Hi everyone, welcome back to my kitchen and welcome to another monthly freezer meal prep. So today's video was just a few different things that I prepped this past week and threw into my freezer. I know I needed some breakfast things and a few other odds and ends. You know that I do a big freezer meal prep where I do a lot of actual meals for the freezer and then usually some other time during the month I do a prep like this one that is breakfast or snacks or just random things that I can keep on hand to quickly heat up and that we can eat. So the first thing that I made was these muffins and they are actually a protein muffin because you use the Kodiak pancake mix and that is a higher protein pancake mix which was excellent and to be honest, these disappeared really quickly. So I think I'm going to be making something like this or else this recipe again next month because my daughters loved these and I also got some muffin papers. Usually I don't use those but I really did like these parchment paper ones and it just seemed to kind of hold the muffins together better, especially if you're going to be freezing them. As usual, the recipes and all of the information will be below in the description box if you want to make some of these things yourself. All right, so if you guys have watched my channel for a long time, then you know I used to make these a lot and it's actually been a very long time since I've made them. In fact, I think it's been maybe almost a year, I don't know but that's homemade chicken nuggets and these are super healthy. They're also gluten-free friendly which I always love to give you guys lots of options including gluten and dairy-free things. So these you just cut up chicken breasts and as you can see, this was like three chicken breasts and it makes so many nuggets and I have used pickle juice in the past to marinate them but this time I just used a little bit of apple cider vinegar and some salt and then I merged all of the chicken into some water and spread it out so it was all under the water and put them into the refrigerator. All right, so again, I'm always looking for lots of options for anybody that is low carb or keto and you know that I love to make breakfast castrules they're just really simple to put into the freezer and really easy to heat up but normally I put like shredded potatoes in the bottom of the breakfast casserole. Well, I got this idea to try using spaghetti squash in place of the shredded potatoes. So one of the things I needed to do was roast up the spaghetti squash so that I could get all of it carved out and put it in the bottom of my pan before I assembled my breakfast casserole. So the way that I like to do it is I just cut the spaghetti squash in half, put it on a cookie sheet at 400 degrees for about 45 minutes and by then it's usually done. Then next time I make these muffins I will definitely be double or tripling the recipe. This day I was also going to be making some breakfast bowls and I wanted bacon bits to go in that so I threw an entire pack of bacon into my air fryer. I love just laying them crossways like this and doing a whole entire pack at one time. Next I had some sausage I needed to fry up for my breakfast casserole and I just used this mild pork sausage and put it on the stove top to cook while I was prepping some of the other things. Then I went ahead and cut up some bell peppers. I feel like this is such a healthy, delicious option to fill your breakfast bowls with and I did use one of each color. I'm not a big fan of green bell peppers. Let me know in the comments which color of bell pepper is your favorite. I also diced up an onion and then I went ahead and kind of stir-fried these just to get them nice and softened up and I think I put a little bit of avocado oil in the bottom of the pan for those as well. So by this point my spaghetti squash was done and I went ahead and sprayed my cookie sheet to assemble my breakfast casserole and just kind of like the shredded potatoes. I went ahead and spread these all over the bottom of the pan and then I started adding my other toppings including my eggs and normally I do about 24 eggs for a cookie sheet this size and I didn't add anything to the eggs this time. I just whisked them up so that they would be nice and scrambled to dump over this and then I did add in some nutritional yeast. It's really high in vitamin B and it is really delicious. It adds a nice savory flavor to anything that you add it to especially. I love it on eggs so I figured it would be great in this casserole. All right, the next thing I started to prep was another ingredient for my breakfast bowls and a lot of you have seen me do this before so those are actually radishes. They are a great low carb option instead of using small potatoes. So what I'm doing is just wedging them up and putting them in a bag and then I go ahead and put some oil in there and just mix them around so they're coated really well and then I dump them out on a cookie sheet and I did line it with parchment paper and I roast them in the oven and I think I roasted them at like 400. Oh, I'm not sure. I may have just kind of kept checking them until I could put a fork through them so maybe about 30 minutes and then start checking them. I did add some salt and then I think some onion or garlic powder but you could season these however. I actually think these would be really great with like some ranch powder on them. You could really do a lot of different things with them. By this point, obviously my bacon was done and cooled so I chopped it up for my breakfast bowls. And then this is how I do my breakfast cast rolls. I just cut them into squares. I let them completely cool and then I store them in gallons of box bags just in one layer inside the bag so that I can pull out the amount of servings I need in the morning for whoever wants it and I always get questions on how I reheat stuff and I do reheat these in the air fryer and they are absolutely delicious. I'm going to be making it again with the spaghetti squash because it just made the flavor so, so good. I love spaghetti squash already and this was just the perfect way to bring it out in a breakfast cast roll. So this is actually the next day and I went ahead and started in on my chicken nuggets so they obviously had gotten to marinate overnight and I just put some, you could actually use breadcrumbs but I put some almond flour into a bowl. I put some salt, some onion powder and then in the opposite bowl, I put some eggs and just whisk them up to make kind of an egg bath so it's pretty simple.  They're not that hard to make and they're just so much more healthy than store-bought chicken nuggets. They remind me a little bit of the Chick-fil-A chicken nuggets. They can just be not quite as breaded and all of that just like a Chick-fil-A nugget. Okay, so I whisked up some more eggs just because I wanted some scrambled eggs in my breakfast bowls and then I dumped them into my frying pan and just scrambled them up with salt and pepper. Next day was time to assemble my breakfast bowls and I also reheat these in the air fryer as well so you should get them out of the freezer and set the glass container right into the air fryer and they reheat just like that. So on the bottom I put the radishes, then I put some of the scrambled eggs and put the rest of the toppings in. This is one of my personal favorite breakfasts. You can put hot sauce on them or even some ketchup and you could even do regular potatoes. You don't have to do radishes like this. It's just a good low carb option. If you eat a little more keto like I do and it's just simple and easy and you could reheat these in the microwave as well. I've done that in the past too. Okay, so here are the chicken nuggets and basically all you'll wanna do is throw them right into the freezer once they've cooled on the cookie sheet, get them frozen and then once they are frozen on the cookie sheet, you can take a spatula and put them into a Ziploc bag and reheat the amount that you need at whatever time you're gonna be eating them. So the next thing I put together was some cookie dough bites and if you guys have been watching a long time, I used to make these very regularly and I'm actually making them dairy-free with a Kite Hill cream cheese, which is a dairy-free cream cheese, but you can use this same exact recipe and use regular cream cheese and they're still just as delicious but I feel like they're a great way to just get a little bite of something sweet and avoid eating like a bunch of ice cream or something like that. So I actually like to store these in the freezer and just pull them out whenever I want a bite. So all you do is mix together all of the ingredients in a mixer or you could do it by hand as well and I did use a stevia sweet and chocolate chip as well so really no, not much sugar and then I just use a cookie scoop and put them into a container that I can stick right into the freezer and they store in there and I can pull them out. I know that a lot of you through the last year or two when I've been making these have really enjoyed them as well so here's a little reminder that they are a great thing to have around especially if you're trying to stay away from a lot of the Christmas goodies or holiday goodies that you have around the house. This is just a good, healthy option. Okay, so my cookie sheets were all busy at this point with other things going on so I pulled out one of my nine by 13s and I just put some of those muffin silicone molds into there and I'm going to make up some lemon raspberry muffins and this recipe is gluten free. It's also keto friendly. I will leave the link below and it turned out really good. You can use frozen raspberries if you want to but I used fresh and here I am with this cute little pot I found on Amazon. I'll leave the link for it below. I really love this little saucepan and I don't have a microwave so I went ahead and melted my coconut oil on the stove top to add into this recipe and the ingredients were really simple. Once they were all mixed together, all I had to do was put them into my muffin papers. Along with the lemon zest, this was not in the recipe but I did add a little bit of lemon essential oil just to amp up that lemon flavor. The last thing that you'll do is fold in the raspberries so they don't get too smushed through your batter. I know this was a really quick meal prep. A lot of times I have a lot more packed into my videos but this is what I wanted to prep for this month. I hope it inspired you, gave you some new ideas, some new recipes and if you're new here, don't forget to subscribe. Leave a comment below that always helps me out and I'll see you all in my next video.


