Good evening.

I'm psychiatrist Jay Fawver, and welcome to Matters of the Mind.

Matters of the Mind is a weekly mental health program where you have the chance to choose the topic for discussion.

So if you have any questions concerning mental health issues that I can answer on the air, you may write me a via the internet.

At MattersOfTheMind - all one word - @wfwa.org.

That's MattersOfTheMind@wfwa.org.

And if you're able to do so, you may call or text during this program.

So let's start with an email I received this week.

It reads Dear Dr.

Fawver, my son has possible vocal cord dysfunction.

I think that's called spasmodic dysphonia now.

The breathing episodes have triggered severe panic attacks and deep depression.

How do you recommend treating the panic and breathing loop as well as the anxiety and depression?

I would certainly suggest that you follow up with an ear, nose and throat clinician because I want to stay in my lane as a psychiatrist.

Spasmodic dysphonia, vocal cord dysfunction basically is where the larynx is spasming up, and it's often treated to my awareness with Botox injections.

Botox injections will essentially freeze the nerve that's causing an abnormal spasm, so to speak, on the larynx.

Now, where I get involved will be I hear about people having more anxiety when they're having difficulty with speaking and they're having trouble with breathing.

And it's a vicious cycle because when they have trouble with speaking and breathing, they have more trouble with anxiety.

And it goes back and forth, back and forth.

So historically in the past, we have given people beta blockers such as propranolol to decrease the anxiety, decrease the norepinephrine, decrease the adrenaline, so to speak, when they're having a lot of panic and anxiety during the spells, when they're trying to speak or they're trying to do something in front of other people, rarely do we give medications like Xanax or Ativan or Klonopin, but they can help if you're in front of a public event and you have to speak.

But we will typically refer those cases to the ear, nose and throat clinicians.

You had asked about dealing with the anxiety and depression itself.

The best way to deal with that would be relaxation exercises.

The FCC with our federal government does not allow me to make specific referrals on the air, so I'd certainly ask your primary care clinicians for some potential therapists in your area to whom you may be referred for the purpose of relaxation, relaxation therapy for your son.

Thanks for your call.

Let's go to our next caller.

Our next caller is let's bring up our next caller.

Oh, do you have a text?

You have a text and the text reads here we go from Tehya from Ohio.

How do you know if you have post?

How about PTSD, post-traumatic stress disorder?

And there's anything to do for post-traumatic stress disorder, I believe is what you're to which you're referring there.

It is basically a condition where you've experienced a horribly traumatic event, either emotional or physical, or a sexual abuse type of an event.

It's something that was very traumatizing for a one way or another.

And because of that traumatic event, whether it occurs as a child, as a young adult, as an older adult, because of that traumatic event, you get really jumpy, you're on edge.

And from a brain standpoint, when you have a traumatic event, it stores in the hippocampus here, the memory center of the brain, which is right next to the anxiety and fear center of the brain, the amygdala.

So you get these recurrent thoughts that might come out as flashbacks, where you see stuff happening all over again.

You might have nightmares, you feel jumpy, you have panic attacks.

When you have memories of the past event, such as sound sites or smell.

So it will cause you to try to avoid those kind of situations.

Post-traumatic stress disorder is basically where you're having all these jumpy feelings and you're hypervigilant, where you're always expecting something bad to happen in a related manner, and it caused you to have difficulty socially, at work, at school.

It has.

It gives you difficulty just getting along and doing things you need to do.

So anytime you have functional impairment from symptoms of anxiety, depression, that's how you know that it's problematic for you.

So that's where we call it post-traumatic stress disorder.

It's a disorder when it's causing functional impairment.

Thanks for your text.

Let's go to our next email question.

Our next email question reads.

Dear Dr.

Fawver, I recently had a baby and had a great response from Zurzuvae.

That's for postpartum depression.

I still feel tired and have a hard time keeping up with my kids.

Is it appropriate for young mothers to take stimulants to help with energy?

I wouldn't recommend it.

