Ask a Psychiatrist: The Grab Bag Special

Preston: [00:00:00] Bill Gates dropped out of college. Mark Zuckerberg dropped outta college and I'm dropping outta college. See the similarity? And you're like, yeah, dude. Half the CEOs on the four on, like the Fortune 500 list dropped out of college. But what percent of people that dropped outta college are on the Fortune 500 list?

Margaret: Welcome back to 

Preston: this is now an AM R podcast. 

Margaret: Ever since we did the coffee. Paton? 

No, just kidding. Hello. Welcome. 

Preston: Because I can't fix my gain. 

Margaret: They don't know what that is. 

Preston: It's a microphone setting because we 

Margaret: do, maybe they know it. Micro. I didn't know it. I still don't really know what it is. It's kind of just like something, what is gain?

Hi guys. Welcome back. 

Preston: It's here. it's a sound multiplier. That's all you need to know about gain. 

Margaret: Okay. 

Preston: And it is a, it's a company that helps with making detergents. I think 

Margaret: that's true. That's true. Welcome back you guys. Today's episode is gonna be an [00:01:00] episode. I don't think we've, I think we've done so far, like won a season, which is a grab bag question bank sort of episode where I take questions from the Instagram that we have not yet answered and maybe we'll answer in more depth next season, but we see if we can talk a little bit about them.

We maybe circle the wagons around a topic we've covered before. People keep asking about We chat. 

Preston: The, yeah, see the, questions vary in shape and size. Some of them are what kind of plants do you have? I don't know if anyone's asked that, but I want you to ask that. And some of them are, how do we fix healthcare in society?

And I think we reply very optimistically in our dms when we say we, we would love to make it episode on this, and we probably will in the future. I don't know if we'll succeed in answering that question. A complete and satisfying way, but it's still a great question, one that we have too. So I think we're gonna balance out all the different shapes and sizes of the questions today.

I actually don't [00:02:00] know a lot of them. Margaret's picked them out for today, but I do have a couple. 

Margaret: I picked them out 

Preston: circling around the old noggin 

Margaret: because why not? You know? First thing though, how are we doing on our steps? Challenge? Let's take a check. 

Preston: Let's check the scoreboard. Oh, I was actually pulling it up right now.

Okay. 

Margaret: You're beating me I think because I didn't do that for the last two days. 

Preston: So yeah, I, 

Margaret: as you guys, we have steps challenge on PACER app. Okay. 

Preston: Yeah. 

Margaret: Where, 

if 

Preston: you're not on pacer, 

Margaret: what is our number one on? 

Preston: What's our girl 

Margaret: Maggie doing? It's so 

Preston: Max, I think. 

Margaret: What's her number? 

Preston: So Mags is comfortably in first place with 320,000 steps.

She's actually 40,000 steps. Yeah, 22 days left. She's 40,000 steps above second place. Who is 2000 steps. Wow. Above third place. So it's actually really a race for second. Right now, with her way in the lead, she's like the max for stopping of, 

Margaret: she must have incredibly strong like le I can't my I my 

Preston: shoes. 

Margaret: I [00:03:00] wanna 

Preston: see 

Margaret: her just thinking about it.

Preston: I'm interested in not get hurt 

Margaret: on the show. Talk about our step challenge. 

Preston: However, rising Star bring your attention down to number 15, Preston with 172,000 steps. Who is just trailing? Avi and Elba? 91 at the 1 78, 180 3 range. 

Margaret: Oh, 

Preston: and then we have the, veteran winner of weekday rush Margaret in 20th at 161,000 steps.

Margaret: I've fallen behind. I've fallen behind, 

Preston: and we have a of 80 of you guys now, so. That's it. I think we were expecting seven. So seven. Seven. Yeah. With tenfold increased our, our expected of census on this. Yeah. Big 

Margaret: dog pack. 

Preston: Oh my gosh. And somebody messaged me on, Instagram, they said, thank you for making this step challenge.

I'm walking more than I thought I ever [00:04:00] would. I'm paraphrasing. 

Margaret: That's awesome. 

Preston: They actually were. Oh, okay. Here we go. Press, thank you for setting up the had to be pedestrian challenge. Went for morning speed walks and occasional light jogging. And I thought why not try doing a 5K. Managed to tackle it.

And I did 28 minutes. First try. We'll update you by the end of the challenge if there are any changes. Thanks. Was ends like an email and I was like, keep it up, but be 

Margaret: well, 

Preston: yeah. it's, I think this is Alyssa is your name. So Alyssa, great work. You are doing great work 

Alyssa. 

Margaret: We are proud of you. That's your para social podcast.

Siblings, brothers in arms, parents, whatever you wanna make us. 

Preston: We're here and we're proud. 

Margaret: We're stepping. It's a long challenge you've made. It's like, how many, is it six weeks? 

Preston: Mm-hmm. Yeah. I think 

Margaret: it's like five weeks. I feel like we got 

Preston: 22 days to go. 

Margaret: I gotta get back in it. But I feel like I didn't, I have not been checking it as obsessively as I was the first week.

So that's probably healthy for my [00:05:00] overall 

Preston: Yeah. 

Margaret: Mind. I 

Preston: mean it, and it's easy to lock in for a week, five weeks is, you know, just gotta keep doing it. Day after day 

Margaret: that week, I got a hundred thousand steps. So for the weekday rush challenge thing, 

Preston: that 

Margaret: was pretty impressive. My, like, hurt for like four days after I was like, did I get, do I have a stress fracture right now?

Preston: this was her Kilimanjaro. 

Margaret: It was and now it's is gonna 

Preston: soon? 

Margaret: No, we'll do 30, all of May. It's just a hundred thousand each week. 

Preston: I was 

Margaret: thinking the 400000th step be with you. No, 

Preston: yeah, that's a good one. I was thinking we could do maybe a unified challenge where as a group, like I said, how to be patient cohort.

We try to get like a million steps or like 25 million steps. That would be cool. So everyone's contributing to the total. So that way, you know, max team is like our fearless leader rather than 

Margaret: Yeah, 

Preston: someone who makes us all look bad. Maybe that's just us protecting our [00:06:00] egos a little bit. 

Margaret: I love that. I think this is a great thing.

As, our listeners, our regular listeners know, I think it would be funny if Preston, Dr. Glaucomflecken Flecking, who is our, one of our executive producers, gotten a beef and now I'm wondering if there's just any way to get him competitively involved with, this, with the beef. I think, I don't know how, but I think, 

Preston: runs, so we could probably get him to 

Margaret: watch you.

