Running Head: POSTTRAUMATIC STRESS DISORDER

Treatment of Posttraumatic Stress Disorder in Military Veterans

Raechel Martin
The Pennsylvania State University

POSTTRAUMATIC STRESS DISORDER

Military personnel who serve overseas in combat related situations often return with
physical, as well as mental disabilities, including posttraumatic stress disorder (PTSD). In order
to better their conditions upon returning home, it is important that efficient treatment plans are
determined and utilized. Due to personality differences in men and women, its possible that men
and women may react differently to different types of treatment, specifically prolonged exposure
therapy, and cognitive processing therapy. Based on this idea, I predict that men will experience
lower symptomology of PTSD when treated with prolonged exposure therapy compared to
cognitive processing therapy, and women will experience lower symptomology when treated
with cognitive processing therapy compared to prolonged exposure therapy. The three articles
presented below give data on reactivity to both prolonged exposure therapy, and cognitive
processing therapy in both male and female military veterans.
The first article by Tuerk, Yoder, Grubaugh, Myrick, Hamner, and Acierno (2011),
explored the effects of prolonged exposure therapy (PE) on male and female veterans. The
researchers hypothesized that veterans treated with PE will experience greater symptom
reduction than when they are not treated with PE. They identified the independent variable as the
treatment, specifically PE, and the dependent variable as levels of PTSD symptoms and
depression symptoms.
Sixty-five participants (11% female) were treated by two clinicians, weekly for 90
minutes using PE; the PE treatment consisted of psycho-education on trauma and treatment, selfassessment of anxiety, in vivo exposure, and repeated prolonged exposure to traumatic events
and discussion of those events (Tuerk et al., 2011). The researchers measured symptoms of
PTSD using the PTSD Checklist-Military Version (PCL-M; Weathers, Huska, &

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Keane, 1991), and symptoms of depression using the Beck Depression Inventory-II
(BDI-II; Beck, Steer, & Brown, 1996).
Once data was collected for both completers (6 or more sessions) and non-completers, the
authors found that differences in the pretest and posttest PCL-M (Weathers et al., 1991) scores
were more significant for completers than non-completers; they also found that 33% of the noncompleters and 50% of completers scored below clinical range for PTSD. Based on these results,
it can be concluded that PE has an effect on PTSD symptom level, and is a potentially effective
treatment for veterans, which was consistent with the hypothesis of interest.
Given that this is a quasi-experiment, there is a lack of a control group, so it is not
reasonable to conclude that PE is better than a different treatment or no treatment at all. Also,
participants were not given a final clinical assessment to determine their PTSD status, and the
results of males were not compared to the results of females, so differences between genders
cannot be assumed from this study. Because gender differences to the treatment cannot be
inferred, I would like to test this in my own hypothesis by comparing means between male and
female participants for PCL-M (Weathers et al., 1991) scores.
The second article by Alvarez, McLean, Harris, Rosen, Ruzek, and Kimerling (2011)
tested the efficacy of cognitive group processing therapy (CPT) on male military veterans. The
hypothesis of interest was as follows: veterans treated with group CPT will experience lower
PTSD symptomology than those who complete a treatment program as usual (TAU); treatment
type was the independent variable, and symptom levels and functioning was the dependent
variable for this study.
The researchers operationalized the independent variable by placing 104 participants in
the group cognitive processing therapy condition and 93 participants in the treatment as usual

POSTTRAUMATIC STRESS DISORDER

condition, and they operationalized the dependent variable by using the PTSD Checklist (PCL;
Weathers, Litz, Herman, Huska, & Keane, 1993), the Beck Depression Inventory (BDI; Beck,
Steer, & Garbin, 1988; Beck, Ward, Mendelsohn, Mock, & Erbaugh, 1961), World Health
Organization Quality of Life-BREF (WHOQOL-BREF; Skevington, Lotfy, & OConnell, 2004),
the COPE (Carver, 1997), and the Symptom Checklist (SCL; Rosen, Drescher, Moos, Finney,
Murphy, & Gusman, 2000) to assess PTSD symptom severity and overall functioning (Alvarez
et al., 2011). Participants placed in the CPT condition completed a 14 session program that
involved writing and rereading a narrative of the traumatic event of interest, and identifying
problematic beliefs and ideas associated with the event. Towards the end of the treatment,
clinicians challenged those problematic ideas as well as beliefs about oneself and others
regarding safety, trust, power/control, esteem, and intimacy (Alvarez et al., 2011). Participants
placed in the TAU condition received psycho-education about PTSD followed by development
of the veterans autobiography with special attention paid to coping styles and functioning; the
last few sessions involved in-session exposure to the trauma memory (Alvarez et al., 2011).
The authors found that participants placed in the CPT condition showed significantly
more improvement than those in the TAU condition specifically in areas of PTSD symptoms,
depression symptoms, psychological quality of life, coping, and psychological distress (Alvarez
et al., 2011). Those who received CPT had a pre-treatment mean PCL (Weathers et al., 1993)
score of 64.05 and a post-treatment score of 55.50; those who received TAU had a pre-treatment
mean PCL score of 66.13 and a post-treatment mean score of 62.12. Because of these results, it
is suggested that cognitive processing therapy is an effective method of treating PTSD; this is
consistent with the predictions of the researchers.

