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Irritability Pearls: Avoiding the Most Common Clinical Mistakes · 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
• 0:10
  npc.
• 0:10
  Here
• 0:11
  your
• 0:11
  preceptor
• 0:12
  in
• 0:12
  your
• 0:12
  pocket
• 0:13
  your
• 0:13
  go
• 0:13
  to
• 0:13
  place
• 0:14
  for
• 0:14
  pearls
• 0:15
  that
• 0:15
  prep
• 0:16
  you
• 0:16
  to
• 0:16
  practice.
• 0:17
  Now,
• 0:17
  my
• 0:18
  friends,
• 0:19
  I
• 0:20
  have
• 0:20
  been
• 0:21
  really
• 0:21
  irritable
• 0:22
  lately
• 0:22
  about
• 0:23
  irritability,
• 0:24
  okay?
• 0:25
  And
• 0:25
  what
• 0:25
  I
• 0:26
  mean
• 0:26
  by
• 0:26
  that
• 0:26
  is
• 0:27
  irritability
• 0:28
  seems
• 0:28
  to
• 0:28
  be
• 0:28
  this
• 0:29
  trans
• 0:29
  diagnostic
• 0:30
  problem
• 0:31
  in
• 0:31
  our
• 0:31
  patients
• 0:33
  that
• 0:33
  isn't
• 0:33
  very
• 0:34
  clear
• 0:35
  with
• 0:35
  respect
• 0:35
  to
• 0:36
  how
• 0:36
  you
• 0:36
  treat
• 0:36
  it,
• 0:37
  okay?
• 0:37
  And
• 0:38
  if
• 0:38
  you
• 0:38
  think
• 0:38
  about
• 0:38
  it,
• 0:39
  you'll
• 0:39
  understand
• 0:40
  that
• 0:40
  what
• 0:41
  I
• 0:41
  just
• 0:41
  said
• 0:41
  is
• 0:42
  kind
• 0:42
  of
• 0:42
  true
• 0:43
  because
• 0:43
  there's
• 0:44
  many
• 0:44
  different
• 0:44
  reasons
• 0:45
  somebody
• 0:45
  could
• 0:45
  be
• 0:45
  irritable.
• 0:46
  There
• 0:46
  are
• 0:47
  many
• 0:47
  different
• 0:47
  mood
• 0:48
  states
• 0:48
  or
• 0:48
  DSM
• 0:49
  5
• 0:50
  diagnoses
• 0:51
  that
• 0:52
  are
• 0:52
  implicated
• 0:53
  in
• 0:53
  irritability.
• 0:54
  And
• 0:54
  so
• 0:55
  it
• 0:55
  can
• 0:55
  be
• 0:56
  really
• 0:56
  confusing
• 0:57
  really
• 0:57
  quickly.
• 0:59
  And
• 0:59
  the
• 0:59
  other
• 0:59
  day
• 1:00
  I
• 1:01
  had
• 1:02
  a
• 1:03
  specific
• 1:03
  situation
• 1:04
  I
• 1:04
  was
• 1:04
  in
• 1:04
  where
• 1:04
  I
• 1:04
  didn't
• 1:05
  really
• 1:05
  understand
• 1:06
  whether
• 1:06
  my
• 1:06
  patient
• 1:07
  was
• 1:07
  more
• 1:08
  irritable
• 1:08
  because
• 1:09
  we
• 1:09
  just
• 1:09
  raised
• 1:10
  the
• 1:10
  dose
• 1:11
  or
• 1:12
  was
• 1:12
  irritable
• 1:13
  because
• 1:13
  the
• 1:13
  dose
• 1:14
  wasn't
• 1:14
  high
• 1:14
  enough
• 1:15
  of
• 1:15
  the
• 1:16
  ssri.
• 1:16
  And
• 1:17
  maybe
• 1:17
  we
• 1:18
  just
• 1:18
  needed
• 1:19
  to
• 1:19
  raise
• 1:19
  it
• 1:20
  to
• 1:21
  control
• 1:21
  her
• 1:21
  anxiety
• 1:22
  better
• 1:22
  and
• 1:23
  thereby
• 1:24
  make
• 1:24
  maybe
• 1:24
  lower
• 1:25
  her
• 1:25
  irritability
• 1:25
  more.
• 1:26
  It's
• 1:27
  really
• 1:27
  hard
• 1:27
  to
• 1:27
  say.
• 1:28
  And
• 1:29
  so
• 1:30
  I
• 1:30
  want
• 1:30
  to
• 1:30
  have
• 1:30
  a
• 1:30
  conversation
• 1:31
  with
• 1:31
  you
• 1:31
  guys
• 1:31
  about
• 1:32
  this
• 1:32
  because
• 1:32
  it
• 1:32
  can
• 1:32
  get
• 1:33
  really
• 1:33
  confusing
• 1:34
  really
• 1:34
  quickly
• 1:35
  and
• 1:35
  I
• 1:35
  want
• 1:35
  to
• 1:35
  talk
• 1:35
  about
• 1:36
  it.
• 1:36
  So
• 1:37
  first
• 1:37
  of
• 1:37
  all,
• 1:38
  why
• 1:38
  do
• 1:38
  people
• 1:38
  get
• 1:39
  irritable?
• 1:39
  Why
• 1:40
  do
• 1:40
  your
• 1:40
  patients
• 1:40
  come
• 1:41
  in
• 1:41
  and
• 1:41
  even
• 1:41
  get
• 1:41
  irritable
• 1:42
  in
• 1:42
  the
• 1:42
  first
• 1:42
  place?
• 1:43
  Well,
• 1:43
  if
• 1:43
  you
• 1:43
  think
• 1:44
  about
• 1:44
  it,
• 1:44
  it's
• 1:44
  a
• 1:44
  universal
• 1:45
  response.
• 1:45
  It's
• 1:46
  a
• 1:46
  survival
• 1:46
  tool,
• 1:47
  okay?
• 1:47
  It's
• 1:48
  part
• 1:48
  of
• 1:48
  our
• 1:48
  brain's
• 1:49
  ancient
• 1:49
  threat
• 1:49
  detection
• 1:51
  system,
• 1:51
  okay?
• 1:52
  The
• 1:52
  brain
• 1:52
  doesn't
• 1:53
  just
• 1:53
  produce
• 1:53
  fear
• 1:54
  when
• 1:54
  there's
• 1:55
  danger.
• 1:56
  It
• 1:56
  actually
• 1:57
  also
• 1:58
  produces
• 1:58
  irritability,
• 1:59
  okay?
• 2:00
  And
• 2:00
  irritability
• 2:00
  is
• 2:01
  a
• 2:01
  way
• 2:01
  to
• 2:01
  kind
• 2:01
  of
• 2:01
  respond
• 2:02
  to
• 2:02
  that
• 2:02
  threat.
• 2:03
  If
• 2:03
  you
• 2:03
  think
• 2:03
  about
• 2:03
  it,
• 2:04
  it
• 2:04
  makes
• 2:04
  perfect
• 2:05
  sense,
• 2:05
  right?
• 2:06
  If
• 2:06
  there's
• 2:06
  a
• 2:06
  bear
• 2:07
  somewhere
• 2:07
  in
• 2:07
  your
• 2:07
  neighborhood
• 2:08
  and
• 2:09
  you're
• 2:09
  out
• 2:10
  near
• 2:10
  your
• 2:10
  playground
• 2:11
  and
• 2:12
  you're
• 2:12
  trying
• 2:12
  to
• 2:12
  figure
• 2:13
  out
• 2:13
  where
• 2:13
  the
• 2:13
  bear
• 2:13
  is,
• 2:14
  and
• 2:14
  if
• 2:14
  somebody's
• 2:15
  bothering
• 2:15
  you
• 2:15
  and
• 2:16
  making
• 2:16
  small
• 2:17
  talk,
• 2:18
  you're
• 2:18
  going
• 2:18
  to
• 2:18
  get
• 2:18
  really
• 2:18
  angry
• 2:19
  really
• 2:19
  quickly
• 2:20
  because
• 2:20
  you're
• 2:20
  focused
• 2:21
  on
• 2:21
  that
• 2:21
  bear.
• 2:21
  The
• 2:22
  small
• 2:22
  talk
• 2:22
  is
• 2:22
  obnoxious.
• 2:23
  I
• 2:23
  know
• 2:24
  I
• 2:24
  would
• 2:24
  be
• 2:24
  furious
• 2:25
  if
• 2:25
  someone
• 2:25
  was
• 2:25
  trying
• 2:26
  to
• 2:26
  make
• 2:26
  small
• 2:26
  talk
• 2:26
  with
• 2:26
  me
• 2:27
  and
• 2:27
  I
• 2:27
  wanted
• 2:27
  to
• 2:28
  get
• 2:28
  home
• 2:28
  safely
• 2:28
  because
• 2:29
  there
• 2:29
  was
• 2:29
  a
• 2:29
  bear.
• 2:30
  So
• 2:30
  my
• 2:30
  irritability
• 2:32
  is
• 2:32
  my
• 2:32
  way
• 2:33
  of
• 2:33
  kind
• 2:33
  of
• 2:33
  defending
• 2:34
  territory.
• 2:35
  It's
• 2:35
  my
• 2:35
  way
• 2:35
  of
• 2:35
  focusing.
• 2:36
  It's
• 2:36
  my
• 2:36
  way
• 2:36
  of
• 2:37
  laying
• 2:38
  down
• 2:38
  clean
• 2:39
  boundaries
• 2:40
  so
• 2:40
  that
• 2:41
  I
• 2:41
  can
• 2:41
  think
• 2:42
  clearly
• 2:42
  and
• 2:43
  not
• 2:43
  be
• 2:43
  subjected
• 2:44
  to.
• 2:44
  To
• 2:45
  that
• 2:45
  threat.
• 2:45
  So
• 2:46
  it's
• 2:46
  part
• 2:46
  of
• 2:46
  the
• 2:46
  threat
• 2:47
  response
• 2:47
  and
• 2:47
  it's
• 2:48
  no
• 2:48
  Coincidence
• 2:49
  that
• 2:50
  many
• 2:51
  of
• 2:51
  the
• 2:51
  ways
• 2:51
  we
• 2:51
  target
• 2:52
  irritability
• 2:53
  run
• 2:53
  through
• 2:53
  the
• 2:53
  amygdala,
• 2:54
  the
• 2:54
  threat
• 2:55
  processing
• 2:55
  circuit.
• 2:56
  Okay.
• 2:57
  And
• 2:57
  I
• 2:57
  won't
• 2:57
  get
• 2:57
  into
• 2:58
  the
• 2:58
  nitty
• 2:58
  gritty
• 2:58
  of
• 2:59
  all
• 2:59
  the
• 2:59
  brain
• 2:59
  circuits
• 3:00
  necessarily
• 3:00
  today,
• 3:00
  but
• 3:01
  suffice
• 3:01
  it
• 3:01
  to
• 3:01
  say,
• 3:01
  the
• 3:01
  amygdala
• 3:02
  is
• 3:02
  a
• 3:02
  big
• 3:03
  way
• 3:04
  we
• 3:04
  can
• 3:04
  confront
• 3:05
  irritability.
