Latest / Pearls and Prep / Have We Been Treating Only Half of Schizophrenia? Vraylar, D3 Dopamine, and the Symptoms That Quietly Ruin Functioning

Transcript

Have We Been Treating Only Half of Schizophrenia? Vraylar, D3 Dopamine, and the Symptoms That Quietly Ruin Functioning · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:05
  back,
• 0:05
  my
• 0:06
  friends,
• 0:06
  to
• 0:06
  another
• 0:07
  episode
• 0:07
  of
• 0:08
  Pearls
• 0:08
  and
• 0:09
  prep.
• 0:09
  This
• 0:09
  is
• 0:09
  NPC
• 0:10
  here,
• 0:10
  your
• 0:11
  preceptor
• 0:11
  in
• 0:11
  your
• 0:12
  pocket,
• 0:12
  your
• 0:12
  go
• 0:12
  to
• 0:12
  place
• 0:13
  for
• 0:13
  pearls
• 0:14
  that
• 0:14
  prep
• 0:14
  you
• 0:15
  to
• 0:15
  practice.
• 0:16
  Well,
• 0:16
  I
• 0:17
  am
• 0:17
  genuinely
• 0:18
  excited
• 0:18
  about
• 0:19
  this
• 0:19
  one
• 0:19
  because
• 0:20
  we
• 0:20
  are
• 0:21
  going
• 0:21
  to
• 0:21
  talk
• 0:21
  about
• 0:22
  schizophrenia.
• 0:23
  And
• 0:24
  one
• 0:24
  thing
• 0:24
  that
• 0:24
  is
• 0:25
  so
• 0:25
  overlooked
• 0:26
  in
• 0:26
  schizophrenia
• 0:27
  that
• 0:27
  we
• 0:27
  need
• 0:27
  to
• 0:27
  talk
• 0:27
  about
• 0:28
  it.
• 0:28
  We
• 0:28
  need
• 0:28
  to
• 0:28
  have
• 0:28
  a
• 0:28
  come
• 0:28
  to
• 0:29
  Jesus
• 0:29
  moment
• 0:29
  today.
• 0:30
  Not
• 0:30
  tomorrow,
• 0:31
  but
• 0:31
  today
• 0:33
  with
• 0:33
  respect
• 0:33
  to
• 0:34
  this
• 0:34
  issue,
• 0:34
  because
• 0:35
  again,
• 0:35
  it
• 0:35
  is
• 0:36
  so
• 0:36
  darn
• 0:37
  important.
• 0:38
  And
• 0:39
  that
• 0:39
  thing
• 0:39
  is
• 0:40
  negative
• 0:41
  symptoms
• 0:42
  in
• 0:42
  schizophrenia.
• 0:43
  We
• 0:44
  are
• 0:44
  so
• 0:44
  used
• 0:45
  to
• 0:45
  the
• 0:45
  positive
• 0:46
  symptoms
• 0:46
  in
• 0:47
  schizophrenia.
• 0:48
  The
• 0:48
  hallucinations.
• 0:49
  I'm
• 0:50
  seeing
• 0:50
  shadows,
• 0:51
  There's
• 0:51
  a
• 0:52
  devil
• 0:52
  on
• 0:52
  my
• 0:52
  shoulder,
• 0:53
  right?
• 0:54
  The
• 0:54
  delusions.
• 0:55
  The
• 0:55
  guy
• 0:56
  at
• 0:56
  the
• 0:56
  dollar
• 0:56
  tree
• 0:57
  is
• 0:57
  recording
• 0:57
  me
• 0:58
  and
• 0:58
  he
• 0:58
  wants
• 0:58
  to.
• 0:59
  He's
• 1:00
  going
• 1:00
  to
• 1:00
  chase
• 1:00
  me
• 1:01
  on
• 1:01
  my
• 1:02
  way
• 1:02
  home
• 1:02
  with
• 1:02
  a
• 1:03
  hunting
• 1:03
  knife,
• 1:03
  right?
• 1:04
  We're
• 1:04
  so
• 1:05
  caught
• 1:05
  up
• 1:05
  in
• 1:05
  the
• 1:05
  Hollywood
• 1:07
  theatrics
• 1:08
  of
• 1:08
  delusions
• 1:08
  and
• 1:08
  hallucinations,
• 1:09
  and
• 1:09
  guess
• 1:10
  what?
• 1:10
  We
• 1:10
  should
• 1:10
  be.
• 1:10
  Those
• 1:11
  are
• 1:11
  completely
• 1:11
  debilitating.
• 1:12
  They're
• 1:13
  awful.
• 1:13
  They're
• 1:14
  torture.
• 1:14
  I
• 1:14
  don't
• 1:15
  know
• 1:15
  if
• 1:15
  you
• 1:15
  all
• 1:15
  in
• 1:16
  your
• 1:16
  psychiatry
• 1:17
  rotations,
• 1:17
  you
• 1:18
  had
• 1:18
  to
• 1:18
  listen
• 1:19
  with
• 1:20
  headphones
• 1:20
  to
• 1:20
  a
• 1:20
  voice
• 1:21
  berate
• 1:21
  you
• 1:22
  and
• 1:22
  call
• 1:22
  you
• 1:22
  names
• 1:23
  as
• 1:23
  you
• 1:23
  were
• 1:23
  trying
• 1:24
  to
• 1:24
  read
• 1:24
  an
• 1:24
  article,
• 1:24
  right?
• 1:25
  That
• 1:25
  was
• 1:25
  one
• 1:25
  of
• 1:25
  the
• 1:25
  most
• 1:26
  effective
• 1:27
  teaching
• 1:28
  lessons
• 1:28
  I've
• 1:29
  ever
• 1:29
  experienced
• 1:29
  in
• 1:30
  my
• 1:30
  entire
• 1:31
  academic
• 1:31
  life.
• 1:32
  When
• 1:32
  you
• 1:33
  were
• 1:33
  trying
• 1:33
  to
• 1:33
  comprehend
• 1:34
  an
• 1:34
  article,
• 1:35
  I
• 1:35
  was
• 1:36
  reading
• 1:36
  an
• 1:36
  article
• 1:38
  about
• 1:38
  the
• 1:38
  Houston
• 1:39
  city
• 1:40
  budget,
• 1:40
  and
• 1:41
  there
• 1:41
  was
• 1:41
  this
• 1:41
  voice
• 1:42
  calling
• 1:42
  me
• 1:42
  names.
• 1:43
  He
• 1:43
  called
• 1:43
  me
• 1:43
  like
• 1:43
  a
• 1:44
  pig
• 1:44
  and
• 1:44
  a
• 1:44
  sloth
• 1:45
  and
• 1:45
  a
• 1:45
  goon.
• 1:46
  And
• 1:46
  I
• 1:46
  could
• 1:47
  not
• 1:47
  focus
• 1:48
  on
• 1:48
  the
• 1:49
  article
• 1:49
  in
• 1:49
  front
• 1:50
  of
• 1:50
  me.
• 1:50
  I
• 1:50
  barely
• 1:51
  even
• 1:51
  knew
• 1:51
  it
• 1:51
  was
• 1:51
  about
• 1:52
  Houston.
• 1:53
  That's
• 1:53
  about
• 1:53
  the
• 1:53
  only
• 1:53
  thing
• 1:53
  I
• 1:54
  really
• 1:54
  knew
• 1:54
  about
• 1:54
  it.
• 1:55
  And
• 1:55
  it
• 1:55
  was
• 1:56
  so
• 1:56
  important
• 1:57
  to
• 1:57
  me
• 1:58
  because
• 1:59
  it.
• 1:59
  It
• 2:00
  just
• 2:00
  spoke
• 2:00
  to
• 2:00
  what
• 2:01
  this
• 2:01
  disease
• 2:01
  process
• 2:02
  feels
• 2:02
  like
• 2:02
  for
• 2:03
  that
• 2:03
  fleeting
• 2:03
  moment.
• 2:04
  And
• 2:04
  it
• 2:05
  was
• 2:05
  torture.
• 2:05
  And
• 2:05
  I
• 2:06
  didn't
• 2:06
  even
• 2:06
  have
• 2:06
  schizophrenia,
• 2:07
  but
• 2:07
  it
• 2:07
  was
• 2:07
  just
• 2:08
  so
• 2:08
  disturbing
• 2:09
  and.
• 2:09
  And
• 2:10
  it
• 2:10
  made
• 2:10
  life
• 2:11
  just
• 2:11
  impossible
• 2:12
  to
• 2:12
  hear
• 2:12
  somebody
• 2:13
  else
• 2:13
  talk
• 2:13
  to,
• 2:14
  to
• 2:14
  understand
• 2:15
  what
• 2:15
  they're
• 2:15
  saying,
• 2:16
  to
• 2:16
  have
• 2:16
  organized
• 2:17
  thoughts
• 2:17
  on
• 2:17
  my
• 2:17
  own.
• 2:18
  It
• 2:18
  was
• 2:18
  just
• 2:19
  absolutely
• 2:20
  brutal
• 2:21
  and
• 2:21
  functionally
• 2:22
  disabling.
• 2:23
  And
• 2:23
  yet,
• 2:24
  despite
• 2:24
  how
• 2:25
  big
• 2:25
  and
• 2:25
  flashy
• 2:26
  those
• 2:26
  symptoms
• 2:27
  are
• 2:27
  and
• 2:27
  how
• 2:27
  badly
• 2:27
  we
• 2:28
  need
• 2:28
  to
• 2:28
  extinguish
• 2:28
  those
• 2:29
  positive
• 2:29
  symptoms,
• 2:30
  it's
• 2:30
  the
• 2:31
  negative
• 2:31
  symptoms,
• 2:32
  my
• 2:32
  friends,
• 2:33
  that
• 2:33
  are
• 2:33
  the
• 2:34
  core
• 2:34
  driver
• 2:34
  of
• 2:35
  disability
• 2:35
  in
• 2:35
  schizophrenia.
• 2:36
  I
• 2:36
  want
• 2:36
  to
• 2:36
  repeat
• 2:37
  that
• 2:37
  because
• 2:37
  it's
• 2:38
  so
• 2:38
  darn
• 2:39
  important.
• 2:39
  Okay?
• 2:40
  The
• 2:41
  negative
• 2:41
  symptoms
• 2:42
  of
• 2:42
  schizophrenia
• 2:43
  are
• 2:43
  the
• 2:44
  single
• 2:44
  greatest
• 2:44
  drivers
• 2:45
  of
• 2:45
  disability
• 2:46
  in
• 2:47
  schizophrenia.
• 2:48
  And
• 2:48
  that
• 2:48
  is
• 2:48
  so
• 2:49
  important.
• 2:50
  Okay?
• 2:50
  You
• 2:51
  absolutely
• 2:51
  have
• 2:52
  to
• 2:52
  help
• 2:52
  control
• 2:53
  your
• 2:53
  hallucinations
• 2:54
  and
• 2:55
  delusions
• 2:55
  via
• 2:55
  D2
• 2:56
  blockade.
• 2:56
  Absolutely.
• 2:57
  But
• 2:58
  don't
• 2:58
  forget
• 2:59
  the
• 2:59
  fact
• 3:00
  that
• 3:00
  your
• 3:00
  patients
• 3:01
  also
• 3:01
  have
• 3:01
  negative
• 3:02
  symptoms
• 3:02
  that
• 3:02
  are
• 3:02
  making
• 3:03
  it
• 3:03
  extremely
• 3:04
  hard
• 3:04
  to
• 3:05
  function.
• 3:05
  Now,
• 3:06
  in
• 3:06
  this
• 3:06
  mock
• 3:06
  case
• 3:07
  study,
• 3:07
  we're
• 3:07
  going
• 3:07
  to
• 3:07
  call
• 3:08
  him
• 3:08
  Vic.
• 3:08
  He's
• 3:08
  28
• 3:09
  years
• 3:09
  old.
• 3:09
  He
• 3:09
  has
• 3:09
  schizophrenia,
• 3:10
  has
• 3:10
  been
• 3:11
  diagnosed
• 3:11
  since
• 3:11
  he
• 3:11
  was
• 3:12
  22.
• 3:13
  He's
• 3:13
  been
• 3:13
  on
• 3:13
  risperidone,
• 3:14
  4
• 3:15
  milligrams
• 3:15
  a
• 3:15
  day,
• 3:15
  for
• 3:16
  three
• 3:16
  years.
• 3:16
  Well
• 3:17
  controlled.
• 3:17
  No
• 3:17
  hallucinations,
• 3:18
  no
• 3:18
  delusions,
• 3:19
  no
• 3:19
  disorganized
• 3:20
  behavior.
• 3:21
  But
• 3:21
  his
• 3:21
  negative
• 3:21
  symptoms
• 3:22
  are
• 3:22
  severe
• 3:22
  and
• 3:23
  they
• 3:23
  are
• 3:23
  worsening
• 3:24
  now.
• 3:24
  He
• 3:25
  has
• 3:25
  not
• 3:25
  worked
• 3:26
  in
• 3:26
  14
• 3:26
  months.
• 3:27
  He
• 3:27
  had
• 3:27
  a
• 3:27
  job
• 3:27
  at
• 3:27
  a
• 3:28
  warehouse.
• 3:29
  And
• 3:30
  he
• 3:31
  is
• 3:31
  no
• 3:31
  longer
• 3:31
  showing
• 3:32
  up.
• 3:32
  Not
• 3:32
  because
• 3:32
  he's
• 3:33
  psychotic,
• 3:33
  but
• 3:34
  he's
• 3:34
  just
• 3:34
  no
• 3:35
  longer
• 3:35
  showing
• 3:35
  up
• 3:35
  to
• 3:36
  work.
• 3:36
  He
• 3:36
  doesn't
• 3:37
  really
• 3:37
  have
• 3:37
  the
• 3:38
  volition
• 3:39
  or
• 3:39
  desire
• 3:39
  to
• 3:40
  work.
