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

Welcome to Matters of the Mind now in its third 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 have any questions concerning mental health issues, give me a call here at PBS Fort Wayne by dialing in the Fort Wayne area (969) 27 two zero or if you're calling coast to coast you may dial toll free at 866- (969) to seven to zero.

>> Now on a fairly regular basis we are broadcasting every Monday night from our spectacular PBS Fort Wayne studios which lie in the shadows of the Purdue Fort Wayne campus.

>> And if you'd like to contact me with an email question that I can answer on the air, you may write me a via the Internet at matters of the mind all one word at a dog that's matters of the mind at WFA a dot org and I'll start tonight's program with a question I recently received.

>> It reads Dear Dr. Fauver what is normal?

>> Who defines it and who determines it?

Very common question that you'd often hear in a high school psychology class.

So that's a fair question.

What's normal?

Basically the four pillars of normal will be self-sufficiency, happiness, social connections and physical health .

>> So if you look at those four pillars of normalcy, so to speak, you have the self-sufficiency being able to take care of yourself, going to school, going to work, doing things that allow you to be able to make a living and be able to take care of yourself.

That's considered to be normal if you get into a position where you're a mentally or physically incapable of doing those type of things, well that's considered to be a health disorder if the condition itself is preventing you from maintaining self-sufficiency.

Secondly, pursuing happiness I mean that's in the Declaration of Independence but the pursuit of happiness is something that we all should be striving to pursue within our within our means.

>> So the pursuit of happiness is often limited.

I see it all the time when people have a mental health disturbance people have difficulty with depression and anxiety and thereby they have difficulty having fun.

They have trouble doing things they enjoy doing.

They give up the things that are enjoyable and the more you give up pleasurable activities the more likely you're going to have more depression.

So the lack of pleasurable activities actually feeds on more difficulty with mental health problems and that in turn will lead to a higher likelihood of having cognitive disturbances such as dementia.

>> So we've got the self sufficiency, the pursuit of happiness being two pillars of wellness or normalcy.

>> A third pillar would be the ability to maintain social connections and social relationships.

It's not considered to be normal to be a hermit if you have the other pillars that are also impaired.

>> So if anxiety, depression, some kind of mental disturbance causes you to be fearful of other people to be more of a recluse where you want to stay away from other people and you can't socialize, that's considered to be possibly a problem for people and finally maintaining some kind of physical activity within your age limitations as we get older.

Sure we're going to be more likely to have difficulty getting around and doing the things we might have done when we were younger from a physical standpoint.

>> But as you have physical limitations to a greater degree than would be expected for your age, that's considered to be an impairment of some type.

So the four pillars of being normal will be no one have being able to be self-sufficient no to the pursuit of happiness.

Number three maintaining social connections and number four, having the physical means of being able to do what you need to do within your age limitations.

>> So that's what we often consider to be normal.

Now who defines that?

>> Well, you can look at social norms and you can look at the so-called bell shaped curve where some people aren't doing so well in terms of what other people are doing.

Other people are doing exceptionally well in various areas.

>> But yeah, there's a normal variant in terms of how well people are able to socialize and enjoy themselves and those type of things.

>> So you can look at that as a psychiatrist I will often look at somebody prior to functioning and if they were previously functioning at a higher level and all of a sudden they're deteriorating and they're functioning with socialization, joy of happiness if they're having trouble being able to do the things they used to do, that's often an indication there's some kind of problem there that's evolved now you'll hear about some people who have always had difficulties with socialization, finding joy in life and goes back to their early childhood.

That might be a whole different issue but in psychiatry will often determine that somebody having some kind of an impairment when is a significant impairment or a drop off from their prior functioning.

>> Thanks for your call.

Let's go to our first caller.

Hello Jeff.

Welcome to Of Mind.

Well, Jeff, you had mentioned that you have a relative who has schizophrenia received shots to balance them out.

How do the shot treatments react to in effect is schizophrenic symptoms and what are these medications?

These are the medications, Jeff, that tend to give a long lasting effect and the medications that are now available for schizophrenia typically will last well at least a month, sometimes three months and we have these longer durations of action and what's happening there, Jeff?

>> I get these injections and they will slowly release over the course of time and the medication release is the very same type of medication.

>> It's being released in the oral form.

