AbstractIntroductionPosttraumatic stress disorder (PTSD) is the one of the most commonly observed psychiatric disorder in veterans. The condition can lead to considerable social, occupational, and interpersonal dysfunction. PTSD occurring after combat injury appears to be strongly correlated with the extent of injury, and develops over several months. Studies have indicated that behavioral and cognitive-behavioral treatments are effective in reducing symptoms of PTSD and depression.MethodsIn this study we evaluated the efficacy of problem solving in improving Quality of life of 60 Iranian veterans after Iran- Iraq war. After learning sessions and implementing the interventions, patients were evaluated by SF-36 Questionnaire during post-intervention and follow-up measurements.Results and conclusionPost-test and follow-up scores were 50±4.4 and 56.1±3.8 in problem solving. Comparing to control group without any treatment, all intervention groups showed significant improvement in quality of life

Ahmadi, Khodabakhsh

Ahmadizadeh, Mohammad Javad

Anisi, Jafar

Borjali, Ahmad

Eskandari, Hossein

Falsafinejad, Mohammad Reza

Teimoori, Mojtaba

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Improvement in quality of life after exposure therapy, problem solving and combined therapy in chronic war-related post traumatic stress disorder Exposure therapy, problem solving and combined therapy in war-related PTSD

1877-0428 © 2010 Published by Elsevier Ltd.
doi:10.1016/j.sbspro.2010.07.085
Procedia Social and Behavioral Sciences 5 (2010) 262–266
Available online at www.sciencedirect.com
WCPCG-2010
Improvement in quality of life after exposure therapy, problem 
solving and combined therapy in chronic war-related post traumatic 
stress disorder 
Subtitle: exposure therapy, problem solving and combined therapy in war-related PTSD 
Mohammad Javad Ahmadizadeha, Khodabakhsh Ahmadib, Hossein Eskandaria,                     
Mohammad Reza Falsafinejada, Ahmad Borjalia, Jafar Anisib, Mojtaba Teimoorib
aAllameh Tabataba’i University, Tehran, Iran 
bBehavioral Sciences Research Center, Baqiyatallah Medical Sciences University, Tehran, Iran 
Received January 14, 2010; revised February 27, 2010; accepted March 23, 2010 
Abstract 
Introduction
Posttraumatic stress disorder (PTSD) is the one of the most commonly observed psychiatric disorder in veterans. The condition 
can lead to considerable social, occupational, and interpersonal dysfunction. PTSD occurring after combat injury appears to be 
strongly correlated with the extent of injury, and develops over several months. Studies have indicated that behavioral and 
cognitive-behavioral treatments are effective in reducing symptoms of PTSD and depression.
Methods 
In this study we evaluated the efficacy of problem solving in improving Quality of life of 60 Iranian veterans after Iran- Iraq war. 
After learning sessions and implementing the interventions, patients were evaluated by SF-36 Questionnaire during post-
intervention and follow-up measurements. 
Results and conclusion
post-test and follow-up scores were 50±4.4 and 56.1±3.8 in problem solving. Comparing to control group without any treatment, 
all intervention groups showed significant improvement in quality of life. 
© 2010 Elsevier Ltd. 
Keywords: posttraumatic stress disorder, problem solving, combined therapy, exposure therapy, SF-36, quality of life 
1. Introduction 
Background: war veterans were exposed frequently to a variety of traumatic events and stressors due to their 
special condition. Posttraumatic stress disorder (PTSD) is the most commonly observed psychiatric disorder in 
communities affected by disasters and mass violence (Galea, Nandi, & Vlahov, 2005). Three characteristic symptom 
clusters develop as a result of traumatic exposure. They comprise reexperiencing, hyperarousal and Avoidance 
symptom clusters (APA, 1994). The pathophysiology of PTSD reflects long-lasting changes in the biological stress 
Open access under CC BY-NC-ND license.
Open access under CC BY-NC-ND license.
Mohammad Javad Ahmadizadeh et al. / Procedia Social and Behavioral Sciences 5 (2010) 262–266 263
response systems that underlie many of the symptoms of PTSD and other trauma-related disorders (Vermetten & 
Bremner, 2002).
Post-traumatic stress disorder (PTSD) has been described as "the complex somatic, cognitive, affective and 
behavioral effects of psychological trauma" (Van der Kolk, 1996). PTSD is characterized by intrusive thoughts, 
nightmares and flashbacks of past traumatic events, avoidance of reminders of trauma, hyper vigilance, and sleep 
disturbance, all of which lead to considerable social, occupational, and interpersonal dysfunction. The diagnosis of 
PTSD can be challenging because of the heterogeneity of the presentation and resistance on the part of the patient to 
discuss past trauma. About 27% of people, who experienced an awful trauma and have been injured physically, 
would suffer from PTSD in future (Shalev et al. 1996). In particular, PTSD imparts substantial functional 
impairment in the exposed and is often comorbid with conditions such as depression, generalized anxiety disorder 
and substance abuse (Kessler et al., 1999). PTSD occurring after combat injury appears to be strongly correlated 
