PTSD Treatment Summary Letter mm/dd/yyyy                    Veterans Affairs Attn:  VSO 123 Main St. City, State zip         Re:      John Doe SSN:  123-45-6789            The following Clinical Assessment has been requested by the veteran in support of his service-connected disability claim for posttraumatic stress disorder (PTSD).                          IDENTIFYING DATA & MILITARY HISTORY:                   Mr. Doe is a 62 year-old male who presented to the Vet Center on November 7, 2007, for a PTSD evaluation.  Currently, Mr. Doe revealed that he is experiencing incapacitating anxiety, severe depressive episodes, and intense anger episodes stemming from traumatic events he experienced while participating in the Vietnam Conflict.  Mr. Doe also reports a history of occasional social isolation, intense frustration, a history of night terrors and severe sleep disruption resulting from action and events experienced during his participation in the Vietnam Conflict zone.                               In October 1965, Mr. Doe joined the U.S. Army.  While serving in the U.S. Army, Mr. Doe served primarily as an infantryman on the front lines .  The duties of infantryman exposed Mr. Doe to a wide array of weapons, security tactics, and enforcement strategies.  Mr. Doe would later draw upon these experiences in Vietnam as a means of surviving brutal combat scenarios.                     In November 1967, while on a search and destroy mission near the Cambodian border, Mr. Doe’s unit was attacked by enemy troops.  During the surprise attack, one member of Mr. Doe’s unit was killed and many were severely injured.  Mr. Doe revealed that he was unsure how he survived the attack, but was glad he did.                 In April 1968, a squadron of F-4 Phantoms from the U.S. Air Force mistakenly dropped “yellow jacket” bombs on Mr. Doe’s unit.  Mr. Doe divulged that the bombs never exploded, but the incident frightened him badly.                Mr. Doe also revealed that during one of many reconnaissance missions in the jungle, his unit was being fired upon by an enemy sniper.  Mr. Doe reported that the sniper killed one member of his unit.  He also reported that the incident was frightening, not only because the sniper seemed to be deadly accurate, but no one knew where he was located.                   On another occasion, on March 31, 1966, veteran was celebrating his birthday with other members of his unit when they were attacked by Vietcong soldiers.  Veteran revealed that the sneak attack scared him very badly.  Veteran said he was thinking obsessively that he did not want to die on his birthday.              Mr. Doe goes on to mention other traumatic events that included, multiple fire-fights, and other scenarios where his life was threatened and where he witnessed dead or severely wounded soldiers.                   The psychological impact of multiple death experiences and multiple search and destroy missions in Vietnam may have led to the many negative psychological issues and cognitive distortions that Mr. Doe has struggled with since departing Vietnam.                                               PRESENTING PROBLEMS:                     Mr. Doe reports a history hypervigilance since departing Vietnam, periodic social isolation, occasional social anxiety, intolerance to loud noises similar to the ones he heard in Vietnam, intrusive thoughts, recollections about events in Vietnam, and intense anger outbursts.  Moreover, Mr. Doe maintains that he has difficulty concentrating, and struggles with staying focused due to the many thoughts in his mind about traumatic events he experienced in Vietnam, and most recently, a restricted range of affect with family members.                                  CLINCAL IMPRESSION/ASSESSMENT:                       As of this report, Mr. Doe has begun group psychotherapy at the Vet Center for what appears to be symptoms associated with PTSD as characterized in the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV).  The constellation of symptoms displayed by Mr. Doe since leaving Vietnam could possibly suggest a chronic condition of PTSD.  Mr. Doe’s exposure to death, destruction, inhumane brutality and unimaginable killings associated with war, and his frequent avoidance of being killed or injured by enemy troops may all be contributing factors that suggest PTSD.  Also, it appears as though Mr. Doe’s intrusive thoughts, occasional anxiety, intense anger outbursts and restricted range of affect could be symptoms associated with PTSD.  Mr. Doe’s reactivity on exposure to internal cues that symbolize or resemble traumatic events experienced in Vietnam may also be contributing factors to his current condition.  Additionally, Mr. Doe’s recent history of hypervigilance, difficulty concentrating, exaggerated startle response to external stimuli, and diminished interest or participation in significant activities all seem to indicate that he may have struggled with PTSD symptoms since leaving Vietnam.                                 CASE DISPOSITION:                        To date, Mr. Doe has been treatment compliant.  Mr. Doe will continue with treatment at the Vet Center weekly or as needed for group psychotherapy and/or individual counseling.  All treatment components will focus on supportive counseling, psycho-education and cognitive behavioral therapy (CBT) in group and/or individual sessions.              At this time, prognosis for significant change for Mr. Doe appears marginal.                                 Respectfully submitted,                                           Jane W. Smith, LCSW Readjustment Counseling Therapist        [ VA Tools ]