Here's the problem with schizophrenia, Jeff.

There's an impairment in the so called awareness center of the brain which is mainly here on the right side.

It's called the insula.

Insula is over here on the right side of the brain right tucked inside there between the temporal lobe and the parietal lobe and that's the area of the brain that allows you to be aware of things happening around you and aware of any difficulties you're having yourself.

And if you combine that with the right front part of the brain that allows you to maintain that social connection.

These are the so-called mirror neurons up here that allow you to mirror the behaviors of other people and you pick up that you might be having some disturbances in communicating with people.

>> Schizophrenia lack those areas so people with schizophrenia often lack the awareness that they are indeed having difficulty with an illness such that well they won't take their pills.

They say oh I'm a problem.

So they quit taking the medication and very subtly they'll have difficulty with those delusions or fixed false beliefs coming back.

They'll start hearing voices that to them are normal and they determine they're functioning and the more they deteriorate the more trouble they have with their judgment.

>> So schizophrenia if you consider it to be a condition of self awareness and a condition of difficulty of insight, foresight, that is a reason why some of these people need long acting injections to allow them to feel normal over the course of time.

So we have Abilify we have in Vegas injections that will last for long period of time and those are the most common types of injections people getting the exact same medications they get the oral form Abilify and Enviga are medications in an oral form.

These medications have basically been packaged such that in an injection formulation they can be slowly released.

>> Jeff, thanks for your call.

>> Let's go our next caller.

Hello Alisha.

Welcome to Matters of Mind.

Yeah, this is Alicia.

I was once a psychiatric nurse and here a while back for quite a while and I developed now that I'm off of IV TB and I'm on this and for those not doesn't seem to be helping get better it can.

>> Alicia, how long have you had the tardive dyskinesia?

>> It's been about a year now.

OK, and how long do you think you're on the medication for schizophrenia or the dopamine blockers?

>> Oh, a few years.

Were you on the medication specifically for schizophrenia, Alicia or you were on the medication for bipolar disorder and was anxiety most yeah.

>> Antipsychotic medications are used not only for schizophrenia, Alicia, but as you know commonly used for bipolar disorder.

Some people are genetically more prone to developing tardive dyskinesia from the antipsychotic medications, especially if they have a mood disorder.

>> There's a particular gene we look at called the D2 gene and if you have a mutation at that gene, sometimes it'll be a predictor.

>> However, Alicia, there's other predictors as well.

No one if you have a mood disturbance as opposed to schizophrenia, you actually more likely to develop tardive dyskinesia with antipsychotic medications, antipsychotic medications basically block dopamine and when you block dopamine receptors, more receptors will kind of out over the course of time.

>> It's called up regulation but when more receptors out sometimes in particular parts of the brain as part of the brain in here called the substantia nigra if you get too many dopamine receptors budding out in that area, you can have some of the twitchy movements that you're describing with tardive dyskinesia, with tardive dyskinesia.

>> People can have hard blinking.

They can have twitches in their mouth.

They can have tongue rolling movements.

>> They can thumb sometimes shrug their shoulders.

They can have disturbances where they will have finger movements that are kind of like they're playing the piano at a time we call in Korea form movements and these movements will be most prominent when you're not really thinking about them.

If you think about trying to keep the movement still you can do that in these people with tardive dyskinesia won't have these kind of movements while they're sleeping.

So basically this is a condition, Aleesha, of overactive dopamine transmission.

>> You have too many dopamine receptors and you're getting too much stimulation the dopamine receptors and in the movement center of the brain that will come across as tardive dyskinesia.

What happens, Aleesha, while you're taking antipsychotic medications?

You don't notice those movements at all.

Why?

Because antipsychotic medications blocked dopamine receptors.

>> So one way of getting over the movements themselves as you are likely aware is to just keep taking antipsychotic medications but just keep taking more and more and more of them.

Well, as you know, that just makes the condition were so Alysha, the first thing we will often do is get people off the medication very slowly as long as their mood can handle it, as long as they don't have the symptoms come back because with bipolar disorder, for instance, we not only use antipsychotic medications but we use antiepileptic or anti seizure medications and we use lithium .

