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| − | === What is it? === |
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| − | Eye Movement Desensitisation and Reprocessing (EMDR) is a rapdily developing treatment method that is being applied to an increasingly wide range of clinical conditions. |
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| + | '''Eye Movement Desensitization and Reprocessing''' ('''EMDR''') is an information processing [[psychotherapy]] that was developed to resolve symptoms resulting from disturbing and unresolved life experiences. EMDR is rated in the highest category of effectiveness and research support in international guidelines for PTSD treatment. It uses a structured approach to address past, present, and future aspects of disturbing memories. The approach was developed by Francine Shapiro<ref name="isbn0-89862-960-8">{{cite book |author=Shapiro, Francine |title=Eye movement desensitization and reprocessing: basic principles, protocols, and procedures |publisher=Guilford Press |location=New York |year=1995 |pages= 398 |isbn=0-89862-960-8 |oclc= |doi=}}</ref> to resolve symptoms resulting from exposure to a traumatic or distressing event, such as rape. Clinical trials have demonstrated EMDR's efficacy in the treatment of [[post-traumatic stress disorder]] (PTSD). In some studies it has been shown to be equivalent to cognitive behavioral and exposure therapies, and more effective than some alternative treatments (see effectiveness sections below). Although some clinicians may use EMDR for various problems, its research support is primarily for disorders stemming from distressing life experiences.<ref>Maxfield, L. (2003). Clinical implications and recommendations arising from EMDR research findings. Journal of Trauma Practice, 2, 61-81.</ref><ref name="Maxfield 2007">{{cite book |author=Louise Maxfield; Shapiro, Francine; Kaslow, Florence Whiteman |title=Handbook of EMDR and Family Therapy Processes|publisher=Wiley |location=New York |year= 2007 |pages= 504 |isbn=0471709476}}</ref> |
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| − | The founder of the approach is [[Francine Shapiro]]. Shapiro claims that the discovery of EMDR was serrendipitous; she claims that she was out walking and was feeling upset when she noticed that if she induced rapid [[saccadic eye movements]], this had an immediate calming effect that elminated her traumatic feelings. She expermimented with her discovery and developed a clinical technique that has aroused extensive interest around the world. |
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| + | The theoretical model underlying EMDR treatment hypothesizes that EMDR works by processing distressing memories. EMDR is based on a theoretical information processing model which posits that symptoms arise when events are inadequately processed, and can be eradicated when the memory is fully processed. It is an integrative therapy, synthesizing elements of many traditional psychological orientations, such as [[psychodynamic]], cognitive behavioral, experiential, physiological, and interpersonal therapies.<ref>Shapiro, F. & Maxfield, L. (2002). Eye movement desensitization and reprocessing (EMDR): Information processing in the treatment of trauma. Journal of Clinical Psychology, 58, 933-948.</ref> |
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| − | Initially, the technique was developed for the treatment of [[psychological trauma]]. However, the protocol has been developed over the past decade to deal with a wide variety of usually anxiety-based disorders. |
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| + | EMDR's most unique aspect is an unusual component of bilateral stimulation of the brain, such as eye movements, bilateral sound, or bilateral tactile stimulation coupled with cognitions, visualized images and body sensation. EMDR also utilizes dual attention awareness to allow the individual to vacillate between the traumatic material and the safety of the present moment. This prevents retraumatization from exposure to the disturbing memory. As EMDR is an integrative therapy which combines elements of cognitive behavioral and psychodynamic therapies to desensitize traumatic memories, some individuals have criticized EMDR and consider the use of eye movements to be an unnecessary component of treatment.<ref name="Herbert">Herbert, Lilienfield et al. 'Science and Pseudoscience in the development of eye movement and reprocessing: Implications for Clinical Psychology'. Clinical Psychology Review, Vol.20, No.8, pp945-971, 2000 PMID1098395</ref><ref>[http://72.14.209.104/search?q=cache:_jqL8TfBgy8J:www.fsu.edu/~trauma/V9/v9i3_EMDRControversy.pdf+emdr+%2Bcontroversy&hl=en&ct=clnk&cd=2] |
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| − | Essentially the technique involves exposing the patient to his traumatic memories whilst simultaneously inducing rapid eye movements (by asking the patient to track an oscillating stimulus such as a finger or light). The patient is also required to hold in mind a cognitive statement about himself that is derived during the assessment process. |
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| + | Traumatology, Vol. 9, No. 3 (September 2003) 169. EMDR: Why the Controversy? Charlotte Sikes and Victoria Sikes</ref>. However, recent studies have examined the effects of eye movements and have found that eye movements in EMDR decrease the vividness and/or negative emotions associated with autobiographical memories, <ref>Andrade, J., Kavanagh, D., & Baddeley, A. (1997). Eye-movements and visual imagery: A working memory approach to the treatment of post-traumatic stress disorder. British Journal of Clinical Psychology, 36, 209-223</ref><ref>Barrowcliff, A.L., et al., Eye-movements reduce the vividness, emotional valence and electrodermal arousal associated with negative autobiographical memories. Journal of Forensic Psychiatry & Psychology, 2004. 15(2): p. 325-345.</ref><ref>Kavanagh, D. J., Freese, S., Andrade, J., & May, J. (2001). Effects of visuospatial tasks on desensitization to emotive memories. British Journal of Clinical Psychology, 40(3), 267-280.</ref><ref>van den Hout, M., Muris, P., Salemink, E., & Kindt, M. (2001. Autobiographical memories become less vivid and emotional after eye movements. British Journal of Clinical Psychology, 40(2), 121-130.</ref>, enhance the retrieval of episodic memories,<ref>Christman S.D., Garvey K.J., Propper R.E., Phaneuf K.A. (2003. Bilateral eye movements enhance the retrieval of episodic memories. Neuropsychology 17 (2): 221-9. PMID 12803427</ref> increase cognitive flexibility,<ref>Kuiken, D., et al. (2001), Eye movement desensitization reprocessing facilitates attentional orienting. Imagination, Cognition & Personality, 21(1): p. 3-20.</ref> and correlate with decreases in heart rate, skin conductance, and an increased finger temperature <ref>Elofsson, U. O. E., von Schèele, B., Theorell, T., & Söndergaard, H. P. (in press). Physiological correlates of eye movement desensitization and reprocessing. Journal of Anxiety Disorders, doi:10.1016/j.janxdis.2007.05.012</ref><ref>Sack, M., Lempa, W., Steinmetz, A. Lamprecht, F., Hofmann, A. (in press). Alterations in autonomic tone during trauma exposure using Eye Movement Desensitization and Reprocessing (EMDR) - results of a preliminary investigation. Journal of Anxiety Disorders (2007), doi:10.1016/j.janxdis.2008.01.007</ref>. These physiological changes associated with EMDR are consistent with earlier research on physiological changes associated with EMDR <ref>Wilson, D., Silver, S. M., Covi, W., & Foster, S. (1996). Eye movement desensitization and reprocessing: Effectiveness and autonomic correlates. Journal of Behavior Therapy and Experimental Psychiatry, 27(3), 219-229.</ref>. Also recent studies that have removed eye movement from the method have found the procedure less effective <ref>Lee, C. W., & Drummond, P.D. (in press). Effects of Eye Movement versus Therapist Instructions on the Processing of Distressing Memories, Journal of Anxiety Disorders, (2007)doi:10.1016/J.janxdis.2007.08.007</ref>. |
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| + | ==Description of therapy== |
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| − | There is considerable debate and controversy regarding how and why EMDR works. When it is successful, the technique can eliminate the intrusive symptoms associated with psychological trauma within a session or two. |
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| + | There are two perspectives on EMDR therapy. One was advanced by the method's creator, with a theory that eye movements provide some neurological and psychological effects that enhance the processing of traumatic memories. The other perspective is that eye movements are an [[epiphenomenon]], unnecessary, and that EMDR is simply a form of [[desensitization]]. |
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| − | It should be noted that EMDR requires specialist training. This is available from the [http://www.emdr.com EMDR Institute]who offer courses around the world. It should also be noted that the technique can induce powerful emotional reactions. Thus, if it is applied without sufficient understanding and experience to a patient for whom the treatment is contraindicated, it can induce a psychotic reaction. |
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| + | ===Theoretical basis for the therapy=== |
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| − | ---- |
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| + | Eye Movement Desensitization and Reprocessing (EMDR) has been used to treat posttraumatic stress disorder (PTSD). It integrates elements of imaginal exposure, cognitive therapy, psychodynamic and somatic therapies. It also uses the unique and somewhat controversial element of bilateral stimulation (e.g. moving the eyes back and forth). According to Francine Shapiro's theory, when a traumatic or distressing experience occurs, it may overwhelm usual ways of coping and the memory of the event is inadequately processed; the memory is dysfunctionally stored in an isolated memory network. When this memory network is activated, the individual may re-experience aspects of the original event, often resulting in inappropriate overreactions. This explains why people who have experienced or witnessed a traumatic incident may have recurring sensory flashbacks, thoughts, beliefs, or dreams. An unprocessed memory of a traumatic event can retain high levels of sensory and emotional intensity, even though many years may have passed. |
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| + | EMDR uses a structured eight-phase approach and addresses the past, present, and future aspects of the dysfunctionally stored memory. During the processing phases of EMDR, the client attends to the disturbing memory in multiple brief sets of about 15-30 seconds, while simultaneously focusing on the dual attention stimulus (e.g., therapist-directed lateral eye movements, alternate hand-tapping, or bilateral auditory tones). Following each set of such dual attention, the client is asked what associative information was elicited during the procedure. This new material usually becomes the focus of the next set. This process of alternating dual attention and personal association is repeated many times during the session. |
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| − | == Eye Movement Desensitisation for the Treatment of Post-Traumatic Stress Disorder: Fact and Fiction == |
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| + | The theory is that EMDR works directly with memory networks and enhances information processing by forging associations between the distressing memory and more adaptive information contained in other semantic memory networks. It is thought that the distressing memory is transformed when new connections are forged with more positive and realistic information. This results in a transformation of the emotional, sensory, and cognitive components of the memory so that, when it is accessed, the individual is no longer distressed. Instead he/she recalls the incident with a new perspective, new insight, resolution of the cognitive distortions, elimination of emotional distress, and relief of related physiological arousal.<ref name="Maxfield">Maxfield, L. (2003). Clinical implications and recommendations arising from EMDR research findings. Journal of Trauma Practice, 2, 61-81.</ref> |
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| − | ==== [[BY]]: Dr. Brian M. Levy ==== |
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| + | When the distressing or [[traumatic event]] is an isolated incident, the symptoms can often be cleared with one to three EMDR sessions. But when multiple traumatic events contribute to a health problem - such as physical, sexual, or emotional abuse, parental neglect, severe illness, accident, injury, or health-related trauma that result in chronic impairment to health and well-being - the time to heal may be longer.<ref name="Phillips">Phillips, Maggie., (2000). Finding the Energy to Heal: How EMDR, hypnosis, TFT, imagery, and body focused therapy can help restore the mind body health. NY:Nortonn.com</ref> |
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| − | ==Introduction – PTSD and EMD== |
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| − | [[Post-traumatic stress disorder]] (PTSD), recognised since 1980 when it was in included as a distinct diagnostic category in the [[DSM-III]] (APA, 1980), is a condition that follows an unusually threatening event which, in most instances, is sudden and catastrophic in proportion. It is characterised by; |
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| − | ''“… the reexperiencing of an extremely traumatic event accompanied by symptoms of increased arousal and by avoidance of stimuli associated with the trauma”'' |
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| − | ([[DSM-IV]], APA, 1995; p.403) |
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| + | === What is it? === |
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| − | Diagnosis of the condition requires a number of factors to be present in each of the following six symptom categories (as outlined in DSM-IV, 1995); |
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| + | Eye Movement Desensitisation and Reprocessing (EMDR) is a rapdily developing treatment method that is being applied to an increasingly wide range of clinical conditions. |
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| + | The founder of the approach is [[Francine Shapiro]]. Shapiro claims that the discovery of EMDR was serrendipitous; she claims that she was out walking and was feeling upset when she noticed that if she induced rapid [[saccadic eye movements]], this had an immediate calming effect that elminated her traumatic feelings. She expermimented with her discovery and developed a clinical technique that has aroused extensive interest around the world. |
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| − | A. The person has been the victim of, or has been exposed to a traumatic event which involved threatened death or serious injury, or the death of others. The person’s response involved intense fear, helplessness or horror. |
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| + | Initially, the technique was developed for the treatment of [[psychological trauma]]. However, the protocol has been developed over the past decade to deal with a wide variety of usually anxiety-based disorders. |
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| − | B. The person persistently reexperiences the traumatic event through, for example, [[nightmare]]s, [[dissociative flashback episode]]s, intrusive re-collections of the event etc. |
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| + | Essentially the technique involves exposing the patient to his traumatic memories whilst simultaneously inducing rapid eye movements (by asking the patient to track an oscillating stimulus such as a finger or light). The patient is also required to hold in mind a cognitive statement about himself that is derived during the assessment process. |
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| − | C. The person persistently avoids stimuli associated with the trauma (e.g. avoidance of places or people that arouse recollections of the trauma) and experiences numbing of general responsiveness (e.g. restricted range of affect, feelings of detachment or estrangement from others). |
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| + | There is considerable debate and controversy regarding how and why EMDR works. When it is successful, the technique can eliminate the intrusive symptoms associated with psychological trauma within a session or two. |
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| − | D. The person experiences persistent symptoms [[hyperarousal]] (e.g. difficulty falling or staying asleep, increased irritability, exaggerated startle response). |
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| − | E. The duration of the disturbance is more than one month. |
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| − | F. The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning. |
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| − | Considerable research into effective treatments for PTSD has been carried out since its inclusion in DSM-III in 1980. [[Exposure techniques]], which are based on the assumption that individuals [[habituate]] to the anxiety provoking memory with a consequent reduction in anxiety, have been frequently used. However some authors have expressed concern about the use of a technique that generates prolonged high levels of anxiety (Fairbank & Brown, 1987) and requires several sessions to achieve a therapeutic effect (Keane, Fairbank & Cadell, 1989). Further, the failure of exposure to have an effect on some patients has been inadequately explained (Wolpe, 1982; Keane et al., 1989). Further, even when exposure techniques seem to have been effective in dealing with some of the symptoms of PTSD, residual difficulties such as nightmares, social isolation and generalised anxiety often remain after treatment (Vaughan & Tarrier, 1992). |
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| − | Relatively recently, a new approach to the treatment of PTSD has emerged for which dramatic claims have been made. The technique, Eye Movement Desensitisation (EMD) was apparently developed by chance when Shapiro (1989a, b) noticed in herself that recurring disturbing thoughts disappeared when she simultaneously engaged in automatic ‘multi-saccadic’ eye movements. Rosen (1995) suggests that saccadic eye movements are involuntary and cannot be detected by people even when they are specifically instructed to look for them. Therefore, he argues that the term ‘saccadic’ is inaccurate. However, this assertion has been disputed by Welch (1996) who suggests that Rosen’s understanding of saccadic eye movements is flawed. Regardless of the specific type of eye movement that Shapiro observed, this debate does not detract from Shapiro’s serendipitous discovery that lead her to consider whether the induction of bilateral eye-movements might reduce the intrusion phenomena commonly associated with PTSD. |
