psychiatry podcast for residents

An Introduction to Psychodermatology: “The Mind-Skin Connection” 

On this week’s episode of the podcast, I sat down with Chloé Walker, a 2019 Loma Linda University graduate with a fresh passion and desire to pursue a career in psychodermatology. We had a candid conversation about how planting awareness of the interconnection between mind and skin will equip this specific patient population and medical professionals with the proper tools and resources that empower positive patient response and care outcomes. 


Chloé Walker, MD and David Puder, MD 

What is Psychodermatology? 

At the most basic level, Psychodermatology encompasses the interaction between mind and skin. It is the marriage between the two disciplines of psychiatry and dermatology, uniting both an internal focus on the non-visible disease, as well as an external focus on the visible disease.  This tight interconnection between mind and skin is maintained at the embryological level of the ectoderm throughout life. 

According to this article, although the history of psychodermatology dates back to ancient times, the field has only recently gained popularity in the United States. More specifically, Hippocrates (460-377 BC) reported the relationship between stress and its effects on skin in his writings, citing cases of people who tore their hair out in response to emotional stress.  

Understanding skin disorders through the lens of psychosomatic medicine allows the clinician to reveal the underlying source of suffering, which may be in the form of repressed expressions of anger and hostility. Stating, “In the skin we see not just our internal physical state but all our psychological processes and reactions. Pressure from within and pressure from without reveals itself on the skin.” 

This study concluded that how patients cope with an internally focused emotion plays an integral role in facilitating how the body externally manifests that emotion through the skin in a process clinically referred to as the conversion phenomenon.  Specifically, PTSD was highly and positively correlated with Escape-avoidance (r = 0.52, p < 0.001), as an emotion-focused coping strategy which were in turn associated with Chronic Idiopathic Urticaria (CIU) severity and psychiatric symptom severity. 

How are Psychodermatological Disorders Classified?  

According to this article, while there is no single universally accepted classification system of psychocutaneous disorders, the most widely accepted system, devised by Dr. Koo and Dr. Lee, involves three main categories

1) Psychophysiologic disorders encompasses those skin conditions that are precipitated or exacerbated by the psychological stressor. Examples include acne, alopecia areata, atopic dermatitis, psoriasis, psychogenic purpura, rosacea, seborrheic dermatitis, and urticaria.  

2) Psychiatric disorders with dermatologic symptoms encompass skin conditions that are associated primarily with an underlying psychopathology in which visible skin lesions are self-inflicted by the patient. Examples include body dysmorphic disorder, delusions of parasitosis, eating disorders, factitial dermatitis, neurotic excoriations, obsessive compulsive disorders, and trichotillomania.

3) Dermatologic disorders with psychiatric symptoms encompass those skin conditions that secondarily develop an emotional disorder in which the psychological consequences often outweigh the physical symptoms in severity. Examples include alopecia areata, albinism, chronic eczema, hemangiomas, ichthyosis, psoriasis, rhinophyma, and vitiligo.

As you can see from this classification system alone, there is a significant amount of overlap that exists between categories.  

Direct vs Indirect classification 

A 2019 comprehensive review article suggests that psychiatric disease may have a direct or indirect association to dermatological disease: 

A direct association involves psychiatric disorders that cause the dermatological disorder purely by itself without any secondary influence. This classification includes stress and tactile hallucinations that are not physically visible.

An indirect association involves psychiatric disorders that trigger behaviors causing physically visible skin damage. This includes the skin changes that result from manual scratching due to psychogenic pruritus.

Some psychiatric diseases may have both direct and indirect associations in the development of dermatological diseases. For example, depression is directly associated with psoriasis through an inflammatory mechanism, and is indirectly associated via trichotillomania. 

Temporal classification 

Most dermatologists encounter patients who report a temporal relationship between disease flares and stressful life events. 

Board certified dermatologist and clinical psychologist, Dr. Fried states, “When it comes to treating patients who we suspect may be experiencing skin, hair, or nail problems as a result of stress or other emotional factors, it is helpful to ask them whether their skin seems to look or feel worse when they are stressed.” 

Developmental classification 

Attachment style changes a patient’s connection with their dermatologist and their overall experience of stress. 

In fact, a 2017 European multicentre study found that secure attachment of dermatological outpatients may be a protective factor in the management of stress. Those participants with secure attachment reported stressful life events significantly less often and increased satisfaction with their dermatologist than those with insecure attachment styles.  

The overall important takeaway highlighted in this study is the value of taking a thorough history of present and past psychosocial factors, including stressors and traumas to have a more in-depth understanding of the skin disease at hand preventing parasuicidal behaviors and suicide. Stating that Up to 90% of patients who commit suicide may have a psychiatric disorder (50% MDD; 25% substance abuse and dependence followed by psychotic disorders, PTSD and body dysmorphic disorder). 

Let’s talk about Psychiatric Morbidity in Dermatology.  

According to an article in the Indian Journal of Psychiatry, the incidence of  psychiatric disorders among dermatological patients is estimated at 30 to 60%

Another study conducted in India suggests that recognition alone of psychiatric disorders by a dermatologist is not adequate. Stating that out of 636 patients, 104 (16.4%) had psychiatric consultations and in 97 of them a psychopathology had been diagnosed. The patients with a psychopathology constituted 15.3% of all the patients and 93.3% of those who received a psychiatric consultation. The most prevalent pathology was depression (31 patients 32.0%). The most prevalent dermatological diagnosis of the patients with psychiatric morbidity was chronic urticaria (25 patients, 25.8%). 

This study showed how the emotional burden of skin increases the risk of self-harm and suicide. Questionnaire results including all consultant dermatologists in the British Association of Dermatologists Members Handbook 1996/97 320 reported (78% of the total sample) encounters of  patients with psychological or psychiatric disturbance which they considered to be a consequence of their skin. Eighty-six participants were aware of a total of 178 patients who had attempted suicide associated with their skin disorder.

Unique fears center around acne. This study concludes that “In the long run acne may cause cutaneous as well a psychological scars.” Stating that in a sample of 355 high school students from the city of João Pessoa with an average age of 16, there was a prevalence of 89.3% of acne vulgaris. The most prevalent psychosocial issue was "afraid that acne will never cease," present in 58% of affected youth. 

Another study supports that acne patients have an increased risk of depression and anxiety with anxiety being more common having a direct relationship to impairment of quality of life. 

What is the Best Plan of Approach involving Treatment Modalities? 

Role of the dermatologist

  1. Have a good screening tool such as GAD-7 and PHQ-9

  2. Get a full history including stressors and potential psychological/ developmental aspects. This largely involves motivational interviewing

This article strongly supports the use of  intake PHQ-9 and GAD-7 questionnaires (which are shorter in length, free to use and self-administered) as a practical approach for busy dermatology clinics.  

Outpatient psychiatry and psychotherapy: 

Psychotherapy (including behavioral modification techniques) are first line especially when addressing pediatric psychocutaneous disorders.

  1. Combined treatment will be most effective: 

Treatment is determined based upon the underlying psychopathology

  • OCD: SSRI Fluoxetine, TCA Clomipramine, or N-acetylcysteine which has shown great promise in the treatment of trichotillomania. 

  • Anxiety: SSRIs for Generalized Anxiety Disorder (GAD). 

  • Depression: SSRI Sertraline preferred for melancholic depression or psychomotor slowing; SNRI Venlafaxine for melancholic depression; TCA Doxepin for psychomotor agitation.

  • Psychosis: Atypical antipsychotics are first line with Pimozide as an alternative option

        2)  Exercise, diet, probiotics,  sleep, mindfulness, spirituality (forgiveness)

Intensive Outpatient Programs (IOPs) and Partial day treatment programs

  1. MEND Outpatient Program (Mastering Each New Direction) specific to chronic disease states- meaning, congruence, family conflicts.

Inpatient:

  1. Recommended for actively suicidal patients with a plan.  

ECT/TMS/Ketamine 

  1. Recommended for treatment resistant patients with failed multiple treatments and therapies. 


How does the Skin Respond to Stress?    

This article discusses how stress activates body response systems including the Hypothalamus-pituitary-adrenal axis (HPA), Sympathetic axis (SA),  Cholinergic axis (CA), and neuropeptides and neurotrophins. Acute stress triggers a “fight or flight” response by changes in memory performance, blood flow and energy metabolism. However, long-term stress exposure, the adaptive capacity of the stress response systems is lost due to lack of time for recovery and regeneration of the responsiveness to stress. 

Stress may precipitate the vicious cycle in the pathogenesis of chronic urticaria (longer than six weeks in duration). This article provides insight into the mechanism of how stress facilitates vasodilation and increased vascular permeability also implicated in the pathophysiology of atopic dermatitis, eczema, and psoriasis. Early responses of stress result in the downstream secretion of cortisol and IL-18 which modulate HPA axis inhibition of secreted corticotropin-releasing hormone (CRH). However, cases of chronic exposure ultimately result in low cortisol release, increased production of proinflammatory cytokines and increased production of CRH secondary to hypocortisolism-induced loss of feedback control. Hair follicle keratinocytes, sebocytes, and mast cells also operate within a peripheral HPA axis equivalent to the central HPA axis in the skin secreting CRH and IL-18, as well as expressing CRH-R1 receptors in response to stress all contributing to severely induced cutaneous inflammation. 




An Inside Look At Eating Disorders: Anorexia, Bulimia, & Orthorexia

On this week’s episode of the podcast, I interviewed Sarah Bradley, a competitive runner who has worked her way through a personal struggle with anorexia, bulimia and orthorexia.  

Sarah Bradley and David Puder, MD

What is an eating disorder? 

One of the most important things about anorexia and bulimia is understanding that they are caused by a complex interplay of genetics, epigenetics, early development, and current stressors. They can lead to dangerous outcomes because of how the eating disorder changes both the body and the brain. Many therapists and nutritionists, as you’ll hear in my conversation with Sarah Bradley, don’t treat from multiple angles, and often lack empathy into this condition.

There are three main types of eating disorders we will cover here:

  • Anorexia is the practice of cutting calories to an extreme deficit or refusing to eat. 

  • Bulimia involves purging, or vomiting, the food that has been eaten. 

  • Orthorexia is a fixation and obsession on eating healthy food (like only eating green vegetables with lemon juice). 

