.

>> Good evening.

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

Welcome to Matters of the Mind Matters.

>> The Mind is a live call in program where you decide to choose the topic for discussion.

>> So if you have any 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 any place coast to coast you may dial toll free at 866- (969) to seven to zero now on a fairly regular basis we're broadcasting live every Monday night from our spectacular PBS Fort Wayne studios which lie in the shadows of the Fort Wayne campus.

>> And if I'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 Wadongo that's matters of the mind at Wakeboard and I'll start tonight's program with an email I received this week.

>> It reads During a revolver I took Paxil.

>> It's also known as paroxetine for depression for a little over a year many years ago despite weaning myself off the drug at that time I still experience side effects.

Is there any way to repair this?

>> Does it put me at a higher risk for eventual dementia?

The good news is being on Paxil showing off Paxil would not put you at a greater risk for dementia fortunately.

But the withdrawal the discontinued patient phenomenon from Paxil is something that makes it unfavorable for many people Paxil or prox team came out in about nineteen ninety five and its claim to fame at the time was it was the most potent of all the serotonin medications and at the time we were thinking in the nineteen nineties well gee more serotonin that's even better for some people because higher amounts of serotonin will give you more of an emotional numbing effect and if you have a lot of anxiety, panic, post-traumatic stress symptoms they can kind of calm things down.

>> But for many people they found not only were there drug interactions where it would cause the blood levels of various medications to increase but also upon your coming off of Paxil you could have zings and zaps in your hands and feet.

You could have kind of a light headed feeling, some dizziness.

It doesn't usually go on for years but it can go on for several weeks or even months for that matter.

For that reason we will often have people slowly taper off the Paxil sometimes over the course of one month, two months I've even had somebody somebody go off the Paxil over the course of three months because they have so much difficulty with the type with a tapering of a sometimes we'll actually add a medication called Fluoxetine also known as Prozac as a means of easing some of the discontinuation phenomenon.

>> But more often than not we just try to do a slow, slow, slow taper on the prox team.

But fortunately it does not put you at a higher risk for dementia going through the discontinuation or for that matter even being on the paroxetine.

>> Thank you for your email.

Let's go to our next email question.

Our next email question reads Dear.

>> Let's bring it on up here if we could.

It is not to fall over.

Are there prescriptions that work well together that treat both attention deficit disorder and bipolar disorder type two in adults?

My sister was just diagnosed with both.

Is it better to start on one medication and then another?

>> Are there other things that can be done to help with the symptoms?

Bipolar disorder type two means that she's experienced four to six days of little highs that don't cause a lot of impairment.

>> But are there and then she'll crash into two weeks of depression or more so little highs for four to six days and then depression for two weeks or more.

>> You can have those episodes n top of attention deficit disorder now it's very important that you differentiate attention deficit disorder from bipolar to disorder number one, aid or attention deficit disorder is a phenomenon that occurs on a day to day basis and it goes back to when you're a kid.

>> So every day you have difficulty with attention span, distractibility, focus, concentrating, persevering, getting things done, getting things initiated especially if not challenging, exciting or novel and new so you can have attention deficit disorder symptoms typically on a day to day basis they'll occasionally get worse on days or weeks where you're more challenged by things that aren't so interesting so people can have a variation of the symptoms.

>> But for the most part those symptoms for ADT or their every day bipolar disorder are quite different.

>> It's a mood disturbance where you can have a little highs and then you have big lows and they come and go.

>> So the treatment priority for ADT in addition to bipolar disorder will be number one, have somebody take a mood stabilizing medication and mood stabilizing medication would be a medication like an anti epileptic medication or a dopamine receptor blocking agent.

They used to be called antipsychotic medications but I think the preferable term would be dopamine receptor blocking agent.

>> These are medications that have been out for several years now.

They used to be used exclusively for schizophrenia.

Now we're using them extensively for bipolar disorder and sometimes as add on medications for depression.

>> So the first thing you want to do with bipolar disorder with ADT is to treat the mood disturbance first, get the mood all leveled out kind of like a cruise control in an automobile then only then you will then treat the attention deficit disorder with ADHD as a condition where if left front part of the brain isn't working so well and to some degree the middle part of the brain's not working so well.

So the left front part of the brain is used for distractibility, attention span concentration.

>> The middle part of the brain is more related to impulsivity and thinking before you do things and with attention deficit disorder you have disruptions in that part of the brain, especially with bipolar type two disorder.

