Psychiatry & Psychotherapy Podcast - Sensorium: Total Brain Function Optimization Part 1

Episode Date: February 19, 2018

Sensorium is the total brain capacity for focusing, processing, and interpreting. It is not a static state—it can fluctuate throughout the day.   It can be influenced by sleep, food, stress, exercise, drugs, medications, and long term, through epigenetic phenomenon.   If there is damage to the structure of the brain, it can permanently lowered. It is a slope, which we all move up and down on, based on our baseline, but then also influenced by many factors.   In your 20s and 30s you are very far on the left side of the line. If you get stressed, sleep deprived, starving, maybe have a small infection, you may still be able to think, but just less clearly. If you did those same things to an elderly person, they would be sent into a full delirium, hallucinating, throwing things, yelling, seeing spiders on the wall, and looking psychotic.  In this way it is common for an elderly person with dementia, they can be more confused in the evening then in the morning, they call this "sundowning".   We all have a baseline level of brain function, and this can be optimized by several factors like good sleep, good amounts of exercise, good mental functions (like reading), meaningful relationships, good spiritual practice, and meaningful work.   By listening to this episode, you can earn 0.75 Psychiatry CME Credits. Link to blog. Link to YouTube video. Join David on Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder Personal Website: www.DavidPuder.com

Welcome to the Psychiatry and Psychotherapy Podcast, the podcast to help you in your journey towards becoming a wise, empathic, genuine, and connected mental health professional. I'm your host, Dr. David Puter, a psychiatrist who splits his time practicing psychopharmacology, individual and group psychotherapy, medical director of a day treatment program, medical education research, and teaching, residents, and medical students. In this podcast episode, I am going to dive into a topic that is near and dear to my heart. I work in a unique kind of role in psychiatry because I am the medical director of a day treatment program, an IOP in a partial program that's about either three or eight hours a day, three to five days a week.

And in this program, I treat people with all sorts of medical issues, whether it be head injuries, strokes, seizures, psychogenic seizures, fibromyalgia, chronic fatigue, chronic migraines, chronic pain, uncontrolled diabetes. So I see a vast sort of conglomeration of people with medical issues and psychiatric issues. And one of the common complaints that I get is with focus and concentration. And I found that also if I am able to optimize their brain function, their total brain function, something that I'm going to call sensorium, if I can optimize that, then they can engage at a higher level in the psychotherapy process. and they can also sort of regain a lot of the function that they may have lost through having

medical issues. And so I have this unique approach to how to kind of think through Sensorium, total brain function, which I would like to share with you. In this first episode, I'm going to go through the basic theory of it and some of the stories that kind of can illustrate it. I'll tell a story of a man who had disability for 10 years and through optimization of his brain function. He was able to once again be a CEO of a large company. I'm also going to tell the story of a therapist who had chronic migraines and came to me after she had an inability to focus and concentrate. She was about to quit her job, which she loved dearly.

And through switching her medications around, lifestyle changes, some things. therapy, she was once again able to thrive in work and personal life. So in this podcast, you know, I have the pleasure to interview experts in different fields of psychiatry. And this is kind of my field of, and something that's a particular interest to me. So I hope you enjoy. All right. So we're going to get into the episode right away. This episode is on Sensorium. Sensorium is total brain function. It's the capacity for focusing, processing, interpreting, and it's not a static state. It fluctuates throughout the day. So basically, we have this capacity to think, to process things, to hold things in our mind. And this capacity actually changes. We have a baseline. We have times in the day when we're

more sleepy, more sedated, we can't think is straight. You know, maybe after a huge meal, all of a sudden you just want to take a nap, you can't think straight, you want to go lie down, or you eat three donuts, and all of a sudden you go into some sort of food coma where you're like, why can't I think straight? I just want to lie down. I just want to sleep. I just want to, you know, conk out for a while. So it's influenced by how we sleep, both, you know, the night before, but also the pattern of are we getting good sleep, are we getting sufficient sleep? It's influenced by our food, the level of stress we have, but acute and chronic, chronic stress can decrease in soarium. It's influenced by the amount of exercise we get. You know, if you have a ton of exercise, you may actually

