Post Traumatic Stress Disorder in the Military

Introduction

Over the past years war-related mental outcome have been given different names as combat neurosis, combat fatigue, shell shock, mental conflict, and mechanical impact exhaustion. Each name reflected a theoretical framework of the cause of psychological trauma (Shalev and others, 1996). The psychological diagnosis posttraumatic stress disorder appeared in 1980 to hallmark long-term reactive psychological disorders in response to exposure to war environment (Margoob and others 2004).

Present time wars’ environment is characteristically indistinct and confusing, with fears of possible injury or death if not for the military itself then perhaps for a colleague. Such an environment results in a mental stress disorder the extent of which depends mainly on the type and severity of trauma, and the time passed since exposure (Reeves, 2007). Based on the duration of symptoms related to the onset of trauma, PTSD is classified into three categories (phases). Acute PTSD of 1-3 months duration, chronic PTSD of 3-6 months duration, and delayed PTSD of more than 6 months (Grace, 2008).

Current research signals that engagement of the US and allied military forces in Iraq and Afghanistan represent important challenges to the medical services of the military. War upholds an existing effect on the life of combat trauma surviving soldier after returning home, as this soldier attempts to get back to the normal social network of relationships including family and social life. This will be significantly influenced by the symptomatic cognitions and behavioral changes linked to posttraumatic stress. These challenges revealed some shortages in conceptual interpretation and healthcare delivery to the psychologically traumatized soldiers (Grace, 2008).

Based on criteria of the diagnostic and statistical manual of mental disorders published by the American Psychological Association (after Grace, 2008), posttraumatic stress disorder is an exposure to a traumatic event with the following conditions. The individual witnessed experienced or confronted with an event (s) that resulted in or threatened either death or serious injury. Second is individual’s response to the event includes severe fear, helplessness, or atrociousness, third, the event re-experienced repeatedly through disturbing assembly of dreams, flashbacks, or psychological distress in response to specific or nonspecific reminders. This links to continuous attempts to avoid reminders and stimuli associated with trauma and persistent symptoms like increased irritability, exaggerated alarm response, and difficulty concentrating. Other symptoms related to sleep and arousals include increased arousal, vigilance, difficulty falling or maintaining sleep. Finally, the duration of symptoms should be more than a month after the onset of trauma (Grace 2008).

Kashdan et al (2006, p. 561) stated that PTSD incidence among veterans ranges from 15% to 72%. In 2004, a US army study suggested that 9.3% of the military served in Iraq and Afghanistan and 17.1% of the military stationed in Iraq met the criteria of PTSD diagnosis (after Reeves, 2007). Further, Reeves (2007, p. 181) stated in a survey conducted on 11400 veterans served in the first gulf war (1991), 10% met the criteria of PTSD diagnosis.

The aim of this essay is to provide a proposal for further research on PTSD in the Military, attempting to explore war time personal factors that contribute to PTSD precipitation. The second research question to attempt will be why more male soldiers are diagnosed with PTSD more than female soldiers in wartime environments?

Literature review

Risk factors of PTSD

Stressors and stress response

Stressors can take different forms, whether they are physical (like biological body demands), or cognitive like fear of death, they are external and have an impact on human behavior. They produce stress responses which vary according to the severity and duration of the stressor (Kavanagh, 2007). For of this essay, the stressors related to combat and deployment will be discussed as pretraumatic stressors, deployment stressors, and stressors in the lights of demand.

Watson and others (1993, p. 311) hypothesized that stresses experienced before the trauma onset affect the trauma potential to induce PTSD in one of two ways, they may wane an individual’s ability to withstand later trauma that increasing PTSD (cumulative effect). Second, they may provoke the development of coping, which reduces severity of PTD (stress vaccination). Therefore, they contrasted two studies on Vietnam War veterans reported high and low premilitary stresses, they inferred for the first study; premilitary stress reduced the impact of trauma. In the second study, they showed the effects of premilitary stress were insignificant. Watson et al (1993, p. 317) could not explain this inconsistency in results, they suggested the explanation is possibly the age difference between the two groups where subjects were significantly younger in the first study.

