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Would You Get This Right? Illness Anxiety vs Somatic vs Factitious vs Malingering · Pearls and Prep

• 0:00
  Foreign.
• 0:06
  My
• 0:06
  friends,
• 0:07
  welcome
• 0:07
  back
• 0:07
  to
• 0:08
  another
• 0:08
  episode
• 0:08
  of
• 0:09
  Pearls
• 0:10
  and
• 0:10
  prep
• 0:11
  your
• 0:11
  go
• 0:12
  to
• 0:12
  place
• 0:12
  for
• 0:12
  Pearls
• 0:13
  that
• 0:13
  prep
• 0:14
  you
• 0:14
  to
• 0:14
  practice
• 0:14
  NPZ
• 0:15
  here,
• 0:16
  your
• 0:16
  preceptor
• 0:17
  in
• 0:17
  your
• 0:17
  pocket.
• 0:18
  My
• 0:18
  friends,
• 0:19
  you
• 0:19
  have
• 0:19
  a
• 0:19
  knock
• 0:20
  at
• 0:20
  the
• 0:20
  door.
• 0:20
  Knock,
• 0:21
  knock,
• 0:21
  knock,
• 0:21
  knock
• 0:21
  knock.
• 0:22
  Who
• 0:22
  is
• 0:22
  it?
• 0:23
  Well,
• 0:24
  well,
• 0:24
  you
• 0:24
  have
• 0:24
  a
• 0:24
  32
• 0:25
  year
• 0:25
  old
• 0:25
  female
• 0:26
  in
• 0:26
  the
• 0:27
  outpatient
• 0:27
  space.
• 0:27
  She's
• 0:28
  an
• 0:28
  ICU
• 0:28
  nurse
• 0:29
  and
• 0:29
  she's
• 0:30
  telling
• 0:30
  you
• 0:30
  that
• 0:30
  she
• 0:31
  thinks
• 0:31
  something
• 0:31
  is
• 0:32
  seriously
• 0:32
  wrong
• 0:32
  with
• 0:33
  her
• 0:33
  immune
• 0:33
  system
• 0:33
  and
• 0:34
  no
• 0:34
  one
• 0:35
  is
• 0:35
  taking
• 0:35
  her
• 0:35
  seriously.
• 0:36
  She's
• 0:37
  had
• 0:37
  anxiety
• 0:38
  since
• 0:38
  her
• 0:38
  teens.
• 0:39
  She's
• 0:39
  never
• 0:39
  been
• 0:39
  hospitalized.
• 0:41
  She's
• 0:41
  been
• 0:41
  in
• 0:42
  therapy
• 0:42
  intermittently,
• 0:43
  not
• 0:43
  always
• 0:43
  engaged.
• 0:44
  Her.
• 0:45
  Her
• 0:45
  medical
• 0:45
  history
• 0:46
  is
• 0:46
  extensive.
• 0:47
  Recurrent
• 0:48
  infections,
• 0:49
  kind
• 0:49
  of
• 0:49
  these
• 0:50
  mystery
• 0:50
  fevers,
• 0:51
  chronic
• 0:51
  fatigue.
• 0:52
  Her
• 0:53
  prior
• 0:53
  workups
• 0:53
  are
• 0:54
  largely
• 0:54
  negative
• 0:54
  or
• 0:55
  kind
• 0:55
  of
• 0:55
  inconclusive.
• 0:57
  She
• 0:57
  takes
• 0:57
  occasional
• 0:57
  antibiotics
• 0:58
  from
• 0:58
  urgent
• 0:59
  care.
• 1:00
  She's
• 1:00
  taken
• 1:00
  some
• 1:01
  zinc,
• 1:01
  vitamin
• 1:01
  C,
• 1:02
  some
• 1:02
  herbal
• 1:02
  blends.
• 1:03
  She
• 1:03
  has
• 1:04
  a
• 1:04
  mom
• 1:04
  with
• 1:04
  depression.
• 1:05
  So
• 1:05
  social
• 1:06
  history
• 1:06
  again,
• 1:06
  you
• 1:07
  know,
• 1:07
  she
• 1:07
  works
• 1:07
  in
• 1:07
  the
• 1:07
  icu.
• 1:08
  She's
• 1:08
  a
• 1:08
  high
• 1:08
  performer,
• 1:09
  but
• 1:10
  she
• 1:10
  hasn't
• 1:10
  worked
• 1:10
  as
• 1:11
  many
• 1:11
  shifts
• 1:11
  lately
• 1:12
  because
• 1:12
  of
• 1:12
  health
• 1:12
  issues
• 1:13
  that
• 1:13
  she's
• 1:13
  telling
• 1:14
  you.
• 1:14
  She
• 1:15
  has
• 1:15
  a
• 1:15
  limited
• 1:15
  social
• 1:15
  circle,
• 1:16
  but
• 1:17
  she
• 1:17
  does
• 1:17
  seem
• 1:18
  to
• 1:18
  have
• 1:18
  a
• 1:18
  lot
• 1:19
  more
• 1:19
  support
• 1:20
  when
• 1:20
  she's
• 1:20
  sick,
• 1:21
  she
• 1:21
  says,
• 1:21
  which
• 1:21
  has
• 1:21
  been
• 1:22
  very
• 1:22
  helpful
• 1:22
  to
• 1:22
  her.
• 1:23
  Her
• 1:23
  fatigue
• 1:24
  is
• 1:24
  constant.
• 1:24
  Her
• 1:25
  pain
• 1:25
  is
• 1:25
  kind
• 1:25
  of
• 1:25
  vague.
• 1:26
  It
• 1:26
  kind
• 1:26
  of
• 1:26
  shifts
• 1:27
  from
• 1:27
  her
• 1:27
  shoulders
• 1:27
  to
• 1:28
  her
• 1:28
  back
• 1:28
  to
• 1:29
  her
• 1:29
  knees.
• 1:30
  Her
• 1:30
  fevers
• 1:30
  will
• 1:30
  come
• 1:31
  and
• 1:31
  go.
• 1:31
  Her
• 1:31
  GI
• 1:32
  issues,
• 1:32
  sometimes
• 1:32
  she
• 1:32
  has
• 1:33
  flare
• 1:33
  ups
• 1:34
  with
• 1:34
  diarrhea
• 1:34
  or
• 1:35
  loose
• 1:35
  stools.
• 1:36
  And
• 1:36
  she
• 1:36
  says
• 1:37
  she
• 1:37
  can't
• 1:37
  sleep
• 1:37
  because
• 1:38
  these
• 1:38
  symptoms
• 1:38
  are
• 1:38
  just
• 1:39
  a
• 1:39
  little
• 1:39
  too
• 1:40
  wild.
• 1:41
  She's
• 1:41
  pretty
• 1:41
  calm
• 1:42
  during
• 1:42
  the
• 1:42
  interview.
• 1:42
  She's
• 1:43
  not
• 1:43
  very
• 1:43
  anxious
• 1:43
  as
• 1:44
  she
• 1:44
  describes
• 1:44
  these
• 1:45
  symptoms.
• 1:46
  Her
• 1:46
  affect
• 1:46
  is
• 1:47
  oddly
• 1:47
  kind
• 1:47
  of
• 1:47
  neutral
• 1:48
  when
• 1:48
  she's
• 1:48
  describing
• 1:49
  these
• 1:49
  symptoms,
• 1:49
  even
• 1:50
  though
• 1:50
  they're
• 1:50
  pretty
• 1:50
  severe.
• 1:51
  She's
• 1:51
  linear,
• 1:52
  she's
• 1:52
  not
• 1:52
  psychotic.
• 1:53
  She's
• 1:54
  highly
• 1:54
  detailed,
• 1:55
  has
• 1:55
  a
• 1:55
  pretty
• 1:55
  good
• 1:55
  medical
• 1:56
  knowledge.
• 1:56
  Okay,
• 1:57
  so
• 1:57
  those
• 1:57
  are
• 1:57
  other
• 1:57
  things.
• 1:57
  She's,
• 1:58
  you
• 1:58
  know,
• 1:58
  there's
• 1:58
  no
• 1:58
  overt
• 1:59
  psychosis
• 1:59
  or
• 1:59
  mania
• 2:00
  or
• 2:00
  delusions
• 2:00
  or
• 2:00
  anything
• 2:01
  like
• 2:01
  that.