• 3:40
  He
• 3:40
  sleeps
• 3:40
  12
• 3:41
  to
• 3:41
  14
• 3:41
  hours
• 3:41
  a
• 3:42
  day.
• 3:42
  He
• 3:42
  doesn't
• 3:42
  really
• 3:42
  initiate
• 3:43
  much
• 3:43
  meals.
• 3:43
  He
• 3:44
  doesn't
• 3:44
  make
• 3:44
  his
• 3:44
  own
• 3:44
  meals.
• 3:45
  He's
• 3:45
  kind
• 3:45
  of
• 3:45
  disheveled.
• 3:46
  When
• 3:46
  you
• 3:46
  see
• 3:46
  him
• 3:47
  in
• 3:47
  your
• 3:47
  outpatient
• 3:48
  practice,
• 3:48
  he's
• 3:49
  not
• 3:49
  answering
• 3:50
  many
• 3:50
  phone
• 3:50
  calls.
• 3:51
  He's
• 3:51
  just
• 3:51
  kind
• 3:51
  of
• 3:52
  flat.
• 3:52
  He
• 3:52
  answers
• 3:53
  you
• 3:53
  in
• 3:53
  three
• 3:53
  to
• 3:53
  word.
• 3:54
  Three
• 3:54
  to
• 3:54
  four
• 3:54
  word
• 3:55
  sentences,
• 3:55
  if
• 3:56
  that.
• 3:56
  His
• 3:57
  friends
• 3:57
  haven't
• 3:57
  even
• 3:57
  seen
• 3:58
  him
• 3:58
  over
• 3:58
  a
• 3:58
  year.
• 3:58
  He
• 3:59
  doesn't
• 3:59
  really
• 3:59
  text
• 3:59
  them
• 3:59
  back.
• 4:00
  He
• 4:00
  doesn't
• 4:00
  really
• 4:00
  want
• 4:00
  to.
• 4:01
  And
• 4:01
  his
• 4:01
  mom
• 4:02
  manages
• 4:02
  everything.
• 4:03
  His
• 4:03
  breakfast,
• 4:04
  his.
• 4:05
  His
• 4:06
  checkbook,
• 4:07
  his
• 4:07
  appointments,
• 4:08
  his
• 4:08
  transport,
• 4:09
  right?
• 4:09
  She's
• 4:10
  doing
• 4:10
  everything
• 4:10
  for
• 4:11
  him.
• 4:11
  And
• 4:12
  he
• 4:12
  doesn't
• 4:12
  really
• 4:12
  care.
• 4:12
  He
• 4:13
  doesn't
• 4:13
  really
• 4:13
  want
• 4:13
  to
• 4:13
  do
• 4:13
  more.
• 4:14
  His
• 4:14
  voices
• 4:15
  are
• 4:15
  gone,
• 4:15
  but
• 4:16
  her.
• 4:16
  His
• 4:16
  mom
• 4:16
  basically
• 4:17
  tells
• 4:17
  you,
• 4:17
  I
• 4:17
  don't
• 4:18
  have
• 4:18
  my
• 4:18
  son
• 4:18
  back.
• 4:19
  So
• 4:20
  it
• 4:20
  goes
• 4:20
  without
• 4:21
  saying
• 4:21
  here,
• 4:21
  but
• 4:22
  I'm
• 4:22
  going
• 4:22
  to
• 4:22
  say
• 4:22
  it
• 4:22
  anyway,
• 4:23
  that
• 4:25
  you
• 4:25
  did
• 4:25
  not
• 4:26
  win,
• 4:26
  right?
• 4:26
  We
• 4:27
  did
• 4:27
  not
• 4:27
  win
• 4:27
  as
• 4:27
  clinicians
• 4:28
  just
• 4:28
  because
• 4:29
  we
• 4:30
  started
• 4:30
  a
• 4:31
  patient
• 4:31
  on
• 4:31
  risperidol
• 4:32
  and
• 4:32
  we
• 4:32
  got
• 4:32
  rid
• 4:33
  of
• 4:33
  the
• 4:33
  big
• 4:33
  scary
• 4:34
  voices,
• 4:35
  the
• 4:35
  delusions.
• 4:36
  That's
• 4:36
  a.
• 4:37
  That's
• 4:37
  a
• 4:37
  great
• 4:38
  thing
• 4:38
  we
• 4:38
  should
• 4:38
  be
• 4:38
  proud
• 4:39
  of.
• 4:39
  But
• 4:39
  we
• 4:39
  cannot
• 4:39
  declare
• 4:40
  victory
• 4:40
  yet
• 4:41
  because
• 4:41
  we
• 4:41
  did
• 4:42
  not.
• 4:42
  We
• 4:43
  did
• 4:43
  not
• 4:43
  extinguish
• 4:45
  this
• 4:45
  man's
• 4:46
  negative
• 4:47
  symptoms.
• 4:48
  And
• 4:48
  that,
• 4:48
  my
• 4:49
  friends,
• 4:49
  is
• 4:50
  a
• 4:50
  very
• 4:51
  big
• 4:51
  problem,
• 4:51
  because,
• 4:52
  again,
• 4:52
  the
• 4:52
  number
• 4:53
  one
• 4:54
  driver,
• 4:55
  the
• 4:55
  number
• 4:55
  one
• 4:55
  driver
• 4:56
  of
• 4:56
  disability
• 4:57
  are
• 4:57
  these
• 4:58
  negative
• 4:58
  symptoms.
• 5:00
  Okay,
• 5:01
  well,
• 5:01
  in
• 5:02
  his
• 5:02
  case
• 5:02
  in
• 5:02
  particular,
• 5:03
  we
• 5:03
  have
• 5:04
  a
• 5:04
  bit
• 5:04
  of
• 5:04
  a
• 5:04
  problem
• 5:04
  here,
• 5:05
  right?
• 5:06
  Because
• 5:06
  this
• 5:06
  is
• 5:06
  affecting
• 5:07
  his
• 5:07
  ability
• 5:07
  to
• 5:07
  work.
• 5:08
  He
• 5:08
  doesn't
• 5:08
  even
• 5:08
  work
• 5:08
  anymore.
• 5:09
  He's
• 5:09
  not
• 5:09
  connecting
• 5:09
  with
• 5:10
  friends.
• 5:10
  He's
• 5:11
  not
• 5:11
  even
• 5:11
  exercising
• 5:12
  basic
• 5:13
  hygiene.
• 5:14
  So
• 5:14
  we
• 5:14
  have
• 5:14
  to
• 5:15
  step
• 5:15
  in
• 5:15
  now.
• 5:15
  Why
• 5:16
  is
• 5:16
  risperidone
• 5:17
  not
• 5:17
  cutting
• 5:17
  the
• 5:18
  mustard
• 5:18
  here?
• 5:18
  Well,
• 5:19
  risperidone
• 5:19
  is
• 5:20
  a
• 5:20
  great
• 5:20
  medication.
• 5:21
  I
• 5:21
  will
• 5:21
  admit
• 5:21
  I
• 5:22
  have
• 5:22
  seen
• 5:22
  it
• 5:22
  do
• 5:22
  wonders
• 5:23
  for
• 5:24
  mania
• 5:25
  and
• 5:25
  psychosis.
• 5:26
  It's
• 5:26
  pretty
• 5:27
  darn
• 5:27
  good.
• 5:28
  It
• 5:28
  has
• 5:28
  Its
• 5:28
  virtues.
• 5:28
  It
• 5:29
  has
• 5:29
  its
• 5:29
  side
• 5:29
  effects
• 5:30
  as
• 5:30
  well,
• 5:31
  but
• 5:31
  it
• 5:31
  might
• 5:32
  be
• 5:32
  blocking
• 5:32
  too
• 5:32
  much
• 5:33
  D2.
• 5:33
  And
• 5:34
  the
• 5:34
  receptor
• 5:34
  that
• 5:35
  we're
• 5:35
  interested
• 5:35
  in
• 5:35
  here
• 5:36
  is
• 5:37
  not
• 5:38
  more
• 5:38
  D2.
• 5:39
  If
• 5:39
  anything,
• 5:40
  we
• 5:40
  want
• 5:40
  to
• 5:40
  block
• 5:40
  less
• 5:41
  of
• 5:41
  D2,
• 5:41
  but
• 5:42
  we're
• 5:42
  kind
• 5:42
  of
• 5:42
  in
• 5:42
  a
• 5:43
  bind
• 5:43
  because
• 5:45
  we
• 5:45
  can't
• 5:46
  really
• 5:47
  do
• 5:47
  that
• 5:49
  because
• 5:49
  the
• 5:49
  psychotic
• 5:50
  symptoms
• 5:50
  might
• 5:51
  come
• 5:51
  back.
• 5:51
  Right.
• 5:52
  So
• 5:52
  it's
• 5:53
  nice
• 5:53
  that
• 5:53
  we
• 5:53
  blocked
• 5:54
  those
• 5:54
  D2
• 5:54
  receptors,
• 5:55
  but
• 5:56
  if
• 5:56
  you
• 5:56
  lower
• 5:57
  the
• 5:57
  dose
• 5:57
  because
• 5:57
  you
• 5:58
  want
• 5:58
  him
• 5:58
  to
• 5:58
  have
• 5:58
  less
• 5:59
  negative
• 5:59
  symptoms,
• 6:00
  it's
• 6:00
  kind
• 6:01
  of
• 6:01
  robbing
• 6:01
  Peter
• 6:01
  to
• 6:01
  pay
• 6:02
  Paul,
• 6:02
  in
• 6:02
  my
• 6:02
  experience,
• 6:03
  you
• 6:03
  just
• 6:03
  might
• 6:03
  have
• 6:04
  a
• 6:04
  resurgence
• 6:04
  of
• 6:04
  psychosis.
• 6:05
  And
• 6:05
  it's
• 6:06
  not
• 6:06
  always
• 6:06
  this
• 6:06
  big,
• 6:06
  fancy,
• 6:07
  dramatic
• 6:07
  thing
• 6:08
  where
• 6:08
  they're
• 6:09
  completely
• 6:09
  psychotic
• 6:10
  and,
• 6:10
  you
• 6:11
  know,
• 6:11
  streaking
• 6:11
  in
• 6:12
  the
• 6:12
  middle
• 6:12
  of
• 6:12
  the
• 6:12
  highway.
• 6:13
  It's
• 6:13
  more
• 6:13
  subtle
• 6:14
  often,
• 6:14
  especially
• 6:15
  with
• 6:15
  the
• 6:15
  gradual
• 6:15
  dose
• 6:16
  reduction
• 6:17
  where
• 6:17
  they
• 6:17
  have
• 6:17
  an
• 6:17
  intrusion
• 6:18
  of
• 6:18
  voices
• 6:19
  that
• 6:19
  they
• 6:19
  used
• 6:20
  to
• 6:20
  experience
• 6:20
  that's
• 6:21
  coming
• 6:21
  back.
• 6:21
  What
• 6:21
  you
• 6:22
  have
• 6:22
  here
• 6:22
  are
• 6:22
  negative
• 6:23
  symptoms.
• 6:24
  And
• 6:25
  in
• 6:26
  schizophrenia,
• 6:26
  criterion
• 6:27
  A
• 6:27
  number
• 6:28
  five
• 6:28
  are
• 6:28
  your
• 6:29
  negative
• 6:29
  symptoms.
• 6:29
  But
• 6:30
  again,
• 6:30
  they're
• 6:30
  kind
• 6:30
  of
• 6:30
  eclipsed
• 6:31
  by
• 6:31
  delusions
• 6:32
  and
• 6:32
  hallucinations,
• 6:33
  which
• 6:33
  are
• 6:33
  1
• 6:34
  and
• 6:34
  2.
• 6:34
  A
• 6:34
  disorganized
• 6:35
  speech,
• 6:35
  which
• 6:36
  is
• 6:36
  3.
• 6:37
  Right.
• 6:38
  So
• 6:39
  this
• 6:39
  is
• 6:39
  kind
• 6:39
  of
• 6:40
  tucked
• 6:40
  into
• 6:40
  the
• 6:40
  DSM.
• 6:41
  I
• 6:41
  feel
• 6:41
  like
• 6:41
  they
• 6:41
  should
• 6:42
  put
• 6:42
  it
• 6:42
  in
• 6:42
  bold
• 6:42
  next
• 6:43
  time
• 6:43
  for
• 6:44
  us
• 6:44
  to
• 6:44
  really
• 6:44
  appreciate
• 6:45
  the
• 6:45
  fact
• 6:45
  that
• 6:45
  this
• 6:45
  is
• 6:46
  so
• 6:46
  functionally
• 6:47
  disabling.
• 6:47
  And
• 6:47
  we
• 6:47
  need
• 6:47
  to
• 6:48
  do
• 6:48
  something
• 6:48
  about
• 6:48
  it
• 6:49
  now.
• 6:49
  Okay,
• 6:50
  and
• 6:51
  so
• 6:51
  what
• 6:52
  do
• 6:52
  we
• 6:52
  do
• 6:52
  about
• 6:52
  this?
• 6:52
  Well,
• 6:53
  first,
• 6:53
  let's
• 6:54
  get
• 6:54
  a
• 6:54
  little
• 6:54
  refresher
• 6:55
  about
• 6:55
  what
• 6:55
  these
• 6:55
  negative
• 6:56
  symptoms
• 6:56
  are.
• 6:57
  So
• 6:57
  when
• 6:57
  we
• 6:57
  talk
• 6:57
  about
• 6:58
  negative
• 6:59
  symptoms,
• 7:00
  we're
• 7:00
  talking
• 7:00
  about
• 7:00
  a
• 7:01
  blunted
• 7:01
  affect,
• 7:02
  right?
• 7:02
  A
• 7:02
  reduced
• 7:02
  emotional
• 7:03
  range
• 7:03
  and
• 7:04
  intensity
• 7:04
  of
• 7:04
  emotional
• 7:05
  expression.
