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Jane’s Mold Meltdown: OCD or Delusional Disorder? · 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
  Npz
• 0:09
  Here,
• 0:09
  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
• 0:15
  practice.
• 0:16
  My
• 0:16
  friends,
• 0:18
  would
• 0:18
  you
• 0:18
  be
• 0:19
  able
• 0:20
  to
• 0:20
  tell
• 0:20
  the
• 0:20
  difference,
• 0:21
  right
• 0:21
  here,
• 0:22
  right
• 0:22
  now,
• 0:23
  between
• 0:24
  a
• 0:25
  delusional
• 0:25
  disorder
• 0:27
  and
• 0:27
  an
• 0:28
  OCD
• 0:29
  with
• 0:29
  absent
• 0:30
  insight
• 0:31
  or
• 0:31
  delusional
• 0:32
  beliefs?
• 0:32
  Do
• 0:33
  you
• 0:33
  know
• 0:33
  the
• 0:33
  difference?
• 0:34
  Do
• 0:34
  you
• 0:34
  know,
• 0:34
  like
• 0:34
  a
• 0:35
  bloodhound,
• 0:35
  how
• 0:36
  to
• 0:36
  smell
• 0:36
  that
• 0:37
  difference
• 0:38
  when
• 0:38
  it
• 0:39
  walks
• 0:39
  into
• 0:40
  your
• 0:40
  practice?
• 0:41
  And
• 0:41
  I
• 0:41
  will
• 0:41
  tell
• 0:41
  you,
• 0:42
  it
• 0:42
  is
• 0:42
  a
• 0:42
  lot
• 0:43
  easier
• 0:43
  than
• 0:43
  you
• 0:43
  think
• 0:44
  and
• 0:44
  it's
• 0:44
  also
• 0:45
  kind
• 0:45
  of
• 0:45
  a
• 0:45
  lot
• 0:45
  harder
• 0:46
  than
• 0:46
  you
• 0:47
  think.
• 0:47
  But
• 0:48
  rest
• 0:48
  assured,
• 0:48
  like
• 0:49
  we
• 0:49
  always
• 0:49
  do
• 0:49
  here,
• 0:50
  we
• 0:50
  are
• 0:51
  going
• 0:51
  to
• 0:51
  get
• 0:51
  to
• 0:51
  the
• 0:52
  bottom
• 0:52
  of
• 0:52
  this
• 0:52
  today.
• 0:52
  We're
• 0:53
  going
• 0:53
  to
• 0:53
  make
• 0:53
  it
• 0:53
  really
• 0:53
  easy
• 0:54
  and
• 0:54
  really
• 0:54
  simple.
• 0:55
  And
• 0:55
  we're
• 0:56
  gonna
• 0:56
  sprinkle
• 0:57
  a
• 0:57
  few
• 0:58
  pearls
• 0:59
  to
• 0:59
  get
• 0:59
  you
• 1:00
  excited.
• 1:01
  Maybe
• 1:01
  pearls
• 1:02
  you
• 1:02
  can
• 1:02
  share,
• 1:03
  you
• 1:03
  can
• 1:03
  reflect
• 1:04
  about.
• 1:05
  Pearls
• 1:05
  that
• 1:05
  we
• 1:06
  intend
• 1:06
  for
• 1:07
  you
• 1:07
  to
• 1:09
  really
• 1:10
  bolster
• 1:10
  your
• 1:10
  practice,
• 1:11
  increase
• 1:11
  your
• 1:12
  confidence
• 1:13
  and
• 1:14
  make
• 1:14
  better
• 1:14
  decisions
• 1:15
  for
• 1:15
  your
• 1:15
  patients
• 1:15
  so
• 1:16
  they
• 1:16
  can
• 1:16
  have
• 1:16
  smoother
• 1:17
  outcomes.
• 1:18
  So
• 1:18
  without
• 1:18
  further
• 1:19
  ado,
• 1:19
  you
• 1:20
  have
• 1:20
  a
• 1:20
  34.
• 1:21
  4
• 1:21
  year
• 1:21
  old
• 1:22
  woman
• 1:22
  in
• 1:23
  your
• 1:23
  office.
• 1:24
  Her
• 1:24
  name
• 1:24
  is
• 1:24
  Jane.
• 1:26
  She's
• 1:26
  fake.
• 1:27
  She's
• 1:27
  not
• 1:27
  a
• 1:27
  fake
• 1:28
  person
• 1:28
  in
• 1:28
  that
• 1:29
  you
• 1:29
  wouldn't
• 1:29
  like
• 1:29
  her
• 1:29
  because
• 1:30
  she's
• 1:30
  acting
• 1:30
  all
• 1:30
  fake
• 1:31
  in
• 1:31
  front
• 1:31
  of
• 1:31
  you.
• 1:31
  I
• 1:31
  mean,
• 1:32
  she's
• 1:32
  like
• 1:32
  a
• 1:32
  mock
• 1:33
  patient.
• 1:33
  It's
• 1:33
  not
• 1:33
  a
• 1:34
  real
• 1:34
  patient.
• 1:34
  Her
• 1:35
  name
• 1:35
  is
• 1:35
  Jane.
• 1:36
  No
• 1:36
  prior
• 1:37
  psychiatric
• 1:37
  history.
• 1:38
  She's
• 1:39
  referred
• 1:39
  by
• 1:39
  her
• 1:40
  primary
• 1:40
  care
• 1:40
  doc
• 1:41
  who
• 1:41
  insists
• 1:41
  she
• 1:42
  has
• 1:42
  paranoid
• 1:43
  delusions.
• 1:44
  Now,
• 1:44
  when
• 1:45
  you
• 1:45
  interview
• 1:45
  her,
• 1:46
  she's
• 1:46
  telling
• 1:46
  you
• 1:47
  basically
• 1:47
  that
• 1:47
  her
• 1:47
  apartment
• 1:48
  is
• 1:48
  contaminated
• 1:49
  with
• 1:49
  toxic
• 1:50
  mold
• 1:51
  and
• 1:51
  she
• 1:51
  believes
• 1:52
  it's
• 1:52
  slowly
• 1:52
  poisoning
• 1:53
  her.
• 1:54
  She's
• 1:54
  hired
• 1:55
  three
• 1:55
  different
• 1:55
  mold
• 1:56
  inspectors.
• 1:57
  All
• 1:57
  of
• 1:57
  them
• 1:57
  said,
• 1:57
  hey
• 1:58
  lady,
• 1:58
  there's
• 1:59
  no
• 1:59
  mold
• 1:59
  in
• 2:00
  your
• 2:00
  apartment.
• 2:01
  But
• 2:01
  she
• 2:01
  remains
• 2:02
  100%
• 2:02
  convinced
• 2:03
  that
• 2:03
  the
• 2:04
  mold
• 2:04
  is
• 2:04
  there
• 2:04
  and
• 2:05
  it's
• 2:05
  not
• 2:05
  really
• 2:05
  being
• 2:06
  detected
• 2:06
  by
• 2:06
  standard
• 2:07
  testing.
• 2:08
  She
• 2:09
  spends
• 2:09
  four
• 2:09
  to
• 2:10
  five
• 2:10
  hours
• 2:10
  a
• 2:10
  day
• 2:12
  wiping
• 2:12
  down
• 2:12
  surfaces
• 2:13
  with
• 2:13
  bleach.
• 2:14
  She's
• 2:15
  thrown
• 2:15
  away
• 2:15
  a
• 2:15
  ton
• 2:15
  of
• 2:16
  her
• 2:16
  furniture.
• 2:16
  She's
• 2:17
  washing
• 2:17
  her
• 2:17
  hands.
• 2:18
  You
• 2:18
  can
• 2:18
  already
• 2:19
  tell
• 2:19
  when
• 2:19
  you
• 2:19
  look
• 2:19
  at
• 2:20
  her
• 2:20
  hands,
• 2:20
  they're
• 2:20
  cracked.
• 2:21
  They're.
• 2:21
  They're
• 2:22
  scabs.
• 2:23
  There's
• 2:23
  bleeding.
• 2:24
  She
• 2:24
  even
• 2:24
  wears
• 2:25
  gloves
• 2:25
  and
• 2:25
  a
• 2:25
  mask
• 2:26
  inside
• 2:26
  her
• 2:26
  own
• 2:26
  home.
• 2:27
  She's
• 2:28
  missed
• 2:28
  out
• 2:28
  on
• 2:28
  work
• 2:29
  because
• 2:29
  she's
• 2:30
  just
• 2:30
  cleaning
• 2:30
  so
• 2:31
  extensively.
• 2:31
  She's
• 2:31
  so
• 2:32
  consumed
• 2:32
  by
• 2:32
  this,
• 2:32
  she's
• 2:33
  booking
• 2:34
  appointments
• 2:34
  with
• 2:35
  new
• 2:35
  inspectors
• 2:36
  who
• 2:36
  might
• 2:36
  give
• 2:36
  her
• 2:36
  a
• 2:37
  new.
• 2:37
  A
• 2:38
  new
• 2:38
  perspective
• 2:39
  on
• 2:39
  what's
• 2:39
  going
• 2:39
  on
• 2:40
  and
• 2:40
  maybe
• 2:40
  solve
• 2:40
  the
• 2:41
  problem.
• 2:41
  And
• 2:42
  she
• 2:42
  feels
• 2:42
  like
• 2:42
  she
• 2:43
  has
• 2:43
  to
• 2:43
  clean
• 2:44
  constantly.
• 2:45
  Or
• 2:45
  she
• 2:45
  has
• 2:45
  this
• 2:46
  unbearable
• 2:47
  sense
• 2:47
  of
• 2:47
  dread
• 2:47
  that
• 2:48
  something
• 2:48
  bad's
• 2:48
  gonna
• 2:49
  happen
• 2:49
  and
• 2:49
  maybe
• 2:50
  will
• 2:50
  even
• 2:50
  happen
• 2:50
  to
• 2:50
  her
• 2:51
  family.
• 2:51
  Okay?
• 2:52
  She's
• 2:52
  exhausted.
• 2:53
  100%,
• 2:54
  she's
• 2:54
  exhausted.
• 2:55
  She
• 2:55
  wishes
• 2:55
  she
• 2:56
  could
• 2:56
  stop
• 2:56
  all
• 2:56
  this,
• 2:57
  but
• 2:57
  she
• 2:57
  just
• 2:57
  feels
• 2:58
  like
• 2:58
  the
• 2:58
  mold
• 2:58
  is
• 2:58
  a
• 2:58
  real
• 2:59
  threat
• 2:59
  to
• 3:00
  her.
• 3:01
  Importantly,
• 3:01
  when
• 3:02
  you
• 3:02
  look
• 3:02
  at
• 3:02
  her,
• 3:02
  Jane
• 3:03
  is
• 3:03
  well
• 3:03
  groomed.
• 3:04
  She's
• 3:04
  very
• 3:04
  cooperative.
• 3:05
  She's
• 3:05
  talking
• 3:06
  to
• 3:06
  you
• 3:06
  in
• 3:06
  very
• 3:07
  linear,
• 3:07
  logical
• 3:08
  fashion.
• 3:08
  She's
• 3:09
  organized.
• 3:10
  There's
• 3:10
  no
• 3:10
  other
• 3:10
  hallucinations
• 3:11
  or
• 3:11
  paranoia
• 3:12
  beyond
• 3:13
  the
• 3:13
  mold
• 3:13
  concern.
• 3:14
  She's
• 3:14
  not
• 3:14
  disorganized,
• 3:15
  and
• 3:15
  there's
• 3:16
  no
• 3:16
  negative
• 3:16
  symptoms.
• 3:17
  In
• 3:17
  other
• 3:17
  words,
• 3:17
  she's,
• 3:18
  you
• 3:18
  know,
• 3:18
  initiating
• 3:20
  words
• 3:20
  spontaneously.
• 3:22
  She's
• 3:22
  pro
• 3:23
  social.
