Latest / Pearls and Prep / Hydroxyzine Explained: The Most Misunderstood Anxiety Medication? Itchy, Edgy… & Its Two Hidden Superpowers

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Hydroxyzine Explained: The Most Misunderstood Anxiety Medication? Itchy, Edgy… & Its Two Hidden Superpowers · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:05
  back,
• 0:05
  my
• 0:05
  friends,
• 0:06
  to
• 0:06
  another
• 0:06
  episode
• 0:07
  of
• 0:07
  Pearls
• 0:07
  and
• 0:08
  Prep.
• 0:08
  Npz.
• 0:09
  Here,
• 0:09
  your
• 0:09
  preceptor
• 0:10
  in
• 0:10
  your
• 0:10
  pocket,
• 0:11
  your
• 0:11
  go
• 0:12
  to
• 0:12
  place
• 0:12
  for
• 0:13
  pearls
• 0:14
  that
• 0:14
  prep
• 0:14
  you
• 0:15
  to
• 0:15
  practice.
• 0:16
  My
• 0:17
  friends,
• 0:18
  we've
• 0:19
  got
• 0:19
  talk.
• 0:19
  There
• 0:20
  is
• 0:20
  a
• 0:20
  medication
• 0:21
  out
• 0:21
  there
• 0:22
  commonly
• 0:22
  known,
• 0:23
  maybe
• 0:24
  not
• 0:24
  as
• 0:24
  commonly
• 0:25
  prescribed,
• 0:25
  but
• 0:26
  I
• 0:26
  know
• 0:27
  I'm
• 0:27
  pretty
• 0:27
  guilty
• 0:27
  myself
• 0:28
  of
• 0:28
  not
• 0:29
  prescribing
• 0:29
  this
• 0:30
  as
• 0:30
  often
• 0:31
  as
• 0:31
  I
• 0:31
  could
• 0:32
  be.
• 0:32
  And
• 0:33
  shame
• 0:33
  on
• 0:33
  me
• 0:33
  for
• 0:34
  that.
• 0:34
  And
• 0:34
  that's
• 0:34
  why
• 0:35
  we
• 0:35
  do
• 0:35
  these
• 0:35
  pearl
• 0:36
  dives
• 0:36
  to
• 0:36
  look
• 0:36
  at
• 0:37
  the
• 0:37
  literature
• 0:38
  and
• 0:38
  see
• 0:39
  the
• 0:39
  fascinating
• 0:40
  shiny
• 0:40
  pearls
• 0:41
  out
• 0:41
  there
• 0:41
  that
• 0:42
  blind
• 0:42
  us
• 0:42
  with
• 0:43
  new
• 0:43
  knowledge
• 0:44
  and
• 0:44
  make
• 0:44
  us
• 0:45
  see
• 0:45
  the
• 0:45
  world
• 0:46
  anew.
• 0:47
  That's
• 0:47
  what
• 0:47
  I
• 0:48
  did
• 0:48
  today.
• 0:49
  That's
• 0:49
  what
• 0:49
  I'm
• 0:49
  so
• 0:49
  excited
• 0:50
  about.
• 0:51
  Because
• 0:52
  hydroxyzine,
• 0:53
  my
• 0:53
  friends,
• 0:54
  is
• 0:54
  all
• 0:55
  the
• 0:55
  rage
• 0:55
  in
• 0:55
  my
• 0:56
  brain
• 0:56
  right
• 0:56
  now.
• 0:56
  And
• 0:57
  we
• 0:57
  have
• 0:57
  to
• 0:57
  talk
• 0:57
  about
• 0:58
  this
• 0:58
  because
• 0:59
  there
• 0:59
  is
• 0:59
  a
• 1:00
  really
• 1:01
  ideal
• 1:02
  scenario
• 1:02
  or
• 1:03
  scenarios
• 1:03
  where
• 1:03
  you
• 1:03
  could
• 1:04
  prescribe
• 1:04
  hydroxyzine.
• 1:06
  And
• 1:06
  I
• 1:06
  don't
• 1:07
  think
• 1:07
  we
• 1:07
  should
• 1:07
  miss
• 1:07
  out
• 1:07
  on
• 1:08
  this
• 1:08
  opportunity.
• 1:08
  As
• 1:09
  clinicians,
• 1:10
  as
• 1:10
  prescribers,
• 1:11
  we
• 1:11
  need
• 1:11
  to
• 1:11
  talk
• 1:11
  about
• 1:12
  what
• 1:12
  this
• 1:12
  is
• 1:12
  actually
• 1:13
  doing
• 1:13
  and
• 1:13
  how
• 1:13
  and
• 1:14
  why.
• 1:14
  And
• 1:15
  so
• 1:15
  I
• 1:15
  am
• 1:15
  just
• 1:17
  so
• 1:17
  excited
• 1:17
  right
• 1:18
  now.
• 1:18
  I'm
• 1:18
  giddy
• 1:19
  with
• 1:20
  excitement.
• 1:21
  I'm
• 1:21
  almost
• 1:21
  slobbering.
• 1:22
  I'm
• 1:22
  not
• 1:22
  quite
• 1:23
  slobbering.
• 1:23
  Sometimes
• 1:24
  I
• 1:24
  do
• 1:25
  spit
• 1:25
  when
• 1:25
  I
• 1:25
  talk,
• 1:26
  very
• 1:26
  rarely,
• 1:27
  not
• 1:27
  at
• 1:27
  people,
• 1:28
  but
• 1:29
  when
• 1:29
  I'm
• 1:29
  really
• 1:29
  excited,
• 1:30
  I
• 1:30
  think
• 1:31
  I
• 1:31
  need
• 1:31
  to
• 1:31
  just
• 1:31
  slow
• 1:32
  down
• 1:32
  so
• 1:32
  that
• 1:33
  the
• 1:33
  spittle
• 1:33
  doesn't.
• 1:34
  Okay,
• 1:36
  let's
• 1:36
  go.
• 1:36
  Let's
• 1:37
  talk
• 1:37
  about
• 1:37
  this.
• 1:37
  So,
• 1:37
  my
• 1:38
  friends,
• 1:38
  the
• 1:39
  biggest
• 1:39
  surprise
• 1:40
  about
• 1:40
  hydroxyzine
• 1:41
  is
• 1:41
  that
• 1:42
  it's
• 1:42
  such
• 1:42
  a
• 1:44
  simple
• 1:44
  med.
• 1:44
  That's
• 1:45
  really
• 1:45
  not
• 1:45
  that
• 1:45
  simple,
• 1:46
  Right?
• 1:46
  When
• 1:47
  you
• 1:47
  compare
• 1:47
  it
• 1:47
  to
• 1:47
  Remeron
• 1:48
  or
• 1:48
  Trazodone
• 1:49
  or
• 1:49
  doxepin,
• 1:50
  or
• 1:51
  you
• 1:51
  compare
• 1:52
  it
• 1:52
  to
• 1:53
  any
• 1:53
  of
• 1:53
  the
• 1:53
  other
• 1:53
  medications
• 1:54
  we
• 1:54
  prescribe,
• 1:55
  you
• 1:55
  might
• 1:55
  think
• 1:55
  it's
• 1:55
  this
• 1:56
  kind
• 1:56
  of
• 1:56
  little
• 1:56
  league,
• 1:57
  eh?
• 1:57
  It's
• 1:57
  hydroxyzine.
• 1:58
  Who
• 1:58
  cares?
• 1:59
  It's
• 2:00
  just
• 2:00
  such
• 2:00
  a
• 2:00
  small
• 2:01
  little
• 2:01
  intervention.
• 2:02
  You
• 2:02
  don't
• 2:02
  even
• 2:02
  think
• 2:03
  twice
• 2:03
  about
• 2:03
  it.
• 2:03
  You
• 2:03
  give
• 2:03
  it
• 2:04
  to
• 2:04
  your
• 2:04
  patient
• 2:04
  because
• 2:05
  you
• 2:05
  think
• 2:05
  they're
• 2:05
  going
• 2:05
  to
• 2:05
  fall
• 2:05
  asleep
• 2:06
  or
• 2:06
  be
• 2:06
  a
• 2:06
  little
• 2:06
  less
• 2:07
  anxious
• 2:07
  or
• 2:07
  on
• 2:07
  edge,
• 2:08
  but
• 2:08
  there's
• 2:09
  so
• 2:09
  much
• 2:09
  more
• 2:09
  to
• 2:09
  it
• 2:10
  than
• 2:10
  that.
• 2:11
  And
• 2:12
  so
• 2:13
  I
• 2:13
  want
• 2:13
  to
• 2:13
  chat
• 2:13
  about
• 2:13
  it.
• 2:14
  I
• 2:14
  want
• 2:14
  to
• 2:14
  chat
• 2:14
  about
• 2:15
  the
• 2:15
  receptor
• 2:16
  profile,
• 2:17
  because,
• 2:18
  yeah,
• 2:19
  it's
• 2:20
  an
• 2:20
  H1
• 2:21
  inverse
• 2:21
  agonist,
• 2:22
  and
• 2:23
  it
• 2:23
  makes
• 2:23
  you
• 2:23
  a
• 2:23
  little
• 2:24
  sedated.
• 2:25
  But
• 2:25
  that
• 2:25
  is
• 2:25
  not
• 2:26
  even
• 2:26
  the
• 2:26
  whole
• 2:26
  story
• 2:27
  at
• 2:27
  all.
