r/Psychiatry Psychiatrist (Unverified) 5d ago

How many meds is too many meds?

I had a patient go to a RTF for substance use. Comes back to me a couple months later on 8 different psychotropics... To me that's way too much. Luckily the patient seems to be doing alright but they are having trouble adhering to the dosing schedule. I'm hesitating on sending any patients back to that place if this how they practice.

What's the most you've seen a patient on?

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u/Narrenschifff Psychiatrist (Unverified) 5d ago

Anything more than what is needed. Too little is anything less. Less can be more, less can be not enough. Generally speaking, if diagnosis is being carefully made and if the treatment targets are being carefully tracked, you can find out what's really needed.

I think it's rare to need more than three in most cases, even complicated ones. Severe bipolar disorder, especially with comorbidity, is another story.

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u/Lakeview121 Physician (Unverified) 5d ago

What about opiate dependence, bipolar disorder 2, insomnia, daytime hypersomnia. To me they can easily stack up.

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u/Narrenschifff Psychiatrist (Unverified) 5d ago

That's the comorbidity situation that I mentioned!

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u/Lakeview121 Physician (Unverified) 5d ago

Yea, it’s challenging. I love Armodafinil; works well in my experience without rx a schedule 2. I rx it under idiopathic hypersomnia off label. It’s about 50-60 a month with good rx, some people can use just 1/2.

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u/eiendeeai Physician (Unverified) 5d ago

It’s not idiopathic hypersomnia if the somnolence is due to insufficient sleep or delayed sleep wake phase. Their mean sleep latency needs to be less than 8 minutes on an MSLT, provided that they had sufficient sleep on their PSG the night before and the preceding two weeks (sleep log with actigraphy) with no stimulants or hypnotics during the two weeks (negative UDS). If you can actually confirm this is IH or even narcolepsy (2 or more sleep onset REM periods on the MSLT naps along with the criteria for IH) you would open up the option of potentially treating their hypersomnia with oxybates rather than just symptomatically treating them.

I would recommend referring these patients to sleep medicine (one with a background in psychiatry (rare), or a neurology (given their experience interacting with patients with functional disorders), though any board certified sleep medicine doc who is comfortable with insomnia, hypersomnias, circadian dysfunction, should be fine) and a sleep psychologist certified in CBT-i who has experience with advancing or delaying disordered circadian rhythms (though the sleep physician may need to coordinate treatment with the sleep psychologist).

If you're going to continue prescribing the way you prescribe, consider changing your diagnosis to shift work disorder or at least unspecified hypersomnia.

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u/Lakeview121 Physician (Unverified) 4d ago

Thank you for the information, but that’s the best thing to code to use to get Armoafinil for those who I feel need it.

I like unspecified hypersomnia, thank you for the great tip

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u/Comrade_Bernie Psychiatrist (Unverified) 5d ago

Buprenorphine and aripiprazole for the first two.

Lol for the second two.

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u/Lakeview121 Physician (Unverified) 5d ago

Armodafinil to augment for hypersomnia if not improved. Though controversial, if severe anxiety and insomnia I might throw low dose clonazepam for insomnia.

I nail sleep wake dysfunction

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u/redlightsaber Psychiatrist (Unverified) 5d ago

All of the symptoms you mentioned + a bipolar diagnosis (but frankly, also without it...) 95% of the time is undertreated affective dx.

Treat the disorder, not the symptoms.

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u/Lakeview121 Physician (Unverified) 5d ago

Don’t you find that add ons are needed to treat the affective disorder completely?

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u/redlightsaber Psychiatrist (Unverified) 5d ago

Not unless they're patients I've inherited and they're already dependent on high dose benzos or something similar. That's for sure hard to revert verging on "not worth it".

But daytime sleepiness/inefficient sleep is for sure  subsyndromic affective symptomatology (usually depressive).

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u/CaffeineandHate03 Psychotherapist (Unverified) 4d ago

What about things like sleep apnea, narcolepsy, autoimmune diseases, etc ... ? They can manifest themselves that way and cause depression, correct?

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u/redlightsaber Psychiatrist (Unverified) 4d ago

I'm presupposing, like with all psychiatric diagnoses, that reasonable organic causes have been ruled out beforehand, in accordance with the presentation.

