When Medical Illnesses Masquerade as Mental Ones
UCSF Osher Center for Integrative Medicine Mini Medical School for the Public, University of California Television (UCTV)
Not all episodes of disturbed or altered behavior can be attributed to purely psychiatric conditions. Many medical problems can present with predominantly behavioral symptoms. Dr. Paul Linde, Clinical Professor of Psychiatry at UCSF, explains that to discover the root cause of these so-called "medical mimics," one must start with an "index of suspicion" and continue the investigation with the clinician's basic tools of history, mental status description, physical examination, and diagnostic testing to uncover the potential medical causes of psychiatric symptoms. Putting together the multiple pieces of a clinical puzzle, accomplished in part by creating and considering a differential list of possibilities, is one of the most satisfying tasks for the psychiatric sleuth. Series: "UCSF Osher Center for Integrative Medicine presents Mini Medical School for the Public" [2/2014] [Health and Medicine] [Show ID: 25803]
Runtime: 88 minutes


Dr. Linde will be interviewed live from 11am to 12pm PST on Monday August 19, 2013 regarding the fate of the seriously psychiatrically ill under health care reform on the online radio program 'Leading Minds by Dr. David Brendel'" The show can be found at

Paul was interviewed by KVIE-TV, a public station in Sacramento, for the documentary "Each Mind Matters" about California's homeless mentally ill. It aired widely on California's public television stations on May 30, 2013 and can be viewed here:

"Danger to Self: On the Front Line with an ER Psychiatrist" is now accessible as an audio book via Audible, Inc.

Available on iTunes and The book is narrated by actor Kirby Heyborne and runs just over 8 hours in length. Also available for the Kindle.

Buy It Here

Accolades & Awards

Paul Linde, 2011 Media Award by NCPS (Northern California Psychiatric Society)
The Media Award, given to a journalist who brings public attention to issues related to mental health was presented to Paul Linde, MD for his book Danger to Self, documenting the world of a psychiatric emergency room.

Psychology Today Blog

Paul is now blogging for the renowned journal Psychology Today. Click on the blog link to read his posts and subscribe via RSS to the feed.

I Haven't Seen the Evidence for Evidence-Based Psychiatry
Patient! Are you a person or a collection of symptoms?
Published on April 15, 2011 by Paul R. Linde, M.D. in The Everyman Psychiatrist

"Patients don't read the textbook" is a perennial truism in medical education, especially in teaching students, interns, and residents how to treat patients. And for good reason. Real patients present with multiple problems simultaneously and, furthermore, some of these issues are not suitable to being medicalized. There are existential, spiritual, social, and moral problems not amenable to facile categorization.

When you go see your doctor, would you rather be seen as a collection of sortable symptoms or as a real-live complex human being? One problem with evidence-based clinical research in psychiatry is that it looks at data collected from the grouping of multiple patients. This data may or may not pertain to you as an individual patient.

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Reviews and Press

Dr. Linde presents Danger to Self to Solano College Accelerated English Class
The Tempest: The Voice of Solano College | Ashley Ching | October 31, 2012

Dr. Linde will present his book, Danger to Self: On the Front Line with an E.R. Psychiatrist to an accelerated English class at Solano College on Nov. 9.

Danger to Self— The Combat Zone of the ER Mental Crisis Ward
The Bright List | Aretha Bright | October 09, 2012

This is an ER psychiatrist's story from the front lines of mental illness and acute situations. This book reminded me why I got my psychology degree in the first place— It should be the next doctor soap on TV.

Linde's book consists of ten case studies drawn from 17 years of working in the high-pressure atmosphere of the Psychiatric Emergency Service at San Francisco General Hospital.

Linde's use of a combat metaphor isn't accidental. The mental health pros at SF General deal with a flood of patients who are hallucinating, drunk, catatonic, aggressive, severely suicidal, high on drugs, paranoid, and physically sick. I couldn't believe some of the stories. Their decisions need to be made as quickly as any physician's, and making the wrong call could have consequences just as lethal as in surgery.

This is the Wild West of medical dramas—and it's all true.
--Aretha Bright

Bush Official John P. Wheeler Murder Case Deepens
The Daily Beast | by Pat Wingert & Christine Pelisek | January 5, 2011

Paul is quoted in this article saying “Friends of Wheeler's told The Daily Beast that they were unaware of any health problems that might be related to such uncharacteristic and bizarre behavior. Paul Linde, an emergency psychiatrist at the University of California San Francisco, said that disorientation that lasts for days can be caused by any number of medical or mental issues, including heart problems, stroke, stress, past mental illness, or a problem with medication.
But Linde said he didn't think that someone Wheeler's age was a likely candidate for a first-time psychotic episode. "It sounds like he had a break from reality, but it is hard to speculate on what could have caused it," he said. While Wheeler's death has been ruled a homicide, police say they are waiting for the results of toxicology tests before announcing a specific cause of death.”

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“Danger to Self” was named on the San Francisco Chronicle's list “Best of 2010 -- Books by Bay Area Authors”.
S.F. | December 19, 2010

See the full list

Danger to Self: On the Front Line with an ER Psychiatrist Review
By Mark H. Fleisher, MD - University of Nebraska College of Medicine, Omaha
JAMA Journal of the American Medical Association
Wednesday, August 10, 2010

In DANGER TO SELF psychiatrist Paul Linde takes readers to places few have been. In a book that may humor, shock, or enlighten, readers are taken into the jails and emergency departments that deal with the interface between the institutions of society and citizens in emotional crises or on the slippery slope of mental illness or those playing the role of being danger to themseslves for personal gain. Few psychiatrists are exposed to the near-constant stress of emergency psychiatry. Far fewer still choose these unique theaters for their clinical practice, as Linde did because it suited his temperament. Thankfully some physicians thrive on that life.

