COMPENSATION & PENSION - PSYCHOLOGICAL EVALUATION

CASE EXAMPLE #2

Mr. Thomas is a 40 year-old married, service connected (40% total for back pain, and right and left
shoulder tendonitis) Caucasian male veteran from Detroit. 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, available medical records, Clinical Interview (90
minutes); Minnesota Multiphasic Personality Inventory-2 (MMPI-2); and the Mississippi Scale for Combat
Related PTSD.

Mr. Thomas 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. The veteran understood the limits of confidentiality and agreed to
participate in the evaluation, as indicated by verbal agreement and the veteran’s signature on the
informed consent. The veteran was provided a copy of the consent form.

MILITARY HISTORY:

Mr. Thomas reported that he joined the Army National Guard in 1986 and was mobilized briefly
for truck driving school from 1988 through 1989. Most recently, he was mobilized again due to
Operation Iraqi freedom in 2004 and served through 2005. He was discharged under honorable
conditions at the rank of E-7. He went to basic training at Fort Dix, NJ in 1986 and AIT at Fort
Bragg for truck driving. He has had additional training in the areas of water purification, combat
medic, and x-ray technician. He was awarded the Army Good Conduct Medal, Army Reserve
Components Achievement Medal (4th) the National Defense Service Medal (2nd),
Noncommissioned Officer Professional Development Ribbon, Army Service Ribbon, Armed
Forces Reserve Medal with /M device, Global War on Terrorism Expeditionary Medal, Global War
on Terrorism Service Medal.

When asked about the circumstances surrounding his filing this claim, Mr. Thomas reported that
his problems snuck up on him a few months after returning from Iraq. He said that he thought he
would be able to work through them but eventually came to terms with the fact that they were too
much for him to handle on his own. This caused him to seek treatment at the VA Medical Center in
Detroit. He said that one of his providers suggested that he file a claim for service-connected
disability for PTSD. He said initially he was ambivalent about filing for disability but after having
to leave his job in January, he felt this would be a good thing to do.
CLINICAL INTERVIEW AND BACKGROUND INFORMATION:

Mr. Thomas described his current mood as tired. He said that test (MMPI-2) and other things that
require him to concentrate wear him out. He added that his thinking about this examination for a
couple of days was also quite distressing. He described his mood as being very low today, worse
than usual. On a scale of one to 10 with one being the worst, he rated his current level of depression
as a seven. He said that most days it has been a three or four over the past few months since starting
Prozac. He said his depression was consistently at a seven before being on medication. Patient
described significant problems with sleep. He described his sleep as very erratic with significant
difficulties five days out of the week. He said that he will have trouble falling asleep and wakes up
every hour, even with the assistance of medication. He said his energy is very low and he does not
have any energy or interest in doing much of anything. He described some feelings of helplessness
and hopelessness but also talked about how he would like to attend school in the future. Mr.
Thomas denied suicidal thoughts. He described a disturbance of appetite but with a 15 pound
weight gain over the past year. He said that he is eating less but is drinking eight to 12 cans of
sweetened soda per day and he has not been exercising. He said that nothing really interests him.
He said the only thing he does is surf the Internet and watch TV but finds none of this interesting or
enjoyable. He reported that “it's just something to do.” He said that for moments he does gets some
pleasure from being with his seven month old son but most of the time just sits there and wonders
why he is not more interested in spending time with his son. Patient described significant problems
with attention/concentration which began about two months into his tour in Iraq. He said the
problems with concentration got worse over the next few months and have worsened significantly
following his being home after a few months. He talked about how this forces him to exert a lot of
effort to pay attention to things even for very short periods of time. He said he is unable to watch
movies or long TV shows but, at times, can focus on brief newscasts or very short newspaper
articles. He said that when other people are talking he is not able to keep his attention focused on
what they are saying. Note: Patient's records indicate a history of dissociation. Patient denied
significant symptoms of depersonalization or de-realization but did talk about how he spaces out
and is not really thinking about anything and this occurs several times per day. He also talked about
having a lot of trouble remembering traumatic events that occurred during his experiences in Iraq
which will be elaborated on later.

Mr. Thomas reported feeling tense and nervous much of the time particularly when out in public
and around other people. He said that he does not like to go out at all and does not go to the grocery
store anymore. He said people agitate him and he particularly avoids being in crowds and
interpersonal situations. He denied physical symptoms of anxiety as well as other symptoms of
obsessions and compulsions.

