E178: Psychiatric Manifestations of MCAS with Dr. Janet Settle as part of the Mast Cell Matters series

Episode 178 December 05, 2023 00:45:10
E178: Psychiatric Manifestations of MCAS with Dr. Janet Settle as part of the Mast Cell Matters series
The POTScast
E178: Psychiatric Manifestations of MCAS with Dr. Janet Settle as part of the Mast Cell Matters series

Dec 05 2023 | 00:45:10

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Hosted By

Cathy Pederson Jill Brook

Show Notes

Dr. Settle is a psychiatrist who believes that mast cell activation is responsible for some symptoms of anxiety, depression, bipolar disorder type II and others. She treats MCAS as a way to stabilize both mast cells and their emotional state.

You can read the transcript for this episode here: https://tinyurl.com/potscast178

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Episode Transcript

Psychiatric Manifestations of MCAS with Dr. Janet Settle [00:00:00] Jill Brook: Hello Mast Cell Patients and lovely people who care about Mast Cell Patients. I'm Jill Brook and this is our monthly episode of Mast Cell Matters where we go deep on all things related to Mast Cell Activation Syndrome aka MCAS with the help of our wonderful guest host, Dr. Tania Dempsey, who is a foremost expert on MCAS and all around physician and researcher extraordinaire. Dr. Dempsey, thank you so much for hosting. Who is our guest today? [00:00:29] Dr. Tania Dempsey: Oh, I'm so happy to introduce Dr. Janet Settle. Dr. Settle is an incredible integrative psychiatrist. She has amazing training. She attended Northwestern University, where she completed her BS in biomedical engineering and her M. D. During training, she did research and after medical school, she completed an internship in medicine and then residency training in psychiatry at the University of Colorado health sciences center in Denver, Colorado. She has spent the last 20 years plus studying and implementing medical treatments that have been referred to as integrative, alternative. And she, she really was one of the first cohorts of physicians board certified by the American Board of Holistic Medicine in 2000. And she completed a fellowship in anti-aging, regenerative and functional medicine in 2009. In 2016, she was board certified by the newly formed American Board of Integrative Medicine. She applies the practice of functional medicine to her integrative psychiatric practice by diagnosing and treating the underlying causes of chronic medical and mental health symptoms. Welcome. Dr Settle. [00:01:41] Dr. Janet Settle: Thank you. Thank you very much, Tania. It's great to be here. [00:01:45] Dr. Tania Dempsey: Oh, it's great to have you. I'd love to just dive right in. Right as a psychiatrist, and we're talking about mast cell issues. So, as a psychiatrist, how is relevant to your work? [00:01:57] Dr. Janet Settle: It's extremely relevant to my work and I definitely get better outcomes with people when I look for and treat mast cell related symptoms. It's very underappreciated, as you know, by medicine in general and by psychiatry in particular, so I find that there's a lot of low hanging fruit to address mast cell issues with you know, a large proportion of patients who come to me. [00:02:28] Dr. Tania Dempsey: So, in general, maybe you could just talk a little bit about what kind of symptoms would you be seeing? What kind of symptoms of MCAS do you see commonly in your practice? [00:02:37] Dr. Janet Settle: Well, it might be an overly simplistic rule of thumb, but just like looking at physical symptoms of MCAS, I look for Mainly episodic mental health symptoms. So, those are extremely common in psychiatry. Mood swings, panic attacks, brain fog, especially people say, I have good days, I have bad days, I have good mood days, bad mood days, I have good cognition days, bad cognition days. The cognitive symptoms can include things like memory and concentration. Obsessive anxietyis a big one where people get rumination or they, you know, get those thought worms that they can't get out of their heads or kind of people find they get stuck on certain things and along with the mood swings and the panic attacks come episodes of suicidal ideation. I don't have so many people in my practice who struggle with psychosis, but I, I would add psychosis to that list as well meaning, you know psychosis is a combination of delusions, that's fixed false beliefs, right? That can be Fearful, that's a paranoid delusion or grandiose, that's an inflated self esteem delusion but that those kind of delusions combined with hallucinations or losing the logical flow of your thought pattern make up psychosis. So I believe that's also a related symptom, but it's not something that I treat on a daily basis. Mostly I'm treating mood swings, panic attacks, brain fog, episodes of suicidal ideation, and cognitive symptoms, obsessive anxiety. [00:04:19] Dr. Tania Dempsey: how would you explain how, how mast cells are involved in the development of those symptoms? What is your way of, of putting it together? [00:04:29] Dr. Janet Settle: It's so complex, and I would say we're very early in