Postdeployment PTSD and Addictive Combat Attachment Behaviors in U.S. Military Service Members

Marjorie S. Campbell, Margaret Ryan, Daniel Wright, Maria D. Devore, Charles W. Hoge
2016 American Journal of Psychiatry  
Studies have shown that about half of U.S. veterans who served in Iraq or Afghanistan report significant postcombat stress symptoms (3), and the prevalence of posttraumatic stress disorder (PTSD) averages 12%213% in infantry personnel (4). Unfortunately, utilization of mental health services by combat veterans is relatively low (5). While evidence-based treatments exist, treatment dropout significantly reduces efficacy. Even among veterans who complete treatment, significant PTSD symptoms often
more » ... PTSD symptoms often remain, and there are high rates of comorbidity and chronicity (6). We hypothesize that the phenomenon of "combat attachment" represents a hidden, underrecognized variable in treatment outcomes. We define combat attachment as a pattern of habitually engaging in combat-related "Lance Corporal A" was a 21-year-old unmarried male infantry marine with no history of serious childhood adversities who deployed to Afghanistan for 7 months. Heavy combat exposure included several close-proximity blast explosions and witnessing multiple deaths and serious injuries of team members. Eight months after his return, LCpl A presented to the Concussion Clinic, Naval Hospital Camp Pendleton, with postconcussive symptoms and severe symptoms of posttraumatic stress disorder (PTSD) and depression. Over 9 months of treatment, he received evidence-based individual trauma-focused psychotherapy, medications (escitalopram, zolpidem), and an 8-week intensive outpatient combat-related PTSD program. Traumatic events and moral injury (defined as perpetrating, failing to prevent, or witnessing acts that transgress deeply held moral beliefs and expectations [1]) were addressed and the patient's distress decreased, but he remained persistently hyperaroused and depressed, with a total score of 71 on the PTSD Checklist (DSM-IV version; range, 17-85) on completion of the intensive outpatient program. Further questioning revealed that LCpl A was reliving stimulating, rewarding combat-related events accompanied by an "adrenaline rush" for long periods-which he described as "getting amped up." Bored at work, he engaged in lengthy animated combat-related discussions with other veterans. When off-duty, he played the video game Call of Duty for hours; watched war documentaries, sometimes with knife in hand; looked at his deployment photos; and watched combat videos (his own and online), stimulating feelings of being back in Afghanistan. He daydreamed about combat frequently-for example, imagining that he was going on patrol when putting his boots on in the morning. In daily 2-hour workouts, he played music from deployment and relived combat scenes; he felt that by doing so he could lift more weight. Overall, he estimated spending 10 or more hours a day with combat-related memories accompanied by an "adrenaline rush," and he felt depressed and withdrawn when not engaging in these activities. He reported that his most exciting event was a firefight in which his unit took no casualties; he felt "invincible, on top of the world, powerful, like Superman!" The interdisciplinary team discussed LCpl A's case and agreed that his combat attachment behaviors should be a specific treatment focus, which the team addressed with a combination of modalities, including motivational interviewing (2) and eye-movement desensitization and reprocessing. This treatment ultimately resulted in reduction in hyperarousal responses to combat thoughts and memories and improvement in all spheres of functioning. LCpl A's PTSD Checklist score 3 months later, at completion of treatment, was 52, and he reported that it felt "weird" to think about combat and not get "amped up," but this no longer interested him. He left the military 2 weeks after completing this treatment. The treating psychologist (M.S.C.) observed that LCpl A's attachment to combat-related behaviors was not unique, and she received permission from the Naval Medicine West Institutional Review Board to collate clinical data on a sequential case series of active duty personnel with combatrelated PTSD to systematically explore characteristics of combat attachment behaviors.
doi:10.1176/appi.ajp.2015.15101297 pmid:27903099 fatcat:brzmw5o3b5eu5pvvzbcfowqj4u