Military History: Trauma Exposure, Service Connection, and Reintegration
This is Part 6 in our series on Social History.
Read Part 5: Living Situation: Housing, Social Support, and Community Integration for the previous component.
Military service carries unique risk factors for PTSD, depression, anxiety, substance use disorders, and traumatic brain injury. Comprehensive assessment of military history is essential for understanding trauma exposure, occupational stressors, and current symptoms that may be service-related.
Veterans experience mental health conditions at higher rates than the general population, with combat exposure, military sexual trauma, and traumatic brain injury representing distinct risk factors requiring specialized assessment and treatment. Understanding military history allows appropriate referrals to VA services, recognition of service-connected conditions, and trauma-informed care that acknowledges the specific context of military trauma.
Learning Objectives
After reading this section, you should be able to:
- Identify key components of military history relevant to psychiatric assessment
- Screen for combat exposure, military sexual trauma, and traumatic brain injury
- Recognize patterns suggesting service-related mental health conditions
- Document military history appropriately and connect veterans with VA resources
Start With Chart Review
Before interviewing the patient, review available documentation for military service information:
DD-214 (Certificate of Release or Discharge from Active Duty) – Official documentation of service branch, dates, discharge characterization, and military occupational specialty
VA medical records – Document service-connected disabilities, ongoing VA treatment, and prior mental health or TBI assessments
Service treatment records – Medical documentation from active duty may reveal injuries, behavioral health treatment, or medical separations
Prior disability evaluations – VA disability ratings for PTSD, TBI, or other conditions indicate service connection and severity
Collateral from family – May describe personality or behavior changes following service that patient doesn’t recognize
💡 Clinical Pearl: Reviewing DD-214 before the interview clarifies discharge status, service era, and potential combat exposure (deployment locations). This prevents confusion and demonstrates respect for the veteran’s service by using correct terminology.
Interview the Patient
After chart review, explore military service systematically to understand trauma exposures, occupational stressors, and current impact. Begin by establishing the scope of military involvement, then explore specific exposures and their consequences.
Opening Questions
- “Which branch did you serve in?”
- “What was your rank and military occupational specialty (MOS)?”
- “How long were you in the service? When did you serve?”
- “What was your discharge status – honorable, general, or other?”
Deployment and Combat Exposure
- “Were you deployed? Where and for how long?”
- “Did you see combat or experience life-threatening situations?”
- “Were you involved in combat operations where you or others were injured or killed?”
- “Did you witness death or serious injury?”
Specific Trauma Exposures
Military Sexual Trauma (MST):
- “During your military service, did you experience any unwanted sexual attention, sexual harassment, or sexual assault?”
- “Did you experience any threatening or violent sexual situations during service?”
Traumatic Brain Injury (TBI):
- “Did you have any head injuries, blast exposures, or concussions during service?”
- “Were you ever knocked unconscious or had your ‘bell rung’?”
- “Do you have ongoing problems with headaches, memory, or concentration since service?”
Service Conduct and Adjustment
- “Did you have any disciplinary actions or legal issues during service?”
- “Were there periods when you struggled with following orders or had conflicts with command?”
- “Did you use alcohol or drugs during service?”
Reintegration and Current Connection
- “How was your transition back to civilian life?”
- “Are you connected with VA services for healthcare or benefits?”
- “Have you filed for disability compensation? What conditions?”
💡 Clinical Pearl: Military sexual trauma is severely underreported due to shame, command retaliation fears, and military culture minimizing sexual violence. Screen every veteran regardless of gender. Male veterans experience MST but report it even less frequently than women. Frame questions neutrally and emphasize confidentiality to facilitate disclosure.
Recognizing Patterns Suggesting Trauma or Current Impact
Certain military history patterns indicate elevated risk for service-related mental health conditions requiring specialized assessment and VA referral.
🚩 Combat exposure with avoidance of discussing specifics – Classic PTSD avoidance symptom. Veteran becomes terse, changes subject, or shows visible distress when discussing deployment. Suggests ongoing trauma symptoms requiring trauma-focused treatment.
🚩 Military sexual trauma with subsequent relationship difficulties or sexual dysfunction – MST frequently causes complex trauma presentation with interpersonal mistrust, sexual avoidance, hypervigilance in relationships, and difficulty with authority figures. Often undiagnosed and untreated for years.
