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Cannabis Psychosis or Schizophrenia? What Do You Do When You Can't Tell? · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:05
  back,
• 0:06
  my
• 0:06
  friends,
• 0:06
  to
• 0:06
  another
• 0:07
  episode
• 0:07
  of
• 0:07
  Pearls
• 0:08
  and
• 0:08
  Prep.
• 0:08
  Npz.
• 0:09
  Here,
• 0:09
  your
• 0:09
  preceptor
• 0:10
  in
• 0:10
  your
• 0:10
  pocket,
• 0:11
  your
• 0:11
  go
• 0:11
  to
• 0:11
  place
• 0:11
  for
• 0:12
  pearls
• 0:13
  that
• 0:13
  prep
• 0:13
  you
• 0:14
  to
• 0:14
  practice.
• 0:15
  Now,
• 0:15
  my
• 0:15
  friends,
• 0:16
  this
• 0:16
  is
• 0:16
  going
• 0:17
  to
• 0:17
  be
• 0:17
  a
• 0:17
  fun
• 0:17
  one.
• 0:17
  It's
• 0:18
  a
• 0:18
  case
• 0:18
  study
• 0:19
  that
• 0:19
  is
• 0:20
  very
• 0:20
  much
• 0:20
  a
• 0:20
  real
• 0:21
  world
• 0:21
  kind
• 0:22
  of
• 0:22
  problem.
• 0:22
  Okay,
• 0:23
  it's
• 0:23
  a
• 0:23
  fake
• 0:23
  patient.
• 0:24
  It's
• 0:24
  a
• 0:24
  mock
• 0:24
  patient
• 0:25
  like
• 0:25
  we
• 0:25
  always
• 0:25
  do.
• 0:26
  But
• 0:27
  it
• 0:27
  is
• 0:27
  the
• 0:27
  exact
• 0:28
  kind
• 0:28
  of
• 0:28
  situation
• 0:29
  you
• 0:29
  are
• 0:29
  going
• 0:29
  to
• 0:30
  find
• 0:30
  in
• 0:30
  real
• 0:31
  life
• 0:31
  where
• 0:31
  you're
• 0:32
  going
• 0:32
  to
• 0:32
  scratch
• 0:32
  your
• 0:33
  head
• 0:33
  and
• 0:34
  be
• 0:35
  genuinely
• 0:35
  dumbfounded
• 0:36
  about
• 0:36
  how
• 0:37
  to
• 0:37
  proceed.
• 0:38
  Because
• 0:39
  it's
• 0:39
  almost
• 0:40
  like
• 0:40
  two
• 0:40
  disorders
• 0:41
  in
• 0:41
  the
• 0:41
  DSM
• 0:42
  pointing
• 0:42
  at
• 0:42
  each
• 0:42
  other,
• 0:43
  playing
• 0:43
  a
• 0:44
  nose
• 0:44
  game
• 0:44
  where
• 0:45
  they
• 0:45
  don't
• 0:45
  want
• 0:45
  to
• 0:46
  take
• 0:46
  ownership.
• 0:47
  And
• 0:47
  yet
• 0:47
  you
• 0:48
  have
• 0:48
  to
• 0:48
  do
• 0:48
  something
• 0:49
  as
• 0:49
  the
• 0:49
  clinician.
• 0:50
  And
• 0:50
  I'm
• 0:50
  not
• 0:50
  going
• 0:51
  to
• 0:51
  go
• 0:51
  into
• 0:51
  a
• 0:51
  billion
• 0:52
  details
• 0:52
  about
• 0:52
  this
• 0:53
  patient.
• 0:54
  I'm
• 0:54
  only
• 0:54
  going
• 0:55
  to
• 0:55
  talk
• 0:55
  about
• 0:55
  the
• 0:55
  pertinent
• 0:56
  details
• 0:57
  so
• 0:58
  we
• 0:58
  can
• 0:58
  really
• 0:59
  get
• 0:59
  to
• 0:59
  the
• 0:59
  point
• 1:00
  and
• 1:00
  get
• 1:00
  to
• 1:01
  the
• 1:01
  heart
• 1:01
  of
• 1:01
  the
• 1:01
  tension
• 1:02
  here.
• 1:03
  In
• 1:03
  other
• 1:04
  episodes,
• 1:04
  we
• 1:04
  definitely
• 1:05
  flesh
• 1:05
  out
• 1:06
  more
• 1:06
  details.
• 1:06
  We
• 1:07
  get
• 1:07
  you
• 1:07
  thinking
• 1:07
  about
• 1:07
  every
• 1:08
  little
• 1:08
  nook
• 1:08
  and
• 1:08
  cranny
• 1:09
  in
• 1:09
  the
• 1:09
  presentation.
• 1:10
  But
• 1:10
  today,
• 1:10
  we're
• 1:10
  really
• 1:11
  going
• 1:11
  to
• 1:11
  focus
• 1:12
  on
• 1:12
  two
• 1:12
  major
• 1:13
  features
• 1:14
  of
• 1:14
  this
• 1:14
  patient's
• 1:15
  presentation.
• 1:16
  Now,
• 1:16
  we're
• 1:16
  going
• 1:16
  to
• 1:16
  call
• 1:16
  this
• 1:16
  patient
• 1:17
  Henry.
• 1:17
  He's
• 1:18
  a
• 1:18
  22
• 1:18
  year
• 1:19
  old.
• 1:19
  He's
• 1:19
  brought
• 1:20
  to
• 1:20
  the
• 1:20
  emergency
• 1:20
  room
• 1:21
  by
• 1:21
  his
• 1:21
  mom.
• 1:22
  Now,
• 1:22
  he's
• 1:23
  convinced
• 1:23
  that
• 1:23
  his
• 1:23
  neighbors
• 1:24
  have
• 1:24
  installed
• 1:24
  cameras
• 1:25
  in
• 1:25
  his
• 1:25
  apartment
• 1:26
  walls
• 1:26
  and
• 1:26
  are
• 1:27
  broadcasting
• 1:27
  his
• 1:28
  thoughts
• 1:28
  to
• 1:28
  the
• 1:28
  Internet.
• 1:29
  Join
• 1:29
  the
• 1:29
  club.
• 1:30
  Okay,
• 1:31
  well,
• 1:31
  he
• 1:31
  hears
• 1:32
  two
• 1:32
  male
• 1:32
  voices
• 1:33
  commenting
• 1:33
  on
• 1:34
  his
• 1:34
  actions
• 1:34
  throughout
• 1:35
  the
• 1:35
  day.
• 1:35
  He's
• 1:36
  guarded,
• 1:36
  he's
• 1:37
  pacing.
• 1:37
  He's
• 1:38
  intermittently
• 1:38
  talking
• 1:39
  to
• 1:39
  himself.
• 1:39
  Okay,
• 1:40
  now
• 1:40
  here's
• 1:40
  the
• 1:40
  key
• 1:41
  that
• 1:41
  you
• 1:41
  got
• 1:41
  to
• 1:41
  remember.
• 1:41
  And
• 1:41
  then
• 1:42
  we're
• 1:42
  going
• 1:42
  to
• 1:42
  go
• 1:42
  into
• 1:42
  this.
• 1:42
  Okay?
• 1:44
  So
• 1:44
  he
• 1:45
  has
• 1:45
  had
• 1:45
  auditory
• 1:46
  hallucinations
• 1:47
  since
• 1:47
  he's
• 1:47
  been
• 1:47
  about
• 1:48
  18
• 1:48
  years
• 1:48
  old.
• 1:49
  He's
• 1:49
  never
• 1:49
  been
• 1:49
  psychiatrically
• 1:50
  hospitalized,
• 1:51
  though
• 1:51
  he's
• 1:51
  never
• 1:51
  been
• 1:51
  in
• 1:51
  outpatient
• 1:52
  treatment.
• 1:53
  He's
• 1:53
  been
• 1:53
  a
• 1:53
  heavy
• 1:54
  daily
• 1:54
  cannabis
• 1:55
  user
• 1:55
  since
• 1:55
  age
• 1:56
  16.
• 1:56
  So
• 1:56
  that's
• 1:57
  two
• 1:57
  years
• 1:58
  prior
• 1:59
  to
• 1:59
  even
• 2:00
  experiencing
• 2:01
  those
• 2:02
  auditory
• 2:02
  hallucinations.
• 2:03
  He
• 2:03
  currently
• 2:04
  smokes
• 2:04
  high
• 2:04
  potency
• 2:05
  concentrates,
• 2:06
  also
• 2:06
  called
• 2:06
  dabs,
• 2:07
  kind
• 2:08
  of
• 2:08
  waxy
• 2:09
  cannabis
• 2:09
  products
• 2:10
  that
• 2:10
  have
• 2:10
  really
• 2:10
  high
• 2:11
  THC
• 2:11
  content.
• 2:11
  He
• 2:12
  does
• 2:12
  that
• 2:12
  multiple
• 2:13
  times
• 2:13
  per
• 2:13
  day.
• 2:14
  There's
• 2:14
  no
• 2:14
  other
• 2:14
  substance
• 2:15
  use
• 2:15
  here.
• 2:16
  Okay.
• 2:16
  And
• 2:17
  he's
• 2:17
  never
• 2:17
  had
• 2:17
  a
• 2:18
  sustained
• 2:18
  period
• 2:18
  of
• 2:19
  abstinence
• 2:19
  with
• 2:20
  respect
• 2:20
  to
• 2:20
  Cannabis
• 2:21
  since
• 2:21
  age
• 2:22
  16
• 2:22
  when
• 2:22
  he
• 2:22
  started.
• 2:23
  So
• 2:23
  that's
• 2:23
  pretty
• 2:23
  important,
• 2:23
  right?
• 2:24
  His
• 2:24
  dad
• 2:24
  has
• 2:25
  schizophrenia.
• 2:25
  His
• 2:26
  dad's
• 2:26
  on
• 2:26
  clozapine.
• 2:27
  This
• 2:28
  patient,
• 2:28
  Henry,
• 2:29
  he
• 2:29
  dropped
• 2:29
  out
• 2:29
  of
• 2:29
  community
• 2:30
  College
• 2:30
  at
• 2:30
  age
• 2:31
  19.
• 2:31
  He
• 2:31
  had
• 2:32
  bad
• 2:32
  Grades.
• 2:32
  He's
• 2:33
  kind
• 2:33
  of
• 2:33
  withdrawn
• 2:34
  socially.
• 2:35
  He
• 2:35
  lives
• 2:35
  with
• 2:35
  his
• 2:35
  mom,
• 2:36
  and
• 2:36
  he
• 2:36
  hasn't
• 2:36
  been
• 2:37
  working
• 2:37
  for
• 2:37
  two
• 2:37
  years
• 2:38
  either.
• 2:38
  No
• 2:38
  major
• 2:39
  medical
• 2:39
  history
• 2:39
  that
• 2:40
  you
• 2:40
  should
• 2:40
  be
• 2:40
  worried
• 2:40
  about.
