I think we're doing something a little different today.
Yeah, that's right. Are you going to tell me what it is?
You tell me.
Mm-hmm. So, um... I don't know if anyone even remembers this that's listening, but I always had a podcast idea called You Tell Me. It's completely a situation where I came up with a name before any kind of idea of what it's supposed to be. And the name is because when I was working in a psych yard, I noticed that people very high on meth were sufficiently paranoid that they would come in, you'd ask them personal questions or details about what brought them in, and they'd say, You Tell Me!
You tell me, because the idea was, of course, that you'd been surveilling them. You knew all about them already, so they didn't need to tell you. So that's completely harebrained, I know, as an idea, name, or podcast, but at least tangentially related to psychiatry. Today, I think we're just going to riff on social media posts and also answer some reader comments, I think, because we feel unprepared this week.
Isn't that correct?
Well, we can't admit to feeling unprepared. We just feel like taking a vacation from the intellectual things.
I think we should admit to our feelings. The feelings aren't true. Feelings can't hurt.
Yeah, and I think we want to try this, and it could flop. This could be the least interesting podcast we do. We'll see.
Yeah, I mean, I'm not sure... I'm not sure how we'll be able to market it, you know, or if it'll even be permissible to be posted on the psychiatry subreddit. Is this psychiatry? Well, I guess we'll find out.
Yeah. I don't think we'll be able to post it, but we can just see. I think we should post it. All right. Why don't we give it a start? Do you want to read the first guy?
Wait, if you're starting, shouldn't you be the one that's reading it?
Oh, and then I guess for the reader's knowledge, we didn't share what we're going to be talking about. So we have no idea what the other person is presenting.
Yeah. If that goes poorly, you can blame me because Dr. Malberg likes to prepare and I think we should go in blind.
All right. Let me see. Which one do we feel like starting with today? All right. So first question, and I'm just going to read it and then I guess I'll. quickly go through the post. What's the harm in more widespread use of stimulants? So this is the person's posts. Stimulants can increase the productivity of people without ADHD. What's the harm in having easier access? Obvious caveat, contraindications of disorders that shouldn't be taking it.
What's the harm in more widespread use of stimulants?
What is the harm indeed? What is the harm? Well, you're really coming out of the gate with a controversial one.
Oh, yeah. I mean,
if you want hate as any kind of mental poster social media presence, just talk about ADHD in a way that doesn't mean everyone should have stimulants. i mean this is a widespread thought i feel like it comes a little bit out of silicon valley you know there's definitely a culture there where people just think it should happen that everyone's on stimulants because i think it happens quite a lot and i've got some unprofessional theories on that and i guess because this is a you tell me episode i'm gonna go for it okay not evidence-based i think that people being basically neuro atypical neurodivergent okay uh people with soft to hard autistic traits and disorder are overrepresented in silicon valley okay shoot me i'm sorry these are programmers and engineers all right let's look at the research that's going to be a higher proportion of systematizing and autistic traits i think that many of them probably do have either soft or hard adhd And on top of that, they have an intense demand from their work environment to be ultra productive to the detriment of their own physical and mental health.
That's the culture of Silicon Valley. That's also the culture that sort of shapes and programs and lives on the Internet, the mass media world that we all draw from today. And so they love stimulants because, number one, they're more likely to actually benefit from them from a psychiatric standpoint. And number two, their culture demands it. So in the microculture of Silicon Valley, everyone's on stimulants. Everyone should be on stimulants.
There's pressure to get on stimulants. I can tell you that some of my friends are acutely living these pressures. What do you think?
Well, now I'm curious. So. And I think to kind of go back to the original question, so what would be the harm of all these people being on stimulants? Why? What's the downside?
The downside is side effects and risks, right? So what are the major risks of stimulants from that standpoint? This is rare, but also I think higher risk in neuroatypical populations, in populations where people do not have, let's say, the typical brain chemistry, if we're going to use brain chemistry like it's a real thing. There's going to be a higher risk of psychosis, mania, insomnia, weight loss, appetite decrease.
Okay. And more importantly than even that small risk.
They're throwing cardiovascular risks and blood pressure increase.
Yeah. And now those are small risks. If you look at the number needed to arm, right? It's going to be a pretty big number I would expect. But I think the bigger risk is... creating a culture for everybody that the best way to meet productivity is to take a psychotropic. Not only a psychotropic, but a drug. Let's face it, it is a drug, a stimulant drug that has habit-forming potential and basically creates tolerance pretty rapidly in most people who do not have ADHD.
