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How We Can Understand Psychopharmacology Through Topamax and McDonald’s 🍔🧠 · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:06
  back,
• 0:06
  my
• 0:06
  friends,
• 0:06
  to
• 0:07
  another
• 0:07
  episode
• 0:08
  of
• 0:08
  Pearls
• 0:09
  and
• 0:09
  Prep
• 0:09
  npz.
• 0:10
  Here,
• 0:11
  your
• 0:11
  preceptor
• 0:12
  in
• 0:12
  your
• 0:12
  pocket,
• 0:12
  your
• 0:13
  go
• 0:13
  to
• 0:13
  place
• 0:13
  for
• 0:13
  pearls
• 0:14
  that
• 0:14
  prep
• 0:14
  you
• 0:15
  to
• 0:15
  practice.
• 0:16
  Today
• 0:16
  we
• 0:17
  are
• 0:17
  going
• 0:17
  to
• 0:18
  do
• 0:19
  a
• 0:19
  fun
• 0:20
  little
• 0:21
  metaphor
• 0:22
  and
• 0:23
  we're
• 0:23
  going
• 0:23
  to
• 0:23
  understand
• 0:24
  topamax
• 0:25
  through
• 0:26
  a
• 0:26
  McDonald's
• 0:27
  analogy.
• 0:28
  Yes,
• 0:28
  it
• 0:28
  can
• 0:28
  be
• 0:28
  done.
• 0:29
  It
• 0:29
  can
• 0:29
  be
• 0:29
  done
• 0:30
  very
• 0:31
  beautifully
• 0:32
  and
• 0:33
  rewardingly.
• 0:34
  And
• 0:34
  I
• 0:34
  can't
• 0:35
  wait
• 0:35
  to
• 0:35
  share
• 0:35
  this
• 0:35
  with
• 0:35
  you.
• 0:36
  I
• 0:36
  worked
• 0:36
  hours
• 0:36
  on
• 0:37
  this
• 0:37
  episode,
• 0:37
  actually
• 0:38
  to
• 0:39
  really
• 0:39
  help
• 0:40
  understand
• 0:40
  and
• 0:40
  appreciate
• 0:41
  the
• 0:41
  receptor
• 0:42
  dynamics
• 0:42
  that
• 0:43
  go
• 0:43
  on
• 0:43
  inside
• 0:44
  of
• 0:44
  Topamax
• 0:45
  and
• 0:45
  how
• 0:46
  this
• 0:46
  compares
• 0:47
  elegantly
• 0:47
  and
• 0:47
  beautifully
• 0:48
  to
• 0:48
  how
• 0:49
  a
• 0:49
  McDonald's
• 0:49
  is
• 0:50
  run.
• 0:50
  I
• 0:50
  really
• 0:51
  hope
• 0:51
  this
• 0:51
  blows
• 0:51
  you
• 0:52
  away
• 0:52
  and
• 0:53
  I
• 0:53
  really
• 0:53
  hope
• 0:53
  we
• 0:53
  can
• 0:54
  share
• 0:54
  this
• 0:54
  metaphor
• 0:55
  and
• 0:55
  laugh
• 0:56
  about
• 0:56
  it
• 0:57
  over
• 0:57
  a
• 0:57
  happy
• 0:57
  Meal
• 0:58
  together.
• 0:59
  Now,
• 0:59
  my
• 1:00
  friends,
• 1:00
  you
• 1:00
  may
• 1:01
  be
• 1:01
  thinking,
• 1:02
  well,
• 1:02
  why
• 1:02
  do
• 1:02
  I
• 1:02
  care
• 1:03
  about
• 1:03
  Topamax?
• 1:04
  I
• 1:04
  hardly
• 1:04
  prescribe
• 1:05
  that.
• 1:05
  I
• 1:06
  have
• 1:06
  two
• 1:06
  answers
• 1:06
  for
• 1:06
  you
• 1:07
  when
• 1:08
  it
• 1:08
  comes
• 1:08
  to
• 1:08
  that
• 1:08
  question.
• 1:09
  My
• 1:10
  first
• 1:10
  answer
• 1:10
  is,
• 1:11
  even
• 1:11
  if
• 1:11
  you
• 1:11
  never
• 1:12
  prescribe
• 1:12
  Topamax,
• 1:13
  understanding
• 1:14
  sodium
• 1:15
  channel
• 1:15
  blockade
• 1:16
  and
• 1:16
  calcium
• 1:17
  channel
• 1:17
  blockade
• 1:18
  is
• 1:18
  so
• 1:18
  darn
• 1:19
  important
• 1:20
  for
• 1:20
  so
• 1:20
  many
• 1:21
  reasons
• 1:21
  because
• 1:22
  other
• 1:22
  meds
• 1:22
  in
• 1:23
  psychiatry
• 1:24
  act
• 1:24
  on
• 1:24
  those
• 1:24
  channels,
• 1:25
  right?
• 1:25
  Like
• 1:26
  gabapentin,
• 1:27
  like
• 1:27
  lamictal,
• 1:28
  like
• 1:28
  depakote,
• 1:29
  right?
• 1:29
  So
• 1:29
  understanding
• 1:30
  this
• 1:30
  is
• 1:31
  really
• 1:31
  important
• 1:31
  to
• 1:31
  all
• 1:32
  the
• 1:32
  other
• 1:32
  things
• 1:32
  you
• 1:32
  do
• 1:32
  because
• 1:33
  these
• 1:33
  are
• 1:33
  fundamental
• 1:34
  ways
• 1:34
  that
• 1:34
  our
• 1:34
  medications
• 1:36
  actually
• 1:36
  exert
• 1:36
  therapeutic
• 1:37
  benefits.
• 1:38
  And
• 1:38
  we've
• 1:39
  gone
• 1:39
  over
• 1:39
  other
• 1:40
  ways
• 1:40
  that
• 1:41
  medications
• 1:41
  exert
• 1:42
  therapeutic
• 1:42
  benefits
• 1:43
  in
• 1:43
  previous
• 1:43
  episodes.
• 1:44
  Inhibition
• 1:45
  of
• 1:45
  serotonin
• 1:45
  reuptake.
• 1:46
  We've
• 1:47
  talked
• 1:47
  about
• 1:48
  MAOI
• 1:49
  inhibitors
• 1:49
  in
• 1:50
  the
• 1:50
  past.
• 1:50
  So
• 1:51
  there's
• 1:51
  many
• 1:51
  different
• 1:51
  ways
• 1:52
  that
• 1:52
  we
• 1:53
  can
• 1:53
  actually
• 1:53
  exert
• 1:54
  therapeutic
• 1:54
  benefits,
• 1:55
  right?
• 1:55
  We
• 1:55
  can
• 1:55
  block
• 1:56
  D2
• 1:56
  receptors
• 1:57
  to
• 1:58
  in
• 1:58
  limbic
• 1:59
  circuits
• 1:59
  to
• 1:59
  calm
• 1:59
  hallucinations
• 2:00
  and
• 2:00
  mania.
• 2:01
  We
• 2:01
  can
• 2:01
  do
• 2:02
  a
• 2:02
  heck
• 2:02
  of
• 2:02
  a
• 2:02
  lot.
• 2:02
  But
• 2:02
  we
• 2:02
  can
• 2:03
  also
• 2:03
  block
• 2:03
  calcium
• 2:04
  channels,
• 2:04
  sodium
• 2:05
  channels,
• 2:05
  we
• 2:05
  can
• 2:06
  have
• 2:06
  positive
• 2:07
  allosteric
• 2:08
  modulators
• 2:09
  and
• 2:09
  all
• 2:10
  kinds
• 2:10
  of
• 2:10
  good
• 2:10
  things.
• 2:11
  So
• 2:12
  that's
• 2:12
  what
• 2:12
  we're
• 2:12
  going
• 2:12
  to
• 2:12
  talk
• 2:13
  about
• 2:13
  today.
• 2:13
  And
• 2:13
  Topamax
• 2:14
  has
• 2:15
  four
• 2:16
  unique
• 2:17
  ways
• 2:17
  that
• 2:17
  it
• 2:18
  can
• 2:18
  exert
• 2:19
  therapeutic
• 2:19
  effects.
• 2:19
  And
• 2:20
  that
• 2:20
  just
• 2:20
  so
• 2:20
  happens
• 2:20
  to
• 2:21
  be
• 2:21
  extremely
• 2:21
  important.
• 2:23
  If
• 2:23
  you
• 2:23
  wanted
• 2:24
  to
• 2:25
  treat
• 2:25
  things
• 2:26
  like
• 2:26
  hyperarousal
• 2:27
  and
• 2:28
  PTSD
• 2:29
  or
• 2:30
  compulsive
• 2:31
  urges
• 2:31
  to
• 2:32
  drink
• 2:33
  or
• 2:33
  binge
• 2:34
  eat.
• 2:34
  And
• 2:35
  so
• 2:35
  it's
• 2:36
  not
• 2:36
  enough
• 2:36
  for
• 2:36
  us
• 2:37
  to
• 2:37
  just
• 2:37
  go,
• 2:37
  Topamax,
• 2:38
  oh,
• 2:39
  I
• 2:39
  heard
• 2:39
  some
• 2:39
  people
• 2:39
  lose
• 2:40
  weight
• 2:40
  on
• 2:40
  that.
• 2:40
  Oh,
• 2:40
  I
• 2:41
  heard
• 2:41
  that
• 2:41
  could
• 2:41
  be
• 2:41
  helpful
• 2:41
  in
• 2:42
  alcohol
• 2:42
  use
• 2:42
  disorder.
• 2:43
  If
• 2:43
  you,
• 2:43
  you
• 2:43
  have
• 2:43
  a
• 2:43
  living,
• 2:44
  breathing
• 2:44
  patient
• 2:45
  in
• 2:45
  front
• 2:45
  of
• 2:45
  you
• 2:46
  that
• 2:46
  wants
• 2:46
  to
• 2:46
  understand
• 2:47
  and
• 2:47
  appreciate
• 2:48
  the
• 2:48
  mechanisms
• 2:49
  by
• 2:49
  which
• 2:49
  Topamax
• 2:50
  works,
• 2:51
  then
• 2:51
  knowing
• 2:51
  those
• 2:52
  mechanisms
• 2:52
  is
• 2:53
  really
• 2:53
  important
• 2:53
  because
• 2:53
  you
• 2:54
  can
• 2:54
  educate
• 2:54
  them,
• 2:55
  you
• 2:55
  can
• 2:55
  give
• 2:55
  them
• 2:56
  anticipatory
• 2:56
  guidance
• 2:57
  as
• 2:57
  to
• 2:57
  what
• 2:57
  they
• 2:57
  might
• 2:58
  expect
• 2:58
  on
• 2:58
  Topamax
• 2:59
  that
• 3:00
  will
• 3:01
  help
• 3:02
  enrich
• 3:02
  your
• 3:03
  rapport
• 3:03
  with
• 3:04
  them.
