Inside Bipolar Podcast: Mixed Episodes: Navigating the Unthinkable

Producer’s Note: Please be mindful that this transcript has been computer generated and therefore may contain inaccuracies and grammar errors. Thank you.

Announcer: You’re listening to Inside Bipolar, a Healthline Media Podcast, where we tackle bipolar disorder using real-world examples and the latest research.

Gabe: Hey everybody. My name is Gabe Howard and I live with bipolar disorder.

Dr. Nicole: And I’m Dr. Nicole Washington, a board-certified psychiatrist.

Gabe: I am really excited about today’s episode. It was recommended by a listener who emailed show@psychcentral.com and they wrote, “my bipolar presents with mixed episodes. From what I’ve been told, this can be tricky to identify and tricky to treat.” I want everybody to know I’m. I’m as curious as to where this episode is going to end up as the listener, because I don’t know a whole lot about mixed episodes, Dr. Nicole.

Dr. Nicole: Well, Gabe, guess what? You are not alone. A lot of people don’t know about mixed episodes, and you can tell because it’s very hard for people to explain what’s going on with them when they’re in a mixed episode. I would bet maybe you have had one and you just didn’t know what words to use. And honestly, as much as you say, it’s difficult for you to identify. It’s also really, really difficult for us to identify on the medical side.

Gabe: There’s a lot to unpack here, so let’s go ahead and start just right at the beginning. Is there a medical definition for the term bipolar mixed episodes?

Dr. Nicole: Yes and no. So let’s be, let’s be muddy.

Gabe: [Laughter] It always make it complicated when it’s yes and no.

Dr. Nicole: Yeah yeah yeah. Let’s be muddy right out the gate. So in previous DSM’s so in in the DSM-IV there was a bipolar mixed episode. And that’s what it was. It was a mixed episode. So you could have mania. You could have depression. You could have hypomania. You could have a mixed episode. Well, in the DSM-IV, to have a mixed episode, you had to meet full criteria. You had to meet full criteria for both episodes you had to be fully manic. So meet all those criteria. Full depression meet those criteria to be considered a mixed episode?

Gabe: I want to I want to stop you right there because as a layperson,

Dr. Nicole: Yes.

Gabe: Again, not a doctor, I believe that mania and depression are literally mutually exclusive. They are literally the opposite sides of the spectrum, and it’s impossible for the two things to meet.

Dr. Nicole: Yeah.

Gabe: I I’ve got this idea in my mind of like the North Pole and the South

Dr. Nicole: Yes.

Gabe: Pole, like touching, like that’s impossible. That is

Dr. Nicole: Yes.

Gabe: That is impossible. How could this even happen?

Dr. Nicole: Well, I and I think that’s part of the problem. Right. We conceptualize bipolar disorder as bipolar two poles. That’s it. You’re either manic or you’re depressed. There is no in-between. And now what I’m telling you is we used to have an in-between. So it now it feels like everything we’ve ever said about bipolar disorder is a lie, because all we ever talk about is mania and depression. We don’t tend to talk about mixed episodes.

Gabe: Well, and when we talk about the in between, we sort of look at that as the middle, right? That’s like the normal mood state, the stereotypical

Dr. Nicole: Right.

Gabe: Mood state,

Dr. Nicole: Right.

Gabe: The average mood state. Or for many people, managing bipolar disorder. The goal, like that’s the promised land. So I don’t know that we should use the term. It’s the in-between, right? Because I think conceptually, people with bipolar disorder see the in-between as the good place. That’s that’s

Gabe: Where they’re trying to get.

Dr. Nicole: Yeah

Gabe: So?

Dr. Nicole: I do too. I see it as the good place.

Gabe: What. So but how do you get both I just it’s it’s like water being on fire which I guess is

Gabe: Possible I write it this I think this is why people have so much trouble wrapping their mind around this idea that you can be two mood states at the exact same time.

Dr. Nicole: So yeah I mean the criteria was that you had to meet full criteria for both episodes at the same time. That’s what it was to be in a mixed episode. So you had depression, you were down, depressed, sad. You didn’t enjoy things like you used to. You had, you know, low energy trouble focusing. Your appetite was different. Your sleep was off. You worthless. Hopeless. Maybe suicidal. You had enough of those things going on to meet criteria for a major depressive episode. You had enough manic stuff going on, you grandiose, increased speech, racing thoughts, impulsivity, increase in risky behavior, increase in activity in general. You had that euphoria or that severe agitation, and you had all that going on at the same time. So you had enough of that going on to meet full criteria for a manic or hypomanic episode. And at the same time, that is incredibly difficult to to tease out.

