good evening.

>> I'm psychiatrist J5 are live from Fort Wayne , Indiana.

Welcome to Matters of the Mind.

Now in this twenty 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.

>> PBS Fort Wayne by dialing in the Fort Wayne area (969) 27 two zero or if you're calling any place else coast to coast you may dial toll free at 866- (969) to seven to zero.

>> Now on a fairly regular basis we are broadcasting live every Monday night from our spectacular PBS thirty nine Fort Wayne studios which lie in the shadows of the 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 WFB Dog that's matters of the mind at about a dog and I have oh the first of a few emails that have come in tonight.

Let's see the first one the first email reads Dear Dr. Farber, what's the future of video visits in medicine?

What are the pros and cons?

I think I got this question several months ago so I'll be happy to answer it again.

Here's the history behind this.

We've had the technology to some degree available for video visits going all the way back to the nineteen nineties and here's a video visit is a video visit is where you pick up your smartphone, you open up your laptop and you talk to your physician, your nurse practitioner, your advanced practice nurse or advanced practice practitioner and you talk to them in such a way that you would in the office.

OK, so the drawback of it you won't have the physical examination part of it but you can at least talk to them about things that don't involve the physical examination aspect, although there are some aspects of physical examination that we as clinicians can do just by looking at you on the video.

>> Now over the course of the past twenty years the video visit technology has advanced dramatic glees such that the quality of the video visits now will be HD quality.

>> When I first saw video visits and action back in the 1990s I was visiting a clinic in the rural Colorado and I was just amazed how they could actually interview people several counties away from this one particular office.

What we do now is we have clinicians as long as they have a license in the state where you're located they can see you from anywhere.

>> So we're no longer geographically confined to hiring clinicians who are living geographically in the area over the course of time we found that since Fort Wayne doesn't have mountains and oceans we have a hard time recruiting some physicians here compared to other parts the country.

So for that reason we can possibly recruit clinicians from other parts of the country as long as they have an Indiana license to be able to work in this area.

So it gives us an opportunity to be able to expand our network of opportunities for other clinicians who simply have an Indiana license so as a patient and gives you the accessibility to see clinicians outside of the usual realm that you might notice.

Now when we talk to somebody on a video visit we often will precede that visit by a couple of days of the request for the completion of several questionnaires.

>> The questionnaires basically are how are how are you doing questionnaires and as a psychiatrist the questionnaires will include questionnaires about depression, anxiety, sleep, how you're functioning overall, how you're concentrating.

Are you drinking alcohol use marijuana?

>> Are these type of things going on such that it can help me assess you from a full spectrum standpoint without having to ask you question by question by question during an interview and with the video visits since you have a couple of days to be able to complete those questionnaires gives you time to think over those things so the appointment won't seem as rushed for you when come in to see a clinician and many people will say it's much more efficient for them to be seen by video.

They'll say they can stay at work and just see us by video over a break or over a lunch break.

They don't have to get child care.

They don't have to drive into our clinics.

They don't have to find a parking space and rush in to the office if they get stopped by a train that's sometimes an issue and they're not having to run behind more often than not when we do video visits we're actually running ahead of time because people will actually get online at five, ten minutes earlier and allows us to be able to run on time as well.

You might wonder sometimes why do physicians why do nurse practitioners run behind on occasion during the office visits?

It's because when patients show up five or ten minutes late, one after another after another that will get us behind and also somebody might need more time.

I mean there might be in crisis that might need to be hospitalized and some patients just do require more time than others and that sometimes cause clinicians do run behind with video visits that's less the case because with video visits people are often signing online a little bit sooner because they're not having to drive in.

>> They're not getting stopped in traffic.

>> They're not getting having the inconveniences of having to drive into the office.

So they're running on time more because they're just picking up their smartphone and getting online and it allows everybody to run more efficiently that way.

Now the drawback yeah, we can't do the physical examination as much and that's a somewhat of a drawback so so that if you're seeing somebody in a primary care office for instance, primary care clinician can do the physical examination in the mental health field we have less of a need to do that directly.

