In this episode, I speak with Dr. Nicholas Kontos, Program Director of the Consultation–Liaison Psychiatry Fellowship at Massachusetts General Hospital, about one of the field’s most challenging topics: malingering and factitious disorder. We discuss how to move beyond the impulse to “catch deception” and instead adopt a framework of clinical curiosity, empathy, and ethical clarity. Dr. Kontos introduces the concept of “thinking dirty”, the disciplined consideration of complex motives such as safety, shelter, or secondary gain, while preserving therapeutic respect. The conversation covers practical strategies for differential diagnosis, documentation, and the therapeutic discharge, reframing it as a compassionate boundary rather than a punishment. 

Takeaways:

Clinicians must be willing to consider non-altruistic motives (sex, money, drugs, safety, attention) without moral judgment. This mindset sharpens diagnostic reasoning while maintaining therapeutic respect.
The classical distinction between factitious disorder and malingering is often clinically unstable. Both exist on a behavioral spectrum shaped by unmet needs, structural deprivation, and adaptive strategies
Properly framed, discharge is not punitive but restorative, a boundary that ends maladaptive cycles while affirming the patient’s moral agency
The note itself is a clinical act. A comprehensive chart review, clear description of inconsistencies, and transparent reasoning both protect the patient and clarify physician thought
 Effective care balances compassion with stewardship of finite resources. Clinicians serve both patient and system by refusing to reinforce maladaptive behavior while still honoring human dignity

• 1. Teaching Psychiatric Trainees to “Think Dirty”: Addressing Hidden Motivations in the Consultation Setting (Beach, 2017)
  2. The Therapeutic Discharge I: An Approach to the Management of Deceptive Suicidality (Kontos, 2017)
  3. The Therapeutic Discharge II: An Approach to Documentation in the Setting of Feigned Suicidal Ideation (Kontos, 2018)

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Functional Neurological Disorder (FND) sits at the crossroads of neurology and psychiatry and for many clinicians, it’s still one of the most challenging diagnoses to understand, explain, and treat. In this episode, I’m joined by Dr. Caitlin Adams, psychiatrist at Massachusetts General Hospital, for a deep dive into how to recognize, diagnose, and manage FND using a modern, evidence-based, and patient-centered approach.
We trace the evolution of the diagnosis from hysteria to conversion disorder to today’s understanding of FND and explore what neuroscience now tells us about how these symptoms arise. Dr. Adams breaks down the myths around voluntary control, shows how to make a positive diagnosis based on key exam findings like Hoover’s sign, tremor variability, and seizure features distinguishing PNES from epilepsy, and shares how to communicate the diagnosis in a way that reduces stigma and builds engagement. We also unpack the biopsychosocial model of FND: the predisposing, precipitating, and perpetuating factors that keep symptoms alive and how to intervene through cognitive behavioral therapy (CBT), specialized physical therapy, mindfulness, and psychodynamic approaches.

Takeaways:

FND is a positive diagnosis, not a diagnosis of exclusion. Key findings like Hoover’s sign and tremor variability distinguish functional from organic presentations.
Symptoms are not “faked.” FND symptoms are involuntary and arise from disrupted brain networks controlling movement, sensation, and perception.
How you explain the diagnosis matters. Patients do better when clinicians validate symptoms, offer clear language, and emphasize that FND is common and treatable.
Treatment is multidisciplinary. Evidence-based care combines psychoeducation, CBT, and physiotherapy that retrains motor and sensory patterns.
Chronic cases require flexibility. Reassess the diagnosis, re-engage the patient, and adjust treatment around functional goals, not full symptom elimination.

