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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 32. This is the beginning of the thread.
Posted by sowhysosad on May 19, 2009, at 20:02:11
Some of the sites of the "paxil progress" variety claim that after a negative serotonin-mediated reaction to an SRI you should avoid all serotonergics for a year. I was a bit sceptical when I read this as there was no indication of where they got this rule of thumb from.
However, I'm now starting to think they might be onto something! Back in October I had akathisia after raising my generic Zoloft dose too quickly, and since then even mildly serotonergic meds (escitalopram/mirtazapine/imipramine) have made the resulting depression worse.
The last few of weeks I've been med-free but experimenting with 5-HTP supplements. Despite some transient good moods, as I've increased the dose I've mostly had increased anxiety, fear and depression and early awakening. It feels almost identical to the startup anxiety I had when starting Paxil, as if I can't tolerate the sudden boost of serotonin.
Is there any evidence - scientific or anecdotal - that the SSRI alarmists might have a point? Does a bad SRI reaction somehow fry the serotonin receptors and make them more sensitive, making other serotonergics intolerable?
Surely, if anything, the receptors would downregulate so you'd be less sensitive to the effects of serotonin, not more!
Posted by yxibow on May 19, 2009, at 23:41:19
In reply to Avoid serotonergics after bad SRI reaction?, posted by sowhysosad on May 19, 2009, at 20:02:11
> Some of the sites of the "paxil progress" variety claim that after a negative serotonin-mediated reaction to an SRI you should avoid all serotonergics for a year. I was a bit sceptical when I read this as there was no indication of where they got this rule of thumb from.
Sounds a bit good to be skeptical.
> However, I'm now starting to think they might be onto something! Back in October I had akathisia after raising my generic Zoloft dose too quickly, and since then even mildly serotonergic meds (escitalopram/mirtazapine/imipramine) have made the resulting depression worse.
Zoloft is one of the few SSRIs known to cause things like akathisia because it has a slight blockade at D2.
> The last few of weeks I've been med-free but experimenting with 5-HTP supplements. Despite some transient good moods, as I've increased the dose I've mostly had increased anxiety, fear and depression and early awakening. It feels almost identical to the startup anxiety I had when starting Paxil, as if I can't tolerate the sudden boost of serotonin.
>
> Is there any evidence - scientific or anecdotal - that the SSRI alarmists might have a point? Does a bad SRI reaction somehow fry the serotonin receptors and make them more sensitive, making other serotonergics intolerable?Not in my belief... there are a fair number of SSRI/SRI/SNRIs out there and you just may not be on the right one. They're definitely not all created equal.
> Surely, if anything, the receptors would downregulate so you'd be less sensitive to the effects of serotonin, not more!They can possibly after a while downregulate dopamine actually. Something that may have contributed to help in my case, but that's another story.
-- Jay
Posted by Phillipa on May 20, 2009, at 0:30:44
In reply to Re: Avoid serotonergics after bad SRI reaction? » sowhysosad, posted by yxibow on May 19, 2009, at 23:41:19
I thought zoloft was about one of the best tolerated SSRI's Love Phillipa
Posted by yxibow on May 20, 2009, at 1:05:49
In reply to Re: Avoid serotonergics after bad SRI reaction?, posted by Phillipa on May 20, 2009, at 0:30:44
> I thought zoloft was about one of the best tolerated SSRI's Love Phillipa
Everyone is different. Never did say it was better or worse tolerated, just said what separates it slightly from other SSRIs.
In an extremely rare circumstance when someone has been on a number of APs and has also been on Zoloft, tardive syndromes can occur. But I'm not saying this to scare people off of Zoloft -- this is a truly rare circumstance.
Supposedly Lexapro is the most tolerated -- but I had two weeks of hellish near vomiting nausea. Everyone is different.
-- tidings
-- Jay
Posted by sowhysosad on May 20, 2009, at 5:45:00
In reply to Re: Avoid serotonergics after bad SRI reaction? » sowhysosad, posted by yxibow on May 19, 2009, at 23:41:19
> Zoloft is one of the few SSRIs known to cause things like akathisia because it has a slight blockade at D2.
That's interesting Jay. I understand depleted dopamine can play a part in akathisia, so maybe Zoloft makes it worse by blocking the D2 receptors?
