EMDR as Add-On Treatment for Psychiatric and Traumatic Symptoms in Patients with Substance Use Disorder

Survival, Attachment, and Healing: An Evolutionary Lens on Interventions for Trauma-Related Dissociation

Purpose

Dissociation is a necessary part of our threat response system, common to all animal species, normally temporarily activated under conditions of extreme or inescapable threat. Pathological dissociation, however, continues to occur after the initial threat has passed, in response to reminders or inaccessibility of safety and security. Present across the spectrum of psychiatric diagnoses, recurrent dissociative symptoms are linked to severe trauma exposure, insecure attachment, treatment non-response, and maladaptive coping behaviors such as substance use, suicidality, and self-harm. However, empirical studies testing treatments specific to dissociative processes remain scarce. This narrative review summarizes existing studies and provides theoretical, neurobiological, and evolutionary perspectives on dissociative processes and treatments for pathological dissociation.

Methods

A systematic search of five databases (MEDLINE, EMBASE, APA PsycINFO, CINAHL plus, Scopus) was conducted on April 13, 2023. Peer-reviewed clinical studies with adult participants, assessing intervention effects on dissociative symptoms, were included. Results were thematically analyzed and summarized.

Results

Sixty-nine studies were identified, mainly focused on posttraumatic stress disorder, trauma-exposed populations, and borderline personality disorder. Psychotherapy was studied in 72.5% of studies; other interventions included medications and neurostimulation. The majority reported positive outcomes, despite the heterogeneous spectrum of interventions. However, treatment of dissociative symptoms was the primary objective in only a minority.

Conclusion

Pathological dissociation is a complex phenomenon involving brain and body systems designed for perceiving and responding to severe threats, requiring an individualized approach. A literature is emerging regarding potentially evidence-based treatments to help those impacted by recurrent dissociative symptoms. When contextualized within a neurobiological and evolutionary perspective, these treatments can be understood as facilitating an internal and/or relational sense of safety, resulting in symptom reduction. Further studies are needed to explore effective treatments for dissociative symptoms.

[Effectiveness of psychotherapy on dissociative symptoms in adult populations: A PRISMA systematic review]

INTRODUCTION

Dissociation is a psychological process in reaction to threat which can be found in many psychiatric conditions. Dissociative symptoms can become very disabling, whether in daily life or in care. Nevertheless, few studies seem to have examined the efficacy of psychotherapy on the latter and its relevance as a therapeutic target.

METHOD

A systematic review of the literature (PRISMA) on the efficacy of psychotherapy on dissociative symptoms in adults with mental disorders was conducted. Effectiveness was considered in terms of reduction in dissociative symptomatology. The search was conducted on Scopus, PubMed and PsycInfo. Overall, 50 full-text articles were evaluated.

RESULTS

Fourteen studies were included in the review. In all, 711 adult subjects with post-traumatic stress disorder, borderline personality disorder or dissociative disorder were included. Overall, this systematic review reports a reduction in dissociative symptoms associated with a variety of psychotherapeutic interventions, without allowing any conclusions to be drawn on the superiority of one psychotherapy over another.

DISCUSSION

The conclusions of this work highlight three possible therapeutic orientations for reducing dissociative symptoms: (i) by reintegrating the dynamic subsystems, (ii) by treating the cognitive processes underlying dissociation, and (iii) by acting on the processes identified as common to the effectiveness of psychotherapy.

Eye movement desensitisation and reprocessing as add-on treatment to enhanced cognitive behaviour therapy for patients with anorexia nervosa reporting childhood maltreatment: A quasi-experimental multicenter study

OBJECTIVE

This quasi-experimental study aimed to compare the outcome of patients with Anorexia Nervosa (AN) reporting moderate/severe childhood maltreatment (CM) treated exclusively with Enhanced Cognitive Behaviour Therapy (CBT-E) or with CBT-E plus Eye Movement Desensitisation and Reprocessing (EMDR).

METHOD

A total of 75 patients with AN reporting moderate/severe CM were initially assessed regarding body mass index (BMI), general and eating disorder (ED)-specific psychopathology, and dissociative symptoms, and re-evaluated after 40 CBT-E sessions (T1). Then, 18 patients received EMDR, whereas the others were placed on a waiting list and continued CBT-E. T2 assessment was performed after 20-25 sessions of EMDR or CBT-E. A control group of 67 patients without CM was also enroled and treated with CBT-E.

RESULTS

Contrary to patients without CM, neither of the traumatised groups improved in BMI, general and ED psychopathology, or dissociation at T1. However, at T2, both traumatised groups improved in BMI and ED-specific psychopathology, with the CBT + EMDR group demonstrating greater improvements. Moreover, only the CBT + EMDR group improved in general psychopathology and dissociative symptoms. The reduction of ED symptoms in traumatised patients was mediated by the amelioration of dissociation.

DISCUSSION

The addition of EMDR to CBT-E may benefit patients with AN reporting moderate/severe CM.