Mr. Thomas denied a history of symptoms indicative of a history of manic/hypomanic episodes. He

also denied a history of paranoia and signs and symptoms indicative of psychosis.

MENTAL STATUS EXAMINATION:

Mr. Thomas 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 appeared
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 very depressed and agitated.
Affect was consistent with mood. He denied suicidal and homicidal ideation.

PTSD SYMPTOMS

When asked how his experiences in Iraq and combat may have affected or changed him, Mr.
Thomas talked about his difficulties with concentration, memory and anger. He said it is very
frustrating that he cannot concentrate or remember things and he gets very angry at himself as well
as having a lot of anger about the war in general and the things that he was forced to do.

CRITERIA A: Mr. Thomas was extremely reluctant to described traumatic experiences that
occurred when he was in Iraq. He said that he had gone through this twice before when seeking
services at the Detroit VA Medical Center, once in Urgent Care and the second in the Alcohol unit
intake. Despite several prompts, he would not talk about them specifically. I reviewed the
descriptions of events in his medical records and he concurred that these were the main things that
bothered him. Again, despite several prompts he was not willing to discuss them. He said it just
makes him feel too bad. The medical records revealed information about an incident in which he
fired shots into a civilian vehicle when the driver did not respond to requests from Army personnel
to move. He did not report any feelings of helplessness, hopelessness, horror, or fear at that time.
He reported he was excited and wired and that he enjoyed the adrenaline rush. He reported that
once he calmed down from the incident he felt nothing but anger. The veteran also reported
another event when he was driving in convoy and passed another convoy that was stopped and as
they drove by he could see a dead American soldier lying on the ground. He reported that his only
emotional experience at this time was anger. He did not report feeling helpless, horrified, or
frightened. In the current interview, when asked how he felt during these events, he talked in a very
expressive manner about how it felt good and it was a rush. He then went on to talk about how he
was not afraid of anything and did not really mind being shot at on a daily basis and being exposed
to IEDs. He specifically denied feeling fear, helplessness, or horror at the time. He said that he now
has a lot of distress and horror when he thinks back on these events. Patient does not meet criteria
A due to his not feeling fear, helplessness, or horror at the time of these traumatic events. Although
it is not possible for him to meet DSM-IV criteria for PTSD without meeting Criteria A, criteria B,
C, D, and E were still fully assessed.

CRITERIA B: Mr. Thomas reported significant re-experiencing of traumatic event. He said that he
thinks about his experiences in Iraq daily. He talked about this re-experiencing being direct
recollections of things that occurred, his anger about what occurred, and what he was forced to do.
He also reported distressing dreams/nightmares related to his experiences in Iraq occurring about
twice per week. He said these always involved themes of violence and death and about half of the
time are strongly tied to experiences that occurred during his time in Iraq. He said the dreams have
become more vivid since February of this year. He is not sure why. He denied feeling like he is re-
living events. He did report intense distress and physiological reactivity when encountering things
that remind him of these events including driving and seeing parked cars or debris by the side of the
road, hearing news about the war, encountering various smells particularly those involving exhaust
and fumes, and plumes of smoke. He said that when he encounters these things his chest gets very
tense, his heart rate will increase, and he finds it difficult to breathe. Patient meets Criteria B.
CRITERIA C: Mr. Thomas reported investing considerable energy into avoiding thoughts and
feelings related to his experiences in Iraq. He talked about how he does not like to think about the
war and will not talk about it with other people in detail. He said that if it is someone he knows he
may talk a little bit but there are clear events noted above that he will not discuss with anybody.
Patient was unable to fully explain why he avoids thinking about the war but will yet watch
newscasts and read Internet stories about the war. Note: His avoidance of discussing events was
clearly evident in his refusal to describe Criteria A events in the current interview. Mr. Thomas
talked about avoiding things that remind him of Iraq particularly other people that he has served
with. He said that when he first got back he enjoyed hanging around with his buddies from Iraq but
now avoids all of them. He said that he gets tense or nervous when driving but will still do this. He
also talked about how part of him would like to return to Iraq because of the excitement. He said he
is reluctant because he now knows that this had a negative impact on him. Mr. Thomas appears to
show evidence of significant psychogenic amnesia related to traumatic events. He talked about how
people that he served with tell him about things that they did together and he has no memory of
these events. He said he also met an extremely short man in a bar a few weeks ago who said they
served together in Iraq for months but he has no recollection of him or the experiences this
individual talked about. Patient talked about significantly diminished interests. He said he had a lot
of interests particularly around sports and being outside and interacting with others but now has no
interest in any of these things. He talked about feeling very detached and estranged from other
people and not wanting to interact and generally feeling very agitated and angry around others. He
appeared to evidence a restricted range of affect. He said that he cares about his wife and his son
very much but feels very distant from them. He had trouble describing this further. He did not
appear to evidence a sense of a foreshortened future. Patient meets Criteria C.

