Eye movement desensitization: a partial dismantling study

The Effectiveness of Eye Movement Desensitization for Post-traumatic Stress Disorder in Indonesia: A Randomized Controlled Trial

Objective

Post-traumatic stress disorder (PTSD) may affect individuals exposed to adversity. Eye Movement Desensitization and Reprocessing (EMDR) is an evidence-based trauma-focused psychotherapy for PTSD. There is still some debate whether the eye movements (EMs) are an effective component of EMDR. The primary aim of this study was to investigate the effectiveness of Eye Movement Desensitization (EMD) treatment in reducing PTSD symptoms compared to a retrieval-only active control condition. We also investigated whether PTSD symptom reduction was associated with reductions in depression and anxiety, and improvements in quality of life.

Methodology

Adult PTSD patients (n = 91) were recruited at public psychological services in Jakarta, Bandung and Cimahi, Indonesia. PTSD was diagnosed with the Structured Clinical Interview for DSM-5 disorders (SCID-5). Participants were randomized into: EMD (n = 47) or retrieval-only (n = 44). EMD consisted of clinical history and treatment planning, preparation, assessment, EMs, closure, whereas retrieval-only consisted of the same elements except EMs. Data were collected at baseline (T0), 1-week post-treatment (T1), 1-month follow-up (T2), and 3-months follow-up (T3). Outcome measures included the PTSD Checklist for DSM-5 (PCL-5), Hopkins Symptoms Checklist-25 (HSCL-25), and the World Health Organization Quality of Life-BREF (WHOQoL-BREF). Data were analyzed with linear mixed model analysis in R Statistics.

Results

Although there were main effects of time indicating reductions for both EMD and retrieval-only in PCL-5 and HSCL-25 scores, and improvements in WHOQoL-BREF scores at T1, T2, and T3, no significant differences in PCL-5, HSCL-25, and WHOQoL-BREF total scores between the EMD and retrieval-only groups at T1, T2, and T3 were found (all group x time interaction p's > 0.005).

Conclusion

Within a clinical sample of PTSD patients in Indonesia, both EMD and retrieval-only was associated with reductions in symptoms of PTSD, anxiety and depression, and improvements in quality of life, although EMs did not add to the efficacy of the treatments. Further research to examine the underlying mechanisms of EMDR's effective treatment elements in clinical samples is needed.

Clinical Trial Registration

[www.ClinicalTrials.gov], identifier [ISRCTN55239132].

Posttraumatic Stress Disorder Treatment Effects on Cardiovascular Physiology: A Systematic Review and Agenda for Future Research

Posttraumatic stress disorder (PTSD) is linked to both altered physiological functioning and poorer cardiovascular health outcomes, including an increased risk for cardiovascular disease and cardiovascular-related mortality. An important question is whether interventions for PTSD might ameliorate the risk for poorer health by improving cardiovascular physiological intermediaries. To begin to characterize the literature addressing this question, we conducted a systematic review of empirical studies examining the impact of PTSD interventions on cardiovascular physiological intermediaries, including blood pressure (BP), heart rate (HR), cardiac impedance, and subclinical atherosclerosis. Outcomes included both tonic (i.e., resting) cardiovascular functioning and cardiovascular reactivity (CVR). A total of 44 studies met the inclusion criteria. There was mixed evidence regarding whether PTSD treatment improved tonic cardiovascular functioning. There was stronger evidence that PTSD treatments reduced CVR to trauma-related stressors, particularly for higher-quality studies of cognitive behavioral interventions. No studies examined cardiac impedance or subclinical atherosclerosis. The studies had a high degree of heterogeneity in the populations sampled and interventions tested. Moreover, they generally included small sample sizes and lacked control conditions. Interventions for PTSD may improve cardiovascular physiological outcomes, particularly CVR to trauma cues, although additional methodologically rigorous studies are needed. We outline changes to future research that would improve the literature regarding this important question, including the more frequent use of control groups and larger sample sizes.

On EMDR: Measuring the working memory taxation of various types of eye (non-)movement conditions

BACKGROUND AND OBJECTIVE

A recent, large randomized controlled trial employing different forms of eye (non-)movements in eye movement desensitization and reprocessing (EMDR) showed that fixating the eyes either on a therapist's moving or non-moving hand led to equal reductions in symptoms of post-traumatic stress disorder (PTSD). However, numerous EMDR lab analogue studies found that eye movements produce larger memory effects than eyes stationary. These beneficial effects are typically explained by differences in working memory (WM) taxation. We tested the degree of WM taxation of several eye (non-)movement conditions used in the clinical trial.

METHODS

All participants (N = 40) performed: (1) eyes moving by following the experimenter's moving finger, (2) eyes fixed on the experimenter's stationary finger, (3) eyes closed, or (4) looking unfocused into the room. Simultaneously they performed a simple reaction time task. Reaction times are an objective index of the extent to which different dual attention tasks tax WM.

RESULTS

Eyes moving is more taxing than eyes fixed, while eyes fixed did not differ from eyes unfocused. All conditions were more taxing than eyes closed.

LIMITATIONS

We studied WM taxation in a laboratory setting; no clinical interventions were applied.

CONCLUSIONS

In line with previous lab studies, making eye movements was more taxing than eyes fixed. We discuss why this effect was not observed for reductions in PTSD symptoms in the clinical trial (e.g., differences in dependent variables, sample population, and intervention duration). For more comprehensive future insights, we recommend integration of mechanistically focused lab analogue studies and patient-oriented clinical studies.

