Trauma Case Study: Military Assignment

Trauma Case Study: Military Assignment

Brief Summary

The patient is John whose age is 27 years, not married and had an occupation of a soldier working in the army, was honorably discharged from army 9 months ago. He came alone but he reports he was persuaded by parents to seek care. The presenting complain was nightmares and re-experiencing symptoms by having vivid images of the Eastern Baghdad ambush with an explosively formed projectile.

John has been in the army for 9 years taking part in patrols and has been in up to 61 or 62 fire fights with enemy combatants. There are up to 18 or 19 situations which John remembers vividly well with the last one being the one which occurred in Eastern Baghdad.

He was the tactical commander and their patrol Humvee was blasted by EFP, he was pinned against the door, his feet and leg had severe injuries, he had cracked vertebras and one of his teammates was killed and the other two both injured. He vividly still sees images of this incident when he is sitting watching television and has developed nightmares about it. In a month, he remembers the unwanted images 6 to 12 times.

During these times he develops chest pains, tachycardia and shaking of hands. The nightmares have increased in severity, initially it was once a week but now he reports 2 to 3 nightmares a week. The night mares and memories really affect him such that he takes up to 15 minutes to come back to normal.

To help avoid the memories, John carries out different physical works and increased his alcohol drinking over the past 6 months with severe hangovers. He has forgotten the street name he was on but remembers most of the things. He also has guilt that he caused his colleagues death by being less vigilant.

He has shown symptoms of anger and outburst especially to family and his sleep has severely reduced. His condition has had a negative influence on his relationship with his girlfriend, spending more time drinking and also was took off job because of making mistakes.

He has good social support with the parents persuading him to go for care and he also lives with parents currently. He has a girlfriend who can also provide social support. Premorbid personality was also good, he used to love social activities such as hiking. He has no history of suicides but reports occasions of driving while drink which he describes he is a good driver but has had near misses in the neighborhood.

He has poor insight; he does not think he needs help but the overall cognition is good with mini mental state exam score of 30 which shows normal cognitive functioning. No hallucinations were reported. He is noted to have moderate anxiety and depression based on Becks inventory.

Combat Exposure Scale Interpretation

The combat exposure scale contains 7 questions aimed to determine the scale of combat exposure. On question 1 on the score which was the number of combat patrols or any other dangerous duty, Johns answer during interview was that he has gone to more than 100 combat patrols which scores 5 on the score sheet.

When asked about whether he has been under enemy fire and how long this has occurred he responded that it was more than half of the time he has been in service which is half of 36 months. During this period, they were being showered with mortar or sniper fire. For this question he scored 5.

Question 3 which asked whether he has ever been surrounded by the enemy, he responds that on at least 4 occasions they were surrounded by enemy fire which scored 3 on the score sheet. Of note is that his company had a pretty high killed in action or wounded in action rate of 30% which scored 3 in question 4.

In addition, John replies that he has been involved in 61 or 62 firefights with enemy combatants which in the scale scores 5. At least 40 to 50 times he saw someone being hit by incoming and in 18 or 19 situations which he still remembers, they were ambushed and pinned down by the enemy and each of them thought they were going to be killed or seriously injured.

For these two questions he scored both 4 in the score sheet. On conversion of the total score then adding all of them, the total score after conversion was 34 which showed that John has experienced heavy exposure to combat with his score found in the range of 33 to 41 (Phillips et al.,2018).

Primary Care PTSD Screen for DSM-5 Interpretation

Primary care PTSD screen can help indicate if a person has PTSD or other trauma related problems and hence after screening there is need to do further assessment to determine presence of PTSD and other trauma related problems. For John, on the 4 questions in the primary care PTSD screen, all answers were positive. For instance, currently he experiences 2 to 3 nightmares a week hence question 1 answer was yes.

Also, John tries hard not to think of the day he got injured in Baghdad after their Humvee was hit by explosive. He does this by being involved on working especially physical work and currently his drinking has increased in the past 6 months with severe hangovers to try avoid the images and night mares. Therefore question 2 was yes.

