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Why do so many patients arrive with four, five or six psychiatric diagnoses? Mark Ruffalo, a psychoanalytically trained clinical social worker who teaches psychiatry residents, joins Dr. Malzberg and Dr. Fu to discuss his new paper with psychiatrist Ronald Pies in Psychiatric Services, “The Need for a Validity-Based Diagnostic Hierarchy in DSM-6.” We trace how DSM-III chose reliability over validity, why the Washington University group of Robins and Guze pushed back, and how losing the diagnostic hierarchy opened the door to false comorbidity, polypharmacy and symptom-by-symptom treatment. Mark lays out which conditions sit at the top of a validity-based hierarchy, why ADHD ranks low, how affective temperaments can pass for personality disorders, and what to do when a patient arrives with seven diagnoses: step back and ask what could be driving all of them.

You Can See Everything psychological analysis returns in Part 2 as two psychiatrists revisit Elizabeth Holmes, Billy Evans, and Nathan Fielder’s documentary. We examine the scenes that divided viewers, from the Abbott and Costello joke and Holmes’s statements about Theranos to Billy’s egg-mixing, social media posts, and comments about revenge. Along the way, we discuss narcissism, psychopathy, autistic traits, and the difference between personality traits and psychiatric disorders. We also explore why people repeat familiar relationship dynamics and how a film can become a mirror for the audience’s own assumptions. This is a discussion of psychological ideas, not an attempt to diagnose the people on screen.

What we cover

* A caution at the outset about medicalizing behavior that is within the normal range or rationally driven, and why a diagnosis, willful action and moral responsibility are three separate questions.

* The tendency to repeat, discussed as Freud's repetition compulsion (a bid for mastery) and as habit and homeostasis, followed by Eric Berne's transactional analysis and its recurring sequence of roles and payoffs mapped onto the film.

* Overdiagnosis and the case for talking about traits rather than broad labels, using autism as the example, and whether autism could explain the Abbott and Costello joke and the statements about the Theranos machine.

* Telling autism from personality pathology: inability versus lack of interest in others' emotions, and how aggression in each can look alike.

* Ordinary versus clinical narcissism, the psychodynamic idea of narcissistic injury, antisocial personality and psychopathy, and how they overlap with narcissistic structure.

* Scenes involving Billy Evans, including the egg-mixing moment and the power of attorney and social media posts, treated as a projective test that different viewers read differently.

Clinical takeaways

* A trait is not a disorder. One scene on film suggests a trait at most and cannot explain why someone acted as they did. Consider rational explanations, such as seeking sympathy, and ordinary variation before reaching for a diagnosis.

* Keep apart whether behavior is part of a disorder, whether it was willful, and whether the person is responsible. The three questions are separate.

* A very broad label loses meaning: two people with the same autism diagnosis can have completely different lives. One host prefers to describe traits and leave the question of disorder to clinical assessment.

* To separate autism from personality pathology, ask whether the person cannot understand others' emotions or does not care. Aggression in autism often follows poor regulation or changes in routine, though it can look like calculated aggression.

* Clinical narcissistic personality disorder, as the hosts describe it, means rigid defense of a chosen identity that defeats long-term goals, fragility when not admired, and poor attunement to others. Psychopathy often sits on a narcissistic structure.

* Watch your own values. Clinicians can impose them when drawing the line between normal and pathological, people tend to apply personality labels to those they dislike, and seeing someone only as a victim leaves no hope of change.

Read the full transcript

The complete transcript of this episode is on psycho.farm: The Psychology of Elizabeth Holmes in You Can See Everything: Narcissism, Autism, or Manipulation?.

Related episodes

* You Can See Everything Psychological Analysis by Clinical & Forensic Psychiatrists

* The Psychology of Seinfeld: What’s Really Wrong With George, Kramer, Jerry & Elaine?

* Autism Diagnosis Explained: DSM-5 Criteria, Autistic Traits & the Difficult Differential

For education only. Not medical advice.

You Can See Everything is one of the strangest films about Elizabeth Holmes yet, and in this episode two psychiatrists try to make sense of it. We explore what Nathan Fielder’s interviews bring out in Holmes and Billy Evans, from unusual facial expressions and her distinctive voice to the couple’s intense descriptions of love. Using psychoanalytic concepts such as narcissism, splitting, borderline personality organization, identity diffusion, and the “as-if personality,” we examine how people construct a sense of self and why someone might defend a version of reality that others find impossible to believe. We also ask what documentaries actually let us know about people, and how much of what we see is our own projection. Spoilers throughout.

What we cover

* How the hosts frame the discussion: independent commentary on public material, speculation rather than diagnosis, the Goldwater rule, and the film as a projective test because it is deliberately ambiguous. The episode contains spoilers.

* Nathan Fielder's interviewing style in the film, with sparing words and expressive silence, as an example of clarification and confrontation, and the defenses people show when avoiding a line of questioning.

* How Elizabeth Holmes appears on screen (restricted emotional reactivity, frequent smiling and nodding, a deep voice), whether it is a persona for the camera, and why any film frame removes context.

* Psychoanalytic ideas used as lenses: the as-if personality, identity diffusion in the DSM-5 alternative model, borderline personality organization versus borderline personality disorder, and splitting, with the hosts differing on how far to go.

* Whether a person can state something false and believe it, the film's structure as a magic trick, and what the film says about being a viewer of a performance.

* How Billy Evans and Holmes describe their love: idealization, fusion between self and other, introjection, and borrowing traits from admired people, set against the hosts' point that these tendencies are universal in milder form.

Clinical takeaways

* Interviewing can be done with few words. Attentive facial expression, silence and well-timed clarifying or confrontational comments can draw material out, and the hosts see the film as usable teaching material for clinicians.

* When a person's micro-expressions do not match the other person's, it may reflect difficulty reading another's emotional state. Many conditions can cause this, so the hosts avoid settling on one explanation.

* Borderline personality organization is broader than borderline personality disorder and can include narcissistic, antisocial and histrionic patterns. Its core features include splitting, identity diffusion, primitive defenses and difficulty integrating good and bad in relationships.

* Emotional development is separate from intellectual development, so someone who functions at a high level can still be emotionally underdeveloped in how they understand themselves and others.

* Idealization, devaluation and taking in traits from others are ordinary human processes. What matters clinically is the degree, and whether the sense of self is stable enough to adopt traits without being replaced by them.

* Be cautious about diagnosing from media. One host calls a diagnosis from public material a bridge too far, and both note that behavior filmed for an audience may differ from private behavior.

Read the full transcript

The complete transcript of this episode is on psycho.farm: You Can See Everything Psychological Analysis by Clinical & Forensic Psychiatrists.

Related episodes

* The Psychology of Elizabeth Holmes in You Can See Everything: Narcissism, Autism, or Manipulation?

* The Psychology of Seinfeld: What’s Really Wrong With George, Kramer, Jerry & Elaine?

* What Psychiatrists Get Wrong About Personality Disorders

For education only. Not medical advice.

Antipsychotic medications are not interchangeable, and the tradeoffs between efficacy, metabolic burden, movement side effects, sedation, and adherence can be huge. In this episode, we build an antipsychotic tier list and rank medications including clozapine, olanzapine, haloperidol, risperidone, lurasidone, quetiapine, aripiprazole, and more. Along the way, we connect receptor pharmacology to practical clinical pearls, including food requirements, smoking effects, prolactin, akathisia, EPS, weight gain, long-acting injectables, and clozapine monitoring. We also discuss how medication choice shifts across schizophrenia, bipolar disorder, bipolar depression, and mood symptoms.

What we cover

* The ranking method: efficacy in schizophrenia and bipolar disorder (not as an add-on) weighed against adverse effects, the idea that metabolic burden in a young patient starts a metabolic highway, and how GLP-1 medications and metformin change that calculation.

* Haloperidol in S tier for its low metabolic burden, quetiapine in C tier, and extended-release quetiapine in D tier, with the point that quetiapine acts as a sedative at low doses, a mood agent in the middle and a D2 blocker above 400 mg.

* Clozapine in S tier, olanzapine in A tier and olanzapine-samidorphan in B tier, covering the end of the REMS, restarting titration after a gap of more than 48 hours, bowel care, olanzapine's slow time to peak, and smoking as a CYP1A2 inducer.

* Risperidone and paliperidone with its long-acting injectables in A tier, aripiprazole and cariprazine in B tier, and brexpiprazole in D tier mostly because of cost, including aripiprazole as the most studied add-on in major depression.

* Lurasidone in S tier with its calorie requirement and akathisia risk, then ziprasidone in C tier, asenapine in B tier, lumateperone and xanomeline-trospium in F tier, pimavanserin in D tier, and iloperidone and perospirone as needing more experience.

* The older drugs and add-ons: chlorpromazine in D tier, loxapine and fluphenazine in C tier, perphenazine in B tier, buspirone as a possible add-on in D tier, and adding a mood stabilizer in A tier.

Clinical takeaways

* One host argues haloperidol is underused: dose it like risperidone (most patients respond below 8 mg) and consider it after a couple of failed trials when weight gain and sedation are the worry.

* Clozapine monitoring remains the standard of care even though the REMS is gone, and a gap of more than 48 hours means restarting titration. Ask about smoking and bowel movements.

* Check prolactin early when a patient on risperidone reports menstrual, libido, breast size or milk production changes, and watch for EPS at 4 mg and above.

* Add a mood stabilizer before a second antipsychotic when a schizophrenia spectrum patient shows any mood symptoms: valproate for agitation and impulsivity, lithium or lamotrigine for depression.

* Lurasidone needs about 350 calories with the dose, so it suits steady eaters and is a poor fit when appetite fluctuates with mood or psychosis.

Read the full transcript

The complete transcript of this episode is on psycho.farm: Antipsychotic Tier List: Ranking the Best and Worst Anti-psychotics.

Related episodes

* Choosing Antipsychotics in Schizophrenia: Side-Effects, Maximizing Efficacy, and Finding the Right Medication | Episode 17

* Top 10 Things to Know About Clozapine

* Mood Stabilizers for Bipolar Disorder: Lithium, Lamotrigine, Depakote & More

For education only. Not medical advice.

PTSD diagnosis is more complicated than identifying a trauma history. In this episode, we break down what qualifies as Criterion A trauma, the major PTSD symptom clusters, and how intrusion, avoidance, negative beliefs, hyperarousal, and dissociation can show up in practice. We also discuss acute stress disorder, fragmented traumatic memory, and why PTSD can be mistaken for depression, anxiety, mania, concentration problems, or psychosis. Along the way, we focus on careful trauma assessment: establishing a timeline, considering alternative diagnoses, monitoring the patient’s level of distress, and gathering what you need without turning a diagnostic interview into trauma therapy.

What we cover

* Big T versus little t trauma, and why the DSM-5 Criterion A definition (actual or threatened death, serious injury or sexual violence, whether experienced, witnessed, learned about, or met repeatedly through work) is the one that matters clinically.

* Whether Criterion A is an objective or a subjective test, and two unusual cases: a threat experienced through a delusion or hallucination, and PTSD in perpetrators.

* Why most people who go through a Criterion A trauma never develop PTSD, and why, by some research, many who do develop it remit within a year.

* The DSM-5 criteria read in order (intrusion, avoidance, negative changes in mood and beliefs, hyperarousal) as a sequence that explains how PTSD persists.

* Dissociation: what it means, how it fragments traumatic memory, and why patients may not report a trauma even on a formal trauma screen.

* The differential, from depression, mania and anxiety to attention problems and psychosis, plus acute stress disorder in the first month.

Clinical takeaways

* A mental status pearl: patients with PTSD often say they are depressed but look more mood-reactive than someone with a melancholic depression.

* When the history has an unexplained decline, ask what was happening at that time rather than suggesting a trauma. Be careful about trying to uncover memories.

* Check the timeline. Symptoms must begin or worsen after the trauma and last more than a month.

* Not every voice is psychosis. Flashbacks and dissociative experiences can be described as voices.

* In a diagnostic interview, ask for brief facts (what happened and when), watch the patient's distress, and offer breaks. The goal is a diagnosis, not trauma therapy.

* After early trauma, trust has to be earned. A steady frame and an honest explanation of why you are asking help the patient keep going.

Read the full transcript

The complete transcript of this episode is on psycho.farm: Trauma and PTSD: How the DSM Criteria Actually Help Us Understand What’s Going On.

Related episodes

* Understanding Trauma and PTSD, Diagnosis and Dissociation | Episode 21

* PTSD Medications: Integrating Pharmacotherapy, Therapy, and the Treatment Frame | Episode 22

* CPTSD vs BPD: How to Think About the Difference and What to Do About It

For education only. Not medical advice.

What should patients know when they are diagnosed with depression? In this episode, psychiatrists Dr. Malzberg and Dr. Fu cover what they wish every patient knew from the start. They explain why a depression diagnosis is a useful shorthand rather than a fixed identity, how biological, psychological, and social factors feed into each other, and how medication, therapy, and lifestyle changes work together. You will hear practical first steps like behavioral activation, a steady wake time, morning sunlight, and cutting back on alcohol and cannabis, plus what to do if treatment stalls and how to decide who to tell. It is an hour of clear psychoeducation for patients and a resource clinicians can share.

What we cover

* The purpose of a series on what the hosts wish patients knew about each diagnosis, built as psychoeducation that clinicians can use or hand to patients, and why explaining the problem and the plan supports the alliance.

* What depression and major depressive disorder tell us: an umbrella term that says little about cause or treatment, one host's preference for a syndrome of persistent low mood or anhedonia with changes in energy and sleep, and diagnosis as shorthand.

* A biopsychosocial formulation, how biological, psychological and social sources feed each other, why no lab test or scan sorts them out, and why the hosts favor medication, psychotherapy and lifestyle change together.

* Mimics and reasons for poor response: substance-related depression, PTSD, personality problems and complex trauma, bipolar disorders (including bipolar-type depression) and medical illness, with alcohol, cannabis and other addictions.

* Stability and behavioral activation: a steady wake time, morning light, small scheduled goals and social connection, plus how to judge whether a therapy is a good fit.

* How patients relate to the label, and how and whether to tell family, friends and coworkers.

Clinical takeaways

* Present the diagnosis as shorthand for what to treat. The hosts argue that patients who see the illness as part of who they are may respond less well than those who see it as something they have.

* Offer medication, therapy and lifestyle change together. With no imaging or lab test, the response to treatment shows which source is driving the depression.

* When someone has not improved, revisit the differential: substance use, PTSD, personality or complex trauma, bipolar spectrum (family history is a strong pointer) and medical illness. Nightmares, startle, irritability and fearful avoidance suggest trauma.

* Behavioral activation: schedule an activity that helps and do it whatever the mood, since waiting to feel motivated rarely works. If goals are missed, shrink them. The hosts stress process over outcome.

* Anchor the day with a steady wake time, morning light, regular meals and exercise. Early awakening that a steady wake time does not fix may have a medical cause, and one host then considers medication.

* A failed past therapy does not rule out therapy: check what it targeted and how the therapist responded to concerns. Whom to tell about a diagnosis is the patient's decision, guided by whether disclosure will help.

Read the full transcript

The complete transcript of this episode is on psycho.farm: What Patients Should Know When Diagnosed With Depression.

Related episodes

* Treating Depression: Practical Tips & Pearls for Anti-Depressant Medications

* Antidepressant Tier List: Psychiatrists Rank Depression Medications for MDD

* Serotonin Hypothesis of Depression: Why Low Serotonin Is Too Simple

For education only. Not medical advice.

Autism diagnosis is more complicated than recognizing a handful of autistic traits. In this episode, Dr. Fu and Dr. Malzberg unpack the DSM-5-TR criteria for autism spectrum disorder, including social communication differences, restricted and repetitive behaviors, developmental onset, impairment, and Levels 1–3. They then tackle one of the hardest parts of adult autism assessment: differential diagnosis, including overlap with ADHD, schizophrenia, and personality disorders. The conversation also explores theory of mind, masking, the double empathy problem, weak central coherence, and the empathizing-systemizing framework. The goal is a more clinically useful way to think about what distinguishes autistic traits from autism spectrum disorder and why developmental history matters.

What we cover

* Why the hosts take up autism without a child psychiatry background, then the DSM-5-TR criteria: Criterion A's three social communication domains (social-emotional reciprocity, nonverbal communication, developing and keeping relationships).

* Criterion B (stereotyped movements or speech, insistence on sameness, fixated interests, sensory hyper- or hypo-reactivity), early onset typically recognized in the second year of life, clinically significant impairment, and exclusion of intellectual disability or global delay.

* The 'bucket' problem: one diagnosis covering very different levels of function, the three support levels, the loss of Asperger's, the specifiers (including catatonia), and the argument that both overdiagnosis and underdiagnosis are real.

* Associated features: executive dysfunction and its overlap with ADHD, uneven ability profiles, theory of mind (distinct from the mentalization problems in personality disorders), detail focus, clumsiness, GI and sleep problems, self-injury, and irritability.

* The adult differential: schizophrenia spectrum disorders, narcissistic, schizotypal, schizoid, borderline and antisocial personality traits, and why early developmental history and multiple sources of information matter.

* Theories of autism: social motivation, weak central coherence, mind blindness, and systemizing versus empathizing, with the double empathy idea. Treatment recommendations are left for a later episode.

Clinical takeaways

* Confirm onset in early development and use several sources: clinician observation, caregiver history and self-report. The hosts say a diagnosis based on one short interview is unlikely to be reliable.

* Retrospective recall is fallible, so a history of early imaginative play, repetitive behavior and sensory sensitivities helps most when it is corroborated.

* Literal answers can mislead. A patient asked about hearing voices when no one is there may mean the radio, so concreteness is not automatically thought disorder.

* Ask what else could explain the social and repetitive features. The hosts describe a blind spot between clinicians who recognize personality disorders and those who recognize neurodevelopmental conditions, and say both can coexist.

* Do not assume stimulants will fix executive dysfunction in autism. The DSM allows ADHD and autism to be diagnosed together.