• 7:06
  And
• 7:06
  you
• 7:06
  can
• 7:06
  kind
• 7:06
  of
• 7:06
  see
• 7:07
  this
• 7:07
  on
• 7:07
  a
• 7:07
  mental
• 7:08
  status
• 7:08
  examination.
• 7:09
  These
• 7:09
  folks
• 7:09
  will
• 7:09
  often
• 7:10
  just
• 7:10
  kind
• 7:10
  of.
• 7:11
  They
• 7:11
  won't
• 7:11
  smile
• 7:12
  or
• 7:12
  laugh
• 7:12
  as
• 7:12
  easily.
• 7:13
  They're
• 7:13
  just
• 7:14
  kind
• 7:14
  of
• 7:14
  zoned
• 7:14
  out,
• 7:15
  maybe
• 7:15
  staring
• 7:15
  into
• 7:16
  space,
• 7:16
  just
• 7:16
  barely
• 7:17
  reacting.
• 7:18
  And
• 7:18
  again,
• 7:18
  that's
• 7:19
  very
• 7:19
  hard.
• 7:19
  Right.
• 7:19
  Their
• 7:19
  voice
• 7:20
  might
• 7:20
  be
• 7:20
  monotone.
• 7:21
  They're
• 7:21
  not
• 7:21
  using
• 7:22
  hand
• 7:22
  gestures
• 7:22
  as
• 7:23
  often.
• 7:23
  This.
• 7:23
  This
• 7:24
  is
• 7:24
  the
• 7:24
  fun.
• 7:24
  This
• 7:24
  is
• 7:25
  the
• 7:25
  foundational
• 7:25
  way
• 7:26
  by
• 7:26
  which
• 7:27
  we
• 7:27
  humans
• 7:28
  communicate.
• 7:28
  Right.
• 7:29
  So
• 7:29
  this
• 7:29
  is
• 7:29
  not
• 7:29
  just
• 7:29
  a
• 7:30
  checkbox
• 7:30
  of,
• 7:30
  oh,
• 7:31
  mental
• 7:31
  status
• 7:31
  exam,
• 7:32
  blunted
• 7:32
  affect.
• 7:32
  Right.
• 7:33
  We
• 7:33
  have
• 7:34
  to
• 7:34
  think
• 7:34
  about
• 7:34
  the
• 7:34
  human
• 7:35
  implications
• 7:35
  of
• 7:36
  what
• 7:36
  we
• 7:36
  do.
• 7:36
  What
• 7:36
  are
• 7:36
  the
• 7:37
  human
• 7:37
  implications
• 7:37
  of
• 7:38
  this?
• 7:38
  Somebody
• 7:39
  who's
• 7:39
  not
• 7:39
  able
• 7:40
  to
• 7:40
  express
• 7:40
  themselves
• 7:41
  emotionally
• 7:42
  within
• 7:42
  a
• 7:43
  specific
• 7:44
  range.
• 7:45
  It's
• 7:45
  so
• 7:45
  disabling,
• 7:46
  if
• 7:46
  you
• 7:46
  think
• 7:46
  about
• 7:46
  it.
• 7:47
  I
• 7:47
  mean,
• 7:47
  think
• 7:47
  about
• 7:47
  your
• 7:48
  average
• 7:48
  day
• 7:48
  at
• 7:49
  work.
• 7:49
  How
• 7:49
  important
• 7:49
  it
• 7:49
  is
• 7:50
  that
• 7:50
  you're
• 7:50
  able
• 7:51
  to
• 7:51
  frown
• 7:51
  when
• 7:51
  you're
• 7:52
  upset
• 7:52
  about
• 7:52
  something
• 7:53
  or
• 7:53
  look
• 7:53
  excited
• 7:54
  when
• 7:54
  your
• 7:54
  boss
• 7:55
  tells
• 7:55
  you
• 7:55
  there's
• 7:55
  another
• 7:55
  potluck.
• 7:56
  Today,
• 7:57
  or
• 7:58
  your
• 7:58
  ability
• 7:58
  to
• 7:59
  mirror
• 8:00
  your
• 8:00
  partner
• 8:01
  or
• 8:01
  mirror
• 8:01
  a
• 8:02
  coworker's
• 8:02
  frustration
• 8:03
  so
• 8:03
  that
• 8:03
  you
• 8:03
  can
• 8:03
  connect
• 8:04
  with
• 8:04
  them
• 8:04
  more
• 8:04
  fully.
• 8:06
  Just
• 8:06
  having
• 8:06
  affect,
• 8:07
  right?
• 8:07
  Having
• 8:07
  an
• 8:07
  emotional
• 8:08
  expression
• 8:09
  is
• 8:10
  so
• 8:10
  important
• 8:10
  for
• 8:10
  people
• 8:10
  to
• 8:11
  understand
• 8:11
  who
• 8:11
  you
• 8:11
  are
• 8:12
  and
• 8:12
  thereby
• 8:12
  build
• 8:12
  relationships
• 8:13
  more
• 8:13
  broadly.
• 8:14
  It's
• 8:14
  not
• 8:14
  just
• 8:15
  this
• 8:15
  little
• 8:15
  MSE
• 8:17
  section
• 8:17
  we
• 8:18
  fill
• 8:18
  out.
• 8:18
  We
• 8:18
  have
• 8:19
  to
• 8:19
  really
• 8:20
  challenge
• 8:20
  ourselves
• 8:20
  to
• 8:21
  not
• 8:21
  just
• 8:21
  look
• 8:22
  at
• 8:22
  part
• 8:23
  of
• 8:23
  our
• 8:24
  checklist
• 8:25
  as
• 8:25
  a
• 8:25
  thing
• 8:25
  to
• 8:26
  do
• 8:26
  and
• 8:26
  complete
• 8:26
  and
• 8:27
  document,
• 8:27
  right?
• 8:27
  These
• 8:28
  are
• 8:28
  really
• 8:29
  human
• 8:30
  consequences
• 8:31
  that
• 8:31
  are
• 8:32
  attached
• 8:32
  to
• 8:32
  these
• 8:32
  things.
• 8:33
  I
• 8:33
  almost
• 8:33
  wish
• 8:34
  next
• 8:34
  to
• 8:34
  the
• 8:34
  mse,
• 8:35
  there
• 8:35
  was
• 8:36
  a
• 8:36
  reminder
• 8:37
  to
• 8:37
  all
• 8:37
  of
• 8:37
  us,
• 8:38
  like,
• 8:38
  of,
• 8:38
  of
• 8:39
  an
• 8:39
  immediate
• 8:39
  reminder,
• 8:40
  a
• 8:40
  concrete
• 8:40
  reminder
• 8:41
  about
• 8:41
  why
• 8:42
  these
• 8:42
  things
• 8:43
  are
• 8:43
  so
• 8:43
  problematic
• 8:44
  when
• 8:44
  they
• 8:44
  are
• 8:44
  impaired,
• 8:45
  like
• 8:45
  a
• 8:45
  blunted
• 8:46
  affect,
• 8:46
  right?
• 9:41
  And
• 9:41
  it
• 9:41
  would
• 9:42
  make
• 9:42
  us
• 9:42
  really
• 9:43
  focus
• 9:43
  more
• 9:44
  on.
• 9:44
  Wait,
• 9:44
  like,
• 9:44
  wait
• 9:44
  a
• 9:44
  minute,
• 9:45
  we
• 9:45
  need
• 9:45
  to
• 9:45
  really
• 9:46
  treat
• 9:46
  this
• 9:47
  intensely
• 9:47
  and
• 9:48
  get
• 9:48
  to
• 9:48
  the
• 9:48
  nitty
• 9:48
  gritty
• 9:49
  and
• 9:49
  figure
• 9:49
  out
• 9:50
  how
• 9:50
  this
• 9:50
  is
• 9:50
  hurting
• 9:51
  somebody,
• 9:51
  right?
• 9:52
  Because
• 9:52
  this
• 9:52
  will,
• 9:52
  this
• 9:52
  will
• 9:53
  erode
• 9:53
  Garrett's
• 9:54
  relationships.
• 9:55
  It
• 9:55
  will
• 9:56
  erode
• 9:57
  his
• 9:57
  relationships
• 9:58
  here.
• 9:59
  So
• 9:59
  we
• 9:59
  have
• 9:59
  to
• 9:59
  be
• 10:00
  very
• 10:00
  careful.
• 10:01
  Now,
• 10:02
  the
• 10:02
  second
• 10:02
  negative
• 10:03
  symptom
• 10:03
  is
• 10:04
  elogia,
• 10:04
  or
• 10:05
  poverty
• 10:05
  of
• 10:05
  speech.
• 10:06
  Fewer
• 10:06
  words,
• 10:07
  less
• 10:07
  spontaneous.
• 10:09
  Again,
• 10:09
  words
• 10:10
  are
• 10:10
  how
• 10:10
  we
• 10:10
  communicate,
• 10:11
  right?
• 10:11
  Very
• 10:11
  obvious.
• 10:12
  But
• 10:12
  you're.
• 10:13
  I
• 10:14
  mean,
• 10:14
  how
• 10:14
  can
• 10:14
  you
• 10:15
  have
• 10:15
  a
• 10:15
  successful
• 10:15
  job
• 10:16
  interview
• 10:16
  if
• 10:16
  you're
• 10:16
  barely
• 10:17
  talking?
• 10:18
  How
• 10:18
  can
• 10:18
  you
• 10:18
  express
• 10:18
  yourself
• 10:19
  that
• 10:20
  you
• 10:20
  can't
• 10:20
  even
• 10:20
  express
• 10:20
  yourself
• 10:21
  because
• 10:21
  your
• 10:21
  emotions
• 10:22
  are
• 10:22
  restricted
• 10:23
  now,
• 10:23
  you're
• 10:23
  not
• 10:23
  speaking
• 10:24
  as
• 10:25
  often,
• 10:26
  and
• 10:26
  so
• 10:27
  how
• 10:27
  can
• 10:27
  people
• 10:27
  really
• 10:27
  know
• 10:28
  you?
• 10:28
  Where
• 10:28
  are
• 10:28
  your
• 10:28
  relationships
• 10:29
  going
• 10:29
  to
• 10:29
  go
• 10:29
  if
• 10:29
  you
• 10:30
  can't
• 10:30
  speak
• 10:30
  and
• 10:30
  if
• 10:30
  your
• 10:31
  emotional
• 10:32
  expressions
• 10:33
  are
• 10:33
  just
• 10:33
  completely
• 10:34
  restricted?
• 10:34
  The
• 10:35
  third
• 10:35
  negative
• 10:36
  symptom
• 10:36
  is
• 10:36
  avolition,
• 10:37
  right?
• 10:37
  So
• 10:37
  initiation
• 10:39
  Vic's
• 10:40
  ability
• 10:40
  to
• 10:41
  initiate,
• 10:42
  like
• 10:43
  goal
• 10:43
  directed
• 10:44
  activity.
• 10:44
  You
• 10:45
  got
• 10:45
  to
• 10:45
  do
• 10:45
  your
• 10:45
  taxes,
• 10:46
  you
• 10:46
  got
• 10:46
  to
• 10:46
  wake
• 10:46
  up
• 10:46
  in
• 10:46
  the
• 10:47
  morning
• 10:47
  and
• 10:47
  comb
• 10:47
  your
• 10:47
  hair
• 10:48
  and
• 10:48
  look
• 10:48
  presentable,
• 10:49
  right?
• 10:49
  And,
• 10:50
  and
• 10:50
  do
• 10:50
  your
• 10:50
  laundry
• 10:51
  and,
• 10:52
  you
• 10:53
  know,
• 10:53
  complete
• 10:53
  a
• 10:53
  memo
• 10:54
  at
• 10:54
  work
• 10:54
  or
• 10:54
  send
• 10:55
  an
• 10:55
  email
• 10:55
  or
• 10:56
  apply
• 10:56
  for
• 10:56
  a
• 10:57
  job,
• 10:57
  right?
• 10:58
  And
• 10:58
  just
• 10:58
  doing
• 10:58
  those
• 10:59
  things
• 11:00
  requires
• 11:00
  effort.
• 11:01
  And
• 11:01
  just
• 11:01
  imagine
• 11:02
  how
• 11:02
  seismic
• 11:03
  that
• 11:03
  effect
• 11:03
  can
• 11:04
  be.
• 11:04
  It's
• 11:04
  no
• 11:04
  wonder
• 11:05
  that
• 11:05
  this
• 11:05
  is
• 11:05
  so
• 11:05
  disabling
• 11:06
  if
• 11:06
  part
• 11:07
  of
• 11:07
  the
• 11:08
  illness
• 11:08
  itself
• 11:09
  involves
• 11:10
  what
• 11:10
  we
• 11:10
  call
• 11:10
  avolition.
• 11:12
  Not
• 11:12
  being
• 11:12
  able
• 11:13
  to
• 11:13
  do
• 11:14
  anything
• 11:15
  very
• 11:15
  easily,
• 11:15
  any
• 11:16
  goal
• 11:16
  directed
• 11:16
  activity.
• 11:17
  And
• 11:17
  sure
• 11:17
  enough,
• 11:18
  my
• 11:18
  friends,
• 11:18
  this
• 11:18
  is
• 11:18
  the
• 11:18
  single
• 11:19
  strongest
• 11:19
  predictor
• 11:20
  of
• 11:20
  work
• 11:20
  disability
• 11:20
  in
• 11:21
  particular
• 11:21
  is
• 11:22
  avolition.
• 11:22
  And
• 11:22
  you
• 11:23
  can
• 11:23
  imagine
• 11:23
  if
• 11:24
  you
• 11:24
  don't
• 11:24
  want
• 11:24
  to
• 11:24
  do
• 11:24
  stuff,
• 11:25
  it's
• 11:25
  probably
• 11:25
  hard
• 11:25
  to
• 11:25
  get
• 11:26
  a
• 11:26
  job
• 11:26
  right.