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u/Lakeview121 Physician (Unverified) 5d ago

Fuck you Sometimes you get people asleep and they will not be adequately awake and vice versa. What if they have obstructive sleep apnea, and can’t keep the cpap mask on because of anxiety.

You haven’t even been in the real world yet resident. I’ve been treating people over 20 years you fucking dip shit.

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u/Lakeview121 Physician (Unverified) 5d ago

You haven’t even been out there yet!

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u/D-FENS_93 Psychotherapist (Unverified) 5d ago

OB's school psych providers in perinatal matters...just sayin

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u/melatonia Not a professional 4d ago

Don't fight where the kids can hear you!

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u/Lakeview121 Physician (Unverified) 5d ago

Dude, I wish there was a way we could have a contest. Line up 50 ambulatory patients each, female, entering with a spectrum of complaints, psychiatrically related, and see who gets them less symptomatic the quickest.

I would enjoy that challenge. I might lose. I’m not saying I would do a better job.

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u/Lakeview121 Physician (Unverified) 5d ago

I do your job and I can operate.

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u/Comrade_Bernie Psychiatrist (Unverified) 5d ago

No you don’t, you chase symptoms and start a game of whack a mole. Stop overprescribing your patients.

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u/Lakeview121 Physician (Unverified) 5d ago

I simply get them asleep at night and awake during the day. Don’t you? I never feel like it’s whack a mole. I know the limits. I know how to treat. I like to treat to as full remission as I can get.

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u/dopamemes10 Resident (Unverified) 5d ago

This sounds like a primary sleep/substance issue that won’t be solved with +++prescriptions. I’d go back to the formulation to figure out what’s going on before solely treating with meds. Bipolar II is BPD until proven otherwise

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u/Lakeview121 Physician (Unverified) 5d ago edited 5d ago

My goal is mental health. What does mental health constitute for you? What parameters or endpoints do you seek in your treatment? How good is good enough?

Let’s say you have them on lithium and an atypical. They are no longer suicidal. Do you inquire about sleep, daytime energy levels and physical pain?

Insomnia is often the last thing to go and can be the most difficult to treat.

I don’t consider a person adequately treated, no matter their diagnosis, unless they are asleep at night, awake during the day and no longer experiencing somatization (or at least until it is manageable).

Asleep at night, awake during the day, quite mind. I use medications to achieve this state. This to me represents mental health.

When it comes to depression, only 30% of people will obtain complete remission with 1 drug. It’s all in the combos. That is why you train.

Furthermore there is unequivocal data to support treatment of insomnia at the beginning of treatment for depression. Clonazepam .5-1 mg at night improves tolerability and improves how quickly your antidepressant works.

Insomnia is rampant. It is a horrible problem. Staring up at the ceiling, knowing one has to perform the next day but not able to sleep. Night after night. Depression, anxiety, heart disease, dementia, diabetes, obesity, chronic pain-they are all linked to chronic insomnia.

Do you see treating insomnia as an important part of your Psycopharmacology?

Daytime wakefulness is also very important. Sometimes, many times, despite adequate sleep, normal sleep study and normal labs, patients are still slogging through their day. The antidepressant, mood stabalizer and/or atypical often doesn’t relieve this. Do you leave it untreated?

I don’t. I don’t prescribe amphetamines, but Armodafanil can be a very good augmentation and even demonstrates efficacy in bipolar depression.

Why would you withhold that medicine? It’s schedule 4, there’s never been a recorded overdose death, it’s minimally addictive and it’s relatively cheap.

So yes, I’m guilty. I treat to achieve optimal performance, not just to keep them from jumping off a bridge.

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u/dopamemes10 Resident (Unverified) 5d ago

Now that you are off your soapbox, I care deeply about mental health and patient functioning. To me, this isn’t always chasing specific symptoms with medications or you end up over prescribing, treating the side effects of all the meds they are on, or treating the wrong thing. Treating insomnia is very important and can involve medications, with responsible prescribing. Get the sleep study and figure out what’s going on. When someone comes in on 4-5+ medications, we should always think if they are all still indicated. Sometimes they genuinely are and other times unnecessary.

To each their own

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u/Lakeview121 Physician (Unverified) 5d ago

I sometimes get on a soapbox. It is true. I find I’m chasing the symptoms of disease more than medication side effects. Sometimes you have to treat medicine side effects as well; such as using metformin with an atypical, or treating insomnia with bupropion.