* Distinguish traits from disorder, since the DSM bar is a need for support. One host argues that apparent late-onset worsening usually reflects another condition interacting with baseline autistic traits, and the other agrees only in part.

Read the full transcript

The complete transcript of this episode is on psycho.farm: Autism Diagnosis Explained: DSM-5 Criteria, Autistic Traits & the Difficult Differential.

Related episodes

* ADHD Is Not the Only Diagnosis: Differential and Diagnostic Hierarchy

* What Psychiatrists Get Wrong About Personality Disorders

* Assessment of Personality: Practical Assessment in a Short Timeframe

For education only. Not medical advice.

Diagnosing bipolar disorder is rarely as simple as finding a clear episode of hypomania. Dr. Phelps explains why bipolarity is better understood across a mood spectrum and walks through the clues that can help distinguish bipolar depression from unipolar depression: age of onset, family history, course of illness, treatment response, cyclicity, and collateral history. We also dig into mixed states, the “four A’s” of anxiety, anger, agitation, and attention problems, antidepressant activation, the HCL-32, and the Bipolarity Index. The larger theme is diagnostic humility: uncertainty is often appropriate, and treatment decisions should reflect both the strength of the evidence and the risks of getting the diagnosis wrong.

What we cover

* What hypomania is and why it is hard to rule out: the upper end shades into mania (the question is whether it was destructive), the lower end looks like a good day, and in one long-term study of bipolar II patients, hypomania took up only about 1% of weeks.

* Why no magic screening question exists, and the five dimensions to assess in anyone with a mood or anxiety problem: symptoms plus the four non-manic markers (age of first depression, family history, illness pattern over time, response to treatment), as weighted in the Bipolarity Index.

* Cyclicity over polarity: making the cycling the treatment target, plus clues such as three or more depressive episodes, sudden offset, postpartum onset, leaden paralysis, and odd reactions to an antidepressant.

* The mood spectrum, with bipolarity as pigment added to paint, and its proposed contributors: genes, inflammation, metabolism, reward hypersensitivity and circadian differences.

* Mixed states, especially mixed depression: DSM-5 major depression with mixed features, the four A's (anxiety, anger, agitation, attention problems), overlap with PTSD, GAD, ADHD and borderline traits, and 'borderlineity' as a spectrum idea.

* Three ways through uncertainty (more data, recruit the patient, compare treatment risks), the HCL-32 for collateral, and simplified social rhythm therapy, lamotrigine and low-dose lithium as alternatives to an antidepressant.

Clinical takeaways

* No single question rules out bipolar disorder. Expect only to adjust probabilities in the first interview, and tell the patient how sure you are.

* Ask the four non-manic markers every time. A closer relative counts more, and these markers carry 80% of the Bipolarity Index weight, with symptoms carrying 20%.

* Ask how past depressions ended. A sudden, unexplained lifting is described as a more useful marker than recurrent depressions that each have a reason.

* Aim treatment at less cycling, and reassess any leftover depression once the cycling is quiet.

* When unsure, send the patient home with a one-page HCL-32 for a partner or relative to answer, and gather collateral in proportion to the stakes.

* Compare the risks of an antidepressant with regular bedtime and rise time, lamotrigine or low-dose lithium before choosing. Where suspicion of bipolarity is high, start an antidepressant only with close watching, and treat a bipolar lens as a hypothesis to try to disprove.

Read the full transcript

The complete transcript of this episode is on psycho.farm: How to Diagnose Bipolar Disorder with Dr. Phelps: Hypomania, Mixed States & the Clues DSM Misses.

Related episodes

* How to Diagnose Bipolar Disorder: The Interview Framework That Beats Screening Questions

* Dr. Jim Phelps’ Bipolar Treatment Tier List: Lessons from 30+ Years in Psychiatry

* The Best Bipolar Medication Review From The Best Bipolar Expert

For education only. Not medical advice.

Lindsay Clancy’s insanity defense is the focus of this forensic psychiatry follow-up after the mistrial. We revisit the case through the lens of legal insanity, postpartum psychosis, malingering, criminal responsibility, and the difference between a legal conclusion and a moral judgment. We also discuss why psychosis cannot be reduced to a single reported voice, how forensic psychiatrists think about exaggeration versus malingering, questions around expert testimony and diagnosis, and the relationship between psychosis and violence. Finally, we look at medication nonadherence, culpability, how uncommon the insanity defense may be, and what questions arise when someone is found not guilty by reason of insanity.

What we cover

* Why a legal conclusion is not a moral judgment, why 'legally guilty' and 'legally innocent' are clearer terms, and why a forensic expert applies the rules of the jurisdiction in which the case sits.

* The forensic host's criticism of the Massachusetts insanity rules: the prosecution must disprove insanity beyond a reasonable doubt, the wrongfulness prong is framed unusually, and a volitional prong is hard to assess medically.

* Whether a voice or an intrusive thought matters, why the logic of a psychotic person should be compared with the history and circumstances, and the range of malingering from invented illness to exaggeration.

* How a DSM label captures one slice of a presentation, using the apparent conflict between a bipolar II diagnosis and postpartum psychosis.

* Psychosis and violence, how rarely the insanity defense is raised and succeeds, what release requires, whether nonadherence affects culpability, and the aims of punishment: retribution, rehabilitation and isolation.

* What clinicians could do: build the therapeutic alliance, involve family, document sleep in detail, assess bipolarity with shared decisions, and consider discharging patients who repeatedly decline treatment.

Clinical takeaways

* Malingering is a range. A person can invent an illness, report some false symptoms, exaggerate real ones, or have genuine symptoms that arise from stress or the unconscious and not from the disorder they name.

* Take the facts and work toward a diagnosis, not the reverse. One host argues that a DSM label never explains a person in full and that some questions are left to clinical judgment.

* Both common claims about psychosis and violence are too simple. The host argues that risk is raised but most people with psychotic disorders are not violent, and that substance use and a criminal personality weigh more than hallucinations alone.

* When a patient is not following the plan, check the alliance: agreement on the problem, goals and method. Ask what the patient sees as the problem and compare it with your formulation.

* With limited insight or higher acuity, ask to involve family or friends and document the request. Bipolarity and psychosis are hard to assess by self-report alone, so take a detailed sleep history, including any short-sleep nights.

* Document shared decisions about bipolar risk and the alternatives, and avoid over-correcting by treating every hint of elevated mood as bipolar disorder.

Read the full transcript

The complete transcript of this episode is on psycho.farm: Lindsay Clancy Case: Biggest Misconceptions After the Mistrial Explained by a Forensic Psychiatrist.

Related episodes

* Lindsay Clancy Trial: A Forensic Psychiatrist Explains Psychosis, Malingering, & the Insanity Defense

* Lessons from Forensic Psychiatry: Insanity Defense, Subtle Patients and Culpability

* Detecting Subtle Signs of Psychosis: Assessment of Voices, Delusions, and Psychosis

For education only. Not medical advice.

Lindsay Clancy postpartum psychosis and the insanity defense are examined through a forensic psychiatry lens in this episode. We discuss how psychiatrists distinguish psychosis from malingering, whether someone can be psychotic while still appearing organized, command hallucinations, delusions, altruistic filicide, and what criminal responsibility actually asks. We also look at Dr. Philip Resnick’s testimony, Clancy’s psychiatric treatment, fragmented care, collateral information, and the limits of ruling out bipolar disorder after a brief evaluation. Finally, we explore why the case has produced such intense public reactions and why psychiatry often requires tolerating uncertainty rather than forcing complex patients or cases into simple categories.

What we cover

* Why the case drew so much public attention, how the reactions split into monster versus victim, and why that splitting avoids the ambiguity of real life.

* How the Massachusetts insanity rule differs: the prosecution carries the burden beyond a reasonable doubt, and a behavioral-control element has no scientific test. The question is the legal criteria, not whether the person is mentally ill.

* Motives for filicide a forensic psychiatrist weighs (psychosis, accident, rational motive, impulsive rage), including altruistic filicide, and how pre-evaluation probability from the person's history shapes the opinion.

* How malingering is assessed: self-report is one source, records and video from the time of the act count more than later recollection, and the adversarial system filters which expert opinions reach a jury.

* How someone can be psychotic and look organized, what makes a belief a delusion and not a religious belief, voice versus thought, and the episodic pattern of postpartum psychosis.

* Lessons for clinicians: continuity of care, honest histories, the differential for bipolarity, mood episodes on SSRIs, and the link between postpartum illness and bipolar disorder.

Clinical takeaways

* In a forensic or legal setting, always consider malingering, but weigh records and evidence from the time of the event above later recollection, because memory is fallible. Ask whether the history before the act fits an invented illness.

* Psychosis is not the same as disorganization. In a mood disorder with psychotic features, the DSM describes delusions and hallucinations, so organized behavior does not exclude psychosis.

* A delusion is better defined by origin than by falsity: a belief that arises from a psychotic syndrome, differs from the person's baseline and was not acquired through ordinary cultural or religious routes.

* Whether a voice was heard or was an intrusive thought matters less than the mental state of the person and how their decision-making was impaired at the time.

* A single visit cannot rule out bipolar disorder. Absence of hypomania or a family history of psychosis does not close the question; keep a working diagnosis, say what you will keep monitoring, and revisit it.

* The host argues for thinking about lower-grade bipolarity: brief periods of elevated mood, mixed depression, and agitation or short sleep on an SSRI may call for mood stabilizer augmentation. Take a thorough medication and sleep history and document it.

Read the full transcript

The complete transcript of this episode is on psycho.farm: Lindsay Clancy Trial: A Forensic Psychiatrist Explains Psychosis, Malingering, & the Insanity Defense.

Related episodes

* Lindsay Clancy Case: Biggest Misconceptions After the Mistrial Explained by a Forensic Psychiatrist

* Lessons from Forensic Psychiatry: Insanity Defense, Subtle Patients and Culpability

* How to Diagnose Bipolar Disorder with Dr. Phelps: Hypomania, Mixed States & the Clues DSM Misses

For education only. Not medical advice.

Affective neuroscience in psychiatry may offer a better way to understand patients who do not fit neatly into DSM categories. Dr. White joins us to explain Jaak Panksepp’s seven primary emotional systems, the difference between affect and emotion, and how subcortical emotional arousal interacts with cortical regulation. We discuss anger, borderline personality disorder, cognitive decline, mindfulness, ACT, emotional blunting with SSRIs, and why some cases labeled treatment-resistant depression may need a better formulation rather than another medication. We also get into the neuroscience behind the model… from decortication and brain-stimulation studies to TMS… and ask what psychiatry loses when diagnosis comes before understanding affect.Dr. White’s Substack:

What we cover

* The case from animal neuroscience that conserved subcortical circuits drive emotional behavior in mammals, Jaak Panksepp's work, and why Dr. White thinks the DSM largely leaves affect out (the push for reliable checklists around DSM-III).

* Affect versus emotion: affect as raw subcortical arousal, emotion as affect shaped by cortical appraisal, memory, culture and narrative, and how Dr. White draws a brainstem, midbrain and cortex for patients.

* Panksepp's seven primary systems, including the negative-valence fear, rage and panic-grief (separation distress), and a proposed set of four dimensions for each system: baseline activity, reactivity, recovery time and threshold.

* Clinical uses: patients with intense anger who do not fit a DSM box, borderline personality as arousal outrunning cortical capacity, DBT as building that capacity, and late-life anxiety or distress when cortical regulation declines.

* Medication management and short visits: describing medications as changing emotions broadly, asking about emotional blunting, adding mindfulness and acceptance-based skills, and why bottom-up intensity is not yet treatable.

* Evidence and implications: decortication in cats, children born without a cortex, cortical versus deep brain stimulation, TMS to the DLPFC as top-down input, aprepitant trials in depression, and doubts about treatment-resistant depression labels.

Clinical takeaways

* When a patient has intense anger or big feelings without the full borderline picture, consider formulating it as strong arousal that outpaces regulation. Dr. White finds this less invalidating than a fixed personality label.

* A simple drawing helps: feelings come up from below without planning, and the aim is to build the capacity to observe a feeling and delay a response; the feeling itself stays.

* In older patients with new anxiety or depression and no history, check cognition (Dr. White uses the MoCA). Declining cortical regulation may explain reactions such as distress at separation.

* Counsel that a medication may change emotional intensity broadly, and ask about emotional blunting, which patients prone to intense feelings tend to notice.

* Before calling depression treatment resistant, Dr. White reformulates and asks what would change in the patient's life if they felt better, checking sleep, activity, exercise and connection.

* Pair medication with brief skills and a referral for real psychotherapy. He argues that treatments strengthen top-down control and that evidence for lowering bottom-up intensity is lacking.

Read the full transcript

The complete transcript of this episode is on psycho.farm: Affective Neuroscience: Understanding Patients Beyond DSM Diagnoses.

Related episodes

* What Psychiatrists Get Wrong About Personality Disorders

* Understanding Borderline Personality Disorder with Dr. Mark L. Ruffalo

* Nancy McWilliams on Psychoanalytic Diagnoses, Part 1: Personality, Defenses, Themes, Paranoid Personality

For education only. Not medical advice.

We put the Seinfeld cast on the proverbial couch, not to slap diagnoses on fictional characters, but to show why personality formulation can tell us far more than a psychiatric label.

Is George a vulnerable narcissist, borderline, or something more complicated? Does Jerry’s obsession with cleanliness and order actually resemble OCD or an obsessive-compulsive personality style? Could Kramer meet criteria for antisocial personality disorder despite being charming, affectionate, and largely nonviolent? And is Elaine secretly the healthiest person in the group?

Along the way, we explore flanderization, narcissism, borderline personality organization, obsessive-compulsive personality traits, psychopathy versus antisocial personality disorder, gambling disorder, and the DSM-5 Alternative Model for Personality Disorders.

What we cover

* Why the hosts object to forcing fictional characters into Axis I-type diagnoses, why a formulation says more than a label, and how flanderization (a trait exaggerated over the seasons) shapes the characters.

* The DSM-5 alternative model for personality disorders, which rates identity, self-direction, empathy and intimacy and then maladaptive traits, used throughout to describe each main character.

* George: generalized anxiety disorder as a loose fit, and a disagreement over whether he is best seen as vulnerable narcissism, with false-self performance and a critical mother, or as borderline personality organization.

* Jerry: personality functioning in the normal range, with an obsessive-compulsive style (intellectualization, emotional constriction, the conflict between obedience and defiance, humor as a coping skill) rather than OCD.

* Kramer: the argument for antisocial personality disorder without aggression, the Hare psychopathy checklist's lifestyle features, the question of genuine empathy, and gambling disorder as the one possible Axis I diagnosis.

* Elaine as a higher-functioning George, plus Joe Davola as the clearest case of a major mental illness, and a closing case against over-identifying with a single diagnosis.

Clinical takeaways

* A label often adds little. Two people with the same DSM diagnosis can have very different lives, and a formulation of personality shows what is driving the problem and what can change.

* The DSM-5 alternative model for personality disorders pairs levels of functioning (identity, self-direction, empathy, intimacy) with trait domains. One host recommends clinicians read it because it covers a range from unimpaired to severe.

* Diagnostic criteria for generalized anxiety disorder are loose enough to fit almost anyone. Anxiety may be better explained by personality traits than by a separate Axis I-type diagnosis.

* To tell narcissism from borderline organization, look for a stable protective identity, grandiosity and attention seeking, and whether the person adapts when rejected. One host argues vulnerable narcissism is assigned too readily.

* Obsessive-compulsive personality style is not OCD: look for conscientiousness, order and emotional constriction, and require actual obsessions and compulsions before diagnosing OCD. Antisocial personality disorder does not require aggression and is not the same as psychopathy.

* Axis I-type problems and personality are linked rather than separate, as impulsivity and gambling are in one character. Over-identifying with a single diagnosis can leave a person feeling stuck, while a personality view allows more room to change.

Read the full transcript

The complete transcript of this episode is on psycho.farm: The Psychology of Seinfeld: What’s Really Wrong With George, Kramer, Jerry & Elaine?.

Related episodes

* What Psychiatrists Get Wrong About Personality Disorders

* Assessment of Personality: Practical Assessment in a Short Timeframe

* The Psychology of Elizabeth Holmes in You Can See Everything: Narcissism, Autism, or Manipulation?

For education only. Not medical advice.

In this episode, the hosts rank the behavioral and medication strategies they use for sleep problems in psychiatric practice, starting with strict wake times, CBT-I, sleep hygiene, exercise, and treating the underlying disorder. They compare doxepin, trazodone, mirtazapine, hydroxyzine, melatonin, gabapentin, benzodiazepines, Z-drugs, antipsychotics, and other options, with attention to sleep onset, sleep maintenance, side effects, dependence, sleep architecture, and comorbid conditions. The conversation also covers caffeine and stimulant timing, alcohol and cannabis, primary sleep disorders, and why diagnosis should guide insomnia treatment before medication choice.

What we cover

* The framing for the tier list: treating sleep in patients with psychiatric diagnoses, and why one host considers sleep society guidelines of limited use here, since the underlying studies mostly exclude people who meet DSM criteria.

* The behavioral tiers: a strict waking time, CBT for insomnia (CBT-I) and the pieces that fit into a medication visit, sleep hygiene (including moving the phone charger out of the bedroom), and daytime activity and exercise.

* An ACT-informed way to reduce effort around sleep, the medal system (calm rest in bed as silver, instead of fighting for the gold of sleep), and the caution that sleep hygiene can be taken too far.

* Screening for primary sleep disorders, treating the underlying psychiatric disorder, and limiting and timing stimulants such as caffeine and prescribed stimulants.

* The medication ranks: doxepin, trazodone, mirtazapine, hydroxyzine, tricyclics such as amitriptyline, gabapentin and pregabalin, melatonin and ramelteon, buspirone, paroxetine, quetiapine, and the sedating antihistamines.

* The bottom of the list: benzodiazepines, Z-drugs, alcohol, cannabis, olanzapine and risperidone used only for sleep, valerian, and sodium oxybate, plus a short comment on orexin antagonists, which neither host has used enough to rank firmly.

