CSSN D is a black American single 21-year-old female with approximately 2 years and 3 months active duty as of our initial meeting in August 2014. The patient started to see her ship’s psychologist regularly starting in February 2014 following an incident on her ship. She stated that while in ranks, an active duty officer was angrily addressing the group, and punched her on the back of her shoulder. She stated this immediately reminded her of childhood abuse, and soon brought back memories she had suppressed for years.

Over the next 2 months, she saw the psychologist and the ship’s medical officer, and took a selective serotonin reuptake inhibitor (SSRI) for anxiety. The record revealed that she endorsed beliefs that her coworkers and chain of command were pursuing information about her in order to make her life worse. At some point, she presented to them with myoclonic jerking , which continued to occur episodically while she was onboard the ship. This was a concern for her and staff, as she worked in the ship’s kitchen and was often around knives and hot food. She was admitted to our hospital on 8 April 2014 for a neurology and mental health evaluation. Workups at that time revealed a history consistent with adjustment disorder, present since enlistment, with consideration for posttraumatic stress disorder (PTSD). She was not suicidal in either the inpatient or the outpatient settings, and was discharged from the hospital on 9 April 2014. A brain MRI and EEG were both within normal limits.

Over the course of the early summer months of 2014, the patient’s episodes of jerking continued. Episodes persisted and during one, she had reportedly fallen to the floor, but denied alteration or loss of consciousness. She had been evaluated in psychology with psychological testing. Finally, as the ship was preparing for a long underway period, she was sent to the ER in the context of yet another episode in the kitchen, while working with a large pot of boiling water.

When I met CSSN D, she was angry—not upset, not anxious, but grossly angry. The volume of her voice oscillated, and she had a southern accent that was made staccato by her waves of rage. She was agitated. I spent the larger part of an hour establishing rapport and the periods of calm ultimately became longer, the periods of rage, shorter. She felt betrayed by her ship’s medical department, stating she had trusted them, but then felt many knew her history (of abuse) that she had kept secret for years. She felt betrayed by the Navy, citing stigma in seeing mental health.

I acknowledged her strength and asked if she had ever described herself as a survivor. It was not smoke and mirrors; she was clearly a woman who had lived through a lot; multiple History & Physical (H&Ps) had already established that fact. Further, in my brief assessment of her educational background, I felt she was not the most prepared or well educated to handle her life’s circumstances.

She discussed how when she thinks “bad thoughts,” they are very loud in her head and she has to speak loudly so she will not hear the “bad thoughts.” She reported feeling unsupported, not cared for, and often lonely. She reported that she cries herself to sleep most nights. She stated that she had been getting 3–4 h of sleep a night, and that it took her approximately an hour to fall asleep due to anxiety. She is woken often by nightmares but is unable to remember them. She denied any change in her eating habits or weight. The patient denied auditory/visual hallucinations or mania. She would not elaborate on her “bad thoughts,” but flatly denied suicidal or homicidal ideation and provided her younger sister and God as reasons to live.

A psychiatric review of systems was negative for manic or psychotic symptoms, and she did not complain of significant pain or dysfunction in other organ systems. Labs and radiological scans were negative for pathology.

She was in therapy as an adolescent while in foster care, which she reported was not helpful. Since that time, she was not in care, until she began to see her ship’s medical officer and psychologist. She took Paxil (paroxetine) for approximately 1 month and had been engaging in supportive therapy with the ship’s psychologist. She had never attempted suicide.

Her mother was treated for an unknown diagnosis. Her maternal grandmother was diagnosed with depression. Both biologic parents were diagnosed with substance use disorders.

The patient was born and raised in southern Illinois to an intact family system. She is the oldest child, and has one brother, 17 years old, and one sister, 12 years old who currently reside with their parents. She reported that as a result of her father’s infidelity, her mother became physically and emotionally abusive, as well as neglectful when the patient was 7 years old. Eventually, both parents became abusive, and the patient perceived that she needed to withstand the abuse to protect her siblings, although they occasionally were also emotionally and physically abused. The patient reported that after a particularly intense event in which she was whipped by her father with a belt and threatened with a knife, she fled to a neighbor’s house and called the police. She reported that she was placed in foster care, first living with her aunts for 1 year, and then with her best friend’s family until awkward interactions with her friend’s father led her to leave the home to join the US Navy. (She would not elaborate on these interactions and when questioned, denied sexual abuse.)

The patient denied any learning or disciplinary problems while in school and graduated on time with a 3.0 GPA. She went on to attain 25 credits of college prior to US Navy service, and was subsequently able to enter the service as an E-2. The patient worked in the fast food industry and as a cyber-lounge librarian. She denied any military or civilian legal issues.

She reported that she felt chronically guilty for escaping her home environment and leaving her siblings with her parents. The patient does not maintain a relationship with either of her parents and has not spoken to them since she was removed from the home.

The patient is single, never married, and does not have children. She noted that her last romantic involvement was in “A” School (Naval trade school for enlisted members). She reports that she feels unable to trust others enough to develop an emotional relationship.