Demystifying Neurotransmitters: Serotonin, Dopamine, and Beyond

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs. Register@Allce.com Counselortoolbox you I'd like to welcome everybody to today's presentation on neurobiology. Dopamine, gaba, serotonin, acetylcholine, norepinephrine and glutamate. So we're really going to be hitting the Big Six today. The PowerPoint is a little bit longer than it usually is in terms of the number of slides, but there are a lot of things that I'm going to go through quickly because you'll be able to go back and reference them and they don't need a whole lot of explanation. As always, if you have something to add, if you have a comment question, please feel free to type that in the chat window and I will answer it or segue it in as soon as I can. So we're going to define neurobiology and for the following neurotransmitters, you know, the big six, we're going to look at their mechanism of action. Why are they there, where are they found? And I know, yeah, the brain. But where else are they found? Symptoms of excess and insufficiency? Because when we're looking at anxiety, when we're looking at fatigue, when we're looking at difficulty concentrating, there are a lot of symptoms that are transdiagnostic. They're present in multiple diagnoses and you know, they can be caused by different things. We'll look at nutritional building blocks for each neurotransmitter because I always harp on having reasonable nutrition. And reasonable is, you'll see as we go through, really shouldn't be that hard. And then we'll look at some medications that are used to increase and decrease or medications that may inadvertently increase and decrease the neurotransmitters in the brain. So neurobiology is the study of the brain and the nervous system, which generates sensation, perception, movement, learning, emotion, and many of the functions that just make us human. When we have an emotion, where does that come from? Well, it's a chemical reaction that whatever happens kicks off a chemical reaction. And if we're getting upset or getting stressed or getting excited, then we're going to have glutamate and norepinephrine and dopamine probably going out if we're excited, for example. So we want to pay attention to that. If we're calming down, then we're going to have gaba, serotonin, kind of coming in and saying, all right, now's the time to rest and relax. So our emotions, or what we label as emotions, are triggered by neurochemicals. And why is that important? Well, because if somebody comes in and they're trying to address their depression, you know, whatever that looks like for them, well, that's great, but they need to understand where that's coming from. There are some cognitive things that can trigger that, their brain to think that there's a threat, which sets off the stress response. But they need to understand that there is a neurochemical, a biological component to it. So it's not just about changing their thinking. They also need to be making sure that their body machine is in top working order. So think about it as we go through this presentation. You have a client who presents with apathy, loss of pleasure, sleep disturbances, fatigue, and difficulty concentrating. Yeah. My first thought is major depressive disorder or persistent depressive disorder. What would your diagnosis be? You may say too little information yet. That would be a great answer, too. If somebody presented to their physician with these symptoms, what medication would you expect the doctor to put him or her on? My experience has been with most physicians, the first thing they do, SSRIs. Let's increase serotonin. And as you'll learn as we go through this, these symptoms are transdiagnostic, and they can be caused by either too much or too little of most of the big six. So we don't necessarily know whether the person has too little serotonin. So if we start increasing it and that's not their problem, then we're going to have symptoms of too much serotonin, which can be really unpleasant. And it's also whatever else was lacking down here, more serotonin means that's even more lacking, so to speak, because everything needs to be in a balance. Like, I always make the analogy of a good marinara sauce. You know, if you taste it and there's not enough oregano, you know, or it's just not right, and you start dumping oregano in, then maybe it was garlic and not oregano. So now the oregano is even stronger and the garlic taste comparatively is even weaker. So we want to pay attention to what's going on. And obviously we're not making diagnoses. And none of this presentation is meant to tell patients to change their medication regime or start eating a certain way or take any supplements. All of that should be covered through their primary care physician. But it's important for us to be aware. So if clients are struggling, because we know that antidepressants only work for 30 to 40% of the people who take them. We want to look at. Why is that? Well, maybe it isn't serotonin that's out of whack for this person. Maybe there's an underlying biochemical cause. Maybe it's a different neurotransmitter. We can help people sort of advocate for themselves. Maybe they need a norepinephrine reuptake inhibitor so they can talk with their doctor about what the options are. We can help them educate themselves. They need to do the advocacy and work with their physician. So dopamine, we're going to start out with the pleasure chemical because, well, it's first in the alpha. No, it's not first. Anyway, it's the first one that comes to mind for most people. Mechanism of action, it is involved in movement, memory, pleasurable reward behavior and cognition, attention, inhibition of prolactin production, sleep, mood and learning. So it's involved in everything. So if your dopamine levels are out of whack, you're probably going to experience some difficulty in one or more of these areas. Now, obviously, if you're having difficulty focusing attention, your memory is probably going to falter as well, as well as your cognition. You know, you're not going to be thinking as well if your mind's racing, if you're having racing thoughts. So all of these can come together. If you're not getting a good sleep, you may start feeling sort of depressed and blue and not be motivated to focus and learn. So we want to pay attention to dopamine's impact in the person and look at our clients who are experiencing some of these symptoms that seem depressive in nature and take a look at, especially if they start on