A stimulant for energy because when you take stimulus for energy, you have to take more and more to get the same effect.

Now, I remember when I was a pharmacist way back in the early 1980s.

This is before I went to medical school.

When I was a pharmacist, we prescribed this trade name product called fastin - F-A-S-T-I-N.

Fastin is the trade name for phentermine, which is now available as Adipex.

But phentermine is a medication that will predominantly push out of the neurons.

Norepinephrine.

Norepinephrine is a chemical cousin to adrenaline, so it pushes out a norepinephrine and to a lesser degree, it pushes out dopamine and to a much lesser degree it pushes out serotonin.

So phentermine would give a lot of people energy and fast and was predominantly prescribed back in the 1980s.

And what was found was, well, people who took fastin for the purpose of having more energy and get up and go and suppressing their appetites.

Eventually it lost its effects because the side effect of energy will fade over the course of time.

So if you take Adderall, you take Ritalin mainly for energy and not so much for original intention, such as attention deficit disorder.

If you take stimulant medications for energy, you're going to be very disappointed as time goes on because the effects will fade and that can be problematic.

So in the 21st century, no, we're not recommending stimulants, even though you're a young mother.

I'm glad you had a great effect from Zurzuvae, it is used for postpartum depression, but you can have some tiredness that's still lingering.

Now, I don't want to just dismiss the tiredness because I want to make sure, number one, you don't have postpartum thyroiditis, which occurs in about one out of eight women where their thyroid will poop out after they have birth.

Number two, I want to make sure you don't have gestational diabetes, which might have occurred during pregnancy and lingering on now, so diabetes will make you really tired.

Number three, I want to make sure you don't have low iron.

So we want to check iron level because very commonly women who especially have complicated deliveries and have heavy bleeding will have low iron.

Those will all make you tired.

Now once in a while, okay, you're on Zurzuvae that helps with postpartum depression.

Once in a while, women with recurrent depression will have continuing depression thereafter, and they will have fatigue related to the depression itself.

So in those cases will give an activating antidepressant medication like bupropion, also known as Wellbutrin.

Vortioxetine also known as Trintellix and activating antidepressant.

But a stimulant itself would not give you ongoing long term effects and might even make you more irritable and angry than you'd want to be.

So we don't recommend taking a stimulant when you're feeling tired after delivery.

Thanks for your thanks for your call.

Let's go to our next caller.

Hello, Joy.

Welcome to Matters of the Mind.

Joy, you mentioned that you just started taking Xanax and you feel more clumsy.

Is that normal?

Yeah.

Joy, Xanax is a medication.

It's a benzodiazepine.

It's in the same class as Ativan, Klonopin, Valium.

Those medications are basically putting the brakes on the brain.

If you think about the brain having brakes called GABA and they have an accelerator called glutamate, the GABA and glutamate are in balance like a teeter totter.

The Xanax is putting the brakes on the brain, and it will slow things down and make you feel less anxious.

That's good, but it can also put the brakes on your motor control and make you feel clumsy.

Typically dose related and it's age related, so the higher the dosage, the more likely you're going to be clumsy, especially if you drink alcohol with it or take any other sedating medications with it.

And it's also related to your age, because older people will typically have more difficulty with having the clumsiness and even memory impairment from a medication like Xanax, also known as alprazolam.

So Xanax and Alprazolam, yeah, if you're feeling clumsy with it, certainly talk to your prescribing clinician and possibly decrease the dosage or look for other options.

Thanks for your email.

Let's go to the next text.

Our next text refers to having a severe brain injury.

It stems from decades ago.

It's just now rearing its head.

Is that normal for a traumatic brain injury being treated?

You're being treated with Abilify long acting injection.

You're also exposed to mercury in a dental office, where you are mixing the mercury with silver at the age of 12 to 15.

A severe head injury, yeah, it can sometimes cause you problems on down the line.

Now, you mentioned that you're on Abilify long acting injection.

I presume that's for a more chronic condition like bipolar disorder and where it's commonly used possibly schizophrenia.

