3.6 Catatonia: Management

Dr. Nicholas Kontos, Director of the Consultation-Liaison Psychiatry Fellowship at Massachusetts General Hospital and assistant professor of psychiatry at Harvard Medical School, joins us for a reflective conversation on factitious disorder, malingering, and clinical deception.  We begin by unpacking the concept of “thinking dirty”—a term used in consultation-liaison psychiatry to describe the delicate and often uncomfortable task of considering deception in clinical care. Dr. Kontos walks us through why patients may deceive providers, including both conscious and unconscious motivations, and shares strategies for approaching these situations with clinical humility, curiosity, and compassion.  We explore practical interviewing techniques to elicit more accurate histories and review key distinctions between factitious disorder and malingering, including diagnostic criteria, prevalence, and typical management strategies. Dr. Kontos discusses the concept of the “therapeutic discharge,” a framework for ending unproductive hospitalizations while still maintaining a therapeutic posture.  Throughout the episode, we emphasize the central role of dignity and professionalism in managing deceptive behavior in medical settings, highlighting a model of psychiatry that avoids antagonism and centers patient care, even in the most complex situations.  Teaching Psychiatric Trainees to “Think Dirty”: Addressing Hidden Motivations in the Consultation Setting (Beach, 2017) The Therapeutic Discharge I: An Approach to the Management of Deceptive Suicidality (Kontos, 2017) The Therapeutic Discharge II: An Approach to Documentation in the Setting of Feigned Suicidal Ideation (Kontos, 2018) Learn more about your ad choices. Visit megaphone.fm/adchoices

Dr. Caitlin Adams, psychiatrist at Massachusetts General Hospital, provides an overview of functional neurological disorder (FND). This episode covers how to recognize, explain, and treat FND using a modern, evidence-based, and patient-centered approach.  We begin by defining FND and discussing nomenclature from hysteria through conversion disorder and into our current construct of FND. Dr. Adams directly addresses one of the most critical misconceptions in clinical practice: whether symptoms like functional weakness or psychogenic non-epileptic seizures (PNES) are under voluntary control. We explore what current neuroscience tells us about the pathophysiology of FND and how this can support compassionate and effective care.  The episode outlines how to positively diagnose FND—including key physical exam findings such as Hoover’s sign, tremor variability, and features that distinguish PNES from epileptic seizures. We also review how to communicate the diagnosis to patients, reduce stigma, and improve treatment engagement.  Dr. Adams describes the biopsychosocial model of FND, including common predisposing, precipitating, and perpetuating factors. We discuss the central role of cognitive behavioral therapy (CBT), the benefits of specialized physical therapy for functional movement symptoms, and additional psychotherapeutic approaches such as mindfulness and psychodynamic therapy. Finally, we address how to manage chronic or treatment-resistant FND, and when to re-evaluate the diagnosis.  Key References:   ​Incidence and prevalence of functional neurological disorder: a systematic review (Finkelstein 2025)   ​Neurosymptoms.org   ​Cognitive behavioural therapy for adults with dissociative seizures (CODES): a pragmatic, multicentre, randomised controlled trial- (Goldstein 2020)  ​FND Hope   ​Overcoming Functional Neurological Symptoms Workbook (Williams)  Learn more about your ad choices. Visit megaphone.fm/adchoices

Dr. Christina Wichman, Professor of Psychiatry and Obstetrics & Gynecology, Medical Director of The Periscope Project and Director of Women’s Mental Health at the Medical College of Wisconsin, joins us for an in-depth introduction to reproductive psychiatry. This episode is co-hosted by Erica Browne, an M4 at Saint Louis University School of Medicine. We explore the unique clinical and ethical challenges of treating psychiatric illness during pregnancy and the postpartum period, including how to navigate the needs of both mother and child. Dr. Wichman walks us through distinctions between common perinatal mental health presentations—such as baby blues, perinatal depression, and major depressive disorder—and discusses how to differentiate normal postpartum stress from psychiatric conditions that require treatment. The episode covers validated screening tools, pharmacologic treatment during pregnancy and lactation, and non-pharmacologic options for patients with limited access to care. Dr. Wichman shares her clinical approach to balancing risk and benefit when initiating or continuing psychotropic medications, and offers guidance on red flags for perinatal psychosis. We also highlight The Periscope Project, a model for expanding access to reproductive psychiatry expertise, and discuss training pathways and future directions in women’s mental health. Key References & Clinical Resources The Periscope Project – A perinatal psychiatry consultation and resource program based in Wisconsin. National Access Programs – Lifeline for Moms – A directory of statewide perinatal mental health access programs. National Curriculum in Reproductive Psychiatry (NCRP) – Free, evidence-based training for clinicians in reproductive psychiatry. MGH Center for Women’s Mental Health – Clinical and research resource for perinatal and reproductive psychiatry. MotherToBaby – Trusted information on medication and other exposures during pregnancy and breastfeeding. Pharmacologic Treatments for Mania (Kishi 2021) – Meta-analysis regarding antimanic effects of selective estrogen receptor modulators. Learn more about your ad choices. Visit megaphone.fm/adchoices

