Psychiatry Boot Camp

Six Critical Suggestions for DSM-6 with Dr. Awais Aftab

Mon, 20 Apr 2026 09:00:00 -0000

In this second part of a special double feature, Dr. Awais Aftab, MD, Clinical Associate Professor at Case Western Reserve University, presents a rigorous framework for the next iteration of the Diagnostic and Statistical Manual of Mental Disorders.

Dr. Aftab details six specific structural reforms for the DSM-6, beginning with a conceptual clarification of "mental disorder" to distinguish between biological dysfunction and socio-cultural atypicality. The discussion challenges the arbitrary nature of current diagnostic thresholds and the "equalizing" effect of the manual that obscures the empirical weight of different conditions.

Dr. Aftab advocates for the inclusion of the Hierarchical Taxonomy of Psychopathology (HiTOP) as an alternative dimensional model and calls for radical transparency regarding pharmaceutical industry ties within the APA task forces. This episode serves as a high-level roadmap for clinicians and researchers seeking a more scientifically valid and clinically honest diagnostic system.

Takeaways:

Conceptual Precision: The DSM must explicitly define "dysfunction" to prevent muddled debates about whether psychiatry is medicalizing normal suffering or identifying biological breakdowns.
Empirical Indexing: All diagnoses should be accompanied by an indicator of their empirical validation to avoid treating disparate conditions, like schizophrenia and intermittent explosive disorder, as having equal scientific standing.
Threshold Rationalization: Diagnostic cutoffs (e.g., 5 out of 9 symptoms) should be optimized based on data regarding treatment response and functional outcomes rather than historical "vibes" or consensus.
Dimensional Integration: Including HiTOP in the DSM appendix would recognize robust statistical evidence that mental health problems exist on spectra (e.g., internalizing, externalizing) rather than as discrete categorical "packets".
Closing Schema Gaps: The manual should shift toward dimensional descriptions to accommodate the high volume of "unspecified" patients who fall through the "holes" of current categorical schemas.
Public Accountability: To maintain professional legitimacy, the APA should remove paywalls for diagnostic criteria and provide full public transparency regarding industry associations among task force members.

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Scientific Pluralism and the Evolution of Psychiatric Classification with Dr. Awais Aftab

Mon, 06 Apr 2026 09:00:00 -0000

In this episode of Psychiatry Boot Camp, host Dr. Mark Mullen sits down with Dr. Awais Aftab, MD, a psychiatrist and Clinical Associate Professor at Case Western Reserve University. Dr. Aftab, well-known for his "Psychiatry at the Margins" Substack and "Conversations in Critical Psychiatry" series, explores the necessity of "conceptual competence" in modern practice. The discussion delves into the "Psychiatric Psychodrama," analyzing how material inequalities fuel polarized culture wars between "repenting" and "repressing" psychiatric factions. Dr. Aftab further defines scientific pluralism, challenging the 20th-century hope for a unified, reductive biological model of mental illness. Finally, the conversation examines the "Rumpelstiltskin Effect", the therapeutic impact of the diagnostic ritual, while cautioning against the iatrogenic risks of internalized stigma and essentialist misunderstandings.

Takeaways:

Conceptual Competence: Clinicians must understand the underlying philosophical assumptions and vocabulary inherent in psychiatric research and diagnosis to avoid muddled practice.

Psychiatric Psychodrama: Much of the field’s internal conflict is driven by material inequalities and resource scarcity, often manifesting as a "culture war" between those who pathologically condemn the field and those who minimize its failures.

Scientific Pluralism: Psychiatry lacks a single, unitary scientific method; instead, it relies on a "dappled" worldview where biological, psychological, and social explanations function at different, non-reducible levels.The

Rumpelstiltskin Effect: Receiving a formal diagnosis can provide immense relief by shifting a patient’s narrative from one of moral blame to a technical, medical framework.

Essentialist Risks: Over-identifying with a diagnosis as a fixed, unchangeable "essence" can lead to self-fulfilling prophecies of impairment and avoidance, highlighting the need for nuanced patient communication.

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TMS for Treatment-Resistant Depression: A Clinical Guide with Dr. Owen Muir

Mon, 23 Mar 2026 09:00:00 -0000

In this episode of Psychiatry Boot Camp, Dr. Mark Mullen speaks with Dr. Owen Muir, psychiatrist, entrepreneur, and Chief Medical Officer of Radial Health, about the growing role of transcranial magnetic stimulation (TMS) in psychiatric treatment.
The discussion explores how TMS works as a form of noninvasive neuromodulation, using focused magnetic fields to influence neural circuits implicated in depression and other psychiatric conditions. Dr. Muir reviews the evidence supporting TMS for treatment-resistant depression, explains the FDA clearance pathway for neuromodulation devices, and discusses how stimulation parameters, coil positioning, and treatment protocols affect clinical outcomes.
The conversation also addresses the broader implications of neuromodulation in psychiatry, including emerging indications, technological innovation, and how clinicians can integrate TMS into modern psychiatric practice. This episode provides a practical and conceptual overview of one of the fastest-growing treatment modalities in mental health care.

Takeaways:

TMS is a noninvasive neuromodulation technique that uses magnetic fields to induce electrical activity in targeted cortical regions.
The primary FDA-cleared indication is treatment-resistant major depressive disorder, though research continues for other conditions including OCD and PTSD.
Treatment protocols depend on stimulation parameters, including frequency, location (often the dorsolateral prefrontal cortex), and session scheduling.
The FDA device clearance process differs from pharmaceutical approval, relying heavily on device equivalence and clinical safety data.
Neuromodulation represents a growing frontier in psychiatry, complementing pharmacotherapy and psychotherapy in the treatment of complex mood disorders.

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Physician Assisted Suicide: Clinical, Legal, and Ethical Implications for Psychiatry with Dr. Mark Komrad

Mon, 09 Mar 2026 18:03:00 -0000

In this episode of Psychiatry Boot Camp, Dr. Mark Mullen speaks with psychiatrist and medical ethicist Dr. Mark Komrad about physician-assisted suicide and euthanasia, focusing particularly on their implications for psychiatric practice.