• 2:02
  So
• 2:02
  with
• 2:03
  that,
• 2:03
  my
• 2:04
  friends,
• 2:04
  what
• 2:05
  do
• 2:05
  you
• 2:05
  think
• 2:05
  we're
• 2:05
  looking
• 2:06
  at
• 2:06
  here?
• 2:06
  And
• 2:07
  this
• 2:07
  is
• 2:07
  the,
• 2:07
  this
• 2:07
  is
• 2:08
  the
• 2:08
  space
• 2:08
  in
• 2:09
  psychiatry
• 2:09
  that
• 2:09
  I
• 2:10
  just
• 2:10
  love,
• 2:11
  right?
• 2:11
  The
• 2:11
  ambiguity
• 2:12
  where
• 2:12
  you're
• 2:13
  looking
• 2:13
  at
• 2:13
  something
• 2:14
  and
• 2:14
  it's
• 2:14
  just
• 2:14
  dripping
• 2:15
  with
• 2:16
  questions
• 2:17
  unresolved.
• 2:19
  And
• 2:19
  so
• 2:19
  with
• 2:20
  the
• 2:20
  information
• 2:20
  that
• 2:21
  we
• 2:21
  have,
• 2:21
  and
• 2:21
  this
• 2:21
  is
• 2:21
  again
• 2:22
  a
• 2:22
  mock
• 2:22
  patient,
• 2:23
  this
• 2:23
  is
• 2:23
  something
• 2:23
  that
• 2:23
  we
• 2:24
  do
• 2:24
  as
• 2:24
  a
• 2:24
  thought
• 2:24
  exercise.
• 2:25
  But
• 2:26
  a
• 2:26
  few,
• 2:28
  a
• 2:28
  few
• 2:28
  psychiatric
• 2:29
  DSM
• 2:30
  5tr
• 2:30
  diagnoses
• 2:31
  sort
• 2:32
  of
• 2:32
  jump
• 2:32
  out
• 2:32
  at
• 2:32
  you
• 2:33
  when
• 2:34
  you
• 2:34
  start
• 2:34
  hearing
• 2:34
  about
• 2:35
  this,
• 2:35
  right?
• 2:35
  So
• 2:35
  this
• 2:36
  is
• 2:36
  per
• 2:36
  someone
• 2:36
  who
• 2:37
  is
• 2:37
  telling
• 2:37
  you
• 2:38
  off
• 2:38
  the
• 2:38
  bat
• 2:38
  that
• 2:38
  they
• 2:39
  really
• 2:39
  think
• 2:39
  something's
• 2:40
  wrong
• 2:40
  with
• 2:40
  them,
• 2:40
  but
• 2:41
  there's
• 2:41
  nothing
• 2:41
  really
• 2:41
  conclusive.
• 2:42
  Right.
• 2:42
  We
• 2:42
  don't
• 2:43
  have
• 2:43
  like
• 2:43
  a
• 2:43
  lupus
• 2:43
  diagnosis
• 2:45
  or
• 2:45
  an
• 2:45
  autoimmune
• 2:46
  condition
• 2:46
  of
• 2:47
  any
• 2:47
  kind
• 2:47
  here.
• 2:48
  You
• 2:48
  know,
• 2:49
  like
• 2:49
  lupus
• 2:49
  or
• 2:50
  anything.
• 2:50
  We
• 2:50
  don't
• 2:51
  have,
• 2:51
  we
• 2:51
  don't
• 2:52
  have
• 2:52
  mold
• 2:52
  toxicity.
• 2:53
  We
• 2:53
  don't
• 2:53
  have.
• 2:55
  We
• 2:55
  don't
• 2:55
  have
• 2:55
  anything
• 2:55
  to
• 2:56
  go
• 2:56
  off
• 2:56
  of.
• 2:56
  Right.
• 2:56
  A
• 2:56
  leaky
• 2:57
  gut.
• 2:57
  We
• 2:57
  have
• 2:58
  nothing
• 2:58
  concrete.
• 2:59
  And
• 2:59
  yet
• 2:59
  the
• 2:59
  patient
• 3:00
  is
• 3:00
  clearly
• 3:01
  complaining
• 3:02
  of
• 3:02
  these
• 3:02
  chronic
• 3:03
  issues.
• 3:04
  When
• 3:04
  I
• 3:04
  think
• 3:04
  about
• 3:05
  this.
• 3:05
  Right?
• 3:05
  Just
• 3:06
  if
• 3:06
  this
• 3:06
  person
• 3:06
  drops
• 3:07
  into
• 3:07
  my
• 3:07
  clinic,
• 3:08
  a
• 3:08
  few
• 3:08
  differentials
• 3:09
  pop
• 3:09
  out
• 3:09
  right
• 3:10
  away.
• 3:10
  So
• 3:10
  I'm
• 3:10
  thinking
• 3:10
  somatic
• 3:11
  symptom
• 3:11
  disorder.
• 3:12
  Right
• 3:13
  away
• 3:13
  I'm
• 3:13
  thinking
• 3:13
  illness
• 3:14
  anxiety
• 3:14
  disorder.
• 3:15
  Those
• 3:15
  are
• 3:15
  the
• 3:15
  first
• 3:16
  two
• 3:16
  that
• 3:16
  kind
• 3:17
  of
• 3:17
  jump
• 3:17
  at
• 3:17
  me.
• 3:17
  I
• 3:17
  might
• 3:18
  even
• 3:18
  think
• 3:18
  generalized
• 3:19
  anxiety
• 3:19
  disorders
• 3:20
  because
• 3:20
  anyone
• 3:21
  who's
• 3:21
  kind
• 3:21
  of
• 3:21
  worried,
• 3:22
  they
• 3:22
  have,
• 3:22
  they
• 3:22
  have
• 3:23
  worries
• 3:24
  that
• 3:24
  are
• 3:24
  popping
• 3:24
  up
• 3:25
  everywhere.
• 3:25
  She
• 3:26
  said
• 3:26
  she's
• 3:26
  anxious
• 3:27
  since
• 3:27
  her
• 3:27
  teens.
• 3:28
  She's
• 3:28
  been
• 3:28
  in
• 3:28
  therapy.
• 3:29
  She's
• 3:29
  definitely
• 3:30
  worried
• 3:30
  a
• 3:30
  lot
• 3:30
  about
• 3:31
  health.
• 3:32
  But
• 3:32
  I
• 3:32
  would
• 3:32
  definitely
• 3:33
  put
• 3:33
  GAD
• 3:33
  on
• 3:33
  the
• 3:34
  differential
• 3:34
  right
• 3:34
  away.
• 3:34
  A
• 3:35
  worry,
• 3:35
  right?
• 3:35
  It's
• 3:35
  kind
• 3:36
  of
• 3:36
  broad.
• 3:36
  It
• 3:36
  may
• 3:36
  not
• 3:37
  be
• 3:37
  that
• 3:37
  helpful
• 3:37
  or
• 3:37
  that
• 3:38
  specific.
• 3:39
  But
• 3:39
  again,
• 3:39
  in
• 3:39
  the
• 3:39
  beginning,
• 3:40
  you're
• 3:40
  just
• 3:41
  kind
• 3:41
  of
• 3:42
  thinking
• 3:43
  out
• 3:43
  loud,
• 3:43
  or
• 3:43
  hopefully
• 3:44
  you're
• 3:44
  not
• 3:44
  thinking
• 3:44
  out
• 3:45
  loud
• 3:45
  in
• 3:45
  front
• 3:45
  of
• 3:45
  the
• 3:45
  patient,
• 3:46
  but
• 3:46
  you're
• 3:47
  thinking.
• 3:47
  Right.
• 3:47
  We're
• 3:48
  thinking
• 3:48
  out
• 3:48
  loud
• 3:48
  right
• 3:49
  now.
• 3:49
  So
• 3:49
  I
• 3:50
  think
• 3:50
  GAD
• 3:50
  is
• 3:50
  a
• 3:50
  helpful,
• 3:51
  broad
• 3:51
  differential
• 3:52
  here.
• 3:52
  There's
• 3:53
  nothing
• 3:53
  in
• 3:53
  here
• 3:53
  that
• 3:54
  suggests
• 3:54
  social
• 3:54
  anxiety
• 3:55
  disorder.
