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Transcript

Mock Patient Elias: “Am I Real?” | The Diagnostic Tangle of Depersonalization vs Panic vs PTSD · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:05
  back,
• 0:06
  my
• 0:06
  friends,
• 0:06
  to
• 0:06
  another
• 0:07
  episode
• 0:07
  of
• 0:07
  Pearls
• 0:08
  and
• 0:08
  Prep.
• 0:08
  This
• 0:09
  is
• 0:09
  NPZ
• 0:09
  here,
• 0:10
  your
• 0:10
  preceptor
• 0:11
  in
• 0:11
  your
• 0:11
  pocket,
• 0:12
  your
• 0:12
  go
• 0:12
  to
• 0:12
  place
• 0:13
  for
• 0:13
  pearls
• 0:14
  that
• 0:14
  prep
• 0:14
  you
• 0:14
  to
• 0:14
  practice.
• 0:15
  All
• 0:15
  right,
• 0:16
  well,
• 0:16
  we
• 0:16
  have
• 0:17
  a
• 0:17
  doozy
• 0:17
  today.
• 0:19
  Knocking
• 0:20
  at
• 0:20
  your
• 0:20
  door.
• 0:21
  Knock,
• 0:21
  knock,
• 0:21
  knock.
• 0:22
  Is
• 0:22
  a
• 0:22
  mock
• 0:22
  patient.
• 0:23
  We're
• 0:23
  going
• 0:23
  to
• 0:23
  call
• 0:23
  him
• 0:24
  Elias.
• 0:25
  Okay,
• 0:25
  I'm
• 0:25
  going
• 0:25
  to
• 0:25
  spend
• 0:25
  about
• 0:26
  three
• 0:26
  minutes
• 0:26
  just
• 0:27
  giving
• 0:27
  you
• 0:27
  his
• 0:27
  background
• 0:28
  so
• 0:28
  you
• 0:28
  can
• 0:29
  start
• 0:29
  to
• 0:29
  put
• 0:29
  your
• 0:29
  thinking
• 0:30
  caps
• 0:30
  on
• 0:31
  and
• 0:32
  get
• 0:32
  your
• 0:32
  feet
• 0:33
  wet
• 0:33
  with
• 0:33
  a
• 0:33
  really
• 0:34
  high
• 0:34
  yield
• 0:35
  study
• 0:36
  that
• 0:36
  you're
• 0:37
  going
• 0:37
  to
• 0:37
  feel
• 0:37
  you're
• 0:38
  on.
• 0:38
  You're
• 0:38
  at
• 0:38
  the
• 0:38
  top
• 0:39
  of
• 0:39
  your
• 0:39
  game
• 0:39
  after
• 0:39
  this.
• 0:40
  All
• 0:40
  right,
• 0:40
  my
• 0:40
  friend?
• 0:41
  So
• 0:41
  Elias
• 0:42
  is
• 0:42
  22
• 0:43
  years
• 0:43
  old.
• 0:43
  He's
• 0:43
  a
• 0:44
  male
• 0:44
  graduate
• 0:45
  student
• 0:46
  and
• 0:46
  his
• 0:46
  university
• 0:47
  counseling
• 0:47
  center
• 0:48
  referred
• 0:48
  him
• 0:48
  here.
• 0:49
  He's
• 0:49
  telling
• 0:49
  you
• 0:50
  as
• 0:50
  a
• 0:50
  chief
• 0:50
  complaint
• 0:51
  that
• 0:51
  he
• 0:51
  feels
• 0:52
  like
• 0:52
  he's
• 0:52
  watching
• 0:53
  his
• 0:53
  life
• 0:53
  through
• 0:53
  a
• 0:54
  window.
• 0:54
  Nothing
• 0:55
  feels
• 0:55
  real.
• 0:55
  He
• 0:56
  says,
• 0:56
  not
• 0:56
  me,
• 0:56
  not
• 0:57
  the
• 0:57
  world.
• 0:57
  It's
• 0:58
  been
• 0:58
  like
• 0:58
  this
• 0:58
  for
• 0:58
  months
• 0:59
  and
• 0:59
  I
• 0:59
  think
• 0:59
  I'm
• 1:00
  going
• 1:00
  insane
• 1:01
  now.
• 1:02
  He
• 1:02
  has
• 1:02
  a
• 1:03
  seven
• 1:03
  month
• 1:03
  history
• 1:04
  of
• 1:05
  persistent,
• 1:05
  near
• 1:06
  constant
• 1:06
  experiences
• 1:07
  of
• 1:07
  feeling
• 1:07
  detached
• 1:08
  from
• 1:08
  himself
• 1:09
  and
• 1:09
  his
• 1:09
  surroundings.
• 1:10
  He
• 1:10
  feels
• 1:11
  like
• 1:11
  an
• 1:11
  automaton,
• 1:12
  he
• 1:12
  said,
• 1:12
  going
• 1:12
  through
• 1:12
  the
• 1:13
  motions
• 1:13
  of
• 1:13
  daily
• 1:13
  life.
• 1:14
  His
• 1:14
  own
• 1:15
  hands
• 1:15
  don't
• 1:15
  even
• 1:16
  look
• 1:16
  familiar.
• 1:16
  His
• 1:16
  voice
• 1:17
  sounds
• 1:17
  distant,
• 1:18
  like
• 1:18
  it's
• 1:19
  coming
• 1:19
  from
• 1:19
  a
• 1:19
  speaker
• 1:20
  in
• 1:20
  another
• 1:20
  room.
• 1:21
  He
• 1:21
  says
• 1:21
  his
• 1:21
  conversations
• 1:22
  feel
• 1:22
  scripted
• 1:23
  and
• 1:23
  artificial.
• 1:24
  He
• 1:24
  reports
• 1:25
  the
• 1:25
  world
• 1:25
  looks
• 1:25
  flat,
• 1:26
  kind
• 1:26
  of
• 1:26
  two
• 1:26
  dimensional
• 1:27
  and
• 1:27
  objects
• 1:28
  kind
• 1:28
  of
• 1:28
  change
• 1:29
  in
• 1:29
  size
• 1:29
  when
• 1:29
  he
• 1:30
  looks
• 1:30
  at
• 1:30
  them.
• 1:30
  His
• 1:31
  coffee
• 1:31
  mug
• 1:31
  will
• 1:32
  look
• 1:32
  really
• 1:32
  big
• 1:32
  and
• 1:32
  then
• 1:33
  really
• 1:33
  small.
• 1:33
  Colors
• 1:34
  are
• 1:34
  kind
• 1:34
  of
• 1:34
  muted,
• 1:35
  almost
• 1:35
  like
• 1:36
  someone's
• 1:36
  turning
• 1:36
  the
• 1:36
  saturation
• 1:37
  down.
• 1:37
  So
• 1:38
  this
• 1:38
  is
• 1:38
  a
• 1:38
  little
• 1:38
  bit
• 1:39
  unusual.
• 1:40
  You
• 1:40
  might
• 1:40
  see
• 1:40
  this
• 1:41
  and
• 1:41
  go,
• 1:41
  oh
• 1:41
  my
• 1:41
  God,
• 1:41
  what
• 1:41
  am
• 1:42
  I
• 1:42
  looking
• 1:42
  at
• 1:42
  here?
• 1:43
  That's
• 1:43
  okay.
• 1:43
  That's
• 1:44
  why
• 1:44
  we
• 1:44
  do
• 1:44
  these
• 1:45
  episodes
• 1:45
  to
• 1:45
  prepare
• 1:46
  you
• 1:46
  for
• 1:47
  and
• 1:47
  prep
• 1:47
  you
• 1:47
  to
• 1:47
  practice.
• 1:48
  Right.
• 1:49
  Because
• 1:49
  this
• 1:49
  is
• 1:49
  something
• 1:49
  very
• 1:50
  definable.
• 1:50
  We're
• 1:51
  going
• 1:51
  to
• 1:51
  get
• 1:51
  through
• 1:51
  this.
• 1:52
  We
• 1:52
  are
• 1:52
  going
• 1:53
  to
• 1:53
  tackle
• 1:53
  this.
• 1:53
  So
• 1:53
  what
• 1:54
  else
• 1:54
  do
• 1:54
  we
• 1:54
  have
• 1:54
  on
• 1:55
  Mr.
• 1:55
  Elias
• 1:56
  here?
• 1:56
  Well,
• 1:57
  he's
• 1:57
  very
• 1:57
  distressed
• 1:58
  by
• 1:58
  these
• 1:58
  experiences.
• 1:59
  He
• 1:59
  spends
• 2:00
  two
• 2:00
  to
• 2:00
  three
• 2:00
  hours
• 2:01
  a
• 2:01
  day
• 2:01
  googling
• 2:01
  symptoms,
• 2:02
  oscillating
• 2:03
  between
• 2:03
  fear
• 2:04
  that
• 2:04
  he
• 2:04
  has
• 2:04
  like
• 2:05
  this
• 2:05
  early
• 2:05
  onset
• 2:06
  schizophrenia
• 2:07
  or
• 2:07
  fear
• 2:07
  that
• 2:07
  he
• 2:07
  has
• 2:08
  permanent
• 2:08
  brain
• 2:08
  damage,
• 2:09
  he's
• 2:10
  developed
• 2:10
  like
• 2:10
  a
• 2:10
  checking
• 2:11
  ritual,
• 2:11
  even
• 2:12
  he's
• 2:13
  pinching
• 2:13
  himself
• 2:13
  repeatedly
• 2:14
  throughout
• 2:14
  the
• 2:14
  day
• 2:15
  just
• 2:15
  to
• 2:15
  make
• 2:15
  sure
• 2:15
  he
• 2:15
  can
• 2:16
  feel
• 2:16
  anything.
• 2:16
  He
• 2:16
  avoids
• 2:17
  crowds
• 2:18
  because
• 2:18
  overstimulation
• 2:19
  kind
• 2:20
  of
• 2:20
  worsens
• 2:20
  his
• 2:21
  symptoms.
• 2:22
  Now
• 2:22
  he
• 2:22
  tells
• 2:22
  you
• 2:23
  that
• 2:23
  he
• 2:23
  intellectually
• 2:24
  he
• 2:24
  knows
• 2:24
  he's
• 2:25
  real
• 2:25
  and
• 2:25
  the
• 2:25
  world
• 2:25
  is
• 2:26
  real,
• 2:26
  but
• 2:26
  it
• 2:26
  doesn't
• 2:27
  feel
• 2:27
  that
• 2:27
  way.
• 2:28
  And
• 2:28
  he
• 2:28
  says
• 2:29
  it's
• 2:29
  the
• 2:29
  most
• 2:29
  terrifying
• 2:30
  disconnect
• 2:30
  he's
• 2:30
  ever
• 2:31
  experienced.
• 2:31
  He
• 2:32
  did
• 2:32
  smoke
• 2:32
  high
• 2:32
  potency
• 2:33
  cannabis.
• 2:33
  It
• 2:34
  was
• 2:34
  an
• 2:34
  edible
• 2:34
  at
• 2:34
  a
• 2:34
  party.
• 2:35
  And
• 2:35
  he
• 2:36
  did
• 2:36
  that
• 2:36
  about
• 2:37
  seven
• 2:37
  months
• 2:37
  ago
• 2:37
  and,
• 2:38
  and
• 2:38
  within
• 2:38
  90
• 2:38
  minutes,
• 2:39
  sure
• 2:39
  enough,
• 2:39
  he
• 2:40
  had
• 2:40
  a
• 2:40
  huge
• 2:40
  panic
• 2:41
  attack
• 2:41
  where
• 2:42
  the
• 2:42
  world
• 2:42
  didn't
• 2:42
  really
• 2:42
  feel
• 2:43
  real.
• 2:43
  His
• 2:43
  heart
• 2:43
  was
• 2:44
  beating
• 2:44
  really
• 2:44
  fast
• 2:44
  and
• 2:45
  he
• 2:45
  thought
• 2:45
  he
• 2:45
  was
• 2:45
  for
• 2:46
  sure
• 2:46
  dying.
• 2:47
  It
• 2:47
  resolved
• 2:47
  within
• 2:48
  several
• 2:48
  hours,
• 2:49
  but
• 2:49
  the,
• 2:49
  the
• 2:50
  feeling
• 2:50
  like
• 2:50
  the,
• 2:50
  the
• 2:51
  world
• 2:51
  was
• 2:51
  never
• 2:51
  really
• 2:52
  real,
• 2:52
  never
• 2:52
  really
• 2:53
  cleared
• 2:53
  from
• 2:53
  him.
• 2:54
  And
• 2:54
  over
• 2:54
  the
• 2:54
  last,
• 2:55
  you
• 2:55
  know,
• 2:55
  over
• 2:56
  the
• 2:56
  following
• 2:56
  weeks,
• 2:56
  it
• 2:57
  kind
• 2:57
  of
• 2:57
  got
• 2:57
  worse
• 2:58
  and
• 2:58
  the
• 2:58
  depersonalization
• 2:59
  component
• 3:00
  kind
• 3:00
  of
• 3:00
  emerged
• 3:01
  where
• 3:01
  he
• 3:01
  was
• 3:01
  kind
• 3:01
  of
• 3:01
  detached
• 3:02
  from
• 3:02
  himself.
• 3:04
  He
• 3:04
  hasn't
• 3:04
  really
• 3:04
  used
• 3:04
  cannabis
• 3:05
  since
• 3:05
  then
• 3:05
  because
• 3:06
  he's
• 3:06
  terrified
• 3:06
  of
• 3:06
  the
• 3:07
  thing.
• 3:07
  He
• 3:07
  does
• 3:08
  have
• 3:08
  a
• 3:08
  diagnosis
• 3:08
  of
• 3:08
  generalized
• 3:09
  anxiety.
• 3:10
  It's
• 3:10
  never
• 3:10
  been
• 3:10
  formally
• 3:11
  treated.
• 3:11
  He
• 3:12
  is
• 3:13
  described
• 3:13
  as
• 3:13
  a
• 3:13
  warrior.
• 3:14
  Since
• 3:14
  his
• 3:14
  childhood,
• 3:15
  he's
• 3:15
  never
• 3:15
  been
• 3:15
  depressed,
• 3:16
  no
• 3:16
  prior
• 3:16
  psychotic
• 3:17
  episodes,
• 3:17
  no
• 3:17
  mania,
• 3:18
  no
• 3:18
  hypomania,
• 3:19
  no
• 3:19
  prior
• 3:20
  disassociative
• 3:20
  episodes,
• 3:21
  no
• 3:21
  amnesia,
• 3:22
  no
• 3:22
  identity
• 3:22
  disturbance.
• 3:23
  He
• 3:24
  has
• 3:24
  no
• 3:24
  history
• 3:24
  of
• 3:24
  self
• 3:24
  harm
• 3:25
  or
• 3:25
  suicidal
• 3:26
  behavior.
• 3:27
  His
• 3:27
  parents
• 3:27
  did
• 3:27
  divorce
• 3:28
  at
• 3:28
  age
• 3:28
  10.
• 3:28
  He
• 3:29
  said
• 3:29
  it
• 3:29
  was
• 3:29
  stressful,
• 3:30
  but
• 3:30
  not
• 3:30
  really
• 3:30
  traumatic.
• 3:31
  He
• 3:32
  denies
• 3:32
  any
• 3:32
  physical,
• 3:32
  sexual
• 3:33
  or
• 3:33
  emotional
• 3:33
  abuse.
• 3:34
  He
• 3:34
  denies
• 3:34
  witnessing
• 3:35
  violence.