an SSRI or they've been on them before and it hasn't worked, you know, we may want to look at, is there something else causing it? Altered dopamine neurotransmission. So if you're not getting enough or you're getting too much cognitive control, people will have racing thoughts. Attentional control, can't focus, impulse control, self explanatory working memory is going to kind of go, which you would expect with problems with attentional control and racing thoughts, Mood, motivation and sleep are all going to be impacted. So where is dopamine found? You know, okay, we realized that there may be a problem with it. Where do we find it? Well, it's in the brain and the kidneys. Kidneys. So if you have a client who has kidney disease or is taking Any kind of medication that alters kidney functioning or, and, or maybe engaging in high intensity activities that are causing fluctuations in hydration. It can alter to a certain extent dopamine levels, definitely can alter medication levels. Dopamine functions in several parts of the peripheral nervous system. In blood vessels, it inhibits norepinephrine, which is our motivation and focus, chemical and excitatory chemical. And it acts as a vasodilator, so it helps us relax. So if you have a client who's kind of stressed, high strung dopamine may be part of it. In the kidneys, it increases sodium and urine excretion, so it keeps the kidneys functioning well. If you don't have the right sodium balance, you can have something called rhabdomyolysis, which can be really bad. And we want to, so we want to make sure that clients are going to the bathroom enough. In the pancreas, it reduces insulin production. If we're working with a client who is diabetic, paying attention to their moods, their sugar levels and, you know, all of that may be important. And if they're having difficulty stabilizing their sugar levels, looking maybe at dopamine in the digestive system, it reduces gastrointestinal motility and, and protects the intestinal mucosa. So it slows things down in the immune system. It reduces lymphocyte activity. So why do we care? We're mental health. Because it can be implicated in autoimmune diseases. And I've linked to several articles through here that have indicated that if dopamine is increased, they found an increase or is decreased. I'm sorry, they found an increase in lymphocyte activity. So people who have autoimmune diseases may not have enough dopamine. So if dopamine's increased, then that lymphocyte activity, that overactive immune system is blunted. Sometimes symptoms of excess. And when we think about dopamine, one of the first things we often think about is schizophrenia. Not necessarily the only thing. And we don't know that dopamine problems actually cause schizophrenia. Because when we address schizophrenia with dopamine antagonists or dopamine agonists, depending on whether you're looking at positive or negative symptoms, it only partially addresses the problems people are having and then the side effects are horrid. There are other medications, and I'm getting ahead of myself, that also produces psychotic like features. So we're not for sure whether dopamine is it. We think dopamine is involved, but there are probably other Neurochemicals that are also involved in the development of schizophrenia. So too much dopamine, unnecessary movements, repetitive tics, psychosis, hypersexuality, nausea. This can also kind of overlap a little bit with hypomania or mania. If you've got somebody who is really, you know, physiologically agitated and they may with mania, they're going to have some psychotic features. There's hypersexuality is common. So these are all common in when there is, is too much dopamine. Most antipsychotic drugs are dopamine antagonists. So they're going to make these things go away, they're going to slow the person down, get rid of the psychosis, reduce the sexuality, reduce the nausea in order to bring it back in line with what the person wants as a quality of life. Dopamine antagonist drugs are also some of the most effective anti nausea agents. If you have somebody who's going and going out on a boat, on a cruise and they're gonna, they're afraid they're gonna be seasick and they start taking anti nausea agents. Women who are pregnant sometimes take anti nausea agents if they have really bad morning sickness. There are a lot of times where you may see this used. When my son got out of the nicu, he had gastric esophageal reflux disease and they prescribed him Reglan, which I didn't realize at the time how powerful of a drug that was. But it increased gastric emptying so the food got out of his stomach faster so it didn't repeat on him. If somebody doesn't have enough dopamine, they may have blunting of affect and apathy, loss of motivation, increased pain, symptoms of Parkinson's disease or restless leg syndrome, attention deficit hyperactivity disorder. Because dopamine helps us focus, neurological symptoms that increase in frequency with age, such as decreased arm swing and increased rigidity and changes in dopamine levels may also cause age related changes in cognitive flexibility. So as dopamine goes down, we lose some cognitive flexibility. But thinking again, if we have a client who has normal dopamine levels and they start taking a powerful anti nausea agent for some reason, and they start feeling sort of depressive symptoms or restless legs or ADHD type things, we want to try to connect the dots as a side effect of that, potentially a side effect of that anti nausea agent that they may need to talk over with their doctor. If they didn't have the symptoms until they started taking the medication and then all of a sudden they're having them. Other symptoms of insufficient dopamine, lack of motivation, fatigue, apathy, procrastination, low libido, sleep problems, mood swings, hopelessness, memory loss and difficulty concentrating. I think I covered those on the other slides leading up to this. But a lot of this looks like, on a quick glance, looks like depression, which again, a lot of times doctors are going to go straight for a selective serotonin reuptake inhibitor. So that might not be the best thing for that person. Nutritional building blocks. Eating a diet high in magnesium and tyrosine. Magnesium is obviously a vitamin, actually mineral, and tyrosine is an amino acid. If you eat a good quality diet that has decent quality proteins, you're going to get the tyrosine, but it ensures you've got the basic building blocks needed for dopamine