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Awais Aftab

@awaisaftab.bsky.social
8.1K followers 5K following 1.3K posts

Psychiatrist with philosophical interests | Conversations in Critical Psychiatry (Oxford University Press, 2024) | Psychiatry at the Margins www.psychiatrymargins.com

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Reposted by Awais Aftab
Hermione Gingold @hermionegingold.bsky.social · 29/09/2026
Phew! This post hit the nail on the head.
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Haydon @haydonmp.bsky.social · 29/09/2026
Really important and useful article.
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Awais Aftab @awaisaftab.bsky.social · 29/09/2026
I am doing a series of articles (“Therapeutic Window”) for the Science desk at The New York Times. The first article is about whether ADHD is better understood as a disorder of “attention” or something else: www.nytimes.com/2026/09/29/s...
nytimes.com
What If A.D.H.D. Isn’t About Attention at All? (Gift Article)
Evidence suggests that it really affects what psychiatrists like me call sustained engagement — an important difference in understanding how to think about the condition.
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Laura Routh @laurarouth.bsky.social · 26/09/2026
“The system is organized around scarcity of attention and time. It is relatively easy to ask for and be prescribed medications, but quite difficult to see a physician who actually cares and listens and thoughtfully attends to diagnostic work-up and treatment risks and patient concerns.”
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Awais Aftab @awaisaftab.bsky.social · 26/09/2026
I Believe in a Radical Abundance of Relational Care “The more I practice, the more I believe that attention is the rarest and purest form of clinical generosity.” www.psychiatrymargins.com/p/i-believe-...
psychiatrymargins.com
I Believe in a Radical Abundance of Relational Care
I am wary of movements that focus on a subtractive agenda, one whose primary ambition is to take things away from people.
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Laura Routh @laurarouth.bsky.social · 19/09/2026
In supporting a loved one with a mental illness, I’m painfully acquainted with, and appreciate, what @awaisaftab.bsky.social describes regarding the harms and benefits of psychiatric medication, now both a necessity and godsend for my loved one, and us. Do I wish for something better? You bet.
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Joshua Richardson @schizosemia.bsky.social · 19/09/2026
“I feel like the psychiatric profession messed up big in the tone it took when it came to public outreach and mental health awareness efforts. We communicated to people that we have stuff figured out, that we know what to do.”
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Alejandra Hope @alejandrahope.bsky.social · 19/09/2026
As always, I deeply appreciate Awais's honesty re psychiatric prescribing, and I so wish I experienced more of that honesty from psychiatrists and other clinicians in my own care.
We have highly imperfect tools at our disposal, and more and more we rely on these tools in situations where their use is less-than-necessary. I am focusing mainly on psychiatric medications here, but psychotherapy is no less imperfect and sought after. Neurostimulation, imperfect as well.
Psychedelics, don't even get me started. Anyway, the point is, there is no refuge. Anyone selling you anything better than
'highly imperfect' in the realm of mental healthcare is a fool or a grifter. (And this includes deprescribing and tapering...)
I don't know, man, I feel like the psychiatric profession messed up big in the tone it took when it came to public outreach and mental health awareness efforts. We communicated to people that we have stuff figured out, that we know what to do. Come to us with your problems and we will fix you! Unfortunately, we know jack shit...When we start treating weak norms of consultation as strong norms, when we assign preemptive authority in areas where only contributory authority is justified, when we destroy traditional cultural means of support to shunt people into medical treatment, we erode people's capacity to meet suffering with the resources they already have or could have had outside medicine. When we rely on interventions that are weak or unreliable and at times harmful in situations where their use is optional and based on unrealistic expectations, we set ourselves up for frustrations and complications. There are situations that are high stakes, that require specialized knowledge, where there is a scarcity of viable alternatives outside medicine, and where deference to experts makes sense, but these are (were?) also rather circumscribed and uncommon.
