Comparing Veterans with Posttraumatic Stress Disorder Related to Military Sexual Trauma or Other Trauma Types: Baseline Characteristics and Residential Cognitive Processing Therapy Outcomes

Abstract

The Veterans Health Administration (VHA) has called for improved assessment and intervention for survivors of military sexual trauma (MST) to mitigate deleterious sequalae, including posttraumatic stress disorder (PTSD). Research on the impact of MST-related PTSD (MST-IT) on men is limited, and few studies have examined the differential effects of treatment across genders and MST-IT. Additionally, studies have utilized varying definitions of MST (e.g., sexual assault only vs. including sexual harassment), contributing to disparate outcomes across studies. Utilizing data from 343 veterans seeking residential cognitive processing therapy (CPT) for PTSD in VHA, this study examined the impact of MST-IT and gender on differences in demographic characteristics; pre-treatment severity of PTSD (overall and clusters), depression, and negative posttraumatic cognitions (NPCs); and post-treatment severity of these variables after accounting for pre-treatment severity. Results from 2x2 factorial ANOVAs found no differences in pre-treatment depression or overall PTSD by MST-IT, gender, or their interaction; however, MST-IT survivors presented with greater pre-treatment avoidance, global NPCs, and self-blame. Results from hierarchical linear regression models found only pre-treatment symptom severity significantly predicted post-treatment severity for overall PTSD and all NPCs. These findings suggest veteran survivors of MST-IT appear to benefit similarly from CPT delivered in a VHA residential PTSD program compared to veterans with other index traumas, regardless of gender. Although there were minimal post-treatment differences in PTSD and NPCs by MST-IT status and gender, residual symptoms related to negative cognitions and mood appear to differ across gender and MST-IT status. Specifically, in individuals without MST-IT, post-treatment PTSD symptoms of negative alterations in cognition and mood were higher in men than women. Moreover, women with MST-IT reported more symptoms of depression than both men with MST-IT and women without MST-IT. These findings suggest depressive symptoms decrease through residential PTSD treatment differentially by MST-IT status and gender and warrant further examination.

Keywords

Military sexual trauma cognitive processing therapy veterans posttraumatic stress disorder clusters negative posttraumatic cognitions treatment outcomes gender

Introduction

The Department of Defense (DoD) and Veterans Health Administration (VHA) have formally recognized military sexual trauma (MST) as an issue of high importance warranting coordinated assessment, prevention, and intervention efforts (Department of Defense, 2020; Kimerling et al., 2007). According to the federal definition, MST refers to assault, battery, or harassment of a sexual nature that occurred during military service (Title 38 U.S. Code 1720D). Of service members and veterans, a staggering 38.4% of women and 3.9% of men report MST (Wilson, 2018), though actual rates are likely higher due to underreporting (Morris et al., 2014). To emphasize, compared to other public health concerns evidenced in service members and veterans, prevalence of MST appears at least as prevalent as traumatic brain injury (TBI; 23%, Terrio et al., 2009) and intimate partner violence (IPV; 35%, Gierisch et al., 2014). Relative to veterans without MST, MST survivors experience higher rates of emotion regulation difficulties (Lofgreen et al., 2020), psychological symptoms like posttraumatic stress disorder (PTSD; Surís & Lind, 2008), and greater dissatisfaction with VHA services (Kelly et al., 2008).

Although women experience MST at disproportionately higher rates than men, given the greater number of men in the military, MST is reported by similar numbers of women and men who seek VHA care (e.g., in one nationally representative study of VHA outpatients, 29,418 women and 31,797 men reported lifetime MST; Kimerling et al., 2007). Notably, MST may present unique difficulties for men when considering masculine stereotypes, which may discourage MST reporting, decrease the likelihood of seeking related treatment, and contribute to greater negative beliefs about one’s masculinity and/or sexuality (Morris et al., 2014). Despite these compelling factors, research on MST and related sequelae has primarily concentrated on women with MST, largely ignoring or understudying the effects of MST on mental health, PTSD, and treatment outcomes in men. In fact, a number of studies have noted their sample included too few men who endorsed MST as a significant limitation and this sample may be too small for findings to generalize to all men with MST (Carroll et al., 2018; Holliday et al., 2018; Zalta et al., 2018). As these studies involved predominantly women, no specific effects for men were noted, and it is unclear whether these effects exist for men.

In treatment outcomes literature, research on the impact of MST has produced disparate findings, likely due in part, to varying definitions of MST across studies (Holliday et al., 2020; Khan et al., 2020; Tiet et al., 2015; Voelkel et al., 2015; Zalta et al., 2018). Some studies use the broad, federal definition of MST that encompasses a wide range of stressful experiences from sexual harassment to actual and threatened harm and assault. Other studies define MST specifically as sexual assault or threat of violence used as coercion for a sexual act. The latter definition aligns more closely with a qualifying Criterion A traumatic event for diagnosing PTSD according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association, 2013). A recent meta-analysis comparing MST by these definitions suggests that MST assessed by the broad definition (i.e., sexual harassment and assault) captures the experiences of more individuals and therefore prevalence rates by this definition are higher than those of assault-only MST (Wilson, 2018). These methodological differences may introduce variance across studies in who is categorized in an MST group versus non-MST group, making it difficult to interpret and compare findings.

These differences in defining MST highlight the importance of clarifying whether researchers are examining PTSD outcomes for those who have ever experienced any form of sexual harassment or assault or examining PTSD outcomes as a result of MST (i.e., with MST as the Criterion A most distressing, index trauma; MST-IT). To illustrate, some research suggests that individuals with and without MST respond similarly to PTSD treatment across varying MST definitions (sexual harassment and assault, Khan et al., 2020; sexual assault, Tiet et al., 2015; and MST-IT, Voelkel et al., 2015), while others report that treatment is not as effective for individuals with MST-IT compared to individuals with PTSD resulting from other traumas (Zalta et al., 2018). These discrepancies indicate that it is imperative to clearly define MST and delineate whether samples include individuals who have experienced MST (which may or may not be related to a PTSD diagnosis) versus MST-IT when evaluating PTSD treatment outcomes.