production. Chicken, almonds, apples, avocados, bananas, chocolate. I like chocolate. And you know, you can get the chocolate powder, the Hershey's cocoa dark chocolate powder. And it has like, I think it's 10 calories per tablespoon. So it's not the same as eating a chocolate bar. So if people are trying to increase their chocolate consumption, that's one way to do it, where they're not getting all those saturated fats and everything. Green leafy vegetables, green tea, lima beans, oatmeal, sesame and pumpkin seeds, Turmeric, which is a spice. You're not going to eat enough turmeric to really increase your dopamine levels unless you're really experimenting with your cooking. Watermelon and wheat germ. So most people can find two or three things on this list that they're willing to eat. And you know, that's all we're talking about. We're not talking about anything huge in terms of altering their diet. Again, they need to talk it over with their nutritionist. If they're on any sort of medications, especially MAOIs or typical antipsychotics, it's going to be even more important that they talk with their nutritionist or physician because there's a lot of dietary restrictions with those medications. Dopamine in the blood is not able to cross the blood brain barrier to reach the brain. So people can't just take a supplement of dopamine and go, okay, cool, I'm good. So they need to have provide their body the building blocks so their brain can make the dopamine, the most common dopamine agonists. So this is what increases dopamine and is going to get rid of negative symptoms, which are your apathy, your depressive type symptoms. You're not wanting to Speak your catatonia, restless legs, Parkinson's, Mirapex and Requip are the name brands of two of the more common medications that are prescribed. Levodopa, Carbidopa and that's the generic is converted to dopamine in the brain. So that's another drug that they often prescribe. But a side one to consider and a lot of our clients are on Buspirone. So a side one to consider and just to learn a little bit about is buspirone because it does increase freely available dopamine in the brain. So that might be one. It's not nearly as powerful as the other two, but it might be one that our clients look towards. If you're not familiar with buspirone, it's not a benzodiazepine or a barbiturate, but it has a lot of anti anxiety type properties. It's one that takes time to get into the system like an antidepressant takes two to four weeks to build up in the system but it's non addictive in the same way, you know, it's not addictive like Xanax or Valium or any of those are. So it is one option especially for clients who have co occurring issues that they can consider for anxiety if some of the other things make them too tired. Like some of the antidepressants that are also used for anxiety at high levels. And what's the other one I was thinking of? Seroquel, that's another one I've seen prescribed for anxiety. So these are options for them. Most common dopamine antagonists, these are the ones that get rid of the positive symptoms such as the hypersexuality and nausea and things like that. Risperdone, Haldol and Zyprexa, they will also get rid of the hallucinations, the delusions, things that you don't want to be there, that are there. Reglan is the one I told you about that Metoclopramide is an anti nausea medication and it also helps speed up gastric emptying. So some of your clients, especially your elderly clients who are, or people who have gastric esophageal reflux disease, GERD may be on this. So being aware that this, this medication will blunt and slow people down a little bit. So if they're starting to feel depressed, take a look at side effects of medications, supplements which can increase dopamine. L theanine is another amino acid that's found in green tea. So if people are just drinking green tea, they're not going to get enough L theanine to, you know, cause any problems or negative interactions with their medication, but you can get it as a supplement. So if clients are talking about taking this as a supplement, especially if they're taking other psychotropic meds, they need to let their doctor know. Rhodiola rosea or golden root also increases dopamine by enhancing the stability of it and supporting its reuptake, which has been shown to produce decreases in depression, anxiety and fatigue and an increased ability to handle stress. So it's an herb that's used a lot in eastern medicine in order to provide anti anxiety, antidepressant type effects. Blood levels of antipsychotic medications and lithium are especially sensitive to hydration levels. So if your client is taking any of those, it's important that they are aware of this fact that they don't get too dehydrated, but they also don't get too hydrated. Neuromalignant syndrome is caused by a sudden marked reduction in dopamine activity either from withdrawal of dopaminergic agents or from blockade of dopamine receptors. Symptoms include high fever, confusion, rigid muscles, variable blood pressure, sweating and fast heart rate. Now this is also very similar to the symptoms that you're going to see when we talk about serotonin syndrome. So it's important to pay attention when these symptoms are there because it's life threatening. Complications can include rhabdomyolysis, the kidney problems, high blood potassium, kidney failure or seizures. So we want to be aware of what's going on with our clients. We want to talk with them about any symptoms that they're having. This can be caused by any sort of sudden reduction and it doesn't have to be just from a reduction in a dopamine type medication. They've shown it with some other medications as well. Dopamine levels declined by around 10% per decade from early adulthood and and have been associated with declines in cognitive and motor performance. Dopamine levels are also impacted by the availability of estrogen. So here's another age related change. If you're working with a woman who is older, a woman who is experiencing premenstrual dysphoric disorder, a woman who is recently postpartum. It's important to look and realize that hormone levels are fluctuating widely, which also means dopamine levels are going to fluctuate widely. As far as Wellbutrin as an agonist, I'm not aware, I don't know the answer to that. Norepinephrine, this is my Favorite neurochemical, if you will. It's your fight or flight. Excitatory neurotransmitter. It's implicated in motivation and focus. So norepinephrine goes out. You get that kind of laser focus when people