PsyDactic

In this episode, I discuss a medication that patients who saw a psychiatrist or their primary care provider between about 1997 and 2015 were very likely to find themselves prescribed.  More recently, it has been taken down a notch or two on prescribers lists of preferred meds.  This medication is quetiapine, marketed as Seroquel by AstraZeneca in the US.  Whether you were diagnosed with schizophrenia, bipolar disorder, depression, anxiety, an eating disorder, insomnia, PTSD, borderline personality disorder, obsessive compulsive disorder, and many others it appeared in the mid 2000s that Quetiapine was just the thing for you.  Was it ever?

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References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

This episode continues an intermittent series called “In a Word.”  Past episodes have explored words like Akathisia, Dissociation, Perseveration, and even the difference between Impulsive and Compulsive.  This episode explores Confabulation, including some of the brain circuits involved, and what might differentiate confabulation from other kinds of false or implanted memories or delusions.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

In 2012 the Supreme Court heard two related cases involving adolescents convicted of murder and sentenced to life in prison without parole because of mandatory minimum sentencing guidelines in their states.  One of the boys, Evan Miller along with an accomplice, had beat a man unconscious with a baseball bat after a fight that ensued when the man awoke to find Miller robbing him.  Miller and his friend then decided to set fire to the home to cover up the evidence.  This resulted in the man’s death.  The second petitioner, Kuntrell Jackson, had accompanied two other boys to a convenience store in order to rob it.  During the robbery, one of the boys, not Jackson, shot and killed the clerk.  

Both boys were convicted and were sentenced according to minimum sentencing guidelines to life in prison without parole.  The decision that the court was asked to make was not whether the boys should have been convicted, but instead, whether the sentencing guidelines that resulted in them being given life without parole constituted cruel and unusual punishment.

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References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

I am lucky today to be able to bring you an interview with Dr. Zac Brooks who is passionate about serious mental illness (SMI).  “What is serious mental illness?” you might ask.  That is one of the things we are going to discuss, and you may be surprised when Dr. Brooks explains how it was first formally defined.  We also discuss the numerous ways the US has tried to reform how SMI is treated with variable results.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

PsyDactic welcomes Dr. Jon Lindefjeld for a discussion of the history of HIV and AIDS.  In particular, we discuss the development of effective antiretroviral therapies, including pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP), highlighting the CDC guidelines for use and monitoring, need to treat psychiatric com-morbidities, and the importance of monitoring adherence and drug interactions.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

Dr. O'Leary discusses some of the history of the borderline personality, how different perspectives have attempted to explain its origin, how to treat it and how not to treat it.  He starts in 1947 with some colorful descriptions of patients living with borderline personality disorder that would never get published today, and highlights some of the ways in which we have made progress (or not made progress) in our understanding of this disorder over the next 75 years.  As usual, Dr. O'Leary also waxes philosophical about science or the lack thereof in certain perspectives or treatments.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

Our current diagnostic criteria for personality disorders have failed to demonstrate validity or reliability.  The DSM 5 encouraged psychiatrists to start considering a broad range of personality features adapted from the Five Factor Model. These are combined with global functioning measures to build a personality inventory for any patient who is having dysfunction related to their personality.  Proposed criteria include a Personality Disorder - Trait Specified diagnostic category that permits diagnosticians to accommodate the new formulation.  Criterion A considers the salient aspects of personality functioning while Criterion B catalogs which of the Big 5 Factors are notably deranged.  Dr. O'Leary reviews the basics of these criteria and explores why our current formulations are in such dire need of reform.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

Humans have a history of tattooing that stretches millennia into prehistory.  The western ban on tattoos by the early church resulted in a systematic effort to paint tattooed individuals as pagan, primitive, vulgar, criminal, and mentally ill.  Psychiatrists have historically contributed to this characterization but are in a position to help reframe how citizens and policymakers view tattooed individuals. 