with the extent of injury, and develops over several months (Grieger et al., 2006).  
Evidence suggests that severity of PTSD is related to the degree of combat exposure and war duration (Sutker et 
al., 1991; Hermann and Eryavec, 1994; Spiro et al., 1994). Since Iran-Iraq war lasted for 8 years (1982-1989), it has 
been presumed to burden a variety of uncompensated psychological damages such as PTSD, on both sides. In a 
study done by anxiety, depression, and PTSD in Iranian survivors of chemical warfare were reported (Hashemian et 
al.,2006, Ahmadi et al, 2006; Ahmadi et al, 2007). In their investigation the respondents had a mean age of 45 years 
and were all of Kurdish ethnicity. Among individuals exposed to both high-intensity warfare and chemical weapons, 
prevalence rates for lifetime PTSD, current PTSD, major anxiety symptoms, and severe depressive symptoms were 
59%, 33%, 65%, and 41%, respectively.
Cognitive-behavioral treatment (CBT) comprising interactive psychoeducation, cognitive restructuring and 
anxiety management training, offers the best outcome supported by RCT studies (Tarrier et al., 1999; Rothbaum et 
al., 2000; Harvey et al., 2003). Generally, controlled research studies have indicated that behavioral and cognitive-
behavioral treatments are effective in reducing symptoms of PTSD and depression (Sherman, 1998). 
Problem solving therapy, a short-term, cognitive behavioral intervention, teaches a systematic method for solving 
current and future problems. Patients acquire new skills for successfully resolving interpersonal difficulties. These 
skills include the following sequential steps: 1) recognizing the general situation; 2) defining and formulating of the 
problem and Goal setting; 3) Generating, choosing, and implementing a novel solutions; 4) decision making to 
continue to the end; and 5) proofreading and evaluating outcomes. By consistently implementing these steps and 
making them part of their repertoire, patients can cope adaptively with new challenges. 
Cognitive avoidance of trauma related material is one of the defining characteristics of posttraumatic stress 
disorder (APA, 1987). Exposure-based behavioral treatments utilize gradual, systematic, repeated exposure to the 
feared object or situation to allow patients with anxiety disorders to become desensitized to the feared stimulus. The 
exposures are predictable and under the patient’s control. The patient is taught a variety of adaptive coping strategies 
to utilize throughout treatment. Some recent studies provide support for exposure therapy for war veterans, although 
the effects have been small (Ready, 2008). 
Objectives: Our goals in this study were: To assess the efficacy of problem solving in Quality of life of war-related 
PTSD in veterans compared to control group, 
2. Methods 
 We established an empirical; multiple groups pre- and post- test study. Participants were recruited in Tehran 
from 120 volunteer veterans, admitted to Bonyad Shahid due to war-related PTSD. They were assigned to 
interventions in 2 equal groups to receive: 1. problem solving therapy; 2. control group, by using random allocation  
Sample: The sample for this study was comprised of Iranian veterans in 8 years consecutive Iraq-Iran War 
combat, who presented with a variety of concerns to the Deployment Health Clinic of Bonyad Shahid and Sepah 
Pasdaran between 2005 and 2006 in Tehran. The Deployment Health Clinic is structured to screen for PTSD purely 
or PTSD with concomitant depression by DSM IV TR (Diagnostic and Statistical Manual of Mental Disorder, 
Fourth Edition, Text Revision) diagnosis criteria and psychological interview. Participants were a random sample of 
men, ages 25 to 50 years, with 14 years of education, diagnosed with PTSD merely or PTSD with concomitant 
depression, who had a recorded profile in Hazrat Abolfazl clinic, Sani Khani clinic, and psychiatric Sadr Bonyad 
center.
264  Mohammad Javad Ahmadizadeh et al. / Procedia Social and Behavioral Sciences 5 (2010) 262–266
Sampling: In the first stage, 60 PTSD patients were selected from among patient’s dossiers of clinical centers 
belonging to Islamic Revolution Guards Corp & Bonyad in Tehran (Baqiyatallah Hospital, Hazrate Aboulfazl clinic, 
Shahid Sanie Khani clinic& Sadr psychiatry center). Of 60 patients invited after sending written invitation and 
making phone contact. They were informed about the reason of the invitation, the to-be-done study and its 
conditions, procedures and treatments. To make up the deficit, the dossiers were checked again, and those absent in 
the session were invited again. Additionally psychiatrists of the above mentioned clinical centers added new 
candidates from their new referrals.  Before the study begins, all participants filled demographic questionnaires, and 
gave written informed consent. According to the participants’ answers, it has been programmed that patients attend 
therapeutically sessions twice weekly.  
Instruments: The following items were employed: 
1) Quality of life questionnaire (QLQ) or SF-36 is a multi-purpose, short-form health survey with only 36 
questions. It yields an 8-scale profile of functional health and well-being scores as well as psychometrically-based 
physical and mental health summary measures and a preference-based health utility index. It is a generic measure, as 
