.

good evening, I'm psychiatrist Fauver live from Fort Wayne , Indiana.

Welcome to Matters of the Mind now and it's twenty sixth 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 questions concerning mental health issues, give me a call in the Fort Wayne area by dialing (969) 27 two zero or if you're calling long distance you may dial toll free at 866- (969) to seven to zero now on a fairly regular basis I am broadcasting live every Monday night from our spectacle or 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 concerning mental health issues 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 drug that's matters of the mind at WFA a dog and I'll start tonight's program with a question I recently received it Regional Revolver.

How do I know if I have a newer epinephrine problem if I have a deficiency can I take medications that increase norepinephrine?

>> Well, it used to naively be perceived that we could simply measure for breakdown products of norepinephrine and the spinal cord or the urine for that matter and just determine if somebody needed more norepinephrine.

Well, that was pretty naive and that was about three or four decades ago that was determined.

>> Now we realize it's not a matter of norepinephrine deficiency.

It's a matter of norepinephrine balance.

So two little norepinephrine will give you difficulty with fatigue, poor concentration and lack of initiative.

>> Too much norepinephrine on the other hand, will give you difficulty with the possibility of irritability, anger, difficulty with impatience.

>> So you want that fine balance one way or another if you don't get enough sleep you can have norepinephrine disturbances where you can have both an imbalance of low and high norepinephrine.

>> So that's why people with lack of sleep will often feel kind of wired up but they're tired so they can feel irritable but at the same time they feel fatigued so you want to get the fine balance with norepinephrine, with norepinephrine there are nine different receptors for norepinephrine.

So if you simply flood the brain with norepinephrine you'll stimulate all these different receptors.

Some of the receptors are accelerators and some are brakes.

So you want the balance and that's why a lot of these newer medications that we're hearing about have specific receptor activity so you've got the brake.

So those are called the Alpha two receptors for norepinephrine.

Then you've got the accelerators which are the alpha one and the beta receptors.

So you want to balance out if you're getting the brakes hit or you're hitting the accelerator and balance that out and some medications will be very selective in doing that .

>> So basically what we do is we look at people from a symptomatic standpoint.

We call it phenotypes.

You heard about genotypes.

>> Maybe that's where you do genetic testing.

We do phenotypes where we look at the specific symptoms somebody might be having and we look at not only the current symptoms but what their past treatment responses might have been.

If we look at the past treatment responses we can sometimes determine what worked and what didn't work.

We look at family histories of medication responses if family members have done well with norepinephrine medications we could certainly consider that for you as well.

And finally we'll look at the genotype which I mentioned previously looking at genetic testing, you can get a little bit of a clue on whether somebody will be overactive in their breakdown of norepinephrine and if they need something is going to be more norepinephrine enhancing or something is going to be more breaking an example be in post-traumatic stress disorder with post-traumatic stress disorder.

Many people have an acceleration of norepinephrine coming from the brain stem.

>> The brain looks like a big cauliflower and it's got a stem down here that's the brainstem in the brainstem.

There's too much norepinephrine being released and it makes people jumpy.

We call it hyper vigilant weather always on guard expecting something to happen.

People have endured a past.

Traumatic experiences will often be irritable.

They will avoid situations.

They will often have nightmare and have difficulty with sleeping.

Those people often have an overactivity in that part of the brain on norepinephrine.

So we're trying to shut down the excessive norepinephrine in that area, being careful not to make people fatigued and make them have more difficulty with concentration because if you overshoot and double down the norepinephrine transmission you can make people fatigued and they have trouble with concentration and attention span.

>> So it's always a delicate balance.

It's not a matter of just filling up the brain with norepinephrine or serotonin or dopamine.

>> We have to be very selective in how we do so.

Thanks for your email.

>> Let's go to our first caller.

Hello Chris .

What kind of is the mind?

>> Well, Chris , I don't think we have oh hello Chris .

Are you on the line?

>> Oh, Chris , we'll have you call on back here.

Next thing have laundry detergent in the backseat of the car on the floor.

>> Well, I want you to go ahead and get that laundry detergent if he can.

Chris .

But we go to our next email if we could.

Our next email reads Dear Dr. Fauver, are there are supplements or certain habits that help with memory and focus?