Clinical takeaways

* A fixed waking time is described as the easiest anchor for circadian rhythm, though hard at first. Reserving the bed for sleep and sex is a CBT-I element that can be taught piecemeal in medication visits.

* Before starting a sleep medication, ask about snoring, a partner's report, wearable data, cardiovascular risk factors, obesity and metabolic syndrome. With marked fatigue or heavy snoring, one host refers to a sleep specialist first.

* Ask whether the sleep problem is secondary. With early morning awakening plus other depressive symptoms, one host expects sleep to improve as depression is treated. The other adds a non-habit-forming sleep aid at the first visit if the patient wants one.

* Patients are poor judges of how stimulants affect their sleep. Ask about timing and quantity; even an early morning stimulant can matter.

* Both hosts favor doxepin first. Coverage of the branded low-dose tablets varies, and the liquid is often cheaper. Trazodone helps some patients and agitates others. Mirtazapine brings weight gain even at low doses and a few days of daytime slowing at the start.

* When patients say alcohol or cannabis helps them sleep, one host agrees that it helps them fall asleep, then explains the cost to sleep quality. After stopping cannabis, expect weeks of vivid dreams from REM rebound.

Read the full transcript

The complete transcript of this episode is on psycho.farm: Sleep Medications Treatment Tier List: Best Insomnia Medications Ranked.

Related episodes

* Insomnia and Sleep Medications in Psychiatry

* Antidepressant Tier List: Psychiatrists Rank Depression Medications for MDD

* Anxiety Medications Tier List: The Best and Worst Treatments for GAD

For education only. Not medical advice.

Mood stabilizers for bipolar disorder can be confusing because lithium, lamotrigine, Depakote, carbamazepine, and oxcarbazepine have very different strengths, risks, and clinical roles. In this episode, two psychiatrists break down how they think about maintenance treatment, lithium dosing and monitoring, common side effects, lab levels, toxicity counseling, and medication interactions. They also compare Depakote for mania, lamotrigine for bipolar depression, carbamazepine’s interaction burden, and the potential role of oxcarbazepine. Along the way, they discuss combination treatment, diagnostic uncertainty, pregnancy and fertility considerations, rash counseling, and why effective bipolar care requires focusing on long-term episode prevention rather than the symptom of the day.

What we cover

* Why 'mood stabilizer' is a loose label covering lithium, valproate, lamotrigine, carbamazepine and oxcarbazepine, how these differ from antipsychotics, and why maintenance and episode prevention drive outcomes in bipolar disorder.

* When polypharmacy is reasonable, the risk of stacking medications on a wrong diagnosis such as a personality disorder, and uses beyond bipolar I and II, including subthreshold presentations and adjunctive use in schizophrenia.

* Lithium: why prescribers avoid it, starting approach, counseling on hydration, salt, NSAIDs and interacting blood pressure drugs, kidney, thyroid and calcium monitoring, common side effects, and level ranges.

* Valproate: easier monitoring (platelets, ammonia, liver), the fertility and fetal risks, and the special cases the hosts consider, such as irritability, migraine and brain injury.

* Lamotrigine: its role in bipolar depression and maintenance, tolerability, Stevens-Johnson syndrome counseling, the slow titration, and the valproate interaction.

* Carbamazepine, oxcarbazepine, gabapentin and benzodiazepines: interactions, the debate over evidence, sodium checks, and the place of scheduled benzodiazepines in catatonia and as a last resort.

Clinical takeaways

* Confirm the diagnosis before adding agents. Polypharmacy is common in serious bipolar disorder, but the hosts warn against layering mood stabilizers onto a personality disorder or unaddressed comorbidity, and describe cases where the diagnosis had to be updated over time.

* For lithium, treat the patient rather than the number. Standard teaching puts maintenance at 0.6 to 0.8 and acute mania at 0.8 to 1.2, with lower levels sometimes enough for depression or adjunct use. Bring the level down once mania resolves.

* Counsel on stable hydration and salt intake, avoiding NSAIDs, and telling every prescriber about lithium. One host frames the lab monitoring as what makes lithium safer, and both suggest walking patients through a written sheet with their results.

* Be careful lowering or stopping lithium abruptly, since it may provoke mania. Onset takes at least two weeks and benefit builds over months, so set expectations early.

* Valproate needs platelet, ammonia and liver monitoring, and the hosts avoid it in people who could become pregnant. Lamotrigine needs the slow titration followed exactly.

* For lamotrigine, warn patients to stop it and seek urgent evaluation for any new rash. With valproate on board the lamotrigine dose is reduced, so check the prescribing information. The FDA label recommends HLA-B testing before carbamazepine in patients of Asian ancestry.

Read the full transcript

The complete transcript of this episode is on psycho.farm: Mood Stabilizers for Bipolar Disorder: Lithium, Lamotrigine, Depakote & More.

Related episodes

* Dr. Jim Phelps’ Bipolar Treatment Tier List: Lessons from 30+ Years in Psychiatry

* The Best Bipolar Medication Review From The Best Bipolar Expert

* How to Diagnose Bipolar Disorder with Dr. Phelps: Hypomania, Mixed States & the Clues DSM Misses

For education only. Not medical advice.

Bipolar disorder treatment is put to the test in this clinically grounded tier list with psychiatrist Jim Phelps. He and Dr. Malzberg rank low-dose lithium, lamotrigine, social rhythm therapy, dark therapy, dawn simulators, antidepressants, carbamazepine, supplements, ketogenic diet, mood tracking, and group psychoeducation. Along the way, they discuss why sleep and circadian rhythm belong in the mood stabilizer conversation, how antidepressants may worsen cycling or mixed states, and why the long-term goal is not simply treating the mood of the day. The episode also explores practical adherence, bipolar comorbidity, passive sleep tracking, and underused nonmedication approaches.

Dr. Phelps’ YouTube: https://www.youtube.com/@psycheducation

What we cover

* Low-dose lithium, graded S by Jim Phelps: start at 150 mg, step up by 150 mg every four to seven days, step back after any side effect, and check a level near 600 mg. Lithium orotate gets a provisional B for lack of data.

* Rhythm and light tools: simplified social rhythm therapy (regular bedtime and rise time), dawn simulators and dark therapy (a very dark bedroom, blue-blocking glasses), all graded S, with formal light boxes at C for cost, hassle and risk.

* Lamotrigine, graded S for the middle of the mood spectrum: very low long-term risk, a gap between Phelps's experience and the meta-analyses, little value in unipolar depression, and only adjunct use in bipolar I.

* Antidepressants in bipolar disorder, placed in the bottom tier: the concern is mood instability, cycling and mixed states more than mania. Bupropion would come first and venlafaxine last, after mood stabilizers with antidepressant effects (lithium, lamotrigine, quetiapine).

* Carbamazepine (B, bumped to A for effect) and oxcarbazepine (B): a slow build toward about 1200 mg because of enzyme induction, Stevens-Johnson and teratogenicity cautions, and oxcarbazepine's low sodium risk and thin evidence.

* Omega-3 and the ketogenic diet (both C), why paper mood charts fail, passive tracking of sleep and activity, and the 20-session group psychoeducation manual that Phelps says has some of the best efficacy data in psychiatry.

Clinical takeaways

* Lithium is easier to start when the patient holds the dial. We found that promising to step back at the first side effect opens the conversation with patients who fear blood tests and toxicity.

* Ask before advising on sleep. Phelps asks what keeps a patient up at 2 a.m., then moves bedtime earlier in 15 minute steps every couple of nights.

* Treat the cycling first. Phelps then reassesses apparent ADHD, anxiety and trauma symptoms, which he finds often shrink once mood is steady.

* A formal morning light box acts like an antidepressant in bipolar disorder and, per Phelps, can induce mixed states and irritability. A dawn simulator carried no such risk in his experience.

* Antidepressants worry us in bipolar disorder because of long-term instability and mixed states. Stopping one abruptly is also an acute stressor, so changes need care.

* Count pills and tasks. Pill burden leads some patients to stop everything, and stacking lifestyle changes early overwhelms them.

Read the full transcript

The complete transcript of this episode is on psycho.farm: Dr. Jim Phelps’ Bipolar Treatment Tier List: Lessons from 30+ Years in Psychiatry.

Related episodes

* How to Diagnose Bipolar Disorder with Dr. Phelps: Hypomania, Mixed States & the Clues DSM Misses

* Mood Stabilizers for Bipolar Disorder: Lithium, Lamotrigine, Depakote & More

* The Best Bipolar Medication Review From The Best Bipolar Expert

For education only. Not medical advice.

Anxiety medications tier list: two psychiatrists rank the treatments they actually use for generalized anxiety disorder… and the ones they avoid. The discussion covers first-line SSRIs, why buspirone may be underrated, when benzodiazepines can help or harm, and how to think about mirtazapine, hydroxyzine, propranolol, gabapentin, pregabalin, quetiapine, and bupropion. Just as important, the episode argues that “anxiety” is not a diagnosis: re-diagnosis, mindfulness, CBT and ACT principles, exercise, reducing caffeine or stimulants, and understanding avoidance may matter more than adding another prescription. The result is a practical, opinionated guide to anxiety treatment that combines evidence, clinical experience, side effects, dependence risk, and long-term recovery.

What we cover

* Scope and stance: we rank treatments for trait-like, physiological anxiety, apart from anxious distress in depression, personality disorders or trauma, and favor scheduled treatment over as-needed pills.

* Non-drug S-tier picks: mindfulness, the CBT book Feeling Great, the acceptance and commitment therapy book The Happiness Trap, spirituality, and re-diagnosis, since anxiety is a nonspecific signal that many conditions produce.

* SSRIs and SNRIs: sertraline and escitalopram first, long-acting fluoxetine for patients who start and stop, venlafaxine held back by withdrawal, paroxetine low for weight gain and anticholinergic effects, and duloxetine for comorbid pain or migraine.

* Buspirone, graded S minus: no sexual side effects or weight gain, but twice-daily dosing and weeks to work, so it is not an as-needed drug. One of us tries it before the SSRIs.

* Benzodiazepines and Z drugs, graded C to F: they work quickly, but we weigh dependence and impaired learning in exposure-based work. Hydroxyzine, propranolol, gabapentin and pregabalin sit in the middle or lower tiers.

* Other picks: mirtazapine (B), quetiapine (neither of us uses it despite trial evidence), bupropion (disputed), caffeine and stimulants, exercise (A or S), kava (low), lavender oil (B or A), and tricyclics as late options.

Clinical takeaways

* Make the diagnosis before choosing the drug. Anxiety can come from mania, depression, personality disorders and many other conditions, and treating only the stated complaint leaves no shared understanding.

* Benzodiazepines are most defensible for an acute decompensation in a patient without addiction risk, with a clear plan for short-term use. They also interfere with learning that feared situations are safe.

* Bupropion divides us. One of us thinks it can worsen generalized anxiety over time. The other might still offer it for weight loss or smoking cessation, with warnings and close tracking of sleep and function.

* Check stimulants and caffeine. They raise physiological anxiety, though in true ADHD treatment can lower psychological anxiety enough to outweigh that.

* Propranolol is rated higher for performance anxiety than for generalized anxiety. Gabapentin trials showing benefit used much higher doses than many clinicians prescribe.

Read the full transcript

The complete transcript of this episode is on psycho.farm: Anxiety Medications Tier List: The Best and Worst Treatments for GAD.

Related episodes

* Psychiatrist's Guide to Anxiety Medications: First Line to Last Resort

* Understanding Anxiety, GAD, and Treatments of Anxiety

* Antidepressant Tier List: Psychiatrists Rank Depression Medications for MDD

For education only. Not medical advice.

Psychodynamic therapy interventions are the focus of this episode, organized through a practical levels framework for clinicians. Dr. Fu and Dr. Greg break down empathic mirroring as a way to keep the patient’s narrative moving, clarification as a tool for deepening detail, confrontation as a gentle way to point out patterns or discrepancies, and interpretation as the rare intervention that should come only after enough groundwork. Along the way, they connect these skills to diagnostic interviewing, medication management, forensic psychiatry, therapeutic alliance, and the difference between helping a patient talk more and pushing too quickly toward insight.

What we cover

* A recap of the levels framework, which orders interventions by how often they are used, with level zero (support, alliance and technical containment) covered in the earlier episode.

* Level one, empathic mirroring, defined as anything that keeps the narrative going without changing its direction: 'tell me more', nonverbal acknowledgment, varied 'hmm' sounds, and punctuation (repeating a key word the patient just said), with the hosts differing on how it relates to containment.

* Level two, clarification, split into surface questions (events, sequence, context) and depth questions (feelings, wishes, fantasies), a river analogy for noticing when the narrative dams up, and paraphrasing to check understanding.

* Exploring memory in a hallucinatory level of detail, meaning step-by-step sensory recall used in therapy, diagnostic interviews and forensic work such as insanity evaluations, with the caution that memory is edited.

* Level three, confrontation, defined as holding up a pattern, a discrepancy or a gap between values and behavior for the patient to look at, with examples from therapy, diagnostic interviews and medication management.

* The ordinary reasonable person standard and shared cultural scotoma as checks against colluding with patients, then level four, interpretation, and why it is rare.

Clinical takeaways

* Prompts that add no new content, such as repeating a key word, can bring a richer narrative than direct questions in therapy, diagnostic interviewing and forensic evaluation.

* Clarify before challenging: gather concrete details first, then feelings and wishes, without disputing the story or pointing out inconsistencies yet.

* Confrontation needs a good alliance and a gentle manner. Dr. Fu says to start by the third session of formal therapy, and it can also appear in a first diagnostic interview, for example by asking how a main complaint relates to regular cannabis use.

* Compare the patient with population norms and use common sense to avoid colluding with defenses, for example when someone reports doing spectacularly well right after a breakup.

* Hold interpretation back until a pattern has been confronted many times and the patient is nearly able to say it. Both hosts see no place for it in infrequent medication visits.

Read the full transcript

The complete transcript of this episode is on psycho.farm: Psychodynamic Technique and Therapeutic Intervention: Mirroring, Clarification, Confrontation, Interpretation.

Related episodes

* Psychodynamic Technique and Therapeutic Intervention: Containment

* Psychiatric Technique for Diagnostic Interviewing and Therapy: 6 Mantras Every Clinician Should Know

* Probably The Most Important Topic in Psychiatry: Therapeutic Alliance and Frame

For education only. Not medical advice.

Unfortunately no Dr. Fu today, but Dr. Malzberg speaks with the wonderful psychiatrist Dr. Mary Ellen Eller, who walks through what modern electroconvulsive therapy actually looks like and when clinicians should consider it. The episode covers ECT history, stigma, seizure monitoring, memory concerns, side effects, and the real-world logistics patients face during a treatment course. It also explores where ECT fits in the algorithm for severe depression, depression with psychosis, catatonia, bipolar mania. The result is a grounded, clinician-friendly guide to a misunderstood treatment.

Suicide risk assessment is often taught like a checklist, but this episode argues that the real work is formulation. We talk about why history is only the starting point, how acute and chronic risk differ, and why suicidal ideation can mean very different things depending on context. We cover stress-related suicidality, intoxication, baseline recurrent thoughts, mood and psychotic disorders, OCD intrusive thoughts, hospitalization decisions, red flags, countertransference, and documentation. The result is a practical psychiatry conversation for clinicians and trainees who want to think more clearly about suicide risk without pretending they can predict the future.

What we cover

* Why suicide screening mandates and checkbox forms can replace clinical thinking, why they still matter for the standard of care, and how rapid yes or no questions teach patients which answers lead to discharge.

* The first rule of emergency work (take your own pulse, be professional rather than afraid), building a narrative of how the patient got here, and two starting points: the Columbia Suicide Severity Rating Scale and a 2007 Psychiatric Times article on documentation.

* What an assessment is: grading chronic and acute risk as an actuary would, not predicting the future, followed by diagnosis, formulation and a treatment plan, with a car insurance analogy.

* Varieties of suicidal ideation: rational suicidality (rare in psychiatric settings), a dysregulated response to stress or intoxication, baseline recurrent ideation, ideation secondary to mood or psychotic disorders, and ego-dystonic obsessions in OCD.

* How the variety shapes treatment: brief detention for stress or intoxication crises, possible harm from admission for recurrent baseline ideation, lithium in bipolar disorder, clozapine in schizophrenia, and telling OCD from borderline presentations.

* Galynker's suicide crisis syndrome (entrapment, affective disturbance, loss of cognitive control, hyperarousal, social withdrawal), countertransference as a signal, red flags, and liability that follows process and documentation.

Clinical takeaways

* Separate history from assessment. A scale such as the Columbia scale collects history, and the assessment is the judgment that links risk to a formulation and a treatment plan.

* Avoid a checklist interview. Patients who learn that denying ideation leads to discharge may stop being candid, so we favor an open narrative interview.

* Suicidal ideation is not by itself a reason to start an SSRI. The hosts point to lithium in bipolar disorder and clozapine in schizophrenia as the medications with evidence for reducing suicidality, and argue that SSRIs have not shown a specific anti-suicide effect.

* Match the response to the variety. Stress or intoxication crises often settle with time and support, while recurrent baseline ideation may do better with therapy such as DBT, and admission can slow progress.

* Listen for entrapment, hopelessness, agitation and insomnia, and notice a pull to rescue or give up. Change from baseline, planning, or refusing a safety agreement call for rethinking the level of care.

* Liability attaches to process. Assess to the standard of care and document the exam, history and reasoning.

Read the full transcript

The complete transcript of this episode is on psycho.farm: Suicide Risk Assessment: Acute vs Chronic Risk, Formulation, and Suicidal Ideation Types.

Related episodes

* Involuntary Treatment & Agency, Thoughts and Feelings | Episode 19

* Handling Difficult Situations in Psychiatry: ADHD Evaluations, Benzo Requests, Disability Claims, and Involuntary Admissions

* Treating Borderline Personality Effectively aka How To Be A Good Psychiatrist Through GPM

For education only. Not medical advice.