Statistics:

  • Anorexia traditionally lasts for an average of eight years.

  • Bulimia traditionally lasts for an average of five years

  • Approximately 46% of anorexia patients fully recover, 33% improve, and 20% remain chronically ill. 

  • Approximately 45% of those with bulimia make a full recovery, 27% improve, and 23% continue to suffer.

Symptoms:

In a future episode, I will go into details like the DSM V diagnosis of anorexia or bulimia. For this episode, we wanted to keep it more practical. 

A patient with anorexia will desire food but choose not to eat it (unlike depression, in which the patient does not desire food). A patient with bulimia vomits their food after consumption, which can cause significant electrolyte abnormalities, seizures, and potential death. 

Treating patients with eating disorders

Having empathy towards someone with eating disorders can be difficult if you are approaching it from your own experience (or lack of experience). If you are not careful, as a psychiatrist or therapist, you can actually make things worse. And if you suggest a certain diet to aid in recovery, you can push a patient into orthorexia. 

The mortality of anorexia and bulimia is considerable, which is why my practice often gets patients into an eating disorder day treatment program.  

In this episode we talked about what not to say. In particular, we talked about not saying things like “you have a great body, why do you want to lose weight?” Or a dietitian who told Bradley, “We will only talk about food, not emotions,” which assumes that eating disorders are a physical, and not emotional, problem.  

When we looked at online chat forums to see how patients experienced their doctors when they discussed their eating disorders, these are some comments we found:

“Went to a dr to try to get referred to an Ed therapist I think last year? My bmi was 15, and I was told by the dr "you obviously don't need help. It's not like you need inpatient. You aren't at a weight that I feel it would be appropriate for me to refer you to someone. If you want to, you can go to the er for a voluntary psych hold." I was so humiliated that I just nodded and left.”

“When my bulimia was at its worst, on the very first appointment, and right in front of my dad, the guy said, "I'm going to put you on Wellbutrin. You don't binge and purge right? Like eat and make yourself throw up." I said no because I was right in front of my dad. So the therapist said, "oh, yeah I didn't think so. You aren't overweight like people with bulimia, because it doesn't cause weight loss. I just have to ask. Also at the very beginning of my ED, my school counsellor dismissed me when I said I was trying to stop eating, because I wasn't a girl, extremely underweight, or actually not eating. I'm still pissed about it.”

“I told my therapist about my starving and then b/p-ing cycle a couple of sessions back, and then she told me after a while "do you still do your vomiting thing?" and I told her, "yeah, but maybe just 2 or 3 times a week now" and she's like "oh okay, at least that's better" and then proceeded to change the topic into something other than my "bad eating habits". Needless to say, I've never been diagnosed and I feel like my disorder isn't real.”

“An actual medical doctor said, after I told her how much weight I had lost by eating almost nothing, "At least you had the weight to lose.  Let's get you on some antidepressants..." Um... ok, yeah, NO. I also told her I thought 88 lbs was a nice weight, I'm 5'2, she said that was much too low.  She then added that when she immigrated to America, she weighed 88 lbs, but she is shorter. Like, WTF??”

Overall, mental health professionals need to do research into understanding the disorder and be empathic when responding to their patients. 

Creating mental separation from the disorder 

Although behaviors associated with the eating disorder are carried out by the patient, the confusion that the disorder is an aspect of their self (rather than a disorder or illness) can make it difficult for them to detach sufficiently from the disorder. Being able to detach from the disorder means that they can evaluate the role of the eating disorder in their life: both the positive and negative aspects.

Here are some good examples from an online eating disorder toolkit to help you, as a therapist, be able to help your patients differentiate between their eating disorder and themselves: 

“We’ve spoken about the ways anorexia can seem like a best friend to you. I wonder if you can see any ways in which the anorexia is making life harder for you?”

“Our job is to give you back some control over the Eating Disorder and keep you healthy no matter what.”

“You are here because the Eating Disorder has gone too far and made staying healthy impossible for you.” 

Eating Disorder Patients’ Interpretations of Therapists’ Bodies

Clients evaluate their therapists’ body size and speculate on their relationship with food. This can determine what impact this might have on the therapeutic process. 

According to this article, three main themes emerged during analysis of how patients feel about their therapists’ bodies: 

1. They automatically look at the therapist’s body. 

2. They believe thinner therapists can help them more than overweight therapists. Still, “healthy looking” was as perceived better able to help than thin or overweight therapists. 

3. The patients were less likely to take advice or help from therapists they viewed as overweight or too thin. 

Delusional thinking with eating disorders:

In patients suffering from anorexia nervosa, disturbances of thought content may vary in severity depending on how much insight is preserved, ranging from obsessions to full-blown delusions. They often can believe food is “poisoned, contaminated, still alive or ready to attack; food may be animalized or described as a poison.” 

They can even believe that their body is “under the influence of external forces, dissolving or being under attack; some patients fear that the contents of their body might spill outside or have a sense of all the body fat going down to their stomach. Delusions of sinfulness may emerge...There are patients who complain about hearing the ‘voice of anorexia’ or a voice that forbids them to eat.”  

Sarah Bradley recounts some of her experiences:

  • “I have major anxiety when being in close proximity to people with obesity while eating: I honestly worry in some nearly magical way, their eating will make me eat and potentially overeat. Often if I am exposed to someone with obesity eating, I cannot eat the rest of the day.”

  • “Not letting myself sit, sleep, or rest for too long out of fear that the lack of energy expenditure will cause automatic weight gain.”

  • “Being incredibly paranoid about the risk of weight gain from psychiatric medications, even if little to no risk exists for a certain drug. Before adhering to my current medications of zoloft, lamictal, and trazodone, I had to have several long conversations with my psychiatrist to get reassurance even though I knew those particular drugs held no serious risk for weight gain. Historically, my paranoia had been so bad, I would lie about taking medication or stop seeing my doctor altogether.”

  • “Thinking about food all day and thinking about my body all day. Literally, having these constant ruminations about what I could or could not eat and how large I must look to the point that I was falling behind in school and couldn’t hold a social conversation for too long.”

Severe clinical cases of eating disorders

Often, in severe/chronic cases of eating disorders, clinicians do not even use psychotherapy until there has been a substantial improvement in nutritional standing and the patient has reached a healthier weight. One’s cognitive functioning is also very low after having entered starvation, and they are often very focused on food beyond a point of interest that comes with an eating disorder, but because the body is crying out for energy.

In these severe cases, sometimes the patient is not willing to make progress and is defiant towards weight gain or diet change, so they may need to be hospitalized. 

Even though this isn’t specific to psychotherapy, it is vital to recovery to reach a healthier diet and body weight (even if someone is overweight who is malnourished and has been starving themselves for rapid weight loss). And so, another big part of how to stop obsessing about food is the ability to achieve a better diet and healthier weight. For some, this means gaining weight. For some, this means maintaining weight. For some, this may mean ceasing binging and/or purging that can result in weight maintenance/weight loss.

What works to help patients with eating disorders?

In Sarah’s experience, here’s how she stopped thinking about food, and therefore is “90% better” after her long-standing eating disorder.:

  • Gaining weight, helped her stop thinking about food. 

  • Finding other passions in life helped her focus future goals and aspirations.

  • Finding a good therapist that understood her and was open to learn about her perspective rather than putting on their own perspective (empathy).

  • Taking and sticking with a medication to treat comorbid depression.  

  • Creating a stronger network of friends.

As therapists, we can help our patients accomplish all of these things through empathic listening and encouraging to move towards healthy connections. 








The Process of Grief

On today’s episode of the podcast, I am interviewing Maris Loeffler, LMFT. We cover different types of grief (acute, complicated, traumatic, etc.), attachment styles in relation to grief, and  some helpful things to consider in caring for a grieving patient as a mental health provider.   

An Overview of Grief 

Joseph Wong (MS3), Tyler Rigdon (MS2), David Puder M.D.

This article complements the above podcast, with some research findings we did not talk about in detail, and is written for mental health professionals to understand some of the research behind grief work.

Grief is the multifaceted response—emotional, behavioral, social—to a loss or major life adjustment (like a divorce, loss of a job, etc.). Bereavement is the process of grieving specific to the loss of affection or bond to a person or animal (Parkes & Prigerson, 2013; Shear, Ghesquiere & Glickman, 2013; Shear, 2015). 

Some of the signs and symptoms of grief are: 

  • somatic symptoms (e.g. choking or tightness in the throat, abdominal pain or feeling of emptiness, chest pain) 

  • physiological changes (e.g. increased heart rate and blood pressure, increased cortisol levels)

  • sleep disruption and changes in mood (e.g. dysphoria, anxiety, depression, anger) 

(Buckley et al., 2012; Lindemann, 1944; O’Connor, Wellisch, Stanton, Olmstead & Irwin, 2012; Shear & Skritskaya, 2012; Shear, 2015; Zisook & Kendler, 2007

Medical and psychiatric complications can also arise due to grief and include:

Acute grief begins after a person has learned of the passing of a loved one (Shear, 2015). During acute grief, a person may experience immense sadness, yearning for the deceased, and persistent thoughts of the decreased (Maciejewski, Zhang, Block & Prigerson, 2007; Shear, 2015). Auditory and visual hallucinations are benign hallucinations commonly found in acute grief and involve the person seeing, talking to or hearing the voice of the deceased (Grimby, 1993). 

The process of grief has long been seen through the lens of Kubler-Ross’ 5 stages of grief (denial, anger, bargaining, depression and acceptance). Now, however, it is now more commonly understood that the process of grief is not as linear or predictable as originally posited by Kubler-Ross, and that there may not even be stages of grief that a person has to pass through in their grieving process (Maciejewski, Zhang, Block & Prigerson, 2007; Stroebe, Schut & Boerner, 2017). 

Most bereaved individuals are able to progress from acute grief to integrated grief, in which the individual has adapted to their grief and is able to once again enjoy daily life and activities (Shear & Mulhare, 2008; Shear, Ghesquiere & Glickman, 2013). About 6 months after the loss of the decreased, negative grief indicators (e.g. disbelief, yearning, anger) are in decline (Maciejewski, Zhang, Block & Prigerson, 2007). Thus, this transition from acute grief to integrated grief means that the individual only experiences grief as a temporary period rather than a prolonged chronic state. However, approximately 10% to 20% of people who lose a romantic partner do not transition from acute grief to integrated grief and instead transition to complicated grief (prolonged grief disorder) where the individual experiences grief for a longer period of time than expected to the point where it causes impairment in daily functioning (Bonanno & Kaltman, 2001; Shear, 2015). 