Right. It doesn't matter if everyone can theoretically benefit from it. I mean, things are bad enough, I think, with social practices around caffeine and nicotine. And those were our productivity drugs of choice back in the day. But it's just another order of magnitude of risk for harm and effect on the brain acutely when you take Adderall versus caffeine. So in one way... we know the risks. In another way, we don't know the risks.
It's blobby. I know it's vague, but I'm saying if you create a culture where that is normal, we will come to find out why that's a bad thing. And I think it's essentially diminishing of human life to turn that into a norm to say that you should be like burning out an engine overclocking yourself to the extent that is maximum possible that's not a good thing fundamentally
And that's I think what you're responding to. I kind of get, I don't know, annoyed or frustrated when I see psychiatry marketed as optimization. Like I see a lot of psychiatric practices, nurse practitioners practices, you know, really growing practices where it's like optimal psychiatry or optimal mental health. That's just not how I frame the work that I do in regards to treating pathology more so than optimization of productivity or optimization of well-being.
I think of it as fixing deficits more so than optimization of people.
yeah i mean i i still point my finger at kind of tech culture and sultan valley culture that whole idea of optimization right this it's optimization for optimization's sake right you have to ask to what end and we have to come back to our roots we have to say and think about what medicine is supposed to be medicine is supposed to be about some kind of restoration or return to a natural homeostatic process okay now you can say oh there's a naturalistic fallacy fine i don't care you can still look at the group of human beings across history and say what do most people do and how do most people thrive and how was this individual uh in the past and currently and what do they want And so just as you shouldn't overclock a chip too much to get to maximum productivity because you'll burn it out, you should not be doing that with yourself in any way, I would say.
And guess what? You can't wait until NVIDIA releases the new version of you in two to four years, okay? There's only one you, and there's only one society that we have. So we should be a little bit careful about that stuff.
Yeah. You know, another thing that I worry about with too much stimulants, and I'm actually thinking of a particular friend, and I'm not saying this is everyone. I'm just saying that this is characteristic of a lot of people that I see is a problem. Because of the high work demands, like I don't think of him as someone who has ADHD, he's been having escalating stimulant doses. And there's a lot of problems going on in his life that are going unaddressed.
And As his body tells him to stop working or that he's exhausted, rather than address those problems, recognize that it's not in his nature to be working 14 hours a night and sleeping very few hours and working, he just keeps escalating his stimulant dose. And I see his relationship suffering. He then picked up the habit of because his stimulant dose was so high, he drinks a few Miller Lights at night to be able to wind down and fall asleep.
And I just see this like escalation of patches rather than addressing the core problems. And I'm not again, I'm not saying that's everyone, but I do see a lot of people who are adding and adding and adding rather than looking for what the problem is and how to fix it.
Yeah, I mean, you're pointing at probably maybe the most important part that I neglected to mention. And you don't even have to bring up a personal anecdote. This is something you see all the time, you know, both in clinic and out of clinic people. This is the track towards essentially substance use. And even if your motivation for substance use is not. a fundamental use disorder that most people imagine where they're doing it for recreational purposes, right?
If you use a chemical defense, essentially, like in place of a psychological defense, you use exogenous chemicals in a manner where you're trying to rescue yourself from something or push yourself to some limit, that's a downward spiral. That's not a good kind of... And I would say then based on that clinically, probably the biggest harm, uh, over focusing on stimulants and symptomatic treatment is that it's very, very, very easy to ignore underlying problems or glaring problems.
And from what I see in my clinic, the biggest things that are ignored are trauma disorders, proper trauma disorders, not just people of history, trauma, um, What else is ignored is mood disorders, and the most harmful one to ignore is, of course, bipolar disorder. And of course, personality disorders are being ignored and basically mitigated through the use of all kinds of medications, including stimulants. And if you don't address those things, if you just break over the symptoms and the impairments with effective medication, let's face it, they're effective, there's no hope for improvement in the long term.
And there's also a high risk of getting worse.
Yeah, that's that's another huge one is, you know, treating the symptom of difficulty concentrating, difficulty focusing rather than looking at the problem. You know, for a lot of people, that symptom is information that's important to be listening to. It doesn't mean I need to seal that over with a Band-Aid, you know. For some people, it means that the job isn't right for them. For some people, it means that it could just mean so many different things.
And by addressing it with more medications or more fixes is just compounding and compounding the problem. And as I mentioned, my one friend, I see him become more irritable. I see his relationship suffering. There are downstream negative side effects. stimulants do cause increased anxiety. It does cause increased mood instability. It does cause, like, you interact with people differently if you're on too high of the dose. There are problems with it.