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| − | The essential feature of EMD in the treatment of PTSD is that the patient is required to generate an anxiety-inducing image, associated with the traumatic event, and isolate a thought about that scene. For example, Shapiro (1989b) cites examples including, “I am helpless” or “I have no control”. While the patient repeats the phrase to himself, [[bilateral eye movement]]s are induced by tracking the therapist’s finger which is held between 9 and 12 inches in front of the patient and moved back and forth across the patient’s visual field at a rate of 1-1 seconds (Shapiro, 1989a). Each complete bilateral eye movement cycle is termed a ‘scad’. Next, the patient is required to revisualise the scene in terms that are more acceptable or preferred and generates a counter anxiety-inducing phrase, e.g. “I am safe now”. Eye movements are then induced again with the new image and phrase. The procedure is repeated with all anxiety-provoking memories until no further anxiety is reported. Shapiro (1989a) claims that EMD will be successful in 60-70% of patients in a single 50-minute session. |
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| − | Shapiro (1989a) suggests that the traumatic memory is weakened or eradicated when the patient maintains awareness of one or more of the following; (1) an image of the memory, (2) the negative self-statement or assessment of the trauma, (3) the physical anxiety response. She suggests that the optimum response to EMD occurs when the patient is aware of all three but that desensitisation can occur when only one is present. |
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It should be noted that, in her later work, Shapiro changed the name of the technique “Eye Movement Desensitisation and Reprocessing” to connote the “accelerated information processing” that she assumed to be of major importance in the efficacy of the approach. However, the mechanisms by which the technique works have not been conclusively identified and, as Lohr, Kleinknecht, Tolin & Barrett (1995) point out; |
It should be noted that, in her later work, Shapiro changed the name of the technique “Eye Movement Desensitisation and Reprocessing” to connote the “accelerated information processing” that she assumed to be of major importance in the efficacy of the approach. However, the mechanisms by which the technique works have not been conclusively identified and, as Lohr, Kleinknecht, Tolin & Barrett (1995) point out; |
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''"... there is no empirical evidence of the effects of treatment that justifies the use of the term reprocessing”'' (p.286) |
''"... there is no empirical evidence of the effects of treatment that justifies the use of the term reprocessing”'' (p.286) |
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| − | Lohr et al (1995) chose to adhere to the popular name for the treatment protocol, EMDR, because it is now the most commonly used term. However, it is suggested that incorrect labelling of the technique perpetuates a myth which implies the establishment of a mechanism for the phenomenon. |
+ | Lohr et al (1995) chose to adhere to the popular name for the treatment protocol, EMDR, because it is now the most commonly used term. However, it is suggested that incorrect labelling of the technique perpetuates a myth which implies the establishment of a mechanism for the phenomenon. |
| + | {{Main|Mechanisms underlying the effectiveness of EMDR}} |
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| − | This review will restrict itself to a consideration of the efficacy of EMD in the treatment of PTSD. The review begins with a discussion of early single-case design and uncontrolled studies of applying EMD to the treatment of PTSD. The review then considers both therapeutically successful and unsuccessful controlled outcome studies prior to concluding with a summary that draws the available literature together. Readers wishing to consider how EMD has been applied to other disorders should consult Lohr et al. (1995). |
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| + | It should be noted that while EMDR requires specialist training available from the [http://www.emdr.com EMDR Institute]which offers courses around the world, it is a technique and not a therapy in and of itself and is most effectively employed by broadly trained and experienced therapists who use it when in their clinical judgement it fits the situation. The technique can induce powerful emotional reactions. Thus, if it is applied without sufficient understanding and experience to a patient for whom the treatment is contraindicated, it can induce a psychotic reaction. |
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| − | == Investigating the Efficacy of EMD == |
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| − | === Single-Case and Uncontrolled Studies === |
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| − | Early studies of EMD were typically single-case or uncontrolled studies. The studies by Puk (1991), Marquis (1991), Lipke and Botkin (1992), McCann (1992), Spector and Huthwaite (1993) and Spates and Burnette (1995) all seemed to indicate the efficacy of EMD. However, few of these studies used [[standardised]] psychological tests and established diagnostic tools and hence caution should be exercised in interpreting the reported outcomes. |
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| + | ===Description of therapy process=== |
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| − | Wolpe and Abrams (1991) utilised the [[Fear Survey]] (Wolpe & Lang, 1969) which offers a global rating of overall fear level in their treatment of an individual rape victim. They demonstrated significant improvements in subjective distress and collateral reductions in overall fearfulness and social dysfunction at follow-up. However, the 15-session intervention used a modified EMD procedure including [[systematic desensitisation]] and [[relaxation training]] which precludes conclusions about EMD being drawn (Renfrey & Spates, 1994). Further, the patient had received [[psychodynamic therapy]] and [[rape counselling]] prior to receiving EMD. Thus, the fact that several other treatment techniques besides EMD makes it difficult to draw conclusions about the efficacy of EMD per se. |
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| + | *'''Phase I:''' In the first sessions, the patient's history and an overall treatment plan are discussed. During this process the therapist identifies and clarifies potential targets for EMDR. Target refers to a disturbing issue, event, feeling, or memory for use as an initial focus for EMDR. Maladaptive beliefs are also identified. |
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| + | *'''Phase II:''' Before beginning EMDR for the first time, it is recommended that the client identify a safe place, an image or memory that elicits comfortable feelings and a positive sense of self. This safe place can be used later to bring closure to an incomplete session or to help a client tolerate a particularly upsetting session. |
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| + | *'''Phase III:''' In developing a target for EMDR, prior to beginning the eye movements, a snapshot image is identified that represents the target and the disturbance associated with it. Using that image is a way to help the client focus on the target, a negative cognition (NC) is identified - a negative statement about the self that feels especially true when the client focuses on the target image. A positive cognition (PC) is also identified - a positive self-statement that is preferable to the negative cognition. |
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| + | *'''Phase IV:''' The therapist asks the patient to focus simultaneously on the image, the negative cognition, and the disturbing emotion or body sensation. Then the therapist usually asks the client to follow a moving object with his eyes; the object moves alternately from side to side so that the client's eyes also move back and forth. After a set of eye movements, the client is asked to report) the targeted memory. |
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| + | ===Vocabulary of terms=== |
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| − | Renfrey & Spates (1994) suggest that the most thorough single case replication of Shapiro’s work was a report concerning the treatment of a 40-year-old counselling psychologist who was the victim of a shooting (Kleinknecht and Morgan, 1992). During the EMD treatment, two further traumatic memories were elicited. The first of these was the memory of a fatal car crash in which the patient (who had been the driver) lost his wife and unborn child. The application of EMD to this trauma elicited a further anxiety provoking memory from the patient’s late teens when he had worried about the effect of imprisonment (for being a conscientious objector to the Vietnam war) on his [[claustrophobia]]. |
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| + | The following basic terms are described in Shapiro's 2001 text<ref name="isbn0-89862-960-8"/> |
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| + | ; Information Processing: During information processing, a physiologically-based system sorts new (perceptual) information, makes connections between new information and other information already stored in associated memory networks, encodes the material, and stores it in memory. |
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| − | Formal psychological assessments, including the [[Brief Symptom Inventory]] (BSI: Derogatis & Spencer, 1982), the [[State-Trait Anxiety Scale]] (STAI-Trait Form Y: Spielberger, Gorusch, Luschene, Vagg & Jacobs, 1983) and the [[Centre for Epidemiological Studies Depression Scale]] (CES-D: Weismann, Sholomkas, Pottenger, Prusoff & Locke, 1977) were administered pre-treatment and at 4 and 8 month follow up. The patient received two sessions comprising history-taking, relaxation and anxiety management prior to administration of the EMD procedure. |
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| + | ; Adaptive Resolution: When information processing is complete, learning takes place, and information is stored in memory with appropriate emotion. The new information is therefore available to guide future action. |
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| + | ; Dysfunctionally Stored Information: When information processing is incomplete, the information is not connected to more adaptive information, and it is stored in a memory network with a high negative emotional charge. It can cause reactivity and can be the cause of various symptoms. |
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| + | ; Reprocessing: During reprocessing in EMDR, new associative links are forged between dysfunctionally stored information and adaptive information, resulting in complete information processing and adaptive resolution. |
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| + | ; Memory Networks: Neurobiological associations of related memories, sensations, images, thoughts, and emotions. |
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| + | ; Target Memory: The memory of a distressing or traumatic event, which still causes current distress, and which has been selected to be targeted during EMDR treatment. |
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| + | ; Memory Components: All components of the target memory are accessed during Phase Three to ensure that the memory network is fully activated. These components include the image, cognitions, emotions, and body sensations. |
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| + | ; VOC (Validity of cognition) scale: VOC ratings are used in EMDR to measure baseline validity of the positive cognition during Phase Three, and to assess progress being made, where 1 = not true, and 7 = completely true. |
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| + | ; SUD (Subjective units of disturbance) scale: SUD ratings are used in EMDR, exposure therapies, and other treatments to measure baseline emotional or physical pain and also to assess progress being made. This is a personal measurement of distress, where 0 = no distress, and 10 = worst distress possible. |
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| + | ; Interweave: A specific strategy used by the clinician to assist processing if the client appears to be having difficulty accessing more adaptive information. Ideally, the interweave contains needed information that would have been available except for blockage of inner pathways by trauma responses. |
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| + | ==Empirical evidence regarding EMDR== |
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| − | The authors report reductions on all clinical dimensions of the BSI as well as significant improvements on the STAI and CES-D. The patient also made a post-treatment statement in which he claims that previously disturbing visual images were diffuse and no longer emotionally charged. Further, he reported substantial reductions in hypervigilance as well as collateral improvements socially in terms of his self-image and confidence. |
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| + | Over the last 18 years evidence has accumulated that supports EMDR as an effective treatment for problems associated with distressing memories that relate to the experience of a negative/traumatic event. The evidence about whether EMDR is effective will be first considered on the basis of what scientific committees from around the world have concluded, then EMDR will be compared to typical treatments, medication and traditional exposure based treatments. Although, as discussed below, EMDR is generally considered an efficacious treatment for the treatment of trauma, and its effectiviness is considered to be eqivalent to that of traditional exposure therapy, the working mechanisms that underlie the effectiveness of EMDR, and whether the eye movement component in EMDR contributes to its clinical effectiveness it still a point of uncertainty and contentious debate. {{details|http://en.wikipedia.org/wiki/Eye_Movement_Desensitization_and_Reprocessing#Controversy EMDR:Controversy}}. |
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| + | '''Effectiveness: Conclusions from international scientific committees'''<br> |
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| − | Although the study does appear to demonstrate overall clinical improvements, the measures used failed to cover the full range of PTSD symptomatology. There was no assessment of the extent of the patient’s PTSD using a standardised instrument, e.g. the [[Clinician Administered PTSD Scale]] (CAPS: Blake, Weathers, Nagy, Kaloupek, Klauminzer, Charney & Keane, 1990). Further, no objective data were available to verify the collateral improvements claimed. Finally, the patient studied was unusual. He had received psychological training that may have offered him an advantage in maximising any help offered. Further, there is no suggestion that he had received previous treatments that had failed. Thus, other treatments may have proved to be equally effective, for example. |
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| + | Based on the evidence of controlled research both the practice guidelines of the American Psychiatric Association <ref>{{cite journal | last = American Psychiatric Association | year = 2004 | title = Practice Guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. | location = Arlington, VA | publisher = American Psychiatric Association Practice Guidelines }}</ref> and the Department of Veterans Affairs and Defense <ref>{{citation | last = Department of Veteran Affairs & Department of Defense | year = 2004 | title = VA/DoD clinical practice guideline for the management of post-traumatic stress | place = Washington, DC | publisher = Author | url = http://www.oqp.med.va.gov/cpg/PTSD/PTSD_cpg/frameset.htm. }}</ref> have placed EMDR in the highest category of effectiveness and research support in the treatment of trauma. This status is reflected in a number of international guidelines where EMDR is a recommended treatment for trauma <ref>{{citation | last = Australian Centre for Posttraumatic Mental Health. | date = 2007 | title = Australian guidelines for the treatment of adults with acute stress disorder and post traumatic stress disorder. | place = Melbourne, Victoria | publisher = ACPTMH. | isbn online = 978-0-9752246-6-3 | url = http://www.acpmh.unimelb.edu.au/resources/resources-guidelines.html#1}}</ref><ref>{{citation | last = National Institute for Clinical Excellence| title = Post traumatic stress disorder (PTSD): The management of adults and children in promary and secondary care.| place = London | publisher = NICE Guidelines | year = 2005 | url = http://www.nice.org.uk/guidance/index.jsp?action=byID&r=true&o=10966}}</ref><ref>{{Citation | last = Dutch National Steering Committee Guidelines Mental Health and Care. | title = Guidelines for the diagnosis treatment and management of adult clients with an anxiety disorder. | place = Utrecht, Netherlands | publisher = The Dutch Institute for Healthcare Improvement (CBO)}}</ref><ref>{{Citation | last = Foa | first = E.B. | last2 = Keane | first2 = T.M. | last3 = Friedman | first3 = M.J. | title = Effective treatments for PTST: Practice guidelines of the International Society for Traumatic Stress Studies | place = New York | publisher = Guilford Press | year = 2000}}</ref><ref>{{Citation | last = Bleich | first = A. | last2 = Kolter | first2 = M. | last3 = Kutz | first3 = E. | last4 = Shaley | first4 = A. | title = A position paper of the (Israeli) National Council for Mental Health: Guidelines for the assessment and professional intervention with terror victime in the hospital and the community. | place = Jerusalem, Israel. | year = 2002}}</ref><ref>{{Citation | last = United Kingdom Department of Health | title = Treatment choice in psychological therapies and counseling evidence based on clinical practice guideline. | place = London | publisher = Author | year = 2001 | url = http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4007323}}</ref>. |
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| + | '''Effectiveness: EMDR compared to typical treatments'''<br> |
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| − | While the collection of single-case studies provide a useful indication that EMD maybe a promising treatment for aspects of PTSD that is worthy of further consideration, they offer only limited evidence in evaluating its efficacy. This is because generally, single-case designs are limited in their capacity to validate cause-effect relationships (Kazdin, 1992). Single case designs lack a comparative control and are, therefore, susceptible to ‘false-positive’ results (Type I Error). |
