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Running Head: COMBAT-RELATED PTSD TREATMENTS 1

Treatment Options for Combat-Related Posttraumatic Stress Disorder

Jocelyn Williams

Wake Forest University

COMBAT-RELATED PTSD TREATMENTS 2

Abstract

With the return of military personnel from Operation Enduring Freedom and Operation

Iraqi Freedom, combat-related posttraumatic stress disorder (PTSD) is once again in the

limelight. This literature review examines the efficacy of two evidenced-based therapies,

Prolonged Exposure Therapy (PE) and Cognitive Processing Therapy (CPT), along with

three lesser researched treatment options - Group-Based Exposure Therapy, Brief

Exposure Therapy, and Meditation/Mindfulness-Based Therapies. Research was conducted

via peer-reviewed journal articles in psychology databases. Research results are

statistically and clinically significant for PE and CPT in the reduction of PTSD symptoms,

but the alternative approaches also provide promising results to be expanded on in the

future in hopes of diversifying treatment options available to clinicians.

Keywords: posttraumatic stress disorder, PTSD, military personnel, veterans,

prolonged exposure therapy, cognitive processing therapy, treatments


Introduction

Posttraumatic stress disorder (PTSD) is categorized by the Diagnostic and Statistical

Manual V (DSM-5) as a trauma and stress related disorder that can develop upon exposure

to traumatic and distressing events. It significantly impairs daily functioning. The first

appearance of PTSD was in the Diagnostic and Statistical Manual III (DSM-III) in 1980 in

reaction the mental health effects of the Vietnam War on veterans and readjustment

problems (Creamer, Wade, Fletcher, & Forbes, 2011; Wells, Miller, Adler, Engel, Smith, &

Fairbank, 2011). With the increasing return of military personnel from Operation Enduring

Freedom and Operation Iraqi Freedom, rates of PTSD are increasing once again (Wells et

al., 2011; Reger, Durham, Tarantino, Luxton, Holloway, & Lee, 2013). It has become

imperative that we assess various treatment options for those who have fought for our

freedom.

The purpose of this literature review is to examine the efficacy of two evidence

based therapies for combat-related PTSD, specifically in regards to those returning from

Operation Enduring Freedom and Operation Iraqi Freedom - Prolonged Exposure Therapy

(PE) and Cognitive Processing Therapy (CPT). Additionally, this review will assess the use

of alternate therapies, such as Group-Based Exposure Therapy (GBET), Brief Exposure

Therapy, and Complementary and Alternative Therapies such as meditation and

mindfulness-based interventions. The ultimate goal is to provide a stepping stone to inform

clinical practice regarding what interventions exist to help active duty military personnel

and veterans decrease debilitating PTSD symptoms.

Methods


Research regarding treatment options for combat-related PTSD was conducted

through the PsycINFO database available through the Z. Smith Reynolds Library at Wake

Forest University. General keywords and phrases included “PTSD”, “posttraumatic stress

disorder”, “treatment of posttraumatic stress disorder”, “posttraumatic stress disorder

AND military”, and “treatment of posttraumatic stress disorder AND military”. Once a basic

understanding of treatment options was obtained, additional keywords and phrases

included “treatment of posttraumatic stress disorder AND military AND prolonged

exposure therapy”, and “treatment of posttraumatic stress disorder AND military AND

cognitive processing therapy”. Results were limited to peer-reviewed journal articles

published between 2000 and 2013. Additional limits included major subject headings -

“posttraumatic stress disorder”, “combat experience”, “war”, “military personnel”,

“treatment”, “epidemiology”, “exposure therapy”, and “cognitive processing therapy”.

Those articles unavailable on the database required additional search tactics to include

searching the website of the professional journal from which the article was originally

published and requests through Interlibrary Loan.

Results

Diagnosis of Combat-Related PTSD.

A diagnosis of Posttraumatic Stress Disorder (PTSD) for adults, adolescents, and children

over the age of six requires the following eight criteria: (A) direct or indirect exposure to

death, serious injury, or sexual violence, (B) re-experience of the traumatic event through

intrusive and distressing memories or dreams, flashbacks, and intense psychological

distress, (C) avoidance of triggering stimuli, (D) negative and/or erroneous cognitions and

mood in relation to the traumatic event, (E) marked changes in behavior, (F) persistence of


A-E for more than one month, (G) impairment in social, occupational, or other important

areas of functioning, and (H) disturbances are not due to other conditions or substance use

(American Psychiatric Association, 2013). Exposure to war, the main cause of combat-

related PTSD, would satisfy Criterion A.

