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Navigating Acute Dystonias: Clinical Insights and Management · Pearls and Prep

• 0:00
  Foreign.
• 0:04
  Welcome
• 0:04
  back,
• 0:04
  my
• 0:05
  friends,
• 0:05
  to
• 0:05
  another
• 0:05
  episode
• 0:06
  of
• 0:06
  Pearls
• 0:07
  and
• 0:07
  Prep.
• 0:07
  We
• 0:08
  have
• 0:08
  a
• 0:08
  doozy
• 0:09
  for
• 0:09
  you
• 0:10
  today.
• 0:10
  We
• 0:10
  are
• 0:11
  going
• 0:11
  to
• 0:11
  talk
• 0:11
  about
• 0:12
  dystonias,
• 0:13
  that
• 0:14
  term
• 0:14
  that
• 0:14
  you're
• 0:15
  asking
• 0:15
  yourself,
• 0:15
  what
• 0:16
  do
• 0:16
  I
• 0:16
  do
• 0:16
  if
• 0:16
  I
• 0:17
  see
• 0:17
  a
• 0:17
  dystonia
• 0:18
  in
• 0:19
  the
• 0:19
  outpatient
• 0:19
  space?
• 0:20
  What
• 0:20
  is
• 0:20
  dystonia?
• 0:21
  How
• 0:21
  do
• 0:21
  I
• 0:21
  manage
• 0:22
  it?
• 0:22
  What
• 0:22
  does
• 0:22
  it
• 0:23
  mean?
• 0:23
  We're
• 0:23
  going
• 0:23
  to
• 0:23
  demystify
• 0:24
  that
• 0:24
  today
• 0:25
  with
• 0:25
  a
• 0:25
  mock
• 0:25
  patient
• 0:26
  patient
• 0:26
  case
• 0:26
  named
• 0:27
  Mario.
• 0:28
  Mario
• 0:29
  was
• 0:30
  started
• 0:30
  on
• 0:30
  risperidol
• 0:32
  within
• 0:32
  the
• 0:32
  last
• 0:33
  week.
• 0:33
  He's
• 0:33
  up
• 0:34
  to
• 0:34
  about
• 0:34
  1.5mg
• 0:35
  bid
• 0:36
  now
• 0:37
  for
• 0:37
  a
• 0:37
  first
• 0:37
  episode
• 0:38
  psychosis.
• 0:40
  He's
• 0:40
  coming
• 0:40
  to
• 0:40
  you
• 0:41
  saying,
• 0:41
  my
• 0:42
  neck
• 0:42
  is
• 0:42
  killing
• 0:42
  me.
• 0:43
  It's
• 0:43
  just
• 0:43
  twisting
• 0:43
  on
• 0:44
  its
• 0:44
  own
• 0:44
  and
• 0:44
  it
• 0:44
  won't
• 0:45
  relax.
• 0:45
  It
• 0:45
  hurts
• 0:46
  and
• 0:46
  it
• 0:46
  feels
• 0:47
  stuck.
• 0:48
  His
• 0:48
  neck
• 0:49
  is
• 0:49
  rotated
• 0:49
  to
• 0:49
  the
• 0:50
  right
• 0:50
  a
• 0:50
  little
• 0:50
  bit.
• 0:51
  He's
• 0:51
  got
• 0:51
  some
• 0:51
  tight
• 0:52
  muscle
• 0:53
  contractions.
• 0:53
  He
• 0:54
  doesn't
• 0:54
  have
• 0:54
  a
• 0:54
  fever.
• 0:54
  He's
• 0:55
  not
• 0:55
  confused.
• 0:55
  His
• 0:55
  vital
• 0:56
  signs
• 0:56
  are
• 0:56
  otherwise
• 0:57
  stable.
• 0:57
  He's
• 0:57
  mentally
• 0:57
  alert
• 0:58
  and
• 0:58
  anxious,
• 0:59
  asking
• 0:59
  if
• 0:59
  he's
• 0:59
  paralyzed.
• 1:00
  He
• 1:00
  has
• 1:00
  no
• 1:01
  trouble
• 1:01
  swallowing
• 1:01
  or
• 1:02
  breathing.
• 1:02
  You
• 1:03
  recognize
• 1:03
  this
• 1:03
  as
• 1:04
  an
• 1:04
  acute
• 1:05
  dystonia
• 1:05
  from
• 1:06
  risperidone
• 1:07
  starting
• 1:07
  recently.
• 1:07
  And
• 1:08
  if
• 1:08
  you're
• 1:08
  in
• 1:08
  the
• 1:08
  clinic
• 1:09
  and
• 1:09
  you
• 1:09
  have
• 1:09
  the
• 1:09
  tools
• 1:10
  to
• 1:10
  do
• 1:10
  this,
• 1:11
  intramuscular
• 1:12
  benztropine
• 1:13
  would
• 1:13
  be
• 1:14
  the
• 1:14
  way
• 1:14
  to
• 1:14
  do
• 1:14
  this.
• 1:15
  That
• 1:15
  would
• 1:15
  probably
• 1:16
  be
• 1:16
  about
• 1:16
  2
• 1:16
  milligrams
• 1:17
  in
• 1:17
  the
• 1:17
  clinic.
• 1:17
  Now,
• 1:18
  we're
• 1:18
  going
• 1:18
  to
• 1:18
  go
• 1:18
  into
• 1:18
  more
• 1:19
  of
• 1:19
  this
• 1:19
  a
• 1:19
  little
• 1:19
  bit
• 1:20
  later.
• 1:20
  I
• 1:20
  don't
• 1:21
  want
• 1:21
  you
• 1:21
  to
• 1:21
  focus
• 1:21
  so
• 1:22
  much
• 1:22
  on
• 1:23
  the
• 1:24
  specifics
• 1:24
  of
• 1:24
  Mario
• 1:25
  today.
• 1:25
  I
• 1:25
  want
• 1:26
  you
• 1:26
  to
• 1:26
  conceptualize
• 1:27
  this
• 1:27
  more
• 1:27
  broadly
• 1:28
  about
• 1:29
  what's
• 1:29
  happening,
• 1:29
  why
• 1:30
  it's
• 1:30
  happening,
• 1:31
  how
• 1:31
  often
• 1:31
  does
• 1:32
  this
• 1:32
  happen?
• 1:33
  That's
• 1:33
  really
• 1:34
  what
• 1:34
  we
• 1:34
  want
• 1:34
  to
• 1:35
  wrap
• 1:35
  our
• 1:35
  heads
• 1:36
  around
• 1:36
  today
• 1:36
  before
• 1:37
  we
• 1:37
  get
• 1:37
  into
• 1:38
  the
• 1:38
  nitty
• 1:38
  gritty
• 1:39
  of
• 1:39
  how
• 1:39
  to
• 1:40
  treat
• 1:40
  this.
• 1:40
  I
• 1:40
  know
• 1:40
  we
• 1:40
  just
• 1:41
  mentioned
• 1:41
  the
• 1:41
  IM
• 1:42
  benztrapine,
• 1:43
  but
• 1:44
  I
• 1:44
  want
• 1:44
  to
• 1:44
  get
• 1:44
  into
• 1:45
  an
• 1:45
  overarching
• 1:47
  definition
• 1:47
  of
• 1:47
  dystonia
• 1:48
  and
• 1:48
  what
• 1:49
  this
• 1:49
  is.
• 1:49
  So,
• 1:49
  dystonia
• 1:50
  is
• 1:50
  a
• 1:50
  neurological
• 1:51
  movement
• 1:51
  disorder
• 1:52
  where
• 1:52
  muscles
• 1:53
  contract
• 1:53
  involuntarily,
• 1:54
  causing
• 1:54
  twisting,
• 1:55
  repetitive
• 1:55
  movements
• 1:56
  or
• 1:56
  abnormal
• 1:57
  postures.
• 1:58
  Movements
• 1:58
  are
• 1:58
  often
• 1:59
  sustained
• 2:00
  or
• 2:00
  jerky.
• 2:00
  They
• 2:01
  can
• 2:01
  affect
• 2:01
  any
• 2:01
  body
• 2:02
  part,
• 2:02
  commonly
• 2:02
  the
• 2:03
  neck,
• 2:03
  the
• 2:03
  eyes,
• 2:03
  the
• 2:03
  shoulders,
• 2:04
  the
• 2:04
  jaw,
• 2:04
  or
• 2:05
  the
• 2:05
  limbs.
• 2:05
  It
• 2:06
  worsens
• 2:06
  with
• 2:06
  voluntary
• 2:07
  movement
• 2:07
  and
• 2:08
  with
• 2:08
  stress.
• 2:08
  You
• 2:09
  try
• 2:09
  to
• 2:09
  write
• 2:09
  with
• 2:09
  your
• 2:09
  hand
• 2:10
  and
• 2:10
  instead
• 2:10
  your
• 2:10
  wrist
• 2:11
  twists
• 2:11
  or
• 2:12
  your
• 2:12
  shoulder
• 2:12
  lifts
• 2:13
  without
• 2:13
  you
• 2:13
  really
• 2:13
  meaning
• 2:14
  to.
• 2:14
  Well,
• 2:14
  dystonia
• 2:15
  has
• 2:15
  Greek
• 2:16
  origins
• 2:16
  in
• 2:16
  its
• 2:17
  word
• 2:17
  dys,
• 2:17
  meaning
• 2:18
  bad
• 2:18
  or
• 2:18
  abnormal,
• 2:19
  and
• 2:19
  tonos,
• 2:20
  meaning
• 2:20
  tension
• 2:20
  or
• 2:20
  muscle
• 2:21
  tone.
• 2:21
  So
• 2:21
  dystonia
• 2:22
  literally
• 2:22
  means
• 2:23
  abnormal
• 2:24
  muscle
• 2:24
  tone.
• 2:25
  We're
• 2:25
  talking
• 2:25
  about
• 2:26
  sustained,
• 2:26
  involuntary
• 2:27
  muscle
• 2:28
  contractions
• 2:29
  causing
• 2:29
  twisting,
• 2:29
  abnormal
• 2:30
  postures
• 2:30
  or
• 2:31
  repetitive
• 2:31
  movements.
• 2:32
  Some
• 2:32
  Dystonias
• 2:33
  are
• 2:34
  medical
• 2:34
  emergencies.
• 2:35
  If
• 2:35
  the
• 2:36
  tongue,
• 2:36
  the
• 2:36
  pharynx
• 2:37
  or
• 2:37
  larynx
• 2:37
  are
• 2:37
  involved,
• 2:38
  Right.
• 2:38
  And
• 2:38
  we're
• 2:38
  hearing
• 2:39
  stridor
• 2:39
  or
• 2:39
  choking
• 2:40
  or
• 2:40
  airway
• 2:40
  obstruction,
• 2:41
  those
• 2:41
  are
• 2:41
  true
• 2:42
  medical
• 2:42
  emergencies.
• 2:43
  Patients
• 2:43
  need
• 2:44
  to
• 2:44
  go
• 2:44
  to
• 2:44
  the
• 2:44
  ER
• 2:44
  immediately
• 2:45
  for
• 2:45
  airway
• 2:46
  support.