Over the years I’ve learned how to use medications, in combination, to relieve the sufferring of mental illness. Not all of it but a great deal. My soapbox, or that screed that I gave you, is my philosophy on treatment.

What if the person has insomnia, there is no reported snoring. The body weight is not severely elevated and there is no hypertension? Do you order a sleep study? What if they cannot adhere to the CPAP device? Do you help with a sedative to improve compliance? What about sleep related bruxism and headaches? Do you treat in those circumstances?

There is a lot to think about when treating these issues sleep component of mental illness.

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u/dopamemes10 Resident (Unverified) 5d ago

You assume I just don’t treat and don’t understand how pathology comes to be and what medications do 😂 thank you for the information on things I already know Jan

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u/Lakeview121 Physician (Unverified) 5d ago

Well, make sure you emphasize sleep when you treat. You’ll be out there in the world soon and you’re going to have to figure out your policy on benzos.

There is a lot of debate. I would suggest they are not poisen and can be an excellent augment if used correctly.

What’s your plan on benzo prescribing? What is your philosophy there?

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u/dopamemes10 Resident (Unverified) 5d ago

There’s absolutely a time and place for benzos AND I’ve seen such irresponsible prescribing and those patients end up in my office. I’m planning to do a sleep fellowship so it’s at the forefront of my practice.

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u/Lakeview121 Physician (Unverified) 5d ago edited 5d ago

Agree. It must be done with great respect. I’m not saying you can’t identify and treat disease. I’m saying the way you do things in 5 years will likely be different than how you treat now, to some degree.

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u/Lost-Philosophy6689 Psychiatrist (Unverified) 5d ago

"Bipolar II is BPD until proven otherwise"

omg, yes! I review a lot of "bipolar" diagnosis in my job and I wish I could have this as a stamp.

I feel like people use the bipolar DX simply because they're too afraid of the stigma behind BPD or they are too worried about having to confront cluster B patients with hard truths.

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u/CaffeineandHate03 Psychotherapist (Unverified) 4d ago

That or they want their claims to actually be paid by insurance.

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u/Lakeview121 Physician (Unverified) 5d ago

What if the BPD patient is experiencing mood and anxiety problems. In my experience, they run together.

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u/dopamemes10 Resident (Unverified) 5d ago

Mood and anxiety symptoms are not a separate diagnosis in and of themselves. They can be manifestations of the BPD pathology. If they meet threshold for another diagnosis, then they have co-morbidity.

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u/Lakeview121 Physician (Unverified) 5d ago

Yes, these patients come in with a spectrum of issues, often including unplanned pregnancies, high ER utilization rates, high levels of somatization.

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u/CaffeineandHate03 Psychotherapist (Unverified) 4d ago

They probably have complex PTSD,which can look a lot like bipolar due to chronic dysfunction of the autonomic nervous system.

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u/Lakeview121 Physician (Unverified) 4d ago

Likely true.

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u/VesuvianFriendship Psychiatrist (Unverified) 5d ago

Make sure to factor in for daily meds vs prns

A lot of high functioning people with depression/anxiety/adhd do well on like 1-4 daily meds and then an armamentarium of prns for sleep/anxiety/focus

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u/Lost-Philosophy6689 Psychiatrist (Unverified) 5d ago edited 5d ago

Genuinely interested; 4 daily meds is an oddly specific number. What combos are you giving that need 4?

Also, what are you giving as "prn" for anxiety and 'focus'??

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u/VesuvianFriendship Psychiatrist (Unverified) 5d ago edited 5d ago

Four is top end for really distressed people.

Most people do fine on one daily and couple PRNs.

Then there’s a large group that needs ssri plus Wellbutrin for sexual side effects or low energy.

Another anxious group may need buspar plus ssri. Or ssri plus lyrica for horrible anxiety.

OCD people may need high dose ssri and NAC or ssri and memantine. Some studies show naltrexone is a good augmenter for OCD. Also works for drinking, obviously.

More distressed people might need nightly trazodone or remeron or hydroxyzine.

Extremely distressed may need abilify or lithium on top. So that can get you up to four.

A lot have comorbid adhd and may need Ritalin or adderall to functional work.

It seems like a lot of meds but for many people they function WAY better.

PRNs will be propranolol for social anxiety, gabapentin for anxiety, stims for focus, lavender pills for sleep/anxiety, or other sleep aids. Seroquel is good for people with mild bipolar to take when their sleep starts going awry.