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| + | EMDR has been demonstrated to have significant advantages over usual treatment for PTSD in an HMO setting, and improvement was maintained at a six month follow-up.<ref>Marcus, S., P. Marquis, and C. Sakai, Three- and 6-Month Follow-Up of EMDR Treatment of PTSD in an HMO Setting. International Journal of Stress Management, 2004. 11(3): p. 195-208.</ref> EMDR has been shown to be effective on measures of trauma, depression and anxiety in women who had been sexually abused as children.<ref>Edmond, T., L. Sloan, and D. McCarty, Sexual Abuse Survivors' Perceptions of the Effectiveness of EMDR and Eclectic Therapy. Research on Social Work Practice, 2004. 14(4): p. 259-272.</ref><ref>Edmond, T., A. Rubin, and K. Wambach, The effectiveness of EMDR with adult female survivors of childhood sexual abuse. Social Work Research, 1999. 23(2): p. 103-116.</ref> |
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| + | '''Effectiveness: EMDR compared to medication'''<br> |
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| − | ===Controlled Outcome Studies=== |
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| + | To date EMDR has only been compared directly to medication in one study. Van der Kolk et al. found EMDR to be more effective than [[fluoxetine]], an [[SSRI]] in treating trauma, especially six months post-treatment. The study also suggests a role for SSRIs as a reliable first-line intervention.<ref name="pmid17284128">{{cite journal |author=van der Kolk BA, Spinazzola J, Blaustein ME, ''et al'' |title=A randomized clinical trial of eye movement desensitization and reprocessing (EMDR), fluoxetine, and pill placebo in the treatment of posttraumatic stress disorder: treatment effects and long-term maintenance |journal=The Journal of clinical psychiatry |volume=68 |issue=1 |pages=37-46 |year=2007 |pmid=17284128 |doi=}}</ref> |
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| − | There have been a number of controlled outcome studies of varying quality. Shapiro (1989b) carried out the first systematic investigation of the efficacy of her new treatment method with a patient group of 22 rape and molestation victims, and Vietnam Veterans. She used anxiety levels, the validity of positive self-statements and self-assessments (VoC: Validity of Cognitions ) and presenting complaints as dependent variables. The group varied considerably in the length of time they had experienced the symptoms prior to treatment and the number of years of previous treatment. |
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| + | '''Effectiveness: EMDR versus traditional exposure treatments (studies in the last 5 years)'''<br> |
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| − | Shapiro claimed that a single session of EMD was sufficient to reduce the mean value of the Subjective Units of Disturbance (SUD) for the cohort from 7.45 to 0.13 compared with no appreciable change in the control group. The effect was maintained at 3-month follow-up when additional behavioural change resulting in collateral symptom alleviation had also occurred. However, treatment was terminated when patients reported a SUD reduction to 0 or 1. Thus, demand characteristics, alone, could explain the impressive improvement. For example, patients may have reported a reduction in SUD scores merely because they knew that this was expected and wished to comply with the therapist’s demands. Further, if patients experienced the revisualisation of their trauma as aversive, they might have been motivated to end the session as quickly as possible by reporting a substantial decrease in their SUD score. Herbert and Mueser (1992) note that the study was further confounded because the requirement for patients to report a SUD score of 0 or 1, in order to terminate the session, was only placed on the experimental group and not upon the control group. |
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| + | EMDR proved significantly better than stress inoculation training with prolonged exposure in a study with 24 participants diagnosed with post traumatic stress disorder.<ref>Lee, C., et al., Treatment of PTSD: Stress inoculation training with prolonged exposure compared to EMDR. Journal of Clinical Psychology, 2002. 58(9): p. 1071-1089. PMID 12209866 </ref> Although reduction in symptom severity was equivalent post treatment, at follow-up, EMDR lead to greater gains on both self report and observer rated measures of PTSD and self report measures of depression. In another study of 22 participants who had also been diagnosed with PTSD, both EMDR and prolonged exposure were found to be effective post treatment.<ref>Ironson, G., et al., Comparison for two treatments for traumatic stress: A community-based study of EMDR and prolonged exposure. Journal of Clinical Psychology, 2002. 58(1): p. 113-128.</ref> Participants receiving EMDR appeared to improve quicker in that 70% had reached a level of clinically significant improvement in PTSD after three EMDR sessions compared to only 17% in the prolonged exposure condition. |
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| + | EMDR was also found to work more quickly than exposure based treatments in a larger trial with 105 participants.<ref>Power, K.G., et al., A controlled comparison of eye movement desensitisation and reprocessing versus exposure plus cognitive restructuring, versus waiting list in the treatment of posttraumatic stress disorder. Journal of Clinical Psychology and Psychotherapy, 2002. 9(5): p. 299-318.</ref> At a fifteen-month follow-up, gains for both treatments were generally maintained. The only significant difference at follow-up was an improvement in depression according to an independent observer in favour of EMDR.<br> |
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| + | EMDR and Prolonged Exposure (PE) were found to be equivalently efficacious and both superior to a waitlist control in a controlled trial of 74 female rape victims.<ref>Rothbaum, B.O., M.C. Astin, and F. Marsteller, Prolonged Exposure Vs Eye Movement Desensitisation and Reprocessing (EMDR) for PTSD Rape Victims. Journal of Traumatic Stress, 2005. 18(6): p. 607-616.</ref> Measures used by blind assessors included PTSD, depression, dissociation and state anxiety. Unlike other studies noted above, there was no difference between the active treatments in rate of improvement. However EMDR seemed to do adequately well despite utilising no homework tasks and less exposure. The study met the highest criteria for methodological rigour proposed by Foa and Meadows.<ref>Foa, E.B. and E.A. Meadows, Psychosocial treatments for posttraumatic stress disorder: A critical review. Annual Review of Psychology, 1997. 48: p. 449-480.</ref><br> |
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| + | The improvements in EMDR over CBT are not limited to English speaking cultures. In a study involving Iranian girls who had been sexually abused, EMDR was found to be significantly more efficient than CBT.<ref>Jaberghaderi, N., et al., A Comparison of CBT and EMDR for Sexually-abused Iranian Girls. Clinical Psychology & Psychotherapy, 2004. 11(5): p. 358-368.</ref><br> |
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| + | Although most studies show EMDR and CBT to be about the same, one study reported an opposite effect.<ref name="pmid12699027">{{cite journal |author=Taylor S, Thordarson DS, Maxfield L, Fedoroff IC, Lovell K, Ogrodniczuk J |title=Comparative efficacy, speed, and adverse effects of three PTSD treatments: exposure therapy, EMDR, and relaxation training |journal=Journal of consulting and clinical psychology |volume=71 |issue=2 |pages=330-8 |year=2003 |pmid=12699027 |doi=10.1037/0022-006X.71.2.330}}</ref> Analysis of changes in symptoms for the 15 participants who completed treatment indicated greater reductions on symptom measures of avoidance and re-experiencing for imaginal exposure treatment over EMDR but equivalent reductions on hyper arousal. However there were no differences between the two treatments in the intent to treat analysis and no differences between the two treatments on percentage of people with PTSD diagnosis at follow-up. |
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| + | '''Effectiveness: meta-analysis '''<br> |
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| − | Sanderson and Carpenter (1992) employed a two-treatment crossover design to compare EMD with Image Confrontation (IC). The IC technique was identical to EMD except that these patients were instructed to keep their eyes closed and stationary. Both techniques were applied to patients with a variety of phobic disorders. The authors reported significant and equivalent reductions in the SUD scores associated with both treatments. The 8 patients with trauma symptoms did best. However, standardised psychological tests were not employed and the crossover design precluded the analysis of the unique effects of EMD and IC. Although Shapiro’s (1989b) control group was almost identical in nature to the IC group in Sanderson and Carpenter’s study, she noted a significant difference between the experimental and control group, whilst no such difference between the EMD and IC groups was observed. This may provide further evidence that the extent of the success in the Shapiro study was exaggerated owing to the effects of the demand characteristics already discussed. |
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| + | EMDR was found in the first ever meta-analysis of PTSD to be equally effective as exposure therapy and SSRIs<ref>van Etten, M. L., & Taylor, S. (1998). Comparative Efficacy of Treatments for Post-traumatic Stress Disorder: A Meta-Analysis. Clinical Psychology and Psychotherapy, 5, 126-144. [http://www.emdr.nl/acrobat/VANETT.PDF Full text available PDF]</ref>. Two recent meta-analyses concluded that traditional exposure therapy and EMDR have equivalent effects both immediately after treatment and at follow-up.<ref name="pmid15677582">{{cite journal |author=Bradley R, Greene J, Russ E, Dutra L, Westen D |title=A multidimensional meta-analysis of psychotherapy for PTSD |journal=The American journal of psychiatry |volume=162 |issue=2 |pages=214-27 |year=2005 |pmid=15677582 |doi=10.1176/appi.ajp.162.2.214}}</ref><ref name="pmid16740177">{{cite journal |author=Seidler GH, Wagner FE |title=Comparing the efficacy of EMDR and trauma-focused cognitive-behavioral therapy in the treatment of PTSD: a meta-analytic study |journal=Psychological medicine |volume=36 |issue=11 |pages=1515-22 |year=2006 |pmid=16740177 |doi=10.1017/S0033291706007963}}</ref>The most recent meta-analysis looked at 38 randomized controlled trials for PTSD treatment and concluded that the first-line psychological treatment for PTSD should be Trauma-Focused CBT or EMDR.<ref name="pmid17267924">{{cite journal |author=Bisson JI, Ehlers A, Matthews R, Pilling S, Richards D, Turner S |title=Psychological treatments for chronic post-traumatic stress disorder. Systematic review and meta-analysis |journal=The [[British Journal of Psychiatry]] : the journal of mental science |volume=190 |issue= |pages=97-104 |year=2007 |pmid=17267924 |doi=10.1192/bjp.bp.106.021402}}</ref> |
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| + | ==Other applications of EMDR== |
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| − | Boudewyns, Stwertka, Hyer, Albrecht, & Sperr (1993) used psychological, physiological and standardised diagnostic measures in a controlled study of EMD to treat combat related PTSD in Veterans hospital patients. Prior to treatment, all patients recorded their traumatic experiences on audiotape. Patients were then randomly divided into three groups. One group was treated with EMD, one group received an exposure control procedure and the last group received a milieu control procedure. They noted a significantly greater reduction in SUD scores for the EMD and exposure control groups (with the greatest reductions achieved in the EMD group) than displayed by the milieu control group. When the audiotape was played back to patients following treatment, there was no significant difference in physiological reactivity between the groups. Indeed, none of the treatments appeared to affect physiological reactivity. Further, there were no pre- and post treatment differences for any of the conditions on the CAPS (Blake et al., 1990), Impact of Events Scale (IES: Horowitz, Wilner & Alvarez, 1979) and the Mississippi PTSD Scale (Keane, Cadell & Taylor, 1986). |
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| + | Although controlled research has concentrated on the application of EMDR to PTSD, a number of studies have investigated EMDR’s efficacy with other anxiety disorders as well as numerous reports of diverse clinical applications. |
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| − | In evaluating the effectiveness of EMD in the treatment of PTSD, it is imperative that outcome measures have adequate construct validity. For example, Puk (1991) reported that the patient was able to reduce the vividness of his visualisations. However, vividness of the image only relates to one dimension of the PTSD syndrome. Similarly, Richards and Rose (1991) used an exposure approach in their treatment of PTSD. They utilised measures of depression, phobic anxiety and social adjustment as outcome measures. However, if any treatment for PTSD is being evaluated, then its effect on the whole range of PTSD symptoms must be considered. This point has been observed by other authors (Baggaley, 1991; Vaughan, Wiese, Gold, & Tarrier, 1994a). |
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| + | Case reports have been published on the application of EMDR to the treatment of (a) [[personality disorders]] ( Fensterheim, 1996a; Korn & Leeds, in press; Manfield, 1998), (b) [[dissociative disorders]] ( Fine & Berkowitz, 2001; Lazrove & Fine, 1996; Paulsen, 1995; Twombly, 2000), ( c ) a variety of [[anxiety disorders]]<ref name="pmid10225501">{{cite journal |author=De Jongh A, Ten Broeke E, Renssen MR |title=Treatment of specific phobias with Eye Movement Desensitization and Reprocessing (EMDR): protocol, empirical status, and conceptual issues |journal=Journal of anxiety disorders |volume=13 |issue=1-2 |pages=69-85 |year=1999 |pmid=10225501 |doi=}}</ref> ( De Jongh & Ten Broeke, 1998; Goldstein & Feske, 1994; Lovett, 199; Nadler, 1996; Shapiro & Forrest, 1997) and (d) [[somatoform disorders]] ( Brown, Mcgoldrick, & Buchanan, 1997; Grant & Threlfo, 2002). However, controlled research is needed to evaluate the efficacy of these applications. |
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| − | This issue was addressed by Forbes, Creamer and Rycroft (1994) in a study of eight patients. They used a variety of instruments including a structured interview (SI-PTSD: Davidson, Smith & Kudler, 1989), the SCL-90-R (Derogatis, 1977), the Beck Depression Inventory (BDI: Beck, Rush, Shaw & Emery, 1979) and the Impact of Events Scale (IES: Horowitz, Wilner & Alvarez, 1979). Comorbidity was assessed using the Structured Clinical Interview for DSM-III-R (SCID-NP: Spitzer, Williams, & Gibbon, M, 1987)). The possibility that the EMD protocol has features reminiscent of hypnosis was investigated using the Stanford Hypnotic Clinical Scale (SHCS: Morgan & Hilgard, 1975). The authors reasoned that the dramatic results of EMD might be attributable to suggestibility. Finally, electromyography (EMG) was used to measure possible physiological changes resulting from EMD. |
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| + | In designing the research the entire EMDR protocol should be evaluated within the context of the potential special needs of the particular population. For instance, Brown et al. (1997) evaluated the application of EMDR in seven consecutive cases of [[Body Dysmorphic Disorder]] (BDD), which has been reported to necessitate 8 to 20 sessions of cognitive behavior therapy with varying success rates ( Neziroglu, McKay, Todaro, & Yaryura-Tobias, 1996; Beale et al., 1996; Wilhelm, Otto, Lohr, & Deckersbach, 1999). In contrast, Brown et al. reported the elimination of BDD in five of the seven consecutive cases in one to three sessions of EMDR through the processing of the etiological memory. While this result indicates the EMDR holds promise for the treatment of this disorder, future controlled research should include a greater number of sessions in order to evaluate the more comprehensive clinical picture. |
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| − | In comparisons between pre- and post treatment scores, the authors found significant decreases in intrusion, avoidance and hyper-arousal on the SI-PTSD and decreases in intrusion and avoidance on the IES. They also observed significant decreases on the BDI and on the Global Severity Index of the SCL-90-R. These improvements were maintained at 3-month follow-up. Although significant improvements were observed in 6 of the 8 patients, 50% continued to meet the criteria for PTSD post-treatment and at follow-up. |
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| + | EMDR can work on a multitude of problems that are less complex than PTSD. One of these is uncomplicated depression. The EMDR Casebook by Philip Manfield, PH.D. has documented several case studies in which EMDR was used. In the case about uncomplicated depression, Manfield was able to help his client, George, resolve several childhood issues that have plagued his adult life. Moreover, EMDR can work for diseases such as postpartum depression. By having the client target a distinctive memory and work through it with a series of eye movements, the client is then able to achieve a positive cognition.<ref name="Manfield">Manfield, Philip. (2003). EMDR Casebook. NY: W.W. Norton & Company, Inc.</ref> |
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| − | EMG results indicated a decrease in physiological reactivity with progressive EMD treatments although these results did not correlate significantly with SI-PTSD data. The authors found a modest positive correlation between overall symptom reduction (i.e. the total SI-PTSD score) and suggestibility as measured by the Stanford Hypnotic Clinical Scale (SHCS: Morgan & Hilgard, 1975). The authors submit that suggestibility is a measure of the degree to which patients can generate images. Consequently, treatment success may depend of the ability of patients to visualise traumatic scenes. Finally a negative relationship between chronicity and longer term response to treatment was observed, supporting the view that chronic forms of PTSD are more resistant to treatment (Peterson, Prout and Schwartz, 1991). Although the study offers support for the efficacy of EMD, the small sample size used in the study and the absence of any form of control group are reasons to be cautious about over-interpretation. |
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| + | EMDR has been used on children to treat a variety of conditions.<ref name="Tinker">Tinker, R., & Wilson S., (1999) Through the eyes of a child: EMDR with children. NY: Norton.</ref><ref name="Greenwald">Greenwald, R.,(1999). Eye movement desensitization and reprocessing in child and adolescent psychotherapy. NY: Norton.</ref> |