understanding this. As I said, there's next to no recognition or appreciation for the role of histamine and mast cell activation in psychiatry. Although we use medications, and a lot of the standard medications that we use do influence mast cells and histamine producing neurons. So... I think we're doing it sort of without knowing that we're doing it, but our earliest capacity to measure and track messenger substances in the brain started with other neurotransmitters like acetylcholine, dopamine, serotonin, norepinephrine, and our ability to stain the brain cells for histamine came at least 20 years later than the others. So we're at least that far behind in understanding histamine in the brain. When that knowledge gap closes, I do expect that there will be a lot more focus and appreciation for the role of histamine in mental health and cognitive symptoms. For example, just this year in 2023 there was a publication that mapped out all the histamine, the neuronal histamine projections in the brain. In the mouse brain. So that's that's much later than, you know, we have projection maps for lots of other different neurotransmitters in the mouse brain and in the human brain for things like serotonin and norepinephrine. So just to say that we're behind and that's because the staining of histamine containing neurons is more difficult and that there are some new methods that are speeding that up. And. So it's kind of a non answer to your question that I think we don't really know, but I will say just like mast cells live in the boundaries of all the other different organ systems in the body, the lining of the gut, the lining of the bladder, the skin, the lining of the sinuses and the lungs also mast cells exist at the blood brain barrier. And so the mast cells, just like in other parts of the body, they're the sentry cells that send the alert signal when there's some kind of danger that's perceived, and then they flood the area with histamine and the hundreds of other signaling molecules that come from mast cells. And there are mast cells throughout the brain tissue that are responding to threats and using these signaling molecules. Also, there's a whole array of histamine producing neurons that start in the hypothalamus. Which is a specialized brain region that has to do with a bunch of things, but also has to do with fear responses and has to do with kind of defeat behaviors, which I think of fear responses as being related to anxiety and those defeat behaviors as being related to depression or, or, you know, mood swings, suicidal ideation. So there are the mast cells and then there are these histamine producing neurons. Which, interestingly, they don't release the histamine at the synapses, like a more typical neurotransmitter, but at different ports along the length of the neuronal axon, which is just sort of an interesting factoid. So there's a convergence of information on the hypothalamus having to do with light and smell and autonomic inputs, you know, that has to do with heart rate and blood pressure and all those POTS kind of symptoms and feeding all of those hormones that that ghrelin and insulin and leptin and you know, all those things about hunger and satiety and stress. And so this area of the hypothalamus where all of this is happening in ways that we do not yet understand, I think is intricately associated with histamine. So it's going to be an exciting, you know, some exciting decades to come. [00:08:40] Dr. Tania Dempsey: Fascinating. You know, I was going to go in a slightly different direction, but now that you've piqued my interest of the hypothalamus, I want to talk a little bit about the other parts of the brain. So in the MCAS world you know, a lot of people have tried or are trying these various programs like limbic retraining and brain retraining. And how does that fit into what you're talking about in terms of the hypothalamus and other parts of the brain? I'm curious about that connection and the connection to the mast cells. [00:09:08] Dr. Janet Settle: It absolutely fits in. Yes, those programs like the Gupta program and like the dynamic neural retraining system ... I think of it as an alternative to using medications to control your physiology. It's you're using your brain, your thoughts, your emotional training system to control your physiology. We all need help with emotional regulation that that's with and without mast cell activation, but especially for people who are very physiologically sensitive, those kinds of emotional soothing, self soothing skills. The point is that learning those skills changes your biology, it changes your biochemistry, and it changes the brain in ways that I don't know if we've had enough time yet to, Determine exactly. We can see the end effect of those changes, but I don't know that we've gotten in there and dissected the brains and stained the neurons to see like, oh, well, you just changed your histamine neurons in this way or that way. But, yes, I'm a huge proponent for those kinds of systems. And for the most sensitive people, since you brought that up, I really like this mindful self compassion. You can Google