Diagnosis and Treatment of PTSD-Related Compulsive Checking Behaviors in Veterans of the Iraq War: The Influence of Military Context on the Expression of PTSD Symptoms
This case study presents an overview of the conceptualization and treatment of two veterans of the Iraq War who presented for combat-related treatment at a Veterans Administration Medical Center. In addition to posttraumatic stress disorder (PTSD) symptoms of reexperiencing, arousal, and avoidance, the veterans exhibited compulsive checking behaviors that appear to be influenced by theater-specific combat duties and traumatic events. These cases represent what the authors believe to be an increasingly common expression of PTSD in veterans of the Iraq and Afghanistan wars. Both veterans were treated with prolonged exposure therapy, which includes imaginal and in vivo exposure to anxiety-provoking stimuli, processing of traumatic events, and self-assessment of anxiety. Treatment also included in vivo exposure with response prevention techniques borrowed from the literature on obsessive-compulsive disorder to address compulsive checking behaviors within the ecological context of each patient’s symptom presentation. Measures related to PTSD and depression were obtained before, during, and after treatment. Treatment was associated with significant declines in symptom severity and improved functioning for both veterans. The unique nature of the conflict in the Middle East represents role challenges for soldiers that affect symptom presentation. Variations in symptom presentation can in turn complicate efforts to identify and appropriately address PTSD-related health concerns in this population. Thus, clinicians and researchers must remain cognizant of how theater-specific duties influence the manifestation and treatment of PTSD in order to provide optimal care to a new generation of veterans.
Since 2001, more than 1.5 million U.S. troops have been deployed to Iraq or Afghanistan as part of Operations Iraqi Freedom and Enduring Freedom (OIF/OEF) (1) . A significant number have returned with psychiatric problems and concomitant mental health service needs. A recent large-scale study of OIF/OEF Army and Marine personnel indicated that 10%–20% of personnel meet criteria for posttraumatic stress disorder (PTSD), depending on the stringency of the diagnostic standard used (2) . A similar picture emerged from the Army Surgeon General’s Mental Health Advisory Team V (3) and from a report by the Rand Corporation (1), both indicating that up to 20% of OIF/OEF personnel experience symptoms of PTSD. These data suggest that hundreds of thousands of individuals returning from Iraq and Afghanistan suffer from at least some posttraumatic stress symptoms.
Although such estimates of risk for PTSD may seem inflated, it is reasonable to expect that multiple deployments, the experiencing of numerous traumas, and the long periods of sustained threat associated with OIF/OEF deployment would increase the risk of developing PTSD. When the sheer scale of these military efforts is taken into account, even more modest estimates of risk translate into large numbers of individuals who may need mental health services. Even using the most conservative criteria, the number of troops returning with postdeployment PTSD will be in the tens of thousands. Such projected estimates raise public health concerns that may transcend the capacities of the Department of Defense and Department of Veterans Affairs (VA) health care systems. While efficacious cognitive-behavioral interventions for PTSD have been developed (4, 5), we need to improve methods for disseminating such treatments to community- and hospital-based clinics where mental health professionals provide day- to-day services to patients with PTSD. Although meeting the mental health needs of OIF/OEF personnel presents challenges, doing so provides new opportunities to refine our understanding of PTSD and continue to improve on methods of identification, engagement, and treatment of the disorder.
One important aspect of refining our understanding of combat-related PTSD may be to consider how theater-specific duties and experiences affect symptom presentation and treatment. Our clinical observation suggests that compulsive checking as a safety behavior may be a frequent component of OIF/OEF-related PTSD symptom presentation (25%–30% of OIF/OEF veterans diagnosed with PTSD who present to our clinic engage in compulsive checking); however, appropriate research has not been conducted to investigate this observation. The clinical sample that forms the basis of these observations is not ideal for establishing base rates for checking behaviors in PTSD patients in general or for investigating the correlates of PTSD-related checking behavior. Such data are also difficult to gather without objective measures in place to assess checking behaviors in a reliable and valid manner or otherwise establish objective criteria for distinguishing general hypervigilance from compulsive checking. Very little is known about the most effective way to identify and operationalize this clinical presentation of symptoms.
