PsyDactic

Psychoanalysis, Active Inference, Artificial Intelligence, and Human Development with Dr. Grant Brenner

Fri, 08 May 2026 21:00:00 -0400

Dr. Grant Brenner joins Dr. O'Leary to explore the fascinating intersection of human psychology, physics, psychotherapy and artificial intelligence. We discuss Active Inference and The Free Energy Principle along side how babies develop a sense of self and so much more.

Please leave feedback at https://www.psydactic.com or send any comments to feedback@psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

Dissociated Identities (aka Alters) - How are they formed?

Fri, 06 Mar 2026 17:00:00 -0500

Is it possible to house multiple alternate selves within the same brain? Dr. O'Leary argues that it is not only possible, but under certain conditions it is likely to happen. Dissociative Identity Disorder is discussed not as a "shattering of the self," but instead as a failure to integrate the self during development. Dr. O'Leary explores different biologically and computationally plausible models to explain how the self might fail to integrate during the normal process children go through in order to distinguish the self from others and others from others, as they build a (usually) coherent model of themselves.

Dissociation - What is it really?

Tue, 03 Feb 2026 13:00:00 -0500

Dr. O'Leary explores the neuroscience of dissociation, defining it as a degenerate concept that refers to a wide range of functional disconnections within the brain rather than a single clinical entity. The discussion moves from the standard medical definitions—such as depersonalization, derealization, and amnesia—toward a broader view of dissociation as a neurobiological defense mechanism that uses sensory attenuation to manage background noise and overwhelming trauma. By examining how specific regions like the temporal parietal junction and the default mode network integrate our sense of self and environment, Dr. O'Leary compares how disruptions in these areas lead to the fragmented reality experienced in various psychiatric conditions. This discussion aims to shift the listener's perspective of dissociation from a vague symptom to a complex breakdown of mental integration that can be induced by drugs, trauma, or even intentional meditative practices.

Can hooking your head up to a fancy battery (tDCS) cure depression?

Mon, 05 Jan 2026 18:00:00 -0500

In December 2025, the FDA authorized the Flow F100, an innovative at-home wearable headset that utilizes transcranial direct current stimulation (tDCS) to treat major depressive disorder. Unlike traditional pharmaceuticals that act systemically, this device targets the dorsolateral prefrontal cortex with localized electricity to modulate neuronal excitability and address the asymmetry hypothesis of depression. While the Empower study that evaluated this technology demonstrated statistically significant improvements in response and remission rates, the FDA approved it with a moderate level of uncertainty regarding its true efficacy due to a clinically insignificant 2.3-point difference on the average improvement using the Hamilton scale and potential unblinding bias in the trial. By contrasting frequentist and Bayesian statistical frameworks, Dr. O'Leary encourages a skeptical but curious evaluation of whether this technology represents a genuine clinical breakthrough or a temporary trend in the long history of electrotherapy.

Game Theory for Parents and Other Humans with Kevin Zollman

Sun, 28 Dec 2025 15:00:00 -0500

PsyDactic welcomes The Game Theorist's Guide to Parenting co-author, Kevin Zollman who discusses game theory as the science of strategic thinking. We explore how mathematical models like the Prisoner’s Dilemma and mechanism design can be used to manage family dynamics by creating win-win solutions rather than competitive, zero-sum outcomes. The conversation highlights practical techniques such as "I cut, you pick" for fairness, the importance of making credible threats that parents are actually willing to execute, and ways to make honesty more profitable than lying through strategic questioning. While children may be impulsive and at times difficult to predict, applying game theory helps parents influence behavior by understanding their children's incentives and fostering a predictable environment built on reciprocity and trust.

Childhood Deficit Disorder and the Atrophy of American Childhood

Wed, 10 Dec 2025 17:00:00 -0500

Dr. O'Leary proposes Childhood Deficit Disorder as a way to conceptualize the rise in mental health issues among modern youth, exploring how systemic changes in culture and environment contribute. He contrasts the "free-range" parenting style prior to the 1980s, which fostered autonomy and resilience, with the modern trend of intensive, managerial parenting driven by economic anxiety and a "culture of fear" fueled by media. Dr. O'Leary explores how children's independent mobility has plummeted due to these shifts and in response to a built environment hostile to pedestrians, leading to a loss of key socialization spaces. Digital media, including social media, both actively displaced healthy social spaces and filled the void created by anxious, fearful parenting, and poor urban design. Childhood Deficit Disorder (CDD) is a framework—not a clinical diagnosis—to describe the developmental consequences of chronic deprivation of autonomous play, independent movement, and connection to the physical world, often exacerbated by the "digital colonization of childhood."

For references and a more in depth discussion: https://sciencebasedpsych.blogspot.com/2025/12/childhood-deficit-disorder-and-atrophy.html

Clozapine - Beyond the Basics

Thu, 04 Sep 2025 21:00:00 -0400

Dr. O'Leary explores the history of clozapine, highlighting its initial revolutionary impact as the first atypical antipsychotic, followed by a ban on its use, followed by its re-emergences as a strictly monitored medication, and then culminating in new recommendations that greatly encourage its use. The discussion details the severe side effects that led to its initial discontinuation, and then emphasizes other critical but often overlooked adverse effects, such as metabolic syndrome, sialorrhea, and especially severe gastrointestinal hypomotility, which can be life-threatening.

Therapeutic Ultrasound with Dr. Michael Canney PhD

Wed, 11 Jun 2025 14:00:00 -0400

This episode includes a fascinating interview with a researcher in ultrasound, Dr. Michael Canney who is an acoustics researcher the chief scientific officer at a French company named Carthera (https://carthera.eu/) and they make ultrasound devices that can disrupt the blood-brain barrier in order to let medicines into the brain that otherwise could only get through in very small amounts.

We talk more broadly about the explosion of various applications of ultrasound beyond imaging, including things like tissue ablation (or basically cooking highly focussed loci of tissue inside your body), or cavitation (where ultrasound causes tiny bubbles to rapidly expand inside cells or vessels), and I end with a brief discussion of the potential of ultrasound for neuromodulation.