• 3:55
  She's
• 3:56
  not
• 3:56
  talking
• 3:56
  about
• 3:57
  any
• 3:57
  anxiety
• 3:58
  that's
• 3:58
  popping
• 3:58
  up
• 3:58
  in
• 3:59
  a
• 3:59
  performative
• 3:59
  sense.
• 4:00
  Is
• 4:00
  it
• 4:00
  possible?
• 4:00
  Sure.
• 4:01
  Is
• 4:01
  she,
• 4:02
  Is
• 4:02
  she
• 4:02
  also
• 4:02
  afraid
• 4:03
  of
• 4:03
  spiders?
• 4:03
  It's
• 4:04
  possible.
• 4:04
  Okay.
• 4:05
  But
• 4:05
  I'm
• 4:05
  not
• 4:06
  here
• 4:06
  to
• 4:06
  diagnose
• 4:06
  arachnophobia.
• 4:07
  Okay.
• 4:07
  I'm
• 4:08
  not
• 4:08
  going
• 4:08
  to
• 4:08
  open
• 4:08
  up
• 4:08
  the
• 4:08
  whole
• 4:08
  DSM
• 4:09
  and
• 4:09
  just
• 4:09
  ask
• 4:10
  her
• 4:10
  every
• 4:11
  disorder
• 4:11
  in
• 4:11
  the
• 4:11
  book.
• 4:12
  What
• 4:12
  we
• 4:12
  have
• 4:13
  here
• 4:13
  is
• 4:13
  clearly
• 4:13
  a
• 4:14
  health
• 4:14
  related
• 4:15
  anxiety.
• 4:16
  The
• 4:16
  question
• 4:16
  is
• 4:16
  which
• 4:17
  one?
• 4:17
  Right.
• 4:18
  I
• 4:18
  will
• 4:18
  tell
• 4:18
  you.
• 4:19
  When
• 4:19
  I
• 4:19
  was
• 4:19
  a
• 4:19
  student,
• 4:20
  illness
• 4:20
  anxiety
• 4:21
  disorder
• 4:21
  and
• 4:21
  somatic
• 4:22
  symptom
• 4:22
  disorder.
• 4:23
  Felt
• 4:23
  like
• 4:24
  I
• 4:24
  was
• 4:25
  trying
• 4:25
  to
• 4:25
  figure
• 4:25
  out
• 4:26
  the
• 4:26
  difference
• 4:26
  between
• 4:26
  an
• 4:26
  orange
• 4:27
  and
• 4:27
  a
• 4:27
  tangerine.
• 4:28
  It
• 4:28
  seemed
• 4:29
  impossible
• 4:30
  to
• 4:30
  really
• 4:31
  parse
• 4:31
  out
• 4:31
  the
• 4:31
  difference
• 4:32
  between
• 4:32
  those
• 4:32
  two.
• 4:33
  And
• 4:33
  then
• 4:33
  there's
• 4:34
  other
• 4:34
  disorders
• 4:35
  there
• 4:35
  that
• 4:36
  you
• 4:36
  kind
• 4:36
  of
• 4:36
  don't
• 4:36
  want
• 4:36
  to
• 4:36
  miss
• 4:37
  here.
• 4:37
  And
• 4:37
  the
• 4:38
  devil's
• 4:38
  really
• 4:38
  in
• 4:39
  the
• 4:39
  details.
• 4:39
  Okay?
• 4:40
  So
• 4:41
  with
• 4:41
  this
• 4:41
  person,
• 4:41
  I
• 4:42
  will
• 4:42
  tell
• 4:42
  you
• 4:43
  because
• 4:43
  I
• 4:43
  don't
• 4:44
  have
• 4:44
  a,
• 4:44
  like
• 4:44
  a,
• 4:45
  like
• 4:45
  a
• 4:45
  symptom
• 4:45
  that's
• 4:46
  really
• 4:47
  pinned
• 4:47
  down
• 4:48
  on
• 4:48
  the
• 4:48
  patient.
• 4:48
  I'm
• 4:49
  much
• 4:49
  more
• 4:49
  suspicious
• 4:50
  here
• 4:50
  of
• 4:50
  illness
• 4:51
  anxiety
• 4:51
  disorder,
• 4:52
  also
• 4:52
  known
• 4:53
  before,
• 4:53
  I
• 4:53
  think,
• 4:53
  as
• 4:53
  hypochondriacis.
• 4:54
  Right.
• 4:55
  So
• 4:56
  Illness
• 4:56
  anxiety.
• 4:57
  The
• 4:57
  way
• 4:57
  I
• 4:57
  differentiate
• 4:58
  it
• 4:58
  from
• 4:58
  somatic
• 4:59
  symptom
• 4:59
  disorder
• 5:00
  is
• 5:00
  that
• 5:01
  in
• 5:01
  illness
• 5:01
  anxiety,
• 5:02
  we
• 5:02
  are
• 5:03
  preoccupied
• 5:04
  about
• 5:04
  acquiring
• 5:05
  a
• 5:05
  specific
• 5:05
  disease
• 5:06
  or
• 5:06
  syndrome.
• 5:06
  Right.
• 5:07
  People
• 5:07
  who
• 5:07
  think
• 5:08
  they
• 5:08
  might
• 5:08
  have
• 5:08
  cancer
• 5:09
  because
• 5:10
  their
• 5:10
  fingers
• 5:11
  tingle
• 5:11
  a
• 5:11
  little
• 5:11
  bit
• 5:12
  more
• 5:12
  than
• 5:12
  usual.
• 5:13
  Right.
• 5:13
  People
• 5:13
  who
• 5:14
  feel
• 5:15
  as
• 5:15
  though
• 5:16
  maybe
• 5:17
  they
• 5:17
  have
• 5:18
  lupus
• 5:19
  because
• 5:19
  their
• 5:20
  cough
• 5:20
  is
• 5:21
  a
• 5:21
  little
• 5:21
  too
• 5:21
  intense.
• 5:22
  And
• 5:22
  whether
• 5:22
  or
• 5:22
  not
• 5:22
  a
• 5:23
  cough
• 5:23
  is
• 5:23
  super
• 5:24
  common
• 5:24
  in
• 5:24
  lupus,
• 5:25
  I'd
• 5:25
  have
• 5:25
  to
• 5:25
  whip
• 5:26
  out
• 5:26
  the
• 5:26
  textbook
• 5:26
  myself.
• 5:27
  But
• 5:27
  the
• 5:27
  point
• 5:28
  is
• 5:28
  they
• 5:28
  are
• 5:29
  worried
• 5:29
  about
• 5:30
  acquiring
• 5:30
  a
• 5:31
  specific
• 5:31
  syndrome
• 5:32
  or
• 5:32
  illness
• 5:32
  and
• 5:33
  their
• 5:33
  center
• 5:33
  of
• 5:34
  gravity
• 5:34
  is
• 5:34
  acquiring
• 5:35
  that,
• 5:36
  as
• 5:36
  opposed
• 5:36
  to
• 5:37
  somatic
• 5:37
  symptom
• 5:38
  disorder,
• 5:38
  where
• 5:39
  the
• 5:39
  center
• 5:39
  of
• 5:39
  gravity
• 5:40
  is
• 5:40
  the
• 5:40
  symptom
• 5:41
  itself.
• 5:42
  Okay,
• 5:43
  but.
• 5:43
  But
• 5:43
  really,
• 5:44
  this
• 5:44
  is
• 5:45
  where
• 5:45
  the
• 5:45
  actual
• 5:46
  name
• 5:46
  of
• 5:46
  the
• 5:47
  disorder
• 5:47
  is
• 5:47
  very
• 5:48
  helpful
• 5:48
  because
• 5:49
  illness
• 5:50
  anxiety
• 5:50
  is
• 5:50
  exactly
• 5:51
  how
• 5:51
  it
• 5:51
  sounds.
• 5:51
  You're
• 5:52
  preoccupied.
• 5:52
  Your
• 5:53
  anxiety
• 5:53
  is
• 5:53
  about
• 5:53
  getting
• 5:54
  an
• 5:54
  illness.
• 5:55
  It's
• 5:55
  not
• 5:55
  about
• 5:55
  the
• 5:56
  symptom
• 5:56
  itself.
• 5:57
  It's
• 5:57
  about
• 5:57
  the
• 5:57
  illness
• 5:58
  itself.
• 5:58
  That
• 5:58
  is
• 5:59
  main
• 5:59
  chief
• 6:00
  fear.
