The AIP model as a theoretical framework for the treatment of personality disorders with EMDR therapy

Research has shown that the impact of traumatic events and circumstances on individuals is cumulative and potentially has a wide range of harmful consequences, including negative consequences on mental health. One such consequence is the development of a personality disorder, a persistent mental condition characterized by a pronounced pattern of difficulties in impulse control, emotional regulation, cognitive functions, self-esteem, and interpersonal relationships. A wide array of studies indicates that the personal history of individuals with a personality disorder is often marked by exposure to traumatic events or other types of adverse childhood experiences (ACEs). Because existing treatments for personality disorders are usually long and costly, it is essential to continue exploring alternative and complementary interventions. Nowadays, knowledge and clinical experience in regard to personality disorders have been gained in addressing ACEs by processing memories of these events through eye movement desensitization and reprocessing (EMDR) therapy. In this paper, we present a theoretical framework for this treatment approach, based on Shapiro's Adaptive Information Processing (AIP) model, describe its current empirical basis, and provide guidance on how to formulate a useful case conceptualization that can serve as a basis for the treatment of personality disorders with EMDR therapy. This approach is illustrated with a case example.

Case report: Brief, intensive EMDR therapy for borderline personality disorder: results of two case studies with one year follow-up

Background

Exposure to adverse childhood events plays an important role in the development of borderline personality disorder (BPD). Emerging evidence suggests that trauma-focused therapy using eye movement desensitization and reprocessing (EMDR) can be beneficial for patients with BPD symptoms. To date, the effects of brief, intensive EMDR treatment for this target group have not been investigated in this population.

Objective

This study aimed to evaluate the effects of a brief and intensive trauma-focused therapy course using EMDR therapy in two patients diagnosed with BPD who did not fulfill the diagnostic criteria for post-traumatic stress disorder (PTSD). It was hypothesized that this approach would be associated with a decline in the core symptoms of BPD, and that this would have an enduring long-term effect on patients' diagnostic status.

Method

Ten sessions of EMDR therapy were carried out across four consecutive treatment days, with the aim of processing patients' core adverse childhood experiences. Both A-criterion-worthy memories (without intrusive reliving) and non-A-criterion-worthy memories that were considered responsible for the patients' most prominent symptoms were targeted. The effects of EMDR therapy on trauma symptom severity and BPD diagnostic status (as established by the Structured Clinical Interview DSM-5) were determined. Additionally, the effects on psychological distress, quality of life, and difficulties in emotion regulation were determined at intake, post-treatment, and at 3-, 6-, and 12-months follow-up.

Results

Both patients showed a strong decline in psychological distress and difficulties in emotion regulation, and reported an improvement in their quality of life. At post-treatment, and at 3-, 6-, and 12-months follow-up they no longer met the DSM-5 criteria for BPD.

Conclusion

The findings of this small case study are in line with mounting evidence that a brief track of intensive trauma-focused therapy can result in long-term remission in patients with BPD. EMDR therapy seems to be a promising treatment approach for patients with BPD; however, the results need to be replicated in clinical trials.

Couple relational ethics: From theory to lived practice

Distressed couples often become polarized and caught up in power struggles, with competing claims and perspectives. When escalated, partners may become reactive and unkind. The competitive-individualistic worldview of the Euro-American culture feeds polarization between partners. This article explores relational views of the self and relational ethics developed in philosophy, psychology, feminist theory, neurobiology, and couple and family therapy that counter this individualistic view. A major focus is on the ways in which partners impact each other's identity and well-being for better or worse, and the ethical responsibility this entails. The discussion addresses couple relational ethics within the larger sociocultural context that privileges power and competition. The paper offers applications to couple relationships and couple therapy, with interventions to promote mutual responsibility, fairness, dialogue, and care-helping partners to identify their higher values and interact with greater intentionality. A case example is offered to illustrate therapeutic techniques to enhance relational ethics in couples.

Adding EMDR for PTSD at the onset of treatment of borderline personality disorder: A pilot study

BACKGROUND AND OBJECTIVES

Eye movement desensitization and reprocessing (EMDR) is an effective treatment for individuals suffering from posttraumatic stress disorder (PTSD). However, EMDR is not typically offered to people with PTSD who also meet the criteria for borderline personality disorder (BPD). This study examines the feasibility and clinical benefits of EMDR for PTSD delivered in addition to the onset of treatment as usual (TAU) for BPD.