Complicated grief is more common in parents who have lost children, when the loss of the decreased is sudden or violent (e.g. suicide, homicide, accident), and is less common after an expected loss (e.g. chronic illness) (Meert et al., 2011; Mitchell, Kim, Prigerson & Mortimer, 2005; Nakajima, Masaya, Akemi, & Takako, 2012; van Denderen, de Keijser, Kleen & Boelen, 2015; Young et al., 2012). Complicated grief has been found to be most prevalent in women above 60 years old (Kersting, Brähler, Glaesmer, & Wagner, 2011). 

Complications of complicated grief include:

  •  sleep disturbances

  • suicidal ideation

  • substance use disorders

  • decreased immune function

  • increased risk for cardiovascular disease and cancer (Buckley et al., 2012; Shear, 2015). 

Like acute grief, the symptoms of complicated grief involve intense yearning for the decreased and persistent sadness. In complicated grief, these symptoms are accompanied by the fact that the individual is unable to accept the reality of the death of the deceased, and has intrusive thoughts or images of the deceased, and excessive ruminations and recurring negative emotions (e.g. anger, guilt, bitterness) surrounding the death Shear & Mulhare, 2008; Shear, 2015; Simon, 2012). Individuals with complicated grief commonly avoid situations, events or places that remind them of their loss and are fixated by viewing, touching or smelling momentos left behind by the decreased (Shear, 2015). 

Attachment Styles and Grief 

Attachment theory was first established by Mary Ainsworth in the 1960s and 70s and applied to children with 4 attachment styles in children being classified: 

In the 1980s, attachment theory was extended to adults and 4 attachment styles were also classified: 

The anxious attachment style reflects worry concerning the availability of the attachment figure, while the avoidant attachment style reflects a tendency to keep at arm’s length from attachment figures (Shear & Shair, 2005). 

Secure attachment style is characterized by low anxiety and low avoidance. Anxious-preoccupied is characterized by high anxiety and low avoidance, dismissive-avoidant is characterized by low anxiety and high avoidance and fearful-avoidant is characterized by high anxiety and high avoidance (Shear & Shair, 2005). 

It has been well-documented that bereaved individuals with insecure attachment styles are at risk for increased grief symptoms. Insecure attachment styles have been found to put spouses of terminally ill patients at greater risk for traumatic grief symptoms (Van Doorn, Kasl, Beery, Jacobs & Prigerson, 1998). Individuals with an anxious ambivalent attachment style that lost a close friend or family member in the previous year experienced greater levels of grief and depression, while individuals with an avoidant attachment style experienced greater somatic symptoms in comparison to individuals with secure attachment styles (Fraley and Bonnano, 2004; Wayment & Vierthaler, 2002).

Below are the prototypic behaviors and characteristics of the adult attachment styles with respect to grief. 

Anxious Attachment

Typically occupied with fear of abandonment, exhibits hypervigilance and seeking behaviors. Afraid that their partner might leave them. 

Patients with anxious attachment styles latch onto items or articles of clothing; however, people can normally hold onto momentos as part of the grieving process, so further investigation should be done to differentiate the two. 

Avoidant Attachment

Fearful of intimacy and emotional engagement. Prefers to process things alone. They withdraw with signs of emotional neediness from partner. 

How does this attachment style impact the grieving process and hinder healing? 

  • Have trouble with acknowledging the depth/importance of the relationship. 

  • Don’t like to be vulnerable in the relationship.  

  • Avoid fully looking within themselves and processing their grief response.  

  • By pushing down their emotions, it makes it hard to get through the grief process ,as when you grieve, you need to feel emotions, and it makes it difficult to process emotions if you’re not acknowledging them. 

    • Maris’ approach is to work with the body if they can’t put words to what they’re feeling as part of the grief process. People with avoidant attachment styles have more somatic symptoms (headaches, stomachaches), so putting that into words for them can help them better understand their grief process. 

Disorganized Attachment

Kids with disorganized attachment have no organized way of regaining connection. They later will have higher rates of dissociation. Patients with high amounts of dissociation will need to feel grounded and present to process through things, and learning when someone is dissociating will be helpful to help them progress in their emotional development. I (Dr. Puder) often look for microexpressions in the midst of someone dissociating to help me know what emotions are felt but not being allowed to experience.

Other Considerations 

The following are some of Maris’ considerations that have helped her in approaching a patient with grief. 

  • One of Maris’ grounding principles is centered around, “When I bring a person into the room, I need to understand what they need.” This mindset helps her to just let the client speak their story for the first few sessions, after which she will begin formulating her own ideas about the client’s grieving process. In a non-confrontational manner, she will ask questions like the following to dig deeper. 

    • “I’m noticing that it’s difficult for you to talk about the funeral.” 

    • “It feels like you get angry when you notice how your brother is handling the situation.”

  • Realize a patient’s grief hits them after the funeral service. After the deceased has passed and before the funeral, usually family members and friends gather to give support to the grieving. However, after the funeral, those people are no longer there and the patient is left alone. Consider this timeline when helping the patient through their grieving process. 

  • Sometimes it’s difficult to determine the fine line between supporting a friend with grief and exhausting them with your presence. So what are the things to consider in comforting a friend with grief? 

    • Firstly, it depends on your relationship with the person

    • Second, ask them what would be most helpful for them at the moment

      • Right after a loss, everyone comes around, but sometimes people want to be left alone and it can be exhausting for the person in question to feel overburdened with emotional comfort. 

      • Sometimes it’s valuable to check in and reach out. That alone can make an impact, even if you can’t find the right words to comfort the person.

  • The importance of personally going through therapy cannot be understated in this line of work. Even therapists need therapists, and being a patient can help you become a better therapist by allowing you that first-person perspective. 

  • Some patients may be doing really well with therapy for a period of time, but encounter roadblocks associated with life events without the presence of the decreased (first Christmas or the first anniversary after the loss of their loved one). The patient may need to revisit their grief once again, and that’s perfectly fine—grieving is not linear, nor is it the same for everyone. 

  • Every patient has their own way of talking about and processing their grief. Certain patients may even repeat the process of the passing of the decreased over and over. While it may be repetitive to hear the same thing every session, allowing the patient to talk about their experience helps the patient with their process of grieving.

  • Some patients might feel a lot of guilt towards themselves while grieving. Normalize the feeling of guilt, express the difficulty in feeling things, and help them look at the guilt with less judgement. 

  • Some patients may even feel anger towards the deceased, which they might have difficulty acknowledging or getting it out. It is common for people to remember the decreased in terms of their good aspects or attributes, but that may not always be the case for the patient. Allow them the space and time to express their negative emotions, which may not always be apparent on the surface in their grieving process. 


Maybe at some point, you have thought to yourself that you don’t have the ability to process grief with your patients or that it simply isn’t your strong suit. I hope that some of the points brought up in this podcast will be helpful in your own practice and journey as a mental health provider. 

Connect with Maris Loeffler, LMFT on Instagram, Linked In, Psychology Today



Clozapine for Treatment Resistant Schizophrenia

On today’s episode of the podcast, Dr. Cummings and I talk about clozapine, a medication that treats schizophrenia.

Mikayla Cho B.A., Michael Cummings, M.D., David Puder, M.D.

What is clozapine?

Not only is clozapine the gold standard medication for treatment-resistant schizophrenia, it is also one of the most unique drugs used in psychiatry.

It was synthesized 1958, only eight years after chlorpromazine, the first antipsychotic drug, was created. At that time, researchers tested for antipsychotic properties by taking various compounds and testing to see if lab mice developed dystonia and catalepsy. When researchers tested clozapine, they found that it did not cause dystonia, but instead made the mice sleepy. Because of this, clozapine was almost missed entirely as an antipsychotic medication. Eventually, however, clozapine was found to be more successful than other antipsychotic drugs.

By the 1970s, Austria, Germany, and Finland had produced positive data on clozapine proving its efficacy. However, clozapine was also found to have caused severe neutropenia in sixteen patients in Finland, and even caused the death of eight of those patients. For this reason, clozapine did not enter the United States until it was approved by the FDA in 1989.

Defining “Treatment-Resistant” Schizophrenia

Clozapine was approved largely due to the work of John Kane. In his work, Kane helped define “treatment-resistant” schizophrenia, and ultimately the context in which clozapine has proven benefits. The term “treatment-resistant” can be defined as schizophrenia that has failed to respond to an adequate dosage of two antipsychotic medications given for an adequate duration:

  • The dosage should be a minimum of 600-1000 mg chlorpromazine equivalents.

  • Duration should be a minimum of six weeks.

  • Additionally, patients must have failed a prospective trial of haloperidol 15 mg given daily.

With this definition, Kane and his team found that a patient’s odds of responding to clozapine was 50-60%, whereas the probability of responding to other antipsychotic medications was 0-5% (with an average response of 2%). Today, these rates are essentially unchanged.

In 2017 Howes et al. found similar response rates to clozapine. The team largely followed Kane’s original criteria for treatment-resistant schizophrenia but did not include the failed prospective trial of haloperidol. Additionally, the team measured plasma levels of clozapine to assess patients’ adherence. Ultimately, they found that the odds of responding to clozapine was 40-60% while the odds of responding to other antipsychotics was 7% or less.

In contrast, there have been meta-analyses, including Cochrane, suggesting that clozapine is not more effective than other antipsychotics. However, these studies have failed to strictly define or include “treatment-resistant” schizophrenia criteria. It is likely that schizophrenic patients who were not truly treatment-resistant were included in those studies. In this context, clozapine is not more effective than other antipsychotic medications.

Unique Effects

In addition to being the gold standard for treatment-resistant schizophrenia, clozapine has other unique effects. It has been found to reduce both suicide and violence in patients, independent of the drug’s antipsychotic effects. Criminal behavior is also decreased. Clozapine can also be used to treat psychogenic polydipsia and refractory mixed bipolar states.

