Comparative Study of Cognitive Behavior Therapy and Virtual Reality Exposure Therapy for PTSD Patients

doi:10.21203/rs.3.rs-3897225/v2

INTRODUCTION: Posttraumatic stress disorder (PTSD) is a severe and multifarious anxiety disorder precipitated by exposure to psychotically stressful events that affects 5 to 10% of the population (Yehuda et al., 2015). It is characterized by constant disturbing memories about the traumatic event, consisting of escaping stimuli associated with the disturbance and persistent symptoms of increased stimulation. PTSD can be triggered by either bodily trauma or psychological trauma (APA, 2013). Among the most common traumatic I-e traffic accidents, earth quakes, floods, rape, and all other psychological problems, PTSD is most common (Huang, et al., 2010).

OBJECTIVEV: The objective of the present study was to analyse the effectiveness of cognitive therapy and EMDR therapy for PTSD patients with posttraumatic stress disorder.

MATERIAL AND METHODS: A purposive sampling method was used. Samples consisted of thirty known posttraumatic stress disordersamples taken from Nishtar Hospital Multan. TheMississippi Scale for Combat Related Post-Traumatic Stress Disorders (Keane et al., 1988) was used to measure the severity of posttraumatic stress disorder. Three groups were established as group one (A), in which ten patients were provided cognitive therapy. The second ten groups (B) were subjected to eye movement desensitization and reprocessing (EMDR). The third group was used as a control.

RESULTS: SPSS version 26 and an independent t test were used to determine the significance of the therapeutic efficacy. The results revealed a significant difference in the number of patients in the experimental group who received cognitive behaviour therapy (t=-3.588, df=18, p>0.05). Systematic desensitization for posttraumatic stress disorder (t=--2.527, df=18, p=0.05) was concluded.

Conclusions: Cognitive behaviour therapy is more effective for the rapid and better management of PTSD.

Psychology

PTSD

cognitive therapy

purposive sampling

exposure

EMDR

Occurrence of any traumatic event, such as a serious car accident, witnessing a murder or being raped. Alternatively, a series of emotionally overwhelming events can affect us like shock waves through every aspect of our lives. They can damage our psychological stability and take away our sense of wellbeing. Uncontrollable, devastating experiences usually generate feelings of being unsafe, powerless, and vulnerable (Helzer et al., 1987). These conditions can cause symptoms called posttraumatic stress disorder (PTI), which can be as powerful and difficult to cope with as can any other psychological disorder. A traumatic event may be an ongoing repetitive event, such as ongoing incest combat. Trauma may be physical, psychological, or a combination of both. Posttraumatic stress disorders, like symptoms, have also been recognized in combat veterans of much military conflict, but the current understanding of posttraumatic stress disorder dates from the 1970s, largely as a result of the problems that were still being experienced by US military veterans of the war in Vietnam (Mills et al., 2011).

The purpose of the present study was to analyse the effectiveness of cognitive therapy and systematic desensitization in patients with posttraumatic stress disorder. It is assumed that there might be a strong effect of cognitive behaviour therapy and systematic desensitization on PTSD among victims. Traumatic events that may cause PTSD symptoms to develop include cruel assault, kidnapping, sexual assault, and torture; being a criminal prisoner of war or attention camp victim; experiencing a disaster; violent automobile accidents; or getting a diagnosis of a life-frightening illness (APA, 2013).

Cognitive behavioural therapy is a form of psychotherapy or can be called conversation therapy. The aims of cognitive behaviour therapy are to solve problems such as focusing on abnormal and dysfunctional feelings of emotions, actions, behaviour and cognitions through a goal-oriented approach and behaviour targeted through systematic procedures in the present condition. Concepts have been traced as far as the writings of the Greek Stoic philosophers and have been linked to a number of other influences, including the phenomenological thought of philosophy (Smithet al., 2007).