• 3:05
  And
• 3:05
  so
• 3:06
  if
• 3:06
  you
• 3:06
  conceptualize
• 3:07
  irritability
• 3:08
  in
• 3:08
  the.
• 3:10
  Through
• 3:10
  the
• 3:10
  frame
• 3:11
  of
• 3:11
  fight
• 3:11
  or
• 3:11
  flight
• 3:12
  or
• 3:12
  a
• 3:13
  physical
• 3:13
  threat,
• 3:14
  now,
• 3:14
  you
• 3:15
  can
• 3:15
  understand
• 3:15
  why
• 3:16
  an
• 3:16
  SSRI
• 3:17
  might
• 3:17
  make
• 3:17
  a
• 3:17
  lot
• 3:17
  of
• 3:18
  sense
• 3:18
  when
• 3:19
  it
• 3:19
  comes
• 3:19
  to
• 3:19
  that,
• 3:19
  because
• 3:20
  it
• 3:20
  kind
• 3:20
  of
• 3:20
  cools
• 3:21
  off
• 3:21
  the
• 3:22
  amygdala
• 3:23
  or
• 3:23
  the
• 3:23
  fight
• 3:23
  or
• 3:23
  flight
• 3:24
  parts
• 3:25
  of
• 3:25
  our
• 3:25
  brain.
• 3:26
  Right?
• 3:26
  The
• 3:26
  part
• 3:26
  of
• 3:26
  our
• 3:27
  brain
• 3:27
  that's
• 3:27
  deciding
• 3:28
  whether
• 3:28
  we
• 3:28
  should
• 3:29
  freeze
• 3:29
  or.
• 3:30
  Or
• 3:31
  fear
• 3:31
  and
• 3:31
  escape
• 3:32
  or.
• 3:32
  Or
• 3:32
  be
• 3:32
  angry
• 3:33
  and
• 3:33
  actually
• 3:34
  fight
• 3:34
  and
• 3:34
  defend
• 3:35
  the
• 3:35
  territory,
• 3:36
  or
• 3:36
  be
• 3:36
  aggressive.
• 3:37
  Right.
• 3:37
  So
• 3:37
  that
• 3:37
  lives,
• 3:38
  by
• 3:38
  and
• 3:38
  large,
• 3:39
  in
• 3:39
  the
• 3:40
  amygdala.
• 3:40
  Okay?
• 3:41
  But
• 3:41
  for
• 3:41
  simplicity's
• 3:42
  sake,
• 3:42
  the
• 3:42
  amygdala
• 3:42
  is
• 3:43
  fight
• 3:43
  or
• 3:43
  flight,
• 3:43
  and
• 3:43
  irritability
• 3:44
  is
• 3:44
  part
• 3:44
  and
• 3:44
  parcel
• 3:45
  of
• 3:46
  that
• 3:47
  threat
• 3:47
  response.
• 3:48
  Okay?
• 3:48
  So
• 3:49
  that
• 3:49
  really
• 3:49
  helps
• 3:49
  us
• 3:50
  because
• 3:51
  when
• 3:51
  we're
• 3:51
  looking
• 3:51
  at
• 3:52
  ptsd,
• 3:52
  it
• 3:52
  makes
• 3:53
  sense
• 3:53
  that
• 3:54
  why
• 3:54
  someone
• 3:54
  might
• 3:55
  be
• 3:55
  irritable
• 3:55
  all
• 3:55
  the
• 3:56
  time
• 3:57
  because
• 3:57
  they're
• 3:57
  trying
• 3:58
  to
• 3:58
  really
• 3:59
  focus
• 3:59
  on
• 3:59
  this
• 4:00
  threat
• 4:00
  that
• 4:00
  is
• 4:00
  unresolved
• 4:01
  in
• 4:02
  those
• 4:02
  brain
• 4:02
  circuits,
• 4:03
  and
• 4:03
  we
• 4:03
  have
• 4:03
  to
• 4:03
  cool
• 4:03
  that
• 4:03
  off
• 4:04
  via
• 4:04
  SSRIs
• 4:05
  or
• 4:05
  SNRIs.
• 4:06
  Um,
• 4:07
  and.
• 4:07
  And
• 4:07
  so
• 4:07
  it
• 4:08
  makes
• 4:08
  perfect
• 4:08
  sense,
• 4:09
  right?
• 4:09
  And
• 4:09
  that's
• 4:09
  what
• 4:09
  we
• 4:10
  do
• 4:10
  all
• 4:10
  of
• 4:11
  the
• 4:11
  time.
• 4:12
  Okay.
• 4:12
  And
• 4:13
  we
• 4:13
  see
• 4:13
  our
• 4:13
  patients,
• 4:14
  they
• 4:14
  often
• 4:14
  take
• 4:14
  this
• 4:15
  out
• 4:15
  on
• 4:15
  their.
• 4:16
  On
• 4:16
  their
• 4:16
  spouses
• 4:17
  or
• 4:18
  their
• 4:18
  coworkers.
• 4:19
  It's
• 4:19
  a
• 4:19
  really
• 4:19
  disruptive
• 4:20
  problem,
• 4:20
  actually.
• 4:21
  Um,
• 4:22
  and
• 4:22
  some
• 4:22
  studies
• 4:23
  even
• 4:23
  go
• 4:23
  as
• 4:24
  far
• 4:24
  to
• 4:25
  say
• 4:25
  that
• 4:25
  irritability
• 4:26
  in
• 4:26
  and
• 4:26
  of
• 4:27
  itself
• 4:27
  is
• 4:27
  a
• 4:28
  marker
• 4:28
  that
• 4:29
  can
• 4:29
  predict
• 4:30
  relapse
• 4:31
  of
• 4:32
  your
• 4:33
  psychiatric
• 4:33
  disorders.
• 4:34
  Okay?
• 4:35
  And
• 4:35
  so
• 4:35
  that's
• 4:36
  a
• 4:36
  real
• 4:36
  problem,
• 4:36
  right?
• 4:37
  Because
• 4:38
  prognostically,
• 4:40
  if
• 4:40
  irritability
• 4:41
  is
• 4:42
  not
• 4:42
  being
• 4:42
  treated
• 4:43
  well,
• 4:43
  then
• 4:44
  it
• 4:45
  can
• 4:45
  be
• 4:45
  a
• 4:45
  predictor
• 4:46
  of
• 4:46
  treatment
• 4:46
  response.
• 4:47
  But
• 4:47
  there's
• 4:47
  actually
• 4:48
  been
• 4:49
  data
• 4:49
  of
• 4:50
  that,
• 4:50
  specifically
• 4:51
  in
• 4:51
  depression
• 4:51
  severity.
• 4:52
  So
• 4:52
  just
• 4:53
  like
• 4:53
  sleep,
• 4:54
  treat
• 4:54
  it
• 4:54
  like
• 4:54
  an
• 4:54
  independent
• 4:55
  marker
• 4:55
  that
• 4:55
  if
• 4:56
  it's
• 4:56
  still
• 4:56
  not
• 4:56
  resolved,
• 4:57
  your
• 4:57
  prognosis
• 4:58
  is
• 4:58
  going
• 4:58
  to
• 4:58
  be
• 4:59
  bleeker.
• 5:00
  Okay?
• 5:01
  And
• 5:01
  so
• 5:01
  we've
• 5:01
  got
• 5:02
  to
• 5:02
  solve
• 5:02
  it.
• 5:02
  Now,
• 5:02
  we
• 5:02
  don't
• 5:03
  always
• 5:03
  know
• 5:03
  how
• 5:03
  to
• 5:03
  solve
• 5:03
  it,
• 5:04
  because
• 5:04
  a
• 5:04
  patient
• 5:04
  can
• 5:04
  be
• 5:04
  irritable
• 5:05
  for
• 5:05
  many
• 5:05
  reasons.
• 5:05
  It
• 5:06
  can
• 5:06
  be
• 5:06
  irritable
• 5:06
  because
• 5:07
  of
• 5:07
  a
• 5:07
  threat.
• 5:07
  We
• 5:07
  just
• 5:08
  described
• 5:08
  in
• 5:08
  ptsd,
• 5:09
  we
• 5:09
  know
• 5:10
  that
• 5:10
  generalized
• 5:10
  anxiety
• 5:11
  disorder
• 5:11
  has
• 5:11
  irritability
• 5:12
  as
• 5:12
  one
• 5:12
  of
• 5:13
  its
• 5:13
  features,
• 5:14
  literally
• 5:14
  baked
• 5:15
  into
• 5:15
  the
• 5:16
  criteria
• 5:17
  of
• 5:17
  diagnosing
• 5:18
  gad.
• 5:18
  Right?
• 5:18
  Irritability.
• 5:20
  Okay?
• 5:20
  We
• 5:21
  know
• 5:21
  that
• 5:21
  people
• 5:21
  are
• 5:22
  very
• 5:22
  irritable
• 5:23
  when
• 5:23
  they
• 5:23
  have
• 5:23
  ADHD
• 5:24
  at
• 5:24
  times.
• 5:25
  Right.
• 5:25
  They
• 5:25
  have
• 5:25
  a
• 5:25
  lack
• 5:25
  of
• 5:26
  prefrontal
• 5:26
  cortex
• 5:27
  control,
• 5:28
  and
• 5:28
  it
• 5:28
  makes
• 5:29
  it
• 5:29
  hard
• 5:29
  to
• 5:29
  modulate
• 5:30
  that
• 5:31
  threat
• 5:31
  response
• 5:31
  or
• 5:32
  that
• 5:32
  those
• 5:33
  kind
• 5:33
  of
• 5:33
  more
• 5:34
  base
• 5:34
  emotions
• 5:35
  of
• 5:35
  fear
• 5:36
  or
• 5:36
  impulsivity
• 5:37
  and
• 5:37
  irritability.
• 5:38
  Right?
• 5:38
  Their,
• 5:38
  their
• 5:39
  prefrontal
• 5:39
  cortex
• 5:40
  is
• 5:40
  not
• 5:40
  always
• 5:40
  as
• 5:40
  engaged.
• 5:41
  The
• 5:41
  CEO
• 5:42
  is
• 5:42
  not
• 5:42
  always
• 5:43
  in
• 5:43
  charge.
• 5:43
  And
• 5:44
  so
• 5:44
  we
• 5:44
  see
• 5:44
  it,
• 5:44
  and
• 5:45
  we
• 5:45
  see
• 5:45
  it
• 5:45
  in
• 5:45
  adhd,
• 5:46
  we
• 5:46
  see
• 5:46
  it
• 5:46
  in
• 5:47
  gad,
• 5:47
  we
• 5:47
  see
• 5:47
  it
• 5:47
  in
• 5:47
  ptsd.