• 3:36
  He
• 3:36
  does
• 3:36
  state
• 3:36
  that
• 3:37
  his
• 3:37
  mom
• 3:37
  was
• 3:37
  kind
• 3:37
  of
• 3:38
  emotionally
• 3:38
  unavailable,
• 3:39
  however,
• 3:40
  and
• 3:40
  dad
• 3:40
  was
• 3:40
  this
• 3:41
  high
• 3:41
  achieving
• 3:41
  surgeon
• 3:42
  who
• 3:43
  was
• 3:43
  a
• 3:43
  super
• 3:43
  big
• 3:44
  perfectionist.
• 3:45
  And
• 3:45
  Elias
• 3:45
  says
• 3:46
  that
• 3:46
  his
• 3:46
  childhood
• 3:46
  was
• 3:47
  kind
• 3:47
  of
• 3:47
  walking
• 3:47
  on
• 3:47
  eggshells
• 3:48
  and
• 3:48
  he
• 3:48
  really
• 3:49
  learned
• 3:49
  to
• 3:49
  suppress
• 3:50
  his
• 3:50
  emotions.
• 3:50
  Okay.
• 3:51
  His
• 3:51
  mom
• 3:51
  also
• 3:52
  has
• 3:52
  gad.
• 3:52
  She's
• 3:53
  treated
• 3:53
  with
• 3:53
  buspirone.
• 3:54
  Dad
• 3:55
  doesn't
• 3:55
  really
• 3:55
  have
• 3:55
  a
• 3:55
  psychiatric
• 3:56
  history
• 3:56
  and
• 3:56
  there's
• 3:57
  no
• 3:57
  family
• 3:57
  history
• 3:57
  of
• 3:57
  bipolar
• 3:58
  psychosis,
• 3:59
  suicide,
• 3:59
  so
• 4:00
  none
• 4:00
  of
• 4:00
  that
• 4:00
  going
• 4:00
  on.
• 4:01
  Okay.
• 4:02
  Again,
• 4:02
  he's
• 4:03
  used
• 4:03
  cannabis
• 4:03
  three
• 4:04
  times
• 4:04
  in
• 4:04
  his
• 4:04
  life.
• 4:05
  Last
• 4:05
  one
• 4:05
  was
• 4:06
  seven
• 4:06
  months
• 4:06
  ago.
• 4:06
  He
• 4:06
  doesn't
• 4:07
  really
• 4:07
  drink,
• 4:07
  no
• 4:07
  other
• 4:08
  substance
• 4:08
  use,
• 4:08
  and
• 4:08
  his
• 4:08
  UDS
• 4:09
  is
• 4:09
  negative.
• 4:10
  Okay,
• 4:11
  so
• 4:12
  all
• 4:12
  very
• 4:12
  important
• 4:13
  stuff.
• 4:13
  Now,
• 4:13
  his
• 4:14
  labs
• 4:14
  came
• 4:14
  back.
• 4:15
  CBC,
• 4:15
  CMP,
• 4:16
  TSH,
• 4:16
  B12,
• 4:17
  folate,
• 4:18
  RPR,
• 4:19
  all
• 4:19
  within
• 4:19
  normal
• 4:20
  limits.
• 4:20
  His,
• 4:21
  there's
• 4:21
  no
• 4:21
  drugs
• 4:22
  in
• 4:22
  his
• 4:22
  system.
• 4:23
  They
• 4:23
  even
• 4:23
  ordered
• 4:24
  an
• 4:24
  eeg.
• 4:25
  His
• 4:25
  primary
• 4:25
  care
• 4:26
  provider
• 4:27
  used,
• 4:27
  ordered
• 4:27
  an
• 4:28
  eeg
• 4:28
  and
• 4:29
  there's
• 4:29
  no,
• 4:30
  no
• 4:30
  form
• 4:31
  of
• 4:31
  epilepsy
• 4:32
  or
• 4:32
  seizure
• 4:32
  activity.
• 4:33
  Okay,
• 4:34
  so
• 4:34
  with
• 4:35
  everything
• 4:35
  that
• 4:35
  we
• 4:36
  know
• 4:36
  about
• 4:36
  this,
• 4:37
  right,
• 4:38
  what
• 4:38
  is
• 4:38
  at
• 4:38
  the
• 4:38
  top
• 4:39
  of
• 4:39
  your
• 4:39
  mind?
• 4:40
  Now?
• 4:41
  I
• 4:41
  always
• 4:42
  kind
• 4:42
  of
• 4:42
  urge
• 4:42
  you
• 4:42
  guys,
• 4:43
  if
• 4:43
  you're,
• 4:43
  if
• 4:44
  you're
• 4:44
  stuck
• 4:44
  in
• 4:45
  session
• 4:45
  and
• 4:46
  something
• 4:46
  like
• 4:46
  this
• 4:47
  is,
• 4:47
  is
• 4:48
  coming
• 4:48
  at
• 4:48
  you,
• 4:49
  and
• 4:49
  this
• 4:49
  is
• 4:49
  not
• 4:50
  your
• 4:50
  run
• 4:50
  of
• 4:50
  the
• 4:50
  mill
• 4:50
  depression
• 4:51
  or
• 4:52
  anxiety
• 4:52
  or
• 4:52
  even
• 4:53
  ptsd,
• 4:53
  right?
• 4:54
  This
• 4:54
  is
• 4:55
  kind
• 4:55
  of
• 4:55
  more
• 4:55
  of
• 4:55
  an
• 4:56
  unusual
• 4:56
  patient.
• 4:57
  However,
• 4:57
  it
• 4:58
  does
• 4:58
  show
• 4:58
  up
• 4:58
  in
• 4:58
  your
• 4:58
  outpatient
• 4:59
  practice
• 4:59
  and
• 5:00
  you
• 5:00
  will
• 5:00
  have
• 5:00
  to
• 5:00
  be
• 5:00
  somewhat
• 5:01
  prepared
• 5:02
  and
• 5:02
  you
• 5:02
  have
• 5:02
  to
• 5:02
  have
• 5:02
  the
• 5:03
  vocabulary
• 5:03
  and
• 5:03
  the
• 5:04
  knowledge
• 5:04
  to
• 5:04
  kind
• 5:04
  of
• 5:04
  understand
• 5:05
  what
• 5:05
  this
• 5:05
  is
• 5:05
  and
• 5:05
  what
• 5:06
  to
• 5:06
  do
• 5:06
  with
• 5:06
  it.
• 5:06
  But
• 5:07
  I
• 5:07
  always
• 5:07
  encourage
• 5:08
  you
• 5:08
  guys
• 5:09
  to
• 5:09
  zoom
• 5:10
  out
• 5:10
  a
• 5:10
  little
• 5:10
  bit,
• 5:11
  take
• 5:11
  a
• 5:11
  deep
• 5:11
  breath
• 5:11
  and
• 5:12
  say,
• 5:12
  okay,
• 5:12
  well,
• 5:12
  regardless
• 5:13
  of
• 5:13
  what
• 5:13
  we're
• 5:13
  looking
• 5:14
  at
• 5:14
  here,
• 5:14
  right,
• 5:15
  we
• 5:15
  don't
• 5:15
  even
• 5:15
  need
• 5:16
  to
• 5:16
  know
• 5:16
  the
• 5:16
  exact
• 5:17
  diagnosis
• 5:17
  right
• 5:18
  now,
• 5:18
  but
• 5:18
  we
• 5:19
  clearly
• 5:19
  have
• 5:19
  somebody
• 5:20
  in
• 5:20
  our
• 5:20
  office
• 5:21
  who
• 5:21
  is
• 5:22
  super
• 5:22
  nervous,
• 5:23
  super
• 5:24
  anxious,
• 5:25
  right?
• 5:26
  And
• 5:26
  they're
• 5:26
  giving
• 5:26
  you
• 5:27
  some
• 5:27
  sense
• 5:28
  that
• 5:28
  they
• 5:28
  understand
• 5:28
  what's
• 5:29
  going
• 5:29
  on.
• 5:30
  Right?
• 5:30
  Elias,
• 5:31
  during
• 5:32
  this
• 5:32
  interview
• 5:32
  that
• 5:32
  I
• 5:32
  shared
• 5:33
  with
• 5:33
  you
• 5:33
  in,
• 5:34
  at
• 5:34
  no
• 5:34
  point
• 5:35
  did
• 5:35
  he
• 5:36
  exhibit
• 5:36
  that
• 5:36
  he
• 5:37
  was
• 5:37
  out
• 5:37
  of
• 5:37
  touch
• 5:37
  with
• 5:38
  reality.
• 5:39
  Okay?
• 5:39
  He
• 5:40
  even
• 5:40
  made
• 5:40
  it
• 5:40
  very
• 5:40
  clear
• 5:41
  to
• 5:41
  you
• 5:41
  when
• 5:41
  he
• 5:41
  said,
• 5:41
  I
• 5:42
  know
• 5:42
  that
• 5:42
  intellectually,
• 5:43
  I'm.
• 5:43
  I'm
• 5:44
  in
• 5:44
  the
• 5:44
  real
• 5:44
  world.
• 5:44
  The
• 5:44
  world
• 5:45
  is
• 5:45
  real,
• 5:45
  but
• 5:45
  I
• 5:45
  don't
• 5:46
  feel
• 5:46
  that
• 5:46
  way.
• 5:47
  So
• 5:47
  that
• 5:47
  alone
• 5:47
  is
• 5:47
  like
• 5:48
  a
• 5:48
  huge
• 5:49
  win
• 5:49
  for
• 5:49
  Elias.
• 5:50
  It's
• 5:50
  a
• 5:50
  huge
• 5:51
  win
• 5:51
  for
• 5:51
  you.
• 5:52
  And
• 5:52
  so
• 5:52
  we
• 5:52
  can
• 5:52
  kind
• 5:52
  of
• 5:52
  back
• 5:53
  up
• 5:53
  and
• 5:53
  go,
• 5:53
  we
• 5:53
  have
• 5:53
  a
• 5:53
  really
• 5:54
  anxious
• 5:54
  person,
• 5:54
  but
• 5:55
  he's
• 5:55
  understanding
• 5:56
  of.
• 5:57
  He
• 5:57
  has
• 5:57
  full
• 5:57
  awareness
• 5:58
  about
• 5:58
  what
• 5:58
  is
• 5:58
  going
• 5:59
  on,
• 5:59
  that
• 5:59
  something
• 5:59
  is
• 6:00
  not
• 6:00
  right
• 6:00
  here.
• 6:01
  He
• 6:01
  knows
• 6:01
  who
• 6:01
  he
• 6:01
  is.
• 6:02
  He
• 6:02
  doesn't
• 6:02
  think
• 6:02
  he's
• 6:03
  some
• 6:03
  alien.
• 6:04
  He's
• 6:04
  not
• 6:04
  completely
• 6:05
  divorced
• 6:06
  from
• 6:06
  reality.
• 6:06
  He
• 6:06
  understands
• 6:07
  enough
• 6:07
  to
• 6:07
  know
• 6:07
  that
• 6:08
  this
• 6:08
  is
• 6:09
  bizarre
• 6:09
  and
• 6:10
  distressing
• 6:11
  and
• 6:11
  not
• 6:12
  how
• 6:12
  he
• 6:12
  wants
• 6:12
  to
• 6:12
  feel
• 6:13
  or
• 6:13
  how
• 6:13
  he
• 6:13
  used
• 6:13
  to
• 6:13
  feel.
• 6:14
  So
• 6:14
  that
• 6:14
  alone
• 6:15
  is
• 6:15
  extremely
• 6:16
  important
• 6:16
  on
• 6:17
  the
• 6:17
  mental
• 6:17
  status
• 6:17
  exam.
• 6:18
  You
• 6:18
  noticed
• 6:18
  also,
• 6:19
  he
• 6:19
  was
• 6:19
  well
• 6:19
  groomed,
• 6:20
  appropriately
• 6:20
  dressed.
• 6:21
  That
• 6:21
  might
• 6:21
  feel
• 6:22
  like
• 6:22
  a
• 6:22
  checkbox
• 6:23
  for
• 6:23
  a
• 6:23
  lot
• 6:23
  of
• 6:23
  you
• 6:23
  students
• 6:24
  or
• 6:24
  new
• 6:24
  clinicians.
• 6:25
  Well
• 6:26
  groomed,
• 6:26
  appropriately
• 6:26
  dressed,
• 6:27
  cooperative.
• 6:28
  But
• 6:28
  I
• 6:28
  want
• 6:28
  you
• 6:28
  to
• 6:28
  think
• 6:29
  about
• 6:29
  what
• 6:29
  the
• 6:29
  opposite
• 6:29
  of
• 6:30
  that
• 6:30
  looks
• 6:30
  like,
• 6:30
  right?
• 6:30
  If
• 6:31
  he
• 6:31
  was
• 6:31
  disheveled
• 6:31
  in
• 6:32
  your
• 6:32
  office
• 6:32
  with
• 6:33
  these
• 6:33
  same
• 6:33
  concerns,
• 6:34
  or
• 6:35
  if
• 6:35
  he
• 6:35
  was
• 6:35
  kind
• 6:36
  of
• 6:36
  his
• 6:36
  mind
• 6:36
  or
• 6:37
  his
• 6:37
  eyes
• 6:38
  were
• 6:38
  kind
• 6:38
  of
• 6:38
  wandering
• 6:38
  around
• 6:39
  the
• 6:39
  room
• 6:39
  suspiciously,
• 6:40
  right?
• 6:40
  So
• 6:41
  even
• 6:41
  though
• 6:41
  it's
• 6:41
  a
• 6:42
  checkbox,
• 6:42
  it
• 6:42
  feels
• 6:43
  like
• 6:43
  a
• 6:43
  checkbox
• 6:43
  to
• 6:44
  say,
• 6:44
  well
• 6:44
  groomed,
• 6:44
  appropriately
• 6:45
  dressed,
• 6:45
  cooperative.
• 6:46
  The
• 6:46
  opposite
• 6:47
  of
• 6:47
  that
• 6:47
  can
• 6:47
  definitely
• 6:48
  steer
• 6:48
  you
• 6:48
  into
• 6:48
  a
• 6:49
  different
• 6:49
  kind
• 6:49
  of
• 6:49
  diagnosis,
• 6:50
  which
• 6:50
  would
• 6:50
  be,
• 6:50
  you
• 6:51
  know,
• 6:51
  maybe
• 6:51
  this
• 6:51
  disorganized
• 6:53
  schizophrenia,
• 6:54
  right?
• 6:54
  If
• 6:54
  somebody's
• 6:54
  disheveled,
• 6:55
  they're
• 6:55
  not
• 6:55
  well
• 6:55
  kept,
• 6:56
  they're
• 6:56
  not
• 6:56
  able
• 6:56
  to
• 6:57
  really
• 6:57
  think
• 6:57
  in
• 6:58
  a
• 6:58
  clear,
• 6:58
  logical,
• 6:59
  linear,
• 6:59
  organized
• 6:59
  fashion
• 7:00
  to
• 7:00
  even
• 7:00
  comb
• 7:00
  their
• 7:01
  hair
• 7:01
  or
• 7:01
  iron
• 7:02
  their
• 7:02
  shirt,
• 7:03
  button
• 7:03
  their
• 7:03
  shirt.
• 7:04
  So
• 7:04
  his
• 7:04
  mental
• 7:05
  status
• 7:05
  exam,
• 7:05
  he's
• 7:06
  certainly
• 7:06
  anxious,
• 7:07
  and
• 7:07
  that's
• 7:08
  something
• 7:08
  to
• 7:08
  take
• 7:08
  note
• 7:08
  of.
• 7:09
  But
• 7:09
  again,
• 7:09
  he's
• 7:09
  well
• 7:09
  groomed,
• 7:10
  he's
• 7:10
  appropriately
• 7:11
  dressed,
• 7:11
  he's
• 7:12
  not
• 7:12
  suicidal,
• 7:13
  and
• 7:13
  he's
• 7:13
  not
• 7:14
  hallucinating,
• 7:14
  Right?