So Anna doesn't think that I can cover all the visual fields in ten minutes. Do you want her to cover visual fields? No. Okay, so just sort of to review, I'm going to just hit some of the highlights of how to do visual fields, how to document visual fields, and then the anatomy of visual fields. Well that's going to be very brief because most of that's going to be covered in the cases. So, you know, the concept of the island of vision in the sea of darkness, where the steepness of the slope of what you're able to see kind of increases rapidly and further out of the gap to the point where you can't see any of it all.  This is the most basic way of documenting visual fields, is what you're taught and do every single day. You're fixating your eye and patient's eye and presenting targets in all four quadrants of the visual field, not out here, this is extremely insensitive. The semaphore of you, when we're teaching the medical students next month, that's the habit that must be extinguished. I just do one or two fingers. Some people do one, two, or five. You have to make sure that the stimuli are presented straight on rather than kind of on an angle. This is the bowl that is used for automated perimetry, also for kinetic perimetry. The difference being that with kinetic perimetry the targets of varying sizes are brought in from the edge, from the non-seeing to the seeing, and the patient indicates the first point that they see them, the smaller the target, the closer towards the center they see them. When you join up those lines of where they do see them, it makes an ice octer, and this is sort of a demonstration of the kinetic versus the static perimetry. Here is, of course, the physiologic blind spot. It's an absolute scatoma. There's no retina there, therefore there's no vision. The other format that we use quite frequently is the tangent screen. So easy to use, so very useful. It can be used for non-physiologic vision loss for children and for people with very bad vision. It can also be used for extremely sensitive testing of the central vision for drug toxicity. Some people use a central red target. You document the visual fields by presence or absence of finger counting or hand motion or light perception in the four different quadrants, the right on the right eye, and the right eye on the right side, left eye on the left side. The only thing in medicine that is documented this way, backwards. Okay, so just to sort of cover the field of the anatomy of the vision, I love this picture just because it's like antique, but basically the concept is the right side of the brain deals with the left half of the vision, and you can see here how the left field of vision goes to the right part of the retina of both eyes and gets transmitted here over to the left side of the brain through those radiations and the tracts. The anatomy is dependent on, sorry, the visual field is dependent on the anatomy, and it's one of the nice anatomic correlations that we have in medicine. It's one of the reasons I think why neurothemologists are such happy people. So this is the field of it. This is the physiologic blind spot where the optic nerve is coming into the back of the eye, and then the fibers radiate in these patterns. The retinas is a demonstration here of an area of damaged retina just above the horizontal refa was going to lead to a scatoma down below. I actually like to use the physiologic blind spot as a reference spot, so if the patient is saying that the defect is towards their nose, they're going to be looking in the retina in a corresponding location compared to the physiologic blind spot. This is just another graphic representation, and I'm including this because it also talks about the pupillary fibers, specifically talking about the optic tracts, and the fibers that deque off the tract in the superior colliculus, the breaking of the superior colliculus, taking care of the pupillary responses, which becomes very important in an optic tract. Lesion characterized by an incongruous, meaning different in the two eyes visual field defect, often with a relative affluent pupillary defect, which is small. There can be damage to the nearby structures, which would include the temporal lobe, the thalamus is just right above here, and you can get associated damage with the cortical spinal tract as well. You can, because of this, get a pupillary defect without a visual field defect. It's pretty rare. The relative affluent pupillary defect occurs in the eye contralateral to the affected tract because of the different percentage of fibers that are crossing in the chiasm, and that's the correct way of considering it. I personally sort of think of it a little bit more in a mechanistic way, so if you have a left hemianopia, you have a bigger left visual field than you have right visual field, and therefore there are going to be more pupillary fibers represented in that bigger visual field, and therefore the defect will be in your left relative affluent pupillary defect from a left visual field defect from the right tract. This is just a nice little example here, stolen from Stanford of a tract lesion. The chiasm is just right here, and then the tracts are going here to the lateral genicula. This is meant to explain why you get bowtie atrophy, but we're not going to talk about that. We're going to talk a little bit about the lateral geniculate, which is an extremely small structure right here, shaped like a Napoleon hat. As you can see how close it is also to the thalamus and the descending corticospinal tracts. The lateral geniculate lesions are extremely rare, but much discussed because they're so cool. The lateral geniculate lesions come in two varieties, anterior, posterior, and I don't know if you're going to be talking about those more, but this is a representation of a classic anterior lesion, and this is a posterior lesion. I personally think that you need to just memorize how these look, because it's just too hard to go through the math every single time to work it out, but you can have your own way of remembering this. I'm thinking of this sort of looking at it anatomically as more of an anterior kind of a thing, and that is a little bit more of a posterior kind of a thing, but out yourselves out, you can figure out a way to memorize it yourselves. Retrogeniculate loss can occur from a variety of pathologies, including strokes and masses. I don't know that there's necessarily any way of figuring out before imaging what it is that's caused the defect other than by the classic did it come on slowly or gradually. Geniculate lesions are often seen with small strokes and masses, and particularly with thalamotomies, which are movement disorder surgeries. The temporal lobe lesions are typically superior visual fields. The parietal are typically inferior visual fields. Temporal lobe pathology would include things like hallucinations, seizures, oras, specifically rising fear, deja vu, jame vu, those kinds of things. Parietal are often associated with language or association problems. We'll talk a little bit more about that. Excipital lesions are often associated with reading problems, but can be almost asymptomatic as well. I don't think I'm going to have time to talk about the macular splitting and sparing. Temporal lobe lesions, as I said, can be associated with these hemipirotic hallucinations, language problems as well. This is a nice example of a temporal lobe lesion way up high. One of the things about the anatomy of the visual field that you can count on, and if you can remember this, it can be very helpful, especially the temporal parietal, is that the lower portion of the retina goes to the lower portion of the optic nerve, goes to the lower portion of the chiasm, and goes to the temporal lobe, and then goes to the lower portion of the lobe. The right and left and the chiasm and all that sort of stuff is happening independently, but the lobe stays below. So all of that, all of those lower things are going to give you an upper visual field effect. The parietal lobe, if you remember, is kind of up here, upper portion of the retina, upper portion of the nerve, portion of the chiasm, skipping through the temporal lobe and up through the parietal lobe is going to give you lower visual field effects. So the upper portion of the occipal lobes. And so to the extent that that's another useful way of trying to remember the anatomy, that can be helpful. Parietal lobes, lesions can be associated with some really interesting neurologic syndromes, language problems, hemisensory defects in the dominant hemisphere and Gershman syndrome of agraphia, acalkylia, finger agnosia, and left-right disorientation, which is extremely hard to document, especially if you have finger agnosia, because if you're asking which finger it is and they can't even name their finger, then how do you know? Kathleen and I have had a little thought experiment about that one. The parietal lobe, the non-dominant parietal lobe is associated with spatial disorientation, constructional apraxia, dressing apraxia, shaving apraxia, and anisegnogea, an awareness of the defect. And I just wanted to show you a nice parietal lesion. You can see that it's down below fixation. It is incongruous, but it's not exactly the same in both eyes. So we're not all the way back to the except for the lobes. And then this is my favorite picture of a letter that a neighbor wrote to my mom, which I think you've probably all seen at this point, which is, dear Ray, how are things going? Things are really great, blah, blah, blah. Have a little stroke. Don't let me drive. I don't know why. I'm going to first see you again soon. So obviously this is demonstrating left-sided neglect, but she's no language problems, right? She's riding away like a champ, and she is not really aware of exactly what happened. And just to touch on the exceptional projections, of course this is, remember, as I was saying, the inferior rim of the calcine cortex here is from the inferior, inferior, inferior. So now projecting to the superior portion of the nerve, the central fibers are more posterior, and there's this little rim of very, very temporal fibers that take care of the temporal crescent, which looks like that. So this is a nice example of the left eye visual field, the right eye visual field, and then the both eyes together visual field, where somebody has a hemianopia, was sparing of the temporal crescent. This is a really nice example. Sorry, the lesion was right there in the oximeter. That was oximeter, yeah. And so would that be more anterior or more posterior, more of the front end of the oximeter lobe or in the back end of the oximeter lobe? The back end. So the center fibers are involved, and the very, very anterior end of the oximeter lobe is spared because that temporal crescent is still there. So the posterior pole is more affected than the front end of the oximeter lobe. So it wouldn't be a crescent in that anterior oximeter lobe? Yeah, if the whole oximeter lobe gets out, then you get out your temporal crescent. You lose your temporal crescent. Not demonstrated on Humphrey visual field testing. Is it not demonstrated on Humphrey just because it doesn't go out? It doesn't go out far enough, because you can see it's way the heck out there. That's like at 60 to 80 degrees. But the patients may say, well I think I can see something out here and you try and get a stimulus into there and it's hard because it's way the heck out there and they can't really read with it or anything. I don't know if you need this. Do you need this for... That was something from him. There we go. All right, so now it's all cases all the time. The quiz is going to be interspersed, right? Well, it's some... Yes. So I got a little carried away, as I always do, so 10 cases and I was like, that's a lot of cases. So I kind of put a quiz between them. 45 minutes? I know. Well, we're going to work through it and as you know I like things to be a little interactive, so we're going to keep it a little interactive, keeping in mind the entire time limitations. But with visual fields, especially, I feel like you have to really talk through it and I think even the most experienced of us have to sometimes, I think, think deeply when we look at visual field deficits because of all upside down, right, left anatomy. So we're going to start with this visual field and so I'm going to get one of you guys and maybe let's start with one of the junior residents describing this visual field and then we'll talk about what this is and why this is happening. So, Tara, do you want to start? Yeah, so there's like some scattered scatomas almost like in the same location. So why don't you start with like, remember how you were taught to read an X, right? Yeah. So this is a chest X-ray of the right person, maybe you don't know, and what eye, so what kind of visual field is this? Okay, so this is a Humphrey visual field. And what kind of Humphrey visual field is it? A central ting. Well, see that little 30 there on the right? Oh, 