzled
• 21:49
  on
• 21:49
  top
• 21:49
  of
• 21:50
  it.
• 21:50
  And
• 21:50
  there's
• 21:51
  going
• 21:51
  to
• 21:51
  be
• 21:52
  some
• 21:52
  creme
• 21:52
  brulee
• 21:53
  on
• 21:53
  the
• 21:54
  side
• 21:54
  with
• 21:55
  a
• 21:55
  few
• 21:55
  lettuce
• 21:56
  leaves
• 21:56
  and
• 21:57
  beef
• 21:57
  brisket
• 21:58
  dumped
• 21:58
  on
• 21:58
  the
• 21:58
  top.
• 21:58
  Right?
• 21:59
  So
• 21:59
  generalized
• 22:00
  anxiety
• 22:00
  could
• 22:00
  absolutely
• 22:01
  coexist
• 22:02
  with
• 22:02
  ocd.
• 22:02
  In
• 22:02
  addition
• 22:03
  to
• 22:04
  having
• 22:04
  obsessional
• 22:05
  thought
• 22:05
  patterns
• 22:06
  and
• 22:06
  compulsions
• 22:06
  that
• 22:07
  take
• 22:07
  up
• 22:07
  at
• 22:07
  least
• 22:07
  an
• 22:07
  hour
• 22:08
  or
• 22:08
  more
• 22:08
  a
• 22:08
  day
• 22:09
  and
• 22:09
  are
• 22:09
  highly
• 22:10
  distressing
• 22:10
  and
• 22:11
  not
• 22:11
  attributable
• 22:11
  to
• 22:11
  another
• 22:12
  medical
• 22:12
  or
• 22:12
  psychiatric
• 22:13
  condition,
• 22:13
  you
• 22:14
  could
• 22:14
  also
• 22:14
  have
• 22:15
  broad
• 22:15
  worrying
• 22:16
  about
• 22:16
  a
• 22:16
  wide
• 22:17
  range
• 22:17
  of
• 22:17
  topics.
• 22:18
  Patients
• 22:18
  who
• 22:18
  meet
• 22:18
  that
• 22:19
  criteria
• 22:19
  are
• 22:20
  not
• 22:20
  going
• 22:20
  to
• 22:20
  only
• 22:21
  have
• 22:21
  obsessions
• 22:22
  and
• 22:22
  compulsions.
• 22:22
  They're
• 22:23
  also
• 22:23
  going
• 22:23
  to
• 22:23
  be
• 22:23
  just
• 22:23
  worried
• 22:24
  about
• 22:24
  everything.
• 22:25
  Right?
• 22:25
  And
• 22:25
  I
• 22:25
  don't
• 22:26
  mean
• 22:26
  like,
• 22:26
  oh,
• 22:26
  I'm
• 22:26
  worried.
• 22:27
  I
• 22:27
  have
• 22:27
  a
• 22:27
  midterm
• 22:27
  next
• 22:28
  week.
• 22:28
  I'm
• 22:28
  talking
• 22:29
  about
• 22:29
  catastrophic
• 22:30
  irrational
• 22:31
  worries
• 22:31
  that
• 22:31
  the
• 22:31
  patient
• 22:32
  knows
• 22:32
  are
• 22:33
  irrational.
• 22:34
  I'm
• 22:34
  worried
• 22:35
  that
• 22:35
  my
• 22:35
  family's
• 22:36
  Gonna
• 22:36
  die
• 22:36
  in
• 22:36
  a
• 22:36
  car
• 22:36
  crash.
• 22:37
  Even
• 22:37
  though
• 22:38
  they
• 22:38
  haven't
• 22:38
  been
• 22:39
  in
• 22:39
  one.
• 22:39
  They're
• 22:39
  perfectly
• 22:40
  healthy.
• 22:40
  I
• 22:40
  just
• 22:41
  wanna
• 22:41
  make
• 22:41
  sure
• 22:41
  they
• 22:41
  get
• 22:41
  home
• 22:42
  safe.
• 22:42
  I'm
• 22:42
  worried
• 22:43
  I'm
• 22:43
  gonna
• 22:44
  lose
• 22:44
  my
• 22:44
  job
• 22:44
  even
• 22:44
  though
• 22:45
  I
• 22:45
  have
• 22:45
  no
• 22:45
  performance
• 22:46
  issues,
• 22:46
  right?
• 22:47
  So
• 22:47
  these
• 22:47
  are
• 22:47
  just
• 22:47
  worst
• 22:48
  case
• 22:48
  scenario,
• 22:48
  catastrophic
• 22:49
  worries.
• 22:50
  Patients
• 22:50
  in
• 22:50
  the
• 22:51
  past
• 22:51
  have
• 22:51
  described
• 22:51
  it
• 22:52
  beautifully.
• 22:52
  They'll
• 22:52
  say
• 22:53
  it's
• 22:53
  almost
• 22:53
  like
• 22:54
  they
• 22:54
  think
• 22:54
  in
• 22:54
  fear.
• 22:55
  There's
• 22:55
  like
• 22:55
  a
• 22:55
  lens
• 22:56
  of
• 22:56
  fear
• 22:57
  in
• 22:57
  their
• 22:57
  thoughts.
• 22:58
  It's
• 22:58
  almost
• 22:58
  like
• 22:58
  those
• 22:59
  Instagram
• 22:59
  filters,
• 23:00
  right?
• 23:00
  You
• 23:00
  have
• 23:00
  a
• 23:00
  filter
• 23:01
  on
• 23:01
  a
• 23:02
  photo
• 23:02
  and
• 23:03
  for
• 23:03
  generalized
• 23:04
  anxiety,
• 23:04
  everything's
• 23:05
  just
• 23:05
  put
• 23:05
  through
• 23:05
  like
• 23:05
  a
• 23:06
  fear
• 23:06
  filter,
• 23:06
  right?
