🧵Ketogenic Diets-Promising or Problematic? The Data Just Got Interesting. 🚨1/6

Ketogenic diets are gaining traction in psychiatry-early reports show promise for depression, bipolar, and schizophrenia.

But a new study in JACC (KETO-CTA) just raised eyebrows-and it has big implications for patients in psychiatry . 👀 1/ The Study

👉100 lean, metabolically healthy individuals on a ketogenic diet-with LDL-C ≥190, HDL ≥60, and triglycerides ≤80-were followed for 1 year using coronary CT scans.

Note 👉 these are lean metabolically healthy individuals ✅

🧵 The Paradox of Medication: Sometimes You Need It to Stop Needing It 🚨

Sounds paradoxical, right?

But clinicians who follow patients long-term recognise that treatment unfolds in distinct phases.

1. Short-term stabilisation
2. Long-term recovery.

Let's explore 👇 1/7 1/ When allostatic load overwhelms an individual’s control mechanisms, we see clear markers:

-Worsening symptoms
-New symptoms emerging
-Increasing effort just to function

At this stage, medication may act as a regulatory intervention, reducing allostatic load and restoring homeostatic control to the individual.

🧵The Skin as a Boundary and Container for ‘The Self’ 🚨

The skin, both literal and symbolic, offers a window into the fragmented self.

Psychodermatology in BPD 👇1/11 1/ Clinicians would have heard the statement “I feel uncomfortable in my own skin."

Psychodynamically, the skin is more than a physical boundary-it’s a container for the self.

It separates "me" from "not me," creating a sense of cohesion.

In borderline personality organisation, this boundary is fragile, leading to feelings of exposure, vulnerability, and chaos.

🧵15 Commandments of Psychopharmacology 🚀

Textbooks taught me psychopharmacology-UNTIL I stepped into real-world practice as a consultant psychiatrist. 🚨

Here’s what experience taught me that textbooks don’t (or can’t). 👇1/16 1/ Psychopharmacology without phenomenology is blind.

Meds must align with symptom constructs, functional impairment, and lived experience-not just diagnostic labels.

Treat the patient, not the category.

🧵 From Tabula Rasa to Conscious Being 1/11

We are born as a blank slate- how do we transform ‘raw’ needs into emotions, identity, and thought?

Let’s explore 👇1/11 1/ At birth, we are Tabula Rasa- a blank slate.

A newborn's only task?

To have its needs met.

Survival hinges on fulfilling homeostatic needs: warmth, nourishment, and safety.

🧵The Art of Diagnostic Understanding - Thinking Backwards in Psychiatry 1/9

We think forwards-quick, easy, and categorical. But is that what’s needed?

When psychiatric disorders involve molecular to societal influences, thinking backwards-from patterns to pathology to formulation-is the key to individualised care

Here’s how we navigate complexity 👇1/9 1/ Formulation is often misunderstood as simply writing a summary.

But diagnostic understanding is more than a summary-it’s an evaluative process.

It requires:

1. A hierarchy of differentials 📊

2. The integration of biopsychosocial, neurobiological & psychological factors ✅

3. The ability to place labels correctly without premature closure 🏷️

🧵Antidepressants & Discontinuation: Why Stopping Is a New Adaptation, Not a Rewind Button 🚨

Antidepressants are prescribed to help create stability.

But stopping isn’t just a 'reset ’- it’s a new physiological change with multiple possible trajectories. 👇 1/11 1/ The process:

A. Person has distress (symptoms).

B. Medication is prescribed.

C. Medication helps reduce distress, allowing for some stability.

D. Person decides to reduce.

*Note that at this stage, it is the shared decision-making that is important - discussing risks, benefits, short and long-term, and alternatives with their risks and benefits.

🧵The Stability Paradox in BPD: Why Attention-Seeking Is Not What You Think 🚨

Most misunderstand attention-seeking in BPD.

It’s not (always) conscious manipulation- often a deeply automatised habit shaped by implicit memory, predictive coding, and reward prediction errors (RPEs)

Let's break it down 👇 1/14 1/ Can you remember a time you trusted someone or something-only to realise it wasn’t true?

-A friendship that let you down?
-An exam you thought you’d ace but didn’t?
- A betrayal that left you questioning everything?

-That pain.
-The sinking feeling.
-The moment of shock.

🧵Lithium & Long-Term Risks: What You Need to Know 🚨

Lithium remains the gold standard for bipolar disorder (BD), but what are the risks for thyroid dysfunction and chronic kidney disease (CKD)?

And at what lithium levels do these risks emerge? 1/ 1/ A cohort study (2025) of patients with BD in Hong Kong (n=7,029) analysed the risk of hypothyroidism, hyperthyroidism, and CKD associated with lithium vs. other mood stabilisers.

The Paradox of BPD – When Diagnosis Becomes a Barrier to Care. 🚨 1/13

Borderline Personality Disorder (BPD) is a disorder of paradox.
Is the way we diagnose and treat it paradoxical, too?

Let's explore 👇 1/ A/ Prof Sandra Sulzer interviewed 22 clinicians in a 2015 study to understand how BPD patients are perceived.

7 psychiatrists, 8 psychologists, 5 Licensed Clinical Social Workers (LCSW’s), and 2 BPD activists.

Her findings? BPD is not just seen as difficult- it is often functionally demedicalized.

🧵The Unique Receptor Pharmacology of Clozapine: Acetylcholine in Focus 🧵 1/ 9

Let’s break it down. 👇 (From Morrison et al., 2025) 1/ Most antipsychotics antagonise muscarinic receptors.

