Psychiatry & Psychotherapy Podcast
By David Puder, M.D.
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Join David Puder as he covers different topics on psychiatry and psychotherapy. He will draw from the wisdom of his mentors, research, in-session therapy and psychiatry experience, and his own journey through mental health to discuss topics that affect mental health professionals and popsychology enthusiasts alike. Through interviews, he will dialogue with both medical students, residents and expert psychiatrists and psychotherapists, and even with people who have been through their own mental health journey. This podcast was created to help others in their journey to becoming wise, empathic, genuine and connected in their personal and professional lives.
||CleanHow Empathy Works And How To Improve It||Link to show on: iTunes, Google Play, Stitcher, Overcast, PlayerFM, PodBean, TuneIn, Podtail, Blubrry, Podfanatic What is empathy? Empathy is the ability to understand another’s state of mind or emotions. It is also is being able to feel, understand and share with someone else in what they are saying, their meaning of life, their motivations and values. In research there are 3 types of empathy that are commonly described: cognitive, affective, and compassionate. Cognitive empathy Cognitive empathy is also known as perspective taking, and it can help someone understand another’s personal experience. It also tends to reduce interpersonal aggression. Cognitive empathy is exactly what it sounds like—cognitively understanding someone’s situation, emotions, and motivations. When we understand someone else, we are more likely to view their behavior as similar to our own. One study of Asperger syndrome showed they had lower cognitive empathy but NOT affective empathy. (Dziobek, 2008) Affective empathy Affective empathy is about a shared emotional experience, one of feeling together. It uses the mirror neuron system, which I will discuss later on in the article. Affective empathy forms powerful emotional relationships. Boys with higher aggression had ½ the affective empathy, but the same level of cognitive empathy, as the non aggressive control group (Schechtman, 2002) Compassionate empathyThe third form of empathy is compassionate empathy, which is also called empathic motivation, prosocial concern, or sympathy. This is when you feel moved to help another from how to experience their reality. The science of empathyMirror Neurons are sharing neuronsOur brain has neurons solely designed to mirror other people. From birth, when we focus on another's movements, emotions and intentions, our brain lights up automatically, and largely unconsciously, around 10% the same way. Our own body-state can be derived from someone else outside of us. We can therefore understand and map out the mind of others by placing ourselves in a comparable body state. This process is important for empathy, intuition, transference, countertransference, enactment, projection, internalization and intersubjectivity. The discovery of mirror neurons:In 1992, while studying a monkey's brain with electrodes attached to the motor area (the area that lights up when movements by the body are made), researchers accidentally discovered that not only would the neurons become activated by the monkey reaching out to pick up a piece of food, but also when the researchers made a similar movement. Later, the same team published a paper that showed that there were mirror neurons responding to mouth actions and facial expressions. Further studies confirmed that around 10% of neurons in certain areas of a monkey's brain had mirror abilities. Later, these studies were expanded to humans. Current research:A recent study summarizing the data of 125 fMRI studies of humans (brain imaging that shows what is active), found that there were many areas of the brain with this capacity. (Molenberghs, 2012) Beyond seeing actions performed by others and having them represented in our brain, there are 3 other areas of the brain that are activated in a similar fashion: Ever wonder why watching people embrace enthusiastically at an airport is fun? When you observe someone being touched, a similar area in your brain (the secondary somatosensory cortex) activates in a similar way as the person being touched. (Keysers, 2004) When you only hear something, like someone cracking open a peanut, how do you know what is occurring? Another study showed that there was a similar brain circuit firing in both doing the action and hearing it, and just hearing it. This study also showed that those with higher scores on perspective taking (ability to slip into another's shoes) had stro||1/7/2019||Free||View in iTunes|
||CleanADHD: Diagnosis, Symptoms & Treatment||Link to show on: iTunes, Google Play, Stitcher, Overcast, PlayerFM, PodBean, TuneIn, Podtail, Blubrry, PodfanaticIn this week’s episode of the podcast, I interview Dr. Michael Cummings about psychopharmacology for Attention Deficit/Hyperactivity Disorder (ADHD). We talk about the symptoms, the treatments, and the typical myths about the disorder. What is ADHD? ADHD is a brain neurotransmitter disorder that affects a person’s ability to concentrate, their social interactivity, and their impulsivity. Diagnosing ADHDPeople who truly have ADHD typically experience inattentive and hyper symptoms across all areas of their life. For example, if they are in a job that requires periods of attention to complete or organize a project, it will be inherently more difficult for people with ADHD. One of the things that’s important in diagnosing people (particularly younger people) is their collateral history. People around the person with suspected ADHD are often more aware of the person’s deficits than the person themselves. When they reach adulthood, the problems might be made more obvious when they integrate into normal society and notice they struggle with symptoms of ADHD (compared to other people). Although not required for diagnosis, PhD level psychologists can do psychological testing, along with ADD/ADHD testing and IQ testing, to get a full idea of the patient’s symptoms. It helps confirm the diagnosis because these tests are widely used among the entire population, which provides a large sample mean to compare with. It’s also helpful to get a benchmark of performance before beginning treatment and then follow it up with later testing to see how effective the treatment has been. Myths about ADHDIf a child is hyper, he or she has ADHD.ADHD diagnosis has, at times, been a fad in the public, leading to many misdiagnoses and overmedicating, especially in children. Children are inherently hyperactive and less attentive than adults are. Doctors who are performing diagnostic tests must really pay attention to the criteria in children to make sure that the