CRITERIA D: Regarding symptoms of increased arousal, Mr. Thomas described significant

difficulties with sleep, irritability, anger, and difficulty concentrating. His difficulties with sleep
and concentration were described earlier. With regard to irritability and anger, he said that he never
had a temper or was a particularly angry person before serving in Iraq, but since Iraq, he gets
frustrated by simple things particularly with regard to being around other people. He said that his
job involved him being around other people and he found this extremely uncomfortable and
eventually “could not take it anymore” so he quit in January of this year. Patient described
symptoms of hypervigilance occurring a few times per week. He said this is usually triggered by
some event that will make him perceive threats such as driving or finding abandoned cars or some
debris along the side of the road. He said that he tells himself “it will not explode” but he still feels
overly-alert and as if there is a threat or presence. He denied significant problems with an
exaggerated startle response. Patient meets Criteria D.

CRITERIA E: Mr. Thomas reported that his difficulties with concentration began a couple of
months into his tour in Iraq and progressed over the next several months. He said this was fairly
consistent but about three months after returning from Iraq, he began to have more problems with
concentration and memory as well as problems with depression and anger. He said the difficulties
with re-experiencing have been pretty consistent over the past nine months.

Mr. Thomas denied any post-military traumatic events. Patient did report being in a motorcycle
accident in 1993 but denied any trauma symptoms related to this event.
PSYCHIATRIC HISTORY:

Mr. Thomas reported that his first contact with the mental health profession was in November of
2006 when he called the VAMC requesting help with issues with regard to reintegration. He was
seen in August as part of a mental health intake. That contact indicated diagnoses of Depressive
Disorder NOS and Anxiety Disorder NOS. He was referred for an intake with the Mental Health
team and seen by Dr. Edwards. That evaluation, which did not include a CAPS due to patient's
irritability/fatigue, yielded a diagnosis of Depressive Disorder NOS and ruled out Major Depressive
Disorder. Patient was also seen by psychiatrist Dr. James as part of the intake process. Dr. James
indicated diagnoses of Depressive Disorder NOS and Anxiety Disorder NOS. A psychological and
neuropsychological evaluation conducted on September 4th indicated problems with concentration
and memory likely secondary to heightened levels of distress including anxiety and depression.
Patient has been followed in individual therapy by psychology fellow Dr. Lewis focusing on
attaining skills to deal with his distress and tendency for dissociation. Dr. Lewis notes indicate that
patient has not entirely followed through with homework assignments. Patient is currently being
prescribed Prozac by Dr. James. Patient feels this is somewhat helpful. He indicated that he is not
sure if the therapy helps and he often feels worse after therapy session since it forces him to feel
things more. Patient reported that his father had a history of problems with alcohol and his mother
had a history of problems with depression.

SUBSTANCE USE HISTORY:

Mr. Thomas described a history of alcohol abuse beginning in middle adolescence with binge
drinking as a teenager. He said this continued through early adulthood. Since then he reported
drinking on one to two occasions per month averaging five to six drinks per occasion. He said that
he drank fairly heavily when he returned from Iraq but this was to celebrate. He said at this point he
was drinking nightly, averaging seven to eight beers per evening. He said that he stopped drinking
for several weeks but over the past few weeks has been drinking quite heavily again, daily,
averaging seven to eight beers per day. Over the past week, on two of these occasions he drank as
much as 15 beers. Patient talked about how his recent use of alcohol is different than when he came
back from Iraq in that now it is just to escape and make himself numb. He described having more
problems in the past month blacking out and not being able to remember what happened. He also
admitted that he has been driving while intoxicated a few times and fears that he will get arrested
for DWI. Patient also reported using cocaine three times over the past year with his last use in
December of 2006. He said he is not sure why he did this because it could jeopardize his status with
the National Guard. He denied any regular use of this or any other substance. He reported abusing
cocaine at times as a way to escape. Patient did report receiving a DWI in 2006 and attended
MADD classes. He denied ever participating in substance use treatment services. He indicated that
he smokes approximately 1 pack of cigarettes per day. Patient reported that he consumes about a 12
pack of coke per day or a 12 pack of red bull per day. He denied a history of problems with
gambling.

