Single System Research Design (SSRD) Paper

A Single System Research Design Paper on the Use of CBT in Reduction of PTSD Symptoms
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Abstract
Mental health issues are often ignored due to embarrassment from most persons experiencing them. As such, individuals who seek professional help have made a bold move and should be appreciated. Post-traumatic stress disorder (PTSD) is one psychological condition affecting millions of Americans and other citizens worldwide. Traumatic memories trigger the onset of PTSD and can arise as a result of witnessing acts of violence, rape, murder, war, and horrific accidents. Soldiers returning from wars have been prone to suffering this condition although some symptoms may take longer to emerge (Rosen et al., 2010). The military is, therefore, the largest unit to dedicate resources for treatment of PTSD due to these high prevalence rates. Among the numerous treatment options, the most common is cognitive behavioral therapy (CBT). Studies show that CBT greatly reduces symptoms of PTSD such as anxiety and although the treatment is mainly carried out for a short time (a couple of weeks) the impact on most patients lives has been proven to be long-term.
Keywords: Post-traumatic stress disorder, cognitive behavioral therapy, baseline
The Efficacy of CBT Treatment in Reduction of Panic Attacks and Other PTSD Symptoms
Introduction
The paper is an investigative piece on PTSD among military officers. We will concentrate on Tammy, a Navy reserve military officer who on returning from Afghanistan after serving in a confinement facility for one year has been diagnosed with PTSD.

It is imperative that we will define PTSD, its symptoms, and prevalence and thus have a clear impression on the subject matter of discussion.
In recent times, individuals have displayed characteristics of anxiety, stress, panic attacks, and insomnia after experiencing traumatic events in their lives. The trauma may have occurred as a result of violent attacks such as rape, robbery, terrorism and in the case of military officers; loss of comrades in the battle-field, combat or injuries. Traumatic events lead to a situation where the memories recur numerous times in the patient’s life, and the individual is, therefore, diagnosed with PTSD (Tuerk et al., 2011). These memories may never disappear from the patient’s mind and would most probably get worse making the patient appear withdrawn and, therefore, requiring medical intervention. Further, the continued exposure of a person to these symptoms such as nightmares, insomnia may lead to engagement of individuals in anti-social behavior such as alcohol and substance abuse. This creates the need for implementation of an intervention program as fast as possible on Tammy to avert such a disastrous occurrence in her life.
To treat the PTSD symptoms experienced by Tammy I have decided to begin CBT treatment after a two-weeks observation period to determine the extent of the disease. CBT involves a series of programs that involve the engagement of a patient’s mind by encouraging them to remember the traumatic memories and with the help of a social worker, the patient is advised to embrace these thoughts as part of their lives and thus reduce the feelings of panic or depression with every session. Further, the mental health worker offers hope and a feeling of wellness and thus renewing optimism and hope in the patient’s life.
Statement of the Problem
The case study in this paper is about an individual named Tammy, who works in the justice department. In the recent past, she worked as a Navy reserve officer and was posted to a confinement facility in Afghanistan for one year. In prisons and during the wars, such as in this case, it is unavoidable that a person may witness torture, death, and injuries being meted upon inmates to extract information. Further, Tammy may have experienced other war-related activities such as loud explosions, close combat, death or injuries of her comrades et cetera. All these have created a situation whereby upon return from military service, Tammy now experiences frequent panic attacks, insomnia, depression, and anxiety all of which have led to her diagnosis of PTSD.
It is imperative, therefore, that the social worker formulates a plan to enable Tammy to counter these traumatic memories that induce nightmares, anxiety and other symptoms. The goal of this study is to establish an intervention for reducing the frequent traumatic thoughts by using these thoughts to positively influence Tammy’s life. The acceptance of negative traumatic experiences will enable the patient to construe these views as normal and with continued support to reduce their occurrence and replace them with feelings that bring them contentment rather than anxiety (Wang & Saudino, 2011).
As earlier expressed the patient has had frequent bouts of panic attacks and anxiety brought about by memories of trauma experienced during her stay in Afghanistan. Tammy would thus wish to use an intervention that would erase these traumatic thoughts or moreover, replace these thoughts with less traumatic memories. The prevention of resurgence of these traumatic thoughts is Tammy’s ultimate goal and hence provide her cure for PTSD. It is reported that more than 70% of patients suffering from PTSD would wish to have their traumatic memories erased or ultimately get a cure for their condition. As in any healing process, the first step is acceptance of the condition one is suffering from. It, therefore, follows that if the patient is taught to accept their memories whether good or bad, they will realize that no one can change the past and it is, therefore, prudent to learn to live with it and consequently these thoughts will fade and so will the nightmares and panic attacks.
