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Transcript

🧠💣 BOARD BOMBS: The OCD Gold Standard Almost Nobody Actually Gets — And It Delays Treatment for YEARS. · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:05
  back,
• 0:06
  my
• 0:06
  friend,
• 0:06
  to
• 0:07
  another
• 0:07
  episode
• 0:08
  of
• 0:08
  Pearls
• 0:08
  and
• 0:09
  prep
• 0:09
  npz.
• 0:10
  Here,
• 0:10
  your
• 0:10
  preceptor
• 0:11
  in
• 0:11
  your
• 0:11
  pocket,
• 0:11
  your
• 0:12
  go
• 0:12
  to
• 0:12
  place
• 0:13
  for
• 0:13
  pearls
• 0:13
  that
• 0:14
  prep
• 0:14
  you
• 0:14
  to
• 0:14
  practice.
• 0:15
  Today
• 0:16
  we
• 0:16
  have
• 0:16
  a
• 0:16
  board
• 0:17
  bomb
• 0:18
  back
• 0:18
  by
• 0:18
  popular
• 0:19
  demand.
• 0:19
  A
• 0:20
  fun
• 0:20
  one,
• 0:20
  a
• 0:21
  juicy
• 0:21
  one.
• 0:21
  This
• 0:21
  one
• 0:21
  is
• 0:22
  dripping
• 0:22
  with
• 0:22
  pearls
• 0:23
  and
• 0:23
  it's
• 0:23
  going
• 0:23
  to
• 0:24
  really
• 0:24
  keep
• 0:24
  you
• 0:24
  at
• 0:25
  the
• 0:25
  edge
• 0:25
  of
• 0:25
  your
• 0:25
  seat
• 0:25
  and
• 0:26
  at
• 0:26
  the
• 0:26
  top
• 0:26
  of
• 0:26
  your
• 0:26
  game
• 0:27
  in
• 0:27
  your
• 0:27
  clinic.
• 0:28
  Okay,
• 0:28
  my
• 0:28
  friends,
• 0:29
  so
• 0:30
  you
• 0:30
  have
• 0:30
  a
• 0:31
  28
• 0:31
  year
• 0:31
  old
• 0:32
  mock
• 0:32
  patient
• 0:33
  named
• 0:33
  Terri.
• 0:34
  Okay?
• 0:35
  She's
• 0:35
  28.
• 0:36
  She
• 0:37
  presents
• 0:37
  to
• 0:37
  you
• 0:38
  after
• 0:38
  three
• 0:39
  years
• 0:39
  of
• 0:39
  treatment
• 0:40
  from
• 0:40
  her
• 0:40
  primary
• 0:40
  care
• 0:41
  provider
• 0:41
  for
• 0:42
  generalized
• 0:42
  anxiety
• 0:43
  disorder.
• 0:43
  Okay?
• 0:44
  She
• 0:44
  has
• 0:44
  these
• 0:44
  persistent,
• 0:45
  really
• 0:46
  intrusive
• 0:46
  images
• 0:47
  of
• 0:47
  stabbing
• 0:48
  her
• 0:48
  grandmother,
• 0:49
  which
• 0:49
  she
• 0:50
  finds
• 0:50
  really
• 0:50
  horrifying,
• 0:51
  really
• 0:52
  ego
• 0:52
  dystonic.
• 0:53
  She's
• 0:53
  never
• 0:53
  harmed
• 0:54
  anyone
• 0:54
  in
• 0:54
  her
• 0:54
  life.
• 0:55
  But
• 0:55
  she
• 0:55
  does
• 0:55
  avoid
• 0:56
  being
• 0:56
  alone
• 0:57
  because
• 0:57
  she
• 0:58
  repeatedly
• 0:59
  asks
• 0:59
  her
• 0:59
  husband's
• 1:00
  for
• 1:00
  husband
• 1:00
  for
• 1:00
  reassurance
• 1:01
  that
• 1:01
  she's
• 1:02
  not
• 1:02
  a
• 1:02
  monster.
• 1:03
  She
• 1:03
  checks
• 1:03
  her
• 1:04
  kitchen
• 1:04
  knives
• 1:04
  multiple
• 1:05
  times
• 1:05
  daily
• 1:06
  to
• 1:06
  confirm
• 1:06
  that
• 1:06
  they're
• 1:07
  locked
• 1:07
  away.
• 1:08
  Now
• 1:08
  she's
• 1:08
  on
• 1:08
  Effexor
• 1:09
  150mg
• 1:10
  every
• 1:10
  day.
• 1:10
  She's
• 1:11
  on
• 1:11
  Klonopin
• 1:12
  1mg
• 1:12
  twice
• 1:13
  a
• 1:13
  day,
• 1:14
  also
• 1:14
  started
• 1:14
  by
• 1:15
  her
• 1:15
  previous
• 1:16
  provider
• 1:16
  who's
• 1:17
  sending
• 1:17
  her
• 1:17
  to
• 1:17
  you.
• 1:18
  She
• 1:18
  says
• 1:19
  the
• 1:19
  meds
• 1:19
  help
• 1:20
  kind
• 1:20
  of
• 1:20
  take
• 1:20
  the
• 1:20
  edge
• 1:20
  off,
• 1:21
  but
• 1:21
  the
• 1:21
  intrusive
• 1:21
  images
• 1:22
  and
• 1:22
  rituals
• 1:22
  are
• 1:23
  persistent.
• 1:24
  They're
• 1:24
  unchanged.
• 1:25
  She
• 1:25
  also
• 1:26
  sees
• 1:26
  her
• 1:26
  therapist
• 1:27
  weekly
• 1:27
  for
• 1:28
  talk
• 1:28
  therapy,
• 1:29
  focused
• 1:30
  really
• 1:30
  on
• 1:30
  like,
• 1:30
  exploring
• 1:31
  unconscious
• 1:32
  roots
• 1:32
  of
• 1:32
  her
• 1:32
  anxiety.
• 1:33
  Now,
• 1:34
  which
• 1:34
  of
• 1:34
  the
• 1:34
  following
• 1:35
  is
• 1:35
  the
• 1:35
  most
• 1:35
  appropriate
• 1:36
  next
• 1:37
  step
• 1:37
  in
• 1:37
  the
• 1:37
  management
• 1:38
  of
• 1:38
  our
• 1:38
  friend
• 1:38
  Terri?
• 1:40
  Is
• 1:40
  it
• 1:40
  a,
• 1:41
  adding
• 1:42
  Risperdal
• 1:43
  0.5mg
• 1:44
  daily
• 1:44
  to
• 1:45
  augment
• 1:46
  her
• 1:46
  Effexor
• 1:47
  regimen?
• 1:48
  Is
• 1:49
  it
• 1:49
  B,
• 1:50
  discontinue
• 1:50
  effexor,
• 1:52
  start
• 1:52
  Prozac
• 1:53
  20mg
• 1:53
  daily
• 1:54
  and
• 1:54
  reassess
• 1:55
  in
• 1:55
  four
• 1:55
  weeks?
• 1:56
  Is
• 1:56
  it
• 1:56
  C,
• 1:57
  discontinue
• 1:58
  Effexor,
• 1:59
  start
• 2:00
  Fluvoxamine
• 2:01
  or
• 2:01
  Luvox,
• 2:02
  titrated
• 2:02
  to
• 2:03
  the
• 2:03
  maximum
• 2:03
  tolerated
• 2:04
  dose,
• 2:05
  tapering
• 2:05
  off
• 2:06
  her
• 2:06
  Klonopin
• 2:07
  and
• 2:07
  referring
• 2:07
  her
• 2:07
  to
• 2:07
  erp.
• 2:09
  Okay,
• 2:10
  is
• 2:11
  it
• 2:11
  D,
• 2:11
  continue
• 2:12
  her
• 2:12
  current
• 2:12
  medications
• 2:13
  and
• 2:13
  refer
• 2:14
  her
• 2:14
  to
• 2:14
  cbt?
• 2:15
  Focus
• 2:16
  on
• 2:16
  cognitive
• 2:16
  restructuring
• 2:17
  of
• 2:17
  her
• 2:17
  intrusive
• 2:18
  thoughts,
• 2:19
  or
• 2:19
  is
• 2:19
  it
• 2:19
  E,
• 2:20
  discontinue
• 2:21
  Effexor,
• 2:22
  start
• 2:23
  Prozac
• 2:25
  titrated
• 2:25
  to
• 2:26
  60
• 2:26
  to
• 2:26
  80
• 2:26
  every
• 2:27
  day.
