From the War Zone to the Home Front: Supporting the Mental Health of Veterans and Families

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1 From the War Zone to the Home Front: Supporting the Mental Health of Veterans and Families Clinical Case Conference-When Substance Abuse and PTSD Collide Sonya Norman, PhD Margaret Harvey, PsyD Author of Clinical Case: Brittany Davis, PhD Setting the stage - initial presentation to clinic o Demographics and presenting complaints Kasey is a 32 year-old single Hispanic female that has been medically discharged from the U.S. Marine Corps (USMC) approximately 7 months ago. She rents an apartment in southern California, very close to her former military base, and lives with her 2 year-old daughter. She identifies herself as a religious person, and attends church regularly. She was referred for PTSD and substance use services by her VA case manager. Kasey reported her current stressors include difficulty with sleep, feeling on edge all the time, and being the sole caregiver of an active 2 year-old Mental status at time of intake assessment Kasey presented as guarded as evidenced by limited responses to questions, and intermittent eye contact. Over the course of the intake, Kasey became more open and appeared more comfortable in the room. Her thought content was logical and linear, and presented with anxious affect as evidenced by mild psychomotor agitation. o Current life situation Kasey lives alone with her 2 year-old daughter in an apartment close to base. She described having a limited support system, and has disconnected herself from her friends and family since her return from her 2 nd deployment; and stated that she has become even more distant over the past 7 months. Kasey reported she is having a difficult time adjusting to civilian life, especially since she did not want out of the USMC, and wishes that she could redeploy. 1

2 Kasey reported she also has limited support from her family. She reported that they don t understand and she described that mental health symptoms are not supported or discussed in her culture. She has reported that her mother is helpful with her daughter. Kasey s current source of income in from her military disability compensation and education funds from her GI Bill Kasey identifies her sexual orientation as heterosexual, and is currently single. Kasey denied a history of abusive interpersonal relationships. Background History o Childhood/Family History Kasey was born and raised in southern California, and is the oldest of two children. Her sister is 4 years younger. She reported that her parents never married, however they were both involved in her life. Kasey denied a history of childhood abuse. Kasey reported that she always had close friends growing up and stated until recently she was still in contact with some of the friends she grew up with. Kasey reported that her father probably drinks more than he should, and thinks that her mother may have some depression from time to time, however stated that mental health was not openly discussed in her household. She reported that this has been a current significant stressor, because her family thinks that she should just get over it. Kasey reported that she graduated high school with A s and B s, however stated that she found school pretty boring. Kasey has obtained her AA while in the USMC, and is currently working on her BA for kinesiology. She stated that her goal is to become a physical therapist, but is having a hard time motivating herself right now. Kasey reported feeling like she is just going through the motions and has been having a difficult time concentrating. She reported often times spacing out and spending most of her day thinking about her 2 nd deployment. o Military Kasey reported entering the USMC at 18 years old, right after high school. She served as enlisted for 13 years and discharged with a rank of noncommissioned officer Staff Sergeant (SSGT) (E-6). 2

3 Kasey reported that she was the only female in her platoon with this rank and reported feeling like she was treated negatively by her peers. She reported feeling like she was never good enough with her peers and stated that this thought used to motivate her to push harder. Military Operations Specialty (MOS) Logistics Specialist Deployments 2 combat Afghanistan (Helmand Province/Kandahar) (2009 and 2011) 2 humanitarian Haiti (2010) and Central America (2007) Trauma history Kasey reported exposure to combat related traumatic events as well as exposure to death and destruction. o During her first combat deployment, she was in an Improvised Explosive Device (IED) blast resulting in a brief Loss of Consciousness (LOC) and chronic pain due to back injury. She reported that she was not treated at the time of the blast, and did not think that anything was wrong at that time. o Haiti and Central America she reported difficulties with crowd control, and while in Haiti reported an instance in which she had to use excessive force against small children that were trying to get her weapon. o Kasey reported her 2 nd combat deployment as being the most distressing. She was placed with a new unit and had only trained with them for 2 months prior to her deployment. She lost several Marines during an ambush under her watch, and identifies this incident as being her fault. Approximately 1 month after the ambush (half way through her deployment) while on a morning run on the Forward Operating Base (FOB) she was attacked by 3 peers and was physically and sexually assaulted. She was able to identify her perpetrators, and was in constant fear the remaining 3 months of her deployment. After this incident she did not 3

