In this week’s episode of the podcast, we interview Dr. Michael Cummings, a psychiatrist, researcher, and associate professor at Loma Linda University. This podcast is the first of a series on addiction and the focus of this week’s episode is on alcohol use disorder. In this episode, Dr. Puder and Dr. Cummings dive into the history of alcohol use, vulnerabilities and mechanisms responsible for the development of alcohol use disorder and its related neurobiological circuits, and common pharmacological, psychotherapeutic, and behavioral interventions and treatments for alcohol use disorder.

Link to blog here.

In this week's episode of the podcast, we interview Dr. Michael Garrett, Professor Emeritus of Clinical Psychiatry and former Vice Chair and Director of Psychotherapy Education at SUNY Downstate Medical Center, Brooklyn, NY. He also wrote a book called, Psychotherapy for Psychosis: Integrating Cognitive-Behavioral and Psychodynamic treatment. He is husband to the prior beloved presenter, Dr. Nancy McWilliams. In this episode, we will discuss how psychotherapy can be effective for patients experiencing psychosis. 

Full blog here.

In a previous episode of the podcast, we discussed exercise for the brain, reviewing the pathophysiology between exercise and dementia, the pathophysiological mechanisms associated between low skeletal muscle mass and cognitive function, exercise as a treatment, and cardiorespiratory fitness and its relationship to all-cause mortality. In today’s episode, we look at the extensive research available on these subjects.

Link to blog here.

From childhood, Russell experienced intense social anxiety to the point that, on more than one occasion, he discontinued certain extracurricular activities and socially normal gatherings to avoid it. Red Face is a narrative of his struggles with this social anxiety, the accompanying idiopathic craniofacial erythema (uncontrollable blushing), and the many successful and unsuccessful coping mechanisms he has attempted over the years. 

In today's episode, Russell shares his experience with social anxiety, which started at a young age and continued into adulthood. He will share what he does to overcome the often debilitating fear. 

Link to blog here.

In this week’s episode of the podcast, we interview Dr. Kirk Schneider, a psychologist, psychotherapist, and author of, Life-enhancing Anxiety: Key to a Sane World. Dr. Schneider is a practicing psychotherapist and director of the Existential-Humanistic Institute, a psychotherapy training institute. As a former mentee of the great existential psychologist Rollo May and a self-described existential-integrative psychotherapist, he has made significant contributions to the fields of humanistic psychology and existential psychology throughout his career. 

Link to blog here.

The idea of using psychedelics to treat psychiatric symptoms has been approaching mainstream popularity thanks to podcasters like Joe Rogan, Tim Ferris, and Sam Harris. As interest in these substances continues to grow, so does the size of the online communities centered around this topic. While there is undoubtedly value in recognizing some of the claims being made about microdosing, it’s important to recognize where the literature currently stands and to identify where there are gaps in understanding. In this episode, Dr. David Puder and Liam Browning discuss the state of Microdosing in current research.

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Over the last several years, Dr. Puder has worked as the medical director for Loma Linda University Health’s MEND program, a hospital-based intensive outpatient program (IOP) and partial program that works with patients who have chronic illness and their families. Jesse has been a lead therapist instrumental to the program’s success and Brian Distelberg oversees the MEND program and acts as the Director of Research for the program. During this episode, they come together to discuss the MEND program. 

Link to blog here.

In today’s episode of the podcast, we are joined by psychiatrist and neuropharmacologist Dr. Ken Gillman who is the founder and convener of the International MAOI (monoamine oxidase inhibitor) Expert Group and widely recognized as a world expert in serotonin toxicity. 

Serotonin toxicity (syndrome) is a rare as well as potentially lethal form of toxicity that results from excess serotonin within neuronal synapses. There are numerous poorly written/controlled case reports that have perpetuated misinformation about drugs that can cause serotonin toxicity. While the word “syndrome” is often used, toxicity is a more accurate description given that toxicity represents a spectrum of severity rather than a defined set of symptoms. In today’s podcast, we will discuss the pathophysiology, causes, clinical presentation, criteria, controversies, and medical management of serotonin toxicity. 

Full blog here.

On this week’s episode of the podcast, we interview psychiatrist, author, and founder of Gemma Women, Dr. Pooja Lakshmin. Dr. Lakshmin founded Gemma Women for the purpose of educating women on cultural and social structures that impact their mental health. Gemma also provides community groups, evidence-based conversations, and courses covering topics such as stress, inequity, and structural violence. In her new book, Real Self-Care, she discusses personal experiences that led her to create this transformative movement to redefine wellness.

Link to blog here.

In today’s episode of the podcast, we speak with Professor Nicholas Reid, author of, Prisons in Ancient Mesopotamia. After introducing us to how Mesopotamians viewed and treated mental health, Reid talks to us about the earliest historical records on imprisonment in the history of the world. 

In his book, Reid discusses the evolution of the modern prison system as it relates to ancient Mesopotamia. Together we discuss the commonalities that can be seen between the ancient and modern systems and the benefits that come from learning about past cultures’ successes and weaknesses.

It may seem safely assumable to believe that because we are thousands of years removed from some ancient societies and their often barbaric methods of treating humanity, that we have automatically advanced into a superior, more humane society.  

But with our reliance on solitary confinement and a loss of meaning, our system is missing what could be a more healing and transformative journey.

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In today’s episode of the podcast, I speak with Nancy McWilliams, Ph.D, a renowned psychologist-psychoanalyst. She has authored several books, including, Psychoanalytic Diagnosis (1994; rev. ed. 2011), Psychoanalytic Case Formulation (1999), Psychoanalytic Psychotherapy (2004), and Psychoanalytic Supervision (2021). She was also the Associate Editor of the Psychodynamic Diagnostic Manual (2006; 2nd ed. 2017).

We discuss different aspects of mental health and how it pertains to relationships. We also discuss qualities that make a strong therapist and the ideas of dissociation and transference in therapy. 

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In today’s episode of the podcast, I would like to give you my take on transference. I want to share with you what I actually believe. Often lectures focus on the history of transference or what certain papers say, but I’d like to share my accumulated, internalized experiences and understanding of transference.

My hope is to make this easy to read and understand. I want to give a talk on this that can be understood both by experienced clinicians who are familiar with these concepts, who will imagine where I am pulling different pieces of wisdom and maybe where I am being creative and uniquely contributing to the field, but also by people who don’t have much of a background on transference and want to further explore it.

Link to blog here.

In this episode, Dr. Cummings joins the podcast to discuss and give tips on overcoming social anxiety disorder. Individuals with social anxiety disorder tend to avoid important events and activities, such as classes, meetings, or public speaking. The disorder is essentially the fear of rejection by a group one would like to be part of. This is different from shyness because of the intensity and pervasiveness of the symptoms.

Link to blog here.

For over a century, psychoanalytic psychology has recognized certain types of personality configurations that we see repeatedly. A clinician who understands these familiar patterns has a map of the patient’s interior terrain to help navigate treatment. In today’s episode of the podcast, we are joined by Dr. Jonathan Shedler to discuss obsessive-compulsive personality and the continuum on which personalities operate.

Link to blog here.

In today’s episode of the podcast, Dr. Michael Cummings returns to discuss the use of long-acting injectable (LAI) antipsychotics. LAIs are administered in intervals ranging from every 2 weeks to every 6 months, eliminating the need for daily oral antipsychotics and thereby improving adherence.

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Malingering is the conscious misrepresentation of psychiatric symptoms for a secondary gain (such as hospitalization, obtaining disability benefits, avoiding criminal responsibility, proceedings or sentencing, or avoiding military service). In today’s episode of the podcast, we are joined by Dr. Phillip Resnick and Dr. Alex Scott as we discuss the topic of malingering.

Link to blog here.

Exercise is an integral contributor to brain health. Physical activity has been proven to slow the rate of cognitive decline. In this episode, Dr. Puder invites four guests to discuss the importance of incorporating exercise into mental health routines. 

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In this episode, Dr. Puder discusses the importance of dynamic listening with patients in order to alleviate guilt, shame, and self-disgust. Building connection with your patients is a crucial element for mental health professionals, and this episode dives into the best practices that build connection through dynamic listening for the benefit of the patient. 

Link to blog here. 

In today’s episode of the podcast, we interview Dr. Chris Palmer, a psychiatrist, researcher, and expert in using the keto diet as a medical treatment for some treatment-resistant patients. Dr. Palmer is currently the director of the Department of Postgraduate and Continuing Education at McLean Hospital and is an assistant professor of psychiatry at Harvard Medical School. He also runs his private practice specializing in treatment-resistant mental health patients.

Link to blog here.

In today’s episode of the podcast, we are joined by Dr. Michael Cummings to discuss the most recent and popular diagnosis wave of individuals believing they may have autism, which has become a recent TikTok phenomenon.

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In this episode, Dr. Corrin Pelini and Dr. Michael Cummings join the podcast to discuss the documentary involving the 2014 case involving Michelle Carter and Conrad Roy, both teenagers at the time in Massachusetts. The state of Massachusetts investigated the suicide of Conrad and filed a charge of involuntary manslaughter against Michelle. We discuss our views on the documentary as well as possible treatments that could have been used.

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Amidst the rise of dating apps and websites lurks a new form of deviance: online romance scams. In this episode, we interview Dr. Annabel Kuhn on the subject of online catfishing relationship scams. We discuss with Dr. Kuhn how to identify an online scammer, the personality types of both the scammer and the scammed, and how providers can help patients who have fallen victim to such a scam.

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In this episode of the podcast, we interview Alyse Price-Tobler, who is a practicing clinical psychotherapist (MCAP) and also in her final year of her PhD., and Dr. Mandy Matthewson on the topic of parental alienation.  

Note: This will be discussed as a form of family violence and child abuse. As such, the content of this presentation will involve discussion of child abuse and its consequences. Please speak to someone if you become distressed during or after this presentation.  

Link to blog here.

In today’s episode of the podcast, I interview Dr. Rocio Salas-Whalen, owner of New York Endocrinology on Park Avenue. Dr. Salas-Whalen has deep expertise in diabetes, metabolism, obesity, thyroid abnormalities and other endocrine disorders. She completed her internal medicine residency at Albert Einstein College of Medicine and her endocrinology fellowship at the University of Maryland School of Medicine in Baltimore. Additionally, she was a research fellow at Johns Hopkins University School of Medicine and is board certified in Obesity Medicine.

We will be discussing obesity and weight loss. The definition of obesity has changed significantly in the last few years. In 1942, WHO classified obesity as a chronic disease. In 2013, the American Medical Association accepted it as a chronic metabolic and multifactorial disease.

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Becoming an expert at reducing polypharmacy requires being an expert in not only psychopharmacology, but being a coach that directs a patient toward a holistic path. In this episode, I am joined by Jacob McBride, D.O., a psychiatrist in Pittsburgh, PA. We will be discussing some issues within polypharmacy and encouraging more holistic care for patients. 

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In this week’s episode of the podcast, I interview Dr. Ragy Girgis, a clinical researcher at Columbia University in New York where he also completed his residency in psychiatry in 2009. He received a T32 (training grant) during this time and now conducts clinical trials and high-risk psychosis research. He practiced privately for a time, but is now a full-time clinical researcher. Although primarily a schizophrenia researcher, his interest led him to research the relationship between schizophrenia and mass shootings, leading to the creation of what may be the largest database on mass murder and mass shootings, studying cases dating all the way back to 1900.

Link to blog here.

In this episode, we welcome back Dr. Michael Cummings to discuss a new study that explores the idea that depression may not be merely a chemical imbalance. This episode covers the origin of belief in the connection of depression with a chemical imbalance, the new study that has created questions surrounding the efficacy of antidepressants, and a holistic view on the treatment of depression. 

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In today’s episode of the podcast, I speak with Dr. Mary Jo Peebles, a renowned psychoanalyst, speaker and author, about the significance of psychotherapy from her most recent book, When Psychotherapy Seems Stuck. Dr. Peebles received her Bachelors of Psychology from Wellesley College and her PhD in clinical psychology from Case Western Reserve University. She currently works at her private practice in Bethesda, Maryland.

Link to Blog.

Dr. Mark Solms, author of,  The Hidden Spring, gives us a guided tour of a journey into different aspects of consciousness, how Freud can be updated with the work of Jaak Pankseep and affective neuroscience, as well as some of the more fundamental principles and groundbreaking work in which he comes to the conclusion that the why, how and where of consciousness centers on our “in the moment” experience of emotions and feelings.

Link to blog here. 

In this episode of the podcast, we sit down with Dr. Cummings to discuss the benefits, progress, and fears related to electroconvulsive therapy. For years the efficacy of electroconvulsive therapy has been debated, but we’ve learned that it still remains an essential part of psychiatric treatment in patients with severe mental health disorders.

Link to full blog here.

On this episode, Dr. David Puder and Dr. Robert Feinstein discuss the journey of becoming a good psychotherapist and how to increase one's skill in the realm of psychotherapy training through the cognitive apprenticeship model.

In this episode of the podcast, I speak with Dorothy Kaufman, a marriage and family therapist who was married to the late Daniel Wile. We discuss the book that they both co-authored together called, Solving the Moment: A Collaborative Couple Therapy Manual. Dan is a well-known marriage and family therapist, the creator of Collaborative Couple Therapy, and spoken very highly of by Dr. Gottman.

In this episode of the podcast, I will be discussing something near and dear to my heart—a tool I created to measure the connection between physician/student and teacher/medical learner in medical education. It is a tool called the Connection Index and its purpose is to improve the quality of the medical education experience. I wanted to answer the question of how we create better supervisors and mentors as students embark on their own “hero’s journey” to becoming physicians.

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In this episode of the podcast, we discuss the work of Karen Horney, M.D., titled, Neurosis and Human Growth: The Struggle Towards Self Realization. In the book, Horney discusses the concept of neurosis as it stands juxtaposed against what she deems healthy growth and human development. We will be discussing this concept and some of her prevalent theories introduced in the writing, such as the development of neurosis, the contrast to the healthy individual, the components of growth, the tyranny of the “should,” the search for glory, and neurotic claims.

We hope that you will be inspired to pick up this book by Karen Horney and join us in thinking about her important work.

PANS/PANDAS is the hypothesis that there are certain types of obsessive compulsive symptoms, tic symptoms or restrictive eating symptoms that are caused by an infection and the immune response to an infection. Kyle Williams, MD, PHD and Sarah O'Dor, PhD join the podcast to discuss their research and diagnoses of PANS/PANDAS. 

In this episode of the podcast, we interview Dr. Herbert Harman, a psychiatrist who works as a practice line director for Vituity. We will be discussing “moral injury”, an emerging term defined as “perpetuating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations” (Griffin et al., 2019). Moral injury is similar to PTSD but has distinct differences. While it is often seen in military settings, various front-line careers also present opportunities for moral injury, including psychiatry. 

Violence and aggression are often used interchangeably, with subtle distinctions differentiating the two. Aggression is an umbrella term that encompasses violence and is defined as actions that lead to harm towards self, others, or objects, while violence is defined as actions that lead to harm, specifically toward other individuals (Newman, 2012). Aggression, according to the 3-factor approach initially detailed by investigators from the New York State Hospital system, is categorized into three types of assault: impulsive, predatory/organized, and psychotic. Impulsive aggression was the most common type at 54%, with predatory/organized type (29%) and psychotic type (17%) trailing behind (Quanbeck CD, 2007; Meyer et al., 2016). This episode aims to explore the management of agitation, aggression, and violence in the inpatient setting.