The Complexity of Evidence Notwithstanding: A Reply to Swartz

This article is a response to the caveats raised by Swartz (this issue) regarding the complexities of emphasising evidence-based interventions in psychology. It is acknowledged that the process of amassing evidence to support psychological interventions requires overcoming considerable logistical and contextual difficulties. Yet, the dangers of not taking into account the vast body of data on the effectiveness of psychotherapy are likely to have serious consequences for consumers of psychological service and for the profession of psychology itself. The challenge for South African psychology is to address the complexities raised by Swartz in ways that minimise leaps of faith regarding the effectiveness of interventions so that therapeutic decisions are based on sound data rather than unsubstantiated theoretical conjecture.

Eye movement desensitization and reprocessing versus cognitive-behavioral therapy for adult posttraumatic stress disorder: systematic review and meta-analysis

Posttraumatic stress disorder (PTSD) is a relatively common mental disorder, with an estimated lifetime prevalence of ∼5.7%. Eye movement desensitization and reprocessing (EMDR) and cognitive-behavioral therapy (CBT) are the most often studied and most effective psychotherapies for PTSD. However, evidence is inadequate to conclude which treatment is superior. Therefore, we conducted a meta-analysis to confirm the effectiveness of EMDR compared to CBT for adult PTSD. We searched Medline, PubMed, Ebsco, Proquest, and Cochrane (1989-2013) to identify relevant randomized control trials comparing EMDR and CBT for PTSD. We included 11 studies (N = 424). Although all the studies had methodological limitations, meta-analyses for total PTSD scores revealed that EMDR was slightly superior to CBT. Cumulative meta-analysis confirmed this and a meta-analysis for subscale scores of PTSD symptoms indicated that EMDR was better for decreased intrusion and arousal severity compared to CBT. Avoidance was not significantly different between groups. EMDR may be more suitable than CBT for PTSD patients with prominent intrusion or arousal symptoms. However, the limited number and poor quality of the original studies included suggest caution when drawing final conclusions.

Using neurobiological measures to predict and assess treatment outcome of psychotherapy in posttraumatic stress disorder: systematic review

BACKGROUND

Trauma-focused cognitive-behavioral therapy (TF-CBT) and eye movement desensitization and reprocessing (EMDR) are effective treatments for posttraumatic stress disorder. However, little is known about their neurobiological effects. The usefulness of neurobiological measures to predict the treatment outcome of psychotherapy also has yet to be determined.

METHODS

Systematic review of randomized controlled trials (RCTs) focused on neurobiological treatment effects of TF-CBT or EMDR and trials with neurobiological measures as predictors of treatment response.

RESULTS

We included 23 publications reporting on 16 separate trials. TF-CBT was compared with a waitlist in most trials. TF-CBT was associated with a decrease in heart rate and blood pressure and changes in activity but not in volume of frontal brain structures and the amygdala. Neurobiological changes correlated with changes in symptom severity. EMDR was only tested against other active treatments in included trials. We did not find a difference in neurobiological treatment effects between EMDR and other treatments. Publications on neurobiological predictors of treatment response showed ambiguous results.

CONCLUSION

TF-CBT was associated with a reduction of physiological reactivity. There is some preliminary evidence that TF-CBT influences brain regions involved in fear conditioning, extinction learning and possibly working memory and attention regulation; however, these effects could be nonspecific psychotherapeutic effects. Future trials should use paradigms aimed specifically at these brain regions and physiological reactivity. There are concerns regarding the risk of bias in some of the RCTs, indicating that methodologically more rigorous trials are required. Trials with neurobiological measures as predictors of treatment outcome render insufficient results to be useful in clinical practice.

A meta-analysis of the contribution of eye movements in processing emotional memories

BACKGROUND AND OBJECTIVES

Eye Movement Desensitisation and Reprocessing (EMDR) is now considered evidence based practice in the treatment of trauma symptoms. Yet in a previous meta-analysis, no significant effect was found for the eye movement component. However methodological issues with this study may have resulted in a type II error. The aim of this meta-analysis was to examine current published studies to test whether eye movements significantly affect the processing of distressing memories.

METHOD

A systematic review of the literature revealed two groups of studies. The first group comprised 15 clinical trials and compared the effects of EMDR therapy with eye movements to those of EMDR without the eye movements. The second group comprised 11 laboratory trials that investigated the effects of eye movements while thinking of a distressing memory versus the same procedure without the eye movements in a non-therapy context. The total number of participants was 849.

RESULTS

The effect size for the additive effect of eye movements in EMDR treatment studies was moderate and significant (Cohen's d = 0.41). For the second group of laboratory studies the effect size was large and significant (d = 0.74). The strongest effect size difference was for vividness measures in the non-therapy studies (d = 0.91). The data indicated that treatment fidelity acted as a moderator variable on the effect of eye movements in the therapy studies.

CONCLUSIONS

Results were discussed in terms of current theories that suggest the processes involved in EMDR are different from other exposure based therapies.

Treatment of posttraumatic stress disorder in U.S. combat veterans: a meta-analytic review

Among U.S. veterans who have been exposed to combat-related trauma, significantly elevated rates of posttraumatic stress disorder (PTSD) are reported. Veterans with PTSD are treated for the disorder at Veterans Affairs (VA) hospitals through a variety of psychotherapeutic interventions. Given the significant impairment associated with PTSD, it is imperative to assess the typical treatment response associated with these interventions. 24 studies with a total sample size of 1742 participants were quantitatively reviewed. Overall, analyses showed a medium between-groups effect size for active treatments compared to control conditions. Thus, the average VA-treated patient fared better than 66% of patients in control conditions. VA treatments incorporating exposure-based interventions showed the highest within-group effect size. Effect sizes were not moderated by treatment dose, sample size, or publication year. Findings are encouraging for treatment seekers for combat-related PTSD in VA settings.