magnitude of the problems truly cause stress and social dysfunction before they try to diagnose or medicate a child. For example, the LA times published an article that ⅓ of the children in Orange County suffered from ADHD. Real studies show that prevalence in children is around 6-8%, in adolescence about 2.8%, and in adults about 2.5% of the population. ADHD disappears with the onset of puberty.Attentional deficits sometimes remains into adulthood, while hyperactivity may disappear as a child matures. We are giving people methamphetamines as medication. Methamphetamines and amphetamines are completely different drugs on a molecular level. The methyl group paired with amphetamines increases its absorption and effect on the brain. The amphetamines that are used to treat ADHD are essentially variants of dextroamphetamines. There are even versions that are difficult to abuse, such as with vyvanse, where lysine (the amino acid) is bound to the amphetamine. The lysine make the amphetamines unabsorbable unless it’s in the GI tract. It cannot be inhaled or injected and still be effective. Similarly, some of the slow-release versions are encapsulated in pills that won’t release the drug easily, except very slowly in the GI tract, making it difficult to divert or abuse those formulations. Dopamine stimulants are the only treatments for ADHD.There are other drugs that are useful for ADHD symptoms. They are (for the most part) drugs that increase brain norepinephrine. They can be used for people who don’t tolerate increases in dopamine, or for other reasons cannot be treated with dopaminergic agents. The most common side effect from amphetamines are increased anxiety, insomnia, increased sweating, hypertension, heart rate and blood pressure. These are things that ca||12/14/2018||Free||View in iTunes|
||CleanUnderstanding Placebo||sign up for an annual subscription to receive CME credit for this activity and more! Learn more Here.On this week’s episode of the Psychiatry and Psychotherapy podcast, I interview Mark Ard, M.D., a third year psychiatry resident at Loma Linda University. On the state level, he works towards developing means of access to care, in-patient psychiatric care, affordability of care, and further access to mental health. Mark is also the person who encouraged me to start pursuing weight training through Starting Strength, which we will link in this article. Link to show on: iTunes, Google Play, Stitcher, Overcast, PlayerFM, PodBean, TuneIn, Podtail, Blubrry, PodfanaticUnderstanding PlaceboDavid Puder, M.D., Mikyla Cho, Mark Ard, M.D. What is placebo? The original meaning of the word placebo is, “I will please.” That statement comes from a time when doctors didn’t have our modern code of ethics, and they would prescribe whatever would make the person feel better. They probably had the best intentions, but they also would have known that whatever they were prescribing might not have been a real medication for the symptoms the patient was experiencing. Doctors, even then, knew that suggestion was powerful, sometimes more powerful than the medicine they were prescribing. Laypeople who hear the word “placebo” automatically think of sugar pills. They may think only that it’s something a doctor gives to placate and make people feel better when they aren’t getting the active medication. Placebos have long been used as a comparison arm for clinical trials. Usually it is in the form of an inert sugar pill or sham-procedure. Researchers can observe a psychobiological response known as the placebo effect. But when thinking about the word “placebo,” we must think of the entire effect of it, and it is perhaps better termed “the meaning effect.” As I discussed in last week’s episode of the podcast, the meaning we give something creates belief, and belief is a potent change mechanism, even when it comes to our physical health. It is especially potent when it comes to mental health. The placebo effect encompasses the therapeutic alliance, expectations, natural healing of the body and mind, and the environment of therapy. It involves the power of suggestion, mood, and the beliefs behind even one positive or negative interaction with a doctor. It also, as we will see, involves studies involving heavy-hitting medication. When there is an increased ritual, there is an increased placebo effect. During a hospital stay, the surgery preparation, meetings with doctors, nurses and therapists can have an incredibly therapeutic effect on a patient. It is possible to see biological mechanisms triggered by psychosocial context and attribute it to a placebo effect. What is the power of suggestion, the meaning effect, placebo effect, and how do we use it or avoid it in our practices and when testing new medical treatments? Why do we study placebo?We study placebos because we need to understand how meaning works, how belief works, and on the other side, if a medicine actually works. As doctors, we need to be able to read studies critically, with an eye for placebo. We need to see what actually works and what the study was controlling the treatment group to. We also need to know if there parts of the treatment that are working only because of the placebo effect, and if so, how do we use that to heal people. How does the placebo effect work?The efficacy of the placebo goes up because of the expectation and meaning we give to placebo. In one study, half of the patients got the actual medication, half got the placebo. In the same study, in another group, 25% of the patients got the placebo, and 75% of them got the actual medication. In both of these studies, the participants were told the percentage chance they would get the real m||11/28/2018||Free||View in iTunes|
||CleanPerinatal Mood and Anxiety Disorders||In this podcast and article Dr. Kelly Rivinius, a licensed clinical psychologist who helps women suffering from PMAD, gives her insights about PMAD, its risk factors, prevention, and her own experience with perinatal OCD and anxiety.||11/14/2018||Free||View in iTunes|
||CleanTherapeutic Alliance Part 2: Meaning and Viktor Frankl’s Logotherapy||In the celebrated book Man’s Search for Meaning, author Viktor Frankl wrote about his intimate and horrific Holocaust experience. He found that meaning often came from the prisoners’ small choices—to maintain belief in human dignity in the midst of being tortured and starved and bravely face these hardships together.||10/29/2018||Free||View in iTunes|