Pre-traumatic factors include age at the time of trauma, lower socioeconomic status,

lower education, exposure to prior trauma, minority racial/ethnic status, and a family

psychiatric history. Peri-traumatic factors specific to military personnel include being a

perpetrator, witnessing atrocities, or killing the enemy. Lastly, posttraumatic factors

include subsequent exposures or upsetting reminders, subsequent adverse life events, and

financial or other trauma-related losses (American Psychiatric Association, 2013). All these

factors increase one’s risk of developing PTSD.

Evidence-Based Treatments

Prolonged Exposure Therapy. Prolonged Exposure Therapy (PE), an evidenced

based practice broadly considered the first-line-of-defense intervention for combat-related

PTSD (Tuerk, Yoder, Grubaugh, Myrick, Hamner, & Acierno., 2011; Kip, Sullivan, Lengacher,

Rosenzweig, Hernandez, Kadel, Kozel, Shuman, Girling, Hardwick, & Diamond, 2013),

emerges from Emotional Processing Theory of PTSD, meaning PE emphasizes the

significance of emotional processing in reducing the effects and symptoms of PTSD (Foa,

Hembree, Rothbaum, 2007). The central aspects of PE include (A) psychoeducation

regarding attention to PTSD symptoms and the client’s personal reactions to them, as well

as the significance of avoiding trauma reminders in the maintenance of PTSD symptoms,

(B) providing the client with tactics to reduce anxiety and tension, specifically breathing

training, (C) in vivo exposure to trauma-related situations that invoke distressed responses


with the intent of enhancing emotional processing, and (D) repeated and prolonged

imaginal exposure aloud to stimulus followed by discussion of the experience (Foa,

Hembree, Rothbaum, 2007). In vivo and imaginal exposures comprise the therapy’s most

important procedures.

In a study conducted by Tuerk et al (2011), the researchers investigated the efficacy

of PE with 65 Veterans diagnosed with PTSD. Pre- and post-treatment scores were

collected for both PTSD and Depression using the PTSD Checklist-Military Version (PCL-M)

and the Beck Depression Inventory II (BDI-II), as well as every two weeks in treatment to

determine effectiveness. Pre- and post- treatment scores for both the PCL-M and the BDI-II

were clinically and statistically significant, indicating that PE is an effective

treatment/intervention for combat-related PTSD (Tuerk et al., 2011).

Another study conducted by Yoder, Tuerk, Price, Grubaugh, Strachan, Myrick, &

Acierno (2012) examined the use of PE for 112 veterans from various wars: 34 Vietnam

veterans, 17 Gulf War veterans, and 61 veterans from Operation Enduring Freedom (OEF)

and Operation Iraqi Freedom (OIF). Researchers gathered pre- and post-treatment scores

through the use of the PTSD Checklist-Military version (PCL-M). The findings suggested

that though all groups reported statistically significant results in terms of efficacy of the

treatment, Gulf War veterans reported significantly lower rates of symptom declination

than those of the Vietnam and OEF/OIF wars.

Cognitive Processing Therapy. The second most cited evidence-based therapy for

combat-related PTSD is Cognitive Processing Therapy (CPT) (Karlin, Ruzek, Chard,

Eftekhari, Monson, Hembree, Resick, & Foa, 2010; Kip et al., 2013). Cognitive Processing

Therapy (CPT), a 12-session treatment, has its roots in social cognition theory. It focuses on


the meaning that individuals place on traumatic events and their coping strategies to

regain control of their lives (Resick, Monson, & Chard, 2007).

A study conducted by Monson, Schnurr, Friedman, Young-Xu, Stevens, & Resick

(2006) investigated the efficacy of CPT treatments for combat-related PTSD. Participants

included 60 veterans randomly assigned to two conditions: receiving treatment

immediately or waitlisted for ten weeks. Pre- and post-treatment assessments were taken,

both clinician administered - the Clinician-Administered Posttraumatic Stress Disorder

Scale (CAPS) - and self-reports utilizing the Posttraumatic Stress Disorder Checklist (PCL).

