September 12, 2019
On this week’s episode of the podcast, I interview Dr. Drew Ramsey, a nutritional psychiatrist. When I was a resident, I saw him give a lecture on diet and how it affects our mood, and I’ve been wanting to interview him for a long time. He is the author of several books about diet and health.
September 5, 2019
Lithium is indicated for a number of things. Most clearly, as a mood stabilizer in bipolar spectrum disorders. It is unique among mood stabilizers in that it is very robustly anti-manic. The medication treats and prevents manic episodes from occurring, providing fairly robust prophylaxis against mood cycling. Lithium is also effective in treating bipolar depression, though not as effectively. Very few of the other mood stabilizers are effective for the depressed pole of bipolar illness.
August 29, 2019
This week the Psychiatry and Psychotherapy Podcast is joined by Dr. Walter A. Brown, Clinical Professor Emeritus in the Department of Psychiatry and Human Behavior at Brown University, author of the brand new book “Lithium: A Doctor, a Drug, and a Breakthrough”.
August 21, 2019
Dr. Cummings and I (Dr. Puder) believe that these technology advances may help those who suffer with severe mental illness. There are still patients who don’t respond to therapy, medications, and treatments like ECT. It is likely that Neuralink’s plans for a BMI are not impossible, as the same thing is already being done on a small scale with brain stimulators.
August 10, 2019
Working with a good therapist often requires fewer sessions than other therapists to see improvement; in contrast, working with a therapist you don’t connect with, or with inadequate training, may require an extended number of sessions (Okiishi et al. 2003).  People that see effective therapists are more likely to recover or partially recover, whereas those that work with a “bad” therapist are more likely to see no change or an increase in symptoms (Okiishi et al. 2006).   Link to full article/b
August 3, 2019
On this week’s episode of the podcast, I interview Jaeger Ackerman, 4th year medical student about suicide risk factors and treatments. As a therapist, attempt to closely approximate their reality of feeling suicidal with words. When I first hear their thoughts and feelings, I try to clarify with the patient to make sure I’m understanding their feelings. I usually try to put it into other words, and echo back to them. I’ll say something like, “I hear that you feel like there’s no other way out, that you feel lost and like it’s a very dark time for you.” I ask myself continually how to be present with them in their feelings, in the moment. Link to full episode: notes Resource Library: here Link to sign up for CME go: here Member Login to do CME activity go: here Instagram:dr.davidpuder Twitter:@DavidPuder Facebook: DrDavidPuder Youtube channel
July 25, 2019
In this episode of the podcast, I interview Steven, one of my patients who had a rare form of a stroke—in the right orbital frontal cortex. He participated in a psychiatric program that I run. He tells his story of how his function and emotions changed, and how he dealt with it. At the end of the episode, I talk more with Jaeger Ackerman (a 4th year medical student) about the science and neurology of his case so other mental health professionals can have a basis for how to think about approaching brain injury with these psychiatric specifics. Steven was a former hotel executive, actor and certified professional accountant (CPA). Link to full episode: notes Resource Library: here Link to sign up for CME go: here Member Login to do CME activity go: here Instagram:dr.davidpuder Twitter:@DavidPuder Facebook: DrDavidPuder Youtube channel
July 20, 2019
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. Link to full article/blog: notes Resource Library: here Link to sign up for CME go: here Member Login to do CME activity go: here Instagram:dr.davidpuder Twitter:@DavidPuder Facebook: DrDavidPuder Youtube channel
July 13, 2019
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. Link to full episode: notes Resource Library: here Link to sign up for CME go: here Member Login to do CME activity go: here Instagram:dr.davidpuder Twitter:@DavidPuder Facebook: DrDavidPuder Youtube channel
July 4, 2019
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: -An increased risk for myocardial infarction -Takotsubo cardiomyopathy (Broken Heart Syndrome) -The development of mood, anxiety and substance-use disorders (Cheng & Kounis, 2012; Keyes et al., 2014; Mostofsky et al., 2012; Shear, 2015). 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). Link to full episode: notes Resource Library: here Link to sign up for CME go: here Member Login to do CME activity go: here Instagram:dr.davidpuder Twitter:@DavidPuder Facebook: DrDavidPuder Youtube channel Maris Loeffler Instagram: @marisloefflerlmft
June 20, 2019
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. Link to full episode: notes Resource Library: here Link to sign up for CME go: here Member Login to do CME activity go: here Instagram:dr.davidpuder Twitter:@DavidPuder Facebook: DrDavidPuder Youtube channel
June 13, 2019
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. 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 Hyperreactivity Hyperarousal (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). The lifetime prevalence of PTSD in the general population of the US was found to be 6.1% in one national epidemiologic study with certain populations at higher risk for PTSD (e.g. female sex, low socioeconomic status, previously married status, experienced trauma at a young age, African Americans, Native Americans, refugees or immigrants from countries with conflicts) (Alegría et al., 2013; Brewin, Andrews & Valentine, 2000; Goldstein et al., 2017; Kisely et al., 2017; Marshall, Schell, Elliott, Berthold & Chun, 2005). Link to full episode: notes Resource Library: here Link to sign up for CME go: here Member Login to do CME activity go: here Instagram:dr.davidpuder Twitter:@DavidPuder Facebook: DrDavidPuder Youtube channel
June 6, 2019
Schizophrenia is a diagnosis of exclusion. Doctors and therapists need to be able to rule everything else out before they can land on schizophrenia as an official diagnosis. There are 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. Link to full episode: notes Resource Library: here Link to sign up for CME go: here Member Login to do CME activity go: here Instagram:dr.davidpuder Twitter:@DavidPuder Facebook: DrDavidPuder Youtube channel
May 27, 2019
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 Link to full episode: notes Link to sign up for CME go: here Member Login to do CME activity go: here Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder Youtube channel
May 16, 2019
Episode 1 in a series on schizophrenia, with this episode focusing on schizophrenia in culture, film and history.
