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C&P Report Example
Mark D Worthen PsyD
https://www.PTSDexams.net
mark@drworthen.net
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This is an example of how I might write the relevant history, opinion, and rationale for Alcohol Use Disorder secondary PTSD. 

**This is a hypothetical case example, i.e., the text is not about a specific person, it is a composite description based on my experience evaluating veterans (C&P exams).**

Note: I wrote this example in 2013, so the references reflect the available research literature at that time. I suggest using the references listed below as a springboard for finding subsequent relevant studies published in peer-reviewed journals and books.

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ALCOHOL USE HISTORY
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The Veteran did not drink alcohol as a teenager. He drank occasionally as a young adult before joining the Navy but never more than three standard drinks at a time and he never experienced alcohol-related problems. The Veteran began to drink alcoholic beverages more often after joining the Navy but only socially, and he tended to drink less than other sailors ("I usually ended up being the designated driver".) His alcohol use escalated markedly after his first deployment to Afghanistan, concomittant with the onset of PTSD symptomatology. He began to drink to intoxication to "make the bad memories go away", to feel less depressed, and to cope with insomnia. He has exhibited an episodic binge drinking pattern since that time, consuming between 6 and 10 standard drinks over the course of two to three hours, six to eight times per month.

The veteran's alcohol use and associated effects meet the following DSM-5 diagnostic criteria:

+ sometimes drinks alcohol in larger amounts than originally intended 
+ has unsuccessfully tried to cut back on the amount of alcohol he consumes 
+ has a persistent craving for alcohol use 
+ has continued alcohol use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to be exacerbated by alcohol use
+ has observed a need for markedly increased amounts of alcohol to achieve a desired effect

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// OPINION //
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It is MORE likely than not that the Veteran's Alcohol Use Disorder is proximately due to or the result of his service-connected posttraumatic stress disorder (PTSD). 

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// RATIONALE //
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1. The Veteran did not drink alcohol in a problematic manner prior to his first deployment to Afghanistan in 2004. He developed posttraumatic stress symptoms near the end of his first deployment (after the traumatic stressors described earlier in this report), although he "held it together", only to find that PTSD symptoms became increasingly more intense and frequent when he returned to CONUS and after his honorable discharge. When he returned home he also began to drink excessively, a pattern that increased in frequency after his discharge from the Navy. He spontaneously reported drinking to "numb out" PTSD symptoms such as disturbing intrusive images, smells, and sounds; nightmares; and chronic tension, and drinking to "try to get some sleep".

2. Research indicates that alcohol use disorders are often comorbid with PTSD and that PTSD probably drives the development of the secondary alcohol use disorder.

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References
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** Bremner, J., Southwick, S. M., Darnell, A., & Charney, D. S. (1996). Chronic PTSD in Vietnam combat veterans: Course of illness and substance abuse. The American Journal Of Psychiatry, 153(3), 369-375. ==> ## Quote from article: "The onset of alcohol and substance abuse was associated with the onset of PTSD symptoms, and the increase in use paralleled the increase of symptoms."

Chilcoat, H. D. (1998). Posttraumatic Stress Disorder and Drug Disorders: Testing Causal Pathways. Archives of General Psychiatry, 55(10), 913–917. doi:10.1001/archpsyc.55.10.913 ==> ## Quote from article: "The results suggest that drug abuse or dependence in persons with PTSD might be the inadvertent result of efforts to medicate symptoms, although the possibility of shared vulnerability to PTSD and drug use disorders cannot be ruled out."

Cougle, J. R., Bonn-Miller, M. O., Vujanovic, A. A., Zvolensky, M. J., & Hawkins, K. R. (2011). Posttraumatic stress disorder and cannabis use in a nationally representative sample. Psychology of Addictive Behaviors, 25(3), 554-558. ==> ## Quote from article: "...PTSD diagnoses were associated with increased odds of lifetime history of cannabis use as well as past year daily cannabis use."

** Driessen, M., Schulte, S., Luedecke, C., Schaefer, I., Sutmann, F., Ohlmeier, M., et al. (2008). Trauma and PTSD in patients with alcohol, drug, or dual dependence: a multi-center study. Alcoholism, Clinical And Experimental Research, 32(3), 481-488. ==> ## Quote from article: "PTSD seems to be an independent risk factor for an unfavorable outcome of SUD [Substance Use Disorders]."

Foa, E. B., & Williams, M. T. (2010). Methodology of a randomized double-blind clinical trial for comorbid posttraumatic stress disorder and alcohol dependence. Mental Health And Substance Use: Dual Diagnosis, 3(2), 131-147. ==> ## Quote from article: "Alcohol dependence (AD) and posttraumatic stress disorder (PTSD) are each associated with profound disruptions in psychological, social, and physical functioning, and these disruptions are compounded in individuals with both disorders. Comorbidity between the two disorders is high, with the risk for AD increasing substantially among individuals with PTSD ..."

** Hien, D. A., Jiang, H., Campbell, A. N. C., Hu, M.-C., Miele, G. M., Cohen, L. R., … Nunes, E. V. (2010). Do treatment improvements in PTSD severity affect substance use outcomes? A secondary analysis from a randomized clinical trial in NIDA’s Clinical Trials Network. The American journal of psychiatry, 167(1), 95–101. doi:10.1176/appi.ajp.2009.09091261 ==> ## Quote from article: "PTSD severity reductions were more likely to be associated with substance use improvement, with minimal evidence of substance use symptom reduction improving PTSD symptoms. Results support the self-medication model of coping with PTSD symptoms..."

