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Ninjas at Costco: OCD, PTSD, GAD, or Emerging Psychosis? · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:06
  back,
• 0:06
  my
• 0:06
  friends,
• 0:06
  to
• 0:07
  another
• 0:07
  episode
• 0:07
  of
• 0:07
  Pearls
• 0:08
  and
• 0:08
  Prep.
• 0:08
  Npz.
• 0:09
  Here,
• 0:10
  your
• 0:10
  preceptor
• 0:10
  in
• 0:11
  your
• 0:11
  pocket,
• 0:11
  your
• 0:11
  go
• 0:12
  to
• 0:12
  place
• 0:12
  for
• 0:12
  pearls
• 0:13
  that
• 0:13
  prep
• 0:13
  you
• 0:13
  to
• 0:14
  practice
• 0:14
  well.
• 0:15
  Knock
• 0:15
  knock,
• 0:15
  knock,
• 0:16
  knock.
• 0:17
  At
• 0:17
  your
• 0:17
  door
• 0:18
  in
• 0:18
  the
• 0:18
  outpatient
• 0:19
  Clinic
• 0:19
  is
• 0:19
  a
• 0:19
  34
• 0:20
  year
• 0:20
  old
• 0:20
  man.
• 0:21
  We're
• 0:21
  going
• 0:21
  to
• 0:21
  call
• 0:21
  him
• 0:22
  Dustin.
• 0:23
  This
• 0:23
  is
• 0:23
  a
• 0:23
  mock
• 0:24
  case
• 0:24
  study,
• 0:25
  but
• 0:25
  a
• 0:25
  very
• 0:25
  real
• 0:26
  world
• 0:26
  type
• 0:26
  of
• 0:27
  ambiguous
• 0:27
  case
• 0:28
  that
• 0:28
  is
• 0:29
  full
• 0:29
  of
• 0:30
  juicy
• 0:30
  pearls
• 0:31
  and
• 0:32
  interesting
• 0:32
  takes.
• 0:33
  So
• 0:34
  Dustin's
• 0:34
  at
• 0:34
  your
• 0:35
  door.
• 0:35
  He's
• 0:35
  an
• 0:35
  IT
• 0:36
  technician.
• 0:37
  He's
• 0:38
  telling
• 0:38
  you
• 0:38
  that
• 0:38
  he's
• 0:39
  not
• 0:39
  really
• 0:39
  able
• 0:39
  to
• 0:39
  leave
• 0:40
  his
• 0:40
  house
• 0:40
  anymore.
• 0:41
  And
• 0:41
  his
• 0:41
  exact
• 0:42
  quote
• 0:42
  in
• 0:43
  his
• 0:43
  chief
• 0:43
  complaint
• 0:43
  that
• 0:44
  you
• 0:44
  later
• 0:44
  record
• 0:44
  is,
• 0:45
  I
• 0:45
  can't
• 0:46
  go
• 0:46
  to
• 0:46
  the
• 0:46
  store,
• 0:46
  I'll
• 0:47
  be
• 0:47
  attacked,
• 0:48
  like
• 0:48
  by
• 0:48
  ninjas
• 0:49
  or
• 0:49
  something.
• 0:50
  Okay,
• 0:51
  we're
• 0:51
  going
• 0:51
  to
• 0:51
  get
• 0:51
  into
• 0:51
  that
• 0:52
  in
• 0:52
  a
• 0:52
  moment.
• 0:52
  That's
• 0:52
  if
• 0:53
  that
• 0:53
  sounds
• 0:53
  a
• 0:53
  little
• 0:53
  weird.
• 0:55
  It
• 0:55
  should
• 0:55
  be.
• 0:56
  But
• 0:56
  here's
• 0:56
  a
• 0:56
  little
• 0:56
  context
• 0:57
  for
• 0:58
  why
• 0:58
  he
• 0:58
  might
• 0:58
  think
• 0:59
  that.
• 0:59
  And
• 0:59
  then
• 1:00
  we're
• 1:00
  going
• 1:00
  to
• 1:00
  get
• 1:00
  into
• 1:00
  the
• 1:00
  diagnostic
• 1:01
  speculation
• 1:02
  and
• 1:02
  key
• 1:03
  questions.
• 1:03
  We
• 1:04
  might
• 1:04
  want
• 1:04
  to
• 1:04
  ask
• 1:04
  Dustin
• 1:05
  to
• 1:07
  start
• 1:07
  to
• 1:07
  gain
• 1:08
  a
• 1:08
  command
• 1:09
  on
• 1:09
  these
• 1:09
  diagnoses
• 1:11
  when
• 1:11
  they
• 1:12
  are
• 1:12
  sitting
• 1:12
  in
• 1:12
  front
• 1:12
  of
• 1:13
  us.
• 1:13
  Right.
• 1:13
  When
• 1:13
  we
• 1:13
  have
• 1:14
  this
• 1:14
  ambiguity
• 1:14
  sitting
• 1:15
  in
• 1:15
  front
• 1:15
  of
• 1:15
  us
• 1:15
  in
• 1:16
  a
• 1:16
  clinic,
• 1:16
  it's
• 1:17
  really
• 1:17
  important
• 1:17
  that
• 1:17
  we're
• 1:18
  prepared
• 1:18
  and
• 1:18
  we're
• 1:19
  ready
• 1:19
  to
• 1:20
  tackle
• 1:20
  the
• 1:20
  ambiguity
• 1:21
  and
• 1:21
  ask
• 1:21
  the
• 1:21
  right
• 1:22
  question.
• 1:22
  So
• 1:22
  here's
• 1:22
  a
• 1:23
  little
• 1:23
  background
• 1:23
  on
• 1:23
  Dustin.
• 1:24
  Okay.
• 1:24
  Six
• 1:24
  months
• 1:25
  ago,
• 1:25
  Dustin
• 1:25
  was
• 1:26
  mugged
• 1:26
  at
• 1:26
  knifepoint
• 1:27
  outside
• 1:27
  of
• 1:28
  a
• 1:28
  7
• 1:28
  11.
• 1:29
  Okay.
• 1:29
  It's
• 1:29
  kind
• 1:30
  of
• 1:30
  important
• 1:30
  to
• 1:30
  know,
• 1:30
  right?
• 1:31
  Since
• 1:31
  then,
• 1:32
  he's
• 1:32
  avoided
• 1:32
  sores
• 1:33
  and
• 1:33
  public
• 1:33
  places
• 1:34
  more
• 1:34
  broadly,
• 1:35
  he
• 1:35
  has
• 1:36
  a
• 1:36
  persistent
• 1:36
  belief
• 1:37
  when
• 1:37
  you
• 1:37
  interview
• 1:37
  him
• 1:38
  that
• 1:38
  trained
• 1:38
  attackers
• 1:39
  are
• 1:39
  waiting
• 1:39
  for
• 1:39
  him
• 1:40
  in
• 1:40
  parking
• 1:41
  lots.
• 1:42
  Sometimes
• 1:42
  he'll
• 1:43
  say
• 1:43
  ninjas,
• 1:44
  but
• 1:44
  he
• 1:45
  clarifies
• 1:45
  really
• 1:46
  that
• 1:46
  these
• 1:47
  are
• 1:47
  people
• 1:47
  who
• 1:47
  are
• 1:47
  skilled
• 1:48
  at
• 1:48
  hurting
• 1:48
  others
• 1:50
  very
• 1:50
  effectively.
• 1:51
  Okay.
• 1:52
  He
• 1:52
  does
• 1:53
  check
• 1:53
  locks
• 1:53
  on
• 1:53
  his
• 1:54
  car
• 1:54
  about
• 1:54
  five
• 1:55
  times
• 1:55
  before
• 1:55
  he
• 1:55
  drives,
• 1:56
  counts
• 1:57
  to
• 1:57
  seven
• 1:57
  silently
• 1:58
  before
• 1:58
  he
• 1:58
  enters
• 1:59
  any
• 1:59
  building
• 1:59
  because
• 2:00
  he
• 2:00
  thinks
• 2:00
  if
• 2:00
  he
• 2:00
  doesn't,
• 2:01
  something,
• 2:01
  quote,
• 2:02
  very
• 2:02
  bad
• 2:02
  might
• 2:03
  happen.
• 2:03
  Okay.
• 2:04
  He
• 2:04
  also
• 2:05
  is
• 2:05
  a
• 2:05
  bit
• 2:05
  of
• 2:05
  a
• 2:05
  worrier
• 2:06
  when
• 2:06
  you
• 2:06
  ask
• 2:07
  him.
• 2:07
  Throughout
• 2:07
  his
• 2:07
  life,
• 2:08
  he
• 2:08
  worries
• 2:08
  about
• 2:08
  getting
• 2:09
  fired
• 2:09
  or
• 2:09
  written
• 2:10
  up
• 2:10
  or
• 2:10
  the
• 2:10
  health
• 2:11
  of
• 2:11
  his
• 2:11
  mother,
• 2:12
  that
• 2:12
  his
• 2:12
  car
• 2:12
  may
• 2:12
  break
• 2:13
  down
• 2:13
  randomly
• 2:13
  at
• 2:14
  inconvenient
• 2:14
  times
• 2:15
  in
• 2:15
  inconvenient
• 2:16
  places.
• 2:17
  He's
• 2:18
  a
• 2:18
  bit
• 2:18
  of
• 2:18
  a
• 2:18
  worrier.
• 2:19
  He
• 2:19
  has
• 2:19
  two
• 2:19
  to
• 2:19
  three
• 2:19
  nightmares
• 2:20
  a
• 2:20
  week
• 2:21
  of
• 2:21
  being
• 2:21
  grabbed
• 2:22
  from
• 2:22
  behind.
• 2:22
  He
• 2:23
  kind
• 2:23
  of
• 2:23
  wakes
• 2:23
  up
• 2:23
  in
• 2:23
  a
• 2:23
  sweat,
• 2:24
  he's
• 2:24
  startled
• 2:25
  very
• 2:25
  easily
• 2:27
  and
• 2:29
  so
• 2:29
  no,
• 2:30
  no
• 2:30
  hallucinations.
• 2:31
  He,
• 2:32
  you
• 2:32
  know,
• 2:32
  he's
• 2:32
  pretty
• 2:33
  organized
• 2:33
  in
• 2:33
  his
• 2:33
  speech
• 2:34
  and
• 2:34
  his
• 2:34
  functioning.
• 2:35
  His
• 2:35
  functioning
• 2:35
  is
• 2:36
  otherwise
• 2:36
  pretty
• 2:37
  solid
• 2:37
  right
• 2:38
  now.
• 2:38
  So
• 2:38
  based
• 2:38
  on
• 2:39
  what
• 2:39
  we
• 2:39
  know
• 2:40
  about
• 2:40
  Dustin.
• 2:41
  What
• 2:41
  are
• 2:41
  your
• 2:42
  thoughts,
• 2:42
  my
• 2:42
  friends?
• 2:43
  Feel
• 2:43
  free
• 2:43
  to
• 2:43
  pause
• 2:44
  this.
• 2:45
  Discuss
• 2:45
  it
• 2:45
  with
• 2:45
  your
• 2:46
  peers.
• 2:46
  Get
• 2:46
  out,
• 2:46
  get
• 2:47
  out
• 2:47
  into
• 2:47
  zoom
• 2:48
  sessions
• 2:49
  if
• 2:49
  you
• 2:49
  need
• 2:49
  to,
• 2:49
  the
• 2:50
  breakout
• 2:50
  sessions.
• 2:51
  But
• 2:52
  this
• 2:52
  is
• 2:52
  a
• 2:52
  very
• 2:52
  interesting
• 2:53
  case
• 2:53
  because
• 2:54
  I
• 2:54
  think
• 2:54
  it
• 2:54
  speaks
• 2:55
  to
• 2:56
  situations
• 2:56
  you're
• 2:57
  going
• 2:57
  to
• 2:57
  see
• 2:57
  all
• 2:57
  of
• 2:57
  the
• 2:57
  time
• 2:58
  in
• 2:58
  practice
• 2:59
  where
• 2:59
  there's
• 3:00
  little
• 3:01
  trickles
• 3:02
  of
• 3:02
  many
• 3:02
  different
• 3:03
  DSM
• 3:03
  diagnoses
• 3:04
  at
• 3:04
  once.
• 3:04
  And
• 3:05
  of
• 3:05
  course,
• 3:06
  it
• 3:06
  is
• 3:07
  more
• 3:07
  than
• 3:07
  possible
• 3:08
  that
• 3:08
  several
• 3:08
  of
• 3:08
  these
• 3:09
  diagnoses
• 3:10
  are
• 3:10
  co
• 3:10
  occurring.
• 3:12
  But
• 3:12
  it's
• 3:12
  really
• 3:12
  important
• 3:13
  to
• 3:13
  get
• 3:13
  to
• 3:13
  the
• 3:14
  root
• 3:14
  of
• 3:15
  the
• 3:16
  diagnosis
• 3:17
  as
• 3:17
  well.
• 3:17
  Okay,
• 3:18
  like
• 3:18
  what
• 3:18
  is
• 3:18
  the
• 3:19
  root
• 3:19
  problem
• 3:19
  here?
• 3:20
  And
• 3:20
  we
• 3:20
  can
• 3:21
  tell
• 3:21
  right
• 3:21
  away
• 3:21
  the
• 3:21
  root
• 3:22
  problem
• 3:22
  is
• 3:22
  that
• 3:22
  he
• 3:22
  is
• 3:23
  avoidant.
• 3:23
  He's
• 3:23
  not
• 3:24
  going
• 3:24
  to
• 3:24
  stores,
• 3:25
  he
• 3:25
  can't,
• 3:25
  you
• 3:26
  know,
• 3:26
  so
• 3:26
  this
• 3:26
  is
• 3:26
  certainly
• 3:26
  disrupting
• 3:27
  his
• 3:27
  ability
• 3:28
  to
• 3:28
  function.
• 3:29
  But
• 3:29
  his
• 3:29
  use
• 3:30
  of
• 3:30
  the
• 3:30
  term
• 3:30
  ninja
• 3:31
  can
• 3:31
  really
• 3:32
  throw
• 3:32
  us
• 3:32
  off.