Key References:  

1. ​Incidence and prevalence of functional neurological disorder: a systematic review (Finkelstein 2025)  
2. ​Neurosymptoms.org  
3. ​Cognitive behavioural therapy for adults with dissociative seizures (CODES): a pragmatic, multicentre, randomised controlled trial- (Goldstein 2020) 
4. ​FND Hope  
5. ​Overcoming Functional Neurological Symptoms Workbook (Williams) 

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Pregnancy and postpartum are times of profound change and nowhere is that complexity more visible than in psychiatry. In this episode, 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 a deep dive into reproductive psychiatry. Co-hosted by Erica Browne, an M4 at Saint Louis University School of Medicine, this conversation explores how to care for both mother and baby with empathy, evidence, and balance. We walk through distinctions between baby blues, perinatal depression, and major depressive disorder, discuss how to identify red flags for perinatal psychosis, and explore the ethical and clinical nuances of treating psychiatric illness during pregnancy and lactation. Dr. Wichman explains how to approach risk–benefit decisions around psychotropic medications, highlights validated screening tools, and offers real-world strategies for supporting patients who face barriers to care. We also spotlight The Periscope Project, a pioneering model for connecting clinicians with reproductive psychiatry expertise—and discuss how the field is expanding training, access, and awareness for the next generation of women’s mental health specialists.
Takeaways:
Pregnancy changes everything, but not always for the worse. Psychiatric treatment during pregnancy can and should be individualized, balancing the safety of both mother and baby.
Know the distinctions. Baby blues typically resolve within two weeks; perinatal depression lasts longer, while postpartum psychosis requires urgent evaluation.
Medication decisions are about risk versus risk. Untreated psychiatric illness carries real dangers, sometimes greater than the medications themselves.
Access matters. Programs like The Periscope Project expand reproductive psychiatry consultation to clinicians everywhere, improving outcomes system-wide.
The future is integrated care. Psychiatrists, OB-GYNs, and primary care providers working together can transform perinatal mental health into standard, not specialized, care.

Key References & Clinical Resources

• 1. ⁠The Periscope Project⁠ – A perinatal psychiatry consultation and resource program based in Wisconsin.
  2. ⁠National Access Programs – Lifeline for Moms⁠ – A directory of statewide perinatal mental health access programs.
  3. ⁠National Curriculum in Reproductive Psychiatry (NCRP)⁠ – Free, evidence-based training for clinicians in reproductive psychiatry.
  4. ⁠MGH Center for Women’s Mental Health⁠ – Clinical and research resource for perinatal and reproductive psychiatry.
  5. ⁠MotherToBaby⁠ – Trusted information on medication and other exposures during pregnancy and breastfeeding.
  6. ⁠Pharmacologic Treatments for Mania (Kishi 2021)⁠ – Meta-analysis regarding antimanic effects of selective estrogen receptor modulators.

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Eating disorders are among the most lethal conditions in psychiatry and some of the most misunderstood. In this episode, I’m joined by Dr. Patricia Westmoreland and Dr. Anne O’Melia, two internationally recognized experts with eight combined board certifications spanning psychiatry, internal medicine, pediatrics, and consultation-liaison psychiatry. Together, we take a deep dive into the medical, psychiatric, ethical, and forensic complexities of eating disorders, especially as they appear in the general medical hospital. We talk through how to recognize eating disorders in patients who may not even identify as ill, when to intervene, and what the thresholds for medical stabilization really look like. We also explore the psychological underpinnings, how control, trauma, and insight all intersect, and the delicate balance between autonomy and safety when capacity is limited.

Takeaways:

Eating disorders are both psychiatric and medical emergencies. Anorexia nervosa has one of the highest mortality rates of any psychiatric illness, surpassed only by opioid use disorder.
Early recognition saves lives. Common signs include unexplained bradycardia, electrolyte disturbances, fatigue, hypoglycemia, or rapid weight loss, even in patients who deny an eating disorder.
Patients often lack insight. Many individuals with severe anorexia are highly intelligent but unable to apply their knowledge to themselves, leading to deceptive presentations of “capacity.”
Treatment is multidisciplinary and stepwise. Levels of care range from outpatient and intensive outpatient programs to residential, psychiatric inpatient, and medical stabilization units, depending on weight, vitals, and lab findings.
Recovery is possible and expected. Full restoration of nutrition and function can reverse nearly every medical complication of starvation, and with the right care, patients can go on to live full, independent lives.