The discussion reviews the terminology, legal frameworks, and international trends surrounding assisted death, including developments in Belgium, the Netherlands, Canada, and multiple U.S. states. Dr. Komrad outlines concerns regarding capacity assessments, the expansion from terminal illness to psychiatric suffering, and the ethical tensions between autonomy and the physician’s role as healer.
The episode also examines countertransference, projective identification, and the clinical dynamics that arise when treating chronically suicidal patients in jurisdictions where assisted death is permitted. Position statements from the American Medical Association and the American Psychiatric Association are reviewed, along with questions of conscientious objection

Takeaways:

Terminology matters. Major professional organizations continue to prefer the term “physician-assisted suicide,” reflecting ongoing ethical debate about whether these practices are distinct from suicide prevention work.
Capacity assessment standards remain variable. In many jurisdictions, evaluations are left largely to physician (or provider) discretion without standardized psychiatric frameworks.
Expansion beyond terminal illness is occurring internationally. Countries that initially limited eligibility to end-of-life conditions have broadened criteria to include chronic disability and, in some regions, primary psychiatric diagnoses.

Borderline personality disorder and mood disorders are disproportionately represented in psychiatric assisted death cases in some European jurisdictions.
Countertransference and projective identification are clinically relevant. Physicians must remain vigilant about how therapeutic fatigue and induced hopelessness can influence decision-making in chronically suicidal patients.
Key professional organizations in the United States maintain opposition to physician assisted suicide. The AMA and APA have articulated clear ethical boundaries regarding the role of physicians and psychiatrists in assisted death.

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Complex PTSD, Borderline Personality Disorder, and Diagnostic Validity with Dr. Mark L. Ruffalo

Mon, 23 Feb 2026 10:00:00 -0000

In this episode of Psychiatry Bootcamp, Dr. Mark Mullen is joined by Dr. Mark Ruffalo for an in-depth examination of complex post-traumatic stress disorder (C-PTSD), a construct widely discussed in academic and public discourse, but not currently recognized as a distinct DSM diagnosis.
The conversation situates C-PTSD within the historical and theoretical landscape of psychiatry, tracing its origins to Judith Herman’s work and examining its proposed relationship to borderline personality disorder and classical PTSD. Dr. Ruffalo explores core questions of diagnostic validity versus reliability, drawing on foundational psychiatric theory, communication models such as the double bind, and contemporary critiques of the DSM’s proliferation of categories.
Listeners will gain a framework for understanding why diagnostic labels matter, how trauma-informed care can coexist with diagnostic rigor, and the potential clinical consequences of adopting constructs without clear discriminant validity. The episode emphasizes careful formulation, treatment matching, and ethical responsibility in an era of expanding diagnostic language.

Takeaways:

Complex PTSD lacks consensus diagnostic criteria, raising concerns about discriminant validity when compared with borderline personality disorder and PTSD.
Diagnostic reliability is not the same as validity, a central limitation of DSM-based classification systems.
Borderline personality disorder encompasses heterogeneous pathways, including, but not limited to, trauma exposure.
Mislabeling can lead to mismatched treatment, particularly when trauma-focused approaches obscure underlying personality pathology.
Thoughtful diagnosis strengthens, rather than harms, therapeutic alliance when delivered with empathy, dimensional framing, and attention to prognosis.

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Severe Mental Illness Behind Bars: A Breakdown in Care with Jesse Bogan

Mon, 09 Feb 2026 10:00:00 -0000

In this episode of Psychiatry Bootcamp, Dr. Mark Mullen speaks with Jesse Bogan, journalist with The Marshall Project, about a profound and often invisible failure at the intersection of psychiatry and the criminal legal system: the prolonged incarceration of individuals found incompetent to stand trial without access to timely psychiatric treatment.
Using Missouri as a case study, the conversation traces how defendants with severe mental illness can spend months to years in jail awaiting competency evaluations and restoration, despite legal mandates requiring prompt assessment and care. Jesse shares detailed reporting on systemic delays, limited forensic bed capacity, underfunded community mental health services, and pilot programs that have failed to meet the clinical needs of profoundly ill patients.
The episode examines ethical and constitutional implications, including potential violations of the Sixth Amendment right to a speedy trial, and highlights the human cost of untreated psychosis, mania, and depression in carceral settings. This discussion challenges clinicians to confront how structural failures transform jails into default psychiatric holding facilities and asks what role psychiatry must play in reform.

Takeaways:

Incompetency to stand trial creates legal limbo. Defendants may be jailed for years while their criminal cases are paused, awaiting psychiatric treatment that is legally required but operationally unavailable.
Jails are not treatment settings. Severe mental illness often worsens during prolonged incarceration, reducing the likelihood of competency restoration and increasing morbidity and mortality.
Systemic underfunding drives criminalization. Gaps in outpatient care, involuntary treatment mechanisms, and forensic infrastructure funnel untreated patients into the justice system.
Competency restoration programs have limits. Jail-based and mobile models often fail for patients who are too psychotic or disorganized to engage meaningfully in treatment.
This is a national problem. While Missouri is highlighted, similar backlogs and constitutional concerns exist across the United States and internationally.

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Involuntary Psychiatric Treatment in Modern Psychiatry with Dr. Dinah Miller

Mon, 26 Jan 2026 10:00:00 -0000

In this episode of Psychiatry Bootcamp, Dr. Mark Mullen is joined by Dr. Dinah Miller, psychiatrist, writer, and author of Committed: The Battle Over Involuntary Psychiatric Care, for a rigorous examination of civil commitment and involuntary treatment in modern psychiatry.

The conversation explores the legal structures underlying involuntary hospitalization, medication over objection, and outpatient civil commitment, while highlighting the profound ethical tensions between patient autonomy, public safety, and clinical responsibility. Dr. Miller traces the historical evolution of involuntary care, examines why state systems vary so widely, and explains why outcomes data remain limited and difficult to interpret.

