.

Good evening.

I'm psychiatrist Jay Fawver live from Fort Wayne , Indiana.

Welcome to Matters of the Mind.

Now in his 26 year Matters of the Mind is a live call in program where you have the chance to choose the topic for discussion.

So if you any questions concerning mental health issues, you may call me in the Fort Wayne area by you may dial toll free coast to coast at 866- (969) to seven to zero now at a fairly regular basis I am broadcasting live every Monday night from our spectacular Fort Wayne studios which lie in the shadows of the Purdue University Fort Wayne campus.

And if you'd like to contact me with an email question than I can answer on the air or you may write me via the Internet at matters of the mind all one word at Wagan that's matters of the mind at a dot org and I'll start tonight's program with an email I received just this past week.

>> It reads To favor will the correct dosage of gabapentin or something similar eventually work as well as clonazepam to treat generalized anxiety or panic disorder with no signs of depression?

>> How would the switch affect daily dosage?

Well, the first thing I'd want to know is what's the source of the panic or the anxiety because there's different sources of panic and anxiety and we're going to treat them a little bit differently now when people talk about panic disorder, they're talking about an episode where something may or may not provoke symptoms of nausea fast heart rate tremulousness, sweatiness, diarrhea, feeling like you're going to die, feeling like you're going to pass out.

>> These are symptoms of panic, a panic attack and emerge within a matter of minutes and they'll stay around sometimes for minutes or even hours and t's a horrific experience for people to endure.

>> You always want to know what's the source of that.

>> So as you look at anxiety and panic attacks and those type of things clonazepam sure.

>> Klonopin Glennis Obama's a benzodiazepine medication that is in the category of the antianxiety medications and it works by going to this part of the brain right here call the amygdala and dial down the volume control on the amygdala.

The amygdala regulates anxiety ,fear, anger and Ardiles down that anxiety volume control right there.

>> So works very well.

>> The problem is Clunies EPAM is you can kind of get used to its effects over the course of time so we try not to use it more than just a few weeks for most people and also it can make you kind of cognitively dull so you'll have a hard time with your speed of processing in your brain and the longer you use it sometimes at the that's going to be worse for some people as we get older, especially over that magic age of sixty five years of age clonazepam Xanax, Ativan the medications in the class of the benzodiazepines can be more problematic with your memory.

So for that reason we try to get people off Clunies EPAM but OK what direction you go if the panic is related to a social events let's say you're going into a social occasion and you have social anxiety associated with that.

We might use a medication more like a beta blocker or something that blocks adrenaline slows down your heart rate decreases the tremulousness decreases sweating a beta blocker and at least get you out the door to get you in that kind of situation.

>> Now Klonopin or Clonazepam can as well but here's the issue I often see with Clonazepam I hear about people taking it and then they kind of sit at home.

If you take Clonazepam I expected to be doing something for you to allow you to function at a higher level and if you just take the clonazepam and sit at home and kind of veg out for the evening, no, that's not a good use of clonazepam whether it's clonazepam beta blocker, it should be used for a purpose to allow you to function at a higher level and allow you to do more things if the panic attack is related to a phobia, a fear of driving down the interstate, a fear of going into a certain situation again a medication can help you may be overcome that fear but the the key will be for you to keep working at exposing yourself to that fear to be able to overcome it and be able to be desensitized from having the fear overall if the panic attack is related to a physical problem such as high thyroid.

>> I saw a person at my office a few weeks ago who had a high thyroid, had a fast heart rate related to to the high thyroid felt like she was having panic attacks well appeared to be due to the high thyroid so we decreased the thyroid dosage a bit and that took care of the symptoms within a few days.

So I want to make sure it's not a physical type of problem such as a high thyroid glucose disturbances going up and down can be problematic.

Some people can have hormonal disturbances.

It O'Collins caused them to have panic attacks again, you don't want to just tranquilize those kind of symptoms with Clonazepam or even Gabapentin for that matter.

You want to try to get to the heart of them and try to to take care the underlying problem.

>> So we've got to look at the overall reason why somebody might be having panic attacks.

The panic attacks are due to obsessive compulsive disorder where you're feeling compelled to do something over and over again and you're getting more anxious when you don't do it.

We might give somebody a serotonin medication such as higher doses of Zoloft, Prozac, those kind of medications.

So we're going to take a look at all that now what if you do change over from Clonazepam to gabapentin?

>> There's not a specific dose equivalent for everybody.