||CleanPsychiatric Approach to Delirium with Dr. Timothy Lee||sign up for an annual subscription to receive CME credit for this activity and more! Learn more Here. This week on the podcast, I am joined by Dr. Timothy Lee, the Loma Linda residency program director and the head of medical consult and liaison services. One of his specialities is delirium, so this week we will be discussing both hypoactive and hyperactive delirium. What is delirium? Delirium is an acute change in a person’s sensorium (the perception of one’s environment or understanding of one’s situation). It can include confusion about their orientation, cognition or mental thinking. With hyperactive delirium, a patient can become aggressive, violent and agitated with those around them. A patient experiencing delirium can have hallucinations and hear things, they can become paranoid, and they are overall confused. A family, or non-psychiatric medical staff, might be concerned that the patient is experiencing something like schizophrenia. Hyperactive delirium symptoms in patients: Waxing and waning—it comes and goes Issues with concentration Pulling out medical lines Yelling profanities Throwing things Agitated Responding to things in the room that aren’t there Not acting like themselves Hypoactive delirium is much more common than hyperactive delirium (based on research studies), but it is often missed because the presentation is much less dramatic. People with hypoactive delirium are confused and disoriented, but they do not express their confusion verbally or physically. Hypoactive delirium symptoms: Slower movement Softer speech Slower responses Withdrawn Not eating as much Often, nurses and physicians can miss the fact that the patient has the typical confusion that denotes delirium because the patient is quieter, so it doesn’t come to the attention of the medical team or psychiatrist consult service. Delirium can even be confused for depression. One Mayo Clinic study showed that when consulting a doctor about their depression, 67% of the time, the patient ended up having delirium. Why does delirium happen? Often we see it happen, even to relatively healthy people, in physically stressful situations—post surgery, during an acute illness, or even just being stuck in the hospital for a few days. This does not mean it is indicative of a sudden onset of a long term mental illness, such as schizophrenia. To consider what can cause delirium, I like to think systematically from the top of the body and work my way down. This is by no means exhaustive, but it can be helpful. Many things can cause delirium. I like to think about starting at the top of the body and going down, as a way to not miss the cause. Here are a few we would consider as we go down the body: Stroke—check strength in both arms and legs, have the patient smile Hypertensive emergency Infection or meningitis Physical trauma—concussion, head injury with initial loss of consciousness, then after regaining consciousness they can have delirium Brain bleeding Medications that affect the brain, such as ones that produce anticholinergic side effects. (They suppress acetylcholine, causing brain imbalances and confusion. Anti-allergy medicines, pain medications, and some psychiatric medications are anticholinergic.) Circulatory issues Thyroid imbalances or parathyroid hormones Cancer Heart attack Traumatic injury to the heart Aspiration pneumonia Lung infection Lung cancer Viral pneumonia Pancreatic inflammation Urinary tract infections in women Liver cirrhosis Hepatitis Gallbladder inflammation Low bilirubin Hepatic encephalopathy How do we identify delirium in a patient? Asking certain questions to the patient and/or medical team and family can help us understand if the patient is experiencing delirium. Often, a patient experiencing delirium will still know where they are, what they are doing, and who they are. The main test to really||10/8/2018||Free||View in iTunes|
||CleanKetamine and Psychedelics with Dr. Michael Cummings||What has piqued interest in psychiatry is that infusion of a smaller dose of ketamine produces a rapid response in terms of reversal of depressed mood, suicidality, and some treatment-resistant depressed patients.||9/24/2018||Free||View in iTunes|
||CleanWhat is psychodynamic theory?||sign up for an annual subscription to receive CME credit for this activity and more! Learn more Here.On this week’s episode of the podcast, I interviewed Allison Maxwell-Johnson, a social worker and PhD student of clinical social work. I refer patients to her regularly for psychoanalysis, and she has had a wonderful impact on their mental health journey. Link to show on: iTunes, Google Play, Stitcher, Overcast, PlayerFM, PodBean, TuneIn, Podtail, Blubrry, Podfanatic Psychodynamic therapy is a form of talk therapy where the practitioner work focuses on the patient’s emotion, fantasies, dreams, unconscious drives and wishes, early and current life relationships, and the relationship that is forming between the patient and therapist. The history of psychodynamic therapySigmund Freud is known as the father of psychodynamic therapy. He practiced in the late 1800’s and early 1900’s. Some psychiatrists and therapists think that Freud has been debunked because he is a controversial figure. But my colleague, Allison Maxwell, and I, think his impact on furthering the mental health field has been positive. Historically, people with borderline personality disorder, somatic disorder and post traumatic stress disorder (PTSD) were all grouped under the title of “hysteria.” A few hundred years ago, these people would have been killed as witches, put in asylums, and there wasn’t much ability to, or interest in, digging into their psyche. There was certainly no warmth or empathy given to them. Freud began to grapple with those deeper, tougher issues, claiming it wasn’t just a medical disorder. He gave empathy, and a level of connectedness to his patients that hadn’t been done before. As the first psychoanalyst, he was a pioneer in his field, and he figured out that having an emotionally connected relationship with his patients (he would even have is patients over for dinner and go for walks with them) could actually heal the patient. AffectAffect is something therapists need to pay attention to when it comes to each individual patient. It’s about noting the facial and emotional state of the person. Is the patient emotionally flat or expressive? Are they depressed or happy? Are they peaceful or agitated? We focus on their emotional state and try to lean in to understand what a patient is feeling during a session. As the doctor or therapist, what is the emotional reaction you're having to the patient, in the moment? Analyze the situation—both your feelings and theirs. Ask them for clarification on their feelings, then ask yourself how you can use that information to understand and connect with the patient emotionally. There are multiple emotions going on which can be conflicting. We need to ask ourselves if we can empathize with the distress that is in the room. It’s not only about intellectually understanding what’s happening with a patient, or diagnosis. It’s about understanding how to create an emotional connection and help someone. TransferenceA therapist applies the principle of transference when we pay attention to the emotional state the patient has towards them. If the therapist reminds them of their abusive father, and they react emotionally, it’s a classic transference situation. Understanding transference can help a therapist remain empathic and curious, even when a patient is angry at them. Transference can be seen in their complete reaction towards you, both from their past, and how you are interacting with them. CountertransferenceAs therapists, we are also humans. We will have reactions to the patients we work with. Countertransference is the complete reaction we have towards our patients, both coming from how the patient reminds us of people from our past, and our reaction towards the things that the patient is uniquely doing. The unconscious exists both in our patients and||9/19/2018||Free||View in iTunes|