• 2:27
  In
• 2:27
  fact,
• 2:28
  most
• 2:28
  people
• 2:29
  get
• 2:29
  kind
• 2:30
  of
• 2:30
  habituated
• 2:31
  to
• 2:31
  the
• 2:32
  sedation,
• 2:33
  so
• 2:33
  that's
• 2:33
  not
• 2:33
  even
• 2:33
  the
• 2:34
  main
• 2:34
  squeeze.
• 2:34
  And
• 2:35
  so
• 2:35
  now
• 2:35
  we're
• 2:35
  really
• 2:36
  at
• 2:36
  the
• 2:36
  edge
• 2:36
  of
• 2:36
  our
• 2:36
  seats
• 2:37
  going,
• 2:37
  well,
• 2:37
  what
• 2:37
  does
• 2:38
  this
• 2:38
  thing
• 2:38
  do?
• 2:39
  NPZ
• 2:39
  I
• 2:39
  thought
• 2:40
  that's
• 2:40
  all
• 2:40
  it
• 2:40
  did.
• 2:40
  I
• 2:40
  thought
• 2:41
  it
• 2:41
  was
• 2:41
  just
• 2:41
  kind
• 2:41
  of
• 2:41
  makes
• 2:42
  you
• 2:42
  a
• 2:42
  little
• 2:42
  sedated
• 2:43
  and
• 2:43
  maybe
• 2:43
  not
• 2:44
  care
• 2:44
  as
• 2:44
  much
• 2:44
  about
• 2:45
  your
• 2:45
  anxieties
• 2:46
  and
• 2:46
  tones
• 2:46
  you
• 2:46
  down
• 2:46
  a
• 2:47
  little.
• 2:47
  No,
• 2:47
  no,
• 2:47
  no,
• 2:48
  no,
• 2:48
  no.
• 2:48
  There's
• 2:48
  so
• 2:48
  much
• 2:49
  more
• 2:49
  that
• 2:49
  meets
• 2:50
  the
• 2:50
  eye.
• 2:51
  Now,
• 2:52
  before
• 2:52
  we
• 2:52
  get
• 2:52
  into
• 2:53
  that
• 2:53
  too
• 2:53
  much,
• 2:53
  I
• 2:54
  want
• 2:54
  you
• 2:54
  guys
• 2:55
  to
• 2:55
  picture
• 2:56
  a
• 2:57
  29
• 2:57
  year
• 2:57
  old
• 2:58
  guy,
• 2:58
  just
• 2:58
  a
• 2:58
  mock
• 2:59
  patient,
• 2:59
  okay?
• 3:00
  He's
• 3:00
  a
• 3:00
  plumber,
• 3:01
  okay?
• 3:02
  And
• 3:02
  his
• 3:03
  name
• 3:03
  is
• 3:03
  Paul.
• 3:03
  Paul
• 3:04
  the
• 3:04
  plumber,
• 3:05
  okay?
• 3:05
  And
• 3:05
  he
• 3:06
  comes
• 3:06
  to
• 3:06
  you
• 3:06
  in
• 3:06
  the
• 3:06
  outpatient
• 3:07
  clinic
• 3:08
  and
• 3:09
  he's
• 3:09
  all
• 3:09
  wound
• 3:09
  up,
• 3:10
  he's
• 3:10
  tight,
• 3:10
  he's
• 3:11
  not
• 3:11
  crying,
• 3:12
  he's
• 3:12
  not
• 3:12
  panicking.
• 3:13
  And
• 3:13
  he's
• 3:14
  telling
• 3:14
  you
• 3:14
  like,
• 3:15
  he's
• 3:15
  not
• 3:15
  really
• 3:15
  a
• 3:15
  big
• 3:15
  worrier.
• 3:16
  He's
• 3:17
  never
• 3:17
  been
• 3:17
  depressed
• 3:18
  before.
• 3:18
  He's
• 3:19
  not
• 3:19
  your
• 3:19
  classic
• 3:20
  GAD
• 3:20
  or
• 3:20
  major
• 3:21
  depressed
• 3:21
  patient.
• 3:22
  His
• 3:22
  jaw
• 3:23
  is
• 3:23
  clenched,
• 3:23
  his
• 3:24
  shoulders
• 3:24
  are
• 3:24
  tight,
• 3:25
  he's
• 3:25
  kind
• 3:25
  of
• 3:25
  scratchy,
• 3:26
  scratches
• 3:26
  himself
• 3:27
  a
• 3:27
  lot.
• 3:28
  You.
• 3:28
  You
• 3:28
  notice
• 3:29
  a
• 3:29
  few
• 3:29
  shallow
• 3:30
  excoriations
• 3:31
  around
• 3:31
  his
• 3:32
  arms
• 3:32
  and
• 3:32
  wrists.
• 3:33
  Not
• 3:33
  self
• 3:33
  harm.
• 3:34
  He's
• 3:34
  just
• 3:34
  kind
• 3:34
  of
• 3:34
  an
• 3:34
  itchy,
• 3:35
  tense
• 3:36
  guy
• 3:36
  who
• 3:37
  doesn't
• 3:37
  meet
• 3:37
  clean
• 3:38
  criteria
• 3:38
  for
• 3:38
  like
• 3:39
  GAD
• 3:39
  or
• 3:39
  mdd.
• 3:40
  And
• 3:41
  he's
• 3:41
  not
• 3:41
  panicky.
• 3:41
  There's
• 3:42
  no
• 3:42
  major
• 3:42
  trauma
• 3:43
  history.
• 3:43
  And
• 3:44
  he
• 3:44
  picks
• 3:44
  at
• 3:45
  his
• 3:45
  cuticles,
• 3:45
  at
• 3:45
  his
• 3:46
  skin,
• 3:46
  and
• 3:46
  he
• 3:46
  tells
• 3:46
  you
• 3:46
  it's
• 3:47
  a
• 3:47
  bad
• 3:47
  habit
• 3:47
  and
• 3:47
  he
• 3:47
  wants
• 3:48
  help
• 3:48
  with
• 3:48
  that.
• 3:49
  And
• 3:49
  he's
• 3:49
  just
• 3:49
  kind
• 3:49
  of
• 3:49
  tense
• 3:50
  and
• 3:50
  edgy
• 3:50
  and
• 3:50
  itchy
• 3:51
  all
• 3:51
  of
• 3:52
  the
• 3:52
  time.
• 3:52
  He
• 3:52
  used
• 3:53
  to
• 3:53
  drink
• 3:53
  more
• 3:53
  than
• 3:53
  he'd
• 3:54
  like
• 3:54
  to
• 3:54
  drink.
• 3:54
  He's
• 3:54
  been
• 3:55
  sober
• 3:55
  for
• 3:55
  14
• 3:55
  months
• 3:56
  now,
• 3:56
  though.
• 3:56
  And
• 3:57
  he
• 3:57
  tells
• 3:57
  you
• 3:57
  he
• 3:57
  doesn't
• 3:58
  really
• 3:58
  want
• 3:58
  to
• 3:58
  be
• 3:58
  on
• 3:58
  a
• 3:58
  lot
• 3:59
  of
• 3:59
  pills.
• 4:00
  And
• 4:00
  so
• 4:01
  you
• 4:01
  look
• 4:02
  at
• 4:02
  this
• 4:02
  guy
• 4:02
  and
• 4:02
  you're
• 4:03
  like,
• 4:03
  wait
• 4:03
  a
• 4:03
  minute,
• 4:03
  what
• 4:04
  is
• 4:04
  this?
• 4:04
  And
• 4:04
  I
• 4:04
  have
• 4:05
  had
• 4:05
  patients
• 4:05
  like
• 4:05
  this,
• 4:06
  my
• 4:06
  friends,
• 4:06
  and
• 4:06
  they
• 4:06
  really
• 4:07
  throw
• 4:07
  you
• 4:07
  off
• 4:07
  if
• 4:08
  you
• 4:08
  don't
• 4:08
  really
• 4:08
  know
• 4:09
  the
• 4:09
  medications
• 4:10
  in
• 4:10
  your
• 4:10
  arsenal
• 4:11
  because
• 4:12
  you're
• 4:12
  thinking
• 4:12
  of
• 4:12
  a
• 4:13
  patient
• 4:13
  like
• 4:13
  this
• 4:13
  and
• 4:13
  going,
• 4:14
  wait
• 4:14
  a
• 4:14
  minute,
• 4:15
  he
• 4:15
  doesn't
• 4:16
  really
• 4:16
  have
• 4:16
  gad.
• 4:16
  So
• 4:17
  I'm
• 4:17
  not
• 4:17
  going
• 4:17
  to,
• 4:17
  I'm
• 4:18
  not
• 4:18
  going
• 4:18
  to
• 4:18
  prescribe
• 4:19
  Zoloft
• 4:19
  or
• 4:19
  Prozac
• 4:20
  here
• 4:20
  or
• 4:21
  Effexor.
• 4:22
  This
• 4:22
  isn't
• 4:22
  really
• 4:23
  the
• 4:23
  right
• 4:23
  person
• 4:24
  for
• 4:24
  that.
• 4:24
  Right?
• 4:24
  That's
• 4:25
  like
• 4:25
  shooting
• 4:25
  squirrels
• 4:25
  with
• 4:26
  shotguns.