• 3:04
  And
• 3:05
  it
• 3:05
  also
• 3:05
  makes
• 3:05
  you
• 3:05
  a
• 3:06
  better
• 3:06
  prescriber
• 3:06
  because
• 3:07
  you
• 3:07
  have
• 3:07
  specific
• 3:08
  targets
• 3:09
  in
• 3:09
  mind
• 3:10
  when
• 3:10
  a
• 3:10
  patient
• 3:10
  is
• 3:11
  being
• 3:11
  interviewed
• 3:12
  by
• 3:12
  you.
• 3:12
  And
• 3:13
  so
• 3:13
  you
• 3:13
  can
• 3:13
  pair
• 3:14
  their
• 3:14
  symptoms
• 3:15
  with
• 3:16
  very
• 3:16
  distinct
• 3:17
  medications
• 3:18
  in
• 3:18
  your
• 3:19
  arsenal.
• 3:19
  And
• 3:20
  that's
• 3:20
  where
• 3:20
  I
• 3:20
  think
• 3:20
  Topamax
• 3:21
  shines.
• 3:21
  And
• 3:22
  so
• 3:22
  I
• 3:22
  hope
• 3:22
  you
• 3:22
  enjoy
• 3:23
  this
• 3:23
  one.
• 3:24
  Now,
• 3:24
  let's
• 3:24
  talk
• 3:24
  about
• 3:24
  those
• 3:25
  four
• 3:25
  targets,
• 3:25
  okay?
• 3:26
  And
• 3:27
  in
• 3:27
  order
• 3:27
  to
• 3:27
  do
• 3:27
  that,
• 3:27
  I
• 3:28
  want
• 3:28
  you
• 3:28
  to
• 3:28
  think
• 3:29
  of
• 3:29
  the
• 3:29
  brain
• 3:30
  as
• 3:30
  a
• 3:30
  McDonald's
• 3:31
  restaurant
• 3:31
  during
• 3:32
  a
• 3:32
  huge
• 3:33
  lunch
• 3:33
  rush.
• 3:34
  Okay?
• 3:34
  Now,
• 3:35
  in
• 3:35
  a
• 3:35
  healthy
• 3:35
  brain,
• 3:36
  orders
• 3:37
  come
• 3:37
  in
• 3:37
  and
• 3:38
  out
• 3:38
  at
• 3:38
  a
• 3:38
  manageable
• 3:39
  pace,
• 3:39
  right?
• 3:39
  The
• 3:40
  kitchen's
• 3:40
  keeping
• 3:40
  up
• 3:41
  just
• 3:41
  fine,
• 3:41
  the
• 3:41
  customers
• 3:42
  are
• 3:42
  slurping
• 3:43
  on
• 3:43
  their
• 3:43
  Dr.
• 3:44
  Peppers,
• 3:44
  they're
• 3:45
  happy.
• 3:45
  The
• 3:46
  manager's
• 3:46
  running
• 3:47
  things
• 3:47
  pretty
• 3:48
  smoothly.
• 3:48
  But
• 3:49
  in
• 3:49
  conditions
• 3:50
  like
• 3:50
  PTSD
• 3:51
  or
• 3:51
  alcohol
• 3:51
  use
• 3:52
  disorder,
• 3:52
  or
• 3:52
  even
• 3:53
  migraines
• 3:53
  and
• 3:53
  binge
• 3:54
  eating,
• 3:54
  I
• 3:54
  want
• 3:55
  you
• 3:55
  to
• 3:55
  think
• 3:55
  of
• 3:55
  this
• 3:55
  McDonald's
• 3:56
  as
• 3:56
  total
• 3:56
  chaos,
• 3:57
  okay?
• 3:57
  Orders
• 3:58
  are
• 3:58
  just
• 3:58
  flying
• 3:59
  around
• 4:00
  way
• 4:00
  too
• 4:00
  fast.
• 4:00
  The
• 4:01
  kitchen
• 4:01
  and
• 4:01
  the
• 4:01
  cooks
• 4:02
  are
• 4:02
  super
• 4:02
  overwhelmed.
• 4:03
  The
• 4:03
  customers
• 4:04
  are
• 4:04
  furious.
• 4:05
  Nobody's
• 4:05
  really
• 4:05
  in
• 4:06
  control,
• 4:06
  okay?
• 4:07
  And
• 4:07
  Topamax
• 4:08
  works
• 4:09
  because
• 4:09
  it
• 4:10
  has
• 4:10
  four
• 4:10
  different
• 4:10
  ways
• 4:11
  of
• 4:11
  restoring
• 4:12
  order
• 4:12
  in
• 4:12
  this
• 4:12
  chaotic
• 4:13
  McDonald's
• 4:14
  lunch
• 4:14
  rush
• 4:15
  all
• 4:15
  at
• 4:15
  the
• 4:15
  same
• 4:15
  time.
• 4:16
  Now,
• 4:16
  how
• 4:16
  does
• 4:16
  it
• 4:17
  do
• 4:17
  that?
• 4:17
  That's
• 4:18
  a
• 4:18
  great
• 4:18
  question.
• 4:19
  So
• 4:19
  the
• 4:20
  first
• 4:20
  mechanism
• 4:20
  we
• 4:20
  can
• 4:21
  think
• 4:21
  about
• 4:21
  is
• 4:21
  sodium
• 4:22
  channel
• 4:23
  blockade.
• 4:24
  Okay,
• 4:24
  this
• 4:25
  is
• 4:25
  really
• 4:25
  interesting.
• 4:26
  Okay?
• 4:28
  Now,
• 4:29
  neurons,
• 4:30
  and
• 4:30
  I
• 4:30
  don't
• 4:31
  want
• 4:31
  to
• 4:31
  get
• 4:31
  too
• 4:31
  technical
• 4:31
  with
• 4:32
  this,
• 4:32
  but
• 4:32
  a
• 4:32
  general
• 4:33
  conceptual
• 4:33
  appreciation.
• 4:34
  Neurons
• 4:35
  fire
• 4:35
  by
• 4:35
  opening
• 4:36
  voltage
• 4:36
  gated
• 4:37
  sodium
• 4:38
  channels.
• 4:38
  Okay?
• 4:39
  Sodium
• 4:40
  ions
• 4:40
  rush
• 4:40
  in.
• 4:41
  It
• 4:41
  creates
• 4:42
  a
• 4:42
  rapid
• 4:42
  electrical
• 4:43
  spike,
• 4:43
  also
• 4:44
  known
• 4:44
  as
• 4:44
  an
• 4:44
  action
• 4:44
  potential.
• 4:45
  Okay?
• 4:46
  And
• 4:47
  in
• 4:47
  a
• 4:47
  healthy
• 4:47
  brain,
• 4:48
  the
• 4:49
  channels
• 4:49
  open,
• 4:50
  they
• 4:50
  fire,
• 4:50
  they
• 4:51
  snap
• 4:51
  shut,
• 4:52
  and
• 4:52
  then
• 4:53
  rinse
• 4:54
  and
• 4:54
  repeat,
• 4:54
  right?
• 4:55
  Thoughts
• 4:56
  happen.
• 4:57
  Thoughts
• 4:57
  come
• 4:58
  and
• 4:58
  go.
• 4:58
  They're
• 4:58
  more
• 4:59
  or
• 4:59
  less
• 4:59
  measured,
• 4:59
  calculated,
• 5:00
  and
• 5:00
  clear.
• 5:01
  But
• 5:01
  in
• 5:02
  conditions
• 5:02
  like
• 5:02
  PTSD
• 5:03
  or
• 5:03
  epilepsy
• 5:04
  or
• 5:04
  migraines,
• 5:05
  the
• 5:05
  neurons
• 5:05
  kind
• 5:05
  of
• 5:06
  get
• 5:06
  stuck.
• 5:06
  And
• 5:07
  it's
• 5:07
  this
• 5:07
  pattern
• 5:08
  of
• 5:08
  rapid,
• 5:08
  repetitive
• 5:09
  firing.
• 5:09
  And
• 5:10
  Topamax
• 5:11
  blocks
• 5:12
  that
• 5:12
  excess
• 5:13
  sodium
• 5:14
  channel
• 5:14
  activity.
• 5:15
  And
• 5:15
  it
• 5:15
  would
• 5:16
  be
• 5:16
  similar
• 5:16
  to,
• 5:16
  like,
• 5:17
  a
• 5:17
  McDonald's
• 5:17
  drive
• 5:18
  through,
• 5:18
  where
• 5:19
  too
• 5:19
  many
• 5:20
  orders
• 5:20
  are
• 5:20
  coming
• 5:20
  in
• 5:21
  at
• 5:21
  once,
• 5:21
  too
• 5:21
  many
• 5:21
  people
• 5:22
  are
• 5:22
  shouting
• 5:22
  into
• 5:22
  the
• 5:23
  megaphone
• 5:23
  at
• 5:23
  once.
• 5:24
  Or
• 5:24
  maybe
• 5:24
  you
• 5:24
  have
• 5:24
  a
• 5:25
  guy
• 5:25
  who's
• 5:25
  just.
• 5:25
  He's
• 5:26
  ordering
• 5:26
  a
• 5:26
  Big
• 5:26
  Mac,
• 5:27
  and
• 5:27
  then
• 5:27
  he's.
• 5:27
  He's
• 5:27
  listening
• 5:28
  to
• 5:28
  his
• 5:28
  kids
• 5:28
  in
• 5:28
  the
• 5:28
  back
• 5:29
  or
• 5:29
  shouting
• 5:29
  their
• 5:29
  next
• 5:29
  order,
• 5:30
  and
• 5:30
  everybody's
• 5:31
  shouting
• 5:31
  an
• 5:31
  order
• 5:31
  into
• 5:31
  this
• 5:32
  megaphone,
• 5:32
  and
• 5:33
  the
• 5:33
  kitchen
• 5:33
  is
• 5:33
  in
• 5:33
  chaos.
• 5:34
  But
• 5:35
  what
• 5:35
  Topamax
• 5:36
  does
• 5:36
  is
• 5:37
  it
• 5:37
  kind
• 5:37
  of
• 5:38
  adds
• 5:38
  a
• 5:38
  please
• 5:39
  hold
• 5:39
  sign.
• 5:40
  It
• 5:40
  stops
• 5:41
  you
• 5:41
  from
• 5:41
  just
• 5:43
  Bombarding
• 5:44
  the
• 5:44
  system
• 5:44
  with
• 5:44
  too
• 5:44
  many
• 5:45
  orders
• 5:45
  at
• 5:45
  once.
• 5:46
  So
• 5:46
  you
• 5:46
  get
• 5:46
  your
• 5:46
  Big
• 5:47
  Mac
• 5:47
  order
• 5:47
  in
• 5:47
  and
• 5:47
  then
• 5:47
  it
• 5:48
  kind
• 5:48
  of
• 5:48
  stops
• 5:48
  and
• 5:48
  it
• 5:48
  loads
• 5:49
  and
• 5:49
  it
• 5:49
  thinks
• 5:50
  and
• 5:50
  it's
• 5:50
  not
• 5:50
  going
• 5:51
  to
• 5:51
  take
• 5:51
  all
• 5:51
  of
• 5:51
  your
• 5:51
  orders
• 5:52
  at
• 5:52
  once.