Studies show that patients with PTSD have frequent nightmares and often relive the experience leading to insomnia. These patients further tend to show characteristics of depression whereby they may dis-associate from their normal lifestyle, family, friends, and careers. For a woman’s career, like Tammy, such effects can be disastrous. She has already had severe bouts of panic attacks if left unchecked the effects of PTSD can last a lifetime and in its wake effects on family, marriage/relationship and parental difficulties. Further, the risk of suicide and instability in the patient’s daily life occurs in the long run, hence, treatment is the best thing for Tammy before the disorder completely ruins her life and career.
Literature Review
Interventions Done on the Patient Earlier to Counter This Condition
Treatments on PTSD may either be medications or psychotherapy. When the first experienced symptoms of PTSD they received medical treatment. The patient had been prescribed to take anti-anxiety medication for a while so as to counter the frequent anxious feeling. However, this prescription was halted so as to prevent misuse of this drugs. The patient was also on anti-insomnia drugs due to her frequent nightmares that affected her sleeping patterns. The next treatment that the social worker used on the patient was present-centered therapy (PCT). PCT focuses on issues currently affecting the patient and ignores the traumatic memory. The issues that are affecting the daily activities of the person such as current relationships take the utmost importance in the thought process. The intention of this treatment is to ensure that the individual does not stress over the history. This treatment helps the individual overcome trauma by enabling the individual to focus more on the future and further the individual is taught new strategies to deal with the current issues in their lives. The intention of using this treatment on Tammy was key in determining the best method to reduce her disturbing thoughts.
Measures Used to Assess Change in Behavior
Tammy experiences frequent panic attacks and nightmares. To determine the efficacy of an intervention in the reduction of these symptoms, the frequency of attacks is first measured in a period of two weeks which will be labelled as baseline period ‘m’. After careful analysis and a stable pattern of behavior established, Tammy will now start receiving the treatment (CBT) while being observed and this labelled as period ‘n’ (Ehring et al., 2011). After carefully observing the frequency of attacks during the treatment period with constant and prompt reviews of this results, the application of CBT is stopped, and the behavior of the patient evaluated again (period m). Finally, the social worker would then reinstate the treatment regimen and further monitor the patient for changes in behavior (period ‘n’). For a conclusion to be made on the effect of the treatment on the frequency of attacks, the withdrawal of the intervention would lead to a similar pattern as that on the baseline period. Likewise, the resumption of treatment would follow a similar treatment as that observed when the intervention was first introduced.

The Effect of Cultural Competency on the Use of Various Intervention to Treat a Patient
Studies show that various factors are involved in choosing and implementing a treatment plan on an individual suffering from PTSD such as age, and degree of severity of the condition. There are two broad options of intervention: psychotherapy and pharmacotherapy. Pharmacotherapy involves the use of drugs such as anti-depressants. The use of medication is discouraged for children and young adults. This is because apart from side effects, patients may suffer withdrawal symptoms which may affect the treatment process of individuals especially if they suffer from other mental conditions or are likely to experience psychological health issues as they grow older. Use of medication is exempt to those who are using other of psychological treatment. Certain careers such as military encourage their members to involve themselves in certain treatment to supplement the therapies they may undergo. For example, group therapy is encouraged by the military and therefore even if the social worker has encouraged Tammy to use CBT it would be better to also involve group therapy as part of her recovery program (Pietrzak et al., 2010). In group therapy, members sit in a group and discuss issues affecting them. It is common to find such groups in the military, and one major advantage is that those individuals may have faced similar events and thus it would be easier for the members to understand each other and thus fast-tracking the coping mechanism on patients.
Hypothesis
CBT has become widely accepted as one of the best psychotherapy treatments among individuals with PTSD.In the military, where officers are prone to experience traumatic events and further experience nightmares if these memories are left unchecked, CBT has been widely encouraged as is the case with Tammy. Therefore, for purposes of this study, the research question will be: Does CBT reduce symptoms of PTSD on war veterans?
In the course of the intervention, the social worker will also determine whether CBT causes an improvement in the moods and social well-being of an individual.
Methodology
The study used a single subject research design on one subject following a singular baseline. The subject is a young, female navy reserve officer who upon returning from Afghanistan has experienced heightened anxiety levels and insomnia all symptoms of PTSD. A baseline period of two weeks was offered and then a further intervention period of six weeks followed. The dependent variables are to reduce anxiety and panic attacks measured upon an independent variable of CBT. The effect of the independent variable on the dependent variable was measured using two methods: Overall anxiety severity and impairment scale (OASIS) and perseverative thinking questionnaire (PTQ).
The OASIS method measures response by highlighting five key points that test the severity of anxiety and possible reduction when intervention is applied. The scale awards marks from 0 to 4 that give an overall score of 20. The patient was analyzed from the baseline period to the end of the treatment with close monitoring of the results on the scale with a consistency placed at 0.89 (Peterson et al., 2011).
