By Stephen M. Raffle, M.D.

(Also Spelled Posttraumatic Stress Disorder)

Post-Traumatic Stress Disorder (PTSD) is a psychiatric condition originally diagnosed in soldiers. The earliest description was in the Crimean War. Since then it has had a variety of names attached to it such as shell shock (World War I) or war neurosis (World War II). It is an anxiety disorder arising as a result of an emotionally overwhelming experience. The symptom complex commonly includes nightmares that recapitulate the traumatic event, recurrent intrusive thoughts about the event, phobias (overwhelming fears) when the person is exposed to a situation reminiscent or resembling the traumatic event, and unbidden intrusive thoughts about the event. Continue reading… »

By Stephen M. Raffle, M.D.

There are a disproportionate number of litigants who have Borderline Personality Disorders than exist in the overall population, due to the nature of their behavioral traits. Continue reading… »

By Stephen M. Raffle, M.D.

Catastrophic Injuries—Traumatic Brain Injuries (TBIs) Post-Traumatic Stress Disorders, and similar events—are a significant aspect of my practice. A catastrophic head injury usually involves an element of brain injury. Diverse questions therefore are raised regarding the injured person’s competence to manage funds as well as the need for caregivers, the prognosis, emotional impact/distress (on the individual as well as the family/network), level of chronic pain, the need for treatment, testamentary capacity and undue influence. Continue reading… »

By Stephen M. Raffle, M.D.

I taught in the Department of Orthopedic Surgery at the University of California, San Francisco, School of Medicine for 15 years as an Assistant Clinical Professor of Orthopedics in my specialty of Psychiatry. My interest and focus of teaching was the emotional impact of chronic pain on patients. At the Back Clinic, I worked with medical students, interns, and residents in evaluating many hundreds of patients to help the treaters understand the effect chronic pain has on an individual. We also looked at the impact of psychopathology on the perception of pain. My instruction was directed at a clinical level, although some of the patients reevaluated were involved in medical-legal controversy. Continue reading… »

By Stephen M. Raffle, M.D.

As a forensic psychiatrist, I have been deposed about 500 times and been examined in about 150 trials. Because my field is so specialized, I believe it is one of my duties to assist attorneys in preparing cross-examination questions so the attorney can obtain the necessary information about psychiatric damages in order to understand the case better. Expert witnesses by their very nature are permitted to testify because they know and understand a body of knowledge that laypeople are not expected to know. Attorneys are laypeople as far as psychiatry is concerned; for that reason they deserve the participation of an expert to help them understand less obvious aspects of my specialty. When an opposing expert offers an opinion that is contrary to mine and is based upon certain evidence, I believe it is necessary for me to point out where the disagreement exists and why my position is the better one. This can become the basis for preparing attorneys for the cross-examination of another expert. By so doing, I believe I advance the truth-finding process, which is the purpose of a trial and certainly the purpose of discovery.

In greater depth, Dr. Raffle addresses this topic in the article posted on this site “A Few Thoughts About the Direct Examination and Cross-Examination of a Mental Health Expert Witness.” Read more…

By Stephen M. Raffle, M.D.

“Dangerousness” has three constituents: the assessment of risk (”risk factors”), the type of violence being predicted (”harm”) and the likelihood harm will occur (”risk”). (Violence and Mental Disorder. Monahan and Steadman. Univ. of Chicago Press. 1994). Dangerousness at the workplace takes many forms. I will be using the workplace as an example of one setting because so many people call me about HR addressing a coworker of whom others are afraid, but Dangerousness (a term of art) exists in any environment.  Stalking is another example of behavior which can be dangerous and should never be ignored.

The most common image is a worker losing control of his anger, getting a gun and shooting co-workers and anyone else who gets in his way. Fortunately, this is a rare occurrence. Less rare are situations where an employee is seriously depressed and, for example, tells a co-worker or manager he is suicidal, or wants to end it all, or is making inappropriate good-byes to those around him, or has had a series of uncharacteristic accidents at work which may endanger co-workers. Continue reading… »

By Stephen M. Raffle, M.D.

