4.Alexander Niss — Direct

ALEXANDER NISS: So my name is Alexander Niss. First name Alexander, like in English, through X; and Niss, N, like "Nancy," I-S-S.

ALEXANDER NISS: More in Russian, but I'll try to speak English here.

ALEXANDER NISS: Right now I work in Hollywood Mental Health Center in Los Angeles. And this is County Mental Center, and one day I have private practice.

ALEXANDER NISS: In psychiatry, of course.

ALEXANDER NISS: Yes, I have -- you know, in Russia I have several medical degree because a medical degree as a physician I got after graduation of medical school in 1967. But after that, I defended two dissertations, I had two more medical degree, but they don't exist in the United States.

ALEXANDER NISS: Yes.

ALEXANDER NISS: So I had medical school. This is six years. Then one-year internship, then four years of residency and one year in forensic psychiatry fellowship.

ALEXANDER NISS: I work most -- mostly I work in Moscow psychiatric research institute based on the big psychiatric hospital. So I did a lot of research but with people. This is clinical research.

ALEXANDER NISS: Treating, diagnosing.

ALEXANDER NISS: I was the chief of department last years. And between '92 and '94, I left this institute and I worked as the chief of department of alcoholism and psychotherapy in international Netherlands-Russian medical company.

ALEXANDER NISS: Yes. I came to the United States in '94.

ALEXANDER NISS: Following my family, mostly my son, because his fiancée was in Los Angeles by that time, and so it was his decision. And after that, all family and my parents, too, all of us came to the United States.

ALEXANDER NISS: Yes.

ALEXANDER NISS: I was 50.

ALEXANDER NISS: Sorry?

ALEXANDER NISS: Yes, but I had to start everything, all the tests and -- plus residency. That's why I was in Boston, in St. Elizabeth Medical Center.

ALEXANDER NISS: Yes.

ALEXANDER NISS: So I was two years -- from 2001st until 2005th I was in the Boston St. Elizabeth Medical Center; two years in inpatient psychiatry; and two last years in outpatient psychiatry.

ALEXANDER NISS: Yes, this is my residency.

ALEXANDER NISS: Yes. Yes.

ALEXANDER NISS: Yes, I met him in 2003. He came to me -- I started this outpatient practice in September, so pretty soon he came to me and was -- was under my care until June or -- yeah, June 2005.

ALEXANDER NISS: Yes.

ALEXANDER NISS: He was very sick guy.

ALEXANDER NISS: So --

ALEXANDER NISS: His main problem was posttraumatic stress disorder as he was -- it was time of Russian-Chechen wars, and he came from the Kirgizia, where he was born, to Chechen republic. According to him, he was close to Dzhokhar Dudayev, first president of Chechnya.

ALEXANDER NISS: He told me -- so I diagnose him objectively. I took his whole history, what happened with him. So he was in some filtration camp organized by Russian troops, and he was there, according to him, as a whole mass; according to his wife, Zubeidat, less.

ALEXANDER NISS: Okay. So he was tortured; he experienced a lot of this --

ALEXANDER NISS: -- filtration camp.

ALEXANDER NISS: So he had typical signs and symptoms of posttraumatic stress disorder. It means --

ALEXANDER NISS: -- he has a lot of anxiety, panic attacks. He had flashbacks. He was re-experiencing his -- you know, that time in that camp.

ALEXANDER NISS: Yeah?

ALEXANDER NISS: So I saw it. He was, you know, startling from loud sound; from -- you know, he couldn't tolerate light. You know, he always ask me to turn off. And so it was typical objective and subjective picture of posttraumatic stress disorder. Plus he had -- you know, he had seizures from childhood. He had some injury at age eight. He had seizures. By that time, much less frequent in the childhood. But later -- this is already after I had left -- he had additional head injury, very severe, and all his PTSD experienced together with new organic symptoms are historic.

ALEXANDER NISS: Yes.