We're going to give you the dosage that seems to be working the best for you.

But in tapering off Clonazepam ,I'm going to take a look at a couple of things.

I'm going to look at the dosage you're taken.

I'm going to look at how long you've been taking it if you've been taking a pan for thirty years and I've seen people taking Clonazepam for thirty years I might take about 30 weeks to have to taper off of it very slowly, especially if you're at a high dosage.

If you're on a low dosage it might not be so problematic.

Usually if somebody has been on a high dosage for a lot of years I'm going to be very slowly slowly tapering them down.

>> But I will also use the gabapentin as a means of providing that bridge and quite frankly, as I get people off of Clonazepam and over the Gabapentin many times I will see people over the course of time being able to even come off the gabapentin.

But the Gabapentin is not as prone to causing you to have the difficulty with thinking and not as prone to causing you to get used to it to the degree that Clonazepam can hope that helps.

>> Thanks for your email.

Let's go to our first caller.

Hello Paul.

Welcome to Matters of Mind.

Paul, you had mentioned the you're on Cymbalta that's also known as Dellucci 18.

It makes you feel more anxious and you're having trouble sleeping.

Should you ask for a new prescription?

I wouldn't necessarily ask for a new prescription on Cymbalta if I was you in that case.

Paul, I don't want to talk it over with your clinician and say, hey, you know, I'm feeling more anxious and I'm having trouble sleeping and I think it might be related to Cymbalta.

Go back to see when you see and when you started the Cymbalta and compare how you feeling now on the Cymbalta compared to how you were feeling before the Cymbalta?

So sometimes it's a matter of figuring out, you know, is this medication making me more anxious?

Is this medication giving me trouble sleeping Cymbalta is known as a serotonin norepinephrine uptake inhibitor.

It increases serotonin to norepinephrine by a ratio of about three to one.

So it increases serotonin primarily but it does increase norepinephrine.

Norepinephrine is kind like a chemical cousin to adrenaline.

>> Most people know what adrenaline is all about.

Adrenaline will make you more energetic, hyped up, give you a faster heart rate can make you more anxious if you get too much of it if you're not in need of it now keep in mind some people need the higher norepinephrine transmission we do genetic testing sometimes that will pick it up a little bit in terms of looking at the different genes that we test, we can figure out who might need more of the norepinephrine transmission and who might not needed it so much.

Cymbalta is also a medication that goes to a particular metabolic pathway and if you happen to be a slow metabolism through that pathway in other words you slowly are breaking down Cymbalt or Delux team that dosage is going to be much higher than it might be for most people who aren't slow metabolism.

So there could be a genetic propensity in that regard.

It might be just a matter of a dosage phenomenon.

>> Most people do best on Cymbalta for depression at least at sixty milligrams a day but some people get by on thirty even twenty milligrams a day.

Perhaps a lower dosage would be in your best interest but I'd wonder OK you've been on Cymbalta I'd wonder what's it doing for you?

Is it doing you any good in any way?

If it is we might stick with subalterns simply have you to go on the lower dosage as opposed to bailing out on it and go into something else so I'd want to know did it ever do you any good did you feel better on it the first few days or the first couple of weeks and then seems to make you more anxious?

That's usually indicative that the dosage is just too high for you but I always want to make sure that there's a cause and effect there in terms of determining if you still need the Cymbalta or if it's something where you just can get by on a lower dosage.

Paul, thanks for your call.

Let's go our next caller.

>> Hello Nancy.

Welcome to Matters of Mind.

Well, Nancy, you wanted to if you want to know if it was OK to gabapentin before better at bedtime actually Nancy, it's actually preferable for a lot of people to take gabapentin at bedtime.

It's an interesting medication.

It's it's been around since the 1980s and it was originally under the trade name of Neurontin Neuroligin was FDA approved.

>> Food and Drug Administration approved for seizure disorders.

But over the course of time it was found it was a very good medication for anxiety sleep.

It got used for pain.

It got used over the course of time for tightening the jaws called bruxism restless legs.

It's used for many, many different things unlike Clonazepam, alprazolam, lorazepam, all the benzodiazepines which primarily affect Gabb inside a little neuron itself we call it the synapse they effect Gabb inside the synapse drug directly affecting gabbin thereby enhancing chloride flow into the set up giving your brain kind of a calming effect.

What the gabapentin will do is modulate a whole different type of channel called a calcium channel and in doing so decrease the activity of the neuron itself.