Yeah, just something to think on. here's my. First question from the grab bag that is not from the grab bag and it's more of just a comment and it's that medicine, TikTok has been a mess the last six weeks. Like I feel like there's been more stuff going on than, and I know that you had Paul Tran on, and so we've been talking about like content creation and med influencing.

But I feel like with like the way the world is right now, burn everyone's burnout, the continued burnout in medicine, it's just like. I don't know. I feel like it feels like there's something constantly happening on Med Talk. Do [00:07:00] you feel that way? 

Preston: Yeah, it's, it just feels like a more tense place. 

Margaret: Mm-hmm. 

Preston: I guess is how I'd put 

Margaret: it.

Yeah. Which I feel like usually this time of year it's like the match. So it's like usually like happy and everyone's like, we're all like, welcome and, or it's not happy. Like obviously not everyone's happy at the match, you know what I mean? It's The videos that I feel like there's lot of like time of year 

Preston: super positive things that come out and then there's everyone that reveals like their my tragic match day story and then a lot of like commiseration and negative emotions too.

It's just, I think it's just a high intensity motion time. 

Margaret: That's true. I think you're right, but. I don't know. I've just been noticing, I feel like there's like a lot more discourse in Med talk than there used to be. Granted, maybe it's just 'cause doing this podcast, I used to never get any of the videos before and now I get them and I'm, so maybe it's just that I was like in like creative journal club TikTok before and now.

Mm-hmm. My TikTok is showing me [00:08:00] healthcare videos over and then edits from the pit 

Preston: and then we react to edits from the pit 

Margaret: and then we react to edits. 

Preston: I like the pit. I think it's a good show. Good show. You watched it. I don't like watching it. I watched the first season. 

Margaret: oh, you're one of those.

Preston: Yeah. And it's nothing to do with the quality of the show, it just mm-hmm. I think when I watch TV, I wanna escape work it, and I 

Margaret: feel that 

Preston: it's like hyper realistic work, especially the psych stuff in there for me. 

Margaret: Mm-hmm. 

Preston: I'm you know, I, and it's funny because I would. I would like to watch like industry or succession and mm-hmm.

These are like high intense corporate cutthroat y you know, wars that, that are happening. Mm-hmm. And I've tried to watch that with my friends who are in corporate jobs and they're like, I can't watch this, is like triggering me. You know, they might as well have teams messages popping up here.

And I'm like, oh, for me it's a break. I'm like doing [00:09:00] something else. You know, get, I leaves him outta the hospital. And it's funny 'cause those are the friends that like watching the pit. 

Margaret: Really, I feel like there's some sort of like enjoyment of suffering that you don't have to go through in it. Like I feel I, 'cause I feel somewhat similarly, I will say all of the, like the pit edits got me to watch it and now I'm locked in 'cause I'm like shipping different couples in it and I'm like, okay, Jack Abbott, Mohan.

Like what are we doing? But I otherwise agree with you. Like I feel like it is, like I don't need to be consuming stories about the negative traumas and things that bring people into the hospital and then impact healthcare workers like off the clock. Like that is not something I need to do. It really has been the edits that got me to lock in.

Now. I can't look away 

Preston: if you make edits. Just know you've got Margaret. 

Margaret: [00:10:00] They're so powerful. 

Preston: Yeah, she's, 

Margaret: they're so powerful. 

Preston: I say that like, I don't respond to edits. The problem is the edits that I consume are like, it's tractors and like high powered form equipment. They, and I'm man, do I want be a farmer?

That thing is, you're telling me that thing is $300,000 and it can like bail several tons, like a second of, of Korney. That's sick. You know, 

Margaret: how long have you been being shown edits of farm equipment? 

Preston: Like an 

Margaret: ongoing theme? 

Preston: Like before that? No, it used to be like a lot of shark edits, polar bears, dinosaurs, went through a dinosaur phase.

Margaret: Why are you just like, like archetype like, like, do you have a five-year-old boy who has interests? We've got the right thing for you. And it's like, I love sharknato. Like my nephews, literally you're listing, I'm just like thinking of all the things you're listing are things they also love. 

Preston: I mean, here's the thing.

You, you could show, [00:11:00] I think any man, you know, five to 50 a tractor at and be like, that's kind of a sick tractor, you knows, mean's something deep inside of a man who, just, you just like farm equipment and trains. That's 

Margaret: fair. It's 

Preston: cool. 

Margaret: That and that tracks did you know my town? It wasn't my high school, but that there was a like, ride your tractor to school day.

Bring your 

Preston: tractor to school day. Yeah. Or drive your tractor to school day. I've been watching those videos too, where they'll like, like, they'll be like, I'm, jet da and this is my four, my John Deere F 6 2 80. And then all the comments were like, my dad's F 6 2 89 is way better than that one.

And I'm like, Jedi, you just got mogged. Good lord. And then they're all like tractor mo each other. 

Margaret: And you're like, I get involved with this community, people year, the C I'm 

Preston: just watching outside like, man, how does it feel to live my [00:12:00] dream? 

Margaret: And you're like, I just, after the, and then I 

Preston: walk back into Epic.

Margaret: You're like, that's it. okay. Well, we're gonna take a very quick break and then we're gonna come back and try and question you guys with all the questions. We continue to not answer or answer 

Preston: your questions. 

Margaret: We're gonna answer you question 

Preston: by truth. We're gonna max the questions. 

Margaret: We'll be right 

back.

The only person who is more stressed out by our medical training than us is our moms because they hear every single bad test, every question mark around admissions and every bad night call, and this Mother's day, I wanna celebrate my mom by giving her an anxiety relieving comforting gift like she gives me.

But this time it's gonna be from cozy Earth. 

Preston: Sometimes we wanna say more than thank you in this time. A great bathrobe and slippers is gonna be our way of saying thank you [00:13:00] for putting up with us all this time. 

Margaret: One of the great things about Cozy Earth is that everything that they make has a 10 year warranty or 100 night sleep trial.

So. Just like your mom was there through all 100 nights a night shift that you went through. So will your cozy Earth, rove and slippers? 

Preston: Yeah, and you can get those nights back unlike the night shift. So let this Mother's Day be a reminder that she deserves care too. Discover a cozy earth and how it turns routines into moments of softness and ease.