Key References:

1. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Eating Disorders (Crone 2023)

2. Ethical Challenges in the Treatment of Patients With Severe Anorexia Nervosa (Westmoreland 2024)

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In this episode, I sit down with Dr. Mira Zein, clinical associate professor at Stanford and co-author of the APA Resource Document on Decisional Capacity Determinations, to break down one of the most frequent and misunderstood consults in psychiatry.
We go deep into the Appelbaum–Grisso criteria and discuss how they apply to real-world cases where the answer isn’t always clear. Dr. Zein walks us through difficult scenarios, from life-saving refusals to medically complex delirium cases, highlighting how to think, document, and communicate clearly when capacity is in question. This episode will help you shine on rounds, guide your primary team through their own assessments, and remind you that capacity isn’t about saying “yes” or “no”, it’s about respecting autonomy while protecting patients at their most vulnerable.

Takeaways:

Capacity is decision-specific and time-specific. It’s not a global judgment, and it can fluctuate with illness, treatment, or environment.
The Appelbaum–Grisso framework defines the process. Every evaluation should include communication, understanding, appreciation, and reasoning.
Primary teams can and should do their own assessments. Psychiatrists are consultants, not gatekeepers; the best work happens through collaboration.
Delirium, dementia, and psychosis are common culprits. Each affects different aspects of capacity, requiring tailored interventions and re-evaluation.
Documentation is key. Define the specific decision, describe your assessment of each criterion, and explain your reasoning clearly for the record.

Key resources:

1) APA Resource Document on Decisional Capacity Determinations in Consultation-Liaison Psychiatry: A Guide for the General Psychiatrist (2019)

2) Seminal Article on Appelbaum-Grisso Criteria (Appelbaum 1988)

3) Evaluating Capacity: Appelbaum’s Framework Interpreted Diagrammatically (Bari 2023)

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Organ transplantation isn’t just a medical miracle, it’s a psychological marathon. In this episode, I talk with Dr. Paula Zimbrean, Yale psychiatrist and pioneer in Transplant Psychiatry, about what really happens when mind and medicine intersect at the edge of life and death. We walk through the evolution of psychiatry’s role on transplant teams,  from risk gatekeeping to long-term integration, and explore what pre-transplant evaluations truly aim to uncover. Dr. Zimbrean shares how to assess risk, capacity, and motivation in patients preparing for transplant, and what it means to treat not just the organ recipient, but their family and support system as well. We also discuss the unseen emotional toll of the transplant journey, from steroid-induced mood changes to post-traumatic stress symptoms, and why empathy is as vital as immunosuppression.

Takeaways:

Transplant psychiatry has evolved. It began with managing post-op delirium and psychosis, but now focuses on enhancing long-term outcomes through integrated psychiatric care.
Pre-transplant evaluations go beyond “yes” or “no.” They assess diagnosis, prognosis, capacity, adherence potential, and the patient’s understanding of lifelong treatment demands.
Psychiatrists aren’t gatekeepers, they’re collaborators. The goal is to identify modifiable risks, optimize mental health, and align medical decisions with patient values.
The journey is psychologically intense. From waiting list uncertainty to post-op PTSD and steroid-induced mood shifts, every stage requires active psychiatric support.
The future is integration. As patients live longer post-transplant, psychiatry’s role will increasingly involve ongoing care, research, and improving quality of life beyond survival.

Selected references:

1. Transplant Psychiatry: A Case-Based Approach to Clinical Challenges
2. Transplant Psychiatry: An Introduction

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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:

1. ⁠Changeability, confidence, common sense and corroboration: comprehensive suicide risk assessment (O'Connor 2004)⁠

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In this episode, I talk with Dr. George Grossberg, a pioneer in geriatric psychiatry, about the neuropsychiatric symptoms of dementia and what they look like, why they happen, and how to approach them with empathy and strategy. We walk through the most common behavioral disturbances in dementia, including apathy, depression, psychosis, and agitation. Dr. Grossberg shares how to think through these cases, when to reach for medication, when to hold back, and how to anchor every decision in an understanding of who the patient truly is.

Takeaways:

Neuropsychiatric symptoms are nearly universal in dementia. Expect them, don’t be surprised by them.
Apathy and depression aren’t the same. Treating apathy like depression often fails; gentle engagement works better than antidepressants.
Start with environment and empathy. Music, structure, exercise, and caregiver education should come before medication.
Use medication sparingly and strategically. When needed, match the drug to the symptom, and always reassess risk versus relief.
Knowing the person changes everything. Understanding a patient’s history, preferences, and rhythms is as therapeutic as any pharmacologic plan.