• 5:48
  And
• 5:49
  guess
• 5:49
  what?
• 5:49
  A
• 5:50
  lot
• 5:50
  of
• 5:50
  people,
• 5:50
  even
• 5:50
  though
• 5:50
  it's
• 5:50
  not
• 5:51
  part
• 5:51
  of
• 5:51
  the
• 5:51
  dsm,
• 5:52
  a
• 5:52
  lot
• 5:52
  of
• 5:52
  people
• 5:52
  will
• 5:53
  tell
• 5:53
  you
• 5:53
  they
• 5:53
  know
• 5:53
  they're
• 5:54
  depressed
• 5:54
  because
• 5:54
  they're
• 5:54
  getting
• 5:55
  more
• 5:55
  irritable
• 5:55
  and
• 5:55
  edgy.
• 5:56
  Not
• 5:56
  in
• 5:57
  the
• 5:57
  DSM
• 5:58
  necessarily
• 5:58
  under
• 5:59
  the
• 5:59
  diagnostic
• 5:59
  criteria
• 6:00
  for
• 6:00
  depression,
• 6:01
  but
• 6:01
  they
• 6:02
  do
• 6:02
  say
• 6:02
  they
• 6:02
  get
• 6:03
  very
• 6:03
  irritable
• 6:03
  and
• 6:04
  edgy
• 6:04
  on
• 6:06
  when
• 6:06
  they're
• 6:06
  depressed.
• 6:07
  So
• 6:07
  it's
• 6:07
  just
• 6:07
  one
• 6:07
  of
• 6:07
  those
• 6:08
  red
• 6:08
  flags
• 6:09
  for
• 6:09
  those
• 6:09
  people.
• 6:10
  But
• 6:11
  we
• 6:11
  see
• 6:11
  this
• 6:11
  all
• 6:11
  the
• 6:12
  time.
• 6:12
  Okay?
• 6:13
  We
• 6:13
  can
• 6:13
  see
• 6:13
  this
• 6:13
  in
• 6:13
  mania,
• 6:14
  right?
• 6:14
  Patients
• 6:14
  are
• 6:15
  pressured,
• 6:15
  they're
• 6:16
  thinking
• 6:17
  quickly,
• 6:17
  their
• 6:17
  thoughts
• 6:18
  are
• 6:18
  racing,
• 6:18
  they're
• 6:18
  talking
• 6:19
  really
• 6:19
  fast,
• 6:19
  and
• 6:19
  if
• 6:19
  you
• 6:19
  interrupt
• 6:20
  them,
• 6:21
  they
• 6:21
  can
• 6:21
  get
• 6:21
  really
• 6:22
  irritated
• 6:22
  really
• 6:22
  quickly.
• 6:23
  I
• 6:23
  mean,
• 6:23
  irritability
• 6:24
  is
• 6:24
  a
• 6:24
  major
• 6:26
  diagnostic
• 6:27
  feature
• 6:27
  of
• 6:27
  bipolarity,
• 6:28
  right?
• 6:28
  It's
• 6:29
  actually
• 6:29
  one
• 6:29
  of
• 6:30
  the
• 6:30
  major
• 6:31
  diagnostic
• 6:31
  criteria
• 6:32
  criteria.
• 6:33
  In
• 6:33
  addition
• 6:33
  to
• 6:34
  elevated
• 6:34
  or
• 6:34
  expanded
• 6:35
  mood,
• 6:35
  there's
• 6:35
  that
• 6:35
  irritability
• 6:36
  which
• 6:37
  is
• 6:37
  driven
• 6:38
  differently
• 6:39
  than
• 6:39
  the
• 6:40
  irritability
• 6:41
  we
• 6:41
  see
• 6:41
  in
• 6:42
  PTSD
• 6:43
  or
• 6:44
  in
• 6:44
  gad.
• 6:44
  Right?
• 6:44
  Because
• 6:45
  when
• 6:45
  we're
• 6:45
  talking
• 6:46
  about
• 6:46
  bipolar,
• 6:46
  we're
• 6:46
  talking
• 6:47
  about
• 6:47
  excess
• 6:47
  dopaminergic
• 6:49
  activity
• 6:49
  in
• 6:49
  those
• 6:49
  limbic
• 6:50
  circuits
• 6:51
  as
• 6:51
  opposed
• 6:51
  to
• 6:52
  the
• 6:52
  amygdala,
• 6:53
  where
• 6:54
  the
• 6:54
  threat
• 6:54
  processing
• 6:55
  needs
• 6:55
  to
• 6:56
  be
• 6:56
  softened
• 6:57
  with
• 6:57
  SSRIs
• 6:58
  that
• 6:58
  help
• 6:59
  again,
• 6:59
  kind
• 6:59
  of
• 6:59
  calm
• 6:59
  the
• 7:00
  amygdala
• 7:00
  and
• 7:00
  restore
• 7:02
  top
• 7:02
  down
• 7:03
  prefrontal
• 7:04
  regulation.
• 7:05
  Okay?
• 7:05
  And
• 7:06
  that's
• 7:06
  really,
• 7:06
  really
• 7:07
  important.
• 7:07
  So
• 7:07
  in,
• 7:07
  in
• 7:08
  mania,
• 7:08
  we're
• 7:09
  blocking
• 7:09
  the
• 7:09
  D2
• 7:10
  receptors
• 7:11
  to
• 7:12
  kind
• 7:12
  of
• 7:12
  take
• 7:12
  the
• 7:13
  foot
• 7:13
  off
• 7:13
  the
• 7:13
  gas.
• 7:13
  Because
• 7:14
  with
• 7:14
  dopamine
• 7:15
  is
• 7:15
  very
• 7:15
  much
• 7:15
  a
• 7:15
  go
• 7:15
  signal.
• 7:16
  It's
• 7:16
  kind
• 7:16
  of
• 7:17
  pressing
• 7:17
  the
• 7:17
  gas.
• 7:18
  So
• 7:18
  it's
• 7:18
  overactive
• 7:20
  in
• 7:20
  a
• 7:20
  lot
• 7:20
  of
• 7:20
  those
• 7:21
  brain
• 7:21
  circuits.
• 7:21
  And
• 7:22
  people
• 7:22
  feel
• 7:22
  impulsive,
• 7:23
  they're
• 7:23
  aggressive,
• 7:24
  and
• 7:25
  so
• 7:25
  they
• 7:26
  over
• 7:26
  respond
• 7:27
  to
• 7:27
  perceived
• 7:28
  threats
• 7:29
  or
• 7:29
  frustrations.
• 7:30
  Right.
• 7:30
  And
• 7:31
  so
• 7:31
  there's
• 7:31
  many
• 7:31
  different
• 7:31
  ways
• 7:32
  to
• 7:32
  do
• 7:32
  this.
• 7:32
  And
• 7:32
  it
• 7:32
  starts
• 7:33
  with
• 7:33
  trying
• 7:33
  to
• 7:33
  figure
• 7:34
  out
• 7:34
  what
• 7:35
  diagnosis
• 7:36
  are
• 7:36
  we
• 7:36
  looking
• 7:36
  at?
• 7:37
  Is
• 7:37
  there
• 7:37
  too
• 7:37
  much
• 7:37
  dopaminergic
• 7:38
  activity?
• 7:39
  We
• 7:39
  can
• 7:39
  use
• 7:39
  D2
• 7:40
  blockade,
• 7:40
  we
• 7:41
  can
• 7:41
  take
• 7:41
  antipsychotics.
• 7:42
  Right.
• 7:43
  If
• 7:43
  there
• 7:44
  is
• 7:45
  an
• 7:45
  issue
• 7:45
  with
• 7:46
  regard
• 7:46
  to
• 7:46
  anxiety
• 7:47
  and
• 7:47
  threat
• 7:47
  and
• 7:48
  PTSD
• 7:49
  criterion
• 7:49
  A
• 7:49
  traumas,
• 7:51
  we
• 7:51
  may
• 7:51
  want
• 7:51
  to
• 7:51
  cool
• 7:51
  off
• 7:52
  the
• 7:52
  amygdala
• 7:52
  a
• 7:52
  little
• 7:53
  bit
• 7:53
  with
• 7:53
  SSRIs.
• 7:54
  Okay.
• 7:55
  And
• 7:56
  kind
• 7:56
  of
• 7:56
  restore
• 7:56
  that
• 7:57
  prefrontal
• 7:58
  cortex
• 7:58
  top
• 7:58
  down
• 7:59
  regulation.
• 8:00
  But
• 8:00
  it's
• 8:01
  good
• 8:01
  to
• 8:01
  know
• 8:01
  that
• 8:01
  we
• 8:01
  have
• 8:02
  multiple
• 8:02
  different
• 8:03
  pathways
• 8:03
  to
• 8:03
  do
• 8:03
  this.
• 8:04
  Right.
• 8:04
  You
• 8:04
  even
• 8:05
  have
• 8:05
  guanfacine
• 8:05
  out
• 8:06
  there.
• 8:06
  Alpha
• 8:06
  2
• 8:06
  agonism.
• 8:07
  Pretty
• 8:08
  neat
• 8:08
  medication.
• 8:08
  I
• 8:08
  see
• 8:09
  it
• 8:09
  prescribed
• 8:09
  mainly
• 8:09
  in
• 8:10
  children.
• 8:10
  I've
• 8:11
  seen
• 8:11
  some
• 8:11
  adults
• 8:11
  on
• 8:11
  it
• 8:12
  by
• 8:12
  happen
• 8:12
  chance.
• 8:13
  They
• 8:13
  seem
• 8:13
  to
• 8:13
  speak
• 8:14
  pretty
• 8:14
  highly
• 8:14
  of
• 8:14
  it.
• 8:15
  But
• 8:15
  it
• 8:15
  strengthens
• 8:16
  the
• 8:16
  prefrontal
• 8:16
  cortex
• 8:17
  network
• 8:17
  connectivity,
• 8:18
  kind
• 8:19
  of
• 8:19
  enhances
• 8:19
  top
• 8:19
  down
• 8:20
  regulation
• 8:20
  of
• 8:20
  the
• 8:21
  amygdala
• 8:22
  by
• 8:23
  turning
• 8:24
  down
• 8:24
  the
• 8:24
  norepinephrine
• 8:25
  release,
• 8:27
  both
• 8:28
  by
• 8:29
  activating
• 8:29
  the
• 8:29
  adrenergic
• 8:30
  autoreceptor.
• 8:31
  We
• 8:31
  talked
• 8:31
  about
• 8:32
  autoreceptors
• 8:32
  in
• 8:33
  the
• 8:33
  past,
• 8:33
  Right.