METHODS

In a non-concurrent, multiple baseline design, 12 patients with BPD and PTSD received fifteen weekly 45-min sessions of TAU. During this period, eight weekly 90-min EMDR sessions were added. Outcome measures were obtained weekly for self-reported PTSD symptoms (PTSD checklist for DSM-5), levels of psychopathology (Brief Symptom Checklist), and the effect of psychopathology on different areas of life (Sheehan Disability Scale).

RESULTS

9 participants completed the treatment protocol. In the EMDR phase, PTSD severity scores decreased significantly between sessions, while no between-session drop in scores occurred during the TAU only phase. Similar results were obtained for general symptoms and disability. No adverse events were reported.

LIMITATIONS

Results on the efficacy and safety of EMDR in patients with BPD and PTSD need to be replicated in larger samples and in RCTs before they can be generalized to the entire population.

CONCLUSIONS

The results of our study suggest that EMDR may be feasible and effective in reducing PTSD symptoms in patients concurrently receiving BPD treatment. EMDR appears to be a promising intervention for patients with BPD and comorbid PTSD.

Eye Movement Desensitization and Reprocessing versus Cognitive Behavior Therapy for Treating Post-Traumatic Stress Disorder: A Systematic Review and Meta-Analysis

This meta-analysis review compared eye movement desensitization and reprocessing and cognitive behavior therapy efficacy in reducing post-traumatic stress disorder (PTSD), anxiety, and depression symptoms. A systematic search for articles published between 2010 and 2020 was conducted using five databases. The RevMan software version 5 was used. Out of 671 studies, 8 fulfilled the inclusion criteria and were included in this meta-analysis. Three studies reported that eye movement desensitization and reprocessing reduced depression symptoms better than cognitive behavior therapy in both children, adolescents, and adults (SDM (95% CI) = -2.43 (-3.93--0.94), p = 0.001). In three other studies, eye movement desensitization and reprocessing were shown to reduce anxiety in children and adolescents better than cognitive behavior therapy (SDM (95% CI) = -3.99 (-5.47--2.52), p < 0.001). In terms of reducing PTSD symptoms, eye movement desensitization and reprocessing and cognitive behavior therapy did not demonstrate any statistically significant differences (SDM (95% CI) = -0.14 (-0.48-0.21), p = 0.44). There was no statistically significant difference at the three-month follow-up and at the six-month follow-up for depression (p = 0.31), anxiety (p = 0.59), and PTSD (p = 0.55). We recommend randomized trials with larger samples and longer follow-up times in the future.

EMDR as Treatment Option for Conditions Other Than PTSD: A Systematic Review

Eye Movement Desensitisation and Reprocessing (EMDR) is a treatment for post-traumatic stress disorder (PTSD). The technique is known to facilitate reprocessing of maladaptive memories that are thought to be central to this pathology. Here we investigate if EMDR therapy can be used in other conditions. We conducted a systematic literature search on PubMed, ScienceDirect, Scopus, and Web of Science. We searched for published empirical findings on EMDR, excluding those centred on trauma and PTSD, published up to 2020. The results were classified by psychiatric categories. Ninety articles met our research criteria. A positive effect was reported in numerous pathological situations, namely in addictions, somatoform disorders, sexual dysfunction, eating disorders, disorders of adult personality, mood disorders, reaction to severe stress, anxiety disorders, performance anxiety, Obsessive-Compulsive Disorder (OCD), pain, neurodegenerative disorders, mental disorders of childhood and adolescence, and sleep. Some studies reported that EMDR was successful in usually uncooperative (e.g., Dementia) or unproductive cases (e.g., aphasia). Moreover, in some severe medical conditions, when psychological distress was an obstacle, EMDR allowed the continuation of treatment-as-usual. Furthermore, the effects observed in non-pathological situations invite for translational research. Despite a generally positive outlook of EMDR as an alternative treatment option, more methodologically rigorous studies are needed. We discuss the advantages and limitations and possible implications for the hypothesised mechanisms of action.