||CleanAdvice for medical students applying to psychiatric residency||sign up for an annual subscription to receive CME credit for this activity and more! Learn more Here. Timothy Lee has talked to thousands of medical students about how to applying for residency programs, and here, he gives us a few tips on how to make it through the gauntlet, and how to have your best chance at landing the program you want. Here is what Timothy Lee says: Stay calmMany students have been fine tuning their personal statements, and trying to get their resume just right, or hurrying to press the faculty to write letters of recommendation. It can be very stressful. It’s okay to turn in information a little bit later, in order to have all of the paperwork you need. It’s even okay to review your statement after you’ve already turned it in. No one will lower their opinion based on that. You will need to have applied for the majority of the programs you are interested in by early or mid-October, otherwise the program director might wonder if you’re applying to them later as a backup plan. What matters in a personal statement?Every program director will have different opinions on what you write, and every program director will be looking for different things from your personal statement. For some people, it’s a chance to get to know the applicant a little bit. For others, it doesn’t really matter that much. As long as your grammar and syntax are competent, you should be fine. Some people don’t worry about the format, and others are more particular. To be on the safe side, if you have access to a good mentor, run it by them. Also, don’t be too wordy—stick to a page and a half. Do step scores matter? Step scores are a very convenient screening tool for what matters, but there are studies that show that step scores are not directly correlated to success in residency performance. They are helpful, but are not the end-all-be-all. It’s only one part of the picture of an applicant. However, if you are going for a highly-competitive school, you might need to worry about step scores a bit more. Apply to the right number of programsThe number of programs is not the only way to increase your chance of success of getting in. Pay attention to the types of programs you are applying to as well. If you are applying for a good number of programs, make sure at least half of them are are ones you are a solid and potentially attractive candidate for. Keep a good perspectiveUltimately, you are more than your CV, step score, or personal statement. If patients like you, that’s going to go a long ways. Your patients won’t know your scores, or where you graduated from medical school. They will know if you were competent, caring and connected. That is ultimately what matters.||9/15/2018||Free||View in iTunes|
||CleanTherapeutic Alliance Part 1||sign up for an annual subscription to receive CME credit for this activity and more! Learn more Here. Link to show on: iTunes, Google Play, Stitcher, Overcast, PlayerFM, PodBean, TuneIn, Podtail, Blubrry, Podfanatic What is a therapeutic alliance?The therapeutic alliance is a collaborative relationship between the physician and the patient. Together, you jointly establish goals, desires, and expectations of your working partnership. Every interview with a patient, whether it’s for diagnostic, intake, evaluative, or psychopharmacology purposes, has therapeutic potential. The treatment starts from your first greeting—how you listen, empathize, and even how you say goodbye. It’s built from a partnership and dialogue, like any other relationship. It’s not built from medical interrogation. It’s not about pulling medical information to be able to make a diagnosis. We have to make it a positive experience for patient, so they can begin to talk about what's negative in their lives. The therapeutic alliance is full of meaning, and it uses every emotional transaction therapeutically. If they get angry, sad, or have fear you will abandon them, as a therapist, it’s our job to figure out how to help them through that feeling within the relationship. The doctor can express desire for the patient to share, in real time, how the patient is feeling, even about his or her relationship with the doctor. Why do we care?We all know that some talk therapists have better outcomes than other talk therapists. What’s interesting though, is that some some psychiatrists’ placebos worked better than other psychiatrists’ active drugs. One study of NIMH data of 112 depressed patients treated by 9 psychiatrists with placebo or imipramine, found that variance in BDI score (a score that measures depression) due to medication, was 3.4% and variance due to psychiatrist was 9.1%. One-third of psychiatrists had better outcomes with the placebo than one-third had with imipramine. Another book argues that the therapist is more important to outcome than theory or technique. Many other studies have shown that therapeutic alliance directly correlates to success rates. What builds a therapeutic alliance?Research shows there are a few things that grow therapeutic alliance: Expertness Facilitating a greater level of understanding When residents are worried they are an imposter, I tell them that humility is good, but realize that you have experience that most will never have, medical school, being highly educated, being around vast different ways of thinking and reflecting on the world... Consistency Structuring your office to run on time. Being consistent to respond to refill request, lab results, or patient’s questions. Non-verbal gestures Eye contact Leaning forward Mirroring of emotion occurs naturally when people pay attention to emotion Maintenance of the therapeutic frame A dual relationship (eg, dating) breaks down therapeutic alliance. Patients will test the frame. It can be helpful to say, "There will be positive and negative feelings between us and what will be safe is to talk about them." Empathy, attunement, positive regard Patient: “Therapist is both understanding and affirming." Patient: “Therapist adopts supportive stance.” Patient: “Therapist is sensitive to patient’s feelings, attuned to patient, empathic.” Research has found that for beginning therapists, setting and maintaining treatment goals is harder Research has shown that strength of therapeutic bond is not associated with level of training Therapist should appear alert, relaxed and confident rather than bored, distracted and tired Foundational concepts of the therapeutic allianceOur profession gives us a privileged glimpse into the human heart and mind. Each patient is idiosyncratic, unique, precious. Each patient has unique strengths which we should pla||9/5/2018||Free||View in iTunes|