30 dash two. So you have one, two, and three, and this is 30, so it gives you 30 from fixation, and which eye is this? I think this is the right eye. It is the right eye, and why don't you think this is a blind spot? Why do you think it's a physiologic blind spot? Physiologic blind spot. Because it's only located superior to the right eye? Well, no, but I mean, sure, but that's true, but sometimes because of the indices of the test you might not get some points there, but what you're seeing here is the fact that it's kind of within seven degrees or so of the fixation, and where you see here it's kind of within the 12 and a half that we normally have between the blind spot, the physiologic blind spot and the fixation. Myself and Paras here? 12 and a half. All right, so, and okay, so it's a Humphrey 30 dash whatever. You won't know this, but it's a 30 dash two visual field of the right eye. And as you mentioned, what kind of describe what you're seeing? So there is, it looks like an enlargement of the physiologic blind spot, and then there is a scatoma that looks like it could be near a fixation and then four other scatomas kind of in the midperfury of the all. Yeah, so I mean the gist is that you have these depressed quadrantic visual field deficits in each quadrant you have that, right? So does anybody recognize kind of pattern recognition what this field is? So let's start with categories. Is it brain, nerve? It looks retinal? Retinal? It looks retinal. Yeah. So to understand this visual field you really have to understand how Humphrey visual field algorithm works. And I understand that you guys have regular lectures and rotation kind of describing the algorithms and how to read visual fields. But what Humphrey visual field algorithm does it usually checks the quadrants first and kind of more central quadrants just to see what the kind of the kind of general threshold is in that quadrant. And so if the patient falls asleep at the beginning of the test or doesn't recognize the test is started they actually miss those areas that the Humphrey visual field algorithm checks. And so you get this visual field where you have these isolated quadrantic defects. Now this can be of course retinal lesions but you have to look at the retinates and make sure they correspond to these particular lesions. Does that make sense? So Lee, do you want to take this one on? So this is a gentleman we saw a few weeks ago and he's got thyroid eye disease and had multiple surgeries and he does his visual field and this is what it looks like. Looks like he broke into it. Did he start it to the patient? Yeah, that sounds good enough. So this is a Humphrey visual field 30-2. Sorry, I'm going to take it back. Is it 30-2? Or maybe 30-2. And why is that? Because he has his 30 there. So the question for you is what amount in degrees of visual field is a Humphrey 24-2? Humphrey 24-2 tested. And I'm giving a hint. Horizontal and vertical. So this is 10. This is 10. This is 10. Maybe it's too early to do math this morning. Well, it's 24 on the other side. Sorry? Yes. So 24 and then 30. So it's a combination of... Yup. It is turned into 2-2 math. Alright. And so in the horizontal versus the vertical you get 30 plus 24, 50-4 degrees. Do you know the reason why we get 30 degrees in the nasal quadrant? No. So Humphrey visual field was designed to check for glaucoma. So by design the test is to check for visual field deficits associated with glaucoma. The earliest visual field deficits commonly associated with glaucoma is a nasal step. So this is why you have 30 degrees here and that's why they kept it when a 24-2 algorithm was designed versus a 30-2, which is an older algorithm. In order to speed up the test reduce the amount of visual field but increase or still keep your sensitivity up for glaucoma to see the field deficit. So hence you have the 30 degrees nasally that is kept in the 24-2. Alright, so the pattern recognition of this visual field is what does that mean? The patient wasn't attentive during the testing. When during the testing? I think later on. Correct. So this is again an important aspect of interpreting visual fields is understanding how the visual fields are performed and how they're tested. If we use the information that we got from the previous case we know that these central quadrants are tested first and so when the patient is paying attention they've got their central quadrants in each eye but then they kind of fall asleep or they're tired or they're malingering and then they kind of give up and stop pressing the button. And so you have this pattern of a cloverly visual field test and it doesn't always indicate that the patient is malingering but it can also indicate somebody who is tired and just falls asleep at the end of the case or at the end of the test. Nika, do you want to take this time? Sure. So this is a visual field defect I'm not sure what it is maybe a 24-2 of the not sure well I'm not sure which eye as well the pattern deviation the maybe the left and right eyes which shows a central OK So this patient is a 79-year-old man who came into our clinic a few weeks ago and he complained of difficulties driving and his wife thought he kind of drove the road a little bit before she warned him and on two separate occasions these visual fields were reproduced this was a reliable visual field and what is really important to note about this field is kind of symmetric what I'll talk about throughout this lecture is about how we're looking at the flavor of the visual field so it doesn't always have to be perfect because of the imperfections of our field testing but the important thing is when you look back at the fields you have to think about the pattern and the flavor visual field rather than just well it doesn't quite fit we're going to see a few cases later on that show us that but this is basically as you can see almost like a ring scatoma so it doesn't quite form a ring but almost there so that's what I mean by the flavor so the vision I put for you here on purpose because it is not a central visual field but a central kind of ring scatoma and you know the definitions about central, paracentral versus mid-perforal ring scatomas kind of are beyond our discussion here but it's important to understand what things can cause it because there's a lot of visual field deficits that can present that way and it's relative to the anatomy that Dr. Warner had discussed earlier so what I want you to think about and tell me what clinical tests would you be able to do to confirm that this is a maculopathy versus an optic neuropathy so we talked about this and the visual field approach to visual fields or approach to vision loss a few weeks ago just a few tests that you guys can think about sorry, yep, very good multi focal multi focal, yeah I mean that's great and of course we talked a little bit about color vision but you have to think about how you're going to differentiate in this patient between maculopathy and optic neuropathy and of course part of it is your clinical exam this patient was sent by an ophthalmologist he had a full dilated exam and this was sent as an unexplained vision loss of this particular pattern so I don't have a color photo for you because it's not impressive and we actually didn't take it but I will show you this and what this patient has is large areas of geographic atrophy and as you can see on the OCT you have outer retinal atrophy which is consistent with GA but on clinical exam it's difficult to see because there was not a lot of pigmentation there was not a lot of drusen it was just atrophy and maybe if you're not looking carefully enough you're just not seeing it well so again the clinical exam is important but this was an ophthalmology referral and it's easily missed these kind of things you might not always look as you expect them to look I just want to point out again this is talking about using the physiologic blind spot as an anatomic reference point so you know that you can't really see it very well because it's an absence but Anastasia why don't you point out that's where the physiologic blind spot is on that visual field and the same thing on the other side and so you could say okay well the physiologic blind spots here and then the foveas here and then on the other side you've got about that same amount of space so you know that the pathology that is being demonstrated by this visual field is between the physiologic blind spot and about the same distance away from the macula so if you kind of look at that that's where the central 10 degrees of the 24-2 is representing is this kind of center area within the arcades and you know again the other thing to point out is you can look at this physiologic blind spot and see well is this a psychocentral scatoma but as you can see the visual acuity was quite good and of course you have the corresponding pathology to see on my presentation they didn't do a OCC no because they didn't see anything on the macula and thought the macula looked good it was really dramatic here but on the real life it didn't look good yeah again this is because of the imaging we used right so you wouldn't see much you might see a little bit of color difference in the retina just because of the ARP atrophy but you know if you're just doing a slit length exam and you have a quick look and say you had a occipital lobe lesion or say you had visual field that had congris-central scatoma and you were trying to decide whether or not this is maybe a rebel lesion which is an occipital lesion would you have any kind of visual acuity changes that would kind of induce that maybe this is more of an occipital versus well I mean you have to think about where that your center of your visual field is and what fibers correspond to that so you'd have to have like bilateral occipital lesions with only affecting the macula that gives you this which is what can happen so the answer is with a unilateral occipital lobe lesion there shouldn't be any acuity loss but with bilateral occipital lesions you can be anywhere from 2020 to blind but looking at those visual fields that's definitely a good thought you just want to look at each one of those maybe the black one the greater than .05% chance that this is abnormal right the ones that you're surely abnormal and you look at each one and these are not congris the things you want with an occipital lesion which is a great thought you really want those to be a little more congris but if you look it's like it's not congris right it's almost like the number of spots that are different is way more than the number of spots that are the same right alright so this is a case of a 24 year old who came in because she had these new headaches and she had some visual lures and her PCP watered MRI and it was okay and so she was told to go see an eye doctor so she comes to see an eye doctor and she comes in with this so again maybe Reese, pattern recognition so it's 24-2 visual field and then it's she's got kind of bilateral generalized constriction anything else you can call this um keywords Central Ireland yeah I mean this is we call this a ring scatoma okay so you got central so basically it's a scatoma that's centered on the visual axis or the visual center and I think this is a really really really important differential diagnosis to understand that I don't think you guys get taught enough and um you know a ring scatoma like I said is an annular defect which is centered on fixation and it encircles fixation but visual acuity is preserved okay so I briefly mentioned that um you can get central paracentral or midperforal ring scatomas it depends on the site of pathology um we saw kind of more of a central a ring scatoma in the case that I showed previously um the paracentral usually incorporates the blind spot so this is where you see um things like glaucoma, coalescing inferior to your