Heinrichs and others (2005, p. 2276) recognized that most studies evaluating pretraumatic effects on PTSD were retrospective. Therefore, they planned a prospective study on fire-fighters exposed to similar but not identical trauma. Their results showed individual’s high-level of hostility and low-level of self-confidence at baseline evaluation (before trauma) were the commonest PTSD predictors. In addition, these subjects showed increased symptom severity evidenced by higher PTSD symptom measures. They inferred that specific personality characteristics are more important to predict the severity of psychopathological symptoms of PTSD.

Deployment stressors

Hoge et al (2004) looked at deployment in Afghanistan and Iraq as major deployment stressors. In their survey conducted three to four months on troops after returning home, they showed that 58% of army personnel returning from Afghanistan and 89% of those returning from Iraq were ambushed or attacked during their deployment. Further, they showed that 93% of army military and 97% of Marines were shot at with small firearms in Iraq during deployment, while 66% of army military were shot at in Afghanistan. They suggested that deployment stressors are significant among military deployed in these two combat fields, besides, despite deployment stresses in Iraq and Afghanistan are grouped together; yet, experiences are different. With changing war environment in these two areas, Hoge et al (2004) identified the need of further research on the military of recent deployment.

There are few studies that examined the difference in deployment stressors between active duty military and National Guard or reserve military. Available studies focus on identifying difference in health status after deployment; however, none addressed the link between deployment stressors and health outcomes (Vogt et al, 2008). Therefore, Vogt et al (2008) performed a study on 311 first Gulf War veterans to examine the association between deployment stress and posttraumatic stress symptoms. They suggested there significant differences between active duty military and National Guard or reserve personnel in deployment stress exposure. Further, association analysis suggested more negative impact of deployment stress exposure of PTSD symptoms in active duty military. They explained their results in the lights of the possible role unit cohesion plays.

Stressors in the lights of demand (Combat stressors)

Litz et al (2004, p. 198) the US military considerations and experiences of the Kosovo piece keeping assignment using a prospective designed study to evaluate prevalence, severity and predictors of mental health outcomes on redeployment. Results showed that the soldier’s assessment of combat events in Kosovo was moderate with low postdeployment psychological pathology. Interestingly soldiers reported more severe predeployment mental health problems pointing to the negative anticipatory predeployment stress. Redeployment evaluation showed hostility and alcohol abuse are more chronic problems emerging on such moderate exposure to combat stressors than depression or PTSD symptoms. Litz et al (2004) inferred the latter symptoms become more relevant with variable severity when soldiers’ experiences are associated with potentially traumatizing incidents during piece keeping.

Helmus and Glenn (2005) interviewed infantry soldiers in Iraq and Afghanistan about the nature of urban combat warfare. Results showed a large number of severe combat stressors related to these areas including intense fire-fights, presence of tall building obstructing enemy visibility, the persistent presence of unidentified constantly changing enemy, and high causality rates. Despite the variability and severity of combat stressors in urban areas, the authors inferred the prevalence of PTSD among those military personnel is not higher than among veterans as a whole.

Psychological, biological, and genetic risk factors

In a review article Boscarino (2004) suggested that literature displays enough evidence supporting severe stressors leading to development of PTSD correlate to a number of biological alterations. First, there is a decreased cortisol (a suprarenal glucocorticoid) level among PTSD patients, second, there is also cytokine-mediated activation of adrenal control and cytokine independent cell mediated immune adrenal interactions. Both changes are responsible for adrenal dysfunction and disease. Of importance to stress-psychological disorder disease process, Boscarino (2004) pointed to disturbances of the hypothalamic-adrenal-pituitary axis function in concert with the adrenal medulla as a biological risk factor. Further, Boscarino (2004) inferred that neuro-endocrinal disturbance secondary to stress influence the physiologic adjustment response.

Genetics researchers look at PTSD as a complex polygenetic disorder, yet with no responsible gene isolated. However, there are possibly responsible genes which induce an interchangeable additive role to the inherited likelihood of PTSD (Koenen, 2003).

Wilson and others (2008, p. 385) performed a retrospective study to examine the influence of pre and postdeployment psychological health status on recall of risk factors. Their results showed postdeployment psychological health status is more significant than predeployment one in explaining recall traumatic experiences. In addition, postdeployment status showed little impact on most risk factors. The suggested there is no enough evidence to infer predeployment psychological status is useful in correcting a recall bias, except only for predeployment of intrusive disturbing thoughts.