The efficacy and psychophysiological correlates of dual-attention tasks in eye movement desensitization and reprocessing (EMDR)

This study aimed to investigate the psychophysiological correlates and the effectiveness of different dual-attention tasks used during eye movement desensitization and reprocessing (EMDR). Sixty-two non-clinical participants with negative autobiographical memories received a single session of EMDR without eye movements, or EMDR that included eye movements of either varied or fixed rate of speed. Subjective units of distress and vividness of the memory were recorded at pre-treatment, post-treatment, and 1 week follow-up. EMDR-with eye movements led to greater reduction in distress than EMDR-without eye movements. Heart rate decreased significantly when eye movements began; skin conductance decreased during eye movement sets; heart rate variability and respiration rate increased significantly as eye movements continued; and orienting responses were more frequent in the eye movement than no-eye movement condition at the start of exposure. Findings indicate that the eye movement component in EMDR is beneficial, and is coupled with distinct psychophysiological changes that may aid in processing negative memories.

Dissociation Following Traumatic Stress

We postulate that the cascade “Freeze-Flight-Fight-Fright-Flag-Faint” is a coherent sequence of six fear responses that escalate as a function of defense possibilities and proximity to danger during life-threat. The actual sequence of trauma-related response dispositions acted out in an extremely dangerous situation therefore depends on the appraisal of the threat by the organism in relation to her/his own power to act (e.g., age and gender) as well as the perceived characteristics of threat and perpetrator. These reaction patterns provide optimal adaption for particular stages of imminence. Subsequent to the traumatic threats, portions of the experience may be replayed. The actual individual cascade of defense stages a survivor has gone through during the traumatic event will repeat itself every time the fear network, which has evolved peritraumatically, is activated again (i.e., through internal or external triggers or, e.g., during exposure therapy).When a parasympathetically dominated ‘‘shut-down’’ was the prominent peri-traumatic response during the traumatic incident, comparable dissociative responses may dominate responding to subsequently experienced threat and may also reappear when the traumatic memory is reactivated. Repeated experience of traumatic stress forms a fear network that can become pathologically detached from contextual cues such as time and location of the danger, a condition which manifests itself as posttraumatic stress disorder (PTSD). Intrusions, for example, can therefore be understood as repetitive displays of fragments of the event, which would then, depending on the dominant physiological response during the threat, elicit a corresponding combination of hyperarousal and dissociation. We suggest that trauma treatment must therefore differentiate between patients on two dimensions: those with peritraumatic sympathetic activation versus those who went down the whole defense cascade, which leads to parasympathetic dominance during the trauma and a corresponding replay of physiological and dissociative responding, when reminded. The differential management of dissociative stages (“fright” and “faint”) has important treatment implications.

Dosed versus prolonged exposure in the treatment of fear: an experimental evaluation and review of behavioral mechanisms

Exposure-based treatments have proven effective in treating a range of fears and phobias and can be accounted for by mechanisms described in behavioral theory. Enhanced dosed and dosed-only exposure are promising new behavioral approaches for treating fears and phobias. Thirty-nine participants with speech anxiety were randomly assigned to a prolonged exposure (PE) condition, a positively enhanced dosed exposure (PDE) condition, a dosed-only exposure (DE) condition, or a negatively-supplemented dosed exposure (NDE) condition. Results indicated that both the PDE and DE conditions produced less measured aversive arousal and significantly more rapid arousal reduction than the tested alternatives. These techniques may represent an important advancement, in that the treatment gains of traditional exposure therapies might be achieved without the degree of aversive arousal (and possibly high drop out rates) typically seen in exposure therapies. Additionally, these data contradict prevailing opinion concerning the necessity for sustained aversive arousal during exposure-based treatment.

Treating Spider Phobics with Eye Movement Desensitization and Reprocessing: A Controlled Study

The present study examined the efficacy of eye movement desensitization and reprocessing (EMDR) in the treatment of a specific phobia. Twenty-four spider phobic subjects were randomly assigned to either (1) an EMDR group (n=8), (2) an imaginal exposure group (n=8), or (3) a control group (n=8). Both the EMDR and the imaginal exposure group underwent a one-hour treatment. The control group initially received no treatment, and waited for one hour. Next, all groups received exposure in vivo. Treatment outcome was evaluated with a standardized Behavioural Avoidance Test (BAT). No evidence was found for EMDR being more effective than imaginal exposure or waiting list control. In fact, only exposure in vivo therapy resulted in significant improvement on the BAT.