Thanks to public messaging colored by delulu optimism, many people showing up at the clinics have a misplaced confidence in our ability to scientifically characterize their problems or help them in a timely, efficient, low-hassle manner.
The real message to the public should've been something like: we are an immature science; our treatments are imperfect and flawed; they help some people some of the time, and we don't quite know who will benefit or how much; they come with risks, at times serious risks, and no one can know in advance how they'll affect you; when they work, no one can say how your relationship to them will change over time. If the resources of ordinary life, self-help, and support available to you through family and friends have failed you, then these imperfect tools are available for you, but don't expect any miracles. There is so much suffering out there and we are just scratching the surface. If you seek help, you may find a collaborative doctor who is attuned to your concerns and sensitive to iatrogenesis, but don't count on your luck.
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Awais Aftab @awaisaftab.bsky.social · 19/09/2026
“Psychiatric treatment is often enough a frustrating affair, for the patient, for the clinician, for the caregivers, basically for everyone involved…” On imperfect tools www.psychiatrymargins.com/p/maybe-dont...
psychiatrymargins.com
Maybe Don’t Ask Your Doctor if Zoloft Is Right for You
On imperfect tools
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Awais Aftab @awaisaftab.bsky.social · 12/09/2026
The Lawsuit That Came to Symbolize the Fall of Psychoanalytic Psychiatry: Eric Caplan on Osheroff v. Chestnut Lodge www.psychiatrymargins.com/p/the-lawsui...
psychiatrymargins.com
The Lawsuit That Came to Symbolize the Fall of Psychoanalytic Psychiatry: Eric Caplan on Osheroff v. Chestnut Lodge
Eric Caplan is a historian of American psychiatry and the author of "When Healing Harms"
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Colette Delawalla, PhD @cdelawalla.bsky.social · 06/09/2026
Tons of ~discourse~ about AOC taking meetings with voters in the MAHA block. I’m about to sit down and write all my thoughts down, but in the mean time, I wrote extensively about my experience trying to survive a horrid pregnancy & I get the vulnerability. www.psychiatrymargins.com/p/i-am-train...
psychiatrymargins.com
I Am Trained to Diagnose Depression, Yet I Overlooked My Own Amidst a Rock Bottom Pregnancy
Guest post by Colette Delawalla
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Awais Aftab @awaisaftab.bsky.social · 06/09/2026
Depression & anxiety seem common & familiar but few can appreciate the psychopathological depths possible. Once in a while I come across an Omega level neurosis in the clinic, & it is like witnessing something alien & ancient, a horror & dread with the gravity of a neutron star…
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Awais Aftab @awaisaftab.bsky.social · 06/09/2026
Defending the Mechanistic Plausibility of Protracted and Delayed Antidepressant Withdrawal Guest post by Daniel Cohrs www.psychiatrymargins.com/p/defending-...
psychiatrymargins.com
Defending the Mechanistic Plausibility of Protracted and Delayed Antidepressant Withdrawal
Guest post by Daniel Cohrs
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Awais Aftab @awaisaftab.bsky.social · 04/09/2026
Postpartum Psychosis and Diagnostic Sclerosis The DSM needs postpartum psychosis more than postpartum psychosis needs the DSM www.psychiatrymargins.com/p/postpartum...
psychiatrymargins.com
Postpartum Psychosis and Diagnostic Sclerosis
The DSM needs postpartum psychosis more than postpartum psychosis needs the DSM
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Dr K WILDSCHUT @drkwildschut1984.bsky.social · 04/09/2026
Postpartum Psychosis is a well known clinical syndrome, yet not firmly categorised as a disease in DSM and perhaps there’s the issue that this trial reveals. Timely blog here to elaborate on the matter, by @awaisaftab.bsky.social open.substack.com/pub/awaisaft...
open.substack.com
Postpartum Psychosis and Diagnostic Sclerosis
The DSM needs postpartum psychosis more than postpartum psychosis needs the DSM
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Awais Aftab @awaisaftab.bsky.social · 04/09/2026
Postpartum Psychosis and Diagnostic Sclerosis The DSM needs postpartum psychosis more than postpartum psychosis needs the DSM www.psychiatrymargins.com/p/postpartum...