Our goal in this article is to discuss how to conceptualize and treat what we believe to be a common expression of PTSD in OIF/OEF veterans. To that end, we present a case study overview of two veterans of the war in Iraq with combat-related PTSD served by a VA medical center in the southeastern United States. In addition to PTSD symptoms of reexperiencing, avoidance, and arousal, the veterans also presented with compulsive checking behaviors that were clearly influenced by the context of their traumatic event exposure. The compulsive checking behaviors did not qualify these patients for a concomitant diagnosis of obsessive-compulsive disorder (OCD) because the criteria for OCD specify that compulsions cannot be restricted to the context of another axis I diagnosis—in this case, PTSD. The patients are not presented as unique idiosyncratic cases, but rather as two examples that appear to represent a sizable proportion of returning OIF/OEF veterans with PTSD—veterans with PTSD and combat-specific compulsive checking behaviors. We then discuss these case presentations within the broader context of OIF/OEF-related PTSD, particularly with regard to implications of compulsive checking behaviors for diagnostic considerations and treatment planning.
Case Presentations
Measures and Treatment
Three instruments for diagnostic assessment and ongoing treatment planning were used in both of the cases presented: the PTSD module of the Structured Clinical Interview for DSM-IV (SCID) (6) ; the PTSD Checklist–Military Version (7), and the Beck Depression Inventory–II (BDI) (8) . Both patients were treated with prolonged exposure therapy (9), which included imaginal and in vivo exposure exercises, processing of traumatic events, and patient self-assessment using subjective units of distress (10) . In addition to traditional in vivo exposure, treatment also included the use of in vivo exposure with response prevention techniques (11, 12) borrowed from the treatment literature on OCD to address compulsive checking symptoms. Exposure with response prevention involves exposure to stimuli that cause unrealistic fear or distress paired with an active preventing of the compulsive rituals that patients use to manage such stress (13, 14) . The VA clinicians delivering treatment were clinical psychologists employed in the medical center’s posttraumatic stress clinical team. Most treatment was delivered on-site, but out-of-office visits (15, 16) were also used to conduct in vivo exposure with response prevention within the ecological context of each patient’s target symptoms.
Case 1
Treatment and progress
Case 2
Treatment and progress
Discussion
The PTSD-related compulsive checking behaviors presented here appear to have a functional role similar to general PTSD hypervigilance. Both behaviors are negatively reinforced as a means of anxiety control, and the impetus for both can be explained by a failure to completely process traumatic experiences. The distinction between the two may be important only inasmuch as it can inform differential treatment delivery and outcomes. In theory, in vivo exposure (to address hypervigilance) and exposure with response prevention (to address compulsive checking) differ only in that the latter focuses on preventing a patient’s specific compulsive response(s) to anxiety-provoking stimuli. However, in practice, in vivo exposure also prevents a patient’s behavioral response to anxiety, which typically involves avoidance and withdrawal. Furthermore, working from the basic principles of nonavoidance and anxiety tolerance to objectively safe stimuli, any experienced exposure therapist would encourage his or her patients with PTSD not to repeatedly check locks or check cars for bombs. However, one potentially important distinction for treatment is that there is a robust OCD literature and history concerning the benefits of conducting in vivo exposure and response prevention within the ecological context of the symptoms by using out-of-office therapist-assisted sessions (14, 15) .
Although in vivo exposure, by definition, emphasizes the need to address symptoms within the context in which they occur, the technique is usually assigned to patients as “homework,” to be done without the direct presence and support of a therapist. Often patients excel at completing and habituating to their homework assignments, especially if the in vivo exposure hierarchies are graded appropriately (10) . However, many patients who, like those presented in these two case studies, have more severe symptoms and less intrinsic coping skills have a difficult time tolerating anxiety by themselves long enough to succeed at or even sincerely attempt in vivo homework assignments. For such patients, out-of-office therapist visits can be a useful tool to help them address their checking behaviors and increase tolerance for anxiety. Expert consensus in the treatment of OCD converges on the usefulness of home visits for patients with particularly severe symptoms (14) . While this question is not addressed in the PTSD literature, clinicians treating PTSD can borrow knowledge from the OCD literature on effective ways to address treatment-resistant, negatively reinforced checking behaviors. Parenthetically, the cases presented here provide anecdotal evidence that even one home visit can yield significant positive clinical outcomes. The adaptation of compulsive checking measures, such as the Yale-Brown Obsessive Compulsive Scale (20), for use in PTSD populations may give researchers a useful tool for assessing the impact of home visits on compulsive checking behaviors.