that I have had some people who are even too sensitive for Gupta program and get triggered by the exercises. And I find this mindful self compassion is almost, you know, it's like even a step more gentle and foundational to work up to, you know, Gupta program and DNRS. [00:10:45] Dr. Tania Dempsey: Oh, that's a great, great tip. Thank you. Thank you. So. So, kind of thinking about then the patients in your practice that have some of the symptoms that you mentioned, what is your approach? Do you test them for MCAS? Do you make certain assumptions? How would you approach a patient who has some of the MCAS symptoms, but obviously is having that, that interplay between MCAS and the psychiatric manifestations? What's your sort of, like, first line approach? And maybe it is partially limbic retraining or those types of things as well. Right? [00:11:19] Dr. Janet Settle: well, 1st, I'm looking for the pattern on exam, on interview. I mean, in my practice is primarily a clinical diagnosis, right? I do test the blood or the urine for metabolites for histamine and for other metabolites. Like, I'm sure other guests that you're interviewing would say the same thing and we all are on the same page about that. And if I can find, you know, laboratory evidence to support the diagnosis of mast cell activation. That's just like icing on the cake. That's a bonus. Right? And it helps everyone. It helps the patient. It helps the family members. It helps the other doctors on the team. It helps everyone. But A large proportion of the time, that's not the way this goes. It's primarily a clinical diagnosis in my practice. That's partly because LabCorp, which is the local lab that I rely on in Denver to test people, they've closed down so many of their locations. We have only two locations left in the city of Denver. Which is [00:12:21] Dr. Tania Dempsey: Wow. Yeah. [00:12:24] Dr. Janet Settle: they, I think they have a hard time keeping people, they have a lot of turnover, all of my efforts and all of Jill Schofield's efforts to try to talk to the people there, you know, the boots on the ground there about how to process the samples have just basically bailed. So, I don't have the capacity, I don't have people in my office, you know, drawing blood so I can tell them exactly how to do it. So, so anyway, that's a long story short to say it's primarily a clinical diagnosis in my practice. I'm looking for a pattern. I'm looking for a pattern of the symptoms that I mentioned earlier. And then most often I would say those symptoms co occur with symptoms that are skin symptoms, you know, like, Itching and hives, or migraines, or asthma, or you know gastrointestinal IBS type symptoms. Bladder symptoms are extremely common, because I see a lot of women and, and see women for hormones to, through different, you know, stages of the female life cycle, and so there are a lot of bladder symptoms, body pain. So it's more like mapping a constellation, you know, where I get all these different points and then from that point, really it's a trial and error where the testing out the treatments is part of how we confirm the diagnosis of mast cell activation. So we'll do the procedure like Larry advocates, Larry Afrin, our fearless leader. [00:13:54] Dr. Tania Dempsey: Yeah [00:13:54] Dr. Janet Settle: When people are able ... let's try two weeks of, you know, an H1 blocker, or let's try two weeks of an H2 blocker, or let's try all the other things that are on the list. Sometimes we don't have the luxury of all those two week, two weeks, two weeks, two weeks, two weeks, you know? And it's just like, okay, here are the four things we need to start today, you know, and I know that people might have excipient reactions. And I know that that can be complicated, but sometimes people really need to just get out of the ditch. And so. I would say that I tried to collaborate with the patient and give them lots of education so that they can help me decide if it's a diagnosis that makes sense. So I try to educate them about the triggers and the flares and the waxing and waning symptoms. And you know, sometimes people come in and it's just a wall of white noise. You know, they have just symptoms, symptoms, symptoms, symptoms, symptoms, right? And as we kind of like bring it down, then they can start to see, oh, tomatoes. Oh, you know, stress, oh, I, you know, talk to this person who really pushes my buttons. Oh, I see a blip in my symptoms for two or three days, or, oh, you know, I traveled and stayed in a moldy room on vacation, oh, you know, and so I try to educate people that this is what we might be up against. It may not be clear right away, even if there's a small decrease in symptoms as we try these different things, let's hang in there. And I mean that has, I have to say, worked beautifully, and I have lots of people who rave about the benefits that they've gotten and how glad they are to know about this and how empowering it is to have the information, how much of a difference it makes to not just feel like you're at the effect, you know, being just buffeted around on the sea of histamine and all these other