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Running head: POSTTRAUMATIC STRESS DISORDER

Treatment of Posttraumatic Stress Disorder in Military Veterans


Raechel Martin
The Pennsylvania State University

POSTTRAUMATIC STRESS DISORDER

Abstract
The effects of prolonged exposure therapy and cognitive processing therapy on military veterans
with PTSD were examined in the following study. The theory behind the study is that males and
females have personality differences that may cause them to respond differently to these
different kinds of treatment. The research will be conducted in order to determine if there are
differences between males in females that cause differences in PTSD symptom alleviation when
treated with the two therapies. It is predicted that males and females will both experience
significant improvement to both therapies, but males will respond better to prolonged exposure
therapies compared to females, and females will respond better to cognitive processing therapy
compared to males. Results would show that males and females both experienced significant
improvement in PTSD symptoms when treated with both prolonged exposure therapy and
cognitive processing therapy. Males would also experience fewer PTSD symptoms compared to
females when treated with prolonged exposure therapy, and females would experience fewer
PTSD symptoms compared to males when treated with cognitive processing therapy. These
results suggest that there are differences, such as those within personality, that cause differences
in PTSD symptom alleviation.

POSTTRAUMATIC STRESS DISORDER

Treatment of Posttraumatic Stress Disorder in Military Veterans


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, so I also think it is important
that the most effective treatments for specific groups are utilized. I am interested specifically in
prolonged exposure therapy, and cognitive processing therapy because they are popular methods
of treating those with PTSD, and they have proven to be effective. They also have very similar
components; both feature psycho-education on PTSD and talking about the traumatic event or
events of interest. However, PE therapy is distinct from CPT in that it features in vivo exposure:
a process of reliving the traumatic event several times. CPT is unique from PE because it
features a focus on internal beliefs about oneself and the traumatic event and how the two relate.
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. Researchers treated participants weekly for 90
minutes using PE and measured their PTSD symptoms before and after using the PTSD
Checklist-Military Version (PCL-M; Weathers, Huska, & Keane, 1991; Tuerk et al., 2011).
Once data was collected for completers (6 or more sessions) and non-completers (less
than 6 sessions), the authors found that completers had a more pronounced difference in the

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pretest and posttest PCL-M (Weathers et al., 1991) scores compared to non-completers. 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
(Tuerk et al., 2011). However, since 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. The results of this study helped to confirm that PE was a suitable therapy to investigate, but
since gender differences cannot be concluded, I would like to compare the results of males to
females in a study of my own.
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).
The researchers placed 104 participants in the group cognitive processing therapy
condition and 93 participants in the treatment as usual condition, which focused on psychoeducation, and coping styles and functioning with exposure to the trauma memory in the last few
sessions. They measured the dependent variable by using several scales one of which was the
PTSD Checklist (PCL; Weathers, Litz, Herman, Huska, & Keane, 1993) to assess PTSD
symptom severity (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. Because of these results, it is suggested that cognitive processing
therapy is an effective method of treating PTSD which is consistent with the predictions of the
researchers. However, the CPT specifically compared to treatment as usual, not a lack of
treatment, therefore the study lacks some controls. Although it has a large sample size, it also

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does not include any women, so the results are not very generalizable. In the way of my research
hypothesis, I would implement a waitlist group instead of a TAU in order to provide more
control and include more females for increased external validity. Also, this study helped show
the efficacy of CPT as a treatment overall, it would just be necessary to include women in my
study in order to see differences between the genders.
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. They hypothesized that those placed in the CPT condition will
experience lower PTSD symptomology than those placed in the waitlist condition. The
researchers placed 28 males and two females in the CPT condition, who received treatment for
ten weeks, and 26 males and four females in a waitlist condition, who received no treatment for
ten weeks. They measured PTSD symptom severity by using several scales including the
Clinician-Administered Posttraumatic Stress Disorder Scale (CAPS; Blake, Weathers, Nagy,
Kaloupek, Gusman, Charney, & 1995), and the Posttraumatic Stress Disorder Checklist (PCL;
Weathers, Litz, Herman, Huska, & Keane, 1993; Monson et al., 2006).
The authors found that that those in the CPT group experienced significant symptom
alleviation overtime compared to the waitlist group (Monson et al., 2006). Significantly more
individuals in the CPT condition did not meet PTSD criteria post treatment, had reliable
improvement, and experienced lower PTSD symptomology compared to those in the waitlist
condition according to their CAPS (Blake et al., 1995) and PCL (Weathers et al., 1993) scores.
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
many more males than females, so results are not generalizable to both sexes. This study was