In examining treatment outcomes across groups, it is important to first evaluate baseline differences between the groups, such as demographic characteristics and pre-treatment symptoms, as these may confound changes otherwise attributed to treatment. Research suggests that individuals with MST-IT PTSD tend to demographically differ from those with PTSD from other index traumas. Although there is variability across samples, those with MST-IT are more likely to be women, racial minorities, veterans of the Army, unmarried, unemployed, and less educated (Carroll et al., 2018; Voelkel et al., 2015). Also, those with MST-IT tend to have more severe PTSD when presenting for treatment than those with PTSD from other traumas (Holliday et al., 2020; Voelkel et al., 2015), though this has not always been found (Khan et al., 2020; Tiet et al., 2015).

Despite differences in overall PTSD severity, no study to date has examined differences in the types of PTSD symptoms experienced by veterans with or without MST-IT. According to DSM-5 (American Psychiatric Association, 2013), PTSD symptoms are categorized into four clusters: intrusions (ITN), avoidance (AV), negative alterations in cognitions and mood (NACM), and alterations in arousal and reactivity (AAR). Cluster scores tend to differ according to trauma type, resulting in distinct PTSD symptom presentations (Kelley et al., 2009). For example, female survivors of sexual assault reported more severe NACM symptoms (e.g., more restricted range of affect and feelings of detachment) and internal avoidance, whereas female survivors of a motor vehicle accident evidenced increased hypervigilance and physiological reactivity (Kelley et al., 2009). Likewise, veterans with combat or MST-IT were more likely to experience AV, NACM, and AAR symptoms than veterans with civilian trauma (Graham et al., 2016). In their predominantly male sample, Graham and colleagues (2016) did not find any cluster-level differences between veterans with combat trauma and MST-IT; however, veterans with MST-IT were more likely to experience specific symptoms of social detachment, concentration difficulties, and sleep disturbance.

Although cluster differences by trauma type have been evidenced in both predominantly male and female samples, direct comparisons between female and male sexual assault survivors are somewhat inconsistent. For example, one study revealed that male and female civilians appear to manifest a similar psychiatric presentation following sexual assault (Galovski et al., 2011), whereas an examination of active duty military personnel found differences in cluster severity by trauma type and gender (Hourani et al., 2015). Specifically, Hourani and colleagues (2015) found that although women reported greater distress on all PTSD clusters across trauma types, in survivors of sexual assault since joining the military, men reported higher PTSD symptoms than women. These findings highlight the importance of assessing baseline differences in total and cluster-level PTSD severity across trauma types, gender, and population (e.g., civilian, active duty, or veteran) prior to trauma-focused treatment in order to determine the efficacy of treatment across demographics. Some studies suggest there may be cluster-level differences in symptom reduction across trauma-focused therapy (Monson et al., 2006; Taylor et al., 2003). These findings highlight the importance of examining cluster scores across men and women with or without MST-IT before and after treatment in order to evaluate differences across treatment in the full range of PTSD symptoms.

An evidence-based PTSD treatment that may be particularly relevant for individuals with MST-IT is cognitive processing therapy (CPT; Resick et al., 2016), which involves identifying and restructuring negative posttraumatic cognitions (NPCs) that precipitate and maintain the disorder (Schumm et al., 2015). In studies using one instrument designed specifically to measure NPCs (Posttraumatic Cognitions Inventory; Foa et al., 1999), there is some evidence that suggests veterans with MST-IT tend to have stronger NPCs, specifically related to self-blame, than those seeking treatment for other index traumas (e.g., combat; Carroll et al., 2018; Sexton et al. 2018). CPT has demonstrated effectiveness in reducing PTSD symptoms in veterans with MST-IT across samples that were diverse in terms of gender, minority status, service era, branch of service, and treatment setting (Surís et al., 2013; Voelkel et al., 2015; Walter, Varkovitzky, et al., 2014; Zalta et al., 2018; Zappert & Westrup, 2008); however, only one study has also demonstrated its effectiveness in reducing NPCs in individuals with MST-IT over the course of treatment. Specifically, Holliday and colleagues (2018) found significant reductions in NPCs from baseline to 6-month follow-up in a sample of male and female veterans (n = 32, 71.9% female) with MST-IT. They also found significant relationships between self- and clinician-rated PTSD symptoms and NPCs about oneself and the world, across all time points. Importantly, given the effect baseline characteristic such as demographic differences may have on outcome comparisons, no studies have evaluated differences in reductions of NPCs by MST-IT status and gender across treatment. It is essential to examine whether NPCs change comparably for individuals with MST-IT PTSD and PTSD from other trauma types in order to determine if CPT is equally effective in reducing the severity of NPCs for MST-IT. Given the use of predominantly female samples in studies to date, further research is required to determine if these effects are similar in men and women with MST-IT.

Therefore, in the present study, we addressed these gaps in the literature using data collected from a sample of veterans seeking residential CPT for PTSD in a VA PTSD Clinic. First, we aimed to further clarify the demographic differences between individuals who present for PTSD with MST-IT compared to other index traumas. To do this, we examined differences among various demographic variables (i.e., age, employment, marital status, minority status, and gender), military service variables (i.e., combat exposure, military branch, service connection status, and service era) and comorbid diagnoses when we compared groups on MST-IT status (i.e., MST-IT vs. no MST-IT, the category representing individuals with all other index trauma type), gender (i.e., men vs. women), and gender within MST-IT status (i.e., interaction of MST-IT by gender). We expected to find more women in the MST-IT group (Carroll et al., 2018; Holliday et al., 2020; Khan et al., 2020; Voelkel et al., 2015), but did not make hypotheses about other variables given the inconsistencies in the literature.