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

The brain understands the world by building models that predict the future.  One of the ways that it does this is by utilizing attractor networks.  These small world networks are constantly trying to determine what is a true signal from the constant noise in the neural net.  Dr. O'Leary explores how attractor networks have been hypothesized to explain psychosis, depression, and obsessive compulsive disorder, and how our various treatments might work to stabilize these networks.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

When I started to make this episode, I thought I would try to do a comprehensive review of all of the various functions of serotonin across its 15 or more receptor types, but I soon found myself overwhelmed.  More importantly, I found that some stories are more interesting to tell than others, so here I discuss serotonin and focus on how a few 5-HT receptors can not only help us survive, but also motivate ourselves to reach our goals, and, sometimes, convince us that we are fusing bodies with a tree.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

Frequently I have complained that the terms "typical and atypical" or "first generation and second generation" antipsychotics were not very helpful.  When I give chalk talks to junior residents and interns about antipsychotics, this is one of the first things that I note.  It is the medicines relative affinities for different receptors that appear to make the difference, not whether they were discovered prior to 1980 or not.  A few weeks ago, I was lucky enough to encounter a paper that was published in April of 2023 by McCutcheon et al in Biological Psychiatry titled "Data-Driven Taxonomy for Antipsychotic Medication: A New Classification System."  In this episode, I use their results to guide a discussion of variability in target effects and side effects of different groups of antipsychotics.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

This episode explores side effects of antipsychotics at the molecular level.  It starts by exploring receptors and their ligands and takes a turn into the dorsal striatum where dopamine, acetylcholine, serotonin, and glutamate work together to help us dance the mamba.  Dr. O'Leary explores what happens when the complex pathways of the cortico-striatal-thalamo-cortical tract are disrupted by antipsychotics both in the short term and after many months or years of use.  As the title suggests, there is a ridiculous amount of detail, so let's get our nerd on!

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

The authors of the famous sequenced treatment alternatives to relieve depression trial or STAR*D reported that about two-thirds or 67% of patients had achieved remission after 4 trials of antidepressant medication.   This remission rate has been questioned over the years and in October of 2023, the journal BMJ Open published an article that reports to have reanalyzed the date from STAR*D using the original study design.  This re-analysis found much much lower rates of remission.  It reported the cumulative remission rate as only 35 percent.  How do two different sets of researchers using the same data set get a result that is just half of what the other researchers reported?  That is the mystery that I report on today.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

This episode is about dopamine.  In episode 32, I discussed the pseudoscientific trend of the “dopamine detox”  or "dopamine fasting."  Instead of talking about pseudoscience in this episode, I discuss the actual science surrounding dopamine and its relationship with the neuroleptics or antipsychotics as they are more commonly known.   The effects and side effects of antipsychotics are related to the function of the major dopamine networks of the brain: the mesolimbic, mesocortical, nigrostriatal, and tuberoinfundibular pathways.  Dopamine levels in each of these pathways can be regulated also by serotonin receptors, and so this episode contains a discussion of how first generation, second generation, and novel antipsychotics affect dopamine by affecting serotonin receptors.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

In this Episode, I  continue an intermittent series called “In A Word.”  The difference between prior episodes and this one is that today I have two words.  I chose these words because I don’t really know the difference between them, and even after reading and trying to understand the difference, I am not sure that there is a clear difference.  The two words are Impulsive and Compulsive.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

I discuss something  that is likely to present itself to a physician long after the fact: a single mild brain injury.  This episode focuses on how to classify the severity of a single brain injury.  While working in a brain injury unit, I noticed that some providers used the term severe brain injury when referring patients to neurology or neuropsychiatry, and this communicates something very specific that they may not realize they are communicating. Those of us seeing a patient after a brain injury may not know the specific terminology to use, so this episode is meant to help the listener understand how brain injury experts classify these injuries.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

This episode continues a series on the prefrontal cortex, a complex region of the brain that gives us the ability to have the kinds of thoughts no other species on earth is known to have.   The medial (or mesial) prefrontal cortex is especially important for emotional and autonomic regulation, attention and goal-directed behaviors (including addiction), and building our sense of self (that is our identity as a thing separate from the world around us), and considering salient aspects of the social context we are in and what others might be thinking (among many other things).