It is not possible to discuss Diminished Capacity without first understanding the legal concept of insanity since both are joined at their ideological hip by mens rea. Diminished Capacity, like insanity, is a legal concept not a medical diagnosis. I have discussed insanity in another section and will not repeat myself here.

The overarching principle of diminished capacity is that an accused’s level of responsibility for committing an illegal act is reduced because a mental disease or defect diminished his ability to form the intent to commit the act. The act itself must be in the “specific intent” category of crimes, such as murder. Continue reading… »

By Stephen M. Raffle, M.D.

There is no limit on the amount a jury may award for emotional distress. The only guidance for the jury is an amount a reasonable person could possibly estimate as fair compensation. Although a psychiatrist may not testify to the ultimate issue of the value of emotional distress damages, still he is permitted to provide useful information to the jury.

The California Supreme Court spoke on the matter of monetarily valuing emotional distress in Beagle v. Vasold, 65 Cal.2d 166, 53 Cal.Rptr. 129, 131 (1966):

“No method is available to the jury by which it can objectively evaluate such damages, and no witness may express his subjective opinion on the matter…In a very real sense, the jury is asked to evaluate in terms of money a detriment for which monetary compensation cannot be ascertained with any demonstrable accuracy. As one writer on the subject has said, “Translating pain and anguish into dollars can, at best, be only an arbitrary allowance, and not a process of measurement, and consequently the judge can, in his instructions give the jury no standard to go by; he can only tell them to allow such amount as in their discretion they may consider reasonable…The chief reliance for reaching reasonable results in attempting to value suffering in terms of money must be the restraint and common sense of the jury.”

The civil code of evidence permits a psychiatrist to contribute expert information to assist the jury’s deliberation:

The Mental Evaluation

It is not necessary for a plaintiff to have a mental examination in order to prove emotional distress and be compensated for it, nor for a psychiatrist to testify about the above four areas. A record review may be sufficient including sworn testimony taken at trial. When the occasion arises that an examination is conducted by a mental health professional, usually a psychiatrist or psychologist, then the scope of the examination must be established. This may include areas of inquiry, time to be spent, or the number of psychological tests to be performed. Most mental health professionals believe the broader the scope of inquiry, the greater the certainty of their opinions. The format of the evaluation includes examining the plaintiff with inquiry into areas which will reasonably yield information relevant to the case at hand. When indicated, collateral examinations are performed.

Whenever possible I want to review personally all medical records and all relevant deposition testimony, personnel records including military records, police records and expert reports including previous psychological testing raw data. Sometimes an executive summary of the review is prepared. Psychological testing usually is performed.

Upon completion of the total evaluation, I usually prepare a report explaining my opinions although an exception to this practice may occur if I expect to give expert testimony shortly after the evaluation. This decision is made in consultation with the referral source. In Federal court where a Rule 35(a) examination has been ordered, a report is required “if requested by the party against whom an order is made.” An “agreed-to” examination may expressly provide for a written report. Many attorneys have told me that when a plaintiff alleges emotional distress, this constitutes a good cause for the defendant to require the plaintiff to undergo a mental examination as part of the pre-trial discovery process. By so doing, other important information about the plaintiff also may be learned.

Emotional Distress is not a medical diagnosis, for example in the DMS-IV-TR. However, common examples of the manifestation of emotional distress are depression, depression related to chronic pain, anxiety, Post-Traumatic Stress Disorder (PTSD) and many, many other mental conditions linked to a cause of action, described among damages claimed, perhaps relevant to an issue of mitigation of damages, and other permutations, which I have come across in my career as a Forensic Psychiatrist. There is no substitute for a conversation about the details of a case (this includes issues of Fitness for Duty and Threat Assessment in the workplace setting). As we all know, what is obvious to one may be nuanced to another. I can be reached at (415) 461-4845.

You might find it interesting to read a Case Study I discuss: “Head Injury or Schizophrenia?”

By Stephen M. Raffle, M.D.

