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

Discussion And Case Series

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%−13% 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 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 experiences for considerable amounts of time, accompanied by feelings of excitement or euphoria and physiological hyperarousal, with impairment in social or occupational functioning.

Descriptions of this behavioral pattern exist from previous conflicts. Solursh (7), who interviewed 100 Vietnam veterans diagnosed with chronic PTSD, observed that these veterans experienced a cyclical pattern of reexperiencing memories of the exciting “high” or “rush,” followed by periods of feeling down, guilty, or emotionally numb; he termed this phenomenon “combat addiction.” Ninety-four of these veterans reported combat-related flashbacks or nightmares as exciting, powerful, arousing, or intensely pleasurable; 81 reported engaging in hunting, maintaining loaded weapons, or reenacting combat outdoors. Solursh suggested that this phenomenon may contribute to PTSD chronicity and treatment resistance.

Grigsby (8) used the label “combat rush” to describe the phenomenon of intense, pleasurable arousal that combat veterans experience when recalling exciting combat memories. Nadelson (9) found that a group of combat veterans diagnosed with PTSD experienced “positive excitement when reliving memories of mortal risk and killing,” which he called “attachment to killing.” These researchers postulated that noradrenergic hyperarousal and endorphin activation mediate these behaviors.

Considerable research supports the biological plausibility of these observations. Solomon’s (10) opponent-process theory posited that the “development of addictive behaviors, whether initiated by pleasurable or by aversive events,” includes tolerance and withdrawal syndromes, likely mediated by endorphins. Pitman et al. (11) showed that pain tolerance was significantly increased in Vietnam veterans when they watched war movie clips compared with neutral clips; 15 minutes of war footage produced endorphin-mediated analgesia equivalent to 8 mg of morphine. Van der Kolk (12) referenced endorphins in explaining the compulsion to repeat traumatic scenarios, which he termed “addiction to trauma.” An increasing number of studies have demonstrated overlapping neurocircuitry and neurotransmitters involved in stress and addiction (13–16).

Vietnam veteran and author Karl Marlantes observed that “the least acknowledged aspect of war today is how exhilarating it is” and, furthermore, that “combat is the crack cocaine of all excitement highs—with crack cocaine costs” (17). Combat, an intense experience accompanied by extreme physiological arousal, may include both distressing and rewarding experiences. Clearly, the experience of helplessly watching a team member die is dramatically different from the experience of vanquishing the enemy in a firefight and saving a buddy’s life. Veterans report feeling fully alive and experiencing intense feelings of competence, leadership, and brotherhood during deployment.

Clinical Case Series.

The case series of service members with PTSD was derived from 120 consecutive active duty marines and sailors in Camp Pendleton, California, who presented to the Concussion Clinic from April 2012 to April 2014 and were referred to the embedded clinical psychologist for evaluation and treatment of coexisting mental health symptoms. Of these patients, 14 had experienced concussions in civilian settings, and five did not complete the initial assessment with the embedded psychologist. The remaining 101 patients included 64 who were diagnosed with PTSD per electronic medical records (the focus of this series). These 64 patients, of whom 60 were marines and four were Navy medics embedded with marine units, all of whom returned from Iraq and/or Afghanistan, were comparable to other clinical populations of personnel deployed in Iraq and Afghanistan (4). Their mean age was 28 years, they had a mean of 2.4 deployments, and their mean high score on the PTSD Checklist was 64.

Patients completed a modified version of the PTSD Checklist, which included an additional eight questions mirroring the first eight questions referencing a “stressful” experience but reworded to refer to “positive/exciting” combat experiences (Table 1). Additional structured clinical worksheets, developed organically to better understand the clinical phenomenon, asked patients about time spent engaging in activities involving stimulating, rewarding combat-related experiences combined with an “adrenaline rush” (Table 2) and to explore whether these behaviors shared characteristics with substance dependence (Table 3), using items adapted from the DSM-IV-TR criteria for substance abuse or dependence and gambling disorders. The sample of patients who completed the clinical worksheets was somewhat smaller (N=50–54) than the sample of those who completed the modified PTSD Checklist (N=64), because of the later development and evolution of these worksheets over time.

Similar, but opposite, responses were demonstrated for reexperiencing and avoidance items and corresponding exciting, positive items (Table 1). For example, 89% endorsed “repeated distressing memories, thoughts, or images of a stressful combat experience,” while 92% endorsed “repeated exciting memories, thoughts, or images of combat”; likewise, 80% endorsed “avoiding thinking or talking about a stressful combat experience,” while 73% endorsed “deliberately thinking or talking about positive/exciting combat experiences.” Cronbach’s alpha values were 0.86 for the eight modified exciting/positive items (items 1a–8a) and 0.79 for the eight original items (items 1b–8b).