4 disclose this information and did not seek medical attention until she was back from her deployment. She did not press charges for fear of increased backlash. She identified herself as feeling weak because they got in my head and that this sexual assault is negatively affecting her life. o Substance use Alcohol Kasey reported that she first experimented with alcohol in high school. She reported her drinking was like everyone else in the military and described her alcohol use as being a part of military culture. She stated that from the ages of she typically drank on the weekends. Kasey reported that after the return from her first combat deployment she almost immediately started drinking daily. She stated that her drinking was not problematic and she was able to function at work. Following the return from her 2 nd combat deployment, her drinking increased to approximately 1 pint of vodka a night. She stated that she has been drinking to that extent nightly for the past year. Kasey identified her primary reason to drink is to help with sleep. Kasey denied a history of DUI and did not identify any negative consequences to her use. Opiates prescription medications Kasey reported that she was first prescribed pain medications in 2009 after the return from her first combat deployment. She reported that recently (past 7 months) that her pain medications have not been working, and she has been doubling her dose throughout the day. Kasey reported that she frequently takes her pain medications when she has been drinking, and stated that helps with her sleep. Kasey receives her prescription pain medications through her primary care provider. Benzodiazepines Approximately 10 months ago, prior to her discharge from the USMC Kasey reported that she was prescribed Lorazepam to assist with her sleep and anxiety by her primary care provider. She stated 4

5 that at first she was only taking this medication when she felt extreme panic however reported about the last 6 months, she has been taking the medication daily and at times will take up to 3 times the recommended amount. She stated that she is nervous because she is almost out of her medication and does not have any other refills. o Medical history/injury Kasey reports chronic back pain due to a blast injury. She reported a baseline pain level of 6 on a scale from Kasey identified during times of high stress her pain level will rise to about an 8. Kasey has been prescribed prescription opiates and non-opiate pain medications since 2009 through primary care providers. Kasey reported having a brief LOC related to a blast injury in She endorsed light sensitivity, migraines, difficulty with concentration, and increased irritability. Kasey reported difficulty with sleep and endorsed nightly trauma related nightmares that consist both of combat trauma and sexual assault. Kasey estimates that she is currently sleeping 4 hours a night of non-restful sleep. o Mental health treatment history Kasey denied a previous mental health history. She stated that she tried to see a provider on base and attended a few sessions before deciding that treatment was not helpful. Kasey reported noticing that since her discharge from the USMC, she has felt not in control and has an overwhelming fear that something bad is going to happen to her or her daughter. As a result to this feeling, Kasey reported feeling more on guard and having to be constantly aware of her surroundings which has made it difficult for her to go to public places, such as her school campus. Kasey did not volunteer that she is suffering from re-experiencing symptoms other than nightmares, however when probed she reported experiencing daily intrusive images of combat situations and her sexual assault and flashbacks while intoxicated on alcohol. Kasey reported that she is seeking treatment due to feeling scared that she does not understand what is currently going on in her life, and feeling like she is going crazy. 5

6 Kasey denied a history of suicide attempts and denied a history of selfinjurious behaviors. Although she denied current suicidal thoughts, she did endorse current feelings of hopelessness and helplessness. Kasey does own a firearm, which she keeps locked in her home. She denied homicidal thoughts and denied a history of psychosis and mania. o Medications - Kasey reported that all of her medications are prescribed by her primary care physician. She reported that recently she has not been using her medications as prescribed some days she misses doses, while other days she over uses her medications. Sleep o Prazosin o Trazadone PTSD o Sertraline o Lorazepem Pain o Oxycodone o Gabapentin o Flexeril o Employment History Kasey reported that she is currently unemployed, and is a full-time student. She does not have an employment history outside of the USMC. Kasey is also a full-time parent, as she is a single mother of a 2 year-old. o DSM-5 diagnostic impressions Posttraumatic stress disorder (combat and military sexual trauma) R/O unspecified depressive disorder Alcohol use disorder, severe Opioid use disorder, moderate Anxiolytic use disorder, moderate Chronic pain Traumatic brain injury with LOC, by self-report 1) What is the Veteran s current risk level? Questions to consider 6

7 2) What may be some of the clinicians immediate concerns? 3) What are the Veteran s current treatment options? a. Substance use treatment? PTSD treatment? Combined treatment? 4) Why is the Veteran seeking services now and how do you assess for readiness for treatment? 5) What does the Veteran s prognosis look like? 7