May 2, 2019
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. 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. For more of the article go here Link to sign up for CME go: here Member Login to do CME activity go: here Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder
April 18, 2019
On today’s episode of the podcast, I interview Ginger Simonton, a PhD student finishing her dissertation. We will cover her in-depth research on alleviating the symptomology of childhood sexual abuse. We will specifically be talking about the link between women who have been sexually abused, never given a chance to heal, and how it has affected their mental and physical health, and programs that can benefit them. What is childhood sexual abuse? “The CDC defines the act of CSA as “inducing or coercing a child to engage in sexual acts” that include “fondling, penetration, and exposing a child to other sexual activities” (2017).” The facts: 88% of sexual abuse cases happen with someone the child knows (Finkelhor, Ormrod, Turner, & Hamby, 2005) 20-30% of women experience some form of sexual abuse before they reach 18 years old (Pereda et al., 2009; Stoltenborgh, Van Ijzendoorn, Euser, Bakermans-Kranenburg, 2011; Bolen & Scannapieco, 1999; Holmes & Slap, 1998; Finkelhor, 1994) 20-40% of survivors have no adverse effects later in life (resilience is the norm) (Paras, Murad, Chen, Goranson, Sattler, Colbenson, Elamin, Seime, Prokop, & Zirakzadeh, 2009) For more of the article go here Link to sign up for CME go: here Member Login to do CME activity go: here Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder
April 11, 2019
On this week’s episode of the podcast, I talk about the power of forgiveness. It’s scientifically proven that forgiveness can impact our health. As mental health professionals, this has important impacts both personally and professionally. I have also included a downloadable PDF for you to give your patients to help you walk them through the act of forgiving. As a therapist, when I say the word “forgiveness,” my patients can shut down if I don’t explain it properly. Why? Because just the need for forgiveness is proof that they have been wronged. When we are wronged, it can be hard to let go of that hurt. That’s why I wanted to start out by saying what forgiveness (and this episode) is not about. Forgiveness is not: It is not approving. It is not excusing the action, denying it, or overlooking it. It is not just moving on (particularly not with cold indifference). It is not forgetting or pretending it did not occur. It is not justifying or letting go of possibly needed justice. It is not calming down. It is not a bargain or negotiation. It is more than ceasing to be angry. It is more than being neutral towards the other. It is more than making oneself feel good. It is one step towards reconciliation, but it is different from reconciliation, which requires a sincere apology from all parties. It is not dependent on the one you forgive—that would give the other power to control you by keeping you in your bitterness. Consider Corrie Ten Boom, who forgave the Nazis after losing her family in the Holocaust, or Marietta Jaeger who, after her daughter was kidnapped and brutally murdered, was able to forgive. People can forgive, even when the person who wronged them is unknown or dead. It is not a one time event, but may need to be repeated (sometimes the hurt comes back, sometimes you need to start every morning with forgiveness). It is not a restoration of full trust (trust takes time to develop or to be reinstated). For full article go: here For resource library: go here Link to sign up for CME go: here Member Login to do CME activity go: here Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder
April 1, 2019
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 is uncomfortable to share what one feels. For full article go: here For resource library: go here Link to sign up for CME go: here Member Login to do CME activity go: here Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder
March 7, 2019
Violent aggression in the inpatient psychiatric setting has developed into an important issue that negatively affects patients and staff. There are some simple and surprising treatments different clinics are taking to prevent violent aggression. It’s time we paid attention to this issue so we can prevent injury of both patients and hospital staff.
February 28, 2019
On this week’s episode of the podcast, I am joined by Dr. Carolina Osorio, a geriatric psychiatrist (and one of my favorite people). After she finished her psychiatry residency, she also went on to finish a fellowship in geriatric psychiatry to take care of her favorite people. Dr. Osorio runs a special program that treats elderly people with depression and anxiety. For the rest of the article, go: here For resource library: go here Link to sign up for CME go: here Member Login to do CME activity go: here Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder
February 6, 2019
Ted Bundy came off as friendly and charming, described as “one of us.” A friend of his from Washington State even said, “He’s the kind of person you’d want your sister to marry.” As disturbing as this is, it is a common trait of psychopathic antisocial behavior.
January 23, 2019
The words “aggression” and “violence” are sometimes used synonymously, but in reality, aggression can be physical or non-physical, and directed either against others or oneself. Violence is more of a use of force with an intent to inflict damage. One study looked at the principle types of aggression and violence that occur in psychiatric patients, and broke it down into three categories: Impulsive violence (the most common category) Predatory violence (purposeful and planned violence) Psychotically-driven violence (least common) For the rest of the article, go: here For resource library: go here Link to sign up for CME go: here Member Login to do CME activity go: here Instagram: dr.davidpuder Twitter: @DavidPuder Facebook:DrDavidPuder
January 8, 2019
Empathy is the ability to understand another’s state of mind or emotions. It is also is being able to feel, understand and share with someone else in what they are saying, their meaning of life, their motivations and values. In research there are 3 types of empathy that are commonly described: cognitive, affective, and compassionate. For the rest of the article, go: here Link to sign up for CME go: here Member Login to do CME activity go: here Instagram: dr.davidpuder Twitter: @DavidPuder Facebook:DrDavidPuder
December 15, 2018
People who truly have ADHD typically experience inattentive and hyper symptoms across all areas of their life. For example, if they are in a job that requires periods of attention to complete or organize a project, it will be inherently more difficult for people with ADHD. One of the things that’s important in diagnosing people (particularly younger people) is their collateral history. People around the person with suspected ADHD are often more aware of the person’s deficits than the person themselves. When they reach adulthood, the problems might be made more obvious when they integrate into normal society and notice they struggle with symptoms of ADHD (compared to other people). For the rest of the article, go: here Link to sign up for CME go: here Member Login to do CME activity go: here Instagram: dr.davidpuder Twitter: @DavidPuder Facebook:DrDavidPuder
November 29, 2018
What is placebo? The original meaning of the word placebo is, “I will please.” That statement comes from a time when doctors didn’t have our modern code of ethics, and they would prescribe whatever would make the person feel better. They probably had the best intentions, but they also would have known that whatever they were prescribing might not have been a real medication for the symptoms the patient was experiencing. Doctors, even then, knew that suggestion was powerful, sometimes more powerful than the medicine they were prescribing. Laypeople who hear the word “placebo” automatically think of sugar pills. They may think only that it’s something a doctor gives to placate and make people feel better when they aren’t getting the active medication. Placebos have long been used as a comparison arm for clinical trials. Usually it is in the form of an inert sugar pill or sham-procedure. Researchers can observe a psychobiological response known as the placebo effect. But when thinking about the word “placebo,” we must think of the entire effect of it, and it is perhaps better termed “the meaning effect.” As I discussed in last week’s episode of the podcast, the meaning we give something creates belief, and belief is a potent change mechanism, even when it comes to our physical health. It is especially potent when it comes to mental health. The placebo effect encompasses the therapeutic alliance, expectations, natural healing of the body and mind, and the environment of therapy. It involves the power of suggestion, mood, and the beliefs behind even one positive or negative interaction with a doctor. It also, as we will see, involves studies involving heavy-hitting medication. When there is an increased ritual, there is an increased placebo effect. During a hospital stay, the surgery preparation, meetings with doctors, nurses and therapists can have an incredibly therapeutic effect on a patient. It is possible to see biological mechanisms triggered by psychosocial context and attribute it to a placebo effect. What is the power of suggestion, the meaning effect, placebo effect, and how do we use it or avoid it in our practices and when testing new medical treatments? For the rest of the article, go: here Link to sign up for CME go: here Member Login to do CME activity go: here Instagram: dr.davidpuder Twitter: @DavidPuder Facebook:DrDavidPuder
November 15, 2018
For many, motherhood is a beautiful, unique, and meaningful experience. The mother-child bond is a relationship that has the potential to be a deeply loving and positive experience for both the mother and child. However, motherhood can be distressing, which is why it is imperative that we, as providers, understand the unique psychiatric issues that are associated with this time period in a woman’s life. Perinatal mood and anxiety disorders, or PMAD for short, is the term used to describe mood and anxiety disorders that affect women during the perinatal period, which is the timeframe from pregnancy to 12 months postpartum. PMAD encompasses a variety of disorders, such as anxiety, depression, obsessive-compulsive disorder, bipolar mood disorder, psychosis, and PTSD. Link to full article go: here Details on connecting with Kelly Rivinius through social media or about her free support group:here Link to sign up for CME go: here Member Login to do CME activity go: here
October 30, 2018
In the celebrated book Man’s Search for Meaning, author Viktor Frankl wrote about his intimate and horrific Holocaust experience. He found that meaning often came from the prisoners’ small choices—to maintain belief in human dignity in the midst of being tortured and starved and bravely face these hardships together.
