By Stephen M. Raffle, M.D.

Beginning in 1974 I performed worker’s compensation evaluations on a weekly basis until 1993. During that 1000 week – 2000 case time span, I saw many different combinations and permutations of symptoms and disability. Because of my exposure to and familiarity with orthopedic injury, chronic pain, concurrent psychopathology and complex disability issues, I was appointed Assistant Clinical Professor of Orthopedic Surgery at UCSF Medical School in 1984 and thereafter taught about this complex interface until I stepped down in 2000.

Between 1993 and 2009 I pursued other clinical and forensic psychiatric interest. During this time I retained a warm professional friendship with John Warbritton, III, M.D., an orthopedist, and beginning in 2000 we shared offices although our practices remained separate.

In 2009, Dr. Warbritton began the Warbritton Associates Impairment Rating Specialists and he invited me to join, which I did. Presently, I am scheduling one (1) QME or AME psychiatric evaluation per week.

Evaluations can be scheduled with Wairbritton & Associates Impairment Rating Specialists at (510) 251-8851 or my office directly at (415) 461-4845.

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. A relatively easy and standardized test for pain measurement is the McGill Pain Inventory, which assists the clinician in identifying various components of pain. Sternbach first published the McGill Pain Inventory data in 1976 and since then many investigators and clinicians, myself included, have found it a useful adjunct in assessing the quantity and quality of a person’s complaint of pain.

In my clinical experience, the best assessment of pain complaints is the diagnostic psychiatric interview. Here, I assess the interaction between emotional conflict and complaint of physical pain.

Ultimately, pain, be it psychogenic, physical or an admixture of the two, is a symptom and not a disease. I must identify the underlying cause of the pain and explain it. Treatment should be directed at the source of the pain, although symptomatic reduction of pain perception often is necessary while other measures are taken.

Some of the causes of pain with a psychiatric component include but are not limited to pain as a depressive equivalent, pain as a conversion type disorder, delusional pain, sexual pain disorders such as pain with intercourse or pain due to chronic spasm of the vagina, pain associated with drug withdrawal and pain associated with a wide variety of medical conditions such as diabetic neuropathy, migraines, or chronic back pain. Pain may arise from physical injury from which a psychological injury results. The psychological injury may be experienced as a heightened perception of pain, in excess of what is expected only from the seriousness of the physical injury. Chronic pain conditions often benefit from psychiatric intervention in order to help limit the use of habituating drugs.

The augmentation of pain by psychological factors in the presence of bona fide physical pain commonly occurs if, for example, an individual has been in a motor vehicle accident, or suffered a Post-Traumatic Stress Disorder, with depression and also suffers from a physical injury. The psychiatric conditions may magnify the perception of pain because the individual’s coping skills to deal with the pain are diminished due to the presence of emotional difficulties and the debilitating effects of the physical injury. This, then, would constitute a pain disorder with both psychological factors and a general medical condition.

In the Back Clinic at UCSF when I was teaching there, it was not unusual to see patients who were suffering both from physical injuries and psychological injuries, which taken together incapacitated the person more than either circumstance would have by itself. As such, there existed a synergism between the emotional and physical problems, which may be as a whole greater than the sum of the parts. Aggressive treatment of both aspects of the pain was necessary for relief.

Particularly in litigated situations, I, as the forensic evaluator, must also be aware that some individuals intentionally embellish existing pain symptoms or create complaints when none actually exist. This is malingering, lying for a profit.

By Stephen M. Raffle, M.D.

(Sometimes 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 plaintiffs 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.

These assessments usually require the participation of other physicians or mental health professionals, such as neuropsychologists. As a rule, the assessment of a catastrophic injury is extremely time-consuming; the expert must be prepared and available to spend the necessary time to understand the dimensions of the case. Psychiatrists who only occasionally undertake forensic evaluations generally do not have either the experience in assessing a catastrophic injury or the time necessary to satisfactorily perform the assessment. Treaters commonly do not have the time available to work up such cases because their focus is on treatment and not on the forensic ramifications.

In catastrophic injury cases, the expert must be prepared to write a lengthy, comprehensive medical-legal report so that all parties can understand the dimensions of the case—emotional distress, prognosis, any likelihood that permanent disability will result, the need for treatment and its types and costs, including those for therapists, care and caregivers, medication, and long-term neuropsychological rehabilitation, and other relevant issues—to help the attorneys on both sides and the plaintiff understand the various needs of the plaintiff has and the financial consequences.

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.