• 3:32
  I'll
• 3:33
  be
• 3:33
  honest,
• 3:33
  when
• 3:33
  I
• 3:33
  see
• 3:34
  that
• 3:34
  or
• 3:34
  hear
• 3:35
  that,
• 3:35
  I'm
• 3:35
  thinking
• 3:36
  psychosis
• 3:36
  right
• 3:37
  away
• 3:37
  because
• 3:37
  that's
• 3:37
  very
• 3:38
  bizarre.
• 3:39
  That
• 3:39
  is
• 3:39
  not
• 3:40
  a
• 3:40
  typical
• 3:41
  way
• 3:41
  to
• 3:41
  describe
• 3:42
  a
• 3:42
  fear.
• 3:43
  Okay.
• 3:43
  But
• 3:44
  it
• 3:44
  would
• 3:44
  be
• 3:44
  wrong
• 3:44
  of
• 3:45
  me
• 3:45
  to
• 3:46
  assume
• 3:46
  that
• 3:47
  so
• 3:47
  literally
• 3:48
  right
• 3:48
  away
• 3:48
  because
• 3:49
  maybe
• 3:49
  that
• 3:49
  is
• 3:50
  just
• 3:50
  a
• 3:50
  semantic
• 3:51
  distinction
• 3:52
  that
• 3:52
  Dustin
• 3:52
  is
• 3:53
  using
• 3:53
  to
• 3:53
  describe
• 3:53
  an
• 3:54
  image
• 3:54
  in
• 3:54
  his
• 3:54
  head.
• 3:55
  And
• 3:55
  if
• 3:55
  you
• 3:56
  really
• 3:57
  have
• 3:57
  elicit
• 3:57
  it
• 3:58
  out
• 3:58
  of
• 3:58
  him,
• 3:58
  you
• 3:59
  may
• 3:59
  find
• 3:59
  that
• 3:59
  he's
• 4:00
  really
• 4:00
  just
• 4:00
  thinking
• 4:01
  of
• 4:01
  masked
• 4:01
  individuals
• 4:02
  who
• 4:02
  were
• 4:02
  ready
• 4:03
  to
• 4:03
  attack
• 4:03
  him.
• 4:04
  I
• 4:04
  would
• 4:04
  really
• 4:05
  be
• 4:05
  curious
• 4:05
  when
• 4:05
  he
• 4:06
  was
• 4:06
  mugged
• 4:06
  at
• 4:06
  knifepoint,
• 4:08
  how
• 4:08
  those
• 4:09
  perpetrators
• 4:10
  were
• 4:10
  dressed,
• 4:10
  if
• 4:10
  he
• 4:10
  has
• 4:10
  any
• 4:11
  recollection
• 4:11
  of
• 4:11
  that.
• 4:11
  And
• 4:12
  of
• 4:12
  course,
• 4:12
  in
• 4:13
  practice
• 4:13
  you
• 4:13
  have
• 4:13
  to
• 4:13
  do
• 4:14
  that
• 4:14
  very
• 4:14
  gingerly
• 4:15
  because
• 4:15
  he
• 4:15
  may
• 4:16
  not
• 4:16
  be
• 4:16
  ready
• 4:16
  to
• 4:17
  relive
• 4:17
  that
• 4:17
  so
• 4:18
  easily
• 4:19
  when
• 4:19
  you
• 4:19
  ask
• 4:19
  him
• 4:19
  for
• 4:19
  specific
• 4:20
  details.
• 4:21
  As
• 4:21
  we
• 4:21
  know,
• 4:22
  trauma
• 4:23
  can
• 4:23
  be
• 4:23
  very
• 4:23
  fragmented
• 4:24
  and
• 4:25
  strange
• 4:25
  and
• 4:26
  triggering.
• 4:27
  So
• 4:27
  this
• 4:27
  is
• 4:28
  the
• 4:28
  art
• 4:28
  and
• 4:29
  science
• 4:29
  of
• 4:29
  what
• 4:29
  we
• 4:29
  do.
• 4:30
  We
• 4:30
  don't
• 4:30
  want
• 4:31
  to
• 4:31
  trigger
• 4:31
  his
• 4:31
  amygdala
• 4:32
  to
• 4:32
  the
• 4:32
  point
• 4:32
  where
• 4:32
  he
• 4:32
  shuts
• 4:33
  down
• 4:33
  in
• 4:33
  front
• 4:33
  of
• 4:33
  us
• 4:34
  and.
• 4:34
  But
• 4:34
  just
• 4:35
  enough
• 4:35
  to
• 4:35
  where
• 4:36
  he
• 4:36
  can
• 4:36
  safely
• 4:38
  reprocess
• 4:38
  that
• 4:39
  detail.
• 4:39
  Maybe
• 4:39
  just
• 4:40
  to
• 4:40
  give
• 4:40
  us
• 4:40
  some
• 4:40
  diagnostic
• 4:41
  clarity.
• 4:42
  But
• 4:42
  I
• 4:42
  would
• 4:42
  certainly
• 4:43
  be
• 4:43
  curious
• 4:43
  to
• 4:44
  understand
• 4:45
  if
• 4:46
  the
• 4:46
  people
• 4:47
  who
• 4:47
  mugged
• 4:47
  him
• 4:47
  at
• 4:48
  knife
• 4:48
  point
• 4:49
  were
• 4:49
  dressed
• 4:50
  in
• 4:51
  a
• 4:51
  garb
• 4:51
  similar
• 4:52
  to
• 4:52
  a
• 4:52
  ninja.
• 4:53
  Okay,
• 4:54
  do
• 4:54
  they
• 4:54
  have
• 4:54
  like
• 4:54
  that
• 4:55
  ski
• 4:55
  mask
• 4:56
  with
• 4:56
  just
• 4:56
  the
• 4:56
  eye
• 4:57
  slits
• 4:57
  showing?
• 4:58
  Are
• 4:59
  they
• 4:59
  kind
• 4:59
  of
• 4:59
  lean,
• 4:59
  dressed
• 5:00
  in
• 5:00
  black?
• 5:01
  Are
• 5:02
  they
• 5:02
  acrobatic?
• 5:03
  Are
• 5:03
  they
• 5:03
  agile?
• 5:04
  You
• 5:04
  know,
• 5:04
  I
• 5:04
  think
• 5:05
  of
• 5:05
  ninjas
• 5:05
  like
• 5:05
  in
• 5:05
  Hollywood
• 5:06
  movies,
• 5:07
  but
• 5:07
  get
• 5:07
  the.
• 5:08
  I
• 5:08
  get
• 5:08
  an
• 5:08
  idea.
• 5:08
  If
• 5:09
  this
• 5:09
  is
• 5:09
  just
• 5:09
  his
• 5:10
  nomenclature,
• 5:11
  his
• 5:11
  way
• 5:11
  he's
• 5:12
  the
• 5:12
  way,
• 5:12
  he's
• 5:13
  the
• 5:13
  shorthand
• 5:13
  he's
• 5:13
  using
• 5:14
  to
• 5:14
  describe
• 5:14
  something.
• 5:15
  Or
• 5:15
  are
• 5:15
  these
• 5:15
  actual
• 5:16
  ninjas
• 5:16
  which
• 5:16
  have
• 5:16
  A
• 5:17
  more
• 5:17
  bizarre
• 5:17
  and
• 5:18
  fictitious
• 5:18
  connotation,
• 5:19
  which
• 5:20
  would
• 5:20
  be
• 5:20
  much
• 5:20
  more
• 5:21
  consistent
• 5:21
  with,
• 5:21
  like,
• 5:21
  a
• 5:22
  delusional
• 5:22
  disorder
• 5:23
  or
• 5:23
  psychotic
• 5:23
  disorder.
• 5:24
  Right.
• 5:24
  We
• 5:24
  already
• 5:24
  established
• 5:25
  the
• 5:25
  fact
• 5:25
  that
• 5:25
  he
• 5:26
  has
• 5:27
  organized
• 5:27
  speech.
• 5:28
  He's
• 5:29
  clear,
• 5:29
  linear,
• 5:30
  logical.
• 5:31
  He's
• 5:31
  not
• 5:31
  disheveled.
• 5:32
  He's
• 5:33
  able
• 5:33
  to
• 5:33
  speak
• 5:34
  and
• 5:34
  talk.
• 5:34
  You
• 5:34
  know,
• 5:35
  we
• 5:35
  don't
• 5:35
  see
• 5:35
  a
• 5:35
  lot
• 5:35
  of
• 5:35
  negative
• 5:35
  symptoms.
• 5:36
  He's
• 5:36
  denying
• 5:36
  auditory
• 5:37
  hallucinations.
• 5:38
  So
• 5:38
  we're
• 5:38
  not
• 5:38
  worried
• 5:38
  about
• 5:38
  schizophrenia
• 5:39
  per
• 5:40
  se.
• 5:40
  But
• 5:40
  could
• 5:40
  this
• 5:41
  be
• 5:41
  a
• 5:41
  delusional
• 5:41
  disorder?
• 5:42
  Does
• 5:42
  he
• 5:43
  feel
• 5:43
  like
• 5:44
  ninjas
• 5:44
  are
• 5:44
  out
• 5:45
  to
• 5:45
  get
• 5:45
  him?
• 5:45
  And
• 5:45
  I
• 5:46
  will
• 5:46
  tell
• 5:46
  you,
• 5:46
  if
• 5:46
  it
• 5:46
  is
• 5:46
  a
• 5:47
  delusional
• 5:47
  disorder,
• 5:48
  what
• 5:48
  you
• 5:48
  can
• 5:48
  expect
• 5:49
  is
• 5:49
  a
• 5:50
  fixed,
• 5:51
  unshakable
• 5:51
  conviction.
• 5:52
  Okay?
• 5:53
  You
• 5:53
  would
• 5:53
  expect
• 5:54
  a
• 5:54
  patient
• 5:54
  who
• 5:54
  genuinely
• 5:55
  believes
• 5:55
  and
• 5:55
  then
• 5:56
  just
• 5:56
  will
• 5:56
  attack,
• 5:56
  and
• 5:57
  they
• 5:57
  cannot
• 5:58
  entertain
• 5:58
  the
• 5:58
  possibility
• 5:59
  that
• 5:59
  this
• 5:59
  is
• 5:59
  irrational.
• 6:00
  Okay.
• 6:00
  In
• 6:01
  other
• 6:01
  words,
• 6:01
  it's
• 6:01
  not
• 6:01
  ego
• 6:02
  dystonic.
• 6:02
  Okay.
• 6:03
  It's
• 6:03
  not
• 6:03
  something
• 6:03
  that
• 6:04
  bothers
• 6:04
  him
• 6:04
  in
• 6:05
  ptsd.
• 6:05
  It's
• 6:05
  very
• 6:05
  ego
• 6:06
  dystonic.
• 6:06
  Right.
• 6:08
  Patients
• 6:08
  don't
• 6:08
  really
• 6:09
  want
• 6:09
  to
• 6:09
  have
• 6:09
  these.
• 6:10
  These.
• 6:12
  These
• 6:12
  worries
• 6:12
  or
• 6:13
  concerns
• 6:13
  about
• 6:13
  what
• 6:14
  might
• 6:14
  happen
• 6:14
  if
• 6:14
  they
• 6:14
  go
• 6:14
  to
• 6:15
  the
• 6:15
  store.
• 6:16
  In
• 6:17
  ocd,
• 6:17
  they're
• 6:17
  also
• 6:18
  usually
• 6:18
  ego
• 6:19
  dystonic,
• 6:19
  where
• 6:20
  they're
• 6:20
  bizarre
• 6:21
  thoughts,
• 6:21
  but
• 6:21
  they're
• 6:22
  unwanted.
• 6:22
  They
• 6:22
  don't
• 6:23
  want
• 6:23
  to
• 6:23
  think
• 6:23
  about
• 6:24
  this
• 6:24
  stuff.
• 6:24
  They're
• 6:24
  intruding
• 6:25
  in
• 6:25
  their
• 6:25
  mind,
• 6:26
  and
• 6:26
  they
• 6:26
  realize
• 6:26
  it's
• 6:27
  bizarre
• 6:27
  and
• 6:27
  uncomfortable
• 6:28
  and
• 6:28
  there's
• 6:28
  a
• 6:28
  stigma
• 6:29
  to
• 6:29
  even
• 6:29
  share
• 6:29
  them,
• 6:30
  but
• 6:30
  they
• 6:31
  nonetheless
• 6:31
  feel
• 6:32
  very
• 6:32
  distressed
• 6:32
  by
• 6:32
  it.
• 6:33
  But
• 6:33
  in
• 6:33
  delusional
• 6:34
  disorder,
• 6:34
  you
• 6:35
  believe
• 6:35
  that
• 6:35
  ninjas
• 6:36
  are
• 6:37
  going
• 6:37
  to
• 6:37
  attack
• 6:38
  you,
• 6:38
  and
• 6:38
  it's
• 6:38
  usually
• 6:39
  fixed.
• 6:39
  Again,
• 6:39
  it's
• 6:40
  unshakable,
• 6:40
  and
• 6:41
  it
• 6:41
  usually
• 6:42
  is
• 6:43
  beyond
• 6:43
  an
• 6:44
  isolated
• 6:44
  event.
• 6:45
  In
• 6:45
  other
• 6:45
  words,
• 6:46
  in
• 6:46
  my
• 6:46
  experience,
• 6:47
  and
• 6:47
  I
• 6:47
  think
• 6:47
  the
• 6:48
  evidence
• 6:48
  would
• 6:48
  confirm
• 6:49
  this,
• 6:50
  delusional
• 6:51
  thought
• 6:52
  processes
• 6:53
  are
• 6:54
  more
• 6:55
  broad.
• 6:56
  They're
• 6:56
  fixed,
• 6:57
  but
• 6:57
  they're
• 6:57
  more
• 6:57
  broad.
• 6:58
  Right.
• 6:58
  And
• 6:59
  the
• 6:59
  patient
• 6:59
  will
• 6:59
  usually
• 6:59
  have
• 7:00
  more
• 7:00
  of
• 7:00
  a
• 7:00
  story
• 7:00
  beyond,
• 7:01
  oh,
• 7:01
  ninjas
• 7:01
  are
• 7:02
  going
• 7:02
  to
• 7:02
  attack
• 7:02
  me
• 7:02
  at
• 7:02
  the
• 7:02
  store.