So they work in entirely different ways.

But Clonazepam is a medication.

It can be somewhat potentially addictive over the course of time where gabapentin would not be.

So Gabapentin is a medication that works in an entirely different way and it's something that can be taken at bedtime.

>> It's been studied recently with people with early dementia so us older folks, you know, the older we get the more likely we're going to have trouble with memory and concentration in using with early dementia.

The problem a lot of older people will experience will have will be that they have less depth of their sleep.

In other words, they don't go into non REM sleep so much that real deep sleep where your whole body can recharge and if you awaken during that sleep you're very confused.

That's called non rem sleep.

You need to have more of that as you get older and you get less you also need to have more dream sleep over the course of time and as you get older you tend to have less dreams, sleep less dreams.

>> Sleep can affect memory and concentration and very characteristically many people with early signs of dementia will have trouble with getting into a deep sleep and they'll say they don't dream that much anymore.

They just notice they don't dream that much anymore.

>> Gabapentin will help with deep sleep the non REM sleep and it will help with dream low doses for the purpose of getting somebody to sleep within twenty minutes and lasting for about eight hours while during that time giving people a greater depth of sleep and giving them improvement with sleep efficient efficiency which the benzodiazepines like Klonopin and Xanax and so forth they won't give you that kind of quality of sleep itself.

So we're using gabapentin a lot for sleep typically about twenty minutes before people go to sleep and often people don't need that high of a dosage.

>> It can be used anywhere between two hundred and 400 milligrams at bedtime.

Typically the nice added benefit for gabapentin not only does it give you a greater depth of sleep but it also decreases the aches and pains that many older people will experience from arthritis.

They'll have arthritic pain, their joints will hurt.

They take gabapentin at nighttime.

It helps them sleep and it helps them with pain in general.

So we use for those reasons and if they happen to have restless legs it can help with that too.

But I'm always kind of leery when I hear about restless legs and just trying to medicate it with gabapentin because sometimes restless legs I want to know how their iron is doing.

>> If your iron is low you can have restless legs if you are having kidney problems of any kind you can have restless legsn medications that enhance serotonin as a side effect they can give your restless leg.

So when I hear about restless legs I don't want don't want to just medicate it with a restless leg medication.

I want to see if there's any underlying issues that might be overall.

But Gabapentin can be used for all those different reasons and that's why it's a very nice medication to take at bedtime or most people.

As I said, it tends to wear off after about eight hours if somebody feels overly tired, overly sleepy the next morning on gabapentin that's an easy fix.

You just have to take a lesser dosage.

But I have people take typically between 200, 300, 400 milligrams at bedtime but especially it can be useful for the older people and it's metabolized entirely through the kidneys.

It does not need any liver metabolism which is nice because you're going to have well, minimal drug interactions that way and it's something where if somebody has liver problems the gabapentin will not be a factor for those people.

>> Thank you for your call.

Let's go next caller.

Hello Lexi.

Welcome to Mastermind.

>> Let's you want to know about the difference between a phobia and a normal fear.

>> Normal fear is basically where you're naturally scared of something and it's it's something that does not cause you functional impairment.

causes functional impairment where you will avoid it to the degree that it causes you to have difficulty doing things day by day that you wish to do .

Now let me give you an example.

There is the phobia of driving.

There's a phobia of social anxiety where you don't want to be around people if you have that kind of phobia it's causing you impairment your day to day activity that can be a phobia.

>> Fear is a normal emotion, fear, anxiety, sadness, anger, apathy those are all normal emotions.

We should have those emotions in our day to day lives but we should be able to overcome them and they shouldn't be something that define us from an emotional standing so we should be able to overcome those fears, be aware of them, learn from them and with further exposure to those fearful type of sources we should be able to endure them and learn of how to overcome them.

But a phobia is something that sticks with you.

It's functionally impairing.

It keeps you from doing the things you need to do on a day to day basis fear.

>> Yeah, that's just a normal emotion people should all experience now people often say well gee depression for instance we all get depressed.

>> What's all this about people getting depressed?

We hear about this epidemic of depression in the United States going on right now.

What depression is a normal emotion.

>> We should feel sad when our favorite football team loses.

We should feel sad when we have a disappointing event occurring in our life in our lives.

>> So sadness is a normal emotion but when you having sadness hang over your head like a dark cloud and day by day it's just consuming you and goes along with it, you're having trouble with motivation, energy.

You can't eat or sleep properly.