Listeners will gain a framework for understanding the competing advocacy groups shaping policy, the real-world consequences of emergency department boarding and bed shortages, and the psychological impact involuntary care can have on patients long after discharge. The episode also addresses language, stigma, and how psychiatrists can practice humane, ethically grounded care even when coercion is unavoidable.

This is a sober, thoughtful discussion of one of psychiatry’s most challenging responsibilities.

Takeaways:

Civil commitment is distinct from forensic commitment, yet often conflated in public discourse and policy discussions.

Evidence linking involuntary treatment to improved public safety is limited, in part due to ethical and methodological constraints on research.

System failures (bed shortages, ED boarding, lack of housing) amplify the harms of coercive care, even when clinically justified.

Outpatient commitment models vary widely, with New York’s AOT program offering one of the most studied but resource-intensive approaches.

How psychiatrists communicate, document, and set boundaries during involuntary care profoundly affects patient trust and future engagement.

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Artificial Intelligence and the Future of Psychiatry with Dr. Allen Frances

Mon, 12 Jan 2026 10:00:00 -0000

Psychiatry stands at the threshold of one of its greatest disruptions, the rise of artificial intelligence. In this episode, Dr. Mark Mullen speaks with Dr. Allen Frances, Professor Emeritus and former Chair of Psychiatry at Duke University and Chair of the DSM-IV Task Force, about the clinical, ethical, and societal implications of AI’s rapid entry into mental health care. Drawing from his recent paper in the British Journal of Psychiatry (August 2025), Dr. Frances explores how psychotherapy chatbots have already become the world’s most widely used form of therapy, often beneficial for mild distress but profoundly dangerous for severe mental illness.

The discussion examines where chatbots outperform human therapists, where they fail catastrophically, and how clinicians can adapt their practices in anticipation of hybrid human-AI models. Dr. Frances also warns of broader threats, privacy loss, manipulation, and the potential use of AI for political or psychological control This conversation challenges clinicians to approach AI with both curiosity and caution, recognizing its utility while defending the irreplaceable humanity of psychiatric care.

Takeaways:

AI in psychiatry is no longer hypothetical. Over one billion people now engage with chatbots for therapy or companionship, exceeding all human clinicians combined.
Clinical utility is bifurcated. AI can enhance care for mild distress but poses major risks for psychosis, suicidality, and eating disorders.
Validation over truth. Chatbots are programmed to please users, not challenge delusions, amplifying psychosis, mania, and self-harm behaviors.
Privacy and ethics lag behind innovation. Conversations with chatbots may not be confidential, raising serious HIPAA and legal concerns.
Hybrid models are inevitable. Future psychiatrists must integrate AI tools safely, focus on severely ill populations, and preserve the relational aspects machines can’t replicate.

References:

AI Chatbots: The Good, the Bad, and the Ugly (Frances' column in Psychiatric Times): https://www.psychiatrictimes.com/series/ai-chatbots-the-good-the-bad-and-the-ugly

Warning: AI Chatbots will soon dominate psychotherapy (Frances' feature in the British Journal of Psychiatry): https://www.cambridge.org/core/services/aop-cambridge-core/content/view/DBE883D1E089006DFD07D0E09A2D1FB3/S0007125025103802a.pdf/warning_ai_chatbots_will_soon_dominate_psychotherapy.pdf

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Beyond Boot Camp: Conversations on Psychiatry's Future (Season 4 Trailer)

Mon, 29 Dec 2025 10:00:00 -0000

Welcome to Season 4! Join Dr. Mark Mullen and expert guests as we explore AI in psychotherapy, emerging treatments, and the ethical, clinical questions reshaping psychiatric care, and MUCH more.

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Malingering and Factitious Disorder: An Approach to Clinical Deception with Dr. Nicholas Kontos

Mon, 04 Aug 2025 11:00:00 -0000

In this episode, I speak with Dr. Nicholas Kontos, Program Director of the Consultation–Liaison Psychiatry Fellowship at Massachusetts General Hospital, about one of the field’s most challenging topics: malingering and factitious disorder. We discuss how to move beyond the impulse to “catch deception” and instead adopt a framework of clinical curiosity, empathy, and ethical clarity. Dr. Kontos introduces the concept of “thinking dirty”, the disciplined consideration of complex motives such as safety, shelter, or secondary gain, while preserving therapeutic respect. The conversation covers practical strategies for differential diagnosis, documentation, and the therapeutic discharge, reframing it as a compassionate boundary rather than a punishment.

Takeaways:

Clinicians must be willing to consider non-altruistic motives (sex, money, drugs, safety, attention) without moral judgment. This mindset sharpens diagnostic reasoning while maintaining therapeutic respect.
The classical distinction between factitious disorder and malingering is often clinically unstable. Both exist on a behavioral spectrum shaped by unmet needs, structural deprivation, and adaptive strategies
Properly framed, discharge is not punitive but restorative, a boundary that ends maladaptive cycles while affirming the patient’s moral agency
The note itself is a clinical act. A comprehensive chart review, clear description of inconsistencies, and transparent reasoning both protect the patient and clarify physician thought
Effective care balances compassion with stewardship of finite resources. Clinicians serve both patient and system by refusing to reinforce maladaptive behavior while still honoring human dignity

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Functional Neurological Disorders: Modern Diagnosis & Evidence-Based Management | Dr. Caitlin Adams

Mon, 28 Jul 2025 11:00:00 -0000

Functional Neurological Disorder (FND) sits at the crossroads of neurology and psychiatry and for many clinicians, it’s still one of the most challenging diagnoses to understand, explain, and treat. In this episode, I’m joined by Dr. Caitlin Adams, psychiatrist at Massachusetts General Hospital, for a deep dive into how to recognize, diagnose, and manage FND using a modern, evidence-based, and patient-centered approach.
We trace the evolution of the diagnosis from hysteria to conversion disorder to today’s understanding of FND and explore what neuroscience now tells us about how these symptoms arise. Dr. Adams breaks down the myths around voluntary control, shows how to make a positive diagnosis based on key exam findings like Hoover’s sign, tremor variability, and seizure features distinguishing PNES from epilepsy, and shares how to communicate the diagnosis in a way that reduces stigma and builds engagement. We also unpack the biopsychosocial model of FND: the predisposing, precipitating, and perpetuating factors that keep symptoms alive and how to intervene through cognitive behavioral therapy (CBT), specialized physical therapy, mindfulness, and psychodynamic approaches.