Psychiatrists rank antidepressants for major depressive disorder, including SSRIs like sertraline, escitalopram, fluoxetine, and paroxetine; SNRIs like venlafaxine and duloxetine; and atypical options like bupropion and mirtazapine. They also cover lithium, low-dose aripiprazole, trazodone, esketamine, stimulants, benzodiazepines, TCAs, and MAOIs, with emphasis on diagnosis, side effects, withdrawal, weight gain, sexual dysfunction, anxiety, insomnia, and why “which antidepressant is best” depends on the patient.

What we cover

* How the hosts set the rules for a tier list of antidepressants for major depressive disorder: one ranks by tolerability (especially avoiding weight gain) and then efficacy, the other goes by feel, and both say the ranking depends on the patient population.

* Why stimulants and benzodiazepines land in the bottom tier for depression: the hosts argue they give a drug effect that fades with tolerance and leaves the underlying illness untreated, and they debate a one-week benzodiazepine during an acute crisis.

* The SSRIs: sertraline at the top, then escitalopram, fluoxetine (a split between the hosts, with its long half-life and high ceiling), paroxetine, citalopram, fluvoxamine, vortioxetine and vilazodone.

* SNRIs and atypicals: venlafaxine and its withdrawal syndrome, duloxetine, desvenlafaxine, milnacipran, then mirtazapine, bupropion and trazodone, judged for depression only, with their uses for sleep or trauma set aside.

* Lithium as a position statement for recurrent depression, low-dose aripiprazole, quetiapine and buspirone as add-ons, and why lamotrigine stays off the unipolar list.

* Esketamine, tricyclics and MAOIs: why esketamine sits in a low tier, and why tricyclics and MAOIs (phenelzine, selegiline patch) remain options for true treatment-resistant depression.

Clinical takeaways

* If a patient reaches a third antidepressant in a row without remission, reconsider the diagnosis. The hosts say treatment-resistant depression is where personality disorders can hide.

* In a patient with ADHD plus depression, a stimulant can feel good on day one while the depression goes untreated, and irritability and somatic symptoms may creep up. Waning benefit may reflect the drug effect fading.

* Bupropion can worsen anxiety, especially at the start, so one host suggests a first dose when the patient has nothing to do. The hosts caution against choosing it only because a patient wants to avoid side effects.

* Venlafaxine works well for some patients but has the worst withdrawal syndrome of the class, so taper slowly. The hosts disagree on its rank and agree that an SSRI should not be combined with an SNRI.

* Low-dose trazodone is not an antidepressant dose, and its metabolite mCPP can cause agitation in some people. Describe possible sleep effects carefully, and believe a patient who reports a bad night.

* Low-dose aripiprazole augmentation carries a tardive dyskinesia risk, including in patients without schizophrenia, so learn to do an AIMS. Be sure of the diagnosis before adding antipsychotics or lithium.

Read the full transcript

The complete transcript of this episode is on psycho.farm: Antidepressant Tier List: Psychiatrists Rank Depression Medications for MDD.

Related episodes

* Treating Depression: Practical Tips & Pearls for Anti-Depressant Medications

* Sleep Medications Treatment Tier List: Best Insomnia Medications Ranked

* Anxiety Medications Tier List: The Best and Worst Treatments for GAD

For education only. Not medical advice.

Mindfulness in psychiatry is the focus of this episode, with Doctors Malzberg and Fu treating it as a practical clinical skill rather than vague wellness advice. They define mindfulness as deliberate attention to the present moment without judgment, then connect it to DBT, MBCT, ACT, anxiety, depression, PTSD, substance use, and trauma-informed care. The conversation also covers when mindfulness should be modified, why it is not always a standalone treatment, and how clinicians can teach it through short, scheduled practice, DBT “what skills,” grounding techniques, and careful follow-up.

What we cover

* Why mindfulness can be treated as a medical intervention the patient does, like CBT for insomnia, though it grew from religious traditions, and its path through mindfulness-based stress reduction, DBT, ACT and MBCT.

* A three-part definition: deliberate attention, to the present moment, without judgment (including not judging yourself for judging), and why drifting off is part of the practice.

* What it targets: rumination and inward focus (with a brief mention of the default mode network), stepping back from thoughts as a process, and the paradox that practicing in order to get better undermines it.

* Indications we grade: generalized anxiety disorder (A), major depression (A minus, mainly relapse prevention), substance use disorder (A), PTSD with an asterisk because grounding may fit better, and bipolar disorder and schizophrenia as general wellness only.

* Safety: practice should not be distressing or effortful, should not depend on apps in the long run, and should not serve as a rescue during panic.

* How to teach it: plain-language psychoeducation, DBT mindfulness handouts (observe, describe, participate, wise mind), a short scheduled practice, role play and CBT-style follow-up.

Clinical takeaways

* Schedule a short, specific practice, such as five minutes once a week at a calm time, and ask the patient to try two or three exercises over about a month.

* Do not let it become an as-needed rescue for panic; it stops working like any as-needed drug and becomes linked to distress. At high distress, other skills such as DBT distress tolerance fit better.

* In PTSD and complex trauma, prefer grounding or a modified practice, and stop any practice that causes distress.

* Do not sell mindfulness as a cure for depression. Present it as a tool that helps prevent slipping into episodes, since patients can turn it into self-blame.

* Follow up with a neutral, curious stance, and check that the patient does not feel they had to enjoy it. Benefit builds over months, like medication.

* Observe and describe are easy starting skills; describe may be riskier in people who ruminate.

Read the full transcript

The complete transcript of this episode is on psycho.farm: Mindfulness in Psychiatry: How to Teach It as a Clinical Treatment Skill.

Related episodes

* Anxiety Medications Tier List: The Best and Worst Treatments for GAD

* Understanding Anxiety, GAD, and Treatments of Anxiety

* Beyond Medications: The Best Lifestyle Treatments for Mental Health

For education only. Not medical advice.

Psychotherapeutic techniques are the subject of this episode, as the conversation lays out six memorable therapy mantras for better diagnosis, formulation, and treatment. Rather than focusing on abstract theory, the discussion shows how clinicians can stay close to patient material, clarify vague symptom language, notice countertransference, rewind key moments, and make links that improve both psychotherapy and medication management. It’s a practical lesson in interviewing: ask simpler questions, tolerate not knowing too quickly, observe contradictions, and avoid getting lost in content when the process is where the diagnostic data actually lives.

What we cover

* Why interviewing and therapy technique sets the quality of diagnostic data, and why the levels of intervention are for retrospective review (process notes, video, supervision) while short mantras can be used inside the session.

* Who is doing what to whom: transference and countertransference in interviews and medication visits, process over content, and cases where a clinician's reaction, or a patient's focus on one symptom, steered the work away from the real problem.

* Make links and name things: how diagnosis and formulation connect symptoms and causes, using the patient's own words, with examples such as self-sabotage after doing well and concentration problems driven by obsessions rather than ADHD.

* Stay close to the material and act stupider: ask what a vague word like anxiety means to this patient before reaching for a framework, including the Columbo-style approach of curious, unassuming questions.

* Rewind the tape: going back to an important point that slipped past, why venting alone is not treatment, and slowing down a fast-talking manic history.

* Observe and confront: saying aloud what you notice, including contradictions in the narrative, as in motivational interviewing, and staying focused on practice rather than outcome.

Clinical takeaways

* Treat interview technique as the resolution of your diagnostic tools. A weak interview gives a low-resolution picture, however good the later workup.

* Notice your own reaction as data. Wanting to raise a dose, dismiss a patient or rush a risk question can be part of an interpersonal process. An abrupt question about harm can provoke a guarded patient who has met uncaring providers before.

* Stay with the patient's words. If concentration is the complaint, ask what changed in the last few weeks before asking about childhood ADHD. Avoid clinical terms at intake and ask what the person experienced when they say anxiety.

* Aim for a formulation that someone with no clinical training could follow, and name the link (for example, tying two main symptoms to a diagnosis and a treatment) out loud.

* Be willing to interrupt and go back, for example to a physical symptom mentioned in passing before the patient moved on to a crisis.

* Point out patterns and contradictions without waiting for agreement. Patients may push back, and change can come months later. Things may also get worse before they get better.

Read the full transcript

The complete transcript of this episode is on psycho.farm: Psychiatric Technique for Diagnostic Interviewing and Therapy: 6 Mantras Every Clinician Should Know.

Related episodes

* Psychodynamic Technique and Therapeutic Intervention: Containment

* Psychodynamic Technique and Therapeutic Intervention: Mirroring, Clarification, Confrontation, Interpretation

* How to Do a Psychiatric Intake | The Art and Science of the First Hour

For education only. Not medical advice.

Psychodynamic technique is the throughline of this episode, which argues that the core skills of therapy belong at the center of psychiatry, not at the margins. The conversation maps five levels of intervention, from level zero through interpretation, while stressing that the most important work usually happens earlier: frame, alliance, follow the affect, and technical containment. Rather than glamorizing clever interpretations, the episode shows why reflective listening, emotionally accurate language, and careful therapeutic interventions help patients think, regulate, and elaborate on their experience. It’s a practical discussion for clinicians who want to improve interviewing, formulation, and treatment across everyday psychiatric practice.

Lots of material from this lecture is from here:

https://www.appi.org/Products/Psychotherapy/Clinician-Technique-in-Personalized-Psychotherapy

What we cover

* Why psychotherapy technique matters across psychiatry, including diagnostic interviews and medication visits, and how reviewing your own sessions afterward helps. The hosts also warn against using psychodynamic ideas as quick interpretations in short visits.

* Frame and alliance as skills (noticing a step outside the frame or a rupture and repairing it), and the mantra of following the affect, including affect that runs too hot or too cold relative to what is being said.

* Keeping a patient in a workable zone of emotional regulation: staying calm yourself first, the physiological sigh, grounding and orienting questions for a patient who freezes or dissociates, and what to do with an over-regulated patient.

* The five levels of intervention: level zero (frame, boundaries, psychoeducation, safety and technical containment), then empathic mirroring, clarification, confrontation or observation, and interpretation, with interpretation the rarest.

* Containment: Bion's idea that thinking develops when a caretaker receives and gives back a child's internal experience, alexithymia seen as a developmental deficit, and a diagnosis such as OCD acting as a container.

* How to do technical containment in four steps, a short role-play, links to Carl Rogers and motivational interviewing, and why unconditional agreement with one part of a patient is a weak form of support.

Clinical takeaways

* Follow the affect. Notice emotion that is too intense or too absent for the story being told, and treat it as both a diagnostic signal and information about what is happening between you and the patient.

* When a patient becomes dysregulated, check your own state first. If a patient freezes or dissociates, name what you see, ask simple orienting questions, label the emotion you think is present, and offer only reassurance that is true.

* Earlier levels of intervention should be used more often than interpretation. An interpretation offered before the patient feels heard will not land, and one host warns against reflexive lines such as asking about a patient's history with authority.

* Technical containment has four steps: observe what the patient says and does, notice your own reaction, form a working idea of their inner experience, and say it back in words. Repeating the patient's account in slightly different words is often enough.

* Reflecting shows you are listening and helps the patient slow down and observe their own process. It also builds rapport and information in a diagnostic interview or medication visit, not only in therapy.

* Check that patients can explain their diagnosis in their own words from their own history, and watch for over-explaining out of your own anxiety.

Read the full transcript

The complete transcript of this episode is on psycho.farm: Psychodynamic Technique and Therapeutic Intervention: Containment.

Related episodes

* Psychodynamic Technique and Therapeutic Intervention: Mirroring, Clarification, Confrontation, Interpretation

* Psychiatric Technique for Diagnostic Interviewing and Therapy: 6 Mantras Every Clinician Should Know

* Probably The Most Important Topic in Psychiatry: Therapeutic Alliance and Frame

For education only. Not medical advice.

In this episode, Dr. Fu and Dr. Malzberg share practical systems for time protection: start on time, end on time, finish documentation inside the visit, and use tools like AI scribes and quiet typing gear. They also lay out clear messaging rules so emails, texts, and forms do not become off-the-clock clinical care, plus the value of emergency slots. The deeper work is emotional: process the job with mentors or supervision, know your limits, and build a real life outside medicine so you can stay effective for the long game.

What we cover

* Why outpatient psychiatry is wearing, why small daily decisions add up, and the line that burnout may not be your fault but is your responsibility to address.

* Time protection: starting and ending on time, finishing the note, recommendations, resources and prescriptions inside the booked slot, using AI scribes or documenting in session, quiet keyboards and a task list cleared each day.

* Keeping care inside appointments: forms, medication questions and non-emergency problems wait for a visit, protected emergency slots in private practice, and a short, consistent style for emails and texts.

* Why a predictable frame helps both patients and clinicians, drawing on the contrast between kind and wicked learning environments, and why clinicians should stay within standards of practice and not bend rules for what seems like a good cause.

* The emotional side of the work: finding safe people, containment, supervision and mentorship, and scheduling a short, capped time for venting.

* Perspective and recovery: knowing what you cannot change, having a life outside work, protecting vacations, recognizing burnout as something like an adjustment disorder, and options when changes at work are not enough.

Clinical takeaways

* Treat the whole visit slot as the encounter. Talk, write the note, send resources and handle prescriptions before the next patient, and neither start early nor run late.

* Set expectations at intake: for example, an hour for the intake and 20 minutes for follow-ups. A reminder five minutes before the end lets a patient in the middle of something heated hear the limit coming.

* One host uses an AI scribe and the other documents in session. Either way, be open with patients that you are writing, and use a silent keyboard and mouse.

* Reserve open slots for urgent needs so an emergency does not push you into the evening. One host keeps two protected 30-minute blocks, and both prefer a staff member as the first stop for messages.

* Burnout can look like an adjustment disorder: fatigue, irritability, detachment and negative thinking about work. If you feel the same after more than five days off, consider a larger change.

* Know the limits of your role. Do not oversell what a medication can do, and accept that some suffering cannot be changed. One host schedules a weekly activity alone, with one person and with a group, though he notes there is no research behind it.

Read the full transcript

The complete transcript of this episode is on psycho.farm: Tips to Avoid Burnout in Psychiatry (Outpatient, mostly).

Related episodes

* Probably The Most Important Topic in Psychiatry: Therapeutic Alliance and Frame

* Handling Difficult Situations in Psychiatry: ADHD Evaluations, Benzo Requests, Disability Claims, and Involuntary Admissions

* Psychiatric Technique for Diagnostic Interviewing and Therapy: 6 Mantras Every Clinician Should Know

For education only. Not medical advice.

In this episode, Dr. Malzberg and Dr. Fu tackle one of psychiatry’s hottest diagnostic debates: complex PTSD versus borderline personality disorder. They walk through the DSM-5 and ICD-11 definitional differences, the historical roots of the C-PTSD concept in Judith Herman’s work, and the real clinical distinctions clinicians can use to differentiate the two. More than a theoretical argument, the conversation zeroes in on how to communicate these diagnoses to patients, why BPD stigma drives some of the debate, and what therapies fit each presentation… from DBT and mentalization-based therapy to EMDR and trauma-focused approaches.

What we cover

* Why definitions come first: DSM-5 and ICD-11 define PTSD differently, and one host argues that DSM-5 PTSD, with its negative mood and cognition criterion, already covers much of what ICD-11 calls complex PTSD.

* The caricatured debate (BPD as the patient's fault, complex PTSD as justified reactions) and its history in Judith Herman's Trauma and Recovery, which links borderline personality, somatization and multiple personality to trauma and to the old label hysteria.

* The ICD-11 definition of complex PTSD as PTSD plus disturbances of self-organization: emotion dysregulation, negative beliefs about oneself with shame, and difficulty keeping close relationships.

* Two positions: one host calls complex PTSD an unnecessary reorganization of existing categories, with causes mixing outside events and inner tendencies; the other finds it a useful umbrella in which BPD is one presentation.

* Stigma, and one host's view that BPD tends to be given to patients clinicians dislike and complex PTSD to patients they like.

* Practical differentiation: the McLean Screening Instrument for BPD, relationship patterns, the DSM-5 alternative model of personality functioning, and therapy options for personality dysfunction.

Clinical takeaways

* Define terms before debating. Research and colleagues may mean DSM-5 PTSD, ICD-11 complex PTSD or an informal idea of complex trauma, and these are different things.

* One host weighs impulsivity, fear of abandonment, temper outbursts and swings between idealization and devaluation toward BPD, and an avoidant attachment style toward complex PTSD, while calling these overgeneralizations.

* Mixing McLean screening questions into the intake narrative can show whether BPD is a main feature. Talking about BPD traits, not a yes or no label, can open the topic with patients who use a complex PTSD label to avoid looking at personality.

* When personality dysfunction does not fit BPD, the DSM-5 alternative model gives language for self and interpersonal problems. Treat co-occurring conditions first, then explain personality as how a person deals with themselves and others.

* We caution against confirming a personality disorder diagnosis at a first visit unless the history is clear, and note that a loaded diagnosis can serve as resistance to treatment. Ask patients what the label means to them.

* When resources are thin, a longitudinal, affect-focused talk therapy that the patient commits to may matter more than a named therapy such as TFP, MBT or DBT. One host would add trauma-focused therapy for complex PTSD.

Read the full transcript

The complete transcript of this episode is on psycho.farm: CPTSD vs BPD: How to Think About the Difference and What to Do About It.

Related episodes

* Trauma and PTSD: How the DSM Criteria Actually Help Us Understand What’s Going On

* Understanding Borderline Personality Disorder with Dr. Mark L. Ruffalo

* Treating Borderline Personality Effectively aka How To Be A Good Psychiatrist Through GPM

For education only. Not medical advice.

Subtle psychosis can be missed when you rely on checklists or slip into an interrogator stance. We break down a clinician-friendly approach to detecting psychosis early: use countertransference as a signal, mirror emotion without agreeing with delusions, and clarify the patient’s narrative without derailing it. You’ll also get an OLDCARTS-style framework for taking a voice-hearing history (onset, location, duration, character, and more), plus practical alliance moves for paranoia. We close with how to bridge the treatment gap once you’re seeing the pattern clearly.