It's more of a mood disturbance.

Inner workings of the brain are more disrupted.

So with bipolar two disorder you're going to treat somebody with a mood level or a medication that will stabilize the mood like the cruise control and then with 8D what you want to do is fire up this front part of the brain.

>> You fire it up with stimulant medications not uncommonly the methylphenidate or Ritalin products, the amphetamine products sometimes we can use non stimulant medications with some success.

>> They will affect serotonin and norepinephrine sometimes dopamine to a different degree.

But what you're trying to do there is to fire up the front part of the brain with attention deficit disorder.

>> Now sometimes you'll hear about people having a lessening of effect for aid as they go through their lifetimes because they won't have the cognitive challenge and the academic pressures they might have had earlier in life , especially when they're in school trying to remember and learn things that weren't that interesting.

When people have attention deficit disorder, they often have almost a hyperfocus is for things that are really interesting to them.

>> But if they're not that interesting that is can't focus at all and that's a challenge for them in school and often in a new job situation.

>> But if you've been on the job for five or ten years, you pretty much have the routine down with a might not be as much of a problem for you once routine of life.

>> So with ADT it might not impact you as much later on with bipolar two disorder.

>> Often it has us on set as an adolescent, perhaps as a young adult in your early 20s and then you have these little highs that might not be too problematic for you but then you hate the big lows and when people come to see me about and they have bipolar disorder they'll often complain drastically about the lows but they won't be so concerned about those little highs.

>> But the problem is is if you have those little highs you're more predictably going to have the big lows.

So you've got to get the both up and settle down and that's where the cruise control comes in.

So it's bipolar type two disorder with adead you're going to use a mood stabilizer.

>> See how much difficulty is still there with attention span and focus and concentration.

Then if needed treat the attention deficit disorder symptoms thereafter.

>> Thanks for your email.

Let's go to our first caller.

>> Hello Ryan.

Welcome to mastermind Ryan.

You mentioned that you're having issues with high blood pressure and you were just cleared to go back to work.

>> What kind of techniques can you practice to keep your stress level down and how to stress affect your blood pressure and why?

>> Well, stress is basically a change, Ryan.

>> So if you have a change in your day to day routine of any kind, you're going to feel stress so stress isn't all bad.

>> It's just you have to be able to cope with it.

You have to adapt to it.

Our lives would be really boring if we didn't have differences occurring in our lives, if we didn't have some kind of changes occurring.

So yeah, we need to be able to adapt.

>> It makes us sharper and makes us better in our day to day functioning if we can be challenged on a regular basis so that stress the key for you is to be able to be to be to deal with that stress depending on the nature of it sometimes writing things down, knowing what your priorities might be, getting this done and that done and that done in order is often helpful.

But many people will get stressed out because they procrastinate and they'll do a little bit of something kind of bored with it or lose interest and they go to something else and they go something some of these people do have add which I to which I referred earlier.

But if you don't get things done and you keep it hanging over your head and you don't address what you need to do, that's a big stress in itself.

>> So on the workplace you have to get things done accordingly.

Now you need to be able to compartmentalize your stresses and figure out from a prioritization standpoint do I do this first or that first and that's often a means of managing stress.

>> If you want some basic behavioral techniques for managing stress, I would suggest taking inhalations and exhalations where you inhale over the course of perhaps two seconds exhale over the course of four seconds because as you're exhaling this particular autonomic nervous system called parasympathetic parasympathetic nervous system kicks in as you're exhaling and it actually slows down your heart rate.

>> So you actually are calmer as you exhale compared to when you're inhaling.

So inhaling for two seconds, exhaling for four seconds is one technique inhaling for four seconds, exhaling for eight seconds can also be down.

>> But the bottom line is have a longer period of time where you're exhaling it can calm you down and then there's a very simple behavioral technique where you put your arms on the side of the chair and you just imagine starting with your fingertips going all through your body you imagine yourself getting heavier and heavier and heavier in the chair itself.

It's kind of a technique we used to use with hypnosis but it's a means of just making yourself very relaxed and thinking about every single muscle fiber in your body and making yourself heavier and heavier and heavier.

And in doing so that is also a means of relaxing having maybe five minutes during the day here or there where you're not really thinking or focusing so much on your day to day work activity.

You're just kind of going into kind of a meditative state can be helpful often tell people when they're really stressed out at work, go easy on the coffee .