Yeah, and this is true both of people who really don't have ADHD who are benefiting from stimulant. And in my opinion, people who do have ADHD who do benefit from stimulant, but are frankly not too high of a dose. There are diminishing returns. You need to differentiate between the energy boost in euphoria and the clinical treatment of ADHD. And I don't think the UCLA protocol, extremely high doses right out the gate is inappropriate.
I don't even know if that's appropriate for children. I'm going to defer on an opinion of that because I'm not a child psychiatrist, but it just is really unlike any other kind of dosing schedule that we use in psychiatry or any kind of medicine. Okay. Low and slow, please. A lot of people are going to ask, well, what am I supposed to do instead? I'm stuck in this system where productivity is being demanded of me.
I have to do good. I need them. I need them. What's the alternative? I think the alternative is to unask the question. You know, there's an assumption that whatever it is you think you're going to get with those stimulants is what you're supposed to be getting or where you're supposed to be going. I think you need to dial back people who are in this situation and ask, what is important to me?
What do I value? And what do I want my life to look like outside of work or outside of whatever I think these stimulants are going to do for me? In five to ten years, think of the long term, dial back and ask, is this really worth it? Or are there other ways of doing this?
This has less to do with the impact on the individual. We're kind of talking about the impact on society. There's a lot of people who don't fit in with the standard norms and then find alternative life plans that work for them. I watch a lot of those extreme documentaries of... you know, like rock climbers who do extreme things and skiers who do extreme things. And I wonder how many of them would be doing that if they were diagnosed with ADHD and stayed in school the whole time.
I don't know. I just think that there's a lot of people that these medications are bringing them, are normalizing individuals that could have, if they didn't, I don't know. I think like it changed their life plan as a result of like, Does that make sense?
Maybe. Yeah. I thought a similar thing. I just don't know what the effect is broadly, both individually or on society. We're in uncharted waters here in terms of the degree and duration of prescription high grade stimulant treatments across the board and the diagnosis of ADHD and autism. If they had given Isaac Newton vilify and by vans from the age of eight onwards, what would his life been like?
I don't know. But I think we can get very preachy here. I did not think that this was going to be such a sanctimonious, you know, shaking fist at clouds episode. We're going to do some light and fluffy stuff.
No, we're shaking fists. I think more stimulus. We're going to have more countants and less extreme skiers.
Okay. Well, maybe we leave it at that. We already angered people. If they left the podcast to write some angry comments and posts, then we can do something a little lighter and fluffier after this one.
All right. Now your turn.
My turn. Hmm. There's a funny post, not funny post exactly, a typical or expected post on the psychiatry subreddit titled simply, my ex-surgeons slash ex-surgeon wannabes, what kind of psychiatry do you do? Are you satisfied? Any regrets? And one of the comments says, wanting to be a surgeon To a psychiatrist's pipeline is real. A reply says, too real. And another reply, which was removed because it's unflared.
Ah, man, I wouldn't want to be around this crap. No offense.
I am not in that crowd. I learned of the limitations of my abilities in my surgical rotation. My brain is so unequipped to be a surgeon.
Well, in what way? What did you learn about yourself?
Well, I guess I thought I... I feel like I'd have to go give too many personal details to fully tell the story. I went into medical school knowing I was doing psychiatry. I thought I would probably be decent at surgery because I think I do have good hand-eye coordination. I thought I would like procedural stuff. You have to be really meticulous and you have to be someone who cares about details and you have to be someone who's comfortable in the environment of surgery, which is a high intensity environment where you can't make mistakes.
Yeah. That doesn't fit me. I could tell, I guess, one little anecdote. Okay. So I was on my surgical rotation. I am not someone who's spectacular with details. I'm not someone who's spectacular with any gritties. You probably learn in terms of how I teach. I'm a big picture person. I'm more of a feeling person than memorizing details. Anatomy was tough for me. And I was... I got crushed on my surgical rotation.
I wasn't comfortable in the surgical room. I was with another med student who was one of those... It's been a while since I've used this word or even heard it. Gunner. He was just like... Coming in with a smile and then, you know, helping out the nurses and like shifting bedpans and picking up patients. And it was that was my first rotation. So I wasn't comfortable in the hospital.
I didn't know what I was supposed to be doing. Like I constantly was just like, oh, God, I'm in the way and I don't know how to be helpful, which, yeah, it shouldn't go too far off. I don't want to. I wish I made infinitely more mistakes as a medical student, which I made up for in residency, but we'll go. I'll just keep pushing on. I remember being in surgery and a lot of times you get pimped.