Gabe: I have two very distinct thoughts that as a person experiencing mania and depressive symptoms at the exact same time, just sounds like its own personal hell. It just sounds absolutely horrific. But the other thing that I think about from a doctor’s perspective is in my mind, and this is only in my mind. So I’m, I’m I’m curious. It seems like the mania has more pronounced physical symptoms. So if you were manic and depressed at the same time, I would think that the mania, the rapid talking, the hand movements, the energy would overrun the depression. So as a doctor, you might spot the mania but miss the depression and then miss the mixed episode. And obviously the patient is just going through hell, so they’re probably

Dr. Nicole: Yeah.

Gabe: Not accurately reporting anything.

Dr. Nicole: That that is a good way to put it. I mean, it it is an absolute mess on both ends. Just all around. It’s a mess. I mean, actually, mixed episodes have a higher suicide rate than any of the other bipolar episodes, and you can see why you just said it’s a personal hell. Like I am depressed, but but speedy, I use the analogy of the like vodka and Red Bull. It’s it’s it’s the upper and the downer at the same time. It’s the how can they how can they exist together in the same in the same being. Because to me, the vodka Red Bull is a horrible combination of, of things that people could drink, but it’s very popular. Like it’s a popular thing. People say, oh, I’d like a vodka and Red Bull. And every time somebody does, I think that is the most ridiculous thing I’ve ever heard. You’re going to put both of those things in the same glass and ingest them, and you’re going to have the ability to experience both things that caffeine brings you and alcohol. This is like your own little mixed episode in a glass. I don’t know. It doesn’t seem right, but people tend to be able to to wrap their hands around. Oh, like alcohol and caffeine. They do totally different things. You drink them together, you can get the the feel of both at the same time, which to me would not be a good feeling. Mixed episodes aren’t a good feeling, and they’re insanely difficult to point out and to diagnose, but it’s important that we be able to. Okay, because there are certain medications that work better on mixed episodes. Are better at hitting mixed episodes than others.

Gabe: One of the things that you said, Dr. Nicole, is that there’s a higher rate of suicide during a mixed episode. So? So the stakes have gone really far up in my mind. I mean, all bad outcomes are bad outcomes, but suicide is the bad outcome. It’s the worst of the worst. And I and I really want to make sure that that people have good research on this. Now, earlier you said that the DSM-IV had some research and some understanding on it, but of course we’re on the DSM-5. So it sounds like research into this has evolved and continued, and maybe it hasn’t reached the greater community yet. So what are the differences between the DSM-IV’s definition that we’ve been discussing so far and the DSM-5, which is the latest information?

Dr. Nicole: So Gabe in the in the four, we talked about how you had to meet full criteria for both episodes at the same time to get the mixed episode in the five. And with all the discussion and the research and in between, you know, it’s clear One, it’s very difficult for a patient to be able to give you that information to imagine being in. I think you described it as a personal hell of being in a mixed episode, and you’re having to try to give the information that is needed to meet criteria for both. Well, that’s just really, really hard. So in the DSM-5, we now have mixed features. So we don’t necessarily have a full mixed episode. But you can be manic with mixed features. You can be depressed with mixed features. You can be hypomanic with mixed features, which means you meet full criteria for whatever the main episode is, and then you have a few symptoms of the other so you can be manic and have mixed features if you meet full criteria for mania, but then you have a few symptoms of depression, you can, you know, be depressed, meet full criteria for that, and have a few symptoms of mania. And so that may make it a little bit easier for doctors to feel comfortable making the diagnosis, because I think what would happen under the four is you would see somebody and you would think, I mean, is this mixed? But you couldn’t get enough information from them to be able to say, oh, this is a full episode of mania and a full episode of depression. So this is mixed. So then you were hesitant to make the diagnosis because you couldn’t really document full criteria for both.

