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CREW: Department of Veterans Affairs: Regarding PTSD Diagnosis: PTSD example

CREW: Department of Veterans Affairs: Regarding PTSD Diagnosis: PTSD example

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Published by CREW
CREW: Department of Veterans Affairs: Regarding PTSD Diagnosis; Number of Pages: 6; FOIA Request: CREW: Department of Veterans Affairs: Regarding PTSD Diagnosis; Holder of Document: CREW; Producing Agency: Department of Veterans Affairs (VA); Date Received: Dec 12, 2008;
CREW: Department of Veterans Affairs: Regarding PTSD Diagnosis; Number of Pages: 6; FOIA Request: CREW: Department of Veterans Affairs: Regarding PTSD Diagnosis; Holder of Document: CREW; Producing Agency: Department of Veterans Affairs (VA); Date Received: Dec 12, 2008;

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Published by: CREW on Apr 15, 2010
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11/14/2013

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COMPENSATION & PENSION - PSYCHOLOGICAL EVALUATION
CASE EXAMPLE #1

Mr. Brown is a 33 year-old non-service connected African American male veteran from Duluth,
MN. He was referred for psychological evaluation as part of a Compensation and Pension
Examination for Post Traumatic Stress Disorder (PTSD)

SOURCES OF INFORMATION & PROCEDURES ADMINISTERED:
Review of relevant records including C-file, DD-214, Clinical Interview (90 minutes); Minnesota
Multiphasic Personality Inventory-2 (MMPI-2); and the Mississippi Scale for Combat Related PTSD.

Mr. Brown presented for the interview in a polite and cooperative manner. He appeared to
understand the purpose of this evaluation as it relates to his claim for service-connected disability.
The veteran was provided with an informed consent form explaining that the test results and
interview would have limited confidentiality, and that a summary report of the assessment would
be forwarded to the ratings board. Exceptions of confidentiality and mandatory reporting
requirements were discussed with the veteran. The veteran understood the limits of confidentiality
and agreed to participate in the evaluation, as indicated by verbal agreement and the veteran\u2019s
signature on the informed consent. Mr. Brown initially expressed significant reservations regarding
how his possible psychiatric diagnosis might affect his employment in the future. We discussed
several scenarios where this might occur but after some deliberation, patient freely consented to
participate in the examination process.

MILITARY HISTORY:

Mr. Brown reported that he was enlisted in the United States Army June 1995 and served through January
2005; and was discharged under honorable conditions at the rank of E-4. He served in Iraq from October
2003 through May 2005 initially as a paratrooper and then serving with the military police doing guard
duty. He was awarded the Army Commendation Medal, Army Achievement Medal (2nd), Meritorious Unit
Citation Medal, Army Good Conduct Medal, National Defense Service Medal, Global War on Terrorism
Service Medal, and Army Service Ribbon.

When asked about the circumstances surrounding his filing this claim, Mr. Brown talked about
becoming more concerned with his symptoms (particular hypervigilance; these will be elaborated
below) since returning from Iraq, was wondering if they were normal, and if not, was help
available. Note: He reported that he has a 40% disability rating from the Army for his back and is
pursuing service connected disability through VBA. Later in the interview, it became clear that he
was not aware that compensation was available for mental health conditions.

CLINICAL INTERVIEW AND BACKGROUND INFORMATION:

Mr. Brown described his current mood as \u201cnormal \u2013 neither up nor down.\u201d He denied any
prolonged difficulties with sad or depressed mood. He talked about how he is a very positive
person and does not dwell on negatives. However, he did report experiencing brief periods where

his mood will drop when he thinks about things related to the war. Mr. Brown described significant
problems with middle insomnia mostly related to his waking up nightly in response to nightmares
about his experiences in Iraq (these will be elaborated on later). He said he is usually able to fall
back asleep but is may take a little while. He denied difficulties with decreased energy, feeling of
helplessness and hopelessness, suicidal thoughts, or disturbance of appetite. He did report some
difficulties with concentration and attention related to \u201cthinking back about the war\u201d. He talked
about how it requires a lot of effort to stay focused on what he is doing and getting his job done. He
also appeared to evidence anhedonia stating that that the only thing he enjoys is work. He said work
is very engaging for him and serves as a great distraction for \u201cnot thinking about the war.\u201d When
prompted again for things that he finds pleasurable, he could only state that he was very into sports
and physical activities in the past but cannot do them now because of his back pain.

Mr. Brown denied a history of symptoms indicative of manic/hypomanic episodes. He also denied
a history of paranoia and signs and symptoms indicative of psychosis. Patient did report that he
feels as though people may be watching him and he is on the alert for individuals who may leave
bags or brief cases behind, with their hands in their pockets, or those that make sudden moves. This
seems to not be specific to any person or group and appears to be reflective of hypervigilance rather
than paranoia.