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In this episode, Dr. Puder interviews Jonathan Shedler, Ph.D. Their conversation covers the ideal length of therapy treatment, the efficacy of psychodynamic therapy, and the role of psychodynamic processes in multiple therapeutic modalities.

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Inaccurate diagnosis of schizophrenia and/or missed diagnosis of affective disorders can lead to inappropriate and inadequate treatment; worsened outcomes can follow. Because schizophrenia is a complex condition with a broad range of signs and symptoms that also occur in other mental disorders, it can be difficult to differentiate it from other serious mental disorders, especially mood disorders. Notably, these other conditions should actually be ruled out before arriving at a diagnosis of schizophrenia.  In this episode, Danielle Hairston, M.D. and Chantel Fletcher join the podcast to discuss the issue of overdiagnosis of schizophrenia in Black male patients, especially.

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Link to The Next 72 Hours Podcast.

Physical activity has been shown to reduce stress reactivity and reduce all cause mortality. Physical activity also results in decreased psychosocial stress. In this episode, Dr. Puder speaks with Dr. Stephen Seiler about the connection between mental health and physical activity.

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Dr. Joseph F. Goldberg is a psychiatrist and clinician researcher with over 180 publications and 3 books. This article focuses on his newest book,  Practical Psychopharmacology: Translating Findings From Evidence-Based Trials into Real-World Clinical Practice. In this article, we discuss psychopharmacology and his approach to psychiatry.   

Link to BLog.

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In this episode, I interview Dr. Robert Feinstein, on his new book, Primer on Personality Disorders. In a chapter he authored in the book, he writes about the commonalities of effective treatments for Borderline Personality Disorder.  Dr. Feinstein states that six major types of psychotherapy achieve around 70% effectiveness in the treatment of borderline personality disorders.

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On this week’s episode, Dr. Puder interviews Francis Stevens, Ph.D., a clinical psychologist and author of the new book, Affective Neuroscience in Psychotherapy: A Clinician’s Guide for Working With Emotions. Dr. Stevens trained as a therapist under cognitive behavioral and psychodynamic theories, as well as completing a postdoctoral degree in neuroscience. The lack of emphasis on emotion in these two approaches led Dr. Stevens to begin research on the neurobiological basis of emotion and to ultimately compile this book.

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In this podcast episode, David Puder, M.D. and Kevin Ing, M.D., M.Div. interview Kenneth I. Pargament, PhD, and Julie J. Exline, PhD about their new book Working with Spiritual Struggles in Psychotherapy: From Research to Practice. Dr. Pargament is a pioneering expert on the role of religion and spirituality in coping with stress and trauma. Dr. Exline is a researcher in the area of spiritual struggles and supernatural attributions. Both clinical psychologists, they are nationally recognized experts in the integration of research on religion and spirituality into clinical practice. 

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Esketamine is the first non-monoaminergic based medication which is FDA approved and indicated for treatment refractory depression. A longer duration of undertreated depression is associated with poor longitudinal functional outcomes. Instead of cycling patients through monoaminergic antidepressant trials and cognitive behavioral therapy approaches, according to Dr. Kitay, providers should consider treatments like esketamine much sooner in the treatment course.

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On this week’s episode, Dr. Puder interviews Mary Lynch Barbera, Ph.D., RN, BCBA-D, creator of the approach and book titled Turn Autism Around. Dr. Barbera began her journey in the autism world over 20 years ago, when her first son, Lucas, was diagnosed with autism. Dr. Barbera made the incredible transformation from a confused parent to a doctoral-level behavioral analyst, best-selling author, and a tremendous resource for health professionals and parents of children with autism all over the world.

Full Blog here.

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In this episode, we will be discussing, From Survive to Thrive, a new book by John Hopkins’ professor and author, Dr. Margaret Chisolm. In her book, she outlines the four perspectives of psychiatry that are the standard approach used at Johns Hopkins when assessing patients. Problems are considered from each of these perspectives.  It is about discovering the origin of a patient's problems and using that as a guide for treatment.

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With dyslexia being present in 20% of the population, we have to ask ourselves what the upside is to dyslexia. What do these individuals bring to the table? With such a huge portion of the population having a particular cognitive makeup, it is highly unlikely that dyslexia is to be deemed a corruption of normal pattern—nature is favoring large groups of people to display these traits. This episode dives into the strengths of dyslexic thought processes to hopefully help decrease the negative views surrounding dyslexia. 

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In a podcast episode with award-winning author and screenwriter Norman Ohler, Dr. Puder and Dr. Borecky discussed Ohler’s recent book, Blitzed, about how the Third Reich used drugs to optimize performance during World War II and how it may have changed the course of history.

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Special guest Dr. Joseph F. Goldberg is a psychiatrist and clinician researcher with over 180 publications and 3 books. This episode focuses on his newest book, written with Dr. Stephen M. Stahl,  Practical Psychopharmacology: Translating Findings From Evidence-Based Trials into Real-World Clinical Practice. In this episode, we discuss psychopharmacology and his approach to psychiatry. 

Link to Blog.

Link to Resource Library. 

In this episode, we welcome back Dr. Drew Ramsey to discuss his new book, Eat to Beat Depression and Anxiety. Rather than writing a diet book, Dr. Ramsey has made healthy eating accessible for everyone by detailing the needed nutrients and the food items that can easily be added to our diet. We will discuss Dr. Ramsey’s journey of finding ways to make healthy eating accessible and his insights into how the food we eat affects our mood and brain function.

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Schema therapy is a model of psychotherapy that was originally designed for chronic mental health problems. It comes from the Cognitive Behavioral Therapy (CBT) tradition, but also integrates different arms of psychotherapy, such as elements from the Gestalt tradition, and also aspects of object relations theory. In this episode, we have an in-depth discussion about schema therapy, which has proven to be effective in treating borderline personality disorder (BPD), with Australian schema therapist, Andrew Phipps.

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In this episode we discuss, with Dr. Michael Cummings, a new book he co-authored with Steven M. Stahl on the management of treatment-resistant psychosis. An increasing number of individuals with psychotic illnesses deal with homelessness, repeated incarceration, and associated trauma. There is limited access to care for these individuals, leading to poor prognosis. This book provides prescribers with information regarding treatment of the most challenging, treatment-resistant, severely psychotic patients.

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In this episode, we will be discussing some of the themes within Fyodor Dostoevsky’s legendary text, Crime and Punishment. It deals with the suffocating guilt and uneasy journey towards redemption of impoverished ex-student, Raskolnikov, who commits a horrific murder of a pawnbroker and tries to justify it, unsuccessfully, with noble purposes. Not only is the novel a stellar thriller, its themes deal with the eternal struggle between good and evil that encapsulates the human condition.

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On this episode, we are joined by psychiatrist, psychopharmacologist, and author, Dr. Jonathan Meyer, to talk about using antipsychotic plasma levels to assess treatment response, safety, and oral medication adherence. He is a clinical professor of psychiatry at the University of California, San Diego. He recently published a book with Dr. Stephen Stahl for clinicians to utilize called, The Clinical Use of Antipsychotic Plasma Levels: Stahl's Handbooks.

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On this podcast episode, we interview Dr. Fred Penzel who received both his MA and PhD in School and Clinical Psychology from Hofstra University in 1985. In 1989, he founded Western Suffolk Psychological Services in Huntington, New York, where he is the executive director and a practicing psychologist. Since 1982, he has been involved in the treatment of numerous disorders including OCD, body dysmorphic disorder, body-focused repetitive behaviors such as hair-pulling disorder (Trichotillomania) and excoriation disorder (compulsive skin-picking), panic and agoraphobia, phobias, and post-traumatic stress disorder. He specializes in the treatment of these disorders within his practice. He is a founding and active member of both the International Obsessive-Compulsive Disorder Foundation (IOCDF) and the TLC Foundation for BFRB’s Science Advisory Boards. He is also a member of advisory board of the United Kingdom’s Anxiety UK organization. In addition, he is an adjunct faculty member and community supervisor for the doctoral psychology program at Long Island University (C.W. Post campus). He is the author of Obsessive Compulsive Disorders: A Complete Guide to Getting Well and Staying Well (2017) and The Hair Pulling Problem: A Complete Guide to Trichotillomania (2003). He has no conflicts of interest to report.

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There is a real danger of medical professionals treating or behaving differently with someone they perceive to be a Very Important Patient, which leads to inferior treatment. In this episode, Dr. Puder and Dr. Heacock discuss the complicating factors of treating physicians, the famous, and the wealthy.

Dr. Heacock is the host of a podcast called: “Back from the Abyss.”

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Insomnia is a fairly common problem; it is likely that almost all individuals suffer from at least transient insomnia. In this episode, Michael Cummings, M.D., Shizuka Tomatsu, M.D., and Shilpa Krishnan, D.O. join the discussion on psychopharmacological treatments, lifestyle, and therapy recommendations for insomnia. 

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A 2019 poll reported that one-third of adults say they feel they “cannot go anywhere without worrying about being a victim of mass shooting” and “more than half of American teenagers worry about a shooting at their school.” A mass shooting is generally defined as the murder of at least four people at one time. Why do mass shootings take place? Are there any commonalities between the perpetrators? Could these shootings have been stopped before they started?

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Alzheimer’s disease is a devastating neurodegenerative condition that affects the entire family. As psychiatrists and psychologists, we often support these patients and their families throughout this entire disease process. With the recent and controversial FDA approval of aducanumab (Aduhelm™), a new pharmacotherapy for Alzheimer’s disease, we can expect to be asked about this drug from our patients and their family.

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Interview regarding the recent court case of Britney Spears and unique aspects of conservatorship law and treating people with large amounts of fame or money.

Conservatorship Lawyer: Mark McGuire

Psychiatrist: Herndon Harding M.D.

Psychiatry Resident: Serena Weber, M.D.

Psychiatrist Host: David Puder, M.D.

No conflicts of interest to report.

Contact me on IG: here

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In this episode, we will be discussing some themes observed in Meditations, a collection of notebooks written by the 16th Roman emperor, Marcus Aurelius, during the last years of his reign. His writings are still relevant to us and resonate within us, as the emperor himself struggled with some core questions that anyone who is living this thing called life might ponder.

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In this episode, I am joined once again by Michael Cummings. M.D. and Melissa Pereau, M.D. along with Chantel Fletcher who will soon be a fourth year medical student going into Psychiatry. We will be doing an in-depth analysis on Obsessive Compulsive Disorder including history, assessments, diagnosis, and so much more. 

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In this episode, I am going to build on the therapeutic alliance series to express my thoughts on how understanding emotion, specifically microexpressions, can better help you make connections with your clients. The research is amazing; there are thousands of articles on the subject. I thought I would share a bit about the evolution of my interest in emotion and microexpression in this episode and how I translated it from the forensic world into a psychotherapy setting.

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In this podcast episode, we will interview Jeffrey Paul Kahn, MD, a psychiatrist who recently co-edited a book called Psychotic Disorders: Comorbidity Detection Promotes Improved Diagnosis and Treatment. Our focus will be on different presentations of psychosis and how through a good history you can better treat the underlying issue and choose optimal treatments.

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In this episode, I interviewed Carl B. Gacono, PhD, who is an expert in the areas of criminal psychopathology, behavior, and treatment. We dive into understanding and acknowledging the distinct differences between psychopathic and non-psychopathic patients and how their assessment with the PCL-R and Rorschach aid in their management and treatment. We also discuss how understanding transference and countertransference is essential when interacting with these difficult patients.

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In this episode of the podcast, we introduce borderline personality disorder (BPD). We discuss its history, nomenclature, epidemiology, etiology, and diagnosis while providing perspectives from clinicians regarding the treatment of individuals with BPD.

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On this week’s podcast, I interview Jason Smith, Psy.D., A.B.P.P., Chief Psychologist at a prison in the United States, and Ted B. Cunliffe, Ph.D., who is a clinical and forensic psychologist at a private practice in Florida. Together, along with Carl B. Gacono, Ph.D., ABAP, they have written the book Understanding Female Offenders, researching how female offenders’ psychopathic behaviors present differently than in males and how we can address biases we may have in order to identify, assess, and treat these women.

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In this episode, we will be going over a book every therapist and psychiatrist should read, Viktor Frankl’s “Man’s Search for Meaning.” Being in the trenches with our patients, we see so much pain and suffering and potentially undergo vicarious trauma ourselves through their suffering. The question, “What is the meaning of life?” often comes up in such a context.

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In today’s episode of the podcast, we’ll be continuing our deep dive into duloxetine, a serotonin-norepinephrine reuptake inhibitor (SNRI). In this second part, we’ll be covering the approved indications and off-label uses of duloxetine. 

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In this episode of the podcast, we discuss akathisia, the horrible and all too common side effect of psychiatric medications. Subsequently, we go through definitions, history, mechanism, how to rate it, and treatment.

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In the last episode, we talked about the first two stages of the hero’s journey. In this episode, I will focus on the path of the hero as it specifically applies to mental health professionals. I will discuss exactly what those are and how these are areas in our core being that simply cannot be faked. The areas we will be discussing require the hero (us) to develop and mature at the core of our being, to embody these things, and to be fundamentally transformed.

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In today’s episode of the podcast, we will be doing a deep dive into duloxetine, a serotonin-norepinephrine reuptake inhibitor (SNRI). In part one of this two-part series, we will cover the history of SNRIs as well as mechanisms of action, cytochrome P450 issues, side effects, and contraindications to consider when prescribing duloxetine and this class of medications.

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There are several disorders so branded with taboo, stigma, and legal consequences that they are almost never diagnosed and very little research has been done on them. These patients are literally seen by every specialty, often without knowing it, and without a good solution. I am hoping this podcast brings awareness to this important topic and gives providers insight into the power of empathy in helping these patients.

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“The Hero’s Journey” entails several predictable steps of leaving and returning transformed. Striving towards one’s heroic possibilities and unfolding one’s potentials is deeply pleasurable. Realizing that our narratives can be seen as part of a journey can encourage these pleasurable aspirational attempts and reframe hardships. This concept of The Hero’s Journey is something I use often in my practice and find very useful.

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With the background from part 1 in mind, in part 2, we review the modern era of research exploring the treatment of various psychopathology. The results for these studies begin to elucidate the various effects individuals experience with psilocybin. The benefits are potentially impressive, however, there are significant limitations that are noteworthy. Psilocybin therapy is just coming out of its nascence and it is useful to have a critical view of the research coming out to avoid pitfalls in the future. 

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The basis of cognitive behavioral therapy is that we should put our thoughts on trial and not just believe them. CBT works by digging into the foundation of our thinking patterns so we can rewire the patterns that are messed up. 

On this week’s episode of the podcast, I speak to Dr. David Burns M.D. about cognitive behavioral therapy. He’s the author of several industry-leading books on the subject, including Feeling Good and Feeling Great.

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Psilocybin has been increasingly part of western consciousness. As the scientific community explores its therapeutic use and safety in controlled settings, there are a lot of people outside of that community who are passionate advocates for its recreational use. If we are to be knowledgeable about this subject, it is useful to know the sources that our patients are getting their information from, the history of its use, and what we currently know about its safety.