• 8:33
  When
• 8:33
  you
• 8:34
  activate
• 8:35
  that
• 8:35
  adrenergic
• 8:36
  autoreceptor,
• 8:36
  that
• 8:36
  alpha
• 8:37
  2
• 8:37
  autoreceptor
• 8:38
  kind
• 8:38
  of
• 8:39
  tells
• 8:39
  the
• 8:40
  neuron
• 8:40
  to
• 8:41
  cool
• 8:41
  down
• 8:41
  the
• 8:41
  norepinephrine
• 8:42
  release.
• 8:43
  Right.
• 8:43
  Too
• 8:43
  much
• 8:43
  norepinephrine,
• 8:44
  too
• 8:44
  much
• 8:44
  noise,
• 8:45
  and
• 8:45
  now
• 8:45
  you
• 8:45
  have
• 8:46
  that
• 8:46
  irritability
• 8:46
  again.
• 8:47
  Right.
• 8:47
  We
• 8:47
  see
• 8:47
  that
• 8:47
  in
• 8:48
  ADHD
• 8:49
  in
• 8:49
  particular.
• 8:50
  Right.
• 8:50
  We
• 8:51
  can
• 8:51
  see
• 8:51
  that
• 8:51
  in
• 8:51
  ptsd.
• 8:52
  Right.
• 8:52
  There's
• 8:53
  an
• 8:53
  elegant
• 8:53
  overlap
• 8:54
  there
• 8:54
  between
• 8:54
  excess
• 8:55
  norepinephrine
• 8:56
  release
• 8:57
  and
• 8:57
  activity.
• 8:58
  And
• 8:58
  why
• 8:58
  we
• 8:58
  would
• 8:59
  use
• 8:59
  something
• 8:59
  like
• 8:59
  guanfacine.
• 9:00
  Again,
• 9:00
  typically
• 9:01
  in
• 9:01
  children,
• 9:01
  a
• 9:01
  lot
• 9:02
  of
• 9:02
  that
• 9:02
  would
• 9:02
  be
• 9:02
  off
• 9:02
  label
• 9:03
  with
• 9:03
  respect
• 9:03
  to
• 9:04
  ptsd,
• 9:04
  but
• 9:05
  I
• 9:05
  have
• 9:05
  seen
• 9:05
  it
• 9:05
  used
• 9:06
  in
• 9:06
  that
• 9:06
  context.
• 9:07
  But
• 9:07
  the
• 9:08
  bottom
• 9:08
  line
• 9:08
  is
• 9:09
  we're
• 9:09
  using
• 9:09
  those
• 9:10
  alpha
• 9:10
  2
• 9:10
  adrenergic
• 9:11
  receptors
• 9:12
  to
• 9:14
  tone
• 9:14
  down
• 9:14
  norepinephrine
• 9:15
  release.
• 9:16
  Right.
• 9:16
  And
• 9:17
  strengthen
• 9:17
  the
• 9:17
  prefrontal
• 9:18
  cortex.
• 9:18
  So
• 9:18
  that
• 9:18
  can
• 9:19
  happen
• 9:19
  with
• 9:19
  Alpha
• 9:20
  2
• 9:20
  agonism
• 9:21
  with
• 9:21
  Guanfacine.
• 9:22
  And
• 9:23
  we
• 9:23
  can
• 9:23
  also
• 9:23
  help,
• 9:25
  you
• 9:25
  know,
• 9:25
  modulate
• 9:26
  irritability
• 9:26
  or
• 9:26
  that
• 9:26
  amygdala
• 9:27
  through
• 9:27
  SSRIs.
• 9:28
  We
• 9:28
  can
• 9:29
  help
• 9:29
  with.
• 9:29
  We
• 9:29
  can
• 9:29
  help
• 9:30
  that
• 9:30
  through
• 9:30
  D2
• 9:30
  blockades.
• 9:31
  Right.
• 9:32
  So
• 9:32
  isn't
• 9:32
  it
• 9:32
  pretty
• 9:32
  interesting
• 9:33
  in
• 9:33
  psychiatry
• 9:34
  how
• 9:34
  there's
• 9:34
  many
• 9:34
  different
• 9:35
  ways
• 9:35
  to
• 9:35
  skin
• 9:35
  a
• 9:36
  cat,
• 9:36
  but
• 9:36
  you
• 9:36
  have
• 9:36
  to
• 9:36
  make
• 9:36
  sure
• 9:37
  you're
• 9:37
  skinning
• 9:37
  the
• 9:37
  right
• 9:38
  cat,
• 9:38
  so
• 9:38
  to
• 9:39
  speak.
• 9:39
  And
• 9:39
  the
• 9:39
  cat
• 9:39
  in
• 9:40
  this
• 9:40
  analogy
• 9:40
  is
• 9:40
  not
• 9:40
  the
• 9:41
  patient.
• 9:41
  We're
• 9:41
  not
• 9:41
  going
• 9:41
  to
• 9:41
  skin
• 9:42
  patients.
• 9:42
  We're
• 9:43
  going
• 9:43
  to
• 9:43
  skin
• 9:43
  their
• 9:43
  awful
• 9:44
  mental
• 9:44
  health
• 9:45
  syndromes
• 9:45
  that
• 9:46
  they
• 9:46
  don't
• 9:46
  want
• 9:46
  to
• 9:46
  live
• 9:46
  with.
• 9:46
  We've
• 9:47
  got
• 9:47
  to
• 9:47
  get
• 9:47
  rid
• 9:47
  of
• 9:47
  them
• 9:48
  so
• 9:48
  the
• 9:48
  patients
• 9:49
  can
• 9:49
  live
• 9:49
  happier,
• 9:49
  full
• 9:50
  lives.
• 9:50
  Right?
• 9:51
  So
• 9:51
  every
• 9:52
  time
• 9:52
  you're
• 9:52
  in
• 9:52
  front
• 9:52
  of
• 9:53
  a
• 9:53
  patient,
• 9:54
  you've
• 9:54
  got
• 9:54
  to
• 9:54
  hear
• 9:54
  their
• 9:55
  story.
• 9:55
  But
• 9:55
  again,
• 9:55
  you
• 9:56
  have
• 9:56
  to
• 9:56
  translate
• 9:56
  that
• 9:57
  into
• 9:58
  a
• 9:58
  clinical
• 9:58
  syndrome
• 9:59
  and
• 9:59
  then
• 9:59
  isolate
• 10:00
  specific
• 10:02
  neurotransmitters
• 10:03
  that
• 10:03
  might
• 10:03
  be
• 10:03
  implicated
• 10:04
  and
• 10:04
  then
• 10:05
  use
• 10:05
  the
• 10:05
  tools
• 10:05
  you
• 10:05
  have
• 10:06
  pharmacologically
• 10:06
  to
• 10:07
  target
• 10:07
  those
• 10:09
  receptors.
• 10:09
  It's
• 10:10
  very,
• 10:10
  very
• 10:10
  important.
• 10:11
  Right.
• 10:11
  And
• 10:12
  we
• 10:12
  can
• 10:12
  do
• 10:12
  that
• 10:12
  through
• 10:13
  a
• 10:13
  myriad
• 10:13
  of
• 10:13
  ways.
• 10:14
  And
• 10:14
  we
• 10:14
  have
• 10:15
  to
• 10:15
  ask
• 10:15
  ourselves,
• 10:16
  what's
• 10:16
  running
• 10:16
  amok?
• 10:17
  So
• 10:18
  when
• 10:18
  you
• 10:18
  have
• 10:18
  a
• 10:18
  patient
• 10:19
  who's
• 10:19
  irritable,
• 10:20
  it's
• 10:21
  wise
• 10:21
  to
• 10:22
  assume
• 10:22
  that
• 10:23
  their
• 10:23
  prefrontal
• 10:23
  cortex
• 10:24
  is
• 10:24
  not
• 10:25
  as
• 10:25
  engaged.
• 10:25
  We
• 10:26
  might
• 10:26
  need
• 10:26
  to
• 10:26
  strengthen
• 10:27
  it.
• 10:27
  And
• 10:28
  there's
• 10:28
  various
• 10:28
  ways,
• 10:29
  of
• 10:29
  course,
• 10:30
  to
• 10:30
  do
• 10:30
  that.
• 10:31
  Now,
• 10:31
  interestingly,
• 10:32
  Zoloft,
• 10:33
  if
• 10:33
  you
• 10:33
  scour
• 10:34
  open
• 10:34
  evidence,
• 10:35
  Zoloft
• 10:36
  seems
• 10:36
  to
• 10:36
  have
• 10:36
  the
• 10:36
  best
• 10:37
  overall
• 10:37
  evidence
• 10:38
  for
• 10:38
  reducing
• 10:39
  irritability
• 10:39
  as
• 10:40
  a
• 10:40
  specific
• 10:40
  symptom.
• 10:41
  And
• 10:41
  in
• 10:41
  the
• 10:41
  Embark
• 10:42
  study,
• 10:42
  it
• 10:43
  actually
• 10:43
  demonstrated
• 10:43
  that
• 10:44
  Zoloft
• 10:44
  reduced
• 10:44
  irritability
• 10:45
  significantly
• 10:46
  more
• 10:46
  than
• 10:46
  placebo.
• 10:47
  But
• 10:47
  most
• 10:48
  critically,
• 10:49
  the
• 10:49
  improvement
• 10:49
  in
• 10:49
  irritability
• 10:50
  was
• 10:50
  independent
• 10:51
  of
• 10:51
  its
• 10:51
  effect
• 10:52
  on.
• 10:52
  On
• 10:52
  depression
• 10:53
  severity.
• 10:54
  So
• 10:54
  that's
• 10:54
  pretty
• 10:55
  neat,
• 10:55
  right?
• 10:55
  It's
• 10:56
  doing
• 10:56
  something
• 10:56
  specific
• 10:57
  for
• 10:57
  irritability.
• 10:58
  Now,
• 10:59
  you
• 10:59
  could
• 11:00
  argue
• 11:00
  any
• 11:00
  of
• 11:00
  these
• 11:00
  SSRIs
• 11:01
  are
• 11:01
  pretty
• 11:02
  darn
• 11:02
  good
• 11:02
  for
• 11:02
  irritability.
• 11:03
  Why?
• 11:03
  Again,
• 11:04
  for
• 11:04
  the
• 11:04
  same
• 11:05
  reasons
• 11:05
  that
• 11:05
  they
• 11:06
  strengthen
• 11:06
  the
• 11:06
  prefrontal
• 11:07
  cortex.
• 11:07
  They
• 11:07
  give
• 11:07
  the
• 11:08
  CEO
• 11:08
  a
• 11:08
  little
• 11:08
  more
• 11:09
  power
• 11:10
  and
• 11:10
  they
• 11:10
  can
• 11:10
  modulate
• 11:11
  the
• 11:11
  threat
• 11:11
  response.
• 11:12
  It
• 11:12
  also
• 11:12
  cools
• 11:13
  down
• 11:13
  the
• 11:13
  threat
• 11:13
  response
• 11:14
  in
• 11:14
  the
• 11:14
  amygdala.
