In the case of this practice question, the topic was an appropriate treatment for a 25-year-old female with flashbacks and post-traumatic stress disorder. While there are several possible treatments for this particular condition, the ones relevant to the practice question were EMDR and CBT. After researching through the literature available on these two treatments, as well as their applicability to the patient, it was concluded that EMDR is the most appropriate treatment method. That is because it was the treatment recommended by sources with higher levels of evidence and high applicability. In the review below, the various relevant sources that were found will be outlined, discussed, and assessed for their level of evidence and applicability.
Sources Identified
A review of the available literature on the efficacy of CBT vs. the efficacy of PTSD was done, especially considering the individual's presenting symptoms and their demographics. The following five studies were identified as relevant to the practice question:
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Haagen, J. F., Smid, G. E., Knipscheer, J. W., & Kleber, R. J. (2015). The efficacy of recommended treatments for veterans with PTSD: A metaregression analysis. Clinical Psychology Review , 40 , 184-194.
One paper from 2015 summarized a study done by Haagen et al. (2015)which studied the efficacy of EMDR as a treatment for individuals with post-traumatic stress disorder. The study compared the efficacy of EMDR with other modes of treatment, such as group therapy, exposure therapy, and CPT (Haagen et al., 2015). Overall, the findings showed that for individuals working in the military. EMDR was the treatment showing the least efficiency. Furthermore, the efficacy of EMDR is tested against CPT's efficacy – cognitive processing therapy – which is a type of cognitive-behavioral therapy. The authors found that EMDR performed significantly lower efficacy rates than CPT. The results of this study mean that in most cases, military personnel will see a slower and lower impact from the use of EMDR to diminish the symptoms of post-traumatic stress disorder and flashbacks. That is useful to the practice question in that it indicates that CBT may be a better treatment for the individual described by it.
Chen, L., Zhang, G., Hu, M., & Liang, X. (2015). Eye movement desensitization and reprocessing versus cognitive-behavioral therapy for adult posttraumatic stress disorder: systematic review and meta-analysis. The Journal of nervous and mental disease , 203 (6), 443-451.
A different study by Chen, et al. (2015) showed mixed results. Their study identified a gap – there was exhaustive research available on both EMDR treatment and CBT treatment, but little information on which treatment showed more effective results overall. The authors carried out a systematic review of the available data and found that EMDR provided better results for PTSD patients in most cases. However, what is important to note is that the authors stated that in cases where the individual has a case of prominent intrusion or arousal, EMDR is generally recommended over CBT. In the case of the practice question, the patient suffers from prominent intrusion, via flashbacks. Thus, according to this paper, she would best benefit from EMDR.
Reisman, M. (2016). PTSD treatment for veterans: What’s working, what’s new, and what’s next. Pharmacy and Therapeutics , 41 (10), 623.
One article by Reisman (2016) summarizes the origins and treatment of PTSD among military personnel, as are recognized by industry standards today. In this review, Reisman explains both CBT as used in treating veterans, as well as EMDR. This paper was relevant to the practice question because it details the treatment of individuals with severe flashbacks, as the patient in the practice question has. The article states that while EMDR is often successful, the industry standard for treating individuals with PTSD and flashbacks is CBT. It is often the first line of treatment due to its high efficacy so far. According to this article, CBT is the best treatment for a patient with the symptoms described in the question.
Diehle, J., Opmeer, B. C., Boer, F., Mannarino, A. P., & Lindauer, R. J. (2015). Trauma-focused cognitive behavioral therapy or eye movement desensitization and reprocessing: What works in children with posttraumatic stress symptoms? A randomized controlled trial. European child & adolescent psychiatry , 24 (2), 227-236.
One study carried out by Diehle et al. (2015) was the first source found directly comparing CBT to EMDR in terms of efficacy in treating symptoms of PTSD. The study investigated how each of these treatments affected the symptoms of the children that received it. Although the difference in symptoms was small, it was found that CBT yielded slightly better results than EMDR. Thus, although the study was carried out on children rather than adults, the results once again lean towards CBT as being more effective.