don't have enough norepinephrine, then it causes problems with arousal and a lot of other things. When faced with severe stress, the stress response system activates raising norepinephrine as well as other stress hormones, which increases arousal, increases insomnia, you know, you don't want to be sleeping if you're under threat. It increases anxiety, irritability, emotional instability. And if it goes on for too long, it can also increase depression. So cortisol, if you remember from other lectures, cortisol causes the body to say, you know, we're going to reduce estrogen right now because we don't have a need for procreation. There's a threat out here. Which tells you from the last slide that dopamine levels are going to go down too. Ooh, okay, so. But we also know that serotonin availability is affected by estrogen levels. So serotonin is a calming chemical and helps with mood. So dopamine and serotonin go down. When estrogen goes down, norepinephrine goes up, which increases heart rate and respiration and focus and all kinds of stuff like that. We also know that a lack of serotonin or less serotonin is going to be implicated in sleep problems. So norepinephrine and serotonin are kind of teeter totters. You know, when one goes up, the other one tends to go down. Prolonged stress leads to under activity of the stress response system, desensitization. So your brain over prolonged stress is going to start saying, you know what? I've only got so much energy and I can't fight or flee from everything right now. I have to conserve it for what's really the most important. So people may not have norepinephrine sent out as much, which is when you start feeling depressed or seeing depressive symptoms, symptoms of excess norepinephrine, ADHD or problems with concentration. Remember, you saw that in dopamine, too. Depression. If people are too wound up for too long, they may start experiencing some depression and anxiety and poor sleep. Nutrition, again, Tyrosine. Rich foods. You want to look at bananas, beans and legumes, chicken, cheese, chocolate, eggs, fish and seafood, meat and oatmeal. So tyrosine we're seeing repeatedly, making sure that people are getting access to some of these and I included. I made sure to include vegetarian options as well as other options in case people aren't good with eggs, fish or chicken. A daytime nap, they found, can also double your levels of norepinephrine. Now, naps should never be, well, ideally longer than 45 minutes. You don't want people to go into a full REM cycle because that just throws their circadian rhythms completely off. A 20 minute nap where you're resting your eyes, some people find that that makes them feel a ton better. I can't seem to shake it. If I lay down for 20 minutes or sit, sit in the easy chair for 20 minutes, I feel groggy afterwards. So people will have to figure out for themselves if that works for them. So glutamate is another excitatory neurotransmitter. So dopamine is our pleasure neurotransmitter. It helps keep us motivated. Norepinephrine is our motivation and our fight or flight neurotransmitter. Glutamate is also another excitatory neurotransmitter. It's going to rev people up. Glutamate is actually an amino acid which is present in most high protein foods. So you don't even have to go out of your way to find this one. If you're eating protein, you're probably getting it. It's the most prevalent excitatory neurotransmitter and it's used to make gaba. The brain breaks down glutamate to make gaba. So if you don't have enough glutamate, which revs you up, you're not going to be able to likely make enough GABA to calm you down. And GABA is our primary chillax neurotransmitter. It facilitates learning and memory. It keeps us alert. Too much glutamate, though, is associated with panic attacks and anxiety impulsivity, obsessive compulsive disorder, and sometimes depression. Glutamate availability declines with age and it's affected by serotonin availability. So, you know, if there's more serotonin, then there's not going to be as much glutamate and vice versa. Too little glutamate can lead people to feel agitated, have memory loss, sleepless, low energy level and depression. Glutamate we don't talk about a lot. We talk more about gaba. And GABA is designed as an anti anxiety anticonvulsant sort of neurochemical. It's made from glutamate and functions as an inhibitory neurotransmitter. So it inhibits our functions. It's slows our breathing, slows our heart rate, lowers our blood pressure. It's just a great neurotransmitter. GABA does the opposite of glutamate. And instead of telling all the nerves to fire, it says, don't fire. Just relax. Close to 40% of the GABA synapses in the human brain work with GABA and therefore have GABA receptors. So think about that in your brain, not just in one little part of your brain, but in your brain. Close to 40% of the synapses work with GABA. So if you don't have enough GABA, then you could have some significant side effects. Insufficiency, anxiety, depression, difficulty concentrating, insomnia and seizure disorders. One of the medications that we'll talk about in a few minutes, Klonopin is an anticonvulsant and it increases GABA levels. Symptoms of excess. And sometimes you'll see Klonopin prescribed for anxiety as well, because the prescribing physician doesn't like some of this traditional benzos for some reason. Symptoms of excess, excess sleepiness, shallow breathing, decreased blood pressure, memory problems, dizziness, blurred vision, slurred speech, and weakness. So all the symptoms of what you would see with an opiate overdose, what you would see with a GABA overdose, what you would see in somebody who's intoxicated. You know, these are the things that we're going to be looking for. Nutritional building blocks, fermented foods. Now that's, that's, this is the only one that nutritional building block is a fermented food. Almonds and walnuts, cherry tomatoes, tomatoes with a thicker skin, have more of what's needed to improve GABA levels. Bananas again, brown rice again, potatoes, oats, lentils. If the person's deficient in vitamin B6, it can impair the production of GABA, even if they have all the building blocks. It's kind of like trying to build a brick house without mortar. So they need to make sure that they're getting enough B6. Most people get enough in their diet and, or with a multivitamin, but that's between them and their doctor. B8 is another one that's really important for Gaba. You can find that in wheat germ, brown rice, green leafy