Latest / Pearls and Prep / How to Choose the RIGHT Neurotransmitter Target

Transcript

How to Choose the RIGHT Neurotransmitter Target · 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
• 0:07
  of
• 0:08
  Pearls
• 0:08
  and
• 0:08
  Prep.
• 0:09
  Npz.
• 0:09
  Here,
• 0:10
  your
• 0:10
  preceptor
• 0:10
  in
• 0:11
  your
• 0:11
  pocket,
• 0:11
  your
• 0:11
  go
• 0:11
  to
• 0:12
  place
• 0:12
  for
• 0:12
  pearls
• 0:13
  that
• 0:13
  prep
• 0:13
  you
• 0:13
  to
• 0:14
  practice.
• 0:14
  My
• 0:14
  friends,
• 0:15
  today
• 0:15
  we
• 0:15
  are
• 0:15
  going
• 0:16
  to
• 0:16
  talk
• 0:16
  about
• 0:17
  the
• 0:17
  big
• 0:17
  bad
• 0:18
  three
• 0:19
  neurotransmitters
• 0:21
  that
• 0:21
  you
• 0:21
  have
• 0:22
  to
• 0:22
  know
• 0:22
  about.
• 0:23
  Serotonin,
• 0:24
  norepinephrine
• 0:25
  and
• 0:25
  dopamine.
• 0:27
  The
• 0:27
  big
• 0:27
  bad
• 0:28
  three.
• 0:28
  There
• 0:28
  are
• 0:28
  others
• 0:29
  that
• 0:29
  we
• 0:29
  care
• 0:29
  about
• 0:30
  in
• 0:30
  psychiatry.
• 0:31
  There
• 0:31
  are
• 0:31
  other
• 0:31
  neurotransmitters
• 0:32
  that
• 0:32
  are
• 0:32
  very
• 0:33
  important.
• 0:34
  GABA
• 0:34
  and
• 0:34
  glutamate.
• 0:35
  Those
• 0:35
  deserve
• 0:36
  their
• 0:36
  own
• 0:37
  episode.
• 0:37
  But
• 0:38
  today,
• 0:38
  it's
• 0:38
  very
• 0:39
  important
• 0:39
  that
• 0:39
  we
• 0:39
  understand
• 0:40
  serotonin,
• 0:41
  dopamine
• 0:41
  and
• 0:41
  norepinephrine,
• 0:42
  not
• 0:43
  just
• 0:43
  on
• 0:43
  a
• 0:43
  surface
• 0:44
  level,
• 0:44
  but
• 0:45
  more
• 0:45
  intimately
• 0:46
  and
• 0:46
  more
• 0:47
  practically.
• 0:47
  And
• 0:48
  I
• 0:48
  will
• 0:48
  admit
• 0:48
  to
• 0:48
  you,
• 0:48
  as
• 0:49
  a
• 0:49
  student,
• 0:50
  I
• 0:50
  radically
• 0:51
  oversimplified
• 0:53
  the
• 0:53
  role
• 0:54
  of
• 0:54
  these
• 0:55
  neurotransmitters
• 0:56
  and
• 0:56
  what
• 0:56
  they
• 0:56
  actually
• 0:57
  do
• 0:57
  in
• 0:57
  practice.
• 0:58
  And
• 0:58
  if
• 0:58
  you
• 0:58
  don't
• 0:59
  have
• 0:59
  a
• 0:59
  very
• 1:00
  rich
• 1:00
  appreciation
• 1:01
  for
• 1:01
  what
• 1:01
  these
• 1:01
  do
• 1:01
  and
• 1:02
  what
• 1:02
  they
• 1:02
  don't
• 1:02
  do,
• 1:03
  then
• 1:03
  your
• 1:03
  patients,
• 1:04
  sure,
• 1:04
  sure
• 1:05
  as
• 1:05
  heck,
• 1:05
  will
• 1:05
  also
• 1:06
  have
• 1:06
  no
• 1:06
  idea
• 1:07
  what
• 1:07
  we're
• 1:07
  actually
• 1:08
  doing
• 1:08
  for
• 1:08
  them
• 1:08
  in
• 1:09
  practice.
• 1:10
  Now,
• 1:10
  this
• 1:10
  is
• 1:11
  actually
• 1:11
  pretty
• 1:11
  simple
• 1:12
  and
• 1:12
  pretty
• 1:12
  fun
• 1:13
  when
• 1:13
  you
• 1:13
  boil
• 1:13
  it
• 1:13
  down.
• 1:14
  And
• 1:14
  it
• 1:15
  starts
• 1:15
  with
• 1:15
  dispelling
• 1:16
  some
• 1:16
  myths.
• 1:17
  Now,
• 1:18
  I
• 1:18
  think
• 1:18
  that
• 1:19
  it's
• 1:19
  in
• 1:19
  the
• 1:20
  general
• 1:20
  public,
• 1:20
  it's
• 1:20
  safe
• 1:21
  to
• 1:21
  say
• 1:22
  serotonin
• 1:23
  is
• 1:23
  considered
• 1:24
  happiness,
• 1:25
  right?
• 1:25
  Dopamine
• 1:26
  is
• 1:26
  considered
• 1:27
  happiness.
• 1:28
  Norepinephrine
• 1:29
  might
• 1:29
  be
• 1:30
  a
• 1:30
  little
• 1:30
  more
• 1:30
  nuanced,
• 1:31
  right?
• 1:31
  There
• 1:32
  might
• 1:32
  be
• 1:32
  connotations
• 1:34
  with
• 1:34
  respect
• 1:34
  to
• 1:34
  energy
• 1:35
  and
• 1:35
  alertness,
• 1:36
  and
• 1:36
  that
• 1:36
  is
• 1:36
  actually
• 1:37
  a
• 1:37
  little
• 1:37
  more
• 1:37
  accurate
• 1:38
  at
• 1:38
  least.
• 1:39
  But
• 1:40
  popular
• 1:41
  opinion
• 1:42
  may
• 1:43
  serve
• 1:43
  to
• 1:43
  substantiate
• 1:44
  the
• 1:44
  fact
• 1:44
  that
• 1:45
  serotonin
• 1:45
  means
• 1:46
  happy
• 1:46
  and
• 1:46
  more
• 1:46
  serotonin
• 1:47
  means
• 1:47
  good
• 1:48
  and
• 1:48
  more
• 1:48
  dopamine
• 1:49
  means
• 1:49
  good.
• 1:49
  And
• 1:50
  except
• 1:50
  for
• 1:50
  the
• 1:50
  fact
• 1:50
  that
• 1:51
  more
• 1:51
  does
• 1:52
  not
• 1:52
  always
• 1:52
  mean
• 1:52
  good
• 1:53
  and
• 1:53
  serotonin
• 1:54
  does
• 1:54
  not
• 1:54
  really
• 1:54
  mean
• 1:55
  happy.
• 1:55
  And
• 1:56
  that
• 1:56
  is
• 1:56
  bastardizing
• 1:58
  the
• 1:58
  role
• 1:58
  of
• 1:58
  serotonin
• 1:59
  in
• 2:00
  our
• 2:01
  toolkit
• 2:02
  as
• 2:02
  clinicians,
• 2:02
  because
• 2:03
  it's.
• 2:03
  Its
• 2:03
  role
• 2:04
  is
• 2:04
  actually
• 2:04
  a
• 2:04
  lot
• 2:05
  more
• 2:05
  precise
• 2:05
  than
• 2:05
  that.
• 2:06
  And
• 2:06
  I
• 2:06
  found
• 2:06
  that
• 2:07
  when
• 2:07
  I
• 2:07
  share
• 2:07
  what
• 2:08
  the
• 2:08
  role
• 2:08
  actually
• 2:08
  is
• 2:09
  with
• 2:09
  my
• 2:09
  patients,
• 2:10
  they,
• 2:11
  number
• 2:11
  one,
• 2:12
  are
• 2:12
  very
• 2:12
  grateful.
• 2:12
  And
• 2:12
  number
• 2:13
  two,
• 2:14
  they
• 2:14
  have
• 2:15
  a
• 2:16
  more
• 2:16
  realistic
• 2:17
  or
• 2:17
  accurate
• 2:17
  compass
• 2:18
  going
• 2:18
  into
• 2:18
  their
• 2:18
  treatment.
• 2:19
  This
• 2:19
  is
• 2:19
  exactly
• 2:20
  what
• 2:20
  the
• 2:20
  prescriber
• 2:21
  had
• 2:21
  talked
• 2:22
  about.
• 2:22
  I
• 2:22
  know
• 2:22
  the
• 2:23
  meds
• 2:23
  are
• 2:23
  working
• 2:23
  because
• 2:23
  that's
• 2:24
  exactly
• 2:24
  what
• 2:25
  he
• 2:25
  said
• 2:25
  they
• 2:26
  would
• 2:26
  do,
• 2:27
  or
• 2:27
  pretty
• 2:27
  close
• 2:27
  to
• 2:28
  what
• 2:28
  I
• 2:28
  think
• 2:28
  he
• 2:28
  said
• 2:28
  they
• 2:29
  would
• 2:29
  do.
• 2:29
  And
• 2:30
  that's
• 2:30
  what
• 2:30
  we
• 2:30
  want
• 2:30
  to
• 2:31
  talk
• 2:31
  about.
• 2:32
  So,
• 2:32
  my
• 2:32
  friends,
• 2:33
  the
• 2:33
  very
• 2:34
  first
• 2:34
  thing
• 2:35
  that
• 2:35
  we
• 2:35
  should
• 2:36
  remember,
• 2:37
  the
• 2:37
  first
• 2:37
  big
• 2:37
  juicy
• 2:38
  pearl
• 2:38
  here
• 2:39
  when
• 2:39
  it
• 2:39
  comes
• 2:40
  to
• 2:40
  serotonin,
• 2:41
  is
• 2:41
  that
• 2:41
  it
• 2:41
  is
• 2:42
  not
• 2:42
  about
• 2:42
  happiness.
• 2:44
  Contrary
• 2:44
  to
• 2:45
  that,
• 2:45
  it
• 2:45
  is
• 2:46
  a
• 2:46
  lot
• 2:46
  more
• 2:47
  about
• 2:47
  emotional
• 2:48
  regulation.
• 2:49
  More
• 2:50
  specifically,
• 2:50
  I
• 2:50
  would
• 2:51
  argue
• 2:51
  serotonin
• 2:52
  is
• 2:53
  a
• 2:53
  little
• 2:54
  bit
• 2:54
  like
• 2:54
  a
• 2:55
  brake
• 2:56
  pedal,
• 2:56
  okay?
• 2:57
  It
• 2:57
  prevents
• 2:58
  emotional
• 2:59
  signals
• 3:00
  from
• 3:00
  becoming
• 3:00
  too
• 3:01
  loud.
• 3:02
  Now,
• 3:02
  notice
• 3:03
  how
• 3:03
  radically
• 3:03
  different,
• 3:04
  how
• 3:04
  qualitatively
• 3:05
  different
• 3:05
  that
• 3:05
  is.
• 3:06
  Then
• 3:06
  it
• 3:07
  just
• 3:07
  makes
• 3:07
  you
• 3:07
  happy.
• 3:08
  And
• 3:08
  it's
• 3:08
  so
• 3:08
  important
• 3:09
  to
• 3:09
  emphasize
• 3:09
  this,
• 3:09
  because
• 3:10
  if
• 3:10
  your
• 3:10
  patients
• 3:10
  think
• 3:11
  they're
• 3:11
  going
• 3:11
  to
• 3:11
  take
• 3:11
  this
• 3:11
  medication
• 3:12
  and
• 3:12
  at
• 3:13
  three
• 3:13
  or
• 3:13
  four
• 3:13
  to
• 3:13
  six
• 3:14
  weeks
• 3:14
  later,
• 3:14
  they
• 3:15
  start
• 3:15
  to
• 3:15
  feel
• 3:15
  happy
• 3:16
  and
• 3:16
  giddy
• 3:16
  and
• 3:17
  euphoric,
• 3:17
  they're
• 3:18
  going
• 3:18
  to
• 3:18
  be
• 3:18
  let
• 3:18
  down,
• 3:18
  and
• 3:19
  they're
• 3:19
  going
• 3:19
  to
• 3:19
  be
• 3:19
  convinced
• 3:20
  that
• 3:20
  this
• 3:20
  medication
• 3:21
  is
• 3:21
  not
• 3:21
  working
• 3:22
  and
• 3:22
  it's
• 3:22
  not
• 3:22
  doing
• 3:22
  what
• 3:23
  it's
• 3:23
  supposed
• 3:23
  to
• 3:23
  do.
• 3:24
  But
• 3:24
  what
• 3:24
  we
• 3:25
  want
• 3:25
  to
• 3:25
  really
• 3:25
  do
• 3:26
  is
• 3:26
  when
• 3:26
  we
• 3:27
  have
• 3:27
  a
• 3:27
  patient
• 3:27
  in
• 3:27
  front
• 3:27
  of
• 3:28
  us
• 3:28
  who
• 3:28
  looks
• 3:29
  like
• 3:29
  they
• 3:29
  could
• 3:29
  benefit
• 3:30
  from
• 3:30
  modulating
• 3:31
  serotonin,
• 3:32
  that's
• 3:32
  exactly
• 3:32
  what
• 3:32
  we
• 3:33
  want
• 3:33
  to
• 3:33
  do.
• 3:33
  We
• 3:33
  want
• 3:33
  to
• 3:34
  modulate
• 3:34
  this.
