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From Volcanoes to Nightmares: A Deep Dive on Prazosin · Pearls and Prep

• 0:00
  Foreign.
• 0:04
  My
• 0:04
  friends,
• 0:05
  welcome
• 0:05
  back
• 0:05
  to
• 0:05
  another
• 0:06
  episode
• 0:06
  of
• 0:06
  Pearls
• 0:07
  and
• 0:07
  prep
• 0:07
  your
• 0:08
  go
• 0:08
  to
• 0:08
  place
• 0:09
  for
• 0:09
  pearls
• 0:10
  that
• 0:10
  prep
• 0:10
  you
• 0:10
  for
• 0:11
  practice.
• 0:11
  Now
• 0:12
  I'd
• 0:12
  like
• 0:12
  you
• 0:12
  to
• 0:13
  meet
• 0:13
  our
• 0:13
  mock
• 0:14
  patient.
• 0:14
  His
• 0:15
  name
• 0:15
  is
• 0:15
  Marcus.
• 0:16
  He's
• 0:17
  coming
• 0:17
  to
• 0:17
  you
• 0:17
  in
• 0:17
  the
• 0:17
  outpatient
• 0:18
  space
• 0:18
  today
• 0:19
  because
• 0:19
  he
• 0:19
  fell
• 0:19
  into
• 0:20
  a
• 0:20
  non
• 0:20
  active
• 0:21
  volcano
• 0:22
  several
• 0:22
  years
• 0:22
  ago.
• 0:23
  He
• 0:23
  was
• 0:24
  able
• 0:24
  to
• 0:24
  climb
• 0:24
  his
• 0:25
  way
• 0:25
  out,
• 0:25
  but
• 0:25
  he
• 0:25
  has
• 0:25
  been
• 0:26
  having
• 0:27
  traumatic
• 0:27
  nightmares
• 0:28
  ever
• 0:28
  since.
• 0:29
  His
• 0:29
  wife
• 0:30
  wants
• 0:31
  him
• 0:31
  to
• 0:31
  get
• 0:31
  seen
• 0:32
  by
• 0:32
  you
• 0:32
  because
• 0:33
  he's
• 0:33
  been
• 0:33
  waking
• 0:34
  up
• 0:35
  in
• 0:35
  the
• 0:35
  middle
• 0:36
  of
• 0:36
  the
• 0:36
  night,
• 0:36
  sweaty,
• 0:37
  diaphoretic,
• 0:38
  heart
• 0:39
  racing,
• 0:39
  very
• 0:42
  uncomfortable,
• 0:43
  about
• 0:43
  three
• 0:43
  to
• 0:43
  four
• 0:43
  nights
• 0:44
  per
• 0:44
  week.
• 0:44
  He's
• 0:44
  been
• 0:45
  on
• 0:45
  Zoloft
• 0:45
  for
• 0:46
  about
• 0:46
  a
• 0:46
  year
• 0:47
  and
• 0:47
  a
• 0:47
  half
• 0:48
  for
• 0:48
  PTSD
• 0:49
  type
• 0:49
  symptoms.
• 0:50
  His
• 0:51
  nightmares
• 0:51
  are
• 0:51
  just
• 0:52
  over
• 0:52
  the
• 0:53
  top
• 0:53
  and
• 0:53
  extreme.
• 0:54
  He,
• 0:55
  his
• 0:55
  nightmares
• 0:56
  are
• 0:56
  about
• 0:57
  him
• 0:57
  jumping
• 0:58
  into
• 0:58
  an
• 0:59
  active
• 0:59
  volcano
• 1:00
  and
• 1:00
  burning
• 1:01
  alive.
• 1:01
  Very
• 1:02
  terrifying,
• 1:03
  if
• 1:03
  you
• 1:04
  will.
• 1:04
  He
• 1:04
  wakes
• 1:05
  up
• 1:05
  pretty
• 1:05
  distressed,
• 1:06
  fatigued
• 1:07
  the
• 1:07
  next
• 1:07
  day
• 1:09
  and
• 1:09
  it's
• 1:09
  really
• 1:10
  just
• 1:10
  ruining
• 1:11
  his
• 1:11
  quality
• 1:11
  of
• 1:11
  life.
• 1:12
  Just
• 1:12
  doesn't
• 1:12
  have
• 1:12
  much
• 1:13
  energy
• 1:13
  or
• 1:13
  motivation
• 1:14
  to
• 1:14
  do
• 1:14
  a
• 1:14
  whole
• 1:15
  lot.
• 1:15
  He's
• 1:16
  not
• 1:16
  currently
• 1:16
  in
• 1:17
  therapy,
• 1:17
  but
• 1:17
  he
• 1:17
  is
• 1:18
  on
• 1:18
  Zoloft,
• 1:18
  150
• 1:19
  milligrams
• 1:19
  a
• 1:20
  day.
• 1:21
  He
• 1:22
  also
• 1:22
  has
• 1:22
  a
• 1:23
  beer,
• 1:23
  occasionally
• 1:24
  cannabis
• 1:25
  to
• 1:25
  sleep,
• 1:25
  but
• 1:25
  not
• 1:26
  too
• 1:26
  often,
• 1:26
  maybe
• 1:26
  two
• 1:27
  or
• 1:27
  three
• 1:27
  times
• 1:27
  per
• 1:27
  month.
• 1:28
  His
• 1:28
  dad
• 1:28
  had
• 1:28
  anxiety.
• 1:29
  He's
• 1:30
  never
• 1:30
  been
• 1:30
  hospitalized
• 1:31
  before.
• 1:32
  He
• 1:32
  has
• 1:33
  never
• 1:33
  been
• 1:33
  on
• 1:33
  any
• 1:33
  meds
• 1:34
  prior
• 1:34
  to
• 1:35
  the
• 1:35
  Zoloft.
• 1:36
  So
• 1:36
  that's
• 1:36
  the
• 1:37
  gist
• 1:37
  of
• 1:37
  what
• 1:37
  you
• 1:37
  have
• 1:38
  from
• 1:38
  him.
• 1:39
  And
• 1:39
  now
• 1:39
  it's
• 1:39
  up
• 1:40
  to
• 1:40
  you
• 1:40
  to
• 1:40
  look
• 1:40
  at
• 1:41
  this
• 1:41
  patient
• 1:41
  and
• 1:41
  say,
• 1:42
  what
• 1:42
  do
• 1:42
  I
• 1:42
  do
• 1:43
  next?
• 1:43
  He
• 1:43
  fell
• 1:43
  into
• 1:44
  a
• 1:44
  non
• 1:44
  active
• 1:44
  volcano.
• 1:46
  You
• 1:46
  know,
• 1:46
  pretty
• 1:46
  traumatic,
• 1:48
  pretty
• 1:48
  terrifying.
• 1:49
  He's
• 1:49
  been
• 1:50
  on
• 1:50
  Zoloft
• 1:51
  and
• 1:52
  what
• 1:52
  else?
• 1:52
  So
• 1:53
  the
• 1:53
  first
• 1:53
  thing
• 1:53
  I
• 1:53
  like
• 1:54
  to
• 1:54
  do
• 1:54
  when
• 1:54
  I
• 1:54
  have
• 1:54
  this,
• 1:55
  a
• 1:55
  story
• 1:55
  like
• 1:55
  this
• 1:56
  is
• 1:56
  I,
• 1:57
  I
• 1:57
  like
• 1:58
  to
• 1:58
  understand
• 1:58
  the
• 1:58
  context,
• 1:59
  right?
• 1:59
  I
• 2:00
  like
• 2:00
  to
• 2:00
  have
• 2:00
  a
• 2:00
  general
• 2:00
  idea
• 2:01
  of
• 2:02
  when
• 2:02
  his
• 2:02
  mental
• 2:03
  health
• 2:03
  symptoms
• 2:04
  started.
• 2:04
  More
• 2:05
  generally.
• 2:06
  Many
• 2:06
  patients
• 2:06
  in
• 2:07
  this
• 2:07
  case
• 2:07
  will
• 2:07
  say,
• 2:07
  you
• 2:08
  know,
• 2:08
  I
• 2:08
  had
• 2:08
  no
• 2:09
  mental
• 2:09
  health
• 2:09
  symptoms
• 2:10
  prior
• 2:10
  to
• 2:11
  this
• 2:11
  trauma.
• 2:12
  You
• 2:12
  can
• 2:12
  ask
• 2:12
  them
• 2:12
  that,
• 2:13
  you
• 2:13
  know,
• 2:13
  have
• 2:13
  you
• 2:14
  had
• 2:14
  two
• 2:14
  or
• 2:14
  more
• 2:14
  weeks
• 2:15
  in
• 2:15
  a
• 2:15
  row
• 2:15
  where
• 2:15
  you
• 2:15
  felt
• 2:16
  down
• 2:16
  sad
• 2:16
  or
• 2:17
  depressed
• 2:17
  or
• 2:18
  you
• 2:18
  couldn't
• 2:18
  get
• 2:18
  much
• 2:18
  joy
• 2:19
  out
• 2:19
  of
• 2:19
  things?
• 2:19
  Has
• 2:20
  that
• 2:20
  ever
• 2:20
  happened
• 2:20
  to
• 2:20
  you
• 2:20
  in
• 2:20
  your
• 2:21
  life?
• 2:21
  Has
• 2:21
  that
• 2:22
  ever
• 2:22
  happened
• 2:22
  to
• 2:22
  you
• 2:23
  prior
• 2:23
  to
• 2:23
  the
• 2:24
  time
• 2:24
  when
• 2:24
  you
• 2:24
  fell
• 2:25
  into
• 2:25
  a
• 2:25
  non
• 2:25
  active
• 2:26
  volcano?
• 2:27
  Those
• 2:27
  are
• 2:28
  important
• 2:28
  questions
• 2:29
  to
• 2:29
  ask.
• 2:29
  We
• 2:29
  want
• 2:29
  to
• 2:29
  get
• 2:29
  an
• 2:30
  idea
• 2:30
  of
• 2:31
  what
• 2:31
  was
• 2:31
  his
• 2:32
  mental
• 2:32
  health
• 2:33
  profile
• 2:34
  looking
• 2:34
  like
• 2:34
  before
• 2:35
  this
• 2:35
  trauma.
• 2:36
  In
• 2:36
  his
• 2:36
  case,
• 2:37
  he's
• 2:37
  telling
• 2:37
  you
• 2:38
  there
• 2:38
  wasn't
• 2:38
  a
• 2:38
  whole
• 2:39
  lot
• 2:39
  going
• 2:39
  on
• 2:40
  prior
• 2:40
  to
• 2:40
  this
• 2:40
  trauma.
• 2:41
  No
• 2:41
  depression.
• 2:42
  Now
• 2:42
  you
• 2:42
  can
• 2:43
  ask
• 2:43
  him
• 2:43
  about
• 2:43
  worry
• 2:44
  and
• 2:44
  anxiety.
• 2:44
  Have
• 2:45
  you
• 2:45
  been
• 2:45
  much
• 2:45
  of
• 2:45
  a
• 2:45
  worrier
• 2:46
  Your
• 2:46
  whole
• 2:46
  life.
• 2:46
  Yeah.
• 2:47
  I
• 2:47
  see
• 2:47
  here
• 2:47
  your
• 2:47
  dad
• 2:48
  had
• 2:48
  generalized
• 2:48
  anxiety
• 2:49
  disorder.
• 2:50
  Do
• 2:50
  you
• 2:50
  feel
• 2:50
  similar
• 2:51
  in
• 2:51
  that
• 2:51
  you
• 2:51
  worry
• 2:52
  about
• 2:52
  worst
• 2:52
  case
• 2:52
  scenarios
• 2:53
  that
• 2:53
  frequently
• 2:53
  could
• 2:54
  happen?
• 2:54
  To
• 2:55
  get
• 2:55
  a
• 2:55
  sense
• 2:55
  of
• 2:55
  your
• 2:56
  patient's
• 2:57
  mental
• 2:57
  health
• 2:58
  history
• 2:59
  outside
• 3:00
  of
• 3:00
  the
• 3:00
  traumatic
• 3:01
  context,
• 3:01
  at
• 3:02
  least
• 3:02
  that's
• 3:02
  what
• 3:02
  I
• 3:02
  like
• 3:02
  to
• 3:02
  do.
• 3:03
  I
• 3:03
  like
• 3:03
  to
• 3:03
  see
• 3:03
  what
• 3:03
  his
• 3:04
  baseline
• 3:04
  functioning
• 3:05
  was
• 3:05
  prior
• 3:06
  to
• 3:07
  this
• 3:07
  criterion
• 3:08
  a
• 3:08
  event,
• 3:09
  this
• 3:09
  near
• 3:09
  death
• 3:10
  experience
• 3:10
  as
• 3:11
  he's
• 3:11
  describing
• 3:11
  it
• 3:12
  to
• 3:12
  you.
• 3:12
  And
• 3:12
  we'll
• 3:13
  get
• 3:13
  into
• 3:13
  the
• 3:13
  particulars
• 3:14
  of
• 3:14
  criterion
• 3:14
  A
• 3:15
  a
• 3:15
  little
• 3:15
  bit
• 3:15
  later.
• 3:16
  But
• 3:17
  suffice
• 3:17
  it
• 3:17
  to
• 3:17
  say,
• 3:18
  it
• 3:18
  sounds
• 3:18
  like
• 3:18
  a
• 3:18
  pretty
• 3:19
  traumatic
• 3:19
  event
• 3:19
  where
• 3:20
  he
• 3:20
  at
• 3:20
  least
• 3:20
  may
• 3:20
  have
• 3:20
  perceived
• 3:21
  that
• 3:22
  he
• 3:22
  would
• 3:22
  die,
• 3:22
  which
• 3:23
  would
• 3:23
  constitute
• 3:24
  a
• 3:24
  criterion
• 3:24
  a
• 3:25
  traumatic
• 3:26
  event
• 3:26
  in
• 3:26
  ptsd.
• 3:27
  But
• 3:28
  right
• 3:28
  now
• 3:28
  we
• 3:29
  clearly
• 3:29
  see
• 3:29
  that
• 3:30
  before
• 3:31
  this
• 3:31
  fall
• 3:32
  he
• 3:32
  was
• 3:33
  functioning
• 3:33
  pretty
• 3:34
  well.