October 8, 2018
Delirium is an acute change in a person’s sensorium (the perception of one’s environment or understanding of one’s situation). It can include confusion about their orientation, cognition or mental thinking. With hyperactive delirium, a patient can become aggressive, violent and agitated with those around them. A patient experiencing delirium can have hallucinations and hear things, they can become paranoid, and they are overall confused. A family or non-psychiatric medical staff might be concerned that the patient is experiencing something like schizophrenia. Hyperactive delirium symptoms in patients: Waxing and waning —it comes and goes Issues with concentration Pulling out medical lines Yelling profanities Throwing things Agitated Responding to things in the room that aren’t there Not acting like themselves Hypoactive delirium is much more common than hyperactive delirium (based on research studies), but it is often missed because the presentation is much less dramatic. People with hypoactive delirium are confused and disoriented, but they are not expressing their confusion verbally or physically. Hypoactive delirium symptoms: Slower movement Softer speech Slower responses Withdrawn Not eating as much For the rest of the article go: here For Dr. Lee’s powerpoints on delirium, go: here Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder
September 25, 2018
What has piqued interest in psychiatry is that infusion of a smaller dose of ketamine produces a rapid response in terms of reversal of depressed mood, suicidality, and some treatment-resistant depressed patients.
September 20, 2018
On this week’s episode of the podcast, I interviewed Allison Maxwell, a social worker and PhD student of clinical social work. I refer patients to her regularly for psychoanalysis, and she has had a wonderful impact on their mental health journey. What is psychodynamic theory? Psychodynamic therapy is a form of talk therapy where the practitioner work focuses on the patient’s emotion, fantasies, dreams, unconscious drives and wishes, early and current life relationships, and the relationship that is forming between the patient and therapist. For the blog that goes with this episode, go here Join and discuss this episode with David on Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder
September 16, 2018
Timothy Lee has talked to thousands of medical students about how to applying for residency programs, and here, he gives us a few tips on how to make it through the gauntlet, and how to have your best chance at landing the program you want. Here is what Timothy Lee says: Stay calm Many students have been fine tuning their personal statements, and trying to get their resume just right, or hurrying to press the faculty to write letters of recommendation. It can be very stressful. It’s okay to turn in information a little bit later, in order to have all of the paperwork you need. It’s even okay to review your statement after you’ve already turned it in. No one will lower their opinion based on that. You will need to have applied for the majority of the programs you are interested in by early or mid-October, otherwise the program director might wonder if you’re applying to them later as a backup plan. What matters in a personal statement? Every program director will have different opinions on what you write, and every program director will be looking for different things from your personal statement. For some people, it’s a chance to get to know the applicant a little bit. For others, it doesn’t really matter that much. As long as your grammar and syntax are competent, you should be fine. Some people don’t worry about the format, and others are more particular. To be on the safe side, if you have access to a good mentor, run it by them. Also, don’t be too wordy—stick to a page and a half. Do step scores matter? Step scores are a very convenient screening tool for what matters, but there are studies that show that step scores are not directly correlated to success in residency performance. They are helpful, but are not the end-all-be-all. It’s only one part of the picture of an applicant. However, if you are going for a highly-competitive residency, you might need to worry about step scores a bit more. Apply to the right number of programs The number of programs is not the only way to increase your chance of success of getting in. Pay attention to the types of programs you are applying to as well. If you are applying for a good number of programs, make sure at least half of them are are ones you are a solid and potentially attractive candidate for. Keep a good perspective Ultimately, you are more than your CV, step score, or personal statement. If patients like you, that’s going to go a long ways. Your patients won’t know your scores, or where you graduated from medical school. They will know if you were competent, caring and connected. That is ultimately what matters. Join and discuss this episode with David on Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder
September 6, 2018
What is a therapeutic alliance? The therapeutic alliance is a collaborative relationship between the physician and the patient. Together, you jointly establish goals, desires, and expectations of your working partnership. Every interview with a patient, whether it’s for diagnostic, intake, evaluative, or psychopharmacology purposes, has therapeutic potential. The treatment starts from your first greeting—how you listen, empathize, and even how you say goodbye. It’s built from a partnership and dialogue, like any other relationship. It’s not built from medical interrogation. It’s not about pulling medical information to be able to make a diagnosis. We have to make it a positive experience for patient, so they can begin to talk about what's negative in their lives. The therapeutic alliance is full of meaning, and it uses every emotional transaction therapeutically. If they get angry, sad, or have fear you will abandon them, as a therapist, it’s our job to figure out how to help them through that feeling within the relationship. The doctor can express desire for the patient to share, in real time, how the patient is feeling, even about his or her relationship with the doctor. Why do we care? We all know that some talk therapists have better outcomes than other talk therapists. What’s interesting though, is that some some psychiatrists’ placebos worked better than other psychiatrists’ active drugs. One study of NIMH data of 112 depressed patients treated by 9 psychiatrists with placebo or imipramine, found that variance in BDI score (a score that measures depression) due to medication, was 3.4% and variance due to psychiatrist was 9.1%. One-third of psychiatrists had better outcomes with the placebo than one-third had with imipramine. Another book argues that the therapist is more important to outcome than theory or technique. Many other studies have shown that therapeutic alliance directly correlates to success rates. For the rest of the blog/article go here Join and discuss this episode with David on Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder
August 23, 2018