• 3:35
  We
• 3:35
  want
• 3:35
  to
• 3:35
  put
• 3:36
  the
• 3:36
  brakes
• 3:37
  on
• 3:37
  their
• 3:38
  emotional
• 3:39
  representation
• 3:39
  that
• 3:40
  can
• 3:40
  often
• 3:40
  come
• 3:40
  across
• 3:41
  as
• 3:41
  very
• 3:42
  impulsive,
• 3:42
  very
• 3:43
  moody,
• 3:43
  very
• 3:44
  hypervigilant,
• 3:45
  very
• 3:45
  agitated,
• 3:45
  very
• 3:46
  anxious.
• 3:47
  Okay?
• 3:47
  And
• 3:47
  those
• 3:47
  things,
• 3:47
  of
• 3:48
  course,
• 3:48
  can
• 3:48
  make
• 3:48
  a
• 3:49
  patient
• 3:49
  have
• 3:50
  insomnia.
• 3:50
  They're
• 3:51
  on
• 3:51
  edge.
• 3:51
  They're
• 3:52
  snapping
• 3:52
  at
• 3:52
  their
• 3:52
  family
• 3:53
  members,
• 3:53
  right?
• 3:53
  So
• 3:54
  this
• 3:54
  is
• 3:54
  too
• 3:54
  intense.
• 3:54
  Their
• 3:55
  emotional
• 3:55
  presentation
• 3:56
  is
• 3:56
  a
• 3:56
  little
• 3:56
  bit
• 3:57
  too
• 3:57
  intense
• 3:57
  even
• 3:57
  for
• 3:58
  them.
• 3:58
  They
• 3:58
  have
• 3:58
  catastrophic
• 3:59
  worries,
• 4:00
  right?
• 4:00
  They,
• 4:00
  you
• 4:01
  and
• 4:01
  I
• 4:01
  may
• 4:01
  worry.
• 4:02
  These
• 4:02
  folks
• 4:02
  will
• 4:02
  worry
• 4:03
  and
• 4:04
  worry
• 4:04
  and
• 4:04
  worry
• 4:04
  and
• 4:05
  ruminate
• 4:05
  and
• 4:05
  spiral,
• 4:06
  and
• 4:06
  they're
• 4:06
  sort
• 4:07
  of
• 4:07
  tormented.
• 4:07
  And
• 4:09
  that
• 4:09
  serotonergic
• 4:10
  system
• 4:11
  in
• 4:11
  the
• 4:11
  brain
• 4:11
  stem
• 4:12
  projects
• 4:13
  to
• 4:13
  virtually
• 4:13
  every
• 4:14
  brain
• 4:14
  region.
• 4:14
  Okay?
• 4:15
  So
• 4:15
  we're
• 4:15
  talking
• 4:15
  about
• 4:15
  mood,
• 4:16
  anxiety,
• 4:17
  impulse
• 4:17
  control,
• 4:18
  sleep
• 4:18
  architecture,
• 4:19
  appetite,
• 4:20
  pain
• 4:20
  perception,
• 4:20
  cognition,
• 4:21
  all
• 4:22
  of
• 4:22
  the
• 4:22
  above.
• 4:23
  Right?
• 4:23
  This
• 4:23
  is
• 4:24
  not
• 4:24
  as
• 4:24
  simple
• 4:24
  as
• 4:25
  increase
• 4:25
  serotonin
• 4:26
  happy.
• 4:27
  It's
• 4:28
  about,
• 4:28
  well,
• 4:29
  where
• 4:30
  does
• 4:30
  serotonin
• 4:31
  project
• 4:31
  in
• 4:31
  the
• 4:32
  brain
• 4:33
  or
• 4:33
  in
• 4:33
  the
• 4:33
  rest
• 4:33
  of
• 4:33
  the
• 4:33
  body,
• 4:34
  but
• 4:34
  where
• 4:35
  does
• 4:35
  it
• 4:35
  project
• 4:35
  in
• 4:35
  the
• 4:35
  brain
• 4:36
  and
• 4:36
  in
• 4:37
  those
• 4:37
  brain
• 4:37
  regions.
• 4:38
  What
• 4:38
  are
• 4:38
  we
• 4:38
  exactly
• 4:39
  doing
• 4:39
  when
• 4:39
  we
• 4:39
  modulate
• 4:40
  serotonin?
• 4:41
  Right.
• 4:41
  If
• 4:41
  we're
• 4:41
  modulating
• 4:42
  serotonin
• 4:43
  in
• 4:43
  the
• 4:43
  amygdala,
• 4:43
  the
• 4:44
  fight
• 4:44
  or
• 4:44
  flight
• 4:44
  area
• 4:44
  of
• 4:45
  the
• 4:45
  brain,
• 4:45
  we're
• 4:46
  helping
• 4:46
  people
• 4:47
  not
• 4:47
  get
• 4:48
  so
• 4:48
  anxious
• 4:48
  with
• 4:49
  respect
• 4:49
  to
• 4:49
  maybe
• 4:49
  those
• 4:50
  catastrophic
• 4:50
  worries
• 4:51
  or
• 4:51
  their.
• 4:51
  Their
• 4:52
  trauma
• 4:52
  response,
• 4:53
  their
• 4:53
  fight
• 4:53
  or
• 4:53
  flight
• 4:54
  that
• 4:54
  is
• 4:54
  being.
• 4:55
  That
• 4:55
  is
• 4:55
  essentially
• 4:56
  too
• 4:56
  intense
• 4:56
  too
• 4:56
  often.
• 4:57
  Right?
• 4:58
  And
• 4:58
  so
• 4:58
  that's,
• 4:58
  again,
• 4:58
  why
• 4:59
  we
• 4:59
  come
• 4:59
  back
• 4:59
  to
• 4:59
  a
• 5:00
  serotonin
• 5:01
  being
• 5:01
  a
• 5:01
  brake
• 5:01
  system.
• 5:02
  It
• 5:02
  is
• 5:03
  modulating
• 5:04
  the
• 5:04
  emotional
• 5:04
  intensity
• 5:05
  of
• 5:05
  a
• 5:05
  thing.
• 5:06
  Panic,
• 5:07
  impulsivity,
• 5:08
  agitation.
• 5:08
  Right?
• 5:09
  These
• 5:09
  are
• 5:09
  all
• 5:09
  emotional
• 5:10
  states
• 5:10
  that
• 5:11
  are
• 5:11
  just
• 5:11
  too
• 5:11
  intense.
• 5:12
  And
• 5:12
  they're
• 5:12
  so
• 5:12
  intense
• 5:13
  that
• 5:13
  the
• 5:13
  patients
• 5:13
  are
• 5:13
  miserable.
• 5:14
  Right?
• 5:14
  They're
• 5:14
  way
• 5:15
  too
• 5:15
  on
• 5:15
  edge.
• 5:15
  They
• 5:16
  can't
• 5:16
  focus
• 5:16
  they're
• 5:17
  nervous
• 5:17
  all
• 5:17
  the
• 5:18
  time.
• 5:18
  It
• 5:18
  steals
• 5:18
  joy
• 5:19
  from
• 5:19
  their
• 5:19
  relationships.
• 5:20
  They're
• 5:20
  hyper
• 5:20
  vigilant.
• 5:21
  So
• 5:21
  it's,
• 5:21
  it's
• 5:22
  just
• 5:22
  really
• 5:23
  too
• 5:23
  much.
• 5:24
  And
• 5:25
  so
• 5:25
  notice
• 5:25
  again
• 5:26
  and
• 5:26
  try
• 5:26
  to
• 5:26
  appreciate
• 5:27
  how
• 5:27
  different
• 5:27
  that
• 5:27
  is
• 5:28
  than
• 5:28
  just
• 5:28
  happiness.
• 5:29
  Okay?
• 5:30
  Because
• 5:30
  a
• 5:30
  lot
• 5:30
  of
• 5:31
  patients,
• 5:31
  their
• 5:31
  only
• 5:32
  exposure
• 5:32
  to
• 5:32
  medications
• 5:33
  are
• 5:34
  drugs
• 5:34
  maybe
• 5:35
  they've
• 5:35
  used
• 5:35
  in
• 5:35
  college,
• 5:36
  right?
• 5:36
  It's
• 5:36
  almost
• 5:36
  this
• 5:37
  interchangeable
• 5:38
  nomenclature
• 5:39
  to
• 5:39
  them,
• 5:39
  drugs
• 5:40
  and
• 5:40
  meds.
• 5:41
  And
• 5:41
  they
• 5:41
  almost
• 5:42
  don't
• 5:43
  really
• 5:43
  make
• 5:44
  a
• 5:44
  distinction
• 5:44
  in
• 5:44
  their
• 5:45
  minds.
• 5:45
  And
• 5:45
  I
• 5:45
  don't
• 5:45
  blame
• 5:45
  them.
• 5:46
  Right.
• 5:46
  Not
• 5:46
  every
• 5:46
  patient
• 5:47
  you
• 5:47
  meet
• 5:47
  is
• 5:47
  like
• 5:47
  a
• 5:47
  psychopharmacologist.
• 5:49
  They
• 5:49
  don't
• 5:49
  know
• 5:49
  this
• 5:50
  stuff.
• 5:50
  So
• 5:50
  in
• 5:50
  their
• 5:51
  minds
• 5:51
  they're,
• 5:51
  you
• 5:51
  know,
• 5:52
  a
• 5:52
  lot
• 5:52
  of
• 5:52
  them
• 5:52
  will,
• 5:52
  will
• 5:52
  come
• 5:53
  to
• 5:53
  me
• 5:53
  and
• 5:53
  say,
• 5:53
  well
• 5:54
  npz,
• 5:54
  I've
• 5:55
  never
• 5:55
  taken,
• 5:55
  taken
• 5:55
  drugs
• 5:56
  before
• 5:56
  and
• 5:56
  it's
• 5:56
  almost
• 5:57
  like
• 5:57
  the
• 5:57
  word
• 5:57
  drug
• 5:58
  is
• 5:58
  this
• 5:58
  catch
• 5:59
  all
• 5:59
  for
• 5:59
  a
• 6:00
  thing
• 6:00
  that
• 6:00
  is
• 6:00
  supposed
• 6:01
  to
• 6:01
  just
• 6:01
  make
• 6:01
  me
• 6:01
  feel
• 6:02
  completely
• 6:02
  foreign.
• 6:03
  And
• 6:03
  that's
• 6:03
  not
• 6:03
  the
• 6:04
  case.
• 6:04
  Right.
• 6:04
  And
• 6:04
  when
• 6:05
  we
• 6:05
  appreciate
• 6:05
  what
• 6:06
  serotonin
• 6:06
  actually
• 6:07
  does,
• 6:07
  we
• 6:07
  can
• 6:07
  reinforce
• 6:08
  to
• 6:08
  the
• 6:08
  patient
• 6:08
  that
• 6:09
  hey,
• 6:09
  this
• 6:09
  isn't
• 6:09
  gonna
• 6:10
  turn
• 6:10
  you
• 6:10
  into
• 6:10
  a
• 6:10
  zombie.
• 6:11
  But
• 6:11
  no,
• 6:11
  this
• 6:12
  isn't
• 6:12
  about
• 6:12
  making
• 6:12
  you
• 6:13
  into
• 6:13
  a
• 6:13
  different
• 6:13
  person.
• 6:14
  This
• 6:14
  is
• 6:14
  about
• 6:14
  actually
• 6:15
  allowing
• 6:16
  you
• 6:16
  to
• 6:16
  be
• 6:16
  who
• 6:16
  you
• 6:16
  are
• 6:17
  underneath
• 6:17
  that
• 6:18
  noise.
• 6:18
  Right?
• 6:18
  Because
• 6:19
  right
• 6:19
  now,
• 6:19
  emotionally,
• 6:21
  your
• 6:21
  signaling
• 6:21
  is
• 6:21
  too
• 6:22
  intense
• 6:22
  and
• 6:22
  we
• 6:22
  need
• 6:23
  to
• 6:23
  put
• 6:23
  a
• 6:23
  break
• 6:23
  on
• 6:23
  that,
• 6:23
  we
• 6:24
  need
• 6:24
  to
• 6:24
  modulate
• 6:24
  it,
• 6:25
  okay?
• 6:25
  And
• 6:25
  so
• 6:26
  that's
• 6:26
  the
• 6:26
  role
• 6:26
  of
• 6:27
  serotonin,
• 6:28
  keeping
• 6:28
  things
• 6:29
  just
• 6:30
  steady
• 6:30
  enough
• 6:31
  where
• 6:31
  they're
• 6:31
  not
• 6:31
  overwhelming,
• 6:33
  okay.
• 6:33
  Where
• 6:33
  you
• 6:33
  just
• 6:34
  feel
• 6:34
  a
• 6:35
  little
• 6:35
  more
• 6:36
  in
• 6:36
  control
• 6:38
  and
• 6:38
  less
• 6:38
  hyper
• 6:39
  reactive
• 6:39
  on
• 6:40
  an
• 6:40
  emotional
• 6:40
  level
• 6:41
  and
• 6:42
  where
• 6:42
  you're
• 6:42
  able
• 6:42
  to
• 6:43
  better
• 6:43
  inhibit
• 6:44
  your
• 6:44
  ruminations
• 6:44
  and
• 6:45
  catastrophic
• 6:45
  thoughts
• 6:46
  or
• 6:46
  impulses,
• 6:46
  you
• 6:47
  know,
• 6:47
  whether
• 6:47
  you
• 6:47
  have
• 6:47
  an
• 6:48
  eating
• 6:48
  disorder,
• 6:48
  you're
• 6:48
  binging,
• 6:49
  right?