Mechanism of Action

Part of the reason that makes clozapine so unique is its mechanism of action. Typically, second generation antipsychotics antagonize dopamine but more selectively than their first generation counterparts. Additionally, atypical antipsychotics antagonize the 5-HT2a receptors, which actually assist with dopamine transduction in the frontal lobe. Although clozapine does have atypical antipsychotic properties, it also works by modulating glutamate signal transduction, particularly in the frontal and temporal lobes. Even at high plasma levels, the concentration of clozapine at the D2 and D3 receptor is only 30-40%. It is the modulation of glutamate that helps stimulate and “awaken” the hypoactive brain of a schizophrenic patient.

Improving glutamate decreases the positive symptoms, improves the negative symptoms, and even helps with cognitive symptoms. Clozapine’s unique mechanism of action may be why Krakowski et al (2006) found that although clozapine, olanzapine, and haloperidol had approximately the same reduction in psychosis for violent schizophrenic patients, clozapine was superior to olanzapine and haloperidol in decreasing violence in the same patients because it significantly mediated the executive function of the frontal lobe.

Other than glutamate, clozapine does affect other key molecules and receptors. The major daily side effects are most likely due to the blockade of the His-1 receptors, and the subsequent sedation may become a dose-limiting side effect for the patient, especially at higher plasma levels of clozapine. Alpha-adrenergic antagonism also contributes to the drug’s side effect profile, such as hypotension. Additionally, although clozapine’s robust and positive effect on glutamate likely overrides much of the drug’s anticholinergic effects, there is still the chance for anticholinergic burden, especially if the patient is taking other anticholinergic medications.

Target Dose and Medication Adherence

It is vital to maintain a therapeutic alliance with a patient on clozapine, as noncompliance is a major factor for treatment failure in schizophrenic patients. For example, the adherence rate for antipsychotic medications in general is less than 40%. This is partially alleviated with long-term injectable agents, but clozapine does not have this option. The only forms of clozapine are tablets, wafers, and liquid agents. Therefore, it is beneficial to schedule regular meetings with patients on clozapine.

One method to assess medication adherence is by checking plasma concentrations and blood levels of clozapine. If patients are adherent, their plasma concentration of clozapine should be fairly consistent. Obtaining blood levels also assures the provider that the current medication dose is optimal, as patients vary in metabolism and absorption rates and other factors, such as smoking and different medications, can also affect hepatic metabolism.

To treat psychosis, the target range of clozapine should be 350-600 ng/mL. If symptoms are not adequately controlled at this level, but patients are tolerating the medication, clozapine can be gradually titrated to approximately 600-1000 ng/mL. After 1000 ng/mL there is a diminishing return of benefits and an increased likelihood of side effects. Rarely, patients will need to go above the 1000 ng/mL level. If the goal is to not treat psychosis but another issue like criminality, then patients will generally respond at much lower doses. For example, in 2014 Brown et al. found that there was a dramatic reduction in violence in seven psychopathic patients with an average clozapine concentration of 171 ng/mL.

Benefits of Clozapine

On-going, uncontrolled psychosis only leads to mental decline. Early in the disease process, patients lose 2% of their brain mass every year for the first five years, and although this decline slows after that point, it never reaches zero. Additionally, although a healthy lifestyle with adequate nutrition and exercise prevents cognitive decline, it is particularly difficult to motivate schizophrenic patients because of the nature of the disease. On average, schizophrenic patients live 20 years less than the general population.

Clozapine helps address both issues. It has been shown to slow the progress of schizophrenia than any other antipsychotic, and it has been shown to prolong a patient’s lifespan. In 2017 Yoshimura et al. found that the efficacy of clozapine begins to decline about 2.8 years after a patient has been shown to be treatment-resistant. This finding along with clozapine’s other benefits create the argument that clozapine should be prescribed sooner rather than later to help patients suffering from treatment-resistant schizophrenia.

You can download an extensive, FREE management summary from the episode here:




The Unspeakable Mind: Stories of Trauma and Healing from the Frontline of PTSD Science

On today’s episode of the podcast, I am interviewing Dr. Shaili Jain. We cover Dr. Jain’s personal interest in PTSD work, moral injury, causes of PTSD, presentation of PTSD and treatment modalities for PTSD.

Joseph Wong (MS3), David Puder M.D.

An overview of PTSD

PTSD, or Post Traumatic Stress Disorder, occurs when someone experiences, or subjectively experiences, a near death or psychologically overwhelming event, and then goes on to develop specific symptoms because of it. Different types of trauma/stressors that can lead to PTSD include sexual violence, combat experience, medical conditions (e.g. myocardial infarction), and natural disasters (e.g. hurricane) (Chivers-Wilson, 2006; Edmondson et. al, 2012; Grieger et al., 2006; Hussain, Weisaeth & Heir, 2011).

It is characterized by:

  • Direct exposure or witnessing of trauma/stressor

  • Presence of intrusive symptoms post-traumatic experience

  • Avoidance of traumatic stimuli

  • Negative changes in mood and cognition

  • Hyper-reactivity

  • Hyper-arousal (APA, 2013).

Here are a few stats about PTSD:

  • In 2017, over 47,000 Americans died by suicide (CDC, 2019). This number has been climbing about 1,000 new cases per year from 31,000 American deaths by suicide in 2000 (CDC, 2019). One contributor to this statistic are people with Post-traumatic stress disorder (PTSD), who are at increased risk of suicide (Wilcox, Storr & Breslau, 2009).


Symptoms and Diagnosis of PTSD

Certain symptoms of PTSD, like negative changes in mood and cognition, can be associated with other conditions, like anxiety, depression, and borderline personality disorder. Using screening tools like PCL-5 can help delineate PTSD from other conditions, although they can come with false positives (more people who are labeled as having PTSD than actually have it). Experienced clinicians can correctly diagnose through detailed history taking. Diagnosing PTSD begins with listening for a history of major trauma, which can take many forms. The patient will usually describe that they felt their sense of normalcy was shattered, and that they felt totally helpless in the face of that traumatic event.

During the first 4 weeks after the trauma, the impact of the trauma should be noted, and the duration of the symptoms should also be observed. The diagnosis of PTSD involves a disturbance of > 1 month with characteristic symptoms such as intrusive nightmares, flashbacks, memories, hypervigilance (APA, 2013). Subtle signs to look for are the patient’s mood states such as shame, guilt, anger, fear, horror, which are particular for PTSD (Hendin & Haas, 1991).

These patients also show a restricted range of emotion (they never show pure happiness, anger or sorrow). Avoidance is another key characteristic of patients with PTSD as they avoid places, people and memories associated with the traumatic event. This avoidance behavior is particularly tricky to deal with as some patients never make it to see a mental health professional.


Complex PTSD

Complex PTSD is a subtype of PTSD with complex symptomatology in response to chronic trauma (Herman, 1992). Usually, the patient has an extensive history of childhood abuse where the patient can’t remember a time when they weren’t being abused. Another example of chronic trauma includes victims of long-term intimate partner violence. In comparison with textbook patients with PTSD, who have a distinct life before and after their traumatic experience, patients with complex PTSD are only familiar with the traumatic experience.

Patients with complex PTSD have issues with emotional regulation, and can range from rageful to regretful in a single session, much like patients with borderline personality disorder. Patients with complex PTSD often get caught up in cycles of re-enactment where they act out in their personal relationships, and even in their therapeutic relationships, in ways that mimic the trauma that they’ve felt. In Dr. Jain’s experience, although patients with complex PTSD exhibit emotional lability, just like borderline personality disorder, she would think a diagnosis would lean more towards borderline personality disorder if the classic symptoms (such as identity issues, self-injury, chronic suicidality and attachment issues) were present (APA 2013).


Dissociative PTSD

Dissociative PTSD is a subtype of PTSD that occurs in 15-30% of PTSD patients, in which the patient not only meets the criteria for PTSD, but also exhibit persistent dissociative symptoms (e.g. depersonalization, derealization) (APA, 2013; Armour, Karstoft & Richardson, 2014).

Derealization is the feeling of detachment from one’s environment, while depersonalization is the feeling of detachment from one’s body, thoughts, perceptions and actions (APA, 2013). Patients often describe the feelings of depersonalization and derealization as “they don’t feel real,” or that “the world around them doesn’t feel real.”

Because patients with the dissociative subtype of PTSD experience these symptoms persistently, their day is often derailed as they don’t live in the present, but in their dissociative world. Patients who have had severe childhood abuse tend to have the dissociative subtype, which is associated with a poorer prognosis. Patients can dissociate in many environments, including the therapy environment, thus grounding techniques such as breathing techniques and anxiety-reducing exercises may be useful to bring patients from their dissociative state.


PTSD Treatments

Therapy and PTSD

The gold-standard treatment for PTSD is psychotherapy, with an emphasis on a strong therapeutic alliance. In her book, Jain Shaili talks about the importance of the story being given a voice. Many times when someone experiences trauma, it has violated the heart of what they find to be sacred and true, and the effects can be that they have experienced things they find completely unspeakable.

When memories remain unspeakable, even unthinkable, they become sticking points that prevent the brain, and person, from being able to move on. Because of this, many people with PTSD are difficult to reach, emotionally. It’s built into the nature of the disorder that they can be avoidant, don’t want to address the trauma, and are often mistrustful.

As a result of this psychosocial stress, patients with PTSD experience many negative emotions such as guilt, shame and remorse as well as increased suicidality (Hendin & Haas, 1991). PTSD thrives when patients hold it in, rather than talking about it, so an important part of treatment is to establish a therapeutic alliance so that the patient feels comfortable sharing their traumatic experience. Another important factor that contributes to healing is connecting the patient’s spiritual beliefs to their moral injury (Currier, Holland & Drescher, 2015).


The Search for Meaning

In the face of trauma, there are some that show resilience by making meaning out of the trauma and catapulting their lives into a direction where trauma is integrated into their lives rather than directing it.

Although not everyone is fortunate enough to arrive at that place by themselves, trauma-focused psychotherapy can add new learning, adjust maladaptive beliefs and help patients re-evaluate their trauma and its impact on their lives so that they can move forward meaningfully.