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We are privileged to be joined by Dr. Steven Hayes for this podcast. Dr. Hayes is a psychologist with a remarkable academic career. He is the author of a number of seminal papers and pioneered Relational Frame Theory (RFT) and Acceptance and Commitment Therapy (ACT).

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There are medications that worsen cognitive function and all mental health providers should be aware, and work on optimizing sensorium. In this episode, we'll cover a spectrum of sensorium disruptions and medications that you need to look out for. 

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In this last episode of the Big Five personality model series, we are going to focus on extraversion which is the positive emotion dimension associated with gregariousness, charisma, enthusiasm, assertiveness, and social ability.

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In this episode, we continue our discussion on the Big Five. We will do a deep dive into agreeableness discussing it's sub facets: trust, straightforwardness, altruism, compliance, modesty, and tender-mindedness. We will also discuss the strengths and weaknesses of having high trait agreeableness.

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In Conscientiousness Part 1 we explored the sub-facets of conscientiousness, summarizing the advantages and disadvantages of each. For completeness, we will provide sources for that material as well as brief summaries of those sources. Today, in Part 2, we will focus largely on conscientiousness in daily life, psychopathology, and therapy.

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In this podcast, we discuss openness, the third of five in our podcast series looking at the domains within the Five Factor Model of personality. We look at how openness is defined, its heritability, and its effects on physical health, personal attributes, psychopathy, pharmacotherapy, and therapeutic techniques. 

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In this episode, we continue our Big Five Personality Traits series by doing a deep dive into Conscientiousness. We'll look into studies that show how low conscientiousness increases mortality rate as well as positive aspects of high conscientiousness. We also explore the 6 domains, genetic factors, and different life stages of conscientiousness. 

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In this episode, we review studies on strength training, exercise, and depression from the last 2 years. It is well known that any form of exercise is beneficial for people with depressive symptoms, with strength training being most effective. Strength training can be both a treatment for patients with depression and a protective mechanism against the onset of depression.

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In part 2 if the Big Five series we talk about how medications, such as Selective Serotonin Reuptake Inhibitors (SSRIs), psychotherapy, and exercise can make an impact. Trial studies of mindfulness-based cognitive therapy and cognitive behavioral therapy (CBT) have shown promise in the treatment of neuroticism. We also discuss the possible benefits of neuroticism. Studies have shown that neurotic people may outperform their stable counterparts in a work context. This “healthy neuroticism” may exist when the effects of neuroticism and conscientiousness interact. 

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Netflix has recently come under fire for its release of the French film "Cuties." While critics have praised the movie for exploring themes of the oversexualization of children, audience members are consistently appalled at the provocative situations that the 11-year-old characters are put through. In this episode, I discuss our culture's saturation with the oversexulization of children in media with Maddie Ulrich B.S., Randy Stinnett, Psy.D., ABPP, and Caroline Osorio M.D.

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In this episode, Dr. Cummings and I discuss forensic pedophilia and the sexualization of children in our society.

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In today’s podcast, we discuss the Big Five personality traits, focusing on neuroticism and how it fits into this set. We then explore each of the six domains of neuroticism and the research of how it manifests in other parts of one’s life and affects relationships.

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In today’s episode of the podcast, we’ll be doing a deep-dive into nortriptyline, a lesser-talked about medication in psychopharmacology. We’ll cover a little about the history of tricyclic antidepressants (TCAs) as well as the characteristics, side-effects, and indications to consider when prescribing this class of medication.

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The COVID-19 pandemic and subsequent lockdowns have seemed to foster a “sub-epidemic” of suicidality and deteriorating mental health. Suicidal thoughts have spiked across every demographic due to the loss of connection to usual psychosocial supports, normal activities, and in a lot of cases, jobs, leading to significant financial stress. These stressors compound and massively impact the mental resiliency of everyone reached by this pandemic.

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If you are a medical student or someone studying for a big exam, this episode is for you. We will first discuss the mental roadblocks that prevent students from performing at their top potential for exams. We also break down and outline some effective study strategies, and provide a sample day-by-day study plan for any 2nd year medical student preparing for the USMLE Step 1 exam. Finally, we have also created a 3-step challenge all students can follow.

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On this episode of the Psychiatry and Psychotherapy Podcast, we continue our conversation with geriatric psychiatrist, Dr. Osorio, to talk about retirement—specifically, how to retire well and happy.  She recently published a book for people in this transition: Stop Freaking Out About Retirement

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Understanding disorganized attachment as medical professionals is important because some patients have experienced trauma, or 2nd generation influences of trauma, which leads to this issue. As we continue to explore disorganized attachment and how we can help patients with this attachment style, it’s important to remember that this information provides the foundation for why empathy, connection, and emotion mirroring is vital in psychotherapy and psychiatry.

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When people dissociate, it means they feel disconnected from their body. They feel fear and dread, sometimes feeling completely frozen. As mental health professionals, understanding disorganized attachment gives us appreciation and understanding for the necessity of empathy, attunement and deeply understanding the experience of another.

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In this final part of the free will series, we take a look at the relationship between the concept of free will and mental health. Is free will altered in those suffering from schizophrenia? How is well-being related to free will? Thinking about these questions and the rise of neuroessentialism within psychiatry allows us to recognize the influence of our environment on our decision-making. The debate is far from settled, but a belief in free will clearly affects daily life and the practice of psychiatry.

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This is the second episode in our Free will series. In this episode, we will describe some definitions of free will, explore determinism (the opposite of free will), cover some quotes by famous authors on the topic, and break down some statistics, and studies about it. 

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On this episode of the Psychiatry and Psychotherapy Podcast I have a conversation with Matthew Hagele, a soon to be 4th year medical student with a masters in bioethics.  We will talk about the history, the why, and the cultural importance of free will. We will examine the implications of free will on mental health. 

This is the first of a three part series. We hope they provide interesting application information for your own practice.

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Join Dr. Danielle Hairston and Dr. Puder on a discussion of recent events. Dr. Hairston has served as the Black Psychiatrists of America Scientific Program Chair since 2016. She is also the American Psychiatric Association Black Caucus’ Early Career Representative.  She is the residency director at Howard University.  She has a Consultation-Liaison Psychiatry Fellowship. Dr. Hairston has also had the opportunity to speak nationally and internationally about the impact of racial trauma and culture on mental health. She is a contributing author to the recently published book, Racism and Psychiatry: Contemporary Issues and Interventions. Her interests include consultation-liaison psychiatry, resident education, minority mental health, cultural psychiatry, and collaborative care. 

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On this episode of the Psychiatry and Psychotherapy Podcast, we talk about meaning, and how it relates to suicide. 

This is part 3 of a series of podcasts on suicide. If you haven’t listened to the first two episodes, they are here: 

Suicide Epidemiology, Risk Factors, and Treatments

Genetics and Environmental Factors in Suicide

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As the economy continues to shut down during COVID-19, people are growing more concerned about work and finances. Even if the virus is miraculously contained in the next few months, the economy will still be reeling from the damage of the lockdown. 

As psychiatrists, we are concerned about the increases in mental illness from the lack of employment and a potential increase in suicides. In this episode, we begin to look at past studies on the links between economic disaster and the subsequent rates of depression and suicide, and what we might be able to do to help.

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On this week’s episode of the Psychiatry and Psychotherapy Podcast, I interview Dr. Daved Van-Stralen. During this season of COVID-19, Van-Stralen is focusing on the unique stresses on the healthcare system. How can the healthcare system improve the way that things are currently being done? How can people handle stress and the stress of seeing multiple deaths, exposure to the disease, and increased hours?

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In the US, people do not talk about death often or even acknowledge their own mortality. Instead, we act as if we just work hard enough we can do anything, even refuse the grim reaper.

In this episode, we wrestle with the current issues created by COVID-19. Join us as we think more about death and the necessity to have conversations around it. 

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In a previous episode, we covered COVID-19 and its effect on mental health. In today’s episode of the podcast, we will be covering COVID-19 from the medical perspective with regards to its effect on the brain as well as treatment options, their side effects and special considerations.

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On this week’s episode of the Psychiatry and Psychotherapy podcast, I interview Scott D. Miller, Ph.D. and Daryl Chow, Ph.D., authors (along with Mark A. Hubble, Ph.D.) of Better Results. Better Results is a book that sums up thirty years of research to demonstrate what clinicians can reliably do to improve therapy results by personal and professional development. 

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Stress and anxiety are going to be very common during this time. In one study of Wang et al, 2020 they found that in China, 53.8% of the respondents to a survey rated their psychological impact as moderate-to-severe and 28.8% had moderate to severe anxiety, 16.5% had moderate to severe depressive symptoms, 8.1% had moderate to severe stress levels.

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In this week’s episode, we sat down with Shawna Chan, Mona Mojtahedzadeh, M.D., Salman Otoukesh, M.D., David Puder, M.D. and discussed different aspects of mental health in humans bravely facing cancer. Below is a link to the notes which go beyond the podcast episode in content and depth and hopefully equips you to have more empathy, compassion and knowledge.

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This week I interviewed Dr. Joel Weinberger and Dr. Valentina Stoycheva who recently published the book “The Unconscious: Theory, Research, and Clinical Implications .” We discussed their book and even their unconscious reasons for writing a thrilling, deep dive into the unconscious. This book was graduate level in detail, deep, thoughtful, articulate, sometimes very theoretical, and definitely worthy of reading and contemplating.

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Catatonia is a severe motor syndrome. It is a secondary response to an underlying illness that requires quick diagnosis and treatment. There are many different things that lead to catatonia, so finding out the underlying cause is very important. In this episode, Dr. Cummings and I discuss the history, diagnosis, and treatment of catatonia. 

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In this short episode of The Psychiatry and Psychotherapy Podcast, I interview Dr. Cummings, a forensic psychiatrist, on the topic of the correlation of mental illness and violent crime, and what causes violent crime. I start out with reviewing some studies and then subsequently interview Dr. Cummings, a leading psychiatrist at one of the largest forensic psychiatric hospitals in the United States. 

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In this episode, David Puder, M.D. and Michael Cummings, M.D. discuss the history, uses, and side effects of Valproic Acid which is a mood stabilizer for various conditions including: Bipolar Disorder, Schizophrenia, and Borderline Personality Disorder. 

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In this episode, Dr. Puder talks about the importance of therapeutic alliance in the psychiatric interview, emphasizing the need for a strong therapeutic alliance in order to help patients with psychosis continue their medication.  

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Therapy is an intensely focused relationship that involves acceptance, trust, unconditional positive regard, hope, attunement, tolerance, and mending empathic strains and ruptures. There is also emotional contagion between a therapist and patient, with transference and countertransference.

On this week’s episode, I talk about how attachment theory can be a powerful predictor in helping someone move forward past trauma and develop attachment to their therapist in a healthy and therapeutic way.

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What is intelligence? Why is IQ controversial? In this week's episode Nelson Horsley (a 4th year medical student) and David Puder, M.D. discuss the IQ - if it is a predictor for a successful life, and what things can predict or influence IQ.

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Joaquin Phoenix stars in "Joker" which has divided critics and movie goers alike. Surprisingly, it has divided mental health professionals as well. Some say Phoenix's performance shines a light on the misunderstandings of mental illness while others believe it promotes a falsehood that mental illness is responsible for violence. In this episode, David Puder, M.D. and Hans von Walter, M.D. discuss Joker's cinematic and mental health themes.

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Fentanyl is a highly addictive drug which has led to the deaths of countless people including several well known celebrities. Fentanyl is being used to strengthen the potency of other drugs, such as cocaine, which means that people are being exposed to it without their knowledge. In this episode, David Puder, M.D. discusses the history, impact, and statistical analysis pertaining to the dangers of Fentanyl. 

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Since its introduction in the early 2000’s, social media has become an integral part of our daily lives. It influences culture, current affairs, and connects us to the world like never before. As people spend more and more of their lives online, it's important for us to consider how this new online world is changing us. After all, healthy social connection is one of the key factors in good mental health and well-being. It’s time to check in and find out: how does social media affect mental health? 

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In this episode, David Puder, M.D., and Victoria Agee discuss possible links between marijuana use and psychosis. There a multiple studies which reveal links in genetics and marijuana potency that can lead to an increase in schizophrenia and psychosis. 

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On this week’s episode we will be covering a special topic-interviewing well-for psychiatry residency, and even in other interviews post residency. I am interviewing Neal Christopher, a 4th year, chief resident and the host of a podcast for the APA, The American Journal of Psychiatry Residents’ Journal Podcast. 

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AJP Resident Podcast with Dr. Christopher

People often think of emotions as ethereal, complicated depths that are difficult to explore. They are actually adaptive physical reactions to stimuli. There are a few main categories, and as we will discover, they are concrete, identifiable, and usually in a healthy therapeutic alliance, they can be discussed and even when emotions are painful to express or come with shame or linked with traumatic memories, can be disarmed and understood. 

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This week on the Psychiatry and Psychotherapy Podcast, I am joined by Dr. Mark Ard, a chief resident physician at Loma Linda University’s Psychiatry program, to talk about holds and capacity evaluations as it relates to medicine and psychiatry.

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In the previous episode on Suicide, we discussed epidemiology, general risk factors, and associations of suicide with various mental health disorders. Now, in this second part of this series, we will focus on genetic and environmental factors associated with suicide.  The data here might be cold and distant, and so is the nature of suicide. It cuts at the core of families that have struggled with it. I have had many patients who have had family members commit suicide, and it devastates them forever.  

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On this week’s episode of the podcast, I interview Dr. Drew Ramsey, a nutritional psychiatrist. When I was a resident, I saw him give a lecture on diet and how it affects our mood, and I’ve been wanting to interview him for a long time. He is the author of several books about diet and health.

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Lithium is indicated for a number of things. Most clearly, as a mood stabilizer in bipolar spectrum disorders. It is unique among mood stabilizers in that it is very robustly anti-manic. The medication treats and prevents manic episodes from occurring, providing fairly robust prophylaxis against mood cycling. Lithium is also effective in treating bipolar depression, though not as effectively. Very few of the other mood stabilizers are effective for the depressed pole of bipolar illness.

Link to full article with details on up to date research and more: here

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This week the Psychiatry and Psychotherapy Podcast is joined by Dr. Walter A. Brown, Clinical Professor Emeritus in the Department of Psychiatry and Human Behavior at Brown University, author of the brand new book “Lithium: A Doctor, a Drug, and a Breakthrough”.  In order to capture the full experience of this week’s episode, I’ve posted a transcript of my interview with Dr. Brown which you can access in the article link below.

Link to full article with details on up to date research and more: here

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One of the more controversial components of the Neuralink presentation was Musk’s inclusion of his beliefs about the future of humanity and artificial intelligence. During the press release he stated one of his goals was to create the ability to achieve a “full symbiosis with artificial intelligence,” essentially removing the “existential threat of AI” which he believes will one day “leave us behind” (Neuralink, 2019). This goal has been met with a bit more skepticism, especially by the national media, than the medical applications of Neuralink’s BMI. Forbes describes it as “a bit more fantastical” than the company’s primary goal of treating brain disorders (Knapp, 2019). Other publications have been far less kind, such as The Atlantic, which published its coverage of the Neuralink press release with the title: “Elon Musk’s Next Wild Promise: If someone is going to revolutionize what it means to be human, do we want it to be a tech titan?” (Mull, 2019). Although the New York Times surmised that “one of the biggest challenges may be for his scientists to match his grand vision,” (Markoff, 2019), it serves as a good example of what most major media outlets have chosen to do: stick to the facts.  