Next, we aimed to further clarify differences in pre-treatment symptom severity by examining PTSD symptoms and clusters, depressive symptoms, and NPCs by MST-IT status, gender, and their interaction (i.e., gender by MST-IT status). We expected our results to replicate established differences regarding total PTSD severity (e.g., higher severity in MST-IT), and extend this to PTSD cluster scores (e.g., higher severity AV and NACM in MST-IT). We expected to find similar rates of depression symptoms at admission across all individuals, consistent with similar studies which have documented no baseline differences in depression. In line with previous research, we expected to find greater severity of NPCs in the MST-IT group, specifically NPCs related to self-blame. Finally, we sought to examine the role of MST-IT status, gender, and their interaction on post-treatment PTSD symptom severity, PTSD cluster scores, depressive symptoms, and NPCs after accounting for pre-treatment scores. Based on similar studies, we hypothesized that individuals would benefit similarly from treatment on overall PTSD severity regardless of MST-IT status and gender. We did not make further hypotheses on differences in post-treatment PTSD cluster scores, depressive symptoms, and NPCs given limited literature comparing reductions in these symptoms between MST-IT and non–MST-IT groups.

Method

Participants

As part of standard clinical care, archival data were collected from veterans (N = 343; M age = 50.4 years, SD = 10.5) who completed a 7-week PTSD residential rehabilitation program (PRRP) for men (n = 186) or women (n = 147) at a VA in the Midwestern United States. Exclusionary criteria included active substance use requiring detoxification, unmanaged psychosis, or active suicidal or homicidal ideation with plan and intent requiring immediate inpatient hospitalization. Veterans missing demographic information (n = 1) or measures at pre- or post-treatment (n = 9) were removed, leaving a final sample of 333 veterans for analysis. Participants met full (99.1%, n = 330) or subthreshold (0.9%, n = 3; i.e., did not endorse sufficient symptoms needed for one of Criteria B–E) as assessed by clinicians using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5; Weathers, Blake, et al., 2013). Of the final sample, slightly over half were seeking treatment for MST-IT PTSD (n = 178; 53%), including both men (n = 76; 22.8%) and women (n = 102; 30.6%). The remaining individuals were seeking treatment for PTSD related to other traumas such as combat (40.1%), childhood sexual assault (15.1%), and witness to death (9.9%), among others.

Procedure

Data use and study procedures were approved by the VA Office of Research and Development and the affiliated university institutional review board. All veterans participated in pre- and post-treatment assessments, which included a battery of clinician-rated and self-report measures. Post-treatment assessments were conducted following treatment completion in the last week of the program. Treatment consisted of the 12-session combined group and individual CPT protocol (Chard et al., 2009), involving twice-weekly 75-minute group sessions and twice weekly 60-minute individual sessions, in addition to psychoeducational groups that promote general well-being (e.g., nutrition and yoga) (see Walter, Dickstein, and colleagues (2014) for a detailed program description).

Data Sources and Measures

Demographic Information

Demographic data (i.e., age, employment, marital status, minority status, and gender) and military service information (i.e., combat exposure, branch, service connection, and service era) were obtained during the pre-treatment assessment and from participant health records.

Comorbid Mental Health Diagnoses

The Structured Clinical Interview for DSM-5 (SCID-5; First et al., 2015) is a semi-structured interview to assess current and lifetime presence of comorbid mood, anxiety, and substance use disorders and psychotic symptoms. The most common categories of mental health disorders present at pre-treatment assessment were current depressive disorders (79.9%), past year tobacco use disorder (36.6%), past year alcohol use disorder (26.8%), other past year substance use disorders (20.7%), and anxiety disorders (15.4%).

Posttraumatic Stress Disorder Diagnosis and Symptom Severity

The CAPS-5 (Weathers, Blake, et al., 2013) is a structured clinical interview to assess PTSD symptoms related to a specific index trauma (IT; i.e., the worst or most distressing event as determined by the participant). Participants were coded as having MST-IT PTSD if they (1) reported sexual assault as the index trauma and (2) reported that the index trauma occurred while they were in the military. Clinicians rate the severity of each symptom from 0 (absent) to 4 (extreme), with scores of 2 or greater counting as a symptom for diagnosis. Items are summed for a total severity score used in study analyses. Total scores range from 0 to 80, with higher scores indicating greater symptom severity. Consistent with standard assessment protocol, pre-treatment symptoms were assessed during the past month, whereas post-treatment symptoms were assessed during the past week to ensure that the assessment time frame did not significantly overlap with treatment (Walter, Dickstein, et al., 2014). The internal consistency was good at pre-treatment (Cronbach’s α = .82) and excellent at post-treatment (Cronbach’s α = .91).

The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5; Weathers, Litz, et al., 2013) is a 20-item self-report measure of how much participants have been bothered by each PTSD symptom from 0 (not at all) to 4 (extremely). Items are summed for a total severity score used in study analyses. Total scores range from 0 to 80, with higher scores indicating a greater level of symptom severity. Pre-treatment symptoms were assessed during the past month, while post-treatment symptoms were assessed during the past week. The internal consistency was good at pre-treatment (Cronbach’s α = .89) and excellent at post-treatment (Cronbach’s α = .95).

Depression Symptom Severity

The Patient Health Questionnaire-9 (PHQ-9; Kroenke & Spitzer, 2002) is a 10-tem self-report measure of depressive symptoms (Items 1–9) and related functional impairment (Item 10). Participants rate how much they have been bothered by each symptom in the past 2 weeks (Items 1–9) from 0 (not at all) to 3 (extremely) and how difficult the problems have made it to engage in work, at home, or with others from 0 (not difficult at all) to 3 (extremely difficult). Items 1–9 are summed for a total score that ranges from 0 to 27, with higher scores indicating greater symptom severity; the final item is not included in the total score. The internal consistency was good at pre- (Cronbach’s α = .86) and post-treatment (Cronbach’s α = .89).