• 2:27
  Continue
• 2:28
  the
• 2:28
  Klonopin
• 2:29
  and
• 2:29
  refer
• 2:29
  for
• 2:29
  psychodynamic
• 2:30
  therapy.
• 2:31
  So
• 2:32
  y'
• 2:32
  all
• 2:32
  can
• 2:32
  get
• 2:32
  into
• 2:32
  your
• 2:33
  breakout
• 2:33
  sessions
• 2:33
  on
• 2:34
  Zoom.
• 2:34
  All
• 2:35
  right,
• 2:35
  I'm
• 2:35
  gonna
• 2:35
  start
• 2:36
  going
• 2:36
  over
• 2:36
  the
• 2:36
  answers
• 2:37
  here.
• 2:37
  Now,
• 2:37
  what
• 2:38
  this
• 2:38
  question
• 2:38
  is
• 2:39
  trying
• 2:39
  to
• 2:39
  tease
• 2:39
  out
• 2:39
  is
• 2:40
  really
• 2:41
  important.
• 2:41
  It's
• 2:42
  trying
• 2:42
  to
• 2:42
  tease
• 2:42
  out
• 2:42
  whether
• 2:43
  you
• 2:43
  Know
• 2:44
  the
• 2:45
  evidence
• 2:46
  based
• 2:47
  therapy,
• 2:47
  the
• 2:48
  guidelines
• 2:48
  for
• 2:49
  ocd.
• 2:50
  And
• 2:50
  some
• 2:50
  of
• 2:50
  these
• 2:51
  should
• 2:51
  jump
• 2:51
  out
• 2:51
  at
• 2:51
  you
• 2:52
  right
• 2:52
  away
• 2:52
  as,
• 2:53
  yes,
• 2:54
  that
• 2:54
  sounds
• 2:54
  like
• 2:54
  what
• 2:54
  we
• 2:55
  need
• 2:55
  to
• 2:55
  do
• 2:55
  in
• 2:55
  ocd.
• 2:56
  And
• 2:56
  no,
• 2:56
  that's
• 2:57
  definitely
• 2:57
  not
• 2:57
  what
• 2:58
  we
• 2:58
  need
• 2:58
  to
• 2:58
  do
• 2:58
  with
• 2:58
  ocd.
• 2:59
  Okay?
• 3:01
  And
• 3:01
  the
• 3:01
  biggest
• 3:02
  thing
• 3:02
  to
• 3:02
  recognize
• 3:03
  here
• 3:03
  is
• 3:03
  that
• 3:03
  OCD
• 3:04
  is
• 3:04
  even
• 3:04
  happening
• 3:04
  in
• 3:04
  the
• 3:05
  first
• 3:05
  place.
• 3:05
  You
• 3:05
  have
• 3:05
  this
• 3:06
  anchoring
• 3:06
  bias
• 3:06
  where
• 3:07
  the
• 3:07
  primary
• 3:07
  care
• 3:08
  provider
• 3:08
  refers
• 3:09
  Terry
• 3:10
  over
• 3:10
  to
• 3:10
  you,
• 3:11
  telling
• 3:11
  you
• 3:12
  that
• 3:12
  Terri
• 3:13
  has
• 3:13
  generalized
• 3:13
  anxiety
• 3:14
  disorder.
• 3:14
  You're
• 3:14
  going
• 3:14
  to
• 3:15
  get
• 3:15
  this
• 3:15
  all
• 3:15
  the
• 3:15
  time.
• 3:16
  We
• 3:16
  talk
• 3:16
  about
• 3:16
  anchoring
• 3:17
  bias
• 3:17
  all
• 3:17
  of
• 3:18
  the
• 3:18
  time
• 3:18
  on
• 3:18
  this
• 3:18
  podcast.
• 3:20
  You're
• 3:20
  going
• 3:20
  to
• 3:20
  be
• 3:20
  get.
• 3:21
  You're
• 3:21
  going
• 3:21
  to
• 3:21
  receive
• 3:22
  a
• 3:22
  diagnosis
• 3:23
  from
• 3:23
  a
• 3:23
  qualified
• 3:24
  professional
• 3:25
  who's
• 3:25
  wonderful
• 3:25
  and
• 3:25
  they
• 3:26
  mean
• 3:26
  well
• 3:26
  and
• 3:26
  they're
• 3:27
  highly
• 3:27
  educated,
• 3:28
  but
• 3:28
  it's
• 3:29
  not
• 3:29
  always
• 3:29
  their
• 3:29
  specialty.
• 3:30
  And
• 3:30
  sometimes
• 3:31
  the
• 3:31
  fast
• 3:32
  heuristic
• 3:33
  for
• 3:33
  them
• 3:33
  is
• 3:34
  to
• 3:34
  slap
• 3:34
  on
• 3:35
  a
• 3:35
  very
• 3:35
  common
• 3:37
  disorder
• 3:37
  in
• 3:38
  the
• 3:38
  DSM
• 3:38
  5
• 3:39
  that
• 3:39
  may
• 3:39
  even
• 3:39
  be
• 3:40
  comorbid
• 3:40
  and
• 3:40
  may
• 3:41
  even
• 3:41
  be
• 3:41
  kind
• 3:41
  of
• 3:41
  accurate,
• 3:42
  but
• 3:42
  it
• 3:42
  might
• 3:43
  not
• 3:43
  be
• 3:43
  the
• 3:44
  principal
• 3:44
  issue
• 3:44
  and
• 3:45
  it
• 3:45
  might
• 3:45
  lack
• 3:45
  the
• 3:45
  specificity
• 3:46
  of
• 3:47
  what
• 3:47
  you
• 3:47
  need
• 3:47
  as
• 3:48
  the
• 3:48
  psychiatric
• 3:48
  prescriber.
• 3:49
  There's
• 3:49
  a
• 3:49
  reason
• 3:49
  he's
• 3:50
  sending
• 3:50
  Terry
• 3:51
  to
• 3:51
  you
• 3:51
  in
• 3:51
  the
• 3:51
  first
• 3:51
  place,
• 3:52
  right?
• 3:52
  Because
• 3:52
  something
• 3:53
  isn't
• 3:53
  perfect.
• 3:54
  And
• 3:54
  so
• 3:54
  you
• 3:54
  want
• 3:54
  to
• 3:55
  question
• 3:55
  right
• 3:56
  away
• 3:56
  whether
• 3:56
  the
• 3:57
  diagnosis
• 3:57
  is
• 3:57
  accurate.
• 3:58
  Not
• 3:58
  because
• 3:58
  we
• 3:58
  want
• 3:58
  to
• 3:59
  be
• 3:59
  antagonistic
• 3:59
  to
• 3:59
  our
• 4:00
  good
• 4:00
  friends
• 4:00
  in
• 4:00
  primary
• 4:01
  care,
• 4:02
  but
• 4:02
  because
• 4:02
  they're
• 4:03
  coming
• 4:03
  to
• 4:03
  you
• 4:03
  for
• 4:03
  a
• 4:03
  reason.
• 4:04
  Something
• 4:04
  isn't
• 4:04
  right
• 4:04
  here.
• 4:05
  Their
• 4:05
  treatment
• 4:05
  isn't
• 4:05
  right.
• 4:06
  Well,
• 4:06
  if
• 4:06
  their
• 4:06
  treatment
• 4:06
  isn't
• 4:07
  right,
• 4:07
  it
• 4:07
  begs
• 4:07
  the
• 4:07
  question,
• 4:08
  is
• 4:08
  their
• 4:08
  diagnosis
• 4:09
  right?
• 4:09
  That's
• 4:09
  sort
• 4:09
  of
• 4:09
  a
• 4:10
  fundamental
• 4:11
  way
• 4:11
  of
• 4:11
  examining
• 4:12
  every
• 4:12
  case
• 4:12
  that
• 4:13
  comes
• 4:13
  your
• 4:13
  way,
• 4:13
  right?
• 4:13
  Is
• 4:14
  the
• 4:14
  dose
• 4:14
  right?
• 4:14
  Is
• 4:15
  the
• 4:15
  adherence
• 4:15
  right?
• 4:16
  Is
• 4:16
  the
• 4:16
  diagnosis
• 4:17
  right?
• 4:17
  Is
• 4:17
  substance
• 4:18
  use
• 4:18
  getting
• 4:18
  in
• 4:19
  the
• 4:19
  way?
