@2024 Afarand., IRAN

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ISSN: 2008-2630    Iranian Journal of War & Public Health 2017;9(4):169-175

Background
The main feature of Post-Traumatic Stress Disorder (PTSD) is that a person experiences a traumatic event, followed by a disturbance that lasts for more than a month [1].
Previous Studies
Symptoms of PTSD disrupt the occupational, social, and educational performance of people with this disorder and disrupt their lives [2]. … [3-6]. One of the risk factors for PTSD after exposure to injury is the reduction of executive function. … [3-6]. One of the risk factors for PTSD after exposure to injury is the reduction of executive function. … [7-19]. In a study, it was found that people with PTSD had lower performance than those who suffered from harm [20]. … [21]. Another risk factor for PTSD after experiencing injury is experiential avoidance. … [22]. Studies have shown that continuous use of experimental avoidance exacerbates the symptoms of PTSD [23]. … [24-26]. In a study, it was concluded that empirical avoidance was significantly associated with a decrease in positive interactions and inappropriate behavior and psychological disturbances in people with PTSD [27]. … [28-39].
Aim(s)
The aim of this study was to determine the effectiveness of cognitive-behavioral therapy on performance and experimental avoidance of veterans with posttraumatic stress disorder.
Research type
This quasi-experimental research was carried out in pretest and posttest form with control group
Research society, place and time
The population included all veterans of posttraumatic stress disorder hospitalized in Qods Hospital in Sanandaj city (as the only referable center for these patients) in the second half of 2016.
Sampling method and number
Sampling method was in form of convenience sampling method. Visitors to this center initially responded to the Wisconsin Card Classification Test (WCST) and the experiential avoidance questionnaire. A total of 40 people who obtained higher scores in the questionnaire were selected as sample and then randomly assigned into two experimental and control groups (20 participants in each group). Having a diagnosis of post-traumatic stress disorder by a psychiatrist was based on a psychiatric assessment. Therefore, there was no need to implement a post-traumatic stress disorder inventory and clinical interview. In order to meet the conditions for homogeneity of the groups, entry and exit criteria were observed. In the absence of severe physical and psychiatric disorders, non-addiction, the least literacy of reading and writing, as well as non-intake of drugs or other mental interventions simultaneously, the inclusion criteria were the subjects and the absence in more than one-third sessions of treatment, lack of cooperation and not doing assignment were the exclusion criteria of the subjects.
Used devices&materials
The following tools were used to collect information: Wisconsin Card Sorting Test (WCST): This questionnaire was used to measure executive function. The Wisconsin card sorting test is one of the most widely used method for evaluating executive performance (assessment of path route and achievement) [40]. This test consists of 128 non-similar cards with different shapes (triangle, star, cross, and circle) in different colors. To run the test, first, 4 template cards are placed in front of the subject. The examiner first considers the color as the principle of categorization without telling the subjects and asking him to put all the cards one by one under four template cards. After the attempt, the subject is told that his placement is correct. If the subject can consistently set a correct category of 10 cards, the classification principle will change, and this principle will be categorized as “shape”. The key change will only be done by changing the feedback pattern of “yes” and “no”. Thus, the correct answer in the new principle is considered to be the wrong answer. The next principle is the number and after that the principles are repeated accordingly. The test is stopped when the subject can successfully classify six classes correctly. For this test, it is possible to calculate several scores that two scores of this test are more important: 1) Failure errors: This type of errors are observed when the subject, in spite of the change in principle, continue the sorting based on the previous principle, or in the first series, do the sorting based on an incorrect guess, and despite receiving the “no” feedback, continues his incorrect response. 2. The number of errors: it includes the number of errors that occur after considering the new rule and receiving feedback from the subject. In this study, two main indicators of total number of errors and number of failures were used. Reliability between the assessment of this test is excellent and higher than 0.83. 