>> A lot of workplaces have the caffeinated coffee readily available and it's great for waking up the brain some.

But when you're already have high blood pressure, be careful of how much of that you're consuming.

It's great for focusing and helping fire up the concentration but if you get a little bit too much caffeine it can actually make you more more anxious.

>> Thanks for your call.

Let's go our next caller.

Hello Deb.

Welcome to Matters of Mind.

Hello.

Hi Deb.

Hi.

I have a daughter that has bipolar.

I just turned you guys died and I was wondering if the medicine can counteract with her brain hopefully in a good way.

>> Deb, in what way or would you wonder how the medication is working on her brain?

>> OK, she gets NEPI that's one way I can say it one minute she's real nice and then all I can say is she's nepi see because I have seizures so I know what my problem is that she was diagnosed with bipolar and she can be really snappy.

>> Yeah.

So why do people get snappy when they have bipolar disorder.

>> Deb does this happiness come and go based on her mood whether her moods on the high side or the low side if you can identify such polarity of her mood, OK, she's usually in the group beside I should say all the time OK, if she's more on the grippy side all the time it might not be a direct manifestation of her having highs and lows.

>> Now it's interesting that you have seizures yourself, Deb, because we see a lot of correlations between a seizure disorder and bipolar disorder.

In other words, there's a disturbance of glutamate.

>> Glutamate is that excitatory is an excitatory chemical in this outside part of the brain we call the gray matter of the brain and if you have disturbances of glutamate it can cause you to have seizures and it can also give you mood disturbances.

>> So nowadays, you know, we'll treat a lot of people with anti seizure medications even they don't have seizures.

>> They might have bipolar mood instability.

So we'll use medications like Depakote, Lamictal, Trileptal, Tegretol sometimes Topamax is used.

>> These are medications that have historically been used for seizures.

Now we are using them extensively for bipolar disorder.

So there's not a direct correlation genetically between seizure disorders and bipolar disorder but it's a kind of phenomenon where you can stabilize glutamate with seizure disorders or bipolar disorder and thereby get some help.

Now why do you get snappy?

Well, again, it comes down to a glutamate disturbance because when you have a glutamate disturbance which is a disturbance in that excitatory chemical in the brain, you will have disturbances in the how well you're able to control this front part of the brain called the orbital lateral prefrontal cortexes right above the eyeball.

That's why they call it orbital lateral talks to the outside orbital right above the eye socket.

But that part of the brain controls your ability to think before you say things and think before you do things.

>> When people have a disturbance with bipolar disorder, often this part of the brain is decreased in its activity that will cause you to be more impulsive and more irritable and more snappy.

How do you treat that?

Well, we were used medications will often treat seizures in the same way because what we're trying to do is as stabilize the glutamate.

>> So from a neurobiological standpoint yeah, there are mood stabilizers in medication that will allow a person to think before they say something, think before they do something .

But on the other hand, sometimes that's where the counseling comes in to help them try to be aware of OK, count in two or three seconds before they blurt out their thoughts about a particular type of situation in which they may encounter and they need to understand how their moods and how their happiness will be affecting others especially their loved ones because as you can imagine, Deb, when somebody has mood disturbances they often lash out the most at the people with whom they love the most because they know that they will be accepting and they'll be able to still be there with them in the end.

>> Well, you have to be aware of that because it can wear on a lot of people's type of patients as well.

>> Deb, thanks for your call.

>> Let's go our next caller.

Hello, John.

Welcome to Matters of Mind.

John, you mentioned that you were recently prescribed propranolol that used to be known as Inderal and you're also on alprazolam, also known as Xanax and Fluoxetine also known as Prozac.

So you're on propranolol alprazolam and Fluoxetine.

>> How do these medications interact?

Are there possible side effects basically propranolol as a so-called beta blocker it blocks adrenaline and propranolol will decrease tremors.

>> If you get anxious and you get tremors, it'll decrease the difficulty with having kind of a tremulous voice when you get really anxious will decrease some of the overall tension.

It's a good medication to decrease the heart rate when you get really anxious situation.

So we use propranolol not uncommonly for people who have anxiety that's manifested in a lot of physical ways propranolol will decrease sweating for people get really sweaty before they have to speak or they have to have a performance.

The biggest drawback of propranolol, John, is that if you get too much of it it can slow your heart down too much and can cause you to have a lower blood pressure that wouldn't be good.