Takeaways:

FND is a positive diagnosis, not a diagnosis of exclusion. Key findings like Hoover’s sign and tremor variability distinguish functional from organic presentations.
Symptoms are not “faked.” FND symptoms are involuntary and arise from disrupted brain networks controlling movement, sensation, and perception.
How you explain the diagnosis matters. Patients do better when clinicians validate symptoms, offer clear language, and emphasize that FND is common and treatable.
Treatment is multidisciplinary. Evidence-based care combines psychoeducation, CBT, and physiotherapy that retrains motor and sensory patterns.
Chronic cases require flexibility. Reassess the diagnosis, re-engage the patient, and adjust treatment around functional goals, not full symptom elimination.

Key References:

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Perinatal Psychiatry: Risk, Ethics, and Clinical Decision-Making with Dr. Christina Wichman

Mon, 21 Jul 2025 10:00:00 -0000

Pregnancy and postpartum are times of profound change and nowhere is that complexity more visible than in psychiatry. In this episode, Dr. Christina Wichman, Professor of Psychiatry and Obstetrics & Gynecology, Medical Director of The Periscope Project, and Director of Women’s Mental Health at the Medical College of Wisconsin, joins us for a deep dive into reproductive psychiatry. Co-hosted by Erica Browne, an M4 at Saint Louis University School of Medicine, this conversation explores how to care for both mother and baby with empathy, evidence, and balance. We walk through distinctions between baby blues, perinatal depression, and major depressive disorder, discuss how to identify red flags for perinatal psychosis, and explore the ethical and clinical nuances of treating psychiatric illness during pregnancy and lactation. Dr. Wichman explains how to approach risk–benefit decisions around psychotropic medications, highlights validated screening tools, and offers real-world strategies for supporting patients who face barriers to care. We also spotlight The Periscope Project, a pioneering model for connecting clinicians with reproductive psychiatry expertise—and discuss how the field is expanding training, access, and awareness for the next generation of women’s mental health specialists.
Takeaways:
Pregnancy changes everything, but not always for the worse. Psychiatric treatment during pregnancy can and should be individualized, balancing the safety of both mother and baby.
Know the distinctions. Baby blues typically resolve within two weeks; perinatal depression lasts longer, while postpartum psychosis requires urgent evaluation.
Medication decisions are about risk versus risk. Untreated psychiatric illness carries real dangers, sometimes greater than the medications themselves.
Access matters. Programs like The Periscope Project expand reproductive psychiatry consultation to clinicians everywhere, improving outcomes system-wide.
The future is integrated care. Psychiatrists, OB-GYNs, and primary care providers working together can transform perinatal mental health into standard, not specialized, care.

Key References & Clinical Resources

1. ⁠The Periscope Project⁠ – A perinatal psychiatry consultation and resource program based in Wisconsin.
2. ⁠National Access Programs – Lifeline for Moms⁠ – A directory of statewide perinatal mental health access programs.
3. ⁠National Curriculum in Reproductive Psychiatry (NCRP)⁠ – Free, evidence-based training for clinicians in reproductive psychiatry.
4. ⁠MGH Center for Women’s Mental Health⁠ – Clinical and research resource for perinatal and reproductive psychiatry.
5. ⁠MotherToBaby⁠ – Trusted information on medication and other exposures during pregnancy and breastfeeding.
6. ⁠Pharmacologic Treatments for Mania (Kishi 2021)⁠ – Meta-analysis regarding antimanic effects of selective estrogen receptor modulators.

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Assessment And Management Of Eating Disorders with Dr. Patricia Westmoreland and Dr. Anne O’Melia

Mon, 14 Jul 2025 10:00:00 -0000

Eating disorders are among the most lethal conditions in psychiatry and some of the most misunderstood. In this episode, I’m joined by Dr. Patricia Westmoreland and Dr. Anne O’Melia, two internationally recognized experts with eight combined board certifications spanning psychiatry, internal medicine, pediatrics, and consultation-liaison psychiatry. Together, we take a deep dive into the medical, psychiatric, ethical, and forensic complexities of eating disorders, especially as they appear in the general medical hospital. We talk through how to recognize eating disorders in patients who may not even identify as ill, when to intervene, and what the thresholds for medical stabilization really look like. We also explore the psychological underpinnings, how control, trauma, and insight all intersect, and the delicate balance between autonomy and safety when capacity is limited.

Takeaways:

Eating disorders are both psychiatric and medical emergencies. Anorexia nervosa has one of the highest mortality rates of any psychiatric illness, surpassed only by opioid use disorder.
Early recognition saves lives. Common signs include unexplained bradycardia, electrolyte disturbances, fatigue, hypoglycemia, or rapid weight loss, even in patients who deny an eating disorder.
Patients often lack insight. Many individuals with severe anorexia are highly intelligent but unable to apply their knowledge to themselves, leading to deceptive presentations of “capacity.”
Treatment is multidisciplinary and stepwise. Levels of care range from outpatient and intensive outpatient programs to residential, psychiatric inpatient, and medical stabilization units, depending on weight, vitals, and lab findings.
Recovery is possible and expected. Full restoration of nutrition and function can reverse nearly every medical complication of starvation, and with the right care, patients can go on to live full, independent lives.