• 4:19
  All
• 4:19
  of
• 4:19
  these
• 4:19
  things
• 4:20
  need
• 4:20
  to
• 4:20
  be
• 4:21
  at
• 4:21
  the
• 4:21
  top
• 4:21
  of
• 4:22
  your
• 4:22
  mind
• 4:22
  as
• 4:23
  routinely
• 4:23
  as
• 4:23
  possible
• 4:24
  as
• 4:24
  you
• 4:24
  begin
• 4:24
  to
• 4:25
  practice.
• 4:26
  Now,
• 4:26
  what's
• 4:26
  weird
• 4:27
  about
• 4:27
  Terry's
• 4:28
  presentation
• 4:29
  today
• 4:29
  is
• 4:29
  that
• 4:30
  she
• 4:30
  has
• 4:30
  this
• 4:30
  gad
• 4:31
  dia
• 4:31
  diagnosis
• 4:32
  slapped
• 4:32
  on
• 4:32
  her,
• 4:33
  on
• 4:33
  her
• 4:33
  case
• 4:34
  file.
• 4:35
  But
• 4:35
  she's
• 4:36
  really
• 4:36
  describing
• 4:37
  ocd,
• 4:38
  right?
• 4:38
  The
• 4:38
  ego
• 4:38
  dystonic,
• 4:39
  persistent,
• 4:40
  inappropriate,
• 4:40
  intrusive
• 4:41
  images
• 4:42
  stabbing
• 4:42
  her
• 4:43
  grandmother.
• 4:43
  Right?
• 4:43
  These
• 4:43
  are
• 4:44
  violent,
• 4:44
  unwanted
• 4:46
  intrusions
• 4:47
  in
• 4:47
  her
• 4:47
  mind.
• 4:48
  That
• 4:48
  is
• 4:48
  categorically
• 4:49
  different
• 4:49
  than
• 4:50
  generalized
• 4:50
  anxiety
• 4:51
  where
• 4:51
  you
• 4:52
  are
• 4:52
  worried
• 4:52
  about
• 4:52
  actual
• 4:53
  things.
• 4:53
  Your
• 4:54
  budget,
• 4:54
  your
• 4:54
  health,
• 4:55
  you
• 4:55
  know,
• 4:56
  your
• 4:56
  job.
• 5:52
  It
• 5:52
  may
• 5:52
  be
• 5:52
  exaggerated
• 5:53
  worries,
• 5:53
  they
• 5:54
  might
• 5:54
  be
• 5:54
  catastrophic
• 5:55
  worries,
• 5:55
  but
• 5:55
  they
• 5:56
  are
• 5:56
  worried.
• 5:56
  You're
• 5:57
  typically
• 5:57
  worried
• 5:57
  about
• 5:58
  everyday
• 5:58
  things
• 5:58
  that
• 5:59
  are
• 5:59
  real
• 6:00
  and
• 6:00
  could
• 6:00
  go
• 6:01
  wrong.
• 6:01
  But
• 6:02
  this
• 6:02
  is
• 6:02
  different.
• 6:03
  What
• 6:03
  Terry's
• 6:03
  bringing
• 6:04
  to
• 6:04
  you
• 6:04
  is
• 6:04
  this
• 6:04
  ego
• 6:05
  dystonic,
• 6:05
  intrusive
• 6:06
  thought
• 6:06
  that
• 6:06
  is
• 6:07
  you
• 6:07
  violent.
• 6:08
  I
• 6:08
  would
• 6:08
  argue
• 6:09
  it's
• 6:09
  maybe
• 6:10
  not
• 6:10
  as
• 6:10
  bizarre
• 6:11
  as
• 6:11
  it
• 6:11
  is
• 6:11
  violent.
• 6:12
  I
• 6:12
  would
• 6:12
  argue
• 6:12
  it's
• 6:12
  more
• 6:13
  violent
• 6:14
  than
• 6:14
  it
• 6:14
  is
• 6:14
  bizarre.
• 6:15
  But
• 6:15
  again,
• 6:15
  it's
• 6:15
  unwanted.
• 6:16
  And
• 6:17
  so
• 6:17
  you're
• 6:17
  not
• 6:17
  really
• 6:19
  looking
• 6:19
  at
• 6:19
  GAD
• 6:20
  here.
• 6:20
  This
• 6:20
  is
• 6:21
  much
• 6:21
  more
• 6:22
  consistent
• 6:23
  with
• 6:23
  ocd.
• 6:23
  And
• 6:24
  if
• 6:24
  that
• 6:25
  wasn't
• 6:25
  the
• 6:25
  biggest
• 6:25
  tip
• 6:26
  off,
• 6:26
  her
• 6:27
  checking
• 6:27
  the
• 6:27
  kitchen
• 6:27
  knives
• 6:28
  multiple
• 6:28
  times
• 6:28
  a
• 6:29
  day
• 6:29
  is
• 6:30
  the
• 6:30
  compulsion
• 6:31
  associated
• 6:32
  with
• 6:32
  the
• 6:32
  obsession
• 6:33
  and
• 6:33
  her
• 6:33
  way
• 6:34
  of
• 6:34
  trying
• 6:34
  to
• 6:34
  neutralize
• 6:35
  the
• 6:35
  anxiety.
• 6:35
  Oh,
• 6:36
  if
• 6:36
  I
• 6:36
  check
• 6:36
  the
• 6:36
  kitchen
• 6:37
  knives,
• 6:37
  then
• 6:38
  the
• 6:38
  obsessions
• 6:39
  aren't
• 6:39
  as
• 6:40
  frightening
• 6:41
  to
• 6:41
  me
• 6:41
  because
• 6:41
  I
• 6:41
  can't
• 6:42
  do
• 6:42
  harm
• 6:42
  even
• 6:42
  if
• 6:43
  I
• 6:43
  wanted
• 6:43
  to,
• 6:44
  and
• 6:44
  I
• 6:44
  don't
• 6:44
  want
• 6:45
  to.
• 6:45
  But
• 6:46
  the
• 6:46
  compulsion,
• 6:46
  again,
• 6:47
  is
• 6:47
  trying
• 6:47
  to
• 6:47
  extinguish
• 6:48
  the
• 6:48
  obsessional
• 6:48
  anxiety
• 6:49
  here.
• 6:49
  So
• 6:49
  this
• 6:50
  sounds
• 6:51
  very
• 6:51
  pervasive,
• 6:52
  very
• 6:52
  intrusive,
• 6:53
  and
• 6:53
  very
• 6:53
  classic
• 6:54
  of
• 6:54
  an
• 6:54
  obsessional
• 6:55
  compulsive
• 6:57
  pathology
• 6:57
  and
• 6:58
  not
• 6:58
  general
• 6:58
  worry.
• 6:59
  That's
• 6:59
  not
• 6:59
  quite
• 6:59
  the
• 6:59
  flavor
• 7:01
  that
• 7:01
  we
• 7:01
  have
• 7:01
  here.
• 7:02
  So
• 7:02
  I
• 7:02
  think
• 7:02
  it's
• 7:02
  really
• 7:03
  worth
• 7:03
  just
• 7:04
  staring
• 7:04
  that
• 7:05
  right
• 7:05
  in
• 7:05
  its
• 7:05
  eyes
• 7:06
  and
• 7:06
  saying
• 7:06
  this.
• 7:06
  Something's
• 7:07
  not
• 7:07
  right
• 7:07
  here.
• 7:08
  The
• 7:08
  specificity's
• 7:09
  off.
• 7:09
  The
• 7:09
  provider
• 7:10
  got
• 7:10
  the
• 7:10
  anxiety
• 7:10
  right,
• 7:11
  but
• 7:11
  we're
• 7:11
  not
• 7:12
  quite
• 7:12
  in
• 7:12
  the
• 7:12
  right
• 7:12
  direction.
• 7:13
  Now,
• 7:13
  this
• 7:13
  matters,
• 7:14
  right?
• 7:14
  This
• 7:14
  matters
• 7:14
  a
• 7:15
  lot
• 7:15
  because
• 7:15
  it's
• 7:16
  going
• 7:16
  to
• 7:16
  qualitatively
• 7:17
  change
• 7:17
  the
• 7:18
  way
• 7:18
  we
• 7:18
  treat
• 7:18
  this
• 7:19
  patient,
• 7:19
  right?
• 7:20
  The
• 7:20
  dose,
• 7:21
  the
• 7:21
  duration,
• 7:22
  the
• 7:22
  kinds
• 7:22
  of
• 7:22
  medications
• 7:23
  get
• 7:23
  more
• 7:23
  specific,
• 7:24
  the
• 7:24
  kinds
• 7:24
  of
• 7:24
  therapy
• 7:25
  get
• 7:25
  more
• 7:26
  specific.