• 3:34
  He
• 3:35
  said
• 3:35
  he
• 3:35
  didn't
• 3:36
  feel
• 3:36
  down
• 3:37
  or
• 3:37
  sad
• 3:37
  or
• 3:38
  particularly
• 3:38
  worried.
• 3:39
  You
• 3:39
  do
• 3:40
  more
• 3:40
  of
• 3:40
  a
• 3:40
  screen
• 3:40
  and
• 3:40
  he's
• 3:41
  telling
• 3:41
  you
• 3:41
  he
• 3:42
  doesn't
• 3:42
  have
• 3:42
  any
• 3:42
  childhood
• 3:43
  abuse
• 3:43
  or
• 3:43
  neglect.
• 3:44
  So
• 3:44
  his
• 3:44
  pre
• 3:45
  trauma
• 3:46
  functioning
• 3:46
  was
• 3:47
  pretty
• 3:47
  sound.
• 3:47
  And
• 3:48
  so
• 3:48
  that's
• 3:48
  the
• 3:48
  baseline.
• 3:49
  Right?
• 3:49
  That's
• 3:50
  what
• 3:50
  you
• 3:50
  want
• 3:50
  to
• 3:50
  compare
• 3:51
  your
• 3:52
  treatment
• 3:52
  to.
• 3:53
  In
• 3:53
  large
• 3:53
  part,
• 3:53
  it's
• 3:54
  very
• 3:54
  valuable
• 3:54
  to
• 3:54
  get
• 3:55
  that
• 3:55
  history
• 3:55
  because
• 3:55
  moving
• 3:56
  forward,
• 3:57
  you
• 3:57
  want
• 3:57
  to
• 3:57
  try
• 3:58
  and
• 3:58
  get
• 3:59
  him
• 3:59
  to
• 3:59
  the
• 3:59
  place
• 4:00
  where
• 4:00
  he
• 4:01
  was
• 4:01
  prior
• 4:02
  to
• 4:02
  falling
• 4:03
  into
• 4:04
  this
• 4:04
  volcano,
• 4:05
  you
• 4:05
  know,
• 4:05
  and
• 4:06
  that's
• 4:06
  going
• 4:06
  to
• 4:06
  be
• 4:06
  really
• 4:07
  important.
• 4:07
  But
• 4:07
  you
• 4:07
  do
• 4:08
  have
• 4:08
  a
• 4:08
  bit
• 4:08
  of
• 4:08
  an
• 4:08
  uphill
• 4:09
  battle
• 4:09
  right
• 4:09
  now.
• 4:10
  So
• 4:10
  long
• 4:10
  as
• 4:10
  he
• 4:10
  has
• 4:11
  nightmares.
• 4:11
  Nightmares
• 4:12
  are
• 4:12
  where
• 4:13
  so
• 4:13
  much
• 4:13
  of
• 4:13
  our
• 4:13
  emotional
• 4:14
  memories
• 4:14
  are
• 4:15
  being
• 4:15
  reprocessed.
• 4:16
  It's
• 4:16
  very
• 4:16
  hard
• 4:17
  to
• 4:17
  treat
• 4:17
  trauma
• 4:18
  when
• 4:19
  the
• 4:20
  emotional
• 4:21
  reprocessing
• 4:22
  can't
• 4:22
  take
• 4:22
  place
• 4:23
  because
• 4:24
  nightmares
• 4:24
  are
• 4:26
  like
• 4:26
  this
• 4:26
  torpedo
• 4:27
  that's
• 4:27
  sinking
• 4:27
  his
• 4:28
  ship.
• 4:28
  He
• 4:28
  wakes
• 4:29
  up
• 4:29
  all
• 4:30
  sweaty,
• 4:30
  nervous
• 4:31
  and
• 4:31
  fatigued.
• 4:32
  We
• 4:33
  all
• 4:33
  know
• 4:33
  that
• 4:33
  when
• 4:33
  you're
• 4:34
  not
• 4:34
  sleeping,
• 4:35
  your
• 4:35
  cortisol
• 4:36
  surges
• 4:37
  the
• 4:37
  next
• 4:37
  day.
• 4:38
  Cortisol
• 4:38
  can
• 4:38
  be
• 4:39
  toxic
• 4:39
  in
• 4:40
  excess
• 4:40
  to
• 4:40
  neurotransmitters,
• 4:41
  which
• 4:41
  further
• 4:42
  make
• 4:42
  it
• 4:42
  difficult
• 4:42
  for
• 4:42
  him
• 4:43
  to
• 4:43
  feel
• 4:44
  good
• 4:45
  and
• 4:46
  be
• 4:46
  in
• 4:46
  a
• 4:46
  good
• 4:47
  mood
• 4:47
  or
• 4:47
  not
• 4:47
  anxious.
• 4:48
  Right.
• 4:48
  All
• 4:48
  the
• 4:48
  things
• 4:48
  you're
• 4:49
  trying
• 4:49
  to
• 4:49
  treat.
• 4:50
  All
• 4:50
  of
• 4:50
  the
• 4:50
  other
• 4:50
  potential
• 4:51
  comorbidities
• 4:52
  get
• 4:52
  a
• 4:52
  lot
• 4:52
  harder
• 4:53
  when
• 4:53
  a
• 4:53
  patient
• 4:54
  is
• 4:54
  not
• 4:54
  sleeping.
• 4:55
  Now,
• 4:55
  I
• 4:55
  would
• 4:56
  really
• 4:56
  want
• 4:56
  to
• 4:57
  ask
• 4:58
  Marcus
• 4:59
  more
• 4:59
  broadly
• 5:00
  about
• 5:00
  his
• 5:00
  sleep
• 5:01
  patterns.
• 5:01
  When
• 5:01
  does
• 5:01
  he
• 5:01
  go
• 5:01
  to
• 5:02
  bed?
• 5:02
  Right.
• 5:02
  How
• 5:03
  many
• 5:03
  times
• 5:03
  is
• 5:03
  he
• 5:04
  waking
• 5:04
  up
• 5:04
  throughout
• 5:04
  the
• 5:05
  night?
• 5:05
  Share
• 5:06
  the
• 5:06
  content
• 5:06
  of
• 5:06
  these
• 5:07
  dreams
• 5:07
  if
• 5:07
  you
• 5:07
  can.
• 5:07
  You
• 5:08
  have
• 5:08
  to
• 5:08
  always
• 5:08
  make
• 5:08
  sure
• 5:09
  you're
• 5:09
  being
• 5:09
  trauma
• 5:09
  informed.
• 5:10
  Right.
• 5:10
  A
• 5:10
  lot
• 5:10
  of
• 5:10
  patients,
• 5:11
  they
• 5:11
  don't
• 5:11
  like
• 5:12
  going
• 5:12
  into
• 5:13
  nitty
• 5:13
  gritty
• 5:14
  details
• 5:14
  about
• 5:14
  these
• 5:14
  nightmares.
• 5:15
  It's
• 5:15
  bad.
• 5:15
  Bad
• 5:15
  enough
• 5:16
  that
• 5:16
  they
• 5:17
  almost
• 5:17
  fell
• 5:17
  into
• 5:17
  a
• 5:18
  volcano.
• 5:18
  It's
• 5:19
  even
• 5:19
  worse
• 5:19
  that
• 5:20
  they're
• 5:20
  dreaming
• 5:20
  about
• 5:20
  it
• 5:21
  every
• 5:21
  night.
• 5:21
  So
• 5:22
  they
• 5:22
  don't
• 5:22
  always
• 5:22
  love
• 5:22
  to
• 5:23
  divulge
• 5:23
  the
• 5:23
  details
• 5:24
  of
• 5:25
  them
• 5:25
  plummeting
• 5:25
  into
• 5:26
  magma
• 5:27
  in
• 5:27
  your
• 5:27
  office.
• 5:28
  Be
• 5:28
  a
• 5:28
  little
• 5:28
  sensitive
• 5:29
  about
• 5:29
  that.
• 5:30
  But
• 5:30
  I
• 5:30
  like
• 5:30
  to
• 5:30
  get
• 5:31
  an
• 5:31
  idea
• 5:31
  of
• 5:32
  when
• 5:32
  they
• 5:33
  fall
• 5:33
  asleep,
• 5:33
  how
• 5:33
  many
• 5:34
  times
• 5:34
  they're
• 5:34
  waking
• 5:34
  up,
• 5:35
  how
• 5:35
  many
• 5:35
  nightmares
• 5:36
  per
• 5:36
  week.
• 5:37
  Can
• 5:38
  you
• 5:38
  recall
• 5:38
  these
• 5:38
  nightmares
• 5:39
  vividly?
• 5:40
  How
• 5:40
  often
• 5:40
  are
• 5:40
  you
• 5:40
  thinking
• 5:41
  about
• 5:41
  these
• 5:41
  nightmares
• 5:42
  after
• 5:43
  the
• 5:43
  fact
• 5:43
  the
• 5:43
  next
• 5:44
  day?
• 5:44
  That's
• 5:44
  another
• 5:44
  good
• 5:45
  question.
• 5:45
  I
• 5:45
  like
• 5:45
  to
• 5:45
  ask,
• 5:46
  what
• 5:46
  does
• 5:46
  it
• 5:47
  make
• 5:47
  you
• 5:47
  feel
• 5:47
  like
• 5:47
  when
• 5:48
  you
• 5:48
  carry
• 5:49
  on
• 5:49
  your
• 5:49
  day
• 5:49
  after
• 5:49
  these
• 5:50
  nightmares?
• 5:51
  What
• 5:51
  is
• 5:51
  that
• 5:51
  like
• 5:51
  for
• 5:52
  you?
• 5:52
  Some
• 5:52
  people
• 5:53
  are
• 5:53
  in
• 5:53
  a
• 5:53
  daze
• 5:53
  or
• 5:54
  very
• 5:54
  anxious,
• 5:55
  and
• 5:55
  some
• 5:55
  people
• 5:55
  dread
• 5:56
  sleep.
• 5:56
  Another
• 5:57
  critical
• 5:57
  question
• 5:57
  is
• 5:58
  to
• 5:58
  assess
• 5:58
  for
• 5:59
  substance
• 5:59
  use
• 5:59
  disorder.
• 6:00
  Right.
• 6:00
  The.
• 6:00
  The
• 6:01
  incidence
• 6:02
  of
• 6:02
  substance
• 6:02
  use
• 6:03
  disorders
• 6:03
  goes
• 6:04
  up
• 6:04
  markedly
• 6:05
  when
• 6:05
  you're
• 6:05
  suffering
• 6:06
  from
• 6:06
  a
• 6:06
  mental
• 6:07
  health
• 6:07
  issue,
• 6:07
  especially
• 6:08
  ptsd.
• 6:09
  Right.
• 6:09
  A
• 6:09
  lot
• 6:09
  of
• 6:10
  folks
• 6:10
  want
• 6:10
  to
• 6:10
  numb
• 6:10
  their
• 6:11
  symptoms
• 6:11
  because
• 6:12
  these
• 6:12
  are
• 6:12
  very
• 6:13
  fight
• 6:13
  or
• 6:13
  flight,
• 6:14
  emotionally
• 6:16
  volatile
• 6:17
  type
• 6:17
  feelings.
• 6:18
  Right?
• 6:19
  Adrenaline
• 6:19
  surging
• 6:20
  in
• 6:20
  your
• 6:20
  blood.
• 6:20
  So
• 6:21
  you
• 6:21
  want
• 6:21
  to
• 6:21
  calm
• 6:22
  that
• 6:22
  down
• 6:22
  with
• 6:22
  alcohol
• 6:23
  or
• 6:23
  cannabis
• 6:23
  or
• 6:24
  whatever
• 6:24
  you
• 6:24
  have
• 6:24
  available
• 6:25
  to
• 6:25
  feel
• 6:26
  a
• 6:26
  little
• 6:26
  bit
• 6:26
  better.
• 6:27
  And
• 6:27
  so
• 6:27
  you've
• 6:28
  got
• 6:28
  to
• 6:28
  do
• 6:28
  a
• 6:28
  good
• 6:28
  substance
• 6:29
  use
• 6:29
  screen
• 6:29
  because
• 6:30
  of
• 6:30
  the
• 6:30
  comorbidities.
• 6:31
  It's
• 6:31
  very
• 6:32
  important
• 6:33
  to
• 6:33
  do
• 6:33
  that
• 6:34
  now.
• 6:36
  It
• 6:37
  might
• 6:37
  also
• 6:37
  help
• 6:38
  to
• 6:38
  ask
• 6:38
  Marcus,
• 6:39
  do
• 6:39
  you
• 6:40
  feel
• 6:40
  hypervigilant
• 6:41
  throughout
• 6:42
  the
• 6:42
  day,
• 6:42
  or
• 6:43
  is
• 6:43
  it
• 6:43
  mainly
• 6:44
  in
• 6:44
  the
• 6:44
  context
• 6:45
  of
• 6:45
  these
• 6:45
  nightmares
• 6:45
  when
• 6:46
  you
• 6:46
  wake
• 6:46
  up
• 6:46
  in
• 6:46
  the
• 6:46
  middle
• 6:46
  of
• 6:46
  the
• 6:46
  night?
• 6:47
  Or
• 6:47
  do
• 6:47
  you
• 6:47
  feel
• 6:47
  like
• 6:47
  you're
• 6:48
  just
• 6:48
  always
• 6:48
  kind
• 6:49
  of
• 6:49
  on
• 6:49
  edge
• 6:49
  and
• 6:49
  on
• 6:50
  guard?
• 6:50
  Now
• 6:50
  this
• 6:51
  gets
• 6:51
  interesting.
• 6:51
  It
• 6:52
  depends
• 6:52
  on
• 6:52
  the
• 6:52
  trauma.
• 6:53
  Sometimes
• 6:54
  if
• 6:55
  the
• 6:55
  trauma
• 6:55
  is
• 6:55
  circumscribed
• 6:56
  to
• 6:56
  a
• 6:57
  dormant
• 6:57
  volcano,
• 6:59
  you
• 6:59
  may
• 6:59
  be
• 6:59
  on
• 7:00
  the
• 7:00
  luckier
• 7:00
  side
• 7:01
  in
• 7:01
  that
• 7:01
  there's
• 7:01
  not
• 7:01
  a
• 7:02
  lot
• 7:02
  of
• 7:02
  cues
• 7:02
  and
• 7:02
  triggers
• 7:03
  that
• 7:03
  bother
• 7:04
  you
• 7:04
  during
• 7:05
  the
• 7:05
  day.
