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Psychiatric Board Bomb: Can You Nail this Diagnosis? It is Trickier Than You Think! · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:05
  back,
• 0:05
  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.
• 0:09
  This
• 0:09
  is
• 0:09
  a
• 0:09
  bonus
• 0:10
  episode.
• 0:11
  Board
• 0:11
  bombs.
• 0:12
  Backed
• 0:12
  by
• 0:13
  popular
• 0:13
  demand,
• 0:14
  we
• 0:14
  had
• 0:14
  a
• 0:14
  technical
• 0:15
  glitch
• 0:15
  yesterday.
• 0:16
  We
• 0:16
  apologize
• 0:17
  to
• 0:17
  the
• 0:18
  hundreds
• 0:18
  of
• 0:18
  millions
• 0:19
  of
• 0:19
  you
• 0:19
  who
• 0:19
  were
• 0:19
  tuning
• 0:20
  in,
• 0:20
  sending
• 0:21
  me
• 0:21
  hate
• 0:21
  mail.
• 0:22
  It's
• 0:22
  okay.
• 0:22
  We
• 0:22
  are
• 0:23
  back
• 0:23
  and
• 0:23
  we
• 0:23
  have
• 0:23
  an
• 0:23
  even
• 0:24
  better
• 0:24
  board
• 0:24
  bomb
• 0:25
  today.
• 0:25
  And
• 0:25
  the
• 0:26
  best
• 0:26
  part
• 0:26
  of
• 0:26
  this
• 0:26
  board
• 0:26
  bomb
• 0:27
  is
• 0:27
  that
• 0:27
  you're
• 0:27
  going
• 0:27
  to
• 0:27
  actually
• 0:28
  hear
• 0:28
  it
• 0:28
  to
• 0:29
  completion.
• 0:29
  We
• 0:29
  really
• 0:30
  left
• 0:30
  you
• 0:30
  on
• 0:30
  a
• 0:30
  cliffhanger
• 0:31
  yesterday
• 0:32
  due
• 0:32
  to
• 0:32
  technical
• 0:33
  glitches,
• 0:33
  okay?
• 0:34
  But
• 0:35
  hey,
• 0:35
  here
• 0:35
  we
• 0:36
  are.
• 0:36
  And
• 0:36
  I
• 0:36
  think
• 0:36
  this
• 0:37
  is
• 0:37
  going
• 0:37
  to
• 0:37
  really
• 0:37
  test
• 0:37
  you
• 0:38
  and
• 0:38
  it's
• 0:38
  going
• 0:39
  to
• 0:39
  really
• 0:39
  keep
• 0:39
  you
• 0:39
  at
• 0:39
  the
• 0:39
  top
• 0:40
  of
• 0:40
  your
• 0:40
  game.
• 0:40
  And
• 0:40
  that's
• 0:41
  why
• 0:41
  we
• 0:41
  do
• 0:41
  these
• 0:41
  pearls,
• 0:42
  right?
• 0:42
  I
• 0:42
  sift
• 0:43
  through
• 0:43
  the
• 0:43
  depths
• 0:44
  of
• 0:44
  the
• 0:44
  ocean
• 0:44
  floor
• 0:45
  to
• 0:45
  find
• 0:46
  that
• 0:46
  shiny
• 0:47
  pearl,
• 0:47
  right?
• 0:47
  I
• 0:48
  swim
• 0:48
  past
• 0:48
  beluga
• 0:49
  whales
• 0:49
  who
• 0:49
  are
• 0:50
  trying
• 0:50
  to
• 0:50
  swallow
• 0:50
  me
• 0:51
  whole.
• 0:51
  I
• 0:52
  swim
• 0:52
  past
• 0:52
  the
• 0:53
  fishing
• 0:53
  lines
• 0:53
  that
• 0:53
  are
• 0:53
  trying
• 0:54
  to
• 0:54
  hook
• 0:54
  me
• 0:54
  and
• 0:55
  make
• 0:55
  my
• 0:55
  gums
• 0:56
  bleed
• 0:56
  and
• 0:57
  reel
• 0:57
  me
• 0:57
  up
• 0:57
  to
• 0:58
  the
• 0:58
  top.
• 0:58
  So
• 0:58
  I'm
• 0:58
  flopping
• 0:59
  on
• 0:59
  the
• 0:59
  bottom
• 1:00
  of
• 1:00
  a
• 1:00
  boat
• 1:00
  being
• 1:01
  slapped
• 1:01
  around
• 1:01
  by
• 1:01
  a
• 1:02
  bearded
• 1:02
  fisherman,
• 1:03
  right?
• 1:03
  My
• 1:04
  job
• 1:04
  is
• 1:04
  to
• 1:05
  swim
• 1:05
  to
• 1:05
  the
• 1:05
  depths
• 1:05
  and
• 1:06
  find
• 1:06
  you
• 1:06
  those
• 1:06
  shiny
• 1:07
  pearls
• 1:07
  so
• 1:08
  that
• 1:08
  you
• 1:08
  can
• 1:09
  separate
• 1:10
  the
• 1:10
  sand
• 1:11
  from
• 1:11
  the
• 1:11
  pearl
• 1:12
  and
• 1:13
  have
• 1:13
  what
• 1:13
  you
• 1:13
  need
• 1:14
  to
• 1:14
  practice
• 1:14
  at
• 1:14
  the
• 1:15
  top
• 1:15
  of
• 1:15
  your
• 1:15
  game.
• 1:15
  This
• 1:16
  isn't
• 1:16
  meant
• 1:16
  so
• 1:16
  that
• 1:16
  you
• 1:17
  can
• 1:17
  just
• 1:17
  call
• 1:17
  your
• 1:17
  friends
• 1:18
  and
• 1:18
  impress
• 1:18
  them
• 1:18
  with
• 1:19
  knowledge
• 1:19
  that
• 1:19
  you
• 1:19
  have.
• 1:20
  That's
• 1:20
  not
• 1:20
  what
• 1:20
  this
• 1:21
  is
• 1:21
  about.
• 1:21
  This
• 1:21
  is
• 1:22
  about
• 1:22
  high
• 1:23
  yield
• 1:23
  pearls
• 1:23
  that
• 1:23
  make
• 1:24
  you
• 1:24
  better
• 1:24
  in
• 1:24
  your
• 1:24
  practice.
• 1:25
  They
• 1:26
  help
• 1:26
  you
• 1:26
  pass
• 1:26
  your
• 1:27
  boards,
• 1:27
  they
• 1:27
  help
• 1:27
  you
• 1:28
  get
• 1:28
  that
• 1:28
  job,
• 1:29
  that
• 1:29
  competitive
• 1:30
  edge,
• 1:30
  because
• 1:31
  you
• 1:31
  understand
• 1:31
  the
• 1:31
  nuance
• 1:32
  and
• 1:32
  the
• 1:33
  diagnostics
• 1:33
  and
• 1:34
  the
• 1:34
  treatment
• 1:34
  implications
• 1:35
  and
• 1:35
  your
• 1:35
  patients
• 1:36
  get
• 1:36
  better
• 1:36
  and
• 1:37
  your
• 1:37
  clinic
• 1:37
  runs
• 1:38
  smoother
• 1:38
  and
• 1:38
  their
• 1:39
  lives
• 1:39
  are
• 1:39
  smoother.
• 1:40
  So
• 1:41
  without
• 1:42
  further
• 1:42
  ado,
• 1:42
  my
• 1:42
  friends,
• 1:43
  knock,
• 1:43
  knock,
• 1:44
  knock.
• 1:45
  In
• 1:45
  your
• 1:45
  office
• 1:45
  you
• 1:46
  have
• 1:46
  a
• 1:46
  28
• 1:46
  year
• 1:47
  old
• 1:47
  woman.
• 1:47
  She
• 1:47
  presents
• 1:49
  with
• 1:49
  a
• 1:49
  history
• 1:50
  of
• 1:50
  reoccurring
• 1:50
  major
• 1:51
  depressive
• 1:51
  episodes
• 1:52
  over
• 1:52
  the
• 1:53
  past
• 1:53
  two
• 1:53
  years.
• 1:54
  She
• 1:54
  described
• 1:55
  several
• 1:55
  distinct
• 1:56
  four
• 1:56
  to
• 1:56
  five
• 1:57
  day
• 1:57
  episodes
• 1:57
  of
• 1:57
  elevated
• 1:58
  mood,
• 1:59
  decreased
• 1:59
  need
• 1:59
  for
• 2:00
  sleep,
• 2:00
  pressured
• 2:00
  speech,
• 2:01
  and
• 2:01
  increased
• 2:02
  goal
• 2:02
  directed
• 2:02
  activity.
• 2:04
  And
• 2:04
  they
• 2:04
  have
• 2:05
  not
• 2:05
  required
• 2:05
  hospitalization.
• 2:06
  Now,
• 2:07
  she's
• 2:07
  currently
• 2:08
  euthymic.
• 2:09
  Okay.
• 2:09
  She
• 2:10
  reports
• 2:10
  that
• 2:10
  about
• 2:11
  18
• 2:11
  days
• 2:12
  ago,
• 2:12
  little
• 2:13
  over
• 2:13
  two
• 2:13
  and
• 2:13
  a
• 2:13
  half,
• 2:13
  you
• 2:14
  know,
• 2:14
  two
• 2:14
  and
• 2:14
  a
• 2:14
  half
• 2:14
  weeks
• 2:14
  ago.
• 2:15
  During
• 2:16
  her
• 2:16
  most
• 2:16
  recent
• 2:17
  elevated
• 2:17
  mood
• 2:18
  episode,
• 2:18
  she
• 2:19
  became
• 2:19
  convinced
• 2:20
  that
• 2:20
  her
• 2:20
  neighbor
• 2:20
  was
• 2:20
  recording
• 2:21
  her
• 2:21
  conversations
• 2:22
  through
• 2:22
  the
• 2:22
  walls.
• 2:23
  It's
• 2:23
  really
• 2:23
  the
• 2:24
  only
• 2:24
  big
• 2:24
  difference
• 2:25
  that
• 2:26
  you've
• 2:26
  gathered
• 2:26
  since
• 2:27
  you've
• 2:27
  last
• 2:27
  seen
• 2:27
  your
• 2:27
  patient.
• 2:28
  The
• 2:29
  belief
• 2:29
  lasted
• 2:29
  about
• 2:30
  10
• 2:30
  days
• 2:30
  and
• 2:30
  then
• 2:30
  it
• 2:30
  kind
• 2:31
  of
• 2:31
  resolved
• 2:31
  when
• 2:31
  the
• 2:31
  episode
• 2:32
  ended.
• 2:33
  You
• 2:33
  did
• 2:33
  a
• 2:33
  uds.
• 2:34
  Urine
• 2:34
  drug
• 2:34
  screen
• 2:35
  is
• 2:35
  negative.
• 2:35
  Labs
• 2:36
  are
• 2:36
  unremarkable
• 2:36
  and
• 2:36
  there's
• 2:37
  no
• 2:37
  history
• 2:37
  of
• 2:38
  substance
• 2:38
  abuse
• 2:40
  in
• 2:40
  the
• 2:40
  record
• 2:41
  at
• 2:41
  all.
• 2:42
  So,
• 2:42
  my
• 2:42
  friends,
• 2:42
  which
• 2:43
  of
• 2:43
  the
• 2:43
  following
• 2:43
  is
• 2:44
  the
• 2:44
  most
• 2:44
  accurate
• 2:45
  diagnosis?
• 2:46
  Is
• 2:46
  it
• 2:46
  A,
• 2:47
  brief
• 2:48
  psychotic
• 2:48
  disorder?
• 2:49
  Is
• 2:50
  it
• 2:50
  B,
• 2:51
  bipolar
• 2:51
  2
• 2:52
  disorder?
• 2:52
  Is
• 2:53
  it
• 2:53
  C,
• 2:53
  bipolar
• 2:54
  1
• 2:54
  disorder?
• 2:55
  Is
• 2:55
  it
• 2:56
  D,
• 2:56
  MDD,
• 2:57
  severe
• 2:57
  with
• 2:58
  psychotic
• 2:58
  features?
• 2:59
  Or
• 2:59
  is
• 2:59
  it
• 2:59
  E,
• 3:00
  schizoaffective
• 3:01
  disorder,
• 3:02
  bipolar
• 3:03
  type?
