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’s
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 “normal – neither up nor down.” 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 “thinking back about the war”. 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 “not thinking about the war.” 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, “they know not to ask me personal questions because they know not to.” 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.
CRITERIA E: Mr. Brown reported that the above-mentioned symptoms onset while he was
stationed in Iraq and have persisted with significant strength since then. He expressed concern that
they have not dissipated over time in what this may mean for him in the future.

Mr. Brown denied any post-military traumatic events.

PSYCHIATRIC HISTORY:

Mr. Brown denied a history of contact with the mental health profession. He reported that his
mother has been diagnosed with bipolar disorder and takes medication. He denied knowledge of
other family members with mental health difficulties and was unable to provide further specifics
with regard to his mother’s mental health problems.

SUBSTANCE USE HISTORY:

Mr. Brown denied a history of problems with drugs and alcohol. He said that he drinks socially but
only at special events such as weddings or parties and may have one to two glasses of wine at the
most. He denied a history of drug use. He also denied a history or problems with gambling.

SOCIAL HISTORY:

Mr. Brown reported that he was born in Chicago, Ill. and moved to Duluth, MN when he was 17
years of age. He said that he was raised by his biological mother and stepfather. He had minimal
contact with his biological father while growing up. He has one younger stepsister. When asked
about his family relationships he indicated that they were “fine.” Patient denied a history of
physical or sexual abuse. He denied any significant behavioral or conduct problems while growing
up.

Mr. Brown reported that he graduated high school with good grades. He added that from courses he
took during his time in the Army, he is three credits short of an associate's degree in general
studies. He reported taking a lot of coursework in computer networking.

Mr. Brown reported that he has never been married and has no children. He said he is not currently
involved in a relationship. His last relationship was for two years and ended about 11 months ago.

Mr. Brown's military history is described above.

Mr. Brown reported that he has been working as a Computer Specialist since May of this year for a
private company that installs computer networks throughout the United States and around the
world. He talked about enjoying his job in that he finds it interesting and it serves as a good
distraction from thinking about the war. Patient talked a lot about wanting to excel in what he does
and move up within the company. He talked about how he had a lot of responsibility and was “the
man” in the military and now realizes he has to work his way up. At several points during the
interview he expressed concern how his symptoms will affect his ability to do his job and move up
in his profession.

Mr. Brown reported that he currently lives alone in an apartment in Duluth, MN but recently
purchased a house in Minneapolis; he will be moving their next month. He talked about how he has
not formed any real friendships since his discharge from the military and spends most of his time
alone when not working.

MEDICAL HISTORY:

Mr. Brown described significant physical health problems consisting of chronic backache, headaches and
neck pain.

TESTS ADMINISTERED:

MMPI-2, Mississippi Scale for Combat Related PTSD

TEST RESULTS:

Mr. Brown produced an invalid MMPI-2 profile. His responded to items in a very naïvely
defensive manner. Similar individuals tend to see themselves as overly virtuous and of high moral
character and tend to overlook minor faults and normal everyday human imperfections in
themselves. Repression and denial based defenses tended to be over-utilized. Due to this validity
configuration, Clinical scales are not interpretable.

On the Mississippi Scale for Combat Related PTSD, Mr. Brown obtained a score of 101 which falls below
the suggested cutoff for individuals diagnosed with PTSD. However, given the defensive response set on
the MMPI-2, his responses on this instrument likely under-represent the breath and magnitude of reported
symptoms.

DIAGNOSES:

Axis I: Post Traumatic Stress Disorder, Chronic

Axis II: None

Axis III: Chronic back and neck pain, headaches

Axis IV: History of traumatic experiences during military service; Limited social support

Axis V: Current GAF = 65

IMPRESSIONS:

Mr. Brown appears to have provided an accurate and reliable representation of his symptoms and
current life circumstances based upon findings from my review of available records, and his
presentation during the clinical interview. His MMPI-2 results were invalid and reflective of a
defensive response set or an unwillingness to report mental health or psychological symptoms.
Overall, results of this evaluation are consistent with a DSM-IV diagnosis of PTSD. Patient clearly
experienced significant criteria A events during his tour in Iraq and clearly meets criteria A
(traumatic event). In addition, he also meets criterias B (re-experiencing), C (avoidance and
numbing), and D (hyperarousal).

Mr. Brown mental health condition (PTSD) appears to be caused by or the result of traumas experienced
during his tour in Iraq. Furthermore, his mental health conditions appear to have significantly impaired his
ability to function fully in social and occupations settings. Although significant impairment does exist,
patient possesses significant intrapersonal coping strengths which appear to allow him to function at a level
that is significantly higher than his symptoms might suggest. In other words, most individuals with similar
symptoms would typically show a significantly higher level of impairment socially and occupationally.
The extent to which he will be able to successfully employ these coping techniques is unclear.

There does 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.

Mr. Brown appears fully competent to handle his own financial affairs and does not appear to need any for
restriction for 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.