What is trauma? Emotional trauma comes from stress that is overwhelms a person’s neurological system. Some stress can be good and formative, or it can be bad and get stuck in the brain, causing someone deep emotional pain. Think of climbing Mount Everest. Some people choose to do that, and it’s easily one of the most stressful situations you can put yourself in on purpose. That’s good stress if you have trained for years and are ready for it. If someone forced you to climb Mount Everest, it would register in the brain as a trauma. Trauma is too big for the mind, brain, and nervous system to assimilate. It’s a memory, or experience, that gets stuck because the person believed it would result in their death, or at least serious injury. The brain has several mechanisms to keep something stuck so that the person will remember it, and try to avoid getting hurt in the same way in the future. It is a survival instinct. People commonly demonstrate symptoms of trauma when they’ve: Experienced a sexual violation Seen violence Experienced violence or abuse Been neglected—experienced the absence of something that they should have had. Been in near death experiences like car accidents or war People who have PTSD, or post traumatic stress disorder, have experienced a soul-level of brokenness, and even talking about the event, or having a memory of it, can bring it back with the same force that occured in the actual accident. They often have recurring nightmares, or repetitive symptoms that continue long after the event. Typical PTSD symptoms alternate between chronic shut down and fight and flight Fight and flight symptoms are: Sweating, nightmares, flashbacks, anger, rage, panic, hypervigilance, tense muscles, painful knotted gut Shut down symptoms are: Dissociation, freezing, emotional detachment, voice trembling, difficulty getting words out, numbness, apathy, fear, helplessness, dizzy, empty, nausea Moments in connection mode look like: curiosity, exploration, relaxed and full breathing, feeling grounded, true smiles To read more about trauma, go to the full blog on this episode here. Join and discuss this episode with David on Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder
August 11, 2018
What are boundaries? When we refer to boundaries, we are talking about emotional walls that are healthy. Boundaries are meant to keep us in relationship with the people that we love. Think of them as your property lines around your house. You know where your lines are, where your property ends and your neighbors begins. Therefore you know what you are supposed to take care of and what your neighbor is supposed to take care of. A boundary defines our self. Within ourselves, our “property” consists of our physical body, our desires, our intellect, and our ability to make decisions. It gives us a sense of defining what is “me” and what is “not me.” We are not supposed to take on too much of other people’s emotional experiences. When I was a newly practicing psychiatrist, I didn’t know that, and I felt depressed after meeting with a depressed patient. It is possible to have an understanding of what is happening in someone’s emotional world, but not take it on yourself. For more go to the blog that was written from this content: here Connect With and Join Lindsay Puder’s Instagram: LindsayPuder Join David on Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder
August 2, 2018
In this episode we discuss: The history of bipolar illness, mood stabilizers, common treatments, psychopharmacology, psychotherapy goals, and more. For paraphrased transcription and blog: go here For more detailed notes by Dr. Cummings, go to my resource page.   Join David on Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder
July 24, 2018
In this week’s episode of the podcast, Dr. Michael Cummings and I talk about the history of antidepressants, and their use in overcoming depression and anxiety disorders. For blog and extended notes go here Join David on Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder
July 10, 2018
Have you ever felt like you wavered between anxiety and panic, or feeling totally emotionally numb? Did you know that’s one of the ways your body is wired to protect you? There are ways to feel healthy, normal, and deal with the reason you feel that way. This week on the podcast I talk to Dr. Kevin Ing and Adam Borecky about the body’s fight or flight response, and then the deepest response to trauma—emotional shutdown.
July 3, 2018
This week’s podcast guest, Dr. Jackson Brammer used to be an expert procrastinator. He used a few simple tricks to overcome his procrastination habit, and he’s sharing how he transformed his life on this week’s episode of the Psychiatry and Psychotherapy podcast.
June 30, 2018
Do you ever feel out of touch with your emotions? Or have you ever felt like you had to hide your real emotions? When people do that—emotionally detach—they develop what therapists call “incongruence.” Most therapy is actually centered around getting patients back in touch with their emotions. On this weeks podcast, Ginger Simonton and I talk about the different methods we use to help our patients develop and maintain healthy emotional congruence. For more details, links, and blog go here Join David on Instagram: dr.davidpuder Twitter: @DavidPuder
June 19, 2018
In the latest podcast, Dr. Cummings and I talked about antipsychotics, the particular branch of psychopharmacology that deals with medicines that treat psychotic experiences and other mental disorders.
June 12, 2018
In the latest episode of the Psychiatry and Psychotherapy Podcast, Dr. Puder interviews Dr. Cummings, a psychopharmacologist. They discuss the way medicine works in our bodies, and if medicine or therapy is more effective for treating different disorders. They also talk about the different factors that affect absorption rates, such as gastrointestinal surgeries, liver health and actual dosage. For article and notes go: here Join David on Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder
May 29, 2018
sign up for an annual subscription to receive CME credit for this activity and more! Learn more Here. Link to show on: iTunes, Google Play, Stitcher, Overcast, PlayerFM, PodBean, TuneIn, Podtail, Blubrry, Podfanatic My guest for the podcast was Trent Jones, a Starting Strength athlete. I interviewed him about his story, how he discovered strength training, and how it changed his emotional state. We will cover how strength training can decrease depression and help people deal with anger and develop confidence and assertiveness. Then we will give you resources to know how you can get started on your own, simple strength training program. Trent was a football player in middle and high school. He was always a self-professed “smaller guy,” hovering around 150 pounds, even though he was athletic. During those formative years, he struggled with depression and outbursts of anger, causing his therapist to put him on antidepressants. Once he graduated high school, he wasn’t participating in sports any longer, even though he still exercised. During college, he struggled with prolonged bouts of major depression. He began to lose his confidence in his abilities to perform everyday tasks, and because of that, he doubted his self worth. He detached from friends and wasn’t enjoying life.   