good evening.
>> I'm psychiatrist Jay Forfar live from Fort Wayne, Indiana.
Welcome to Matters of the Mind.
Now this twenty second year matters of the Mind is a live call in program where you have the chance to choose the topic for discussion.
So if you have any questions concerning mental health issues, give me a call here at PBS for Wayne by dialing and then Fort Wayne Area nine six nine two seven two zero or if you're calling long distance you may dial toll free coast to coast nine eight six six nine six nine two seven two zero.
>> Now on a fairly regular basis we are broadcasting live every Monday night from our PBS Fort Wayne studios which lie in the shadows of the Produ 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 WFYI org that's matters of the mind at WFA dot org and I'll start tonight's program with the first of a couple of emails I recently received.
The first one reads Dear Dr. Fauver, what have you heard about the new Alzheimer's medication that was approved?
>> Should I recommend it to a family member that has dementia?
Many people have asked me this question to this today and it's a medication it's been discussed for several years called ADD you can IMAP and add you can have as a medication that basically is human monoclonal antibodies so it's little antibodies that will attack part of the protein that is thought to contribute to Alzheimer's dementia.
>> So here's how this works.
>> Alzheimer's dementia is basically a progressive condition where the side parts of the brain on side here gradually shrinks down especially the the memory center of the brain called the hippocampus.
So with Alzheimer's dementia you start to lose track of where you are, what you did earlier that day.
It has to do with short term memory loss and a key feature will be difficulty naming things and getting the right words out.
And people with Alzheimer's dementia slowly become more withdrawn and they have less to say in conversations.
>> So with Alzheimer's dementia it's a condition that affects us all as we get older such that by the time we get to be 100 years of age half of us have Alzheimer's dementia.
If we get to be 90 years of age one out of three of us have Alzheimer's dementia.
>> It also has a genetic component where if you have this particular genotype called apolipoprotein E four you're more likely to have Alzheimer's compared to if you have three.
>> So there is these different risk factors head injuries, diabetes, hypertension, depression these can all increase the likelihood for Alzheimer's and we're seeing it progressively increase around our country as we get older.
So for the past 30 years we've not had any new mechanisms of action for treating Alzheimer's dementia.
>> We've had mechanisms where you increase acetylcholine so we have the so-called acetylcholine state race inhibitors Aricept rhapsodize xylene just to name three of them.
>> And then we have this medication called Namenda Memantine that tends to block NMDA receptors and that will decrease the toxicity sometimes caused by Alzheimer's overly stimulating the nerves and releasing excessive amounts of calcium.
So that's been our mechanisms really for the past thirty years of treatment.
>> Well now we have a medication that can actually go an attack.
>> The protein gunk that is accumulating in the brain with Alzheimer's is called beta amyloid.
So you might hear about beta amyloid the news it's basically like a gel like protein that kind of gunk up the brain and it's thought that between beta amyloid and what's called tau proteins which are kind of like stringy little proteins, those are the two pathological means by which we see with Alzheimer's.
So as you cut somebody's brain open after they've died of Alzheimer's dementia, you see those kind of pathologies, the tau protein and the beta amyloid.
So the question always was well gee, if you could dissolve the beta amyloid, wouldn't that be a nice treatment for all time heimer's does disease and several companies have tried to develop compounds that would dissolve the so-called beta amyloid and the medication was recently approved.
>> AD you can imagine is a medication that tends to go in attack the beta amyloid by using antibodies so antibody human antibodies will attack a foreign tissue and try to destroy that tissue and get rid of it in this case is the beta amyloid.
>> So what was found over the course of a year and a half of study for this particular compound was that compared to a saline injection?
It's a once a month injection and you can do that at a doctor's office.
>> But with this once a month injection it was found that as people looked at these scans of the brain they had a 30 percent decrease in beta amyloid compared to people who just took a sailin or like a sugar injection.
>> So that was thought to be well successful at least from a pathological standpoint.
>> Here's the problem and here's the controversy and I'm sure you're hearing about this at this point.
>> The Food and Drug Administration approved it today based on it theoretics helping Alzheimer's dementia symptoms although in the clinical trials, the memory tests and the attention tests that were performed didn't do that much better than the placebo arm where people had either sugar water sailing or whatever.
They just didn't do that much better compared to the people who didn't get any drug at all.
So the question was was it really worth it?