||CleanHow to Treat Emotional Trauma||This week on the podcast I spoke with fellow therapist, Randy Stinnett Psy. D, about how trauma works, and how we can help our patients overcome it.||8/22/2018||Free||View in iTunes|
||CleanSetting Boundaries in Relationships||sign up for an annual subscription to receive CME credit for this activity and more! Learn more Here. Link to show on: iTunes, Google Play, Stitcher, Overcast, PlayerFM, PodBean, TuneIn, Podtail, Blubrry, Podfanatic What are boundaries?When we refer to boundaries, we are talking about emotional walls that are healthy. Boundaries are meant to keep us in relationship with the people that we love. Think of them as your property lines around your house. You know where your lines are, where your property ends and your neighbors begins. Therefore you know what you are supposed to take care of and what your neighbor is supposed to take care of. A boundary defines our self. Within ourselves, our “property” consists of our physical body, our desires, our intellect, and our ability to make decisions. It gives us a sense of defining what is “me” and what is “not me.” We are not supposed to take on too much of other people’s emotional experiences. When I was a newly practicing psychiatrist, I didn’t know that, and I felt depressed after meeting with a depressed patient. It is possible to have an understanding of what is happening in someone’s emotional world, but not take it on yourself. There is a psychological principle that is common among people who struggle with having good boundaries with others. It’s called “siding with the aggressor.” For example, if someone grows up in a home where the father is constantly displaying angry behavior, a child might learn to develop a sense of humor if he or she learns that will diffuse the situation. Rather than running away from, or fighting back, these people joined with the aggressors, paying attention to them, calming them, helping them. Early on in childhood, people who side with the aggressor understand how to make others happy. This continues into adulthood and is formative in new relationships in how the person would choose to interact with others. I don’t think of it as a weakness, I think of it almost as a superpower—these people are incredibly skilled interpersonally when they get older. They know how to react to others, how to make others happy, and how to make angry people calm down. They are great peacemakers, therapists, and psychiatrists. It was an adaptive feature for them in childhood. But as they grow into adulthood, they need to learn to choose when to use this superpower, or when to have a boundary. My wife, Lindsay, first began learning about boundaries when she was experiencing burnout as a young, working woman. She never said no, always went above and beyond the requirements of her job. And at the end of the night, she was exhausted. After awhile, she started to become upset—upset at herself, and even a her situation. Within the Big 5 personality types test, Lindsay scores high in Trait Agreeableness. People who are high in that trait value relationships, are empathic and helpful. They will do things they don’t want to, merely to maintain their relationships. Women typically test higher in the trait than men. I see many women come into my practice who have high markers of agreeableness—they haven’t found (or been able to express) their boundaries. They have issues with chronic pain, problems with expressing anger, either within themselves, or towards others. It’s also common that these people have no idea that their “helpfulness” is causing them huge amounts of physical pain. People who are caretakers, who feel looped in to being someone’s source for happiness, life, wellbeing, often get looped into these types of situations if they don’t have a strong sense of self. Obviously, many people are caretakers for their relatives. I’m not talking about being a nice person versus being selfish, or being a caretaker versus letting someone you love be alone. I’m talking about the emotional position of your heart during those||8/10/2018||Free||View in iTunes|
||CleanThe History and Nuances of Bipolar Illness||sign up for an annual subscription to receive CME credit for this activity and more! Learn more Here. Link to show on: iTunes, Google Play, Stitcher, Overcast, PlayerFM, PodBean, TuneIn, Podtail, Blubrry, Podfanatic Below is a detailed review of the podcast episode, with most of the content that Dr. Michael Cummings and I (Dr. Puder) discussed. Special thanks to Arvy Wuysang (MS4) for his work in the initial transcription and organization. The history & nuances of bipolar illnessBipolar Illness was first discovered by Emil Kraepelin, who was also the first to describe schizophrenia in the 19th century. Kraepelin noticed another major mental illness in which people had episodic disturbances of mood. He saw either elevation of mood and increased energy, along with a decreased need for sleep, and often impulsive or psychotically related behaviors. Then, the same patient would experience the opposite, sleeping through the day, demonstrating lowered energy and depression. These patients were noted to have normal function in-between these episodes. Nuances of the bipolar illness diagnosisThe Diagnostic Statistical Manual of Mental Disorders (DSM) identifies bipolar illness primarily by the presence of at least one episode of mood elevation to help distinguish it from unipolar or major depressive disorder. Here are some defining symptoms: Patients are fairly normal between episodes. When they’re manic, their mood elevates their lack of sleep. They will sleep four to five hours at first, later progresses to no sleep at all on a nightly basis. Every true manic episode will end in three places: hospitalization of some type, jail, or death. Initial peak is in the 20s and 30s. Although, people suspect that many individuals who become bipolar don’t initially declare themselves. They