Behavioral and cognitive changes in PTSD

Interpretation and generalization of PTSD observations based on a behavioral concept depends on the two-factor theory proposed by Mowrer in 1960 (after Herman, 1997). The first factor is correlating the emotions experienced during a traumatic incident to a sensation (sight, sound or any other), second is avoidance that is avoiding the signal or cues that stir up the psychological disturbances. The range of cues increases over time because of generalization that is similar signals (not necessarily identical) to the original one incite psychological disturbances, and as a result of high order conditioning where a neutral cue provokes the disturbance (Herman, 1997). Based on this concept, McNally et al (2003, p. 49) suggested a cognitive model to explain these phenomena. The model consists of a sensual stimulus associated with the traumatic incident, the physiological and or psychological response, and the meaning linked to both the stimulus and response.

To assess the role of cognitive processing in PTSD, Halligan et al (2003) examined two (one cross sectional, and a second prospective) studies of assault victims to identify the role of disorganized trauma memories in developing PTSD. They also assessed the role of peritraumatic cognitive processing in developing disturbing memories and PTSD, and the role of ongoing dissociation and negative evaluation of memories in maintaining PTSD symptoms. Analysis of the two studies showed that both studies produced the same outcome, which is peritraumatic cognitive processing relates significantly to PTSD, and ongoing dissociation and negative valuation of memories act to sustain PTSD symptoms. Further, Halligan et al (2003) suggested the severity of the incident explained 22% of the symptoms variability, while measures of cognitive processing successfully raised PTSD symptoms prediction by more than 70%.

Neuroscience research shows that severe stress affects brain functions rendering traumatized individuals are more susceptible to react to sensory stimuli with responses initiated sub-cortically, which, characteristically, is not related and is often harmful. Besides, reminders of traumatic incidents’ experiences activate certain brain areas supporting intense emotions. At the same time, these reminders decrease activation of areas responsible for sensory input integration with motor output, modulation of physiological arousal, and the capability to communicate in words. Further, neuroscience research shows that intense stress interferes with memory and the capacity to get involved in present environment. Collectively, these changes lead to a PTSD patient who appears as if lost the roadmap of life (Van der Kolk, 2006).

In many cases, individuals suffering from PTSD show hostility and violence behavior. Jovanovic et al (2009) assessed 104 combat veterans suffering from PTSD using Historical. Clinical, and risk management, a 20 items instrument, to evaluate the risk of violence. They inferred that combat veterans with PTSD have higher risk of violent behavior than veterans without PTSD, or other psychiatric patients. They emphasized Historical. Clinical, and risk management is a useful instrument to assess violent behavior.

Gender-related differences in PTSD

In general, studies of gender-related risk of PTSD show that females are more likely to meet PTSD diagnostic criteria although they are less likely to experiences potentially traumatic events (Tolin and Foa, 2006). The rational question to ask is this related to hormones? Pineles et al (2007) responded to this question and suggested that sex-related hormones as estrogen and progesterone are partially responsible for the PTSD gender-related difference. However, as the level of these hormones fluctuates during female life, evidence suggests the role of these hormones in developing and maintaining PTSD is dependent on their level so that by the age of 55 there is no difference between males and females.

Fontana et al (1997) reported that sexual trauma to female veterans is more common than thought to be. Therefore, they examined female military personnel from Vietnam theatre and era to evaluate the etiological role of sexual and war trauma producing chronic PTSD type. They created a causal model to explicate the pathways mediating causation between types of trauma and PTSD (as variables) across time. Results pointed to both types of trauma contributing to PTSD. Results also showed that lack of social support at the time of home-return is a significant arbitrator for trauma. They inferred that sexual trauma is an important contributing factor in developing PTSD in Vietnam War female veterans.

Zlotnick et al (2001) examined the clinical profiles of males and females with PTSD seeking treatment. Their results displayed that females suffer from more reexperiencing symptoms and to report sexual trauma as their trauma index. Males, on the other hand, suffer more from drug abuse and antisocial personality disorders; Zlotnick et al (2001) found no significant gender differences in comorbidity disorders.