Negative Posttraumatic Cognitions

The Posttraumatic Cognitions Inventory (PTCI; Foa et al., 1999) is a 33-item self-report measure of trauma-related beliefs across three subscales: Negative Cognitions about Self (21 items; e.g., “I am a weak person”), Negative Cognitions About the World (7 items; e.g., “The world is a dangerous place”), and Self-Blame (5 items; e.g., “The event happened because of the way I acted”). The PTCI has demonstrated reliability and validity among trauma-exposed samples and discriminates between individuals with and without PTSD (Foa et al., 1999). The internal consistency of each subscale could not be calculated due to methodological constraints that led to the lack of item-level data for this measure. However, prior research suggests good to excellent internal consistency for the total score and all three subscales in a similar sample of veterans (i.e., PTCI total score, Cronbach’s α = .97; Negative Cognitions About Self, Cronbach’s α = .97; Negative Cognitions About the World, Cronbach’s α = .88; and Self-Blame, Cronbach’s α = .86; Holliday et al., 2014).

Data Analytic Plan

We first examined differences in pre-treatment variables by comparing groups across gender, MST-IT status, and their interaction. Differences in categorical demographic variables (i.e., employment, marital status, and minority status), military service information (i.e., combat exposure, military branch, service connection status, and service era), and comorbid diagnoses were examined by conducting loglinear analyses (i.e., multiway frequency analyses). For continuous demographic (i.e., age and years of education) and psychological (i.e., PTSD total and cluster severity, depression symptom severity, and NPCs) variables, we conducted 2x2 analyses of variance (ANOVAs) to examine the relationship between gender, MST-IT status, and each psychological variable of interest.

Next, we examined differences in treatment outcomes across groups by gender and MST-IT status by conducting stepwise hierarchical linear regression models on each post-treatment measure. For each model, we controlled for pre-treatment score and examined whether post-treatment score varied by MST-IT status and/or gender. We then included the MST-IT by gender interaction into the model to test its impact on post-treatment score. Demographics that were significantly correlated with a psychological variable and either gender or MST-IT status did not change the pattern of results when included in that variable’s regression model; therefore, they were omitted for brevity of reporting. To determine specific differences between groups, we conducted post-hoc tests using simple effects analyses on regression models that included significant MST-IT by gender interaction effects to clarify the interaction.

Results

Baseline Characteristics

Demographic Information and Comorbid Mental Health Diagnoses

Demographic information grouped by MST-IT status and gender is presented in Table 1. Loglinear analyses revealed main effects of MST-IT status on gender, combat exposure, and service era, such that a greater proportion of individuals with MST-IT were female (z = 2.285, p < .001), did not serve in combat (z = −4.675, p < .001), and served in the post-Vietnam era (i.e., served on active duty between May 1975 and August 1990; z = −3.849, p < .001). There were significant relationships between gender and minority status, employment status, service era, and comorbid diagnoses. Specifically, a greater proportion of men than women were of minority status (z = −2.687, p = .007); disabled, retired, or unemployed (z = −2.772, p = .006); and served in the post-Vietnam era (z = 3.827, p < .001). There was a significant relationship between gender and comorbid diagnoses such that a greater proportion of men than women had a past year alcohol use disorder (AUD; z = −3.145, p = .002) and other past year substance use disorder (SUD; z = −3.642, p < .001), whereas a greater proportion of women than men presented with a comorbid anxiety disorder (z = 4.106, p < .001).

Table 1.

Demographic Variables by MST Status and Gender.

Variable	MST-IT				No MST-IT
	Men (n = 77)		Women (n = 104)		Men (n = 109)		Women (n = 43)
	n	%	n	%	n	%	n	%
Minority status^a
White, non-Latinx	28	36.4	57	54.8	58	53.2	29	67.4
Racial/Ethnic minority	49	63.6	43	41.3	51	46.8	12	27.9
Marital status^b
Currently married	19	24.7	41	39.4	48	44.0	10	23.3
Previously married	47	61.0	45	43.3	45	41.3	17	39.5
Never married	11	14.3	18	17.3	16	14.7	16	37.2
Employment^a
Employed/Student	8	10.5	27	25.0	21	19.3	15	34.9
Retired/Disabled/Unemployed	68	89.5	77	74.0	88	80.7	28	65.1
Military branch^a
Army	44	57.1	48	46.2	54	49.5	22	51.2
Navy	15	19.5	18	17.3	22	20.2	6	14.0
Air Force	7	9.1	22	21.2	8	7.3	6	14.0
Marines	9	11.7	10	9.6	19	17.4	3	7.0
National Guard/Other	0	0	4	3.9	2	1.8	1	2.3
More than one branch	2	2.6	2	1.9	4	3.7	5	11.6
Service era^a,c
Vietnam	13	16.9	5	4.8	20	18.3	0	0
Post-Vietnam	52	67.5	42	40.4	36	33	4	9.3
Persian Gulf	10	13.0	29	27.9	28	25.7	13	30.2
OEF/OIF	2	2.6	28	26.9	25	22.9	26	60.5
Combat exposure^c
Combat	10	13	18	17.3	58	53.2	25	58.1
No combat	67	87	86	82.7	51	46.8	18	41.9
Service connection
SC for PTSD	41	53.2	56	53.8	58	53.2	21	48.8
Not SC for PTSD	36	46.8	48	46.2	51	46.8	21	48.8
Comorbid diagnosis
Current depressive disorder	62	80.5	80	76.9	87	79.8	37	86.0
Current anxiety disorder^c	3	3.9	35	33.7	2	1.8	11	25.6
History of bipolar disorder	5	6.5	10	9.6	8	7.3	4	9.3
Past 12-month alcohol use disorder^c	30	39.0	18	17.3	34	31.2	7	16.3
Past 12-month tobacco use disorder^b	40	51.9	18	17.3	50	45.9	14	32.6
Other past 12-month substance use disorder^c	25	32.5	10	9.6	30	27.5	4	9.3