• 4:26
  It
• 4:26
  doesn't
• 4:27
  make
• 4:27
  a
• 4:27
  lot
• 4:27
  of
• 4:27
  sense.
• 4:27
  Like,
• 4:28
  I
• 4:28
  don't
• 4:28
  need
• 4:28
  one
• 4:28
  of
• 4:29
  these
• 4:29
  heavier
• 4:29
  hitters
• 4:30
  if
• 4:30
  he's
• 4:30
  not
• 4:30
  really
• 4:30
  worried
• 4:31
  and
• 4:31
  panicky
• 4:31
  and
• 4:31
  avoidant.
• 4:32
  And
• 4:32
  I
• 4:33
  don't
• 4:33
  see
• 4:33
  any
• 4:33
  trauma
• 4:34
  in
• 4:34
  his
• 4:34
  past.
• 4:35
  He's
• 4:35
  picking
• 4:36
  at
• 4:36
  his
• 4:36
  skin.
• 4:36
  He's
• 4:37
  a
• 4:37
  little
• 4:37
  edgy.
• 4:37
  Like,
• 4:37
  what
• 4:37
  do
• 4:38
  I
• 4:38
  do
• 4:38
  for
• 4:38
  that?
• 4:38
  I
• 4:38
  don't
• 4:39
  want
• 4:39
  to
• 4:39
  prescribe
• 4:40
  Ativan
• 4:40
  or
• 4:40
  Xanax.
• 4:41
  And
• 4:41
  now
• 4:41
  he's
• 4:42
  got
• 4:42
  dependency
• 4:43
  issues
• 4:43
  again.
• 4:44
  It's
• 4:44
  kind
• 4:44
  of
• 4:44
  shooting
• 4:45
  squirrels
• 4:45
  with
• 4:45
  shotguns.
• 4:46
  And
• 4:46
  assuming
• 4:47
  we
• 4:48
  rule
• 4:48
  out
• 4:48
  all
• 4:48
  the
• 4:49
  medical
• 4:49
  pieces
• 4:49
  of
• 4:50
  this
• 4:50
  first,
• 4:50
  which
• 4:51
  is
• 4:51
  fine,
• 4:51
  and
• 4:51
  we
• 4:51
  can
• 4:52
  certainly
• 4:52
  do
• 4:52
  that,
• 4:53
  but
• 4:53
  let's
• 4:53
  say
• 4:53
  that
• 4:54
  the
• 4:54
  medical
• 4:54
  piece
• 4:55
  has
• 4:55
  been
• 4:55
  ruled
• 4:55
  out
• 4:56
  already.
• 4:56
  What
• 4:57
  do
• 4:57
  you
• 4:57
  do
• 4:57
  with
• 4:57
  a
• 4:57
  guy
• 4:57
  like
• 4:58
  this?
• 4:58
  And
• 4:58
  you
• 4:58
  almost
• 4:58
  feel
• 4:59
  quite
• 4:59
  powerless.
• 5:00
  And
• 5:00
  you
• 5:01
  might
• 5:01
  ask
• 5:01
  him
• 5:01
  about
• 5:02
  sleep
• 5:02
  and
• 5:02
  appetite
• 5:02
  and
• 5:03
  see
• 5:03
  if
• 5:03
  there's
• 5:03
  a
• 5:03
  way
• 5:03
  you
• 5:04
  can
• 5:04
  round
• 5:04
  out
• 5:05
  the
• 5:05
  edges
• 5:05
  by
• 5:05
  giving
• 5:06
  him
• 5:06
  Trazodone
• 5:06
  if
• 5:06
  he
• 5:07
  can't
• 5:07
  sleep
• 5:07
  and
• 5:07
  send
• 5:08
  him
• 5:08
  packing
• 5:08
  for
• 5:08
  the
• 5:08
  day
• 5:09
  just
• 5:09
  to
• 5:09
  give
• 5:09
  him
• 5:10
  something,
• 5:10
  you
• 5:11
  know,
• 5:11
  oh,
• 5:11
  he's
• 5:11
  sober
• 5:12
  for
• 5:12
  14
• 5:12
  months.
• 5:12
  He
• 5:13
  used
• 5:13
  to
• 5:13
  drink
• 5:13
  a
• 5:13
  lot.
• 5:13
  Maybe
• 5:14
  we
• 5:14
  can
• 5:14
  give
• 5:14
  him
• 5:15
  naltrexone
• 5:15
  to
• 5:16
  support
• 5:16
  his
• 5:16
  cravings,
• 5:17
  but
• 5:17
  we're
• 5:17
  not
• 5:17
  really
• 5:17
  doing
• 5:18
  him
• 5:18
  a
• 5:18
  justice.
• 5:19
  He's
• 5:19
  edgy,
• 5:19
  he
• 5:20
  picks
• 5:20
  his
• 5:20
  skin,
• 5:21
  he's
• 5:21
  itchy,
• 5:22
  and
• 5:23
  he
• 5:23
  needs
• 5:23
  something
• 5:23
  to
• 5:23
  take
• 5:24
  the
• 5:24
  edge
• 5:24
  off.
• 5:24
  He
• 5:24
  has
• 5:25
  muscle
• 5:25
  tension.
• 5:25
  And
• 5:26
  so
• 5:26
  hydroxyzine
• 5:27
  is
• 5:27
  absolutely
• 5:28
  perfect
• 5:29
  for
• 5:29
  a
• 5:29
  guy
• 5:29
  like
• 5:29
  this
• 5:30
  because
• 5:30
  it's
• 5:31
  not
• 5:31
  all.
• 5:31
  It
• 5:31
  doesn't
• 5:32
  have
• 5:32
  all
• 5:32
  of
• 5:32
  the
• 5:32
  baggage
• 5:33
  and
• 5:33
  the
• 5:34
  big
• 5:34
  scary
• 5:35
  disclaimers
• 5:35
  that
• 5:36
  maybe
• 5:36
  benzos
• 5:37
  have.
• 5:37
  Again,
• 5:38
  it's.
• 5:38
  He's
• 5:38
  not.
• 5:38
  He
• 5:39
  doesn't
• 5:39
  have
• 5:39
  gad
• 5:40
  where
• 5:40
  we
• 5:40
  need
• 5:40
  to
• 5:41
  target
• 5:42
  very
• 5:43
  specific
• 5:43
  thought
• 5:44
  circuits
• 5:44
  with
• 5:44
  serotonin
• 5:45
  reuptake
• 5:46
  inhibition.
• 5:47
  And
• 5:47
  so
• 5:47
  hydroxyzine
• 5:48
  becomes
• 5:49
  this
• 5:49
  really
• 5:49
  perfect
• 5:50
  antidote
• 5:51
  to
• 5:51
  a
• 5:51
  lot
• 5:52
  of
• 5:52
  his
• 5:52
  complaints.
• 5:53
  The
• 5:54
  histamine.
• 5:56
  The.
• 5:56
  The
• 5:56
  histamine
• 5:57
  affinity
• 5:57
  for
• 5:58
  this
• 5:58
  is
• 5:59
  a
• 5:59
  big
• 5:59
  reason
• 5:59
  it
• 5:59
  helps
• 6:00
  with,
• 6:00
  like
• 6:00
  the
• 6:00
  itching
• 6:01
  and
• 6:01
  scratching
• 6:01
  and
• 6:02
  excoriation,
• 6:02
  which
• 6:03
  is
• 6:03
  so
• 6:03
  important.
• 6:04
  But
• 6:04
  it
• 6:04
  doubles
• 6:05
  down
• 6:06
  as
• 6:06
  an
• 6:07
  anxiolytic,
• 6:08
  specifically
• 6:08
  in
• 6:08
  its
• 6:08
  5ht
• 6:09
  2a
• 6:09
  blockade.
• 6:10
  Seroquel
• 6:11
  has
• 6:12
  potent
• 6:13
  2a
• 6:13
  antagonism.
• 6:14
  Trazodone,
• 6:14
  Remeron,
• 6:15
  Some
• 6:15
  of
• 6:15
  my
• 6:15
  favorite
• 6:16
  medications
• 6:16
  that
• 6:16
  all
• 6:17
  have
• 6:17
  such
• 6:17
  rich
• 6:18
  versatility
• 6:19
  are
• 6:20
  antagonists
• 6:21
  at
• 6:21
  5ht
• 6:21
  2a.
• 6:22
  And
• 6:22
  that
• 6:22
  does
• 6:23
  so
• 6:23
  many
• 6:23
  things
• 6:23
  at
• 6:23
  once.
• 6:24
  And
• 6:24
  it's
• 6:24
  so
• 6:25
  important
• 6:25
  in
• 6:26
  psychiatry,
• 6:27
  right?
• 6:27
  It
• 6:27
  mitigates
• 6:28
  motor
• 6:28
  effects.
• 6:29
  It
• 6:29
  helps
• 6:30
  undo
• 6:30
  some
• 6:30
  of
• 6:30
  the
• 6:31
  sexual
• 6:31
  side
• 6:31
  effects.
• 6:32
  It
• 6:32
  helps
• 6:32
  address
• 6:33
  the
• 6:33
  fact
• 6:33
  that
• 6:34
  SSRIs
• 6:35
  will
• 6:35
  agonize
• 6:36
  or
• 6:36
  stimulate
• 6:36
  2A,
• 6:37
  making
• 6:37
  you
• 6:37
  really
• 6:37
  anxious.