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

In this episode, I am sliding down and under the front part of the brain and consider the orbital frontal cortex, that part of the brain right above and a little behind your eyes.  It is much smaller than the lateral gyri on the prefrontal cortex, but appears to be an important probability generator in our brain when we need to consider different options that can result in different rewards or in order to avoid aversive stimuli.  The most basic kinds of rewards that neuroscientists can study are for food, because lab animals will respond to those, and while the OFC is definitely intimately related to food, in humans, its powers of prognostication are much more generalized.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

We seem to understand the specializations of the the dorsolateral prefrontal cortex on the left better than the right side of our brain.  That is because most of us do a lot more language processing on the left or dominant side.  The more inferior and caudal parts of the dorsolateral PFC on the left side are more specialized for speech.  The more superior parts are more involved in working memory, attention control, and task switching.  The entire DLPFC is extensively connected to other cortical regions that pass information to it for consideration, and the DLPFC is extensively connected to the supplementary and motor regions that help to plan actions, and the striatum, which helps coordinate those actions.   It is also intimately involved with motivation and helps us to control our emotions.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

Besides being relatively hairless apes, there are some things about humans that make us special among animals.  In the past we have noted things like, “We have big brains and we use tools,” or “We contemplate the future and our own mortality,” or “We use a truly complex language both verbal and written to communicate complex ideas.”  These are things we have and do, but what is it about our brains that makes that possible.  More and more we are identifying crucial hubs or nodes within our brain that specialize in various tasks, but none of these work alone. I am going to start by discussing that big blob of gooey mush on the front of our brains called the prefrontal cortex, and in subsequent episodes, I will discuss how these regions function in tandem with deeper structures within the brain to create what we think of when we say “human.”

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

This episode is about how to decide whether to send a patient to get neuropsychological or just psychological testing, and this decision is determined by at least two things.  The first is the question that you are trying to answer.   The second  is, what can the service that I am referring to provide for the patient?  In this episode, I will focus primarily on the first consideration:  the question that you are asking.  As a referring provider, then, it is helpful to know what kinds of tests a psychologist or neuropsychologist can administer, because these are designed to answer very specific questions. 

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

Today I discuss the term “validity.”  Let’s say we wanted to develop a test that identifies pathological character traits or quantifies depression symptom burden on a patient.  A good test is going to do more than simply list the diagnostic criteria for various diagnoses and then ask the patient if they think that sounds like them.  A test needs to have a few things.  First it needs to have a defined purpose.  Is it to be used for diagnosis in a clinic or for research?  Is it going to measure symptoms in already diagnosed patients and track their response to therapy?  Is it meant to predict if a person would be a good candidate for something like being an astronaut or a member of the military?  Once the purpose is determined, then you need to define something called a construct, and then you have to determine the validity of that construct.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

Today I talk about guns.  More specifically, I talk about talking about guns.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

Today I am continuing an intermittent series called, “In a Word,” and the word that I chose for today is akathisia.  Akathisia is broadly defined as an inability to remain still.  If you ask someone with Akathisia to stop moving, they will likely become very uncomfortable, but while they are moving, they experience at least some relief.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

There is a narrative wave in popular psychology and neuroscience that has taken a small amount of very basic science and twisted it into a fantastic narrative of feast and famine.  Its central character is dopamine.  The Dopamine Detox also known as dopamine fasting is a pseudoscientific treatment that at best illustrates how magnificently strange and evidence-less some claims about dopamine can be.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

I have recently added some artificial intelligence produced answers to psychiatry questions in my past episodes in an effort to try to understand what it is that AI text generators can do and what value they might add to my future as a psychiatrist versus what problems it might introduce into my practice. I realized that since I have opened this pandora's box, I need to provide some more context. 