Pediatric Bipolar vs Disruptive Mood Dysregulation Disorder

Fri, 16 May 2025 13:00:00 -0400

This PsyDactic podcast episode, hosted by Dr. O'Leary, delves into the complex and often controversial topic of diagnosing Pediatric Bipolar Disorder and its differentiation from other conditions, particularly Disruptive Mood Dysregulation Disorder (DMDD). Dr. O'Leary, a Child and Adolescent Psychiatry Fellow, explores the DSM-5-TR diagnostic framework, the history of Pediatric Bipolar diagnosis, the debate surrounding irritability as a diagnostic criterion, and the challenges of distinguishing it from ADHD, Autism Spectrum Disorder, and trauma-related disorders. Using case vignettes and drawing on both personal knowledge and AI-assisted research, the episode aims to provide a comprehensive and nuanced understanding of this challenging area of child psychiatry.

Gambling Disorder - Rarely Diagnosed, Highly Prevalent

Thu, 27 Mar 2025 14:00:00 -0400

Gambling disorder may be the most under-diagnosed disorder in the DSM. This is an exhaustive treatment of the neurobiological, psychological, and societal aspects of gambling addiction, featuring discussions on the brain's reward system, cognitive distortions, and the impact of advertising and the design of gambling products.

Functional Neurological Disorder, Predictive Processing and Active Inference

Thu, 20 Mar 2025 12:00:00 -0400

Functional Neurological Disorder was previously called Conversion Disorder or psychogenic neurological symptoms and is a condition in which a patient develops any number of neurological symptoms (such as loss of ability to move or seizure like episodes or inability to feel parts of their body or phantom pain) that cannot be explained by a clear lesion in the nervous system. It was called conversion disorder because it was previously thought that repressed emotions or desires had been converted into neurological symptoms as a defense against those emotions or desires. Therefore, the symptoms were "psychogenic" instead of neurological or biological. Even though emotional states contribute to neurological function, we now know that this model is incorrect. The most compelling new models of functional neurological symptoms come from the theories of the Bayesian brain, predictive processing, and active inference.

Behaviorism Part 1 - Classical Conditioning

Mon, 10 Mar 2025 14:00:00 -0400

Dr. O'Leary introduces PsyDactic - Child and Adolescent Board Study edition by sharing the first of two episodes on behaviorism, that field of psychology that took the radical stance of completely ignoring the fact that we have a mind.

Nicotinic Receptors, Anxiety, and PTSD - an A.I. generated discussion

Sun, 23 Feb 2025 15:00:00 -0500

-- Dr. O'Leary explores how an artificial intelligence tool summarizes recent data on the use of nicotinic receptor modulators for the treatment of anxiety and PTSD. Please send any comments to feedback@psydactic.com.

An extraordinary perspective on Suicide Risk Assessments from Dr. Tyler Black via Psychiatry Boot Camp

Thu, 30 Jan 2025 22:00:00 -0500

"People are 14 times more likely to die during a hospital stay than outside of hospital for inpatient psychiatry." In the last episode, I shared an episode of Psychiatry Boot Camp, which is a podcast created by Dr. Mark Mullen to help medical students and junior residents hone their psychiatric skills. Mark interviews some of the most competent and amazing psychiatrists our country has to offer. I am excited that Mark let me share his interview with Dr. Tyler Black, who talks about evaluating suicidal patients. I have never heard any advice about suicide assessments as insightful and compassionate as what Tyler Black has to offer.

Dr. Mark Mullen interviews Dr. Awais Aftab and Dr. Allen Frances on Psychiatry Boot Camp

Thu, 09 Jan 2025 17:00:00 -0500

In the last episode, Dr. O'Leary interviewed the creator and host of the Psychiatry Bootcamp Podcast, Dr. Mark Mullen, who is currently a psychiatry clerkship director at St. Louis University School of Medicine. He created this podcast after discovering a dearth of resources available for medical students and junior psychiatry residents to prepare them for their transition to practice.

He graciously allowed PsyDactic to include a couple of his episodes in this feed as a way to spread the good news about Psychiatry Boot Camp. This is his introductory episode where he sets the tone of PBC by interviewing Dr. Awais Aftab, Clinical Professor of Psychiatry at Case Western University, and Dr. Allen Frances, Chair of the DSM-4 Task Force and Chair Emeritus at Duke.

Check out Psychiatry Boot Camp!

https://linktr.ee/psychbootcamp

https://pubmed.ncbi.nlm.nih.gov/38724723/

https://podcasts.apple.com/us/podcast/psychiatry-boot-camp/id1671902940

https://open.spotify.com/show/4Vjlz4CO0G5D6nGo74O0jE

https://www.audible.com/podcast/Psychiatry-Boot-Camp/B0BVK4HYLW

https://x.com/markrmullen

Meet the Psychiatry Bootcamp Podcast brought to you by Dr. Mark Mullen

Thu, 09 Jan 2025 15:00:00 -0500

Dr. O'Leary is excited to introduce you to Psychiatry Boot Camp (PBC), a podcast created by Dr. Mark Mullen during his psychiatry residency to help prepare medical students for psychiatry residency. It covers fundamental topics in psychiatry and inspires young psychiatrists to think critically about their approach to the field. The curriculum is based on published literature on psychiatry crash courses and boot camps, and features interviews with experts in the field. Some specific PBC episodes that are discussed include those introducing students to psychiatry as a discipline with unique challenges, including interviews with Dr. Awais Aftab, Clinical Professor of Psychiatry at Case Western University, and Dr. Allen Frances, Chair of the DSM-4 Task Force and Chair Emeritus at Duke. We also discuss Dr. Mullen's eye-opening interview with Dr. Tyler Black, a suicidologist and child psychiatrist at British Columbia Children's Hospital who provides the best foundational discussion of the suicide assessment that Dr. O'Leary has ever encountered.