EMDR Treatment of Childhood Sexual Abuse for a Child Molester: Self-Reported Changes in Sexual Arousal

Expanding on previous findings that eye movement desensitization and reprocessing (EMDR) therapy may alter deviant sexual arousal in adult child molesters with a history of childhood sexual abuse (CSA), this article describes the changes reported following the application of EMDR therapy to the memories of CSA in an adult male who had sexually offended against prepubescent children. The client had previously completed a cognitive behavioral intervention to address his offending behavior. EMDR therapy took place over 11 months and consisted of 32 sessions, including preparation and review phases. The aim of the therapy was to alleviate current reported distress and symptoms of posttraumatic stress disorder (PTSD) related to his memories of CSA. The client reported positive changes in emotional, cognitive, and physiological functioning, consistent with reductions on a range of subscales of the Trauma Symptom Inventory 2 and the Inventory of Altered Self-Capacities. However, on completion of therapy, he also reported a reduction in the frequency and strength of sexual arousal to children, which was maintained at a 3-year follow-up, although this was not a target for treatment. The experiences described during the EMDR process by this client are discussed and related to the adaptive information processing (AIP) model and previous findings on reported changes in sexual arousal in this client group.

[The Eyes Movement Desensitization and Reprocessing for children with traumatic traumatic stress disorder: A Tunisian experience]

OBJECTIVES

Evaluate the effectiveness of the Eyes Movement Desensitization and Reprocessing psychotherapy for children with Post-Traumatic Stress Disorder.

METHODS

A retrospective study was conducted in the Child Psychiatry Department of CHU Mongi Slim, Marsa (Tunis, Tunisia). All Outpatients with a Post-Traumatic Stress Disorder diagnosis and who had Eyes Movement Desensitization and Reprocessing psychotherapy during the period from July 2016 to May 2018 were included. They were evaluated according to DSM 5 criteria in pre and post therapy.

RESULTS

The sample consisted of sixteen children with a sex-ratio of 1.6. Their age ranged from 3 to 17 years old with a mean age of 9.5±4.6 years. Five patients were less than six years old. Our patients were exposed to a sexual assault (4 cases), a death of a family member (3 cases), a road accident (3 cases), a physical assault (4 cases), an arrest of the father (1 case) and burglary of the house (1 case). In 15 cases, the traumatic event was unique while it was repeated in one sexual assault case. The total number of follow-up sessions ranged from one to seven sessions with an average of 3±2.4 sessions. The average number of sessions for preschool children was 2.6±0.5 sessions. Bilateral tactile stimulations were used with thirteen children in our population, including the five children younger than six years old. At the end of the therapy all patients no longer met the criteria for Post-Traumatic Stress Disorder diagnosis. All the preschool patients and eight children older than 6 years did not respond to any of the four Post-Traumatic Stress Disorder criteria. The difference between the scores of the DSM 5 criteria in pre and post EMDR was statistically significant. We found P=10-3 for children over six years and P<0.05 for children under six years old.

CONCLUSION

Eyes Movement Desensitization and Reprocessing is a therapy that has several advantages. First, it is effective in Post Traumatic Stress Disorder in children. Second, its protocol is flexible and adaptable to all ages and developmental level of the child. Third, the number of sessions is usually reduced, which is a great advantage over other trauma-focused psychotherapies.

Changing the Adult State of Mind With Respect to Attachment: An Exploratory Study of the Role of EMDR Psychotherapy

We aimed to assess changes in the attachment internal working model and reflective function (RF) as mechanisms of change in eye movement desensitization and reprocessing (EMDR) treatment for patients with traumatic memories. Twenty adult female patients with parenting and relational problems participated in the study. Attachment organization was assessed with the Adult Attachment Interview (AAI) and the RF coding scale pre- and posttreatment. We found that EMDR therapy increased patients' narrative coherence and RF. We noted a significant decrease in the number of participants classified as unresolved following the course of EMDR treatment in which loss and/or trauma were resolved. This article summarizes the changes after EMDR therapy regarding attachment status and its efficacy to reprocess early traumatic memories in a more adaptive way. Finally, our results also support the usefulness of the AAI as a tool for understanding the changing processes during a therapeutic treatment.

