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What If Your Most Stable Patient Is Developing Your Biggest Blind Spot? · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:05
  back,
• 0:06
  my
• 0:06
  friends,
• 0:06
  to
• 0:06
  another
• 0:06
  episode
• 0:07
  of
• 0:07
  Pearls
• 0:08
  and
• 0:08
  prep.
• 0:09
  NPZ
• 0:09
  Here,
• 0:10
  your
• 0:10
  preceptor
• 0:11
  in
• 0:11
  your
• 0:11
  pocket,
• 0:11
  your
• 0:11
  go
• 0:12
  to
• 0:12
  place
• 0:13
  for
• 0:13
  pearls
• 0:13
  that
• 0:14
  prep
• 0:14
  you
• 0:14
  to
• 0:14
  practice.
• 0:15
  My
• 0:16
  friends,
• 0:16
  we
• 0:17
  are
• 0:17
  going
• 0:17
  to
• 0:17
  talk
• 0:18
  all
• 0:18
  about
• 0:18
  tardive
• 0:19
  dyskinesia
• 0:20
  today.
• 0:20
  We're
• 0:21
  going
• 0:21
  to
• 0:22
  outline
• 0:23
  what
• 0:23
  the
• 0:23
  heck
• 0:23
  this
• 0:24
  is,
• 0:24
  how
• 0:24
  to
• 0:25
  identify
• 0:25
  it,
• 0:26
  how
• 0:26
  to
• 0:26
  treat
• 0:26
  it,
• 0:27
  and
• 0:27
  what
• 0:27
  not
• 0:28
  to
• 0:28
  do
• 0:28
  when
• 0:28
  you're
• 0:29
  dealing
• 0:29
  with
• 0:29
  tardive
• 0:30
  dyskinesia.
• 0:30
  And
• 0:31
  you're
• 0:31
  going
• 0:31
  to
• 0:31
  feel
• 0:31
  so
• 0:32
  empowered
• 0:32
  by
• 0:32
  the
• 0:32
  end
• 0:33
  of
• 0:33
  this,
• 0:33
  you're
• 0:34
  going
• 0:34
  to
• 0:34
  want
• 0:34
  to
• 0:34
  find
• 0:35
  random
• 0:35
  people
• 0:35
  at
• 0:36
  the
• 0:36
  711
• 0:37
  and
• 0:37
  do
• 0:37
  an
• 0:37
  Ames
• 0:38
  exam
• 0:38
  on
• 0:38
  them
• 0:39
  because
• 0:39
  you're
• 0:39
  going
• 0:39
  to
• 0:39
  be
• 0:39
  just
• 0:40
  so
• 0:40
  jazzed
• 0:41
  about
• 0:42
  figuring
• 0:42
  out
• 0:42
  who
• 0:42
  has
• 0:43
  tardive
• 0:43
  dyskinesia
• 0:44
  and
• 0:44
  what
• 0:44
  to
• 0:44
  do
• 0:44
  about
• 0:44
  it.
• 0:45
  Lots
• 0:46
  of
• 0:46
  good
• 0:46
  pearls
• 0:47
  here,
• 0:48
  lots
• 0:48
  of
• 0:48
  practical
• 0:49
  advice
• 0:49
  here,
• 0:50
  and
• 0:50
  I
• 0:50
  think
• 0:51
  you're
• 0:51
  going
• 0:51
  to
• 0:51
  just
• 0:51
  love
• 0:51
  this.
• 0:52
  Now
• 0:52
  we're
• 0:52
  going
• 0:52
  to
• 0:52
  kick
• 0:52
  this
• 0:52
  off
• 0:53
  with
• 0:53
  a
• 0:53
  guy
• 0:53
  named
• 0:53
  Joe.
• 0:54
  And
• 0:54
  Joe
• 0:55
  is
• 0:55
  fake.
• 0:56
  I
• 0:56
  don't
• 0:56
  mean
• 0:56
  that
• 0:56
  his
• 0:56
  personality
• 0:57
  is
• 0:57
  fake
• 0:58
  as
• 0:58
  if,
• 0:58
  like
• 0:58
  you
• 0:58
  wouldn't
• 0:59
  like
• 0:59
  him
• 0:59
  if
• 0:59
  you
• 0:59
  met
• 0:59
  him
• 1:00
  fake.
• 1:00
  I
• 1:00
  just
• 1:01
  mean
• 1:01
  he's
• 1:01
  a
• 1:01
  fake
• 1:01
  mock
• 1:02
  patient.
• 1:02
  Now,
• 1:03
  he's
• 1:03
  55
• 1:03
  years
• 1:03
  old.
• 1:04
  He
• 1:04
  comes
• 1:05
  into
• 1:05
  your
• 1:06
  outpatient
• 1:06
  practice
• 1:07
  with
• 1:07
  chronic
• 1:08
  schizophrenia,
• 1:08
  but
• 1:09
  it's
• 1:09
  well
• 1:09
  controlled
• 1:10
  on
• 1:10
  Haldol.
• 1:10
  10
• 1:11
  milligrams
• 1:11
  for
• 1:11
  the
• 1:11
  last
• 1:12
  eight.
• 1:12
  Eight
• 1:12
  years.
• 1:13
  Okay,
• 1:13
  I
• 1:14
  said
• 1:14
  eight
• 1:14
  years,
• 1:14
  not
• 1:15
  88
• 1:15
  years.
• 1:15
  Eight
• 1:16
  years.
• 1:16
  Okay.
• 1:18
  Now,
• 1:18
  Joe
• 1:18
  has
• 1:18
  these
• 1:19
  repetitive
• 1:19
  lip
• 1:19
  smacking,
• 1:20
  tongue
• 1:20
  darting
• 1:21
  movements.
• 1:22
  He
• 1:22
  doesn't
• 1:22
  really
• 1:22
  even
• 1:23
  notice
• 1:23
  it,
• 1:23
  but
• 1:23
  his
• 1:23
  wife
• 1:24
  Rosa
• 1:25
  says
• 1:26
  it's
• 1:26
  been
• 1:27
  getting
• 1:27
  worse
• 1:27
  and
• 1:28
  he
• 1:28
  embarrassed
• 1:29
  her
• 1:30
  at
• 1:30
  their
• 1:30
  last
• 1:31
  family
• 1:31
  reunion.
• 1:32
  So
• 1:32
  she's
• 1:32
  pretty
• 1:33
  concerned
• 1:33
  about
• 1:33
  it.
• 1:34
  She
• 1:34
  wants
• 1:34
  you
• 1:34
  to
• 1:34
  look
• 1:35
  in,
• 1:36
  in
• 1:36
  on
• 1:36
  this
• 1:37
  and
• 1:37
  figure
• 1:37
  out
• 1:38
  what's
• 1:38
  going
• 1:38
  on.
• 1:39
  And
• 1:39
  so
• 1:39
  as
• 1:40
  a
• 1:40
  new
• 1:40
  grad
• 1:40
  or
• 1:40
  as
• 1:41
  a
• 1:41
  student,
• 1:41
  your
• 1:42
  instinct
• 1:42
  might
• 1:42
  be
• 1:43
  to
• 1:43
  say,
• 1:43
  okay,
• 1:43
  let's
• 1:44
  lower
• 1:44
  the
• 1:44
  Haldol.
• 1:45
  Right.
• 1:45
  Maybe
• 1:46
  you
• 1:46
  got
• 1:46
  away
• 1:46
  with
• 1:46
  that.
• 1:47
  Um,
• 1:47
  when
• 1:48
  it
• 1:48
  came,
• 1:48
  when
• 1:48
  it
• 1:48
  came
• 1:48
  to
• 1:49
  Prozac
• 1:49
  in
• 1:49
  the
• 1:49
  past
• 1:50
  or
• 1:50
  Zoloft,
• 1:51
  you
• 1:51
  had
• 1:51
  a
• 1:51
  stimulant
• 1:52
  that
• 1:52
  the
• 1:52
  patient
• 1:52
  was
• 1:53
  a
• 1:53
  little
• 1:53
  too
• 1:53
  jittery
• 1:53
  and
• 1:54
  you
• 1:54
  might
• 1:54
  think,
• 1:54
  okay,
• 1:54
  let's
• 1:55
  lower
• 1:55
  the
• 1:55
  dose
• 1:55
  and
• 1:56
  everything's
• 1:56
  gonna
• 1:56
  be
• 1:56
  hunky
• 1:57
  dory.
• 1:57
  That's
• 1:58
  not
• 1:58
  the
• 1:58
  case
• 1:58
  with
• 1:59
  these
• 1:59
  antipsychotics
• 2:00
  necessarily.
• 2:01
  You
• 2:01
  have
• 2:01
  to
• 2:01
  be
• 2:01
  very
• 2:01
  careful.
• 2:02
  And
• 2:02
  there's
• 2:02
  a
• 2:02
  few
• 2:02
  reasons
• 2:03
  for
• 2:03
  that,
• 2:03
  my
• 2:03
  friend.
• 2:04
  So
• 2:04
  not
• 2:04
  all
• 2:05
  dose
• 2:05
  reductions
• 2:06
  are
• 2:06
  created
• 2:07
  equal
• 2:07
  in
• 2:07
  psychiatry.
• 2:08
  Sure,
• 2:09
  that
• 2:09
  might
• 2:09
  make
• 2:09
  sense
• 2:10
  if
• 2:10
  your
• 2:10
  patient
• 2:11
  was
• 2:11
  like
• 2:11
  95%
• 2:12
  perfect
• 2:13
  at
• 2:13
  20mg
• 2:14
  xr
• 2:14
  of
• 2:15
  Adderall
• 2:15
  and
• 2:16
  you
• 2:16
  bump
• 2:16
  them
• 2:16
  up
• 2:16
  to
• 2:16
  30
• 2:17
  and
• 2:17
  turns
• 2:17
  out
• 2:18
  they
• 2:18
  have
• 2:18
  insomnia
• 2:19
  and
• 2:19
  bumping
• 2:19
  them
• 2:20
  back
• 2:20
  down
• 2:20
  to
• 2:20
  20
• 2:21
  is
• 2:22
  covering
• 2:22
  the
• 2:23
  vast
• 2:23
  majority
• 2:23
  of
• 2:23
  their
• 2:24
  symptoms.
• 2:24
  And
• 2:24
  maybe
• 2:24
  executive
• 2:25
  coaching
• 2:25
  or
• 2:26
  clonidine
• 2:26
  can
• 2:27
  augment
• 2:27
  the
• 2:27
  rest.
• 2:27
  Fine.
• 2:28
  But
• 2:29
  in
• 2:29
  Haldol,
• 2:30
  especially
• 2:31
  with
• 2:31
  schizophrenia,
• 2:32
  very
• 2:32
  chronic
• 2:33
  condition,
• 2:33
  very
• 2:33
  severe
• 2:34
  condition,
• 2:34
  and
• 2:34
  especially
• 2:35
  with
• 2:35
  Joe,
• 2:35
  who's
• 2:36
  been
• 2:36
  stable
• 2:36
  for
• 2:36
  eight
• 2:36
  years,
• 2:37
  the
• 2:37
  last
• 2:38
  thing
• 2:38
  you
• 2:38
  want
• 2:38
  to
• 2:38
  do
• 2:38
  is,
• 2:39
  is
• 2:39
  test
• 2:39
  out
• 2:40
  whether
• 2:41
  or
• 2:41
  not
• 2:41
  he's
• 2:41
  gonna
• 2:42
  do
• 2:42
  just
• 2:42
  fine
• 2:42
  on
• 2:43
  5
• 2:43
  milligrams
• 2:43
  of
• 2:43
  Haldol.
• 2:44
  Okay?
• 2:44
  There's
• 2:45
  a
• 2:45
  lot
• 2:45
  of
• 2:45
  problems
• 2:45
  with
• 2:45
  that.
• 2:46
  The
• 2:46
  first
• 2:46
  problem
• 2:47
  is,
• 2:47
  of
• 2:47
  course,
• 2:48
  that
• 2:48
  he's
• 2:48
  gonna
• 2:48
  have
• 2:48
  some
• 2:49
  rebound
• 2:49
  psychosis.