chemicals. So it's worked really well. It's worked really well for me. Yeah. [00:15:59] Dr. Tania Dempsey: Yeah, thank you for that. So would you approach these patients with both psychiatric drugs at times and, and MCAS drugs at the same time? Are you in a position sometimes where you really have to get them from both ends? Is that kind of what you're saying? [00:16:14] Dr. Janet Settle: Typically. Yep. Most often people don't come to me for the casual stuff, you know? [00:16:21] Dr. Tania Dempsey: Right. [00:16:22] Dr. Janet Settle: By the time people have fought their way through the system to find their way to see a psychiatrist usually, it's kind of like, okay, we have some heavy lifting to do here at the beginning and we can sort this out. People are afraid if they get on their psychiatric medications, they're going to be taking them forever. That's not even, that's not even partly true. It's just a tool. I would say I'm fairly pro psychiatric medications. They're excellent tools. I've taken a ton of training in holistic medicine, looking for the way around psychiatric medications, and I'm sitting here to tell you, I have not found it [00:17:02] Dr. Tania Dempsey: I believe that. [00:17:04] Dr. Janet Settle: and that doesn't mean I don't help people get off, I do, but only when the time is right, if you're in the middle of You know, a massive inflammatory state with mast cell activation and who knows what toxins, you know Mold toxins and other infections and things going on. That's not the time for you to say. Oh No, I'm only gonna take St. John's Wort. I'm not gonna take Prozac. That doesn't make sense to me, right? We we have these tools and they are gifts. These are gifts. I would also say that, you know, as I said earlier, a lot of the psychiatric medications that we use are either in whole or in part affecting inflammation and, Mast cells, like for example, Benadryl, right? What's the most common sleep medication used in the country? Benadryl. It's anti histamine. Doxepin is great. Trazodone, you know, Trazodone is probably the most commonly prescribed. Benadryl is probably the most common over the counter sleep med. Trazodone is probably the most commonly psychiatrically prescribed sleep meds. So people who take SSRIs or whatever, when they can't sleep, Trazodone is the number one thing a psychiatrist will reach for. Well, that's. In part, an antihistamine and Seroquel is used for depression, antidepressant augmentations, used for sleep. It's not really much of an antipsychotic, I mean, it's typically, it's classified as an antipsychotic, but it's really... Not a very potent antipsychotic. It's mainly an antihistamine, especially at doses under 100 milligrams. So all those people walking around who are taking 25 or 12. 5 milligrams of Seroquel, that's an antihistamine. Lamotrigine, I lean on that pretty heavily. That's anti inflammatory and neuroprotective. It's good for mood swings, but I think it's, it's working through an anti inflammatory mechanism. And lithium, similarly, ancient, stigmatized, sadly stigmatized lithium [00:19:08] Dr. Tania Dempsey: Yeah, yeah, I know. Poor drug. [00:19:10] Dr. Janet Settle: fantastic medication for immunomodulation and it has been shown to inhibit histamine release from mast cells in rats. So yes, you asked, do I use psychiatric medications? I do. [00:19:24] Dr. Tania Dempsey: Thank you for that, because I think I hear this a lot from my patients always questioning, you know, concerned about having to take those types of meds, they're worried about psychiatric meds that are not going to be quote unquote bad for their MCAS and, and often, right? It's the opposite. If you can find the right drug, it could be actually very good for the MCAS. And so I love your, your approach to that. [00:19:50] Dr. Janet Settle: Yes, yes, I agree completely. I try to encourage people. Let's use all the tools that we can to help you feel as good as you can possibly feel. And then we'll back our way out. Then we'll pick and choose and we can back our way out of anything and everything. You know, nothing is permanent. I didn't mention fluvoxamine, one of my recent favorites as an antidepressant SSRI. Fluvoxamine is approved for obsessive compulsive disorder and it's unique among SSRIs in that it's anti inflammatory in a unique way. It works at the Sigma 1 receptor, so it's been used, you know A bunch of this has really been validated through the whole COVID and long COVID research, right? So I've been getting some mileage out of helping people change off their other SSRI, you know, their Prozac, Zoloft, Lexpro over to fluvoxamine and getting some good anti neuroinflammatory results from that, so that's kind of fun and there was something else. Oh, Benzo. We should talk [00:21:01] Dr. Tania Dempsey: Yeah, let's talk about benzos [00:21:03] Dr. Janet Settle: yeah. You never want to say 100%, but I would say, I would say 100% of the [00:21:09] Dr. Tania Dempsey: Wow. Wow, that's strong. [00:21:11] Dr. Janet Settle: when people have the terrible, terrible, terrible trouble tapering off their benzodiazepines. [00:21:18] Dr. Tania Dempsey: Yeah. [00:21:19] Dr. Janet Settle: It's mast cell activation syndrome [00:21:22] Dr. Tania Dempsey: I agree. 