• 6:00
  That
• 6:01
  is,
• 6:02
  I
• 6:02
  think,
• 6:03
  animating
• 6:03
  the
• 6:04
  patient's
• 6:04
  concerns.
• 6:05
  Right.
• 6:05
  I'm
• 6:05
  worried
• 6:06
  about
• 6:06
  cancer.
• 6:06
  I'm
• 6:07
  not
• 6:07
  worried
• 6:07
  about
• 6:07
  the
• 6:08
  back
• 6:08
  pain.
• 6:08
  I
• 6:08
  have
• 6:09
  that
• 6:09
  I
• 6:09
  think
• 6:09
  is
• 6:10
  cancer.
• 6:10
  That
• 6:10
  would
• 6:11
  be
• 6:11
  more
• 6:11
  somatic
• 6:12
  symptom
• 6:12
  disorder
• 6:13
  where
• 6:13
  I'm
• 6:13
  fixated
• 6:13
  on
• 6:14
  the
• 6:14
  back
• 6:14
  pain.
• 6:14
  And
• 6:14
  again,
• 6:15
  in
• 6:15
  somatic
• 6:15
  symptom
• 6:16
  disorder,
• 6:16
  this
• 6:16
  is
• 6:16
  another
• 6:16
  chief
• 6:17
  way
• 6:17
  to
• 6:18
  differentiate
• 6:18
  the
• 6:18
  two.
• 6:19
  The
• 6:19
  symptom
• 6:20
  has
• 6:20
  to
• 6:20
  actually
• 6:20
  be
• 6:20
  there
• 6:21
  in
• 6:21
  somatic
• 6:21
  symptom
• 6:22
  disorder.
• 6:22
  Right.
• 6:23
  So
• 6:23
  that
• 6:23
  you
• 6:23
  actually
• 6:24
  have
• 6:24
  to
• 6:24
  have
• 6:24
  the
• 6:25
  back
• 6:25
  pain
• 6:25
  for
• 6:25
  like,
• 6:26
  at
• 6:26
  least
• 6:26
  six
• 6:26
  months.
• 6:27
  Right.
• 6:28
  And
• 6:28
  so
• 6:28
  it's
• 6:28
  not
• 6:28
  this
• 6:29
  nebulous
• 6:30
  thing
• 6:30
  that
• 6:31
  you're
• 6:31
  worried
• 6:31
  you
• 6:32
  might
• 6:32
  have,
• 6:32
  and
• 6:32
  you're
• 6:33
  getting
• 6:33
  a
• 6:33
  bunch
• 6:33
  of
• 6:33
  tests
• 6:33
  to
• 6:34
  see
• 6:34
  if
• 6:34
  you
• 6:34
  have.
• 6:35
  No
• 6:35
  somatic
• 6:35
  symptom
• 6:36
  disorder
• 6:36
  is
• 6:36
  an
• 6:36
  actual
• 6:37
  real.
• 6:38
  It's
• 6:38
  an
• 6:38
  actual
• 6:38
  symptom.
• 6:39
  Are
• 6:40
  we
• 6:40
  worried
• 6:40
  about
• 6:41
  getting
• 6:41
  an
• 6:41
  illness
• 6:42
  or
• 6:42
  are
• 6:42
  we
• 6:42
  worried
• 6:43
  about
• 6:43
  an
• 6:43
  existing
• 6:44
  symptom?
• 6:44
  And
• 6:44
  that's
• 6:44
  going
• 6:45
  to
• 6:45
  help
• 6:45
  you
• 6:45
  differentiate
• 6:46
  those
• 6:46
  two.
• 6:47
  Now,
• 6:47
  another
• 6:48
  thing
• 6:48
  that
• 6:48
  might.
• 6:49
  Another
• 6:49
  case
• 6:50
  that
• 6:50
  might
• 6:50
  slip
• 6:50
  into
• 6:50
  your
• 6:51
  clinic
• 6:51
  in
• 6:51
  line
• 6:52
  with
• 6:52
  this,
• 6:52
  and
• 6:52
  we
• 6:52
  have
• 6:52
  to
• 6:53
  think
• 6:53
  about
• 6:53
  this
• 6:54
  with
• 6:54
  our
• 6:54
  case
• 6:54
  today
• 6:55
  is,
• 6:56
  you
• 6:57
  know,
• 6:57
  is
• 6:57
  this
• 6:57
  a
• 6:58
  fictitious
• 6:58
  disorder?
• 6:59
  Right.
• 7:00
  And
• 7:01
  what
• 7:01
  is
• 7:01
  the
• 7:01
  difference
• 7:01
  between
• 7:02
  that
• 7:02
  and,
• 7:02
  like,
• 7:03
  malingering?
• 7:04
  Right.
• 7:04
  And
• 7:04
  again,
• 7:05
  it's.
• 7:05
  It's.
• 7:06
  It's
• 7:06
  not
• 7:07
  obviously,
• 7:07
  these
• 7:07
  are
• 7:08
  not
• 7:09
  diagnosis.
• 7:10
  You
• 7:10
  want
• 7:10
  to
• 7:10
  float
• 7:10
  out
• 7:11
  in
• 7:11
  front
• 7:11
  of
• 7:11
  your
• 7:11
  patient.
• 7:11
  They
• 7:12
  could
• 7:12
  be
• 7:12
  very
• 7:12
  offended
• 7:12
  that
• 7:13
  you
• 7:13
  think
• 7:13
  they're
• 7:13
  malingering.
• 7:14
  One
• 7:14
  of
• 7:14
  my
• 7:14
  old
• 7:15
  mentors
• 7:15
  said,
• 7:16
  you
• 7:16
  know,
• 7:16
  never
• 7:16
  assume
• 7:17
  malingering
• 7:17
  unless
• 7:18
  you
• 7:18
  want
• 7:18
  to
• 7:18
  buy
• 7:18
  a
• 7:18
  lawyer
• 7:19
  a
• 7:19
  Tesla.
• 7:19
  Right.
• 7:20
  You
• 7:20
  really
• 7:20
  don't
• 7:21
  want
• 7:21
  to
• 7:21
  start
• 7:21
  dismissing
• 7:22
  symptoms
• 7:23
  and
• 7:23
  under
• 7:24
  valuing
• 7:25
  symptoms.
• 7:25
  And
• 7:25
  then,
• 7:26
  lo
• 7:26
  and
• 7:26
  behold,
• 7:26
  these
• 7:27
  are
• 7:27
  Real
• 7:27
  problems.
• 7:28
  And
• 7:28
  you
• 7:28
  just
• 7:29
  documented
• 7:30
  that.
• 7:30
  You
• 7:31
  didn't
• 7:31
  even
• 7:31
  believe
• 7:31
  them.
• 7:32
  And
• 7:32
  now
• 7:32
  they're
• 7:33
  in
• 7:33
  the
• 7:33
  ICU
• 7:34
  on
• 7:34
  a
• 7:34
  stretcher
• 7:35
  and
• 7:36
  it's
• 7:36
  pandemonium.
• 7:37
  And
• 7:37
  you're
• 7:37
  the,
• 7:38
  you're
• 7:38
  the
• 7:38
  provider
• 7:38
  who
• 7:38
  didn't
• 7:39
  take
• 7:39
  them
• 7:39
  seriously.
• 7:39
  So
• 7:40
  that's
• 7:40
  really
• 7:40
  not
• 7:40
  a
• 7:40
  good
• 7:41
  idea,
• 7:41
  generally
• 7:41
  speaking.
• 7:42
  But
• 8:37
  again,
• 8:37
  these
• 8:38
  are
• 8:38
  appropriate
• 8:38
  differentials
• 8:39
  to
• 8:39
  float
• 8:40
  in
• 8:40
  your
• 8:40
  brain
• 8:41
  because
• 8:41
  if
• 8:41
  nothing
• 8:42
  else,
• 8:42
  they
• 8:42
  will.
• 8:43
  When
• 8:43
  you
• 8:43
  say,
• 8:43
  oh,
• 8:43
  no,
• 8:44
  that
• 8:44
  can't
• 8:44
  be
• 8:44
  the
• 8:44
  case,
• 8:45
  it
• 8:45
  will
• 8:45
  orient
• 8:46
  you
• 8:46
  to
• 8:46
  what
• 8:46
  is
• 8:47
  the
• 8:47
  case.