So pimped just means like you get asked a question, like essentially on the spot quizzed.
There's a reverse... story that says it means put in my place but that i don't think that's the actual origin of that term but it's a classic uh standby of medical education to be asked progressively more difficult questions until you're stumped and humiliated correct
and in surgery you could ask like you know really tiny like veins and arteries that you're supposed to know, like the super tiny branches. So the surgeon goes, look, he pointed something. He goes, what is that? And I look and I go, I don't know what that is. And he goes, look at that. What is that? And I'm like, I, I'm sorry. I don't, I don't know what that is.
He looks at me. Dr. Melsberg. That's a mistake right there.
He looks at me. He goes, that's the kidney.
Oh,
And I remember walking away from that day saying, like, I'm never going to be a doctor. There's no chance in hell that I'm going to be a doctor.
Oh, boy. Well, you know, I'm glad that we're not all surgeons. I'm glad we have surgeons, but I'm glad that most people aren't surgeons. I'll just say that. Myself, I did not go into medical school thinking I was going to be a psychiatrist. In retrospect, it was stupid not to think of that because it's basically my perfect specialty for myself. But I resisted it all the way up until the end of third year.
You know, OR stuff was on the table. On my general surgery rotation, I was the only medical student for that rotation that did not get a cruel, hazing nickname, denigrant nickname from the chief. And I was instead told, you know, you should really consider doing this. You've got the personality for it, which I don't see as a badge of honor. So...
I mean, you're an interesting mix. I don't think the average person who's equipped for surgery is a good match for psychiatry. You're a rare breed of mixes, though.
Well, the thing is this, right? I do think maybe about 20% of psychiatrists are the ex-surgeon or neurosurgeon phenotype, the personality type. And no, they're not the typical surgeon, but there are some proportion of surgeons that are out there. And I like the analogy or the metaphor that one of my mentors uses. It's that psychotherapy is a form of surgery. It's being very invasive. You are almost playing God.
You're this authority figure, and you cut into the psyche, and you go in there and move stuff around. okay you're putting people taking people apart and putting them back together it's fundamentally aggressive you know i think law psychotherapists and psychiatrists don't necessarily see things that way but i think that's a part of our practice that we hide from ourselves and it comes through a lot in the discourse of the anti-psychiatry crowd i think they make plain just how aggressive we can be in our attempts to help people so there is that personality there i think but The aspect that is less common in psychiatry, but unfortunately still exists within psychiatry, I think is the very concrete and direct minded kind of thinking that often you can see in surgical subspecialties.
I think of surgeons as very detail-focused, very analytical, able to chop things up into parts, and Psychiatrists, on the other hand, especially when you're thinking about therapists or something, I don't think of it as surgical at all. I get the analogy, but I think to be able to take in the patient, it's a very holistic, right-brained sort of thing in terms of... Understanding over-determinism and picking up on meanings in different levels.
It's a lot less of that concrete, step-by-step thinking. It's a lot more of that holistic, touchy-feely thinking.
Well, you say that, but then we have CBT, don't we?
Yeah, but I'm talking about... the tool of, you know, patient assessment and, and like you really, you need to be thinking on multiple different levels and understanding how to think on multiple different levels and not get stuck on a certain level. I don't know. It's just very different than maybe, maybe.
And then we also have the skid. We have structured interviews, right? I think you need both, honestly. And I think I don't disagree. I don't disagree. There's a problem there.
I completely agree, and I think psychiatry can definitely go too far in one direction or the other. But I'm just saying that the average, as you say, phenotype, like the average psychiatrist...
Yeah, but I do think it's actually the field, honestly. I think that fields can get too... There's like a tipping point where a profession can have too much of one personality type. And that makes the profession weak because people who have different personalities will no longer want to enter into that profession because they have to hang around with all these people who they don't necessarily get so much along with.
Right. So that becomes an exclusionary space. And then the profession becomes blind. reminds me of the psychoanalytic concept of a shared cultural scotoma you know scotoma like a total blind spot in the field of vision yeah if you have two people right an analyst and a patient who are both of the same culture they may have the same cultural scotoma and neither of them will ever be able to process that part because it's squarely within both their unconscious culturally right i think the same thing happens in professions and uh unfortunately because of how much choice there is and how much ability to discriminate in the application process there is that we're probably seeing this worse and worse in various fields today, not just in medicine.
