COMPENSATION & PENSION - PSYCHOLOGICAL EVALUATION

CASE EXAMPLE #3

Mr. Johnson is a 54-year-old divorced service connected (hearing loss and Tinnitus) Caucasian
male veteran. 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, available medical records, Clinical Interview (90 minutes);
Minnesota Multiphasic Personality Inventory-2 (MMPI-2); and the Mississippi Scale for Combat Related
PTSD.

Mr. Johnson 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. The veteran was provided a copy of the consent form.

MILITARY HISTORY:

Mr. Johnson reported that he served in the United States Navy from 1971 through 1972 and was
discharged under honorable conditions at the rank of E-4. He served off the coast of Vietnam but could not
recall the dates he was there. He said he served as a Fire Control Technician. Note: His DD-214 was not
available so I did not have access to a confirmation of rank at discharge or possible citation/awards.

When asked about the circumstances surrounding his filing this claim, Mr. Johnson reported that he
was having flashbacks a long time ago and originally filed a claim in 1994. He said they asked for
records of which he did not have copies so he gave up. He added that three years ago, he was
having significant problems with flashbacks again and lost his job as a result. He said that he then
received some treatment at the Long Beach VA and then moved back to Minnesota and contacted
the American Legion to start processing the claim again.

CLINICAL INTERVIEW AND BACKGROUND INFORMATION:

Mr. Johnson described his current mood as tired and agitated. He said that he did not sleep at all
last night in anticipation of this examination. When asked about depressive symptoms specifically
he said “kind of.” He talked about feeling down and having no interests. When asked for further
description of depressive symptoms he talked about feeling apathetic. On a scale from 1-10 with 10
being the worst, he rated his current level of depressive symptoms as a six. He indicated that this is
typical of most days but his moods tend to fluctuate. He said that when he does not sleep well his
mood will get worse and will sometimes go to a seven or higher. He said there are no times when
he is not feeling depressed and anxious. Mr. Johnson described significant problems with early and
middle insomnia. He said it takes him an hour or two to fall asleep and he wakes up again in a
couple of hours and it takes another hour or two to fall back asleep. He said he is tired throughout
much of the day and does not have much energy or interest to do anything. He said that he thinks
about suicide at times but has never formulated a plan or intent. He denied a history of attempts. He
said that his appetite is okay and averages about two meals per day. He said his eating pattern has
been that way for years. He was unable to identify anything that truly interests him. He said
occasionally he may watch TV or read but his concentration fluctuates and he can typically not
focus on such things for more than 15 to 20 minutes. Patient denied a history of symptoms
indicative of manic/hypomanic episodes. He did report somewhat chronic feelings of anxiety and
nervousness particularly in crowds, at malls and movie theaters. He said he can tolerate people if he
has to but strongly prefers not to and does engage in significant avoidance of such things. He said
in general he does not like to be in social/interpersonal situations and has little interest in being
around other people as they agitate him.

Patient described some paranoia but this appears to be related to hypervigilance. He said that he is
always ready for things to happen and he protects himself particularly when around other people.
He said he will sit with his back to the wall. He said that his feeling of threat is not specific to
situations or people. He denied hallucinations and other signs and symptoms indicative of psychotic
processes.

MENTAL STATUS EXAMINATION:

Mr. Johnson 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 appeared euthymic and the patient
described depression and significant anxiety and agitation. He denied suicidal and homicidal
ideation.