> Not in my belief... there are a fair number of SSRI/SRI/SNRIs out there and you just may not be on the right one. They're definitely not all created equal.
My pdoc doesn't want to try me on a new med yet, which I think might be a good judgement call. I've also been off supplements for a few days and feel a little better.
> They can possibly after a while downregulate dopamine actually. Something that may have contributed to help in my case, but that's another story.
Dopamine release or receptor sensitivity? As I understand it, most SRI's (although obviously not Zoloft!) sensitise D2 receptors.
Posted by sowhysosad on May 20, 2009, at 5:47:34
In reply to Re: Avoid serotonergics after bad SRI reaction?, posted by Phillipa on May 20, 2009, at 0:30:44
> I thought zoloft was about one of the best tolerated SSRI's Love Phillipa
According to some data it's one of the more powerful ones.
I guess they all have the potential to cause a bad reaction if the dose is raised too quickly. I should've respected it more and taken things more slowly.
Posted by sowhysosad on May 20, 2009, at 5:51:01
In reply to Re: Avoid serotonergics after bad SRI reaction? » Phillipa, posted by yxibow on May 20, 2009, at 1:05:49
> Supposedly Lexapro is the most tolerated -- but I had two weeks of hellish near vomiting nausea. Everyone is different.
Ouch! Not pleasant Jay.
I found Lex to be very light on side effects, with the exception of provoking a minor movement disorder in my jaw which was a major pain. Sexual dysfunction was minimal at 10mg, I had no nausea and none of the irregular heartbeat I get on some serotonergics.
Posted by SLS on May 20, 2009, at 5:56:10
In reply to Avoid serotonergics after bad SRI reaction?, posted by sowhysosad on May 19, 2009, at 20:02:11
> Some of the sites of the "paxil progress" variety claim that after a negative serotonin-mediated reaction to an SRI you should avoid all serotonergics for a year. I was a bit sceptical when I read this as there was no indication of where they got this rule of thumb from.
>
> However, I'm now starting to think they might be onto something! Back in October I had akathisia after raising my generic Zoloft dose too quickly, and since then even mildly serotonergic meds (escitalopram/mirtazapine/imipramine) have made the resulting depression worse.
>
> The last few of weeks I've been med-free but experimenting with 5-HTP supplements. Despite some transient good moods, as I've increased the dose I've mostly had increased anxiety, fear and depression and early awakening. It feels almost identical to the startup anxiety I had when starting Paxil, as if I can't tolerate the sudden boost of serotonin.
>
> Is there any evidence - scientific or anecdotal - that the SSRI alarmists might have a point? Does a bad SRI reaction somehow fry the serotonin receptors and make them more sensitive, making other serotonergics intolerable?
>
> Surely, if anything, the receptors would downregulate so you'd be less sensitive to the effects of serotonin, not more!
Look into "kindling". Kindling might be operating as the result of the overactivity of certain neural pathways (perhaps glutamatergic) that produce severe side effects. Kindling would account very nicely for subsequent hypersensitivity to these drugs with regard to side effects.I think poop-out is another phenomenon entirely.
- Scott
Posted by sowhysosad on May 20, 2009, at 5:59:25
In reply to Re: Avoid serotonergics after bad SRI reaction? » sowhysosad, posted by SLS on May 20, 2009, at 5:56:10
> Look into "kindling". Kindling might be operating as the result of the overactivity of certain neural pathways (perhaps glutamatergic) that produce severe side effects. Kindling would account very nicely for subsequent hypersensitivity to these drugs with regard to side effects.
Will do!
Thanks Scott!
Posted by sowhysosad on May 20, 2009, at 6:18:53
In reply to Re: Avoid serotonergics after bad SRI reaction? » sowhysosad, posted by SLS on May 20, 2009, at 5:56:10
> Look into "kindling". Kindling might be operating as the result of the overactivity of certain neural pathways (perhaps glutamatergic) that produce severe side effects. Kindling would account very nicely for subsequent hypersensitivity to these drugs with regard to side effects.
I just remembered - in another thread bleauberry was speculating that a large dose of MSG in a Chinese meal may have amplified the effects of some 5-HTP I took. But bleau says this would point to REDUCED glutamate function rather than overactivity.
What would this tell us in the light of your theory above?