Enjoy this interview and afterward, please check out Psychiatry Boot Camp.

https://pubmed.ncbi.nlm.nih.gov/38724723/

https://podcasts.apple.com/us/podcast/psychiatry-boot-camp/id1671902940

https://open.spotify.com/show/4Vjlz4CO0G5D6nGo74O0jE

https://www.audible.com/podcast/Psychiatry-Boot-Camp/B0BVK4HYLW

https://x.com/markrmullen

In a Word - Agonist

Fri, 27 Dec 2024 12:00:00 -0500

--In today's episode, Dr. O'Leary explores agonists, inverse agonists, partial agonists, and antagonists. These terms describe how molecules bind to receptors and either increase, decrease, or prevent changes in receptor signaling. Agonists increase receptor activity, with full agonists like dopamine and serotonin raising activity to its maximum. Partial agonists can increase activity in the absence of full agonists but decrease it in their presence. Inverse agonists reduce the baseline activity of receptors. Antagonists block receptor activity without changing the baseline rate. We also discussed the complex interactions between these molecules and how their effects can vary depending on the presence of other molecules and the specific receptors involved.

Below are a couple of helpful references:

https://pmc.ncbi.nlm.nih.gov/articles/PMC2804881/

https://link.springer.com/article/10.2165/00023210-199605050-00007

In a Word - Transference (with a dash of neuroscience)

Sat, 17 Aug 2024 21:00:00 -0400

--Dr. O'Leary discusses the term Transference, and if you listen until the end, he relates it to some computational neuroscience. Transference is a historically loaded term. Transference is supposed to be an unconscious process, so it can not really be observed, only inferred, so this means that both the definition of transference and any instance of it in psychotherapy is dependent upon the therapist’s model and their particular way of interpreting that model. But what exactly is this elusive but data rich unconscious process?

Catatonia in Autism and Neuroatypical Patients - Easy to miss, Harder to Treat

Sat, 10 Aug 2024 21:00:00 -0400

-- More recently I have faced the diagnostic conundrum of catatonia in autism, and that is what I want to explore in more excruciating detail today. There is surprisingly little literature on the subject, and that is concerning because being able to identify and treat catatonia can be life-saving, not to mention life-altering for patients and their caretakers. Misidentifying catatonia as mere aggression or highly limited interests in autism can result in exactly the wrong medication being given or no medication being given and a worsening of the condition. --

Mindhunting with Forensic Psychiatrist Dr Michael Schirripa

Mon, 22 Jul 2024 21:00:00 -0400

-- Dr. O’Leary interviews forensic psychiatrist and author Dr. Michael Schirripa about his career as a forensic psychiatrist, the release of his first thriller, Mindhunt, and his podcast Mindhunting. Dr. Shirripa explores how his love of literature influenced his decision to pursue forensic psychiatry and ultimately resulted in his creation of an international thriller with an ambitious forensic psychiatrist as the main character. We explore topics like medical ethics, medical education, popular culture, mental health stigma, Australian football, and how people react when we tell them we are psychiatrists. Learn more about Michael at https://michaelschirripa.com/.

Psychedelics - A skeptical approach to MDMA aka Ecstasy

Thu, 11 Jul 2024 20:00:00 -0400

- - In the world of psychotropic medication, the question is not just whether it works or not, but whether it works better than a placebo and whether the effect size is clinically significant and the benefits outweigh the risks. In the case of MDMA (aka molly or ecstasy), the effect size for improving post-traumatic stress disorder symptoms reported by researchers has been very large. Often it is found to be two to three times higher than is often found for serotonin reuptake inhibitors, which are currently the first line therapy for PTSD. On the surface this is super exciting. A deeper look will reveal why excitement may need to be tempered, and why an independent panel recommended that the FDA not approve this medication.

The Narrative Fallacy in Psychological and Psychiatric Clinical Practice with Dr. Alexey Tolchinsky, PsyD

Sun, 30 Jun 2024 20:00:00 -0400

The Narrative Fallacy describes our tendency to find meaning, connections, and causal relationships where they do not necessarily exist. In this episode, Dr. O'Leary had the pleasure of interviewing Dr. Alexey Tolchinsky.

He recently published a paper called “Narrative fallacy and other limitations of psychodynamic case formulation.” Dr. Tolchenski did not invent the idea of the Narrative Fallacy, but he is working to apply this idea to his own clinical practice. We could all benefit from recognizing the ways that Narrative Fallacy plays out in our lives. The great thing about these ideas is that they are so generalizable. The Narrative fallacy is not limited to medicine or science, but can be applied, for example in how we explain to ourselves why our neighbor seems to hate us.

Tolchinsky, A. (2023). Narrative fallacy and other limitations of psychodynamic case formulation. Practice Innovations.

https://osf.io/preprints/psyarxiv/znxs5

Psychometrics - The Dangers of Rating Scales and Screeners

Wed, 26 Jun 2024 18:00:00 -0400

Dr. O'Leary discusses a variety of concerns that all clinicians should have in mind when using psychometrics. In the end, he hopes you come away with some level of agreement with the statement: “Our primary concern should not be with the quantity of data, but with the quality of the data.” Statistics are conceptual machines that will produce results no matter what you feed them. These results can be truly helpful and informative. But statistics are also poop in poop out machines, and adding more malarky does not magically convert the results into something other than BS.

In a Word - Aphasia

Sun, 09 Jun 2024 09:00:00 -0400

In this episode, Dr. O'Leary discusses a word that he has struggled to understand since medical school. The word is aphasia. The root “phasia” comes from the Greek phanai which means “to speak.” When aphasia is used medically, it refers to an inability to speak, although not always. More generally it is often used to mean a failure to understand or produce language, but it gets complicated. Dr. O'Leary reviews the brain regions responsible for various kinds of aphasia and how to identity them.

WTF Cerebellum - Little Brain, Big Deal

Fri, 03 May 2024 22:00:00 -0400

I did not until recently even consider the cerebellum when thinking about psychiatric conditions, but the more I read, the more I wonder why the cerebellum is not considered a potential important player in nearly every psychiatric disorder. Although it can be said that all brain regions primarily function to make predictions, the cerebellum is especially active at refining impromptu predictions through short periods of time as sensory data changes to help us better navigate the world, not only in physical space, but our entire internal space.