in one day you have decreased in sorenum, you know, you may feel actually a little bit drunk. I remember coming off of a six-hour hike with my now wife, and she was in some state of delirium, like laughing, just acting really, really humorous, and really enjoying herself. And I think she was in an altered sensorium state there. It can be influenced by drugs, and I'm going to go into the particulars on that, and medications. And so a lot of times when people come into my treatment program, they have multiple medical issues and I'm looking through the medications and I'm thinking to myself which of these medications could be decreasing their sensorium, meaning bringing down their total brain function. I remember

one patient who was seeing things, hearing things, she came in my program, she had a chronic kidney disease, but she was also on several medications that were anticholinergic, which, you know, like diphenhydramine or benedril. When you decrease acetylcholine, you decrease your sensorium. And so she got into a place where she was very confused. And so we switched her medications around. And she could think more clearly. And she was very thankful.

I will go into several other cases on medications and how I changed them and what we can do there. You know, long term, you can change your sensorium. and it's largely an epigenetic phenomenon. You are not stuck with the same genes because you can upregulate and downregulate different types of genes. So just because we have, you know, been born with one set of genes

doesn't mean that we can't change our genes. We can actually, you know, squish some of our genes together through chromatin and those won't get expressed and we can pull out other ones that are good that we want to express. And so long term, there's a bunch of really cool studies that have shown that you can actually increase your cognitive function and there's also a lot of studies comparing people and those on certain diets over time have decreased cognitive function as they get older and other ones actually stay the same or

sometimes even slightly better cognitive function. So largely an epigenetic phenomenon. if there is damage to the brain, it can, a sensorium can be permanently lowered. For example, if you've had a severe traumatic brain injury, if you've had a tumor in your brain and had part of it resected, if you've had maybe, you know, radiation, that could be more of a temporary decrease in sensorium in your brain if they're pointing the radiation at your brain.

and so there are different brain sort of structural issues which can decrease your sensorium and all of a sudden the medications that you're taking or your lifestyle become very very important and you know just small changes to to diet and lifestyle if you've had a traumatic brain injury or had damage to your brain can drastically change things for the better. And so I'm going to explain stories about that. So, Sensorum, picture you're on like a hill, okay? And let's say you're at towards the top of the hill and you're looking down. And so this is the hill that represents this kind of idea of sensorium. And so you can take some steps down the hill and let's say you have decreased sensorium. Or you can take steps up the hill and you have

increased sensorium. And so you have a baseline. You have a baseline that fluctuates throughout the day. So maybe you're taking, you know, 10 steps up, 10 steps down at different points in the day. You know, today at about two or three, I needed to lie down. I lied down for about 15 minutes and I felt so much better. My sensorium was better. Other days, you know, a little bit of coffee brings up your sensorium for a little bit. So throughout your day, you're fluctuating a little bit. But now imagine you have poor, sleep. So let's say you've been not sleeping eight hours or seven hours a day. Let's say you've been sleeping two to three hours a day or let's say you just had a call and you know, you're a medical student or a resident and so you were up, you know, 24 hours straight. And now your sensorium is a little bit lower. So maybe you walked, you know, 20 steps down the hill. And let's say you've been eating just junk food and fast food for several months. And so your sensorium is even lower. So you step down another 10 steps. And then let's say you have chronic never-ending stress. So the type of stress

that's, you know, every day, ongoing, never-ending, and you can never sort of find peace from the difficulties of your life or what you're going through. And so that can decrease your sensorium some more. And let's say on top of that, you have some untreated medical issues. You develop diabetes, your diabetes is out of control, and so your glucose is out of control. And so that's causing some stress, but you also have your, you know, just that dysregulation can decrease sensorium. And then on top of that, let's say, you know, you got prescribed some medication that for your anxiety now that you have, you know, all this stress and everything, and the medication can also potentially decrease your sensorium. So I'm giving you this idea.