• 2:47
  We're
• 2:47
  not
• 2:47
  going
• 2:47
  to
• 2:47
  focus
• 2:47
  too
• 2:48
  much
• 2:48
  on
• 2:48
  that
• 2:48
  today,
• 2:50
  but
• 2:51
  we
• 2:51
  are
• 2:51
  going
• 2:52
  to
• 2:52
  focus
• 2:52
  on
• 2:52
  a
• 2:52
  dystonia
• 2:53
  that
• 2:53
  lands
• 2:53
  in
• 2:54
  your
• 2:54
  office.
• 2:54
  And
• 2:54
  it
• 2:55
  is
• 2:56
  very
• 2:56
  uncomfortable,
• 2:57
  but
• 2:57
  not
• 2:57
  necessarily
• 2:58
  life
• 2:58
  threatening.
• 2:59
  You
• 2:59
  always
• 2:59
  have
• 2:59
  to
• 3:00
  err
• 3:00
  on
• 3:00
  the
• 3:00
  side
• 3:00
  of
• 3:00
  caution,
• 3:01
  of
• 3:01
  course.
• 3:01
  And
• 3:01
  this
• 3:02
  one
• 3:02
  is
• 3:02
  pretty
• 3:03
  disturbing
• 3:03
  because
• 3:03
  it
• 3:04
  involves
• 3:04
  his
• 3:04
  neck
• 3:04
  and
• 3:05
  he
• 3:05
  can't
• 3:05
  really
• 3:05
  move
• 3:06
  or
• 3:06
  he
• 3:06
  feels
• 3:07
  paralyzed.
• 3:07
  So
• 3:07
  this
• 3:08
  requires
• 3:08
  immediate
• 3:09
  intervention.
• 3:10
  That's
• 3:10
  why
• 3:10
  we
• 3:10
  talk
• 3:10
  about
• 3:11
  intramuscular
• 3:12
  15
• 3:12
  to
• 3:12
  30
• 3:13
  minutes.
• 3:13
  This
• 3:14
  will
• 3:14
  be
• 3:14
  more
• 3:14
  or
• 3:15
  less
• 3:15
  resolved
• 3:16
  with
• 3:16
  the
• 3:16
  benstropine.
• 3:17
  Now
• 3:18
  we
• 3:18
  want
• 3:18
  to
• 3:19
  dig
• 3:19
  a
• 3:19
  little
• 3:19
  deeper
• 3:19
  here.
• 3:20
  Remember,
• 3:20
  with
• 3:21
  acute
• 3:21
  dystonias
• 3:22
  that
• 3:22
  are
• 3:22
  medical
• 3:22
  emergencies,
• 3:23
  they
• 3:23
  could
• 3:23
  look
• 3:23
  like
• 3:24
  a
• 3:24
  laryngospasm,
• 3:25
  involuntary
• 3:26
  closure
• 3:26
  of
• 3:26
  the
• 3:26
  vocal
• 3:27
  cord.
• 3:27
  Right.
• 3:28
  An
• 3:28
  oculogyric
• 3:29
  crisis
• 3:30
  where
• 3:30
  your
• 3:30
  eyes
• 3:30
  roll
• 3:31
  upward
• 3:31
  for
• 3:31
  hours.
• 3:31
  Very
• 3:32
  distressing,
• 3:32
  very
• 3:33
  scary,
• 3:33
  but
• 3:33
  it
• 3:33
  can
• 3:33
  be
• 3:34
  resolved
• 3:34
  very
• 3:35
  quickly.
• 3:35
  Again,
• 3:36
  with
• 3:36
  IM
• 3:37
  or
• 3:37
  IV
• 3:38
  anticholinergics.
• 3:39
  The
• 3:39
  oculogyric
• 3:40
  crisis
• 3:41
  can
• 3:41
  be
• 3:41
  confused
• 3:41
  for
• 3:42
  or
• 3:42
  misdiagnosed
• 3:42
  as
• 3:43
  a
• 3:43
  seizure
• 3:43
  too.
• 3:44
  Just
• 3:44
  keep
• 3:44
  that
• 3:44
  in
• 3:45
  mind.
• 3:45
  And
• 3:45
  then
• 3:45
  of
• 3:46
  course,
• 3:46
  you
• 3:46
  can
• 3:46
  have
• 3:46
  a
• 3:46
  neck
• 3:47
  dystonia,
• 3:47
  tongue,
• 3:48
  jaw
• 3:48
  or
• 3:48
  throat
• 3:48
  spasms
• 3:49
  that
• 3:49
  risks
• 3:50
  the
• 3:50
  airway
• 3:50
  obstruction,
• 3:51
  difficulty
• 3:52
  swallowing,
• 3:53
  aspiration.
• 3:53
  So
• 3:54
  these
• 3:54
  could
• 3:54
  be
• 3:54
  very
• 3:55
  significant
• 3:56
  medical
• 3:56
  emergencies.
• 3:57
  So
• 3:57
  just
• 3:58
  remember,
• 3:58
  when
• 3:58
  you
• 3:58
  start
• 3:59
  somebody
• 3:59
  on
• 3:59
  a
• 4:00
  high
• 4:00
  potency,
• 4:01
  first
• 4:01
  generation
• 4:01
  antipsychotic
• 4:02
  or
• 4:03
  certain
• 4:03
  second
• 4:03
  generation
• 4:04
  antipsychotics,
• 4:05
  this
• 4:05
  is
• 4:05
  potentially
• 4:06
  on
• 4:06
  the
• 4:06
  table.
• 4:07
  Statistics
• 4:08
  Show
• 4:08
  it's
• 4:08
  about
• 4:09
  2
• 4:09
  to
• 4:09
  10%
• 4:10
  of
• 4:10
  individuals
• 4:10
  who
• 4:11
  may
• 4:11
  experience
• 4:12
  these
• 4:12
  acute
• 4:13
  dystonias.
• 4:13
  2
• 4:13
  to
• 4:14
  10%
• 4:14
  gives
• 4:14
  you
• 4:15
  a
• 4:15
  rough
• 4:15
  estimate
• 4:15
  of
• 4:16
  what
• 4:16
  you
• 4:16
  can
• 4:16
  expect.
• 4:16
  Remember
• 4:17
  the
• 4:17
  high
• 4:17
  potency,
• 4:18
  first
• 4:18
  generation
• 4:19
  generation
• 4:19
  antipsychotics
• 4:20
  block
• 4:21
  those
• 4:21
  D2
• 4:22
  receptors.
• 4:22
  They
• 4:23
  have
• 4:23
  higher
• 4:23
  affinity
• 4:24
  for
• 4:24
  D2
• 4:24
  receptors.
• 4:25
  Their
• 4:25
  occupancy
• 4:26
  levels
• 4:26
  are
• 4:27
  higher
• 4:27
  for
• 4:27
  D2
• 4:28
  receptors.
• 4:28
  Think
• 4:29
  of
• 4:29
  occupancy
• 4:29
  of
• 4:30
  receptors
• 4:30
  like
• 4:30
  parking
• 4:31
  spots.
• 4:31
  They
• 4:31
  park
• 4:31
  in
• 4:32
  more
• 4:32
  spots,
• 4:32
  so
• 4:33
  their
• 4:33
  occupancy
• 4:33
  is
• 4:34
  higher.
• 4:34
  Thus
• 4:34
  they
• 4:35
  cause
• 4:36
  potentially
• 4:36
  high
• 4:36
  worsening
• 4:37
  dystonias
• 4:39
  or
• 4:39
  extra
• 4:40
  pyramidal
• 4:40
  side
• 4:41
  effects.
• 4:41
  The
• 4:42
  higher
• 4:42
  the
• 4:42
  occupancy,
• 4:43
  the
• 4:43
  higher
• 4:43
  the
• 4:43
  affinity.
• 4:44
  Affinity
• 4:45
  is
• 4:45
  more
• 4:45
  like
• 4:45
  a
• 4:45
  magnet.
• 4:46
  When
• 4:46
  you
• 4:47
  prescribe
• 4:47
  these
• 4:47
  medications,
• 4:48
  they
• 4:48
  have
• 4:49
  an
• 4:49
  affinity
• 4:49
  to
• 4:49
  the
• 4:49
  receptor.
• 4:50
  They're
• 4:50
  drawn
• 4:50
  to
• 4:50
  the
• 4:51
  receptor
• 4:51
  more
• 4:51
  easily.
• 4:52
  Those
• 4:52
  first
• 4:52
  generation
• 4:53
  antipsychotics
• 4:54
  have
• 4:54
  a
• 4:54
  little
• 4:54
  bit
• 4:54
  more
• 4:55
  affinity,
• 4:56
  so
• 4:56
  keep
• 4:57
  that
• 4:57
  in
• 4:57
  mind.
• 4:58
  But
• 4:58
  again,
• 4:58
  you
• 4:59
  have
• 4:59
  second
• 4:59
  generation
• 4:59
  antipsychotics
• 5:00
  that
• 5:00
  also
• 5:00
  have
• 5:02
  pretty
• 5:02
  strong
• 5:03
  affinities
• 5:03
  like
• 5:04
  Risperdal
• 5:04
  or
• 5:04
  invega,
• 5:05
  which
• 5:06
  is
• 5:06
  the
• 5:06
  metabolic
• 5:07
  offshoot
• 5:07
  of
• 5:07
  risperidol.
• 5:08
  We're
• 5:08
  going
• 5:08
  to
• 5:08
  go
• 5:08
  into
• 5:09
  that
• 5:09
  in
• 5:09
  more
• 5:09
  detail
• 5:09
  later.
• 5:10
  Dystonia
• 5:11
  is
• 5:11
  an
• 5:11
  abnormal,
• 5:12
  involuntary
• 5:13
  twisting
• 5:14
  or
• 5:15
  repetitive
• 5:15
  movement,
• 5:16
  an
• 5:16
  abnormal
• 5:16
  posture.
• 5:17
  It's
• 5:17
  a
• 5:17
  neurological
• 5:18
  movement
• 5:18
  disorder.
• 5:19
  Jerky,
• 5:20
  sustained
• 5:20
  movements,
• 5:21
  and
• 5:21
  they
• 5:21
  can
• 5:21
  affect
• 5:22
  really
• 5:22
  any
• 5:22
  body
• 5:22
  part.
• 5:23
  So
• 5:23
  keep
• 5:23
  that
• 5:23
  in
• 5:23
  mind
• 5:24
  and
• 5:24
  especially
• 5:24
  keep
• 5:25
  it
• 5:25
  in
• 5:25
  mind
• 5:25
  when
• 5:25
  we're
• 5:26
  talking
• 5:26
  about
• 5:26
  medical
• 5:27
  emergencies.
• 5:28
  Now,
• 5:29
  dystonia
• 5:29
  arises
• 5:30
  from
• 5:30
  abnormal
• 5:30
  signaling
• 5:31
  in
• 5:31
  the
• 5:31
  basal
• 5:32
  ganglia.
• 5:32
  It's
• 5:32
  a
• 5:32
  motor
• 5:33
  control
• 5:33
  hub
• 5:33
  of
• 5:33
  our
• 5:33
  brain.
• 5:34
  Normally,
• 5:34
  the
• 5:34
  brain
• 5:35
  sends
• 5:36
  a
• 5:36
  signal
• 5:37
  saying,
• 5:37
  move
• 5:37
  this
• 5:37
  muscle
• 5:38
  and
• 5:38
  suppress
• 5:38
  that
• 5:39
  muscle.
