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)

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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)

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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:

1. Transplant Psychiatry: A Case-Based Approach to Clinical Challenges
2. Transplant Psychiatry: An Introduction

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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:

1. ⁠Changeability, confidence, common sense and corroboration: comprehensive suicide risk assessment (O'Connor 2004)⁠

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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:

1. ⁠Progress in Pharmacologic Management of Neuropsychiatric Syndromes in Neurodegenerative Disorders: A Review (Cummings 2024)
2. Neuropsychiatric Symptoms of Dementia and their nonpharmacological and pharmacological management (Tampi 2022)⁠
3. Management of BPSD Algorithm (Chen with Osser 2021)⁠
4. Atypical Antipsychotics for Aggression and Psychosis in Alzheimer's disease (Ballard 2006)
5. Efficacy and Adverse Effects of Atypical Antipsychotics for Dementia (Schneider 2006)
6. Sequential Drug Treatment Algorithm for Agitation and Aggression in Alzheimer's and Mixed Dementia (Davies 2018)

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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:

1. ⁠British Association for Psychopharmacology Guidelines⁠
2. ⁠⁠Rochester Catatonia Assessment Resources⁠⁠
3. ⁠NEJM Review on Catatonia⁠
4. ⁠Nature Review on Catatonia⁠
5. ⁠Schizophrenia Research Volume on Catatonia⁠
6. ⁠Describing the Features of Catatonia (Oldham)⁠

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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:

1. British Association for Psychopharmacology Guidelines
2. ⁠Rochester Catatonia Assessment Resources⁠
3. NEJM Review on Catatonia
4. Nature Review on Catatonia
5. Schizophrenia Research Volume on Catatonia
6. Describing the Features of Catatonia (Oldham)

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Dr. Mark Oldham, Associate Professor of Psychiatry at University of Rochester Medical Center, President-Elect of the American Delirium Society, and Deputy Editor of the Journal of the Academy of Consultation-Liaison Psychiatry, further explores delirium. This episode covers the pathophysiology of delirium including predisposing and precipitating factors, neurocircuitry, and neurotransmitters. We then discuss conceptual frameworks for management of delirium, the importance of identifying and addressing the underlying cause, and strategies for managing specific neuropsychiatric disturbances in delirium.

References can be found on the ⁠episode website.⁠

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Dr. Mark Oldham, Associate Professor of Psychiatry at University of Rochester Medical Center, President-Elect of the American Delirium Society, and Deputy Editor of the Journal of the Academy of Consultation-Liaison Psychiatry, introduces us to delirium. This episode covers the epidemiology, clinical features, and diagnosis of delirium.

References can be found on the ⁠episode website.⁠

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Dr. John C. Markowitz, Professor of Clinical Psychiatry at Columbia University, introduces us to supportive psychotherapy. We discuss the principles that underpin supportive psychotherapy and "common factors" in psychotherapy. Dr. Markowitz helps us to understand where supportive psychotherapy fits into modern psychiatric practice, and provides clinical wisdom about building a therapeutic alliance and pursuing affect.

What is Supportive Psychotherapy? (Markowitz 2014)

Brief Supportive Psychotherapy (2022)

Psychiatrist Effects in the Psychopharmacological Treatment of Depression (McKay 2006)

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