Head to cozy earth.com and use R Code Patient for an exclusive 20% off. And if you see a post-purchase survey, make sure you let them know that we sent you 

Margaret: because home starts with mom.

All right. Preston, would you like to, I wanna, so basically what we're gonna do is I'm gonna go through questions and comments that we've gotten in the last like few months 

Preston: Okay. 

Margaret: On a variety of things. And I'm gonna give you a chance to respond. And you can either say, [00:14:00] you can go or you can say, pass.

Smash your pass. Right, exactly. You can smash that light button to the questions Smash 

Preston: and swipe left. Swipe right on the questions. 

Margaret: Sure. Yes. And if you swipe left, I have to answer it. Okay. 

Preston: Okay. 

Margaret: Ready? Fair enough. I'm gonna pick ones that I think you, 

Preston: it's gonna be easy. Genius. I like to answer questions, 

Margaret: period.

Exactly. okay. One question that was asked was if we could talk more about harm reduction.

I'll make it more specific. I think harm reduction in terms of substance use, then maybe harm reduction in terms of like self harm or like preventing self harm or things like that. 

Preston: So like, like a closed harm reduction or like an open harm reduction, surgical harm reduction, or, it is a lot of those, the, [00:15:00] I guess when I think about harm reduction, I'm, I frame it as.

This saying, my friend, shout out Daniel. He's an anesthesia resident. He went, he was on the Stanford swim team and he said their unofficial model is we're not just good, we're good enough. And I think that's how I frame harm reduction, which is what can I do that's good enough right now? 

Margaret: Mm-hmm. '

Preston: cause I can't do good or reach the high level of good that I'm hoping to.

So. I would say there's like a couple categories of harm reduction. One is keeping the patient in care with you because if you can keep the patient coming back to see you for more appointments, then that's gonna give them more opportunity to receive and engage with care. And I guess what I mean by that can be anything from, Continuing, like on an intake, continuing medications that you wouldn't [00:16:00] otherwise continue because you know that they're like very attached to those medicines. It can also be, pivoting to doing more therapeutic conversation or just listening when you have like standardized templated questions to get through.

But I know if I don't make this person feel validated right now 

Margaret: mm-hmm. 

Preston: They're not coming back for a follow up. Or I guess I would never know that, but I have a strong suspicion that this is a, you know, a delicate person who's liable not to follow up with me. And so the priority is just kind of establishing reporting and then I can get more information in the next visit.

So those would kinda be like forms of harm reduction. I guess what I would say is what harm reduction is not, is enabling bad behavior. Or unhealthy behavior. I had a, friend, he's a, he's my co-resident now, but when we were fourth year med students, [00:17:00] he, we were giving like presentations, you know, as you do at like a noon conference kind of thing.

And my presentation was on. How the, like neuropsychologic battery for A DHD testing is essentially just a really close clinician interview, and that's the only one that really has a lot of validity and all the, like little clicky tests that you do on the computer end up just not having grand sensitivity or specificity for it.

And everyone's kind of bored. They're like, whatever. They're like, yeah, I usually decide a HD. Rob comes up after me and he goes, alright, your patient's gonna take steroids anyways, so you need to get 'em on a statin. You need to get 'em on, losartan. we can do aromatase inhibitors to prevent them from getting gynecomastia since they're gonna take the steroids anyways.

You might as well do all these things. And then a resident raised their hand. They're like, at what point are we doing calling this harm reduction? Or are we just kind of enabling this person's steroid use? And he was like. Valid. Good [00:18:00] point. Because, 

Margaret: and at what 

Preston: point production is it turning yourself into like a men's wellness clinic where we're like, we're gonna optimize your like anabolic steroid cycle and make sure that we're prescribing you all the ancillary medicines to reduce your side effects from this and like enable to gain that you're looking for.

And I think we're gonna actually, we can frame that as harm reduction when I think that's harm enabling. I guess, 

Margaret: yeah, I mean, I think, like, I think that there's valid ethical questions that come up, not necessarily with like, I'm sure there is for people in that field, but like when it comes to like harm reduction, I think like there's like a good faith question of like what is the right amount of support and what is enabling when you get into the gray.

Mm-hmm. But I think I agree with you that it's, it can go too far either way. I think often, like based on like a structural approach, like in terms of like what is funded. Where can there be clinics for like harm reduction or where is there, like where is it allowed to have things like safe needle drop off or [00:19:00] stuff like that, or, other things like Yeah, it's actually, 

Preston: it's a huge spectrum.

I'm glad you brought up the needle. Drop off. Sorry. Keep going. 

Margaret: Yeah. 

Preston: This is good. You're cooking. 

Margaret: but the. It's a huge spectrum that I think in good faith it can have different questions, different places. But I think in general there's been a kind of like people just need to pull their butt. Like people need to stop self-harming, they need to stop using substances, they need to stop, blah, blah, blah, blah, blah.

And then a very much a like not in my backyard esque thing of like, I don't want a methadone clinic here, blah, blah, blah, blah, blah, blah, blah. So I think that like there's, when it comes to harm reduction, the kind of impulse can be a bias. A lot of people that I've seen have like against to be like, well, no, whatever.

But it can also go too far as to be like, well, if you get the testosterone next door, then we can't help that you're doing that. So we might as well just build a men's wellness clinic, right next to it and just happen to profit off of this complex 

Preston: though, and ac Yeah, [00:20:00] and actually I think that maybe I'm being too harsh and you could make the argument that.

Rob is Rob, my co-resident was just arguing for harm reduction and that the next step would be if you said something like, well, you're taking the testosterone anyways and I don't want you to get it from the dirty street where it could be laced with something, so I'll prescribe it for you. Just let me manage your testosterone because harm reduction, right?

I think most people would agree. That's like absolutely the line. 

Margaret: What about like, I mean, for. Yeah, I think it just like, like who wants the testosterone and for what reason? And who gets to decide what the right amount of impact on testosterone you want, whether that's, you know, body image or in like gender clinics and stuff like that.

Yeah. Or whether it's someone who's like a really old man who now, like maybe the medical stuff says hormone therapy is indicated. I dunno, but it, [00:21:00] yeah. Isn't it interesting how it like, comes up even in this like teeny tiny, like, we're gonna spend a minute on this question. It brings up this like, well what about this?

And like, oh, I could imagine 

Preston: this s yeah, maybe reduction could be its own episode. Honestly, the, that's also a good point. So let's say the patient in Texas, actually you're not allowed, doctors aren't allowed to prescribe medications to adolescents to transition, 

Margaret: right? 