But the traumatic brain injury is a separate phenomenon in those conditions.

So a traumatic brain injury can give you difficulty with long term problems with dizziness, memory impairment, difficulty with word finding.

Not uncommonly, people with traumatic traumatic brain injury might have off and on difficulties with sleep.

They might have headaches.

So we'll often try to treat traumatic brain injuries with medications that will modulate or block glutamate.

Glutamate is that excitatory neurotransmitter in the brain is thought that when you have a head injury, okay, you got this brain.

It's about 3 pounds in weight, and it has the consistency of a kind of a mushy sponge.

And on top of that brain is a hard skull.

So when you have a head injury, you're having the brain hit one side of the hard skull.

And that causes a profound release of glutamate.

That's the simple way to look at it.

The profound release of glutamate being an exciting neurotransmitter can cause you at the extreme seizures in some cases, but in many cases, it can make you irritable, moody, give you personality changes, and you can notice subtle changes over the course of time.

We will often try to modulate glutamate with a medication like lamotrigine or Lamictal, which basically will decrease the firing of glutamate from its firing neurons.

We'll use supplements sometimes, like N-Acetyl Cysteine if you don't have a sulfa allergy.

N-Acetyl Cysteine, basically will also stabilize glutamate release.

And it works very well with something like lamotrigine.

So when I think about a traumatic brain injury, I'm often thinking long term, okay, you're going to have most of your bad effects from the traumatic brain injury within the next two years after experiencing it, but you can have a subtle effects years down the line.

That's why when we do a diagnostic assessment in psychiatry, one of the questions we'll ask on the first appointment is have you ever experienced a traumatic brain injury?

I saw a person a few months ago who had a severe traumatic brain injury as an infant, and here he is now in his 40s.

And you wonder, well, gee, how did anybody not address that?

Because with that severe traumatic brain injury as an infant, your brain is very much growing and it can impact you later on.

And we want to try to address that the best way possible.

So yeah, a traumatic brain injury as a child or earlier on can still affect you later on.

We also will would consider the after effects of the Covid injections for the vaccines, as well as Covid infections as sometimes causing traumatic brain injury for some people.

We've heard it from the vaccines, we've heard it from the infections.

Some people will say they just weren't right after they had the Covid vaccine or the Covid infection.

And I think later on we're coming to realize, okay, these people had traumatic brain injuries, and I am indeed treating those people as if they had a traumatic brain injury, such as a concussion or any other head injury.

So that's something we consider.

Thanks for your call.

Let's go to our next email question.

Our next email question reads why does exercise slow down the heart rate when performed regularly?

Is the decrease of heart rate related to an improvement mood?

It can be.

The decrease in heart rate related to exercise is from a peptide that comes from the heart, called atrial natriuretic peptide.

A-T, A. Let's see, it's A-N-P, A-N-P.

Atrial natriuretic peptide.

It gets released from the heart when you're exercising and it will slow down the heart rate.

It's a good nice anti-inflammatory type of peptide which is a piece of a protein.

And in doing so, it can help you feel better, more emotionally stable in a sense that a lower heart rate, lower blood pressure will make you feel less anxious.

So when we hear about people exercising, I'm mentioning glutamate tonight.

I'll mention it again.

Glutamate is excitatory Neurotransmitter.

GABA is the brakes on the brain.

When you exercise, glutamate increases in the brain, as does GABA.

So you've got this accelerating neurotransmitter increasing.

And you have GABA which is a brake increasing.

That's why people when they exercise, they'll notice they feel energized afterwards, but they also feel calm.

So how can you feel energized but calm at the same time?

It's because these two opposing neurotransmitters increase at the same time, and it's a good effect in that regard.

But other good things happen.

For instance, the atrial peptide coming from the heart will slow down the heart rate, and for many people, that will feel better emotionally and physically from that.

Thanks for your email.

Let's go to our next caller.

Hello, Bob, welcome to Matters of the Mind.