• 3:23
  She's
• 3:24
  able
• 3:24
  to
• 3:25
  get
• 3:25
  up
• 3:25
  and
• 3:25
  do
• 3:25
  things.
• 3:26
  She
• 3:26
  has
• 3:26
  a
• 3:27
  stable
• 3:27
  job
• 3:27
  when
• 3:27
  she
• 3:28
  goes,
• 3:28
  okay?
• 3:29
  She
• 3:29
  has
• 3:30
  good
• 3:30
  relationships,
• 3:31
  and
• 3:31
  there's
• 3:31
  no
• 3:31
  substance
• 3:32
  use
• 3:32
  to
• 3:32
  your
• 3:32
  knowledge.
• 3:33
  So
• 3:33
  this
• 3:33
  isn't
• 3:33
  like
• 3:33
  a
• 3:33
  trick
• 3:34
  question
• 3:34
  of
• 3:34
  like,
• 3:34
  oh,
• 3:35
  my
• 3:35
  God,
• 3:35
  she's
• 3:36
  been
• 3:36
  on
• 3:36
  cocaine
• 3:36
  this
• 3:36
  whole
• 3:37
  time,
• 3:37
  okay?
• 3:37
  It's
• 3:37
  not
• 3:38
  the
• 3:38
  kind
• 3:38
  of
• 3:38
  teaching
• 3:39
  environment
• 3:39
  that
• 3:39
  I'm
• 3:40
  trying
• 3:40
  to
• 3:40
  create
• 3:40
  right
• 3:40
  now,
• 3:40
  okay?
• 3:41
  The
• 3:41
  answer
• 3:41
  isn't
• 3:42
  going
• 3:42
  to
• 3:42
  be
• 3:42
  that
• 3:43
  Jane
• 3:43
  is
• 3:44
  snorting
• 3:44
  PCP
• 3:45
  in
• 3:46
  the
• 3:46
  bathroom,
• 3:46
  like,
• 3:47
  gotcha.
• 3:47
  Okay?
• 3:48
  That's
• 3:48
  not
• 3:48
  what
• 3:49
  we're
• 3:49
  talking
• 3:49
  about,
• 3:49
  okay?
• 3:50
  She's
• 3:50
  just
• 3:50
  very
• 3:50
  anxious.
• 3:51
  She's
• 3:51
  not
• 3:51
  flat.
• 3:51
  Her
• 3:51
  affect
• 3:52
  is
• 3:52
  anxious.
• 3:53
  She's
• 3:53
  not
• 3:53
  flat.
• 3:55
  Okay?
• 3:56
  Now,
• 3:56
  when
• 3:56
  you
• 3:56
  ask
• 3:56
  her
• 3:57
  directly,
• 3:57
  is
• 3:57
  there
• 3:58
  any
• 3:58
  chance
• 3:58
  the
• 3:58
  mold
• 3:58
  isn't
• 3:59
  real?
• 3:59
  She
• 4:00
  says,
• 4:00
  no,
• 4:00
  No,
• 4:00
  I
• 4:00
  know
• 4:01
  it's
• 4:01
  there.
• 4:02
  And
• 4:02
  the
• 4:02
  inspectors
• 4:02
  just
• 4:03
  need
• 4:03
  to
• 4:03
  find
• 4:03
  the
• 4:03
  right
• 4:03
  damn
• 4:04
  equipment.
• 4:05
  Okay,
• 4:06
  so
• 4:07
  what
• 4:07
  do
• 4:07
  we
• 4:07
  do
• 4:07
  here?
• 4:08
  Ooh,
• 4:08
  this
• 4:08
  is
• 4:08
  juicy,
• 4:09
  right?
• 4:09
  This
• 4:10
  is
• 4:10
  juicy
• 4:10
  because
• 4:11
  this
• 4:11
  really
• 4:12
  looks
• 4:12
  like
• 4:12
  a
• 4:13
  fixed
• 4:13
  false
• 4:14
  belief.
• 4:14
  Jane
• 4:14
  is
• 4:15
  absolutely
• 4:15
  convinced
• 4:17
  that
• 4:17
  she
• 4:17
  has
• 4:17
  a
• 4:17
  mold
• 4:18
  problem.
• 4:18
  And
• 4:18
  there's
• 4:19
  contradictory
• 4:19
  evidence.
• 4:19
  Right?
• 4:20
  She
• 4:20
  has
• 4:20
  actual
• 4:21
  inspectors
• 4:21
  coming
• 4:21
  in
• 4:22
  saying,
• 4:22
  lady,
• 4:22
  there's
• 4:23
  no
• 4:23
  mold
• 4:24
  here.
• 4:25
  Okay?
• 4:26
  But
• 4:26
  she
• 4:26
  also
• 4:26
  has
• 4:27
  these
• 4:28
  kind
• 4:28
  of
• 4:28
  repetitive,
• 4:28
  driven
• 4:29
  behaviors.
• 4:30
  Cleaning,
• 4:30
  hand
• 4:31
  washing.
• 4:32
  And
• 4:32
  she
• 4:32
  doesn't
• 4:33
  like
• 4:33
  any
• 4:33
  of
• 4:33
  this,
• 4:33
  right?
• 4:34
  This
• 4:34
  isn't
• 4:34
  enjoyable
• 4:35
  to
• 4:35
  her.
• 4:35
  It's
• 4:36
  taking
• 4:36
  up
• 4:36
  a
• 4:36
  lot
• 4:36
  of
• 4:36
  her
• 4:36
  time.
• 4:37
  She's
• 4:37
  even
• 4:38
  missing
• 4:38
  work.
• 4:39
  So
• 4:39
  zooming
• 4:39
  out
• 4:40
  here,
• 4:40
  we
• 4:40
  clearly
• 4:41
  see
• 4:41
  there's
• 4:41
  a
• 4:41
  disorder,
• 4:42
  right?
• 4:42
  She
• 4:42
  wouldn't
• 4:43
  be
• 4:43
  in
• 4:43
  your
• 4:43
  office
• 4:43
  if
• 4:43
  there
• 4:44
  wasn't
• 4:44
  a
• 4:44
  disorder.
• 4:45
  So
• 4:45
  we
• 4:45
  know
• 4:46
  some
• 4:46
  form
• 4:46
  of
• 4:46
  treatment
• 4:47
  is
• 4:47
  absolutely
• 4:47
  essential,
• 4:48
  right?
• 4:48
  And
• 4:49
  I
• 4:49
  think
• 4:49
  that's
• 4:49
  the
• 4:49
  key,
• 4:49
  because
• 4:50
  if
• 4:50
  you
• 4:50
  look
• 4:50
  at
• 4:50
  this
• 4:51
  at
• 4:52
  first,
• 4:52
  you
• 4:52
  might
• 4:52
  say,
• 4:52
  well,
• 4:53
  wait,
• 4:53
  maybe
• 4:53
  she
• 4:53
  does
• 4:53
  have
• 4:54
  a
• 4:54
  mold
• 4:54
  problem.
• 4:54
  And
• 4:54
  who
• 4:55
  am
• 4:55
  I
• 4:55
  to
• 4:55
  pathologize
• 4:56
  this?
• 4:56
  Who
• 4:56
  am
• 4:57
  I
• 4:57
  to
• 4:57
  put
• 4:58
  her
• 4:58
  on
• 4:58
  in
• 4:58
  a
• 4:58
  high
• 4:58
  dose
• 4:59
  SSRI
• 4:59
  and
• 5:00
  assume
• 5:00
  this
• 5:00
  is
• 5:00
  OCD
• 5:01
  and
• 5:02
  send
• 5:02
  her
• 5:02
  to
• 5:02
  a
• 5:02
  therapist?
• 5:03
  Because
• 5:03
  you
• 5:03
  know
• 5:03
  what?
• 5:03
  What
• 5:03
  if
• 5:03
  it
• 5:04
  is
• 5:04
  mold?
• 5:04
  What
• 5:04
  if
• 5:04
  it
• 5:04
  is
• 5:04
  harming
• 5:05
  her?
• 5:05
  I'm
• 5:06
  not
• 5:06
  a
• 5:06
  mold
• 5:06
  expert.
• 5:07
  I
• 5:07
  Can't
• 5:07
  test
• 5:08
  her
• 5:08
  home.
• 5:09
  And
• 5:09
  so
• 5:09
  your
• 5:09
  inclination
• 5:10
  might
• 5:10
  be
• 5:10
  to
• 5:10
  just
• 5:11
  not
• 5:11
  pathologize
• 5:12
  this.
• 5:12
  Not
• 5:12
  that
• 5:12
  you
• 5:12
  should
• 5:13
  pathologize
• 5:13
  anything.
• 5:14
  But
• 5:14
  we
• 5:14
  don't
• 5:14
  want
• 5:15
  to
• 5:15
  underestimate
• 5:16
  what
• 5:16
  she's
• 5:16
  going
• 5:16
  through.
• 5:17
  And
• 5:18
  it's
• 5:18
  clear
• 5:18
  though
• 5:19
  that
• 5:19
  this
• 5:19
  is
• 5:19
  a
• 5:19
  problem.
• 5:20
  Right.
• 5:20
  She's
• 5:20
  missing
• 5:20
  work.
• 5:21
  She's
• 5:21
  spending
• 5:21
  four
• 5:21
  to
• 5:22
  five
• 5:22
  hours
• 5:22
  a
• 5:22
  day
• 5:23
  on
• 5:23
  this
• 5:24
  very
• 5:24
  time
• 5:24
  consuming
• 5:25
  to
• 5:25
  consuming
• 5:26
  distressive
• 5:26
  thought.
• 5:27
  So
• 5:27
  the
• 5:27
  amount
• 5:27
  of
• 5:27
  time
• 5:28
  she's
• 5:28
  spending,
• 5:28
  the
• 5:28
  fact
• 5:28
  that
• 5:29
  she's
• 5:29
  missing
• 5:29
  work,
• 5:30
  these
• 5:30
  are
• 5:31
  all
• 5:31
  problems.
• 5:32
  And
• 5:32
  she's
• 5:32
  again,
• 5:33
  this
• 5:33
  is
• 5:33
  ego
• 5:33
  dystonic.
• 5:34
  What
• 5:34
  we
• 5:34
  would
• 5:34
  call
• 5:34
  ego
• 5:35
  dystonic
• 5:35
  in
• 5:35
  that
• 5:35
  she's
• 5:36
  clearly
• 5:36
  bothered
• 5:38
  by
• 5:38
  all
• 5:38
  of
• 5:38
  this.
• 5:39
  So
• 5:39
  you
• 5:39
  do
• 5:39
  need
• 5:40
  an
• 5:40
  intervention,
• 5:40
  whether
• 5:41
  it's
• 5:41
  going
• 5:41
  to
• 5:41
  be
• 5:41
  therapy
• 5:41
  or
• 5:42
  antipsychotics
• 5:43
  or
• 5:43
  high
• 5:43
  dose
• 5:43
  SSRIs.
• 5:44
  That's
• 5:45
  what
• 5:45
  we
• 5:45
  need
• 5:45
  to
• 5:45
  get.
• 5:46
  Right,
• 5:46
  Right.
• 5:46
  That's
• 5:46
  the
• 5:46
  big
• 5:47
  challenge
• 5:47
  here.
• 5:47
  You
• 5:47
  can't
• 5:47
  just
• 5:48
  lay
• 5:48
  back
• 5:48
  and
• 5:48
  go,
• 5:49
  is
• 5:49
  this
• 5:50
  bipolar
• 5:50
  or
• 5:51
  is
• 5:51
  this,
• 5:51
  you
• 5:51
  know,
• 5:51
  is
• 5:51
  this
• 5:52
  bipolar
• 5:52
  or
• 5:52
  unipolar
• 5:53
  depression?
