“Patients, including Veterans, are at 8 times the risk after head trauma, study finds…In this study of 559 patients with traumatic brain injury, more than half (53.1 percent) also endured major depressive disorder at some point during the study follow-up.”

…read the complete article at HealthDay.com Los Angeles Times, Booster Shots (Health Blog at latimes.com), “In concussion’s wake, sadness and anxiety thrive” By Melissa Healy, May 18, 2010

“In the year following a traumatic brain injury, roughly half of survivors likely experience a bout of clinical depression — a rate almost eight times higher than that found in the general population, says a study published Tuesday [5/18/10] in The Journal of the American Medical Assn.…And …reported significantly more pain, greater mobility problems and more difficulty carrying out their usual responsibilities than those who were not plagued by post-injury depression…”

“…Traumatic brain injury…sometimes called concussion…affects 1.5 million Americans yearly. Its symptoms are often subtle — including personality changes, problems of memory and concentration, headaches and mood disturbances…”  …read the complete article at latimesblogs.com/booster shots 

Reuters, “Major Depression Common After Brain Injury,” By Rachael Myers Lowe, May 18, 2010

Severe depression within the first year of a traumatic brain injury [TBI] is common but treatment is not,  Washington State Researchers Report.” …read the complete article at reuters.com

Research Referenced (in all articles) from The Journal of the American Medical Association: “Rates of Major Depressive Disorder and Clinical Outcomes Following Traumatic Brain Injury.” By Charles H. Bombardier, PhD; Jesse R. Fann, MD, MPH; Nancy R. Temkin, PhD; Peter C. Esselman, MD; Jason Barber, MS; Sureyya S. Dikmen, PhD. JAMA. 2010;303(19):1938-1945.

[Background: Col. Russell Williams in the Canadian Forces and a former Base Commander is accused in a string of murders, rapes, now 82 counts of breaking and entering and an unfolding story of escalating violent behavior. Toronto Star reporter Jim Rankin interviewed Stephen Raffle, M.D., and other forensic mental health experts to gain insight into Col. Williams' recent behavior in jail: a hunger strike, what appear to be suicide attempts and their meaning]

“…the major thing is loss of control and trying to remain in control of an out-of-control situation,” says Raffle, who has interviewed serial killers and gives expert testimony in criminal cases…Hypothetically, assuming that he did these things, there may be a sense of shame, and he sees (suicide) as an honourable way out,” says Raffle. “I think this is a man trying to regain control. It’s his only possible escape at this point….”   

…read the complete article at www.thestar.com

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.

The definition of unwelcomeness I use is “behavior not incited or solicited.” This definition is directly linked to attitudes and expectations by the aggrieved party and becomes part of the basis of my evaluation. If I am evaluating an employee for fitness for duty and he/she is said by others to have engaged in threatening, bullying, sexual touching, or other unwanted or unsolicited behavior, then I may have a person who is creating a potentially hostile work environment. If the examinee denies the behavior, then I must examine him/her for underlying psychopathology to assess the level of reality he/she is operating in (reality testing). The person may feel justified in the behavior due to a belief the object of attention wants it, e.g. a sexual relationship. Also I must consider the idiosyncrasy of the person I’m examining, especially in civil litigation, but also in fitness for duty exams. For example, one person may claim a hostile work environment and harassment because a co-worker chews and cracks gum. Such hypersensitivity doesn’t create an abusive work environment. To determine “idiosyncrasy,” I try to apply a “reasonable person” test to the alleged wrongdoing and complaint.

One “take away” from all of these parameters and perspectives is that too often employers who seek a fitness-for-duty exam for an employee vis-a-vis the employee’s ability to work, fail to consider that his/her identified behavior may be creating a hostile work environment for co-workers or supervisors.

Postmenopausal Women Taking Antidepressants May Be At Risk
“Postmenopausal Women Taking Antidepressants May Be at Higher Risk for Stroke, Death,” Los Angeles Times, By Melissa Healy, December 14, 2009. See below.