>> So were you'd have to bank on would be the possibility of shrinking down this particular beta amyloid and the one of the means by which it's thought to cause dementia, the pathology of the brain, would that be worth it to take a medication just on that or would you want to wait longer period of time?
This drug was used early in the process of Alzheimer's dementia.
These people did have a positive electron tomography scans PET scans to make sure that they did have the amyloid plaques in their brain at the start of the treatment and that's how they were measured as as time went on to see if they actually had a decrease in the plaques.
But the question was did it make any difference and their memory and the actual symptoms of Alzheimer's.
So that's why the Food and Drug Administration approved the use of this particular medication is going to be called add you helme I believe it's a trade name add you helme so they approved add you home based on it theoretically helping Alzheimer's by shrinking down the amyloid plaques or decreasing the amyloid plaque development compared to placebo the placebo arm.
>> But it didn't show dramatically an improvement with memory and attention span .
But the question always is could it help people in other ways with Alzheimer's disease?
So it's something that you can discuss with your primary care doctor, your neurologist to talk about your family member with dementia would be worth it or not.
>> It's a once a month objection.
It will be expensive obviously it'll be expensive.
Insurance may or may not cover it because insurance might say well gee, it wasn't shown to be any better than placebo in terms of treating the symptoms of Alzheimer's.
But what it does it actually treats the underlying pathology associate with Alzheimer's.
So it's the first medication that I know of of its kind that was approved by the FDA based on its mechanism of action and what it actually did as opposed to its results in treating a condition.
>> Thanks for your email.
Let's go to our first caller.
Hello Grace.
Welcome to Matters of the Mind .
Hi.
Hi, Grace.
Great.
Yes.
And I'm calling because I'm fighting depression and so my doctor put me on the generic for Abilify neuropeptides all well it's not working good for me at first it seemed like it did good for about a week but then I got mouth sores and I also got a pain in my left side like my jaw and my throat.
It just felt kind of hurt and I don't know what's wrong but I I just went off of it first I took half of a pill now I just went off of it because I I don't like the way it makes me feel.
>> Grace is also known as Abilify.
Was it a medication that was used with another medication or was it used by itself.
>> Yes like the generic for Boosler this Birhan is a medication that is often used for worry and anxiety.
>> Abilify is a medication that will subtly increase dopamine if you need an increase in dopamine but it can block dopamine if you have excessive dopamine.
The bottom line is grace.
What was a dosage of that tablet size that you took?
>> Was it ten milligrams?
Five milligrams, two milligrams?
OK, the booster shot five milligram and also two milligram for the Abilify.
>> OK, you took a nice low dosage Grace.
You were very sensitive to it obviously you got the sore jaw because Abilify can block dopamine more so at the higher doses obviously but some people are really sensitive to it and you've got the tight jaw we call it bruxism and basically it's where you get excessive dopamine blockade and that could have been a factor there.
>> I always tell people Grace, you know, I learned this way back in pharmacy school back in the 1970s but you know, if a medication rarely causes a side effect but you're a person who has a side effect well you're the person who has that side effects.
>> So if it caused a particular side effect, why you're taking the medication you went off the medication, the side effect went away.
Well, that was a side effect of that medication for you individually and that was the case with the mouth sores.
It's unusual to hear about mouth sores with Abilify.
We hear about hear about it with other medications.
Sometimes it cause a dry mouth, perhaps an Lamictal Lamotrigine and is a medication where we sometimes will hear about Mauser's.
But Abilify doesn't usually cause Mauser's.
But if it did for you and you went off of it in the Mauser's went away that was a side effect you had.
But the your jaw is not uncommon again it's called bruxism.
It's from dopamine blockade's.
So the good news is there's a lot of other types of treatments out there besides Abilify.
>> Abilify is often used as a means of adding on another medication to an antidepressant medication.
So we'll often use Abilify with medications like Zoloft, Cymbalta, Ramras and Mirtazapine Wellbutrin.
So you add Abilify on top of that that sometimes makes them work better.
So Abilify is something that can help with those kind of conditions but not for you.
So it's kind of situation where you probably need to go a different direction.
We'll do genetic testing on people Grace and when some people we identify they're just not a good fit for our medication like Abilify and from a genetic testing standpoint it comes out to about one out of five people just aren't a good genetic fit for Abilify based on this mechanism of action.