• 2:50
  Well,
• 2:50
  that
• 2:50
  would
• 2:50
  be
• 2:50
  tragic.
• 2:51
  We
• 2:51
  don't
• 2:51
  want
• 2:51
  that.
• 2:52
  That
• 2:52
  could
• 2:52
  be
• 2:52
  completely
• 2:54
  impairing.
• 2:54
  He
• 2:54
  could
• 2:55
  send
• 2:55
  him
• 2:55
  straight
• 2:55
  back
• 2:56
  to
• 2:56
  the
• 2:56
  hospital.
• 2:57
  Right?
• 2:58
  In
• 2:58
  addition
• 2:58
  to
• 2:59
  that,
• 2:59
  you've
• 2:59
  been
• 2:59
  blocking
• 3:00
  dopamine
• 3:00
  receptors
• 3:01
  so
• 3:01
  strongly
• 3:02
  and
• 3:03
  rigidly
• 3:03
  with
• 3:03
  Haldol
• 3:04
  for
• 3:04
  eight
• 3:04
  years.
• 3:05
  You
• 3:05
  could
• 3:05
  have
• 3:06
  a
• 3:06
  super
• 3:06
  sensitive
• 3:07
  dopamine
• 3:08
  response
• 3:09
  and
• 3:09
  it
• 3:09
  could
• 3:09
  get
• 3:10
  really
• 3:11
  wild
• 3:11
  really
• 3:11
  quickly.
• 3:12
  Which
• 3:12
  of
• 3:12
  course
• 3:14
  feeds
• 3:14
  into
• 3:14
  the
• 3:15
  fact
• 3:15
  that
• 3:15
  he
• 3:15
  might
• 3:15
  have
• 3:15
  this
• 3:16
  rebound
• 3:16
  psychosis.
• 3:17
  Because
• 3:17
  remember,
• 3:17
  when
• 3:17
  you
• 3:18
  block
• 3:18
  dopamine
• 3:19
  for
• 3:19
  that
• 3:19
  long,
• 3:19
  you
• 3:20
  block
• 3:20
  those
• 3:20
  receptors,
• 3:22
  there
• 3:23
  are
• 3:23
  going
• 3:23
  to
• 3:23
  be.
• 3:24
  There
• 3:24
  is
• 3:24
  going
• 3:24
  to
• 3:24
  be
• 3:24
  an
• 3:25
  upregulation
• 3:25
  process
• 3:26
  where
• 3:26
  there's
• 3:26
  going
• 3:26
  to
• 3:27
  be
• 3:27
  more
• 3:27
  dopamine
• 3:27
  receptors
• 3:28
  and
• 3:28
  they're
• 3:28
  more
• 3:28
  sensitive
• 3:29
  to
• 3:29
  compensate,
• 3:30
  right?
• 3:30
  Because
• 3:31
  our
• 3:31
  body
• 3:31
  and
• 3:32
  our
• 3:32
  brains
• 3:32
  are
• 3:33
  homeostatic.
• 3:34
  They
• 3:34
  don't
• 3:34
  just
• 3:35
  sit
• 3:35
  there
• 3:35
  and
• 3:35
  take
• 3:35
  a
• 3:35
  beating.
• 3:36
  They
• 3:36
  fight
• 3:36
  back.
• 3:36
  When
• 3:37
  you
• 3:37
  do
• 3:37
  something
• 3:38
  pretty
• 3:38
  extreme
• 3:39
  to
• 3:39
  the
• 3:39
  brain
• 3:40
  or
• 3:40
  body,
• 3:40
  there's
• 3:41
  usually
• 3:41
  adaptations
• 3:42
  that
• 3:42
  occur,
• 3:42
  right?
• 3:43
  And
• 3:43
  we've
• 3:43
  learned
• 3:43
  this.
• 3:44
  This
• 3:44
  is
• 3:44
  a
• 3:45
  dominant
• 3:45
  theme
• 3:46
  in
• 3:46
  all
• 3:46
  of
• 3:47
  our,
• 3:47
  you
• 3:47
  know,
• 3:47
  psychopharmacology
• 3:48
  courses,
• 3:49
  neurobiology,
• 3:50
  biology,
• 3:50
  chemistry.
• 3:52
  The
• 3:52
  body
• 3:53
  is
• 3:53
  homeostatic.
• 3:54
  It's
• 3:55
  a,
• 3:55
  it's
• 3:55
  an
• 3:55
  iron
• 3:55
  rule,
• 3:57
  right,
• 3:57
  that
• 3:57
  it's
• 3:57
  going
• 3:57
  to
• 3:57
  try
• 3:58
  to
• 3:58
  balance
• 3:59
  the
• 3:59
  seesaw.
• 4:00
  So
• 4:00
  you've
• 4:00
  been
• 4:00
  blocking
• 4:01
  dopamine
• 4:02
  2
• 4:02
  receptors
• 4:03
  for
• 4:03
  a
• 4:03
  very
• 4:03
  long
• 4:04
  time
• 4:04
  with
• 4:04
  Haldol.
• 4:05
  Watch
• 4:05
  out,
• 4:05
  right?
• 4:06
  If
• 4:06
  you
• 4:06
  get
• 4:06
  rid
• 4:06
  of
• 4:06
  it,
• 4:07
  all
• 4:07
  of
• 4:07
  a
• 4:07
  sudden
• 4:08
  your,
• 4:08
  your
• 4:08
  body
• 4:08
  is
• 4:09
  going
• 4:09
  to
• 4:09
  be.
• 4:09
  And
• 4:10
  your
• 4:10
  brain
• 4:10
  is
• 4:10
  going
• 4:10
  to
• 4:11
  really
• 4:11
  freak
• 4:11
  out
• 4:11
  because
• 4:12
  dopamine
• 4:12
  is
• 4:13
  super
• 4:13
  sensitive.
• 4:13
  There's
• 4:14
  more
• 4:14
  upregulated
• 4:15
  receptors,
• 4:15
  and
• 4:16
  the
• 4:16
  psychosis
• 4:16
  will
• 4:16
  be
• 4:17
  very
• 4:18
  real.
• 4:19
  Okay?
• 4:20
  So
• 4:20
  that's
• 4:21
  what
• 4:21
  we
• 4:21
  have
• 4:21
  to
• 4:21
  be
• 4:21
  careful
• 4:21
  about.
• 4:22
  It's
• 4:22
  very
• 4:22
  much
• 4:22
  akin
• 4:23
  to,
• 4:24
  you
• 4:24
  know,
• 4:24
  you,
• 4:24
  you,
• 4:24
  you
• 4:25
  fall
• 4:25
  asleep
• 4:25
  and
• 4:26
  let's
• 4:26
  say
• 4:26
  you
• 4:26
  sleep
• 4:26
  eight
• 4:27
  to
• 4:27
  10
• 4:27
  hours.
• 4:27
  It's
• 4:27
  a
• 4:28
  lazy
• 4:28
  weekend.
• 4:28
  You
• 4:28
  have
• 4:28
  blackout
• 4:29
  curtains.
• 4:29
  It's
• 4:30
  completely
• 4:30
  dark
• 4:31
  and
• 4:31
  black
• 4:31
  for
• 4:31
  eight
• 4:31
  to
• 4:32
  10
• 4:32
  hours.
• 4:32
  And
• 4:33
  then
• 4:33
  your
• 4:33
  roommate
• 4:34
  walks
• 4:34
  in
• 4:34
  and
• 4:35
  dramatically
• 4:36
  opens
• 4:36
  the
• 4:36
  curtains
• 4:37
  and
• 4:37
  says,
• 4:37
  wake
• 4:38
  up.
• 4:38
  Happy
• 4:39
  Saturday.
• 4:39
  And
• 4:40
  then
• 4:40
  what's
• 4:40
  going
• 4:40
  to
• 4:40
  Happen
• 4:41
  like
• 4:41
  it's
• 4:41
  going
• 4:41
  to
• 4:42
  look
• 4:42
  like
• 4:42
  you're
• 4:42
  going
• 4:42
  to
• 4:42
  be
• 4:42
  completely
• 4:43
  blinded,
• 4:44
  right?
• 4:44
  Now,
• 4:44
  normally
• 4:45
  you
• 4:45
  wouldn't
• 4:45
  just
• 4:46
  like
• 4:46
  walk
• 4:46
  into
• 4:46
  your
• 4:47
  room
• 4:47
  at
• 4:47
  noon
• 4:48
  and
• 4:48
  be
• 4:48
  blinded
• 4:48
  by
• 4:49
  the
• 4:49
  sunlight,
• 4:49
  right?
• 4:49
  Unless
• 4:50
  you're
• 4:50
  a
• 4:50
  vampire,
• 4:51
  you're
• 4:51
  going
• 4:51
  to
• 4:51
  just
• 4:52
  walk
• 4:52
  in
• 4:52
  and
• 4:52
  it's
• 4:52
  fine,
• 4:53
  right?
• 4:53
  It's
• 4:53
  no
• 4:53
  big
• 4:53
  deal.
• 4:54
  Oh,
• 4:54
  there's
• 4:54
  the
• 4:54
  sun
• 4:54
  again.
• 4:55
  How
• 4:55
  boring.
• 4:55
  I
• 4:55
  see
• 4:56
  the
• 4:56
  sun
• 4:56
  every
• 4:56
  day.
• 4:57
  Right.
• 4:57
  But
• 4:57
  if
• 4:57
  you've
• 4:57
  been
• 4:58
  in
• 4:58
  with,
• 4:58
  you
• 4:59
  know,
• 4:59
  blackout
• 4:59
  shades
• 5:00
  for
• 5:00
  10
• 5:00
  hours,
• 5:01
  it's
• 5:01
  been
• 5:02
  pitch
• 5:02
  black,
• 5:02
  and
• 5:02
  your
• 5:03
  roommate
• 5:03
  even
• 5:03
  turns
• 5:04
  on
• 5:04
  a
• 5:04
  small
• 5:04
  light
• 5:05
  above
• 5:05
  your
• 5:06
  head,
• 5:07
  you're
• 5:07
  going
• 5:07
  to
• 5:07
  be
• 5:08
  super
• 5:08
  sensitive
• 5:09
  to
• 5:09
  that
• 5:09
  light
• 5:10
  because
• 5:10
  your
• 5:11
  body's
• 5:11
  just
• 5:11
  been
• 5:11
  completely
• 5:12
  used
• 5:12
  to
• 5:13
  being
• 5:14
  in
• 5:14
  the
• 5:14
  darkness.
• 5:14
  And
• 5:15
  I'm
• 5:15
  not
• 5:15
  an
• 5:15
  ophthalmologist.
• 5:17
  Um,
• 5:17
  you
• 5:17
  know,
• 5:17
  I
• 5:17
  think
• 5:18
  we
• 5:18
  need
• 5:18
  like
• 5:18
  Andrew
• 5:18
  Huberman
• 5:19
  on
• 5:19
  this
• 5:19
  podcast
• 5:20
  at
• 5:20
  some
• 5:20
  point,
• 5:20
  but
• 5:21
  I
• 5:21
  think
• 5:21
  he
• 5:21
  would
• 5:21
  argue
• 5:22
  that
• 5:23
  there
• 5:23
  are
• 5:23
  some
• 5:23
  sort
• 5:23
  of
• 5:24
  receptors
• 5:24
  in
• 5:25
  your
• 5:25
  ocular
• 5:25
  circuits
• 5:27
  that
• 5:27
  are
• 5:27
  trying
• 5:27
  to
• 5:28
  make
• 5:28
  you
• 5:28
  super
• 5:28
  sensitive
• 5:29
  to
• 5:29
  light
• 5:29
  because
• 5:29
  you're
• 5:29
  in
• 5:30
  darkness
• 5:30
  for
• 5:30
  so
• 5:30
  long.
• 5:31
  So
• 5:31
  you
• 5:32
  know,
• 5:32
  in
• 5:32
  order
• 5:32
  to
• 5:32
  adapt
• 5:33
  and
• 5:33
  see
• 5:33
  again,
• 5:33
  you
• 5:34
  need
• 5:34
  to
• 5:34
  be
• 5:34
  super
• 5:34
  sensitive
• 5:35
  to
• 5:35
  any
• 5:35
  kind
• 5:35
  of
• 5:36
  light.