Either way, it looks like glutamate function could be a factor in why I've been feeling so screwed up over the past 8 months, so I'd really appreciate any pointers you can give me Scott!
Posted by SLS on May 20, 2009, at 7:10:25
In reply to Re: Avoid serotonergics after bad SRI reaction? » SLS, posted by sowhysosad on May 20, 2009, at 6:18:53
> > Look into "kindling". Kindling might be operating as the result of the overactivity of certain neural pathways (perhaps glutamatergic) that produce severe side effects. Kindling would account very nicely for subsequent hypersensitivity to these drugs with regard to side effects.
>
> I just remembered - in another thread bleauberry was speculating that a large dose of MSG in a Chinese meal may have amplified the effects of some 5-HTP I took. But bleau says this would point to REDUCED glutamate function rather than overactivity.
>
> What would this tell us in the light of your theory above?
>
> Either way, it looks like glutamate function could be a factor in why I've been feeling so screwed up over the past 8 months, so I'd really appreciate any pointers you can give me Scott!
1. lamotrigine (Lamictal)
2. memantine (Namenda)
3. topiramate (Topamax)All three drugs reduce glutamatergic neurotransmission, each using a different mechanism.
The price is prohibitive, but riluzole (Rilutek) is another antiglutamtergic drug.
Other anti-kindling drugs that work through sodium channel inhibition
Na+ channel inhibition > pro-GABA > anti-glutamate:
1. valproate (Depakote)
2. oxcarbazepine (Trileptal)Gabapentin (Neurontin) is a calcium receptor antagonist (alpha-2-delta subunit). I don't know if it would help.
Tiagabine (Pregabalin) is a GABA reuptake inhibitor with anti-kindling properties. It might help, but I feel the drug is unpredictable. Lower dosages might be the way to go with this drug.
- Scott
Posted by newquestions on May 20, 2009, at 8:42:29
In reply to Re: Avoid serotonergics after bad SRI reaction? » sowhysosad, posted by SLS on May 20, 2009, at 7:10:25
I would argue that the adverse reaction was caused by a new hypersensitivity to the SRI based on prior years of use and that you needed to go off the SRI anyway...
Posted by SLS on May 20, 2009, at 10:50:40
In reply to Re: Avoid serotonergics after bad SRI reaction?, posted by newquestions on May 20, 2009, at 8:42:29
> I would argue that the adverse reaction was caused by a new hypersensitivity to the SRI based on prior years of use and that you needed to go off the SRI anyway...
No need to argue. We really are in agreement. The mechanism by which someone becomes hypersensitive to SRI may or may not be due to DOWNSTREAM glutamatergic hyperactivity produced by chronic use of these drugs. However to understand this as a kindling process makes sense to me.
- Scott
Posted by SLS on May 20, 2009, at 15:06:26
In reply to Re: Avoid serotonergics after bad SRI reaction? » newquestions, posted by SLS on May 20, 2009, at 10:50:40
> > I would argue that the adverse reaction was caused by a new hypersensitivity to the SRI based on prior years of use and that you needed to go off the SRI anyway...
>
> No need to argue. We really are in agreement. The mechanism by which someone becomes hypersensitive to SRI may or may not be due to DOWNSTREAM glutamatergic hyperactivity produced by chronic use of these drugs. However to understand this as a kindling process makes sense to me.I almost forgot. I think one of the things that kindling might be responsible for is a worsening of withdrawal effects, either as an unusually protracted period of withdrawal after chronic exposure to the drug or progressively more severe withdrawal effects as the result of repeated drug discontinuations.
- Scott
Posted by bleauberry on May 20, 2009, at 18:28:40
In reply to Avoid serotonergics after bad SRI reaction?, posted by sowhysosad on May 19, 2009, at 20:02:11
I saw my doc today. He said that as sensitive as I am, he has actually had a few other patients even more sensitive. Hard to imagine.
Anyway, he said in all cases it was an unseen yeast or bacterial infection that caused it. The sensitivities went away after successful treatment. So, just another angle to consider, though I'm sure there are a handful of valid explanations.
Anyway, in those sensitive patients, he had one lady who did very well on...you won't believe it...1 drop of lexapro. That's 1mg. Another on drops of zoloft. I talked to a girl with 3 mg lexapro as her perfect dose...more was depressing, less was not enough. And there was someone here a couple months ago that took a sand-grain size of lexapro.