>> So that's something you have to modulate.

Alprazolam is something that's been used since nineteen eighty three I think it came out it's been around for a long long time.

>> It was an alternative to Xanax.

I'm sorry it was an alternative to Valium.

So alprazolam also a Xanax was an alternative to Valium and Librium because they were more sedating Xanax or alprazolam isn't as sedating as Valium and liberate more but it did cause the potential for getting used to it and needing higher or higher doses which is that extensively back in the 80s, 90s, even early 2000s nowadays we're trying to get away from using alprazolam or Xanax because we realize especially as people get older they'll have trouble with memory impairment and it's something that's not recommended long term now.

So alprazolam or Xanax can be used short term maybe no more than two weeks at a time for some people higher doses you can get used to it.

>> You can feel kind of mentally dull in some ways and it will affect your concentration.

>> In other words, the speed of processing with alprazolam will slow a bit so it'll feel like your brain has slow Internet speed.

So alprazolam has those drawbacks so you want to use that sparingly.

Fluoxetine also known as Prozac is the third medication you're taking.

>> It's increasing serotonin among other things but mainly it's increasing serotonin when you're using for anxiety it's a medication that can be used safely long term.

>> It was originally used as an activating energizing medication that increased serotonin has an extra feature will help you lose a few pounds because of suppresses the appetite.

But increasing serotonin will give your brain kind of a calming effect.

It has kind of an emotionally calming effect for some people.

It'll make them not care and that's not good for some people that's the biggest side effect of Fluoxetine or Prozac or any medication.

It increases serotonin.

It can make you not feel happy, not feel sad.

You don't feel anything.

We call that emotional blunting also known as alexithymia but it just makes you not care about anything.

We don't want that that's a side effect we're trying to avoid.

But outplays limned propranolol flu vaccine they all work in different ways.

Fluxing will increase the blood levels of propranolol a little bit.

So ten milligrams of propranolol might feel like twenty milligrams.

That's the biggest direct drug interaction.

We call that a pharmacokinetic drug interaction but overall those medications can get along just fine.

I was just suggestion if you can try to go easy on the alprazolam or Xanax especially .

>> John, thanks for your call.

Let's go our next caller.

Hello Katie.

Welcome to Mastermind Katie.

>> You want to know when does having trouble sleeping turn into diagnosed in somnia?

Basically if you're not sleeping well, Katie, you'll feel tired the next day off tribal concentration the next day and you won't feel like you had a decent night's sleep.

Now most of us have cell phones now and if you think about it when you're recharging your cell phone, if you're not getting a good charge on your cell phone or let's say your battery on your cell phone started to go bad, you'll notice that your battery lasts maybe four to six hours.

It doesn't last the whole day and you have to keep recharging it.

Well, that's what happened to your brain if your brain doesn't get adequately recharged at night with two very important phases of sleep, there's a non rapid eye movement sleep and there's a rapid I'm asleep it's called non REM and REM and the non rapid eye movement sleep is where your whole body is getting very relaxed if you get awakened during non rim which is what's occurring within 30 minutes of you're going to sleep if you get awakened or in the time you be kind of confused for a few seconds because you're going into a very deep sleep that's called non REM that helps your body physically recharge and then there's REM sleep where you're dreaming REM sleep your body's paralyzed during that time but if you're awake and you're going to be alert and awake but you're dreaming during that time often very abstract dreams when you dream that actually helps with your memory and you are shutting down this left front part of your brain here that you use for intense focus and concentration out the day.

So in doing so you're giving that thinking part of your brain a rest when you're in REM sleep.

So if you've gotten your non REM sleep, your body feels refreshed, your REM sleep gives your brain refreshed.

>> You need both phases of sleep to really feel like you slept well.

>> If you don't you have what we call functional impairment.

You feel like you are not as sharp the next day you'll feel like you just can't get things done as well.

You'll have to have frequent naps.

You're always tired now there's a lot of things we'll examine if people are having those kind of symptoms.

We'll look at your thyroid sometimes ion especially a woman who's heavily menstruating.

We will look at glucose disturbances.

>> Sleep apnea is something we're often trying to identify because it's so readily treatable.

>> Sleep apnea is where you might be snoring or pausing your breathing at night and it's not allowing you to have a good night's sleep but basically insomnia becomes problematic when you have what's called functional impairment.

