COMPENSATION & PENSION - PSYCHOLOGICAL EVALUATION

CASE EXAMPLE – MILITARY SEXUAL TRAUMA (MALE)

Background
Mr. Smith is a 68 year old, African-American male who served in the Army from 1960-
62. He denies any childhood experiences of abuse but reports growing up in a relatively
impoverished family in the Western United States. His father had difficulty maintaining
employment and therefore the family moved often and struggled to make ends meet.
When Mr. Smith was 10 years old, his father left the family; at 12, his mother remarried a
man whom Mr. Smith describes as kind and a good provider. Mr. Smith excelled in high
school and after graduation was able to enroll in the local community college, which he
attributes to a more stable family life after his mother's remarriage. After completing 2
years of college, Mr. Smith enlisted in the Army in the hopes of being able to attend a
four-year college.

Mr. Smith initially did well in the Army, making friends easily and impressing his
superiors with his work ethic. Mr. Smith did notice, however that there were soldiers
from other parts of the United States who expressed prejudiced and racist views about
African-Americans, which he had encountered less often where he grew up. This made
Mr. Smith feel uncomfortable and angry, but he tried to avoid these individuals as much
as possible. Near the beginning of his second year of service, he and a close friend were
out drinking at a bar one night. His friend met a woman and decided to leave the bar with
her. Mr. Smith stayed for one more drink and then left the bar alone. When he arrived
back at the barracks, they were dark and appeared deserted. As soon as he entered, he
was attacked by a group of three men. Mr. Smith was not able to identify all of the
assailants that night, but he recognized the voices of as least two of the men as soldiers
that he knew. Mr. Smith reports that he was terrified and tried to get away, but he was
not able to do so. Mr. Smith recalls that one of the men punched him in the face and that
another man had a bat or stick that the man threatened to hit Mr. Smith with if Mr. Smith
did not stay quiet. Two of the men took turns holding Mr. Smith down while the other
penetrated him anally. He was also forced to perform oral sex on two of the men.
During the assault, the perpetrators told Mr. Smith repeatedly that if he ever told anyone
about what had happened they would come back and kill him. The next morning, Mr.
Smith did not report to duty. He was disciplined for not showing up for duty and for
being hung-over. When he was asked about his swollen eye, he reported that he had been
in a fight at the bar.

For the next several months, Mr. Smith became increasingly despondent, as well as angry
and hostile toward others. He engaged in verbal and physical fights with several of his
friends, other soldiers, and even his commanding officer. He reports that he was on edge
all the time; fearing that his assailants would return was so intense that he barely slept at
night and kept a weapon with him at all times. He began drinking heavily every night to
help himself sleep. Before long, he was drinking during the day as well. His work
performance declined significantly as he was often hung-over in the morning and failed
to show up for duty; while on duty, he was frequently drunk and preoccupied with trying
to track down and kill his assailants. Over the course of the year following the assault, he
received several Article 15’s for disobeying orders and fighting. Eventually, Mr. Smith
was discharged from the Army with an other than honorable discharge.

Mr. Smith never told anyone in the military about the sexual assault, nor did he tell his
family when he returned home. He thought if he could just "forget about it" he could
move on. He reported that he had never discussed his experiences with anyone until
entering therapy six months ago.

PTSD Symptoms
Mr. Smith’s symptoms of Post-traumatic Stress Disorder were assessed using the
Clinician Administered PTSD Scale for DSM-IV (CAPS). Results indicate that he meets
criteria for Post-Traumatic Stress Disorder, Chronic, Severe. He denies having any
mental health difficulties prior to his service and recalls the hyperarousal and
avoidance/numbing symptoms described below beginning shortly after he was sexually
assault. He also reported having dreams with themes related to the sexual assault in the
months following the attack. All of his symptoms have worsened since disclosing his
experiences and beginning to discuss them in therapy six months ago.

Criterion A: Mr. Smith reported that at the time of the sexual assault he experienced
extreme feelings of terror and helplessness and feared for his life. This fulfills Criterion
A for a diagnosis of PTSD.