• 7:26
  So
• 7:27
  getting
• 7:27
  back
• 7:27
  to
• 7:28
  the
• 7:28
  question,
• 7:28
  do
• 7:28
  we
• 7:28
  add
• 7:28
  Risperdal
• 7:29
  here
• 7:29
  to
• 7:30
  augment
• 7:30
  Venlafaxine
• 7:31
  or
• 7:32
  the
• 7:32
  Effexor
• 7:33
  regimen?
• 7:33
  We
• 7:33
  might
• 7:34
  see
• 7:34
  antipsychotic
• 7:35
  augmentation
• 7:36
  if
• 7:37
  a
• 7:37
  patient
• 7:37
  was
• 7:37
  on
• 7:38
  an
• 7:38
  SSRI
• 7:38
  at
• 7:39
  a
• 7:39
  maximal
• 7:39
  dose
• 7:40
  for
• 7:40
  8
• 7:40
  to
• 7:40
  12
• 7:40
  weeks
• 7:40
  in
• 7:41
  OCD.
• 7:42
  But
• 7:42
  this
• 7:42
  patient
• 7:42
  is
• 7:43
  not
• 7:43
  on
• 7:43
  an
• 7:43
  SSRI
• 7:44
  for
• 7:44
  OCD.
• 7:45
  They're
• 7:45
  on
• 7:45
  an
• 7:45
  S
• 7:46
  N
• 7:46
  R
• 7:46
  I,
• 7:47
  which
• 7:47
  is.
• 7:48
  Doesn't
• 7:48
  have
• 7:49
  the
• 7:49
  evidence
• 7:49
  base
• 7:49
  of
• 7:49
  SSRIs.
• 7:51
  So
• 7:51
  augmenting
• 7:52
  when
• 7:52
  you're
• 7:52
  already
• 7:52
  in
• 7:52
  the
• 7:53
  wrong
• 7:53
  drug
• 7:53
  class
• 7:54
  with
• 7:54
  a
• 7:54
  suboptimal
• 7:55
  regimen
• 7:55
  doesn't
• 7:56
  make
• 7:56
  a
• 7:56
  lot
• 7:56
  of
• 7:56
  sense.
• 7:56
  So
• 7:57
  I
• 7:57
  say
• 7:57
  get
• 7:57
  rid
• 7:57
  of
• 7:57
  Risperidone.
• 7:58
  That
• 7:58
  is
• 7:58
  not
• 7:59
  the
• 7:59
  right
• 8:00
  context.
• 8:00
  It
• 8:00
  might
• 8:01
  work
• 8:01
  in
• 8:01
  a
• 8:01
  different
• 8:02
  scenario
• 8:03
  clinically.
• 8:03
  But
• 8:04
  putting
• 8:04
  the
• 8:04
  cart
• 8:05
  before
• 8:05
  the
• 8:05
  horse?
• 8:05
  Our
• 8:05
  main
• 8:06
  problem
• 8:06
  here
• 8:06
  is
• 8:07
  not
• 8:07
  that
• 8:07
  we're
• 8:07
  not
• 8:08
  augmenting
• 8:08
  with
• 8:08
  Risperdal.
• 8:09
  So
• 8:09
  forget
• 8:10
  option
• 8:11
  A.
• 8:11
  Option
• 8:12
  A
• 8:12
  is
• 8:12
  not
• 8:12
  the
• 8:12
  answer.
• 8:13
  Option
• 8:13
  B,
• 8:14
  do
• 8:14
  we
• 8:14
  discontinue
• 8:15
  effexor,
• 8:16
  start
• 8:16
  Prozac
• 8:16
  20
• 8:17
  milligrams
• 8:17
  daily
• 8:17
  and
• 8:18
  reassess
• 8:18
  in
• 8:18
  four
• 8:18
  weeks?
• 8:19
  Well,
• 8:20
  there's
• 8:20
  two
• 8:20
  issues
• 8:20
  with
• 8:20
  this.
• 8:21
  The
• 8:21
  first
• 8:21
  thing
• 8:21
  is
• 8:22
  that
• 8:23
  Prozac
• 8:23
  20
• 8:24
  is
• 8:24
  not
• 8:24
  going
• 8:24
  to
• 8:24
  do
• 8:24
  anything
• 8:25
  for
• 8:25
  this
• 8:25
  patient
• 8:26
  that's
• 8:26
  not
• 8:26
  an
• 8:26
  OCD
• 8:27
  dose,
• 8:27
  right?
• 8:27
  We
• 8:27
  want
• 8:28
  to
• 8:28
  really
• 8:28
  push
• 8:29
  OCD
• 8:29
  doses
• 8:30
  to
• 8:30
  the
• 8:30
  maximal
• 8:31
  range
• 8:32
  with
• 8:32
  SSRI,
• 8:33
  so
• 8:33
  we're
• 8:33
  talking
• 8:34
  more
• 8:34
  like
• 8:34
  60
• 8:34
  to
• 8:35
  80
• 8:35
  milligrams.
• 8:35
  I've
• 8:36
  seen
• 8:36
  patients
• 8:36
  go
• 8:36
  well
• 8:36
  above
• 8:37
  the
• 8:37
  FDA
• 8:37
  max.
• 8:38
  Of
• 8:38
  course,
• 8:38
  you've
• 8:38
  got
• 8:38
  to
• 8:39
  consult
• 8:39
  your
• 8:39
  guidelines
• 8:40
  patient
• 8:40
  by
• 8:41
  patient.
• 8:41
  Scour
• 8:42
  the
• 8:42
  literature
• 8:42
  for
• 8:43
  that
• 8:43
  one.
• 8:43
  That's
• 8:43
  not
• 8:44
  something
• 8:44
  that
• 8:45
  I
• 8:45
  will
• 8:45
  recommend
• 8:45
  here.
• 8:46
  Okay.
• 8:46
  I'm
• 8:46
  just
• 8:47
  kind
• 8:47
  of
• 8:47
  explaining
• 8:48
  how
• 8:48
  things
• 8:48
  happen
• 8:48
  in
• 8:49
  practice.
• 8:49
  But
• 8:49
  I
• 8:49
  have
• 8:50
  seen
• 8:50
  heroically
• 8:50
  high
• 8:50
  doses
• 8:51
  for
• 8:51
  OCD
• 8:52
  well
• 8:52
  past
• 8:53
  the
• 8:53
  FDA
• 8:54
  maximums
• 8:54
  in
• 8:55
  practice.
• 8:55
  But
• 8:56
  at
• 8:56
  20
• 8:56
  milligrams
• 8:57
  of
• 8:57
  of
• 8:58
  Prozac
• 8:58
  is
• 8:59
  like
• 9:00
  you.
• 9:00
  You
• 9:00
  have
• 9:00
  a
• 9:01
  charging
• 9:01
  rhino
• 9:01
  in
• 9:02
  front
• 9:02
  of
• 9:02
  you
• 9:02
  and
• 9:02
  you're
• 9:02
  trying
• 9:03
  to
• 9:03
  beat
• 9:03
  it
• 9:03
  on
• 9:03
  the
• 9:03
  head
• 9:03
  with
• 9:04
  a
• 9:04
  spatula.
• 9:04
  It's
• 9:04
  just
• 9:05
  not
• 9:05
  going
• 9:05
  to
• 9:05
  happen.
• 9:05
  Okay.
• 9:06
  And
• 9:06
  so
• 9:06
  that's
• 9:07
  not
• 9:07
  a
• 9:07
  really
• 9:07
  good
• 9:08
  idea.
• 9:08
  Also,
• 9:09
  four
• 9:09
  weeks.
• 9:09
  Here
• 9:10
  is
• 9:10
  the
• 9:10
  tip
• 9:10
  off
• 9:10
  again,
• 9:11
  the
• 9:11
  question's
• 9:11
  trying
• 9:11
  to.
• 9:12
  To
• 9:13
  sniff
• 9:13
  out
• 9:13
  whether
• 9:14
  you
• 9:14
  understand
• 9:15
  how
• 9:15
  long
• 9:15
  a
• 9:16
  patient
• 9:16
  needs
• 9:16
  to
• 9:16
  be
• 9:16
  on
• 9:16
  medications
• 9:17
  and
• 9:17
  OCD
• 9:18
  for
• 9:18
  to
• 9:19
  understand
• 9:19
  a
• 9:19
  proper
• 9:20
  response
• 9:20
  and.