• 7:15
  He
• 7:16
  has
• 7:16
  these
• 7:16
  very
• 7:16
  bizarre
• 7:17
  perceptual
• 7:19
  disturbances.
• 7:20
  But
• 7:20
  he's
• 7:20
  aware
• 7:20
  of
• 7:21
  the
• 7:21
  fact
• 7:21
  that
• 7:22
  this
• 7:22
  does
• 7:22
  not
• 7:22
  necessarily
• 7:23
  Express
• 7:23
  reality.
• 7:24
  This
• 7:24
  is
• 7:24
  his
• 7:24
  own
• 7:25
  subjective
• 7:26
  perception.
• 7:27
  And
• 7:27
  that
• 7:27
  is
• 7:28
  the
• 7:28
  key,
• 7:28
  my
• 7:28
  friends,
• 7:28
  if
• 7:29
  you.
• 7:29
  If
• 7:29
  your
• 7:29
  patient
• 7:30
  is
• 7:30
  aware
• 7:32
  that
• 7:33
  something
• 7:33
  is
• 7:34
  wrong
• 7:35
  and
• 7:35
  it's
• 7:35
  ego
• 7:36
  dystonic,
• 7:36
  in
• 7:37
  other
• 7:37
  words,
• 7:37
  it's.
• 7:37
  It's.
• 7:38
  It's
• 7:38
  not
• 7:38
  something
• 7:38
  that
• 7:39
  resonates
• 7:39
  warmly
• 7:40
  with
• 7:40
  them,
• 7:40
  they're
• 7:40
  disturbed
• 7:41
  by
• 7:41
  this
• 7:41
  stuff.
• 7:42
  That
• 7:42
  is
• 7:42
  all
• 7:43
  that
• 7:43
  is
• 7:43
  reassuring
• 7:43
  and
• 7:44
  should
• 7:44
  kind
• 7:44
  of
• 7:44
  guide
• 7:45
  you
• 7:45
  away
• 7:45
  from
• 7:45
  a
• 7:46
  psychotic
• 7:46
  disorder.
• 7:47
  Right.
• 7:47
  The
• 7:47
  distress
• 7:48
  is
• 7:48
  a
• 7:48
  signal
• 7:49
  and
• 7:49
  a
• 7:49
  sign
• 7:49
  that
• 7:50
  they're
• 7:50
  in
• 7:50
  tune
• 7:50
  with
• 7:51
  something
• 7:51
  that
• 7:51
  is
• 7:51
  not
• 7:52
  consistent
• 7:52
  or,
• 7:53
  Or.
• 7:53
  Or
• 7:54
  right
• 7:54
  with
• 7:54
  them.
• 7:55
  And
• 7:55
  I
• 7:55
  use
• 7:55
  that
• 7:55
  as
• 7:56
  a
• 7:56
  moment
• 7:56
  to
• 7:56
  kind
• 7:57
  of
• 7:57
  reinforce
• 7:59
  the
• 7:59
  fact
• 7:59
  that
• 7:59
  my
• 7:59
  patients
• 8:00
  are.
• 8:01
  Are.
• 8:02
  I
• 8:02
  don't
• 8:02
  want
• 8:02
  to
• 8:02
  say
• 8:02
  healthy,
• 8:03
  but
• 8:03
  I
• 8:04
  kind
• 8:04
  of
• 8:04
  reassure
• 8:04
  my
• 8:05
  patients
• 8:05
  on
• 8:05
  those
• 8:05
  facts.
• 8:06
  Right.
• 8:06
  A
• 8:06
  lot
• 8:07
  of
• 8:07
  times
• 8:07
  you'll
• 8:07
  have
• 8:07
  patients
• 8:07
  come
• 8:08
  into
• 8:08
  your
• 8:08
  office
• 8:08
  who
• 8:09
  have
• 8:09
  morbid
• 8:09
  suicidal
• 8:10
  ideations,
• 8:12
  and
• 8:12
  they're
• 8:13
  very
• 8:13
  disturbing.
• 8:13
  You
• 8:14
  know,
• 8:14
  they
• 8:14
  think
• 8:14
  about
• 8:14
  swerving
• 8:15
  into
• 8:15
  traffic,
• 8:16
  but
• 8:16
  they
• 8:16
  think
• 8:16
  about
• 8:17
  that.
• 8:17
  Right.
• 8:18
  They
• 8:18
  don't
• 8:18
  want
• 8:18
  to
• 8:19
  do
• 8:19
  that.
• 8:19
  They're
• 8:19
  not
• 8:19
  contemplating
• 8:20
  that.
• 8:20
  In
• 8:21
  fact,
• 8:21
  the
• 8:21
  idea,
• 8:22
  the
• 8:22
  image
• 8:23
  and
• 8:23
  the
• 8:23
  thought
• 8:23
  is
• 8:23
  extremely
• 8:24
  disturbing
• 8:25
  to
• 8:25
  them.
• 8:25
  And
• 8:26
  so
• 8:26
  I
• 8:26
  use
• 8:26
  that
• 8:26
  as
• 8:26
  a.
• 8:27
  As
• 8:27
  an
• 8:27
  opportunity
• 8:28
  to
• 8:28
  reassure
• 8:29
  them
• 8:29
  that
• 8:30
  so
• 8:30
  long
• 8:30
  as
• 8:30
  this
• 8:30
  distresses
• 8:31
  you
• 8:31
  and
• 8:31
  this
• 8:32
  is
• 8:32
  not
• 8:32
  consistent
• 8:32
  with
• 8:32
  a
• 8:33
  plan
• 8:33
  or
• 8:33
  any
• 8:34
  actual
• 8:35
  desire
• 8:35
  to
• 8:35
  do
• 8:35
  this,
• 8:35
  and
• 8:36
  if
• 8:36
  it
• 8:36
  really
• 8:36
  bothers
• 8:36
  you
• 8:37
  that
• 8:37
  you're
• 8:37
  thinking
• 8:37
  about
• 8:37
  this
• 8:38
  stuff,
• 8:38
  it's
• 8:39
  reassuring
• 8:39
  that
• 8:40
  you
• 8:40
  are
• 8:40
  absolutely
• 8:41
  concerned
• 8:41
  about
• 8:41
  your
• 8:42
  safety
• 8:42
  and
• 8:43
  that
• 8:43
  this
• 8:43
  is
• 8:43
  not
• 8:43
  something
• 8:44
  that
• 8:44
  fully
• 8:44
  resonates
• 8:45
  with
• 8:45
  you.
• 8:45
  Right.
• 8:45
  I
• 8:46
  encourage
• 8:46
  my
• 8:46
  patients
• 8:47
  and
• 8:47
  I
• 8:48
  educate
• 8:48
  them
• 8:48
  and
• 8:48
  say,
• 8:48
  hey,
• 8:49
  look,
• 8:49
  not
• 8:49
  every
• 8:49
  thought
• 8:50
  that
• 8:50
  we
• 8:50
  have
• 8:50
  is
• 8:51
  something
• 8:51
  that
• 8:51
  we
• 8:51
  want
• 8:51
  to
• 8:52
  sign
• 8:52
  the
• 8:52
  dotted
• 8:52
  line
• 8:52
  on.
• 8:53
  They're
• 8:53
  spam
• 8:54
  thoughts
• 8:54
  or
• 8:55
  thoughts
• 8:55
  that,
• 8:55
  you
• 8:55
  know,
• 8:56
  emails
• 8:56
  that
• 8:57
  come
• 8:57
  to
• 8:57
  your
• 8:58
  inbox
• 8:58
  that
• 8:59
  maybe
• 8:59
  you
• 8:59
  don't
• 8:59
  want
• 8:59
  to
• 9:00
  read
• 9:00
  or
• 9:00
  you
• 9:00
  don't
• 9:00
  find
• 9:01
  irrelevant.
• 9:01
  Well,
• 9:01
  our
• 9:01
  thoughts
• 9:02
  are
• 9:02
  kind
• 9:02
  of
• 9:02
  similar.
• 9:02
  Right.
• 9:03
  I'm
• 9:03
  thinking
• 9:04
  right
• 9:04
  now
• 9:04
  of
• 9:05
  robbing
• 9:05
  a
• 9:05
  bank.
• 9:06
  Okay.
• 9:06
  I'm
• 9:07
  literally
• 9:07
  thinking
• 9:07
  right
• 9:08
  now
• 9:08
  of
• 9:08
  robbing
• 9:08
  a
• 9:08
  bank.
• 9:09
  But
• 9:09
  I'm
• 9:09
  just
• 9:10
  thinking
• 9:10
  of
• 9:10
  me
• 9:10
  with
• 9:10
  a
• 9:11
  ski
• 9:11
  mask
• 9:11
  on
• 9:11
  and
• 9:11
  a
• 9:12
  baseball
• 9:12
  bat.
• 9:12
  But
• 9:13
  that
• 9:13
  doesn't
• 9:13
  mean
• 9:13
  I
• 9:14
  want
• 9:14
  to
• 9:14
  rob
• 9:14
  a
• 9:14
  bank.
• 9:14
  I've
• 9:15
  never
• 9:15
  robbed
• 9:15
  a
• 9:15
  bank.
• 9:15
  I
• 9:16
  have
• 9:16
  no
• 9:16
  intention
• 9:17
  of
• 9:17
  robbing
• 9:18
  a
• 9:18
  bank.
• 9:18
  It
• 9:18
  would
• 9:18
  be
• 9:18
  way
• 9:18
  too
• 9:19
  difficult,
• 9:20
  and
• 9:20
  I
• 9:20
  don't
• 9:20
  want
• 9:20
  to
• 9:20
  spend
• 9:20
  the
• 9:21
  rest
• 9:21
  of
• 9:21
  my
• 9:21
  life
• 9:21
  in
• 9:21
  the
• 9:21
  slammer.
• 9:22
  And
• 9:23
  so
• 9:23
  just
• 9:23
  because
• 9:23
  I'm
• 9:23
  thinking
• 9:24
  about
• 9:24
  it
• 9:24
  right
• 9:24
  now
• 9:24
  does
• 9:25
  not
• 9:25
  is
• 9:25
  not
• 9:26
  any
• 9:26
  reflection
• 9:26
  on
• 9:27
  the
• 9:27
  fact
• 9:27
  that
• 9:27
  I
• 9:27
  want
• 9:27
  to
• 9:28
  do
• 9:28
  it.
• 9:28
  I
• 9:28
  will
• 9:28
  do
• 9:28
  it,
• 9:28
  I'm
• 9:29
  likely
• 9:29
  to
• 9:29
  do
• 9:29
  it,
• 9:30
  or
• 9:30
  that
• 9:30
  I
• 9:30
  should
• 9:30
  be
• 9:30
  in
• 9:30
  some
• 9:31
  kind
• 9:31
  of,
• 9:31
  like,
• 9:32
  prison
• 9:32
  cell
• 9:33
  to
• 9:33
  prevent
• 9:33
  me
• 9:33
  from
• 9:34
  robbing
• 9:34
  a
• 9:34
  bank.
• 9:34
  Right.
• 9:34
  Cause
• 9:35
  it's
• 9:35
  just
• 9:35
  a
• 9:35
  thought.
• 9:36
  And
• 9:36
  I'll
• 9:36
  share
• 9:37
  that
• 9:37
  analogy
• 9:37
  sometimes
• 9:38
  in
• 9:38
  practice,
• 9:38
  and
• 9:38
  it
• 9:38
  always
• 9:39
  gets
• 9:39
  kind
• 9:39
  of
• 9:39
  a
• 9:39
  chuckle
• 9:40
  and
• 9:40
  loosens
• 9:41
  the
• 9:41
  mood.
• 9:41
  And,
• 9:42
  of
• 9:42
  course,
• 9:42
  you
• 9:42
  want
• 9:43
  to
• 9:43
  make
• 9:43
  sure
• 9:43
  that
• 9:43
  your
• 9:43
  patient.
• 9:44
  You
• 9:45
  want
• 9:45
  to
• 9:45
  really
• 9:45
  get
• 9:45
  granular
• 9:46
  and
• 9:46
  make
• 9:46
  sure
• 9:46
  that
• 9:46
  this
• 9:46
  isn't
• 9:47
  attached
• 9:48
  to
• 9:48
  any
• 9:48
  actual
• 9:49
  plan,
• 9:49
  means,
• 9:49
  or
• 9:49
  intent.
• 9:50
  Right.
• 9:50
  But
• 9:50
  that's
• 9:50
  another
• 9:51
  story.
• 9:51
  But
• 9:51
  in
• 9:51
  other
• 9:52
  words,
• 9:52
  this
• 9:52
  patient
• 9:52
  is
• 9:53
  really
• 9:53
  disturbed
• 9:54
  by
• 9:54
  this
• 9:54
  and
• 9:54
  knows
• 9:54
  that
• 9:55
  something
• 9:55
  wrong
• 9:55
  is
• 9:55
  happening.
• 9:56
  Therefore,
• 9:56
  I
• 9:56
  would
• 9:57
  argue
• 9:57
  his
• 9:57
  reality
• 9:58
  testing
• 9:58
  is
• 9:59
  intact.
• 10:00
  And.
• 10:00
  And,
• 10:00
  you
• 10:01
  know,
• 10:01
  that's.
• 10:01
  That's.
• 10:02
  I.
• 10:02
  Again,
• 10:02
  very
• 10:02
  reassuring.
• 10:03
  It.
• 10:03
  It
• 10:03
  would
• 10:04
  be.
• 10:04
  We'd
• 10:04
  be
• 10:04
  going
• 10:05
  the
• 10:05
  opposite
• 10:05
  way
• 10:06
  if
• 10:06
  he
• 10:06
  actually
• 10:07
  believed
• 10:08
  that
• 10:08
  his
• 10:08
  cup,
• 10:08
  his
• 10:09
  coffee
• 10:09
  mug,
• 10:09
  was
• 10:10
  like
• 10:10
  a
• 10:10
  giant
• 10:10
  that
• 10:11
  was
• 10:11
  going
• 10:11
  to
• 10:11
  squash
• 10:12
  him,
• 10:12
  or
• 10:12
  it
• 10:12
  was.
• 10:13
  There
• 10:13
  was
• 10:13
  some
• 10:13
  kind
• 10:14
  of
• 10:14
  microphone
• 10:15
  implanted
• 10:15
  in
• 10:15
  his
• 10:16
  coffee
• 10:16
  mug,
• 10:16
  and
• 10:16
  he
• 10:16
  really
• 10:17
  believed
• 10:17
  that,
• 10:17
  and
• 10:17
  that
• 10:18
  bothered
• 10:18
  him.
• 10:18
  Now
• 10:19
  we're
• 10:19
  talking
• 10:19
  a
• 10:20
  whole
• 10:20
  different
• 10:20
  diagnostic.
• 10:21
  But
• 10:21
  no.
• 10:22
  So
• 10:22
  his
• 10:22
  reality
• 10:22
  testing
• 10:23
  is
• 10:23
  intact.
• 10:23
  You
• 10:24
  definitely
• 10:24
  know
• 10:24
  he's
• 10:25
  anxious,
• 10:25
  and
• 10:26
  so
• 10:26
  you
• 10:26
  zoom
• 10:26
  out
• 10:27
  and
• 10:27
  go,
• 10:27
  okay,
• 10:27
  my
• 10:28
  treatment
• 10:28
  needs
• 10:28
  to
• 10:28
  align
• 10:29
  somehow
• 10:30
  with
• 10:30
  a
• 10:30
  reduction
• 10:31
  in
• 10:31
  anxiety.
• 10:32
  Perhaps
• 10:32
  my
• 10:32
  treatment
• 10:33
  needs
• 10:33
  to
• 10:33
  be
• 10:33
  aligned
• 10:34
  in
• 10:34
  some
• 10:35
  way
• 10:35
  with
• 10:36
  reorganizing
• 10:37
  his
• 10:37
  thought
• 10:37
  patterns.