• 5:39
  In
• 5:40
  dystonia,
• 5:40
  the
• 5:41
  inhibitory
• 5:41
  suppression
• 5:42
  is
• 5:42
  broken.
• 5:43
  Too
• 5:43
  many
• 5:43
  muscles
• 5:44
  fire
• 5:44
  at
• 5:44
  once.
• 5:45
  That's
• 5:45
  an
• 5:45
  overflow
• 5:46
  muscle
• 5:46
  activation
• 5:47
  where
• 5:47
  muscles
• 5:48
  that
• 5:48
  shouldn't
• 5:48
  be
• 5:48
  involved
• 5:49
  contract,
• 5:50
  and
• 5:50
  that's
• 5:50
  a
• 5:50
  problem.
• 5:51
  Why
• 5:51
  is
• 5:51
  that
• 5:51
  happening?
• 5:52
  Because
• 5:52
  we
• 5:52
  block
• 5:53
  dopamine.
• 5:53
  First
• 5:53
  generation
• 5:54
  antipsychotics,
• 5:55
  High
• 5:55
  affinity
• 5:56
  for
• 5:56
  dopamine
• 5:56
  receptors,
• 5:57
  high
• 5:58
  occupancy
• 5:58
  levels.
• 5:59
  That
• 6:00
  goes
• 6:00
  ahead
• 6:01
  and
• 6:01
  blocks
• 6:02
  dopamine.
• 6:02
  And
• 6:02
  now
• 6:03
  your
• 6:03
  seesaw
• 6:03
  between
• 6:04
  dopamine
• 6:05
  and
• 6:05
  acetylcholine
• 6:06
  is
• 6:08
  out
• 6:08
  of
• 6:08
  whack.
• 6:08
  It
• 6:09
  needs
• 6:09
  to
• 6:09
  be
• 6:09
  a
• 6:09
  balanced
• 6:10
  seesaw
• 6:10
  between
• 6:10
  dopamine
• 6:11
  and
• 6:11
  acetylcholine.
• 6:12
  Dopamine
• 6:14
  in
• 6:14
  the.
• 6:14
  So
• 6:15
  there's
• 6:15
  a
• 6:15
  key
• 6:15
  balance
• 6:16
  in
• 6:16
  this
• 6:16
  striatum,
• 6:17
  right?
• 6:17
  A
• 6:17
  nigrostriatal
• 6:18
  pathway.
• 6:19
  You've
• 6:19
  probably
• 6:19
  learned
• 6:19
  about
• 6:20
  this
• 6:20
  in
• 6:20
  school.
• 6:20
  And
• 6:21
  the
• 6:21
  key
• 6:21
  balance
• 6:21
  there
• 6:21
  is
• 6:22
  between
• 6:22
  dopamine
• 6:22
  and
• 6:23
  acetylcholine.
• 6:23
  There's
• 6:24
  a
• 6:24
  fine
• 6:24
  neurochemical
• 6:25
  balance,
• 6:26
  okay?
• 6:26
  Now,
• 6:26
  dopamine
• 6:27
  in
• 6:27
  that
• 6:28
  particular
• 6:28
  brain
• 6:28
  region
• 6:29
  fine
• 6:29
  tunes
• 6:29
  and
• 6:30
  inhibits
• 6:30
  excessive
• 6:31
  motor
• 6:31
  signals.
• 6:32
  And
• 6:32
  acetylcholine
• 6:33
  excites
• 6:34
  motor
• 6:34
  signals.
• 6:34
  It
• 6:35
  increases
• 6:35
  muscle
• 6:36
  activation.
• 6:36
  So
• 6:37
  when
• 6:37
  antipsychotics
• 6:38
  block
• 6:38
  dopamine
• 6:38
  2
• 6:38
  receptors,
• 6:39
  the
• 6:39
  inhibitory
• 6:40
  break
• 6:40
  is
• 6:41
  lost.
• 6:41
  And
• 6:42
  now
• 6:42
  acetylcholine
• 6:43
  goes
• 6:43
  unchecked
• 6:43
  and
• 6:43
  the
• 6:43
  seesaw's
• 6:44
  all
• 6:44
  the
• 6:44
  way
• 6:44
  up
• 6:44
  in
• 6:44
  the
• 6:45
  air
• 6:45
  and
• 6:45
  you
• 6:45
  have
• 6:45
  muscle
• 6:46
  over
• 6:46
  activation
• 6:47
  or
• 6:47
  dystonia.
• 6:48
  So
• 6:48
  anticholinergics
• 6:49
  like
• 6:49
  Benztropine
• 6:50
  jump
• 6:50
  in
• 6:51
  there
• 6:51
  and.
• 6:51
  And
• 6:51
  block
• 6:52
  muscarinic
• 6:52
  acetylcholine
• 6:53
  receptors,
• 6:54
  which
• 6:54
  reduces
• 6:54
  the
• 6:54
  excessive
• 6:55
  acetylcholine
• 6:56
  tone.
• 6:57
  Right?
• 6:58
  So
• 6:58
  you
• 6:58
  have,
• 6:58
  in
• 6:58
  this
• 6:59
  case,
• 6:59
  Risperdal.
• 7:00
  Mario's
• 7:00
  taking
• 7:01
  Risperdal
• 7:02
  and
• 7:02
  dopamine's
• 7:03
  blocked.
• 7:03
  It
• 7:04
  has
• 7:04
  a
• 7:04
  higher
• 7:04
  affinity.
• 7:05
  Dopamine,
• 7:06
  Risperidol
• 7:06
  has
• 7:07
  a
• 7:07
  higher
• 7:07
  affinity
• 7:07
  with
• 7:07
  those
• 7:08
  dopamine
• 7:08
  receptors.
• 7:09
  Higher
• 7:09
  occupancy
• 7:10
  rates
• 7:10
  at.
• 7:11
  At
• 7:11
  lower
• 7:11
  doses
• 7:12
  and
• 7:12
  it's
• 7:13
  being
• 7:13
  blocked.
• 7:13
  And
• 7:14
  acetylcholine
• 7:15
  is
• 7:16
  overstimulated
• 7:16
  in
• 7:17
  those
• 7:17
  motor
• 7:17
  pathways
• 7:17
  and
• 7:18
  hence
• 7:18
  his
• 7:18
  neck
• 7:19
  movements
• 7:19
  and
• 7:20
  his
• 7:20
  feelings
• 7:21
  of
• 7:21
  paralysis.
• 7:22
  Anticholinergics
• 7:23
  will
• 7:23
  restore
• 7:23
  the
• 7:23
  balance
• 7:24
  and
• 7:24
  that's
• 7:24
  exactly
• 7:25
  why
• 7:25
  we
• 7:25
  want
• 7:25
  to
• 7:26
  give
• 7:26
  him
• 7:26
  entropy
• 7:27
  to
• 7:27
  help
• 7:27
  his
• 7:27
  situation.
• 7:28
  Now
• 7:28
  remember,
• 7:29
  with
• 7:29
  EPS
• 7:29
  symptoms,
• 7:30
  drug
• 7:31
  induced
• 7:31
  movement
• 7:32
  disorders,
• 7:33
  acute
• 7:33
  dystonia
• 7:34
  is
• 7:34
  the
• 7:34
  one
• 7:34
  on
• 7:34
  your
• 7:35
  boards.
• 7:35
  They're
• 7:35
  going
• 7:35
  to
• 7:36
  ask
• 7:36
  you
• 7:36
  to
• 7:37
  potentially
• 7:37
  match
• 7:37
  these
• 7:38
  up
• 7:38
  or
• 7:38
  on
• 7:38
  your
• 7:38
  tests,
• 7:39
  Tony,
• 7:39
  as
• 7:39
  are
• 7:40
  one
• 7:40
  of
• 7:40
  the
• 7:40
  first
• 7:40
  guests
• 7:41
  at
• 7:41
  the
• 7:41
  parties,
• 7:42
  right.
• 7:42
  They
• 7:43
  come
• 7:43
  between
• 7:43
  hours
• 7:44
  and
• 7:44
  days
• 7:45
  when
• 7:45
  you
• 7:45
  start
• 7:46
  a
• 7:46
  medication
• 7:46
  or
• 7:46
  when
• 7:47
  you
• 7:47
  increase
• 7:47
  a
• 7:47
  dose.
• 7:48
  Right?
• 7:48
  So
• 7:49
  hours
• 7:49
  to
• 7:49
  days.
• 7:49
  Then
• 7:50
  you
• 7:50
  have
• 7:50
  aesthesia,
• 7:50
  which
• 7:51
  comes
• 7:51
  days
• 7:51
  to
• 7:51
  weeks
• 7:52
  later
• 7:52
  and
• 7:53
  involves
• 7:53
  restlessness.
• 7:54
  Then
• 7:54
  you
• 7:54
  have
• 7:55
  parkinsonism
• 7:55
  symptoms,
• 7:56
  weeks
• 7:56
  to
• 7:57
  months,
• 7:57
  tremors,
• 7:57
  rigidity,
• 7:58
  slowness.
• 7:59
  And
• 7:59
  then
• 7:59
  you
• 7:59
  have
• 7:59
  the
• 7:59
  tardive
• 8:00
  dyskinesia
• 8:00
  as
• 8:01
  months
• 8:01
  to
• 8:01
  years
• 8:01
  repetitive
• 8:02
  orofacial
• 8:03
  limb
• 8:03
  movement.
• 8:04
  So
• 8:04
  knowing
• 8:04
  the
• 8:04
  order
• 8:04
  of
• 8:05
  that,
• 8:05
  of
• 8:05
  course
• 8:05
  is
• 8:06
  a
• 8:06
  very
• 8:06
  important
• 8:06
  pearl.
• 8:07
  The
• 8:07
  acute
• 8:07
  dystonia
• 8:08
  is
• 8:08
  hours
• 8:08
  today,
• 8:09
  so
• 8:09
  be
• 8:09
  on
• 8:09
  alert.
• 8:10
  And
• 8:10
  it's
• 8:10
  one
• 8:11
  of
• 8:11
  those
• 8:11
  medication
• 8:12
  side
• 8:12
  effects
• 8:13
  you
• 8:13
  want
• 8:13
  to
• 8:13
  make
• 8:13
  very
• 8:13
  clear
• 8:14
  for
• 8:14
  your
• 8:15
  patients,
• 8:15
  especially
• 8:16
  with
• 8:17
  respect
• 8:17
  to
• 8:17
  the
• 8:17
  potential
• 8:18
  emergencies
• 8:19
  they
• 8:19
  might
• 8:19
  have
• 8:20
  to
• 8:20
  deal
• 8:20
  with.
• 8:21
  Now
• 8:22
  we
• 8:22
  talked
• 8:22
  about
• 8:23
  Risperdal
• 8:24
  being
• 8:24
  a
• 8:24
  high
• 8:25
  D2
• 8:25
  occupancy
• 8:26
  second
• 8:26
  generation
• 8:27
  antipsychotic,
• 8:28
  right?