• 11:15
  So
• 11:15
  you
• 11:15
  could
• 11:15
  argue
• 11:15
  all
• 11:16
  of
• 11:16
  these
• 11:16
  SSRIs
• 11:17
  are
• 11:18
  viable
• 11:18
  options
• 11:19
  to
• 11:19
  reduce
• 11:19
  irritability.
• 11:20
  Assuming
• 11:21
  you're
• 11:21
  looking
• 11:21
  at
• 11:21
  irritability
• 11:23
  as
• 11:23
  it's
• 11:23
  implicated
• 11:24
  in
• 11:24
  a
• 11:24
  threat
• 11:24
  response
• 11:25
  of
• 11:25
  some
• 11:25
  kind,
• 11:26
  whether
• 11:26
  it
• 11:26
  be
• 11:26
  ptsd,
• 11:27
  whether
• 11:27
  it
• 11:27
  be
• 11:28
  gad,
• 11:28
  and
• 11:28
  you're
• 11:29
  having
• 11:29
  catastrophic
• 11:30
  worries
• 11:30
  and
• 11:30
  your
• 11:31
  amygdala
• 11:31
  is
• 11:32
  just
• 11:33
  on
• 11:33
  fire
• 11:33
  more
• 11:33
  than
• 11:34
  it
• 11:34
  should
• 11:34
  be.
• 11:35
  And
• 11:35
  so,
• 11:36
  yes,
• 11:36
  all
• 11:37
  SSRIs
• 11:38
  are
• 11:38
  viable,
• 11:39
  but
• 11:39
  some
• 11:39
  are
• 11:39
  more
• 11:40
  viable
• 11:40
  than
• 11:40
  others.
• 11:41
  You
• 11:41
  have
• 11:41
  to
• 11:41
  be
• 11:41
  a
• 11:41
  little
• 11:41
  bit
• 11:42
  careful
• 11:42
  with
• 11:42
  Prozac.
• 11:43
  Now,
• 11:43
  I
• 11:43
  think
• 11:44
  Prozac
• 11:44
  is
• 11:44
  a
• 11:44
  fantastic
• 11:45
  medication.
• 11:45
  It's
• 11:46
  absolutely
• 11:46
  one
• 11:46
  of
• 11:46
  my
• 11:46
  favorites
• 11:47
  to
• 11:47
  prescribe.
• 11:48
  Anecdotally,
• 11:49
  for
• 11:49
  what
• 11:49
  it's
• 11:49
  worth,
• 11:49
  I
• 11:50
  get
• 11:50
  extraordinary
• 11:52
  good
• 11:52
  results
• 11:53
  with
• 11:53
  Prozac.
• 11:54
  But
• 11:54
  in
• 11:54
  this
• 11:55
  case,
• 11:55
  Zoloft
• 11:55
  has
• 11:56
  the
• 11:56
  most
• 11:56
  direct
• 11:56
  evidence
• 11:57
  of
• 11:57
  irritability
• 11:58
  as
• 11:58
  a
• 11:58
  chief
• 11:58
  concern.
• 11:58
  And
• 11:59
  you
• 11:59
  will
• 11:59
  meet
• 11:59
  patients
• 12:00
  who
• 12:00
  tell
• 12:00
  you
• 12:00
  flat
• 12:01
  out,
• 12:01
  irritability
• 12:01
  is
• 12:02
  my
• 12:02
  problem.
• 12:02
  I'm
• 12:03
  edgy,
• 12:03
  I'm
• 12:03
  grumpy.
• 12:04
  My
• 12:04
  wife's
• 12:04
  sending
• 12:05
  me
• 12:05
  here,
• 12:05
  she
• 12:05
  can't
• 12:05
  handle
• 12:06
  it
• 12:06
  anymore.
• 12:07
  Of
• 12:07
  course,
• 12:07
  I
• 12:07
  would
• 12:07
  be
• 12:08
  very
• 12:08
  worried
• 12:08
  that
• 12:08
  the
• 12:09
  patient
• 12:09
  might
• 12:09
  be
• 12:09
  bipolar,
• 12:10
  um,
• 12:10
  because
• 12:11
  irritability
• 12:11
  is
• 12:11
  just
• 12:12
  such
• 12:12
  a
• 12:13
  major
• 12:13
  problem
• 12:13
  in
• 12:13
  bipolar.
• 12:14
  But
• 12:14
  with
• 12:14
  bipolarity,
• 12:15
  the
• 12:16
  irritability
• 12:16
  would
• 12:16
  look
• 12:17
  more
• 12:17
  episodic.
• 12:17
  Right.
• 12:18
  It's
• 12:18
  not
• 12:18
  like
• 12:18
  an
• 12:18
  everyday
• 12:19
  problem.
• 13:14
  It's
• 13:14
  not
• 13:15
  consistent
• 13:16
  all
• 13:16
  the
• 13:17
  time.
• 13:17
  It's
• 13:17
  more
• 13:17
  episodic
• 13:18
  where
• 13:18
  they're
• 13:18
  just
• 13:19
  irritable
• 13:19
  for
• 13:19
  no
• 13:19
  reason.
• 13:20
  There's
• 13:20
  not
• 13:20
  a
• 13:20
  lot
• 13:21
  of
• 13:21
  triggers,
• 13:21
  even
• 13:22
  right
• 13:22
  in
• 13:22
  ptsd.
• 13:23
  You're
• 13:23
  going
• 13:23
  to
• 13:23
  see
• 13:23
  triggers.
• 13:24
  Typically,
• 13:24
  typically,
• 13:25
  not
• 13:25
  always.
• 13:25
  It's
• 13:26
  not
• 13:26
  always
• 13:26
  that
• 13:26
  clean.
• 13:27
  But
• 13:27
  in
• 13:27
  ptsd,
• 13:28
  people
• 13:28
  are
• 13:28
  usually
• 13:29
  irritable
• 13:30
  when
• 13:30
  they're
• 13:30
  in
• 13:30
  that
• 13:31
  kind
• 13:31
  of
• 13:31
  fight
• 13:31
  or
• 13:31
  flight,
• 13:32
  they
• 13:33
  mode.
• 13:33
  They
• 13:33
  don't
• 13:34
  feel
• 13:34
  physically
• 13:34
  safe.
• 13:35
  And
• 13:35
  that's
• 13:35
  when
• 13:35
  that
• 13:35
  edgy
• 13:36
  irritability
• 13:36
  can
• 13:37
  kind
• 13:37
  of
• 13:37
  creep
• 13:37
  in.
• 13:39
  But
• 13:39
  I
• 13:39
  find
• 13:39
  that
• 13:40
  bipolarity,
• 13:41
  it's
• 13:41
  more
• 13:41
  theatrical
• 13:42
  and
• 13:42
  episodic,
• 13:43
  right?
• 13:43
  Things,
• 13:43
  because
• 13:44
  seas
• 13:44
  are
• 13:44
  kind
• 13:44
  of
• 13:44
  calm.
• 13:45
  And
• 13:45
  then
• 13:45
  there's
• 13:46
  these,
• 13:46
  this.
• 13:46
  This
• 13:47
  rogue
• 13:47
  storm
• 13:48
  that
• 13:48
  lasts
• 13:48
  several
• 13:49
  days,
• 13:49
  and
• 13:49
  anything
• 13:50
  can
• 13:50
  make
• 13:50
  the
• 13:51
  patient
• 13:51
  just
• 13:51
  irritated,
• 13:52
  argumentative
• 13:53
  towards
• 13:53
  coworkers.
• 13:54
  You
• 13:54
  see
• 13:54
  a
• 13:54
  lot
• 13:55
  of
• 13:55
  spillover
• 13:55
  into
• 13:55
  jobs,
• 13:56
  or
• 13:56
  they
• 13:56
  just
• 13:56
  disagree
• 13:57
  with
• 13:57
  their
• 13:57
  bosses,
• 13:57
  they're
• 13:58
  fighting
• 13:58
  more,
• 13:58
  they're
• 13:59
  just
• 13:59
  edgy.
• 14:01
  Again,
• 14:01
  that's
• 14:01
  a
• 14:02
  little
• 14:02
  bit
• 14:02
  different
• 14:02
  than
• 14:02
  kind
• 14:03
  of
• 14:03
  the
• 14:03
  grumpy
• 14:03
  guy
• 14:04
  at
• 14:04
  breakfast
• 14:04
  who's
• 14:05
  otherwise
• 14:05
  kind
• 14:06
  of
• 14:06
  quiet,
• 14:06
  maybe
• 14:07
  restricted
• 14:07
  affect,
• 14:08
  but
• 14:08
  just
• 14:08
  grumpy
• 14:09
  here
• 14:09
  and
• 14:09
  there,
• 14:09
  as
• 14:10
  opposed
• 14:10
  to
• 14:10
  this
• 14:10
  episodic
• 14:11
  market
• 14:11
  change
• 14:12
  you
• 14:12
  see
• 14:12
  in
• 14:12
  bipolarity.
• 14:13
  So
• 14:13
  we've
• 14:14
  got
• 14:14
  to
• 14:14
  know
• 14:14
  where
• 14:15
  this
• 14:15
  is
• 14:15
  coming
• 14:15
  from
• 14:16
  in
• 14:16
  order
• 14:16
  to
• 14:16
  treat
• 14:17
  it
• 14:17
  and
• 14:17
  target
• 14:17
  it.
• 14:18
  But
• 14:19
  Zoloft
• 14:19
  would
• 14:19
  be
• 14:19
  a
• 14:20
  good
• 14:20
  start
• 14:20
  if
• 14:20
  it's
• 14:20
  a
• 14:21
  major
• 14:21
  feature,
• 14:21
  if
• 14:21
  they're
• 14:22
  just
• 14:22
  irritable.
• 14:23
  And
• 14:23
  their
• 14:24
  biggest
• 14:24
  feature,
• 14:25
  though,
• 14:25
  of
• 14:25
  their
• 14:25
  depression
• 14:26
  is
• 14:26
  not
• 14:26
  irritability,
• 14:28
  and
• 14:28
  maybe
• 14:28
  it's
• 14:28
  poor
• 14:28
  sleep.
• 14:29
  You
• 14:30
  know,
• 14:30
  I
• 14:30
  might
• 14:30
  look
• 14:30
  at
• 14:31
  something
• 14:31
  different.
• 14:31
  I
• 14:31
  might
• 14:31
  look
• 14:32
  at
• 14:32
  Remeron,
• 14:32
  right?
• 14:33
  This
• 14:33
  is
• 14:33
  where
• 14:33
  you
• 14:34
  might
• 14:34
  have
• 14:34
  to
• 14:35
  kind
• 14:35
  of
• 14:35
  put
• 14:35
  everything
• 14:35
  through
• 14:36
  a
• 14:36
  filter.