opposed to one that targets a specific age, disease, or treatment group. Accordingly, the SF-36 has been proven 
useful in surveys of general and specific populations, comparing the relative burden of diseases, and in 
differentiating the health benefits produced by a wide range of different treatments. 
2) Symptom Checklist-90-Revised (SCL-90-R) is a widely used self-report instrument for assessing psychiatric 
problems (Dragotis, 1983). It assesses a wide range of psychopathic comorbid problems and is brief enough to be 
taken in only 15-20 minutes. The checklist has many archival databases. It is possible to measure PTSD by this 
instrument in a wide range of clinical and research settings. We applied Global Severity Index (GSI) of this 
checklist in this study. 
Problem solving therapy: 15 therapy sessions were held containing 7 group sessions each lasting 2 hours, and 8 
individual sessions each lasting 45 minutes. Patients were trained 5 steps of problem solving therapy by an expert 
therapist, throughout 7 group sessions. At the end of session 1, patients were assessed by Questionnaires as pre-
therapy tests.
Individual sessions were devoted to recognizing the exact stressor situations and memories of each case. Then 
patients were asked to perform their learning on their own virtual problems and trying to go through each step by 
therapist assistance. Post-therapy tests were held at the end of 15th session and 3 months later.  
3. Results 
Each of two groups of problem solving and control were composed of 25 individuals. Overall mean age was 
42.37±4.55 (ranging from 34 to 57 years). Table shows baseline characteristics of the subjects in detail.  
Short form of QLQ was applied to assess quality of life. Table 2 demonstrate the total score and sub scores. 
There was significant increase in the total scores of post-test phase and follow-up period comparing to baseline 
condition in all three intervention groups. Analysis of the components of SF36 revealed a similar trend in sub scores. 
Considering post-test and follow-up measurement among groups it was observed that all interventions were 
significantly effective in improving the scores. Nevertheless, this impact was more outstanding in exposure therapy 
with significant difference comparing to problem solving and control group. 
Analysis of Global Severity Index (GSI) between groups depicted that all intervention could diminish the scores 
significantly in post-test phase comparing to pre-test measurement. This decrement was more in subjects who 
underwent exposure therapy.  
Mohammad Javad Ahmadizadeh et al. / Procedia Social and Behavioral Sciences 5 (2010) 262–266 265
Table 1. baseline characteristics of individuals enrolled in the study.
Exposure therapy Problem solving Combined therapy control 
Age 42.9±5.3 41.58±3.9 42.4±5.2 42.52±3.4 
Academic education (%) 52 46 35 64
Percent of injury (%) 43 41.5 42.5 42.4 
Table 2.  Scores of SF36 and GSI in pre-test, post-test and follow-up measurements.
SF36 GSI 
Pre-test Pre-test* Follow-up* Pre-test Post-test* Follow-up*
Problem solving 36.4±3.2 50±4.4 56.1±3.8 1.78±0.3 1.38±0.2 1.32±0.3 
control 45.9±4.6 45.7±3.2 46.1±2.5 1.5±0.3 1.54±0.2 1.3±0.2 
SF36: Short Form of Quality of Life Questionnaire, GSI: Global Severity Index 
*post-test and follow-up have significant difference with pre-test measurements. 
4. Discussion 
Applying pharmacotherapy and psychotherapy for treatment of patients with post traumatic stress disorder was 
focused in different studies. Among psychotherapy method, cognitive-behavioural therapy appeared to be the first 
line especially in chronic cases of combat-related PTSD. In this study we evaluate outcome of problem solving in 
treatment of chronic PTSD in veterans of Iraq-Iran war. To assess adjustment ability of subjects and intervention 
efficacy, BAQ and GSI were applied as pre-test and post-test measurements. A repeated test after 3 months was 
used to ascertain long time efficacy.  
Our finding showed that problem solving approaches alone is effective in treatment of PTSD in veterans 
(considering GSI scores). Nevertheless, problem solving seems to have more persistent effects after 3-month 
evaluation.
Regarding adjustment ability, it was observed that applied approache could improve SF-36 scores. This is 
consistent with other studies which employed problem solving method as therapeutic approach and implies that 
assisting patients in finding better solution for their problems is a crucial principle. 
Although there were slight differences among results of components of SF-36, the total trend was similar. 
Findings of this study are consistent with previous works which offered problem solving approaches as effective 
treatments for PTSD patients. It is often reported that this method of intervention have similar effectiveness. It can 
be implied that problem solving can provide more effective remedies for victims of psychological trauma to 
encounter the problems.  
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Improvement in quality of life after exposure therapy, problem solving and combined therapy in chronic war-related post traumatic stress disorder Exposure therapy, problem solving and combined therapy in war-related PTSD

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