Clozapine? It’s different.

It exhibits partial agonism at M4, while its metabolite norclozapine is a potent M1 agonist.

Could this be key to its unique clinical effects?

🧵Are you in the mood for a journal club?
Does Cannabis Cause Schizophrenia? 🚨

I've just finished an 8-hour teaching session on Critical Appraisal for Registrars on the wkend and am in the mood to jump into critical analysis.

Let’s break it down. 1/12 👇 1️⃣A population-based retrospective cohort study in Ontario, Canada, examined the Population Attributable Risk Fraction (PARF) of schizophrenia associated with Cannabis Use Disorder (CUD) over 17 years (2006–2022).

Does it meet Bradford Hill’s causality criteria?

🧵What Can RFK Jr. Teach Us About Pharmacology? 💊

Let’s explore Methylene Blue ( MB) 1/9 1/ Methylene Blue

The internet is abuzz speculating about Robert Francis Kennedy Jr adding Methylene blue to his drink.

MB is being ‘promoted’ for its health benefits-enhancing mitochondrial function, improving mood, and enhancing cognitive performance.

But could its benefits ( including the downstream mitochondrial effects) be likely tied to its MAO inhibition, which is often underplayed?

🧵ADHD & Evolution – An Adaptation or a Mismatch? 1/ 10 👇 1/ ADHD: An Evolutionary Advantage in the Wrong Era?

ADHD is, as the diagnosis states, framed as a disorder, but what if the traits that define it- impulsivity, hyperactivity, distractibility, and novelty-seeking- were once an adaptation?

What if these traits weren’t inherently dysfunctional but rather context-dependent, shaped by evolutionary pressures that made them advantageous in one environment yet challenging in another?

* Understanding ADHD through this lens doesn’t mean minimising the struggles it creates today. 🚨

Instead, it offers a broader perspective.

Let’s explore ADHD through an evolutionary lens.

🧵Antidepressants are no better than placebo – is this true? 1/8

Let’s break this down. 👇 1/ “Antidepressants only improve depression by 2 points!” Sounds damning, right?

Writes Moncrieff et al 👇

“Mean differences between antidepressants and placebo reported in meta-analyses of the Food and Drug Administration data set have ranged from 1.80 to 2.56 points on the widely used Hamilton rating scale for depression (HAM-D) [4], with effect sizes (d) ranging from 0.31 to 0.32”

🧵"Nothing in biology makes sense except in the light of evolution." – Theodosius Dobzhansky

What can Darwin teach us about mental health? 👇1/11 1/ I read this fascinating paper recently published - below is a summary : 👇

Evolutionary medicine views diseases not just as malfunctions but as outcomes of trade-offs, constraints, and mismatches shaped by natural selection.

“Despite being fit for the function that they carry out, adaptations are far from representing the ideal device that an engineer would design to solve a specific problem.

Instead, they are a "patch-work" of previously, reproductively speaking, successful intermediates, each intermediate with similar or different functions from the current one (Dawkins, 2016). “

SSRIs: A Double-Edged Sword? The Bleeding & Clotting Paradox 🧵 1/7

https://twitter.com/drkeithsiau/status/1886187875043065965

1/ SSRIs & Bleeding Risk 🩸

SSRIs inhibit serotonin uptake into platelets, depleting platelet serotonin stores by >80% (e.g., paroxetine).

Since 99% of blood serotonin is stored in platelets, this leads to impaired platelet aggregation, increasing the risk of bleeding diathesis.

This risk is exacerbated with concurrent NSAIDs and anticoagulant use.

Caution in elderly as well.

🧵Insulin Resistance & Psychiatry - We knew it then ; What's changed? 1/11 1/ We knew this in 2008. In my paper on antipsychotic-induced weight gain, I highlighted the role of metformin & topiramate in addressing metabolic dysfunction.

Yet, despite clear recommendations, monitoring rates remain poor. Has much changed?

🧵IPSRT: The Bridge Between Psychodynamic Therapy and Neurobiology in BPAD 1/11

Here is how I use this integration in psychoeducation in BPAD

*Lithium has the best evidence for prophylaxis and acute Rx of mania.

This post is aimed at showing how a psychodynamic and neurobiological understanding can enhance treatment. 1/ Interpersonal and social rhythm therapy (IPSRT) is an evidence-based treatment for Bipolar Affective Disorder (BPAD)

BPAD is shaped by both neurobiological rhythms and interpersonal dynamics influenced by early life experiences. (Approximately 30% to 50% of individuals with BPAD have experienced traumatic events in childhood.)

IPSRT bridges these two worlds.

*(the unconscious doesn't tend to be overtly discussed or applied in IPSRT, but we as clinicians can use this understanding to enhance Rx)

🧵ADHD meds & Raynaud’s Syndrome: Should we be monitoring? 1/10

Findings from a systematic review 👇 1/ What is Raynaud’s Syndrome (RS)?

RS is a peripheral vasculopathy causing impaired blood flow to extremities, leading to skin discolouration (pallor, cyanosis, erythema) and increased sensitivity to cold.

🧵 What is Borderline Personality Disorder (BPD)?

Here's how I conceptualise it: 👇 1/8 1/ BPD is best understood as a condition where developmental, neurobiological, and psychodynamic processes intersect.

At its core, unmet developmental needs or unresolved demands act as a chronic allostatic load on the individual.