• 2:41
  His
• 2:41
  affect's
• 2:42
  rather
• 2:42
  flat.
• 2:43
  He's
• 2:43
  pretty
• 2:43
  suspicious
• 2:44
  when
• 2:44
  you
• 2:45
  evaluate
• 2:46
  him,
• 2:46
  he's
• 2:47
  a
• 2:47
  little
• 2:47
  tangential.
• 2:48
  He
• 2:48
  has
• 2:48
  some
• 2:49
  persecutory
• 2:49
  delusions,
• 2:50
  too,
• 2:51
  that
• 2:51
  neighbors
• 2:51
  are
• 2:52
  monitoring
• 2:52
  him.
• 2:53
  We
• 2:53
  talked
• 2:54
  about
• 2:54
  the
• 2:54
  auditory
• 2:54
  hallucinations.
• 2:55
  His
• 2:55
  insight
• 2:56
  is
• 2:56
  not.
• 2:57
  Not
• 2:57
  really
• 2:57
  there.
• 2:58
  He
• 2:58
  doesn't
• 2:58
  feel
• 2:58
  like
• 2:59
  he's
• 2:59
  very
• 2:59
  ill,
• 2:59
  and
• 3:00
  his
• 3:00
  judgment's
• 3:00
  pretty
• 3:01
  impaired.
• 3:02
  So
• 3:03
  as
• 3:03
  I.
• 3:04
  As
• 3:04
  I
• 3:04
  said,
• 3:04
  right,
• 3:05
  we
• 3:05
  have
• 3:05
  two
• 3:06
  competing
• 3:07
  diagnoses
• 3:08
  here,
• 3:08
  as
• 3:08
  you
• 3:08
  can
• 3:09
  probably
• 3:09
  imagine.
• 3:09
  They
• 3:10
  probably
• 3:10
  jumped
• 3:10
  out
• 3:11
  at
• 3:11
  you
• 3:11
  already
• 3:13
  and
• 3:13
  for
• 3:14
  good
• 3:14
  reason,
• 3:14
  right?
• 3:15
  This
• 3:15
  is
• 3:16
  not
• 3:16
  a
• 3:16
  curveball,
• 3:16
  right?
• 3:17
  I'm
• 3:17
  not
• 3:17
  gonna,
• 3:18
  at
• 3:18
  the
• 3:18
  end
• 3:18
  of
• 3:18
  this,
• 3:18
  pretend
• 3:19
  that
• 3:19
  this
• 3:19
  was
• 3:19
  generalized
• 3:20
  anxiety
• 3:20
  the
• 3:21
  whole
• 3:21
  time
• 3:21
  or
• 3:22
  that
• 3:22
  he's
• 3:23
  been
• 3:23
  doing
• 3:23
  bath
• 3:23
  salts
• 3:24
  or
• 3:24
  he
• 3:24
  went
• 3:24
  on
• 3:24
  some
• 3:25
  surprise
• 3:25
  ayahuasca
• 3:26
  retreat.
• 3:27
  Okay?
• 3:27
  This
• 3:27
  is
• 3:28
  front
• 3:28
  and
• 3:28
  center.
• 3:29
  Either
• 3:30
  a
• 3:30
  cannabis
• 3:30
  induced
• 3:31
  psychotic
• 3:31
  disorder.
• 3:32
  That's
• 3:32
  CIPD
• 3:33
  for
• 3:33
  short.
• 3:34
  But
• 3:34
  I'll
• 3:34
  try
• 3:34
  to
• 3:35
  just
• 3:35
  say
• 3:35
  cannabis
• 3:36
  to
• 3:36
  keep
• 3:36
  it
• 3:36
  clear.
• 3:37
  So
• 3:38
  it's
• 3:38
  either
• 3:38
  a
• 3:38
  cannabis
• 3:39
  induced
• 3:39
  psychotic
• 3:40
  disorder
• 3:40
  or
• 3:40
  it's
• 3:40
  schizophrenia.
• 3:41
  Okay?
• 3:42
  It's
• 3:42
  one
• 3:42
  of
• 3:43
  those
• 3:43
  things,
• 3:44
  okay?
• 3:44
  And
• 3:44
  it
• 3:44
  could
• 3:45
  obviously
• 3:45
  be
• 3:45
  a
• 3:45
  schizophrenia
• 3:46
  with
• 3:47
  comorbid
• 3:47
  cannabis
• 3:48
  use
• 3:48
  disorder.
• 3:48
  But
• 3:49
  you
• 3:49
  get
• 3:49
  my
• 3:49
  point,
• 3:49
  right?
• 3:50
  So
• 3:50
  the
• 3:51
  problem
• 3:51
  with
• 3:51
  this
• 3:51
  kind
• 3:52
  of
• 3:52
  a
• 3:52
  case
• 3:52
  that
• 3:52
  you.
• 3:52
  You
• 3:53
  guys
• 3:53
  might
• 3:53
  experience
• 3:54
  in
• 3:54
  real
• 3:54
  life
• 3:55
  is
• 3:56
  there's
• 3:57
  no
• 3:57
  way
• 3:57
  to
• 3:57
  really
• 3:58
  know,
• 3:58
  right?
• 3:59
  You
• 3:59
  can
• 3:59
  get
• 3:59
  all
• 3:59
  the
• 4:00
  collateral
• 4:00
  you
• 4:00
  want.
• 4:00
  You
• 4:01
  can
• 4:01
  sit
• 4:01
  his
• 4:01
  mom
• 4:02
  down,
• 4:02
  let
• 4:03
  an
• 4:03
  FBI
• 4:03
  interrogator
• 4:04
  and
• 4:04
  ask
• 4:05
  her
• 4:05
  a
• 4:05
  thousand
• 4:05
  questions,
• 4:06
  and
• 4:06
  it
• 4:06
  still
• 4:07
  may
• 4:07
  not
• 4:07
  be
• 4:07
  clear
• 4:07
  what
• 4:08
  came
• 4:08
  first,
• 4:09
  his
• 4:09
  cannabis
• 4:09
  use
• 4:10
  or
• 4:11
  his
• 4:12
  schizophrenia,
• 4:13
  if
• 4:13
  he
• 4:13
  even
• 4:14
  has
• 4:14
  schizophrenia
• 4:15
  or.
• 4:16
  Okay,
• 4:16
  his
• 4:16
  cannabis
• 4:17
  use
• 4:17
  came
• 4:17
  first
• 4:18
  here
• 4:18
  when
• 4:18
  he
• 4:19
  was
• 4:19
  16.
• 4:19
  He
• 4:19
  had
• 4:19
  hallucinations
• 4:20
  at
• 4:20
  18.
• 4:21
  But
• 4:21
  is
• 4:22
  that
• 4:22
  because
• 4:23
  of
• 4:23
  the
• 4:23
  cannabis?
• 4:24
  Is
• 4:24
  it
• 4:25
  exclusively
• 4:26
  because
• 4:26
  of
• 4:26
  the
• 4:26
  cannabis
• 4:27
  and
• 4:27
  nothing
• 4:27
  else?
• 4:28
  Or
• 4:28
  was
• 4:28
  it
• 4:28
  his
• 4:29
  genetic
• 4:29
  predisposition
• 4:30
  because
• 4:30
  of
• 4:30
  his
• 4:30
  dad
• 4:31
  having
• 4:31
  schizophrenia,
• 4:32
  or
• 4:32
  was
• 4:32
  it
• 4:32
  both?
• 4:33
  And
• 4:33
  if
• 4:33
  it's
• 4:34
  both,
• 4:34
  what
• 4:34
  degree
• 4:35
  of
• 4:35
  both
• 4:35
  is
• 4:36
  it?
• 4:36
  Is
• 4:36
  it
• 4:36
  to
• 4:37
  a
• 4:37
  degree
• 4:37
  where
• 4:37
  if
• 4:38
  he
• 4:38
  was
• 4:38
  abstinent
• 4:39
  from
• 4:39
  cannabis
• 4:39
  for
• 4:39
  30
• 4:40
  days,
• 4:40
  he
• 4:40
  would
• 4:41
  still
• 4:41
  be
• 4:41
  psychotic
• 4:42
  or
• 4:42
  would
• 4:42
  he
• 4:42
  not
• 4:42
  be
• 4:43
  psychotic?
• 4:43
  Right?
• 4:44
  And
• 4:44
  so
• 4:44
  here
• 4:44
  you
• 4:45
  are
• 4:45
  going,
• 4:45
  wait
• 4:45
  a
• 4:45
  minute,
• 4:46
  I
• 4:46
  can't
• 4:46
  really
• 4:47
  diagnose
• 4:48
  schizophrenia
• 4:48
  here
• 4:49
  because
• 4:50
  he
• 4:50
  has
• 4:50
  never
• 4:51
  had
• 4:51
  a
• 4:51
  30
• 4:52
  day
• 4:52
  period
• 4:53
  in
• 4:53
  the
• 4:53
  absence
• 4:54
  of
• 4:54
  cannabis.
• 4:55
  And
• 4:55
  it
• 4:55
  clearly
• 4:56
  states
• 4:56
  in
• 4:56
  the
• 4:56
  DSM
• 4:57
  that
• 4:58
  if
• 4:58
  cannabis
• 4:59
  or
• 4:59
  a
• 4:59
  substance
• 5:00
  that
• 5:00
  is
• 5:00
  capable
• 5:00
  of
• 5:01
  producing
• 5:01
  psychosis
• 5:02
  is
• 5:02
  on
• 5:02
  board,
• 5:03
  you
• 5:04
  cannot
• 5:04
  necessarily
• 5:05
  attribute
• 5:06
  it
• 5:06
  to
• 5:06
  a
• 5:07
  primary
• 5:07
  psychotic
• 5:08
  disorder.
• 5:09
  Right?
• 5:11
  That's
• 5:11
  extremely
• 5:12
  important.
• 5:13
  So
• 5:15
  we
• 5:15
  have
• 5:15
  to.
• 5:15
  We
• 5:16
  have
• 5:16
  to
• 5:16
  read
• 5:16
  These
• 5:16
  criteria
• 5:17
  and
• 5:17
  understand
• 5:18
  them.
• 5:18
  And
• 5:19
  we
• 5:19
  can't
• 5:19
  really
• 5:20
  slap
• 5:20
  a
• 5:20
  label
• 5:21
  on
• 5:21
  him
• 5:21
  that
• 5:21
  he's
• 5:21
  schizophrenic
• 5:22
  just
• 5:22
  yet.
• 5:23
  But
• 5:23
  another
• 5:24
  problem
• 5:24
  is
• 5:24
  we
• 5:25
  might
• 5:25
  not
• 5:25
  be
• 5:25
  able
• 5:26
  to
• 5:26
  get
• 5:26
  him
• 5:26
  to
• 5:26
  be
• 5:27
  abstinent
• 5:27
  for
• 5:28
  30
• 5:28
  days
• 5:28
  to
• 5:28
  figure
• 5:29
  this
• 5:29
  out.