• 7:03
  It's
• 7:03
  part
• 7:03
  of
• 7:03
  a
• 7:04
  narrative
• 7:04
  or
• 7:05
  an
• 7:05
  arc,
• 7:05
  a
• 7:05
  story
• 7:05
  arc
• 7:06
  that
• 7:07
  involves
• 7:07
  ninjas
• 7:08
  thwarting
• 7:08
  that
• 7:09
  person
• 7:09
  more
• 7:09
  broadly
• 7:10
  throughout
• 7:10
  their
• 7:10
  lives,
• 7:11
  maybe
• 7:12
  hijacking
• 7:12
  parts
• 7:12
  of
• 7:12
  their
• 7:13
  brain.
• 7:13
  Now,
• 7:13
  it's
• 7:14
  not
• 7:14
  to
• 7:14
  the
• 7:14
  point
• 7:14
  where
• 7:15
  they
• 7:15
  can't
• 7:15
  function.
• 7:16
  These
• 7:16
  people
• 7:16
  are
• 7:16
  usually.
• 7:18
  Their
• 7:18
  functioning
• 7:18
  is
• 7:18
  otherwise
• 7:19
  preserved,
• 7:21
  and
• 7:21
  the
• 7:21
  delusion
• 7:22
  is
• 7:22
  circumscribed,
• 7:23
  but
• 7:24
  it
• 7:24
  is
• 7:24
  often
• 7:25
  very
• 7:25
  bizarre.
• 7:26
  It's
• 7:26
  very
• 7:27
  fixed,
• 7:27
  it's
• 7:27
  very
• 7:27
  stubborn.
• 7:28
  And
• 7:28
  the
• 7:29
  patient
• 7:29
  doesn't
• 7:29
  feel
• 7:30
  this
• 7:31
  sense
• 7:31
  of
• 7:31
  distress
• 7:32
  or
• 7:32
  recoil
• 7:33
  at
• 7:33
  the
• 7:33
  delusion
• 7:33
  necessarily.
• 7:34
  It's
• 7:35
  sort
• 7:35
  of
• 7:35
  stated
• 7:36
  as
• 7:36
  a
• 7:36
  matter
• 7:36
  of
• 7:36
  fact,
• 7:37
  as
• 7:37
  a
• 7:37
  way
• 7:37
  of
• 7:37
  being.
• 7:38
  It's
• 7:38
  kind
• 7:38
  of
• 7:38
  integrated
• 7:39
  in
• 7:39
  their
• 7:39
  lives
• 7:39
  in
• 7:40
  this
• 7:40
  fixed,
• 7:40
  hard
• 7:41
  way,
• 7:41
  as
• 7:42
  opposed
• 7:42
  to
• 7:42
  the
• 7:42
  resistance
• 7:43
  that
• 7:43
  you
• 7:43
  naturally
• 7:44
  see
• 7:44
  and
• 7:44
  feel
• 7:44
  with
• 7:45
  people
• 7:45
  who
• 7:45
  come
• 7:45
  to
• 7:46
  you
• 7:46
  with
• 7:46
  ocd.
• 7:46
  Right?
• 7:47
  These
• 7:47
  are
• 7:47
  really
• 7:47
  intrusive,
• 7:48
  unwanted,
• 7:48
  ego
• 7:49
  dystonic
• 7:49
  thoughts
• 7:50
  that
• 7:50
  the
• 7:50
  patients
• 7:51
  recognize
• 7:51
  for
• 7:51
  the
• 7:52
  most
• 7:52
  part
• 7:52
  in
• 7:52
  OCD
• 7:53
  are
• 7:53
  irrational,
• 7:53
  at
• 7:54
  least
• 7:54
  partially,
• 7:54
  but
• 7:55
  they
• 7:55
  can't
• 7:55
  seem
• 7:55
  to
• 7:56
  stop
• 7:56
  it,
• 7:56
  and
• 7:56
  they
• 7:57
  feel
• 7:57
  the
• 7:58
  need
• 7:58
  to.
• 8:00
  To.
• 8:00
  To
• 8:01
  neutralize
• 8:01
  it
• 8:02
  in
• 8:02
  the.
• 8:02
  In
• 8:02
  the
• 8:03
  form
• 8:03
  of
• 8:03
  a
• 8:03
  compulsion.
• 8:04
  Okay.
• 8:05
  And
• 8:05
  that
• 8:06
  would
• 8:06
  be
• 8:06
  more
• 8:06
  consistent
• 8:06
  with
• 8:07
  ocd,
• 8:08
  Right?
• 8:08
  And
• 8:09
  sure
• 8:09
  enough,
• 8:09
  Dustin
• 8:10
  is
• 8:11
  counting
• 8:11
  to
• 8:11
  seven
• 8:12
  before
• 8:12
  he
• 8:12
  enters
• 8:12
  a
• 8:12
  building.
• 8:13
  So
• 8:13
  that
• 8:13
  is
• 8:13
  a
• 8:14
  compulsion.
• 8:14
  I
• 8:14
  am
• 8:14
  very
• 8:15
  suspicious
• 8:15
  now
• 8:16
  of
• 8:16
  ocd,
• 8:17
  and
• 8:17
  I'm
• 8:17
  going
• 8:17
  to
• 8:17
  go
• 8:17
  down
• 8:17
  that
• 8:18
  rabbit
• 8:18
  hole
• 8:18
  with
• 8:18
  him
• 8:18
  now
• 8:19
  because
• 8:19
  he
• 8:19
  endorsed
• 8:20
  a
• 8:20
  clear
• 8:20
  compulsion.
• 8:21
  That
• 8:21
  compulsion,
• 8:22
  counting
• 8:22
  to
• 8:22
  seven
• 8:23
  before
• 8:23
  he
• 8:23
  enters
• 8:23
  a
• 8:23
  building,
• 8:24
  is
• 8:24
  clearly
• 8:25
  associated
• 8:25
  with
• 8:26
  trying
• 8:26
  to
• 8:26
  neutralize
• 8:27
  an
• 8:27
  obsessional
• 8:28
  thought
• 8:28
  process.
• 8:29
  And
• 8:29
  lo
• 8:30
  and
• 8:30
  behold,
• 8:30
  you
• 8:30
  have
• 8:31
  a
• 8:31
  pretty
• 8:31
  concrete
• 8:32
  OCD
• 8:32
  symptom.
• 8:33
  And
• 8:33
  that
• 8:33
  sounds
• 8:34
  very
• 8:34
  functionally
• 8:35
  impairing
• 8:35
  because
• 8:35
  he's
• 8:36
  unable
• 8:36
  to
• 8:36
  really
• 8:37
  go
• 8:37
  places
• 8:38
  because
• 8:38
  of
• 8:38
  this
• 8:39
  thought
• 8:39
  process.
• 8:40
  But
• 8:40
  your
• 8:40
  job
• 8:41
  is
• 8:41
  really
• 8:42
  to
• 8:42
  figure
• 8:42
  out,
• 8:43
  is
• 8:43
  he
• 8:44
  having
• 8:44
  a
• 8:44
  disturbing
• 8:45
  thought
• 8:45
  of
• 8:45
  a
• 8:46
  ninja
• 8:46
  that
• 8:46
  he
• 8:46
  recognizes
• 8:47
  is
• 8:47
  irrational.
• 8:48
  Like,
• 8:48
  does
• 8:49
  he
• 8:49
  actually
• 8:49
  believe
• 8:49
  in
• 8:50
  ninjas?
• 8:50
  And
• 8:50
  if
• 8:50
  he
• 8:51
  tells
• 8:51
  you,
• 8:51
  oh,
• 8:51
  no,
• 8:51
  absolutely
• 8:52
  not.
• 8:52
  I
• 8:52
  know
• 8:53
  this
• 8:53
  is
• 8:53
  absurd.
• 8:54
  This
• 8:54
  is
• 8:54
  crazy,
• 8:55
  right?
• 8:55
  I
• 8:56
  know
• 8:56
  ninjas
• 8:56
  don't
• 8:56
  exist,
• 8:57
  but
• 8:57
  I
• 8:57
  just
• 8:58
  have
• 8:58
  this
• 8:58
  image
• 8:58
  of
• 8:58
  a
• 8:59
  ninja
• 8:59
  I
• 8:59
  can't
• 8:59
  get
• 8:59
  out
• 8:59
  of
• 9:00
  my
• 9:00
  mind
• 9:00
  and
• 9:00
  I
• 9:00
  have
• 9:00
  to
• 9:01
  count
• 9:01
  to
• 9:01
  seven
• 9:02
  before
• 9:02
  I
• 9:02
  go
• 9:03
  into
• 9:03
  any
• 9:03
  store,
• 9:04
  because
• 9:05
  this
• 9:05
  thought
• 9:06
  pro.
• 9:06
  This
• 9:06
  thought
• 9:06
  or
• 9:07
  image
• 9:07
  of
• 9:07
  a
• 9:07
  ninja
• 9:08
  just
• 9:08
  drives
• 9:08
  me
• 9:08
  nuts.
• 9:09
  And
• 9:09
  it's
• 9:09
  the
• 9:09
  only
• 9:10
  way
• 9:10
  I
• 9:10
  feel
• 9:10
  like
• 9:10
  I
• 9:11
  can
• 9:11
  guarantee
• 9:11
  my
• 9:11
  safety,
• 9:12
  even
• 9:12
  though
• 9:12
  I
• 9:12
  know
• 9:13
  I'll
• 9:13
  probably
• 9:13
  be
• 9:14
  safe.
• 9:14
  But
• 9:14
  just
• 9:15
  in
• 9:15
  case,
• 9:16
  I'm
• 9:16
  going
• 9:16
  to
• 9:16
  have
• 9:16
  to
• 9:16
  do
• 9:17
  this
• 9:17
  anyway
• 9:17
  to
• 9:17
  neutralize
• 9:18
  any
• 9:18
  residual
• 9:19
  anxiety.
• 9:20
  Bam.
• 9:20
  That
• 9:20
  is
• 9:21
  definitely
• 9:21
  more.
• 9:24
  That
• 9:24
  is.
• 9:24
  That
• 9:24
  is
• 9:25
  more
• 9:25
  akin
• 9:25
  to
• 9:25
  ocd
• 9:26
  right
• 9:26
  there,
• 9:27
  as
• 9:27
  opposed
• 9:27
  to
• 9:28
  delusional
• 9:28
  disorder,
• 9:29
  where,
• 9:29
  again,
• 9:30
  um,
• 9:30
  the.
• 9:30
  The
• 9:31
  idea
• 9:31
  is
• 9:32
  very
• 9:32
  fixed.
• 9:32
  And
• 9:33
  you're
• 9:33
  stating,
• 9:33
  matter
• 9:34
  of
• 9:34
  fact,
• 9:34
  that
• 9:34
  you
• 9:34
  believe,
• 9:35
  you
• 9:35
  know,
• 9:35
  maybe
• 9:35
  the
• 9:36
  government
• 9:36
  hires
• 9:36
  ninjas
• 9:37
  to
• 9:37
  spy
• 9:37
  on
• 9:37
  you
• 9:38
  or
• 9:38
  attack
• 9:38
  you
• 9:38
  at
• 9:39
  random
• 9:39
  times
• 9:39
  or
• 9:39
  thwart
• 9:40
  you
• 9:40
  or
• 9:40
  keep
• 9:40
  you
• 9:41
  from
• 9:41
  the
• 9:41
  grocery
• 9:41
  store,
• 9:42
  because
• 9:43
  maybe
• 9:43
  those
• 9:43
  ninjas
• 9:44
  don't
• 9:44
  want
• 9:44
  you
• 9:44
  to
• 9:44
  eat
• 9:44
  healthy
• 9:45
  food
• 9:45
  and
• 9:45
  they
• 9:45
  don't
• 9:45
  want
• 9:45
  you
• 9:45
  to
• 9:46
  live
• 9:46
  to
• 9:47
  your
• 9:47
  life
• 9:47
  expectancy.
• 9:48
  And
• 9:48
  so
• 9:48
  again,
• 9:49
  it's
• 9:49
  part
• 9:49
  of
• 9:49
  this
• 9:49
  broader,
• 9:50
  bizarre
• 9:50
  arc
• 9:51
  that
• 9:51
  is
• 9:52
  otherwise
• 9:52
  not
• 9:52
  that
• 9:53
  impairing,
• 9:53
  but
• 9:54
  the
• 9:54
  patient
• 9:54
  doesn't
• 9:55
  seem
• 9:55
  to
• 9:55
  question
• 9:55
  it
• 9:56
  or
• 9:56
  be
• 9:56
  disturbed
• 9:56
  by
• 9:56
  it.
• 9:57
  Okay?
• 9:58
  And
• 9:58
  so
• 9:58
  with
• 9:59
  this
• 9:59
  patient
• 9:59
  in
• 9:59
  particular,
• 10:00
  I'm
• 10:00
  very
• 10:00
  suspicious
• 10:01
  that
• 10:02
  there's
• 10:02
  an
• 10:02
  OCD
• 10:02
  process
• 10:03
  going
• 10:03
  on.
• 10:03
  I'm
• 10:04
  very
• 10:04
  suspicious
• 10:05
  that
• 10:05
  this
• 10:05
  was
• 10:05
  trauma
• 10:06
  provoked.
• 10:07
  Right.
• 10:07
  He
• 10:07
  clearly
• 10:08
  has
• 10:08
  six
• 10:08
  months
• 10:09
  ago
• 10:10
  a
• 10:10
  very
• 10:10
  significant
• 10:11
  event
• 10:11
  where
• 10:11
  he
• 10:12
  has
• 10:12
  a
• 10:12
  perceived
• 10:12
  threat
• 10:13
  to
• 10:13
  life
• 10:13
  of
• 10:13
  being
• 10:14
  mugged
• 10:14
  at
• 10:14
  knifepoint.
• 10:15
  And
• 10:15
  his
• 10:15
  nightmares
• 10:16
  are
• 10:17
  consistent
• 10:18
  with
• 10:18
  that
• 10:18
  traumatic
• 10:19
  event.