Gabe: Not that anybody asked me, Dr. Nicole, but I really like the change. And here’s why. Because the old method sounded like you needed 100% of both. You needed to take a, you know, like almost equal parts. Right. You needed 50% this, 50% that you needed to mix it together. And that’s how you got your mixed episode. And I’m just thinking of the most basic analogy. Right. If you take a whole pizza. Right. The pizza is ginormous and somebody sneezes on it, right? The pizza to sneezing ratio is not equal, but that sneezing impacts the pizza and makes us not want to eat it. It sounds like in the DSM-IV you couldn’t have called that a mixed episode because it wasn’t equal parts diseases and pizza. Hey, analogies are hard to come by.

Dr. Nicole: Oh [Sigh]. They are.

Gabe: We’re on almost episode 100.

Dr. Nicole: They are.

Gabe: I’ve got to think outside the box.

Dr. Nicole: Oh my gosh, I just can’t get past somebody sneezing on a pizza. I don’t know, I don’t know. I don’t know there might be.

Gabe: Not only can you not get past it though, but think about the old DSM-IV definition, right?

Dr. Nicole: Yeah.

Gabe: You would have to ignore that sneeze and just declare it a pizza. You couldn’t call it a mixed episode pizza because there wasn’t enough viral load. You know, there was just a sneeze, but now just a sneeze is enough to get us there.

Dr. Nicole: I don’t know. Sneezes go pretty far and they cover a pretty wide range. I bet there was quite a bit of quite a bit of disease on that pizza.

Gabe: Listen, we got it. We got to stick to the analogy. You understand what I’m saying? I just. I do understand what you’re saying. But my point is,

Dr. Nicole: Yes.

Gabe: Is that nobody wants to eat that pizza. If somebody sneezes on that pizza. We’re done, and nobody’s eating it. So if somebody comes along and they’re afraid to diagnose the pizza as a, quote, mixed episode pizza because of the sneeze, then they wouldn’t warn other people not to eat it. And that’s really the point that I’m getting at. I think that if you are fully manic, but you have some of the traits of, of of depression, I think those can be really, really dangerous, especially. And here’s what it kind of looks like in my mind. And please correct me if I’m wrong.

Dr. Nicole: Okay.

Gabe: I think of somebody who is very manic. They have a lot of energy

Dr. Nicole: Right.

Gabe: And they feel like life is meaningless. So

Dr. Nicole: Right.

Gabe: That would allow them to drive the car really, really fast. Roll down all the windows, turn up the radio, take off their seatbelt and scream, you know, rage against the machine that looks

Dr. Nicole: Right, yeah.

Gabe: Both like mania and like depression because they don’t care if they wreck.

Dr. Nicole: Yeah. So if you, you think of what a manic person looks like in your mind. And let’s think of a person who is impulsive and grandiose and increase in risky behavior and talking fast and racing thoughts and all of those things. And then at the exact same time, they feel worthless and hopeless and they’re suicidal and they’re not eating because they’re depressed in the same body. It’s incredibly dangerous. It’s incredibly scary.

Gabe: One of the things that’s going through my mind is the number of times that I hear about people with bipolar disorder who have died, and the question is, was this self-inflicted? Was this, suicidal? Was this? And did they take unnecessary risks? And one of the hallmarks of mania is this consequence free environment. And it’s really scary because you can feel so good that you think that no harm can befall you. But of course, it’s also possible that you can have so much energy and so much just manic passion that you steer into the danger for a rush. These

Dr. Nicole: Mm-hmm.

Gabe: Seem like more examples of a mixed episode, and less examples of the consequence free mania. And the reason that I’m trying to tease this out is because if you’re feeling this way, or if you love someone and you’re noticing this in them, I think there’s a big difference between saying they’re so manic, they’re so happy, they’re so grandiose, they don’t think they can get hurt, versus they’re in a mixed episode where they have all of this energy and they’re trying to get hurt.

Dr. Nicole: Yeah. I mean that could, that could be a distinguishing factor for some people. And if you are the person who is dealing with it, it just might be really hard for you to even get the words out because you’re manic and your thoughts are racing and you’re going from topic to topic and you’re all over the place. At least it seems that way on the outside looking at you. It may be a lot to ask for you to be the one to give me that information.

Sponsor Break

Dr. Nicole: And we’re back discussing mixed episodes in bipolar disorder.