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| − | In a study of 10 patients, Vaughan, Wiese, Gold, & Tarrier (1994a) found EMD effective for the re-experiencing, hyper-arousal and avoidance categories of the DSM-III-R. A significant reduction in depression was also seen although this and the hyper-arousal results were not maintained at follow-up. |
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| + | It has been used in the treatment of children who have experienced trauma and complex trauma.<ref name="Tinker">Tinker, R., & Wilson S., (1999) Through the eyes of a child: EMDR with children. NY: Norton.</ref><ref name="Greenwald">Greenwald, R.,(1999). Eye movement desensitization and reprocessing in child and adolescent psychotherapy. NY: Norton.</ref> |
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| + | It is often cited as a component in the treatment of [[Complex Post Traumatic Stress Disorder]],<ref name="isbn0-7619-2921-5">{{cite book |author=Scott, Catherine V.; Briere, John |title=Principles of Trauma Therapy : A Guide to Symptoms, Evaluation, and Treatment |publisher=Sage Publications |location=Thousand Oaks |year= 2006 |pages= 312 |isbn=0-7619-2921-5}}</ref> [[emotional dysregulation]], and in the treatment of children exposed to chronic early maltreatment that is related to [[Attachment disorder]]. It is recognised by the UK National Institute for Health & Clinical Excellence (NICE) Guidelines as a treatment for PTSD. |
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| + | Full article: EMDR 12 Years after Its Introduction: Past and Future Research Francine Shapiro; Mental Research Institute, Palo Alto, CA Journal of Clinical Psychology, Vol. 58(1), 1-22 (2002) 2002 John Wiley & Sons, Inc. |
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| − | Vaughan, Armstrong, Gold, O’Connor, Jenneke, & Tarrier (1994b) compared EMD with image habituation training (IHT) and applied muscle relaxation (AMR) in 36 randomly assigned PTSD patients. In IHT, patients were required to listen to continuous audiotaped loops of descriptions of their trauma. They then recorded cognitions and anxiety levels on a homework sheet. The treatment took approximately 60 minutes per day. It has been reported as being effective in PTSD by Vaughan and Tarrier (1992). Patients in the AMR group were taught to recognise their own symptoms of anxiety so that they could apply Ost’s (1987) progressive relaxation technique. The relaxation was practised for two 20-minute sessions each day. |
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| + | ==How does EMDR work?== |
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| − | Patients in all three groups were initially assessed using the SI-PTSD (Davidson, Smith & Kudler, 1989), the STAI (Spielberger, 1983), the BDI (Beck, 1978) and the IES (Horowitz, Wilner & Alvarez, 1979). Comorbidity was also assessed using the Anxiety Disorders Interview Schedule (ADIS-R: Di Nardo & Barlow, 1988) and the Hamilton Rating Scale for Depression (HRSD: Hamilton, 1960). Seventeen of the patients were initially assigned to a waiting list after assessment and then reassessed two to three weeks later prior to undergoing treatment. The groups were balanced with respect to number of treatment sessions, demographic and trauma-related variables. |
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| + | There is no definitive explanation as to how EMDR works. There is some empirical support for three explanations regarding how an external stimulus such as eye movement can facilitate the processing of traumatic memories. The first hypothesis views PTSD as a failure by the individual to process episodic memory;<ref name="isbn1572306726 ">{{cite book |author=Shapiro, Francine |title=Eye Movement Desensitization and Reprocessing (EMDR), Second Edition: Basic Principles, Protocols, and Procedures |publisher=The Guilford Press |location=New York |year= 2001 |pages= 472 |isbn=1572306726 |oclc= |doi=}}</ref><ref name="pmid11748597">{{cite journal |author=Stickgold R |title=EMDR: a putative neurobiological mechanism of action |journal=Journal of clinical psychology |volume=58 |issue=1 |pages=61-75 |year=2002 |pmid=11748597 |doi=10.1002/jclp.1129}}</ref> the bilateral eye movements involved in EMDR facilitate interaction between the brain's hemispheres, which then improves the processing of trauma-related memories. This hypothesis is supported by a study that tested the effects of eye movement on the ability to retrieve episodic memory. The study found better recall following a horizontal eye movement task compared to that following no eye movement or a vertical eye movement task.<ref name="pmid12803427">{{cite journal |author=Christman SD, Garvey KJ, Propper RE, Phaneuf KA |title=Bilateral eye movements enhance the retrieval of episodic memories |journal=Neuropsychology |volume=17 |issue=2 |pages=221-9 |year=2003 |pmid=12803427 |doi=10.1037/0894-4105.17.2.221}}</ref> |
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| + | A second hypothesis suggests that eye movements facilitate processing of trauma memories by activating a neurobiological state similar to REM sleep wherein associative links to episodic memories are formed and these memories are then integrated into general semantic networks. Stickgold proposed that PTSD occurs when an event is sufficiently arousing to prevent its transfer from encoding from an episodic memory to a semantic memory.<ref name="pmid11748597"/> As a result of high arousal levels, associations between the traumatic event and other related events fail to develop. He argues that the attentional redirecting in EMDR induces a neurobiological state similar to REM sleep. He then reviews the research that suggests that REM sleep enhances processing of episodic memory through the preferential activation of weak associative and semantic links. Thus in EMDR trauma-related information that is closely associated with a target event is weakened and ancillary information loosely related to the event is strengthened, allowing the integration of trauma-related material with other loosely associated events in the person’s life. Support for this argument comes from a study that found that, compared to eye fixation, eye movement promoted attentional flexibility and increased preparedness to process metaphorical material.<ref>Kuiken, D., et al., Eye movement desensitization reprocessing facilitates attentional orienting. Imagination, Cognition & Personality, 2001. 21(1): p. 3-20.</ref> |
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| + | A third hypothesis links the eye movements in EMDR with the orienting response.<ref>MacCulloch, M.J. and P. Feldman, Eye Movement Desensitisation Treatment Utilises the Positive Viscereal Element of the Investigatory Reflex to Inhibit the Memories of Post-Traumatic Stress Disorder: a Theoretical Analysis. [[British Journal of Psychiatry]], 1996. 169(5): p. 571-579.</ref> MacCulloch and Feldman argued that eye movements trigger the investigation component of the orienting response, which can either produce avoidance behaviour or inhibit avoidance responses. Inhibiting avoidance behaviour includes reducing both negative somatic responses and cognitive changes that would allow fresh investigatory behaviour to commence. MacCulloch and Feldman proposed that initially when danger is identified there is a negative affect response. However a second part of the orienting response is to scan for further danger, and this investigatory reflex seems to accompany a positive physical response. In the authors’ opinion, eye movement induces this investigatory reflex and produces a relaxation response. A relaxation response was, in fact, found in a study that investigated the autonomic responses of participants when they were engaged in an eye movement task as part of EMDR treatment<ref name="pmid8959423">{{cite journal |author=Wilson DL, Silver SM, Covi WG, Foster S |title=Eye movement desensitization and reprocessing: effectiveness and autonomic correlates |journal=Journal of behavior therapy and experimental psychiatry |volume=27 |issue=3 |pages=219-29 |year=1996 |pmid=8959423 |doi=10.1016/S0005-7916(96)00026-2}}</ref> and when participants focused on negative memories while engaging in eye movement [23]. However there is not a differential effect of eye movement on a relaxation response when participants focused on positive memories.<ref>Barrowcliff, A.L., et al., Eye-movements reduce the vividness, emotional valence and electrodermal arousal associated with negative autobiographical memories. Journal of Forensic Psychiatry & Psychology, 2004. 15(2): p. 325-345.</ref> This supports the hypothesis that eye movements are an orienting response mechanism rather than a simple relaxation mechanism. In addition, recent research that has examined the physiological correlates of eye movements in EMDR has found that a clear orienting response pattern of psycho-physiological de-arousal occurs when eye movements begin, and this de-arousal is characteristic of the physiological changes that occur when an orienting response is elicited <ref>Sack, M., Lempa, W., Steinmetz, A. Lamprecht, F., Hofmann, A. (in press). Alterations in autonomic tone during trauma exposure using Eye Movement Desensitization and Reprocessing (EMDR) - results of a preliminary investigation. Journal of Anxiety Disorders (2007), doi:10.1016/j.janxdis.2008.01.007</ref>. |
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| − | Significant reductions in hyper-arousal and avoidance symptoms between waiting list and post-treatment assessment occurred for all three groups. However, at post-treatment, 47% of patients still met the criteria for PTSD. At 3-month follow-up this had fallen further to 30%. Significant reductions in total PTSD symptoms for all three groups were observed. Further, reductions in hyperarousal were seen in the EMD and IHT groups. Although improvements were seen across all three groups with regard to re-experiencing and intrusive symptoms, only EMD produced significant improvements in ‘flashbacks’, nightmares and avoidance symptoms. Patients perceived therapists in the EMD group to show more ‘warmth’ than in the other two conditions although they did not report differences in genuineness or empathy. EMD may rely on greater patient-therapist interaction than does IHT or AMR. If so, this could account for the difference in perceived warmth. |
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| + | Further data consistent with the orienting response hypothesis was the finding that EMDR treatment was associated with increased left pre-frontal hemisphere activation.<ref name="pmid16387993">{{cite journal |author=Lansing K, Amen DG, Hanks C, Rudy L |title=High-resolution brain SPECT imaging and eye movement desensitization and reprocessing in police officers with PTSD |journal=The Journal of neuropsychiatry and clinical neurosciences |volume=17 |issue=4 |pages=526-32 |year=2005 |pmid=16387993 |doi=10.1176/appi.neuropsych.17.4.526}}</ref><ref name="pmid10225506">{{cite journal |author=Levin P, Lazrove S, van der Kolk B |title=What psychological testing and neuroimaging tell us about the treatment of Posttraumatic Stress Disorder by Eye Movement Desensitization and Reprocessing |journal=Journal of anxiety disorders |volume=13 |issue=1-2 |pages=159-72 |year=1999 |pmid=10225506 |doi=10.1016/S0887-6185(98)00045-0}}</ref> Investigatory and approach behavior has been shown to be associated with the anterior left hemisphere regions.<ref>Kinsbourne, M., Evolution of language in relation to lateral action., in Asymmetrical function of the brain., M. Kinsbourne, Editor. 1978, New York Cambridge University Press. p. 553-556.</ref> |
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| − | The absence of a true placebo condition is a flaw in the methodology given that placebo treatments have been shown to be superior to waiting lists (McConaghy, 1990). Additionally, although all patients had symptoms identified in the DSM-III criteria, 22% failed to meet all the criteria required for a diagnosis of PTSD. Small numbers in each group in the study make it difficult to draw clear conclusions about the relative effectiveness of one treatment over another. However, given that EMD was superior with respect to nightmares and flashbacks and that it does not require the homework commitment associated with IHT and AMR, it may be that EMD is at least as effective as these alternatives and in less treatment time, too. |
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| − | Wilson, Becker and Tinker (1995) assigned 80 patients to either an immediate treatment, or delayed treatment, group. Only 37 of the patients met the criteria for a diagnosis of PTSD. The key criterion for inclusion in the study was that patients had to have experienced some traumatic memory that interfered with their lives. Both groups of patients received 3 EMD sessions. The SUDS, VoC, IES, STAI and SCL-90-R were used as process or outcome measures. Patients assigned to each of the groups were matched demographically and for length of trauma. The demand characteristics issue was addressed by using an independent assessor. They found a decrease in SUDS and concomitant increase in VoC, which were maintained at 90-day follow-up. However, as has been the case with many studies, comorbidity was inadequately assessed. The authors suggest that whilst EMD may be effective for the treatment of specific intrusive and avoidant aspects of PTSD, the impact of the technique on more general psychological functioning (as measured by the SCL-90-R, for example) is less clear. |
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| + | ==Controversy== |
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| − | ===Unsuccessful treatments using EMD=== |
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| − | A number of studies are reported in the literature that describe unsuccessful treatments using EMD. However, without exception, these are fraught with methodological flaws that do not support the notion that EMD may be a non-efficacious treatment for PTSD. |
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| + | EMDR has generated a great deal of controversy since its inception. Critics of EMDR argue that the eye movements do not play a central role, that the mechanisms of eye movements are speculative, and that the theory leading to the practice is not falsifiable and amenable to scientific enquiry.<ref name="Herbert">Herbert, Lilienfield et al. 'Science and Pseudoscience in the development of eye movement and reprocessing: Implications for Clinical Psychology'. Clinical Psychology Review, Vol.20, No.8, pp945-971, 2000[http://catenation.com/pub/drexelpsych/papers/herbertscience.pdf]</ref><ref name="Devilly 1999">Devilly, G.J., & Spence, S.H. (1999). The relative efficacy and treatment distress of EMDR and a cognitive behavioral trauma treatment protocol in the amelioration of post traumatic stress disorder. Journal of Anxiety Disorders, 13, 131–157[http://web.archive.org/web/20040909104756/http://www.emdr-europe.org/dls/devilly_spence.pdf]</ref> |
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| − | The study by Oswalt, Anderson, Hagstrom & Berkowitz (1993) on the EMD treatment of 8 patients provides an early attempt to replicate the findings of Shapiro. Only 3 patients were judged to have been successfully treated and they were regarded by the authors to have the least pathology. However, the study can be considered methodologically unsound for the following reasons: The patients were recruited via an advert in a campus newspaper. Of the eight who responded, 5 were hospital inpatients who had been diagnosed as having PTSD. However, no independent assessment of the cohort's PTSD status was made. Further, no account was taken of the patient’s mental health status in general and whether they were suffering from any form of psychiatric disorder that would have precluded them from a well designed study (e.g. personality disorder, psychosis etc.). In fact, the only criterion for inclusion in the study was a report of intrusive traumatic memories. Although Oswalt et al. (1993) claim to have followed Shapiro’s method exactly, this was not the case. In addition to therapist and patient being present in the room, a researcher and psychology student were also present to make observations. The study failed to use standardised psychological tests to assess treatment effect (using only the SUD scale and patient post-treatment reports about whether the memories were still ‘bothersome’). Additionally, there was no indication that the Validity of Cognitions scale (VoC) was used as in the original Shapiro method. Finally, in contrast to Shapiro’s (1989b) study, the authors failed to include a control group in their study. In view of the shortcomings of this study, it fails to qualify as a reasonable replication of Shapiro’s work and tells us nothing about the efficacy of EMD. It does suggest that a degree of caution must be adopted in the selection of patients who might benefit from the approach. |
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| + | Although one meta-analysis concluded that EMDR is not as effective, or as long lasting, as specific exposure therapy,<ref name=Devilly 2002"> Devilly, G.J. (2002). Eye Movement Desensitization and Reprocessing: A chronology of its development and scientific standing. Scientific Review of Mental Health Practice, 1, 113-138 [http://www.srmhp.org/0102/eye-movement.html] </ref> several other researchers using meta-analyses have found EMDR to be at least equivalent in effect size to specific exposure therapies.<ref>Bisson, J. I., Ehlers, A., Matthews, R., Pilling, S., Richards, D., & Turner, S. (2007). Psychological treatments for chronic post-traumatic stress disorder: Systematic review and meta-analysis. [[British Journal of Psychiatry]], 190(2), 97-104.</ref><ref>Bradley, R., Greene, J., Russ, E., Dutra, L., & Westen, D. (2005). A Multidimensional Meta-Analysis of Psychotherapy for PTSD. American Journal of Psychiatry, 162(2), 214-227.</ref><ref>Seidler, G. H., & Wagner, F. E. (2006). Comparing the efficacy of EMDR and trauma-focused Cognitive-Behavioral Therapy in the Treatment of PTSD: a meta–analytic study Psychological Medicine 36 1515-1522.</ref><ref>van Etten, M. L., & Taylor, S. (1998). Comparative Efficacy of Treatments for Post-traumatic Stress Disorder: A Meta-Analysis. Clinical Psychology and Psychotherapy, 5, 126-144.</ref> |