Bob, you mentioned your doctor thinks you have bipolar disorder, where you have a few days where you're revved up and other days, few days where you're depressed.

Zoloft isn't helping.

What should you do?

If your doctor is thinking, yeah, bipolar disorder, your doctor probably is considering that you're having these highs and lows now an unnatural high if it lasts between gee a matter of hours, up to three days.

That's called a subclinical hypomania.

And if it's lasting more than three days, maybe lasting into four days, and then you're having two weeks or more of depression, that would be bipolar disorder type two.

However, if you're just having, let's say, 3 or 4 days where you're high and you're not functionally impaired, in that time, you're still able to get stuff done, but you notice you have more energy.

You're not sleeping as much, you're a little bit more impulsive, but you're not getting yourself into trouble.

That's called a hypomania.

If it's not lasting more than six days, that's hypomania.

And then if you get depressed for no more than two weeks, let's be called a minor depression.

So if you're having a little highs, little lows, little highs and lows we call that cyclothymia.

It used to be called bipolar disorder type three.

And it's where you still need a mood stabilizer.

And Zoloft by itself isn't going to help you that much.

Zoloft is basically lifting you up.

Push it on the accelerator trying to bring you up out of the low, and it's not going to account for the highs.

And the problem is if you have these unnatural highs, the hypomania is you're more likely to crash and go into the lows because it's like you run out of gas when you're on the high side.

They might feel pretty good.

On the high side.

Other people might say, gee, you seem really happy today.

And you might notice, yeah, I only got six hours of sleep.

And I have all these ideas, but you're not getting yourself into trouble.

And what I mean by that, you're not doing things and saying things that you later regret.

So if you're not doing things and saying things that you later regret, we don't call that functional impairment.

That's called hypomania.

And in those cases, we still want to treat you with a mood stabilizer.

Maybe.

Maybe not with an antidepressant medication.

But first and foremost, you want to take a medication that's going to act as a cruise control on the mood, because just an antidepressant like Zoloft is just going to be like pushing on the accelerator with not having any brakes, and you'll have more moodiness.

And that's why some people get worse when they don't get the proper diagnosis for bipolar disorder, when it's thought that they merely have depression.

Thanks for your call.

Let's go.

Next caller.

Hello, Betty.

Welcome to Matters of the Mind.

Betty, you want to know why would someone go off of Xanax and go into gabapentin?

Betty in my experience, we've been using gabapentin now for 25 years.

Gabapentin is also known as a Neurotin and gabapentin is a medication.

In my experience, it's easier to manage it compared to Xanax.

Now Xanax is controlled.

It's a schedule four medication.

Gabapentin is federally overseen, but it's not considered to be controlled because it's not thought to be as addictive as a medication like Xanax.

Now, some individual states, such as Michigan and Ohio, will watch the prescribing of of gabapentin very carefully, and they will treat it as a controlled medication.

But the federal level, they won't, because gabapentin is not as addictive as Xanax.

With Xanax, it's been around since 1983, I think.

But Xanax is thought to be a medication where you really shouldn't take it more than 2 or 3 weeks.

Now I see people all the time who have been on Xanax for 30 years, I get it.

And for those people, I'm very conscious.

consciousness is to slowly decrease the Xanax because yeah, the textbooks will say you can taper off of Xanax over the course of a week or two.

In a lot of cases I will taper off Xanax.

If somebody's been on for 30 years, I'll taper off over the course of 30 weeks if we need to, but I'll replace it with a medication like gabapentin.

Now, Xanax works on GABA directly.

You think gabapentin would work on GABA?

It doesn't work on GABA directly.

It works on the calcium channels.

So and working on the calcium channels, it's working in a whole different part of the brain.

The gabapentin GABA works on the chloride channels that put the brakes on the brain, whereas gabapentin works on the calcium channels, and in doing so will decrease the itchy trigger fingers of the excitatory neurons.

In other words, that's why gabapentin works for pain.

It decreases the excessive firing of neurons that shouldn't be firing that much.

That's why it helps with pain.