• 9:21
  And
• 9:21
  at
• 9:22
  what
• 9:22
  dose.
• 9:22
  So
• 9:22
  four
• 9:23
  weeks
• 9:23
  is
• 9:23
  absolutely
• 9:24
  insufficient.
• 9:25
  OCD
• 9:26
  guidelines
• 9:26
  are
• 9:27
  typically
• 9:27
  requiring
• 9:27
  eight
• 9:28
  to
• 9:28
  12
• 9:28
  weeks
• 9:28
  at
• 9:28
  a
• 9:29
  maximal
• 9:29
  tolerated
• 9:30
  dose
• 9:30
  before
• 9:31
  we
• 9:32
  declare
• 9:32
  failure,
• 9:33
  before
• 9:33
  we
• 9:33
  move
• 9:33
  on
• 9:33
  to
• 9:33
  something
• 9:34
  else.
• 9:34
  Right.
• 9:35
  So
• 9:35
  I
• 9:35
  don't
• 9:36
  like
• 9:36
  this
• 9:36
  question.
• 9:36
  It's
• 9:37
  insufficient.
• 9:37
  It's
• 9:38
  weak
• 9:38
  or.
• 9:38
  I
• 9:39
  don't
• 9:39
  like
• 9:39
  this
• 9:39
  choice.
• 9:39
  It's
• 9:40
  insufficient
• 9:40
  in
• 9:40
  weak.
• 9:40
  So
• 9:41
  B
• 9:41
  is
• 9:42
  actually
• 9:42
  wrong.
• 9:43
  Let's
• 9:43
  go
• 9:43
  to
• 9:43
  option
• 9:44
  D
• 9:44
  real
• 9:44
  quick.
• 9:45
  Do
• 9:45
  we
• 9:45
  continue
• 9:46
  these
• 9:46
  current
• 9:46
  meds
• 9:47
  and
• 9:47
  refer
• 9:47
  to
• 9:47
  cbt?
• 9:48
  Focus
• 9:48
  on
• 9:49
  focusing
• 9:49
  on,
• 9:49
  like,
• 9:50
  restructuring
• 9:50
  these
• 9:51
  intrusive
• 9:51
  thoughts.
• 9:52
  And
• 9:52
  that's
• 9:52
  the
• 9:53
  wrong
• 9:53
  answer.
• 9:53
  That
• 9:53
  might
• 9:53
  be
• 9:53
  one
• 9:54
  of
• 9:54
  the
• 9:54
  most
• 9:54
  wrong
• 9:55
  answers.
• 9:55
  Actually.
• 9:57
  This
• 9:57
  is
• 9:57
  not
• 9:57
  a
• 9:57
  good
• 9:57
  idea.
• 9:58
  Number
• 9:58
  one,
• 9:58
  we're
• 9:58
  keeping
• 9:59
  in
• 9:59
  a
• 9:59
  regimen
• 9:59
  that
• 10:00
  isn't
• 10:00
  really
• 10:00
  evidence
• 10:01
  based.
• 10:01
  There's
• 10:01
  not
• 10:02
  a
• 10:02
  lot
• 10:02
  of
• 10:02
  evidence
• 10:02
  for
• 10:02
  SNRIs
• 10:03
  with
• 10:03
  OCD
• 10:04
  or
• 10:04
  benzos.
• 10:05
  Not
• 10:05
  a
• 10:05
  good
• 10:05
  idea.
• 10:06
  Again,
• 10:06
  we
• 10:06
  want
• 10:06
  high
• 10:07
  dose
• 10:07
  SSRIs.
• 10:07
  8
• 10:08
  to
• 10:08
  12
• 10:08
  weeks.
• 10:09
  Sustained
• 10:10
  high,
• 10:10
  maximally
• 10:10
  tolerated
• 10:11
  SSRI
• 10:12
  dose.
• 10:12
  The
• 10:12
  whole.
• 10:13
  The
• 10:13
  whole
• 10:14
  rigmarole
• 10:15
  here
• 10:15
  is
• 10:15
  the
• 10:16
  serotonergic
• 10:17
  piece
• 10:18
  in
• 10:18
  ocd.
• 10:19
  It
• 10:19
  usually
• 10:19
  requires
• 10:20
  higher
• 10:20
  doses.
• 10:21
  Okay,
• 10:22
  so
• 10:23
  keeping
• 10:23
  the
• 10:23
  status
• 10:24
  quo
• 10:24
  and
• 10:24
  just
• 10:24
  adding
• 10:25
  CBT
• 10:25
  is
• 10:25
  not
• 10:25
  gonna
• 10:26
  work.
• 10:26
  In
• 10:26
  fact,
• 10:26
  erp.
• 10:27
  Okay.
• 10:28
  Exposure
• 10:29
  response
• 10:30
  is
• 10:30
  what
• 10:31
  we
• 10:31
  need
• 10:31
  to
• 10:31
  do.
• 10:31
  Not
• 10:32
  C,
• 10:33
  not
• 10:33
  cbt.
• 10:34
  Okay.
• 10:35
  An
• 10:35
  exposure
• 10:36
  response
• 10:37
  is
• 10:38
  much
• 10:38
  more
• 10:39
  specific
• 10:40
  to
• 10:40
  ocd.
• 10:41
  And
• 10:41
  of
• 10:42
  course,
• 10:42
  that's
• 10:42
  extremely
• 10:43
  important
• 10:43
  because
• 10:44
  you
• 10:44
  don't
• 10:44
  want
• 10:44
  to
• 10:45
  just
• 10:45
  restructure
• 10:46
  your
• 10:46
  response
• 10:47
  to
• 10:47
  the
• 10:47
  obsessional
• 10:48
  thoughts
• 10:48
  that
• 10:48
  can
• 10:49
  actually
• 10:49
  feed
• 10:50
  the
• 10:50
  obsessional
• 10:51
  thoughts
• 10:51
  even
• 10:51
  more
• 10:52
  because
• 10:52
  you're
• 10:52
  asking
• 10:53
  for
• 10:53
  reassurance
• 10:54
  and
• 10:54
  you're
• 10:54
  working
• 10:54
  to
• 10:55
  get
• 10:55
  reinsurance
• 10:55
  to
• 10:56
  reassurance
• 10:56
  to
• 10:57
  reframe
• 10:57
  a
• 10:58
  thought
• 10:58
  that's
• 10:58
  disturbing.
• 10:59
  Kind
• 10:59
  of
• 10:59
  feed
• 10:59
  that
• 11:00
  obsessional
• 11:00
  thought
• 11:01
  cycle.
• 11:02
  And
• 11:02
  so
• 11:02
  you
• 11:02
  need
• 11:03
  erp.
• 11:03
  You
• 11:03
  need
• 11:03
  to
• 11:04
  be
• 11:04
  able
• 11:04
  to
• 11:04
  resist
• 11:05
  the
• 11:05
  compulsions
• 11:06
  and
• 11:06
  tolerate
• 11:07
  anxiety
• 11:07
  and
• 11:07
  not
• 11:08
  feel
• 11:08
  compelled
• 11:09
  to
• 11:09
  act
• 11:10
  on
• 11:10
  the
• 11:10
  obsession.
• 11:11
  And
• 11:11
  that's
• 11:12
  why
• 11:12
  ERP
• 11:13
  is
• 11:13
  more
• 11:13
  of
• 11:13
  a
• 11:13
  gold
• 11:13
  standard
• 11:14
  in
• 11:14
  ocd.
• 11:15
  So
• 11:15
  now
• 11:15
  we've
• 11:16
  this,
• 11:16
  this
• 11:16
  choice,
• 11:17
  this
• 11:17
  answer
• 11:17
  choice
• 11:18
  is
• 11:18
  drifting
• 11:18
  not
• 11:18
  only
• 11:19
  from
• 11:19
  the
• 11:19
  fact
• 11:19
  that
• 11:20
  we
• 11:20
  need
• 11:20
  to
• 11:20
  change
• 11:20
  these
• 11:20
  meds
• 11:21
  up,
• 11:21
  but
• 11:21
  now
• 11:21
  we're,
• 11:22
  we're
• 11:23
  orienting
• 11:23
  to
• 11:23
  a
• 11:24
  specific
• 11:24
  kind
• 11:25
  of
• 11:25
  therapy
• 11:25
  that
• 11:25
  may
• 11:26
  even
• 11:26
  be
• 11:26
  counterproductive
• 11:27
  and
• 11:27
  certainly
• 11:27
  is
• 11:28
  not
• 11:28
  the
• 11:28
  gold
• 11:28
  standard.