Feasibility of EMDR for posttraumatic stress disorder in patients with personality disorders: a pilot study

Background: Trauma and posttraumatic stress disorder (PTSD) are prevalent in patients with personality disorders. Despite the established efficacy of eye movement desensitisation and reprocessing (EMDR) for PTSD, EMDR has barely been examined in patients with comorbid PTSD and personality disorders. Objective: The aim of this study was to explore what changes occur in symptom severity of PTSD, dissociative symptoms, insomnia, non-suicidal self-injurious behaviour and auditory verbal hallucinations in patients with personality disorders during treatment with EMDR. Method: This uncontrolled open feasibility study on EMDR for PTSD was an addition to treatment-as-usual for personality disorders. The outcome measures were the severity of PTSD symptoms, dissociation, insomnia, non-suicidal self-injury, and auditory verbal hallucinations. Results: Forty-seven participants (22 with a borderline personality disorder, 25 with other personality disorders) were included. A significant reduction in the severity of symptoms of PTSD, dissociation and insomnia was observed after EMDR treatment (median of four sessions), and 40% of the participants scored below the threshold for PTSD diagnosis. No differences in efficacy were found between patients with borderline personality disorder and other personality disorders. EMDR treatment was completed by 68% of the participants. Conclusions: The addition of EMDR techniques to treatment, as usual, may be beneficial in the treatment of PTSD in patients with personality disorders in order to reduce symptoms of PTSD, dissociation and insomnia. Although one-third of these patients did not complete the additional EMDR treatment, no severe complications (e.g. suicidal behaviour or hospitalisation) occurred. Controlled studies are needed to further investigate the validity of these findings.

The Efficacy of Eye Movement Desensitization and Reprocessing in Children and Adults Who Have Experienced Complex Childhood Trauma: A Systematic Review of Randomized Controlled Trials

Background: Survivors of complex childhood trauma (CT) such as sexual abuse show poorer outcomes compared to single event trauma survivors. A growing number of studies investigate Eye Movement Desensitization and Reprocessing (EMDR) treatment for posttraumatic stress disorder (PTSD), but no systematic reviews have focused on EMDR treatment for CT as an intervention for both adults and children. This study therefore systematically reviewed all randomized controlled trials (RCTs) evaluating the effect of EMDR on PTSD symptoms in adults and children exposed to CT. Methods: Databases including PubMed, Web of Science, and PsycINFO were searched in October 2017. Randomized controlled trials which recruited adult and children with experience of CT, which compared EMDR to alternative treatments or control conditions, and which measured PTSD symptoms were included. Study methodology quality was evaluated with Platinum Standard scale. Results: Six eligible RCTs of 251 participants were included in this systematic review. The results indicated that EMDR was associated with reductions in PTSD symptoms, depression and/or anxiety both post-treatment and at follow-up compared with all other alternative therapies (cognitive behavior therapy, individual/group therapy and fluoxetine) and control treatment (pill placebo, active listening, EMDR delayed treatment, and treatment as usual). However, studies suffered from significant heterogeneity in study populations, length of EMDR treatment, length of follow-up, comparison groups, and outcome measures. One study had a high risk of bias. Discussion: This systematic review suggests that there is growing evidence to support the clinical efficacy of EMDR in treating CT in both children and adults. However, conclusions are limited by the small number of heterogenous trials. Further RCTs with standardized methodologies, as well as studies addressing real world challenges in treating CT are required.

Conceptualization of Parenting Stress in the Context of EMDR Therapy

Shapiro’s adaptive information processing (AIP) model hypothesizes that chronic parenting stress may result from past distressing parental experiences that were not adaptively processed. Our correlational study conducted a preliminary test of the AIP model to determine if current levels of parenting stress were associated with the number of reported distressing parental experiences. Thirty-five parents, whose children were being treated in a community clinic, were interviewed to identify memories of events related to the onset and aggravation of parenting stress. Standardized measure of present parenting stress was obtained. Regression analysis indicated that the number of reported unprocessed parenting experiences was a strong predictor for the level of parenting stress. The results support the AIP conceptualization of parenting stress and are discussed in the context of the development of an eye movement desensitization and reprocessing (EMDR) intervention to reduce parenting stress.

Application of EMDR Therapy for Borderline Personality Disorder

There is a growing interest in the use of eye movement desensitization and reprocessing (EMDR) therapy beyond posttraumatic stress disorder (PTSD) where its application is well established. With strong scholarly consensus that early traumatic and adverse life experiences contribute to the development of borderline personality disorder (BPD), EMDR would appear to offer much to the treatment of persons with BPD. However, given the specific characteristics of these clients, the application of EMDR therapy to their treatment can be challenging and necessitates several minor adaptations of the standard EMDR procedures for PTSD. This article provides an orientation to principles and strategies for safely and effectively preparing clients with BPD for EMDR therapy and for accessing and reprocessing the traumatic origins of BPD. Clinical examples are provided throughout.