arcuate causing a ring scatoma or you can see that of course in any type of optic nerve disease with arcuate defects and then midperforal is usually seen with a non-advanced retinitis pigmentosa or a faked correction where you get the jack in the box phenomenon that we often talk about um and that usually is between 30 and 60 degrees which um not often um if it's early enough not picked up on a Humphrey test because of the amount of testing that we do but sometimes is so um this is a acute macular nerve um yeah it's a specific condition that we don't fully understand yet and basically it's just uh like we think is an inflammatory or possibly even vascular condition where you have acute paracentral visual field deficits sometimes you get central visual field deficits but then the central vision comes back and you get this paracentral defects that stay um it is it is an entity um that is relatively new um but it has been um described in the literature uh before now one thing I did want to mention you know we did see the um uh geographic atrophy in the previous case that I showed you um all the rest of the things I think are a little self-explanatory but um this is an interesting timbit um there's a kind of a not so new entity but people talk about something about coffee and donut maculopathy so um you know there's cases been reported of patients who drink like 20 cups of coffee a day so be careful and don't do that but the thought behind that is um when um we have a dentist in a vasculature that uh basically vasodilate um retinal vasculature and coffee is thought to be an inhibitor of that and so it causes vasoconstriction so uh presumably uh when you I guess drink a lot of coffee and continuously vasoconstrict your uh perimacular fiber of perimacular vessels you have um an impairment of the macular blood flow and that in turn causes uh perimacular deficits or visual field deficits so it's kind of an interesting thing that's kind of relevant um to us but um phobia is good because it's still getting the the uh uh perfusion from the coroid because it's so thin um but you get these paracentral or central abarynx sputomas okay so important to keep in mind so this particular patient um had uh these peripheral retinal pathology that you can see here and um um she had a retinitis pigmentosa okay this is the next case 64 year old man with blurry vision in the left eye I think this has to be an easy one just to be quick okay what does this look like Ashley? uh so this is a 24-2 and a uh inferior um hemi defect in the left eye so altitudinal so uh since this is neurophthalmology um what do you think this is classical as a student? yeah so this patient did have an AION and why does this make sense with this OCT? you're part of the nervous you're part of the legal field so the one question I do want to ask you though is how long do you think it's been since he acutely developed an AION? over four weeks yeah so I think usually kind of six weeks six to eight weeks is when you think about atrophy setting in um to the optic nerve so um it's important to kind of realize that if there's no edema that it's probably been an extended period of time now if again I think we've kind of discussed this point before but if I just see atrophy like this and nobody's told me that he's had swelling what would I be concerned about? yes so compressive optic neuropathy so again think about it if you do not see swelling in an AION classic an AION presentation you have to rule out compressive optic neuropathy so if this person came and swollen you would scan it? well if it's a classic you know presentation and he's got the risk factor yes then um probably not but if as he did not and it was not a classic presentation okay 35 year old woman with this visual field deficit Kristen? yeah Kristen we've got Kristen very good it's like bonus points for a neurologist I don't know what that means so what's supposed to be there? what's normally in that area? so enlargement so this is a bilaterally enlarged blind spot very good and again you should have a differential most common things that cause an enlarged blind spot um of course dyskidema is one of those things that we always have to think about and you have hope that you do look in the back of the eye to confirm or deny that um you can have peripapillary retinal lesions and um coriditis or something like that or atrophy um or peripapillary atrophy just in myopic tilted nerves that you can get enlarged blind spot and um one other entity that's not really good to think about because you actually don't see much on examination and often um it's missed because unless you do specialized testing um you will not pick this up um so acute idiopathic blind spot enlargement or variation of the mutes syndrome is important to keep in mind especially when you have a unilateral um isolated temporal deficit that's an important thing to rule out so it doesn't send you down the garden path looking at brain lesions okay so this lady had um alright so this is the next case um and uh again this should be kind of your garden variety of things that um we need to think about and like I mentioned to you before because of the inconsistencies in field testing and lack of exact precision um we look at the flavor of the visual field so this lady came in um because she went to see an optometrist to get by focals um he did a screening visual field and he noticed this visual field deficit so you guys can just generally yell out what do you think this is yeah so this is a by temporal visual field deficit and um you know yes there's a few lesions here but again the flavor is that it does respect the vertical midline so you really have to think back right so you have um which portion of the superior versus inferior visual field is located um is it inferior or superior inferior visual field so that would correspond to correct so what is the most common lesion in the pituitary pituitary adenoma right so macro macro whatever but that's the most common so this is naturally how it works it expands and it pushes on the chiasm it compresses inferior chiasm and causes your superior visual field deficits alright so this this is her um MR which uh showed of course chiasm compression from below I don't know if you can like even see a little bit of it there and um she was operated on alright next case is a 41 year old woman with a three month history of decreased visual acuity in her left eye she was sent by an optometrist um because he thought she had a CSR and um uh she was sent to us to treat it and uh I uh this is where I profess my love for amsla grids because I really do like them and um I I want to kind of briefly mention the fact that um you should really differentiate on amsla grid whether you have like a field deficit or metamorphopsia so um you know with things like CSR you actually get metamorphopsia because there's some movement of the uh of the retina kind of side or forward and there's distortion so you always get metamorphopsia type field deficits whereas with a field deficit or absence of RP photoreceptors gangram cells or whatever else or damage to them you actually will have a deficit um or blurry spot or a visual field deficit so it's really kind of important for you um to ask the patients what exactly they're seeing if it's a metamorphopsia or a visual field deficit and um we had a look at a back over and we're like what? I guess pretty good macula let's at that time was like 2013 we did a serious OCT so um she uh of note is the fact that she had a visual acuity on the right of 2020 and on the left of 20 over 100 okay but normal visual fields oh sorry normal um um not normal macular exam so we did a goldman visual field and so if you look at this visual field um I really again want you to think about that flavor okay so like what is the general area these sceptomas are in there so where is my mind going exactly and the reason why you know it's you know okay fine say maybe that's in a large blind spot but it's not really going right like it's going straight to the vertical to the vertical midline there and the same thing there now this is again to speak to the in precision of our visual field testing she has even though you don't quite see the involvement of the center with this particular goldman you know that the center is involved because why she's 2100 right so she has a central visual field deficit on the left very good so really important it doesn't look like your classic your you know wedge defect or you know kind of your junctional scatoma but this is this is your junctional scatoma which is maybe a little bit harder to pick out and you're not always going to see kind of where it's described nicely and drawn in with the wedge defect but this is your junctional scatoma so this patient had a large intercellar mass that was about two and a half by about three and a half centimeters it was elevating the optic chiasm clearly compressing one of the interuptic nerves and the concept that we always talk about in junctional scatoma is what it's a bit of a theoretical thing and anatomically not supported but what is the name of very good so von Wilbrensney is something we talk about theoretically to convince ourselves that this junctional field deficit makes sense so this patient actually had pituitary apoplexy because she had some methamoglobin in the in the lesion and so she was operated on so is that just kind of you can see that just like or regularly on the just quick question this is so bit anatomically this is a left junctional defect correct so she's come exactly she's compressing her left optic nerve right and so you just have to always think about chiasm with the junctional so this is one case before we do the quiz this kind of incorporates the fuel things that Dr. Werner talked about and kind of helps us get more conceptualization of the anterior visual pathway so it's a 49 year old man who presented with a headache and ptosis on the left and double vision and as you remember I talk about the three musketeers of extracurricular motility so you always need to talk about the pupil he had some light near dissociation of the pupil on his left side and he doesn't typically get headaches and this is what so again what is so take this one step at a time what is the flavor of this visual field deficit or kind of where's the biggest abnormality very good so write homonymous write homonymous and if you forget about this it's right homonymous and I need a few more qualifiers there or one at least one right sorry so we talk about complete and incomplete homonymous visual field deficit if you forget about this because we'll talk about this in a second but this here is a complete homonymous visual field deficit where is the lesion with complete homonymous visual field deficit we have tracts so actually you cannot say there's nothing in that visual field that qualifies for a location once you have a homonymous visual field deficit that is complete it is retrochiasmal so you just there's just no way to tell so it's either imaging or some other auxiliary testing we can talk about later they can help you distinguish where exactly it is but there's some help here so if you look at let's talk about this here so this visual field deficit which is an inferior temporal on the left right what on the left correct which what could this be what pattern could this be associated with so if you look at this and you look at that what could be hiding behind this homonymous field deficit very good but also if you just were to isolate the left eye and just look at that what would this give you an idea so you have options here because you either have a visual field deficit this is complete so you think it's retrochiasmal somewhere you think maybe that could be by temporal so that locates you into the into the chiasm right or you can have this altitudinal visual field deficit which