• 7:05
  So
• 7:06
  long
• 7:06
  as
• 7:06
  you're
• 7:06
  not
• 7:06
  driving
• 7:07
  to
• 7:07
  work
• 7:07
  next
• 7:08
  to
• 7:08
  a
• 7:08
  volcano,
• 7:09
  that
• 7:09
  might
• 7:09
  be
• 7:10
  a
• 7:10
  little
• 7:10
  easier.
• 7:10
  However,
• 7:11
  don't
• 7:12
  underestimate
• 7:14
  the
• 7:14
  sensory
• 7:15
  component
• 7:15
  of
• 7:15
  trauma.
• 7:16
  Right.
• 7:16
  And
• 7:16
  so
• 7:16
  I
• 7:17
  would
• 7:17
  ask
• 7:17
  Marcus,
• 7:18
  what
• 7:18
  is
• 7:18
  your
• 7:18
  relationship
• 7:20
  to
• 7:20
  fire
• 7:20
  and
• 7:21
  smoke
• 7:21
  nowadays?
• 7:22
  Are
• 7:22
  there
• 7:22
  other
• 7:22
  cues
• 7:23
  or
• 7:23
  triggers
• 7:24
  you
• 7:24
  find
• 7:24
  very
• 7:24
  unsettling
• 7:25
  around
• 7:26
  you
• 7:26
  since
• 7:27
  this
• 7:27
  happened
• 7:27
  to
• 7:28
  you?
• 7:28
  Right.
• 7:28
  And
• 7:28
  he
• 7:28
  might
• 7:28
  say,
• 7:29
  you
• 7:29
  know,
• 7:29
  I
• 7:29
  can't
• 7:29
  handle
• 7:30
  smoke,
• 7:30
  I
• 7:30
  can't
• 7:30
  handle
• 7:31
  fire.
• 7:31
  I
• 7:31
  can't
• 7:31
  even
• 7:31
  handle
• 7:32
  barbecues
• 7:32
  or
• 7:33
  on
• 7:33
  Sundays.
• 7:34
  So
• 7:35
  with
• 7:35
  my
• 7:35
  kids,
• 7:35
  I
• 7:36
  just
• 7:36
  can't
• 7:36
  handle
• 7:37
  it.
• 7:37
  You
• 7:37
  really
• 7:37
  want
• 7:37
  to
• 7:38
  have
• 7:38
  an
• 7:38
  understanding
• 7:38
  of
• 7:39
  how
• 7:40
  he
• 7:40
  is
• 7:40
  reinterpreting
• 7:41
  the
• 7:41
  world
• 7:41
  since
• 7:42
  this
• 7:42
  trauma
• 7:42
  occurred.
• 7:43
  What
• 7:44
  is
• 7:44
  it
• 7:44
  like
• 7:44
  trying
• 7:44
  to
• 7:44
  plan
• 7:45
  another
• 7:45
  vacation?
• 7:46
  What
• 7:47
  is
• 7:47
  it
• 7:47
  like
• 7:48
  going
• 7:48
  outside
• 7:49
  on
• 7:49
  a
• 7:49
  hot
• 7:49
  day?
• 7:50
  You
• 7:50
  want
• 7:50
  to
• 7:51
  have
• 7:51
  an
• 7:51
  idea
• 7:51
  of
• 7:52
  how
• 7:52
  this
• 7:52
  has
• 7:52
  impacted
• 7:53
  him?
• 7:53
  If
• 7:54
  you
• 7:54
  ask
• 7:54
  some
• 7:54
  of
• 7:54
  those
• 7:54
  questions
• 7:55
  and
• 7:55
  you're
• 7:56
  not
• 7:56
  sure.
• 7:57
  Ask
• 7:57
  more
• 7:57
  open
• 7:58
  ended
• 7:58
  questions.
• 7:59
  Walk
• 7:59
  me
• 8:00
  through
• 8:01
  your
• 8:02
  day
• 8:02
  to
• 8:02
  day
• 8:03
  and
• 8:04
  how
• 8:04
  this
• 8:04
  event
• 8:05
  continues
• 8:06
  to
• 8:06
  impact
• 8:07
  you
• 8:07
  as
• 8:07
  you
• 8:07
  navigate
• 8:08
  your
• 8:08
  life.
• 8:09
  That's
• 8:09
  a
• 8:09
  key
• 8:09
  question
• 8:10
  because
• 8:10
  he
• 8:10
  might
• 8:11
  also
• 8:11
  tell
• 8:11
  you,
• 8:12
  I
• 8:12
  think
• 8:12
  about
• 8:12
  this
• 8:13
  all
• 8:13
  the
• 8:13
  time.
• 8:13
  It
• 8:13
  was
• 8:13
  such
• 8:14
  a
• 8:14
  terrifying
• 8:14
  experience.
• 8:15
  I
• 8:15
  feel
• 8:15
  like
• 8:15
  I'm
• 8:16
  reliving
• 8:16
  it.
• 8:16
  I
• 8:17
  can
• 8:17
  feel
• 8:17
  the
• 8:18
  hot
• 8:19
  ashes
• 8:19
  on
• 8:19
  my
• 8:20
  feet.
• 8:20
  I
• 8:21
  get
• 8:21
  this
• 8:21
  tingly
• 8:21
  sensation
• 8:22
  throughout
• 8:23
  the
• 8:23
  day.
• 8:23
  Right?
• 8:23
  Because
• 8:24
  one
• 8:24
  of
• 8:24
  the
• 8:24
  major
• 8:25
  criteria
• 8:26
  for
• 8:26
  ptsd
• 8:27
  in
• 8:27
  the
• 8:27
  DSM
• 8:28
  5
• 8:28
  TR
• 8:28
  are
• 8:28
  intrusions.
• 8:29
  He
• 8:30
  already
• 8:30
  has
• 8:30
  the
• 8:30
  nightmare.
• 8:31
  So
• 8:31
  there
• 8:31
  you
• 8:31
  go.
• 8:31
  You
• 8:31
  only
• 8:31
  need
• 8:32
  one
• 8:33
  symptom
• 8:34
  in
• 8:34
  the
• 8:34
  intrusion
• 8:34
  box.
• 8:35
  So
• 8:35
  he
• 8:35
  already
• 8:35
  has
• 8:35
  the
• 8:36
  traumatic
• 8:36
  nightmares.
• 8:37
  But
• 8:37
  you
• 8:37
  can
• 8:37
  ask
• 8:37
  him
• 8:37
  about
• 8:38
  the
• 8:38
  flashbacks.
• 8:38
  You
• 8:38
  can
• 8:39
  ask
• 8:39
  him
• 8:39
  about
• 8:39
  things
• 8:39
  that
• 8:40
  he
• 8:40
  might
• 8:40
  be
• 8:40
  avoiding
• 8:41
  that
• 8:41
  are
• 8:42
  related
• 8:42
  to
• 8:42
  the
• 8:43
  trauma.
• 8:44
  You
• 8:44
  can
• 8:45
  ask
• 8:45
  him
• 8:45
  about
• 8:45
  how
• 8:46
  he
• 8:46
  sees
• 8:46
  the
• 8:46
  world.
• 8:46
  I
• 8:47
  frequently
• 8:47
  do
• 8:47
  that.
• 8:48
  I
• 8:48
  ask
• 8:48
  patients,
• 8:48
  how
• 8:49
  do
• 8:49
  you
• 8:49
  see
• 8:49
  the
• 8:49
  world
• 8:50
  differently
• 8:51
  after
• 8:51
  this
• 8:51
  has
• 8:52
  happened
• 8:52
  to
• 8:52
  you?
• 8:53
  Some
• 8:53
  patients
• 8:53
  will
• 8:54
  say,
• 8:54
  the
• 8:54
  world
• 8:54
  is
• 8:55
  much
• 8:55
  more
• 8:55
  of
• 8:55
  a
• 8:55
  dangerous
• 8:56
  place.
• 8:56
  Life
• 8:57
  is
• 8:57
  uncertain,
• 8:58
  death
• 8:58
  is
• 8:58
  always
• 8:58
  around
• 8:59
  the
• 8:59
  corner.
• 9:00
  I
• 9:00
  don't
• 9:00
  feel
• 9:01
  like
• 9:01
  I'm
• 9:01
  present
• 9:02
  anymore.
• 9:02
  I
• 9:02
  feel
• 9:04
  like
• 9:04
  my
• 9:04
  life
• 9:05
  and
• 9:05
  safety
• 9:06
  can't
• 9:06
  be
• 9:07
  trusted.
• 9:07
  I
• 9:07
  don't
• 9:07
  feel
• 9:08
  comfortable
• 9:08
  navigating
• 9:09
  around
• 9:09
  the
• 9:09
  world.
• 9:10
  A
• 9:10
  lot
• 9:10
  of
• 9:10
  times
• 9:10
  with
• 9:11
  trauma,
• 9:12
  you
• 9:12
  see
• 9:12
  that,
• 9:13
  right?
• 9:13
  You
• 9:14
  see
• 9:14
  the
• 9:14
  criterion
• 9:15
  D,
• 9:15
  negative
• 9:16
  cognitions,
• 9:16
  alterations
• 9:17
  in
• 9:17
  mood
• 9:18
  and
• 9:18
  cognition,
• 9:19
  where
• 9:20
  a
• 9:20
  patient
• 9:21
  may
• 9:21
  experience
• 9:21
  a
• 9:21
  wide
• 9:22
  range
• 9:22
  of
• 9:22
  symptoms,
• 9:24
  whether
• 9:24
  they're
• 9:24
  unable
• 9:25
  to
• 9:25
  recall
• 9:25
  key
• 9:25
  parts
• 9:26
  of
• 9:26
  their
• 9:26
  trauma,
• 9:27
  which
• 9:27
  is
• 9:27
  part
• 9:27
  of
• 9:27
  the
• 9:27
  criteria,
• 9:28
  or
• 9:28
  negative
• 9:29
  beliefs
• 9:29
  about
• 9:30
  themselves
• 9:30
  or
• 9:31
  others.
• 9:31
  The
• 9:31
  world
• 9:31
  it
• 9:32
  diminished
• 9:32
  interest
• 9:32
  in
• 9:33
  activities.
• 9:33
  You
• 9:33
  know,
• 9:34
  I
• 9:34
  always
• 9:34
  say
• 9:34
  to
• 9:34
  patients,
• 9:35
  if
• 9:35
  you're
• 9:35
  running
• 9:36
  from
• 9:36
  a
• 9:36
  bear,
• 9:37
  it's
• 9:37
  not
• 9:37
  easy
• 9:38
  to
• 9:38
  play
• 9:38
  around
• 9:38
  and
• 9:39
  have
• 9:39
  fun.
• 9:39
  Right?
• 9:40
  It's
• 9:40
  not
• 9:40
  easy
• 9:40
  to
• 9:40
  connect
• 9:41
  with
• 9:41
  others
• 9:41
  because
• 9:41
  you're
• 9:42
  running
• 9:42
  from
• 9:42
  a
• 9:42
  bear.
• 9:42
  That
• 9:43
  takes
• 9:43
  up
• 9:43
  99.999%
• 9:46
  of
• 9:46
  your
• 9:46
  entire
• 9:48
  mental
• 9:48
  and
• 9:48
  emotional
• 9:49
  world.
• 9:49
  People
• 9:49
  who
• 9:50
  are
• 9:50
  running
• 9:50
  from
• 9:50
  a
• 9:50
  bear
• 9:51
  are
• 9:51
  not
• 9:51
  going
• 9:51
  to
• 9:51
  have
• 9:51
  the
• 9:52
  time
• 9:52
  to
• 9:53
  plan
• 9:53
  vacations
• 9:54
  and
• 9:54
  laugh
• 9:55
  at
• 9:55
  jokes
• 9:55
  and
• 9:56
  connect
• 9:56
  with
• 9:56
  their
• 9:56
  kids
• 9:57
  as
• 9:57
  easily
• 9:58
  because
• 9:58
  they're
• 9:58
  running
• 9:59
  from
• 9:59
  a
• 9:59
  bear.
• 9:59
  Criterion
• 10:00
  D,
• 10:00
  negative
• 10:00
  alterations
• 10:01
  in
• 10:02
  mood
• 10:02
  and
• 10:02
  cognition
• 10:03
  are
• 10:04
  par
• 10:04
  for
• 10:05
  the
• 10:05
  course
• 10:05
  with
• 10:06
  a
• 10:06
  criterion
• 10:06
  A
• 10:07
  trauma
• 10:07
  like
• 10:07
  this.
• 10:08
  And
• 10:08
  then
• 10:08
  you
• 10:08
  want
• 10:08
  to
• 10:08
  assess
• 10:09
  the
• 10:09
  arousal
• 10:09
  and
• 10:09
  reactivity
• 10:11
  component
• 10:12
  of
• 10:12
  the
• 10:12
  DSM
• 10:12
  5TR,
• 10:13
  which
• 10:13
  would
• 10:13
  be
• 10:13
  the
• 10:14
  criterion
• 10:15
  E,
• 10:15
  marked
• 10:16
  alterations
• 10:16
  in
• 10:17
  arousal
• 10:17
  and
• 10:17
  reactivity
• 10:18
  associated
• 10:19
  with
• 10:19
  the
• 10:19
  traumatic
• 10:20
  event.
• 10:20
  Well,
• 10:20
  he's
• 10:20
  already
• 10:20
  telling
• 10:21
  you
• 10:21
  he's
• 10:21
  having
• 10:22
  nightmares.
• 10:23
  You
• 10:23
  know,
• 10:23
  you
• 10:23
  ask
• 10:23
  him
• 10:24
  about
• 10:24
  his
• 10:25
  day
• 10:25
  to
• 10:25
  day
• 10:25
  in
• 10:25
  terms
• 10:25
  of
• 10:26
  is
• 10:26
  he
• 10:26
  hypervigilant
• 10:27
  throughout
• 10:27
  the
• 10:27
  day?