SOCIAL HISTORY:
Mr. Thomas reported that he was born and raised in Kalamazoo, Michigan by his biological parents
until they divorced when he was about four years old. He said he had limited contact with his father
while growing up and has had no contact with him for the past 20 years. He is the youngest of four
children. He described his relationship with his family as OK. He said they were fairly close. He
denied a history of physical or sexual abuse. He said that he was fairly social and outgoing as a
child and enjoyed sports and other outdoor activities. He denied a history of significant conduct or
behavioral problems.

Mr. Thomas reported that he graduated high school but did not exert much effort obtaining mostly
C's and D's. He said he completed courses at Kalamazoo Community College and then at the
University of Michigan over a couple of years but still had problems maintaining good grades. He
said he could have put forth more effort but was into partying and women at the time. He did not
have a major or particular academic interest.

Mr. Thomas reported that he has been married since December of 2005. He described his marriage
as good but getting more stressful since he has not been working. He said that his wife is very
understanding of his problems but he knows this is wearing on her. He said that she gets frustrated
with his not being able to concentrate, remember anything, or getting anything done around the
house. As previously noted, he has a seven month old son but his son goes to daycare despite the
patient not working. Patient also commented that his wife is getting increasingly more frustrated
with his use of alcohol.

Mr. Thomas reported that he has worked in various restaurants and bars as a bartender over the past
15 years. For the previous three years he worked as a bartender but quit this position in January of
this year due to the increased stress and anxiety of having to be around people every day. He said
that he would like to find a new job after he goes back to school but cannot do this until his ability
to concentrate and remember improves. He talked about wanting to study business and someday
owning his own franchise of some sort.

Mr. Thomas denied a history of arrests as an adult or as a juvenile other than the 2006 arrest for
DWI.

Mr. Thomas reported that he currently resides in a house with his wife, his 7-month-old son and his
mother. He said she recently moved in because of financial difficulties and that may be the case for
the next couple of years. He said that he is OK with her because she spends most of her time
downstairs but believes that his wife is not crazy about the situation. He denied any significant
financial difficulties. He said his wife works full time as an accountant for a local business. He said
their bills are getting paid but his wife does not like the idea of her working and him not working.

Mr. Thomas had a lot of trouble describing his daily activities. He said he will get up and give his
son a bottle, get him dressed and drive him to daycare. He said he will then usually take a nap until
noon and then watch TV or surf the Internet for a couple of hours. He said his wife gives him a list
of things to do but he will not get to it until an hour or so before she gets home. Patient talked about
wanting to be more productive but not having any energy or motivation. He said he does not like to
go out and just likes to be home by himself. He said that when watching TV or on the Internet, he
will sometimes just stare at the screen blankly not thinking about anything.
MEDICAL HISTORY:

Mr. Thomas described his physical health as poor. He talked at length about how this is the worst physical
shape he has ever been in. He talked about feeling tired easily and having multiple pains in his back,
shoulder, and knees. He said he hurts every day and this makes it harder to get back into shape but he
knows being inactive makes it hurt worse. Mr. Thomas reported that he was involved in a motor cycle
accident in 1992 when he was hit by a car head on. He reported that he had multiple broken bones (arms,
pelvis, and ankle). He was wearing a helmet although he did receive a fractured eye socket. He was in the
hospital for 4 to 5 weeks and then involved in rehabilitation for one year. He is not sure if he lost
consciousness. However, he has no memory of the accident or the events following the accident. He
indicated that he eventually, did regain memory of most of the events. He reported that he had no
lingering cognitive problems, memory problems, language problems, or problems with organization after
he recovered from the accident. His current medications are Fluoxetine (60 mg per day) and he takes
Benadryl for sleep. He rated his level of pain at three today (10=Highest). He states that his pain can vary
between two and eight.