• 11:27
  Now,
• 11:27
  the
• 11:27
  fourth
• 11:27
  negative
• 11:28
  symptom,
• 11:28
  anhedonia.
• 11:29
  Anhedonia
• 11:30
  is
• 11:30
  such
• 11:30
  a
• 11:30
  big
• 11:30
  one,
• 11:30
  right?
• 11:31
  And
• 11:31
  there's
• 11:32
  two
• 11:32
  forms
• 11:32
  of
• 11:32
  anhedonia.
• 11:33
  This
• 11:33
  is
• 11:33
  kind
• 11:34
  of
• 11:34
  a
• 11:34
  nerdy
• 11:34
  way
• 11:35
  to
• 11:35
  look
• 11:35
  at
• 11:35
  this.
• 11:35
  But
• 11:35
  it's
• 11:36
  helpful
• 11:36
  to
• 11:36
  know
• 11:37
  there's
• 11:37
  the
• 11:37
  anticipatory
• 11:38
  anhedonia,
• 11:38
  where
• 11:39
  Vic
• 11:39
  doesn't
• 11:40
  really
• 11:40
  look
• 11:40
  forward
• 11:40
  to
• 11:41
  doing
• 11:41
  anything.
• 11:42
  If
• 11:42
  you
• 11:42
  tell
• 11:42
  Vic,
• 11:43
  hey,
• 11:43
  Vic,
• 11:43
  we're
• 11:43
  going
• 11:43
  to
• 11:43
  go
• 11:43
  to
• 11:44
  a
• 11:44
  Green
• 11:44
  Bay
• 11:44
  packers
• 11:45
  game,
• 11:45
  he's
• 11:45
  not
• 11:46
  excited.
• 11:46
  He
• 11:46
  doesn't
• 11:46
  look
• 11:47
  forward
• 11:47
  to
• 11:47
  it.
• 11:47
  Well,
• 11:48
  that
• 11:48
  sucks,
• 11:48
  right?
• 11:49
  Life
• 11:49
  is
• 11:49
  all
• 11:49
  about
• 11:50
  looking
• 11:50
  forward
• 11:50
  to
• 11:51
  fun
• 11:51
  things,
• 11:51
  playing
• 11:51
  with
• 11:52
  your
• 11:52
  kids,
• 11:52
  looking
• 11:52
  forward
• 11:53
  to
• 11:53
  a
• 11:54
  picnic
• 11:54
  or
• 11:54
  a
• 11:55
  birthday
• 11:55
  party
• 11:56
  or
• 11:57
  a
• 11:57
  new,
• 11:58
  a
• 11:58
  new
• 11:58
  $0.50
• 11:59
  album.
• 11:59
  Right?
• 12:00
  Those
• 12:00
  are
• 12:00
  all
• 12:00
  very
• 12:00
  exciting
• 12:01
  things.
• 12:01
  I
• 12:02
  was
• 12:02
  like
• 12:02
  thrilled
• 12:03
  when
• 12:03
  I
• 12:03
  heard
• 12:03
  50
• 12:03
  cents
• 12:04
  was
• 12:04
  coming
• 12:04
  out
• 12:04
  with
• 12:04
  one
• 12:05
  of
• 12:05
  his
• 12:05
  albums.
• 12:06
  And
• 12:06
  I
• 12:06
  think
• 12:06
  it
• 12:06
  was
• 12:06
  the
• 12:07
  early
• 12:07
  2000s
• 12:08
  party
• 12:08
  in
• 12:08
  the
• 12:08
  clubs.
• 12:09
  I
• 12:09
  forget
• 12:10
  what
• 12:10
  it
• 12:10
  was
• 12:10
  called.
• 12:10
  It
• 12:11
  was
• 12:11
  great
• 12:11
  though.
• 12:11
  I
• 12:11
  was
• 12:11
  excited.
• 12:12
  If
• 12:12
  you
• 12:12
  don't
• 12:13
  have
• 12:13
  excitement
• 12:13
  in
• 12:14
  your
• 12:14
  life,
• 12:14
  imagine
• 12:14
  just
• 12:15
  how
• 12:15
  debilitating
• 12:15
  and
• 12:16
  bleak
• 12:16
  life
• 12:16
  can
• 12:17
  be.
• 12:17
  So
• 12:17
  that's
• 12:17
  anticipatory
• 12:18
  anhedonia.
• 12:19
  Then
• 12:19
  there's
• 12:19
  consumatory
• 12:20
  anhedonia.
• 12:21
  They're
• 12:22
  actually
• 12:22
  quite
• 12:22
  helpful
• 12:22
  though,
• 12:23
  because
• 12:23
  one
• 12:24
  is,
• 12:24
  I
• 12:24
  don't
• 12:25
  anticipate
• 12:26
  pleasure.
• 12:26
  And
• 12:26
  one
• 12:26
  is
• 12:26
  when
• 12:27
  I'm
• 12:27
  eating
• 12:27
  ice
• 12:27
  cream
• 12:28
  or
• 12:28
  when
• 12:28
  I'm,
• 12:29
  when
• 12:30
  I'm
• 12:30
  with
• 12:30
  my
• 12:30
  kids
• 12:31
  or
• 12:31
  when
• 12:31
  I,
• 12:31
  when
• 12:32
  I'm
• 12:32
  feeding
• 12:32
  the
• 12:32
  ducks.
• 12:33
  I
• 12:33
  don't
• 12:33
  actually
• 12:34
  enjoy
• 12:34
  anything
• 12:34
  in
• 12:35
  the
• 12:35
  present.
• 12:36
  Right.
• 12:37
  It's
• 12:37
  good
• 12:37
  to
• 12:37
  kind
• 12:37
  of
• 12:37
  have
• 12:38
  an
• 12:38
  idea
• 12:38
  of
• 12:38
  which
• 12:39
  one
• 12:39
  your
• 12:39
  patient
• 12:40
  is
• 12:40
  lacking.
• 12:41
  Probably
• 12:42
  both.
• 12:43
  And
• 12:43
  again,
• 12:43
  the
• 12:44
  fifth
• 12:44
  negative
• 12:45
  symptom
• 12:45
  now
• 12:45
  is
• 12:45
  asociality,
• 12:46
  which
• 12:46
  of
• 12:47
  course
• 12:47
  goes
• 12:48
  without
• 12:48
  saying,
• 12:48
  right?
• 12:49
  They
• 12:49
  don't
• 12:50
  initiate
• 12:50
  contacts
• 12:51
  with
• 12:51
  other
• 12:51
  people,
• 12:52
  their
• 12:52
  social
• 12:52
  interactions,
• 12:53
  they
• 12:53
  don't
• 12:54
  reach
• 12:54
  out,
• 12:54
  they
• 12:54
  don't
• 12:54
  respond
• 12:55
  well.
• 12:55
  That's
• 12:55
  a
• 12:55
  big
• 12:56
  problem
• 12:56
  too.
• 12:56
  And
• 12:57
  we
• 12:57
  can,
• 12:57
  we
• 12:57
  can
• 12:58
  just
• 12:58
  start
• 12:58
  to
• 12:58
  reflect
• 12:59
  on
• 12:59
  the
• 12:59
  exponential
• 13:01
  damage
• 13:01
  that
• 13:01
  is
• 13:02
  wrought
• 13:02
  by
• 13:03
  frayed
• 13:03
  social
• 13:04
  relationships.
• 13:04
  Right?
• 13:05
  People
• 13:05
  who
• 13:05
  can
• 13:05
  monitor
• 13:06
  you
• 13:06
  kind
• 13:06
  of
• 13:06
  keep
• 13:06
  tabs
• 13:07
  on
• 13:07
  you.
• 13:07
  I
• 13:07
  have
• 13:08
  so
• 13:08
  many
• 13:08
  patients
• 13:08
  who
• 13:08
  come
• 13:09
  in
• 13:09
  because
• 13:09
  their
• 13:09
  friends
• 13:09
  tell
• 13:10
  them,
• 13:10
  hey,
• 13:10
  you're
• 13:11
  not
• 13:11
  really
• 13:11
  in
• 13:11
  a
• 13:11
  good
• 13:11
  place.
• 13:12
  It's
• 13:12
  just
• 13:12
  so
• 13:13
  integral
• 13:13
  to
• 13:13
  our
• 13:13
  sense
• 13:14
  of
• 13:14
  self,
• 13:14
  our
• 13:15
  sense
• 13:15
  of
• 13:15
  motivation,
• 13:16
  our
• 13:16
  ability
• 13:16
  to
• 13:17
  co
• 13:17
  regulate,
• 13:17
  right?
• 13:18
  So
• 13:18
  now
• 13:18
  you
• 13:18
  have
• 13:18
  someone
• 13:19
  who's
• 13:19
  not
• 13:19
  even
• 13:19
  interested
• 13:20
  in
• 13:20
  initiating
• 13:21
  that
• 13:21
  stuff.
• 13:21
  It
• 13:22
  just
• 13:22
  gets
• 13:22
  harder
• 13:22
  and
• 13:23
  harder
• 13:23
  and
• 13:23
  harder,
• 13:24
  right?
• 13:24
  People
• 13:24
  lose
• 13:24
  their
• 13:25
  jobs,
• 13:25
  they
• 13:26
  isolate
• 13:26
  to
• 13:26
  the
• 13:26
  point
• 13:27
  where
• 13:27
  it's
• 13:27
  permanent.
• 13:28
  Basic
• 13:28
  bills,
• 13:29
  insurances
• 13:30
  pile
• 13:31
  up,
• 13:31
  appointments
• 13:32
  are
• 13:32
  missed.
• 13:33
  It's
• 13:34
  just,
• 13:34
  it's
• 13:34
  just
• 13:35
  a
• 13:35
  mess,
• 13:35
  right?
• 13:36
  Negative
• 13:36
  symptoms
• 13:38
  are
• 13:38
  a
• 13:38
  total
• 13:39
  mess.
• 13:40
  And
• 13:40
  they're
• 13:41
  so
• 13:41
  debilitating,
• 13:41
  as
• 13:42
  you
• 13:42
  can
• 13:42
  tell.
• 13:42
  And
• 13:43
  we
• 13:43
  do
• 13:43
  have
• 13:43
  to
• 13:43
  be
• 13:44
  able
• 13:44
  to
• 13:44
  differentiate
• 13:45
  these
• 13:45
  negative
• 13:45
  symptoms
• 13:46
  from
• 13:47
  depression.
• 13:48
  I
• 13:48
  think
• 13:48
  that's
• 13:49
  really
• 13:49
  important
• 13:50
  because
• 13:50
  there
• 13:50
  is
• 13:50
  anhedonia
• 13:51
  in
• 13:52
  depression.
• 13:53
  And
• 13:53
  you,
• 13:54
  you
• 13:54
  have
• 13:54
  to
• 13:54
  kind
• 13:54
  of
• 13:54
  figure
• 13:55
  out
• 13:55
  the
• 13:55
  difference
• 13:56
  between
• 13:56
  the
• 13:56
  two.
• 13:57
  That's
• 13:57
  very
• 13:57
  important.
• 13:59
  With
• 13:59
  depression,
• 14:00
  it
• 14:00
  is
• 14:00
  more
• 14:01
  episodic.
• 14:01
  It
• 14:02
  can
• 14:02
  be
• 14:02
  more
• 14:02
  fleeting
• 14:03
  at
• 14:03
  times.
• 14:04
  And
• 14:04
  in
• 14:05
  schizophrenia,
• 14:06
  again,
• 14:06
  it's
• 14:06
  kind
• 14:07
  of
• 14:07
  baked
• 14:07
  into
• 14:07
  the
• 14:07
  cake
• 14:08
  with
• 14:08
  the
• 14:08
  disease
• 14:09
  itself,
• 14:10
  right?
• 14:10
  So
• 14:10
  you
• 14:10
  have
• 14:10
  to
• 14:10
  think
• 14:11
  about
• 14:11
  that.
• 14:11
  You
• 14:11
  have
• 14:11
  to
• 14:11
  think
• 14:12
  about
• 14:12
  trauma.
• 14:13
  Trauma
• 14:13
  can
• 14:13
  also
• 14:14
  look
• 14:14
  like
• 14:14
  a
• 14:14
  lot
• 14:14
  of
• 14:15
  withdrawal,
• 14:15
  similar
• 14:16
  to
• 14:16
  the
• 14:16
  avolition
• 14:17
  in
• 14:17
  schizophrenia.
• 14:18
  Right?
• 14:18
  So
• 14:18
  you've
• 14:18
  got
• 14:18
  to
• 14:19
  be
• 14:19
  asking
• 14:19
  the
• 14:19
  trauma
• 14:20
  questions.
• 14:20
  You've
• 14:20
  got
• 14:21
  to
• 14:21
  be
• 14:21
  making
• 14:21
  sure
• 14:21
  your
• 14:21
  patient
• 14:22
  isn't
• 14:22
  just
• 14:22
  sedated.
• 14:23
  These
• 14:23
  medications
• 14:23
  and
• 14:24
  their
• 14:24
  anticholinergic
• 14:25
  side
• 14:25
  effects,
• 14:26
  and
• 14:26
  they're
• 14:26
  anti
• 14:27
  histaminergic
• 14:28
  side
• 14:28
  effects,
• 14:28
  right?
• 14:28
  People
• 14:28
  get
• 14:29
  kind
• 14:29
  of
• 14:29
  sedated
• 14:29
  and
• 14:30
  slow.
• 14:30
  That
• 14:31
  can
• 14:31
  look
• 14:31
  like
• 14:32
  low
• 14:33
  motivation.
• 14:33
  It
• 14:33
  could
• 14:34
  just
• 14:34
  be
• 14:34
  a
• 14:34
  medication
• 14:34
  side
• 14:35
  effect.