• 6:50
  So
• 6:50
  it's
• 6:50
  not
• 6:50
  just
• 6:50
  as,
• 6:51
  as
• 6:51
  simple
• 6:51
  as
• 6:51
  depression.
• 6:52
  If
• 6:52
  you
• 6:52
  have
• 6:53
  depression
• 6:53
  and
• 6:53
  you're
• 6:53
  ruminating
• 6:54
  about
• 6:54
  the
• 6:54
  past,
• 6:55
  which
• 6:55
  a
• 6:55
  lot
• 6:55
  of
• 6:56
  folks
• 6:56
  with
• 6:56
  depression
• 6:57
  do,
• 6:57
  again,
• 6:57
  serotonin
• 6:58
  is
• 6:58
  going
• 6:58
  to
• 6:58
  help
• 6:58
  modulate
• 6:59
  that,
• 6:59
  turn
• 6:59
  that
• 7:00
  down
• 7:00
  so
• 7:01
  it's
• 7:01
  not
• 7:01
  as
• 7:02
  much
• 7:02
  of
• 7:02
  a
• 7:02
  weight
• 7:03
  on
• 7:03
  your
• 7:03
  shoulders
• 7:04
  and
• 7:04
  it
• 7:04
  doesn't
• 7:04
  torment
• 7:05
  you
• 7:05
  as
• 7:05
  much
• 7:05
  and
• 7:06
  you're
• 7:06
  not
• 7:06
  so
• 7:06
  self
• 7:06
  critical.
• 7:07
  Right?
• 7:07
  Again,
• 7:08
  modulating
• 7:09
  your
• 7:09
  emotions,
• 7:10
  turning
• 7:11
  down
• 7:11
  that
• 7:11
  emotional
• 7:11
  volume,
• 7:12
  that
• 7:13
  is
• 7:13
  so
• 7:13
  key.
• 7:13
  And
• 7:13
  for
• 7:13
  a
• 7:14
  lot
• 7:14
  of
• 7:14
  people,
• 7:14
  that
• 7:15
  is
• 7:15
  the
• 7:15
  reason
• 7:15
  they're
• 7:16
  coming
• 7:16
  to
• 7:16
  you,
• 7:16
  right?
• 7:16
  Everything's
• 7:17
  too
• 7:17
  intense.
• 7:18
  So
• 7:18
  they
• 7:18
  welcome
• 7:19
  this,
• 7:19
  right?
• 7:19
  Absolutely
• 7:20
  welcome
• 7:20
  this.
• 7:21
  But
• 7:22
  again,
• 7:23
  remember
• 7:24
  though,
• 7:24
  and
• 7:24
  this
• 7:24
  is
• 7:25
  why
• 7:25
  we're,
• 7:26
  I'm
• 7:26
  emphasizing
• 7:27
  to
• 7:28
  not
• 7:28
  be
• 7:28
  so
• 7:28
  reductionist
• 7:29
  about
• 7:29
  serotonin,
• 7:30
  not
• 7:30
  only
• 7:30
  does
• 7:30
  it
• 7:31
  not
• 7:31
  just
• 7:31
  make
• 7:31
  you
• 7:32
  happy,
• 7:32
  because
• 7:32
  it
• 7:33
  doesn't
• 7:33
  really
• 7:33
  make
• 7:33
  you
• 7:33
  happy
• 7:34
  per
• 7:34
  se,
• 7:34
  it's
• 7:35
  just
• 7:35
  not
• 7:35
  the
• 7:35
  right
• 7:35
  word
• 7:36
  for
• 7:36
  it,
• 7:36
  but
• 7:36
  it's
• 7:37
  also
• 7:37
  not
• 7:37
  as
• 7:37
  simple
• 7:38
  as
• 7:38
  it
• 7:38
  does
• 7:38
  one
• 7:39
  thing,
• 7:39
  right?
• 7:39
  Serotonin,
• 7:40
  depending
• 7:41
  on
• 7:41
  where
• 7:41
  it's
• 7:41
  acting
• 7:42
  in
• 7:42
  the
• 7:42
  body,
• 7:43
  is
• 7:43
  gonna
• 7:43
  do
• 7:43
  many
• 7:44
  things
• 7:44
  at
• 7:44
  once,
• 7:44
  right?
• 7:45
  So
• 7:45
  when
• 7:45
  you
• 7:45
  give
• 7:45
  somebody
• 7:46
  a
• 7:46
  serotonergic
• 7:47
  medication,
• 7:47
  remember
• 7:48
  that
• 7:48
  that
• 7:48
  medication
• 7:49
  travels
• 7:50
  bloodstream
• 7:50
  and
• 7:51
  it's
• 7:51
  hitting
• 7:51
  different
• 7:51
  receptors.
• 7:52
  So
• 7:52
  it's
• 7:52
  opening
• 7:53
  new
• 7:53
  doors
• 7:53
  in
• 7:54
  various
• 7:54
  parts
• 7:54
  of
• 7:54
  the
• 7:55
  body
• 7:55
  or
• 7:55
  brain
• 7:56
  that
• 7:56
  exert
• 7:56
  a
• 7:57
  myriad
• 7:58
  amount
• 7:58
  of
• 7:58
  different
• 7:59
  consequences
• 8:00
  or
• 8:01
  therapeutic
• 8:02
  effects
• 8:02
  or
• 8:02
  actually
• 8:03
  adverse
• 8:03
  side
• 8:04
  effects,
• 8:04
  right?
• 8:05
  So
• 8:05
  when
• 8:05
  serotonin
• 8:06
  is
• 8:07
  stimulating
• 8:08
  those
• 8:08
  receptors,
• 8:08
  it
• 8:09
  could
• 8:09
  be
• 8:09
  very
• 8:09
  good.
• 8:09
  If
• 8:10
  that's
• 8:10
  a
• 8:10
  5ht1a
• 8:11
  receptor
• 8:11
  and
• 8:11
  it's
• 8:12
  calming,
• 8:12
  okay,
• 8:13
  that
• 8:13
  could
• 8:13
  be
• 8:13
  very
• 8:13
  good.
• 8:14
  Something
• 8:14
  like,
• 8:14
  you
• 8:14
  know,
• 8:15
  buspirone
• 8:15
  does
• 8:15
  that
• 8:16
  too,
• 8:16
  right?
• 8:16
  So,
• 8:17
  Sera,
• 8:17
  that
• 8:18
  could
• 8:18
  be
• 8:18
  a
• 8:18
  nice
• 8:18
  anxiolytic
• 8:19
  effect,
• 8:19
  but
• 8:19
  it
• 8:20
  could
• 8:20
  also
• 8:20
  be
• 8:20
  activating.
• 8:21
  If
• 8:21
  serotonin
• 8:22
  is
• 8:22
  stimulating
• 8:23
  the
• 8:23
  5ht2a
• 8:24
  receptor,
• 8:25
  right?
• 8:25
  That's
• 8:25
  what
• 8:25
  psychedelics
• 8:26
  do
• 8:26
  almost
• 8:26
  too
• 8:27
  intensely,
• 8:27
  where
• 8:28
  you're
• 8:28
  completely
• 8:28
  overwhelmed
• 8:29
  and
• 8:29
  maybe
• 8:29
  you
• 8:30
  have
• 8:30
  a
• 8:30
  trip
• 8:30
  and
• 8:30
  you're
• 8:30
  extremely
• 8:31
  anxious.
• 8:32
  Well,
• 8:32
  guess
• 8:32
  what?
• 8:33
  Serotonin
• 8:34
  medications
• 8:35
  like
• 8:35
  Zoloft
• 8:36
  and
• 8:36
  Prozac,
• 8:36
  they
• 8:37
  absolutely
• 8:38
  do.
• 8:38
  They,
• 8:39
  they
• 8:39
  can
• 8:39
  overstimulate
• 8:40
  that
• 8:40
  5ht2a
• 8:42
  receptor.
• 8:43
  And
• 8:43
  that's
• 8:43
  why
• 8:43
  people
• 8:43
  actually
• 8:44
  have
• 8:44
  worse
• 8:44
  anxiety
• 8:45
  before
• 8:45
  it
• 8:45
  even
• 8:45
  improves,
• 8:47
  right?
• 8:47
  They're,
• 8:47
  they're
• 8:48
  ruminating
• 8:48
  more
• 8:48
  at
• 8:49
  night.
• 8:49
  It's
• 8:49
  harder
• 8:49
  to
• 8:49
  sleep.
• 8:50
  They're
• 8:50
  just
• 8:50
  agitated
• 8:51
  and
• 8:51
  anxious.
• 8:52
  And
• 8:52
  so
• 8:52
  again,
• 8:53
  serotonin,
• 8:54
  is
• 8:54
  it
• 8:54
  good
• 8:54
  or
• 8:54
  bad?
• 8:54
  It
• 8:55
  depends.
• 8:55
  What
• 8:55
  receptor
• 8:56
  is
• 8:56
  it?
• 8:57
  Is
• 8:57
  it
• 8:57
  stimulating?
• 8:58
  Is
• 8:58
  that
• 8:58
  a
• 8:58
  desired
• 8:59
  effect
• 8:59
  in
• 8:59
  your
• 8:59
  particular
• 9:00
  patient?
• 9:01
  For
• 9:01
  most
• 9:01
  people
• 9:02
  that
• 9:02
  come
• 9:02
  here
• 9:02
  for
• 9:03
  anxiety
• 9:03
  or
• 9:03
  agitation
• 9:04
  or
• 9:04
  irritability,
• 9:05
  stimulating
• 9:06
  5ht
• 9:06
  2a
• 9:06
  is
• 9:07
  not
• 9:07
  as
• 9:07
  simple
• 9:08
  as.
• 9:08
  Well,
• 9:08
  that's
• 9:08
  good,
• 9:09
  right?
• 9:09
  They're
• 9:09
  actually
• 9:10
  pretty
• 9:10
  miserable.
• 9:10
  They
• 9:10
  might
• 9:11
  even
• 9:11
  need
• 9:11
  a
• 9:11
  benzodiazepine
• 9:12
  bridge
• 9:12
  for
• 9:13
  14
• 9:13
  days.
• 9:13
  Or
• 9:14
  you
• 9:14
  might
• 9:14
  need
• 9:14
  to
• 9:14
  slap
• 9:14
  Trazodone
• 9:15
  on
• 9:15
  there,
• 9:15
  which
• 9:16
  antagonizes
• 9:17
  5ht
• 9:17
  2a.
• 9:18
  We've
• 9:18
  gone
• 9:18
  over
• 9:18
  that
• 9:19
  extensively
• 9:19
  in
• 9:19
  past
• 9:20
  episodes.
• 9:20
  There's
• 9:20
  so
• 9:21
  much
• 9:21
  there
• 9:21
  that
• 9:22
  you
• 9:22
  need
• 9:22
  to
• 9:22
  know
• 9:22
  with
• 9:22
  respect
• 9:23
  to
• 9:23
  antipsychotics,
• 9:23
  antidepressants,
• 9:25
  what
• 9:25
  psychedelics
• 9:26
  are
• 9:26
  doing
• 9:26
  to
• 9:26
  the
• 9:26
  5ht
• 9:27
  2a
• 9:27
  and
• 9:27
  how
• 9:28
  that
• 9:28
  works.
• 9:28
  But
• 9:28
  suffice
• 9:28
  it
• 9:29
  to
• 9:29
  say,
• 9:29
  serotonin
• 9:30
  not
• 9:30
  always
• 9:31
  good.
• 9:32
  It
• 9:32
  depended
• 9:32
  where
• 9:33
  the
• 9:33
  effect
• 9:33
  is
• 9:33
  being
• 9:34
  exerted.
• 9:34
  It
• 9:35
  depends
• 9:35
  on
• 9:35
  which
• 9:36
  receptor,
• 9:36
  what
• 9:36
  part
• 9:36
  of
• 9:37
  the
• 9:37
  brain
• 9:37
  or
• 9:37
  what
• 9:37
  part
• 9:37
  of
• 9:37
  the
• 9:38
  body,
• 9:38
  right?
• 9:39
  Look
• 9:39
  at
• 9:40
  5ht2c,
• 9:42
  okay?
• 9:42
  If
• 9:43
  you
• 9:43
  blockade
• 9:44
  the
• 9:44
  5ht2c
• 9:45
  receptor
• 9:46
  with
• 9:46
  a
• 9:46
  serotonergic
• 9:47
  medication
• 9:48
  like
• 9:48
  Remeron,
• 9:49
  then
• 9:50
  you're
• 9:50
  actually
• 9:51
  causing
• 9:51
  weight
• 9:51
  gain,
• 9:52
  right?
• 9:53
  If
• 9:53
  you
• 9:54
  agonize
• 9:54
  that
• 9:54
  receptor,
• 9:55
  you
• 9:56
  have
• 9:56
  a
• 9:56
  little
• 9:56
  bit
• 9:56
  of
• 9:56
  appetite
• 9:57
  suppression.
• 9:58
  So
• 9:58
  again,
• 9:58
  good
• 9:58
  or
• 9:59
  bad,
• 9:59
  I
• 9:59
  don't
• 9:59
  know.
• 9:59
  But
• 10:00
  there's
• 10:00
  many
• 10:00
  different
• 10:01
  cool
• 10:01
  things
• 10:01
  that
• 10:01
  you
• 10:02
  can
• 10:02
  do.