psychiatrymargins.com
Postpartum Psychosis and Diagnostic Sclerosis
The DSM needs postpartum psychosis more than postpartum psychosis needs the DSM
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Awais Aftab @awaisaftab.bsky.social · 29/08/2026
Lindsay Clancy and the Dream of a World Beyond the Insanity Defense The absurdity of mad versus bad www.psychiatrymargins.com/p/lindsay-cl...
psychiatrymargins.com
Lindsay Clancy and the Dream of a World Beyond the Insanity Defense
The absurdity of mad versus bad
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American Academy of Child & Adolescent Psychiatry @aacap.bsky.social · 24/08/2026
Psychiatry is under more public scrutiny than it has seen in a generation. In our #AACAP26 Presidential Interview, Drs. Walkup and @awaisaftab.bsky.social will tackle diagnostic validity, deprescribing, and the future of psychiatric classification and treatment. aacap.confex.com/aacap/2026/m...
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Awais Aftab @awaisaftab.bsky.social · 23/08/2026
What the New York AOT Evaluation Team Actually Found New York State Legislature ordered a comprehensive independent study of Kendra’s Law in 2022. The results have now been published and are being misrepresented. Guest post by Nev Jones & PathLab www.psychiatrymargins.com/p/setting-th...
psychiatrymargins.com
Setting the Record Straight: What the New York AOT Evaluation Team Actually Found
New York State Legislature ordered a comprehensive independent study of Kendra’s Law in 2022. The results have now been published and are being misrepresented.
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Awais Aftab @awaisaftab.bsky.social · 21/08/2026
Erotic Countertransference Disclosure & the Collapse of the “as-if” Relationship Some psychotherapists argue that erotic countertransference disclosures may serve a therapeutic function... but what are the pitfalls? Guest post by @frannyfanny.bsky.social www.psychiatrymargins.com/p/erotic-cou...
psychiatrymargins.com
Erotic Countertransference Disclosure and the Collapse of the “as-if” Relationship
Some psychotherapists argue that erotic countertransference disclosures may serve a therapeutic function... but what are the pitfalls?
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Mr. Chimpanzy @cyanescens.bsky.social · 19/08/2026
Great article (if you’re interested in such things) that I missed at the time:
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Awais Aftab @awaisaftab.bsky.social · 15/08/2026
Notes on Freud and Cocaine Sometimes cocaine use is just cocaine use, and sometimes it is a prelude to the development of psychoanalysis... www.psychiatrymargins.com/p/notes-on-f...
psychiatrymargins.com
Notes on Freud and Cocaine
Sometimes cocaine use is just cocaine use, and sometimes it is a prelude to the development of psychoanalysis...
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Shane Glackin @eltorosolo.bsky.social · 10/08/2026
The very excellent @awaisaftab.bsky.social had an excellent piece on the difficulties of deprescription just a couple of days ago: www.psychiatrymargins.com/p/psychiatri...
psychiatrymargins.com
Psychiatric Deprescribing as a Wicked Problem
Problems that resist definitive articulation
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Alex Mendelsohn, PhD @alexmendelsohn.bsky.social · 10/08/2026
Footnotes from the Margins I love footnotes, so I'm sharing my favs Steve Hyman (writing in @awaisaftab.bsky.social Psychiatry at the Margins) introduces a delightfully succinct word describing a complex idea. www.psychiatrymargins.com/p/a-note-fro...