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| − | In a laboratory experiment to test whether EMD reduces the aversiveness of visual imagery, Merckelbach, Hogervorst, Kampman and de Jongh (1994) found no significant reduction in heart rate, ability to visualise an aversive stimulus or the perceived aversiveness of the stimulus after EMD. Further, there was no difference between the experimental group and a finger-tapping control group. However, it could be argued that the experimental situation differs markedly from a ‘real life’ traumatic situation in that PTSD victims have to contend with considerably more than a simple aversive visual stimulus. For example, some authors have argued that in PTSD a classically conditioned association is produced between the emotional response to the situation and the entire contents of the memory buffer that occurs during the trauma (Pearce, 1987; Dyck, 1993). Further, recent evidence from a study of PTSD (using Positron Emission Tomography (PET scan) and script-driven imagery) suggests that the emotions associated with PTSD are mediated within the limbic and paralimbic systems within the right hemisphere (Rauch, van der Kolk, Fisler, Alpert, Orr, Savage, Fischman, Jenike & Pitman, 1996). One implication from this study is that information processing in PTSD may not comprise a verbal component. Thus, it is possible that information processing, in the case of highly personalised trauma, is different to that involved in dealing with a non-personal aversive stimulus. It is unlikely that the aversive stimulus evoked personal cognitive statements (e.g. “I am helpless” or “I am going to die”) as is the case with PTSD. This precluded an essential aspect of EMD treatment (Shapiro, 1991) which is the ‘reprocessing’ of these cognitions. |
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| + | ===Are eye movements necessary?=== |
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| − | Jensen (1994) examined 25 Vietnam veterans who met the criteria for PTSD. All patients received a pre-treatment structured interview prior to random assignment to the treatment or control group. The SUD scale was utilised as was the VoC scale. Post-treatment measures included the Mississippi PTSD Scale (Keane, Cadell & Taylor, 1986) and Goal Attainment Scaling (Kiresuk & Sherman, 1968). The control group comprised a group of veterans who simply accessed Veteran Administration services ad libitum. The experimental group received two treatment sessions of EMD within a 10-day period. Jensen reports no significant differences on the post-treatment measures between the groups although there was a significant reduction in SUD scores in the treatment group when compared with the control group. However, Lohr et al. (1995) suggest that the Mississippi PTSD Scale is based on historical information and may not be a sensitive measure of symptom change. Further, a number of authors have noted a negative correlation between chronicity of PTSD and successful treatment outcome (Peterson, Prout and Schwartz, 1991; Forbes, Creamer & Rycroft, 1994). Finally, EMD requires that the procedure be repeated for each traumatic image. Whilst is possible that some of the patients may have only required one or two sessions, it is likely that many would have required several sessions if there was to be any reasonable chance of the EMD being effective. Nevertheless, the study does suggest that Shapiro’s claim that 60-70% of patients will improve after a single session cannot be generalised to all PTSD populations. Furthermore, the efficacy of EMD with combat veterans suffering from chronic PTSD has yet to be established. |
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| + | An early critical review and metanalysis that looked at the contribution of eye movements to treatment effectiveness in EMDR concluded that eye movements are not necessary to the treatment effect.<ref> Davidson PR, Parker KC (2001). "Eye movement desensitization and reprocessing (EMDR): a meta-analysis". Journal of consulting and clinical psychology 69 (2): 305-16. </ref><ref> Cahill SP, Carrigan MH, Frueh BC (1999). "Does EMDR work? And if so, why?: a critical review of controlled outcome and dismantling research". Journal of anxiety disorders 13 (1-2): 5-33.</ref> However, recent research has demonstrated that when the eye movement component of EMDR is removed from the method the procedure is less effective.<ref>Lee, C. W., & Drummond, P.D. (in press). Effects of Eye Movement versus Therapist Instructions on the Processing of Distressing Memories, Journal of Anxiety Disorders, (2007)doi:10.1016/J.janxdis.2007.08.007</ref>. This finding supports previous research that has demonstrated that EMDR with eye movements is more effective than treatment conditions that do not utilise eye movements in the method <ref>{{cite journal | last = Shapiro | first = F. | title = Efficacy of the eye movement desensitization procedure in the treatment of traumtic memories | journal = Journal of Traumatic Stress Studies | volume = 2 | pages = 199-223 | date = 1989 }}</ref><ref>{{cite journal | last = Boudewyns | first = P.A.| coauthors = Stwertka, S. A., Hyer, L. A., Albrecht, J. W., & Sperr, E. V. | title = Eye movement desensitization and reprocessing: A treatment outcome pilot study | journal = The Behavior Therapist | volume = 16 | pages = 30-33 | date = 1993}}</ref><ref>{{cite journal | last = Gosselin | first = P. | last2 = Matthews | first2 = W.J. | title = Eye movement desensitization and reprocessing in the treatment of test anxiety: A study of the effects of expectancy and eye movement | journal = Journal of Behavior Therapy & Experimental Psychiatry | volume = 26 | issue = 4 | pages = 331-337 | date = 1995 }}</ref>, or instead use a dual attention task such as tapping<ref>{{cite journal | last1 = Wilson | first1 = D. | last2 = Silver | first2 = S.M. | last3 = Covi | first3 = W. | last4 = Foster | first4 = S. | title = Eye movement desensitization and reprocessing: Effectiveness and autonomic correlates. | journal = Journal of Behaviour Therapy and Experimental Psychiatry, | volume = 27 | pages = 219-229 | date = 1996}}</ref>. |
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| + | MacCulloch (2006) argued that the eye movements make a unique contribution to EMDR,<ref> MacCulloch, M. (2006). Effects of EMDR on previously abused child molesters: Theoretical reviews and preliminary findings from Ricci, Clayton, and Shapiro. Journal of Forensic Psychiatry & Psychology, 17(4), 531-537.</ref> whereas Salkovskis (2002) reported that the eye movements are irrelevant and that the effectiveness of the procedure is solely due to it sharing similar properties to cognitive behavioral therapies, such as desensitization and exposure.<ref>Salkovskis P (2002). "Review: eye movement desensitization and reprocessing is not better than exposure therapies for anxiety or trauma". Evidence-based mental health 5 (1): 13.</ref> |
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| − | ==Summary and Conclusions== |
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| − | Of the seventeen studies considered in this review, 13 (7 single-case design and 6 controlled outcome studies) found evidence to suggest that EMD may be a useful technique in the treatment of PTSD. |
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| − | |||
| − | Three studies found no evidence to support the use of EMD in the treatment of PTSD. The first of these (Oswalt et al., 1993) was severely methodologically flawed. The researchers used a small highly selected group (respondents to an advertisement) of which 5 patients were hospitalised psychiatric patients. No account of comorbidity was taken. Furthermore, the authors failed to independently assess the subjects’ PTSD status using a standardised assessment. The only measure used was the SUD scale. Finally, the procedure used failed to include central aspects of the EMD treatment (i.e. use of the VoC scale) and the patients were required to undergo the treatment with an audience of at least three people, two of whom were unknown to them. |
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| + | ===The effect of eye movements on memory, cognitive processes, and physiology in EMDR=== |
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| − | It is true that the laboratory study by Merckelbach et al. (1994) which failed to find reductions in heart rate or the ability to visualise an aversive stimulus following EMD did not specifically set out to evaluate EMD as a treatment for PTSD. |
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| + | Although the necessity of eye movements in EMDR is still a point of controversy and contentious debate, a separate body of research has examined what effects eye movements have on physiology, memory, and cognition during the process of EMDR. To date the research in this area has demonstrated that eye movements decrease the vividness and/or emotional valence of autobiographical memories <ref>{{Citation | last = Andrade | first = J. | last2 = Kavanagh | first2 = D. | last3 = Baddeley | first3 = A. | title = Eye-movements and visual imagery: A working memory approach to the treatment of post-traumatic stress disorder | journal = Journal of Clinical Psychology | volume = 36 | pages = 209-223 | year = 2001}}</ref><ref>{{Citation | last = Kavanagh | first = D.J. | last2 = Freese | first2 = S. | last3 = Andrade | first3 = J.| last4 = May | first4 = J. | title = Effects of visuospatial tasks on desensitization to emotive memories | journal = British Journal of Clinical Psychology | volume = 40 | issue = 3 | pages = 267-280 | year = 2001 }}</ref><ref>{{Citation | last = van den Hout | first = M. | last2 = Muris | first2 = P. | last3 = Salemink | first3 = E. | last4 = Kindt | first4 = M. | title = Autobiographical memories become less vivid and emotional after eye movements | journal = British Journal of Clinical Psychology | volume = 40 | issue = 2 | pages = 121-130 | year = 2001}}</ref>, they enhance the retrieval of episodic memories <ref>{{cite journal | last = Christman | first = S.D. | authorlink = S.D. | coauthors = Garvey, K. J., Propper, R. E., & Phaneuf, K. A. | title = Bilateral eye movements enhance the retrieval of episodic memories | volume = 17 | pages = 221-229 | date = 2003 | doi = 10.1037/0894-4105.17.2.221 | isbn = 0894-4105/03/$12.00 | journal = Neuropsychology}}</ref>, produce a physiological relaxation effect, similar to that which is characteristically seen when an orienting response is elicited <ref>{{citation | last = Barrowcliff | first = A.L. | coauthors = Gray, N. S., Freeman, T. C. A., & MacCulloch, M. J. | title = Eye-movements reduce the vividness, emotional valence and electrodermal arousal associated with negative autobiographical memories | journal = Journal of Forensic Psychiatry and Psychology | volume = 15 | pages = 325-354 | year = 2004 | doi = 10.1080/14789940410001673042 | doi =10.1080/14789940410001673042}}</ref><ref>{{cite journal | last = Barrowcliff | first = A.L. | coauthors = Gray, N. S., MacCulloch, S., Freeman, T. C. A., & MacCulloch, M. J. | title = Horizontal rhythmical eye-movements consistently diminish the arousal provoked by auditory stimuli.| journal = British Journal of Clinical Psychology | volume = 42 | issue = | pages = 289-302 | year = 2003}}</ref><ref>Sack, M., Lempa, W., Steinmetz, A. Lamprecht, F., Hofmann, A. (in press). Alterations in autonomic tone during trauma exposure using Eye Movement Desensitization and Reprocessing (EMDR) - results of a preliminary investigation. Journal of Anxiety Disorders (2007), doi:10.1016/j.janxdis.2008.01.007</ref>, and they have been found to increase cognitive flexibility <ref>{{cite journal | last = Kuiken, | first = D., et al. | title = Eye movement desensitization reprocessing facilitates attentional orienting. | journal =Imagination, Cognition & Personality | volume = 21 | issue = 1 | pages = 3-20 ,| year = 2001}}</ref>. Although a wide range of researchers have proposed various models and theories to explain the effect of eye movements, and the possible role that eye movements may play in the process of EMDR, to date, no single model or theory exists that can explain all of the above mentioned findings. Further research is therefore required in this area. |
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| + | ===Similarity to desensitization and exposure treatments=== |
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| − | Nevertheless, it does serve as a warning about the limitations of analogue studies. PTSD is a highly personal syndrome in which the patient was confronted by a situation involving actual or threatened death or severe injury. All of the symptoms of PTSD are based upon this fundamental aspect of the disorder. Thus, it is possible that information from an aversive stimulus that is not considered personal will be processed in a different way to intensely personal traumatic information. Consequently, this study neither supports nor refutes the claimed efficacy of EMD as a procedure for treating PTSD. |
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| + | Several papers have highlighted key differences between EMDR and traditional exposure treatments.<ref name="pmid11748596">{{cite journal |author=Rogers S, Silver SM |title=Is EMDR an exposure therapy? A review of trauma protocols |journal=Journal of clinical psychology |volume=58 |issue=1 |pages=43-59 |year=2002 |pmid=11748596 |doi=10.1002/jclp.1128}}</ref><ref>Smyth, N.J. and A.D. Poole, EMDR and cognitive-behavior therapy: Exploring convergence and divergence, in EMDR as an integrative psychotherapy approach: Experts of diverse orientations explore the paradigm prism, F. Shapiro, Editor. 2002, American Psychological Association: Washington, DC. p. 151-180.</ref> A recent study has found key differences in the crucial processes of EMDR and traditional exposure.<ref>Lee, C.W., G. Taylor, and P. Drummond, The active ingredient in EMDR; is it traditional exposure or dual focus of attention? Clinical Psychology & Psychotherapy, 2006. 13: p. 97-107.</ref> Unlike traditional exposure where reliving responses in the treatment session was found to be associated with post session improvement,<ref name="pmid9489273">{{cite journal |author=Jaycox LH, Foa EB, Morral AR |title=Influence of emotional engagement and habituation on exposure therapy for PTSD |journal=Journal of consulting and clinical psychology |volume=66 |issue=1 |pages=185-92 |year=1998 |pmid=9489273 |doi=10.1037/0022-006X.66.1.185}}</ref> reliving responses were not associated with any improvement in EMDR.<ref>Lee, C.W., G. Taylor, and P. Drummond, The active ingredient in EMDR; is it traditional exposure or dual focus of attention? Clinical Psychology & Psychotherapy, 2006. 13: p. 97-107.</ref> Instead, greater improvement in PTSD symptoms was found to be associated with distancing responses given in session. |
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| + | ==Areas in which EMDR has been studied== |
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| − | The study by Jensen (1994) suggests that Shapiro’s claim that EMD is effective 60-70% of patients after the first session is excessive, at least when war veterans with chronic PTSD are considered. It also lends further weight to the assertion of other authors that there is a negative correlation between chronicity and successful outcome when EMD is applied to PTSD (Peterson, Prout and Schwartz, 1991; Forbes, Creamer & Rycroft, 1994). |
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| + | EMDR has been investigated as a treatment of a wide variety of conditions. |
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| + | {{Main|EMDR and the treatment of PTSD}} |
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| − | Owing to the variability in research designs employed by the various authors reviewed, it is difficult to fully evaluate the efficacy of EMD in the treatment of PTSD. Even so, a number of observations can be drawn from the literature. To begin with, none of the studies provided conclusive evidence that EMD is a comprehensive treatment for all aspects of PTSD. Indeed, evidence from some studies suggests that as many as 50% of patients continued to meet the criteria for PTSD post-treatment (e.g. Forbes, Creamer & Rycroft, 1994; Vaughan et al., 1994b). Additionally, the effect of EMD on general psychological functioning remains unclear. Whilst some authors report reductions in depression and anxiety (e.g. Renfrey & Spates, 1994; Forbes, Creamer & Rycroft, 1994) others suggest that their results were less clear (e.g. Boudewyns et al., 1993; Wilson, Becker & Tinker, 1995). There is also clear evidence that alternative approaches to EMD are effective in reducing some of the symptoms associated with PTSD (Sanderson & Carpenter, 1992; Boudewyns et al., 1993; Vaughan et al., 1994b). Finally, as has been stated, it may transpire that EMD is of limited utility in patients with long-term PTSD. |
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| + | {{Main|EMDR and the treatment of phobias}} |
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| − | There are a number of positive indications that emerge from the literature. Thus, several authors agree that EMD seems to be particularly effective in reducing intrusion and avoidance symptoms in PTSD (e.g. Shapiro, 1989; Puk, 1991; Renfrey & Spates, 1994; Sanderson & Carpenter, 1992; Forbes, Creamer & Rycroft, 1994; Vaughan et al., 1994; Wilson, Becker & Tinker, 1995). Further, whilst other treatments were shown to be effective in reducing these symptoms (Sanderson & Carpenter, 1992, Boudewyns et al., 1993; Vaughan et al., 1994b), EMD appears to have been more effective than these alternatives. Finally, when effective, EMD seems to require less treatment time than any of the alternatives examined (e.g. Vaughan et al., 1994b). |
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| + | {{Main|EMDR and the treatment of OCD}} |
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| − | There are practical advantages to a technique that requires relatively few sessions (thus preventing prolonged high levels of anxiety) and does not require the (unreliable) compliance associated with homework. The fact that EMD appears to be an effective treatment for some aspects of PTSD and not others, may be evidence for the multi-factorial structure of the PTSD syndrome. It is suggested that there is sufficient evidence to warrant continuing research into the application of EMD for treating PTSD. Future research should address itself to the deconstruction of the EMD procedure to establish exactly how the technique produces its effects. The development of a clear theoretical basis for the technique may result in it being better targeted and, consequently, more effective. |
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| − | |||
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| − | Vaughan, K., Armstrong, M. S., Gold, R., O’Connor, Jenneke, W., & Tarrier, N. (1994b). A trial of eye movement desensitisation compared to image habituation training and applied muscle relaxation in post-traumatic stress disorder. ''Journal of Behavior Therapy and Experimental Psychiatry'', 25, 283-291. |
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| − | Welch, R. B. (1996). On the origin of eye movement desensitization and reprocessing: A response to Rosen. ''Journal of Behaviour Therapy and Experimental Psychiatry''. 27, 175-179. |
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| − | Weismann, M., Sholomkas, D., Pottenger, M., Prusoff, B. & Locke, B. (1977). Assessing depressive symptoms in five psychiatric populations: A validation study. ''American Journal of Epidemiology'', 106, 203-214. |
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| − | Wilson, S. A., Becker, L. A. & Tinker, R. H. (1995). Eye movement desensitisation and reprocessing (EMDR) treatment for psychologically traumatized individuals. ''Journal of Consulting and Clinical Psychology'', 6, 928-937. |