Preston: Straight up. So actually we've gotten into certain jurisdiction battles where the, on-base clinic.

Is technically federal property, so they follow federal law. So if a child of a service member is hoping to transition and they're seen at. A military clinic that's on Texas soil. The military providers can appeal to the federal law to then prescribe, 

Margaret: oh, interesting. 

Preston: Gender affirming care. It gives really, complicated fast, but, like, yeah.

Okay. Well, what do you do if you're the military psychiatrist for a patient and their civilian PCP? Does it feel [00:22:00] comfortable prescribing, the testosterone or estrogen for the patient? Well then now is that harm reduction because you're trying to treat, you may be going outside of your scope. But you're also treating a psychiatric disorder or really a whole body disorder.

Margaret: Yeah. I think, yeah. I wouldn't use it as harm reduction then in that point. But your point would be more like the ethical issue of prescribing it outside of 

Preston: scope. Yeah. That's fair. That's fair. It's, a d. Related principle. and yeah, I did, and I did wanna clarify that like the testosterone context we were talking about was for a cisgendered man who was looking for cosmetic muscle performance specifically.

'cause there are like medical reasons that we'd prescribe testosterone 

Margaret: production. How, even just like the, this conversation about it, like, I don't know the whole, I mean we've been trying, we have been trying to do, this isn't harm reduction, but we've been trying to do a like. Kind of like men's eating [00:23:00] disorder slash like men's body image, men's wellness stuff.

I think wasn't this friend you were mentioning, wasn't he the one we were gonna try to have on then We kept struggling and then I have a friend Jason. Is gonna come on. Jason is in the step challenge and he, me and I go, Jason, I can feel the creatine pumping through my veins right now. So I was like, when are coming on the podcast?

And he and I would talk about lifting after like clinic every day. And I would just be like, Jason, he's al also child psychiatry. Shout out. but yeah, harm reduction would be a good episode. It seems like we would have a lot to talk about and the ethical nuances of it are very interesting. 

Preston: Okay. I know we have more questions to get to, but last point.

Margaret: Yes. 

Preston: Did you see there's like a fentanyl, I think it's a fentanyl clinic in either Portland or Seattle. The new, oh really? York Times did an interesting pot on this one or two years ago, and it's essentially the next step beyond a needle exchange where they also sus supply clean opiates that like non methadone clean opiates to [00:24:00] patients to use.

And it's like a safe place for them to use and a place for them to have safe needles. And so it's doing okay in the Pacific Northwest, but I think that's also like an interesting point or data point along the spectrum of like harm reduction versus enabling. 

Margaret: Yeah, because my 

Preston: gut 

Margaret: like No, 

that's, 

too far ing that now.

Yeah, Which is, kind of just arbitrary, if I think about it. Like it is kind of, it's, both arbitrary and a bias and also. We know from like the opioid crisis that like when we gave more access to opioids, if opioids are an immunogenic substance, like they induce, they're more likely to make a normal human brain become dependent and seek more and seek and craving.

Mm-hmm. And all those things. Than having more access this 

Preston: people who are already dependent. So Exactly. So 

Margaret: then adds 

Preston: another layer to it. Yeah. 

Margaret: I love how we're giving, we're like, we're gonna give you guys answers as a joke, this episode. And now we're like, what if you give us a question and we give you 40 more 

Preston: [00:25:00] mm-hmm.

Margaret: To, tinker with. 

Preston: Yeah. So, so really you wanna speak more about harm reduction? We'll highlight the harm reduction and enabling live on a continuum with each other. And it just depends on where you want to draw the line. 

Margaret: Yeah. Who you are now and we're 

trying 

Preston: to figure that out too. Yeah, 

Margaret: healthcare and the law will see you.

Okay, cool. Great work. Okay, someone said, they said just autism. That was all they said, I, we can do an episode on autism. We, I need to think about people we could ask to, I'm, 

Preston: you know, I'm gonna pass on autism. It's a hard question. Is it, so is it just autism period or is it autism? Question mark. Because those are two different, 

Margaret: is it actually, no.

Oh, you can't see that. there's no punctuation. It's 

Preston: no punctuation. 

Margaret: It's just autism, like on its own. [00:26:00] So we will do an autism episode. I should ask more questions 'cause like there's so much we can cover there. someone said. 

Preston: I think this is a common one that people have asked us about too, which is, detecting autism in young boys versus young girls.

So, 

Margaret: yeah, 

Preston: I don't know if you have any expertise or like experience on that yet in child fellowship, but that could 

Margaret: be. I definitely don't have expertise yet. I will say, I will not pass on this one. I'll smash this question. I think that there are ways in which. Young girls are socialized and there's always, there does appear to be something different between biologic girls and biologic boys in terms of development.

Where people then take that in current kind of discussions in public about like, why are boys falling? This is like generally true for like why are boys falling by in school? Where, what are, what's a five-year-old boy on average, like in terms of like [00:27:00] verbal and emotion regulation versus girls dah, that's outside of autism.

And then there's a socialization upon the biologic kind of base. Which is equally as strong, if not stronger in some ways in my mind. And I think the combination of the biologic differences in girls versus boys within autism, and then the socialization combined to just make the presentations look different.

I also think socialization for girls with mental health illnesses is a hell of a. Hell of a factor in terms of like internalizing versus externalizing behaviors. So girls tend to internalize more, boys tend to externalize. That is generally true and I think in autism there's a way it does show up more similar to like the A DH ADHD literature that maybe less clearly disruptive, but with mates also depends.

Preston: Subtypes are more common in 

Margaret: women. 

Preston: but 

Margaret: it depends on what level we're [00:28:00] talking about. Of autism too. Like are we talking about like kind of level one autism, which is like quote unquote high functioning and like these, like people who weren't diagnosed super young versus like going to like the level of autism that is like when the, there's like not ability to, can you roll through the levels really quick?

Level 1, 2, 3. No, we can do a episode on I'm Enough detail on that.

There. Yes we could. And in fact, there's someone who I've been meeting to email who like did a really great autism lecture for us that I think could be great to come on and be an actual expert because I for sure am not, and I would love to keep learning from him. But to the point about girl versus boy, autism, like any illness can look individual for any individual regardless of gender.