The point I'm trying to make is that when someone has a bad reaction to therapeutic doses of meds, they need to listen their bodies and disregard doses that other people take. You gotta take the dose that your body wants, not someone else's.
Keep in mind that in clincal studies, people like us were not included. Complicating illnesses, infections, sensitivities, previous episodes, etc, are almost always excluded from the trials. So the doses that are preached to us are not representative doses of the population that we are. We at pbabble probably need significantly different doses than the general public, either much higher or much lower.
Just my 2 cents.
Posted by sowhysosad on May 20, 2009, at 18:37:57
In reply to Re: Avoid serotonergics after bad SRI reaction? » sowhysosad, posted by SLS on May 20, 2009, at 7:10:25
Fascinating stuff Scott - thanks so much.
I'm actually starting to think that my glutamate function may be compromised rather than over-active. I mentioned elsewhere that I have a noticeable improvement in mood after eating MSG-heavy food.
Also, my depression got significantly worse on imipramine and then improved dramatically after quitting it. Earlier I found this piece of research:
> > > Look into "kindling". Kindling might be operating as the result of the overactivity of certain neural pathways (perhaps glutamatergic) that produce severe side effects. Kindling would account very nicely for subsequent hypersensitivity to these drugs with regard to side effects.
> >
> > I just remembered - in another thread bleauberry was speculating that a large dose of MSG in a Chinese meal may have amplified the effects of some 5-HTP I took. But bleau says this would point to REDUCED glutamate function rather than overactivity.
> >
> > What would this tell us in the light of your theory above?
> >
> > Either way, it looks like glutamate function could be a factor in why I've been feeling so screwed up over the past 8 months, so I'd really appreciate any pointers you can give me Scott!
>
>
> 1. lamotrigine (Lamictal)
> 2. memantine (Namenda)
> 3. topiramate (Topamax)
>
> All three drugs reduce glutamatergic neurotransmission, each using a different mechanism.
>
> The price is prohibitive, but riluzole (Rilutek) is another antiglutamtergic drug.
>
> Other anti-kindling drugs that work through sodium channel inhibition
>
> Na+ channel inhibition > pro-GABA > anti-glutamate:
>
> 1. valproate (Depakote)
> 2. oxcarbazepine (Trileptal)
>
> Gabapentin (Neurontin) is a calcium receptor antagonist (alpha-2-delta subunit). I don't know if it would help.
>
> Tiagabine (Pregabalin) is a GABA reuptake inhibitor with anti-kindling properties. It might help, but I feel the drug is unpredictable. Lower dosages might be the way to go with this drug.
>
>
> - Scott
Posted by sowhysosad on May 20, 2009, at 18:42:59
In reply to Re: Avoid serotonergics after bad SRI reaction?, posted by bleauberry on May 20, 2009, at 18:28:40
> Anyway, in those sensitive patients, he had one lady who did very well on...you won't believe it...1 drop of lexapro. That's 1mg. Another on drops of zoloft. I talked to a girl with 3 mg lexapro as her perfect dose...more was depressing, less was not enough. And there was someone here a couple months ago that took a sand-grain size of lexapro.
Yeah, I recall reading about a woman who did really well by opening Prozac capsules and taking a couple of granules!
> The point I'm trying to make is that when someone has a bad reaction to therapeutic doses of meds, they need to listen their bodies and disregard doses that other people take. You gotta take the dose that your body wants, not someone else's.
>
> Keep in mind that in clincal studies, people like us were not included. Complicating illnesses, infections, sensitivities, previous episodes, etc, are almost always excluded from the trials. So the doses that are preached to us are not representative doses of the population that we are. We at pbabble probably need significantly different doses than the general public, either much higher or much lower.Great points, but the odd thing is that my depression was always pretty straightforward before the akathisia and responded well to SSRI's.
I was also able to tolerate "normal" doses of SSRI's pre-akathisia: 20mg of Prozac, Lexapro and (IIRC) Paxil.
Posted by yxibow on May 20, 2009, at 22:02:54
In reply to Re: Avoid serotonergics after bad SRI reaction? » yxibow, posted by sowhysosad on May 20, 2009, at 5:51:01
> > Supposedly Lexapro is the most tolerated -- but I had two weeks of hellish near vomiting nausea. Everyone is different.