Khan, A. M., Dar, S., Ahmed, R., Bachu, R., Adnan, M., & Kotapati, V. P. (2018). Cognitive-behavioral therapy versus eye movement desensitization and reprocessing in patients with post-traumatic stress disorder: Systematic review and meta-analysis of randomized clinical trials. Cureus , 10 (9).
Lastly, a paper by Khan et al. published in 2018 demonstrated the results of a systematic review of literature on the difference between CBT and EMDR when it comes to treating PTSD. The paper was targeted at providing an updated review, as the last one using legitimate RCT sources had been done more than five years prior. The results showed that EMDR provided a better long-term reduction of PTSD symptoms. In comparison to CBT. However, at the 3-month mark, both methods performed similarly. Thus, they are similar in the short-term in terms of efficacy.
Level of Evidence
Evidence Hierarchy
In the hierarchy of evidence, the paper by Haagen, Smid, Knipscheer, and Kleberab would fall under Level V. Level V is for evidence-based on meta-synthesis or systematic reviews of several studies.
In the hierarchy of evidence, the paper by Chen, Zhang, Hu, and Liang would likewise fall under Level V because it is a review of several other studies.
In the hierarchy of evidence, the article by Reisman falls under Level VII. Level VII is reserved for sources that use authorities or reports by experts. In this paper, Reisman uses a variety of scientific reports and studies as her sources; thus, this paper falls under level VII
In the hierarchy of evidence, the article by Diehl, Opmeer, Boer, Mannarino, & Lindauer falls under Level I, as it is a randomized controlled trial.
The paper by Khan falls under level I, as it uses only RCTs as its source of information.
The evidence that was found was not consistent with the type that was expected. There were limited direct comparisons of CBT and EMDR on the RCT level. Most of the sources directly comparing them were not at high levels of evidence.
Methodological Strength/Rigor of the Study Methods and Procedures
The papers were of various methodological strengths. Beginning with the weakest, Reisman was more of a collation of information from reputable sources than a study. As a result, it followed the least rigorous procedure. Chen et al. and Haagen et al. 's methodological strengths were moderate, as they were not RCTs, but they followed specific quasi-experimental or review procedures. The studies by Khan and Diehle were of the highest methodological strength, as each followed the rigorous process of using primary data from randomized controlled studies. The validity implications follow the level of methodological strength for each paper.
Applicability of Evidence
None of the sources were specifically applicable to the patient in the question, as there were no papers identified that directly addressed the efficacy of CBT versus EMDR for young adult females. However, most addressed the efficacy of each procedure – or both together – for adults. In this way, the papers with the highest applicability are Haagen et al., Reisman, and Khan et al. These all referred to the appropriate age group – adults. The paper by Diehle et al. successfully compared both procedures, but only for underage persons. In the formulation of my final answer, I took into account this applicability and the level of evidence that each source had.
References
Chen, L., Zhang, G., Hu, M., & Liang, X. (2015). Eye movement desensitization and reprocessing versus cognitive-behavioral therapy for adult posttraumatic stress disorder: systematic review and meta-analysis. The Journal of nervous and mental disease , 203 (6), 443-451.
Diehle, J., Opmeer, B. C., Boer, F., Mannarino, A. P., & Lindauer, R. J. (2015). Trauma-focused cognitive behavioral therapy or eye movement desensitization and reprocessing: What works in children with posttraumatic stress symptoms? A randomized controlled trial. European child & adolescent psychiatry , 24 (2), 227-236.
Haagen, J. F., Smid, G. E., Knipscheer, J. W., & Kleber, R. J. (2015). The efficacy of recommended treatments for veterans with PTSD: A metaregression analysis. Clinical Psychology Review , 40 , 184-194.
Khan, A. M., Dar, S., Ahmed, R., Bachu, R., Adnan, M., & Kotapati, V. P. (2018). Cognitive-behavioral therapy versus eye movement desensitization and reprocessing in patients with post-traumatic stress disorder: Systematic review and meta-analysis of randomized clinical trials. Cureus , 10 (9).
Reisman, M. (2016). PTSD treatment for veterans: What’s working, what’s new, and what’s next. Pharmacy and Therapeutics , 41 (10), 623.