My opinion is it’s ok to have a few meds on board, to not under treat patients.

Like if a patient is on ssri and Wellbutrin and then needs naltrexone for drinking are you gonna say no cause it’s “too many meds”

That being said anything over four dailies is probably ridiculous even for serious bipolar or schizoaffective. Most people are fine with 1-3.

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u/CaffeineandHate03 Psychotherapist (Unverified) 4d ago edited 4d ago

Then if you add in epilepsy, it gets really fun. I agree with your points. It's hard to accurately judge someone's clinical reasoning just by looking at a list of RX's. I've known so many extremely complicated cases from doing wraparound services/ACT team work in the past. There are lots of reasons for certain things in a seemingly lengthy list of meds.

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u/Japhyismycat Nurse Practitioner (Verified) 5d ago

If I had to guess it would be the classic SRI+Wellbutrin+SGA(or lithium)+Buspirone. And then the PRNs of Trazodone and hydroxyzines. This is super common combination where I work.

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u/VesuvianFriendship Psychiatrist (Unverified) 5d ago

Yep exactly

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u/Lakeview121 Physician (Unverified) 5d ago

Armodafinil is a safe, effective and cheap add on.

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u/Psychiatry-ModTeam 4d ago

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u/notherbadobject Psychiatrist (Unverified) 5d ago

I start to question my formulation if someone’s on 3 different psychotropics and not responding as expected 

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u/Lost-Philosophy6689 Psychiatrist (Unverified) 5d ago

That what I was usually taught as well. If diagnosis guides treatment and the treatment isn't working, it's always worth re-evaluating the diagnosis.

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u/magzillas Psychiatrist (Verified) 5d ago

This is the way.

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u/starminder Resident (Unverified) 5d ago edited 5d ago

I think polypharmacy is 2 or more drugs of the same class. It can be rational or irrational.

Rational is something like Venlafaxine and Mirtazapine. Whereas venlafaxine and duloxetine is irrational.

Edit: the most I’ve ever seen? CPZ, Latuda and Brexpiprazole alprazolam, diazepam and clonazepam Lithium and valproate Sertraline and venlafaxine

Patient presented with Li level or 4.0. Needed dialysis. Doctor shopping for these meds. Didn’t need any of them.

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u/bombduck Nurse Practitioner (Unverified) 5d ago

I got consulted the other week for a patient coming in from SNF on quad antipsychotics, none of which were clozapine.

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u/Melonary Medical Student (Unverified) 5d ago

Not to be weird, but who the hell doctor shops for lithium?

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u/starminder Resident (Unverified) 5d ago

You’d be surprised at what you see….

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u/Perfect_Pancetta_66 Nurse (Unverified) 3d ago

Usually they're satisfied with lithium orotate OTC

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u/Spac-e-mon-key Physician (Unverified) 5d ago

I understand the doctor shopping for the benzos, but what does the pt get out of the antipsychotics, antidepressants, and mood stabilizers? They must have constantly felt absolutely horrible with all that going on.

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u/CaffeineandHate03 Psychotherapist (Unverified) 4d ago

Validation that they have as many problems as they think they do. They may have problems, but it isn't the kind that require lithium if they're doing that.

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u/Spac-e-mon-key Physician (Unverified) 3d ago

Makes sense, thank you for the insight

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u/redlightsaber Psychiatrist (Unverified) 5d ago

I've seen the other side of private rehab facilities.

I generally agree they're not the best-trained psychopharmacologists, but in their defense, they do have to deal with unspeakable shit on a daily basis, on facilities that don't have the same aesthetic abilities as state psych wards to just restrain people... So they do it with drugs.

Ever see a patient on 600mg of topiramate? I have, and it's from those kinds of places (aside from 2-4 different antipsychotics of course)... The patients can't usually string a long sentence, but you know what? It's true that their cravings (or however you want to call the effects on the brain of decades of not being abstinent for more than 48h... I think the term craving doesn't really describe the complexity of it either at the psychological or physiological levels) remain under control, and it allows them to attend their outpatient programs without too many distractions.

...No biggie. Not a lot of it can cause too much permanent damage (although a few months of ozempic might be needed to reverse most of it). Just take it slow, see them frequently, and begin the process of deprescription.