And some people with Abilify will have the kind of symptoms you're having especially with a sore jaw.
And if you were to stay on it you could get twitches in the mouth and tongue movements and you could have tics in the eyes and things like that and we'd want to keep you off with that kind of medication.
So there's lots of other options available for Grace obviously mention these kind of side effects that you had from Abilify to your doctor.
Your doctor should put those on record that those are the kind of side effects you had with Abilify would likely keep you off medications in that same class because as we know you know, if one medication in a class causes certain side effects, we probably won't want to stay away from other medications in that class and that's why it's so important for us as clinicians to carefully track how people did on various classes of medication and document that visit to visit, to visit, to see how people do and how these medications are working for them because you can start to get a picture based on a patient's medication responses how they do based on mechanisms of action with different medication.
And it's very important for us as a clinician to keep track of that.
Grace, thanks for your call.
Let's go to our next email.
Our next email reads Dear Dr. Farber, please discuss covert narcissism.
Can it ever be cured or covertness narcissism used to be called closet narcissism I think several decades ago by a psychologist by the name of James Masterson and it's not the kind of out there in narcissism you often hear about when people hear about narcissism, they hear about they think about the exhibitionist, the guy that is wanting all this attention and they are being very flamboyant.
>> They're a know it all.
>> They're very annoying to be around and that's why people with narcissistic personality disorder can be very difficult to tolerate and it's more of a social and interpersonal problem.
Closet narcissism is also known as covert narcissism.
I think it's called vulnerable narcissism.
These are people that are much more subtle and these are people where they will put themselves in the role of the victim and they're always fishing for compliments.
In other words, they perceive themselves to be at a higher level than everybody else on the hierarchy scale.
>> They want compliments.
They are will be very passive aggressive in how they interact with other people and they will place themselves in this victim role as a means of getting more attention to themselves.
And it's called covert narcissism.
It can cause a lot of interpersonal relationship difficulties.
These people will often be well somewhat exaggerating in a lot of the stories they're telling about what's happening in their lives and it's very subtle for people around them but other people around them start to get annoyed and angry for them and they don't know why a person with covert narcissism will be at a higher risk for depression because they will often perceive they're not getting the praise that they really deserve.
>> I love her narcissism from a neurobiology standpoint to be better studied.
But the problem is a lot of people with narcissism don't realize they have narcissism because it's a condition where they lack self-awareness and there's a self-aware as part of the brain called the insular.
>> It's right inside the over here the temporal lobe.
So there's a frontal part of the brain temporal lobes here and it's right there in the crease of the temporal lobe.
The insula is the body of tissue that's called that's used for self awareness and when you have this self awareness you have increased activity with the insula.
>> And I wonder if people with narcissistic personality disorder or covert narcissism as you had mentioned, have difficulty from a neurobiological standpoint with the insula transmission.
>> So can it be cured basically with covert narcissism is very difficult to treat because these people aren't going to seek treatment because from their perspective the problem is everybody else's.
>> So they're not going to seek treatment the way you deal with overt narcissism as you call the person out on it without being overly deflating for them because people with covert narcissism can be absolutely devastated with any criticism and that's where they're very, very sensitive and you might actually shut them off from a relationship standpoint if you were to call them out to directly.
So the key is to be aware of what they're doing, be aware of what they're what is happening around you subtly confront them on different issues but try not try not to be overly confrontational because you can be so demoralizing that they will just shut you out the relationship entirely.
But it's important that these people be subtly confronted what they are doing when they're fishing for the compliments they're lying and they're making up stories about different things happening as a means of getting more attention to themselves.
But you have to remember with covert narcissism the whole ideas are trying to get more attention on themselves or trying to be very passive aggressive in terms of how they generate that attention.
But basically they will put themselves in the victim role.
They'll put themselves in a role where they appear to be very vulnerable, very humble, very innocent and a lot of cases.
But underlying that is this narcissism where they're trying to get a lot of attention for themselves.
>> Thanks for email.
Let's go to our next caller.
Hello Susie.
Welcome to Mastermind.
>> Well, Susie, you'd been you'd been taking the generic form of Lexapro also known as escitalopram.
Twenty milligrams for the past twenty years.
You've got some side effects of a loss of appetite, anxiety, early morning awakening.