Absolutely. And I definitely see those blind spots in terms of, you know, as you're saying that I'm thinking that like I don't fit in that well with psychiatrists. I fit in a lot better with therapists in terms just in terms of like how they think. And even like I feel like because there's a huge overlap between how like similarity and how you think. And also like just if you get along with those people, I get along with therapists in general a lot more so than psychiatrists.
The failure mode of therapists is when they kind of what your point is like they get too touchy feely. They get too emotional. They get to like the there are, you know, general types. And then there's failure modes of those types. So I definitely agree. You need you need a whole mix. And certain people are better equipped for certain things.
Yeah. In the spirit of fun, should we also talk about some stereotypes about other medical specialties or some specialties within psychiatry? Which one should we do?
I feel like you're probably better at this. Let's do psychiatry first.
That one's a little harder because we're all so samey, I think. But I would say generally that forensic is the most mean and hard-nosed and surgeon type.
So that's probably why you see the surgery. Because I don't see that many of the... Obviously, I can think of a few clear examples in my head. But I don't interact with that many forensic-y type psychiatrists. So don't typically see that surgical mindset. Right.
Yeah. Geriatric is like the sweetest friendliest person ever. Right? Yeah. Uh, child, I'm going to defer on talking about that right now, but we can talk a little about pediatrics in general. Uh, CL is basically nerds. I'm sorry. Nerds. Nerds. Definitely. Am I missing any other stuff special to your addiction? Oh yeah. Addiction kind of mixed back addiction. I feel like do you, do you notice the trend of addiction?
like all i i'm having a tough time because i feel like i see such a big mixed bag in a lot of them child addiction i have a tough time like pinning down just because
i saw such a wide range i mean obviously they're all we're stereotyping here for fun but yeah addiction i i don't have a threat on addiction it seems like all kinds of different psychiatrists want to do addiction training or practice yeah how about uh interventions Oh, boy.
So I guess I do a small disclaimer. I'm currently working at an interventional practice. So yeah, we'll start with that. So I want to hear your thoughts.
I guess I'll just say entrepreneurial or optimistic is how I would phrase that. You can tell maybe I'm being kind. You're being way too kind. I want to hear. There's also a few too many tech bro optimizers in that area for my taste. But that's Penny Broadbrush. Most of the people in the field of that area are not like that.
Agreed. I think what I catch is, like, the marketing on it. So you do have that, like, marketing type of personality of the person of, like, pitching these things as, like, panaceas. Like, they're going to fix the world and, you know, just the... I look at my partner's Instagram all the time and it's just like all these ads. This isn't even for psychiatry practices are just like this mushroom product is like what you need to really be living life.
Like this is going to open up. You're going to have clear mindedness. You're finally going to reach nirvana. And I feel like that mindset is the interventional mindset of like. We go in, we fix the problem, and then finally you get to live the life of perfection and nirvana.
Yeah, it's one major mode of the modern age. It reminds me of Zizek's formulation that the traditional superego was a prohibiting superego. It said you may not do X, Y, Z. You must not do X, Y, Z. Whereas he says the modern superego is a superego of enjoyment. It says you may. OK. And in fact, people begin to feel compelled to enjoy. You need to enjoy this.
You need to optimize that. And I think the advertisements kind of reflect that. That's just kind of part of the wave that I'm on right now.
You can read Zizek. Zizek, how do you read Zizek?
I mostly listen, you know, because I like to hear a man sniffle every five seconds. I've tried reading a little. No, I read more of his short form work. Yeah, I got into Lacan stuff for a while there back in the day.
I struggle with both those things. My experience of reading those things is just referencing more abstract, even more – like to understand this, you must understand the big other. To understand the big other, you must understand the abstract little A. The abstract little A is obviously pointing – it's just like deeper and deeper into more concepts that I don't understand.
That's a very good observation. To explain concepts I don't understand. If I may, I'm going to do a little glance into the back of the textbook here. And here's the thing. If you look at the answers in the back of a math textbook, you may know the answer, but you haven't learned anything, right? I see the Lacanian and the Zizek field of that kind of forever referencing as sort of a broader process that mirrors their core philosophy in that language is just symbols pointing to symbols.
OK, and that, you know, it's not actually tied tightly to reality at all. Right. The words and the symbols we use more refer to each other than any fundamental reality, which is why we can construct hyper reality. And so that's how they write their work. And that's because the value in engaging with Lacan and with Lacanian work isn't so much in the concrete theories that are being put forward but in how much struggle you have to put in in order to learn so that you can come to your own insights and enlightenment let's say uh by struggling with that and it's the same process that you i i see that same process as a zen practice right i was about to say that that's like the whole it's not about figuring out the koan itself it's about that process of struggling with it
Yeah. And I don't feel like going through that process. All right. Should we go to our next question?