🚩 Traumatic brain injury with cognitive complaints, headaches, or mood changes – Post-concussive syndrome from blast exposure or head trauma causes persistent cognitive symptoms, mood lability, headaches, and sleep disturbance. Often co-occurs with PTSD, complicating both conditions.
🚩 Disciplinary issues suggesting impulse control or substance use during service – Pattern of non-judicial punishment, demotions, or other-than-honorable discharge may indicate undiagnosed ADHD, conduct problems, substance use disorder, or personality pathology predating service.
🚩 Difficult reintegration suggesting PTSD or adjustment disorder – Inability to maintain employment, relationship breakdowns, social isolation, substance use escalation, or legal problems following service indicate failed adjustment requiring comprehensive mental health intervention.
🚩 Discharge characterization as “other than honorable” or “bad conduct” – May affect VA benefits eligibility but doesn’t preclude treatment. These discharges often result from behavioral health conditions that went untreated during service.
Special Considerations
Service Era and Combat Exposure Context
Different service eras carry distinct trauma exposure patterns:
Vietnam Era (1960s-1970s) – Jungle warfare, Agent Orange exposure, hostile homecoming, delayed PTSD recognition and treatment
Gulf War (1990-1991) – Chemical exposure concerns, brief intense combat, Gulf War syndrome
Post-9/11 (2001-present) – Multiple deployments, IED/blast exposure, counterinsurgency operations, higher TBI rates
Understanding service era context helps interpret trauma type and provides validation for veterans’ experiences.
Women Veterans
Women veterans face unique challenges often overlooked:
- Higher MST rates than men (approximately 1 in 3 vs. 1 in 50)
- Combat exposure despite officially restricted roles
- “Invisible veterans” – less likely to identify as veterans or seek VA care
- Pregnancy and childcare challenges during service
Ask women veterans specifically about MST and validate their service regardless of combat role.
VA Benefits and Service Connection
Understanding VA disability system helps treatment planning:
- Veterans can receive VA healthcare even without service-connected disability
- Service-connected conditions receive compensation and priority treatment
- Disability ratings range 0% to 100% in 10% increments
- Combat-related PTSD has presumptive service connection
Encourage veterans to apply for service connection if experiencing mental health conditions potentially related to service.
Discharge Status and Benefits Eligibility
Discharge characterization affects benefits:
- Honorable or General – Full VA benefits eligibility
- Other Than Honorable (OTH) – May receive some benefits pending “character of discharge” determination
- Bad Conduct or Dishonorable – Typically bars VA benefits, but case-by-case review possible
Veterans with OTH discharges due to mental health or trauma-related behaviors may petition for discharge upgrade.
What to Document
Your documentation should capture military service, trauma exposures, and implications for current presentation.
| Documentation Level | What to Include | Example | When to Use This Level |
|---|---|---|---|
| Minimal | Branch, years of service, discharge status, VA connection | “Served 4 years Army, honorable discharge. Not currently connected with VA.” | Routine evaluations; remote military service without combat or trauma; patient denies service-related symptoms |
| Standard | Minimal + Deployment history, general trauma exposure, current VA engagement, basic service-connected conditions | “Served 4 years Army (2010-2014) with one 12-month deployment to Afghanistan. Reports combat exposure. Honorable discharge. Receives VA healthcare, 50% service-connected for PTSD. Reports ongoing nightmares and hypervigilance.” | When military service is relevant to current presentation; combat exposure documented; active VA engagement; service-connected mental health conditions |
| Detailed | Standard + Specific combat exposures, MST assessment, TBI history, pattern of symptoms related to service, reintegration difficulties, treatment history, specific clinical implications | “Patient is Army veteran who served 2006-2010 with two deployments to Iraq (15 months total). Military occupational specialty was combat engineer (route clearance). Reports multiple IED blast exposures with at least 3 documented concussions, most significant in 2008 requiring 2-day medical hold. Describes ongoing cognitive difficulties (memory, concentration), persistent headaches, and mood lability since blast injuries. Also reports significant combat exposure including witnessing deaths of fellow soldiers and enemy combatants. Since separation, experiences intrusive memories, nightmares, hypervigilance, avoidance of crowds and loud noises, and difficulty maintaining employment due to interpersonal conflicts. Screened positive for military sexual trauma – reports sexual harassment by supervisor during second deployment but did not report at time due to fear of retaliation. Describes ongoing mistrust of authority and difficulty with male providers. Honorable discharge. Currently receives VA care and is 70% service-connected for PTSD and post-concussive syndrome. Has completed one trial of Prolonged Exposure therapy with partial benefit. Reintegration marked by multiple job losses, divorce, and social isolation.” | Complex presentations where military trauma is central; multiple service-related conditions (PTSD, TBI, MST); when military history explains current symptoms and functional impairment; coordination with VA care needed; disability evaluations; forensic contexts |
Why This Information Matters
Military history provides essential context for understanding trauma exposure, symptom etiology, and appropriate treatment resources. Veterans experience distinct forms of trauma and face unique reintegration challenges that civilian providers must recognize to provide effective care.