• 10:19
  He's
• 10:20
  waking
• 10:20
  up
• 10:20
  in
• 10:20
  a
• 10:20
  sweat.
• 10:21
  He's
• 10:21
  excessively
• 10:22
  startled.
• 10:22
  He's
• 10:23
  being
• 10:23
  grabbed
• 10:23
  from
• 10:23
  behind.
• 10:24
  It
• 10:24
  would
• 10:24
  definitely
• 10:25
  be
• 10:25
  helpful
• 10:25
  to
• 10:25
  ask
• 10:26
  the
• 10:26
  patient,
• 10:26
  you
• 10:27
  know,
• 10:27
  how.
• 10:27
  How
• 10:28
  long
• 10:28
  have
• 10:28
  these
• 10:28
  nightmares
• 10:28
  been
• 10:29
  going
• 10:29
  on?
• 10:29
  So
• 10:29
  you
• 10:29
  want
• 10:29
  to
• 10:30
  really
• 10:30
  try
• 10:30
  and
• 10:31
  see
• 10:32
  if
• 10:32
  there
• 10:32
  is
• 10:32
  a
• 10:33
  concrete
• 10:33
  association
• 10:34
  between
• 10:34
  the
• 10:34
  nightmares
• 10:34
  and
• 10:35
  being
• 10:35
  mugged.
• 10:35
  I
• 10:35
  would
• 10:35
  imagine
• 10:36
  there
• 10:36
  is.
• 10:37
  And
• 10:37
  then,
• 10:37
  of
• 10:37
  course,
• 10:38
  not
• 10:38
  to
• 10:38
  state
• 10:38
  the
• 10:38
  obvious,
• 10:39
  you.
• 10:39
  But
• 10:39
  you
• 10:39
  want
• 10:40
  to
• 10:40
  make
• 10:40
  sure
• 10:40
  that
• 10:41
  these
• 10:41
  newfound.
• 10:42
  This
• 10:43
  newfound
• 10:44
  behavior
• 10:44
  of
• 10:44
  avoiding
• 10:45
  supermarkets
• 10:46
  happened
• 10:47
  exactly
• 10:47
  after
• 10:48
  this
• 10:48
  trauma,
• 10:48
  or
• 10:48
  has
• 10:48
  this
• 10:49
  been
• 10:49
  happening
• 10:49
  his
• 10:49
  whole
• 10:49
  life?
• 10:49
  Is
• 10:50
  he
• 10:50
  agoraphobic?
• 10:51
  Does
• 10:51
  he
• 10:51
  avoid
• 10:52
  large
• 10:52
  places
• 10:52
  or
• 10:53
  large
• 10:53
  crowds
• 10:53
  more
• 10:53
  broadly
• 10:54
  where
• 10:54
  he
• 10:54
  can't
• 10:54
  escape?
• 10:55
  Well,
• 10:55
  that's
• 10:55
  a
• 10:55
  whole
• 10:55
  other
• 10:56
  diagnostic
• 10:57
  rabbit
• 10:57
  hole.
• 10:57
  But
• 10:58
  usually
• 10:58
  a
• 10:58
  patient
• 10:59
  will
• 10:59
  say,
• 10:59
  no,
• 10:59
  this
• 10:59
  is
• 11:00
  kind
• 11:00
  of
• 11:00
  new.
• 11:00
  I
• 11:00
  was
• 11:00
  able
• 11:01
  to
• 11:01
  go
• 11:01
  to
• 11:01
  stores,
• 11:02
  but
• 11:02
  after
• 11:02
  this
• 11:03
  happened,
• 11:03
  I'm
• 11:03
  very
• 11:03
  wary.
• 11:04
  Right,
• 11:04
  but
• 11:05
  it
• 11:05
  doesn't
• 11:05
  quite.
• 11:06
  It.
• 11:07
  This
• 11:07
  doesn't
• 11:07
  quite
• 11:08
  address
• 11:08
  the
• 11:08
  ninja
• 11:08
  comment.
• 11:09
  And
• 11:09
  you
• 11:09
  really
• 11:09
  want
• 11:10
  to
• 11:11
  get
• 11:11
  nitty
• 11:12
  gritty
• 11:12
  with
• 11:12
  the
• 11:12
  semantics
• 11:13
  of
• 11:13
  ninja,
• 11:14
  and
• 11:14
  you
• 11:14
  really
• 11:14
  want
• 11:14
  him
• 11:15
  to.
• 11:15
  You
• 11:15
  really
• 11:16
  want
• 11:16
  to
• 11:16
  figure
• 11:16
  out,
• 11:16
  does
• 11:16
  this
• 11:17
  guy,
• 11:18
  you
• 11:18
  know,
• 11:18
  is
• 11:18
  he
• 11:18
  bothered
• 11:19
  by
• 11:19
  that
• 11:19
  ninja
• 11:20
  thing?
• 11:20
  Does
• 11:21
  he
• 11:21
  actually
• 11:21
  believe
• 11:21
  in
• 11:22
  ninjas?
• 11:22
  Or
• 11:22
  is
• 11:23
  he
• 11:23
  describing.
• 11:24
  Is
• 11:24
  he
• 11:24
  using
• 11:24
  it
• 11:24
  as
• 11:25
  shorthand
• 11:25
  to
• 11:25
  describe
• 11:26
  folks
• 11:27
  who
• 11:27
  are
• 11:27
  more
• 11:28
  clad
• 11:28
  in
• 11:28
  black
• 11:29
  and
• 11:31
  resemble
• 11:31
  ninjas,
• 11:32
  but
• 11:32
  he's
• 11:32
  aware
• 11:32
  that
• 11:32
  real
• 11:33
  ninjas
• 11:33
  don't
• 11:33
  exist?
• 11:34
  That's
• 11:34
  a
• 11:34
  very
• 11:34
  important,
• 11:36
  very
• 11:36
  important
• 11:37
  way
• 11:37
  to
• 11:37
  put
• 11:37
  it.
• 11:38
  And
• 11:38
  again,
• 11:38
  getting
• 11:39
  an
• 11:39
  accurate
• 11:39
  trauma
• 11:41
  depiction
• 11:41
  of
• 11:41
  what
• 11:42
  happened
• 11:42
  that
• 11:42
  day
• 11:42
  is
• 11:42
  also
• 11:43
  very
• 11:43
  important
• 11:43
  because
• 11:44
  maybe
• 11:44
  the
• 11:45
  people
• 11:45
  who
• 11:45
  attacked
• 11:45
  him
• 11:45
  really
• 11:46
  did
• 11:46
  look
• 11:46
  like
• 11:46
  ninjas.
• 11:47
  And
• 11:49
  again,
• 11:49
  he's
• 11:49
  using
• 11:49
  it
• 11:50
  as
• 11:51
  shorthand
• 11:51
  now.
• 11:52
  Could
• 11:52
  this
• 11:52
  be
• 11:52
  generalized
• 11:53
  anxiety
• 11:53
  disorder?
• 11:54
  I
• 11:54
  find
• 11:54
  it
• 11:55
  very
• 11:55
  unlikely.
• 11:56
  And
• 11:56
  again,
• 11:56
  I
• 11:57
  think
• 11:57
  the
• 11:57
  word
• 11:57
  generalized
• 11:58
  anxiety
• 11:59
  disorder,
• 12:00
  that.
• 12:00
  That.
• 12:00
  That
• 12:01
  phrase
• 12:01
  or
• 12:02
  that
• 12:02
  diagnosis
• 12:03
  was
• 12:03
  perfectly
• 12:05
  named
• 12:05
  in
• 12:05
  the
• 12:05
  DSM
• 12:06
  because
• 12:06
  it's
• 12:06
  general.
• 12:07
  Right?
• 12:07
  Nothing
• 12:07
  about
• 12:07
  what
• 12:08
  we're
• 12:08
  talking
• 12:08
  about
• 12:08
  right
• 12:08
  now
• 12:09
  is
• 12:09
  general.
• 12:10
  Pretty
• 12:10
  much
• 12:10
  the
• 12:11
  opposite
• 12:11
  of
• 12:12
  a
• 12:13
  general
• 12:13
  worry
• 12:13
  is
• 12:14
  being
• 12:14
  worried
• 12:14
  about
• 12:14
  a
• 12:14
  ninja.
• 12:15
  Right?
• 12:15
  That
• 12:16
  is
• 12:16
  the
• 12:16
  most
• 12:16
  specific
• 12:16
  kind
• 12:17
  of
• 12:17
  worry
• 12:17
  versus
• 12:17
  the
• 12:18
  general
• 12:18
  worry.
• 12:18
  He's
• 12:19
  not
• 12:19
  coming
• 12:19
  to
• 12:19
  you
• 12:19
  because
• 12:20
  he's
• 12:20
  on
• 12:20
  edge
• 12:20
  all
• 12:20
  of
• 12:21
  the
• 12:21
  time
• 12:21
  about
• 12:22
  many
• 12:22
  different
• 12:22
  things.
• 12:22
  He
• 12:23
  definitely
• 12:23
  talked
• 12:24
  about
• 12:24
  that,
• 12:24
  that
• 12:25
  he
• 12:25
  is
• 12:25
  a
• 12:25
  worrier
• 12:26
  in
• 12:26
  his
• 12:26
  past,
• 12:26
  and
• 12:26
  that's
• 12:27
  kind
• 12:27
  of
• 12:27
  his
• 12:27
  personality.
• 12:28
  But
• 12:28
  why
• 12:28
  he's
• 12:29
  coming
• 12:29
  to
• 12:29
  you
• 12:29
  today,
• 12:29
  it's
• 12:30
  very
• 12:30
  specific.
• 12:31
  It
• 12:31
  sounds
• 12:31
  like
• 12:31
  avoidance.
• 12:32
  And
• 12:32
  there's
• 12:33
  a
• 12:33
  very
• 12:34
  specific
• 12:34
  reason
• 12:34
  he
• 12:35
  states
• 12:37
  that
• 12:37
  he.
• 12:37
  There's
• 12:38
  a
• 12:38
  very
• 12:38
  specific
• 12:38
  reason
• 12:39
  that
• 12:39
  he's
• 12:40
  implicating
• 12:40
  in
• 12:40
  his
• 12:40
  avoidance
• 12:41
  ninjas
• 12:42
  or
• 12:42
  being
• 12:43
  assaulted
• 12:43
  or
• 12:43
  harmed
• 12:43
  more
• 12:44
  broadly,
• 12:44
  we
• 12:44
  can
• 12:44
  figure
• 12:45
  out
• 12:45
  again,
• 12:46
  what
• 12:46
  is
• 12:47
  how
• 12:48
  he
• 12:48
  characterizes
• 12:48
  that
• 12:49
  threat
• 12:49
  and
• 12:49
  perceives
• 12:49
  that
• 12:50
  threat
• 12:50
  to
• 12:50
  get
• 12:50
  us
• 12:50
  more
• 12:50
  diagnostic
• 12:51
  clarity.
• 12:52
  But
• 12:52
  this
• 12:52
  is
• 12:52
  not
• 12:52
  a
• 12:53
  generalized
• 12:53
  worry
• 12:54
  complaint.
• 12:54
  Again,
• 12:55
  it
• 12:55
  might
• 12:55
  be
• 12:55
  comorbid.
• 12:56
  It's
• 12:56
  often,
• 12:57
  it
• 12:57
  often
• 12:57
  is
• 12:57
  comorbid
• 12:58
  with
• 12:58
  a
• 12:58
  lot
• 12:58
  of
• 12:58
  these
• 12:58
  diagnoses.
• 13:00
  There's
• 13:00
  definitely
• 13:00
  a
• 13:00
  higher
• 13:01
  incidence
• 13:01
  of
• 13:01
  comorbidity
• 13:02
  once
• 13:02
  these
• 13:03
  initial
• 13:03
  diagnoses
• 13:04
  are
• 13:04
  here.
• 13:05
  But
• 13:05
  it's
• 13:05
  not
• 13:06
  really
• 13:06
  the
• 13:06
  reason
• 13:06
  he's
• 13:06
  coming
• 13:07
  to
• 13:07
  you.
• 13:07
  And
• 13:07
  it
• 13:07
  probably
• 13:08
  shouldn't
• 13:08
  be
• 13:08
  your
• 13:09
  main
• 13:09
  area
• 13:10
  of
• 13:10
  focus
• 13:10
  either,
• 13:11
  because
• 13:12
  he's
• 13:13
  not
• 13:13
  coming
• 13:13
  to
• 13:13
  you
• 13:14
  to
• 13:15
  restore
• 13:15
  his,
• 13:16
  his
• 13:16
  functional
• 13:17
  impairment.
• 13:17
  From
• 13:17
  a
• 13:18
  GAD
• 13:18
  perspective,
• 13:18
  this
• 13:19
  sounds
• 13:19
  more
• 13:19
  like
• 13:19
  traumatic
• 13:20
  avoidance,
• 13:21
  maybe
• 13:21
  delusional,
• 13:22
  maybe
• 13:22
  ocd.
• 13:23
  Right.
• 13:24
  And
• 13:24
  so
• 13:25
  now
• 13:26
  getting
• 13:26
  a
• 13:26
  little
• 13:26
  deeper
• 13:26
  into
• 13:27
  this,
• 13:28
  you,
• 13:29
  you
• 13:29
  really
• 13:30
  want
• 13:30
  to
• 13:30
  look
• 13:30
  into
• 13:31
  gad,
• 13:31
  right?
• 13:32
  And
• 13:32
  I
• 13:33
  don't,
• 13:33
  I
• 13:33
  don't
• 13:33
  think
• 13:33
  it
• 13:33
  is
• 13:34
  gad.
• 13:34
  Um,
• 13:35
  now
• 13:35
  maybe
• 13:36
  folks
• 13:36
  with
• 13:36
  GAD
• 13:37
  are
• 13:37
  worried
• 13:37
  they
• 13:38
  will
• 13:38
  get
• 13:38
  mugged
• 13:38
  when
• 13:39
  they
• 13:39
  walk
• 13:39
  down
• 13:39
  the
• 13:39
  street.