Key References:

1. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Eating Disorders (Crone 2023)

2. Ethical Challenges in the Treatment of Patients With Severe Anorexia Nervosa (Westmoreland 2024)

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Assessment of Decisional Capacity: Guidelines, Ethics, and Evidence with Dr. Mira Zein

Mon, 30 Jun 2025 11:00:00 -0000

In this episode, I sit down with Dr. Mira Zein, clinical associate professor at Stanford and co-author of the APA Resource Document on Decisional Capacity Determinations, to break down one of the most frequent and misunderstood consults in psychiatry.
We go deep into the Appelbaum–Grisso criteria and discuss how they apply to real-world cases where the answer isn’t always clear. Dr. Zein walks us through difficult scenarios, from life-saving refusals to medically complex delirium cases, highlighting how to think, document, and communicate clearly when capacity is in question. This episode will help you shine on rounds, guide your primary team through their own assessments, and remind you that capacity isn’t about saying “yes” or “no”, it’s about respecting autonomy while protecting patients at their most vulnerable.

Takeaways:

Capacity is decision-specific and time-specific. It’s not a global judgment, and it can fluctuate with illness, treatment, or environment.
The Appelbaum–Grisso framework defines the process. Every evaluation should include communication, understanding, appreciation, and reasoning.
Primary teams can and should do their own assessments. Psychiatrists are consultants, not gatekeepers; the best work happens through collaboration.
Delirium, dementia, and psychosis are common culprits. Each affects different aspects of capacity, requiring tailored interventions and re-evaluation.
Documentation is key. Define the specific decision, describe your assessment of each criterion, and explain your reasoning clearly for the record.

Key resources:

1) APA Resource Document on Decisional Capacity Determinations in Consultation-Liaison Psychiatry: A Guide for the General Psychiatrist (2019)

2) Seminal Article on Appelbaum-Grisso Criteria (Appelbaum 1988)

3) Evaluating Capacity: Appelbaum’s Framework Interpreted Diagrammatically (Bari 2023)

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Transplant Psychiatry and The Psychiatrist’s Role in Organ Transplantation with Dr. Paula Zimbrean

Mon, 23 Jun 2025 11:00:00 -0000

Organ transplantation isn’t just a medical miracle, it’s a psychological marathon. In this episode, I talk with Dr. Paula Zimbrean, Yale psychiatrist and pioneer in Transplant Psychiatry, about what really happens when mind and medicine intersect at the edge of life and death. We walk through the evolution of psychiatry’s role on transplant teams, from risk gatekeeping to long-term integration, and explore what pre-transplant evaluations truly aim to uncover. Dr. Zimbrean shares how to assess risk, capacity, and motivation in patients preparing for transplant, and what it means to treat not just the organ recipient, but their family and support system as well. We also discuss the unseen emotional toll of the transplant journey, from steroid-induced mood changes to post-traumatic stress symptoms, and why empathy is as vital as immunosuppression.

Takeaways:

Transplant psychiatry has evolved. It began with managing post-op delirium and psychosis, but now focuses on enhancing long-term outcomes through integrated psychiatric care.
Pre-transplant evaluations go beyond “yes” or “no.” They assess diagnosis, prognosis, capacity, adherence potential, and the patient’s understanding of lifelong treatment demands.
Psychiatrists aren’t gatekeepers, they’re collaborators. The goal is to identify modifiable risks, optimize mental health, and align medical decisions with patient values.
The journey is psychologically intense. From waiting list uncertainty to post-op PTSD and steroid-induced mood shifts, every stage requires active psychiatric support.
The future is integration. As patients live longer post-transplant, psychiatry’s role will increasingly involve ongoing care, research, and improving quality of life beyond survival.

Selected references:

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3.8 Suicide Risk Assessment

Mon, 16 Jun 2025 11:00:00 -0000

A season on consultation-liaison psychiatry would not be complete without an episode on suicide risk assessment!

Dr. Black: "I say without exaggeration that this podcast, in which Dr. Mullen and I discuss suicide risk assessment, is one of the professional things in life that I am most proud of."

WOW! That's quite the claim from one of the world's foremost psychiatrists about a podcast episode. Take a listen and see what you think!

Dr. Tyler Black, a suicidologist and child psychiatrist at British Columbia Children's Hospital, walks through common suicide myths, structuring the suicide risk assessment interview, common motivations for suicide, clinical decision making, best practices for documentation, and what works in preventing suicide.

Selected references:

⁠Changeability, confidence, common sense and corroboration: comprehensive suicide risk assessment (O'Connor 2004)⁠

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Behavioral and Psychological Symptoms of Dementia: A Clinical Guide with Dr. George Grossberg

Mon, 09 Jun 2025 11:00:00 -0000

In this episode, I talk with Dr. George Grossberg, a pioneer in geriatric psychiatry, about the neuropsychiatric symptoms of dementia and what they look like, why they happen, and how to approach them with empathy and strategy. We walk through the most common behavioral disturbances in dementia, including apathy, depression, psychosis, and agitation. Dr. Grossberg shares how to think through these cases, when to reach for medication, when to hold back, and how to anchor every decision in an understanding of who the patient truly is.

Takeaways:

Neuropsychiatric symptoms are nearly universal in dementia. Expect them, don’t be surprised by them.
Apathy and depression aren’t the same. Treating apathy like depression often fails; gentle engagement works better than antidepressants.
Start with environment and empathy. Music, structure, exercise, and caregiver education should come before medication.
Use medication sparingly and strategically. When needed, match the drug to the symptom, and always reassess risk versus relief.
Knowing the person changes everything. Understanding a patient’s history, preferences, and rhythms is as therapeutic as any pharmacologic plan.

Selected References:

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Catatonia: The Art and Urgency of Treatment with Dr. Mark Oldham

Tue, 27 May 2025 11:00:00 -0000

Catatonia isn’t just mysterious, it’s one of the most treatable yet misunderstood syndromes in psychiatry.

In this episode, I continue my conversation with Dr. Mark Oldham, diving deep into what to actually do when you suspect catatonia. We talk through the Lorazepam challenge, what a “positive” response really means, and why sometimes a single dose can look like a miracle. We also dig into the gray zones—how to approach patients who don’t respond, when to move to ECT, and what to do when catatonia overlaps with delirium or psychosis.