• 14:36
  You
• 14:36
  got
• 14:36
  to
• 14:36
  look
• 14:37
  at
• 14:37
  the
• 14:37
  FDA
• 14:37
  approvals,
• 14:38
  you
• 14:38
  got
• 14:38
  to
• 14:38
  justify
• 14:38
  what
• 14:39
  you're
• 14:39
  doing
• 14:39
  in
• 14:39
  your
• 14:39
  notes.
• 14:40
  But
• 14:40
  if
• 14:40
  the
• 14:41
  patient's
• 14:41
  chief
• 14:41
  concern
• 14:42
  is,
• 14:42
  hey,
• 14:43
  I
• 14:43
  absolutely
• 14:44
  cannot
• 14:44
  sleep
• 14:44
  and
• 14:45
  I'm
• 14:45
  not
• 14:45
  eating
• 14:45
  anything,
• 14:46
  and
• 14:46
  those
• 14:46
  two
• 14:46
  things
• 14:46
  are
• 14:47
  my
• 14:47
  number
• 14:47
  one
• 14:47
  treatment
• 14:48
  targets.
• 14:48
  I've
• 14:49
  got
• 14:49
  to
• 14:49
  get
• 14:49
  my
• 14:49
  appetite
• 14:50
  back.
• 14:50
  I've
• 14:51
  got
• 14:51
  to
• 14:51
  go
• 14:51
  back
• 14:51
  to
• 14:51
  sleep.
• 14:51
  Well,
• 14:52
  then
• 14:52
  Remeron
• 14:52
  might
• 14:53
  be
• 14:53
  a
• 14:53
  really
• 14:54
  good
• 14:54
  idea.
• 14:55
  And
• 14:55
  even
• 14:55
  though
• 14:55
  they.
• 14:55
  They
• 14:56
  told
• 14:56
  you
• 14:56
  they're
• 14:57
  a
• 14:57
  little
• 14:57
  irritable,
• 14:58
  it
• 14:58
  doesn't
• 14:58
  matter,
• 14:59
  right?
• 14:59
  What
• 14:59
  matters
• 15:00
  more
• 15:00
  than
• 15:01
  anything
• 15:01
  is
• 15:02
  what
• 15:02
  your
• 15:02
  patient
• 15:03
  really
• 15:03
  needs
• 15:03
  and
• 15:03
  wants
• 15:04
  and
• 15:04
  how
• 15:04
  it's
• 15:05
  disrupting
• 15:05
  their
• 15:05
  lives.
• 15:06
  Right?
• 15:06
  Not
• 15:06
  what
• 15:06
  your
• 15:07
  textbook
• 15:09
  answer
• 15:09
  might
• 15:09
  be.
• 15:10
  You
• 15:10
  might
• 15:10
  want,
• 15:11
  you
• 15:11
  might
• 15:11
  love
• 15:11
  to
• 15:12
  extinguish
• 15:12
  their
• 15:12
  irritability,
• 15:13
  but
• 15:13
  it
• 15:13
  doesn't
• 15:14
  make
• 15:14
  a
• 15:14
  big
• 15:14
  difference
• 15:14
  if
• 15:15
  the
• 15:15
  patient
• 15:15
  has
• 15:16
  a
• 15:16
  really
• 15:17
  busy
• 15:17
  lifestyle
• 15:18
  and
• 15:18
  their
• 15:18
  lack
• 15:18
  of
• 15:18
  sleep
• 15:19
  is
• 15:19
  really
• 15:19
  crushing
• 15:20
  them
• 15:20
  in
• 15:20
  a
• 15:20
  major
• 15:20
  way.
• 15:21
  Right?
• 15:21
  So
• 15:21
  always
• 15:22
  identify
• 15:22
  and
• 15:23
  work
• 15:23
  to
• 15:23
  identify
• 15:24
  where
• 15:24
  your
• 15:25
  patient
• 15:25
  is
• 15:25
  most
• 15:25
  impaired.
• 15:26
  I
• 15:26
  think
• 15:26
  that's
• 15:27
  super
• 15:27
  important.
• 15:28
  Now,
• 15:28
  Lexapro
• 15:29
  is.
• 15:30
  It's
• 15:30
  a
• 15:30
  little
• 15:30
  bit
• 15:30
  of
• 15:30
  a
• 15:30
  tricky
• 15:31
  one.
• 15:32
  Again,
• 15:32
  you
• 15:32
  wouldn't
• 15:33
  go
• 15:33
  wrong
• 15:33
  by
• 15:34
  trying
• 15:34
  to
• 15:34
  improve
• 15:35
  irritability
• 15:35
  with
• 15:35
  Lexapro,
• 15:36
  but.
• 15:39
  Well,
• 15:39
  not
• 15:39
  but.
• 15:39
  But
• 15:40
  I
• 15:40
  think
• 15:40
  that
• 15:40
  it
• 15:41
  doesn't
• 15:41
  really
• 15:43
  target
• 15:43
  irritability.
• 15:44
  At
• 15:44
  least
• 15:45
  the
• 15:45
  evidence
• 15:45
  doesn't
• 15:46
  show
• 15:46
  that
• 15:46
  it
• 15:46
  is
• 15:47
  as
• 15:47
  strong
• 15:48
  for
• 15:48
  irritability
• 15:49
  as
• 15:49
  Zoloft.
• 15:50
  But
• 15:50
  again,
• 15:50
  it
• 15:51
  works.
• 15:51
  And
• 15:51
  the
• 15:51
  reason
• 15:52
  it
• 15:52
  might
• 15:52
  work
• 15:52
  or
• 15:53
  be
• 15:53
  a
• 15:53
  good
• 15:53
  second
• 15:53
  choice
• 15:54
  for
• 15:54
  you
• 15:54
  is
• 15:54
  because
• 15:55
  it's
• 15:55
  just
• 15:56
  one
• 15:56
  of
• 15:56
  the
• 15:56
  more
• 15:56
  tolerable
• 15:57
  antidepressants.
• 15:58
  I
• 15:58
  mean,
• 15:58
  they've
• 15:58
  done
• 15:59
  a
• 15:59
  network
• 15:59
  meta
• 16:00
  analysis
• 16:00
  and
• 16:00
  there's
• 16:01
  a
• 16:01
  famous
• 16:01
  one
• 16:01
  in
• 16:01
  2018,
• 16:03
  Cipriani.
• 16:04
  We've
• 16:04
  talked
• 16:04
  about
• 16:04
  it
• 16:05
  in
• 16:05
  prior
• 16:05
  podcast
• 16:06
  episodes
• 16:06
  where
• 16:07
  Lexapro
• 16:07
  is
• 16:08
  just
• 16:08
  so
• 16:08
  well
• 16:08
  tolerated,
• 16:09
  right?
• 16:09
  I've
• 16:09
  compared
• 16:09
  it
• 16:10
  to
• 16:10
  like
• 16:10
  asking
• 16:11
  your
• 16:11
  patient
• 16:11
  to
• 16:11
  have
• 16:11
  a
• 16:12
  banana
• 16:12
  every
• 16:12
  day
• 16:13
  versus
• 16:13
  a
• 16:13
  Brussels
• 16:14
  sprout.
• 16:14
  Maybe
• 16:14
  Paxil
• 16:15
  is
• 16:15
  more
• 16:15
  of
• 16:15
  a
• 16:15
  Brussels
• 16:16
  sprout,
• 16:16
  right?
• 16:16
  It's
• 16:17
  good,
• 16:17
  it's
• 16:17
  healthy,
• 16:18
  it's
• 16:18
  great.
• 16:18
  It's
• 16:18
  going
• 16:18
  to
• 16:18
  help
• 16:19
  it
• 16:19
  with
• 16:19
  depression,
• 16:19
  anxiety.
• 16:20
  But
• 16:21
  Lexapro
• 16:22
  is
• 16:22
  more
• 16:22
  of
• 16:22
  a
• 16:22
  banana.
• 16:22
  It's
• 16:23
  tolerated.
• 16:24
  Right.
• 16:24
  And
• 16:24
  so
• 16:24
  typically
• 16:25
  cleaner
• 16:26
  antidepressants,
• 16:26
  ones
• 16:27
  that
• 16:27
  don't
• 16:27
  have
• 16:27
  as
• 16:27
  many
• 16:27
  side
• 16:28
  effects,
• 16:28
  you
• 16:29
  know,
• 16:29
  with
• 16:29
  Paxil
• 16:29
  you
• 16:29
  have
• 16:30
  those
• 16:30
  Muscarinic
• 16:30
  side
• 16:31
  effects.
• 16:31
  With
• 16:31
  Lexapro
• 16:32
  you
• 16:32
  don't.
• 16:33
  It's
• 16:33
  not
• 16:33
  as
• 16:33
  sedating,
• 16:34
  it's
• 16:34
  a
• 16:34
  little
• 16:34
  more
• 16:34
  clean.
• 16:35
  And
• 16:35
  by
• 16:35
  virtue
• 16:36
  of
• 16:36
  that,
• 16:36
  it
• 16:36
  might
• 16:37
  just
• 16:37
  be
• 16:37
  easier
• 16:37
  to
• 16:38
  tolerate.
• 16:39
  And
• 16:39
  you
• 16:39
  might
• 16:39
  reduce
• 16:39
  irritability
• 16:40
  by
• 16:40
  virtue
• 16:41
  of
• 16:41
  the
• 16:41
  fact
• 16:41
  that
• 16:41
  they
• 16:41
  can
• 16:41
  actually
• 16:42
  tolerate
• 16:42
  the
• 16:42
  medication
• 16:43
  and
• 16:43
  it's
• 16:44
  not
• 16:44
  really
• 16:44
  activating
• 16:45
  the
• 16:45
  patient
• 16:46
  in
• 16:46
  other
• 16:46
  respects.
• 16:47
  Remember,
• 16:47
  a
• 16:47
  lot
• 16:47
  of
• 16:48
  your
• 16:48
  antidepressants
• 16:49
  in
• 16:49
  the
• 16:49
  wrong
• 16:49
  patients
• 16:50
  who
• 16:50
  are
• 16:51
  predisposed
• 16:51
  to
• 16:51
  bipolarity,
• 16:52
  they
• 16:53
  absolutely
• 16:54
  could
• 16:54
  activate
• 16:54
  a
• 16:54
  bipolarity,
• 16:55
  and
• 16:55
  that's
• 16:56
  going
• 16:56
  to
• 16:56
  look
• 16:56
  like
• 16:57
  irritability.
• 16:57
  And
• 16:58
  you're
• 16:58
  going
• 16:58
  to
• 16:58
  go,
• 16:58
  wait
• 16:58
  a
• 16:58
  minute,
• 16:58
  I
• 16:58
  thought
• 16:59
  SSRIs
• 16:59
  help
• 17:00
  with
• 17:00
  irritability.
• 17:01
  It
• 17:01
  looks
• 17:02
  like
• 17:02
  it's
• 17:02
  causing
• 17:02
  irritability.
