Psychiatry Boot Camp

Catatonia isn’t just mysterious, it’s one of the most treatable yet misunderstood syndromes in psychiatry.

In this episode, I continue my conversation with Dr. Mark Oldham, diving deep into what to actually do when you suspect catatonia. We talk through the Lorazepam challenge, what a “positive” response really means, and why sometimes a single dose can look like a miracle. We also dig into the gray zones—how to approach patients who don’t respond, when to move to ECT, and what to do when catatonia overlaps with delirium or psychosis.

Dr. Oldham shares his framework for identifying special cases, from benzodiazepine withdrawal to clozapine discontinuation, and explains why history-taking, not algorithms, is psychiatry’s most powerful diagnostic tool.

Takeaways:

Start simple, but think deeply. Lorazepam remains first-line for catatonia, but the absence of RCTs means clinical reasoning still leads the way.

ECT is definitive and underused. For refractory or malignant catatonia, ECT is often curative, but access and consent barriers remain a major challenge.

Not all catatonia is the same. Withdrawal states, chronic schizophrenia, and periodic catatonia each demand tailored interventions.

Delirium and catatonia can coexist. Treat both cautiously, start low, go slow, and always look for autoimmune or neurological causes.

History is your best guide. Behind every catatonic presentation is a story, missing it can mean missing the cure.

Selected references:

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When a patient stops moving, stops speaking, or stares through you like you’re not there, it’s easy to miss what’s really happening.

In this episode, I’m joined again by Dr. Mark Oldham, one of the leading voices on catatonia, to break down what this strange, often misunderstood syndrome actually looks like in the real world. We walk through the diagnostic features step-by-step, how to assess, what to ask, and what’s too often overlooked.

From the history of the disorder to modern DSM confusion, from the meaning of “waxy flexibility” to the haunting truth about patients who are fully aware but trapped inside their bodies, this conversation will completely change the way you think about motor symptoms and psychiatric emergencies.

Takeaways:

Catatonia is common, but underrecognized. It’s not just “psychiatric immobility.” It spans a spectrum from stupor to hyperactivity.

Diagnosis starts with curiosity. Learn to test for features like mutism, posturing, and negativism systematically.

Many patients are aware. Always treat them with dignity and assume comprehension, even when they can’t respond.

It’s treatable and rapidly reversible. A single dose of lorazepam can sometimes unlock a frozen mind and body.

Malignant catatonia kills. When autonomic instability appears, it’s a medical emergency that demands immediate escalation and often ECT.

Selected references:

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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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When you think about core topics in consultation-liaison psychiatry, “supportive psychotherapy” probably isn’t the first thing that comes to mind. But maybe it should be.

In this episode, I sit down with Dr. John C. Markowitz, Columbia psychiatrist, researcher, and co-author of Supportive Psychotherapy: A Guide, to talk about the therapy that “gets no respect.” Dr. Markowitz explains how this deceptively simple approach, built on empathy, affect, and alliance, rivals more “sophisticated” treatments for depression.

We explore why the most powerful interventions often come down to being present, listening well, and helping patients feel understood. And we talk about the threat facing psychotherapy itself and what we stand to lose if psychiatrists give it up.

Takeaways:

Supportive psychotherapy works and evidence shows it can be just as effective as CBT or IPT for depression.

Common factors like alliance, empathy, affect focus, and ritual account for much of what makes any therapy succeed.

Following affect matters emotions are uncomfortable, but they’re not dangerous, and they guide the healing process.

Less is often more letting patients lead, listening actively, and resisting the urge to “fix” can create deeper insight.

Psychotherapy is under siege and preserving its human core may be psychiatry’s most important act of resistance.

Selected references:

What is Supportive Psychotherapy? (Markowitz 2014)

Brief Supportive Psychotherapy (2022)

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

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Welcome to Season 3 of Psychiatry Bootcamp.

This time, I’m stepping into the world of consultation-liaison psychiatry. The bridge between medicine and meaning. To kick things off, I’m joined by the legendary Dr. Allen Frances, former chair of the DSM-IV Task Force and Duke Psychiatry, who reminds us that the briefest interactions can be the most transformative.

We talk about what really happens when you walk into a hospital room: the loneliness, the fear, the need to be seen. Dr. Frances shares why “magic moments” aren’t superstition, but the heart of good medicine, and how to create hope in patients who’ve all but lost it.

Takeaways:

Every patient encounter is a chance for transformation, even a 15-minute consult can change a life.

Consult psychiatry lives between medicine and therapy and requires both logic and empathy.

Corrective emotional experiences can happen in moments, not months, when vulnerability meets presence.

Demoralization is the real danger, hope and understanding are often the most powerful treatments.

The “magic moment” is simply humanity made visible and it’s what patients remember long after the diagnosis.

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Dr. Sameer Jauhar, Senior Clinical Lecturer in Affective Disorders and Psychosis at the Institute of Psychiatry, Psychology and Neuroscience, King's College, London, and as a Consultant Psychiatrist at Maudsley NHS Foundation Trust, introduces us to schizophrenia. Explore core clinical features of schizophrenia and what is known about the neuroscience of schizophrenia. We'll also discuss psychopharmacological and psychosocial treatment approaches, rooted in Dr. Jauhar's humanistic approach.

This episode is intended to supplement Dr. Jauhar's Lancet Seminar on Schizophrenia (2022).

Connect with Dr. Jauhar: @SameerJauhar

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Dr. Laura Watkins, Clinical Psychologist and Assistant Professor of Psychiatry at Emory University School of Medicine, introduces us to post-traumatic stress disorder (PTSD).

We walk though the diagnostic criteria and discuss how these symptoms can impact a person's day-to-day life. We then learn to conceptualize PTSD in terms of both classical and operant conditioning. Finally, we explain evidence based psychotherapies for PTSD and conclude with a primer on psychopharmacology for PTSD.

Essential references:

1) Osser Psychopharmacology Algorithm for PTSD

2) Clinical Guidelines for PTSD (United States Department of Veteran's Affairs and Department of Defense)

3) This American Life: Ten Sessions

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Dr. John Walkup, Chair of the Pritzker Department of Psychiatry and Behavioral Health at Ann and Robert H. Lurie Children’s Hospital of Chicago, Professor of Psychiatry at Northwestern Feinberg School of Medicine, and president-elect of the American Academy of Child and Adolescent Psychiatry, introduces us to anxiety disorders.

We discuss the phenomenon of normal, adaptive anxiety and contrast this with symptomatology that may warrant a diagnosis of an anxiety disorder. We learn to appreciate anxiety disorders from a developmental lens, discuss clinical pearls for building a therapeutic alliance with anxious patients, and explore psychotherapies for anxiety disorders. We also discuss psychopharmacological considerations for both SSRIs and benzodiazapines.

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