• 5:29
  You're
• 5:30
  in
• 5:30
  an
• 5:30
  ER.
• 5:30
  What
• 5:31
  are
• 5:31
  you
• 5:31
  going
• 5:31
  to
• 5:31
  do?
• 5:31
  Oh,
• 5:31
  come
• 5:31
  back
• 5:32
  in
• 5:32
  30
• 5:32
  days,
• 5:32
  and
• 5:33
  if
• 5:33
  you're
• 5:33
  still
• 5:34
  feeling
• 5:34
  as
• 5:34
  though
• 5:35
  your
• 5:35
  neighbors
• 5:35
  are
• 5:36
  trying
• 5:36
  to
• 5:36
  slice
• 5:36
  your
• 5:36
  head
• 5:37
  off,
• 5:37
  then
• 5:37
  come
• 5:38
  back
• 5:38
  and
• 5:38
  see
• 5:38
  me.
• 5:38
  Right.
• 5:39
  That's
• 5:39
  extremely
• 5:41
  unreasonable.
• 5:42
  It's
• 5:42
  just
• 5:42
  not
• 5:42
  going
• 5:42
  to
• 5:43
  happen.
• 5:43
  And
• 5:43
  in
• 5:43
  my
• 5:43
  experience,
• 5:44
  patients
• 5:44
  don't
• 5:45
  just
• 5:46
  voluntarily
• 5:48
  try
• 5:48
  to
• 5:48
  be
• 5:49
  abstinent
• 5:49
  to
• 5:50
  help
• 5:50
  you
• 5:50
  out
• 5:50
  in
• 5:50
  the
• 5:51
  case
• 5:51
  either.
• 6:46
  Uh,
• 6:46
  they
• 6:47
  oftentimes
• 6:48
  even
• 6:48
  think
• 6:48
  cannabis
• 6:49
  is
• 6:50
  medicinal.
• 6:50
  They
• 6:51
  feel
• 6:51
  it
• 6:51
  calms
• 6:51
  them
• 6:51
  down.
• 6:52
  Sometimes
• 6:52
  they'll
• 6:52
  tell
• 6:52
  you
• 6:53
  it's
• 6:53
  the
• 6:53
  only
• 6:53
  thing
• 6:53
  that's
• 6:54
  worked.
• 6:54
  Right.
• 6:54
  They've
• 6:55
  been
• 6:55
  on
• 6:55
  a
• 6:55
  hundred
• 6:55
  other
• 6:55
  meds
• 6:56
  that
• 6:56
  have
• 6:56
  never
• 6:56
  helped
• 6:57
  them.
• 6:57
  They've
• 6:57
  caused
• 6:57
  sexual
• 6:58
  dysfunction,
• 6:59
  they've
• 6:59
  caused
• 7:00
  motor
• 7:00
  problems,
• 7:01
  and
• 7:01
  so
• 7:01
  they.
• 7:01
  The
• 7:02
  only
• 7:02
  thing
• 7:02
  that
• 7:02
  they
• 7:02
  think
• 7:03
  does
• 7:03
  work
• 7:03
  is
• 7:04
  cannabis,
• 7:04
  even
• 7:04
  if
• 7:04
  you
• 7:05
  are
• 7:05
  convinced
• 7:05
  it
• 7:06
  doesn't
• 7:06
  and
• 7:06
  it's
• 7:06
  worsening
• 7:07
  this
• 7:07
  psychosis.
• 7:09
  Okay,
• 7:10
  so
• 7:11
  that's
• 7:11
  very
• 7:12
  important.
• 7:12
  Right.
• 7:12
  But
• 7:13
  we
• 7:13
  have
• 7:13
  to
• 7:13
  stay
• 7:14
  faithful
• 7:14
  to
• 7:15
  criterion
• 7:16
  E
• 7:16
  in
• 7:16
  schizophrenia.
• 7:17
  That
• 7:17
  says
• 7:18
  it
• 7:19
  warns
• 7:19
  you
• 7:19
  to
• 7:20
  not
• 7:20
  make
• 7:20
  the
• 7:20
  diagnosis
• 7:21
  if
• 7:21
  the
• 7:21
  disturbance
• 7:22
  is
• 7:24
  attributable
• 7:25
  to
• 7:26
  the
• 7:26
  physiological
• 7:27
  effects
• 7:27
  of
• 7:27
  a
• 7:28
  substance.
• 7:28
  Okay.
• 7:29
  And
• 7:29
  so
• 7:30
  it.
• 7:30
  Cannabis
• 7:31
  is
• 7:31
  absolutely
• 7:32
  something
• 7:32
  that
• 7:33
  could
• 7:33
  contribute
• 7:34
  to
• 7:35
  psychosis,
• 7:36
  bring
• 7:36
  out
• 7:36
  dormant
• 7:37
  psychosis,
• 7:38
  worsen
• 7:38
  a
• 7:38
  psychosis.
• 7:39
  Absolutely.
• 7:40
  Right.
• 7:40
  Very,
• 7:41
  very
• 7:42
  important.
• 7:43
  Okay.
• 7:43
  We
• 7:44
  also
• 7:44
  can't
• 7:45
  really
• 7:45
  nail
• 7:46
  down
• 7:46
  a
• 7:46
  cannabis
• 7:47
  use
• 7:48
  disorder,
• 7:49
  because
• 7:51
  in
• 7:51
  criterion
• 7:52
  C
• 7:53
  of
• 7:53
  cannabis
• 7:54
  induced
• 7:54
  psychotic
• 7:55
  disorder,
• 7:55
  criterion
• 7:57
  it
• 7:57
  says
• 7:57
  the
• 7:57
  disturbance
• 7:58
  is
• 7:58
  not
• 7:58
  better
• 7:58
  explained
• 7:59
  by
• 7:59
  an
• 7:59
  independent
• 8:00
  psychotic
• 8:00
  disorder.
• 8:01
  Okay,
• 8:03
  so
• 8:04
  we're
• 8:04
  kind
• 8:04
  of
• 8:05
  in
• 8:05
  a
• 8:05
  bind
• 8:05
  here.
• 8:06
  Okay,
• 8:07
  We're
• 8:07
  a
• 8:07
  little
• 8:08
  bit
• 8:08
  in
• 8:08
  a
• 8:08
  bind
• 8:08
  now.
• 8:08
  It's
• 8:09
  pretty
• 8:09
  clear,
• 8:09
  though,
• 8:09
  at
• 8:10
  least
• 8:10
  we
• 8:10
  have
• 8:10
  the
• 8:10
  fact
• 8:11
  that
• 8:11
  he
• 8:11
  started
• 8:11
  cannabis
• 8:12
  first.
• 8:13
  So
• 8:13
  in
• 8:13
  this
• 8:13
  case,
• 8:14
  I
• 8:14
  might
• 8:14
  say,
• 8:15
  all
• 8:15
  right,
• 8:16
  we
• 8:16
  probably
• 8:17
  have
• 8:17
  a
• 8:17
  cannabis
• 8:18
  use
• 8:18
  disorder
• 8:18
  here
• 8:18
  that's
• 8:19
  chronic.
• 8:20
  But
• 8:21
  my
• 8:21
  bigger
• 8:21
  question
• 8:22
  is,
• 8:22
  do
• 8:23
  we
• 8:23
  just
• 8:23
  dismiss
• 8:24
  this
• 8:24
  schizophrenia
• 8:25
  as
• 8:25
  a
• 8:25
  cannabis
• 8:26
  problem,
• 8:26
  or
• 8:26
  is
• 8:27
  this
• 8:27
  legitimate
• 8:28
  comorbid
• 8:28
  schizophrenia
• 8:29
  and
• 8:30
  we
• 8:30
  have
• 8:30
  to
• 8:30
  get
• 8:30
  to
• 8:30
  the
• 8:30
  bottom
• 8:31
  of
• 8:31
  it?
• 8:31
  The
• 8:32
  good
• 8:32
  news,
• 8:32
  my
• 8:32
  friends,
• 8:33
  is
• 8:34
  no
• 8:34
  matter
• 8:34
  what,
• 8:35
  you
• 8:35
  need
• 8:35
  to
• 8:36
  zoom
• 8:36
  out
• 8:36
  and
• 8:36
  just
• 8:37
  think
• 8:37
  of
• 8:37
  this
• 8:38
  very
• 8:38
  simply.
• 8:38
  And
• 8:39
  you
• 8:39
  just
• 8:39
  have
• 8:39
  to
• 8:39
  treat
• 8:40
  his
• 8:40
  psychosis.
• 8:41
  Right.
• 8:42
  Whether
• 8:42
  or
• 8:42
  not
• 8:42
  this
• 8:43
  came
• 8:43
  from
• 8:43
  cannabis
• 8:44
  or
• 8:45
  his
• 8:46
  father's
• 8:46
  psychosis
• 8:47
  or
• 8:50
  a
• 8:50
  bad
• 8:50
  bag
• 8:51
  of
• 8:51
  pop
• 8:51
  tarts,
• 8:51
  you
• 8:52
  have
• 8:52
  to
• 8:53
  treat
• 8:54
  his
• 8:54
  psychosis.
• 8:55
  It's
• 8:55
  an
• 8:55
  emergency.
• 8:56
  He's
• 8:56
  losing
• 8:56
  touch
• 8:56
  with
• 8:57
  reality.
• 8:57
  He
• 8:57
  doesn't
• 8:57
  have
• 8:57
  a
• 8:58
  lot
• 8:58
  of
• 8:58
  insight.
• 8:59
  Lord
• 8:59
  knows
• 8:59
  he
• 9:00
  could
• 9:00
  lash
• 9:00
  out
• 9:00
  at
• 9:00
  the
• 9:01
  neighbors
• 9:01
  he
• 9:01
  thinks
• 9:01
  are
• 9:02
  trying
• 9:02
  to
• 9:02
  hurt
• 9:02
  him.
• 9:03
  And
• 9:04
  he's
• 9:04
  so
• 9:04
  disorganized,
• 9:05
  he
• 9:05
  may
• 9:05
  not
• 9:05
  be
• 9:06
  able
• 9:06
  to
• 9:06
  put
• 9:06
  his
• 9:06
  pants
• 9:06
  on,
• 9:07
  let
• 9:07
  alone
• 9:08
  get
• 9:08
  a
• 9:08
  job
• 9:08
  or
• 9:08
  find
• 9:09
  a
• 9:09
  partner
• 9:10
  for
• 9:10
  the
• 9:10
  rest
• 9:10
  of
• 9:10
  his
• 9:10
  life.
• 9:11
  We've
• 9:11
  got
• 9:11
  to
• 9:11
  help
• 9:12
  this
• 9:12
  guy,
• 9:12
  period.
• 9:13
  Non
• 9:13
  negotiable.