to give this kind of idea that you're going down the hill further and further. And eventually, you will feel very fatigued, you'll have a really hard time focusing, you'll wonder if you have ADHD, and potentially you can even get what's called a delirium. I think first you may have like a hypoactive delirium where basically what this means is it's a really horrible focus and concentration issue. You look depressed. you look sedated. It fluctuates throughout the day. But you can even go into an active psychotic delirium in which you're hearing things or seeing things that aren't there. You know, visual hallucinations.

If you're in the hospital and this is happening, maybe you're pulling out your IV lines. Maybe you're throwing things. Acting very out of character. You know, they used to, someone gave me the advice. you know, when you're dating, take the person you're dating, go on a camping trip, you know, and make things absolutely miserable for several days. And then you'll see who the real person is. And I actually think you are not yourself at your lowest sensorium. No, that is not you. Your whole brain is not functioning. So that is very bad advice. Okay, let's say on the other hand, you have your baseline, but you're able to make good, healthy diet decisions. You know, you're eating a lot of greens, a lot of really healthy food. I'll go into the specifics about diet in a little bit.

You're getting some good exercise. You know, you're doing some strike training, some endurance work as well. And so you're just getting a good amount of exercise, not too much, not too little, but meaningful exercise. And let's say you also have meaningful work and relationships, you don't have drugs or medications on board that could decrease sensorium, you may actually have a higher sensorium than your natural baseline if you weren't doing all those good things for yourself. You know, if you're sleeping well, if you're eating well, all of these things will increase your sensorium. And so this is really my argument for medical students who are going through, you know, really intensive studies and training to not sleep

deprive themselves, you know, two, three weeks out into a test cycle, but to really continue to get good sleep, continue to get good exercise, eat healthy, you know, take care of those basic things, and your brain will just absorb information a lot better. And you may say, wait, are you telling me that you always went to bed at a normal hour and you were a medical student? And I'll tell a short story here. When I was first a medical student, I actually stayed up till about three or four in the morning. I was on stress overdrive. I was so stressed. I had like stress skin rashes going on and I would nap for like three hours during the day and I was tired all the time. And then I got in this good cycle of waking up at six in the morning, going for half an hour run, going to bed or turning off everything like,

you know, believe it or not, we didn't have smartphones back then. So turning off everything, meaning turning off all the lights, being in bed by 10 o'clock, and to wake up again at 6. And so I got in this really good cycle of eating very healthy or relatively healthy and sleeping and some good exercise for about half an hour every morning. And I continued that throughout all of my medical school career. So, okay. So in your 20s and 30s, you're pretty high up the mountain. Your sensorium at baseline is pretty good. That's probably, you know, the peak. Maybe, you know, maybe if you're a kid, it's even higher. But in general, the 20s and 30s are the best, I think, because you have the most frontal lobe function. I mean, you know, your frontal lobe is fully developed and you probably have the best sensorium. So you can get stressed. You can be sleep deprived, starving.

And maybe you'll be okay. Maybe you'll be thinking clearly. But, you know, throw maybe a small infection or a medical issue on top of it. And all of a sudden, you're thinking less clearly. But if you were to do, if you were to do the same thing to an elderly person. So if you were to, for example, give them a small urinary tract infection. And let's say this is a person who's 80 years old, all of a sudden, this person could be in a full delirium, meaning they can't focus. they're hallucinating, throwing things, yelling, seeing spiders on a wall, and looking psychotic. And in the same way, someone with like dementia, dementia is, you know, like Alzheimer's or there's different types of dementias, but the basic idea is that you have issues with memory and issues with remembering facts and things and it's progressive and it's a brain dysfunction. these people are even more prone to sensorium issues. So they could get confused on a normal basis just later in the day. They go through something called sundowning.