What we cover

* Using countertransference as a signal: noticing your own automatic reaction to a patient (an uncanny feeling, a pit in the stomach, or growing confusion as every thread leads to more threads) as a prompt to ask for more history.

* Harry Stack Sullivan's advice to sit alongside a paranoid patient, literally or figuratively, so the feared object is externalized and the clinician does not become the persecutor.

* Living in the world of the patient's belief during assessment, much like suspending disbelief at a film, while neither arguing with nor agreeing with delusions.

* Empathic mirroring (also called reflective statements or containment) and clarification, which gathers information without challenging or changing the narrative, and why the interrogator stance gets less information.

* An OLDCARTS-style history for voice hearing: onset, location, duration, character (who the voices are), aggravating and alleviating factors, associated symptoms and timing, followed by repeated questions about what the patient thinks is causing them.

* Bridging the gap between clinician and patient, why outpatient psychosis is not an emergency, and early antipsychotic choice with attention to weight gain, akathisia and tardive dyskinesia.

Clinical takeaways

* A countertransference reaction works like a positive PHQ-9: it is a screening signal that tells you to look further, and it does not make a diagnosis. Reactions differ between clinicians, so learn your own pattern.

* Do not argue with a delusion and do not agree with it. Acknowledge the emotional effect (for example, that it sounds terrifying) without endorsing the content.

* During clarification, stay with the narrative the patient is telling. If they drift, gently return to the thread, unless you are watching for disorganized thinking.

* Ask about voices more than once, including who the patient thinks the voices are and why they think they are happening. Fear of being judged can make early answers guarded.

* If a patient sees no mental health problem, look for a shared problem such as avoiding rehospitalization, sleep, fear, disorganized thinking or stress, and tie treatment to that.

* Build the alliance and take a thorough history before prescribing. When choosing an antipsychotic, we consider weight-sparing options and ask directly about akathisia, which in outpatients is often subjective.

Read the full transcript

The complete transcript of this episode is on psycho.farm: Detecting Subtle Signs of Psychosis: Assessment of Voices, Delusions, and Psychosis.

Related episodes

* What is Psychosis? Look at the DSM, Common Mimics, and a Framework for the Differential

* What Makes a Belief a Delusion? Delusions, Thought Disorder, the TALD Scale

* Psychodynamic Technique and Therapeutic Intervention: Mirroring, Clarification, Confrontation, Interpretation

For education only. Not medical advice.

Bipolar diagnosis is tricky without labs, so this episode lays out a practical, semi-structured interview you can use in real clinics. We start with what many clinicians skip: a medication and substance timeline, plus medical causes, before jumping into mood symptoms. Then we map major depressive episodes, screen for hypomania with narrative follow-ups, and compare behavior to baseline instead of trusting yes/no answers. Along the way we cover classic pitfalls and mimics, including PTSD insomnia, borderline traits, psychosis-related agitation, and ADHD mislabeling. Finally, we talk about when tools like the MDQ or Rapid Mood Screener help, and why collateral history can change the case.

What we cover

* Why the questions are the exam in psychiatry: pretest probability, the patient population, and why a semi-structured interview that pulls threads and gathers narrative works better than fixed screening questions outside research.

* Why bipolar disorder is both over- and underdiagnosed, and why interview data is unreliable: poor memory of past episodes, different meanings of the word bipolar, limited time and mimics.

* Starting with medical history, medication history (including non-psychiatric drugs) and a detailed substance timeline, including which substances rarely cause mania and which prescriptions, supplements and steroids can.

* Mapping major depressive episodes next, plus the Kraepelin and Ghaemi view that recurrent mood episodes, not polarity, define bipolar illness.

* Screening for mania and hypomania with open follow-ups, our disagreement on the four day cutoff, and confirmatory questions on energy, mood, talk, thinking and indiscreet behavior.

* Mimics and look-alikes: substances, medical causes, trauma-related insomnia, psychosis, paradoxical insomnia, ADHD and borderline personality, plus the early-awakening sleep pattern typical of mania.

Clinical takeaways

* Ask about medications and substances as a timeline, not a list, and look for periods of at least a month of sobriety. Cannabis and nicotine use often rises during mood episodes, which is not taken to mean they caused them.

* Do not screen for depression by asking whether the patient was depressed. Look for an episode (almost all day, almost every day for two weeks, with changes in energy, sleep or appetite), then ask about the first one, how often, how long, and time free in between.

* A yes to a screening question is the start. Ask for the story: what happened, how long it lasted, what a day looked like and where the crash came. Wired nights during finals with caffeine can be an ordinary response.

* Ask about energy and activity separately from mood, since agitated patients may deny energy while pacing and cleaning. Hypomania shows as a change in activity together with a change in mood; sleep is the most recalled symptom but not required.

* Do not blame a substance only because one was present, since people in a mood episode tend to use more. Pin down when the episode started, and get family history and collateral, which can also be unreliable.

* One host lowers the threshold for a mood stabilizer trial in patients with clear recurrent depressive episodes and failed medication trials.

Read the full transcript

The complete transcript of this episode is on psycho.farm: How to Diagnose Bipolar Disorder: The Interview Framework That Beats Screening Questions.

Related episodes

* How to Diagnose Bipolar Disorder with Dr. Phelps: Hypomania, Mixed States & the Clues DSM Misses

* Dr. Jim Phelps’ Bipolar Treatment Tier List: Lessons from 30+ Years in Psychiatry

* The Best Bipolar Medication Review From The Best Bipolar Expert

For education only. Not medical advice.

How do you actually evaluate a “delusion” in the room, especially when the belief could be plausible, culturally reinforced, or tied to mood or substances? In this episode, we break down a practical approach to psychosis language, why “fixed false belief” is often insufficient, and the interview questions that help clarify origin, certainty, flexibility, and function. We also use the TALD framework to expand beyond the usual linear vs circumstantial vs tangential model of thought disorder, then apply everything to a case vignette where a single supplement becomes the explanation for an entire life collapse. Educational and clinically focused.

TALD: https://ars.els-cdn.com/content/image/1-s2.0-S0920996414005933-mmc1.docx

Understanding Delusions Paper: https://journals.lww.com/inpj/fulltext/2009/18010/understanding_delusions.2.aspx

What we cover

* Clarifications from the previous episode: tapering is individualized and can be risky in primary psychotic or serious bipolar disorders, plus a debate over whether one definition describes psychosis broadly or only the schizophrenia spectrum.

* Thought disorganization beyond the linear, circumstantial and tangential scheme, and the Thought and Language Disorder (TALD) scale as a reading resource that defines derailment, perseveration, neologisms, blocking, poverty of content and concretism.

* Why fixed false belief falls short: a delusion need not be false or fixed, only relatively impervious to reasoning, and truth, bizarreness and how many people share a belief are poor tests.

* Separating delusions from religious, cultural and overvalued beliefs by origin, plus beliefs that arise in substance-induced, mood-related and personality-related states.

* Interview questions about origin, certainty and flexibility: how the belief arose, what makes the patient more sure, what could change their mind, how others react, and how strongly it is held.

* A made-up case of a patient who blames lost drive and enjoyment on one past supplement dose, worked through as overvalued idea versus depression versus delusion, and how to talk with such a patient.

Clinical takeaways

* Judge a belief by its origin, certainty and flexibility, not its content. Plausible beliefs can be delusional, and implausible ones can be shared, learned or culturally reinforced.

* Challenge gently, with the tone of someone who wants to understand more, for example by saying it is a lot to take in and asking to hear more.

* A patient may deny the belief once they sense judgment, then reaffirm it when you return to the topic later. A first denial is not resolution.

* When answers stay general, ask the patient to walk through the last episode step by step in concrete detail.

* Outside the assessment, avoid arguing with delusions or overvalued ideas. Acknowledge them and find problems you both agree on. Psychosis alone is not an emergency without an emergency feature, and patients rarely take medication they do not believe in.

* In edge cases such as forensic competency evaluations, plausible beliefs (distrust of police or a lawyer) can be true or learned from others, so trace how the belief arose before calling it psychotic.

Read the full transcript

The complete transcript of this episode is on psycho.farm: What Makes a Belief a Delusion? Delusions, Thought Disorder, the TALD Scale.

Related episodes

* What is Psychosis? Look at the DSM, Common Mimics, and a Framework for the Differential

* Detecting Subtle Signs of Psychosis: Assessment of Voices, Delusions, and Psychosis

* Psychosis: History, Delusions, Diagnosis, Theories, and Modern Care

For education only. Not medical advice.

What does “psychosis” actually mean, and how do clinicians recognize it in practice? In this episode, we define psychosis as a syndrome (not a single diagnosis) and walk through the core symptom domains: delusions, hallucinations, disorganized thinking/speech, disorganized behavior, and negative symptoms. We focus on the differential diagnosis, including how to distinguish schizophrenia-spectrum and schizoaffective disorders from mood disorders with psychotic features, trauma-related phenomena, borderline personality disorder, neurodevelopmental presentations (including autism spectrum traits), and substance-induced psychosis. We share red flags that can be easy to miss, like new-onset suspiciousness, functional decline, social withdrawal, and subtle thought disorganization, and we emphasize the value of collateral history and longitudinal follow-up. We close with treatment implications: when antipsychotics are helpful, why risks and benefits need to be individualized, and when psychotherapy and supportive interventions are the better first move. Educational disclaimer: This episode is for educational purposes only and is not medical advice.

What we cover

* Psychosis as a syndrome rather than one diagnosis, using the DSM domains (delusions, hallucinations, disorganized speech, disorganized behavior, negative symptoms, with catatonia placed in the chapter), and a proposal to reserve those terms for primary psychotic disorders.

* A short history: why pre-1980 schizophrenia diagnoses are unreliable, how the DSM-II described schizophrenia, the DSM-IV subtypes (paranoid, disorganized, catatonic, undifferentiated, residual), and a disagreement about whether schizophrenia is better called neurodevelopmental or neurodegenerative.

* Common mimics: substance-induced psychosis (including chronic methamphetamine use), PTSD and borderline personality, and the case for calling trauma-related experiences voice hearing, hypervigilance or overvalued ideas.

* More mimics and risk factors: autism, cluster A traits and other neurodevelopmental conditions, culture and religion, plus a generic case of a patient with autistic traits whose history only made sense after a hypomanic episode.

* Treatment questions: separate symptom domains, clozapine and psychosocial rehabilitation for negative and cognitive symptoms, how long to continue an antipsychotic after a first episode, and psychotic features in mood disorders.

* Gray zones such as very severe borderline personality, why outpatient psychosis is not usually an emergency, and a note that delusions and subtle signs are saved for a later episode.

Clinical takeaways

* Verify old diagnoses yourself. The hosts say a schizophrenia label from before the DSM-III era, and sometimes a recent one, should not be taken at face value.

* Do not blame substances automatically, or rule them out. A primary psychotic disorder can coexist with substance use, and a serious episode from a substance that rarely causes psychosis may point to underlying vulnerability.

* In trauma or personality presentations without clear disorganization or negative symptoms, one host holds back antipsychotics unless there is a true emergency, and reaches first for gabapentin, hydroxyzine, buspirone or propranolol.

* Assess what the voices mean to the patient and how much they impair function. Zero hallucinations is often not reachable without intolerable side effects, and negative and cognitive symptoms need more than a higher antipsychotic dose.

* When the diagnosis is unclear, use collateral and time, keep the patient engaged in monitoring, and discuss a placeholder diagnosis. One host recommends continuing an antipsychotic for six months to a year after an episode, then tapering with follow-up if the patient prefers.

* Outpatient psychosis is rarely an emergency, because patients cannot be made to take medication. Build the alliance and gather information before pushing a start.

Read the full transcript

The complete transcript of this episode is on psycho.farm: What is Psychosis? Look at the DSM, Common Mimics, and a Framework for the Differential.

Related episodes

* Psychosis: History, Delusions, Diagnosis, Theories, and Modern Care

* Detecting Subtle Signs of Psychosis: Assessment of Voices, Delusions, and Psychosis

* What Makes a Belief a Delusion? Delusions, Thought Disorder, the TALD Scale

For education only. Not medical advice.

In this episode, we outline the top 10 things clinicians need to know before prescribing clozapine. Aimed at psychiatrists and trainees, we cover when to use Clozaril. for treatment-resistant schizophrenia and highlight unique benefits like reducing suicidal behavior and aggression. We also discuss why this gold-standard treatment remains underused and review the monitoring protocols. Crucial safety considerations are addressed, including how to watch for neutropenia and constipation. Tune in for practical tips on clozapine titration, side effect management, and best practices to ensure safe and effective use of this life-changing medication.

Today we tackle a nerve-wracking topic for many clinicians: psychiatric disability assessments and paperwork. We break down everything from FMLA leave and short-term disability to Social Security benefits, explaining how to evaluate mental health impairments and fill out disability forms ethically. They discuss how to handle patient requests for time off work, balance treatment with recovery, and even touch on ADA accommodations like emotional support animals. Without the jargon, they share tips to avoid pitfalls and personal biases, helping you feel more confident in this tricky area. It’s a practical guide to navigating the gray areas of disability claims in mental health care.

What we cover

* Why disability work makes clinicians nervous, and why the first question is which rule set applies. The hosts criticize both sending everything to a forensic evaluator and signing everything requested.

* Programs: FMLA (up to 12 weeks of unpaid, job-protected leave at employers with 50 or more employees), employer short-term and long-term disability (policy specific), state disability insurance, and workfare-related forms.

* SSDI versus SSI (work history versus financial need), the shared requirement of an impairment lasting at least 12 months, and workers' compensation, which needs a diagnosable condition linked to a workplace exposure and timely reporting.

* A first approach to a request at intake: ask what type and what paperwork, schedule a dedicated visit, sometimes decline, and be wary of boilerplate attorney forms that ask for free expert opinions.

* The assessment: a DSM diagnosis with a timeline, then the four functional domains of the SSA Blue Book mental disorder listings (understand and apply information, interact with others, concentrate and keep pace, adapt and manage oneself), with the WHODAS as an aid.

* How long to grant leave, the downsides of disability for recovery and employment, and why ADA accommodations and emotional support animal letters can signal impairments that deserve treatment.

Clinical takeaways

* Most disability work is your usual assessment: diagnosis, timeline, impairments, and a stated link between them. You do not need to act as a forensic evaluator.

* It is acceptable to buy time. Do the assessment needed to form a reasonable opinion, and write nothing you would not be willing to testify to under oath.

* If you suspect exaggeration, one host prefers documenting the specific discrepancy (for example, a calm exam alongside maximal scale scores) over labeling malingering without formal training.

* Keep countertransference out in both directions: suspicion that a patient only wants money and sympathy toward a patient against a big employer both distort the assessment.

* Tie the length of leave to expected recovery and change the treatment plan, such as intensive outpatient care, medication changes, behavioral activation or therapy. Avoid open-ended leave, because work often stabilizes and gaps can hurt later employability.

* Treat accommodation and emotional support animal requests as a prompt to ask what the patient is avoiding or what the animal helps with, since the underlying anxiety may be a treatment target.

Read the full transcript

The complete transcript of this episode is on psycho.farm: Disability Claims 101 for Psychiatrists: Programs, Pitfalls, and Practical Steps.

Related episodes

* Handling Difficult Situations in Psychiatry: ADHD Evaluations, Benzo Requests, Disability Claims, and Involuntary Admissions

* How to Do a Psychiatric Intake | The Art and Science of the First Hour

* Lessons from Forensic Psychiatry: Insanity Defense, Subtle Patients and Culpability

For education only. Not medical advice.

Many adults who struggle with concentration, disorganization, or procrastination wonder if they have ADHD. But when is it ADHD, and how can you suss this out? In this episode, two psychiatrists explore a nuanced case of possible ADHD to demonstrate why diagnosis isn’t always straightforward. They discuss how personal history, childhood environment, mood swings, and even personality traits can all cloud the clinical picture. Listeners will learn how a comprehensive evaluation is done, what other conditions can mimic ADHD, and which practical strategies (like structured routines or therapy) can help improve focus. We emphasize careful assessment and a holistic approach to treating attention difficulties.

What we cover

* Why no clean line separates ADHD from normal variation: it is a clinical judgment with no fixed cutoff, each clinician sets a personal threshold, and a diagnosis is a map that simplifies the territory.

* A fictional composite case of a young adult with long-standing concentration and academic trouble, a critical home in adolescence, mood swings, anxious attachment, obsessive traits, cannabis use and relationship conflict.

* Reading the story as a whole first: onset after family disruption and trouble with identity, self-direction and intimacy (the DSM-5 alternative model for personality disorders), compared with typical histories of ADHD, mood disorder, and substance or trauma related inattention.

* The ranked differential for the case (personality and developmental issues, ADHD, substances, mood disorder) and the risk that calling ADHD the primary problem narrows attention and invites escalating stimulant doses.

* Technical confrontation as a diagnostic tool: asking why now, why no childhood treatment, and what changed recently, then following loose threads to gather information and show the patient their own mind.

* A role-played wrap-up and follow-up covering uncertainty, declining a stimulant while assessment continues, workbooks, scheduled work blocks, a request for medication, and non-stimulant options.

Clinical takeaways

* Ask why now, and pull threads that do not add up, such as why no childhood evaluation happened and why an earlier medication trial stopped.

* ADHD usually shows early, persistent problems across settings. A stepwise decline at an identifiable time points toward substances, trauma or head injury, and concentration problems that track with mood episodes and sleep point toward a mood disorder.

* Before prescribing for an undifferentiated adult, this host settles the history of mood episodes, trauma and personality, then uses a semi-structured interview such as the DIVA, collateral and school records instead of self-report scales.

* This host prescribes a stimulant on the first or second visit when evidence of a neurodevelopmental disorder is strong, and waits in uncertain cases, comparing it to not removing a gallbladder without certainty.

* Alongside assessment: scheduled work blocks with breaks, one small task per visit, a therapist or occupational therapist familiar with ADHD, and attention to leisure time. If about 60 to 70 percent sure of ADHD, this host goes straight to atomoxetine.