• 6:38
  And
• 6:39
  so
• 6:39
  by
• 6:39
  antagonizing
• 6:40
  it,
• 6:40
  you
• 6:41
  help
• 6:41
  mitigate
• 6:42
  or
• 6:42
  soften
• 6:43
  the
• 6:43
  activating
• 6:44
  parts
• 6:44
  of
• 6:45
  the
• 6:45
  SSRI
• 6:46
  activation.
• 6:46
  I
• 6:46
  think
• 6:47
  it's
• 6:47
  so
• 6:47
  important.
• 6:47
  I
• 6:47
  think
• 6:47
  we
• 6:48
  need
• 6:48
  to
• 6:48
  know
• 6:49
  which
• 6:49
  medications
• 6:50
  we
• 6:50
  have
• 6:51
  in
• 6:51
  our
• 6:51
  toolkit
• 6:52
  that
• 6:52
  antagonize
• 6:53
  2A
• 6:54
  and
• 6:54
  why
• 6:54
  that's
• 6:54
  so
• 6:54
  key.
• 6:55
  And
• 6:55
  so
• 6:56
  hydroxyzine
• 6:57
  has
• 6:57
  a
• 6:57
  moderate
• 6:58
  affinity
• 6:58
  for
• 6:58
  serotonin
• 6:59
  5
• 7:00
  HT2A,
• 7:00
  and
• 7:00
  that's
• 7:01
  going
• 7:01
  to
• 7:01
  act
• 7:01
  as
• 7:01
  a
• 7:02
  little
• 7:02
  bit
• 7:02
  of
• 7:02
  an
• 7:02
  anxiolytic.
• 7:03
  Again,
• 7:03
  it
• 7:03
  kind
• 7:03
  of
• 7:03
  calms
• 7:04
  the
• 7:05
  subcortical
• 7:06
  regions
• 7:06
  of
• 7:06
  the
• 7:07
  brain
• 7:08
  to
• 7:08
  make
• 7:08
  folks
• 7:09
  ruminate
• 7:09
  a
• 7:09
  little
• 7:09
  less.
• 7:10
  They're
• 7:10
  less
• 7:10
  anxious,
• 7:11
  they're
• 7:11
  less
• 7:11
  on
• 7:11
  edge.
• 7:12
  Trazodone
• 7:13
  does
• 7:13
  the
• 7:13
  same
• 7:13
  thing,
• 7:14
  but
• 7:14
  again,
• 7:15
  you
• 7:15
  have
• 7:15
  the
• 7:15
  specificity
• 7:16
  of
• 7:17
  the
• 7:17
  histaminergic
• 7:18
  action
• 7:19
  here.
• 7:19
  With
• 7:20
  hydroxyzine,
• 7:21
  he's,
• 7:21
  he's
• 7:21
  picking
• 7:22
  and
• 7:22
  he's
• 7:23
  itching.
• 7:23
  And
• 7:24
  so
• 7:24
  that
• 7:24
  really
• 7:24
  helps,
• 7:25
  especially
• 7:25
  if
• 7:25
  he's
• 7:26
  picking
• 7:26
  and
• 7:27
  itching
• 7:27
  as
• 7:27
  a
• 7:28
  result
• 7:28
  of
• 7:28
  the
• 7:28
  anxiety.
• 7:29
  Before
• 7:29
  that,
• 7:30
  you
• 7:30
  also
• 7:30
  have
• 7:30
  his
• 7:31
  past
• 7:31
  history
• 7:32
  of
• 7:32
  heavy
• 7:33
  alcohol
• 7:33
  use.
• 7:34
  And
• 7:34
  so
• 7:34
  you
• 7:34
  don't
• 7:35
  have
• 7:35
  to
• 7:35
  worry
• 7:35
  because
• 7:36
  hydroxyzine
• 7:37
  is
• 7:37
  not
• 7:37
  habit
• 7:38
  forming.
• 7:38
  It
• 7:38
  doesn't
• 7:39
  cause,
• 7:40
  you
• 7:40
  know,
• 7:40
  lead
• 7:40
  to
• 7:40
  addiction.
• 7:41
  So
• 7:41
  you
• 7:42
  don't
• 7:42
  have
• 7:42
  the
• 7:42
  drama
• 7:43
  of
• 7:43
  that
• 7:43
  either.
• 7:44
  So
• 7:44
  it's
• 7:44
  a
• 7:45
  really
• 7:45
  good
• 7:46
  place
• 7:46
  for
• 7:46
  your
• 7:47
  patients.
• 7:47
  Now,
• 7:47
  I've
• 7:48
  been
• 7:48
  hesitant
• 7:48
  to
• 7:48
  prescribe
• 7:49
  this
• 7:49
  when
• 7:49
  I
• 7:50
  was
• 7:50
  a
• 7:50
  new
• 7:50
  prescriber
• 7:51
  because
• 7:51
  I
• 7:52
  thought
• 7:52
  that
• 7:52
  it
• 7:52
  was
• 7:53
  too
• 7:53
  sedating.
• 7:54
  I
• 7:54
  didn't
• 7:54
  quite
• 7:54
  know
• 7:54
  how
• 7:54
  to
• 7:55
  dose
• 7:55
  it
• 7:55
  during
• 7:55
  the
• 7:56
  day.
• 7:56
  And
• 7:56
  of
• 7:56
  course
• 7:57
  I
• 7:57
  always
• 7:57
  tell
• 7:57
  you
• 7:57
  to
• 7:57
  consult
• 7:58
  your
• 7:58
  guidelines
• 7:59
  to
• 7:59
  figure
• 7:59
  out
• 7:59
  how
• 7:59
  to
• 7:59
  dose
• 8:00
  things
• 8:00
  precisely.
• 8:01
  I
• 8:01
  don't
• 8:01
  give
• 8:01
  that
• 8:02
  advice
• 8:02
  on
• 8:02
  this
• 8:02
  podcast,
• 8:03
  but
• 8:03
  I
• 8:03
  can
• 8:04
  say
• 8:04
  as
• 8:04
  a
• 8:04
  general
• 8:04
  rule,
• 8:05
  there's
• 8:05
  good
• 8:05
  evidence
• 8:06
  that
• 8:06
  patients
• 8:07
  will
• 8:07
  habituate.
• 8:08
  They'll
• 8:08
  develop
• 8:09
  a
• 8:09
  very
• 8:09
  quick
• 8:09
  tolerance
• 8:10
  to
• 8:11
  the
• 8:11
  sedating
• 8:11
  parts
• 8:12
  of
• 8:13
  the
• 8:13
  hydroxyzine.
• 8:14
  Of
• 8:14
  course,
• 8:15
  every
• 8:15
  patient
• 8:15
  is
• 8:15
  different.
• 8:15
  They
• 8:16
  all
• 8:16
  metabolize
• 8:16
  medications
• 8:17
  different.
• 8:17
  You
• 8:17
  have
• 8:18
  to
• 8:18
  verify
• 8:18
  that
• 8:18
  with
• 8:18
  your
• 8:18
  patients.
• 8:20
  But
• 8:20
  they
• 8:20
  do
• 8:20
  tend
• 8:20
  to
• 8:21
  get
• 8:22
  used
• 8:22
  to
• 8:22
  that
• 8:22
  rather
• 8:23
  quickly.
• 8:24
  But
• 8:24
  they
• 8:24
  don't
• 8:24
  habituate
• 8:25
  or
• 8:25
  they
• 8:26
  don't
• 8:26
  poop
• 8:26
  out
• 8:26
  or
• 8:26
  have
• 8:27
  tolerance
• 8:27
  with
• 8:27
  respect
• 8:27
  to
• 8:28
  the
• 8:28
  anxiety
• 8:29
  reduction,
• 8:30
  which
• 8:30
  is
• 8:30
  awesome,
• 8:30
  right?
• 8:31
  Because
• 8:31
  you
• 8:31
  want
• 8:31
  them
• 8:32
  to
• 8:32
  not
• 8:32
  be
• 8:32
  that
• 8:32
  sedated.
• 8:33
  If
• 8:33
  they
• 8:33
  can
• 8:33
  start
• 8:34
  to
• 8:34
  take
• 8:34
  this
• 8:34
  throughout
• 8:35
  the
• 8:35
  day,
• 8:35
  you
• 8:35
  can
• 8:35
  dose
• 8:36
  it
• 8:36
  throughout
• 8:36
  the
• 8:36
  day,
• 8:37
  which
• 8:37
  is
• 8:38
  really
• 8:38
  awesome
• 8:39
  because
• 8:39
  a
• 8:39
  lot
• 8:39
  of
• 8:40
  patients
• 8:40
  need
• 8:40
  help
• 8:41
  throughout
• 8:41
  the
• 8:41
  day.
• 8:42
  They're
• 8:42
  a
• 8:42
  little
• 8:42
  anxious
• 8:43
  and
• 8:43
  they
• 8:43
  feel
• 8:43
  guilty
• 8:43
  and
• 8:44
  there's
• 8:44
  a
• 8:44
  stigma
• 8:44
  attached
• 8:45
  to
• 8:45
  taking
• 8:45
  Ativan
• 8:46
  multiple
• 8:46
  times
• 8:46
  a
• 8:47
  day.