So this person would have a sensorium issue in the afternoon when they have this, you know, kind of the normal lull, and they would go into something called like sundowning. So we all have a baseline level of brain function. And we can optimize it by several factors. good sleep, good amounts of exercise, good mental functioning, like reading, meaningful relationships, good spiritual practice, and meaningful work. So we can lower sensorium through drugs, excessive alcohol, significant medical issues, poor sleep, poor diet, unrelenting stress, untreated medical issues, like out-of-control diabetes or obstructive sleep apnea. And obstructive sleep apnea, just a side note

that. I'm going to go into these in more depth, but this is a very common thing that causes increased fatigue and sleepiness during the day. So this applies directly to psychiatry, because we want to think about how to make our patients function the best possible that they possibly can. We want them in the highest sensorium state possible so they can engage in meaningful work in life. and I've found that the better I can optimize someone's sensorium, the better they'll be able to perform at work and in relationships. And a lot of patients come to me thinking they have depression, thinking they have some issue, they just don't know what to do,

they just have come to a place in their life where they feel stuck, and by looking at them through this lens of sensorium and optimizing different aspects of their life, it can make a huge difference, a huge difference. So I'm going to talk a little bit about delirium because if you understand delirium, you understand a severe sensorium issue. And I would define delirium as an acute, confusional state.

So unlike dementia, which is chronic and progressive, delirium acutely occurs, where there's a decrease, significantly from the baseline level of function. For example, an older person who gets that urinary tract infection and starts hearing things, throwing things, that's what I would consider like a hyperactive delirium. There's also something called a hypoactive delirium

when someone is confused, down, seems depressed, but is not hallucinating. Interestingly, they looked at in Mayo, the number of consults to psychiatry for depression. And they found something like 60% of them were from a hypoactive delirium, meaning it wasn't like they were depressed or needed antidepressants.

They actually needed treatment for their delirium, their hypoactive delirium. Okay. So delirium is waxing and waning, which means, you know, at some points of the day, they may be more clear than others. in some studies of hospitalized patients, it can affect up to 38% of the patients in the hospital that are older. Now, some studies show like 5% or 10% or 15%, but 38% was the upper limit in this one study. So studying what can be the cause of delirium or worsened delirium can inform our study of lesser states of sensorium issues.

for example here's a list of things that provoke or worsen delirium infection okay so it could be uh you know a urinary tract infection like i've talked about it could be a cold a virus a bacterial infection and you can think about that as leaking out all sorts of toxins your innate immune system is revved up you're trying to fight off this thing and so you're you're in this sort of heightened of stress, okay? Illness severity. So illness, how severe an illness in particular is, will determine if the person ends up in a delirious state.

So if your illness is more severe, you will have worse sensorium issues. If your illness is more controlled, your sensorium will be better. And that is true for things like hypertension and diabetes. and so often I'll get patients in my treatment program and my outpatient clinic who have uncontrolled diabetes and at this point they don't really care to some degree that they have uncontrolled diabetes or they have some weird ideas about medications or why they don't want to take medications

and if I can help them understand the importance of it and they start to control it it's a lot easier to control their mood symptoms because their sensorium increases. it's a lot easier for the therapy to work because their sensorium increases. Another category of things that worsens delirium or provokes delirium is adverse drug effects. Okay, so I'm going to go into this in more detail, but basically anticholinergic drugs like Benadryl, central nervous system depressants like benzodiazepines and opiates can worsen delirium. Polypharmacy, like multiple drugs that decrease censorium. can provoke this. And a side note on pain, pain itself, untreated pain, can provoke delirium.