• 10:02
  And
• 10:03
  if
• 10:03
  you
• 10:03
  target
• 10:03
  them
• 10:03
  wisely
• 10:04
  and
• 10:04
  you
• 10:04
  know,
• 10:04
  the
• 10:05
  affinity
• 10:05
  of
• 10:05
  your
• 10:05
  medications,
• 10:06
  like
• 10:06
  this
• 10:07
  medication
• 10:07
  has
• 10:07
  a
• 10:07
  high
• 10:08
  affinity
• 10:08
  for
• 10:09
  this
• 10:09
  receptor,
• 10:10
  well,
• 10:10
  then
• 10:10
  you
• 10:11
  actually
• 10:11
  have
• 10:12
  a
• 10:12
  lot
• 10:12
  more
• 10:12
  power
• 10:13
  as
• 10:13
  a
• 10:13
  prescriber
• 10:14
  because
• 10:14
  you
• 10:14
  can
• 10:14
  exert
• 10:15
  the
• 10:15
  effects
• 10:15
  that
• 10:15
  are
• 10:16
  intended
• 10:17
  based
• 10:17
  on
• 10:17
  your
• 10:17
  knowledge
• 10:18
  of
• 10:18
  those
• 10:18
  receptors.
• 10:19
  Right.
• 10:19
  If
• 10:19
  a
• 10:19
  patient
• 10:20
  is
• 10:20
  too
• 10:21
  stimulated
• 10:21
  and
• 10:22
  anxious
• 10:22
  and
• 10:23
  has
• 10:23
  insomnia
• 10:23
  by.
• 10:24
  Because
• 10:24
  you
• 10:25
  started
• 10:25
  Zoloft
• 10:25
  and
• 10:26
  it
• 10:26
  agonized
• 10:26
  the
• 10:27
  5ht2a
• 10:27
  receptor,
• 10:28
  well,
• 10:28
  remeron
• 10:29
  is
• 10:29
  a
• 10:29
  nice
• 10:29
  counter
• 10:30
  to
• 10:30
  that.
• 10:30
  So
• 10:30
  is
• 10:30
  Trazodone.
• 10:31
  It's
• 10:31
  a
• 10:31
  nice
• 10:31
  counter
• 10:32
  to
• 10:32
  that.
• 10:32
  It
• 10:33
  directly
• 10:33
  acts
• 10:33
  on
• 10:33
  that
• 10:34
  receptor
• 10:34
  to
• 10:34
  help
• 10:35
  make
• 10:35
  people
• 10:35
  not
• 10:36
  as
• 10:36
  anxious
• 10:36
  as
• 10:37
  they're
• 10:37
  trying
• 10:37
  to
• 10:37
  go
• 10:37
  to
• 10:37
  sleep
• 10:38
  at
• 10:38
  night.
• 10:38
  That's
• 10:38
  a
• 10:38
  big
• 10:39
  win.
• 10:39
  5Ht
• 10:40
  2a.
• 10:40
  Right?
• 10:41
  So
• 10:41
  again,
• 10:41
  it
• 10:42
  all
• 10:42
  matters.
• 10:42
  And
• 10:42
  remember,
• 10:43
  95%
• 10:43
  of
• 10:44
  your
• 10:44
  serotonin
• 10:45
  is
• 10:45
  produced
• 10:45
  in
• 10:45
  the
• 10:45
  gut,
• 10:46
  not
• 10:46
  in
• 10:46
  the
• 10:47
  brain.
• 10:47
  Okay.
• 10:48
  That
• 10:48
  peripheral
• 10:49
  serotonin
• 10:49
  cannot
• 10:50
  cross
• 10:50
  the
• 10:50
  blood
• 10:50
  brain
• 10:51
  barrier.
• 10:51
  Okay?
• 10:52
  So
• 10:52
  the
• 10:52
  central
• 10:53
  and
• 10:53
  peripheral
• 10:53
  pools
• 10:54
  of
• 10:54
  serotonin
• 10:55
  are
• 10:55
  functionally
• 10:55
  separate.
• 10:56
  Okay?
• 10:57
  But
• 10:57
  that
• 10:57
  explains
• 10:58
  why
• 10:58
  you
• 10:59
  have
• 10:59
  these
• 10:59
  GI
• 10:59
  side
• 11:00
  effect
• 11:00
  profile
• 11:00
  of
• 11:01
  SSRIs,
• 11:02
  right?
• 11:02
  You
• 11:02
  might
• 11:02
  wonder,
• 11:03
  like,
• 11:03
  wait
• 11:03
  a
• 11:03
  minute,
• 11:03
  why
• 11:03
  am
• 11:04
  I,
• 11:04
  I'm
• 11:04
  giving
• 11:04
  an
• 11:04
  ssri
• 11:05
  and
• 11:05
  the
• 11:05
  patient
• 11:05
  has
• 11:05
  loose
• 11:06
  stools
• 11:07
  and,
• 11:07
  and
• 11:07
  they're
• 11:07
  nauseous
• 11:08
  and
• 11:08
  they,
• 11:08
  and
• 11:09
  they
• 11:09
  have
• 11:09
  cramping.
• 11:10
  Like,
• 11:10
  what's
• 11:10
  going
• 11:10
  on?
• 11:10
  Well,
• 11:11
  because
• 11:11
  again,
• 11:11
  serotonin
• 11:12
  is
• 11:12
  neither
• 11:13
  good
• 11:13
  nor
• 11:13
  bad.
• 11:14
  It's
• 11:14
  not
• 11:14
  about
• 11:14
  too
• 11:14
  little,
• 11:15
  too
• 11:15
  much
• 11:16
  all
• 11:16
  the
• 11:16
  time.
• 11:16
  It's
• 11:17
  about,
• 11:17
  where.
• 11:17
  Where
• 11:18
  are
• 11:18
  you
• 11:18
  doing
• 11:18
  this?
• 11:18
  Well,
• 11:19
  there's
• 11:19
  a
• 11:19
  lot
• 11:19
  of
• 11:19
  serotonin
• 11:20
  receptors
• 11:21
  in
• 11:21
  the
• 11:22
  gut,
• 11:22
  five
• 11:23
  H
• 11:23
  T3
• 11:24
  receptors
• 11:24
  in
• 11:24
  particular.
• 11:25
  Okay.
• 11:26
  And
• 11:27
  so
• 11:27
  if
• 11:27
  you
• 11:27
  stimulate
• 11:28
  those,
• 11:28
  you
• 11:28
  can
• 11:28
  cause
• 11:29
  nausea,
• 11:29
  diarrhea
• 11:30
  and
• 11:30
  cramping,
• 11:30
  especially
• 11:31
  in
• 11:31
  the
• 11:31
  very
• 11:31
  beginning.
• 11:32
  Okay.
• 11:33
  And
• 11:33
  those
• 11:34
  are
• 11:34
  pharmacologically
• 11:35
  predictable.
• 11:36
  Okay.
• 11:36
  They
• 11:36
  take
• 11:37
  time
• 11:37
  to
• 11:37
  resolve
• 11:37
  as
• 11:38
  your,
• 11:38
  you
• 11:38
  know,
• 11:38
  brain
• 11:38
  and
• 11:39
  body
• 11:39
  kind
• 11:39
  of
• 11:39
  habituate
• 11:40
  to
• 11:40
  those
• 11:40
  effects.
• 11:41
  But
• 11:41
  again,
• 11:41
  it
• 11:41
  gives
• 11:42
  you
• 11:42
  an
• 11:42
  appreciation
• 11:42
  for
• 11:43
  the
• 11:43
  fact
• 11:43
  that
• 11:43
  serotonin
• 11:44
  is
• 11:44
  not
• 11:44
  this
• 11:44
  one
• 11:44
  dimensional
• 11:45
  thing.
• 11:45
  And
• 11:45
  when
• 11:46
  you
• 11:46
  prescribe,
• 11:47
  you
• 11:47
  have
• 11:47
  to
• 11:47
  really
• 11:47
  zoom
• 11:48
  out
• 11:48
  and
• 11:48
  think
• 11:48
  about
• 11:48
  all
• 11:49
  the
• 11:49
  things
• 11:49
  that
• 11:49
  you
• 11:50
  need
• 11:50
  to
• 11:50
  think
• 11:50
  about.
• 11:50
  And
• 11:51
  so
• 11:52
  anyway,
• 11:52
  I
• 11:52
  love
• 11:52
  that
• 11:52
  it
• 11:53
  kind
• 11:53
  of
• 11:53
  breaks
• 11:53
  things
• 11:54
  down
• 11:54
  very
• 11:54
  simply
• 11:54
  with
• 11:55
  respect
• 11:55
  to
• 11:55
  serotonin.
• 11:56
  And
• 11:57
  remember
• 11:57
  too,
• 11:58
  if
• 11:58
  you
• 11:58
  needed
• 11:59
  more
• 11:59
  proof
• 11:59
  that
• 11:59
  serotonin's
• 12:00
  either
• 12:00
  good
• 12:01
  or
• 12:01
  bad,
• 12:01
  it's
• 12:02
  neither
• 12:02
  good
• 12:02
  nor
• 12:02
  bad.
• 12:03
  Look
• 12:03
  at
• 12:03
  what
• 12:04
  happens
• 12:04
  when
• 12:04
  there's
• 12:04
  too
• 12:04
  much
• 12:04
  serotonin.
• 12:05
  We
• 12:05
  have
• 12:05
  an
• 12:05
  actual
• 12:06
  name
• 12:06
  for
• 12:06
  that
• 12:06
  serotonin
• 12:07
  syndrome,
• 12:08
  right?
• 12:08
  So
• 12:09
  it
• 12:09
  clearly
• 12:09
  isn't
• 12:10
  good
• 12:10
  when
• 12:10
  there's
• 12:10
  too
• 12:11
  much
• 12:11
  of
• 12:11
  it
• 12:11
  too
• 12:11
  quickly
• 12:12
  because
• 12:13
  you
• 12:14
  will
• 12:14
  potentially
• 12:15
  deal
• 12:15
  with
• 12:15
  serotonin
• 12:16
  syndrome.
• 12:17
  That's
• 12:17
  excess
• 12:17
  serotonergic
• 12:18
  activity,
• 12:18
  right?
• 12:19
  You
• 12:19
  have
• 12:19
  clonus
• 12:19
  hyperreflexia
• 12:20
  tremor,
• 12:21
  your
• 12:22
  blood
• 12:22
  pressure
• 12:22
  and
• 12:22
  heart
• 12:23
  rate
• 12:23
  can
• 12:23
  shoot
• 12:24
  up
• 12:24
  and
• 12:24
  your,
• 12:24
  your
• 12:25
  body
• 12:25
  tem,
• 12:25
  your
• 12:25
  core
• 12:25
  body
• 12:26
  temperature
• 12:26
  goes
• 12:26
  up,
• 12:26
  you're
• 12:27
  sweaty,
• 12:27
  you're
• 12:27
  confused,
• 12:27
  you're
• 12:28
  agitated
• 12:28
  and
• 12:28
  is
• 12:28
  a
• 12:29
  life
• 12:29
  threatening
• 12:30
  problem,
• 12:31
  especially
• 12:31
  if,
• 12:33
  you
• 12:33
  know,
• 12:33
  you
• 12:33
  combine
• 12:33
  Maois
• 12:34
  with
• 12:35
  SSRIs.
• 12:36
  So
• 12:36
  the
• 12:37
  key
• 12:37
  takeaway
• 12:37
  here
• 12:38
  is
• 12:38
  serotonin
• 12:38
  at
• 12:39
  optimal
• 12:39
  levels
• 12:40
  means
• 12:40
  emotional
• 12:40
  regulation.
• 12:41
  Serotonin
• 12:42
  in
• 12:42
  excess
• 12:43
  is
• 12:43
  a
• 12:43
  medical
• 12:43
  emergency
• 12:44
  and
• 12:45
  you
• 12:45
  want
• 12:45
  to
• 12:45
  target
• 12:45
  serotonin.
• 12:46
  When
• 12:46
  you
• 12:46
  have
• 12:46
  a
• 12:46
  patient
• 12:47
  in
• 12:47
  front
• 12:47
  of
• 12:47
  you
• 12:47
  who
• 12:48
  has
• 12:48
  that
• 12:48
  emotional
• 12:49
  temperament,
• 12:50
  that's
• 12:50
  just
• 12:50
  too
• 12:50
  much
• 12:50
  for
• 12:50
  them.
• 12:51
  It's
• 12:51
  too
• 12:51
  overwhelming,
• 12:52
  they're
• 12:52
  too
• 12:52
  anxious,
• 12:53
  they're
• 12:53
  too
• 12:53
  tearful,
• 12:54
  they're
• 12:54
  ruminating,
• 12:54
  they're
• 12:55
  obsessing,
• 12:55
  they're
• 12:55
  irritable,
• 12:56
  they're
• 12:57
  emotionally
• 12:58
  reactive,
• 12:58
  maybe
• 12:58
  they're
• 12:59
  panicked,
• 12:59
  they
• 13:00
  can't
• 13:00
  control
• 13:00
  their
• 13:01
  impulses,
• 13:01
  they
• 13:01
  can't
• 13:02
  sleep.
• 13:02
  That
• 13:03
  excessive
• 13:04
  too
• 13:04
  much
• 13:04
  signal
• 13:05
  intensity
• 13:05
  is
• 13:06
  exactly
• 13:06
  what
• 13:07
  you
• 13:07
  want
• 13:07
  to
• 13:07
  target
• 13:08
  when
• 13:08
  you
• 13:08
  are
• 13:09
  talking
• 13:09
  about
• 13:09
  serotonin.