• 8:29
  And
• 8:30
  we
• 8:30
  talked
• 8:30
  a
• 8:30
  little
• 8:31
  bit
• 8:31
  about
• 8:31
  affinity
• 8:31
  and
• 8:31
  I
• 8:32
  just
• 8:32
  want
• 8:32
  to
• 8:32
  circle
• 8:32
  back
• 8:32
  that.
• 8:33
  Affinity
• 8:33
  is
• 8:33
  how
• 8:33
  tightly
• 8:34
  a
• 8:34
  drug
• 8:34
  binds
• 8:35
  to
• 8:35
  a
• 8:35
  receptor.
• 8:36
  It's
• 8:37
  usually
• 8:37
  measured
• 8:38
  in
• 8:38
  a
• 8:38
  KD
• 8:38
  value
• 8:39
  and
• 8:39
  the
• 8:39
  lower
• 8:39
  that
• 8:39
  KD
• 8:40
  value,
• 8:41
  the
• 8:41
  tighter
• 8:41
  the
• 8:42
  affinity
• 8:42
  is.
• 8:42
  Risperdal,
• 8:43
  as
• 8:44
  we
• 8:44
  shared,
• 8:44
  has
• 8:44
  actually
• 8:45
  a
• 8:45
  pretty
• 8:45
  high
• 8:45
  affinity
• 8:46
  for
• 8:46
  that
• 8:46
  D2
• 8:47
  receptor.
• 8:47
  Occupancy
• 8:48
  is
• 8:48
  how
• 8:49
  many
• 8:49
  receptors
• 8:49
  are
• 8:50
  actually
• 8:50
  are
• 8:50
  actually
• 8:51
  bound
• 8:52
  at
• 8:52
  a
• 8:52
  given
• 8:53
  concentration.
• 8:53
  We
• 8:54
  talked
• 8:54
  about
• 8:54
  parking
• 8:54
  spots
• 8:55
  with
• 8:55
  occupancy.
• 8:55
  We
• 8:56
  talk
• 8:56
  about
• 8:56
  affinity,
• 8:56
  how
• 8:57
  tightly
• 8:57
  a
• 8:57
  drug
• 8:58
  binds
• 8:58
  to
• 8:58
  a
• 8:58
  receptor.
• 8:59
  I
• 8:59
  think
• 8:59
  of
• 8:59
  a
• 8:59
  sticky
• 9:00
  or
• 9:00
  like
• 9:00
  a
• 9:00
  magnet.
• 9:01
  Low
• 9:01
  affinity
• 9:02
  is
• 9:02
  loose,
• 9:02
  it
• 9:02
  binds
• 9:03
  and
• 9:03
  then
• 9:03
  it
• 9:03
  slips
• 9:03
  off
• 9:04
  quickly
• 9:05
  from
• 9:05
  the
• 9:05
  receptor,
• 9:06
  which
• 9:06
  can
• 9:06
  be
• 9:06
  beneficial
• 9:07
  at
• 9:07
  times
• 9:08
  with
• 9:08
  medications
• 9:08
  like
• 9:09
  Quetiapine
• 9:10
  might
• 9:10
  be
• 9:10
  a
• 9:10
  different
• 9:10
  podcast
• 9:11
  episode.
• 9:11
  We
• 9:12
  can
• 9:12
  go
• 9:12
  into
• 9:12
  that
• 9:12
  later.
• 9:13
  Suffice
• 9:14
  it
• 9:14
  to
• 9:14
  say
• 9:14
  these
• 9:14
  high
• 9:15
  affinity
• 9:16
  second
• 9:16
  generation
• 9:16
  antipsychotics,
• 9:18
  there's
• 9:18
  not
• 9:18
  many
• 9:19
  of
• 9:19
  them.
• 9:19
  Remember
• 9:19
  the
• 9:19
  first
• 9:20
  generation
• 9:20
  antipsychotics,
• 9:21
  the
• 9:21
  Haldols,
• 9:22
  right.
• 9:22
  Those
• 9:23
  are
• 9:23
  usually
• 9:23
  the
• 9:23
  higher
• 9:24
  affinity
• 9:24
  for
• 9:24
  D2,
• 9:25
  where
• 9:25
  they
• 9:26
  really
• 9:26
  latch
• 9:27
  onto
• 9:27
  those
• 9:27
  D2
• 9:28
  receptors
• 9:28
  potently.
• 9:29
  They
• 9:29
  occupy
• 9:30
  a
• 9:30
  lot
• 9:30
  of
• 9:30
  those
• 9:30
  receptors
• 9:31
  and
• 9:32
  hence
• 9:32
  cause
• 9:32
  muscle
• 9:33
  movements
• 9:34
  like
• 9:34
  the
• 9:34
  one
• 9:34
  we're
• 9:34
  talking
• 9:34
  with
• 9:35
  Mario?
• 9:35
  But
• 9:35
  again,
• 9:36
  second
• 9:36
  generation
• 9:36
  antipsychotics
• 9:37
  are
• 9:37
  not
• 9:38
  immune
• 9:38
  to
• 9:38
  this.
• 9:38
  You
• 9:38
  still
• 9:39
  have
• 9:39
  to
• 9:39
  be
• 9:39
  a
• 9:39
  little
• 9:39
  bit
• 9:39
  on
• 9:40
  guard,
• 9:40
  particularly
• 9:41
  with
• 9:41
  Risperidol
• 9:42
  and
• 9:42
  Invega.
• 9:43
  High
• 9:43
  affinity
• 9:44
  for
• 9:44
  D2,
• 9:44
  risperidol,
• 9:45
  risperidone
• 9:46
  binds
• 9:46
  tightly
• 9:47
  and
• 9:47
  it
• 9:47
  doesn't
• 9:47
  really
• 9:48
  let
• 9:48
  go.
• 9:48
  It
• 9:48
  leads
• 9:48
  to
• 9:48
  high
• 9:49
  occupancy
• 9:50
  even
• 9:50
  at
• 9:50
  low
• 9:50
  to
• 9:50
  moderate
• 9:51
  doses,
• 9:51
  70
• 9:52
  to
• 9:52
  80%
• 9:53
  D2
• 9:53
  occupancy.
• 9:54
  That
• 9:54
  high
• 9:54
  affinity,
• 9:55
  high
• 9:55
  occupancy
• 9:56
  can
• 9:56
  definitely
• 9:57
  raise
• 9:57
  the
• 9:57
  EPS
• 9:58
  risk.
• 9:59
  Contrast
• 9:59
  that
• 10:00
  with
• 10:00
  something
• 10:00
  like
• 10:00
  Seroquel,
• 10:01
  which
• 10:01
  has
• 10:01
  a
• 10:01
  lower
• 10:01
  affinity
• 10:02
  for
• 10:02
  D2.
• 10:02
  It
• 10:03
  binds
• 10:03
  more
• 10:03
  weakly,
• 10:03
  comes
• 10:04
  off
• 10:04
  the
• 10:04
  receptor
• 10:05
  a
• 10:05
  little
• 10:05
  bit
• 10:06
  more
• 10:06
  often.
• 10:07
  It's
• 10:07
  what
• 10:07
  we
• 10:08
  call
• 10:08
  fast
• 10:08
  off
• 10:08
  kinetics.
• 10:09
  So
• 10:09
  it
• 10:09
  gets
• 10:10
  on
• 10:10
  the
• 10:10
  receptor,
• 10:10
  binds
• 10:11
  weakly
• 10:11
  and
• 10:11
  slips
• 10:12
  off,
• 10:12
  which
• 10:13
  sort
• 10:13
  of
• 10:13
  helps
• 10:13
  a
• 10:13
  little
• 10:14
  bit
• 10:14
  because
• 10:14
  it's
• 10:15
  not
• 10:15
  blocking
• 10:15
  it
• 10:15
  as
• 10:16
  often
• 10:16
  and
• 10:17
  allows
• 10:17
  endogenous
• 10:18
  dopamine
• 10:18
  to
• 10:18
  bind
• 10:19
  there
• 10:19
  more
• 10:20
  frequently,
• 10:20
  which
• 10:20
  mitigates
• 10:21
  some
• 10:21
  of
• 10:22
  these
• 10:22
  movement
• 10:22
  side
• 10:22
  effects.
• 10:23
  It
• 10:23
  is
• 10:23
  fascinating
• 10:24
  to
• 10:24
  consider
• 10:25
  that
• 10:25
  the
• 10:25
  way
• 10:26
  the
• 10:26
  stickiness
• 10:27
  of
• 10:27
  these
• 10:28
  drugs
• 10:28
  on
• 10:28
  the
• 10:29
  receptors,
• 10:29
  some
• 10:30
  are
• 10:30
  just
• 10:30
  like
• 10:30
  a
• 10:30
  magnet
• 10:31
  that's
• 10:31
  airtight.
• 10:32
  It
• 10:32
  just
• 10:32
  sticks
• 10:32
  immediately.
• 10:33
  It's
• 10:33
  one
• 10:33
  of
• 10:33
  those
• 10:33
  magnets
• 10:34
  you're
• 10:34
  trying
• 10:34
  to
• 10:34
  pull
• 10:34
  off
• 10:35
  the
• 10:35
  refrigerator
• 10:35
  and.
• 10:36
  And
• 10:36
  then
• 10:36
  you
• 10:36
  have
• 10:36
  the
• 10:37
  ones
• 10:37
  that
• 10:37
  kind
• 10:37
  of
• 10:37
  float
• 10:37
  there
• 10:38
  like
• 10:38
  floating
• 10:39
  magnets.
• 10:39
  They
• 10:40
  come
• 10:40
  on
• 10:40
  and
• 10:40
  come
• 10:40
  off
• 10:41
  this
• 10:41
  little
• 10:41
  dance.
• 10:42
  They're
• 10:43
  a
• 10:43
  little
• 10:43
  more
• 10:43
  fluid.
• 11:38
  So
• 11:38
  you're
• 11:38
  not
• 11:38
  blocking
• 10:44
  D2
• 11:39
  as
• 11:40
  strongly.
• 11:40
  Hence
• 11:41
  why
• 11:41
  Seroquel
• 11:42
  might
• 11:42
  not
• 11:42
  block
• 11:42
  D2
• 11:43
  as
• 11:43
  strongly.
• 11:44
  And
• 11:44
  it
• 11:44
  might
• 11:44
  not
• 11:44
  be
• 11:45
  the
• 11:45
  best
• 11:45
  antipsychotic
• 11:46
  in
• 11:46
  like
• 11:46
  fluoride
• 11:47
  psychosis,
• 11:48
  but
• 11:48
  it's
• 11:48
  lower
• 11:49
  affinity
• 11:49
  is
• 11:50
  kind
• 11:50
  of
• 11:50
  more
• 11:50
  of
• 11:50
  a,
• 11:51
  again,
• 11:51
  it's
• 11:51
  more
• 11:51
  of
• 11:51
  a
• 11:52
  fluid
• 11:52
  blocking
• 11:53
  where
• 11:53
  it's
• 11:53
  on
• 11:53
  and
• 11:54
  off
• 11:54
  that
• 11:54
  receptor.