Link to full article with details on up to date research and more: here

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Working with a good therapist often requires fewer sessions than other therapists to see improvement; in contrast, working with a therapist you don’t connect with, or with inadequate training, may require an extended number of sessions (Okiishi et al. 2003).  People that see effective therapists are more likely to recover or partially recover, whereas those that work with a “bad” therapist are more likely to see no change or an increase in symptoms (Okiishi et al. 2006). 

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On this week’s episode of the podcast, I interview Jaeger Ackerman, 4th year medical student about suicide risk factors and treatments.

As a therapist, attempt to closely approximate their reality of feeling suicidal with words. When I first hear their thoughts and feelings, I try to clarify with the patient to make sure I’m understanding their feelings. I usually try to put it into other words, and echo back to them. I’ll say something like, “I hear that you feel like there’s no other way out, that you feel lost and like it’s a very dark time for you.” I ask myself continually how to be present with them in their feelings, in the moment.

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In this episode of the podcast, I interview Steven, one of my patients who had a rare form of a stroke—in the right orbital frontal cortex. He participated in a psychiatric program that I run. He tells his story of how his function and emotions changed, and how he dealt with it. At the end of the episode, I talk more with Jaeger Ackerman (a 4th year medical student) about the science and neurology of his case so other mental health professionals can have a basis for how to think about approaching brain injury with these psychiatric specifics. Steven was a former hotel executive, actor and certified professional accountant (CPA).

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What is Psychodermatology?

At the most basic level, Psychodermatology encompasses the interaction between mind and skin. It is the marriage between the two disciplines of psychiatry and dermatology, uniting both an internal focus on the non-visible disease, as well as an external focus on the visible disease. This tight interconnection between mind and skin is maintained at the embryological level of the ectoderm throughout life.

According to this article, although the history of psychodermatology dates back to ancient times, the field has only recently gained popularity in the United States. More specifically, Hippocrates (460-377 BC) reported the relationship between stress and its effects on skin in his writings, citing cases of people who tore their hair out in response to emotional stress.

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What is an eating disorder?

One of the most important things about anorexia and bulimia is understanding that they are caused by a complex interplay of genetics, epigenetics, early development, and current stressors. They can lead to dangerous outcomes because of how the eating disorder changes both the body and the brain. Many therapists and nutritionists, as you’ll hear in my conversation with Sarah Bradley, don’t treat from multiple angles, and often lack empathy into this condition.

There are three main types of eating disorders we will cover here:

Anorexia is the practice of cutting calories to an extreme deficit or refusing to eat.

Bulimia involves purging, or vomiting, the food that has been eaten.

Orthorexia is a fixation and obsession on eating healthy food (like only eating green vegetables with lemon juice).

Statistics:

Anorexia traditionally lasts for an average of eight years.

Bulimia traditionally lasts for an average of five years.

Approximately 46% of anorexia patients fully recover, 33% improve, and 20% remain chronically ill.

Approximately 45% of those with bulimia make a full recovery, 27% improve, and 23% continue to suffer.

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Grief is the multifaceted response—emotional, behavioral, social—to a loss or major life adjustment (like a divorce, loss of a job, etc.). Bereavement is the process of grieving specific to the loss of affection or bond to a person or animal (Parkes & Prigerson, 2013; Shear, Ghesquiere & Glickman, 2013; Shear, 2015).

Some of the signs and symptoms of grief are:

-somatic symptoms (e.g. choking or tightness in the throat, abdominal pain or feeling of emptiness, chest pain)

-physiological changes (e.g. increased heart rate and blood pressure, increased cortisol levels)

-sleep disruption and changes in mood (e.g. dysphoria, anxiety, depression, anger)

(Buckley et al., 2012; Lindemann, 1944; O’Connor, Wellisch, Stanton, Olmstead & Irwin, 2012; Shear & Skritskaya, 2012; Shear, 2015; Zisook & Kendler, 2007)

Medical and psychiatric complications can also arise due to grief and include:

-An increased risk for myocardial infarction

-Takotsubo cardiomyopathy (Broken Heart Syndrome)

-The development of mood, anxiety and substance-use disorders (Cheng & Kounis, 2012; Keyes et al., 2014; Mostofsky et al., 2012; Shear, 2015).

Acute grief begins after a person has learned of the passing of a loved one (Shear, 2015). During acute grief, a person may experience immense sadness, yearning for the deceased, and persistent thoughts of the decreased (Maciejewski, Zhang, Block & Prigerson, 2007; Shear, 2015). Auditory and visual hallucinations are benign hallucinations commonly found in acute grief and involve the person seeing, talking to or hearing the voice of the deceased (Grimby, 1993).

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Maris Loeffler Instagram: @agatetherapy

What is clozapine?

Not only is clozapine the gold standard medication for treatment-resistant schizophrenia, it is also one of the most unique drugs used in psychiatry.

It was synthesized 1958, only eight years after chlorpromazine, the first antipsychotic drug, was created. At that time, researchers tested for antipsychotic properties by taking various compounds and testing to see if lab mice developed dystonia and catalepsy. When researchers tested clozapine, they found that it did not cause dystonia, but instead made the mice sleepy. Because of this, clozapine was almost missed entirely as an antipsychotic medication. Eventually, however, clozapine was found to be more successful than other antipsychotic drugs.

By the 1970s, Austria, Germany, and Finland had produced positive data on clozapine proving its efficacy. However, clozapine was also found to have caused severe neutropenia in sixteen patients in Finland, and even caused the death of eight of those patients. For this reason, clozapine did not enter the United States until it was approved by the FDA in 1989.

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PTSD, or Post Traumatic Stress Disorder, occurs when someone experiences or subjectively experiences a near death or psychologically overwhelming event and then goes on to develop specific symptoms. Different types of trauma/stressors that can lead to PTSD include sexual violence, combat experience, medical conditions (e.g. myocardial infarction), and natural disasters (e.g. hurricane) (Chivers-Wilson, 2006; Edmondson et. al, 2012; Grieger et al., 2006; Hussain, Weisaeth & Heir, 2011).

It is characterized by:

Direct exposure or witnessing of trauma/stressor

Presence of intrusive symptoms post-traumatic experience

Avoidance of traumatic stimuli

Negative changes in mood and cognition

Hyperreactivity

Hyperarousal (APA, 2013).

Here are a few stats about PTSD:

In 2017, over 47,000 Americans died by suicide (CDC, 2019). This number has been climbing about 1,000 new cases per year from 31,000 American deaths by suicide in 2000 (CDC, 2019). One contributor to this statistic are people with Post-traumatic stress disorder (PTSD), who are at increased risk of suicide (Wilcox, Storr & Breslau, 2009).

The lifetime prevalence of PTSD in the general population of the US was found to be 6.1% in one national epidemiologic study with certain populations at higher risk for PTSD (e.g. female sex, low socioeconomic status, previously married status, experienced trauma at a young age, African Americans, Native Americans, refugees or immigrants from countries with conflicts) (Alegría et al., 2013; Brewin, Andrews & Valentine, 2000; Goldstein et al., 2017; Kisely et al., 2017; Marshall, Schell, Elliott, Berthold & Chun, 2005).

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Schizophrenia is a diagnosis of exclusion. Doctors and therapists need to be able to rule everything else out before they can land on schizophrenia as an official diagnosis. There are specific symptoms are known as “first-rank symptoms,” which we will cover later in the article, that will help with diagnosing patients (Schneider, 1959). Eighty-five percent of people with schizophrenia endorse these symptoms, but be wary of jumping to conclusions because they are not specific to schizophrenia and, in some studies, are also endorsed by bipolar manic patients (Andreasen, 1991).

DSM5 (Diagnostic and Statistical Manual of Mental Disorders 5th ed.)

Schizophrenia is a clinical diagnosis made through observation of the patient and the patient’s history.

There must be 2 or more of the characteristic symptoms below (Criterion A) with at least one symptom being items 1, 2 or 3. These symptoms must be present for a significant portion of time during a 1 month period (or less, if successfully treated).

The patient must have continuous, persistent signs of disturbance for at least 6 months, which includes the 1 month period of symptoms (or less, if successfully treated) and may include prodromal or residual periods.

For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset.

If the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational achievement.

Criterion A:

A. Positive symptoms (presence of abnormal behavior)

1. Delusions

2. Hallucinations

3. Disorganized speech (eg, frequent derailment or incoherence)

4. Grossly disorganized or catatonic behavior

B. Negative symptoms (absence or disruption of normal behavior)

5. Negative symptoms include affective flattening, alogia, avolition, anhedonia, asociality.

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Clinical manifestations

Many people worry that they have schizophrenia. I receive messages or inquires often of people asking about symptoms and manifestations. If you have those types of questions, or if you’re a mental health professional who needs to brush up on symptoms and medications, this article should help you.

There are many clinical observations of how schizophrenia presents itself. Cognitive impairments usually precede the onset of the main symptoms[1], while social and occupational impairments follow those main symptoms.

Here are the main symptoms of schizophrenia:

Hallucinations: a perception of a sensory process in the absence of an external source. They can be auditory, visual, somatic, olfactory, or gustatory reactions.

Most common for men “you are gay”

Most common for women “you are a slut or whore”

Delusions: having a fixed, false belief. They can be bizarre or non-bizarre and their content can often be categorized as grandiose, paranoid, nihilistic, or erotomanic

Erotomania = an uncommon paranoid delusion that is typified by someone having the delusion that another person is infatuated with them.

This is a common symptom, approximately 80% of people with schizophrenia experience delusions.

Often we only see this from their changed behavior, they don’t tell us this directly.

Disorganization: present in both behavior and speech.

Speech disorganization can be described in the following ways:

Tangential speech – The person gets increasingly further off the topic without appropriately answering a question.

Circumstantial speech – The person will eventually answer a question, but in a markedly roundabout manner.

Derailment – The person suddenly switches topic without any logic or segue.

Neologisms – The creation of new, idiosyncratic words.

Word salad – Words are thrown together without any sensible meaning.

Verbigeration – Seemingly meaningless repetition of words, sentences, or associations

To note, the most commonly observed forms of abnormal speech are tangentiality and circumstantiality, while derailment, neologisms, and word salad are considered more severe.

Cognitive impairment:

Different processing speeds

Verbal learning and memory issues

Visual learning and memory issues

Reasoning/executive functioning (including attention and working memory) issues

Verbal comprehension problems

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What is schizophrenia?

It is a psychotic disorder that typically results in hallucinations and delusions, leaving a person with impeded daily functioning. The word schizophrenia translates roughly as the "splitting of the mind," and comes from the Greek roots schizein ( "to split") and phren- ( "mind").

The onset of the disease typically occurs in young adulthood; for males, around 21 years of age, for females, around 25 years of age.

We don’t know exactly what causes schizophrenia. There are certain predictors for it, and as I discussed the basics and pharmacology a previous podcast, frequent marijuana use can increase the risk of a psychotic or schizophrenic illness to about 4 times what it would be without THC use.

History of schizophrenia

Sometimes, in ancient literature, it can be difficult to distinguish between the different psychotic disorders, but as far as we know, the oldest available description of an illness resembling schizophrenia is thought to have existed in in the Ebers papyrus from Egypt, around 1550 BC. Throughout history, in groups with religious beliefs, the misunderstanding of the psychopathologies caused people to paint those with mental health disorders as receiving divine punishments. This theme of divine punishment continues today in some parts of the world.

It wasn’t until Emil Kraeplin, a german psychiatrist (1856-1926) that schizophrenia was suggested to be more biological and genetic in origin. In around 1887, Kraeplin differentiated what we call schizophrenia today from other forms of psychosis. At that time he described schizophrenia as dementia of early life.

In 1911, Eugen Bleuler introduced schizophrenia as a word in a lecture at a psychiatric conference in Berlin (Kuhn, 2004). Bleuler also identified the positive and negative symptoms of schizophrenia which we use today.

Kurt Schneider, a german psychiatrist, coined the difference between endogenous depression and reactive depression. He also improved the diagnosis of schizophrenia by creating a list of psychotic symptoms typical in schizophrenia that were termed “first rank symptoms.”

His list was:

Auditory hallucinations

Thought insertion

Thought broadcasting

Thought withdrawal

Passivity experiences

Primary delusions

Delusional perception (the belief that a normative perception has a certain significance)

Sigmund Freud furthered the research, believing that psychiatric illnesses may result from unconscious conflicts originating in childhood. His work eventually affected how the psychiatric world and society generally viewed the disease.

The history and lack of understanding of the disease is a dark history, and it is still deeply stigmatized, but psychiatry has made massive leaps in understanding schizophrenia and changing how it is viewed in modern society.

Nazi germany, the United States, and other Scandinavian countries (Allen, 1997) used to sterilize individuals with schizophrenia. In the Action T4 program in Nazi Germany, there was involuntary euthanasia of the mentally unwell, including people with schizophrenia. The euthanasia started in 1939, and officially discontinued in 1941 but didn’t actual stop until military defeat of Nazi Germany in 1945 (Lifton, 1988). Dr. Karl Brandt and the chancellery chief Philipp Bouhler expanded the authority for doctors so they could grant anyone considered incurable a mercy killing. In reading about this event, it seems that This caused approximately 200,000 deaths.

In the 1970’s, psychiatrists Robins and Guze introduced new criteria for deciding on the validity of a diagnostic category (Kendell, 2003). By the 1980’s, so much was understood about the disease that the DSM (Diagnostic and Statistical Manual of Mental Disorders) was revised. Now, schizophrenia is ranked by World Health Organization as one of the top 10 illnesses contributing to global burden of disease (Murray, 1996).

Unfortunately, it is still largely stigmatized, leading to an increased schizophrenia in the homeless population, some estimates showing up to 20% vs the less than 1% incidence in the US average population.

In conclusion

On the podcast episode, we discuss the media’s portrayal of schizophrenia. Although media paints mentally ill as often violent, on average people with mental illness only cause 5% of violent episodes. This is just one example of how the stigma is furthered.

The more we understand about this disorder—what causes it, how we can help, how we can provide therapy and medicate and treat patients—the better. Getting rid of the stigma by learning the history and also moving beyond preconceived ideas to the newest science will also help de-isolate people with schizophrenia and help support them in communities, giving them a chance at a normal, healthy life.

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On today’s episode of of the podcast, I will discuss marijuana use and how it affects mental health with Daniel Binus, the chief psychiatrist at Beautiful Minds, near Sacramento, California. Also joining us is a third-year medical student, Victoria Agee.

There are a few reasons we believe this is important to talk about. First, as medical professionals, we often see patients who want help with their anxiety, depression, ADD and suicidality. They say they use cannabis, and that they need cannabis, to help calm those symptoms. When we explain the research to them, it still takes them awhile to let go of their habits and embrace other forms of therapy and medication that is a better long-term option.