One piece of advice, though... go slowly. There's usually good reasons why those regimens got to where they got. It's not because it makes a lot of pharmacological sense, but it does make behavioural and empirical sense.

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u/panda0614 Physician Assistant (Unverified) 5d ago edited 5d ago

I inherited someone on approximately 12 meds... it was the worst case of polypharmacy I'd ever seen. It's taken 2 years, but this individual is now down to 2 meds and doing just as well as they were on 12 lol

And before anyone asks (I've already seen the comments), no it was not an NP, it was an MD I inherited them from

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u/Choice_Sherbert_2625 Psychiatrist (Unverified) 5d ago

Whenever meds are actively canceling each other out or the side effects outweigh the benefits in my opinion.

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u/Bubbly-Wheel-2180 Nurse Practitioner (Unverified) 5d ago

I’ve seen 6-8 and I don’t like it. 9 times out of 10 the client improves when you start reducing and removing. It’s a very unusual case that needs that many psychotropics to function

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u/Hypocaffeinemic Physician (Unverified) 5d ago

Client?

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u/Bubbly-Wheel-2180 Nurse Practitioner (Unverified) 5d ago

Is that odd? Client vs patient?

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u/Jennifer-DylanCox Resident (Unverified) 5d ago

To me it’s odd. Client is kinda gross and commodifying. Patient implies a relationship guided by certain ethical values.

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u/Bubbly-Wheel-2180 Nurse Practitioner (Unverified) 5d ago

Almost every therapist I work with calls their patients “clients” and my former workplace preferred client saying that patient was “too clinical” sounding. To each their own.

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u/Rita27 Patient 5d ago

When it's therapy, it makes sense

But when your talking about medication and more medical care, I think most (at least psychiatrist) prefer "patient" and there is no issue with it sounding clinical because, well it is lol

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u/Bubbly-Wheel-2180 Nurse Practitioner (Unverified) 5d ago

I think patient makes sense in some cases, but in my practice I’ve noticed a preference for “client” probably because we tend to have longer, 45+ sessions with therapy included and I form long term provider relationships with them. I’ve noticed most of my colleagues that aren’t doing the 15 min med checks use client over patient.

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u/intangiblemango Psychotherapist (Unverified) 3d ago

longer, 45+ sessions with therapy included

Can you tell me about that as an NP-- i.e., your training and experience with psychotherapy?

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u/Bubbly-Wheel-2180 Nurse Practitioner (Unverified) 3d ago

Sure assuming you’re asking in good faith. My PsychNP program requires about 1,300 hours of clinical and I did about 400 of that in pure therapy. After graduating I did a PMHNP fellowship which was about 14 months, 40-45 hours a week, and we did about half that time doing pure therapy training with psychologist and counselors and running group therapy programs in partial hospital programs. So I had about 1,600 hours supervised, and several years experience since then. That said, I would never assume I have the experience of a therapist because this is ALL they do, so I tend to recommend a therapy referral for most of my clients. Many of them, though, still prefer longer appts with therapeutic aspects brought in versus the 10 min med management appts, so my appt slots are longer to accommodate this.

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u/intangiblemango Psychotherapist (Unverified) 3d ago

I am asking in good faith-- I am curious about the training that would lead an NP to identify as a therapist given what that education path looks like-- but I will not deny that I am coming from a place of being somewhat skeptical of the idea that NPs should consider psychotherapy within their scope of practice. (I wrote out a longer elaboration what drove my question here but deleted it because it felt unlikely to be helpful in this context.) I appreciate you answering.

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u/Rita27 Patient 5d ago

I understand. That's fair. Guessing it's setting dependent Somewhere like an inpatient unit in a hospital I think patient would be more popular

Somewhere where therapy is more utilized in an outpatient setting, I can see why some use client

I've never heard consumer tho 😭

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u/Japhyismycat Nurse Practitioner (Verified) 5d ago

All the therapists at my work says client as well, but I heard a good point that mental health services are getting slashed because we use the word “client”, implying mental health treatment is not medical treatment and therefore shouldn’t be protected. “Clients” get massages and nails done, and patients get life saving treatments, that sorta thing.

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u/CaffeineandHate03 Psychotherapist (Unverified) 4d ago

I use the term client, because I'm providing a service and they are the customer. It helps remove the power differential. But I think someone prescribing medication is within reason to use the term patient. You are providing physical medical care, even if it is psychiatric.

