Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How reliable do you find it to make the diagnosis of bipolar disorder based on a patient report of prior symptoms or questionnaire and not the actual observation of hypo/mania on the exam?
I agree that direct observation is always nice, but we certainly don't want to wait for a manic episode to determine the correct diagnosis. I find that by asking lots of detailed questions, most people who have experienced and manic episode can report enough history to correctly. Identify the episod...
How do you approach the management of mild to moderate tics induced by stimulants in children?
If dose reduction or medication switch is not possible, first-line treatment includes adding an alpha agonist like guanfacine or clonidine. I prefer guanfacine as clonidine is more sedating and less tolerated by kids. CBIT (Comprehensive Behavioral Interventions for Tics) would be great but hard to ...
What is your pharmacologic approach to treating insomnia comorbid with sleep apnea?
I do not usually treat any insomnia, regardless of comorbidities, with any targeted medication for the insomnia itself. If the patient is getting over 5 hours of sleep, then I use CBT-I as this is guideline-recommended (AASM) first-line treatment for insomnia and has efficacy lasting over a year out...
In addition to a therapist, what are your favorite resources for tackling perfectionism?
Perfectionism is a pattern of thinking and behaving characterized by rigid, unrealistic, harsh judgments about the performance of the self and others. For a perfectionist, the outcome of their actions is almost never sufficient. Even the measurement itself of each outcome is distorted by their perf...
How do you manage patients with body dysmorphic disorder who pursue repeated dermatologic or other cosmetic procedures despite reassurance or prior interventions?
I run a monthly psychodermatology clinic, and over the years, I’ve met quite a few patients with body dysmorphic disorder who come in asking for recommendations or referrals for cosmetic or surgical treatments. Many of them are genuinely convinced there’s something seriously wrong with the way they ...
How do you address mental health and online presence with teenage patients?
There are four variables that I talk to parents/teens about: Volume of screen exposure; low vs high. There is some data that pure volume is a risk factor, but not uniformly so. Psychiatric vulnerability; low vs high. Some kids are more vulnerable (e.g., social and generalized anxiety disorder and d...
What is the best way to manage low systolic blood pressures on clozapine when the patient has failed multiple other antipsychotic trials?
Orthostatic hypotension is considered a common side effect during clozapine titration, specifically due to its alpha-1 receptor antagonism. This effect is most commonly seen when initiating clozapine or with dose increases.General initial strategies to address this side effect include reevaluating t...
What clinical factors guide your decision about if and when to restart antipsychotic medications in patients with primary psychotic disorders recovering from catatonia after stabilization with benzodiazepines or ECT?
The American Psychiatric Association's catatonia workgroup recently published an excellent Resource Document for Catatonia.In this document, they discuss some relevant points on pages 25 - 27: There is a longstanding history of using antipsychotics in catatonia, with available reports on the use of ...
What is your approach to determining eligibility for hospice in persons with Alzheimer's disease?
We strongly recommend early hospice enrollment for patients with dementia as soon as they meet eligibility criteria. In our approach, we carefully evaluate both functional and cognitive decline. One area that is often overlooked, however, is nutrition. When a patient with Alzheimer’s disease begins ...
How does comorbid epilepsy influence your decision on antipsychotic medications?
In general, epilepsy is not a contraindication to the use of antipsychotic medications if they are needed despite the known risk of lowering the seizure threshold. In general, the risk of seizures for most antipsychotics is low, though some antipsychotics, such as clozapine, olanzapine, and quetiapi...