Oh, we're not going to do a brief overview of stereotyping and slandering. Oh, I missed that.
I missed that. Sorry. Yeah. Do you have any funny ones?
Well, we mentioned pediatrics. And I like to say that there are two kinds of medical students that go into pediatrics. They're the ones that love children and they're the ones that hate adults. Maybe we can leave it at that. Internal medicine is the nerds. Obviously, they're the wonks. We need those people. We need people being that detailed and knowledgeable. That's good. Surgeons are the jocks, as we've mentioned.
I don't think they are the jocks anymore. Ortho is definitely the jocks. The surgeons now are something different.
We're talking about jocks within the field of nerds, right? We're all medical students to begin with. We can pick a specialty.
Yeah, I think ortho is the bros, obviously. But the surgeon now, I think of as the people who over-fantasize about what it means to be a surgeon.
So you're saying narcissist. You're basically saying narcissist.
I'm trying to rework the... to back-solve for narcissism.
There's plenty of those, let's face it. Durham is the mean girls Durham is the hot mean girls right big time very perfect always great at painting an image great customer service you gotta be good in
customer service terrible friends I feel bad one of my closest friends is Durham but he doesn't fit the stereotype okay anesthesia is to me just the chill well-rounded guy poor girl bro
Boy, I've seen too much tragedy in anesthesia. So I thought I was going to do anesthesia.
If I were to do anything else, I did a little anesthesia research, actually.
They seem chill. I think what happens is that a lot of anesthesiologists live a... What's the phrase I'm thinking of here? A life of quiet... Work-life balance. No, it's like quiet tragedy or something. You know what I'm talking about. Living a life of quiet something. I don't know. I don't remember. But the point is, I think a lot of them are just like in their profession, constantly applying defenses so that they have an output of someone who's very balanced and good and nice.
And they're not it's not that they're not nice. It's that I think they are suffering. a lot of the time they have a very high suicide rate but of course that may be because their access to lethal overdose medications very easily high addiction rate too so it's a tough job anesthesia i'm glad i didn't do it quiet desperation i'm thinking of the quiet desperation yes i i that's what i was thinking of thank you that may be a bias based on
some things i've encountered in that area the pink floyd lyric is hanging on in quiet desperation is the anesthesiology way yeah that's right that's right um i think the other other um special come up with one for any of them but i think those are the main ones pmr has i feel like you can You don't have any for PMR?
Uh, smart people who are well balanced and, uh, want to live a good life.
Yeah, that was, that was my experience too.
Yeah. Hey, we didn't talk about psychiatry itself, like general psychiatry, uh, insane people, right?
God, I'd want to think about my answer before even talking about that.
Well, generally speaking, depressives. Depressive meaning people who feel that they owe something to somebody else because they're not good enough or that they're bad in some way. That's probably the...
I see the cohort. Sorry, I keep interrupting. I'll let you continue.
No, no, you should. It's you telling me.
The cohort I see and I think is expanding. And here we're going to get the anti-psychiatry advocates supporting us. I do see that there's a widening of the narcissistic person who wants the work-life balance and doesn't actually care about people but puts on a front that they do.
Yeah, that's probably the 20%. That's a major but still more minority phenotype within psychiatry. But I would say the bulk are the depressives. The depressives, yeah. Is there any other variation in psychiatry? Just general, not thinking of the subspecialties. Yeah, I would basically put about 80, 20, 70, 30. Majority being depressives. People who are basically, especially anticolytic depressives. They want to be close to people. They feel that they owe people things.
They want to make up for their perceived flaws and failures of the past and connect, be close to, love, take care of. And then, yes, the more narcissistic types.
Which I saw a lot of those. In my residency, it was flipped. It was the 30, 70, not 70.
Well, there's some strengths to that personality type. I don't know if you've read Jonathan Shetler's chapter on the personality syndromes, but I do think it's a compelling argument that any uh normal human variation even if it has certain detriments is going to come with certain strengths right and we need all these variations within a functioning and healthy society and that kind of ties us back to the point we're making that stimulants and that if you try to be too much of a social orthotic if you try to align everybody to some specific outcome or way of being you're kind of tamping down on the natural variation of humanity and our uniqueness and you're going to make us less adaptive yeah um
Another big divide in terms of personality types, inpatient versus outpatient versus emergency room. Huge. I think that catches a bigger divide in regards to outpatient has much, much bigger of the antaclidic depressive you're talking about. Inpatient has more of the able to compartmentalize surgical types.