As shown in Table 2, patients spent a large amount of time engaged in activities that produced stimulating, rewarding feelings associated with combat. Patients reported a mean of 2.5 hours per day engaged in combat-related video games, 2.4 hours watching war-related movies or TV shows or reading about war, and 2.4 hours talking with others about combat, accompanied by the “adrenaline rush.” Overall, these patients reported a mean of 5.5 hours/day during the work week, and 4.8 hours/day on weekends, engaged in combat attachment behaviors. In contrast, they reported a mean of 1.2 hours/day reexperiencing distressing combat-related memories (or, as several patients said, “as little as possible”).

There was also high endorsement of items related to addiction to combat attachment behaviors (Table 3) (Cronbach’s alpha=0.69), mostly ranging from 70% to 85%. More than 98% of patients endorsed at least one item of dependence (either tolerance or withdrawal), and more than 88% endorsed five or more of the 10 items. Percentages remained high when endorsement ratings were restricted to 4 (quite a bit) or 5 (extremely) on the 5-point scale.

Combat Attachment Phenomenology.

Clinical phenomenology consistently observed in this case series included the following:

1. Distressing and rewarding combat-related reexperiencing was intertwined, involving both avoiding distressing experiences and gravitating toward rewarding aspects of combat experiences.

2. Rewarding combat-related reexperiencing varied from memories of extreme bravery and competence to camaraderie and humor; it also included imagining combat-related scenes, such as novel scenarios overseas, or responding to threats in the United States.

3. Activities such as playing video games and watching war movies changed after deployment, with markedly higher physiological arousal; the activities became more frequent, intense, and compulsively serious, with corresponding reductions in social interaction and enjoyment.

4. Most combat veterans appeared to be unaware of the degree to which they engaged in combat attachment behaviors, and they reported difficulty not engaging in these behaviors. They described “drifting” into or “finding” themselves engaged in these behaviors without conscious intention. For example, one patient reported that after finding himself cradling his assault rifle while watching a war movie, he put the rifle down, only to find himself holding it again minutes later.

5. Most patients were unaware of potential consequences of their behaviors and thus had little motivation to decrease them.

6. Combat attachment highs were consistently followed by depressive lows, consistent with Solursh’s observations (7).

7. Most importantly, many combat veterans reported feeling confusion and shame for reliving combat events, and questioned their character. One veteran of three deployments stated, “I think about combat all the time. I feel trapped.”

These observations may be better understood by considering research findings that extreme hyperarousal gives rise to recurrent and intrusive memories for both “negative” and “positive” events that are involuntary as well as intentional (18, 19). Furthermore, the subjective interpretation of an experience (negative versus positive) often depends on context and perceived control (20, 21). Initially terrifying situations, such as skydiving, become incredibly exciting and enjoyable when individuals repeat the activity and master their fear (10). Although some combat veterans may have premorbid characteristics of sensation seeking, research indicates that risk taking increases significantly after deployment (22); DSM-5 includes this as a PTSD symptom.

Conclusions

In this case and clinical series of combat veterans with PTSD referred from the Concussion Clinic at Naval Hospital Camp Pendleton, we found that many patients reported habitually engaging in stimulating, rewarding combat-related activities, which were accompanied by strong physiological hyperarousal. This was closely associated with distressing reexperiencing of combat events, and it suggests a bivalent nature to combat-related PTSD. Patients reported engaging in combat attachment behaviors for 5 hours/day on average, more frequently than negative reexperiencing symptoms, and it appears to reflect an addictive pattern of behavior that is associated with impairment.

Limitations of these findings include their exploratory nature, based on clinical observations from only one referral source—a concussion clinic; the lack of a control group; and use of nonvalidated worksheets. However, these patients were similar to those from other mental health settings treating combat veterans. Concussion-related symptoms are commonly comorbid with PTSD in combat veterans; many studies have shown that deployment-related concussions are strongly associated with PTSD, likely because of the traumatic context in which these concussions occur (23). Although the worksheets were developed for the purposes of better categorizing the phenomenon of combat attachment, they included modifications to well-validated measures as well as several ways of looking at the phenomenon that showed consistency across responses, including subjective perceptions (e.g., “exciting/positive”), as well as measures of time spent engaging in activities and addictive behavioral patterns.

Combat attachment behaviors may represent a significant variable contributing to suboptimal treatment utilization and outcomes, but barriers may impede exploration of this area, particularly negative judgments concerning these behaviors, by both clinicians and patients. As Solursh stated, “Our history-taking may discourage the reporting of the intensely pleasurable aspects of our patients’ experiences and behaviors,” which may result from “our own difficulty as clinicians in accepting that aggression and violence might be (commonly) pleasurable” (7). Findings from this observational series suggest that combat attachment behaviors may be more important than is currently appreciated in understanding the broad dimension of PTSD. While assessment measures for these behaviors require refinement and validation, this report represents a first step in elucidating this potentially important and underrecognized clinical phenomenon, with implications for developing and disseminating more effective treatment strategies.