• 11:28
  So
• 11:29
  I
• 11:29
  don't
• 11:29
  like
• 11:29
  option
• 11:29
  D
• 11:30
  either.
• 11:30
  Option
• 11:31
  E
• 11:31
  is
• 11:32
  asking
• 11:32
  us
• 11:32
  if
• 11:32
  we
• 11:33
  want
• 11:33
  to
• 11:33
  add
• 11:34
  psychodynamic
• 11:35
  therapy
• 11:36
  and
• 11:36
  push
• 11:36
  Prozac
• 11:37
  to
• 11:37
  60
• 11:37
  to
• 11:38
  80.
• 11:38
  Well,
• 11:38
  the
• 11:39
  Prozac
• 11:39
  dose
• 11:40
  sounds
• 11:40
  pretty
• 11:40
  good
• 11:40
  here,
• 11:41
  but
• 11:42
  you
• 11:42
  know,
• 11:43
  I
• 11:43
  don't
• 11:43
  like
• 11:43
  the
• 11:43
  idea
• 11:44
  that
• 11:44
  we're
• 11:44
  supposed
• 11:45
  to
• 11:45
  continue
• 11:46
  Klonopin.
• 11:47
  That's
• 11:47
  not
• 11:47
  a
• 11:47
  smart,
• 11:48
  that's
• 11:48
  not
• 11:49
  what
• 11:49
  we're
• 11:49
  looking
• 11:49
  for.
• 11:50
  That
• 11:50
  can
• 11:50
  interfere
• 11:51
  with
• 11:51
  ERP
• 11:52
  actually.
• 11:53
  So.
• 11:54
  Wrong,
• 11:54
  wrong,
• 11:55
  wrong.
• 11:55
  And
• 11:55
  psychodynamic
• 11:56
  therapy,
• 11:57
  there's
• 11:57
  really
• 11:57
  no
• 11:57
  evidence
• 11:58
  base
• 11:58
  for
• 11:58
  that
• 11:58
  for
• 11:59
  ocd.
• 12:00
  Again,
• 12:00
  not
• 12:00
  the
• 12:00
  gold
• 12:01
  standard
• 12:02
  approach.
• 12:03
  So
• 12:03
  yeah,
• 12:04
  we
• 12:05
  are
• 12:06
  zeroing
• 12:06
  in
• 12:07
  on
• 12:07
  the
• 12:07
  right
• 12:07
  answer
• 12:08
  then,
• 12:08
  which
• 12:08
  would
• 12:08
  be
• 12:09
  C,
• 12:10
  we're
• 12:10
  going
• 12:10
  to
• 12:10
  discontinue
• 12:11
  Effexor,
• 12:12
  we're
• 12:12
  going
• 12:12
  to
• 12:12
  start
• 12:12
  Luvox,
• 12:13
  titrate
• 12:14
  to
• 12:14
  the
• 12:14
  maximum
• 12:14
  tolerated
• 12:15
  dose,
• 12:15
  taper
• 12:16
  off
• 12:16
  Clonazepam
• 12:17
  or
• 12:17
  Klonopin
• 12:18
  and
• 12:18
  refer
• 12:19
  to
• 12:19
  erp.
• 12:21
  Okay,
• 12:22
  that's
• 12:23
  what
• 12:23
  we
• 12:24
  need
• 12:24
  to
• 12:25
  do.
• 12:26
  So
• 12:27
  and
• 12:27
  that,
• 12:27
  that
• 12:27
  answer
• 12:28
  has
• 12:29
  all
• 12:30
  of
• 12:30
  the,
• 12:30
  the
• 12:31
  juice
• 12:31
  we
• 12:31
  need
• 12:31
  for
• 12:32
  OCD,
• 12:32
  right?
• 12:33
  We
• 12:33
  have
• 12:33
  a
• 12:33
  maximum
• 12:34
  tolerated
• 12:34
  dose,
• 12:35
  eight
• 12:35
  to
• 12:35
  12
• 12:35
  weeks.
• 12:36
  Get
• 12:36
  off
• 12:36
  the
• 12:36
  Klonopin,
• 12:37
  get
• 12:38
  going
• 12:38
  with
• 12:38
  ERP.
• 12:39
  Now
• 12:39
  we
• 12:40
  are
• 12:40
  approaching
• 12:41
  the
• 12:41
  evidence
• 12:42
  base
• 12:42
  and
• 12:43
  I
• 12:43
  think
• 12:43
  that's
• 12:44
  completely
• 12:44
  wonderful
• 12:45
  because
• 12:45
  OCD
• 12:46
  is
• 12:46
  a
• 12:46
  radically
• 12:47
  under
• 12:47
  treated
• 12:48
  or
• 12:48
  I
• 12:48
  could
• 12:49
  even
• 12:49
  say
• 12:49
  untreated
• 12:51
  mental
• 12:51
  health
• 12:52
  issue.
• 12:52
  Actually
• 12:53
  it's
• 12:53
  a
• 12:53
  radical
• 12:54
  minority
• 12:54
  of
• 12:55
  folks
• 12:55
  with
• 12:55
  O
• 12:55
  C,
• 12:56
  D
• 12:56
  are
• 12:57
  even
• 12:57
  ever
• 12:58
  enrolled
• 12:58
  in
• 12:58
  anything
• 12:59
  like
• 12:59
  ERP
• 13:00
  and
• 13:01
  their
• 13:01
  OCD
• 13:01
  is
• 13:02
  usually
• 13:02
  found
• 13:03
  very
• 13:04
  far
• 13:04
  down
• 13:04
  the
• 13:04
  road.
• 13:05
  It's
• 13:05
  not
• 13:05
  diagnosed
• 13:05
  very
• 13:06
  quickly.
• 13:06
  It
• 13:07
  can
• 13:07
  take
• 13:07
  years
• 13:08
  before
• 13:08
  OCD
• 13:08
  is
• 13:09
  properly
• 13:09
  diagnosed.
• 13:09
  It's
• 13:10
  misdiagnosed
• 13:10
  as
• 13:11
  depression
• 13:11
  or
• 13:12
  adhd,
• 13:12
  even
• 13:12
  psychosis
• 13:13
  when
• 13:13
  there's
• 13:14
  violent
• 13:14
  or
• 13:14
  bizarre
• 13:15
  obsessional
• 13:16
  images
• 13:16
  or
• 13:16
  compulsions.
• 13:17
  Right?
• 13:17
  So
• 13:17
  that
• 13:18
  delays
• 13:18
  treatment.
• 13:19
  And
• 13:19
  then
• 13:19
  once
• 13:20
  folks
• 13:20
  are
• 13:20
  even
• 13:21
  diagnosed
• 13:21
  with
• 13:21
  O
• 13:22
  C,
• 13:22
  D,
• 13:22
  only
• 13:23
  5
• 13:23
  to
• 13:23
  10%
• 13:24
  of
• 13:24
  OCD
• 13:25
  patients
• 13:25
  ever
• 13:25
  receive
• 13:26
  therapist
• 13:27
  guided
• 13:28
  ERP.
• 13:29
  And
• 13:29
  yeah,
• 13:30
  that's
• 13:30
  due
• 13:30
  to
• 13:31
  staffing
• 13:31
  shortages,
• 13:32
  lack
• 13:32
  of
• 13:32
  training,
• 13:33
  lack
• 13:33
  of
• 13:33
  available,
• 13:34
  available
• 13:34
  man
• 13:35
  Hours
• 13:35
  and
• 13:35
  insurance
• 13:36
  reimbursement.
• 13:37
  But
• 13:38
  I
• 13:38
  can
• 13:38
  tell
• 13:38
  you
• 13:39
  right
• 13:39
  now
• 13:39
  that
• 13:40
  exposure
• 13:40
  and
• 13:41
  response
• 13:41
  prevention
• 13:42
  is
• 13:43
  gold
• 13:43
  standard.
• 13:44
  High
• 13:44
  dose
• 13:44
  SSRIs,
• 13:45
  8
• 13:45
  to
• 13:45
  12
• 13:45
  weeks
• 13:46
  without
• 13:46
  Klonopin
• 13:47
  straying
• 13:48
  away
• 13:48
  from
• 13:48
  CBT.
