Psychiatry & Psychotherapy Podcast

Latest Episodes:

Therapeutic Alliance Part 2: Meaning and Viktor Frankl's Logotherapy Oct 30, 2018

Show notes

Episode CME activity objectives:

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

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

Define psychic determinism.

Recognize that meaning is idiosyncratic and unique to each individual.

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

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

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

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

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

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

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

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

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

By listening to this episode, you can earn 0.75 Psychiatry CME Credits.

Link to blog.

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Psychiatric Approach to Delirium Oct 08, 2018

Show notes

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

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

Hyperactive delirium symptoms in patients:

Waxing and waning —it comes and goes

Issues with concentration

Pulling out medical lines

Yelling profanities

Throwing things

Agitated

Responding to things in the room that aren't there

Not acting like themselves

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

Hypoactive delirium symptoms:

Slower movement

Softer speech

Slower responses

Withdrawn

Not eating as much

By listening to this episode, you can earn 0.75 Psychiatry CME Credits.

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Ketamine and Psychedelics with Dr. Michael Cummings Sep 25, 2018

Show notes

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

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

Ketamine

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

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

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

By listening to this episode, you can earn 0.75 Psychiatry CME Credits.

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What is psychodynamic theory? Sep 20, 2018

Show notes

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

What is psychodynamic theory?

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

By listening to this episode, you can earn 0.75 Psychiatry CME Credits.

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Advice for medical students applying to psychiatric residency Sep 16, 2018

Show notes

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

Here is what Timothy Lee says:

Stay calm

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

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

What matters in a personal statement?

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

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

Do step scores matter?

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

Apply to the right number of programs

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

Keep a good perspective

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

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Therapeutic Alliance Part 1 Sep 06, 2018

Show notes

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.

By listening to this episode, you can earn 0.75 Psychiatry CME Credits.

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How to Treat Emotional Trauma Aug 23, 2018

Show notes

What is trauma?

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

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

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

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

People commonly demonstrate symptoms of trauma when they've:

Experienced a sexual violation

Seen violence

Experienced violence or abuse

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

Been in near death experiences like car accidents or war

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

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

Fight and flight symptoms are:

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

Shut down symptoms are:

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

Moments in connection mode look like:

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

By listening to this episode, you can earn 1.25 Psychiatry CME Credits.

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Setting Boundaries in Relationships Aug 11, 2018

Show notes

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.

By listening to this episode, you can earn 0.75 Psychiatry CME Credits.

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The History and Nuances of Bipolar Illness Aug 02, 2018

Show notes

In this episode we discuss:

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

For paraphrased transcription and blog: go here

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

By listening to this episode, you can earn 0.75 Psychiatry CME Credits.

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The History, Mechanism and Use of Antidepressants Jul 24, 2018

Show notes

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.

By listening to this episode, you can earn 1 Psychiatry CME Credits.

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