WTF - Thalamus

Wed, 24 Apr 2024 16:00:00 -0400

The thalami are bilaterally symmetrical structures in the subcortical part of the brain that are cradled by the basal ganglia. They are major hubs of pretty much everything your brain does and all of the sensory information coming into the brain with the exception of smell.

More primitive models of the brain visualized it as a bunch of relatively isolated modules, each specialized to perform a single task when queried and able to send that information to wherever it should go. More modern ideas propose a more integrated picture, with various regions of the brain contributing to a more diffuse process through parallel connections with other network communities and hubs. It appears that nearly every integrated process in the brain is influenced at some level by thalamic modulation. You could characterize the Thalamus as a brain wide gateway to the cortex, modulator and mediator of inputs, coordinator of feedback, relay between higher cognitive areas, manager of brainstem nuclei, and facilitator of attention.

Seroquel (Quetiapine) - Drugs, Sex, Money and Psychopharm

Thu, 11 Apr 2024 23:00:00 -0400

In this episode, I discuss a medication that patients who saw a psychiatrist or their primary care provider between about 1997 and 2015 were very likely to find themselves prescribed. More recently, it has been taken down a notch or two on prescribers lists of preferred meds. This medication is quetiapine, marketed as Seroquel by AstraZeneca in the US. Whether you were diagnosed with schizophrenia, bipolar disorder, depression, anxiety, an eating disorder, insomnia, PTSD, borderline personality disorder, obsessive compulsive disorder, and many others it appeared in the mid 2000s that Quetiapine was just the thing for you. Was it ever?

In a Word - Confabulation

Wed, 20 Mar 2024 15:00:00 -0400

This episode continues an intermittent series called “In a Word.” Past episodes have explored words like Akathisia, Dissociation, Perseveration, and even the difference between Impulsive and Compulsive. This episode explores Confabulation, including some of the brain circuits involved, and what might differentiate confabulation from other kinds of false or implanted memories or delusions.

How guilty are adolescents for their crimes?

Sun, 03 Mar 2024 00:00:00 -0500

In 2012 the Supreme Court heard two related cases involving adolescents convicted of murder and sentenced to life in prison without parole because of mandatory minimum sentencing guidelines in their states. One of the boys, Evan Miller along with an accomplice, had beat a man unconscious with a baseball bat after a fight that ensued when the man awoke to find Miller robbing him. Miller and his friend then decided to set fire to the home to cover up the evidence. This resulted in the man’s death. The second petitioner, Kuntrell Jackson, had accompanied two other boys to a convenience store in order to rob it. During the robbery, one of the boys, not Jackson, shot and killed the clerk.

Both boys were convicted and were sentenced according to minimum sentencing guidelines to life in prison without parole. The decision that the court was asked to make was not whether the boys should have been convicted, but instead, whether the sentencing guidelines that resulted in them being given life without parole constituted cruel and unusual punishment.

Serious Mental Illness in America with Dr. Zac Brooks

Fri, 16 Feb 2024 01:00:00 -0500

I am lucky today to be able to bring you an interview with Dr. Zac Brooks who is passionate about serious mental illness (SMI). “What is serious mental illness?” you might ask. That is one of the things we are going to discuss, and you may be surprised when Dr. Brooks explains how it was first formally defined. We also discuss the numerous ways the US has tried to reform how SMI is treated with variable results.

HIV, PrEP, and Mental Health with Dr. Jon Lindefjeld

Fri, 09 Feb 2024 01:00:00 -0500

PsyDactic welcomes Dr. Jon Lindefjeld for a discussion of the history of HIV and AIDS. In particular, we discuss the development of effective antiretroviral therapies, including pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP), highlighting the CDC guidelines for use and monitoring, need to treat psychiatric com-morbidities, and the importance of monitoring adherence and drug interactions.

Perspectives on the Borderline: The Most Disordered Personality

Fri, 02 Feb 2024 01:00:00 -0500

Dr. O'Leary discusses some of the history of the borderline personality, how different perspectives have attempted to explain its origin, how to treat it and how not to treat it. He starts in 1947 with some colorful descriptions of patients living with borderline personality disorder that would never get published today, and highlights some of the ways in which we have made progress (or not made progress) in our understanding of this disorder over the next 75 years. As usual, Dr. O'Leary also waxes philosophical about science or the lack thereof in certain perspectives or treatments.

The Ghost of Personality Disorders Future

Fri, 26 Jan 2024 12:00:00 -0500

Our current diagnostic criteria for personality disorders have failed to demonstrate validity or reliability. The DSM 5 encouraged psychiatrists to start considering a broad range of personality features adapted from the Five Factor Model. These are combined with global functioning measures to build a personality inventory for any patient who is having dysfunction related to their personality. Proposed criteria include a Personality Disorder - Trait Specified diagnostic category that permits diagnosticians to accommodate the new formulation. Criterion A considers the salient aspects of personality functioning while Criterion B catalogs which of the Big 5 Factors are notably deranged. Dr. O'Leary reviews the basics of these criteria and explores why our current formulations are in such dire need of reform.

Tattoos, Stigma, Racists, and Psychiatry

Mon, 22 Jan 2024 15:00:00 -0500

Humans have a history of tattooing that stretches millennia into prehistory. The western ban on tattoos by the early church resulted in a systematic effort to paint tattooed individuals as pagan, primitive, vulgar, criminal, and mentally ill. Psychiatrists have historically contributed to this characterization but are in a position to help reframe how citizens and policymakers view tattooed individuals.

Attractor Networks and the Bayesian Brain

Tue, 16 Jan 2024 17:00:00 -0500

The brain understands the world by building models that predict the future. One of the ways that it does this is by utilizing attractor networks. These small world networks are constantly trying to determine what is a true signal from the constant noise in the neural net. Dr. O'Leary explores how attractor networks have been hypothesized to explain psychosis, depression, and obsessive compulsive disorder, and how our various treatments might work to stabilize these networks.

Serotonin - Jack of All Trades, Master of None

Sat, 30 Dec 2023 19:00:00 -0500

When I started to make this episode, I thought I would try to do a comprehensive review of all of the various functions of serotonin across its 15 or more receptor types, but I soon found myself overwhelmed. More importantly, I found that some stories are more interesting to tell than others, so here I discuss serotonin and focus on how a few 5-HT receptors can not only help us survive, but also motivate ourselves to reach our goals, and, sometimes, convince us that we are fusing bodies with a tree.