• 13:49
  This
• 13:49
  question
• 13:50
  has
• 13:50
  a
• 13:50
  lot
• 13:50
  of
• 13:50
  juice
• 13:51
  in
• 13:51
  it,
• 13:52
  and
• 13:52
  really
• 13:52
  to
• 13:52
  appreciate
• 13:53
  it
• 13:53
  to
• 13:53
  my
• 13:54
  friends
• 13:54
  is
• 13:54
  you
• 13:54
  gotta
• 13:54
  remember
• 13:55
  that
• 13:55
  the
• 13:56
  pathology
• 13:57
  in
• 13:58
  gad,
• 13:59
  as
• 13:59
  opposed
• 14:00
  to
• 14:00
  ocd,
• 14:02
  it's
• 14:02
  just.
• 14:03
  It's
• 14:03
  just
• 14:03
  different,
• 14:04
  okay?
• 14:05
  In
• 14:05
  gad,
• 14:06
  we're
• 14:06
  really
• 14:06
  looking
• 14:06
  at
• 14:06
  the
• 14:07
  amygdala,
• 14:08
  and
• 14:08
  in
• 14:08
  ocd,
• 14:09
  it's
• 14:10
  the
• 14:10
  CSTC
• 14:11
  loop.
• 14:12
  Okay?
• 14:12
  The
• 14:12
  corticostriato
• 14:13
  thalamo
• 14:14
  cortical
• 14:14
  loop.
• 14:15
  That's
• 14:15
  a
• 14:15
  mouthful,
• 14:15
  right?
• 14:16
  The
• 14:16
  CSTC
• 14:17
  loop.
• 14:17
  And
• 14:18
  so
• 14:18
  we're
• 14:18
  talking
• 14:18
  about
• 14:18
  different
• 14:19
  neurobiology
• 14:19
  between
• 14:20
  these
• 14:20
  two
• 14:21
  pathologies.
• 14:22
  And
• 14:22
  it
• 14:22
  requires
• 14:23
  a
• 14:23
  more
• 14:24
  intense
• 14:25
  foot
• 14:25
  on
• 14:26
  the
• 14:26
  gas,
• 14:27
  more
• 14:27
  pressure
• 14:27
  on
• 14:27
  the
• 14:28
  gas
• 14:28
  as
• 14:28
  it
• 14:28
  relates
• 14:29
  to
• 14:30
  the
• 14:30
  serotonergic
• 14:31
  work
• 14:31
  being
• 14:32
  done
• 14:32
  here,
• 14:32
  okay?
• 14:33
  High
• 14:33
  doses,
• 14:33
  longer
• 14:34
  timeframes
• 14:35
  with
• 14:35
  erp,
• 14:36
  ideally.
• 14:37
  And
• 14:37
  so
• 14:37
  it's
• 14:37
  a
• 14:37
  kind
• 14:37
  of
• 14:38
  a
• 14:38
  different
• 14:38
  pathology,
• 14:38
  right?
• 14:39
  It's
• 14:39
  a
• 14:39
  sensitive
• 14:39
  smoke
• 14:40
  detector
• 14:40
  with
• 14:41
  the
• 14:41
  amygdala.
• 14:42
  And,
• 14:43
  you
• 14:43
  know,
• 14:43
  so
• 14:44
  oftentimes
• 14:45
  benzos
• 14:45
  do
• 14:46
  work
• 14:46
  for
• 14:46
  that,
• 14:46
  okay,
• 14:47
  to
• 14:47
  kind
• 14:47
  of
• 14:48
  cool
• 14:48
  down
• 14:48
  the
• 14:48
  threat
• 14:48
  response.
• 14:49
  But
• 14:49
  you
• 14:49
  have
• 14:50
  this
• 14:50
  habit
• 14:50
  loop
• 14:51
  in
• 14:51
  the
• 14:51
  CSTC
• 14:52
  that
• 14:53
  is
• 14:53
  fundamentally
• 14:54
  different.
• 14:54
  It's
• 14:54
  a
• 14:54
  qualitatively
• 14:55
  different
• 14:56
  experience.
• 14:56
  It's
• 14:56
  a.
• 14:56
  It's
• 14:57
  a
• 14:57
  stuck
• 14:57
  point,
• 14:58
  okay?
• 14:58
  And
• 14:58
  that
• 14:58
  has
• 14:59
  its
• 14:59
  own
• 14:59
  neurobiology.
• 15:00
  So
• 15:00
  that's
• 15:00
  why
• 15:00
  we
• 15:00
  have
• 15:00
  to
• 15:01
  get
• 15:01
  this
• 15:01
  right.
• 15:01
  There
• 15:02
  are
• 15:02
  moments
• 15:02
  in
• 15:03
  psychiatry
• 15:04
  where
• 15:04
  not
• 15:04
  getting
• 15:05
  the
• 15:05
  diagnosis
• 15:05
  perfectly
• 15:06
  right
• 15:07
  is.
• 15:08
  Although
• 15:08
  it's
• 15:09
  ideal,
• 15:09
  if
• 15:09
  we
• 15:09
  do,
• 15:10
  we
• 15:10
  can
• 15:10
  accidentally
• 15:11
  be
• 15:11
  right.
• 15:11
  We've
• 15:12
  talked
• 15:12
  about
• 15:12
  this
• 15:12
  in
• 15:12
  the
• 15:12
  past,
• 15:13
  right?
• 15:13
  If
• 15:13
  you're
• 15:13
  not
• 15:13
  sure
• 15:14
  if
• 15:14
  something
• 15:14
  is
• 15:14
  unipolar
• 15:15
  bipolar
• 15:15
  depression,
• 15:16
  you
• 15:16
  do
• 15:16
  have
• 15:16
  mixed
• 15:17
  features.
• 15:17
  You
• 15:17
  might
• 15:18
  get
• 15:18
  away
• 15:18
  with
• 15:18
  latuda
• 15:19
  as
• 15:20
  a
• 15:20
  hedge,
• 15:20
  right?
• 15:20
  You're
• 15:21
  not
• 15:21
  sure
• 15:21
  if
• 15:21
  it's
• 15:21
  morphing
• 15:22
  into
• 15:22
  bipolar
• 15:22
  2,
• 15:23
  if
• 15:23
  it'll
• 15:23
  ever
• 15:23
  be
• 15:23
  bipolar
• 15:24
  2.
• 15:24
  But
• 15:24
  there's
• 15:24
  enough
• 15:25
  mixed
• 15:25
  features
• 15:25
  that
• 15:26
  makes
• 15:26
  you
• 15:26
  nervous,
• 15:26
  and
• 15:27
  you
• 15:27
  avoid
• 15:27
  antidepressant
• 15:28
  monotherapy.
• 15:29
  You
• 15:29
  might
• 15:30
  get
• 15:30
  away
• 15:30
  with
• 15:30
  not
• 15:30
  being
• 15:31
  able
• 15:31
  to
• 15:31
  know
• 15:31
  that
• 15:31
  declaratively
• 15:33
  because
• 15:33
  you're
• 15:33
  human,
• 15:34
  and
• 15:34
  it's
• 15:34
  not
• 15:34
  always
• 15:34
  possible
• 15:35
  to
• 15:35
  know
• 15:35
  right
• 15:35
  away.
• 15:36
  And
• 15:36
  you
• 15:36
  could
• 15:36
  prescribe
• 15:37
  something
• 15:37
  like
• 15:38
  latuda.
• 15:38
  We
• 15:38
  talked
• 15:39
  about
• 15:39
  the
• 15:39
  RCT
• 15:39
  evidence
• 15:40
  as
• 15:40
  it
• 15:40
  relates
• 15:41
  to
• 15:41
  latuda
• 15:41
  in
• 15:42
  mdd
• 15:42
  mixed
• 15:42
  features.
• 15:43
  However,
• 15:44
  you
• 15:44
  don't
• 15:45
  have
• 15:45
  that
• 15:45
  luxury.
• 15:45
  If
• 15:46
  you
• 15:46
  are,
• 15:47
  you
• 15:47
  are
• 15:48
  thinking
• 15:48
  about
• 15:48
  the
• 15:48
  difference
• 15:49
  between
• 15:49
  GAD
• 15:49
  and
• 15:49
  OCD.
• 15:50
  Again,
• 15:50
  two
• 15:50
  different
• 15:51
  neurobiological
• 15:52
  signatures.
• 15:53
  One
• 15:53
  requires
• 15:54
  high
• 15:54
  dose
• 15:54
  SSRIs,
• 15:55
  one
• 15:55
  requires
• 15:56
  an
• 15:56
  ERP.