ALEXANDER NISS: Yes.

ALEXANDER NISS: Yes, yes.

ALEXANDER NISS: Yeah.

ALEXANDER NISS: Yes. It is what I say.

ALEXANDER NISS: So at that time I diagnosed PTSD, posttraumatic stress disorder, but just academically I wrote "Rule out panic disorder with agoraphobia" and "rule out mild neurocognitive disorder."

ALEXANDER NISS: So I felt if he's speech impaired, especially as I knew he had good education -- according to him he was prosecutor in Kirgizia. So his speech/thought process was too concrete, too direct. Just -- it was clinical impression. Later, I checked -- I think it should be later, maybe in the notes -- I checked his MMSE, Mini Mental Status Exam. He gave 25 from 30. But, you know, beginning from 21 dementia starts. So this is not dementia, but this is pretty substantial impairment of cognitive function.

ALEXANDER NISS: Also this, yes.

ALEXANDER NISS: You see -- let me see.

ALEXANDER NISS: Maybe I didn't give him -- maybe I didn't have enough time and I needed to meet him one more time to decide about medications.

ALEXANDER NISS: That happens sometimes.

ALEXANDER NISS: In a week. I see here.

ALEXANDER NISS: Yes.

ALEXANDER NISS: So at that time --

ALEXANDER NISS: -- I started from --

ALEXANDER NISS: Yes, I see.

ALEXANDER NISS: Yes. According to my notes, they started to work.

ALEXANDER NISS: For example, at this time --

ALEXANDER NISS: This time I added Zyprexa. Zyprexa is antipsychotic medication, given his paranoid part in his status. And Zyprexa is antipsychotic. At the same time, Zyprexa is mildly sedative, depending on dose, and anti-anxious medication. So Zyprexa also multifunctional medication. In this case, it was done for paranoia and as a complement of his status.

ALEXANDER NISS: Yes. But going ahead, I have to say that this paranoid part went away first. He was -- he had all other symptoms, you know, just weighing like this, better/worse. Also there are some -- he had some triggers that reminded him about his previous experience, and -- but paranoid part went away.

ALEXANDER NISS: Yeah, it was the best reaction to treatment.

ALEXANDER NISS: What date you said, October?

ALEXANDER NISS: 24th. Because I have it here. So this is 2003. He still had this, but I said going ahead, so later, but let's say 2004, by 2005, they went away, paranoid symptoms. But all the other symptoms -- PTSD cannot be recovered. It could be better, but PTSD is forever, posttraumatic stress disorder.

ALEXANDER NISS: Yes. I gave him Zydis. And, yes, I changed several medications. It means I was looking for better combination. I give him Zydis. Zydis is the same as Zyprexa, but Zydis can be absorbed from the mouth. Zydis has same role as Zyprexa, but also good for panic because it removes panic attack. Lexapro, this is another SSRI. So this is same group as Zoloft. So I decided to try another one because the previous one was not completely effective. And Ativan is a medication like Klonopin, same group, but Ativan is shorter. Klonopin has a longer period of elimination. So I decided it will be better for faster action, for anxiety and panic.

ALEXANDER NISS: Yes.

ALEXANDER NISS: Yes. This what I said. This test -- usually we give this test to people with dementia, but they have results 11, 12, 13. This is Alzheimer. But beginning from 21st and below, this is already some kind of dementia. 25, this is bad result, you know? This is not dementia, but this is significant cognitive impairment. All these people in this auditorium will give 30, without exception.

ALEXANDER NISS: Everybody here will give 30.

ALEXANDER NISS: It's not compliment; this is just there.

ALEXANDER NISS: Excuse me?

ALEXANDER NISS: No, not at all.

ALEXANDER NISS: Yes.