100%. [00:21:24] Dr. Janet Settle: just to define for the listeners, you know, benzodiazepine is the family of anti anxiety meds that includes Valium, Ativan, which is lorazapam, Xanax, which is Alprazolam. Those are the most common ones. [00:21:37] Dr. Tania Dempsey: clonapin, [00:21:40] Dr. Janet Settle: Thank you. Clonazepam. Clonopin. Most people who don't have mast cell activation can start and stop benzodiazepines pretty darn easily. And that's one of the reasons that I don't have too much trouble prescribing those for people. Especially when I'm Well, either way, I mean, with or without mast cell activation, I don't have trouble prescribing them. But if someone does not have mast cell activation, I, I think, you know, you're going to be able to take this for three weeks while we're waiting for your Lexapro to work or whatever, you know, and then you'll taper off and it'll be fine and by and large, most people don't want to take benzodiazepines and they work themselves off and it's fine and easy. But in the cases where it's not, and we've all seen those people, and I've seen a bunch of them, you know, people who can't come off or only with a lot of suffering and difficulty and teeth gnashing, can try to come off. That's almost always mast cell activation. So my strategy in that situation is to try to help the mast cells, calm down the mast cells and Try to address whatever might be underlying the mast cell activation and then people have a much easier time coming down on their benzos. I just saw a woman the other day who, tapered her lorazepam. A lot of times people get started on their benzodiazepines, you know, innocently by the PCP, who says, Oh yeah, it's not a problem, which in most cases it's not, you know, but somehow like in this case, you know, she had fairly quickly gotten up to two and a half milligrams a day, which is a pretty substantial dose of lorazepam at bedtime and then spent Literally years with a dropper bottle, you know, just inching her way down almost, you know, 1% at a time over the course of several years. And she just finished and she successfully came off. And I saw her the other day. I don't see her very often cause she's very stable. She said, you know, the weirdest thing is happening lately. I've got this burning mouth syndrome. And I said, I think it's because you came off the lorazepam, right? I mean, that's a mast cell symptom that your lorazepam was treating, but you know, her dentist didn't say that her, whatever, all the other people she's consulting didn't say like, Oh, this might be related to your mast cells and your lorazepam taper. So I think that's a real diagnostic flag for me. [00:24:20] Dr. Tania Dempsey: And what is the reasoning for that so the listeners understand what's your theory as to why this is happening in MCAS patients? [00:24:27] Dr. Janet Settle: Because benzodiazepines calm mast cells. Right? And people think, oh, the benzodiazepines are just working on anxiety. But I think the benzodiazepines are actually anti inflammatory. And they're calming the mast cells. And so when people have a panic attack, that's a mast cell flare and they take a benzodiazepine and it, yes, it calms the anxiety in the brain, but also it's calming the mast cells. So it's also treating the histamine and we just don't know it yet. You know, we just don't know it yet. [00:24:59] Dr. Tania Dempsey: know, well, we know it, you know, intuitively, anecdotally, we just need the research, right? We got to publish more. [00:25:08] Dr. Janet Settle: That's right. Yeah. Mm hmm. Yep. Yeah. So I try to reassure people who have mast cell activation that the benzodiazepines are fine. This is not like they're falling down into some chasm of addiction or something even if they're taking regular doses of benzodiazepines for some extended period of time because I said, well, we're just work on the mast cell activation. And then when the time is right, you'll come down off the benzodiazepines because other things will be in place. So, the mast cells will be calmer and, you know, we'll get there. It's a process, but yeah, that's another thing that gets really stigmatized and people get freaked out about taking the Benzos. Yeah. [00:25:50] Dr. Tania Dempsey: But they can work really well. Yes, [00:25:52] Jill Brook: Have a question and I've been feeling a little stupid, but I figured that with thousands of listeners, someone else is going to have this question too. But just for clarity, are you saying that you think there's a component of a lot of these psychiatric symptoms that is mast cell activation, like depression, anxiety, panic, brain fog, like what are we talking about specifically as far as psychiatric symptoms that could be partially accounted for by mast cells? [00:26:25] Dr. Janet Settle: Absolutely. That's exactly what I'm saying. I would say the top of the list, for me, is Bipolar Type 2. [00:26:35] Dr. Tania Dempsey: Yeah. [00:26:35] Dr. Janet Settle: This thing, this beast we call Bipolar Type 2, right? This is mast cell activation in my