• 23:07
  So
• 23:07
  that
• 23:07
  could
• 23:07
  very
• 23:08
  well
• 23:08
  be
• 23:08
  the
• 23:08
  case
• 23:08
  if
• 23:09
  it
• 23:09
  needs
• 23:09
  to
• 23:09
  be
• 23:10
  lumped
• 23:11
  in
• 23:11
  with
• 23:11
  OCD
• 23:11
  and
• 23:12
  you
• 23:12
  have
• 23:12
  two
• 23:12
  diagnoses.
• 23:13
  Don't
• 23:13
  sit
• 23:13
  there
• 23:13
  as
• 23:14
  a
• 23:14
  new
• 23:14
  grad
• 23:14
  and
• 23:14
  go,
• 23:15
  oh
• 23:15
  my
• 23:15
  God,
• 23:15
  which
• 23:15
  one
• 23:15
  is
• 23:16
  it?
• 23:17
  GAD
• 23:17
  or
• 23:17
  ocd?
• 23:18
  Don't
• 23:18
  worry
• 23:19
  about
• 23:19
  it.
• 23:19
  Lucky
• 23:20
  for
• 23:20
  you,
• 23:21
  these
• 23:23
  disorders
• 23:24
  share
• 23:24
  real
• 23:25
  estate
• 23:25
  in
• 23:25
  the
• 23:25
  brain.
• 23:26
  So
• 23:27
  the
• 23:27
  same
• 23:27
  kind
• 23:27
  of
• 23:28
  treatments
• 23:29
  are
• 23:29
  similar
• 23:29
  in
• 23:30
  that
• 23:30
  SSRIs
• 23:31
  are
• 23:31
  going
• 23:31
  to
• 23:31
  treat
• 23:31
  both.
• 23:32
  So
• 23:32
  don't
• 23:32
  panic
• 23:33
  because
• 23:34
  from
• 23:34
  a
• 23:35
  practical
• 23:36
  perspective,
• 23:37
  your
• 23:38
  medication
• 23:38
  won't
• 23:39
  really
• 23:39
  change.
• 23:40
  There
• 23:40
  are
• 23:41
  other
• 23:41
  distinctions
• 23:41
  that
• 23:42
  become
• 23:42
  more
• 23:42
  relevant
• 23:43
  in
• 23:43
  ocd.
• 23:43
  There's
• 23:44
  exposure
• 23:44
  therapy,
• 23:45
  that's
• 23:46
  much
• 23:46
  more
• 23:47
  of
• 23:47
  a
• 23:47
  gold
• 23:47
  standard
• 23:48
  with
• 23:48
  OCD
• 23:48
  rather
• 23:48
  than
• 23:49
  gad.
• 23:49
  But
• 23:49
  again,
• 23:50
  first
• 23:51
  interview,
• 23:52
  first
• 23:53
  outpatient
• 23:53
  experience,
• 23:54
  just.
• 23:55
  You
• 23:55
  can
• 23:55
  always
• 23:56
  collaborate
• 23:56
  with
• 23:56
  your
• 23:56
  team
• 23:57
  and
• 23:57
  get
• 23:57
  mentorship
• 23:58
  and
• 23:58
  do
• 23:59
  homework
• 23:59
  if
• 23:59
  you're
• 23:59
  not
• 24:00
  extremely
• 24:00
  confident.
• 24:01
  But
• 24:01
  get
• 24:02
  in
• 24:02
  the
• 24:02
  right
• 24:02
  ballpark
• 24:03
  and
• 24:03
  remember,
• 24:04
  OCD,
• 24:05
  GAD,
• 24:06
  depression,
• 24:07
  first
• 24:07
  line,
• 24:07
  are
• 24:07
  these
• 24:07
  SSRIs,
• 24:08
  at
• 24:08
  least
• 24:09
  from
• 24:09
  a
• 24:09
  pharmacological
• 24:10
  perspective.
• 24:10
  Make
• 24:11
  sure
• 24:12
  the
• 24:12
  patient
• 24:12
  doesn't
• 24:12
  have
• 24:13
  schizophrenia.
• 24:13
  It's
• 24:14
  pretty
• 24:14
  clear
• 24:14
  that
• 24:14
  Sarah
• 24:15
  does
• 24:15
  not.
• 24:15
  You
• 24:16
  do
• 24:16
  her
• 24:16
  mental
• 24:16
  status
• 24:17
  exam,
• 24:17
  she's
• 24:17
  not
• 24:17
  disheveled.
• 24:19
  She's
• 24:19
  not
• 24:19
  talking
• 24:19
  in
• 24:20
  circles
• 24:21
  in
• 24:21
  a
• 24:21
  disorganized
• 24:22
  fashion.
• 24:22
  She's
• 24:22
  able
• 24:23
  to
• 24:23
  follow
• 24:23
  you
• 24:24
  pretty
• 24:24
  clearly
• 24:25
  and
• 24:25
  linearly.
• 24:26
  Right?
• 24:26
  There's
• 24:26
  no
• 24:27
  major
• 24:27
  deviations
• 24:28
  or
• 24:28
  tangents.
• 24:29
  She's
• 24:29
  well
• 24:30
  kept.
• 24:30
  She
• 24:30
  showers
• 24:31
  every
• 24:31
  day.