• 10:28
  Because
• 10:28
  as
• 10:29
  you'll
• 10:29
  see
• 10:29
  in
• 10:29
  a
• 10:29
  few
• 10:29
  moments,
• 10:30
  we
• 10:30
  can
• 10:30
  actually
• 10:30
  treat
• 10:31
  that
• 10:31
  Pharmacologically
• 10:32
  if
• 10:33
  he
• 10:33
  is
• 10:33
  a
• 10:33
  little
• 10:33
  bit
• 10:33
  hypervigilant.
• 10:34
  So
• 10:34
  you
• 10:35
  really
• 10:35
  want
• 10:35
  to
• 10:35
  pinpoint
• 10:35
  this?
• 10:36
  I
• 10:36
  always
• 10:36
  say
• 10:37
  to
• 10:37
  our
• 10:37
  students,
• 10:38
  we've
• 10:38
  got
• 10:39
  to
• 10:39
  look
• 10:39
  at
• 10:39
  this
• 10:39
  like
• 10:39
  a
• 10:39
  Picasso
• 10:40
  painting.
• 10:40
  You
• 10:40
  want
• 10:41
  your
• 10:41
  patient
• 10:41
  in
• 10:41
  there
• 10:43
  and
• 10:43
  try
• 10:43
  to
• 10:43
  paint
• 10:44
  the
• 10:44
  most
• 10:45
  accurate
• 10:45
  portrayal
• 10:46
  imaginable
• 10:47
  of
• 10:47
  what
• 10:47
  their
• 10:48
  life
• 10:48
  is
• 10:48
  like.
• 10:48
  You
• 10:49
  want
• 10:49
  them
• 10:49
  to
• 10:49
  paint
• 10:49
  that
• 10:50
  for
• 10:50
  you.
• 10:50
  So
• 10:50
  you
• 10:51
  have
• 10:51
  an
• 10:51
  idea,
• 10:52
  right?
• 10:52
  Because
• 10:52
  as
• 10:53
  they're
• 10:53
  talking,
• 10:54
  you're
• 10:54
  thinking,
• 10:54
  diagnostics.
• 10:55
  What
• 10:55
  am
• 10:56
  I
• 10:56
  looking
• 10:56
  at
• 10:56
  diagnostically?
• 10:57
  And
• 10:57
  in
• 10:57
  the
• 10:57
  back
• 10:57
  of
• 10:58
  your
• 10:58
  mind
• 10:58
  you're
• 10:58
  thinking,
• 10:59
  what
• 10:59
  are
• 10:59
  the
• 10:59
  treatments
• 11:00
  that
• 11:00
  I
• 11:01
  might
• 11:01
  have
• 11:01
  at
• 11:01
  my
• 11:02
  disposal
• 11:02
  to
• 11:03
  make
• 11:03
  this
• 11:03
  person's
• 11:04
  life
• 11:04
  a
• 11:05
  little
• 11:05
  bit
• 11:05
  easier?
• 11:06
  Right?
• 11:06
  If
• 11:06
  they're
• 11:06
  hyper
• 11:07
  vigilant
• 11:07
  and
• 11:07
  hyper
• 11:08
  aroused,
• 11:08
  if
• 11:08
  they're
• 11:08
  having
• 11:08
  nightmares,
• 11:09
  if
• 11:09
  they're
• 11:09
  sad,
• 11:10
  there
• 11:10
  are
• 11:10
  neurotransmitters
• 11:11
  that
• 11:12
  pair
• 11:12
  to
• 11:12
  those
• 11:12
  specific
• 11:13
  symptoms
• 11:14
  in
• 11:14
  very
• 11:15
  specific
• 11:16
  pharmacological
• 11:17
  agents
• 11:17
  that
• 11:18
  you
• 11:18
  can
• 11:18
  choose.
• 11:18
  So
• 11:19
  you're
• 11:19
  just
• 11:19
  gathering
• 11:19
  this
• 11:20
  throughout
• 11:20
  the
• 11:21
  interview
• 11:21
  and
• 11:21
  it's
• 11:22
  extremely
• 11:23
  valuable.
• 11:24
  Now,
• 11:24
  one
• 11:24
  question
• 11:24
  I
• 11:25
  would
• 11:25
  love
• 11:25
  to
• 11:25
  ask
• 11:25
  Marcus
• 11:26
  too
• 11:27
  is
• 11:27
  how
• 11:27
  do
• 11:27
  you
• 11:27
  feel
• 11:28
  Zoloft
• 11:29
  has
• 11:30
  done
• 11:30
  for
• 11:31
  you
• 11:31
  so
• 11:31
  far
• 11:32
  since
• 11:32
  beginning
• 11:33
  it?
• 11:33
  What
• 11:33
  role
• 11:34
  does
• 11:34
  Zoloft
• 11:34
  play
• 11:35
  in
• 11:35
  your
• 11:36
  recovery
• 11:36
  from
• 11:36
  these
• 11:36
  trauma
• 11:37
  symptoms?
• 11:37
  Again,
• 11:38
  a
• 11:38
  nice
• 11:38
  open
• 11:39
  ended
• 11:39
  question.
• 11:40
  I
• 11:40
  can't
• 11:40
  emphasize
• 11:41
  how
• 11:41
  important
• 11:41
  it
• 11:41
  is
• 11:42
  to
• 11:42
  ask
• 11:42
  open
• 11:43
  ended
• 11:43
  questions
• 11:44
  because
• 11:44
  they
• 11:44
  maximize
• 11:45
  your
• 11:45
  ability
• 11:46
  to
• 11:46
  get
• 11:46
  high
• 11:47
  yield
• 11:47
  information
• 11:48
  in
• 11:48
  a
• 11:48
  very
• 11:48
  limited
• 11:49
  amount
• 11:49
  of
• 11:49
  time.
• 11:49
  And
• 11:50
  the
• 11:50
  more
• 11:50
  information
• 11:50
  you
• 11:51
  get
• 11:51
  from
• 11:51
  your
• 11:52
  interview,
• 11:52
  the
• 11:53
  absolute
• 11:53
  better
• 11:53
  you
• 11:54
  will
• 11:54
  be
• 11:54
  at
• 11:55
  diagnosing
• 11:55
  something
• 11:56
  accurately
• 11:56
  and
• 11:56
  treating
• 11:57
  it
• 11:57
  accurately
• 11:58
  because
• 11:58
  you
• 11:58
  diagnosed
• 11:59
  it
• 11:59
  accurately.
• 12:00
  Right?
• 12:00
  You're
• 12:00
  not
• 12:00
  going
• 12:00
  to
• 12:00
  get
• 12:00
  a
• 12:00
  good
• 12:01
  treatment
• 12:01
  if
• 12:01
  your
• 12:01
  diagnosis
• 12:02
  is
• 12:02
  off.
• 12:02
  And
• 12:03
  you're
• 12:03
  not
• 12:03
  going
• 12:03
  to
• 12:03
  get
• 12:04
  a
• 12:04
  good
• 12:05
  diagnosis
• 12:05
  if
• 12:05
  you
• 12:05
  don't
• 12:06
  know
• 12:06
  how
• 12:06
  to
• 12:06
  ask
• 12:07
  questions.
• 12:08
  So
• 12:08
  I
• 12:09
  would
• 12:09
  definitely
• 12:09
  ask,
• 12:09
  what
• 12:10
  role
• 12:10
  is
• 12:10
  Zoloft
• 12:11
  playing
• 12:11
  here?
• 12:11
  What
• 12:11
  do
• 12:11
  you
• 12:11
  think
• 12:11
  it's
• 12:12
  doing
• 12:12
  for
• 12:12
  you?
• 12:13
  I
• 12:13
  would
• 12:13
  ask
• 12:13
  that
• 12:13
  nonjudgmentally.
• 12:14
  It
• 12:14
  can
• 12:14
  be
• 12:15
  tempting
• 12:15
  sometimes
• 12:16
  to
• 12:17
  disparage
• 12:18
  a
• 12:18
  medication
• 12:18
  because
• 12:19
  you're
• 12:19
  on
• 12:20
  this
• 12:20
  medication.
• 12:20
  He's
• 12:20
  at
• 12:21
  150
• 12:21
  milligrams.
• 12:22
  It's
• 12:22
  a
• 12:22
  pretty
• 12:22
  robust
• 12:23
  dose.
• 12:23
  Like
• 12:23
  why
• 12:24
  aren't
• 12:24
  you
• 12:24
  better?
• 12:24
  You
• 12:24
  obviously
• 12:25
  don't
• 12:25
  say
• 12:25
  that,
• 12:26
  but
• 12:26
  sometimes
• 12:26
  I'm
• 12:27
  thinking
• 12:27
  that,
• 12:27
  why
• 12:27
  isn't
• 12:28
  this
• 12:28
  patient
• 12:28
  better?
• 12:28
  He's
• 12:29
  at
• 12:29
  a
• 12:29
  robust
• 12:29
  dose
• 12:30
  of
• 12:30
  Zoloft.
• 12:31
  What
• 12:31
  else
• 12:31
  could
• 12:32
  this
• 12:32
  medication
• 12:32
  be
• 12:32
  doing
• 12:33
  for
• 12:33
  him?
• 12:33
  Do
• 12:33
  we
• 12:33
  need
• 12:34
  to
• 12:34
  switch
• 12:34
  it?
• 12:34
  Do
• 12:35
  we
• 12:35
  need
• 12:35
  to
• 12:35
  augment?
• 12:36
  Is
• 12:36
  he
• 12:36
  in
• 12:36
  psychotherapy?
• 12:37
  This
• 12:38
  is
• 12:38
  me
• 12:38
  thinking
• 12:38
  out
• 12:38
  loud,
• 12:39
  right?
• 12:40
  This
• 12:40
  is
• 12:40
  not
• 12:41
  what
• 12:41
  I
• 12:41
  say
• 12:41
  to
• 12:41
  patients
• 12:42
  directly.
• 12:43
  We're
• 12:43
  trying
• 12:43
  to
• 12:44
  get
• 12:44
  you
• 12:44
  to
• 12:44
  have
• 12:45
  an
• 12:45
  appreciation
• 12:45
  for
• 12:46
  the
• 12:46
  mind
• 12:47
  of
• 12:47
  a
• 12:47
  clinician,
• 12:48
  as
• 12:49
  this
• 12:49
  is
• 12:49
  unfolding
• 12:49
  in
• 12:50
  real
• 12:50
  time
• 12:50
  with
• 12:50
  a
• 12:50
  mock
• 12:51
  case.
• 12:52
  So
• 12:53
  definitely
• 12:53
  we
• 12:54
  need
• 12:54
  to
• 12:54
  understand
• 12:54
  what's
• 12:55
  happening
• 12:55
  with
• 12:55
  Zoloft.
• 12:55
  And
• 12:55
  Marcus
• 12:56
  tells
• 12:56
  you,
• 12:57
  you
• 12:57
  know,
• 12:57
  Zoloft
• 12:58
  has
• 12:58
  helped
• 12:58
  me
• 12:58
  worry
• 12:58
  a
• 12:59
  little
• 12:59
  less.
• 12:59
  It's
• 12:59
  taken
• 13:00
  an
• 13:00
  edge
• 13:00
  off.
• 13:00
  I'm
• 13:01
  not
• 13:01
  worried
• 13:01
  as
• 13:01
  much,
• 13:01
  but
• 13:02
  I
• 13:02
  still
• 13:02
  feel
• 13:03
  really
• 13:03
  on
• 13:04
  edge.
• 13:04
  And
• 13:04
  that's
• 13:04
  really
• 13:05
  on
• 13:05
  point
• 13:06
  with
• 13:06
  what
• 13:06
  Zoloft
• 13:07
  does.
• 13:07
  Zoloft
• 13:07
  calms
• 13:08
  the
• 13:09
  amygdala,
• 13:09
  the
• 13:09
  threat
• 13:10
  centers
• 13:11
  in
• 13:11
  the
• 13:11
  brain.
• 13:12
  It
• 13:12
  allows
• 13:13
  you
• 13:13
  to
• 13:14
  work,
• 13:14
  reduce
• 13:15
  cognitive
• 13:15
  levels
• 13:16
  of
• 13:16
  worry
• 13:17
  in
• 13:17
  a
• 13:17
  major
• 13:17
  way.
• 13:18
  So
• 13:18
  a
• 13:18
  lot
• 13:18
  of
• 13:18
  the
• 13:19
  worries
• 13:19
  and
• 13:19
  cognitions
• 13:20
  involved
• 13:20
  in
• 13:21
  trauma
• 13:21
  get
• 13:22
  cooled
• 13:22
  down
• 13:22
  or
• 13:23
  softened
• 13:23
  with
• 13:24
  SSRIs,
• 13:24
  among
• 13:25
  other
• 13:25
  things.
• 13:25
  But
• 13:26
  as
• 13:26
  you
• 13:26
  can
• 13:26
  see,
• 13:26
  he's
• 13:27
  not
• 13:27
  really
• 13:27
  coming
• 13:27
  to
• 13:28
  you
• 13:28
  because
• 13:28
  he's
• 13:29
  worried
• 13:30
  all
• 13:30
  day
• 13:30
  or
• 13:30
  on
• 13:30
  edge
• 13:31
  all
• 13:31
  day.
• 13:32
  He's
• 13:32
  not
• 13:32
  coming
• 13:32
  to
• 13:33
  you
• 13:33
  because
• 13:33
  he
• 13:33
  said
• 13:33
  he's
• 13:34
  depressed
• 13:34
  or
• 13:34
  anything,
• 13:35
  although
• 13:35
  you
• 13:35
  definitely
• 13:35
  need
• 13:36
  to
• 13:36
  ask
• 13:36
  that
• 13:37
  as
• 13:37
  well,
• 13:37
  given
• 13:38
  its
• 13:38
  comorbidities.
• 13:39
  But
• 13:39
  he's
• 13:40
  coming
• 13:40
  to
• 13:40
  you
• 13:40
  for
• 13:41
  nightmares,
• 13:41
  right?
• 13:42
  And
• 13:42
  so
• 13:43
  that
• 13:43
  is
• 13:43
  really
• 13:44
  important.