The applicability of randomized controlled trials of psychosocial treatments for PTSD to a veteran population

The extent to which the results of randomized controlled trials can be expected to generalize to clinical populations has been the subject of much debate. To examine this issue among a population of individuals diagnosed with posttraumatic stress disorder (PTSD), the clinical characteristics of Veterans Affairs (VA) patients with PTSD were compared to the eligibility criteria for clinical trials of psychosocial treatments for PTSD. Administrative data for 239,668 patients who received a diagnosis of PTSD within the VA healthcare system during the 2003 fiscal year were compared with inclusion and exclusion criteria of 31 clinical trials for PTSD. Based on available data, all patients appeared to be eligible for at least one study, and half (50%) were eligible for between 16 and 21 (50% or more) of the 31 studies examined. The studies for which the most veterans with PTSD would have been eligible targeted combat-related trauma or did not specify type of trauma in their eligibility criteria. Veterans who exhibited psychotic symptoms (3% of the sample) were ineligible for most, but not all, of the studies. However, most veterans with comorbid Axis I conditions, such as depression, anxiety disorders, and substance use disorders, were eligible for multiple studies. These findings, which indicate that the existing literature on the efficacy of psychosocial treatment may inform the treatment of the majority of veterans who present with PTSD, have applications for the design of future clinical trials and for consultation of the literature regarding appropriate treatments for veterans with PTSD.

Physiological correlates of eye movement desensitization and reprocessing

Eye movement desensitization and reprocessing (EMDR) is an established treatment for post-traumatic stress disorder (PTSD). However, its working mechanism remains unclear. This study explored physiological correlates of eye movements during EMDR in relation to current hypotheses; distraction, conditioning, orienting response activation, and REM-like mechanisms. During EMDR therapy, fingertip temperature, heart rate, skin conductance, expiratory carbon dioxide level, and blood pulse oximeter oxygen saturation, were measured in male subjects with PTSD. The ratio between the low and high frequency components of the heart rate power spectrum (LF/HF) were computed as measures of autonomic balance. Respiratory rate was calculated from the carbon dioxide trace. Stimulation shifted the autonomic balance as indicated by decreases in heart rate, skin conductance and LF/HF-ratio, and an increased finger temperature. The breathing frequency and end-tidal carbon dioxide increased; oxygen saturation decreased during eye movements. In conclusion, eye movements during EMDR activate cholinergic and inhibit sympathetic systems. The reactivity has similarities with the pattern during REM-sleep.

Circumventing the Vasovagal Fainting Response

A novel method of in vivo exposure therapy was administered to a 26-year-old female with injection phobia. She had a history of fainting at the sight of syringes, needles, and other medical devices and went to great lengths to avoid physicians and optometrists, putting off receiving necessary examinations and vaccinations. The patient was treated in one long session. The session began with presentation of a series of noninvasive fear-evoking stimuli (i.e., still and video images) shown briefly, but repeatedly, with increasing trial durations, followed by invasive exposures (i.e., finger pricks & a sham injection). Self-report measures showed significant changes that were maintained after 10 months. In addition, the patient donated blood, had an eye examination, and received three vaccinations, all without fainting. Traditional treatments employ prolonged exposures to fear-evoking stimuli; the results of this intervention suggest that a massed series of brief exposures might provide a less aversive alternative.

Treatment of PTSD: a comparison of imaginal exposure with and without imagery rescripting

We tested whether the effectiveness of imaginal exposure (IE) treatment for posttraumatic stress disorder (PTSD) was enhanced by combining IE with imagery rescripting (IE+IR). It was hypothesized that IE+IR would be more effective than IE by (1) providing more corrective information so that more trauma-related problems can be addressed, and (2) allowing patients to express emotions that they had been inhibiting, such as anger. In a controlled study 71 chronic PTSD patients were randomly assigned to IE or IE+IR. Data of 67 patients were available. Treatment consisted of 10 weekly individual therapy sessions and treatment evaluation was conducted post-treatment and at 1-month follow-up. Results show that when compared with wait-list, treatment reduced severity of PTSD symptoms. More patients dropped out of IE than out of IE+IR before the 8th sessions, 51% vs. 25%, p=.03. Completers and intention-to-treat analyses indicated that both conditions did not differ significantly in reduction of PTSD severity. IE+IR was more effective for anger control, externalization of anger, hostility and guilt, especially at follow-up. Less strong effects were found on shame and internalized anger. Therapists tended to favor IE+IR as it decreased their feelings of helplessness compared to IE. Results suggest that the addition of rescripting to IE makes the treatment more acceptable for both patients and therapists, and leads to better effects on non-fear problems like anger and guilt.

The relative efficacy of bona fide psychotherapies for treating post-traumatic stress disorder: a meta-analysis of direct comparisons

Psychotherapy has been found to be an effective treatment of post-traumatic stress disorder (PTSD), but meta-analyses have yielded inconsistent results on relative efficacy of psychotherapies in the treatment of PTSD. The present meta-analysis controlled for potential confounds in previous PTSD meta-analyses by including only bona fide psychotherapies, avoiding categorization of psychotherapy treatments, and using direct comparison studies only. The primary analysis revealed that effect sizes were homogenously distributed around zero for measures of PTSD symptomology, and for all measures of psychological functioning, indicating that there were no differences between psychotherapies. Additionally, the upper bound of the true effect size between PTSD psychotherapies was quite small. The results suggest that despite strong evidence of psychotherapy efficaciousness vis-à-vis no treatment or common factor controls, bona fide psychotherapies produce equivalent benefits for patients with PTSD.

Eye movement desensitization and reprocessing for posttraumatic stress disorder: a pilot blinded, randomized study of stimulation type

BACKGROUND

Eye movement desensitization and reprocessing (EMDR) is becoming a recognized and accepted form of psychotherapy for posttraumatic stress disorder (PTSD). Yet, its mechanism of action remains unclear and much controversy exists about whether eye movements or other forms of bilateral kinesthetic stimulation contribute to its clinical effects beyond the exposure elements of the procedure.