As a natural people pleaser, Trent struggled with being assertive in his interactions, appearing kind and calm. He dealt with angry outbursts when he was alone. After college, his job was stressful, and his people-pleasing personality, mixed with his bosses’ lack of boundaries, caused Trent to feel overwhelmed. He’d work all day, then go home and stew in frustration in the evenings, losing sleep, and even throwing plates during bouts of anger. Work was difficult and his depression came in waves. Trent decided he wanted to find a hobby and revisit his athletic past. He’d always loved strength training because of his experience with football. He decided to get into weight lifting, so he searched for a simple way to build muscle mass. In his exercise since high school, Trent had only focused on cardio and lifting random weights for random sets and repetitions. On the left Trent Jones prior to systematic strength training. On the right Trent Jones lifts 411 lbs during a "Starting Strength" meet. When he started weight lifting with a purpose, using the Starting Strength model, he started to see changes in his mood and physical strength. He eventually put on 50 pounds of muscle as he upped his training regimen and fine-tuned his eating habits. He noticed he started to feel more assertive in his relationships and work. He gained confidence and his depression symptoms declined. He’d found out a secret that most people don’t know: strength training can be an effective treatment for depression. The research behind strength training and decreased depression Trent’s transformation—both physical and emotional, is a great tool for taking control of total health. But, it’s one that most people don’t think about when they think about classic depression. Most patients that come to me don’t expect me to recommend a weight lifting regimen when they step into my office for psychotherapy and medication management. Of course, medicine and talk therapy are incredibly helpful. Strength training is just one of the tools in my toolbelt for depression, but it’s a very powerful additive force for long-term treatment success. In a recent large meta analysis showed the overall effect size (the amount of change the strength training group had compared to the control groups) for strength training was 0.66 (95% CI, 0.48-0.83; P< .001). Learning to understand effect size can be very important so I will mention a few things here to make sense of this. Effect size is the difference between treatment and control group, expressed in standard deviation units, where an effect size of 1 means that the treatment arm moved one standard deviation from the control group. An effect size of 0.8 is a large effect, 0.5 is a moderate effect, and 0.2 is a small effect (Cohen, 1998). It compares two treatments, and looks at how far they move away from each other.  The larger the effect size, the better the treatment. As a point of reference, a different meta-analysis of 37 psychotherapy studies looking at the treatment of depression found an effect size of 0.73 (Robinson, 1990). Therefore recent meta analysis for strength training was very impressive!    In this met analysis, they also found that total volume of resistance training, participant health status, and previous strength status didn’t really matter. However, sometimes when a group of studies are looked at simultaneously they miss the nuance of well designed individual studies. One study in particular showed the more strength gained the larger reduction in depression. Translation? It didn’t matter how out of shape people were when they started, it only mattered that they started the strength training program—it still helped depression. This is something that as a doctor, I’d rarely say, but: You don't have to comply fully in order to reap benefits. You don’t have to be an expert lifter to gain benefits. If you can train even two days a week, you will still get benefits from that. However, the people who gained the most strength had a correlated decrease in depressive symptoms. Basically, the more strength you gain, the more effective it is for treating depression. The other key is to notice what Trent noticed: exercise and even unregimented, random training isn’t as effective as a systematic lifting program. On another level, strength training helps patients with developing assertiveness, which increases confidence and happiness. To understand this, we have to talk about anger. We often think anger is a bad feeling, a wrong emotion. But it’s not. Anger has an adaptive function. The primal purpose of anger is so we can protect ourselves, loved ones and overcome obstacles (like being disconnected with a loved one). When we feel anger, hormones like adrenaline, result in courage to fight the bear that’s trying to attack us. Or to pay attention to our spouse so we can remove the emotional obstacle between us and feel close to them. When we feel angry, it may be a message that someone has violated our space, talents or abilities and we need to therefore allow the anger to empower us to put up a boundary. Most often, in our childhoods, demonstrating anger was not acceptable behavior. As we age, we keep that messaging and suppress our anger inwardly, leading to a lack of assertiveness. That lack of assertiveness then can lead to further issues like less respect for ourselves in relationships, which develops from being constantly getting “run over.” Then we tend to misplace our anger—like how Trent wouldn’t confront his boss for overstepping his boundaries, but would go home and throw plates to act out his aggression. When people start strength training, they are, quite literally, adding stress to their body. But, with a systematic training program, the stress is sequential and leads to adaptation. When we do something difficult, we practice courage. Overtime we no only grow strong, but also more competent to meet the huge challenges that life throws our way. Like Trent, I used to be an athlete in college. When I started medical school, and on into residency, I exercised, but didn’t strength train the way I do now. It has changed my life. As a psychiatrist, I write prescriptions for medicines for severe mental illness. I prescribe talk therapy to almost everyone as part of the process of overcoming. And I also write a prescription for strength training. In my therapy practice, I’ve personally seen the results of the training on decreasing depression in my patients—it absolutely helps. The link between empathy and self-care Some of my patients who are incredibly empathic also struggle with depression. They are so empathic, so giving, that their schedules often reflect this—they don’t make time for themselves. Strength training can help, as it did with Trent, to develop assertiveness and even deal with chronic, unresolved anger. Self care through strength training can aid in decreasing depression. Empaths naturally lean towards being professional therapists, or are live-giving people in their myriad of relationships. As professional caretakers, it’s important to make time in our schedules for ourselves to do things like strength training. Where to start and how to succeed? The first key is just to begin. Remember that perfection isn’t important. You don’t have to jump in to a five day a week routine. Start simple and build the habit of two days a week of training if you’re just beginning. Start with watching youtube videos (see below) of proper technique, and I highly recommend to hire a coach (online or in person) to help you for the first few months to show you how to properly lift the weight so you do not hurt yourself.  If you buy one book, buy this one.  If you want a free place to post questions and videos for technique critique join this facebook group (be warned people will be concise and to the point which may come out blunt). Start by mastering these multi-muscle movements with a barbell: Squat Bench Press Press Deadlift Do 3 sets of five repetitions each, with increasing weights with each workout. The exercise and sets and reps don’t change for the first 3-6 months of doing this. Only the weights change. Add five pounds each new day you work out. Repeat every time you go to the gym. To start, go to the gym optimally three days a week. Gordon, B. R., McDowell, C. P., Hallgren, M., Meyer, J. D., Lyons, M., & Herring, M. P. (2018). Association of Efficacy of Resistance Exercise Training With Depressive Symptoms: Meta-analysis and Meta-regression Analysis of Randomized Clinical Trials. JAMA Psychiatry.      