Antipsychotics and their discontents

Fri, 15 Dec 2023 16:00:00 -0500

Frequently I have complained that the terms "typical and atypical" or "first generation and second generation" antipsychotics were not very helpful. When I give chalk talks to junior residents and interns about antipsychotics, this is one of the first things that I note. It is the medicines relative affinities for different receptors that appear to make the difference, not whether they were discovered prior to 1980 or not. A few weeks ago, I was lucky enough to encounter a paper that was published in April of 2023 by McCutcheon et al in Biological Psychiatry titled "Data-Driven Taxonomy for Antipsychotic Medication: A New Classification System." In this episode, I use their results to guide a discussion of variability in target effects and side effects of different groups of antipsychotics.

Extrapyramidal Side Effects and Tardive Dyskinesia for Super Nerds

Wed, 13 Dec 2023 19:00:00 -0500

This episode explores side effects of antipsychotics at the molecular level. It starts by exploring receptors and their ligands and takes a turn into the dorsal striatum where dopamine, acetylcholine, serotonin, and glutamate work together to help us dance the mamba. Dr. O'Leary explores what happens when the complex pathways of the cortico-striatal-thalamo-cortical tract are disrupted by antipsychotics both in the short term and after many months or years of use. As the title suggests, there is a ridiculous amount of detail, so let's get our nerd on!

The STAR*D Trial: Scientifically Flawed or Scientific Fraud?

Sun, 10 Dec 2023 20:00:00 -0500

The authors of the famous sequenced treatment alternatives to relieve depression trial or STAR*D reported that about two-thirds or 67% of patients had achieved remission after 4 trials of antidepressant medication. This remission rate has been questioned over the years and in October of 2023, the journal BMJ Open published an article that reports to have reanalyzed the date from STAR*D using the original study design. This re-analysis found much much lower rates of remission. It reported the cumulative remission rate as only 35 percent. How do two different sets of researchers using the same data set get a result that is just half of what the other researchers reported? That is the mystery that I report on today.

Dopamine Networks and Psychosis

Sun, 03 Dec 2023 13:00:00 -0500

This episode is about dopamine. In episode 32, I discussed the pseudoscientific trend of the “dopamine detox” or "dopamine fasting." Instead of talking about pseudoscience in this episode, I discuss the actual science surrounding dopamine and its relationship with the neuroleptics or antipsychotics as they are more commonly known. The effects and side effects of antipsychotics are related to the function of the major dopamine networks of the brain: the mesolimbic, mesocortical, nigrostriatal, and tuberoinfundibular pathways. Dopamine levels in each of these pathways can be regulated also by serotonin receptors, and so this episode contains a discussion of how first generation, second generation, and novel antipsychotics affect dopamine by affecting serotonin receptors.

In a Word - Impulsive vs Compulsive

Sat, 11 Nov 2023 15:00:00 -0500

In this Episode, I continue an intermittent series called “In A Word.” The difference between prior episodes and this one is that today I have two words. I chose these words because I don’t really know the difference between them, and even after reading and trying to understand the difference, I am not sure that there is a clear difference. The two words are Impulsive and Compulsive.

Traumatic Brain Injury - How Severe Was It?

Tue, 17 Oct 2023 20:00:00 -0400

I discuss something that is likely to present itself to a physician long after the fact: a single mild brain injury. This episode focuses on how to classify the severity of a single brain injury. While working in a brain injury unit, I noticed that some providers used the term severe brain injury when referring patients to neurology or neuropsychiatry, and this communicates something very specific that they may not realize they are communicating. Those of us seeing a patient after a brain injury may not know the specific terminology to use, so this episode is meant to help the listener understand how brain injury experts classify these injuries.

The Medial Prefrontal Cortex

Mon, 07 Aug 2023 18:00:00 -0400

This episode continues a series on the prefrontal cortex, a complex region of the brain that gives us the ability to have the kinds of thoughts no other species on earth is known to have. The medial (or mesial) prefrontal cortex is especially important for emotional and autonomic regulation, attention and goal-directed behaviors (including addiction), and building our sense of self (that is our identity as a thing separate from the world around us), and considering salient aspects of the social context we are in and what others might be thinking (among many other things).

The Orbitofrontal Cortex - Our built-in Economist

Tue, 18 Jul 2023 14:00:00 -0400

In this episode, I am sliding down and under the front part of the brain and consider the orbital frontal cortex, that part of the brain right above and a little behind your eyes. It is much smaller than the lateral gyri on the prefrontal cortex, but appears to be an important probability generator in our brain when we need to consider different options that can result in different rewards or in order to avoid aversive stimuli. The most basic kinds of rewards that neuroscientists can study are for food, because lab animals will respond to those, and while the OFC is definitely intimately related to food, in humans, its powers of prognostication are much more generalized.

The Dorsolateral Prefrontal Cortex - Our Executor and Speech Writer

Sun, 16 Jul 2023 21:00:00 -0400

We seem to understand the specializations of the the dorsolateral prefrontal cortex on the left better than the right side of our brain. That is because most of us do a lot more language processing on the left or dominant side. The more inferior and caudal parts of the dorsolateral PFC on the left side are more specialized for speech. The more superior parts are more involved in working memory, attention control, and task switching. The entire DLPFC is extensively connected to other cortical regions that pass information to it for consideration, and the DLPFC is extensively connected to the supplementary and motor regions that help to plan actions, and the striatum, which helps coordinate those actions. It is also intimately involved with motivation and helps us to control our emotions.

The Prefrontal Cortex - An Introduction to What Makes Us Human

Fri, 14 Jul 2023 17:00:00 -0400

Besides being relatively hairless apes, there are some things about humans that make us special among animals. In the past we have noted things like, “We have big brains and we use tools,” or “We contemplate the future and our own mortality,” or “We use a truly complex language both verbal and written to communicate complex ideas.” These are things we have and do, but what is it about our brains that makes that possible. More and more we are identifying crucial hubs or nodes within our brain that specialize in various tasks, but none of these work alone. I am going to start by discussing that big blob of gooey mush on the front of our brains called the prefrontal cortex, and in subsequent episodes, I will discuss how these regions function in tandem with deeper structures within the brain to create what we think of when we say “human.”

