But good evening, I'm ppsychiatrist Jay Fawver live from Fort Wayne , Indiana.

>> Welcome to Matters of the Mind now in its 10th 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 the Fort Wayne area by dialing (969) 27 two zero or if you're calling any place coast to coast you may toll free at 866- (969) to seven to zero.

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

>> And if you'd like to contact me with an email question that I can answer on the air, you may write me via the Internet at matters of the mind all one word at WSW org.

That's matters of the mind at Edgard.

>> I'll start tonight's program with a question I recently received.

It reads during the former What are your recommendations on treating borderline personality disorder impulsiveness?

>> In other words, borderline personality disorder does have impulsiveness as a characteristic of it.

Now let's go back to what causes borderline personality disorder.

I don't like the terminology.

There's always been discussion among the American Psychiatric Association and changing the term borderline personality disorder.

>> It's based on an old psychoanalytic term where you have symptoms somewhere between neurosis and psychosis.

Well, people don't use the term nerve neurosis anymore but that's what they did in the old days.

If you have symptoms that are between neurosis and psychosis, it's considered to be borderline and they call that borderline personality disorder.

>> If you have symptoms of anxiety, distrust, moodiness, difficulty with quasi psychotic thinking where you get really paranoid and part of the symptomatology will be difficulty with impulsiveness where you do things and say things you ordinarily shouldn't do.

Now it sometimes is confused with bipolar disorder.

I think it's a spectrum along the lines of bipolar disorder.

My preference would be that we call it bipolar spectrum disorder kind of like what we do with autism now we don't talk about Asperger's disorder anymore.

We talk about autism spectrum disorder.

I think we should do the same with borderline personality disorder because I think it's a condition where you have moodiness related to difficulty with putting up with stuff.

In other words, it's a condition where you have impaired resilience.

Resilience just means you're able to put up with things with borderline personality disorder.

>> You get moody, you get devastatingly depressed, you get irritable and you get impulsive when you have relationship difficulties or things in your environment aren't going as you would expect with bipolar disorder.

You'll wake up on a Wednesday or a Thursday and all of a sudden you're a high sky high.

You don't need to sleep for a few days.

You're talking a mile a minute.

You're going from topic to topic you're spending and it goes on for days and then you'll crash and in a uncharacteristic manner such that you get really depressed for no particular reason and that depression goes on day by day by day.

So with bipolar disorder is several days up, several days down very typically with borderline personality disorder you'll have so many make you angry.

You go off on him in a rage perhaps or you get extremely depressed because you hurt your feelings that might go on for a few hours and then you're OK now you might think well gee, everybody does that well with borderline personality disorder you do it to an extreme where it gets you into trouble with relationships, it gets you into trouble sometimes with the law, with your workplace it becomes a personality disorder to the extent that it causes what we call functional impairment.

>> So everybody has some irritability.

Everybody has highs, lows.

>> Everybody has difficulty with feeling anger but with borderline personality disorder goes to an extreme where it gives you significant consequences.

So is there treatment for borderline personality disorder related impulsiveness?

Yes there is now we'll do it in various ways.

Number one, there are talk therapies or counseling treatments for borderline personality disorder where people are particularly focusing on the here and now and there are developing coping strateges to address that resilience that they lack resilience being where they have trouble putting up with stuff.

And one of the best treatments for borderline personality disorder will be dialectic behavioral therapy.

People don't know it as DBT but DBT is a treatment where ou're focused ow you're not going back into your past and looking at all the reasons for borderline personality disorder and all your past traumas.

You just look at the here and now and you're figuring out how to best cope with your day to day situations.

>> Now people will wonder well what brings on borderline personality disorder?

It's starts in your early childhood development before the age of eight years old we start developing our personality.

It's gradually develops and evolves over the course of your adolescence and early adult years.

But the bottom line is when you have traumatic events occur before your eight years of age that makes a big difference in your overall personality.

So you're shaping your personality as a very young child if you have adverse childhood experiences occurring before the age of eight years old that will give you a greater likelihood of actually having chemical changes in the brain that will cause you to have trouble putting up with stuff later on so early bad childhood experiences can cause you to have a compromised ability to cope and be able to put up with stuff later on in life and a neurobiological changes your brain if you do that and it even happens in the if you're a mother when you were in the, if your mother is going through some extremely traumatic events including the loss of a loved one or a difficulty with job or relationship issues while you're in the you have been born yet your brain is still developing in the.