Family Doctor Keeping an Eye out For Depression
“Doctors Called on to Screen All Adults for Depression,”Amednews (published by the American Medical Association), By Kevin B. O’Reilly, October 26, 2009. See below.

Housing the Mentally Ill - The Courts Decide
“State Discriminated Against Mentally Ill, Judge Rules,” New York Times, By James Barron, September 8, 2009.

Mental Health: “ARMY STRONG”?
Articles from the New York Times and CNN@AOL.com. See below.

Mind/Body Connection: Does Exercise Diminish Depression?
“Exercise helps fight depression,” Los Angeles Times, By Jeannine Stein, August 3, 2009. See below.

PTSD - Dementia Link?
“Vets with post-traumatic stress are at high risk of dementia,” USA Today, By Mary Brophy Marcus, July 12, 2009. See below.

Post-Traumatic Stress, Autism Covered by Insurance? Mental and Physical Illness Gap Closing in Massachusetts Under New Law
“Widened Mental Benefits Pose Test,” The Boston Globe, By Kay Lazar, July 6, 2009. See below.

Referenced Research: “Antidepressant Use and Risk of Incident Cardiovascular Morbidity and Mortality Among Postmenopausal Women in the Women’s Health Initiative Study,” Smoller et al., Archives of Internal Medicine 2009; 169: 2128-213.

“Post-menopausal women taking antidepressants are at higher risk of suffering a stroke or of dying of any cause than are those who do not take such medications,” a study released Monday found.

“The authors of the study, published in the Archives of Internal Medicine, called the increased risk a woman faces modest. But they noted that since post-menopausal women make up the largest segment of patients in the United States on antidepressants, the resulting increases in strokes and deaths across the country could be significant…”

…Read the complete article at latimesblogs.latimes.com/booster_shots

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.

The current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) is more than 900 pages long and describes in detail most of the psychiatric disorders which exist and their characteristics. It describes psychopathology, which is to say psychiatric malfunctioning. The DSM also categorizes “other conditions or problems which may be the focus of clinical attention,” but which is not the result of a mental disorder, or the individual has a mental disorder but it is unrelated to the problem, or the individual has a mental disorder that is related to the problem but the problem is sufficiently severe to warrant independent clinical attention.

One of the “other conditions” is Occupational Problem (DSM-IV-TR 62.2). I have evaluated employees who have been identified by their company as having an “Occupational Problem” because the person isn’t working well with others. The question to be answered for the employer is whether or not the occupational conflict / controversy / difference of opinion / “disability” / stress is due to psychopathology. Sometimes there is no diagnosable psychiatric disorder causing the workplace problem but personality traits (not considered pathology) exist in the person which are contributing to the problems. For example, the person may have paranoid personality traits which do not fulfill the diagnostic criteria for a Paranoid Personality Disorder but nevertheless cause the person to misperceive and unconscientiously (unintentionally) distort verbal and non-verbal communications between him and others. He may feel belittled, persecuted, stressed, anxious, or mistrustful, but not to the level of diagnosable pathology. This creates interpersonal difficulty which then becomes the performance problem of an employee not following instructions from others, not getting along with others, creating a disharmonious – not hostile – work environment, and doing the job he was hired for. The dispute, though framed as workplace dysfunction, becomes an “Occupational Problem” not due to psychopathology, because no underlying diagnosable psychopathology exists. The resolution of the problem becomes administrative/managerial and not medical.

Workplace maladaptive behaviors are not considered to be intrinsically psychopathological because maladaptive workplace behavior in and of itself doesn’t define a specific psychiatric condition, i.e. psychopathology, as described in the various DMS diagnostic categories. The legal implication of the maladaptive occupational behaviors is that the employee’s workplace problems are not causing a disability, as described by the Americans with Disabilities Act (ADA), because psychopathology is absent, and therefore the employer is not required to provide reasonable accommodation.

Once a diagnosis of Occupational Problem (DSM 62.2) is made, questions of whether or not, and to what extent, the employer investigates complaints about the employee’s workplace performance, and takes administrative action, is not a medical matter, and is beyond medical/psychiatric expertise.