• 5:52
  It
• 5:52
  sort
• 5:52
  of
• 5:53
  interrupts
• 5:54
  the
• 5:54
  process
• 5:54
  of
• 5:54
  frantic
• 5:55
  orders
• 5:55
  and
• 5:56
  frantic
• 5:56
  activity
• 5:57
  coming
• 5:57
  through
• 5:57
  the
• 5:57
  drive
• 5:57
  thru
• 5:58
  speaker.
• 5:58
  And
• 5:58
  by
• 5:59
  doing
• 5:59
  that,
• 5:59
  the
• 5:59
  kitchen
• 6:00
  is
• 6:00
  not
• 6:00
  as
• 6:00
  overwhelmed.
• 6:01
  The
• 6:01
  kitchen
• 6:01
  isn't
• 6:02
  getting
• 6:02
  nine
• 6:03
  of
• 6:03
  your
• 6:03
  orders
• 6:04
  and
• 6:04
  your
• 6:04
  son,
• 6:05
  your
• 6:05
  nine
• 6:05
  year
• 6:05
  old
• 6:05
  son
• 6:06
  in
• 6:06
  the
• 6:06
  back
• 6:06
  and
• 6:06
  your
• 6:06
  wife's
• 6:07
  order
• 6:07
  and
• 6:07
  your
• 6:07
  dog's
• 6:08
  barking,
• 6:09
  right?
• 6:09
  It's
• 6:10
  muffling
• 6:10
  that,
• 6:10
  it's
• 6:11
  blocking
• 6:11
  that
• 6:11
  excessive
• 6:12
  activity.
• 6:13
  Call
• 6:13
  it,
• 6:13
  you
• 6:14
  know,
• 6:14
  call
• 6:15
  it
• 6:15
  extra
• 6:15
  orders,
• 6:16
  call
• 6:16
  it
• 6:16
  extra
• 6:17
  static,
• 6:18
  it's
• 6:18
  blocking
• 6:19
  that.
• 6:19
  So
• 6:19
  the
• 6:19
  signal
• 6:20
  is
• 6:20
  very
• 6:20
  clear.
• 6:20
  And
• 6:21
  it's
• 6:21
  getting
• 6:21
  one
• 6:21
  order
• 6:22
  in
• 6:22
  at
• 6:22
  a
• 6:22
  time.
• 6:23
  A
• 6:23
  Big
• 6:24
  Mac
• 6:24
  with
• 6:24
  fries
• 6:25
  and
• 6:25
  an
• 6:25
  onion,
• 6:26
  no
• 6:27
  lettuce,
• 6:27
  right?
• 6:28
  But
• 6:28
  it's
• 6:28
  not
• 6:28
  getting,
• 6:29
  oh,
• 6:29
  and
• 6:29
  I
• 6:29
  want
• 6:30
  a
• 6:30
  Happy
• 6:31
  Meal
• 6:31
  and
• 6:31
  oh,
• 6:31
  I
• 6:31
  want
• 6:32
  fish
• 6:32
  sticks
• 6:32
  from,
• 6:33
  from
• 6:33
  the
• 6:33
  back.
• 6:33
  And
• 6:33
  the
• 6:33
  dog's
• 6:34
  drooling
• 6:34
  and
• 6:34
  barking
• 6:35
  and
• 6:35
  telling
• 6:36
  his
• 6:36
  dad
• 6:36
  he
• 6:36
  wants
• 6:36
  a
• 6:36
  McFlurry,
• 6:38
  right?
• 6:39
  And
• 6:39
  so
• 6:40
  that's
• 6:41
  the
• 6:41
  first
• 6:41
  mechanism
• 6:42
  that
• 6:42
  Topamax
• 6:43
  is
• 6:43
  exerting
• 6:44
  therapeutic
• 6:44
  effects
• 6:45
  on.
• 6:45
  It's
• 6:45
  a
• 6:45
  sodium
• 6:45
  channel
• 6:46
  blocker.
• 6:47
  Very
• 6:47
  cool,
• 6:48
  right?
• 6:48
  It's
• 6:48
  slowing
• 6:49
  the
• 6:49
  pace
• 6:49
  down
• 6:49
  of
• 6:50
  neuronal
• 6:50
  activity,
• 6:51
  okay,
• 6:52
  by
• 6:53
  blocking
• 6:53
  excess
• 6:54
  sodium
• 6:54
  channel
• 6:55
  activity.
• 6:56
  Very
• 6:56
  important,
• 6:57
  right?
• 6:57
  Those
• 6:57
  action
• 6:58
  potentials
• 6:58
  that
• 6:58
  keep
• 6:59
  getting
• 6:59
  propagated
• 7:00
  in
• 7:00
  a
• 7:00
  rapid
• 7:01
  fashion,
• 7:02
  we're
• 7:03
  blocking
• 7:03
  that
• 7:03
  excess
• 7:04
  sodium
• 7:05
  channel
• 7:05
  activity.
• 7:06
  Now
• 7:06
  the
• 7:06
  second
• 7:07
  mechanism
• 7:07
  is
• 7:07
  a
• 7:07
  calcium
• 7:08
  channel
• 7:09
  blockade,
• 7:09
  okay?
• 7:10
  And
• 7:10
  again,
• 7:10
  we
• 7:10
  don't
• 7:10
  want
• 7:11
  to
• 7:11
  go
• 7:11
  too
• 7:11
  far
• 7:11
  into
• 7:12
  the
• 7:12
  weeds
• 7:12
  here,
• 7:12
  but
• 7:12
  to
• 7:12
  give
• 7:13
  you
• 7:13
  a
• 7:13
  conceptual
• 7:13
  appreciation,
• 7:15
  Topamat,
• 7:16
  Topamax
• 7:17
  also
• 7:17
  inhibits
• 7:18
  high
• 7:18
  voltage
• 7:19
  activated
• 7:20
  calcium
• 7:20
  channels,
• 7:21
  okay?
• 7:23
  By
• 7:23
  doing
• 7:23
  that,
• 7:23
  it
• 7:23
  kind
• 7:24
  of
• 7:24
  reduces
• 7:24
  the
• 7:24
  amount
• 7:24
  of
• 7:24
  calcium
• 7:25
  entering
• 7:25
  the
• 7:26
  nerve
• 7:26
  terminal
• 7:27
  when
• 7:27
  a
• 7:27
  signal
• 7:28
  arrives,
• 7:28
  okay?
• 7:29
  And
• 7:29
  when
• 7:29
  less
• 7:30
  calcium's
• 7:30
  going
• 7:31
  in,
• 7:31
  that
• 7:31
  means
• 7:32
  less
• 7:32
  neurotransmitters
• 7:33
  being
• 7:33
  released
• 7:34
  into
• 7:34
  the
• 7:34
  synapse,
• 7:35
  okay?
• 7:36
  That's
• 7:36
  very,
• 7:37
  very
• 7:37
  important.
• 7:38
  Okay?
• 7:39
  It's
• 7:39
  very
• 7:40
  important.
• 7:41
  And
• 7:41
  as
• 7:41
  you
• 7:41
  all
• 7:42
  know,
• 7:42
  right,
• 7:43
  calcium
• 7:43
  channels
• 7:44
  at
• 7:44
  the
• 7:44
  nerve
• 7:44
  terminal,
• 7:45
  when
• 7:45
  they
• 7:45
  open,
• 7:45
  calcium
• 7:46
  rushes
• 7:46
  in.
• 7:47
  And
• 7:47
  that
• 7:48
  calcium
• 7:48
  influx
• 7:49
  is
• 7:49
  a
• 7:49
  direct
• 7:49
  trigger
• 7:50
  that
• 7:50
  causes
• 7:51
  neurotransmitters
• 7:51
  to
• 7:52
  be
• 7:52
  released
• 7:52
  in
• 7:52
  a
• 7:52
  synapse.
• 7:53
  So
• 7:53
  when
• 7:53
  we're
• 7:54
  blocking
• 7:54
  calcium
• 7:55
  channels,
• 7:56
  we
• 7:56
  are
• 7:56
  it
• 7:56
  result,
• 7:57
  it
• 7:57
  results
• 7:57
  in
• 7:58
  less
• 7:58
  neurotransmitters
• 7:59
  entering
• 8:00
  the
• 8:00
  synapse,
• 8:01
  so
• 8:01
  less
• 8:02
  of
• 8:02
  the
• 8:03
  neurotransmitter
• 8:03
  is
• 8:03
  being
• 8:04
  delivered.
• 8:05
  And
• 8:05
  so
• 8:05
  you
• 8:05
  can
• 8:05
  actually
• 8:06
  calm
• 8:06
  excitatory
• 8:07
  activity
• 8:08
  in
• 8:08
  doing
• 8:08
  so.
• 8:09
  And
• 8:09
  that's
• 8:09
  exactly
• 8:09
  what
• 8:10
  this
• 8:10
  does,
• 8:11
  right?
• 8:11
  It's
• 8:11
  a
• 8:11
  calcium
• 8:12
  channel
• 8:12
  blocker.
• 8:13
  Believe
• 8:13
  gabapentin
• 8:14
  exerts
• 8:14
  the
• 8:15
  same
• 8:15
  kind
• 8:15
  of
• 8:15
  effect
• 8:16
  as
• 8:16
  a
• 8:16
  calcium
• 8:17
  channel
• 8:18
  blocker,
• 8:19
  okay?
• 8:20
  And
• 8:21
  so
• 8:22
  this
• 8:22
  would
• 8:22
  be
• 8:23
  equivalent
• 8:24
  of
• 8:24
  your
• 8:25
  McDonald's
• 8:25
  Chaos
• 8:27
  lunch
• 8:27
  hour.
• 8:28
  You
• 8:28
  have
• 8:28
  these
• 8:28
  delivery
• 8:29
  trucks,
• 8:29
  they
• 8:30
  deliver
• 8:30
  buns
• 8:30
  and
• 8:31
  ketchup
• 8:31
  and
• 8:31
  frozen
• 8:32
  patties,
• 8:32
  and
• 8:33
  they're
• 8:34
  delivering
• 8:35
  all
• 8:35
  of
• 8:36
  those
• 8:36
  products
• 8:37
  or
• 8:37
  materials
• 8:38
  to
• 8:38
  the
• 8:38
  McDonald's
• 8:39
  kind
• 8:39
  of
• 8:39
  in
• 8:40
  the
• 8:40
  back
• 8:40
  in
• 8:40
  the
• 8:41
  warehouse
• 8:41
  there.
• 8:42
  And
• 8:42
  it's
• 8:42
  almost
• 8:42
  like
• 8:43
  blocking
• 8:43
  those
• 8:43
  deliveries,
• 8:44
  okay.