• 10:38
  Okay,
• 10:38
  so
• 10:38
  you're
• 10:39
  kind
• 10:39
  of
• 10:39
  getting
• 10:39
  in
• 10:39
  the
• 10:39
  ballpark.
• 10:40
  We
• 10:40
  don't
• 10:40
  really
• 10:40
  know
• 10:40
  are
• 10:41
  we
• 10:41
  going
• 10:41
  to
• 10:41
  prescribe
• 10:41
  an
• 10:41
  ssri.
• 10:42
  We
• 10:42
  don't
• 10:42
  know
• 10:42
  if
• 10:42
  this
• 10:43
  is
• 10:43
  like,
• 10:43
  GAD
• 10:43
  or
• 10:44
  illness
• 10:44
  anxiety
• 10:45
  or
• 10:45
  panic
• 10:45
  disorder
• 10:46
  or
• 10:46
  what
• 10:46
  it
• 10:46
  is
• 10:47
  quite
• 10:47
  yet,
• 10:47
  but
• 10:48
  we
• 10:48
  know
• 10:48
  that
• 10:48
  it's
• 10:48
  anxiety.
• 10:49
  We
• 10:49
  know
• 10:49
  that
• 10:50
  SSRIs
• 10:50
  can
• 10:50
  treat
• 10:51
  anxiety.
• 10:51
  We
• 10:51
  know
• 10:51
  that
• 10:52
  CBT
• 10:52
  is
• 10:52
  great
• 10:52
  for
• 10:53
  anxiety.
• 10:53
  So
• 10:54
  we're
• 10:54
  getting.
• 10:54
  What
• 10:54
  matters
• 10:55
  the
• 10:55
  most
• 10:55
  as
• 10:56
  your
• 10:56
  patient
• 10:56
  starts
• 10:56
  to
• 10:56
  talk
• 10:57
  to
• 10:57
  you
• 10:57
  and
• 10:57
  you
• 10:58
  have
• 10:58
  time
• 10:58
  to
• 10:58
  buy
• 10:59
  before
• 10:59
  you
• 10:59
  come
• 10:59
  up
• 10:59
  with
• 11:00
  an
• 11:00
  assessment
• 11:00
  and
• 11:00
  plan
• 11:01
  is
• 11:01
  just
• 11:01
  get.
• 11:01
  Get
• 11:02
  in
• 11:02
  the
• 11:02
  ballpark.
• 11:02
  Right.
• 11:03
  Don't
• 11:03
  overthink
• 11:03
  this.
• 11:04
  SSRIs,
• 11:05
  you
• 11:05
  know,
• 11:06
  in
• 11:06
  extreme
• 11:06
  cases,
• 11:07
  benzodiazepines
• 11:08
  for
• 11:08
  acute
• 11:08
  anxiety
• 11:09
  and
• 11:09
  panic
• 11:09
  and
• 11:10
  cbt.
• 11:11
  And
• 11:11
  it
• 11:11
  doesn't
• 11:11
  mean,
• 11:11
  like,
• 11:11
  those
• 11:12
  are
• 11:12
  the
• 11:12
  right
• 11:12
  treatments
• 11:13
  for
• 11:13
  him
• 11:13
  right
• 11:13
  now.
• 11:13
  But
• 11:14
  again,
• 11:14
  it
• 11:14
  gets
• 11:14
  you.
• 11:14
  It
• 11:15
  kind
• 11:15
  of
• 11:15
  orients
• 11:15
  you
• 11:15
  into
• 11:16
  the
• 11:16
  ballpark
• 11:16
  of,
• 11:16
  like,
• 11:17
  don't
• 11:17
  panic.
• 11:18
  There
• 11:18
  are
• 11:18
  tools
• 11:19
  to.
• 11:20
  To
• 11:20
  address
• 11:21
  symptoms
• 11:21
  that
• 11:21
  we
• 11:21
  know
• 11:22
  work.
• 11:22
  And
• 11:23
  regardless
• 11:23
  of
• 11:23
  the
• 11:23
  source
• 11:24
  of
• 11:24
  the
• 11:24
  anxiety,
• 11:25
  these
• 11:25
  are
• 11:25
  not
• 11:26
  crazy
• 11:27
  interventions
• 11:28
  to
• 11:28
  think
• 11:28
  about
• 11:29
  right
• 11:29
  now.
• 11:30
  And
• 11:30
  so
• 11:30
  we
• 11:30
  don't
• 11:31
  need
• 11:31
  to
• 11:31
  really,
• 11:31
  really
• 11:32
  panic
• 11:32
  in
• 11:33
  that
• 11:33
  sense.
• 11:33
  Okay,
• 11:35
  so
• 11:35
  what
• 11:35
  should
• 11:36
  we
• 11:36
  be
• 11:36
  thinking
• 11:36
  about?
• 11:37
  Right.
• 11:37
  We've
• 11:37
  done
• 11:37
  a
• 11:37
  bunch
• 11:38
  of
• 11:38
  labs.
• 11:38
  We've
• 11:39
  ruled
• 11:39
  out
• 11:39
  anything
• 11:40
  major
• 11:40
  here
• 11:41
  to
• 11:41
  our
• 11:41
  knowledge.
• 11:42
  Right.
• 11:42
  That
• 11:42
  it's
• 11:42
  not
• 11:42
  a
• 11:43
  seizure
• 11:44
  because
• 11:44
  the
• 11:44
  EEG
• 11:44
  was
• 11:45
  ordered.
• 11:46
  Now,
• 11:46
  for
• 11:46
  me,
• 11:47
  these
• 11:48
  kinds
• 11:48
  of
• 11:48
  diagnoses
• 11:49
  are
• 11:49
  A
• 11:49
  little
• 11:49
  bit
• 11:49
  tricky.
• 11:51
  It
• 11:51
  does
• 11:51
  sound
• 11:51
  like
• 11:52
  the
• 11:52
  patient
• 11:52
  is
• 11:53
  depersonalizing
• 11:54
  a
• 11:55
  little
• 11:55
  bit
• 11:55
  or
• 11:55
  derealization.
• 11:56
  Right.
• 11:57
  He's
• 11:57
  experiencing
• 11:58
  depersonalization
• 11:58
  and
• 11:59
  derealization.
• 12:00
  And
• 12:00
  those
• 12:01
  are
• 12:01
  not
• 12:02
  things
• 12:02
  that
• 12:02
  end
• 12:03
  up
• 12:04
  in
• 12:04
  your
• 12:05
  outpatient
• 12:06
  practice
• 12:06
  every
• 12:07
  day,
• 12:08
  but
• 12:08
  they
• 12:08
  absolutely
• 12:09
  can.
• 12:10
  And,
• 12:11
  and,
• 12:12
  and
• 12:12
  it,
• 12:12
  the
• 12:12
  actual
• 12:13
  disorder,
• 12:13
  though,
• 12:14
  is
• 12:14
  not
• 12:14
  as
• 12:14
  common.
• 12:15
  Right.
• 12:15
  It's
• 12:15
  not
• 12:15
  as
• 12:16
  common
• 12:16
  that
• 12:16
  a
• 12:16
  depersonalization
• 12:17
  disorder
• 12:17
  or
• 12:17
  deal
• 12:18
  derealization
• 12:18
  disorder
• 12:19
  is
• 12:19
  going
• 12:19
  to
• 12:19
  end
• 12:20
  up
• 12:20
  in
• 12:20
  your
• 12:20
  office.
• 12:20
  You'll
• 12:20
  often
• 12:21
  see
• 12:21
  this
• 12:22
  as
• 12:23
  a
• 12:24
  part
• 12:24
  of
• 12:24
  a
• 12:25
  larger
• 12:25
  diagnosis.
• 12:26
  Right.
• 12:26
  Panic
• 12:27
  disorder.
• 12:28
  One
• 12:28
  of
• 12:28
  the
• 12:29
  13
• 12:29
  DSM
• 12:30
  5
• 12:31
  panic
• 12:32
  attack
• 12:32
  symptoms
• 12:33
  is
• 12:33
  derealization
• 12:34
  or
• 12:35
  depersonalization.
• 12:36
  So
• 12:36
  you've
• 12:36
  got
• 12:37
  a
• 12:37
  lot
• 12:37
  on
• 12:37
  your
• 12:37
  hands
• 12:37
  here
• 12:38
  to
• 12:38
  differentiate
• 12:38
  between
• 12:39
  panic
• 12:39
  and
• 12:40
  a
• 12:40
  depersonalization
• 12:40
  derealization
• 12:41
  disorder.
• 13:36
  That
• 13:37
  would
• 13:37
  be
• 13:37
  on
• 13:37
  my
• 13:37
  differential,
• 13:38
  right?
• 13:38
  Is
• 13:38
  this
• 13:38
  a
• 13:38
  panic
• 13:39
  disorder?
• 13:40
  Okay,
• 13:41
  so
• 13:41
  we
• 13:41
  gotta
• 13:41
  keep
• 13:41
  that
• 13:42
  on
• 13:42
  the
• 13:42
  table.
• 13:42
  Now,
• 13:42
  is
• 13:43
  this
• 13:43
  a
• 13:43
  psychotic
• 13:43
  disorder?
• 13:44
  We
• 13:44
  already
• 13:44
  talked
• 13:44
  about
• 13:45
  how
• 13:46
  this
• 13:46
  doesn't
• 13:47
  really
• 13:48
  look
• 13:48
  like
• 13:48
  one
• 13:49
  because
• 13:49
  he
• 13:49
  has
• 13:49
  intact
• 13:50
  reality
• 13:50
  testing.
• 13:51
  And
• 13:51
  that
• 13:52
  is
• 13:52
  a
• 13:52
  key
• 13:52
  differentiator
• 13:53
  when
• 13:53
  you're
• 13:53
  trying
• 13:53
  to
• 13:54
  diagnose
• 13:54
  depersonalization
• 13:55
  disorder.
• 13:55
  Cause
• 13:56
  in
• 13:56
  depersonalization
• 13:56
  disorder
• 13:57
  or
• 13:57
  in
• 13:58
  derealization
• 13:58
  disorder,
• 13:59
  they
• 13:59
  have
• 14:00
  intact
• 14:00
  reality
• 14:01
  testing.
• 14:01
  That
• 14:01
  is
• 14:01
  how
• 14:02
  you
• 14:02
  can
• 14:02
  kind
• 14:02
  of
• 14:02
  tease
• 14:03
  out
• 14:03
  whether
• 14:03
  this
• 14:03
  is
• 14:04
  a,
• 14:04
  A,
• 14:05
  a,
• 14:05
  a
• 14:05
  psychotic
• 14:06
  disorder
• 14:07
  or
• 14:07
  more
• 14:08
  of
• 14:08
  a
• 14:08
  depersonalization
• 14:09
  derealization
• 14:10
  disorder.
• 14:10
  It's
• 14:11
  their
• 14:11
  level
• 14:11
  of
• 14:11
  insight.
• 14:12
  In
• 14:12
  psychosis,
• 14:13
  you
• 14:14
  might
• 14:14
  have
• 14:14
  some
• 14:14
  nihilistic
• 14:15
  delusions
• 14:15
  where
• 14:16
  your
• 14:16
  patient
• 14:16
  feels
• 14:17
  like
• 14:17
  they're
• 14:17
  already
• 14:17
  dead
• 14:18
  and,
• 14:18
  and
• 14:19
  they
• 14:19
  have
• 14:19
  a
• 14:19
  delusional
• 14:20
  conviction
• 14:20
  about
• 14:21
  that.
• 14:21
  Right.
• 14:21
  There's
• 14:22
  no
• 14:22
  ambiguity.
• 14:22
  There's
• 14:23
  no
• 14:23
  worry
• 14:23
  about
• 14:23
  the
• 14:24
  fact
• 14:24
  that
• 14:24
  they're,
• 14:25
  quote,
• 14:25
  going
• 14:25
  crazy.
• 14:26
  As
• 14:26
  you'll
• 14:26
  hear
• 14:26
  your
• 14:26
  patients
• 14:27
  describe
• 14:27
  it.
• 14:27
  They
• 14:28
  actually
• 14:28
  believe
• 14:29
  it.
• 14:29
  They
• 14:29
  resonate
• 14:30
  with
• 14:30
  it.
• 14:30
  They
• 14:30
  sign
• 14:31
  the
• 14:31
  dotted
• 14:31
  line
• 14:31
  on
• 14:32
  it.
• 14:32
  And
• 14:32
  so
• 14:33
  the
• 14:33
  biggest
• 14:34
  thing
• 14:34
  that
• 14:34
  I
• 14:35
  think
• 14:35
  you
• 14:35
  need
• 14:35
  to
• 14:36
  rule
• 14:36
  out
• 14:36
  here
• 14:36
  right
• 14:37
  away
• 14:37
  with
• 14:37
  Elias
• 14:38
  is,
• 14:39
  is
• 14:39
  this
• 14:39
  psychosis
• 14:40
  or
• 14:40
  is
• 14:40
  this
• 14:41
  something
• 14:41
  different?
• 14:41
  Because
• 14:41
  that,
• 14:42
  my
• 14:42
  friends,
• 14:42
  is
• 14:42
  a
• 14:43
  totally
• 14:43
  different
• 14:43
  treatment
• 14:44
  algorithm.
• 14:44
  Right
• 14:44
  now
• 14:45
  we're
• 14:45
  talking
• 14:45
  antipsychotics.
• 14:46
  We're,
• 14:47
  you
• 14:47
  know,
• 14:47
  if
• 14:47
  we
• 14:47
  go
• 14:48
  down
• 14:48
  the
• 14:48
  psychosis
• 14:49
  path,
• 14:50
  we
• 14:50
  have
• 14:50
  to
• 14:50
  question
• 14:50
  whether
• 14:51
  or
• 14:51
  not
• 14:51
  he's
• 14:51
  gravely
• 14:52
  disabled.
• 14:52
  If
• 14:52
  he
• 14:53
  can
• 14:53
  even
• 14:53
  cook
• 14:54
  a
• 14:54
  meal
• 14:54
  for
• 14:54
  himself
• 14:55
  and
• 14:55
  keep
• 14:55
  himself
• 14:56
  safe.
• 14:56
  Does
• 14:56
  he
• 14:56
  need
• 14:56
  to
• 14:56
  be
• 14:57
  admitted?
• 14:57
  So
• 14:58
  it
• 14:58
  just
• 14:59
  kind
• 14:59
  of
• 14:59
  goes
• 14:59
  back
• 14:59
  to
• 15:00
  your,
• 15:00
  the
• 15:00
  ABCs
• 15:01
  of
• 15:01
  like,
• 15:01
  psychiatric
• 15:02
  triage.
• 15:02
  Right?
• 15:02
  He's
• 15:03
  not
• 15:03
  suicidal.
• 15:03
  You're
• 15:04
  good.
• 15:04
  Right?
• 15:04
  He
• 15:04
  has
• 15:05
  no
• 15:05
  plan,
• 15:05
  no
• 15:05
  means,
• 15:06
  no
• 15:06
  intent.
• 15:06
  You're
• 15:06
  good.
• 15:07
  He's
• 15:07
  clearly
• 15:08
  aware
• 15:08
  of
• 15:08
  the
• 15:09
  fact
• 15:09
  that
• 15:09
  he's
• 15:10
  in
• 15:10
  distress,
• 15:11
  which
• 15:11
  is
• 15:11
  reassuring
• 15:12
  because
• 15:12
  he's
• 15:12
  not
• 15:12
  psychotic.
• 15:13
  He
• 15:13
  has
• 15:13
  intact
• 15:13
  reality
• 15:14
  testing.