• 24:31
  A
• 24:32
  lot
• 24:32
  of
• 24:32
  times,
• 24:33
  those
• 24:33
  negative
• 24:33
  symptoms
• 24:34
  and
• 24:34
  schizophrenia,
• 24:34
  your
• 24:35
  patient
• 24:35
  will
• 24:36
  not
• 24:36
  shower
• 24:37
  or
• 24:37
  they're
• 24:37
  not
• 24:38
  combing
• 24:38
  their
• 24:38
  hair,
• 24:39
  they're
• 24:39
  dressed
• 24:39
  in
• 24:39
  a
• 24:40
  kind
• 24:40
  of
• 24:40
  bizarre
• 24:40
  way.
• 24:41
  So
• 24:41
  you
• 24:41
  lean
• 24:42
  on
• 24:42
  your
• 24:42
  mental
• 24:42
  status
• 24:43
  exam
• 24:43
  as
• 24:43
  well.
• 24:43
  To
• 24:44
  really,
• 24:44
  to
• 24:44
  get
• 24:44
  a
• 24:45
  finer
• 24:45
  appreciation
• 24:46
  for
• 24:46
  this,
• 24:46
  lean
• 24:47
  on
• 24:47
  your
• 24:47
  screening
• 24:47
  tools.
• 24:48
  Right,
• 24:48
  the
• 24:48
  Y
• 24:49
  box.
• 24:49
  I've
• 24:50
  included
• 24:50
  them
• 24:50
  in
• 24:51
  our
• 24:51
  Patreon
• 24:51
  membership.
• 24:52
  I
• 24:52
  highly
• 24:52
  recommend
• 24:53
  you
• 24:53
  go
• 24:53
  and
• 24:53
  join.
• 24:55
  Become
• 24:55
  a
• 24:55
  Patreon
• 24:56
  member.
• 24:56
  We
• 24:56
  have
• 24:56
  these
• 24:56
  screening
• 24:57
  tools
• 24:57
  ready
• 24:57
  for
• 24:58
  you.
• 24:58
  You
• 24:58
  can
• 24:58
  see
• 24:59
  the
• 24:59
  kinds
• 24:59
  of
• 24:59
  high
• 24:59
  yield
• 25:00
  diagnostic
• 25:00
  questions
• 25:01
  you
• 25:01
  should
• 25:01
  ask
• 25:02
  by
• 25:02
  incorporating
• 25:03
  those
• 25:03
  tools
• 25:03
  into
• 25:03
  your
• 25:04
  assessments.
• 25:04
  And
• 25:04
  you
• 25:04
  will
• 25:05
  Be
• 25:05
  a
• 25:05
  superhero.
• 25:06
  So
• 25:07
  definitely
• 25:07
  join
• 25:08
  our
• 25:08
  Patreon
• 25:09
  that
• 25:09
  will
• 25:10
  turbocharge
• 25:11
  your
• 25:11
  academic
• 25:12
  and
• 25:12
  clinical
• 25:13
  performance.
• 25:14
  Aside
• 25:14
  from
• 25:14
  the
• 25:15
  screening
• 25:15
  tools
• 25:15
  that
• 25:15
  I
• 25:16
  highly
• 25:16
  recommend
• 25:16
  you
• 25:17
  embed
• 25:17
  in
• 25:17
  your
• 25:17
  questioning
• 25:18
  and
• 25:19
  use
• 25:19
  in
• 25:19
  your
• 25:20
  practice,
• 25:21
  you
• 25:21
  always
• 25:21
  have
• 25:21
  your
• 25:21
  DSM
• 25:22
  5
• 25:22
  TR
• 25:22
  and
• 25:23
  never
• 25:23
  be
• 25:23
  ashamed
• 25:24
  to
• 25:24
  whip
• 25:24
  it
• 25:24
  out.
• 25:24
  Patients
• 25:25
  respect.
• 25:25
  When
• 25:25
  you
• 25:25
  get
• 25:26
  it
• 25:26
  right,
• 25:26
  they
• 25:26
  don't
• 25:27
  want
• 25:27
  you
• 25:27
  to
• 25:27
  guess.
• 25:28
  I
• 25:28
  thought
• 25:28
  you
• 25:29
  had
• 25:29
  OCD
• 25:29
  last
• 25:30
  time
• 25:30
  and
• 25:31
  really
• 25:31
  all
• 25:31
  this
• 25:32
  time
• 25:32
  you
• 25:33
  had
• 25:34
  ADHD
• 25:35
  combined
• 25:36
  type
• 25:36
  and
• 25:36
  I
• 25:36
  should
• 25:36
  have
• 25:37
  given
• 25:37
  you
• 25:37
  Adderall,
• 25:38
  right?
• 25:38
  Don't
• 25:38
  do
• 25:39
  that.
• 25:39
  Take
• 25:40
  your
• 25:40
  time.
• 25:40
  If
• 25:41
  you
• 25:41
  need
• 25:41
  to
• 25:41
  whip
• 25:41
  out
• 25:41
  the
• 25:41
  dsm,
• 25:42
  sometimes
• 25:43
  that
• 25:43
  helps.
• 25:43
  And
• 25:43
  sometimes
• 25:44
  patients
• 25:44
  feel
• 25:45
  very
• 25:46
  comforted
• 25:46
  by
• 25:46
  the
• 25:47
  fact
• 25:47
  that
• 25:47
  there
• 25:47
  is
• 25:47
  some
• 25:48
  sort
• 25:48
  of
• 25:48
  structured,
• 25:49
  well
• 25:49
  known
• 25:50
  process
• 25:50
  that's
• 25:50
  happening
• 25:51
  that
• 25:51
  is
• 25:51
  treatable
• 25:52
  and
• 25:52
  identifiable
• 25:53
  and
• 25:53
  that
• 25:53
  they're
• 25:53
  not
• 25:53
  alone.