• 8:45
  Or
• 8:45
  slowing
• 8:45
  those
• 8:46
  delivery
• 8:46
  trucks
• 8:47
  from
• 8:47
  even
• 8:48
  delivering
• 8:48
  the
• 8:48
  buns,
• 8:49
  the
• 8:49
  patties
• 8:49
  and
• 8:49
  the
• 8:50
  cheese
• 8:50
  to
• 8:50
  the
• 8:50
  restaurant.
• 8:51
  Okay?
• 8:51
  Some
• 8:52
  of
• 8:52
  the
• 8:52
  trucks
• 8:52
  are
• 8:52
  coming,
• 8:53
  okay?
• 8:53
  The
• 8:54
  kitchen
• 8:54
  doesn't
• 8:54
  shut
• 8:54
  down
• 8:55
  altogether,
• 8:55
  but
• 8:55
  fewer
• 8:56
  supplies
• 8:56
  arrive
• 8:57
  per
• 8:57
  delivery,
• 8:58
  AKA
• 8:59
  less
• 8:59
  neurotransmitters
• 9:00
  are
• 9:00
  being
• 9:01
  delivered.
• 9:02
  So
• 9:03
  the
• 9:03
  kitchen
• 9:03
  is,
• 9:03
  is
• 9:04
  a
• 9:04
  lot
• 9:04
  calmer,
• 9:05
  right?
• 9:05
  Because
• 9:06
  it's
• 9:06
  not
• 9:06
  getting
• 9:06
  an
• 9:07
  insane
• 9:07
  amount
• 9:07
  of
• 9:07
  burgers
• 9:08
  and
• 9:08
  fries
• 9:09
  and
• 9:10
  all
• 9:10
  of
• 9:10
  this
• 9:10
  ketchup
• 9:11
  and
• 9:11
  this
• 9:11
  overwhelm,
• 9:12
  right?
• 9:12
  They're
• 9:12
  already
• 9:13
  dealing
• 9:14
  with
• 9:14
  this
• 9:15
  frenzy
• 9:15
  of
• 9:15
  orders
• 9:16
  that
• 9:16
  they're
• 9:17
  trying
• 9:17
  to
• 9:17
  contend
• 9:17
  with
• 9:18
  by
• 9:18
  putting
• 9:19
  a
• 9:19
  please
• 9:19
  hold
• 9:20
  sign
• 9:20
  and,
• 9:21
  and
• 9:21
  on
• 9:21
  the,
• 9:21
  on
• 9:22
  the
• 9:22
  drive
• 9:22
  thru
• 9:22
  speaker
• 9:23
  and
• 9:23
  slowing
• 9:23
  down
• 9:23
  the
• 9:24
  speaker
• 9:24
  or
• 9:24
  the
• 9:24
  amount
• 9:25
  of
• 9:25
  orders
• 9:25
  coming
• 9:26
  in,
• 9:26
  right?
• 9:26
  This
• 9:27
  chaos
• 9:27
  over
• 9:27
  there.
• 9:27
  And
• 9:28
  another
• 9:28
  way
• 9:28
  they
• 9:28
  can
• 9:29
  stop
• 9:29
  the
• 9:29
  chaos
• 9:30
  or
• 9:30
  stem
• 9:30
  the
• 9:30
  chaos
• 9:31
  is
• 9:31
  calcium
• 9:32
  channel
• 9:32
  blockade
• 9:33
  by
• 9:34
  partially
• 9:34
  slowing
• 9:35
  down
• 9:35
  the
• 9:36
  delivery
• 9:37
  of
• 9:37
  these
• 9:37
  products,
• 9:37
  AKA
• 9:38
  neurotransmitters,
• 9:39
  AKA
• 9:40
  going
• 9:40
  straight
• 9:41
  to
• 9:41
  the
• 9:41
  electrical
• 9:42
  and
• 9:42
  chemical
• 9:42
  signaling
• 9:43
  that
• 9:43
  is
• 9:43
  calcium
• 9:44
  and
• 9:44
  blocking
• 9:45
  that
• 9:45
  process
• 9:46
  so
• 9:46
  that
• 9:47
  there
• 9:48
  is
• 9:48
  less
• 9:49
  neurotransmitter
• 9:50
  being
• 9:50
  released
• 9:51
  into
• 9:51
  the
• 9:52
  synapse.
• 9:52
  And
• 9:53
  so
• 9:53
  by
• 9:53
  targeting
• 9:54
  calcium,
• 9:55
  that's
• 9:55
  a
• 9:55
  very
• 9:55
  important
• 9:56
  mechanism
• 9:58
  of
• 9:58
  action.
• 9:59
  As
• 9:59
  you
• 9:59
  can
• 9:59
  probably
• 10:00
  tell,
• 10:01
  this
• 10:02
  is
• 10:02
  pretty
• 10:02
  similar
• 10:03
  to
• 10:03
  sodium
• 10:04
  channel
• 10:04
  blockade
• 10:05
  in
• 10:06
  that
• 10:06
  both
• 10:06
  are
• 10:06
  mechanisms
• 10:07
  to
• 10:07
  calm
• 10:08
  down
• 10:08
  excitatory
• 10:10
  neuro
• 10:11
  neural
• 10:11
  activity,
• 10:12
  if
• 10:12
  you
• 10:13
  will,
• 10:13
  okay.
• 10:14
  Which
• 10:14
  is
• 10:14
  pretty
• 10:15
  neat,
• 10:15
  okay.
• 10:16
  With
• 10:16
  sodium,
• 10:17
  it's
• 10:17
  the
• 10:17
  repetitive
• 10:18
  firing
• 10:18
  that
• 10:19
  gets
• 10:19
  kind
• 10:19
  of
• 10:19
  slowed
• 10:20
  down,
• 10:21
  okay.
• 10:21
  With
• 10:21
  calcium,
• 10:22
  it's
• 10:22
  the
• 10:22
  actual
• 10:24
  propagation
• 10:24
  of
• 10:25
  the
• 10:25
  neurotransmitter
• 10:26
  release
• 10:26
  itself,
• 10:27
  okay?
• 10:28
  And
• 10:29
  acting
• 10:29
  on
• 10:30
  the
• 10:32
  electrical
• 10:33
  and
• 10:33
  chemical
• 10:33
  signaling
• 10:35
  that,
• 10:36
  you
• 10:36
  know,
• 10:36
  once
• 10:36
  calcium
• 10:37
  rushes
• 10:37
  in,
• 10:38
  it
• 10:38
  triggers
• 10:39
  the
• 10:39
  neurotransmitter
• 10:40
  release.
• 10:40
  And
• 10:40
  that's
• 10:41
  what
• 10:41
  we're
• 10:41
  trying
• 10:41
  to
• 10:41
  interrupt,
• 10:42
  okay?
• 10:43
  Especially
• 10:44
  we're
• 10:44
  trying
• 10:44
  to
• 10:44
  interrupt.
• 10:45
  Interrupt
• 10:45
  the
• 10:45
  excitatory
• 10:46
  neurotransmitter
• 10:47
  release.
• 10:48
  Now,
• 10:49
  the
• 10:49
  third
• 10:50
  mechanism
• 10:51
  that
• 10:51
  Topamax
• 10:52
  exerts
• 10:53
  on
• 10:54
  a
• 10:55
  patient
• 10:56
  is
• 10:56
  the
• 10:57
  GABA
• 10:57
  A
• 10:57
  enhancement,
• 10:59
  okay?
• 10:59
  And
• 10:59
  this
• 10:59
  is
• 11:00
  kind
• 11:00
  of
• 11:00
  an
• 11:00
  interesting
• 11:01
  one
• 11:01
  as
• 11:02
  well,
• 11:02
  okay?
• 11:04
  So
• 11:04
  it
• 11:05
  does
• 11:05
  not
• 11:05
  directly
• 11:06
  agonize
• 11:07
  the
• 11:07
  GABA
• 11:08
  receptor
• 11:08
  like
• 11:08
  a
• 11:08
  benzodiazepine
• 11:10
  does,
• 11:10
  but
• 11:10
  it's
• 11:10
  a
• 11:11
  positive
• 11:11
  allosteric
• 11:12
  modulator,
• 11:13
  a
• 11:13
  pam.
• 11:14
  And
• 11:14
  for
• 11:15
  those
• 11:15
  of
• 11:15
  you
• 11:15
  who
• 11:15
  are
• 11:15
  curious,
• 11:16
  we
• 11:16
  have
• 11:16
  a
• 11:16
  really
• 11:16
  good
• 11:17
  visual
• 11:17
  metaphor
• 11:18
  of
• 11:18
  a
• 11:19
  pam
• 11:19
  and
• 11:19
  on
• 11:20
  our
• 11:20
  Patreon
• 11:20
  page,
• 11:20
  that
• 11:21
  makes
• 11:21
  it
• 11:21
  really
• 11:21
  simple
• 11:22
  to
• 11:22
  understand,
• 11:23
  and
• 11:23
  it's
• 11:23
  really
• 11:24
  kind
• 11:24
  of
• 11:24
  cool,
• 11:24
  and
• 11:25
  I
• 11:25
  think
• 11:25
  you'll
• 11:25
  love
• 11:25
  it.
• 11:25
  And
• 11:25
  we
• 11:26
  have
• 11:26
  tons
• 11:26
  of
• 11:26
  awesome
• 11:26
  visual
• 11:27
  metaphors
• 11:28
  on
• 11:28
  our
• 11:28
  Patreon
• 11:29
  page
• 11:29
  that
• 11:29
  make
• 11:29
  psychiatry
• 11:30
  really
• 11:30
  sticky
• 11:31
  and
• 11:31
  really
• 11:31
  interesting.
• 11:32
  So
• 11:32
  definitely
• 11:32
  encourage
• 11:33
  you
• 11:33
  to
• 11:33
  go
• 11:33
  to
• 11:33
  the
• 11:33
  show
• 11:33
  notes
• 11:34
  and
• 11:34
  become
• 11:34
  a
• 11:35
  Patreon
• 11:35
  member
• 11:35
  asap.
• 11:36
  But
• 11:37
  the
• 11:38
  third
• 11:38
  mechanism,
• 11:39
  Topamax,
• 11:40
  acts
• 11:40
  as
• 11:40
  a
• 11:41
  gaba,
• 11:41
  a
• 11:41
  enhancement
• 11:42
  through
• 11:42
  positive
• 11:43
  allosteric
• 11:44
  modulation.
• 11:45
  Pretty
• 11:45
  darn
• 11:46
  cool.
• 11:46
  Now,
• 11:47
  how
• 11:47
  does
• 11:47
  it
• 11:47
  do
• 11:47
  that
• 11:47
  exactly?
• 11:49
  Okay,
• 11:50
  so
• 11:51
  I
• 11:51
  want
• 11:52
  you
• 11:52
  to
• 11:52
  imagine
• 11:52
  here
• 11:53
  that
• 11:53
  customers
• 11:54
  are
• 11:54
  getting
• 11:54
  really
• 11:54
  angry
• 11:55
  because
• 11:55
  the
• 11:55
  kitchen
• 11:56
  is
• 11:56
  overwhelmed.