	M	SD	M	SD	M	SD	M	SD
Age^b,c	55.83	6.02	47.62	10.88	52.31	10.14	42.35	10.18
Education^c	12.81	1.91	14.32	2.02	13.28	1.85	14.38	2.06

Note. MST-IT refers to individuals diagnosed with PTSD whose index trauma was military sexual trauma that met DSM-5 Criterion A for PTSD; SC refers to service connection within the Veteran’s Affairs system; n = number of individuals in that groups; M = mean; SD = standard deviation.

^aSignificant interaction between gender and demographic variable.

^bSignificant three-way interaction between MST-IT status, gender, and demographic variable.

^cSignificant interaction between MST-IT status and demographic variable.

There was a three-way interaction between MST-IT status, gender, and marital status (z = −3.070, p = .002) such that a greater proportion of women who reported MST-IT were currently or previously married compared to women without MST-IT, and a smaller proportion of men who reported MST-IT were currently married compared to men without MST-IT or women who reported MST-IT. Additionally, there was a smaller proportion of women with MST-IT who presented with past 12-month tobacco use disorder than women without MST-IT (z = 2.119, p = .034), though the proportion of men who presented with past 12-month tobacco use disorder was similar regardless of MST-IT status.

For continuous demographic variables and pre-treatment symptom severity, we conducted 2x2 factorial ANOVAs to examine differences across groups. In general, men (M = 53.8 years, SD = 8.8, η ² = .165) and individuals who reported MST-IT (M = 51.1 years, SD = 10.0, η² =.044) were older; however, there was no significant MST-IT by gender interaction effect on age. Women had more years of education than men (M = 14.3 years, SD = 2.0, η ² = .165). There was a non-significant main effect of MST-IT status on years of education.

Posttraumatic Stress Disorder and Depression Symptom Severity

Regarding baseline symptom severity, there were no significant differences in pre-treatment CAPS-5, PCL-5, or PHQ-9 total scores by MST-IT status, gender, or their interaction (see Table 2). Individuals who reported MST-IT had greater pre-treatment CAPS-5 AV symptoms, F (1, 329) = 4.588, p = .033, and η ² = .014, than those without MST-IT. There were no differences by gender or MST-IT status in any other CAPS-5 clusters. On the PTCI, a comparison of pre-treatment total scores revealed a main effect of MST-IT status such that individuals who reported MST-IT also reported greater overall NPCs than those without MST-IT, F (1, 329) = 5.501, p = .020, and η ² = .016. At the subscale level, individuals with MST-IT reported greater self-blame than those without MST-IT, F (1, 329) = 19.759, p < .001, and η ² = .057. There were no differences in the pre-treatment PTCI Negative Cognitions about Self or Negative Cognitions about World subscales by MST-IT status, gender, or their interaction.

Table 2.

Means and Standard Deviations of Outcome Variables at Pre- and Post-treatment by MST-IT Status and Gender.

Variable	MST-IT								No MST-IT
	Men (n = 77)				Women (n = 104)				Men (n = 109)				Women (n = 43)
	Pre		Post		Pre		Post		Pre		Post		Pre		Post
	M	SD	M	SD	M	SD	M	SD	M	SD	M	SD	M	SD	M	SD
CAPS	43.6	8.8	24.5	12.0	44.2	9.2	24.1	13.2	43.3	9.8	24.3	12.4	43.1	8.1	20.0	10.9
ITN	11.1	2.9	6.5	3.6	10.4	3.4	6.0	3.8	10.7	3.3	6.2	3.8	10.2	3.2	4.8	2.9
AV	5.4^a	1.2	2.8	2.0	5.6^a	1.2	2.5	1.9	5.1^a	1.6	2.5	1.9	5.2^a	1.3	2.4	1.8
NACM	16.2	3.9	7.8	5.0	16.8	3.8	8.5	6.0	15.5	4.1	8.4	5.2	16.5	3.1	6.7	4.7
AAR	11.1	3.0	7.5	3.4	11.4	3.1	7.0	3.4	12.0	3.5	7.2	3.5	11.3	3.3	6.1	3.1
PCL-5	57.3	11.8	33.7	16.9	59.4	11.8	35.7	18.9	56.9	12.9	33.7	18.2	56.2	10.8	30.5	16.2
PHQ-9	16.4	5.6	9.9	5.0	17.9	5.7	12.3	6.4	17.3	6.0	11.3	6.6	16.5	5.0	9.4	4.8
PTCI	164.4^a	38.2	114.4	40.9	172.0^a	37.4	120.5	49.4	159.8^a	33.0	121.5	42.9	156.9^a	33.4	110.7	40.5
NCAS	4.8	1.2	3.3	1.3	5.1	1.1	3.5	1.5	4.8	1.2	3.5	1.4	4.7	1.1	3.2	1.2
NCAW	5.9	1.2	4.3	1.4	6.1	0.9	4.5	1.6	5.9	1.2	4.7	1.4	5.7	1.0	4.4	1.4
SB	4.3^a	1.7	2.9	1.5	4.7^a	1.6	3.2	1.7	3.6^a	1.6	2.7	1.5	3.7^a	1.8	2.7	1.6

Note. M = mean; SD = standard deviation; CAPS = Clinician-Administered PTSD Scale -5; ITN = intrusions cluster of CAPS-5 symptoms; AV = avoidance cluster of CAPS-5 symptoms; NACM = negative alterations in cognition and mood cluster of CAPS-5 symptoms; AAR = alterations in arousal and reactivity cluster of CAPS-5 symptoms; PCL-5 = PTSD Checklist for DSM-5; PHQ-9 = Patient Health Questionnaire-9; PTCI = Posttraumatic Cognitions Inventory; NCAS = Negative Cognitions About Self subscale of PTCI; NCAW = Negative Cognitions About World subscale of PTCI; SB = Self-Blame subscale of PTCI

^aSignificant interaction between MST-IT status and pre-treatment variable.