Also, we head into a time when marijuana is being legalized, there are tons of THC companies that will benefit from suppressing this information and even suppress these studies we will reference here. Hiding this information could be detrimental to society’s mental health. While there are some potential benefits to one component of marijuana (CBD), something I will review in the future (evidence is fairly young in that field), the THC component can be highly damaging to mental health.

Whether or not people are willing to admit it, cannabis is actually highly addictive. One of the symptoms of addiction is intellectualizing reasons for use. Not only does it change the way the brain functions, it changes the way we see and perceive the world. It also changes our visual and spatial abilities. If you’re an architect or use math in your job, it deeply affects those abilities as well. THC stays in your brain a long time—it can be weeks (or even a month) before people get the full function of their brain back and the fog has cleared.

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On today’s episode of the podcast, I interview Ginger Simonton, a PhD student finishing her dissertation. We will cover her in-depth research on alleviating the symptomology of childhood sexual abuse.

We will specifically be talking about the link between women who have been sexually abused, never given a chance to heal, and how it has affected their mental and physical health, and programs that can benefit them.

What is childhood sexual abuse?

“The CDC defines the act of CSA as “inducing or coercing a child to engage in sexual acts” that include “fondling, penetration, and exposing a child to other sexual activities” (2017).”

The facts:

88% of sexual abuse cases happen with someone the child knows (Finkelhor, Ormrod, Turner, & Hamby, 2005)

20-30% of women experience some form of sexual abuse before they reach 18 years old (Pereda et al., 2009; Stoltenborgh, Van Ijzendoorn, Euser, Bakermans-Kranenburg, 2011; Bolen & Scannapieco, 1999; Holmes & Slap, 1998; Finkelhor, 1994)

20-40% of survivors have no adverse effects later in life (resilience is the norm) (Paras, Murad, Chen, Goranson, Sattler, Colbenson, Elamin, Seime, Prokop, & Zirakzadeh, 2009)

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On this week’s episode of the podcast, I talk about the power of forgiveness. It’s scientifically proven that forgiveness can impact our health. As mental health professionals, this has important impacts both personally and professionally. I have also included a downloadable PDF for you to give your patients to help you walk them through the act of forgiving.

As a therapist, when I say the word “forgiveness,” my patients can shut down if I don’t explain it properly. Why? Because just the need for forgiveness is proof that they have been wronged. When we are wronged, it can be hard to let go of that hurt. That’s why I wanted to start out by saying what forgiveness (and this episode) is not about.

Forgiveness is not:

It is not approving.

It is not excusing the action, denying it, or overlooking it.

It is not just moving on (particularly not with cold indifference).

It is not forgetting or pretending it did not occur.

It is not justifying or letting go of possibly needed justice.

It is not calming down.

It is not a bargain or negotiation.

It is more than ceasing to be angry.

It is more than being neutral towards the other.

It is more than making oneself feel good.

It is one step towards reconciliation, but it is different from reconciliation, which requires a sincere apology from all parties.

It is not dependent on the one you forgive—that would give the other power to control you by keeping you in your bitterness. Consider Corrie Ten Boom, who forgave the Nazis after losing her family in the Holocaust, or Marietta Jaeger who, after her daughter was kidnapped and brutally murdered, was able to forgive. People can forgive, even when the person who wronged them is unknown or dead.

It is not a one time event, but may need to be repeated (sometimes the hurt comes back, sometimes you need to start every morning with forgiveness).

It is not a restoration of full trust (trust takes time to develop or to be reinstated).

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What is transference?

Historically the term “transference” refers to the feelings, fantasies, beliefs, assumptions and experiences unconsciously displaced on the therapist that originate in the patients’ past relationships. More recently, transference is seen as the here and now, valid experience the patient has of the therapist.

It is “a mixture of real characteristics of the therapist and aspects of the patient’s figures from the past—in effect, it’s a combination of old and new relationships.” (Gabbard)

How does transference work?

The patient’s early experiences develop organizing principles, constructing a framework for future interpersonal interactions. (Maybe their dad was an abuser, so they project that you will abuse them.) Transference is the continuing influence of these ways of organizing and giving meaning to experiences. They crystallized in the past, but they continue in an ongoing way in the here and now. The therapist’s actual behavior is always influencing the patient’s experience of the therapist because of this.

When a patient visits a therapist, they seek a new developmentally needed experience, but they expect the old, repetitive experience.

There is often misattunement to painful circumstances that can't be integrated into a person’s emotional world. For example—a child who can’t demonstrate his emotion in a way that his parents can handle causes the parents to move away from the child, creating distance. The child then subdues the emotion and creates a new “ideal self” so they can interact with others and no be rejected. The child then doesn’t know how to deal with strong emotion, even moving into adulthood.

Unintegrated affects become lifelong emotional conflicts and vulnerabilities to traumatic states. To handle the difficult situation, they develop defense mechanisms. Those defenses against affects become necessary to maintain psychological organization.

That “ideal self” will stay in place with others until you come along. If they see you as a safe person, they will express their emotions—anger and all—towards you.

This is where it’s important to understand transference, and to be able to give your patient a safe place to express their emotions.

When we understand transference is happening, we can listen from the patient's world, acknowledge their subjective perspective, resonate with them, look for their meanings, and form and alliance with the patient's expressed experience.

Of course we must expect their hesitations to trust us, avoid us, have feelings of shame, guilt, and embarrassment...it is uncomfortable to share what one feels.

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Inpatient Psychiatric Violence with Dr. Gillian Friedman, M.D.

In this week’s episode of the podcast, I interview Gillian Friedman and was joined by Nate Hoyt, a fourth year medical student.

Link to show on: iTunes, Google Play, Stitcher, Overcast, PlayerFM, PodBean, TuneIn, Podtail, Blubrry, Podfanatic

Article by: Nate Hoyt (MS4), David Puder, M.D., Gillian Friedman, M.D.

Violent aggression in the inpatient psychiatric setting has developed into an important issue that negatively affects patients and staff. There are some simple and surprising treatments different clinics are taking to prevent violent aggression. It’s time we paid attention to this issue so we can prevent injury of both patients and hospital staff.

Check out these startling facts:

• Greater than 75% of nursing staff on acute psychiatric reported being assaulted by a patient at least once over the course of their careers (Iozzino et al., 2015).

• One in four psychiatric nurses report disabling injuries from patient assaults (Quanbeck, 2006).

• Aggression, when present, works against discharge planning and typically prolongs patient stays (Quanbeck, 2006).

How widespread is inpatient violence? Can it be predicted and prevented? What are the best measures for managing it?  And how do we fix the issue? Traditional methods of responding to aggression, such as seclusion or restraints could result in physical and psychological harm to patients.

Clearly, a discussion of inpatient violence would be beneficial.

Prevalence & Risk Factors

How often is this happening? Studies show that a smaller percentage of the patients cause most of the violence, and that there are predictive risk factors that can determine if a patient will be more likely to be a first time offender, or a repeat offender.

A meta analysis of 35 studies including 23,972 patients admitted to acute psychiatric units in 31 high-income countries found that about 17% committed at least one act of violence while hospitalized (Iozzino et al., 2015). It is important to note, however, that a small percentage of aggressive psychiatric patients, cause 10 times more serious injuries than those who less frequently assault (Convit et al., 1990, Cheung et al., 1997).  Six percent of aggressors are responsible for 71% of incidents according to Barlow, Grenyer & Ilkiw-Lavalle, 2000).

Targeting these so called “recidivistic assaulters” could lead to the greatest decrease in aggressive incidents.

To an extent, the risk of inpatient aggression can be predicted.

Here are some of the risk factors:

• The most significant risk factor for physical violence was history of aggression, and violence 1 month before admission further increased risk (Amore et al, 2008); number of past violent acts is correlated with an increase in violence risk (Quanbeck, 2006)

• Males are associated with greater aggression (Amore et al, 2008)

• Certain psychiatric diagnoses are associated with higher rates of aggression:

  • Schizophrenia

  • personality disorder

  • impulse control disorder (eg, anger/temper control problems)

  • bipolar and schizoaffective disorder is also associated with aggression (Amore et al, 2008, Barlow, Grenyer & Ilkiw-Lavalle, 2000, Quanbeck, 2006)

• A high percentage aggressors have a secondary diagnosis of substance use disorder (50% according to Olupona et al., 2017) (Barlow, Grenyer & Ilkiw-Lavalle, 2000)

• Aggressive patients are likely younger, with age <32 years (Barlow, Grenyer & Ilkiw-Lavalle, 2000)

• Aggression is associated with history of being the recipient of abuse; 67% of assaultive patients had been victims of violence themselves according to Flannery et al. (2002); 66% of assaultive patients suffered abuse as children according to Hoptman et al. (1999)

• Dr. Friedman gave some incredible clinical wisdom on this episode: She says she often notices increased violence:

  • When patients return after losing a hearing (either having to stay in the hospital on a 5250 or having to take medications involuntarily—a Riese hearing)

  • During times where they demand to leave and are told no (especially early on in the hospital stay) prior to discharge

  • When things change

How to clinically assess psychiatric violence

The risk factors above emphasize the need to carefully assess patients for aggression risk.

There are many different assessment models in the literature. The California State Hospital Violence Assessment and Treatment (Cal-VAT) (Stahl et al., 2014) is a good example of a standardized model used over multiple sites.

It is recommended that patients The Cal-VAT assessment process recommends the following:

• Assess for etiology of aggression; we’ve mentioned the types of aggression in previous podcast episodes, but here is a quick reminder:

  • Psychotic violence patients: misunderstand/misinterpret stimuli, experience paranoia, command hallucinations

  • Impulsively violent patients: are hyper-reactive to stimuli, have emotional hypersensitivity, and autonomic arousal

  • Predatory violence: is planned, they show a lack of remorse, autonomic arousal absent

• Assess for medical conditions that could contribute to risk for aggression

  • psychomotor agitation

  • akathisia

  • Pain

  • Delirium

  • Intoxication/withdrawal

  • Complex partial seizures

  • Sleep issues

  • Abnormalities with glucose/calcium/sodium/thyroid, or cognitive impairment

• Be conscious of environmental factors that could contribute to aggression

  • lack of supervision/structure

  • waiting in line

  • Crowding

  • excessive noise

  • poor staff teamwork

• Violence risk assessment (should be systematic and performed by trained individual)

  • Includes violence history

  • Screen for common comorbidities

    • Psychosis

    • Substances

    • Psychopathy

    • emotional instability

    • borderline personality disorder

    • intellectual disability

    • TBI

  • Some good assessment tools are:

    • Historical Clinical Risk Management-20 (HCR-20)

    • Short-Term Assessment of Risk and Treatability (START)

    • Violence Risk Screening-10 (V-RISK-10)

    • Brief Psychiatric Rating Scale (BPRS) (Amore et al., 2008)

How can we help violent psychiatric patients?

Traditional Methods

Isolation, restraints, and especially psychopharmacology form the backbone of inpatient violence prevention. While these serve an important role, heavy reliance on them has been perceived by patients as “controlling” ( Duxbury, 2002). It can be very useful to augment these methods with newer strategies that promote cooperation and partnership with patients.

We won’t delve into the traditional methods here other than to direct the reader to the Cal-VAT guidelines (Stahl et al., 2014) for an excellent discussion of the psychopharmacologic treatment of violence including off-label medications and higher-than-normal dosages.

De-escalation Strategies

Diligent attempts to deescalate can result in reduced use of traditional methods. Below we’ve included Dr. Puder’s resources from the podcast.

1.Richmond et al. (2012):

• 1st patient is verbally engaged

• 2nd collaborative relationship established

• 3rd: verbally de-escalated

  • Verbal loop: listen to the patient-> find ways to respond that  agrees with or validates the patient’s position-> tell the patient what you want (take meds, sit down, ect)

    • May take a dozen times (requires patience)

    • Each cycle may take 1 minute, so 10 minutes for 10 cycles

2. Fishkind, A. (2002), 10 domains of de-escalation:

1. Respect personal space

   1. 2 arms distance at least

   2. Understand many have been sexually abused

2. Do not be provocative

   1. Not fist clenched, not closed off body language, not excessive staring

3. Establish verbal contact

   1. Only one person (trained person)

   2. Explain who you are and your goal is to keep everyone safe

4. Be concise

   1. Simple language, simple vocabulary, bit sized info at a time

   2. Persistently repeat message

5. Identify wants and feelings

   1. “Even if I can’t provide it, I would like to know so we could work on it.”

6. Listen closely to what the patient is saying

   1. Through body language, verbal acknowledgement, repeat back to their satisfaction

   2. “To Understand what another person is saying, you must assume that it is true and try to imagine what it could be true of.”

7. Agree or agree to disagree (find things to agree with)

   1. Agree with the truth

   2. Agree with the principle

      1. “I believe everyone should be treated respectfully”

   3. Agree with the odds

      1. “There would probably be other patients who would be upset also…”

8. Lay down the law and set clear limits

   1. Lay down the expectations for expected behavior matter of fact (not as a threat)

9. Offer choices and optimism

   1. Propose alternative to violence

   2. Offer kindness (blankets, magazines, access to phone, food, drink)

10. Debrief the patient and staff

3.  Dr. Friedman recommends all doctors on her unit to have prn (as needed) medications available as part of the initial order set. Then nurses can administer them if a patient starts escalating.

Alternate Measures

Literature suggests significant decreases in inpatient violence from some interventions further off the beaten path than those we’ve mentioned thus far.

Surprisingly simple interventions working toward improving staff relationships with patients can lead to significant decreases in inpatient violence. Two British studies offer some opportunity for reflection.

Bowers et al. 2015 tested 10 Safewards interventions in a randomized controlled trial that included 31 wards at 15 hospitals in London. The interventions tested included a requirement to say something good about each patient at nursing shift handover, emphasis on de-escalation, structured, innocuous, personal information sharing between staff and patients (favorite music/sports), anticipating and talking through bad news patient may receive, and display of positive messages about the ward from discharged patients. The test sites that used the interventions experienced a 15% reduction in conflict events and a 23.2% reduction in containment events.

Antonysamy (2013) reported that one inpatient adult unit in Blackpool, England began taking patients on weekly trips to the local zoo. Over the course of 12 months, aggressive incidents dropped from 482 to 126, and average length of stay reduced by about 50%. Furthermore, the rate of staff taking sick time was reduced by more than 50% (they attributed this to increased enthusiasm).

Conclusions

Inpatient psychiatric violence poses a significant risk to patient and staff health. Risk factors offer staff an opportunity to predict and prevent aggression through thorough violence assessments.

Pharmacotherapy, isolation, and restraints provide a valuable core of intervention options that will likely never be replaced, but is could be beneficial to begin to view these as more of a last line of defense. When we resort to these interventions by default, patients perceive entering into a very control-oriented power dynamic with staff, and patient-staff relationships suffer. When we utilize alternative interventions that emphasize the humanity of patients and foster cooperative partnerships with staff, the need for traditional interventions is reduced.

Antonysamy’s (2013) intervention of the weekly trip to the zoo is well nigh impossible to test in the United States, but it offers an important opportunity for reflection. If simple, humanizing interventions like this can be so effective, where should we place our emphasis in future research?

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On this week’s episode of the podcast, I am joined by Dr. Carolina Osorio, a geriatric psychiatrist (and one of my favorite people). After she finished her psychiatry residency, she also went on to finish a fellowship in geriatric psychiatry to take care of her favorite people. Dr. Osorio runs a special program that treats elderly people with depression and anxiety.