• 17:03
  Well,
• 17:03
  they
• 17:03
  can.
• 17:04
  SSRIs
• 17:04
  can
• 17:05
  absolutely
• 17:05
  cause
• 17:05
  irritability
• 17:06
  in
• 17:07
  the
• 17:07
  first
• 17:07
  one
• 17:07
  to
• 17:07
  two
• 17:08
  weeks
• 17:08
  when
• 17:08
  you
• 17:08
  start
• 17:08
  it
• 17:09
  or
• 17:09
  if
• 17:09
  you
• 17:09
  increase
• 17:09
  the
• 17:10
  dose.
• 17:10
  Right?
• 17:10
  But
• 17:11
  here's
• 17:11
  the
• 17:11
  pearl.
• 17:11
  Here's
• 17:12
  how
• 17:12
  you're
• 17:12
  going
• 17:12
  to
• 17:12
  know
• 17:13
  that
• 17:13
  it
• 17:13
  may
• 17:13
  be
• 17:13
  your
• 17:14
  meds.
• 17:14
  You're
• 17:14
  going
• 17:15
  to
• 17:15
  know
• 17:15
  it
• 17:15
  may
• 17:15
  be
• 17:15
  your
• 17:15
  meds
• 17:16
  because
• 17:16
  you
• 17:16
  normally
• 17:17
  don't
• 17:17
  just
• 17:17
  get
• 17:18
  irritability
• 17:18
  when,
• 17:19
  when
• 17:19
  the
• 17:19
  patient's
• 17:20
  complaining
• 17:20
  of
• 17:20
  it.
• 17:20
  You
• 17:21
  also
• 17:21
  get
• 17:21
  restlessness.
• 17:22
  You
• 17:22
  get,
• 17:23
  you
• 17:24
  get
• 17:24
  insomnia,
• 17:25
  right?
• 17:25
  Maybe
• 17:25
  you
• 17:25
  get
• 17:26
  a
• 17:26
  little
• 17:26
  bit
• 17:26
  of
• 17:26
  impulsivity
• 17:27
  and
• 17:27
  emotional
• 17:28
  ability.
• 17:28
  It's
• 17:28
  kind
• 17:29
  of
• 17:29
  a
• 17:29
  cluster
• 17:29
  of
• 17:29
  symptoms,
• 17:30
  right?
• 17:30
  So
• 17:31
  you're,
• 17:31
  so
• 17:31
  if
• 17:32
  you're,
• 17:32
  if
• 17:32
  you're
• 17:32
  wondering
• 17:33
  and
• 17:33
  you're
• 17:33
  scratching
• 17:33
  your
• 17:33
  head
• 17:33
  and
• 17:34
  going,
• 17:34
  wait,
• 17:34
  A
• 17:34
  minute,
• 17:34
  we
• 17:34
  just
• 17:35
  raised
• 17:35
  this
• 17:35
  dose
• 17:35
  and
• 17:35
  they're
• 17:36
  feeling
• 17:36
  irritable.
• 17:36
  Do
• 17:37
  I
• 17:37
  need
• 17:37
  to
• 17:37
  raise
• 17:37
  it
• 17:37
  even
• 17:38
  more?
• 17:39
  Because
• 17:39
  I
• 17:39
  need
• 17:39
  to
• 17:39
  just
• 17:40
  keep
• 17:40
  treating
• 17:40
  their
• 17:40
  anxiety,
• 17:41
  which
• 17:41
  is
• 17:41
  causing
• 17:41
  irritability.
• 17:42
  Take
• 17:43
  a
• 17:43
  pause
• 17:44
  and
• 17:44
  ask
• 17:44
  yourself,
• 17:44
  wait
• 17:45
  a
• 17:45
  minute,
• 17:45
  wait
• 17:46
  a
• 17:46
  minute.
• 17:46
  What
• 17:46
  other
• 17:46
  symptoms
• 17:47
  are
• 17:47
  going
• 17:47
  on
• 17:47
  here?
• 17:47
  And
• 17:48
  if
• 17:48
  you
• 17:48
  see
• 17:48
  that
• 17:48
  cluster
• 17:49
  where
• 17:49
  your
• 17:49
  patient's
• 17:49
  also
• 17:49
  saying,
• 17:50
  I
• 17:50
  can't
• 17:50
  sleep,
• 17:51
  I'm
• 17:51
  a
• 17:51
  little
• 17:52
  bit
• 17:52
  more
• 17:52
  impulsive,
• 17:52
  I'm
• 17:53
  shopping
• 17:53
  a
• 17:53
  little
• 17:53
  more
• 17:53
  lately,
• 17:54
  I'm
• 17:54
  edgy,
• 17:54
  I'm
• 17:54
  irritable,
• 17:55
  chances
• 17:55
  are
• 17:56
  it's
• 17:56
  the
• 17:56
  recent
• 17:56
  dose
• 17:57
  increase.
• 17:57
  We
• 17:57
  gotta
• 17:57
  slow
• 17:58
  it
• 17:58
  down
• 17:58
  or
• 17:58
  discontinue
• 17:59
  or
• 17:59
  switch,
• 18:00
  depending
• 18:00
  on
• 18:00
  the
• 18:00
  patient.
• 18:01
  And
• 18:02
  it's
• 18:02
  not
• 18:02
  necessarily
• 18:03
  that
• 18:03
  you
• 18:03
  have
• 18:03
  to
• 18:03
  raise
• 18:04
  the
• 18:04
  dose.
• 18:05
  I
• 18:05
  wouldn't
• 18:05
  say
• 18:05
  that's
• 18:06
  the
• 18:06
  case.
• 18:06
  I
• 18:06
  think
• 18:06
  if
• 18:06
  you
• 18:07
  have
• 18:07
  a
• 18:07
  patient
• 18:07
  who's
• 18:08
  super
• 18:08
  irritable
• 18:10
  at
• 18:10
  baseline,
• 18:10
  and
• 18:11
  you've
• 18:11
  established
• 18:11
  that
• 18:11
  and
• 18:12
  agreed
• 18:12
  upon
• 18:12
  that
• 18:12
  as
• 18:12
  a
• 18:13
  major
• 18:13
  treatment
• 18:13
  target,
• 18:14
  and
• 18:14
  they
• 18:14
  come
• 18:14
  back
• 18:15
  and
• 18:15
  they're
• 18:15
  still
• 18:15
  super
• 18:15
  irritable,
• 18:17
  maybe
• 18:17
  a
• 18:17
  little
• 18:17
  better,
• 18:18
  that's
• 18:18
  when
• 18:18
  you
• 18:18
  could
• 18:19
  then
• 18:19
  raise
• 18:19
  the
• 18:19
  dose
• 18:19
  and
• 18:20
  go,
• 18:20
  okay,
• 18:20
  you
• 18:21
  know,
• 18:21
  you
• 18:21
  are
• 18:21
  still
• 18:21
  irritable,
• 18:22
  but
• 18:22
  I'm
• 18:22
  not
• 18:22
  too
• 18:22
  worried
• 18:23
  that
• 18:23
  my
• 18:23
  meds
• 18:23
  are
• 18:24
  making
• 18:24
  you
• 18:24
  more
• 18:24
  irritable.
• 18:25
  Because
• 18:26
  all
• 18:26
  things
• 18:26
  considered,
• 18:27
  if
• 18:27
  anything,
• 18:27
  we're
• 18:27
  getting
• 18:28
  better
• 18:28
  from
• 18:28
  baseline.
• 18:29
  That's
• 18:29
  when
• 18:29
  you
• 18:30
  can
• 18:30
  consider
• 18:30
  a
• 18:30
  dose
• 18:31
  increase.
• 18:31
  Right.
• 18:32
  But
• 18:32
  you've
• 18:32
  got
• 18:32
  to
• 18:32
  really
• 18:33
  get
• 18:33
  a
• 18:33
  good
• 18:33
  baseline
• 18:34
  irritability
• 18:34
  state
• 18:35
  from
• 18:35
  your
• 18:35
  patient.
• 18:35
  It's
• 18:36
  actually
• 18:36
  one
• 18:36
  of
• 18:36
  those
• 18:36
  things
• 18:37
  that
• 18:37
  I
• 18:37
  would
• 18:37
  say
• 18:38
  you
• 18:38
  really
• 18:38
  need
• 18:38
  to
• 18:38
  document
• 18:39
  at
• 18:39
  baseline
• 18:40
  very
• 18:40
  thoroughly.
• 18:41
  So
• 18:41
  you
• 18:41
  have
• 18:41
  an
• 18:42
  idea.
• 18:42
  Because
• 18:42
  patients
• 18:42
  aren't
• 18:43
  going
• 18:43
  to
• 18:43
  always
• 18:43
  just
• 18:44
  know
• 18:44
  how
• 18:44
  irritable
• 18:44
  they
• 18:45
  were
• 18:45
  when
• 18:45
  they
• 18:45
  first
• 18:45
  saw
• 18:46
  you.
• 18:46
  Right.
• 18:46
  And
• 18:47
  so
• 18:47
  you're
• 18:47
  going
• 18:47
  to
• 18:47
  be
• 18:47
  able
• 18:47
  to
• 18:48
  make
• 18:48
  sense
• 18:48
  of
• 18:49
  that
• 18:49
  during
• 18:49
  the
• 18:49
  follow
• 18:49
  up
• 18:50
  and
• 18:50
  go,
• 18:50
  okay,
• 18:50
  wait
• 18:50
  a
• 18:50
  minute.
• 18:51
  This
• 18:51
  is
• 18:51
  brand
• 18:51
  new.
• 18:51
  You
• 18:52
  really
• 18:52
  weren't
• 18:52
  irritable
• 18:53
  before
• 18:53
  at
• 18:53
  all.
• 18:54
  You
• 18:54
  even
• 18:54
  told
• 18:54
  me
• 18:54
  you're
• 18:55
  not
• 18:55
  an
• 18:55
  irritable
• 18:55
  type.
• 18:56
  And
• 18:56
  now
• 18:56
  we
• 18:56
  clearly
• 18:56
  have
• 18:57
  a
• 18:57
  problem.
• 18:57
  Right.
• 18:57
  And
• 18:57
  that's
• 18:58
  when
• 18:58
  you
• 18:58
  want
• 18:59
  to
• 18:59
  assess,
• 18:59
  is
• 18:59
  this
• 19:00
  a
• 19:00
  bipolarity
• 19:00
  creeping
• 19:01
  in?
• 19:02
  It's
• 19:02
  not
• 19:02
  always
• 19:02
  a
• 19:02
  bipolarity
• 19:03
  creeping
• 19:03
  in.
• 19:03
  It
• 19:04
  just
• 19:04
  could
• 19:04
  be
• 19:04
  that
• 19:04
  activation,
• 19:05
  that
• 19:05
  kind
• 19:05
  of
• 19:05
  edgy,
• 19:06
  poor
• 19:06
  response
• 19:07
  to
• 19:07
  SSRIs.