Self-report outcomes indicated that 40%of the CPT condition and 3% of the waitlist

condition no longer met diagnostic criteria for PTSD at post-treatment. Additionally, at

post-treatment, results from the CAPS indicated that 50% of CPT participants had reliable

improvement compared to 10% in the waitlist condition, 50% in the CPT condition had no

reliable change compared to 80% in the waitlist condition, and 0% from the CPT condition

had a reliable deterioration in their symptoms compared to 10% in the waitlist condition.

Lastly, after the one month follow up, self-report measures demonstrated that 30% from

the CPT condition maintained their decline in PTSD symptoms and only 3% from the

waitlist group maintained their progress. Additionally, at the one month follow up, CAPS

results indicated that 47% from the CPT condition had reliable improvement and 30%

from the waitlist continued to improve; 43% of CPT participants had no reliable change as

opposed to 53% from the waitlist condition; and lastly, 10% of CPT participants had a

reliable deterioration in their symptoms in comparison to 17% deterioration in the waitlist

condition. Essentially, this study found that CPT had a significant improvement in both self-

report and clinician reported PTSD symptoms.


Additional Treatment Options

In addition to evidence-based therapy, there are a number of other interventions

and treatment options available to therapists working with clients presenting with combat-

related PTSD symptoms. Detailed below are examples such as Group-Based Exposure

Therapy (GBET), Brief Exposure Therapy, Accelerated Resolution Therapy (ART), and

Meditation/Mindfulness-Based Interventions.

Group-Based Exposure Therapy. Group-Based Exposure Therapy (GBET) requires

clients to attend group therapy three hours a day, twice a week for 16-18 weeks (Ready,

Thomas, Worley, Backscheider, Harvey, Baltzell, & Rothbaum, 2008). Its main components

include three stages: (A) didactic training, to include stress management skills, and group

cohesion building, (B) exposure therapy, and (C) grief, guilt, and relapse prevention (Ready

et al., 2008).

Ready et al. (2008) conducted a study to investigate the effectiveness of GBET in

treating combat-related PTSD in 102 veterans. Participants were required to participate in

stress management and a minimum of 60 hours of exposure. Pre- and post-treatment

assessments were conducted using the Clinician-Administered PTSD Scale (CAPS) and the

Burns PTSD Scale, as well as a six-month posttreatment assessment utilizing the Burns

PTSD scale. Results indicated that 81% of participants’ pre- to post-treatment scores were

clinically significant. Additionally, 81% of participants’ scores from post-treatment to the

six-month check up assessment were also clinically significant indicating that GBET

produced long term decreases in PTSD symptoms. However, scores on CAPS at the six-

month assessment indicated that many patients still retained significant PTSD symptoms.


In a second study investigating the efficacy of GBET, conducted by Ready, Worley,

Butt, Mascaro, Sylvers, & Bradley (2012), thirty combat veterans were divided into three

cohorts of ten. Researchers utilized the PTSD Checklist (PCL) and the Beck Depression

Inventory 2 (BDI-2), administered at three intervals: pre-treatment, post-treatment, and a

7-11 month check up. Results indicated a significant effect on both PCL and BDI-2 scores

from pretreatment through the 7-11 month check up, with 53.6% of participants reporting

a reduction in PCL scores. Additionally 35.7% of participants reported PCL scores below

the cut off, indicating they no longer met the criteria required for a PTSD diagnosis.

Brief Exposure Therapy. Brief Exposure Therapy, a secondary prevention for

posttraumatic stress disorder, is ideally used before a client meets all of the criteria for

PTSD to ward off a full diagnosis. Treatment is similar to Prolonged Exposure Therapy

(PE), but shorter in duration. It involves repeated and prolonged imaginal and in vivo

exposures to the traumatic event in four therapy sessions over a five week period.

In a case study conducted by Cigrang, Peterson, and Schobitz (2005), three

American troops were recruited to test the effectiveness of the therapy as a second level

defense. Researchers utilized the PTSD Checklist-Military version (PCL-M) to assess

baseline measures of soldiers’ PTSD symptoms and all three scored 50 or higher (A - 69, B -

59, C - 67), the range used to denote PTSD. After the completion of the intervention, results

indicated that all three soldiers’ scores had declined by an average of 56% and were within

normal, non-clinical limits (A - 24, B - 39, C - 20).