Psychological versus Neuropsychological Testing

Tue, 11 Jul 2023 22:00:00 -0400

This episode is about how to decide whether to send a patient to get neuropsychological or just psychological testing, and this decision is determined by at least two things. The first is the question that you are trying to answer. The second is, what can the service that I am referring to provide for the patient? In this episode, I will focus primarily on the first consideration: the question that you are asking. As a referring provider, then, it is helpful to know what kinds of tests a psychologist or neuropsychologist can administer, because these are designed to answer very specific questions.

In a Word - Validity

Tue, 11 Jul 2023 00:00:00 -0400

Today I discuss the term “validity.” Let’s say we wanted to develop a test that identifies pathological character traits or quantifies depression symptom burden on a patient. A good test is going to do more than simply list the diagnostic criteria for various diagnoses and then ask the patient if they think that sounds like them. A test needs to have a few things. First it needs to have a defined purpose. Is it to be used for diagnosis in a clinic or for research? Is it going to measure symptoms in already diagnosed patients and track their response to therapy? Is it meant to predict if a person would be a good candidate for something like being an astronaut or a member of the military? Once the purpose is determined, then you need to define something called a construct, and then you have to determine the validity of that construct.

Guns - Starting the Conversation

Wed, 07 Jun 2023 22:00:00 -0400

Today I talk about guns. More specifically, I talk about talking about guns.

In a Word - Akathisia

Tue, 16 May 2023 23:00:00 -0400

Today I am continuing an intermittent series called, “In a Word,” and the word that I chose for today is akathisia. Akathisia is broadly defined as an inability to remain still. If you ask someone with Akathisia to stop moving, they will likely become very uncomfortable, but while they are moving, they experience at least some relief.

Dopamine Detox and Pseudoscience

Wed, 03 May 2023 21:00:00 -0400

There is a narrative wave in popular psychology and neuroscience that has taken a small amount of very basic science and twisted it into a fantastic narrative of feast and famine. Its central character is dopamine. The Dopamine Detox also known as dopamine fasting is a pseudoscientific treatment that at best illustrates how magnificently strange and evidence-less some claims about dopamine can be.

Artificial Intelligence and Psychiatry

Wed, 12 Apr 2023 22:00:00 -0400

I have recently added some artificial intelligence produced answers to psychiatry questions in my past episodes in an effort to try to understand what it is that AI text generators can do and what value they might add to my future as a psychiatrist versus what problems it might introduce into my practice. I realized that since I have opened this pandora's box, I need to provide some more context.

What is a placebo?

Mon, 13 Mar 2023 19:00:00 -0400

What is a placebo? You may already be thinking something like: A placebo is an imitation, fake, sham, decoy, or trick treatment that we give to people in studies to see if the treatment under investigation is any better or worse. Placebos are supposed to be both benign and inert, meaning they should neither harm nor help a patient beyond the patient feeling or reporting that they are better or worse after they received some kind of treatment. It seems strange that there is something that can take innumerable forms and still seems to work at least a little bit on so many different things. Placebos are like an all-powerful potion or magic spell. For some treatments, even active treatments, placebo effects account for the vast majority of the effect size and it is not just an illusion.

In a Word - Dissociation

Sun, 26 Feb 2023 18:00:00 -0500

This episode is the second in an intermittent series I am calling In A Word. Psychiatry is full of terms that are either poorly defined or used in such broad ways that they are not very helpful by themselves. Trying to come to terms with terms we throw around can help us to understand the conditions we treat better, and hopefully will help us to communicate more precisely and effectively in the future. Dissociation is a word that has frustrated me. I have heard it used to describe everything from daydreaming to a feeling of complete detachment of someone from their own body to having lost a previous identity and adopted a new one. The term is used to describe various aspects of many psychiatric disorders. It is prominently featured in disorders like borderline personality disorder and post-traumatic stress disorder. There is even a controversial diagnosis called Dissociative Identity Disorder.

At the end, I give ChatGPT another go.

Adult ADHD and Bayesian Reasoning

Fri, 13 Jan 2023 17:00:00 -0500

Bayesian reasoning is likely operating in your mind whether you realize it or not, whether you can do the math or not. In this episode, Dr. O'Leary explores how to explicitly use Bayesian reasoning to put actual numbers to our inherent biases. Attention Deficit Hyperactivity Disorder (ADHD) seems like a good place to start.

Artificial Challenges for Physician Mental Health

Wed, 04 Jan 2023 18:00:00 -0500

Society is in upheaval in the way that it discusses mental health. There are many loud voices out there. Some of these advocate for more openness and less stigma with regard to how we treat people with behavioral and psychological disorders, and by "treat," I don’t mean with drugs or therapy, but with our words, actions, policies, laws, and inaction. One example of these voices is Dr. Jake Goodman who posed with a pill on his tongue in a TIC TOC post to demonstrate that even as a physician, he may also need medication assistance for his mental health. The outpouring of support, vitriol and shenanigans that resulted demonstrates how divided our society is on this issue, and in many ways how unrealistic our view of doctors and of mental illness is.

Neuropsychiatry - Huntington Disease

Sat, 03 Dec 2022 12:00:00 -0500

Dr. O'Leary reviews one of the most frustrating diseases that a patient and their family might approach a psychiatrist with: Huntington’s Disease. Huntington’s Disease is a neurodegenerative disorder, which means that over the course of the disease neurons die or cease to function correctly and this worsens over time. The death of neurons in the caudate nucleus and putamen results in choreiform or dance-like movements of the extremities which earned it the moniker “Huntington’s Chorea." Huntington's Disease can result in many psychiatric symptoms and these may start to occur during the prodromal stage before the choreiform movements develop. Sleep disturbances, apathy, executive dysfunction, memory impairment, personality change, irritability and aggression, disinhibition and impulsivity (including hyper-sexuality), depression, mania, delusions, paranoia and other psychotic symptoms, obsessions and compulsions, and most prominently a high risk of suicide.