• 5:36
  Well,
• 5:36
  that's
• 5:37
  great.
• 5:37
  But
• 5:37
  then
• 5:38
  when
• 5:38
  the
• 5:38
  light
• 5:38
  comes
• 5:38
  on
• 5:39
  too
• 5:39
  quickly
• 5:39
  thereafter,
• 5:40
  you're
• 5:40
  super
• 5:41
  sensitive
• 5:41
  and
• 5:41
  you're
• 5:41
  blinded.
• 5:43
  Very
• 5:43
  similar
• 5:43
  to
• 5:44
  what
• 5:44
  happens
• 5:44
  when
• 5:45
  we
• 5:45
  block
• 5:46
  postsynaptic
• 5:47
  dopamine
• 5:47
  receptors
• 5:47
  for
• 5:48
  too
• 5:48
  long
• 5:48
  and
• 5:49
  then
• 5:49
  bam,
• 5:49
  look
• 5:50
  what
• 5:50
  happens
• 5:50
  when
• 5:51
  we
• 5:51
  just
• 5:51
  cold
• 5:51
  turkey
• 5:52
  stop
• 5:52
  Haldol.
• 5:53
  So
• 5:53
  the
• 5:53
  worst
• 5:53
  thing
• 5:53
  you
• 5:53
  can
• 5:54
  do
• 5:54
  in
• 5:54
  Joe's
• 5:54
  case
• 5:55
  here
• 5:55
  to
• 5:55
  manage
• 5:56
  his
• 5:56
  tardive
• 5:56
  dyskinesia
• 5:57
  would
• 5:57
  be
• 5:57
  to
• 5:57
  lower
• 5:58
  the
• 5:58
  dose
• 5:58
  and
• 5:58
  bring
• 5:58
  on
• 5:59
  a
• 5:59
  psychosis
• 6:01
  or
• 6:01
  just
• 6:01
  lower
• 6:02
  the
• 6:02
  dose
• 6:02
  and
• 6:04
  he
• 6:04
  has
• 6:04
  this
• 6:05
  withdrawal
• 6:06
  dyskinesia
• 6:07
  which
• 6:07
  is
• 6:07
  really
• 6:08
  awful
• 6:08
  too
• 6:08
  this,
• 6:09
  these
• 6:09
  hyper
• 6:10
  kinetic
• 6:10
  movements
• 6:11
  again
• 6:11
  because
• 6:11
  his
• 6:11
  dopamine
• 6:12
  is
• 6:12
  really
• 6:13
  sensitive.
• 6:14
  So
• 6:14
  the
• 6:14
  most
• 6:14
  routine
• 6:15
  thing
• 6:15
  you
• 6:15
  can
• 6:15
  do
• 6:16
  with
• 6:16
  Joe
• 6:17
  is
• 6:17
  to
• 6:17
  perform
• 6:18
  an
• 6:18
  Ames
• 6:18
  exam.
• 6:19
  But
• 6:19
  before
• 6:19
  we
• 6:20
  do
• 6:20
  that,
• 6:20
  I
• 6:20
  want
• 6:20
  to
• 6:21
  kind
• 6:21
  of
• 6:21
  back
• 6:21
  up
• 6:22
  and
• 6:22
  really
• 6:23
  just
• 6:23
  explain
• 6:24
  what's
• 6:24
  going
• 6:24
  on
• 6:25
  so
• 6:25
  you
• 6:25
  understand
• 6:25
  it
• 6:26
  very
• 6:26
  clearly.
• 6:26
  Right?
• 6:27
  Tardive
• 6:27
  dyskinesia
• 6:28
  is
• 6:29
  the
• 6:29
  movement
• 6:29
  disorder
• 6:30
  that
• 6:30
  is
• 6:30
  caused
• 6:31
  by
• 6:31
  medications
• 6:32
  like
• 6:32
  Haldol,
• 6:33
  these
• 6:34
  dopamine
• 6:34
  receptor
• 6:35
  blockers.
• 6:36
  Um,
• 6:36
  very
• 6:37
  commonly
• 6:37
  first
• 6:38
  generation
• 6:38
  antipsychotics
• 6:39
  which
• 6:39
  block
• 6:39
  dopamine
• 6:40
  more,
• 6:41
  more
• 6:41
  rigorously.
• 6:42
  Second
• 6:43
  generation
• 6:43
  antipsychotics
• 6:44
  are
• 6:44
  not
• 6:44
  blocking
• 6:45
  them
• 6:45
  as
• 6:45
  much
• 6:47
  as
• 6:47
  the
• 6:47
  first
• 6:48
  generation
• 6:48
  antipsychotics.
• 6:49
  Second
• 6:49
  generation
• 6:50
  antipsychotics
• 6:51
  also
• 6:51
  have
• 6:51
  that
• 6:52
  5ht
• 6:52
  2a
• 6:53
  antagonism
• 6:54
  that
• 6:54
  you,
• 6:54
  you've
• 6:54
  learned
• 6:54
  about
• 6:55
  in
• 6:55
  your
• 6:55
  courses
• 6:56
  that
• 6:56
  kind
• 6:56
  of
• 6:57
  mitigate
• 6:57
  some
• 6:57
  of
• 6:57
  the
• 6:57
  motor
• 6:58
  functions.
• 6:58
  They
• 6:59
  actually
• 7:00
  release
• 7:01
  a
• 7:01
  little
• 7:02
  more
• 7:02
  dopamine
• 7:02
  in
• 7:02
  those
• 7:03
  motor
• 7:03
  circuits
• 7:04
  which
• 7:04
  can
• 7:05
  thereby
• 7:05
  mitigate
• 7:06
  the
• 7:06
  movement
• 7:07
  problems.
• 7:08
  Right?
• 7:09
  Because
• 7:10
  remember,
• 7:10
  when
• 7:10
  you
• 7:10
  agonize,
• 7:11
  when
• 7:11
  5ht
• 7:12
  2a
• 7:12
  is,
• 7:13
  is
• 7:13
  stimulated,
• 7:14
  it.
• 7:14
  It
• 7:14
  puts
• 7:14
  a
• 7:15
  clamp
• 7:15
  on
• 7:15
  dopamine,
• 7:15
  but
• 7:16
  when
• 7:16
  you
• 7:16
  antagonize
• 7:17
  it,
• 7:17
  it
• 7:17
  kind
• 7:17
  of
• 7:18
  removes
• 7:18
  that
• 7:18
  clamp
• 7:19
  and
• 7:19
  more
• 7:19
  dopamine
• 7:20
  is
• 7:20
  released
• 7:21
  in
• 7:21
  those
• 7:21
  motor
• 7:21
  circuits.
• 7:22
  So
• 7:22
  again,
• 7:23
  second
• 7:23
  generation
• 7:23
  antipsychotics
• 7:24
  don't
• 7:25
  block
• 7:25
  dopamine
• 7:25
  to
• 7:26
  the
• 7:26
  extent
• 7:27
  that
• 7:28
  first
• 7:28
  generation
• 7:29
  does.
• 7:30
  And
• 7:30
  they
• 7:30
  have
• 7:30
  that
• 7:31
  5ht2a
• 7:32
  antagonism
• 7:32
  that
• 7:33
  mitigates
• 7:33
  the
• 7:34
  motor
• 7:34
  issues
• 7:35
  commonly
• 7:36
  seen
• 7:36
  in
• 7:36
  first
• 7:36
  generations.
• 7:37
  However,
• 7:38
  second
• 7:38
  generation
• 7:39
  antipsychotics
• 7:40
  also
• 7:40
  do
• 7:40
  block
• 7:41
  dopamine,
• 7:41
  and
• 7:42
  they
• 7:42
  are
• 7:42
  absolutely
• 7:43
  a
• 7:43
  risk
• 7:44
  for,
• 7:44
  to.
• 7:44
  To
• 7:45
  develop
• 7:45
  tardive
• 7:45
  dyskinesia
• 7:46
  and
• 7:46
  maybe
• 7:46
  even
• 7:47
  more
• 7:47
  so
• 7:48
  in
• 7:48
  your
• 7:49
  world
• 7:49
  right
• 7:49
  now,
• 7:50
  because
• 7:50
  most
• 7:50
  of
• 7:50
  your
• 7:51
  patients
• 7:51
  that
• 7:51
  you're
• 7:51
  going
• 7:51
  to
• 7:51
  see
• 7:52
  are
• 7:52
  going
• 7:52
  to
• 7:53
  be
• 7:53
  on
• 7:54
  second
• 7:55
  generation
• 7:55
  antipsychotics
• 7:56
  relative
• 7:57
  to
• 7:57
  first
• 7:57
  generation
• 7:58
  antipsychotics.
• 7:58
  Right.
• 7:59
  Of
• 7:59
  the
• 8:00
  patients
• 8:00
  on
• 8:00
  antipsychotics,
• 8:01
  the
• 8:01
  vast
• 8:01
  majority,
• 8:02
  depending
• 8:02
  on
• 8:02
  where
• 8:02
  you
• 8:03
  work,
• 8:03
  are
• 8:03
  likely
• 8:04
  to
• 8:04
  be
• 8:04
  on
• 8:05
  Zyprexa
• 8:05
  and
• 8:05
  Risperidol
• 8:07
  as
• 8:07
  opposed
• 8:07
  to
• 8:07
  like
• 8:07
  Haldol
• 8:08
  or
• 8:08
  Prolixin
• 8:09
  in
• 8:09
  the
• 8:09
  first
• 8:09
  generation
• 8:10
  family.
• 8:10
  Okay?
• 8:11
  So
• 8:12
  you
• 8:12
  cannot
• 8:13
  underestimate
• 8:13
  these.
• 8:14
  They
• 8:14
  can
• 8:14
  absolutely
• 8:15
  cause
• 8:15
  movement
• 8:15
  disorders.
• 8:16
  They
• 8:16
  do
• 8:16
  all
• 8:16
  the
• 8:16
  time.
• 8:16
  They
• 8:17
  can
• 8:17
  cause
• 8:17
  tardive
• 8:17
  dyskinesia
• 8:18
  because
• 8:19
  it's
• 8:19
  not
• 8:19
  just
• 8:19
  about
• 8:20
  first
• 8:20
  versus
• 8:21
  second
• 8:21
  generation,
• 8:21
  although
• 8:22
  that
• 8:22
  is
• 8:22
  important.
• 8:22
  Right.
• 8:22
  The
• 8:23
  degree
• 8:23
  of
• 8:23
  dopamine
• 8:24
  blockade
• 8:24
  is
• 8:24
  important.
• 8:26
  The
• 8:26
  5ht
• 8:27
  2a
• 8:27
  affinity
• 8:28
  is
• 8:28
  important.
• 8:29
  But
• 8:29
  this
• 8:29
  is
• 8:29
  also
• 8:29
  about
• 8:30
  dose
• 8:30
  and
• 8:30
  duration.
• 8:31
  So
• 8:31
  you
• 8:31
  could
• 8:32
  have
• 8:32
  someone
• 8:32
  who's
• 8:32
  not
• 8:32
  even
• 8:33
  treated
• 8:33
  for
• 8:33
  psychosis,
• 8:34
  they're
• 8:34
  depressed.
• 8:36
  A
• 8:36
  little
• 8:36
  old
• 8:36
  lady
• 8:37
  who's
• 8:37
  depressed
• 8:38
  and
• 8:38
  has
• 8:38
  been
• 8:38
  augmenting
• 8:39
  with
• 8:39
  Abilify
• 8:40
  for
• 8:40
  10
• 8:40
  years
• 8:40
  or
• 8:41
  15
• 8:41
  years.
• 8:41
  Well,
• 8:42
  that's
• 8:42
  very
• 8:42
  much
• 8:42
  a
• 8:43
  problem.
• 8:43
  You
• 8:43
  have
• 8:43
  to
• 8:43
  consider
• 8:44
  tardive
• 8:44
  dyskinesia
• 8:45
  because
• 8:45
  you
• 8:46
  still
• 8:46
  are
• 8:46
  blocking
• 8:46
  some
• 8:47
  dopamine,
• 8:47
  depending
• 8:48
  on,
• 8:48
  you
• 8:48
  know
• 8:49
  exactly
• 8:49
  what
• 8:49
  the
• 8:49
  dose
• 8:50
  is
• 8:50
  and
• 8:50
  in
• 8:50
  what
• 8:50
  circuit.