• 15:14
  Now
• 15:15
  you
• 15:15
  Got
• 15:15
  to
• 15:15
  get
• 15:15
  granular,
• 15:16
  though,
• 15:16
  and
• 15:16
  be
• 15:16
  like,
• 15:16
  what
• 15:16
  am
• 15:17
  I
• 15:17
  looking
• 15:17
  at?
• 15:17
  Is
• 15:17
  this
• 15:17
  a
• 15:17
  panic
• 15:18
  disorder?
• 15:19
  Is
• 15:19
  this
• 15:19
  ptsd?
• 15:20
  Because
• 15:20
  in
• 15:20
  ptsd,
• 15:22
  sure
• 15:22
  enough,
• 15:23
  there
• 15:23
  are
• 15:23
  disassociative
• 15:24
  subtypes
• 15:24
  of
• 15:25
  ptsd,
• 15:26
  right?
• 15:26
  Depersonalization
• 15:27
  and
• 15:27
  derealization.
• 15:29
  What
• 15:29
  part
• 15:29
  of
• 15:29
  his
• 15:30
  presentation
• 15:30
  today
• 15:31
  sounded
• 15:32
  to
• 15:32
  you
• 15:32
  like
• 15:32
  ptsd?
• 15:33
  Think
• 15:34
  about
• 15:34
  that
• 15:34
  for
• 15:34
  a
• 15:35
  second.
• 15:35
  Well,
• 15:36
  the
• 15:36
  answer
• 15:36
  is
• 15:36
  no
• 15:37
  part
• 15:37
  of
• 15:37
  it,
• 15:37
  right?
• 15:38
  He
• 15:38
  had
• 15:38
  a
• 15:39
  divorce
• 15:39
  that
• 15:40
  was
• 15:40
  stressful
• 15:40
  in
• 15:41
  his
• 15:41
  family
• 15:41
  at
• 15:41
  age
• 15:41
  10.
• 15:42
  But
• 15:42
  he
• 15:43
  explicitly
• 15:43
  denied
• 15:44
  any
• 15:44
  criterion
• 15:45
  A
• 15:45
  traumas,
• 15:46
  right?
• 15:46
  Near
• 15:47
  death
• 15:47
  experiences,
• 15:48
  sexual
• 15:48
  violence,
• 15:49
  witnessing
• 15:49
  the
• 15:49
  death
• 15:50
  of
• 15:50
  somebody
• 15:51
  close
• 15:51
  to
• 15:52
  him,
• 15:52
  handling
• 15:52
  the
• 15:52
  remains
• 15:53
  of.
• 15:53
  We
• 15:54
  got
• 15:54
  none
• 15:54
  of
• 15:54
  that
• 15:55
  in
• 15:55
  his
• 15:55
  background.
• 15:55
  None
• 15:56
  of
• 15:56
  that,
• 15:56
  right?
• 15:57
  So
• 15:57
  in
• 15:58
  order
• 15:58
  for
• 15:58
  you
• 15:58
  to
• 15:58
  diagnose
• 15:59
  or
• 15:59
  suspect
• 16:00
  that
• 16:00
  this
• 16:00
  was
• 16:00
  ptsd,
• 16:01
  you've
• 16:02
  got
• 16:02
  to
• 16:02
  find
• 16:02
  the
• 16:02
  worm
• 16:02
  at
• 16:03
  the
• 16:03
  core.
• 16:03
  And
• 16:03
  the
• 16:03
  worm
• 16:03
  at
• 16:04
  the
• 16:04
  core
• 16:04
  of
• 16:05
  this
• 16:05
  entire
• 16:06
  vignette
• 16:07
  today
• 16:08
  had
• 16:08
  nothing
• 16:08
  to
• 16:09
  do
• 16:09
  with
• 16:09
  a
• 16:09
  trauma
• 16:10
  he
• 16:10
  endured,
• 16:10
  right?
• 16:11
  So
• 16:11
  sometimes
• 16:11
  we
• 16:11
  don't
• 16:12
  need
• 16:12
  to
• 16:12
  overthink
• 16:12
  this
• 16:13
  stuff,
• 16:13
  right?
• 16:14
  Even
• 16:14
  though
• 16:15
  we
• 16:15
  know
• 16:15
  disassociation
• 16:16
  is
• 16:16
  a
• 16:17
  subtype
• 16:17
  in
• 16:17
  ptsd,
• 16:18
  we
• 16:18
  don't
• 16:18
  really
• 16:19
  need
• 16:19
  to
• 16:19
  go
• 16:19
  down
• 16:19
  that
• 16:19
  rabbit
• 16:20
  hole
• 16:20
  at
• 16:20
  all
• 16:20
  and
• 16:20
  look
• 16:21
  at
• 16:21
  what
• 16:21
  it
• 16:21
  says
• 16:21
  about
• 16:21
  that
• 16:22
  subtype.
• 16:22
  Because
• 16:23
  he's
• 16:23
  clearly
• 16:24
  not
• 16:24
  coming
• 16:24
  to
• 16:24
  you
• 16:25
  with
• 16:25
  a
• 16:25
  criterion,
• 16:26
  a
• 16:26
  trauma,
• 16:26
  and
• 16:27
  if
• 16:27
  he
• 16:27
  was,
• 16:27
  it
• 16:27
  would
• 16:27
  dominate
• 16:28
  the
• 16:29
  majority
• 16:29
  of
• 16:29
  this
• 16:30
  conversation
• 16:30
  or
• 16:30
  certainly
• 16:31
  would
• 16:31
  dominate
• 16:31
  a
• 16:31
  lot
• 16:32
  more
• 16:32
  of
• 16:32
  this
• 16:32
  conversation.
• 16:33
  And
• 16:33
  we
• 16:33
  just
• 16:33
  don't
• 16:34
  have
• 16:34
  that
• 16:34
  here.
• 16:35
  Right.
• 16:35
  Sometimes
• 16:36
  it's
• 16:36
  important
• 16:36
  for
• 16:36
  you
• 16:36
  to
• 16:37
  pay
• 16:37
  attention
• 16:37
  to
• 16:37
  what
• 16:37
  your
• 16:37
  patients
• 16:38
  don't
• 16:38
  say
• 16:38
  as
• 16:39
  much
• 16:39
  as
• 16:40
  what
• 16:40
  they
• 16:40
  do
• 16:40
  say.
• 16:40
  And
• 16:41
  what's
• 16:41
  dominating
• 16:42
  this
• 16:42
  conversation
• 16:43
  is
• 16:43
  like
• 16:44
  a
• 16:44
  perceptual.
• 16:45
  It's
• 16:45
  perceptual
• 16:46
  distress,
• 16:47
  right?
• 16:47
  It
• 16:48
  is
• 16:48
  not.
• 16:49
  Oh,
• 16:49
  I,
• 16:49
  you
• 16:49
  know,
• 16:50
  I
• 16:50
  got
• 16:50
  hit
• 16:50
  by
• 16:50
  an
• 16:50
  Amtrak
• 16:51
  train
• 16:51
  three
• 16:52
  months
• 16:52
  ago,
• 16:52
  and
• 16:52
  I
• 16:52
  can't
• 16:53
  stop
• 16:53
  thinking
• 16:53
  about
• 16:54
  how
• 16:54
  horrible
• 16:54
  that
• 16:55
  was.
• 16:55
  Right.
• 16:56
  It
• 16:56
  wasn't
• 16:56
  the
• 16:56
  fact
• 16:56
  that
• 16:57
  I've
• 16:57
  witnessed
• 16:58
  somebody
• 16:58
  get
• 16:58
  attacked
• 16:59
  at
• 16:59
  a
• 16:59
  tennis
• 16:59
  court
• 17:00
  and
• 17:01
  by
• 17:01
  a
• 17:01
  burglar
• 17:02
  robber,
• 17:03
  and
• 17:03
  then
• 17:03
  a
• 17:03
  bear
• 17:04
  came
• 17:04
  in
• 17:04
  and
• 17:04
  attacked
• 17:05
  both
• 17:05
  of
• 17:05
  them
• 17:06
  and
• 17:06
  rip
• 17:06
  them
• 17:06
  to
• 17:06
  pieces.
• 17:07
  That's
• 17:07
  a
• 17:07
  very,
• 17:07
  in
• 17:08
  your
• 17:08
  face,
• 17:08
  flashy
• 17:10
  trauma.
• 17:11
  And
• 17:11
  patients
• 17:12
  may
• 17:12
  not
• 17:12
  be
• 17:12
  very
• 17:12
  open
• 17:13
  about
• 17:13
  the
• 17:13
  details
• 17:13
  of
• 17:14
  their
• 17:14
  trauma
• 17:14
  because
• 17:14
  it
• 17:15
  can
• 17:15
  be
• 17:15
  very
• 17:15
  distressing.
• 17:16
  But
• 17:16
  it's
• 17:17
  pretty
• 17:17
  clear,
• 17:17
  pretty
• 17:18
  early
• 17:18
  that
• 17:18
  a
• 17:18
  trauma
• 17:19
  is
• 17:20
  dominating
• 17:21
  the
• 17:21
  conversation
• 17:22
  or
• 17:22
  the
• 17:23
  center
• 17:23
  of
• 17:23
  gravity.
• 17:23
  We
• 17:24
  just
• 17:24
  don't
• 17:24
  have
• 17:24
  that
• 17:24
  here.
• 17:25
  So
• 17:25
  I
• 17:25
  don't
• 17:25
  want
• 17:26
  you
• 17:26
  to
• 17:26
  be
• 17:26
  dismissive
• 17:26
  of
• 17:27
  ptsd.
• 17:28
  Of
• 17:28
  course,
• 17:28
  that's
• 17:28
  one
• 17:28
  of
• 17:28
  the
• 17:29
  most
• 17:29
  common
• 17:30
  illnesses
• 17:30
  that
• 17:30
  walk
• 17:30
  into
• 17:31
  your
• 17:31
  practice.
• 17:32
  But
• 17:32
  certainly,
• 17:33
  if
• 17:33
  there's
• 17:34
  no
• 17:34
  reason
• 17:34
  to
• 17:34
  worry
• 17:35
  about
• 17:35
  it,
• 17:35
  don't
• 17:35
  go
• 17:35
  down
• 17:36
  the
• 17:36
  rabbit
• 17:36
  hole
• 17:36
  either.
• 17:37
  Assess
• 17:37
  for
• 17:38
  It.
• 17:38
  But
• 17:38
  don't
• 17:38
  go
• 17:38
  down
• 17:38
  the
• 17:39
  rabbit
• 17:39
  hole.
• 17:39
  Now,
• 17:40
  is
• 17:40
  this
• 17:40
  ocd?
• 17:41
  He
• 17:41
  did
• 17:41
  mention
• 17:42
  there
• 17:42
  were
• 17:42
  rituals.
• 17:43
  If
• 17:43
  he's
• 17:43
  pinching
• 17:44
  himself
• 17:44
  to
• 17:44
  see
• 17:44
  if
• 17:44
  he
• 17:44
  was
• 17:45
  real,
• 17:45
  it's
• 17:46
  valid
• 17:46
  to
• 17:46
  consider
• 17:47
  if
• 17:47
  this
• 17:47
  is
• 17:47
  ocd.
• 17:48
  But
• 17:49
  again,
• 17:49
  it's
• 17:49
  not
• 17:49
  the
• 17:50
  worm
• 17:50
  at
• 17:50
  the
• 17:50
  core.
• 17:50
  It's
• 17:51
  not
• 17:51
  the
• 17:51
  center
• 17:52
  of
• 17:52
  gravity
• 17:52
  here.
• 17:53
  Yes.
• 17:54
  Pinching
• 17:54
  yourself
• 17:55
  ritually
• 17:56
  because
• 17:56
  you're
• 17:57
  disturbed
• 17:57
  by
• 17:58
  this
• 17:58
  thought
• 17:58
  process.
• 17:59
  That
• 17:59
  seems
• 17:59
  a
• 18:00
  little
• 18:00
  obsessional
• 18:01
  about
• 18:01
  perception.
• 18:02
  Yes.
• 18:03
  That
• 18:03
  does
• 18:03
  kind
• 18:04
  of
• 18:04
  have
• 18:05
  OCD
• 18:05
  vibes.
• 18:06
  But
• 18:06
  again,
• 18:06
  the
• 18:07
  OCD
• 18:07
  is
• 18:07
  sort
• 18:08
  of
• 18:08
  secondary
• 18:09
  to
• 18:10
  what's
• 18:10
  taking
• 18:10
  up
• 18:11
  most
• 18:11
  of
• 18:11
  the
• 18:11
  oxygen
• 18:12
  in
• 18:12
  the
• 18:12
  room,
• 18:12
  which,
• 18:12
  again,
• 18:12
  is
• 18:13
  a
• 18:13
  perceptual
• 18:14
  disturbance
• 18:15
  or
• 18:15
  perceptual
• 18:16
  distress.
• 18:17
  And
• 18:17
  there's
• 18:17
  something
• 18:18
  else
• 18:18
  going
• 18:18
  on.
• 18:18
  So
• 18:18
  the
• 18:18
  OCD
• 18:19
  is
• 18:19
  kind
• 18:19
  of
• 18:19
  secondary.
• 18:21
  And
• 18:21
  it's
• 18:21
  really.
• 18:22
  The
• 18:22
  obsessional
• 18:23
  features
• 18:23
  of
• 18:23
  this
• 18:24
  are
• 18:24
  focused
• 18:25
  on
• 18:25
  the
• 18:25
  depersonalization
• 18:26
  and
• 18:26
  derealization
• 18:27
  experience
• 18:27
  itself.
• 18:29
  And
• 18:29
  we
• 18:29
  don't
• 18:29
  really
• 18:29
  have
• 18:30
  any
• 18:30
  other
• 18:30
  mention
• 18:31
  of
• 18:31
  contamination,
• 18:32
  fears,
• 18:33
  the
• 18:33
  need
• 18:34
  for
• 18:34
  symmetry,
• 18:34
  counting
• 18:35
  his
• 18:35
  steps,
• 18:36
  the
• 18:36
  kind
• 18:36
  of
• 18:37
  classic
• 18:37
  OCD
• 18:37
  content.
• 18:38
  We
• 18:38
  just
• 18:38
  don't
• 18:39
  have
• 18:39
  that
• 18:39
  here.
• 18:40
  But
• 18:40
  he.
• 18:40
  It's
• 18:41
  almost
• 18:41
  like
• 18:41
  he's.
• 18:42
  He's
• 18:42
  definitely
• 18:42
  obsessed,
• 18:43
  obsessively
• 18:43
  ruminating
• 18:44
  and
• 18:44
  worried.
• 18:45
  Um,
• 18:45
  but
• 18:45
  it's
• 18:46
  squarely
• 18:46
  about
• 18:46
  these
• 18:47
  perceptual
• 18:48
  disturbances
• 18:49
  that
• 18:49
  aren't
• 18:49
  quite
• 18:49
  right.
• 18:50
  Okay.
• 18:50
  Same
• 18:51
  thing
• 18:51
  with
• 18:51
  gad.
• 18:51
  Right.
• 18:52
  Gad.
• 18:53
  The.
• 18:53
  The
• 18:53
  name
• 18:54
  of
• 18:54
  the
• 18:54
  illness
• 18:54
  is
• 18:55
  in.
• 18:55
  The
• 18:55
  name
• 18:56
  is
• 18:56
  generalized.
• 18:57
  Well,
• 18:57
  this
• 18:57
  isn't
• 18:57
  really
• 18:58
  generalized.
• 18:58
  This
• 18:58
  is
• 18:59
  a
• 18:59
  very
• 18:59
  focused
• 19:00
  form
• 19:00
  of
• 19:00
  anxiety.
• 19:01
  Right.
• 19:01
  This
• 19:02
  is
• 19:02
  focused
• 19:03
  on
• 19:03
  perceptual
• 19:04
  disturbances.