Also helps with fibromyalgia, aches and pains.

But it does help with anxiety and it's a very good medication for sleep in a sense that it improves the sleep efficiency.

It'll help somebody get into a deeper sleep, and it also helps with dream sleep.

So where's a lot of medications, Xanex being one of them can actually disrupt the efficiency of the sleep.

And you wake up not feeling as rested.

Gabapentin can actually help you sleep deeper and gives you dream sleep, thereby giving you better quality sleep, overall.

Gabapentin works within 20 minutes and it lasts for about eight hours now.

Gabapentin was originally approved for seizures way back in the 1980s, as Neurotin.

I believe it was developed by Pfizer way back then, but within a matter of a couple of years, us psychiatrists, I think we were prescribing 85% of it at one point because we found that it was a very good alternative to the benzodiazepines for anxiety and for sleep, for that matter.

And unlike the benzodiazepines, it doesn't cause as much memory impairment, doesn't cause as much difficulty with balance and concentration.

Some people will say, well, I tried Gabapentin was a horrible experience because of this or that.

Well, keep in mind gabapentin is dosed between 100mg three times a day, all the way up to 900mg three times a day.

People take it at various doses, and the higher doses can give you more side effects.

Secondly, with gabapentin, like with Xanax, if you take it with a narcotic, it will amplify the effect of the narcotic.

Not in a good way.

So you don't want to do that.

It's not as bad as Xanax in terms of amplifying the effect of the narcotic and causing you to have respiratory depression where you don't breathe.

But it can be potentially dangerous with a narcotic, which is a shame, because a lot of people on a narcotic need something that's also going to help them with pain, and gabapentin can help them with pain in a different way, but unfortunately, it can kind of shut down the breathing in a similar manner as a Xanax, although it's not as bad.

So there's always pros and cons with it.

There's a study done in New Jersey 20 years ago on gabapentin, looking at its addictive potential, looking at Medicaid claims, I believe, and they found that only about 2% of people really misused gabapentin.

Now, there will be people out there who take it by the handfuls, okay, those people shouldn't be taking it, but most people are able to tolerate and use gabapentin without too much difficulty.

Why would I take somebody off of gabapentin?

Why would it be intolerable?

Well, number one, if people take two out of a doses, you can be intolerable.

But it also has this weird side effect for some people where they get swelling in the ankles and swell the puffiness and the ankles.

Nobody has figured out what causes that, but for some people, they'll get puffiness in the ankles.

Maybe it has to do because gabapentin is being entirely excreted from the body through the kidneys.

And maybe there's something with fluid retention going on.

I don't know, but gabapentin tends to be safer than Xanax, and we often use it as a trade off to help people get off of Xanax.

We also help people get off marijuana using gabapentin.

That's our number one means of helping people get off of marijuana and alcohol.

That's also a way to get people off the dry drunk period, where they still are having several months after they just after the cease drinking, they still have several months of anxiety and they can't sleep.

Gabapentin is a trade off for those people as well.

And it's often easier to taper off of gabapentin compared to Xanax.

Thanks for your call.

Let's go.

Next caller.

Hello, Jim.

Welcome to Matters of the Mind, Jim, you want to know, can sleep paralysis be dangerous to your health?

Not really Jim, it's scary.

Sleep paralysis is basically where you awaken and you're in non-REM sleep.

What the heck is non-REM sleep?

Non-REM sleep is what the sleep you go into about 30 minutes after you go to sleep.

Initially, you go into this real deep sleep, and if you're awakened from the deep sleep, you might be somewhat confused as you awaken.

So that's non-REM sleep.

I think you're referring to sleep paralysis, where you're awakening during the dream, sleep when you've been dreaming and you're awakened for a few seconds and you can't wake up.

So let me rephrase that.

You can tell this is a live program, because I'm kind of thinking through all this as we talk here, sleep paralysis, that in which I think you're referring will be when you're dreaming and you're in REM sleep and you're awaken and all of a sudden you can't move.

Okay, that's sleep paralysis.