>> You wonder if you should take brand name over generic basically brand name escitalopram at the dosage you're taking probably wouldn't make that much of a difference from my right field bleachers opinion right here.
>> But you know, it's going to be very subtle.
I think you're having side effects from the actual drug itself.
About one out of three people are really good genetic candidates for escitalopram or Lexapro.
Two out of three people are not.
So if you're the one of the two other three people who are not a good candidate for Lexapro, you're going to have a lot of side effects and side effects of Lexapro can be loss of appetite, anxiety, difficulty with sleep and the side effects are related to not only the mechanism of action by increasing serotonin exclusively but also by getting too high of a dosage.
Some people about one out of four people are slow metabolisms for Lexapro you can determine that by doing genetic testing.
I've done genetic testing on about half the people who have come to our office over the years and I find that about one out of five people are slow metabolisms for the enzyme that breaks down Lexapro.
So if you're slow metabolize or that 20 milligrams might be turning out to be like 80 milligram dosage, you get a really high blood level.
So if you're a slow metabolism on Lexapro that could be a factor in why it's causing you all these side effects.
>> Should you take it at night?
Probably wouldn't make that much of a difference.
Lexapro stays in the system for a whole day.
It probably would make that much of a difference.
So the first thing I'd suggest you do is talk to your clinician about the possibility of maybe dropping down the dosage if you've not done genetic testing you could do it for the purpose of determining more precisely the dosage you need 20 milligrams is the maximum recommended dosage with the assumption that you're a normal metabolize are on it.
But if you're one of the one out of five people or so who's a slow metabolism on escitalopram, you're getting an extraordinarily high dosage and that's going to give you a lot of side effects.
So it wouldn't be a generic versus brand name issue with some medication.
That's a case I mean for some people they'll say a generic medication just doesn't work.
We change the brand name and it works because we're getting a higher blood level with a brand name.
You're probably if anything based on these side effects getting too high of a blood level on the generic already.
>> So if anything I'd recommend possibly decrease the dosage going off of it under your clinician supervision and possibly trying something else that wouldn't give you those kind of side effects.
But the side effects you're describing with loss of appetite, anxiety, early morning awakening those are side effects from getting excessive amounts of serotonin which would be more indicative of getting too high low blood level either because it's not getting metabolized quickly enough or it's just not the right medication from a mechanism of action standpoint for you.
>> Suzy, thanks for your call.
>> Let's go to our next email.
Our next email reads Dear Dear Dear Father, I have recently decided that I would like to look into getting a prescription for my anxiety since it has started to affect my daily life .
>> However, I'm not sure where to start any advice on how this process works?
Well, the first thing I always recommend for people when they're wanting to deal with anxiety is talk to their primary care clinician.
>> It's a family doctor or family nurse practitioner, somebody who can kind of take an overview on what's going on in their lives.
The family clinician would always want to take a look at your current medications because quite frankly some medications cause anxiety and some medications as a side effect can cause anxiety.
So you want to take a look at that first and foremost.
Secondly, you want to get some blood work probably done to make sure you don't have diabetes high thyroid sleep apnea can cause anxiety if people are having sleep apnea and they're snoring at night, they're not getting adequate airflow to their lungs thereby getting less oxygen to the brain at night.
That will give you sometimes anxiety and difficulty concentration the next day.
>> So we want to make sure these medical issues are taken care of first and foremost then the family doctor, our family clinician can often recommend you to see a counselor.
>> Counselors can help you gain a different perspective on the world around you.
>> Anxiety is centered right here in this little part of the brain called the amygdala an almond shaped part of the brain.
>> But the amygdala is the anxiety, fear and anger.
Senator.
>> And it gets fired up when you get emotionally charged up, when you get emotionally charged up and you start to get anxious and ruminate about things, it kind of hijacks the front part of the brain which is the reasoning part of the brain.
>> So your emotions can overwhelm your ability to reason and that's why we often find that when you have difficulty with overwhelming anxiety, depression, anger, sadness you can just get overwhelmed and you can't concentrate and you can't reason through things and people often have difficulty with making good judgment decisions when they have overly emotionally charged situations.
So the idea of talk therapy or counseling is to try to fire up the reasoning part of the brain so you can hopefully go from top down help with the reasoning yourself through the anxiety so that won't be so much of a problem now sometimes anxiety gets to be so bad that you can benefit from medication now back in the old days we used to give medications like Xanax, Ativan, Klonopin, Valium these are so-called benzodiazepines and these are medications that work phenomenally well and dialing down the anxiety volume control they work within a matter of minutes they calm down the amygdala and get you feeling calmer.