There are times where we need to maybe check a person's thyroid and see how it feels but for those individuals we can arrange for an office visit.

But quite frankly I think video visits are going to be the wave of the future.

The federal government allowed us to start doing video visits the end of March of twenty twenty .

What was happening then that was the pandemic.

So the federal government well gave us the OK as clinicians to be able to complete assessments by video visits and once the federal government allowed that private insurance companies did so as well.

So we're doing more video visits now.

>> They appear to be around to stay for a good long time.

Thanks for your question.

Let's go to our first caller.

>> Hello, Bridget.

Welcome to Matters of Mind.

Hi.

Hi Bridget.

My mother takes yeah my mother takes gabapentin.

She's ninety four and she takes triacetone and she takes bar and a half and avan and blood pressure pills and they take she was taking too much and we couldn't wake her up.

Oh and they took her to the emergency room now what medicine should she be off.

She can't take and get off the pension because she burns awful because she has the rapidly yeah.

>> I don't know which one to choose from.

You had mentioned Trazodone and you had mentioned gabapentin specifically for sleep.

>> Now you had also mentioned another medication was a Kozhara by chance.

>> No it's burst are obese Pasdar got you in an event a half a milligram so I thought that and and lower the dose on the track I'm not the president the tramadol I meant to say OK so she's taken Tramadol she's taken lorazepam or Ativan beuse bar bu Spierer it is another name for that as well as trousered and gabapentin of that combination giving my right feel bleachers perspective on this number one I would want to see a ninety four year old person coming off the Ativan or lorazepam.

I think she can get adequate anxiety relief by using the gabapentin which we commonly use for anxiety but as you know it's remarkable for neuropathic pain for some people and we also use gabapentin for sleep so gabapentin can be used for anxiety, neuropathic pain and for sleep and using that hopefully she could get off the Ativan or Lorazepam.

>> That would be my first priority.

My second priority would be to have her come off of the Tramadol that's also known as Altrincham and coming off the Tramadol could be helpful because it has some serotonin and norepinephrine activity but it primarily will kind of tweak the MMU receptor of the opiate receptors so kind of effects it's kind of like a light narcotic in that sense and that would be my second priority to try to get her to stop and being able to use the gabapentin as a safer alternative.

She's also taken you Spierer Antabuse bar that's for worry and anxiety typically not a problem doesn't cause people confusion over sedation but Spirent Abuse Bar really will affect one of these fourteen different serotonin receptors and in doing so could make a person a little bit less worried about things without sedation and without with concentration.

TriZetto It's a pretty effective and safe medication for sleep for a lot of people and you can use it throughout your life .

Trazodone is typically used at doses between twenty five up to one hundred milligrams at bedtime for sleep.

Trazodone was originally studied and approved for depression back in nineteen eighty one but by the end of the nineteen eighties we realized it was a remarkable medication for sleep.

It helps you get to sleep within 30 minutes, gives you a deep good quality of sleep, gets out of your system typically by the next morning as long as you've not taken too much so Trazodone can be used for sleep but the least of my concerns of all those medications Jill, would be the use of the gabapentin because gabapentin is a medication that can be used for anxiety, for sleep and for pain in her case.

So gabapentin could be medications because she could stay on.

But I talk to your talk to her clinician about the possibility of stopping Lorazepam number one and maybe trying to really limit the use of the all tram as much as possible.

>> Thanks for your question.

Let's go to our next caller.

Hello, Joe.

Welcome to Matters of Mind.

Joe, you wanted me to define and elaborate on schizotypal disorder, I believe you're saying and its similarities and differences with schizophrenia schizotypal disorder.

>> Basically Jill is a condition where you have a personality disorder which is there throughout the your entire life .

It starts in the late adolescence years and it will cause you to have difficulty being around people because you might be a little bit more fearful than you might be expected to be and you have oddities in your behaviors.

It gives you difficulty with socialization with other people but you don't care about those difficulties with socialization with other people because you don't really care.