>
> Ouch! Not pleasant Jay.
>
> I found Lex to be very light on side effects, with the exception of provoking a minor movement disorder in my jaw which was a major pain. Sexual dysfunction was minimal at 10mg, I had no nausea and none of the irregular heartbeat I get on some serotonergics.
Curious -- it provoked jaw movement too. Plenty. I stopped it. It was a bad time -- I had really melancholic and serious depression. Not that I don't still have dysthymia and secondary depression.But for me I think that was the first sign that I was developing a non-tardive orobuccal/orofacial tic, mostly because of Seroquel.
-- Jay
Posted by SLS on May 20, 2009, at 22:11:33
In reply to Re: Avoid serotonergics after bad SRI reaction?, posted by sowhysosad on May 20, 2009, at 18:37:57
Glutamate does not normally cross the blood-brain barrier in humans. However, MSG has been shown to destroy nerve cells when fed to young animals.
How does coffee (caffeine) affect you? If you had overactive glutamatergic activity, I imagine you would feel very uncomfortable taking caffeine - dysphoria and anxiety. Caffeine is an adenosine receptor blocker. Normally, the stimulation of these receptors helps put the brakes on glutamatergic activity as it is an inhibitory modulator. With these receptors being blocked, glutamate activity might run amok in certain individuals. This is all guesswork on my part. I have yet to form a hypothesis of what one's reaction to caffeine would be if they were chronically hypoactive as you believe you might be. There is just too much about glutamate dynamics that I don't understand. I am looking forward to hearing how caffeine affects you.
- Scott
Posted by sowhysosad on May 21, 2009, at 5:20:19
In reply to Re: Avoid serotonergics after bad SRI reaction? » sowhysosad, posted by yxibow on May 20, 2009, at 22:02:54
> But for me I think that was the first sign that I was developing a non-tardive orobuccal/orofacial tic, mostly because of Seroquel.
Aha! I've only ever taken one med at a time so I can't blame it on an AP.
What's your understanding of the term "tardive"? I take it to mean "developing after some time on a med due to adaptive receptor changes".
However, my neuro insists on referring to my movement disorder as "tardive" even though it started practically the day I started Lex - implying no time for receptors to adapt. He seems to think "tardive" means "lasting a long time".
Posted by sowhysosad on May 21, 2009, at 5:33:40
In reply to Re: Avoid serotonergics after bad SRI reaction? » sowhysosad, posted by SLS on May 20, 2009, at 22:11:33
Hmmm. At the moment I'm tolerating small quantities of caffeine OK, although there have been occasions over the last few weeks where it's made me a little agitated and down.
Not to the same extent as nicotine though - until earlier this week cigarettes were causing pretty bad anxiety and dysphoria.
> Glutamate does not normally cross the blood-brain barrier in humans. However, MSG has been shown to destroy nerve cells when fed to young animals.
>
> How does coffee (caffeine) affect you? If you had overactive glutamatergic activity, I imagine you would feel very uncomfortable taking caffeine - dysphoria and anxiety. Caffeine is an adenosine receptor blocker. Normally, the stimulation of these receptors helps put the brakes on glutamatergic activity as it is an inhibitory modulator. With these receptors being blocked, glutamate activity might run amok in certain individuals. This is all guesswork on my part. I have yet to form a hypothesis of what one's reaction to caffeine would be if they were chronically hypoactive as you believe you might be. There is just too much about glutamate dynamics that I don't understand. I am looking forward to hearing how caffeine affects you.
>
>
> - Scott
>
>
Posted by newquestions on May 21, 2009, at 15:51:09
In reply to Avoid serotonergics after bad SRI reaction?, posted by sowhysosad on May 19, 2009, at 20:02:11
I think it goes like this: years of SSRI use leads to body adaption, person goes off SSRI either because of side effects or because they are sick of being on SSRIs, person gets depressed and so tries to reintroduce SSRI, body rejects it because of prior adaptation which is the bad reaction/hypersensitivity.
Posted by yxibow on May 21, 2009, at 16:44:08
In reply to Re: Avoid serotonergics after bad SRI reaction? » yxibow, posted by sowhysosad on May 21, 2009, at 5:20:19
> > But for me I think that was the first sign that I was developing a non-tardive orobuccal/orofacial tic, mostly because of Seroquel.