• 19:08
  In
• 19:08
  that
• 19:08
  case,
• 19:08
  I
• 19:09
  would
• 19:09
  just
• 19:09
  say,
• 19:09
  all
• 19:09
  right,
• 19:09
  whatever,
• 19:11
  maybe
• 19:11
  we
• 19:12
  need
• 19:12
  to
• 19:12
  lower
• 19:12
  the
• 19:12
  dose.
• 19:12
  If
• 19:13
  it's
• 19:13
  a
• 19:13
  deal
• 19:13
  breaker
• 19:13
  and
• 19:14
  we're
• 19:14
  not
• 19:14
  making
• 19:14
  progress
• 19:15
  anywhere
• 19:15
  else,
• 19:16
  and
• 19:16
  there's
• 19:16
  other
• 19:17
  side
• 19:17
  effects
• 19:17
  that
• 19:17
  the
• 19:17
  patient
• 19:18
  can't
• 19:18
  stand,
• 19:18
  we
• 19:18
  might
• 19:19
  have
• 19:19
  to
• 19:19
  just
• 19:19
  jump
• 19:19
  ship,
• 19:20
  try
• 19:20
  something
• 19:20
  new.
• 19:21
  Right.
• 19:21
  All
• 19:22
  kind
• 19:22
  of
• 19:22
  depends
• 19:22
  on
• 19:22
  the
• 19:23
  patient
• 19:23
  and
• 19:23
  whether
• 19:23
  the
• 19:24
  cost
• 19:24
  benefit
• 19:25
  is
• 19:25
  making
• 19:25
  sense.
• 19:26
  Okay.
• 19:27
  Also,
• 19:27
  their
• 19:28
  sleep.
• 19:28
  Right.
• 19:28
  Your
• 19:29
  patient
• 19:29
  might
• 19:29
  not
• 19:29
  be
• 19:29
  sleeping.
• 19:30
  That
• 19:30
  could
• 19:30
  be
• 19:30
  a
• 19:30
  hidden
• 19:31
  driver
• 19:31
  of
• 19:32
  irritability.
• 19:32
  So
• 19:33
  be
• 19:33
  careful
• 19:33
  also
• 19:34
  not
• 19:34
  to
• 19:34
  just
• 19:35
  throw
• 19:35
  in
• 19:35
  the
• 19:35
  towel
• 19:35
  and
• 19:36
  go,
• 19:36
  this
• 19:36
  patient's
• 19:36
  make.
• 19:37
  This
• 19:37
  medication
• 19:38
  is
• 19:38
  making
• 19:38
  the
• 19:38
  patient
• 19:39
  more
• 19:39
  irritable.
• 19:39
  It
• 19:40
  could
• 19:40
  be
• 19:40
  that
• 19:40
  they're
• 19:40
  just
• 19:40
  not
• 19:41
  sleeping
• 19:41
  much.
• 19:41
  Still,
• 19:42
  we
• 19:42
  didn't
• 19:42
  totally
• 19:43
  address
• 19:43
  the
• 19:43
  sleep
• 19:44
  problems.
• 19:44
  Maybe
• 19:44
  we
• 19:44
  need
• 19:45
  to
• 19:45
  start
• 19:45
  trazodone.
• 19:46
  That
• 19:46
  could
• 19:46
  really
• 19:47
  help,
• 19:49
  you
• 19:49
  know,
• 19:49
  Absolutely.
• 19:50
  So.
• 19:50
  Or
• 19:51
  Remeron
• 19:51
  or
• 19:51
  something,
• 19:52
  right?
• 19:52
  Those
• 19:52
  are
• 19:52
  five
• 19:52
  HT2A
• 19:53
  antagonist,
• 19:54
  which
• 19:54
  actually
• 19:54
  can
• 19:54
  help
• 19:55
  with
• 19:55
  irritability
• 19:55
  and
• 19:56
  restore
• 19:56
  prefrontal
• 19:57
  cortex
• 19:58
  signaling.
• 19:59
  And
• 20:00
  so
• 20:00
  maybe
• 20:01
  we
• 20:01
  need
• 20:01
  to
• 20:01
  do
• 20:01
  that
• 20:02
  before
• 20:02
  we
• 20:02
  jump
• 20:03
  ship.
• 20:03
  And
• 20:03
  remember,
• 20:04
  just
• 20:04
  remember
• 20:05
  when
• 20:05
  you
• 20:05
  can't
• 20:05
  sleep,
• 20:06
  right?
• 20:06
  The
• 20:06
  days
• 20:06
  you
• 20:06
  can't
• 20:07
  sleep,
• 20:07
  you
• 20:07
  get
• 20:07
  really
• 20:08
  darn
• 20:08
  irritable.
• 20:09
  So
• 20:10
  that
• 20:10
  can
• 20:10
  make
• 20:10
  your
• 20:11
  amygdala
• 20:11
  hyperactive
• 20:12
  just
• 20:12
  by
• 20:13
  not
• 20:13
  sleeping,
• 20:13
  independent
• 20:14
  of
• 20:14
  all
• 20:14
  the
• 20:15
  mental
• 20:15
  health
• 20:15
  issues
• 20:16
  that
• 20:16
  the
• 20:16
  patient
• 20:16
  might
• 20:16
  have.
• 20:17
  So
• 20:17
  make
• 20:17
  sure
• 20:18
  you're
• 20:18
  looking
• 20:18
  at
• 20:18
  sleep.
• 20:19
  Make
• 20:19
  sure
• 20:19
  you're
• 20:20
  identifying
• 20:20
  why
• 20:21
  your
• 20:21
  patient
• 20:22
  is
• 20:22
  irritable,
• 20:23
  whether
• 20:23
  it's
• 20:23
  a
• 20:23
  recent
• 20:24
  med
• 20:24
  increase.
• 20:24
  Is
• 20:25
  that
• 20:25
  associated
• 20:25
  with
• 20:25
  a
• 20:26
  cluster
• 20:26
  of
• 20:26
  other
• 20:26
  symptoms?
• 20:27
  Are
• 20:27
  we
• 20:27
  looking
• 20:27
  at
• 20:28
  too
• 20:28
  much
• 20:28
  dopamine,
• 20:28
  too
• 20:29
  much
• 20:29
  gas?
• 20:29
  Do
• 20:29
  we
• 20:29
  need
• 20:30
  to
• 20:30
  throw
• 20:30
  in
• 20:30
  an
• 20:31
  atypical
• 20:31
  antipsychotic
• 20:32
  like
• 20:32
  we
• 20:32
  do
• 20:32
  in,
• 20:33
  you
• 20:33
  know,
• 20:34
  autism
• 20:34
  related
• 20:34
  irritability,
• 20:35
  where
• 20:36
  you're
• 20:36
  throwing
• 20:37
  in
• 20:37
  abilify
• 20:37
  to
• 20:38
  kind
• 20:38
  of
• 20:38
  modulate
• 20:38
  the
• 20:38
  dopamine
• 20:39
  or
• 20:39
  risperdol?
• 20:40
  Are
• 20:40
  we
• 20:40
  looking
• 20:41
  at
• 20:42
  kind
• 20:42
  of
• 20:42
  a,
• 20:43
  a
• 20:44
  PTSD
• 20:45
  or
• 20:45
  gad,
• 20:45
  a
• 20:46
  kind
• 20:46
  of
• 20:46
  a
• 20:46
  threat
• 20:46
  response
• 20:47
  that's
• 20:47
  pretty
• 20:47
  consistent
• 20:48
  with
• 20:48
  their
• 20:48
  catastrophic
• 20:48
  worries?
• 20:49
  Well,
• 20:49
  we
• 20:49
  got
• 20:49
  to
• 20:49
  have
• 20:50
  a
• 20:50
  home
• 20:50
  for
• 20:50
  ssri,
• 20:51
  right?
• 20:52
  So
• 20:52
  you
• 20:52
  got
• 20:52
  to
• 20:53
  differentiate
• 20:54
  all
• 20:54
  of
• 20:54
  these
• 20:55
  things
• 20:55
  together,
• 20:56
  and
• 20:56
  irritability
• 20:57
  will
• 20:57
  become
• 20:58
  a
• 20:58
  lot
• 20:58
  more
• 20:59
  clear
• 20:59
  to
• 20:59
  you
• 20:59
  a
• 21:00
  lot
• 21:00
  faster.
• 21:01
  If
• 21:01
  you're
• 21:01
  looking
• 21:01
  at
• 21:02
  ADHD
• 21:02
  irritability,
• 21:03
  you
• 21:03
  might
• 21:03
  need
• 21:03
  to
• 21:03
  make
• 21:04
  sure
• 21:04
  you
• 21:04
  have
• 21:06
  optimal
• 21:06
  stimulant
• 21:07
  dosing.
• 21:08
  And
• 21:08
  you
• 21:09
  may
• 21:09
  want
• 21:09
  to
• 21:09
  throw
• 21:09
  in
• 21:09
  guanfacine
• 21:10
  or
• 21:10
  clonidine
• 21:11
  or
• 21:12
  make
• 21:12
  sure
• 21:12
  their
• 21:12
  stimulant
• 21:13
  is
• 21:13
  optimized.
• 21:13
  I've
• 21:13
  had
• 21:13
  a
• 21:13
  lot
• 21:14
  of
• 21:14
  patients
• 21:14
  very
• 21:14
  irritable
• 21:15
  when
• 21:15
  their
• 21:15
  ADHD
• 21:16
  is
• 21:16
  untreated.
• 21:17
  My
• 21:17
  friends
• 21:18
  go
• 21:18
  to
• 21:18
  the
• 21:18
  show
• 21:18
  notes,
• 21:19
  become
• 21:19
  a
• 21:19
  Patreon
• 21:19
  member.
• 21:19
  You
• 21:20
  will
• 21:20
  not
• 21:20
  regret
• 21:20
  it.
• 21:21
  People
• 21:21
  are
• 21:22
  loving
• 21:22
  it.
• 21:22
  It's
• 21:23
  making
• 21:23
  everything
• 21:23
  so
• 21:24
  much
• 21:24
  easier
• 21:24
  in
• 21:24
  their
• 21:24
  lives
• 21:25
  to
• 21:25
  just
• 21:25
  retain
• 21:25
  psychiatry,
• 21:26
  pass
• 21:26
  their
• 21:27
  boards,
• 21:27
  kick
• 21:27
  butt
• 21:28
  in
• 21:28
  practice.
• 21:29
  Until
• 21:29
  next
• 21:29
  time,
• 21:29
  my
• 21:30
  friends.
• 21:30
  You
• 21:30
  guys
• 21:30
  take
• 21:30
  care
• 21:31
  of
• 21:31
  yourselves
• 21:32
  and
• 21:32
  each
• 21:32
  other.
• 21:32
  Bye
• 21:33
  Bye.