POSTTRAUMATIC STRESS DISORDER

especially helpful in formulating my hypothesis because the results showed greater improvement
in PTSD symptomology due to CPT treatment than did the results of the second study (Alvarez
et al., 2011). My theory is that the inclusion of females, though a small number, in this study
helped to provide greater PTSD improvement.
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, none of them compare males to females, and there
are several issues of generalizability of the results. 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. 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. One of my independent variables will be gender and
the other will be the treatment; my dependent variable will be PTSD symptom level. Based on
this theory, I predict that there will be a main effect for treatment meaning that both treatments
will result in significant improvement for both genders. I do not expect a main effect for gender,
because based on the articles reviewed both PE and CPT therapy have been effective for both
genders. However, I do expect an interaction between gender and treatment, so one treatment
will produce more significant results for a specific gender and the other will produce more

POSTTRAUMATIC STRESS DISORDER

significant results for the other gender based on the personality differences between men and
women. Because PE therapy has a more aggressive and intense component compared to CPT,
and CPT has more of an inward focus on ones beliefs, I am curious to know if the overt
behaviors of men will help them with PE; likewise, I am wondering if the tendency to reflect on
oneself and act covertly will help women with CPT therapy.
Method
Participants
Participants in this study will be collected from various veteran psychiatric centers. They
will be clinically diagnosed with posttraumatic stress disorder and the traumatic event or events
of interest will be related to their military experience. They will be between the ages of 25 and
50, and at least 20 men and 20 women will be recruited and randomly assigned to each of the
conditions. Participants will be told that they would be receiving new treatment, and will be
asked to stop any medication use. They will be informed that their treatment results may be
anonymously used for data collection by the psychiatric center, and will be asked to sign a
consent form.
Design
The experiment will follow a 2 by 3 factorial design. Gender, males and females, will
count for one of the independent variables, and treatment will represent the other. Within
treatment, there will be three conditions: Prolonged exposure therapy, cognitive processing
therapy, and a waitlist group.
Materials/Procedure
When the participants begin the study they will be given a Posttraumatic Stress Disorder
Checklist-Military Version (Weathers et al., 1991) to complete before the first session. All

POSTTRAUMATIC STRESS DISORDER

conditions will complete nine weeks of treatment in the psychiatric center, and the rooms used
will be controlled for conditions such as temperature and overall design. Those in the PE
condition will receive psycho-education on trauma and treatment (2 sessions), self-assessment
of anxiety (2 sessions), in vivo exposure (4 sessions), repeated prolonged exposure to traumatic
events (5 sessions), and discussion of those events and the fears associated with them (5
sessions) over the course of the 9 weeks (Tuerk et al., 2011). Those in the CPT condition will
complete a program that involves writing and rereading a narrative of the traumatic event of
interest (5 sessions), identifying problematic beliefs and ideas associated with the event (6
sessions), and challenging those problematic ideas as well as beliefs about oneself and others
regarding safety, trust, power, control, esteem, and intimacy (7 sessions) (Alvarez et al., 2011).
Individuals in the waitlist condition will come into the psychiatric center and watch a movie on
nature. Each session will last one hour and occur twice a week for the nine week period,
resulting in 18 total sessions. At the completion of the treatment, individuals will be given
another PCL-M (Weathers et al., 1991) survey to fill out, and results will be analyzed and
compared to their pretest scores.
Results
For this study, an ANOVA would need to be done to analyze the data from the pretest
and posttest PCL-M (Weathers et al., 1991) scores. This would determine whether or not there is
a significant difference between conditions or significant differences between pretest and posttest
scores. This study has a 2 (Gender: Male and Female) x 3 (Treatment type: Prolonged Exposure
Therapy, Cognitive Processing Therapy, Waitlist Group) between subjects factorial design with
PTSD symptomology as the dependent variable. Pretest scores should indicate that there is no
difference between the groups (M = 63; See Table 1 for display of means). The results should