The cases presented, and the observed frequency of such cases in OIF/OEF veterans in general, are also of interest from the perspective of historical context. The patient described in the first case took part in multiple forceful home intrusions as part of his military duties, and these experiences subsequently had an impact on his sense of safety at home. Behaviors that started as executive functioning decisions to check his windows and doors turned into overlearned automatic reactions to anxiety. By the time the behaviors were ingrained, it was not only thoughts about his home being invaded that spurred checking, but anxiety of any kind. Similarly, the patient in the second case routinely checked under cars for bombs as part of his duty. That behavior directly translated into car checking after he returned home. The military context, the rigid following of procedures and orders that the military ingrains and relies upon for the survival of its troops, may also play a role in symptom presentation and maintenance. Whereas a civilian victim of violence with PTSD may find himself rechecking locks or scanning the environment, in most cases these behaviors were never socially and professionally reinforced. Multiple, repetitive, and sustained manifestations of hypervigilance are rewarded in many OIF/OEF combat situations, by both superiors and peers. This reward structure may operate as a parallel process to PTSD which encourages the manifestation of PTSD symptoms as repetitive checking behaviors and socially ingrains those behaviors so as to make extinction more difficult.
Conclusions
We presented these cases to stimulate discussion on what we believe to be an increasingly common expression of combat-related PTSD (i.e., PTSD with combat-specific compulsive checking behaviors). It will be important for clinicians and researchers to remain mindful of how OIF/OEF veterans present with symptoms and how they subsequently respond to traditional treatments for the disorder. As noted in the case presentations, the inclusion of response prevention within the ecological context of each patient’s symptoms appears to have resulted in significant treatment gains that may not have occurred otherwise. Furthermore, the manifestation of specific compulsive checking behaviors is of interest from a broader historical perspective. Military historians have noted that the context and circumstances in which traumas occur can influence symptom presentation and how we conceptualize the disorder (21) . That is, while combat exposure can obviously cause significant distress and pathology, there is reason to believe that specific reactions to combat are to some degree mediated by historical context and military culture. Historical reviews indicate that the prevalence of combat-related PTSD and particular symptoms can change over time within a population, and these changes are only partly explained by improvements in diagnostic procedures (21 – 24) . The nature of the conflicts in Iraq and Afghanistan creates unique role challenges for our veterans that will likely shape symptom presentation and clinical outcomes. Variations in symptom presentation can in turn complicate mental health efforts to identify and appropriately address PTSD-related public health concerns. We encourage ongoing consideration of the cases and issues presented here in order to ensure that OIF/OEF veterans receive mental health services that are appropriately tailored to their needs.
Footnotes
Received Sept. 3, 2008; revision received Jan. 3, 2009; accepted Jan. 21, 2009 (doi: 10.1176/appi.ajp.2009.08091315). From the Ralph H. Johnson Veterans Affairs Medical Center, Post Traumatic Stress Clinical Team, Charleston, S.C.; the Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston; and the Department of Psychiatry, Center for the Treatment and Study of Anxiety, University of Pennsylvania, Philadelphia. Address correspondence and reprint requests to Dr. Tuerk, Charleston VAMC, Mental Health 116, 109 Bee St., Charleston, SC 29401; [email protected] (e-mail).
Drs. Tuerk and Grubaugh report no competing interests. Dr. Hamner has received research grant support from Janssen, Organon, and Otsuka and holds stock in Merck and Pfizer. Dr. Foa reports research support from Pfizer, Solvay, Eli Lilly, SmithKlineBeecham, GlaxoSmithKline, Cephalon, Bristol-Myers Squibb, Forest, Ciba Geigy, and Kali-Duphar. She has also been a speaker for Pfizer, GlaxoSmithKline, Forest Pharmaceuticals, and Jazz Pharmaceuticals and a consultant for Acetelion Pharmaceuticals.
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