• 9:14
  And
• 9:14
  it's
• 9:14
  a
• 9:14
  bonus
• 9:15
  point
• 9:16
  if
• 9:16
  we
• 9:17
  can
• 9:17
  get
• 9:17
  him
• 9:17
  to
• 9:17
  abstain
• 9:18
  from
• 9:18
  cannabis
• 9:18
  to
• 9:18
  achieve
• 9:19
  diagnostic
• 9:19
  clarity.
• 9:20
  But
• 9:20
  we
• 9:21
  may
• 9:21
  not
• 9:21
  be
• 9:22
  able
• 9:22
  to
• 9:22
  do
• 9:22
  that
• 9:22
  at
• 9:22
  all.
• 9:23
  So
• 9:23
  in
• 9:24
  my
• 9:24
  case,
• 9:25
  if
• 9:25
  this
• 9:25
  was
• 9:25
  me,
• 9:26
  I
• 9:26
  would
• 9:27
  definitely
• 9:27
  be
• 9:29
  gunning
• 9:30
  for
• 9:30
  a
• 9:30
  second
• 9:31
  generation
• 9:31
  antipsychotic
• 9:32
  to
• 9:33
  help
• 9:33
  him
• 9:33
  out
• 9:33
  here
• 9:35
  for
• 9:35
  the
• 9:35
  acute
• 9:35
  management.
• 9:36
  We
• 9:36
  might
• 9:36
  even
• 9:37
  start
• 9:37
  him
• 9:37
  on
• 9:37
  a
• 9:37
  benzodiazepine
• 9:38
  like
• 9:39
  Ativan
• 9:39
  if
• 9:40
  he's
• 9:40
  severely
• 9:40
  agitated
• 9:41
  or
• 9:41
  anxious.
• 9:42
  But
• 9:43
  we
• 9:43
  need
• 9:44
  to
• 9:44
  prioritize
• 9:45
  acute
• 9:46
  antipsychotic
• 9:46
  treatment.
• 9:47
  This
• 9:47
  is
• 9:47
  not
• 9:48
  the
• 9:48
  kind
• 9:48
  of
• 9:48
  thing
• 9:48
  that's
• 9:49
  just
• 9:49
  going
• 9:49
  to
• 9:49
  go
• 9:49
  away
• 9:49
  with
• 9:51
  some
• 9:51
  good
• 9:51
  old
• 9:51
  motivational
• 9:52
  interviewing,
• 9:52
  although
• 9:53
  I
• 9:53
  think
• 9:53
  we
• 9:53
  need
• 9:53
  that
• 9:54
  to
• 9:54
  try
• 9:54
  and
• 9:55
  get
• 9:55
  him
• 9:55
  to
• 9:55
  understand
• 9:56
  that
• 9:56
  cannabis
• 9:57
  is
• 9:57
  not
• 9:57
  serving
• 9:58
  his
• 9:58
  needs
• 9:58
  at
• 9:59
  all.
• 9:59
  Because
• 9:59
  it
• 9:59
  is
• 9:59
  certainly
• 10:00
  worsening
• 10:00
  things.
• 10:01
  Those
• 10:01
  high
• 10:02
  THC
• 10:03
  potency
• 10:04
  products
• 10:04
  are
• 10:05
  a
• 10:06
  huge
• 10:06
  problem.
• 10:07
  They're,
• 10:07
  they're,
• 10:07
  they're
• 10:08
  disrupting
• 10:08
  his
• 10:08
  brain
• 10:09
  signaling.
• 10:10
  They
• 10:10
  are
• 10:12
  worsening
• 10:12
  his
• 10:12
  psychosis.
• 10:13
  There's
• 10:14
  absolutely
• 10:14
  no
• 10:14
  doubt
• 10:15
  about
• 10:15
  that.
• 10:15
  But
• 10:16
  I
• 10:16
  would
• 10:16
  be
• 10:16
  reaching
• 10:17
  for
• 10:17
  a
• 10:17
  second
• 10:18
  generation
• 10:18
  antipsychotic.
• 10:19
  Um,
• 10:20
  we
• 10:20
  can
• 10:20
  talk
• 10:20
  about
• 10:20
  Abilify
• 10:21
  in
• 10:21
  particular.
• 10:22
  There's
• 10:22
  a
• 10:22
  lot
• 10:22
  of
• 10:22
  good
• 10:23
  evidence
• 10:23
  for
• 10:23
  Abilify
• 10:24
  in
• 10:24
  this
• 10:24
  case,
• 10:25
  which
• 10:25
  would
• 10:25
  be
• 10:26
  good.
• 10:26
  You
• 10:26
  wouldn't
• 10:26
  be
• 10:26
  that
• 10:27
  wrong
• 10:27
  if
• 10:27
  you
• 10:27
  wanted
• 10:28
  to
• 10:28
  find
• 10:28
  a
• 10:29
  very
• 10:30
  heavy
• 10:31
  duty
• 10:31
  D2
• 10:31
  blocker
• 10:32
  like
• 10:32
  Risperidol
• 10:33
  or
• 10:33
  Zyprexa
• 10:33
  here.
• 10:33
  That
• 10:34
  would
• 10:34
  not
• 10:34
  be
• 10:34
  wrong
• 10:35
  at
• 10:36
  all.
• 10:37
  Now
• 10:37
  you
• 10:37
  would
• 10:37
  be
• 10:38
  probably
• 10:38
  manipulating
• 10:39
  his
• 10:39
  reward
• 10:39
  pathway
• 10:40
  a
• 10:40
  bit.
• 10:40
  You're
• 10:40
  kind
• 10:41
  of
• 10:41
  blocking
• 10:41
  it.
• 10:42
  You're
• 10:42
  shackling
• 10:42
  it
• 10:43
  very
• 10:43
  rigidly
• 10:44
  with
• 10:44
  his
• 10:44
  Zyprexa
• 10:45
  or
• 10:45
  Risperidol.
• 10:46
  It
• 10:46
  would
• 10:46
  definitely
• 10:47
  help
• 10:48
  attenuate
• 10:48
  his
• 10:49
  psychosis,
• 10:49
  though
• 10:50
  pretty
• 10:50
  quickly.
• 10:51
  There'd
• 10:51
  be
• 10:51
  a
• 10:52
  lot
• 10:52
  of
• 10:52
  metabolic
• 10:52
  problems,
• 10:53
  potentially.
• 10:53
  You
• 10:53
  gotta
• 10:54
  watch
• 10:54
  out
• 10:54
  for
• 10:54
  that.
• 10:54
  But
• 10:54
  it
• 10:55
  would
• 10:56
  really
• 10:57
  dampen
• 10:58
  that
• 10:58
  reward
• 10:58
  pathway,
• 10:59
  which
• 10:59
  may
• 10:59
  drive
• 11:00
  his
• 11:00
  cravings
• 11:00
  even
• 11:01
  more
• 11:01
  intensely.
• 11:02
  And
• 11:03
  so
• 11:03
  that's
• 11:03
  why
• 11:03
  I
• 11:04
  would
• 11:04
  probably
• 11:04
  gravitate
• 11:05
  towards
• 11:05
  Abilify,
• 11:06
  because
• 11:06
  there
• 11:06
  is
• 11:06
  some
• 11:07
  evidence
• 11:07
  that
• 11:07
  not
• 11:07
  only
• 11:07
  can
• 11:08
  it
• 11:08
  treat
• 11:08
  psychosis,
• 11:09
  but
• 11:09
  it
• 11:09
  can
• 11:09
  reduce
• 11:10
  his
• 11:10
  cannabis
• 11:10
  cravings
• 11:11
  too,
• 11:12
  which
• 11:12
  is
• 11:13
  kind
• 11:13
  of
• 11:13
  a
• 11:13
  two
• 11:13
  for
• 11:13
  one,
• 11:14
  right?
• 11:14
  Because
• 11:15
  if
• 11:15
  he,
• 11:15
  if
• 11:15
  you
• 11:16
  treat
• 11:16
  his
• 11:16
  psychosis,
• 11:17
  you're
• 11:17
  reducing
• 11:17
  his
• 11:18
  cannabis
• 11:18
  cravings.
• 11:19
  He
• 11:19
  starts
• 11:19
  to
• 11:19
  gain
• 11:20
  some
• 11:20
  insight
• 11:20
  when
• 11:20
  the
• 11:21
  psychosis
• 11:22
  weans
• 11:22
  down
• 11:23
  that
• 11:24
  he
• 11:24
  has
• 11:25
  that
• 11:25
  cannabis
• 11:25
  isn't
• 11:26
  serving.
• 11:26
  And
• 11:26
  maybe
• 11:26
  he
• 11:26
  can
• 11:27
  reduce
• 11:27
  enough
• 11:27
  of
• 11:27
  his
• 11:27
  cannabis
• 11:28
  use.
• 11:29
  Hopefully,
• 11:29
  he
• 11:29
  can
• 11:29
  even
• 11:29
  become
• 11:30
  abstinent
• 11:30
  for
• 11:31
  30
• 11:31
  days,
• 11:31
  and
• 11:31
  you
• 11:32
  can
• 11:32
  have
• 11:32
  an
• 11:32
  understanding
• 11:33
  of
• 11:33
  where
• 11:33
  he's
• 11:34
  at.
• 11:34
  And
• 11:34
  six
• 11:35
  to
• 11:35
  12
• 11:35
  months
• 11:35
  later,
• 11:36
  you
• 11:36
  treat
• 11:36
  him
• 11:36
  with
• 11:37
  the
• 11:37
  Abilify
• 11:38
  until
• 11:38
  the
• 11:38
  psycho
• 11:39
  psychosis
• 11:39
  is
• 11:39
  completely
• 11:40
  gone.
• 11:40
  And
• 11:40
  then
• 11:40
  maybe
• 11:41
  at
• 11:41
  that
• 11:41
  point,
• 11:41
  you
• 11:42
  can
• 11:42
  tease
• 11:42
  out
• 11:43
  whether
• 11:43
  or
• 11:43
  not
• 11:44
  he
• 11:45
  is
• 11:45
  psychotic.
• 11:46
  In
• 11:46
  the
• 11:46
  absence
• 11:47
  of
• 11:48
  cannabis,
• 11:49
  in
• 11:49
  the
• 11:49
  absence
• 11:49
  of
• 11:49
  Abilify,
• 11:50
  of
• 11:50
  course,
• 11:50
  that
• 11:50
  has
• 11:50
  to
• 11:51
  be
• 11:51
  done
• 11:51
  very,
• 11:52
  very
• 11:52
  gingerly.
• 11:53
  Very
• 11:53
  cautiously.
• 11:55
  You
• 11:56
  know,
• 11:56
  you.
• 11:56
  You.
• 11:56
  When
• 11:57
  you
• 11:57
  block
• 11:57
  dopamine
• 11:58
  for
• 11:58
  prolonged
• 11:58
  periods
• 11:59
  of
• 11:59
  time,
• 12:00
  those
• 12:00
  dopamine
• 12:00
  receptors
• 12:01
  get
• 12:01
  very
• 12:01
  super
• 12:02
  sensitive.