Jacobson, I., Ryan, M., Hooper, T., Smith, T., Amoroso, P., Boyko, E., & ... Bell, N. (2008). Alcohol use and alcohol-related problems before and after military combat deployment. JAMA: The Journal Of The American Medical Association, 300(6), 663-675. ==> ## Quote from article: "Reserve and National Guard personnel and younger service members who deploy with reported combat exposures are at increased risk of new-onset heavy weekly drinking, binge drinking, and alcohol-related problems."

Jakupcak, M., Tull, M., McDermott, M., Kaysen, D., Hunt, S., & Simpson, T. (2010). PTSD symptom clusters in relationship to alcohol misuse among Iraq and Afghanistan war veterans seeking post-deployment VA health care. Addictive Behaviors, 35(9), 840-843. ==> ## Quote from article: "Veterans who screened positive for PTSD or depression were two times more likely to report alcohol misuse relative to Veterans who did not screen positive for these disorders." 

Kaysen, D., Stappenbeck, C.,Rhew, I., & Simpson, T. (2014). Proximal relationships between PTSD and drinking behavior. European Journal of Psychotraumatology, 5, 26518. ==> ## Quote: "Overall, findings suggest that specific PTSD symptoms are associated with higher alcohol use and that these relationships are moderated by daily coping self-efficacy."

Leeies, M., Pagura, J., Sareen, J., & Bolton, J. (2010). The use of alcohol and drugs to self-medicate symptoms of posttraumatic stress disorder. Depression And Anxiety, 27(8), 731-736. \ ## Quote from article: "Approximately 20% of individuals with PTSD used substances in an attempt to relieve their symptoms. Men were significantly more likely than women to engage in self-medication behavior."

Seal, K., Cohen, G., Waldrop, A., Cohen, B., Maguen, S., & Ren, L. (2011). Substance use disorders in Iraq and Afghanistan veterans in VA healthcare, 2001-2010: Implications for screening, diagnosis and treatment. Drug And Alcohol Dependence, 116(1-3), 93-101. ## Quote from article: "Post-deployment AUD [Alcohol Use Disorder] and DUD [Drug Use Disorder] diagnoses were more prevalent in subgroups of Iraq and Afghanistan veterans and were highly comorbid with PTSD and depression."

** Simons, J., Gaher, R., Jacobs, G., Meyer, D., & Johnson-Jimenez, E. (2005). Associations between alcohol use and PTSD symptoms among American Red Cross disaster relief workers responding to the 9/11/2001 attacks. The American Journal Of Drug And Alcohol Abuse, 31(2), 285-304. ==> ## Quote from article: "... the association between PTSD and alcohol abuse emphasised the clinical and public health importance of this relationship. The available evidence does ... support the causal nature of this relationship." 

Simpson, T. L., Stappenbeck, C. A., Varra, A. A., Moore, S. A., & Kaysen, D. (2012). Symptoms of posttraumatic stress predict craving among alcohol treatment seekers: results of a daily monitoring study. Psychology of addictive behaviors: journal of the Society of Psychologists in Addictive Behaviors, 26(4), 724–733. doi:10.1037/a0027169 ==> ## Quote from article: "Results suggest that days with greater overall PTSD severity are associated with greater alcohol craving, and greater reports of startle and anger/irritability were particularly associated with same-day craving."

Stewart, S., Mitchell, T., Wright, K., & Loba, P. (2004). The relations of PTSD symptoms to alcohol use and coping drinking in volunteers who responded to the Swissair Flight 111 airline disaster. Journal Of Anxiety Disorders, 18(1), 51-68. ==> ## Quote from article: "Frequency and severity of PTSD symptoms ... were positively correlated with coping-motivated drinking ... and with alcohol use to forget."

Watt, M. H., Ranby, K. W., Meade, C. S., Sikkema, K. J., MacFarlane, J. C., Skinner, D., … Kalichman, S. C. (2012). Posttraumatic stress disorder symptoms mediate the relationship between traumatic experiences and drinking behavior among women attending alcohol-serving venues in a South African township. Journal of studies on alcohol and drugs, 73(4), 549–558. ==> ## Quote from article: "Reporting a greater number of categories of traumatic experiences was strongly associated with drinking behavior, and PTSD explained almost half of the total effect of traumatic exposure on alcohol consumption."

Wolitzky-Taylor, K., Bobova, L., Zinbarg, R. E., Mineka, S., & Craske, M. G. (2012). Longitudinal investigation of the impact of anxiety and mood disorders in adolescence on subsequent substance use disorder onset and vice versa. Addictive behaviors, 37(8), 982–985. doi:10.1016/j.addbeh.2012.03.026  ## Quote from article: "In line with the self-medication hypothesis of emotional disorder/SUDs comorbidity, anxiety and unipolar mood disorders at baseline assessment were associated with later onsets of SUDs [Substance Use Disorders]. In particular, social anxiety disorder (SAD) at baseline predicted onset of alcohol use disorders and PTSD predicted the onset of all SUDs."