Mental and emotional injuries in employment litigation are damages usually sought by plaintiffs. These damages are generally subsumed under the category of “emotional distress” by which is included mental suffering, mental anguish, or mental or nervous shock as well as “all highly unpleasant mental reactions such as fright, horror, grief, shame, humiliation, embarrassment, anger, chagrin, disappointment, worry, and nausea.” Also included under emotional distress would be modification of dignity and physical pain. Generally speaking, emotional distress damages occur because the affected individual has suffered a loss of enjoyment of life Continue reading… »

By Stephen M. Raffle, M.D.

False memory syndrome may occur in a variety of settings, many of which end up in litigation. The litigation may be either civil or criminal. The false memory itself usually occurs during psychotherapy when the therapist suggests to patient that a particular event might have occurred or must have occurred, based upon the patient’s emotional response to a block in memory or a recollection. It is the process of suggestion in a susceptible person that creates the false memory, which then leads the patient to accuse another person of a wrongdoing that he did not commit. Continue reading… »

By Stephen M. Raffle, M.D.

Fitness for Duty examinations are asked for in my practice relatively frequently, and I have performed more than a thousand, for both public and private entities. Sometimes the exam is requested as a pre-employment evaluation because there is a past history of psychiatric illness. On other occasions, an employee has been taken off of work by a treating mental health professional, and the employer wants an independent evaluation of the employee before returning the person to work. Continue reading… »

By Stephen M. Raffle, M.D.

Once liability is established for any tortious act such as those in the caption as well as Wrongful Termination, the issue of damages arises. The damages may be expressed in a number of ways but they generally constitute “emotional distress.” Emotional distress may be measured by the need for psychological treatment or the impact on social functioning.

Many different psychiatric illnesses may arise as a result of these tortious acts. Continue reading… »

By Stephen M. Raffle, M.D.

Insanity is a legal concept, not a medical diagnosis. Historically, the Sharia, in Moslem law, may be the earliest example of a lesser punishment of a person who commits a homicide while in an altered mental state. Both children and “lunatics” are considered unable to intend to kill another and so a homicide by either was deemed unintentional, punishable only by a fine. Intentional or unintentional homicide is punishable by death.  

With the rise of humanism, the enlightenment, and the acceptance of the scientific method in Western cultures, a greater acceptance arose that a verdict of murder required both the act of killing another human being (actus reus) and the ability to have a guilty mind (mens rea). This is more or less the state of affairs today. Continue reading… »

By Stephen M. Raffle, M.D.

Malingering may occur for many reasons, usually involving self-preservation, but in a forensic context it occurs as an attempt to obtain money by lying. The essential characteristic of malingering is a person’s knowledge that a claim is not true; nevertheless the claim is asserted strongly or with a great deal of attention-getting behavior. Continue reading… »

By Stephen M. Raffle, M.D.

As a forensic consultant, I have frequently been asked to review medical records of an individual who is involved in a lawsuit and to provide consultation to attorneys as to what I find in the medical records that is relevant to the plaintiff’s alleged injury. Upon request, I am prepared to do this without preparing a written summary; if so requested, I will prepare a written summary for the referring party.

Medical records can contain revealing and diagnostically relevant material.  You might find it interesting to read the  Case Study (also on this site): “Head Injury or Schizophrenia?”

By Stephen M. Raffle, M.D.

The mind affects the way the body functions just as the body affects the way the mind functions. Psychosomatic Medicine is the study of this interrelationship. Certain aspects of this field are commonly accepted, such as the role of chronic anxiety on blood pressure; other aspects of it are in dispute or are areas of controversy, such as the role of chronic stress in the development of autoimmune disorders. With rare exceptions, the field of psychosomatic medicine is best addressed by a psychiatrist because psychiatrists are medical doctors. Continue reading… »

By Stephen M. Raffle, M.D.