opinion. [00:26:43] Dr. Tania Dempsey: Can you explain a little bit about bipolar 2 while we're on that topic? [00:26:46] Dr. Janet Settle: So, originally bipolar disorder, which is now called bipolar type one, is a disorder where people have distinct episodes of manic and depressive moods. You really don't need the depressive part. Most people have the depressive part. And in fact, in bipolar disorder, depression is a much bigger problem than mania. And the Manic episode is an extreme behavioral episode of driven, very active behavior, spending, reckless, irritable people are Frequently out of touch with reality and either feel very anxious and agitated or feel very euphoric. So mania it is a very dangerous condition. What happened in the 80s and 90s is they started just expanding the definition of bipolar to include more and more people. And they did that by including mood episodes that are what they call hypomanic, which means mildly manic. So people have some symptoms of feeling driven, sleeping less, maybe needing less sleep, but maybe just less able to sleep, feeling agitated, feeling some racing thoughts, feeling some irritability, and I'm sure I'm forgetting some other things. But I think what I find is that this bipolar 2, this hypomania, episodes are mast cell driven episodes. And especially when you see people who have what they call rapid cycling, you know, where you can have episodes that last a day or last a few days and then they go away. I think that's like someone who has hives for a few days and they go away, or, you know, someone who has an IBS attack for a few days and it goes away. I believe that the bipolar two hypomanic episode is a mast cell driven event. So we were talking about which you were asking Jill, which syndromes in particular are related to mast cell activation. Bipolar type 2 is the top of the list. People don't want to hear from me that technically, according to some book, Some ill informed book. Their diagnosis is , bipolar type 2. People think of, you know, one flew over the cuckoo's nest, or people have all these terrible images. I just tell them, just throw all that language out the window. This word bipolar is just a crime against mast cell people. It's a neuroinflammatory syndrome and these are neuroinflammatory episodes and we're going to treat them with the same medications that so, you know, quote unquote treat bipolar disorder like lamotrigine, like lithium, like Seroquel and all the mast cell things, all the other mast cell supplements. but that's a big thing for people to wrap their heads around. They don't like it when I start talking about Bipolar 2. So that's where the education comes in again. But anyway, so Bipolar 2 is one and panic disorder is another one that I think is really highly related to mast cell activation. And I also find a lot of people with attention deficit disorder symptoms who fit into this profile. You don't think of ADHD as being as episodic. So maybe in that way it's a little bit of an outlier, but the trouble with memory, the trouble with concentration and focus, I think a lot of people who say, Oh, I have ADHD are really saying I have brain fog. [00:30:42] Dr. Tania Dempsey: Yeah. [00:30:43] Dr. Janet Settle: Especially people who grew up as A students and then as adults, they're like, Oh, now I have ADHD, but I never did. I think that's largely obsessive compulsive disorder, I don't know that it's as entirely mast cell driven, but there's definitely something, there's definitely a correlation. Obsessive anxiety is is a separate beast that's a neuroinflammatory condition. I don't think it should be co located with panic attacks under this thing called anxiety disorders. I think we should have a category called neuro inflammatory mental disorders, right? And then there would be some bipolar type symptoms like hypomania. There would be depression and OCD, suicidal ideation, panic attacks, and ADHD. Those are the things that I think would go under that category. But they didn't ask me. [00:31:44] Dr. Tania Dempsey: But they need to. [00:31:45] Dr. Janet Settle: They need to. [00:31:47] Dr. Tania Dempsey: that that's such a clear way of saying, saying it and I think that it validates so many people, right, who are having these symptoms and they're labeled and labeled. The labels, I'm sure you'll agree are helpful, right? Because as you're approaching a plan, right? It's helpful to know if they're bipolar 2 right? That's why you give them a name, right? Because it's helpful from a treatment perspective. But at the same time, that labeling actually kind of works against patients as well, because then they're labeled in the system and now they have a psychiatric illness. But really what they have is neuroinflammationthat can be treated [00:32:21] Dr. Janet Settle: Exactly. [00:32:22] Dr. Tania Dempsey: in a variety of ways. And it's just, I see this all the time. [00:32:26] Dr. Janet Settle: Exactly. The labels blur what's really going on, right? And then the patient is having, let's say, debilitating POTS symptoms or something. They go to the emergency room and the doctor looks at the list. Lithium, Lamictal, Ativan. And