• 5:53
  Well,
• 5:53
  if
• 5:54
  I
• 5:54
  need
• 5:54
  to
• 5:54
  just
• 5:54
  hedge
• 5:55
  that
• 5:55
  I
• 5:56
  can
• 5:56
  prescribe
• 5:57
  a
• 5:57
  mood
• 5:57
  stabilizer.
• 5:58
  Right.
• 5:58
  If
• 5:58
  you
• 5:58
  have
• 5:58
  mixed
• 5:58
  features.
• 5:59
  We
• 5:59
  talked
• 5:59
  about
• 5:59
  this
• 5:59
  with
• 6:00
  Latuda,
• 6:00
  where
• 6:01
  sometimes
• 6:01
  in
• 6:01
  psychiatry,
• 6:02
  you
• 6:03
  know,
• 6:03
  it's
• 6:03
  of
• 6:03
  course
• 6:03
  great
• 6:04
  to
• 6:04
  be
• 6:04
  completely
• 6:05
  precise
• 6:05
  on
• 6:06
  your
• 6:06
  first
• 6:06
  try.
• 6:07
  But
• 6:07
  a
• 6:07
  lot
• 6:08
  of
• 6:08
  prescribers
• 6:09
  will,
• 6:09
  it
• 6:10
  will,
• 6:10
  will
• 6:10
  put
• 6:10
  a
• 6:11
  mood
• 6:11
  stabilizer
• 6:11
  on
• 6:12
  board
• 6:12
  if
• 6:12
  they
• 6:13
  see
• 6:13
  significant
• 6:14
  evidence
• 6:14
  of
• 6:14
  mixed
• 6:15
  features
• 6:15
  and
• 6:15
  they're
• 6:15
  not
• 6:16
  quite
• 6:16
  sure
• 6:16
  if
• 6:16
  this
• 6:17
  will
• 6:17
  become
• 6:17
  bipolarity
• 6:18
  or.
• 6:18
  Or
• 6:19
  if
• 6:19
  it
• 6:19
  won't
• 6:19
  become
• 6:20
  bipolarity.
• 6:20
  But
• 6:21
  there
• 6:21
  are
• 6:21
  mixed
• 6:21
  features.
• 6:22
  Right.
• 6:22
  So
• 6:22
  in
• 6:22
  this
• 6:23
  situation,
• 6:23
  you
• 6:23
  can't
• 6:24
  really
• 6:24
  hedge.
• 6:24
  There's
• 6:25
  not
• 6:25
  like
• 6:25
  an
• 6:25
  in
• 6:26
  between
• 6:26
  medication
• 6:26
  that
• 6:27
  you
• 6:27
  can
• 6:28
  confidently
• 6:29
  prescribe
• 6:29
  and
• 6:29
  say,
• 6:30
  oh,
• 6:30
  well,
• 6:30
  I'll
• 6:31
  be
• 6:31
  fine.
• 6:31
  No,
• 6:31
  because
• 6:32
  there
• 6:32
  is
• 6:32
  a
• 6:32
  night
• 6:32
  and
• 6:32
  day
• 6:33
  difference
• 6:33
  between
• 6:33
  a
• 6:33
  high
• 6:33
  dose
• 6:34
  SSRI
• 6:35
  if
• 6:35
  you
• 6:35
  diagnose
• 6:36
  O,
• 6:36
  C,
• 6:36
  D
• 6:36
  here
• 6:37
  and
• 6:38
  a
• 6:38
  antipsychotic
• 6:39
  for
• 6:40
  delusional
• 6:40
  disorder,
• 6:41
  which
• 6:41
  there
• 6:41
  is
• 6:41
  some
• 6:41
  evidence
• 6:42
  on
• 6:42
  that.
• 6:42
  I
• 6:42
  don't
• 6:43
  believe
• 6:43
  anything's
• 6:43
  FDA
• 6:43
  approved
• 6:44
  though,
• 6:44
  for
• 6:44
  delusional
• 6:45
  disorder.
• 6:45
  But
• 6:46
  some
• 6:46
  evidence
• 6:46
  suggests
• 6:47
  antipsychotic
• 6:47
  mono.
• 6:48
  The
• 6:48
  point
• 6:48
  is,
• 6:49
  you
• 6:49
  have
• 6:49
  to
• 6:49
  be
• 6:50
  a
• 6:50
  little
• 6:50
  bit
• 6:50
  precise
• 6:50
  with
• 6:51
  this
• 6:51
  because
• 6:52
  the
• 6:52
  treatment
• 6:53
  paths
• 6:53
  are
• 6:54
  completely
• 6:55
  divergent.
• 6:55
  And
• 6:56
  a
• 6:57
  high
• 6:57
  dose
• 6:57
  SSRI
• 6:58
  for
• 6:58
  someone
• 6:58
  who
• 6:58
  has
• 6:59
  delusional
• 6:59
  disorder
• 7:00
  is
• 7:00
  probably
• 7:00
  not
• 7:01
  going
• 7:01
  to
• 7:01
  do
• 7:01
  anything.
• 7:02
  Okay.
• 7:03
  Same
• 7:03
  thing
• 7:03
  goes
• 7:04
  if
• 7:04
  someone
• 7:04
  has
• 7:04
  OCD
• 7:05
  and
• 7:05
  you
• 7:05
  prescribe
• 7:06
  them
• 7:07
  antipsychotic
• 7:08
  monotherapy.
• 7:09
  There's
• 7:10
  really
• 7:10
  no
• 7:10
  good
• 7:11
  evidence
• 7:11
  for
• 7:11
  that
• 7:11
  either.
• 7:12
  There
• 7:12
  is
• 7:13
  some
• 7:13
  evidence
• 7:13
  with
• 7:13
  adjunct
• 7:14
  SGAs
• 7:16
  tacked
• 7:16
  onto
• 7:16
  SSRIs
• 7:17
  in
• 7:17
  more
• 7:17
  resistant
• 7:18
  cases.
• 7:18
  Okay.
• 7:19
  But
• 7:20
  it
• 7:20
  is
• 7:20
  definitely
• 7:21
  not
• 7:21
  a
• 7:22
  go
• 7:22
  to
• 7:22
  first
• 7:22
  line
• 7:23
  monotherapy
• 7:23
  thing
• 7:24
  to
• 7:24
  do
• 7:24
  at
• 7:24
  all.
• 7:24
  Now,
• 7:25
  my
• 7:25
  friends,
• 7:25
  a
• 7:25
  big,
• 7:26
  a
• 7:27
  very
• 7:27
  big
• 7:28
  clue
• 7:30
  with
• 7:30
  this
• 7:30
  whole
• 7:30
  thing
• 7:31
  is
• 7:31
  that
• 7:31
  you
• 7:32
  have
• 7:32
  compulsions.
• 7:33
  You
• 7:33
  don't
• 7:34
  just
• 7:34
  have
• 7:36
  a
• 7:37
  bizarre
• 7:37
  thought
• 7:37
  or
• 7:38
  a
• 7:38
  delusional
• 7:38
  thought,
• 7:39
  if
• 7:39
  we
• 7:39
  can
• 7:39
  call
• 7:39
  it
• 7:40
  that.
• 7:40
  You
• 7:40
  have
• 7:40
  compulsions
• 7:41
  here.
• 7:41
  You
• 7:42
  have
• 7:42
  four
• 7:42
  to
• 7:42
  five
• 7:42
  hours
• 7:43
  where
• 7:43
  she
• 7:43
  feels
• 7:43
  compelled
• 7:44
  to
• 7:45
  wipe
• 7:45
  down
• 7:45
  surfaces
• 7:46
  with
• 7:46
  bleach
• 7:47
  and
• 7:47
  throwing
• 7:48
  away
• 7:48
  most
• 7:48
  of
• 7:48
  her
• 7:48
  furniture.
• 7:49
  She's
• 7:49
  washing
• 7:49
  her
• 7:50
  hands
• 7:50
  until
• 7:50
  they're
• 7:50
  cracked
• 7:51
  and
• 7:51
  they're
• 7:51
  bleeding.
• 7:52
  So
• 7:53
  this
• 7:53
  definitely
• 7:54
  looks
• 7:54
  a
• 7:54
  lot
• 7:55
  more
• 7:55
  like
• 7:55
  O
• 7:55
  C
• 7:56
  D.
• 7:56
  Now,
• 7:57
  not
• 7:57
  to
• 7:57
  make
• 7:57
  things
• 7:57
  even
• 7:58
  more
• 7:58
  confusing
• 7:58
  to
• 7:58
  you,
• 7:59
  but
• 7:59
  with
• 7:59
  O
• 8:00
  C
• 8:00
  D
• 8:01
  you
• 8:01
  do
• 8:01
  not
• 8:01
  need
• 8:02
  both
• 8:02
  obsessions
• 8:03
  and
• 8:03
  compulsions.
• 8:04
  You
• 8:04
  could
• 8:04
  have
• 8:04
  just
• 8:05
  obsessions
• 8:05
  and
• 8:05
  no
• 8:05
  compulsions.
• 8:06
  I
• 8:06
  will
• 8:07
  be
• 8:07
  honest
• 8:07
  with
• 8:07
  you.
• 8:08
  People
• 8:09
  who
• 8:09
  only
• 8:09
  have
• 8:09
  obsessions
• 8:10
  seem
• 8:10
  to
• 8:10
  be
• 8:11
  unicorns
• 8:12
  out
• 8:12
  there.
• 8:12
  Uh,
• 8:13
  I
• 8:13
  find
• 8:13
  that
• 8:14
  most
• 8:14
  of
• 8:14
  the
• 8:14
  OCD
• 8:15
  I
• 8:15
  diagnose
• 8:16
  has
• 8:16
  obsessions
• 8:17
  with
• 8:17
  compulsions.
• 8:18
  Most
• 8:18
  of
• 8:18
  the
• 8:18
  OCD
• 8:19
  I
• 8:19
  see
• 8:19
  is
• 8:20
  very
• 8:20
  germ
• 8:20
  related.
• 8:21
  However,
• 8:21
  I
• 8:22
  will
• 8:22
  say
• 8:22
  this
• 8:22
  as
• 8:22
  a
• 8:22
  slight
• 8:23
  tangent.
• 8:24
  That
• 8:24
  is
• 8:24
  very
• 8:24
  important
• 8:25
  for
• 8:25
  you
• 8:25
  to
• 8:25
  appreciate
• 8:26
  psychiatry
• 8:27
  for
• 8:27
  what
• 8:27
  it
• 8:27
  is.
• 8:27
  It's
• 8:28
  very
• 8:28
  complex
• 8:28
  and
• 8:28
  rich.
• 8:29
  OCD
• 8:30
  is
• 8:30
  one
• 8:30
  of
• 8:30
  those
• 8:32
  weird
• 8:33
  dimensional
• 8:35
  ingredients,
• 8:35
  if
• 8:36
  you
• 8:36
  will,
• 8:36
  that
• 8:37
  kind
• 8:37
  of
• 8:37
  spills
• 8:37
  over
• 8:38
  into
• 8:38
  so
• 8:38
  many
• 8:38
  other
• 8:39
  treatment
• 8:40
  cases,
• 8:41
  right?
• 8:41
  I'll
• 8:41
  have
• 8:41
  tons
• 8:42
  of
• 8:42
  patients
• 8:42
  who
• 8:42
  are
• 8:42
  depressed
• 8:43
  and
• 8:43
  they
• 8:43
  have
• 8:43
  a
• 8:44
  very
• 8:44
  obsessional
• 8:44
  way
• 8:45
  of
• 8:45
  ruminating,
• 8:46
  right?
• 8:46
  And
• 8:46
  it
• 8:46
  seems
• 8:47
  a
• 8:47
  little
• 8:47
  bit
• 8:47
  beyond
• 8:48
  what
• 8:48
  we
• 8:49
  would
• 8:49
  normally
• 8:49
  see
• 8:49
  in,
• 8:50
  in
• 8:50
  generalized
• 8:51
  anxiety
• 8:51
  disorder.