In another study that included 225 male and 232 female veterans aiming to examine gender-related differences in significant predictors of PTSD, Benda and House (2003) reported these differences exist. For female veterans, interpersonal factors, depression and atrociousness were significant PTSD predictors, while for males, self-confidence, drug abuse, resilience, and combat stressors were more significant predictors. History of family abuse (physical or otherwise) was a significant predictor for both genders. Benda and House (2003) also reported that PTSD associated comorbidity also differ, with depression being more common in females, and drug abuse in males.

Schnurr and Lunney (2008) looked at the research gap about the quality of life of veterans with PTSD. They reported a poor quality of life with no gender differences of veterans survived Vietnam War yet suffering from PTSD. Interestingly, they noticed that numbness was associated with poor quality of life in veterans of both genders.

Race-related PTSD differences

Frueh et al (2002, p. 157) examined the possibility of racial difference in clinical presentation and symptoms of combat veterans suffering from PTSD using Minnesota Multiphasic Personality Inventor-2 (MMPI-2) as a research instrument. They examined African American versus Caucasian veterans and despite the groups did not match for combat trauma level or preexisting trauma; yet, there were no other significant demographic or diagnostic differences. They showed significant differences existed in clinicians’ ratings of symptoms severity but no significant differences in measures of comorbid depression, anxiety or schizophrenia. However, African Americans with PTSD showed more positive symptoms of psychosis but not higher rates of primary psychosis. Grubaugh et al (2006) did not find significant differences in psychopathology between African Americans and Caucasians veterans.

Loo (2008) reported that results of studies on PTSD in ethnic minorities Vietnam veterans were inconsistent. However, the National Vietnam Veterans Readjustment study shows clear difference among Hispanic, African American, and White American in readjustment. Rates of PTSD were 28% for Hispanics, 21% among African Americans, and 14% among White Americans. Among American Indian Vietnam veterans, the rate ranged from 22 to 25% depending on the tribe, acknowledging that this group’s exposure to combat stress was greater than the others. The least rates (2.6%) were among Japanese Americans.

Diagnosis and assessment

Based on DSM-IV (American Psychological Association Diagnostic and Statistics Manual of Mental Disorders), Kaplan consulting and counseling (2006), set the following criteria for diagnosis:

1- Criteria A (gateway criteria, all required):

• The veteran has witnessed a trauma that caused or threatened a serious injury, death, or personal abuse.
• The traumatic event should have caused great fear, horror, or deep feeling of helplessness.

2- Criteria B (reexperiencing symptoms, at least one of the following should be present).

• Recurring disturbing interfering recalling of the event.
• Frightening dreams involving the traumatic incident.
• Experience as if living the incident once again.
• Fear, anxiety on exposure to similar conditions of the trauma cues, and
• Increased symptoms of arousal on exposure to similar cues.

3- Criteria C (symptoms of avoidance, at least three of the following should be present):

• Efforts to avoid cues, feelings, people, or places associated with the trauma.
• Gaps in remembering the time order of the traumatic events.
• Diminished concern of previously enjoyable activities.
• Feelings of being detached or being strange from others.
• Feeling that the course of life will be short or changed.
• Emotional freezing, with the affected veteran appears emotionally cold and unresponsive.

4- Criteria D (hyperarousal manifestations, at least three should be present):

• Sleep disturbances.
• Outbreaks of anger.
• Difficult to focus.
• Being constantly on guard, and
• Abnormally increased alarming frightened response to unexpected stimuli (noises, flashes of light…etc).

To diagnose PTSD, the duration of symptoms should be at least 1 month (Kaplan consulting and counseling, 2006).