• 12:02
  So
• 12:02
  you
• 12:02
  have
• 12:03
  to
• 12:03
  do
• 12:03
  very
• 12:03
  cautious
• 12:04
  taper,
• 12:05
  because
• 12:05
  you
• 12:05
  don't
• 12:06
  want
• 12:06
  rebound
• 12:06
  psychosis.
• 12:07
  You
• 12:07
  want
• 12:08
  diagnostic
• 12:08
  clarity
• 12:09
  here.
• 12:09
  And
• 12:10
  this
• 12:10
  is
• 12:10
  a
• 12:11
  classic
• 12:11
  case
• 12:12
  in
• 12:12
  psychiatry
• 12:13
  where
• 12:14
  you
• 12:14
  get
• 12:14
  really
• 12:14
  muddy
• 12:15
  really
• 12:15
  quickly.
• 12:16
  Cannabis
• 12:16
  is
• 12:16
  the
• 12:17
  ultimate
• 12:17
  mud
• 12:18
  in
• 12:18
  psychiatry.
• 12:19
  That's
• 12:19
  how
• 12:19
  I
• 12:20
  describe
• 12:20
  it.
• 12:20
  It's
• 12:20
  mud.
• 12:21
  It
• 12:21
  makes
• 12:21
  it
• 12:22
  hard
• 12:22
  to
• 12:22
  determine
• 12:23
  what
• 12:23
  anything
• 12:23
  looks
• 12:24
  like
• 12:24
  at
• 12:24
  all,
• 12:25
  right?
• 12:25
  Anxiety,
• 12:26
  depression,
• 12:27
  motivation,
• 12:27
  executive
• 12:28
  dysfunction,
• 12:29
  ADHD
• 12:30
  psychosis.
• 12:31
  Cannabis
• 12:31
  is
• 12:32
  the
• 12:32
  ultimate
• 12:32
  mud.
• 12:33
  It
• 12:33
  just
• 12:33
  makes
• 12:34
  it
• 12:34
  hard
• 12:34
  for
• 12:34
  you
• 12:35
  to
• 12:35
  understand
• 12:35
  anything
• 12:36
  diagnostically.
• 12:37
  And
• 12:37
  so
• 12:37
  it's
• 12:37
  hard
• 12:37
  to
• 12:38
  proceed
• 12:38
  because,
• 12:40
  you
• 12:40
  know,
• 12:40
  you
• 12:40
  don't
• 12:40
  want
• 12:40
  to
• 12:41
  mask
• 12:41
  something,
• 12:41
  cover
• 12:42
  it
• 12:42
  up,
• 12:42
  make
• 12:42
  it
• 12:43
  worse,
• 12:43
  make
• 12:43
  it
• 12:43
  less
• 12:44
  clear.
• 12:45
  And
• 12:45
  so,
• 12:46
  absolutely,
• 12:47
  it
• 12:47
  is
• 12:47
  the
• 12:47
  bane
• 12:48
  of
• 12:48
  my
• 12:48
  existence.
• 12:49
  I'm
• 12:49
  not
• 12:49
  saying
• 12:50
  that
• 12:50
  cocaine
• 12:51
  is
• 12:51
  a
• 12:51
  vegetable
• 12:52
  or
• 12:52
  alcohol
• 12:53
  is
• 12:53
  a
• 12:53
  picnic
• 12:53
  either.
• 12:53
  Those
• 12:54
  are
• 12:54
  very
• 12:54
  deadly,
• 12:54
  very
• 12:55
  destructive
• 12:55
  drugs.
• 12:56
  Um,
• 12:57
  but
• 12:57
  I
• 12:57
  find
• 12:57
  that
• 12:57
  they're
• 12:58
  almost
• 12:58
  so
• 12:58
  deadly
• 12:59
  and
• 12:59
  destructive
• 12:59
  that
• 12:59
  patients
• 13:00
  have
• 13:00
  a
• 13:00
  clear
• 13:00
  understanding
• 13:01
  of
• 13:01
  them
• 13:02
  and
• 13:02
  will
• 13:02
  abstain
• 13:03
  from
• 13:03
  them
• 13:03
  when
• 13:03
  they
• 13:03
  get
• 13:04
  too
• 13:04
  problematic.
• 13:05
  But
• 13:05
  cannabis
• 13:06
  is.
• 13:06
  Has
• 13:06
  this,
• 13:06
  like,
• 13:07
  societal
• 13:07
  stigma
• 13:08
  to
• 13:08
  it
• 13:09
  nowadays,
• 13:09
  where
• 13:10
  it's
• 13:10
  decriminalized,
• 13:11
  and
• 13:11
  people
• 13:12
  treat
• 13:12
  it
• 13:13
  like
• 13:13
  it's
• 13:14
  like
• 13:15
  a.
• 13:15
  Like
• 13:15
  it's
• 13:16
  like
• 13:16
  it's
• 13:16
  broccoli
• 13:17
  and
• 13:17
  it's
• 13:18
  not.
• 13:18
  It's
• 13:18
  really
• 13:19
  not.
• 13:20
  And
• 13:20
  so
• 13:21
  it's
• 13:21
  very
• 13:21
  problematic.
• 13:22
  Now,
• 13:24
  a
• 13:24
  couple
• 13:24
  things
• 13:24
  I
• 13:24
  want
• 13:24
  to
• 13:25
  talk
• 13:25
  about
• 13:25
  here,
• 13:25
  my
• 13:25
  friends.
• 13:26
  We.
• 13:27
  We
• 13:27
  touched
• 13:27
  on
• 13:27
  Abilify,
• 13:28
  how
• 13:28
  it
• 13:28
  might
• 13:28
  be
• 13:28
  ideal
• 13:29
  in
• 13:29
  this
• 13:29
  case,
• 13:29
  again,
• 13:30
  because,
• 13:31
  number
• 13:31
  one,
• 13:31
  again,
• 13:32
  it's
• 13:32
  kind
• 13:32
  of
• 13:32
  a
• 13:32
  dimmer
• 13:33
  switch
• 13:33
  with
• 13:33
  dopamine.
• 13:34
  We've
• 13:34
  gone
• 13:34
  over
• 13:34
  this
• 13:34
  in
• 13:35
  previous
• 13:35
  episodes,
• 13:35
  right?
• 13:36
  But
• 13:36
  it
• 13:37
  will.
• 13:38
  It
• 13:38
  will
• 13:39
  reduce
• 13:40
  the
• 13:40
  amount
• 13:40
  of
• 13:41
  dopamine
• 13:42
  activity
• 13:42
  where
• 13:42
  it
• 13:43
  is
• 13:43
  too
• 13:43
  heightened
• 13:44
  in
• 13:44
  the
• 13:44
  mesolimbic
• 13:45
  areas
• 13:45
  where
• 13:45
  the
• 13:46
  patient
• 13:46
  is
• 13:46
  hallucinating.
• 13:47
  Right?
• 13:48
  So
• 13:48
  we
• 13:48
  can
• 13:48
  kind
• 13:48
  of
• 13:49
  stabilize
• 13:49
  dopamine
• 13:50
  there.
• 13:50
  We
• 13:50
  can
• 13:50
  drive
• 13:51
  down
• 13:51
  the
• 13:51
  psychotic
• 13:52
  signal
• 13:52
  a
• 13:52
  little
• 13:52
  bit,
• 13:53
  and
• 13:54
  we
• 13:54
  can
• 13:54
  also
• 13:55
  drive
• 13:55
  down
• 13:55
  cravings
• 13:56
  in
• 13:56
  that
• 13:57
  hyper
• 13:57
  dopaminergic
• 13:58
  state.
• 13:59
  Right,
• 13:59
  because
• 13:59
  we're
• 13:59
  lowering
• 14:00
  that
• 14:00
  dopamine
• 14:00
  tone
• 14:01
  that
• 14:01
  actually
• 14:01
  reduces
• 14:02
  cravings
• 14:02
  a
• 14:02
  little
• 14:02
  bit.
• 14:03
  Okay.
• 14:04
  Dials
• 14:04
  down
• 14:04
  the
• 14:05
  dopamine
• 14:05
  Signaling,
• 14:06
  and
• 14:06
  then
• 14:06
  we
• 14:06
  can
• 14:06
  also
• 14:07
  increase
• 14:07
  the
• 14:07
  dopamine
• 14:08
  signaling
• 14:08
  in
• 14:09
  areas
• 14:09
  where
• 14:10
  the
• 14:10
  patient
• 14:11
  could
• 14:11
  use
• 14:11
  a
• 14:12
  little
• 14:12
  more
• 14:12
  motivation
• 14:13
  and
• 14:13
  executive
• 14:13
  functioning,
• 14:14
  which
• 14:14
  could
• 14:14
  really
• 14:14
  help.
• 14:15
  Okay,
• 14:17
  and
• 14:18
  so
• 14:18
  it's.
• 14:19
  You
• 14:19
  get
• 14:19
  kind
• 14:19
  of
• 14:19
  a
• 14:19
  two
• 14:20
  for
• 14:20
  one.
• 14:20
  There's
• 14:21
  even
• 14:21
  better
• 14:21
  if
• 14:21
  you
• 14:21
  can
• 14:22
  get
• 14:22
  the
• 14:22
  patient
• 14:22
  transition
• 14:23
  onto
• 14:23
  a
• 14:23
  long
• 14:23
  acting
• 14:24
  injectable
• 14:24
  Abilify.
• 14:25
  There
• 14:25
  is
• 14:25
  an
• 14:25
  LAI
• 14:26
  for
• 14:26
  Abilify,
• 14:27
  and
• 14:27
  that
• 14:28
  might
• 14:28
  be
• 14:28
  very
• 14:29
  beneficial
• 14:29
  because
• 14:30
  we
• 14:30
  know
• 14:30
  in
• 14:30
  cannabis
• 14:31
  in
• 14:31
  particular,
• 14:32
  adherence
• 14:33
  to
• 14:33
  antipsychotics
• 14:34
  drops.
• 14:34
  It's
• 14:34
  a
• 14:35
  very
• 14:35
  big
• 14:35
  problem
• 14:36
  with
• 14:37
  adherence.
• 14:37
  So
• 14:38
  getting
• 14:38
  your
• 14:38
  patient
• 14:38
  onto
• 14:38
  an
• 14:38
  LAI
• 14:39
  might
• 14:39
  be
• 14:40
  a
• 14:40
  very
• 14:40
  good
• 14:41
  idea.
• 14:43
  It's.
• 14:43
  It's
• 14:44
  pretty
• 14:44
  intuitive.
• 14:44
  But
• 14:44
  you
• 14:45
  should
• 14:45
  know
• 14:45
  cannabis
• 14:47
  use
• 14:48
  impairs
• 14:48
  executive
• 14:49
  functioning.
• 14:49
  People
• 14:49
  have
• 14:50
  a
• 14:50
  little
• 14:50
  less
• 14:50
  insight
• 14:50
  into
• 14:51
  their
• 14:51
  illness.