points you to the to the nerve and if I gave you some clues here so there was a relative after people are defect on the left and this pattern of the OCT and you're going to probably wear it to the Saturday Christmas party very good alright so you are really worried about this I think you more exhibit a little here you think you want an anterior here exactly so I just wanted to go over this so we can put this together and the problem here Dr. Warner had mentioned about an APD on the opposite eye here unfortunately because you have this optic neuropathy with global atrophy here now it doesn't quite meet the opposite eye or APD criteria subsumed into the optic neuropathy alright so this gentleman had this large pituitary macro that was like invading all tissues around and involving the tracts as well which is why you get the bowtie atrophy and why you get a homonymous field deficit alright here's a quiz and then there's a few pieces after we have time but progressively harder essay points essay questions we got you multiple choice this is separating the week from the jab here guys there's a signed reading for each lecture right we did the reading when they cut down on our lecture schedules we pumped up the reading and plus we brought Anna on board this is what I was discussing with Dr. Warner yesterday I was like well I can use a quiz to just reiterate which we just learned or we can use the quiz to learn some more we'll do half and half alright good alright as far as we're going to get that's the answer to this question very good D so why wouldn't it be a full field that'd be normal in both right no differentiation whatsoever why is it not a DEP it looks a nerve but what would we do with maculopathy or optoneuropathy the VEP is actually very driven by the folial response so you can get reduced VEPs with optoneuropathy and maculopathy so that's not the test to use again these are the things we think about when we order testing why is it not EOG what do you test very good and of course multifocal ERG will tell you that there's abnormalities good okay what about this one sorry be very good so it is actually more common in children than adults you have supercellar mass which it is probably one of the more common causes of a C-cell nystagmus even though C-cell nystagmus is very rare and it does have a favorable survival prognosis of about 98% of 10 years or so but we talked about this right so inferior versus superior visual field deficits and which part of the chiasm is being compressed you just need to understand the anatomy of the chiasm of fibers to answer that question do you need the list of the ring scatomas to help you or do you guys I think this is just pretty much from that list so I think you can mark that as you wish so does anybody know what riddle phenomenon is and it's neurological that's why so um so I forgot so riddle phenomenon is actually this visual field phenomenon where if a patient has an injury to generally the occipital lobes or occipital cortex sometimes it can be seen with other lesions as well but they perceive moving targets but not static objects so if there's a car parked there they do not see it but as the car moves they begin to see it and we think it is because there's kind of more predilectional visual system to respond to better to moving stimuli rather than stationary stimuli and the last two questions I think are really important to know about because Hemifield riddle phenomenon is a relevant phenomenon clinically because we see patients with bi-temporal deficits and so basically what this is is that you can see if the patient has any predilection so this is double vision without any peresis of extraocular muscles and any predilection of a patient with visual field deficit where you have a phoria so either a vertical an exo or an esophoria all of a sudden because you don't have overlapping visual fields you're losing that fixation so you know how we break fusion when we do our tropion phoria testing you're pretty much doing that with eliminating their visual fields so eliminating their hemifield and so once fusion is disrupted the existing phoria just has no the existing phoria just has kind of no check on it because of that fusional drive for it to keep the eyes together so once the fusion is disrupted the pre-existing phoria comes out and becomes a tropia and so patients will either have a crossed or uncross diplopia depending on what their tendency was prior to having their hemifield visual field deficits so well described phenomenon it is sometimes asked about on boards and this is why I put that up there and then the other important thing about bi-temporal deficits is this phenomenon of post-fixation blindness and what that deals with is the fact that of course your temporal visual field is affected and so when you're fixating on a near target so when you have a near target again this is your phobia and this is your center so you're not you're missing, your visual field does not allow you to see anything that's post-fixation so patients are not aware of it but they're actually going to be missing so fixating a near target they're missing everything that's located in that area because of that overlap so again it's a related to fixation when you fixating a near target when you're looking far away that's not an issue right because you're not overlapping but here because you are you've got this post-fixation blindness phenomenon almost never described by patients but we actually had a guy at the VA who that was his presenting complaint because he was a truck driver and he observed in the long hours that when he was looking at the car right ahead of him he couldn't see the cars beyond which incredibly rare observation I've never ever heard anybody mention it ever before or since except for this truck driver and so it that's not really a near target but the same principle applies it's not an infinity so anywhere closer than infinity this will of course apply post-fixation right okay so good observation alright so I'm going to stop here what do you have two or three two oh I want that third eye first is the third eye refractive okay guys I can't go


is today's an important message on Monday, recovery Monday, episode 32. It is that not everything is recovery. You cannot be recovering 24-7. Life is happening at the same time. Life is recovery, recovery is life. So let's talk about it today. Let's pull the chat up. So you kind of pile it in the room. Hopefully the usual suspects will arrive. As you get in, just let me know that you can hear me. Let me know everything is working. I'm gonna turn up my volume just a little bit. Make sure everything is good. Seven people. Where's everybody coming from today? Has everybody doing? I will remind those of you watching while everybody's sort of filing in that every Monday, at least for the past 31 weeks or so, we have done lessons out of this book, The Anxious Truth. We just take one lesson after another out of this recovery guide. If you do not have a copy of this book and you would like it, you can get it on my website at the anxioustruth.com. Everything I do is there actually. My books, all the podcast episodes, all my social stuff, the anxious morning email newsletter and podcasts is there, which is free, so go check it out. So yeah, pop on over to the website and see what's there. There's a ton of good stuff, hopefully for you to take advantage of. So today we're gonna talk about the idea that not everything in recovery is recovery. We also have to know that life is happening and the two are kind of connected and intertwined. So we're gonna talk about that. What is up everybody? Who do we have? Bethany says she can hear me. Thanks B, South Africa, Sweden, Oklahoma. Katya's here from Russia. Long Island, fellow Long Islander, looking down at the comments, not trying to be rude. I just gotta see the screen. If you're coming from the Facebook group, I'm sorry, Restream doesn't show me your name. So if you wanna make a comment, just maybe tell me your name. I only see Facebook user. Tennessee is here. We always have a really varied audience and I certainly appreciate that. You guys come from all over the world. And it's great that we get to gather here every Monday at this time. We only have one more of these. So we're gonna have to think about what we do after this. But hey, Bethlehem, Pennsylvania, what up Colleen? So we got about 30 people. Everybody's still Nova Scotia is here. Everybody's still filing in. Let's get into it. I wanna talk about the idea that not everything is recovery. So one of the most common mistakes, and it's not really a mistake. I'm not blaming anybody. Everybody gets caught up in this. In recovery is that people start to think that every waking moment is about doing recovery. Like, and I get it. Everybody wants to get better. Everybody's desperate for improvement. You wanna do everything you can, do it right, make all the right moves and move forward. I get that. But it's easy to fall into the trap where every waking moment is seen as recovery. Like, I have to do my recovery every moment that I'm awake. And that can be bad. That can lead to paralysis or over-analysis where you get into a situation where you're constantly questioning everything that you do all day long. Is this recovery? Is this recovery? Is this recovery? Am I doing it right? Is this wrong? Is this against the rules? Am I messing up? So it's really common for people to kind of fall into that trap where they start to judge every single thing they do during every waking moment in relation to recovery. And if it's good for recovery, bad for recovery, and if it's making them better or not. And that's, you don't have to be there. That's not practical. You cannot be recovering during every waking moment. You cannot be actively recovering 24 hours a day, seven days a week. It just doesn't happen that way. So that's the first part of the chapter that I kind of wanna go over. I'm just gonna read through a little bit as you go. And the common questions that people start to ask is, should I be doing this now? Am I supposed to be having these thoughts? Did anyone else do, and then you insert your thing, this thing during recovery? Am I doing it right now? What about now? Am I doing it right now? So that becomes really, really common, especially in the beginning, where you're trying to make sure, like, oh, I just wanna make sure I'm doing it right. Which I completely get, especially after maybe what could be a prolonged period of months or even years of sort of maybe going down counterproductive directions where things weren't changing. Now everybody sort of gets fired up because like, oh, I got this cool new way to recover and you get really caught up in it and you wanna be doing it all the time, right? And you're hoping to get really fast relief if you do it right. But that's not fair to yourself, it can't happen. So you have to accept that in the end, life is actually happening all around you, all the time. So while you are recovering, life is actually happening. And this is really important.  