• 8:47
  And
• 8:47
  I
• 8:48
  think
• 8:48
  that's
• 8:48
  very
• 8:48
  helpful.
• 8:49
  Right.
• 8:50
  We
• 8:50
  don't
• 8:50
  have
• 8:51
  a
• 8:51
  lot
• 8:51
  of
• 8:51
  evidence
• 8:52
  to
• 8:52
  suggest
• 8:53
  that
• 8:54
  these
• 8:54
  symptoms
• 8:55
  are
• 8:55
  manufactured.
• 8:56
  That
• 8:56
  would
• 8:56
  be
• 8:56
  something
• 8:57
  more
• 8:57
  like
• 8:57
  a
• 8:57
  fictitious
• 8:58
  disorder
• 8:59
  or
• 8:59
  a
• 8:59
  malingering
• 9:00
  disorder
• 9:01
  of
• 9:01
  some
• 9:01
  kind.
• 9:02
  Right.
• 9:02
  And
• 9:02
  in
• 9:02
  fictitious
• 9:03
  disorder,
• 9:04
  the
• 9:04
  patient
• 9:04
  is
• 9:04
  not
• 9:05
  always
• 9:05
  necessarily
• 9:07
  aware
• 9:07
  of
• 9:07
  what
• 9:08
  they're
• 9:08
  doing.
• 9:08
  Their
• 9:09
  motivations
• 9:09
  at
• 9:09
  least,
• 9:10
  might
• 9:10
  not
• 9:10
  be
• 9:11
  blatantly
• 9:12
  obvious
• 9:12
  to
• 9:12
  them.
• 9:12
  They
• 9:12
  might
• 9:13
  have
• 9:13
  this
• 9:13
  underlying
• 9:13
  motivation
• 9:14
  to
• 9:14
  be
• 9:14
  nurtured
• 9:15
  or
• 9:15
  cared
• 9:15
  for.
• 9:16
  It's
• 9:16
  kind
• 9:16
  of
• 9:17
  this
• 9:17
  psychodynamic
• 9:18
  thing
• 9:18
  where
• 9:19
  being
• 9:19
  the
• 9:20
  victim
• 9:20
  or
• 9:20
  being
• 9:20
  the
• 9:21
  sick,
• 9:21
  ill
• 9:21
  person
• 9:22
  is
• 9:23
  fulfilling
• 9:23
  some
• 9:23
  kind
• 9:24
  of
• 9:24
  psychological
• 9:24
  need.
• 9:26
  It's
• 9:26
  not
• 9:26
  to
• 9:26
  get
• 9:27
  disability.
• 9:28
  It's
• 9:28
  not
• 9:28
  to
• 9:28
  avoid
• 9:29
  a
• 9:29
  military
• 9:29
  draft
• 9:30
  like
• 9:30
  in
• 9:30
  malingering.
• 9:31
  Right.
• 9:31
  Malingering
• 9:31
  is
• 9:32
  secondary
• 9:32
  gain.
• 9:33
  It's
• 9:33
  to
• 9:33
  escape
• 9:34
  a
• 9:34
  prison
• 9:34
  sentence
• 9:35
  or
• 9:35
  a
• 9:35
  military
• 9:36
  service
• 9:36
  or,
• 9:37
  or
• 9:37
  to
• 9:37
  get
• 9:37
  disability
• 9:37
  of
• 9:38
  some
• 9:38
  kind.
• 9:38
  Right.
• 9:38
  There's
• 9:38
  an
• 9:39
  external
• 9:39
  reward
• 9:39
  there.
• 9:40
  Fictitious
• 9:41
  disorder.
• 9:41
  There's
• 9:41
  not
• 9:41
  that
• 9:42
  obvious
• 9:42
  external
• 9:43
  reward,
• 9:43
  but
• 9:43
  it
• 9:44
  may
• 9:44
  be
• 9:44
  fulfilling
• 9:45
  some
• 9:45
  kind
• 9:45
  of
• 9:46
  an
• 9:46
  emotional.
• 9:47
  But
• 9:47
  with
• 9:47
  fictitious
• 9:48
  disorder,
• 9:49
  that
• 9:50
  patient
• 9:50
  is
• 9:51
  intentionally,
• 9:52
  intentionally
• 9:53
  inducing
• 9:54
  their
• 9:54
  symptoms.
• 9:54
  Right.
• 9:54
  They
• 9:55
  might
• 9:55
  like,
• 9:55
  put
• 9:56
  blood
• 9:56
  in
• 9:56
  their
• 9:56
  urine
• 9:57
  or,
• 9:57
  you
• 9:57
  know,
• 9:57
  to
• 9:57
  make
• 9:58
  somebody
• 9:58
  think
• 9:58
  that
• 9:59
  their
• 9:59
  urinalysis
• 10:00
  is
• 10:01
  that
• 10:01
  the
• 10:01
  patient
• 10:01
  might,
• 10:02
  might
• 10:02
  have
• 10:02
  like,
• 10:02
  GI
• 10:03
  bleeding
• 10:03
  and
• 10:04
  they
• 10:04
  don't.
• 10:04
  So
• 10:04
  they're,
• 10:05
  they're
• 10:05
  feigning
• 10:06
  symptoms,
• 10:06
  but
• 10:06
  not
• 10:06
  because
• 10:07
  it
• 10:07
  gets
• 10:07
  them
• 10:07
  a
• 10:07
  disability
• 10:08
  ch.
• 10:09
  But
• 10:09
  it
• 10:09
  might
• 10:09
  be
• 10:10
  putting
• 10:10
  them
• 10:11
  in
• 10:11
  a
• 10:11
  certain
• 10:11
  role.
• 10:11
  Now
• 10:12
  that
• 10:12
  would
• 10:12
  be
• 10:13
  something
• 10:13
  you
• 10:13
  want
• 10:13
  to
• 10:14
  think
• 10:14
  about
• 10:14
  with
• 10:14
  our
• 10:14
  32
• 10:15
  year
• 10:15
  old
• 10:15
  mock
• 10:15
  patient
• 10:16
  here.
• 10:16
  Right.
• 10:16
  Are
• 10:17
  these
• 10:17
  symptoms
• 10:17
  being
• 10:18
  manufactured
• 10:19
  by
• 10:19
  her?
• 10:19
  Because
• 10:19
  I
• 10:19
  don't
• 10:19
  see
• 10:20
  any
• 10:20
  hard
• 10:20
  diagnoses.
• 10:21
  It's
• 10:21
  possible,
• 10:22
  but
• 10:23
  we
• 10:23
  don't
• 10:23
  really
• 10:23
  have
• 10:23
  evidence
• 10:24
  for
• 10:24
  that.
• 10:24
  And
• 10:24
  that,
• 10:24
  of
• 10:24
  course,
• 10:25
  is
• 10:25
  a
• 10:25
  very
• 10:25
  fine
• 10:26
  line
• 10:26
  to
• 10:27
  walk
• 10:27
  with
• 10:27
  your
• 10:28
  patient.
• 10:28
  Right.
• 10:28
  Because
• 10:29
  if
• 10:29
  these
• 10:29
  are
• 10:30
  in
• 10:30
  fact
• 10:31
  very
• 10:31
  real
• 10:31
  symptoms
• 10:32
  to
• 10:32
  her
• 10:33
  and
• 10:33
  they're
• 10:33
  causing
• 10:33
  a
• 10:34
  lot
• 10:34
  of
• 10:34
  distress,
• 10:34
  the
• 10:35
  last
• 10:35
  thing
• 10:35
  you
• 10:35
  want
• 10:35
  to
• 10:35
  do
• 10:35
  is
• 10:36
  immediately
• 10:36
  minimize
• 10:37
  them
• 10:37
  with,
• 10:37
  or
• 10:37
  cast
• 10:38
  doubt
• 10:38
  on
• 10:38
  them.
• 10:39
  And
• 10:39
  God
• 10:39
  forbid
• 10:40
  you
• 10:40
  suspect
• 10:41
  that
• 10:41
  she's
• 10:41
  dipping
• 10:42
  her
• 10:42
  thermometer
• 10:43
  in
• 10:43
  like
• 10:44
  boiling
• 10:44
  oatmeal
• 10:45
  before
• 10:46
  she's,
• 10:47
  you
• 10:47
  know,
• 10:47
  getting
• 10:47
  her
• 10:48
  temperature
• 10:48
  taken.