The assessment of risk or threat of violence at the workplace or elsewhere is a difficult undertaking at best. During the course of over 30 years of psychiatric practice, I have examined approximately 150 murderers to determine whether or not some emotional component might mitigate their actions, the mens rea dimension of guilt. These assessments have provided me with a personal clinical experience for assessing the potential for violence and other anti-social behaviors. Continue reading… »

By Stephen M. Raffle, M.D.

The U.S. Department of Health & Human Services estimates 1 out of 7 females is sexually molested at some time in their lives. In general, the younger the age of molestation, the greater the damage. Sometimes, the damage is repressed, that is, the person puts it out of awareness but always remember it. When a child, male or female, is sexually molested, the child will inevitably undergo an emotional reaction. The reaction(s) may be emotional withdrawal, irritability, forgetfulness, behavioral problems at home and/or at school, inappropriate sexual behavior at school or elsewhere, depression, emotional isolation, sleep disorders, bedwetting, a reversion to baby talk, thumb sucking, or a general failure to reach the next expected stage of emotional development. Often the impact can be life‑changing. Continue reading… »

By Stephen M. Raffle, M.D.

The question of testamentary capacity traditionally arises within the context of the execution of a Will. I have performed many types of evaluations around this question: Continue reading… »

By Stephen M. Raffle, M.D.

Toxic exposure to certain substances is one of the causes of dementia. Please refer to my discussion of Traumatic Brain Injury and Other Dementias which touch on many of the same issues as dementia as a result of Toxic Exposure.

By Stephen M. Raffle, M.D.

Beginning in my residency and continuing thereafter, I have been interested in learning about neurological disorders which cause psychopathology. From 1971-1975 I was the neuropsychiatric consultant to the neurological rehabilitation unit at Herrick Hospital in Berkeley, California, and thereafter I treated mental disorders of patients who had neurological diseases. Years later, as part of my practice I was a neuropsychiatrist at Kentfield Rehabilitation Hospital, a facility which mainly treats neurologically impaired patients.

Assessment for forensic purposes of the impact of traumatic brain injury (TBI) on an individual’s functioning usually requires a multidisciplinary team which would include a psychiatrist who is experienced with the evaluation and treatment of TBI, a neurologist with similar experience, and a neuropsychologist who also is clinically involved in the evaluation and treatment of TBI. Continue reading… »

By Stephen M. Raffle, M.D.

Discharge is considered wrongful when it occurs as a breach of public policy. The public policy is expressed in the statutes of various (but not all) states, some state constitutions, and policies which forbid retaliation against an employee who has acted in a way the public would encourage, or not acting in a way the public would forbid. Continue reading… »

By Stephen M. Raffle, M.D.

Assessment of the impact of undue influence and its effect on limiting a person’s free will in making choices falls within the purview of the forensic psychiatrist. I have evaluated both civil and criminal matters on the issue of undue influence, usually within the rubric of testamentary capacity, but occasionally as an aspect of a cult. Continue reading… »

By Stephen M. Raffle, M.D.

Beginning in 1974 I performed worker’s compensation evaluations on a weekly basis Continue reading… »

By Stephen M. Raffle, M.D.

The clinical aspects of psychogenic pain have occupied my attention for many years. As Assistant Clinical Professor of Orthopedics at University of California San Francisco Medical School, for 15 years I focused my work in that Department as a psychiatrist on the assessment and treatment of chronic pain and psychopathology. The mind-body dichotomy has occupied physicians for hundreds of years because of the long appreciation about the ways in which the mind may affect the expression of clinical symptoms as well as how physical symptoms may affect the appearance and continuation of mental disorders. It is widely recognized and accepted that pain may have psychological origins as well as physical origins and that the expression of pain may be a symbolic expression of emotional disturbance, i.e., emotional pain. A related problem is a Conversion Disorder, where anxiety is converted into a physical symptom other than pain.

Pain is difficult to measure at best, although attempts have been made to do so. The Tourniquet Test is a measure of pain threshold perception, which generally is used in a laboratory setting, but may be used in a clinical setting. The Cold Water Immersion test is another means of measuring an individual’s perception of pain and pain threshold when compared to a normalized population. Continue reading… »