>> Now that's different from schizophrenia and people with schizophrenia often have an authentic desire to want to be around other people but they have difficulty with processing information in their brains and they have difficulty with conversing with people because they're going on one topic to another to another.

>> People are schizotypal personality disorder will not do that as much.

People with schizophrenia will often hear voices talking to them and they'll have these fixed false beliefs where they have these and these perceptions of things are happening around them but they're not accurate and they're obviously false and they're fixed because you can't talk them out of a people schizotypal personality disorder as you said, they'll have oddities and behaviors.

They'll have some odd perceptions but they won't be outrageous.

They won't be bizarre.

They can be kind of realistic but they'll come across to other people as being kind of unusual.

But they don't have what we would consider to be a a mental illness that would warrant the use of an antipsychotic necessarily.

>> However, Jill with schizotypal personality disorder there are some studies showing that if you have schizotypal personality disorder, for instance in your late adolescence, early 20s, that can be a precursor to the possibility of schizophrenia.

In other words, people who develop schizophrenia as they often do in their early 20s that's when you'll often see the onset schizophrenia.

These people prior to that for several years will have these oddities of behaviors.

They'll have what we call autistic mannerisms where they are kind of finding it difficult to relate to other people and communicate with other people.

They have difficulty with tolerating stress which is a very autistic type of symptom.

People with autism typically have tremendous difficulty with change and because the difficulty with change they'll have these repetitive movements and repetitive behaviors that come across to some people looking like tics but they're not really tics.

They're basically means by which they're trying to relieve the anxiety related to the changes in their environments so people with schizophrenia will have those autistic behaviors and you'll see those kind of emerge over the course of time when people have had schizotypal personality disorder.

But a personality disorder is a day to day type of disturbance gives you some type of functional impairment meaning you have difficulty with socialization maintaining a job, going to school, doing things you need to do and it gives you functional impairment to the point where it can be problematic and you're being able to succeed in various areas of your life .

>> Joel, thanks for your call.

>> Let's go to our next e-mail question.

Our next e-mail question reads Dear Dr. Fauver, are there any symptoms of autism?

>> Oh, we're just talking about autism that are similar to Torretta syndrome.

I think you'd mentioned that I well, I was alluding to some tics and twitches with Tourette's syndrome that can overlap with autism in some cases that's true.

Do people on the autism spectrum ever show signs of Tourette's syndrome?

>> You'll hear about that overlap some time.

About one out of a hundred people in the population have Tourette's syndrome one out of 50 and sometimes it's going I'm hearing that's went on to one out of forty.

People can have autistic features.

They are different but they sometimes will kind of overlap but they are different conditions neurologically and from a neurobiological standpoint autism as I just mentioned is a condition where people will indeed have difficulty with communication.

>> So I have trouble with tolerating stress.

They'll have difficulty interacting with other people and they can have repetitive movements as a means of trying to overcome the anxiety related to changes.

So if you think about autism, the extreme is where people have severe autism and it's very noticeable they did a movie years ago with Tom Cruise and Dustin Hoffman called Rainman and he had autism.

He has a savant type of ability which some people have autism will exhibit where they have tremendous abilities to remember things and that was the basis of that movie which was based on a true story.

So people with autism will have tremendous difficulties with changes in their environments.

>> They like things to be the same.

People with autism don't do so well on these so-called antidepressant medications that increase serotonin such as Zoloft, Lexapro, Prozac.

You know, for people anxiety those medications can sometimes help with autism not so much people with autism do better on the so-called second generation antipsychotic medications and they also do better on medications that help you put up with stuff like Lamictal or Lamotrigine and it's an anti epileptic medication that stabilizes the chemical glutamate and it seems like they're doing better with that overall the with autism basically it's a condition or the right front part of your brain lacks these particular sets of neurons called mirror neurons.

Mirror neurons like the name implies has to do with being able to mirror the behavior of other people.

So when you're talking with somebody you should normally be picking up their mannerisms, picking up their inflection to their voices.

You should be able to mirror what they are saying and doing and in such a way the way we interact with people is sometimes by mirroring the behavior of others and that's how we form more of a connection with them.