• 3:04
  I'm
• 3:04
  going
• 3:05
  to
• 3:05
  let
• 3:05
  you
• 3:05
  think
• 3:05
  about
• 3:05
  it.
• 3:05
  You
• 3:06
  can
• 3:06
  hit
• 3:06
  pause.
• 3:07
  This
• 3:07
  is
• 3:07
  a
• 3:07
  good
• 3:08
  time
• 3:08
  to
• 3:08
  break
• 3:08
  out
• 3:08
  into
• 3:09
  your
• 3:09
  zoom
• 3:09
  sessions
• 3:10
  and
• 3:11
  get
• 3:11
  into
• 3:12
  verbal
• 3:13
  altercations.
• 3:14
  Hopefully
• 3:14
  not
• 3:14
  physical,
• 3:15
  although
• 3:15
  it's
• 3:15
  over
• 3:16
  zoom,
• 3:16
  so
• 3:16
  it's
• 3:17
  pretty
• 3:17
  rare
• 3:17
  that
• 3:18
  anybody
• 3:18
  throws
• 3:18
  a
• 3:18
  punch.
• 3:20
  They
• 3:21
  have
• 3:21
  like
• 3:21
  a
• 3:22
  thumbs
• 3:22
  up
• 3:22
  sign
• 3:23
  on
• 3:23
  zoom,
• 3:23
  but
• 3:24
  they
• 3:24
  don't
• 3:24
  have
• 3:24
  fists
• 3:25
  yet.
• 3:27
  I
• 3:27
  don't
• 3:27
  think
• 3:27
  we're
• 3:28
  going
• 3:28
  that
• 3:28
  route.
• 3:28
  I
• 3:28
  know
• 3:28
  that
• 3:29
  we're
• 3:29
  all
• 3:29
  getting
• 3:30
  kind
• 3:30
  of
• 3:30
  angrier
• 3:30
  as
• 3:31
  a
• 3:31
  society,
• 3:31
  but
• 3:31
  I
• 3:32
  haven't
• 3:32
  seen
• 3:32
  fists
• 3:33
  on
• 3:33
  zoom.
• 3:33
  So
• 3:34
  if
• 3:34
  you
• 3:34
  need
• 3:34
  to
• 3:34
  pause
• 3:34
  this,
• 3:35
  go
• 3:35
  for
• 3:35
  it
• 3:36
  and,
• 3:37
  okay,
• 3:37
  I'm
• 3:37
  going
• 3:37
  to
• 3:37
  tell
• 3:38
  you
• 3:38
  the
• 3:38
  answer.
• 3:38
  Okay?
• 3:39
  Or
• 3:39
  maybe
• 3:40
  we'll
• 3:40
  dance
• 3:40
  around
• 3:40
  the
• 3:41
  answer
• 3:41
  and
• 3:41
  go
• 3:42
  to
• 3:42
  the
• 3:42
  wrong
• 3:42
  ones
• 3:42
  first.
• 3:43
  So
• 3:43
  what
• 3:43
  are
• 3:43
  we
• 3:44
  thinking
• 3:44
  about
• 3:44
  this,
• 3:44
  my
• 3:44
  friends?
• 3:45
  This
• 3:45
  is
• 3:45
  kind
• 3:45
  of
• 3:45
  a
• 3:45
  confusing
• 3:46
  one
• 3:47
  at
• 3:48
  the
• 3:48
  surface,
• 3:48
  right?
• 3:49
  So
• 3:49
  you,
• 3:49
  you
• 3:49
  clearly
• 3:50
  see
• 3:50
  there's,
• 3:51
  it's
• 3:51
  a
• 3:51
  very
• 3:52
  good
• 3:52
  bet
• 3:52
  when
• 3:52
  you
• 3:52
  look
• 3:52
  at
• 3:53
  this
• 3:53
  to
• 3:53
  say,
• 3:53
  okay,
• 3:54
  there's
• 3:54
  some
• 3:54
  bipolar,
• 3:55
  bipolarity
• 3:55
  going
• 3:56
  on
• 3:56
  here,
• 3:56
  right?
• 3:56
  This
• 3:56
  isn't,
• 3:57
  this
• 3:57
  isn't
• 3:59
  decreased
• 3:59
  need
• 3:59
  for
• 3:59
  sleep
• 4:00
  and
• 4:00
  pressured
• 4:00
  speech
• 4:01
  like
• 4:01
  this
• 4:01
  isn't
• 4:01
  normal.
• 4:01
  This
• 4:02
  is
• 4:02
  not
• 4:02
  just
• 4:02
  unipolar
• 4:03
  depression,
• 4:03
  right?
• 4:03
  And
• 4:04
  I've
• 4:04
  always
• 4:04
  urged
• 4:05
  you
• 4:05
  guys,
• 4:05
  before
• 4:06
  you
• 4:07
  panic
• 4:08
  and
• 4:08
  scramble
• 4:09
  about
• 4:09
  with,
• 4:09
  with
• 4:10
  the
• 4:10
  specifiers
• 4:11
  or
• 4:11
  the
• 4:11
  specifics
• 4:11
  of
• 4:12
  what
• 4:12
  you're
• 4:12
  looking
• 4:12
  at
• 4:13
  when
• 4:13
  you're
• 4:13
  hearing
• 4:13
  a
• 4:13
  patient
• 4:14
  talk
• 4:14
  to
• 4:14
  you
• 4:15
  before
• 4:15
  the
• 4:15
  panic
• 4:16
  sets
• 4:16
  in,
• 4:16
  just
• 4:17
  kind
• 4:17
  of
• 4:17
  zoom
• 4:17
  out
• 4:17
  and
• 4:18
  go,
• 4:18
  okay,
• 4:18
  this
• 4:18
  sounds
• 4:19
  like
• 4:19
  a
• 4:19
  mood
• 4:19
  disorder.
• 4:20
  This
• 4:20
  sounds
• 4:20
  like
• 4:20
  bipolarity.
• 4:21
  Something
• 4:22
  about
• 4:22
  bipolarity
• 4:23
  has
• 4:23
  to
• 4:23
  be
• 4:24
  talked
• 4:24
  about
• 4:24
  here,
• 4:25
  right?
• 4:25
  Because
• 4:25
  we're
• 4:26
  seeing
• 4:26
  a
• 4:26
  constellation
• 4:27
  of
• 4:27
  symptoms,
• 4:28
  right?
• 4:28
  This
• 4:29
  is
• 4:29
  not
• 4:29
  just
• 4:30
  someone
• 4:31
  who
• 4:31
  is
• 4:31
  worried
• 4:32
  their
• 4:32
  neighbor
• 4:32
  is
• 4:33
  recording
• 4:33
  them.
• 4:33
  Okay,
• 4:34
  that,
• 4:34
  that
• 4:34
  could
• 4:35
  definitely.
• 4:35
  We
• 4:36
  can
• 4:36
  talk
• 4:36
  about
• 4:36
  delusions
• 4:37
  and
• 4:37
  schizophrenia.
• 4:39
  We've
• 4:39
  ruled
• 4:40
  out
• 4:40
  substance
• 4:40
  use
• 4:41
  problems,
• 4:41
  but
• 4:41
  you
• 4:41
  know
• 4:41
  what
• 4:41
  I
• 4:42
  mean,
• 4:42
  that,
• 4:42
  that's
• 4:42
  one
• 4:42
  rabbit
• 4:43
  hole,
• 4:43
  but
• 4:43
  this
• 4:44
  is
• 4:44
  a
• 4:44
  constellation
• 4:45
  on
• 4:45
  your
• 4:45
  lap.
• 4:46
  It's
• 4:46
  almost
• 4:46
  like
• 4:46
  somebody
• 4:47
  just
• 4:47
  picked
• 4:48
  apart
• 4:48
  sentences
• 4:49
  from
• 4:49
  the
• 4:49
  DSM
• 4:50
  and,
• 4:50
  and
• 4:51
  just
• 4:51
  shared
• 4:51
  em
• 4:52
  with
• 4:52
  you.
• 4:52
  And
• 4:53
  they're
• 4:53
  specific
• 4:53
  sentences
• 4:54
  from
• 4:54
  a
• 4:54
  very
• 4:54
  specific
• 4:55
  mood
• 4:55
  disorder,
• 4:56
  bipolar.
• 4:56
  Whether
• 4:56
  it's
• 4:57
  one
• 4:57
  or
• 4:57
  two,
• 4:57
  we
• 4:57
  don't
• 4:57
  know.
• 4:58
  Whether
• 4:58
  it's
• 4:58
  cyclothymia,
• 4:59
  we
• 4:59
  don't
• 4:59
  know.
• 5:00
  That's
• 5:00
  what
• 5:00
  we
• 5:00
  need
• 5:01
  to
• 5:01
  parse
• 5:01
  out
• 5:01
  and
• 5:02
  think
• 5:02
  about.
• 5:02
  But
• 5:03
  this
• 5:03
  is
• 5:04
  clearly
• 5:05
  a
• 5:06
  constellation
• 5:07
  of
• 5:07
  mood
• 5:07
  disorder
• 5:08
  symptoms.
• 5:09
  I
• 5:09
  don't
• 5:09
  see
• 5:10
  GAD
• 5:10
  here.
• 5:10
  Remember,
• 5:12
  it's
• 5:12
  not
• 5:12
  just
• 5:12
  enough
• 5:12
  to
• 5:13
  think
• 5:13
  about
• 5:13
  what
• 5:13
  your
• 5:14
  patient
• 5:14
  is
• 5:14
  telling
• 5:15
  you.
• 5:15
  It's
• 5:16
  also
• 5:16
  important
• 5:16
  to
• 5:16
  think
• 5:17
  about
• 5:17
  what
• 5:17
  they
• 5:17
  are
• 5:17
  not
• 5:18
  telling
• 5:18
  you.
• 5:19
  And
• 5:19
  I
• 5:19
  know
• 5:19
  that
• 5:19
  may
• 5:19
  sound
• 5:20
  extremely
• 5:21
  obvious
• 5:21
  to
• 5:21
  some
• 5:22
  of
• 5:22
  you,
• 5:22
  but
• 5:22
  it
• 5:22
  is
• 5:22
  a
• 5:23
  nice
• 5:23
  way
• 5:23
  to
• 5:23
  kind
• 5:23
  of
• 5:24
  reinforce
• 5:26
  your
• 5:27
  some
• 5:27
  diagnostic
• 5:28
  certainty
• 5:28
  or
• 5:29
  some
• 5:29
  confidence
• 5:30
  because
• 5:31
  none
• 5:31
  of
• 5:31
  this
• 5:31
  screams
• 5:32
  anxiety.
• 5:32
  Yes,
• 5:33
  she's
• 5:34
  convinced
• 5:35
  that
• 5:35
  her
• 5:35
  neighbor
• 5:36
  is
• 5:36
  recording
• 5:36
  her,
• 5:36
  but
• 5:37
  did
• 5:37
  she
• 5:37
  tell
• 5:37
  you
• 5:37
  she's
• 5:38
  having
• 5:38
  anxiety
• 5:39
  attacks
• 5:39
  about
• 5:39
  it?
• 5:40
  Did
• 5:40
  she
• 5:40
  tell
• 5:40
  you
• 5:40
  she's
• 5:41
  staying
• 5:41
  up
• 5:41
  all
• 5:41
  night
• 5:41
  worrying
• 5:42
  about
• 5:42
  that?
• 5:43
  No.
• 5:43
  I
• 5:43
  don't
• 5:44
  see
• 5:44
  anything
• 5:44
  on
• 5:44
  here
• 5:45
  that
• 5:45
  speaks
• 5:45
  about
• 5:46
  anxiety.
• 5:46
  I.
• 5:47
  I
• 5:47
  don't
• 5:47
  see
• 5:47
  anything
• 5:47
  about
• 5:47
  here
• 5:48
  anything
• 5:48
  on
• 5:49
  here
• 5:49
  that
• 5:49
  has
• 5:49
  anything
• 5:50
  to
• 5:50
  do
• 5:50
  with
• 5:50
  trauma.
• 5:51
  Right.