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indicate that there is a main effect for treatment type so participants who are in the PE or CPT
condition (M = 34.3) will have lower posttest PTSD symptomology than those in the waitlist
condition (M = 62.2; p < .05). There would be no main effect for gender so males will have the
same average score (M = 43.6) as females (M = 43.6; p < .05). The results are also expected to
indicate that there is a significant interaction between treatment type and gender (p < .05). Refer
to Table 2 for expected pattern of means.
In order to determine the nature of the interaction, the means for each condition will be
plotted and are expected to look like Figure 1. When participants are male and complete PE
treatment they will have lower posttest scores (M= 28.3) than females who complete PE
treatment (M= 37.2). When participants are female and complete CPT treatment they will have
lower posttest scores (M= 29.3) than males who complete CPT treatment (M=42.4).Therefore,
when participants are male, they will improve more than females when they complete PE
treatment, and when participants are female they will improve more than males when they
complete CPT treatment.
Discussion
The expected finding of the main effect for treatment would imply that both
prolonged exposure therapy and cognitive processing therapy help military veterans with PTSD
significantly improve their symptoms compared to those who receive no treatment. This
information would support the idea that both are adequate treatments and are helpful in treating
those who return from the service with PTSD. Given that there would be no main effect for
gender, it is implied that both males and females would improve significantly when treated with
PE or CPT, supporting the idea that males and females both respond well to treatment. However,
the expected interaction between gender and treatment would show that males would improve

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more significantly than females when treated with PE, and females would improve more
significantly than males when treated with CPT. This would imply that there is a significant
difference between males and females that causes their scores to differ; this could potentially be
a difference in their personality. If the data does not turn out as expected, it may appear that
males and females respond equally to both treatments resulting in parallel lines on a graph. This
would suggest that there is no difference, in personality or otherwise, between males and females
that causes them to improve more or less to treatment. It is also possible that none of the
participants will have significant improvement, which may suggest that nine weeks is not a long
enough time to incur results. This could be considered a possible limitation of the study as some
individuals may need a longer time to experience PTSD symptom improvement. Another
limitation may be the use of only one survey to determine PTSD symptom alleviation. Though
this is an accurate measure used in many studies, there are other things that may go along with
PTSD symptoms, such as depression, which are not measured fully by the PCL-M (Weathers et
al., 1991). Without measuring all aspects of an individuals PTSD symptoms, it is unreasonable
to conclude that the treatments affect the individuals overall improvement or well-being, which
is the ultimate goal of therapy. The lack of personality measurements may also pose a problem as
well. Even though the expected results suggest that there is a difference between men and
women that causes a difference in scores, it is unreasonable to conclude that that difference
comes from personality without measuring traits in the study. The resulting differences could be
because of a number of factors, with personality simply being a possibility. In order to further
this research and better confirm the results, future studies should treat participants for a longer
amount of time, use more measures to determine PTSD symptom alleviation, and use surveys to
track personality traits and see how they relate to measurement scores. Overall, I also think this

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research has a more general importance. Many men and women have risked their lives or spent
several years serving our country; though it was their choice to do so, I think it is not only
appropriate, but also obligatory to take it upon ourselves to help those who do not return to
civilian life unscathed, both physically and mentally. In order to help those with PTSD, we need
to understand the effect it has on military personnel as well as the effect of treatments on
different groups, like males and females.