Gabe: I’m really starting to see why so many people wrote in to ask us to cover mixed episode, because I can imagine that it’s difficult to get information because so far, every question that I’ve asked has been qualified with a well, sort of, well, maybe, the research is ongoing, but it’s really dangerous and we really want to get ahead of it, but we’re not sure. And it could be this and we often see this. So I, I, I want to give a big shout out to our, our bipolar community, especially those who have been diagnosed with mixed episodes and say, I’m really starting to see the, well, frankly, the frustration. But the fear. So thank you for hanging in. And Dr. Nicole, I want to ask another question. So I’m thinking about my own life. Right?

Dr. Nicole: Mm-hmm.

Gabe: I’m thinking about my own experience with bipolar disorder. And I’m starting to wonder, did I ever experienced a mixed episode? Now I

Dr. Nicole: Mm-hmm.

Gabe: Am honestly not sure, but. But here is my question to you. I describe what I call the whiplash effect, where I would go from feeling like a god and feeling like garbage in the same moment where I thought that I was the greatest thing to ever lived. And then I thought that my mother would be happy at my funeral because, you know, thank God I was dead. And this would go back and forth in the same day. Now, I always consider that to be rapid cycling. I didn’t consider that to be a mixed episode, but I’m curious. It sounds like maybe I have mislabeled that particular symptom or feeling or time in my life.

Dr. Nicole: Well, I would really question, Gabe, if that was a mixed episode and not rapid cycling. So by definition, by definition, rapid cycling is having four or more distinct mood episodes in the same year, not in the same episode.

Gabe: Yeah. Like in the same moment. I mean, I really do describe it even

Dr. Nicole: Yes.

Gabe: As I’m thinking about it right now. It was like whiplash. You know, I’m God, I’m garbage, I’m God, I’m garbage, I’m God, I’m garbage. That I thought that was rapid cycling.

Dr. Nicole: So rapid cycling is four or more episodes in a year, whether it be mania, depression, hypomania, but it’s four or more in a year that when we say rapid cycling on my end of the interaction, that’s what we think of as rapid cycling. So maybe it’s a definition thing. Maybe, maybe we’re using the we’re using the same word to describe very different things. And that can absolutely be true. I could see how to you it did feel like rapid cycling, but maybe it was a mixed episode. You know, if you’re having racing thoughts and typically during mania, you’re racing thoughts are largely positive and grandiose and kind of far out. That may be your mania. But if during a mixed episode you’re racing, thoughts are of wanting to die and how worthless you are, that might be the sign that you’re in a mixed episode.

Gabe: So I really want to talk about this for a moment, because I think we’re at the crux of people with bipolar disorder being able to evaluate themselves and also talk to their Dr. Nicole, their therapist, their support people. And I’ve heard a lot of people refer to the whiplash effect of bipolar disorder. It sounds like if you’re experiencing this whiplash effect, if you’re if you’re feeling, you know, like for me, God and garbage, or if you’re having racing thoughts that are trending very negative. If you have a lot of energy towards Self-Destruction or worthlessness or hopelessness. Sort of a manic energy that is self-defeating or even harmful. It sounds like you really should talk to somebody about whether or not you are in a mixed episode, and have them take it from there.

Dr. Nicole: Yeah. And that I’ve never heard the whiplash effect. I’ve never had anybody tell me about that. So that’s my first time hearing that. So that that was interesting for me because I that’s not something, something I’d ever heard anybody explain in that way, but it makes sense.

Gabe: So, Dr. Nicole, just out of curiosity, are there any key words that your patients have used that you have picked up on that that makes you think mixed episode?

Dr. Nicole: Usually it’s the tone. It is. It is mania with a very dark undertone. So, you know, usually when I see people who are manic, they’re usually very light and very happy and on that end of things. So when the tone gets to, you know what? What’s the content of your racing thoughts? Or if the things that they’re telling me are sounding more depression, but it doesn’t match the package it’s wrapped in, that’s when my ears kind of perk up and I kind of, oh, okay, well, let’s talk, let’s talk about this. That’s usually what tips me off. Not so much any particular keyword. But patients have said to me, I feel like I’m losing my mind. I feel depressed and high at the same time, which, like you said earlier, feels like a personal hell. And it’s a very uncomfortable feeling. So usually the patient will tell me how uncomfortable they feel if I just give them the room to sit and talk long enough and get out what’s going on.

Gabe: And of course, we should acknowledge that that can be difficult, especially in the age of managed care where you get 12 minutes with your doctor. Many of us have trained ourselves to answer questions quickly so it can be hard to get that out. So I

Dr. Nicole: Mm-hmm.