• 13:45
  So
• 13:45
  now
• 13:46
  when
• 13:46
  we're
• 13:46
  looking
• 13:46
  at
• 13:46
  this
• 13:48
  all
• 13:48
  together
• 13:48
  and
• 13:49
  he's
• 13:49
  telling
• 13:49
  you,
• 13:50
  basically,
• 13:50
  Zoloft
• 13:51
  hasn't
• 13:51
  gotten
• 13:51
  him
• 13:51
  all
• 13:52
  the
• 13:52
  way
• 13:52
  there,
• 13:52
  you
• 13:52
  can
• 13:53
  bridge
• 13:53
  that
• 13:53
  conversation
• 13:54
  and
• 13:54
  say,
• 13:54
  well,
• 13:55
  what
• 13:55
  else
• 13:55
  have
• 13:55
  you
• 13:56
  done
• 13:56
  to
• 13:56
  try
• 13:56
  and
• 13:56
  soften
• 13:57
  these
• 13:57
  symptoms?
• 14:52
  What
• 14:52
  has
• 13:59
  worked
• 14:54
  for
• 14:54
  you?
• 14:54
  What
• 14:54
  hasn't
• 14:54
  worked
• 14:55
  for
• 14:55
  you?
• 14:55
  Some
• 14:55
  patients
• 14:56
  tell
• 14:56
  you,
• 14:56
  I'll
• 14:56
  be
• 14:56
  honest,
• 14:56
  I
• 14:57
  know
• 14:57
  it's
• 14:57
  not
• 14:57
  healthy,
• 14:58
  but
• 14:58
  I
• 14:58
  drink
• 14:59
  alcohol
• 14:59
  before
• 14:59
  bed
• 15:00
  to
• 15:00
  try
• 15:01
  and
• 15:01
  sleep
• 15:01
  or
• 15:01
  to
• 15:01
  reduce
• 15:02
  the
• 15:02
  nightmares.
• 15:02
  Now,
• 15:03
  you
• 15:03
  can
• 15:03
  always
• 15:03
  educate
• 15:04
  your
• 15:04
  patients
• 15:04
  that
• 15:05
  alcohol
• 15:05
  reduces
• 15:06
  the
• 15:06
  percentage
• 15:07
  of
• 15:07
  time
• 15:07
  that
• 15:07
  you
• 15:07
  spend
• 15:08
  in
• 15:08
  REM
• 15:08
  cycles.
• 15:09
  Right.
• 15:10
  And
• 15:10
  that
• 15:10
  can
• 15:10
  be
• 15:10
  detrimental
• 15:11
  when
• 15:11
  you're
• 15:11
  trying
• 15:11
  to
• 15:12
  reprocess
• 15:12
  emotional
• 15:13
  memories.
• 15:14
  We
• 15:15
  can
• 15:15
  also
• 15:15
  have
• 15:15
  conversations
• 15:16
  about
• 15:17
  SSRIs
• 15:18
  and
• 15:18
  how
• 15:19
  they
• 15:19
  can
• 15:19
  increase
• 15:19
  the
• 15:20
  intensity
• 15:20
  of
• 15:20
  dreaming,
• 15:21
  almost
• 15:21
  making
• 15:22
  it
• 15:22
  feel
• 15:22
  like
• 15:22
  you're
• 15:23
  there.
• 15:23
  Sometimes
• 15:23
  SSRIs
• 15:24
  can
• 15:24
  get
• 15:24
  in
• 15:24
  our
• 15:25
  way
• 15:25
  a
• 15:25
  little
• 15:25
  bit
• 15:25
  too,
• 15:26
  potentially,
• 15:27
  just
• 15:27
  by
• 15:27
  the
• 15:27
  nature
• 15:27
  of
• 15:28
  how
• 15:28
  we
• 15:28
  dream.
• 15:29
  It's
• 15:29
  not
• 15:29
  always
• 15:29
  as
• 15:30
  simple
• 15:30
  as,
• 15:30
  I
• 15:30
  give
• 15:30
  you
• 15:30
  an
• 15:31
  ssri.
• 15:31
  You're
• 15:32
  better,
• 15:32
  right?
• 15:32
  There's.
• 15:33
  There's
• 15:33
  nuance
• 15:34
  to
• 15:34
  this.
• 15:34
  There's
• 15:35
  many
• 15:35
  different
• 15:36
  treatments
• 15:37
  that
• 15:37
  need
• 15:37
  to
• 15:37
  be
• 15:37
  on
• 15:38
  the
• 15:38
  table
• 15:38
  and
• 15:38
  approaches
• 15:39
  that
• 15:39
  need
• 15:39
  to
• 15:39
  be
• 15:39
  on
• 15:39
  the
• 15:39
  table.
• 15:40
  Not
• 15:40
  everyone
• 15:40
  who's
• 15:41
  on
• 15:41
  an
• 15:41
  SSRI
• 15:41
  is
• 15:42
  going
• 15:42
  to
• 15:42
  report
• 15:42
  that
• 15:42
  they're
• 15:43
  having
• 15:43
  really
• 15:43
  vivid
• 15:43
  dreams.
• 15:44
  Some
• 15:45
  may
• 15:45
  still
• 15:45
  tell
• 15:45
  you
• 15:45
  they're
• 15:45
  not
• 15:46
  dreaming
• 15:46
  at
• 15:46
  all,
• 15:46
  and
• 15:46
  some
• 15:47
  may
• 15:47
  say
• 15:47
  they're
• 15:47
  having
• 15:48
  traumatic
• 15:48
  nightmares
• 15:49
  on
• 15:49
  a
• 15:49
  daily
• 15:50
  basis.
• 15:50
  It
• 15:50
  just
• 15:51
  sort
• 15:51
  of
• 15:51
  depends.
• 15:51
  Of
• 15:52
  course,
• 15:53
  there
• 15:53
  are
• 15:53
  all
• 15:54
  kinds
• 15:54
  of
• 15:54
  things
• 15:54
  that
• 15:54
  can
• 15:55
  act
• 15:55
  as
• 15:55
  a
• 15:55
  monkey
• 15:55
  wrench
• 15:56
  in
• 15:56
  our
• 15:57
  treatment
• 15:58
  plans
• 15:58
  that,
• 15:58
  that
• 15:58
  you
• 15:59
  have
• 15:59
  to
• 15:59
  Ask
• 15:59
  about
• 15:59
  withdrawal
• 16:00
  from
• 16:00
  alcohol
• 16:01
  or
• 16:01
  cannabis,
• 16:02
  even
• 16:02
  if
• 16:02
  it's
• 16:03
  a
• 16:03
  short
• 16:03
  term
• 16:04
  withdrawal.
• 16:05
  You
• 16:05
  drink
• 16:05
  heavy
• 16:06
  one
• 16:06
  day,
• 16:06
  you
• 16:06
  use
• 16:07
  cannabis
• 16:07
  heavy
• 16:07
  the
• 16:08
  other
• 16:08
  day,
• 16:08
  and
• 16:09
  what
• 16:09
  that
• 16:09
  can
• 16:09
  do
• 16:09
  to
• 16:09
  your
• 16:10
  REM
• 16:10
  cycle
• 16:10
  and
• 16:10
  your
• 16:11
  sleep
• 16:11
  and
• 16:11
  your
• 16:11
  overall
• 16:12
  anxiety
• 16:12
  and
• 16:12
  mood.
• 16:13
  There's
• 16:13
  a
• 16:13
  lot
• 16:13
  of
• 16:14
  things
• 16:14
  you
• 16:14
  want
• 16:14
  to
• 16:14
  assess
• 16:15
  in
• 16:15
  detail
• 16:16
  surrounding
• 16:16
  these
• 16:17
  nightmares.
• 16:17
  If
• 16:18
  nothing
• 16:18
  else,
• 16:18
  educate
• 16:19
  your
• 16:19
  patient
• 16:19
  about
• 16:20
  what
• 16:20
  might
• 16:20
  be
• 16:21
  making
• 16:21
  this
• 16:21
  worse
• 16:22
  or
• 16:22
  more
• 16:22
  complicated
• 16:23
  diagnostically
• 16:24
  and
• 16:24
  have
• 16:24
  that
• 16:24
  conversation
• 16:25
  with
• 16:25
  them.
• 16:26
  Um,
• 16:26
  I
• 16:26
  think
• 16:26
  it
• 16:27
  would
• 16:27
  be
• 16:27
  a
• 16:27
  really
• 16:28
  good
• 16:28
  idea.
• 16:29
  Go
• 16:29
  into
• 16:29
  sleep
• 16:29
  schedules
• 16:30
  with
• 16:30
  them.
• 16:30
  What
• 16:30
  does
• 16:30
  your
• 16:31
  sleep
• 16:31
  routine
• 16:32
  look
• 16:32
  like?
• 16:33
  Not
• 16:33
  just
• 16:33
  when
• 16:33
  do
• 16:34
  you
• 16:34
  go
• 16:34
  to
• 16:34
  bed
• 16:34
  and
• 16:34
  all
• 16:34
  about
• 16:35
  the
• 16:35
  nightmares,
• 16:35
  but
• 16:36
  what
• 16:36
  do
• 16:37
  you
• 16:37
  do
• 16:37
  to
• 16:37
  prepare
• 16:37
  to
• 16:38
  go
• 16:38
  to
• 16:38
  bed
• 16:39
  every
• 16:39
  day?
• 16:39
  How
• 16:40
  long
• 16:40
  do
• 16:40
  you
• 16:40
  take
• 16:41
  to
• 16:42
  prepare
• 16:42
  to
• 16:42
  go
• 16:43
  to
• 16:43
  bed
• 16:43
  every
• 16:43
  day?
• 16:43
  You're
• 16:44
  cultivating
• 16:46
  this
• 16:47
  environment
• 16:47
  by
• 16:48
  which
• 16:48
  you
• 16:48
  can
• 16:48
  go
• 16:48
  to
• 16:49
  bed
• 16:50
  more
• 16:50
  smoothly.
• 16:52
  We
• 16:52
  talk
• 16:52
  about
• 16:52
  going
• 16:52
  to
• 16:53
  bed
• 16:53
  as
• 16:53
  like
• 16:53
  landing
• 16:54
  a
• 16:54
  plane.
• 16:55
  It
• 16:55
  should
• 16:55
  be
• 16:55
  graceful,
• 16:56
  it
• 16:56
  shouldn't
• 16:56
  be
• 16:56
  abrupt
• 16:57
  where
• 16:57
  you
• 16:57
  just
• 16:57
  run
• 16:57
  under
• 16:58
  the
• 16:58
  covers
• 16:58
  and
• 16:58
  try
• 16:58
  to
• 16:59
  sleep.
• 16:59
  That's
• 16:59
  not
• 16:59
  how
• 16:59
  sleep
• 17:00
  works.
• 17:00
  It
• 17:01
  needs
• 17:01
  to
• 17:01
  be
• 17:01
  actualized
• 17:02
  in
• 17:02
  a
• 17:02
  gradual
• 17:03
  basis,
• 17:03
  sort
• 17:03
  of
• 17:04
  like
• 17:04
  landing
• 17:04
  a
• 17:04
  plane.
• 17:05
  And
• 17:05
  that's
• 17:05
  very
• 17:06
  important.
• 17:06
  Right.
• 17:07
  So
• 17:07
  you
• 17:07
  want
• 17:07
  to
• 17:08
  get
• 17:08
  an
• 17:08
  idea
• 17:08
  of
• 17:09
  all
• 17:09
  of
• 17:09
  the
• 17:10
  stuff
• 17:10
  that's
• 17:10
  surrounding
• 17:11
  his
• 17:11
  impairment
• 17:12
  that
• 17:12
  could
• 17:12
  be
• 17:12
  worsening
• 17:13
  force
• 17:14
  through
• 17:14
  motivational
• 17:14
  interviewing
• 17:15
  too.
• 17:15
  And
• 17:15
  so
• 17:15
  that's
• 17:16
  the
• 17:16
  kind
• 17:16
  of
• 17:16
  stuff
• 17:17
  you
• 17:17
  want
• 17:17
  to
• 17:17
  talk
• 17:17
  about
• 17:17
  in
• 17:18
  the
• 17:18
  interview.
• 17:18
  Now,
• 17:19
  of
• 17:19
  course,
• 17:19
  you
• 17:19
  want
• 17:19
  to
• 17:20
  assess
• 17:20
  for
• 17:20
  depression.
• 17:21
  Right?
• 17:21
  It's
• 17:21
  exhausting
• 17:22
  to
• 17:22
  have
• 17:22
  to
• 17:23
  run
• 17:23
  from
• 17:24
  a
• 17:24
  bear
• 17:24
  every
• 17:24
  day.
• 17:25
  It's
• 17:26
  very
• 17:26
  problematic
• 17:27
  to
• 17:27
  not
• 17:27
  be
• 17:27
  getting
• 17:28
  restorative
• 17:28
  sleep.
• 17:29
  What
• 17:29
  that
• 17:29
  does
• 17:30
  to
• 17:30
  us
• 17:30
  metabolically,
• 17:32
  it's
• 17:33
  just
• 17:33
  a
• 17:33
  very
• 17:34
  big
• 17:34
  issue.
• 17:34
  So
• 17:35
  you
• 17:35
  want
• 17:35
  to
• 17:36
  ask
• 17:36
  him
• 17:36
  about
• 17:36
  depression.
• 17:37
  Comorbidity
• 17:38
  with
• 17:38
  PTSD
• 17:38
  is
• 17:39
  high.
• 17:39
  Recent
• 17:40
  studies
• 17:40
  indicating
• 17:40
  over
• 17:41
  50%
• 17:41
  of
• 17:42
  individuals
• 17:42
  with
• 17:42
  PTSD
• 17:43
  also
• 17:43
  experience
• 17:44
  major
• 17:44
  depressive
• 17:45
  disorder.
• 17:45
  That's
• 17:45
  a
• 17:45
  lot.
• 17:46
  50
• 17:46
  up
• 17:46
  to
• 17:46
  50%
• 17:47
  is
• 17:48
  a
• 17:48
  pretty
• 17:48
  big
• 17:48
  deal.
