Psychofarm Podcast

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

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

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

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

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

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit https://psychofarm.substack.com

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

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit https://psychofarm.substack.com

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

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit https://psychofarm.substack.com

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

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit https://psychofarm.substack.com

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

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit https://psychofarm.substack.com

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

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit https://psychofarm.substack.com

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

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

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

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

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit https://psychofarm.substack.com

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

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit https://psychofarm.substack.com

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

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit https://psychofarm.substack.com

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

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

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit https://psychofarm.substack.com

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

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit https://psychofarm.substack.com

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

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit https://psychofarm.substack.com

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

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit https://psychofarm.substack.com

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

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit https://psychofarm.substack.com

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

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit https://psychofarm.substack.com