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Sofia Jeppsson @jeppsson.bsky.social · 09/08/2026
www.cambridge.org/core/journal... Important piece by @awaisaftab.bsky.social . Whether it's better to stay on one's meds or come off them is a complex and value-laden question. Psychiatry must acknowledge this instead of labeling every desire to quit as "lack of insight" and force compliance.
cambridge.org
Clinical guidelines addressing complex and ‘wicked’ problems | BJPsych Bulletin | Cambridge Core
Clinical guidelines addressing complex and ‘wicked’ problems
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Awais Aftab @awaisaftab.bsky.social · 08/08/2026
Psychiatric Deprescribing as a Wicked Problem www.psychiatrymargins.com/p/psychiatri...
psychiatrymargins.com
Psychiatric Deprescribing as a Wicked Problem
Problems that resist definitive articulation
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Awais Aftab @awaisaftab.bsky.social · 01/08/2026
Adiposity by Self-Report What if obesity were invisible in the same way as ADHD is? www.psychiatrymargins.com/p/adiposity-...
psychiatrymargins.com
Adiposity by Self-Report
If obesity were like ADHD
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Awais Aftab @awaisaftab.bsky.social · 01/08/2026
Adiposity by Self-Report What if obesity were invisible in the same way as ADHD is? www.psychiatrymargins.com/p/adiposity-...
psychiatrymargins.com
Adiposity by Self-Report
If obesity were like ADHD
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enlightenededu.bsky.social @enlightenededu.bsky.social · 25/07/2026
The Principle of Rumpelstiltskin: Psychiatrists & Witchdoctors Torrey on the magic of the right word Awais Aftab 25 July 2026 @awaisaftab.bsky.social
open.substack.com
The Principle of Rumpelstiltskin: Psychiatrists and Witchdoctors
Torrey on the magic of the right word
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Awais Aftab @awaisaftab.bsky.social · 25/07/2026
The Principle of Rumpelstiltskin: Psychiatrists and Witchdoctors On how E. Fuller Torrey articulated the Rumpelstiltskin effect as a principle of psychotherapy a half century before @alanlevinovitz.bsky.social and I did www.psychiatrymargins.com/p/the-princi...
psychiatrymargins.com
The Principle of Rumpelstiltskin: Psychiatrists and Witchdoctors
Torrey on the magic of the right word
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Awais Aftab @awaisaftab.bsky.social · 19/07/2026
The Future of Withdrawal Studies Is Already Written Guest post by Adele Framer in response to my earlier post on predictions about the future of withdrawal studies www.psychiatrymargins.com/p/the-future...
psychiatrymargins.com
The Future of Withdrawal Studies Is Already Written
Guest post by Adele Framer
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Awais Aftab @awaisaftab.bsky.social · 11/07/2026
Forever Cousins: Relationships With My Voices “If I thought my voice was nothing more than random, psychotic noise, then that’s all she ever would have been.” Guest post by Amanda Peery-Wolf www.psychiatrymargins.com/p/forever-co...
psychiatrymargins.com
Forever Cousins: Relationships with My Voices
“If I thought my voice was nothing more than random, psychotic noise, then that’s all she ever would have been.”
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Alejandra Hope @alejandrahope.bsky.social · 05/07/2026
As always, excellent thoughts from Awais on the (mostly unfortunate) state of affairs in psychiatric practice these days:
"Therapy is not easy and it's particularly not easy when the patient is extremely emotionally unstable because they've never had a figure in their lives to help them contain their emotions. So, the whole point of therapy (not only for "borderline" patients but for all patients) is
for the therapist to act as a container: they need to remain calm enough, and neutral enough in order to gracefully receive the projections, identify with them
"just enough" so that they can understand them, contain them, then metabolize them, and then return them back to the patient in a more palatable and thinkable form.
And this is a lot to ask of a person but that's the job..."
- Orestis Zavlis, in conversation with Sorbie
In a recent exchange on Miss Apprehension, Zavlis offers a delightfully lucid Bionian picture of psychotherapy. The patient projects onto the therapist, on this reading, to communicate, to regulate, to evacuate an affect they cannot bear on their own. The clinician's task is to receive it, to identify with it just enough to understand it without being swept into it, to process it, and to return it in a form the patient can tolerate. "This is a lot to ask of a person," Zavlis writes, "but that's the job."