• 17:49
  So
• 17:49
  we
• 17:49
  have
• 17:49
  to
• 17:50
  differentiate
• 17:50
  some
• 17:50
  of
• 17:51
  this
• 17:51
  too,
• 17:51
  and
• 17:52
  ask,
• 17:52
  you
• 17:52
  know,
• 17:52
  when
• 17:52
  did
• 17:53
  your
• 17:53
  mood
• 17:53
  get
• 17:53
  to
• 17:53
  the
• 17:53
  point
• 17:54
  where
• 17:54
  you
• 17:54
  couldn't
• 17:54
  get
• 17:54
  a
• 17:55
  lot
• 17:55
  of
• 17:55
  joy
• 17:55
  out
• 17:56
  of
• 17:56
  everyday
• 17:56
  activities?
• 17:57
  Now,
• 17:57
  I
• 17:58
  find
• 17:58
  in
• 17:58
  my
• 17:58
  own
• 17:58
  clinical
• 17:59
  experience
• 17:59
  that
• 18:00
  with
• 18:00
  trauma,
• 18:01
  mood
• 18:01
  tends
• 18:01
  to
• 18:01
  be
• 18:02
  kind
• 18:02
  of
• 18:02
  flat,
• 18:03
  since
• 18:03
  the
• 18:03
  trauma,
• 18:03
  in
• 18:04
  large
• 18:04
  part,
• 18:04
  mood
• 18:05
  tends
• 18:05
  to
• 18:05
  be
• 18:05
  sort
• 18:06
  of
• 18:06
  flat.
• 18:06
  Diminish
• 18:06
  interest
• 18:07
  in
• 18:07
  activities,
• 18:08
  not
• 18:08
  getting
• 18:08
  a
• 18:08
  lot
• 18:08
  of
• 18:09
  joy
• 18:09
  out
• 18:09
  of
• 18:09
  things,
• 18:10
  because
• 18:10
  again,
• 18:10
  you're
• 18:11
  running
• 18:11
  from
• 18:11
  a
• 18:11
  bear.
• 18:12
  I
• 18:12
  find
• 18:13
  that
• 18:13
  classic
• 18:13
  depression,
• 18:14
  especially
• 18:15
  major
• 18:15
  depressive
• 18:16
  disorder,
• 18:17
  recurring
• 18:17
  major
• 18:18
  depressive
• 18:18
  disorder
• 18:19
  tends
• 18:19
  to
• 18:19
  be
• 18:19
  more
• 18:19
  cyclical.
• 18:20
  You're
• 18:20
  kind
• 18:20
  of
• 18:21
  in
• 18:21
  and
• 18:21
  out
• 18:21
  of
• 18:21
  it.
• 18:21
  You
• 18:21
  go
• 18:22
  back
• 18:22
  to
• 18:22
  your
• 18:22
  baseline
• 18:22
  where
• 18:23
  you
• 18:23
  get
• 18:23
  joy
• 18:23
  out
• 18:23
  of
• 18:23
  things.
• 18:24
  Again,
• 18:24
  you're
• 18:24
  not
• 18:25
  as
• 18:25
  sad
• 18:25
  or
• 18:25
  down,
• 18:26
  and
• 18:26
  then
• 18:26
  you
• 18:26
  get
• 18:26
  depressed
• 18:27
  again.
• 18:27
  Again,
• 18:28
  not
• 18:28
  a
• 18:28
  perfect
• 18:29
  science,
• 18:29
  but
• 18:30
  I
• 18:30
  tend
• 18:30
  to
• 18:30
  see
• 18:31
  that
• 18:31
  the
• 18:32
  traumatic
• 18:33
  type
• 18:33
  of
• 18:33
  diminished
• 18:34
  interest
• 18:34
  is
• 18:35
  more
• 18:35
  persistent
• 18:36
  and
• 18:36
  less
• 18:37
  cyclical.
• 18:37
  And,
• 18:37
  of
• 18:38
  course,
• 18:38
  what
• 18:38
  complicates
• 18:39
  things
• 18:39
  even
• 18:39
  more
• 18:39
  is
• 18:40
  that
• 18:40
  these
• 18:40
  two
• 18:40
  things
• 18:40
  can
• 18:41
  happen
• 18:41
  at
• 18:41
  the
• 18:41
  same
• 18:42
  time
• 18:42
  and
• 18:42
  be
• 18:43
  a
• 18:43
  little
• 18:43
  harder
• 18:43
  to
• 18:44
  understand.
• 18:44
  Like
• 18:45
  I
• 18:45
  always
• 18:45
  say,
• 18:46
  though,
• 18:46
  pharmacological
• 18:47
  treatments
• 18:48
  are
• 18:48
  often
• 18:48
  the
• 18:49
  same
• 18:49
  for
• 18:49
  ptsd,
• 18:50
  for
• 18:50
  depression,
• 18:51
  for
• 18:51
  anxiety.
• 18:52
  Right.
• 18:52
  We're
• 18:52
  talking
• 18:52
  ssri.
• 18:53
  A
• 18:53
  lot
• 18:54
  of
• 18:54
  these
• 18:54
  neural
• 18:55
  circuits
• 18:55
  share
• 18:56
  real
• 18:56
  estate
• 18:56
  in
• 18:56
  our
• 18:57
  brain.
• 18:57
  It's
• 18:58
  always
• 18:58
  good
• 18:58
  to
• 18:59
  make
• 18:59
  sure
• 18:59
  you
• 18:59
  are
• 19:00
  ruling
• 19:00
  out
• 19:01
  any
• 19:01
  substance
• 19:01
  use
• 19:02
  disorders.
• 19:02
  Because
• 19:02
  if
• 19:03
  you're
• 19:03
  running
• 19:03
  from
• 19:03
  a
• 19:03
  bear
• 19:04
  all
• 19:04
  day
• 19:04
  and
• 19:04
  your
• 19:05
  day
• 19:06
  is
• 19:06
  laced
• 19:06
  in
• 19:06
  fear
• 19:07
  and
• 19:07
  avoidance
• 19:08
  and
• 19:08
  hyperarousal,
• 19:09
  you'd
• 19:10
  better
• 19:10
  believe
• 19:10
  you're
• 19:11
  more
• 19:11
  inclined
• 19:12
  to
• 19:12
  grab
• 19:12
  a
• 19:13
  beer
• 19:13
  to
• 19:13
  cool
• 19:14
  down
• 19:14
  the
• 19:14
  nervous
• 19:14
  system,
• 19:15
  to
• 19:15
  grab
• 19:15
  any
• 19:16
  kind
• 19:16
  of
• 19:16
  substance,
• 19:17
  for
• 19:17
  that
• 19:17
  matter.
• 19:17
  Cannabis,
• 19:18
  heroin,
• 19:18
  you
• 19:19
  name
• 19:19
  it.
• 19:19
  To
• 19:19
  grab
• 19:20
  methamphetamines.
• 19:21
  You
• 19:21
  know,
• 19:22
  if
• 19:22
  you
• 19:23
  feel
• 19:23
  like
• 19:24
  you're
• 19:24
  exhausted
• 19:25
  in
• 19:25
  the
• 19:25
  mornings
• 19:26
  because
• 19:26
  you're
• 19:27
  running
• 19:27
  from
• 19:27
  a
• 19:27
  bear
• 19:28
  when
• 19:28
  you're
• 19:28
  sleeping
• 19:28
  and
• 19:29
  you're
• 19:29
  jumping
• 19:29
  into
• 19:29
  volcanoes
• 19:30
  and
• 19:31
  you're
• 19:31
  covered
• 19:31
  in
• 19:31
  magma,
• 19:32
  well,
• 19:32
  yeah,
• 19:33
  you
• 19:33
  might
• 19:33
  need
• 19:33
  something
• 19:33
  to
• 19:33
  wake
• 19:34
  up
• 19:34
  in
• 19:34
  the
• 19:34
  morning.
• 19:34
  This
• 19:35
  is
• 19:35
  one
• 19:35
  of
• 19:35
  the
• 19:35
  many
• 19:36
  reasons
• 19:36
  that
• 19:36
  patients
• 19:37
  grab
• 19:37
  substances,
• 19:38
  because
• 19:39
  they
• 19:39
  don't
• 19:39
  always
• 19:39
  have
• 19:40
  the
• 19:40
  tools
• 19:40
  they
• 19:41
  need
• 19:41
  to
• 19:42
  cope
• 19:42
  with
• 19:42
  some
• 19:42
  of
• 19:43
  the
• 19:43
  horrible
• 19:43
  things
• 19:43
  that
• 19:44
  have
• 19:44
  happened
• 19:44
  to
• 19:44
  them.
• 19:45
  Right.
• 19:45
  And
• 19:45
  so
• 19:46
  that's
• 19:46
  where
• 19:46
  you
• 19:46
  deliver
• 19:46
  that
• 19:47
  compassionate
• 19:47
  care,
• 19:47
  and
• 19:48
  you
• 19:48
  work
• 19:48
  to
• 19:48
  understand
• 19:49
  them
• 19:49
  and
• 19:49
  offer
• 19:50
  them
• 19:50
  different
• 19:50
  tools
• 19:51
  that
• 19:51
  are
• 19:52
  a
• 19:52
  little
• 19:52
  bit,
• 19:52
  you
• 19:53
  know,
• 19:53
  less
• 19:53
  risky
• 19:54
  and
• 19:54
  more
• 19:55
  evidence
• 19:55
  based.
• 19:55
  Certainly
• 19:56
  anything's
• 19:57
  a
• 19:57
  little
• 19:57
  more
• 19:57
  evidence
• 19:57
  based
• 19:57
  than
• 19:58
  methamphetamines
• 19:59
  in
• 19:59
  the
• 19:59
  morning.
• 20:00
  We
• 20:00
  have
• 20:00
  some
• 20:01
  options
• 20:01
  here
• 20:01
  medwise.
• 20:02
  Right.
• 20:03
  By
• 20:03
  the
• 20:03
  way,
• 20:03
  before
• 20:03
  we
• 20:04
  go
• 20:04
  into
• 20:04
  meds,
• 20:04
  always
• 20:05
  assess
• 20:05
  SI
• 20:06
  in
• 20:06
  all
• 20:06
  these
• 20:07
  episodes.
• 20:08
  Assess
• 20:08
  safety.
• 20:09
  That's
• 20:09
  a
• 20:09
  core
• 20:09
  part
• 20:10
  of
• 20:10
  your
• 20:10
  practice.
• 20:10
  Don't
• 20:10
  ever
• 20:11
  forget
• 20:11
  that.
• 20:12
  For
• 20:12
  the
• 20:12
  sake
• 20:12
  of
• 20:12
  these
• 20:12
  case
• 20:13
  studies,
• 20:13
  I
• 20:13
  don't
• 20:13
  always
• 20:14
  mention
• 20:14
  absolutely
• 20:15
  everything
• 20:15
  you
• 20:15
  need
• 20:15
  to
• 20:16
  ask.
• 20:16
  We
• 20:16
  focus
• 20:17
  on
• 20:17
  the
• 20:17
  main
• 20:18
  squeeze
• 20:19
  of
• 20:19
  these
• 20:20
  cases
• 20:20
  that
• 20:21
  are
• 20:21
  very
• 20:21
  important
• 20:21
  to
• 20:22
  go
• 20:22
  over.
• 20:23
  Now,
• 20:23
  unless
• 20:24
  this
• 20:25
  patient
• 20:25
  lives
• 20:25
  in
• 20:26
  a
• 20:26
  national
• 20:27
  park
• 20:27
  surrounded
• 20:28
  by
• 20:28
  active
• 20:29
  volcanoes,
• 20:30
  I
• 20:30
  would
• 20:31
  assume
• 20:32
  that
• 20:32
  he
• 20:32
  doesn't
• 20:33
  have
• 20:34
  agoraphobia
• 20:35
  where
• 20:35
  he's
• 20:35
  not
• 20:35
  leaving
• 20:36
  his
• 20:36
  house
• 20:36
  or
• 20:36
  he's
• 20:36
  afraid
• 20:37
  to
• 20:37
  leave
• 20:37
  his
• 20:37
  house
• 20:37
  on
• 20:38
  a
• 20:38
  regular
• 20:38
  basis.
• 20:39
  But
• 20:39
  we
• 20:39
  don't
• 20:39
  know
• 20:39
  that,
• 20:39
  and
• 20:40
  we
• 20:40
  should
• 20:40
  never
• 20:40
  assume
• 20:41
  that.
• 20:41
  How
• 20:41
  dare
• 20:41
  any
• 20:42
  of
• 20:42
  us
• 20:42
  ever
• 20:42
  assume
• 20:43
  that.
• 20:43
  We
• 20:43
  have
• 20:44
  to
• 20:44
  ask
• 20:44
  those
• 20:44
  questions,
• 20:45
  too.
• 20:45
  Are
• 20:45
  you
• 20:46
  able
• 20:46
  to
• 20:46
  navigate
• 20:47
  around
• 20:47
  your
• 20:48
  community
• 20:48
  and
• 20:48
  run
• 20:48
  errands
• 20:49
  and
• 20:50
  go
• 20:50
  to
• 20:50
  work
• 20:51
  and
• 20:51
  attend
• 20:52
  events
• 20:52
  with
• 20:52
  family?
• 20:53
  You
• 20:53
  definitely
• 20:53
  want
• 20:53
  to
• 20:53
  ask
• 20:54
  about
• 20:54
  that,
• 20:54
  right.
• 20:54
  You
• 20:54
  want
• 20:55
  to
• 20:55
  have
• 20:55
  a
• 20:55
  sense
• 20:55
  of
• 20:56
  how
• 20:56
  avoidant
• 20:56
  is
• 20:56
  this
• 20:57
  individual.
• 20:58
  Right?
• 20:58
  Because
• 20:58
  he
• 20:58
  might
• 20:59
  have
• 20:59
  flashbacks
• 21:00
  in
• 21:00
  random
• 21:01
  locations.
• 21:01
  Maybe
• 21:01
  when
• 21:02
  he's
• 21:02
  flying,
• 21:02
  maybe
• 21:03
  when
• 21:03
  he's
• 21:03
  shopping,
• 21:04
  maybe
• 21:04
  when
• 21:04
  he's
• 21:05
  taking
• 21:05
  a
• 21:05
  walk
• 21:05
  with
• 21:05
  the
• 21:05
  dog.