• 5:51
  Obviously,
• 5:52
  maybe
• 5:53
  a
• 5:53
  patient
• 5:53
  would
• 5:53
  tell
• 5:53
  you
• 5:53
  it's
• 5:54
  traumatic
• 5:54
  that
• 5:54
  their
• 5:54
  neighbor
• 5:55
  is
• 5:55
  recording
• 5:55
  them,
• 5:56
  but
• 5:56
  that's
• 5:56
  not
• 5:56
  really
• 5:57
  what's
• 5:57
  said
• 5:57
  here.
• 5:58
  I
• 5:58
  don't
• 5:58
  see
• 5:58
  a
• 5:58
  near
• 5:58
  death
• 5:59
  experience.
• 6:00
  I
• 6:00
  don't
• 6:00
  see
• 6:01
  any
• 6:02
  rumination
• 6:02
  about
• 6:03
  the
• 6:03
  past
• 6:03
  here
• 6:03
  per
• 6:04
  se,
• 6:04
  or
• 6:05
  some
• 6:05
  event
• 6:05
  that
• 6:05
  they're
• 6:06
  thinking
• 6:06
  about
• 6:06
  that
• 6:06
  they're
• 6:07
  reliving.
• 6:08
  So
• 6:08
  that
• 6:08
  can
• 6:09
  really
• 6:09
  clear
• 6:10
  out
• 6:10
  a
• 6:10
  lot
• 6:10
  of
• 6:11
  the
• 6:11
  brush
• 6:11
  for
• 6:11
  you
• 6:11
  guys
• 6:12
  is
• 6:12
  just
• 6:14
  appreciate
• 6:15
  what's
• 6:15
  not
• 6:15
  being
• 6:16
  said
• 6:16
  so
• 6:16
  that
• 6:17
  you
• 6:17
  can
• 6:17
  really
• 6:17
  zero
• 6:18
  in
• 6:18
  on
• 6:18
  what
• 6:18
  is
• 6:19
  being
• 6:19
  said.
• 6:19
  Clearly
• 6:20
  a
• 6:20
  mood
• 6:20
  disorder.
• 6:21
  Now,
• 6:21
  it's
• 6:22
  extremely
• 6:22
  reasonable
• 6:23
  for
• 6:23
  you
• 6:23
  guys
• 6:23
  to
• 6:23
  also
• 6:24
  go,
• 6:24
  wait
• 6:24
  a
• 6:24
  minute,
• 6:24
  is
• 6:25
  schizophrenia
• 6:25
  in
• 6:25
  the
• 6:25
  cards
• 6:26
  here?
• 6:26
  Oh,
• 6:27
  they're
• 6:27
  depressed.
• 6:29
  So
• 6:29
  maybe
• 6:29
  this
• 6:29
  is
• 6:30
  psychotic
• 6:31
  features
• 6:31
  with
• 6:32
  mdd.
• 6:32
  Oh,
• 6:33
  no.
• 6:33
  Is
• 6:33
  this
• 6:33
  bipolar
• 6:34
  one
• 6:34
  or
• 6:34
  bipolar
• 6:35
  two?
• 6:35
  All
• 6:36
  right,
• 6:36
  here's
• 6:36
  where
• 6:36
  we
• 6:37
  get
• 6:37
  in
• 6:37
  the
• 6:37
  weeds
• 6:37
  and
• 6:37
  where
• 6:38
  this
• 6:38
  always
• 6:38
  gets
• 6:39
  really
• 6:39
  fun.
• 6:40
  So,
• 6:40
  my
• 6:40
  friends,
• 6:40
  I
• 6:41
  will
• 6:41
  tell
• 6:41
  you
• 6:41
  what
• 6:41
  the
• 6:41
  answer
• 6:42
  is
• 6:42
  not.
• 6:42
  It
• 6:42
  is
• 6:43
  not
• 6:43
  a
• 6:43
  brief
• 6:43
  psychotic
• 6:44
  disorder.
• 6:45
  Now,
• 6:45
  you
• 6:45
  might
• 6:45
  have
• 6:45
  been
• 6:45
  thrown
• 6:46
  off
• 6:46
  because
• 6:47
  in
• 6:47
  the
• 6:47
  question,
• 6:48
  it
• 6:49
  did
• 6:49
  say
• 6:49
  that
• 6:49
  the
• 6:50
  belief
• 6:50
  lasted
• 6:50
  10
• 6:51
  days.
• 6:51
  So
• 6:51
  she
• 6:51
  believed
• 6:52
  her
• 6:52
  neighbor
• 6:52
  was
• 6:52
  recording
• 6:52
  her
• 6:53
  for
• 6:53
  10
• 6:53
  days
• 6:53
  and
• 6:53
  then
• 6:54
  it
• 6:54
  resolved.
• 6:55
  Well,
• 6:55
  that
• 6:55
  is
• 6:55
  true
• 6:56
  that
• 6:56
  in
• 6:56
  brief
• 6:57
  psychotic
• 6:57
  disorder,
• 6:58
  the
• 6:59
  psychotic
• 7:00
  delusion
• 7:01
  is
• 7:02
  normally
• 7:03
  one
• 7:04
  to
• 7:04
  30
• 7:04
  days.
• 7:05
  Okay.
• 7:06
  And
• 7:06
  I
• 7:06
  will
• 7:06
  argue
• 7:07
  in
• 7:07
  practice
• 7:07
  this
• 7:08
  is
• 7:08
  extremely
• 7:09
  rare.
• 7:09
  I
• 7:09
  have
• 7:09
  had
• 7:09
  professors
• 7:10
  who
• 7:10
  swear
• 7:11
  that
• 7:11
  they've
• 7:12
  seen
• 7:12
  this
• 7:12
  in
• 7:12
  practice
• 7:12
  and
• 7:13
  clinicians
• 7:13
  that
• 7:13
  have
• 7:14
  seen
• 7:14
  it
• 7:14
  in
• 7:14
  practice.
• 7:15
  I
• 7:15
  rarely
• 7:16
  see
• 7:16
  this.
• 7:16
  I
• 7:16
  may
• 7:16
  have
• 7:17
  seen
• 7:17
  it
• 7:17
  once
• 7:17
  in
• 7:17
  my
• 7:18
  career
• 7:18
  so
• 7:18
  far.
• 7:19
  It
• 7:19
  definitely
• 7:19
  exists.
• 7:21
  Part
• 7:21
  of
• 7:21
  the
• 7:21
  reason
• 7:21
  you
• 7:22
  don't
• 7:22
  see
• 7:22
  this
• 7:22
  as
• 7:23
  readily
• 7:23
  as
• 7:24
  bipolar
• 7:24
  or
• 7:24
  depression
• 7:25
  is
• 7:26
  that
• 7:26
  normally
• 7:27
  in
• 7:27
  a
• 7:27
  brief
• 7:27
  psychotic
• 7:28
  disorder,
• 7:28
  I
• 7:28
  don't
• 7:28
  want
• 7:29
  to
• 7:29
  speak
• 7:29
  for
• 7:29
  everybody
• 7:30
  because
• 7:30
  everybody
• 7:30
  has
• 7:30
  a
• 7:31
  different
• 7:31
  form
• 7:31
  of
• 7:31
  psychosis
• 7:32
  that
• 7:32
  suffers
• 7:32
  from
• 7:32
  this.
• 7:33
  But
• 7:33
  normally
• 7:34
  the
• 7:34
  delusion
• 7:35
  is
• 7:36
  not
• 7:37
  necessarily
• 7:38
  a
• 7:38
  showstopper.
• 7:39
  It's
• 7:39
  not
• 7:39
  getting
• 7:39
  in
• 7:39
  the
• 7:40
  way
• 7:41
  of
• 7:42
  their
• 7:42
  functioning
• 7:43
  all
• 7:43
  of
• 7:43
  the
• 7:43
  time.
• 7:43
  It
• 7:43
  might
• 7:43
  be
• 7:44
  a
• 7:44
  delusion
• 7:44
  that
• 7:44
  has
• 7:45
  this
• 7:45
  kind
• 7:45
  of
• 7:45
  compartmentalized.
• 7:46
  Maybe
• 7:47
  they
• 7:47
  do
• 7:47
  think
• 7:48
  that
• 7:48
  the
• 7:49
  cashier
• 7:50
  at
• 7:50
  the
• 7:50
  Dollar
• 7:50
  Tree
• 7:51
  wants
• 7:52
  to
• 7:52
  beat
• 7:52
  them
• 7:52
  with
• 7:52
  the
• 7:53
  sledgehammer
• 7:53
  and
• 7:54
  that's
• 7:54
  terrifying,
• 7:54
  right?
• 7:55
  But
• 7:55
  maybe
• 7:55
  they
• 7:55
  don't
• 7:55
  go
• 7:55
  to
• 7:56
  the
• 7:56
  Dollar
• 7:56
  Tree
• 7:56
  that
• 7:56
  much.
• 7:57
  Maybe,
• 7:59
  you
• 8:00
  know,
• 8:00
  they
• 8:00
  just
• 8:00
  went
• 8:01
  in
• 8:01
  there
• 8:01
  randomly,
• 8:03
  last
• 8:03
  minute
• 8:03
  because
• 8:03
  they
• 8:04
  were
• 8:04
  late
• 8:04
  to
• 8:05
  a
• 8:05
  neighbor's
• 8:05
  birthday
• 8:06
  party.
• 8:07
  Not
• 8:07
  the
• 8:07
  neighbor's
• 8:07
  birthday
• 8:08
  party,
• 8:08
  but
• 8:08
  the
• 8:08
  children.
• 8:09
  You
• 8:09
  know,
• 8:09
  maybe
• 8:09
  they
• 8:09
  were
• 8:09
  getting
• 8:09
  like
• 8:10
  little
• 8:10
  party
• 8:10
  hats
• 8:11
  for
• 8:11
  the
• 8:11
  birthday
• 8:12
  party
• 8:12
  or
• 8:12
  stickers
• 8:13
  or
• 8:13
  whatever.
• 8:14
  I
• 8:14
  don't
• 8:14
  clearly,
• 8:15
  I
• 8:15
  don't
• 8:15
  know
• 8:15
  why
• 8:15
  people
• 8:16
  go
• 8:16
  to
• 8:16
  the
• 8:16
  Dollar
• 8:16
  Tree.
• 8:17
  It's
• 8:17
  a
• 8:17
  fine
• 8:17
  store.
• 8:17
  I
• 8:18
  don't
• 8:18
  go
• 8:18
  there
• 8:18
  very
• 8:18
  often.
• 8:19
  By
• 8:19
  greater
• 8:20
  point
• 8:20
  is,
• 8:20
  a
• 8:20
  lot
• 8:21
  of
• 8:21
  these
• 8:21
  delusions
• 8:21
  can
• 8:21
  be
• 8:22
  circumscribed
• 8:23
  and
• 8:23
  so
• 8:24
  they're
• 8:24
  not
• 8:24
  pervasive.
• 8:25
  They're
• 8:25
  not
• 8:25
  in
• 8:25
  your
• 8:25
  face
• 8:26
  all
• 8:26
  of
• 8:26
  the
• 8:26
  time
• 8:26
  creating
• 8:27
  massive
• 8:27
  impairment.
• 8:29
  And
• 8:30
  it's
• 8:31
  again,
• 8:31
  I
• 8:31
  think
• 8:32
  kind
• 8:33
  of
• 8:33
  circumscribe
• 8:34
  that
• 8:34
  diagnosis
• 8:34
  to
• 8:35
  the
• 8:35
  actual
• 8:35
  delusion
• 8:35
  itself.
• 8:36
  With
• 8:36
  schizophrenia,
• 8:38
  your
• 8:38
  delusion
• 8:39
  or
• 8:39
  hallucination
• 8:39
  is
• 8:40
  not
• 8:40
  circumscribed
• 8:41
  just
• 8:41
  to
• 8:41
  the
• 8:41
  delusion
• 8:41
  or
• 8:41
  hallucination.
• 8:42
  You're
• 8:43
  talking
• 8:43
  about
• 8:44
  disorganized
• 8:45
  speech
• 8:45
  and
• 8:46
  thoughts
• 8:46
  and
• 8:46
  you're
• 8:47
  disheveled
• 8:47
  and
• 8:47
  you're
• 8:47
  not
• 8:48
  able
• 8:48
  to
• 8:49
  really
• 8:50
  get
• 8:50
  your
• 8:50
  things
• 8:51
  together
• 8:51
  and
• 8:51
  think
• 8:51
  clearly
• 8:52
  as
• 8:52
  easily.
