Article

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

Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, United States
American Journal of Psychiatry (Impact Factor: 14.72). 08/2009; 166(7):762-7. DOI: 10.1176/appi.ajp.2009.08091315
Source: PubMed

ABSTRACT 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.

1 Bookmark
 · 
180 Views
  • [Show abstract] [Hide abstract]
    ABSTRACT: IntroductionThe aim of this study was to investigate the neurofunctional alterations in both acute and chronic post-traumatic stress disorder (PTSD) resulting from the same stress experience.Methods Brain responses to emotional trauma-related and neutral pictures with a symptom provocation task were measured using functional magnetic resonance imaging (fMRI). Twenty-four PTSD patients resulting from a mining accident and 14 controls exposed to the same accident without PTSD two months post-trauma were recruited. In the follow-up study 20 PTSD patients and 14 controls were also recruited after 24 months post-trauma. Correlations were conducted in PTSD between altered fMRI blood oxygenation level-dependent (BOLD) signals of areas extracted as regions of interest and three Clinician-Administered PTSD Scale (CAPS) subscores respectively.ResultsIn response to picture stimulus (traumatic negative pictures versus neutral pictures), the acute PTSD group showed greater activation in the bilateral posterior cingulate gyri, left precuneus, right fusiform and left parahippocampal gyrus than the chronic PTSD group (P 20 voxels). In the acute PTSD group, BOLD signals of either posterior cingulate gyrus correlated positively with CAPS intrusion subscores. There was also no significant correlation between BOLD signals of five regions mentioned above in the chronic PTSD group and three CAPS subscores.DiscussionThese findings suggested that brain circuits affected in acute PTSD may be more extended than chronic PTSD. The reason may due to the formation of traumatic memory in the acute phase of PTSD.
    Asia-Pacific Psychiatry 12/2011; 3(4). DOI:10.1111/j.1758-5872.2011.00152.x · 0.47 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: In this paper, we consider ethical issues related to the treatment of posttraumatic stress disorder (PTSD) in combat zones, via exposure therapy. Exposure-oriented interventions are the most well-researched behavioral treatments for PTSD, and rigorous studies across contexts, populations, and research groups provide robust evidence that exposure therapy for PTSD is effective and can be widely disseminated. Clinical procedures for Prolonged Exposure therapy, a manualized exposure-oriented protocol for PTSD, are reviewed, and we illustrate the potential benefits, as well as the potential difficulties, associated with providing this treatment in combat zones.Several ethical considerations are identified: (1) Assuming successful treatment, is it ethical to send individuals with a known risk of developing PTSD back into combat? (2) If treatment is unsuccessful in theater (perhaps due to the confounding factor of ongoing danger), could that impact treatment effectiveness for soldiers who attempt therapy again post-deployment? (3) If the military finds combat-zone treatment effective and useful in maintaining an efficient work force, will treatment become mandatory for those diagnosed with PTSD? (4) What unintended consequences might be associated with large-scale dissemination of exposure therapy in or near combat, outside of mental health care infrastructures? (5) How would genetic variations known to be associated with PTSD risk influence decisions regarding who receives treatment or returns to combat? We conclude with a review of the personal and societal costs associated with not providing evidence-based PTSD treatments wherever possible.
    The Journal of Law Medicine &amp Ethics 06/2014; 42(2). DOI:10.1111/jlme.12132 · 0.94 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Zhang L, Li W, Shu N, Zheng H, Zhang Z, Zhang Y, He Z, Hou C, Li Z, Liu J, Wang L, Duan L, Jiang T, Li L. Increased white matter integrity of posterior cingulate gyrus in the evolution of post‐traumatic stress disorder.Objective: Functional imaging studies of post‐traumatic stress disorder (PTSD) have shown an increased activation of posterior cingulate gyrus (PCG) of the brain. The aim of this study was to explore white matter integrity of PCG in PTSD subjects.Methods: White matter integrity, as determined from fractional anisotropy (FA) value using diffusion tensor imaging, was assessed for PCG in subjects with and without PTSD from a severe mine accident. All subjects were also measured by the PTSD Checklist Civilian Version (PCL‐C), the State‐Trait Anxiety Inventory (STAI), the logical memory subtest and the visual reproduction subtest of the Wechsler Memory Scale‐Revised in China. Sixteen PTSD subjects (8 subjects in each group) in the longitudinal study and 13 PTSD subjects as well as 14 non‐PTSD controls in the cross‐sectional case–control study were respectively recruited.Results: In the longitudinal study, subjects with PTSD showed increased FA values in left PCG during the follow‐up scan. In the cross‐sectional study, FA values in bilateral PCG in PTSD subjects were higher than controls. Within the PTSD group (n = 13), FA values in the left PCG correlated positively with logical memory and negatively with PCL‐C intrusion and STAI‐trait (STAI‐t) subscores. FA values in right PCG correlated negatively with STAI‐t and STAI‐state subscores.Conclusion: These findings suggest that alterations of white matter integrity in PCG link to mnemonic and affective processing in PTSD over the long‐term follow‐up period.
    Acta Neuropsychiatrica 02/2012; 24(1). DOI:10.1111/j.1601-5215.2011.00580.x · 0.61 Impact Factor