• 13:10
  Now
• 13:10
  the
• 13:11
  opposite
• 13:11
  of
• 13:11
  that
• 13:11
  is
• 13:12
  really
• 13:12
  dopamine.
• 13:12
  Now
• 13:12
  dopamine
• 13:13
  is
• 13:13
  also
• 13:13
  kind
• 13:14
  of
• 13:14
  bastardized
• 13:15
  in
• 13:15
  pop
• 13:15
  culture
• 13:16
  as
• 13:16
  like
• 13:16
  happy
• 13:16
  dopamine
• 13:17
  equals
• 13:17
  happy.
• 13:18
  Well,
• 13:18
  dopamine
• 13:19
  also
• 13:20
  equals
• 13:20
  psychosis
• 13:21
  if
• 13:21
  there's
• 13:22
  too
• 13:22
  much
• 13:22
  of
• 13:22
  it
• 13:22
  on
• 13:23
  board.
• 13:23
  And
• 13:24
  serotonin
• 13:24
  can
• 13:25
  also
• 13:25
  be
• 13:25
  considered
• 13:26
  the
• 13:26
  diarrhea
• 13:27
  neurotransmitter
• 13:28
  just
• 13:28
  as
• 13:28
  much
• 13:28
  it
• 13:28
  can
• 13:29
  be
• 13:29
  considered
• 13:29
  the,
• 13:30
  the
• 13:31
  happy,
• 13:32
  happy
• 13:32
  neurotransmitter.
• 13:33
  I
• 13:34
  mean
• 13:34
  it,
• 13:34
  it
• 13:34
  makes
• 13:35
  sense
• 13:35
  if
• 13:35
  you're
• 13:35
  happy
• 13:35
  because
• 13:36
  you're
• 13:36
  more
• 13:36
  emotionally
• 13:37
  regulated.
• 13:38
  I
• 13:38
  get
• 13:38
  that.
• 13:38
  But
• 13:39
  again,
• 13:39
  it
• 13:39
  could
• 13:39
  also
• 13:39
  be
• 13:39
  called
• 13:40
  the
• 13:40
  diarrhea
• 13:41
  neurotransmitter
• 13:42
  just
• 13:42
  as
• 13:43
  often
• 13:43
  or
• 13:43
  just
• 13:44
  as
• 13:44
  much
• 13:45
  so.
• 13:45
  So
• 13:45
  think
• 13:45
  about
• 13:46
  that
• 13:46
  too,
• 13:46
  right?
• 13:46
  These
• 13:46
  are
• 13:47
  not
• 13:47
  just
• 13:47
  one
• 13:47
  dimensional
• 13:48
  characterizations.
• 13:49
  We
• 13:49
  have
• 13:49
  to
• 13:49
  put
• 13:50
  this
• 13:50
  all
• 13:50
  through
• 13:50
  a
• 13:50
  filter.
• 13:51
  Now
• 13:51
  dopamine
• 13:52
  is
• 13:52
  not
• 13:52
  really
• 13:52
  a
• 13:53
  pleasure
• 13:53
  chemical
• 13:54
  per
• 13:54
  se.
• 13:54
  That
• 13:54
  is
• 13:55
  again
• 13:55
  not
• 13:55
  doing
• 13:55
  it
• 13:55
  a
• 13:56
  justice.
• 13:56
  It
• 13:56
  is
• 13:56
  more
• 13:56
  about
• 13:57
  motivation,
• 13:58
  salience.
• 13:58
  So
• 13:59
  what's
• 13:59
  important
• 13:59
  to
• 14:00
  the
• 14:00
  patient?
• 14:00
  What
• 14:00
  motivates
• 14:01
  that
• 14:01
  person
• 14:01
  to
• 14:02
  a
• 14:02
  task
• 14:02
  to
• 14:02
  begin
• 14:03
  with?
• 14:04
  What
• 14:04
  is,
• 14:04
  what
• 14:04
  is
• 14:05
  something
• 14:06
  in
• 14:06
  their
• 14:06
  environment
• 14:06
  that
• 14:07
  deserves
• 14:07
  their
• 14:07
  attention.
• 14:08
  And
• 14:08
  it's
• 14:08
  also
• 14:09
  a
• 14:09
  prediction
• 14:10
  signal.
• 14:10
  Okay.
• 14:12
  It
• 14:12
  doesn't
• 14:12
  really
• 14:12
  create
• 14:12
  pleasure
• 14:13
  itself,
• 14:14
  but
• 14:14
  it
• 14:14
  rather
• 14:15
  encodes
• 14:16
  reward
• 14:17
  prediction
• 14:17
  errors.
• 14:18
  It
• 14:18
  means
• 14:18
  that
• 14:19
  a
• 14:20
  patient
• 14:21
  who
• 14:21
  gets
• 14:21
  a
• 14:21
  little
• 14:22
  bit
• 14:22
  of
• 14:22
  a
• 14:22
  dopaminergic
• 14:23
  boost
• 14:24
  is
• 14:24
  able
• 14:25
  to
• 14:26
  understand
• 14:27
  the
• 14:27
  cause
• 14:27
  and
• 14:28
  effect
• 14:28
  of
• 14:29
  a
• 14:29
  particular
• 14:29
  action
• 14:30
  so
• 14:31
  that
• 14:31
  it
• 14:31
  is
• 14:31
  tethered
• 14:32
  to
• 14:32
  a
• 14:33
  reward
• 14:33
  or
• 14:34
  a
• 14:34
  signal.
• 14:34
  And
• 14:34
  in
• 14:35
  the
• 14:35
  absence
• 14:35
  of
• 14:35
  dopamine,
• 14:36
  that's
• 14:36
  a
• 14:36
  lot
• 14:36
  harder,
• 14:37
  right?
• 14:37
  Patients
• 14:37
  don't
• 14:38
  intuitively
• 14:38
  see
• 14:38
  the
• 14:39
  point
• 14:39
  of
• 14:39
  getting
• 14:40
  something
• 14:40
  done.
• 14:40
  Even
• 14:41
  something
• 14:41
  simple
• 14:41
  as
• 14:42
  doing
• 14:42
  the
• 14:42
  laundry
• 14:43
  might
• 14:43
  give
• 14:43
  you
• 14:43
  a
• 14:43
  sense
• 14:43
  of
• 14:44
  achievement
• 14:44
  and
• 14:45
  a
• 14:45
  sense
• 14:45
  of
• 14:45
  pleasure
• 14:46
  or,
• 14:46
  and
• 14:46
  it
• 14:46
  might
• 14:46
  motivate
• 14:47
  you
• 14:47
  to
• 14:47
  do
• 14:47
  it
• 14:47
  and
• 14:48
  achieve
• 14:48
  it,
• 14:48
  and
• 14:48
  it
• 14:48
  might
• 14:49
  give
• 14:49
  you
• 14:49
  a
• 14:49
  sense
• 14:49
  of
• 14:49
  pleasure
• 14:50
  thereafter
• 14:51
  by,
• 14:51
  or
• 14:52
  even
• 14:52
  before
• 14:52
  by
• 14:53
  just
• 14:53
  trying
• 14:53
  to
• 14:54
  do
• 14:54
  the
• 14:54
  task
• 14:54
  itself.
• 14:55
  The
• 14:55
  reward
• 14:56
  and
• 14:56
  motivation
• 14:57
  circuits
• 14:58
  are
• 14:58
  not
• 14:58
  functioning
• 14:59
  as
• 15:00
  optimally
• 15:00
  as
• 15:01
  somebody
• 15:01
  with
• 15:02
  a
• 15:02
  no
• 15:02
  normal
• 15:03
  dopaminergic
• 15:04
  tone
• 15:04
  in
• 15:04
  those
• 15:04
  specific
• 15:05
  brain
• 15:05
  areas.
• 15:06
  So
• 15:06
  you
• 15:06
  can
• 15:06
  imagine
• 15:07
  they're
• 15:07
  not
• 15:07
  going
• 15:07
  to
• 15:07
  be
• 15:08
  able
• 15:08
  to
• 15:08
  experience
• 15:08
  much
• 15:09
  pleasure
• 15:09
  or
• 15:09
  motivation
• 15:10
  from
• 15:11
  doing
• 15:11
  much
• 15:11
  because
• 15:12
  they
• 15:12
  don't
• 15:12
  really
• 15:13
  see
• 15:13
  the
• 15:13
  point
• 15:14
  in
• 15:14
  motivating
• 15:15
  to
• 15:15
  a
• 15:15
  task.
• 15:15
  And
• 15:15
  those
• 15:16
  tasks
• 15:16
  aren't
• 15:16
  very
• 15:17
  salient
• 15:17
  to
• 15:17
  them
• 15:18
  or
• 15:18
  important
• 15:18
  to
• 15:18
  them
• 15:19
  intrinsically
• 15:20
  to
• 15:20
  get
• 15:20
  something
• 15:21
  done.
• 15:21
  And
• 15:22
  therefore
• 15:22
  what's
• 15:22
  the
• 15:23
  point,
• 15:23
  right?
• 15:23
  If
• 15:24
  you
• 15:24
  never
• 15:24
  had
• 15:24
  a
• 15:25
  reason
• 15:25
  to
• 15:25
  actually
• 15:26
  do
• 15:26
  something,
• 15:27
  why
• 15:27
  would
• 15:27
  you
• 15:27
  do
• 15:27
  it?
• 15:28
  Right?
• 15:29
  All
• 15:29
  of
• 15:29
  us
• 15:29
  are
• 15:29
  intrinsically
• 15:30
  motivated
• 15:30
  for
• 15:30
  a
• 15:31
  certain
• 15:31
  reason.
• 15:31
  A
• 15:32
  desire
• 15:32
  to
• 15:32
  learn,
• 15:32
  a
• 15:33
  desire
• 15:33
  to
• 15:33
  connect,
• 15:34
  a
• 15:34
  desire
• 15:34
  to
• 15:34
  be
• 15:35
  praised,
• 15:35
  a
• 15:36
  desire
• 15:36
  to
• 15:36
  achieve
• 15:37
  and
• 15:37
  just
• 15:37
  have
• 15:38
  self
• 15:38
  efficacy.
• 15:39
  But
• 15:39
  if
• 15:39
  that's
• 15:39
  missing,
• 15:40
  the
• 15:40
  reward
• 15:41
  pathway
• 15:42
  that
• 15:42
  involves
• 15:43
  that
• 15:43
  feeling
• 15:44
  is
• 15:44
  missing
• 15:44
  or
• 15:45
  severed.
• 15:45
  You're
• 15:45
  not
• 15:45
  gonna
• 15:46
  really
• 15:46
  have
• 15:46
  the
• 15:46
  motivation
• 15:47
  to
• 15:47
  do
• 15:47
  anything,
• 15:48
  right?
• 15:48
  It's
• 15:49
  like,
• 15:49
  okay,
• 15:49
  you
• 15:49
  wanna
• 15:49
  be
• 15:50
  the
• 15:50
  world's
• 15:50
  best
• 15:50
  bowler
• 15:51
  in
• 15:51
  the
• 15:51
  world,
• 15:52
  but
• 15:52
  if
• 15:52
  this
• 15:53
  was
• 15:53
  like
• 15:53
  the
• 15:53
  Twilight
• 15:53
  Zone
• 15:54
  and
• 15:54
  you
• 15:54
  were
• 15:54
  the
• 15:54
  only
• 15:54
  one
• 15:55
  left
• 15:55
  in
• 15:55
  the
• 15:55
  world
• 15:55
  with
• 15:56
  a
• 15:56
  bunch
• 15:56
  of
• 15:56
  bowling
• 15:56
  pins,
• 15:57
  who
• 15:57
  really
• 15:57
  cares
• 15:58
  how
• 15:58
  good
• 15:58
  you
• 15:58
  are
• 15:58
  at
• 15:58
  bowling?
• 15:59
  No
• 15:59
  one's
• 15:59
  there
• 15:59
  to
• 16:00
  clap.
• 16:00
  You
• 16:00
  should
• 16:00
  be
• 16:01
  proud
• 16:01
  of
• 16:01
  yourself
• 16:01
  if
• 16:01
  you
• 16:03
  bowl
• 16:03
  like
• 16:03
  three
• 16:04
  strikes
• 16:04
  in
• 16:04
  a
• 16:04
  row,
• 16:05
  even
• 16:05
  if
• 16:05
  everyone
• 16:06
  else
• 16:06
  is
• 16:06
  dead
• 16:07
  and
• 16:07
  no
• 16:07
  one's
• 16:07
  clapping
• 16:08
  and
• 16:08
  no
• 16:08
  one
• 16:08
  cares
• 16:09
  about
• 16:09
  how
• 16:09
  good
• 16:09
  you
• 16:09
  are
• 16:09
  at
• 16:10
  bowling.
• 16:10
  But
• 16:10
  my
• 16:10
  greater
• 16:11
  point
• 16:11
  is
• 16:11
  like,
• 16:11
  what
• 16:12
  would
• 16:12
  be
• 16:12
  the
• 16:12
  motivation
• 16:13
  if
• 16:13
  no
• 16:13
  one
• 16:13
  ever
• 16:14
  cared
• 16:14
  and
• 16:15
  no
• 16:15
  one
• 16:15
  was
• 16:15
  there
• 16:16
  to
• 16:16
  to
• 16:17
  even
• 16:18
  validate
• 16:18
  your
• 16:18
  sense
• 16:19
  of
• 16:19
  achievement,
• 16:19
  right?