So we're kind of in this catch-22 where we don't want to over-medicate the pain, but we don't want to under-medicate the pain because we want them to not be in this sort of altered sensorium. Okay. Pre-existing dementia can increase the risk of delirium, vision impairment, malnutrition. if they have low abumin levels. So abumin is kind of a measure of the dietary sort of state that a person is in. And if they haven't been eating well for a long time, they'll be in a state of malnutrition. So someone who's, for example, in anorexia is in a sort of malnourished state. They're not getting enough of the good foods to their brain. and people with severe anorexia are actually very, very hard to treat

until they get a certain percentage of body fat, at which time, you know, the therapy and the medications will work. But at a certain point, the amount of nourishment is so low that it's really hard to have any therapy be effective. And so sometimes we have to actually hospitalize these patients. But that goes into my next one. Long hospital stays can actually worsen delirium. And you can think about that for several reasons.

One is just think about how many people visit someone in the middle of the night in a hospital, or how many times you get interrupted, or how many times beepers go off, or this goes off, or you need to go in for this test, or just you're there for a reason, you're stressed out. Stressful events can provoke delirium and worsen delirium. So if you have gone through something incredibly stressful, this can worsen it. and heavy alcohol use is another risk factor. So all of this information kind of made me curious on how to optimize Sensorium, both in how to decrease dives in Sensorium,

but also how to increase Sensorium long term. And I really think that this lens that I look through really helps me optimize someone's life. And so I'm going to go through three stories on kind of some people that have helped in their Sensorium. And I'm going to change quite a bit of the biographical demographic information so that I can hide their identities. So, for example, Jake was a 60-year-old man who came to my clinic after being on disability for

about 10 years. He had lost his daughter, and that really weighed on him heavily when he came in. He used to be a business executive and had a history of running several very successful companies with over 200 employees. He was an expert at turning around dysfunctional companies, and when they were failing, that's when he was at his best. He would come in, he would move things around, change staff, redo the books, and within a year or two, he could change around a very dysfunctional company and make it thrive again. So he had helped thousands of people throughout his career, maintain their jobs and find meaningful work and, you know, keep their pensions and all that good stuff. But then, you know, he had this very severe head injury and he had a very severe head

injury and he had a loss of consciousness for greater than an hour. He needed to be hospitalized for a while afterwards and he was on, he was put on pain medications and muscle relaxants because of his back pain. And he went back to work and was fired by the board of directors twice because he would fly into these fits of anger that were very uncontrolled. You know, before he was a very passionate man. He was, I think he probably naturally had a higher sort of baseline level of anger, but was able to focus it and control it. But now it kind of came out when he didn't want it to necessarily. He lacked control over it. And he ended up on chronic disability and without hope for ever working again. He kind of stumbled in my clinic and

I got him into my treatment program. So he was in my three-day-a-week program working with my therapist and myself. And, you know, at first, you know, when I remember talking to him and he said he couldn't even sit down and read a book, he had trouble completing tasks. His wife had to go with him everywhere. And so the first visit, I tried to give him some hope. hope. And I tried to sort of lay out a pathway for him to optimize his brain function and improve his sensorium. We started grieving the loss of his daughter together and working through some of the psychological stuff that was kind of chronic stress at this point because it was kind of on his mind taking up emotional energy throughout the day as, you know, I would expect it to. But in grieving the loss,

He was able to at least get through some of the stages of grief, anger, numbness, sadness. And he was able to do that work as well with the therapists in the program. And I managed his medication closely. I tapered him off of opiates. Opiates are like a very strong painkiller. Benzodiazepines, he was on clonopin, one milligram three times. a day. I tapered them off Baclophon, which is a muscle relaxant, which is centrally acting, which means it gets inside the brain and influences the brain. And we also worked on optimizing

positive things, like doing strength training and cardiovascular exercise and diet changes. His concentration returned, and after about a year of working with him, he was able to get back to work. And he took a job as a CEO and he once again was able to turn around a company and, you know, completely kind of reestablish his career, which was incredibly satisfying. Second example I'm going to give is a middle-aged woman who was a therapist and she was having issues with memory and reading. She always felt like she was like in this fog when she first came to see me. She had a difficult time keeping her schedule and frequently miss things, and she was worried about having dementia. We did several exercises, including helping her give up her chronic anger.