But I do think the socializing and then probably something about the neurobiology is responsible for different. Ways that it comes out in the genders that may or may not make it [00:29:00] harder to recognize or diagnose. Yeah, 

Preston: absolutely. the other fascinating thing, about autism in that I've observed is its relationship with borderline personality disorder.

Not that they actually directly lead to each other, but I've had patients with borderline personality disorder wonder if they may have autism and patients with autism wonder if they may have borderline personality disorder because. Both disorders have difficulty with affect regulation, recognizing other people's perspectives, maybe, you know, hypersensitivity to either a certain emotional or physical stimuli.

So it's kind of easy to confuse both of those. I think it was fascinating when I was doing mostly my adult clinic, I had, you know, several patients with borderline person disorder saying like, I think this might all be autism. And I thought it was kinda like a one way street. And then. When I was started doing CAP psychiatry this year, 'cause like I'm not doing cap fellowship, but like we all rotate through it.

So I've been in a cap clinic this whole year. I've had several patients with autism that are like, [00:30:00] actually I think everyone, the psychologists were wrong. I think this is borderline. And I was like, whoa. Like to tell me more about that. And it's the same reason this, it's just the emotional dysregulation, trouble recognizing these things and then they almost want to be shed of that label of autism.

So I just kind of find that to be like an inter, like an interesting, Dynamic between the two diagnoses. 

Margaret: Yeah. Yeah. No, that's fascinating. I've not really like, thought about that. And it's also interesting to think about like, you know, if we think about Marsha Lenahan who is alive, if we think about her understanding, think 

Preston: she's autistic.

Margaret: Well, neither do I. 

Preston: we won't, we're not commenting on public figures level of autism. This is 

gonna 

ruin the, or presuming worse things.

Margaret: the, her understanding and kind of the, of like, how does BPD happen is from like an inval, a combination of an [00:31:00] invalidating environment and a level of a speci, kind of. High affect or difficulty with emotion regulation child. So it could be like a child that doesn't have any kind of genetic loading and then like a really, difficult or traumatizing, environment to an extent all the way to a kid with a lot of difficulty.

Or like a, you know, you think of this is not true for like all coy babies, but you think of like the babies that parents are like, we just have been really struggling really hard this whole time and like they just seem angry, like. a more irritable child and you put them in an environment. So if you think about like a sensitivity within autism, like the ability or the capacity for the family to respond to that and hold that well, like it kind of fits with linehan's understanding of BPA.

Not that always happens or that it's like causative, but it's interesting to think about of like a child with different needs. Can their environment be validating [00:32:00] enough? For them to feel attached and connected and consistently. 

Preston: Yeah. It's not to oversimplify it, but it just becomes nature nurture.

Margaret: It does, yeah. 

Preston: Yeah. 

Margaret: Like everything, when you come in, you're like, okay, well which part should we fix? You know, like, 

Preston: nature nurture, and then I just spam it. I just say nature nurture over and over again, and 

Margaret: they 

Preston: get better. I say 

Margaret: medication therapy. Medication therapy, lifestyle change. 

Preston: Mm-hmm.

Margaret: Medication. 

Preston: don't you wish you could just shout Lifestyle change at people, then they get better. 

Margaret: What do you think my clinic is? 

Preston: Yeah. It's actually my private practice. I just yell 

Margaret: it's 

Preston: lifestyle changes 

Margaret: and I just say we lot. 

Preston: If I don yell out loud enough, then probably just need to turn up the volume next time.

Margaret: Although that is like one of the fun things of child is like, I feel like now going back and like treating adults, like part of me just wants to be like. You know, maybe are you having a hard time opening up because it's like where there's [00:33:00] resistance or there's whatever, blah, blah, blah. I'm like, well, would it be if we just like walked and got and talked and did our session while we walked and got coffee or got ice cream or like went on a walk along like the Charles River, like would your session just be more productive?

'cause you're just someone who like processes things better moving and I feel like with kids you have a lot of creativity of being able to do that. I don't know how this is related to it, but I just feel like I wish I could do that more with adults. 

Preston: You could be, you could open up a hiking therapy clinic.

Sure. I think some people do that already. What are your thoughts on oppositional defiant disorder and I guess this is a hot take from someone who's not a child psychiatrist. But I have met several patients that carry the diagnosis of oppositional defiant disorder and after quite literally treating them like an equal or doing some like normal, empathetic listening, they are not oppositional or defiant and actually somewhat like [00:34:00] engaged in like treatment with me, which to me seems inconsistent with the diagnosis.

So I've wondered maybe incorrectly, possibly incorrectly in the back of my mind. Is it possible that this is just the externalization of parents and caregivers that don't know how to relate to this kid and that's why we're giving them a label? 

Margaret: Yes. 100%, yes. 

Preston: Okay. 

Margaret: Do I think that's why it happens most time?

Not necessarily. Have you ever considered, you're also just such a good doctor that they walk into your office and you cure them immediately. 

Preston: It is possible. I did shout lifestyle modifications at them on their way in, and I'm not taking that into account. 

Margaret: Yeah. Like I did Jauntily kick a soccer ball around and made them feel at ease with this.

Preston: I have one of those mugs that say World's Best Doctor, so we, there's a lot of really strong factors pulling 

Margaret: a lot. It's, you know, it's correlation, not causation. 

Preston: Yeah. What if actually the second they sit down in my chair. [00:35:00] I cure them of their oppositional defiant disorder. So it's really, it, is a real disorder and exists.

It's just I am, the cure for it. 

Margaret: Right. You're like Jesus, in a way. And, I've always said 

Preston: that kinda, yeah. I'm, it's, I'm glad you're finally saying things online that you believe and say offline. 

Margaret: Right. I mean, I, you, I have a burner account for those things. I make the edits of Preston, 

Preston: the gospel himself.

Yeah. Okay. That, that I, mean, it's just validating for you to hear that too. And, maybe like it's just for like thrown around as a diagnosis, but in some cases it does apply. 

Margaret: Well, ODD is highly comorbid with, A DHD, right? And so that presents the question of like, how is the A DHD needs being?

Kind of behaviorally conditioned and so, 

mm-hmm. 

I think ODD is a valid diagnosis, but I think it's complicated by how comorbid it is with A [00:36:00] DHD and like actually handling a DHD well and like an informed way is difficult. and then also kids do grow out of the ODD diagnosis, like they, as in like the symptoms tend to over the course of a lifetime, reduce.