• 14:35
  So
• 14:35
  you
• 14:35
  always
• 14:35
  gotta,
• 14:36
  you
• 14:36
  know,
• 14:36
  assess
• 14:37
  the
• 14:37
  side
• 14:37
  effects,
• 14:38
  figure
• 14:38
  out
• 14:38
  if
• 14:38
  things
• 14:38
  are
• 14:39
  getting
• 14:39
  worse
• 14:39
  when
• 14:39
  you
• 14:39
  increase
• 14:40
  the
• 14:40
  dose.
• 14:40
  That
• 14:41
  would
• 14:41
  definitely
• 14:41
  be
• 14:41
  more
• 14:42
  of
• 14:42
  a
• 14:42
  sign
• 14:42
  it's
• 14:42
  your
• 14:42
  medications
• 14:43
  as
• 14:43
  opposed
• 14:44
  to
• 14:44
  the
• 14:45
  primary
• 14:45
  negative
• 14:46
  symptom.
• 14:46
  Primary
• 14:47
  negative
• 14:47
  symptom,
• 14:47
  again,
• 14:48
  would
• 14:48
  be
• 14:48
  the
• 14:48
  schizophrenia
• 14:49
  itself.
• 14:50
  Secondary
• 14:50
  negative
• 14:51
  symptom
• 14:51
  would
• 14:51
  be
• 14:52
  a
• 14:53
  sedation
• 14:53
  as
• 14:54
  a
• 14:54
  result
• 14:54
  of
• 14:55
  the
• 14:55
  anti
• 14:56
  histaminergic
• 14:56
  side
• 14:57
  effects.
• 14:57
  Right?
• 14:58
  A
• 14:58
  flatness
• 14:59
  or
• 14:59
  slowness,
• 15:00
  maybe.
• 15:00
  If
• 15:00
  your
• 15:00
  patient's
• 15:01
  physically
• 15:01
  slow,
• 15:02
  it
• 15:02
  could
• 15:02
  be
• 15:02
  the
• 15:02
  eps,
• 15:03
  Parkinsonism,
• 15:04
  and
• 15:05
  not
• 15:05
  so
• 15:06
  much
• 15:06
  the
• 15:07
  negative
• 15:07
  symptoms
• 15:08
  itself,
• 15:09
  right?
• 15:09
  Big
• 15:10
  difference.
• 15:11
  Okay.
• 15:12
  The
• 15:12
  emotional
• 15:13
  blunting
• 15:13
  that
• 15:13
  comes
• 15:13
  from
• 15:14
  maybe
• 15:14
  too
• 15:15
  much
• 15:15
  dopamine
• 15:15
  blockade.
• 15:16
  Well,
• 15:16
  that
• 15:16
  would
• 15:17
  be
• 15:17
  like
• 15:17
  a
• 15:17
  secondary
• 15:18
  negative
• 15:18
  symptom,
• 15:18
  right?
• 15:18
  It's
• 15:19
  not
• 15:19
  primary
• 15:19
  from
• 15:19
  the
• 15:20
  actual
• 15:20
  schizophrenia
• 15:21
  itself.
• 15:22
  The
• 15:22
  five
• 15:23
  negative
• 15:23
  symptoms
• 15:23
  I
• 15:23
  just
• 15:24
  shared
• 15:24
  with
• 15:24
  you
• 15:24
  as
• 15:25
  a
• 15:25
  core
• 15:25
  feature
• 15:25
  of
• 15:26
  schizophrenia.
• 15:26
  No,
• 15:26
  this
• 15:27
  would
• 15:27
  be
• 15:27
  secondary
• 15:27
  because
• 15:28
  of
• 15:28
  medication.
• 15:29
  Could
• 15:29
  be
• 15:29
  a
• 15:29
  substance
• 15:30
  like
• 15:30
  cannabis
• 15:30
  that's
• 15:31
  sapping
• 15:31
  their
• 15:32
  motivation.
• 15:32
  And
• 15:33
  here
• 15:33
  we
• 15:33
  are,
• 15:33
  we
• 15:33
  think
• 15:34
  it's
• 15:34
  the
• 15:35
  schizophrenia
• 15:35
  and
• 15:36
  it's
• 15:36
  not.
• 15:36
  And
• 15:36
  that
• 15:37
  matters,
• 15:37
  right?
• 15:37
  Because
• 15:37
  if
• 15:38
  you
• 15:38
  think
• 15:38
  it's
• 15:38
  the
• 15:38
  schizophrenia
• 15:39
  itself,
• 15:40
  you're
• 15:40
  going
• 15:40
  to
• 15:40
  want
• 15:40
  to
• 15:41
  target
• 15:42
  the
• 15:43
  negative
• 15:43
  symptom
• 15:43
  with
• 15:44
  something
• 15:44
  like
• 15:44
  Vraylar,
• 15:45
  which
• 15:45
  we'll
• 15:45
  go
• 15:45
  into
• 15:46
  in
• 15:46
  a
• 15:46
  minute,
• 15:46
  that
• 15:47
  that
• 15:47
  specifically
• 15:48
  targets
• 15:48
  the
• 15:48
  D3
• 15:49
  receptor.
• 15:49
  That
• 15:50
  allows
• 15:50
  for
• 15:51
  a
• 15:51
  little
• 15:51
  bit
• 15:51
  more
• 15:52
  motivation
• 15:52
  and
• 15:53
  initiative.
• 15:53
  But
• 15:54
  if
• 15:54
  it's
• 15:54
  substance
• 15:54
  use
• 15:55
  and
• 15:55
  you
• 15:55
  haven't
• 15:55
  screened
• 15:56
  that
• 15:56
  properly,
• 15:57
  you
• 15:57
  had
• 15:57
  a
• 15:57
  good
• 15:57
  opportunity
• 15:58
  there
• 15:58
  to
• 15:58
  get
• 15:58
  the
• 15:58
  patient
• 15:59
  to
• 15:59
  reduce
• 15:59
  or
• 15:59
  eliminate
• 16:00
  their
• 16:00
  cannabis
• 16:00
  use
• 16:01
  as
• 16:01
  opposed
• 16:01
  to
• 16:02
  slapping
• 16:02
  on
• 16:03
  a
• 16:03
  new
• 16:03
  medication
• 16:04
  or
• 16:04
  switching
• 16:04
  from
• 16:05
  Risperdal
• 16:05
  to
• 16:06
  Vralar.
• 16:06
  It's
• 16:07
  this
• 16:07
  complicated
• 16:07
  switch,
• 16:08
  potentially.
• 16:08
  It
• 16:09
  doesn't
• 16:09
  go
• 16:09
  well,
• 16:09
  maybe.
• 16:10
  And
• 16:10
  all
• 16:10
  you
• 16:11
  had
• 16:11
  to
• 16:11
  do
• 16:11
  that
• 16:11
  whole
• 16:11
  time
• 16:12
  was
• 16:13
  reduce
• 16:14
  or
• 16:14
  eliminate
• 16:14
  cannabis.
• 16:15
  So
• 16:15
  think
• 16:16
  about
• 16:16
  that,
• 16:16
  right?
• 16:17
  Is
• 16:17
  there
• 16:17
  a
• 16:17
  depression
• 16:18
  going
• 16:18
  on?
• 16:18
  Do
• 16:18
  I
• 16:18
  have
• 16:18
  medication
• 16:19
  side
• 16:19
  effects
• 16:20
  going
• 16:20
  on?
• 16:20
  That
• 16:20
  are
• 16:20
  causing
• 16:20
  motor
• 16:21
  symptoms
• 16:21
  that
• 16:22
  I'm
• 16:22
  mistaking
• 16:23
  for
• 16:23
  slowness,
• 16:24
  that
• 16:24
  I'm
• 16:24
  mistaking
• 16:25
  for
• 16:25
  negative
• 16:25
  symptoms.
• 16:26
  Is
• 16:26
  there
• 16:27
  sedation
• 16:27
  from
• 16:28
  these
• 16:28
  medications?
• 16:28
  Is
• 16:28
  there
• 16:29
  trauma
• 16:29
  that's
• 16:29
  making
• 16:30
  this
• 16:30
  patient
• 16:30
  so
• 16:30
  withdrawn?
• 16:31
  It's
• 16:31
  more
• 16:31
  fear
• 16:32
  based.
• 16:32
  They
• 16:32
  don't
• 16:32
  want
• 16:33
  to
• 16:33
  be
• 16:33
  triggered
• 16:34
  by
• 16:34
  a
• 16:34
  specific
• 16:35
  concrete
• 16:35
  trauma
• 16:36
  in
• 16:36
  their
• 16:36
  environment
• 16:37
  that
• 16:37
  they
• 16:37
  feel
• 16:38
  like
• 16:38
  they
• 16:38
  would
• 16:38
  be
• 16:38
  exposed
• 16:39
  to.
• 16:39
  So
• 16:39
  they
• 16:39
  just
• 16:39
  kind
• 16:39
  of
• 16:40
  withdraw
• 16:40
  into
• 16:40
  a
• 16:40
  traumatic
• 16:41
  shell.
• 16:41
  That,
• 16:42
  of
• 16:42
  course,
• 16:42
  happens
• 16:43
  a
• 16:43
  lot.
• 16:43
  So
• 16:44
  think
• 16:44
  about
• 16:45
  the
• 16:45
  differentiating
• 16:46
  features.
• 16:46
  This
• 16:46
  is
• 16:46
  why
• 16:47
  we
• 16:47
  need
• 16:47
  to
• 16:47
  ask
• 16:47
  good
• 16:47
  questions,
• 16:48
  because
• 16:48
  it
• 16:48
  guides
• 16:49
  our
• 16:49
  treatment.
• 16:50
  Right.
• 16:50
  Very,
• 16:51
  very
• 16:52
  important.
• 16:52
  Now
• 16:52
  remember
• 16:53
  too,
• 16:53
  a
• 16:53
  little
• 16:53
  key.
• 16:54
  With
• 16:54
  depression
• 16:55
  and
• 16:55
  negative
• 16:55
  symptoms,
• 16:56
  in
• 16:56
  addition
• 16:57
  to
• 16:57
  what
• 16:57
  I
• 16:57
  mentioned,
• 16:58
  the
• 16:58
  depression
• 16:58
  is
• 16:58
  more
• 16:58
  episodic
• 16:59
  and
• 16:59
  not
• 16:59
  consistent.
• 17:00
  Remember,
• 17:01
  in
• 17:01
  depression,
• 17:01
  there
• 17:01
  usually
• 17:02
  is
• 17:02
  sadness
• 17:03
  or
• 17:03
  guilt.
• 17:04
  And
• 17:04
  in
• 17:05
  primary
• 17:05
  schizophrenia,
• 17:06
  those
• 17:06
  negative
• 17:07
  symptoms,
• 17:07
  it's
• 17:08
  kind
• 17:08
  of
• 17:08
  absent.
• 17:08
  So
• 17:09
  just
• 17:09
  think
• 17:09
  about
• 17:09
  that
• 17:09
  a
• 17:09
  little
• 17:10
  bit.
• 17:10
  That's
• 17:10
  one
• 17:10
  key
• 17:10
  way
• 17:11
  to
• 17:11
  distinguish
• 17:13
  than
• 17:13
  both.
• 17:13
  Okay.
• 17:15
  And
• 17:15
  if
• 17:15
  it
• 17:16
  is
• 17:16
  truly
• 17:16
  depression
• 17:17
  and
• 17:17
  not
• 17:17
  a
• 17:18
  negative
• 17:18
  symptom
• 17:18
  of
• 17:18
  schizophrenia,
• 17:19
  it
• 17:19
  usually
• 17:20
  will
• 17:20
  get
• 17:20
  better.
• 17:20
  With
• 17:21
  antidepressants,
• 17:22
  there's
• 17:22
  pretty
• 17:23
  good
• 17:23
  evidence
• 17:23
  for
• 17:24
  mirtazapine
• 17:25
  in
• 17:25
  particular
• 17:26
  because
• 17:26
  of
• 17:26
  its
• 17:26
  5ht2a
• 17:27
  blockade.
• 17:28
  We
• 17:28
  have
• 17:28
  whole.
• 17:29
  A
• 17:29
  whole
• 17:30
  beautiful
• 17:30
  presentation
• 17:31
  on
• 17:31
  Patreon
• 17:32
  about
• 17:32
  5ht2a
• 17:33
  and
• 17:33
  how
• 17:33
  incredibly
• 17:34
  important
• 17:34
  that
• 17:34
  targeting
• 17:35
  that
• 17:35
  receptor
• 17:35
  can
• 17:36
  be
• 17:36
  in
• 17:37
  depression
• 17:38
  and
• 17:39
  in
• 17:39
  schizophrenia.
• 17:40
  And
• 17:41
  in
• 17:41
  just.
• 17:41
  It's
• 17:42
  just
• 17:42
  a.
• 17:42
  It's
• 17:43
  a.
• 17:43
  Such
• 17:43
  an
• 17:43
  integral
• 17:43
  receptor
• 17:44
  to
• 17:44
  understand
• 17:45
  psychopharmacology.
• 17:46
  And
• 17:46
  so,
• 17:47
  yeah,
• 17:47
  you're.
• 17:48
  If
• 17:48
  this
• 17:48
  is
• 17:48
  depression,
• 17:49
  antidepressants
• 17:49
  are
• 17:50
  going
• 17:50
  to
• 17:50
  help
• 17:51
  this,
• 17:51
  and
• 17:51
  there
• 17:51
  are
• 17:52
  ways
• 17:52
  to
• 17:53
  do
• 17:53
  that.