vegetables, nuts and navy, and lima beans specifically. So that may be a little bit harder to get if you don't like brown rice or green leafy vegetables. But it's possible and you know, you will find it in some of the better nutritional multivitamins medications that increase the available amount of GABA typically have a relaxing anti anxiety and anticonvulsive effect. Gabapentin is one of the more common ones that we think of. Or Neurontin is a GABA analog and is used to treat epilepsy and neurotic pain. Benzodiazepines and barbiturates including ghb, Valium and Xanax also increase GABA levels. Baclofen and Klonopin. Well, Baclofen as a muscle relaxant, my dog is actually on that right now, she's 14, so. But it's a newer muscle relaxant and painkiller sort of thing. And Klonopin is the anticonvulsant that I told you about before. This is not an exhaustive list, but it gives you an idea that we're kind of covering a broad spectrum. If you're working with somebody who has co occurring issues, the doctors are probably going to steer away from the last three and more towards Neurontin for chronic pain and muscle problems. Now serotonin, our favorite chemical to talk about, not mine, but in general it helps regulate mood symptoms, mood, sleep patterns, appetite and pain. So how you feel, how you sleep, whether you're hungry and if you're in pain, it's a big one. And there are a lot of other things that it does. If you go here, let me see if I can get it to come up. Maybe, maybe not. And this is far too small for you to really read right now. But if you go to this Wikipedia page on serotonin, it talks about all the different serotonin receptors and binding profiles and talks about what it's involved in. Like 5ht1a is responsible for dopamine release in the preface frontal cortex in addition to being a serotonin receptor. So it gives you an idea about how broadly some of these neurochemicals can affect someone anyhow, where's it found? It's found in your brain, but 80% of your serotonin is found in your gut and intestines. So if you're working with somebody who has gut and intestinal problems that are reducing bioavailability, reducing absorption, you could have some problems here. So brief little talk about serotonin syndrome because we don't talk about it enough and it's so important, one dose too much, one time, it's not something that has to build up over time like most SSRIs do. If you overdose one time, you can Develop serotonin syndrome. Now, it generally goes away when the offending chemical gets out of your system. But it can cause shivering, diarrhea, muscle rigidity, fever, high high fever, like 108 plus, seizures, irregular heartbeat, agitation, high blood pressure, stroke. So it's important to be aware that too much serotonin can be really, really bad. And people who take supplements like 5 HTP can easily get too much serotonin. There are also a lot of other things that you're going to find out in a minute that increase serotonin that people aren't aware of as being serotonin increasers. So it's really important to educate clients about the side effects so they're more cognizant. So too little serotonin leads to feelings of depression, anxiety, pain sensitivity. Serotonin is involved in regulating our pain threshold. When our serotonin is low, our pain threshold is lower. Same thing again with dopamine. When our dopamine is low, our pain threshold is lower because dopamine helps with pain. Poor sleep because melatonin is made by breaking down serotonin. If somebody doesn't have enough serotonin, they may not be able to get quality sleep. Difficulty concentrating. Carb cravings. Our body when we eat high sugar, high carb foods tends to release serotonin and dopamine. See how these things are so hard to ferret out? Especially since we can't really experiment on the human brain Anyhow, Carb cravings are common in people who have, or we believe in people who have low serotonin and constipation. Serotonin keeps everything moving. If somebody has hypothyroid or low serotonin, they could have constipation caused by either one of those. Among other things. Nutritional building blocks are foods rich and trip to fan. The body cannot make tryptophan, so you have to get tryptophan from what you eat. Whole wheat, potatoes, brown rice, lentils, oats and beans. I feel like a broken record when I read this. So hopefully your clients are willing to look at something in here. And if they don't like these options, obviously they're working with their nutritionist. They can go online and google I believe it's world's healthiest foods and find out which foods are high in tryptophan and find something that suits their fancy a little bit better. I just listed the top ones. Medications and supplements that increase serotonin. Selective serotonin reuptake inhibitors. Obviously we know that's the first line for a lot of people. When they're depressed, Doctors give them SSRIs. Your Paxil, Prozac, Zoloft, Lexapro, yada, yada. Selective norepinephrine reuptake inhibitors also make the serotonin more available. They prevent the reuptake of serotonin as well as norepinephrine. 5 HTP increases serotonin. Same. St. John's wort. The last three. 5 HTP, same. And St. John's wort. People can buy over the counter, which can be really scary because they can accidentally get too much. And atypical antipsychotics have been used in people for whom the first line SSRIs and SNRIs didn't work. So some of the serotonin receptors are responsible for sleep regulation, feeding thermoregulation. So people are getting cold a lot or too hot. Hyperactivity, hypoactivity, locomotion, muscle tone, learning, peripheral vasoconstriction, stomach contraction, nausea and vomiting, and gastrointestinal motility. And you're like, okay, why do I care? Because. Oops, where did it go? I'm gonna jump around a little. When somebody has serotonin syndrome, there are three things that we're gonna look for, and it's the acronym or mnemonic. Can cognitive changes, including agitation, confusion, euphoria, insomnia, hypomania, and hallucinations. A stands for autonomic changes, including racing heart fever, arrhythmias, which is an irregular heartbeat, sweating, and dilated pupils. And N stands for neuromuscular changes including tremor, rigidity, incoordination, and seizures. If you see this, it's a medical emergency. Just don't even think about, well, is it dopamine? Is it serotonin? Is it alcohol? What's going on? If you see these, it's likely that there's a problem and they need to be evaluated by a medical