PTSD Treatment Outcomes

Hierarchical linear regression models were conducted for variables related to treatment outcome (i.e., CAPS-5 total and cluster scores, PCL-5 total score, and PHQ-9 total score) and treatment mechanisms (i.e., PTCI total and subscale scores) to examine group differences by MST-IT status, gender, and their interaction while accounting for pre-treatment severity. Regression results are presented in Table 3. Results indicated that only pre-treatment score was a significant predictor of post-treatment score on the PCL-5 (β = .376, p < .001) and CAPS-5 total score (β = .371, p < .001), as well as PTCI total (β = .405, p < .001) and all PTCI subscale scores (βs ranged =.292–.443, all ps < .001).

Table 3.

Regressions for Post-treatment Variables after Accounting for MST-IT Status, Gender, and Pre-treatment Score.

Post-treatment Score	Step 1				Step 2		Change R²
	β			R²	β	R²
	MST-IT status	Gender	Pre-treatment score		MST-IT*Gender
CAPS Total	.059	–.087	.372**	.147	.129	.151	.004
ITN	.069	–.081	.396**	.171	.133	.175	.004
AV	.026	–.080	.261**	.072	-.060	.073	.001
NACM	.019	–.056	.299**	.090	.225*	.102	.013*
AAR	.111	–.105	.327**	.120	.047	.121	.001
PCL-5	.033	–.020	.378**	.145	.094	.147	.002
PHQ-9	.030	.029	.408**	.170	.254*	.187	.016*
PTCI Total	–.054	–.028	.409**	.164	.122	.168	.004
NCAS	–.029	–.043	.446**	.198	.089	.200	.002
NCAW	–.102	.000	.396**	.160	.141	.165	.005
SB	.021	.036	.295**	.095	.082	.097	.002

Note. Degrees of freedom for all models = 328; β = standardized regression coefficient; R² = proportion of variance; CAPS = Clinician-Administered PTSD Scale -5; ITN = intrusions cluster of CAPS-5 symptoms; AV = avoidance cluster of CAPS-5 symptoms; NACM = negative alterations in cognition and mood cluster of CAPS-5 symptoms; AAR = alterations in arousal and reactivity cluster of CAPS-5 symptoms; PCL-5 = PTSD Checklist for DSM-5; PHQ-9 = Patient Health Questionnaire-9; PTCI = Posttraumatic Cognitions Inventory; NCAS = Negative Cognitions About the Self subscale on PTCI; NCAW = Negative Cognitions About the World subscale on PTCI; SB = Self-Blame subscale on PTCI.

*p < .05, **p < .001.

For most post-treatment CAPS-5 clusters (ITN, AV, and AAR), only pre-treatment score was a significant predictor (all ps <.001); however, in addition to pre-treatment score (β = .302, p < .001), there were significant interaction effects of MST-IT by gender on post-treatment CAPS-5 NACM cluster score (β = .302, p < .001). Simple effects analyses revealed post-treatment CAPS-5 NACM symptoms were similar between women (M = 8.28, SE = .50) and men with MST-IT (M = 7.82, SE = .58); however, in individuals without MST-IT, NACM symptoms were higher in men (M = 8.66, SE = .49) than women (M = 6.525, SE = .78).

There was also a significant interaction of MST-IT by gender in predicting post-treatment PHQ-9 severity (β = .254, p = .011) after accounting for pre-treatment score (β = .396, p < .001). Specifically, women with MST-IT endorsed more symptoms of depression (M = 11.99, SE = .54) than their male counterparts (M = 10.27, SE = .63), and women without MST-IT (M = 9.65, SE =.84). There was no difference on PHQ-9 severity at post-treatment between women with MST-IT (M = 11.99, SE = .54) and men without MST-IT (M = 11.24, SE = .65).

Discussion

Military sexual trauma is a pervasive problem among military service members and veterans. Despite efforts to study characteristics of MST survivors and related treatment outcomes, research has produced disparate findings, likely due to varying definitions of MST and subsequent sample heterogeneity in studied MST groups. Furthermore, much of the research has focused on female MST survivors, despite evidence that suggests MST occurs in similar numbers (Kimerling et al., 2007; Wilson, 2018) and with unique problems among men (Morris et al., 2014). The present study investigated differences in (1) baseline characteristics (i.e., demographic variables, comorbid diagnoses, and symptom severity) and (2) treatment outcomes based on MST-IT status, gender, and the interaction between MST-IT and gender among veterans with PTSD receiving CPT in a VA residential PTSD treatment setting. This study builds on two previous examinations of MST-IT and gender in a VA residential PTSD treatment setting (Tiet et al., 2015; Voelkel et al., 2015) by utilizing with DSM-5 PTSD criteria (American Psychiatric Association, 2013) as well as self-report (e.g., PCL-5 and PHQ-9) and clinician-rated measures (e.g., CAPS-5 and SCID-5). This is the first study to examine differences in pre- and post-treatment PTSD cluster severity by MST-IT status and gender.