So the three types of treatments for bipolar disorder for mood stabilization will be antipsychotics, antiepileptic medications and lithium so frequently will move people over to lithium or antiepileptic medications if they don't seem to be able to tolerate the so-called antipsychotic medications to antipsychotic medications have been shown to potentially decrease the likelihood of having tardive dyskinesia or at least alleviating the symptoms one being Clozaril and another one being Zyprexa and a newer medication called Carolita might be have some potential with tardive dyskinesia as well.

We haven't looked at that one so much over the course of time but you can take those kind of medications to actually block the dopamine receptor some kind of ease off the brake and allow the dopamine receptors to decrease the number over the course of time.

But you're probably aware of medications like like new plasmids that can decrease the likelihood of tardive dyskinesia symptoms emerging.

Basically what it is doing is decreasing the dopamine transmission so that it's not so prominent that you'd have difficulty with tardive dyskinesia medication that have that mechanism sometimes will work, sometimes they won't but they will specifically use be used for the purpose of relieving the symptoms of tardive dyskinesia.

So we have those kind of medications out there to try to relieve tardive dyskinesia.

>> But the first thing will always be done is to try to stay off the psychotic medication long term, especially if you don't have schizophrenia, if you have schizophrenia, yeah, we'd keep you on those medications and try to work around those tardive dyskinesia symptoms.

But if you have a mood disturbance like a bipolar disorder, yeah, there's other treatments for it.

>> In the meantime you try to deal with the tardive dyskinesia symptoms the best you can.

Can there be other treatments outside of medications that will reverse tardive dyskinesia specifically?

Yeah, there's medications like Clonidine that has been used over the course of time.

Klonopin is a benzodiazepine antianxiety medication.

It's been used vitamin E has been discussed over the course of the past twenty years but overall we try to treat the symptoms very directly and try to get them under better control with medications that are going to be more specifically used for tardive dyskinesia.

So talk to your clinician about the potential possibilities out there for the relief of of tardive dyskinesia itself.

But the longer you stay off the antipsychotic medication the more likely and the hope is that those little dopamine receptors will come back to normal and normalize out so you won't have those abnormal movements like that.

But it is something we see occasionally there's the risk factors we hear about with tardive dyskinesia who's going to get it while the people who have difficulty with a mood disturbance versus schizophrenia are more likely to get people with this genetic mutation at the D2 gene are more likely to have tardive dyskinesia.

It's thought the people with diabetes are more likely to develop tardive dyskinesia.

So we have risk factors that are out there as we get older we're all more likely to get tardive dyskinesia a predictor early on of tardies dyskinesia would be if you got extra pyramidal symptoms from your medication.

In other words, if you start taking the medication or for a mood disorder and it's an antipsychotic medication, you start taking it and it gives you shakiness and you have what's called kog feeling where you get kind of stiff and you don't have much facial expression you might have some difficulty with shuffling in your in your gait where you kind of shuffling your gait and you don't use much arms swing if you take a medication and it causes those kind of side effects that might be a predictor later on of getting tardive dyskinesia.

So we're always looking for that.

There is the skill called the abnormal involuntary movement scale, the aim scale that we do for people over the course of every three to six months typically if they're on an antipsychotic medication blocking dopamine, what we're doing there is we're trying to examine people for tardive dyskinesia movements and I've heard the the apprehension about video visits more recently since the covid restrictions that occurred March of twenty twenty we started doing more video visits for people and a lot of folks were apprehensive that we couldn't do these EAMS evaluations.

>> We could do the evaluations just fine by video visits.

So the video visits don't restrict us from doing an evaluation like that.

We can simply ask a person over the video screen to demonstrate certain movements for us and we can certainly see those tardive dyskinesia movements so we want to catch tardive dyskinesia early.

>> Aleesha if we see it we want people to taper off of the medication the best they can and then if they still have the tardive dyskinesia we've got some ideas on what can be used to try to relieve some of those symptoms so we do the best we can to try to get those under control.

>> Alicia, thanks for your call.

Let's go to our next email question.

>> Our next e-mail question reads Dear Dr. Farber, why are there so many different kinds of medication for treating depression and anxiety?

>> Is it possible for none of them to work for me?

>> Well gee since nineteen eighty seven there have been 16 oral antidepressant medications come out and we have antianxiety medications that are often overlap with the answer oppressive medications.

The anti anxiety medications historically have been the barbiturates from a long time ago and then we have the benzodiazepines that started coming out of the 1960s.