And Roger Waters, who was the bassist in Pink Floyd and wrote many other songs, once said in an interview about the song Time, Pink Floyd has a song called Time. And he said, the origin of that song was kind of a British thing when he was growing up and he was sort of being taught that like, well, you're learning to get ready for life. You're always getting ready for life. And he realized one day, well, wait a minute, but life has been happening since I was born. What am I getting ready for? I'm in it now. So he was sort of being raised and taught like, hey, we got to prepare for life. And then he realized one day that like, oh, wait a minute, life is actually happening now. And that was a hugely impactful statement to hear him say in that interview, which was years ago. And if you ever want to look it up, it's there somewhere, but and that kind of prompted him to start to write Time, which is one of their classic songs. But it really does apply in the recovery situation too. Like we often make the mistake of thinking, oh, I have to do recovery so that I can live my life. But really and truly life is happening even during recovery. And if you want to get super philosophical about this, and I wrote about this not too long ago, I think in one of the morning newsletters, you actually don't recover to do life. In the end, when you start to get the hang of this and get into a groove, you're actually living life again to recover. Boom, like mic drop, I don't know, mind blown sort of thing. But that's true. That is actually true. We don't recover so that we can live our life. We start to live our life again, little by little as best we can so that we recover. See how that works? It's actually the other way of what most people think. So it's important to recognize that life is happening all around you, even while you're trying to do recovery, you cannot separate them. Now in the book, I talk about it as soup. Like if there's life soup, as we live our life, we're making life soup. Recovery is just one of the ingredients in that soup. So you can't take the ingredients away and somehow deconstruct the soup like the soup is there.  Recovery is just one of them. It's not the soup itself. So we don't make recovery soup and put life in it. We're always making life soup because we're just in life anyway. So recovery is one of the ingredients in our life soup. You cannot separate them out. It's still just soup. It all gets mixed together. And once it's in, it's in. So you can't take it back out. That's really important. So you have to remember that life is happening all around you and that in the end, we have to start to really think about the fact that we're engaging in life in order to get better. So not everything, first of all, not everything has to be judged in the context of is this recovery? Is it not recovery? Oh, my friend called me. I haven't seen them in a couple of months and they want to go out for coffee. Is that okay? Like if I do that, is that recovery? If I don't do that, is that avoidance? Like just do the life thing as best you can and it's not gonna be perfect but people tend to start to take those sort of life events and try to analyze it based on is this good for my recovery or is this good recovery? Is this good form? Is it a mistake? Will it be air quotes too much? We'll talk about too much in a minute. Very common concern. Like oh, this is gonna be too much. It's gonna set me back. It's gonna ruin my recovery. But in the end, the goal is to try to get to the point where your friend calls you and asks you for coffee and you really wanna go, you don't even think about it. You just say yeah, sure, I'll meet you for coffee tomorrow. So the only way to get better at that and to get to that point is to actually go ahead and meet that person for coffee even when you're not so good at it now. So it's super important to remember all of this. Life goes on. Now, how do our exposures fit into that? How does our intentional practice fit into that? How does sort of the mechanics of what we call recovery fit into that? Well, we're trying to get to the point where we use those exposures to sort of artificially manufacture situations that will trigger your fear, right? Recovery is all about learning to move through that fear and building a new relationship with anxiety, putting it back in its normal place, healthy place in a human life. And to do that, we have to actually face it. So we use exposures as ways to sort of artificially manufacture the anxiety, the fear, the panic, the discomfort, the thoughts, the sensations. We use exposures to manufacture those things, to trigger them in situations that you might otherwise not be in. You've withdrawn from life in certain ways, depending on what your context is. So we start to intentionally make activities up that sort of simulate life, but they're really designed to trigger those feelings so you can practice going through those feelings. Now, that's the way everybody starts. We start by just sort of, I'm gonna do my planned exposures, my planned practices. That's okay. There's a reason why we do it that way. But as you start to go down the road, you have to start to think about integrating life into that too. Because our exposures, they were basically mimicking life events. Like nobody has to learn to drive around the block. Driving around the block doesn't help you at all. In life, driving helps you in life. Oops, I gotta turn off my screen blanking. I forgot all about that. Yes, skip it, please. So let me turn this off. Anyway, driving around the block isn't a life skill, but driving is a life skill. So we take driving around the block as practice for getting back into the skill of using driving as part of your life. Staying home alone for a half hour is not a life skill, but the ability to be alone or with other people and in all contexts and be okay. Yeah, that's life. So we manufacture these things with exposures to artificially trigger those things. But down the road, we actually start to have life seeped back into that. So let me sort of dovetail them together now. Now you're doing only planned exposures, especially in the beginning of your recovery. You've withdrawn completely. You're refusing to engage with life, generally speaking. So now you're going to start to do planned exposures to start to get back into that. But then life is also gonna throw stuff at you. I did a podcast episode, I don't know when, about unplanned exposures and life challenges. If you go to my website, theangstruth.com and search for unplanned exposures, you'll see that. But life will begin to throw challenges at you. And you see it all the time in the community. Oh my God, I just got invited to my friend's wedding and that's in two months, how am I ever gonna do it? I haven't been to a restaurant in two years. Well, life starts to happen and life throws things at you and those are unplanned exposures. So in that situation, that's when we start to have to embrace the idea that, oh, that's right, I'm in recovery right now but life is also happening. Life is also happening. And the object of my recovery is to begin to live life again so that I will get to the end of recovery. So I'm gonna have to go to that wedding. I can practice doing things but I'm going to do it because I understand it will be really challenging. I might feel really uncomfortable. I might feel uncertain. I might not have very much confidence that I could do this but I'm going to do it because this teaches me how to live life again and that is how I recover. So it's super important to do that. Just to go through this a little bit. One of the questions that people wind up asking, they start to ask, should I do that? Or if I don't do that, is that avoidance? Am I doing too much? Will I trigger a setback? But in the end, what I essentially wrote here is, you're gonna be tempted to overanalyze everything that isn't specifically part of your recovery plan. You may worry that accepting an invitation to share a cup of coffee with a neighbor isn't right. Your child's upcoming holiday band concert could become a source of stress as you try to make it fit into the context of your anxiety disorder. I'm asked all the time about vacations, family functions, job interviews, parties, picnics and a wide variety of other typical life events. Like, oh, does this fit into recovery? Is this okay? Is this part of recovery? And the answer is, yeah, it's part of recovery. It's all part of recovery. Now that being said, it's important to understand that if you have withdrawn for the most part for a lot from life, and for instance, in the case of an agoraphobic, if you're basically not leaving the house without a safe person and haven't done that for a year, it's a huge ask to say, oh yeah, my family reunion is across the country. I have to fly six hours and stay for two weeks. That's a big ask, of course. And I wouldn't, that's not where you start. But we're heading toward that. And along the way, we try to do as many regular life events planned or unplanned as we possibly can. Life is recovery and recovery is life. As we start the process, it looks almost like all recovery and no life. But as you go down the road, and I know I'm sort of watching people in the comments here and I'll go back and go through that, some folks who are down the road and a little bit more advanced in this can attest to this. And if you're in this situation, by all means, chime in. At first, it's all recovery all the time. But as you start to get down the other side of the road, it just becomes life most of the time. And you realize like, oh yeah, I'm still recovering. So at first, it looks like all recovery.  But in the end, it was all life anyway. So you can't draw a line between the two. So it's really important. There you go. So GBG says that for sure. I know Kathleen is here. Kathleen is out on a trip. It's a big deal. But yeah, in the end, this is what happens. Like they start to become intertwined.  Life itself becomes the exposure more and more and more often. And suddenly, you discover that you're not just recovering anymore. You're living again. Maybe not perfectly. Maybe not exactly the way you want to. But over time, you've gone from doing recovery to doing life while recovery is still happening. Really important. It's this may be one of the most subtly important lessons in the book in the end. I did in the end, you know what? I'm not going to go through the whole thing. I don't want to read the whole chapter for sure. But the one thing that I do want to end on, and then I'll go into comments and questions and stuff is, and I'll just read what I wrote. Finally, I want to touch on the drive to have someone confirm and validate every life choice you make along the road to recovery. This is not required, which I say all the time over deadly. At first, you're learning. So you're going to ask those questions. That's normal in the beginning. Like you're going to want to ask me. You're going to want to ask the Facebook group. You're going to want to ask your support people. Is this right? Am I doing it right? Am I doing it right? It's natural at first to do that, but you have to start to wean yourself off that. Is this okay? Is this okay? Is this okay? It's actually not required. Just go and do and let the experiences teach you and guide you. So much of recovery is learning and rediscovering your own capability and building that sense of competence and confidence that you don't need the constant assurance from your support group that, yeah, that's okay to do that. Yes, that's okay. Yes, that's okay. In the end, you'll start to back away from that, but you don't have to have every single step validated for you. Like stand up, start to do things, and then you will understand that like, okay, how did that work for me? It worked like this, it worked like that. It worked like this, it worked like that. I can adjust. I can learn from this. So so much of it is learning to navigate on your own. Not that your support people should abandon you or shut you down, but in the beginning it's really common to want to verify that you're making right choices on every step, but as you start to progress and get the concepts under your belt and understand the concepts of recovery, I did a podcast episode on this too. This is your main to this topic. I urge you, if you want to find a way to integrate recovery and life and make them start to mesh together and look like each other, one of the best things that you can do is to start to understand the concepts of recovery so you can apply them rather than continually asking for directions. I did a podcast episode on that in the last six months. Again, search for that on my website. It's critically important. That's one of the ingredients that helps you move from recover, recover, recover to life. Like, oh, I could just apply the concepts because I understand why I'm doing this as opposed to asking for tips and tricks and directions in every specific circumstance. Okay, now tell me to do if my heart beats too fast. Now tell me what to do if I get nauseous. Oh, now tell me what to do if I get depersonalized. Understand the concepts underneath it all and you could start to apply them in multiple contexts. And when you start to apply recovery concepts across multiple contexts in multiple situations, suddenly, accidentally, you start living life again. Thank you, B. So Bethany just put up that podcast episode. It was episode number 179. When you listen to my podcast, if you know the episode number, you can always go to the anxioustruth.com slash and the episode number and you get to it. So thank you, I appreciate that. All right, peeps, that's about it. So 17 minutes in, I'm done yacking. Let's go through the comments and questions. I'll answer as many as I can. Let's see what we got here. Washington, New Hampshire, and then I'll be in New Hampshire actually in June. I will be in Nashua for about a week. Let's see here. Lebanon, Pennsylvania, Canada, St. Louis, Taos, New Mexico. Donna says, I love how this flows into many other things. I'll just put Donna stop. I'll start putting stuff up on the screen best I can. Can't put them all up on the screen. It can't answer every question, but I'll try. I'm an emotional train wreck.  