This last bit has been rattling around in my mind. Zavlis is talking about psychotherapists but it applies, in part, to psychiatrists as well since we deal with many of the same problems and the same patients. And yet it seems to me that the psychiatric community has decided that it is not, in fact, our job.Many "psychopharmacologists" (as well as nurse practitioners and other advanced practice providers who do a great deal of psychiatric prescribing these days in the US) adopt the attitude that they can be responsible for diagnostic assessments and medication management and do a good job of it while distancing themselves from the emotional lives of their patients. The psychological tangle of ambivalence, frustrations, idealizations, projections, etc., belongs to the therapy hour and to the therapist. The presence of these dynamics in the prescribing room is irksome, met with annoyance and impatience. The prescriber's remit is narrow and clean. "I'm just here to manage your medications. That sounds like something to bring up with your therapist."
The trouble is that this is not how prescribing works. (David Mintz's psychodynamic psychopharmacology is the prime source of wisdom here; see my_Q&A with him. The neurochemistry of illness exists in a web of temperament, medications carry meaning and emotional significance, treatment response and resistance are relational as well as pharmacodynamic, and the patient-doctor relationship exists in the graveyard of developmental history.
So affect does not stay politely in the therapist's office. It shows up wherever it needs to, wherever it must, in whether the patient takes the drug, in how they take the drug, in whether and how they experience its side effects, in the patterns of their exacerbations, in whether they feel heard and seen and how they act out, and in whether they need the treatment to fail. The prescriber who is unable to or refuses to metabolize the emotions finds that the undigested material returns to haunt the therapeutic relationship... as nonadherence, as nocebo, as the slow accretion of polypharmacy, as the "treatment-resistant" patient who is resistant in part because no one in the pharmacological relationship would hold their hesitation and fear and fury long enough to make sense of it.
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enlightenededu.bsky.social @enlightenededu.bsky.social · 05/07/2026
"Most psychiatrists do not need to be psychotherapists (I am not), but they do still need to be attuned to the psychological complexity of the whole person & the relational aspects of psychiatric treatment." 5 July 2026 Psychiatry at the Margins Awais Aftab @awaisaftab.bsky.social
open.substack.com
The Fantasy of Being “Just” a Psychiatric Prescriber
The job of containment and metabolism
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Awais Aftab @awaisaftab.bsky.social · 05/07/2026
The Fantasy of Being “Just” a Psychiatric Prescriber The job of containment and metabolism www.psychiatrymargins.com/p/the-fantas...
psychiatrymargins.com
The Fantasy of Being “Just” a Psychiatric Prescriber
The job of containment and metabolism
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Adam DeVille @adamdeville.bsky.social · 04/07/2026
Dr Aftab again raising crucial questions in psychiatric nosology.
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Awais Aftab @awaisaftab.bsky.social · 03/07/2026
What Psychosis Classification Can Learn from Epilepsy Classification The Future of “Schizophrenia” www.psychiatrymargins.com/p/what-psych...
psychiatrymargins.com
What Psychosis Classification Can Learn from Epilepsy Classification
The Future of “Schizophrenia”
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Laura Routh @laurarouth.bsky.social · 04/07/2026
“DSM-5 schizophrenia, however, is an awkward construct that cannot give up chronicity and cognitive impairment but also cannot commit to it.” It has always felt clumsy to me. Fascinating post!