Selected References:

1. ⁠Progress in Pharmacologic Management of Neuropsychiatric Syndromes in Neurodegenerative Disorders: A Review (Cummings 2024)
2. Neuropsychiatric Symptoms of Dementia and their nonpharmacological and pharmacological management (Tampi 2022)⁠
3. Management of BPSD Algorithm (Chen with Osser 2021)⁠
4. Atypical Antipsychotics for Aggression and Psychosis in Alzheimer's disease (Ballard 2006)
5. Efficacy and Adverse Effects of Atypical Antipsychotics for Dementia (Schneider 2006)
6. Sequential Drug Treatment Algorithm for Agitation and Aggression in Alzheimer's and Mixed Dementia (Davies 2018)

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Catatonia isn’t just mysterious, it’s one of the most treatable yet misunderstood syndromes in psychiatry.

In this episode, I continue my conversation with Dr. Mark Oldham, diving deep into what to actually do when you suspect catatonia. We talk through the Lorazepam challenge, what a “positive” response really means, and why sometimes a single dose can look like a miracle. We also dig into the gray zones—how to approach patients who don’t respond, when to move to ECT, and what to do when catatonia overlaps with delirium or psychosis.

Dr. Oldham shares his framework for identifying special cases, from benzodiazepine withdrawal to clozapine discontinuation, and explains why history-taking, not algorithms, is psychiatry’s most powerful diagnostic tool.

Takeaways:

• Start simple, but think deeply. Lorazepam remains first-line for catatonia, but the absence of RCTs means clinical reasoning still leads the way.

• ECT is definitive and underused. For refractory or malignant catatonia, ECT is often curative, but access and consent barriers remain a major challenge.

• Not all catatonia is the same. Withdrawal states, chronic schizophrenia, and periodic catatonia each demand tailored interventions.

• Delirium and catatonia can coexist. Treat both cautiously, start low, go slow, and always look for autoimmune or neurological causes.

• History is your best guide. Behind every catatonic presentation is a story, missing it can mean missing the cure.

Selected references:

1. ⁠British Association for Psychopharmacology Guidelines⁠
2. ⁠⁠Rochester Catatonia Assessment Resources⁠⁠
3. ⁠NEJM Review on Catatonia⁠
4. ⁠Nature Review on Catatonia⁠
5. ⁠Schizophrenia Research Volume on Catatonia⁠
6. ⁠Describing the Features of Catatonia (Oldham)⁠

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When a patient stops moving, stops speaking, or stares through you like you’re not there, it’s easy to miss what’s really happening.

In this episode, I’m joined again by Dr. Mark Oldham, one of the leading voices on catatonia, to break down what this strange, often misunderstood syndrome actually looks like in the real world. We walk through the diagnostic features step-by-step, how to assess, what to ask, and what’s too often overlooked.

From the history of the disorder to modern DSM confusion, from the meaning of “waxy flexibility” to the haunting truth about patients who are fully aware but trapped inside their bodies, this conversation will completely change the way you think about motor symptoms and psychiatric emergencies.

Takeaways:

• Catatonia is common, but underrecognized. It’s not just “psychiatric immobility.” It spans a spectrum from stupor to hyperactivity.

• Diagnosis starts with curiosity. Learn to test for features like mutism, posturing, and negativism systematically.

• Many patients are aware. Always treat them with dignity and assume comprehension, even when they can’t respond.

• It’s treatable and rapidly reversible. A single dose of lorazepam can sometimes unlock a frozen mind and body.

• Malignant catatonia kills. When autonomic instability appears, it’s a medical emergency that demands immediate escalation and often ECT.

Selected references:

1. British Association for Psychopharmacology Guidelines
2. ⁠Rochester Catatonia Assessment Resources⁠
3. NEJM Review on Catatonia
4. Nature Review on Catatonia
5. Schizophrenia Research Volume on Catatonia
6. Describing the Features of Catatonia (Oldham)

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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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