• 19:04
  Again,
• 19:05
  if
• 19:05
  I
• 19:05
  sound
• 19:05
  like
• 19:05
  a
• 19:06
  broken
• 19:06
  record,
• 19:06
  it's.
• 19:06
  It's.
• 19:07
  I
• 19:07
  try.
• 19:07
  I
• 19:08
  hope
• 19:08
  it's
• 19:08
  a
• 19:08
  little
• 19:08
  constructive
• 19:09
  here.
• 19:09
  Right.
• 19:09
  The.
• 19:10
  The
• 19:10
  center
• 19:10
  of
• 19:10
  gravity
• 19:11
  is
• 19:11
  right
• 19:12
  in
• 19:12
  your
• 19:12
  face
• 19:12
  here.
• 19:13
  It's
• 19:13
  a
• 19:13
  very
• 19:14
  specific
• 19:14
  kind
• 19:14
  of
• 19:15
  thing
• 19:15
  that's
• 19:15
  happening.
• 19:15
  So
• 19:16
  I
• 19:16
  always
• 19:16
  get
• 19:17
  suspicious
• 19:17
  when
• 19:17
  something's
• 19:18
  too
• 19:18
  specific.
• 19:19
  I
• 19:19
  zoom
• 19:20
  away.
• 19:20
  I
• 19:20
  kind
• 19:20
  of
• 19:20
  get
• 19:21
  away
• 19:21
  from
• 19:21
  the
• 19:22
  generalized
• 19:22
  anxiety
• 19:23
  stuff.
• 19:24
  Right.
• 19:24
  I
• 19:24
  don't
• 19:25
  even
• 19:25
  think
• 19:25
  of
• 19:25
  social
• 19:25
  anxiety
• 19:26
  disorder
• 19:27
  because,
• 19:27
  again,
• 19:28
  that's
• 19:28
  not
• 19:28
  the
• 19:29
  center
• 19:29
  of
• 19:29
  gravity
• 19:29
  here.
• 19:30
  He
• 19:30
  didn't
• 19:30
  say
• 19:30
  anything
• 19:31
  about
• 19:31
  being
• 19:31
  nervous
• 19:31
  in
• 19:31
  front
• 19:32
  of
• 19:32
  other
• 19:32
  people.
• 19:33
  Panic
• 19:33
  disorder.
• 19:34
  I
• 19:34
  think
• 19:34
  that's
• 19:34
  kind
• 19:35
  of
• 19:35
  a
• 19:35
  very
• 19:35
  valid
• 19:36
  differential
• 19:37
  if
• 19:37
  you're
• 19:37
  thinking
• 19:38
  about
• 19:38
  that
• 19:38
  here,
• 19:39
  only
• 19:39
  because
• 19:40
  it
• 19:40
  does
• 19:40
  sound
• 19:40
  like
• 19:41
  he's
• 19:41
  acting
• 19:42
  quite
• 19:43
  nervously
• 19:44
  and
• 19:44
  high
• 19:44
  level
• 19:44
  of
• 19:45
  anxiety
• 19:45
  towards.
• 19:46
  I
• 19:47
  would
• 19:47
  argue
• 19:47
  it's
• 19:47
  probably
• 19:48
  the
• 19:48
  most.
• 19:49
  The
• 19:49
  interesting
• 19:50
  differential
• 19:50
  would
• 19:51
  be
• 19:51
  panic
• 19:51
  disorder
• 19:52
  here,
• 19:53
  mainly
• 19:53
  because,
• 19:53
  again,
• 19:54
  both
• 19:54
  of
• 19:55
  his
• 19:55
  symptoms
• 19:55
  do
• 19:56
  in
• 19:56
  fact,
• 19:56
  are
• 19:57
  in
• 19:57
  fact
• 19:58
  included
• 19:59
  in
• 19:59
  the
• 19:59
  DSM
• 19:59
  5
• 19:59
  criteria
• 20:00
  for
• 20:00
  panic
• 20:00
  attacks.
• 20:01
  The
• 20:01
  only
• 20:02
  reason
• 20:02
  I
• 20:03
  would
• 20:03
  say
• 20:04
  this
• 20:04
  is
• 20:04
  not
• 20:04
  a
• 20:05
  panic
• 20:05
  disorder,
• 20:06
  though,
• 20:06
  is
• 20:06
  because
• 20:08
  the.
• 20:09
  This
• 20:09
  is
• 20:09
  a
• 20:10
  little
• 20:10
  hard
• 20:10
  to
• 20:10
  Explain.
• 20:10
  I
• 20:11
  suppose.
• 20:12
  But
• 20:12
  the.
• 20:12
  This
• 20:13
  is
• 20:13
  constant,
• 20:13
  right?
• 20:14
  The.
• 20:14
  His
• 20:14
  depersonalization,
• 20:15
  derealization
• 20:17
  is
• 20:17
  going
• 20:17
  on
• 20:17
  constantly
• 20:18
  for
• 20:18
  months.
• 20:19
  So
• 20:19
  it's
• 20:19
  kind
• 20:20
  of
• 20:20
  exceeding
• 20:20
  the
• 20:20
  timeframe
• 20:21
  of
• 20:21
  a
• 20:21
  traditional
• 20:22
  panic
• 20:22
  attack
• 20:23
  in
• 20:23
  duration.
• 20:25
  And
• 20:25
  so
• 20:26
  I
• 20:26
  just.
• 20:26
  I
• 20:26
  just
• 20:26
  don't
• 20:27
  think
• 20:27
  that's
• 20:27
  really
• 20:28
  what's
• 20:28
  going
• 20:28
  on
• 20:28
  here.
• 20:29
  He
• 20:29
  did
• 20:29
  have
• 20:30
  a
• 20:30
  single
• 20:30
  precipitating
• 20:31
  panic
• 20:31
  attack
• 20:31
  seven
• 20:32
  months
• 20:32
  ago,
• 20:32
  but
• 20:33
  the
• 20:33
  panic
• 20:33
  did
• 20:33
  resolve,
• 20:34
  but
• 20:34
  the
• 20:34
  depersonalization
• 20:35
  and
• 20:35
  derealization
• 20:36
  did
• 20:36
  not.
• 20:37
  And
• 20:37
  he
• 20:37
  has
• 20:37
  intense
• 20:38
  worry
• 20:38
  about
• 20:38
  depersonalization,
• 20:39
  derealization,
• 20:40
  but
• 20:40
  it
• 20:41
  didn't
• 20:41
  appear
• 20:41
  to
• 20:42
  be
• 20:42
  at
• 20:42
  the
• 20:43
  level
• 20:43
  of
• 20:43
  panic.
• 20:44
  These
• 20:44
  are
• 20:44
  not
• 20:44
  discrete
• 20:45
  episodes
• 20:46
  of
• 20:46
  panic
• 20:46
  that
• 20:46
  come
• 20:46
  on
• 20:46
  for
• 20:47
  two
• 20:47
  or
• 20:47
  three
• 20:47
  minutes
• 20:47
  and
• 20:47
  then
• 20:48
  subside.
• 20:49
  This
• 20:49
  is
• 20:49
  a
• 20:49
  constant
• 20:50
  bombardment
• 20:51
  of
• 20:52
  concern
• 20:52
  about
• 20:53
  perceptual
• 20:54
  disturbances.
• 20:56
  So
• 20:56
  it
• 20:56
  is
• 20:56
  important
• 20:57
  to
• 20:57
  remember,
• 20:57
  though,
• 20:57
  that
• 20:58
  depersonalization
• 20:59
  disorder
• 20:59
  can
• 20:59
  be
• 21:00
  diagnosed
• 21:00
  if
• 21:01
  the
• 21:01
  depersonalization
• 21:03
  clearly
• 21:04
  exceeds
• 21:05
  the
• 21:06
  panic
• 21:06
  attacks
• 21:06
  and
• 21:06
  duration
• 21:07
  and
• 21:07
  intensity
• 21:08
  from
• 21:08
  the
• 21:08
  start,
• 21:09
  and
• 21:09
  it
• 21:09
  continues
• 21:10
  after
• 21:10
  panic
• 21:11
  has
• 21:12
  remitted.
• 21:12
  And
• 21:12
  I
• 21:12
  know
• 21:12
  that
• 21:13
  can
• 21:13
  be
• 21:13
  hard
• 21:13
  to
• 21:13
  figure
• 21:13
  out,
• 21:14
  but
• 21:14
  the
• 21:14
  way
• 21:14
  I
• 21:15
  look
• 21:15
  at
• 21:15
  it
• 21:15
  in
• 21:15
  clinic
• 21:16
  is,
• 21:16
  are
• 21:16
  these
• 21:16
  discrete
• 21:17
  episodes
• 21:18
  of
• 21:18
  terror?
• 21:19
  Right.
• 21:19
  That's
• 21:19
  the
• 21:19
  best
• 21:20
  way
• 21:20
  I
• 21:20
  can
• 21:20
  describe
• 21:20
  it.
• 21:21
  Discrete
• 21:21
  episodes
• 21:22
  of
• 21:22
  terror
• 21:23
  that
• 21:23
  last
• 21:23
  only
• 21:24
  a
• 21:24
  few
• 21:24
  minutes,
• 21:25
  and
• 21:25
  they
• 21:26
  tend
• 21:26
  to
• 21:26
  be
• 21:26
  random.
• 21:26
  If
• 21:26
  we're
• 21:27
  talking
• 21:27
  about
• 21:27
  panic
• 21:27
  disorder,
• 21:29
  and
• 21:29
  they
• 21:29
  have.
• 21:29
  They
• 21:30
  encompass
• 21:30
  a
• 21:30
  wide
• 21:31
  range
• 21:31
  of
• 21:31
  somatic
• 21:31
  distress,
• 21:32
  not
• 21:33
  exclusively
• 21:33
  depersonalization
• 21:34
  or
• 21:35
  disassociation,
• 21:36
  but,
• 21:36
  you
• 21:36
  know,
• 21:37
  your
• 21:37
  heart
• 21:37
  will
• 21:37
  race,
• 21:38
  shortness
• 21:38
  of
• 21:38
  breath,
• 21:38
  you're
• 21:39
  trembling,
• 21:39
  you're
• 21:39
  sweating,
• 21:40
  you're
• 21:40
  shaking.
• 21:40
  Right.
• 21:41
  And
• 21:41
  so
• 21:41
  there's
• 21:42
  like
• 21:42
  this
• 21:42
  wide
• 21:42
  constellation
• 21:43
  of
• 21:43
  distress.
• 21:44
  You
• 21:45
  avoid
• 21:45
  places
• 21:46
  because
• 21:46
  you
• 21:46
  don't
• 21:47
  want
• 21:47
  to
• 21:47
  have
• 21:47
  a
• 21:47
  panic
• 21:47
  attack
• 21:48
  in
• 21:48
  those
• 21:48
  places.
• 21:48
  Typically,
• 21:49
  you
• 21:49
  dread
• 21:49
  the
• 21:50
  next
• 21:50
  attack.
• 21:51
  He's
• 21:51
  not
• 21:51
  dreading
• 21:52
  the
• 21:52
  next
• 21:52
  attack,
• 21:53
  per
• 21:53
  se.
• 21:53
  He's
• 21:54
  dreading
• 21:54
  a
• 21:54
  consistent
• 21:55
  drip,
• 21:56
  a
• 21:56
  slow
• 21:57
  drip,
• 21:57
  consistent
• 21:58
  drip,
• 21:59
  distressing
• 21:59
  drip
• 22:00
  of
• 22:00
  very
• 22:00
  specific
• 22:01
  states
• 22:02
  that
• 22:02
  are
• 22:03
  much
• 22:03
  more
• 22:03
  narrow
• 22:04
  than
• 22:04
  a
• 22:05
  panic
• 22:05
  attack.
• 22:05
  So
• 22:06
  he's
• 22:06
  really
• 22:06
  laser
• 22:07
  focused
• 22:07
  on
• 22:07
  two
• 22:07
  symptoms.
• 22:08
  Panic
• 22:09
  attacks,
• 22:10
  again,
• 22:10
  kind
• 22:11
  of
• 22:11
  encompass
• 22:11
  more.
• 22:11
  But
• 22:12
  it
• 22:12
  does
• 22:12
  get
• 22:12
  muddy.
• 22:12
  You
• 22:12
  see
• 22:13
  how
• 22:13
  this
• 22:13
  gets
• 22:13
  muddy?
• 22:13
  And
• 22:14
  it
• 22:14
  can
• 22:14
  be
• 22:14
  very
• 22:14
  difficult
• 22:15
  because
• 22:15
  patients
• 22:16
  may
• 22:16
  characterize
• 22:18
  their
• 22:18
  battle
• 22:18
  with
• 22:19
  depersonalization
• 22:20
  in
• 22:20
  very
• 22:21
  panicky
• 22:21
  terms
• 22:22
  or
• 22:22
  panicky
• 22:22
  language.
• 22:23
  Right.
• 22:23
  You
• 22:23
  do
• 22:23
  have
• 22:24
  to
• 22:24
  get
• 22:24
  granular
• 22:24
  with.
• 22:25
  And
• 22:26
  the
• 22:26
  way
• 22:26
  I
• 22:26
  ask
• 22:26
  it
• 22:27
  is,
• 22:27
  do
• 22:27
  you
• 22:27
  feel
• 22:27
  like
• 22:27
  you
• 22:27
  have
• 22:28
  sudden
• 22:28
  surges
• 22:28
  of
• 22:29
  terror
• 22:29
  that
• 22:30
  feel
• 22:30
  beyond
• 22:30
  your
• 22:30
  control?
• 22:31
  Do
• 22:31
  you
• 22:31
  feel
• 22:31
  like
• 22:31
  you
• 22:31
  have
• 22:32
  sudden
• 22:32
  surges
• 22:33
  of
• 22:33
  anxiety
• 22:34
  that
• 22:34
  manifest
• 22:35
  in
• 22:35
  your
• 22:35
  body
• 22:36
  in
• 22:36
  many
• 22:36
  different
• 22:36
  places
• 22:37
  that
• 22:37
  just
• 22:37
  feel
• 22:37
  terrifying
• 22:38
  and
• 22:39
  then
• 22:39
  kind
• 22:39
  of
• 22:39
  subside
• 22:40
  a
• 22:40
  couple
• 22:40
  minutes
• 22:40
  later?
• 22:41
  Then,
• 22:41
  if
• 22:41
  your
• 22:41
  patient's
• 22:42
  biting
• 22:42
  that
• 22:42
  bait,
• 22:43
  definitely
• 22:43
  get
• 22:44
  in
• 22:44
  the
• 22:44
  panic
• 22:44
  disorder
• 22:45
  category.
• 22:46
  If
• 22:46
  not,
• 22:47
  you're
• 22:47
  probably
• 22:47
  looking
• 22:48
  at
• 22:48
  something
• 22:48
  different.
• 22:50
  So
• 22:50
  temporal
• 22:51
  lobe
• 22:51
  epilepsy,
• 22:51
  tle.
• 22:52
  Okay.
• 22:53
  You
• 22:53
  can
• 22:54
  actually
• 22:54
  find
• 22:55
  like
• 22:55
  these
• 22:56
  dreamy
• 22:56
  states,
• 22:56
  these
• 22:57
  kind
• 22:57
  of
• 22:57
  odd
• 22:57
  perceptual
• 22:59
  what,
• 22:59
  what
• 23:00
  they
• 23:00
  call
• 23:00
  ictal
• 23:01
  phenomenon.
• 23:01
  Right.
• 23:02
  So
• 23:02
  you
• 23:02
  can
• 23:02
  see
• 23:03
  visual
• 23:03
  distortions
• 23:04
  where.