• 8:53
  Right?
• 8:53
  Maybe
• 8:54
  you're
• 8:54
  making
• 8:54
  up
• 8:54
  words
• 8:55
  or,
• 8:56
  um,
• 8:56
  you're
• 8:56
  engaged
• 8:57
  in
• 8:57
  repetitive
• 8:57
  behaviors
• 8:58
  because
• 8:58
  your
• 8:58
  hallucinations
• 8:59
  are
• 8:59
  telling
• 8:59
  you
• 8:59
  to
• 9:00
  do
• 9:00
  certain
• 9:00
  things.
• 9:00
  Right?
• 9:01
  So
• 9:01
  again,
• 9:01
  it's
• 9:01
  a
• 9:01
  constellation
• 9:02
  of
• 9:02
  symptoms
• 9:03
  versus
• 9:03
  this
• 9:03
  kind
• 9:03
  of
• 9:04
  circumscribed
• 9:05
  symptom
• 9:05
  in
• 9:05
  brief
• 9:06
  psychotic
• 9:06
  disorder.
• 9:07
  So
• 9:08
  this
• 9:08
  is
• 9:09
  not
• 9:09
  brief
• 9:09
  psychotic
• 9:10
  disorder
• 9:11
  because
• 9:12
  a
• 9:12
  brief
• 9:12
  psychotic
• 9:13
  disorder
• 9:13
  cannot
• 9:14
  be
• 9:14
  diagnosed
• 9:14
  when
• 9:14
  psychotic
• 9:15
  symptoms
• 9:15
  are
• 9:15
  better
• 9:16
  explained
• 9:16
  by
• 9:16
  a
• 9:16
  mood
• 9:17
  episode.
• 9:18
  So
• 9:18
  clearly
• 9:18
  there
• 9:18
  is
• 9:18
  a
• 9:19
  mood
• 9:19
  episode
• 9:19
  going
• 9:19
  on
• 9:20
  with
• 9:20
  this
• 9:20
  28
• 9:20
  year
• 9:21
  old
• 9:21
  woman.
• 9:21
  We'll
• 9:21
  call
• 9:21
  her
• 9:22
  Sandy.
• 9:22
  Okay?
• 9:22
  It's
• 9:23
  not
• 9:23
  a
• 9:23
  real
• 9:23
  person,
• 9:24
  okay?
• 9:24
  And
• 9:24
  I
• 9:24
  don't
• 9:25
  mean
• 9:25
  she's
• 9:25
  not
• 9:25
  real
• 9:25
  as
• 9:26
  in
• 9:26
  she's
• 9:26
  not
• 9:26
  like
• 9:26
  authentic
• 9:27
  and
• 9:27
  honest
• 9:27
  and
• 9:27
  fun
• 9:28
  to
• 9:28
  talk
• 9:28
  to.
• 9:28
  I
• 9:28
  just
• 9:28
  mean
• 9:28
  this
• 9:29
  is
• 9:29
  a
• 9:29
  mock
• 9:29
  patient.
• 9:30
  I
• 9:30
  don't
• 9:30
  mean
• 9:30
  she's
• 9:30
  fake.
• 9:31
  Like
• 9:31
  she
• 9:32
  has
• 9:32
  a
• 9:32
  fake
• 9:32
  personality
• 9:33
  and
• 9:33
  you
• 9:33
  hate
• 9:33
  being
• 9:33
  around
• 9:34
  her.
• 9:34
  I
• 9:34
  just
• 9:34
  mean
• 9:34
  she's,
• 9:35
  she's
• 9:35
  not
• 9:35
  a
• 9:35
  real.
• 9:36
  This
• 9:36
  is
• 9:36
  a
• 9:36
  mock
• 9:36
  patient,
• 9:37
  okay?
• 9:37
  This
• 9:38
  is
• 9:38
  not
• 9:38
  like
• 9:38
  someone
• 9:38
  I
• 9:39
  met
• 9:39
  today
• 9:39
  or
• 9:39
  yesterday,
• 9:40
  okay?
• 9:41
  So.
• 9:42
  And
• 9:42
  anyhow,
• 9:44
  there's
• 9:44
  too
• 9:44
  much
• 9:44
  going
• 9:45
  on
• 9:45
  here.
• 9:45
  There's
• 9:45
  a
• 9:45
  constellation
• 9:46
  of
• 9:46
  symptoms
• 9:47
  and
• 9:47
  therefore
• 9:47
  you
• 9:47
  can't,
• 9:47
  you
• 9:48
  can't
• 9:48
  call
• 9:48
  this
• 9:48
  a
• 9:48
  brief
• 9:49
  psychotic
• 9:49
  disorder.
• 9:49
  This
• 9:49
  is
• 9:50
  great.
• 9:50
  This
• 9:50
  is
• 9:50
  part
• 9:50
  of
• 9:50
  a
• 9:51
  greater
• 9:51
  mood
• 9:52
  Episode.
• 9:53
  Now,
• 9:53
  is
• 9:53
  this
• 9:54
  MDD
• 9:54
  severe
• 9:55
  with
• 9:55
  psychotic
• 9:55
  features?
• 9:56
  Well,
• 9:56
  this
• 9:57
  could
• 9:57
  be
• 9:57
  very
• 9:57
  confusing,
• 9:58
  right?
• 9:58
  Because,
• 9:58
  oh,
• 9:58
  my
• 9:58
  God,
• 9:59
  I'm
• 9:59
  getting
• 9:59
  so
• 9:59
  dizzy,
• 10:00
  right?
• 10:00
  This
• 10:00
  patient
• 10:00
  is
• 10:01
  depressed
• 10:01
  and
• 10:02
  now
• 10:02
  there's
• 10:02
  like,
• 10:02
  what?
• 10:03
  There's
• 10:03
  like
• 10:03
  a
• 10:04
  delusion
• 10:04
  here.
• 10:04
  So
• 10:05
  is
• 10:05
  this
• 10:05
  MDD
• 10:05
  with
• 10:05
  psychosis?
• 10:07
  Well,
• 10:07
  no,
• 10:08
  and
• 10:08
  we
• 10:08
  don't
• 10:09
  need
• 10:09
  to
• 10:09
  overthink
• 10:09
  this,
• 10:09
  right?
• 10:10
  Because
• 10:12
  she
• 10:13
  clearly
• 10:13
  told
• 10:13
  you
• 10:14
  in
• 10:14
  the
• 10:14
  question,
• 10:15
  or
• 10:15
  I
• 10:15
  clearly
• 10:16
  told
• 10:16
  you
• 10:16
  in
• 10:16
  the
• 10:16
  question,
• 10:18
  that
• 10:19
  this
• 10:19
  belief,
• 10:20
  this
• 10:20
  delusional
• 10:21
  belief
• 10:21
  was
• 10:22
  happening
• 10:22
  during
• 10:23
  her
• 10:24
  most
• 10:24
  recent
• 10:24
  elevated
• 10:25
  mood.
• 10:26
  So
• 10:26
  the
• 10:26
  timing,
• 10:26
  my
• 10:27
  friends,
• 10:27
  is
• 10:27
  so
• 10:27
  important
• 10:28
  here.
• 10:28
  If
• 10:29
  you
• 10:29
  want
• 10:29
  to
• 10:29
  make
• 10:29
  your
• 10:29
  life
• 10:30
  super
• 10:30
  simple.
• 10:31
  When
• 10:31
  you're
• 10:31
  wondering
• 10:32
  about,
• 10:32
  like,
• 10:32
  psychosis
• 10:33
  and
• 10:33
  specifiers
• 10:34
  and
• 10:34
  MDD
• 10:34
  versus
• 10:35
  bipolar,
• 10:36
  just
• 10:36
  ask
• 10:36
  yourself,
• 10:37
  when
• 10:37
  did
• 10:37
  the
• 10:37
  psychosis
• 10:38
  happen?
• 10:38
  Did
• 10:38
  it
• 10:39
  happen
• 10:39
  exclusively
• 10:40
  during
• 10:40
  depression?
• 10:41
  Well,
• 10:41
  then
• 10:41
  it
• 10:41
  very
• 10:42
  well
• 10:42
  could
• 10:42
  be
• 10:42
  MDD
• 10:43
  with
• 10:43
  psychotic
• 10:43
  features.
• 10:44
  But
• 10:44
  if
• 10:45
  the
• 10:45
  psychosis
• 10:45
  occurred
• 10:46
  exclusively
• 10:47
  during
• 10:47
  an
• 10:48
  elevated
• 10:48
  mood
• 10:49
  episode,
• 10:49
  it
• 10:49
  is.
• 10:50
  And
• 10:50
  not
• 10:50
  during
• 10:50
  a
• 10:50
  depressive
• 10:51
  episode,
• 10:52
  then
• 10:52
  no,
• 10:52
  we're
• 10:52
  not
• 10:53
  looking
• 10:53
  at
• 10:53
  MDD
• 10:54
  severe
• 10:54
  with
• 10:54
  psychotic
• 10:55
  features,
• 10:55
  okay?
• 10:57
  Psychosis
• 10:57
  during
• 10:57
  an
• 10:58
  elevated
• 10:58
  mood
• 10:59
  is
• 10:59
  mania.
• 11:00
  It
• 11:00
  is
• 11:00
  not
• 11:01
  MDD
• 11:01
  with
• 11:02
  psychotic
• 11:02
  features.
• 11:03
  Okay?
• 11:04
  Again,
• 11:04
  the
• 11:05
  key
• 11:05
  is
• 11:05
  that
• 11:05
  it
• 11:06
  is
• 11:06
  co
• 11:06
  occurring
• 11:07
  with
• 11:07
  the
• 11:08
  elevated
• 11:10
  mood,
• 11:11
  okay?
• 11:12
  That
• 11:12
  is
• 11:13
  the
• 11:13
  key.
• 11:14
  Now,
• 11:14
  is
• 11:14
  this
• 11:14
  schizoaffective
• 11:15
  disorder.
• 11:16
  It's
• 11:17
  valid
• 11:17
  for
• 11:17
  you
• 11:17
  to
• 11:17
  think
• 11:18
  that,
• 11:18
  right?
• 11:19
  Totally
• 11:19
  valid.
• 11:20
  It's
• 11:21
  a
• 11:21
  schizoaffective
• 11:22
  disorder
• 11:22
  is
• 11:22
  a
• 11:22
  pretty
• 11:22
  intricate
• 11:23
  diagnosis.
• 11:24
  But
• 11:24
  remember,
• 11:25
  again,
• 11:25
  timing,
• 11:26
  timing,
• 11:26
  timing.
• 11:27
  In
• 11:27
  schizoaffective
• 11:28
  disorder,
• 11:29
  it
• 11:29
  requires
• 11:30
  that
• 11:30
  you
• 11:30
  have
• 11:30
  psychotic
• 11:31
  symptoms
• 11:32
  that
• 11:32
  persist
• 11:33
  for
• 11:33
  at
• 11:33
  least
• 11:33
  two
• 11:33
  weeks
• 11:34
  in
• 11:34
  the
• 11:35
  absence
• 11:35
  of
• 11:35
  a
• 11:35
  mood
• 11:36
  episode.
• 11:37
  Okay?
• 11:37
  So
• 11:38
  I
• 11:38
  was
• 11:38
  always
• 11:38
  intimidated
• 11:39
  by
• 11:39
  schizoaffective
• 11:40
  disorder.
• 11:41
  I
• 11:41
  always
• 11:41
  had
• 11:42
  a
• 11:42
  hard
• 11:42
  time
• 11:42
  articulating
• 11:43
  what
• 11:43
  it
• 11:43
  was
• 11:43
  or
• 11:43
  what
• 11:44
  it
• 11:44
  meant.
• 11:44
  And
• 11:44
  it
• 11:45
  felt
• 11:45
  so
• 11:45
  blurred
• 11:46
  in
• 11:46
  my
• 11:46
  mind
• 11:47
  between,
• 11:47
  like,
• 11:47
  bipolar
• 11:48
  and
• 11:48
  schizophrenia.