Today we have TWO world renowned experts to teach us about eating disorders! Dr. Anne O'Melia is the Chief Clinical and Quality Officer at ERC Pathlight, where she leads a multidisciplinary team of over 1,000 therapists, dietitians, and nurses caring for patients across the country. She is board certified in pediatrics, general psychiatry, child and adolescent psychiatry, and consultation-liaison psychiatry. She has co-authored numerous articles and book chapters on eating disorders. Dr. Patricia Westmoreland has spent decades traveling the globe speaking and publishing about eating disorders, and is currently working in private practice. Dr. Westmoreland has particular expertise in the forensic aspects of eating disorders, and in managing the medical complications of eating disorders. Dr. Westmoreland is board certified in internal medicine, general psychiatry, forensic psychiatry, and consultation-liaison psychiatry. We review how to identify when disordered eating patterns require clinical attention and outline the most common eating disorders encountered in the general medical hospital, including anorexia nervosa, bulimia nervosa, and avoidant/restrictive food intake disorder (ARFID). The episode covers prevalence rates, high-risk populations, and the significant morbidity and mortality associated with eating disorders. Our guests discuss key clinical information needed for diagnosis, criteria for medical hospitalization, and the spectrum of available levels of care. We take a deep dive into anorexia nervosa, reviewing its clinical trajectory, diagnostic criteria, subtypes, and complications. Finally, we examine evidence-based approaches to medical stabilization, psychotherapy, and pharmacotherapy in the treatment of eating disorders. Key References: 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) SUPPORT OUR PARTNERS: ⁠⁠SimplePractice.com/bootcamp⁠⁠ (Now with AI documentation! Exclusive 7 day free trial and 70% off four months) ⁠⁠Oasis Psychiatry Conferences ⁠⁠(enter code BOOTCAMP at checkout for additional 10% savings) ⁠⁠Beat the Boards⁠⁠ (enter code BOOTCAMP at checkout for addition 10% savings) ⁠⁠CME to Go⁠⁠ (enter code BOOTCAMP at checkout for addition 10% savings) Learn more about your ad choices. Visit megaphone.fm/adchoices

Dr. Mira Zein, Associate Professor of Psychiatry and Behavioral Science at Stanford University, walks us through decisional capacity determinations. This is a great episode for learners rotating through a consultation-liaison psychiatry service, and will really help you shine on rounds when you quote the Appelbaum-Grisso criteria (seriously, do it)! We also invite psychiatry residents and CL psychiatrists to share this episode with their favorite primary team to help non-psychiatrists make capacity determinations on their own... They are often best suited to do so! Dr. Zein walks us through the Appelbaum-Grisso criteria and discusses each criterion (communication, appreciation, understanding, rationality) in detail. This discussion goes beyond a textbook understanding of the topic, delving into several difficult cases of determining decisional capacity. We discuss common reasons for psychiatric consultation regarding capacity, and how to navigate difficult conversations when fielding consults. You will also learn about common illnesses that can cause diminished capacity, and how to proceed if a patient is found to lack decisional capacity (for a certain decision, at a certain time 😉). Key resources: 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) SUPPORT OUR PARTNERS: ⁠SimplePractice.com/bootcamp⁠ (Now with AI documentation! Exclusive 7 day free trial and 70% off four months) ⁠Oasis Psychiatry Conferences ⁠(enter code BOOTCAMP at checkout for additional 10% savings) ⁠Beat the Boards⁠ (enter code BOOTCAMP at checkout for addition 10% savings) ⁠CME to Go⁠ (enter code BOOTCAMP at checkout for addition 10% savings) Learn more about your ad choices. Visit megaphone.fm/adchoices

Dr. Paula Zimbrean, Professor of Psychiatry and Yale School of Medicine and Director of Transplant Psychiatry Services at Yale New Haven Hospital, introduces us to the field of transplant psychiatry. We discuss the role of psychiatrists in solid organ transplantation, including pre-transplant evaluations. We then discuss the various phases through which transplant patients require support, starting with a diagnosis of advanced organ disease. We cover the pre-transplant phase, peri-operative recovery, early post-transplant stressors, and finally psychiatric considerations that last months to years after transplant. Dr. Zimbrean discusses ethical challenges faced by psychiatrists working in a transplant setting, and shares considerations for the future of transplant psychiatry. Selected references: Transplant Psychiatry: A Case-Based Approach to Clinical Challenges Transplant Psychiatry: An Introduction SUPPORT OUR PARTNERS: SimplePractice.com/bootcamp (Now with AI documentation! Exclusive 7 day free trial and 70% off four months) Oasis Psychiatry Conferences (enter code BOOTCAMP at checkout for additional 10% savings) Beat the Boards (enter code BOOTCAMP at checkout for addition 10% savings) CME to Go (enter code BOOTCAMP at checkout for addition 10% savings) Learn more about your ad choices. Visit megaphone.fm/adchoices