Those are medications like Valium, Xanax, Klonopin, Ativan, seracs.

>> My goodness, what all those medications do is they will go to this anxiety and fear and anger volume control right here on the brain called the amygdala and the amygdala is an almond shaped body.

Amygdala in Latin means almond shaped and it's basically the volume control for anger, anxiety, fear and and guilt rage all that's basically right here in the amygdala what the benzodiazepine medications do is they go right there and they turn that down and people feel less anxious.

>> Now that sounds great but the problem is if you take these medications regularly for over a couple of weeks you can kind of get used to them and next thing you know you're going up and up on the dosage.

And secondly, we've just realized this in the past few years.

The longer you take these kind of medications, the more difficulty you can have with your memory and concentration such that it can give you the cognition or the ability to think and remember things and be able to maintain attention.

>> It can give you the cognition of somebody who's mildly inebriated with alcohol so people can kind of go through life with this difficulty with thought processing and being able to process information.

They're going to have trouble at attention span memory executive functioning which refers to judgment and decision making overall.

And if you take the benzodiazepines long term you can have all those problems.

So for anxiety that can be an issue.

The antidepressants will all do different things.

My goodness, the antidepressants primarily will affect dopamine, norepinephrine or serotonin.

Now we have antidepressant medications like ketamine or ketamine injections that will affect glutamate.

We have a medication that's in development right now that to be used for depression called dextromethorphan and dextromethorphan will be in a medication formulation and it will mildly affect opiate receptors in a non addicting manner.

But the main thing it will do is it'll affect the glutamate system to allow people to be able to have better concentration, to have less anxiety and to have less depression.

It'll work entirely differently than anything else.

So we're looking all these different mechanisms of action for depression for people from neuro neurochemistry standpoint.

>> But when I hear somebody tell me that nothing has worked for depression or anxiety, the very first thing I want to do is go back and look at OK, the underlying symptoms and I want a very carefully dissect what might be going on underlying the depression and anxiety.

For instance, I've seen over the course of my career a lot of people who had so-called treatment refractory depression they had been on eight , nine , ten different antidepressant medications.

Nothing was working and we simply did a sleep study and we found that the person sleep apnea sleep apnea is where you're not getting adequate airflow to the lungs at night because you're snoring or you're closing off your airway that decreases your oxygen to your brain and then the next day you can have trouble with low motivation depression, poor concentration, irritability and it comes across as depressive symptoms.

But it's really just sleep apnea and you have to be able to treat that accordingly and it's a very treatable condition.

Some people have metabolic disturbances like low thyroid diabetes.

I saw a lady today that had very low iron and if you have low iron that's going to make you tired.

>> You can't concentrate.

It'll make you depressed.

So when I hear somebody say nothing works, it might have been that they tried a lot of different medications.

But you have to look at the underlying things that might be going on.

We always want to look at the family history.

Did other people in your family have similar symptoms?

If they did, that's a huge tipoff that what you might be experiencing is something that indeed is genetic and we want to look for what did work and what didn't work for your family members.

It's a very important part of our evaluation because if you know what medications or what treatments did work or didn't work for your family members who had similar symptoms, that's an enormous tip off on what might work, not work for you.

>> We want to look at any any type of ways you might be self medicating.

>> In other words, if you're knocking down six hours a day to try to treat your anxiety or help you sleep at night, that might be a factor in your having more anxiety and more depression because alcohol even though initially gives you that calming effect it gives you a rebound effect will make you much more anxious and alcohol is a depressant will make you more depressed in the long run.

Same with cannabis or marijuana.

Many, many people especially as marijuana is becoming more acceptable in some states due to their recreational availability.

Marijuana is being extensively used for anxiety and people will give you all sorts of reasons why they're using.

But the bottom line is these same people often have trouble with concentration.

They'll have trouble with feeling depressed.

They have less motivation.

They don't want to go and go to work and they start to have some of these psychiatric disturbances for which they seek our care when underlying all of those problems might be there marijuana.

So we want to look at any substances or any alcohol they're using.

We also want to make sure that we're on the right track.

Do you really have depression?

You really have an anxiety.