I'm sure that you're having a lot of emotions, but you're always handling it, always, right? But I know how, I know to get out there anyway, do it anyway, walking out anyway. So much of this happens. And part of that recovery process and learning to live life again is that, yeah, sometimes life will trigger big emotions. Sometimes we have really shitty days where we feel sad or we're shattered or we're angry or we're disappointed or just things that humans feel. But we begin to learn that, oh, this isn't necessarily a recovery question. This is just a life question. So I'm gonna have to get better at experiencing life and all its forms. So there you go. No, no, no, who is in a Pink Floyd fan says, says Colleen, I don't know. I haven't found one yet and I hope to never find one. If you're not a Pink Floyd fan, we can't be friends. Anyway, this is good. So let's put Nikki up on the screen here. When you learn a new way to relate to anxiety, you start focusing less inwards and more outwards. What is the outward focus?  That focus question is that focus concept is really a big one here and is part of this topic today. That inward focus, recovery, recovery, recovery is, how do I feel? Am I getting better? How do I feel? Am I getting better? When your focus slowly starts to move from in here, out here more and more and more, it's because you're engaged with the world, that side of your own skin.  So that just starts to happen. Oh, this is perfect right here. Thank you, Kat. Kat listens to Pink Floyd while reading my book. That's a perfect combination. I couldn't get any better than that. That made me laugh. Thank you. Let's see. Okay. I feel like I have to be on with my anxiety practice. It does get tiring. Yes. If it comes back then I must have done something wrong, but Julie, the feeling it is why you do the practice. Like you don't do the practice to try and make it go away. The practice is just to get better at moving through these things. So if you immediately declare, I failed, I am a failure. I can't do this. I don't get anything right. When you feel things, that's gonna be so challenging for you. My friend, it's something you have to, somebody, I'm gonna bring it up here. It's not fair to do it in a public forum, but that continued return to, but I'm failing, but I can't get it. I'm failing, I can't get it. Is it an obstacle for you? That I would love it if you signed to kind of address that if possible. Let's see. I know it's exhausting. Today drove someone that gave me panic. That's a big comment. So we'll just cover the whole screen. Progress, baby step at a time. Okay. So somebody talked about doing a difficult drive today. It gave me panic. I made it halfway there and then turned around. Okay. That step counts. So that step actually does count. And sometimes it happens. We bail, and we're gonna call it, oh, we failed in that situation. Like, oh, we didn't really fail. But as long as you learn a lesson, then it's okay. As long as you learn a lesson, then it's okay. So good job. Oh, this is good too. Feeling like they can't do it because they haven't gotten to that part of their fear ladder. So when I say re-engaging with life, that's why I made that comment, maybe five or seven minutes ago, that you have to get in a situation where you also are realistic. If you're completely homebound, it's not realistic to say, oh, Drew said live life again, so I'm gonna take a cruise around the world next week. Yeah, that's not really gonna work out in the end. So it is important to understand that you are, this is incremental. There's a progression here for sure. Yes, leaning toward our values. This is huge.  The things that matter to you, they become important again. What you value becomes important again, as opposed to just avoiding fear. So yes, it is definitely value-driven for the, for most part. Oh, this is good too. GBG always with great comments. Recovery for me has been solely losing interest in recovery. Ah, that's a golden comment right there. That is 100% true. People ask me all the time, like how do you know that you're recovered? Well, the answer is when you stop asking if you're recovered, which sounds like a really glib, smart ass kind of thing to say, but this comment right here from a member of our own community confirms that. Slowly losing interest in whether or not I'm recovering or not, I'm just doing things and how I feel or not. It's just, oh yeah, I can handle all of those feelings. So that's really great comment. Love it. Kathleen says the same thing. Ooh, love it. This is a good one from Katya. At some point I stopped calling everything I do an exposure. I could not love this anymore. That's true.  But then it just becomes life. Like, yeah, it was a challenge. Maybe it was difficult thing, but it's not and not everything looks like an exposure. This is so good. You guys are killing it today. Love it. Let's see here. All right, well, hang on a second here. But this is, so I'm stuck on the exposure thing and I forget to really live my life in the moment. Don't beat yourself up on that. In the beginning of this journey, that's where everybody starts. And I started a chapter by saying that, like everybody starts that way. It's all about recovery, recovery, recovery. It's the progression over time where it's less about doing recovery, doing exposures and more about just engaging with life. But that's a progression. Everybody starts being almost totally attuned to just recovery and forgetting about life. So that's okay.  That happens. So let's see. It's a slow process, but it's liberating. That's very true. This is really great. You start to forget that you're doing recovery. That is correct. So GBG said before, like, I stopped thinking about recovery so much. Katya says, well, I just stopped calling everything exposures and Viola says, I kind of just forget that I'm doing recovery. That's really good. Really good. Let's see. You got it, you got it. Oh, we're coming to the end of the comments. This is great. We're cranking here. Kid, I've been a glorophobic. I'm ready to start working. I've done a few exposures. I haven't done enough. Let's pop this up on the screen real quick. Hey, kid. I've been a glorophobic and I'm ready to start working. I've done a few exposures, but I feel like I haven't done enough. That's kind of a common feeling. The job that I have requires me being in the car a lot. Is it okay if I go for it? Well, that's an individual thing. Sure, it's okay. You know what you're capable of. First of all, I always say, we're capable of everything. We choose not to do the things because of how we feel when we do them. So it's always important to start from the premise that says, well, I'm capable of actually doing everything. So even the homebound agoraphobic is literally technically, physically capable of taking your cruise around the world. Like that's true. Just that they will feel terrible when they do that. And it's just a matter of how much can I tolerate feeling terrible? So really, kid, it's a really good question. I can't answer it. There's no harder, fast yes or no on that. Do as much practice as you can and in the end understand what that means. Like I might have to be in the car a whole lot more because I've accepted this job that I want to accept because it's important to me. And I have to know that I have to be willing to tolerate the discomfort that I experience while I'm in the car. And in that situation, it's like, well, can I tolerate that every day, four or five hours, eight hours a day, three days a week, whatever that job is gonna be. And know that I'm practicing my tolerance and practicing my navigation when I do that. So I wish I had a definite yes or no answer. There's no right answer to that. Just know what you're getting into going in and this way it can help you navigate through it if you decide to take it. And whatever way you do it, I hope it works out for you. Thanks for the question, man, appreciate it. Oh, no, no, no, no. How do you not, okay, this is a pretty big one. How do you not fear the fear even if you sit with your anxiety? You don't, this is a very common misconception also that somehow or other there's a technique for not being afraid. There is no technique to not be afraid, right? So it's really important. You will be afraid. The object of the game when we do these recovery things and in the beginning where it's solely focused on exposures and recovery, you will be afraid. The fear is the point. So it's really common for people to think like, oh, please give me the tip on how to turn off my fear so that I can do this. Well, no, no, you do this while afraid so that the fear over time begins to dial back down. You don't get to choose to be afraid or not be afraid. You only get to act certain ways and over time that fear will start to decrease.  So, okay, I'm really afraid right now. I'm really uncomfortable right now. I'm going to engage with my life to the best of my ability right now even though I am afraid. And those repeated experiences with the positive outcome and a positive outcome is, I didn't die, I didn't go insane, I didn't snap, nothing bad really happened. I was just uncomfortable, but I could handle it. Over time, that's what turns down the volume and brings that fear knob back to its normal, healthy place in your life. I hope that helps. It's really important to think, to understand that, no, no, no, there's no knob. You can't just turn off the fear and decide to not be afraid. That takes time, it takes time. Let's see here. I look, I'm seeing an answer here to Gen P. What did Gen P ask? Cause somebody said, I've been asking that and haven't gotten a straightforward answer. Gen P, I'm scrolling up, what did you ask? That somebody hasn't gotten a straightforward answer? I've wondered that too, Jamie. Oh, here you go. Is it this? I'll try and get this. Do you think you can overwhelm yourself with anxiety content? Yeah, you completely and utterly can overwhelm yourself with anxiety content. 