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References
Alvarez, J., McLean, C., Harris, A. H. S., Rosen, C. S., Ruzek, J. I., & Kimerling, R. (2011). The
comparative effectiveness of cognitive processing therapy for male veterans treated in a
VHA posttraumatic stress disorder residential rehabilitation program. Journal of
Consulting and Clinical Psychology, 79(5), 590-599. doi:
http://dx.doi.org/10.1037/a0024466 Retrieved from
http://search.proquest.com.ezaccess.libraries.psu.edu/docview/876239623/13C7F4464D8
EBBBD2A2/3?accountid=13158#
Blake, D. D., Weathers, F. W., Nagy, L. M., Kaloupek, D. G., Gusman, F. D., Charney,
D. S., et al. (1995). The development of a Clinician-Administered PTSD Scale. Journal
of Traumatic Stress, 8, 7590.
Monson, C. M., Schnurr, P. P., Resick, P. A., Friedman, M. J., Young-Xu, Y., & Stevens, S. P.
(2006). Cognitive processing therapy for veterans with military-related posttraumatic
stress disorder. Journal of Consulting and Clinical Psychology, 74(5), 898-907. doi:
http://dx.doi.org/10.1037/0022-006X.74.5.898 Retrieved from
http://search.proquest.com.ezaccess.libraries.psu.edu/docview/614486685/13C7F42E378
EBBBD2A2/1?accountid=13158#
Tuerk, P. W., Yoder, M., Grubaugh, A., Myrick, H., Hamner, M., & Acierno, R. (2011).
Prolonged exposure therapy for combat-related posttraumatic stress disorder: An
examination of treatment effectiveness for veterans of the wars in afghanistan and iraq.
Journal of Anxiety Disorders, 25(3), 397-403. doi:
http://dx.doi.org/10.1016/j.janxdis.2010.11.002 Retrieved from

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http://www.sciencedirect.com.ezaccess.libraries.psu.edu/science/article/pii/S0887618510
002203
Weathers, . (2007). PTSD Checklist (PCL). In United States Department of Veterans Affairs.
Retrieved from http://www.ptsd.va.gov/professional/pages/assessments/ptsd-checklist.asp
Weathers, F. W., Litz, B. T., Herman, J. A., Huska, J. A., & Keane, T. M. (1993, November).
The PTSD Checklist (PCL): Reliability, validity and diagnostic utility. Paper presented at
the 9th annual conference of the International Society for Traumatic Stress Studies, San
Antonio, TX.
Weathers, F. W., Huska, J., & Keane, T. (1991). The PTSD checklist-military version. Boston,
MA: National Center for PTSD.

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Table 1
Treatment Type
Gender

PE

CPT

Waitlist

Male

65.1

63.2

60.5

Female

61.4

63.0

66.1

Table 1. This table shows the pretest PCL-M scores of individuals in each condition. The
marginal means for each variable are M= 63, indicating that there is no significant difference
between the individuals pre-treatment.
Table 2
Treatment Type
Gender

PE

CPT

Waitlist

Male

28.3

42.4

60.1

Female

37.2

29.3

64.2

Table 2. This table shows posttest scores for individuals in each group. The numbers
represent PCL-M scores. A clinically significant improvement is characterized by at least a 10
point difference (Weathers, 2007). Compared to pretest scores in Table 1 these scores represent a
clinically significant change.

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Figure 1
70

Post Treatment

PCL-M Score Means

60
50
40
Male

30

Female
20
10
0
PE Therapy

CPT Therapy

Waitlist Group

Treatment Type

Figure 1.This chart displays the posttest PCL-M mean scores for each condition. As
predicted, there is a significant difference between males and females for the two
treatment types. Males have lower PCL-M scores compared to females in the PE
condition, and females have lower PCL-M scores compared to males in the CPT
condition.