• 25:54
  Remember,
• 25:54
  a
• 25:54
  lot
• 25:54
  of
• 25:54
  people
• 25:55
  with
• 25:55
  ocd,
• 25:55
  they
• 25:56
  feel
• 25:56
  very
• 25:56
  ashamed
• 25:57
  with
• 25:57
  their
• 25:57
  symptoms.
• 25:58
  It's
• 25:58
  very
• 25:58
  hard
• 25:58
  for
• 25:58
  them
• 25:59
  to
• 25:59
  come
• 25:59
  forward
• 25:59
  in
• 25:59
  the
• 25:59
  first
• 26:00
  place.
• 26:00
  So
• 26:01
  keep
• 26:01
  that
• 26:01
  in
• 26:01
  mind.
• 26:02
  Now,
• 26:02
  some
• 26:02
  patients
• 26:03
  also
• 26:03
  might
• 26:03
  feel
• 26:03
  the
• 26:04
  opposite.
• 26:04
  They
• 26:04
  might
• 26:04
  feel
• 26:05
  deeply
• 26:05
  stigmatized
• 26:06
  that
• 26:06
  you're
• 26:06
  just
• 26:06
  reducing
• 26:07
  them
• 26:07
  down
• 26:08
  to
• 26:08
  three
• 26:08
  pages
• 26:09
  in
• 26:09
  a
• 26:09
  textbook.
• 26:09
  But
• 26:10
  it's
• 26:10
  all
• 26:10
  about
• 26:10
  how
• 26:10
  you
• 26:11
  approach
• 26:11
  it.
• 26:11
  And
• 26:11
  you
• 26:11
  have
• 26:12
  to
• 26:12
  approach
• 26:12
  it
• 26:12
  compassionately
• 26:13
  and
• 26:13
  kindly.
• 26:14
  And
• 26:14
  I
• 26:14
  sometimes
• 26:15
  open
• 26:15
  this
• 26:15
  book
• 26:16
  so
• 26:16
  that
• 26:16
  we
• 26:16
  have
• 26:16
  a
• 26:17
  good
• 26:17
  reference
• 26:17
  as
• 26:18
  to
• 26:18
  what
• 26:18
  we're
• 26:18
  looking
• 26:19
  at.
• 26:19
  I
• 26:19
  can
• 26:19
  help
• 26:20
  describe
• 26:20
  these
• 26:20
  symptoms
• 26:21
  and
• 26:21
  understand
• 26:21
  whether
• 26:22
  they
• 26:22
  resonate
• 26:22
  with
• 26:23
  you.
• 26:23
  Does
• 26:23
  that
• 26:24
  sound
• 26:24
  like
• 26:24
  a
• 26:24
  plan?
• 26:25
  I
• 26:25
  found
• 26:25
  that
• 26:26
  most
• 26:26
  patients
• 26:26
  are
• 26:26
  very
• 26:27
  understanding
• 26:27
  of
• 26:27
  that.
• 26:28
  I
• 26:28
  always
• 26:28
  qualify
• 26:29
  it
• 26:29
  with,
• 26:29
  hey,
• 26:29
  you're
• 26:30
  not
• 26:30
  this
• 26:30
  diagnosis.
• 26:31
  These
• 26:31
  are
• 26:31
  just
• 26:32
  ways
• 26:32
  that
• 26:33
  help
• 26:34
  us
• 26:34
  clinicians
• 26:34
  orient
• 26:36
  ourselves
• 26:36
  to
• 26:36
  what
• 26:37
  you
• 26:37
  might
• 26:37
  be
• 26:37
  going
• 26:37
  through.
• 26:38
  This
• 26:38
  is
• 26:38
  just
• 26:38
  a
• 26:39
  bunch
• 26:39
  of
• 26:39
  categories
• 26:40
  in
• 26:40
  a
• 26:40
  text.
• 26:40
  I
• 26:41
  don't
• 26:41
  let
• 26:41
  them
• 26:41
  feel
• 26:41
  stigmatized
• 26:42
  because
• 26:42
  that's
• 26:42
  not
• 26:43
  the
• 26:43
  point
• 26:43
  of
• 26:43
  the
• 26:43
  meeting.
• 26:44
  The
• 26:44
  point
• 26:44
  is
• 26:44
  to
• 26:45
  have
• 26:45
  a
• 26:45
  compassionate
• 26:46
  conversation
• 26:47
  and
• 26:47
  get
• 26:48
  them
• 26:48
  doing
• 26:48
  better
• 26:49
  in
• 26:49
  their
• 26:49
  personal
• 26:50
  lives.
• 26:50
  Now,
• 26:51
  we
• 26:52
  have
• 26:52
  some
• 26:52
  options
• 26:52
  with
• 26:53
  Sarah
• 26:53
  and
• 26:54
  we
• 26:54
  don't
• 26:54
  have
• 26:54
  to
• 26:54
  go
• 26:54
  into
• 26:54
  too
• 26:55
  much
• 26:55
  detail
• 26:55
  here,
• 26:56
  but
• 26:57
  first
• 26:57
  line
• 26:58
  intervention
• 26:58
  would
• 26:58
  be
• 26:58
  SSRIs,
• 26:59
  right?
