EMDR Treatment for PTSD

Post traumatic stress disorder (PTSD) is a serious mental health condition that comes as a result of the brain’s inability to process an extremely psychologically distressing event. Many veterans who’ve lived through wartime violence suffer from the condition, however PTSD is indiscriminate and can affect people of all ages, occupations, genders, and ethnicities. In the US, rates of PTSD are higher than in other western countries, with 3.5% of US adults affected and women twice as likely to have PTSD as men.

The most well researched treatments for PTSD are those centered around trauma focused cognitive behavioral psychotherapy, a type of therapy which focuses on the memory of the traumatic event or its meaning. Several treatments fall within this category: Cognitive Processing Therapy (CPT), Prolonged Exposure Therapy (PE), and Eye Movement Desensitization and Reprocessing Therapy (EMDR).

Eye Movement Desensitization and Reprocessing therapy (EMDR) is a well researched therapy and one recommended by the World Health Organization (WHO) to treat trauma. EMDR is based on the idea that our brain naturally wants to heal and achieve optimal mental health, and that trauma can overwhelm our natural ability to heal and become “stuck” in our memory. Our associations around the traumatic incident remain negative and destructive, and we may become sensitive to people, places, or things that remind us of the event.

EMDR works by having the individual focus their attention on the traumatic event as well as any associated images, thoughts, sensations and emotions so that healthy processing can take place - all with the guidance of a therapist, bilateral stimulation, the use of stress management tools, and in a safe environment.

Many believe that EMDR can attain what would otherwise have taken years of psychotherapy to achieve, simply by harnessing what we know about how the brain processes pain. Research on EMDR for PTSD treatment is substantial and today we will take a look at a recent meta analysis that evaluates the latest research on the effectiveness EMDR therapy for PTSD.

PTSD

PTSD develops as a result of the brain being unable to process a traumatic event such as personal physical or sexual abuse, wartime violence, terrorist act, natural disaster, or other personal assault. When the event is extremely intense, it may overwhelm our body’s processing systems and we may have a difficult time coping with the emotional distress. As a result, disturbing thoughts and emotions surrounding the incident can persist long after the trauma has occurred. Other signs of PTSD include reliving the original incident through flashbacks or trauma; feelings of sadness or anger; feeling detached or estranged from people; and having strong negative responses to things as simple as an accidental touch or loud noise.

According to the American Psychiatric Association, there are 4 main categories of PTSD symptoms:

1. Intrusive thoughts related to the traumatic event: Repeated involuntary memories; distressing dreams or flashbacks of the traumatic event. It can feel as though you are reliving the trauma.

2. Avoiding reminders of the traumatic event: can include avoiding people, places, activities, objects, or situations that being on distressing memories as well as avoiding talking about the traumatic event.

3. Negative thoughts and feelings: Ongoing distorted beliefs about oneself; ongoing horror, anger, guilt, shame

4. Arousal and reactive symptoms: being irritable, behaving recklessly, having angry outbursts, and having difficulty sleeping or concentrating

Despite the possible range of side effects, it is very possible to lead a normal, functioning life with PTSD. The condition will vary in severity and presentation depending on the trauma and how the psychological burden of that experience manifests in any one person’s life.

EMDR

EMDR is a focused approach to treating trauma which reconnects a person to images, emotions, thoughts, and sensations associated with the event(s). When we experience trauma but are unable to process it fully and heal, it gets stored in our long term memory. EMDR provides a means of retrieving the traumatic memory, and bringing it back into short term memory or “working memory” so that it can be fully processed and healed.

EMDR uses something called adaptive resolution to transform the trauma from something that has the potential to be distressing and triggering, into a form that is no longer associated with negative, charged emotional, physical, behavioral, and congitive responses. This is the ‘desensitization and reprocessing’ component of EMDR. The key to adaptive resolution is relearning, so that the harmful and disturbing information related to the trauma (again, thoughts, feelings, behaviors) are replaced with new, more “adaptive” information and associations. For example, someone who has experienced a rape may have recurring thoughts of “I deserved it” or “I am not worthy of love” and through adaptive resolution may be able to adopt useful, healing, supportive thoughts to replace the destructive ones, such as “I am worthy of love” or “what happened to me was not my fault.”

Information processing is enhanced through bilateral stimulation which facilitates the forging of new, more adaptive associations with the trauma. This is perhaps one of the most fascinating aspects of EMDR therapy, the use of bilateral stimulation. Often a therapist will have the client follow their fingers from side to side, although other techniques can be used like hand tappers or auditory stimulation. When a person actively recalls a trauma and simultaneously focuses on the bilateral stimulation, the trauma starts to lose its charge. Eventually the image of the trauma held by the client will become less upsetting and associated feelings of anxiety and depression will begin to lessen.

It is important that EMDR sessions take place in a safe environment, under the guidance of a trained therapist, and with the use of relaxation tools. When done correctly, EMDR can facilitate complete information processing and new learning, elimination of emotional distress, and development of new insights.

EMDR sessions typically take about 1 hour. There are 8 phases to the treatment:

1. Personal history taken by therapist.

2. Stress reduction tools: Therapist teaches individual tools that can be used during and in between sessions to handle any emotional distress that arises.

3. Assessment: Target traumatic event identified along with any related images, negative beliefs about oneself, and emotions and body sensations.

4. Desensitization: Trauma is processed via bilateral stimulation during which time the individual focuses on trauma while engaging in EMDR. The therapist will instruct the person to let the mind go blank after each set of EMDR, and to notice whatever thoughts, feelings, and emotions come up.