• 16:20
  And
• 16:20
  maybe
• 16:20
  you
• 16:20
  don't
• 16:21
  even
• 16:21
  have
• 16:21
  that
• 16:21
  internal
• 16:22
  sense
• 16:22
  of
• 16:23
  motivation
• 16:24
  or,
• 16:24
  or
• 16:25
  a
• 16:25
  sense
• 16:25
  of
• 16:25
  achieving
• 16:26
  anything
• 16:26
  where
• 16:27
  a
• 16:27
  reward
• 16:27
  would
• 16:27
  benefit
• 16:28
  you
• 16:28
  or
• 16:28
  mean
• 16:28
  anything
• 16:29
  to
• 16:29
  you,
• 16:29
  right?
• 16:29
  So
• 16:30
  in
• 16:30
  these
• 16:30
  states
• 16:30
  where
• 16:30
  a
• 16:31
  patient
• 16:31
  just
• 16:31
  doesn't
• 16:32
  have
• 16:32
  a
• 16:32
  lot
• 16:32
  of
• 16:32
  motivation
• 16:33
  to
• 16:33
  do
• 16:33
  anything,
• 16:33
  doesn't
• 16:34
  get
• 16:34
  a
• 16:34
  lot
• 16:34
  of
• 16:34
  joy
• 16:35
  out
• 16:35
  of
• 16:35
  anything
• 16:35
  that
• 16:36
  happens,
• 16:36
  and
• 16:37
  as
• 16:37
  a
• 16:37
  result
• 16:38
  is
• 16:39
  just
• 16:39
  sort
• 16:39
  of
• 16:39
  negatively
• 16:40
  reinforced
• 16:40
  where
• 16:40
  they
• 16:41
  don't
• 16:41
  really
• 16:41
  do
• 16:41
  much,
• 16:42
  I
• 16:42
  would
• 16:42
  absolutely
• 16:43
  start
• 16:44
  to
• 16:44
  target
• 16:44
  the
• 16:45
  dopamine
• 16:45
  receptor.
• 16:46
  Notice
• 16:46
  how
• 16:46
  that
• 16:46
  is
• 16:46
  so
• 16:47
  different
• 16:47
  than
• 16:47
  what
• 16:48
  we
• 16:48
  just
• 16:48
  explained
• 16:49
  experience
• 16:49
  with
• 16:49
  serotonin,
• 16:50
  right?
• 16:50
  You
• 16:51
  see
• 16:51
  qualitatively
• 16:52
  different
• 16:52
  experiences,
• 16:53
  lack
• 16:53
  of
• 16:53
  motivation,
• 16:54
  lack
• 16:55
  of
• 16:55
  joy,
• 16:55
  lack
• 16:56
  of
• 16:56
  ability
• 16:56
  to
• 16:57
  really
• 16:57
  initiate
• 16:57
  to
• 16:57
  a
• 16:58
  task,
• 16:58
  to
• 16:58
  get
• 16:58
  something
• 16:59
  done.
• 16:59
  That
• 17:00
  is
• 17:00
  so
• 17:01
  different.
• 17:02
  And
• 17:02
  we
• 17:02
  are
• 17:03
  talking
• 17:03
  sometimes
• 17:04
  about
• 17:04
  different
• 17:04
  brain
• 17:04
  regions,
• 17:05
  Right?
• 17:05
  Right
• 17:05
  now
• 17:05
  we're
• 17:05
  probably
• 17:06
  talking
• 17:06
  about
• 17:06
  the
• 17:06
  mesolimbic
• 17:07
  dopamine
• 17:08
  hypo
• 17:09
  function.
• 17:10
  And
• 17:10
  this
• 17:10
  is
• 17:10
  not
• 17:10
  really
• 17:11
  like
• 17:11
  a
• 17:11
  serotonin
• 17:12
  deficiency.
• 17:12
  This
• 17:13
  is
• 17:13
  a
• 17:13
  different
• 17:13
  issue.
• 17:14
  Right?
• 17:14
  In
• 17:15
  serotonin,
• 17:15
  with
• 17:15
  serotonergic
• 17:16
  meds,
• 17:16
  we're
• 17:17
  targeting
• 17:17
  the
• 17:17
  amygdala,
• 17:18
  oftentimes
• 17:18
  or
• 17:18
  the
• 17:18
  hippocampus.
• 17:19
  Okay.
• 17:20
  Or
• 17:20
  maybe
• 17:20
  the
• 17:20
  parts
• 17:21
  of
• 17:21
  the
• 17:21
  hypothalamus
• 17:22
  if
• 17:22
  we're
• 17:23
  dealing
• 17:23
  with
• 17:23
  impulsivity.
• 17:24
  But
• 17:24
  here
• 17:25
  we're
• 17:25
  targeting
• 17:25
  dopamine,
• 17:26
  anhedonia,
• 17:27
  the
• 17:27
  core
• 17:28
  symptom,
• 17:28
  I
• 17:28
  would
• 17:28
  argue,
• 17:29
  that
• 17:29
  distinguishes
• 17:31
  your
• 17:31
  ability
• 17:32
  to
• 17:33
  prescribe
• 17:33
  a
• 17:34
  dopamine
• 17:34
  medication
• 17:35
  or
• 17:35
  serotonin
• 17:36
  medication
• 17:36
  would
• 17:36
  be
• 17:37
  anhedonia.
• 17:37
  If
• 17:37
  your
• 17:38
  patient
• 17:38
  just
• 17:38
  can't
• 17:38
  get
• 17:38
  joy
• 17:39
  out
• 17:39
  of
• 17:39
  anything.
• 17:39
  If
• 17:40
  your
• 17:40
  patients
• 17:40
  tried
• 17:40
  an
• 17:40
  SSRI
• 17:41
  and
• 17:41
  they're
• 17:41
  like,
• 17:41
  you
• 17:41
  know
• 17:42
  what?
• 17:42
  I,
• 17:42
  I'm
• 17:43
  not
• 17:43
  as
• 17:43
  emotionally
• 17:44
  reactive,
• 17:44
  impulsive,
• 17:45
  I'm
• 17:45
  agitated,
• 17:46
  but
• 17:46
  I
• 17:46
  just
• 17:46
  don't
• 17:47
  love
• 17:47
  my
• 17:47
  life.
• 17:47
  There's
• 17:48
  really
• 17:48
  nothing
• 17:48
  I'm
• 17:48
  excited
• 17:49
  to
• 17:49
  do.
• 17:49
  I
• 17:49
  don't
• 17:50
  have
• 17:50
  a
• 17:50
  lot
• 17:50
  of
• 17:50
  motivation.
• 17:50
  Well,
• 17:51
  my
• 17:51
  friends,
• 17:51
  that
• 17:51
  is
• 17:51
  your
• 17:52
  cue
• 17:52
  to
• 17:53
  look
• 17:53
  at
• 17:53
  a
• 17:53
  dopaminergic
• 17:54
  medication
• 17:55
  like
• 17:55
  Wellbutrin.
• 17:56
  Right?
• 17:56
  And
• 17:56
  oftentimes
• 17:57
  that
• 17:57
  is
• 17:57
  the,
• 17:58
  the
• 17:58
  next
• 17:58
  play,
• 17:59
  I
• 17:59
  often
• 17:59
  call
• 17:59
  it
• 18:00
  like
• 18:00
  the
• 18:00
  peanut
• 18:00
  butter
• 18:00
  and
• 18:00
  jelly
• 18:01
  of,
• 18:01
  of
• 18:01
  psychiatry
• 18:02
  is
• 18:02
  like
• 18:02
  Lexapro
• 18:03
  and
• 18:03
  Wellbutrin.
• 18:04
  Right?
• 18:04
  You
• 18:04
  have
• 18:04
  the
• 18:04
  serotonergic
• 18:05
  meds
• 18:05
  and
• 18:05
  the
• 18:05
  dopamine
• 18:06
  med.
• 18:06
  Okay?
• 18:07
  Very
• 18:07
  important.
• 18:09
  So
• 18:09
  that's
• 18:09
  your
• 18:09
  cue.
• 18:10
  Right?
• 18:10
  And
• 18:10
  sure
• 18:10
  enough,
• 18:11
  especially
• 18:11
  with
• 18:11
  treatment
• 18:12
  resistant
• 18:12
  depression,
• 18:13
  you
• 18:13
  have
• 18:14
  a
• 18:14
  very
• 18:14
  diverse
• 18:15
  phenotype
• 18:16
  of
• 18:16
  depression.
• 18:17
  It's
• 18:17
  not
• 18:17
  as
• 18:17
  simple
• 18:18
  as,
• 18:18
  oh,
• 18:18
  this
• 18:18
  is
• 18:18
  a
• 18:19
  perfect
• 18:19
  presentation
• 18:19
  for
• 18:20
  serotonin.
• 18:20
  We're
• 18:20
  going
• 18:20
  to
• 18:20
  solve
• 18:21
  all
• 18:21
  this
• 18:21
  person's
• 18:21
  problems
• 18:22
  and
• 18:22
  we're
• 18:22
  going
• 18:23
  to
• 18:23
  be
• 18:23
  good.
• 18:23
  No,
• 18:24
  there's
• 18:24
  usually
• 18:25
  a
• 18:26
  convergence
• 18:27
  of
• 18:28
  serotonergic
• 18:29
  modulation
• 18:30
  that
• 18:30
  needs
• 18:30
  to
• 18:30
  take
• 18:31
  place
• 18:31
  and
• 18:32
  dopaminergic
• 18:33
  modulation
• 18:33
  because
• 18:34
  a
• 18:34
  patient
• 18:34
  is
• 18:35
  both
• 18:35
  agitated,
• 18:36
  anxious
• 18:36
  and
• 18:37
  obsessive.
• 18:38
  But
• 18:38
  they
• 18:38
  also
• 18:38
  can't
• 18:39
  get
• 18:39
  a
• 18:39
  lot
• 18:39
  of
• 18:39
  joy
• 18:39
  out
• 18:40
  of
• 18:40
  things.
• 18:40
  Right?
• 18:41
  So
• 18:41
  it's.
• 18:42
  They're
• 18:42
  not
• 18:42
  really
• 18:42
  mutually
• 18:43
  exclusive.
• 18:43
  We
• 18:44
  have
• 18:44
  to
• 18:44
  often
• 18:44
  do
• 18:44
  the
• 18:45
  work
• 18:45
  across
• 18:46
  the
• 18:46
  board.
• 18:46
  So
• 18:47
  think
• 18:47
  about
• 18:47
  dopamine.
• 18:47
  And
• 18:48
  again,
• 18:48
  just
• 18:48
  like
• 18:48
  serotonin,
• 18:49
  it's
• 18:50
  not
• 18:50
  as
• 18:50
  simple
• 18:50
  as
• 18:51
  too
• 18:51
  much
• 18:51
  dopamine
• 18:52
  is.
• 18:52
  Or
• 18:52
  dopamine's
• 18:53
  either
• 18:53
  good
• 18:53
  or
• 18:54
  bad.
• 18:54
  No,
• 18:54
  too
• 18:55
  much
• 18:55
  dopamine
• 18:55
  means
• 18:56
  psychosis,
• 18:57
  a
• 18:57
  lot
• 18:57
  of
• 18:58
  stress,
• 18:58
  disorganized
• 18:59
  thinking,
• 18:59
  paranoia,
• 19:00
  stereotype
• 19:01
  behavior.
• 19:01
  Right.
• 19:01
  There
• 19:02
  are
• 19:02
  people
• 19:02
  on
• 19:03
  meth
• 19:03
  who,
• 19:03
  like,
• 19:03
  reassemble
• 19:04
  clocks
• 19:04
  all
• 19:05
  day.
• 20:00
  That's
• 20:00
  not
• 20:00
  healthy.
• 20:01
  Okay?
• 20:02
  Then
• 20:02
  there's
• 20:02
  people
• 20:03
  who
• 20:03
  have
• 20:03
  adhd,
• 20:04
  and
• 20:04
  they're
• 20:04
  under
• 20:04
  stimulated
• 20:05
  and.
• 20:06
  And
• 20:06
  they're
• 20:06
  distractable,
• 20:07
  and
• 20:07
  they
• 20:07
  don't
• 20:07
  know
• 20:07
  how
• 20:08
  to
• 20:08
  plan
• 20:08
  very
• 20:08
  well.
• 20:09
  And
• 20:09
  they're
• 20:09
  disorganized
• 20:10
  in
• 20:10
  their
• 20:10
  ability
• 20:10
  to
• 20:10
  even
• 20:11
  run
• 20:11
  errands
• 20:11
  and
• 20:11
  think
• 20:12
  clearly.
• 20:12
  So
• 20:13
  it's
• 20:13
  not
• 20:13
  about
• 20:14
  too
• 20:14
  little,
• 20:14
  too
• 20:14
  much.
• 20:15
  It's
• 20:15
  about
• 20:15
  an
• 20:15
  optimal
• 20:16
  amount
• 20:16
  of
• 20:16
  dopamine.
• 20:17
  Same
• 20:17
  with
• 20:17
  serotonin.
• 20:18
  Right?
• 20:18
  We
• 20:18
  want
• 20:19
  an
• 20:19
  optimal
• 20:19
  amount,
• 20:19
  and
• 20:20
  we
• 20:20
  want
• 20:20
  to
• 20:20
  target
• 20:20
  specific
• 20:21
  circuits,
• 20:22
  specific
• 20:22
  receptors
• 20:23
  to
• 20:23
  get
• 20:24
  that
• 20:24
  done.