METHODS

Twenty-one patients with single-event PTSD (average Impact of Event Scale score: 49.5) received three consecutive sessions of EMDR with three different types of auditory and kinesthetic stimulation (tones and vibrations): intermittent alternating right-left (as commonly used with the standard EMDR protocol), intermittent simultaneous bilateral, and continuous bilateral. Therapists were blinded to the type of stimulation they delivered, and stimulation type assignment was randomized and counterbalanced.

RESULTS

All three stimulation types resulted in clinically significant reductions of subjective units of distress (SUD). Yet, alternating stimulation resulted in faster reductions of SUD when only sessions starting with a new target memory were considered.

CONCLUSIONS

There are clinically significant effects of the EMDR procedure that appear to be independent of the nature of the kinesthetic stimulation used. However, alternating stimulation may confer an additional benefit to the EMDR procedure that deserves attention in future studies.

Heart rate responsivity to script-driven imagery in posttraumatic stress disorder: specificity of response and effects of psychotherapy

OBJECTIVE

Previous psychophysiological studies of posttraumatic stress disorder (PTSD) have found heightened physiological responsivity to trauma-specific stimuli, but mostly in combat veterans with high comorbidity rates and with psychiatric medication. Our aim was to investigate psychophysiological responses in two new populations while excluding those confounding influences and to assess the effects of psychotherapy on such responses.

METHODS

Thirty-nine subjects with PTSD (24 civilian outpatients and 15 police officers) and 15 trauma-exposed, non-PTSD control subjects underwent psychophysiological assessment while listening to neutral, stressful, and trauma scripts. Psychophysiological measures were heart rate (HR) and blood pressure in combination with subjective anxiety ratings. In a randomized clinical trial, 20 of the civilians were then assigned to treatment or waitlist groups. Psychophysiological assessment was repeated on them after the treatment stage.

RESULTS

Both civilians and police with PTSD showed significantly higher HR responses to trauma scripts than the control subjects. After successful psychotherapy with the civilians, HR responsivity to the trauma scripts was significantly reduced, and it correlated positively with PTSD clinical symptoms.

CONCLUSIONS

We confirmed previous findings of heightened psychophysiological responses in PTSD for two new populations while minimizing comorbidity and medication as confounding factors. Successful psychotherapy normalized HR response to trauma imagery.

Can the Randomized Controlled Trial Literature Generalize to Nonrandomized Patients?

To determine the extent to which published randomized controlled trials (RCTs) of psychotherapy can be generalized to a sample of outpatients, the authors matched information obtained from charts of patients who had been screened out of RCTs to inclusion and exclusion criteria from published RCT studies. Most of the patients in the sample who had primary diagnoses represented in the RCT literature were judged eligible for at least 1 RCT. However, many patients in the sample with substance use disorders or social anxiety disorder were not eligible for at least 2 RCTs. Common reasons that patients did not match with at least 2 published RCTs for psychotherapy included (a) patients were in partial remission, (b) patients failed to meet minimum severity or duration criteria, (c) patients were being treated with antidepressant medication, and (d) the disorder being studied was not primary (mostly for social anxiety patients). The implications of these findings for future research and clinical practice are discussed.

Are samples in randomized controlled trials of psychotherapy representative of community outpatients? A new methodology and initial findings

To determine the extent to which published randomized controlled trials (RCTs) of psychotherapy can be generalized to a sample of community outpatients, the authors used a method of matching information obtained from outpatient charts to inclusion and exclusion criteria from published RCT studies. They found that 80% of the patients in their sample who had diagnoses represented in the RCT literature were judged eligible for at least 1 published RCT; however, 58% of the patients had primary diagnoses such as adjustment disorder or dysthymia, which were not represented in the existing psychotherapy outcome literature. The most common reasons that patients in their sample did not match with published RCTs for psychotherapy are listed, and the implications of these findings for research and practice are discussed.

Assessing the long-term effects of EMDR: results from an 18-month follow-up study with adult female survivors of CSA

This 18-month follow-up study builds on the findings of a randomized experimental evaluation that found qualified support for the short-term effectiveness of Eye Movement Desensitization and Reprocessing (EMDR) in reducing trauma symptoms among adult female survivors of childhood sexual abuse (CSA). The current study provides preliminary evidence that the therapeutic benefits of EMDR for adult female survivors of CSA can be maintained over an 18-month period. Furthermore, there is some support for the suggestion that EMDR did so more efficiently and provided a greater sense of trauma resolution than did routine individual therapy.

Behavioral aspects of trauma in children and youth

Trauma is prevalent in the lives of children. It derives from many sources, and, depending on its characteristics, can produce transient or enduring and devastating consequences. Early trauma, if left untreated, can set the stage for chronic deficits in the behavioral repertoires of affected children, and thus shape personality development. Additionally, when trauma is repetitive and chronic, the developing brain may be affected in ways that impede otherwise effective intervention. Yet diagnosing traumatic stress in children requires a departure from exclusively adult-like considerations and attention must be devoted to the ongoing developmental processes. Trauma-associated clinical features in children are sharply distinct from those that are associated with adult traumatization and must be taken into account from screening and diagnosis through treatment and outcome evaluation. We suggest that a learning foundation for symptom development will best assist the identification and selection of efficacious treatments. Pediatricians should make use of validated screening procedures that effectively identify affected children to facilitate timely referral and ongoing monitoring of treatment outcomes for their patients. A representative list of such instruments can be found in Table 1. With respect to hospital-based trauma work, we suggest the following recommendations: Professionals must be alert to the presence of acute stress symptoms in any child or parent after all injury incidents. These symptoms may occur in any injured child regardless of age, gender, injury severity, mechanism of injury, or length of time since injury. Certain mechanisms of injury, (ie, pedestrian versus motor vehicle collision), place the parent at higher risk for symptomatology. All family members, including parents and siblings, must be considered at risk for acute and long-term functional abnormalities. It is important to educate patients and family members that acute stress symptoms are common after an injury incident and are likely to resolve as the patient's injuries heal. Yet despite this, before discharge from the hospital, parents must be taught to evaluate their traumatized child's behavior, as well as their own, for any evidence of posttraumatic stress disorder. Health care providers must anticipate potential strain upon family relationships and financial resources. Parent's posttraumatic stress symptoms may result in deterioration of their own ability to support their injured child. And finally, reassessment of patient and family members should occur within the first days, at 1 to 2 weeks, 6 months, and 1 year following injury to ensure proper recovery and optimization of psychosocial function.