• 11:49
  And
• 11:49
  what
• 11:49
  does
• 11:49
  that
• 11:49
  mean?
• 11:50
  Okay,
• 11:51
  but
• 11:51
  it's
• 11:51
  actually
• 11:52
  pretty
• 11:52
  simple.
• 11:53
  It's
• 11:53
  really
• 11:54
  what
• 11:54
  schizoaffective
• 11:55
  disorder
• 11:56
  is
• 11:56
  trying
• 11:56
  to
• 11:57
  tell
• 11:57
  you
• 11:57
  or
• 11:58
  define
• 11:58
  itself
• 11:59
  as
• 11:59
  is,
• 11:59
  do
• 12:00
  we
• 12:00
  have
• 12:00
  two
• 12:00
  different
• 12:01
  processes
• 12:01
  happening
• 12:02
  here
• 12:02
  independently,
• 12:03
  right?
• 12:03
  Do
• 12:04
  we
• 12:04
  have
• 12:04
  bipolar
• 12:05
  and
• 12:05
  do
• 12:05
  we
• 12:05
  also
• 12:05
  have
• 12:06
  schizophrenia?
• 12:07
  Separately,
• 12:08
  okay?
• 12:09
  That
• 12:09
  they're
• 12:09
  happening
• 12:10
  separately.
• 12:10
  They're
• 12:10
  not
• 12:11
  happening
• 12:11
  at
• 12:11
  the
• 12:11
  same
• 12:11
  time,
• 12:12
  okay?
• 12:13
  And
• 12:15
  that
• 12:16
  is
• 12:16
  the
• 12:16
  key
• 12:16
  distinction.
• 12:17
  So
• 12:18
  if
• 12:18
  you
• 12:18
  are
• 12:19
  having
• 12:19
  psychotic
• 12:20
  symptoms
• 12:21
  in
• 12:21
  the
• 12:22
  absence
• 12:22
  of
• 12:22
  your
• 12:22
  depression,
• 12:23
  in
• 12:23
  the
• 12:23
  absence
• 12:24
  of
• 12:24
  your
• 12:24
  mania,
• 12:25
  okay?
• 12:27
  And
• 12:27
  it's
• 12:27
  persisting
• 12:28
  for
• 12:28
  at
• 12:28
  least
• 12:28
  two
• 12:29
  weeks,
• 12:30
  okay?
• 12:30
  And
• 12:30
  of
• 12:30
  course,
• 12:30
  it's
• 12:30
  gotta
• 12:31
  meet
• 12:31
  that
• 12:31
  other
• 12:31
  criteria
• 12:32
  of
• 12:32
  schizophrenia.
• 12:32
  And
• 12:33
  you
• 12:33
  know,
• 12:33
  I
• 12:33
  encourage
• 12:34
  you
• 12:34
  to
• 12:34
  go
• 12:34
  back
• 12:34
  to
• 12:34
  the
• 12:34
  DSM
• 12:35
  for
• 12:35
  that,
• 12:36
  right?
• 12:36
  That
• 12:37
  constellation
• 12:37
  of
• 12:37
  symptoms,
• 12:38
  those
• 12:38
  neg.
• 12:38
  Those
• 12:39
  negative
• 12:39
  symptoms,
• 12:40
  right?
• 12:40
  The
• 12:40
  disorganization.
• 12:41
  But
• 12:41
  the
• 12:42
  key
• 12:42
  is
• 12:42
  if
• 12:42
  this
• 12:42
  is
• 12:42
  happening
• 12:43
  independently
• 12:44
  and
• 12:44
  you
• 12:44
  also
• 12:45
  have
• 12:46
  your,
• 12:46
  your
• 12:48
  mania
• 12:48
  or
• 12:49
  your
• 12:49
  bipolarity,
• 12:50
  right?
• 12:50
  Which
• 12:51
  includes
• 12:51
  depression
• 12:51
  and
• 12:51
  mania.
• 12:52
  So
• 12:52
  these
• 12:52
  are
• 12:52
  happening
• 12:53
  separately.
• 12:53
  You
• 12:54
  have
• 12:54
  schizoaffective.
• 12:55
  But
• 12:56
  mind
• 12:56
  you,
• 12:56
  my
• 12:56
  friends,
• 12:56
  that
• 12:57
  is
• 12:57
  not
• 12:57
  what
• 12:57
  happened
• 12:57
  here.
• 12:58
  What
• 12:58
  happened
• 12:59
  here
• 12:59
  with
• 12:59
  Sandy
• 13:00
  is
• 13:00
  that
• 13:01
  her
• 13:01
  delusion
• 13:02
  or
• 13:02
  her
• 13:02
  psychosis
• 13:03
  is
• 13:03
  happening
• 13:03
  exactly
• 13:04
  at
• 13:04
  the
• 13:05
  same
• 13:05
  time
• 13:05
  as
• 13:05
  her
• 13:06
  mood
• 13:06
  is
• 13:07
  elevated.
• 13:07
  So
• 13:08
  it
• 13:08
  really
• 13:08
  can't
• 13:08
  get
• 13:09
  more
• 13:09
  crystal
• 13:09
  clear
• 13:10
  than
• 13:10
  that.
• 13:10
  Right?
• 13:11
  You're.
• 13:11
  If
• 13:11
  you
• 13:11
  are
• 13:12
  currently
• 13:12
  depressed
• 13:13
  and
• 13:13
  you're
• 13:14
  seeing
• 13:14
  shadows
• 13:15
  and
• 13:15
  you're
• 13:15
  hearing
• 13:15
  self
• 13:16
  critical
• 13:16
  voices.
• 13:16
  That's
• 13:17
  usually
• 13:17
  the
• 13:17
  way
• 13:17
  I
• 13:18
  see
• 13:18
  it
• 13:18
  in
• 13:18
  clinic.
• 13:19
  Right.
• 13:19
  My
• 13:19
  patients
• 13:20
  who
• 13:20
  are
• 13:20
  severely
• 13:20
  depressed,
• 13:21
  they'll
• 13:21
  see
• 13:21
  shadows,
• 13:22
  they'll
• 13:22
  hear
• 13:23
  some
• 13:23
  kind
• 13:23
  of
• 13:23
  muffled
• 13:24
  self
• 13:24
  critical
• 13:24
  voices
• 13:25
  every
• 13:25
  once
• 13:25
  in
• 13:25
  a
• 13:25
  while.
• 13:26
  And
• 13:26
  it's
• 13:26
  during
• 13:27
  depression.
• 13:27
  Boom.
• 13:27
  Don't
• 13:28
  overthink
• 13:28
  it.
• 13:28
  Don't
• 13:29
  overthink
• 13:29
  it.
• 13:29
  It's
• 13:29
  MDD
• 13:30
  with
• 13:31
  psychotic
• 13:31
  features
• 13:32
  or
• 13:32
  like
• 13:32
  with
• 13:32
  psychosis,
• 13:34
  right?
• 13:34
  Absolutely.
• 13:35
  Mdd,
• 13:36
  Severe
• 13:36
  with
• 13:36
  psych.
• 13:36
  With
• 13:37
  psychotic
• 13:37
  features.
• 13:38
  If
• 13:38
  it's
• 13:38
  happening
• 13:38
  during
• 13:39
  the
• 13:39
  mania,
• 13:40
  okay,
• 13:42
  then
• 13:42
  we
• 13:43
  have.
• 13:43
  And
• 13:43
  that's
• 13:43
  what
• 13:43
  we're
• 13:44
  about
• 13:44
  to
• 13:44
  get
• 13:44
  into
• 13:44
  here.
• 13:45
  We
• 13:45
  have
• 13:45
  a
• 13:45
  different
• 13:45
  diagnosis.
• 13:46
  Now.
• 13:47
  Here's
• 13:48
  the
• 13:49
  juggernaut.
• 13:50
  Here's
• 13:50
  the,
• 13:50
  here's
• 13:51
  the
• 13:51
  moment
• 13:51
  when
• 13:51
  you
• 13:52
  pass
• 13:53
  your
• 13:53
  boards
• 13:54
  and
• 13:54
  you
• 13:54
  post
• 13:55
  it
• 13:55
  on
• 13:55
  Facebook
• 13:56
  and
• 13:56
  you
• 13:56
  get
• 13:56
  like
• 13:57
  140
• 13:57
  likes.
• 13:58
  I
• 13:58
  got
• 13:58
  like
• 13:59
  60
• 13:59
  because
• 13:59
  I
• 13:59
  don't
• 14:00
  have
• 14:00
  as
• 14:00
  many
• 14:00
  friends
• 14:00
  as
• 14:00
  you
• 14:00
  guys
• 14:01
  do.
• 14:01
  I
• 14:01
  have
• 14:01
  quality
• 14:02
  friends,
• 14:02
  okay?
• 14:03
  I'll
• 14:03
  be
• 14:03
  willing
• 14:04
  to
• 14:04
  go
• 14:05
  toe
• 14:05
  to
• 14:05
  toe
• 14:05
  with
• 14:06
  your
• 14:06
  friends.
• 14:06
  You're
• 14:07
  140.
• 14:09
  Hats
• 14:09
  off
• 14:09
  to
• 14:09
  you.
• 14:09
  You
• 14:10
  have
• 14:10
  more
• 14:10
  friends
• 14:10
  than
• 14:10
  me.
• 14:10
  But
• 14:10
  my
• 14:11
  friends
• 14:11
  are
• 14:11
  better.
• 14:11
  I
• 14:11
  used
• 14:12
  to
• 14:12
  have
• 14:12
  a
• 14:12
  friend
• 14:12
  named
• 14:12
  Norman
• 14:13
  when
• 14:14
  I
• 14:14
  was
• 14:14
  in
• 14:14
  first
• 14:15
  grade.
• 14:15
  I
• 14:16
  would
• 14:16
  have
• 14:16
  traded
• 14:16
  him.
• 14:17
  Excuse
• 14:17
  me?
• 14:18
  I
• 14:18
  would
• 14:18
  not
• 14:18
  have.
• 14:18
  It
• 14:19
  sounded
• 14:19
  horrible.
• 14:19
  I
• 14:20
  would
• 14:20
  not
• 14:20
  have
• 14:20
  traded
• 14:20
  him
• 14:21
  for
• 14:21
  30
• 14:22
  lukewarm,
• 14:23
  lukewarm
• 14:23
  friends.
• 14:24
  Maybe
• 14:25
  50
• 14:25
  lukewarm
• 14:26
  friends.
• 14:26
  I
• 14:26
  would
• 14:26
  have
• 14:26
  not
• 14:26
  traded
• 14:27
  him
• 14:28
  for
• 14:28
  30
• 14:28
  lukewarm
• 14:29
  friends
• 14:29
  because
• 14:29
  he
• 14:29
  was
• 14:29
  so
• 14:31
  darn
• 14:32
  awesome
• 14:32
  and
• 14:32
  loyal.
• 14:33
  Okay?
• 14:34
  So
• 14:34
  you're
• 14:34
  going
• 14:34
  to
• 14:35
  pass
• 14:35
  your
• 14:35
  boards.
• 14:35
  You're
• 14:35
  going
• 14:35
  to
• 14:36
  be
• 14:36
  so
• 14:36
  excited.
• 14:36
  You're
• 14:36
  going
• 14:36
  to
• 14:37
  tell
• 14:37
  all
• 14:37
  your
• 14:37
  friends
• 14:37
  because
• 14:37
  of
• 14:38
  what
• 14:38
  I'm
• 14:38
  about
• 14:38
  to
• 14:38
  tell
• 14:38
  you.
• 14:39
  And
• 14:39
  what
• 14:39
  I'm
• 14:39
  about
• 14:39
  to
• 14:40
  tell
• 14:40
  you,
• 14:40
  my
• 14:40
  friends,
• 14:41
  is
• 14:41
  that
• 14:41
  when
• 14:41
  you
• 14:42
  see
• 14:42
  delusions
• 14:43
  like
• 14:43
  this
• 14:43
  during
• 14:44
  an
• 14:44
  elevated
• 14:44
  mood
• 14:45
  episode,
• 14:46
  I
• 14:46
  don't
• 14:46
  care
• 14:47
  how
• 14:48
  convinced
• 14:48
  you
• 14:48
  are
• 14:49
  that
• 14:49
  you
• 14:50
  think
• 14:50
  it's
• 14:50
  bipolar
• 14:51
  2,
• 14:52
  you
• 14:53
  are
• 14:54
  wrong,
• 14:55
  my
• 14:55
  friends.