You thereby based on your mother's experiences can have difficulty with resilience.

>> So we're frequently asking people about early childhood experiences and there's a scale that's copyrighted called the Adverse Childhood Experiences Scale also known as the ACS and the adverse childhood experiences skills a ten item scale if you have four over four of those items that you check off, it puts you at higher risk for having difficulty later on in life with depression, anxiety and symptoms of borderline personality disorder.

So it's something we will ask many, many people in their initial evaluation.

We will give them the ACS questionnaire just to try to screen if they have difficulty with early childhood experiences that sometimes will set the template in the brain.

>> Now if you have those kind of experiences, yeah, you can have some neurobiological changes that have occurred in the brain to some degree.

We always hope that talk therapy will help with those neurobiological changes.

>> Talk therapy if it's successful will change the chemistry.

>> The front part of the brain, the front part of the brain is where you will have the ability to put up with things, control your impulses, concentrate focus to decrease distractions and so forth.

>> So the front part of your brain needs to be able to work properly for you to have a good quality of life.

>> You'll have functional impairment at the front part of the brain's not working.

Talk therapy indirectly can help the front part the brain help reasoned through your life circumstances.

>> However, if you've had some really bad childhood experiences it can sometimes create a template in your brain where you're going to have more trouble coping with things and it's kind of predictive that if you have experienced a lot of bad trauma emotional abuse, sexual trauma, all sorts of stuff in your early childhood years, it's a predictor that you will not respond to these very common and commonly commonly prescribed medications called the exercise the selective serotonin reuptake inhibitors.

>> These medications include Lexapro, Celexa, Zoloft, Paxil, Prozac.

These are medications commonly prescribed to people for depression and anxiety.

But if you had early bad childhood experiences they might not work and that's predictive.

>> They won't work if you had a really bad childhood experiences you couple that with genetics about one out of three people will have a really good response to the serotonin medication that have for depression and anxiety but two out of three won't and it's predictive that those two out of three who don't have good experiences with the SSRI well they also had not only genetics that predict that but also bad childhood experiences.

So you have to couple the genetics with childhood experiences to try to figure out how a person is going to respond to different medications.

So for impulsivity yeah, Dilek behavioral therapy based on somebody's genetics and based on their early childhood experiences, we may or may not select the serotonin medications but many times they won't work.

So what do we do?

We'll often use the so-called antiepileptic medication.

>> If you think about early childhood development with the brain being kind of like a seizure disorder with a seizure disorder you have electrical currents that are occurring and they cause you to have movement disturbances.

>> We know about seizures if you have difficulty with seizures there's a disturbance with glutamate and another chemical called GABA glutamate is the accelerator on the brain gabbers the break bottom line is with seizures you have too much acceleration, not enough brake and excessive glutamate activity two little GABA activity.

>> So what we're trying to do is balance that out like a teeter totter.

The same can be true when you're treating somebody with moodiness, anger, irritability, impulsiveness.

We're trying to balance out that glutamate and GABA so to balance out the glutamate GABA will often use a medication like an anti seizure medication such as Lamotrigine Trileptal also known as Carbone's Carbamazepine.

>> These are kind the medications that will dampen down the effect of glutamate transmission sometimes will increase GABA with the medication that indirectly will affect GaveKal gabapentin.

Another one called Lyrica also known as Pregabalin.

So these are medications that are dampening down glutamate enhancing GABA and in doing so can decrease irritability, anger, moodiness and impulsivity related to borderline personality disorder.

So borderline personality disorder typically starts in childhood to some degree it's kind of setting the foundation in childhood with early childhood experiences based on traumatic experiences where you've had parental abandonment, you've had abuse, you've had a parent or a close loved one in the household who is no longer in your life .

>> You're getting you're getting the sense of abandonment at an early, early age.

>> You've had you've witnessed your parents having divorced or having some mental health issues of themselves.

These are all childhood traumas that can affect the brain neurobiology and physically impact your ability to put up with stuff later on and many times that will come across as impulsivity.

Many, many times people with borderline personality disorder will use alcohol or any kind of drugs of abuse to try to self medicate.

They often gravitate towards toward toward cannabis, THC marijuana as a means of calming down the anxiety and they'll say it helps.