Whether that's like the same story as a DHD where we were like they go down and now we're like, we think they go down. But maybe also we just don't know how to look at it for adults is a whole question. Maybe otherwise, maybe we just 

Preston: started judging them for it. 

Margaret: Maybe we said shout didn't go down. 

Preston: We just started calling them failures.

Margaret: Maybe we just said, Knock it off. Off. So, but I do think it goes down over time. So I don't know if there's something about maturity and like whatever they said, cut it out. 

Preston: Yeah, I'm just picturing like you have a DHD and you have all the same symptoms and none of the behavior changes, but in 18 we're just like, it's not a H ADHD anymore.

You actually just suck. Suck. 

Margaret: It looks looking good. 

Preston: Yeah, 

Margaret: it's looking good. 

Preston: Yeah. A ADHD symptoms don't follow into adulthood. It just turns out they're shitty adults. 

Margaret: Can I [00:37:00] tell you one of my like pet peeves? That's gonna sound like the opposite of this though. And it's like online where like people will be like, did you know?

And it like the neuroscience of like, they're going so far. 

Preston: When they say, neuroscience says, 

Margaret: yeah, 

Preston: who's neuroscience and why is he saying this? Or is she saying, 

Margaret: yeah, she's got, a lot to say, but like, I feel like it's so common with a DH, ADHD where it'll be like, and, I don't. I think that there's like a big way, you guys know this, listeners, you know this, like women are undiagnosed, people are undiagnosed in general, people don't get the help they need.

There's systemic issues, dah, And at the same time, it just grinds my gears when it's like to try to like people feel unheard and then to address that, we just give them misinformation. And I don't even think people know that they're necessarily giving it misinformation, but they like find like a recap of a study on like a random website and they're like.

I just like, there's 800 things I'll see online. They're like, did you know A DHD brains actually like can't think about the color [00:38:00] purple because purple's a long word and a DHD brains can't think about that long enough. And it just like pisses me off because it's like, you're not helping this misinformation.

Like, 

Preston: yeah. Or I think some of my, one of my favorite ones, this is like not necessarily related to A DHD, but they did a study on like. High IQ people or something like they had 'em take the Mensa IQ test and then they asked, and then they found that they like report that they procrastinate at a higher rate than the general population.

And then they come out there and you're like, it turns out that if you procrastinate, it may be sign that you're more intelligent and you're like. First of all,

and then all these people are progressing. They're like, I knew it. I was a genius. 

Margaret: Knew it. And it's like, it's one thing when we're like, this is a Facebook mom post. Like this is a post that we are, know, we're being a little silly. We're being a little haha. But. Some of the [00:39:00] people in those comments and the people making them are like really serious.

Preston: And, you say, neuroscience says that if you procrastinate, it's a sign that you're more intelligent. And it's like giving the same energy as saying, first of all, you 

Margaret: should have gotten over that at 18 when you got over your A DH adhd. So 

Preston: false is, you know, like Bill, bill Gates dropped out of college.

Mark Zuckerberg dropped outta college. I'm dropping outta college. See the similarity? And you're like, yeah, dude. Half the CEOs on the four on, like the fortune 500 list dropped out of college. But what percent of people that dropped outta college are on the Fortune 500 list? Like you gotta look at 

Margaret: neuroscience.

Is silence 

Preston: a realistic way? Yeah. Yeah. Gagged. I clocked their tea. Really? 

Margaret: Yeah. I clocked their tea. I know you and I talk about that offline after I tell you're the second coming of Jesus Christ, et cetera, et cetera. 

Preston: it's a nighttime ritual at this point, [00:40:00] 

Margaret: but it just like. I see them every day or someone will be like, do you know what, okay, this is me being a hater.

I feel like I see a lot of videos and maybe I'm just being a hater, but I'll be like, I'm a neuroscientist and I'm just, I look at their credentials and I see no credentials that are like, I'm a neuroscientist. I'm like, just because you took a neuroscience class, just, I don't even say I'm a neuroscientist.

Because I'm not a PhD in there. I'm sorry. I'm being a hater. But then they misquote a study and that's why it really pisses me off because it's like mm-hmm. If you were quo, it's a one two punch. If quoing the, 

Preston: yeah. 

Margaret: Research correctly. I wouldn't really have that much of an issue with it, but it's both together that I'm like, can we stop, make neuroscience uncool again.

Preston: Stolen valor. Yeah. 

Margaret: Stolen 

Preston: valor.

Margaret: okay. Let's move on to next question. We have 

Preston: questions? Yeah. 

Margaret: We don't have answers, but we do have questions. Oh, I can, I have a question. I can ask you for that. Okay. So question for you [00:41:00] is now that you're like ending, getting to the end of third year, how do you plan to like spend fourth year? Like do you get like elective time or do you have any things you're trying to do before?

Preston: Oh, 

Margaret: fellowship. 

Preston: So actually I'm on a research track, so 

Margaret: boom, 

Preston: my fourth year is kinda the same as my third year. 

Margaret: Okay. So. 

Preston: I'm like continuing in outpatient clinics. but I have like more time per week to dedicate to research and I think what I Oh, nice. I'm planning on doing is possibly doing like certain like electives where maybe a couple days a week I'll be like helping out on the inpatient consult service or cool.

Like. Like, you know, like going in and like helping, like we have a thing called back to bedside, which is actually where we go take the interns in the hospital to like certain patients and like show them therapy techniques in the hospital. Like, like little like, 

Margaret: oh, that's super cool. 

Preston: PRN supportive psychotherapy stuff.

And we do like mini lectures, [00:42:00] so that'll probably be a big part of it. I am interested in therapy and if you're an in, if you're an incoming intern, you're gonna be getting a lot of existential psychotherapy. Sorry guys. But, that's what we'll we be talking about. Here we go. 

Margaret: someone, me that they really liked.

Oh, someone I talked with someone in real life for an interview thing and it was, they were like, I loved that you guys did existential psychotherapy as part of it. I didn't even know psychiatrists thought about that. And I was like. We be thinking about it. So do, I was like, Preston was reading and then we were both thinking, 

Preston: you're like, it's, Preston got excited, he just learned how to read and then he found all these books and he's just been digesting them.

Margaret: I said he's hooked on phonics and he has, we have really little star chart and everything. 

Preston: I get to be unhooked. Yeah. So, so, so fourth year I think will be good. for my research, I've been doing a lot of like MRI imaging stuff. Looking at like, kind of describing possible [00:43:00] new radio imaging, biomarkers for Lewy body.