Medications for PTSD:

  • SSRIs/SNRIs

    • The most well-studied medication class used to treat PTSD and are 1st line due to favourable adverse effect profiles (Asnis, Kohn, Henderson & Brown, 2004).

    • Sertraline and paroxetine are also both FDA-approved for the treatment of PTSD (Asnis, Kohn, Henderson & Brown, 2004). However, in practice, SSRIs and SNRIs are pretty much equivalent, so tailor fit the medication according to the patients needs. For example, many patients with PTSD have chronic pain, so Venlafaxine (Effexor®) would be a good choice.  

    • Fluoxetine, paroxetine, and sertraline have been found to reduce hypervigilance, emotional numbing, and intrusion levels in clinical trials of over 3,000 participants with PTSD with over 60% of participants seeing a reduction in their symptoms (Kapfhammer, 2014). Many patients with PTSD are mistrustful of medication, so developing a good relationship with the patient through the therapeutic alliance can help convince patients that medications and medication adherence are in their best interest. With a strong therapeutic alliance and good medication management, that 60% can be even higher.

  • Mirtazapine

    • Can be used to treat insomnia at lower doses (7.5 mg - 15 mg). Has antidepressant effects at higher doses.

    • We try to avoid polypharmacy. If treating PTSD with medications, only starts with 1 medication at a low dose and see how that works. Patients that suffer from insomnia can improve dramatically after a few weeks of good sleep from such a medication as mirtazapine.

    • For insomnia, Dr. Jain prefers to use non-pharmacological therapy like Cognitive Behavioral Therapy for Insomnia (CBTI) and only uses medication for the short term to get them to the point where therapy like CBTI can treat the root cause of their insomnia.

  • Mood stabilizers

    • Once again, the general approach is to put the patient on SSRIs/SNRIs at a lower dose and move up the dose as needed.

    • In patients that have issues with hostility, aggression, harm to self and don’t improve on SSRIs/SNRIs, we would consider mood stabilizers as a possible treatment.

  • Second generation antipsychotics

    • Used to be popular in the past to give a low dose for patients with PTSD that exhibited hostility and aggression. Unfortunately, risperidone was shown to not be an effective treatment for PTSD and came with many worrying side effects (e.g. metabolic syndrome, fatigue, sleepiness) (Krystal et al., 2011) .

  • Benzodiazepines

    • In the past, patients with PTSD used to be put on benzodiazepines, but it is now known that benzodiazepines are just a band aid rather than a true treatment for PTSD with especially concerning side-effects in the elderly population (i.e. increased risk fall and impaired cognition) (Cumming & Le Conteur, 2003).

    • In 2012, a study involving over 10,000 patients who were prescribed benzodiazepines were found to have 50% increased mortality with long-term use (Kripke, Langer & Kline, 2012).

    • Dr. Jain would only prescribe very-short term prescriptions (5 day supply) for emergencies like horrific flashbacks and dissociative events.

    • PTSD and addiction go hand in hand due to the addictive nature of benzodiazepines, so education is important in teaching patients that there are serious side-effects associated with benzodiazepines (e.g. impairment in cognition and increased fall risk in the elderly) and that other treatment modalities can be helpful in managing their PTSD.

  • Marijuana

    • Although there are many strong personal testimonies and anecdotes concerning the efficacy of marijuana in alleviating the various symptoms of PTSD, there were no high quality randomized clinical trials as of 2016 that have looked at the efficacy of marijuana for PTSD (Wilkinson, Radhakrishnan & D'Souza, 2016).

    • There are clinical trials underway (one in a VA in Arizona) testing CBD for PTSD.

    • 3 things worry about marijuana usage in patients with PTSD

  1. Adverse interactions between psych meds and marijuana are currently unknown and can be dangerous as patients are often taking both their medications and marijuana.

  2. Marijuana impairs driving, attention, memory, IQ, and increases rate of psychosis.  View my prior blog, Youtube and podcast on Marijuana: here

  • Ketamine and MDMA

    • There are currently ongoing studies in the VA, but it’s still too early to tell without seeing the data.


I would highly recommend checking out Dr. Jain’s book:

The Unspeakable Mind: Stories of Trauma and Healing from the Frontline of PTSD Science

Here are several of my prior episodes on PTSD:

How to Help Patients With Sexual Abuse

How to Treat Emotional Trauma

Emotional Shutdown—Understanding Polyvagal Theory



Schizophrenia Differential Diagnosis & DSM5

On today’s episode of the podcast, I am interviewing with Dr. Ariana Cunningham. We cover the DSM5 criteria for schizophrenia and the differential diagnoses for schizophrenia.

Joseph Wong (MS3), Ariana Cunningham, M.D., David Puder M.D.

Diagnosing schizophrenia  

Doctors and therapists need to be able to rule everything else out before they can land on schizophrenia as an official diagnosis. The specific symptoms are known as “first-rank symptoms,” which we will cover later in the article, that will help with diagnosing patients (Schneider, 1959). Eighty-five percent of people with schizophrenia endorse these symptoms, but be wary of jumping to conclusions, because they are not specific to schizophrenia and, in some studies, are also endorsed by bipolar manic patients (Andreasen, 1991).

DSM5 (Diagnostic and Statistical Manual of Mental Disorders 5th ed.)

Schizophrenia is a clinical diagnosis made through observation of the patient and the patient’s history.

  • There must be 2 or more of the characteristic symptoms below (Criterion A) with at least one symptom being items 1, 2 or 3. These symptoms must be present for a significant portion of time during a 1 month period (or less, if successfully treated).

  • The patient must have continuous, persistent signs of disturbance for at least 6 months, which includes the 1 month period of symptoms (or less, if successfully treated) and may include prodromal or residual periods.

    • For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care, are markedly below the level achieved prior to the onset.

    • If the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational achievement.

Criterion A:

A. Positive symptoms (presence of abnormal behavior)

1. Delusions

2. Hallucinations

3. Disorganized speech (eg, frequent derailment or incoherence)

4. Grossly disorganized or catatonic behavior

B. Negative symptoms (absence or disruption of normal behavior)

5. Negative symptoms include affective flattening, alogia, avolition, anhedonia, asociality.

Development, Course and Risk Factors

Psychotic symptoms of schizophrenia typically occur in young adulthood (late teens to mid-30s) (American Psychiatric Association, 2013). About 80% of schizophrenia presents with acute onset, intermittent symptoms and few/no symptoms while about 20% present with insidious onset, continuous symptoms and poorer outcomes (Bleuler, 1978). In terms of age of onset, it has been well documented that males present earlier than females (early to mid 20s for males vs late 20s for females) (Patel, Cherian, Gohil & Atkinson, 2014).

There are two key factors that have been associated with poorer prognosis. Earlier age of onset, which is highly associated with schizophrenia in males, has been well-documented to be associated with a poorer prognosis (Kao & Liu, 2010). The deficit form of schizophrenia (persistent negative symptoms of schizophrenia) have also been shown to be associated with a poorer prognosis (Kirkpatrick, 2008).

The highest risk factors for schizophrenia have been tied to genetic factors such as having an affected immediate family member or being the offspring of an immigrant from certain countries (Torrey, 2012). Molecular genetics have also been used to show that genetic inheritance is highly associated with schizophrenia, although it is not currently known how much genetic variation increases the risk for schizophrenia (Ripke, 2014). Non-genetic risk factors for schizophrenia include infectious causes such as Toxoplasmosis, living in an urban environment, birth seasonality and maternal exposure to influenza (Torrey, 2012).

Although functional recovery is rarer early on in the course of schizophrenia, the good news is that timely and intensive treatment can impact functional recovery early in the illness (Robinson, 2004). Patients who had more intensive intervention showed greater improvement in quality of life, higher functioning in school/work, and less psychopathology (Kane, 2016).

Differential diagnosis

When I see a patient that presents with these symptoms, the first thing I consider is substance use. I check if they had prior urine drug screens in their medical records, physical signs of substance use (e.g. poor dentition, track marks) and history of motor vehicle accidents. Even if history and physical condition do not suggest substance use, it’s common practice to order a urine drug screen on anyone coming into an inpatient psychiatry unit and look at prior drug screens in the medical record.

Other considerations include psychosis due to another medical condition (e.g. Wilson’s disease), personality disorder (long history of passive suicidal intent dating back to adolescence for borderline personality disorder, odd beliefs associated with Cluster A personality disorders, etc.), mania (e.g. rapid talking, grandiosity, decreased need for sleep) or severe depression (long progressive history with eventual psychosis).

For patients manifesting with some, but not all of the symptoms of schizophrenia, here is a list of differential diagnoses. With schizophrenia being a diagnosis of exclusion, it is important to consider all possible diagnoses.

A. Based on timeline of symptoms (American Psychiatric Association, 2013):

  • Brief Psychotic Disorder: Presence of > 1 positive symptom lasting 1 day to 1 month .  

    • Can be precipitated by stressors or have peripartum onset.

  • Schizophreniform: Same diagnostic criteria as schizophrenia, except lasting for at least 1 month, but less than 6 months. May be the start of schizophrenia, but not all patients with schizophreniform go on to be diagnosed with schizophrenia.

    • Social and occupational decline do not need to be present like they do in schizophrenia.


B. Presence of mood disorder features (APA, 2013)

  • Schizoaffective: Meets criteria for schizophrenia as well as major mood disorder (manic episodes or significant depressive episodes that have occurred at different times in the person’s life).

    • Schizoaffective disorder is differentiated by major mood disorder with psychotic features by the presence of > 2 weeks of psychotic symptoms without major mood episode.

  • Bipolar Mood Disorder: Bipolar I: Meets criteria for current or past manic episode that could be preceded or followed by hypomanic or major depressive episodes. Bipolar II: Meets criteria for current or past hypomanic episode and major depressive episode.  

    • Typically, a manic patient will take a few days to fall asleep when they are in an episode even when on significant medications.

  • Major Depressive Disorder Severe with Psychotic Symptoms: Psychotic symptoms (e.g. delusions or hallucinations) exclusively occur during a major depressive or manic episode, which is differentiated by schizoaffective disorder, which is characterized by > 2 weeks of psychotic symptoms with major mood episode.

    • There is a long period of depression leading up to the psychotic symptoms. The patient usually by the time they have psychosis has been depressed for months if not years. The psychosis and depression will not change in 2-3 days like they can in someone hospitalized with borderline personality disorder.  