May 24, 2018
In the third and final installment on microexpressions, Ariana Cunningham and Dr. David Puder talk about how learning microexpressions can help you build empathy and connect with other people. As Paul Eckman demonstrated in his research, they can be potent glimpses into someone’s emotional experience. In this episode we talk about: How emotions come into play in our dreams and other unconscious ways. How to use what we learn from them carefully and with curiosity, rather than with a know-it-all attitude. How we create psychological defense to cope with reality How we might experience problematic relationship patterns through a theory called object relations. How our emotions happen out of our awareness. Preventing emotional overload and empathic exhaustion. Emotional transference and how to stop it. Read the blog that goes with this here Join Ariana on Instagram: @joyspotting Join David on Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder IOS Emotion Connection App
May 15, 2018
Microexpressions are brief, involuntary facial expressions that are cues to the true emotions that someone is feeling. We see microexpressions in tiny twitches of the brows, the lips and nose. They can last for as little as 1/15th of a second on the face. In this episode we describe the science of the microexpressions of fear, disgust, and surprise and how to use it to connect with others. For full PDF of the episode with links to videos of each emotion go to: For link to the simple app that trains you on how to read microexpression go to: IOS Emotion Connection App Join Ariana on Instagram: @joyspotting Join David on Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder
May 8, 2018
Microexpressions are brief, involuntary facial expressions that are cues to the true emotions that someone is feeling. We see microexpressions in tiny twitches of the brows, the lips and nose. They can last for as little as 1/15th of a second on the face. In this episode we describe the science of microexpressions, emotion and how to use it to connect with others. For full PDF of the episode with links to videos of each emotion go to: For link to the simple app that trains you on how to read microexpression go to: IOS Emotion Connection App Join Ariana on Instagram: @joyspotting Join David on Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder
May 3, 2018
New research on hormonal contraceptives, “the pill”, and how it influences mental health. Dr. David Puder and Dr. Mona Mojtahedzadeh explore: Claims about the mental health consequences of hormonal contraception Unique Influences of progesterone and estrogen on the brain How ovulation changes attraction and desire Discuss the controversy around recent studies that show that hormonal contraception increases risk of depression Critique of those studies and counters to those critiques Kelly Brogan and other contrasting views and their influence on this field Link to full notes and blog: Join Dr. Puder on: Join David on Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder
April 24, 2018
Overcoming Postpartum Depression sign up for an annual subscription to receive CME credit for this activity and more! Learn more Here. Link to show on: iTunes, Google Play, Stitcher, Overcast, PlayerFM, PodBean, TuneIn, Podtail, Blubrry, Podfanatic This week on the podcast, I joined with Dr. Pereau to talk about postpartum depression, both from a personal level and as those who treat it in our patients. Dr. Pereau is incredibly honest and vulnerable in this emotional episode as she shares her story. Throughout it, she talks about the symptoms of her postpartum depression, including: Intrusive thoughts Emotional disconnection from her baby Sleep deprivation Hopelessness Problems with concentration Disconnection from passion and joy Panic attacks and anxiety Poor self care It had never occurred to Dr. Pereau that she would struggle with postpartum depression, though she had treated many people with it, and could easily recognize symptoms in others. Often, when we are experiencing these kinds of things, it’s hard to identify the symptoms within ourselves. We understand the need for someone with a recognizable disorder, such as bipolar or schizophrenia, to get help. But depression can be a slippery, indefinable problem when it comes to labeling ourselves. If you are dealing with postpartum depression, know that it can be treated, and there absolutely hope to work through it. Here are some things that can help: Breastfeeding to stimulate connection and positive hormone production SSRI treatment (medications prescribed by a doctor) Talk therapy A good support system If you’ve been experiencing the symptoms we discuss in this podcast, there are plenty of resources, plenty of people who can help you during this time. The Edinburgh Postnatal Depression Scale is a simple questionnaire that can tell you if you are experiencing postpartum depression. For a list of local support groups in the region, is a wonderful resource. Postpartum Support International is another great resource for online support groups and educational materials.   PPD Silence Sucks has many educational materials and links to other resources— 2020 Mom is an online advocacy group for maternal mental health. It includes blogs, educational materials and legal support. Below is a touching excerpt from her story: “My mother always said that when I had a child, I would know true love in a way I could never conceptualize. It had been a very long path to finally getting the child, and when he finally came I felt nothing. Actually, I felt worse than nothing. For the first couple months, all I can remember is darkness. I felt alone to my core. I felt like I was drifting, disconnected and lost. In my mind, my life was over. It was forfeit. The child wasn’t a beaming ray of sunshine, filling me with hope and life and love. When I looked at him I felt nothing. The guilt of this overwhelmed me. I found myself wrestling through the options, fantasizing about packing a bag and running away in the middle of the night, or giving the baby up for adoption, or crashing my car off the edge of the mountain on my way home from work, or throwing myself off our cabin’s third floor balcony. The images whirled through my mind and I would clench my teeth and force them away. It was all so dark. I didn’t want him. I didn’t want my life. I believed I knew these things for certain. I believed these were my thoughts. I mentioned to my husband Bryan about having a dream where I  jumped off the balcony, but then I quickly minimized it. I filled out the Edinburgh Scale in the OBGYN office with just enough depression items to be flagged but not enough to get hospitalized. We use the term, “A cry for help,” and generally refer to something gamey or indicative of less severe illness. I can see how it looks that way. But I now know without any doubt what a cry for help really is. It was the weak, thready voice of the last piece of me left in my mind, the last flicker of light not darkened by postpartum depression. It was the last bit of me that was not pinned down under the weight of illness. Those weak cries were the best I was capable of. The illness was too great. My mind did not belong to me. My thoughts did not belong to me. I just didn’t realize it. As a society, we believe that depression is something that can be willed away if a person is strong enough. If they just try hard enough. And yet nobody tells a schizophrenic to just try to not hallucinate. We don’t tell a person with bipolar disorder to just try to not cash out their retirement to finish that half built bomb shelter in their back yard they’ve been building the last few weeks. Even conditions like alcoholism have been embraced within a medical model. We don’t tell the alcoholic to just try to stop drinking anymore. We recognize this to be a medical illness deserving of care and treatment. And yet we tell the depressed person to try to be positive. Try to be happy. And I think I know why.  As humans on the planet, each of us suffer, faces grief, loss, and even hopelessness. And we find ways to survive, often becoming stronger because of it. We assume our experiences with emotional pain are similar to what a person with depression goes through. I know I thought that, and I’ve faced considerable loss throughout my life. Unfortunately, depression isn’t anything like that. It’s disease. It’s organic. It’s neuro chemical. It is an illness where your very thoughts become twisted and distorted, your perception of the world around you becomes altered. You lose who you are and generally have no idea that it’s even happening. We have to stop assuming that depression is something like the subjective painful experiences we all encounter in life. It’s a biological illness of the brain. In the past decade completed suicide rates in the United States have increased 20%, taking the lives of 121 people a day. Attempting to will away depression cost me 11 months of my life, where each month that passed took me deeper into a hole I couldn't claw out of. Postpartum depression affects the lives of over half a million women a year. It destroys families and severs the connection between a mother and child. It is a deadly disease which cannot be combatted through willpower. I believe a new approach is needed to proactively educate and better screen our patients. I don’t begin to have all of the answers, but I can say that the culture around mental illness must change. There is no room for judgment. Maybe it starts with a simple, “I’m worried about you. I think you’re hurting.” Maybe it starts with spending the time to paint a clear biologic picture for the family surrounding a mother to heighten monitoring. All I know is that “holding it together” is no way to live, work, or raise a child. I chose to accept help. I chose to take medications to treat postpartum depression, nearly a year later. Eleven months after my son was born, I remember a pivotal moment. It was 3 in the morning and he had just fallen back to sleep, there in my arms. As I looked down at his beautiful face, there in the darkness, I whispered to him, “I would choose you.” It was like it was the first time I had ever seen him. The Joy that normally present in my everyday life came back. My thoughts became my own again, no longer twisted and distorted. I have firsthand knowledge of what it looks like to be overcome by an illness of brain, of the mind. It’s chemical. It’s biologic. And it’s one of the most terrifying illnesses I can imagine.  And help exists. I know Sharing this helps to dispel shame, despite this being...a bit overwhelming. But it’s seriously about life and death, and if hearing my story helps you to better understand what 1 in 7 women who have had a child is experiencing, then this is worth it to me.”  