• 10:48
  I
• 10:49
  mean,
• 10:49
  it's
• 10:49
  kind
• 10:49
  of
• 10:49
  an
• 10:49
  insulting
• 10:50
  insinuation,
• 10:50
  right?
• 10:51
  So
• 10:51
  you
• 10:51
  have
• 10:51
  to
• 10:51
  be
• 10:52
  very
• 10:52
  careful
• 10:52
  with
• 10:53
  this.
• 10:53
  And
• 10:53
  that's
• 10:53
  where
• 10:53
  the
• 10:54
  collateral
• 10:54
  history
• 10:55
  is
• 10:55
  very
• 10:55
  important.
• 10:56
  That's
• 10:56
  where
• 10:56
  you
• 10:57
  kind
• 10:57
  of
• 10:57
  sift
• 10:57
  through
• 10:57
  the
• 10:57
  documentation
• 10:58
  to
• 10:58
  kind
• 10:59
  of
• 10:59
  understand
• 10:59
  if
• 10:59
  anybody
• 11:00
  caught
• 11:00
  something
• 11:00
  strange
• 11:02
  that
• 11:02
  she
• 11:02
  may
• 11:02
  have,
• 11:03
  you
• 11:03
  know,
• 11:03
  did
• 11:03
  she,
• 11:04
  did
• 11:04
  she
• 11:04
  do
• 11:05
  do
• 11:05
  sprints
• 11:06
  in
• 11:06
  the
• 11:06
  hallway
• 11:07
  before
• 11:07
  somebody
• 11:07
  took
• 11:08
  her
• 11:08
  heart
• 11:08
  rate
• 11:08
  and
• 11:08
  blood
• 11:09
  pressure?
• 11:09
  That
• 11:10
  might
• 11:10
  be
• 11:10
  documented.
• 11:10
  That
• 11:10
  might
• 11:11
  be
• 11:11
  a
• 11:11
  little
• 11:11
  suspicious,
• 11:12
  right?
• 11:13
  I
• 11:13
  mean,
• 11:13
  there's
• 11:13
  all
• 11:13
  kinds
• 11:14
  of
• 11:14
  ways
• 11:14
  you
• 11:14
  can
• 11:14
  manufacture
• 11:15
  symptoms,
• 11:16
  but
• 11:16
  definitely
• 11:17
  I
• 11:17
  would
• 11:17
  be
• 11:17
  a
• 11:17
  little
• 11:17
  suspicious
• 11:18
  in
• 11:18
  the
• 11:18
  absence
• 11:19
  of
• 11:19
  a
• 11:19
  concrete
• 11:19
  diagnosis,
• 11:20
  right?
• 11:20
  You
• 11:21
  got
• 11:21
  infections
• 11:21
  and
• 11:21
  fevers
• 11:22
  and
• 11:22
  fatigue
• 11:23
  and
• 11:23
  nothing's
• 11:24
  really
• 11:24
  happening
• 11:24
  here.
• 11:25
  That
• 11:26
  would
• 11:26
  be
• 11:26
  a
• 11:26
  little
• 11:26
  weird,
• 11:27
  especially
• 11:27
  if
• 11:27
  there's
• 11:28
  an
• 11:28
  overutilization
• 11:29
  of
• 11:29
  healthcare
• 11:29
  and
• 11:30
  we're
• 11:30
  still
• 11:30
  not
• 11:30
  getting
• 11:30
  anything.
• 11:31
  Another
• 11:32
  big
• 11:32
  clue
• 11:33
  is
• 11:33
  if
• 11:33
  your
• 11:33
  patient
• 11:34
  does
• 11:35
  not
• 11:35
  seem
• 11:35
  distressed.
• 11:36
  In
• 11:36
  my
• 11:36
  experience
• 11:37
  with
• 11:37
  patients
• 11:38
  who
• 11:38
  have
• 11:38
  illness
• 11:38
  anxiety
• 11:39
  disorder
• 11:39
  or
• 11:39
  somatic
• 11:40
  symptom
• 11:40
  disorder,
• 11:40
  they're
• 11:41
  distressed
• 11:41
  like
• 11:41
  they're
• 11:41
  nervous.
• 11:42
  They
• 11:42
  don't
• 11:42
  want
• 11:42
  these
• 11:42
  symptoms.
• 11:43
  They
• 11:43
  don't
• 11:44
  want
• 11:44
  to
• 11:44
  feel
• 11:44
  this
• 11:44
  way,
• 11:45
  right.
• 11:45
  It's
• 11:45
  very
• 11:46
  ego
• 11:46
  dystonic.
• 11:47
  When
• 11:47
  a
• 11:47
  patient
• 11:47
  thinks
• 11:48
  they
• 11:48
  might
• 11:48
  have
• 11:48
  cancer
• 11:48
  because
• 11:49
  of
• 11:49
  tingling
• 11:50
  in
• 11:50
  their
• 11:50
  nose,
• 11:51
  it's
• 11:51
  a
• 11:51
  scary
• 11:51
  experience.
• 11:52
  They're
• 11:52
  not
• 11:52
  making
• 11:53
  it
• 11:53
  up.
• 11:53
  They
• 11:53
  hope
• 11:53
  it's
• 11:54
  not
• 11:54
  real.
• 11:54
  They
• 11:54
  go
• 11:54
  to
• 11:54
  great
• 11:55
  lengths
• 11:55
  to
• 11:55
  make
• 11:55
  sure
• 11:56
  it's
• 11:56
  not
• 11:56
  real.
• 11:57
  And
• 11:57
  it's
• 11:57
  terrifying.
• 11:58
  Right?
• 11:58
  But
• 11:58
  in
• 11:59
  a
• 11:59
  patient
• 11:59
  who's
• 12:00
  potentially
• 12:01
  inducing
• 12:01
  these
• 12:01
  symptoms
• 12:02
  in
• 12:02
  a
• 12:02
  fictitious
• 12:03
  disorder
• 12:03
  or
• 12:03
  malingering,
• 12:05
  their
• 12:05
  affect
• 12:05
  tends
• 12:06
  to
• 12:06
  be
• 12:07
  kind
• 12:07
  of
• 12:07
  incongruent
• 12:08
  to
• 12:08
  what
• 12:08
  you
• 12:08
  would
• 12:08
  expect,
• 12:09
  right?
• 12:09
  You
• 12:09
  would
• 12:09
  expect
• 12:09
  someone
• 12:10
  to
• 12:10
  be
• 12:10
  nervous,
• 12:10
  they're
• 12:11
  more
• 12:11
  calm,
• 12:11
  they
• 12:12
  might
• 12:12
  even
• 12:12
  appear
• 12:12
  borderline
• 12:13
  enthusiastic
• 12:14
  as
• 12:14
  they're
• 12:14
  talking
• 12:15
  about
• 12:15
  this
• 12:15
  stuff.
• 12:15
  I
• 12:15
  don't
• 12:16
  mean
• 12:16
  to
• 12:16
  at
• 12:17
  all
• 12:17
  minimize
• 12:17
  what
• 12:18
  they're
• 12:18
  going
• 12:18
  through,
• 12:18
  but
• 12:19
  the
• 12:19
  affect
• 12:20
  doesn't
• 12:20
  seem
• 12:21
  to
• 12:21
  be
• 12:21
  consistent
• 12:22
  with
• 12:22
  how
• 12:22
  an
• 12:22
  ordinary
• 12:23
  person
• 12:23
  would
• 12:24
  interpret
• 12:25
  the
• 12:25
  potential
• 12:25
  consequences
• 12:26
  of
• 12:26
  these
• 12:26
  symptoms.
• 12:27
  And
• 12:27
  that's
• 12:27
  my
• 12:27
  clue
• 12:28
  that
• 12:28
  something's
• 12:29
  just
• 12:29
  not
• 12:29
  right
• 12:29
  here.
• 12:29
  Like
• 12:30
  we,
• 12:30
  you
• 12:30
  know,
• 12:30
  when
• 12:31
  we're
• 12:31
  this
• 12:31
  excited,
• 12:31
  we
• 12:32
  should
• 12:32
  be
• 12:32
  talking
• 12:32
  about
• 12:32
  like
• 12:33
  a
• 12:33
  Yankees
• 12:34
  game
• 12:34
  we're
• 12:34
  going
• 12:34
  to
• 12:35
  or
• 12:35
  the
• 12:36
  Macy's
• 12:36
  Day
• 12:36
  parade
• 12:37
  or
• 12:38
  I'm
• 12:38
  about
• 12:38
  to
• 12:38
  eat
• 12:38
  a
• 12:38
  deep
• 12:39
  dish
• 12:39
  pizza
• 12:39
  tonight.