• 8:51
  But
• 8:51
  there
• 8:51
  is
• 8:51
  dopamine
• 8:52
  blockade.
• 8:53
  Um,
• 8:53
  yes,
• 8:54
  it's
• 8:54
  a
• 8:54
  partial
• 8:54
  agonist,
• 8:55
  but
• 8:55
  there's
• 8:55
  dopamine
• 8:55
  blockade.
• 8:56
  And
• 8:57
  you
• 8:57
  add
• 8:57
  up
• 8:57
  the,
• 8:58
  the
• 8:58
  months
• 8:58
  and
• 8:58
  years
• 8:59
  that
• 8:59
  they're
• 8:59
  on
• 9:00
  these
• 9:00
  medications,
• 9:01
  and
• 9:01
  you
• 9:01
  can
• 9:01
  certainly
• 9:02
  develop
• 9:03
  these
• 9:03
  motor
• 9:03
  problems.
• 9:04
  Very
• 9:04
  big
• 9:05
  problem.
• 9:05
  Okay,
• 9:06
  so
• 9:06
  just
• 9:06
  remember,
• 9:06
  tardive
• 9:07
  dyskinesia
• 9:08
  is
• 9:08
  a
• 9:08
  movement
• 9:08
  disorder
• 9:08
  caused
• 9:09
  by
• 9:09
  medications
• 9:09
  that
• 9:10
  block
• 9:10
  dopamine
• 9:11
  receptors
• 9:11
  in
• 9:11
  the
• 9:12
  brain.
• 9:12
  The
• 9:12
  most
• 9:12
  common
• 9:13
  culprits
• 9:13
  are
• 9:13
  the
• 9:13
  FGAs,
• 9:14
  first
• 9:14
  generations.
• 9:15
  And
• 9:15
  some
• 9:15
  of
• 9:16
  the
• 9:16
  second
• 9:16
  generations,
• 9:16
  like
• 9:17
  Risperdal
• 9:17
  and
• 9:17
  Olanzapine
• 9:18
  or
• 9:18
  Zyprexa,
• 9:19
  also
• 9:19
  known
• 9:20
  as.
• 9:20
  Right.
• 9:20
  You
• 9:21
  could
• 9:21
  even
• 9:21
  see
• 9:21
  this.
• 9:22
  You
• 9:22
  could
• 9:22
  even
• 9:22
  see
• 9:22
  this
• 9:23
  in
• 9:23
  nausea
• 9:24
  medications.
• 9:24
  Right.
• 9:26
  So
• 9:26
  anything
• 9:27
  really
• 9:27
  that
• 9:27
  blocks
• 9:28
  dopamine.
• 9:29
  And
• 9:29
  so
• 9:30
  that's
• 9:31
  a
• 9:31
  really
• 9:31
  big
• 9:31
  problem.
• 9:31
  Now,
• 9:32
  the
• 9:32
  etiology
• 9:33
  of
• 9:33
  the
• 9:33
  word
• 9:33
  tardive
• 9:33
  dyskinesia.
• 9:34
  Think
• 9:34
  tardy.
• 9:35
  Late.
• 9:36
  Tardy.
• 9:36
  You're
• 9:37
  tardy
• 9:37
  to
• 9:37
  a
• 9:38
  party.
• 9:38
  You
• 9:38
  are
• 9:39
  late,
• 9:39
  usually
• 9:40
  because
• 9:40
  tardive
• 9:40
  dyskinesia
• 9:41
  develops
• 9:41
  within
• 9:42
  a
• 9:42
  few
• 9:42
  months
• 9:42
  or
• 9:43
  up
• 9:43
  to
• 9:43
  a
• 9:43
  year
• 9:43
  or
• 9:43
  more
• 9:44
  into
• 9:44
  treatment.
• 9:45
  Right.
• 9:45
  It's
• 9:45
  not
• 9:45
  one
• 9:46
  of
• 9:46
  those
• 9:46
  acute
• 9:46
  dystonias,
• 9:47
  which
• 9:47
  could
• 9:47
  be
• 9:47
  hours.
• 9:48
  It's
• 9:48
  not
• 9:49
  the
• 9:49
  Parkinsonian
• 9:50
  symptoms
• 9:50
  that
• 9:51
  can
• 9:51
  be
• 9:51
  like
• 9:51
  weeks
• 9:51
  or
• 9:51
  months.
• 9:52
  This
• 9:53
  is
• 9:53
  usually
• 9:53
  like
• 9:53
  months
• 9:54
  to
• 9:54
  years,
• 9:54
  potentially.
• 9:55
  And
• 9:55
  so
• 9:55
  it
• 9:56
  kind
• 9:56
  of
• 9:56
  arrives
• 9:56
  late
• 9:57
  to
• 9:57
  the
• 9:57
  party.
• 9:57
  And
• 9:57
  of
• 9:58
  course,
• 9:58
  dyskinesia
• 9:59
  means
• 9:59
  dis,
• 10:00
  as
• 10:00
  in
• 10:00
  like
• 10:01
  you're
• 10:01
  dissing
• 10:02
  your
• 10:02
  friend.
• 10:02
  It's
• 10:02
  bad.
• 10:03
  It's
• 10:03
  a
• 10:03
  bad
• 10:04
  thing.
• 10:04
  Like
• 10:04
  when
• 10:04
  Eminem
• 10:05
  dissed
• 10:05
  Moby.
• 10:06
  I
• 10:06
  can't
• 10:06
  even
• 10:06
  repeat
• 10:07
  what
• 10:07
  he
• 10:07
  said
• 10:07
  about
• 10:07
  Moby.
• 10:08
  Or
• 10:09
  this
• 10:09
  podcast
• 10:09
  will
• 10:10
  be,
• 10:10
  like,
• 10:10
  banned.
• 10:11
  But
• 10:11
  he
• 10:12
  dissed
• 10:12
  Moby
• 10:12
  in
• 10:13
  one
• 10:13
  of
• 10:13
  his
• 10:13
  famous
• 10:14
  lyrics.
• 10:14
  I
• 10:14
  don't
• 10:15
  think
• 10:15
  they
• 10:15
  like
• 10:15
  each
• 10:15
  other.
• 10:15
  I
• 10:16
  don't
• 10:16
  know
• 10:16
  why.
• 10:16
  I
• 10:16
  don't.
• 10:17
  I
• 10:17
  don't
• 10:17
  think
• 10:17
  I'll
• 10:17
  ever
• 10:17
  know
• 10:18
  why.
• 10:19
  But
• 10:20
  dyskinesia,
• 10:21
  right?
• 10:21
  So
• 10:21
  it's.
• 10:21
  It's
• 10:21
  like
• 10:22
  an
• 10:22
  abnormal
• 10:22
  movement.
• 10:23
  Kinesia,
• 10:23
  meaning
• 10:24
  movement,
• 10:24
  kinetics,
• 10:25
  movement.
• 10:25
  Right.
• 10:26
  So
• 10:26
  tardive
• 10:27
  dyskinesia
• 10:28
  are
• 10:28
  movements
• 10:28
  that
• 10:28
  arrive
• 10:29
  late
• 10:29
  to
• 10:30
  the
• 10:30
  party.
• 10:31
  Kind
• 10:31
  of
• 10:31
  a
• 10:31
  good
• 10:31
  way
• 10:31
  for
• 10:32
  you
• 10:32
  to
• 10:32
  memorize
• 10:32
  that
• 10:33
  they're
• 10:33
  involuntary.
• 10:34
  The
• 10:34
  patient
• 10:34
  cannot
• 10:35
  control
• 10:35
  them,
• 10:35
  which
• 10:36
  makes
• 10:36
  them
• 10:36
  even
• 10:37
  more
• 10:38
  serious,
• 10:38
  potentially.
• 10:39
  Now,
• 10:39
  some
• 10:39
  of
• 10:40
  these.
• 10:40
  These
• 10:40
  movements
• 10:40
  can
• 10:41
  be
• 10:41
  barely
• 10:41
  noticeable.
• 10:42
  But
• 10:42
  if
• 10:42
  you
• 10:42
  do
• 10:42
  kind
• 10:43
  of
• 10:43
  take
• 10:43
  the
• 10:43
  time
• 10:43
  and
• 10:43
  do
• 10:44
  an
• 10:44
  Ames
• 10:44
  assessment,
• 10:45
  that's
• 10:46
  the
• 10:46
  abnormal
• 10:46
  involuntary
• 10:47
  movement
• 10:48
  screening.
• 10:48
  If
• 10:49
  you
• 10:49
  do
• 10:49
  that,
• 10:50
  then
• 10:51
  you
• 10:51
  might
• 10:51
  find
• 10:51
  that
• 10:52
  they
• 10:52
  are
• 10:52
  noticeable
• 10:52
  and
• 10:52
  they
• 10:53
  can
• 10:53
  be
• 10:53
  severely
• 10:54
  disabling.
• 10:54
  Right.
• 10:55
  These
• 10:55
  patients
• 10:55
  can
• 10:57
  have
• 10:57
  a
• 10:57
  really
• 10:58
  difficult
• 10:58
  time
• 11:00
  functioning.
• 11:01
  They
• 11:01
  can
• 11:01
  have
• 11:02
  mouth
• 11:03
  and
• 11:03
  jaw
• 11:03
  issues,
• 11:04
  lip
• 11:04
  smacking,
• 11:05
  tongue
• 11:06
  protrusion,
• 11:07
  like
• 11:08
  jaw
• 11:08
  clenching,
• 11:09
  kind
• 11:10
  of
• 11:10
  making
• 11:10
  chewing
• 11:10
  motion,
• 11:11
  motions.
• 11:12
  Just
• 11:12
  their.
• 11:13
  Their.
• 11:14
  Their
• 11:14
  tongue
• 11:14
  can
• 11:15
  kind
• 11:15
  of
• 11:15
  jerk
• 11:15
  around.
• 11:15
  They
• 11:16
  can
• 11:16
  have
• 11:16
  these
• 11:16
  vocal
• 11:16
  spasms.
• 11:17
  Fingers
• 11:18
  can
• 11:18
  wiggle,
• 11:18
  kind
• 11:19
  of
• 11:19
  like
• 11:19
  piano
• 11:19
  playing,
• 11:20
  but
• 11:20
  there's
• 11:20
  no
• 11:20
  piano.
• 11:21
  You'll
• 11:21
  know
• 11:21
  because
• 11:22
  you
• 11:22
  won't
• 11:22
  hear
• 11:22
  music
• 11:23
  that
• 11:23
  they're.
• 11:24
  They're.
• 11:24
  Pelvic
• 11:25
  pelvis
• 11:25
  is
• 11:26
  like
• 11:26
  thrusting
• 11:26
  and
• 11:27
  rocking.
• 11:27
  You
• 11:27
  can
• 11:27
  imagine
• 11:28
  all
• 11:28
  of
• 11:28
  these
• 11:28
  things,
• 11:29
  right?
• 11:29
  It's
• 11:29
  going
• 11:29
  to
• 11:29
  be
• 11:29
  hard.
• 11:30
  It's
• 11:30
  going
• 11:30
  to
• 11:30
  be
• 11:31
  hard
• 11:31
  to
• 11:31
  walk.
• 11:32
  It's
• 11:32
  going
• 11:32
  to
• 11:32
  be
• 11:32
  hard
• 11:32
  to
• 11:33
  pick
• 11:33
  up
• 11:33
  a
• 11:33
  pen
• 11:33
  and
• 11:34
  write,
• 11:34
  to
• 11:34
  hold
• 11:34
  a
• 11:35
  phone
• 11:36
  to
• 11:36
  type
• 11:36
  or
• 11:36
  do
• 11:37
  remote
• 11:37
  work.
• 11:37
  It's
• 11:37
  going
• 11:38
  to
• 11:38
  be
• 11:38
  hard
• 11:38
  to
• 11:38
  swallow.