Dr. Oldham shares his framework for identifying special cases, from benzodiazepine withdrawal to clozapine discontinuation, and explains why history-taking, not algorithms, is psychiatry’s most powerful diagnostic tool.

Takeaways:

Start simple, but think deeply. Lorazepam remains first-line for catatonia, but the absence of RCTs means clinical reasoning still leads the way.
ECT is definitive and underused. For refractory or malignant catatonia, ECT is often curative, but access and consent barriers remain a major challenge.
Not all catatonia is the same. Withdrawal states, chronic schizophrenia, and periodic catatonia each demand tailored interventions.
Delirium and catatonia can coexist. Treat both cautiously, start low, go slow, and always look for autoimmune or neurological causes.
History is your best guide. Behind every catatonic presentation is a story, missing it can mean missing the cure.

Selected references:

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Catatonia: Diagnosis, Features, and Clinical Nuance with Dr. Mark Oldham

Mon, 19 May 2025 11:00:00 -0000

When a patient stops moving, stops speaking, or stares through you like you’re not there, it’s easy to miss what’s really happening.

In this episode, I’m joined again by Dr. Mark Oldham, one of the leading voices on catatonia, to break down what this strange, often misunderstood syndrome actually looks like in the real world. We walk through the diagnostic features step-by-step, how to assess, what to ask, and what’s too often overlooked.

From the history of the disorder to modern DSM confusion, from the meaning of “waxy flexibility” to the haunting truth about patients who are fully aware but trapped inside their bodies, this conversation will completely change the way you think about motor symptoms and psychiatric emergencies.

Takeaways:

Catatonia is common, but underrecognized. It’s not just “psychiatric immobility.” It spans a spectrum from stupor to hyperactivity.
Diagnosis starts with curiosity. Learn to test for features like mutism, posturing, and negativism systematically.
Many patients are aware. Always treat them with dignity and assume comprehension, even when they can’t respond.
It’s treatable and rapidly reversible. A single dose of lorazepam can sometimes unlock a frozen mind and body.
Malignant catatonia kills. When autonomic instability appears, it’s a medical emergency that demands immediate escalation and often ECT.

Selected references:

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3.4 Delirium: Pathophysiology and Management

Mon, 12 May 2025 11:05:00 -0000

Dr. Mark Oldham, Associate Professor of Psychiatry at University of Rochester Medical Center, President-Elect of the American Delirium Society, and Deputy Editor of the Journal of the Academy of Consultation-Liaison Psychiatry, further explores delirium. This episode covers the pathophysiology of delirium including predisposing and precipitating factors, neurocircuitry, and neurotransmitters. We then discuss conceptual frameworks for management of delirium, the importance of identifying and addressing the underlying cause, and strategies for managing specific neuropsychiatric disturbances in delirium.

References can be found on the ⁠episode website.⁠

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3.3 Delirium: Clinical Features and Diagnosis

Mon, 12 May 2025 11:00:00 -0000

References can be found on the ⁠episode website.⁠

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Supportive Psychotherapy: Structure, Empathy, and Evidence with Dr. John C. Markowitz

Mon, 05 May 2025 10:00:00 -0000

When you think about core topics in consultation-liaison psychiatry, “supportive psychotherapy” probably isn’t the first thing that comes to mind. But maybe it should be.

In this episode, I sit down with Dr. John C. Markowitz, Columbia psychiatrist, researcher, and co-author of Supportive Psychotherapy: A Guide, to talk about the therapy that “gets no respect.” Dr. Markowitz explains how this deceptively simple approach, built on empathy, affect, and alliance, rivals more “sophisticated” treatments for depression.

We explore why the most powerful interventions often come down to being present, listening well, and helping patients feel understood. And we talk about the threat facing psychotherapy itself and what we stand to lose if psychiatrists give it up.

Takeaways:

Supportive psychotherapy works and evidence shows it can be just as effective as CBT or IPT for depression.
Common factors like alliance, empathy, affect focus, and ritual account for much of what makes any therapy succeed.
Following affect matters emotions are uncomfortable, but they’re not dangerous, and they guide the healing process.
Less is often more letting patients lead, listening actively, and resisting the urge to “fix” can create deeper insight.
Psychotherapy is under siege and preserving its human core may be psychiatry’s most important act of resistance.

Selected references:

What is Supportive Psychotherapy? (Markowitz 2014)

Brief Supportive Psychotherapy (2022)

Psychiatrist Effects in the Psychopharmacological Treatment of Depression (McKay 2006)

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What Makes a Moment “Magic” in Psychiatry?

Mon, 28 Apr 2025 11:00:00 -0000

Welcome to Season 3 of Psychiatry Bootcamp.

This time, I’m stepping into the world of consultation-liaison psychiatry. The bridge between medicine and meaning. To kick things off, I’m joined by the legendary Dr. Allen Frances, former chair of the DSM-IV Task Force and Duke Psychiatry, who reminds us that the briefest interactions can be the most transformative.

We talk about what really happens when you walk into a hospital room: the loneliness, the fear, the need to be seen. Dr. Frances shares why “magic moments” aren’t superstition, but the heart of good medicine, and how to create hope in patients who’ve all but lost it.

Takeaways:

Every patient encounter is a chance for transformation, even a 15-minute consult can change a life.
Consult psychiatry lives between medicine and therapy and requires both logic and empathy.
Corrective emotional experiences can happen in moments, not months, when vulnerability meets presence.
Demoralization is the real danger, hope and understanding are often the most powerful treatments.
The “magic moment” is simply humanity made visible and it’s what patients remember long after the diagnosis.

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Season 3: Exploring Consultation-Liaison Psychiatry

Fri, 10 Jan 2025 16:59:34 -0000

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2.11 Schizophrenia

Mon, 29 Apr 2024 23:19:51 -0000

Dr. Sameer Jauhar, Senior Clinical Lecturer in Affective Disorders and Psychosis at the Institute of Psychiatry, Psychology and Neuroscience, King's College, London, and as a Consultant Psychiatrist at Maudsley NHS Foundation Trust, introduces us to schizophrenia. Explore core clinical features of schizophrenia and what is known about the neuroscience of schizophrenia. We'll also discuss psychopharmacological and psychosocial treatment approaches, rooted in Dr. Jauhar's humanistic approach.