She felt towards her ex. So exercises of psychotherapy and processing things. We also switched her migraine medication from two things that lowered her sensorium. She was on topiramate and an anticholinergic medication amatryptylene to other medications which did not lower sensorium. We changed her to Simbalta. We also did some lifestyle changes like got her exercising four days a week and eating more healthy food. All of this put together, her memory and focus came back to her baseline level. And she once again found work meaningful. She was able to read, have pleasurable interactions with family and friends, not feel so tired

all the time. And I think it was the combination of all these things that really helped her thrive. The third example is Tom, who was a man in his mid-40s, who could not focus and he felt like he was depressed. He came to me wanting actually ADHD medication and something for depression. But on further history, he had no history of ADHD in childhood or adolescence. He had been able to get through college and high school and actually do really well. And it was only in the last four years that he started having these issues with focus

and his sort of feeling down and depressed. So he had gained about 30 pounds in his early. early 40s, and at the time when I first started seeing him was 300 pounds. He would wake up with headaches, he had out of control type 2 diabetes, and he ate fast food and drank alcohol two to three times a week, usually three to four servings per night of alcohol. He was snoring at night, and so I ordered, I was highly suspicious because of the history of the headaches when he woke up, and the increase in the weight. I was highly... suspicious that he had obstructive sleep apnea. And lo and behold, he did. And so I got him a sleep

study and had him start wearing a sleep mask, which at first he completely resisted. Nobody likes wearing a sleep mask. But I pleaded with him that this was going to be the life changer for him. And so he gave it a shot. He also cut out soda, fast food and other non-healthy foods. He also was able to work through some marriage conflicts, so some of that sort of chronic stress that was going on. Maybe that was at the root of some of his eating and trying to distract himself. He was able to work through that in therapy.

So over the course of about two years, he lost 50 pounds. His diabetes came under better control. He was actually able to increase his strength through strength training to about double of what he first started seeing me in terms of his strength. So, you know, at first when he came in, you know, maybe he started squating. He could squat about 70 pounds. And after two years, he was squatting around 250 pounds, three sets of five, which may seem like a lot, but it's totally doable if you know how to build strength. So he also was able to decrease his medications to only metformin for his diabetes.

And his hemoglobin A1C, which is like the level of glucose over past three months was normalized. It's been under very good control. So he also stopped drinking excessive alcohol except maybe one or two drinks per week. And when he would drink, he would only drink a max of two drinks at a time rather than four. He would also meal prep and was eating high-quality food pretty much in line with the Mediterranean diet. And after all of this, he says now his focus is the best that it's ever been. And he feels more purpose and meaning in his work and life and his relationships have improved. And he enjoys time with his kids and his wife.

he's able to get back to doing what he loves doing. So I illustrated these three stories to show some common issues we face with Sensorium and how if, you know, you approach multiple sort of issues all at the same time, you can really make a big difference. And sometimes, you know, we can only get a person to do one thing at a time. Maybe it's just lower this medication or start to go to therapy. and, you know, sometimes we're able to get them to do multiple things at the same time. And I think when they're able to do multiple good things and eliminate some of the bad things all at once,

if you have a highly motivated patient, then you can really make progress very quickly. So some of this is psychoeducation that's really important. And I'm actually looking forward to being able to share this podcast with some of my patients to sort of give them, you know, basically a one-hour lecture into my ideas on Sensorium and why I'm trying to convince them to get off of certain medications or, you know, do therapy or do lifestyle changes, because all of those things when put together can be really, really powerful. Okay. So I'm now going to go through some specific studies and specific topics relating to the sensorium.