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On this week’s episode of the podcast, I interview...quite a few people! We are covering Ted Bundy, America’s most infamous serial killer, and since the world has been fascinated by him lately, I figured I’d get a group of mental health professionals in a room to talk about him. His horrific acts made the news and have scared people for decades now, and rightfully so. Did media and pornography cause this? What was his diagnosis and was it correct? We have so many questions...

As my special guests and panel of experts, I invited Dr. Tony Angelo, who is head of services for a local prison and in charge of prisoners transitioning into normal life. I also invited Dr. Randy Stinnett, a clinical psychologist who co-manages an outpatient behavioral health department in a local community health clinic. Also with me is Nathan Hoyt and Adam Borecky, 4th year medical students who will be going into psychiatry.

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The words “aggression” and “violence” are sometimes used synonymously, but in reality, aggression can be physical or non-physical, and directed either against others or oneself. Violence is more of a use of force with an intent to inflict damage.

One study looked at the principle types of aggression and violence that occur in psychiatric patients, and broke it down into three categories:

Impulsive violence (the most common category)

Predatory violence (purposeful and planned violence)

Psychotically-driven violence (least common)

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Empathy is the ability to understand another’s state of mind or emotions. It is also is being able to feel, understand and share with someone else in what they are saying, their meaning of life, their motivations and values.

In research there are 3 types of empathy that are commonly described: cognitive, affective, and compassionate.

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People who truly have ADHD typically experience inattentive and hyper symptoms across all areas of their life. For example, if they are in a job that requires periods of attention to complete or organize a project, it will be inherently more difficult for people with ADHD.

One of the things that’s important in diagnosing people (particularly younger people) is their collateral history. People around the person with suspected ADHD are often more aware of the person’s deficits than the person themselves. When they reach adulthood, the problems might be made more obvious when they integrate into normal society and notice they struggle with symptoms of ADHD (compared to other people).

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What is placebo?

The original meaning of the word placebo is, “I will please.” That statement comes from a time when doctors didn’t have our modern code of ethics, and they would prescribe whatever would make the person feel better. They probably had the best intentions, but they also would have known that whatever they were prescribing might not have been a real medication for the symptoms the patient was experiencing.

Doctors, even then, knew that suggestion was powerful, sometimes more powerful than the medicine they were prescribing.

Laypeople who hear the word “placebo” automatically think of sugar pills. They may think only that it’s something a doctor gives to placate and make people feel better when they aren’t getting the active medication. Placebos have long been used as a comparison arm for clinical trials. Usually it is in the form of an inert sugar pill or sham-procedure. Researchers can observe a psychobiological response known as the placebo effect.

But when thinking about the word “placebo,” we must think of the entire effect of it, and it is perhaps better termed “the meaning effect.” As I discussed in last week’s episode of the podcast, the meaning we give something creates belief, and belief is a potent change mechanism, even when it comes to our physical health. It is especially potent when it comes to mental health.

The placebo effect encompasses the therapeutic alliance, expectations, natural healing of the body and mind, and the environment of therapy. It involves the power of suggestion, mood, and the beliefs behind even one positive or negative interaction with a doctor. It also, as we will see, involves studies involving heavy-hitting medication.

When there is an increased ritual, there is an increased placebo effect. During a hospital stay, the surgery preparation, meetings with doctors, nurses and therapists can have an incredibly therapeutic effect on a patient. It is possible to see biological mechanisms triggered by psychosocial context and attribute it to a placebo effect.

What is the power of suggestion, the meaning effect, placebo effect, and how do we use it or avoid it in our practices and when testing new medical treatments?

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For many, motherhood is a beautiful, unique, and meaningful experience. The mother-child bond is a relationship that has the potential to be a deeply loving and positive experience for both the mother and child. However, motherhood can be distressing, which is why it is imperative that we, as providers, understand the unique psychiatric issues that are associated with this time period in a woman’s life.

Perinatal mood and anxiety disorders, or PMAD for short, is the term used to describe mood and anxiety disorders that affect women during the perinatal period, which is the timeframe from pregnancy to 12 months postpartum. PMAD encompasses a variety of disorders, such as anxiety, depression, obsessive-compulsive disorder, bipolar mood disorder, psychosis, and PTSD.

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Episode CME activity objectives:

In the context of a therapeutic alliance, apply the information given in this episode to help draw out meaning in others.

Identify who Viktor Frankl was and how his work and legacy have shaped how we understand and utilize meaning in psychiatry.

Define psychic determinism.

Recognize that meaning is idiosyncratic and unique to each individual.

Recognize the multitude of ways people can find meaning in their lives and the various ways they can express and convey this.

Summarize the various studies listed in this episode that have shown how meaning and the creation of meaning can have a positive impact.

David Puder, M.D. has no conflicts of interest to report.

In the celebrated book Man’s Search for Meaning, author Viktor Frankl wrote about his intimate and horrific Holocaust experience. He found that meaning often came from the prisoners’ small choices—to maintain belief in human dignity in the midst of being tortured and starved and bravely face these hardships together.

“The way in which a man accepts his fate and all the suffering it entails, the way in which he takes up his cross, gives him ample opportunity—even under the most difficult circumstances—to add a deeper meaning to his life. It may remain brave, dignified and unselfish. Or in the bitter fight for self-preservation he may forget his human dignity and become no more than an animal.” - Viktor Frankl

“We who lived in concentration camps can remember the men who walked through the huts comforting others, giving away their last piece of bread. They may have been few in number, but they offer sufficient proof that everything can be taken from a man but one thing: the last of the human freedoms—to choose one’s attitude in any given set of circumstances, to choose one’s own way.” - Viktor Frankl

Frankl argued that the ultimate human drive is the “will to meaning,” which could be described as the meaning to be found in the present and in the future. For example, I have had patients who are suicidal, yet they would not kill themselves, despite part of them desiring death, because they would not get to see their grandkids grow up. The meaning of the future moments and being able to help their grandkids in some small way empowers them to keep going to treatment.

People’s meaning keeps them going, even when other drives, like sex or desire for power, are completely gone. In this way, Frankl noted, “Focus on the future, that is on the meaning to be fulfilled by the patient in his future…I speak of a will to meaning in contrast to the pleasure principle (or, as we could speak also term it, the will to pleasure) on which Freudian psychoanalysis is centered, as well as in contrast to the will to power on which Adlerian psychology, using the term ‘striving for superiority,’ is focused.”

This idea led to the beginning of a new type of therapy—logotherapy.

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Delirium is an acute change in a person’s sensorium (the perception of one’s environment or understanding of one’s situation). It can include confusion about their orientation, cognition or mental thinking.

With hyperactive delirium, a patient can become aggressive, violent and agitated with those around them. A patient experiencing delirium can have hallucinations and hear things, they can become paranoid, and they are overall confused. A family or non-psychiatric medical staff might be concerned that the patient is experiencing something like schizophrenia.

Hyperactive delirium symptoms in patients:

Waxing and waning —it comes and goes

Issues with concentration

Pulling out medical lines

Yelling profanities

Throwing things

Agitated

Responding to things in the room that aren’t there

Not acting like themselves

Hypoactive delirium is much more common than hyperactive delirium (based on research studies), but it is often missed because the presentation is much less dramatic. People with hypoactive delirium are confused and disoriented, but they are not expressing their confusion verbally or physically.

Hypoactive delirium symptoms:

Slower movement

Softer speech

Slower responses

Withdrawn

Not eating as much

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On this week’s episode of the podcast, I interview Dr. Cummings, a reputable psychopharmacologist, about ketamine. We talk about psychedelics, the research behind it, both the positives and the negatives. We will look at how it is or is not helpful in psychiatric treatments.

(Disclaimer: There are no conflicts of interest to report. Neither Dr. Puder or Cummings is affiliated with any companies in favor of ketamine and other drug companies.)

Ketamine

Although ketamine has recently become a medication of great interest in psychiatry, it actually is a fairly old medication. It was first synthesized in 1962 and began human trials for anesthesia in 1964. It was finally approved by the FDA as a dissociative anesthetic in 1970.

What has piqued interest in psychiatry is that infusion of a smaller dose of ketamine produces a rapid response in terms of reversal of depressed mood, suicidality, and some treatment-resistant depressed patients.

The literature is rich (in one sense) as the most recent consensus statement (Sanacora, 2017) looked at seven randomized controlled trials, all of which support a robust antidepressant response and anti-suicide response. The difficulty with those trials is the majority of them lasted only one week. A few of the later trials lasted two to three weeks with two to three infusions per week. So, what’s lacking at this point is adequate data regarding long term treatment response and data about transitions to more traditional antidepressant treatments.

For the rest of the blog that goes with this episode, go: here

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On this week’s episode of the podcast, I interviewed Allison Maxwell, a social worker and PhD student of clinical social work. I refer patients to her regularly for psychoanalysis, and she has had a wonderful impact on their mental health journey.

What is psychodynamic theory?

Psychodynamic therapy is a form of talk therapy where the practitioner work focuses on the patient’s emotion, fantasies, dreams, unconscious drives and wishes, early and current life relationships, and the relationship that is forming between the patient and therapist.

For the blog that goes with this episode, go here

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Timothy Lee has talked to thousands of medical students about how to applying for residency programs, and here, he gives us a few tips on how to make it through the gauntlet, and how to have your best chance at landing the program you want.

Here is what Timothy Lee says:

Stay calm

Many students have been fine tuning their personal statements, and trying to get their resume just right, or hurrying to press the faculty to write letters of recommendation. It can be very stressful.

It’s okay to turn in information a little bit later, in order to have all of the paperwork you need. It’s even okay to review your statement after you’ve already turned it in. No one will lower their opinion based on that. You will need to have applied for the majority of the programs you are interested in by early or mid-October, otherwise the program director might wonder if you’re applying to them later as a backup plan.

What matters in a personal statement?

Every program director will have different opinions on what you write, and every program director will be looking for different things from your personal statement. For some people, it’s a chance to get to know the applicant a little bit. For others, it doesn’t really matter that much.

As long as your grammar and syntax are competent, you should be fine. Some people don’t worry about the format, and others are more particular. To be on the safe side, if you have access to a good mentor, run it by them. Also, don’t be too wordy—stick to a page and a half.

Do step scores matter?

Step scores are a very convenient screening tool for what matters, but there are studies that show that step scores are not directly correlated to success in residency performance. They are helpful, but are not the end-all-be-all. It’s only one part of the picture of an applicant. However, if you are going for a highly-competitive residency, you might need to worry about step scores a bit more.

Apply to the right number of programs

The number of programs is not the only way to increase your chance of success of getting in. Pay attention to the types of programs you are applying to as well. If you are applying for a good number of programs, make sure at least half of them are are ones you are a solid and potentially attractive candidate for.

Keep a good perspective

Ultimately, you are more than your CV, step score, or personal statement. If patients like you, that’s going to go a long ways. Your patients won’t know your scores, or where you graduated from medical school. They will know if you were competent, caring and connected. That is ultimately what matters.

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What is a therapeutic alliance?

The therapeutic alliance is a collaborative relationship between the physician and the patient. Together, you jointly establish goals, desires, and expectations of your working partnership.

Every interview with a patient, whether it’s for diagnostic, intake, evaluative, or psychopharmacology purposes, has therapeutic potential. The treatment starts from your first greeting—how you listen, empathize, and even how you say goodbye.

It’s built from a partnership and dialogue, like any other relationship. It’s not built from medical interrogation. It’s not about pulling medical information to be able to make a diagnosis. We have to make it a positive experience for patient, so they can begin to talk about what's negative in their lives.

The therapeutic alliance is full of meaning, and it uses every emotional transaction therapeutically. If they get angry, sad, or have fear you will abandon them, as a therapist, it’s our job to figure out how to help them through that feeling within the relationship. The doctor can express desire for the patient to share, in real time, how the patient is feeling, even about his or her relationship with the doctor.

Why do we care?

We all know that some talk therapists have better outcomes than other talk therapists. What’s interesting though, is that some some psychiatrists’ placebos worked better than other psychiatrists’ active drugs. One study of NIMH data of 112 depressed patients treated by 9 psychiatrists with placebo or imipramine, found that variance in BDI score (a score that measures depression) due to medication, was 3.4% and variance due to psychiatrist was 9.1%. One-third of psychiatrists had better outcomes with the placebo than one-third had with imipramine.

Another book argues that the therapist is more important to outcome than theory or technique. Many other studies have shown that therapeutic alliance directly correlates to success rates.

For the rest of the blog/article go here

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What is trauma?

Emotional trauma comes from stress that is overwhelms a person’s neurological system. Some stress can be good and formative, or it can be bad and get stuck in the brain, causing someone deep emotional pain.

Think of climbing Mount Everest. Some people choose to do that, and it’s easily one of the most stressful situations you can put yourself in on purpose. That’s good stress if you have trained for years and are ready for it. If someone forced you to climb Mount Everest, it would register in the brain as a trauma.

Trauma is too big for the mind, brain, and nervous system to assimilate. It’s a memory, or experience, that gets stuck because the person believed it would result in their death, or at least serious injury.

The brain has several mechanisms to keep something stuck so that the person will remember it, and try to avoid getting hurt in the same way in the future. It is a survival instinct.

People commonly demonstrate symptoms of trauma when they’ve:

Experienced a sexual violation

Seen violence

Experienced violence or abuse

Been neglected—experienced the absence of something that they should have had.

Been in near death experiences like car accidents or war

People who have PTSD, or post traumatic stress disorder, have experienced a soul-level of brokenness, and even talking about the event, or having a memory of it, can bring it back with the same force that occured in the actual accident. They often have recurring nightmares, or repetitive symptoms that continue long after the event.

Typical PTSD symptoms alternate between chronic shut down and fight and flight

Fight and flight symptoms are:

Sweating, nightmares, flashbacks, anger, rage, panic, hypervigilance, tense muscles, painful knotted gut

Shut down symptoms are:

Dissociation, freezing, emotional detachment, voice trembling, difficulty getting words out, numbness, apathy, fear, helplessness, dizzy, empty, nausea

Moments in connection mode look like:

curiosity, exploration, relaxed and full breathing, feeling grounded, true smiles

To read more about trauma, go to the full blog on this episode here.

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What are boundaries?

When we refer to boundaries, we are talking about emotional walls that are healthy. Boundaries are meant to keep us in relationship with the people that we love.

Think of them as your property lines around your house. You know where your lines are, where your property ends and your neighbors begins. Therefore you know what you are supposed to take care of and what your neighbor is supposed to take care of.

A boundary defines our self. Within ourselves, our “property” consists of our physical body, our desires, our intellect, and our ability to make decisions. It gives us a sense of defining what is “me” and what is “not me.”

We are not supposed to take on too much of other people’s emotional experiences. When I was a newly practicing psychiatrist, I didn’t know that, and I felt depressed after meeting with a depressed patient. It is possible to have an understanding of what is happening in someone’s emotional world, but not take it on yourself.

For more go to the blog that was written from this content: here

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In this episode we discuss:

The history of bipolar illness, mood stabilizers, common treatments, psychopharmacology, psychotherapy goals, and more.

For paraphrased transcription and blog: go here

For more detailed notes by Dr. Cummings, go to my resource page.  