Read the full transcript

The complete transcript of this episode is on psycho.farm: How to Decide When ADHD Is Actually ADHD.

Related episodes

* ADHD Is Not the Only Diagnosis: Differential and Diagnostic Hierarchy

* ADHD Again, But Juicier: Unpacking Misdiagnosis, Medication Overuse, and Cultural Trends

* ADHD... Diagnosis, What is ADHD? Is ADHD real? Do I have ADHD? Is ADHD biological?

For education only. Not medical advice.

Dr. Catherine Eubanks, PhD joins us to unpack the therapeutic alliance in everyday practice: how to spot withdrawal and confrontation ruptures, why Bordin’s goals–tasks–bond still predicts outcomes, and how metacommunication jump starts repair. We translate research into concrete moves you can use in brief psychiatric visits, psychotherapy, and supervision. We discuss telehealth, boundaries, and measuring ruptures with the 3RS system. Clinicians, trainees, and curious listeners will leave with a clearer lens and usable language for repair that strengthens trust and improves care across settings.

Upcoming Workshop

Alliance Rupture Repair with Dr. J. Christopher Muran & Dr. Catherine EubanksWhen: Thursday, November 13 (1:00–4:00 PM EST)Where: Virtual via ZoomCost: $60 CE | $50 General | Students 50% off (code: STU)CEs: APA for psychologists; NYSED for LCAT, LCSW, and clinical psychologists

Description:A 3-hour transtheoretical workshop on recognizing and repairing alliance ruptures. Includes didactics, video analysis, and skills training to improve repair strategies and strengthen therapeutic effectiveness.

Register: https://www.eventbrite.com/e/alliance-rupture-repair-3-ces-tickets-1797546502979?aff=oddtdtcreator

Recommended Books & Videos

Therapist Performance Under Pressure: Negotiating Emotion, Difference, and Ruptureby Catherine Eubanks & J. Christopher Muranhttps://www.apa.org/pubs/books/therapist-performance-under-pressure

Rupture and Repair in Psychotherapy: A Critical Process for Changeedited by J. Christopher Muran, Catherine Eubanks, & Lisa Wallner Samstaghttps://www.apa.org/pubs/books/rupture-repair-psychotherapy

Video: Rupture and Repair in Psychotherapyhttps://www.apa.org/pubs/videos/rupture-repair-psychotherapy

Alliance-Focused Training: An Evidence-Based Guide to Negotiating Ruptures in Therapyby J. Christopher Muran, Catherine Eubanks, Lisa Wallner Samstag, & James Macdonaldhttps://www.apa.org/pubs/books/alliance-focused-traininga

Video: Using Alliance-Focused Traininghttps://www.apa.org/pubs/videos/using-alliance-focused-training

What we cover

* Bordin's three parts of the alliance (goals, tasks, bond), and why Dr. Eubanks uses 'rupture' broadly to include very subtle signs of not being on the same page, as a product of clashing needs for agency and for connection.

* Why ruptures are inevitable and informative, how defensiveness about them gets in the way, and the finding that unrepaired ruptures predict poor outcome while repaired ones go with good outcome, sometimes better than no reported ruptures.

* Withdrawal ruptures, the ones clinicians miss: minimal responses, brief retreating pauses, long silence, intellectualizing and abstraction, and masking feelings with a smile, rated from mild to strong on an observer-based coding measure.

* Confrontation ruptures (criticism, complaints, pressure) and the lack of a clear finding on which type is worse or harder to repair.

* Repair through metacommunication: naming what is happening between us, using 'we' language, disclosing your own reaction, owning your part, negotiating, or respecting a difference, with therapist anxiety as a common obstacle.

* Training and research: role plays in group supervision, the process versus content lens, staying with the here and now, measuring ruptures (including AI coding), and little difference so far between online and in-person therapy.

Clinical takeaways

* Noticing is half the work. Watch for sudden quiet, one-word answers, a pause that feels like pulling away, abstract talk when asked about feelings, a smile over painful material, and your own boredom or unease.

* Name the process with 'we' language, such as asking what is happening between you right now. In a brief medication visit, the hosts suggest naming the shared tension when the patient seems irritable.

* If you hesitate to raise it, you can say so aloud. Taking responsibility for your own part (rushing, being unclear) is a repair move.

* There is no script for repair. Invite a conversation, follow where it goes, and if you cannot agree, respect the difference.

* Dr. Eubanks finds that therapist anxiety is often what blocks existing empathic skills. With patients at lower personality functioning, being sincere and clear about your own limits is described as especially useful.

* When you keep arguing about the same content, such as whether to take a medication, step back and ask what is happening in the process. Practice hard conversations in role plays.

Read the full transcript

The complete transcript of this episode is on psycho.farm: Why the Therapeutic Alliance Matters in Psychiatry: Recognizing and Repairing Ruptures with Dr. Catherine Eubanks.

Related episodes

* Probably The Most Important Topic in Psychiatry: Therapeutic Alliance and Frame

* The Treatment Frame in Action: Lessons from ‘I Fell in Love with My Psychiatrist’

* Psychodynamic Technique and Therapeutic Intervention: Mirroring, Clarification, Confrontation, Interpretation

For education only. Not medical advice.

Why does it feel like everyone thinks they have ADHD lately? In this episode, two psychiatrists discuss the differential of ADHD. They explore how social media trends (like viral TikTok videos) are fueling ADHD self-diagnosis, and they emphasize the importance of careful evaluation. You’ll learn how to think through whether it’s ADHD vs. look-alike conditions such as depression, anxiety, trauma, OCD, sleep deprivation, or even just chronic stress and burnout. The doctors also talk about the burnout mental health providers are facing with so many people seeking ADHD meds, and they share their balanced approach to diagnosing and treating attention issues in an evidence-based way.

What we cover

* Why so many patients now think they have ADHD: an attention economy, choice overload and social media content, and the point that inattention is a symptom with many causes, like a cough.

* A differential for inattention in rough order of frequency (depression and adjustment disorder, anxiety, trauma, OCD, sleep problems, substances and medical conditions, eating disorders, work or school mismatch, personality, psychosis, learning disorders), which depends on each clinic's population.

* The diagnostic hierarchy: organic causes, substances, psychosis and bipolar disorders first, then depression, anxiety, trauma and eating disorders, then personality, with ADHD last, and why child psychiatrists place ADHD higher.

* Look-alikes in turn: concentration as a criterion in depression and PTSD, college-age OCD that resembles hyperfocus (with the Y-BOCS symptom checklist as a screen), bipolar disorders, sleep, substances, and late-onset stimulant-induced psychosis.

* Social and work mismatches that get medicalized, the principle of not taking yes for an answer, and personality functioning (self-direction and self-regulation) as a contributor, which can coexist with ADHD.

* Making the call in mild cases: why checklist answers are easy to produce, the need for a longitudinal history first, and the limited role of neuropsychological testing.

Clinical takeaways

* Ask what else explains inattention before accepting the label. A longitudinal life history, including recent moves, job changes and losses, helps separate a recent change from a lifelong neurodevelopmental pattern.

* If there is evidence for conditions higher on the hierarchy, treat those first. The hierarchy does not mean assuming the higher condition is present.

* For trauma, one host reads the relevant DSM criteria aloud with the patient so the symptoms can be compared with the criteria. Trauma screens can still miss dissociated events.

* Consider OCD in young adults who reread, over-edit or spend long hours on schoolwork, and screen for bipolar disorder, since stimulants can worsen it.

* Check sleep, caffeine, alcohol, supplements, other medications and eating, and consider a sleep specialist when a sleep disorder is suspected.

* There is no biomarker or diagnostic test for ADHD. Neuropsychological testing can show learning disorders and intellectual functioning, but results still need clinical correlation.

Read the full transcript

The complete transcript of this episode is on psycho.farm: ADHD Is Not the Only Diagnosis: Differential and Diagnostic Hierarchy.

Related episodes

* How to Decide When ADHD Is Actually ADHD

* ADHD... Diagnosis, What is ADHD? Is ADHD real? Do I have ADHD? Is ADHD biological?

* ADHD Again, But Juicier: Unpacking Misdiagnosis, Medication Overuse, and Cultural Trends

For education only. Not medical advice.

Is psychoanalysis still relevant in modern psychiatry and medication management? We unpack psychodynamic therapy, DSM-5 personality disorders, object relations, ego psychology, splitting, projective identification, attachment theory, and how solid psychiatric formulation improves outcomes in even medication management.

What we cover

* The opening question of whether psychoanalysis matters in an era of medication management, and why the terms psychoanalysis, psychoanalytic psychotherapy and psychodynamic therapy are used loosely, with the hosts disagreeing on whether they differ.

* A quick tour of the schools: Freud's drive theory, Anna Freud and ego psychology, object relations (Klein and Kernberg), Kohut's self psychology, relational approaches, and a brief word on Lacan, plus a debate on jargon versus plain language.

* Where psychoanalytic ideas sit in modern practice: the origin of talk therapy, the melancholic subtype of depression, CBT, and the idea of 'cargo cult' psychiatry when the DSM is taken at face value without its history.

* Personality organization on a neurotic, borderline and psychotic continuum, how this differs from psychosis as a biological syndrome, and the point that the DSM general personality criteria and alternative model in Section III are rarely read.

* Development and object relations: the unconscious, Erikson's stages, attachment theory, the paranoid-schizoid and depressive positions, the manic defense, splitting and projective identification.

* Id, ego and superego, language and naming as part of treatment, the loss of the old Axis I and Axis II split, and how psychological formulation helps even in medication management.

Clinical takeaways

* A psychological formulation can explain apparent treatment resistance. One host describes patients with ten or more medication trials where nobody had formulated how personality shaped the presentation.

* Read the general personality disorder criteria and the surrounding text, not only the checklists. Many patients are better described by traits and general personality dysfunction than by one named disorder.

* Expect splitting. A patient may make the clinician all good or all bad, and projective identification can pull clinicians into feeling what the patient expects from others. Recognizing it is the first step in managing it, and the hosts note that everyone splits under strain.

* Naming a condition can reorganize a patient's story and lower stress, but a label helps or harms depending on accuracy and fit. Patients often arrive with strong, culturally shaped ideas about what they have.

* Personality runs through every diagnosis. A diagnosis is a small slice of the person and meant to guide treatment, and personality does not come off like sunglasses when mood improves.

* In medication management, one host aims for a way of living that moves the patient toward what they want rather than permanent remission. The other host thinks that idea does not need psychoanalytic language.

Read the full transcript

The complete transcript of this episode is on psycho.farm: Is Psychoanalysis Still Relevant in Modern Psychiatry?.

Related episodes

* Nancy McWilliams on Psychoanalytic Diagnoses, Part 1: Personality, Defenses, Themes, Paranoid Personality

* Psychodynamic Technique and Therapeutic Intervention: Containment

* What Psychiatrists Get Wrong About Personality Disorders

For education only. Not medical advice.

In this episode, we dive into the complexities of the therapeutic alliance and the real challenges psychiatrists face in everyday practice. From patients insisting on ADHD diagnoses and stimulant prescriptions to those requesting Xanax, disability paperwork, or resisting involuntary admission, we role play common clinical encounters and discuss practical strategies for navigating them. Drawing on concepts like collaboration and alliance, we highlight tools for psychiatrists, therapists, and clinicians to manage difficult conversations without burning out.

What we cover

* Therapeutic alliance as purposeful collaboration (agreement on tasks and goals) plus an affect bond (mutual trust and respect), and an approach to difficult encounters: clarify your role, avoid challenging overvalued ideas head on, find common ground.

* A role play with a patient who insists on an ADHD diagnosis and stimulants although the history shows no developmental pattern, and the differential for inattention (substances, sleep, mood, anxiety, trauma, personality traits).

* A role play with a patient on a high dose of alprazolam who wants a month's supply: license risk, benzodiazepine withdrawal, the state prescription record, and a taper or detox plan.

* Disability paperwork: identifying the kind of disability requested, applying its rules, and judging what time off will do for the patient's long-term good.

* An involuntary admission role play with a patient who denies suicidality and demands discharge, the agent of treatment (patient, family or the law), and a side-by-side stance with psychotic patients.

* The help-seeking, help-rejecting patient from the hateful patient paper, why a stream of solutions backfires, and a role play built on listening and open questions.

Clinical takeaways

* Resentment toward a kind of patient, such as those asking for ADHD evaluations, shows in the room. The hosts suggest working it through outside the visit so the evaluation stays open.

* When the history does not support ADHD, one host explains that a diagnosis exists to guide evidence-based treatment, says none fits yet, names other possibilities, and offers to keep working together.

* For a benzodiazepine request, one host puts the clinician's license first: check for urgency, check the state controlled substance record, and send the patient to medically observed withdrawal if medical necessity cannot be established.

* Disability decisions start with the rules of that specific program. Both hosts want time off paired with a changed treatment plan, since work gives structure and long leave can worsen mood.

* In an involuntary admission, stay truthful: you cannot simply discharge, you owe an assessment of safety, and talking is the quickest route out. Arguing about dangerousness with an agitated patient does not help.

* With a help-rejecting patient, shift from giver to receiver by asking what they think would help, and hold off on new prescriptions unless the evidence is clear. Use these techniques as yourself.

Read the full transcript

The complete transcript of this episode is on psycho.farm: Handling Difficult Situations in Psychiatry: ADHD Evaluations, Benzo Requests, Disability Claims, and Involuntary Admissions.

Related episodes

* Disability Claims 101 for Psychiatrists: Programs, Pitfalls, and Practical Steps

* Involuntary Treatment & Agency, Thoughts and Feelings | Episode 19

* ADHD Is Not the Only Diagnosis: Differential and Diagnostic Hierarchy

For education only. Not medical advice.

In this episode we break down how to run a focused, humane, and evidence informed psychiatric intake. We start with setting the frame and role clarity, then show how to use a free narrative to map life course symptoms before moving into targeted history, DSM-5 criteria, and the mental status exam. Along the way we tackle common requests for ADHD or autism evaluations, the risks of checklist thinking, and when to pivot to structured tools. We close with communicating impressions, treatment planning, and next steps.

What we cover

* Why the intake is hard, especially when patients ask for an assessment for a named condition such as ADHD or autism, and why a yes or no criteria interview works like a self-questionnaire. We suggest dividing the available time into rough percentages in a set order.

* Setting the frame: clarifying your role and scope of practice, stating that the visit is a diagnostic interview and not a place for venting, warning the patient you will interrupt, and offering a way out of overwhelming topics.

* The first 20 percent of the interview: open narrative built around why now and the chief complaint, with empathic mirroring and clarification, and avoiding clinical jargon from patients or trainees.

* Drawing a timeline of symptoms and function across the patient's life, forming a differential from the major DSM chapters (about three leading categories), and treating a fragmented narrative as diagnostic information.

* The middle of the interview: focused history (psychiatric, medical, family, social, treatment, substance use) shaped to your patient population, then structured interviews to confirm a diagnosis, using non-leading questions.

* The last 20 to 30 percent: sharing impressions and a plan, explaining diagnostic terms plainly, checking for disagreement, saying so when information is insufficient, and scheduling a second visit.

Clinical takeaways

* DSM criteria are an incomplete description of a syndrome, not a diagnostic test. Take a traditional medical history (onset, duration, remissions, aggravating factors) and build a differential from it.

* Ask for a narrative before structured questions. Ask repeatedly what else bothers the patient, when it started, and what made this the time to come in.

* Picture the timeline of the person's life. Asking how many episodes someone has had can show a lot, especially in mood disorders.

* How a patient answers matters as much as yes or no. In an ADHD assessment, patients who readily give many concrete examples differ from those who simply agree.

* Track dysregulation while you interview, because it can look like freezing rather than agitation. Tailor your questions to the group you see, such as asking about school, work and housing when patients deny symptoms.

* Keep a template of the basic history questions in front of you, take notes openly, and pause to think. At the end, ask whether the patient agrees with your impression and recommendations.

Read the full transcript

The complete transcript of this episode is on psycho.farm: How to Do a Psychiatric Intake | The Art and Science of the First Hour.

Related episodes

* Psychiatric Technique for Diagnostic Interviewing and Therapy: 6 Mantras Every Clinician Should Know

* Assessment of Personality: Practical Assessment in a Short Timeframe

* How to Decide When ADHD Is Actually ADHD

For education only. Not medical advice.

Boundaries aren’t just rules in psychiatry… they’re part of the treatment itself. In this episode, we explore therapeutic ruptures, transference and countertransference, and how clear treatment frames protect patients, clinicians, and the therapeutic process. From handling “doorknob comments” to navigating burnout, we highlight the practical ways psychiatrists and therapists can use boundaries to strengthen care and reduce resentment.

What we cover

* Addressing ruptures, boundary crossings and frame violations early, with one host's own frame for medication management: starting and ending on time, rescheduling when too much of a visit is lost, and being explicit that medication management is not psychotherapy.

* Why firm boundaries are part of the treatment for patients who push them, how addressing lateness early prevents resentment and burnout, and the case for one uniform procedure for patient complaints.

* A discussion of reality and reality testing: reality as shared rather than private, asking patients how strongly they hold a belief, and why clinicians benefit from listening to many perspectives.

* Telling patients their diagnosis: we reject the idea that diagnoses are just for billing, discuss when disclosure might be withheld temporarily, and note that personality disorder is the diagnosis most often left unspoken.

* Case scenarios: a patient hugging the psychiatrist, a clinician mentioning a book a patient found helpful, doorknob comments about a special relationship, and a sexual dream about the psychiatrist, with the question of erotic transference.

* Reality testing in borderline-range patients, mentalization and early reflective listening as a developmental root, and why personality pathology calls for tighter boundaries.

Clinical takeaways

* A frame works best when it is the same for every patient you see. Practices that can be applied to everyone, such as a handshake or fist bump, are easier to hold than a hug.

* Say what the visit is. Tell patients whether it is medication management or psychotherapy, and that talking about recent stressors is not psychotherapy.