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: ⁠Changeability, confidence, common sense and corroboration: comprehensive suicide risk assessment (O'Connor 2004)⁠ SUPPORT OUR PARTNERS: ⁠SimplePractice.com/bootcamp⁠ (Now with AI documentation! Exclusive 7 day free trial and 70% off four months) ⁠Oasis Psychiatry Conferences ⁠(enter code BOOTCAMP at checkout for additional 10% savings) ⁠Beat the Boards⁠ (enter code BOOTCAMP at checkout for addition 10% savings) ⁠CME to Go⁠ (enter code BOOTCAMP at checkout for addition 10% savings) Learn more about your ad choices. Visit megaphone.fm/adchoices

Dr. George Grossberg, Henry and Amelia Nasrallah Endowed Professor of Psychiatry & Behavioral Neuroscience at Saint Louis University School of Medicine, past president of the American Association for Geriatric Psychiatry, and past president of the International Psychogeriatric Association, orients us to behavioral disturbances in patients with neurocognitive disorders. We walk through common behavioral disturbances in patients with dementia, including apathy, depression, psychosis, and agitation. We discuss management strategies including nonpharmacological and pharmacological interventions. Dr. Grossberg shares his expertise on difficult clinical management decisions when working with this population, and centers us around the importance of knowing the patient as well as the disease. Selected References: ⁠Progress in Pharmacologic Management of Neuropsychiatric Syndromes in Neurodegenerative Disorders: A Review (Cummings 2024) Neuropsychiatric Symptoms of Dementia and their nonpharmacological and pharmacological management (Tampi 2022)⁠ Management of BPSD Algorithm (Chen with Osser 2021)⁠ Atypical Antipsychotics for Aggression and Psychosis in Alzheimer's disease (Ballard 2006) Efficacy and Adverse Effects of Atypical Antipsychotics for Dementia (Schneider 2006) Sequential Drug Treatment Algorithm for Agitation and Aggression in Alzheimer's and Mixed Dementia (Davies 2018) SUPPORT OUR PARTNERS: ⁠SimplePractice.com/bootcamp⁠ (Now with AI documentation! Exclusive 7 day free trial and 70% off four months) ⁠Oasis Psychiatry Conferences ⁠(enter code BOOTCAMP at checkout for additional 10% savings) ⁠Beat the Boards⁠ (enter code BOOTCAMP at checkout for addition 10% savings) ⁠CME to Go⁠ (enter code BOOTCAMP at checkout for addition 10% savings) Learn more about your ad choices. Visit megaphone.fm/adchoices

Dr. Mark Oldham, Associate Professor of Psychiatry at the University of Rochester Medical Center, President of the American Delirium Society, and Deputy Editor of the Journal of the Academy of Consultation-Liaison Psychiatry, returns to discuss management of catatonia. We delve into management guidelines that everyone working with catatonia should know. We then have a candid discussion about common clinical challenges in treating catatonia, and describe unique cases of catatonia that require adjusting our approach. Selected references: ⁠British Association for Psychopharmacology Guidelines⁠ ⁠⁠Rochester Catatonia Assessment Resources⁠⁠ ⁠NEJM Review on Catatonia⁠ ⁠Nature Review on Catatonia⁠ ⁠Schizophrenia Research Volume on Catatonia⁠ ⁠Describing the Features of Catatonia (Oldham)⁠ SUPPORT OUR PARTNERS: ⁠SimplePractice.com/bootcamp⁠ (Now with AI documentation! Exclusive 7 day free trial and 70% off four months) ⁠Oasis Psychiatry Conferences ⁠(enter code BOOTCAMP at checkout for additional 10% savings) ⁠Beat the Boards⁠ (enter code BOOTCAMP at checkout for addition 10% savings) ⁠CME to Go⁠ (enter code BOOTCAMP at checkout for addition 10% savings) Learn more about your ad choices. Visit megaphone.fm/adchoices

Dr. Mark Oldham, Associate Professor of Psychiatry at the University of Rochester Medical Center, President of the American Delirium Society, and Deputy Editor of the Journal of the Academy of Consultation-Liaison Psychiatry, introduces us to catatonia. We discuss the clinical features of catatonia and compare and contrast catatonia's description in the DSM with the Busch-Francis Catatonia Rating Scale. We describe and discuss various signs and symptoms of catatonia in detail. Selected references: British Association for Psychopharmacology Guidelines ⁠Rochester Catatonia Assessment Resources⁠ NEJM Review on Catatonia Nature Review on Catatonia Schizophrenia Research Volume on Catatonia Describing the Features of Catatonia (Oldham) Support our partners: SUPPORT OUR PARTNERS: ⁠SimplePractice.com/bootcamp⁠ (Now with AI documentation! Exclusive 7 day free trial and 70% off four months) ⁠Oasis Psychiatry Conferences ⁠(enter code BOOTCAMP at checkout for additional 10% savings) ⁠Beat the Boards⁠ (enter code BOOTCAMP at checkout for addition 10% savings) ⁠CME to Go⁠ (enter code BOOTCAMP at checkout for addition 10% savings) Learn more about your ad choices. Visit megaphone.fm/adchoices