April 17, 2018
Our bodies are “wired” to perform. Learning how to consciously modulate your internal sympathetic state is the key to unlocking optimal performance. The autonomic nervous system (ANS) facilitates survival by generating the fight-or-flight response and promotes recovery following activation (the ability to relax). The ANS achieves this by balancing two complementary systems: the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS). For example, your ANS is currently adjusting your pupillary diameter, respiratory rate, blood pressure, heart rate, skin conductance, sweat production, sphincter tone and postural muscles (just to name a few) to allow you to focus your eyes to read this information without passing out, falling over, overheating or urinating on yourself. For PDF with full notes on our discussion and breathing: Join Dr. Eller on: Facebook: @PhysicalTherapyRX Instagram: rxpt_ Join David on Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder
April 5, 2018
Learn: Why to optimize medical issues like hypertension and diabetes Change psychiatric and non-psychiatric medications to optimize brain function Optimize sleep to obtain rest and increase brain function How drugs influence the brain short and long term to change sensorium How viewing yourself without "free will" influences brain function For PDF with citations and full notes go to: Join David on Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder IOS Emotion Connection App
March 23, 2018
Western society faces is the most unhealthy we’ve ever been. It’s reached epidemic proportions: depression, anxiety, poor focus and sensorium issues, chronic stress, and diseases of chronic stress (like diabetes). The solution is simple—exercise and healthy eating. In this episode I will be going through 17 studies on how exercise influences and improves these factors. I will cover how it works, and how to develop an exercise program from the perspective of a doctor, not just for body sculpting.   Some things I am covering: Strength training decreases depression Strength training increases cognitive function Fitness decreases risk of dementia Exercise increases BDNF Strength training and exercise in treatment for diabetes For PDF with citations: Post questions and comments on Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder IOS Emotion Connection App Starting Strength Online Coaching
March 15, 2018
What are the best diets for the brain and cognitive function?   How much does diet influence our sensorium? What particular foods are important?   How do we change our genes to optimize our brain? For PDF with citations and detailed notes go to: My Resource Page Ask David questions on Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder IOS Emotion Connection App
March 6, 2018
In this episode, Dr. Puder addresses the fascinating realm of schizophrenia with Dr. Cummings, a previous guest in the show. Dr. Cummings is a psychiatrist with a wealth of experience from working at Patton State Hospital in California, one of the biggest forensic hospitals in the world. -Defining Schizophrenia -Living with Schizophrenia and Perception of Reality -Are Negative Symptoms in Schizophrenia Precipitated by Medications? -Emil Kraepelin, and the Early Studies on Schizophrenia -The Pathology, Biology, and Genetics of Schizophrenia -Cannabis Use and Risk For Schizophrenia -The Loss of Brain in Schizophrenia -Counter-arguments Against Robert Whitaker’s “Anatomy of an Epidemic”         -Schizophrenia Prevention in High Risk Population -Australian Study on Children of Schizophrenic Parents -Crime, Violence, Mass Shootings and Schizophrenia -Medical Management of Schizophrenia -1st Break Psychosis -Long-acting Injectable Antipsychotics in Early Illness -Medication Adherence -Exercise, Lifestyle, Diet Optimization For more notes on this episode, links to articles, visit our website: Join David on Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder CV of Dr. Michael A. Cummings Assistant Producer: Arvy Wuysang Editor: Trent Jones
February 28, 2018
This week I had a discussion with Dr. Darcy Trenkle on the difficulty of providers to get psychiatric treatment, using ourselves as the examples.  In a recent article nearly 40% of physicians surveyed said they would be reluctant to seek formal medical care for treatment of a mental health problem because of concern that this may put their medical license in jeopardy.  Physicians have three times the national average for suicide and have unique stressors and often a culture not conducive to seeking help.  We discussed difficulties we had in contemplating getting care for different issues we faced.  Hopefully this will open a discussion regarding the conflicts providers have in engaging needed help.  Dr. Trenkle is a psychiatrist in Southern California and is affiliated with Loma Linda University Health.  She received her Medical Degree from Loma Linda University School of Medicine. She completed her residency training at Loma Linda University in 2015. She is the Medical Director for Electroconvulsive Therapy as well as Program Development for the Behavioral Medical Center at Loma Linda University.  If you are a Medical Student, Resident or Attending listening to this and need help, please reach out to a local provider.  We are open to receive emails if you are local, our names are searchable in the Loma Linda email system.   For more notes on this episode go to: Join David on Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder
February 19, 2018
Sensorium is the total brain capacity for focusing, processing, and interpreting. It is not a static state—it can fluctuate throughout the day.   It can be influenced by sleep, food, stress, exercise, drugs, medications, and long term, through epigenetic phenomenon.   If there is damage to the structure of the brain, it can permanently lowered. It is a slope, which we all move up and down on, based on our baseline, but then also influenced by many factors.   In your 20s and 30s you are very far on the left side of the line. If you get stressed, sleep deprived, starving, maybe have a small infection, you may still be able to think, but just less clearly. If you did those same things to an elderly person, they would be sent into a full delirium, hallucinating, throwing things, yelling, seeing spiders on the wall, and looking psychotic.  In this way it is common for an elderly person with dementia, they can be more confused in the evening then in the morning, they call this “sundowning”.   We all have a baseline level of brain function, and this can be optimized by several factors like good sleep, good amounts of exercise, good mental functions (like reading), meaningful relationships, good spiritual practice, and meaningful work.   For more notes on this episode go to: Join David on Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder Personal Website: IOS Emotion Connection App
February 13, 2018
This week David Puder, M.D., has a discussion with Randy Stinnett, Psy.D, regarding his journey to become an excellent therapist.  Randy shares aspects of his journey and insights.  His enthusiasm is contagious.  He discusses formative influences including Habib Davanloo, Donald Kalsched, and Todd Burley.  Please follow the link to the website for Randy Stinnett's list of 5 recommendations for someone aspiring to be an excellent therapist. Join David on Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder Personal Website: IOS Emotion Connection App Link to Randy Stinnett, Psy.D Short CV
February 6, 2018