PTSD SYMPTOMS

CRITERIA A: When asked about the most difficult or troublesome aspects of his military service,
Mr. Johnson talked about spending time on a destroyer off the coast of Vietnam. He was unable to
identify specific incidents stating that it was all bad and is all blurred into one event. He talked
about how they shot at the enemy from their ship almost every night, on occasion received fire and,
on a couple occasions, was strafed by Russian MIGs. He said that he was particularly bothered by
the sound of 50” cannons firing 200 plus rounds almost every night. He talked about an incident
where a friend/fellow sailor got hurt on the ship but did not provide specifics. He said that he was
below deck performing other duties when this incident occurred but said this still bothered him. He
was unable to talk about how this bothered him. He also talked in general about how his service in
the military, especially his time in Vietnam, was very difficult and that he had to pull 36 hour
shifts. In general, his response to my questions regarding specifics events was very vague and non-
descript. Also, it is unclear whether he experienced fear, helplessness, or horror during these
events. Patient does not appear to meet Criteria A.
CRITERIA B: Mr. Johnson reported re-experiencing traumatic event in the form of nightmares
occurring about twice per week. He said the nightmares are of a recurring theme of running and
white light which he believes is similar to phosphorus explosions that occurred while he was in
Vietnam. He said that there is no other reason to believe that these are related to Vietnam other than
the feeling of fear and the white light. He denied re-experiencing other events. He did report
occasionally thinking about events in Vietnam while he is awake but said that he invests a lot of
energy into trying not to think about these things. He also said that he is able to distract himself
when he does think about such things. It does not appear as though this re-experiencing is
significantly distressing. Patient also denied feeling like he is reliving events with the exception of
one episode on the Fourth of July many years ago when an explosion from fireworks made him
think that he was back in Vietnam for 30 seconds or so. He denied a recurrence of this type of
experience. Mr. Johnson described triggers for these events consisting of fireworks and helicopters
but indicated that helicopters do not bother him much in recent years. He was unable to describe
other triggers that resemble or symbolize these events and is unclear whether his reaction to these
constitutes intense distress. He also denied physiological reactivity other than feeling muscle
tension and a knot in his stomach. Patient does not meet Criteria B.

CRITERIA C: Mr. Johnson reported investing considerable energy into avoiding thoughts and
feelings related to his experiences in Vietnam. He said that he does not think about Vietnam and
does not talk about it with anybody, even fellow veterans. When asked about possibly avoiding
activities or situations that may remind him of Vietnam, he said that he avoids being around people.
Patient was unable to describe how this may be related to traumatic events. He denied psychogenic
amnesia related to events. He described diminished interest and talked about being somewhat social
and outgoing and how he enjoyed playing music prior to the war but lost interest in these things
after the war. He also talked about feeling detached or estranged from other people. Note: It is
unclear how attached he was to others prior to his service in the military. He denied a restricted
range of affect or inability to have loving feelings for others. He did describe a sense of a
foreshortened future in that he said he cannot think about the future stating that things look bleak
for him. Patient technically meets Criteria C but the extent to which these reported symptoms may
also be attributable to depressive symptoms is unclear.

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

difficulties with sleep and irritability. As previously noted he reported problems with early and
middle insomnia. He talked about feeling very uptight and irritable in crowds. Patient said that he
gets upset when people do “stupid things” or when he does “stupid things.” He was unable to
provide examples when asked. He said that sometimes he has problems concentrating but
sometimes he is able to concentrate OK. He did describe hypervigilance, being on guard in
situations and being able to only sit with his back to a wall. Note: He did appear to be relaxed and
comfortable in the current interview. He also described overreacting to loud noises stating that he
feels jumpy especially when he is surprised. Patient marginally meets Criteria D.

CRITERIA E: Mr. Johnson reported that the above-mentioned symptoms have been present since
his return from Vietnam.

Mr. Johnson denied any post-military traumatic events.

PSYCHIATRIC HISTORY:

Mr. Johnson described a long history of contact with the mental health profession and stated that he
has been treated for PTSD on multiple occasions. However, in reviewing his records which
consisted of private facilities in the 80’s and at the Northport VAMC in the later 80’s and 90’s, it
appears as though all of his psychiatric treatment has occurred in the context of treatment for
alcohol dependence. Some of these records do indicate a diagnosis of PTSD. Other records indicate
a diagnosis of ruled out PTSD. All records are consistent for a diagnosis of alcohol dependence.
Most recently, he has been followed by the Psychiatry Section of the Minneapolis VA Medical
Center. His psychiatric care is managed by Dr. Jorgan who has prescribed Citalopram and
Mirtazapine. Dr. Jorgan indicates diagnoses of alcohol dependence and depressive disorder NOS.
Patient is case managed by social worker Rachel who indicated diagnoses of alcohol dependence,
early remission and depressive disorder NOS. Patient is currently participating in a joint addictive
disorders and post traumatic stress recovery team program called Seeking Safety designed for
individuals with trauma related difficulties and substance use. Patient reported that he feels this is
somewhat helpful in that he is learning some skills but acknowledged that he has continued to drink
through his participation in this program. Note: None of the available records that document
diagnoses of PTSD or ruled out PTSD provide any rationale or description of symptoms justifying
these diagnoses. Patient denied a history of substance abuse or mental illness in his family.