• 23:04
  In,
• 23:05
  in
• 23:05
  temporal
• 23:05
  lobe
• 23:06
  epilepsy,
• 23:06
  where
• 23:07
  objects
• 23:07
  appear
• 23:08
  bigger
• 23:08
  or
• 23:08
  smaller
• 23:08
  that
• 23:09
  can
• 23:09
  overlap
• 23:09
  for
• 23:10
  sure.
• 23:10
  The
• 23:11
  difference,
• 23:11
  though,
• 23:12
  that
• 23:12
  can
• 23:12
  help
• 23:12
  you
• 23:13
  figure
• 23:13
  this
• 23:13
  out
• 23:13
  is
• 23:13
  that
• 23:14
  in
• 23:14
  epileptic
• 23:15
  depersonalization,
• 23:16
  it's
• 23:17
  typically
• 23:17
  seconds
• 23:17
  to
• 23:18
  minutes.
• 23:18
  Typically
• 23:19
  it's
• 23:19
  not
• 23:19
  this
• 23:20
  prolonged
• 23:20
  seven
• 23:21
  month
• 23:22
  feeling
• 23:22
  where
• 23:22
  you're
• 23:22
  detached
• 23:23
  from
• 23:23
  reality.
• 23:24
  Right.
• 23:25
  And
• 23:25
  some
• 23:25
  of
• 23:25
  the
• 23:26
  epilepsy
• 23:27
  presentations
• 23:27
  you'll
• 23:28
  also
• 23:28
  see
• 23:28
  like
• 23:28
  olfactory
• 23:29
  or
• 23:30
  gustatory
• 23:30
  hallucinations,
• 23:32
  confusion.
• 23:32
  We
• 23:33
  didn't
• 23:33
  get
• 23:33
  a
• 23:33
  lot
• 23:33
  of
• 23:33
  that
• 23:33
  here.
• 23:34
  And
• 23:34
  again,
• 23:35
  that
• 23:35
  doesn't
• 23:35
  usually
• 23:35
  occur
• 23:36
  for
• 23:36
  months
• 23:36
  at
• 23:37
  a
• 23:37
  time
• 23:37
  with
• 23:38
  temporal
• 23:38
  lobe
• 23:38
  epilepsy.
• 23:39
  So
• 23:39
  the
• 23:39
  duration
• 23:40
  is
• 23:40
  not
• 23:40
  consistent.
• 23:41
  Elias
• 23:42
  is
• 23:42
  experiencing
• 23:43
  this
• 23:43
  for
• 23:43
  months.
• 23:44
  He's.
• 23:44
  He
• 23:44
  didn't
• 23:44
  talk
• 23:44
  to
• 23:45
  you
• 23:45
  about
• 23:45
  any
• 23:45
  kind
• 23:45
  of
• 23:45
  hallucinations
• 23:46
  where
• 23:46
  he's
• 23:46
  smelling
• 23:47
  something
• 23:47
  that's
• 23:47
  not
• 23:47
  there,
• 23:48
  tasting
• 23:48
  something
• 23:48
  that's
• 23:49
  not
• 23:49
  there.
• 23:49
  He's
• 23:49
  not
• 23:49
  confused.
• 23:50
  But
• 23:51
  there
• 23:51
  is
• 23:51
  overlap
• 23:51
  enough
• 23:52
  to
• 23:52
  definitely
• 23:52
  look
• 23:52
  at
• 23:53
  this.
• 23:53
  And
• 23:53
  if
• 23:53
  your
• 23:53
  patient's
• 23:54
  over
• 23:54
  40,
• 23:55
  it
• 23:55
  is
• 23:56
  very
• 23:57
  important
• 23:57
  that
• 23:58
  you
• 23:58
  probably
• 23:59
  send
• 23:59
  your
• 23:59
  patient
• 23:59
  to
• 24:00
  get
• 24:00
  a
• 24:00
  neuroeval
• 24:01
  because
• 24:01
  the
• 24:02
  mean
• 24:02
  age
• 24:03
  of
• 24:03
  onset
• 24:03
  for
• 24:03
  depersonalization
• 24:04
  disorder
• 24:05
  is
• 24:05
  like
• 24:05
  16
• 24:05
  years.
• 24:06
  So
• 24:07
  less
• 24:07
  than
• 24:07
  20%
• 24:07
  of
• 24:08
  these
• 24:08
  cases
• 24:08
  begin
• 24:08
  after
• 24:09
  20
• 24:09
  and
• 24:10
  only
• 24:10
  5%
• 24:10
  after
• 24:11
  25.
• 24:11
  So
• 24:11
  if
• 24:12
  your
• 24:12
  patient's
• 24:12
  suddenly
• 24:13
  becoming
• 24:13
  depersonalized
• 24:14
  at
• 24:14
  age
• 24:14
  40,
• 24:15
  it
• 24:15
  should
• 24:16
  probably
• 24:16
  prompt
• 24:16
  a
• 24:16
  medical
• 24:17
  workup
• 24:17
  to
• 24:17
  neuro
• 24:18
  and
• 24:18
  rule
• 24:18
  out
• 24:18
  temporal
• 24:19
  lobe
• 24:19
  epilepsy,
• 24:20
  among
• 24:20
  other
• 24:21
  things.
• 24:21
  We'll
• 24:21
  leave
• 24:21
  that
• 24:21
  to
• 24:22
  the
• 24:22
  neurologist.
• 24:22
  But
• 24:23
  definitely
• 24:23
  I
• 24:24
  would
• 24:24
  be
• 24:24
  worried
• 24:24
  in
• 24:25
  someone
• 24:25
  who
• 24:25
  was
• 24:25
  40,
• 24:27
  although
• 24:27
  15%
• 24:28
  of
• 24:29
  these
• 24:29
  cases,
• 24:29
  these
• 24:29
  depersonalization
• 24:30
  disorder
• 24:31
  cases,
• 24:31
  are
• 24:31
  precipitate,
• 24:32
  precipitated
• 24:33
  by
• 24:34
  substance
• 24:34
  ingestion,
• 24:35
  mostly
• 24:36
  cannabis
• 24:36
  or
• 24:36
  hallucinogens.
• 24:37
  You
• 24:38
  want
• 24:38
  to
• 24:38
  make
• 24:38
  it
• 24:38
  clear
• 24:38
  that
• 24:39
  though
• 24:39
  it
• 24:39
  catalyzed,
• 24:41
  though
• 24:41
  it
• 24:41
  can
• 24:41
  catalyze
• 24:42
  these
• 24:42
  disorders,
• 24:43
  it
• 24:43
  doesn't
• 24:43
  cause
• 24:44
  them.
• 24:44
  Right.
• 24:45
  And
• 24:45
  because
• 24:45
  if
• 24:45
  you
• 24:45
  make
• 24:46
  the
• 24:46
  case
• 24:46
  that
• 24:46
  cannabis
• 24:47
  caused
• 24:47
  this,
• 24:48
  it's
• 24:48
  this
• 24:48
  permanent
• 24:49
  process,
• 24:49
  you're
• 24:49
  gonna,
• 24:50
  the
• 24:50
  patient's
• 24:50
  gonna
• 24:50
  lose
• 24:51
  a
• 24:51
  lot
• 24:51
  of
• 24:51
  hope
• 24:51
  really
• 24:51
  quickly.
• 24:52
  They're
• 24:52
  gonna
• 24:52
  catastrophize
• 24:53
  their
• 24:54
  anxiety
• 24:54
  even
• 24:55
  more.
• 24:55
  So
• 24:55
  you
• 24:55
  wanna
• 24:56
  really
• 24:56
  back
• 24:56
  up
• 24:57
  and
• 24:57
  reassure
• 24:57
  your
• 24:57
  patient
• 24:58
  there
• 24:58
  is
• 24:58
  treatment
• 24:58
  for
• 24:59
  this,
• 24:59
  there's
• 24:59
  evidence
• 25:00
  that
• 25:00
  we
• 25:00
  can
• 25:01
  manage
• 25:01
  this,
• 25:02
  and
• 25:02
  you
• 25:02
  wanna
• 25:02
  give
• 25:02
  them
• 25:02
  a
• 25:03
  little
• 25:03
  insight
• 25:03
  into
• 25:03
  why
• 25:04
  they
• 25:04
  may
• 25:05
  have
• 25:05
  developed
• 25:06
  DDD
• 25:06
  or
• 25:06
  depersonalization
• 25:08
  Derealization
• 25:09
  disorder.
• 25:09
  Right.
• 25:10
  And
• 25:10
  part
• 25:11
  of
• 25:11
  it
• 25:11
  has
• 25:11
  to
• 25:11
  do
• 25:11
  with.
• 25:12
  At
• 25:12
  least
• 25:12
  the
• 25:12
  evidence
• 25:13
  suggests
• 25:14
  that
• 25:14
  it
• 25:15
  has
• 25:15
  to
• 25:15
  do
• 25:15
  with
• 25:16
  not
• 25:16
  being
• 25:17
  able
• 25:17
  to
• 25:17
  express
• 25:17
  your
• 25:18
  emotions
• 25:18
  as
• 25:18
  safely
• 25:19
  or
• 25:19
  fluidly
• 25:20
  in
• 25:20
  childhood.
• 25:21
  And
• 25:21
  perhaps
• 25:21
  that
• 25:22
  detaches
• 25:22
  you
• 25:22
  a
• 25:22
  little
• 25:23
  bit
• 25:23
  from
• 25:23
  a
• 25:23
  key
• 25:23
  emotional
• 25:24
  signals
• 25:25
  in
• 25:25
  specific
• 25:26
  parts
• 25:26
  of
• 25:26
  the
• 25:26
  brain.
• 25:27
  And
• 25:27
  so
• 25:27
  you
• 25:27
  experience
• 25:28
  reality
• 25:29
  less
• 25:29
  internally
• 25:29
  through
• 25:30
  your
• 25:30
  body
• 25:30
  and
• 25:31
  more
• 25:31
  externally
• 25:32
  through
• 25:32
  the
• 25:32
  world.
• 25:32
  And
• 25:32
  that
• 25:33
  can
• 25:33
  actually
• 25:33
  create
• 25:34
  this
• 25:34
  kind
• 25:34
  of
• 25:35
  sense
• 25:35
  of
• 25:35
  depersonalization
• 25:36
  or
• 25:36
  derealization.
• 25:37
  So
• 25:37
  much
• 25:37
  of
• 25:38
  us,
• 25:38
  we
• 25:38
  experience
• 25:39
  reality
• 25:39
  in
• 25:40
  our
• 25:40
  own
• 25:40
  emotions,
• 25:40
  right?
• 25:41
  In
• 25:41
  our
• 25:41
  ability
• 25:41
  to
• 25:42
  feel
• 25:42
  internally
• 25:43
  or
• 25:43
  internal
• 25:44
  states.
• 25:44
  But
• 25:45
  that's
• 25:45
  not
• 25:45
  the
• 25:45
  case
• 25:45
  with
• 25:46
  ddd,
• 25:47
  right?
• 25:47
  They
• 25:47
  might
• 25:47
  have
• 25:48
  been
• 25:48
  kind
• 25:48
  of
• 25:49
  challenged
• 25:49
  or
• 25:49
  forced
• 25:49
  at
• 25:50
  a
• 25:50
  young
• 25:50
  age
• 25:51
  to.
• 25:51
  To
• 25:52
  not
• 25:52
  inhabit
• 25:52
  that
• 25:53
  emotional
• 25:53
  world,
• 25:54
  that
• 25:54
  inner
• 25:54
  world.
• 25:54
  And
• 25:55
  so
• 25:55
  a
• 25:55
  lot
• 25:55
  of
• 25:55
  it
• 25:55
  is
• 25:55
  externalized,
• 25:56
  and
• 25:56
  that
• 25:56
  feels
• 25:57
  very
• 25:57
  different
• 25:58
  on
• 25:58
  a
• 25:58
  perceptual
• 25:59
  level.
• 25:59
  This
• 25:59
  is
• 25:59
  really
• 26:00
  challenging
• 26:00
  for
• 26:00
  clinicians
• 26:01
  because
• 26:01
  we
• 26:02
  don't
• 26:02
  always
• 26:02
  relate
• 26:02
  to
• 26:03
  this.
• 26:03
  Right.
• 26:03
  Not
• 26:03
  everybody
• 26:04
  has
• 26:04
  ever
• 26:04
  felt
• 26:05
  what
• 26:05
  derealization
• 26:06
  feels
• 26:06
  like
• 26:07
  or
• 26:07
  depersonalization
• 26:08
  feels
• 26:08
  like.
• 26:09
  Right.
• 26:10
  So
• 26:10
  it
• 26:11
  can
• 26:11
  be
• 26:11
  kind
• 26:11
  of
• 26:12
  hard
• 26:12
  to
• 26:12
  understand
• 26:12
  this.
• 26:13
  Right.
• 26:13
  If
• 26:13
  we've
• 26:13
  all
• 26:14
  felt
• 26:14
  panic
• 26:14
  attacks
• 26:15
  before
• 26:15
  or
• 26:16
  maybe
• 26:16
  we've
• 26:16
  been
• 26:16
  in
• 26:16
  a
• 26:16
  depressed
• 26:17
  mood
• 26:17
  state
• 26:17
  before,
• 26:18
  we
• 26:19
  kind
• 26:19
  of
• 26:19
  get
• 26:19
  that.
• 26:19
  Right?
• 26:20
  We
• 26:20
  know
• 26:20
  what
• 26:20
  it
• 26:20
  looks
• 26:21
  like,
• 26:21
  what
• 26:21
  it
• 26:21
  feels
• 26:21
  like,
• 26:22
  what
• 26:22
  it
• 26:22
  sounds
• 26:22
  like
• 26:22
  as
• 26:23
  it's
• 26:23
  being
• 26:23
  described.
• 26:24
  But
• 26:24
  this
• 26:25
  vocabulary
• 26:25
  and
• 26:26
  this
• 26:26
  kind
• 26:26
  of
• 26:26
  experiential.
• 26:28
  This
• 26:28
  experience
• 26:28
  is
• 26:29
  a
• 26:29
  lot
• 26:29
  different
• 26:29
  because
• 26:30
  this
• 26:30
  is
• 26:30
  kind
• 26:31
  of
• 26:31
  abstract.
• 26:31
  Unless
• 26:32
  you've
• 26:32
  really
• 26:32
  experienced
• 26:33
  this
• 26:33
  yourself
• 26:33
  before,
• 26:34
  it
• 26:34
  can
• 26:34
  be
• 26:35
  a
• 26:35
  very
• 26:35
  abstract
• 26:35
  thing.
• 26:36
  And
• 26:36
  it
• 26:36
  might.
• 26:36
  We
• 26:36
  might
• 26:36
  be
• 26:37
  inclined
• 26:37
  to
• 26:37
  think
• 26:37
  this
• 26:37
  is
• 26:38
  psychosis
• 26:38
  because
• 26:39
  in
• 26:39
  the
• 26:39
  patient's
• 26:40
  defense,
• 26:40
  the
• 26:40
  way
• 26:40
  they're
• 26:41
  describing
• 26:41
  depersonalization
• 26:42
  and
• 26:42
  derealization,
• 26:44
  it's
• 26:44
  hard
• 26:44
  not
• 26:45
  to
• 26:45
  feel
• 26:45
  like
• 26:45
  somebody's
• 26:46
  genuinely
• 26:47
  losing
• 26:47
  touch
• 26:47
  with
• 26:47
  reality
• 26:48
  and
• 26:48
  becoming
• 26:48
  psychotic.
• 26:49
  And
• 26:49
  yet
• 26:50
  it's
• 26:50
  clearly
• 26:50
  not
• 26:50
  the
• 26:51
  same
• 26:51
  thing,
• 26:51
  because
• 26:51
  you
• 26:51
  can
• 26:52
  describe
• 26:52
  this
• 26:52
  stuff
• 26:53
  and
• 26:53
  your
• 26:53
  reality
• 26:54
  testing
• 26:54
  can
• 26:54
  be
• 26:55
  perfectly
• 26:55
  intact.