professional asap. So how do we increase serotonin? Because this is another thing that trips people up. They think the only way you can do it is by taking a psychotropic drug. You can increase serotonin synthesis, like taking L tryptophan through supplementation. So you can get pure L tryptophan and you can ingest it. The likelihood of causing serotonin syndrome from supplements, from amino acid supplements. It's really pretty low, but it's not something I'd want to play with. Reduction in serotonin breakdown. So instead of increasing the serotonin available, we just keep what's there from being broken down. Your maois do that. We can increase serotonin release. Things that cause that include your amphetamines, ADHD medications, mdma, anorectics, any of your appetite suppressants, weight loss drugs like Dexedrine, anti migraine medications, and this is a big one, such as triptans. Anti migraine medications prevent the serotonin or increase the release of serotonin. And if somebody is also taking a selective serotonin reuptake inhibitor, then they're giving themselves a double whammy. So they need to make sure that they're aware and their doctors aware if they're on an SSRI and prescribed anti migraine medication. We can also stimulate postsynaptic receptors. Buspirone does this, so it increases dopamine and it can increase serotonin, lithium and pain medications. So again, you wouldn't have thought opiates increase serotonin, but they do, so it's important. And Tylenol with codeine, fentanyl, hydrocodone, oxycodone and tramadol are some of your more common pain medications. If you have a client who goes in for surgery, even oral surgery, outpatient surgery, and they're taking an SSRI or they're taking five HTP as a supplement, make sure they know that the pain medications that they may be prescribed could also increase serotonin. And what to look for in terms of serotonin syndrome and serotonin reuptake inhibitors. The last one we have it, we keep it from being broken down and then we keep it in the synapse longer. Your typical SSRIs. Ultram is also a it's a painkiller as well as an ssri. So that can be a double whammy. Trazodone is a serotonin agonist and reuptake inhibitor. So it increases serotonin and it prevents reuptake, which makes it more available. Your tricyclic antidepressants, your serotonin and norepinephrine reuptake inhibitors. And bupropion, which is Wellbutrin or Zyban, is also a norepinephrine dopamine reuptake inhibitor. All of these can increase serotonin as well as norepinephrine and dopamine. For the, for the last one, other drugs that act to raise serotonin, illicit drugs including LSD, ecstasy, cocaine and amphetamines. Herbal supplements, St John's Wort, ginseng, nutmeg are added to the list of five HTP and Sami over the counter cough and cold medications containing dextromethorphan, Delsum, Mucinex, DM and others. Some of the youth today are using dextromethorphan rectally in order to get high off of it. And so knowing that they can actually cause serotonin syndrome by overdosing on dextromethorphan, there's a really fine line between getting high and causing yourself to go into serotonin syndrome. Worth being aware of anti nausea medications such as metoclopramide, which is Reglan, I'm not going to. And Zofran. I can read that one. So again, you see, Reglan, which we talked about under dopamine, also may increase serotonin. So it's important to be aware that if somebody is on an SSRI or, you know, a dopamine agonist, it's important that they also be aware that Reglan is possibly contraindicated. Zovox is an antibiotic. Who knew an antibiotic could increase dopamine or not dopamine? But serotonin, it's not one that I've ever seen prescribed, but obviously it is. And Norvir, which is an antiretroviral medication used to treat HIV and aids. And I have seen this one prescribed a lot. Doctors need to be aware. Clients need to be aware, because not all doctors are aware of all of these things that increase serotonin. And unfortunately, right now, the studies still show that only about 60% of doctors are really aware of serotonin syndrome and think to look for it. Serotonin does change with age. It goes down when estrogen or testosterone go down. So, you know, guys, you don't get a pass on this one. Melatonin, however, doesn't seem to decline as we age unless serotonin declines significantly. So generally, the amount of serotonin we need to make enough melatonin to sleep through the night. Even as serotonin goes down, it doesn't go down enough to affect our melatonin production. Some people find that melatonin supplementation does help them sleep. That's something to consider with their doctor. There are new studies out, as an aside, that long term taking of benzodiazepine, not benzodiazepines of sleep aids. What am I thinking of? Like Benadryl. Antihistamines can increase risk of dementia. So people are advised not to use sleep aids for long periods of time and they need to talk with their doctor about other options and, you know, try to figure out why they're having difficulty sleeping. Acetylcholine. See, I told you we would whip through these things. The mechanism of action. In lower amounts, acetylcholine can act like a stimulant by releasing norepinephrine and dopamine. It also enhances memory, motivation, higher order thought processes, sexual desire and activity and sleep. One of the things, well, I don't want to get ahead of myself. If there's too much acetylcholine, the person may have all the symptoms of depression, nightmares, mental fatigue and anxiety. There's an inverse relationship between serotonin and acetylcholine. So as serotonin goes down, acetylcholine goes up. So if somebody doesn't have enough serotonin, then they might start experiencing depression, nightmares, mental fatigue and anxiety. If they take an ssri, increases their serotonin, theoretically their acetylcholine is going to go down. So then they'll start feeling better. Whether it works that way for your particular client is really going to depend on which neurochemicals are out of balance. For them. Too little acetylcholine leads to symptoms of Alzheimer's and dementia, Parkinson's, impaired cognition, attention and arousal. So this is another one of our sort of. It's not, they call it a modulating neurochemical. It's not necessarily excitatory, but it's not necessarily inhibitory. But we do see when there's not enough acetylcholine that people start experiencing, you know, tremors, cognitive problems and difficulty with attention. Nutritional building