Specific and nonspecific treatment factors in the experimental analysis of behavioral treatment efficacy

Interest in the empirical demonstration of the clinical efficacy of psychosocial treatments has been rekindled by societal concerns over accountability and cost-effectiveness in the delivery of mental health services. Behavior therapy has had a long history of experimental research on treatment efficacy and enjoys a visible presence in contemporary mental health practice. The demonstration of behavioral treatment efficacy, however, requires experimental evidence that shows the efficacy of prescriptive structured procedures beyond nonspecific factors in delivery of such procedures. The authors provide an analysis of the nature of nonspecific treatment factors and nonspecific effects and suggest experimental procedures testing the incremental validity of specific treatments. They examine two widely promoted, prescriptive structured treatments to analyze the specificity of their clinical efficacy: eye movement desensitization and reprocessing for anxiety disorders and cognitive-behavioral treatment of generalized anxiety disorder. They conclude that the treatments show different levels of efficacy and different degrees of specificity.

[Psychotraumatology: Recent therapy approaches]

Present-day therapy approaches in psychotraumatology center around the problem of effective access to specific trauma symptoms: intrusions; affective blunting and avoidance behaviors; hyperarousal. Taking its bearings from the German and American PTSD therapy guidelines, the article outlines the most important therapy methods and assesses them in terms of relevant quality criteria. EMDR, cognitive/behavioral approaches, modified psychodynamic methods and trauma-adapted inpatient psychotherapy can be recommended as long as they are used in conjunction with stabilizing therapy elements. Normally, further therapeutic interventions are also necessary, drawing on traditional methods for integrating the trauma into the patient's biography.

EMDR 12 years after its introduction: past and future research

Eye Movement Desensitization and Reprocessing (EMDR) was one of the first treatments of posttraumatic stress disorder (PTSD) to be evaluated in controlled research and has to date been empirically supported by 13 such studies. This article reviews the historical context and empirical research of EMDR over the past dozen years. Historically, EMDR's name has caused confusion in that "desensitization" is considered to be only a by-product of reprocessing and because the eye movement component of EMDR is only one form of dual stimulation to be successfully used in this integrative approach. Research is needed to determine the comparative efficacy of EMDR relative to cognitive-behavioral treatments of PTSD. However, this has been hampered by the lack of independent replication studies of the latter treatments. Current component analyses of EMDR have failed to effectively evaluate the relative weighting of its procedures. Parameters for future research and the testing of protocols for diverse disorders are suggested.

A critical evaluation of current views regarding eye movement desensitization and reprocessing (EMDR): clarifying points of confusion

EMDR is an active psychological treatment for PTSD that has received widely divergent reactions from the scientific and professional community. This article examines points of confusion in the published literature on EMDR, including the theoretical, empirical, and historical issues around EMDR and placebo effects, exposure procedures, the eye movement component, treatment fidelity issues, and outcome studies. It also examines historical information relevant to the scientific process and charges of "pseudoscience" regarding EMDR. We conclude that the confusion in the literature is due to (a) the lack of an empirically validated model capable of convincingly explaining the effects of the EMDR method, (b) inaccurate and selective reporting of research, (c) some poorly designed empirical studies, (d) inadequate treatment fidelity in some outcome research, and (e) multiple biased or inaccurate reviews by a relatively small group of authors. Reading the original research articles frequently helps to reduce the confusion arising from the research review literature.

Eye movement desensitization and reprocessing (EMDR): a meta-analysis

Eye movement desensitization and reprocessing (EMDR), a controversial treatment suggested for posttraumatic stress disorder (PTSD) and other conditions, was evaluated in a meta-analysis of 34 studies that examined EMDR with a variety of populations and measures. Process and outcome measures were examined separately. and EMDR showed an effect on both when compared with no treatment and with therapies not using exposure to anxiety-provoking stimuli and in pre post EMDR comparisons. However, no significant effect was found when EMDR was compared with other exposure techniques. No incremental effect of eye movements was noted when EMDR was compared with the same procedure without them. R. J. DeRubeis and P. Crits-Christoph (1998) noted that EMDR is a potentially effective treatment for noncombat PTSD. but studies that examined such patient groups did not give clear support to this. In sum, EMDR appears to be no more effective than other exposure techniques, and evidence suggests that the eye movements integral to the treatment, and to its name, are unnecessary.