• 11:55
  And
• 11:55
  that
• 11:55
  can
• 11:55
  mitigate
• 11:56
  some
• 11:56
  of
• 11:56
  the
• 11:56
  worst
• 11:57
  side
• 11:57
  effects
• 11:57
  we
• 11:57
  deal
• 11:58
  with
• 11:58
  when
• 11:58
  it
• 11:58
  comes
• 11:58
  to
• 11:59
  the
• 11:59
  first
• 11:59
  generations.
• 12:00
  And
• 12:01
  risperidone.
• 12:02
  Very
• 12:02
  interesting
• 12:03
  stuff
• 12:03
  here
• 12:03
  with
• 12:04
  Mario.
• 12:04
  We
• 12:04
  have
• 12:05
  the
• 12:05
  tools
• 12:05
  to
• 12:05
  help
• 12:05
  him
• 12:05
  out.
• 12:06
  Before
• 12:06
  we
• 12:07
  go
• 12:07
  into
• 12:07
  that
• 12:07
  a
• 12:07
  little
• 12:07
  more,
• 12:08
  I
• 12:08
  also
• 12:09
  wanted
• 12:09
  to
• 12:09
  touch
• 12:09
  on
• 12:10
  second
• 12:11
  generation
• 12:11
  antipsychotics
• 12:12
  and
• 12:12
  why
• 12:12
  movement
• 12:13
  disorders
• 12:14
  typically
• 12:15
  aren't
• 12:15
  as
• 12:16
  significant
• 12:16
  as
• 12:16
  first
• 12:17
  generation
• 12:17
  antipsychotics
• 12:18
  and
• 12:19
  how
• 12:19
  that
• 12:19
  works
• 12:19
  out.
• 12:19
  It
• 12:20
  is
• 12:20
  interesting
• 12:20
  because
• 12:21
  second
• 12:21
  generation
• 12:21
  antipsychotics
• 12:22
  are
• 12:22
  usually
• 12:23
  buffered
• 12:23
  by
• 12:23
  their
• 12:24
  antagonism
• 12:25
  of
• 12:25
  5ht2a.
• 12:27
  Because
• 12:27
  we
• 12:27
  know
• 12:28
  that
• 12:28
  5ht2a
• 12:30
  normally
• 12:30
  it's
• 12:31
  like
• 12:31
  a
• 12:31
  break
• 12:31
  on
• 12:32
  dopamine
• 12:32
  in
• 12:33
  the
• 12:33
  striatum.
• 12:34
  And
• 12:34
  we
• 12:34
  don't
• 12:34
  really
• 12:34
  want
• 12:35
  dopamine
• 12:35
  to
• 12:35
  be
• 12:36
  pumped
• 12:36
  like
• 12:36
  the
• 12:36
  brakes
• 12:36
  to
• 12:37
  be
• 12:37
  pumped
• 12:37
  on
• 12:37
  dopamine
• 12:37
  in
• 12:38
  the
• 12:38
  striatum.
• 12:38
  That's
• 12:39
  the
• 12:39
  whole
• 12:39
  problem,
• 12:39
  right?
• 12:40
  Because
• 12:40
  too
• 12:40
  much
• 12:40
  dopamine
• 12:41
  is
• 12:41
  being
• 12:41
  blocked.
• 12:41
  And
• 12:42
  when
• 12:42
  you
• 12:42
  block
• 12:42
  dopamine,
• 12:43
  the
• 12:43
  other
• 12:43
  edge
• 12:43
  of
• 12:43
  that
• 12:44
  seesaw
• 12:44
  starts
• 12:44
  flying,
• 12:45
  the
• 12:45
  acetylcholine
• 12:46
  and
• 12:46
  you
• 12:46
  have
• 12:46
  muscle
• 12:47
  overactivity.
• 12:48
  So
• 12:48
  SGAs,
• 12:49
  they,
• 12:50
  instead
• 12:50
  of
• 12:50
  putting
• 12:51
  a
• 12:51
  break
• 12:51
  on
• 12:51
  the
• 12:51
  dopamine,
• 12:52
  Instead
• 12:52
  of
• 12:52
  agonizing
• 12:53
  5ht
• 12:54
  2a,
• 12:55
  they
• 12:55
  antagonize
• 12:56
  it,
• 12:56
  which
• 12:56
  actually
• 12:57
  releases
• 12:58
  the
• 12:58
  break
• 12:58
  on
• 12:58
  dopamine
• 12:59
  a
• 12:59
  little
• 12:59
  bit
• 12:59
  and
• 12:59
  boom,
• 13:00
  more
• 13:00
  dopamine
• 13:01
  in
• 13:01
  this
• 13:01
  triatum.
• 13:02
  It
• 13:02
  mitigates
• 13:03
  some
• 13:03
  of
• 13:03
  those
• 13:03
  movement
• 13:04
  side
• 13:04
  effects.
• 13:05
  Right?
• 13:05
  But
• 13:06
  again,
• 13:06
  remember,
• 13:06
  this
• 13:07
  is
• 13:07
  all
• 13:07
  sort
• 13:07
  of
• 13:07
  a
• 13:07
  dance.
• 13:08
  It's
• 13:08
  a
• 13:08
  fun
• 13:08
  dance,
• 13:09
  it's
• 13:09
  an
• 13:09
  exciting
• 13:09
  dance.
• 13:10
  But
• 13:10
  risperdal
• 13:11
  has
• 13:12
  high
• 13:12
  D2
• 13:13
  occupancy,
• 13:13
  so
• 13:13
  it's
• 13:14
  blocking
• 13:14
  D2
• 13:15
  so
• 13:15
  forcefully,
• 13:16
  more
• 13:16
  so
• 13:16
  than
• 13:16
  those
• 13:17
  other
• 13:17
  second
• 13:17
  generation
• 13:18
  antipsychotics.
• 13:19
  So
• 13:19
  that
• 13:19
  buffer,
• 13:20
  that
• 13:20
  5ht2a
• 13:22
  antagonism,
• 13:22
  it's
• 13:23
  competing
• 13:23
  with
• 13:23
  more
• 13:24
  because
• 13:24
  risperidol
• 13:25
  is
• 13:25
  just
• 13:25
  really
• 13:25
  blocking
• 13:26
  D2.
• 13:26
  So
• 13:26
  that
• 13:27
  doesn't
• 13:27
  really
• 13:27
  help.
• 13:28
  And
• 13:28
  with
• 13:28
  Seroquel,
• 13:29
  Seroquel
• 13:30
  actually
• 13:30
  does
• 13:31
  go
• 13:31
  ahead
• 13:31
  and
• 13:32
  antagonize
• 13:32
  5ht2
• 13:33
  a
• 13:33
  little
• 13:33
  bit.
• 13:34
  And
• 13:34
  that
• 13:34
  helps,
• 13:35
  right?
• 13:35
  That
• 13:35
  helps
• 13:35
  release
• 13:36
  a
• 13:36
  little
• 13:36
  more
• 13:37
  dopamine
• 13:37
  in
• 13:37
  the
• 13:37
  striatum
• 13:38
  and
• 13:38
  mitigate
• 13:39
  or
• 13:39
  lower
• 13:40
  some
• 13:40
  of
• 13:41
  those
• 13:41
  movement
• 13:42
  side
• 13:42
  effects.
• 13:42
  Very
• 13:43
  interesting.
• 13:43
  You
• 13:43
  have
• 13:44
  medications
• 13:44
  like
• 13:45
  Seroquel
• 13:45
  with
• 13:45
  their
• 13:46
  anticholinergic
• 13:47
  effects
• 13:47
  embedded
• 13:48
  in
• 13:48
  the
• 13:48
  medication.
• 13:49
  Right?
• 13:49
  Which
• 13:49
  is
• 13:50
  neat
• 13:50
  because
• 13:50
  they
• 13:51
  have
• 13:51
  some
• 13:51
  muscarinic
• 13:52
  activity.
• 13:52
  Don't
• 13:53
  worry
• 13:53
  about
• 13:53
  muscarinic
• 13:54
  and
• 13:54
  anticholinergic.
• 13:55
  These
• 13:55
  are
• 13:56
  just
• 13:56
  ways
• 13:56
  to
• 13:57
  buffer
• 13:57
  against
• 13:57
  movement
• 13:58
  disorders.
• 13:59
  Even
• 13:59
  more
• 13:59
  so
• 13:59
  when
• 14:00
  a
• 14:00
  drug
• 14:00
  like
• 14:00
  Seroquel
• 14:01
  has
• 14:01
  muscarinic
• 14:01
  activity
• 14:02
  and
• 14:02
  naturally
• 14:03
  embedded
• 14:03
  anticholinergic
• 14:04
  side
• 14:05
  effects,
• 14:05
  then
• 14:06
  we
• 14:06
  have
• 14:06
  this
• 14:06
  little
• 14:07
  embedded
• 14:07
  cushion
• 14:08
  in
• 14:08
  the
• 14:08
  medication
• 14:08
  that
• 14:09
  brings
• 14:09
  that
• 14:09
  seesaw
• 14:10
  back.
• 14:11
  Very
• 14:11
  cool
• 14:12
  way
• 14:12
  to
• 14:12
  mitigate
• 14:13
  this.
• 14:13
  If
• 14:13
  you're
• 14:14
  worried
• 14:14
  about
• 14:14
  anticholinergic
• 14:15
  side
• 14:15
  effects,
• 14:15
  we
• 14:15
  could
• 14:16
  even
• 14:16
  get
• 14:16
  rid
• 14:16
  of
• 14:16
  the
• 14:16
  risperidol
• 14:17
  altogether.
• 14:17
  You
• 14:18
  have
• 14:18
  to
• 14:18
  address
• 14:19
  his
• 14:20
  neck
• 14:20
  paralysis
• 14:21
  and
• 14:21
  neck
• 14:21
  movements
• 14:21
  right
• 14:22
  now
• 14:22
  because
• 14:22
  that
• 14:22
  is
• 14:23
  an
• 14:23
  urgent
• 14:23
  situation.
• 14:24
  We've
• 14:24
  gotta
• 14:25
  take
• 14:25
  care
• 14:25
  of
• 14:25
  that.
• 14:25
  Now.
• 14:26
  After
• 14:26
  we
• 14:26
  give
• 14:27
  him
• 14:27
  benztropine
• 14:28
  and
• 14:28
  cogentin
• 14:29
  orally
• 14:29
  for
• 14:29
  a
• 14:30
  few
• 14:30
  days
• 14:30
  to
• 14:30
  make
• 14:30
  sure
• 14:31
  he's
• 14:31
  out
• 14:31
  of
• 14:31
  the
• 14:31
  clouds
• 14:32
  and
• 14:32
  monitor
• 14:32
  him
• 14:33
  closely,
• 14:33
  you
• 14:34
  may
• 14:34
  be
• 14:34
  able
• 14:34
  to
• 14:35
  to
• 14:35
  actually
• 14:36
  switch
• 14:36
  him.
• 14:37
  If
• 14:37
  he
• 14:37
  says,
• 14:37
  hell
• 14:38
  no,
• 14:38
  I'm
• 14:38
  done
• 14:38
  with
• 14:38
  this
• 14:39
  medication,
• 14:39
  I'm
• 14:39
  not
• 14:39
  doing
• 14:40
  it.
• 14:41
  You
• 14:41
  could
• 14:41
  transition
• 14:42
  him
• 14:42
  to
• 14:42
  something
• 14:42
  like
• 14:42
  Seroquel.