Watson and others (2008) prepared the best practices manual for posttraumatic stress disorder (PTSD) compensation and pension examinations. The assessment protocol in this manual included two instruments for assessment, namely, the trauma exposure assessment protocol, and assessment of PTSD. The objective of the trauma exposure assessment tool is to document whether the veteran was exposed to a traumatic event, during military service, severe enough to meet the DSM-IV (Diagnostic and Statistical Manual for Mental Disorders-IV) stressor criterion. The DSM-IV stressor criterion is the gateway criterion (Criteria A) mentioned previously. Watson and others (2008) suggested the following guidelines for interview assessment of trauma exposure: 1- To familiarize the veteran to the trauma assessment, as it may help to alert the veteran that although brief, trauma assessment interview may cause some distress. It is important also to inform the veteran that trauma assessment interview is a mutual collaborative process and there is no need for unnecessarily detailed answers. 2- Documentation of trauma related information including a tale description of the traumatic episode. Such description should include features of the event; date and place, names of witnessed other individuals, what healthcare facilities provided treatment, what decorations or medal received, and the veteran’s view of supposed results and subjective emotional reaction and behavioral response. Watson and other suggested the following protocol for assessment of PTSD. The PTSD assessment protocol has four objectives, first is to establish or deny the diagnosis of PTSD. In this pursuit, various methods are used as questionnaires, interviews. Many clinicians recommend the Minnesota multi-phasic personality inventory (MMPI) as a helpful tool. In addition, the infrequency psychopathology scale is a useful validity measure. Establishing the diagnosis may need some biological measure as heart rate, measuring blood pressure, measuring skin conductance, EKG, and measuring muscle tension. The second step in assessment is to determine the symptoms’ severity, next is to establish the logical relationship between trauma and resulting symptoms. Finally is to describe how PTSD symptoms change social, occupational performance and quality of life of the veteran.

Adler et al (2008) reviewed the changes in diagnosis criteria produced by PTSD research. Criteria A for diagnosis is further divided into A1, which centres on threat-related events, and A2 focusing on the subjective feeling of helplessness, fear, or horror. They reported that since military personnel training on responding to traumatic events might alter their subjective feelings for A2 criteria, the validity of this criterion becomes questionable. Adler et al (2008) interviewed 202 military personnel returning from a year in Iraq and suggested A2 criteria correlate to high PTSD scores; further, they stated that responses correlate strongly to level of training and the feeling of anger. They inferred that A2 criteria should expand to include feeling of those who received higher training so as not to drop out from treatment.

Schnurr et al (2003) highlighted the problem of chronicity and showed that more than 45% of the sample surveyed (239/550) suffered delayed onset PTSD with partial or full lifetime PTSD. They found that females are predominantly in the delayed group, and men of ethnic minority are in the severely affected chronic group. Kennedy et al (2007) addressed the problem of PTSD differential diagnosis from PTSD like symptoms secondary to mild traumatic brain injuries and concussions. They suggested future research should focus on the clinical aspects of both disorders including separate diagnostic criteria, the biological overlap of the two disorders, comorbidity, and the different treatment strategies to adopt.

Rosen et al (2008) discussed problems in diagnosing PTSD and focused on the lack of a specific etiology since by definition PTSD results from a set of traumatic incidents. Second is the lack of syndrome or disease uniqueness because of the combination of symptoms and frequent comorbidity besides lacking a specific etiology. Third, based on the DSM-IV, it is not necessarily to witness a traumatic event, PTSD may result from hearing of incident occurred to others; thus, an expansion of the PTSD model took place (after Rosen et al, 2008).

Treatment Strategies

In 2007, the Institute of Medicine (IOM) Committee of PTSD treatment carried out a systematic review on 2771 studies on treatment of PTSD and assumed there are two main strategies for treatment of the disorder; namely pharmacotherapy and psychotherapy. Pharmacotherapy protocols include alpha-adrenergic blocking agents, anticonvulsants, and antipsychotic agents like olanzapine and risperidone. These protocols include also medications acting on serotonin as brain chemical transmitter monoamine oxidase inhibitors (MAOIs) and serotonin reuptake inhibitors. However; the committee reported there is lacking evidence on the efficacy of these medications in treating PTSD. Psychotherapy includes many lines of treatment like cognitive restructuring, cognitive behavioral therapy, exposure therapy, coping skills training, reprocessing and group format therapy. Of these modalities, the IOM committee (2007) inferred evidence is clear on the efficacy of exposure therapy and is encouraging about cognitive behavioral therapy.

PTSD: Unanswered questions

Based on the analytical reviews of Batien (2005), and Litz (2007), there are still many unanswered questions about PTSD that can be categorized under three headings:

Questions about risk factors

Research is still to provide more details on biological and genetic predisposition to PTSD. Further the changing face of war has created what can be named disconnectedness from field action, which may seriously affect how military personnel will subjectively describe trauma incidents. In addition, since war, now, have no clear front lines, females are increasingly exposed to combat environment, which mandates a further deeper look on the gender-related differences of PTSD.

On the individual level, research is still to provide a deeper look of resilience and protective factors, and variations of personal moral and guilt as they link to the size of trauma.