• 8:47
  Right.
• 8:47
  Or
• 8:47
  maybe
• 8:48
  their
• 8:48
  SSRIs
• 8:49
  just
• 8:49
  aren't
• 8:49
  quite
• 8:50
  cutting
• 8:50
  the
• 8:51
  mustard
• 8:51
  with
• 8:51
  serotonin
• 8:52
  reuptake
• 8:53
  inhibition
• 8:53
  and
• 8:53
  you
• 8:53
  need
• 8:53
  a
• 8:54
  different
• 8:54
  way
• 8:55
  to
• 8:55
  target
• 8:56
  this.
• 8:56
  Well,
• 8:56
  you
• 8:56
  have
• 8:57
  that
• 8:57
  a
• 8:57
  little
• 8:57
  bit
• 8:58
  in
• 8:58
  the
• 8:58
  form
• 8:58
  of
• 8:59
  the
• 8:59
  mild
• 8:59
  2A
• 9:00
  antagonism
• 9:01
  here
• 9:02
  with,
• 9:02
  with
• 9:03
  your
• 9:03
  Atarax.
• 9:04
  That's
• 9:05
  pretty
• 9:05
  cool
• 9:05
  too.
• 9:06
  You
• 9:07
  have
• 9:07
  a
• 9:08
  little
• 9:08
  bit
• 9:08
  of
• 9:08
  a
• 9:08
  calming
• 9:09
  effect
• 9:09
  because
• 9:09
  it's
• 9:10
  a
• 9:10
  bit
• 9:10
  anticholinergic.
• 9:11
  So
• 9:12
  there's
• 9:12
  a,
• 9:12
  some
• 9:13
  contribution
• 9:13
  to
• 9:14
  a
• 9:14
  calming
• 9:14
  effect.
• 9:14
  Of
• 9:15
  course,
• 9:15
  that's
• 9:15
  a
• 9:15
  double
• 9:15
  edged
• 9:16
  sword
• 9:16
  because
• 9:16
  it
• 9:17
  also
• 9:18
  causes
• 9:18
  dry
• 9:19
  mouth
• 9:19
  constipation
• 9:20
  urinary
• 9:20
  retention.
• 9:21
  The
• 9:22
  main
• 9:22
  reason
• 9:22
  that
• 9:22
  this
• 9:22
  medication
• 9:23
  is
• 9:23
  on
• 9:23
  the
• 9:23
  beers
• 9:24
  list
• 9:24
  for
• 9:24
  folks
• 9:24
  65
• 9:25
  and
• 9:25
  older,
• 9:26
  because
• 9:26
  it
• 9:26
  can
• 9:26
  make
• 9:26
  them
• 9:27
  fall.
• 9:27
  So
• 9:27
  again,
• 9:27
  like
• 9:28
  every
• 9:28
  other
• 9:28
  med,
• 9:28
  there's
• 9:29
  a
• 9:29
  double
• 9:29
  edged
• 9:29
  sword
• 9:30
  here.
• 9:30
  It's
• 9:30
  the
• 9:30
  you
• 9:31
  gotta
• 9:31
  find
• 9:31
  the
• 9:31
  right
• 9:31
  patient
• 9:32
  at
• 9:32
  the
• 9:32
  right
• 9:32
  time.
• 9:33
  But
• 9:34
  this
• 9:34
  is
• 9:34
  a
• 9:34
  really
• 9:35
  fascinating
• 9:35
  one,
• 9:36
  right?
• 9:36
  So
• 9:36
  you
• 9:36
  have
• 9:36
  multiple
• 9:37
  avenues
• 9:38
  by
• 9:38
  which
• 9:38
  it's
• 9:38
  kind
• 9:39
  of
• 9:39
  calming,
• 9:39
  relaxes
• 9:40
  the
• 9:40
  GI
• 9:41
  tract
• 9:41
  just
• 9:41
  a
• 9:41
  bit
• 9:42
  through
• 9:42
  its
• 9:42
  anticholinergic
• 9:43
  effects.
• 9:44
  Okay.
• 9:45
  That
• 9:45
  can
• 9:45
  be
• 9:45
  helpful
• 9:46
  if
• 9:46
  you
• 9:46
  have
• 9:46
  a
• 9:46
  patient
• 9:46
  who's
• 9:47
  has
• 9:47
  a
• 9:47
  GI
• 9:48
  disturbance
• 9:49
  as
• 9:49
  a
• 9:49
  result
• 9:49
  of
• 9:50
  their
• 9:50
  anxiety.
• 9:50
  That
• 9:50
  kind
• 9:51
  of
• 9:51
  bidirectional
• 9:52
  nausea
• 9:52
  causing
• 9:53
  loose
• 9:53
  stools
• 9:54
  or,
• 9:54
  or
• 9:54
  you
• 9:55
  know,
• 9:55
  and
• 9:55
  again
• 9:56
  the
• 9:56
  sedation,
• 9:57
  if
• 9:57
  we
• 9:57
  can
• 9:58
  get
• 9:58
  past
• 9:58
  that,
• 9:58
  if
• 9:59
  it
• 9:59
  is
• 9:59
  temporary,
• 9:59
  which
• 10:00
  some
• 10:00
  of
• 10:01
  the
• 10:01
  evidence
• 10:01
  shows
• 10:02
  that
• 10:03
  though
• 10:03
  it's
• 10:04
  significantly
• 10:04
  sedating
• 10:05
  right
• 10:05
  away,
• 10:06
  that
• 10:06
  once
• 10:07
  it
• 10:07
  reaches
• 10:07
  steady
• 10:08
  state,
• 10:08
  maybe
• 10:08
  after
• 10:08
  a
• 10:09
  week,
• 10:09
  the
• 10:10
  evidence
• 10:10
  suggests
• 10:10
  that
• 10:11
  sometimes
• 10:12
  the
• 10:12
  CNS
• 10:12
  will
• 10:13
  adapt
• 10:13
  to
• 10:13
  that
• 10:14
  and
• 10:15
  patients
• 10:15
  won't
• 10:15
  be
• 10:16
  as
• 10:16
  drowsy.
• 10:16
  Especially
• 10:16
  if
• 10:17
  you
• 10:17
  hang
• 10:17
  out
• 10:17
  in
• 10:17
  like
• 10:17
  the
• 10:17
  10
• 10:18
  to
• 10:18
  25
• 10:18
  milligram
• 10:19
  dosing
• 10:19
  range,
• 10:20
  that
• 10:20
  drowsiness
• 10:21
  can
• 10:21
  be
• 10:21
  transitory.
• 10:22
  Now
• 10:22
  that
• 10:22
  would
• 10:23
  be
• 10:23
  great
• 10:23
  because
• 10:24
  again
• 10:25
  then
• 10:25
  now
• 10:25
  you
• 10:25
  have
• 10:26
  some
• 10:26
  anxiolytic
• 10:27
  effect
• 10:27
  and
• 10:27
  coverage
• 10:28
  throughout
• 10:28
  the
• 10:28
  day
• 10:28
  and
• 10:29
  you
• 10:29
  can
• 10:29
  dose
• 10:29
  it
• 10:29
  up
• 10:29
  to
• 10:29
  four
• 10:30
  times
• 10:30
  a
• 10:30
  day.
• 10:30
  The
• 10:30
  dose
• 10:31
  goes
• 10:31
  really
• 10:31
  high
• 10:32
  actually
• 10:32
  as
• 10:33
  the
• 10:33
  FDA
• 10:34
  guidance
• 10:34
  suggests.
• 10:35
  And
• 10:35
  remember,
• 10:35
  the
• 10:36
  FDA
• 10:36
  approves
• 10:36
  this
• 10:37
  for
• 10:37
  anxiety.
• 10:37
  This
• 10:37
  is
• 10:38
  not
• 10:38
  some
• 10:38
  like
• 10:38
  off
• 10:38
  label
• 10:39
  wandering
• 10:39
  off
• 10:40
  the
• 10:40
  farm.
• 10:40
  Oh
• 10:40
  my
• 10:40
  God,
• 10:41
  let's
• 10:41
  throw
• 10:41
  a
• 10:41
  hail
• 10:42
  Mary.
• 10:42
  What
• 10:42
  do
• 10:42
  we
• 10:42
  do?
• 10:44
  This
• 10:44
  is
• 10:44
  actually
• 10:45
  a
• 10:45
  big
• 10:45
  deal
• 10:46
  because
• 10:46
  the
• 10:47
  FDA
• 10:47
  approved
• 10:48
  this
• 10:48
  for
• 10:48
  anxiety.
• 10:49
  And
• 10:49
  that's
• 10:50
  really
• 10:51
  kind
• 10:51
  of
• 10:51
  fascinating
• 10:52
  if
• 10:52
  you
• 10:52
  ask
• 10:52
  me.
• 10:53
  I
• 10:53
  again,
• 10:54
  forgive
• 10:55
  my
• 10:55
  ignorance,
• 10:55
  but
• 10:55
  when
• 10:55
  I
• 10:56
  graduated
• 10:56
  I
• 10:56
  thought
• 10:57
  that
• 10:57
  this
• 10:57
  was
• 10:58
  a
• 10:58
  lot
• 10:58
  more
• 10:59
  of
• 10:59
  a
• 10:59
  medication
• 11:00
  that
• 11:00
  was
• 11:00
  kind
• 11:00
  of
• 11:00
  off
• 11:01
  label
• 11:01
  for
• 11:01
  sleep
• 11:02
  and
• 11:02
  off
• 11:03
  label
• 11:03
  for
• 11:03
  other
• 11:04
  maybe
• 11:04
  anxiety
• 11:05
  edginess.