• 13:40
  That
• 13:40
  is
• 13:40
  certainly
• 13:40
  common
• 13:41
  with
• 13:41
  gad.
• 13:41
  Right.
• 13:42
  A
• 13:42
  classic
• 13:42
  example
• 13:43
  of
• 13:43
  a
• 13:43
  worry
• 13:43
  that
• 13:44
  is
• 13:44
  unlikely
• 13:44
  to
• 13:44
  happen,
• 13:45
  but
• 13:45
  we
• 13:45
  still
• 13:45
  are
• 13:46
  always
• 13:46
  on
• 13:46
  edge
• 13:46
  about
• 13:47
  it
• 13:47
  anyway.
• 13:47
  We
• 13:48
  can't
• 13:48
  seem
• 13:48
  to
• 13:48
  stop
• 13:48
  worrying
• 13:49
  about
• 13:49
  it
• 13:49
  anyway,
• 13:50
  even
• 13:50
  though
• 13:51
  we
• 13:51
  know
• 13:51
  it's
• 13:52
  unlikely.
• 13:52
  But
• 13:52
  it's
• 13:53
  still
• 13:53
  possible.
• 13:53
  It's
• 13:53
  a
• 13:54
  plausible
• 13:54
  worry.
• 13:54
  Right.
• 13:54
  It's
• 13:55
  not
• 13:55
  bizarre.
• 13:55
  Ninjas
• 13:56
  are
• 13:56
  bizarre.
• 13:57
  That's
• 13:57
  when
• 13:57
  you
• 13:57
  should
• 13:57
  go,
• 13:57
  hmm,
• 13:58
  this
• 13:58
  definitely
• 13:59
  sounds
• 13:59
  like
• 13:59
  delusional
• 13:59
  disorder.
• 14:00
  Sounds
• 14:00
  a
• 14:01
  little
• 14:01
  ocd,
• 14:01
  like
• 14:01
  an
• 14:02
  unwanted
• 14:02
  bizarre
• 14:03
  thought
• 14:03
  and
• 14:03
  ocd.
• 14:04
  But
• 14:04
  if
• 14:05
  you're
• 14:05
  worried
• 14:06
  that
• 14:06
  you're
• 14:06
  just
• 14:06
  going
• 14:06
  to
• 14:06
  get
• 14:06
  mugged,
• 14:07
  that
• 14:07
  might
• 14:07
  be
• 14:08
  more
• 14:08
  GAD
• 14:08
  or
• 14:08
  ptsd.
• 14:09
  Of
• 14:10
  course,
• 14:10
  it's
• 14:10
  very
• 14:10
  important
• 14:10
  to
• 14:11
  ask
• 14:11
  the
• 14:11
  patient,
• 14:11
  how
• 14:11
  many
• 14:11
  times
• 14:12
  in
• 14:12
  your
• 14:12
  life
• 14:12
  have
• 14:12
  you
• 14:12
  been
• 14:13
  mugged?
• 14:13
  Have
• 14:13
  you
• 14:14
  ever
• 14:14
  been
• 14:14
  exposed
• 14:14
  to
• 14:15
  situations
• 14:15
  where
• 14:15
  someone
• 14:16
  around
• 14:16
  you
• 14:16
  was
• 14:16
  mugged
• 14:17
  and
• 14:17
  it
• 14:17
  really
• 14:17
  left
• 14:18
  an
• 14:18
  impression
• 14:18
  on
• 14:18
  you?
• 14:19
  Are
• 14:19
  there
• 14:19
  any
• 14:19
  other
• 14:19
  times
• 14:20
  in
• 14:20
  your
• 14:20
  life
• 14:21
  that
• 14:21
  you
• 14:21
  can
• 14:21
  share
• 14:21
  with
• 14:22
  me
• 14:22
  where
• 14:22
  your
• 14:22
  life
• 14:23
  or
• 14:23
  was
• 14:23
  in
• 14:24
  serious
• 14:24
  jeopardy
• 14:25
  and
• 14:25
  you
• 14:25
  know,
• 14:26
  so
• 14:26
  those
• 14:27
  are
• 14:27
  things
• 14:27
  I
• 14:27
  would
• 14:27
  want
• 14:27
  to
• 14:28
  know
• 14:28
  to
• 14:28
  understand.
• 14:29
  Why
• 14:29
  are
• 14:29
  we
• 14:29
  worried
• 14:30
  about
• 14:30
  being
• 14:30
  mugged?
• 14:31
  And
• 14:31
  if
• 14:31
  it's
• 14:31
  not
• 14:31
  just
• 14:32
  about
• 14:32
  being
• 14:32
  mugged,
• 14:32
  but
• 14:33
  they're
• 14:33
  also
• 14:33
  worried
• 14:33
  they're
• 14:34
  going
• 14:34
  to
• 14:34
  go
• 14:34
  bankrupt
• 14:34
  and
• 14:34
  they're
• 14:35
  going
• 14:35
  to
• 14:35
  get
• 14:35
  fired
• 14:36
  and
• 14:36
  that
• 14:36
  their
• 14:37
  car
• 14:37
  is
• 14:37
  going
• 14:37
  to
• 14:37
  break
• 14:37
  down?
• 14:38
  Now,
• 14:39
  usually
• 14:39
  in
• 14:39
  your
• 14:40
  interview,
• 14:40
  there's
• 14:40
  enough
• 14:40
  of
• 14:41
  these
• 14:41
  worries
• 14:41
  coming
• 14:42
  out
• 14:42
  that
• 14:43
  you
• 14:43
  recognize
• 14:44
  the
• 14:44
  main
• 14:44
  problem
• 14:44
  here
• 14:45
  is
• 14:45
  that
• 14:45
  everything
• 14:45
  is
• 14:46
  non
• 14:46
  specific.
• 14:46
  It's
• 14:47
  generalized.
• 14:48
  That's
• 14:48
  when
• 14:48
  you
• 14:48
  go
• 14:48
  down
• 14:48
  the
• 14:49
  GAD
• 14:49
  rabbit
• 14:49
  hole.
• 14:50
  But
• 14:50
  when
• 14:51
  you
• 14:51
  know
• 14:51
  this
• 14:51
  is
• 14:52
  you
• 14:52
  don't
• 14:52
  need
• 14:52
  to
• 14:52
  really
• 14:53
  overthink
• 14:53
  this,
• 14:53
  my
• 14:53
  friends,
• 14:54
  because
• 14:54
  you're
• 14:55
  going
• 14:55
  to
• 14:55
  kind
• 14:55
  of
• 14:55
  know
• 14:55
  when
• 14:55
  you
• 14:56
  see
• 14:56
  it
• 14:56
  in
• 14:56
  clinic,
• 14:56
  is
• 14:57
  this
• 14:57
  a
• 14:57
  general
• 14:57
  problem
• 14:57
  or
• 14:58
  a
• 14:58
  very
• 14:58
  specific
• 14:59
  problem
• 14:59
  in
• 14:59
  front
• 14:59
  of
• 14:59
  me?
• 15:00
  You
• 15:00
  should
• 15:00
  implicitly
• 15:01
  know
• 15:01
  that
• 15:01
  and
• 15:01
  implicitly
• 15:02
  answer
• 15:02
  that.
• 15:03
  And
• 15:03
  sometimes
• 15:03
  it's
• 15:03
  important
• 15:04
  to
• 15:04
  just
• 15:04
  ask
• 15:04
  yourself,
• 15:05
  what
• 15:05
  is
• 15:05
  this
• 15:05
  not
• 15:06
  right?
• 15:06
  So
• 15:07
  in
• 15:07
  the.
• 15:07
  In
• 15:07
  the
• 15:07
  middle
• 15:07
  of
• 15:08
  the
• 15:08
  fog,
• 15:08
  when
• 15:08
  you're
• 15:09
  trying
• 15:09
  to
• 15:09
  make
• 15:09
  a
• 15:09
  diagnosis,
• 15:10
  don't
• 15:10
  just
• 15:10
  think,
• 15:11
  what
• 15:11
  am
• 15:11
  I
• 15:11
  seeing?
• 15:11
  But
• 15:12
  really
• 15:12
  think
• 15:12
  to
• 15:13
  yourself,
• 15:13
  what
• 15:13
  am
• 15:13
  I
• 15:13
  not
• 15:13
  seeing?
• 15:14
  Well,
• 15:14
  I'm
• 15:14
  not
• 15:15
  hearing
• 15:15
  a
• 15:15
  lot
• 15:15
  of
• 15:15
  general
• 15:16
  worry
• 15:16
  here.
• 15:16
  This
• 15:16
  is
• 15:17
  very
• 15:17
  specific
• 15:17
  to
• 15:17
  being
• 15:18
  assaulted
• 15:19
  by
• 15:19
  specific
• 15:20
  figures
• 15:21
  dressed
• 15:21
  in
• 15:21
  black
• 15:22
  with
• 15:22
  eyelets
• 15:23
  and
• 15:24
  whatever
• 15:25
  else.
• 15:25
  Ninja.
• 15:25
  I
• 15:25
  think
• 15:25
  ninjas
• 15:26
  carry
• 15:26
  swords
• 15:27
  or
• 15:28
  throwing
• 15:29
  stars.
• 15:30
  And
• 15:30
  so
• 15:31
  we're
• 15:31
  looking
• 15:32
  at
• 15:32
  something
• 15:32
  very
• 15:33
  specific
• 15:33
  here.
• 15:34
  Okay.
• 15:34
  And
• 15:35
  so
• 15:35
  I
• 15:35
  think
• 15:36
  we
• 15:36
  can
• 15:36
  throw
• 15:36
  GAD
• 15:37
  into
• 15:37
  the
• 15:37
  dustbin.
• 15:38
  It
• 15:38
  could
• 15:38
  be
• 15:38
  comorbid.
• 15:39
  That's
• 15:39
  a
• 15:39
  different.
• 15:40
  That's
• 15:40
  maybe
• 15:40
  a
• 15:40
  different
• 15:41
  appointment,
• 15:42
  but
• 15:42
  right
• 15:42
  now
• 15:42
  we
• 15:42
  can
• 15:43
  throw
• 15:43
  that
• 15:43
  in
• 15:43
  the
• 15:43
  dustbin.
• 15:44
  Um,
• 15:45
  so
• 15:45
  I
• 15:45
  think
• 15:45
  that's
• 15:45
  really
• 15:45
  important.
• 15:46
  I
• 15:46
  think
• 15:46
  the
• 15:46
  compulsions
• 15:47
  and
• 15:47
  the
• 15:47
  rituals
• 15:47
  here
• 15:48
  are
• 15:48
  really
• 15:48
  key.
• 15:48
  I
• 15:49
  would
• 15:49
  definitely
• 15:49
  ask
• 15:49
  the
• 15:50
  patient,
• 15:50
  how
• 15:50
  long
• 15:50
  is
• 15:50
  this
• 15:51
  taking
• 15:51
  you?
• 15:52
  Every.
• 15:53
  Every
• 15:53
  day.
• 15:53
  You
• 15:54
  know,
• 15:54
  the
• 15:54
  DSM
• 15:54
  has
• 15:55
  this.
• 15:56
  It's
• 15:57
  not
• 15:57
  really
• 15:57
  an
• 15:57
  official
• 15:57
  cutoff,
• 15:58
  but
• 15:58
  it
• 15:58
  suggests
• 15:59
  about
• 15:59
  an
• 15:59
  hour
• 15:59
  or
• 16:00
  more
• 16:00
  is
• 16:00
  indic.
• 16:01
  It.
• 16:01
  It.
• 16:02
  It's
• 16:02
  indicative
• 16:03
  of
• 16:03
  ocd.
• 16:04
  It's
• 16:05
  not
• 16:05
  a
• 16:05
  hard
• 16:05
  requirement,
• 16:06
  but
• 16:06
  it
• 16:06
  is
• 16:06
  a
• 16:08
  more
• 16:08
  of
• 16:09
  a,
• 16:09
  I
• 16:09
  think,
• 16:09
  a
• 16:09
  yardstick
• 16:10
  for
• 16:10
  you
• 16:10
  to
• 16:11
  think
• 16:11
  about.
• 16:12
  Right.
• 16:12
  If
• 16:12
  your
• 16:12
  patient
• 16:13
  is
• 16:13
  spending
• 16:14
  way
• 16:14
  too
• 16:14
  much
• 16:15
  time
• 16:17
  engaged
• 16:17
  in
• 16:18
  rituals
• 16:18
  or
• 16:18
  compulsions,
• 16:19
  it's
• 16:20
  definitely
• 16:20
  more
• 16:21
  plausible
• 16:22
  they
• 16:22
  are
• 16:22
  suffering
• 16:23
  from
• 16:23
  ocd.
• 16:23
  So
• 16:24
  I
• 16:24
  would
• 16:24
  ask
• 16:24
  Dustin,
• 16:25
  how.
• 16:25
  How
• 16:25
  often
• 16:25
  are
• 16:26
  you
• 16:26
  checking
• 16:26
  locks?
• 16:26
  How
• 16:26
  much
• 16:26
  time
• 16:27
  does
• 16:27
  this
• 16:27
  take?
• 16:27
  Is
• 16:27
  there
• 16:28
  any
• 16:28
  other
• 16:28
  part
• 16:28
  of
• 16:29
  your
• 16:29
  routine
• 16:29
  where
• 16:29
  you
• 16:30
  spend
• 16:30
  a
• 16:30
  lot
• 16:30
  of
• 16:30
  time
• 16:30
  trying
• 16:31
  to
• 16:31
  guarantee
• 16:31
  your
• 16:31
  safety?
• 16:32
  Of
• 16:32
  course
• 16:32
  that
• 16:33
  gets
• 16:33
  really
• 16:33
  muddy
• 16:34
  because
• 16:34
  this
• 16:34
  is
• 16:34
  also
• 16:35
  a
• 16:35
  trauma
• 16:35
  response.
• 16:36
  Right.