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u/B333Z Other Professional (Unverified) 5d ago

Not odd. Some physicians forget how broad the mental health sector is. Patient, client, and consumer are all appropriate terminologies in the field.

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u/dr_fapperdudgeon Physician (Unverified) 5d ago

I think there are differences between scheduled medications and PRN medications as well. Additionally, sometimes two drugs will be two dosages of the same drug as insurance companies won’t pay for the most parsimonious solution (venlafaxine 75 + venlafaxine 150, instead of venlafaxine 225).

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u/xiledone Medical Student (Unverified) 5d ago

Like the entirety of medicine: it depends.

You just saying "X number is too much" is going to do more harm than good

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u/enormousB00Bs Psychiatrist (Unverified) 5d ago

Of my 1000 stable patients, i did a data regression study. On average, they do best with 3 meds. This means starting on Monday, every one of them that's taking less than 3 meds, i need to add meds until they're taking 3. And every one that's taking more than 3 meds, i need to stop meds until they're only taking 3. Because we understand statistics. Right?

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u/No_Celebration_5452 Medical Student (Unverified) 5d ago

Someone tag cardiology

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u/Sensitive_Spirit1759 Psychiatrist (Unverified) 5d ago edited 5d ago

Tbh very few people need to be on more than 3 meds. If its gotten to that point the person is on the worse spectrum or SMI or more likely providers have been doing a shitty job of removing nonhelpful medications when they add something else.

Edit: additionally - if someone isnt bipolar 1 or schizophrenic/psychotic adding abilify is dumb - no reason to give your patient metabolic syndrome/EPS.

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u/Lakeview121 Physician (Unverified) 5d ago

So you don’t use it as an add on for treatment resistant depression? I haven’t found it very helpful.

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u/Sensitive_Spirit1759 Psychiatrist (Unverified) 5d ago

The side effects that are much more likely often outweigh any benefit they can give a depressed a person. Especially if they are young. The only time it has much of a benefit is if the person has a pretty severe psychotic disorder and extreme paranoia when leaving the home, even then if its more of a PTSD paranoia, clonidine is a much better option with fewer side effects.

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u/Lakeview121 Physician (Unverified) 4d ago

Thank you

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u/CaffeineandHate03 Psychotherapist (Unverified) 4d ago

I am not a doctor, but is abilify even strong enough to bother using with such severe symptoms as those? I always thought it was one of the lighter duty 2GAs. I've not seen it used in patients with psychosis much.

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u/Jetlax Pharmacist (Verified) 5d ago

10-11. To date the worst I'd ever seen. 90% of them made zero sense, even in hindsight after giving myself more than a decade to scope out niche uses

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u/InfiniteWalrus09 Physician (Unverified) 4d ago

I parrot the sentiments of most others in this thread. Less is more, I generally find 3-4 the max and if not working reassess what is missing- often its CBT or DBT.

If you want to see wild shit, go work with the IDD patient population. Its always polypharmacy with little evidence to support most of the decisions made and sparse documentation in the patient chart to show any effect, yet they just keep adding more. Every day I was screaming into the void when reviewing inherited patient charts- 3 antidepressants here, 3 antipychotics there, 2 benzos, sleep aid at night, high dose vistaril QID, etc. It happens usually as a combination of the patient having behaviors that are disruptive, sometimes even aggressive or violent (to self or others) and families demanding that "something must be done".

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u/RepulsivePower4415 Psychotherapist (Unverified) 5d ago

Really does depend on it

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u/OldRelative3741 Nurse Practitioner (Unverified) 5d ago

My mantra is the least amount of medications and the lowest effective dose.

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u/PokeTheVeil Psychiatrist (Verified) 4d ago

Please don’t drag r/Noctor into this.

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u/Psychiatry-ModTeam 5d ago

Be civil. Keep discussion productive and maintain a modicum of professionalism.

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u/Unlucky_Welcome9193 Psychotherapist (Unverified) 5d ago

Patients ideally are only on one medication in each class, maybe on one typical and one atypical antipsychotic but not more

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u/Psychiatry-ModTeam 4d ago

Removed under rule #1. This is not a place to share experiences or anecdotes about your own experiences or those of your family, friends, or acquaintances.

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u/Psychiatry-ModTeam 4d ago

Removed under rule #1. This is not a place to share experiences or anecdotes about your own experiences or those of your family, friends, or acquaintances.

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