Psychofarm Podcast

Why do so many patients arrive with four, five or six psychiatric diagnoses? Mark Ruffalo, a psychoanalytically trained clinical social worker who teaches psychiatry residents, joins Dr. Malzberg and Dr. Fu to discuss his new paper with psychiatrist Ronald Pies in Psychiatric Services, “The Need for a Validity-Based Diagnostic Hierarchy in DSM-6.” We trace how DSM-III chose reliability over validity, why the Washington University group of Robins and Guze pushed back, and how losing the diagnostic hierarchy opened the door to false comorbidity, polypharmacy and symptom-by-symptom treatment. Mark lays out which conditions sit at the top of a validity-based hierarchy, why ADHD ranks low, how affective temperaments can pass for personality disorders, and what to do when a patient arrives with seven diagnoses: step back and ask what could be driving all of them.


This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit psychofarm.substack.com

You Can See Everything psychological analysis returns in Part 2 as two psychiatrists revisit Elizabeth Holmes, Billy Evans, and Nathan Fielder’s documentary. We examine the scenes that divided viewers, from the Abbott and Costello joke and Holmes’s statements about Theranos to Billy’s egg-mixing, social media posts, and comments about revenge. Along the way, we discuss narcissism, psychopathy, autistic traits, and the difference between personality traits and psychiatric disorders. We also explore why people repeat familiar relationship dynamics and how a film can become a mirror for the audience’s own assumptions. This is a discussion of psychological ideas, not an attempt to diagnose the people on screen.
What we cover
* A caution at the outset about medicalizing behavior that is within the normal range or rationally driven, and why a diagnosis, willful action and moral responsibility are three separate questions.
* The tendency to repeat, discussed as Freud's repetition compulsion (a bid for mastery) and as habit and homeostasis, followed by Eric Berne's transactional analysis and its recurring sequence of roles and payoffs mapped onto the film.
* Overdiagnosis and the case for talking about traits rather than broad labels, using autism as the example, and whether autism could explain the Abbott and Costello joke and the statements about the Theranos machine.
* Telling autism from personality pathology: inability versus lack of interest in others' emotions, and how aggression in each can look alike.
* Ordinary versus clinical narcissism, the psychodynamic idea of narcissistic injury, antisocial personality and psychopathy, and how they overlap with narcissistic structure.
* Scenes involving Billy Evans, including the egg-mixing moment and the power of attorney and social media posts, treated as a projective test that different viewers read differently.
Clinical takeaways
* A trait is not a disorder. One scene on film suggests a trait at most and cannot explain why someone acted as they did. Consider rational explanations, such as seeking sympathy, and ordinary variation before reaching for a diagnosis.
* Keep apart whether behavior is part of a disorder, whether it was willful, and whether the person is responsible. The three questions are separate.
* A very broad label loses meaning: two people with the same autism diagnosis can have completely different lives. One host prefers to describe traits and leave the question of disorder to clinical assessment.
* To separate autism from personality pathology, ask whether the person cannot understand others' emotions or does not care. Aggression in autism often follows poor regulation or changes in routine, though it can look like calculated aggression.
* Clinical narcissistic personality disorder, as the hosts describe it, means rigid defense of a chosen identity that defeats long-term goals, fragility when not admired, and poor attunement to others. Psychopathy often sits on a narcissistic structure.
* Watch your own values. Clinicians can impose them when drawing the line between normal and pathological, people tend to apply personality labels to those they dislike, and seeing someone only as a victim leaves no hope of change.
Read the full transcript
The complete transcript of this episode is on psycho.farm: The Psychology of Elizabeth Holmes in You Can See Everything: Narcissism, Autism, or Manipulation?.
Related episodes
* You Can See Everything Psychological Analysis by Clinical & Forensic Psychiatrists
* The Psychology of Seinfeld: What’s Really Wrong With George, Kramer, Jerry & Elaine?
* Autism Diagnosis Explained: DSM-5 Criteria, Autistic Traits & the Difficult Differential
For education only. Not medical advice.