• 12:40
  You
• 12:40
  shouldn't
• 12:40
  talk
• 12:40
  in,
• 12:40
  in
• 12:41
  that
• 12:41
  kind
• 12:41
  of
• 12:41
  tone
• 12:42
  if
• 12:42
  you're
• 12:43
  worried
• 12:43
  that
• 12:43
  you
• 12:44
  might
• 12:44
  have
• 12:44
  like
• 12:44
  myocarditis,
• 12:45
  right.
• 12:46
  That,
• 12:46
  that's,
• 12:46
  that's
• 12:46
  not
• 12:47
  going
• 12:47
  to
• 12:47
  make
• 12:47
  you
• 12:47
  like,
• 12:48
  nice
• 12:48
  and
• 12:48
  cheerful.
• 12:49
  So
• 12:50
  I
• 12:50
  have
• 12:50
  found
• 12:51
  in
• 12:51
  my,
• 12:51
  in
• 12:51
  the
• 12:52
  past
• 12:52
  that
• 12:53
  if
• 12:53
  we're
• 12:53
  talking
• 12:53
  about
• 12:53
  malingering
• 12:54
  or
• 12:54
  fictitious
• 12:55
  disorder,
• 12:55
  your
• 12:55
  patients,
• 12:56
  there's
• 12:56
  a,
• 12:56
  there's
• 12:57
  a
• 12:57
  kind
• 12:57
  of
• 12:57
  a
• 12:57
  whiff
• 12:57
  of
• 12:57
  Almost
• 12:58
  enthusiasm
• 12:59
  or
• 12:59
  at
• 12:59
  least
• 12:59
  a
• 13:00
  lack
• 13:00
  of
• 13:00
  anxiety
• 13:01
  or
• 13:01
  fear
• 13:02
  in,
• 13:02
  in
• 13:03
  what
• 13:03
  they
• 13:03
  are
• 13:04
  talking
• 13:04
  about
• 13:05
  when
• 13:05
  you're
• 13:05
  combing
• 13:06
  through
• 13:06
  their
• 13:06
  symptoms.
• 13:07
  And
• 13:07
  this
• 13:07
  is
• 13:07
  why
• 13:07
  your
• 13:08
  mental
• 13:08
  status
• 13:09
  exam
• 13:09
  is
• 13:10
  just
• 13:10
  so
• 13:10
  important,
• 13:11
  right?
• 13:11
  Because
• 13:11
  you,
• 13:12
  you,
• 13:12
  you
• 13:12
  really
• 13:12
  want
• 13:13
  to
• 13:13
  be.
• 13:14
  It
• 13:14
  really,
• 13:14
  it
• 13:14
  really
• 13:14
  helps
• 13:15
  you
• 13:15
  kind
• 13:15
  of,
• 13:16
  it's
• 13:16
  like
• 13:16
  a
• 13:16
  tip
• 13:16
  off.
• 13:17
  Okay.
• 13:18
  And
• 13:18
  you
• 13:18
  know,
• 13:19
  again,
• 13:19
  no
• 13:19
  need
• 13:20
  to
• 13:20
  underestimate
• 13:20
  this
• 13:20
  stuff.
• 13:21
  At
• 13:21
  the
• 13:21
  end
• 13:21
  of
• 13:21
  the
• 13:21
  day,
• 13:22
  my
• 13:22
  friends,
• 13:22
  whether
• 13:22
  it's
• 13:23
  fictitious,
• 13:23
  whether
• 13:23
  it's
• 13:24
  somatic
• 13:24
  or
• 13:24
  illness
• 13:25
  anxiety,
• 13:25
  you
• 13:25
  still
• 13:26
  have
• 13:26
  a
• 13:26
  suffering
• 13:26
  patient
• 13:27
  in
• 13:27
  front
• 13:27
  of
• 13:27
  you
• 13:28
  who
• 13:28
  probably
• 13:29
  did
• 13:29
  not
• 13:29
  have
• 13:29
  a
• 13:30
  textbook
• 13:30
  childhood,
• 13:31
  who
• 13:31
  probably
• 13:31
  doesn't
• 13:32
  have
• 13:32
  this
• 13:32
  textbook
• 13:33
  life
• 13:33
  where
• 13:33
  they're
• 13:34
  super
• 13:34
  supported
• 13:34
  and
• 13:35
  understood.
• 13:36
  There's
• 13:36
  probably,
• 13:36
  there's,
• 13:37
  you
• 13:37
  know,
• 13:37
  this
• 13:37
  is
• 13:37
  still
• 13:37
  someone
• 13:38
  that
• 13:38
  is
• 13:38
  being
• 13:38
  harmed
• 13:39
  and
• 13:39
  we
• 13:39
  need
• 13:39
  to
• 13:39
  help
• 13:39
  them
• 13:40
  compassionately.
• 13:41
  Even
• 13:41
  if
• 13:41
  it
• 13:41
  takes
• 13:42
  a
• 13:42
  little
• 13:42
  extra
• 13:42
  time
• 13:43
  to
• 13:43
  kind
• 13:43
  of
• 13:44
  understand
• 13:44
  the
• 13:44
  mechanics
• 13:45
  of
• 13:45
  this.
• 13:46
  In
• 13:46
  my
• 13:46
  experience,
• 13:47
  psychotherapy
• 13:48
  is
• 13:48
  good
• 13:48
  to
• 13:49
  kind
• 13:49
  of
• 13:49
  understand
• 13:49
  the
• 13:49
  roots
• 13:50
  of
• 13:50
  these
• 13:50
  behaviors.
• 13:51
  I
• 13:51
  think
• 13:52
  there's
• 13:52
  some
• 13:52
  resistance
• 13:52
  there.
• 13:53
  Typically
• 13:54
  when
• 13:54
  you
• 13:54
  confront
• 13:54
  this,
• 13:55
  assessing
• 13:56
  how
• 13:56
  they
• 13:57
  actually
• 13:57
  view
• 13:57
  the
• 13:58
  threats
• 13:58
  they're
• 13:58
  talking
• 13:58
  about
• 13:59
  is
• 13:59
  really
• 14:00
  important.
• 14:01
  Okay.
• 14:02
  What
• 14:02
  they
• 14:02
  do
• 14:02
  when
• 14:02
  these
• 14:03
  symptoms
• 14:03
  start,
• 14:03
  do
• 14:03
  they
• 14:04
  immediately
• 14:04
  seek
• 14:04
  healthcare?
• 14:05
  Does
• 14:05
  it
• 14:06
  bother
• 14:06
  them?
• 14:07
  How
• 14:07
  do
• 14:07
  you
• 14:07
  feel
• 14:07
  when
• 14:08
  the
• 14:08
  tests
• 14:08
  come
• 14:08
  back
• 14:08
  normal?
• 14:09
  Right.
• 14:09
  When
• 14:09
  the
• 14:09
  tests
• 14:09
  come
• 14:10
  back
• 14:10
  normal,
• 14:10
  are
• 14:10
  you
• 14:10
  happy?
• 14:11
  Are
• 14:11
  you
• 14:11
  sad?
• 14:11
  Are
• 14:11
  you
• 14:12
  relieved?
• 14:13
  And
• 14:13
  so
• 14:13
  all
• 14:13
  of
• 14:13
  these
• 14:13
  are
• 14:14
  really,
• 14:14
  really
• 14:15
  interesting
• 14:15
  questions.
• 14:16
  Again,
• 14:16
  illness,
• 14:16
  anxiety
• 14:17
  disorder,
• 14:17
  the
• 14:18
  core
• 14:18
  is
• 14:18
  fear
• 14:18
  of
• 14:19
  having
• 14:19
  an
• 14:19
  illness,
• 14:19
  somatic
• 14:20
  symptom.
• 14:20
  The
• 14:20
  core
• 14:21
  is
• 14:21
  real
• 14:21
  symptoms
• 14:22
  and
• 14:22
  excessive
• 14:22
  distress
• 14:23
  attached
• 14:23
  to
• 14:24
  those
• 14:24
  symptoms.
• 14:25
  Right.