Margaret: Mm-hmm. 

Preston: And then per, that's kind of what I'm doing with my pi. Personally, I kind of want to get into looking at communication. So a lot of people have been using AI to write their notes, but with that, a lot of those programs actually save verbatim transcripts of the conversation. And then. I kind of wanna do is take that and run it through the, like motivational interviewing templates, or maybe even create a new template and examine the therapeutic utterances that are given in different patient encounters.

Because I, because, oh, 

Margaret: that's cool. 

Preston: My hypothesis is if you are engaging with someone of a similar age, ethnicity, or gender, you're more likely to use, Affirmations, validating utterances, complex reflections and have more open-ended questions. And that I think people maybe with the different demographics might use [00:44:00] more close-ended questions, for example, or actually spend more of the session talking.

So I think the metrics I look at were like percent of the session you spend talking and then like the amounts of the different utterances. And I think that just became a interesting, you a 

Margaret: therapy guy now. 

Preston: I mean, I find it. Yeah. I've always found a 

Margaret: fascinating You like happy patty squid word? 

Preston: Yeah, I do Mari sound.

That's cool though. Yeah, I just, and I think like the data is already building itself, so we might as well look at it. And then it's nice because it's already anonymized. 

Margaret: Mm-hmm. 

Preston: Yeah. we could just scrub them. They wrote transcripts and then all you need is the demographics of whoever the therapist is, whoever the patient is.

Margaret: That's true. Yeah. That would be cool. That would be cool. It'll be interesting to see like how that plays out. I think even just like the methodology would be interesting of like how you're getting the data. 

Preston: yeah. 

Margaret: Cool. 

Preston: And, what if it's not? Like, that'd be interesting too, you know, turns out, you know, gender doesn't play a [00:45:00] role, but like race does in, you know, differences in therapeutic utters is like, that can be really fascinating also.

Margaret: Well, and also the like, I don't know, in the setting that you're in, like, does that apply? Does that generalize outside of like. Is it the same everywhere? Is it the same as a clinic in Boston, the same as a clinic back in like Southern Illinois? For me, like 

mm-hmm. 

Probably not. It would be my hypothesis, but we can't know until you look at the data.

I wanted to circle back to the question we started with, because I meant to say something about harm reduction, which is. gonna feel out of left field, but I need to say it because I feel like the person who asked me want, I don't know if they'll want that, but just like concrete things that I feel like I found to be really helpful, for people if they are.

If this is like literally so harm reduction substance, I would think we covered that. But harm reduction, like self harm. In my mind when someone's like, I struggle with like cutting or scratching or something like that, I ask them more. Or with like [00:46:00] skin picking excoriation, I ask them how much of it is like unconscious when they start.

So like a body focused, repetitive behavior. And then, 'cause I find a lot of my patients, like my patients will cut, but a lot of them will also have like. They like, they're like nails are picked down and they pull their skin and they pull in their scabs and they like pick their skin on their face. And like the thing that maybe my hypothesis is that like makes self harm a way of regulating, is also something that makes any type of like pain stimuli.

I think people have done this research, but like pain stimuli more soothing to them. If that is getting in the way, like if they're, like, my nails are always bitten down and like painful in a bad way. My skin is whatever, or like I'm, I feel like cutting whenever I can like, feel whatever. one of the things to do is to create barriers similar to how you might with substance to make self harm more difficult to do.

And so if they have the like [00:47:00] scratching kind of like they start. Scratching and pulling at their skin. And they don't mean to start, they just do it when they're like searching for a skin tag or something. Having, have, if it's more body focused, like repetitive behaviors, having like nails for a lot of people can be helpful, like as in like acrylic nails 'cause there's less sensory input and therefore less skin picking, which can lead to the cutting and lead to like more pain seeking.

So having like fake nails can be. Extremely helpful for them. If there's someone that's interesting picks, yeah. If there's someone who like picks at their face or like pulls their hair, which you know, can be a compulsion, but I think it, I'm sure you've seen this, I can kind of toe the line. Yeah. Between like compulsion and self-harm and 

Preston: so like a wig, 

Margaret: one of those then 

Preston: would that help?

So 

Margaret: I mean actually like a wig might help. I was gonna say. For trichotillomania, maybe less so, but the nails will still help 'cause it'll reduce the sensory input for people. But I was gonna say, if they do the thing where they like go [00:48:00] in the mirror and are like looking at themselves and then they start like scratching or hitting themselves like in the bathroom, turning the lights lower and having like less good mirrors.

Not because they're like, it's bad to look at yourself, but just like reducing the thing that starts the self-harm. Like reducing the intensity of some of these things and I just find a lot of people who like cut with a razor also have these other kind of skin picking and body focused stuff. So I just wanted to get that out there.

Sorry to bring it back, kind of unrelated, but 

Preston: it's good. I think any chance I have to hate on overhead lights is a good chance to do something good for the world because it really does come down to overhead lights being the, greatest evil, 

Margaret: the cause of psychiatric illness when you think 

Preston: about it. So when someone comes into my office, I scream lifestyle changes at them.

I say, we're gonna get you some acrylic nails, and there better not be any overhead lights in your house, what you say 

Margaret: We're gonna, we're 

Preston: gonna hard [00:49:00] days work. So first of all, your nails 

Margaret: look awful 

Preston: and, 

you are no longer oppositional defined. I'm changing your diagnosis. 

Margaret: I've changed it. I changed your look and I changed your diagnosis.

Preston: Meanwhile, like the 14-year-old boy sitting across from me with the acrylic nails is like, help. 

Margaret: He's like, I don't get how this was supposed to help me. okay. You can just say you're 

Preston: welcome. 

Margaret: the last question I have was, whether we would be, this is like too broad of a question for us to do anything on, but people wanna talk about PTSD in veterans.

And I think that could be a really good episode for us to do and to do a history of like PTSD as like a diagnosis and how that led to like funding for a lot of different things, the wars, and then also your experience, with 

Preston: Oh, I would, 

Margaret: working with your population, actually, 

Preston: that I can do a lot about that.

we [00:50:00] can do the history of PTSD. We can talk about the comorbidity between PTSD and traumatic brain injury. So you're actually more likely to develop, PTSDs if it's during like a concussive blast. that's like related to the initial trauma. and then, and even like anecdotally, like I work at a pretty high volume va.