A variety of stress disorders, including acute, chronic and delayed onset disorders recently used for posttraumatic stress disorder, could more fully describe the phenomenology of those who are survivors of trauma and have very important management ramifications. In addition to moving beyond away from anxiety-provoking symptom re-presentation and improving recovery among survivors of traumatic stress, cognitive behaviour therapy for trauma is regarded as an approach to other commonly observed serious psychological, disruptive and interpersonal problems. Despite the consequences of the diagnostic scheme used, the epidemiological and taximetric results argue for distinct assessments of and multielement management for the multidimensional character of posttraumatic pathology (Mendes, et al., 2008).

Systematic desensitization is a kind of behaviour therapy technique used in the field of psychology to promote effective management of fear and phobias and for other anxiety disorders. To start the procedure of systematic desensitization, the client must first be taught relaxation skills training to address fear and anxiety reactions to specific phobias. Once the individual has been an expert on these skills, he or she must use them to react to and overcome situations in an established hierarchy of fear. The goal of this process is for an individual to learn to address and overcome phobia at each step of the hierarchy, which helps individuals deal with the last step of the phobia in the hierarchy (Frank, et al., 1988).

Participants

Purposive and convenient sampling was carried out for the recruitment of participants. Thirty diagnosed clients were also assessed for PTSD according to the DSM 5^TH criteria and were selected for psychotherapy, and one group (10) was taken as the experimental group for cognitive therapy. Changes in negative thoughts caused by changing behavioural techniques (Leahy, 2006) were used in eight sessions. The second experimental group (10) was subjected to systematic desensitization in eight sessions. The third group (10) was used as the control group, and no therapy was applied. The age range was between 20 and 60 years. The data were taken from Nishtar Hospital (psychiatry ward). Demographic information was also used to obtain personal information about the respondents, such as sex, age, education, socioeconomic status and marital status.

QUESTIONAIRE

The Mississippi Scale for Combat Related Posttraumatic Stress Disorder (PTSD) developed by Keane et al. (1983, 1988) was used for this study. The NRS-2002 was constructed to measure the subjective reports of dreadful situations, wartime stressors experienced by combatants and natural disasters. The Mississippi Scale for Combat Related Posttraumatic Stress Disorders (MSS) consists of 39 items, and each item receives a score ranging from 1-5. The following items are reverse scored: 2, 6, 11, 17, 19, 22, 24, 27, 30, and 34. These scores are added to obtain the total score, which correctly classifies 90% of all participants as PTSD or non-PTSD. The means for the three validation groups were as follows: PTSD, 130 (SD=18); PSYCH, 86 (SD=26); and well-adjusted, 76 (SD=18).

PROCEDURE

Prior permission was obtained from the participants to assess the effectiveness of cognitive therapy and systematic desensitization for patients with posttraumatic stress disorder, and the purpose of the study was explained. The purposive and convenient sampling technique was used for data collection. Eighty-two participants were taken from different areas with posttraumatic stress disorder. Patients were instructed to feel free if they had any queries and to carefully complete the questionnaire without skipping any statements; eighty of those patients met the criteria for posttraumatic stress disorder. Only 30 agreed to participate in the research process. Three groups were established—one as an experimental group with cognitive therapy. Patients were advised to change their negative thoughts by changing their behaviour during eight sessions. In the second experimental group, systematic desensitization was applied during eight sessions. The third group was the control group. The Mississippi Scale for Combat Related PTSD was used for the diagnosis of PTSD after translation in Urdu. For this purpose, the back translation method was adopted, and Cronbach’s alpha reliability was calculated as .928. Changes in negative thoughts resulting from changing behaviour (cognitive therapy) were applied to follow the therapist’s aims for the session, which were to make the client’s treatment goals more concrete and to provide a management plan for fallowing (Ehlers, et al., 2010). Systematic desensitization is a type of behavioural therapy used more specifically; it is a type classical conditioning therapy developed by a South African psychiatrist (Joseph Wolpe.1958). The goal of this process is for an individual to learn to cope with and overcome fear in each step of the hierarchy, which will lead to overcoming the last step of fear in the hierarchy (Kleim et al., 2013). Videos were made only for those clients who agreed to make their videos. Images and tape recordings were also taken.