>
> Aha! I've only ever taken one med at a time so I can't blame it on an AP.Well.... I won't go down that road... its neither here nor there
> What's your understanding of the term "tardive"? I take it to mean "developing after some time on a med due to adaptive receptor changes".Yes, Tardive Dyskinesia and Tardive Dystonia have a /potential/ to occur after long term use of APs (there are other substances that can cause it as well but they're not nearly as relevant).
With new atypicals the general thought is 5% per year (aggregate, all of them) for an unknown period of time, while typicals are about 25% for again, an unknown but long period of time (many years to much more than a decade).
> However, my neuro insists on referring to my movement disorder as "tardive" even though it started practically the day I started Lex - implying no time for receptors to adapt. He seems to think "tardive" means "lasting a long time".
I'm not quite sure how to respond to your neurologist's description.Tardive dyskinesia will basically fully recover in at least 30% if not more of the cases, remain the same in the next 30% and possibly become worse in the remaining.
I defer to someone who is a specialist in movement disorders but without knowing the length of time you've been on Lexapro (and Zoloft ?) or any length of time on any APs you might have taken I can't get a good picture.
Certainly for Lexapro and Zoloft, actual TD is rare.
As for atypicals I can't say either... its a tossup and everyone is different but its definitely an extended period of years+ usually
But normally TD is a phenomenon not known to the patient initially -- its something that is almost always not felt with pain, and requires someone else to point it out to you.
It also doesn't just occur at one time of the day, it occurs randomly but consistently throughout the day and usually stops during sleep.
So really the only practical ways to know if there is any 'lasting' phenomenon would be to be off all medications for a while but that isn't practical I would think for your health.
A challenge to TD would be to see if this "movement" can be changed by a rx of Artane or Cogentin, or OTC Benadryl (would not suggest driving on it).
If the movement doesn't significantly get worse or in fact might even be improved, its likely not to be TD.
That doesn't mean it isn't a form of EPS if it slows down. But that's quite different.
It just doesn't seem like TD to me but you would have to go over again all of this I suspect with your neurologist or give a bit of background on what he had mentioned perhaps, if you are open to that.Its your personal medical history so I'm not asking you to post it here if you're uncomfortable.
-- best wishes-- Jay
Posted by sowhysosad on May 22, 2009, at 6:35:02
In reply to Re: Avoid serotonergics after bad SRI reaction?, posted by newquestions on May 21, 2009, at 15:51:09
But the prior adaptation would be one of DE-sensitisation of the 5HT receptors, not hypersensitivity.
Although I guess they'll upregulate after removing the first SRI, perhaps rendering them too sensitive for a second one.
> I think it goes like this: years of SSRI use leads to body adaption, person goes off SSRI either because of side effects or because they are sick of being on SSRIs, person gets depressed and so tries to reintroduce SSRI, body rejects it because of prior adaptation which is the bad reaction/hypersensitivity.
Posted by SLS on May 22, 2009, at 7:33:22
In reply to Re: Avoid serotonergics after bad SRI reaction? » newquestions, posted by sowhysosad on May 22, 2009, at 6:35:02
> But the prior adaptation would be one of DE-sensitisation of the 5HT receptors, not hypersensitivity.
Perhaps the post-drug return to baseline sensitivity overshoots and produces supersensitivity of both postsynaptic and presynaptic receptors, along with the kindling of certain glutamatergic pathways. When an SSRI is reintroduced, the change in the dynamics of the 5-HT synapse never again reach a normal equilibrium, with an increase in the sensitivity of side effects - even at a lower dosage.
Just a thought. I haven't researched this at all.
There is more to consider relating to neuronal behavior in the presence of a serotonin reuptake inhibitor - accomodation for instance - that might explaing the acute effects of these drugs during the first week that disappear upon chronic use. Anxiety would be one such side effect.
As an aside, I am of the tentative belief that the more acute the discontinuation of an SRI along with subsequent withdrawal symptoms, the worse the withdrawal symptoms become subsequently. This might also be a part of the kindling process. The lesson here is that the gradual withdrawal from an SRI is critical to prevent subsequent sensitivities.
Of course, I am not sure about this stuff as I have never seen it written anywhere. I find these things quite fascinating, but extremely relevant.
- Scott
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