100%. So, Gen, I don't know if that is what you're saying, Jamie, that you've asked the same question. Yeah, you can completely and utterly overwhelm yourself. You can paralyze yourself with that. I'm not telling you, you're here in my video, so thank you for watching, I hope I'm helping, not telling you to only watch me. But it's really important to understand when you are just going from video to video to podcast to podcast, to book to book to book to post to post. You belong to 16 anxiety groups on Facebook. That is in no way healthy or productive in any way, in no way. So let me be, if so, Gen said, I've yet to get a straightforward answer, I'm gonna try and give you a super straightforward answer. Don't do that. That is 100% overwhelming and can often lead to paralysis, especially if you're going to consume content, say like mine, or maybe Josh Fletcher or Kimberly Quinlan, or anybody that sounds like us, like Lauren Rosen, who this same sort of approach. And then you're also gonna try and temper it with the gentler kind of things. Paralysis can happen super fast, super fast. So you could choose the sources you want. I'm not telling you you must choose me as a source. I appreciate if you trust me that you do, but pick a couple that align sort of together and then go down that road. You may decide, nope, that road is not for me and then you can go down a different path. But no, you can't, you just don't drown yourself all day long in anxiety content. It's not gonna help you at all. Because recovery and engaging in life, like we're talking about today, is a process of doing. It's a doing thing. So listening, learning, reading, watching, reading, watching, asking, questioning, discussing, that's not recovery. In the end, reading my books, listening to my podcast, watching these videos is not recovery. This can only inform your action, the action is recovery. Really important. Oh, no, no, no, no. I see a loaded question here about another anxiety quote, coach. I'm not gonna put it on the screen. Do you know what his name on the screen? The answer to the question is, when somebody who claims to be a mental health helper also describes the content they put out as cutting edge marketing, which he does, that guy has unabashedly called it that, I would tell you that what I'm putting out is psycho-educational content, hopefully encouraging content, informative content. My content is not marketing to get me clients or sell books, but that dude unabashedly tells his high-impact, big-ticket sales, closing sales force that he is priming you with his cutting-edge marketing of drone footage at Hudson Yards in New York City so that you call and talk to a closer to buy an $8,000 coaching package. That's a problem. That's not helping. That's not ethical. None of that is. So the answer is, what do I think of him? That's what I think of him. I think very little of him. And I don't have a problem saying that either. And I'll put his name on the screen because I don't need any more publicity for that guy. Anyway, okay, so that was my little mini rant here. Let's see what else we got. When you stop buying every book ever written on anxiety, it's a good thing. It's a good thing to not buy every book ever written by anxiety, buy my book. No, I'm just kidding. You don't have to buy my book. There's a lot of, you know what? Let's touch on that for just a second, 31 minutes. So why do I write these books? If I'm telling you to buy them or not buy them, which is true, like in the end, buy them, don't buy them in the end. But why is something like this? Why did I write this? Like a lot of people asked me to write this book for years and I'm like, eh, I don't have to write a book. But the difference between this book and not this book, just this book, I'm not comparing it to anything else, is here I was able to lay it out in a logical sequence. So I could keep asking and answering the same questions again and again and again on these videos in the comments, social media posts, in the Facebook group, Instagram comments, the same questions again, again, again, again, or I can put the content in a logical sequence that you can follow step by step by step and then go back to refer to it. That's why I did that. That's why I did that. So that's the benefit of the books. So the books are really meant, the good books are not cures, they don't fix you and they are not recovery, but they should give you the information you need to at least base your actions on, which is why I wrote this particular book and why I wrote 7% slower. All right, let's see here. I think I need to work on my attitude while doing things that make, okay, well, that's okay. Let's throw this up here. Sup Shaughnessy, good to see you. I think I need to work on my attitude while doing things that make me uncomfortable. I keep thinking I'm really not enjoying this, but that's okay. It's not supposed to be enjoyable. I mean, it would be nice if it was, but nobody does hard things and finds them enjoyable. I know that that's really like in the personal development space, that's a little bit of a trope like, yeah, get comfortable being an uncomfortable man. Yeah, and it sort of implies that somehow you should be embracing the process. You can understand why you're doing it and understand why you are intentionally doing things you don't like. Why am I intentionally making myself uncomfortable? So it's okay to sort of understand the why you're doing that, but it's also okay to not like it.  I really hate doing this.  Because I did, I did hate it. It was okay, but I knew I was doing it for a reason. So both of those things kind of go together. This is how does someone do exposure for derealization? You don't because it just happens. So whenever it happens, that is your exposure. If it happens to you right now, then unfortunately you're not getting to plan it. I mean, unless you specifically know of situations where you can definitely trigger it or you're likely to trigger it, then okay, you can do those things. But generally speaking, exposures for derealization is not when it happens, it happens. That is your opportunity to do the exposure in the practice. Hopefully that helps. People ask that all the time. Derealization and depersonalization are just other anxiety symptoms. So if it's a symptom that gets triggered when you get anxious, then go do things that make you anxious. If it's a little bit more amorphous and you can't necessarily guarantee that you will trigger it, then whenever it happens is your exposure. So in that situation, you have to understand, okay, when it happens, this is what I do. Which essentially I do nothing. I just let it happen. Hopefully that helps. Let's see. I tried to read everything. Oh, this is so good. This is so good. Like I'm hidden behind the comments here. I tried to read everything about panic because I was searching for the golden nugget that would help it go away faster. That is so incredibly common. That's so incredibly common and it's why people get stuck in the old like, oh, I'm gonna read another book. I'm gonna read another podcast, I'm gonna follow another person. Always hoping for that one thing, the thing that will make it click. I just need a way to make it click. I just need a way to make it get okay with it so that it can start to recover. But in the end, there is no golden nugget cure. That's 100% true. And there's also nothing to click. Like this sucks because it only clicks after you do it. So so many people get stuck in paralysis, reading and reading and trying all kinds of different sources, hoping to find something that will make it click so that they can start to recover, but it only clicks after. And then that's, that's shitty, but that's true. So you only get it after you do it. We only learn it after we do it. First we do, then we learn. So you're doing it while afraid. You're doing it while unsure. You're doing it without thinking that you know what to do. Is this gonna work? I don't know. I don't know until I do it. So it's really important, really important. Okay, we're scrolling to the end here. I'm gonna wrap it up in a few. Let's see here. No, no, no, I just got back from a very large trip. She made an app, she untitled soul. No, no, no, I'll throw this up here. I think I saw a comment about this. How is the best way to talk to your anxiety? You don't. I did a podcast episode on that too and I saw a link, maybe that was it, I don't know. There you go, Bethany put it up to comments down. The answer is you don't because it's not listening. You must talk to your anxiety with action. It only knows experiences, it doesn't know words. So you can again and again and again, you could try to talk yourself down and say mantras and this too shall pass and I'm safe and everything's okay and your lizard brain, your amygdala, it's not listening, doesn't understand. It's like trying to call somebody who doesn't even own a phone. So you cannot talk to it, you must teach it through action. And if you look at the link that Bethany couple of comments down, that's a podcast episode exactly on that. So hopefully that helps. No cracking the code moment, no, no, no, no, no, no. There you go. Oh, this is good. All right, so we'll follow up here with Viola's comment about derealization for the person who asked about that. Used to be my main symptom. Once I realized what it was and then I wasn't going crazy, it started slowly going away. I get it now and it doesn't even bother me. 100% like for me too, if I'm having an anxious day, derealization and depersonalization are symptoms that I can still experience. Those are anxiety red flags for me. That's how I know that I'm having an anxious day. I will start to experience those things. I just don't care. And since I don't care, which I think Viola is saying here, they tend to not to hang around. I notice it like, oh, okay, something's going on here. And then I'm able to sort of like slow things down and really just start to get a little bit more mindful and realize that maybe I've gone off the rails a little bit into some bad habits. And then I realize that, no, I'm not even paying attention to my derealization anymore. So it doesn't last very long at all. I cannot answer this question because I cannot diagnose you here. I don't know. I've done a lot of exposure, where do we think I'm going wrong? Without knowing you, I would have no way to answer that question. There's probably 10 or 15 different things up top of my head that I could think of that might be a problem. But unfortunately, I can't answer the question because it would be completely irresponsible. I don't know. I can guess, but I don't know. Okay, folks, that's it. We are at the end of the comments at 38 minutes. We're two minutes under our usual. So I appreciate you guys coming by. I think this is a good sort of under-appreciated lesson in the book. It's one that we don't talk about a lot and I'm glad we got to talk about it today. I do believe though that next week, chapter six is the end of the book. Chapter six doesn't have lessons. It actually just is a chapter. It's called, What's Next? So just a housekeeping thing. We'll be back again next Monday in the same place for the very last entry in this book. And then we have to decide what we want to do from there. So do we want to keep Recovery Monday going? What format do we want to be in? Do we want to have Q&A? Do we want to have different topics? So if you have ideas on this, by all means put them in the comments wherever you happen to be watching. Otherwise, I thank you for coming by today and I will see you again next week at the same time. And then we'll see where we go from there. I like the Monday live streams. I love interacting with you guys. I like the Q&A part that's kind of cool. So maybe we'll combine it in some way. I'll put up a Q&A post on Instagram or something and you guys can ask questions and then I can answer them that way. So we'll figure it out. Anyway, thanks for coming by today. I'll see you again next week. This will stay on YouTube, Facebook, Facebook group, online yards. You can come back and watch these as many times as you want. And that's it. See you guys next.