• 11:57
  All
• 11:57
  of
• 11:57
  their
• 11:58
  food
• 11:58
  is
• 11:58
  delayed,
• 11:59
  and
• 12:00
  so
• 12:00
  they're
• 12:00
  irritated,
• 12:00
  they
• 12:00
  want
• 12:01
  their
• 12:01
  money
• 12:01
  back.
• 12:01
  They're
• 12:01
  demanding
• 12:02
  refunds.
• 12:02
  They're
• 12:03
  banging
• 12:03
  their
• 12:03
  fists
• 12:03
  on
• 12:04
  the
• 12:04
  table.
• 12:04
  They're
• 12:04
  throwing
• 12:04
  soda
• 12:05
  at
• 12:05
  each
• 12:05
  other.
• 12:05
  They
• 12:06
  want
• 12:06
  to
• 12:06
  feel
• 12:06
  better
• 12:06
  and
• 12:07
  calmer.
• 12:07
  And
• 12:07
  there
• 12:07
  needs
• 12:08
  to
• 12:08
  be
• 12:08
  a
• 12:09
  restoration
• 12:09
  of
• 12:09
  order
• 12:10
  in
• 12:11
  this
• 12:11
  McDonald's.
• 12:12
  So
• 12:13
  now,
• 12:13
  if
• 12:13
  you
• 12:13
  gave
• 12:13
  now,
• 12:14
  a
• 12:14
  benzodiazepine
• 12:15
  in
• 12:15
  this
• 12:15
  analogy
• 12:15
  would
• 12:16
  be
• 12:16
  like
• 12:16
  shutting
• 12:16
  the
• 12:16
  whole
• 12:17
  McDonald's
• 12:17
  down,
• 12:18
  right?
• 12:18
  It's
• 12:18
  like,
• 12:18
  things
• 12:19
  will
• 12:19
  get
• 12:19
  real
• 12:19
  calm
• 12:20
  real
• 12:20
  fast.
• 12:20
  We
• 12:20
  just
• 12:20
  turn
• 12:21
  the
• 12:21
  lights
• 12:21
  off,
• 12:21
  everybody
• 12:22
  goes
• 12:22
  home,
• 12:22
  no
• 12:23
  more
• 12:23
  chaos,
• 12:23
  right?
• 12:24
  But
• 12:24
  a
• 12:24
  positive
• 12:25
  allosteric
• 12:25
  modulator
• 12:26
  is
• 12:26
  like
• 12:27
  Ronald
• 12:27
  McDonald
• 12:28
  coming
• 12:28
  in
• 12:29
  and
• 12:29
  handing
• 12:30
  everyone
• 12:30
  a
• 12:30
  free
• 12:31
  Happy
• 12:31
  Meal.
• 12:31
  You
• 12:32
  could
• 12:32
  even
• 12:32
  argue
• 12:32
  that
• 12:33
  the
• 12:33
  benzo
• 12:33
  in
• 12:34
  this
• 12:34
  case
• 12:34
  would
• 12:34
  be
• 12:35
  a
• 12:35
  Happy
• 12:36
  Meal
• 12:36
  itself.
• 12:36
  So
• 12:36
  the
• 12:37
  benzo
• 12:37
  is
• 12:37
  a
• 12:37
  Happy
• 12:38
  Meal,
• 12:38
  right?
• 12:38
  You
• 12:38
  get
• 12:38
  the
• 12:38
  Happy
• 12:39
  Meal.
• 12:39
  It's
• 12:39
  directly
• 12:40
  reducing
• 12:41
  anxiety.
• 12:41
  It's
• 12:41
  like
• 12:42
  Klonopin
• 12:42
  or
• 12:42
  Ativan.
• 12:43
  Okay?
• 12:43
  Bam.
• 12:44
  That's.
• 12:44
  It's
• 12:44
  like,
• 12:44
  wow,
• 12:44
  that
• 12:45
  directly
• 12:45
  makes
• 12:45
  me
• 12:46
  happy.
• 12:46
  I'm
• 12:46
  calmer.
• 12:47
  I'm
• 12:47
  not
• 12:47
  going
• 12:47
  to
• 12:47
  complain.
• 12:47
  I'm
• 12:48
  not
• 12:48
  going
• 12:48
  to
• 12:48
  argue,
• 12:49
  right?
• 12:49
  But
• 12:49
  Ronald
• 12:50
  McDonald
• 12:50
  is
• 12:51
  sort
• 12:51
  of
• 12:51
  the
• 12:52
  positive
• 12:52
  allosteric
• 12:53
  modulator.
• 12:54
  He's
• 12:54
  handing
• 12:54
  you
• 12:55
  the
• 12:55
  Happy
• 12:55
  Meal.
• 12:55
  He's
• 12:55
  not
• 12:56
  the
• 12:56
  Happy
• 12:56
  Meal
• 12:56
  himself.
• 12:56
  He's
• 12:57
  not
• 12:57
  the
• 12:57
  Benzo
• 12:57
  himself,
• 12:58
  right?
• 12:58
  So
• 12:59
  he
• 12:59
  doesn't
• 12:59
  make
• 12:59
  you
• 12:59
  happy
• 13:00
  in
• 13:00
  and
• 13:01
  in
• 13:01
  and
• 13:01
  of
• 13:01
  himself.
• 13:02
  That
• 13:02
  would
• 13:02
  be
• 13:02
  the
• 13:03
  Happy
• 13:03
  Meal,
• 13:03
  right?
• 13:03
  You
• 13:03
  bite
• 13:04
  into
• 13:04
  the
• 13:04
  chicken
• 13:04
  nugget,
• 13:05
  you
• 13:05
  get
• 13:05
  a
• 13:05
  little
• 13:06
  treat.
• 13:06
  That's
• 13:06
  the
• 13:06
  happiness.
• 13:07
  That's
• 13:07
  the
• 13:07
  Benzo
• 13:08
  or
• 13:08
  the.
• 13:08
  Or
• 13:08
  the
• 13:08
  Ativan
• 13:09
  in
• 13:09
  this
• 13:09
  analogy.
• 13:10
  But
• 13:10
  Ronald
• 13:11
  McDonald
• 13:11
  is
• 13:12
  facilitating
• 13:12
  the
• 13:13
  experience.
• 13:13
  He's
• 13:14
  maybe
• 13:14
  playing
• 13:15
  with
• 13:15
  balloon
• 13:15
  animals
• 13:16
  and
• 13:16
  making
• 13:16
  funny
• 13:17
  faces
• 13:17
  and
• 13:17
  taking
• 13:18
  selfies
• 13:18
  with
• 13:18
  you
• 13:18
  and
• 13:19
  handing
• 13:19
  you
• 13:19
  the
• 13:19
  Happy
• 13:19
  Meal.
• 13:20
  He's
• 13:20
  a
• 13:20
  positive
• 13:21
  allosteric
• 13:21
  modulator
• 13:22
  in
• 13:22
  this
• 13:22
  analogy,
• 13:23
  right?
• 13:23
  He's
• 13:23
  facilitating
• 13:25
  the
• 13:26
  feelings
• 13:27
  of
• 13:27
  calm
• 13:28
  directly
• 13:28
  by
• 13:28
  handing
• 13:29
  you
• 13:29
  that
• 13:29
  Happy
• 13:29
  Meal
• 13:30
  and
• 13:30
  creating
• 13:31
  a
• 13:32
  much
• 13:32
  more
• 13:32
  calming,
• 13:33
  relaxed
• 13:33
  atmosphere.
• 13:34
  And
• 13:34
  it's
• 13:34
  just
• 13:35
  one
• 13:35
  of
• 13:35
  the
• 13:35
  many
• 13:35
  ways
• 13:36
  we
• 13:36
  can
• 13:37
  modulate
• 13:37
  the
• 13:37
  experience
• 13:38
  in
• 13:39
  the
• 13:39
  McDonald's
• 13:40
  itself.
• 13:41
  Okay.
• 13:41
  And
• 13:42
  that,
• 13:42
  to
• 13:42
  me,
• 13:42
  is
• 13:42
  a
• 13:42
  good
• 13:43
  example
• 13:43
  of
• 13:44
  differentiating
• 13:45
  between
• 13:46
  a,
• 13:46
  you
• 13:47
  know,
• 13:47
  GABA
• 13:47
  agonist
• 13:48
  where
• 13:48
  you're
• 13:48
  directly
• 13:49
  hitting
• 13:49
  the
• 13:49
  GABA
• 13:50
  receptor
• 13:51
  and
• 13:52
  you're,
• 13:53
  you
• 13:53
  know,
• 13:53
  it's,
• 13:53
  it's,
• 13:54
  you're,
• 13:54
  you're
• 13:55
  kind
• 13:55
  of
• 13:55
  shutting
• 13:56
  down
• 13:56
  or
• 13:56
  slowing
• 13:57
  down
• 13:58
  the
• 13:58
  firing
• 13:58
  of
• 13:58
  the
• 13:59
  neurons
• 13:59
  as
• 14:00
  opposed
• 14:00
  to
• 14:00
  a
• 14:00
  positive
• 14:01
  allosteric
• 14:02
  modulator.
• 14:03
  Okay.
• 14:03
  Which
• 14:03
  again,
• 14:04
  is
• 14:04
  a
• 14:04
  little
• 14:04
  bit
• 14:05
  different.
• 14:05
  Positive
• 14:06
  allosteric
• 14:07
  modulators
• 14:08
  enhance
• 14:08
  the
• 14:09
  effect
• 14:09
  of
• 14:10
  what's
• 14:10
  already
• 14:10
  there.
• 14:10
  The
• 14:10
  Happy
• 14:11
  Meal's
• 14:11
  already
• 14:11
  there.
• 14:12
  Ronald
• 14:12
  McDonald
• 14:13
  is
• 14:13
  enhancing
• 14:14
  that
• 14:15
  effect
• 14:15
  very
• 14:16
  deliberately.
• 14:17
  Okay,
• 14:17
  that.
• 14:18
  Does
• 14:18
  that
• 14:18
  make
• 14:19
  sense?
• 14:20
  Basically,
• 14:21
  negatively
• 14:22
  charged
• 14:22
  chloride
• 14:23
  ions
• 14:23
  flow
• 14:24
  into
• 14:24
  the
• 14:24
  cell,
• 14:24
  making
• 14:25
  the
• 14:25
  neuron
• 14:25
  harder
• 14:26
  to
• 14:26
  fire,
• 14:26
  thereby
• 14:27
  quieting
• 14:28
  down
• 14:28
  the
• 14:28
  neuron
• 14:29
  and
• 14:29
  calming
• 14:29
  things
• 14:30
  down
• 14:31
  significantly.
• 14:32
  Okay.
• 14:33
  And
• 14:33
  Topamax
• 14:34
  specifically
• 14:35
  enhances
• 14:36
  GABA
• 14:37
  activity,
• 14:37
  GABA
• 14:38
  A
• 14:38
  receptor
• 14:38
  activity
• 14:39
  at
• 14:39
  a
• 14:39
  non
• 14:40
  benzodiazepine
• 14:41
  site.