blocks. Foods high in choline, that's easy to remember. Meats, dairy, poultry, chocolate, peanut butter, wheat germ, brussels sprouts and broccoli. Now I don't know about you, I've never developed a taste for brussels sprouts, but broccoli I can work in. Wheat germ is pretty easy to get most people to consider. Chocolate, poultry and dairy. There's also a lot of acetylcholine in eggs. So the medications, cholinergic medications are used for glaucoma, bladder control and severe muscle weakness. So we see this sometimes in especially more so in older adults than in younger adults. So they may be on medications that increase their acetylcholine. So we could go back here to symptoms of excess. If they start having anxiety, mental fatigue, depression or nightmares, that may be a side effect of the medication and they need to talk with their doctor. Anticholinergenics, cholinergics, sorry, may worsen gastroesophageal reflux disease. So if they're taking it and their acetylcholine is reduced they may have more reflux problems. These medications, anticholinergics, are used for extrapyramidal symptoms with schizophrenia, such as muscle spasms, a feeling of motor restlessness, tension, nervousness or anxiety, drug induced Parkinsonianism, trembling, shaking, loss of muscle control and tardive dyskinesia, which is the involuntary muscle movements in the lower face and distal extremities. So if people are having side effects from some of their and is generally your, your antipsychotic medications, then well, obviously with schizophrenia then acetylcholine, maybe they may be getting too much acetylcholine. So the doctor may prescribe medication to reduce that too. Now, depending on the person, you know, they may not be able to come off whatever antipsychotic they're on. So we have to medicate the side effects. That is probably going to produce some side effects, which is how people end up on like seven different medications. Medications that are anticholinergic, atropine, Benz atropine, and I have the brand names over here, so you may have seen them on client charts. Chlorphenramine, which is chlortrimaton, Demonhydrinate, which is Dramamine. It, you know, seasick medication. Diphenhydramine, which is Benadryl, Salmonex, all your sleep aids, hydroxyzine, bupropion and dextromethorphan are all anticholine cholinergic in their own way. So again, they're taking a prescription drug for something, for a neurotransmitter and they start taking any of these over the counter ones or prescribed drugs. It's important that they're aware of the interaction because people will not think twice about taking a Benadryl if their allergies are acting up or taking Dramamine if they're getting ready to go on a flight. And they can have really unexpected side effects from that. Dextromethorphan. You know, I haven't seen any reports that have indicated that when taken as prescribed, you know, if you've got a cold that it interacts negatively with any of the SSRIs or anything to produce problems. But knowing that it is a common drug of abuse right now, you know, that's when you start getting into problems. When people are taking double and triple and quintuple, the amount of medication that they're supposed to take. Anticholinergic drugs are used to treat a variety of conditions, including gastrointestinal disorders, which, you know, think about your clients, what they have, genitourinary disorders, respiratory disorders such as chronic bronchitis and copd, something else we see in older adults especially, and possibly insomnia, usually only on a short term basis. So going back to these drugs, thinking about what may be going on. Diphenhydramine, not uncommon for insomnia on a short term basis. So there are a variety of different neurotransmitters involved in addiction and mental health disorders. It's not always about increasing a neurotransmitter. Sometimes you need to decrease it. The human brain tries to maintain homeostasis, and too much or too little can be bad if you think about it. I mean, let's go back to acetylcholine for a second, if I can get there. How many of the neurotransmitters did we talk about today? That either an insufficiency or an excess impairs cognition, attention and arousal? Pretty much every single one of them. So the cause of your client's depressive symptoms or anxiety symptoms, we're really good at, you know, theoretically at helping them figure out the cognitive distortions that may be contributing to turning on their threat response system or maintaining their depression. But as far as what neurochemicals might be out of whack, especially for somebody who appears to have long standing, organically involved depression, it's not situational, but they've had depression since they were, you know, in grade school. Well, then we want to look at what might be. Where might a problem be in the plumbing, so to speak. Where might not enough of a particular neurotransmitter be getting through. This is something that a really awesome psychiatrist is going to help them kind of sort through. But one of the things I do with my clients is I have a check sheet of the different symptoms that they're experiencing. And I encourage them to keep track of their symptoms on a daily basis. If they're, especially if they're working with a doctor trying to get on a good medication regime for them. Identify when they start taking this medication, if there are side effects, if it starts helping them feel better, and anything that they want to talk with the doctor about so they can figure out if they put them on a snri, a selective norepinephrine reuptake inhibitor. If they put them on that, and that just makes them feel anxious as all get out, then they may try an SSRI or something else. But it's sort of the whittling down, which is, you know, some of our clients we see with treatment resistant depression, as they call it, the doctors often wait until, you know, they've Tried three or four or seven other things before they start looking at Seroquel and some of your atypical antipsychotics. And I can understand why. I mean, Seroquel is extremely sedating and does have some side effects. However, for some people, it may be a matter of getting the dopamine system back online. So encouraging clients not to give up, to recognize that. Unfortunately, and I had this question come up when I taught this class before, there is no way to measure neurotransmitters in your brain while you are alive. So people who advertise that you can measure your neurotransmitters through your blood or your