Read the Full Review (pdf)

When politics and the law determine psychiatric practice
By Dennis Rosen, MD | Division of Respiratory Diseases | Children's Hospital Boston | Harvard Medical School | Boston, Mass.
CMAJ, May 17, 2010

Dr. Paul Linde, an attending physician with the psychiatric emergency services at San Francisco General Hospital, California, senses sometimes that his work is derided by colleagues in other, more “glamorous” branches of medicine as “meatball... or veterinary psychiatry” and not given the respect it deserves. In this book, which chronicles some of his professional experiences and highlights a number of ethical and moral dilemmas he has had to wrestle with during his career, he defends his professional choice, noting that the work he and his coworkers do “is deeply rooted in respect for the patient. Most of us want to help people who have been left behind and forgotten by society.”

Read the Full Review (PDF)

The Other ER: Human tragedies unfold in the psychiatric emergency room.
By Anneli Rufus, East Bay Express
Wednesday, April 14, 2010

The young man had just had his stomach pumped after downing a hundred ibuprofen and untold quantities of alcohol. The previous day, he'd been dumped by his girlfriend during a transatlantic call. At San Francisco General Hospital, the young man promised Paul Linde that he wouldn't try to kill himself again. Linde, a psychiatrist tasked with deciding whether patients should be retained or released, let him go. Three days later, the young man hanged himself.

Viewing this tragedy through what he sardonically dubs a "retrospectoscope," Linde airs his regrets in Danger to Self: On the Front Line with an ER Psychiatrist, a moving memoir that offers a rare look at SF General's psychiatric emergency room, where Linde and his colleagues strive to help those he calls "society's most disenfranchised and hopeless."

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‘Danger to Self’ a wild yet poignant look into the life of an ER psychiatrist
By Tom Larson, Morris Sun Tribune
Thursday February 19, 2010

Paul Linde still wonders why he does what he does. In the myriad medical careers he had to choose from, why psychiatry? And as his career in the field unfolds, why, in middle age, does he still venture daily into the chaotic, soul-chilling and often dangerous world of a big-city hospital’s psychiatric emergency room?

Linde’s book, “Danger to Self -- On the Front Line with an ER Psychiatrist,” is a vivid look at the patients, staff and politics alive in an environment most people can scarcely imagine, much less ever experience first-hand.

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More Reviews, Press and Articles

Danger to Self

on the front line with an er psychiatrist

The psychiatric emergency room, a fast-paced combat zone with pressure to match, thrusts its medical providers into the outland of human experience where they must respond rapidly and decisively in spite of uncertainty and, very often, danger.

In this lively first-person narrative, Paul R. Linde takes readers behind the scenes at an urban psychiatric emergency room, with all its chaos and pathos, where we witness mental health professionals doing their best to alleviate suffering and repair shattered lives.

As he and his colleagues encounter patients who are hallucinating, drunk, catatonic, aggressive, suicidal, high on drugs, paranoid, and physically sick, Linde examines the many ethical, legal, moral, and medical issues that confront today's psychiatric providers. He describes a profession under siege from the outside-health insurance companies, the pharmaceutical industry, government regulators, and even "patients' rights" advocates-and from the inside-biomedical and academic psychiatrists who have forgotten to care for the patient and have instead become checklist-marking pill-peddlers.

While lifting the veil on a crucial area of psychiatry that is as real as it gets, Danger to Self also injects a healthy dose of compassion into the practice of medicine and psychiatry.

Paul R. Linde, MD

Paul R. Linde, M.D., a San Francisco based author and clinical professor of psychiatry at the UCSF School of Medicine, has worked in several high-intensity psychiatric settings over the years. His first book, Of Spirits and Madness: An American Psychiatrist in Africa, was published by McGraw-Hill in 2002. Linde has also written for JAMA, the San Francisco Chronicle, the San Jose Mercury News, and DoubleTake magazine. He lives in the San Francisco Bay Area with his wife, two sons, and a rambunctious one-eyed dog. Dr. Linde's Bio


A Day in the Life of PES: Twenty-Four Hours at the Psychiatric Emergency Services Department of San Francisco General Hospital
David Elkin, MD; Paul R. Linde, MD; and Eric Woodward, MD | San Francisco Medecine, Journal of the San Francisco Medical Society | "Extreme Medicine" Vol. 82, No. 2 | March 2009

It's 7:00 a.m., and a group of a dozen men and women-psychiatrists, social workers, nurses, and other mental health personnel-are gathered around a desk in the staff room, per- forming the daily ritual of the morning report in the Psychiatric Emergency Service (PES) at San Francisco General Hospital. A glowing LCD screen-one of few high-tech devices in an otherwise outdated and unadorned space-displays patients' names, diagnoses, and lengths of stay. Almost all of the twenty patients (an average case load) are in PES on an involuntary basis.

The State of California's Welfare and Institutions Code 5150 provides the legal justification for a person to be involuntarily taken into custody for up to seventy-two hours for an evaluation on the basis of being a danger to self, danger to others, and/or gravely disabled on the basis of a psychiatric illness. The PES at San Francisco General is open for business 24 hours a day, 7 days a week, 365 days a year. It is the only designated receiving facility in the city for people placed on 5150 psychiatric holds.

Often, working in PES can be compared to diving into the swirl of a cyclone and hanging on for dear life. The staff adjusts to the velocity and spin enough to manage as many as four equally compelling tasks at the same time. It helps to come equipped with an unusual combination of keen diagnostic skills, a sense of humor, tolerance for ambiguity, and the ability to react quickly to changing circumstances.

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