• 16:36
  And
• 16:37
  then
• 16:37
  I
• 16:37
  would
• 16:37
  ask
• 16:37
  him
• 16:37
  on
• 16:38
  top
• 16:38
  of
• 16:38
  that,
• 16:39
  if
• 16:39
  you
• 16:39
  think
• 16:39
  it
• 16:39
  is
• 16:39
  a
• 16:39
  trauma
• 16:40
  response
• 16:40
  and
• 16:40
  you're
• 16:40
  kind
• 16:41
  of
• 16:41
  conflating
• 16:41
  the
• 16:41
  two,
• 16:42
  I
• 16:42
  would
• 16:42
  ask
• 16:42
  him,
• 16:42
  well,
• 16:43
  did
• 16:43
  you
• 16:43
  have
• 16:43
  any
• 16:43
  of
• 16:44
  these
• 16:44
  kinds
• 16:44
  of
• 16:44
  behaviors
• 16:44
  before
• 16:45
  you
• 16:45
  were
• 16:45
  assaulted
• 16:46
  where
• 16:46
  you
• 16:46
  were,
• 16:47
  you
• 16:48
  know,
• 16:48
  checking
• 16:48
  the
• 16:48
  oven
• 16:48
  to
• 16:49
  make
• 16:49
  sure
• 16:49
  it
• 16:49
  was
• 16:49
  turned
• 16:50
  off
• 16:50
  multiple
• 16:50
  times
• 16:50
  per
• 16:51
  night,
• 16:51
  or
• 16:52
  counting
• 16:52
  your
• 16:52
  steps
• 16:53
  or
• 16:53
  washing
• 16:53
  hands
• 16:54
  compulsively.
• 16:54
  Are
• 16:54
  there
• 16:55
  any.
• 16:55
  Is
• 16:55
  there
• 16:55
  any
• 16:55
  trace
• 16:56
  of
• 16:56
  that
• 16:56
  prior
• 16:56
  to
• 16:57
  your
• 16:57
  assault
• 16:58
  at
• 16:58
  the
• 16:58
  7
• 16:58
  11?
• 16:59
  And
• 16:59
  usually
• 17:00
  if
• 17:00
  OCD
• 17:01
  is
• 17:01
  a.
• 17:02
  And
• 17:02
  it,
• 17:03
  you
• 17:03
  know,
• 17:03
  a
• 17:03
  long
• 17:03
  time
• 17:04
  problem,
• 17:04
  and
• 17:04
  usually
• 17:05
  it
• 17:05
  is
• 17:05
  the
• 17:05
  age
• 17:06
  of
• 17:06
  onset
• 17:07
  is
• 17:07
  usually
• 17:07
  a
• 17:07
  lot
• 17:07
  younger,
• 17:08
  they
• 17:08
  will
• 17:08
  tell
• 17:08
  you,
• 17:08
  oh,
• 17:08
  yeah,
• 17:09
  that's
• 17:09
  always
• 17:09
  been
• 17:09
  a
• 17:09
  problem.
• 17:10
  But
• 17:10
  maybe
• 17:10
  it's
• 17:11
  been
• 17:11
  flared
• 17:11
  up
• 17:12
  by
• 17:12
  the
• 17:12
  trauma
• 17:12
  now
• 17:13
  and
• 17:13
  the
• 17:13
  process,
• 17:14
  the
• 17:14
  obsessional
• 17:15
  process
• 17:15
  now
• 17:15
  is
• 17:15
  taking
• 17:16
  on
• 17:16
  the
• 17:16
  content
• 17:16
  of
• 17:16
  a
• 17:16
  traumatic
• 17:17
  theme.
• 17:18
  And
• 17:18
  so
• 17:18
  again,
• 17:19
  two
• 17:19
  can
• 17:19
  absolutely
• 17:21
  reoccur
• 17:21
  together
• 17:23
  a
• 17:23
  hundred
• 17:23
  percent,
• 17:24
  right?
• 17:24
  A
• 17:25
  hundred
• 17:25
  percent.
• 17:25
  It
• 17:26
  will
• 17:26
  help
• 17:26
  you
• 17:26
  a
• 17:26
  lot
• 17:27
  here
• 17:27
  to
• 17:27
  of
• 17:27
  course,
• 17:28
  go
• 17:28
  over
• 17:29
  the
• 17:29
  other
• 17:29
  DSM
• 17:30
  5
• 17:30
  criteria
• 17:31
  for
• 17:31
  PTSD
• 17:32
  to
• 17:32
  see
• 17:33
  if
• 17:33
  he's
• 17:33
  or
• 17:35
  re
• 17:36
  experiencing
• 17:36
  what
• 17:37
  happened
• 17:37
  to
• 17:37
  him
• 17:37
  during
• 17:37
  the
• 17:38
  day.
• 17:38
  Maybe
• 17:39
  he
• 17:39
  is
• 17:39
  having
• 17:39
  these
• 17:39
  disassociative
• 17:41
  episodes
• 17:41
  that
• 17:41
  are
• 17:42
  almost
• 17:43
  similar
• 17:43
  to
• 17:44
  psychosis
• 17:44
  in
• 17:45
  how
• 17:45
  they're
• 17:45
  experienced,
• 17:46
  where
• 17:47
  he
• 17:47
  kind
• 17:47
  of
• 17:47
  zones
• 17:48
  out
• 17:48
  and
• 17:48
  he's,
• 17:49
  he
• 17:49
  just
• 17:49
  feels
• 17:50
  that
• 17:50
  trauma
• 17:50
  fragmentation.
• 17:51
  The
• 17:51
  sensory
• 17:53
  processing
• 17:54
  just
• 17:54
  gets
• 17:54
  kind
• 17:54
  of
• 17:55
  jumbled
• 17:55
  up
• 17:56
  and
• 17:56
  he
• 17:56
  feels
• 17:56
  like
• 17:56
  he's
• 17:57
  being
• 17:57
  attacked
• 17:57
  by
• 17:57
  a
• 17:57
  ninja
• 17:58
  in
• 17:58
  the
• 17:58
  moment.
• 17:58
  It's
• 17:58
  not
• 17:58
  happening.
• 17:59
  He's
• 17:59
  not
• 17:59
  necessarily
• 18:00
  seeing
• 18:00
  ninjas
• 18:00
  in
• 18:01
  a
• 18:01
  psychotic
• 18:01
  sense,
• 18:02
  but,
• 18:02
  but
• 18:02
  again,
• 18:03
  it
• 18:03
  could
• 18:03
  be
• 18:04
  enough
• 18:04
  of
• 18:05
  a
• 18:05
  disorientation
• 18:06
  of
• 18:06
  his
• 18:06
  present
• 18:07
  consciousness
• 18:08
  where
• 18:08
  it
• 18:09
  almost
• 18:09
  looks
• 18:09
  like
• 18:10
  psychosis.
• 18:10
  It
• 18:11
  almost
• 18:12
  looks
• 18:12
  like
• 18:12
  he's
• 18:13
  losing
• 18:13
  touch
• 18:13
  with
• 18:14
  reality
• 18:14
  when
• 18:14
  he
• 18:14
  isn't.
• 18:15
  And
• 18:15
  so
• 18:16
  you
• 18:16
  really
• 18:16
  have
• 18:16
  to
• 18:16
  get
• 18:17
  clear
• 18:17
  about
• 18:17
  that
• 18:18
  when
• 18:19
  that's
• 18:19
  happening,
• 18:19
  how
• 18:20
  often
• 18:20
  it's
• 18:20
  happening,
• 18:20
  what
• 18:21
  it
• 18:21
  looks
• 18:21
  like.
• 18:22
  That's
• 18:23
  also
• 18:23
  very
• 18:24
  important.
• 18:24
  A
• 18:24
  lot
• 18:24
  of
• 18:24
  people
• 18:25
  with
• 18:25
  PTSD
• 18:25
  too,
• 18:26
  they'll
• 18:27
  say
• 18:27
  things
• 18:27
  that
• 18:27
  sound
• 18:28
  borderline
• 18:28
  psychotic,
• 18:29
  but
• 18:29
  they're
• 18:29
  not
• 18:29
  really
• 18:31
  there.
• 18:31
  Turns
• 18:31
  out
• 18:31
  they're
• 18:32
  very
• 18:32
  hyper
• 18:32
  vigilant,
• 18:33
  they're
• 18:33
  easily
• 18:33
  startled.
• 18:34
  They're.
• 18:34
  They
• 18:34
  have
• 18:34
  hyper
• 18:34
  arousal
• 18:35
  where
• 18:36
  they,
• 18:37
  they
• 18:38
  think
• 18:38
  they
• 18:38
  might
• 18:38
  see
• 18:38
  things.
• 18:39
  It's
• 18:39
  almost
• 18:39
  like
• 18:40
  an
• 18:40
  exaggerated
• 18:40
  response
• 18:41
  where
• 18:41
  you
• 18:42
  get
• 18:42
  bit
• 18:42
  by
• 18:42
  a
• 18:42
  snake
• 18:43
  and
• 18:43
  then
• 18:43
  next
• 18:43
  time
• 18:44
  you're
• 18:44
  in
• 18:44
  the
• 18:44
  forest,
• 18:45
  everything
• 18:45
  looks
• 18:46
  like
• 18:46
  a
• 18:46
  snake.
• 18:46
  Even
• 18:47
  if
• 18:47
  it
• 18:47
  used
• 18:47
  to
• 18:47
  look
• 18:48
  more
• 18:48
  like
• 18:48
  a
• 18:48
  stick
• 18:48
  to
• 18:49
  you.
• 18:49
  Of
• 18:49
  course
• 18:49
  there's
• 18:50
  an
• 18:50
  evolutionary
• 18:51
  component
• 18:51
  to
• 18:51
  that
• 18:52
  that's
• 18:52
  protected
• 18:52
  us
• 18:53
  for
• 18:53
  millions
• 18:53
  of
• 18:54
  years.
• 18:54
  But
• 18:55
  I
• 18:55
  found
• 18:55
  that
• 18:55
  with
• 18:56
  a
• 18:56
  lot
• 18:56
  of
• 18:56
  trauma
• 18:56
  folks,
• 18:57
  it's
• 18:58
  not
• 18:58
  that
• 18:58
  they
• 18:58
  are
• 18:59
  seeing
• 18:59
  and
• 18:59
  hearing
• 18:59
  things
• 19:00
  you
• 19:00
  don't
• 19:00
  see
• 19:00
  or
• 19:00
  hear,
• 19:01
  they're
• 19:01
  just
• 19:02
  in
• 19:02
  this
• 19:02
  hyper
• 19:03
  arousal
• 19:03
  state
• 19:04
  where
• 19:04
  they
• 19:04
  will
• 19:04
  frequently
• 19:05
  err
• 19:05
  on
• 19:06
  the
• 19:06
  side
• 19:06
  of
• 19:06
  I'm
• 19:07
  about
• 19:07
  to
• 19:07
  be
• 19:07
  harmed,
• 19:07
  as
• 19:08
  opposed
• 19:08
  to,
• 19:08
  ooh,
• 19:08
  that's
• 19:08
  an
• 19:09
  innocent
• 19:09
  stick,
• 19:09
  I'm
• 19:09
  fine.
• 19:10
  And
• 19:10
  so
• 19:11
  definitely
• 19:11
  take
• 19:11
  your
• 19:12
  time
• 19:12
  just
• 19:13
  to
• 19:13
  make
• 19:13
  sure
• 19:13
  that
• 19:14
  they're
• 19:14
  not
• 19:14
  psychotic.
• 19:15
  Because
• 19:16
  when
• 19:16
  you
• 19:16
  already
• 19:16
  hear
• 19:17
  the
• 19:17
  word
• 19:17
  ninja,
• 19:18
  you,
• 19:19
  you
• 19:19
  definitely,
• 19:19
  your
• 19:19
  daggers
• 19:20
  are
• 19:20
  out.
• 19:20
  You're
• 19:20
  waiting
• 19:21
  to
• 19:21
  diagnose
• 19:22
  that.
• 19:22
  And
• 19:23
  it
• 19:23
  very
• 19:24
  well
• 19:24
  could
• 19:24
  be
• 19:24
  the
• 19:25
  case.
• 19:25
  So
• 19:25
  you
• 19:25
  have
• 19:25
  to
• 19:25
  kind
• 19:25
  of
• 19:26
  put
• 19:26
  all
• 19:26
  of
• 19:26
  this
• 19:27
  on
• 19:27
  the
• 19:27
  table,
• 19:28
  right?
• 19:29
  And
• 19:29
  so
• 19:29
  that's.
• 19:30
  To
• 19:30
  me,
• 19:30
  that's
• 19:30
  very
• 19:31
  helpful
• 19:31
  as
• 19:31
  well.
• 19:33
  Two
• 19:33
  big
• 19:34
  pearls,
• 19:34
  GAD
• 19:34
  and
• 19:35
  ocd.
• 19:35
  They're
• 19:36
  usually
• 19:36
  Things
• 19:36
  that
• 19:36
  develop
• 19:37
  gradually,
• 19:38
  right.
• 19:38
  Even
• 19:38
  delusional
• 19:39
  disorder,
• 19:39
  these
• 19:39
  are
• 19:39
  more
• 19:40
  gradual,
• 19:41
  slow
• 19:41
  burn
• 19:41
  diagnoses.
• 19:44
  So
• 19:45
  I
• 19:45
  would
• 19:45
  argue
• 19:46
  again
• 19:46
  that
• 19:46
  the
• 19:47
  speed
• 19:47
  by
• 19:47
  which
• 19:47
  this
• 19:48
  is
• 19:48
  happening
• 19:49
  and
• 19:49
  the
• 19:49
  degree
• 19:49
  of
• 19:49
  impairment
• 19:50
  that
• 19:50
  is
• 19:50
  happening
• 19:51
  this
• 19:51
  quickly
• 19:52
  is
• 19:52
  more
• 19:52
  suggestive
• 19:53
  of
• 19:53
  trauma
• 19:54
  and
• 19:55
  not
• 19:56
  gad,
• 19:57
  OCD
• 19:57
  or
• 19:57
  delusional
• 19:58
  disorder.
• 19:59
  And
• 20:00
  so
• 20:00
  think
• 20:00
  about
• 20:00
  the
• 20:01
  timeline.