• 14:41
  Again,
• 14:41
  the
• 14:41
  key
• 14:41
  is
• 14:42
  it's
• 14:42
  a
• 14:42
  positive
• 14:42
  allosteric
• 14:43
  modulator.
• 14:43
  It
• 14:43
  does
• 14:44
  not
• 14:44
  bind
• 14:44
  on
• 14:45
  the
• 14:45
  GABA
• 14:45
  receptor
• 14:46
  itself.
• 14:46
  It's
• 14:46
  a
• 14:46
  non
• 14:47
  benzodiazepine
• 14:48
  site,
• 14:48
  and
• 14:48
  it
• 14:48
  increases
• 14:49
  that
• 14:49
  flow
• 14:50
  of
• 14:50
  chloride
• 14:50
  ions
• 14:51
  into
• 14:51
  the
• 14:51
  neurons
• 14:52
  when
• 14:53
  GABA
• 14:53
  is
• 14:53
  already
• 14:54
  present.
• 14:54
  Okay.
• 14:56
  Basically
• 14:57
  turning
• 14:57
  up
• 14:57
  the
• 14:57
  volume
• 14:58
  on
• 14:58
  the
• 14:58
  brain's
• 14:58
  own
• 14:59
  calming
• 14:59
  signals
• 15:00
  without
• 15:00
  creating
• 15:01
  a
• 15:01
  new
• 15:01
  signal
• 15:01
  on
• 15:02
  its
• 15:02
  own.
• 15:02
  Again,
• 15:02
  this
• 15:02
  can
• 15:03
  be
• 15:03
  very
• 15:03
  helpful
• 15:05
  if
• 15:05
  we
• 15:05
  need
• 15:06
  more
• 15:06
  inhibitory
• 15:07
  signal
• 15:08
  signals
• 15:08
  in
• 15:08
  a
• 15:09
  brain
• 15:09
  that
• 15:09
  is
• 15:09
  just
• 15:10
  way
• 15:10
  too
• 15:11
  excitable.
• 15:11
  Right.
• 15:12
  In
• 15:12
  an
• 15:12
  amygdala
• 15:13
  that's
• 15:13
  chronically
• 15:13
  under
• 15:14
  inhibited,
• 15:15
  fear
• 15:15
  circuits
• 15:15
  that
• 15:16
  are
• 15:16
  firing
• 15:16
  too
• 15:16
  quickly,
• 15:17
  Patients
• 15:17
  who
• 15:17
  are
• 15:18
  hypervigilant,
• 15:18
  excessively
• 15:19
  startled,
• 15:19
  they
• 15:20
  have
• 15:20
  nightmares.
• 15:21
  This
• 15:22
  can
• 15:22
  really
• 15:22
  change
• 15:22
  the
• 15:23
  game.
• 15:23
  Right.
• 15:23
  We're
• 15:24
  creating
• 15:24
  an
• 15:24
  atmosphere
• 15:25
  in
• 15:25
  the
• 15:25
  amygdala
• 15:26
  so
• 15:26
  that
• 15:27
  these
• 15:27
  Happy
• 15:28
  Meals
• 15:28
  actually
• 15:29
  land.
• 15:29
  They
• 15:30
  help
• 15:30
  restore
• 15:30
  balance
• 15:31
  between
• 15:31
  the
• 15:31
  excitation
• 15:32
  in
• 15:32
  the
• 15:32
  kitchen,
• 15:32
  the
• 15:33
  frenzy,
• 15:33
  and
• 15:33
  the
• 15:34
  inhibition.
• 15:35
  Um,
• 15:35
  and
• 15:36
  so
• 15:36
  that's
• 15:36
  really
• 15:36
  what
• 15:36
  we're
• 15:37
  looking
• 15:37
  for
• 15:37
  with
• 15:37
  the
• 15:37
  third
• 15:38
  mechanism,
• 15:39
  which
• 15:39
  again
• 15:40
  is
• 15:40
  GABA
• 15:41
  A
• 15:41
  enhancement.
• 15:42
  And
• 15:42
  the
• 15:42
  fourth
• 15:43
  mechanism
• 15:44
  would
• 15:44
  be
• 15:44
  glutamate
• 15:45
  blockade.
• 15:45
  Okay.
• 15:46
  Glutamate
• 15:47
  is
• 15:47
  rather
• 15:47
  a
• 15:47
  complex
• 15:49
  neurotransmitter.
• 15:50
  In
• 15:50
  my
• 15:50
  opinion,
• 15:51
  it's
• 15:51
  the
• 15:51
  most
• 15:52
  abundant
• 15:52
  excitatory
• 15:53
  neurotransmitter
• 15:54
  in
• 15:54
  the
• 15:54
  brain.
• 15:54
  It's
• 15:54
  the
• 15:54
  counterpart
• 15:55
  to
• 15:55
  GABA.
• 15:55
  It's
• 15:55
  the
• 15:55
  seesaw
• 15:56
  to
• 15:56
  GABA.
• 15:56
  GABA's
• 15:57
  calming
• 15:57
  glutamate
• 15:57
  is
• 15:58
  not.
• 15:58
  It's
• 15:58
  more
• 15:58
  excitatory.
• 15:59
  It's
• 16:00
  important
• 16:00
  with
• 16:00
  learning.
• 16:00
  It's
• 16:01
  not
• 16:01
  like
• 16:01
  an
• 16:01
  altogether
• 16:02
  bad
• 16:02
  neurotransmitter.
• 16:03
  It's
• 16:03
  just
• 16:03
  if
• 16:03
  the
• 16:04
  balance
• 16:04
  between
• 16:04
  GABA
• 16:05
  and
• 16:05
  glutamate
• 16:05
  is
• 16:05
  off
• 16:06
  in
• 16:06
  a
• 16:06
  specific
• 16:07
  circuit
• 16:07
  of
• 16:07
  the
• 16:07
  brain,
• 16:08
  you
• 16:08
  can
• 16:08
  have
• 16:08
  Problems,
• 16:09
  most
• 16:09
  notably
• 16:10
  in
• 16:10
  alcohol
• 16:10
  use
• 16:11
  disorder,
• 16:12
  chronic
• 16:12
  alcohol
• 16:13
  use.
• 16:14
  You
• 16:15
  know,
• 16:15
  you're
• 16:16
  hitting
• 16:16
  that
• 16:16
  GABA
• 16:16
  receptor
• 16:17
  so
• 16:17
  often
• 16:17
  that
• 16:18
  eventually
• 16:18
  what
• 16:18
  happens
• 16:19
  is,
• 16:20
  is
• 16:21
  your
• 16:21
  brain
• 16:22
  is
• 16:22
  much
• 16:23
  more
• 16:23
  conducive
• 16:24
  to
• 16:24
  an
• 16:24
  excitatory
• 16:25
  state
• 16:25
  because
• 16:26
  you've
• 16:26
  been
• 16:26
  whacking
• 16:27
  that
• 16:27
  GABA
• 16:28
  receptor
• 16:29
  so
• 16:29
  much
• 16:29
  with
• 16:29
  alcohol
• 16:31
  that
• 16:31
  eventually
• 16:33
  it
• 16:33
  gets
• 16:33
  desensitized.
• 16:34
  And
• 16:34
  so
• 16:35
  the
• 16:35
  excitatory
• 16:36
  circuits
• 16:36
  are
• 16:36
  upregulated.
• 17:31
  And
• 17:32
  here
• 17:32
  you
• 17:32
  are
• 17:32
  nervous
• 17:33
  all
• 17:33
  the
• 17:33
  time
• 17:33
  and
• 17:34
  you
• 17:34
  have
• 17:35
  cravings
• 17:36
  and
• 17:36
  you're
• 17:36
  driven
• 17:36
  and
• 17:37
  comp.
• 17:37
  And
• 17:37
  you
• 17:37
  have
• 17:37
  a
• 17:38
  compulsion
• 17:38
  to
• 17:38
  drink.
• 17:39
  And
• 17:39
  so
• 17:39
  again,
• 17:40
  not
• 17:41
  only
• 17:41
  does
• 17:41
  Topamax
• 17:42
  enhance
• 17:42
  the,
• 17:44
  the,
• 17:44
  the
• 17:44
  calm
• 17:45
  down
• 17:45
  parts
• 17:45
  of
• 17:45
  our
• 17:46
  brain
• 17:46
  through
• 17:46
  that
• 17:46
  GABA
• 17:47
  potentiation.
• 17:47
  We
• 17:47
  just
• 17:48
  talked
• 17:48
  about
• 17:48
  Ronald
• 17:49
  McDonald
• 17:49
  handing
• 17:50
  the
• 17:50
  happy
• 17:50
  Meal
• 17:50
  out,
• 17:51
  but
• 17:51
  it,
• 17:51
  it
• 17:52
  also
• 17:52
  enacts
• 17:53
  that
• 17:53
  glutamate
• 17:53
  blockade,
• 17:54
  which
• 17:55
  turns
• 17:56
  the
• 17:56
  excitatory
• 17:57
  neurotransmission
• 17:59
  down,
• 17:59
  which
• 17:59
  can
• 17:59
  really
• 18:00
  help.
• 18:00
  And
• 18:00
  in
• 18:00
  this
• 18:00
  analogy,
• 18:02
  glutamate
• 18:02
  would
• 18:03
  be
• 18:03
  like
• 18:03
  the
• 18:03
  hysterical
• 18:04
  cashier
• 18:05
  screaming
• 18:05
  orders
• 18:05
  into
• 18:06
  the
• 18:06
  kitchen
• 18:06
  microphone.
• 18:07
  He's
• 18:07
  got
• 18:07
  that
• 18:07
  headset
• 18:08
  and
• 18:08
  he's
• 18:08
  just
• 18:08
  yelling,
• 18:09
  five
• 18:09
  Big
• 18:09
  Macs,
• 18:09
  ten
• 18:10
  Mc,
• 18:10
  ten
• 18:10
  McNuggets,
• 18:11
  three
• 18:11
  filets
• 18:12
  o
• 18:12
  fish.
• 18:12
  Now,
• 18:12
  now,
• 18:13
  McFlurry's.
• 18:13
  McFlurry's,
• 18:14
  McFlurry's.
• 18:14
  And
• 18:14
  the
• 18:14
  kitchen
• 18:15
  is
• 18:15
  in
• 18:15
  a
• 18:15
  frenzy.
• 18:15
  They're
• 18:16
  panicked.
• 18:16
  They're
• 18:16
  trying
• 18:16
  to
• 18:16
  keep
• 18:17
  up.
• 18:17
  The
• 18:17
  mistakes
• 18:18
  are
• 18:18
  flying.
• 18:18
  The
• 18:19
  whole
• 18:19
  restaurant
• 18:19
  is
• 18:19
  feeding
• 18:20
  off
• 18:20
  the
• 18:20
  panic.
• 18:21
  That
• 18:21
  cashier
• 18:22
  yelling
• 18:22
  all
• 18:22
  of
• 18:23
  those
• 18:23
  orders
• 18:23
  is
• 18:23
  like
• 18:23
  glutamate,
• 18:24
  okay?