Questions about the design of studies needed

Most studies are cross sectional, given the knowledge that PTSD adjustments unfold by time; there is a need for more longitudinal studies.

Questions about further studies’ objectives

There is a need to study the life impact of PTSD because of two reasons, first is although patients with anxiety and affective disorders secondary to PTSD may show signs of remission, yet, they keep the chronic burden of the disorder for long time. Second, animal studies show clearly that trauma memory cannot be eliminated naturally or by treatment-induced annihilation. This leads to the second area where research should undertake that is self-management of PTSD. Until present time PTSD treatment is either therapist or resource targeted, although self-help programs if evidence-base guided will provide care to larger numbers of PTSD military.

Methods

Research question

Based on the above discussion on PTSD unanswered questions, this research will attempt to answer the question of further detailed risk factors leading to PTSD on the individual’s level. This will include considering factors like age, gender, race, rank (will be an indicator to the nature of wartime work and exposure to trauma). Factors to consider will also include years of experience, level of training, frequency of deployment (times deployed), and era of deployment. All these factors will be considered in the general framework of gender-related differences in posttraumatic stress disorder.

Worldview of the study

The term worldview reflects a series of assumptions or conjectures that one holds about reality or a phenomenon. In this sense it affects individuals’ judgment on phenomena, and at this point it is nearer to philosophy or in other words is the product of a philosophy. A scientific or a research worldview is centered on modeling the reality (phenomenon) besides seeking to provide explanatory strength based on or verified by observation or experimentation (Bishop, 2007).

In mental health research, advocacy worldview is a means of increasing attentiveness on mental health problems to ensure that a mental health issue is on the authorities’ priority agenda. Thus, advocacy can lead to improvements in policy, legislation, or service development (Funk, 2003).

The second worldview approach to mental health research is community-based participatory research. It aim at augmenting the study’s value for researchers and the community studied. The participatory approach is of importance to academics and health researchers in dealing with persistent problems of healthcare disparities or those taking place in a variety of populations or a diverse population identified by gender, ethnicity, socioeconomic status or otherwise.

Based on the above discussion, the researcher will attempt the community-based participatory approach in future work.

Research design

There are three educational research designs (paradigms or models); the qualitative, quantitative and mixed research methods. The qualitative research has five main subtypes namely; phenomenological where the researcher tries to explain how individuals experience a certain observable event or trend. The second qualitative subtype is ethnography that is describing a culture; a third subtype is case studies providing a detailed account on one or more cases and from there reaching an inference. Fourth is grounded theory research, which is a qualitative approach for building up a theory from the data collected, and finally the historical qualitative approach. Thus, qualitative research reaches a conclusion based on observation (inductive methodology). Quantitative research, on the other hand, depends on deductive reasoning, and conclusive confirmatory strategy. This type of research is used mainly describe, explain, or predict an incident, that is to test for significance, correlation and regression. It uses quantitative data on analysis of variables so the results are statistical aiming to generalize finding. There are two types of data in quantitative research design, categorical variables (vary in type or kind), and quantitative variables (vary in degree, extent or severity) (Mahoney and Goertz, 2006). In the present study, gender and will be categorical variables, while age, rank, level of training, and severity of PTSD will be quantitative variables.

Bryman (2007) discussed barriers to quantitative and qualitative research and suggested the main barrier is it produces statistical relations which are not enough for concurring causations. The research must display correct time order, that is if X cause Y, then Y should have preceded X in time, finally the researcher must rule out all other possibilities other than X causes Y.

Based on the above discussion, the research will conduct a quantitative study design.

Type of the study

A longitudinal study is when the variables for analysis are followed over time (i.e. measured at different points of time); while a cross sectional study is when data are collected once at a given point of time from all units of analysis (veterans). A longitudinal research type is more difficult, time consuming and expensive, whereas cross sectional studies can be a good substitute for longitudinal studies. An example is instead of waiting to the effect of age as a categorical variable on other variable, a researcher can include all ages in a cross sectional study and examine the effect of age on variables (Gerstman, 2008). Therefore, in future work, the researcher will conduct a cross sectional type of study.