Neuronal Networks: Depression

Wed, 02 Nov 2022 23:00:00 -0400

It is unlikely that any model of major depressive disorder is likely to find universal signals among those diagnosed because the symptoms are so diverse. However, it does seem likely that models, such as brain-network models, will be able to identify common dysfunctions among those with similar symptom burdens (for example, those with primarily anhedonic symptoms, dysphoria, or with excessive rumination over their own worthlessness), and then help identify how various modalities may be more or less effective to treat these symptoms specifically.

Treating Bipolar Depression with Dr. Tom DePietro

Sun, 23 Oct 2022 16:00:00 -0400

Bipolar disorder is a complex, often debilitating and potentially life threatening illness in which the patient goes from episodes of depression to episodes of mania or hypomania, most often with periods of relative euthymia in between these episodes. The most common way to conceptualize the treatment of bipolar disorder is by phase. The ideal goal would be preventing the distinct manic and depressive episodes. This is done mostly with medications although psychotherapy, lifestyle modifications and even neuromodulation potentially have a role. A particularly difficult aspect of bipolar disorder is treating the acute phase of bipolar depression. Each is treated mostly with psychotropic medication. In this Episode, Dr. DePietro will focus on treating acute bipolar depression.

Neuronal Networks: The Central Executive Network... and some philosophy

Tue, 04 Oct 2022 21:00:00 -0400

In previous episodes I have tried to draw pictures in your mind (using those fat crayons that babies like to chew on) of some of the brain networks that are important in many mental illnesses. We have talked specifically about the Default Mode Network (that is concerned with imaginal thoughts and self-referential thoughts and memories), the Dorsal and Ventral Attention Networks (that help us to identify and pick out details of both our environment and our thoughts and memories), and the Salience Network (that brings the most important details of our perceptions, thoughts, and memories to the forefront of our mind). What we are missing is a network that takes those salient things, considers alternative options about what they mean and what to do about them, organizes a plan to execute, and motivates us to move. Our Central Executive Network and its connections to the other networks are integral in these processes.

Neuronal Networks: The Salience Network

Sat, 10 Sep 2022 18:00:00 -0400

What is salience? Fundamentally it is a value judgment that determines where your brain will place its limited resources. There are a lot of things that could draw our attention. The world is full of sights, sounds, smells, pressures, temperatures, stretches. Our mind is full of thoughts. Without a salience network, we wouldn’t know what matters and what doesn’t. We would just randomly scan our thoughts and the environment and hope what we are noticing at any point in time is what will help keep us alive. That is a losing evolutionary strategy.

Neuronal Networks: The Attention Networks

Wed, 24 Aug 2022 18:00:00 -0400

Today, I am going to explore the Attention Networks, which are the parts of our brain that get really excited when, for example, we see something that we have never seen before, something that appears to be moving on its own volition (and might harm us), something that appears out of place (like an eyeball on the floor), or something that reminds us of something we really want (I’ll let you pick the example).

Neuronal Networks: The Default Mode Network

Tue, 09 Aug 2022 22:00:00 -0400

Behaviors are complex. We have networks of neurons functioning in systems, some of which ramp other systems up, and some of which dampen others down. This ballet of correlation (when increased activity in one network predicts increased activity in another) and anticorrelation (when increased activity in one network predicts decreased activity in another) can help us to understand what is going on in the brains of humans who qualify for psychiatric diagnoses, and can help us to develop better targeted treatments that will predictably increase activity in select areas of the brain. Today I discuss a single networking hub in the brain: the default mode network.

The Noradrenergic Paradox

Thu, 28 Jul 2022 20:00:00 -0400

One of the most influential models in psychiatry’s history for understanding brain dysfunction is the monoamine hypothesis. In short, it proposes that deficiencies or excess of certain neuromodulating agents, in particular the monoamines serotonin, dopamine, and norepinephrine (AKA noradrenaline) drive many psychiatric disorders. The paper I will primarily reference is a publication by the same name in 2016 by Montoya, Bruins, Katzman, and Blier in Neuropsychiatric Disease and Treatment. Its basic proposal is that, at the time of publication, there were at least 52 controlled clinical trials published that consistently showed a benefit of using SNRIs (like venlafaxine and duloxetine) and NERIs (like atomoxetine and reboxitine) for reducing anxiety in patients without the expected side effect of noradrenergic agents: to increase anxiety. This is a paradox.

Gender Language and the DSM 5-TR

Fri, 24 Jun 2022 20:00:00 -0400

This is an episode to report updates in the DSM 5-TR that can be practice changing. I will also divulge a little about myself and how my philosophy and values have changed. In particular, I am reminded of how I have struggled to understand transgendered and other gendered individuals.

Bush Francis versus the DSM

Tue, 14 Jun 2022 18:00:00 -0400

I originally promised a review of the Bush Francis Catatonia Rating Scale, but while reviewing it, I came across some questions that I think are even more interesting. I will discuss Bush Francis, but I want to do it in a larger context of the challenges that Psychiatrists face with diagnosis in general.

Catatonic Signs - Echolalia, Echopraxia, and Agitation

Sat, 21 May 2022 14:00:00 -0400

Dr. O discusses the remaining hyperactive or “excited” signs of catatonia including echolalia, echopraxia, and agitation. In previous episodes, Dr. O discussed other hyperactive or “excited” signs, including mannerisms and stereotypy. All of these signs share the common feature that the patient is doing something odd, repetitive, or unexpected. Dr. O also gets on his soap box about the arbitrary use of the term agitation to describe patients.

Catatonic Signs - Catalepsy, Postering, Grimacing and Waxy Flexibility

Fri, 13 May 2022 23:00:00 -0400

In this episode, I discuss Catalepsy, Postering, Grimacing and Waxy Flexibility. I grouped the diagnostic signs that I am going to cover today because they are all similar. Your patient acts like a wax statue.