• 20:25
  Now,
• 20:26
  norepinephrine
• 20:27
  is
• 20:27
  our
• 20:27
  third
• 20:27
  neurotransmitter,
• 20:29
  and
• 20:30
  norepinephrine
• 20:31
  is
• 20:31
  a
• 20:31
  very
• 20:32
  interesting
• 20:32
  one.
• 20:32
  I
• 20:32
  think
• 20:33
  it's
• 20:33
  a
• 20:33
  very
• 20:33
  underrated
• 20:34
  one,
• 20:34
  maybe
• 20:34
  a
• 20:34
  misunderstood
• 20:35
  one.
• 20:35
  And
• 20:36
  it
• 20:36
  took
• 20:36
  me
• 20:36
  some
• 20:36
  time
• 20:36
  to
• 20:36
  appreciate
• 20:37
  the
• 20:38
  significance
• 20:38
  of
• 20:38
  this
• 20:38
  neurotransmitter.
• 20:41
  But
• 20:42
  norepinephrine
• 20:43
  is
• 20:43
  really
• 20:44
  the
• 20:44
  brain's
• 20:44
  arousal
• 20:45
  and
• 20:45
  vigilance
• 20:46
  and
• 20:46
  signal
• 20:47
  detection
• 20:48
  system.
• 20:49
  It's
• 20:49
  sort
• 20:49
  of
• 20:49
  like
• 20:49
  a
• 20:49
  spotlight.
• 20:50
  Okay?
• 20:51
  It
• 20:51
  determines
• 20:51
  what
• 20:52
  gets
• 20:52
  your
• 20:52
  attention
• 20:53
  and
• 20:53
  how
• 20:53
  intensely
• 20:54
  that
• 20:54
  attention
• 20:55
  is
• 20:55
  focused.
• 20:56
  Okay?
• 20:57
  It's
• 20:57
  how
• 20:57
  alert
• 20:58
  you
• 20:58
  are.
• 20:58
  It's
• 20:58
  your
• 20:58
  ability
• 20:59
  to
• 20:59
  sustain
• 20:59
  attention,
• 21:00
  your
• 21:00
  working
• 21:00
  memory,
• 21:01
  and
• 21:02
  your
• 21:02
  overall
• 21:03
  stress
• 21:03
  response.
• 21:03
  And
• 21:04
  we
• 21:04
  see
• 21:04
  how
• 21:04
  this
• 21:04
  can
• 21:05
  run
• 21:05
  amok
• 21:05
  in,
• 21:05
  like,
• 21:05
  ptsd,
• 21:06
  where
• 21:07
  the
• 21:07
  noradrenergic
• 21:09
  activity
• 21:09
  is
• 21:10
  way
• 21:10
  too
• 21:11
  excessive.
• 21:11
  Right?
• 21:11
  People
• 21:12
  are
• 21:12
  having
• 21:12
  nightmares.
• 21:13
  They're
• 21:13
  just
• 21:14
  always
• 21:14
  on
• 21:15
  edge.
• 21:16
  And
• 21:16
  so
• 21:16
  too
• 21:16
  much
• 21:16
  of
• 21:16
  this
• 21:17
  is,
• 21:18
  like,
• 21:18
  flooding
• 21:19
  the
• 21:19
  system.
• 21:19
  And
• 21:19
  people
• 21:20
  are
• 21:20
  really
• 21:20
  hypervigilant
• 21:21
  and
• 21:21
  anxious
• 21:22
  and
• 21:22
  everything's
• 21:23
  threatening
• 21:23
  to
• 21:23
  them.
• 21:23
  Right?
• 21:23
  So
• 21:24
  we
• 21:24
  definitely
• 21:24
  don't
• 21:25
  want
• 21:25
  excessive
• 21:25
  norepinephrine
• 21:26
  activity.
• 21:27
  That's
• 21:28
  a
• 21:28
  problem.
• 21:28
  You
• 21:29
  have
• 21:29
  panic
• 21:30
  attacks,
• 21:30
  ptsd,
• 21:31
  hyperarousal,
• 21:32
  really
• 21:32
  anxious
• 21:32
  people
• 21:33
  with
• 21:33
  excessive
• 21:34
  norepinephrine
• 21:35
  activity.
• 21:36
  You
• 21:36
  want
• 21:36
  this,
• 21:36
  again
• 21:37
  to
• 21:37
  be
• 21:38
  kind
• 21:38
  of
• 21:38
  in
• 21:39
  a
• 21:39
  sweet
• 21:39
  spot,
• 21:39
  right?
• 21:40
  Where
• 21:41
  it's.
• 21:41
  It's
• 21:41
  right
• 21:41
  in
• 21:41
  the
• 21:42
  middle,
• 21:42
  where
• 21:42
  you
• 21:42
  have
• 21:42
  enough
• 21:42
  focus
• 21:43
  and
• 21:43
  arousal,
• 21:43
  where
• 21:44
  you
• 21:44
  can
• 21:44
  plan
• 21:44
  your
• 21:44
  day
• 21:45
  and
• 21:45
  you
• 21:45
  can
• 21:45
  encode
• 21:46
  memories
• 21:46
  properly
• 21:47
  and
• 21:47
  you're
• 21:48
  engaged
• 21:48
  and
• 21:48
  alert,
• 21:49
  but
• 21:49
  not
• 21:49
  to
• 21:50
  the
• 21:50
  point
• 21:50
  where
• 21:50
  everything
• 21:50
  is
• 21:51
  a
• 21:51
  threat
• 21:51
  around
• 21:51
  you.
• 21:52
  Right?
• 21:52
  And
• 21:53
  so
• 21:53
  you
• 21:53
  have
• 21:53
  to
• 21:53
  have
• 21:53
  an
• 21:54
  idea.
• 21:54
  Is
• 21:54
  your
• 21:54
  patient
• 21:55
  suffering
• 21:55
  from
• 21:56
  a
• 21:56
  hyperactivity
• 21:57
  of
• 21:58
  norepinephrine,
• 21:58
  like
• 21:59
  an
• 21:59
  overwhelming
• 21:59
  amount
• 22:00
  of
• 22:00
  norepinephrine
• 22:01
  in
• 22:01
  the
• 22:01
  wrong
• 22:01
  circuits,
• 22:02
  or
• 22:03
  is
• 22:03
  this
• 22:03
  more
• 22:03
  of
• 22:04
  a
• 22:04
  deficiency?
• 22:05
  Do
• 22:05
  I
• 22:05
  need
• 22:05
  to
• 22:05
  put
• 22:06
  an
• 22:06
  NDRI
• 22:07
  like
• 22:07
  Wellbutrin
• 22:07
  on
• 22:08
  board
• 22:08
  or
• 22:08
  an
• 22:08
  SNRI
• 22:09
  to
• 22:09
  compensate
• 22:10
  for
• 22:10
  the
• 22:10
  fact
• 22:10
  that
• 22:10
  they're
• 22:10
  very
• 22:11
  apathetic,
• 22:11
  they're
• 22:11
  fatigued.
• 22:12
  Maybe
• 22:12
  they
• 22:13
  have
• 22:13
  psychomotor
• 22:13
  retardation
• 22:14
  and
• 22:14
  depression
• 22:14
  where
• 22:15
  they're
• 22:15
  moving
• 22:15
  really
• 22:15
  slow,
• 22:15
  they
• 22:16
  can't
• 22:16
  concentrate.
• 22:17
  Right.
• 22:17
  That
• 22:17
  would
• 22:17
  be
• 22:18
  a
• 22:18
  good
• 22:18
  Idea
• 22:18
  then
• 22:18
  to
• 22:19
  recruit
• 22:19
  a,
• 22:20
  a,
• 22:20
  a
• 22:21
  medication
• 22:21
  that
• 22:22
  directly
• 22:23
  enhances
• 22:24
  that
• 22:25
  norepinephrine
• 22:26
  activity.
• 22:27
  Right.
• 22:27
  Like
• 22:27
  an
• 22:27
  snri.
• 22:28
  Okay.
• 22:29
  Notice
• 22:29
  how
• 22:29
  that's
• 22:29
  so
• 22:30
  distinct
• 22:30
  from
• 22:31
  serotonin.
• 22:31
  But
• 22:31
  the
• 22:32
  combination
• 22:32
  of
• 22:32
  the
• 22:32
  two
• 22:33
  could
• 22:33
  be
• 22:33
  really
• 22:34
  good
• 22:34
  if
• 22:34
  you
• 22:34
  can
• 22:35
  actually
• 22:35
  make
• 22:36
  sure
• 22:36
  that
• 22:37
  the
• 22:37
  norepinephrine
• 22:39
  activity
• 22:39
  is
• 22:39
  optimal.
• 22:40
  Right.
• 22:40
  It's
• 22:40
  not
• 22:41
  too
• 22:41
  much,
• 22:41
  it's
• 22:41
  not
• 22:41
  too
• 22:42
  little.
• 22:42
  So
• 22:42
  if
• 22:43
  somebody
• 22:43
  can
• 22:43
  wake
• 22:43
  up,
• 22:44
  they
• 22:44
  can
• 22:44
  focus,
• 22:44
  they
• 22:44
  can
• 22:45
  concentrate,
• 22:45
  they
• 22:45
  have
• 22:45
  the
• 22:45
  energy
• 22:46
  to
• 22:46
  start
• 22:46
  their
• 22:46
  day,
• 22:47
  which
• 22:47
  is
• 22:47
  very
• 22:48
  powerful
• 22:49
  in
• 22:49
  depression,
• 22:50
  to
• 22:50
  just
• 22:50
  being
• 22:50
  able
• 22:51
  to
• 22:51
  kind
• 22:51
  of
• 22:51
  focus
• 22:51
  your
• 22:52
  mind.
• 22:52
  I've
• 22:53
  noticed
• 22:53
  some
• 22:53
  of
• 22:53
  my
• 22:53
  patients
• 22:54
  when
• 22:54
  they're
• 22:55
  on
• 22:55
  SNRIs
• 22:56
  or
• 22:56
  even
• 22:56
  when
• 22:56
  they're
• 22:56
  on
• 22:56
  Wellbutrin,
• 22:57
  which
• 22:57
  isn't
• 22:57
  even
• 22:58
  prescribed
• 22:58
  for
• 22:59
  anxiety,
• 22:59
  they
• 22:59
  feel
• 23:00
  like
• 23:00
  they
• 23:00
  have
• 23:00
  more
• 23:01
  executive
• 23:01
  functioning
• 23:02
  where
• 23:02
  they're
• 23:02
  not
• 23:03
  ruminating
• 23:03
  as
• 23:03
  much
• 23:04
  because
• 23:04
  their
• 23:04
  mind
• 23:04
  is
• 23:04
  just
• 23:05
  a
• 23:05
  little
• 23:05
  bit
• 23:06
  more
• 23:06
  clear.
• 23:06
  And
• 23:07
  I
• 23:07
  suspect
• 23:07
  this
• 23:07
  is
• 23:08
  just
• 23:08
  my
• 23:08
  own
• 23:08
  suspicion
• 23:09
  wandering
• 23:10
  off
• 23:10
  the
• 23:10
  farm
• 23:10
  a
• 23:10
  little
• 23:11
  bit
• 23:11
  here.
• 23:11
  But
• 23:11
  I'm
• 23:11
  suspecting
• 23:12
  that
• 23:12
  the
• 23:12
  norepinephrine
• 23:14
  response
• 23:15
  is,
• 23:15
  is
• 23:15
  helping
• 23:16
  them
• 23:16
  in
• 23:16
  some
• 23:16
  way
• 23:16
  that
• 23:17
  they're
• 23:17
  able
• 23:17
  to
• 23:18
  pay
• 23:18
  attention
• 23:19
  and
• 23:19
  stay
• 23:19
  alert
• 23:20
  and
• 23:20
  ready
• 23:21
  and,
• 23:22
  and
• 23:22
  kind
• 23:22
  of
• 23:22
  think
• 23:23
  more
• 23:23
  clearly.
• 23:24
  Probably
• 23:24
  is
• 23:24
  also
• 23:25
  dopaminergic
• 23:26
  too.
• 23:26
  But
• 23:26
  I
• 23:26
  think
• 23:26
  they're
• 23:27
  able
• 23:27
  to
• 23:27
  focus
• 23:28
  and
• 23:28
  energize
• 23:29
  themselves
• 23:30
  towards
• 23:30
  a
• 23:30
  particular
• 23:31
  task
• 23:31
  which
• 23:32
  allows
• 23:32
  their
• 23:32
  mind
• 23:33
  to
• 23:33
  not
• 23:33
  run
• 23:33
  away
• 23:34
  so
• 23:34
  much
• 23:34
  in
• 23:34
  a
• 23:35
  kind
• 23:35
  of
• 23:35
  obsessive,
• 23:35
  ruminative,
• 23:36
  ruminative
• 23:37
  spiral.
• 23:38
  It's
• 23:38
  a
• 23:38
  little
• 23:38
  bit
• 23:38
  of
• 23:38
  a
• 23:38
  jump
• 23:39
  start,
• 23:39
  a
• 23:39
  little
• 23:39
  bit
• 23:39
  of
• 23:39
  a
• 23:40
  spark
• 23:40
  in
• 23:40
  your
• 23:41
  antidepressant
• 23:41
  than
• 23:42
  norepinephrine,
• 23:42
  which
• 23:43
  really
• 23:43
  helps
• 23:43
  because
• 23:44
  so
• 23:44
  many
• 23:44
  people
• 23:44
  do
• 23:44
  come
• 23:45
  to
• 23:45
  us
• 23:45
  very
• 23:45
  apathetic.