SUBSTANCE USE HISTORY:

Mr. Johnson described a long history of problems with alcohol dependence beginning while still on
active duty in the military service. He said that he drank regularly nearly daily while in the military
and for many years after his military service. He said that he began drinking to self-medicate his
sleep problems. He denied that his use of alcohol was problematic early on in that he still worked
and was able to carry out his day-to-day duties and responsibilities. He said that in the last few
years his drinking has been more sporadic averaging one half a quart of vodka once a week or so.
He did admit to drinking this amount nightly for the past three days because he was anticipating
this evaluation. Note: No agitation or nervousness was evidenced in the current interview. Patient
talked about how alcohol makes him feel normal and believes that he can function while drinking
including driving but knows that would not be appropriate so he does not drive when drinking. He
added that he knows he is not supposed to drink while attending the Seeking Safety group and feels
guilty when he does because he is supposed to tell the other group members. Mr. Johnson reported
that he has attended approximately 6 treatment programs over the course of his life but the only
time he has been able to put any period of abstinence or significantly diminished use was following
a treatment in 1982 were he was abstinent for 18 months. He said that he started drinking again
because he was in a motor cycle accident where he was injured significantly and his bike was
totaled. He explained that he got upset because the woman who hit him only had to pay a traffic
ticket due to California laws. When asked if his symptoms improved or worsened during the period
of abstinence he said it was so long ago he could not recall. He said that he was working and caring
for his two daughters during that period. He said things might have been better. Mr. Johnson denied
a history of problems with drugs. He said he experimented with marijuana in the 80’s, but never
used this or other substances on a regular basis. Patient denied a history of problems with gambling.
He said he did gamble periodically while living in Las Vegas but this was never a problem for him.
He said he has not gambled since moving to Minneapolis in December of 2005.

SOCIAL HISTORY:

Mr. Johnson reported that he was born in Arkansas but moved to North Dakota when he was two or
three years old. He said he was raised by his biological parents and is the older of two children. He
described good relationships with his family members and having several friends. Patient said that
he enjoyed playing sports and doing outdoor things through his childhood. Through his adolescent
years he said that he played sports, participated in the science club and play guitar in a rock 'n roll
band. He denied a history of physical or sexual abuse. He denied a history of behavioral problems
or signs or symptoms indicative of conduct disorder. Mr. Johnson reported that he graduated high
school with above average grades. He denied any secondary training or college other than what he
received in the military.

Mr. Johnson reported that he married in 1972 and divorced in 1978 secondary to his wife's mental
health problems. He said they had two young daughters and he was patient through her multiple
hospitalizations but divorced her after she tried to hurt their children. He said he was awarded
custody and raised them with the assistance of his mother. They were ages 2 and 3 at the time of
the divorce. Patient reported that he has never remarried and has not really had any significant or
sustained relationships since then.

Mr. Johnson's military history is detailed at the beginning of this report. The only addition is his
report of two disciplinary actions for missing ships. The first one resulted in a reduction of rank
from E-3 to E-2.

Mr. Johnson described a relatively consistent history of employment following his discharge from
the military. He said that he held a variety of handyman jobs and then worked for 16 years in a
brewery. He then worked as a security guard and was terminated after missing work for two
consecutive days drinking in his mobile home. He said he was fired because of his PTSD. He
explained that he had learned that a Vietnam veteran friend had committed suicide and this
disturbed him greatly causing flashbacks, so he started drinking excessively and did not go to work.
Patient said he was found passed out on the floor of his mobile home. He reported that he has not
worked since that time. It is also interesting to note that he has not been able to achieve any periods
of abstinence since that time.

