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Identifying More Effective Treatment for Veterans with Posttraumatic Stress Disorder and

Traumatic Brain Injury: Literature Survey Process

Student Name

School of Psychology, Fielding Graduate University

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Abstract

Veterans continue to battle comorbid posttraumatic stress disorder (PTSD) and traumatic brain

injury (TBI) after leaving the battlefield and returning home. Medical and mental health

providers and researchers continue to support this severely impacted population with new

strategies. Understanding the challenges posed when PTSD and TBI are present is paramount

for designing effective studies and treatments to improve patient outcomes. Furthermore, patient

self-perception of their care must be considered more than ever when the possibility of PTSD

symptomology is present. Alarming but insightful is the possibility that comorbid PTSD and TBI

has unique and more severe symptomology than when diagnosed separately. Collectively, these

factors impact the success rates of veteran treatment. A systematic approach must be taken to

examine the abovementioned challenges to ascertain relationships and joint leverage points that

will produce the most significant and positive results. It is essential to conduct a deliberate and

thorough analysis of existing literature on comorbid PTSD and TBI in veterans to develop

integrated claims across the literature that focus and refine the topic for future study.

Keywords: goal-oriented attentional self-regulation (GOALS), traumatic brain injury

(TBI), posttraumatic stress disorder (PTSD), cognitive symptom management and rehabilitation

therapy and cognitive processing therapy (SMART-CPT), veteran self-perception, gait function

decline
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Identifying More Effective Treatment for Veterans with Posttraumatic Stress Disorder and

Traumatic Brain Injury: Literature Survey Process

Traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD) pose individual

and integrated challenges to veterans. Identifying more effective treatment is paramount for

reducing suicides and overall patient outcomes in this population. Researchers (Jak et al., 2019;

Maruyama et al., 2021) have taken the fight to comorbid PTSD and TBI by developing and

testing strategies to combat these conditions simultaneously. While others (Merritt et al., 2019;

Teutsch et al., 2018) have taken a different approach by trying to segregate the comorbid

symptomology to see if there are unique aspects and different levels of severity that arise when

PTSD and TBI are simultaneously present. As research and treatment improvements continue,

veterans are still struggling. In some cases, the veteran's negative perception of their outlook

induced by PTSD could have tangible detrimental treatment outcomes reinforcing their negative

outlook (Porter et al., 2018). Understanding the relationships of these unique areas is crucial for

refining the research topic and completing a meaningful literature review. Using the literature

survey process proposed by Machi and McEvoy (2019), five articles were reviewed in the initial

literature search for this topic. The intent was to identify evidence-based and warrant-supported

simple claims that could be used to formulate complex claims. Evidence categories were also

identified that refined the focus areas and led to the development of the complex argument for

the thesis.

Exercise 4.1 Data Organization and Claim Development

Exercise 4.1 was divided in three tasks that focused on assembling, organizing, and

analyzing the data from five articles gleaned in previous assignments. The tasks were split across

Tables 1, 2, and 3, with the five articles remaining alphabetically in column one of each table to
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clarify the findings. As each article was input and examined, clear relationships arose regarding

content, topics, and sub-topics. At this point, the most promising cross-relational finding was that

researchers and clinicians in the field have already begun to work towards improved treatment

for veterans exhibiting PTSD and TBI comorbidities with varying degrees of success. Overall,

the findings identified in the tables below will aid in the development of a formal literature

review on this topic and govern additional literature searches to address gaps.