I don't think I have a serious concern but I find myself struggling with keeping on top of my schedule many days I'd want to know in your case if you're having any difficulty with low thyroid depression, attention deficit disorder, glucose disturbances, low iron.

>> There's so many different reasons why somebody can have disturbances with low iron or low glucose or thyroid disturbances.

>> Giving them problems with memory and concentration could take supplements if there were supplements to take I would certainly be recommending them to everybody and I would take The only supplement I'd strongly recommend to everybody with your clinician's consent would be vitamin D supplement because in northeastern Indiana where I live often we're kind of on the low side on vitamin D you can get blood level on that with your clinician's order but man of us are low on vitamin D and that's something that can help with mood concentration and actually helping with with some evidence of decreasing likelihood of cancer.

So vitamin D is a remarkable supplement.

What I recommend a supplement for concentrate and focus not necessarily.

>> I mean you'll hear about caffeine being in a lot of these different supplements that are used for memory and concentration.

>> Caffeine basically will will mimic this particular chemical in our brains called adenosine Adenosine is kind of like the byproduct of ATP.

>> So ATP breaks down.

That's the fuel in our brain.

Think of adenosine as being like the fumes that are being released as the brain is metabolizing glucose and in doing so adenosine in the fumes of the metabolism and the fumes of the energy will make you tired and as the day goes on you'll get more adenosine release that makes you kind of tired.

>> Caffeine goes to the brain and mimics adenosine fools the brain to think and adenosine is there will knock us down unseen out of the way and there are by adenosine can't block the particular or can't stimulate the adenosine receptor and that makes you more awake.

So caffeine will basically knock adenosine out of the way thereby making you less fatigued but also caffeine indirectly will increase a little bit of dopamine, a little bit of norepinephrine and give you a little bit more energy and help with concentration.

>> Now the problem with caffeine even though it's in a lot of these supplements is is that it only lasts about two hours or so so it gets in your system and out of your system.

>> So I always recommend to people if they're drinking coffee and using the caffeine content in coffee as a means of helping with their concentration or focus.

>> I certainly recommend that they sip it slowly and try to slip it over the course of three or four hours if they can.

>> Thanks for email.

Let's go to our next caller.

Hello Chris .

Welcome to Mary's Mind.

Chris , you had mentioned you have a friend battling with depression and agoraphobia where your friend does not want to leave the household and won't see family or friends.

>> She's seeing somebody on Zoome but the medication is not helping.

So you when you say you're seeing you're seeing somebody your friend is seeing somebody on Zoome I mean your friend is seeing a therapist on Zoome doing what we call telehealth medication's not helping.

What's the next step?

I think the going back to square one Chris your friend battling depression with panic attacks and agoraphobia would need to make sure that an adequate diagnosis is made.

For instance, if your friend has depression there are now 17 different oral antidepressant medications that can be determined.

>> So you go through the the listing and based on mechanism of action determine what medications have been tried and which ones have not and try to see if there's a pattern there of how medications have done.

But even prior to that, let's sort out if the diagnosis is correct of depression.

Many people will have depression with agoraphobia when they indeed will have sleep apnea.

Sleep apnea is where you might be snoring at night.

You're gasping in your breathing.

You're pausing your breathing for that matter and there's not enough airflow going to the lungs thereby not enough oxygen going to the brain with not enough oxygen going to the brain.

>> You can feel depressed, you can feel tired, you can't concentrate, you feel blah.

And many people who have sleep apnea will indeed have panic attacks because if you're not getting enough oxygen to the brain you'll feel like you're on hyper alert throughout the night.

>> It increases cortisol levels.

It'll give you more panic attacks.

Some people will get nauseated in the morning after having a bad night of sleep either pausing their breathing and their snoring.

Not getting enough oxygen to the brain will cause you a lot of different problems the next day.

>> So there might be other reasons outside of straight depression and panic attacks with agoraphobia phobia why your friend might be having some difficulty with medication response as well as to talk therapy itself.

>> So go back to square one sought out the diagnosis, look at past medication treatment responses, look for any any other medical conditions depression with panic attacks.

The first thing I'm going to think about think about from a medical standpoint will be sleep apnea.

But the second thing I'll think about will be thyroid disturbances low or high thyroid can give people difficulty with panic attacks and anxiety and having difficulty with more depression.