Mr. Johnson reported that his only income is about $200 per month from the VA for his service
connected hearing loss and tinnitus.

Mr. Johnson reported that he currently resides with two elderly women ages 80 and 86 years old. He said
the older one is deaf and legally blind and the younger one is now undergoing chemotherapy for cancer.
He said that he expects to lose his current living situation because Olga is thinking of moving and believes
Betty will die shortly so he will be looking for a place to live which causes him increased anxiety.

MEDICAL HISTORY:
Mr. Johnson described his physical health as good, “as long as I am not drinking.” He added that he has
problems with high blood pressure and high cholesterol but these are under control with medication. He
also is significantly overweight. He admitted to having an extremely poor diet when he is drinking.

TESTS ADMINISTERED:

MMPI-2, Mississippi Scale for Combat Related PTSD

TEST RESULTS:

Mr. Johnson produced a valid MMPI-2 profile but responded to items in an exaggerated manner likely
over endorsing breadth and magnitude of psychopathology. Overall, his response pattern is indicative of
extreme levels of psychological/emotional distress. Specifically, he is endorsing extreme levels of
depression and profound anhedonia or a lack of positive emotional experiences. In addition, he is
endorsing difficulties with alienation and feeling out of control over his thoughts, feelings and behavior.
Significant anxiety, tension and rumination are also indicated. In general, Mr. Johnson likely feels
extremely uncomfortable around others and invests considerable energy into avoiding such situations.
Note: The two scales that tend to be reflective of PTSD symptomatology are extremely elevated.

On the Mississippi Scale for Combat Related PTSD, Mr. Johnson obtained a score of 145 which falls well
above the suggested cutoff for individuals diagnosed with PTSD. Given the extremely high nature of this
score and the exaggerated response set on the MMPI-2, results of the Mississippi Scale should be
interpreted with caution.

DIAGNOSES:

Axis I: Alcohol Dependence, Continuous

Depressive Disorder NOS
Anxiety Disorder, NOS

Axis II: None

Axis III: High cholesterol, hypertension

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

Axis V: Current GAF = 60

IMPRESSIONS:

Mr. Johnson appears to have over-represented his level of psychopathology 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 appears to
have experienced significant Criteria A events while in Vietnam. However, it is unclear whether he
actually meets criteria since it is unclear if he experienced fear, helplessness, or horror during those
events. Regardless, Mr. Johnson also does not meet criteria B (re-experiencing). He described
nightmares related to his time off the coast of Vietnam but these are not related to specific instances
and appear to be only very loosely tied to his experiences in Vietnam. Furthermore, he denied other
re-experiencing symptoms. Mr. Johnson does appear to meet criterias C (avoidance and numbing),
and D (hyperarousal) but the extent to which these are attributable to traumas, depressive
symptoms, or his alcohol use is unclear. Mr. Johnson also meets diagnostic criteria's for depressive
disorder and anxiety disorder NOS but the extent to which the symptoms are attributable to his
Alcohol Dependence is unclear since he does not have any prolonged periods of abstinence. It is
also worth noting that Mr. Johnson's MMPI-2 was reflective of very extreme levels of
psychological distress and psychopathology but his presentation in the current interview was highly
inconsistent with the breadth and magnitude of psychopathology noted on the MMPI-2. In the
interview, he did described anxiety and depressive symptoms that are somewhat consistent with
psychopathology but the manner in which he presented himself and his symptoms was less than
convincing.

In sum, Mr. Johnson does not meet diagnostic criteria for PTSD. He does describe difficulties with
depression and anxiety but to the extent to which these are related to his alcohol use is unclear. The
majority of his dysfunction in social and occupational areas appears to be caused mostly by his Alcohol
Dependence. It is less likely (much less than 50/50 probability) that his psychological/emotional problems
and resulting dysfunction are caused by his military experiences.

Mr. Johnson may have difficulties handling his own financial affairs due to the high probability he would
spend them on alcohol.

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.