Table 1

Article Data Collection and Assembly

Author Key Citation or Reference Main Ideas Data Quality

Concept
Jak et al., Developed Jak, A. J., Jurick, S., Crocker, L. D., Efficacy of Data was
2019 and tested Sanderson-Cimino, M., Aupperle, R., SMART-CPT accurate, precise,
SMART- Rodgers, C. S., Thomas, K. R., Boyd, B., compared to and authoritative;
CPT for Norman, S. B., Lang, A. J., Keller, A. V., CPT; veteran methods and
comorbid Schiehser, D. M., & Twamley, E. W. (2019). health procedures were
PTSD and SMART-CPT for veterans with comorbid outcomes after thorough and
TBI in post-traumatic stress disorder and history of SMART-CPT rigorous; findings
veterans traumatic brain injury: A randomised used for were logical
controlled trial. Journal of Neurology, comorbid
Neurosurgery and Psychiatry, 90(3), 333- PTSD and
341. [Link] TBI
319315
Maruyama Applied Maruyama, B. A., Abrams, G., Kornblith, E., Veteran health Data was precise
et al., GOALS Posecion, L. F., McQuaid, J. R., Neylan, T. outcomes after and authoritative;
2021 TBI C., Groberio, J., Chen, A. J. -W., & GOALS used standards-based
treatment to Novakovic-Agopian, T. (2021). for comorbid methods were
patients Improvement in executive functioning after PTSD and strictly followed;
with goal-oriented attentional self-regulation TBI; however, they
comorbid training is associated with reduced PTSD emotional were moderately
PTSD hyperarousal symptoms among veterans with improvements accurate since
comorbid PTSD and mild TBI. Applied post-GOALS findings showed
Neuropsychology: Adult. Advance online affect on a relationship but
publication, 1–9. PTSD did not account
[Link] emotional for other factors
531 distress of causality
Merritt et Compared Merritt, V. C., Jurick, S. M., Crocker, L. D., Comorbid Data was
al., 2019 objective Hoffman, S. N., Keller, A. V., DeFord, N., & PTSD and accurate, precise,
and Jak, A. J. (2019). Evaluation of objective and TBI group and authoritative;
subjective subjective clinical outcomes in combat outcome methods and
outcomes veterans with and without mild TBI and perception measures were
for PTSD, PTSD: A four-group design. Journal of poorer than deliberate; results
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TBI, Clinical and Experimental Neuropsychology, objective were supported

comorbid, 41(7), 665–679. results and detailed
and control [Link]
.2019.1610161
Porter et Relationship Porter, K. E., Stein, M. B., Martis, B., PTSD Study did not rule
al., 2018 between Avallone, K. M., McSweeney, L. B., Smith, symptoms out preexisting
PTSD E. R., Simon, N. M., Gargan, S., Liberzon, I., influencing TBI or
symptoms Hoge, C. W., & Rauch, S. A. M. (2018). PCS depression; data
and PCS Postconcussive symptoms (PCS) following symptoms was not entirely
symptoms combat-related traumatic brain injury (TBI) could lead to accurate, precise,
with or in veterans with posttraumatic stress disorder misdiagnosis or authoritative
without TBI (PTSD): Influence of TBI, PTSD, and of TBI
depression on symptoms measured by the
neurobehavioral symptom inventory (NSI).
Journal of Psychiatric Research, 102, 8-13.
[Link]
004
Teutsch et Tested Teutsch, P., Jones, C. E., Kaiser, M. E., Comorbid Data was precise,
al., 2018 physical and Avalon Gardner, N., & Lim, M. M. (2018). PTSD and accurate, and
neurological Gait and conditioned fear impairments in a TBI have authoritative;
behavior in mouse model of comorbid TBI and PTSD. exclusive very detailed
mice for Behavioural Neurology, 2018(4), 6037015– symptoms methods and
PTSD, TBI, 10. [Link] compared to procedures led to
comorbid, individual or significant
and control no diagnosis findings in mice

Note. CPT = cognitive processing therapy; GOALS = goal-oriented attentional self-regulation;

PCS = postconcussive symptoms; SMART-CPT = cognitive symptom management and

rehabilitation therapy and cognitive processing therapy.

Table 2

Article Data Organization

Author Evidence Warrant Scheme and Simple Claim Claim

Categories Simple Arguments Statement Acceptability
(yes or no?;
why?)
Jak et al., CT; CS; IS; OC Joint reasoning SMART-CPT Yes, results
2019 is as effective indicated no
as CPT for significant
treating PTSD difference
symptoms in between the
veterans. two
treatments.
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Maruyama et CT; CS; IS; OC Joint reasoning Hyperarousal Yes, results

al., 2021 PTSD indicated
symptoms are hyperarousal
reduced when symptoms
neurocognitivedeclined as
improvements neurocognitive
post-GOALS function
occur. improved.
Merritt et al., IS; OC; VP Joint reasoning PTSD patients Yes, results
2019 with or indicated a
without other significant
comorbidities relationship
experience between
worse patients with
depression, PTSD and
pain-related, their resulting
and sleep symptoms
symptoms. compared with
other groups.
Porter et al., CS; IS; OC; VP Joint reasoning PTSD and Yes, results
2018 depression indicated a
symptoms significant
influence PCS relationship
more than between
TBI. PTSD and
depression
symptoms
with PCS after
controlling for
symptom
overlap
Teutsch et CS; IS; OC Joint reasoning Comorbid Yes, results
al., 2018 PTSD and TBI indicated
degrades gait significant gait
worse than function
TBI alone in decline
mice. between TBI
only versus
TBI + PTSD
groups.

