A 43-year-old woman presented to the ED at 5:30 am on a weekday. While being triaged, she indicated she was hesitant to speak with anyone. The patient reported to the consulting psychologist that she had been deployed to Iraq as a reservist nurse 2 years earlier. During that time, an unknown assailant whom she believed to be an Iraqi national working with military security forces sexually assaulted her. The veteran confided that she had been too embarrassed and ashamed to report the assault.
When an ED nurse asked about the nature of her current emergency, the patient reported that she had not slept for several nights because of ongoing marital arguments, and had become progressively more preoccupied with suicidal thoughts since telling her husband about the sexual assault. The patient indicated that she had withheld the information from her spouse for fear that he would accuse her of marital infidelity based on a previous affair when she had been deployed in Gulf War I. The patient also indicated that she has not been interested in sexual activity since her return, although she has made multiple attempts—typically at her spouse’s initiation. The patient indicated that her limited sexual interest had strengthened her spouse’s concerns about her possible extramarital affair and increased his subsequent accusations. The patient told the nurse that “out of desperation, I told him the truth about my rape, but he only says I’m lying.”
The patient had insomnia before the assault and had used sleep medications and sometimes alcohol to help with sleep, “although I know it’s bad for me.” In further discussion, the patient reported that she was not sure of some of the details of the sexual trauma, because at the time of the assault she had taken sleeping medications and had also used contraband alcohol. In addition, she had sustained a head injury with brief loss of consciousness (less than 1 minute) 2 nights earlier before the assault.
This case illustrates the complexity and interaction of the characteristic medical, psychiatric, and social problems of returning OIF/OEF veterans. This returnee belongs to the growing cohort of female veterans who have served in the military, and she represents the early research showing that women are more likely than men to report mental health concerns, such as depression and suicidal thoughts.1 The patient in this case is also a victim of sexual trauma that appears to have gone both undiagnosed and unreported—an all too frequent occurrence for OIF/OEF veterans.2
The patient is at risk for domestic violence, given her husband’s reaction in the context of long-standing marital tensions. The patient’s immediate safety is the number one priority of the ED psychologist’s crisis intervention. If the patient does not endorse suicidal intent or have a plan and does not feel in acute danger from her husband, then the treatment plan would need to proceed simultaneously on several fronts.
With the patient in the ED, the physician and psychologist would want to screen for traumatic brain injury and perform a good general physical examination focused on other sources of trauma. Laboratory work and a brain scan are indicated if not performed previously. Because it is likely the veteran did not report the injury, her underlying cognitive impairment combined with use of alcohol and sleep medication raises her vulnerability to further trauma. Psychological methods of managing the insomnia would be the treatment of choice rather than continued use of sleeping medications.
A mental health screening should assess for depression, PTSD, and alcohol abuse—which are frequently comorbid with sexual trauma and traumatic brain injury.3 The patient’s avowed guilt and shame regarding the circumstances of her assault and prior affair raise the risk of violence and warrant rapid referral for individual and marital counseling (assuming the husband would accept the latter). This referral is part of arranging comprehensive follow-up with the VA, if at all possible, and helps ensure that the patient receives comprehensive military sexual-trauma assessment and treatment.4
1. Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA. 2006;295:1023-1032.
2. Valente S, Wight C. Military sexual trauma: violence and sexual abuse. Mil Med. 2007;172:259-265.
3. Schneiderman AI, Braver ER, Kang HK. Understanding sequelae of injury mechanisms and mild traumatic brain injury incurred during the conflicts in Iraq and Afghanistan: persistent postconcussive symptoms and posttraumatic stress disorder. Am J Epidemiol. 2008;167:1446-1452.
4. Kimerling R, Gima K, Smith MW, et al. The Veterans Health Administration and military sexual trauma. Am J Public Health. 2007;97:2160-2166.