• 23:46
  They
• 23:46
  can't
• 23:46
  focus,
• 23:47
  they're
• 23:47
  fatigued,
• 23:47
  that
• 23:48
  brain
• 23:48
  fog.
• 23:49
  So
• 23:49
  if
• 23:49
  you
• 23:49
  need
• 23:49
  to
• 23:49
  jumpstart
• 23:50
  the
• 23:50
  engine
• 23:50
  a
• 23:51
  little
• 23:51
  bit,
• 23:51
  serotonin
• 23:52
  itself
• 23:52
  is
• 23:52
  not
• 23:53
  going
• 23:53
  to
• 23:53
  be
• 23:53
  that
• 23:54
  successful.
• 23:54
  You
• 23:55
  might
• 23:55
  turn
• 23:55
  down
• 23:55
  a
• 23:55
  lot
• 23:56
  of
• 23:56
  the
• 23:56
  noise
• 23:57
  and
• 23:57
  attenuate
• 23:58
  their
• 23:58
  emotional
• 23:59
  reactivity.
• 24:00
  But
• 24:00
  the
• 24:00
  norepinephrine
• 24:01
  is
• 24:01
  that
• 24:01
  little
• 24:01
  spark
• 24:02
  that
• 24:02
  you
• 24:02
  may
• 24:02
  need
• 24:02
  to
• 24:03
  include
• 24:03
  in
• 24:03
  the
• 24:04
  picture
• 24:04
  that
• 24:04
  could
• 24:04
  really
• 24:05
  help.
• 24:05
  Right.
• 24:06
  And
• 24:06
  I'm
• 24:06
  talking
• 24:06
  about
• 24:07
  an
• 24:07
  energy
• 24:07
  spark.
• 24:08
  I'm
• 24:08
  not
• 24:08
  talking
• 24:08
  about
• 24:09
  giving
• 24:09
  them
• 24:09
  more
• 24:10
  motivation
• 24:10
  like
• 24:10
  in
• 24:11
  dopamine,
• 24:11
  where
• 24:11
  they're
• 24:11
  intrinsically
• 24:12
  motivated
• 24:12
  to
• 24:13
  do
• 24:13
  something
• 24:13
  or
• 24:14
  they
• 24:14
  have
• 24:14
  more
• 24:14
  joy
• 24:14
  in
• 24:15
  doing
• 24:15
  it,
• 24:15
  which
• 24:15
  is
• 24:15
  great
• 24:16
  for
• 24:16
  dopamine.
• 24:16
  I'm
• 24:17
  talking
• 24:17
  about
• 24:17
  giving
• 24:17
  them
• 24:18
  the
• 24:18
  actual
• 24:18
  energy
• 24:19
  to
• 24:19
  do
• 24:20
  it.
• 24:20
  Okay.
• 24:21
  Where
• 24:21
  they
• 24:22
  can't
• 24:22
  concentrate,
• 24:23
  they
• 24:23
  can't
• 24:23
  focus,
• 24:23
  like
• 24:23
  you're
• 24:24
  giving
• 24:24
  them
• 24:24
  kind
• 24:25
  of
• 24:25
  a
• 24:25
  shot
• 24:25
  of
• 24:25
  adrenaline
• 24:26
  to
• 24:27
  make
• 24:27
  things
• 24:27
  happen.
• 24:28
  It's,
• 24:28
  to
• 24:28
  me,
• 24:28
  it's
• 24:29
  a
• 24:29
  very
• 24:29
  action
• 24:29
  oriented
• 24:30
  neurotransmitter
• 24:31
  as
• 24:31
  opposed
• 24:31
  to
• 24:31
  the
• 24:32
  other
• 24:32
  two,
• 24:32
  which
• 24:32
  seem
• 24:32
  to
• 24:33
  me
• 24:33
  a
• 24:33
  little
• 24:33
  more
• 24:33
  emotionally.
• 24:35
  Emotionally
• 24:35
  involved.
• 24:36
  Right.
• 24:36
  This
• 24:36
  one
• 24:37
  is
• 24:37
  like
• 24:37
  the
• 24:37
  actual
• 24:38
  juice
• 24:38
  or
• 24:38
  the
• 24:38
  fuel
• 24:39
  or
• 24:39
  the
• 24:39
  action.
• 24:40
  And
• 24:40
  so
• 24:40
  when
• 24:40
  you
• 24:41
  need
• 24:41
  that,
• 24:41
  it's
• 24:41
  very
• 24:42
  good
• 24:42
  to
• 24:42
  deploy,
• 24:43
  and
• 24:43
  it's
• 24:43
  just
• 24:44
  fundamentally
• 24:44
  different.
• 24:44
  Right.
• 24:45
  But,
• 24:45
  of
• 24:45
  course,
• 24:45
  you
• 24:45
  have
• 24:45
  to
• 24:46
  be
• 24:46
  careful,
• 24:46
  because
• 24:48
  it
• 24:49
  in.
• 24:49
  In
• 24:49
  excess,
• 24:49
  it
• 24:50
  can
• 24:50
  make
• 24:50
  people
• 24:50
  pretty
• 24:51
  anxious.
• 24:51
  Those
• 24:51
  are
• 24:52
  the
• 24:52
  folks
• 24:52
  who
• 24:52
  do
• 24:52
  take
• 24:53
  Wellbutrin,
• 24:54
  and
• 24:54
  they
• 24:54
  can't
• 24:54
  tolerate
• 24:54
  it.
• 24:55
  Maybe
• 24:55
  it's
• 24:55
  just
• 24:55
  too
• 24:55
  stimulating
• 24:56
  to
• 24:56
  them.
• 24:56
  Their
• 24:57
  norepinephrine
• 24:58
  response
• 24:59
  or
• 24:59
  activity
• 25:00
  is
• 25:00
  just
• 25:01
  too
• 25:01
  much
• 25:01
  for
• 25:01
  them,
• 25:02
  because,
• 25:02
  again,
• 25:02
  we
• 25:03
  need
• 25:03
  a
• 25:03
  little
• 25:03
  bit,
• 25:03
  but
• 25:04
  not
• 25:04
  too
• 25:04
  much.
• 25:04
  Every
• 25:04
  human
• 25:05
  needs
• 25:05
  a
• 25:05
  little
• 25:05
  bit,
• 25:06
  but
• 25:06
  not
• 25:06
  too
• 25:06
  much.
• 25:07
  And
• 25:07
  to
• 25:07
  understand
• 25:07
  these
• 25:08
  three
• 25:08
  neurotransmitters
• 25:09
  and
• 25:09
  to
• 25:10
  understand
• 25:10
  that,
• 25:11
  you
• 25:11
  know,
• 25:11
  that
• 25:11
  they're
• 25:12
  complex
• 25:13
  and
• 25:13
  fascinating
• 25:14
  and
• 25:15
  multilayered,
• 25:15
  and
• 25:16
  they
• 25:16
  hit
• 25:16
  different
• 25:16
  receptors
• 25:17
  in
• 25:17
  different
• 25:17
  ways,
• 25:17
  I
• 25:18
  think
• 25:18
  when
• 25:18
  we
• 25:18
  understand
• 25:18
  that,
• 25:19
  we
• 25:19
  can
• 25:19
  really
• 25:20
  empower
• 25:20
  our
• 25:20
  patients
• 25:21
  and
• 25:21
  educate
• 25:22
  them
• 25:22
  to
• 25:22
  understand
• 25:23
  why
• 25:23
  we're
• 25:23
  doing
• 25:24
  certain
• 25:24
  things,
• 25:25
  anticipate
• 25:25
  problems
• 25:26
  in
• 25:26
  advance
• 25:27
  so
• 25:27
  we
• 25:27
  can
• 25:27
  build
• 25:27
  trust
• 25:28
  and
• 25:29
  dodge
• 25:29
  bullets
• 25:30
  and
• 25:30
  really
• 25:30
  just
• 25:31
  walk
• 25:31
  our
• 25:31
  patients
• 25:32
  down
• 25:32
  the.
• 25:33
  Down
• 25:33
  the
• 25:33
  lane
• 25:34
  and
• 25:34
  successfully.
• 25:35
  I
• 25:35
  think
• 25:35
  that's
• 25:35
  just
• 25:36
  really
• 25:36
  important.
• 25:37
  And.
• 25:37
  And
• 25:38
  my
• 25:38
  friends,
• 25:38
  I
• 25:38
  can't
• 25:39
  emphasize
• 25:39
  enough.
• 25:40
  If
• 25:41
  you
• 25:41
  want
• 25:42
  to
• 25:42
  be
• 25:42
  the
• 25:42
  kind
• 25:42
  of
• 25:42
  clinician
• 25:43
  that
• 25:43
  doesn't
• 25:43
  just
• 25:44
  memorize
• 25:44
  spreadsheets
• 25:45
  and
• 25:45
  algorithms,
• 25:46
  you
• 25:46
  should
• 25:46
  definitely
• 25:47
  go
• 25:48
  to
• 25:48
  the
• 25:48
  Show
• 25:48
  Notes
• 25:48
  after
• 25:49
  this
• 25:49
  episode
• 25:49
  and
• 25:49
  become
• 25:50
  a
• 25:50
  Patreon
• 25:50
  member.
• 25:51
  Click
• 25:51
  our
• 25:51
  Show
• 25:52
  Notes.
• 25:52
  Become
• 25:52
  a
• 25:53
  Patreon
• 25:53
  member.
• 25:53
  Because
• 25:54
  patients
• 25:54
  can
• 25:54
  smell
• 25:55
  it
• 25:55
  a
• 25:55
  mile
• 25:55
  away.
• 25:56
  When
• 25:56
  you're
• 25:56
  just
• 25:56
  the
• 25:57
  prescriber
• 25:57
  who
• 25:58
  knows
• 25:58
  the
• 25:58
  algos,
• 25:59
  but
• 26:00
  you
• 26:00
  don't
• 26:00
  really
• 26:00
  know
• 26:00
  the
• 26:00
  how
• 26:01
  and
• 26:01
  the
• 26:01
  why,
• 26:01
  it
• 26:02
  really
• 26:02
  changes
• 26:03
  the
• 26:03
  way
• 26:03
  you
• 26:03
  practice.
• 26:03
  I
• 26:04
  would.
• 26:04
  I
• 26:04
  am
• 26:04
  genuinely
• 26:05
  terrified
• 26:05
  about
• 26:06
  where
• 26:06
  I
• 26:06
  would
• 26:06
  be
• 26:07
  if
• 26:07
  I
• 26:07
  didn't
• 26:07
  have
• 26:08
  my
• 26:08
  clinical
• 26:08
  library
• 26:09
  I
• 26:09
  built
• 26:10
  for
• 26:10
  everyone
• 26:11
  to
• 26:11
  go
• 26:11
  over
• 26:11
  this
• 26:11
  stuff
• 26:12
  and
• 26:12
  to
• 26:12
  understand
• 26:12
  it
• 26:13
  more
• 26:13
  cleanly
• 26:13
  and
• 26:13
  intuitive
• 26:14
  and
• 26:14
  beautiful.
• 26:15
  Intuitively
• 26:15
  and
• 26:15
  beautifully.
• 26:16
  I
• 26:16
  built
• 26:17
  that
• 26:17
  library.
• 26:18
  And
• 26:18
  again,
• 26:18
  I
• 26:19
  would
• 26:19
  be
• 26:19
  genuinely
• 26:20
  scared
• 26:20
  to
• 26:20
  know
• 26:21
  where
• 26:21
  I
• 26:21
  would
• 26:21
  be
• 26:21
  as
• 26:21
  a
• 26:22
  prescriber
• 26:23
  if
• 26:23
  we
• 26:23
  didn't
• 26:24
  have
• 26:24
  that
• 26:24
  library.
• 26:24
  And
• 26:25
  so
• 26:25
  we
• 26:25
  welcome
• 26:25
  you
• 26:25
  all.
• 26:25
  If
• 26:26
  there's
• 26:26
  one
• 26:26
  thing
• 26:26
  you
• 26:26
  don't
• 26:26
  forget
• 26:27
  tonight,
• 26:27
  get
• 26:27
  to
• 26:27
  our
• 26:27
  Show
• 26:28
  Notes
• 26:28
  and
• 26:28
  become
• 26:29
  a
• 26:29
  Patreon
• 26:29
  member.
• 26:30
  You're
• 26:30
  going
• 26:30
  to
• 26:30
  love
• 26:30
  it
• 26:31
  right
• 26:31
  away.
• 26:31
  It's
• 26:31
  a
• 26:31
  lot
• 26:32
  of
• 26:32
  fun.
• 26:32
  It's
• 26:33
  like
• 26:33
  nothing
• 26:33
  you've
• 26:34
  seen
• 26:34
  in
• 26:34
  psychiatry.
• 26:34
  It's
• 26:35
  really
• 26:35
  cool
• 26:35
  and
• 26:36
  sticky,
• 26:36
  and
• 26:37
  it's
• 26:37
  being
• 26:37
  built
• 26:38
  every
• 26:38
  week
• 26:38
  even
• 26:39
  more
• 26:39
  so.
• 26:39
  Anyhow,
• 26:40
  great
• 26:40
  to
• 26:41
  have
• 26:41
  all
• 26:41
  of
• 26:41
  you.
• 26:41
  Until
• 26:42
  next
• 26:42
  time
• 26:42
  here
• 26:42
  on
• 26:42
  Pearls
• 26:43
  and
• 26:43
  Prep.