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| − | Wolpe, J. (1982). The Practice of Behavior Therapy. New York: Pergamon. |
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| − | Wolpe, J. & Abrams, J. (1991). Post-traumatic stress disorder overcome by eye-movement desensitisation: a case report. ''Journal of Behavior Therapy and Experimental Psychiatry'', 22, 39-43. |
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| − | Wolpe, J. & Lang, P. J. (1969). Fear Survey Schedule, San Diego, CA: Educational and Industrial Testing Service. |
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==See also== |
==See also== |
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| + | *[[Attachment disorder]] |
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| + | *[[Anxiety disorder]] |
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| + | *[[Behavior therapy]] |
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| + | *[[Complex post-traumatic stress disorder]] |
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| + | *[[EMDR and crisis intervention]] |
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| + | *[[Emotional dysregulation]] |
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| + | *[[Eye movements]] |
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*[[Post-traumatic stress disorder]] |
*[[Post-traumatic stress disorder]] |
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*[[Rapid eye movement]]s |
*[[Rapid eye movement]]s |
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*[[Saccade]]s |
*[[Saccade]]s |
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| + | |||
| + | *[[Additional EMDR references]] |
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| + | |||
| + | ==Bibliography== |
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| + | ===References=== |
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| + | {{reflist|2}} |
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| + | |||
| + | ===Key texts – Books=== |
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| + | *Shapiro, F (2001)Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols, and Procedures. Guildford Press. ISBN 1572306726 |
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| + | *Shapiro, F (2002) (ed) EMDR as an Integrative Psychotherapy Approach: Experts of Diverse Orientations Explore the Paradigm Prism. APA. ISBN 1557989222 |
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| + | *Shapiro, F (2002) (ed) Light in the Heart of Darkness: EMDR and the Treatment of War and Terrorism Survivors. W W Norton. ISBN 0393703665 |
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| + | *Shapiro, F & Forrest, M S (2004) EMDR: The Breakthrough Therapy for Overcoming Anxiety, Stress and Trauma . Basic books.ISBN 0465043011 |
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| + | *Shapiro, F., (2005). Eye movement desensitization and reprocessing: Basic principles, protocols and procedures (2nd ed.). New York: Guilford Press. |
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| + | *Shapiro, F (2007) Handbook of EMDR and Family Therapy Processes.Wiley. ISBN 0471709476 |
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==External links== |
==External links== |
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Eye Movement Desensitization and Reprocessing (EMDR) is an information processing psychotherapy that was developed to resolve symptoms resulting from disturbing and unresolved life experiences. EMDR is rated in the highest category of effectiveness and research support in international guidelines for PTSD treatment. It uses a structured approach to address past, present, and future aspects of disturbing memories. The approach was developed by Francine Shapiro[1] to resolve symptoms resulting from exposure to a traumatic or distressing event, such as rape. Clinical trials have demonstrated EMDR's efficacy in the treatment of post-traumatic stress disorder (PTSD). In some studies it has been shown to be equivalent to cognitive behavioral and exposure therapies, and more effective than some alternative treatments (see effectiveness sections below). Although some clinicians may use EMDR for various problems, its research support is primarily for disorders stemming from distressing life experiences.[2][3]
The theoretical model underlying EMDR treatment hypothesizes that EMDR works by processing distressing memories. EMDR is based on a theoretical information processing model which posits that symptoms arise when events are inadequately processed, and can be eradicated when the memory is fully processed. It is an integrative therapy, synthesizing elements of many traditional psychological orientations, such as psychodynamic, cognitive behavioral, experiential, physiological, and interpersonal therapies.[4]
EMDR's most unique aspect is an unusual component of bilateral stimulation of the brain, such as eye movements, bilateral sound, or bilateral tactile stimulation coupled with cognitions, visualized images and body sensation. EMDR also utilizes dual attention awareness to allow the individual to vacillate between the traumatic material and the safety of the present moment. This prevents retraumatization from exposure to the disturbing memory. As EMDR is an integrative therapy which combines elements of cognitive behavioral and psychodynamic therapies to desensitize traumatic memories, some individuals have criticized EMDR and consider the use of eye movements to be an unnecessary component of treatment.[5][6]. However, recent studies have examined the effects of eye movements and have found that eye movements in EMDR decrease the vividness and/or negative emotions associated with autobiographical memories, [7][8][9][10], enhance the retrieval of episodic memories,[11] increase cognitive flexibility,[12] and correlate with decreases in heart rate, skin conductance, and an increased finger temperature [13][14]. These physiological changes associated with EMDR are consistent with earlier research on physiological changes associated with EMDR [15]. Also recent studies that have removed eye movement from the method have found the procedure less effective [16].
Description of therapy
There are two perspectives on EMDR therapy. One was advanced by the method's creator, with a theory that eye movements provide some neurological and psychological effects that enhance the processing of traumatic memories. The other perspective is that eye movements are an epiphenomenon, unnecessary, and that EMDR is simply a form of desensitization.
Theoretical basis for the therapy
Eye Movement Desensitization and Reprocessing (EMDR) has been used to treat posttraumatic stress disorder (PTSD). It integrates elements of imaginal exposure, cognitive therapy, psychodynamic and somatic therapies. It also uses the unique and somewhat controversial element of bilateral stimulation (e.g. moving the eyes back and forth). According to Francine Shapiro's theory, when a traumatic or distressing experience occurs, it may overwhelm usual ways of coping and the memory of the event is inadequately processed; the memory is dysfunctionally stored in an isolated memory network. When this memory network is activated, the individual may re-experience aspects of the original event, often resulting in inappropriate overreactions. This explains why people who have experienced or witnessed a traumatic incident may have recurring sensory flashbacks, thoughts, beliefs, or dreams. An unprocessed memory of a traumatic event can retain high levels of sensory and emotional intensity, even though many years may have passed.
EMDR uses a structured eight-phase approach and addresses the past, present, and future aspects of the dysfunctionally stored memory. During the processing phases of EMDR, the client attends to the disturbing memory in multiple brief sets of about 15-30 seconds, while simultaneously focusing on the dual attention stimulus (e.g., therapist-directed lateral eye movements, alternate hand-tapping, or bilateral auditory tones). Following each set of such dual attention, the client is asked what associative information was elicited during the procedure. This new material usually becomes the focus of the next set. This process of alternating dual attention and personal association is repeated many times during the session.
The theory is that EMDR works directly with memory networks and enhances information processing by forging associations between the distressing memory and more adaptive information contained in other semantic memory networks. It is thought that the distressing memory is transformed when new connections are forged with more positive and realistic information. This results in a transformation of the emotional, sensory, and cognitive components of the memory so that, when it is accessed, the individual is no longer distressed. Instead he/she recalls the incident with a new perspective, new insight, resolution of the cognitive distortions, elimination of emotional distress, and relief of related physiological arousal.[17]
When the distressing or traumatic event is an isolated incident, the symptoms can often be cleared with one to three EMDR sessions. But when multiple traumatic events contribute to a health problem - such as physical, sexual, or emotional abuse, parental neglect, severe illness, accident, injury, or health-related trauma that result in chronic impairment to health and well-being - the time to heal may be longer.[18]
What is it?
Eye Movement Desensitisation and Reprocessing (EMDR) is a rapdily developing treatment method that is being applied to an increasingly wide range of clinical conditions.
The founder of the approach is Francine Shapiro. Shapiro claims that the discovery of EMDR was serrendipitous; she claims that she was out walking and was feeling upset when she noticed that if she induced rapid saccadic eye movements, this had an immediate calming effect that elminated her traumatic feelings. She expermimented with her discovery and developed a clinical technique that has aroused extensive interest around the world.
Initially, the technique was developed for the treatment of psychological trauma. However, the protocol has been developed over the past decade to deal with a wide variety of usually anxiety-based disorders.
Essentially the technique involves exposing the patient to his traumatic memories whilst simultaneously inducing rapid eye movements (by asking the patient to track an oscillating stimulus such as a finger or light). The patient is also required to hold in mind a cognitive statement about himself that is derived during the assessment process.
There is considerable debate and controversy regarding how and why EMDR works. When it is successful, the technique can eliminate the intrusive symptoms associated with psychological trauma within a session or two.
It should be noted that, in her later work, Shapiro changed the name of the technique “Eye Movement Desensitisation and Reprocessing” to connote the “accelerated information processing” that she assumed to be of major importance in the efficacy of the approach. However, the mechanisms by which the technique works have not been conclusively identified and, as Lohr, Kleinknecht, Tolin & Barrett (1995) point out;
"... there is no empirical evidence of the effects of treatment that justifies the use of the term reprocessing” (p.286)
Lohr et al (1995) chose to adhere to the popular name for the treatment protocol, EMDR, because it is now the most commonly used term. However, it is suggested that incorrect labelling of the technique perpetuates a myth which implies the establishment of a mechanism for the phenomenon.
- Main article: Mechanisms underlying the effectiveness of EMDR
It should be noted that while EMDR requires specialist training available from the EMDR Institutewhich offers courses around the world, it is a technique and not a therapy in and of itself and is most effectively employed by broadly trained and experienced therapists who use it when in their clinical judgement it fits the situation. The technique can induce powerful emotional reactions. Thus, if it is applied without sufficient understanding and experience to a patient for whom the treatment is contraindicated, it can induce a psychotic reaction.
Description of therapy process
- Phase I: In the first sessions, the patient's history and an overall treatment plan are discussed. During this process the therapist identifies and clarifies potential targets for EMDR. Target refers to a disturbing issue, event, feeling, or memory for use as an initial focus for EMDR. Maladaptive beliefs are also identified.
- Phase II: Before beginning EMDR for the first time, it is recommended that the client identify a safe place, an image or memory that elicits comfortable feelings and a positive sense of self. This safe place can be used later to bring closure to an incomplete session or to help a client tolerate a particularly upsetting session.
- Phase III: In developing a target for EMDR, prior to beginning the eye movements, a snapshot image is identified that represents the target and the disturbance associated with it. Using that image is a way to help the client focus on the target, a negative cognition (NC) is identified - a negative statement about the self that feels especially true when the client focuses on the target image. A positive cognition (PC) is also identified - a positive self-statement that is preferable to the negative cognition.
- Phase IV: The therapist asks the patient to focus simultaneously on the image, the negative cognition, and the disturbing emotion or body sensation. Then the therapist usually asks the client to follow a moving object with his eyes; the object moves alternately from side to side so that the client's eyes also move back and forth. After a set of eye movements, the client is asked to report) the targeted memory.
Vocabulary of terms
The following basic terms are described in Shapiro's 2001 text[1]
- Information Processing
- During information processing, a physiologically-based system sorts new (perceptual) information, makes connections between new information and other information already stored in associated memory networks, encodes the material, and stores it in memory.
- Adaptive Resolution
- When information processing is complete, learning takes place, and information is stored in memory with appropriate emotion. The new information is therefore available to guide future action.
- Dysfunctionally Stored Information
- When information processing is incomplete, the information is not connected to more adaptive information, and it is stored in a memory network with a high negative emotional charge. It can cause reactivity and can be the cause of various symptoms.
- Reprocessing
- During reprocessing in EMDR, new associative links are forged between dysfunctionally stored information and adaptive information, resulting in complete information processing and adaptive resolution.
- Memory Networks
- Neurobiological associations of related memories, sensations, images, thoughts, and emotions.
- Target Memory
- The memory of a distressing or traumatic event, which still causes current distress, and which has been selected to be targeted during EMDR treatment.
- Memory Components
- All components of the target memory are accessed during Phase Three to ensure that the memory network is fully activated. These components include the image, cognitions, emotions, and body sensations.
- VOC (Validity of cognition) scale
- VOC ratings are used in EMDR to measure baseline validity of the positive cognition during Phase Three, and to assess progress being made, where 1 = not true, and 7 = completely true.
- SUD (Subjective units of disturbance) scale
- SUD ratings are used in EMDR, exposure therapies, and other treatments to measure baseline emotional or physical pain and also to assess progress being made. This is a personal measurement of distress, where 0 = no distress, and 10 = worst distress possible.
- Interweave
- A specific strategy used by the clinician to assist processing if the client appears to be having difficulty accessing more adaptive information. Ideally, the interweave contains needed information that would have been available except for blockage of inner pathways by trauma responses.
Empirical evidence regarding EMDR
Over the last 18 years evidence has accumulated that supports EMDR as an effective treatment for problems associated with distressing memories that relate to the experience of a negative/traumatic event. The evidence about whether EMDR is effective will be first considered on the basis of what scientific committees from around the world have concluded, then EMDR will be compared to typical treatments, medication and traditional exposure based treatments. Although, as discussed below, EMDR is generally considered an efficacious treatment for the treatment of trauma, and its effectiviness is considered to be eqivalent to that of traditional exposure therapy, the working mechanisms that underlie the effectiveness of EMDR, and whether the eye movement component in EMDR contributes to its clinical effectiveness it still a point of uncertainty and contentious debate.
- For more details on this topic, see [EMDR:Controversy]..
Effectiveness: Conclusions from international scientific committees
Based on the evidence of controlled research both the practice guidelines of the American Psychiatric Association [19] and the Department of Veterans Affairs and Defense [20] have placed EMDR in the highest category of effectiveness and research support in the treatment of trauma. This status is reflected in a number of international guidelines where EMDR is a recommended treatment for trauma [21][22][23][24][25][26].
Effectiveness: EMDR compared to typical treatments
EMDR has been demonstrated to have significant advantages over usual treatment for PTSD in an HMO setting, and improvement was maintained at a six month follow-up.[27] EMDR has been shown to be effective on measures of trauma, depression and anxiety in women who had been sexually abused as children.[28][29]
Effectiveness: EMDR compared to medication
To date EMDR has only been compared directly to medication in one study. Van der Kolk et al. found EMDR to be more effective than fluoxetine, an SSRI in treating trauma, especially six months post-treatment. The study also suggests a role for SSRIs as a reliable first-line intervention.[30]
Effectiveness: EMDR versus traditional exposure treatments (studies in the last 5 years)
EMDR proved significantly better than stress inoculation training with prolonged exposure in a study with 24 participants diagnosed with post traumatic stress disorder.[31] Although reduction in symptom severity was equivalent post treatment, at follow-up, EMDR lead to greater gains on both self report and observer rated measures of PTSD and self report measures of depression. In another study of 22 participants who had also been diagnosed with PTSD, both EMDR and prolonged exposure were found to be effective post treatment.[32] Participants receiving EMDR appeared to improve quicker in that 70% had reached a level of clinically significant improvement in PTSD after three EMDR sessions compared to only 17% in the prolonged exposure condition.