• 26:56
  Right.
• 26:57
  So
• 26:57
  we
• 26:57
  want
• 26:57
  to
• 26:57
  reassure
• 26:58
  our
• 26:58
  patient
• 26:58
  that
• 26:58
  we
• 26:58
  can
• 26:59
  do
• 26:59
  CBT
• 26:59
  for
• 26:59
  this.
• 27:00
  The
• 27:00
  best
• 27:00
  evidence
• 27:01
  out
• 27:01
  there
• 27:01
  seems
• 27:02
  to
• 27:02
  suggest
• 27:02
  that
• 27:03
  CBT
• 27:04
  is
• 27:04
  really
• 27:05
  the
• 27:05
  only
• 27:05
  intervention
• 27:06
  was
• 27:06
  significant
• 27:06
  clinical
• 27:07
  impact
• 27:07
  on
• 27:08
  alleviating
• 27:08
  these
• 27:08
  symptoms
• 27:09
  in
• 27:09
  the
• 27:09
  systematic
• 27:10
  reviews
• 27:10
  that
• 27:10
  we
• 27:10
  looked
• 27:11
  at.
• 27:11
  Okay.
• 27:13
  And
• 27:13
  CBT
• 27:14
  accomplishes
• 27:14
  this
• 27:15
  through
• 27:16
  many
• 27:17
  different
• 27:17
  ways.
• 27:17
  But
• 27:18
  one
• 27:18
  way
• 27:18
  would
• 27:18
  be
• 27:19
  just
• 27:19
  catastrophic
• 27:19
  misinterpretation
• 27:20
  of
• 27:21
  symptoms.
• 27:22
  That's
• 27:22
  what
• 27:22
  CBT
• 27:23
  is
• 27:23
  really
• 27:23
  targeting.
• 27:24
  Right?
• 27:24
  The
• 27:24
  I'm
• 27:25
  going
• 27:25
  crazy.
• 27:25
  So
• 27:26
  kind
• 27:26
  of
• 27:26
  restructuring
• 27:27
  the
• 27:28
  patient
• 27:28
  on
• 27:28
  a
• 27:28
  cognitive
• 27:29
  basis
• 27:30
  helps
• 27:30
  them
• 27:31
  not
• 27:31
  generate
• 27:31
  this
• 27:32
  kind
• 27:32
  of
• 27:32
  emotional
• 27:32
  distress.
• 27:33
  Right.
• 27:33
  CBT
• 27:34
  focuses
• 27:34
  on
• 27:35
  a
• 27:35
  lot
• 27:36
  of
• 27:36
  the
• 27:36
  avoidance
• 27:36
  behaviors,
• 27:37
  kind
• 27:37
  of
• 27:37
  graded
• 27:38
  exposure,
• 27:38
  so
• 27:38
  they
• 27:39
  can
• 27:40
  engage
• 27:40
  emotionally
• 27:41
  again
• 27:42
  and.
• 27:42
  And
• 27:42
  pay
• 27:43
  attention
• 27:43
  to
• 27:43
  their
• 27:43
  internal
• 27:44
  processes.
• 27:44
  So
• 27:45
  some
• 27:45
  refocusing
• 27:46
  techniques
• 27:46
  cause,
• 27:46
  again,
• 27:47
  they're
• 27:47
  a
• 27:47
  little
• 27:47
  detached
• 27:48
  from
• 27:48
  their
• 27:48
  internal
• 27:48
  Environment,
• 27:49
  they
• 27:50
  maybe
• 27:50
  they're
• 27:50
  in
• 27:50
  their
• 27:50
  internal
• 27:51
  emotions.
• 27:52
  So
• 27:52
  guiding
• 27:53
  the
• 27:53
  patient
• 27:53
  back
• 27:54
  towards
• 27:55
  those
• 27:55
  emotions
• 27:56
  in
• 27:56
  the
• 27:56
  form
• 27:56
  of
• 27:57
  addressing
• 27:57
  their
• 27:57
  attentional
• 27:58
  bias
• 27:59
  and
• 27:59
  their
• 27:59
  avoidance
• 28:00
  of
• 28:00
  those
• 28:00
  emotions.
• 28:01
  So
• 28:01
  CBT
• 28:02
  sort
• 28:02
  of
• 28:03
  targets
• 28:03
  all
• 28:03
  of
• 28:04
  those
• 28:04
  things
• 28:04
  at
• 28:04
  once.
• 28:05
  There's
• 28:05
  very
• 28:05
  limited
• 28:06
  data
• 28:06
  on
• 28:07
  SSRIs
• 28:08
  when
• 28:08
  it
• 28:08
  comes
• 28:08
  to
• 28:09
  this.
• 28:09
  We
• 28:09
  learn
• 28:09
  in,
• 28:10
  in
• 28:10
  school,
• 28:10
  of
• 28:11
  course,
• 28:11
  you,
• 28:11
  you
• 28:11
  can
• 28:12
  always
• 28:12
  try
• 28:13
  and
• 28:14
  address
• 28:14
  the
• 28:15
  associated
• 28:16
  symptoms.
• 28:16
  Right.
• 28:16
  We
• 28:17
  hear
• 28:17
  that
• 28:17
  all
• 28:17
  the
• 28:17
  time
• 28:17
  with
• 28:17
  borderline
• 28:18
  personality
• 28:18
  disorder.
• 28:19
  Right.
• 28:19
  That
• 28:20
  there's
• 28:20
  no
• 28:20
  real
• 28:21
  FDA
• 28:21
  approved
• 28:21
  treatment
• 28:22
  for
• 28:22
  that
• 28:23
  in
• 28:23
  the
• 28:23
  form
• 28:23
  of
• 28:23
  an
• 28:23
  oral
• 28:24
  tablet.
• 28:24
  But
• 28:25
  sure
• 28:25
  enough,
• 28:25
  you
• 28:25
  know,
• 28:26
  if
• 28:26
  the
• 28:26
  patient
• 28:26
  is
• 28:27
  empty
• 28:27
  and
• 28:27
  depressed
• 28:28
  and
• 28:28
  has,
• 28:28
  and
• 28:29
  we
• 28:29
  know
• 28:29
  comorb,
• 28:30
  comorbidly,
• 28:31
  there's
• 28:31
  all
• 28:31
  kinds
• 28:31
  of
• 28:32
  anxiety
• 28:32
  depressive
• 28:32
  disorders
• 28:33
  associated
• 28:34
  with
• 28:35
  treating
• 28:35
  the
• 28:36
  symptoms,
• 28:36
  incidentally
• 28:37
  is
• 28:37
  helpful,
• 28:37
  but
• 28:38
  getting
• 28:38
  to
• 28:38
  the
• 28:38
  worm
• 28:38
  at
• 28:39
  the
• 28:39
  core,
• 28:39
  we
• 28:39
  know
• 28:40
  that
• 28:40
  DBT
• 28:40
  is
• 28:40
  the
• 28:40
  most
• 28:41
  important
• 28:41
  for,
• 28:42
  for
• 28:42
  borderline.
• 28:43
  Right.
• 28:43
  And
• 28:43
  the
• 28:43
  same
• 28:43
  thing
• 28:43
  goes
• 28:44
  with
• 28:44
  ddd.
• 28:45
  Can
• 28:45
  we,
• 28:46
  can
• 28:46
  we
• 28:47
  treat
• 28:47
  around
• 28:48
  the
• 28:48
  edges
• 28:48
  and,
• 28:49
  and
• 28:49
  contain
• 28:49
  some
• 28:49
  of
• 28:50
  the
• 28:50
  high
• 28:50
  anxiety
• 28:50
  if
• 28:51
  we
• 28:51
  need
• 28:51
  to
• 28:52
  with
• 28:52
  an
• 28:52
  SSRI
• 28:52
  or
• 28:53
  clonazepam,
• 28:54
  maybe?
• 28:54
  There
• 28:54
  might
• 28:54
  be
• 28:54
  select
• 28:55
  cases
• 28:55
  that
• 28:55
  you
• 28:56
  could
• 28:56
  do
• 28:56
  that,
• 28:56
  that
• 28:56
  some
• 28:56
  evidence
• 28:57
  points
• 28:57
  to
• 28:57
  that.
• 28:58
  But
• 28:58
  the
• 28:58
  real
• 28:59
  gold
• 28:59
  standard
• 28:59
  here
• 29:00
  is
• 29:01
  long
• 29:01
  term
• 29:01
  psychotherapy.
• 29:02
  50
• 29:02
  to
• 29:02
  100
• 29:03
  sessions,
• 29:03
  particularly
• 29:04
  when
• 29:04
  early
• 29:05
  attachment
• 29:05
  disruption
• 29:06
  is
• 29:06
  a
• 29:06
  contributing
• 29:06
  factor.
• 29:07
  Because
• 29:07
  again,
• 29:07
  my
• 29:07
  friends,
• 29:08
  these
• 29:08
  are
• 29:08
  long
• 29:09
  held
• 29:09
  cemented
• 29:10
  belief
• 29:11
  systems
• 29:11
  and
• 29:12
  emotional
• 29:13
  patterns
• 29:14
  with
• 29:14
  neurobiological
• 29:15
  organization
• 29:16
  in
• 29:16
  the
• 29:16
  brain
• 29:17
  that
• 29:17
  need
• 29:18
  to
• 29:18
  be
• 29:18
  unlearned
• 29:18
  or
• 29:19
  undone
• 29:19
  or
• 29:19
  addressed.
• 29:20
  It's
• 29:21
  something
• 29:21
  that's
• 29:21
  uniquely
• 29:22
  suited
• 29:22
  actually
• 29:23
  for
• 29:23
  psychotherapy.
• 29:24
  Definitely
• 29:25
  do
• 29:25
  a
• 29:25
  nerdy
• 29:25
  deep
• 29:26
  dive
• 29:26
  if
• 29:26
  you
• 29:26
  haven't
• 29:26
  already.
• 29:27
  In
• 29:27
  the
• 29:27
  DSM
• 29:28
  5TR
• 29:28
  diagnostic
• 29:29
  criteria
• 29:29
  for
• 29:30
  Depersonalization
• 29:30
  Disorder,
• 29:31
  it's
• 29:31
  relatively
• 29:32
  easy
• 29:32
  to
• 29:32
  diagnose
• 29:33
  in
• 29:33
  terms
• 29:34
  of.
• 29:34
  You
• 29:34
  don't
• 29:34
  have
• 29:34
  to
• 29:34
  memorize
• 29:35
  a
• 29:35
  thousand
• 29:36
  different
• 29:37
  criteria
• 29:38
  for
• 29:38
  it.
• 29:38
  Right.
• 29:39
  It's
• 29:39
  basically
• 29:39
  people
• 29:40
  who
• 29:40
  experience
• 29:40
  unreality.
• 29:41
  This
• 29:41
  is
• 29:41
  criterion
• 29:42
  A,
• 29:42
  experiencing
• 29:43
  unreality
• 29:44
  detachment,
• 29:44
  or
• 29:45
  being
• 29:45
  an
• 29:45
  outside
• 29:45
  observer
• 29:46
  with
• 29:46
  respect
• 29:46
  to
• 29:46
  one's
• 29:47
  thoughts,
• 29:47
  feelings,
• 29:47
  sensations,
• 29:48
  body
• 29:48
  or
• 29:49
  actions.
• 29:49
  Right.
• 29:50
  Derealization
• 29:51
  is
• 29:51
  like
• 29:51
  experiencing
• 29:52
  unreality
• 29:53
  or
• 29:53
  detachment
• 29:54
  with
• 29:54
  respect
• 29:54
  to
• 29:54
  your
• 29:55
  surroundings.
• 29:55
  Okay,
• 29:56
  well,
• 29:56
  kind
• 29:56
  of
• 29:57
  like
• 29:57
  when
• 29:57
  Elias
• 29:57
  talked
• 29:58
  about
• 29:58
  he
• 29:58
  lives
• 29:58
  in
• 29:59
  a
• 29:59
  two
• 29:59
  dimensional
• 29:59
  world.
• 30:00
  He
• 30:00
  mentioned
• 30:01
  the
• 30:01
  colors
• 30:01
  don't
• 30:01
  really
• 30:01
  have
• 30:02
  the
• 30:02
  saturation
• 30:03
  they
• 30:03
  normally
• 30:03
  do.
• 30:04
  The
• 30:04
  environment
• 30:05
  kind
• 30:05
  of
• 30:05
  felt
• 30:05
  artificial.
• 30:06
  That's
• 30:06
  what
• 30:06
  derealization
• 30:07
  is.
• 30:07
  Right.
• 30:08
  The
• 30:08
  key
• 30:09
  criterion
• 30:09
  B,
• 30:09
  and
• 30:10
  we
• 30:10
  really
• 30:10
  emphasized
• 30:11
  this
• 30:11
  earlier,
• 30:11
  but
• 30:11
  the
• 30:11
  key
• 30:12
  criterion
• 30:12
  B
• 30:13
  for,
• 30:14
  for
• 30:14
  this
• 30:14
  disorder
• 30:15
  is
• 30:15
  that
• 30:15
  reality
• 30:16
  testing
• 30:16
  is
• 30:17
  intact.
• 30:18
  Okay.
• 30:19
  So
• 30:20
  can't
• 30:20
  emphasize
• 30:21
  that
• 30:21
  enough.
• 30:22
  Very
• 30:22
  important
• 30:24
  that
• 30:24
  you
• 30:25
  make
• 30:25
  an
• 30:26
  effort
• 30:26
  to
• 30:27
  understand
• 30:27
  if
• 30:27
  your
• 30:28
  patient
• 30:28
  understands
• 30:29
  that
• 30:30
  these
• 30:30
  are
• 30:30
  disturbances
• 30:31
  that
• 30:31
  are
• 30:31
  distressing
• 30:32
  and
• 30:32
  that
• 30:33
  he
• 30:33
  understands
• 30:34
  that
• 30:34
  reality
• 30:34
  is
• 30:34
  real
• 30:35
  and
• 30:35
  that
• 30:35
  he's
• 30:35
  inhabiting
• 30:36
  his
• 30:36
  own
• 30:36
  body.
• 30:37
  But
• 30:37
  he.
• 30:37
  And
• 30:38
  he
• 30:38
  gets
• 30:38
  why
• 30:39
  he's
• 30:39
  so
• 30:39
  distressed
• 30:40
  because
• 30:40
  he.
• 30:40
  He
• 30:41
  feels
• 30:42
  kind
• 30:43
  of
• 30:43
  cut
• 30:43
  off
• 30:43
  from
• 30:43
  that.
• 30:45
  I
• 30:45
  hope
• 30:45
  you
• 30:45
  all
• 30:45
  enjoyed
• 30:46
  that.
• 30:47
  You
• 30:47
  know,
• 30:47
  don't
• 30:47
  forget
• 30:47
  to
• 30:48
  run
• 30:48
  your
• 30:48
  drug
• 30:48
  screens.
• 30:48
  Don't
• 30:49
  forget
• 30:49
  to
• 30:49
  run
• 30:49
  your
• 30:49
  medical
• 30:50
  component
• 30:50
  of
• 30:50
  this.
• 30:51
  But
• 30:52
  this
• 30:52
  was
• 30:52
  a
• 30:53
  doozy.
• 30:53
  It's
• 30:53
  fun.
• 30:53
  It's
• 30:54
  high
• 30:54
  yield.
• 30:54
  Gets
• 30:54
  you
• 30:55
  thinking.
• 30:55
  And
• 30:55
  join
• 30:56
  us
• 30:56
  next
• 30:56
  time
• 30:56
  here
• 30:56
  on
• 30:57
  Pearls
• 30:57
  and
• 30:57
  Pro.