C. Personality Disorders (APA 2013):

  • Borderline Personality Disorder (Cluster B): Long-standing pattern of unstable interpersonal relationships, impulsive behavior (e.g. sexual or self-harming), and mood instability (e.g. feelings of emptiness, intense dysphoria) .

    • A borderline personality disorder patient will have negative inner “voices” that will lead them to fear they are hearing things, but they can put on a social veneer and appear put together. A schizophrenic patient cannot put on a social veneer when in a disorganized and psychotic state.

    • These patients also have a history of passive suicidality dating back to adolescence.

  • Schizotypal personality (Cluster A): Long-standing pattern of odd or eccentric beliefs and/or perceptual disturbances that do not rise to the level of delusions or hallucinations.

    • Shares many similar symptoms as schizophrenia, but schizotypal personality disorder can be distinguished from schizophrenia as the personality disorder is present before the onset of psychotic symptoms and persists even when the psychotic symptoms vs. a period of persistent psychotic symptoms in schizophrenia.  

  • Schizoid personality (Cluster A): Long-standing pattern of little interest in social relationships or intimacy.

    • Shares similar symptoms as schizophrenia such as flattened affect, but does not present with psychosis.

    • Schizoid personality disorder can be distinguished from schizophrenia as the personality disorder is present before the onset of psychotic symptoms and persists even when the psychotic symptoms vs. a period of persistent psychotic symptoms in schizophrenia.  

D. Other considerations:

  • Substance-induced psychosis: Symptoms occur during intoxication or acute withdrawal and do not persist after the individual is sober.

    • The people who are coming off of methamphetamines typically want to sleep the first few days and are irritable coming off of meth, while people with schizophrenia will talk with you for a bit, and be awake during the day (although sometimes lying in bed doing nothing).  

    • THC has been associated with an increased risk of developing psychosis. A meta-analysis of 18 studies involving 66,816 individuals gave an OR of 3.90 (95% CI 2.84 to 5.34) for the risk of schizophrenia and other psychosis-related outcomes among the heaviest cannabis users compared to nonusers (Marconi, 2016).

  • Psychosis due to a general medical condition or medication: Symptoms can occur with other medical conditions such as CVA or TBI, Wilson’s disease, porphyria, or syphilis infection (watch for it in HIV patients) as well as medications (e.g. steroids) and certain dietary supplements.

  • Delusional disorder: One or more delusions (false belief system) that are fixed and persistent, lasting for > 1 month.

    • Can be differentiated from schizophrenia by the lack of other symptoms besides delusions. An exception to this is that patients may have olfactory or tactile hallucinations consistent with the delusion, but they won’t have auditory hallucinations that is most commonly associated with schizophrenia (Chaudhury, 2010; Opjordsmoen, 2014).

    • Functioning is also not impaired compared to schizophrenia.

  • Pervasive developmental disorders: May present with symptoms resembling psychosis or negative symptoms; however, an important factor to consider before diagnosing schizophrenia is the patient’s developmental pattern.

    • For example, for a 3 - 5 year old child, imaginary friends are common for that developmental stage and shouldn’t be instantly labelled as a visual hallucination- so when you listen to their vocabulary consider what age they are even if they look physically much older (Taylor & Mottweiler, 2008).

    • “An additional diagnosis of schizophrenia should only be made in a patient with autism spectrum disorder or communication disorders if psychotic symptoms are present for at least a month” (APA 2013).

For more on schizophrenia check out these other episodes:

Schizophrenia with Dr. Cummings: Controversies, Brain Science, Crime, History, Exercise, Successful Treatment

The History and Use of Antipsychotics with Dr. Cummings  



Do I have Schizophrenia?

On today’s episode of the podcast, Ariana Cunningham and I continue our discussion from the first episode about schizophrenia, focusing on the clinical manifestations of the disease.

Ariana Cunningham, M.D., David Puder, M.D., 

Clinical manifestations 

Many people worry that they have schizophrenia. I receive messages or inquires often of people asking about symptoms and manifestations. If you have those types of questions, or if you’re a mental health professional who needs to brush up on symptoms and medications, this article should help you.

There are many clinical observations of how schizophrenia presents itself. Cognitive impairments usually precede the onset of the main symptoms[1], while social and occupational impairments follow those main symptoms. 

Here are the main symptoms of schizophrenia:

  • Hallucinations: a perception of a sensory process in the absence of an external source. They can be auditory, visual, somatic, olfactory, or gustatory reactions.

  • Most common for men “you are gay”

  • Most common for women “you are a slut or whore”

  • Delusions: having a fixed, false belief. They can be bizarre or non-bizarre and their content can often be categorized as grandiose, paranoid, nihilistic, or erotomanic 

  • Erotomania = an uncommon paranoid delusion that is typified by someone having the delusion that another person is infatuated with them.

  • This is a common symptom, approximately 80% of people with schizophrenia experience delusions.

  • Often we only see this from their changed behavior, they don’t tell us this directly.

  • Disorganization: present in both behavior and speech. 

  • Speech disorganization can be described in the following ways:

  • Tangential speech – The person gets increasingly further off the topic without appropriately answering a question.

  • Circumstantial speech – The person will eventually answer a question, but in a markedly roundabout manner.

  • Derailment – The person suddenly switches topic without any logic or segue.

  • Neologisms – The creation of new, idiosyncratic words.

  • Word salad – Words are thrown together without any sensible meaning.

  • Verbigeration – Seemingly meaningless repetition of words, sentences, or associations

  • To note, the most commonly observed forms of abnormal speech are tangentiality and circumstantiality, while derailment, neologisms, and word salad are considered more severe.

  • Cognitive impairment:

  • Different processing speeds 

  • Verbal learning and memory issues

  • Visual learning and memory issues

  • Reasoning/executive functioning (including attention and working memory) issues

  • Verbal comprehension problems

  • Mood and/or anxiety: mood and anxiety disorders occur at a higher rate in schizophrenic patients than in the general population, and for this reason it is important for providers to . Estimates of the lifetime prevalence of depression in schizophrenia vary widely—from 6 to 75%—based on differing study characteristics including varying definitions of depression, patient settings, and durations of observation (Conus et al, 2010Hausman et al, 2002McRenolds, 2013). There is a higher prevalence of anxiety in patients with early-onset schizophrenia than in patients with later onset. 

  • Suicidality: People with schizophrenia have a higher rate of suicide than the general population. Generally, 5% of 10% of all completed suicides are people with schizophrenia (Hor et al, 2010; Arsenault et al, 2004).

There are also some associated signs we want to make sure you are aware of, even though they aren’t considered central to the diagnosis of schizophrenia:

  • Neurological signs aka “soft signs” include slight impairments of sensory integration and motor coordination (Heinrichs et al, 1988). Some examples of this include: R-L confusion, agraphesthesia (the inability to recognize letters or numbers traced on the skin, usually on the palm of the hand), olfactory dysfunction, astereognosis (the inability to identify familiar objects by touch alone). Be sure if you see one of these symptoms that you consider the possibility that they could be a side effect of medications.

  • Catatonia is another important state sometimes associated we would like you to be familiar with. A helpful tool to use when evaluating a patient is the Busch Francis Catatonia rating scale which lists all the criteria associated with catatonia and 0-3 rating scale for each.

  • Interestingly, another association we see in people with schizophrenia is that there are higher rates of diabetes, hyperlipidemia, and hypertension. In fact the life expectancy is reduced 10-20 years compared with the general population. The main medical mortality is heart disease.

In conclusion

On the podcast episode, we discuss the clinical manifestations of schizophrenia and what you would be looking for when making a diagnosis. The more we understand about this disorder—how the symptoms manifest, in what order they often present, and how to differentiate these signs from adverse drug reactions, and expected comorbidities—the better. Improved understanding of this will improve diagnosis and equip providers to implement treatment sooner, thus improving the prognosis and projected functionality of patients with schizophrenia.

In the next podcast we will be discussing the following topics:

  • How the disease progresses?

  • DSMV definition and diagnostic criteria

  • Differential diagnoses

  • Symptom management:

  • Pharmaceutical

  • Non pharmaceutical

Here are some further episodes on schizophrenia:

How Psychiatric Medications Work with Dr Cummings

Schizophrenia with Dr. Cummings

Schizophrenia in Film and History



Schizophrenia in Film and History

In today’s episode of the podcast, Ariana Cunningham and I talk about schizophrenia. Ariana is a psychiatry resident who is also on my research team.

David Puder, M.D., Ariana Cunningham, M.D.

What is schizophrenia?

It is a psychotic disorder that typically results in hallucinations and delusions, leaving a person with impeded daily functioning. The word schizophrenia translates roughly as the "splitting of the mind," and comes from the Greek roots schizein ( "to split") and phren- ( "mind").

The onset of the disease typically occurs in young adulthood; for males, around 21 years of age, for females, around 25 years of age.

We don’t know exactly what causes schizophrenia. There are certain predictors for it, and as I discussed the basics and pharmacology a previous podcast, frequent marijuana use can increase the risk of a psychotic or schizophrenic illness to about 4 times what it would be without THC use.

History of schizophrenia

Sometimes, in ancient literature, it can be difficult to distinguish between the different psychotic disorders, but as far as we know, the oldest available description of an illness resembling schizophrenia is thought to have existed in in the Ebers papyrus from Egypt, around 1550 BC. Throughout history, in groups with religious beliefs, the misunderstanding of the psychopathologies caused people to paint those with mental health disorders as receiving divine punishments. This theme of divine punishment continues today in some parts of the world.  

It wasn’t until Emil Kraeplin, a german psychiatrist (1856-1926) that schizophrenia was suggested to be more biological and genetic in origin. In around 1887, Kraeplin differentiated what we call schizophrenia today from other forms of psychosis. At that time, he described schizophrenia as dementia of early life.

In 1911, Eugen Bleuler introduced schizophrenia as a word in a lecture at a psychiatric conference in Berlin (Kuhn, 2004). Bleuler also identified the positive and negative symptoms of schizophrenia, which we use today.