• 8:52
  These
• 8:52
  are
• 8:52
  very
• 8:53
  obsessional
• 8:53
  ruminations,
• 8:54
  sometimes
• 8:54
  with
• 8:55
  very
• 8:55
  ego
• 8:55
  dystonic,
• 8:56
  catastrophic
• 8:56
  thoughts
• 8:57
  that
• 8:57
  seem
• 8:58
  very
• 8:58
  unwanted
• 8:59
  and
• 8:59
  intrusive.
• 9:00
  Like
• 9:00
  in
• 9:00
  the
• 9:00
  dsm,
• 9:01
  they
• 9:01
  ask
• 9:01
  for
• 9:02
  about
• 9:02
  an
• 9:02
  hour
• 9:02
  or
• 9:02
  more
• 9:03
  a
• 9:03
  day.
• 9:03
  That's
• 9:03
  not
• 9:03
  a
• 9:03
  hard
• 9:04
  requirement,
• 9:04
  but
• 9:05
  it's,
• 9:05
  it's
• 9:05
  just
• 9:05
  a
• 9:07
  requirement
• 9:07
  that
• 9:08
  this
• 9:08
  is
• 9:09
  so
• 9:09
  time
• 9:09
  consuming
• 9:11
  to
• 9:11
  the
• 9:11
  extent
• 9:11
  that
• 9:11
  it's
• 9:12
  so
• 9:12
  distressing
• 9:12
  that
• 9:12
  you
• 9:13
  need
• 9:13
  to
• 9:13
  intervene
• 9:14
  kind
• 9:14
  of
• 9:14
  thing.
• 9:14
  Okay,
• 9:15
  that's
• 9:15
  sort
• 9:15
  of
• 9:15
  a
• 9:15
  mouthful.
• 9:16
  But
• 9:16
  that's
• 9:16
  what
• 9:16
  the
• 9:16
  DSM
• 9:17
  I
• 9:17
  think
• 9:17
  is
• 9:17
  intending
• 9:18
  is,
• 9:18
  you
• 9:19
  know,
• 9:19
  if,
• 9:19
  if
• 9:19
  somebody
• 9:20
  just
• 9:20
  thinks
• 9:20
  that
• 9:21
  their
• 9:21
  counter
• 9:22
  is
• 9:22
  dirty
• 9:23
  and
• 9:23
  they
• 9:23
  feel
• 9:23
  the
• 9:24
  need
• 9:24
  to
• 9:24
  wipe
• 9:24
  it
• 9:24
  down
• 9:24
  once
• 9:25
  or
• 9:25
  twice
• 9:25
  a
• 9:25
  day
• 9:25
  and
• 9:25
  then
• 9:26
  they
• 9:26
  just
• 9:26
  carry
• 9:26
  on
• 9:26
  with
• 9:26
  their
• 9:27
  day
• 9:27
  and
• 9:27
  it
• 9:28
  otherwise
• 9:28
  doesn't
• 9:28
  really
• 9:29
  bother
• 9:29
  them,
• 9:29
  that's
• 9:29
  not
• 9:29
  really
• 9:30
  ocd,
• 9:30
  right?
• 9:30
  It's
• 9:31
  not
• 9:31
  causing
• 9:32
  functional
• 9:32
  impairment
• 9:33
  or
• 9:33
  severe
• 9:33
  levels
• 9:34
  of
• 9:34
  distress
• 9:34
  in
• 9:34
  a,
• 9:35
  an
• 9:35
  important
• 9:35
  area.
• 9:36
  It's
• 9:36
  not
• 9:36
  that
• 9:36
  time
• 9:37
  consuming.
• 9:37
  But
• 9:37
  if
• 9:37
  somebody's
• 9:38
  wiping
• 9:38
  down
• 9:38
  their
• 9:38
  counter
• 9:39
  so
• 9:39
  often
• 9:40
  that
• 9:40
  they're
• 9:40
  not
• 9:40
  able
• 9:41
  to
• 9:41
  get
• 9:41
  to
• 9:41
  dinner
• 9:41
  on
• 9:42
  time
• 9:42
  or
• 9:43
  connect
• 9:43
  with
• 9:44
  their
• 9:44
  friends
• 9:45
  and
• 9:45
  they
• 9:45
  just
• 9:45
  have
• 9:46
  a
• 9:46
  more
• 9:46
  ingrained
• 9:47
  obsessional
• 9:48
  thought
• 9:48
  process
• 9:48
  that
• 9:49
  if
• 9:49
  they
• 9:49
  don't
• 9:49
  wipe
• 9:50
  that
• 9:50
  counter,
• 9:50
  something
• 9:50
  bad's
• 9:51
  going
• 9:51
  to
• 9:51
  happen
• 9:51
  to
• 9:51
  their
• 9:51
  family.
• 9:52
  Now
• 9:52
  we
• 9:52
  have
• 9:53
  a
• 9:53
  bigger
• 9:53
  problem
• 9:53
  on
• 9:53
  our
• 9:54
  hands.
• 9:54
  Okay.
• 9:55
  But
• 9:55
  suffice
• 9:55
  it
• 9:56
  to
• 9:56
  say,
• 9:56
  I
• 9:57
  typically
• 9:57
  see
• 9:57
  obsessions
• 9:58
  and
• 9:58
  compulsions.
• 9:59
  And.
• 9:59
  And
• 9:59
  if
• 9:59
  you
• 10:00
  do
• 10:00
  see
• 10:00
  compulsions,
• 10:01
  which
• 10:01
  you
• 10:01
  do
• 10:01
  here,
• 10:01
  these
• 10:01
  are
• 10:02
  clear
• 10:02
  compulsions
• 10:02
  that
• 10:03
  Jane
• 10:03
  is
• 10:03
  exhibiting.
• 10:04
  I
• 10:04
  would
• 10:05
  definitely
• 10:05
  raise
• 10:06
  the
• 10:06
  index
• 10:06
  of
• 10:06
  suspicion
• 10:07
  that
• 10:08
  she
• 10:09
  is.
• 10:09
  Is
• 10:09
  dealing
• 10:10
  with
• 10:10
  OCD
• 10:11
  here.
• 10:11
  And
• 10:12
  we
• 10:12
  can
• 10:12
  talk
• 10:12
  about
• 10:12
  the
• 10:12
  insight
• 10:13
  specifiers,
• 10:14
  which
• 10:14
  is
• 10:14
  the
• 10:14
  whole
• 10:14
  ball
• 10:15
  game
• 10:15
  here.
• 10:15
  We'll
• 10:15
  talk
• 10:15
  about
• 10:16
  that
• 10:16
  in
• 10:16
  a
• 10:16
  moment.
• 10:16
  But
• 10:17
  I
• 10:17
  would
• 10:17
  definitely
• 10:18
  raise
• 10:18
  my
• 10:18
  index
• 10:18
  of
• 10:18
  suspicion
• 10:19
  that
• 10:19
  this
• 10:19
  is
• 10:19
  ocd,
• 10:20
  because
• 10:20
  you
• 10:20
  do
• 10:20
  have
• 10:20
  the
• 10:21
  compulsions.
• 10:22
  If
• 10:22
  this
• 10:22
  was
• 10:22
  just
• 10:22
  an
• 10:23
  obsession
• 10:23
  that
• 10:24
  there's
• 10:24
  mold
• 10:25
  toxicity
• 10:26
  that
• 10:26
  she's
• 10:26
  suffering
• 10:26
  from,
• 10:27
  that's
• 10:28
  a
• 10:28
  different
• 10:28
  story.
• 10:28
  That
• 10:28
  would
• 10:28
  make
• 10:29
  this
• 10:29
  case
• 10:29
  a
• 10:29
  little
• 10:29
  bit
• 10:30
  more
• 10:30
  complicated
• 10:30
  if
• 10:30
  she
• 10:31
  kind
• 10:31
  of
• 10:31
  just
• 10:31
  sat
• 10:31
  there
• 10:31
  with
• 10:32
  this
• 10:32
  belief,
• 10:33
  which
• 10:33
  it
• 10:33
  could
• 10:33
  be
• 10:33
  ocd.
• 10:34
  Right.
• 10:35
  But
• 10:35
  you.
• 10:36
  You
• 10:36
  know,
• 10:36
  is
• 10:36
  it.
• 10:37
  Is
• 10:37
  it
• 10:37
  time
• 10:37
  consuming?
• 10:38
  I
• 10:38
  mean,
• 10:39
  we.
• 10:39
  And
• 10:39
  that's
• 10:39
  usually
• 10:40
  where
• 10:40
  the
• 10:40
  compulsions
• 10:41
  trickle
• 10:41
  in.
• 10:41
  Right.
• 10:42
  Because
• 10:42
  people
• 10:42
  are
• 10:43
  compelled
• 10:43
  to
• 10:43
  do
• 10:43
  something
• 10:44
  about
• 10:44
  these
• 10:44
  obsessional
• 10:45
  thoughts.
• 10:45
  And
• 10:45
  that
• 10:45
  is
• 10:46
  what.
• 10:46
  In
• 10:46
  my
• 10:46
  experience.
• 10:47
  What
• 10:47
  is
• 10:47
  even
• 10:47
  more
• 10:48
  time
• 10:48
  consuming.
• 10:48
  Right.
• 10:49
  Not
• 10:49
  only
• 10:49
  are
• 10:49
  they
• 10:49
  thinking
• 10:49
  about
• 10:50
  this
• 10:50
  all
• 10:50
  day,
• 10:50
  but
• 10:51
  they
• 10:51
  feel
• 10:51
  compelled
• 10:52
  to
• 10:52
  neutralize
• 10:53
  the
• 10:53
  unsustainable
• 10:54
  sense
• 10:54
  of
• 10:55
  anxiety
• 10:55
  in
• 10:55
  their
• 10:55
  minds
• 10:56
  by
• 10:56
  either
• 10:56
  showering
• 10:57
  all
• 10:57
  the
• 10:57
  time.
• 10:57
  In
• 10:58
  this
• 10:58
  case,
• 10:58
  Jane
• 10:59
  is
• 10:59
  wiping
• 10:59
  down
• 10:59
  surfaces.
• 11:00
  Right.
• 11:01
  And
• 11:01
  so
• 11:02
  they
• 11:02
  usually
• 11:03
  do
• 11:03
  go
• 11:03
  together.
• 11:04
  Okay,
• 11:04
  But
• 11:04
  I
• 11:04
  would
• 11:04
  pry,
• 11:05
  right?
• 11:05
  Is
• 11:05
  this.
• 11:06
  Does
• 11:06
  this
• 11:06
  go
• 11:06
  beyond
• 11:07
  the
• 11:07
  mold?
• 11:08
  And
• 11:08
  that's
• 11:08
  where
• 11:08
  you
• 11:09
  can
• 11:09
  really
• 11:09
  differentiate
• 11:10
  a
• 11:10
  delusional
• 11:10
  disorder
• 11:11
  from
• 11:11
  ocd.
• 11:12
  My
• 11:12
  patients
• 11:12
  with
• 11:12
  delusional
• 11:13
  disorders,
• 11:14
  the
• 11:14
  mold
• 11:14
  is
• 11:14
  part
• 11:15
  of
• 11:15
  the
• 11:15
  story.
• 11:15
  It's
• 11:15
  an
• 11:16
  obsession.
• 11:16
  It
• 11:16
  bothers
• 11:17
  them.
• 11:17
  It's
• 11:17
  ego
• 11:17
  dystonic,
• 11:18
  potentially,
• 11:19
  where
• 11:19
  they
• 11:19
  don't
• 11:20
  like
• 11:20
  the
• 11:20
  fact
• 11:20
  that
• 11:20
  there's
• 11:21
  mold
• 11:21
  that's
• 11:21
  poisoning
• 11:22
  them
• 11:22
  in
• 11:22
  their
• 11:22
  house.
• 11:22
  But
• 11:23
  it's
• 11:23
  part
• 11:23
  of
• 11:23
  a
• 11:23
  grander
• 11:24
  narrative.