• 27:00
  Starting
• 27:00
  something
• 27:01
  like
• 27:01
  Zoloft,
• 27:02
  maybe
• 27:02
  25
• 27:03
  milligrams,
• 27:04
  going
• 27:04
  up
• 27:04
  to
• 27:04
  50
• 27:05
  milligrams
• 27:06
  after
• 27:06
  a
• 27:06
  couple
• 27:07
  of
• 27:07
  weeks,
• 27:07
  you
• 27:07
  want
• 27:07
  to
• 27:07
  go
• 27:08
  low
• 27:08
  and
• 27:08
  slow
• 27:08
  because
• 27:09
  patients
• 27:09
  who
• 27:09
  do
• 27:10
  have
• 27:10
  severe
• 27:10
  anxiety
• 27:11
  can
• 27:11
  get
• 27:12
  a
• 27:12
  little
• 27:12
  more
• 27:12
  activated
• 27:13
  when
• 27:13
  you're
• 27:14
  using
• 27:14
  SSRIs
• 27:15
  initially.
• 27:16
  Although
• 27:16
  with
• 27:16
  OCD,
• 27:17
  it's
• 27:17
  a
• 27:17
  balancing
• 27:18
  act
• 27:18
  because
• 27:18
  you
• 27:18
  also
• 27:18
  want
• 27:19
  to
• 27:19
  titrate
• 27:20
  more
• 27:20
  aggressively
• 27:20
  and
• 27:21
  get
• 27:21
  up
• 27:22
  to
• 27:22
  a
• 27:23
  high
• 27:23
  dose
• 27:23
  as
• 27:23
  soon
• 27:24
  as
• 27:24
  you
• 27:24
  can.
• 27:25
  Consult
• 27:25
  your
• 27:25
  textbooks
• 27:26
  on
• 27:26
  this.
• 27:26
  Do
• 27:26
  it
• 27:27
  the
• 27:27
  right
• 27:27
  way,
• 27:28
  because
• 27:28
  the
• 27:28
  rule
• 27:28
  with
• 27:28
  OCD
• 27:29
  is
• 27:29
  you
• 27:29
  really
• 27:29
  want
• 27:30
  to
• 27:30
  get
• 27:30
  to
• 27:30
  higher
• 27:30
  doses
• 27:31
  for
• 27:32
  more
• 27:32
  prolonged
• 27:32
  periods
• 27:33
  of
• 27:33
  time,
• 27:33
  they
• 27:33
  tend
• 27:34
  to
• 27:34
  respond
• 27:34
  a
• 27:34
  little
• 27:35
  bit
• 27:35
  later.
• 27:36
  It's
• 27:36
  not
• 27:36
  necessarily
• 27:37
  the
• 27:37
  four
• 27:37
  to
• 27:37
  six
• 27:37
  weeks.
• 27:38
  Sometimes
• 27:38
  it's
• 27:38
  a
• 27:38
  little
• 27:38
  past
• 27:39
  six
• 27:39
  weeks
• 27:39
  where
• 27:39
  you
• 27:40
  get
• 27:40
  that
• 27:40
  more
• 27:40
  full
• 27:40
  response.
• 27:41
  And
• 27:41
  it's
• 27:42
  not
• 27:42
  always
• 27:42
  a
• 27:42
  complete
• 27:42
  response.
• 27:43
  Sometimes
• 27:44
  augmentation
• 27:44
  is
• 27:44
  the
• 27:45
  rule
• 27:45
  with
• 27:45
  ocd.
• 27:46
  Whether
• 27:46
  it's
• 27:46
  augmenting
• 27:47
  with
• 27:47
  a
• 27:47
  second
• 27:48
  generation
• 27:48
  antipsychotic
• 27:49
  like
• 27:49
  Abilify,
• 27:50
  whether
• 27:50
  it's
• 27:51
  augmenting
• 27:52
  with
• 27:52
  things
• 27:52
  like
• 27:52
  N
• 27:52
  acetylcysteine.
• 27:53
  Now
• 27:53
  these
• 27:54
  are
• 27:54
  things
• 27:54
  we
• 27:54
  can
• 27:54
  go
• 27:55
  on
• 27:55
  in
• 27:55
  future
• 27:55
  episodes.
• 27:56
  But
• 27:56
  remember
• 27:57
  that
• 27:57
  augmentation
• 27:57
  a
• 27:58
  lot
• 27:58
  of
• 27:58
  times
• 27:58
  is
• 27:58
  the
• 27:58
  rule
• 27:59
  with
• 27:59
  ocd.
• 28:00
  High
• 28:00
  doses
• 28:01
  and
• 28:02
  many
• 28:03
  weeks
• 28:03
  of
• 28:03
  treatment
• 28:03
  to
• 28:04
  really
• 28:04
  understand
• 28:05
  how
• 28:05
  the
• 28:05
  patient
• 28:06
  is
• 28:06
  doing.
• 28:06
  And
• 28:06
  you
• 28:06
  can
• 28:06
  start
• 28:07
  with
• 28:07
  a
• 28:07
  medication
• 28:08
  like
• 28:08
  Zoloft.
• 28:09
  Of
• 28:09
  course,
• 28:09
  you
• 28:09
  want
• 28:09
  to
• 28:10
  meet
• 28:10
  the
• 28:10
  patient
• 28:10
  where
• 28:10
  they're
• 28:11
  at.
• 28:11
  If
• 28:11
  you
• 28:11
  have
• 28:12
  a
• 28:12
  patient
• 28:13
  that
• 28:13
  is
• 28:14
  having
• 28:14
  a
• 28:15
  really
• 28:15
  hard
• 28:15
  time
• 28:16
  falling
• 28:16
  asleep,
• 28:16
  not
• 28:17
  eating,
• 28:17
  and
• 28:17
  suffering
• 28:18
  from
• 28:18
  severe
• 28:19
  OCD
• 28:19
  symptoms,
• 28:20
  something
• 28:20
  like
• 28:20
  Paxil
• 28:21
  might
• 28:21
  be
• 28:21
  more
• 28:21
  compatible
• 28:22
  than
• 28:22
  something
• 28:22
  like
• 28:23
  Zoloft.