>> But the problem is then they get to the point where they can get more depressed, they get less motivated.

They don't they don't find themselves as productive as they ordinarily would because we know especially when marijuana is used before the age of twenty four it dampens the growth of the brain and it can actually decrease your IQ points.

>> So the with especially younger people we try to tell them and stay off the marijuana, stay off the alcohol and we try to medicate them if they need medication with medications it'll be safer in the long run for them but we try to get people away from self medicating with borderline personality disorder because they're often prone to do so.

>> Thanks for your email.

>> Let's go to our first caller.

Hello Stephanie.

Welcome to Matters of Mind.

Stephanie, you had mentioned earlier on Mirtazapine it's also known as Remicon and you're taking it for sleep disturbances and you feel like you're snacking all the time.

How can you curb your appetite?

Mirtazapine is a medication.

It has five mechanisms of actions.

>> It came out about thirty years ago and we were really thrilled when it came out because it enhances the firing of norepinephrine and serotonin and then the target site it does some nice things in terms of the different receptors at it targets.

So you have serotonin, you have norepinephrine firing out of the firing neuron going to the targets and that was all a good thing.

>> But one of the things that will do is it'll block histamine so by blocking histamine mirtazapine or Remicon it'll help with sleep but it'll profoundly increase the appetite that's been the biggest drawback of mirtazapine over the course of time.

If we could have a mirtazapine that didn't block histamine, would it be more popula?

>> You'd have a serotonin norepinephrine medication that's firing Precint optically or from the firing neurons so we'd be more excited about that but that's always the drawback.

>> So we use mirtazapine not uncommonly for people who are not having trouble with weight gain.

As a matter of fact, if they're more slender they're having trouble with appetite.

Mortez means great medication.

We'll use mirtazapine for older adults people over 55 or 60 because they often will have more trouble with appetite anyway and often they're not gaining weight as it is.

>> So we'll use it intentionally to try to fire up their appetite.

Many in many cases we will use mirtazapine for people who are undergoing chemotherapy.

>> Chemotherapy will dull the appetite.

>> Mirtazapine does a marvelous job fire up the appetite and helping with sleep so mirtazapine as a medication helps with sleep, depression, anxiety and nausea.

>> We give it not uncommonly for women who are pregnant because throughout the all three trimesters of pregnancy and during breastfeeding mirtazapine appears to be a safe medication.

>> So we use it in specific situations.

My thought would be if Mirtazapine is giving you difficulties increased appetite you could consider if you've not done so already asking your clinician about the possibility of another medication that can help us sleep in a different way.

>> Perhaps like Trazodone, Trazodone will affect some of those same type of receptor activity that Mirtazapine will but it won't give you the increased appetite gabapentin I mentioned that earlier Neurontin used not uncommon name for people who are anxious and they're having trouble with anxiety in general.

We use gabapentin as a medication for sleep not uncommonly because it helps people get a sleep within twenty thirty minutes and then it lasts for about eight hours.

>> It gives you a good quality of sleep so you get the REM sleep, you get the non REM sleep.

It does not appear to be addictive for most people.

There's about two percent of the people who get in trouble with gabapentin but most people do fine with it.

>> So if mirtazapine is a medication that is increasing your appetite, you know you could always try to use discipline and make and just force yourself not to eat especially after 7:00 p.m.

But for some people it's very difficult to control because they get that craving for carbohydrates.

>> A high protein diet is a way to get around that if you insist if you really want to stay on Mortez Pincus's doing a wonderful job with anxiety, depression, sleep, all these different things, you can still take it but just make sure to have some protein available on a regular basis.

You'll notice that it's difficult to binge on protein.

>> Nobody ever binge is on t bones or falaise.

You have so much and you're done you will binge on carbohydrates.

>> So the key would be to eat not carbohydrates but eat more protein and eat some of fatty foods like cheeses and things like that as a means of trying to suppress your appetite as well.

But what you don't want to do when you're on mirtazapine if you notice you have an increased appetite, you don't want to increase or eat the carbohydrates because you won't stop with those.

>> You'll go on and on.

>> So if you don't want to go off mirtazapine and change over to Trazodone Gabapentin Dock's appends another option at low doses.

>> If you'd rather not do that, change your diet and eat a lower carb diet overall.

>> Stephanie Stephanie, thanks for your call.