often present with a series of recurrent depressive episodes and then, at some point, they exhibit a period of mood elevation meeting the criteria for either hypomania or mania, which earns them the diagnostic label of bipolar mood disorder. There are two types. Type I, in which the person has fully evolved to mania or mood elevation and fully evolved episodes of depression. Type II, in which the person may have a milder form of mood elevation but still has fully evolved periods of depression. Grandiosity is a major part of mania. Although historically some people with bipolar illness have often been incredibly productive during episodes of mood elevation, before they become disorganized or psychotic. There is often impaired judgment during manic episodes. For example, someone who is manic will propose to 5 different girls, max out multiple credit cards, buy extra houses/cars/boats, etc. Bipolar and the limbic systemUnderlying pathophysiology is centered around the limbic system. Involves the temporal lobes and and structures which swings upward into the mamillary bodies into the anterior cingulate gyrus, which then projects forward into the frontal lobe. That circuit goes through periods of hypo-activity or depression in people who are bipolar. They have depressed metabolic rates of the system upto 30 to 40 % below normal. During periods of mood elevation, there is an increase in metabolic activity and instability in that limbic circuit. The mood is an element of that, but the person’s overall activity, sleep-wake cycle, circadian rhythms, along with all the things related to the functioning of the limbic system are disturbed in bipolar illness. Bipolar illness and sleep patternsThere are some models of the illness that suggest that perhaps the core of the pathophysiology of bipolar illness is an abnormally regulated biological clock. In most of us, the nerve cells, the neurons that make up the biological clock, are very tightly linked to each other in terms of their operation. They literally form two pacemakers or oscillators in a very s||8/1/2018||Free||View in iTunes|
||CleanThe History, Mechanism and Use of Antidepressants||sign up for an annual subscription to receive CME credit for this activity and more! Learn more Here.In this week’s episode of the podcast, Dr. Michael Cummings and I talk about the history of antidepressants, and their use in overcoming depression and anxiety disorders. Below is a short blog on the topic to complement the podcast and subsequently I you can find detailed notes on the topic further below. Link to show on: iTunes, Google Play, Stitcher, Overcast, PlayerFM, PodBean, TuneIn, Podtail, Blubrry, Podfanatic What is depression?The overarching term “depression” is characterized by feelings of sadness and hopelessness, anxiety, and loss of pleasure. But there are many different types of depression and depressive disorders: Psychotic depression Bipolar disorder with depression Seasonal affective disorder Major depression Chronic depression (dysthymia) Postpartum depression Premenstrual dysphoric disorder Atypical depression Melancholic depression Depression due to a medical illness or medication Some symptoms of depression are: Weight gain or loss Sadness Anxiety Agitation Social isolation Sleep problems Guilt Loss of pleasure Loss of interest in activities Mood swings Major depressionMajor depression is characterized by a continuous feeling of sadness—it does not lift for long periods of time. The average length of an episode of major depression, if not treated, last around 11 months. People with major depressive disorder often had an average of four to eight episodes during their lifetime. Each episode of major depression usually makes the next episode more likely. The annual prevalence rate for major depression estimated in the US and in Europe ranges from 2-7%. But, if somebody has an episode of major depression, the odds that they have a second episode at some point in their life rises to almost 50%. Then, for each episode they have after that, the probability of the next one becomes more likely. For people who had recurrent episodes of major depression, by the time they were in their 50s, 60s, or 70s, they had often become chronically depressed or apathetic; their life had deteriorated significantly. Melancholic depressionMelancholic depression is at the severe end of the depressive spectrum. These people have a severe loss of enjoyment, and they usually lack energy. They often develop mood congruent psychotic symptoms, such as delusions that they are guilty for everything in the world. This tends to be the most resistant form of depression. When severe. people who suffer with melancholic depression sometimes require electroconvulsive therapy to snap them out of a depressive state. Is depression a chemical imbalance? People with recurring bouts of major depression can actually experience anatomical damage to the cortex and the spine, because depression is caused by, and can also cause further, chemical changes in the brain. How does this work? One main marker for major depressive occurence is a rise in the release of corticotropin from the pituitary, which eventually stimulates our adrenal glands to produce more cortisol. There is a 30-40% decline in the rate of metabolic activity among neurons. Lowered metabolic activity among neurons. There is a steep decline in the production of neurotrophic factors, proteins that promote neuron activity and cell growth in the brain. As a consequence, there is a thinning of the cortex, a loss of the dendritic spines on neurons. The history of antidepressantsDoctors used to believe depression was norepinephrine or serotonin deficiency. We now view depression as the inability of the limbic system to be modulated by the neurotransmitters. Antidepressant medications target this problem by increasing the ability of these molecules that deal with our emotions, motivations and memory to do what they need to do. Before antidepressantsPrior to the discovery of antip||7/23/2018||Free||View in iTunes|
||CleanEmotional Shutdown—Understanding Polyvagal Theory||Have you ever felt like you wavered between anxiety and panic, or feeling totally emotionally numb? Did you know that’s one of the ways your body is wired to protect you? There are ways to feel healthy, normal, and deal with the reason you feel that way. This week on the podcast I talk to Dr. Kevin Ing and Adam Borecky about the body’s fight or flight response, and then the deepest response to trauma—emotional shutdown.||7/9/2018||Free||View in iTunes|
||CleanThe Psychology of Procrastination||This week’s podcast guest, Dr. Jackson Brammer used to be an expert procrastinator. He used a few simple tricks to overcome his procrastination habit, and he’s sharing how he transformed his life on this week’s episode of the Psychiatry and Psychotherapy podcast.||7/2/2018||Free||View in iTunes|