TESTS ADMINISTERED:

MMPI-2, Mississippi Scale for Combat Related PTSD

TEST RESULTS:

Mr. Thomas produced a valid MMPI-2 profile. His responses appear to accurately reflect his
current level of functioning. Overall, his response pattern is reflective of significant levels of
psychological/emotional distress. Mr. Thomas’ responses are reflective of generally feeling
unhappy and distressed. Significant levels of feelings of demoralization are indicated. In addition,
he appears to evidence significant difficulties with depression. His response pattern indicates that
he gains little pleasure from activities he engages in. There are also indications of a significant
tendency to over-focus or be preoccupied with physical/somatic functioning. There are also
indications of difficulties with anxiety, agitation, and ruminative thinking. Overall, patient’s
responses are highly consistent with moderate PTSD symptomatology. It is also worth noting that
the two supplementary scales that tend to be indicative of PTSD symptoms are elevated above the
recommended cutoffs.

On the Mississippi Scale for Combat Related PTSD, Mr. Thomas obtained a score which falls well above
the suggested cutoff for individuals diagnosed with PTSD

DIAGNOSES:

Axis I: Anxiety Disorder NOS

Major Depressive Disorder
Alcohol Dependence

Axis II: None

Axis III: Ankle foot, back, and shoulder pain

Axis IV: History of traumatic experiences during military service; Limited social support,
unemployment, new parent

Axis V: Current GAF = 45

IMPRESSIONS:

Mr. Thomas appears to have provided an accurate and reliable representation of his symptoms and
current life circumstances based upon findings from the MMPI-2, review of available records, and
presentation during the clinical interview. Results of this evaluation are not consistent with a DSM-
IV diagnosis of PTSD. Patient clearly experienced significant criteria A events during his tour in
Iraq but did not experienced fear, helplessness, or horror at the time of those events. He talked
about feeling exhilarated and enjoying them. Thus, Criteria A is not met and it is not possible for
him to meet full DSM-IV criteria for PTSD. Regardless, he provided a very rich description of
symptoms that were highly consistent with DSM-IV PTSD criterias B (re-experiencing), C
(avoidance and numbing), and D (hyperarousal). He does qualify for a diagnosis of Anxiety
Disorder NOS due to these post-traumatic stress-related symptoms. Mr. Thomas also evidences
significant depressive symptoms and clearly meets diagnostic criteria for Major Depressive
Disorder. His difficulties with depression appear to be directly linked to his military experiences,
but there are no indications of problems with depression before serving in Iraq. In addition, patient
has a long history of difficulties with alcohol abuse and, although this predates his military related
trauma, his use of alcohol appears to be significantly exacerbated following his tour in Iraq. He is
currently using alcohol at extremely hazardous levels in response to anxiety and depressive
symptoms related to his experiences in Iraq and meets full criteria for alcohol dependence. Patient
also appears to use caffeine extensively consuming up to a 12 pack of non-diet soda per day. The
impact of the caffeine and sugar on his mood and anxiety is unclear.

Mr. Thomas mental health conditions, Anxiety Disorder NOS (with post-traumatic features) and
depression, appear to be caused by or the result of traumas experienced during his tour in Iraq. Patient’s
mental health conditions appear to have significantly impaired his ability to function in social and
occupational settings. He has a significantly restricted social life and has been unable to form and maintain
consistent intimate relationships since his return from Iraq. Occupationally, he has had difficulty
maintaining employment as a result of the symptoms.

There did not appear to be any pre-military risk factors or characteristics that may have rendered the
veteran vulnerable to developing PTSD subsequent to trauma exposure.

In summary, Mr. Thomas does (not) meet diagnostic criteria for PTSD but does meet diagnostic criteria for
Anxiety Disorder NOS (with post-traumatic features) as well as Major Depressive Disorder and Alcohol
Dependence. His anxiety and depression appears to be caused by, or a result of, his military service. His
problems with alcohol appear to predate his military service, but are significantly exacerbated following
his return, and appeared to be partially caused by, or a result of, the service in Iraq.
Mr. Thomas appears fully competent to handle his own financial affairs and does not appear to need any
restriction to any benefits to which he might be entitled.

The above opinions are made within a reasonable degree of psychological certainty based on review of the
available medical and military records, interpretation of psychological instruments, and direct examination
of the veteran.