• 14:43
  You
• 14:43
  have
• 14:43
  the
• 14:43
  anticholinergic
• 14:45
  effects
• 14:45
  embedded
• 14:45
  in
• 14:46
  Seroquel.
• 14:47
  To
• 14:47
  bring
• 14:47
  the
• 14:47
  seesaw
• 14:48
  back,
• 14:48
  you
• 14:48
  have
• 14:49
  the
• 14:49
  5ht
• 14:49
  2a
• 14:50
  antagonism
• 14:51
  to
• 14:51
  encourage
• 14:52
  that
• 14:52
  dopamine
• 14:53
  release
• 14:53
  in
• 14:53
  the
• 14:53
  striatum.
• 14:54
  That
• 14:54
  might
• 14:55
  be
• 14:55
  more
• 14:55
  compatible.
• 14:56
  But
• 14:56
  again,
• 14:56
  there's
• 14:57
  trade
• 14:57
  offs.
• 14:57
  Right.
• 14:58
  Got
• 14:58
  that
• 14:58
  potent
• 14:59
  histaminergic
• 15:00
  anti
• 15:00
  histaminergic
• 15:01
  activity,
• 15:02
  which
• 15:02
  can
• 15:02
  cause
• 15:02
  weight
• 15:03
  gain
• 15:03
  and
• 15:03
  sedation.
• 15:04
  So,
• 15:04
  my
• 15:05
  friends,
• 15:05
  if
• 15:05
  you've
• 15:05
  noticed
• 15:06
  something
• 15:06
  about
• 15:06
  psychopharm,
• 15:07
  there's
• 15:08
  a
• 15:08
  balance,
• 15:08
  an
• 15:08
  elegant
• 15:09
  balance
• 15:09
  between
• 15:09
  everything.
• 15:10
  There's
• 15:10
  trade
• 15:11
  offs.
• 15:11
  It's
• 15:11
  not
• 15:11
  as
• 15:11
  simple
• 15:12
  as
• 15:12
  this
• 15:12
  one's.
• 15:13
  Better.
• 15:13
  That
• 15:13
  one's
• 15:14
  better.
• 15:14
  Because
• 15:15
  if
• 15:15
  Mario
• 15:15
  already
• 15:16
  was
• 15:16
  100
• 15:16
  pounds
• 15:17
  overweight,
• 15:17
  it's
• 15:17
  problematic
• 15:18
  to
• 15:19
  transition
• 15:19
  him
• 15:19
  to
• 15:19
  a
• 15:20
  medication
• 15:20
  that
• 15:20
  might
• 15:21
  cause
• 15:21
  even
• 15:21
  more
• 15:21
  weight
• 15:22
  gain.
• 15:22
  And
• 15:23
  we
• 15:23
  go
• 15:23
  over
• 15:23
  in
• 15:23
  old
• 15:23
  episodes,
• 15:24
  the
• 15:24
  5ht2c
• 15:25
  receptor.
• 15:26
  And
• 15:26
  if
• 15:26
  you
• 15:26
  have
• 15:26
  a
• 15:26
  strong
• 15:27
  antagonist
• 15:27
  like
• 15:28
  Zyprexa,
• 15:29
  that's
• 15:29
  going
• 15:29
  to
• 15:29
  cause
• 15:29
  more
• 15:30
  weight
• 15:30
  gain.
• 15:30
  So
• 15:30
  you
• 15:31
  got
• 15:31
  to
• 15:31
  really
• 15:31
  look
• 15:31
  at
• 15:31
  this
• 15:32
  and
• 15:32
  know
• 15:32
  all
• 15:32
  your
• 15:33
  receptors
• 15:33
  and
• 15:33
  what
• 15:34
  they
• 15:34
  do
• 15:34
  and
• 15:34
  why
• 15:35
  we
• 15:35
  choose
• 15:35
  them.
• 15:35
  It's
• 15:36
  so
• 15:36
  important.
• 15:36
  And
• 15:37
  if
• 15:37
  you're
• 15:37
  at
• 15:37
  all
• 15:38
  realize
• 15:38
  that
• 15:38
  I
• 15:39
  repeat
• 15:39
  stuff
• 15:39
  on
• 15:39
  this
• 15:39
  podcast,
• 15:40
  I
• 15:40
  do
• 15:40
  that
• 15:40
  on
• 15:40
  purpose.
• 15:41
  I
• 15:42
  repeat
• 15:42
  a
• 15:42
  lot
• 15:42
  of
• 15:42
  things
• 15:43
  because
• 15:43
  I
• 15:43
  find
• 15:43
  that's
• 15:43
  a
• 15:44
  good
• 15:44
  way
• 15:44
  to
• 15:44
  learn.
• 15:44
  I
• 15:45
  go
• 15:45
  over
• 15:45
  one
• 15:45
  thing
• 15:46
  in
• 15:46
  the
• 15:46
  case
• 15:46
  and
• 15:46
  then
• 15:46
  I
• 15:47
  repeat
• 15:47
  it
• 15:47
  again
• 15:47
  later
• 15:48
  because
• 15:48
  I
• 15:48
  recognize
• 15:49
  there's
• 15:49
  a
• 15:49
  lot
• 15:49
  of
• 15:49
  moving
• 15:50
  pieces
• 15:50
  here.
• 15:50
  And
• 15:50
  it
• 15:51
  really
• 15:51
  helps
• 15:51
  to
• 15:51
  go
• 15:51
  back
• 15:52
  to
• 15:52
  things
• 15:52
  and
• 15:53
  come
• 15:53
  full
• 15:53
  circle.
• 15:55
  Now
• 15:55
  Mario's
• 15:56
  getting
• 15:56
  treated.
• 15:57
  We
• 15:57
  have
• 15:57
  a
• 15:57
  little
• 15:58
  better
• 15:58
  of
• 15:58
  an
• 15:58
  idea
• 15:58
  of
• 15:59
  what's
• 15:59
  going
• 15:59
  on.
• 15:59
  The
• 16:00
  blockade
• 16:00
  of
• 16:00
  dopamine
• 16:01
  receptors
• 16:01
  in
• 16:01
  his,
• 16:02
  the
• 16:02
  striatal
• 16:03
  areas,
• 16:03
  the
• 16:04
  basal
• 16:04
  ganglia,
• 16:05
  more
• 16:05
  broadly
• 16:06
  part
• 16:06
  of
• 16:06
  his
• 16:06
  brain
• 16:07
  that
• 16:07
  affect
• 16:07
  his
• 16:07
  kind
• 16:08
  of
• 16:08
  motor
• 16:08
  control
• 16:08
  center.
• 16:09
  Right.
• 16:09
  We're
• 16:09
  blocking
• 16:09
  dopamine.
• 16:10
  So
• 16:10
  we
• 16:11
  have
• 16:11
  an
• 16:11
  idea
• 16:11
  of
• 16:11
  why
• 16:12
  this
• 16:12
  is
• 16:12
  a
• 16:12
  problem.
• 16:12
  Risperidone
• 16:13
  is
• 16:13
  one
• 16:14
  of
• 16:14
  the
• 16:14
  more
• 16:14
  potent
• 16:14
  blockers.
• 16:15
  So
• 16:16
  what's
• 16:16
  a
• 16:16
  risk
• 16:16
  factor
• 16:17
  for
• 16:17
  dystonia?
• 16:17
  Let's
• 16:18
  pivot
• 16:18
  a
• 16:18
  little
• 16:18
  bit.
• 16:19
  Well,
• 16:19
  young
• 16:19
  people
• 16:19
  are
• 16:20
  more
• 16:20
  privy
• 16:20
  to
• 16:20
  it.
• 16:20
  They
• 16:21
  have
• 16:21
  higher
• 16:21
  dopaminergic
• 16:22
  tone,
• 16:22
  they're
• 16:22
  more
• 16:22
  sut.
• 16:23
  They're
• 16:23
  more
• 16:23
  vulnerable
• 16:23
  to
• 16:24
  sudden
• 16:24
  D2
• 16:24
  blockades.
• 16:25
  Males,
• 16:26
  they
• 16:26
  have
• 16:26
  a
• 16:27
  higher
• 16:27
  baseline
• 16:27
  muscle
• 16:28
  tone,
• 16:28
  high
• 16:29
  potency
• 16:29
  or
• 16:29
  high
• 16:29
  dose
• 16:30
  D2
• 16:30
  blockers.
• 16:31
  First
• 16:31
  generation
• 16:31
  antipsychotics
• 16:32
  like
• 16:32
  we
• 16:33
  mentioned,
• 16:33
  as
• 16:33
  well
• 16:33
  as
• 16:33
  Risperdal
• 16:34
  or
• 16:34
  Invega,
• 16:35
  they
• 16:35
  tend
• 16:35
  to
• 16:36
  be
• 16:36
  a
• 16:36
  little
• 16:36
  bit
• 16:36
  more
• 16:36
  potent,
• 16:37
  rapid
• 16:37
  titration.
• 16:38
  So
• 16:38
  if
• 16:38
  you're
• 16:39
  increasing,
• 16:39
  maybe
• 16:39
  you're
• 16:40
  in
• 16:40
  an
• 16:40
  inpatient
• 16:40
  setting
• 16:41
  and
• 16:41
  you're
• 16:41
  rapidly
• 16:41
  increasing
• 16:42
  an
• 16:42
  antipsychotic,
• 16:43
  guess
• 16:43
  what?
• 16:44
  That
• 16:44
  is
• 16:44
  also
• 16:44
  going
• 16:45
  to
• 16:45
  increase
• 16:45
  the
• 16:45
  possibility
• 16:46
  of
• 16:47
  these
• 16:47
  side
• 16:47
  effects
• 16:47
  happening
• 16:48
  and
• 16:48
  maybe
• 16:49
  would
• 16:49
  even
• 16:49
  warrant
• 16:50
  prophylactic
• 16:51
  use
• 16:52
  of
• 16:52
  benztropine.
• 16:53
  Now,
• 16:53
  that's
• 16:53
  not
• 16:54
  standard.
• 16:54
  I
• 16:54
  advise
• 16:55
  you
• 16:55
  all
• 16:55
  dig
• 16:55
  into
• 16:55
  the
• 16:56
  guidelines
• 16:56
  to,
• 16:57
  to
• 16:57
  get
• 16:57
  this,
• 16:58
  get
• 16:58
  a
• 16:58
  more
• 16:58
  specific
• 16:59
  protocol
• 17:00
  here.
• 17:00
  I'm
• 17:01
  not
• 17:01
  advising
• 17:01
  that,
• 17:02
  but
• 17:02
  certain
• 17:02
  people,
• 17:03
  prophylactic
• 17:04
  anticholinergics
• 17:05
  would
• 17:05
  be
• 17:05
  wise.
• 17:05
  If
• 17:06
  someone
• 17:06
  has
• 17:06
  a
• 17:06
  history
• 17:06
  of
• 17:07
  acute
• 17:07
  dystonias.
• 17:08
  They're
• 17:08
  young
• 17:09
  and
• 17:09
  male.
• 17:09
  They're
• 17:09
  on
• 17:09
  first
• 17:10
  generation
• 17:10
  antipsychotics
• 17:11
  that
• 17:11
  require
• 17:11
  rapid
• 17:12
  titration.