• 28:23
  This
• 28:24
  is
• 28:24
  where
• 28:24
  it
• 28:24
  really
• 28:24
  becomes
• 28:25
  case
• 28:25
  by
• 28:25
  case.
• 28:25
  That's
• 28:26
  very
• 28:26
  important
• 28:27
  that
• 28:27
  you
• 28:27
  look
• 28:27
  at
• 28:27
  this
• 28:28
  with
• 28:28
  the
• 28:28
  OCD
• 28:29
  neurocircuitry.
• 28:30
  It's
• 28:30
  a
• 28:31
  lot
• 28:31
  like
• 28:31
  a
• 28:31
  hypersensitive
• 28:32
  smoke
• 28:32
  detector,
• 28:33
  right?
• 28:34
  A
• 28:34
  lot
• 28:35
  of
• 28:35
  us,
• 28:35
  our
• 28:35
  smoke
• 28:36
  detector
• 28:36
  goes
• 28:36
  off
• 28:36
  when
• 28:37
  there's
• 28:37
  a
• 28:37
  fire,
• 28:37
  but
• 28:37
  with
• 28:38
  ocd,
• 28:38
  it
• 28:38
  can
• 28:38
  often
• 28:39
  feel
• 28:39
  like
• 28:39
  your
• 28:40
  smoke
• 28:40
  alarm
• 28:40
  is
• 28:40
  going
• 28:41
  off
• 28:41
  even
• 28:41
  when
• 28:42
  you're
• 28:42
  making
• 28:42
  pop
• 28:42
  tarts,
• 28:43
  right?
• 28:44
  And
• 28:44
  so
• 28:45
  you.
• 28:45
  It's
• 28:46
  very
• 28:46
  important
• 28:47
  that
• 28:47
  we
• 28:47
  use
• 28:48
  things
• 28:48
  like
• 28:48
  exposure
• 28:49
  response
• 28:49
  therapy
• 28:50
  and
• 28:50
  SSRIs.
• 28:51
  These
• 28:51
  are
• 28:52
  first
• 28:52
  line
• 28:52
  tools
• 28:52
  to
• 28:53
  really
• 28:54
  alleviate
• 28:54
  these
• 28:55
  symptoms.
• 28:55
  Because
• 28:56
  we
• 28:56
  want
• 28:56
  to
• 28:56
  recalibrate
• 28:57
  that
• 28:58
  smoke
• 28:58
  detector,
• 28:59
  right?
• 28:59
  And
• 29:00
  in
• 29:00
  ocd,
• 29:00
  compulsions
• 29:01
  are
• 29:01
  almost
• 29:01
  like
• 29:02
  frantically
• 29:02
  waving
• 29:03
  an
• 29:03
  ace
• 29:03
  of
• 29:03
  spade
• 29:04
  card
• 29:05
  at
• 29:05
  the
• 29:05
  detector
• 29:06
  instead
• 29:06
  of
• 29:06
  just
• 29:07
  adjusting
• 29:07
  the
• 29:07
  settings.
• 29:08
  So
• 29:08
  we
• 29:08
  go
• 29:09
  in
• 29:09
  there
• 29:09
  and
• 29:09
  try
• 29:09
  to
• 29:09
  adjust
• 29:10
  the
• 29:10
  settings
• 29:11
  by
• 29:11
  recalibrating
• 29:12
  the
• 29:12
  threat
• 29:13
  response
• 29:14
  in
• 29:14
  those
• 29:14
  key
• 29:15
  areas,
• 29:15
  the
• 29:15
  amygdala,
• 29:16
  the
• 29:17
  orbital
• 29:17
  frontal
• 29:18
  circuit.
• 29:18
  We,
• 29:19
  we
• 29:19
  try
• 29:19
  to
• 29:19
  recalibrate
• 29:20
  the
• 29:20
  threat
• 29:21
  response
• 29:21
  with
• 29:21
  SSRIs,
• 29:22
  exposure
• 29:22
  therapy
• 29:23
  and
• 29:24
  things
• 29:24
  like
• 29:24
  that.
• 29:24
  But
• 29:25
  right
• 29:25
  now,
• 29:25
  their
• 29:25
  tools,
• 29:26
  their
• 29:26
  compulsions,
• 29:27
  they're
• 29:27
  trying
• 29:27
  to
• 29:28
  manage
• 29:28
  their
• 29:28
  anxiety
• 29:29
  in
• 29:29
  a
• 29:29
  way
• 29:29
  that
• 29:29
  doesn't
• 29:30
  really
• 29:30
  help.
• 29:30
  It's
• 29:30
  like
• 29:31
  waving
• 29:31
  an
• 29:31
  ace
• 29:31
  of
• 29:32
  spades
• 29:32
  at
• 29:33
  the
• 29:33
  smoke
• 29:33
  detector
• 29:34
  instead
• 29:34
  of
• 29:34
  just
• 29:35
  adjusting
• 29:35
  its
• 29:35
  settings.
• 29:36
  This
• 29:36
  sort
• 29:36
  of
• 29:37
  superstitious,
• 29:37
  I'm
• 29:38
  going
• 29:38
  to
• 29:38
  do
• 29:38
  this
• 29:38
  because
• 29:38
  I
• 29:38
  feel
• 29:39
  like
• 29:39
  it
• 29:39
  might
• 29:39
  make
• 29:39
  me
• 29:39
  safe,
• 29:40
  but
• 29:40
  it's
• 29:40
  really
• 29:41
  not.