• 11:06
  The
• 11:06
  FDA
• 11:06
  label
• 11:07
  also
• 11:07
  has
• 11:07
  this
• 11:07
  really
• 11:08
  fascinating
• 11:08
  pearl
• 11:09
  attached
• 11:09
  to
• 11:09
  it,
• 11:10
  which
• 11:10
  I
• 11:10
  think
• 11:11
  we
• 11:11
  all
• 11:11
  need
• 11:11
  to
• 11:11
  think
• 11:11
  about
• 11:14
  all
• 11:14
  of
• 11:14
  the
• 11:15
  time.
• 11:15
  When
• 11:15
  we
• 11:15
  think
• 11:15
  about
• 11:15
  hydroxyzine,
• 11:17
  the
• 11:17
  FDA
• 11:17
  says
• 11:18
  that
• 11:18
  it
• 11:19
  it
• 11:20
  this
• 11:20
  might
• 11:20
  be
• 11:20
  an
• 11:21
  overlooked
• 11:22
  indication
• 11:23
  in
• 11:23
  patients
• 11:24
  who
• 11:24
  are
• 11:24
  disturbed
• 11:25
  about
• 11:25
  psychotherapy.
• 11:27
  The
• 11:27
  disturbed
• 11:27
  patient
• 11:28
  more
• 11:28
  amenable
• 11:29
  to
• 11:29
  psychotherapy.
• 11:30
  Hydroxyzine
• 11:31
  can
• 11:32
  render
• 11:32
  them
• 11:33
  more
• 11:33
  amenable
• 11:34
  to
• 11:34
  psychotherapy.
• 11:35
  That's
• 11:35
  pretty
• 11:36
  amazing,
• 11:36
  right?
• 11:36
  Because
• 11:36
  we
• 11:36
  have
• 11:37
  a
• 11:37
  lot
• 11:37
  of
• 11:37
  patients
• 11:37
  that
• 11:37
  do
• 11:38
  exposure
• 11:38
  therapy,
• 11:38
  CBT,
• 11:39
  trauma
• 11:39
  processing.
• 11:40
  So
• 11:40
  maybe
• 11:41
  a
• 11:41
  PRN
• 11:41
  dose
• 11:42
  30
• 11:42
  to
• 11:42
  60
• 11:42
  minutes
• 11:43
  before
• 11:43
  the
• 11:43
  session
• 11:44
  might
• 11:44
  be
• 11:44
  able
• 11:44
  to
• 11:45
  lower
• 11:45
  the
• 11:45
  arousal
• 11:46
  threshold
• 11:46
  just
• 11:47
  enough
• 11:47
  to
• 11:47
  participate
• 11:48
  meaningfully
• 11:49
  in
• 11:49
  psychotherapy
• 11:50
  without
• 11:50
  the
• 11:51
  cognitive
• 11:51
  blunting
• 11:51
  of
• 11:52
  benzodiazepines.
• 11:53
  That's
• 11:53
  pretty
• 11:53
  awesome.
• 11:54
  If
• 11:55
  especially
• 11:55
  in
• 11:55
  our
• 11:56
  plumber
• 11:57
  right.
• 11:57
  If
• 11:57
  he
• 11:57
  has
• 11:57
  some
• 11:58
  habit
• 11:58
  reversal
• 11:58
  therapy
• 11:59
  session
• 11:59
  for
• 12:00
  his
• 12:00
  skin
• 12:00
  picking,
• 12:01
  maybe
• 12:01
  taking
• 12:01
  the
• 12:02
  edge
• 12:02
  off
• 12:02
  a
• 12:02
  little
• 12:02
  bit
• 12:02
  before,
• 12:03
  without
• 12:03
  the
• 12:05
  negative
• 12:05
  evidence
• 12:05
  that
• 12:06
  benzodiazepines
• 12:07
  have
• 12:07
  in
• 12:07
  a
• 12:07
  lot
• 12:07
  of
• 12:08
  these
• 12:08
  a
• 12:08
  deeper
• 12:09
  psychotherapy.
• 12:10
  So
• 12:10
  that's
• 12:10
  a
• 12:10
  pretty
• 12:10
  cool
• 12:11
  thing.
• 12:11
  There's
• 12:12
  also
• 12:12
  a
• 12:12
  suggestion
• 12:13
  that
• 12:13
  you
• 12:13
  can
• 12:14
  use
• 12:14
  hydroxyzine
• 12:15
  in
• 12:15
  that
• 12:16
  bridge
• 12:16
  when
• 12:17
  you're
• 12:17
  onboarding
• 12:17
  an
• 12:18
  ssri.
• 12:18
  Now,
• 12:18
  my
• 12:19
  friends,
• 12:19
  this
• 12:19
  is
• 12:19
  really
• 12:20
  cool
• 12:20
  because
• 12:20
  I
• 12:21
  will
• 12:21
  admit
• 12:22
  I
• 12:22
  am
• 12:22
  very
• 12:23
  squirrely
• 12:23
  about
• 12:24
  starting
• 12:24
  a
• 12:24
  benzodiazepine
• 12:26
  when
• 12:26
  patients
• 12:27
  are
• 12:27
  onboarding
• 12:28
  a
• 12:29
  ssri.
• 12:30
  I
• 12:30
  know
• 12:30
  that
• 12:31
  a
• 12:31
  lot
• 12:31
  of
• 12:32
  the
• 12:32
  evidence
• 12:32
  suggests
• 12:32
  we
• 12:33
  should
• 12:33
  do
• 12:33
  that.
• 12:33
  In
• 12:34
  my
• 12:34
  experience,
• 12:34
  a
• 12:35
  lot
• 12:35
  of
• 12:35
  patients,
• 12:35
  though,
• 12:35
  they
• 12:36
  don't
• 12:36
  really
• 12:36
  want
• 12:36
  to
• 12:36
  get
• 12:36
  off
• 12:37
  of
• 12:37
  it.
• 12:37
  Enough
• 12:37
  of
• 12:38
  them
• 12:38
  are
• 12:39
  going
• 12:39
  through
• 12:39
  a
• 12:40
  tough
• 12:40
  enough
• 12:40
  time
• 12:41
  where
• 12:41
  they
• 12:41
  kind
• 12:41
  of
• 12:41
  want
• 12:41
  that
• 12:42
  prescription
• 12:42
  to
• 12:42
  be
• 12:43
  extended.
• 12:43
  And
• 12:44
  pretty
• 12:44
  soon
• 12:44
  you
• 12:44
  have
• 12:45
  a
• 12:45
  panel
• 12:45
  of
• 12:45
  patients
• 12:46
  that
• 12:46
  are
• 12:46
  just
• 12:46
  indefinitely
• 12:47
  continuing
• 12:48
  benzodiazepines
• 12:49
  without
• 12:49
  much
• 12:49
  of
• 12:49
  a
• 12:49
  plan.
• 12:50
  And
• 12:50
  anything
• 12:51
  else
• 12:51
  you
• 12:51
  try
• 12:51
  to
• 12:51
  use
• 12:51
  at
• 12:52
  that
• 12:52
  point
• 12:52
  is
• 12:52
  a
• 12:52
  lot
• 12:52
  more
• 12:53
  difficult.
• 12:53
  You
• 12:54
  have
• 12:54
  the
• 12:54
  comorbidities
• 12:55
  of
• 12:55
  people
• 12:55
  who
• 12:55
  also
• 12:56
  have
• 12:56
  ptsd.
• 12:56
  And
• 12:57
  that's
• 12:57
  really
• 12:57
  not
• 12:58
  good
• 12:58
  to
• 12:58
  have
• 12:58
  a
• 12:59
  benzodiazepine
• 12:59
  on
• 13:00
  board
• 13:00
  when
• 13:00
  a
• 13:00
  patient
• 13:00
  also
• 13:01
  has
• 13:01
  ptsd
• 13:02
  because
• 13:02
  now
• 13:02
  they're
• 13:03
  psychotherapy
• 13:04
  is
• 13:04
  going
• 13:04
  to
• 13:04
  be
• 13:04
  affected
• 13:05
  by
• 13:05
  that.
• 13:05
  You
• 13:05
  have
• 13:05
  therapists
• 13:06
  who
• 13:06
  get
• 13:07
  really
• 13:07
  up
• 13:08
  in
• 13:08
  arms
• 13:08
  about
• 13:09
  that
• 13:09
  and
• 13:10
  for
• 13:10
  good
• 13:11
  measure.
• 13:11
  And
• 13:11
  so
• 13:11
  I
• 13:12
  don't
• 13:12
  like
• 13:12
  that.
• 13:12
  It's,
• 13:13
  it's,
• 13:13
  it's
• 13:14
  not
• 13:14
  a
• 13:14
  very
• 13:14
  good
• 13:14
  approach.
• 13:15
  Again,
• 13:15
  it
• 13:15
  might
• 13:15
  work
• 13:16
  in
• 13:16
  a
• 13:16
  textbook
• 13:17
  sense,
• 13:17
  but
• 13:18
  not
• 13:18
  in
• 13:18
  a
• 13:18
  practical
• 13:19
  sense.