>> The problem with long term use of these medications more than a couple weeks is they can do all your concentration that can make you more depressed, make you less motivated and the longer you take them, the more your brain starts to need them to feel normal.
>> So that's why we're trying to get away from those kind of medications and using them within two weeks you can use them every now and then in some cases and decrease the panic that might go along.
But the idea is to slowly taper off of those medications and try to deal with the anxiety in other ways counseling being one way serotonin medications that increase serotonin can dampen down the emotional response such that you have an emotional dampening effect so you won't feel as angry, you won't feel as irritable, you won't feel as anxious.
You just have a calming of the emotions overall.
Now the benzodiazepines like Xanax and Klonopin and Ativan, they actually deal directly on the anxiety center itself where the serotonin medications work more on the front part of the brain, the reasoning part of the brain you know you're taking too much of the serotonin medications.
>> However, if you feel like you don't care, you don't feel happy, you don't feel sad, you just don't care and that means you're getting too much.
>> And I remember when Prozac first came out in nineteen eighty seven that was one of the complaints people had about it because they were taken higher and higher doses of it and they just got to the point where they just didn't care and they felt like you're an emotional robot and that gave them a bad perception of those classes of medication for a long time.
Well the problem was people just took too high of a dosage of them.
If you dial down the dosage and don't take quite as much, it should help with depression and anxiety but not make you feel like you are emotional robot.
>> So we use medications for anxiety.
You know, you always want to look at the source of anxiety.
There's lots of different types of anxiety.
There's obsessive compulsive disorder is that's where you have this ruminative kind of needle stuck feeling where you just can't get this thought off your mind.
You know, it's an outrageous nonsensical thought but you just can't get the thought off your mind that leads you to do things over and over and over again to try to relieve the thought that's called obsessive compulsive disorder.
That's a type of anxiety social anxieties where you're apprehensive about being around people or going into new situations especially that will sometimes give you performance anxiety if you have to speak around people and do things you ordinarily don't have to do.
There's generalized anxiety disorder where people will have trouble with brooding and they ruminate about the future and they're always asking what if, what if, what if?
>> And it's it's an it's a condition where the front part of the brain is overactive and you just brooding and brooding and brooding and you can't get things off your mind.
>> Some people have panic attacks or panic disorder where they have blasts of anxiety, where they have a fast heart rate.
>> They shake, they have nausea .
>> Sometimes they'll have diarrhea and they get horrifically anxious and it peaks within ten minutes and if it goes on and on and on and causes them to be very apprehensive about having another panic attack that will cause them to have difficulty with having this ongoing anxiety expecting another another panic attack to occur and that's called panic disorder so you can have panic disorder, social anxiety, obsessive compulsive disorder, generalized anxiety.
>> There's all these different types of anxiety and we're going to treat them differently.
Post-Traumatic stress disorder is an anxiety that's related to having a past traumatic occurrence and then you have this jumpiness.
>> You're always on edge expecting something bad to happen.
You have nightmares.
Some people will have flashbacks you don't want to treat post-traumatic stress disorder with Xanax or Ativan or Klonopin because it'll make the memories actually more embedded and makes the condition worse and actually worsens asleep as well.
So we'll treat these kind of conditions medicinals with entirely different medications.
So if you have OCD, you have panic disorder, you have post-traumatic stress disorder medicinally we're going to treat those entirely different and the same with the talk therapy standpoint with with post-traumatic stress stress disorder we might use something called rapid resolution therapy.
You might use Dilek to behavioral therapy, eye movement desensitization and reprocessing.
These are all types of therapies that are specific to post-traumatic stress disorder whereas with generalized anxiety, with social anxiety you might do something like exposure therapy where you're actually exposing yourself situations that might make you anxious and a desensitizing yourself in that way.
>> Thank you for your email unforeseen.
I'm out of time for this evening.
I'm psychiatrist Jeff Offer and you've been watching matters of the mind.
You have a question I can answer on the air.
You can write me via the Internet at matters of the mind at FWC dot org God willing and PBSC willing.
>> I'll be back again next week.
Thanks for watching.
Good night