Jimmy Jones is a 35 year old Caucasian male who came to therapy at insistence of his wife. Jimmy was medically released from active duty with the National Guard six months ago. During his time in the guard, he was deployed as a Platoon sergeant with an infantry unit to Iraq (once) and Afghanistan (twice) for tours lasting anywhere from 8 months to a year each. During his last tour in Afghanistan, he was critically wounded when his outfit was ambushed one night on patrol. During the firefight, he lost five soldiers from his unit and he was critically injured during heroic actions to save his other men. Although medically cleared, Jimmy still complains about the ache in his shoulder from multiple bullet wounds.

His wife, Pat, reports that Jimmy has not been himself since he was released from active duty. She also says if he does not change quickly, she and the children will leave. She no longer feels safe at home and worries that Jimmy's over reactions to loud noises and the children approaching him may end up in one of the children getting hurt. Jimmy is very moody, gets angered easily (5 times per week) - going from zero to rage in seconds, has intense nightmares (3-5 nights per week), and experiences flashbacks (daily). He sleeps 3-4 hours a night because of the nightmares. He says he feels tired and fatigued daily and has daily problems concentrating. Jimmy's wife reports that Jimmy "will do everything possible to avoid thinking about that terrible day." including refusing to drive close to any type of military building or graveyard. Jimmy will not talk with anyone about the incident and refuses to read any type of report on the incident. He keeps a loaded pistol with him all the time, saying he has to stay on guard and vigilant, "the world is not a safe place". He has been known to pull his weapon out when loud noises startle him or when he is extremely angry at adults, especially those who cut him off while he is driving. Jimmy's wife states that Jimmy has always been "uptight" and "anxious" but since the incident he is easily startled and very negative about the world, often stating that there is no place safe for anyone.

Jimmy's wife also reports he has started drinking alcohol "to dull the pain from his injured shoulder and help him relax as he is always anxious." He started out drinking a 2-4 of beers each night upon returning home, but now he drinks a six pack of beer and a pint of Bourbon every night. Over the last month his drinking has increased and his wife notes there are beer cans left in the trash during the day when she is at work and the kids are at school. Jimmy reports that he used to feel better after a few beers but is has seemed to take more and more for his to feel his anxiety and pain lessen. Jimmy has attempted to reduce his alcohol consumption, but states he feels tense all the time and the alcohol helps him relax. He feels guilty over the amount of alcohol he is drinking and has been fighting with his wife 3-5 days per week due to his drinking. Jimmy says he hardly leaves the house except "for VA follow up appointments and running out for more beer and bourbon." Other than these times, he has no interest in doing anything outside of the home. Pat has tried to get him to go to church, which he used to enjoy, but he refuses. Once an active father who spent as much time with his children as possible, he now has no desire to play with sons (Ages 6 and 8). He feels extremely guilty daily for loosing members of his outfit even though reports reflect no wrong doing on his part. He says at least four times during the assessment that he was supposed to take care of his men. When queried, he denies current or past suicidal ideation. Most days he feels sad and empty. Although he received a commendation for heroism under fire and a purple heart, he says he would rather just have his guys back alive. Jimmy has not returned to his job as a Postal Letter Carrier, even though the Postal Service said they will accommodate his medical issues. His wife is worried he will lose that job and the benefits associated with it if he does not return to work soon.

Jimmy says he is tired of the VA, tired of hospitals, and tired of his wife nagging him. Jimmy states he does not want to lose his marriage and indicates he is willing to do what it takes to save the marriage. He says he misses the good times he used to have with his boys and his wife and desires to return to a "normal" life.

Jimmy is the second of four children born to his parents union. Jimmy has two younger sisters and an older brother. Jimmy's father was an abusive alcoholic who beat his mother. His parents divorced when he was 14 years old and he has had no contact with his father since the divorce. The family was forced to relocate after his mother filed for divorce due to his father attempting numerous times to physically harm his mother. Jimmy reports he has always felt guilty that he did not do more to protect his mother from his father. Jimmy had weekly contact with his mother and two sisters and monthly contact with his brother until after his discharge. He has had no contact with his family in over four months. His mother and sisters continue to call and he refuses to speak to them, saying he is too tired to hold a decent conversation. Prior to his last deployments, Jimmy and his wife had multiple families they socialized with on a weekly basis. Since his return, Jimmy has refused to attend any social gathering because "they just will not understand. And I feel like they all know that I failed. I cannot stand looking at them with them knowing about my failure."

Jimmy has a high school education. He appears tired and has blood shot eyes. He is clean and presents himself well, but he has not shaved in some time. He is oriented times four. Jimmy says he does not eat much because he is just not hungry. Pat says he has lost 20 pounds in the six months he has been home. He insists he is not depressed, just tired and needs to rest. He is currently taking Lexapro (20 mg 1x) and has sleeping pills prescribed as needed (Ambien 20 mg). Jimmy has no history of physical illness and no mental health treatment. His mother and two sisters have a history of long term depression. His brother has a history of alcohol abuse and interactions with the criminal justice system due to anger. Jimmy's psychiatrist is Dr. John Horton at the VA hospital in Salem, who he sees once every three months for a medication management. Jimmy reports he knows that if he does not change, he will become like his Dad. He states that he is a Christian, but he feels like he has been abandoned by God. When asked, he indicated he would consider attending a local Veterans support group once a week and begin addressing his alcohol use.

What is the primary diagnosis? What are all the secondary diagnoses?