Our results regarding baseline demographic variations by MST-IT status and gender were partially consistent with previous literature. Our first hypothesis was supported, as we found veterans with MST-IT were more likely to be female than male, even in our nearly balanced sample of 186 men and 147 women. In line with our findings, several previous studies have found that veterans with MST-IT were more likely to be female (Carroll et al., 2018; Holliday et al., 2020; Voelkel et al., 2015); however, only a few studies have also found veterans with MST-IT to be older (Carroll et al., 2018; Holliday et al., 2020) and to have served pre-9/11 (Carroll et al., 2018). Like Kimerling et al. (2007), we found that men, regardless of MST-IT status, were more likely to be of a minority status. Consistent with findings from a previous study in this clinic (Voelkel et al., 2015), we found that men were more likely to be older and less educated than women regardless of MST-IT status. Similarly, in line with this previous study, our results showed women were more likely to have a comorbid anxiety disorder and men were more likely to have a history of alcohol or other substance use disorder. Although some studies have found that individuals with MST are less likely to be currently married (Kimerling et al., 2007; Voelkel et al., 2015), this was only true for men with MST-IT in our sample. Given the mixed findings throughout the literature comparing demographic variables for individuals with and without MST (Carroll et al., 2018; Holliday et al., 2020; Khan et al., 2020; Kimerling et al., 2007; Voelkel et al., 2015), it remains difficult to conclude any distinct differences in demographic presentation beyond gender for individuals with and without MST-IT.

Additionally, consistent with previous studies (Holliday et al., 2020; Voelkel et al., 2015), we hypothesized that individuals with MST-IT would report higher PTSD symptom severity and similar rates of depression severity. These hypotheses were partially supported, as pre-treatment self-rated PTSD and depressive symptoms, as well as clinician-rated PTSD severity, did not differ between individuals with and without MST-IT. However, while most clinician-rated PTSD symptom clusters (i.e., CAPS-5 ITN, NACM, and AAR) also did not differ at pre-treatment, our results revealed individuals with MST-IT demonstrated elevated clinician-rated avoidance of trauma-related cues (i.e., CAPS-5 AV). This finding is consistent with existing literature that found civilian survivors of sexual assault reported greater avoidance than those with PTSD from other trauma types (Kelley et al., 2009) and veteran survivors of MST-IT evidenced greater avoidance than their counterparts who experienced a civilian trauma (Graham et al., 2016). The literature is limited on why this trend may occur, though one study suggests institutional betrayal (i.e., failure of an institution to provide protection and/or support following trauma) as a factor associated with higher avoidance symptoms among MST survivors (Blais et al., 2018). They hypothesized that MST-IT survivors may have been punished for or discouraged from reporting their MST within the military organization, potentially resulting in a pattern of internalization, suppression, or avoidant coping. In turn, societal norms and gender-related stereotypes, which are particularly poignant for sexual trauma of an interpersonal and intimate nature (e.g., victim blaming), propagate self-blame through shame, guilt, and embarrassment and increase the difficulty of disclosing a sexual trauma. Consistent with this theory and previous research, we hypothesized that MST-IT survivors would have greater NPCs, and this would specifically be evident in NPCs related to self-blame. This hypothesis was supported as our results revealed elevated total NPCs and self-blame NPCs among individuals with MST-IT versus no MST-IT regardless of gender.

Although literature has demonstrated the effectiveness of CPT for MST-IT PTSD, few studies have investigated differences in treatment outcomes at pre- and post-treatment across individuals with and without MST-IT and by gender. In the present study, our final hypothesis was supported. The results of hierarchical regression models showed that neither MST-IT status, gender, nor the interaction between MST-IT and gender predicted post-treatment self- or clinician-rated overall PTSD severity after accounting for pre-treatment severity. These findings are consistent with previous literature (Holliday et al., 2020; Tiet et al., 2015; Voelkel et al., 2015), suggesting residential CPT is similarly effective in reducing PTSD symptoms in individuals with and without MST-IT, regardless of gender. Our study is also one of the first to compare reductions in NPCs across groups by MST-IT status and gender in cohorts with mixed trauma type. Our findings suggest that individuals with MST-IT may present with greater NPCs like self-blame; however, when controlling for pre-treatment differences, MST-IT status and gender had minimal impact on post-treatment NPCs. This suggests that CPT targets NPCs equally well regardless of MST-IT status or gender, after accounting for pre-treatment severity.

Examinations into the effectiveness of CPT for reducing PTSD and comorbid depressive symptoms suggest these symptoms decrease concurrently throughout treatment and that reduction in one does not drive the other (Liverant et al., 2012). Interestingly, in our sample, though overall PTSD symptom severity post-treatment with residential CPT did not differ by MST-IT status, gender, or MST-IT status by gender, post-treatment depressive symptom severity did. Specifically, after controlling for pre-treatment scores, the severity of self-reported post-treatment depression in women with MST-IT was greater than men with MST-IT and women without MST-IT, but similar to the severity reported by men without MST-IT. Women with MST-IT and men without MST-IT reported the highest residual symptoms of self-reported depression (e.g., PHQ-9) and clinician-rated PTSD symptoms of negative alterations in cognitions and mood (e.g., CAPS-5 NACM), followed by men with MST-IT and women without MST-IT. Even so, the post-treatment severity of self-reported depression in our sample of women with MST-IT was lower than residual depressive symptoms in a similar study with co-ed sample of survivors of MST-IT (e.g., post-treatment PHQ-9 average of 9.4–12.3 compared to 11.03–13.83; Zalta et al., 2018). Additional research is warranted to better understand the similarities between these groups (women with MST-IT and men without MST-IT) as they relate to residual symptoms of depression and other negative emotional experiences following a course of CPT.