5. Installation: Once the individual stops experiencing distress associated with the trauma, they will then think of a positive belief and focus on it during the subsequent sets of EMDR in order to build new associations with the trauma and heal unresolved pain.

6. Body Scan: The therapist will ask the person to scan the body for any sensations or emotions related to the event. If any are identified, more EMDR sets will be administered.

7. Closure: The person will be asked to keep a record of anything that comes up after the sessions related to the trauma. The self-calming techniques learned in step 2 can be used as needed.

8. Reevaluation: Therapist and individual will examine progress made and determine whether or not further EMDR therapy is safe, needed, and likely to be beneficial.

The Latest Research on EMDR for PTSD

A recent meta- analysis by Wilson et al in 2018 examined 37 studies to evaluate the efficacy of EMDR treatment for PTSD. One of the major limitations across these studies is a lack of consistency and methodological quality, thus the goal of this most recent review study was to take a look at the best evidence for EMDR. Only studies that used a control group were included, where the control was either a wait-list group with no intervention, or some type of alternative therapy for PTSD.

There was substantial heterogeneity between the studies in terms of study design, number of participants enrolled, number and length of treatments, and timing of follow up. There were also inconsistencies between outcome measures used to assess symptoms of PTSD, anxiety, and depression and inconsistencies across the different scales used for evaluation. Despite these limitations, researchers found that EMDR therapy was significantly more effective than the control or other therapeutic interventions in reducing PTSD symptoms.

One study (Chen et al, 2014) found that EMDR carried out in a group setting was significantly more effective with an experienced therapist versus an inexperienced therapist. They also found that the length of treatment matters, with sessions lasting 60 minutes or longer having significantly better results for reducing symptoms of depression and anxiety for PTSD patients than shorter sessions. In a follow up study, Chen et Al also found that EMDR was particularly excellent for reducing symptoms of intrusion and arousal among participants with PTSD.

Between 2014 and 2017, four studies were conducted on EMDR therapy for PTSD and three different patient populations were enrolled: one study enrolled multiple sclerosis patients who also suffered from PTSD, two studies enrolled refugees, and one enrolled patients suffering from chronic psychotic disorders with PTSD comorbidity.

These four most recent studies used different treatment protocols, follow up time periods, and outcome measures. The studies had low drop out rates and decent levels of enrollment (between 50 and155 subjects per study). EMDR was found to be the superior therapy in most cases, but one study found it no more effective than the control stabilization group.

Based on these latest RCTs (randomized controlled trial) as well as earlier research conducted on EMDR in PTSD patients, Wilson et al concluded that EMDR:

• Significantly improves PTSD diagnosis and symptoms

• Significantly reduces symptoms of depression, anxiety, subjective distress, paranoid thoughts, functional assessment, and severe fatigue

• Is more effective than comparative interventions and control

• Is effective with range of presenting problems and symptoms

• Is well tolerated by patients

• Is effective across a range of cultures

• Is  effective in improving paranoid thoughts- post treatment and over time

• Has no impact on auditory hallucinations or personal social performance compared to wait-list control

In one study (Carletto et Al, 2016), 17 of 20 EMDR participants no longer met PTSD diagnostic criteria 12-15 weeks post-treatment. At the 6 month follow-up, none of the 20 EMDR patients met the PTSD diagnostic criteria. Similarly, another study (Acarturk et Al, 2016) evaluated the effectiveness of EMDR among Syrian refugees and found similarly effective longterm treatment effects. Immediately after EMDR treatments, participants who were assigned to the wait-list control group were 24.1 times more likely to be diagnosed with PTSD than those who has just received EMDR treatment. At a one month follow up, the wait list was 23 times more likely to be diagnosed with PTSD.

EMDR was not always the superior treatment option in these most recent studies. Ter Heide et Al (2016) found that EMDR treatment was not more effective in reducing symtptoms of depression and anxiety in the longterm among study participants compared to stabilization treatment. De Bont et al (2016) found that prolonged exposure was more effective in reducing symptoms of depression among PTSD patients than EMDR, both at a six months follow up time point and over time. This study also found that EMDR did not significantly impact auditory hallucinations or personal social performances compared to a wait list control group. It also did not seem to have a significant effect on overall quality of life for study participants.

Given the overall positive results of the above studies, the meta-analysis concluded that EMDR significantly improved PTSD diagnosis and symptoms over time compared to relaxation therapy and wait list control. It significantly reduces symptoms of ptsd, anxiety, and depression over time, though prolonged exposure therapy may be superior in reducing symptoms of depression.

Wilson et al summarized the limitations across studies:

• Limited follow up time

• Heterogeneity among study design, enrollment, and scales used

• Lack of economic considerations

• Additional research needed to examine differences between adult and child PTSD to ascertain which psychological treatment approaches for kids and adolescents are more effective and efficient

• More standardization of normative outcome measures needed to facilitate comparison across studies

• Longitudinal follow up needed past 6 months

• Analysis of economic benefits vs. other trauma interventions would be useful

• Efficacy of EMDR across cultures is weak

Conclusions and Recommendations

If you or someone you know is suffering from PTSD, consider EMDR treatment. The research on this therapy is sound and the associated risks are relatively low. If you do pursue this kind of treatment, remember to work with an experienced therapist and try to schedule sessions that are at least 60 minutes. This will improve your chances for success.

At Mind Body Seven, Natasha Felton, NP provides EMDR treatment. If you would like to learn more about the treatment or schedule an appointment for EMDR therapy, please reach out today.