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

What is a placebo?  You may already be thinking something like: A placebo is an imitation, fake, sham, decoy, or trick treatment that we give to people in studies to see if the treatment under investigation is any better or worse.  Placebos are supposed to be both benign and inert, meaning they should neither harm nor help a patient beyond the patient feeling or reporting that they are better or worse after they received some kind of treatment.  It seems strange that there is something that can take innumerable forms and still seems to work at least a little bit on so many different things. Placebos are like an all-powerful potion or magic spell.  For some treatments, even active treatments, placebo effects account for the vast majority of the effect size and it is not just an illusion.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

This episode is the second in an intermittent series I am calling In A Word. Psychiatry is full of terms that are either poorly defined or used in such broad ways that they are not very helpful by themselves.  Trying to come to terms with terms we throw around can help us to understand the conditions we treat better, and hopefully will help us to communicate more precisely and effectively in the future.  Dissociation is a word that has frustrated me.  I have heard it used to describe everything from daydreaming to a feeling of complete detachment of someone from their own body to having lost a previous identity and adopted a new one.  The term is used to describe various aspects of many psychiatric disorders.  It is prominently featured in disorders like borderline personality disorder and post-traumatic stress disorder. There is even a controversial diagnosis called Dissociative Identity Disorder.

At the end, I give ChatGPT another go.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

Bayesian reasoning is likely operating in your mind whether you realize it or not, whether you can do the math or not.  In this episode, Dr. O'Leary explores how to explicitly use Bayesian reasoning to put actual numbers to our inherent biases.  Attention Deficit Hyperactivity Disorder (ADHD) seems like a good place to start.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

You may have heard that Dr. Google now has some serious competition.  It comes from artificial intelligence. Chat GPT is a text generating program that was trained to respond to prompts from users like you and me.  What will it say to our psychiatry patients?  I gave it some prompts to find out.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

Society is in upheaval in the way that it discusses mental health.  There are many loud voices out there. Some of these advocate for more openness and less stigma with regard to how we treat people with behavioral and psychological disorders, and by "treat," I don’t mean with drugs or therapy, but with our words, actions, policies, laws, and inaction.  One example of these voices is Dr. Jake Goodman who posed with a pill on his tongue in a TIC TOC post to demonstrate that even as a physician, he may also need medication assistance for his mental health.  The outpouring of support, vitriol and shenanigans that resulted demonstrates how divided our society is on this issue, and in many ways how unrealistic our view of doctors and of mental illness is.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

Dr. O'Leary reviews one of the most frustrating diseases that a patient and their family might approach a psychiatrist with: Huntington’s Disease.  Huntington’s Disease is a neurodegenerative disorder, which means that over the course of the disease neurons die or cease to function correctly and this worsens over time.   The death of neurons in the caudate nucleus and putamen results in choreiform or dance-like movements of the extremities which earned it the moniker “Huntington’s Chorea." Huntington's Disease can result in many psychiatric symptoms and these may start to occur during the prodromal stage before the choreiform movements develop.  Sleep disturbances, apathy, executive dysfunction, memory impairment, personality change, irritability and aggression, disinhibition and impulsivity (including hyper-sexuality), depression, mania, delusions, paranoia and other psychotic symptoms, obsessions and compulsions, and most prominently a high risk of suicide.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

It is unlikely that any model of major depressive disorder is likely to find universal signals among those diagnosed because the symptoms are so diverse.  However, it does seem likely that models, such as brain-network models, will be able to identify common dysfunctions among those with similar symptom burdens (for example, those with primarily anhedonic symptoms, dysphoria, or with excessive rumination over their own worthlessness), and then help identify how various modalities may be more or less effective to treat these symptoms specifically. 

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

Bipolar disorder is a complex, often debilitating and potentially life threatening illness in which the patient goes from episodes of depression to episodes of mania or hypomania, most often with periods of relative euthymia in between these episodes.  The most common way to conceptualize the treatment of bipolar disorder is by phase. The ideal goal would be preventing the distinct manic and depressive episodes. This is done mostly with medications although psychotherapy, lifestyle modifications and even neuromodulation potentially have a role.  A particularly difficult aspect of bipolar disorder is treating the acute phase of bipolar depression. Each is treated mostly with psychotropic medication. In this Episode, Dr. DePietro will focus on treating acute bipolar depression.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

In previous episodes I have tried to draw pictures in your mind (using those fat crayons that babies like to chew on) of some of the brain networks that are important in many mental illnesses.  We have talked specifically about the Default Mode Network (that is concerned with imaginal thoughts and self-referential thoughts and memories), the Dorsal and Ventral Attention Networks (that help us to identify and pick out details of both our environment and our thoughts and memories), and the Salience Network (that brings the most important details of our perceptions, thoughts, and memories to the forefront of our mind).  What we are missing is a network that takes those salient things, considers alternative options about what they mean and what to do about them, organizes a plan to execute, and motivates us to move.  Our Central Executive Network and its connections to the other networks are integral in these processes.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