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In this week’s episode of the podcast, Dr. Michael Cummings and I talk about the history of antidepressants, and their use in overcoming depression and anxiety disorders.

For blog and extended notes go here

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Polyvagal theory by Stephen Porges explains three different parts of our nervous system, and their responses to stressful situations. Once we understand those three parts, we can understand our emotional reactions to trauma or high amounts of stress.

Why is polyvagal theory important?

For therapists, and pop-psychology enthusiast alike, understanding polyvagal theory can help with:

Understanding trauma and PTSD

Understanding the dance of attack and withdrawal in relationships

Understanding how extreme stress leads to dissociation or shutting down

Understanding how to read body language

For more please check out the: blog

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What is procrastination?

Procrastination is the act of avoiding something through delay or postponement.

You might be procrastinating when:

There is a gap between your intention and action

You feel like avoiding something

You find yourself easily distracted

You feel overwhelmed by tasks at the last minute

You always feel rushed to complete a project

You’re hesitant to truthfully update someone on your progress

It usually brings about feelings of:

Shame

Guilty

Anxiety

Regret

Anger

Inauthenticity

Why do we procrastinate?

We procrastinate because our brains receive a reward for avoidance. Avoidance brings immediate relief from the distress associated with the task. Although we may experience discomfort in the final moments before a task is due, we rarely think about the past or future when procrastinating.

This creates a problematic cycle, one that erodes at our self-confidence. It also causes us to keep up a steady stream of “I should be…” in our subconscious minds.

The ingredients for procrastination
Personal & System Based Factors of Procrastination

There are fixed factors related to procrastination, things that are innate to each of our different psychological experiences. For example, someone with ADHD is more likely to procrastinate.

The fixed personal factors are:

Higher Impulsivity

Lower conscientiousness—lower drive to be organized and accomplish.

Limited attention-span

Boredom / Low Interest

The variable personal factors are:

Willpower

Distress tolerance

Willingness to ask for help

Task-focused vs value-focused

Self-consciousness & anxiety

The variable task or system-based factors are:

Unclear goals & expectations

Unrealistic goals & expectations

Distractions

Lack of accountability or mentors

Link to the complete show notes: here

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Do you ever feel out of touch with your emotions? Or have you ever felt like you had to hide your real emotions? When people do that—emotionally detach—they develop what therapists call “incongruence.”

Most therapy is actually centered around getting patients back in touch with their emotions. On this week's podcast, Ginger Simonton and I talk about the different methods we use to help our patients develop and maintain healthy emotional congruence.

For more details, links, and blog go here

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In the latest podcast, Dr. Cummings and I talked about antipsychotics, the particular branch of psychopharmacology that deals with medicines that treat psychotic experiences and other mental disorders, such as:

Schizophrenia

Severe depression

Severe anxiety

Bipolar disorder

Psychosis exhibiting hallucinations and delusions

For blog and detailed notes and citations from the episode: here

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In the latest episode of the Psychiatry and Psychotherapy Podcast, Dr. Puder interviews Dr. Cummings, a psychopharmacologist. They discuss the way medicine works in our bodies, and if medicine or therapy is more effective for treating different disorders. They also talk about the different factors that affect absorption rates, such as gastrointestinal surgeries, liver health and actual dosage.

For article and notes go: here

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My guest for the podcast was Trent Jones, a Starting Strength athlete. I interviewed him about his story, how he discovered strength training, and how it changed his emotional state.

We will cover how strength training can decrease depression and help people deal with anger and develop confidence and assertiveness. Then we will give you resources to know how you can get started on your own, simple strength training program.

Trent was a football player in middle and high school. He was always a self-professed “smaller guy,” hovering around 150 pounds, even though he was athletic. During those formative years, he struggled with depression and outbursts of anger, causing his therapist to put him on antidepressants.

Once he graduated high school, he wasn’t participating in sports any longer, even though he still exercised. During college, he struggled with prolonged bouts of major depression. He began to lose his confidence in his abilities to perform everyday tasks, and because of that, he doubted his self worth. He detached from friends and wasn’t enjoying life.  

As a natural people pleaser, Trent struggled with being assertive in his interactions, appearing kind and calm. He dealt with angry outbursts when he was alone. After college, his job was stressful, and his people-pleasing personality, mixed with his bosses’ lack of boundaries, caused Trent to feel overwhelmed. He’d work all day, then go home and stew in frustration in the evenings, losing sleep, and even throwing plates during bouts of anger.

Work was difficult and his depression came in waves. Trent decided he wanted to find a hobby and revisit his athletic past. He’d always loved strength training because of his experience with football. He decided to get into weight lifting, so he searched for a simple way to build muscle mass. In his exercise since high school, Trent had only focused on cardio and lifting random weights for random sets and repetitions.

On the left Trent Jones prior to systematic strength training. On the right Trent Jones lifts 411 lbs during a "Starting Strength" meet.

When he started weight lifting with a purpose, using the Starting Strength model, he started to see changes in his mood and physical strength. He eventually put on 50 pounds of muscle as he upped his training regimen and fine-tuned his eating habits. He noticed he started to feel more assertive in his relationships and work. He gained confidence and his depression symptoms declined.

He’d found out a secret that most people don’t know: strength training can be an effective treatment for depression.

The research behind strength training and decreased depression

Trent’s transformation—both physical and emotional, is a great tool for taking control of total health. But, it’s one that most people don’t think about when they think about classic depression.

Most patients that come to me don’t expect me to recommend a weight lifting regimen when they step into my office for psychotherapy and medication management. Of course, medicine and talk therapy are incredibly helpful. Strength training is just one of the tools in my toolbelt for depression, but it’s a very powerful additive force for long-term treatment success.

In a recent large meta analysis showed the overall effect size (the amount of change the strength training group had compared to the control groups) for strength training was 0.66 (95% CI, 0.48-0.83; P< .001). Learning to understand effect size can be very important so I will mention a few things here to make sense of this.

Effect size is the difference between treatment and control group, expressed in standard deviation units, where an effect size of 1 means that the treatment arm moved one standard deviation from the control group. An effect size of 0.8 is a large effect, 0.5 is a moderate effect, and 0.2 is a small effect (Cohen, 1998). It compares two treatments, and looks at how far they move away from each other.  The larger the effect size, the better the treatment. As a point of reference, a different meta-analysis of 37 psychotherapy studies looking at the treatment of depression found an effect size of 0.73 (Robinson, 1990). Therefore recent meta analysis for strength training was very impressive!   

In this met analysis, they also found that total volume of resistance training, participant health status, and previous strength status didn’t really matter. However, sometimes when a group of studies are looked at simultaneously they miss the nuance of well designed individual studies. One study in particular showed the more strength gained the larger reduction in depression.

Translation?

It didn’t matter how out of shape people were when they started, it only mattered that they started the strength training program—it still helped depression. This is something that as a doctor, I’d rarely say, but: You don't have to comply fully in order to reap benefits. You don’t have to be an expert lifter to gain benefits.

If you can train even two days a week, you will still get benefits from that.

However, the people who gained the most strength had a correlated decrease in depressive symptoms. Basically, the more strength you gain, the more effective it is for treating depression.

The other key is to notice what Trent noticed: exercise and even unregimented, random training isn’t as effective as a systematic lifting program.

On another level, strength training helps patients with developing assertiveness, which increases confidence and happiness. To understand this, we have to talk about anger. We often think anger is a bad feeling, a wrong emotion. But it’s not. Anger has an adaptive function. The primal purpose of anger is so we can protect ourselves, loved ones and overcome obstacles (like being disconnected with a loved one). When we feel anger, hormones like adrenaline, result in courage to fight the bear that’s trying to attack us. Or to pay attention to our spouse so we can remove the emotional obstacle between us and feel close to them.

When we feel angry, it may be a message that someone has violated our space, talents or abilities and we need to therefore allow the anger to empower us to put up a boundary. Most often, in our childhoods, demonstrating anger was not acceptable behavior. As we age, we keep that messaging and suppress our anger inwardly, leading to a lack of assertiveness. That lack of assertiveness then can lead to further issues like less respect for ourselves in relationships, which develops from being constantly getting “run over.” Then we tend to misplace our anger—like how Trent wouldn’t confront his boss for overstepping his boundaries, but would go home and throw plates to act out his aggression.

When people start strength training, they are, quite literally, adding stress to their body. But, with a systematic training program, the stress is sequential and leads to adaptation. When we do something difficult, we practice courage. Overtime we no only grow strong, but also more competent to meet the huge challenges that life throws our way.

Like Trent, I used to be an athlete in college. When I started medical school, and on into residency, I exercised, but didn’t strength train the way I do now. It has changed my life.

As a psychiatrist, I write prescriptions for medicines for severe mental illness. I prescribe talk therapy to almost everyone as part of the process of overcoming. And I also write a prescription for strength training. In my therapy practice, I’ve personally seen the results of the training on decreasing depression in my patients—it absolutely helps.

The link between empathy and self-care

Some of my patients who are incredibly empathic also struggle with depression. They are so empathic, so giving, that their schedules often reflect this—they don’t make time for themselves.

Strength training can help, as it did with Trent, to develop assertiveness and even deal with chronic, unresolved anger. Self care through strength training can aid in decreasing depression.

Empaths naturally lean towards being professional therapists, or are live-giving people in their myriad of relationships. As professional caretakers, it’s important to make time in our schedules for ourselves to do things like strength training.

Where to start and how to succeed?

1. The first key is just to begin. Remember that perfection isn’t important. You don’t have to jump in to a five day a week routine. Start simple and build the habit of two days a week of training if you’re just beginning.

2. Start with watching youtube videos (see below) of proper technique, and I highly recommend to hire a coach (online or in person) to help you for the first few months to show you how to properly lift the weight so you do not hurt yourself.  If you buy one book, buy this one.  If you want a free place to post questions and videos for technique critique join this facebook group (be warned people will be concise and to the point which may come out blunt).

3. Start by mastering these multi-muscle movements with a barbell:

   1. Squat

   2. Bench Press

   3. Press

   4. Deadlift

4. Do 3 sets of five repetitions each, with increasing weights with each workout. The exercise and sets and reps don’t change for the first 3-6 months of doing this. Only the weights change. Add five pounds each new day you work out.

5. Repeat every time you go to the gym. To start, go to the gym optimally three days a week.

Gordon, B. R., McDowell, C. P., Hallgren, M., Meyer, J. D., Lyons, M., & Herring, M. P. (2018). Association of Efficacy of Resistance Exercise Training With Depressive Symptoms: Meta-analysis and Meta-regression Analysis of Randomized Clinical Trials. JAMA Psychiatry.

In the third and final installment on microexpressions, Ariana Cunningham and Dr. David Puder talk about how learning microexpressions can help you build empathy and connect with other people.

As Paul Eckman demonstrated in his research, they can be potent glimpses into someone’s emotional experience.

In this episode we talk about:

How emotions come into play in our dreams and other unconscious ways.

How to use what we learn from them carefully and with curiosity, rather than with a know-it-all attitude.

How we create psychological defense to cope with reality

How we might experience problematic relationship patterns through a theory called object relations.

How our emotions happen out of our awareness.

Preventing emotional overload and empathic exhaustion.

Emotional transference and how to stop it.

Read the blog that goes with this here

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IOS Emotion Connection App

Microexpressions are brief, involuntary facial expressions that are cues to the true emotions that someone is feeling. We see microexpressions in tiny twitches of the brows, the lips and nose. They can last for as little as 1/15th of a second on the face.

In this episode, we describe the science of the microexpressions of fear, disgust, and surprise and how to use it to connect with others.

For full PDF of the episode with links to videos of each emotion go to: https://psychiatrypodcast.com/resources

For link to the simple app that trains you on how to read microexpression go to: IOS Emotion Connection App

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Microexpressions are brief, involuntary facial expressions that are cues to the true emotions that someone is feeling. We see microexpressions in tiny twitches of the brows, the lips and nose. They can last for as little as 1/15th of a second on the face.

In this episode we describe the science of microexpressions, emotion and how to use it to connect with others.

For full PDF of the episode with links to videos of each emotion go to: https://psychiatrypodcast.com/resources

For link to the simple app that trains you on how to read microexpression go to: IOS Emotion Connection App

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New research on hormonal contraceptives, “the pill”, and how it influences mental health. Dr. David Puder and Dr. Mona Mojtahedzadeh explore:

Claims about the mental health consequences of hormonal contraception

Unique Influences of progesterone and estrogen on the brain

How ovulation changes attraction and desire

Discuss the controversy around recent studies that show that hormonal contraception increases the risk of depression

Critique of those studies and counters to those critiques

Kelly Brogan and other contrasting views and their influence on this field

Link to full notes and blog: https://psychiatrypodcast.com/hormonal-contraceptives

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Overcoming Postpartum Depression

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This week on the podcast, I joined with Dr. Pereau to talk about postpartum depression, both from a personal level and as those who treat it in our patients.

Dr. Pereau is incredibly honest and vulnerable in this emotional episode as she shares her story. Throughout it, she talks about the symptoms of her postpartum depression, including:

• Intrusive thoughts

• Emotional disconnection from her baby

• Sleep deprivation

• Hopelessness

• Problems with concentration

• Disconnection from passion and joy

• Panic attacks and anxiety

• Poor self care

It had never occurred to Dr. Pereau that she would struggle with postpartum depression, though she had treated many people with it, and could easily recognize symptoms in others. Often, when we are experiencing these kinds of things, it’s hard to identify the symptoms within ourselves. We understand the need for someone with a recognizable disorder, such as bipolar or schizophrenia, to get help. But depression can be a slippery, indefinable problem when it comes to labeling ourselves.

If you are dealing with postpartum depression, know that it can be treated, and there absolutely hope to work through it. Here are some things that can help:

• Breastfeeding to stimulate connection and positive hormone production

• SSRI treatment (medications prescribed by a doctor)

• Talk therapy

• A good support system

If you’ve been experiencing the symptoms we discuss in this podcast, there are plenty of resources, plenty of people who can help you during this time.

The Edinburgh Postnatal Depression Scale is a simple questionnaire that can tell you if you are experiencing postpartum depression.

For a list of local support groups in the region, www.postpartumprogress.com is a wonderful resource.

Postpartum Support International is another great resource for online support groups and educational materials. www.postpartum.org  

2020 Mom is an online advocacy group for maternal mental health. It includes blogs, educational materials and legal support. www.2020mom.org

Below is a touching excerpt from her story:

“My mother always said that when I had a child, I would know true love in a way I could never conceptualize. It had been a very long path to finally getting the child, and when he finally came I felt nothing. Actually, I felt worse than nothing. For the first couple months, all I can remember is darkness. I felt alone to my core. I felt like I was drifting, disconnected and lost. In my mind, my life was over. It was forfeit. The child wasn’t a beaming ray of sunshine, filling me with hope and life and love. When I looked at him I felt nothing. The guilt of this overwhelmed me.

I found myself wrestling through the options, fantasizing about packing a bag and running away in the middle of the night, or giving the baby up for adoption, or crashing my car off the edge of the mountain on my way home from work, or throwing myself off our cabin’s third floor balcony. The images whirled through my mind and I would clench my teeth and force them away. It was all so dark. I didn’t want him. I didn’t want my life. I believed I knew these things for certain. I believed these were my thoughts.