I mentioned before diabetes, low iron these are all reasons it will often see as reasons why people might not be recovering from depression.

Now if you're having trouble with panic attacks and depression, we're also wondering if somebody has what's called bipolar disorder where they're having highs, where they don't need to sleep as much periodically.

They're more impulsive.

They have racing thoughts and then they crash in the lows.

If you're having bipolar disorder, you can treat somebody with all the antidepressants you want.

They're not going to get better because they're eventually going to cycle into the highs and they'll have moodiness that will often be described as panic agitation.

So they'll have revved up feelings periodically and they'll describe it to us as having panic attacks and they'll have trouble going out because they feel very uncomfortable being around other people because of racing thoughts and a fast heart rate .

>> They'll just feel very anxious when they go out into the public so they'll often isolate themselves and stay home.

So first I want to do is make sure the diagnosis is proper.

Second thing I want to do is take a really good look at what medications have been tried.

We have medications for instance in the serotonin class called SSRI Selective serotonin reuptake inhibitors.

>> There's five of them Lexapro, Paxil, Zoloft, Celexa and Prozac.

And then you can add Luvox to that mix which is kind of an SSRI that does other things.

>> But if somebody has tried two of those, they're probably not going to do so well in a third or fourth one.

>> But I have indeed seen as a clinician people who have been on five different SSRI and they don't work at some point you've got to go to another class.

So we look at going to different classes of medication historically we've had medications will affect serotonin, norepinephrine and dopamine but now we're looking at medications that more directly affect glutamate which is a different type of treatment.

We have medications that affect glutamate such as ketamine, ketamine which is a nasal spray and a new medication called All Velarde.

You see there are medications that will not just affect norepinephrine dopamine and serotonin but they affect glutamate differently.

So you have a wide array array of different medication treatment approaches that can be made and then from a psychotherapy standpoint talk therapy I always wonder what kind of talk therapy is being pursued if somebody has post-traumatic stress disorder and you want a particular kind of therapy eye movement and desensitize and reprocessing can be a very effective treatment.

MDR as the mnemonic for that be a very effective treatment if somebody has depression with comorbid post-traumatic stress disorder, if they have social anxiety on the other hand the idea would be to help them in social situations and get them around people to try to desensitize a lot of that like with any phobia with you with social phobia or social anxiety, the best way to treat it would be with exposure gradual doses of getting out and being around people over the course of time can be very helpful.

>> And finally, I don't want to make sure if somebody has depression with agoraphobia that they're trying to get back into doing things that used to be fun, a key symptom of depression that will linger even with pretty successful treatment will be anhedonia.

Anhedonia is a fancy term for having no fun and means no hedonism means fun.

Anhedonia is a term that we use that refers to no fun and when people get depressed they tend to give pleasurable activity.

>> So it's so important that we get people doing things that they previously found enjoyable and even as people recover from depression they still give those previously enjoyable activities up and they don't have fun anymore.

So we've got to get people out there doing things, socializing, having fun again and finding things that are enjoyable even though they initially might not want to do it.

It's kind of like exercise, physical exercise.

It's tough to get out there to do it but after you do it you feel good and exercise is another good treatment for depression as well.

Chris , thanks for your call.

Let's go to next caller.

Hello Alberta.

Welcome to Matters of Mind Alberta wondered about a sense of startle complex what causes it and what can help.

But your mother also when people are readily startled Alberta I'm always thinking gee, there can be several things going on.

>> I mean you can go all down all different rabbit holes.

But the first thing I'm going think about if somebody is readily startled, startled somebody had a traumatic experience perhaps in the past that might have contributed to them being more jumpy.

>> So again, we call that hyper vigilance where or easily startle it is a symptom of post-traumatic stress.

>> So as a young child usually under the age of eight years of age, if you've had jumpy traumatic experiences you can be more easily startled.

We see this with quite frankly shelter animals.

If you get a dog at a shelter you'll often find that certain dogs are easily startled because of their past experiences.

>> We see the same thing with people.

If as a child you were easily startled because of certain traumatic experiences that can be a factor.

>> So that's the first thing we think of if somebody is easily startled startled, a second factor can be maybe some autism spectrum conditions.