ALEXANDER NISS: I see here there is some impairment of his condition, but this is some -- only some resumé from my notes. That's why no full description here. That is why it's difficult to say if he had any trigger for this or it happened spontaneously. I don't remember this. But, again, I changed his treatment. I added one medication, Remeron, for sleep, and I give him Topamax, which is anti-seizure medication. At the same time, Topamax is mood stabilizer.

ALEXANDER NISS: A mood stabilizer so you don't get so much, you know, emotional reaction.

ALEXANDER NISS: You know, this -- basically, his panic, his anxiety, this is part of his PTSD. PTSD is very complex disease, including many, many other symptoms. PTSD is here and many, many symptoms here, you know, which I included, involved in PTSD. So this is large category, PTSD. But, you know, in the United States, your American classification request to qualify any condition separately. Any condition has its core, for example, panic disorder, his agoraphobia. This is why I mention this and this and this. But basically, this is part of PTSD. But encephalopathy, this is not part of PTSD. It was related. There was a point that he was not only injured in his childhood, but also he had -- he was a boxer. You know, any knockout is a concussion. You know, in nine seconds people can come to their consciousness. This is some small concussions. So he had a lot of concussions in his life. So maybe this factors less seizure disorder, most probably from head injury. Seizure disorder also brings to cognitive impairment. So, finally, I included encephalopathy as additional diagnosis secondary to head injuries or...

ALEXANDER NISS: Sorry. I didn't know who to listen to.

ALEXANDER NISS: Yes. Yes, that's true.

ALEXANDER NISS: Yes, right here.

ALEXANDER NISS: You see I write again PTSD always, but also I write mental disorder secondary to general medical condition. This is what I meant by encephalopathy. You know, could be different terms for the same. So this is nothing new. I don't see anything new here.

ALEXANDER NISS: Yes. So it means at that time he still had some of this paranoid part because Risperdal is antipsychotic medication.

ALEXANDER NISS: Antipsychotic, yeah.

ALEXANDER NISS: Wrong date?

ALEXANDER NISS: Yes. Yes, I am writing he is no longer suspicious, despite being anxious. But he had -- when I say encephalopathy, he has not only cognitive problems; he was -- he had a lot of weakness. He was physically ill, you know? He had a lot of physical problems. Once I had to hospitalize him from my office. He had acute kidney stone. But it does not relate to anything, just anybody can have it. But, in general, he's physically -- you know, physically -- he was kind of, you know, putting his head very often on the table because he had some dizziness. He had some -- sometimes headaches. He was just -- (Through the interpreter) He was unwell. There was a general condition of not being well. (In English) So this day I decided to add Provigil. Provigil, this is good medication for alertness, just for being well, you know? So people feel alert, better mood. It's not anti-depressant; this is just medication contributing to this feeling of well-being.

ALEXANDER NISS: Yes. I added Provigil.

ALEXANDER NISS: Yes.

ALEXANDER NISS: This is some confirmation I see here in my notes, confirmation of what I said. He had epistasis -- so he had lot of bleedings from nose. He was going -- at that time, he was going to emergency room almost every day. So he had this -- every time he had some additional somatic symptoms.

ALEXANDER NISS: Physical.

ALEXANDER NISS: So different physical symptoms, not involving only one system of body, but general, like he was weakened in general. That's why he had this, he had this, he had many, many, many -- he was a sick guy.

ALEXANDER NISS: He couldn't drive. I remember, especially first half year, he couldn't drive, and even his -- the owner of his apartment, she was driving -- she was bringing him to our clinic.

ALEXANDER NISS: He -- at that time, he was really disabled. He couldn't work, in my opinion, but it seems to me he had -- I never filled out any forms for him for disability, but it seems to me he had disability.

ALEXANDER NISS: Yeah.

ALEXANDER NISS: (Through the interpreter) Can you repeat the question, please?

ALEXANDER NISS: Still, he was -- no such panic attacks, no paranoia anymore by that time, but the rest was like in the beginning.

ALEXANDER NISS: Yeah.