Our findings must be considered in light of several limitations. Given the nature of residential programming, all veterans attended individual and group CPT, in addition to other psychoeducational group programming. As such, it is unknown if individuals with MST-IT respond similarly to CPT as those with PTSD from other index traumas due to other aspects of residential programming (e.g., DBT skills-training groups focused on emotion regulation and distress tolerance; Holliday et al., 2020). Future examinations should aim to test these confounding effects, as research suggests that incorporating skills targeting emotional regulation and interpersonal effectiveness can improve MST-IT treatment outcomes comparable to those with other traumas (Lofgreen et al., 2020). Additionally, individuals with PTSD from other trauma types (i.e., not MST-IT) in this sample may also have a history of military sexual assault. Although it would be ideal to include individuals who have only experienced one trauma (their index trauma), most trauma-exposed veterans have experienced more than one traumatic event (e.g., 99.4% of our sample endorsed at least one traumatic event in addition to their index trauma; Kilpatrick et al., 2013), thus making results examining treatment effects on an index trauma likely to generalize to individuals with polytrauma. Finally, due to methodological constraints we were unable to examine the effect of rank by gender and/or MST-IT status. Given mixed results on demographic differences noted in the literature and the putative association of rank with other demographic characteristics (e.g., enlisted tend to be younger, less educated, and racial minorities) and mental health, rank disparities should be included in future studies of demographic differences in treatment-seeking individuals with and without MST-IT.

Despite these limitations, our study had several advantages, including the use of longitudinal clinical data with both self- and clinician-rated symptom inventories at multiple time points. The longitudinal nature of the data allowed for regression analyses using time points pre- and post-treatment. Moreover, our sample included a modest number of men with MST-IT, addressing the limitation in several previous studies of inadequate power to conduct analyses of differences by gender (Carroll et al., 2018; Holliday, Holder et al., 2018; Zalta et al., 2018). We extended the existing literature on treatment outcomes and NPCs between groups on MST-IT status and gender using updated DSM-5 PTSD criteria and self- and clinician-report measures (Zalta et al., 2018). However, while Zalta and colleagues (2018) examined effects of overall PTCI score on PTSD and depression outcomes, our study examined differences in specific NPC subtypes (i.e., PTCI subscales) by gender and MST-IT status before and after treatment. Furthermore, ours is the first to examine differences in symptom severity by clinician-rated PTSD symptom clusters, an important component in understanding changes in clinical presentation and which symptoms are improving or persisting over the course of treatment.

In summary, our results suggested that there are modest demographic differences between individuals with and without MST-IT, with gender differences being the most supported by the literature. Though our results did not show a difference in combat status by gender, it seems imperative to continue examining the impact of combat and gender on mental health as women’s role in the military diversifies and women become increasingly involved in combat. Individuals with MST-IT may present to treatment with greater avoidance and NPCs, specifically those related to self-blame, yet after a course of CPT delivered in a residential PTSD treatment program, there is no significant difference in the rate of symptom reduction of overall negative posttraumatic cognitions or PTSD symptom severity in individuals with or without MST-IT regardless of gender. There were, however, some differences in residual symptoms of depression by gender by MST-IT status group. These findings suggest that it may be clinically beneficial to attend more closely to symptoms of depression and NACM in women with MST-IT and in men without MST-IT as these symptoms may persist despite reductions in PTSD symptom severity. These findings suggest a need for longitudinal investigations that extend past treatment completion to study residual symptoms. More research is also needed to clarify mixed results regarding whether PTSD symptoms remain in remission or increase after treatment for those with MST-IT (Holliday et al., 2020; Voelkel et al., 2015). Our results warrant replication in an outpatient setting of CPT and with other trauma-focused treatments (e.g., prolonged exposure; Foa & Rothbaum, 1998).

Finally, it is worth mentioning that the most common type of index trauma in our sample (53%) was MST. The gravity of this statistic does not go unnoticed. It is particularly jarring when considering that our specialty VA PTSD clinic is treating more individuals for MST, often perpetrated by fellow service members, than combat or exposure to other traumatic events before, during, or after military service combined. Therefore, we place an emphatic call for continued MST prevention efforts to decrease the occurrence of MST and subsequently reduce the rate of MST-related PTSD cases seen in clinics such as our own and for continued research and strengthening of intervention efforts for MST survivors.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Nicole M. Christ

Author Biographies

Nicole M. Christ, PhD, received her doctorate in clinical psychology at the University of Toledo after completing her clinical internship at the Cincinnati VA Medical Center, Trauma Recovery Track. Her research interests include accurate assessment of PTSD and examining factors involved in treatment response, such as trauma type, comorbid symptoms, and transdiagnostic variables (e.g., emotion regulation).

Rachel C. Blain, PsyD, is a staff psychologist in Research Service at the Cincinnati VA Medical Center. She completed predoctoral and postdoctoral training at the Cincinnati VA, specializing in evidence-based treatment for Veterans with PTSD, substance abuse, homelessness, and other psychosocial stressors. Her research interests include understanding factors that predict suicidality and treatment response among Veterans with PTSD.

Nicole D. Pukay-Martin, PhD, is a staff psychologist in the Trauma Recovery Center at the Cincinnati VA Medical Center. Her research interests include examining PTSD treatment outcomes, couple-based treatments for PTSD, interpersonal effects of PTSD, and relational factors involved in the development and maintenance of PTSD.

Jessica M. Petri, PhD, received her doctorate in clinical psychology from Auburn University after completing her clinical internship at the Cincinnati VA Medical Center, Trauma Recovery Track. Her research interests include accurate assessment of PTSD across diverse populations and settings, and variables that influence access to evidence-based and trauma-informed care.

Kathleen M. Chard, PhD, is the Associate Chief of Staff for Research and Director of the Trauma Recovery Center at the Cincinnati VA, and a Professor at the University of Cincinnati. She authored Cognitive Processing Therapy for Sexual Abuse and directs the National VA CPT Dissemination Initiative. Her research interests include examining the effectiveness of empirically-supported, cognitive treatments for PTSD.

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