• 14:52
  They
• 14:52
  self
• 14:52
  medicate
• 14:53
  believing
• 14:53
  that
• 14:54
  the
• 14:54
  cannabis
• 14:55
  works
• 14:55
  and
• 14:55
  maybe
• 14:55
  the
• 14:55
  prescribed
• 14:56
  meds
• 14:56
  don't.
• 14:57
  And
• 14:57
  so
• 14:58
  it's
• 14:58
  a
• 14:58
  lot
• 14:58
  harder
• 14:59
  for
• 14:59
  those
• 14:59
  patients
• 15:00
  to
• 15:00
  motivate
• 15:01
  and
• 15:01
  have
• 15:01
  critical
• 15:02
  insight
• 15:02
  and
• 15:03
  executive
• 15:03
  functioning
• 15:04
  to
• 15:04
  really
• 15:04
  maintain
• 15:05
  consistent,
• 15:05
  reliable
• 15:06
  adherence.
• 15:07
  Okay,
• 15:07
  so
• 15:08
  when
• 15:08
  cannabis
• 15:08
  is
• 15:08
  in
• 15:08
  the
• 15:09
  cards,
• 15:09
  think
• 15:09
  Lai.
• 15:10
  Think
• 15:11
  Lai.
• 15:12
  It's
• 15:12
  very
• 15:12
  important,
• 15:13
  right?
• 15:13
  And
• 15:14
  Abilify,
• 15:14
  again,
• 15:14
  has
• 15:15
  an
• 15:15
  Lai
• 15:15
  where
• 15:15
  you
• 15:16
  can
• 15:16
  reduce
• 15:16
  the
• 15:16
  cravings.
• 15:17
  Okay.
• 15:18
  You
• 15:18
  can
• 15:18
  shore
• 15:18
  up
• 15:18
  some
• 15:18
  executive
• 15:19
  dysfunction.
• 15:20
  It
• 15:20
  can
• 15:20
  really
• 15:21
  help
• 15:21
  in
• 15:21
  that
• 15:21
  case.
• 15:22
  Okay.
• 15:23
  Pretty.
• 15:24
  Pretty
• 15:24
  neat,
• 15:24
  right?
• 15:25
  One
• 15:25
  other
• 15:26
  little
• 15:26
  pearl
• 15:26
  that
• 15:27
  was
• 15:27
  a
• 15:27
  little
• 15:27
  bit
• 15:27
  new
• 15:28
  to
• 15:28
  me.
• 15:28
  Even
• 15:29
  that
• 15:29
  I
• 15:29
  think
• 15:29
  we
• 15:29
  should
• 15:29
  all
• 15:30
  look
• 15:30
  into
• 15:30
  a
• 15:30
  little
• 15:30
  more
• 15:31
  is
• 15:31
  that
• 15:31
  some
• 15:32
  evidence
• 15:32
  suggests
• 15:32
  that
• 15:33
  THC
• 15:33
  upregulates
• 15:34
  a
• 15:34
  P
• 15:34
  glycoprotein
• 15:36
  at
• 15:36
  the
• 15:37
  blood
• 15:37
  brain
• 15:37
  barrier.
• 15:38
  And
• 15:38
  long
• 15:38
  story
• 15:38
  short,
• 15:39
  what
• 15:39
  that
• 15:39
  does
• 15:39
  is,
• 15:40
  is
• 15:41
  it
• 15:41
  actually
• 15:42
  pumps
• 15:43
  certain
• 15:43
  drugs
• 15:44
  out
• 15:44
  of
• 15:44
  the
• 15:44
  brain,
• 15:44
  making
• 15:45
  them
• 15:45
  less
• 15:46
  effective.
• 15:47
  Okay?
• 15:47
  So
• 15:47
  depending
• 15:48
  on
• 15:48
  which
• 15:48
  drugs
• 15:50
  are.
• 15:51
  Are.
• 15:51
  Are
• 15:51
  navigating
• 15:52
  the
• 15:52
  blood
• 15:53
  brain
• 15:53
  barrier
• 15:54
  using
• 15:55
  that
• 15:56
  P
• 15:56
  glycoprotein
• 15:58
  transporter.
• 15:59
  Okay,
• 16:01
  Depending
• 16:02
  on
• 16:02
  those
• 16:02
  drugs,
• 16:03
  you
• 16:04
  could
• 16:04
  actually.
• 16:05
  Cannabis
• 16:06
  could
• 16:06
  actually
• 16:07
  make
• 16:07
  that
• 16:07
  harder
• 16:08
  and
• 16:08
  make
• 16:08
  those
• 16:09
  drugs
• 16:09
  less
• 16:09
  effective.
• 16:11
  Risperidone
• 16:12
  and
• 16:12
  paliperidone.
• 16:14
  So
• 16:14
  risperidol
• 16:14
  and
• 16:14
  invigorate,
• 16:15
  okay,
• 16:16
  Those
• 16:16
  are
• 16:16
  P
• 16:16
  glycoprotein
• 16:18
  substrate.
• 16:19
  So
• 16:19
  THC
• 16:19
  is
• 16:20
  literally
• 16:20
  reducing
• 16:21
  their
• 16:21
  brain
• 16:22
  concentrations,
• 16:23
  making
• 16:23
  those
• 16:23
  meds
• 16:23
  less
• 16:24
  effective.
• 16:25
  If
• 16:25
  Henry
• 16:25
  were
• 16:25
  to
• 16:26
  take
• 16:26
  either
• 16:27
  invigora
• 16:28
  or
• 16:28
  risperidol,
• 16:29
  well,
• 16:29
  that's
• 16:29
  a
• 16:29
  big
• 16:29
  problem,
• 16:30
  right?
• 16:30
  Abilify
• 16:30
  does
• 16:31
  not
• 16:31
  have
• 16:31
  that
• 16:31
  problem.
• 16:32
  Neither
• 16:32
  does
• 16:33
  Clozapine.
• 16:34
  So
• 16:34
  their
• 16:34
  brain
• 16:35
  levels
• 16:35
  are
• 16:35
  not
• 16:36
  reduced
• 16:36
  by
• 16:37
  concurrent
• 16:37
  cannabis
• 16:37
  use.
• 16:38
  So
• 16:38
  you
• 16:38
  got
• 16:38
  to
• 16:38
  think
• 16:38
  of
• 16:38
  all
• 16:39
  these
• 16:39
  things,
• 16:39
  right?
• 16:39
  This
• 16:39
  is
• 16:40
  what
• 16:40
  makes
• 16:40
  psychiatry
• 16:41
  so
• 16:41
  fascinating
• 16:42
  and
• 16:42
  so
• 16:42
  fun.
• 16:43
  It's
• 16:43
  not
• 16:43
  as
• 16:43
  simple
• 16:44
  as
• 16:44
  half
• 16:44
  lives.
• 16:45
  It's
• 16:45
  not.
• 16:46
  You
• 16:46
  got
• 16:46
  to
• 16:46
  think
• 16:46
  about
• 16:46
  the
• 16:47
  blood
• 16:47
  brain
• 16:47
  barrier.
• 16:47
  We
• 16:48
  got
• 16:48
  to
• 16:48
  think
• 16:48
  about
• 16:48
  lipophilicity.
• 16:49
  We
• 16:49
  talked
• 16:50
  about
• 16:50
  that
• 16:50
  in
• 16:50
  our
• 16:50
  benzo
• 16:51
  Episode
• 16:52
  where
• 16:52
  we
• 16:52
  tried
• 16:52
  to
• 16:53
  prescribe
• 16:53
  a
• 16:53
  benzo
• 16:54
  to
• 16:54
  someone
• 16:54
  who
• 16:54
  had
• 16:54
  flight
• 16:55
  anxiety.
• 16:55
  And
• 16:55
  you're
• 16:56
  timing
• 16:56
  the
• 16:56
  benzo
• 16:56
  half
• 16:57
  life
• 16:57
  to
• 16:58
  how
• 16:58
  long
• 16:58
  their
• 16:59
  flight
• 16:59
  is.
• 16:59
  But
• 16:59
  lo
• 17:00
  and
• 17:00
  behold,
• 17:00
  you've
• 17:00
  got
• 17:00
  to
• 17:00
  focus
• 17:01
  on
• 17:01
  lipophilicity
• 17:02
  because
• 17:03
  how
• 17:03
  quickly
• 17:03
  these
• 17:03
  meds
• 17:04
  cross
• 17:04
  the
• 17:05
  blood
• 17:05
  brain
• 17:05
  barrier
• 17:06
  is
• 17:06
  also
• 17:07
  a
• 17:07
  major
• 17:07
  factor,
• 17:08
  if
• 17:08
  not
• 17:08
  more
• 17:08
  so
• 17:08
  than
• 17:09
  the
• 17:09
  half
• 17:09
  life.
• 17:10
  Right.
• 17:11
  So
• 17:11
  there's
• 17:11
  all
• 17:11
  kinds
• 17:12
  of
• 17:12
  things
• 17:12
  we
• 17:12
  have
• 17:12
  to
• 17:12
  stay
• 17:13
  attuned
• 17:13
  to
• 17:14
  when
• 17:14
  we're
• 17:14
  treating
• 17:15
  patients
• 17:15
  like
• 17:15
  Henry.
• 17:16
  And
• 17:17
  you
• 17:17
  know,
• 17:18
  you're
• 17:18
  not
• 17:18
  wrong
• 17:18
  to
• 17:18
  pick
• 17:19
  Cyprexa
• 17:19
  or
• 17:19
  Risperdal.
• 17:20
  Right.
• 17:20
  It's
• 17:21
  not
• 17:21
  like
• 17:21
  that
• 17:21
  is
• 17:21
  a
• 17:21
  wrong
• 17:22
  textbook
• 17:22
  answer.
• 17:22
  You're
• 17:23
  still
• 17:23
  trying
• 17:23
  to
• 17:23
  treat
• 17:24
  the
• 17:24
  psychosis,
• 17:25
  but
• 17:25
  you
• 17:25
  could
• 17:25
  be
• 17:26
  more
• 17:26
  correct
• 17:26
  by
• 17:27
  choosing
• 17:27
  an
• 17:27
  antipsychotic
• 17:28
  that
• 17:28
  has
• 17:29
  less
• 17:29
  of
• 17:29
  a
• 17:29
  metabolic
• 17:30
  burden.
• 17:30
  That
• 17:30
  would
• 17:30
  be
• 17:30
  abilifying
• 17:31
  and
• 17:32
  one
• 17:32
  that
• 17:32
  might
• 17:32
  also
• 17:33
  be
• 17:33
  fine
• 17:33
  tuned
• 17:34
  to
• 17:34
  assist
• 17:34
  him
• 17:35
  with
• 17:35
  cannabis
• 17:35
  cravings.