• 21:06
  Maybe
• 21:06
  those
• 21:06
  flashbacks
• 21:07
  are
• 21:07
  so
• 21:07
  debilitating
• 21:08
  and
• 21:09
  uncertain
• 21:10
  that
• 21:11
  he
• 21:11
  does
• 21:11
  want
• 21:11
  to
• 21:12
  retreat
• 21:12
  and
• 21:12
  spend
• 21:13
  all
• 21:13
  of
• 21:13
  his
• 21:13
  time
• 21:13
  in
• 21:13
  his
• 21:14
  house
• 21:14
  because
• 21:14
  it's
• 21:15
  the
• 21:15
  safest
• 21:15
  place.
• 21:16
  You've
• 21:16
  got
• 21:16
  to
• 21:16
  ask
• 21:16
  those
• 21:17
  questions,
• 21:17
  right?
• 21:17
  Among
• 21:18
  many
• 21:18
  others.
• 21:18
  Of
• 21:19
  course,
• 21:20
  now
• 21:21
  we
• 21:22
  have
• 21:22
  ptsd.
• 21:22
  It's
• 21:23
  pretty
• 21:23
  clear,
• 21:23
  in
• 21:24
  fact,
• 21:24
  he's
• 21:24
  coming
• 21:24
  to
• 21:24
  you
• 21:25
  with
• 21:25
  an
• 21:25
  established
• 21:25
  PTSD
• 21:26
  diagnosis.
• 21:27
  We
• 21:27
  have
• 21:27
  that
• 21:28
  criterion
• 21:28
  A
• 21:28
  trauma,
• 21:29
  future
• 21:29
  episodes.
• 21:30
  We'll
• 21:30
  definitely
• 21:30
  go
• 21:30
  over
• 21:31
  more
• 21:31
  criterion
• 21:32
  A
• 21:32
  traumas
• 21:33
  and
• 21:33
  specify
• 21:34
  what
• 21:34
  they
• 21:34
  are
• 21:34
  and
• 21:34
  what
• 21:35
  they
• 21:35
  are
• 21:35
  not
• 21:35
  as
• 21:36
  far
• 21:36
  as
• 21:36
  the
• 21:36
  DSM
• 21:37
  5
• 21:37
  TR
• 21:37
  is
• 21:38
  concerned.
• 21:39
  But
• 21:39
  we
• 21:40
  have
• 21:40
  a
• 21:40
  very
• 21:40
  good
• 21:41
  pharmacological
• 21:43
  agent
• 21:43
  to
• 21:43
  address
• 21:44
  the
• 21:44
  patient's
• 21:44
  symptoms.
• 21:45
  And
• 21:46
  that
• 21:46
  medication
• 21:47
  is
• 21:47
  called
• 21:47
  Prazosin.
• 21:48
  It
• 21:48
  is
• 21:48
  an
• 21:49
  alpha1
• 21:49
  adrenergic
• 21:50
  antagonist
• 21:51
  and
• 21:52
  it
• 21:52
  blocks
• 21:52
  the
• 21:52
  alpha1
• 21:53
  adrenergic
• 21:54
  receptors
• 21:55
  that
• 21:55
  are
• 21:55
  frequently
• 21:56
  implicated
• 21:56
  in
• 21:56
  the
• 21:56
  body's
• 21:57
  fight
• 21:57
  or
• 21:57
  flight
• 21:58
  response.
• 21:59
  This
• 21:59
  action
• 21:59
  reduces
• 22:00
  noradrenergic
• 22:01
  norepinephrine
• 22:02
  hyperactivity,
• 22:03
  particularly
• 22:04
  during
• 22:04
  REM
• 22:04
  sleep,
• 22:05
  which
• 22:05
  is
• 22:05
  believed
• 22:05
  to
• 22:06
  be
• 22:06
  a
• 22:06
  key
• 22:06
  driver
• 22:06
  of
• 22:07
  trauma
• 22:07
  related
• 22:07
  nightmares
• 22:08
  and
• 22:08
  ptsd.
• 22:09
  Prazosin
• 22:10
  does
• 22:10
  cross
• 22:10
  the
• 22:11
  blood
• 22:11
  brain
• 22:11
  barrier
• 22:11
  and
• 22:12
  it
• 22:12
  blocks
• 22:12
  A1
• 22:12
  receptors,
• 22:13
  Alpha
• 22:14
  1
• 22:14
  receptors
• 22:14
  in
• 22:15
  key
• 22:15
  brain
• 22:15
  areas,
• 22:16
  thereby
• 22:17
  mitigating
• 22:17
  fear
• 22:17
  responses
• 22:18
  and
• 22:18
  improving
• 22:19
  overall
• 22:19
  sleep
• 22:20
  architecture.
• 22:20
  That's
• 22:20
  a
• 22:21
  big
• 22:21
  deal
• 22:22
  for
• 22:22
  trauma.
• 22:22
  And
• 22:22
  remember,
• 22:23
  the
• 22:23
  SSRIs
• 22:24
  are
• 22:24
  not
• 22:24
  totally
• 22:25
  cutting
• 22:25
  it
• 22:25
  when
• 22:26
  it
• 22:26
  comes
• 22:26
  to
• 22:26
  those
• 22:26
  nightmares
• 22:27
  in
• 22:27
  all
• 22:27
  of
• 22:27
  your
• 22:27
  patients.
• 22:28
  So
• 22:28
  you
• 22:28
  have
• 22:29
  to
• 22:29
  treat
• 22:29
  the
• 22:29
  complete
• 22:30
  picture
• 22:30
  here.
• 22:31
  And
• 22:31
  that's
• 22:31
  where
• 22:31
  prazosin
• 22:32
  gets
• 22:32
  very
• 22:32
  interesting.
• 22:33
  Now,
• 22:34
  I
• 22:34
  usually
• 22:34
  start
• 22:34
  patients,
• 22:35
  I
• 22:35
  always
• 22:35
  start
• 22:36
  patients
• 22:36
  at
• 22:36
  1
• 22:36
  milligram
• 22:37
  of
• 22:37
  prazosin
• 22:38
  because
• 22:38
  it
• 22:39
  can
• 22:39
  cause
• 22:39
  orthostatic
• 22:40
  hypotension,
• 22:41
  dizziness,
• 22:42
  headaches,
• 22:43
  and
• 22:43
  in
• 22:43
  rare
• 22:44
  cases,
• 22:44
  an
• 22:44
  erection
• 22:45
  that
• 22:46
  is
• 22:47
  just
• 22:47
  doesn't
• 22:48
  go
• 22:48
  away
• 22:48
  and
• 22:48
  it's
• 22:48
  very
• 22:49
  urgent.
• 22:49
  That's
• 22:49
  another
• 22:49
  podcast
• 22:50
  episode.
• 22:51
  I
• 22:51
  start
• 22:51
  people
• 22:52
  at
• 22:53
  1
• 22:53
  milligram
• 22:54
  of
• 22:54
  prazosin
• 22:55
  and
• 22:56
  have
• 22:56
  them
• 22:56
  increase
• 22:56
  it
• 22:57
  by
• 22:57
  1
• 22:58
  milligram
• 22:59
  every
• 22:59
  week
• 22:59
  or
• 23:00
  so
• 23:00
  until
• 23:00
  they
• 23:00
  get
• 23:00
  to
• 23:01
  about
• 23:01
  3
• 23:01
  milligrams
• 23:02
  as
• 23:02
  tolerated,
• 23:04
  making
• 23:04
  sure
• 23:04
  they
• 23:05
  are
• 23:06
  able
• 23:06
  to
• 23:07
  withstand
• 23:08
  the
• 23:08
  side
• 23:08
  effects.
• 23:09
  You
• 23:09
  want
• 23:09
  to
• 23:09
  make
• 23:09
  sure
• 23:10
  that
• 23:11
  they
• 23:11
  get
• 23:11
  up
• 23:11
  slowly,
• 23:12
  that
• 23:12
  they
• 23:12
  hydrate,
• 23:13
  that
• 23:13
  they're
• 23:13
  aware
• 23:14
  this
• 23:14
  could
• 23:14
  potentially
• 23:15
  make
• 23:15
  them
• 23:15
  dizzy
• 23:15
  or
• 23:16
  fall.
• 23:16
  You
• 23:17
  want
• 23:17
  to
• 23:17
  know
• 23:17
  what
• 23:17
  their
• 23:17
  blood
• 23:17
  pressures
• 23:18
  look
• 23:18
  like
• 23:18
  without
• 23:19
  getting
• 23:19
  too
• 23:19
  far
• 23:19
  in
• 23:19
  the
• 23:20
  weeds.
• 23:20
  I
• 23:21
  encourage
• 23:21
  you
• 23:21
  to
• 23:22
  join
• 23:22
  our
• 23:22
  Patreon
• 23:23
  if
• 23:23
  you
• 23:23
  want
• 23:23
  to
• 23:24
  get
• 23:24
  go
• 23:24
  into
• 23:24
  A
• 23:24
  deeper
• 23:25
  dive
• 23:25
  where
• 23:26
  we
• 23:26
  have
• 23:26
  beautiful
• 23:26
  slide
• 23:27
  decks
• 23:27
  chock
• 23:27
  full
• 23:28
  of
• 23:28
  evidence.
• 23:28
  If
• 23:28
  you
• 23:29
  become
• 23:29
  a
• 23:29
  Patreon
• 23:29
  member,
• 23:30
  you
• 23:30
  have
• 23:30
  these
• 23:30
  slides
• 23:30
  with
• 23:31
  evidence
• 23:32
  based
• 23:32
  pearls
• 23:32
  and
• 23:32
  research
• 23:33
  articles.
• 23:34
  See
• 23:34
  them
• 23:34
  try
• 23:35
  to
• 23:35
  get
• 23:35
  to
• 23:35
  their
• 23:35
  magic
• 23:36
  number
• 23:36
  slowly
• 23:37
  but
• 23:37
  surely.
• 23:37
  You
• 23:37
  do
• 23:37
  not
• 23:38
  want
• 23:38
  to
• 23:38
  raise
• 23:38
  prazosin
• 23:39
  aggressively
• 23:39
  because
• 23:40
  of
• 23:40
  those
• 23:40
  side
• 23:40
  effects.
• 23:41
  But
• 23:41
  everyone
• 23:42
  has
• 23:42
  a
• 23:42
  different
• 23:42
  number.
• 23:43
  I
• 23:43
  find
• 23:43
  that
• 23:43
  some
• 23:44
  patients
• 23:44
  respond
• 23:45
  at
• 23:45
  1mg
• 23:45
  and
• 23:46
  a
• 23:46
  lot
• 23:46
  of
• 23:46
  their
• 23:46
  nightmares
• 23:47
  go
• 23:47
  away.
• 23:47
  But
• 23:47
  more
• 23:47
  commonly
• 23:48
  it's
• 23:48
  much
• 23:49
  higher
• 23:49
  than
• 23:49
  that.
• 23:49
  Whether
• 23:50
  their
• 23:50
  magic
• 23:50
  number's
• 23:51
  4
• 23:51
  or
• 23:51
  7
• 23:51
  or
• 23:52
  10.
• 23:52
  Some
• 23:53
  people
• 23:53
  are
• 23:53
  dosed
• 23:53
  at
• 23:54
  15
• 23:54
  milligrams
• 23:54
  or
• 23:55
  higher.
• 23:55
  Everyone
• 23:56
  seems
• 23:56
  to
• 23:56
  have
• 23:56
  a
• 23:56
  different
• 23:57
  magic
• 23:57
  number
• 23:57
  of
• 23:58
  what
• 23:58
  milligrams
• 23:59
  will
• 23:59
  result
• 24:00
  in
• 24:00
  a
• 24:00
  reduction
• 24:00
  of
• 24:01
  nightmares
• 24:01
  entirely,
• 24:02
  an
• 24:02
  elimination
• 24:03
  of
• 24:03
  nightmares.
• 24:04
  Some
• 24:04
  people
• 24:04
  will
• 24:04
  say
• 24:05
  they
• 24:05
  just
• 24:05
  don't
• 24:05
  know
• 24:06
  the
• 24:06
  nightmare
• 24:06
  content
• 24:07
  might
• 24:07
  be
• 24:07
  happening,
• 24:07
  but
• 24:08
  they
• 24:08
  just
• 24:08
  don't
• 24:08
  have
• 24:08
  the
• 24:09
  emotional
• 24:09
  reaction
• 24:10
  towards
• 24:11
  it.
• 24:11
  Or
• 24:11
  they
• 24:11
  don't
• 24:11
  really
• 24:11
  remember
• 24:12
  them
• 24:12
  the
• 24:12
  next
• 24:13
  day
• 24:13
  like
• 24:13
  they
• 24:13
  used
• 24:13
  to,
• 24:14
  but
• 24:14
  they
• 24:14
  just
• 24:14
  don't
• 24:15
  feel
• 24:15
  as
• 24:15
  physiologically
• 24:16
  aroused
• 24:17
  when
• 24:17
  the
• 24:17
  nightmare
• 24:18
  is
• 24:18
  happening.
• 24:18
  And
• 24:18
  I
• 24:18
  always
• 24:19
  liken
• 24:19
  this
• 24:20
  sort
• 24:20
  of
• 24:20
  to
• 24:20
  a
• 24:20
  horror
• 24:21
  film.
• 24:21
  Imagine
• 24:21
  watching
• 24:22
  a
• 24:22
  scary
• 24:23
  movie,
• 24:24
  but
• 24:25
  instead
• 24:25
  of
• 24:26
  a
• 24:26
  scary
• 24:26
  movie
• 24:27
  without
• 24:27
  the
• 24:27
  soundtrack,
• 24:28
  it's
• 24:29
  like
• 24:29
  a
• 24:29
  skillful
• 24:30
  sound
• 24:30
  editors
• 24:30
  in
• 24:31
  there
• 24:31
  that
• 24:31
  turns
• 24:32
  off
• 24:32
  all
• 24:32
  the
• 24:32
  jarring,
• 24:32
  frightening
• 24:33
  horror
• 24:33
  music.
• 24:34
  Right.
• 24:34
  And
• 24:34
  you
• 24:35
  might
• 24:35
  see
• 24:35
  the
• 24:35
  scene
• 24:35
  sometimes,
• 24:36
  but
• 24:36
  you
• 24:37
  don't
• 24:37
  have
• 24:37
  that
• 24:37
  terrifying
• 24:38
  soundtrack.