Let's go our next caller.

Hello Paul.

Welcome to Matters of Mind.

Paul, you had mentioned that when you get stressed out you have eye twitches and you might sometimes get blurred vision.

>> What's the connection between stress and vision, Paul Sometimes people will notice this with caffeine.

If you if you consume excessive caffeine you get it which is why do you get eye twitches with caffeine?

>> Well, it's because you've increased norepinephrine so much when you increase norepinephrine that's a chemical derivative of adrenaline.

>> When you increase norepinephrine it can make you a little bit more twitchy and another thing that it can do is dilate your pupils.

So when your pupils dilate you'll notice sometimes it'll give you a blurred vision.

You'll be able to see things close up just fine not uncommonly but you can have blurred vision because you can have a dilation of the pupils when you get more stressed out and that's where you can also get more twitchy.

So the first thing I'd recommend especially if somebody is having twitches or having blurred vision maybe that's from tremor upset stomach these are all symptoms of possibly getting too much caffeine.

So if somebody is having a lot of trouble with anxiety and they're having symptoms of getting a little bit too much caffeine, we try to give in to back off of the caffeine.

>> So the first thing I want to do if you're consuming oh three or four cups of coffee a day, you're consuming a significant amount of caffeine in one way or another.

I certainly have.

>> You consider cutting back on the caffeine by half and it'll make you less twitchy and probably give you less difficulty blurred vision in that regard but that is certainly related to anxiety twitches, blurred vision, tremulousness those are all related to excessive adrenaline release and again that's related to norepinephrine.

>> Thanks for your call Paul.

Let's go to our next email question.

>> Our next email question reads Dear Dr. Farber, why do I have a hard time sleeping when my partner is away?

>> Is there anything I can do to help me sleep when my partner is gone?

It depends if your partner is there and you perceive that you're unsafe when your partner is away, that's one factor you're describing a reason why some people get a dog now dogs can be a blessings or curses with sleep if you allow your dog to to sleep in your room on one hand it can be a blessing in the sense that you can possibly sleep better because you feel safer.

On the other hand, if the dog is jumping up on your bed or making noises during the night ,that can be a factor in terms of keeping you awake.

But some people will get a dog if they feel unsafe especially when their partner is away.

>> Dogs they're related to the wolves.

They are there for the protection.

They're very much on guard.

They know when things are happening that are unusual around the house if they hear noises so dogs can help you feel safe, some people will feel like they don't sleep as well when they're partners away simply because they like that other person in the bed.

And I hear that's not uncommon only for people who have lost a spouse.

They're not just a way temporarily they passed away and they feel very lonely in that bed.

So for those people a real simple trick is to have a few pillows there where your spouse would have been just to give you the physical sensation.

It's some something or somebody is there.

So that's another type thing.

So I think the first step would be to try to determine when your partner is away.

Do you feel unsafe or is it because you feel more lonely?

>> And in those cases depending on the situation there are different things that could be done.

>> Thanks for your email.

Let's go to our next caller.

Hello Carla.

Welcome to Matters of Mind.

>> Carla, you want to know why you say weird disturbing things in your sleep when you're sleeping?

Carla, you're not supposed to be speaking.

>> So there is a neurobiological phenomenon that goes on there when you sleep and you go into rapid eye movement sleep, your brain is very, very active and your brain's active and your brain wants you to talk and move and do all sorts of things but you can't it's a matter of fact if you awaken normally during rapid eye movement sleep you'll notice he can't talk and many people say when they're having a bad dream they will feel like screaming but they can't and if they get halfway awake they'll notice they can't scream.

>> That's a good thing.

You don't want to wake the rest of the household by screaming.

>> So it's a good protective ability to be able to dampen your motor reflexes when you're dreaming.

So when you're in rapid eye movement sleep or dream sleep you shouldn't be able to move around or talk.

>> But some people do.

It's called REM Behavior Disorder with REM behavior disorder your body does not get paralyzed down like it should so it doesn't shut down like it should.

So sometimes it will be medications it will use as a means of suppressing those type of things.

>> But you might have difficulty with kind of these mini awakenings where you're saying things in your sleep but normally people should not talk during their sleep if you are talking to in their sleep what they're doing is talking through their dreams and it's always a matter of OK, how much of a problem is if you're moving around at night time during your dreams, if you're talking during your dreams the question is of making you tired the next day and it's actually a factor on why some people feel like they did not get a restorative sleep.