On the question of being watchful or easily startled, He says he “wakes up sweating and breathing hard and having the ‘shakes’ until I figure out that I’m still safe in my bed. This occurs during the night mares. Also, during the time, he is re-experiencing the symptoms through vivid images, he says his “heart starts beating faster, my chest starts hurting, my hands start shaking; I think I’m dying, even though I know I’m safe back ‘state-side.’” So, for this question the reply was yes.

On the final question his reply is emotionally he is not just there, maybe he feels numb. Therefore, this screening question was also marked yes. The total score for John was 4 hence the score was positive for PTSD since the patient answered yes in more than 3 of the questions.

Clinician-Administered PTSD Scale for DSM-5 Interpretation

According to the DSM-5 interpretation of PTSD by the American Psychiatric Association (2013), John meets most of the criteria for PTSD. John met criteria A since he was exposed to a serious injury in combat sustaining serious injury to the feet and leg and also vertebral fractures.

Apart from directly experiencing the traumatic event, he also witnessed his colleague killed and his other 2 colleagues get injured. There was a threat to both his life and that of his colleagues. John also met criteria B since all the 5 items were positive. On item 1, he has intrusive memories which occurred 6 to 12 times in the past one month. The intrusive memories were clearly present and the severity was moderate.

He also has severe recurrent dreams which are pronounced which are the major reason he came to seek care. The nightmares occur 2 to 3 times per week. In addition, he has flashbacks of the event. He says when the “vivid mental pictures start on the big screen in my head, it is like I’m living it all over again.” These flashbacks are pronounced hence severity is at 3.

He has also experienced psychological distress many times when he gets the flashbacks, getting angry at the family members and friends which he describes he blew up and yelled at his friends and family for no good reason. He feels emotionally he is not just there, maybe numb.

Of note he also develops physiological reactions which are clearly present and happens about 6 to 12 times.  He says “heart starts beating faster, my chest starts hurting, my hands start shaking think I’m dying, even though I know I’m safe back ‘state-side.’” Since criteria B requires at least one of the items, John has met criteria B.

John has also met criteria C since he persistently tries to avoid the flashbacks. For instance, he says he is constantly on guard while walking down street or when driving since he thinks there may be a bomb out there or an enemy trying to kill him. He tries to avoid the mental images by drinking and doing physical work which he says helps.

On criteria D which is alteration in mood and cognitions associated with the traumatic event, he scored 5 out of the 7 items. First, John does not remember some aspects of the traumatic event. For example, even though he has passed through the street multiple times during patrols, he says he doesn’t remember the name of the street where the ambush occurred. Also, he is a little fuzzy about where and how the IED was placed.

Secondly, in D3, he constantly blames himself for the death of his teammate whom he says was a good man and also injury of his other colleagues. John also has very strong negative feelings which include fear of being attacked again and guilt that he was to be blamed for the death of his colleague and anger often yelling at his friends and colleagues.

He used to love hiking and other activities with friends but currently he says he does not feel like doing anything other than the usual wake up and work out. He also wants to go to bar and hang out with other old soldiers which makes him ignore his girlfriend. Therefore, criteria D was met.

John also met criteria E, being irritable and yelling at parents and friends, reckless driving, being on guard while walking down streets hence hyper vigilance, having problems with concentration waking up at night and having 3 to 4 hours of sleep each night.

The symptoms have been there for more than 1 month, he received honorable discharge 9 months ago. Also, occupationally he is affected, he was stopped from work due to mistakes. The sum of the PTSD score for B, C, D and E was at 18. Therefore, being the gold standard score, the patient has Post traumatic stress disorder since it met all the criteria based on clinician administered PTSD scale.

Primary and Secondary Diagnostic Impressions

Primary Diagnosis with Culture/Gender Issues, Suicidal Risks

Post-traumatic stress disorder (PTSD) with no dissociative symptoms. The PTSD is severe. The patient met criteria A where he was directly exposed to a traumatic injury and also experienced the traumatic event with his teammate being killed during the attack.

He also met criteria B having all the 5 of the criteria B symptoms which include distressing memories, night mares, and flashbacks, physical and psychological distress. He also had avoidance techniques hence meet criteria C. In addition, he had alterations in mood and cognitions which satisfied criteria D such as fear, guilt, and shame, not remembering parts of the event and lack of interest in activities.