• 11:24
  It's
• 11:24
  not
• 11:25
  just
• 11:25
  mold
• 11:25
  and,
• 11:26
  oh,
• 11:26
  I
• 11:26
  need
• 11:26
  to
• 11:26
  wipe
• 11:27
  down
• 11:27
  the
• 11:27
  surface
• 11:27
  and
• 11:28
  call
• 11:28
  an
• 11:28
  inspector
• 11:28
  and
• 11:28
  extinguish
• 11:29
  the
• 11:29
  mold.
• 11:30
  It's
• 11:30
  usually
• 11:31
  part
• 11:31
  of
• 11:31
  a
• 11:31
  narrative
• 11:32
  where
• 11:32
  the
• 11:33
  mold
• 11:33
  was
• 11:33
  placed
• 11:34
  there
• 11:34
  by
• 11:34
  a
• 11:34
  particular
• 11:34
  person
• 11:35
  to
• 11:35
  get
• 11:36
  in
• 11:36
  that
• 11:36
  patient's
• 11:36
  way
• 11:37
  so
• 11:37
  that
• 11:37
  the
• 11:37
  patient
• 11:37
  can't
• 11:38
  successfully
• 11:38
  get
• 11:38
  promoted.
• 11:40
  Right.
• 11:40
  It's.
• 11:40
  It's
• 11:41
  not
• 11:41
  just
• 11:42
  the
• 11:42
  primary
• 11:42
  concern
• 11:43
  of,
• 11:43
  hey,
• 11:43
  that's
• 11:44
  dirty
• 11:44
  and
• 11:44
  contaminated,
• 11:45
  and
• 11:46
  I
• 11:46
  need
• 11:46
  to
• 11:46
  wash
• 11:46
  my
• 11:46
  hands.
• 11:47
  Right.
• 11:47
  There's
• 11:47
  a
• 11:48
  story.
• 11:48
  There's
• 11:48
  a
• 11:49
  bit
• 11:49
  of
• 11:49
  a
• 11:49
  thought
• 11:49
  process
• 11:50
  typically
• 11:50
  behind
• 11:50
  that.
• 11:51
  I'm
• 11:51
  not
• 11:51
  saying
• 11:52
  it's
• 11:52
  always
• 11:52
  persecutory
• 11:53
  or
• 11:53
  anything
• 11:54
  like
• 11:54
  that.
• 11:54
  There's
• 11:54
  obviously
• 11:55
  many
• 11:55
  different
• 11:55
  subtypes
• 11:56
  of
• 11:57
  delusions
• 11:57
  that
• 11:57
  you've
• 11:58
  heard
• 11:58
  about
• 11:58
  the
• 11:58
  grandiose
• 11:59
  type.
• 12:00
  Right.
• 12:00
  The
• 12:00
  Jealous
• 12:01
  type,
• 12:01
  the
• 12:01
  somatic
• 12:02
  type,
• 12:02
  the
• 12:02
  aridomatic
• 12:03
  type,
• 12:04
  where
• 12:04
  another
• 12:04
  person
• 12:05
  is
• 12:05
  in
• 12:05
  love
• 12:05
  with
• 12:05
  that
• 12:05
  person.
• 12:06
  But
• 12:06
  the
• 12:06
  greater
• 12:07
  point
• 12:08
  here
• 12:08
  is
• 12:08
  that
• 12:08
  with
• 12:08
  delusions,
• 12:09
  it's
• 12:09
  usually
• 12:10
  not
• 12:10
  this
• 12:10
  fixed,
• 12:11
  small
• 12:13
  feature.
• 12:13
  It's
• 12:13
  not
• 12:14
  circumscribed
• 12:14
  to
• 12:15
  just,
• 12:15
  ooh,
• 12:15
  that's
• 12:15
  a
• 12:15
  germ.
• 12:16
  I
• 12:16
  need
• 12:16
  to
• 12:16
  wash
• 12:16
  my
• 12:17
  hands
• 12:17
  and
• 12:17
  neutralize
• 12:18
  it.
• 12:18
  There's
• 12:18
  a
• 12:19
  story,
• 12:19
  there's
• 12:19
  a
• 12:20
  belief
• 12:20
  there
• 12:21
  that
• 12:21
  is
• 12:21
  more
• 12:22
  encompassing
• 12:22
  and
• 12:23
  not
• 12:23
  circumscribed
• 12:24
  to
• 12:24
  the
• 12:24
  thing
• 12:24
  itself.
• 12:25
  Again.
• 12:25
  So
• 12:25
  it's
• 12:26
  never
• 12:26
  just
• 12:26
  about
• 12:26
  the
• 12:26
  mold
• 12:27
  being
• 12:27
  dirty.
• 12:28
  The
• 12:28
  mold
• 12:28
  is
• 12:28
  there
• 12:28
  potentially
• 12:29
  for
• 12:29
  a
• 12:29
  reason.
• 12:31
  Okay.
• 12:31
  That
• 12:32
  would
• 12:32
  be
• 12:32
  something
• 12:33
  that
• 12:33
  I
• 12:34
  really
• 12:35
  look
• 12:35
  for.
• 12:35
  Right.
• 12:35
  There's
• 12:36
  a
• 12:36
  greater
• 12:36
  extension
• 12:37
  in
• 12:37
  the
• 12:37
  belief
• 12:37
  system
• 12:38
  with
• 12:38
  delusional
• 12:39
  disorder.
• 12:40
  Okay.
• 12:41
  There's
• 12:41
  more
• 12:41
  of
• 12:42
  an
• 12:42
  explanatory
• 12:43
  framework
• 12:43
  where
• 12:43
  the
• 12:43
  delusion
• 12:44
  is
• 12:45
  not
• 12:45
  just
• 12:45
  the
• 12:45
  mold
• 12:46
  itself.
• 12:46
  And
• 12:46
  that's
• 12:46
  where
• 12:46
  you
• 12:47
  need
• 12:47
  to
• 12:47
  carefully
• 12:47
  question
• 12:47
  the
• 12:48
  patient
• 12:48
  and
• 12:49
  say,
• 12:49
  why
• 12:49
  do
• 12:49
  you
• 12:49
  think
• 12:49
  the
• 12:49
  mold
• 12:50
  is
• 12:50
  there?
• 12:50
  What
• 12:51
  do
• 12:51
  you
• 12:51
  think
• 12:51
  is
• 12:52
  causing
• 12:53
  the
• 12:53
  mold
• 12:53
  to
• 12:54
  be
• 12:54
  in
• 12:54
  your
• 12:54
  home?
• 12:54
  Is
• 12:55
  anybody.
• 12:55
  Do
• 12:55
  you
• 12:55
  feel
• 12:56
  like
• 12:56
  anybody
• 12:56
  has
• 12:57
  placed
• 12:57
  it
• 12:57
  there
• 12:57
  or
• 12:58
  wants
• 12:58
  it
• 12:58
  to
• 12:58
  be
• 12:58
  there?
• 12:59
  Do
• 12:59
  you
• 12:59
  feel
• 12:59
  like
• 13:00
  anything
• 13:01
  else
• 13:01
  is
• 13:01
  in
• 13:02
  your
• 13:02
  way
• 13:02
  right
• 13:02
  now,
• 13:03
  beyond
• 13:03
  the
• 13:03
  mold?
• 13:04
  Right.
• 13:04
  And
• 13:05
  so
• 13:05
  get
• 13:05
  an
• 13:05
  idea.
• 13:05
  Are
• 13:06
  people
• 13:06
  out
• 13:06
  to
• 13:06
  get
• 13:06
  this
• 13:06
  person?
• 13:07
  Do
• 13:07
  they
• 13:08
  believe
• 13:08
  that?
• 13:09
  What
• 13:09
  is
• 13:09
  the
• 13:09
  significance
• 13:10
  of
• 13:10
  the
• 13:10
  mold
• 13:11
  to
• 13:11
  them?
• 13:11
  And
• 13:11
  if
• 13:11
  they're
• 13:11
  only
• 13:11
  giving
• 13:12
  you
• 13:12
  germaphobe
• 13:13
  vibes
• 13:14
  that,
• 13:14
  hey,
• 13:14
  I
• 13:14
  know
• 13:14
  mold
• 13:15
  is
• 13:15
  toxic,
• 13:16
  there's
• 13:16
  tons
• 13:16
  of
• 13:17
  studies
• 13:17
  on
• 13:17
  it.
• 13:17
  It's
• 13:17
  not
• 13:17
  healthy.
• 13:18
  I
• 13:18
  want
• 13:18
  it
• 13:18
  out
• 13:18
  of
• 13:18
  my
• 13:19
  house,
• 13:20
  I
• 13:20
  would
• 13:20
  be
• 13:20
  much
• 13:21
  more
• 13:21
  suspicious.
• 13:21
  This
• 13:21
  is
• 13:22
  OCD
• 13:22
  and
• 13:22
  not
• 13:22
  a
• 13:22
  delusion.
• 13:23
  And
• 13:23
  if
• 13:23
  there's
• 13:24
  a
• 13:24
  grander
• 13:24
  story,
• 13:25
  I
• 13:25
  would
• 13:25
  definitely
• 13:26
  think
• 13:26
  more.
• 13:26
  It's
• 13:26
  a
• 13:27
  delusional
• 13:27
  disorder.
• 13:27
  And
• 13:28
  of
• 13:28
  course,
• 13:28
  you
• 13:28
  can't
• 13:29
  just
• 13:29
  go
• 13:29
  straight
• 13:29
  to
• 13:29
  delusional
• 13:30
  disorder.
• 13:30
  You
• 13:30
  have
• 13:30
  to
• 13:30
  think
• 13:30
  about
• 13:31
  schizophrenia.
• 13:31
  Right?
• 13:32
  But
• 13:32
  if
• 13:32
  the
• 13:33
  patient,
• 13:33
  and
• 13:33
  she
• 13:33
  is
• 13:34
  Jane,
• 13:34
  if
• 13:35
  she's
• 13:35
  organized
• 13:36
  and
• 13:36
  logical
• 13:37
  and
• 13:37
  linear,
• 13:37
  other.
• 13:38
  Beyond
• 13:38
  this
• 13:39
  particular
• 13:40
  topic.
• 13:40
  Right.
• 13:41
  If
• 13:42
  she's
• 13:42
  talking
• 13:42
  to
• 13:42
  you
• 13:42
  about
• 13:43
  how
• 13:43
  the
• 13:43
  traffic
• 13:43
  was
• 13:44
  so
• 13:44
  intense
• 13:44
  on
• 13:44
  her
• 13:44
  way
• 13:45
  here
• 13:45
  and
• 13:45
  how
• 13:46
  she
• 13:46
  can't
• 13:46
  wait
• 13:46
  to
• 13:46
  go
• 13:46
  to
• 13:46
  Disney
• 13:47
  World
• 13:47
  with
• 13:47
  her
• 13:47
  kids
• 13:48
  in
• 13:48
  June
• 13:49
  and
• 13:49
  how
• 13:50
  she
• 13:50
  went
• 13:50
  to
• 13:50
  a
• 13:50
  wonderful
• 13:51
  steakhouse
• 13:51
  yesterday,
• 13:52
  but
• 13:52
  they
• 13:52
  undercooked
• 13:53
  the
• 13:53
  steak
• 13:53
  a
• 13:53
  little
• 13:53
  bit.
• 13:54
  So
• 13:54
  long
• 13:55
  as
• 13:55
  she
• 13:55
  doesn't
• 13:55
  think
• 13:55
  the
• 13:55
  chefs
• 13:56
  in
• 13:56
  the
• 13:56
  back
• 13:56
  were
• 13:56
  poisoning
• 13:57
  her,
• 13:57
  I
• 13:58
  would
• 13:58
  say
• 13:58
  that.