• 13:19
  And
• 13:19
  so
• 13:20
  I
• 13:21
  think
• 13:21
  hydroxyzine
• 13:22
  has
• 13:22
  a
• 13:22
  really
• 13:22
  good
• 13:23
  role
• 13:23
  to
• 13:23
  play
• 13:23
  here
• 13:24
  where
• 13:24
  you
• 13:24
  could
• 13:25
  onboard
• 13:25
  them
• 13:25
  with
• 13:25
  hydroxyzine
• 13:26
  for
• 13:27
  that
• 13:27
  SSRI
• 13:28
  induced
• 13:29
  activation.
• 13:30
  And
• 13:30
  we
• 13:30
  already
• 13:30
  talked
• 13:30
  about
• 13:30
  how
• 13:31
  the
• 13:31
  SSRI
• 13:31
  induced
• 13:32
  activation
• 13:33
  is
• 13:33
  happening
• 13:33
  specifically
• 13:34
  because
• 13:35
  we're
• 13:35
  stimulating
• 13:35
  that
• 13:36
  2A
• 13:36
  receptor
• 13:36
  which
• 13:37
  is
• 13:37
  antagonized
• 13:38
  by
• 13:38
  hydroxyzine.
• 13:39
  So
• 13:39
  it's
• 13:39
  this
• 13:39
  perfect,
• 13:40
  elegant
• 13:41
  psychopharmacology
• 13:42
  balance
• 13:43
  where
• 13:44
  you
• 13:44
  add
• 13:45
  hydroxyzine
• 13:46
  to
• 13:46
  more
• 13:46
  precisely
• 13:47
  counter
• 13:48
  the
• 13:48
  activation
• 13:48
  of
• 13:48
  your
• 13:49
  SSRIs.
• 13:50
  Win,
• 13:50
  win.
• 13:50
  That's
• 13:51
  really
• 13:51
  cool.
• 13:51
  And
• 13:51
  they
• 13:51
  don't
• 13:51
  have
• 13:52
  to
• 13:52
  take
• 13:52
  hydroxyzine
• 13:53
  every
• 13:53
  day.
• 13:54
  They.
• 13:54
  But
• 13:55
  they
• 13:55
  can,
• 13:55
  they
• 13:55
  can
• 13:56
  take
• 13:56
  it
• 13:56
  to
• 13:56
  kind
• 13:56
  of
• 13:56
  round
• 13:57
  out
• 13:57
  the
• 13:57
  edges
• 13:58
  and
• 13:58
  you
• 13:58
  don't
• 13:59
  have
• 13:59
  to
• 13:59
  worry
• 13:59
  about
• 13:59
  the
• 13:59
  baggage
• 14:00
  of
• 14:00
  it
• 14:00
  being
• 14:00
  habit
• 14:01
  forming.
• 14:01
  Really,
• 14:02
  really
• 14:02
  awesome.
• 14:03
  I
• 14:03
  would
• 14:04
  again,
• 14:04
  watch
• 14:04
  out
• 14:04
  for
• 14:05
  daytime
• 14:05
  sedation
• 14:05
  just
• 14:06
  in
• 14:06
  case,
• 14:06
  especially
• 14:06
  in
• 14:07
  the
• 14:07
  beginning.
• 14:07
  I
• 14:07
  would
• 14:07
  not
• 14:07
  try
• 14:08
  their
• 14:08
  first
• 14:08
  dose
• 14:09
  when
• 14:09
  they're
• 14:09
  driving
• 14:10
  in
• 14:10
  the
• 14:10
  morning.
• 14:10
  That's
• 14:10
  a
• 14:10
  really
• 14:11
  bad
• 14:11
  idea.
• 14:12
  You
• 14:12
  definitely
• 14:12
  want
• 14:13
  to
• 14:13
  check
• 14:13
  your
• 14:13
  patients
• 14:13
  for
• 14:13
  QT
• 14:14
  C
• 14:15
  prolongation
• 14:15
  and
• 14:16
  other
• 14:16
  meds
• 14:16
  that
• 14:16
  might
• 14:16
  be
• 14:17
  contributing
• 14:18
  up
• 14:18
  to
• 14:18
  that
• 14:19
  because
• 14:19
  hydroxyzine
• 14:20
  has
• 14:20
  been
• 14:20
  shown
• 14:21
  to
• 14:21
  potentially
• 14:22
  prolong
• 14:22
  QT
• 14:23
  in
• 14:23
  post
• 14:23
  marketing
• 14:24
  cases.
• 14:24
  So
• 14:24
  look
• 14:24
  out
• 14:25
  for
• 14:25
  Celexa
• 14:25
  and
• 14:26
  methadone
• 14:26
  and
• 14:27
  Geodon
• 14:27
  and
• 14:27
  all
• 14:28
  those
• 14:28
  good
• 14:28
  meds
• 14:29
  that
• 14:29
  might
• 14:29
  be
• 14:29
  adding
• 14:30
  to
• 14:30
  that.
• 14:30
  So
• 14:30
  you
• 14:30
  may
• 14:31
  even
• 14:31
  want
• 14:31
  to
• 14:31
  take
• 14:31
  a
• 14:32
  baseline
• 14:32
  EKG
• 14:33
  if
• 14:33
  you're
• 14:34
  stacking
• 14:34
  a
• 14:34
  lot
• 14:34
  of
• 14:34
  QT
• 14:35
  prolongation
• 14:36
  agents
• 14:36
  out
• 14:37
  there.
• 14:37
  Again,
• 14:37
  we
• 14:37
  talked
• 14:38
  about
• 14:38
  watching
• 14:38
  out
• 14:38
  for
• 14:39
  the
• 14:39
  elderly
• 14:39
  here,
• 14:39
  the
• 14:40
  beers
• 14:40
  list.
• 14:41
  Got
• 14:41
  to
• 14:41
  kind
• 14:41
  of
• 14:41
  avoid
• 14:42
  this
• 14:42
  med.
• 14:42
  In
• 14:42
  folks
• 14:42
  over
• 14:43
  65,
• 14:44
  those
• 14:44
  anticholinergic
• 14:45
  effects
• 14:45
  are
• 14:46
  real.
• 14:46
  The
• 14:46
  sedation,
• 14:47
  the
• 14:47
  confusion.
• 14:48
  We
• 14:48
  just
• 14:48
  want
• 14:49
  to.
• 14:49
  We
• 14:49
  kind
• 14:49
  of
• 14:49
  want
• 14:49
  to
• 14:50
  watch
• 14:50
  that
• 14:50
  a
• 14:50
  little
• 14:50
  bit
• 14:51
  and
• 14:51
  watch
• 14:51
  out
• 14:52
  for
• 14:52
  the
• 14:52
  anticholinergic
• 14:53
  load.
• 14:54
  I
• 14:54
  always
• 14:54
  think
• 14:54
  it's
• 14:54
  good
• 14:54
  practice
• 14:55
  to
• 14:55
  look
• 14:55
  at
• 14:55
  all
• 14:55
  your
• 14:56
  meds
• 14:56
  that
• 14:56
  your
• 14:57
  patient
• 14:57
  is
• 14:57
  on
• 14:57
  and
• 14:58
  see
• 14:58
  the
• 14:58
  anticholinergic
• 15:00
  burden
• 15:00
  that
• 15:00
  they're
• 15:01
  on.
• 15:01
  Because
• 15:02
  people
• 15:02
  can
• 15:02
  fall,
• 15:03
  they
• 15:03
  can
• 15:03
  be
• 15:03
  really
• 15:04
  foggy,
• 15:04
  not
• 15:04
  really
• 15:05
  motivated,
• 15:05
  and
• 15:05
  that
• 15:05
  can
• 15:06
  confuse
• 15:06
  you.
• 15:06
  And
• 15:06
  you
• 15:06
  can
• 15:06
  think
• 15:07
  it's
• 15:07
  a
• 15:07
  hundred
• 15:07
  other
• 15:08
  problems
• 15:08
  like
• 15:09
  depression
• 15:09
  and
• 15:09
  adhd,
• 15:10
  but
• 15:10
  lo
• 15:10
  and
• 15:10
  behold,
• 15:11
  they
• 15:11
  have
• 15:11
  an
• 15:11
  anticholinergic
• 15:12
  burden.
• 15:14
  So
• 15:14
  yeah,
• 15:15
  I
• 15:15
  would
• 15:15
  look
• 15:15
  out.
• 15:15
  And
• 15:16
  the
• 15:16
  FDA
• 15:16
  label
• 15:17
  does
• 15:17
  contraindicate
• 15:18
  hydroxyzine
• 15:18
  in
• 15:19
  early
• 15:19
  pregnancy.
• 15:19
  So
• 15:20
  it's
• 15:20
  not
• 15:20
  always
• 15:20
  a
• 15:20
  safe
• 15:20
  option
• 15:21
  for
• 15:21
  pregnant
• 15:21
  patients
• 15:22
  with
• 15:22
  anxiety.
• 15:23
  So
• 15:23
  watch
• 15:23
  out
• 15:23
  for
• 15:24
  that
• 15:24
  too.