then they get... Blown off, beyond the beyond, right? You've heard the stories, I've heard the stories, and they're horrific stories of people being blown off by the medical system. Because of these labels and these medications, and it's just so... There's such a big blind spot. We just have a gigantic blind spot in medicine about this. [00:33:08] Dr. Tania Dempsey: How can we change the system and the information and how will it change patient care? So loaded question, but. [00:33:16] Dr. Janet Settle: Oh, I think it couldn't be more significant if suddenly or gradually patients and doctors were more aware of the role of mast cells and inflammation, mast cells in particular and inflammation in general on mental health and I think it's a massive change that I hope is coming. It would change the lens through which doctors hear patients symptoms. If there were this web like model of, you know, that there are mast cells through the body and that when mast cells are activated all the different organ systems of the body are going to be having the classic but broad list of mast cell activation symptoms. That would change everything, wouldn't it? The stigma would be better and the stigma is, is awful. And I think the stigma comes, at least the stigma in the physicians, who I think are frequently treating people badly, comes from feeling overwhelmed. Feeling unable to offer help, which is of course what people want to do. People want to feel competent and helpful. And so when these constellations of symptoms show up in clinical settings, people feel overwhelmed, they feel incompetent. They don't like that. So then they need somebody to blame. And the person taking lithium is a good candidate. [00:34:57] Dr. Tania Dempsey: So, that's why we hope with these types of podcasts that we're getting the message out there well, primarily to patients, but I hear more and more that patients are sharing these, these podcasts with doctors. Other doctors, I hope that others are listening, starting to understand that, you know, they're not crazy to for not understanding this. This is complex. Right? And so kind of turning the tables a little bit and say, look, we know that this is not easy, but here's some tools so that maybe you can look at the patient with a different lens. [00:35:34] Dr. Janet Settle: That's right, that's exactly right, yes. And especially to look with a different lens at people who have these things, like in psychiatry we would call this treatment resistant something something, like treatment resistant mood disorder, especially treatment resistant mood swings or bipolar 2 disorder, treatment resistant panic disorder, treatment resistant depression those are a lot of the people who have had just amazing responses to this method of gradually trying to calm the mast cells down and I don't often treat the underlying causes of mast cell activation, but I bring in people to collaborate with me to look for mold toxicity or infections, chronic infections. But there's so much need for this in people who have these long term, protracted, what we would call treatment resistant mental health conditions. There's so much suffering. And I've had the pleasure over the last I think you said in the intro, 20 years you might have been reading an old bio because... [00:36:48] Dr. Tania Dempsey: You think it's longer than that. [00:36:50] Dr. Janet Settle: It's getting to be 30, [00:36:52] Dr. Tania Dempsey: Oh, no. [00:36:53] Dr. Janet Settle: but I've had the pleasure of treating some people for 20, 25, 30 years and really my ability to conceptualize what's going on with them has shifted so dramatically. And some people who, like, I'm thinking of a woman in particular, who back in her Twenties and thirties, you know, was taking every single medication in the book, had ECT for depression, had multiple hospitalizations, I mean, really went through the ringer. And now, I don't think she's taking any psychiatric medications. She's taking a lot of mast cell medications [00:37:31] Dr. Tania Dempsey: oh, [00:37:32] Dr. Janet Settle: A lot of medications and she's, I would not say she's out of the woods. I don't want to present this is like. [00:37:39] Dr. Tania Dempsey: Yeah. [00:37:40] Dr. Janet Settle: Here we are, you know, and this is the silver bullet, but we no longer get confused. She would have episodes before where all of a sudden out of the blue, it seemed out of the blue to her, she would go to bed for three or four days and try not to make a suicide attempt. [00:37:58] Dr. Tania Dempsey: Okay. [00:37:59] Dr. Janet Settle: With her, you know, little son at home and terrible, terrible stressful, you know, for the whole family kind of situation. Well, that doesn't happen anymore at all. And what she's figured out and how she helped me learn so much is that these suicidal episodes she was having were 100% mast cell flares. And so if she has her rescue meds ready, at the ready, which she does all the time, and as soon as she gets a trigger, which could be like a stressor, of course an injury, an environmental exposure, a food, all the different things that we know of infection