• 11:39
  Sometimes
• 11:39
  people
• 11:39
  may
• 11:40
  choke
• 11:40
  more
• 11:40
  often
• 11:41
  or
• 11:41
  they
• 11:41
  have
• 11:42
  to
• 11:42
  Eat
• 11:42
  really
• 11:42
  slowly
• 11:42
  or
• 11:43
  soft
• 11:43
  foods.
• 11:44
  It.
• 11:44
  This
• 11:44
  destroys
• 11:45
  their
• 11:46
  dental
• 11:46
  hygiene.
• 11:47
  It
• 11:48
  can
• 11:48
  be
• 11:48
  hard
• 11:48
  to
• 11:48
  just
• 11:48
  have
• 11:49
  a
• 11:49
  conversation
• 11:49
  or
• 11:50
  sit
• 11:50
  comfortably
• 11:50
  in
• 11:51
  a
• 11:51
  chair
• 11:51
  or
• 11:52
  in
• 11:52
  a
• 11:52
  movie
• 11:52
  theater
• 11:53
  or
• 11:53
  on
• 11:54
  public
• 11:54
  transit.
• 11:54
  So
• 11:55
  this
• 11:55
  is
• 11:55
  a
• 11:55
  really
• 11:55
  serious
• 11:56
  problem,
• 11:56
  my
• 11:57
  friends.
• 11:57
  Like,
• 11:57
  this
• 11:57
  is
• 11:57
  something
• 11:58
  we
• 11:58
  have
• 11:58
  to
• 11:58
  be
• 12:00
  pit
• 12:00
  bulls
• 12:00
  with.
• 12:01
  Like,
• 12:01
  we
• 12:01
  have
• 12:01
  to
• 12:01
  really
• 12:02
  protect
• 12:02
  our
• 12:02
  patients
• 12:03
  and
• 12:03
  identify
• 12:04
  this.
• 12:04
  And
• 12:05
  depending
• 12:05
  on
• 12:05
  the
• 12:05
  guidelines,
• 12:06
  you
• 12:06
  know,
• 12:06
  some
• 12:06
  guidelines
• 12:07
  will
• 12:07
  say
• 12:07
  every
• 12:07
  six
• 12:07
  months
• 12:08
  or
• 12:08
  every
• 12:08
  12
• 12:08
  months.
• 12:08
  Maybe
• 12:09
  six
• 12:09
  months.
• 12:09
  If
• 12:09
  it's
• 12:10
  a
• 12:10
  first
• 12:10
  generation
• 12:11
  antipsychotic,
• 12:11
  you
• 12:12
  do
• 12:12
  an
• 12:12
  AIMS
• 12:12
  assessment.
• 12:14
  12
• 12:14
  months.
• 12:15
  If
• 12:15
  it's
• 12:15
  just
• 12:15
  a
• 12:15
  second
• 12:16
  generation,
• 12:16
  I
• 12:16
  think
• 12:17
  you
• 12:17
  can
• 12:17
  do
• 12:17
  this
• 12:17
  every
• 12:17
  assessment.
• 12:18
  There's
• 12:19
  no
• 12:19
  reason
• 12:19
  why
• 12:20
  you
• 12:20
  can't
• 12:21
  sneak
• 12:21
  in
• 12:21
  an
• 12:22
  ames,
• 12:23
  an
• 12:23
  AMES
• 12:24
  scale,
• 12:26
  or
• 12:26
  an
• 12:26
  AIMS
• 12:26
  assessment
• 12:28
  every
• 12:28
  single
• 12:28
  time.
• 12:28
  Because
• 12:29
  it's
• 12:29
  pretty
• 12:29
  simple,
• 12:29
  right?
• 12:29
  They're
• 12:30
  already
• 12:30
  sitting
• 12:30
  in
• 12:30
  the
• 12:31
  chair.
• 12:31
  And
• 12:32
  so
• 12:32
  much
• 12:32
  of
• 12:32
  your
• 12:32
  assessment
• 12:33
  is
• 12:33
  done
• 12:33
  when
• 12:33
  the
• 12:33
  patient's
• 12:34
  just
• 12:34
  in
• 12:34
  their
• 12:34
  chair.
• 12:35
  And
• 12:35
  if
• 12:35
  you
• 12:35
  become
• 12:35
  a
• 12:36
  Patreon
• 12:36
  member.
• 12:37
  Okay.
• 12:38
  Which
• 12:38
  I
• 12:38
  highly
• 12:39
  recommend
• 12:39
  you
• 12:39
  do,
• 12:40
  we
• 12:40
  have
• 12:40
  a
• 12:41
  really
• 12:41
  sweet
• 12:42
  visual
• 12:42
  that
• 12:42
  helps
• 12:43
  you
• 12:43
  understand
• 12:44
  this
• 12:45
  intuitively
• 12:46
  and
• 12:47
  rate.
• 12:47
  Rate
• 12:48
  the
• 12:48
  patient's
• 12:48
  symptoms
• 12:49
  intuitively.
• 12:49
  It's
• 12:50
  really
• 12:50
  awesome.
• 12:50
  It
• 12:50
  was
• 12:51
  just
• 12:51
  uploaded.
• 12:51
  Highly
• 12:52
  recommend
• 12:52
  you
• 12:52
  go
• 12:53
  over
• 12:53
  to
• 12:53
  patreon.com
• 12:54
  pearls
• 12:55
  and
• 12:55
  prep
• 12:55
  after
• 12:56
  this
• 12:56
  and
• 12:56
  check
• 12:57
  that
• 12:57
  out.
• 12:57
  Become
• 12:57
  a
• 12:58
  member.
• 12:58
  You'll
• 12:59
  love
• 12:59
  it.
• 12:59
  It's
• 12:59
  going
• 13:00
  to
• 13:00
  really
• 13:00
  empower
• 13:00
  you.
• 13:01
  But,
• 13:01
  yeah,
• 13:01
  do
• 13:01
  this
• 13:02
  every
• 13:02
  time
• 13:02
  if
• 13:03
  you
• 13:03
  can.
• 13:03
  Right?
• 13:03
  It's
• 13:04
  like,
• 13:04
  why
• 13:04
  not?
• 13:04
  This
• 13:04
  is
• 13:05
  such
• 13:05
  a
• 13:05
  disabling
• 13:05
  problem.
• 14:01
  Um,
• 14:01
  the
• 14:02
  dopamine
• 14:02
  blockade
• 14:03
  can
• 14:03
  certainly
• 14:04
  cause
• 14:05
  a
• 14:05
  lot
• 14:05
  of
• 14:05
  issues.
• 14:06
  And
• 14:06
  you
• 14:07
  know,
• 14:07
  it.
• 14:07
  This.
• 14:07
  These
• 14:08
  movements
• 14:08
  arrive
• 14:08
  late
• 14:09
  to
• 14:09
  the
• 14:09
  party
• 14:09
  again,
• 14:09
  because
• 14:10
  your
• 14:10
  brain
• 14:10
  is
• 14:10
  kind
• 14:11
  of
• 14:11
  adapting
• 14:11
  to
• 14:12
  that
• 14:12
  chronic
• 14:13
  dopamine
• 14:13
  blockade.
• 14:14
  Again,
• 14:14
  there's
• 14:15
  more
• 14:15
  receptors
• 14:16
  that
• 14:16
  are
• 14:16
  compensating
• 14:19
  and
• 14:19
  there's
• 14:20
  bigger
• 14:20
  dopamine
• 14:20
  bursts.
• 14:21
  Right?
• 14:22
  There's
• 14:22
  the.
• 14:22
  The
• 14:22
  neurons
• 14:23
  are
• 14:23
  literally
• 14:23
  packing
• 14:24
  more
• 14:24
  dopamine
• 14:25
  into
• 14:25
  each
• 14:25
  storage
• 14:26
  vesicle.
• 14:27
  So
• 14:27
  when
• 14:27
  it
• 14:27
  fires,
• 14:27
  a
• 14:28
  bigger
• 14:28
  flood
• 14:28
  of
• 14:28
  dopamine
• 14:29
  is
• 14:29
  hitting
• 14:29
  the
• 14:29
  synapse.
• 14:30
  They're
• 14:30
  doing
• 14:30
  that
• 14:30
  to
• 14:30
  compensate
• 14:31
  because
• 14:31
  they're.
• 14:32
  They
• 14:32
  feel
• 14:32
  that
• 14:33
  dopamine
• 14:33
  is
• 14:33
  being
• 14:33
  starved
• 14:34
  and
• 14:34
  blocked
• 14:35
  by
• 14:36
  your
• 14:36
  medications.
• 14:37
  Right?
• 14:38
  So
• 14:39
  again,
• 14:39
  the
• 14:39
  upshot
• 14:40
  here
• 14:40
  is
• 14:40
  that
• 14:40
  you're
• 14:40
  getting
• 14:41
  a
• 14:41
  super
• 14:41
  sensitive
• 14:42
  dopamine
• 14:42
  response
• 14:43
  where
• 14:43
  these
• 14:43
  movements
• 14:44
  start
• 14:44
  to
• 14:44
  trickle
• 14:45
  in.
• 14:45
  Okay.
• 14:46
  And
• 14:47
  so
• 14:47
  when
• 14:47
  you
• 14:47
  see
• 14:47
  this
• 14:48
  problem
• 14:48
  when
• 14:48
  Joe
• 14:48
  is
• 14:49
  coming
• 14:49
  to
• 14:49
  you
• 14:49
  with
• 14:49
  tardive
• 14:50
  dyskinesia,
• 14:51
  decreasing
• 14:52
  that
• 14:52
  antipsychotic
• 14:53
  can
• 14:53
  definitely
• 14:54
  worsen
• 14:54
  TD
• 14:56
  because
• 14:56
  of
• 14:56
  all
• 14:56
  those
• 14:56
  extra
• 14:57
  sensitive
• 14:58
  dopamine
• 14:59
  receptors
• 15:00
  that
• 15:00
  are
• 15:00
  suddenly
• 15:00
  unblocked
• 15:01
  and
• 15:01
  flooded
• 15:02
  with
• 15:02
  dopamine.
• 15:02
  Okay.
• 15:03
  You
• 15:03
  don't
• 15:03
  want
• 15:04
  to
• 15:04
  increase
• 15:04
  the
• 15:04
  medication
• 15:05
  either.
• 15:05
  That
• 15:05
  might
• 15:05
  suppress
• 15:06
  the
• 15:06
  td.
• 15:06
  You
• 15:07
  Might
• 15:07
  think
• 15:07
  that,
• 15:07
  oh,
• 15:07
  wow,
• 15:08
  the
• 15:08
  movement
• 15:09
  disorders
• 15:09
  are
• 15:09
  getting
• 15:10
  better
• 15:10
  because
• 15:10
  we're
• 15:11
  blocking
• 15:11
  more
• 15:11
  dopamine.
• 15:12
  But
• 15:13
  no,
• 15:13
  that
• 15:13
  is
• 15:14
  just
• 15:14
  temporarily
• 15:14
  suppressing
• 15:15
  the
• 15:16
  td,
• 15:16
  and
• 15:16
  you're
• 15:16
  going
• 15:17
  to
• 15:17
  have
• 15:17
  the
• 15:17
  same
• 15:17
  rebound
• 15:18
  problem,
• 15:18
  right,
• 15:18
  because
• 15:18
  your
• 15:19
  brain's
• 15:19
  going
• 15:19
  to
• 15:19
  crave
• 15:20
  this.
• 15:20
  And.
• 15:21
  And
• 15:21
  it's
• 15:21
  gonna
• 15:21
  continue
• 15:22
  to.
• 15:22
  To.
• 15:22
  To
• 15:23
  pack
• 15:24
  more
• 15:24
  dopamine
• 15:25
  into
• 15:25
  those
• 15:25
  storage
• 15:25
  vesicles,
• 15:26
  fire
• 15:27
  more
• 15:27
  dopamine
• 15:27
  out,
• 15:28
  build
• 15:28
  new
• 15:28
  receptors,
• 15:29
  upregulate.
• 15:30
  It's
• 15:30
  going
• 15:30
  to
• 15:30
  compensate
• 15:31
  for
• 15:31
  being
• 15:31
  blocked.
• 15:32
  Right.