• 17:12
  Maybe
• 17:13
  that
• 17:13
  would
• 17:13
  be
• 17:13
  a
• 17:13
  good
• 17:13
  reason
• 17:14
  to
• 17:15
  prophylactically
• 17:16
  treat
• 17:16
  with
• 17:16
  Benstropine.
• 17:17
  Right.
• 17:18
  Some
• 17:18
  people
• 17:18
  give
• 17:18
  diphenohydramine
• 17:20
  50
• 17:20
  milligrams
• 17:20
  IM
• 17:20
  IV.
• 17:21
  Think
• 17:21
  about
• 17:22
  this
• 17:22
  and
• 17:23
  put
• 17:23
  it
• 17:23
  all
• 17:23
  together
• 17:24
  when
• 17:24
  it
• 17:24
  all
• 17:24
  makes
• 17:25
  sense
• 17:25
  in
• 17:25
  your
• 17:25
  brain.
• 17:26
  Now
• 17:27
  we
• 17:27
  know
• 17:27
  that
• 17:28
  there
• 17:28
  are
• 17:28
  some
• 17:28
  of
• 17:28
  the
• 17:28
  side
• 17:28
  effects
• 17:29
  for
• 17:29
  the
• 17:29
  bentropine,
• 17:30
  also
• 17:30
  known
• 17:30
  as
• 17:30
  cogentin.
• 17:31
  Dry
• 17:31
  mouth,
• 17:32
  blurred
• 17:32
  vision,
• 17:32
  constipation,
• 17:33
  urinary
• 17:33
  retention
• 17:34
  and
• 17:34
  sedation.
• 17:35
  Serious
• 17:36
  or
• 17:36
  rare
• 17:36
  side
• 17:36
  effects.
• 17:36
  A
• 17:37
  paralytic
• 17:37
  ilus.
• 17:38
  Do
• 17:38
  your
• 17:38
  research.
• 17:39
  Right.
• 17:39
  This
• 17:39
  podcast
• 17:40
  isn't
• 17:40
  everything
• 17:41
  but
• 17:41
  just
• 17:41
  wetting
• 17:42
  your
• 17:42
  appetite
• 17:42
  for
• 17:42
  what
• 17:43
  you
• 17:43
  need
• 17:43
  to
• 17:43
  know.
• 17:44
  Some
• 17:44
  basic
• 17:44
  pearls,
• 17:45
  some
• 17:45
  good
• 17:45
  pearls.
• 17:46
  Sometimes
• 17:46
  we
• 17:46
  go
• 17:47
  into
• 17:47
  depth.
• 17:47
  You
• 17:48
  get
• 17:48
  my
• 17:48
  point.
• 17:49
  Now,
• 17:50
  what
• 17:50
  else
• 17:50
  do
• 17:50
  we
• 17:51
  want
• 17:51
  to
• 17:51
  know
• 17:51
  about
• 17:51
  acute
• 17:52
  dystonias?
• 17:53
  Right?
• 17:54
  How
• 17:54
  else
• 17:54
  can
• 17:55
  we
• 17:55
  put
• 17:55
  this
• 17:56
  together?
• 17:56
  We
• 17:56
  talked
• 17:57
  a
• 17:57
  little
• 17:57
  bit
• 17:57
  about
• 17:57
  choosing
• 17:58
  an
• 17:58
  SGA
• 17:59
  with
• 17:59
  lower
• 17:59
  D2
• 18:00
  binding
• 18:00
  affinity.
• 18:01
  Fast
• 18:02
  off
• 18:02
  kinetics
• 18:02
  that
• 18:02
  Seroquel
• 18:03
  magnet
• 18:04
  that
• 18:04
  kind
• 18:04
  of
• 18:04
  comes
• 18:05
  on
• 18:05
  and
• 18:05
  off
• 18:05
  of
• 18:05
  the
• 18:06
  D2
• 18:06
  receptor,
• 18:07
  allowing
• 18:07
  for
• 18:08
  a
• 18:08
  little
• 18:08
  more
• 18:08
  endogenous
• 18:09
  dopamine
• 18:10
  to
• 18:10
  bind
• 18:10
  there.
• 18:10
  As
• 18:11
  opposed
• 18:11
  to
• 18:11
  this
• 18:12
  really
• 18:12
  stuck
• 18:12
  magnet
• 18:13
  where
• 18:13
  the
• 18:13
  endogenous
• 18:14
  dopamine
• 18:14
  you're
• 18:14
  normally.
• 18:15
  That's
• 18:16
  normally
• 18:16
  circulating
• 18:17
  in
• 18:17
  your
• 18:17
  body's
• 18:17
  not
• 18:17
  hitting
• 18:18
  that
• 18:18
  D2
• 18:19
  receptor
• 18:19
  because
• 18:19
  the
• 18:19
  magnet's
• 18:20
  so
• 18:20
  stuck
• 18:20
  to
• 18:20
  it.
• 18:20
  Switching
• 18:21
  to
• 18:21
  Quetiapine
• 18:22
  or
• 18:22
  Seroquel
• 18:23
  might
• 18:23
  be
• 18:23
  an
• 18:23
  option.
• 18:24
  You
• 18:24
  have
• 18:24
  Latuda
• 18:25
  strong
• 18:26
  5ht2a
• 18:27
  antagonism,
• 18:28
  which
• 18:28
  again,
• 18:28
  we
• 18:29
  talked
• 18:29
  about
• 18:29
  5ht2a
• 18:30
  and
• 18:31
  the
• 18:31
  releasing
• 18:32
  the
• 18:32
  break
• 18:32
  on
• 18:33
  dopamine
• 18:33
  and
• 18:33
  the
• 18:33
  nigrostriatal
• 18:34
  pathways,
• 18:35
  also
• 18:35
  pretty
• 18:36
  cool.
• 18:37
  So
• 18:37
  think
• 18:37
  of
• 18:37
  these
• 18:38
  as
• 18:39
  a
• 18:39
  menu
• 18:39
  of
• 18:39
  choices
• 18:40
  you
• 18:40
  have
• 18:40
  based
• 18:40
  on
• 18:41
  your
• 18:41
  patient.
• 18:42
  It
• 18:42
  gets
• 18:42
  so
• 18:42
  fascinating
• 18:43
  and
• 18:43
  I
• 18:43
  hope
• 18:43
  you're
• 18:43
  never
• 18:44
  intimidated
• 18:44
  by
• 18:44
  this
• 18:45
  stuff.
• 18:45
  It's
• 18:45
  always
• 18:45
  good
• 18:45
  to
• 18:46
  be
• 18:46
  humble
• 18:46
  and
• 18:47
  to
• 18:47
  know
• 18:47
  that
• 18:47
  things
• 18:48
  aren't
• 18:48
  so
• 18:48
  simple.
• 18:49
  This
• 18:49
  is
• 18:50
  a
• 18:50
  beautiful
• 18:51
  kind
• 18:51
  of
• 18:51
  art
• 18:51
  and
• 18:51
  a
• 18:52
  science.
• 18:52
  You
• 18:52
  have
• 18:52
  a
• 18:52
  patient
• 18:53
  in
• 18:53
  front
• 18:53
  of
• 18:53
  you
• 18:53
  who
• 18:53
  is
• 18:54
  so
• 18:54
  complex.
• 18:55
  We're
• 18:55
  all
• 18:55
  so
• 18:55
  complex.
• 18:56
  Patients
• 18:57
  have
• 18:57
  certain
• 18:57
  genetics.
• 18:58
  They
• 18:59
  have
• 18:59
  metabolic
• 18:59
  differences
• 19:00
  in
• 19:00
  how
• 19:00
  they
• 19:00
  even
• 19:01
  metabolize
• 19:01
  these
• 19:02
  medications.
• 19:03
  Some
• 19:04
  of
• 19:04
  them
• 19:04
  are
• 19:04
  poor
• 19:05
  metabolizers
• 19:06
  of
• 19:06
  your
• 19:06
  medication,
• 19:07
  right?
• 19:08
  Maybe
• 19:08
  they
• 19:08
  are
• 19:09
  poor
• 19:09
  metabolizers
• 19:10
  and
• 19:10
  more
• 19:11
  of
• 19:11
  the
• 19:11
  drug
• 19:11
  is
• 19:11
  in
• 19:12
  their
• 19:12
  system
• 19:12
  for
• 19:12
  longer.
• 19:13
  These
• 19:13
  side
• 19:14
  effects
• 19:14
  get
• 19:14
  even
• 19:14
  worse
• 19:15
  because
• 19:15
  those
• 19:15
  receptors
• 19:16
  are
• 19:16
  being
• 19:16
  saturated
• 19:17
  by
• 19:17
  all
• 19:17
  this
• 19:17
  risperidone
• 19:18
  that's
• 19:18
  not
• 19:18
  being
• 19:18
  cleared
• 19:19
  out.
• 19:19
  I
• 19:19
  just
• 19:19
  want
• 19:20
  you
• 19:20
  to
• 19:20
  appreciate
• 19:20
  the
• 19:21
  elegance
• 19:21
  and
• 19:21
  complexity
• 19:22
  of
• 19:22
  all
• 19:22
  of
• 19:22
  this
• 19:22
  because
• 19:23
  there's
• 19:23
  so
• 19:23
  much
• 19:23
  going
• 19:23
  on.
• 19:24
  It's
• 19:24
  not
• 19:24
  just
• 19:24
  as
• 19:24
  simple
• 19:25
  as
• 19:25
  here's
• 19:25
  a
• 19:25
  med
• 19:26
  and
• 19:26
  here's
• 19:26
  what
• 19:26
  it's
• 19:27
  going
• 19:27
  to
• 19:27
  do
• 19:27
  to
• 19:27
  you.
• 19:27
  It
• 19:27
  depends
• 19:28
  on
• 19:28
  your
• 19:28
  genetics.
• 19:29
  It
• 19:29
  depends
• 19:29
  on
• 19:29
  your
• 19:30
  endogenous
• 19:30
  dopamine
• 19:31
  levels,
• 19:32
  right?
• 19:32
  It
• 19:32
  depends
• 19:33
  on
• 19:33
  the
• 19:33
  blood
• 19:33
  barrier
• 19:34
  penetration
• 19:35
  that
• 19:35
  varies
• 19:35
  from
• 19:36
  person
• 19:36
  to
• 19:36
  person.
• 19:36
  The
• 19:36
  protein
• 19:37
  binding
• 19:37
  of
• 19:37
  these
• 19:38
  medications
• 19:38
  influences
• 19:39
  the
• 19:39
  concentration
• 19:40
  of
• 19:40
  the
• 19:40
  drugs
• 19:40
  and
• 19:41
  thus
• 19:41
  the
• 19:41
  side
• 19:41
  effects.
• 19:42
  Knowing
• 19:43
  that
• 19:43
  although
• 19:44
  that
• 19:44
  could
• 19:44
  be
• 19:44
  intimidating,
• 19:45
  it
• 19:45
  could
• 19:45
  also
• 19:45
  empower
• 19:46
  you
• 19:46
  to
• 19:46
  understand.
• 19:47
  Here's
• 19:47
  a
• 19:47
  medication.