• 14:56
  There
• 14:57
  is
• 14:57
  no
• 14:57
  such
• 14:57
  thing
• 14:58
  as
• 14:58
  a
• 14:58
  psychosis
• 14:59
  in
• 14:59
  bipolar
• 15:00
  2.
• 15:00
  It's
• 15:01
  not
• 15:01
  happening.
• 15:02
  It
• 15:02
  is
• 15:02
  definitionally
• 15:03
  mania
• 15:04
  at
• 15:04
  that
• 15:05
  point.
• 15:05
  Okay?
• 15:05
  And
• 15:06
  this
• 15:06
  is
• 15:06
  one
• 15:06
  of
• 15:06
  the
• 15:06
  most
• 15:06
  tested
• 15:07
  and
• 15:07
  missed
• 15:07
  rules
• 15:08
  in
• 15:08
  the
• 15:08
  psychiatric
• 15:09
  community.
• 15:10
  And
• 15:10
  the
• 15:10
  boards,
• 15:11
  you
• 15:11
  name
• 15:11
  it.
• 15:12
  Okay?
• 15:12
  Hypomania
• 15:13
  plus
• 15:13
  plus
• 15:14
  psychosis
• 15:15
  does
• 15:15
  not
• 15:15
  exist
• 15:15
  in
• 15:15
  the
• 15:16
  DSM
• 15:16
  5tr.
• 15:17
  If
• 15:17
  there
• 15:18
  are
• 15:18
  psychotic
• 15:18
  features
• 15:19
  during
• 15:19
  an
• 15:19
  elevated,
• 15:20
  expansive
• 15:20
  or
• 15:20
  irritable
• 15:21
  mood
• 15:21
  episode,
• 15:21
  it
• 15:21
  is
• 15:22
  mania,
• 15:22
  full
• 15:23
  stop,
• 15:24
  okay?
• 15:24
  There's
• 15:25
  no
• 15:25
  exceptions
• 15:26
  for
• 15:26
  short
• 15:27
  duration
• 15:27
  or
• 15:28
  lack
• 15:28
  of
• 15:28
  hospitalization,
• 15:30
  okay?
• 15:31
  When
• 15:31
  you
• 15:31
  bring
• 15:31
  psychosis
• 15:32
  into
• 15:32
  the
• 15:32
  mix,
• 15:33
  when
• 15:33
  it's
• 15:33
  happening
• 15:34
  with
• 15:35
  your
• 15:35
  mood
• 15:35
  elevations
• 15:36
  or
• 15:36
  irritability,
• 15:37
  you
• 15:37
  have
• 15:38
  mania.
• 15:39
  And
• 15:40
  remember,
• 15:40
  even
• 15:40
  if
• 15:40
  you've
• 15:41
  never
• 15:41
  had
• 15:41
  depression
• 15:41
  before,
• 15:42
  if
• 15:43
  you
• 15:43
  are
• 15:43
  being
• 15:43
  admitted
• 15:45
  for
• 15:45
  a
• 15:45
  manic
• 15:45
  episode
• 15:48
  now,
• 15:48
  you
• 15:49
  have
• 15:49
  bipolar
• 15:49
  one.
• 15:50
  Oh,
• 15:50
  wait,
• 15:51
  I
• 15:51
  thought
• 15:51
  with
• 15:51
  bipolar
• 15:52
  you
• 15:52
  needed
• 15:52
  to
• 15:52
  be
• 15:52
  depressed.
• 15:55
  No,
• 15:56
  please
• 15:57
  don't
• 15:57
  make
• 15:57
  those
• 15:58
  patients
• 15:58
  have
• 15:58
  more
• 15:59
  than
• 15:59
  they
• 15:59
  need
• 15:59
  to
• 15:59
  have.
• 16:00
  How
• 16:00
  dare
• 16:00
  you?
• 16:00
  They.
• 16:01
  They
• 16:01
  have
• 16:01
  enough
• 16:02
  on
• 16:02
  their
• 16:02
  plate
• 16:02
  already.
• 16:03
  They
• 16:03
  have.
• 16:03
  They
• 16:03
  have
• 16:03
  many,
• 16:04
  many
• 16:04
  other.
• 16:05
  They're
• 16:05
  pacing
• 16:05
  around
• 16:06
  in
• 16:06
  24
• 16:07
  hour
• 16:07
  lockdown,
• 16:09
  being
• 16:09
  chased
• 16:10
  with
• 16:10
  needles
• 16:11
  full
• 16:11
  of
• 16:11
  Haldol.
• 16:12
  Don't
• 16:13
  mandate
• 16:13
  that
• 16:13
  they
• 16:13
  also
• 16:14
  get
• 16:14
  depressed.
• 16:14
  How
• 16:15
  dare
• 16:15
  you?
• 16:15
  Your
• 16:16
  lack
• 16:16
  of
• 16:16
  empathy.
• 16:17
  No,
• 16:18
  no,
• 16:18
  no,
• 16:19
  no,
• 16:19
  no,
• 16:19
  no,
• 16:19
  no,
• 16:19
  no.
• 16:20
  If.
• 16:20
  If
• 16:21
  mania
• 16:21
  brought
• 16:21
  them
• 16:22
  to
• 16:22
  the
• 16:22
  ER,
• 16:22
  right?
• 16:23
  If
• 16:23
  they,
• 16:24
  if.
• 16:25
  If
• 16:25
  they
• 16:25
  woke
• 16:25
  up
• 16:25
  at
• 16:26
  2
• 16:26
  in
• 16:26
  the
• 16:26
  morning
• 16:26
  because
• 16:27
  they
• 16:27
  wanted
• 16:27
  to
• 16:27
  start
• 16:28
  their
• 16:28
  own
• 16:28
  pudding
• 16:29
  company
• 16:30
  like
• 16:30
  a
• 16:31
  banana
• 16:31
  pudding
• 16:32
  company,
• 16:33
  and
• 16:33
  they
• 16:33
  drew
• 16:34
  up
• 16:34
  a
• 16:34
  business
• 16:34
  plan
• 16:35
  and
• 16:35
  they
• 16:35
  wanted
• 16:36
  to
• 16:37
  solve
• 16:37
  world
• 16:38
  hunger,
• 16:39
  and
• 16:39
  none
• 16:40
  of
• 16:40
  this
• 16:40
  is
• 16:40
  funny,
• 16:40
  by
• 16:40
  the
• 16:41
  way.
• 16:41
  If
• 16:42
  you're
• 16:42
  laughing,
• 16:42
  shame
• 16:43
  on
• 16:43
  you.
• 16:43
  These
• 16:43
  are
• 16:43
  very
• 16:44
  real,
• 16:44
  very
• 16:44
  painful
• 16:46
  consequences
• 16:46
  of
• 16:47
  very
• 16:47
  difficult
• 16:47
  disorders.
• 16:50
  But
• 16:50
  that
• 16:50
  kind
• 16:51
  of
• 16:51
  flavor,
• 16:52
  right?
• 16:52
  That
• 16:53
  kind
• 16:53
  of
• 16:53
  grandiosity,
• 16:54
  that
• 16:54
  kind
• 16:54
  of
• 16:55
  impulsivity,
• 16:56
  it
• 16:56
  doesn't
• 16:57
  matter
• 16:57
  at
• 16:58
  that
• 16:58
  point
• 16:59
  with
• 16:59
  respect
• 16:59
  to
• 16:59
  the
• 16:59
  dsm,
• 17:00
  if
• 17:00
  that
• 17:01
  patient
• 17:01
  has
• 17:01
  ever
• 17:01
  experienced
• 17:02
  a
• 17:02
  depressed
• 17:03
  mood.
• 17:04
  Diagnostically,
• 17:05
  if
• 17:05
  that
• 17:05
  has
• 17:05
  resulted
• 17:06
  in
• 17:07
  hospitalization,
• 17:07
  if
• 17:08
  we
• 17:08
  are
• 17:08
  at
• 17:08
  a
• 17:08
  delusional
• 17:09
  level,
• 17:09
  we
• 17:10
  are
• 17:10
  looking
• 17:10
  at
• 17:10
  bipolar
• 17:11
  1.
• 17:11
  If
• 17:11
  it's
• 17:12
  occurring
• 17:12
  during
• 17:13
  elevated
• 17:13
  or
• 17:14
  expanded
• 17:14
  expansive
• 17:15
  or
• 17:15
  irritable
• 17:16
  mood
• 17:16
  mania,
• 17:17
  full
• 17:17
  stop.
• 17:18
  Okay?
• 17:18
  Don't
• 17:19
  let
• 17:19
  the
• 17:19
  duration
• 17:19
  fool
• 17:20
  you
• 17:20
  here.
• 17:20
  With
• 17:20
  brief
• 17:21
  psychotic
• 17:21
  disorder.
• 17:21
  Oh,
• 17:22
  this
• 17:22
  is
• 17:22
  just
• 17:23
  a
• 17:23
  delusion
• 17:23
  that's
• 17:23
  under
• 17:24
  30
• 17:24
  days.
• 17:24
  It's
• 17:25
  only
• 17:25
  lasted
• 17:25
  10
• 17:25
  days.
• 17:26
  Don't
• 17:26
  let
• 17:26
  that
• 17:27
  fool
• 17:27
  you,
• 17:28
  okay?
• 17:28
  Because.
• 17:29
  Because
• 17:30
  again,
• 17:31
  the
• 17:31
  DSM
• 17:31
  is
• 17:32
  very
• 17:32
  clear
• 17:32
  that
• 17:33
  this
• 17:33
  cannot
• 17:33
  be
• 17:33
  attributed
• 17:34
  to
• 17:34
  another
• 17:34
  disorder,
• 17:35
  and
• 17:35
  this
• 17:35
  is
• 17:35
  attributed
• 17:36
  to
• 17:36
  a
• 17:36
  bipolar
• 17:37
  one
• 17:38
  disorder,
• 17:39
  okay?
• 17:40
  Remember?
• 17:41
  Also
• 17:42
  another
• 17:42
  misconception
• 17:44
  is
• 17:44
  hospitalization
• 17:45
  does
• 17:45
  not
• 17:45
  equal
• 17:46
  mania,
• 17:47
  okay?
• 17:48
  Mania
• 17:48
  does
• 17:48
  not
• 17:49
  require
• 17:50
  hospitalization
• 17:51
  either.
• 17:51
  There's
• 17:52
  plenty
• 17:52
  of
• 17:52
  people
• 17:53
  who
• 17:53
  are
• 17:53
  manic
• 17:53
  out
• 17:54
  there
• 17:54
  who
• 17:54
  are
• 17:55
  not
• 17:55
  currently
• 17:55
  in
• 17:55
  the
• 17:56
  hospital,
• 17:56
  right?
• 17:56
  If
• 17:57
  they're
• 17:57
  not
• 17:57
  currently
• 17:57
  in
• 17:57
  the
• 17:57
  hospital,
• 17:58
  we
• 17:58
  can't
• 17:59
  just
• 17:59
  categorically
• 18:01
  exclude
• 18:02
  all
• 18:03
  of
• 18:03
  these
• 18:03
  people
• 18:03
  who
• 18:04
  are
• 18:04
  clinically
• 18:04
  experiencing
• 18:05
  bipolar
• 18:06
  1
• 18:06
  just
• 18:07
  because
• 18:07
  nobody
• 18:08
  has
• 18:08
  sent
• 18:08
  them
• 18:09
  to
• 18:09
  the
• 18:09
  hospital.
• 18:09
  And
• 18:09
  yet
• 18:09
  they
• 18:10
  are
• 18:10
  severely
• 18:10
  delusional
• 18:11
  during
• 18:12
  an
• 18:12
  expansive
• 18:12
  mood
• 18:13
  episode.
• 18:13
  Right.
• 18:13
  So
• 18:14
  that's.
• 18:15
  That
• 18:15
  wouldn't
• 18:15
  make
• 18:16
  any
• 18:16
  sense.
• 18:17
  Okay.