• 20:01
  And
• 20:01
  it's
• 20:01
  very
• 20:02
  important
• 20:02
  that
• 20:02
  you
• 20:02
  study
• 20:03
  the
• 20:04
  age
• 20:04
  of
• 20:04
  onset,
• 20:04
  the
• 20:05
  median
• 20:05
  age
• 20:05
  of
• 20:05
  onset
• 20:06
  of
• 20:06
  all
• 20:06
  of
• 20:06
  these
• 20:06
  DSM
• 20:07
  criteria.
• 20:07
  Again,
• 20:07
  OCD
• 20:08
  is
• 20:08
  much
• 20:08
  younger,
• 20:10
  and
• 20:11
  schizophrenia
• 20:12
  and
• 20:12
  bipolar
• 20:13
  and
• 20:13
  gad.
• 20:14
  It's
• 20:14
  very
• 20:14
  important
• 20:15
  you
• 20:15
  familiarize
• 20:15
  yourself
• 20:16
  and
• 20:16
  understand,
• 20:16
  like,
• 20:17
  wait
• 20:17
  a
• 20:17
  minute,
• 20:17
  is
• 20:18
  this
• 20:18
  the
• 20:18
  typical
• 20:18
  age
• 20:18
  of
• 20:19
  onset
• 20:19
  that
• 20:19
  I
• 20:20
  would
• 20:20
  normally
• 20:21
  see
• 20:21
  this?
• 20:22
  And
• 20:22
  if
• 20:22
  it's
• 20:22
  really
• 20:23
  atypical,
• 20:23
  right.
• 20:23
  If
• 20:24
  you
• 20:24
  have
• 20:24
  a
• 20:24
  patient
• 20:24
  who's
• 20:24
  like
• 20:25
  55
• 20:25
  years
• 20:25
  old
• 20:26
  or
• 20:26
  45
• 20:26
  years
• 20:27
  old,
• 20:27
  and
• 20:27
  for
• 20:27
  the
• 20:28
  first
• 20:28
  time
• 20:28
  in
• 20:28
  their
• 20:28
  life
• 20:29
  they're
• 20:29
  starting
• 20:29
  to
• 20:30
  see
• 20:30
  devils
• 20:31
  dancing
• 20:31
  on
• 20:32
  their,
• 20:32
  on
• 20:32
  their
• 20:32
  piano
• 20:33
  at
• 20:33
  night,
• 20:34
  you
• 20:34
  might
• 20:35
  want
• 20:35
  a
• 20:35
  medical
• 20:35
  workup
• 20:36
  right
• 20:36
  away,
• 20:36
  right?
• 20:37
  Because
• 20:37
  that's
• 20:37
  unusual.
• 20:38
  No
• 20:39
  family
• 20:39
  history.
• 20:39
  Even
• 20:40
  more
• 20:40
  so
• 20:40
  do
• 20:40
  that
• 20:41
  medical
• 20:41
  workup.
• 20:41
  It's
• 20:42
  not
• 20:42
  normal.
• 20:43
  So
• 20:43
  know
• 20:43
  your
• 20:43
  age
• 20:43
  of
• 20:44
  onsets.
• 20:45
  That's
• 20:45
  very
• 20:45
  important.
• 20:47
  And
• 20:47
  then
• 20:47
  ask
• 20:47
  good
• 20:48
  questions,
• 20:49
  right?
• 20:50
  Ask
• 20:50
  good
• 20:50
  questions.
• 20:51
  Ask
• 20:51
  the
• 20:52
  patient.
• 20:52
  Do
• 20:52
  you
• 20:52
  really
• 20:52
  believe
• 20:53
  ninjas
• 20:53
  will
• 20:53
  attack
• 20:54
  you?
• 20:54
  Or
• 20:54
  is
• 20:54
  this
• 20:54
  thought
• 20:55
  something
• 20:55
  that
• 20:55
  you
• 20:55
  can't
• 20:56
  get
• 20:56
  out
• 20:56
  of
• 20:56
  your
• 20:56
  head
• 20:57
  even
• 20:57
  though
• 20:57
  part
• 20:58
  of
• 20:58
  you
• 20:58
  knows
• 20:58
  it
• 20:58
  doesn't
• 20:59
  really
• 20:59
  make
• 20:59
  any
• 20:59
  sense.
• 21:00
  Right?
• 21:03
  That's
• 21:03
  a
• 21:03
  key
• 21:04
  question.
• 21:05
  What
• 21:05
  else
• 21:05
  do
• 21:05
  you
• 21:06
  worry
• 21:06
  about?
• 21:06
  I
• 21:06
  love
• 21:06
  asking
• 21:07
  them
• 21:07
  that.
• 21:07
  Right.
• 21:07
  And
• 21:07
  people
• 21:08
  who
• 21:08
  don't
• 21:08
  have
• 21:08
  GAD
• 21:08
  are
• 21:09
  like,
• 21:09
  eh,
• 21:09
  not
• 21:09
  really
• 21:10
  anything.
• 21:10
  I've
• 21:10
  been
• 21:10
  pretty
• 21:11
  chill
• 21:11
  up
• 21:11
  until
• 21:11
  I
• 21:11
  was
• 21:12
  attacked
• 21:12
  a
• 21:12
  few
• 21:12
  months
• 21:12
  ago.
• 21:13
  Right.
• 21:13
  So
• 21:14
  that's,
• 21:14
  that's
• 21:14
  the
• 21:14
  patient
• 21:15
  orienting
• 21:15
  you
• 21:15
  back
• 21:15
  to
• 21:16
  ptsd
• 21:17
  or
• 21:17
  if
• 21:17
  they
• 21:17
  have
• 21:18
  delusional
• 21:18
  disorder,
• 21:19
  you'll
• 21:19
  find
• 21:20
  they're
• 21:20
  often
• 21:20
  not
• 21:21
  really
• 21:21
  worried
• 21:22
  that,
• 21:22
  that
• 21:22
  much,
• 21:23
  but
• 21:24
  they,
• 21:24
  their
• 21:25
  concerns
• 21:25
  are
• 21:25
  circumscribed
• 21:26
  to
• 21:26
  that
• 21:27
  delusion
• 21:27
  specifically
• 21:28
  and
• 21:28
  the
• 21:28
  themes
• 21:28
  related
• 21:29
  to
• 21:29
  that
• 21:29
  delusion.
• 21:30
  But
• 21:30
  outside
• 21:30
  of
• 21:30
  that,
• 21:31
  you
• 21:31
  don't
• 21:31
  necessarily
• 21:31
  get
• 21:31
  a
• 21:32
  lot
• 21:32
  of
• 21:32
  worry.
• 21:32
  Okay?
• 21:34
  And
• 21:35
  so
• 21:35
  that's
• 21:35
  really
• 21:35
  important.
• 21:36
  That's
• 21:36
  really,
• 21:37
  really
• 21:37
  important.
• 21:38
  I
• 21:38
  don't
• 21:38
  want
• 21:38
  to
• 21:38
  throw
• 21:39
  GAD
• 21:39
  out
• 21:39
  completely.
• 21:40
  I
• 21:40
  know
• 21:40
  I
• 21:40
  told
• 21:40
  you
• 21:41
  to
• 21:41
  throw
• 21:41
  it
• 21:41
  into
• 21:41
  the
• 21:41
  dustbin,
• 21:42
  but
• 21:42
  it
• 21:42
  is
• 21:43
  kind
• 21:43
  of
• 21:43
  important
• 21:44
  because
• 21:45
  a
• 21:45
  lot
• 21:45
  of
• 21:45
  people
• 21:45
  don't
• 21:46
  go
• 21:46
  to
• 21:46
  the
• 21:46
  store
• 21:46
  or
• 21:47
  they,
• 21:47
  they
• 21:47
  don't
• 21:47
  like
• 21:48
  to
• 21:48
  go
• 21:48
  in
• 21:48
  public
• 21:48
  because
• 21:49
  they,
• 21:49
  they
• 21:49
  assume
• 21:49
  the
• 21:50
  worst
• 21:50
  case
• 21:50
  scenario
• 21:50
  is
• 21:51
  going
• 21:51
  to
• 21:51
  happen.
• 21:51
  And
• 21:52
  so,
• 21:53
  yes,
• 21:53
  this
• 21:53
  is
• 21:54
  so
• 21:54
  specific
• 21:54
  that
• 21:54
  you
• 21:54
  can
• 21:55
  kind
• 21:55
  of
• 21:55
  toss
• 21:55
  GAD
• 21:56
  into
• 21:56
  the
• 21:56
  dustbin.
• 21:57
  At
• 21:57
  the
• 21:57
  same
• 21:57
  time,
• 21:57
  if
• 21:57
  they
• 21:58
  have
• 21:58
  a
• 21:58
  lot
• 21:58
  of
• 21:58
  concerns,
• 21:59
  like
• 21:59
  this,
• 22:00
  they
• 22:00
  don't
• 22:00
  go
• 22:00
  to
• 22:00
  concerts
• 22:01
  because
• 22:01
  they're
• 22:01
  afraid
• 22:01
  of,
• 22:02
  you
• 22:02
  know,
• 22:03
  mass
• 22:03
  shootings
• 22:03
  or
• 22:04
  they
• 22:04
  don't
• 22:05
  travel.
• 22:05
  They're
• 22:05
  afraid
• 22:05
  of
• 22:06
  airplane
• 22:06
  crashes.
• 22:08
  You
• 22:08
  may
• 22:08
  notice
• 22:09
  a
• 22:09
  theme
• 22:09
  of
• 22:10
  this
• 22:10
  patient
• 22:10
  is
• 22:11
  routinely
• 22:11
  worried
• 22:12
  about
• 22:12
  the
• 22:12
  worst
• 22:12
  case
• 22:13
  scenario.
• 22:14
  And
• 22:14
  so
• 22:16
  that
• 22:16
  almost
• 22:17
  looks
• 22:17
  delusional
• 22:18
  in
• 22:18
  a
• 22:18
  sense.
• 22:18
  Like,
• 22:18
  why
• 22:18
  do
• 22:19
  you
• 22:19
  feel
• 22:19
  like
• 22:19
  you're
• 22:20
  always
• 22:20
  about
• 22:20
  to
• 22:20
  get
• 22:20
  harmed?
• 22:21
  But
• 22:21
  GAD
• 22:22
  patients
• 22:22
  are
• 22:23
  going
• 22:23
  to
• 22:23
  kind
• 22:23
  of
• 22:23
  help
• 22:23
  you.
• 22:23
  They're
• 22:24
  going
• 22:24
  to
• 22:24
  say,
• 22:24
  I
• 22:25
  don't
• 22:25
  know.
• 22:25
  I
• 22:25
  know
• 22:25
  it's
• 22:26
  like,
• 22:26
  I
• 22:27
  know
• 22:27
  it's
• 22:27
  safe
• 22:27
  intellectually
• 22:28
  to
• 22:28
  fly.
• 22:28
  I
• 22:28
  just
• 22:29
  can't
• 22:29
  get
• 22:29
  myself
• 22:29
  to
• 22:29
  do
• 22:29
  it.
• 22:30
  I
• 22:30
  know
• 22:30
  intellectually
• 22:31
  I'll
• 22:31
  probably
• 22:31
  be
• 22:31
  okay
• 22:32
  at
• 22:32
  that
• 22:32
  concert.
• 22:32
  I
• 22:33
  just
• 22:33
  don't,
• 22:33
  you
• 22:33
  know,
• 22:33
  I
• 22:34
  can't
• 22:34
  muster
• 22:34
  up
• 22:34
  the
• 22:34
  courage
• 22:35
  to
• 22:35
  go
• 22:35
  because
• 22:35
  of
• 22:35
  all
• 22:36
  the
• 22:36
  stuff
• 22:36
  that
• 22:36
  could
• 22:36
  happen
• 22:37
  and
• 22:37
  has
• 22:37
  happened.
• 22:38
  Right.
• 22:38
  So
• 22:39
  the
• 22:39
  fact
• 22:39
  that
• 22:40
  we're
• 22:40
  only
• 22:40
  talking
• 22:41
  about
• 22:41
  ninjas
• 22:42
  is
• 22:42
  why
• 22:42
  I
• 22:42
  don't
• 22:42
  like
• 22:43
  GAD
• 22:43
  here.
• 22:44
  But
• 22:44
  if
• 22:44
  we
• 22:44
  were
• 22:44
  talking
• 22:44
  about
• 22:45
  ninjas
• 22:45
  and
• 22:47
  car
• 22:47
  wrecks
• 22:48
  and
• 22:48
  bankruptcies
• 22:49
  and
• 22:50
  a
• 22:50
  lot
• 22:50
  of
• 22:50
  other
• 22:50
  worst
• 22:50
  case
• 22:51
  scenarios,
• 22:51
  even
• 22:52
  if
• 22:52
  they
• 22:52
  were
• 22:52
  all
• 22:52
  kind
• 22:52
  of
• 22:52
  bizarre
• 22:53
  out
• 22:53
  of
• 22:53
  context,
• 22:54
  I
• 22:54
  may
• 22:54
  be
• 22:55
  a
• 22:55
  little
• 22:55
  more
• 22:55
  open
• 22:55
  to
• 22:56
  gad,
• 22:56
  But
• 22:57
  I
• 22:57
  don't
• 22:57
  think
• 22:57
  it
• 22:57
  quite
• 22:58
  fits
• 22:58
  the
• 22:59
  picture
• 22:59
  here,
• 23:00
  actually.
• 23:01
  So
• 23:01
  I
• 23:01
  hope
• 23:01
  you
• 23:02
  enjoyed
• 23:02
  this.
• 23:02
  I
• 23:02
  know
• 23:02
  I
• 23:03
  did.
• 23:03
  Um,
• 23:04
  I
• 23:04
  love
• 23:04
  those
• 23:05
  sweet
• 23:05
  spots
• 23:05
  in
• 23:05
  psychiatry
• 23:07
  that,
• 23:07
  you
• 23:07
  know,
• 23:07
  they
• 23:07
  come
• 23:07
  to
• 23:08
  your
• 23:08
  office
• 23:08
  and
• 23:08
  they
• 23:08
  could
• 23:09
  be
• 23:09
  nine
• 23:09
  different
• 23:09
  diagnoses
• 23:10
  at
• 23:10
  once,
• 23:11
  and
• 23:11
  you
• 23:11
  really
• 23:11
  don't
• 23:11
  know
• 23:12
  what
• 23:12
  they
• 23:12
  are.