• 29:41
  And
• 29:42
  so
• 29:42
  we
• 29:42
  want
• 29:42
  to
• 29:42
  replace
• 29:43
  that,
• 29:43
  even
• 29:43
  with
• 29:44
  cbt,
• 29:44
  right?
• 29:45
  In
• 29:45
  ways
• 29:45
  of
• 29:46
  reframing
• 29:46
  these
• 29:47
  threats
• 29:47
  and
• 29:48
  overriding
• 29:49
  those
• 29:49
  compulsions
• 29:50
  to
• 29:50
  behaviors
• 29:51
  that
• 29:51
  are
• 29:51
  more
• 29:51
  suitable
• 29:52
  and
• 29:52
  conducive
• 29:53
  to
• 29:53
  a
• 29:54
  smooth
• 29:55
  life
• 29:55
  experience.
• 29:56
  So
• 29:57
  power
• 29:57
  pearls
• 29:58
  for
• 29:58
  the
• 29:58
  day.
• 29:58
  You
• 29:59
  really
• 29:59
  want
• 29:59
  to
• 29:59
  make
• 29:59
  sure
• 30:00
  you're
• 30:01
  assessing
• 30:01
  their
• 30:01
  level
• 30:02
  of
• 30:02
  insight
• 30:02
  because
• 30:02
  there
• 30:03
  is
• 30:03
  a
• 30:03
  specifier
• 30:03
  diagnosis
• 30:04
  with
• 30:04
  OCD
• 30:05
  whether
• 30:05
  they
• 30:05
  have
• 30:06
  poor
• 30:06
  insight
• 30:07
  or
• 30:07
  not.
• 30:08
  I
• 30:08
  would
• 30:08
  say
• 30:08
  Sarah
• 30:09
  does
• 30:09
  not
• 30:09
  have
• 30:09
  poor
• 30:09
  insight.
• 30:10
  She
• 30:10
  has
• 30:11
  very
• 30:11
  good
• 30:11
  insight
• 30:12
  into
• 30:12
  whether
• 30:12
  or
• 30:13
  not
• 30:13
  these
• 30:13
  OCD
• 30:13
  symptoms
• 30:14
  are
• 30:14
  rational.
• 30:15
  She
• 30:15
  is
• 30:15
  not
• 30:16
  delusional.
• 30:16
  You
• 30:17
  definitely
• 30:17
  want
• 30:17
  to
• 30:18
  start
• 30:18
  her
• 30:19
  on
• 30:19
  an
• 30:19
  SSRI
• 30:19
  or
• 30:20
  exposure
• 30:21
  therapy.
• 30:22
  Exposure
• 30:22
  and
• 30:23
  response
• 30:23
  prevention.
• 30:23
  That
• 30:24
  would
• 30:24
  be
• 30:24
  erp.
• 30:24
  It's
• 30:25
  really
• 30:25
  a
• 30:25
  gold
• 30:25
  standard
• 30:26
  psychotherapy.
• 30:27
  There
• 30:27
  will
• 30:27
  be
• 30:27
  more
• 30:27
  about
• 30:28
  this
• 30:28
  in
• 30:28
  our
• 30:28
  slides.
• 30:29
  You
• 30:29
  really
• 30:29
  want
• 30:29
  a
• 30:30
  comprehensive
• 30:31
  treatment
• 30:31
  approach
• 30:31
  here.
• 30:31
  Don't
• 30:32
  just
• 30:32
  rely
• 30:32
  on
• 30:32
  one
• 30:32
  ssri.
• 30:34
  Get
• 30:34
  therapy
• 30:34
  in
• 30:34
  the
• 30:34
  mix
• 30:35
  here,
• 30:36
  specifically
• 30:36
  tailored
• 30:37
  to
• 30:37
  what
• 30:37
  she's
• 30:37
  going
• 30:37
  through.
• 30:38
  And
• 30:38
  I
• 30:38
  think
• 30:38
  you're
• 30:39
  going
• 30:39
  to
• 30:39
  have
• 30:39
  way
• 30:39
  better
• 30:40
  outcomes.
• 30:40
  Right?
• 30:41
  Follow
• 30:41
  the
• 30:41
  outcomes
• 30:42
  with
• 30:42
  the
• 30:42
  largest
• 30:43
  effect
• 30:43
  sizes
• 30:44
  and
• 30:44
  the
• 30:45
  various
• 30:45
  treatment
• 30:45
  guidelines.
• 30:47
  You're
• 30:47
  going
• 30:47
  to
• 30:47
  do
• 30:47
  very,
• 30:48
  very
• 30:48
  well.
• 30:49
  I
• 30:49
  hope
• 30:49
  you
• 30:50
  had
• 30:50
  a
• 30:50
  good
• 30:50
  time
• 30:50
  with
• 30:51
  this
• 30:51
  mock
• 30:51
  case
• 30:52
  study
• 30:52
  today.
• 30:52
  I
• 30:52
  know
• 30:52
  I
• 30:53
  did.
• 30:53
  Every
• 30:54
  patient
• 30:54
  is
• 30:54
  an
• 30:54
  adventure.
• 30:55
  It's
• 30:55
  a
• 30:55
  journey
• 30:56
  that
• 30:56
  you
• 30:56
  go
• 30:56
  on
• 30:56
  together.
• 30:58
  It's
• 30:58
  very
• 30:58
  rewarding
• 30:59
  and
• 30:59
  asking
• 30:59
  the
• 31:00
  right
• 31:00
  questions
• 31:00
  is
• 31:01
  half
• 31:01
  of
• 31:01
  the
• 31:01
  fund
• 31:02
  to
• 31:02
  really
• 31:02
  pinpoint
• 31:03
  the
• 31:03
  best
• 31:03
  diagnosis.