Gabe: Want to say to our patient community, especially if you’re only getting 12 minutes with your Dr. Nicole’s, if you suspect that mixed episodes are at play, you might want to bring that up just right away. You might want to just sit down and say, I feel like I might be having mixed episodes, or I’m worried about mixed episodes, or I

Dr. Nicole: Yeah.

Gabe: Think I’m having mixed episodes because of X and Y, I imagine that most doctors will appreciate that. That’s I’m not giving them bad advice.

Dr. Nicole: No

Gabe: Right.

Dr. Nicole: No no no I think it’s great to come in and say hey I listened to this podcast and they were talking about mixed episodes and I didn’t even know that was a thing. And the more I listened, the more I thought, man, I think I may have had mixed episodes, and this is why. So, that might be something you pick up on.

Gabe: Dr. Nicole, I want to segue for a moment because we’ve been talking about a mixed episode being mania and depression, but could it be other things, like, for example, mania with hypersexuality? Is that a mixed episode?

Dr. Nicole: So no, that wouldn’t be a mixed episode. The hypersexuality in that case would be a symptom of the mania. You know, we think of mania as having an increase in risky behavior without regard to the consequences. So that’s where that hypersexuality would come in. You know, there’d be an increase in risky sex practices or promiscuity or anything like that without thinking about what the consequences of that could be down the road.

Gabe: It really sounds like the cornerstone of this for a mixed episode is the mania and depression that other spots mixing in aren’t a mixed episode. They’re just a symptom of the episode. But when specifically mania and depression meet mixed episode criteria, diagnosis and treatment comes into play.

Dr. Nicole: Yeah, and it is complicated. I mean, I think we’ve spent I don’t know, did you say 100 episodes? We’ve spent around 100 episodes now talking about how complicated bipolar disorder is. And we keep trying to make it be very simple, like, oh, you either have mania or you have depression, and then you take meds and then you’re better and your life is good at the end. It is not that easy. People living with bipolar disorder know it’s not that easy. And now I probably have made it more complicated for a lot of you because now you’re thinking, well, crap. I think I had a mixed episode and didn’t even know what it was. So it is it is very A complicated and it just takes a lot of work.

Gabe: This is my final question. Teasing out mixed episodes versus

Dr. Nicole: Okay, bring it.

Gabe: Just just symptoms of illnesses. I’ve used a lot of mania with examples. I want to use a depression with something. Depression and anxiety. They seem to be besties. They seem to hang out together all the time. If you are in a major depressive episode and you are also very anxious, is that a mixed episode?

Dr. Nicole: Well, I will say this. I think that when people have bipolar disorder, what I have learned over the years is that there are times when people describe to me that they have severe anxiety, but really what they’re describing to me is hypomania or mania. So there are times when a person says, you know, during my depression episodes, I’m just really like, I am super anxious during my depression episodes of my mania. I’m so anxious with it. I mean, that’s really what’s the most uncomfortable is all the anxiety. And as I get them to explain to me what they’re talking about, they really might be explaining mania or hypomania. So it is important to tease out and go that extra step further when the person says, I’m rapid cycling during this episode. It’s a great time to tease out what does that mean to you? Because it didn’t mean the same thing to me by definition, just like it was the case there. It’s the case when somebody tells you they have a ton of anxiety with their depression. To take those questions a little bit further and go a little bit deeper and figure out, is it really anxiety or is it hypomania or mania? Because I have seen that a lot.

Gabe: But let’s say that it’s absolutely depression and it’s absolutely anxiety then.

Dr. Nicole: Okay.

Gabe: Is that a mixed episode?

Dr. Nicole: No.

Gabe: No, it’s still no.

Dr. Nicole: Then that is not a mixed episode. It’s still no. The answer is still no. So either the answer is no, it’s not a mixed episode, or it is a mixed episode. And their their subjective experience of being anxious is actually my definition of mania hypomania. That’s why we have to go further with the questioning. And we can’t just take people’s word for it on the surface when they say, oh, I’m anxious. What does that mean to you? Because it might mean something different to you, especially in a context of a bipolar mood episode.

Gabe: I have learned a lot. Dr. Nicole, I really, really have. You’ve kind of blown my mind here. I’m starting to see why medical school takes so long,

Dr. Nicole: Oh.