This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit psychofarm.substack.com

You Can See Everything is one of the strangest films about Elizabeth Holmes yet, and in this episode two psychiatrists try to make sense of it. We explore what Nathan Fielder’s interviews bring out in Holmes and Billy Evans, from unusual facial expressions and her distinctive voice to the couple’s intense descriptions of love. Using psychoanalytic concepts such as narcissism, splitting, borderline personality organization, identity diffusion, and the “as-if personality,” we examine how people construct a sense of self and why someone might defend a version of reality that others find impossible to believe. We also ask what documentaries actually let us know about people, and how much of what we see is our own projection. Spoilers throughout.
What we cover
* How the hosts frame the discussion: independent commentary on public material, speculation rather than diagnosis, the Goldwater rule, and the film as a projective test because it is deliberately ambiguous. The episode contains spoilers.
* Nathan Fielder's interviewing style in the film, with sparing words and expressive silence, as an example of clarification and confrontation, and the defenses people show when avoiding a line of questioning.
* How Elizabeth Holmes appears on screen (restricted emotional reactivity, frequent smiling and nodding, a deep voice), whether it is a persona for the camera, and why any film frame removes context.
* Psychoanalytic ideas used as lenses: the as-if personality, identity diffusion in the DSM-5 alternative model, borderline personality organization versus borderline personality disorder, and splitting, with the hosts differing on how far to go.
* Whether a person can state something false and believe it, the film's structure as a magic trick, and what the film says about being a viewer of a performance.
* How Billy Evans and Holmes describe their love: idealization, fusion between self and other, introjection, and borrowing traits from admired people, set against the hosts' point that these tendencies are universal in milder form.
Clinical takeaways
* Interviewing can be done with few words. Attentive facial expression, silence and well-timed clarifying or confrontational comments can draw material out, and the hosts see the film as usable teaching material for clinicians.
* When a person's micro-expressions do not match the other person's, it may reflect difficulty reading another's emotional state. Many conditions can cause this, so the hosts avoid settling on one explanation.
* Borderline personality organization is broader than borderline personality disorder and can include narcissistic, antisocial and histrionic patterns. Its core features include splitting, identity diffusion, primitive defenses and difficulty integrating good and bad in relationships.
* Emotional development is separate from intellectual development, so someone who functions at a high level can still be emotionally underdeveloped in how they understand themselves and others.
* Idealization, devaluation and taking in traits from others are ordinary human processes. What matters clinically is the degree, and whether the sense of self is stable enough to adopt traits without being replaced by them.
* Be cautious about diagnosing from media. One host calls a diagnosis from public material a bridge too far, and both note that behavior filmed for an audience may differ from private behavior.
Read the full transcript
The complete transcript of this episode is on psycho.farm: You Can See Everything Psychological Analysis by Clinical & Forensic Psychiatrists.
Related episodes
* The Psychology of Elizabeth Holmes in You Can See Everything: Narcissism, Autism, or Manipulation?
* The Psychology of Seinfeld: What’s Really Wrong With George, Kramer, Jerry & Elaine?
* What Psychiatrists Get Wrong About Personality Disorders
For education only. Not medical advice.


This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit psychofarm.substack.com