Criterion B (Re-experiencing): Numerous times a day, Mr. Smith experiences intrusive,

distressing thoughts related to the assault that “pop into my head without any reason at
all”; when this occurs, he finds himself feeling “shaky”, having physical reactions, and
having difficulty concentrating, to the point that he typically has to stop whatever he was
doing. Prior to beginning therapy, Mr. Smith had dreams with trauma-related themes
(e.g., trying to escape vaguely defined dangerous situations; being attacked by individuals
wearing Army fatigues) approximately once a month which would cause him to wake up
sweaty and with his heart pounding. He currently experiences nightmares with explicit
re-enactments of the assault on a weekly basis. Mr. Smith reported having strong
emotional and physiological reactions upon encountering reminders of his traumatic
experience; this is consistent with the extreme distress (tearful; physical agitation;
pacing) he exhibited during this interview.

Criterion C (Numbing and Avoidance): Prior to disclosing the sexual assault in therapy,
Mr. Smith reported that he had never discussed his traumatic experiences with anyone.
On a daily basis he makes significant efforts to avoid any reminders of the assault and
until the past year, would often drink large amounts of alcohol when encountering such a
reminder. He has stopped engaging in numerous activities that used to be pleasurable,
particularly those that involve being around more than three to four other people. With
regard to social contacts, Mr. Smith reports having two friends with whom he
occasionally spends time, however he refuses to discuss any of his experiences in the
military with them. He has never been married and has not been involved in an intimate
relationship for over ten years. He attributes this to “not caring about others. They just
don’t matter to me.” He reported having restricted affect and chronic feelings of
emotional numbness.

Criterion D (Arousal): Mr. Smith reports severe symptoms of hyperarousal. Most

distressing to him is his difficulty sleeping: most nights he gets about three to four hours
of sleep, broken up by about five to six mid-sleep awakenings. He also reports difficulty
concentrating and noted that since his military service he struggles to read any written
material longer than one page. He is irritable on a daily basis and though not violent in
the past year, has at times physically assaulted others when provoked. Since beginning
therapy he has noticed that his anger often occurs in conjunction with encountering a
trauma-related trigger. Though he rarely leaves his house, when he does, Mr. Smith
makes significant efforts to remain aware of what is happening around him. He does not
allow others to walk or stand behind him and will often leave stores if there is a line at
the checkout.

Criterion F (Impairment of Functioning): Mr. Smith did well in school and finished two
years of college prior to entering the military. Prior to being sexually assaulted, his pre-
military and military work evaluations were all positive. After his discharge from the
service, Mr. Smith was able to maintain employment as a lab technician for a local
chemical company for approximately eight years. He reports, however, that his time with
the company was marked with numerous conflicts with supervisors and fellow
employees. He was eventually fired after becoming physically aggressive during one of
these conflicts. Since that time he has been employed only sporadically and in positions
far below his skill level. As noted above, his social interactions are almost non-existent.

Other Symptoms
In addition to the symptoms described above, Mr. Smith reported that he is depressed.
He has crying spells on a daily basis, has little energy or interest in things he used to
enjoy, and has lost 15 pounds over the past six months. He rarely leaves the house and
has few social contacts. He reports frequent thoughts of dying but denies active
suicidality.

Until being diagnosed with liver problems a year ago, Mr. Smith consumed significant
amounts of alcohol on a daily basis -- one to two shots of hard liquor and six beers a day.
This was less than what he had been drinking immediately after leaving the Army but
more than he had been drinking prior to being fired from his job as a lab technician. He
reported that his cravings to drink are strongest when encountering reminders of his
military experiences.

Conclusions
Overall, it is clear that Mr. Smith has demonstrated a significant change in functioning as
a result of the sexual assault he experienced in the military. He currently meets criteria
for Posttraumatic Stress Disorder, Chronic, Severe, secondary to being sexually assaulted
in the military. He also currently reports significant symptoms of depression and up until
a year ago drank a significant amount of alcohol daily. His symptoms have severely
impaired his social and occupational functioning, as evidenced by his social isolation,
lack of intimate relationships with others, and difficulty maintaining employment. Prior
to being assaulted, Mr. Smith had done well in school and attended two years of college.
His pre-military and military work evaluations were positive and he had close
relationships with others. His symptoms of PTSD and depression began immediately
following the assault; historically he has relied heavily on avoidance strategies to manage
his symptoms, most notably through alcohol use, until entering therapy six months ago.
His symptoms have worsened since beginning to actively process his traumatic
experience in therapy.

Given his good pre-assault functioning, the timing of the onset of his symptoms, and the
content of his re-experiencing symptoms, Mr. Smith’s PTSD and other mental health
difficulties are related to the above described sexual assault in the military and thus
directly connected to his military service.