* When a patient is repeatedly late, ask about it instead of saying no worries. We find that this helps treatment and reduces resentment.

* For a doorknob comment such as a claim of a special relationship, protect the time but screen for anything urgent. Respond concretely and warmly, ask what the patient means, and raise it at the start of the next visit.

* A sexual dream about the clinician may signal erotic transference. Normalize such feelings and invite the patient to say if anything is interfering with treatment. We disagree on how much dream work belongs in medication management.

* Newer clinicians should follow rules strictly before bending them. If this kind of work is not something you can do responsibly, refer out.

Read the full transcript

The complete transcript of this episode is on psycho.farm: The Treatment Frame in Action: Lessons from ‘I Fell in Love with My Psychiatrist’.

Related episodes

* When Patients Fall in Love with their Psychiatrist: Sex, Boundaries, Frame, and Liability

* Probably The Most Important Topic in Psychiatry: Therapeutic Alliance and Frame

* Why the Therapeutic Alliance Matters in Psychiatry: Recognizing and Repairing Ruptures with Dr. Catherine Eubanks

For education only. Not medical advice.

In this episode, we examine the complex phenomenon of erotic transference in psychiatric care and the critical role of maintaining ethical boundaries. Using the therapeutic frame as our guide, we unpack how patients may develop romantic or sexual feelings toward their psychiatrist… especially during medication management… and why strong boundaries and reality testing are essential to safeguard the treatment process. Drawing on clinical experience and ethical principles, this episode offers clinicians strategies for addressing counter-transference, reinforcing the therapeutic alliance, and knowing when referral or supervision is necessary to protect both patient welfare and professional integrity.

What we cover

* Why the episode uses hypotheticals and role play, and how the urge to find fault with the clinician in a bad outcome can be a defense against thinking it could happen to us.

* Boundaries and frame: crossing versus violation, one host favoring clear boundaries that suit the clinician and are explained to the patient, the other favoring firm rules such as staying with Dr. and last name, plus a role play of a patient asking to use a first name.

* Asking about suicidal ideation and self-harm as standard care at every visit, without framing it as a personal interest or padding it with quips.

* Transference as inevitable (positive, negative and erotic), why it is harder to work with in monthly medication visits than in weekly therapy, and two things that can feed a patient's feelings: discussing your own achievements and shifting between warmth and coldness.

* Erotic transference in higher-functioning versus borderline-range patients (gradual and shame-laden versus rapid, fear-driven and boundary testing), the need for high containment, and a role play of a patient declaring romantic feelings.

* A hypothetical in which a patient with possible internal bleeding wants to finish the visit, with a role play of ending the session and sending the patient to emergency care.

Clinical takeaways

* Erotic transference is common and says nothing about diagnosis by itself. How the patient responds to the frame, and how the clinician responds, is more informative.

* When a patient declares romantic feelings, acknowledge them without reciprocating or colluding, restate that the relationship is medical, and state that sex or romance with a patient is never acceptable, including after treatment ends.

* One host would raise a transfer of care in the same visit if the patient cannot proceed professionally, and notes that other good clinicians differ.

* Avoid deep exploration of sexual fantasies in medication management. Doing something markedly different with one patient is a red flag to seek supervision or contact risk management.

* Physical safety comes first. If a patient reports a possible medical emergency, one host would stop the session, advise emergency care and repeat the recommendation if the patient refuses, and the hosts caution against improvising a medical assessment beyond your training.

Read the full transcript

The complete transcript of this episode is on psycho.farm: When Patients Fall in Love with their Psychiatrist: Sex, Boundaries, Frame, and Liability.

Related episodes

* The Treatment Frame in Action: Lessons from ‘I Fell in Love with My Psychiatrist’

* Probably The Most Important Topic in Psychiatry: Therapeutic Alliance and Frame

* Psychodynamic Technique and Therapeutic Intervention: Containment

For education only. Not medical advice.

In this fast‑paced Psychopharm podcast, we break down the OCD medication algorithm for obsessive compulsive disorder. You will hear about pushing SSRI doses, switching to Luvox or clomipramine, adding low‑dose antipsychotics, and glutamate modulators such as N‑acetylcysteine and ondansetron. The conversation also demystifies BrainsWay H7 deep TMS, explains realistic expectations for symptom reduction, and stresses that exposure response prevention remains the centerpiece of care. Helpful for psychiatrists, NPs and trainees who want clinical pearls without the fluff.

NAC: https://drive.google.com/file/d/1b7ZBeFDKAAwLhfzUo0Jv58jEL7B70l5r/view

What we cover

* General principles: treat for about a year, higher doses tend to work better, trials last about eight weeks, and symptoms fall by roughly 30 to 40 percent. A six to eight point Y-BOCS drop is a good result.

* Why exposure and response prevention comes first, with medication for severe symptoms or patient preference, and a short look at inference-based CBT for those who cannot do ERP.

* SSRI steps: sertraline or escitalopram first, paroxetine avoided for weight gain, fluvoxamine (Luvox) as the usual switch after one or two failures, and raising doses while tracking the Y-BOCS.

* Augmentation: Brainsway H7 deep TMS (cleared as an adjunct in adults, with symptom provocation before each session), low-dose aripiprazole or risperidone, and the caution that clozapine and olanzapine can worsen obsessions and compulsions.

* Clomipramine, the clomipramine plus fluvoxamine combination (CYP1A2 rationale, serotonin toxicity risk), glutamatergic add-ons (lamotrigine, N-acetylcysteine, memantine, ondansetron, buspirone), exercise, and implants for the most disabled.

* Comorbidity: OCD that may reflect psychosis, bipolar disorder or autism, avoiding SSRIs where possible in bipolar disorder, and telling OCD from personality-driven obsessionality.

Clinical takeaways

* Use medication to make therapy possible. Score the Y-BOCS each visit and expect some movement within four to eight weeks at each dose step.

* Check which TMS is offered. The clearance is specific to the H7 coil and protocol, so a clinic using older equipment may not deliver it.

* Antipsychotic augmentation is common, but we favor lower-harm options first and monitor for new or worsening compulsions.

* N-acetylcysteine is usually targeted at 2.4 to 3 grams a day based on OCD studies. One steady brand is suggested because quality varies; taste, smell and GI upset can limit tolerance.

* In bipolar disorder with OCD symptoms, treat both poles first, since the OCD often eases. If a serotonergic drug is still needed, use a low dose on a stabilized mood.

* Check the obsessions. Genuine OCD has intrusive obsessions with unsatisfying compulsions, often at least an hour a day. Personality-driven obsessionality tends to feel satisfying or to communicate distress.

Read the full transcript

The complete transcript of this episode is on psycho.farm: Practical OCD Psychopharmacology: Evidence‑Based (& Non Evidence-Based) Medication Approach.

Related episodes

* What Is OCD? How to Understand It, Recognize It, and Treat It

* TMS for OCD: Effectiveness, Protocols, and Patient Selection

* Psychiatrist's Guide to Anxiety Medications: First Line to Last Resort

For education only. Not medical advice.

In the pilot episode of You Tell Me, the hosts dive into the controversial question: “What’s the harm in more widespread stimulant use?” They explore Silicon Valley’s productivity culture, stimulant risks, and the ethical dilemma of turning psychiatry into a tool for optimization. From there, the conversation shifts into a lighter segment on the stereotypes of medical specialties. The episode ends with a candid discussion on trauma, codependency, and why inpatient psychiatry often misses the mark.

This off-the-cuff episode blends unfiltered opinions with occasional psychiatric insights… approachable for clinicians, medical students, or anyone curious about the culture of modern psychiatry.

What we cover

* A reader question asking what harm there is in wider stimulant use for people without ADHD, with the hosts listing psychosis, mania, insomnia, appetite and weight loss, blood pressure and cardiovascular effects, and habit-forming potential.

* Optimization culture: psychiatry framed as treating deficits instead of raising productivity, escalating doses used to cover burnout, and trauma, bipolar and personality disorders hidden behind symptom control.

* A lighter segment on a forum thread about aspiring surgeons who became psychiatrists, the hosts' own surgical rotation stories, psychotherapy as a form of surgery, professions drifting toward one personality type, specialty stereotypes, and the old split between inpatient and outpatient psychiatry.

* A trainee's question about why ask about past trauma: one host says it rarely changes immediate inpatient or emergency decisions, the other gives three reasons to ask routinely, followed by shared criticism of inpatient diagnosis and discharge documentation.

* A reader's question about what codependency is neurobiologically, which the hosts treat as the wrong lens, favoring attachment and psychoanalytic theory, with Panksepp suggested for the biology of emotion.

Clinical takeaways

* Treat a concentration complaint as information. It may reflect a poor job fit or an untreated trauma, mood or personality problem, and raising the stimulant dose covers it without addressing it.

* Separate the energy lift or euphoria from stimulants from a clinical treatment effect for ADHD. One host notes diminishing returns at higher doses and prefers low and slow dosing.

* Using a chemical to rescue or push yourself, or adding alcohol at night to wind down from a stimulant, is described as a warning sign of a downward spiral.

* Ask about trauma in a standard way without forcing disclosure. One host argues that avoidance is part of trauma psychopathology and that the framing signals whether the subject is safe to discuss.

* Inpatient discharge summaries should state the diagnosis and what changed, so the next clinician can continue care.

Read the full transcript

The complete transcript of this episode is on psycho.farm: You Tell Me | Adderall for All?, Surgeons Gone Shrink, Codependency isn't Neurobiological.

Related episodes

* ADHD Again, But Juicier: Unpacking Misdiagnosis, Medication Overuse, and Cultural Trends

* Affective Neuroscience: Understanding Patients Beyond DSM Diagnoses

* Handling Difficult Situations in Psychiatry: ADHD Evaluations, Benzo Requests, Disability Claims, and Involuntary Admissions

For education only. Not medical advice.

Join us in this podcast episode focused on Obsessive Compulsive Disorder, where we explore the DSM‑5 criteria, differentiate OCD vs generalized anxiety, and discuss the neurobiological roots of compulsive behavior. We cover practical guidance on exposure response prevention (ERP), using the Yale‑Brown Obsessive Compulsive Scale as a screener, and outline medication strategies like high‑dose SSRIs to support psychological treatment. Ideal for clinicians and anyone seeking to understand or treat OCD effectively.

What we cover

* Why OCD is both underdiagnosed and overdiagnosed, including the long delay (about seven years) from first mental health contact to diagnosis, and how prior expectations let it hide in plain sight.

* The DSM-5 criteria with the key point that obsessions are met with attempts to suppress or neutralize them, the one-hour-a-day threshold, the insight and tic specifiers, and a debate over the dropped DSM-IV wording about excessive worries.

* OCD versus generalized anxiety and ordinary obsessionality, OCD proper (about 1 to 2 percent of people) versus OCD-type symptoms, and the hosts' different views of how biological and psychological factors, repetition and relief drive it.

* A five-step loop: trigger, intrusive thought, catastrophic appraisal, distress, and a compulsion that is reinforced by relief.

* How to recognize it: listening for intolerance of uncertainty, using the Yale-Brown Obsessive Compulsive Scale as a screener that prompts a narrative, and judging impairment, including what families report.

* Treatment: exposure and response prevention (ERP) and its mechanics, adapting it in medication visits, setting expectations about setbacks, and SSRI dosing and other medication options.

Clinical takeaways

* Direct diagnostic questions are low yield because patients with OCD may not call their behavior obsessions or compulsions. Listen instead for needing to be certain, repeated checking, and repetition without satisfaction, especially with anxiety or poor concentration.

* The Yale-Brown checklist is a prompt, not a diagnosis. Ask about what the patient does, how long it takes and what they fear would happen otherwise. The severity score is more useful for tracking treatment.

* Some patients feel no distress while families are burdened, so ask about daily and interpersonal functioning and what relatives see. Where the cutoff lies is a judgment call.

* ERP is first line. If a patient says it is not working, check what is actually being done: a new compulsion can replace the old one, and breathing, reframing or reassurance seeking can work against it.

* Tell patients that the aim is tolerating uncertainty rather than removing thoughts, that exposure is uncomfortable, and that OCD is chronic and setbacks are expected.

* The hosts describe higher-than-usual SSRI doses, with an ECG, as warranted in moderate to severe OCD. The medication reduces symptoms and may help patients engage in ERP, but evidence beyond SSRIs is thin.

Read the full transcript

The complete transcript of this episode is on psycho.farm: What Is OCD? How to Understand It, Recognize It, and Treat It.

Related episodes

* Practical OCD Psychopharmacology: Evidence‑Based (& Non Evidence-Based) Medication Approach

* TMS for OCD: Effectiveness, Protocols, and Patient Selection

* Understanding Anxiety, GAD, and Treatments of Anxiety

For education only. Not medical advice.

We unpack the anxiety medication algorithm, moving from first-line SSRI picks like Sertraline and Escitalopram to augmentation with buspirone, gabapentin and lavender. CBT, mindfulness and evidence-based psychopharmacology weave throughout the podcast, so clinicians prescribe appropriately and with the right psychoeducation.

What we cover

* Framing: one host doubts that many named DSM anxiety disorders are separate conditions and thinks the GAD criteria are loose, and both agree medication should support psychological treatment, not replace it. Mild anxiety may need no treatment.

* First-line SSRIs: why the hosts lean toward sertraline over escitalopram (more consistent metabolism, easier dose steps, fewer interactions), a typical starting schedule, and what to do after no response or a partial response.

* Why both hosts avoid as-needed medication for anxiety, and how to prepare anxious patients for early side effects and a possible nocebo reaction.

* Augmentation and alternatives: buspirone, gabapentin, pregabalin, hydroxyzine, propranolol, SNRIs, bupropion, mirtazapine, vilazodone, vortioxetine, tricyclics and MAOIs, with the hosts' differing views on bupropion.

* Benzodiazepines: the risks, why they are a late option, the risks of tapering long-term users, and how to answer a patient who asks for one. Antipsychotic augmentation is limited to comorbid conditions.

* Lavender (Silexan) as an over-the-counter option, mindfulness and psychotherapy as core treatments, and checking caffeine and other substances first.

Clinical takeaways

* Assess severity first. Therapy before medication makes sense when the patient can engage; medication first is reasonable when symptoms are too severe for therapy or the patient prefers it.

* Tell patients medication is not meant to remove anxiety entirely. One host tells anxious patients that early side effects peak in the first days and settle over about a week, and discusses risks again even with returning patients.

* Both hosts avoid PRN use for anxiety, arguing it makes a medication the safety signal and teaches reliance on something external. Propranolol for a scheduled, predictable performance situation is the exception (one host mentions 20 to 40 mg about an hour before), with caution in asthma or lung disease.

* Gabapentin for anxiety is often under-dosed, but absorption saturates at larger single doses, so one host splits the dose rather than giving a very large one. The hosts treat pregabalin as a refractory-case option because of dependence risk.

* If a benzodiazepine is used, one host prefers a scheduled long-acting agent over a short-acting PRN, after a clear risk discussion. Stopping long-standing benzodiazepines carries its own risks, so the hosts weigh the individual patient.

* Titrate to function rather than to subjective anxiety. Watch for agitation on SSRIs or bupropion, and treat a request for a benzodiazepine as an innocent question to be answered calmly.

Read the full transcript

The complete transcript of this episode is on psycho.farm: Psychiatrist's Guide to Anxiety Medications: First Line to Last Resort.

Related episodes

* Understanding Anxiety, GAD, and Treatments of Anxiety

* Anxiety Medications Tier List: The Best and Worst Treatments for GAD

* Treating Depression: Practical Tips & Pearls for Anti-Depressant Medications

For education only. Not medical advice.

In this episode, we explore anxiety not as a disease in itself, but as a critical signal from your mind and body. We discuss how this signal can point to deeper issues like hidden emotions or relational trauma, and why common diagnoses like GAD (Generalized Anxiety Disorder) often miss the true source of the problem. We also cover the fundamental brain science of fear, the key differences between anxiety, panic, and worry, and introduce five different treatment models designed to help you find and resolve the root cause.

What we cover

* The argument that anxiety is mostly a signal of other problems (underlying psychopathology, hidden emotions, conflicts or relational trauma) rather than a disease in itself, and why GAD is applied too broadly.

* A simple brain model: the amygdala as a smoke detector and the prefrontal cortex as a watchtower, plus the Yerkes-Dodson curve linking arousal to performance.

* Definitions of fear (immediate threat), anxiety (diffuse and future-focused), worry (the cognitive part) and panic (an abrupt wave of fear), and the difference between trait and state anxiety.

* The DSM anxiety disorders (GAD, panic disorder, specific phobia, agoraphobia, social anxiety, separation anxiety), why PTSD and OCD left the chapter, and the hosts' view that anxiety is not itself a primary emotion.

* Five treatment models (biological, cognitive, exposure, motivational, hidden emotion) and one host's four clinical groups: GAD proper, avoidance loops such as panic disorder and agoraphobia, specific fears, and developmental-relational anxiety.

* Treatment by group: exposure and cognitive work, psychoeducation with feedback loops and mindfulness for panic, an emotion wheel and psychotherapy for relational anxiety, and a case where an anxiety complaint hid trauma and an unsafe home.

Clinical takeaways

* Treat the diagnosis behind the anxiety, not the symptom. Before choosing a medication, consider untreated bipolar disorder, depression with anxious distress, paranoia, PTSD and OCD as sources.

* A true panic attack is a spike lasting minutes, 10 to 20 at most. Patients often describe hours because distress lingers afterward, so ask for detail.

* The hosts differ on GAD. One reserves it for long-standing, early-onset worry with high trait neuroticism and no better explanation; the other notes that the DSM criteria rest on duration and impairment, which many patients meet.

* For panic disorder, explain that avoiding panic feeds it. Drawing the feedback loop of thoughts, arousal and more thoughts with your hands helps patients accept the exposure work.

* For GAD proper, one host starts with motivational work and cognitive therapy and the other leans toward SSRIs plus CBT and exposure. Both say medication alone should not end treatment.