Note: CPT = cognitive processing therapy; CS = comorbid symptoms; CT = comorbid treatment;

GOALS = goal-oriented attentional self-regulation; IS = individual (PTSD or TBI)

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symptomology; OC = outcomes; PCS = postconcussive symptoms; SMART-CPT = cognitive

symptom management and rehabilitation therapy and cognitive processing therapy; VP = veteran

treatment perception.

Table 3

Article Data Pattern Analysis

Author Simple Claim Warrant Scheme and Complex Claim Statement

Statement Simple Argument
Jak et al., SMART-CPT is as Comparative reasoning SMART-CPT should be
2019 effective as CPT for considered for treating
treating PTSD comorbid PTSD and TBI.
symptoms in veterans.
Maruyama et Hyperarousal PTSD Comparative reasoning GOALS should be
al., 2021 symptoms are reduced considered for treating
when neurocognitive comorbid PTSD and TBI.
improvements post-
GOALS occur.
Merritt et al., PTSD patients with or Comparative reasoning PTSD impacts veteran
2019 without other perceptions of treatment
comorbidities outcomes for PTSD
experience worse and/or TBI more than TBI
depression, pain- impacts outcome
related, and sleep perceptions.
symptoms.
Porter et al., PTSD and depression Divergent reasoning NSI and other assessments
2018 symptoms influence that measure PCS for TBI
PCS more than TBI. diagnosis should be used
with caution due to PTSD
and depression symptom
influence masking
potential psychological
disorders as opposed to
brain trauma.
Teutsch et Comorbid PTSD and Comparative reasoning Comorbid PTSD and TBI
al., 2018 TBI degrades gait result in worse physical
worse than TBI alone and psychological
in mice. symptoms than a single
diagnosis.
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Note: CPT = cognitive processing therapy; GOALS = goal-oriented attentional self-regulation;

NSI = neurobehavioral symptom inventory; PCS = postconcussive symptoms; SMART-CPT =

cognitive symptom management and rehabilitation therapy and cognitive processing therapy.

Exercise 4.2 Evaluating an Argument

Simple Argument Evaluation

Soundly Reasoned?

All five of the simple arguments were soundly reasoned. The supporting evidence in each

article led to the creation of unambiguous claims. More than one simple claim was evident for

every article based on how the evidence could be applied. With such diverse evidentiary

applications, identifying warrants for each claim was straightforward. What appeared to be the

primary claim or the claim that supported the complex argument the most was selected for input

into Table 2 and repeated in Table 3.

Supported by Evidence?

Each simple argument was evaluated against the summaries of results and supporting

data in the articles. Evidentiary support was a prerequisite for identifying simple claims to

understand their potential relationship with the authors' complex claims. The evidence was

presumed accurate based on recent publication in peer-reviewed journals. Additionally,

limitations in the studies were compared with the findings to see if the data could reasonably be

accepted. When developing the simple claim for Maruyama et al. (2021), special attention was

paid to the wording of the simple claim regarding the relationship between hyperarousal

symptom reduction and neurocognitive improvements to avoid the misconception that the latter

was solely responsible for the former. Limitations in Maruyama et al.’s (2021) study did not
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address other factors that could impact hyperarousal symptom reduction. The authors only found

that a relationship existed between the two outcomes.

Correctly Warranted?

Sound reasoning patterns were inherent to each simple claim. As noted above, diverse

applications for the evidentiary findings in the articles meant that each simple argument had

more than one piece of supporting evidence that, when added together, formed the simple claim.

Therefore, joint reasoning was the prevailing reasoning for the simple arguments with consistent

progression and logical conclusions for each.

Require Warranting or Discarding?

None of the simple claims listed in Table 2 or 3 need to be discarded or warranted. All

the claims were selected based on their evidentiary support and strong warrant. Additionally,

each simple claim supported the broader evidence categories in column two of Table 2 for their

respective argument. Each article differed in how many simple claims could be derived from the

supporting evidence with varying credibility. However, to establish a solid foundation for

complex claims, the simple claims listed above represented the soundest, best supported with

evidence, least ambiguous, and most overarching for the literature review topic of the claims

analyzed.