Are you aware of the traditional divide within political psychiatry in the United States pertaining to that?
No. No.
Yeah, this is something I think people should know about within the field. It's part of our history. The original organization that is now the APA, I believe it was the Directors of American State Hospitals. That's not the exact title of that organization. they started out as basically the inpatient docs and then the that was pre-1900 right they've had state hospital type asylums for a long time and it was the advent of freud and the movement of psychoanalysis the outpatient treatment the talking cure that created sort of a new kid on the block of outpatient docs.
And so from very early on in American history, we have that dichotomy. As you say, there's the inpatient doc and outpatient doc, different personalities, different pathologies and different ideologies that I think stem from a combination of both the personality types that are attracted to it and also the types of pathologies that you tend to see. And I think that accounts for how the field is a little schizophrenic in the classical meaning of the term.
We're kind of a split field and sometimes we don't make sense and we have contradictions because we have these two undercurrents that are running and coming together and moving apart.
Yeah, and I feel like that theme comes up a lot in our podcast, just how if you are too much in one area, you'll say things that are just objectively untrue because you're only seeing a particular type of patient. The state hospital's definition of bipolar is going to be very different than the outpatient definition of bipolar in terms of what they think about it. Right. You'll see like, yeah, mutually exclusive opinions on things just as a result of the fact that just completely different degrees of pathology.
Yeah. We're getting close to some time. Should we try to do some reader questions or commenter questions?
Sure. I had one other. I have a few, but I guess I have one. Let's go for it.
What were you going to say?
So this one is, today a med student asked, what's the point of asking about past traumas? Doesn't everyone have some? The question was not asked with genuine curiosity, more disdain of the entire concept. How do I educate here? And I think my opinion on this is not going to be what you think it is.
Oh, then I want to hear it.
Um, I If we're talking about inpatient or emergency room, I understand what this particular med student who's saying, what's the point of asking about past traumas, is asking. And that I think your gut feeling when you read that is like, how could someone think past trauma is not relevant in psychiatry? And what I saw in the hospital, if you're working and deciding if someone needs to be inpatient, is that the information isn't actually...
less common than you think changes what you're going to do.
As in, you don't think that particular element of history changes management?
What I'm saying is I can understand how a med student in an emergency room can see how that question doesn't change things in a certain direction. With more understanding and more education, trauma is massively important in terms of your conceptualization, in terms of your understanding of the patient, in terms of your understanding of what you're going to do with that patient. But for the most part, if you were to remove that question, I don't think you would see drastic differences in terms of decision-making on an inpatient and an emergency room ward.
Hmm.
Controversial.
Controversial. I agree. I'm not saying don't ask it. I'm not saying I think trauma is massively important. I'm saying that forcing a person who's hospitalized or not forcing like someone who's already in the hospital who's it doesn't change. I don't want to because I want to be careful. There's a million things that I can say that you can twist this and have it be incorrect. What I'm trying to say is it's not as It doesn't change in the moment what you're doing for the most part.
Okay. I'm not going to come down for this. I'm just going to do a counterpoint. I think there's... couple reasons why you should do it as a matter of course the first being especially in a training environment you need to set and teach a standard and there should be a standard evaluation we should have a standard frame no matter the setting or the treatment and there's not a good reason to exclude trauma screening and discussion trauma second is that We certainly shouldn't force people to disclose traumas they don't want to disclose.
But part of the trauma psychopathology is the avoidance of discussion of trauma, thinking about trauma, feeling about trauma. And I don't want to force anyone, but I also do not want to even implicitly, through the frame of how I approach things, communicate that talking about this stuff is very dangerous or hurtful. And then finally, number three is that History trauma is important to formulating a patient and their distress.
If they've got no trauma component, you know, agitation, then would be better explained by some other diagnoses. So I think we'll have to disagree on this one.
It's weird. I guess. My issue, I think it's important. I completely agree with everything you're saying. I think that my what I'm trying to get at is that my gut instinct of like how trauma is so important for understanding patients is contrasted with how. Unfortunately, in inpatient, it doesn't change that many things. And I'm saying I wish it did. I wish we did have a lot more interventions focused towards it.
I wish we did change a lot of how we interacted with the patient. But just to be frank, I didn't see that.
Yeah, well, I think that's an indictment of inpatient, modern inpatient, and how it works. That's a problem with how we've structured treatment and billing and all that stuff. Inpatient should be vastly different than who it is right now. It's pretty terrible the way it is today in 2025.
And I think that's what I'm trying to get at. Yeah, maybe not that well.