>> You're not able to get the things done the next day that you'd like to get done so you're not able to socialize.

You're not able to think you're not able to focus on things you're not able to do well in school.

You're just not able to get the things done.

You'd like to do.

>> That's called functional impairment.

That's where you have a diagnosable insomnia itself.

>> Katie, thanks for your call.

Let's go our next caller.

Hello, Caleb.

Welcome to Matters of Mind.

>> Caleb, you mentioned you're on sertraline, also known as Zoloft searching for anxiety and you're having intense stomach pain.

>> Is that from the medication or your anxiety depends on what started when Kayla because Ritalin increases serotonin serotonin is in the whole body 90 percent of the serotonin tone in your body is in your gut.

>> So if you have anxiety that causes you to have stomach pain or stomach aching, actually taking a medication like sertraline can relieve some of that by going to the brain enhancing serotonin in the brain and giving your brain a calming effect.

The brain is connected to the gut.

The gut is connected to the brain and if you have a calming sensation in the brain you'll have less anxiety in the gut and less stomach.

>> So sometimes you know it's a matter of what came first if your anxiety previously was manifested by gut ache gut making sure the circling can actually help with that.

However, if you never had any stomach problems before all of a sudden you're taking certainly increasing sertraline can indeed stimulate certain receptors in the gut for serotonin that can give you nausea and sometimes diarrhea and those are side effects we often hear about early on with certain lame it's related to the dosage.

>> The higher the dosage, the more of those type of symptoms will often have people take lower doses with food because food will slow the absorption.

>> Give your got a little bit of a coating effect and it'll decrease some of those side effects.

But with time off in those side effects, do decrease.

But Caleb, anxiety can be manifested by gut pain certainly and can cause gut pain.

>> So it kind of goes back and forth in terms of which started.

Thanks for your call.

Let's go to next caller.

Hello Tina.

Welcome line.

>> Tina, you want to know if technology can be an addiction whenever you take it away from teens electronically they lose it.

>> That's not a good sign, Tina.

Yes, elect technology is very smart because technology with social media especially has algorithms you may have heard about them algorithms kind of get to know what really interests you.

>> And the thing about any kind of addiction is you're firing up.

This is the front part of the brain looking at you I took the brain apart in here is the called the nucleus accumbens.

The nucleus accumbens will fire out dopamine when you're getting excited about something new exciting novel type of experiences will fire out more dopamine and the only way to fire up more dopamine after repeated experiences will be to do something that takes it up a notch and can be even more exciting and in social media and in gaming those type of experiences with technology you can sometimes need that greater thrill and you know it's a problem where if you try to take it away or step away from it you get very anxious and irritable.

Not a good sign there should be a time limit and they should your teen should know that ahead of time they're only have a certain amount of time to be on the social media.

They have to get away from it because the addictive nature of the technolog pulls them in and will cause them to actually have mood disturbances if they're on it too much.

It's cell phones were fantastic when they first came out-tremenl this technology and information.

>> But the problem is it can be troublesome in terms of being able to pull away from it, especially if you're using a late in the evening and it's impairing your ability to socialize with other people.

>> Tina, thanks for your call.

Let's go to our last email.

I think we have another email coming in here.

>> Here it is.

Got about another minute here to follow or other new directions in the treatment of psychiatric disorders disorders that are emerging in the coming years.

>> It seems like there hasn't been any progress in psychiatry like there have been in other medical fields.

>> I think the new direction we're going to be hearing about in psychiatry over these next few years will be this whole concept of being able to treat stress, resilience difficulties.

In other words, stress resilience has to do with how well you're able to put up with stuff I mentioned earlier the whole concept of stress being you're having difficulty coping with day to day changes.

>> Well, that's called stress resilience and I think that's going to be the focus we're going to be seeing and with improved stress resilience people will be able to function better with their social environment, their work environment, their school environment.

>> So I think stress resilience is something will actually be measuring.

There's a test called a Konner Davidson's Conor Davidsen stress resilience test that has come out that we're going to be testing more and more people.

Thanks for your call, Tina.

Unfortunately I'm out of time for this evening.

If you have any questions concerning mental health issues, you may write me a via the Internet at matters of the mind at WFYI dot org.

I'm psychiatrist Jeff all you've been watching matters of the mine on PBS Fort Wayne God willing and PBSC willing.

>> I'll be back here next week.

Thanks for watching.

Goodnight