Complex Argument Evaluation

Complex Argument for Thesis

Recent strategies for treating comorbid PTSD and TBI in veterans have shown promise to

improve patient symptoms, but these strategies are still emerging and under-evaluated. Multiple

factors still exist that degrade treatment outcomes for veterans with comorbid PTSD and TBI. A

unique and complex symptomology exists for comorbid PTSD and TBI that is not observed in
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the individual disorder (i.e., PTSD) or trauma diagnosis (i.e., TBI). Veterans perceive their

treatment outcomes for PTSD or comorbid PTSD and TBI as less effective due to stronger

influences from their PTSD than TBI. Failure to address the influence of PTSD symptoms on

postconcussive symptoms (PCS) can lead to misinterpretation of cognitive functioning

assessments and overall misdiagnosis.

Foundational Premises

Impacts on physical function and neurobehavioral activity worsen when comorbidities in

PTSD and TBI are present. Comorbid treatments have been developed that are more effective

regarding certain aspects of comorbid PTSD and TBI treatment than holistic treatment. Veterans’

self-perception regarding treatment outcomes is susceptible to negative influences from PTSD.

When conducting neurocognitive assessments with potential underlying PTSD comorbidities, a

detailed analysis of the results must be conducted that cross-references psychopathology

symptoms.

Warrant to Premises

The premises that comprised the complex argument for the thesis were developed by a

systematic process of argument construction and deconstruction to ensure accuracy and validity.

This process was initiated by analyzing the evidence categories in Table 2, examining

commonalities in the simple claims in Table 3, and ultimately restructuring the complex claims

statements in Table 3 to develop the complex argument for the thesis. The foundational premises

were then extrapolated from the complex argument and evaluated to see if they could stand

independently. Comparisons were drawn with the original research that supported each

foundational premise. Additional examination explored potential inferential or evidence-

supported relationships from the other articles in the corresponding evidence categories. In

doing
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so, this argument construction and deconstruction process ensured that foundational premises

had both warrant and evidence to support the thesis.

Logic Scheme, Reasoning Pattern, Logicalness, and Warrant

At this point in the process, side-by-side reasoning was the primary reasoning pattern in

the logic scheme. All the premises went through extensive analysis for evidentiary support,

stand-alone value, categorical significance, and overall relevance for identifying effective

treatment outcomes for veterans with comorbid PTSD and TBI. Each premise had enough power

to support the overall topic while collectively and accurately describing the major hurdles to

effective treatment in the complex argument for the thesis. Therefore, the foundational premises

were strong enough to remain independent and not require the additive power of chain or joint

reasoning. The cumulative effect was a complex argument that was logical and supported by

multiple premises that shape the complex warrant from individual and integrated perspectives.

Areas to Improve

A symbiotic relationship existed between the simple claims and complex argument that

made them relevant in their current form. Therefore, nothing strayed from the topic or required

deletion at this point. Two categories were identified that, if examined deeper, may provide

additional insight. First, finding a third treatment that has shown promise in treating comorbid

PTSD and TBI in veterans or any patient would broaden current treatment understanding and

strengthen the comorbid treatment (CT) evidence category. Second, the confidence in the veteran

treatment perception (VP) evidence category could be raised with additional data discovered

about veteran perception impacts to care.

Reflective Exercise Responses

Mindset
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Staying focused while reading the content and working through the exercises in Chapter

4 of Machi and McEvoy's (2019) text was relatively easy. Using five articles selected for my

literature review topic made the assignment much more interesting. No issues were encountered

when applying the concepts in the text to my research topic.

Understanding

Machi and McEvoy’s (2019) method of organizing and analyzing material was not a new

concept for me. I would have no problem using their method again to successfully list, order, and

review information from additional sources. The same is true for applying warranting rules and

logic schemes. Forming complex claims from simple claims was the most beneficial aspect of

this assignment, which I will apply in different areas of my writing and research.