And the first one is chronic stress. So the issue is not stress, but rather stress beyond our scope of comprehending it or handling it, like a near-death experience, or a stress that's also unable to resolve, like a chronic stress. So stress needs a recovery before adaptation. can occur. And if we have a good stress and then we have a recovery, then we will adapt and be stronger, psychologically stronger, physically stronger. The problem with trauma is the stress is overwhelming. So it's kind of like if I were to ask a complete novice weightlifter to squat 300 pounds,

the stress may be so much that it would send them, you know, unable to work out anymore. In the same way, a psychological trauma needs to be catabolized and resolved, and it can be very difficult for that process without kind of an untrained person helping you through that journey. And so that's why, you know, a therapist can be really, really helpful in someone overcoming trauma, whether they're doing EMDR, you know,

like where they're moving their finger back and forth in front of someone, or trauma-focused CBT, or, you know, the therapist is just, you know, very trained in trauma work. So basically, the therapist is helping the person re-experience some aspects of the trauma, but in a new way with a trusted, connected person. So chronic physiological stress in one study caused hippocampal-dependent cognitive deficits. So you can think about the neurons in the hippocampus.

The hippocampus is kind of like where we're, you know, moving memory. from short-term to intermediate to long-term. And it's very important in memory. And we have these neurons that are like trees. And the trees have branches. And they did this study in, I think it was rats, where after 21 days of stress, the rats' trees lost a bunch of their branches.

So they looked at the neurons, and the neurons and the hippocampus lost a bunch of their branches and how they looked. So the type of stress that these rats went under was they put them in these metal wires for six hours per day for 21 days. Interestingly, I like two hours a day for 21 days. It didn't have the same effect. And for like 12 days, it didn't have the same effect at six hours.

So there's something about this sort of idea of chronic psychological stress that was damaging to the areas that consolidate and work through like memory type of stuff. So I am actually going to do a full lecture on how stress influences the body and the brain coming up. But suffice to say, we need to work through unprocessed traumas. We need to resolve unrelenting stresses. And so if you have kind of stress that's in your mind unresolvable, seek help. You know, if you need to work out things in your marriage, seek marriage therapy, seek family therapy.

If you don't find the right therapist the first time, go see a second therapist. Utilize spiritual resources. One sort of chronic stress that I see in a lot of patients is chronic anger, unresolved, bitterness, towards either an ex-spouse or childhood stuff that went on or early, abusers and, you know, they may work through the abuse, the traumatic aspects of abuse, but they still hang on to some of that chronic anger. And I may ask them, what percentage of your day are you ruminating on this anger? And they may say, you know, oh, maybe 10, 20 percent. I spend ruminating. And with, you know, they also may say 70, 80 percent. And it's the people who

who spend, you know, part of their day where their emotional energy is being used up in this way, then I kind of challenge them of like, hey, like, is this what you want? I mean, maybe it is. But maybe it isn't. Maybe you want to let it go. And some people don't know how to let it go. And so that's where some therapy and forgiveness therapy and sometimes it's tapping into people's spiritual resources, so the strengths that they already have that can really help them in that way. Okay, so that will be the end of part one of Sensorium. As I recorded, I realize that this is longer than just one episode. So in the second episode, I'll go a little bit more into stress.

I'll also talk about medications, lifestyle changes, including diet, exercise. I'll talk about drugs and how that influences Sensorium. And if you are interested in learning more, continue to follow this, jump on my website, psychiatrypodcast.com, where I'll have some further notes. And, you know, if this was something you appreciated, shoot me a note on one of my social media handles. They are linked below. And if you have any questions, post them in one of the links on the social media. I usually post just, you know, a picture of something related to the particular episode.

So if you listen to a particular episode and you have a particular question or comment or something that you would have wanted more of or less of or just any feedback or thoughts at all, I appreciate that, post that up there. And I usually correspond with people who write on the social media handles. So with that, have a great day and take care.