• 17:53
  Now,
• 17:54
  risperidone,
• 17:55
  as
• 17:55
  we
• 17:56
  mentioned
• 17:56
  for
• 17:56
  Vic,
• 17:57
  in
• 17:57
  this
• 17:57
  case,
• 17:58
  it's
• 17:58
  too
• 17:59
  potent
• 17:59
  of
• 17:59
  a
• 17:59
  D2
• 18:00
  antagonist.
• 18:01
  It's
• 18:01
  doing
• 18:01
  great
• 18:01
  in
• 18:01
  his
• 18:02
  mesolimbic
• 18:02
  pathway,
• 18:03
  where
• 18:03
  dopamine
• 18:04
  is
• 18:04
  overactive,
• 18:04
  it's
• 18:05
  controlling
• 18:05
  his
• 18:05
  psychosis.
• 18:06
  But
• 18:06
  in
• 18:06
  the
• 18:07
  mesocortical
• 18:07
  pathway,
• 18:08
  where
• 18:09
  dopamine
• 18:09
  is
• 18:09
  already
• 18:10
  low,
• 18:10
  it
• 18:11
  looks
• 18:11
  like
• 18:11
  this
• 18:11
  D2
• 18:12
  blockade
• 18:12
  is
• 18:13
  maybe
• 18:13
  making
• 18:13
  things
• 18:14
  worse
• 18:15
  for
• 18:15
  Mr.
• 18:15
  Vick.
• 18:16
  Okay.
• 18:17
  And
• 18:17
  it's
• 18:18
  making
• 18:18
  him
• 18:18
  not
• 18:19
  want
• 18:19
  to
• 18:19
  reach
• 18:20
  out
• 18:20
  to
• 18:20
  other
• 18:20
  people
• 18:21
  and
• 18:21
  submit
• 18:21
  job
• 18:22
  applications.
• 18:22
  It's
• 18:23
  making
• 18:23
  it
• 18:23
  harder
• 18:23
  for
• 18:23
  him
• 18:23
  to
• 18:24
  enjoy
• 18:24
  things
• 18:25
  that
• 18:25
  he
• 18:25
  used
• 18:25
  to
• 18:25
  love.
• 18:26
  And
• 18:26
  just
• 18:26
  cognitively,
• 18:27
  it's
• 18:27
  kind
• 18:27
  of
• 18:28
  dulling
• 18:28
  him.
• 18:29
  We
• 18:29
  know
• 18:29
  we're
• 18:30
  spirit
• 18:30
  on
• 18:30
  can
• 18:31
  also
• 18:31
  cause
• 18:31
  high
• 18:31
  prolactin,
• 18:32
  of
• 18:32
  course,
• 18:32
  which
• 18:33
  can
• 18:33
  lead
• 18:33
  to
• 18:33
  sexual
• 18:33
  dysfunction,
• 18:34
  kind
• 18:34
  of
• 18:34
  further
• 18:35
  disengagement
• 18:35
  socially.
• 18:36
  And
• 18:37
  we
• 18:37
  need
• 18:37
  to
• 18:37
  target
• 18:37
  D3.
• 18:38
  Vraylar
• 18:39
  is
• 18:39
  a
• 18:39
  really
• 18:40
  good
• 18:40
  medication
• 18:40
  with
• 18:40
  some
• 18:41
  good
• 18:41
  evidence
• 18:42
  that
• 18:42
  specifically
• 18:43
  targets
• 18:43
  D3
• 18:44
  receptors.
• 18:45
  D3
• 18:46
  receptors,
• 18:46
  a
• 18:47
  lot
• 18:47
  of
• 18:47
  them
• 18:47
  live
• 18:47
  in
• 18:47
  the
• 18:47
  nucleus
• 18:48
  accumbens,
• 18:49
  the
• 18:49
  prefrontal
• 18:50
  cortex,
• 18:50
  hippocampus
• 18:51
  Right.
• 18:51
  So
• 18:52
  think
• 18:52
  about
• 18:52
  the
• 18:53
  kind
• 18:53
  of
• 18:53
  limbic
• 18:54
  reward
• 18:54
  motivation
• 18:55
  circuitry
• 18:56
  here.
• 18:56
  In
• 18:56
  other
• 18:57
  words,
• 18:57
  we
• 18:57
  need
• 18:57
  to
• 18:57
  shore
• 18:58
  this
• 18:58
  up
• 18:58
  for
• 18:58
  him
• 18:59
  and
• 18:59
  target
• 18:59
  those
• 19:00
  D3
• 19:00
  receptors.
• 19:01
  Okay.
• 19:02
  They're
• 19:02
  really.
• 19:02
  Those
• 19:02
  D3
• 19:03
  receptors
• 19:03
  are
• 19:03
  really
• 19:04
  enriched
• 19:04
  in
• 19:05
  his
• 19:05
  limbic
• 19:05
  striatum.
• 19:06
  Okay.
• 19:07
  And
• 19:08
  as
• 19:08
  opposed
• 19:08
  to
• 19:08
  D2,
• 19:09
  which
• 19:09
  really
• 19:09
  dominates
• 19:10
  more
• 19:10
  in
• 19:10
  the
• 19:10
  motor
• 19:11
  striatum.
• 19:11
  So
• 19:12
  we're
• 19:12
  trying
• 19:12
  to
• 19:12
  target
• 19:13
  his
• 19:13
  emotional
• 19:13
  response
• 19:14
  to
• 19:15
  the
• 19:15
  future
• 19:16
  to
• 19:16
  get
• 19:17
  a
• 19:17
  little
• 19:17
  more
• 19:17
  motivation
• 19:18
  and
• 19:18
  joy
• 19:19
  in
• 19:19
  his
• 19:19
  life.
• 19:20
  He's
• 19:20
  going
• 19:20
  to
• 19:20
  have
• 19:21
  more
• 19:21
  of
• 19:21
  an
• 19:21
  incentive
• 19:22
  intrinsically
• 19:22
  to
• 19:23
  pursue
• 19:23
  things,
• 19:23
  to
• 19:24
  want
• 19:24
  things,
• 19:24
  to
• 19:24
  motivate
• 19:25
  towards
• 19:25
  things.
• 19:26
  He's
• 19:26
  going
• 19:26
  to
• 19:26
  be
• 19:26
  more
• 19:27
  sensitive
• 19:27
  to
• 19:27
  rewards
• 19:28
  and
• 19:28
  anticipatory
• 19:29
  pleasure.
• 19:29
  His
• 19:30
  cognitive
• 19:30
  and
• 19:30
  executive
• 19:31
  functioning
• 19:32
  are
• 19:32
  going
• 19:32
  to
• 19:32
  be
• 19:32
  enhanced
• 19:33
  by
• 19:34
  targeting
• 19:34
  that
• 19:34
  D3
• 19:35
  receptor.
• 19:35
  His
• 19:35
  emotional
• 19:36
  regulation,
• 19:37
  social
• 19:37
  behavior
• 19:37
  will
• 19:38
  all
• 19:38
  be
• 19:38
  enhanced.
• 19:39
  Very
• 19:40
  important.
• 19:41
  Okay.
• 19:42
  And
• 19:43
  it's
• 19:43
  also
• 19:43
  kind
• 19:43
  of
• 19:44
  a
• 19:44
  cool
• 19:44
  pearl
• 19:44
  to
• 19:44
  know
• 19:45
  that
• 19:45
  vlar
• 19:45
  has
• 19:46
  a
• 19:46
  10
• 19:46
  times
• 19:46
  greater
• 19:47
  affinity
• 19:47
  for
• 19:47
  D3
• 19:48
  than
• 19:48
  D2,
• 19:49
  at
• 19:49
  least
• 19:49
  in
• 19:49
  vitro.
• 19:50
  Okay.
• 19:52
  Anyhow,
• 19:52
  I
• 19:53
  think
• 19:53
  Vlar
• 19:53
  is
• 19:54
  a
• 19:54
  pretty
• 19:54
  cool
• 19:54
  med.
• 19:54
  I
• 19:54
  don't
• 19:55
  use
• 19:55
  it
• 19:55
  all
• 19:55
  the
• 19:55
  time,
• 19:55
  only
• 19:56
  because
• 19:56
  it's
• 19:56
  not
• 19:56
  generic
• 19:57
  yet.
• 19:58
  And
• 19:58
  so
• 19:59
  a
• 19:59
  lot
• 19:59
  of
• 19:59
  my
• 19:59
  patients
• 20:00
  are
• 20:00
  not
• 20:00
  billionaires.
• 20:01
  But
• 20:02
  when
• 20:02
  it
• 20:02
  is
• 20:02
  generic,
• 20:03
  it's
• 20:03
  a
• 20:03
  very
• 20:03
  cool
• 20:04
  medication
• 20:05
  to
• 20:05
  try.
• 20:06
  Or
• 20:06
  if
• 20:06
  you
• 20:06
  have
• 20:07
  to
• 20:07
  fill
• 20:07
  out
• 20:07
  a
• 20:07
  prior
• 20:07
  auth
• 20:08
  and
• 20:08
  you're
• 20:08
  able
• 20:08
  to
• 20:08
  get
• 20:09
  it
• 20:09
  approved,
• 20:10
  it
• 20:10
  could
• 20:10
  be
• 20:10
  a
• 20:11
  very
• 20:11
  good
• 20:11
  idea
• 20:11
  here.
• 20:12
  And
• 20:12
  the
• 20:12
  key,
• 20:12
  though,
• 20:13
  is
• 20:13
  you
• 20:13
  really
• 20:13
  want
• 20:14
  to
• 20:14
  be
• 20:14
  able
• 20:14
  to
• 20:15
  still
• 20:16
  contain
• 20:17
  the
• 20:17
  patient's
• 20:18
  psychosis
• 20:18
  and
• 20:19
  psychotic
• 20:19
  symptoms,
• 20:20
  but
• 20:20
  while
• 20:20
  also
• 20:21
  not
• 20:22
  neglecting
• 20:22
  that
• 20:23
  D3
• 20:23
  receptor,
• 20:24
  which
• 20:24
  is
• 20:25
  implicated
• 20:26
  in
• 20:26
  the
• 20:26
  most
• 20:26
  functional
• 20:27
  disability
• 20:28
  of
• 20:28
  all
• 20:28
  those
• 20:29
  negative
• 20:29
  symptoms.
• 20:29
  And
• 20:30
  so
• 20:30
  VRALAR
• 20:30
  is
• 20:31
  particularly
• 20:32
  important
• 20:33
  as
• 20:33
  it
• 20:33
  relates
• 20:34
  to
• 20:34
  that.
• 20:35
  Okay.
• 20:36
  We've
• 20:36
  also
• 20:37
  talked
• 20:37
  about
• 20:38
  other
• 20:38
  ways
• 20:38
  in
• 20:39
  the
• 20:39
  past
• 20:39
  to
• 20:39
  shore
• 20:40
  up
• 20:40
  some
• 20:40
  negative
• 20:40
  symptoms,
• 20:41
  some
• 20:41
  deficits
• 20:42
  in
• 20:42
  cortical
• 20:43
  areas.
• 20:44
  We've
• 20:44
  talked
• 20:44
  about
• 20:44
  abilify
• 20:45
  with
• 20:45
  its
• 20:45
  D2
• 20:46
  partial
• 20:46
  agonism,
• 20:47
  which
• 20:47
  can
• 20:48
  be
• 20:48
  a
• 20:48
  little
• 20:48
  bit
• 20:49
  better.
• 20:49
  Again,
• 20:50
  kind
• 20:50
  of
• 20:50
  boosting
• 20:51
  the
• 20:51
  mesocortical
• 20:51
  dopamine
• 20:52
  tone,
• 20:53
  allowing
• 20:53
  the
• 20:53
  patient
• 20:54
  to
• 20:54
  focus
• 20:54
  a
• 20:54
  little,
• 20:54
  have
• 20:54
  a
• 20:55
  little
• 20:55
  better
• 20:55
  executive
• 20:56
  functioning.
• 20:57
  There's
• 20:57
  Brexpri.
• 20:58
  Brex,
• 20:58
  Brexpiprazole,
• 20:59
  which
• 20:59
  is
• 21:00
  kind
• 21:00
  of
• 21:00
  a
• 21:00
  new
• 21:00
  kid
• 21:01
  on
• 21:01
  the
• 21:01
  block,
• 21:01
  too.
• 21:02
  Some
• 21:02
  people
• 21:02
  think
• 21:02
  it's
• 21:02
  better
• 21:03
  tolerated
• 21:03
  than
• 21:03
  Abilify.
• 21:04
  A
• 21:04
  little
• 21:04
  bit
• 21:04
  more
• 21:05
  procognitive,
• 21:06
  maybe
• 21:06
  less
• 21:06
  akaesthesia.
• 21:08
  So
• 21:08
  you
• 21:08
  have
• 21:09
  these.
• 21:09
  These
• 21:09
  are
• 21:09
  kind
• 21:10
  of.
• 21:10
  This
• 21:10
  is
• 21:10
  kind
• 21:10
  of
• 21:10
  the
• 21:10
  territory
• 21:11
  you
• 21:12
  may
• 21:12
  want
• 21:12
  to
• 21:12
  float
• 21:12
  in
• 21:13
  if
• 21:13
  you're.
• 21:14
  You
• 21:14
  notice
• 21:14
  your
• 21:15
  patient
• 21:15
  is
• 21:15
  having
• 21:16
  profound
• 21:16
  negative
• 21:17
  symptoms
• 21:17
  and
• 21:17
  you're
• 21:17
  not
• 21:18
  satisfied
• 21:18
  with
• 21:18
  just
• 21:19
  extinguishing
• 21:19
  the
• 21:20
  positive
• 21:20
  ones.
• 21:21
  And
• 21:21
  you
• 21:21
  might
• 21:21
  have
• 21:21
  patients
• 21:22
  that
• 21:22
  perfectly
• 21:22
  love
• 21:23
  Risperdol,
• 21:23
  and
• 21:23
  they
• 21:23
  say,
• 21:24
  I
• 21:24
  absolutely,
• 21:24
  I'm
• 21:24
  doing
• 21:25
  so
• 21:25
  much
• 21:25
  better,
• 21:25
  I
• 21:25
  don't
• 21:25
  want
• 21:25
  to
• 21:26
  change
• 21:26
  it.