• 15:32
  So
• 15:32
  you
• 15:32
  have
• 15:32
  to
• 15:32
  be
• 15:33
  really
• 15:33
  careful
• 15:33
  to
• 15:34
  not
• 15:34
  increase
• 15:34
  the
• 15:34
  MED
• 15:35
  and
• 15:35
  mask
• 15:35
  it
• 15:35
  or
• 15:35
  decrease
• 15:36
  it.
• 15:36
  And
• 15:36
  now
• 15:36
  you
• 15:36
  worsen
• 15:37
  TD
• 15:37
  and
• 15:37
  you
• 15:37
  have
• 15:38
  this
• 15:38
  super
• 15:38
  sensitivity.
• 15:39
  So
• 15:39
  what
• 15:39
  do
• 15:40
  you
• 15:40
  do?
• 15:40
  Well,
• 15:41
  what
• 15:41
  you
• 15:41
  do
• 15:41
  again
• 15:41
  is
• 15:42
  you
• 15:42
  do
• 15:42
  a
• 15:42
  nice
• 15:43
  Ames
• 15:43
  assessment.
• 15:45
  You
• 15:45
  figure
• 15:45
  out
• 15:45
  where
• 15:46
  Joe
• 15:46
  is
• 15:46
  on
• 15:46
  the
• 15:46
  Ames
• 15:47
  assessment.
• 15:48
  Okay,
• 15:48
  let's
• 15:48
  say
• 15:48
  you
• 15:48
  do
• 15:49
  it,
• 15:49
  and
• 15:49
  Joe
• 15:49
  gets
• 15:49
  like
• 15:49
  a
• 15:50
  14,
• 15:51
  which
• 15:51
  is
• 15:51
  pretty
• 15:52
  moderate.
• 15:52
  And
• 15:52
  you
• 15:53
  may
• 15:53
  need
• 15:53
  to
• 15:53
  do
• 15:53
  something,
• 15:54
  right?
• 15:54
  And
• 15:54
  you
• 15:54
  figure
• 15:54
  you
• 15:55
  talk
• 15:55
  to
• 15:55
  him
• 15:55
  and
• 15:55
  his
• 15:55
  wife,
• 15:56
  and
• 15:56
  she's
• 15:56
  confirming
• 15:57
  that,
• 15:57
  hey,
• 15:57
  this
• 15:57
  is
• 15:58
  actually
• 15:58
  pretty
• 15:58
  disabling.
• 15:59
  It's
• 15:59
  pretty
• 16:00
  bad.
• 16:00
  It's
• 16:00
  hard
• 16:01
  for
• 16:01
  him
• 16:01
  to
• 16:01
  write.
• 16:01
  It's
• 16:02
  actually
• 16:02
  hard
• 16:02
  for
• 16:02
  him
• 16:02
  to
• 16:02
  speak
• 16:03
  now.
• 16:03
  He
• 16:04
  can't
• 16:04
  really
• 16:04
  sit
• 16:04
  in
• 16:04
  a
• 16:05
  chair
• 16:05
  very
• 16:05
  long.
• 16:05
  Well,
• 16:06
  for
• 16:06
  moderate
• 16:07
  or
• 16:07
  severe,
• 16:07
  especially
• 16:08
  disabling
• 16:09
  td,
• 16:10
  the
• 16:10
  guidelines
• 16:11
  do
• 16:11
  suggest
• 16:12
  that
• 16:12
  we
• 16:13
  put
• 16:13
  Joe
• 16:14
  on
• 16:14
  a
• 16:14
  VMAT2
• 16:15
  inhibitor.
• 16:16
  Okay.
• 16:17
  That's
• 16:17
  what
• 16:18
  the
• 16:18
  guidelines
• 16:18
  say.
• 16:19
  Now,
• 16:19
  you
• 16:20
  could
• 16:20
  also
• 16:20
  switch
• 16:20
  him
• 16:21
  to
• 16:21
  something
• 16:21
  like
• 16:21
  clozapine
• 16:22
  has
• 16:23
  the
• 16:23
  strongest
• 16:23
  evidence
• 16:25
  for
• 16:26
  TD
• 16:26
  reduction
• 16:27
  because
• 16:27
  it's
• 16:27
  not
• 16:28
  really
• 16:28
  doing
• 16:28
  that
• 16:28
  whole
• 16:29
  BLO
• 16:29
  dope,
• 16:30
  dopamine
• 16:30
  blockade
• 16:31
  thing.
• 16:31
  Quetiapine
• 16:32
  or
• 16:32
  Seroquel
• 16:33
  also
• 16:33
  has
• 16:33
  a
• 16:33
  lower
• 16:33
  D2
• 16:34
  affinity,
• 16:34
  so
• 16:35
  switching
• 16:35
  him
• 16:35
  to
• 16:36
  one
• 16:36
  of
• 16:36
  those
• 16:36
  may
• 16:36
  be
• 16:36
  an
• 16:36
  option
• 16:37
  in
• 16:37
  practice.
• 16:38
  You
• 16:38
  may
• 16:38
  not
• 16:38
  want
• 16:39
  to
• 16:39
  switch
• 16:39
  the
• 16:39
  patient
• 16:39
  on
• 16:39
  clozapine,
• 16:40
  because
• 16:40
  they
• 16:40
  will.
• 16:40
  They'll
• 16:41
  tell
• 16:41
  you
• 16:41
  they
• 16:41
  don't
• 16:41
  want
• 16:41
  to.
• 16:42
  I've
• 16:42
  had
• 16:42
  a
• 16:43
  lot
• 16:43
  of
• 16:43
  patients
• 16:43
  that
• 16:43
  are
• 16:43
  very
• 16:44
  familiar
• 16:44
  with
• 16:44
  schizophrenia,
• 16:45
  and
• 16:46
  they've
• 16:46
  been
• 16:46
  dealing
• 16:46
  with
• 16:46
  it
• 16:47
  for
• 16:47
  a
• 16:47
  long
• 16:47
  time.
• 16:48
  And,
• 16:48
  you
• 16:49
  know,
• 16:49
  they'll
• 16:49
  tell
• 16:49
  me,
• 16:49
  I
• 16:49
  don't
• 16:50
  want
• 16:50
  to
• 16:50
  do
• 16:50
  Clozapine.
• 16:51
  Now,
• 16:51
  clozapine
• 16:51
  is
• 16:52
  a
• 16:52
  remarkable
• 16:53
  medication.
• 16:54
  We
• 16:54
  could
• 16:54
  spend
• 16:55
  hours
• 16:55
  talking
• 16:55
  about
• 16:56
  how
• 16:56
  incredible
• 16:56
  it
• 16:57
  is,
• 16:58
  but
• 16:58
  it
• 16:58
  does
• 16:58
  come
• 16:58
  with
• 16:59
  very
• 17:00
  significant,
• 17:01
  you
• 17:01
  know,
• 17:02
  lab
• 17:02
  draws
• 17:02
  and
• 17:03
  monitoring.
• 17:03
  And
• 17:04
  a
• 17:04
  lot
• 17:05
  of
• 17:05
  clinicians
• 17:05
  don't
• 17:05
  like
• 17:06
  doing
• 17:06
  that.
• 17:06
  More
• 17:06
  of
• 17:07
  them
• 17:07
  should
• 17:07
  do
• 17:07
  it.
• 17:08
  But
• 17:08
  patients
• 17:08
  also
• 17:09
  will
• 17:09
  tell
• 17:09
  you,
• 17:09
  nope,
• 17:09
  I'm
• 17:10
  not
• 17:10
  going
• 17:10
  down
• 17:10
  that
• 17:10
  rabbit
• 17:11
  hole.
• 17:11
  And
• 17:11
  I've
• 17:11
  had
• 17:11
  them
• 17:12
  tell
• 17:12
  me
• 17:12
  that.
• 17:12
  And
• 17:13
  if
• 17:13
  that's
• 17:13
  the
• 17:13
  case,
• 17:13
  it's
• 17:13
  like,
• 17:14
  well,
• 17:14
  that.
• 17:14
  Well,
• 17:14
  that's
• 17:14
  kind
• 17:15
  of.
• 17:15
  That
• 17:15
  kind
• 17:15
  of
• 17:15
  sucked,
• 17:16
  because
• 17:16
  clozapine
• 17:17
  is
• 17:17
  a
• 17:17
  great
• 17:17
  one.
• 17:18
  You
• 17:18
  know,
• 17:18
  that
• 17:19
  doesn't
• 17:19
  block
• 17:19
  D2
• 17:20
  as
• 17:20
  much.
• 17:21
  Then
• 17:21
  you
• 17:21
  can
• 17:21
  look
• 17:21
  at
• 17:21
  Quetiapine
• 17:22
  or
• 17:22
  Seroquel.
• 17:23
  It
• 17:23
  has
• 17:23
  a
• 17:23
  lower
• 17:23
  D2
• 17:23
  affinity.
• 17:24
  This
• 17:24
  is
• 17:24
  why
• 17:24
  you
• 17:25
  guys
• 17:25
  really
• 17:25
  have
• 17:25
  to
• 17:25
  get
• 17:26
  good
• 17:26
  at
• 17:27
  memorizing
• 17:28
  some
• 17:28
  fundamentals
• 17:29
  with
• 17:29
  all
• 17:29
  of
• 17:29
  your
• 17:30
  meds,
• 17:30
  like
• 17:30
  which
• 17:30
  ones
• 17:31
  have
• 17:31
  high
• 17:31
  D2
• 17:32
  affinity,
• 17:32
  which
• 17:33
  ones
• 17:33
  have
• 17:33
  lower
• 17:34
  D2
• 17:34
  affinity.
• 17:35
  We
• 17:35
  go
• 17:35
  over
• 17:35
  that
• 17:35
  extensively
• 17:36
  in
• 17:36
  previous
• 17:36
  episodes.
• 17:37
  But
• 17:37
  it's
• 17:38
  good
• 17:38
  to
• 17:38
  just
• 17:38
  know,
• 17:38
  you
• 17:39
  know,
• 17:39
  as
• 17:40
  a
• 17:40
  new
• 17:40
  grad
• 17:40
  or
• 17:41
  maybe
• 17:41
  a
• 17:41
  student,
• 17:42
  I
• 17:42
  didn't
• 17:42
  necessarily
• 17:43
  appreciate
• 17:43
  or
• 17:43
  know
• 17:44
  that
• 17:44
  seroquel
• 17:45
  had
• 17:45
  lower
• 17:46
  D2
• 17:46
  affinity,
• 17:47
  but
• 17:47
  it's
• 17:47
  something
• 17:48
  you
• 17:48
  just
• 17:48
  pick
• 17:48
  up
• 17:48
  with
• 17:48
  time
• 17:49
  you
• 17:49
  remember
• 17:49
  it,
• 17:49
  and
• 17:50
  it
• 17:50
  becomes,
• 17:50
  like,
• 17:50
  driving
• 17:51
  automatic
• 17:51
  and
• 17:51
  easy.
• 17:52
  Okay?
• 17:52
  So
• 17:53
  you
• 17:53
  can
• 17:53
  switch
• 17:53
  the
• 17:53
  patient,
• 17:54
  but
• 17:54
  you
• 17:54
  can
• 17:54
  also
• 17:55
  treat
• 17:55
  the
• 17:55
  patient
• 17:55
  with
• 17:55
  a
• 17:55
  VMAT2
• 17:56
  inhibitor.
• 17:57
  Okay?
• 17:58
  But
• 17:58
  you
• 17:58
  don't
• 17:59
  want
• 17:59
  to
• 17:59
  just
• 18:00
  abruptly
• 18:01
  discontinue
• 18:02
  the
• 18:02
  antipsychotic,
• 18:03
  right?
• 18:03
  That's
• 18:03
  really
• 18:03
  dangerous
• 18:04
  for
• 18:04
  psychotic
• 18:05
  relapse.
• 18:05
  Worsening
• 18:06
  T.
• 18:06
  Worsening
• 18:07
  his
• 18:08
  T.
• 18:08
  Joe's
• 18:08
  TD.
• 18:10
  Okay?
• 18:11
  So
• 18:12
  I
• 18:12
  like
• 18:12
  the
• 18:13
  idea
• 18:13
  of.