What is salience?  Fundamentally it is a value judgment that determines where your brain will place its limited resources.  There are a lot of things that could draw our attention.  The world is full of sights, sounds, smells, pressures, temperatures, stretches.  Our mind is full of thoughts.  Without a salience network, we wouldn’t know what matters and what doesn’t.  We would just randomly scan our thoughts and the environment and hope what we are noticing at any point in time is what will help keep us alive.  That is a losing evolutionary strategy.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

Today, I am going to explore the Attention Networks, which are the parts of our brain that get really excited when, for example, we see something that we have never seen before, something that appears to be moving on its own volition (and might harm us), something that appears out of place (like an eyeball on the floor), or something that reminds us of something we really want (I’ll let you pick the example).

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

Behaviors are complex.  We have networks of neurons functioning in systems, some of which ramp other systems up, and some of which dampen others down.  This ballet of correlation (when increased activity in one network predicts increased activity in another) and anticorrelation (when increased activity in one network predicts decreased activity in another) can help us to understand what is going on in the brains of humans who qualify for psychiatric diagnoses, and can help us to develop better targeted treatments that will predictably increase activity in select areas of the brain. Today I  discuss a single networking hub in the brain: the default mode network.

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References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

One of the most influential models in psychiatry’s history for understanding brain dysfunction is the monoamine hypothesis.  In short, it proposes that deficiencies or excess of certain neuromodulating agents, in particular the monoamines serotonin, dopamine, and norepinephrine (AKA noradrenaline) drive many psychiatric disorders.  The paper I will primarily reference is a publication by the same name in 2016 by Montoya, Bruins, Katzman, and Blier inNeuropsychiatric Disease and Treatment.  Its basic proposal is that, at the time of publication, there were at least 52 controlled clinical trials published that consistently showed a benefit of using SNRIs (like venlafaxine and duloxetine) and NERIs (like atomoxetine and reboxitine) for reducing anxiety in patients without the expected side effect of noradrenergic agents: to increase anxiety.  This is a paradox. 

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References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

This is an episode to report updates in the DSM 5-TR that can be practice changing.  I will also divulge a little about myself and how my philosophy and values have changed. In particular, I am reminded of how I have struggled to understand transgendered and other gendered individuals.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

I originally promised a review of the Bush Francis Catatonia Rating Scale, but while reviewing it, I came across some questions that I think are even more interesting.  I will discuss Bush Francis, but I want to do it in a larger context of the challenges that Psychiatrists face with diagnosis in general.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

Dr. Odiscusses the remaining hyperactive or “excited” signs of catatonia including echolalia, echopraxia, and agitation.  In previous episodes, Dr. O discussed other hyperactive or “excited” signs, including mannerisms and stereotypy.  All of these signs share the common feature that the patient is doing something odd, repetitive, or unexpected.  Dr. O also gets on his soap box about the arbitrary use of the term agitation to describe patients.

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References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

In this episode, I discuss Catalepsy, Postering, Grimacing and Waxy Flexibility. I grouped the diagnostic signs that I am going to cover today because they are all similar.  Your patient acts like a wax statue.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

Stupor, Mutism, and Negativism on the surface appear to have some overlapping features.  Of all the features of catatonia that non-experts might be able to describe, stupor and mutism are like the ones.  They are also the most common signs.  A patient is not entirely unconscious, but they don’t move, they stare forward, they don’t talk, and they don’t follow commands.

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References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

In the last episode, I promised [or threatened] to get into more of the nitty-gritty of the symptoms of catatonia.  Well, like it or not, that is what I am going to do in this episode.  Today I will focus on Mannerisms and Stereotypy, two of the potential signs of catatonia.