Most of criteria E symptoms were also present such as hypervigilance, problems with concentration and sleep disturbance. The symptoms had been there for more than a month and there were disturbances noted in John both socially and occupationally. No suicidal ideations reported though he reported harmful behaviors such as drunk driving.

Diagnosis of PTSD may be affected by cultural factors for example severity of PTSD may not be very clear since he is a soldier and he is expected by culture to be strong and handle a lot of difficulties. Also living with the parents and feeling like a baby may have affected his PTSD symptoms. Of note he has been exposed to multiple traumatic events in combats hence could have been cumulative effects of the events leading to PTSD symptoms.

Secondary Diagnosis with Culture/Gender Issues, Suicidal Risks

Major depression. John has symptoms of major depression which has met criteria A of major depression. For instance, he has depressed mood with minimal hopelessness, has diminished interest in activities, insomnia sleeping 3 to 4 hours, and has agitation, feeling of guilt which is inappropriate and reduced ability to concentrate. He however has no suicidal ideations.

The symptoms also cause significant distress hence meets criteria B. The gender and cultural issue related include being given honorable discharge from army hence unemployment and feeling of being used, being a soldier, he may also try not to show the symptoms related to major depression so as to seem strong.

Recommendations

Recommendation 1

Trauma focused cognitive behavioral therapy. This will help John change his abnormal beliefs and thoughts which include belief that he caused the death of his mate and blaming of self. Also, the belief that drinking helps solve the problem as drug abuse can come with other effects both physically and psychologically. With change on belief, John will develop better coping mechanism and better lifestyle due to behavior change. Trauma focused cognitive behavioral therapy has been shown to be effective in PTSD amongst army combatants (Skilbeck et al., 2021)

Recommendation 2

Pharmacotherapy such as prazosin to help with the nightmares. Pharmacotherapy can also help with other symptoms such as use of antidepressants to help with the depressive symptoms and avoid progression to severe depression. According to Abdallah et al. (2019), this can be combined with other psychotherapies during treatment.

Recommendation 3

Group therapy. Through sharing and listening to other members with similar problems John will be able to learn about his condition and develop better coping mechanisms with support of therapist and other group members. As Fredman et al. (2020) notes, this will help with improving PTSD symptoms and relationship challenges.

Trauma Case Study: Military Assignment References

• Abdallah, C. G., Averill, L. A., Akiki, T. J., Raza, M., Averill, C. L., Gomaa, H., Adikey, A., & Krystal, J. H. (2019). The neurobiology and pharmacotherapy of posttraumatic stress disorder. Annual Review of Pharmacology and Toxicology, 59(1), 171–189. https://doi.org/10.1146/annurev-pharmtox-010818-021701
• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
• Fredman, S. J., Macdonald, A., Monson, C. M., Dondanville, K. A., Blount, T. H., Hall-Clark, B. N., Fina, B. A., Mintz, J., Litz, B. T., Young-McCaughan, S., Hancock, A. K., Rhoades, G. K., Yarvis, J. S., Resick, P. A., Roache, J. D., Le, Y., Wachen, J. S., Niles, B. L., McGeary, C. A., … Peterson, A. L. (2020). Intensive, multi-couple group therapy for PTSD: A nonrandomized pilot study with military and veteran dyads. Behavior Therapy, 51(5), 700–714. https://doi.org/10.1016/j.beth.2019.10.003
• Phillips, R. D., Wilson, S. M., Sun, D., & Morey, R. (2018). Posttraumatic stress disorder symptom network analysis in U.S. military veterans: Examining the impact of combat exposure. Frontiers in Psychiatry, 9. https://doi.org/10.3389/fpsyt.2018.00608
• Skilbeck, L., Spanton, C., & Roylance, I. (2021). Integrated Trauma-Focused Cognitive Behavioral Therapy for Comorbid Combat-Related Posttraumatic Stress Disorder: A Case Study with a Military Veteran. Clinical Case Studies, 15346501211006922. https://doi.org/10.1177%2F15346501211006922

Trauma Case Study: Military Assignment Instructions