In 1973, Dr. William Collins, Professor of Neurosurgery at Yale, described the salutary effect of Elavil and Prolixin on the perception and experience of pain. This was an empirical observation on his part, although later research revealed there is an overlap between the chemical mediators of pain and the chemical mediators of depression, the dopamine system. The use of antidepressant medication for the treatment of chronic pain gradually became accepted more widely, not as a treatment of depression arising out of pain but rather as a treatment of the neurotransmitters associated with pain. Researchers examining the relationship between the existence of preexisting depression and the subsequent development of chronic pain found a positive correlation between the two. This psychobiological nexus also became more widely accepted once specialists in different fields began to appreciate the contributions other specialists could provide.

It is difficult to quantify pain, although certain clinical assessment tools provide some differentiation between the physical component and the emotional component of pain. I use these tools frequently in my practice as a forensic psychiatrist and they help establish the basis of my opinion regarding the extent, duration, and internal clinical consistency of complaints made by individuals who claimed to be suffering from chronic pain.

Recent research indicates that individuals who do not have their lingering pain adequately treated develop certain feedback loops at a subcortical level, which cause the persistence of pain to develop. These feedback loops are biologic in origin, not psychologic, and often are difficult to treat. Individuals with chronic pain are prone to physical and psychological dependencies on analgesics such as OxyContin, and as a result are challenging to treat. A part of my forensic practice has been to assess the nature of such dependency and/or abuse and whether or not it was iatrogenic(caused by the diagnosis, manner, or treatment of a physician). There have been occasions when the patients taking medication in excess of that prescribed by their treating doctor later blame the doctor for causing a dependency that they themselves brought on. There are other times, however, when individuals become dependent because the treating physician has not been judicious enough in monitoring the amount of medication prescribed. Instances have also occurred in which an individual has more severe pathology than the doctor had diagnosed, causing the person to become susceptible to developing the chronic pain syndrome. In such cases the doctor did not prescribe an aggressive enough therapy regimen to control the pain, leading to the development of the feedback loop that is a component of a chronic pain syndrome.

Chronic pain itself is a complicated topic to assess, but with care, the various components can usually be examined for their contribution to the development of the syndrome.

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 Continue reading… »

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. 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.

Stalking behavior is inherently dangerous. Stalkers are obsessional, that is they have a fixed idea and feeling they can’t diminish without acting in a certain way. Think John Hinckley stalking Jodie Foster and then shooting President Reagan to get her attention. An analogous situation may be an employee romantically fixated on a co-worker turning up unannounced at the co-worker’s house when their social relationship doesn’t warrant this behavior, or telephoning her (usually a woman) repeatedly. This is a boundary crossing. Other boundary crossings occur where an employee is stalked at the workplace by a rejected lover or spouse or an employee may be the love object of a delusional person. These are volatile situations and inherently highly dangerous.

Most violence between co-workers is preceded by warnings. Understanding a warning when it occurs permits a rapid, appropriate effective response, thus increasing the safety of the workers, the workplace, and the organization.

Other behaviors which may be warnings of dangerousness in an employee:

• Chronic drug or alcohol abuse
• Escalating conflicts with co-worker(s) with expressed, implied or symbolic threats
• A failure to respond to supervision/limit setting
• A recent past history of physical fights and assaults by an employee
• Verbal aggression
• Intimidating behavior
• Mood swings, extreme moods, angry outbursts
• Someone taking out a restraining order an employee
• Irrational sensory experiences such as voices telling the person to act in a violent manner (command hallucinations)
• Irrational beliefs and/or accusations about others planning to harm the person
• An expressed sense of entitlement for one’s job
• Preoccupations about violence
• Employee(s) complaining he/they are afraid to work with a co-worker and want to be transferred.

When unaddressed complaints about dangerousness persist at the workplace, the potential exists for allegations by employees about a hostile work environment, harassment, or even constructive termination.

Once a “warning sign” is identified, understanding the degree of actual risk usually requires professional judgment. The determination is usually accomplished through a fitness-for-duty examination and threat assessment, and can also be accomplished by interviews with the complaining persons and obtaining other background information. Differentiating degrees of risk is difficult to establish without a thorough mental examination of the person by a qualified psychiatrist or psychologist experienced with this type of evaluation. Making this determination enables the human resources department to make a proper intervention in order to ensure this individual does not continue to create a hostile work environment by harassing co-workers or is dangerous to himself or others. A no-risk or low-risk determination also is helpful for HR and the complaining parties.

