Dr. Nicholas Kontos, Director of the Consultation-Liaison Psychiatry Fellowship at Massachusetts General Hospital and assistant professor of psychiatry at Harvard Medical School, joins us for a reflective conversation on factitious disorder, malingering, and clinical deception.
We begin by unpacking the concept of “thinking dirty”—a term used in consultation-liaison psychiatry to describe the delicate and often uncomfortable task of considering deception in clinical care. Dr. Kontos walks us through why patients may deceive providers, including both conscious and unconscious motivations, and shares strategies for approaching these situations with clinical humility, curiosity, and compassion.
We explore practical interviewing techniques to elicit more accurate histories and review key distinctions between factitious disorder and malingering, including diagnostic criteria, prevalence, and typical management strategies. Dr. Kontos discusses the concept of the “therapeutic discharge,” a framework for ending unproductive hospitalizations while still maintaining a therapeutic posture.
Throughout the episode, we emphasize the central role of dignity and professionalism in managing deceptive behavior in medical settings, highlighting a model of psychiatry that avoids antagonism and centers patient care, even in the most complex situations.
Dr. Caitlin Adams, psychiatrist at Massachusetts General Hospital, provides an overview of functional neurological disorder (FND). This episode covers how to recognize, explain, and treat FND using a modern, evidence-based, and patient-centered approach.
We begin by defining FND and discussing nomenclature from hysteria through conversion disorder and into our current construct of FND. Dr. Adams directly addresses one of the most critical misconceptions in clinical practice: whether symptoms like functional weakness or psychogenic non-epileptic seizures (PNES) are under voluntary control. We explore what current neuroscience tells us about the pathophysiology of FND and how this can support compassionate and effective care.
The episode outlines how to positively diagnose FND—including key physical exam findings such as Hoover’s sign, tremor variability, and features that distinguish PNES from epileptic seizures. We also review how to communicate the diagnosis to patients, reduce stigma, and improve treatment engagement.
Dr. Adams describes the biopsychosocial model of FND, including common predisposing, precipitating, and perpetuating factors. We discuss the central role of cognitive behavioral therapy (CBT), the benefits of specialized physical therapy for functional movement symptoms, and additional psychotherapeutic approaches such as mindfulness and psychodynamic therapy. Finally, we address how to manage chronic or treatment-resistant FND, and when to re-evaluate the diagnosis.
Key References:
Dr. Christina Wichman, Professor of Psychiatry and Obstetrics & Gynecology, Medical Director of The Periscope Project and Director of Women’s Mental Health at the Medical College of Wisconsin, joins us for an in-depth introduction to reproductive psychiatry. This episode is co-hosted by Erica Browne, an M4 at Saint Louis University School of Medicine.
We explore the unique clinical and ethical challenges of treating psychiatric illness during pregnancy and the postpartum period, including how to navigate the needs of both mother and child. Dr. Wichman walks us through distinctions between common perinatal mental health presentations—such as baby blues, perinatal depression, and major depressive disorder—and discusses how to differentiate normal postpartum stress from psychiatric conditions that require treatment.
The episode covers validated screening tools, pharmacologic treatment during pregnancy and lactation, and non-pharmacologic options for patients with limited access to care. Dr. Wichman shares her clinical approach to balancing risk and benefit when initiating or continuing psychotropic medications, and offers guidance on red flags for perinatal psychosis.
We also highlight The Periscope Project, a model for expanding access to reproductive psychiatry expertise, and discuss training pathways and future directions in women’s mental health.
Key References & Clinical Resources
Today we have TWO world renowned experts to teach us about eating disorders!
Dr. Anne O'Melia is the Chief Clinical and Quality Officer at ERC Pathlight, where she leads a multidisciplinary team of over 1,000 therapists, dietitians, and nurses caring for patients across the country. She is board certified in pediatrics, general psychiatry, child and adolescent psychiatry, and consultation-liaison psychiatry. She has co-authored numerous articles and book chapters on eating disorders.
Dr. Patricia Westmoreland has spent decades traveling the globe speaking and publishing about eating disorders, and is currently working in private practice. Dr. Westmoreland has particular expertise in the forensic aspects of eating disorders, and in managing the medical complications of eating disorders. Dr. Westmoreland is board certified in internal medicine, general psychiatry, forensic psychiatry, and consultation-liaison psychiatry.
We review how to identify when disordered eating patterns require clinical attention and outline the most common eating disorders encountered in the general medical hospital, including anorexia nervosa, bulimia nervosa, and avoidant/restrictive food intake disorder (ARFID). The episode covers prevalence rates, high-risk populations, and the significant morbidity and mortality associated with eating disorders.