The relationship between trauma, PTSD, and medical utilization in three high risk medical populations

OBJECTIVE

Increased use of medical and psychiatric services has been reported as a correlate of exposure to trauma. Recent studies suggest that: 1) physical and sexual abuse traumas are particularly associated with increased utilization and 2) posttraumatic stress disorder (PTSD), a common sequela of abuse, mediates the relationship between trauma exposure andelevated utilization. The goal of this study was to explore the relationships between trauma, abuse, PTSD, and medical utilization in three medical help seeking groups reported to be at high risk for trauma exposure.

METHOD

One hundred and seven patients receiving care at a university-affiliated medical center were surveyed for trauma history and PTSD using the Trauma History Questionnaire (THQ) and the PTSD Checklist (PCL). The sample included: forty-eight gynecologic outpatients, thirty-five inpatients with seizure disorders, and twenty-four psychiatric inpatients with non-PTSD admitting diagnoses. Medical utilization data were obtained from a computerized medical center data base.

RESULTS

Ninety-six patients reported a trauma history. Of these patients, sixty-six reported abuse and forty-five qualified for PTSD diagnoses. Total number of traumas and reported sexual and physical abuse correlated significantly with elevated medical utilization and PTSD prevalence. PTSD diagnosis was not significantly correlated with utilization, but the five highest utilizers received PTSD diagnoses.

CONCLUSIONS

Study results supported hypotheses regarding the relation of trauma exposure to medical utilization, but were less clear about the mediating role of PTSD. These findings suggest that routine screening of high-risk patient groups might promote timely identification of trauma history and PTSD, and subsequently impact health care utilization.

EMDR and hypnosis in the treatment of phobias. Eye Movement Desensitization and Reprocessing

Clinical hypnosis and EMDR have both been employed in the treatment of phobias. EMDR has been a controversial treatment method with the research showing mixed results concerning its efficacy. Many studies have shown the effectiveness of hypnosis in the treatment of phobias, but no studies have directly compared hypnosis to EMDR. This paper discusses each approach to treatment, with special emphasis on EMDR. Relevant research and current theories are reviewed along with questions raised and recommendations for future research.

Does a visual perceptual disturbance characterize trauma-related anxiety syndromes?

The i-test was developed to assess the visual-perceptual disturbances (VPDs) frequently reported by anxious patients. Persons with the disturbance report a specific abnormal illusion of movement when they maintain a fixed gaze at the i-test stimulus. Base rates for positive responses to the i-test and for reports of a "recurrent specific memory" (RSM) of a fear experience were obtained in psychiatric outpatient (n = 301) and community (n = 128) samples. In each case, approximately one fifth of participants had a positive response to the i-test and one fifth of participants reported an RSM of fear. A positive response to the i-test is observed in women more frequently than in men. Among psychiatric patients, approximately 90% of patients who report one symptom also report the other symptom; among community members, the concordance rate is approximately 33%. When psychiatric patients with both an abnormal illusion of movement response and an RSM of trauma are treated with eye movement desensitization, both symptoms are removed in 70% of cases; when these patients undergo some other form of treatment, both symptoms are removed in 30% of cases. These results indicate that the i-test is an effective way of identifying VPDs associated with psychopathologic conditions; the association between the abnormal illusion of movement and reports of recurrent specific memories of fear experiences suggests that the VPD may be a marker of traumatic stress syndromes.

Improving psychotherapeutic services via randomized clinical trials, treatment manuals, and component analysis designs

In order to advance the practice of psychotherapy and to discover how to improve on the benefits of psychotherapy, we propose that practitioners and researchers should rely more on the results of randomized clinical trials research. On the practice side, the routine use by practitioners of manuals for empirically supported treatments holds the promise of providing scientifically based clinical services to clients. On the research side, there is much to be gained in using component analysis designs to determine the effective elements of a treatment that has been established as empirically supported in randomized clinical trials. Once these elements are identified, the next version of the treatment manual then could highlight the crucial aspects of treatment to be included in clinical practice. thus further refining scientifically based psychotherapeutic services.

Individual psychotherapy outcome and process research: challenges leading to greater turmoil or a positive transition?

Psychotherapy is facing challenges that relate to the emergence of managed health care, the possibility of a national health care system, and advances in biological psychiatry. These situations have created pressure to achieve a more accurate assessment of psychotherapeutic effectiveness. Psychotherapy has been proven to be generally effective; however, there is uncertainty as to why. The field is currently experiencing apparent turmoil in three areas: (a) theory development for psychotherapeutic effectiveness, (b) research design, and (c) treatment technique. This chapter reviews the dynamics within each of the areas and highlights the progress made in treating mental disorders. We conclude that recent advances in research design may provide a transition that will bring psychotherapy closer to becoming a unified paradigm with an acceptable theory of effectiveness.

Eye Movement Desensitization and Reprocessing (EMDR) and the anxiety disorders: clinical and research implications of an integrated psychotherapy treatment

Four recent, independent, rigorously controlled studies of Eye Movement Desensitization and Reprocessing (EMDR) have reported that 84 to 100% of single-trauma victims no longer maintain the posttraumatic stress disorder diagnosis after the equivalent of three 90-minute sessions. The rapidity of EMDR treatment effects makes many ancillary research opportunities available. Specifically, the increased number of cases resolved in a relatively short period of time allows investigation of neurophysiological phenomena, patterns of cognitive and emotional processing, component analyses of a large range of procedural factors, and evaluation of the efficacy of application to diverse clinical populations. Unfortunately, some research has been conducted that has been severely hampered by insufficient treatment fidelity and lack of clinical validity. Consequently, this article will attempt to describe the procedures and protocols that are believed to contribute to EMDR's clinical effects and are, therefore, suggested for the EMDR treatment and research of the anxiety disorders. This is particularly relevant given the misconceptions that have abounded due to the unfortunate naming of the procedure after the eye movements, which have proved to be only one of many useful types of stimulation, and only one of many components of this complex, integrated treatment.