• 21:26
  And
• 21:26
  no
• 21:27
  matter
• 21:27
  how
• 21:27
  passionate
• 21:27
  you
• 21:28
  are
• 21:28
  about
• 21:28
  the
• 21:28
  D3
• 21:29
  perceptor,
• 21:29
  your
• 21:30
  patient
• 21:30
  may
• 21:30
  be
• 21:30
  absolutely
• 21:31
  mortified
• 21:32
  at
• 21:32
  the
• 21:32
  idea
• 21:32
  of
• 21:32
  a
• 21:32
  change
• 21:33
  or
• 21:33
  a
• 21:33
  switch.
• 21:34
  And
• 21:34
  then
• 21:34
  maybe
• 21:34
  they've
• 21:35
  been
• 21:35
  fighting
• 21:35
  for
• 21:35
  10
• 21:35
  years
• 21:36
  to
• 21:36
  just
• 21:37
  get
• 21:37
  where
• 21:37
  they
• 21:37
  are
• 21:37
  on
• 21:37
  Risperidone.
• 21:38
  So
• 21:39
  don't
• 21:39
  take
• 21:39
  this
• 21:39
  to
• 21:40
  the
• 21:40
  bank
• 21:40
  either.
• 21:41
  You
• 21:41
  got
• 21:41
  to
• 21:41
  put
• 21:41
  it
• 21:41
  through
• 21:42
  a
• 21:42
  real
• 21:42
  world
• 21:42
  scenario
• 21:43
  and
• 21:43
  say,
• 21:43
  all
• 21:44
  right,
• 21:44
  is
• 21:44
  this
• 21:44
  really
• 21:45
  what
• 21:45
  my
• 21:45
  patient
• 21:45
  wants
• 21:46
  and
• 21:46
  needs
• 21:46
  in
• 21:46
  the
• 21:46
  moment?
• 21:47
  But
• 21:47
  again,
• 21:47
  if
• 21:48
  mom
• 21:48
  is
• 21:48
  coming
• 21:49
  to
• 21:49
  you,
• 21:50
  bringing
• 21:50
  her
• 21:50
  son
• 21:50
  and
• 21:51
  saying,
• 21:51
  hey,
• 21:52
  he's
• 21:52
  a
• 21:52
  shell
• 21:52
  of
• 21:53
  a
• 21:53
  man,
• 21:53
  he's
• 21:54
  no
• 21:54
  longer
• 21:54
  working,
• 21:55
  his
• 21:55
  world
• 21:56
  is
• 21:56
  collapsing,
• 21:57
  we
• 21:57
  need
• 21:57
  to
• 21:57
  do
• 21:58
  something,
• 21:58
  then
• 21:58
  absolutely
• 21:59
  start
• 22:00
  thinking
• 22:00
  negative
• 22:00
  symptoms.
• 22:01
  Do
• 22:01
  a
• 22:01
  good
• 22:01
  inventory
• 22:02
  there
• 22:02
  and
• 22:02
  target
• 22:03
  those
• 22:04
  negative
• 22:04
  symptoms
• 22:04
  with
• 22:04
  vraylar
• 22:05
  via
• 22:05
  the
• 22:06
  D3
• 22:07
  receptor.
• 22:07
  It
• 22:07
  does
• 22:07
  have
• 22:08
  a
• 22:08
  positive
• 22:08
  RCT,
• 22:09
  as
• 22:10
  portrayed
• 22:10
  in
• 22:11
  the
• 22:11
  Lancet
• 22:11
  in
• 22:12
  2017.
• 22:14
  Only
• 22:14
  one,
• 22:14
  but
• 22:14
  it
• 22:14
  does
• 22:15
  have
• 22:15
  a
• 22:15
  positive
• 22:15
  RCT,
• 22:17
  and
• 22:17
  it
• 22:18
  was
• 22:18
  a
• 22:18
  negative
• 22:18
  symptom
• 22:19
  trial.
• 22:19
  It
• 22:19
  does.
• 22:20
  It
• 22:20
  has
• 22:20
  been
• 22:20
  shown
• 22:20
  to
• 22:21
  improve
• 22:21
  functioning.
• 22:22
  Of
• 22:22
  course,
• 22:22
  Akesthesia
• 22:23
  is
• 22:23
  a
• 22:23
  problem
• 22:23
  with
• 22:23
  it,
• 22:24
  too.
• 22:24
  All
• 22:24
  of
• 22:24
  these
• 22:25
  medications
• 22:25
  have
• 22:26
  potential
• 22:27
  drawbacks,
• 22:28
  but
• 22:28
  it's
• 22:28
  a
• 22:29
  very
• 22:29
  good
• 22:29
  target
• 22:30
  for
• 22:31
  you
• 22:32
  to
• 22:32
  shore
• 22:33
  up
• 22:33
  negative
• 22:34
  symptoms.
• 22:34
  There
• 22:35
  is
• 22:35
  some
• 22:35
  evidence,
• 22:35
  again,
• 22:36
  we
• 22:36
  talked
• 22:36
  about
• 22:36
  mirtazapine,
• 22:38
  and
• 22:38
  it.
• 22:39
  It's
• 22:39
  5ht2a
• 22:40
  antagonism.
• 22:42
  Very
• 22:42
  important.
• 22:43
  The
• 22:43
  Alpha
• 22:43
  2
• 22:44
  antagonism
• 22:44
  that
• 22:44
  boosts
• 22:45
  prefrontal
• 22:46
  cortex,
• 22:47
  dopamine
• 22:47
  and
• 22:47
  norepinephrine,
• 22:48
  serotonin.
• 22:49
  So
• 22:49
  that's
• 22:49
  pretty
• 22:50
  cool,
• 22:50
  too.
• 22:50
  It
• 22:50
  kind
• 22:50
  of
• 22:51
  disinhibits
• 22:51
  those
• 22:52
  neurotransmitters.
• 22:53
  I'm
• 22:53
  a
• 22:53
  huge
• 22:54
  fan
• 22:54
  of
• 22:54
  Remeron
• 22:55
  for
• 22:55
  those
• 22:55
  reasons.
• 22:55
  We
• 22:55
  talk
• 22:56
  about
• 22:56
  how
• 22:56
  it
• 22:56
  can
• 22:56
  kind
• 22:56
  of
• 22:57
  undo
• 22:57
  some
• 22:58
  of
• 22:58
  the
• 22:58
  unpleasant
• 22:59
  side
• 22:59
  effects
• 23:00
  that
• 23:00
  are
• 23:01
  generated
• 23:01
  by
• 23:01
  SSRIs.
• 23:03
  One
• 23:03
  of
• 23:03
  those,
• 23:03
  of
• 23:04
  course,
• 23:04
  is
• 23:04
  when
• 23:04
  SSRIs
• 23:05
  activate
• 23:05
  5HT2A,
• 23:07
  it
• 23:07
  can
• 23:07
  be
• 23:07
  a
• 23:08
  little
• 23:08
  anxiety
• 23:08
  provoking,
• 23:09
  a
• 23:09
  little
• 23:09
  overstimulating.
• 23:10
  And
• 23:11
  so
• 23:11
  mirtazapine
• 23:12
  can
• 23:12
  be
• 23:12
  slapped
• 23:13
  on
• 23:13
  there
• 23:13
  not
• 23:14
  only
• 23:14
  to,
• 23:14
  like,
• 23:14
  help
• 23:15
  reverse
• 23:15
  sexual
• 23:16
  side
• 23:16
  effects,
• 23:16
  but
• 23:17
  also
• 23:17
  to
• 23:17
  calm
• 23:18
  a
• 23:18
  lot
• 23:18
  of
• 23:18
  that
• 23:19
  cortical
• 23:19
  overstimulation
• 23:21
  and
• 23:21
  help
• 23:22
  you
• 23:22
  sleep,
• 23:22
  which
• 23:22
  is
• 23:23
  one
• 23:23
  of
• 23:23
  the
• 23:23
  reasons
• 23:23
  I
• 23:23
  love
• 23:24
  it
• 23:24
  more
• 23:24
  than
• 23:24
  any
• 23:25
  other
• 23:25
  medication.
• 23:25
  It
• 23:25
  does
• 23:26
  cause
• 23:26
  weight
• 23:26
  gain.
• 23:27
  That's
• 23:27
  a
• 23:27
  problem.
• 23:28
  But
• 23:29
  has
• 23:29
  some
• 23:30
  evidence
• 23:30
  here
• 23:30
  if
• 23:30
  you're
• 23:30
  looking
• 23:31
  at
• 23:31
  negative
• 23:31
  symptoms,
• 23:32
  especially
• 23:32
  if
• 23:32
  you
• 23:32
  feel
• 23:33
  like
• 23:33
  the
• 23:34
  negative
• 23:34
  symptoms
• 23:34
  also
• 23:35
  overlap
• 23:35
  with
• 23:36
  true
• 23:36
  depression.
• 23:37
  Of
• 23:37
  course,
• 23:37
  the
• 23:37
  incidence
• 23:38
  of
• 23:38
  depression,
• 23:38
  as
• 23:39
  you
• 23:39
  can
• 23:39
  imagine,
• 23:39
  is
• 23:40
  exorbitantly
• 23:41
  higher
• 23:41
  in
• 23:41
  schizophrenia
• 23:43
  than
• 23:43
  in
• 23:44
  the
• 23:44
  absence
• 23:44
  of
• 23:44
  Schizophrenia.
• 23:45
  So
• 23:46
  screen
• 23:46
  for
• 23:46
  it
• 23:46
  anyway.
• 23:47
  Don't
• 23:47
  just
• 23:47
  assume
• 23:47
  negative
• 23:48
  symptoms
• 23:49
  are
• 23:49
  negative
• 23:49
  symptoms.
• 23:50
  You
• 23:50
  could
• 23:50
  have
• 23:50
  both
• 23:51
  of
• 23:51
  them
• 23:51
  happening
• 23:51
  at
• 23:51
  the
• 23:52
  same
• 23:52
  time.
• 23:53
  And
• 23:53
  so
• 23:53
  you
• 23:53
  will
• 23:54
  get
• 23:54
  some
• 23:54
  prefrontal
• 23:55
  cortex
• 23:56
  enhancement
• 23:57
  with
• 23:57
  mirtazapine
• 23:58
  and
• 23:58
  challenge
• 23:59
  those
• 23:59
  negative
• 23:59
  side
• 23:59
  effects
• 24:00
  anyway,
• 24:00
  especially
• 24:00
  if
• 24:00
  they're
• 24:01
  dealing
• 24:01
  with
• 24:02
  insomnia
• 24:02
  and
• 24:02
  depression.
• 24:03
  So
• 24:04
  there's
• 24:04
  some
• 24:04
  evidence
• 24:04
  there.
• 24:05
  It
• 24:05
  also
• 24:05
  has
• 24:05
  potent
• 24:06
  5ht2
• 24:06
  a
• 24:07
  blockade.
• 24:07
  Okay.
• 24:08
  Again,
• 24:09
  disinhibiting
• 24:09
  that
• 24:10
  cortical
• 24:10
  dopamine.
• 24:11
  So
• 24:11
  you
• 24:11
  have
• 24:11
  more
• 24:11
  dopamine
• 24:12
  in
• 24:12
  the.
• 24:13
  In
• 24:13
  the
• 24:13
  cortical
• 24:13
  areas
• 24:14
  of
• 24:14
  the
• 24:14
  brain.
• 24:14
  You
• 24:14
  can
• 24:15
  focus
• 24:15
  more,
• 24:15
  you
• 24:16
  can
• 24:16
  pay
• 24:16
  attention
• 24:17
  more,
• 24:17
  you
• 24:17
  can
• 24:17
  initiate
• 24:18
  motivate
• 24:18
  to
• 24:18
  tasks
• 24:19
  a
• 24:19
  little
• 24:19
  easier.
• 24:20
  Okay?
• 24:21
  So
• 24:21
  you
• 24:21
  have
• 24:21
  options,
• 24:22
  and
• 24:23
  it's
• 24:24
  good
• 24:24
  to
• 24:24
  think
• 24:24
  of
• 24:24
  all
• 24:25
  of
• 24:25
  the
• 24:25
  tools
• 24:25
  you
• 24:26
  have
• 24:26
  in
• 24:26
  your
• 24:26
  toolkit.
• 24:27
  You
• 24:27
  have
• 24:27
  Some
• 24:28
  really
• 24:28
  potent
• 24:29
  D2
• 24:29
  blockers
• 24:30
  that
• 24:30
  can
• 24:31
  restore
• 24:31
  a
• 24:32
  sense
• 24:32
  of
• 24:32
  normalcy
• 24:33
  rather
• 24:33
  quickly
• 24:34
  via
• 24:34
  D2
• 24:34
  blockade
• 24:35
  for
• 24:35
  hallucinations
• 24:36
  and
• 24:36
  delusions.
• 24:36
  But
• 24:37
  remember,
• 24:37
  you're
• 24:37
  not
• 24:37
  quite
• 24:38
  done
• 24:38
  yet.
• 24:39
  And
• 24:39
  it
• 24:39
  may
• 24:39
  be
• 24:39
  good
• 24:40
  to
• 24:40
  try
• 24:41
  and
• 24:41
  gravitate
• 24:41
  towards
• 24:42
  medications
• 24:43
  that
• 24:43
  don't
• 24:44
  just
• 24:45
  attenuate
• 24:45
  the
• 24:46
  psychotic
• 24:46
  symptoms,
• 24:47
  but
• 24:47
  also
• 24:48
  improve
• 24:49
  the
• 24:49
  negative
• 24:50
  symptoms.