We can agree on criticizing how inpatient is. They've turned inpatient into an extended urgent care state. Okay. It should not merely be stabilization. Okay. Ideally, what should happen on the inpatient ward should be diagnosis. Okay. should be diagnosis okay if i can diagnose or if i'm expected to diagnose within one and a half to two hours on outpatient, somebody living there should be diagnosable, right? And the diagnosis should be thorough.
It should incorporate the history, and it should be in the dang medical record for the outpatient doctor to read afterwards, okay? Let alone these discharges I've been getting recently. They don't even give discharge instructions to the patient. I got one where all I got was a copy of the whole. I don't need that. Tell me what you changed on inpatient. It's ridiculous. That's what I'm getting at.
That's what I wanted to heat you up about. That's what I wanted to heat you up about. I had patients that went through a two-week stay and the discharge summary and the output is nothing. Nothing. They were switched medications that they weren't even taking the first one originally. I have less of a clear diagnosis than when they walked in.
yeah i once called a guy and asked about how did you reach a schizoaffective disorder diagnosis for this guy and he was like oh he's looking at the chart well i don't really remember this guy well you know i must have seen something yeah i must have seen something okay great that should be another one that could be another
podcast name i must have seen something i must have seen something yeah yeah oh boy All right. I know you got some reader questions you want to get at.
Not really. I was just wondering if we should do it. We're kind of coming up in time anyway. Let's see. You know, one thing we didn't get to that I had on my mind was to talk about trauma dumping. And it's funny because a very recent comment on our latest episode asks, what is codependency neurobiologically? Dr. Malthwick, do you feel that you can answer that neurobiologically?
So it's funny, I did see that question. And if I had to think about the answer, what I would say is, and we were talking about this earlier, that the lens in psychiatry, a lot of the important things in terms of how I think about it is finding the right lens that is the appropriate thing to answer the question. So that, you know, biologically, you can answer every single question, but oftentimes it's not the right lens to be looking at the problem.
And if you look at something biologically, yes, maybe you'll answer it in terms of the dorsolateral prefrontal cortex is hypoactive in a time when the amygdala is overactivated. But it doesn't give you the juice. You don't learn anything from it. You don't understand more. And if we were to talk about... Codependence, is that was the thing that they're asking? Codependency, yeah. To me, a neurobiological explanation, which would be...
It's the wrong lens to be looking at the problem. And even if you were to hammer me with all the correct brain circuit correlates, you know, the... the limbic system being overactivated and deactivation of the prefrontal cortex, making it so that you're not thinking constructively about the whatever, it doesn't get at it. And codependence to me is more of a psychological phenomenon. And I would think probably the best lenses for that would be probably attachment theory or psychoanalytic theory.
If you wanted to go into the Biological aspects of stuff, I would recommend Panksepp. I feel like he probably gives you the best emotional understanding of different concepts. But for here, I don't think neurobiology tells you much. And I would be looking more for attachment explanations and psychoanalytic explanations.
Yeah, I totally agree. The point of a theoretical framework is to better understand some underlying reality. And unfortunately, some realities are not very accessible. For one, neurobiology is important, but it's not going to be able to capture emergent phenomena now that'll be an interesting one to talk about codependency you know like all those pop psych uh ideas that are floating around these days attachment styles i've been talking about this among my friends just you know lay people friends just recently and uh the concept of trauma dumping we maybe we can get to that in the future one of these you tell me is if people are interested i i think we'll leave on one last i've been combing through the old videos looking at the There's less reader questions than I thought.
So I think five minutes to discuss trauma dumping. No, I would say that. For the future, I will start saving good reader or listener questions to answer for these if we do these again. So I apologize to those who did leave good comments and questions in the past. I'm just going to go back to two months ago, our treating borderline personality effectively video. There's an inappropriate but funny comment from Arby's app.
How do we identify and better seduce borderlines?
No comment on that one.
Yeah, no comment. No comment. All right. Well, let us know if this was a worthwhile use of your time. I doubt it. But if you enjoyed it, maybe we'll do a few more of these and they require less prep and they give me a hope that this will continue beyond when we cover every possible chapter of the DSM.
I think we got lots more chapters to go. I think we also got to swap war stories. I think that would be a good one. But I agree. We'll see how this goes.
Also, I was disappointed to see some people wanted an OCD psychopharmacology review. I guess it's going to have to happen. So maybe next time.
You requested more than five. We got like 15.
I know. It's way too many. Oh, boy. All right. Well, good seeing you. Until next time.
All right. Until next time. Bye. Thank you.