• 24:38
  Those
• 24:39
  huge
• 24:39
  jolts
• 24:40
  where
• 24:40
  the
• 24:40
  goblin
• 24:41
  pops
• 24:41
  out
• 24:41
  of
• 24:41
  the
• 24:41
  corner
• 24:42
  and
• 24:42
  there's
• 24:42
  an
• 24:42
  air
• 24:42
  horn
• 24:43
  and
• 24:43
  you're
• 24:43
  scared
• 24:43
  to
• 24:44
  death.
• 24:44
  Not
• 24:44
  a
• 24:44
  perfect
• 24:45
  analogy,
• 24:45
  but
• 24:45
  a
• 24:46
  pretty
• 24:46
  damn
• 24:46
  good
• 24:46
  one
• 24:46
  at
• 24:47
  the
• 24:47
  same
• 24:47
  time.
• 24:48
  And
• 24:48
  I
• 24:48
  thought
• 24:48
  of
• 24:48
  it
• 24:49
  myself
• 24:49
  and
• 24:49
  prazosin
• 24:50
  is
• 24:50
  sort
• 24:50
  of
• 24:50
  in
• 24:50
  there,
• 24:51
  just
• 24:51
  making
• 24:52
  sure
• 24:52
  that
• 24:52
  the
• 24:52
  horror
• 24:53
  movie
• 24:54
  is
• 24:54
  dialed
• 24:55
  down.
• 24:55
  You
• 24:56
  might
• 24:56
  see
• 24:56
  the
• 24:56
  goon,
• 24:57
  but
• 24:57
  without
• 24:58
  all
• 24:58
  of
• 24:58
  the
• 24:58
  terror
• 24:59
  behind
• 24:59
  it
• 25:00
  in
• 25:00
  coursing
• 25:00
  in
• 25:01
  your
• 25:01
  bloodstream.
• 25:01
  And
• 25:02
  that's
• 25:02
  kind
• 25:02
  of
• 25:02
  what
• 25:02
  it
• 25:02
  does.
• 25:03
  It's
• 25:03
  pretty
• 25:04
  neat
• 25:04
  in
• 25:05
  that
• 25:05
  regard
• 25:05
  too.
• 25:06
  Right.
• 25:06
  But
• 25:07
  I
• 25:07
  would
• 25:08
  definitely
• 25:08
  work
• 25:08
  with
• 25:09
  your
• 25:09
  patient
• 25:09
  to
• 25:09
  do
• 25:09
  some
• 25:10
  nightmare
• 25:10
  tracking.
• 25:11
  I
• 25:11
  would
• 25:11
  have
• 25:11
  them
• 25:12
  report
• 25:12
  back
• 25:12
  to
• 25:12
  you
• 25:12
  frequently
• 25:13
  until
• 25:13
  you
• 25:13
  get
• 25:14
  them
• 25:14
  to
• 25:14
  whatever
• 25:14
  that
• 25:14
  magic
• 25:15
  number
• 25:15
  may
• 25:15
  be.
• 25:16
  Have
• 25:16
  them
• 25:16
  sit
• 25:17
  on
• 25:17
  the
• 25:17
  edge
• 25:17
  of
• 25:17
  the
• 25:17
  bed
• 25:17
  with
• 25:18
  water
• 25:19
  while
• 25:19
  they're
• 25:19
  taking
• 25:19
  the
• 25:19
  medication.
• 25:20
  Remain
• 25:20
  seated
• 25:21
  for
• 25:21
  a
• 25:21
  couple
• 25:21
  minutes
• 25:22
  lying
• 25:22
  down,
• 25:22
  very
• 25:23
  slowly
• 25:23
  reducing
• 25:24
  the
• 25:24
  risk
• 25:24
  of
• 25:24
  orthostatic
• 25:25
  hypertension.
• 25:26
  And
• 25:26
  you
• 25:26
  want
• 25:27
  to
• 25:27
  just
• 25:27
  see
• 25:27
  how
• 25:27
  they
• 25:27
  do.
• 25:28
  Right?
• 25:28
  That's
• 25:28
  really
• 25:28
  the
• 25:29
  goal
• 25:29
  of
• 25:29
  this.
• 25:30
  You
• 25:30
  want
• 25:30
  to
• 25:30
  titrate
• 25:31
  carefully,
• 25:31
  you
• 25:32
  want
• 25:32
  those
• 25:32
  nightmares
• 25:33
  out
• 25:33
  of
• 25:33
  their
• 25:33
  way.
• 25:34
  And
• 25:34
  look,
• 25:34
  when
• 25:34
  you
• 25:35
  have
• 25:35
  someone
• 25:35
  who's
• 25:35
  been
• 25:36
  traumatized,
• 25:36
  you're
• 25:37
  not
• 25:37
  going
• 25:37
  to
• 25:37
  solve
• 25:37
  all
• 25:37
  of
• 25:37
  their
• 25:38
  problems
• 25:38
  at
• 25:38
  once.
• 25:38
  It's
• 25:39
  a
• 25:39
  team
• 25:39
  Effort.
• 25:40
  Every
• 25:40
  crisis
• 25:40
  is
• 25:41
  really
• 25:41
  a
• 25:41
  team
• 25:41
  effort.
• 25:42
  No
• 25:42
  more
• 25:42
  so
• 25:43
  than
• 25:43
  in
• 25:43
  mental
• 25:43
  health.
• 25:44
  It's
• 25:45
  very
• 25:45
  important
• 25:46
  that
• 25:46
  you
• 25:46
  work
• 25:46
  with
• 25:47
  them,
• 25:48
  get
• 25:48
  them
• 25:48
  a
• 25:48
  trauma
• 25:49
  therapist,
• 25:50
  optimize
• 25:50
  their
• 25:51
  SSRI
• 25:51
  dose
• 25:52
  if
• 25:52
  possible.
• 25:52
  He's
• 25:52
  at
• 25:52
  150.
• 25:53
  That
• 25:53
  could
• 25:53
  probably
• 25:54
  go
• 25:54
  up
• 25:54
  to
• 25:54
  200
• 25:55
  if
• 25:55
  you
• 25:55
  believe,
• 25:55
  and
• 25:55
  the
• 25:56
  patient
• 25:56
  believes
• 25:57
  that
• 25:57
  the
• 25:57
  medication
• 25:57
  has
• 25:58
  really
• 25:58
  helped.
• 25:58
  If
• 25:58
  someone's
• 25:59
  sitting
• 25:59
  at
• 25:59
  150
• 26:00
  and
• 26:01
  it
• 26:01
  really
• 26:01
  hasn't
• 26:01
  done
• 26:02
  anything,
• 26:02
  anything
• 26:02
  for
• 26:03
  them
• 26:03
  yet
• 26:03
  and
• 26:03
  they
• 26:03
  can't
• 26:04
  speak
• 26:04
  highly
• 26:04
  of
• 26:04
  the
• 26:04
  medication
• 26:05
  at
• 26:05
  all,
• 26:06
  you
• 26:07
  gotta
• 26:07
  wonder
• 26:07
  whether
• 26:07
  you
• 26:08
  should
• 26:08
  go
• 26:08
  up
• 26:09
  or
• 26:09
  just
• 26:09
  get
• 26:09
  out.
• 26:10
  And
• 26:10
  that's
• 26:10
  a
• 26:10
  real
• 26:11
  patient
• 26:11
  specific
• 26:12
  question
• 26:13
  where
• 26:13
  you
• 26:13
  might
• 26:13
  want
• 26:13
  to
• 26:14
  try
• 26:14
  something
• 26:14
  like
• 26:14
  Prozac
• 26:15
  or
• 26:15
  a
• 26:15
  different
• 26:15
  kind
• 26:15
  of
• 26:16
  medication
• 26:16
  if
• 26:17
  they're
• 26:17
  not
• 26:17
  responding
• 26:18
  to
• 26:18
  the
• 26:18
  Zoloft.
• 26:19
  So
• 26:19
  with
• 26:19
  this
• 26:19
  patient,
• 26:20
  I
• 26:20
  might
• 26:20
  optimize
• 26:20
  the
• 26:21
  Zoloft
• 26:21
  if
• 26:21
  it's
• 26:21
  really
• 26:22
  blown
• 26:22
  them
• 26:22
  away
• 26:22
  and
• 26:22
  helped
• 26:23
  them
• 26:23
  out
• 26:23
  a
• 26:23
  lot,
• 26:24
  or
• 26:24
  I
• 26:24
  may
• 26:24
  consider
• 26:25
  switching
• 26:25
  to
• 26:26
  a
• 26:26
  different
• 26:26
  agent
• 26:26
  if
• 26:27
  I
• 26:27
  feel
• 26:27
  like
• 26:27
  it's
• 26:27
  not
• 26:27
  been
• 26:28
  helping
• 26:28
  as
• 26:28
  much
• 26:29
  as
• 26:29
  it
• 26:29
  could.
• 26:30
  There's
• 26:30
  all
• 26:30
  kinds
• 26:31
  of
• 26:31
  trauma
• 26:31
  therapy
• 26:32
  out
• 26:32
  there.
• 26:32
  There's
• 26:32
  narrative
• 26:33
  therapy
• 26:33
  for
• 26:33
  nightmares,
• 26:34
  emdr,
• 26:35
  prolonged
• 26:35
  exposure,
• 26:36
  cognitive
• 26:37
  processing,
• 26:37
  cognitive
• 26:38
  behavioral
• 26:38
  therapy.
• 26:39
  We
• 26:39
  have
• 26:39
  so
• 26:39
  much
• 26:39
  more
• 26:40
  information
• 26:40
  if
• 26:41
  you
• 26:41
  become
• 26:41
  a
• 26:41
  Patreon
• 26:42
  member
• 26:42
  where
• 26:42
  you'll
• 26:42
  have
• 26:43
  these
• 26:43
  slide
• 26:43
  decks
• 26:43
  in
• 26:43
  front
• 26:44
  of
• 26:44
  you.
• 26:44
  And
• 26:44
  I
• 26:44
  highly
• 26:45
  recommend
• 26:45
  you
• 26:46
  recommend
• 26:47
  that
• 26:47
  you
• 26:47
  join
• 26:48
  our
• 26:48
  Patreon
• 26:49
  membership
• 26:49
  and
• 26:49
  spread
• 26:50
  the
• 26:50
  word.
• 26:50
  This
• 26:50
  podcast
• 26:51
  has
• 26:51
  gotten
• 26:51
  really
• 26:52
  big,
• 26:52
  really
• 26:52
  fast.
• 26:53
  We
• 26:53
  did
• 26:53
  not
• 26:53
  expect
• 26:54
  the
• 26:54
  outpour
• 26:55
  we're
• 26:55
  getting
• 26:55
  from
• 26:55
  psych
• 26:56
  NP
• 26:56
  students
• 26:57
  and
• 26:57
  folks
• 26:57
  who
• 26:57
  were
• 26:58
  fascinated
• 26:58
  by
• 26:59
  mock
• 26:59
  patient
• 27:00
  case
• 27:00
  studies.
• 27:00
  I
• 27:00
  think
• 27:01
  it's
• 27:01
  the
• 27:01
  best
• 27:01
  way
• 27:01
  to
• 27:01
  learn
• 27:02
  when
• 27:02
  you
• 27:02
  humanize
• 27:03
  it
• 27:03
  a
• 27:03
  little
• 27:03
  bit.
• 27:03
  It's
• 27:04
  one
• 27:04
  thing
• 27:04
  you
• 27:04
  learn
• 27:05
  about
• 27:05
  in
• 27:05
  a
• 27:05
  textbook,
• 27:05
  it's
• 27:06
  another
• 27:06
  when
• 27:06
  you're
• 27:06
  out
• 27:07
  there
• 27:07
  humanizing
• 27:08
  it
• 27:08
  in
• 27:08
  a
• 27:08
  mock
• 27:09
  patient
• 27:09
  form.
• 27:09
  It's
• 27:09
  a
• 27:10
  little
• 27:10
  more
• 27:10
  playful.
• 27:10
  We
• 27:10
  can
• 27:11
  have
• 27:11
  a
• 27:11
  more
• 27:11
  fun
• 27:11
  and
• 27:12
  think
• 27:12
  about
• 27:12
  the
• 27:12
  what
• 27:13
  ifs.
• 27:13
  I
• 27:13
  hope
• 27:13
  you
• 27:13
  all
• 27:14
  really
• 27:14
  enjoyed
• 27:14
  this
• 27:15
  case
• 27:15
  study.
• 27:16
  Always
• 27:16
  remember
• 27:17
  to
• 27:17
  optimize
• 27:18
  your
• 27:18
  patient's
• 27:19
  treatment.
• 27:19
  Ask
• 27:19
  great
• 27:20
  questions.
• 27:21
  There's
• 27:21
  really
• 27:21
  an
• 27:21
  art
• 27:21
  to
• 27:22
  this,
• 27:22
  right?
• 27:23
  Asking
• 27:23
  questions
• 27:24
  that
• 27:24
  allow
• 27:24
  you
• 27:24
  to
• 27:24
  connect
• 27:25
  with
• 27:25
  the
• 27:25
  patient
• 27:26
  and
• 27:26
  derive
• 27:27
  high
• 27:27
  yield
• 27:28
  clinical
• 27:29
  and
• 27:29
  orienting
• 27:29
  you
• 27:30
  to
• 27:30
  a
• 27:30
  sound
• 27:31
  diagnosis
• 27:32
  and
• 27:32
  thus
• 27:32
  a
• 27:32
  sound
• 27:33
  treatment.
• 27:34
  There's
• 27:34
  so
• 27:34
  much
• 27:35
  more
• 27:35
  about
• 27:35
  this
• 27:35
  case
• 27:36
  that
• 27:36
  deserves
• 27:37
  to
• 27:37
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• 27:37
  picked
• 27:37
  apart.
• 27:38
  Don't
• 27:38
  think
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• 27:38
  just
• 27:38
  because
• 27:39
  I
• 27:39
  didn't
• 27:39
  include
• 27:39
  it
• 27:40
  or
• 27:40
  talk
• 27:40
  about
• 27:40
  it
• 27:40
  that
• 27:40
  it's
• 27:41
  not
• 27:41
  relevant
• 27:41
  because
• 27:41
  it
• 27:42
  is
• 27:42
  highly
• 27:42
  relevant.
• 27:43
  And
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• 27:43
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  This
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  Prep.