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However, the CPT specifically compared to treatment as usual, not a lack of treatment,
therefore the study lacks some controls. It also does not include any women, so the results are
not very generalizable. In the way of my hypothesis, I would again like to compare males and
females for this treatment. Also, instead of a TAU condition, I would implement a waitlist
condition, which gives the study more control, and gives the rejection of the null hypothesis
more validity.
Lastly, the third article by Monson, Schnurr, Resick, Friedman, Young-Xu, and Stevens
(2006), examined the effect of cognitive processing therapy (CPT) on PTSD symptomology on
both males and females. The researchers identified the independent variable as the treatment
delivered, and the dependent variable as PTSD symptoms.
The authors operationalized the independent variable by placing 28 males and 2 females
in the CPT condition, and 26 males and 4 females in the waitlist condition (Monson et al., 2006).
They operationalized dependent variable by measuring PTSD symptom severity and overall
well-being by using the Clinician-Administered Posttraumatic Stress Disorder Scale (CAPS;
Blake, Weathers, Nagy, Kaloupek, Gusman, Charney, & 1995), the Posttraumatic Stress
Disorder Checklist (PCL; Weathers, Litz, Herman, Huska, & Keane, 1993), the Beck Depression
Inventory (BDI; Beck, et al., 1961), the Spielberger State-Trait Anxiety Inventory (STAI;
Spielberger, 1983), the Trauma-Related Guilt Inventory (TRGI; Kubany, Haynes, Abueg,
Manke, Brennan, & Stahura, 1996), the Affect Control Scale (ACS; Williams, Chambless, &
Ahrens, 1997), the Toronto Alexythymia Scale-20 (TAS-20; Bagby, Steer, & Garbin, 1988), and
the Social Adjustment Scale (SAS; Weissman & Bothwell, 1976).
Participants assigned to the CPT condition completed a 12 session, twice weekly program
focused on psycho-education, the traumatic event of interest and its associated thoughts and

POSTTRAUMATIC STRESS DISORDER

beliefs as well as the thoughts and beliefs about oneself and others; the problematic beliefs were
identified and challenged by clinicians (Monson et al., 2011). Those placed in the waitlist
condition received no treatment for the extent of time that the CPT condition received treatment
(10 weeks) and were put on waitlist to receive treatment. The researchers assessed both of the
groups at mid-treatment (3 weeks), post-treatment (6 weeks) and 1 month post-treatment (10
weeks).
The authors found that that those in the CPT group experienced significant symptom
alleviation overtime compared to the waitlist group (Monson et al., 2006). Thirty percent in the
CPT condition and 3% in the waitlist condition did not meet PTSD criteria at post-treatment, and
47% in the CPT condition and 30% in the waitlist condition had reliable improvement. Also,
those who received CPT had a pre-treatment mean PCL (Weathers et al., 1993) score of 60.66
and a post-treatment mean score of 45.55; those who were assigned to the waitlist condition had
a pre-treatment mean PCL score of 61.50 and a post-treatment mean score of 57.23. These
results suggest that CPT treatment may illicit better PTSD symptom alleviation than no treatment
for both males and females.
However, this was a relatively small sample size with a much greater amount of males
than females. Also, participants were not required to discontinue their psychopharmacological
regimen, so medication may have had an effect on results. This article helped shape my
hypothesis by providing adequate results suggesting that cognitive processing therapy is an
efficient method of treatment. It also included both males and females, however for my
hypothesis I am comparing the two. The operationalization of the two variables plays a role in
the formation of my research question by providing possible ways to test my hypothesis; the use

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of a waitlist group and multiple measures of the dependent variable are of particular interest for
testing my hypothesis.
Overall, the combination of these articles influences my research question by
providing evidence for the efficacy of both prolonged exposure therapy and cognitive processing
therapy. However, none of them compare PE to CPT, and none of them compare males to
females. The differing results of the study by Alvarez et al. (2011) and the study by Monson et
al. (2006), lead me to believe that there may be gender differences in reactivity to CPT, however
it is unable to be identified without conducting a study that compares males and females across
the two treatments. Using this past research, I would like to assess the effectiveness of CPT and
PE for males and females as separate sexes in order to determine whether or not one sex reacts
better to a certain treatment than does the other. My independent variable would be the
treatment, and my dependent variable will be the PTSD symptom level and classification, and
overall functioning of the individual.

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