EMDR was also found to work more quickly than exposure based treatments in a larger trial with 105 participants.[33] At a fifteen-month follow-up, gains for both treatments were generally maintained. The only significant difference at follow-up was an improvement in depression according to an independent observer in favour of EMDR.
EMDR and Prolonged Exposure (PE) were found to be equivalently efficacious and both superior to a waitlist control in a controlled trial of 74 female rape victims.[34] Measures used by blind assessors included PTSD, depression, dissociation and state anxiety. Unlike other studies noted above, there was no difference between the active treatments in rate of improvement. However EMDR seemed to do adequately well despite utilising no homework tasks and less exposure. The study met the highest criteria for methodological rigour proposed by Foa and Meadows.[35]
The improvements in EMDR over CBT are not limited to English speaking cultures. In a study involving Iranian girls who had been sexually abused, EMDR was found to be significantly more efficient than CBT.[36]
Although most studies show EMDR and CBT to be about the same, one study reported an opposite effect.[37] Analysis of changes in symptoms for the 15 participants who completed treatment indicated greater reductions on symptom measures of avoidance and re-experiencing for imaginal exposure treatment over EMDR but equivalent reductions on hyper arousal. However there were no differences between the two treatments in the intent to treat analysis and no differences between the two treatments on percentage of people with PTSD diagnosis at follow-up.
Effectiveness: meta-analysis
EMDR was found in the first ever meta-analysis of PTSD to be equally effective as exposure therapy and SSRIs[38]. Two recent meta-analyses concluded that traditional exposure therapy and EMDR have equivalent effects both immediately after treatment and at follow-up.[39][40]The most recent meta-analysis looked at 38 randomized controlled trials for PTSD treatment and concluded that the first-line psychological treatment for PTSD should be Trauma-Focused CBT or EMDR.[41]
Other applications of EMDR
Although controlled research has concentrated on the application of EMDR to PTSD, a number of studies have investigated EMDR’s efficacy with other anxiety disorders as well as numerous reports of diverse clinical applications.
Case reports have been published on the application of EMDR to the treatment of (a) personality disorders ( Fensterheim, 1996a; Korn & Leeds, in press; Manfield, 1998), (b) dissociative disorders ( Fine & Berkowitz, 2001; Lazrove & Fine, 1996; Paulsen, 1995; Twombly, 2000), ( c ) a variety of anxiety disorders[42] ( De Jongh & Ten Broeke, 1998; Goldstein & Feske, 1994; Lovett, 199; Nadler, 1996; Shapiro & Forrest, 1997) and (d) somatoform disorders ( Brown, Mcgoldrick, & Buchanan, 1997; Grant & Threlfo, 2002). However, controlled research is needed to evaluate the efficacy of these applications.
In designing the research the entire EMDR protocol should be evaluated within the context of the potential special needs of the particular population. For instance, Brown et al. (1997) evaluated the application of EMDR in seven consecutive cases of Body Dysmorphic Disorder (BDD), which has been reported to necessitate 8 to 20 sessions of cognitive behavior therapy with varying success rates ( Neziroglu, McKay, Todaro, & Yaryura-Tobias, 1996; Beale et al., 1996; Wilhelm, Otto, Lohr, & Deckersbach, 1999). In contrast, Brown et al. reported the elimination of BDD in five of the seven consecutive cases in one to three sessions of EMDR through the processing of the etiological memory. While this result indicates the EMDR holds promise for the treatment of this disorder, future controlled research should include a greater number of sessions in order to evaluate the more comprehensive clinical picture.
EMDR can work on a multitude of problems that are less complex than PTSD. One of these is uncomplicated depression. The EMDR Casebook by Philip Manfield, PH.D. has documented several case studies in which EMDR was used. In the case about uncomplicated depression, Manfield was able to help his client, George, resolve several childhood issues that have plagued his adult life. Moreover, EMDR can work for diseases such as postpartum depression. By having the client target a distinctive memory and work through it with a series of eye movements, the client is then able to achieve a positive cognition.[43]
EMDR has been used on children to treat a variety of conditions.[44][45] It has been used in the treatment of children who have experienced trauma and complex trauma.[44][45] It is often cited as a component in the treatment of Complex Post Traumatic Stress Disorder,[46] emotional dysregulation, and in the treatment of children exposed to chronic early maltreatment that is related to Attachment disorder. It is recognised by the UK National Institute for Health & Clinical Excellence (NICE) Guidelines as a treatment for PTSD.
Full article: EMDR 12 Years after Its Introduction: Past and Future Research Francine Shapiro; Mental Research Institute, Palo Alto, CA Journal of Clinical Psychology, Vol. 58(1), 1-22 (2002) 2002 John Wiley & Sons, Inc.
How does EMDR work?
There is no definitive explanation as to how EMDR works. There is some empirical support for three explanations regarding how an external stimulus such as eye movement can facilitate the processing of traumatic memories. The first hypothesis views PTSD as a failure by the individual to process episodic memory;[47][48] the bilateral eye movements involved in EMDR facilitate interaction between the brain's hemispheres, which then improves the processing of trauma-related memories. This hypothesis is supported by a study that tested the effects of eye movement on the ability to retrieve episodic memory. The study found better recall following a horizontal eye movement task compared to that following no eye movement or a vertical eye movement task.[49] A second hypothesis suggests that eye movements facilitate processing of trauma memories by activating a neurobiological state similar to REM sleep wherein associative links to episodic memories are formed and these memories are then integrated into general semantic networks. Stickgold proposed that PTSD occurs when an event is sufficiently arousing to prevent its transfer from encoding from an episodic memory to a semantic memory.[48] As a result of high arousal levels, associations between the traumatic event and other related events fail to develop. He argues that the attentional redirecting in EMDR induces a neurobiological state similar to REM sleep. He then reviews the research that suggests that REM sleep enhances processing of episodic memory through the preferential activation of weak associative and semantic links. Thus in EMDR trauma-related information that is closely associated with a target event is weakened and ancillary information loosely related to the event is strengthened, allowing the integration of trauma-related material with other loosely associated events in the person’s life. Support for this argument comes from a study that found that, compared to eye fixation, eye movement promoted attentional flexibility and increased preparedness to process metaphorical material.[50]
A third hypothesis links the eye movements in EMDR with the orienting response.[51] MacCulloch and Feldman argued that eye movements trigger the investigation component of the orienting response, which can either produce avoidance behaviour or inhibit avoidance responses. Inhibiting avoidance behaviour includes reducing both negative somatic responses and cognitive changes that would allow fresh investigatory behaviour to commence. MacCulloch and Feldman proposed that initially when danger is identified there is a negative affect response. However a second part of the orienting response is to scan for further danger, and this investigatory reflex seems to accompany a positive physical response. In the authors’ opinion, eye movement induces this investigatory reflex and produces a relaxation response. A relaxation response was, in fact, found in a study that investigated the autonomic responses of participants when they were engaged in an eye movement task as part of EMDR treatment[52] and when participants focused on negative memories while engaging in eye movement [23]. However there is not a differential effect of eye movement on a relaxation response when participants focused on positive memories.[53] This supports the hypothesis that eye movements are an orienting response mechanism rather than a simple relaxation mechanism. In addition, recent research that has examined the physiological correlates of eye movements in EMDR has found that a clear orienting response pattern of psycho-physiological de-arousal occurs when eye movements begin, and this de-arousal is characteristic of the physiological changes that occur when an orienting response is elicited [54].
Further data consistent with the orienting response hypothesis was the finding that EMDR treatment was associated with increased left pre-frontal hemisphere activation.[55][56] Investigatory and approach behavior has been shown to be associated with the anterior left hemisphere regions.[57]
Controversy
EMDR has generated a great deal of controversy since its inception. Critics of EMDR argue that the eye movements do not play a central role, that the mechanisms of eye movements are speculative, and that the theory leading to the practice is not falsifiable and amenable to scientific enquiry.[5][58]
Although one meta-analysis concluded that EMDR is not as effective, or as long lasting, as specific exposure therapy,[59] several other researchers using meta-analyses have found EMDR to be at least equivalent in effect size to specific exposure therapies.[60][61][62][63]
Are eye movements necessary?
An early critical review and metanalysis that looked at the contribution of eye movements to treatment effectiveness in EMDR concluded that eye movements are not necessary to the treatment effect.[64][65] However, recent research has demonstrated that when the eye movement component of EMDR is removed from the method the procedure is less effective.[66]. This finding supports previous research that has demonstrated that EMDR with eye movements is more effective than treatment conditions that do not utilise eye movements in the method [67][68][69], or instead use a dual attention task such as tapping[70].
MacCulloch (2006) argued that the eye movements make a unique contribution to EMDR,[71] whereas Salkovskis (2002) reported that the eye movements are irrelevant and that the effectiveness of the procedure is solely due to it sharing similar properties to cognitive behavioral therapies, such as desensitization and exposure.[72]
The effect of eye movements on memory, cognitive processes, and physiology in EMDR
Although the necessity of eye movements in EMDR is still a point of controversy and contentious debate, a separate body of research has examined what effects eye movements have on physiology, memory, and cognition during the process of EMDR. To date the research in this area has demonstrated that eye movements decrease the vividness and/or emotional valence of autobiographical memories [73][74][75], they enhance the retrieval of episodic memories [76], produce a physiological relaxation effect, similar to that which is characteristically seen when an orienting response is elicited [77][78][79], and they have been found to increase cognitive flexibility [80]. Although a wide range of researchers have proposed various models and theories to explain the effect of eye movements, and the possible role that eye movements may play in the process of EMDR, to date, no single model or theory exists that can explain all of the above mentioned findings. Further research is therefore required in this area.
Similarity to desensitization and exposure treatments
Several papers have highlighted key differences between EMDR and traditional exposure treatments.[81][82] A recent study has found key differences in the crucial processes of EMDR and traditional exposure.[83] Unlike traditional exposure where reliving responses in the treatment session was found to be associated with post session improvement,[84] reliving responses were not associated with any improvement in EMDR.[85] Instead, greater improvement in PTSD symptoms was found to be associated with distancing responses given in session.
Areas in which EMDR has been studied
EMDR has been investigated as a treatment of a wide variety of conditions.
- Main article: EMDR and the treatment of PTSD
- Main article: EMDR and the treatment of phobias
- Main article: EMDR and the treatment of OCD
See also
- Attachment disorder
- Anxiety disorder
- Behavior therapy
- Complex post-traumatic stress disorder
- EMDR and crisis intervention
- Emotional dysregulation
- Eye movements
- Post-traumatic stress disorder
- Rapid eye movements
- Saccades
- Additional EMDR references
Bibliography
References
- ↑ 1.0 1.1 Shapiro, Francine (1995). Eye movement desensitization and reprocessing: basic principles, protocols, and procedures, 398, New York: Guilford Press.
- ↑ Maxfield, L. (2003). Clinical implications and recommendations arising from EMDR research findings. Journal of Trauma Practice, 2, 61-81.
- ↑ Louise Maxfield; Shapiro, Francine; Kaslow, Florence Whiteman (2007). Handbook of EMDR and Family Therapy Processes, 504, New York: Wiley.
- ↑ Shapiro, F. & Maxfield, L. (2002). Eye movement desensitization and reprocessing (EMDR): Information processing in the treatment of trauma. Journal of Clinical Psychology, 58, 933-948.
- ↑ 5.0 5.1 Herbert, Lilienfield et al. 'Science and Pseudoscience in the development of eye movement and reprocessing: Implications for Clinical Psychology'. Clinical Psychology Review, Vol.20, No.8, pp945-971, 2000 PMID1098395 Cite error: Invalid
<ref>tag; name "Herbert" defined multiple times with different content - ↑ [1] Traumatology, Vol. 9, No. 3 (September 2003) 169. EMDR: Why the Controversy? Charlotte Sikes and Victoria Sikes
- ↑ Andrade, J., Kavanagh, D., & Baddeley, A. (1997). Eye-movements and visual imagery: A working memory approach to the treatment of post-traumatic stress disorder. British Journal of Clinical Psychology, 36, 209-223
- ↑ Barrowcliff, A.L., et al., Eye-movements reduce the vividness, emotional valence and electrodermal arousal associated with negative autobiographical memories. Journal of Forensic Psychiatry & Psychology, 2004. 15(2): p. 325-345.
- ↑ Kavanagh, D. J., Freese, S., Andrade, J., & May, J. (2001). Effects of visuospatial tasks on desensitization to emotive memories. British Journal of Clinical Psychology, 40(3), 267-280.
- ↑ van den Hout, M., Muris, P., Salemink, E., & Kindt, M. (2001. Autobiographical memories become less vivid and emotional after eye movements. British Journal of Clinical Psychology, 40(2), 121-130.
- ↑ Christman S.D., Garvey K.J., Propper R.E., Phaneuf K.A. (2003. Bilateral eye movements enhance the retrieval of episodic memories. Neuropsychology 17 (2): 221-9. PMID 12803427
- ↑ Kuiken, D., et al. (2001), Eye movement desensitization reprocessing facilitates attentional orienting. Imagination, Cognition & Personality, 21(1): p. 3-20.
- ↑ Elofsson, U. O. E., von Schèele, B., Theorell, T., & Söndergaard, H. P. (in press). Physiological correlates of eye movement desensitization and reprocessing. Journal of Anxiety Disorders, doi:10.1016/j.janxdis.2007.05.012
- ↑ Sack, M., Lempa, W., Steinmetz, A. Lamprecht, F., Hofmann, A. (in press). Alterations in autonomic tone during trauma exposure using Eye Movement Desensitization and Reprocessing (EMDR) - results of a preliminary investigation. Journal of Anxiety Disorders (2007), doi:10.1016/j.janxdis.2008.01.007
- ↑ Wilson, D., Silver, S. M., Covi, W., & Foster, S. (1996). Eye movement desensitization and reprocessing: Effectiveness and autonomic correlates. Journal of Behavior Therapy and Experimental Psychiatry, 27(3), 219-229.
- ↑ Lee, C. W., & Drummond, P.D. (in press). Effects of Eye Movement versus Therapist Instructions on the Processing of Distressing Memories, Journal of Anxiety Disorders, (2007)doi:10.1016/J.janxdis.2007.08.007
- ↑ Maxfield, L. (2003). Clinical implications and recommendations arising from EMDR research findings. Journal of Trauma Practice, 2, 61-81.
- ↑ Phillips, Maggie., (2000). Finding the Energy to Heal: How EMDR, hypnosis, TFT, imagery, and body focused therapy can help restore the mind body health. NY:Nortonn.com
- ↑ American Psychiatric Association (2004). Practice Guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder..
- ↑ Department of Veteran Affairs & Department of Defense (2004), VA/DoD clinical practice guideline for the management of post-traumatic stress, Washington, DC: Author, http://www.oqp.med.va.gov/cpg/PTSD/PTSD_cpg/frameset.htm.