Catatonic Signs - Stupor, Mutism, and Negativism

Wed, 06 Apr 2022 20:00:00 -0400

Stupor, Mutism, and Negativism on the surface appear to have some overlapping features. Of all the features of catatonia that non-experts might be able to describe, stupor and mutism are like the ones. They are also the most common signs. A patient is not entirely unconscious, but they don’t move, they stare forward, they don’t talk, and they don’t follow commands.

Catatonic Signs - Stereotypy and Mannerisms

Fri, 25 Mar 2022 21:00:00 -0400

In the last episode, I promised [or threatened] to get into more of the nitty-gritty of the symptoms of catatonia. Well, like it or not, that is what I am going to do in this episode. Today I will focus on Mannerisms and Stereotypy, two of the potential signs of catatonia.

Catatonia - Introduction and Overview

Sun, 06 Mar 2022 12:00:00 -0500

In this episode, I introduce a diagnosis that is not a diagnosis. By that, I mean that it is a condition that we may find our patients in, but it is not considered to be a diagnosis by itself, like major depressive disorder or schizophrenia are considered to be diagnoses. I am talking about catatonia, a condition characterized by either a lack of interaction with the world or as purposeless interaction with the world.

In a Word - Perseveration

Sat, 26 Feb 2022 02:00:00 -0500

This episode is a quick take in a new intermittent series I am calling “In a Word,” and in this series I hope to dig down into some neuropsychiatric terms that we use every day, but maybe don’t really understand very well. The first word I am taking on is PERSEVERATION. The reason I chose PERSEVERATION is because I see it written in psych notes by med studs and residents frequently, but for you Princess Bride fans out there, “You keep using this word. I don’t not think it means what you think it means.”

Those other obsessive and compulsive disorders

Sat, 19 Feb 2022 02:00:00 -0500

My last three episodes focussed on classical cases of Obsessive Compulsive Disorder, but the DSM 5 has included a few other related diagnoses in the same chapter including body dysmorphic disorder (BDD), hoarding disorder, trichotillomania, and excoriation disorder. Each of these have distinct obsessional components and compulsions, age of onset, degree of insight, and chronic course. Hence, they get their own diagnostic category.

OCD - Treatments

Sat, 12 Feb 2022 12:00:00 -0500

I briefly explore how to treat patients with OCD. Choosing first-line treatment is relatively straight-forward, but there is less clarity on how to proceed if my patient does not respond. It is imperative, then, to make sure that I understand my patient’s symptoms and their goals very well.

OCD - Brain space

Sat, 29 Jan 2022 02:00:00 -0500

This episode explores the brain space of obsessive compulsive disorder (OCD) with a creative journey through neuroanatomy and brain circuitry. I try to make it much less boring than it sounds. After listening to this episode, it is my goal that the listener will understand the complex interactions of the cortico-striatal-thalamo-cortical (CSTC) circuit and have a fuller appreciating of how the brain decides what to do and how to do it.

OCD - A brief history

Sat, 22 Jan 2022 02:00:00 -0500

In previous episodes, I’ve hacked a path through Electroconvulsive Therapy and Transcranial Magnetic Stimulation, trying to reveal some of the secrets in those jungles. Now I am turning my machete to a different landscape: Obsessive Compulsive Disorder or OCD for short. The name is confusing, because the writers of the DSM decided to name a personality disorder Obsessive Compulsive Personality Disorder or OCPD, but this podcast is not about a personality disorder. It is about a neuropsychiatric disorder. I’m going to try to wrap our collective heads around the concept of the OCD itself. And for that, we’ll need a little history lesson which starts by asking the question: What’s in a name?

TMS - Intermittent Theta Bursts and the SAINT Trial

Sat, 15 Jan 2022 06:00:00 -0500

This episode is dedicated to all the med studs and residents who cringe every time they have to go to journal club. I report the results of an initial trial of a special kind of Transcranial Magnetic Stimulation of the brain that might be the future of depression treatment, at least for the treatment resistant or severe varieties. I also use this as an opportunity to explain a little more about how repetitive TMS is usually performed (that is, its current FDA approved form), killing two dinosaurs with one asteroid.

TMS - A brief history

Sat, 08 Jan 2022 06:00:00 -0500

I wanted to do this episode, because when I did my episodes on electroconvulsive therapy (or ECT), I feel like I sounded a tiddly-bit dismissive of it, and I wanted to clarify what I meant when I said, “TMS, short for Transcranial Magnetic Stimulation of the Brain, as of yet is not nearly as efficacious as ECT.” If you haven’t listened to the ECT episodes, you should still be able to follow this discussion, so don’t feel left out. I give a history of TMS development, discuss some of its approved indications, and outline three important ways that TMS is not as effective as ECT. I also mention some promising evidence that TMS is gaining rapidly in at least two of these ways.

ECT Indications, Contra-indications, Patient Evaluation and Consent

Sun, 02 Jan 2022 11:00:00 -0500

In the last episode, I gave a brief discussion about how electroconvulsive therapy (ECT) works by causing convulsive seizures and discussed some of the proposed mechanisms by which seizures might result in benefit. In this episode, I discuss who you should consider sending for ECT, some of the considerations for different patient populations, and how you might approach explaining to a patient that you want to electrify their skull and make them seize.

Electroconvulsive Therapy: A method to the madness

Tue, 28 Dec 2021 20:00:00 -0500

The mechanism of action of electroconvulsive therapy remains elusive, so I am going to describe how ECT induces seizures, discuss the evidence that ECT is not just an elaborate placebo (or in other words, inducing the seizure is what results in the therapeutic benefit), and then briefly discuss some of the many proposed mechanisms by which it might work.

A brief history of Electroconvulsive Therapy

Tue, 28 Dec 2021 20:00:00 -0500

A brief and exciting history of electroconvulsive therapy. You will learn how a method for anesthetizing pigs before slaughter was first used on a homeless and psychotic man and how it soon became the gold standard treatment for severe mood disorders.

Welcome to PsyDactic - Residency Edition

Tue, 28 Dec 2021 19:00:00 -0500

Dr. O'Leary explains what inspired him to start this podcast, where the first episodes will take you, and why you should be skeptical of everything he says.