• 31:04
  And
• 31:04
  remember,
• 31:05
  if
• 31:05
  Sarah
• 31:05
  has
• 31:05
  depression,
• 31:07
  it's
• 31:07
  more
• 31:07
  than
• 31:07
  okay
• 31:08
  to
• 31:08
  lean
• 31:09
  on
• 31:09
  your
• 31:09
  SSRI
• 31:09
  because
• 31:10
  the
• 31:10
  SSRI
• 31:10
  is
• 31:11
  there
• 31:11
  for
• 31:11
  ocd.
• 31:11
  It's
• 31:11
  also
• 31:12
  gonna
• 31:12
  help
• 31:12
  treat
• 31:13
  mood
• 31:13
  and
• 31:13
  depression.
• 31:14
  And
• 31:14
  remember,
• 31:15
  whether
• 31:15
  depression
• 31:15
  is
• 31:16
  secondary
• 31:16
  to
• 31:16
  the
• 31:16
  OCD
• 31:17
  or
• 31:17
  primary
• 31:18
  to
• 31:18
  the
• 31:18
  ocd,
• 31:19
  it
• 31:19
  doesn't
• 31:19
  matter.
• 31:20
  It's
• 31:20
  still
• 31:20
  going
• 31:21
  to
• 31:21
  treat
• 31:21
  both
• 31:22
  because
• 31:22
  that's
• 31:23
  what
• 31:23
  SSRIs
• 31:24
  do,
• 31:24
  right?
• 31:24
  Just
• 31:25
  by
• 31:25
  treating
• 31:25
  the
• 31:25
  OCD
• 31:26
  symptoms,
• 31:26
  you
• 31:26
  might
• 31:27
  see
• 31:27
  a
• 31:27
  relief
• 31:27
  in
• 31:27
  depression
• 31:28
  because
• 31:28
  the
• 31:29
  patient
• 31:29
  has
• 31:29
  a
• 31:29
  little
• 31:29
  more
• 31:30
  room
• 31:30
  and
• 31:30
  energy
• 31:30
  to
• 31:31
  pursue
• 31:31
  their
• 31:31
  goals
• 31:32
  and
• 31:32
  eat
• 31:32
  healthy
• 31:33
  and
• 31:34
  sleep
• 31:34
  well
• 31:34
  at
• 31:34
  night
• 31:35
  because
• 31:35
  those
• 31:35
  obsessional
• 31:36
  thought
• 31:36
  circuits
• 31:37
  aren't
• 31:37
  cutting
• 31:38
  them
• 31:38
  down
• 31:38
  in
• 31:38
  really
• 31:39
  important
• 31:39
  ways.
• 31:40
  Well,
• 31:40
  that's
• 31:40
  all
• 31:40
  for
• 31:41
  today,
• 31:41
  my
• 31:41
  friends.
• 31:42
  I
• 31:42
  appreciate
• 31:43
  each
• 31:43
  and
• 31:43
  every
• 31:44
  one
• 31:44
  of
• 31:44
  you
• 31:44
  for
• 31:44
  joining.
• 31:45
  I
• 31:45
  would
• 31:46
  really
• 31:46
  appreciate
• 31:47
  if
• 31:47
  all
• 31:47
  of
• 31:47
  you,
• 31:48
  even
• 31:48
  if
• 31:48
  you
• 31:48
  learned
• 31:49
  one
• 31:49
  pearl
• 31:49
  today
• 31:50
  that
• 31:50
  will
• 31:50
  empower
• 31:50
  you
• 31:50
  in
• 31:51
  your
• 31:51
  practice.
• 31:51
  The
• 31:52
  only
• 31:52
  way
• 31:52
  I
• 31:52
  ask
• 31:53
  that
• 31:53
  you
• 31:53
  give
• 31:53
  me
• 31:54
  thanks
• 31:54
  is
• 31:54
  run
• 31:54
  over
• 31:55
  to
• 31:55
  Apple
• 31:55
  Podcasts
• 31:56
  and
• 31:56
  rate
• 31:56
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• 31:57
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• 31:58
  Pearls
• 31:58
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• 31:58
  Prep.
• 31:59
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• 31:59
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• 31:59
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• 31:59
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• 32:00
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• 32:00
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• 32:00
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• 32:00
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• 32:01
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• 32:01
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• 32:02
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• 32:02
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• 32:02
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• 32:02
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• 32:03
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• 32:03
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• 32:03
  if
• 32:03
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• 32:04
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• 32:04
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• 32:04
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• 32:05
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• 32:05
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• 32:05
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• 32:08
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• 32:08
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• 32:08
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• 32:09
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• 32:09
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• 32:09
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• 32:09
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• 32:10
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• 32:10
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• 32:10
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• 32:11
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• 32:12
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• 32:19
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• 32:22
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• 32:22
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• 32:23
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• 32:23
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• 32:23
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• 32:23
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• 32:24
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• 32:24
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• 32:24
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• 32:24
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• 32:25
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• 32:25
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• 32:31
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• 32:32
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• 32:32
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• 32:32
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• 32:33
  pearlsandprep
• 32:34
  to
• 32:35
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• 32:35
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• 32:35
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• 32:36
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• 32:36
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• 32:37
  all
• 32:37
  of
• 32:37
  you
• 32:37
  and
• 32:37
  see
• 32:37
  you
• 32:37
  next
• 32:38
  time.
• 32:38
  Bye
• 32:39
  bye.