This episode is intended to supplement Dr. Jauhar's Lancet Seminar on Schizophrenia (2022).

Connect with Dr. Jauhar: @SameerJauhar

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2.10 Post-Traumatic Stress Disorder (PTSD)

Tue, 20 Feb 2024 17:53:16 -0000

Dr. Laura Watkins, Clinical Psychologist and Assistant Professor of Psychiatry at Emory University School of Medicine, introduces us to post-traumatic stress disorder (PTSD).

We walk though the diagnostic criteria and discuss how these symptoms can impact a person's day-to-day life. We then learn to conceptualize PTSD in terms of both classical and operant conditioning. Finally, we explain evidence based psychotherapies for PTSD and conclude with a primer on psychopharmacology for PTSD.

Essential references:

1) Osser Psychopharmacology Algorithm for PTSD

2) Clinical Guidelines for PTSD (United States Department of Veteran's Affairs and Department of Defense)

3) This American Life: Ten Sessions

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2.9 Anxiety Disorders

Tue, 23 Jan 2024 23:25:19 -0000

Dr. John Walkup, Chair of the Pritzker Department of Psychiatry and Behavioral Health at Ann and Robert H. Lurie Children’s Hospital of Chicago, Professor of Psychiatry at Northwestern Feinberg School of Medicine, and president-elect of the American Academy of Child and Adolescent Psychiatry, introduces us to anxiety disorders.

We discuss the phenomenon of normal, adaptive anxiety and contrast this with symptomatology that may warrant a diagnosis of an anxiety disorder. We learn to appreciate anxiety disorders from a developmental lens, discuss clinical pearls for building a therapeutic alliance with anxious patients, and explore psychotherapies for anxiety disorders. We also discuss psychopharmacological considerations for both SSRIs and benzodiazapines.

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2.8 Depressive Disorders

Thu, 18 Jan 2024 17:16:02 -0000

Dr. Roger McIntyre, Professor of Psychiatry and Pharmacology at the University of Toronto and Head of the Mood Disorders Psychopharmacology Unit at the University Health Network in Toronto, Canada, returns to introduce depressive disorders.

We differentiate normal "low mood" from conditions that warrant a psychiatric diagnosis. We discuss historical subtypes of depression and the current DSM specifiers for major depressive disorder. We review epidemiology, discuss the neurophysiology of depressive disorders, and then dive into treatment options.

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2.6 Borderline Personality Disorder (Good Psychiatric Management)

Thu, 18 Jan 2024 17:15:42 -0000

Dr. Lois Choi-Kain, Director of the Gunderson Personality Disorders Institute at McLean Hospital and Associate Professor of Psychiatry at Harvard Medical School, introduces us to borderline personality disorder (BPD).

We discuss the prevalence, naturalistic course, and treatments for BPD. We explore BPD using the “Good Psychiatric Management” (GPM) model, which is intended to empower clinicians of all disciplines to manage patients with BPD effectively. We discuss the principles of GPM and walk through some examples of how it might be used in the clinical setting.

Book: Applications of Good Psychiatric Management for Borderline Personality Disorder: A Practical Guide (Check your academic library!)

References:

(11:30) Grant BF, Chou SP, Goldstein RB, et al. Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry. 2008;69(4):533-545.
(12:30) Trull TJ, Jahng S, Tomko RL, Wood PK, Sher KJ. Revised NESARC personality disorder diagnoses: gender, prevalence, and comorbidity with substance dependence disorders. J Pers Disord. 2010;24(4):412-426.
(15:00) Gregory R, Sperry SD, Williamson D, Kuch-Cecconi R, Spink GL Jr. High Prevalence of Borderline Personality Disorder Among Psychiatric Inpatients Admitted for Suicidality. J Pers Disord. 2021;35(5):776-787.
(20:45) Kernberg O. Borderline personality organization. J Am Psychoanal Assoc. 1967;15(3):641-685.
(29:30) Choi-Kain LW, Finch EF, Masland SR, Jenkins JA, Unruh BT. What Works in the Treatment of Borderline Personality Disorder. Curr Behav Neurosci Rep. 2017;4(1):21-30.
(33:00) Skodol AE, Gunderson JG, Shea MT, et al. The Collaborative Longitudinal Personality Disorders Study (CLPS): overview and implications. J Pers Disord. 2005;19(5):487-504.
(33:00) Temes CM, Zanarini MC. The Longitudinal Course of Borderline Personality Disorder. Psychiatr Clin North Am. 2018;41(4):685-694.

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2.7 Bipolar Disorders

Sun, 07 Jan 2024 16:38:27 -0000

We discuss the key clinical features of bipolar disorders, the relationship between bipolar disorders and circadian rhythm, known pathogenesis, and some first line treatment options. We also contextualize the difference between "type I" and "type II" bipolar disorder, and explore the relationship between bipolar disorder and traumatic life experiences.

For more: Bipolar Disorders (Lancet Seminar)

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2.5 Substance Use Disorders

Mon, 11 Dec 2023 18:33:30 -0000

Dr. Steve Delisi, Chief Medical Officer at YourPath Inc., Associate Director at UC-Irvine School of Medicine's "Train New Trainers" Primary Care - Training and Education in Addiction Medicine Fellowship, Adjunct Professor at Hazelden Betty Ford Graduate School of Addiction Studies, walks through the fundamentals of substance use disorder. We discuss the neurobiology of substance use disorder and explore the clinical use of "translational neuroscience." You'll also learn about the relationship between trauma and substance use, hear best practices for building a therapeutic alliance with this patient population, and catch a glimpse into future research on substance use disorders.