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References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

In this episode, I introduce a diagnosis that is not a diagnosis.  By that, I mean that it is a condition that we may find our patients in, but it is not considered to be a diagnosis by itself, like major depressive disorder or schizophrenia are considered to be diagnoses.  I am talking about catatonia, a condition characterized by either a lack of interaction with the world or as purposeless interaction with the world.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

This episode is a quick take in a new intermittent series I am calling “In a Word,” and in this series I hope to dig down into some neuropsychiatric terms that we use every day, but maybe don’t really understand very well.  The first word I am taking on is PERSEVERATION.  The reason I chose PERSEVERATION is because I see it written in psych notes by med studs and residents frequently, but for you Princess Bride fans out there, “You keep using this word.  I don’t not think it means what you think it means.”

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

My last three episodes focussed on classical cases of Obsessive Compulsive Disorder, but the DSM 5 has included a few other related diagnoses in the same chapter including body dysmorphic disorder (BDD), hoarding disorder, trichotillomania, and excoriation disorder.  Each of these have distinct obsessional components and compulsions, age of onset, degree of insight, and chronic course.  Hence, they get their own diagnostic category.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

I briefly explore how to treat patients with OCD.  Choosing first-line treatment is relatively straight-forward, but there is less clarity on how to proceed if my patient does not respond.  It is imperative, then, to make sure that I understand my patient’s symptoms and their goals very well.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

This episode explores the brain space of obsessive compulsive disorder (OCD) with a creative journey through neuroanatomy and brain circuitry.  I try to make it much less boring than it sounds.  After listening to this episode, it is my goal that the listener will understand the complex interactions of the cortico-striatal-thalamo-cortical (CSTC) circuit and have a fuller appreciating of how the brain decides what to do and how to do it.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

In previous episodes, I’ve hacked a path through Electroconvulsive Therapy and Transcranial Magnetic Stimulation, trying to reveal some of the secrets in those jungles.  Now I am turning my machete to a different landscape: Obsessive Compulsive Disorder or OCD for short.  The name is confusing, because the writers of the DSM decided to name a personality disorder Obsessive Compulsive Personality Disorder or OCPD, but this podcast is not about a personality disorder.  It is about a neuropsychiatric disorder. I’m going to try to wrap our collective heads around the concept of the OCD itself.  And for that, we’ll need a little history lesson which starts by asking the question: What’s in a name?

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

This episode is dedicated to all the med studs and residents who cringe every time they have to go to journal club. I report the results of an initial trial of a special kind of Transcranial Magnetic Stimulation of the brain that might be the future of depression treatment, at least for the treatment resistant or severe varieties.  I also use this as an opportunity to explain a little more about how repetitive TMS is usually performed (that is, its current FDA approved form), killing two dinosaurs with one asteroid.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

I wanted to do this episode, because when I did my episodes on electroconvulsive therapy (or ECT), I feel like I sounded a tiddly-bit dismissive of it, and I wanted to clarify what I meant when I said, “TMS, short for Transcranial Magnetic Stimulation of the Brain, as of yet is not nearly as efficacious as ECT.”  If you haven’t listened to the ECT episodes, you should still be able to follow this discussion, so don’t feel left out.  I give a history of TMS development, discuss some of its approved indications, and outline  three important ways that TMS is not as effective as ECT.  I also mention some promising evidence that TMS is gaining rapidly in at least two of these ways.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

In the last episode, I gave a brief discussion about how electroconvulsive therapy (ECT) works by causing convulsive seizures and discussed some of the proposed mechanisms by which seizures might result in benefit.  In this episode, I discuss who you should consider sending for ECT, some of the considerations for different patient populations, and how you might approach explaining to a patient that you want to electrify their skull and make them seize.

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References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

The mechanism of action of electroconvulsive therapy remains elusive, so I am going to describe how ECT induces seizures, discuss the evidence that ECT is not just an elaborate placebo (or in other words, inducing the seizure is what results in the therapeutic benefit), and then briefly discuss some of the many proposed mechanisms by which it might work.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

A brief and exciting history of electroconvulsive therapy.  You will learn how a method for anesthetizing pigs before slaughter was first used on a homeless and psychotic man and how it soon became the gold standard treatment for severe mood disorders.

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References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

Dr. O'Leary explains what inspired him to start this podcast, where the first episodes will take you, and why you should be skeptical of everything he says.

Please leave feedback at https://www.psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.