I mentioned to my husband Bryan about having a dream where I  jumped off the balcony, but then I quickly minimized it. I filled out the Edinburgh Scale in the OBGYN office with just enough depression items to be flagged but not enough to get hospitalized. We use the term, “A cry for help,” and generally refer to something gamey or indicative of less severe illness. I can see how it looks that way. But I now know without any doubt what a cry for help really is. It was the weak, thready voice of the last piece of me left in my mind, the last flicker of light not darkened by postpartum depression. It was the last bit of me that was not pinned down under the weight of illness. Those weak cries were the best I was capable of. The illness was too great. My mind did not belong to me. My thoughts did not belong to me. I just didn’t realize it.

As a society, we believe that depression is something that can be willed away if a person is strong enough. If they just try hard enough. And yet nobody tells a schizophrenic to just try to not hallucinate. We don’t tell a person with bipolar disorder to just try to not cash out their retirement to finish that half built bomb shelter in their back yard they’ve been building the last few weeks. Even conditions like alcoholism have been embraced within a medical model. We don’t tell the alcoholic to just try to stop drinking anymore. We recognize this to be a medical illness deserving of care and treatment. And yet we tell the depressed person to try to be positive. Try to be happy. And I think I know why.  As humans on the planet, each of us suffer, faces grief, loss, and even hopelessness. And we find ways to survive, often becoming stronger because of it. We assume our experiences with emotional pain are similar to what a person with depression goes through. I know I thought that, and I’ve faced considerable loss throughout my life.

Unfortunately, depression isn’t anything like that. It’s disease. It’s organic. It’s neuro chemical. It is an illness where your very thoughts become twisted and distorted, your perception of the world around you becomes altered. You lose who you are and generally have no idea that it’s even happening. We have to stop assuming that depression is something like the subjective painful experiences we all encounter in life. It’s a biological illness of the brain. In the past decade completed suicide rates in the United States have increased 20%, taking the lives of 121 people a day. Attempting to will away depression cost me 11 months of my life, where each month that passed took me deeper into a hole I couldn't claw out of.

Postpartum depression affects the lives of over half a million women a year. It destroys families and severs the connection between a mother and child. It is a deadly disease which cannot be combatted through willpower. I believe a new approach is needed to proactively educate and better screen our patients. I don’t begin to have all of the answers, but I can say that the culture around mental illness must change. There is no room for judgment. Maybe it starts with a simple, “I’m worried about you. I think you’re hurting.” Maybe it starts with spending the time to paint a clear biologic picture for the family surrounding a mother to heighten monitoring. All I know is that “holding it together” is no way to live, work, or raise a child.

I chose to accept help. I chose to take medications to treat postpartum depression, nearly a year later. Eleven months after my son was born, I remember a pivotal moment. It was 3 in the morning and he had just fallen back to sleep, there in my arms. As I looked down at his beautiful face, there in the darkness, I whispered to him, “I would choose you.” It was like it was the first time I had ever seen him. The Joy that normally present in my everyday life came back. My thoughts became my own again, no longer twisted and distorted. I have firsthand knowledge of what it looks like to be overcome by an illness of brain, of the mind. It’s chemical. It’s biological. And it’s one of the most terrifying illnesses I can imagine.  And help exists. I know Sharing this helps to dispel shame, despite this being...a bit overwhelming. But it’s seriously about life and death, and if hearing my story helps you to better understand what 1 in 7 women who have had a child is experiencing, then this is worth it to me.”

Our bodies are “wired” to perform. Learning how to consciously modulate your internal sympathetic state is the key to unlocking optimal performance. The autonomic nervous system (ANS) facilitates survival by generating the fight-or-flight response and promotes recovery following activation (the ability to relax). The ANS achieves this by balancing two complementary systems: the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS). For example, your ANS is currently adjusting your pupillary diameter, respiratory rate, blood pressure, heart rate, skin conductance, sweat production, sphincter tone and postural muscles (just to name a few) to allow you to focus your eyes to read this information without passing out, falling over, overheating or urinating on yourself.

For PDF with full notes on our discussion and breathing: https://psychiatrypodcast.com/resources

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Learn:

Why to optimize medical issues like hypertension and diabetes

Change psychiatric and non-psychiatric medications to optimize brain function

Optimize sleep to obtain rest and increase brain function

How drugs influence the brain short and long term to change sensorium

How viewing yourself without "free will" influences brain function

For PDF with citations and full notes go to: https://psychiatrypodcast.com/resources

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Western society faces is the most unhealthy we’ve ever been. It’s reached epidemic proportions: depression, anxiety, poor focus and sensorium issues, chronic stress, and diseases of chronic stress (like diabetes). The solution is simple—exercise and healthy eating.

In this episode, I will be going through 17 studies on how exercise influences and improves these factors. I will cover how it works, and how to develop an exercise program from the perspective of a doctor, not just for body sculpting.  

Some things I am covering:

Strength training decreases depression

Strength training increases cognitive function

Fitness decreases risk of dementia

Exercise increases BDNF

Strength training and exercise in treatment for diabetes

For PDF with citations: https://psychiatrypodcast.com/my-resources

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Starting Strength Online Coaching

What are the best diets for the brain and cognitive function?  

How much does diet influence our sensorium?

What particular foods are important?  

How do we change our genes to optimize our brain?

For PDF with citations and detailed notes go to: My Resource Page

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In this episode, Dr. Puder addresses the fascinating realm of schizophrenia with Dr. Cummings, a previous guest in the show. Dr. Cummings is a psychiatrist with a wealth of experience from working at Patton State Hospital in California, one of the biggest forensic hospitals in the world.

-Defining Schizophrenia

-Living with Schizophrenia and Perception of Reality

-Are Negative Symptoms in Schizophrenia Precipitated by Medications?

-Emil Kraepelin, and the Early Studies on Schizophrenia

-The Pathology, Biology, and Genetics of Schizophrenia

-Cannabis Use and Risk For Schizophrenia

-The Loss of Brain in Schizophrenia

-Counter-arguments Against Robert Whitaker’s “Anatomy of an Epidemic”        

-Schizophrenia Prevention in High Risk Population

-Australian Study on Children of Schizophrenic Parents

-Crime, Violence, Mass Shootings and Schizophrenia

-Medical Management of Schizophrenia

-1st Break Psychosis

-Long-acting Injectable Antipsychotics in Early Illness

-Medication Adherence

-Exercise, Lifestyle, Diet Optimization

For more notes on this episode, links to articles, visit our website:

psychiatrypodcast.com

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CV of Dr. Michael A. Cummings

Assistant Producer: Arvy Wuysang

Editor: Trent Jones

This week I had a discussion with Dr. Darcy Trenkle on the difficulty of providers to get psychiatric treatment, using ourselves as the examples.  In a recent article nearly 40% of physicians surveyed said they would be reluctant to seek formal medical care for treatment of a mental health problem because of concern that this may put their medical license in jeopardy.  Physicians have three times the national average for suicide and have unique stressors and often a culture not conducive to seeking help.  We discussed difficulties we had in contemplating getting care for different issues we faced.  Hopefully, this will open a discussion regarding the conflicts providers have in engaging needed help.  Dr. Trenkle is a psychiatrist in Southern California and is affiliated with Loma Linda University Health.  She received her Medical Degree from Loma Linda University School of Medicine. She completed her residency training at Loma Linda University in 2015. She is the Medical Director for Electroconvulsive Therapy as well as Program Development for the Behavioral Medical Center at Loma Linda University.  If you are a Medical Student, Resident or Attending listening to this and need help, please reach out to a local provider.  We are open to receive emails if you are local, our names are searchable in the Loma Linda email system.  

For more notes on this episode go to: psychiatrypodcast.com

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Sensorium is the total brain capacity for focusing, processing, and interpreting. It is not a static state—it can fluctuate throughout the day.  

It can be influenced by sleep, food, stress, exercise, drugs, medications, and long term, through epigenetic phenomenon.  

If there is damage to the structure of the brain, it can permanently lowered.

It is a slope, which we all move up and down on, based on our baseline, but then also influenced by many factors.  

In your 20s and 30s you are very far on the left side of the line. If you get stressed, sleep deprived, starving, maybe have a small infection, you may still be able to think, but just less clearly. If you did those same things to an elderly person, they would be sent into a full delirium, hallucinating, throwing things, yelling, seeing spiders on the wall, and looking psychotic.  In this way it is common for an elderly person with dementia, they can be more confused in the evening then in the morning, they call this “sundowning”.  

We all have a baseline level of brain function, and this can be optimized by several factors like good sleep, good amounts of exercise, good mental functions (like reading), meaningful relationships, good spiritual practice, and meaningful work.  

For more notes on this episode go to: psychiatrypodcast.com

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This week David Puder, M.D., has a discussion with Randy Stinnett, Psy.D, regarding his journey to become an excellent therapist.  Randy shares aspects of his journey and insights.  His enthusiasm is contagious.  He discusses formative influences including Habib Davanloo, Donald Kalsched, and Todd Burley.  Please follow the link to the website for Randy Stinnett's list of 5 recommendations for someone aspiring to be an excellent therapist.

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Link to Randy Stinnett, Psy.D Short CV

In this episode I will be interviewing William Britt, PhD level clinical psychologist, an expert in cognitive behavioral therapy, object relations therapy, EMDR and a board certified neuropsychologist. He runs cognitive rehabilitation groups and neuropsychological assessments, and supervises neuropsychological fellows and interns. He also works closely with the psychiatric residents teaching about suicide.  

In this episode, Dr. William Britt explores his experiences running an inpatient psychiatric group for 5 to 13 year olds who are being treated for violence or attempted suicide, using uses a method based on Irving Yalom’s inpatient group psychotherapy technique.

We discuss how the trend of teen suicide has increased over the years and the typical causes of depression. We also cover common bullying tactics and how cyber bullying has changed society.  We then discuss how to use the group's support to help each other move away from being suicidal. We explore how the Netflix TV series “Thirteen Reasons Why” has influenced young minds and the new terms the patients are using.

In the end, Dr. Britt and Dr. Puder answers how we adapt and recover from trauma, and how we find meaning and value within stress.  

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CV of Dr. Britt

In this episode, Dr. Cummings and I discuss psychopathy: the fearless, empathyless people, who see others as objects, and have the inability to attach within relationships. Dr. Michael Cummings recently contributed to a book called “Violence in Psychiatry,” detailing the biological aspects of psychopathy, edited by Stephen Stahl. Dr. Cummings works at Patton State Hospital, one of the biggest forensic hospitals in the world. He is the Yoda of the psychiatric world, with many other psychiatrists bringing him their most complex and difficult cases.   

In this episode we cover:

History of psychopathy

Influence of early life traumas

Prosocial careers of psychopaths

Biological components in psychopathy

The emotion psychopaths fail to see

BDNF (brain-derived neurotrophic factor)

Prefrontal area (the parent of the brain that warns us “that is not a good idea”)

Amygdala

Why psychopathy has not been bred out of existence

Advice when you are in a relationship with a psychopath

What drugs make someone look psychopathic

Effect of alcohol andmethamphetamines on the brain

Influence of cocaine on the brain

Why more men are violent psychopaths

And treatment of this group of people (clozapine’s influence on glutamate)

The Story of Phineas Gage

We also wrestle with how to increase the percentage of psychopaths that end up helping society vs percentage that become criminals.

Warburton, K and Stahl S (Editors).  Violence in Psychiatry.  The Neurobiology of Psychopathy. Cambridge University Press 2016), pp. 200-05

CV of Dr. Michael A. Cummings     

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Editor: Trent Jones

*This podcast is for informational purposes only and is the opinions of the people on this episode.  For full disclaimer go here.  

This week we discussed cognitive distortions with Adam Borechy. Usually cognitive behavioral therapists deal with cognitive distortions by helping their clients identify habitual negative thoughts and and putting those thoughts on trial. We don’t have to accept every thought that passes through our brains as truth. When we have distressing thoughts, it can be helpful to consider if we might be telling ourselves the full truth about a situation.

We refer to common cognitive distortions—depression, anxiety, feelings of failure, negative thoughts when interacting with people, social anxiety—and we see how they are applying to our thought process.

For a PDF of the cognitive distortions and a 8 days journal task towards better identifying them in your life, please see my resource page. In this 8 day journey you will better identify your own troubling thoughts and move towards gratitude.

Here are a list of the cognitive distortions:

All or nothing thinking: things are black and white, completely without shades of gray.  For example, you may think, “If I am not perfect, I should not try at all, because then I would fail completely.” Or you might think, “My significant other is completely evil.” And then the next day, “My significant other is perfect.”  

Overgeneralization: generalizations are made without context, experience or evidence.  “I am always alone.”  Or “Everyone hates me.”  “I never win.” Always? Never?  Everyone? It happens absolutely all the time, without exceptions? In the moment, it can feel like that, but those statements are actually rarely true. Speaking truth to yourself in this case might look like: I am sometimes alone, several people are upset at me, I win sometimes, even if I didn’t this time.

Mental Filter: focusing on the negative rather than the whole picture. After receiving multiple positive statements and one negative statement, all you focus on is the negative statement.  

Disqualifying the positive: When you do something good like get a compliment or award, you instantly find ways to make less of it! For example, if someone says, “You are looking good today,” but instantly you assume that person is giving you a false compliment.  

Jumping to conclusions (without evidence): reaching conclusions (usually negative) without little evidence.

ind reading: assuming you know what the person is thinking about you.  Connection occurs from accurately knowing another, and with mindreading you blind yourself without evidence.

Fortune telling: predicting negative things in the future.  For example you think “I am going to fail this test even if I study,” so you don’t try, don’t study, and don’t even show up.

Magnification or Minimization: you make some weakness of yours much larger than it is or a strength much less than it really is. For example you see your friends as beautiful whereas you see your own beauty as very average.

Emotional Reasoning: believe that your feelings reflect reality. For example, “I feel stupid, therefore I am.” or “I feel fearful of flying in planes therefore they must be dangerous,” or “I feel ugly therefore I am ugly despite what others tell me.”  

Shoulding: a thing that you believe you should or should not do, often created to try to maintain an image of yourself which is more in line with social pressures. For example, “I should be perfect,” “I should never cry,” “I should always win,” “I should be able to do this on the first try.”

Personalization: blaming oneself for a bad event without looking at external factors that contributed to the bad event. Attributing personal responsibility to things that you have no control over, or when you do not see all the things that caused something. For example, a friend is upset so you think it is something you caused or are responsible for.  

Error Messages: thoughts that are like obsessive compulsive disorder due to having thoughts that are repetitive, intrusive and not meaningful. 

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Co-host: Adam Borecky

Editor: Trent Jones

*This podcast is for informational purposes only and is the opinions of the people on this episode.  For full disclaimer go here.  

In this first episode, I talk about my approach to seeing a new patient for the first time.  I go over the importance of empathy and psychological safety in the first interview.  I then go into how to do some of the components of a psychiatric history.  I go into details on what parts are important and why.  Please see my resource page for a full PDF of my notes and also the PDF of the document I give to patients prior to their first appointment with me.  

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Editor: Arvy Wuysang

*This podcast is for informational purposes only and is the opinions of the people on this episode.  For full disclaimer go here.