• 17:36
  Again,
• 17:37
  that
• 17:37
  would
• 17:37
  be
• 17:37
  abilifying
• 17:38
  because
• 17:38
  it's
• 17:39
  fine
• 17:39
  tuning
• 17:39
  those
• 17:40
  brain
• 17:40
  circuits
• 17:41
  as
• 17:41
  opposed
• 17:41
  to
• 17:41
  just
• 17:41
  bluntly
• 17:42
  blocking
• 17:42
  them
• 17:43
  like
• 17:44
  Zyprexa
• 17:44
  would.
• 17:45
  Okay.
• 17:46
  So
• 17:47
  that's
• 17:47
  very
• 17:47
  key.
• 17:48
  Now,
• 17:49
  I
• 17:49
  think
• 17:50
  you
• 17:50
  might
• 17:50
  have
• 17:50
  a
• 17:50
  better
• 17:51
  picture
• 17:51
  about
• 17:51
  this.
• 17:52
  And
• 17:52
  it's
• 17:52
  no
• 17:53
  surprise
• 17:53
  to
• 17:53
  you
• 17:53
  that
• 17:53
  in
• 17:54
  the,
• 17:54
  in
• 17:54
  the
• 17:54
  er,
• 17:55
  you're
• 17:55
  not
• 17:55
  going
• 17:55
  to
• 17:55
  be
• 17:56
  able
• 17:56
  to
• 17:56
  really
• 17:57
  diagnose
• 17:58
  this
• 17:58
  patient
• 17:59
  in
• 17:59
  a
• 17:59
  declarative
• 18:00
  way.
• 18:00
  You're
• 18:00
  going
• 18:00
  to
• 18:00
  probably
• 18:01
  have
• 18:01
  to
• 18:01
  use
• 18:01
  an
• 18:01
  unspecified
• 18:03
  diagnosis.
• 18:04
  You've
• 18:04
  seen
• 18:04
  those
• 18:04
  in
• 18:05
  the
• 18:05
  DSM
• 18:05
  5TR
• 18:06
  unspecified,
• 18:07
  suggesting
• 18:08
  that
• 18:08
  the
• 18:09
  setting
• 18:09
  we're
• 18:09
  in
• 18:10
  is
• 18:10
  not
• 18:10
  conducive
• 18:10
  to
• 18:11
  making
• 18:11
  this
• 18:11
  diagnosis.
• 18:12
  And
• 18:13
  that's
• 18:13
  exactly
• 18:13
  what
• 18:13
  unspecified
• 18:14
  is
• 18:14
  for.
• 18:15
  Right.
• 18:15
  We
• 18:15
  really
• 18:15
  just
• 18:16
  can't
• 18:16
  make
• 18:16
  this
• 18:16
  diagnosis.
• 18:17
  We
• 18:17
  don't
• 18:17
  have
• 18:18
  enough
• 18:18
  information,
• 18:19
  enough
• 18:19
  context.
• 18:20
  We're
• 18:20
  not
• 18:21
  in
• 18:21
  a
• 18:21
  laboratory
• 18:21
  where
• 18:22
  we
• 18:22
  can
• 18:22
  neatly
• 18:23
  assess
• 18:24
  if
• 18:24
  this
• 18:24
  patient
• 18:25
  is
• 18:25
  still
• 18:25
  psychotic
• 18:26
  in
• 18:26
  the
• 18:27
  absence
• 18:27
  of
• 18:27
  cannabis.
• 18:28
  If
• 18:28
  he
• 18:28
  was,
• 18:28
  if
• 18:29
  he
• 18:29
  was
• 18:29
  30
• 18:29
  days
• 18:29
  sober
• 18:30
  from
• 18:30
  cannabis
• 18:30
  and
• 18:30
  he
• 18:31
  was
• 18:31
  still
• 18:31
  psychotic,
• 18:32
  I
• 18:32
  would
• 18:32
  absolutely
• 18:33
  believe
• 18:33
  this
• 18:33
  is
• 18:34
  a
• 18:34
  primary
• 18:34
  psychotic
• 18:35
  disorder.
• 18:35
  We
• 18:36
  should
• 18:36
  absolutely
• 18:38
  get
• 18:38
  pretty
• 18:38
  quick
• 18:39
  at
• 18:39
  diagnosing
• 18:40
  schizophrenia
• 18:40
  on
• 18:41
  the
• 18:41
  spot
• 18:41
  there,
• 18:41
  assuming
• 18:42
  nothing
• 18:42
  else
• 18:42
  is,
• 18:43
  you
• 18:43
  know,
• 18:43
  confusing
• 18:44
  the
• 18:44
  diagnosis.
• 18:45
  He
• 18:45
  may
• 18:46
  also
• 18:46
  have
• 18:46
  a
• 18:47
  cannabis
• 18:47
  induced
• 18:49
  psychotic
• 18:50
  disorder.
• 18:50
  We
• 18:50
  don't
• 18:50
  know
• 18:50
  that.
• 18:51
  Right.
• 18:51
  If
• 18:51
  he,
• 18:52
  um,
• 18:53
  has
• 18:53
  no
• 18:54
  psychosis
• 18:54
  at
• 18:54
  all
• 18:55
  after
• 18:55
  he
• 18:55
  stops
• 18:55
  cannabis
• 18:56
  and
• 18:57
  he's
• 18:57
  functioning
• 18:58
  pretty
• 18:58
  well,
• 18:58
  which
• 18:59
  I
• 18:59
  highly
• 18:59
  doubt.
• 18:59
  Right.
• 19:00
  That's
• 19:00
  very
• 19:00
  unlikely
• 19:01
  in
• 19:01
  this
• 19:01
  scenario.
• 19:01
  It's
• 19:02
  possible,
• 19:02
  but
• 19:02
  it's
• 19:02
  unlikely
• 19:03
  given
• 19:03
  his
• 19:04
  first
• 19:04
  degree
• 19:05
  family
• 19:06
  member
• 19:06
  with
• 19:06
  schizophrenia
• 19:07
  on
• 19:07
  clozapine,
• 19:08
  but
• 19:09
  in
• 19:09
  the
• 19:09
  event
• 19:09
  it's
• 19:09
  just
• 19:10
  squeaky
• 19:10
  clean
• 19:10
  when
• 19:10
  he's
• 19:11
  off
• 19:12
  his
• 19:12
  cannabis,
• 19:13
  then
• 19:13
  yeah,
• 19:14
  that
• 19:14
  would
• 19:14
  raise
• 19:15
  my
• 19:15
  index
• 19:15
  of
• 19:15
  suspicion
• 19:16
  that
• 19:16
  this
• 19:16
  was
• 19:16
  a
• 19:16
  cannabis
• 19:17
  induced
• 19:17
  psychotic
• 19:18
  disorder
• 19:18
  all
• 19:18
  along.
• 19:19
  That
• 19:19
  he
• 19:19
  had
• 19:19
  a
• 19:19
  genetic
• 19:20
  predisposition
• 19:21
  that
• 19:21
  came
• 19:21
  out
• 19:22
  in
• 19:22
  the
• 19:22
  context
• 19:22
  of
• 19:23
  cannabis.
• 19:23
  Again,
• 19:24
  I
• 19:24
  feel
• 19:24
  like
• 19:24
  in
• 19:25
  the
• 19:25
  real
• 19:25
  world
• 19:25
  though,
• 19:26
  I
• 19:26
  feel
• 19:27
  nine
• 19:27
  times
• 19:27
  outta
• 19:28
  ten
• 19:28
  for
• 19:28
  me,
• 19:28
  anecdotally
• 19:30
  with
• 19:30
  someone
• 19:30
  who
• 19:31
  has
• 19:31
  a
• 19:31
  first
• 19:31
  degree
• 19:31
  family
• 19:32
  member
• 19:32
  like
• 19:32
  this,
• 19:32
  it
• 19:33
  usually
• 19:33
  is
• 19:33
  a
• 19:33
  schizophrenia
• 19:34
  with
• 19:34
  a
• 19:34
  comorbid
• 19:36
  cannabis
• 19:36
  induced
• 19:37
  cannabis
• 19:38
  use
• 19:38
  disorder.
• 19:39
  Whether
• 19:39
  it
• 19:39
  was
• 19:39
  induced
• 19:40
  by
• 19:40
  that's
• 19:40
  a
• 19:40
  different
• 19:41
  story.
• 19:41
  That's
• 19:41
  where
• 19:41
  it
• 19:41
  gets
• 19:42
  complicated.
• 19:43
  But
• 19:43
  again,
• 19:43
  I
• 19:43
  kind
• 19:44
  of
• 19:44
  wanted
• 19:44
  you
• 19:44
  to
• 19:44
  feel
• 19:45
  complicated
• 19:45
  today
• 19:46
  and
• 19:46
  get
• 19:47
  a
• 19:47
  sense
• 19:47
  of
• 19:47
  complicated.
• 19:48
  So
• 19:48
  you're
• 19:49
  not
• 19:49
  surprised
• 19:49
  by
• 19:49
  it
• 19:49
  and
• 19:50
  you
• 19:50
  understand
• 19:50
  that
• 19:51
  we
• 19:51
  all
• 19:51
  go
• 19:52
  through
• 19:52
  this
• 19:53
  in
• 19:53
  our
• 19:53
  practice.
• 19:54
  This
• 19:54
  is
• 19:54
  normal.
• 19:55
  You're
• 19:55
  not
• 19:55
  confused,
• 19:56
  you're
• 19:56
  not
• 19:56
  going
• 19:56
  crazy.
• 19:58
  Real
• 19:59
  life
• 19:59
  psychiatry
• 20:00
  is
• 20:00
  often
• 20:00
  very
• 20:01
  messy
• 20:01
  and
• 20:02
  we're
• 20:02
  juggling
• 20:02
  many
• 20:03
  things
• 20:03
  at
• 20:03
  once.
• 20:04
  Suffice
• 20:04
  it
• 20:04
  to
• 20:05
  say,
• 20:05
  this
• 20:05
  is
• 20:05
  a
• 20:05
  patient
• 20:06
  that
• 20:06
  we
• 20:06
  want
• 20:06
  to
• 20:06
  see
• 20:06
  pretty
• 20:07
  often.
• 20:07
  You
• 20:08
  know,
• 20:08
  during
• 20:09
  follow
• 20:09
  up.
• 20:09
  We
• 20:09
  want
• 20:09
  to
• 20:10
  see
• 20:10
  how
• 20:10
  they're
• 20:10
  doing,
• 20:10
  how
• 20:10
  they're
• 20:11
  tolerating
• 20:11
  the
• 20:11
  abilify,
• 20:13
  how
• 20:13
  their
• 20:13
  adherence.
• 20:14
  Are
• 20:14
  they
• 20:14
  open
• 20:14
  to
• 20:15
  lais
• 20:15
  at
• 20:15
  that
• 20:16
  point?
• 20:16
  Definitely.
• 20:16
  You
• 20:17
  want
• 20:17
  to
• 20:17
  motivational
• 20:17
  interview,
• 20:18
  you
• 20:18
  want
• 20:19
  to
• 20:20
  start
• 20:20
  kind
• 20:20
  of
• 20:20
  warming
• 20:21
  things
• 20:21
  up
• 20:21
  for
• 20:21
  long
• 20:22
  term
• 20:22
  treatment
• 20:23
  in
• 20:23
  the
• 20:23
  event
• 20:23
  we
• 20:24
  need
• 20:24
  it.