You might have what's called bipolar depression where you're having highs and lows if you take antidepressants after antidepressants, after antidepressants and they all make you feel worse if anything it might be that you're having mood swings where you're going high and low and when you're having highs and lows you need more of mood stabilizer as opposed to an accelerator on the mood if you simply take an antidepressant medication and you have bipolar disorder where you have highs and lows, you'll actually get more moody and more irritable and then you'll say the antidepressants didn't work.

There's a particular type of anxiety condition called post-traumatic stress disorder.

PTSD or post-traumatic stress is due to your having a traumatic event sometime in your life and that traumatic event keeps coming back to your mind.

You have memories, you have flashbacks, you have nightmares .

You're always on edge wondering if those kind of events are going to happen again and if you treat from a medication standpoint post-traumatic stress disorder with a so-called benzodiazepine like Ativan, Valium or Xanax, it actually makes the memories worse and it we call it it embeds the memory more tightly that way.

So you don't want to take those kind of medications for that kind of anxiety.

So we always have to consider what kind of depression do you have?

What kind of anxiety do you have, what your family history, what your background, how long had been going on?

Are you medicating with alcohol or some kind of substances like like marijuana and you put all that together and try to come up with a clearer picture but it's rare that we we actually find somebody who truly doesn't respond to anything.

>> And if you have somebody who's at treatment refractory, we will often go a whole different direction and that's where we often have to think outside the box.

If you haven't responded to traditional treatment, the potential is that well you're just not a candidate for the traditional treatment because perhaps you have sleep apnea, low thyroid.

Do you have something else going on that indeed would not respond to traditional treatment?

>> Let's go to next caller.

Hello Ron.

Welcome to Mars.

The uh yes sir.

I was wondering about some of the facilities that are starting to open back up.

I have like agoraphobia and bad anxiety.

I don't drive.

I didn't know if that was true for all facilities but anyway, I was also wondering about like a burning and itching that started out in my feet and as we moved up into my hands and face I've tried some different medications seems to get worse and also a blurred vision comes and goes right.

>> If you had your blood sugar checked with all this going on.

Yes, I have.

Good.

That's first thing I always check when people have blood sugar abnormalities they'll often have blurred vision and as it progresses you can get what's called diabetic neuropathy which can be manifested by a burning and sometimes an itching sensation ,mainly a burning and tingling sensation in the hands and feet.

So we always want to consider that Ron, I'd certainly suggest you talk it over with your primary care clinician, see what kind of options could be there as a psychiatrist.

Yeah, sometimes we see people have burning and itching as a manifestation of anxiety because anxiety sometimes will release histamine in the skin and when you release histamine histamine of the skin it can cause you to have difficulty the sensation of burning and itching for some people who are prone to having anxiety and they have an increased heart rate, they have even panic attacks for that matter we might use a medication as a so-called beta blocker the blocks adrenaline propranolol atenolol metoprolol these are all medications that block adrenaline and in doing so they can sometimes make you less prone to having burning itching anxiety in the hands and feet.

But that's kind of a long shot I'd want you to first see your primary care clinician to look for any metabolic or medical kind of conditions.

Well, sometimes you're about a condition called low vitamin B 12 that can sometimes cause these kind of conditions.

So you want to make sure you get a vitamin B 12 level and the B vitamins in general sometimes if there's a disturbance there that can be a manifestation overall.

Now some of the offices were closed over the covid restriction times.

Now we're into August of twenty twenty one so in August of twenty twenty one offices indeed are opening back up.

But quite frankly one thing we learned during the cold restriction time is that we can do a lot of video visits for people in the federal government really relaxed the restrictions on video visits such that is not uncommon for some offices especially in psychiatry to be doing up to 70 percent video visits now.

So video visits should be readily available for people with agoraphobia who are having difficulty getting out.

So at least you can talk to your clinician by HD quality video and be able to have that same type of interaction hopefully that you would have in the office.

So I think that's a game changer for a lot of people such as yourself fraud if you're having trouble getting out of the house, a video visit can be ideal.

Ron, thanks for your call.

Unfortunately I'm out of time for this evening if you have any questions concerning mental health issues that I can answer on the air, you may write me via the Internet at matters of the mind all one word at a dot org.

I'm psychiatrist Jay Fovea and you've been watching Matters the mine on PBS Fort Wayne God willing and PBS willing.

>> I'll be back again next week.

Thanks for watching.

Have a good night