Table 1:

Differences in Posttraumatic Stress Disorder between the Experimental Group after Cognitive Behaviour Therapy and the Control Group (N=20)

Groups

PTSD

n

M

SD

t(18)

p

95% CI

LL UL

Cohen’s d

Experimental group

10

93.6000

19.25386

-3.588

0.000***

[-42.65131, -11.14869]

-1.691399

Control group

10

120.5000

13.83434

CI=confidence interval, ***p>0.001

Table 1 shows that there was a significant difference in posttraumatic stress disorder scores between the two groups after applying cognitive therapy and the control group on the Post-Traumatic Stress Disorder Scale (t=-3.588, df=18, p>0.05). The results showed that the severity of posttraumatic stress disorder was lower in the experimental group after receiving cognitive therapy than in the control group.

Table 2:

Differences in Posttraumatic Stress Disorder between the Experimental Group and Systematic Desensitization Group and Control Group (N=20)

Groups

PTSD

n

M

SD

t(18)

p

95% CI

LL UL

Cohen’s d

Experimental group 2

10

106.0000

11.73788

-2.527

0.0105**

[26.55363,

-2.44637]

-1.19123

Control group

10

120.5000

13.83434

CI=confidence interval, **p>0.0005

Table 2 reveals the significant difference in scores between the experimental group and the control group on the Post-Traumatic Stress Disorder Scale (t=--2.527, df=18, p=0.05). The results showed that the severity of posttraumatic stress disorder was lower in the experimental group after receiving psychotherapy than in the control group.

Table 3:

Differences in Posttraumatic Stress Disorder between the Two Groups after Providing Cognitive Behaviour Therapy and Systematic Desensitization (N=20)

Groups

PTSD

n

M

SD

t(18)

p

95% CI

LL UL

Cohen’s d

group 1

10

89.0000

12.20200

-3.175

0.0025**

[-2.824860,

-5.75140]

1.496709

group 2

10

106.0000

11.73788

CI=confidence interval, **p>0.0005

Table 3 reveals the significant difference between the scores of both groups after receiving one session of cognitive therapy and after receiving the second session of systematic desensitization on the Scale of Posttraumatic Stress Disorder (t=--3.175, df=18, p=0.005). The results showed that the severity of posttraumatic stress disorder was lower in the group after receiving the cognitive behavior psychotherapy technique than in the group after receiving systematic desensitization.

Table 4:

Differences in posttraumatic stress disorder scores before and after cognitive therapy (n=10)

Groups

PTSD

n

M

SD

t(9)

p

Pre-Testing group 1

10

133.20000

4.10420

10.799

0.00025**

Post-Testing group 1

10

89.0000

12.20200

CI=confidence interval, *p>0.0005

Table 4 reveals the significant differences in the scores of the groups on the Posttraumatic Stress Disorder Scale before and after cognitive therapy on the Scale of Posttraumatic Stress Disorders (t=10.799, df=9, p=0.0005). The results showed that the severity of posttraumatic stress disorder was lower in the group that received cognitive therapy than in the group that did not.

Table 5:

Differences in posttraumatic stress disorder prevalence between pretest and posttest results in the second group after SD was performed (n=10)

Groups

PTSD

n

M

SD

t(9)

p

Pre-Testing group 2

10

129.8000

3.11983

10.664

0.00025**

Post-Testing group 2

10

102.50

10.662

*p>0.0005

Table 5 reveals the significant difference in scores before and after SD on the Post-Traumatic Stress Disorder Scale (t=10.662, df=9, p=0.00025). The results showed that the severity of posttraumatic stress disorder was lower in Group 2 after SD than before therapy.