urine or whatever, yes, you can. But what you're measuring is free circulating neurotransmitters. Remember I said 80% of your serotonin is in your gut? Well, that doesn't do your mood any good. Well, except for when your belly doesn't hurt. That number is really irrelevant to helping doctors figure out which neurotransmitters might be precipitating mood symptoms. So it's a waste of money. I mean, people can do it if they want, you know, no harm, no foul. You also have the possibility of a placebo effect. But in reality, there is no way that we have right now, at least that I'm aware of, to measure the actual levels of the neurotransmitters, specifically in the brain. So encouraging clients, and I use a much less technical presentation when I. When I go through it with clients, and I do the mind body connection, but helping clients see how important it is to eat decently. You know, pizza's fine, you know, a couple of times a week, even if that's what you want, but you need to get some of that brown rice and vegetables and other things. When we start thinking about some of our clients who are going on the trendy nutritional plans where they're cutting out all grains, you know, no rice, no wheat, no oats, no nothing, and they're just eating meat and vegetables. What impact is that having on the availability of neurotransmitters? Since most of these neurotransmitters can be formed from building blocks that are found in green leafy vegetables or your grains. As long as they're getting a fair amount of green leafy vegetables, they're probably going to be okay. But you know, again, once you start monkeying with cutting out entire food groups, it can cause unexpected side effects. So making sure that clients are aware of that, not saying not to do it, they're going to do whatever they want to do, but encouraging them to talk it over with their doctor and, or a nutritionist. And I always say a nutritionist. But most of them, well, I haven't yet had a client that has actually gone to see one because they kind of roll their eyes and they go, well, that's not covered by insurance. Well, so at least talk about it with your doctor before you start monkeying with things just to make sure that you're not going to make anything worse. Human brains try to maintain homeostasis. Too much or too little can be bad. And a balanced diet will provide the brain the necessary nutrients in synergistic combinations. And that's something I didn't talk about earlier. Taking a pill is not a substitute for eating nutritionally balanced foods because those amino acids, for example, are in a very specific ratio in terms of what's absorbable. I will give you an example. We think of turkey and Thanksgiving and we think, well, turkey's high in tryptophan. So when I eat turkey, I get sleepy. And it's because of the tryptophan in the turkey. Research has actually shown that that's not true. Research has shown that yes, turkey does have a high amount of tryptophan, but it also has a high amount of other amino acids that are preferred by your body. So you don't get very much actual tryptophan synthesized when you eat turkey. So they hypothesize that it's actually the sugar crash from the sweet potatoes and everybody everything else, as opposed to turkey. Chicken is actually higher in available tryptophan than turkey is. So these little things that, you know, people don't, don't take into consideration necessarily. And they can get obsessive about it trying to figure out, you know, micronutrients and proteins and amino acids and everything down to the nth degree. And it's really talking to a dietitian friend of mine is it's really not that necessary. If you eat three colors on your plate at every meal, you know, you can have fruit at breakfast because most of us don't want to eat Brussels sprouts at breakfast. And you eat enough calories and you eat quality foods, you know, pizza has a lot of colors, but that doesn't count as, you know, a well rounded meal. For every single meal, then you're probably going to get adequate nutrition. Are there questions, and I will look up that question about Wellbutrin as a dopamine agonist. I just don't know the answer to that. There is another. Let me see, See if I have it linked. If I don't, I will put it in the additional resources course or section of your course. That goes over all the neurotransmitters. So if you like reading that kind of stuff, it's a really awesome book. It's free, it's online. Let's see what we have here. Okay. One of the slides at the end suggested it. Hey, cool. That's not it. Okay, so let's go back here. Yes. Thank you, Carl. Neuropsychopharmacology the fifth generation of Progress editors. Kenneth L. Davis et al. This link will take you directly to it. Oops. And I love it. It is written in, you know, journales, so it's not something that you want to plan on sitting down and reading 100 pages at a time because you'll probably go cross eyed. But it is a fascinating read and it does kind of break down each individual neurotransmitter to help you get an idea about, you know, what it does. And then some of the other articles I just found very interesting. In terms of increasing our understanding and increasing our clients understanding of neurotransmitters. I did like this study and it's, you know, only tangentially related to the neurotransmitters about whether diet soda causes depression because it really does talk about the difference between causation and correlation. Is there a correlation between depressive symptoms and low serotonin? Yes. Do we know whether low serotonin causes depression? No, not necessarily. So we need to be cognizant of what other things might be causing these symptoms. And we talked a lot today about neurochemical imbalances. But there are a ton of physical things like just even hypo or hyperthyroid or imbalances in sex hormones that can cause fatigue, difficulty concentrating, low libido, apathy, you know, so you know, we don't want to assume necessarily. Alrighty, if there are no other questions then I will look up that one thing and I will put that in your additional resources of your class in the next hour. And everybody have an amazing weekend. Do your clients need a little help staying on track between sessions? Are you looking for a great aftercare resource? Look no further than Docsnipes.com for as little as $15 per week. Dr. Snipes provides concierge coaching services to clients through online weekly groups, chat availability seven days a week and members only resources. Learn more@docsnipes.com.