||CleanHow to Fix Emotional Detachment||Link to show on: iTunes, Google Play, Stitcher, Overcast, PlayerFM, PodBean, TuneIn, Podtail, Blubrry, Podfanatic This week on the podcast, Ginger Simonton, PhD candidate, and I (Dr. David Puder) talk about about how to deal with emotional detachment. In the psychiatry world, we call the state of emotional detachment, congruence. What is congruence?Psychological congruence is someone’s ability to feel and express their inner emotions in a consistent manner with their outer world—their speech and body language. As an example, have you ever smiled when you’re talking about something sad? Or felt very emotional, yet had a flat face and still posture? Have you ever felt angry, but pushed it down and developed a headache? These are incongruent speech and behavior patterns. Incongruence happens when we’ve lost touch with our inner world, our emotions that are represented with bodily sensations. Many of my patients experience emotions, but have a hard time expressing them with words, so they shove them out of their experience. Emotions are unavoidable. We experience them all the time, whether we know it or not. Common terms for pushing them out of our awareness are suppression, denial, repression, and other defense mechanisms. We may think we can suppress our emotions, but they will come out in one way or another—sometimes through physical pain and illness. There is extensive research on how the body processes emotion, and how that affects us physically. One of my favorite books on this subject is The Body Keeps the Score, by Bessel van der Kolk and The Feeling of What Happens by Antonio Damasio. I have spoken about the science of emotion in part 1, part 2, part 3 on microexpression and a popular episode on the polyvagal theory which give the science and application of understanding emotion. As psychotherapists, our job is to help people reconnect to those emotions, and be able to experience them in healthy ways. People bury so many of our psychological problems in our bodies that we don’t even feel comfortable in our bodies anymore, and we prefer to be numb. People further push unwanted emotions out of their experience through use of drugs, alcohol, and other addictions like porn, gambling, movie binging, or mindlessly scrolling forever on social media. How do we develop incongruence?But we don’t start out as emotionally disconnected, or incongruent. As children, we express our emotions as we feel them. If we are happy, we giggle, smile, or stick out our tongue as we work on a project. If we are sad, we cry. If we are angry, we bite, yell, spit or claw. If we have disgust we spit things out, push things away and protest against putting things in our mouth! If our emotions are mirrored back, and our caretaker acknowledges them verbally, them we optimally will be connected to our bodily responses from a young age. This is why I always recommend starting any discipline or high emotional moment with kids by empathically mirroring their emotions in words, and adding meaning to why they might feel such a way. To get along with others, most kids, over time, develop a normal adaptive way to conceal emotions, which helps function in family and friendships. We learn that there is a context for truly sharing what is going on, and this is a good thing. Sometimes suppressing strong emotion until later is helpful! Stronger issues develop when repeated messages invalidate or shame our experience, or trauma moves us away from being congruent with our inner experience. It is also possible that there is no one who an individual connects with enough to be congruent around. For example, if everyone you know would shame or attack you, it might not be a good idea to bring out your deepest thoughts and emotions. These kinds of households often have heavy drugs or alcohol, severe mental illness, or predators. We are meaning-ma||6/29/2018||Free||View in iTunes|
||CleanThe History and Use of Antipsychotics||In the latest podcast, Dr. Cummings and I talked about antipsychotics, the particular branch of psychopharmacology that deals with medicines that treat psychotic experiences and other mental disorders.||6/18/2018||Free||View in iTunes|
||CleanHow Psychiatric Medications Work with Dr. Cummings||sign up for an annual subscription to receive CME credit for this activity and more! Learn more Here.This week I interviewed Dr. Cummings, a psychopharmacologist, on the Psychiatry and Psychotherapy Podcast. Below is a brief introduction to the episode. For more detailed notes by Dr. Cummings, go to my resource page. Link to show on: iTunes, Google Play, Stitcher, Overcast, PlayerFM, PodBean, TuneIn, Podtail, Blubrry, Podfanatic What is psychopharmacology?Psychopharmacology is a branch of psychiatry that deals with medications that affect the way the brain works. The medicines used in psychopharmacology treat illnesses whose primary concerns and issues are mood, cognitive processes, behavioral control, and major mental disorders. It is a unique branch of pharmacology because the illnesses are usually addressed by both medication and psychotherapy. What makes a drug psychiatric in nature?What makes a drug labeled as psychotherapeutic, is the intent behind the prescription. Some drugs will serve more than one purpose, so understanding why it was prescribed is important. For example, valproic acid is helpful in treating seizure disorders, and also bipolar disorder. For the seizure disorder, it would not be considered a psychotherapeutic drug. For the bipolar disorder, it would be considered a psychotherapeutic drug. How do medications work?All medicines go through the same steps of digestion in our bodies. They are liquified in the stomach, and then absorbed. The drug travels through the liver, and then into the blood supply, which brings it to the organ it was designed to target. Our bodies have receptor sites, made of protein, that sit on the surface of a neuron, or a nerve cell in the brain. The drug, when it reaches that receptor, either binds to it and blocks it, or it can help the neurotransmitter work to further what it does naturally. For example, caffeine is an adenosine blocker. Adenosine is a naturally occurring molecule in our bodies that calms us down as the day wears on, preparing us for sleep. Caffeine, as a drug, blocks our natural adenosine from reaching its receptor; it keeps us awake. Medicines work in the same way—inhibiting or helping certain molecules reach their targeted organs. How absorption and dosage rates affect medicineMany things can affect absorption rate, and medications absorb at different rates, and at different potencies. Things like gastric bypass, (when they take out a part of the stomach and intestines) can