You're having trouble enjoying things.

You will start to isolate from other people.

That's where it becomes a pathological depression for lack of a better term in the psychiatry world we call it a major depression.

I often refer to those kind of depressions as a clinically significant depression one that warrants adequate treatment now treatment for depression, treatment for anxiety disturbances and so forth can be done with various medications but specific types of talk therapies can be helpful.

>> But as I mentioned earlier, don't overlook the possibility there's some other kind of medical disturbance going on because we're always hunting for those other kinds of medical disturbances we often hear about women, young women especially having panic attacks real fast heart rate to the degree that they can't stand up they pass out and people refer to them as having panic attacks as faking neurological symptoms.

All sorts of things will come up from that while some of them can have posture postural orthostatic or orthostatic tachycardia syndrome also known as Pott's.

Pott's is a phenomenon in the kurzer, particularly with young women is thought to be maybe an autoimmune condition but young women all of a sudden have this really fast heart rate.

>> It goes so fast their blood pressure drops their blood pressure drops, they get weak all over.

>> They can't stand up and people will sometimes say oh you just having a panic attack no is a real phenomenon and is treated by cardiologists in a very specific way.

>> So we have to always keep our eyes open for other medical conditions and cause people to have these symptoms of fear and anxiety and depression and even anger for that matter head injuries not uncommon can cause people to be really moody and irritable and angry.

We might treat that kind of anger and irritability from a head injury differently than we might with somebody with bipolar disorder.

>> Some of the bipolar disorder they'll have mood swings where they have these skyhigh manic episodes during the manic episodes they might have anger and irritability and we're going to treat that differently as we would when people have anger and irritability when they had a traumatic head injury.

So it's always important for us to try to dissect what happened in the past to bring on some of these symptoms.

Some people will ask me about medications and they'll say well no, there's no medication causing this or that.

And it's a pretty simple response from myself.

I'll say when did the symptoms start?

Did they start before you took the medication, after you took the medication?

If the symptoms you're having that are unpleasant started after you took a particular medication even though that medication rarely causes those kind of symptoms.

OK, let's have you go off the medication for a few days and see how you do if symptoms go away that probably is the medication.

>> So we have to kind of sort those out in terms of what's causing the anxiety, the fear, the phobias for that matter.

But the phobias themselves are a specific type of instance directed toward a particular object in that object causes extreme anxiety.

Lexi, thanks for your call.

Let's go to our next email.

Our next email reads Dear Dear Father, my father has a hard time taking many, many medications for depression because of side effects is it his head or can somebody be affected by lots of side effects from taking the medication?

Well, if somebody is having a lot of side effects from medications, we want to kind of backtrack backtrack.

>> We can sort out different things.

Number one, we want to know what are the medications, what other uses what are we treating if you're treating a heart condition and you think it's a stomach condition in treating the heart condition with stomach medications, it might not be an effective treatment.

So if somebody has chest pain that chest pain can be from a heart condition.

>> It can be from gastric reflux.

It can be from asthma, it can be from having a pulmonary thrombosis where you've got a blood clot in the lungs.

>> All those symptoms can be related to an underlying condition that's totally unrelated.

And if you treat a condition that you think is related to the heart with stomach medications, maybe it won't help.

That's what we see in psychiatry not uncommonly so the first question I would ask if your father is being treated medications for depression, does he have true clinical depression because if we all take antidepressants we don't have depression.

>> If we all took antidepressants we're going to probably feel worse.

Antidepressants used unnecessarily or used for conditions other than depression can sometimes make you feel worse.

An example can be if you're using medication for depression, for pain you want to use low doses of certain medications if you are too high of a dosage you can actually feel worse.

>> There was actually a study done 30 years ago in Israel where they had everybody takepPr people take placebo and then tey crisscrossed the people who had more depression did well with Prozac.

>> The people who didn't have depression actually did worse on Prozac they felt lousy.

So this whole concept of putting antidepressants in the water should go by the wayside because you don't want to put antidepressants in the water.

>> You want to treat people with antidepressants who need the antidepressants.

I use the same analogy with people with nearsightedness.

If you have nearsightedness and you wear glasses, your vision improves.

But if you don't have nearsightedness and your vision is 20, 20 and you wear glasses, your vision doesn't get any better.

>> It gets worse if you put glasses on so you want to treat conditions if they need to be treated says the first thing I always wonder.

>> Secondly, can some people have more side effects to medications and others?