• 18:18
  Um,
• 18:20
  so
• 18:20
  remember
• 18:21
  that
• 18:21
  a
• 18:21
  single
• 18:22
  episode
• 18:22
  of
• 18:22
  psychosis
• 18:23
  during
• 18:23
  the
• 18:23
  elevated
• 18:23
  mood
• 18:24
  will
• 18:24
  permanently
• 18:24
  reclassify
• 18:25
  the
• 18:25
  diagnosis
• 18:26
  to
• 18:26
  bipolar
• 18:27
  one.
• 18:27
  And
• 18:27
  there
• 18:28
  are
• 18:28
  major
• 18:28
  treatment
• 18:29
  implications
• 18:29
  for
• 18:29
  this.
• 18:30
  Right
• 18:30
  now,
• 18:30
  lithium's
• 18:31
  on
• 18:31
  the
• 18:31
  table,
• 18:32
  Depakote's
• 18:32
  on
• 18:32
  the
• 18:33
  table,
• 18:33
  atypical
• 18:33
  antipsychotics
• 18:34
  are
• 18:34
  on
• 18:35
  the
• 18:35
  table.
• 18:35
  They
• 18:35
  become
• 18:35
  more
• 18:36
  first
• 18:36
  line,
• 18:36
  and
• 18:37
  antidepressant
• 18:38
  monotherapy
• 18:39
  becomes
• 18:39
  more
• 18:39
  contraindicated.
• 18:40
  Remember
• 18:40
  what
• 18:40
  the
• 18:41
  evidence
• 18:41
  is
• 18:42
  really
• 18:42
  pointing
• 18:43
  you
• 18:43
  away
• 18:44
  from
• 18:44
  antidepressant
• 18:45
  monotherapy
• 18:45
  in
• 18:46
  bipolar
• 18:46
  one.
• 18:46
  In
• 18:46
  bipolar
• 18:47
  two,
• 18:47
  it's
• 18:47
  very
• 18:47
  iffy,
• 18:48
  too.
• 18:48
  As
• 18:49
  a
• 18:49
  clinician,
• 18:50
  I'm
• 18:50
  very
• 18:50
  squeamish
• 18:51
  about
• 18:51
  antidepressants.
• 18:53
  Even
• 18:53
  in
• 18:54
  bipolar
• 18:54
  two,
• 18:55
  Right?
• 18:55
  Even
• 18:55
  in
• 18:56
  bipolar
• 18:56
  two.
• 18:56
  I'm
• 18:57
  a
• 18:57
  little
• 18:57
  squeamish.
• 18:58
  I've
• 18:59
  seen
• 18:59
  it
• 18:59
  done.
• 19:00
  Everybody
• 19:00
  has
• 19:01
  kind
• 19:01
  of
• 19:01
  their
• 19:01
  own
• 19:01
  school
• 19:01
  of
• 19:02
  thought
• 19:02
  sometimes.
• 19:02
  But
• 19:03
  the
• 19:03
  evidence
• 19:03
  is
• 19:04
  definitely
• 19:06
  not
• 19:06
  that
• 19:06
  reassuring
• 19:07
  for
• 19:07
  antidepressant
• 19:08
  monotherapy
• 19:10
  when
• 19:10
  the
• 19:10
  patient
• 19:11
  is
• 19:11
  in
• 19:11
  a
• 19:11
  bipolar
• 19:12
  depressive
• 19:13
  spectrum.
• 19:13
  You
• 19:13
  have
• 19:13
  to
• 19:13
  be
• 19:13
  very
• 19:14
  careful
• 19:14
  there.
• 19:16
  So,
• 19:17
  yes,
• 19:17
  diagnostics
• 19:18
  matter
• 19:18
  a
• 19:19
  lot
• 19:19
  because
• 19:19
  it
• 19:20
  informs
• 19:20
  your
• 19:20
  treatment
• 19:21
  plan
• 19:21
  and
• 19:21
  that
• 19:21
  subsequently
• 19:23
  will
• 19:24
  influence
• 19:24
  the
• 19:24
  trajectory
• 19:25
  of
• 19:25
  your
• 19:25
  patient's
• 19:26
  entire
• 19:26
  life.
• 19:26
  That's
• 19:27
  a
• 19:27
  big
• 19:27
  deal.
• 19:30
  Now,
• 19:34
  now,
• 19:35
  one
• 19:36
  last
• 19:36
  thing.
• 19:38
  Substance
• 19:38
  use.
• 19:40
  We
• 19:40
  gave
• 19:40
  you
• 19:40
  a
• 19:41
  freebie
• 19:41
  here,
• 19:41
  my
• 19:41
  friends,
• 19:43
  where
• 19:45
  this
• 19:45
  Sandy
• 19:46
  had
• 19:46
  a
• 19:46
  negative
• 19:47
  uds.
• 19:47
  But
• 19:47
  remember
• 19:48
  that
• 19:50
  if
• 19:50
  a
• 19:50
  substance
• 19:50
  is
• 19:51
  capable
• 19:51
  of
• 19:51
  producing
• 19:52
  mania,
• 19:54
  we
• 19:54
  must
• 19:54
  rule
• 19:54
  that
• 19:55
  out
• 19:55
  first.
• 20:51
  We
• 20:51
  must
• 20:51
  rule
• 20:52
  that
• 20:52
  out
• 20:52
  first.
• 20:52
  As
• 20:52
  tempted
• 20:53
  as
• 20:53
  you
• 20:53
  might
• 20:53
  be,
• 20:54
  as
• 20:54
  convinced
• 20:55
  in
• 20:55
  your
• 20:55
  bones
• 20:55
  as
• 20:55
  you
• 20:56
  might
• 20:56
  be
• 20:57
  that
• 20:57
  Sandy,
• 20:59
  it
• 20:59
  has
• 20:59
  a
• 21:00
  bipolar
• 21:00
  1
• 21:01
  or
• 21:01
  bipolar
• 21:02
  2
• 21:02
  disorder.
• 21:02
  You've
• 21:03
  got
• 21:03
  to
• 21:03
  make
• 21:04
  sure
• 21:05
  that
• 21:06
  Sandy
• 21:07
  doesn't
• 21:07
  love
• 21:07
  bath
• 21:07
  salts
• 21:08
  on
• 21:08
  the
• 21:08
  weekends,
• 21:09
  that
• 21:09
  Sandy
• 21:10
  hasn't,
• 21:11
  you
• 21:11
  know,
• 21:12
  chugged
• 21:12
  a
• 21:12
  case
• 21:13
  of
• 21:13
  beer
• 21:13
  every
• 21:14
  night
• 21:14
  for
• 21:14
  the
• 21:14
  last
• 21:14
  45
• 21:15
  nights.
• 21:15
  You've
• 21:16
  got
• 21:16
  to
• 21:16
  make
• 21:16
  sure
• 21:16
  Sandy
• 21:18
  doesn't
• 21:18
  venture
• 21:19
  off
• 21:19
  into
• 21:20
  the
• 21:20
  dark
• 21:20
  web
• 21:22
  and
• 21:23
  buys
• 21:23
  a
• 21:23
  special
• 21:23
  kind
• 21:24
  of
• 21:24
  Skittle.
• 21:26
  You
• 21:26
  really
• 21:26
  got
• 21:26
  to
• 21:26
  do
• 21:27
  your
• 21:27
  due
• 21:27
  diligence,
• 21:28
  especially
• 21:29
  nowadays
• 21:29
  where
• 21:29
  it's
• 21:30
  like
• 21:30
  the
• 21:30
  wild
• 21:30
  west
• 21:30
  out
• 21:31
  there.
• 21:31
  You
• 21:31
  don't
• 21:32
  know,
• 21:32
  you
• 21:32
  know,
• 21:32
  how
• 21:32
  many
• 21:33
  websites
• 21:33
  are
• 21:33
  out
• 21:33
  there
• 21:33
  selling
• 21:34
  God
• 21:34
  knows
• 21:34
  what?
• 21:35
  Not
• 21:35
  always
• 21:36
  regulated,
• 21:37
  not
• 21:38
  always
• 21:38
  known.
• 21:38
  So
• 21:38
  you've
• 21:39
  really
• 21:39
  got
• 21:39
  a.
• 21:40
  I've
• 21:41
  seen
• 21:41
  some
• 21:41
  patients
• 21:41
  with
• 21:42
  some.
• 21:44
  Some
• 21:44
  really,
• 21:45
  you
• 21:45
  know,
• 21:46
  Blue
• 21:46
  Lotus
• 21:46
  and
• 21:47
  like,
• 21:47
  really
• 21:47
  weird,
• 21:49
  medicinal,
• 21:51
  quasi
• 21:51
  medicinal,
• 21:53
  suspicious,
• 21:54
  you
• 21:54
  name
• 21:54
  it.
• 21:54
  I
• 21:54
  mean,
• 21:55
  there
• 21:55
  are
• 21:55
  some
• 21:55
  really
• 21:56
  weird
• 21:56
  substances
• 21:57
  out
• 21:57
  there
• 21:57
  that
• 21:57
  even
• 21:58
  patients
• 21:58
  with
• 21:58
  fine
• 21:59
  intentions
• 21:59
  who
• 21:59
  are
• 22:00
  just
• 22:00
  trying
• 22:00
  to
• 22:00
  feel
• 22:00
  better
• 22:01
  don't
• 22:01
  realize
• 22:02
  that
• 22:02
  in
• 22:02
  certain
• 22:02
  potencies
• 22:03
  or
• 22:04
  combinations
• 22:04
  can
• 22:05
  cause
• 22:05
  psychosis.
• 22:06
  Right?
• 22:07
  I
• 22:08
  mean,
• 22:08
  how
• 22:08
  many
• 22:08
  patients
• 22:09
  don't
• 22:09
  even
• 22:09
  realize
• 22:09
  a
• 22:09
  freaking
• 22:10
  grapefruit
• 22:11
  can
• 22:11
  like
• 22:11
  send
• 22:11
  them
• 22:11
  to
• 22:12
  the
• 22:12
  ER
• 22:12
  when
• 22:12
  they're
• 22:13
  taking
• 22:13
  their
• 22:13
  medication.
• 22:14
  So
• 22:14
  they've
• 22:14
  had
• 22:14
  grapefruit,
• 22:15
  can
• 22:16
  send
• 22:16
  you
• 22:16
  to
• 22:16
  the
• 22:16
  er.
• 22:18
  Imagine
• 22:18
  what
• 22:19
  else
• 22:19
  is
• 22:19
  on
• 22:19
  the
• 22:19
  dark
• 22:19
  web.
• 22:20
  We
• 22:20
  don't
• 22:20
  have
• 22:20
  that
• 22:20
  kind
• 22:21
  of
• 22:21
  time
• 22:21
  tonight.
• 22:21
  We're
• 22:21
  not
• 22:22
  going
• 22:22
  to
• 22:22
  go
• 22:22
  there.
• 22:24
  Now,
• 22:25
  is
• 22:25
  this
• 22:26
  schizophrenic
• 22:26
  form
• 22:27
  disorder,
• 22:28
  you
• 22:29
  know,
• 22:29
  you
• 22:29
  might
• 22:29
  know
• 22:29
  from
• 22:29
  the
• 22:30
  definition
• 22:30
  that
• 22:31
  that
• 22:31
  requires
• 22:31
  psychotic
• 22:32
  symptoms
• 22:32
  lasting
• 22:33
  greater
• 22:33
  than
• 22:33
  one
• 22:33
  month,
• 22:34
  but
• 22:34
  less
• 22:35
  than
• 22:35
  six.
• 22:36
  So
• 22:37
  the
• 22:37
  duration
• 22:38
  there,
• 22:38
  if
• 22:38
  you
• 22:38
  study
• 22:39
  for
• 22:39
  your
• 22:39
  boards,
• 22:40
  right,
• 22:40
  you'll,
• 22:40
  you'll
• 22:40
  appreciate
• 22:41
  that
• 22:41
  the
• 22:41
  ten
• 22:42
  day
• 22:42
  thing
• 22:42
  kind
• 22:42
  of
• 22:43
  closes
• 22:43
  the
• 22:43
  door
• 22:43
  on
• 22:43
  that.