• 13:59
  Otherwise,
• 13:59
  I
• 13:59
  would
• 14:00
  rule
• 14:00
  those
• 14:00
  other
• 14:00
  things
• 14:01
  out.
• 14:01
  Right.
• 14:01
  This
• 14:02
  is
• 14:02
  local
• 14:02
  circumscribed
• 14:04
  germ
• 14:04
  themes.
• 14:05
  Very
• 14:05
  consistent
• 14:06
  with
• 14:06
  ocd.
• 14:06
  We
• 14:06
  have
• 14:07
  the
• 14:07
  obsessions,
• 14:07
  we
• 14:07
  have
• 14:07
  the
• 14:07
  compulsions.
• 14:08
  And
• 14:08
  she
• 14:09
  doesn't
• 14:09
  like
• 14:09
  it
• 14:09
  either.
• 14:09
  Right.
• 14:10
  It's
• 14:10
  very
• 14:10
  ego
• 14:10
  dystonic.
• 14:11
  Okay.
• 14:12
  And
• 14:13
  These
• 14:14
  behaviors
• 14:14
  that
• 14:15
  have
• 14:15
  dropped,
• 14:15
  you
• 14:15
  know,
• 14:15
  washing
• 14:16
  her
• 14:16
  hands,
• 14:16
  calling
• 14:17
  inspectors,
• 14:18
  just
• 14:18
  like
• 14:18
  in
• 14:18
  ocd,
• 14:19
  they're
• 14:19
  usually
• 14:19
  very
• 14:19
  much
• 14:20
  unwanted.
• 14:20
  They're
• 14:21
  exhausting,
• 14:21
  they're
• 14:21
  distressing.
• 14:22
  The
• 14:22
  patients
• 14:23
  wish
• 14:23
  it,
• 14:23
  they
• 14:23
  wish
• 14:24
  they
• 14:24
  could
• 14:24
  stop
• 14:25
  doing
• 14:25
  all
• 14:25
  this.
• 14:26
  And
• 14:27
  so
• 14:28
  in
• 14:28
  delusional
• 14:28
  disorder,
• 14:29
  it's
• 14:29
  not
• 14:29
  always
• 14:30
  that
• 14:30
  case,
• 14:30
  right?
• 14:31
  I'm
• 14:31
  not
• 14:31
  saying
• 14:31
  every
• 14:31
  delusion
• 14:32
  is
• 14:32
  this
• 14:32
  pleasant
• 14:33
  thing
• 14:33
  that
• 14:33
  patients
• 14:34
  like
• 14:34
  to
• 14:34
  deal
• 14:35
  with
• 14:35
  and
• 14:35
  handle,
• 14:36
  but
• 14:36
  in
• 14:36
  my
• 14:36
  experience,
• 14:37
  there
• 14:37
  isn't
• 14:38
  always
• 14:38
  this
• 14:39
  compulsion
• 14:40
  to
• 14:40
  ask,
• 14:41
  to
• 14:41
  act.
• 14:41
  In
• 14:42
  delusional
• 14:42
  disorder,
• 14:43
  it's
• 14:43
  kind
• 14:43
  of
• 14:43
  this
• 14:44
  fixed,
• 14:44
  really
• 14:45
  false
• 14:45
  belief
• 14:46
  that
• 14:47
  the
• 14:47
  patient
• 14:48
  is
• 14:48
  being
• 14:48
  affected
• 14:48
  by
• 14:49
  something.
• 14:49
  But
• 14:49
  they
• 14:49
  don't
• 14:49
  feel
• 14:50
  driven
• 14:50
  by,
• 14:50
  to
• 14:51
  neutralize
• 14:51
  it.
• 14:52
  It's
• 14:52
  just
• 14:52
  a
• 14:52
  matter
• 14:52
  of
• 14:53
  fact
• 14:53
  that
• 14:53
  they
• 14:53
  state
• 14:54
  and
• 14:54
  they
• 14:54
  believe
• 14:54
  and
• 14:54
  it's
• 14:55
  kind
• 14:55
  of
• 14:55
  integrated
• 14:55
  in
• 14:55
  their
• 14:56
  lives
• 14:56
  and
• 14:57
  it's
• 14:57
  a
• 14:57
  fact.
• 14:57
  They
• 14:57
  don't
• 14:58
  feel
• 14:58
  like
• 14:59
  it's
• 14:59
  so
• 14:59
  disturbing.
• 15:00
  They
• 15:00
  need
• 15:00
  to
• 15:00
  neutralize
• 15:01
  it
• 15:01
  in
• 15:01
  the
• 15:01
  form
• 15:01
  of
• 15:01
  a,
• 15:02
  an
• 15:02
  exhausting
• 15:02
  ritual.
• 15:03
  And
• 15:03
  of
• 15:03
  course,
• 15:04
  you
• 15:04
  know,
• 15:04
  make
• 15:04
  sure
• 15:04
  Jane
• 15:05
  is
• 15:05
  not
• 15:05
  hallucinating
• 15:06
  there.
• 15:06
  You
• 15:06
  know,
• 15:06
  she
• 15:06
  doesn't
• 15:07
  hear
• 15:07
  voices,
• 15:07
  self
• 15:08
  critical
• 15:08
  voices
• 15:08
  or
• 15:09
  command
• 15:09
  hallucinations,
• 15:10
  or
• 15:10
  she
• 15:10
  doesn't
• 15:10
  see
• 15:10
  shadows
• 15:11
  or
• 15:11
  devils
• 15:12
  on
• 15:12
  her
• 15:12
  shoulder.
• 15:13
  You
• 15:13
  want
• 15:13
  to
• 15:13
  make
• 15:13
  sure
• 15:13
  there's
• 15:14
  not
• 15:14
  a
• 15:15
  greater
• 15:15
  psychosis
• 15:16
  here.
• 15:16
  We
• 15:16
  talked
• 15:16
  about
• 15:16
  substance
• 15:17
  use,
• 15:17
  ruling
• 15:18
  all
• 15:18
  that
• 15:18
  out.
• 15:18
  Of
• 15:18
  course.
• 15:19
  And
• 15:19
  of
• 15:19
  course,
• 15:19
  If
• 15:19
  Jane
• 15:20
  is
• 15:20
  35
• 15:21
  years
• 15:21
  old
• 15:21
  and
• 15:22
  you
• 15:22
  believe
• 15:22
  she
• 15:22
  actually
• 15:22
  has
• 15:23
  a
• 15:23
  delusion
• 15:23
  or
• 15:23
  some
• 15:24
  form
• 15:24
  of
• 15:24
  psychosis,
• 15:25
  you
• 15:25
  might
• 15:25
  want
• 15:25
  to
• 15:26
  get
• 15:26
  medical
• 15:26
  involved
• 15:26
  because
• 15:27
  that's
• 15:27
  a
• 15:27
  much
• 15:27
  more
• 15:27
  atypical
• 15:28
  presentation.
• 15:28
  But
• 15:29
  I
• 15:29
  find
• 15:30
  that
• 15:30
  OCD
• 15:31
  is
• 15:32
  pretty,
• 15:33
  it's,
• 15:33
  it's
• 15:34
  a
• 15:34
  pretty
• 15:34
  understood
• 15:34
  phenomenon
• 15:35
  even
• 15:35
  for
• 15:36
  the
• 15:36
  patient.
• 15:36
  Remember
• 15:36
  that
• 15:36
  ocd,
• 15:37
  the
• 15:37
  mean
• 15:37
  age
• 15:38
  of
• 15:38
  onset
• 15:38
  is
• 15:38
  quite
• 15:38
  young.
• 15:39
  I
• 15:39
  don't
• 15:39
  quote
• 15:39
  me
• 15:39
  on
• 15:39
  this,
• 15:40
  but
• 15:40
  I
• 15:40
  believe
• 15:40
  it's
• 15:41
  early
• 15:41
  childhood
• 15:42
  or
• 15:42
  early
• 15:43
  teens
• 15:43
  where
• 15:43
  OCD
• 15:44
  begins
• 15:44
  to
• 15:44
  manifest.
• 15:45
  So
• 15:45
  typically,
• 15:46
  even,
• 15:46
  even
• 15:46
  if
• 15:46
  your
• 15:47
  patients
• 15:47
  have
• 15:48
  pretty
• 15:48
  poor
• 15:48
  insight,
• 15:49
  I'm
• 15:49
  not
• 15:50
  saying
• 15:50
  maybe
• 15:50
  delusional
• 15:50
  insight,
• 15:51
  but
• 15:51
  very
• 15:51
  poor
• 15:52
  insight.
• 15:52
  They
• 15:52
  will
• 15:52
  give
• 15:53
  you
• 15:53
  a
• 15:53
  pretty
• 15:54
  good
• 15:54
  understanding
• 15:55
  that
• 15:55
  they
• 15:55
  have
• 15:55
  always
• 15:55
  had
• 15:56
  these
• 15:56
  kinds
• 15:56
  of
• 15:57
  obsessions
• 15:57
  and
• 15:58
  concerns
• 15:58
  throughout
• 15:59
  their
• 15:59
  lives
• 16:00
  with
• 16:00
  varying
• 16:00
  insight.
• 16:01
  And
• 16:01
  that's
• 16:01
  another
• 16:01
  key
• 16:02
  pearl
• 16:02
  is
• 16:02
  that
• 16:03
  insight
• 16:03
  is
• 16:03
  not
• 16:03
  this
• 16:04
  fixed
• 16:04
  thing.
• 16:04
  Insight
• 16:05
  can
• 16:05
  wax
• 16:05
  and
• 16:05
  wane.
• 16:06
  Patients
• 16:06
  can
• 16:06
  have
• 16:06
  a
• 16:06
  lot
• 16:07
  of
• 16:07
  insight
• 16:07
  into
• 16:07
  their
• 16:07
  symptoms
• 16:08
  and
• 16:08
  clearly
• 16:09
  realize
• 16:09
  they're
• 16:09
  completely
• 16:10
  irrational.
• 16:10
  And
• 16:11
  they
• 16:11
  hate
• 16:12
  the
• 16:12
  fact
• 16:12
  that
• 16:12
  they
• 16:12
  feel
• 16:12
  driven
• 16:13
  by
• 16:13
  to
• 16:14
  adjust
• 16:15
  the
• 16:15
  angle
• 16:15
  of
• 16:16
  the
• 16:16
  coaster
• 16:16
  on
• 16:17
  the
• 16:17
  counter.
• 16:17
  And
• 16:18
  they
• 16:18
  know
• 16:18
  that
• 16:18
  if
• 16:18
  they
• 16:19
  don't
• 16:19
  adjust
• 16:19
  the
• 16:20
  angle
• 16:20
  that
• 16:20
  everything's
• 16:21
  probably
• 16:21
  going
• 16:22
  to
• 16:22
  be
• 16:22
  okay.
• 16:22
  Their
• 16:23
  uncle's
• 16:23
  not
• 16:23
  going
• 16:23
  to
• 16:24
  die
• 16:24
  of
• 16:24
  lupus,
• 16:24
  but
• 16:25
  they
• 16:25
  have
• 16:25
  to
• 16:25
  adjust
• 16:26
  it
• 16:26
  anyway
• 16:26
  just
• 16:27
  in
• 16:27
  case
• 16:27
  their
• 16:27
  uncle
• 16:27
  does
• 16:28
  die
• 16:28
  of
• 16:28
  lupus,
• 16:29
  and
• 16:29
  they
• 16:29
  get
• 16:29
  that
• 16:30
  it's
• 16:30
  irrational
• 16:30
  and
• 16:31
  insane,
• 16:31
  but
• 16:31
  they
• 16:31
  have
• 16:32
  to
• 16:32
  do
• 16:32
  it
• 16:32
  anyway.
• 16:33
  Right?
• 16:33
  And
• 16:33
  they'll
• 16:33
  talk
• 16:34
  to
• 16:34
  you
• 16:34
  about
• 16:34
  that.
• 16:34
  They'll
• 16:35
  clue
• 16:35
  you
• 16:35
  in.