• 23:13
  And
• 23:13
  you
• 23:14
  only
• 23:14
  can
• 23:14
  know
• 23:15
  through
• 23:15
  careful,
• 23:16
  intentional
• 23:17
  questioning
• 23:17
  of
• 23:18
  your
• 23:18
  patient,
• 23:18
  eliciting
• 23:19
  good
• 23:19
  information,
• 23:20
  getting
• 23:20
  collateral,
• 23:22
  and
• 23:23
  really
• 23:23
  assessing
• 23:24
  what
• 23:24
  is
• 23:24
  the
• 23:24
  root
• 23:25
  problem
• 23:25
  here
• 23:26
  and
• 23:26
  how
• 23:26
  does
• 23:27
  the
• 23:27
  patient
• 23:27
  perceive
• 23:28
  it.
• 23:28
  Right.
• 23:28
  Which
• 23:29
  I
• 23:29
  think
• 23:29
  is
• 23:29
  even
• 23:29
  the
• 23:29
  most
• 23:30
  important
• 23:30
  thing.
• 23:31
  Right.
• 23:31
  It's
• 23:31
  not
• 23:32
  just
• 23:32
  enough
• 23:32
  to
• 23:32
  know
• 23:32
  ninjas,
• 23:33
  the
• 23:33
  content
• 23:34
  of
• 23:34
  what
• 23:34
  they're
• 23:34
  saying,
• 23:35
  but,
• 23:35
  like,
• 23:36
  why
• 23:36
  do
• 23:36
  they
• 23:36
  specifically
• 23:37
  think
• 23:37
  this
• 23:37
  way?
• 23:38
  Right.
• 23:39
  Is
• 23:39
  it
• 23:39
  trauma
• 23:40
  or
• 23:40
  is
• 23:40
  it
• 23:41
  part
• 23:41
  of
• 23:41
  a
• 23:41
  bigger
• 23:41
  story?
• 23:43
  Right.
• 23:43
  That's
• 23:43
  really
• 23:44
  important.
• 23:44
  Do
• 23:45
  they
• 23:45
  believe
• 23:45
  this
• 23:45
  intensely
• 23:46
  or
• 23:46
  they
• 23:46
  do.
• 23:46
  Do
• 23:47
  they
• 23:47
  recognize
• 23:47
  this
• 23:47
  is
• 23:48
  kind
• 23:48
  of
• 23:48
  weak
• 23:49
  and
• 23:49
  thready
• 23:49
  and
• 23:50
  unrealistic?
• 23:51
  Right.
• 23:52
  Also
• 23:53
  super
• 23:53
  important
• 23:54
  and
• 23:54
  super
• 23:54
  interesting.
• 23:56
  And
• 23:56
  it
• 23:56
  really
• 23:56
  relies,
• 23:57
  I
• 23:57
  can't
• 23:57
  emphasize
• 23:57
  enough.
• 23:58
  It
• 23:58
  really
• 23:58
  relies
• 23:58
  on
• 23:59
  you
• 23:59
  being
• 23:59
  able
• 23:59
  to
• 23:59
  ask
• 24:00
  really
• 24:00
  good
• 24:00
  questions.
• 24:01
  And
• 24:01
  having
• 24:01
  an
• 24:01
  understanding
• 24:02
  of
• 24:02
  age
• 24:02
  of
• 24:02
  onset
• 24:03
  is
• 24:04
  really
• 24:04
  important.
• 24:05
  Having
• 24:05
  an
• 24:05
  understanding
• 24:06
  of
• 24:06
  the
• 24:06
  other
• 24:06
  components
• 24:07
  in
• 24:07
  that
• 24:07
  DSM
• 24:08
  diagnosis
• 24:09
  to
• 24:09
  make
• 24:09
  sure
• 24:09
  you're
• 24:10
  ruling
• 24:10
  stuff
• 24:10
  out.
• 24:11
  And
• 24:11
  if
• 24:11
  you
• 24:12
  start
• 24:12
  to
• 24:12
  see
• 24:12
  the
• 24:12
  cluster
• 24:13
  of
• 24:13
  PTSD
• 24:13
  kind
• 24:14
  of
• 24:14
  align
• 24:14
  into
• 24:15
  this
• 24:15
  constellation
• 24:16
  in
• 24:16
  the
• 24:16
  sky,
• 24:17
  then
• 24:17
  then,
• 24:17
  yes,
• 24:18
  that's
• 24:18
  the
• 24:18
  Big
• 24:18
  Dipper.
• 24:19
  That's
• 24:19
  the
• 24:19
  one.
• 24:19
  Right.
• 24:20
  And
• 24:20
  then
• 24:21
  if
• 24:21
  you
• 24:21
  start
• 24:21
  to
• 24:21
  see
• 24:21
  another
• 24:22
  constellation
• 24:23
  align
• 24:24
  well,
• 24:24
  that's
• 24:25
  also.
• 24:26
  That
• 24:26
  also
• 24:26
  might
• 24:26
  be
• 24:26
  the
• 24:27
  one.
• 24:27
  And
• 24:27
  I
• 24:27
  think
• 24:27
  in
• 24:27
  this
• 24:27
  case
• 24:28
  we
• 24:28
  saw
• 24:28
  PTSD
• 24:29
  and
• 24:30
  ocd.
• 24:31
  Both
• 24:31
  constellations
• 24:32
  can
• 24:32
  be
• 24:32
  in
• 24:33
  the
• 24:33
  night
• 24:33
  sky
• 24:33
  at
• 24:33
  the
• 24:34
  same
• 24:34
  time
• 24:34
  and
• 24:34
  it's
• 24:34
  okay
• 24:35
  for
• 24:35
  you
• 24:35
  to
• 24:35
  choose
• 24:35
  both
• 24:35
  of
• 24:36
  them.
• 24:36
  And
• 24:37
  at
• 24:37
  the
• 24:37
  end
• 24:37
  of
• 24:37
  the
• 24:37
  day,
• 24:38
  this
• 24:38
  is
• 24:38
  all
• 24:38
  about
• 24:38
  treating
• 24:39
  the
• 24:39
  patient
• 24:39
  anyway,
• 24:40
  right?
• 24:40
  So
• 24:40
  SSRIs
• 24:41
  are
• 24:41
  first
• 24:42
  line
• 24:43
  for
• 24:43
  OCD,
• 24:44
  high
• 24:44
  dose.
• 24:45
  Typically
• 24:45
  PTSD
• 24:46
  involves
• 24:46
  kind
• 24:47
  of
• 24:47
  high
• 24:47
  dose
• 24:47
  SSRIs
• 24:48
  depending
• 24:49
  on
• 24:49
  the
• 24:49
  patient.
• 24:49
  Of
• 24:50
  course,
• 24:50
  psychotherapy
• 24:51
  is
• 24:51
  extremely
• 24:51
  key.
• 24:51
  It's
• 24:52
  gold
• 24:52
  standard.
• 24:53
  But
• 24:53
  either
• 24:53
  way,
• 24:53
  you're
• 24:54
  not
• 24:54
  going
• 24:54
  to
• 24:54
  be
• 24:54
  that
• 24:54
  wrong
• 24:55
  if
• 24:55
  you
• 24:55
  pick
• 24:55
  an
• 24:55
  SSRI
• 24:56
  here
• 24:56
  to
• 24:56
  treat
• 24:57
  some
• 24:57
  of
• 24:57
  that
• 24:58
  hyperarousal,
• 24:59
  the
• 25:00
  amygdala,
• 25:01
  you
• 25:01
  know,
• 25:01
  overreacting
• 25:03
  in
• 25:03
  real
• 25:04
  time.
• 25:04
  You're
• 25:04
  going
• 25:05
  to
• 25:05
  do
• 25:05
  pretty
• 25:05
  good
• 25:06
  with
• 25:06
  a
• 25:06
  Zoloft
• 25:07
  or
• 25:07
  a
• 25:07
  Lexapo
• 25:08
  or
• 25:08
  a
• 25:08
  Prozac,
• 25:09
  depending
• 25:09
  on
• 25:09
  the
• 25:09
  context.
• 25:10
  So
• 25:11
  yeah.
• 25:11
  Thank
• 25:11
  you
• 25:11
  all
• 25:12
  for
• 25:12
  joining
• 25:13
  this
• 25:13
  discussion
• 25:13
  today.
• 25:14
  And
• 25:14
  I
• 25:14
  cannot
• 25:15
  emphasize
• 25:15
  this
• 25:15
  enough,
• 25:16
  my
• 25:16
  friends.
• 25:19
  The
• 25:19
  difference
• 25:19
  between
• 25:20
  a
• 25:21
  good
• 25:21
  clinician
• 25:22
  and
• 25:22
  a
• 25:22
  great
• 25:23
  clinician
• 25:23
  is
• 25:25
  are
• 25:25
  the
• 25:25
  ones
• 25:25
  who
• 25:25
  really
• 25:26
  understand
• 25:26
  the
• 25:26
  how
• 25:26
  and
• 25:27
  the
• 25:27
  why
• 25:27
  of
• 25:27
  what
• 25:27
  they're
• 25:27
  doing.
• 25:28
  And
• 25:28
  patients
• 25:28
  can
• 25:29
  smell
• 25:29
  that
• 25:29
  a
• 25:29
  mile
• 25:30
  away.
• 25:30
  I
• 25:31
  built
• 25:31
  an
• 25:31
  entire
• 25:31
  Patreon
• 25:32
  clinical
• 25:33
  library
• 25:33
  with
• 25:34
  visual
• 25:34
  sticky,
• 25:35
  beautiful,
• 25:38
  beautiful
• 25:38
  materials
• 25:39
  for
• 25:39
  you
• 25:39
  to
• 25:40
  really
• 25:40
  soak
• 25:40
  this
• 25:40
  up
• 25:41
  and
• 25:41
  know
• 25:41
  it
• 25:41
  like
• 25:42
  the
• 25:42
  back
• 25:42
  of
• 25:42
  your
• 25:42
  hand
• 25:43
  and
• 25:43
  be
• 25:43
  the
• 25:43
  difference
• 25:44
  between
• 25:44
  the
• 25:44
  good
• 25:45
  and
• 25:45
  the
• 25:45
  great
• 25:45
  clinician.
• 25:46
  Not
• 25:46
  just
• 25:46
  to
• 25:46
  memorize
• 25:47
  algos
• 25:47
  and
• 25:48
  medications,
• 25:49
  but
• 25:49
  to
• 25:49
  really
• 25:50
  appreciate
• 25:50
  and
• 25:50
  understand
• 25:51
  the
• 25:52
  how
• 25:52
  and
• 25:52
  why
• 25:53
  of
• 25:53
  your
• 25:53
  meds
• 25:53
  and
• 25:54
  your
• 25:54
  diagnosis.
• 25:55
  That's
• 25:55
  the
• 25:55
  key.
• 25:55
  That's
• 25:55
  what's
• 25:56
  going
• 25:56
  to
• 25:56
  separate
• 25:56
  you,
• 25:56
  give
• 25:56
  you
• 25:57
  the
• 25:57
  confidence
• 25:57
  to
• 25:57
  achieve
• 25:58
  great
• 25:58
  outcomes
• 25:58
  in
• 25:58
  your
• 25:59
  clinic,
• 25:59
  make
• 26:00
  your.
• 26:00
  Make
• 26:00
  your
• 26:00
  patients
• 26:01
  lives
• 26:01
  smoother
• 26:01
  and
• 26:02
  really
• 26:02
  shine
• 26:02
  as
• 26:03
  a
• 26:03
  clinician
• 26:03
  that
• 26:03
  they
• 26:03
  trust
• 26:04
  and
• 26:04
  understand
• 26:05
  and
• 26:05
  to
• 26:05
  get
• 26:05
  really
• 26:06
  precise
• 26:06
  and
• 26:06
  love
• 26:07
  your
• 26:07
  field.
• 27:02
  That's
• 27:02
  why
• 27:02
  we
• 26:08
  built
• 27:03
  this
• 27:03
  library.
• 27:04
  I.
• 27:04
  I
• 27:04
  would
• 27:05
  be
• 27:05
  genuinely
• 27:05
  terrified
• 27:06
  to
• 27:06
  think
• 27:07
  of
• 27:07
  who
• 27:07
  I
• 27:07
  would
• 27:07
  be
• 27:07
  as
• 27:07
  a
• 27:08
  clinician
• 27:08
  without
• 27:08
  this
• 27:09
  library.
• 27:09
  It's
• 27:09
  my
• 27:09
  go
• 27:10
  to
• 27:10
  reference
• 27:10
  point.
• 27:11
  It
• 27:11
  makes
• 27:11
  everything
• 27:12
  make
• 27:12
  sense
• 27:12
  in
• 27:12
  the
• 27:12
  most
• 27:13
  beautiful
• 27:13
  way.
• 27:14
  Highly
• 27:14
  recommend
• 27:15
  you
• 27:15
  go
• 27:15
  to
• 27:15
  the
• 27:15
  show
• 27:15
  notes
• 27:16
  before
• 27:16
  you
• 27:16
  go
• 27:17
  to
• 27:17
  bed
• 27:17
  tonight
• 27:17
  and
• 27:17
  become
• 27:18
  a
• 27:18
  member
• 27:18
  and
• 27:18
  tell
• 27:18
  all
• 27:19
  your
• 27:19
  friends
• 27:19
  because
• 27:19
  it's
• 27:19
  getting
• 27:20
  popular
• 27:20
  quickly.
• 27:21
  We
• 27:21
  love
• 27:21
  it.
• 27:21
  We'd
• 27:21
  love
• 27:22
  to
• 27:22
  have
• 27:22
  you.
• 27:22
  Until
• 27:22
  next
• 27:23
  time,
• 27:23
  my
• 27:23
  friends.
• 27:24
  We
• 27:24
  will
• 27:24
  see
• 27:24
  you
• 27:24
  here
• 27:25
  at
• 27:26
  Pearls
• 27:26
  and
• 27:26
  Prep.
• 27:27
  Bye
• 27:27
  bye.