Posttraumatic stress disorder is the most common post disaster psychiatric disorder. These infections can arise in volcanoes, earthquakes, outbreaks or fires in large contexts. Posttraumatic stress disorder is the most often diagnosed disorder after trauma, and it can persist for many years (Abramowitz et al., 2003). This research was undertaken to investigate the effectiveness of cognitive therapy and systematic desensitization in patients with post-traumatic stress disorder. Overall, the findings suggest that cognitive therapy and systematic desensitization are both effective and helpful for the management of posttraumatic stress disorder victims. The results of the present study suggested that cognitive behavior therapy is more effective for treating posttraumatic stress disorder. Research has shown that cognitive behavior therapy is a very important therapy for anxiety disorder and is significantly superior to information-based therapy for reducing panic attacks in patients with panic disorder and secondary depression (Laberge et al., 1993).

Other research findings support the hypothesis that cognitive behaviour therapy is effective for treating posttraumatic stress disorder following terrorist attacks, for example, in the survivors of the 9/11 terrorist attack on the World Trade Center For the victims of the World Trade Center attack, cognitive therapy for posttraumatic stress disorder was applied flexibly, in 12–25 sessions, by therapists with no prior training through extensive training in cognitive behavior therapy. There were significant pre-post reductions in symptoms of posttraumatic stress disorder and depression (Malta et al., 2007).

Posttraumatic stress disorder was also treated with cognitive behavior therapy in 1998 in the bomb explosion in Omagh, Northern Ireland. Patients with posttraumatic stress disorder secondary to the bomb explosion in Omagh received an average of eight treatment sessions by staff with modest prior training in CBT for PTSD. However, the degree of improvement was comparable to that in reported research trials, although almost half of the patients (53%) had psychiatric comorbidity (Gillespie et al., 2002).

In conclusion, cognitive behaviour therapy may be more effective for the management of posttraumatic stress disorder than systematic desensitization is. The results showed a significant reduction in posttraumatic stress disorder after the application of cognitive behavior therapy. Although systematic desensitization is also effective for the management of posttraumatic stress disorder, as shown by the reduction in the posttraumatic stress disorder scale score, compared to cognitive behaviour therapy, systemic desensitization is a less effective therapy because of the reoccurrence of symptoms PTSD. Gender differences cannot be drawn because the sample size was small.

LIMITATIONS

The overall findings of this study are encouraging, yet it is very important to acknowledge its limitations as well. The most important weakness of the present study was the following. The sample size was very small due to the refusal of the subjects to participate in therapy. The other weakness is that sex differences cannot be measured due to the refusal of male participants to participate in the research. The scale was not culturally adapted.

IMPLICATIONS AND SUGGESTIONS

The results of the present study provide unique information for further research in this area, but much research has yet to be carried out to further strengthen the results. These findings might help researchers understand the importance of cognitive behavior therapy in the management of posttraumatic stress disorder, but they should keep in mind that some education is necessary for clients to understand the concept of cognition and cognitive behavior therapy. Systematic desensitization is also helpful for the management of systematic desensitization, but for researchers, environmental control is a very important aspect of the application of systematic desensitization because the client can regress toward the past inspiration of the healing past, so the researcher can be trapped in trouble bringing back the client to the present.

There is also a need to first learn from the client about the relaxation therapy and assess the client first that if the relaxation is properly working, then SD can be applied so that proper training and assessment are necessary for the client to see the effects of SD.

The effects of socioeconomic status on the effectiveness of cognitive therapy and SD need to be studied. It is suggested that a large sample size be used to increase the statistical power of the analysis.

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The authors declare no competing interests.

Comparative Study of Cognitive Behavior Therapy and Virtual Reality Exposure Therapy for PTSD Patients

Status:

Version 2

Abstract

Figures

INTRODUCTION

METHODOLOGY

RESULTS

DISCUSSION

CONCLUSION

References

Additional Declarations

Status:

Version 2