• 19:48
  I
• 19:48
  have
• 19:48
  many
• 19:49
  different
• 19:49
  receptors.
• 19:50
  I
• 19:50
  have
• 19:50
  many
• 19:50
  different
• 19:50
  options
• 19:51
  as
• 19:51
  to
• 19:52
  what
• 19:52
  this
• 19:53
  medication
• 19:53
  is
• 19:53
  going
• 19:53
  to
• 19:54
  do
• 19:54
  and
• 19:54
  how
• 19:54
  it's
• 19:54
  going
• 19:54
  to
• 19:55
  exert
• 19:55
  an
• 19:55
  influence
• 19:56
  on
• 19:56
  each
• 19:56
  receptor.
• 19:57
  There's
• 19:57
  different
• 19:58
  brain
• 19:58
  areas,
• 19:59
  of
• 19:59
  course,
• 19:59
  and
• 20:00
  we're
• 20:00
  targeting
• 20:00
  different
• 20:01
  brain
• 20:01
  areas
• 20:01
  for
• 20:02
  different
• 20:02
  reasons.
• 20:03
  Opening
• 20:03
  the
• 20:03
  door,
• 20:04
  looking
• 20:04
  behind
• 20:04
  the
• 20:05
  curtain
• 20:05
  to
• 20:05
  understand
• 20:06
  these
• 20:06
  receptors
• 20:07
  and
• 20:07
  their
• 20:07
  pathways
• 20:08
  and
• 20:08
  how
• 20:09
  this
• 20:09
  all
• 20:09
  comes
• 20:09
  together
• 20:09
  is
• 20:10
  going
• 20:10
  to
• 20:10
  empower
• 20:10
  you
• 20:11
  be
• 20:11
  able
• 20:11
  to
• 20:12
  execute
• 20:12
  treatment
• 20:12
  plans
• 20:13
  that
• 20:13
  are
• 20:13
  much
• 20:13
  more
• 20:14
  precise
• 20:14
  and
• 20:14
  intentional.
• 20:15
  When
• 20:16
  you
• 20:16
  look
• 20:16
  behind
• 20:16
  the
• 20:16
  curtain
• 20:17
  and
• 20:17
  actually
• 20:17
  know
• 20:18
  what's
• 20:18
  going
• 20:18
  on.
• 20:19
  I
• 20:19
  hope
• 20:19
  you
• 20:20
  had
• 20:20
  a
• 20:21
  better
• 20:21
  idea
• 20:21
  of
• 20:22
  what
• 20:22
  a
• 20:22
  dystonia
• 20:23
  is,
• 20:23
  how
• 20:23
  to
• 20:24
  manage
• 20:24
  it.
• 20:25
  More
• 20:25
  specifically,
• 20:26
  why
• 20:26
  things
• 20:27
  are
• 20:27
  done
• 20:28
  at
• 20:28
  specific
• 20:29
  times.
• 20:30
  The
• 20:30
  receptor
• 20:30
  profiles.
• 20:31
  I
• 20:32
  encourage
• 20:32
  you
• 20:32
  to
• 20:32
  check
• 20:33
  out
• 20:33
  these
• 20:33
  SGAs,
• 20:34
  the
• 20:34
  second
• 20:34
  generation
• 20:35
  antipsychotics.
• 20:35
  Check
• 20:36
  out
• 20:36
  which
• 20:36
  ones
• 20:37
  have
• 20:37
  the
• 20:37
  highest
• 20:38
  affinity
• 20:38
  for
• 20:38
  5HT2A
• 20:40
  in
• 20:40
  terms
• 20:40
  of
• 20:40
  their
• 20:41
  antagonism
• 20:41
  abilities,
• 20:42
  which
• 20:42
  med
• 20:42
  has
• 20:43
  the
• 20:43
  highest
• 20:43
  affinity
• 20:43
  for
• 20:43
  that,
• 20:44
  which
• 20:44
  has
• 20:44
  the
• 20:44
  Highest
• 20:44
  affinity
• 20:45
  for
• 20:45
  D2
• 20:45
  and
• 20:45
  at
• 20:46
  what
• 20:46
  dose.
• 20:46
  How
• 20:47
  are
• 20:47
  some
• 20:47
  meds
• 20:48
  going
• 20:48
  to
• 20:48
  hit
• 20:48
  a
• 20:48
  high
• 20:49
  affinity
• 20:49
  for
• 20:49
  D2
• 20:50
  rather
• 20:50
  quickly
• 20:50
  like
• 20:51
  Risperdal?
• 20:52
  Are
• 20:52
  some
• 20:52
  meds
• 20:53
  not
• 20:53
  and
• 20:53
  why?
• 20:54
  These
• 20:54
  are
• 20:54
  fascinating,
• 20:55
  fun
• 20:55
  questions
• 20:56
  that
• 20:56
  you
• 20:57
  can
• 20:57
  dig
• 20:57
  into
• 20:57
  and
• 20:58
  really
• 20:58
  empower
• 20:58
  yourself
• 20:59
  with
• 20:59
  psychopharm.
• 21:00
  Mario
• 21:01
  did
• 21:01
  a
• 21:01
  lot
• 21:01
  better.
• 21:02
  We're
• 21:02
  so
• 21:03
  happy
• 21:03
  he's
• 21:03
  doing
• 21:03
  better.
• 21:03
  His
• 21:04
  dystonia
• 21:04
  has
• 21:04
  resolved.
• 21:05
  We
• 21:06
  actually
• 21:06
  ended
• 21:06
  up
• 21:06
  transitioning
• 21:07
  him
• 21:08
  over
• 21:08
  to
• 21:08
  Quetiapine
• 21:10
  because
• 21:10
  risperidol
• 21:11
  was
• 21:11
  not
• 21:11
  a
• 21:11
  good
• 21:11
  fit
• 21:11
  for
• 21:12
  him.
• 21:12
  We
• 21:12
  did
• 21:12
  give
• 21:12
  him
• 21:13
  cogentin.
• 21:14
  We
• 21:14
  gave
• 21:14
  him
• 21:14
  some
• 21:15
  oral
• 21:15
  cogentin
• 21:16
  as
• 21:16
  well
• 21:16
  to
• 21:17
  bridge.
• 21:17
  A
• 21:17
  few
• 21:17
  days
• 21:18
  later,
• 21:18
  once
• 21:19
  we
• 21:19
  were
• 21:19
  able
• 21:19
  to
• 21:19
  safely
• 21:20
  taper
• 21:20
  his
• 21:20
  Risperidone,
• 21:21
  we
• 21:21
  onboarded
• 21:22
  Seroquel.
• 21:23
  I
• 21:23
  won't
• 21:23
  go
• 21:23
  into
• 21:23
  the
• 21:23
  details
• 21:24
  of
• 21:24
  a
• 21:24
  cross
• 21:24
  titration
• 21:25
  that
• 21:25
  is
• 21:25
  certainly
• 21:26
  not
• 21:26
  for
• 21:26
  this
• 21:26
  episode.
• 21:27
  But
• 21:27
  I
• 21:27
  am
• 21:28
  so
• 21:28
  grateful
• 21:28
  for
• 21:28
  each
• 21:29
  and
• 21:29
  every
• 21:29
  one
• 21:29
  of
• 21:29
  you
• 21:29
  who
• 21:29
  tuned
• 21:30
  in
• 21:30
  today.
• 21:30
  And
• 21:31
  um,
• 21:31
  don't
• 21:31
  forget
• 21:32
  to
• 21:32
  become
• 21:32
  Patreon
• 21:33
  members.
• 21:33
  You
• 21:33
  have
• 21:33
  access
• 21:34
  to
• 21:34
  beautiful
• 21:34
  slide
• 21:35
  decks
• 21:35
  where
• 21:36
  you
• 21:36
  can
• 21:36
  see
• 21:36
  all
• 21:36
  of
• 21:36
  this
• 21:37
  visually.
• 21:37
  Evidence
• 21:38
  based
• 21:38
  pearls
• 21:39
  to
• 21:39
  empower
• 21:39
  your
• 21:39
  practice.
• 21:40
  You'll
• 21:40
  get
• 21:40
  a
• 21:40
  bonus
• 21:41
  feed
• 21:42
  for
• 21:42
  bonus
• 21:42
  case
• 21:42
  studies
• 21:43
  and
• 21:43
  a
• 21:43
  bonus
• 21:44
  podcast.
• 21:44
  And
• 21:45
  if
• 21:45
  you
• 21:45
  can't
• 21:45
  do
• 21:45
  that,
• 21:45
  just
• 21:46
  donate
• 21:46
  a
• 21:46
  little
• 21:46
  bit,
• 21:47
  couple
• 21:47
  bucks
• 21:47
  a
• 21:47
  month
• 21:48
  to
• 21:48
  the
• 21:48
  podcast.
• 21:49
  Definitely
• 21:50
  would
• 21:50
  love
• 21:50
  if
• 21:50
  you
• 21:51
  went
• 21:52
  to
• 21:52
  Apple
• 21:52
  and
• 21:52
  rated
• 21:53
  us
• 21:53
  five
• 21:53
  stars
• 21:53
  with
• 21:53
  a
• 21:54
  comment
• 21:54
  that
• 21:55
  really
• 21:55
  helps
• 21:55
  more
• 21:55
  than
• 21:55
  anything.
• 21:56
  This
• 21:56
  podcast
• 21:56
  has
• 21:56
  gotten
• 21:57
  very,
• 21:57
  very
• 21:57
  big.
• 21:57
  Very
• 21:58
  quickly,
• 21:58
  particularly
• 21:59
  in
• 21:59
  NP
• 22:00
  circles
• 22:00
  for
• 22:00
  NP
• 22:01
  students.
• 22:02
  I
• 22:02
  love
• 22:02
  this
• 22:02
  field
• 22:03
  and
• 22:04
  I
• 22:04
  hope
• 22:04
  you
• 22:04
  all
• 22:04
  do
• 22:04
  too.
• 22:05
  It's
• 22:05
  fascinating.
• 22:06
  You're
• 22:06
  learning
• 22:07
  every
• 22:07
  day
• 22:07
  and
• 22:08
  I
• 22:08
  encourage
• 22:08
  you
• 22:08
  to
• 22:09
  spread
• 22:09
  the
• 22:09
  good
• 22:09
  word
• 22:10
  and
• 22:10
  email
• 22:10
  me
• 22:11
  in
• 22:11
  the
• 22:11
  show
• 22:11
  notes
• 22:12
  for
• 22:12
  any
• 22:12
  topics
• 22:12
  that
• 22:13
  you
• 22:13
  want
• 22:13
  covered.
• 22:13
  And
• 22:14
  I'm
• 22:14
  happy
• 22:14
  to
• 22:14
  cover
• 22:14
  them
• 22:15
  because
• 22:15
  it's
• 22:15
  all
• 22:15
  about
• 22:15
  learning
• 22:16
  and
• 22:16
  having
• 22:16
  fun.
• 22:17
  Take
• 22:17
  care
• 22:17
  my
• 22:17
  friends.
• 22:18
  Signing
• 22:18
  off
• 22:18
  now.
• 22:19
  Take
• 22:19
  care.
• 22:19
  Bye
• 22:19
  bye.