2. Acceptance and Action Questionnaire (AAQ): This questionnaire was used to measure empirical avoidance. The acceptance and action questionnaire has been constructed as a tool for measuring empirical avoidance and psychological inflexibility. This tool has 16, 49, 90, and 10-questions versions and is a useful tool for assessing empirical avoidance and treatment outcomes of acceptance and action [42]. The 10 question version of acceptance and action questionnaire, has been designed and validated to solve the problems related to the weakness of the psychometric properties of its various versions. This questionnaire measures empirical avoidance on a seven-point scale from one (never true) to 7 (always true). For the 10 question version of this questionnaire, internal consistency reliability of this questionnaire was 0.84, and test-retest reliability has been r=0.81 after three months and r=0.79 after 12 months) and the construct validity of the questionnaire has been high. The researchers reported that higher scores in this questionnaire were correlated with symptoms of depression, anxiety, stress, suppression of thoughts and psychological disturbance [42]. After receiving written and verbal consent from veterans for not receiving other psychotherapies and not taking self-administrated medication for three months, mentioning the confidentiality of all information, therapeutic sessions with emphasis on voluntary and free attendance of cognitive-behavioral treatment were conducted. For the experimental group, group therapy was conducted with 10 sessions during three months and each session was 1.5 hours. For the second group, no training was provided as a control group (Table 1). For both groups, before implementation, pretest and after the implementation, posttest were implemented. Data were analyzed by SPSS 20 software. In order to check the normal distribution of scores, Kolmogrov-Smirnov test was used. To test the homogeneity of variance between dependent variables, Levine's test and to examine the homogeneity of covariance, box test were used. Using multivariate analysis of covariance analysis, the difference between the two experimental and control groups in terms of the difference between the pretest and posttest scores in dependent variables (executive function, empirical avoidance) were studied.
Findings by Text
The mean age of patients with posttraumatic stress disorder in the experimental group was 55.74±7.94 years and in the control group, it was 45.43±8.53 years, and the mean duration of their presence in the war was 43.21±3.26 and 49.36±5.42 months respectively. The mean posttest of the experimental group was significantly lower than control group in terms of the number of classes and the failure error. While no significant change was observed from the pretest to the posttest. After controlling the pretest scores, there was a significant difference between the control and experimental groups in terms of number of classes (f=172.54), failure error (f=59.12), and experimental avoidance (f=14.16; p<0.001; Table 2).
Main comparison to the similar studies
The findings of this study showed that cognitive-behavioral therapy has been effective in improving performance and experiential avoidance in the post-test phase. These results were consistent with the findings of Berner et al. [19], Olf et al. [20], Johnson et al. [21], Basharpour et al. [26], Brookman et al. [27], and Bardin et al. [28]. The results of these studies have shown that changes in symptoms of panic during treatment have led to increased psychosocial flexibility and reduced avoidance of frightening experiences [43]. … [44-46].
Suggestions
Considering the efficacy of CBT therapy for PTSD symptoms and improving experiential avoidance and performance, it is recommended that these services be used in health centers in Iran, such as mental hospitals. It is also recommended to use this therapy to treat other psychiatric disorders associated with PTSD.
Limitations
Among the limitations of the present research, it was not possible to conduct a follow-up and convenience sampling method. Also, due to the unique gender of this study, the generalization of its finding to women and other cultures and other disorders should be cautious.
Conclusions
Cognitive-behavioral therapy is effective on increasing the executive function and reducing the experimental avoidance of veterans with posttraumatic stress disorder.
Acknowledgments
We are grateful for the cooperation and warmth of the staff of the Qods Hospital in Sanandaj City and the participating veterans in this research.
Conflict of interest
Non-declared
Ethical Permissions
Confidence about the confidentiality of information and the preparation of individuals for mental and psychological research to participate in the research were ethical consideration observed in this research.
Funding Sources
The financial credibility of this research has been provided by the authors.

TABLES and CHARTS

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