• 18:25
  And
• 18:25
  so
• 18:26
  cranking
• 18:27
  down
• 18:27
  the
• 18:27
  cashier's
• 18:28
  microphone
• 18:30
  as
• 18:30
  much
• 18:30
  as
• 18:30
  possible,
• 18:31
  just
• 18:32
  cranking
• 18:32
  it
• 18:32
  down
• 18:33
  is
• 18:34
  Topamax's
• 18:36
  way
• 18:36
  of
• 18:37
  lowering
• 18:38
  the
• 18:38
  excess
• 18:39
  glutamatergic
• 18:40
  activity
• 18:40
  and
• 18:41
  restoring
• 18:41
  order
• 18:42
  to
• 18:42
  the
• 18:42
  whole
• 18:42
  kitchen.
• 18:43
  Right?
• 18:43
  Cause
• 18:43
  now
• 18:43
  those
• 18:44
  orders
• 18:44
  aren't
• 18:44
  coming
• 18:44
  out
• 18:45
  hysterically
• 18:46
  through
• 18:47
  the
• 18:47
  use
• 18:47
  of
• 18:47
  yelling.
• 18:48
  And
• 18:48
  people
• 18:48
  in
• 18:48
  the
• 18:48
  kitchen
• 18:49
  can
• 18:49
  kind
• 18:49
  of
• 18:49
  calm
• 18:49
  down
• 18:50
  because
• 18:50
  they're
• 18:50
  not
• 18:50
  being
• 18:51
  yelled
• 18:51
  at
• 18:51
  with
• 18:51
  orders.
• 18:52
  They
• 18:52
  have
• 18:52
  that
• 18:52
  nice
• 18:53
  sodium
• 18:53
  channel
• 18:53
  blockade
• 18:54
  via
• 18:55
  the
• 18:55
  drive
• 18:55
  through
• 18:55
  where
• 18:55
  the
• 18:55
  orders
• 18:56
  are
• 18:56
  coming
• 18:56
  in
• 18:56
  calmly
• 18:57
  and
• 18:57
  clearly
• 18:57
  and
• 18:58
  not
• 18:58
  repetitively
• 18:59
  or
• 18:59
  chaotically
• 19:01
  being
• 19:01
  slowed
• 19:01
  down
• 19:01
  by
• 19:01
  hold
• 19:02
  signals.
• 19:02
  They're
• 19:02
  being
• 19:03
  just
• 19:03
  slowed
• 19:03
  down
• 19:03
  to
• 19:03
  a
• 19:04
  cadence
• 19:04
  that's
• 19:04
  coming
• 19:04
  in
• 19:05
  regularly.
• 19:05
  The
• 19:06
  calcium
• 19:06
  channel
• 19:06
  blockade.
• 19:07
  You're
• 19:08
  not
• 19:08
  getting
• 19:08
  this
• 19:08
  release
• 19:09
  of
• 19:09
  products
• 19:09
  like
• 19:10
  ketchup
• 19:10
  and
• 19:10
  buns
• 19:10
  and
• 19:11
  meat
• 19:11
  and,
• 19:11
  and
• 19:11
  frozen
• 19:12
  meat.
• 19:12
  It's
• 19:13
  again,
• 19:13
  the
• 19:13
  neurotransmitter
• 19:14
  release
• 19:15
  is
• 19:15
  being
• 19:15
  slowed
• 19:16
  by
• 19:16
  that
• 19:16
  calcium
• 19:17
  channel
• 19:17
  blockade,
• 19:17
  AKA
• 19:18
  the
• 19:19
  release
• 19:19
  of
• 19:20
  products
• 19:20
  coming
• 19:21
  into
• 19:21
  the
• 19:21
  kitchen
• 19:22
  is
• 19:22
  reduced.
• 19:22
  So
• 19:22
  you're
• 19:23
  not
• 19:23
  having
• 19:23
  like
• 19:23
  90
• 19:24
  more
• 19:24
  burgers
• 19:24
  come
• 19:25
  in
• 19:25
  and
• 19:25
  frozen
• 19:26
  patties,
• 19:27
  right?
• 19:27
  And
• 19:27
  all
• 19:27
  this
• 19:27
  ice
• 19:28
  cream
• 19:28
  come
• 19:28
  into
• 19:28
  the
• 19:29
  kitchen.
• 19:29
  So
• 19:29
  there's
• 19:30
  less
• 19:30
  overwhelm
• 19:30
  of
• 19:31
  Supplies
• 19:31
  coming
• 19:31
  in,
• 19:32
  there's
• 19:32
  less
• 19:32
  overwhelm
• 19:33
  of
• 19:34
  drive
• 19:34
  thru
• 19:34
  orders
• 19:34
  coming
• 19:35
  in.
• 19:35
  And
• 19:35
  the
• 19:35
  hysterical
• 19:36
  cashier
• 19:37
  is
• 19:38
  essentially
• 19:38
  being
• 19:39
  muted
• 19:39
  or
• 19:39
  at
• 19:39
  least
• 19:40
  significantly
• 19:40
  lower.
• 19:41
  Not
• 19:41
  a
• 19:41
  full
• 19:41
  mute,
• 19:41
  but
• 19:42
  the
• 19:42
  volume
• 19:43
  is
• 19:43
  significantly
• 19:43
  lowered
• 19:44
  so
• 19:44
  that
• 19:44
  the
• 19:45
  kitchen
• 19:45
  isn't
• 19:45
  in
• 19:46
  this
• 19:46
  crazy
• 19:47
  panic.
• 19:47
  And
• 19:47
  that
• 19:47
  would
• 19:47
  be
• 19:48
  the
• 19:49
  glutamate
• 19:50
  blockade's
• 19:50
  way
• 19:51
  of
• 19:51
  just
• 19:52
  lowering
• 19:52
  the
• 19:54
  volume,
• 19:54
  which
• 19:55
  is
• 19:56
  very
• 19:57
  important.
• 19:58
  Very
• 19:58
  important.
• 19:59
  So
• 20:00
  I
• 20:00
  hope
• 20:00
  you
• 20:00
  appreciated
• 20:01
  the
• 20:01
  four
• 20:02
  different
• 20:02
  mechanisms
• 20:03
  by
• 20:03
  which
• 20:03
  Topamax
• 20:04
  can
• 20:05
  exert
• 20:05
  its
• 20:05
  effects.
• 20:06
  Um,
• 20:07
  you
• 20:07
  can
• 20:07
  just
• 20:08
  imagine
• 20:09
  about
• 20:09
  how
• 20:10
  incredible
• 20:11
  that
• 20:11
  can
• 20:11
  be
• 20:12
  when
• 20:12
  we're
• 20:12
  trying
• 20:12
  to
• 20:13
  reduce
• 20:13
  alcohol
• 20:13
  cravings
• 20:14
  via
• 20:14
  that
• 20:15
  dampening
• 20:16
  of
• 20:16
  the
• 20:16
  glutamate
• 20:17
  excitatory
• 20:19
  state,
• 20:20
  how
• 20:21
  that
• 20:21
  could
• 20:21
  really
• 20:21
  help
• 20:22
  with
• 20:22
  the
• 20:22
  potentiation
• 20:23
  of
• 20:23
  gaba.
• 20:24
  Right.
• 20:25
  In
• 20:25
  addition,
• 20:25
  just
• 20:26
  to
• 20:26
  kind
• 20:26
  of
• 20:26
  calm
• 20:27
  a
• 20:27
  lot
• 20:27
  of
• 20:27
  those
• 20:27
  circuits
• 20:28
  and
• 20:30
  PTSD
• 20:30
  nightmares
• 20:31
  and
• 20:31
  hyperarousal,
• 20:32
  how
• 20:33
  that
• 20:34
  please
• 20:34
  hold
• 20:34
  sign
• 20:35
  in
• 20:35
  the
• 20:35
  drive
• 20:35
  through
• 20:35
  can
• 20:36
  really
• 20:36
  slow
• 20:36
  down
• 20:36
  the
• 20:36
  amygdala's
• 20:37
  rapid
• 20:37
  fire
• 20:38
  orders.
• 20:39
  And
• 20:39
  how
• 20:40
  the
• 20:40
  reduction
• 20:41
  in
• 20:41
  neurotransmitter
• 20:42
  release
• 20:43
  can
• 20:44
  also
• 20:45
  potentially
• 20:46
  help
• 20:46
  the
• 20:46
  pain
• 20:46
  response
• 20:47
  and
• 20:47
  the
• 20:47
  reduction
• 20:48
  of
• 20:48
  migraines.
• 20:49
  Right.
• 20:49
  And
• 20:50
  so
• 20:50
  you
• 20:50
  have
• 20:50
  four
• 20:51
  distinct
• 20:51
  mechanisms
• 20:52
  here
• 20:52
  and
• 20:53
  basically
• 20:53
  four
• 20:54
  ways
• 20:54
  to
• 20:54
  calm
• 20:55
  a
• 20:55
  chaotic
• 20:56
  McDonald's.
• 20:57
  And
• 20:57
  they
• 20:57
  all
• 20:57
  kind
• 20:58
  of
• 20:58
  converge
• 20:58
  on
• 20:59
  overlapping
• 20:59
  neural
• 21:00
  circuits
• 21:00
  that
• 21:01
  drive
• 21:01
  a
• 21:01
  lot
• 21:02
  of
• 21:02
  the
• 21:02
  psychiatric
• 21:02
  and
• 21:02
  neurological
• 21:03
  conditions
• 21:04
  we
• 21:04
  see
• 21:04
  in
• 21:04
  our
• 21:04
  outpatient
• 21:05
  practice.
• 21:06
  And
• 21:06
  it's
• 21:07
  not
• 21:07
  often
• 21:07
  that
• 21:07
  a
• 21:07
  psychiatric
• 21:08
  medication
• 21:09
  has
• 21:10
  these.
• 21:10
  This
• 21:10
  kind
• 21:11
  of
• 21:11
  rich
• 21:12
  versatility
• 21:13
  in
• 21:13
  how
• 21:13
  it's
• 21:14
  going
• 21:14
  about
• 21:15
  the
• 21:16
  treatment
• 21:16
  of
• 21:17
  a
• 21:17
  mental
• 21:17
  health
• 21:17
  issue.
• 21:18
  A
• 21:18
  lot
• 21:18
  of
• 21:18
  it
• 21:18
  is
• 21:18
  off
• 21:19
  label,
• 21:19
  but
• 21:19
  I
• 21:19
  would
• 21:19
  encourage
• 21:20
  you
• 21:20
  guys
• 21:20
  to
• 21:20
  really
• 21:20
  nerd
• 21:21
  out
• 21:21
  and
• 21:22
  find
• 21:22
  a
• 21:22
  good
• 21:22
  place
• 21:23
  for
• 21:23
  this
• 21:23
  in
• 21:23
  your
• 21:24
  toolkit.