Learning

At this point, I am confident I can utilize the articles that I have identified thus far to

complete my literature survey. The evidence categories that manifested from the Chapter 4

exercises are detailed and broad enough to cover the primary areas of my research topic as I see

it now. Reasoning pattern analysis was the least helpful of the concepts. Perhaps this because my

articles were all empirically based and heavily data-driven, resulting in straightforward

reasoning patterns. Furthermore, in qualitative studies, literature reviews, non-peer reviewed, or

less credible sources, I can see where understanding logic schemes and reasoning patterns would

be more fruitful. Despite my thoughts regarding applying reasoning patterns to my articles in

these exercises, I could apply them to future sources of information with little trouble. Again,

using simple claims as building blocks for more complex arguments was the most beneficial

concept in Chapter 4. Taking the next step to build an argument of discovery is something I

could accomplish in the future based on what I learned and practiced.

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Reflect to Correct

Chapter 4 was the most straightforward so far. Nothing resonates that I need to focus on

to apply the concepts in Chapter 4. Overall, the method was more different than new. In this

manner, the material was not any more wrong or right. I enjoyed the different perspective and

process for analyzing and cataloging information. Based on how Machi and McEvoy (2019)

defined and detailed a literature survey, I could repeat the same process on another topic with

limited challenges. A more precise discovery argument will be produced with additional

literature searches that focus on some of the areas I detailed above. Of course, an improved

discovery argument is predicated on finding information of value and relevance as opposed to

simply finding information.

Conclusion

Identifying effective treatment outcomes for veterans with comorbid PTSD and TBI is

challenging. As this brief literature survey exercise highlighted, many integrated factors

negatively impact treatment outcomes. Specifically, patients and providers must understand how

PTSD can negatively influence a patient’s self-perception of their care and lead to actual

detrimental care outcomes. PTSD also can lead to misdiagnosis of trauma-induced injuries when

not properly assessed. Furthermore, comorbid PTSD and TBI exhibit more severe symptoms that

can degrade treatment. Finally, emerging strategies that show promise in simultaneous treatment

exist but require significantly more evaluation. The five articles examined in this literature

survey laid a stable foundation for which additional literature searches and analyses will

augment an effective literature review.

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References

Jak, A. J., Jurick, S., Crocker, L. D., Sanderson-Cimino, M., Aupperle, R., Rodgers, C. S.,

Thomas, K. R., Boyd, B., Norman, S. B., Lang, A. J., Keller, A. V., Schiehser, D. M., &

Twamley, E. W. (2019). SMART-CPT for veterans with comorbid post-traumatic stress

disorder and history of traumatic brain injury: A randomised controlled trial. Journal of

Neurology, Neurosurgery and Psychiatry, 90(3), 333-341. [Link]

2018-319315

Maruyama, B. A., Abrams, G., Kornblith, E., Posecion, L. F., McQuaid, J. R., Neylan, T. C.,

Groberio, J., Chen, A. J. -W., & Novakovic-Agopian, T. (2021). Improvement in

executive functioning after goal-oriented attentional self-regulation training is associated

with reduction in PTSD hyperarousal symptoms among veterans with comorbid PTSD

and mild TBI. Applied Neuropsychology: Adult. Advance online publication, 1-9.

[Link]

Merritt, V. C., Jurick, S. M., Crocker, L. D., Hoffman, S. N., Keller, A. V., DeFord, N., & Jak,

A. J. (2019). Evaluation of objective and subjective clinical outcomes in combat veterans

with and without mild TBI and PTSD: A four-group design. Journal of Clinical and

Experimental Neuropsychology, 41(7), 665–679. [Link]

.2019.1610161

Porter, K. E., Stein, M. B., Martis, B., Avallone, K. M., McSweeney, L. B., Smith, E. R., Simon,

N. M., Gargan, S., Liberzon, I., Hoge, C. W., & Rauch, S. A. M. (2018). Postconcussive

symptoms (PCS) following combat-related traumatic brain injury (TBI) in veterans with

posttraumatic stress disorder (PTSD): Influence of TBI, PTSD, and depression on

LITERATURE SURVEY PROCESS 15

symptoms measured by the neurobehavioral symptom inventory (NSI). Journal of

Psychiatric Research, 102, 8-13. [Link]

Teutsch, P., Jones, C. E., Kaiser, M. E., Avalon Gardner, N., & Lim, M. M. (2018). Gait and

conditioned fear impairments in a mouse model of comorbid TBI and PTSD.

Behavioural Neurology, 2018(4), 6037015–10. [Link]

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I affirm that this is my original work and has not been copied or plagiarized from

any other sources, nor has it been previously submitted for academic credit. This

electronic message counts as my signature. Student Name