• 16:35
  It's
• 16:35
  not
• 16:35
  a
• 16:35
  mystery.
• 16:36
  You
• 16:36
  don't
• 16:36
  have
• 16:36
  to
• 16:36
  guess.
• 16:36
  You
• 16:37
  don't
• 16:37
  have
• 16:37
  to
• 16:37
  play
• 16:37
  20
• 16:37
  questions.
• 16:38
  But.
• 16:39
  So.
• 16:39
  So
• 16:39
  I.
• 16:40
  I
• 16:40
  would
• 16:40
  say
• 16:40
  that
• 16:40
  is
• 16:40
  a
• 16:41
  very
• 16:42
  key
• 16:42
  distinction.
• 16:43
  Okay.
• 16:44
  And
• 16:44
  again,
• 16:44
  you
• 16:45
  have
• 16:45
  to
• 16:45
  get
• 16:45
  this
• 16:45
  right,
• 16:45
  because
• 16:46
  with
• 16:47
  O,
• 16:47
  C,
• 16:47
  d,
• 16:48
  high
• 16:48
  dose
• 16:48
  SSRIs.
• 16:49
  Right.
• 16:49
  Typically
• 16:50
  takes
• 16:50
  a
• 16:50
  little
• 16:50
  longer
• 16:51
  for
• 16:51
  them
• 16:51
  to
• 16:52
  be
• 16:52
  effective,
• 16:52
  in
• 16:53
  my
• 16:53
  experience.
• 16:53
  And
• 16:53
  at
• 16:54
  very
• 16:54
  high
• 16:54
  doses,
• 16:54
  it's
• 16:55
  kind
• 16:55
  of
• 16:55
  a
• 16:55
  marathon
• 16:55
  with
• 16:56
  ocd,
• 16:56
  especially
• 16:57
  with
• 16:58
  absent
• 16:59
  insight
• 16:59
  or
• 16:59
  delusional
• 17:00
  beliefs.
• 17:00
  And
• 17:00
  that's
• 17:01
  probably
• 17:01
  what
• 17:01
  we're
• 17:02
  looking
• 17:02
  at
• 17:02
  here.
• 17:03
  Right?
• 17:03
  We're
• 17:03
  probably
• 17:04
  looking
• 17:04
  at
• 17:05
  absent
• 17:06
  insight
• 17:07
  slash
• 17:07
  delusional
• 17:08
  beliefs.
• 17:08
  It's
• 17:08
  a
• 17:09
  specifier.
• 17:09
  With
• 17:09
  ocd,
• 17:10
  of
• 17:10
  course,
• 17:10
  with
• 17:10
  ocd,
• 17:11
  you
• 17:11
  have
• 17:11
  with
• 17:11
  good
• 17:11
  or
• 17:11
  fair
• 17:12
  insight,
• 17:12
  you
• 17:13
  have
• 17:13
  with
• 17:13
  poor
• 17:13
  insight,
• 17:14
  and
• 17:15
  with
• 17:15
  absent
• 17:16
  insight
• 17:16
  slash
• 17:17
  delusional
• 17:17
  beliefs.
• 17:18
  Now
• 17:18
  almost
• 17:18
  it's
• 17:19
  4%
• 17:20
  or
• 17:20
  fewer
• 17:20
  of
• 17:20
  OCD
• 17:21
  patients
• 17:21
  have
• 17:21
  the
• 17:22
  absent
• 17:22
  insight
• 17:23
  delusional
• 17:23
  beliefs.
• 17:24
  I
• 17:24
  would
• 17:24
  say
• 17:24
  maybe
• 17:24
  poor
• 17:25
  insight
• 17:25
  is
• 17:25
  a
• 17:25
  lot
• 17:26
  more
• 17:26
  common.
• 17:26
  And
• 17:27
  I
• 17:27
  would
• 17:27
  say
• 17:27
  good
• 17:27
  and
• 17:27
  fair
• 17:28
  insight
• 17:28
  is
• 17:28
  probably
• 17:28
  the
• 17:28
  most
• 17:29
  common.
• 17:29
  Again,
• 17:30
  people
• 17:30
  know
• 17:30
  they
• 17:31
  struggle
• 17:31
  with
• 17:31
  this.
• 17:31
  They
• 17:32
  really
• 17:32
  don't
• 17:32
  love
• 17:32
  these
• 17:32
  symptoms.
• 17:33
  They're
• 17:33
  very
• 17:33
  open
• 17:33
  about
• 17:34
  how
• 17:34
  they
• 17:34
  don't
• 17:34
  love
• 17:34
  these
• 17:34
  symptoms.
• 17:35
  Ego
• 17:36
  dystonia
• 17:36
  is
• 17:36
  such
• 17:37
  a
• 17:37
  key
• 17:38
  in
• 17:38
  your
• 17:38
  diagnosis
• 17:39
  here
• 17:39
  because
• 17:40
  they
• 17:40
  just
• 17:40
  know
• 17:41
  something's
• 17:41
  off
• 17:41
  and
• 17:41
  they
• 17:42
  have
• 17:42
  insight.
• 17:42
  They
• 17:43
  have
• 17:43
  enough
• 17:43
  insight
• 17:44
  into
• 17:44
  knowing
• 17:44
  that
• 17:44
  it's
• 17:45
  irrational.
• 17:45
  And
• 17:46
  that's
• 17:46
  how
• 17:46
  you
• 17:46
  can
• 17:46
  typically
• 17:47
  differentiate
• 17:48
  very
• 17:48
  fast
• 17:49
  delusional
• 17:50
  and
• 17:50
  ocd.
• 17:50
  Right.
• 17:51
  Because
• 17:51
  ocd,
• 17:51
  they're
• 17:51
  going
• 17:51
  to
• 17:52
  kind
• 17:52
  of
• 17:52
  elbow
• 17:52
  nudge
• 17:52
  you
• 17:52
  and
• 17:52
  go,
• 17:53
  hey,
• 17:53
  hey,
• 17:53
  I
• 17:53
  know,
• 17:54
  I
• 17:54
  know
• 17:54
  this
• 17:54
  is
• 17:54
  irrational.
• 17:55
  No,
• 17:55
  I
• 17:55
  don't
• 17:55
  actually
• 17:56
  believe
• 17:56
  my
• 17:56
  uncle's
• 17:57
  going
• 17:57
  to
• 17:57
  die
• 17:57
  of
• 17:57
  lupus.
• 17:58
  I
• 17:58
  know
• 17:58
  that
• 17:58
  sounds
• 17:59
  like
• 17:59
  a
• 17:59
  silly,
• 17:59
  irrational
• 18:00
  thought,
• 18:00
  but
• 18:01
  I
• 18:01
  just
• 18:01
  feel
• 18:01
  compelled
• 18:02
  to.
• 18:02
  To
• 18:02
  neutralize
• 18:03
  that
• 18:03
  thought
• 18:04
  as
• 18:04
  much
• 18:04
  as
• 18:04
  I
• 18:04
  can.
• 18:05
  Okay?
• 18:05
  And
• 18:05
  that's
• 18:06
  really
• 18:06
  the
• 18:06
  big
• 18:07
  difference.
• 18:07
  OCD
• 18:08
  will
• 18:08
  often
• 18:08
  help
• 18:08
  you,
• 18:08
  but
• 18:09
  in
• 18:09
  the
• 18:09
  4%
• 18:10
  where
• 18:10
  insight
• 18:11
  is
• 18:11
  absent,
• 18:11
  on
• 18:12
  the
• 18:12
  border
• 18:12
  of
• 18:12
  delusional,
• 18:14
  I
• 18:14
  would
• 18:15
  look
• 18:15
  for
• 18:16
  compulsions
• 18:17
  as
• 18:17
  a
• 18:17
  clue
• 18:17
  that
• 18:17
  you're
• 18:18
  dealing
• 18:18
  with
• 18:18
  OCD
• 18:19
  as
• 18:19
  opposed
• 18:19
  to
• 18:20
  delusional
• 18:20
  disorder.
• 18:21
  I
• 18:21
  would
• 18:21
  look
• 18:21
  at
• 18:21
  whether
• 18:22
  or
• 18:22
  not
• 18:22
  these
• 18:23
  obsessive
• 18:24
  obsessions
• 18:24
  and
• 18:25
  compulsions
• 18:25
  are
• 18:25
  circumscribed
• 18:26
  to
• 18:26
  germs,
• 18:27
  or
• 18:27
  are
• 18:27
  they
• 18:27
  transcending
• 18:28
  this
• 18:28
  into
• 18:28
  a
• 18:29
  more
• 18:29
  elaborate
• 18:29
  story
• 18:30
  that
• 18:30
  is
• 18:30
  delusional?
• 18:31
  I
• 18:31
  would
• 18:31
  wonder
• 18:32
  if
• 18:32
  those
• 18:32
  delusions
• 18:32
  are
• 18:33
  grandiose
• 18:33
  or
• 18:33
  jealous
• 18:34
  or
• 18:34
  persecutory
• 18:35
  or
• 18:35
  somatic.
• 18:36
  Right.
• 18:36
  And
• 18:36
  that
• 18:36
  will
• 18:37
  Clue
• 18:37
  you
• 18:37
  in,
• 18:38
  especially
• 18:38
  if
• 18:38
  it's
• 18:38
  very
• 18:39
  bizarre
• 18:39
  and
• 18:40
  it
• 18:40
  doesn't
• 18:40
  involve
• 18:41
  a
• 18:41
  compulsion
• 18:42
  to
• 18:42
  do
• 18:42
  anything.
• 18:42
  It's
• 18:43
  just
• 18:43
  this
• 18:43
  bizarre,
• 18:43
  fixed
• 18:44
  belief
• 18:45
  that
• 18:45
  isn't
• 18:45
  serving
• 18:46
  the
• 18:46
  patient.
• 18:46
  Right?
• 18:47
  That's
• 18:47
  how
• 18:48
  I
• 18:48
  would.
• 18:49
  Basically,
• 18:49
  that's
• 18:49
  how
• 18:49
  I
• 18:50
  would
• 18:50
  look
• 18:50
  at
• 18:50
  the
• 18:50
  delusional
• 18:51
  disorder
• 18:51
  difference.
• 18:52
  Okay?
• 18:53
  Very,
• 18:53
  very
• 18:54
  important.
• 18:55
  And
• 18:55
  I
• 18:55
  will
• 18:56
  add
• 18:56
  that
• 18:56
  criterion
• 18:57
  C
• 18:58
  in
• 18:58
  delusional
• 18:59
  disorder
• 18:59
  is,
• 19:00
  apart
• 19:00
  from
• 19:01
  the
• 19:01
  impact
• 19:01
  of
• 19:01
  the
• 19:01
  delusion
• 19:02
  or
• 19:02
  its
• 19:02
  ramifications,
• 19:03
  functioning
• 19:03
  is
• 19:04
  not
• 19:04
  markedly
• 19:05
  impaired.
• 19:06
  Okay.
• 19:07
  That's
• 19:07
  a
• 19:07
  key
• 19:08
  criterion
• 19:08
  for
• 19:09
  delusional
• 19:09
  disorder.
• 19:10
  Right.
• 19:10
  People
• 19:10
  with
• 19:11
  delusional
• 19:11
  disorder
• 19:12
  are
• 19:12
  often
• 19:12
  able
• 19:13
  to
• 19:13
  still
• 19:13
  function
• 19:13
  and
• 19:14
  navigate
• 19:14
  around
• 19:14
  their
• 19:15
  delusion.
• 19:15
  They're
• 19:16
  not
• 19:16
  markedly
• 19:17
  impaired.
• 19:17
  It's
• 19:17
  usually
• 19:18
  circumscribed.
• 19:18
  It's
• 19:19
  kind
• 19:19
  of
• 19:19
  hidden.