MENTAL STATUS EXAMINATION:

Mr. Brown was cooperative with the assessment. He was alert and oriented x 4. He displayed no
problems with ambulating or gross motor control. Gross memory and cognitive functions were
intact. Speech was of normal rate, logical, and goal directed. He displayed no evidence of a
thought disorder or other overt psychotic processes. Mood was euthymic. Affect was consistent
with mood. He denied suicidal and homicidal ideation.

PTSD SYMPTOMS

When asked about how his experiences in Iraq and how they may have affected him or changed
him, Mr. Brown talked about how he is now extremely cautious about who is around him and what
they are doing. He also talked about being extremely cautious and aware when driving and never
being able to relax.

CRITERIA A: When asked about the most difficult or troublesome aspects of his time in Iraq, Mr.
Brown talked about the sound of mortars and explosions and the threat of suicide bombers coming
on base. He described several incidents where suicide bombers came on base and there were
explosions usually 100 to 200 feet from him. He talked about one particular incident in which he
cleaned up dead bodies and body parts resulting from a suicide car bomb. Patient talked about
feeling helplessness and horror in response to this event and other suicide bomber attacks. Note:
Later in the interview, patient also talked about seeing remnants of death everywhere including
body parts floating down the river. Patient meets Criteria A.

CRITERIA B: Mr. Brown reported significant re-experiencing of traumatic event. He reported that
he has intrusive thoughts related to his experiences in Iraq nearly every day. He said that several
times throughout the day he will think back about things that happened and dwell on them. He

talked about how this is distressing and very distracting from what he is doing at the time. He said
sometimes they are direct recollections of events and other times they are cued by triggers (will be
elaborated on later) that cause him to think back about people that were killed and other things that
happened. Mr. Brown described experiencing dreams and nightmares nearly every night related to
his experiences in Iraq. He said these are similar to the intrusive thoughts and that sometimes they
are direct recollection of events and sometimes they are loosely related to things that happened
during his time in Iraq. Patient reported that during the past Fourth of July he felt as though he was
actually back in Iraq and reliving experiences. He said the loud concussion explosions at the end of
the fireworks show felt exactly how the explosions felt in Iraq. Mr. Brown described intense
distress when encountering things that resemble or symbolize events such as loud noises, driving
by seeing objects by the side of the road, driving beneath under passes, other people carrying or
leaving objects or bags behind, or people with their hands in their pockets or making sudden
moves. He said these experiences are distressing and makes him feel flushed, short of breath, like
his body is getting hot, and with increased heart rate. Patient meets Criteria B.

CRITERIA C: Mr. Brown reported investing considerable energy into avoiding thoughts and
feelings related to his experiences in Iraq. He said he does not talk about his experiences with
anyone and does his best to keep these things out of his consciousness but is unsuccessful at times
as noted above. He said that he specifically avoids fireworks, groups of people in open areas,
newscasts and articles related to the war, pictures or images related to the war, and other soldiers
particularly injured soldiers. He also talked about avoiding war movies and that he enjoyed these
before going to Iraq. He denied experiences reflective of psychogenic amnesia. He denied
significant diminished interest other than sports related activities which appear to be related to his
physical health problems. He also talked about how he is not interested in being outside in large
groups of people anymore but this also appears to be reflective of avoidance and not diminished
interest. Mr. Brown described feeling detached and disconnected from other people. He said that he
confides in no one and although he has some friends, they know very little about his experiences
and, in fact, \u201cthey know not to ask me personal questions because they know not to.\u201d He added that
he has been in his current job since May of this year and although he gets along okay with his
coworkers is not close or friendly with any of them despite them having to travel and spend a lot of
time together for network installations. Mr. Brown described some restriction of affect but talked
about caring about people especially a couple of close friends who are still in the military. He
denied a sense of a foreshortened future and described several things that he would like to see occur
in the future. However, at the end of the interview he did express concern about how his symptoms
have been impacting his ability to do his job and how they may impact in the future especially with
them possibly interfering with his being able to consistently perform at a level that he expects too.
Patient meets Criteria C.

CRITERIA D: Regarding symptoms of increased arousal, Mr. Brown described significant
difficulties with middle insomnia, irritability, and hypervigilance. As previously noted he described
problems with nightmares almost every night and having difficulty getting back to sleep. He also
said that he is more irritable but attributed this to his pain. Note: The extent to which this may be
attributable to traumas experienced is unclear. Mr. Brown also described problems with
attention/concentration precipitated by intrusive thoughts related to his time in Iraq. In addition, he
described marked symptoms indicative of hypervigilance (this was well described previously) as
well as an exaggerated startle response. Patient meets Criteria D.

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