• 15:24
  But
• 15:24
  again,
• 15:24
  this
• 15:25
  is
• 15:25
  a
• 15:25
  really
• 15:25
  cool
• 15:26
  medication
• 15:26
  when
• 15:27
  you
• 15:27
  feel
• 15:27
  like
• 15:27
  the
• 15:27
  patient
• 15:28
  doesn't
• 15:28
  quite
• 15:28
  have
• 15:28
  gad,
• 15:29
  or
• 15:29
  maybe
• 15:30
  they
• 15:30
  do
• 15:30
  have
• 15:30
  GAD
• 15:30
  and
• 15:31
  they
• 15:31
  need
• 15:31
  a
• 15:31
  supplement.
• 15:32
  Okay,
• 15:32
  that's
• 15:33
  also
• 15:33
  nice.
• 15:33
  But
• 15:34
  you
• 15:34
  know,
• 15:34
  they
• 15:34
  don't
• 15:34
  quite
• 15:34
  have
• 15:35
  gad,
• 15:35
  mdd,
• 15:36
  ptsd,
• 15:37
  but
• 15:37
  they're
• 15:37
  just
• 15:38
  kind
• 15:38
  of
• 15:38
  on
• 15:38
  edge.
• 15:39
  I
• 15:39
  know,
• 15:39
  I've
• 15:40
  seen
• 15:40
  patients
• 15:40
  with
• 15:40
  just
• 15:41
  excoriation
• 15:41
  or
• 15:42
  skin
• 15:42
  picking
• 15:42
  and
• 15:43
  you
• 15:43
  want
• 15:43
  to
• 15:43
  do
• 15:43
  something
• 15:43
  for
• 15:44
  them
• 15:44
  to
• 15:44
  take
• 15:44
  off
• 15:44
  the
• 15:44
  edge
• 15:45
  and
• 15:45
  they
• 15:45
  don't
• 15:46
  quite
• 15:46
  have
• 15:46
  that
• 15:46
  cognitive
• 15:47
  catastrophic
• 15:47
  worry
• 15:48
  you
• 15:48
  see
• 15:48
  in
• 15:48
  gadget.
• 15:49
  And
• 15:49
  so
• 15:50
  bam,
• 15:50
  you
• 15:50
  have
• 15:50
  this
• 15:51
  beautiful
• 15:51
  place,
• 15:52
  you
• 15:52
  have
• 15:52
  a
• 15:52
  place
• 15:52
  for
• 15:53
  them
• 15:53
  when
• 15:53
  they're
• 15:53
  onboarding
• 15:54
  SSRIs,
• 15:55
  which
• 15:55
  is
• 15:55
  really
• 15:56
  cool.
• 15:56
  Just
• 15:57
  a
• 15:57
  pretty
• 15:57
  versatile
• 15:59
  medication,
• 16:00
  actually.
• 16:00
  Maybe
• 16:01
  to
• 16:01
  get
• 16:01
  them
• 16:01
  acclimated
• 16:02
  to
• 16:02
  psychotherapy.
• 16:03
  This
• 16:04
  med
• 16:04
  has
• 16:04
  really
• 16:04
  opened
• 16:05
  my
• 16:05
  horizons
• 16:06
  for
• 16:07
  a
• 16:07
  lot
• 16:07
  of
• 16:08
  different
• 16:08
  uses.
• 16:08
  I'm
• 16:09
  really
• 16:09
  grateful
• 16:09
  for
• 16:10
  this.
• 16:10
  So
• 16:10
  if
• 16:10
  you
• 16:10
  have
• 16:10
  an
• 16:10
  itchy
• 16:11
  patient,
• 16:13
  I
• 16:13
  think
• 16:13
  this
• 16:13
  is
• 16:13
  a
• 16:14
  good
• 16:14
  itchy,
• 16:14
  edgy
• 16:15
  patient
• 16:16
  with
• 16:16
  past
• 16:16
  alcohol
• 16:17
  use
• 16:17
  that
• 16:18
  needs
• 16:18
  some
• 16:19
  sort
• 16:20
  of
• 16:20
  calming
• 16:21
  that
• 16:21
  isn't
• 16:21
  practical
• 16:22
  with
• 16:23
  SSRIs
• 16:24
  or
• 16:24
  SSRIs
• 16:25
  aren't
• 16:25
  enough,
• 16:25
  then
• 16:25
  bam,
• 16:26
  you
• 16:26
  found
• 16:27
  your
• 16:27
  medication.
• 16:28
  And
• 16:28
  my
• 16:28
  friends,
• 16:30
  if
• 16:30
  you
• 16:30
  want
• 16:31
  more
• 16:31
  deep
• 16:31
  dives,
• 16:32
  if
• 16:32
  you
• 16:32
  want
• 16:32
  to
• 16:32
  understand
• 16:33
  the
• 16:33
  how
• 16:33
  and
• 16:33
  the
• 16:33
  why
• 16:34
  of
• 16:34
  your
• 16:34
  meds
• 16:34
  and
• 16:35
  transform
• 16:36
  the
• 16:36
  way
• 16:36
  you
• 16:37
  present
• 16:37
  as
• 16:37
  a
• 16:37
  prescriber.
• 16:38
  Going
• 16:39
  from
• 16:39
  a
• 16:39
  good
• 16:39
  to
• 16:39
  a
• 16:39
  great
• 16:40
  prescriber.
• 16:40
  Definitely
• 16:41
  join
• 16:41
  Ahrq
• 16:42
  Patreon
• 16:43
  membership.
• 16:44
  The
• 16:44
  difference
• 16:45
  between
• 16:45
  a
• 16:45
  good
• 16:45
  and
• 16:46
  great
• 16:46
  clinician
• 16:46
  is
• 16:47
  the.
• 16:47
  The
• 16:47
  one
• 16:47
  who
• 16:48
  understands
• 16:48
  the
• 16:48
  how
• 16:48
  and
• 16:49
  the
• 16:49
  why
• 16:49
  of
• 16:49
  what
• 16:49
  they're
• 16:50
  doing.
• 16:50
  Patients
• 16:51
  can
• 16:51
  smell
• 16:51
  that
• 16:51
  a
• 16:51
  mile
• 16:52
  away.
• 16:52
  That's
• 16:53
  why
• 16:53
  we
• 16:53
  built
• 16:53
  Patreon.
• 16:54
  I
• 16:54
  am
• 16:54
  genuinely
• 16:55
  terrified
• 16:55
  to
• 16:55
  consider
• 16:56
  who
• 16:56
  I
• 16:56
  would
• 16:56
  be
• 16:57
  if
• 16:57
  I
• 16:57
  didn't
• 16:57
  have
• 16:57
  this
• 16:58
  full
• 16:58
  library
• 16:58
  of
• 16:59
  really
• 16:59
  neat
• 16:59
  pearls.
• 17:00
  How
• 17:00
  and
• 17:00
  why,
• 17:01
  Depth
• 17:01
  of
• 17:01
  what
• 17:02
  we're
• 17:02
  doing.
• 17:02
  It
• 17:03
  has
• 17:03
  transformed
• 17:04
  the
• 17:04
  way
• 17:04
  I
• 17:04
  communicate
• 17:05
  with
• 17:05
  my
• 17:05
  patients,
• 17:05
  the
• 17:05
  way
• 17:06
  I
• 17:06
  practice.
• 17:06
  And
• 17:07
  again,
• 17:07
  I'd
• 17:07
  be
• 17:07
  scared
• 17:08
  to
• 17:08
  know
• 17:08
  who
• 17:08
  I
• 17:08
  was
• 17:09
  without
• 17:09
  it.
• 17:09
  And
• 17:09
  so
• 17:09
  we'd
• 17:10
  really
• 17:10
  welcome
• 17:10
  you
• 17:11
  to
• 17:11
  join
• 17:12
  our
• 17:12
  Patreon
• 17:12
  family.
• 17:13
  If
• 17:13
  there's
• 17:14
  one
• 17:14
  thing
• 17:14
  you
• 17:14
  don't
• 17:14
  forget
• 17:14
  by
• 17:15
  the
• 17:15
  end
• 17:15
  of
• 17:15
  the
• 17:15
  day,
• 17:15
  that
• 17:16
  would
• 17:16
  be
• 17:16
  a
• 17:16
  great
• 17:17
  thing.
• 17:18
  So
• 17:18
  I
• 17:18
  hope
• 17:18
  you
• 17:18
  enjoyed
• 17:19
  this
• 17:19
  and
• 17:19
  I
• 17:19
  hope
• 17:19
  you
• 17:20
  found
• 17:20
  a
• 17:20
  new
• 17:20
  home
• 17:20
  for
• 17:20
  hydroxyzine.
• 17:21
  I
• 17:22
  know
• 17:22
  I
• 17:22
  did.
• 17:23
  And
• 17:23
  enjoy
• 17:24
  it.
• 17:24
  Do
• 17:24
  more
• 17:24
  of
• 17:24
  a
• 17:25
  deep
• 17:25
  dive
• 17:25
  and
• 17:26
  let
• 17:26
  me
• 17:26
  know
• 17:26
  what
• 17:26
  you
• 17:26
  think.
• 17:27
  Until
• 17:27
  next
• 17:27
  time,
• 17:28
  my
• 17:28
  friends.
• 17:28
  Take
• 17:28
  care
• 17:28
  of
• 17:29
  yourselves
• 17:29
  and
• 17:30
  each
• 17:30
  other.
• 17:30
  Bye.
• 17:31
  Bye.