Strategy of inquiry

Research strategy of inquiry will be experimental in design, which aims at investigating the possible cause-effect relationship between categorical variables and the quantitative variables. In this case the categorical variable is called the independent variables while other variables will be dependent. Thus, an experimental design identifies the independent and dependent variables pointing to various relationships and statistical aspects of the data obtained. The design of an experimental strategy includes few interconnected activities (Schnika and Velicer, 2003):

1. Formulation of a statistical hypothesis relevant to the scientific one, which may show similarity but rarely identical. A statistical hypothesis is a statement about one or more population parameters or the running functional form of the population.
2. Determination of the independent variable and the dependent ones to record.
3. Determination of the statistical analysis test to perform (significance, correlation or regression).

Research instrument

The research instrument to assess PTSD is Davidson Trauma Scale (DTS). It is a 17 items self-report measure assessing 17 PTSD symptoms as described in the American Psychological Association Diagnostic and Statistics Manual of Mental Disorders (DSM-IV). The scale was developed by Davidson et al (1997) and items are assessed in terms of frequency (5 points scale, 0 is not at all to 4 that is every day) and severity (5 points scale, 0 not at all to 4 that is severely distressing). The scale results in quantitative scores for frequency (0 to 68) and severity (0 to 68), and a total score ranging from 0 to 136. The scale is recognized by the National Center for PTSD assessment (Davidson et al, 1997), and is available at Mental Health Systems, Inc. PO Box 950, 908 Niagara Falls Blvd, North Tonawanda, NY 14120-2060.

The test internal consistency is high for frequency, severity, and total scores. Test retest correlation after two weeks displays no change on an independent measure of clinical improvement. Specifically DTS has the potential of measuring clinical improvement after treatment (Norris and Hamblen, 2004).

Orsillo (2001, p.261) evaluated test convergent validity, sensitivity, specificity and efficiency and sensitivity to treatment effect.

Recent factor analysis studies support 4-factor models of PTSD symptoms that include reexperiencing, avoidance, numbing and hyperarousal. Alternatively, 4-factor models that include intrusion, avoidance, hyperarousal, and dysphoria (hopelessness and unhappiness) are also recognized. McDonald et al (2008) designed a study that examined PTSD symptoms’ structure using DTS in three veteran samples and a 4-factor structural model including reexperiencing, avoidance, numbing and hyperarousal. Results of the study support the use of 4-factor structural model in assessing veterans’ PTSD symptoms (McDonald et al, 2008).

Therefore, SPAN 4-items structural model can be used as an alternative to DTS in assessing PTDS symptoms (Davidson, 2002). This model is a self-reported screening measure derived from DTS and the 4 symptoms assessed are startle (reaction to surprise), physically upset by reminders, anger, and numbing. Its main use is to screen PTDS in a sample of veterans to categorize those who are symptoms’ positive from others with no PTDS symptoms (Davidson, 2002). The SPAN test is available at Multi-Health Systems, Inc. PO Box 950, North Tonawanda, NY 14120-0950.

Because PTSD diagnosis needs an etiological factor, the SPAN 4-items model includes a request to the responder to point the most traumatic event; however, it needs grade four reading level of the respondent to complete it successfully. The test displayed high sensitivity, specificity, and efficiency related to an independent (categorical) variable. The test’s diagnostic accuracy is 88%, and proved convergent validity with the impact of traumatic events scale, besides, being useful in differentiating between respondents and non-respondents to treatment (Davidson, 2002, a).

Data handling

Data sources about veterans will be through the National Personnel Records Center and Military Personnel Records. Available military personnel data will be categorized according to date, field of service, and gender. Personal data will be extracted from the files, and research data will be collected from the questionnaires. Preparing the data for statistical analysis in rough tables classified according to variables recognized will be done under institutional supervision. Data analysis will be done using SPSS statistical social package for social sciences guided by institutional review and the book; SPSS for introductory statistics: use and interpretation (Morgan et al, 2004).

Conclusion

To examine individuals’ risk factors that contribute precipitating PTSD in the framework of gender-related differences in PTSD, the researcher hopes to conduct an exploratory study. The study will be a participatory, cross sectional quantitative and experimental study. The research instrument will be Davidson Trauma Scale and veterans’ data will be collected from the National Personnel Records Center and Military Personnel records. Data preparation and statistical analysis using SPSS statistical social package for social sciences will be guided and by institutional supervision.

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