>> People with autism spectrum basically have decreased functioning of their right front part of their brain up here and they have difficulty with social cues but they also have trouble not uncommonly with being easily startled and they have trouble with needing things to stay the same.

If they have a change in their environment they can be readily irritated and easily startle in those kind of conditions.

And finally, if you've had a past history of a concussion, a past history of concussion can make you a little bit more jumpy and more easily startled later on you can be more sensitive to light, more sensitive to sounds and you might notice that sensory input is more startling for you.

So those can be some various reasons are Alberta why people can be more easily startled.

>> Alberta, thanks for your call.

Let's go to our next caller.

Hello Doug.

Welcome to Matters of Mind.

>> Doug, you had mentioned that you're recovering from a concussion.

I just mentioned that and you want to know when you'll be back to your full capacity.

>> Doug, a concussion is basically a brain bruise.

It's where your brain which has the consistency of giallo I mean it's kind of mushy and it's inside this really thick, hard skull of ours.

>> And when you hit your head, this brain just kind bounces around inside there and hits the hard skull and it kind of gives you a brain bruise.

>> What happens during the time as you get this release of glutamate?

Glutamate is an excitatory neuro chemical and like norepinphrine which I mentioned earlier, you don't want too little but you don't want too much.

>> And with a concusion not-uncs surge of glutamate the factors that might contribute to how soon somebody might recover or how quickly somebody might recover from a concussion will include how many concussions you've had previously the more concussions you've had previously, the more difficult it will to be to recover.

Secondly, the severity of the concussion where you knocked unconscious or did you just get your bell rung and you didn't notice that much of a difference for a while and finally your age I mean the older we are the more difficult it is to recover from head injuries.

So there are various factors like that that can determine how quickly you can recover from a from a concussion.

>> The key is take it seriously.

We call it traumatic brain injury.

If you have several traumatic brain injuries, several concussions over the course of time it can lead to post traumatic encephalopathy which is something we hear about a lot with a professional football players who played twenty thirty years ago, especially as they get older they have dementia like symptoms primarily from these repeated concussions they had that were not addressed until about twenty years ago.

And at that time the onset concussion protocols came out and people started taking that seriously.

So basically, Doug, you want to have various tests for concussion for the concussion and see what kind of recovery you're having at this point.

Be very careful about doing any sports or any activities that might lead to another head injury in the future.

>> Doug, thanks for your call.

Let's go to our next caller.

Hello, Nancy.

Welcome to Matters of the Mind, Nancy.

>> Want to know the difference between a psychiatrist and a counselor and do you need to go to a psychiatrist for a diagnosis?

>> Counselors are often masters level people who psychology degrees they went has some extra studies and they got a counseling degree.

Psychologists are PhDs, psychologists are PhDs not uncommonly sometimes you see side Y d their doctor level not medical doctors but their doctorate level in research and in counseling as well.

>> So you'll often hear about psychologist doing a lot of psychological testing and they will oversee the master's level counselors.

>> A psychiatrist on the other hand is a physician, a medical doctor who had four years of medical training, then four years of residency training after that.

>> So a psychiatrist will indeed be able to make a diagnosis and look at the whole holistic issue that might be going on there.

>> I mentioned several times earlier that as a psychiatrist I will look at medical conditions that might be making other underlying psychiatric symptoms themselves.

>> So a psychiatry in 2023 won't be doing a lot of counseling.

I was trained in counseling back in the 1980s but as time has gone on the complexity of the medical treatments for psychiatric disturbances had been has become so extensive that psychiatrists are primarily in the role of taking care of medical oversight and prescribing medications.

In twenty twenty three psychologists and the counselors will be more likely to do the psychotherapy and the talk therapy overall.

>> Thanks for your call.

Let's go to our next caller.

Hello Jason.

>> Walking to matters of mind, Jason you want to know is going to be too many people involved in treatment.

>> Jason, are you on the line?

Oh yes.

Fantastic.

I love I'd love for you to elaborate on that a bit, OK. >> For instance, I have a MDR person, a talk therapist, a skills coach, a psychiatrist that doesn't know medications or family after four or five different people that are adjusting medications appointments, what would that cause anxiety get worse?

One says it's PTSD, onset of depression, months of anxiety.

I'm not sure who's supposed to be in charge or regulating things like the medications get mixed up.