People with autism lack those particular neurons and they have difficulty with making that connection with other people from an interpersonal and from a social standpoint.

So with autism it's a disturbance where people will have difficulty with communication being able to interact with other people because they can't mirror the behaviors of others and they'll have repetitive movements as a means of trying to alleviate the stress of changing in their changes in their environment.

>> Tourette's, however, entirely different phenomenon with Tourette's syndrome.

It's where people will have some type of physical tic or twitch and on top of that they have some kind of vocal impairment where they will have grunts they will use profanity on occasion.

That's a real phenomenon and basic with Tourette's syndrome and so the front part of the brain being affected, it's more the middle part of the brain, the basal ganglia.

So are threats syndrome.

We will indeed treat that with a dopamine blocking agent because it's thought that people with Tourette syndrome have an excessive transmission of dopamine and to some degree norepinephrine.

So we try to block that with dopamine blocking medications whereas with autism it's a different phenomenon.

>> But what you hear about will be the combination sometimes of autism and Tourette's but repetitive movements that people are having with autism when they're under a lot of stress.

We have to make sure we don't misdiagnose those as Tourette's because sometimes people with autism they'll they'll slap at themselves, they'll bang their heads against the wall.

They do that as a means of trying to relieve the stress related to the change in the environment.

>> And as I often tell people, you know, when they're trying to hurt themselves, when they're slapping themselves, when they're hitting themselves, when they're banging their walls, what they're trying to do and in those cases is they're trying to distract themselves from the emotional trauma that they're experiencing the emotional distress that they're experiencing related to the change itself.

Now we have a fancy term for that in psychiatry it's called stress tolerance.

When you have poor stress tolerance, you're having difficulty adapting to the change of things happening around you.

>> So when something is changing around you we should be able to adapt.

We calmly process in our brains.

OK, I've been through this before based on what's happened before my past experiences.

Here's how I'm going to deal with this situation.

That's how you're supposed to process that information and process process that information the front part of your brain if your front part of your brain is not adequately working, that will cause you to have difficulty making the best decision and then if the front part of brain's not working to help you, the decisions what happens the amygdala in your brain, the anxiety volume control kind of hijacks everything else so the amygdala takes over anxiety overwhelms you and that's the same part of the brain that's related to anxiety not only anxiety but also fear, anger and fear for that matter.

>> So anger, fear and anxiety can all come from the amygdala if the volume gets turned up too high and when the volume gets turned up too high on the amygdala then you can't think so it's a vicious cycle if you can't think your emotional volume control takes over, if your emotional volume control takes over, it's all the more difficult for you to be able to think and process through the information, try to make good decisions in those ways.

So that's why from a medication standpoint we're trying to get that balance back with the brain from a medication perspective we're trying to allow the front part of the brain to get back on track to be able to process information.

So in those cases not only can you make decisions but if you do go into counseling and go into therapy, you're able to apply the information that the therapist is trying to advise you.

>> Thanks for your question.

Let's go to our next caller.

Hello Ryan.

Welcome to Mars The Mind.

Hi.

I just had a question about restless legs.

Yes.

Remember my family has had restless legs for about ten, fifteen years, has taken a lot of medications, tried a lot of different things.

She still kind of dealing with it so I was wondering if you had any recommendations.

>> Amy Ryan as a psychiatrist I will hear about restless legs in a lot of situations because no one some of our psychiatric medications will actually cause restless legs as the side effects.

I need to be aware of that.

And secondly, we'll hear about having people having difficulty with sleep.

>> If you have difficulty with sleep due to restless legs, you can have trouble with depression and all this cascade of symptoms that follow insomnia.

So the medications that give you restless legs will be medications basically enhance serotonin.

So if you're taking a medication like Lexapro Zoloft, if your family members taken Prozac, these are medications by increasing serotonin can increase can indirectly decrease dopamine and in doing so that can give people restless leg.

So we're always going to be looking for the serotonin medications out there that might be contributing to restless legs.

Secondly, I mentioned that when people have restless leg they can have difficulty with sleep.