Diagnostic Clarity and Service Connection: Many psychiatric symptoms in veterans are directly service-related. PTSD from combat, depression following TBI, anxiety from MST, or substance use as self-medication for untreated trauma all have service connection implications. Recognizing these connections allows appropriate VA referrals for service-connected disability claims, which provide financial compensation and prioritized treatment. Distinguishing service-related conditions from civilian trauma or primary psychiatric disorders shapes treatment approach and benefits eligibility.
Trauma-Informed Care: Military trauma differs qualitatively from civilian trauma. Combat exposure involves prolonged threat, moral injury from participating in or witnessing violence, survivor guilt from losing fellow service members, and betrayal trauma when leadership failures cause casualties. MST involves authority figure violations within closed institutional systems where reporting brings retaliation. Understanding military-specific trauma contexts prevents retraumatization through inappropriate interventions and allows culturally competent trauma processing that acknowledges military culture and values.
Identifying Traumatic Brain Injury: TBI from blast exposure is signature injury of recent conflicts. Repetitive blast exposure causes cumulative cognitive impairment, mood dysregulation, and increased PTSD risk. Symptoms overlap significantly with PTSD – irritability, sleep disturbance, concentration difficulties, emotional lability – making differential diagnosis challenging. Cognitive complaints in combat veterans warrant specific TBI assessment and possible neuropsychological testing. Treatment approaches differ for PTSD vs. TBI, making accurate identification essential.
Recognizing Military Sexual Trauma: MST creates complex trauma presentations often missed in standard PTSD screening. Survivors experience institutional betrayal when command fails to protect or punish perpetrators. They face ongoing contact with perpetrators in closed military environments. Women face gender-specific military culture challenges. Men experience shame reporting sexual violence that prevents disclosure. MST screening must be universal, confidential, and normalized to facilitate disclosure and appropriate referral to specialized MST treatment programs.
VA System Navigation: Veterans have access to comprehensive VA healthcare system but many don’t utilize it due to stigma, mistrust, or unawareness of benefits. Understanding discharge status, service connection process, and benefits eligibility allows civilian providers to encourage VA engagement. Veterans with service-connected conditions receive free VA healthcare for those conditions. Combat veterans receive free care for 5 years post-separation. Facilitating VA connection provides veterans with specialized military-informed care and financial resources supporting recovery.
Reintegration and Occupational Functioning: Military service provides intense structure, clear mission, and close-knit unit cohesion. Transition to civilian life removes this structure, often precipitating decompensation. Understanding military occupational specialty reveals transferable skills and adjustment challenges. Combat arms veterans face greater difficulty finding civilian employment comparable to their military role. Support specialists may transition more smoothly. Knowing military background helps anticipate reintegration challenges and provide appropriate vocational resources.
Discharge Status Implications: Discharge characterization profoundly affects veterans’ post-service trajectories. Other-than-honorable discharges often result from behavioral health symptoms (PTSD, TBI, depression, substance use) that went undiagnosed during service. These veterans face double jeopardy – mental health conditions plus reduced access to VA treatment. Civilian providers may be only access point for care. Understanding discharge status allows advocacy for discharge upgrades and connection to veteran service organizations providing support regardless of discharge characterization.
Military history assessment identifies service-related trauma, connects veterans with specialized resources, and provides context for understanding symptoms that might otherwise seem treatment-resistant or personality-based. This specialized assessment component transforms veterans’ care by recognizing their unique sacrifice and ensuring appropriate recognition and treatment of service-related conditions.
Next in this series: Part 7 – Social History Overview: Integrating Domains for Formulation and Treatment Planning
Previous post: Part 5 – Living Situation: Housing, Social Support, and Community Integration