Kurt Schneider, a German psychiatrist, coined the difference between endogenous depression and reactive depression. He also improved the diagnosis of schizophrenia by creating a list of psychotic symptoms typical in schizophrenia that were termed “first rank symptoms.”

His list was:

  • Auditory hallucinations

  • Thought insertion

  • Thought broadcasting

  • Thought withdrawal

  • Passivity experiences

  • Primary delusions

  • Delusional perception (the belief that a normative perception has a certain significance)

Sigmund Freud furthered the research, believing that psychiatric illnesses may result from unconscious conflicts originating in childhood. His work eventually affected how the psychiatric world and society generally viewed the disease.

The lack of understanding of the disease is a dark history, and it is still deeply stigmatized, but psychiatry has made massive leaps in understanding schizophrenia and changing how it is viewed in modern society.

Nazi germany, the United States, and other Scandinavian countries (Allen, 1997) used to sterilize individuals with schizophrenia. In the Action T4 program in Nazi Germany, there was involuntary euthanasia of the mentally unwell, including people with schizophrenia. The euthanasia started in 1939, and officially discontinued in 1941 but didn’t actual stop until military defeat of Nazi Germany in 1945 (Lifton, 1988). Dr. Karl Brandt and the chancellery chief Philipp Bouhler expanded the authority for doctors so they could grant anyone considered incurable a mercy killing. In reading about this event, it seems that this caused approximately 200,000 deaths.

In the 1970’s, psychiatrists Robins and Guze introduced new criteria for deciding on the validity of a diagnostic category (Kendell, 2003). By the 1980’s, so much was understood about the disease that the DSM (Diagnostic and Statistical Manual of Mental Disorders) was revised. Now, schizophrenia is ranked by World Health Organization as one of the top 10 illnesses contributing to global burden of disease (Murray, 1996).

Unfortunately, it is still largely stigmatized, leading to an increased schizophrenia in the homeless population, some estimates showing up to 20% vs the less than 1% incidence in the US average population.

In conclusion

On the podcast episode, we discuss the media’s portrayal of schizophrenia. Although media paints mentally ill as often violent, on average people with mental illness only cause 5% of violent episodes. This is just one example of how the stigma is furthered.

The more we understand about this disorder—what causes it, how we can help, how we can provide therapy and medicate and treat patients—the better. Getting rid of the stigma by learning the history and also moving beyond preconceived ideas to the newest science will also help de-isolate people with schizophrenia and help support them in communities, giving them a chance at a normal, healthy life.




Marijuana and Mental Health

On today’s episode of of the podcast, I will discuss marijuana use and how it affects mental health with Daniel Binus, the chief psychiatrist at Beautiful Minds, near Sacramento, California. Also joining us is a third-year medical student, Victoria Agee.

David Puder, M.D., Victoria Agee

Why are we even talking about marijuana?

There are a few reasons we believe this is important to talk about. First, as medical professionals, we often see patients who want help with their anxiety, depression, ADD and suicidality. They say they use cannabis, and that they need cannabis, to help calm those symptoms. When we explain the research to them, it still takes them awhile to let go of their habits and embrace other forms of therapy and medication that is a better long-term option.

Also, we head into a time when marijuana is being legalized, there are tons of THC companies that will benefit from suppressing this information and even suppress these studies we will reference here. Hiding this information could be detrimental to society’s mental health. While there are some potential benefits to one component of marijuana (CBD), something I will review in the future (evidence is fairly young in that field), the THC component can be highly damaging to mental health.

Whether or not people are willing to admit it, cannabis is actually highly addictive. One of the symptoms of addiction is intellectualizing reasons for use. Not only does it change the way the brain functions, it changes the way we see and perceive the world. It also changes our visual and spatial abilities. If you’re an architect or use math in your job, it deeply affects those abilities as well. THC stays in your brain a long time—it can be weeks (or even a month) before people get the full function of their brain back and the fog has cleared.

What is the research on cannabis?

Ganja is from the cut tops of leaves (5-8% THC content) and hashish is from the resin and is therefore more potent (10-20% THC content) Delta-9-tetrahydrocannabinol (THC) is the most commonly used substance worldwide.

It causes long-term changes in the brain

Recent research shows that consistent cannabis use will change the way your DNA is expressed in the brain. It will upregulate and downregulate proteins in the brain, and can change the morphology of the way it works. Marijuana, in fact, leads to changes in our genes over time, called epigenetic changes (Szutorisz, 2018). So the initial effect may be pleasure or fun, but long term, it can create changes that take months to develop in a way that people don’t understand why they are having new issues that pop up. Basically, it’s not changing your gene structure, but it is changing the expression of those genes. Anytime you make positive food choices or develop a consistent exercise routine or make physical changes, epigenetic changes occur that are healthy for long term change (see my episode on diet and exercise)

It’s not surprising that marijuana also causes similar changes in the brain, but not in a healthy way.

When people use cannabis heavily, it causes our endogenous cannabinoids that naturally occur within the body to shift, which can create a disruption in our natural release of cannabinoids. This actually creates a direct correlation between heavy cannabis use and lower IQs (He, 2019).

It lowers intelligence

Studies show that over 20 year cannabis use, people lose an average of 6-8 IQ points. That means you could go from intelligent to average, or even average to below average.

It affects men’s sexual health

In a survey of 8,650 people, women had no association with any of the sexual problems from marijuana use. Men, however, had significant associations between daily cannabis use and reporting an inability to reach orgasm (OR 3.94), reaching orgasm too quickly (OR 2.68), and reaching orgasm too slowly (OR. 2.05).

Among the 424 men who reported reaching orgasm too quickly, there was an association between frequency of cannabis use and the extent to which reaching orgasm too quickly was experienced as problematic  (F- 2.85, P <0.01) (Smith, 2010)

Routine usage of cannabis (more than once per week) was also associated with a nearly 30% reduction in median sperm concentration and total sperm count after adjustment (Gunderson, 2015).

It increases risk for psychotic disorders

Multiple studies have shown a link between marijuana use and psychotic effects that demonstrate that it is definitely causal in contributing to psychotic disorders.

A meta-analysis of 66,000 individuals showed that heavy cannabis and average cannabis users were 4x and 2x, respectively, as likely to develop schizophrenia or other psychosis-related symptoms compared to nonusers (Marconi, 2016).

In a study that came out this year (2019), young adults who used cannabis were about 1.5x more likely to develop depression and suicidal ideation and 3.5x more likely to attempt suicide (Gobbi, 2019).

It has negative effects at any age

Cannabis exposure during gestational development has a direct correlation to drug-seeking behavior later in life. Early life cannabis exposure (adolescents) upregulates expression of Penk mRNA, an opioid neuropeptide in mesocorticolimbic system, which has direct causal link to enhanced behavioral susceptibility to heroin use as an adult(Szutorisz, 2018).

Studies also show that in teens, even a few uses of marijuana makes them predisposed to depression, psychotic disorders and suicidal ideation.

It causes impaired social functioning

It increases the amount of impulsivity and hostility in daily life. It increased hostile behaviors and also paranoia of others being hostile. It also deadens the ability to detect microexpressions and create social connection so that it may remove appear to improve social anxiety. However, it's not an actual solution, because it prevents someone from presenting their real self.

How to help a patient who uses cannabis

Cannabis can potentially help the symptoms of anxiety, ADD, depression, and a whole host of mental health issues initially. The problem is that cannabis fundamentally changes the brain in a way that causes long-term damage. Not only that, but if people are using cannabis as a coping mechanism for their mental health issues instead of therapy, they will not deal with the underlying issues, only medicate the symptoms.

When a new patient comes in and reports regular marijuana use, I highly recommend for them to get off of it, for at least the course of therapy. However, it also is important to mention that the first stance to take with every patient is empathy. I tell them there is no shame in their marijuana use. I liken it to them using a log when they’re in an ocean—it helped them keep their head above water because it floated. But when a rescue boat comes along, if they try to heft the log into the boat, it won’t work. With proper therapy, with the boat, they won’t need the log for survival any longer.

I even tell them they can get back on it after the therapy if it hasn’t helped them. When they are off of marijuana, they have the ability to be present and really process what they will need to process in therapy in order to get over anxiety and depression.

When they do take the symptom suppressor of marijuana away, often they will experience a flood of emotions and memories. Maybe cannabis was the best thing our patients could find in the moment, but there are obviously better ways of helping them deal with their pain.

In conclusion

I have a very extensive worksheet of all of the research about cannabis in my Free Resources Page. It’s important to understand the depth of the ways THC can affect our patients lives and mental health.



What is Transference and Countertransference?

On this week’s episode of the podcast, I talk about transference and countertransference. It’s the fourth episode in my four-part therapeutic alliance series where I discuss best practices on dealing with the doctor - patient relationship.

Here are the three previous episodes:

Part 1 - Introduction

Part 2 - Logotherapy and Meaning

Part 3 - What is empathy and how to improve it

What is transference?

Historically the term “transference” refers to the feelings, fantasies, beliefs, assumptions and experiences unconsciously displaced on the therapist that originate in the patients’ past relationships. More recently, transference is seen as the here and now, valid experience the patient has of the therapist.

It is “a mixture of real characteristics of the therapist and aspects of the patient’s figures from the past—in effect, it’s a combination of old and new relationships.” (Gabbard)

How does transference work?

The patient’s early experiences develop organizing principles, constructing a framework for future interpersonal interactions. (Maybe their dad was an abuser, so they project that you will abuse them.) Transference is the continuing influence of these ways of organizing and giving meaning to experiences. They crystallized in the past, but they continue in an ongoing way in the here and now. The therapist’s actual behavior is always influencing the patient’s experience of the therapist because of this.

When a patient visits a therapist, they seek a new developmentally needed experience, but they expect the old, repetitive experience.

There is often misattunement to painful circumstances that can't be integrated into a person’s emotional world. For example—a child who can’t demonstrate his emotion in a way that his parents can handle causes the parents to move away from the child, creating distance. The child then subdues the emotion and creates a new “ideal self” so they can interact with others and no be rejected. The child then doesn’t know how to deal with strong emotion, even moving into adulthood.

Unintegrated affects become lifelong emotional conflicts and vulnerabilities to traumatic states.  To handle the difficult situation, they develop defense mechanisms. Those defenses against affects become necessary to maintain psychological organization.