In this episode I will be interviewing William Britt, PhD level clinical psychologist, an expert in cognitive behavioral therapy, object relations therapy, EMDR and a board certified neuropsychologist. He runs cognitive rehabilitation groups and neuropsychological assessments, and supervises neuropsychological fellows and interns. He also works closely with the psychiatric residents teaching about suicide.   In this episode, Dr. William Britt explores his experiences running an inpatient psychiatric group for 5 to 13 year olds who are being treated for violence or attempted suicide, using uses a method based on Irving Yalom’s inpatient group psychotherapy technique. We discuss how the trend of teen suicide has increased over the years and the typical causes of depression. We also cover common bullying tactics and how cyber bullying has changed society.  We then discuss how to use the group's support to help each other move away from being suicidal. We explore how the Netflix TV series “Thirteen Reasons Why” has influenced young minds and the new terms the patients are using. In the end, Dr. Britt and Dr. Puder answers how we adapt and recover from trauma, and how we find meaning and value within stress.   Join David on Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder IOS Emotion Connection App CV of Dr. Britt
January 29, 2018
In this episode, Dr. Cummings and I discuss psychopathy: the fearless, empathyless people, who see others as objects, and have the inability to attach within relationships. Dr. Michael Cummings recently contributed to a book called “Violence in Psychiatry,” detailing the biological aspects of psychopathy, edited by Stephen Stahl. Dr. Cummings works at Patton State Hospital, one of the biggest forensic hospitals in the world. He is the Yoda of the psychiatric world, with many other psychiatrists bringing him their most complex and difficult cases.    In this episode we cover: History of psychopathy Influence of early life traumas Prosocial careers of psychopaths Biological components in psychopathy The emotion psychopaths fail to see BDNF (brain-derived neurotrophic factor) Prefrontal area (the parent of the brain that warns us “that is not a good idea”) Amygdala Why psychopathy has not been bred out of existence Advice when you are in a relationship with a psychopath What drugs make someone look psychopathic Effect of alcohol andmethamphetamines on the brain Influence of cocaine on the brain Why more men are violent psychopaths And treatment of this group of people (clozapine’s influence on glutamate) The Story of Phineas Gage We also wrestle with how to increase the percentage of psychopaths that end up helping society vs percentage that become criminals. Warburton, K and Stahl S (Editors).  Violence in Psychiatry.  The Neurobiology of Psychopathy. Cambridge University Press 2016), pp. 200-05 CV of Dr. Michael A. Cummings      Join David on Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder IOS Emotion Connection App Editor: Trent Jones *This podcast is for informational purposes only and is the opinions of the people on this episode.  For full disclaimer go here.  
January 23, 2018
This week we discussed cognitive distortions with Adam Borechy. Usually cognitive behavioral therapists deal with cognitive distortions by helping their clients identify habitual negative thoughts and and putting those thoughts on trial. We don’t have to accept every thought that passes through our brains as truth. When we have distressing thoughts, it can be helpful to consider if we might be telling ourselves the full truth about a situation. We refer to common cognitive distortions—depression, anxiety, feelings of failure, negative thoughts when interacting with people, social anxiety—and we see how they are applying to our thought process. For a PDF of the cognitive distortions and a 8 days journal task towards better identifying them in your life, please see my resource page. In this 8 day journey you will better identify your own troubling thoughts and move towards gratitude. Here are a list of the cognitive distortions: All or nothing thinking: things are black and white, completely without shades of gray.  For example you may think, “If I am not perfect, I should not try at all, because then I would fail completely.” Or you might think, “My significant other is completely evil.” And then the next day, “My significant other is perfect.”   Overgeneralization: generalizations are made without context, experience or evidence.  “I am always alone.”  Or “Everyone hates me.”  “I never win.” Always? Never?  Everyone? It happens absolutely all the time, without exceptions? In the moment, it can feel like that, but those statements are actually rarely true. Speaking truth to yourself in this case might look like: I am sometimes alone, several people are upset at me, I win sometimes, even if I didn’t this time. Mental Filter: focusing on the negative rather than the whole picture. After receiving multiple positive statements and one negative statement, all you focus on is the negative statement.   Disqualifying the positive: When you do something good like get a compliment or award, you instantly find ways to make less of it! For example, if someone says, “You are looking good today,” but instantly you assume that person is giving you a false compliment.   Jumping to conclusions (without evidence): reaching conclusions (usually negative) without little evidence. ind reading: assuming you know what the person is thinking about you.  Connection occurs from accurately knowing another, and with mindreading you blind yourself without evidence. Fortune telling: predicting negative things in the future.  For example you think “I am going to fail this test even if I study,” so you don’t try, don’t study, and don’t even show up. Magnification or Minimization: you make some weakness of yours much larger than it is or a strength much less than it really is. For example you see your friends as beautiful whereas you see your own beauty as very average. Emotional Reasoning: believe that your feelings reflect reality. For example, “I feel stupid, therefore I am.” or “I feel fearful of flying in planes therefore they must be dangerous,” or “I feel ugly therefore I am ugly despite what others tell me.”   Shoulding: a thing that you believe you should or should not do, often created to try to maintain an image of yourself which is more in line with social pressures. For example, “I should be perfect,” “I should never cry,” “I should always win,” “I should be able to do this on the first try.” Personalization: blaming oneself for a bad event without looking at external factors that contributed to the bad event. Attributing personal responsibility to things that you have no control over, or when you do not see all the things that caused something. For example, a friend is upset so you think it is something you caused or are responsible for.   Error Messages: thoughts that are like obsessive compulsive disorder due to having thoughts that are repetitive, intrusive and not meaningful.  Join David on Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder Personal Website: IOS Emotion Connection App Co-host: Adam Borecky Editor: Trent Jones *This podcast is for informational purposes only and is the opinions of the people on this episode.  For full disclaimer go here.  
January 16, 2018
In this first episode I talk about my approach to seeing a new patient for the first time.  I go over the importance of empathy and psychological safety in the first interview.  I then go into how to do some of the components of a psychiatric history.  I go into details on what parts are important and why.  Please see my resource page for a full PDF of my notes and also the PDF of the document I give to patients prior to their first appointment with me.   Join David and post your comments for this episode on Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder Personal Website: IOS Emotion Connection App Editor: Arvy Wuysang *This podcast is for informational purposes only and is the opinions of the people on this episode.  For full disclaimer go here.  
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