• 18:15
  Of
• 18:15
  a
• 18:15
  VMAT2
• 18:16
  inhibitor.
• 18:16
  They
• 18:16
  work
• 18:17
  a
• 18:17
  little
• 18:17
  bit
• 18:17
  differently,
• 18:18
  which
• 18:18
  is
• 18:19
  pretty
• 18:19
  cool.
• 18:20
  Okay?
• 18:22
  Now,
• 18:22
  VMAT2
• 18:23
  is
• 18:23
  a
• 18:23
  protein,
• 18:24
  okay?
• 18:25
  It's
• 18:25
  a
• 18:25
  vesicular
• 18:26
  monoamine
• 18:26
  transporter.
• 18:27
  Don't
• 18:28
  let
• 18:28
  that
• 18:28
  bother
• 18:28
  you.
• 18:28
  Whoever
• 18:29
  named
• 18:29
  that
• 18:30
  wanted
• 18:30
  to
• 18:30
  make
• 18:30
  sure
• 18:31
  that
• 18:31
  you
• 18:31
  would
• 18:31
  never
• 18:31
  understand
• 18:32
  it
• 18:33
  and
• 18:33
  that
• 18:33
  you
• 18:33
  would
• 18:34
  never
• 18:34
  treat
• 18:34
  patients.
• 18:35
  So
• 18:35
  we're
• 18:35
  going
• 18:35
  to
• 18:35
  have
• 18:36
  to
• 18:36
  rename
• 18:36
  that
• 18:36
  at
• 18:36
  some
• 18:36
  point.
• 18:37
  But
• 18:37
  basically,
• 18:38
  VMAT2
• 18:39
  is
• 18:39
  like
• 18:39
  a
• 18:39
  loading
• 18:40
  dock,
• 18:40
  okay?
• 18:41
  It
• 18:41
  grabs
• 18:41
  dopamine
• 18:42
  from
• 18:42
  the
• 18:42
  cytoplasm,
• 18:43
  packages
• 18:44
  it
• 18:44
  into
• 18:45
  a
• 18:45
  tiny
• 18:45
  storage
• 18:45
  vesicle,
• 18:46
  or
• 18:46
  like
• 18:46
  a
• 18:46
  bubble,
• 18:47
  okay?
• 18:48
  And
• 18:48
  then
• 18:49
  it
• 18:49
  will
• 18:49
  eventually
• 18:50
  be
• 18:50
  released
• 18:51
  out
• 18:51
  into
• 18:51
  the
• 18:51
  synapse,
• 18:52
  as
• 18:52
  in
• 18:53
  the
• 18:53
  form
• 18:53
  of,
• 18:53
  like,
• 18:53
  dopamine
• 18:54
  packages
• 18:54
  being
• 18:55
  released.
• 18:55
  But
• 18:56
  we're
• 18:56
  going
• 18:56
  to
• 18:56
  inhibit
• 18:57
  that
• 18:57
  process.
• 18:57
  We're
• 18:57
  inhibiting
• 18:58
  VMAT
• 18:58
  2,
• 18:59
  okay?
• 19:00
  They
• 19:00
  block
• 19:00
  that
• 19:00
  loading
• 19:01
  dock.
• 19:01
  So
• 19:01
  dopamine
• 19:02
  can't
• 19:02
  get
• 19:02
  into
• 19:02
  the
• 19:03
  vesicles
• 19:04
  to
• 19:04
  be
• 19:04
  shipped
• 19:04
  out,
• 19:05
  okay?
• 19:07
  So
• 19:07
  it's
• 19:07
  almost
• 19:07
  like
• 19:08
  VMAT
• 19:08
  is
• 19:09
  a
• 19:09
  UPS
• 19:09
  store
• 19:09
  of
• 19:10
  sorts,
• 19:10
  and
• 19:11
  we're
• 19:11
  just
• 19:11
  putting
• 19:12
  a
• 19:12
  padlock
• 19:13
  on
• 19:13
  it.
• 19:13
  We're
• 19:14
  not
• 19:14
  allowing
• 19:14
  any
• 19:15
  of
• 19:15
  the
• 19:15
  packages
• 19:15
  to
• 19:15
  go
• 19:16
  out,
• 19:16
  okay?
• 19:17
  No
• 19:18
  more
• 19:18
  dopamine.
• 19:18
  And
• 19:19
  that
• 19:19
  kind
• 19:19
  of
• 19:19
  disrupts
• 19:20
  this
• 19:20
  whole
• 19:20
  process
• 19:21
  because
• 19:21
  the
• 19:21
  more
• 19:21
  dopamine
• 19:23
  that
• 19:23
  goes
• 19:24
  out
• 19:24
  there
• 19:24
  and
• 19:25
  gets
• 19:25
  blocked,
• 19:26
  well,
• 19:27
  then
• 19:27
  we
• 19:27
  have
• 19:28
  a
• 19:28
  problem.
• 19:30
  And
• 19:30
  the
• 19:30
  problem
• 19:30
  specifically
• 19:31
  is
• 19:32
  that
• 19:32
  if
• 19:32
  that
• 19:33
  dopamine
• 19:33
  was
• 19:34
  released
• 19:35
  again,
• 19:35
  your
• 19:35
  receptors
• 19:36
  are
• 19:36
  very
• 19:37
  sensitive,
• 19:38
  right?
• 19:38
  Your
• 19:38
  dopamine
• 19:39
  receptors
• 19:39
  are
• 19:40
  very
• 19:40
  sensitive
• 19:40
  because
• 19:41
  you've
• 19:41
  blocked
• 19:42
  them
• 19:42
  for
• 19:42
  so
• 19:43
  long
• 19:43
  with
• 19:43
  your
• 19:43
  antipsychotic.
• 19:44
  And
• 19:45
  here
• 19:45
  you
• 19:45
  go.
• 19:46
  And
• 19:46
  if
• 19:46
  you
• 19:46
  don't
• 19:46
  inhibit
• 19:47
  VMAT
• 19:47
  2,
• 19:48
  they're
• 19:48
  gonna.
• 19:49
  The
• 19:49
  dopamine
• 19:49
  is
• 19:49
  gonna
• 19:50
  be
• 19:50
  stored
• 19:51
  in
• 19:51
  those
• 19:51
  vesicles,
• 19:52
  released
• 19:52
  into
• 19:52
  the
• 19:52
  synapse,
• 19:53
  and
• 19:53
  it's
• 19:53
  going
• 19:53
  to
• 19:53
  hit
• 19:54
  those
• 19:54
  receptors
• 19:55
  that
• 19:55
  are
• 19:55
  now
• 19:55
  super
• 19:56
  sensitive
• 19:57
  to
• 19:57
  dopamine.
• 19:58
  Okay.
• 19:58
  So
• 19:58
  I
• 19:58
  should
• 19:59
  kind
• 19:59
  of
• 19:59
  refine
• 19:59
  what
• 20:00
  I
• 20:00
  just
• 20:00
  said.
• 20:00
  And
• 20:01
  you're.
• 20:01
  It's
• 20:01
  a
• 20:01
  different
• 20:02
  way
• 20:02
  to
• 20:03
  inhibit
• 20:04
  this
• 20:04
  process
• 20:04
  so
• 20:05
  you
• 20:05
  don't
• 20:05
  egg
• 20:05
  it
• 20:05
  on
• 20:06
  by
• 20:07
  stopping
• 20:08
  the
• 20:08
  release
• 20:09
  of
• 20:09
  dopamine
• 20:10
  through
• 20:11
  those
• 20:11
  tiny
• 20:12
  storage
• 20:12
  vesicles.
• 20:13
  Right.
• 20:13
  So
• 20:14
  that
• 20:14
  they
• 20:14
  don't
• 20:14
  get
• 20:15
  to
• 20:15
  be
• 20:15
  sent
• 20:15
  out
• 20:16
  into
• 20:16
  the
• 20:16
  synapse
• 20:17
  and.
• 20:17
  And
• 20:17
  exposed
• 20:18
  to
• 20:18
  those
• 20:18
  hypersensitive
• 20:19
  dopamine
• 20:20
  circuits.
• 20:20
  So
• 20:20
  you're
• 20:21
  inhibiting
• 20:22
  VMAT
• 20:22
  to.
• 20:23
  Okay.
• 20:24
  And
• 20:24
  there's
• 20:25
  two
• 20:25
  good
• 20:25
  medications
• 20:27
  that
• 20:27
  can
• 20:27
  do
• 20:27
  that.
• 20:29
  And
• 20:29
  again,
• 20:29
  if
• 20:30
  you
• 20:30
  are.
• 20:30
  If
• 20:30
  you
• 20:31
  become
• 20:31
  a
• 20:31
  Patreon
• 20:32
  member,
• 20:32
  you
• 20:32
  can
• 20:32
  see
• 20:32
  what
• 20:33
  they
• 20:33
  are.
• 20:34
  We
• 20:34
  won't.
• 20:34
  We
• 20:34
  don't
• 20:34
  need
• 20:34
  to
• 20:34
  get
• 20:35
  into
• 20:35
  them
• 20:35
  today.
• 20:35
  It's
• 20:35
  a
• 20:35
  little
• 20:36
  too
• 20:36
  much
• 20:36
  in
• 20:36
  the
• 20:36
  weeds.
• 20:36
  I
• 20:37
  want
• 20:37
  you
• 20:37
  to
• 20:37
  have
• 20:37
  an
• 20:37
  appreciation,
• 20:38
  a
• 20:38
  conceptual
• 20:39
  appreciation
• 20:39
  for
• 20:40
  what
• 20:40
  TD
• 20:40
  is,
• 20:41
  how
• 20:41
  to
• 20:41
  identify
• 20:42
  it,
• 20:42
  why
• 20:42
  it's
• 20:43
  so
• 20:43
  disabling,
• 20:44
  and
• 20:44
  what
• 20:44
  to
• 20:44
  do
• 20:44
  and
• 20:44
  what
• 20:45
  not
• 20:45
  to
• 20:45
  do.
• 20:45
  But
• 20:46
  suffice
• 20:46
  it
• 20:46
  to
• 20:46
  say,
• 20:46
  these
• 20:47
  VMAT2
• 20:47
  inhibitors
• 20:48
  on
• 20:48
  our
• 20:49
  Patreon
• 20:49
  page,
• 20:49
  you
• 20:49
  will
• 20:50
  be
• 20:50
  able
• 20:50
  to
• 20:50
  look
• 20:50
  at
• 20:51
  that
• 20:51
  and.
• 20:53
  And
• 20:53
  figure
• 20:54
  out
• 20:54
  the
• 20:54
  starting
• 20:54
  dose
• 20:55
  and.
• 20:55
  And
• 20:55
  kind
• 20:56
  of
• 20:56
  how
• 20:56
  to
• 20:56
  manage
• 20:56
  that
• 20:57
  and
• 20:57
  what
• 20:57
  that
• 20:57
  looks
• 20:58
  like.
• 20:58
  Um,
• 20:59
  but
• 20:59
  at
• 20:59
  least
• 20:59
  we
• 21:00
  could
• 21:00
  continue
• 21:01
  our
• 21:01
  antipsychotics
• 21:02
  when
• 21:02
  we
• 21:02
  add
• 21:02
  a
• 21:02
  VMAT2
• 21:03
  inhibitor
• 21:03
  so
• 21:04
  Joe
• 21:04
  does
• 21:04
  not
• 21:05
  have
• 21:05
  to
• 21:05
  sacrifice
• 21:05
  how
• 21:06
  efficacious
• 21:07
  Haldol
• 21:08
  has
• 21:08
  been.
• 21:08
  He
• 21:08
  can
• 21:08
  stay
• 21:08
  on
• 21:08
  Haldol
• 21:09
  10.
• 21:10
  You
• 21:10
  continue
• 21:11
  to
• 21:11
  do
• 21:11
  your
• 21:11
  Ames
• 21:11
  assessments
• 21:12
  every
• 21:12
  time
• 21:13
  you
• 21:13
  see
• 21:13
  him,
• 21:14
  and
• 21:14
  add
• 21:14
  a
• 21:14
  VMAT2
• 21:15
  inhibitor,
• 21:15
  give
• 21:16
  it
• 21:16
  a
• 21:16
  few
• 21:16
  weeks,
• 21:16
  and
• 21:17
  see
• 21:17
  if
• 21:17
  his
• 21:17
  AMES
• 21:18
  score
• 21:18
  drops.