- ↑ Australian Centre for Posttraumatic Mental Health. (2007), Australian guidelines for the treatment of adults with acute stress disorder and post traumatic stress disorder., Melbourne, Victoria: ACPTMH., http://www.acpmh.unimelb.edu.au/resources/resources-guidelines.html#1
- ↑ National Institute for Clinical Excellence (2005), Post traumatic stress disorder (PTSD): The management of adults and children in promary and secondary care., London: NICE Guidelines, http://www.nice.org.uk/guidance/index.jsp?action=byID&r=true&o=10966
- ↑ Dutch National Steering Committee Guidelines Mental Health and Care., Guidelines for the diagnosis treatment and management of adult clients with an anxiety disorder., Utrecht, Netherlands: The Dutch Institute for Healthcare Improvement (CBO)
- ↑ Foa, E.B.; Keane, T.M.; Friedman, M.J. (2000), Effective treatments for PTST: Practice guidelines of the International Society for Traumatic Stress Studies, New York: Guilford Press
- ↑ Bleich, A.; Kolter, M.; Kutz, E.; Shaley, A. (2002), A position paper of the (Israeli) National Council for Mental Health: Guidelines for the assessment and professional intervention with terror victime in the hospital and the community., Jerusalem, Israel.
- ↑ United Kingdom Department of Health (2001), Treatment choice in psychological therapies and counseling evidence based on clinical practice guideline., London: Author, http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4007323
- ↑ Marcus, S., P. Marquis, and C. Sakai, Three- and 6-Month Follow-Up of EMDR Treatment of PTSD in an HMO Setting. International Journal of Stress Management, 2004. 11(3): p. 195-208.
- ↑ Edmond, T., L. Sloan, and D. McCarty, Sexual Abuse Survivors' Perceptions of the Effectiveness of EMDR and Eclectic Therapy. Research on Social Work Practice, 2004. 14(4): p. 259-272.
- ↑ Edmond, T., A. Rubin, and K. Wambach, The effectiveness of EMDR with adult female survivors of childhood sexual abuse. Social Work Research, 1999. 23(2): p. 103-116.
- ↑ van der Kolk BA, Spinazzola J, Blaustein ME, et al (2007). A randomized clinical trial of eye movement desensitization and reprocessing (EMDR), fluoxetine, and pill placebo in the treatment of posttraumatic stress disorder: treatment effects and long-term maintenance. The Journal of clinical psychiatry 68 (1): 37-46.
- ↑ Lee, C., et al., Treatment of PTSD: Stress inoculation training with prolonged exposure compared to EMDR. Journal of Clinical Psychology, 2002. 58(9): p. 1071-1089. PMID 12209866
- ↑ Ironson, G., et al., Comparison for two treatments for traumatic stress: A community-based study of EMDR and prolonged exposure. Journal of Clinical Psychology, 2002. 58(1): p. 113-128.
- ↑ Power, K.G., et al., A controlled comparison of eye movement desensitisation and reprocessing versus exposure plus cognitive restructuring, versus waiting list in the treatment of posttraumatic stress disorder. Journal of Clinical Psychology and Psychotherapy, 2002. 9(5): p. 299-318.
- ↑ Rothbaum, B.O., M.C. Astin, and F. Marsteller, Prolonged Exposure Vs Eye Movement Desensitisation and Reprocessing (EMDR) for PTSD Rape Victims. Journal of Traumatic Stress, 2005. 18(6): p. 607-616.
- ↑ Foa, E.B. and E.A. Meadows, Psychosocial treatments for posttraumatic stress disorder: A critical review. Annual Review of Psychology, 1997. 48: p. 449-480.
- ↑ Jaberghaderi, N., et al., A Comparison of CBT and EMDR for Sexually-abused Iranian Girls. Clinical Psychology & Psychotherapy, 2004. 11(5): p. 358-368.
- ↑ Taylor S, Thordarson DS, Maxfield L, Fedoroff IC, Lovell K, Ogrodniczuk J (2003). Comparative efficacy, speed, and adverse effects of three PTSD treatments: exposure therapy, EMDR, and relaxation training. Journal of consulting and clinical psychology 71 (2): 330-8.
- ↑ van Etten, M. L., & Taylor, S. (1998). Comparative Efficacy of Treatments for Post-traumatic Stress Disorder: A Meta-Analysis. Clinical Psychology and Psychotherapy, 5, 126-144. Full text available PDF
- ↑ Bradley R, Greene J, Russ E, Dutra L, Westen D (2005). A multidimensional meta-analysis of psychotherapy for PTSD. The American journal of psychiatry 162 (2): 214-27.
- ↑ Seidler GH, Wagner FE (2006). Comparing the efficacy of EMDR and trauma-focused cognitive-behavioral therapy in the treatment of PTSD: a meta-analytic study. Psychological medicine 36 (11): 1515-22.
- ↑ Bisson JI, Ehlers A, Matthews R, Pilling S, Richards D, Turner S (2007). Psychological treatments for chronic post-traumatic stress disorder. Systematic review and meta-analysis. The British Journal of Psychiatry : the journal of mental science 190: 97-104.
- ↑ De Jongh A, Ten Broeke E, Renssen MR (1999). Treatment of specific phobias with Eye Movement Desensitization and Reprocessing (EMDR): protocol, empirical status, and conceptual issues. Journal of anxiety disorders 13 (1-2): 69-85.
- ↑ Manfield, Philip. (2003). EMDR Casebook. NY: W.W. Norton & Company, Inc.
- ↑ 44.0 44.1 Tinker, R., & Wilson S., (1999) Through the eyes of a child: EMDR with children. NY: Norton.
- ↑ 45.0 45.1 Greenwald, R.,(1999). Eye movement desensitization and reprocessing in child and adolescent psychotherapy. NY: Norton.
- ↑ Scott, Catherine V.; Briere, John (2006). Principles of Trauma Therapy : A Guide to Symptoms, Evaluation, and Treatment, 312, Thousand Oaks: Sage Publications.
- ↑ Shapiro, Francine (2001). Eye Movement Desensitization and Reprocessing (EMDR), Second Edition: Basic Principles, Protocols, and Procedures, 472, New York: The Guilford Press.
- ↑ 48.0 48.1 Stickgold R (2002). EMDR: a putative neurobiological mechanism of action. Journal of clinical psychology 58 (1): 61-75.
- ↑ Christman SD, Garvey KJ, Propper RE, Phaneuf KA (2003). Bilateral eye movements enhance the retrieval of episodic memories. Neuropsychology 17 (2): 221-9.
- ↑ Kuiken, D., et al., Eye movement desensitization reprocessing facilitates attentional orienting. Imagination, Cognition & Personality, 2001. 21(1): p. 3-20.
- ↑ MacCulloch, M.J. and P. Feldman, Eye Movement Desensitisation Treatment Utilises the Positive Viscereal Element of the Investigatory Reflex to Inhibit the Memories of Post-Traumatic Stress Disorder: a Theoretical Analysis. British Journal of Psychiatry, 1996. 169(5): p. 571-579.
- ↑ Wilson DL, Silver SM, Covi WG, Foster S (1996). Eye movement desensitization and reprocessing: effectiveness and autonomic correlates. Journal of behavior therapy and experimental psychiatry 27 (3): 219-29.
- ↑ Barrowcliff, A.L., et al., Eye-movements reduce the vividness, emotional valence and electrodermal arousal associated with negative autobiographical memories. Journal of Forensic Psychiatry & Psychology, 2004. 15(2): p. 325-345.
- ↑ Sack, M., Lempa, W., Steinmetz, A. Lamprecht, F., Hofmann, A. (in press). Alterations in autonomic tone during trauma exposure using Eye Movement Desensitization and Reprocessing (EMDR) - results of a preliminary investigation. Journal of Anxiety Disorders (2007), doi:10.1016/j.janxdis.2008.01.007
- ↑ Lansing K, Amen DG, Hanks C, Rudy L (2005). High-resolution brain SPECT imaging and eye movement desensitization and reprocessing in police officers with PTSD. The Journal of neuropsychiatry and clinical neurosciences 17 (4): 526-32.
- ↑ Levin P, Lazrove S, van der Kolk B (1999). What psychological testing and neuroimaging tell us about the treatment of Posttraumatic Stress Disorder by Eye Movement Desensitization and Reprocessing. Journal of anxiety disorders 13 (1-2): 159-72.
- ↑ Kinsbourne, M., Evolution of language in relation to lateral action., in Asymmetrical function of the brain., M. Kinsbourne, Editor. 1978, New York Cambridge University Press. p. 553-556.
- ↑ Devilly, G.J., & Spence, S.H. (1999). The relative efficacy and treatment distress of EMDR and a cognitive behavioral trauma treatment protocol in the amelioration of post traumatic stress disorder. Journal of Anxiety Disorders, 13, 131–157[2]
- ↑ Devilly, G.J. (2002). Eye Movement Desensitization and Reprocessing: A chronology of its development and scientific standing. Scientific Review of Mental Health Practice, 1, 113-138 [3]
- ↑ Bisson, J. I., Ehlers, A., Matthews, R., Pilling, S., Richards, D., & Turner, S. (2007). Psychological treatments for chronic post-traumatic stress disorder: Systematic review and meta-analysis. British Journal of Psychiatry, 190(2), 97-104.
- ↑ Bradley, R., Greene, J., Russ, E., Dutra, L., & Westen, D. (2005). A Multidimensional Meta-Analysis of Psychotherapy for PTSD. American Journal of Psychiatry, 162(2), 214-227.
- ↑ Seidler, G. H., & Wagner, F. E. (2006). Comparing the efficacy of EMDR and trauma-focused Cognitive-Behavioral Therapy in the Treatment of PTSD: a meta–analytic study Psychological Medicine 36 1515-1522.
- ↑ van Etten, M. L., & Taylor, S. (1998). Comparative Efficacy of Treatments for Post-traumatic Stress Disorder: A Meta-Analysis. Clinical Psychology and Psychotherapy, 5, 126-144.
- ↑ Davidson PR, Parker KC (2001). "Eye movement desensitization and reprocessing (EMDR): a meta-analysis". Journal of consulting and clinical psychology 69 (2): 305-16.
- ↑ Cahill SP, Carrigan MH, Frueh BC (1999). "Does EMDR work? And if so, why?: a critical review of controlled outcome and dismantling research". Journal of anxiety disorders 13 (1-2): 5-33.
- ↑ Lee, C. W., & Drummond, P.D. (in press). Effects of Eye Movement versus Therapist Instructions on the Processing of Distressing Memories, Journal of Anxiety Disorders, (2007)doi:10.1016/J.janxdis.2007.08.007
- ↑ Shapiro, F. (1989). Efficacy of the eye movement desensitization procedure in the treatment of traumtic memories. Journal of Traumatic Stress Studies 2: 199-223.
- ↑ Boudewyns, P.A., Stwertka, S. A., Hyer, L. A., Albrecht, J. W., & Sperr, E. V. (1993). Eye movement desensitization and reprocessing: A treatment outcome pilot study. The Behavior Therapist 16: 30-33.
- ↑ Gosselin, P. (1995). Eye movement desensitization and reprocessing in the treatment of test anxiety: A study of the effects of expectancy and eye movement. Journal of Behavior Therapy & Experimental Psychiatry 26 (4): 331-337.
- ↑ (1996) Eye movement desensitization and reprocessing: Effectiveness and autonomic correlates.. Journal of Behaviour Therapy and Experimental Psychiatry, 27: 219-229.
- ↑ MacCulloch, M. (2006). Effects of EMDR on previously abused child molesters: Theoretical reviews and preliminary findings from Ricci, Clayton, and Shapiro. Journal of Forensic Psychiatry & Psychology, 17(4), 531-537.
- ↑ Salkovskis P (2002). "Review: eye movement desensitization and reprocessing is not better than exposure therapies for anxiety or trauma". Evidence-based mental health 5 (1): 13.
- ↑ Andrade, J.; Kavanagh, D.; Baddeley, A. (2001), "Eye-movements and visual imagery: A working memory approach to the treatment of post-traumatic stress disorder", Journal of Clinical Psychology 36: 209-223
- ↑ Kavanagh, D.J.; Freese, S.; Andrade, J.; May, J. (2001), "Effects of visuospatial tasks on desensitization to emotive memories", British Journal of Clinical Psychology 40 (3): 267-280
- ↑ van den Hout, M.; Muris, P.; Salemink, E.; Kindt, M. (2001), "Autobiographical memories become less vivid and emotional after eye movements", British Journal of Clinical Psychology 40 (2): 121-130
- ↑ Christman, S.D., Garvey, K. J., Propper, R. E., & Phaneuf, K. A. (2003). Bilateral eye movements enhance the retrieval of episodic memories. Neuropsychology 17: 221-229.
- ↑ Barrowcliff, A.L.; Gray, N. S., Freeman, T. C. A., & MacCulloch, M. J. (2004), "Eye-movements reduce the vividness, emotional valence and electrodermal arousal associated with negative autobiographical memories", Journal of Forensic Psychiatry and Psychology 15: 325-354, doi:
- ↑ Barrowcliff, A.L., Gray, N. S., MacCulloch, S., Freeman, T. C. A., & MacCulloch, M. J. (2003). Horizontal rhythmical eye-movements consistently diminish the arousal provoked by auditory stimuli.. British Journal of Clinical Psychology 42: 289-302.
- ↑ Sack, M., Lempa, W., Steinmetz, A. Lamprecht, F., Hofmann, A. (in press). Alterations in autonomic tone during trauma exposure using Eye Movement Desensitization and Reprocessing (EMDR) - results of a preliminary investigation. Journal of Anxiety Disorders (2007), doi:10.1016/j.janxdis.2008.01.007
- ↑ Kuiken,, D., et al. (2001). Eye movement desensitization reprocessing facilitates attentional orienting.. Imagination, Cognition & Personality 21 (1): 3-20 ,.
- ↑ Rogers S, Silver SM (2002). Is EMDR an exposure therapy? A review of trauma protocols. Journal of clinical psychology 58 (1): 43-59.
- ↑ Smyth, N.J. and A.D. Poole, EMDR and cognitive-behavior therapy: Exploring convergence and divergence, in EMDR as an integrative psychotherapy approach: Experts of diverse orientations explore the paradigm prism, F. Shapiro, Editor. 2002, American Psychological Association: Washington, DC. p. 151-180.
- ↑ Lee, C.W., G. Taylor, and P. Drummond, The active ingredient in EMDR; is it traditional exposure or dual focus of attention? Clinical Psychology & Psychotherapy, 2006. 13: p. 97-107.
- ↑ Jaycox LH, Foa EB, Morral AR (1998). Influence of emotional engagement and habituation on exposure therapy for PTSD. Journal of consulting and clinical psychology 66 (1): 185-92.
- ↑ Lee, C.W., G. Taylor, and P. Drummond, The active ingredient in EMDR; is it traditional exposure or dual focus of attention? Clinical Psychology & Psychotherapy, 2006. 13: p. 97-107.
Key texts – Books
- Shapiro, F (2001)Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols, and Procedures. Guildford Press. ISBN 1572306726
- Shapiro, F (2002) (ed) EMDR as an Integrative Psychotherapy Approach: Experts of Diverse Orientations Explore the Paradigm Prism. APA. ISBN 1557989222
- Shapiro, F (2002) (ed) Light in the Heart of Darkness: EMDR and the Treatment of War and Terrorism Survivors. W W Norton. ISBN 0393703665
- Shapiro, F & Forrest, M S (2004) EMDR: The Breakthrough Therapy for Overcoming Anxiety, Stress and Trauma . Basic books.ISBN 0465043011
- Shapiro, F., (2005). Eye movement desensitization and reprocessing: Basic principles, protocols and procedures (2nd ed.). New York: Guilford Press.
- Shapiro, F (2007) Handbook of EMDR and Family Therapy Processes.Wiley. ISBN 0471709476
External links
Supportive of EMDR
- EMDR Institute, Inc.
- EMDR European Association, Inc.
- EMDR International Association (EMDRIA)
- Child Trauma Institute