• 22:46
  But
• 22:46
  again,
• 22:46
  schizophrenia
• 22:47
  form
• 22:47
  disorder
• 22:48
  cannot
• 22:49
  really
• 22:49
  be
• 22:49
  diagnosed
• 22:50
  when
• 22:50
  the
• 22:50
  psychosis
• 22:51
  is
• 22:51
  better
• 22:51
  explained
• 22:51
  by
• 22:52
  a
• 22:52
  mood
• 22:52
  disorder.
• 22:52
  And
• 22:52
  this,
• 22:53
  you
• 22:53
  know,
• 22:53
  this
• 22:53
  goes
• 22:54
  back,
• 22:54
  my
• 22:54
  friends,
• 22:55
  to
• 22:56
  what
• 22:56
  I
• 22:56
  say
• 22:56
  almost
• 22:57
  every
• 22:57
  episode,
• 22:57
  right?
• 22:58
  And
• 22:58
  it's,
• 22:58
  it's
• 22:59
  find
• 22:59
  the
• 22:59
  worm
• 22:59
  at
• 22:59
  the
• 23:00
  core,
• 23:00
  right?
• 23:01
  Every
• 23:01
  single
• 23:02
  patient
• 23:02
  presentation,
• 23:04
  if
• 23:04
  you
• 23:04
  just
• 23:04
  zoom
• 23:05
  out
• 23:05
  a
• 23:05
  little
• 23:05
  bit,
• 23:05
  close
• 23:06
  your
• 23:06
  eyes,
• 23:08
  you
• 23:09
  will
• 23:10
  get
• 23:10
  a
• 23:11
  very
• 23:11
  good
• 23:11
  sense
• 23:12
  of
• 23:12
  what
• 23:12
  the
• 23:12
  core
• 23:13
  of
• 23:13
  their
• 23:13
  complaint
• 23:14
  is.
• 23:15
  Right?
• 23:15
  And
• 23:15
  the
• 23:16
  core
• 23:16
  of
• 23:16
  Sandy's
• 23:17
  presentation
• 23:18
  today
• 23:18
  was
• 23:18
  mood,
• 23:19
  mood,
• 23:19
  mood,
• 23:20
  mood,
• 23:20
  mood,
• 23:21
  right?
• 23:21
  There
• 23:21
  was
• 23:21
  definitely
• 23:22
  psychosis
• 23:23
  sprinkled
• 23:24
  in
• 23:24
  there.
• 23:24
  You
• 23:25
  know,
• 23:25
  we
• 23:25
  used
• 23:25
  the
• 23:26
  word
• 23:26
  major
• 23:26
  depression
• 23:27
  in
• 23:27
  there,
• 23:28
  right?
• 23:28
  Persecutory
• 23:29
  delusion,
• 23:30
  sure,
• 23:31
  all
• 23:31
  of
• 23:31
  that
• 23:31
  was
• 23:31
  sprinkled
• 23:32
  in
• 23:32
  there.
• 23:33
  But
• 23:33
  the
• 23:33
  meat
• 23:33
  and
• 23:33
  potatoes
• 23:34
  of
• 23:34
  this
• 23:35
  presentation
• 23:35
  was
• 23:36
  mood,
• 23:36
  mood,
• 23:36
  mood.
• 23:37
  The
• 23:37
  amount
• 23:37
  of
• 23:38
  symptoms
• 23:38
  you
• 23:38
  were
• 23:38
  showered
• 23:39
  with
• 23:40
  that
• 23:41
  are
• 23:41
  specifically
• 23:41
  attributable
• 23:42
  to
• 23:43
  a
• 23:43
  mood
• 23:43
  disorder
• 23:44
  in
• 23:44
  the
• 23:44
  DSM
• 23:45
  far
• 23:45
  outweighed
• 23:46
  everything
• 23:46
  else,
• 23:48
  right?
• 23:49
  And
• 23:49
  so
• 23:50
  especially
• 23:50
  when
• 23:51
  you
• 23:51
  see
• 23:51
  a
• 23:51
  constellation
• 23:52
  of
• 23:52
  symptoms
• 23:53
  that
• 23:53
  are
• 23:53
  related
• 23:53
  and
• 23:54
  aligned
• 23:54
  in
• 23:55
  the
• 23:55
  diagnostic
• 23:56
  manual,
• 23:57
  you
• 23:57
  are
• 23:57
  definitely
• 23:59
  orbiting
• 24:00
  around
• 24:00
  the
• 24:00
  core,
• 24:01
  right.
• 24:01
  The
• 24:01
  core
• 24:02
  issue
• 24:02
  as
• 24:03
  to
• 24:03
  why
• 24:03
  they're
• 24:03
  seeing
• 24:04
  you.
• 24:05
  And,
• 24:06
  and
• 24:06
  so
• 24:07
  again,
• 24:07
  that's
• 24:08
  why
• 24:08
  I
• 24:08
  love
• 24:08
  to
• 24:08
  zoom
• 24:09
  out
• 24:09
  and
• 24:09
  say,
• 24:09
  is
• 24:09
  this
• 24:10
  patient
• 24:10
  anxious?
• 24:11
  No,
• 24:11
  I've
• 24:11
  got,
• 24:12
  I
• 24:12
  don't
• 24:12
  smell
• 24:12
  any
• 24:12
  anxiety
• 24:13
  here.
• 24:13
  We're
• 24:14
  not
• 24:14
  talking
• 24:14
  about
• 24:14
  past
• 24:15
  near
• 24:15
  death
• 24:15
  experiences.
• 24:19
  And,
• 24:19
  you
• 24:19
  know,
• 24:19
  so
• 24:19
  just,
• 24:19
  it
• 24:20
  all
• 24:20
  kind
• 24:20
  of
• 24:20
  clicks,
• 24:20
  right?
• 24:21
  And
• 24:21
  I
• 24:21
  think
• 24:21
  the,
• 24:22
  the
• 24:22
  challenging
• 24:23
  piece
• 24:23
  for
• 24:23
  patients
• 24:24
  like
• 24:24
  this,
• 24:24
  I
• 24:24
  know,
• 24:25
  for
• 24:25
  me
• 24:25
  is
• 24:25
  the
• 24:26
  psychosis.
• 24:26
  The
• 24:27
  psychosis
• 24:27
  definitely
• 24:28
  is
• 24:29
  confusing,
• 24:29
  right?
• 24:30
  Because
• 24:30
  now
• 24:30
  you've
• 24:30
  opened
• 24:30
  up
• 24:31
  this
• 24:31
  Pandora
• 24:31
  box,
• 24:32
  Pandora's
• 24:32
  box
• 24:32
  of
• 24:33
  like,
• 24:33
  what
• 24:33
  am
• 24:34
  I
• 24:34
  looking
• 24:34
  at
• 24:34
  here?
• 24:34
  And
• 24:35
  so
• 24:35
  I
• 24:35
  would
• 24:35
  encourage
• 24:36
  you
• 24:36
  to
• 24:36
  replay
• 24:37
  this
• 24:37
  episode
• 24:39
  where
• 24:39
  we
• 24:40
  explain
• 24:40
  the
• 24:40
  timing.
• 24:41
  Right.
• 24:41
  If
• 24:42
  there's
• 24:42
  one
• 24:42
  big
• 24:42
  takeaway
• 24:43
  from
• 24:43
  this
• 24:43
  episode
• 24:44
  is
• 24:44
  that
• 24:44
  it's,
• 24:44
  it
• 24:45
  really
• 24:45
  can
• 24:45
  be
• 24:46
  made
• 24:46
  so
• 24:46
  simple
• 24:47
  if
• 24:47
  you
• 24:47
  just
• 24:47
  look
• 24:47
  at
• 24:48
  the
• 24:48
  timing,
• 24:48
  right?
• 24:49
  Does
• 24:49
  this
• 24:49
  happen
• 24:49
  with
• 24:50
  depression,
• 24:51
  MDD
• 24:52
  with
• 24:52
  psychotic
• 24:52
  features?
• 24:53
  Does
• 24:53
  the
• 24:53
  psychosis
• 24:54
  happen
• 24:55
  with
• 24:55
  elevated,
• 24:56
  expansive,
• 24:57
  irritable
• 24:57
  mood?
• 24:58
  We're
• 24:58
  looking
• 24:58
  at
• 24:58
  a
• 24:59
  bipolar
• 24:59
  one
• 25:00
  does
• 25:00
  it
• 25:00
  happen
• 25:00
  completely
• 25:01
  separate
• 25:02
  while
• 25:02
  we're
• 25:02
  looking
• 25:03
  at
• 25:04
  maybe
• 25:04
  a
• 25:04
  schizoaffective
• 25:05
  disorder
• 25:05
  where
• 25:05
  this
• 25:06
  is
• 25:06
  independent.
• 25:07
  Right.
• 25:07
  The,
• 25:08
  the
• 25:08
  psychosis
• 25:08
  is
• 25:09
  happening
• 25:09
  independently
• 25:10
  of
• 25:11
  the
• 25:11
  mood
• 25:11
  problems
• 25:12
  of
• 25:12
  the
• 25:13
  bad
• 25:13
  mood
• 25:13
  depression
• 25:14
  and
• 25:14
  the
• 25:14
  elevated
• 25:14
  mood
• 25:16
  hypomania.
• 25:17
  Right.
• 25:17
  It's
• 25:17
  happening
• 25:17
  independently.
• 25:18
  So
• 25:18
  just
• 25:19
  ask
• 25:19
  yourself
• 25:20
  is
• 25:20
  this
• 25:20
  separate
• 25:21
  or
• 25:21
  is
• 25:21
  this
• 25:22
  mixed
• 25:22
  with
• 25:22
  something
• 25:24
  that
• 25:24
  my
• 25:25
  friends
• 25:25
  is
• 25:25
  going
• 25:26
  to
• 25:26
  help
• 25:26
  you
• 25:26
  unlock
• 25:27
  this.
• 25:27
  And
• 25:27
  just
• 25:28
  remember
• 25:28
  there
• 25:28
  is
• 25:28
  no
• 25:29
  such
• 25:29
  thing
• 25:30
  as
• 25:31
  psych
• 25:31
  psychosis
• 25:33
  in
• 25:33
  a
• 25:33
  hypomania.
• 25:34
  I'm
• 25:35
  sorry,
• 25:35
  it
• 25:35
  doesn't
• 25:36
  exist.
• 25:37
  And
• 25:39
  you
• 25:39
  know
• 25:40
  ligers
• 25:40
  don't
• 25:41
  exist.
• 25:41
  Half
• 25:41
  lion,
• 25:42
  half
• 25:42
  tigers.
• 25:43
  That
• 25:44
  animal
• 25:44
  does
• 25:44
  not
• 25:44
  exist.
• 25:46
  And
• 25:46
  despite
• 25:46
  how
• 25:46
  much
• 25:47
  people
• 25:47
  think
• 25:47
  it
• 25:48
  exists
• 25:48
  out
• 25:48
  there,
• 25:48
  it
• 25:49
  doesn't.
• 25:49
  Neither
• 25:50
  does
• 25:50
  Bigfoot.
• 25:51
  That,
• 25:52
  that,
• 25:52
  that
• 25:53
  the
• 25:53
  latter
• 25:53
  might
• 25:53
  be
• 25:54
  a
• 25:54
  little
• 25:54
  more
• 25:54
  debatable
• 25:55
  but
• 25:58
  you
• 25:59
  can't
• 25:59
  have
• 25:59
  both.
• 26:00
  Okay?
• 26:00
  And
• 26:01
  that's
• 26:01
  the
• 26:01
  big
• 26:01
  takeaway
• 26:02
  and
• 26:02
  I
• 26:02
  hope
• 26:02
  that
• 26:02
  locks.
• 26:04
  I
• 26:04
  hope
• 26:04
  that
• 26:04
  unlocks
• 26:05
  a
• 26:05
  lot
• 26:05
  of
• 26:05
  potential
• 26:06
  for
• 26:06
  you
• 26:06
  guys
• 26:06
  and
• 26:06
  a
• 26:06
  lot
• 26:06
  of
• 26:07
  intrigue.
• 26:07
  Thank
• 26:08
  you
• 26:08
  for
• 26:08
  tuning
• 26:08
  in
• 26:09
  for
• 26:09
  another
• 26:09
  episode
• 26:09
  of
• 26:10
  Pearls
• 26:10
  and
• 26:10
  Prep.
• 26:11
  Bye
• 26:11
  bye.