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2.4 Delirium

Sun, 03 Dec 2023 16:22:46 -0000

Dr. Mark Oldham, Associate Professor of Psychiatry at University of Rochester Medical Center, President-Elect of the American Delirium Society, and Deputy Editor of the Journal of the Academy of Consultation-Liaison Psychiatry, takes us through a deep dive on delirium. This episode covers an enormous amount of material. We contrast encephalopathy and delirium before diving into the dangerousness of delirium and prevention strategies. We explore the neurobiology of delirium and tie it to validated assessment tools and treatment approaches. We also discuss areas for future research and learn to appreciate the evolutionary function that delirium serves.

References can be found on the episode website.

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2.3 Psychiatric Epidemiology

Sun, 26 Nov 2023 16:00:00 -0000

Dr. Erick Messias, Chair of Psychiatry at Saint Louis University, introduces us to the world of psychiatric epidemiology. Learn how epidemiological figures (that show up on training exams) are derived, and explore how epidemiology can help us to understand the naturalistic course of psychiatric illness. We also delve into the history of our diagnostic system and how it developed into the current model, and run through some of the most important findings to date in psychiatric epidemiology. Dr. Messias also explains how to approach every situation in life "as a 2 by 2 table," and we conclude with some wisdom about inserting meaning into daily psychiatric practice.

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2.2 Medical Mimmickers

Sun, 19 Nov 2023 16:00:00 -0000

Dr. Kimberly Nordstrom, Past President of the American Association for Emergency Psychiatry and Associate Clinical Professor of Psychiatry at the University of Colorado, discusses the process of considering medical contributions to psychiatric illness. We discuss red flags that should guide clinicians to start thinking medically, explain the importance of systematically approaching a differential diagnosis, and provide a brief introduction to a few common medical-psychiatric conditions including autoimmune encephalitis, neuroleptic malignant syndrome (NMS), and serotonin toxicity ("serotonin syndrome").
Book: Quick Guide to Psychiatric Emergencies: Tools for Behavioral and Toxicological Situations

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2.1 Essentials of Psychiatric Diagnosis

Sun, 12 Nov 2023 15:00:00 -0000

Dr. Allen Frances, Chair of the DSM-IV Task Force and Chair Emeritus at Duke, returns to orient listeners to psychiatric diagnosis. Explore diagnostic principles including "stepped diagnosis" and understand the importance of nuance when making and communicating a psychiatric diagnosis. You'll also learn about how these diagnoses are derived, and hear tips for making an accurate and meaningful diagnosis to improve a patient's quality of life.
Book: Essentials of Psychiatric Diagnosis by Dr. Allen Frances

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Hoofbeats on Broadway: Fundamentals of Psychiatric Diagnosis (Intro to Season 2)

Tue, 07 Nov 2023 21:00:00 -0000

Welcome to Psychiatry Boot Camp Season 2: Hoofbeats on Broadway! We are basing this season around the axiom, "When you hear hoofbeats on Broadway, think horses, not zebras." Our global experts will introduce the fundamentals of psychiatric diagnosis before walking us diagnosis-by-diagnosis through the psychiatric stables. Stay tuned!

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1.9 Violence Risk Assesment

Wed, 05 Apr 2023 20:06:00 -0000

Dr. Amy Barhnorst, Associate Professor of Psychiatry and Vice Chair for Community Mental Health at U C Davis, explains various ways to characterize violence, violence prevention strategies, best practices for documentation, firearms, and more.
For more: https://www.bulletpointsproject.org/

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1.8 Intro to Psychotherapy

Mon, 27 Mar 2023 14:00:00 -0000

Dr. Donna Sudak, Professor of Psychiatry and Vice Chair for Education at Drexel University College of Medicine, and Past President of the American Association of Directors of Psychiatric Residency Programs, introduces us to psychotherapy. We explore the role of psychotherapy in psychiatric practice, discuss "common factors" in psychotherapy, and learn to incorporate psychotherapy into each patient encounter.

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1.7 Decisional Capacity

Mon, 20 Mar 2023 15:00:00 -0000

Dr. Rajesh Tampi, Editor-in-Chief of the World Journal of Psychiatry, Past President of the American Association for Geriatric Psychiatry, and Chairman of Psychiatry at Creighton University, walks us through capacity assessments and shares his hard won wisdom for navigating difficult cases.

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1.6 Case Formulation

Mon, 13 Mar 2023 15:00:00 -0000

Dr. Jyotsna Ranga, Program Director for the Adult Psychiatry Residency and Child and Adolescent Psychiatry Fellowship at Creighton University, teaches how to construct case formulations using the biopsychosocial model and the "five Ps."

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1.5 Management of Acute Agitation

Mon, 06 Mar 2023 15:00:00 -0000

Dr. Tony Thrasher, President of the American Association for Emergency Psychiatry and medical director of crisis services in Milwaukee county, discusses best practices for management of the agitated patient. Learn key safety points, verbal de-escalation techniques, medical-legal principles, and pharmacotherapy options.

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1.4 Suicide Risk Assessment

Mon, 27 Feb 2023 17:00:00 -0000

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1.3 Mental Status Examination

Mon, 20 Feb 2023 20:00:00 -0000

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1.2 Clinical Interviewing

Thu, 16 Feb 2023 00:00:00 -0000

Dr. Dana Raml, Assistant Professor of Psychiatry at the University of Nebraska Medical Center, walks through interviewing do's and don'ts, techniques for building a therapeutic alliance, and teaches us how to ask for and organize the information gleaned during an initial psychiatric encounter.

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1.1 The DSM and Critical Psychiatry

Wed, 15 Feb 2023 23:00:00 -0000

Dr. Allen Frances, Chair of the DSM-4 Task Force and Chair Emeritus at Duke, discusses our profession's identity and provides pearls for developing psychiatrists. Dr. Awais Aftab, Clinical Professor of Psychiatry at Case Western University, discusses the validity of the DSM and psychiatric harm.
More from Dr. Frances: https://www.psychiatrictimes.com/view/advice-young-psychiatrists-very-old-one

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Welcome to Boot Camp

Tue, 14 Feb 2023 22:00:00 -0000

An introduction to Psychiatry Boot Camp Season 1!

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