affect absorption rate of drugs. One of my patients had a stomach surgery, and afterwards, their depression came back. I told them to start grinding their pills to help with absorption rate of their antidepressant, and their medication started working again. Our livers play the main part in absorption. Sometimes they are gatekeepers, and they can hinder absorption rates dramatically. Animals and plants have been at war for thousands of years. Plants create toxins to try to discourage animals from eating them. Our livers develop different enzymes to break down those toxins in order to make the plants safe for our bodies. Those same enzymes break down medications. Our bodies are constantly adapting and changing, adjusting to what we consume. As a psychiatrist, it’s important to pay attention to absorption rates to make sure our patients are getting maximum benefit. Maybe a patient has defected genes that limit absorption rate, or deficient enzymes to break down the medication. Or maybe other medications are interacting and changing absorption rates. A few times in my practice I have seen patients come in on multiple medications which are interacting poorly. For example, they are on a medication called amitriptyline and also on something that blocks its breakdown like fluoxetine. In our session they complain that they are confused and disoriented. I figure out that the drugs they||6/11/2018||Free||View in iTunes|
||CleanPrescribing Strength Training for Depression||Recent studies show the power of strength training in treating depression. This blog and podcast episode discuss this important treatment of depression.||5/28/2018||Free||View in iTunes|
||CleanUsing Microexpressions in Psychotherapy||In the third and final installment on microexpressions, Ariana Cunningham and Dr. David Puder talk about how learning microexpressions can help you build empathy and connect with other people.||5/23/2018||Free||View in iTunes|
||CleanMicroexpressions: Fear, Surprise, Disgust, Empathy, and Creating Connection Part 2||This week, we will continue uncovering how different microexpressions look on the face and feel in our body, and their corresponding emotions.||5/14/2018||Free||View in iTunes|
||CleanMicroexpressions to Make Microconnections Part 1||Microexpressions are brief, involuntary facial expressions that are cues to the true emotions that someone is feeling. We see microexpressions in tiny twitches of the brows, the lips and nose. They can last for as little as 1/15th of a second on the fac||5/7/2018||Free||View in iTunes|
||CleanHormonal Contraceptives & Mental Health||New research on hormonal contraceptives, “the pill”, and how it influences mental health.||5/2/2018||Free||View in iTunes|
||CleanPostpartum Depression with Dr. Pereau||This week on the podcast, I joined with Dr. Pereau to talk about postpartum depression, both from a personal level and as those who treat it in our patients.||4/23/2018||Free||View in iTunes|
||CleanPerformance Enhancement with Dr. MaryEllen Eller||Our bodies are “wired” to perform. Learning how to consciously modulate your internal sympathetic state is the key to unlocking optimal performance.||4/16/2018||Free||View in iTunes|
||CleanSensorium: Medications, Drugs (THC, Alcohol), Medical Issues, Sleep, and Free Will||How I optimize patients' brain function through choice of medications, drugs, and free will...||4/4/2018||Free||View in iTunes|
||CleanExercise as a Prescription for Depression, Anxiety, Chronic Stress (like Diabetes) and Sensorium||Exercise is a powerful way to optimize mood and sensorium for the long term||3/22/2018||Free||View in iTunes|
||CleanDiet on Cognitive Function, Brain Optimization, Sensorium Part 2||Dr. David Puder covers research on how to optimize brain function through diet.||3/14/2018||Free||View in iTunes|
||CleanSchizophrenia with Dr. Cummings: Controversies, Brain Science, Crime, History, Exercise, Successful Treatment||We covered schizophrenia: brain changes, long term treatment, violence, lifestyle and controversy...||3/5/2018||Free||View in iTunes|
||CleanPhysicians Receiving Treatment, with Dr. Trenkle||We discussed difficulties we had in contemplating getting care for different issues we faced. Hopefully this will open a discussion regarding the conflicts providers have in engaging needed help.||2/27/2018||Free||View in iTunes|
||CleanSensorium: Total Brain Function Optimization Part 1||Sensorium is the total brain capacity for focusing, processing, and interpreting. It is not a static state—it can fluctuate throughout the day. In this episode I discuss how I increase patient's sensorium.||2/19/2018||Free||View in iTunes|
||CleanA Journey Learning Psychotherapy, with Randy Stinnett, Psy.D||Discussion on learning psychotherapy, the interpersonal, formative mentors, and staying open to feedback...||2/12/2018||Free||View in iTunes|
||CleanInpatient Child and Adolescent Suicidality, “Culture of death”, “13 Reasons Why” with Dr. Britt||Dr. Britt, an expert with three decades of experience, breaks down the increasing trend in teen suicide.||2/5/2018||Free||View in iTunes|
||CleanPsychopathy with Michael A. Cummings M.D.||What is a psychopath and how would you identify one? How are they different from most people? All these and more, answered by a world expert.||1/28/2018||Free||View in iTunes|
||CleanCognitive Distortions and Practicing Truth||Identify habitual negative thoughts and put them on trial||1/23/2018||Free||View in iTunes|
||CleanThe Basics of the Psychiatric Interview Part 1||Dr. David Puder's approach to getting a psychiatric history on the first visit.||1/15/2018||Free||View in iTunes|
Meaningful and Insightful
I am a fourth-year medical student applying into Psychiatry Residency, and I absolutely love this podcast. After listening to just one episode, it was immediately evident to me that Dr. Puder is an incredibly compassionate person who cares and thinks deeply about his patients and the field of psychiatry as a whole. This podcast has lessons relevant to everyone—medical trainees and professionals, patients, individuals passionate about mental health, even people who don’t know anything about psychiatry—and can be enjoyed by all. As for me, I am confident that I will be a more wise, empathic, genuine, and connected future psychiatrist because of this podcast :) Thank you so much, Dr. Puder, and keep up the amazing work. You are listened to and greatly appreciated!
Very Informative w/o Going Over My Head
I’m not psychiatrist or therapist, just interested for my own care. I’m learning a lot which I can share with my own doctor for treatment. Thanks so much!
I just wanted to let you know that I am a mental health professional and I am greatly enjoying your show! I wanted to say: thank you!!
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