They feel like they're still tired when they get up.

It's because they were busy all night either moving all around or talking and things like that.

>> When you're in REM sleep you should be totally quiet.

You shouldn't be moving at all.

>> Now there is a phenomenon called sleepwalking that's not occurring during REM sleep that's during non REM sleep, non REM sleep, not rapid eye movement.

>> Sleep is a very deep sleep.

The EEG, the brain waves are very deep and high and low.

>> It's a very deep sleep and if you're awake and during that sleep normally you'll be kind of confused for a few seconds not knowing where you are or what you've been doing.

It's the first sleep stage of sleep you'll go into when you first go to sleep.

So if you take a nap oh late and late afternoon which is actually very good for the brain during that twenty minute nap twenty five minute nap you'll notice that as you awaken you'll look all around you and not know where you are .

>> You'll be kind of disoriented just for a few seconds then you come out of it.

That's actually a good thing.

That means you were in non rem sleep non REM sleep is very restorative to the brain.

It helps you with concentration.

It helps you download your memories.

>> I often recommend to medical students to whom I will speak that they should get a power nap for no more than maybe 30 40 minutes late in the afternoon if you get a power nap late in the afternoon it actually recharges your brain.

It clears out all the clutter and you're able to download more information and you can study better at night because as a medical student yeah, we need to be on top of our games and we need to study sometimes 12, 14 hours a day when you include classroom time.

So it's very exhausting to maintain that level of concentration for that long.

>> So having a power nap for now no more than forty minutes late afternoon can get you into that non REM sleep if you go into REM sleep where you're dreaming that might be a little bit too much and cause some people will say if they try to take a nap they'll end up napping for two hours.

That's not good at all.

If you do that it means you're not getting enough sleep at nighttime but at twenty to twenty five minute nap maybe 40 minutes at the most late afternoon can help recharge your brain but it should not interfere with your sleep at night.

What you're trying to do there is get into some non REM sleep where you're going to get into that really deep sleep during that time and in both cases non REM sleep and REM sleep you shouldn't be moving around non REM sleep that's where you're sleepwalking if you get up because you're exhausted and you go in a non REM sleep you can have sleepwalking and that's usually indicative that somebody is not getting enough sleep.

non REM sleep is a misperception that if you're awake awaken somebody while they're sleepwalking it's going to cause them some kind of detrimental effects that's not true at all if you awaken them during sleepwalking, number one, take them back to the bed, make sure they're in a safe environment, let them get back to sleep.

>> But usually if somebody is sleepwalking they're not getting enough sleep and they go into this really deep non rem sleep that's so deep they end up getting out of bed sleep terrors by the way, where somebody screams and they're very confused and disoriented.

That's also during non REM sleep as well.

REM sleep is where you're dreaming but you should not-cale around during that time.

>> Carla, thanks for your call.

Let's go next caller.

Hello Donald.

Welcome to Matters of Mind.

>> Donald, do you want to know can chronic pain lead to mental health issues?

Yeah, pain will give you more of a demoralization and depression and being demoralized and depressed will often make the pain worse.

They go back and forth when we talk about pain we're talking about impulses coming up the spinal cord and going to the brain.

>> If you can dampen down those impulses going from the spinal cord up to the brain you can relieve pain and one of the ways you can do that is by increasing serotonin and norepinephrine with antidepressant medications that increase serotonin and norepinephrine concomitantly and those antidepressants can be medications like that.

Zema, Effexor Cymbalta also known as Delux and these are medications that increase both serotonin and norepinephrine and in doing so they can dampen down the pain but in the long run they can help people with her moods.

>> So if you have chronic pain it just wears you down and it can cause you to be morepdeprese hopeless about things and you wonder when's it going to go away and if it's amplified by disability where you have chronic pain causing you to not be able to get stuff done every day that can be demoralizing because that too is a contributor to depression not only thanks for your call unfortunate I'm of time for this evening.

>> Any questions concerning mental health issues that I can answer on the air?

You may write me via the Internet at Matters of the Mind at WFYI dot org.

I'm psychiatrist, chef author and you've been watching Matters of Mind on PBS Fort Wayne now available on YouTube God willing and PBS willing.

>> I'll be back again next week.

Thanks for watching night