So we will try to examine with restless legs are they occurring particularly in the evening and at bedtime?

For some people it's only in the evening other people's evening and bedtime and that can make a big difference.

I don't know why there's a circadian influence on restless legs but for whatever reason tends to affect people more in the evening and at bedtime we try to separate out OK, is it more of the evening or bedtime for people?

>> But Ryan, there's two things I always always always want to assess for somebody having restless legs the first thing we always assess will be if they have low iron, if a person has low iron it will give you horrific restless leg.

So you need to get an iron level check for your family member and secondly we'll make sure their kidneys are working OK if you have a little bit of lack of kidney functioning in the kidneys aren't working so well that will give your restless legs.

>> So overall we'll look at iron test, we'll look at kidney functioning.

You definitely want to make sure we're taking a good look at any difficulty with serotonin, the medications and then if you do have all those things ruled out and it just restless legs for whatever reason it's a dopamine disturbance where we will give people medications that do enhance dopamine transmission either the old Parkinson's medications sentiment as an old medication caba dopa levodopa that's been around for a long time that can help with restless but we'll use these medications that are very specifically and selectively will stimulate dopamine receptors.

So you'll hear about repacks Mirror PEX.

These are medications that specifically will stimulate the dopamine receptors.

Prema Pixel is another name for that type.

Those type of medications they are going the dopamine receptors in stimulating those.

We'll have people take those kind of medications in the evenings for the purpose of trying to get some relief with restless legs and sometimes people will go to a different mechanism of action to try to help with restless legs and use medications such as Neurontin or Gabapentin Horizon.

It is a long acting type of gabapentin or it's a gabapentin.

It will get better absorbed overall that's used specifically for restless legs.

Release is another medication.

It has the same type of mechanism that you'll hear about with gabapentin.

Lyrica sometimes gets used as well but we're always trying to figure out are there preventable means of trying to alleviate the restless leg symptoms because you don't want to treat restless legs if there's an underlying reason that might be causing it that we can identify and the low hanging fruit overall will be trying to get them off the serotonin medications, checking the iron and making sure the kidney tests are OK. Those are the three things we'll always examine right off the bat then we'll go from there.

Ryan, thanks for your call.

Let's go to our next caller.

Hello, Jill.

Walking to Mars the mind.

Hello, Jill.

If you're told how low on iron does that necessarily mean that you're anemic?

If you are told that you're low on iron, does that necessarily mean that you are anemic?

Not necessarily, Jill.

Again, I want to stay inside my lane here because I'm a psychiatrist but as a psychiatrist I will check iron levels.

>> I have seen people that have low normal iron that can make tired and given difficulty concentration.

That's why I'm always looking for a low iron for my patients but they won't necessarily have red blood cell abnormalities and that's what we took that's what we call anemia.

>> When you have decrease in hemoglobin your little red blood cells are getting smaller and smaller.

>> That's called our RCV the mean of the mean corpuscular volume when those are shrinking down that means you're anemic from the low iron itself but sometimes you'll have low iron but you won't actually show it in your CBC or your red blood cells just yet.

In those cases we will obviously want to try to identify do you have a slow gastrointestinal bleed and a lot of patients who I see with low iron it will often be heavily menstruating women who might not be getting enough iron in their diets.

And for those women we often supplement their treatment with a little bit of iron as long as they don't have other identifiable causes that their primary care doctor might not be addressing at that point.

So for those folks will often try to address the iron with iron supplements if they're on a low iron diet.

>> Thanks for your call.

Do I have any other emails for the night?

Oh, there we go.

Here's another email the next email reads Dirda to Forwork and an adolescent or teen outgrow their anxiety or depression can become less of an issue when someone reaches adulthood.

Typically when people have depression as adolescents they'll have difficulty with stress tolerance and as the front part of the brain indeed is maturing.

I think I have to wrap up for the night so unfortunately I'm out of time for this evening.

I'm psychiatrist Father and you've been watching matters of the mind God willing and PBS willing.

>> I'll be back again next week.

Have a good night.

Good night