I was wondering if you could like shed light on if I could have ever seen those too many people involved.

I guess that would raise anxiety and yeah, I guess basically anxiety and agoraphobia make it worse.

>> Yeah.

Jason, thank you so much for staying on the line to clarify that because you're right.

I mean you want one person involved in the prescribing of medications, number one.

>> So if you have a family doctor prescribing some medications and a psychiatrist prescribing other medications, you need to have a person prescribing the medications and usually the thing that family doctors with whom I work are more than happy to allow me to take over the medication treatment.

I'd want to make sure your family doctor knew you're seeing a psychiatrist.

>> The psychiatrist is usually going to be the captain of the ship who's going to make the diagnostic criteria that the psychiatrist will often set the treatment plans anxiety has as a type of anxiety PTSD so you can have post-traumatic stress disorder and anxiety because PTSD is a type of anxiety, other types of anxiety or generalized anxiety disorder which is a fancy term for worry.

You can have social anxiety disorder.

You can have obsessive compulsive disorder.

pThose are types of anxiety panic disorders, another type of anxiety.

So PTSD is a type of anxiety that should be addressed as you'd mentioned with MDR Eye Movement Desensitization and reprocessing.

>> MDR is a specific type of treatment that is good for PTSD.

So that's good that you're having a clinician be able to address that.

The skills coach on the other hand is giving you life coaching basically the purpose of the skills coach is to help you get through day to day and give you some ideas on how to take care of yourself day to day.

>> That's OK.

Totally separate.

What you don't want to have occurring, Jason, is where the clinicians or the physicians or the prescribers are overlapping what they're doing.

>> As a matter of fact, when I hear about a another clinician, a prescribing clinician for instance being involved in the treatment, I'll say, you know, you can have your treatment completed by that clinician but you don't want to go back and forth.

It gets way too confusing but it's not unreasonable for a family doctor, Jason, to be looking at your overall medical needs.

That's a whole mind body concept where the family doctor is making sure your your blood work is looking good, your liver's working well heart, kidneys, spleen everything's working the way it should be doing.

>> Your family doctor can oversee your overall medical condition independently of what the psychiatrist might be doing so the psychiatrist can prescribe medications for sleep and depression and post-traumatic stress disorder that would be independent of what the primary care doctor is doing.

Then you've got your skills coach and you've got your therapist if they're all working together that's fantastic and in an ideal scenario, Jason, they would be communicating with each other now we have electronic records nowadays where it is easier to communicate with clinicians who are especially in the same system.

But that's what I'd want to make sure happening.

If you're doing therapy you'd want to make sure that you're doing the right kind of therapies.

Make sure the psychiatrist or at least the counselor who knows you the best has really nailed the diagnosis and try to be as definitive as possible in terms of determining what you do and what you don't have.

For instance, Jason, if you have let's say chest pain as an example, if you have chest pain you need to know is the chest pain due to a heart condition?

>> Is it due to gastric reflux where you're having heartburn?

>> Is the chest pain due to your having a lung aneurysm of where you are among emboli, where you're having trouble with a blood clot in the lung itself?

>> What's causing the chest pain?

You've got to treat it appropriately.

Some people can have chest pain by as manifested as a symptom of asthma.

>> So with chest pain you need to get the definitive diagnosis and be able to treated accordingly if you have depression and anxiety from a mind body medicine approach, you need to make sure that medically you're in good shape physically it's not creating the situation that might be problematic for you but you also want to make sure you're getting the right therapies.

>> So if you do have past traumatic experience as MDR is very good for that.

>> If you have past traumatic experiences with post-traumatic stress disorder you probably don't want to take a medication in the class of benzodiazepines such as Xanax, Klonopin, Ativan or Valium.

They tend to make the post traumatic memories worse.

>> So you want to make sure that you're getting anxiety treated with the right therapies and the right medication itself.

>> Jason, thanks for your call.

Unfortunately I'm out of time for this evening.

>> If you have any questions concerning mental health issues, you may contact me by Internet at Matters of the mind at WFA Dog and I'll ee if I can get to those net week.

>> I'm psychiatrist Jeff Offer and you've been watching Matters of the Mind on PBS Fort Wayne God willing and PBS willing.

>> I'll be back again next week.

Thanks for watching.

Goodnight