• 15:57
  An
• 15:57
  ERP
• 15:58
  path
• 15:58
  versus
• 15:58
  a
• 15:59
  CBT
• 15:59
  path.
• 16:00
  One
• 16:00
  does
• 16:00
  not
• 16:01
  benefit
• 16:01
  from
• 16:01
  benzodiazepines
• 16:03
  or
• 16:03
  like
• 16:03
  antipsychotic
• 16:04
  augmentation
• 16:05
  as,
• 16:05
  as
• 16:05
  readily.
• 16:06
  You
• 16:06
  so,
• 16:07
  so
• 16:07
  really
• 16:07
  different.
• 16:08
  Right?
• 16:08
  And
• 16:09
  you,
• 16:09
  you
• 16:09
  might
• 16:09
  have
• 16:10
  many
• 16:10
  patients
• 16:10
  I
• 16:10
  know
• 16:10
  I've
• 16:11
  had
• 16:11
  tons
• 16:11
  of
• 16:11
  them
• 16:11
  that
• 16:11
  don't
• 16:12
  respond
• 16:12
  very
• 16:13
  easily
• 16:13
  when
• 16:13
  you
• 16:13
  maximize
• 16:14
  an
• 16:14
  SSRI
• 16:15
  dose.
• 16:15
  It's
• 16:15
  very
• 16:16
  hard
• 16:16
  to
• 16:16
  do
• 16:16
  that
• 16:16
  in
• 16:16
  practice.
• 16:17
  You
• 16:17
  have
• 16:18
  sexual
• 16:19
  side
• 16:19
  effects
• 16:19
  and
• 16:20
  emotional
• 16:20
  flattening
• 16:22
  and
• 16:22
  insomnia
• 16:23
  and
• 16:23
  so
• 16:23
  many,
• 16:24
  so
• 16:24
  many
• 16:24
  issues.
• 16:25
  Stumbling
• 16:25
  blocks
• 16:25
  where
• 16:26
  getting
• 16:26
  the
• 16:26
  80
• 16:27
  milligrams
• 16:27
  of
• 16:27
  Prozac
• 16:28
  is
• 16:28
  not
• 16:29
  always
• 16:29
  easy
• 16:29
  or
• 16:30
  viable.
• 16:30
  Getting
• 16:30
  the
• 16:30
  200mg
• 16:31
  of
• 16:31
  Zoloft
• 16:32
  is
• 16:32
  not
• 16:32
  always
• 16:32
  easy
• 16:33
  or
• 16:33
  viable.
• 16:33
  And
• 16:34
  so
• 16:34
  there
• 16:35
  are
• 16:35
  hard
• 16:35
  limitations
• 16:36
  but
• 16:36
  important
• 16:37
  guidelines
• 16:38
  that
• 16:38
  distinguish
• 16:39
  these
• 16:39
  two
• 16:39
  and
• 16:40
  it
• 16:40
  makes
• 16:40
  all
• 16:40
  the
• 16:40
  difference.
• 16:41
  Now,
• 16:41
  my
• 16:41
  friends,
• 16:42
  if
• 16:42
  you've
• 16:43
  been
• 16:43
  enjoying
• 16:43
  this,
• 16:43
  I
• 16:44
  can't
• 16:44
  emphasize
• 16:45
  enough
• 16:46
  that
• 16:47
  you
• 16:47
  don't
• 16:47
  want
• 16:48
  to
• 16:48
  be
• 16:48
  one
• 16:48
  of
• 16:48
  those
• 16:48
  providers
• 16:49
  that
• 16:50
  just
• 16:50
  follows
• 16:50
  algorithms
• 16:51
  and
• 16:51
  prescribes
• 16:52
  and
• 16:52
  just
• 16:52
  slaps
• 16:53
  on
• 16:53
  a
• 16:53
  diagnosis
• 16:54
  because
• 16:54
  it's
• 16:54
  a
• 16:55
  diagnosis.
• 16:55
  If
• 16:55
  you
• 16:55
  want
• 16:56
  to
• 16:56
  know
• 16:56
  the
• 16:56
  how
• 16:56
  and
• 16:56
  the
• 16:57
  why
• 16:57
  and
• 16:57
  be
• 16:57
  empowered
• 16:58
  and
• 16:58
  completely
• 16:59
  transform
• 16:59
  the
• 17:00
  way
• 17:00
  you
• 17:00
  practice
• 17:01
  and,
• 17:02
  and
• 17:02
  improve
• 17:03
  patient
• 17:03
  outcomes,
• 17:04
  I
• 17:04
  highly
• 17:05
  recommend
• 17:05
  if
• 17:05
  there's
• 17:05
  one
• 17:06
  thing
• 17:06
  you
• 17:06
  don't
• 17:06
  forget
• 17:06
  today
• 17:07
  is
• 17:07
  go
• 17:07
  to
• 17:07
  our
• 17:07
  show
• 17:08
  notes
• 17:08
  and
• 17:09
  become
• 17:09
  a
• 17:09
  Patreon
• 17:10
  member.
• 17:11
  I
• 17:11
  don't
• 17:12
  know
• 17:12
  what
• 17:12
  kind
• 17:12
  of
• 17:12
  clinician
• 17:13
  I
• 17:13
  would
• 17:13
  be
• 17:13
  if
• 17:13
  I
• 17:13
  didn't
• 17:14
  have
• 17:14
  the
• 17:15
  Patreon
• 17:15
  library.
• 17:16
  It's
• 17:16
  fun,
• 17:16
  it's
• 17:16
  sticky,
• 17:17
  it's
• 17:17
  memorable.
• 17:18
  I
• 17:18
  wouldn't
• 17:18
  know
• 17:19
  half
• 17:19
  the
• 17:19
  stuff.
• 17:19
  I
• 17:20
  know
• 17:20
  I
• 17:20
  would
• 17:20
  be
• 17:20
  so
• 17:20
  much
• 17:21
  more
• 17:21
  lost
• 17:22
  and
• 17:22
  stuck
• 17:22
  in
• 17:22
  sessions
• 17:23
  and
• 17:23
  imprecise.
• 17:24
  Learning
• 17:25
  doesn't
• 17:25
  end
• 17:25
  in
• 17:25
  school.
• 17:26
  Right.
• 17:26
  And
• 17:27
  so
• 17:27
  I
• 17:27
  highly
• 17:27
  recommend
• 17:28
  if
• 17:28
  you
• 17:28
  want
• 17:28
  to
• 17:28
  transform
• 17:29
  the
• 17:29
  way
• 17:29
  you
• 17:29
  practice
• 17:30
  and,
• 17:30
  and
• 17:30
  be
• 17:31
  that
• 17:31
  provider
• 17:31
  that
• 17:32
  understands
• 17:32
  the
• 17:32
  how
• 17:33
  and
• 17:33
  why,
• 17:33
  patients
• 17:33
  will
• 17:34
  smell
• 17:34
  that
• 17:34
  a
• 17:34
  mile
• 17:35
  away
• 17:35
  and,
• 17:36
  and
• 17:36
  it'll
• 17:37
  exponentially
• 17:37
  help
• 17:37
  you.
• 17:38
  So
• 17:38
  if
• 17:38
  there's
• 17:38
  one
• 17:38
  thing
• 17:39
  you
• 17:39
  don't,
• 17:40
  you
• 17:40
  don't
• 17:40
  forget
• 17:41
  before
• 17:41
  you
• 17:41
  hit
• 17:41
  the
• 17:42
  hay
• 17:42
  tonight
• 17:42
  and
• 17:42
  go
• 17:43
  to
• 17:43
  bed,
• 17:44
  go
• 17:44
  into
• 17:44
  our
• 17:44
  show
• 17:45
  notes
• 17:45
  and
• 17:45
  join
• 17:46
  Patreon
• 17:46
  and
• 17:46
  tell
• 17:47
  your
• 17:47
  friends
• 17:47
  to.
• 17:47
  It
• 17:47
  is
• 17:48
  sticky
• 17:48
  and
• 17:48
  so
• 17:49
  much
• 17:49
  fun.
• 17:49
  All
• 17:49
  right,
• 17:50
  my
• 17:50
  friends,
• 17:50
  with
• 17:50
  that,
• 17:51
  have
• 17:51
  a
• 17:51
  great
• 17:51
  rest
• 17:52
  of
• 17:52
  your
• 17:52
  week.
• 17:52
  Bye
• 17:52
  Bye.