The cognitive dismantling of Eye Movement Desensitization and Reprocessing (EMDR) treatment of Posttraumatic Stress Disorder (PTSD)

Twenty-seven subjects were exposed to standard Eye Movement Desensitization and Reprocessing (EMDR) treatment or a similar treatment without the explicit cognitive elements found in EMDR. Standardized psychometric assessments were administered (Structured Interview for Post Traumatic Stress Disorder, Impact of Event Scale, Revised Symptom Checklist-90) by independent assessors at pretest, posttest and two separate follow-up periods. Potential subjects met specific inclusion/exclusion criteria. Subjective measures including Subjective Units of Disturbance and Validity of Cognition assessments were also conducted. A two-factor repeated measures analysis of variance revealed that both treatments produced significant symptom reductions and were comparable on all dependent measures across assessment phases. The present findings are discussed in light of previous dismantling research that converges to suggest that several elements in the EMDR protocol may be superfluous in terms of the contribution to treatment outcome. These same elements have nevertheless entered unparsimoniously into consideration as possible explanatory variables.

Does EMDR work? And if so, why?: a critical review of controlled outcome and dismantling research

Research on Eye Movement Desensitization and Reprocessing therapy (EMDR) was reviewed to answer the questions "Does EMDR work?" and "If so, Why?" This first question was further subdivided on the basis of the control group: (a) no-treatment (or wait list control), (b) nonvalidated treatments, and (c) other validated treatments. The evidence supports the following general conclusions: First, EMDR appears to be effective in reducing at least some indices of distress relative to no-treatment in a number of anxiety conditions, including posttraumatic stress disorder, panic disorder, and public-speaking anxiety. Second, EMDR appears at least as effective or more effective than several nonvalidated treatments (e.g., relaxation, active listening) for posttraumatic stress reactions. Third, despite statements implying the contrary, no previously published study has directly compared EMDR with an independently validated treatment for posttraumatic stress disorder (e.g., therapist-directed flooding). In the treatment of simple phobia, participant modeling has been found to be more effective than EMDR. Fourth, our review of dismantling studies reveals there is no convincing evidence that eye movements significantly contribute to treatment outcome. Recommendations regarding further research directions are provided.

Traumatic memories, eye movements, phobia, and panic: a critical note on the proliferation of EMDR

In the past years, Eye Movement Desensitization and Reprocessing (EMDR) has become increasingly popular as a treatment method for Posttraumatic Stress Disorder (PTSD). The current article critically evaluates three recurring assumptions in EMDR literature: (a) the notion that traumatic memories are fixed and stable and that flashbacks are accurate reproductions of the traumatic incident; (b) the idea that eye movements, or other lateralized rhythmic behaviors have an inhibitory effect on emotional memories; and (c) the assumption that EMDR is not only effective in treating PTSD, but can also be successfully applied to other psychopathological conditions. There is little support for any of these three assumptions. Meanwhile, the expansion of the theoretical underpinnings of EMDR in the absence of a sound empirical basis casts doubts on the massive proliferation of this treatment method.

Eye Movement Desensitization and Reprocessing: an analysis of specific versus nonspecific treatment factors

Incremental validity and incremental efficacy have become important issues in the evaluation of psychological assessment and intervention procedures. Incremental validity in assessment is that shown by novel measures over and above established ones. Incremental efficacy is that shown by novel treatments over and above nonspecific and established treatment effects. In this paper, we critically examine the question of whether Eye Movement Desensitization and Reprocessing (EMDR) possesses efficacy above and beyond nonspecific treatment effects and components that are shared with well-established interventions. A review of recently published efficacy studies reveals that (a) the effects of EMDR are largely limited to verbal report indices, (b) eye movements and other movements appear to be unnecessary, and (c) reported effects are consistent with nonspecific treatment features. Examination of individual studies shows that control procedures for nonspecific features have been minimal. We analyze EMDR for nonspecific treatment features and suggest experimental controls to examine the incremental efficacy of EMDR.

The contributions of eye movements to the efficacy of brief exposure treatment for reducing fear of public speaking

The present study was designed to isolate the effects of the eye-movement component of the Eye Movement Desensitization and Reprocessing (EMDR) procedure in the treatment of fear of public speaking. Seventy-one undergraduate psychology students who responded in a fearful manner on the Fear Survey Schedule II and on a standardized, self-report measure of public speaking anxiety (Personal Report of Confidence as a Speaker; PRCS) were randomly assigned to one of four groups in a 2x2 factorial design. The two independent variables assessed were treatment condition (imagery plus eye movements vs. imagery alone) and type of imagery (fear-relevant vs. relaxing). Dependent variables assessed were self-reported and physiological anxiety during exposure and behavioral indices of anxiety while giving a speech. Although process measures indicated exposure to fear-relevant imagery increased anxiety during the procedure, no significant differences among groups were found on any of the outcome measures, except that participants who received eye movements were less likely to give a speech posttreatment than participants who did not receive eye movements. Addition of the eye movements to the experimental procedure did not result in enhancement of fear reduction. It was concluded, consistent with the results of past research, that previously reported positive effects of the EMDR procedure may be largely due to exposure to conditioned stimuli.