Gabe: But I’m. But I’m still confused about something. How

Dr. Nicole: Okay.

Gabe: Is this different from dysphoric mania? Is it the depression versus the anger? Is it the anxiety versus the agitation? Why can that not be a mixed episode? Why do we need dysphoric mania and a mixed episode. Why are they not just one and the same?

Dr. Nicole: That that that is a fair question. I don’t know that I’m going to clear up your confusion, but here we go. So when we think about mania, not a mixed episode mania, we’ve talked about all those symptoms of mania. The only difference between a euphoric mania and an agitated mania is the the foundational mood. So your euphoric or your angry as all get out, right?

Gabe: Right.

Dr. Nicole: Tall the other symptoms are the same.

Gabe: Yep.

Dr. Nicole: All the other symptoms of mania are the same. They don’t change because you’re agitated versus euphoric. They’re all still the same. Depression is still depression, and you still have to meet those criteria, which are still very different from mania criteria. However, to make this really muddy, some people, when they’re depressed are a little more edgy and irritable, and that may be difficult to tease out. And so we have to figure out the differences. There is that irritability and agitation with their depression. Does it rise to the level that we could say, oh, this person has depression with mixed features of hypo, of mania, you know, what does that look like? And it would it would be difficult. It takes time. And I probably have not cleared anything up for you and your confusion. But this isn’t a clear thing. It’s very complicated.

Gabe: One of the things that I’ve really taken away from this, aside from the fact that this is very complicated, is that people who are experiencing mixed episodes are vulnerable. They’re

Dr. Nicole: Yes,

Gabe: Often not diagnosed, they’re

Dr. Nicole: Yes,

Gabe: Often not getting the care that they need

Dr. Nicole: Yes.

Gabe: And that they should be more concerned about this. So I, I hope, if nothing else, even if the listener still is like, I don’t understand this. I hope that if nothing else, they are empowered to realize that this is so complicated that they’re going to need the help of a mental health professional to get through this. If they suspect that they’re having mixed episodes. I think the suspicion is enough. Suspecting that you’re experiencing mixed episodes is enough to see a doctor and to seek treatment, I, I want to say this one more time. Could you imagine if in physical health, if you were only willing to go to a doctor, if you knew exactly what was wrong with you, you know? So if you just felt sick, if you didn’t know for a fact that you had mononucleosis, pneumonia, the flu, COVID, you refuse to see the doctor until you could figure it out? No. In physical health, it’s enough just to feel bad, to suspect we need that in mental health as well. So if you’re listening and you suspect that you’re experiencing mixed episodes, I hope that this has convinced you to seek out the help of a mental health professional to get that looked at. And hey, best case scenario, none of this has anything to do with you and you can forget about it and be reassured.

Dr. Nicole: [Laughter] That would be great. But it could also be that you figure out, maybe we need to try different treatments when I’m in that state. Maybe that’s why I have such a hard time recovering from my episodes. Maybe that’s why I walk around thinking that I’m difficult to treat or I’m treatment resistant. Any of those things could be true, but starting these conversations is going to be the first step in getting you the answers that you need.

Gabe: Well remember everybody, this topic literally came from all of you, our listeners. So if you have show ideas or questions, please hit us up at show@psychcentral.com. Also, wherever you downloaded this podcast, please rate us, rank us, review us, give us all the stars that you can. We would really appreciate it, but we’d also appreciate it if you would share the show with the people you know. Share your favorite episodes on social media. Send somebody a text message. Sharing the show with the people you know is how we grow. All right, everybody. My name is Gabe Howard, and I’m an award-winning public speaker. And I could be available for your next event. I also wrote the book “Mental Illness Is an Asshole and Other Observations,” which you can get on Amazon because everything’s over there. But if you want to get a signed copy with some free swag, just head over to my website, gabehoward.com. You can also follow me on TikTok and Instagram @AskABipolar.

Dr. Nicole: And I’m Dr. Nicole Washington. You can find me on all social media platforms @DrNicolePsych or on my website, DrNicolePsych.com.

Gabe: And we will see everybody next time on Inside Bipolar.

Announcer: You’ve been listening to Inside Bipolar from Healthline Media and psychcentral.com. Have feedback for the show? E-mail us at show@psychcentral.com. Previous episodes can be found at psychcentral.com/ibp or on your favorite podcast player. Thank you for listening.