• 14:26
  And
• 14:26
  fictitious
• 14:26
  disorder,
• 14:27
  it's
• 14:28
  intentional
• 14:28
  symptom
• 14:28
  production
• 14:29
  or
• 14:29
  exaggeration.
• 14:30
  And
• 14:30
  the
• 14:30
  motivation
• 14:31
  is
• 14:31
  often
• 14:31
  psychological,
• 14:32
  not
• 14:33
  external
• 14:33
  gain.
• 14:34
  Right.
• 14:34
  And
• 14:35
  watch
• 14:35
  out,
• 14:35
  because
• 14:36
  a
• 14:36
  lot
• 14:36
  of
• 14:36
  folks
• 14:36
  who
• 14:36
  have
• 14:37
  extensive
• 14:37
  medical
• 14:37
  histories,
• 14:38
  like
• 14:39
  their
• 14:39
  ICU
• 14:39
  nurses
• 14:40
  or,
• 14:40
  or
• 14:40
  PAs,
• 14:41
  they
• 14:41
  are
• 14:41
  often
• 14:42
  very
• 14:42
  medically
• 14:43
  sophisticated,
• 14:43
  so
• 14:44
  they
• 14:44
  might
• 14:44
  throw
• 14:44
  a
• 14:44
  lot
• 14:44
  of
• 14:44
  jargon
• 14:45
  at
• 14:45
  you.
• 14:45
  And
• 14:46
  so
• 14:47
  it's.
• 14:47
  You
• 14:47
  got
• 14:48
  to
• 14:48
  really
• 14:48
  lean
• 14:49
  on
• 14:49
  the
• 14:49
  side
• 14:49
  of
• 14:49
  caution
• 14:50
  here.
• 14:50
  Err
• 14:50
  on
• 14:50
  the
• 14:50
  side
• 14:51
  of
• 14:51
  caution
• 14:51
  because
• 14:51
  your
• 14:51
  patients
• 14:52
  might
• 14:52
  also
• 14:52
  be
• 14:53
  describing
• 14:53
  very
• 14:54
  real
• 14:54
  workups
• 14:54
  that
• 14:54
  are,
• 14:55
  they're
• 14:55
  very
• 14:55
  much
• 14:55
  worried
• 14:56
  about.
• 14:56
  So
• 14:57
  lean
• 14:57
  in,
• 14:57
  be
• 14:57
  objective,
• 14:58
  but
• 14:58
  keep
• 14:59
  these
• 14:59
  differentials
• 15:00
  in
• 15:00
  your
• 15:00
  back
• 15:00
  pocket.
• 15:01
  We
• 15:01
  don't
• 15:01
  really
• 15:02
  know
• 15:02
  what
• 15:02
  this
• 15:02
  mock
• 15:03
  patient
• 15:03
  today
• 15:03
  had.
• 15:04
  That
• 15:05
  wasn't
• 15:05
  really
• 15:05
  the
• 15:05
  point
• 15:05
  of
• 15:05
  this.
• 15:06
  I
• 15:06
  would
• 15:06
  argue
• 15:07
  the
• 15:07
  patient
• 15:08
  probably
• 15:08
  has
• 15:08
  something
• 15:09
  like
• 15:09
  an
• 15:09
  illness
• 15:09
  anxiety
• 15:10
  disorder
• 15:10
  because
• 15:11
  they
• 15:11
  don't
• 15:11
  have
• 15:11
  too
• 15:12
  many
• 15:12
  hardcore
• 15:12
  symptoms
• 15:13
  that
• 15:13
  they're
• 15:13
  specifically
• 15:14
  focus
• 15:14
  on
• 15:14
  focusing
• 15:15
  on.
• 15:15
  They
• 15:16
  seem
• 15:16
  to
• 15:16
  be
• 15:16
  kind
• 15:16
  of
• 15:16
  worried
• 15:17
  about
• 15:17
  particular
• 15:18
  illnesses,
• 15:19
  worried
• 15:19
  about
• 15:19
  their
• 15:19
  immune
• 15:20
  system.
• 15:20
  But
• 15:20
  again,
• 15:21
  it's,
• 15:21
  it's
• 15:21
  an
• 15:22
  imperfect
• 15:22
  case
• 15:22
  study,
• 15:23
  but
• 15:23
  it's
• 15:23
  a
• 15:23
  fun
• 15:23
  one.
• 15:24
  Hopefully
• 15:24
  a
• 15:24
  high
• 15:24
  yield
• 15:25
  one.
• 15:25
  But
• 15:25
  if
• 15:26
  there,
• 15:26
  if
• 15:26
  if
• 15:26
  this,
• 15:26
  if
• 15:27
  this
• 15:27
  mock
• 15:27
  patient
• 15:28
  was
• 15:28
  focused
• 15:28
  on
• 15:28
  symptoms
• 15:29
  in
• 15:29
  particular
• 15:29
  like
• 15:30
  her
• 15:30
  fatigue
• 15:30
  or
• 15:30
  pain
• 15:31
  and
• 15:31
  the
• 15:32
  main
• 15:32
  focus
• 15:32
  of
• 15:32
  her
• 15:33
  interview
• 15:33
  was
• 15:33
  symptoms,
• 15:34
  I
• 15:34
  would
• 15:34
  certainly
• 15:35
  not
• 15:35
  hesitate
• 15:35
  to
• 15:36
  to
• 15:36
  do
• 15:36
  this
• 15:36
  somatic
• 15:37
  symptom
• 15:37
  disorder
• 15:38
  as
• 15:38
  a
• 15:38
  diagnosis.
• 15:39
  So
• 15:40
  anyhow
• 15:41
  I'm
• 15:41
  really
• 15:42
  happy
• 15:42
  you
• 15:42
  guys
• 15:43
  tuned
• 15:43
  in
• 15:43
  today
• 15:43
  and
• 15:44
  remember
• 15:44
  my
• 15:45
  friends
• 15:45
  if
• 15:45
  you
• 15:45
  really
• 15:45
  want
• 15:46
  to
• 15:46
  stand
• 15:46
  out
• 15:46
  as
• 15:46
  a
• 15:47
  clinician
• 15:47
  and
• 15:47
  feel
• 15:48
  confident
• 15:48
  on
• 15:48
  the
• 15:49
  details
• 15:49
  without
• 15:50
  getting
• 15:50
  stuck
• 15:51
  in
• 15:51
  front
• 15:51
  of
• 15:51
  your
• 15:51
  patients,
• 15:52
  please
• 15:52
  become
• 15:53
  Patreon
• 15:53
  members.
• 15:54
  I
• 15:54
  can't
• 15:54
  urge
• 15:54
  it
• 15:55
  enough.
• 15:55
  If
• 15:55
  I
• 15:55
  was
• 15:55
  a
• 15:56
  student
• 15:56
  I
• 15:56
  would
• 15:56
  have
• 15:56
  raced
• 15:57
  to
• 15:57
  the
• 15:57
  Patreon
• 15:58
  I
• 15:58
  created.
• 15:58
  I
• 15:58
  created
• 15:59
  it
• 15:59
  because
• 15:59
  I
• 16:00
  I
• 16:00
  needed
• 16:00
  this
• 16:00
  as
• 16:00
  a
• 16:01
  student
• 16:01
  where
• 16:01
  there's
• 16:02
  full
• 16:02
  case
• 16:02
  breakdowns,
• 16:03
  med
• 16:03
  deep
• 16:04
  dives,
• 16:04
  gritty
• 16:04
  weekly
• 16:05
  street
• 16:05
  pearls
• 16:06
  that
• 16:06
  just
• 16:06
  give
• 16:06
  it
• 16:06
  to
• 16:07
  you
• 16:07
  straight
• 16:07
  and
• 16:07
  make
• 16:07
  you
• 16:08
  better
• 16:08
  at
• 16:08
  the
• 16:08
  top
• 16:08
  of
• 16:08
  your
• 16:09
  game
• 16:09
  and
• 16:09
  give
• 16:09
  you
• 16:09
  that
• 16:10
  edge.
• 16:10
  Until
• 16:10
  next
• 16:11
  time
• 16:11
  my
• 16:11
  friends,
• 16:12
  I
• 16:13
  will
• 16:13
  see
• 16:13
  you
• 16:14
  and
• 16:14
  good
• 16:14
  luck.
• 16:14
  Bye
• 16:15
  bye.