Our guests discuss key clinical information needed for diagnosis, criteria for medical hospitalization, and the spectrum of available levels of care. We take a deep dive into anorexia nervosa, reviewing its clinical trajectory, diagnostic criteria, subtypes, and complications. Finally, we examine evidence-based approaches to medical stabilization, psychotherapy, and pharmacotherapy in the treatment of eating disorders.
Key References:
2. Ethical Challenges in the Treatment of Patients With Severe Anorexia Nervosa (Westmoreland 2024)
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Dr. Mira Zein, Associate Professor of Psychiatry and Behavioral Science at Stanford University, walks us through decisional capacity determinations.
This is a great episode for learners rotating through a consultation-liaison psychiatry service, and will really help you shine on rounds when you quote the Appelbaum-Grisso criteria (seriously, do it)! We also invite psychiatry residents and CL psychiatrists to share this episode with their favorite primary team to help non-psychiatrists make capacity determinations on their own... They are often best suited to do so!
Dr. Zein walks us through the Appelbaum-Grisso criteria and discusses each criterion (communication, appreciation, understanding, rationality) in detail. This discussion goes beyond a textbook understanding of the topic, delving into several difficult cases of determining decisional capacity. We discuss common reasons for psychiatric consultation regarding capacity, and how to navigate difficult conversations when fielding consults. You will also learn about common illnesses that can cause diminished capacity, and how to proceed if a patient is found to lack decisional capacity (for a certain decision, at a certain time 😉).
Key resources:
2) Seminal Article on Appelbaum-Grisso Criteria (Appelbaum 1988)
3) Evaluating Capacity: Appelbaum’s Framework Interpreted Diagrammatically (Bari 2023)
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Dr. Paula Zimbrean, Professor of Psychiatry and Yale School of Medicine and Director of Transplant Psychiatry Services at Yale New Haven Hospital, introduces us to the field of transplant psychiatry.
We discuss the role of psychiatrists in solid organ transplantation, including pre-transplant evaluations. We then discuss the various phases through which transplant patients require support, starting with a diagnosis of advanced organ disease. We cover the pre-transplant phase, peri-operative recovery, early post-transplant stressors, and finally psychiatric considerations that last months to years after transplant. Dr. Zimbrean discusses ethical challenges faced by psychiatrists working in a transplant setting, and shares considerations for the future of transplant psychiatry.
Selected references:
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A season on consultation-liaison psychiatry would not be complete without an episode on suicide risk assessment!
Dr. Black: "I say without exaggeration that this podcast, in which Dr. Mullen and I discuss suicide risk assessment, is one of the professional things in life that I am most proud of."
WOW! That's quite the claim from one of the world's foremost psychiatrists about a podcast episode. Take a listen and see what you think!
Dr. Tyler Black, a suicidologist and child psychiatrist at British Columbia Children's Hospital, walks through common suicide myths, structuring the suicide risk assessment interview, common motivations for suicide, clinical decision making, best practices for documentation, and what works in preventing suicide.
Selected references:
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Dr. George Grossberg, Henry and Amelia Nasrallah Endowed Professor of Psychiatry & Behavioral Neuroscience at Saint Louis University School of Medicine, past president of the American Association for Geriatric Psychiatry, and past president of the International Psychogeriatric Association, orients us to behavioral disturbances in patients with neurocognitive disorders.
We walk through common behavioral disturbances in patients with dementia, including apathy, depression, psychosis, and agitation. We discuss management strategies including nonpharmacological and pharmacological interventions. Dr. Grossberg shares his expertise on difficult clinical management decisions when working with this population, and centers us around the importance of knowing the patient as well as the disease.
Selected References:
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Dr. Mark Oldham, Associate Professor of Psychiatry at the University of Rochester Medical Center, President of the American Delirium Society, and Deputy Editor of the Journal of the Academy of Consultation-Liaison Psychiatry, returns to discuss management of catatonia. We delve into management guidelines that everyone working with catatonia should know. We then have a candid discussion about common clinical challenges in treating catatonia, and describe unique cases of catatonia that require adjusting our approach.
Selected references:
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Dr. Mark Oldham, Associate Professor of Psychiatry at the University of Rochester Medical Center, President of the American Delirium Society, and Deputy Editor of the Journal of the Academy of Consultation-Liaison Psychiatry, introduces us to catatonia. We discuss the clinical features of catatonia and compare and contrast catatonia's description in the DSM with the Busch-Francis Catatonia Rating Scale. We describe and discuss various signs and symptoms of catatonia in detail.
Selected references:
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Dr. Mark Oldham, Associate Professor of Psychiatry at University of Rochester Medical Center, President-Elect of the American Delirium Society, and Deputy Editor of the Journal of the Academy of Consultation-Liaison Psychiatry, further explores delirium. This episode covers the pathophysiology of delirium including predisposing and precipitating factors, neurocircuitry, and neurotransmitters. We then discuss conceptual frameworks for management of delirium, the importance of identifying and addressing the underlying cause, and strategies for managing specific neuropsychiatric disturbances in delirium.