Complementary and Alternative Medicine. Meditation and mindfulness-based

interventions are complementary therapies, meaning they offer a different, and possibly

more acceptable, route for therapy than traditional medicine (Bormann, Thorp, Wetherell,


Golshan, & Lang, 2013). According to Bormann et al (2013), meditation refers to focusing

the attention on an object, mantra, or image. If attention wanders, refocusing is a

nonjudgemental process. This technique leads to an increase in mindfulness, the ability to

focus attention on the present and accepting the experiences nonjudgementally.

Bormann et al (2013) studied the efficacy of a mantram repetition program (MRP)

when paired with treatment as usual (TAU; medication or case management alone). MRP is

a portable and private meditation based intervention with three main aspects: (A) the

selection of a mantram, or sacred word, to be repeated silently throughout the day to train

attention and raise awareness, (B) thinking and acting deliberately, and (C) concentration

on one thing at a time. The overall goal is to interrupt negative thoughts and manage

unwanted negative emotions through a private medium. Results from 136 veterans

indicated 24% in the MRP + TAU condition had significant symptom reduction; only 12%

reported significant symptom reduction in the TAU alone condition.

Another study conducted by Jain, McMahon, Hasen, Kozub, Porter, King, and

Guarneri (2012) investigated the effectiveness of a Healing Touch and Guided Imagery

(HT+GI) intervention with treatment as usual (TAU). HT+GI involves providing the

participant “with practitioner-based treatment (HT) to establish a ‘safe space’ using a

nonstigmatizing touch-based therapy aimed at eliciting the participant’s own healing

response, whereas also engaging in a self-care therapy (listening to GI CD) that helped the

patient to work with trauma-related issues” (Jain et al, 2012). With 123 active duty military

personnel randomized to six sessions in either the HT+GI condition or the TAU condition,

results indicated statistically and clinically significant reductions in PTSD symptoms from

the HT+GI condition.


Discussion

From the review of the literature, it is evident that Prolonged Exposure Therapy

(PE) and Cognitive Processing Therapy (CPT) are the interventions of choice. Studies for

each emphasized the large significant results in terms of the declination of PTSD symptoms

among participants. This literature review also examines a few more lesser researched

options - Group-Based Exposure Therapy (GBET), Brief Exposure Therapy, and

Complementary/Alternative Therapies. Studies for each of these therapies also provide

statistically and clinically significant results that indicate reductions in PTSD symptoms.

Such results indicate obvious space for other therapies in scientific discussions regarding

treatment approaches. To have more treatment options would create more avenues for

clients presenting with combat-related PTSD symptoms that do not respond well to PE or

CPT.

The most pressing limitation for the various treatments is the prevalence of

comorbid disorders. Individuals with PTSD are significantly more likely than those without

PTSD symptoms to meet diagnostic criteria for at least one other disorder, to include

depressive, bipolar, anxiety, or substance use disorders (American Psychiatric Association,

2013). Especially among military personnel and combat veterans of the most recent wars

(Operation Enduring Freedom and Operation Iraqi Freedom), co-occurence of PTSD and

traumatic brain injury (TBI) is nearing 50% (American Psychiatric Association, 2013). It is

important to recognize that many symptoms of PTSD overlap with some of the co-

occurring disorders - for example, sleep and concentration problems are symptoms for

both PTSD and depression and generalized anxiety disorder (Creamer et al, 2011).


Therefore, it is near impossible to treat PTSD by itself and success rates may be

attributable to reductions in such comorbid disorders.

Additionally, this literature review only covers a select few interventions available

and is not comprehensive. Other options, such as Biofeedback Therapy and Eye Movement

Desensitization and Restructuring (EMDR), should be explored as well.

In terms of future research, continued and additional analysis regarding other

therapies besides PE and CPT is necessary to diversify the market. Special attention should

be paid to complementary and alternative therapies such as the meditation and

mindfulness-based interventions presented in this literature because of their emphasis on

destigmatization, a touchy subject for many active duty personnel and veterans (Bormann

et al, 2013). Future research should also strive to expand the demographic range - race,

gender, wars, etc - of their participant pools to allow for more appropriate generalization.


References

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