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by Psychiatry, Skepticism, and Integration.
PsychoFarm Podcast is a deep dive into the intersection of psychiatry, psychopharmacology, and the evolving understanding of mental health. Hosted by 2 psychiatrists, the podcast explores complex topics such as diagnosing mood and personality disorders, the role of medications in treatment, and the challenges of psychiatric training. Each episode breaks down the clinical insights and philosophical debates surrounding mental health care, providing both practitioners and curious listeners with thoughtful analysis, expert opinions, and practical advice. psychofarm.substack.com
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- 6 days ago1h 5m
Diagnostic Hierarchy Explained: Why Patients Get 5 Diagnoses
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
- 1 weeks ago1h 6m
The Psychology of Elizabeth Holmes in You Can See Everything: Narcissism, Autism, or Manipulation?
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 transcriptThe 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 DifferentialFor 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
- 2 weeks ago56 min
You Can See Everything Psychological Analysis by Clinical & Forensic Psychiatrists
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. 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
- 3 weeks ago1h 15m
Antipsychotic Tier List: Ranking the Best and Worst Anti-psychotics
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. 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
- Oct 6, 20261h 1m
Trauma and PTSD: How the DSM Criteria Actually Help Us Understand What’s Going On
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. 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
- Sep 29, 20261h 2m
What Patients Should Know When Diagnosed With Depression
What should patients know when they are diagnosed with depression? In this episode, psychiatrists Dr. Malzberg and Dr. Fu cover what they wish every patient knew from the start. They explain why a depression diagnosis is a useful shorthand rather than a fixed identity, how biological, psychological, and social factors feed into each other, and how medication, therapy, and lifestyle changes work together. You will hear practical first steps like behavioral activation, a steady wake time, morning sunlight, and cutting back on alcohol and cannabis, plus what to do if treatment stalls and how to decide who to tell. It is an hour of clear psychoeducation for patients and a resource clinicians can share. 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
- Sep 21, 202654 min
Autism Diagnosis Explained: DSM-5 Criteria, Autistic Traits & the Difficult Differential
Autism diagnosis is more complicated than recognizing a handful of autistic traits. In this episode, Dr. Fu and Dr. Malzberg unpack the DSM-5-TR criteria for autism spectrum disorder, including social communication differences, restricted and repetitive behaviors, developmental onset, impairment, and Levels 1–3. They then tackle one of the hardest parts of adult autism assessment: differential diagnosis, including overlap with ADHD, schizophrenia, and personality disorders. The conversation also explores theory of mind, masking, the double empathy problem, weak central coherence, and the empathizing-systemizing framework. The goal is a more clinically useful way to think about what distinguishes autistic traits from autism spectrum disorder and why developmental history matters. 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
- Sep 15, 20261h 5m
How to Diagnose Bipolar Disorder with Dr. Phelps: Hypomania, Mixed States & the Clues DSM Misses
Diagnosing bipolar disorder is rarely as simple as finding a clear episode of hypomania. Dr. Phelps explains why bipolarity is better understood across a mood spectrum and walks through the clues that can help distinguish bipolar depression from unipolar depression: age of onset, family history, course of illness, treatment response, cyclicity, and collateral history. We also dig into mixed states, the “four A’s” of anxiety, anger, agitation, and attention problems, antidepressant activation, the HCL-32, and the Bipolarity Index. The larger theme is diagnostic humility: uncertainty is often appropriate, and treatment decisions should reflect both the strength of the evidence and the risks of getting the diagnosis wrong. 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
About Psychofarm Podcast
PsychoFarm Podcast is a deep dive into the intersection of psychiatry, psychopharmacology, and the evolving understanding of mental health. Hosted by 2 psychiatrists, the podcast explores complex topics such as diagnosing mood and personality disorders, the role of medications in treatment, and the challenges of psychiatric training. Each episode breaks down the clinical insights and philosophical debates surrounding mental health care, providing both practitioners and curious listeners with thoughtful analysis, expert opinions, and practical advice. psychofarm.substack.com
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