• 24:51
  Right.
• 24:52
  And
• 24:53
  one
• 24:53
  little
• 24:53
  cool
• 24:53
  thing
• 24:53
  about
• 24:54
  Ralar,
• 24:54
  too,
• 24:55
  in
• 24:55
  particular,
• 24:56
  is
• 24:57
  that
• 24:57
  it
• 24:58
  does
• 24:58
  have
• 24:58
  that
• 24:58
  partial
• 24:59
  agonism
• 24:59
  and
• 24:59
  partial
• 25:00
  agonism
• 25:00
  at
• 25:01
  D2
• 25:01
  in
• 25:02
  theory.
• 25:02
  Right?
• 25:02
  It
• 25:02
  reduces
• 25:03
  dopamine
• 25:04
  output
• 25:04
  when
• 25:04
  the
• 25:04
  concentrations
• 25:05
  are
• 25:05
  too
• 25:05
  high,
• 25:06
  and
• 25:06
  that
• 25:07
  can
• 25:07
  improve
• 25:08
  positive
• 25:08
  symptoms.
• 25:09
  And
• 25:09
  then
• 25:09
  it
• 25:09
  can
• 25:10
  also
• 25:10
  increase
• 25:10
  dopamine
• 25:11
  output
• 25:11
  where
• 25:11
  the
• 25:12
  concentrations
• 25:12
  are
• 25:13
  low,
• 25:13
  which
• 25:13
  help
• 25:14
  his
• 25:15
  cognitive,
• 25:15
  negative,
• 25:16
  and
• 25:16
  mood
• 25:16
  symptoms.
• 25:17
  Right.
• 25:18
  That's
• 25:18
  the
• 25:18
  magic
• 25:19
  of
• 25:19
  these
• 25:20
  D2
• 25:21
  partial
• 25:21
  agonists.
• 25:22
  They're.
• 25:22
  They
• 25:22
  act
• 25:23
  as
• 25:23
  dimmer
• 25:23
  switches,
• 25:24
  but
• 25:24
  they
• 25:24
  help.
• 25:24
  They
• 25:25
  help
• 25:25
  there.
• 25:26
  And
• 25:26
  so
• 25:26
  you
• 25:26
  can
• 25:26
  kind
• 25:27
  of
• 25:27
  hedge
• 25:27
  and
• 25:28
  you
• 25:28
  can
• 25:28
  kind
• 25:28
  of
• 25:28
  balance,
• 25:29
  but
• 25:29
  watch
• 25:29
  out
• 25:29
  for
• 25:30
  that
• 25:30
  akasthesia,
• 25:31
  of
• 25:31
  course,
• 25:31
  because
• 25:31
  I
• 25:31
  have
• 25:31
  had
• 25:32
  patients
• 25:32
  that
• 25:33
  absolutely
• 25:33
  can't
• 25:34
  tolerate
• 25:34
  that.
• 25:34
  It
• 25:34
  is
• 25:35
  very
• 25:36
  debilitating,
• 25:36
  actually,
• 25:37
  when
• 25:37
  it's
• 25:37
  happening.
• 25:38
  It's
• 25:38
  very
• 25:38
  scary.
• 25:39
  There's
• 25:39
  some
• 25:39
  evidence
• 25:40
  that
• 25:40
  it
• 25:40
  actually
• 25:41
  catalyzes
• 25:42
  suicidality
• 25:43
  and
• 25:43
  can
• 25:43
  make
• 25:43
  that
• 25:44
  worse.
• 25:44
  So
• 25:44
  definitely
• 25:45
  watch
• 25:45
  out.
• 25:46
  Akaesthesia
• 25:47
  is
• 25:47
  nothing
• 25:47
  to
• 25:47
  sneeze
• 25:48
  at.
• 25:48
  It's
• 25:48
  more
• 25:49
  of
• 25:49
  an
• 25:49
  inner
• 25:50
  muscle
• 25:50
  restlessness,
• 25:52
  and
• 25:52
  it's
• 25:52
  really
• 25:52
  debilitating
• 25:53
  and
• 25:53
  scary.
• 25:54
  And
• 25:54
  patients
• 25:55
  don't
• 25:55
  always
• 25:55
  know
• 25:55
  what
• 25:56
  it
• 25:56
  is.
• 25:56
  And
• 25:56
  they're
• 25:56
  gonna
• 25:56
  tell
• 25:57
  you
• 25:57
  they're
• 25:57
  more
• 25:57
  anxious,
• 25:58
  and
• 25:58
  maybe
• 25:58
  they're
• 25:58
  pacing
• 25:59
  more,
• 25:59
  and
• 25:59
  you're
• 25:59
  gonna
• 26:00
  go,
• 26:00
  oh,
• 26:00
  I
• 26:00
  need
• 26:00
  to
• 26:00
  raise
• 26:01
  their
• 26:01
  antipsychotic.
• 26:01
  Well,
• 26:02
  no,
• 26:02
  we
• 26:02
  don't
• 26:02
  need
• 26:02
  to
• 26:02
  raise
• 26:03
  their
• 26:03
  antipsychotic.
• 26:04
  That
• 26:04
  would
• 26:04
  make
• 26:04
  things
• 26:04
  even
• 26:05
  worse
• 26:05
  because
• 26:05
  their
• 26:05
  anesthesia
• 26:06
  would
• 26:07
  significantly
• 26:08
  worsen.
• 26:09
  All
• 26:09
  right,
• 26:09
  my
• 26:10
  friends,
• 26:10
  now,
• 26:10
  I
• 26:11
  hope
• 26:11
  you
• 26:11
  enjoyed
• 26:11
  and
• 26:12
  appreciated
• 26:13
  the
• 26:13
  significance
• 26:14
  of
• 26:15
  negative
• 26:15
  symptoms
• 26:16
  and
• 26:16
  how
• 26:16
  functionally
• 26:17
  disabling
• 26:17
  they
• 26:17
  are.
• 26:18
  I
• 26:18
  hope
• 26:18
  it
• 26:18
  leads
• 26:19
  you
• 26:19
  to
• 26:19
  reflect
• 26:20
  upon
• 26:21
  just
• 26:21
  how
• 26:21
  serious
• 26:22
  this
• 26:22
  is
• 26:22
  and
• 26:22
  what
• 26:22
  the
• 26:23
  personal,
• 26:23
  concrete
• 26:24
  implications
• 26:24
  are
• 26:24
  for
• 26:24
  your
• 26:25
  patients.
• 26:25
  I
• 26:25
  hope
• 26:26
  you
• 26:26
  learn
• 26:26
  to
• 26:27
  appreciate
• 26:27
  and
• 26:28
  you
• 26:28
  will
• 26:28
  think
• 26:28
  about
• 26:28
  the
• 26:29
  D3
• 26:29
  receptor
• 26:30
  and
• 26:30
  how
• 26:30
  magical
• 26:31
  that
• 26:31
  receptor
• 26:31
  can
• 26:31
  be
• 26:32
  and
• 26:32
  which
• 26:32
  medications
• 26:32
  specifically
• 26:33
  target
• 26:33
  it.
• 26:34
  And
• 26:34
  if
• 26:34
  you
• 26:34
  can't
• 26:35
  target
• 26:35
  D3
• 26:36
  because
• 26:36
  of
• 26:36
  the
• 26:36
  fact
• 26:37
  that
• 26:37
  it
• 26:37
  causes
• 26:37
  too
• 26:37
  much
• 26:37
  akaesthesia
• 26:38
  or
• 26:38
  it's
• 26:39
  unaffordable
• 26:39
  with
• 26:40
  the
• 26:40
  patient's
• 26:40
  insurance
• 26:41
  that
• 26:41
  you
• 26:41
  still
• 26:41
  have
• 26:42
  other
• 26:42
  ways
• 26:42
  to
• 26:42
  improve
• 26:43
  or
• 26:44
  to
• 26:44
  influence
• 26:44
  the
• 26:45
  prefrontal
• 26:45
  cortex
• 26:46
  a
• 26:46
  little
• 26:46
  bit
• 26:47
  more
• 26:47
  and
• 26:47
  enhance
• 26:48
  cognition
• 26:48
  and
• 26:48
  motivation.
• 26:49
  You
• 26:49
  can
• 26:49
  do
• 26:49
  that
• 26:49
  through
• 26:50
  5ht2
• 26:51
  a
• 26:51
  blockade
• 26:51
  with
• 26:52
  Remeron
• 26:52
  or
• 26:52
  Zyprexa.
• 26:53
  You
• 26:53
  can
• 26:54
  do
• 26:54
  that.
• 26:54
  You
• 26:54
  can
• 26:55
  accomplish
• 26:55
  it.
• 26:56
  And
• 26:56
  so
• 26:56
  there's
• 26:56
  many
• 26:56
  ways
• 26:57
  to
• 26:57
  skin
• 26:57
  a
• 26:57
  cat,
• 26:57
  if
• 26:58
  you
• 26:58
  will.
• 26:58
  And
• 26:58
  my
• 26:59
  friends,
• 26:59
  if
• 27:00
  there's
• 27:00
  one
• 27:00
  thing
• 27:01
  that
• 27:01
  you
• 27:02
  remind
• 27:03
  yourself
• 27:03
  of
• 27:03
  before
• 27:04
  you
• 27:04
  go
• 27:04
  to
• 27:04
  bed
• 27:04
  today,
• 27:05
  there's
• 27:05
  one
• 27:05
  thing
• 27:05
  before
• 27:06
  you
• 27:06
  hit
• 27:06
  that
• 27:06
  pillow.
• 27:07
  I
• 27:07
  definitely
• 27:08
  urge
• 27:08
  you
• 27:08
  to
• 27:08
  go
• 27:09
  to
• 27:09
  our
• 27:09
  show
• 27:09
  notes
• 27:09
  after
• 27:10
  this,
• 27:10
  click
• 27:10
  our
• 27:10
  Patreon
• 27:11
  link
• 27:11
  and
• 27:12
  become
• 27:12
  a
• 27:12
  Patreon
• 27:13
  member.
• 27:13
  Because
• 27:13
  we
• 27:13
  have
• 27:14
  a
• 27:14
  full
• 27:14
  clinical
• 27:14
  library
• 27:15
  here.
• 27:15
  I
• 27:16
  don't
• 27:16
  know
• 27:16
  what
• 27:16
  I
• 27:16
  would
• 27:17
  do
• 27:17
  without
• 27:17
  this
• 27:18
  library
• 27:18
  that
• 27:18
  I
• 27:19
  made
• 27:19
  for
• 27:19
  myself.
• 27:20
  I
• 27:20
  feel
• 27:20
  so
• 27:21
  much
• 27:21
  stronger
• 27:21
  and
• 27:21
  more
• 27:21
  confident
• 27:22
  as
• 27:22
  a
• 27:22
  clinician.
• 27:22
  I
• 27:23
  feel
• 27:23
  like
• 27:23
  I'm
• 27:23
  connecting
• 27:24
  more
• 27:24
  with
• 27:24
  my
• 27:24
  patients.
• 27:25
  I'm
• 27:25
  able
• 27:25
  to
• 27:25
  give
• 27:25
  them
• 27:26
  really
• 27:26
  good
• 27:27
  information.
• 27:27
  It
• 27:28
  enhances
• 27:28
  their
• 27:28
  outcomes.
• 27:29
  Remember,
• 27:30
  the
• 27:30
  difference
• 27:30
  between
• 27:30
  a
• 27:31
  good
• 27:31
  and
• 27:31
  great
• 27:32
  clinician
• 27:32
  is
• 27:33
  somebody
• 27:33
  who
• 27:33
  understands
• 27:34
  the
• 27:34
  how
• 27:34
  and
• 27:34
  the
• 27:34
  why
• 27:35
  behind
• 27:35
  what
• 27:35
  they're
• 27:35
  doing.
• 27:36
  Right?
• 27:36
  It's
• 27:36
  not
• 27:37
  enough
• 27:37
  to
• 27:38
  just
• 27:38
  follow
• 27:38
  an
• 27:39
  algorithm,
• 27:39
  hand
• 27:40
  out
• 27:40
  a
• 27:40
  medication,
• 27:41
  dish
• 27:41
  out
• 27:42
  a
• 27:42
  diagnosis.
• 27:43
  Understanding
• 27:43
  the
• 27:43
  how
• 27:44
  and
• 27:44
  why,
• 27:44
  being
• 27:44
  able
• 27:45
  to
• 27:45
  to
• 27:45
  articulate
• 27:46
  that
• 27:46
  to
• 27:46
  a
• 27:46
  patient
• 27:47
  is
• 27:47
  so
• 27:47
  darn
• 27:48
  important
• 27:48
  for
• 27:48
  the
• 27:49
  therapeutic
• 27:49
  relationship,
• 27:50
  for
• 27:50
  how
• 27:50
  smooth
• 27:51
  your
• 27:51
  clinic
• 27:51
  runs,
• 27:52
  for
• 27:52
  your
• 27:52
  patient
• 27:52
  outcomes.
• 27:53
  And
• 27:53
  our
• 27:53
  Patreon
• 27:53
  library
• 27:54
  is
• 27:54
  absolutely
• 27:55
  dedicated
• 27:55
  for
• 27:56
  that
• 27:56
  and
• 27:56
  it
• 27:56
  will
• 27:56
  transform
• 27:57
  the
• 27:57
  way
• 27:57
  you
• 27:57
  practice.
• 27:58
  Head
• 27:58
  on
• 27:58
  over
• 27:58
  there,
• 27:59
  my
• 27:59
  friends,
• 27:59
  and
• 27:59
  thank
• 28:00
  you
• 28:00
  for
• 28:00
  tuning
• 28:00
  in
• 28:00
  again
• 28:01
  to
• 28:01
  another
• 28:01
  episode
• 28:02
  of
• 28:02
  Pearls
• 28:02
  and
• 28:02
  prep.