• 19:19
  In
• 19:19
  fact,
• 19:19
  you
• 19:20
  may
• 19:20
  not
• 19:20
  even
• 19:20
  find
• 19:20
  it.
• 19:20
  In
• 19:21
  fact,
• 19:21
  most
• 19:22
  people
• 19:22
  with
• 19:22
  delusional
• 19:22
  disorders
• 19:23
  don't
• 19:23
  really
• 19:23
  come
• 19:23
  to
• 19:23
  you
• 19:24
  and
• 19:24
  go,
• 19:24
  hey,
• 19:24
  I
• 19:24
  have
• 19:24
  a
• 19:24
  delusional
• 19:25
  disorder.
• 19:25
  Help
• 19:25
  me.
• 19:26
  Right?
• 19:26
  You
• 19:27
  find
• 19:27
  it
• 19:27
  incidentally,
• 19:28
  okay?
• 19:29
  And.
• 19:31
  And
• 19:31
  so
• 19:32
  it's,
• 19:32
  you
• 19:32
  know,
• 19:33
  you
• 19:33
  find
• 19:33
  it
• 19:33
  maybe
• 19:33
  during
• 19:34
  a.
• 19:36
  An
• 19:36
  anxiety
• 19:37
  check
• 19:37
  or
• 19:37
  depression
• 19:38
  check
• 19:38
  where
• 19:38
  they
• 19:39
  incidentally
• 19:39
  reveal
• 19:40
  that
• 19:40
  the.
• 19:41
  The
• 19:41
  DMV
• 19:42
  secretary
• 19:43
  is
• 19:45
  secretly
• 19:45
  trying
• 19:45
  to
• 19:46
  bludgeon
• 19:46
  them
• 19:46
  with
• 19:46
  a
• 19:47
  baseball
• 19:47
  bat,
• 19:48
  right?
• 19:48
  It's
• 19:48
  like,
• 19:48
  okay,
• 19:49
  well,
• 19:49
  where
• 19:49
  did
• 19:49
  that
• 19:49
  come
• 19:49
  from?
• 19:50
  My
• 19:50
  point
• 19:50
  is,
• 19:50
  you
• 19:50
  usually
• 19:52
  find
• 19:52
  delusional
• 19:53
  disorder
• 19:53
  incidentally,
• 19:54
  and
• 19:54
  it's
• 19:54
  not
• 19:54
  the
• 19:54
  main
• 19:55
  topic
• 19:55
  of
• 19:55
  treatment,
• 19:55
  as
• 19:56
  opposed
• 19:56
  to
• 19:56
  ocd,
• 19:57
  which
• 19:57
  people
• 19:58
  are
• 19:58
  actively
• 19:58
  coming
• 19:59
  to
• 19:59
  you
• 19:59
  with
• 19:59
  insight,
• 20:00
  typically
• 20:01
  knowing
• 20:01
  that
• 20:01
  this
• 20:01
  is
• 20:02
  a
• 20:02
  problem.
• 20:02
  They're
• 20:02
  exhausted.
• 20:03
  They
• 20:03
  can't
• 20:03
  stop
• 20:04
  these
• 20:04
  unwanted
• 20:04
  thoughts.
• 20:05
  They
• 20:05
  feel
• 20:05
  compelled
• 20:05
  to
• 20:06
  neutralize
• 20:06
  them,
• 20:06
  and
• 20:07
  they
• 20:07
  need
• 20:07
  your
• 20:07
  help.
• 20:07
  And
• 20:08
  Jane
• 20:08
  is
• 20:08
  certainly
• 20:09
  much
• 20:09
  more
• 20:10
  of
• 20:10
  that
• 20:10
  flavor
• 20:11
  here,
• 20:11
  and
• 20:11
  that's
• 20:11
  how
• 20:12
  you
• 20:12
  can
• 20:12
  tell.
• 20:12
  And
• 20:13
  then
• 20:13
  you're
• 20:13
  going
• 20:13
  to
• 20:13
  go
• 20:13
  down
• 20:13
  the
• 20:13
  high
• 20:14
  dose
• 20:14
  SSRI
• 20:15
  with
• 20:15
  potential
• 20:15
  antipsychotic
• 20:16
  augmentation,
• 20:17
  potential
• 20:17
  CBT
• 20:18
  exposure
• 20:19
  response
• 20:19
  therapy.
• 20:20
  You're
• 20:20
  going
• 20:20
  down
• 20:20
  that
• 20:21
  treadmill.
• 20:22
  As
• 20:22
  opposed
• 20:22
  to
• 20:22
  the
• 20:23
  delusional
• 20:23
  disorder
• 20:24
  that
• 20:24
  does
• 20:24
  not
• 20:24
  respond
• 20:24
  Right.
• 20:25
  Very
• 20:25
  well
• 20:25
  to
• 20:25
  SSRI
• 20:26
  monotherapy.
• 20:27
  And
• 20:28
  it
• 20:28
  kind
• 20:28
  of
• 20:29
  follows.
• 20:29
  Its
• 20:29
  all.
• 20:30
  It's
• 20:30
  its
• 20:30
  own
• 20:31
  algorithm,
• 20:32
  and
• 20:33
  so
• 20:33
  you
• 20:33
  have
• 20:33
  to
• 20:33
  know
• 20:34
  the
• 20:34
  difference.
• 20:34
  And
• 20:34
  they
• 20:34
  can
• 20:35
  seem
• 20:35
  very
• 20:35
  similar.
• 20:36
  But
• 20:36
  my
• 20:36
  friends,
• 20:37
  if
• 20:37
  you
• 20:37
  ask
• 20:38
  really
• 20:38
  good
• 20:38
  questions
• 20:39
  and
• 20:39
  you
• 20:39
  remember
• 20:39
  those
• 20:40
  little
• 20:40
  pearls
• 20:40
  I
• 20:40
  shared
• 20:41
  with
• 20:41
  you,
• 20:41
  it
• 20:41
  will
• 20:42
  make
• 20:42
  all
• 20:42
  the
• 20:42
  difference.
• 20:43
  Now,
• 20:43
  my
• 20:43
  friends,
• 20:44
  if
• 20:45
  you
• 20:46
  really
• 20:46
  want
• 20:47
  to
• 20:47
  be
• 20:47
  confident
• 20:47
  in
• 20:48
  front
• 20:48
  of
• 20:48
  your
• 20:48
  patients
• 20:49
  and
• 20:49
  you
• 20:49
  want
• 20:49
  to
• 20:49
  stand
• 20:50
  out,
• 20:50
  not
• 20:50
  as
• 20:50
  a
• 20:50
  prescriber
• 20:51
  who
• 20:51
  just
• 20:51
  prescribes
• 20:52
  meds
• 20:53
  with
• 20:53
  algorithms,
• 20:54
  but
• 20:55
  a
• 20:55
  prescriber
• 20:55
  who
• 20:56
  actually
• 20:56
  knows
• 20:56
  the
• 20:56
  how
• 20:56
  and
• 20:57
  the
• 20:57
  why.
• 20:57
  Someone
• 20:58
  who
• 20:58
  diagnoses
• 20:59
  that
• 20:59
  actually
• 20:59
  knows
• 20:59
  the
• 21:00
  how
• 21:00
  and
• 21:00
  the
• 21:00
  why
• 21:00
  behind
• 21:01
  what
• 21:01
  you
• 21:01
  do.
• 21:01
  I
• 21:02
  can't
• 21:02
  emphasize
• 21:02
  enough.
• 21:02
  If
• 21:03
  there's
• 21:03
  one
• 21:03
  thing
• 21:03
  you
• 21:03
  remember
• 21:04
  by
• 21:04
  the
• 21:04
  end
• 21:04
  of
• 21:04
  the
• 21:04
  night,
• 21:05
  go
• 21:05
  to
• 21:05
  our
• 21:06
  show
• 21:06
  notes,
• 21:07
  click
• 21:07
  the
• 21:07
  Patreon
• 21:08
  link
• 21:08
  and
• 21:08
  become
• 21:08
  a
• 21:09
  Patreon
• 21:09
  member.
• 21:09
  I
• 21:10
  don't
• 21:10
  know
• 21:10
  what
• 21:10
  I
• 21:10
  would
• 21:10
  do.
• 21:11
  I
• 21:11
  would
• 21:11
  feel
• 21:11
  so
• 21:12
  far
• 21:12
  behind,
• 21:12
  so
• 21:13
  lost,
• 21:14
  so
• 21:14
  not
• 21:14
  in
• 21:14
  the
• 21:14
  know
• 21:14
  about
• 21:15
  what
• 21:15
  my
• 21:15
  patients
• 21:15
  are
• 21:15
  going
• 21:16
  through.
• 21:16
  So
• 21:16
  disempowered.
• 21:17
  If
• 21:18
  I
• 21:18
  wasn't
• 21:19
  a
• 21:19
  member
• 21:19
  myself
• 21:21
  that
• 21:21
  had
• 21:21
  access
• 21:21
  to
• 21:22
  this
• 21:22
  full
• 21:22
  clinical
• 21:23
  library
• 21:24
  of
• 21:24
  pearls.
• 21:25
  I
• 21:25
  built
• 21:26
  this
• 21:26
  Patreon
• 21:27
  library
• 21:28
  because
• 21:28
  I
• 21:29
  needed
• 21:29
  it
• 21:29
  as
• 21:29
  a
• 21:29
  student
• 21:30
  and
• 21:30
  as
• 21:30
  a
• 21:30
  clinician.
• 21:31
  It
• 21:31
  is
• 21:31
  something
• 21:31
  I
• 21:32
  always
• 21:32
  go
• 21:32
  back
• 21:32
  to.
• 21:32
  And
• 21:33
  again,
• 21:33
  I
• 21:33
  can't
• 21:33
  imagine
• 21:34
  where
• 21:34
  I
• 21:34
  would
• 21:34
  be
• 21:35
  today
• 21:35
  as
• 21:35
  a
• 21:35
  clinician.
• 21:35
  I
• 21:36
  would
• 21:36
  feel
• 21:36
  so
• 21:36
  lost
• 21:37
  and
• 21:37
  so
• 21:37
  disconnected.
• 21:38
  It
• 21:38
  is
• 21:39
  so
• 21:39
  empowering.
• 21:39
  It
• 21:39
  will
• 21:40
  transform
• 21:40
  the
• 21:40
  way
• 21:40
  you
• 21:41
  practice.
• 21:41
  You.
• 21:41
  You
• 21:42
  really
• 21:42
  get
• 21:42
  the
• 21:42
  high
• 21:43
  yield
• 21:43
  pearls
• 21:43
  to
• 21:43
  make
• 21:44
  your
• 21:44
  job
• 21:44
  smoother,
• 21:44
  to
• 21:45
  make
• 21:45
  your
• 21:45
  outcomes
• 21:45
  better.
• 21:46
  So
• 21:46
  if
• 21:46
  there's
• 21:46
  one
• 21:46
  thing
• 21:47
  you
• 21:47
  don't
• 21:47
  forget
• 21:47
  by
• 21:47
  the
• 21:48
  end
• 21:48
  of
• 21:48
  the
• 21:48
  night,
• 21:48
  go
• 21:48
  to
• 21:48
  the
• 21:48
  show
• 21:49
  notes,
• 21:49
  become
• 21:49
  a
• 21:49
  Patreon
• 21:50
  member,
• 21:50
  join
• 21:51
  our
• 21:51
  nice
• 21:51
  community.
• 21:52
  We'd
• 21:52
  love
• 21:52
  to
• 21:52
  have
• 21:52
  you.
• 21:53
  And
• 21:53
  with
• 21:53
  that,
• 21:53
  my
• 21:54
  friends,
• 21:54
  I
• 21:54
  hope
• 21:55
  you
• 21:55
  guys
• 21:55
  have
• 21:55
  a
• 21:56
  wonderful
• 21:56
  rest
• 21:56
  of
• 21:56
  your
• 21:57
  week.
• 21:57
  Bye.
• 21:57
  Bye.