I get that.

Sleep paralysis is caused because when you dream, your body naturally secretes this particular chemical that paralyzes all the muscles.

All right.

That's why you shouldn't be thrashing around and doing stuff when you're dreaming.

Because your body naturally releases chemical that paralyzes your body.

Now, when you're dreaming, if you happen to awaken and you're not quite awake yet.

And that paralyzing chemical which clears out really, really fast if it's still kind of hanging around, you can't move.

And it's really scary.

That's the paralysis.

Now let's go back to non-REM sleep, in which I was originally discussing.

Non-REM sleep occurs within 30 minutes of going to sleep.

You're going to a really deep sleep during that time.

And during non-REM sleep, you can have more difficulty with having night terrors where you awakened screaming, you're very confused.

You don't know what's going on around you.

And that's when people sleepwalk as well.

So night terrors where you're very confused and you wake up screaming.

That happens most commonly with little kids whose brains are still growing and they get a lot of non-REM sleep.

Happens with little kids who have fevers, too.

So a little kid was going to be more likely to have non-REM sleep disturbances.

Adults can have non-REM sleep disturbances with a really deep sleep when they're sleep deprived.

So when you're in sleep debt and you haven't gotten enough sleep because you've been working extra shifts or something, you're going to be more likely to sleepwalk.

And that's because you're going into extra REM sleep.

So with non-REM sleep, you get to sleep terrors.

You get the sleepwalking.

With REM sleep, you get nightmares with REM sleep, you get sleep paralysis where you awaken and you can't move your muscles.

Neither of those conditions are thought to be dangerous, with the exception of if you get if you fall over something, if you're up walking around, for instance, when you're sleepwalking.

Okay, that could be dangerous.

But it's not considered to be dangerous to the brain.

But boy, it's really annoying to experience in those kind of things while you're sleeping.

They're called parasomnias and we will often try to address those by decreasing the phases of non-REM sleep or REM sleep.

If people are troubled by any of those symptoms.

Thanks for your call.

Let's go to our last email question.

Our last email question reads.

Dear Dr.

Fawver, I've been taking two tablets of Auvelity every evening, but I've read online that it should be taken twice a day, separated by at least eight hours.

Will it work better twice a day?

And I'll say maybe it was studied at twice a day.

Auvelity the combination of dextromethorphan and Bupropion.

It was studied it twice a day, and it was studied in a formulation that was originally created for Wellbutrin SR okay, Wellbutrin SR is Bupropion SR sustained release that is designed to release over the course of 12 hours apiece, and they say separated by at least eight hours.

Well, they use that same tablet formulation to create Auvelity but with Auvelity, dextromethorphan is the main ingredient.

Bupropion is there to increase the blood level of dextromethorphan, but dextromethorphan is the main ingredient.

We have found that in clinical practice, if you take two tablets of Auvelity in the evening, it tends to work pretty well.

Yeah, it was studied twice a day, and by all means, that's how the package insert recommends it, because that's how it was studied.

But like with a lot of medications in clinical practice, once we get it in our hands and we try it out for several thousands of patients, we figure out that some people might do just as well with once a day dosing versus twice a day dosing.

So here's how it all comes down.

Number one, if you can take Auvelity twice a day, you're having no side effects from them.

It's easy for you to take it twice a day.

Have at it.

Keep doing it.

However, if you have difficulty remembering the tablets in the morning, for instance, or if you have trouble with dizziness or over sedation when you take that morning dosage, rather than just take one every day.

We really have to have you take two tablets in the evening and watch and see how you do.

But many of our patients have done well with two tablets an evening.

Although the package insert and the original clinical trials were done using over twice a day, at least eight hours apart.

Thanks for your email.

Unfortunately, amount 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 if you have the Internet at MattersOfTheMind - all one word - @wfwa.org.

I'm psychiatrist Jay Fawver, and you've been watching Matters of the Mind on PBS.

God willing and PBS willing.

I'll be back again next week.

Thanks for watching.

Good night.