• 21:19
  Right.
• 21:19
  You
• 21:19
  could
• 21:20
  also
• 21:20
  switch,
• 21:20
  like
• 21:20
  I
• 21:20
  said,
• 21:21
  to
• 21:21
  Clozapine
• 21:21
  or
• 21:22
  Seroquel.
• 21:23
  And
• 21:24
  you
• 21:24
  can
• 21:25
  also
• 21:25
  test
• 21:26
  out
• 21:26
  what
• 21:26
  the
• 21:26
  AIMS
• 21:27
  would
• 21:27
  be
• 21:27
  over
• 21:28
  there,
• 21:28
  too,
• 21:29
  either
• 21:29
  way.
• 21:30
  But
• 21:30
  the
• 21:31
  goal
• 21:31
  is,
• 21:32
  we
• 21:32
  cannot
• 21:32
  allow
• 21:33
  our
• 21:33
  patients
• 21:34
  to
• 21:35
  develop
• 21:36
  this
• 21:37
  chronic,
• 21:38
  potentially
• 21:38
  irreversible
• 21:39
  movement
• 21:39
  disorder
• 21:41
  on
• 21:41
  top
• 21:41
  of
• 21:42
  their
• 21:42
  schizophrenia,
• 21:44
  on
• 21:44
  top
• 21:45
  of
• 21:45
  their
• 21:45
  major
• 21:45
  depression
• 21:46
  with
• 21:46
  psychotic
• 21:47
  features,
• 21:48
  or
• 21:48
  if
• 21:48
  you're
• 21:48
  augmenting
• 21:49
  with
• 21:49
  an
• 21:50
  antipsychotic
• 21:50
  for
• 21:51
  depression,
• 21:51
  now
• 21:51
  you're
• 21:52
  adding
• 21:52
  this
• 21:52
  irreversible
• 21:53
  movement
• 21:54
  disorder
• 21:54
  where
• 21:54
  they
• 21:54
  can't
• 21:55
  speak
• 21:55
  or
• 21:55
  sit
• 21:55
  or
• 21:56
  chew
• 21:56
  or
• 21:57
  hold
• 21:57
  a
• 21:57
  pen,
• 21:58
  talk
• 21:59
  to
• 21:59
  their
• 21:59
  loved
• 21:59
  ones.
• 22:00
  Right.
• 22:00
  Their.
• 22:00
  Their
• 22:00
  lives
• 22:01
  are
• 22:01
  difficult
• 22:01
  enough,
• 22:01
  so
• 22:02
  we
• 22:02
  have
• 22:02
  to
• 22:02
  do
• 22:03
  this
• 22:03
  AIMS
• 22:04
  assessment
• 22:05
  and
• 22:05
  protect
• 22:06
  them
• 22:07
  and
• 22:07
  to
• 22:07
  be
• 22:08
  just
• 22:08
  as
• 22:08
  vigilant
• 22:08
  about
• 22:09
  their
• 22:09
  movements
• 22:09
  as
• 22:09
  we
• 22:09
  are
• 22:10
  about
• 22:10
  their
• 22:10
  metabolism.
• 22:11
  Right.
• 22:11
  We're
• 22:11
  very
• 22:11
  good
• 22:11
  at
• 22:12
  getting
• 22:12
  lipids
• 22:12
  and
• 22:12
  A1Cs
• 22:14
  and
• 22:14
  tracking
• 22:14
  their
• 22:14
  weight
• 22:15
  and
• 22:15
  BMI.
• 22:16
  We
• 22:16
  need
• 22:16
  to
• 22:16
  Be
• 22:16
  just
• 22:16
  as
• 22:17
  vigilant
• 22:17
  about
• 22:18
  the
• 22:18
  potentially
• 22:18
  irreversible
• 22:19
  movement
• 22:20
  disorders
• 22:21
  that
• 22:21
  they
• 22:22
  have
• 22:23
  as
• 22:23
  a
• 22:23
  result
• 22:23
  of
• 22:23
  this.
• 22:24
  Right?
• 22:24
  And
• 22:25
  again,
• 22:25
  if
• 22:25
  you
• 22:25
  check
• 22:26
  out
• 22:26
  our
• 22:26
  Patreon,
• 22:27
  there's
• 22:28
  a
• 22:28
  really
• 22:28
  good
• 22:28
  visual.
• 22:28
  I'm
• 22:29
  a
• 22:29
  very
• 22:29
  visual
• 22:29
  person.
• 22:29
  That's
• 22:30
  why
• 22:30
  I
• 22:30
  built
• 22:30
  the
• 22:30
  Patreon
• 22:31
  library,
• 22:31
  because
• 22:32
  everything
• 22:32
  clicks
• 22:33
  like
• 22:33
  really
• 22:34
  quickly
• 22:35
  and
• 22:35
  easily
• 22:35
  and
• 22:35
  beautifully
• 22:36
  on
• 22:36
  our
• 22:36
  page.
• 22:37
  But
• 22:37
  I
• 22:37
  highly
• 22:38
  recommend
• 22:38
  you
• 22:38
  get
• 22:39
  familiar
• 22:39
  with
• 22:39
  what
• 22:40
  you
• 22:40
  need
• 22:40
  your
• 22:40
  patient
• 22:41
  to
• 22:41
  do
• 22:41
  to
• 22:41
  do
• 22:41
  in
• 22:41
  Ames.
• 22:42
  It's
• 22:42
  very
• 22:42
  simple.
• 22:43
  You
• 22:43
  know,
• 22:43
  they
• 22:44
  sit
• 22:44
  in
• 22:44
  the
• 22:44
  chair,
• 22:44
  they
• 22:44
  get
• 22:45
  up
• 22:45
  and
• 22:45
  walk
• 22:45
  around,
• 22:46
  but
• 22:46
  there's
• 22:46
  specific
• 22:47
  little
• 22:48
  hand
• 22:48
  movements
• 22:49
  and
• 22:49
  things
• 22:49
  that
• 22:50
  make
• 22:50
  this
• 22:50
  really
• 22:51
  easy
• 22:51
  and
• 22:51
  elegant.
• 22:52
  And
• 22:52
  it
• 22:52
  will
• 22:52
  really
• 22:53
  empower
• 22:53
  you
• 22:54
  to
• 22:54
  take
• 22:54
  control
• 22:55
  of
• 22:55
  your
• 22:55
  practice
• 22:55
  and
• 22:56
  to
• 22:56
  do
• 22:56
  really
• 22:56
  well
• 22:57
  for
• 22:57
  your
• 22:57
  patient
• 22:57
  to
• 22:58
  be
• 22:58
  familiar,
• 22:58
  to
• 22:59
  be
• 22:59
  able
• 22:59
  to
• 22:59
  explain
• 22:59
  this
• 23:00
  to
• 23:00
  them,
• 23:01
  to
• 23:01
  help
• 23:01
  them
• 23:01
  be
• 23:01
  vigilant.
• 23:02
  Right?
• 23:02
  If
• 23:02
  we're
• 23:02
  not
• 23:02
  vigilant,
• 23:03
  they
• 23:03
  can't
• 23:03
  be
• 23:03
  vigilant
• 23:04
  for
• 23:04
  these
• 23:04
  things.
• 23:05
  So
• 23:05
  it
• 23:05
  really
• 23:05
  helps.
• 23:06
  It's
• 23:06
  really
• 23:06
  darn
• 23:07
  helpful.
• 23:08
  Now,
• 23:08
  I
• 23:08
  know
• 23:08
  I've
• 23:09
  talked
• 23:09
  a
• 23:09
  lot
• 23:09
  about
• 23:09
  Patreon,
• 23:10
  my
• 23:10
  friends,
• 23:11
  but
• 23:11
  just
• 23:11
  a
• 23:12
  last
• 23:13
  second
• 23:14
  moment
• 23:14
  of
• 23:14
  encouragement
• 23:15
  for
• 23:15
  you
• 23:16
  to
• 23:16
  go
• 23:16
  into
• 23:16
  our
• 23:16
  show
• 23:17
  notes
• 23:17
  and
• 23:18
  become
• 23:18
  a
• 23:18
  member.
• 23:18
  Click
• 23:19
  that
• 23:19
  link
• 23:19
  and
• 23:19
  become
• 23:20
  a
• 23:20
  member.
• 23:20
  Patreon.com
• 23:21
  pearlsandprep
• 23:23
  it
• 23:23
  is
• 23:23
  an
• 23:23
  awesome
• 23:24
  clinical
• 23:24
  library.
• 23:25
  And
• 23:25
  I'll
• 23:26
  tell
• 23:26
  you,
• 23:26
  we
• 23:26
  built
• 23:26
  it
• 23:27
  because
• 23:27
  we
• 23:27
  don't
• 23:27
  wanna
• 23:28
  be
• 23:28
  the
• 23:28
  kinds
• 23:28
  of
• 23:28
  clinicians
• 23:29
  that
• 23:29
  just
• 23:30
  press
• 23:30
  a
• 23:30
  button
• 23:31
  and
• 23:32
  just
• 23:33
  memorize
• 23:34
  meds.
• 23:35
  It's
• 23:35
  not
• 23:35
  enough,
• 23:35
  right?
• 23:36
  Understanding
• 23:37
  the
• 23:37
  how
• 23:37
  and
• 23:37
  the
• 23:37
  why
• 23:37
  so
• 23:38
  we
• 23:38
  can
• 23:38
  educate
• 23:38
  our
• 23:39
  patients
• 23:39
  and
• 23:39
  empower
• 23:39
  them
• 23:40
  to
• 23:40
  achieve
• 23:41
  the
• 23:41
  best
• 23:42
  outcomes
• 23:42
  possible.
• 23:43
  Patients
• 23:43
  can
• 23:43
  smell
• 23:44
  the
• 23:44
  difference
• 23:44
  between
• 23:44
  a
• 23:45
  good
• 23:45
  and
• 23:45
  a
• 23:45
  great
• 23:45
  clinician
• 23:46
  a
• 23:46
  mile
• 23:46
  away.
• 23:47
  One
• 23:47
  who
• 23:47
  just
• 23:48
  memorizes
• 23:48
  meds
• 23:49
  and
• 23:49
  presses
• 23:50
  buttons
• 23:50
  versus
• 23:50
  ones
• 23:51
  who
• 23:51
  really
• 23:52
  understand
• 23:52
  the
• 23:52
  how
• 23:53
  and
• 23:53
  the
• 23:53
  why.
• 23:53
  And
• 23:53
  if
• 23:53
  you
• 23:54
  become
• 23:54
  a
• 23:54
  member
• 23:54
  of
• 23:55
  our
• 23:55
  Patreon
• 23:56
  page,
• 23:57
  you
• 23:57
  will
• 23:57
  become
• 23:58
  that
• 23:58
  clinician
• 23:59
  and
• 23:59
  it
• 23:59
  will
• 23:59
  completely
• 23:59
  change
• 24:00
  the
• 24:00
  way
• 24:00
  you
• 24:00
  do
• 24:00
  things.
• 24:01
  And
• 24:01
  you
• 24:01
  look
• 24:01
  at
• 24:02
  psychiatry.
• 24:02
  It's
• 24:03
  a
• 24:03
  fun
• 24:03
  place
• 24:03
  to
• 24:04
  nerd
• 24:04
  out,
• 24:04
  ask
• 24:04
  questions,
• 24:05
  learn
• 24:05
  new
• 24:06
  things.
• 24:06
  You're
• 24:06
  just
• 24:06
  gonna
• 24:07
  love
• 24:07
  it.
• 24:07
  Patreon.com
• 24:09
  pearlsandprep
• 24:10
  thank
• 24:10
  you
• 24:10
  all
• 24:10
  very
• 24:11
  much
• 24:11
  for
• 24:11
  tuning
• 24:11
  in
• 24:11
  and
• 24:12
  have
• 24:12
  a
• 24:12
  wonderful,
• 24:13
  wonderful
• 24:14
  week.
• 24:14
  Bye.
• 24:14
  Bye.