That “ideal self” will stay in place with others until you come along. If they see you as a safe person, they will express their emotions—anger and all—towards you.  


This is where it’s important to understand transference, and to be able to give your patient a safe place to express their emotions.

When we understand transference is happening, we can listen from the patient's world, acknowledge their subjective perspective, resonate with them, look for their meanings, and form and alliance with the patient's expressed experience.

Of course we must expect their hesitations to trust us, avoid us, have feelings of shame, guilt, and embarrassment...it is uncomfortable to share what one feels.

Positive Transference

Negative transference isn’t the only type of transference—there is also positive transference, where you remind the patient of a positive relationship they had, so they feel deeply connected to you. People with borderline personality disorder are very quick to attach, usually commenting that they have never felt so close to a therapist before. When someone does say very positive things to me, especially in the first few sessions, I let them know that it’s also okay to express negative feelings towards me as well.  

Transference-focused therapy

Kernberg wrote about transference focused psychotherapy. He hypothesized about the developmental birth of borderline personality disorder. By exploring and integrating these “split-off” cognitive-affective units of self and other representations, patients will be able to think more coherently and reflectively. They will be more realistic and accurate in their thoughts, feelings, intentions and desires about themselves and others. Integration will allow for increased modulation of affect, coherence of identity, increased capacity for intimacy, and improved functioning (Kernberg 2008).

Levy (2006) studied transference focused psychotherapy (TFP) vs dialectical behavior therapy (DBT) vs supportive psychodynamic psychotherapy for borderline personality disorder. He found that TFP had increased secure attachments (whereas the other 2 did not change it), with increased narrative coherence. It also improved reflective function—the ability to mentalize the thoughts, feelings, goals of another person.

What are some common transferences?

  • Sibling rivalry

    • Competitiveness, comparing, jealousy.

  • Maternal

    • Possibly see you as nurturing or abusive.

  • Paternal

    • Possibly wants you to solve their problems, asks for direct advice.

  • God

    • Where they want you to be all powerful or omnipotent.

  • Erotic

    • One of their primary attachment figures might have sexualized them, so they might yearn for erotic attention and affection. Perhaps a patient falls in love with you, or someone similar physically to you.

  • Idealizing or contemptuous

    • They could view you as a savior, or feel contemptuous to you.

  • Passively hoping for a miracle

  • A person prone not to trust will view the therapist with suspicion

  • A person who struggles with anger will have anger towards the therapist

  • Transferences are influenced by age, gender, clothing, bodily attributes, context, vocabulary & choice of words, personality characteristics

  • Be a certain way to have you stay connected with them  

How do deal with transference in therapy:

Here is the main, overarching principle when dealing with transference: have empathy. Be empathic. Be open to their feedback. Don’t take things personally. Be connected with your patient. Developing a therapeutic alliance requires you being connected, and being connected requires you to allow your patient to explore their emotional world with you. That requires psychological safety.

When you are a safe place, they will hopefully be able to connect, and you can help them identify their transferences so they have a chance at developing healthy relationships in the future without bringing their past with them.

If my patient had a previous therapist, I always ask them, “What went well and what did not go well in your past therapy relationship?”

Other questions I ask are:

  • “How would you like your past therapy to have been different?”

  • “When you felt disappointed and misunderstood, were you able to share that feeling with your therapist?”

  • “In what ways would you like your relationship with me to be like your experience with your last therapist?”

  • “What are some of your worries about what you might experience in your treatment with me?”  

When I can tell they don’t want to come to therapy. I normalize their feelings so they feel like they can share with me.

  • “This is a laboratory where we look at what goes on between us, and when you tell me you are mad at me, I am going to be excited about your sharing your feelings, good or bad.”

  • “What are you feeling about leaving me for the day?”

  • “What did you do when you were young and something bad happened to you?”

    • “Go to mom? Go to Dad? Go out alone?”

    • “When you looked for help how were you responded to?”

    • “Were you comforted? Did it help?”

    • “How did it make you feel when you wanted somebody to help your upsetness?”

    • “I want to be with you in this moment of sadness and loss.”

When you sense an empathic strain, mending it is priority number 1. I might say, “Help me understand what I might not have understood here.” Or, “If I said something that makes you feel worse about yourself then let’s talk about it now.” Try to prevent an empathic strain from progressing to an empathic rupture in your relationship by catching the strains early on.

Here are a few tips to handle when patients exhibit strong emotions towards you:

  • Be enthusiastic and curious about patients’ experiences when coping with intense feelings.

  • Be particularly encouraging about them discussing their feelings, and especially their feelings towards you. Whereas in the past there might not have been a  safe place to get angry, they are entitled to want to have a different experience with you.

  • Say explicitly that they are allowed to have all of their feelings (including loving and hating) in the therapy relationship and that they will be dealt with in words and not in actions.

  • Convey to them that they can feel secure and accepted and not reproached or rejected, even if they have negative feedback or feelings towards you.

  • You can work cooperatively to help them process and modulate their emotions.

  • You can explore together what actions might be appropriate for them when the flooding feelings erupt and they are unsure about what might happen as consequences.

  • Complicated emotions are inevitable: the opportunity we offer is to enhance ways of coping with desirable as well as disruptive emotions. Emotions may be congruent with experiences in the past, but not necessarily appropriate in the present context in which they recur.

When we are young, we are unable to metabolize emotions correctly, especially in the face of trauma or an unsafe caregiver. When we age, we transfer those patterns of belief onto every other relationship in our life, trying to recreate that. When you, as a therapist, offer a safe environment for a patient to experience those strong emotions, you are helping them rewire their belief system around those emotions. It allows them to interact with every other person in a new way.

Countertransference:

The original and narrower definition of countertransference centered around the therapist unconsciously experiencing the patient as someone from their past (similar to transference). Now, countertransference is seen as the therapists’ total reaction to the patient.

First, it’s important to note that therapists need to practice what they preach: do the work in your own therapy so you can identify your own transferences. The less clouded your vision is of what’s happening in sessions, the better. For example, one therapist saw nearly every patient as a trauma victim, and occasionally led them to believe they’d been traumatized as well in the same way.  

Countertransference is seen as a source of important information about the patient: it can be a major diagnostic and therapeutic tool. “Countertransference is an instrument of research into the patient’s unconscious.” (Paula Heimann)

Now it is seen as a jointly created reaction in the clinician (some reactions from the therapist's past, some induced by the client's behavior).

There are continuously fluctuating levels of influencing the transference and countertransference by contributions from both patient and therapist during all their interactions. My mentor, Dr. Tarr, said, "To every relationship we bring learned expectations from past encounters.”

One way to handle countertransference to make sure you are coming from a healthy place is to use your left brain to integrate with, and therefore dampen, the right brain. Learn from what you are feeling during the session, but observe yourself with curiosity.

Another form of possible transference is sexual attraction towards a patient. Studies show that 85% of male therapists at some point have erotic arousal towards a female patients. Obviously, it is important to not act on or tell your patient about those feelings.

You should also allow yourself to mirror the patient’s emotions, as to follow the patient’s emotional movements and unconscious content.  

Before a patient enters the room, check in with yourself. How are you feeling? What are you feeling?

Here is a checklist I like to use before my sessions with patients. It is based on 7 basic emotions:

  •  Disgust

    • I dislike him/her.  

    • I feel repulsed by him/her.

  • Attraction

    • I have compassion for the patient.

    • If they were not my patient I would want to date him/her.

    • I feel sexually attracted to him/her.

    • If he/she were not my patient I would want to be their friend.

    • I look forward to sessions with him/her.  

    • I wish I could give him/her what others never could, protect him/her like no one could...

    • I feel I understand him/her.  

    • I have warm, almost parental feelings towards him/her.

    • I self-disclose more about my personal life with him/her more than with other patients.

  • Sadness

    • I wish I had never taken the patient on...

    • I feel sadness/depression in sessions with him/her.

    • I feel guilty about my feelings towards him/her.

    • I feel guilty when she/he is distressed or deteriorates, as if I must be somehow responsible.  

  • Angry

    • I feel dismissed or devalued.

    • I feel annoyed in sessions with him/her.

    • I feel criticized in sessions with him/her.

    • I feel angry with him/her.

    • I feel anger at people in his/her life.

    • I feel competitive with him/her.

    • I feel used or manipulated by him/her.

    • I have to stop myself from being aggressive or critical with him/her.

    • I feel pushed to set firm limits with him/her.

    • I feel resentful working with him/her.

  • Dissociation/Shut Down

    • I feel confused in sessions.  

    • I am overwhelmed by strong emotions with him/her.

    • I feel hopeless working with him/her.

    • I feel like my hands are being tied or that I have been put in an impossible bind.

  • Sensorium issue

    • I feel bored in sessions with him/her.

    • My mind wanders to things other than what he/she is talking about.

    • I feel sleepy when talking with him/her.  

  • Fear/Anxiety

    • I feel anxious/frightened working with him/her.

    • I fear I am failing to help him/her.

    • His/her sexual feelings towards me make me anxious or uncomfortable.

    • I fear being incompetent or inadequate to help him/her

    • After treatment ends I worry about him/her more then most patients.

It is completely normal to have feelings—both good and bad—towards patients. We are humans, not robots! Sometimes it might seem like you’re supposed to be perfect or void of feelings towards your patient, but that doesn’t allow a living, growing, healthy therapeutic alliance towards them. The important thing is to notice how you feel, without self judgement. Then, deal with those feelings in a healthy manner, like through seeking out your own therapy, getting a mentor, etc. However, sometimes merely allowing yourself to notice the feelings and owning up to the feeling of anger, attraction, boredom, or sadness, is enough to dissipate it.

It’s easy to be busy after a session. It’s better to practice noting your feelings. After all, how can we help our patients express and normalize their feelings if we cannot do it for ourselves?

Conclusion

If you are a mental health professional, I would love for this to be your community. We are in these trenches together, and it’s pretty common for therapists to feel totally exhausted and burned out from all of the countertransference. I hope that through this community, we can develop better practices, help each other, and grow together.

If any of you have any questions or listen to the podcast, I’m active on social media. I’d welcome any feedback you have. My social handles are: Instagram @Dr.DavidPuder, Facebook: @DrDavidPuder, or Twitter @DavidPuder




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