>> Yeah, I mentioned earlier genetic testing genetic testing can tell who will slowly break down medications who will more quickly break down certain medications and if you slowly break down certain medications you're going to have higher blood levels of those medications as much as five times higher and for those people maybe they shouldn't take that particular kind-of meo they should take a lower dosage so that can be a factor as well looking at somebody's genetics and there is a phenomenon where if somebody has a lot of anxiety there is a little part in the brain called the insula.

It's right here.

There's the thumb of the brain brain's looking at you right there.

The thumb is in the temporal lobe, the yellow part right back here in the crease in the back of the thumb is this area called the insula.

On the top part of that insula is this particular area that overactive.

>> If somebody has anxiety, what will that do?

You'll tend to be increasingly aware of stuff happening around you unnecessarily.

>> In other words, the insula is your part of the brain.

It allows you to be aware of things happening around you and if it's overactive on the top part of it you'll have more side effects from medications because you'll notice little quirks and little nuances with the medication and you'll over interpret what that means.

So there are some people with anxiety who will have more side effects of medication because they're more aware of every single thing is happening in their bodies.

So for those people we need to be aware of that and we're often going to be very sensitive in giving them low doses of medications slowly increasing them being sensitive that they may have more side effects.

>> But it's a real physical phenomenon where if you have anxiety the top part of your insula right there can be overactive and you'll often be more aware of sensory experiences around you.

>> Thanks for your call.

Let's go next caller.

Hello Ben.

Welcome to Matters of Mind.

>> Ben, you want to know how can you can conquer your procrastination this year to set goals that will not leave you feeling depressed if you don't complete them then I just suggest a pretty simple protocol.

>> OK, write down your goals, prioritize your goals.

What do you want to be what you want to do first?

What do you want to do?

>> Second, why you want to do third keep an eye of those goals.

Take a look at them every day or at least every two or three days and see how you're doing with them keeping in mind do you want to get the goals done, get the first done ideally by itself before you go to the second goal, many people will tend to bounce around with their goals then they don't get anything done and we often see this with people with with attention deficit disorder.

People with aid or attention deficit disorder will often bounce from one task to another to another to another and they don't get anything done.

>> So they seem to be really busy.

But when you look at their productivity for the day they haven't got anything done.

So that's where list making is very, very important in terms of maintaining your goals and priorities, know what the most important thing is?

We all have important things to do on our days but we have a prioritization on what really needs to get done today or tomorrow and then on down the line don't go to that third or fourth or fifth goal until you really focus on getting the first one done.

So the whole idea of procrastination is you often procrastinate especially with attention deficit disorder if that's what you're describing then you're procrastinating on things that aren't that challenging, aren't that interesting and we call it vigilance.

Many people with AIDS will get started on something but they lack the vigilance.

They don't stick with it and they don't get it to its completion.

So they like the challenging part.

They like getting things started.

They like the excitement of jumping in there and doing something but then they kind of lose interest over the course of time and they end up not getting that done and not uncommonly they'll go to something else and then something else.

People with attention deficit disorder will often find themselves needing other people around them to keep them on track.

>> Other people around them administratively to make sure they're getting stuff done and we call it with adolescents for instance, we'll call it call them helicopter parents where their parents have to be kind of helicopters over them to make sure they're getting things done.

But from a practical standpoint, keeping a list is always going to be in your best interest to prioritize those and not moving forward to something until you get that done.

So keeping a list would be a good good start with that.

Ben, I love the fact that you're setting some goals but make the goals realistic and make them measurable many times will set these lofty goals.

>> But how do you measure if you got them done you want to be able to measure if you got the goals done don't make them so lofty that they're not even realistic and have a time frame within the next few weeks, the next month when those goals are going to be achieved.

Be careful about making goals five and ten years out.

>> I hear about people making those recommendations all the time.

We don't know we're going to do five and ten years out make the goals over the course of the next three to six months and take them step by step by step because quite frankly bends things change in our life so our goals will always be changing as time goes on.

Ben, thanks for your call.

Unfortunately I'm out of time for this evening.

If you have any questions concerning mental health issues you can write me via the Internet at Matters of the Mind at WFYI Edgard.

I'll see if I can get to your question on the air.

>> We are now on YouTube so if you like to watch this episode or future episodes please do so on YouTube.

Jeff over and I'm out of time for this evening.

Thanks for watching.

God willing and PBSC willing to be back again next week.

>> Have a good evening.

Good night