When “Dangerousness” exists, a rapid response is indicated. A variety of precautions are available even before an evaluation of fitness-for-duty/risk assessment. Because these situations are inherently unstable, the early involvement of an experienced professional to provide guidance is invaluable to reduce the likelihood the situation inadvertently escalates.

Read more about Risk/Threat Workplace Violence Assessment.

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.

Some law-and-order social philosophers and moralists have objected to the concept of Diminished Capacity because it creates a nuanced grey area of relative wrongdoing. They prefer an “all or nothing” approach to responsibility: if you do the act, you do the time. But what if there is impaired understanding? “Diminished capacity” emerged out of complex cases with just such nuances.

In California, the legal concept of Diminished Capacity was introduced by Bernard Diamond, M.D., my teacher and mentor, who was then Professor and Chair of Criminology at U.C. Berkeley, Professor of Law at Boalt Hall at U.C. Berkeley, and Professor of Psychiatry at U.C. San Francisco. He reasoned that was not all or nothing and limited to insanity but that a transition area existed between insanity and full competence to form intent. The transition between the two constituted a diminished capacity to form intent which could lead to less responsibility. Following the introduction of the concept of Diminished Capacity or Diminished Responsibility (depending on the jurisdiction) in an article in the Stanford Law Review, case law began to be published in the federal, military and in various states’ appellate courts citing this article and others defining what was meant by capacity being “diminished.”

In my practice, I have examined many defendants about their level of mens rea.

The mental illnesses which could lead to diminished capacity are a heterogeneous group. The expected conditions are there: Schizophrenia, Manic-Depressive illness (Bipolar Disorder), Post-Traumatic Stress Disorder (PTSD), Mental Retardation, Dementia, Dissociative states, intoxication, obsessions and compulsions (for irresistible impulse). Certain medical conditions also affect the ability to form intent such as medical shock due to blood loss or drug reactions.

Over time, a perception arose with the public that a creative defense attorney could “diminish” the prosecution’s prima facie case and reduce punishment with a clever psychiatric hypothesis which was expressed as an opinion. In California, the legal “last straw” was the successful defense of Dan White’s revenge murder of the Mayor of San Francisco, George Moscone, and gay Supervisor Harvey Milk, using the (misnomer) “Twinkie Defense.” The popular perception was that after Supervisor Dan White, who was hypoglycemic, ingested sugary Twinkies, he could not fully form the intent to sneak into City Hall, search out the Mayor against whom he held a grudge (because the Mayor refused to rescind White’s recent protest resignation from the City Council), shoot him, and then proceed to the other end of the building to hunt down and kill Harvey Milk, his repeated antagonist on the City Council. In fact, testimony of psychiatrists and psychologists was that Mr. White had been suffering bouts of depression and bipolar mood swings, aggravated by a number of factors, and, more as an after thought, a junk food diet which caused hypoglycemia. Jurors believed his capacity was diminished and found him guilty of a reduced charge. (Dan White was convicted of voluntary manslaughter, served approximately five years, and about two years after his release, committed suicide).

White’s perceived acquittal raised a public hue and cry and mobilized State legislators who, I think, identified with the slain public officials, and enacted legislation to do away with the Diminished Capacity defense in California. An “actually formed” mens rea defense became necessary. The new statute states at Sec. 28(b): “There shall be no defense of diminished capacity, diminished responsibility or irresistible impulse.” Sec. 29 states that experts testifying about the defendant’s mental condition “shall not testify as to whether the defendant had or did not have the required mental states” because that “shall be decided by the trier of fact.” Nevertheless, experts are permitted to testify about the “actually formed” mental state, which has led to some confusion as to what the expert is permitted to testify about. Generally, the expert is permitted to testify about the seriousness of the mental illness or mental state at the time of the commission of the act, but cannot testify that the condition diminished the person’s capacity to form intent as related to the facts. The jury is required to bridge the gap between the psychiatric information (”actually formed” mental state) and the jury instructions related to diminished capacity without testimonial opinions by experts whose expertise could assist the trier of fact about information a layman is not expected to know.

The California Supreme Court discusses this legislation in People v. Saille 820 P.2d 786 (1991).

I have testified in many insanity and diminished capacity criminal trials over the years both for prosecution and defense, at state, federal, and military levels.

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. Continue reading… »

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.

At this time, my associate Dr. Shahla Chehrazi, a Child and Adolescent Psychiatrist, conducts medical‑legal evaluations of younger childhood sexual molestation. I do such assessments for older, more verbal children, adolescents, and adults. We are always alert to false memory syndrome issues in these assessments.

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… »