References can be found on the episode website.
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Dr. Mark Oldham, Associate Professor of Psychiatry at University of Rochester Medical Center, President-Elect of the American Delirium Society, and Deputy Editor of the Journal of the Academy of Consultation-Liaison Psychiatry, introduces us to delirium. This episode covers the epidemiology, clinical features, and diagnosis of delirium.
References can be found on the episode website.
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Dr. John C. Markowitz, Professor of Clinical Psychiatry at Columbia University, introduces us to supportive psychotherapy. We discuss the principles that underpin supportive psychotherapy and "common factors" in psychotherapy. Dr. Markowitz helps us to understand where supportive psychotherapy fits into modern psychiatric practice, and provides clinical wisdom about building a therapeutic alliance and pursuing affect.
What is Supportive Psychotherapy? (Markowitz 2014)
Brief Supportive Psychotherapy (2022)
Psychiatrist Effects in the Psychopharmacological Treatment of Depression (McKay 2006)
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Dr. Allen Frances, Chair of the DSM-IV Task Force and Chair Emeritus at Duke University returns to kick off Season 3. We discuss the unique role of consultation-liaison psychiatry in today's healthcare system, and Dr. Frances provides us with a framework for understanding and helping each individual patient during a medical hospitalization. Dr. Frances provides wisdom and encouragement to set the stage for our journey into the world of consultation-liaison psychiatry.
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Dr. Sameer Jauhar, Senior Clinical Lecturer in Affective Disorders and Psychosis at the Institute of Psychiatry, Psychology and Neuroscience, King's College, London, and as a Consultant Psychiatrist at Maudsley NHS Foundation Trust, introduces us to schizophrenia. Explore core clinical features of schizophrenia and what is known about the neuroscience of schizophrenia. We'll also discuss psychopharmacological and psychosocial treatment approaches, rooted in Dr. Jauhar's humanistic approach.
This episode is intended to supplement Dr. Jauhar's Lancet Seminar on Schizophrenia (2022).
Connect with Dr. Jauhar: @SameerJauhar
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Dr. Laura Watkins, Clinical Psychologist and Assistant Professor of Psychiatry at Emory University School of Medicine, introduces us to post-traumatic stress disorder (PTSD).
We walk though the diagnostic criteria and discuss how these symptoms can impact a person's day-to-day life. We then learn to conceptualize PTSD in terms of both classical and operant conditioning. Finally, we explain evidence based psychotherapies for PTSD and conclude with a primer on psychopharmacology for PTSD.
Essential references:
1) Osser Psychopharmacology Algorithm for PTSD
3) This American Life: Ten Sessions
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Dr. John Walkup, Chair of the Pritzker Department of Psychiatry and Behavioral Health at Ann and Robert H. Lurie Children’s Hospital of Chicago, Professor of Psychiatry at Northwestern Feinberg School of Medicine, and president-elect of the American Academy of Child and Adolescent Psychiatry, introduces us to anxiety disorders.
We discuss the phenomenon of normal, adaptive anxiety and contrast this with symptomatology that may warrant a diagnosis of an anxiety disorder. We learn to appreciate anxiety disorders from a developmental lens, discuss clinical pearls for building a therapeutic alliance with anxious patients, and explore psychotherapies for anxiety disorders. We also discuss psychopharmacological considerations for both SSRIs and benzodiazapines.
Dr. Roger McIntyre, Professor of Psychiatry and Pharmacology at the University of Toronto and Head of the Mood Disorders Psychopharmacology Unit at the University Health Network in Toronto, Canada, returns to introduce depressive disorders.
We differentiate normal "low mood" from conditions that warrant a psychiatric diagnosis. We discuss historical subtypes of depression and the current DSM specifiers for major depressive disorder. We review epidemiology, discuss the neurophysiology of depressive disorders, and then dive into treatment options.
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Dr. Lois Choi-Kain, Director of the Gunderson Personality Disorders Institute at McLean Hospital and Associate Professor of Psychiatry at Harvard Medical School, introduces us to borderline personality disorder (BPD).
We discuss the prevalence, naturalistic course, and treatments for BPD. We explore BPD using the “Good Psychiatric Management” (GPM) model, which is intended to empower clinicians of all disciplines to manage patients with BPD effectively. We discuss the principles of GPM and walk through some examples of how it might be used in the clinical setting.
Book: Applications of Good Psychiatric Management for Borderline Personality Disorder: A Practical Guide (Check your academic library!)
References:
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