* Teach mindfulness as a short, regular practice done when not distressed and for its own sake. Used to escape fear it becomes another avoidance, and distress during practice calls for supervised teaching.

Read the full transcript

The complete transcript of this episode is on psycho.farm: Understanding Anxiety, GAD, and Treatments of Anxiety.

Related episodes

* Psychiatrist's Guide to Anxiety Medications: First Line to Last Resort

* Anxiety Medications Tier List: The Best and Worst Treatments for GAD

* Mindfulness in Psychiatry: How to Teach It as a Clinical Treatment Skill

For education only. Not medical advice.

This episode looks at the practical assessment of personality. We explore the nuances of psychiatric diagnosis, moving beyond simplistic heuristics with a focus on the DSM-5's Alternative Model for Personality Disorders. Learn about assessing self-functioning (identity, self-direction) and interpersonal functioning, using clinical interviewing, psychosocial history, and even your countertransference as vital tools for a more comprehensive understanding of personality pathology in busy clinical settings.

What we cover

* Why personality disorders are often diagnosed from vague heuristics, countertransference alone, or a single feature such as recurrent self-harm or arrests, which leads some clinicians to ignore personality or assume medications will not help.

* The case for combining what is seen in the visit with the history over time, using a two-step approach that begins with sensitive signs and moves to confirmatory assessment, much like screening before confirmatory testing.

* Using the interview itself as data: the mental status, how the patient relates to the clinician, and the clinician's own reactions, with the caution that none of these is specific and that the skill takes years to build.

* The four elements of personality functioning in the DSM-5 alternative model (identity, self-direction, empathy, intimacy) and the history that maps onto each: work and school, legal trouble, substance use, relationships and family.

* Confirmatory options: SCID-style narrative questions for clear cases, STIPO-R questions for subtle ones, the Level of Personality Functioning Scale, and optional testing such as the MMPI, PAI and PID-5.

* A reading of level 1 (some impairment) and level 3 (severe impairment) from the scale, plus defenses to listen for: paranoia, idealization and devaluation, black and white thinking, and externalization.

Clinical takeaways

* A personality diagnosis from a short assessment carries lower certainty than one built over repeated visits, because the diagnosis is only as good as the database behind it.

* Judge personality functioning after you understand the onset and history of other psychiatric conditions, and look for patterns that are pervasive and stable rather than one crime or one career change.

* Ask for narratives instead of yes or no answers, for example about extreme ups and downs in close relationships followed by 'tell me more'. This depends on a trusting alliance and a non-punitive tone.

* Listen for discrepancies, such as a relationship described as perfect alongside repeated betrayal. Defenses often become clear only in reflection after the visit, so name your own reaction and compare it across patients.

* Interview patients with ordinary functioning to build a baseline, and ask what happened to the patient in development. One host stresses that the purpose is choosing between psychotherapy, medication or both, not punishing the patient.

Read the full transcript

The complete transcript of this episode is on psycho.farm: Assessment of Personality: Practical Assessment in a Short Timeframe.

Related episodes

* What Psychiatrists Get Wrong About Personality Disorders

* Healthy Personality Traits, Trauma vs. Personality, and Why Trauma Doesn’t Explain It All

* CPTSD vs BPD: How to Think About the Difference and What to Do About It

For education only. Not medical advice.

This episode delves into Good Psychiatric Management (GPM), a practical framework developed by John Gunderson for treating Borderline Personality Disorder (BPD), though its principles offer broad utility across diagnoses. The hosts discuss the importance of integration, managing expectations (both patient and provider), and robust psychoeducation regarding BPD's features, heritability, and treatment course. Key GPM tenets are explored, including focusing on life outside therapy (work/relationships), the adjunctive role of medication, fostering accountability, and the significance of the therapeutic relationship itself as part of the treatment.

What we cover

* Good Psychiatric Management (GPM), John Gunderson's approach built for borderline personality disorder, and why the hosts use its principles with almost every diagnosis in medication visits. The manual is short and, in their view, undertaught.

* Why borderline personality disorder is treatable, how clinician reactions drive stigma, why the natural history tends toward improvement, and why the hosts still want weekly psychotherapy for moderate to severe cases, with split treatment as a common arrangement.

* How the hosts conceptualize the condition: GPM's interpersonal core (idealization and devaluation, fear of abandonment), emotion shifts tied to interpersonal events, unstable identity and emptiness, self-harm and impulsivity, brief paranoid ideas, plus Kernberg's personality organization and the DSM-5 Section III model.

* Psychoeducation: heritability and development, framing symptoms such as poor concentration as secondary to relationship problems, communicating confidence in the diagnosis, and the cycle of an idealized relationship that ends in withdrawal and devaluation.

* Goals and advice-giving: why the primary goal is a life with work and relationships rather than symptom counts, the 'Dutch uncle' idea, and a forensic rule for what advice a clinician should give.

* Medications as adjunctive (SSRIs, mood stabilizers, antipsychotics), checking for comorbid conditions, GPM's eight principles, accountability as agency, and clinician countertransference.

Clinical takeaways

* Tell patients what a medication can and cannot do. Presenting it as a fix for a secondary symptom, not the core problem, avoids early idealization and later disappointment.

* Keep assessing for other conditions such as PTSD, using clear criteria. One host keeps medications minimal and low in side effects, and says the strongest effect comes from a stable therapeutic relationship rather than any drug.

* Place symptoms in their interpersonal context. Concentration problems driven by fear of losing a relationship are unlikely to respond to an antidepressant alone.

* State your confidence in the diagnosis and your reasons rather than calling it just one opinion. Both hosts say patients usually feel understood and less alone.

* Set primary goals around work and relationships, with symptoms and self-harm as secondary goals. Use group, family or individual therapy alongside, and resist rescue fantasies.

* Hold accountability and the frame as part of treatment, and watch your own reactions. A clinician who expects the treatment to fail can make it more likely.

Read the full transcript

The complete transcript of this episode is on psycho.farm: Treating Borderline Personality Effectively aka How To Be A Good Psychiatrist Through GPM.

Related episodes

* Understanding Borderline Personality Disorder with Dr. Mark L. Ruffalo

* CPTSD vs BPD: How to Think About the Difference and What to Do About It

* Assessment of Personality: Practical Assessment in a Short Timeframe

For education only. Not medical advice.

Dive deep into the practicalities of psychiatric medication management for PTSD in this clinical discussion. We explore the often limited evidence base and the necessity of off-label prescribing, focusing on strategies for stabilization, safety, and trust… the first stage of trauma treatment. Learn about experience-based approaches using SSRIs like sertraline, sleep aids such as trazodone and gabapentin, the cautious use of antipsychotics, and why benzodiazepines are discouraged. The conversation also touches on managing sleep disturbances and dissociation, situating medication as a supportive tool alongside essential psychotherapy and lifestyle changes, guided by principles like Pierre Janet's three-stage model.

What we cover

* Treatment goals in PTSD (safety, fewer intrusive symptoms, less hyperarousal and avoidance, comorbidity, functioning), and the framing that medication supports stabilization so trauma-focused psychotherapy can work.

* The thin evidence base: only sertraline and paroxetine are FDA approved, the mainstream algorithm (SSRI, a second SSRI, a second-generation antipsychotic, prazosin for nightmares), why benzodiazepines are avoided, and one host's objection to the algorithm.

* One host's sleep-first approach: trazodone, gabapentin or hydroxyzine, mirtazapine in some patients, avoiding diphenhydramine, with prazosin, clonidine or propranolol as alternatives.

* When to add an antipsychotic: a true comorbid psychotic or bipolar-type mood episode, versus trauma-related voices and apparent mania that may reflect dissociation and severe hypervigilance.

* Psychoeducation on avoidance and fear extinction, a predictive-coding view of PTSD, advice on dissociation and active grounding, and Pierre Janet's three stages: safety and stabilization, trauma processing, integration.

* The treatment frame in medication visits: clear expectations, regularity, keeping promises, leaving trauma processing to a therapist, and motivational interviewing for patients who decline therapy.

Clinical takeaways

* Tell patients that medication can reduce symptoms and improve sleep but does not erase the trauma. The hosts differ on whether it is optional: one treats it as an alternative for patients not ready for therapy, the other as important in moderate to severe cases.

* Keep a low threshold to treat sleep, and still push the SSRI to an adequate dose, since patients who like the sleep agent may stop there.

* Avoid benzodiazepines: they offer no clear benefit, may worsen PTSD and impair learning in exposure therapy.

* Before adding an antipsychotic for voices or days without sleep, one host looks for a true comorbid mood episode and often finds sleep support enough. The target is voices that no longer bother the patient, not zero voices.

* Mirtazapine can be heavily sedating, so take next-day sedation seriously. If trazodone causes agitation, switch rather than push through.

* In medication visits, gather only the data needed for prescribing, avoid drawing out trauma memories, and tell patients a trauma therapist is the place for that work. For dissociation, advise against fighting it and teach active grounding.

Read the full transcript

The complete transcript of this episode is on psycho.farm: PTSD Medications: Integrating Pharmacotherapy, Therapy, and the Treatment Frame | Episode 22.

Related episodes

* Understanding Trauma and PTSD, Diagnosis and Dissociation | Episode 21

* Trauma and PTSD: How the DSM Criteria Actually Help Us Understand What’s Going On

* CPTSD vs BPD: How to Think About the Difference and What to Do About It

For education only. Not medical advice.

Join us for an in-depth exploration of trauma and Post-Traumatic Stress Disorder (PTSD). This episode moves beyond common language to establish a clinical definition of trauma, detailing the DSM-5 criteria required for a PTSD diagnosis. The hosts break down the core PTSD symptom clusters – intrusion, avoidance, negative alterations in cognitions/mood, and arousal/reactivity – providing clear examples like flashbacks, hypervigilance, and negative self-beliefs. They delve into the concept of dissociation, its role in trauma, and the challenges it presents in assessment. Listeners will gain crucial insights into the diagnostic process, common misdiagnoses (like mistaking PTSD for depression), the vital importance of earning therapeutic trust, and effective interviewing techniques for sensitive topics, ultimately highlighting why accurate identification is key to recovery.

What we cover

* Everyday and clinical meanings of trauma: big T versus little t (including emotional abuse and adverse childhood experiences), and the four DSM-5 Criterion A routes of exposure, from direct experience to repeated exposure through work media.

* Whether the Criterion A threat has to be objective, plus unusual cases: a threat that arises from a delusion or hallucination, and PTSD in someone who committed violence.

* The PTSD syndrome taken criterion by criterion: intrusion, avoidance, negative changes in beliefs and mood (self-blame, shame, mixed feelings toward an abuser who was also a caregiver) and hyperarousal, with one host comparing persistent PTSD to the fear and avoidance seen in panic disorder.

* Dissociation as a separation of parts of the mind that normally connect, how it disrupts memory and the telling of a trauma story, subtle freezing in the interview, and the caution against suggesting memories to a patient.

* Duration, the timeline from trauma to symptoms, acute stress disorder in the first month, and the differential: depression, mania, anxiety, neurodevelopmental and neurocognitive disorders, and psychosis with voices.

* Psychotherapy emphasis (CBT, psychodynamic, narrative exposure therapy for complex trauma), community and faith-based support, earning trust, and pacing a diagnostic interview so the patient is not overwhelmed.

Clinical takeaways

* Diagnose PTSD by going through the criteria rather than pairing a trauma history with fear or mood symptoms. The symptoms must start or persist after the trauma and last more than a month.

* PTSD is often misdiagnosed as depression. One host's mental status pearl: patients may say they are depressed yet stay more mood-reactive in the room than someone with a severe, slowed depression. It is not fully reliable.

* A patient may be unable to report a recent trauma even after a formal screen. Where function declines without explanation, ask what was happening at that time instead of suggesting a trauma.

* Voices can be flashbacks or dissociative experiences, so consider PTSD before assuming a psychotic disorder. Severe agitation and sleep loss can also look like mania.

* In a diagnostic interview, ask for brief facts (what happened and when), watch the patient's distress, and offer breaks. If irritation appears, name it and hand control back. The aim is a diagnosis, not trauma therapy.

* After early trauma, trust has to be earned through a steady frame. The hosts also note that most people exposed to a Criterion A event do not develop PTSD, that trauma is over-referenced while PTSD is under-identified, and that not every problem is trauma.

Read the full transcript

The complete transcript of this episode is on psycho.farm: Understanding Trauma and PTSD, Diagnosis and Dissociation | Episode 21.

Related episodes

* Trauma and PTSD: How the DSM Criteria Actually Help Us Understand What’s Going On

* PTSD Medications: Integrating Pharmacotherapy, Therapy, and the Treatment Frame | Episode 22

* CPTSD vs BPD: How to Think About the Difference and What to Do About It

For education only. Not medical advice.

This conversation explores key aspects of forensic psychiatry, including the insanity defense, dissimulating patients, and how clinical practice intersects with legal systems. It highlights the importance of open-ended dialogue, nuanced diagnosis, and maintaining empathy without succumbing to cynicism.

What we cover

* What forensic psychiatry is (psychiatric expertise applied to legal questions, not correctional psychiatry) and the ideal of the independent, neutral expert, which one host argues also improves clinical work.

* Concerns about subjective diagnosis and shifting diagnostic trends in legal settings, how the adversarial system checks weak opinions, and why evaluators differ more in skill and resistance to pressure than in being hired guns.

* The insanity defense: tests of understanding the nature of the act or its wrongfulness, the requirement of a mental illness, the traditional exclusion of antisocial personality disorder, its rarity, and questions of culpability when medication is stopped.

* Competency to stand trial evaluations as routine criminal forensic work, and what they teach: access to subtle patients who rarely reach clinics, including people who hide illness.

* Interview technique for patients who dissimulate: long, open conversation unrelated to symptom lists, a psychosocial timeline, a story that makes sense, and returning to primary sources.

* The uncanny feeling some clinicians report with acute psychosis, countertransference as data, learning the mental status exam by comparing patients, and avoiding a cynical stance toward malingering.

Clinical takeaways

* Aim to make every clinical opinion intelligible to a reasonable layperson: lay out the facts and show how they lead to the conclusion.

* With a patient who denies symptoms but behaves oddly, begin with open questions about life and experience. One host holds back structured and DSM questions for roughly the first fifth of an interview.

* Ask what an experience was like for the patient and request concrete detail. Important material tends to emerge when the topic matters to the patient, not when a checklist is applied.

* Build a timeline of school, work gaps, the longest job and relationships. Illness trajectory and personality functioning often show more than criteria questions, and the interview is not done until the story makes sense.

* Observe expression, eye contact and social cues, and compare patients across diagnoses. Patients with melancholic depression tend to present differently from those whose depression stems from trauma or personality.

* Be cautious about calling malingering. The hosts say it is rare in many clinical settings and that a cynical, gotcha attitude is a trap.

Read the full transcript

The complete transcript of this episode is on psycho.farm: Lessons from Forensic Psychiatry: Insanity Defense, Subtle Patients and Culpability.

Related episodes

* Involuntary Treatment & Agency, Thoughts and Feelings | Episode 19

* Lindsay Clancy Trial: A Forensic Psychiatrist Explains Psychosis, Malingering, & the Insanity Defense

* Lindsay Clancy Case: Biggest Misconceptions After the Mistrial Explained by a Forensic Psychiatrist

For education only. Not medical advice.

Join us in a conversation about involuntary commitment, and the legal framework behind psychiatric treatment. We discuss real-world scenarios, share insights into how clinicians juggle patient autonomy versus societal protection. Whether you are new to the field or a seasoned professional, this episode offers valuable perspectives on balancing ethical duties, legal obligations, and patient care.

What we cover

* How a planned talk on forensic psychiatry became a discussion of involuntary commitment, with forensic psychiatry defined as applying psychiatric expertise to legal questions rather than working in corrections.

* The idea of multiple agents of treatment: the patient, the state, parents, schools or nursing homes, and the split agency inside a single patient. How naming the agents helps with frustration and with building an alliance.

* How commitment works in practice: the rules differ by state, danger to self or others is interpreted by courts, mental illness is defined by law (personality disorders traditionally excluded), and two questions: is this a change from baseline, and is it treatable by psychiatry.

* A worked case of methamphetamine intoxication with violent threats: the differential beyond the obvious, why an interested family's report is not enough, observation, warnings, and the duty-to-warn and liability questions.

* Systems pressures: too few inpatient beds, triage when medical need is equal, and what good documentation looks like.

* Assessing an uncooperative patient, using behavior, collateral and old records, then a case of a patient brought in after a suicidal text who denies it, with ways to get collateral and why a personality diagnosis does not end a risk assessment.

Clinical takeaways

* Be clear about who wants the treatment to happen. In an involuntary setting you serve rules set by society as well as the patient, and saying so openly can reduce confusion and help the alliance.

* Learn your own jurisdiction's commitment statute and how it defines dangerousness and mental illness. The host's rule of thumb: a mental illness whose symptoms make serious physical harm likely without treatment.

* Ask whether the presentation is a change from baseline and whether psychiatric treatment can address it. The host argues substance-induced states fit this, while stable antisocial traits do not.

* An assessment is more than the patient's statements. Use behavior on the unit, collateral and records, observe over days, and keep asking 'why' to get detail. When a patient refuses to allow contact, explain what you need to know and why.

* In many places you can gather information from family without disclosing anything. Emergency exceptions and other limits vary, so check local law and risk management.

* Do not let a personality label end a risk assessment, since those groups carry real suicide risk. The host says following the standard of care and recording your reasoning matters more than being right.

Read the full transcript

The complete transcript of this episode is on psycho.farm: Involuntary Treatment & Agency, Thoughts and Feelings | Episode 19.

Related episodes

* Lessons from Forensic Psychiatry: Insanity Defense, Subtle Patients and Culpability

* Suicide Risk Assessment: Acute vs Chronic Risk, Formulation, and Suicidal Ideation Types

* Lindsay Clancy Trial: A Forensic Psychiatrist Explains Psychosis, Malingering, & the Insanity Defense

For education only. Not medical advice.