• 20:24
  But
• 20:25
  abstinence
• 20:25
  is
• 20:25
  going
• 20:25
  to
• 20:26
  give
• 20:26
  you
• 20:26
  tons
• 20:26
  of
• 20:26
  diagnostic
• 20:27
  clarity.
• 20:28
  It's
• 20:28
  also
• 20:28
  going
• 20:29
  to
• 20:29
  help
• 20:29
  treat
• 20:29
  the
• 20:29
  patient.
• 20:31
  Just
• 20:31
  by
• 20:31
  getting
• 20:31
  the
• 20:32
  high
• 20:32
  potency
• 20:32
  THC
• 20:33
  out
• 20:33
  of
• 20:33
  the
• 20:33
  system
• 20:34
  is
• 20:34
  going
• 20:35
  to
• 20:35
  really
• 20:35
  help
• 20:35
  his
• 20:35
  psychosis
• 20:36
  and
• 20:37
  clear
• 20:38
  you
• 20:38
  diagnostically.
• 20:40
  Okay.
• 20:41
  So
• 20:42
  just
• 20:42
  remember
• 20:42
  that.
• 20:44
  And
• 20:45
  so
• 20:45
  I,
• 20:45
  I
• 20:45
  think,
• 20:46
  I
• 20:46
  think
• 20:46
  you
• 20:46
  have
• 20:46
  enough
• 20:46
  pearls
• 20:47
  to
• 20:48
  keep
• 20:48
  in
• 20:48
  your
• 20:48
  pocket.
• 20:48
  You
• 20:49
  have
• 20:49
  so
• 20:49
  many
• 20:49
  pearls
• 20:50
  in
• 20:50
  your
• 20:50
  pocket,
• 20:50
  your
• 20:50
  pants
• 20:51
  are
• 20:51
  probably
• 20:51
  falling
• 20:51
  off
• 20:52
  at
• 20:52
  this
• 20:52
  point.
• 20:52
  And
• 20:53
  I
• 20:53
  mean
• 20:53
  that
• 20:53
  in
• 20:53
  the
• 20:53
  most
• 20:53
  appropriate
• 20:54
  way
• 20:54
  possible.
• 20:56
  Your
• 20:56
  pants
• 20:56
  did
• 20:57
  not
• 20:57
  fall
• 20:57
  off.
• 20:57
  They're
• 20:58
  falling
• 20:58
  off
• 20:58
  and
• 20:59
  you
• 20:59
  just
• 20:59
  need
• 20:59
  to
• 20:59
  pull
• 21:00
  them
• 21:00
  up
• 21:00
  or
• 21:00
  take
• 21:01
  the
• 21:01
  pearls
• 21:01
  out.
• 21:03
  Anyhow,
• 21:05
  I'm
• 21:05
  not
• 21:05
  always
• 21:05
  the
• 21:05
  best
• 21:06
  with
• 21:06
  analogies
• 21:06
  and
• 21:07
  I'm
• 21:07
  not
• 21:07
  going
• 21:07
  to
• 21:07
  continue
• 21:07
  to
• 21:08
  try
• 21:08
  that
• 21:08
  one.
• 21:09
  But
• 21:10
  this
• 21:10
  was
• 21:10
  a
• 21:11
  fun
• 21:11
  one.
• 21:11
  I
• 21:12
  loved
• 21:12
  this
• 21:13
  case
• 21:13
  study.
• 21:14
  We
• 21:14
  wish
• 21:14
  Henry
• 21:15
  very
• 21:15
  well.
• 21:15
  We
• 21:16
  encourage
• 21:16
  him
• 21:17
  to
• 21:17
  be
• 21:17
  abstinent.
• 21:17
  We
• 21:18
  encourage
• 21:18
  him
• 21:18
  to
• 21:18
  get
• 21:18
  the
• 21:19
  care
• 21:19
  he
• 21:19
  needs
• 21:19
  to
• 21:20
  look
• 21:20
  at
• 21:20
  lais.
• 21:21
  We
• 21:21
  want
• 21:21
  to
• 21:22
  focus
• 21:22
  on
• 21:23
  him
• 21:23
  regularly
• 21:23
  and
• 21:24
  take
• 21:24
  care
• 21:24
  of
• 21:24
  him.
• 21:24
  And
• 21:25
  I
• 21:25
  think
• 21:25
  he's
• 21:25
  going
• 21:25
  to
• 21:25
  be
• 21:25
  okay
• 21:26
  with,
• 21:26
  with
• 21:26
  good
• 21:26
  care.
• 21:27
  My
• 21:28
  friends,
• 21:28
  I
• 21:29
  will
• 21:29
  say
• 21:29
  one
• 21:29
  last
• 21:30
  thing.
• 21:30
  If
• 21:30
  there's
• 21:30
  one
• 21:30
  thing
• 21:31
  you
• 21:31
  don't
• 21:31
  forget
• 21:31
  to
• 21:32
  do
• 21:32
  tonight,
• 21:33
  go
• 21:33
  into
• 21:33
  our
• 21:34
  show
• 21:34
  notes
• 21:35
  and
• 21:35
  become
• 21:35
  a
• 21:35
  Patreon
• 21:36
  member.
• 21:37
  I
• 21:37
  will
• 21:37
  tell
• 21:37
  you
• 21:38
  right
• 21:38
  now,
• 21:38
  the
• 21:38
  difference
• 21:39
  between
• 21:40
  a
• 21:40
  good
• 21:40
  clinician
• 21:41
  and
• 21:41
  a
• 21:41
  great
• 21:41
  clinician
• 21:42
  is
• 21:42
  the
• 21:42
  clinician
• 21:43
  that
• 21:43
  understands
• 21:43
  the
• 21:43
  how
• 21:44
  and
• 21:44
  the
• 21:44
  why
• 21:44
  of
• 21:44
  what
• 21:45
  they're
• 21:45
  doing
• 21:45
  in
• 21:45
  psychiatry.
• 21:46
  They
• 21:46
  don't
• 21:46
  just
• 21:47
  press
• 21:47
  buttons
• 21:47
  and
• 21:47
  memorize
• 21:48
  diagnoses
• 21:49
  in
• 21:49
  meds.
• 21:49
  They
• 21:50
  understand
• 21:50
  the
• 21:50
  how
• 21:50
  and
• 21:51
  the
• 21:51
  why
• 21:51
  of
• 21:52
  the
• 21:52
  meds
• 21:52
  they're
• 21:52
  prescribing.
• 21:53
  They
• 21:53
  can
• 21:53
  explain
• 21:53
  it
• 21:54
  to
• 21:54
  the
• 21:54
  patient.
• 21:54
  They
• 21:55
  can
• 21:55
  empower
• 21:55
  that
• 21:56
  patient
• 21:56
  and
• 21:56
  empower
• 21:57
  the
• 21:57
  whole
• 21:58
  treatment
• 21:58
  plan.
• 21:59
  That's
• 21:59
  why
• 21:59
  I
• 21:59
  built
• 22:00
  this
• 22:00
  Patreon
• 22:00
  Library.
• 22:01
  It
• 22:01
  is
• 22:01
  beautiful,
• 22:02
  with
• 22:02
  visually
• 22:03
  sticky
• 22:03
  metaphors,
• 22:04
  rap
• 22:05
  songs,
• 22:06
  amazing
• 22:06
  little
• 22:07
  presentations,
• 22:07
  and
• 22:08
  pearl
• 22:08
  drops.
• 22:08
  You're
• 22:09
  going
• 22:09
  to
• 22:09
  love
• 22:09
  it.
• 22:09
  People
• 22:10
  love
• 22:10
  it.
• 22:10
  They
• 22:10
  share
• 22:10
  it.
• 22:11
  They
• 22:11
  go
• 22:11
  crazy
• 22:11
  over
• 22:12
  it.
• 22:12
  It's
• 22:12
  patreon.com
• 22:13
  pearlsandprep
• 22:14
  we
• 22:15
  would
• 22:15
  love
• 22:15
  to
• 22:16
  have
• 22:16
  you
• 22:16
  as
• 22:16
  a
• 22:16
  member.
• 22:17
  Patreon.com
• 22:18
  pearlsandprep
• 22:19
  Tell
• 22:20
  your
• 22:20
  friends,
• 22:21
  tell
• 22:21
  your
• 22:21
  family.
• 22:21
  Go
• 22:22
  to
• 22:22
  the
• 22:22
  show
• 22:22
  notes.
• 22:22
  Become
• 22:23
  a
• 22:23
  member.
• 22:23
  We'd
• 22:23
  love,
• 22:24
  love,
• 22:24
  love
• 22:24
  to
• 22:25
  have
• 22:25
  you.
• 22:25
  It
• 22:25
  has
• 22:25
  totally
• 22:26
  transformed
• 22:26
  my
• 22:27
  practice
• 22:27
  having
• 22:27
  this
• 22:27
  library.
• 22:28
  I
• 22:28
  use
• 22:28
  it
• 22:28
  all
• 22:29
  the
• 22:29
  time
• 22:29
  for
• 22:29
  reference
• 22:30
  when
• 22:30
  I'm
• 22:30
  stuck
• 22:31
  or
• 22:31
  for
• 22:31
  a
• 22:31
  good
• 22:32
  reminder
• 22:32
  because
• 22:33
  it
• 22:33
  allows
• 22:33
  you
• 22:33
  to
• 22:34
  really
• 22:34
  learn
• 22:34
  stuff
• 22:35
  quickly
• 22:35
  and
• 22:35
  retain
• 22:36
  it
• 22:36
  in
• 22:36
  a
• 22:36
  very
• 22:37
  sticky
• 22:37
  way.
• 22:37
  And
• 22:38
  again,
• 22:38
  it
• 22:38
  just
• 22:38
  changed
• 22:39
  the
• 22:39
  way
• 22:39
  I
• 22:39
  practice
• 22:40
  completely.
• 22:41
  So
• 22:41
  we'd
• 22:41
  love
• 22:41
  to
• 22:42
  have
• 22:42
  you
• 22:42
  become
• 22:43
  a
• 22:43
  member.
• 22:43
  You
• 22:43
  all
• 22:44
  have
• 22:44
  a
• 22:44
  wonderful
• 22:44
  rest
• 22:45
  of
• 22:45
  your
• 22:45
  week
• 22:45
  and
• 22:45
  take
• 22:45
  care.
• 22:46
  And
• 22:46
  thank
• 22:46
  you
• 22:46
  for
• 22:47
  listening
• 22:47
  to
• 22:47
  another
• 22:47
  episode
• 22:48
  of
• 22:48
  Pearls
• 22:49
  and
• 22:49
  Prep.
• 22:49
  Bye
• 22:49
  Bye.