• 21:25
  It's
• 21:25
  a
• 21:25
  really
• 21:26
  versatile
• 21:26
  medication
• 21:27
  that
• 21:27
  can
• 21:27
  hit
• 21:27
  multiple
• 21:28
  targets
• 21:29
  through
• 21:30
  all
• 21:30
  these
• 21:30
  mechanisms
• 21:31
  we
• 21:31
  talked
• 21:31
  about,
• 21:31
  which
• 21:31
  is
• 21:32
  really
• 21:32
  cool.
• 21:32
  So
• 21:32
  definitely
• 21:33
  think
• 21:33
  about
• 21:33
  it
• 21:33
  more
• 21:33
  with
• 21:34
  alcohol
• 21:34
  use
• 21:34
  disorder,
• 21:35
  ptsd,
• 21:36
  when
• 21:36
  you're
• 21:36
  trying
• 21:36
  to
• 21:36
  reduce
• 21:37
  alcohol
• 21:37
  consumption
• 21:38
  and
• 21:38
  cravings,
• 21:39
  and
• 21:39
  PTSD
• 21:40
  severity
• 21:40
  all
• 21:40
  at
• 21:40
  once.
• 21:41
  It's
• 21:41
  a
• 21:41
  pretty
• 21:41
  cool
• 21:42
  arrow
• 21:43
  in
• 21:43
  your
• 21:43
  quiver.
• 21:44
  And
• 21:44
  it
• 21:44
  has
• 21:44
  some
• 21:45
  pretty
• 21:45
  good
• 21:45
  evidence
• 21:46
  on
• 21:46
  it
• 21:47
  too.
• 21:48
  So
• 21:49
  some
• 21:49
  people
• 21:49
  even
• 21:49
  lose
• 21:50
  a
• 21:50
  little
• 21:50
  bit
• 21:50
  of
• 21:50
  weight.
• 21:50
  It
• 21:51
  can
• 21:51
  reduce
• 21:52
  binge
• 21:52
  eating
• 21:53
  urges
• 21:53
  and
• 21:54
  the
• 21:54
  compulsive
• 21:55
  drive
• 21:55
  to
• 21:55
  binge
• 21:56
  eat.
• 21:57
  So
• 21:57
  it's
• 21:58
  just,
• 21:58
  it's
• 21:58
  just
• 21:58
  pretty
• 21:59
  neat,
• 21:59
  right?
• 22:00
  If
• 22:00
  you
• 22:00
  have
• 22:00
  a
• 22:01
  patient
• 22:01
  with.
• 22:01
  I
• 22:01
  know
• 22:01
  a
• 22:01
  lot
• 22:02
  of
• 22:02
  my
• 22:02
  patients
• 22:02
  have
• 22:02
  migraines
• 22:03
  with
• 22:03
  their
• 22:03
  PTSD
• 22:04
  with
• 22:04
  their
• 22:04
  alcohol
• 22:04
  use
• 22:05
  disorder.
• 22:05
  Some
• 22:06
  people
• 22:06
  have
• 22:06
  alcohol
• 22:06
  use
• 22:06
  disorder
• 22:07
  with
• 22:07
  ptsd.
• 22:08
  Right.
• 22:08
  The
• 22:08
  average
• 22:09
  patient
• 22:09
  who
• 22:09
  walks
• 22:09
  into
• 22:10
  your
• 22:10
  clinic
• 22:10
  is
• 22:10
  gonna
• 22:11
  be
• 22:11
  a
• 22:11
  very
• 22:12
  frustrating
• 22:13
  combination
• 22:13
  of
• 22:13
  many
• 22:14
  DSM
• 22:14
  diagnoses.
• 22:15
  And
• 22:15
  it's
• 22:16
  not
• 22:16
  gonna
• 22:16
  be
• 22:17
  always
• 22:17
  clear
• 22:18
  or
• 22:19
  even
• 22:19
  useful
• 22:19
  for
• 22:20
  you
• 22:20
  to
• 22:20
  just
• 22:21
  say,
• 22:21
  oh,
• 22:22
  that
• 22:22
  one
• 22:22
  med
• 22:22
  is
• 22:22
  for
• 22:23
  this,
• 22:23
  and
• 22:23
  then
• 22:23
  that
• 22:23
  other
• 22:24
  med
• 22:24
  is
• 22:24
  for
• 22:24
  this,
• 22:24
  and
• 22:25
  that
• 22:25
  other
• 22:25
  med
• 22:25
  is
• 22:25
  for
• 22:25
  this
• 22:26
  disorder.
• 22:26
  It's
• 22:26
  not
• 22:27
  that
• 22:27
  simple.
• 22:28
  Right?
• 22:28
  Sometimes
• 22:29
  you
• 22:29
  need
• 22:29
  to
• 22:29
  pick
• 22:29
  a
• 22:29
  med
• 22:30
  in
• 22:30
  the
• 22:30
  interest
• 22:30
  of,
• 22:31
  you
• 22:31
  know,
• 22:32
  not,
• 22:34
  you
• 22:34
  know,
• 22:34
  making
• 22:35
  polypharmacy
• 22:35
  worse.
• 22:36
  You
• 22:36
  might
• 22:36
  need
• 22:36
  to
• 22:36
  pick
• 22:36
  a
• 22:36
  med
• 22:37
  that
• 22:37
  does
• 22:37
  a
• 22:38
  lot
• 22:38
  of
• 22:38
  unique
• 22:38
  things
• 22:39
  at
• 22:39
  once.
• 22:39
  And
• 22:39
  I
• 22:39
  think
• 22:40
  Topamax
• 22:40
  has
• 22:40
  a
• 22:41
  really
• 22:41
  cool
• 22:41
  place
• 22:41
  for
• 22:41
  this.
• 22:42
  I
• 22:42
  have
• 22:43
  a
• 22:43
  stunning
• 22:44
  and
• 22:45
  visual
• 22:46
  of
• 22:46
  this
• 22:47
  McDonald's
• 22:48
  analogy
• 22:48
  that
• 22:48
  I've
• 22:48
  created
• 22:49
  for
• 22:49
  Patreon
• 22:50
  followers.
• 22:50
  So
• 22:50
  I
• 22:51
  highly
• 22:51
  recommend
• 22:51
  you
• 22:52
  join
• 22:52
  in
• 22:53
  our
• 22:53
  show
• 22:53
  notes
• 22:53
  later.
• 22:53
  My
• 22:54
  friends.
• 22:55
  It
• 22:55
  is
• 22:55
  this
• 22:55
  big,
• 22:56
  sticky
• 22:56
  visual
• 22:57
  library
• 22:57
  that
• 22:57
  makes
• 22:57
  psychiatry
• 22:58
  so
• 22:59
  easy
• 22:59
  to
• 22:59
  remember
• 23:00
  and,
• 23:01
  and
• 23:01
  learn
• 23:01
  and,
• 23:02
  and
• 23:02
  it's
• 23:03
  just.
• 23:03
  I
• 23:03
  love
• 23:04
  this
• 23:04
  library.
• 23:05
  Many
• 23:05
  of
• 23:05
  our
• 23:06
  friends
• 23:06
  have
• 23:06
  joined
• 23:06
  it
• 23:07
  and
• 23:07
  are
• 23:07
  sharing
• 23:07
  it.
• 23:09
  I
• 23:09
  highly
• 23:10
  recommend
• 23:10
  it.
• 23:10
  You
• 23:10
  know,
• 23:11
  there
• 23:11
  are
• 23:11
  really
• 23:11
  two
• 23:12
  types
• 23:12
  of
• 23:12
  clinicians,
• 23:12
  right?
• 23:13
  The
• 23:13
  ones
• 23:13
  who
• 23:13
  just
• 23:13
  follow
• 23:14
  the
• 23:14
  algos
• 23:14
  and
• 23:15
  the
• 23:15
  ones
• 23:15
  who
• 23:15
  understand
• 23:16
  the
• 23:16
  how
• 23:16
  and
• 23:16
  the
• 23:16
  why
• 23:17
  of
• 23:17
  what
• 23:17
  they're
• 23:17
  doing.
• 23:17
  And
• 23:17
  I
• 23:18
  feel
• 23:18
  like
• 23:18
  patients
• 23:18
  can
• 23:19
  just
• 23:19
  smell
• 23:19
  that
• 23:19
  a
• 23:20
  mile
• 23:20
  away.
• 23:21
  It
• 23:21
  completely
• 23:22
  transforms
• 23:22
  the
• 23:23
  way
• 23:23
  you
• 23:23
  practice
• 23:24
  your
• 23:24
  ability
• 23:24
  to
• 23:25
  achieve
• 23:25
  better
• 23:25
  outcomes
• 23:26
  for
• 23:26
  your
• 23:26
  patients.
• 23:27
  And.
• 23:27
  And
• 23:27
  it
• 23:27
  just
• 23:28
  increases
• 23:28
  your
• 23:28
  confidence.
• 23:29
  I
• 23:29
  don't
• 23:29
  know
• 23:29
  what
• 23:29
  I
• 23:30
  would
• 23:30
  do
• 23:30
  without
• 23:30
  this
• 23:30
  Patreon
• 23:31
  library.
• 23:31
  I'd
• 23:31
  be
• 23:31
  afraid
• 23:32
  to
• 23:32
  know
• 23:33
  the
• 23:33
  kind
• 23:33
  of
• 23:33
  clinician
• 23:34
  I
• 23:34
  would
• 23:34
  be
• 23:34
  without
• 23:34
  it.
• 23:34
  I
• 23:35
  highly
• 23:35
  recommend
• 23:35
  you
• 23:36
  go
• 23:36
  to
• 23:36
  the
• 23:36
  show
• 23:36
  notes.
• 23:36
  If
• 23:37
  there's
• 23:37
  one
• 23:37
  thing
• 23:37
  you
• 23:37
  don't
• 23:37
  forget
• 23:38
  by
• 23:38
  the
• 23:38
  end
• 23:39
  of
• 23:39
  the
• 23:39
  night,
• 23:39
  get
• 23:40
  to
• 23:40
  those
• 23:40
  show
• 23:40
  notes,
• 23:41
  become
• 23:41
  a
• 23:41
  member.
• 23:41
  We'd
• 23:41
  love
• 23:42
  to
• 23:42
  have
• 23:42
  you.
• 23:42
  Thank
• 23:42
  you
• 23:42
  all
• 23:43
  for
• 23:43
  joining
• 23:44
  and,
• 23:45
  and
• 23:45
  listening
• 23:45
  in
• 23:46
  today.
• 23:48
  Until
• 23:48
  next
• 23:48
  time,
• 23:48
  my
• 23:49
  friends,
• 23:50
  we
• 23:50
  will
• 23:50
  be
• 23:50
  in
• 23:50
  touch
• 23:51
  for
• 23:51
  more
• 23:51
  fun
• 23:52
  episodes
• 23:52
  here
• 23:52
  on
• 23:53
  Pearls
• 23:53
  and
• 23:53
  Prep.
• 23:53
  Thank
• 23:54
  you.
• 23:54
  Bye
• 23:54
  bye,
• 23:55
  Sam.