and she hops on all those rescue meds and loads up on her Benadryl and her Lorazepam and her Ketotifin and her Quercetin and everything. and She doesn't go there. And so even though she's not out of the woods, her life is very, very different. [00:38:58] Jill Brook: wow. [00:38:59] Dr. Tania Dempsey: Well, that's a, that's an amazing case. Thank you for sharing that. [00:39:03] Dr. Janet Settle: Yeah, yeah, it's wonderful. [00:39:06] Dr. Tania Dempsey: Yeah, yeah, [00:39:07] Jill Brook: and I'm just grateful that you've given us enough information that if there's patients out there or people who know someone out there. Some of our earlier episodes about kind of basic control of mast cells, it's enough that they could start trying some of these things while they try to find a physician like you who understands this better. And that's pretty empowering. [00:39:28] Dr. Janet Settle: Yeah, wonderful. [00:39:29] Dr. Tania Dempsey: Yeah. So what would your final message be to the listeners? [00:39:35] Dr. Janet Settle: Just that we have so much to learn about this, and when the doctors and the medical system give you an answer that's not working for you, in your body, you know, like, of course, go see your people, try it out. If it works, fantastic, that's great, if it doesn't work, Then trust your body. Don't trust the authorities, right? Trust your own body that something is going on. Of course it's intertwined with trauma and psychology, and I could say a few more things about that... [00:40:11] Dr. Tania Dempsey: Yeah, please do. [00:40:12] Dr. Janet Settle: But that this is primarily A condition of physiology. this is the physiology of your immune system that's impacting your mood, your fear states, your, what we call these defeat behaviors, which is like depression and suicidality, your cognition, your memory, your concentration. This is physiology. This is not [00:40:40] Dr. Tania Dempsey: whatever happened with your mother. Yeah. [00:40:45] Dr. Janet Settle: then of course I have to qualify that, right? Because of course I, I believe in psychotherapy and pTSD that comes from past traumatic events, primes the brain for inflammation. [00:40:56] Dr. Tania Dempsey: Yeah. [00:40:57] Dr. Janet Settle: And so, to use the ACEs score, the Adverse Childhood Events score, a very helpful way to see how [00:41:10] Dr. Tania Dempsey: go primed [00:41:11] Dr. Janet Settle: is your brain for inflammation. And maybe once the the immune system in the brain and the immune system in the rest of the body is primed for inflammation, then maybe that's a longterm battle to ratchet that down and keep it calm and processing the trauma that laid the groundwork for that physiology is an important part of that. So, you know, the trauma work and the psychotherapy is important, although I will say doing something like the mindful self compassion or the the retraining the brain, those programs, doing those things first before you do trauma work is what I would always recommend. Because trauma work itself can be a trigger for your mast cells. So, if you were going to go jump into EMDR you're going to go jump into [00:42:04] Dr. Tania Dempsey: some other kind [00:42:07] Dr. Janet Settle: of intensive experiencing trauma method. I'm not sure. that's not typically what I would recommend. [00:42:14] Jill Brook: Great [00:42:15] Dr. Janet Settle: So, so back to the final [00:42:17] Dr. Tania Dempsey: is. [00:42:18] Dr. Janet Settle: message. This is your physiology talking. Right? And unfortunately, conventional medicine isn't quite caught up. I have every belief and every hope and every expectation that conventional medicine will catch up to this, but I would encourage people to just trust your own body. If the things that you're being offered aren't working, then move on and keep moving on. Yeah. [00:42:46] Dr. Tania Dempsey: next one message. Excellent. Thank you. Thank you. Dr. Settle. Where can listeners find you? You know, do you have a social media, website. [00:42:59] Dr. Janet Settle: I have a website. It's a little dated, but it's there and it's JanetSettle. com. [00:43:05] Dr. Tania Dempsey: Okay, [00:43:06] Dr. Janet Settle: And I'm not on social media yet. Maybe I will be. [00:43:11] Dr. Tania Dempsey: Yeah, but you have some really great ideas. These are the things we've been talking about. And just to have a psychiatrist. I talked to my patients about these exact things, but you have a psychiatrist to support it. That's just really would be tremendous. So, so think about. [00:43:28] Dr. Janet Settle: Okay, I will. I will. Yeah, I will. [00:43:31] Jill Brook: Dr. Dempsey and Dr. Settle, what beautiful souls you are. What a thrill to have you together talking about this. And I just cannot thank you enough for this information and for all you do to help MCAS patients. This is huge. So, hey listeners, that's all for now, but we'll be back again next week with a normal episode of the POTScast and we'll be back again next month For another episode of mast cell matters. Until then, thank you for listening. May your mast cells be good to you.

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