PTQ on the other hand variations in negative thoughts. As earlier indicated in the paper, it was the intention of the patient to avoid the negative thoughts. The scale contains 15 items, with answers calculated based on a five-point scale ranging from 0 to 4 labelled that give an overall score of 60 marks. The scale has its consistency at 0.95.
To collect the above data, the subject was first briefed on the whole process of treatment. Assurance on the confidentiality of all information shared by the client is emphasized by the social worker. During this period of intervention, the patient was advised to disclose any issues that may affect the treatment process. The main mode of data collection was by visual inspection. Using the weekly measures from the two methods used for calculation of data (OASIS & PTQ) the results are plotted in a graph and inspected and changes in the variables noted.
Results

Note: The line at the middle of the graph indicates the beginning of the intervention.
The patient shows a high level of anxiety, varying in both phases. As time progresses from baseline to intervention phase, there is an increase in anxiety as we progress towards the fourth week and then the slope starts to gradually descend. This further a high positive correlation between the dependent and independent variable.
Discussion
The goal of this study was to test the effectiveness of CBT in PTSD treatment by reducing the frequency of panic attacks and anxiety experienced and also to improve the overall social well-being by creating an improvement in their moods and emotions. It was the intention of the social worker that at the end of the intervention, the patient should have a positive behavioral change by enjoying more feelings of joy and contentment rather than depression (Norman et al., 2011). From the results, we realize that as the treatment progresses, the patient experiences a significant decrease in the feelings of anxiety due to the high positive correlation levels between the independent and dependent variable.
Despite the huge fluctuations in anxiety levels from the baseline to the end of the intervention, the whole process was a success. When the patient first visited the social worker, she experienced panic attacks on a daily basis which was affecting her job and normal lifestyle. As the program progressed, the patient had reduced frequency in attacks to the extent that at the end of the period of treatment the individual had few mild attacks and reported feeling happier than before. This is a breakthrough since the objective of the project has been met.
Though the program was a success, it is imperative that any medical practitioner who would wish to pursue this course understands that it is not foolproof and a margin of error exists. For example, research dictates that the variables of the experiment should be in a controlled environment (Rosen et al., 2010). In this case, it is difficult to keep a human being in such an environment without ethical issues arising. In this case, Tammy is going to job as usual during the study period. It becomes almost impossible to determine which feelings of anxiety are brought about by work pressures and other external factors such as family matters as opposed to traumatic thoughts, thus interfering with the results of the study.
The effects of PTSD cannot be wished away. It can lead to the suicide tendencies and overall feelings of depression. Individuals should, therefore, seek help before the symptoms become chronic. It is also advisable for members of the military to seek preventive measures early in their training period since they are prone to experience traumatic events and this would avert future health effects. It is also advisable that before a social worker begins a treatment, they should have a longer baseline period so as to understand other matters affecting the patient which might come up during the intervention.
References
Ehring, T., Zetsche, U., Weidacker, K., Wahl, K., Schönfeldd, S., & Ehlerse, A. (2011). The Perseverative Thinking Questionnaire (PTQ): Validation of a content-independent measure of repetitive negative thinking. Journal of Behavior Therapy and Experimental Psychiatry, 42, 225-232.
Norman, S. B., Campbell-Sills, L., Hitchcock, C. A., Sullivan, S., Rochlin, A., Wilkins, K. C., et al. (2011). Psychometrics of a brief measure of anxiety to detect severity and impairment: The overall anxiety severity and impairment scale (OASIS). Journal of Psychiatric Research, 45, 262-268
Peterson, A. L., Luethcke, C. A., Borah, E. V., Borah, A. M., & Young-McCaughan, S. (2011). Assessment and treatment of combat-related PTSD in returning war Veterans. Journal of Clinical Psychology Medical Settings, 18(2), 164-75.
Pietrzak, R. H., Goldstein, M. B., Malley, J. C., Rivers, A. J., & Southwick, S. M.(2010).Structure of posttraumatic stress disorder symptoms and psychosocial functioning in Veterans of Operations Enduring Freedom and Iraqi Freedom. Psychiatry Research, 178(2), 323-329.
Rosen, G. M., Lilienfeld, S. O., Frueh, B. C., McHugh, P. R., & Spitzer, R. L. Reflections on PTSD’s future. (2010). British Journal of Psychiatry, 197, 343-344.
Tuerk, P. W., Yoder, M., Grubaugh, A., Myrick, H., Hamner, M., & Acierno, R. (2011). Prolonged exposure therapy for combat-related posttraumatic stress disorder: An examination of treatment effectiveness for Veterans of the wars in Afghanistan and Iraq. Journal of Anxiety Disorders, 25, 397-403.
Wang, M., & Saudino, K. J. (2011). Emotion Regulation and Stress.Journal of Adult Development, 18 95–103.