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enlightenededu.bsky.social @enlightenededu.bsky.social · 04/07/2026
What Psychosis Classification Can Learn from Epilepsy Classification The Future of "Schizophrenia" 3 July 2026 Psychiatry at the Margins Awais Aftab @awaisaftab.bsky.social
open.substack.com
What Psychosis Classification Can Learn from Epilepsy Classification
The Future of “Schizophrenia”
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Awais Aftab @awaisaftab.bsky.social · 03/07/2026
What Psychosis Classification Can Learn from Epilepsy Classification The Future of “Schizophrenia” www.psychiatrymargins.com/p/what-psych...
psychiatrymargins.com
What Psychosis Classification Can Learn from Epilepsy Classification
The Future of “Schizophrenia”
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Awais Aftab @awaisaftab.bsky.social · 20/06/2026
On Suicidality Guest post by Sorbie Richner “Suicidality has been a main character in my life since I was a little kid. I started covertly making it other people’s problem starting when I was about 9 years old by externalizing it as rage…” www.psychiatrymargins.com/p/on-suicida...
psychiatrymargins.com
On Suicidality
Guest post by Sorbie Richner
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Awais Aftab @awaisaftab.bsky.social · 20/06/2026
On Suicidality Guest post by Sorbie Richner “Suicidality has been a main character in my life since I was a little kid. I started covertly making it other people’s problem starting when I was about 9 years old by externalizing it as rage…” www.psychiatrymargins.com/p/on-suicida...
psychiatrymargins.com
On Suicidality
Guest post by Sorbie Richner
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Awais Aftab @awaisaftab.bsky.social · 19/06/2026
Letter to the editor of the American Journal of Psychiatry, making a case that the future DSM should have an independent domain of psychological factors alongside social context, candidate biomarkers, and transdiagnostic features. psychiatryonline.org/doi/10.1176/...
Screenshot of the articleScreenshot of the article
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Awais Aftab @awaisaftab.bsky.social · 19/06/2026
The Dimensional Turn in Psychopathology: Q&A with Robert Krueger (Jan 2025) www.psychiatrymargins.com/p/the-dimens...
psychiatrymargins.com
The Dimensional Turn in Psychopathology: Q&A with Robert Krueger
Distinguished McKnight University Professor at the University of Minnesota
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Awais Aftab @awaisaftab.bsky.social · 18/06/2026
New and beautiful OUP volume on dimensional models of psychopathology
Me holding “The Oxford Handbook of Dimensional Models of Psychopathology”Table of contentsChapter 4. The Medical Model of Psychopathology
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Awais Aftab @awaisaftab.bsky.social · 16/06/2026
Check out the PPP special issue on philosophy of Hierarchical Taxonomy of Psychopathology (HiTOP) muse.jhu.edu/issue/56979
PPP June 2026 issue table of contentsPic of me holding the journal issue
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Alex Mendelsohn, PhD @alexmendelsohn.bsky.social · 15/06/2026
@awaisaftab.bsky.social sits between the critical and commendatory aspects of psychiatry, much to the annoyance of some of his new (ex-)subscribers... #FootnotesFromTheMargins www.psychiatrymargins.com/p/reflection...
1 Occasionally someone subscribes to the newsletter thinking that I share their
hostility towards psychiatry. They are understandably disappointed after reading
what I have to say, and then they'll unsubscribe with a frustrated note along the lines
of, “You just pretend to be critical!”
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Awais Aftab @awaisaftab.bsky.social · 13/06/2026
Some Predictions About the Future of “Withdrawal Studies” What we talk about when we talk about antidepressant withdrawal www.psychiatrymargins.com/p/some-predi...
psychiatrymargins.com
Some Predictions About the Future of “Withdrawal Studies”
What we talk about when we talk about antidepressant withdrawal
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Awais Aftab @awaisaftab.bsky.social · 13/06/2026
Some Predictions About the Future of “Withdrawal Studies” What we talk about when we talk about antidepressant withdrawal www.psychiatrymargins.com/p/some-predi...
psychiatrymargins.com
Some Predictions About the Future of “Withdrawal Studies”
What we talk about when we talk about antidepressant withdrawal
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koenfucius @koenfucius.bsky.social · 10/06/2026
Explaining schizophrenia, anorexia or autism by proposing ways they might offer advantages is tempting but almost always wrong. Diseases are not adaptations shaped by natural selection. @awaisaftab.bsky.social talks evolutionary psychiatry with Randolph Nesse: buff.ly/xK0itkD
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