We're now at the point where like I've, I guess I've seen veterans from three different conflicts. So we have, like a couple Vietnam veterans that still come through. We have the, desert storm veterans, and we have the War on Terror, which they all kind of come with different flavors of PTSD based on the type of conflicts that they were in.

So that, that could also be like a pretty fascinating episode where, you know, like, I guess to give a teaser, Like we're in Texas, right? So if you're used to the [00:51:00] war on terror or your traumas came from the war on terror where you're in like, let's say Afghanistan and you're on a base where you're doing patrol and like your greatest concern is that a, Toyota Tacoma filled with C four is gonna drive into the gate and explode.

Now you're now 20 years later, 10 years later, you're driving through four 10 on San Antonio. Do you know how easy it is to find a Toyota Tacoma on the highways in San Antonio and, you're, just doing your business, and you look in your view mirror and see a Toyota Tacoma that's like coming up behind you and you're just, and you're like trying to keep it together on the fucking, like family vacation, and you're like, whoa.

So it's, like fascinating, right? Because 

Margaret: yeah, 

Preston: there, there was also a lot of big differences. So, and I imagine like in World War ii, I, don't know how many things like emulate the beaches of Normandy when you return [00:52:00] home, right? Like that kind of battle, but. When you're fighting an enemy that's embedded into the population and then you have to return back to a society that imitates aspects of that same population that you were fighting earlier.

It's just so likely to trigger the PTSD and, it was funny is like for the Vietnam veterans, they're like, I could give a crap about a Toyota Tacoma, but you know, God forbid they go to the botanical gardens. With their family. Mm-hmm. And, you know, everyone's getting concealed behind the foliage and they're, you know, playing peekaboo in the monsteras or something that's gonna like, bring a lot back.

So. 

Margaret: Wow. 

Preston: Like that's, 

Margaret: well, 

Preston: yeah, that's 

Margaret: be 

Preston: kind of 

Margaret: interesting. let's do this episode. I wanna learn. 

Preston: Okay. Yeah. So, so that's just kind of like a teaser, but super interesting stuff. Anyways. yeah, we can get more into it. that's all, that's, my add for the p ts d episode when it does come out.

Margaret: I love it. You, know, watch your watch where you get your podcast. Mm-hmm. [00:53:00] those are all my questions that I selected. There were many more that we could have done, which we appreciate. I mean, I, we use your questions when I, like, when I plan episodes, when I put the question box up. We appreciate also just like, obviously people's active engagement with this and helping us know what you want us to talk about.

and all the comments and everything else like helps us. And then the Spotify is really just for partying and the comments that academic mode is off on Spotify. But we are. Take quick break and then we'll be back.

Preston: And we're back from the Rando Patreon. Hope it was fun and spunky. It might have just been us playing Bananagrams, but who knows? Why are you talking 

Margaret: in this 

way? Whatcha talking? This 

Preston: is just my voice talking radio. This is how I talk.

I tried doing a Patreon episode, one of the craziest podcast, and you won't [00:54:00] believe the things that came out of it. Oh my God. Now time for the outro. Thanks so much for listening. If you enjoyed the podcast, please 

Margaret: stop. Please stop. Keep listen. Okay, go back. Keep listen, go back. I won't complain ever again.

Preston: Shout out to Willian. this is coming straight from the Spotify comments. This is for the comment about last week's episode, coffee, tea, and dementia. Hey guys. I don't know if this is the reason why they didn't include cancer patients, but it's been shown that there's a negative risk of dementia when someone has a history of cancer.

So since they're reporting risk in this paper, it's possible that cancer itself would be a confound. Here's the paper. Investigating the association between cancer and dementia risk. A longitudinal COR cohort study by saying ET all. Who I think was one of the authors. I remember it was I know Wang was the, The, PI on that paper. I'm pretty sure I saw Zangs name thrown around too. 

Margaret: Yeah, 

Preston: so it's, [00:55:00] this is like a, it's universe building. I think 

Margaret: this is why we do journal club. This one. This is why I like these journal club episodes. 'cause someone like, actually I was like, I have this question, and then they're like commenting and they're like, oh actually here's the answer.

See guys, this is, oh, I like to learn from them too. 'cause I know they're gonna be able to do sometimes stuff like this in the comment. 

Preston: Well, thanks Willian. There we go. you're making our pod better. How's the show? We always want to hear what you think, like we did today. We will talk about your questions, answer 'em, make up our own questions.

If you give us a question, we'll come back with four more and probably less answerable, but we'll have fun while we do it, and I think that's all that matters. If you've listened. You won and maybe you also had fun. Come chat with us in our Human Content Podcast family on Instagram, TikTok at Human Content Pods, or over at our team directly on how to be patient pod.com.

You can find me at its prerow Margaret at badar. Every way. Bad art, every way, every day, not every way rebrand. The ways are good. 

Margaret: Rebrand [00:56:00] 

Preston: also on Instagram and Substack outside of TikTok. you can find full episodes on my YouTube channel at its pre row. You can also find us on video, on Spotify, and then listen to us anywhere you get your podcasts.

Thanks again for listening. We're your host, Preston Roche and Margaret Duncan. Our executive producers are me, Preston, Roche, Margaret Duncan, will Flannery, Kristin Flannery, Aron Korney, Rob Goldman, and Shahnti Brook. Our editor and engineer is Jason Portizo. Shout out. Jason, you notice that Jason does, makes this symbol when he like inserts himself in.

He's like, 

yeah, I'm more of a lifter. 

So if you 

do 

a lifting challenge, I'll do that one. 

Preston: Jason 

Margaret: out. I love Jason. What? He, so much I like. We'll go and watch the podcast again, just to be like, where's Jason? What did he do? 

Preston: Shout out Jason. Our music 

Margaret: is 

Preston: Benz V. To learn more about our program, disclaimer and ethics policy submission verification, licensing terms, and our HIPAA release terms, go to how to be patient pod.com or reach out to us at [00:57:00] how to be patient@humancontent.com with any questions or concerns.

How to be patient is a human content production.

Thank you for watching. If you wanna see more of us or if you wanna see, this is lilac. She's my cat. She's gonna be waving her hand at one of the floating boxes, which will lead to more episodes. Lilac Point to the other episodes. Lilac doesn't know what the internet is, but I swear they're there. They, probably exist for real.

But in the meantime, I'm just gonna pet lilac and then I'm gonna go dance in the [00:58:00] background.