Antipsychotic medications are not interchangeable, and the tradeoffs between efficacy, metabolic burden, movement side effects, sedation, and adherence can be huge. In this episode, we build an antipsychotic tier list and rank medications including clozapine, olanzapine, haloperidol, risperidone, lurasidone, quetiapine, aripiprazole, and more. Along the way, we connect receptor pharmacology to practical clinical pearls, including food requirements, smoking effects, prolactin, akathisia, EPS, weight gain, long-acting injectables, and clozapine monitoring. We also discuss how medication choice shifts across schizophrenia, bipolar disorder, bipolar depression, and mood symptoms.
What we cover
* The ranking method: efficacy in schizophrenia and bipolar disorder (not as an add-on) weighed against adverse effects, the idea that metabolic burden in a young patient starts a metabolic highway, and how GLP-1 medications and metformin change that calculation.
* Haloperidol in S tier for its low metabolic burden, quetiapine in C tier, and extended-release quetiapine in D tier, with the point that quetiapine acts as a sedative at low doses, a mood agent in the middle and a D2 blocker above 400 mg.
* Clozapine in S tier, olanzapine in A tier and olanzapine-samidorphan in B tier, covering the end of the REMS, restarting titration after a gap of more than 48 hours, bowel care, olanzapine's slow time to peak, and smoking as a CYP1A2 inducer.
* Risperidone and paliperidone with its long-acting injectables in A tier, aripiprazole and cariprazine in B tier, and brexpiprazole in D tier mostly because of cost, including aripiprazole as the most studied add-on in major depression.
* Lurasidone in S tier with its calorie requirement and akathisia risk, then ziprasidone in C tier, asenapine in B tier, lumateperone and xanomeline-trospium in F tier, pimavanserin in D tier, and iloperidone and perospirone as needing more experience.
* The older drugs and add-ons: chlorpromazine in D tier, loxapine and fluphenazine in C tier, perphenazine in B tier, buspirone as a possible add-on in D tier, and adding a mood stabilizer in A tier.
Clinical takeaways
* One host argues haloperidol is underused: dose it like risperidone (most patients respond below 8 mg) and consider it after a couple of failed trials when weight gain and sedation are the worry.
* Clozapine monitoring remains the standard of care even though the REMS is gone, and a gap of more than 48 hours means restarting titration. Ask about smoking and bowel movements.
* Check prolactin early when a patient on risperidone reports menstrual, libido, breast size or milk production changes, and watch for EPS at 4 mg and above.
* Add a mood stabilizer before a second antipsychotic when a schizophrenia spectrum patient shows any mood symptoms: valproate for agitation and impulsivity, lithium or lamotrigine for depression.
* Lurasidone needs about 350 calories with the dose, so it suits steady eaters and is a poor fit when appetite fluctuates with mood or psychosis.
Read the full transcript
The complete transcript of this episode is on psycho.farm: Antipsychotic Tier List: Ranking the Best and Worst Anti-psychotics.
Related episodes
* Choosing Antipsychotics in Schizophrenia: Side-Effects, Maximizing Efficacy, and Finding the Right Medication | Episode 17
* Top 10 Things to Know About Clozapine
* Mood Stabilizers for Bipolar Disorder: Lithium, Lamotrigine, Depakote & More
For education only. Not medical advice.


This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit psychofarm.substack.com

PTSD diagnosis is more complicated than identifying a trauma history. In this episode, we break down what qualifies as Criterion A trauma, the major PTSD symptom clusters, and how intrusion, avoidance, negative beliefs, hyperarousal, and dissociation can show up in practice. We also discuss acute stress disorder, fragmented traumatic memory, and why PTSD can be mistaken for depression, anxiety, mania, concentration problems, or psychosis. Along the way, we focus on careful trauma assessment: establishing a timeline, considering alternative diagnoses, monitoring the patient’s level of distress, and gathering what you need without turning a diagnostic interview into trauma therapy.
What we cover
* Big T versus little t trauma, and why the DSM-5 Criterion A definition (actual or threatened death, serious injury or sexual violence, whether experienced, witnessed, learned about, or met repeatedly through work) is the one that matters clinically.
* Whether Criterion A is an objective or a subjective test, and two unusual cases: a threat experienced through a delusion or hallucination, and PTSD in perpetrators.
* Why most people who go through a Criterion A trauma never develop PTSD, and why, by some research, many who do develop it remit within a year.
* The DSM-5 criteria read in order (intrusion, avoidance, negative changes in mood and beliefs, hyperarousal) as a sequence that explains how PTSD persists.
* Dissociation: what it means, how it fragments traumatic memory, and why patients may not report a trauma even on a formal trauma screen.
* The differential, from depression, mania and anxiety to attention problems and psychosis, plus acute stress disorder in the first month.
Clinical takeaways
* A mental status pearl: patients with PTSD often say they are depressed but look more mood-reactive than someone with a melancholic depression.
* When the history has an unexplained decline, ask what was happening at that time rather than suggesting a trauma. Be careful about trying to uncover memories.
* Check the timeline. Symptoms must begin or worsen after the trauma and last more than a month.
* Not every voice is psychosis. Flashbacks and dissociative experiences can be described as voices.
* In a diagnostic interview, ask for brief facts (what happened and when), watch the patient's distress, and offer breaks. The goal is a diagnosis, not trauma therapy.
* After early trauma, trust has to be earned. A steady frame and an honest explanation of why you are asking help the patient keep going.
Read the full transcript
The complete transcript of this episode is on psycho.farm: Trauma and PTSD: How the DSM Criteria Actually Help Us Understand What’s Going On.
Related episodes
* Understanding Trauma and PTSD, Diagnosis and Dissociation | Episode 21
* PTSD Medications: Integrating Pharmacotherapy, Therapy, and the Treatment Frame | Episode 22
* CPTSD vs BPD: How to Think About the Difference and What to Do About It
For education only. Not medical advice.


This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit psychofarm.substack.com