Why Young Women Who Use Opioids Are at Risk for Rape: The Impact of Social Vulnerabilities and Sexually Coercive Drug Using Contexts

This study tests a theoretically informed model to understand why women who use opioids (WWUO) are at risk of rape while using drugs. Structured interviews were conducted with 168 WWUO. Three domains were hypothesized to increase risk: the sexually coercive context of drug use, women's social vulnerability, and drug use severity. Logistic regression examined the odds of being raped by domain. One-third of WWUO had been raped while using drugs. The sexually coercive context and social vulnerability domains significantly increased women's odds of being raped. Prevention efforts should target social and contextual factors.

Early psychological intervention in adult patients after hospitalization during COVID-19 pandemia. A single center observational study

The coronavirus disease 2019 pandemic has represented an individual and collective trauma with an impact on mental health. COVID-19 survivors need to be screened for psychological distress regularly for timely intervention. After March 2020, an outpatients clinic for follow up of discharged COVID-19 patients was set up at Infectious Diseases Department of the Hospital of Lecco, Italy. Blood exams, specialistic visits were performed for each patients and IES-R and BDI scales were dispensed. 523 patients were referred to the clinic; 93 of them resulted positive at IES-R and/or BDI self-report and 58 agreed to have early interviews with psychologist specialist. Patients could receive only a short psychoeducation/psychological support intervention or in addition to the same, even a specific trauma-focused psychotherapeutic intervention with EMDR where clinically indicated. IES-R e BDI were administered pre- and post-intervention. The results show that the average of the post-traumatic stress scores detected at IES-R is above the clinical cut-off for the entire sample. There is an overall change in the decrease in mean scores on the IES and BDI scales before and after psychological intervention. Among the patients for whom psychopharmacological therapy was also necessary, those who had COVID-mourning in family improved the most at IES-R scale post- intervention. With respect to EMDR treatment, there is a significant improvement in depressive symptoms noticed at BDI for male patients who have received neither psychotropic drugs nor CPAP. Being hospitalized for coronavirus has a significant impact on the patient's mental health and it is a priority to arrange early screening to intercept psychological distress and give it an early response.

Practical Considerations for Treating Comorbid Posttraumatic Stress Disorder in the Addictions Clinic: Approaches to Clinical Care, Leadership, and Alleviating Shame

A practical, common-sense framework for recognizing and addressing comorbid posttraumatic stress disorder (PTSD) in the substance use disorder (SUD) clinic is outlined. The article focuses on strategies that can help establish trauma-informed care or augment an existing approach. Interventions are organized around the task of ameliorating shame (or shame sensitivity), which represents a transdiagnostic mediator of psychopathology and, potentially, capacity for change. Countershaming strategies can guide a trauma-responsive leadership approach. Considering the striking rate of underdiagnosis of PTSD among patients with SUD, implementing routine systematic PTSD screening likely represents the single most consequential trauma-informed intervention that SUD clinics can adopt.

Promoting Mental Health in Healthcare Workers in Hospitals Through Psychological Group Support With Eye Movement Desensitization and Reprocessing During COVID-19 Pandemic: An Observational Study

BACKGROUND

Psychological support was provided by the Eye Movement Desensitization and Reprocessing Integrative Group Treatment Protocol (EMDR-IGTP) within the hospitals in the Northern Italy in favor of healthcare workers during the COVID-19 pandemic. This study aimed at evaluating the effectiveness of treatment in terms of (a) symptomatology reduction related to peri- and post-traumatic stress; (b) clinical improvement over time; and (c) the maintenance of the achieved outcome over time.

METHODS

The population was composed of healthcare workers who spontaneously requested psychological intervention in both the first and the second emergency waves. Statistical analyses were carried out to highlight the differences in Impact of Event-Revised (IES-R) and Post-Traumatic Growth Inventory (PTGI) before and after the group intervention.

RESULTS

In both the first and the second waves, pre-treatment values are higher than post-treatment values for all dimensions of the IES-R. The results show that there are no significant differences between the first and the second wave with regard to the treatment effect. Healthcare workers maintained positive changes over time despite their prolonged exposure to an emergency and the possibility of retraumatization at the onset of a new emergency phase, irrespective of their working place. Healthcare workers who were treated in the first wave showed at the beginning of the second emergency wave less vulnerability and more resilience than those who were treated only in the second wave.Pre-treatment scores of healthcare workers affected by COVID-19 are discussed.

CONCLUSION

COVID-19 had a significant impact on the well-being of healthcare workers who were working in hospitals. Psychological support in case of emergency is needed.

Adverse childhood experiences and adult diet quality

Childhood trauma is strongly associated with poor health outcomes. Although many studies have found associations between adverse childhood experiences (ACEs), a well-established indicator of childhood trauma and diet-related health outcomes, few have explored the relationship between ACEs and diet quality, despite growing literature in epidemiology and neurobiology suggesting that childhood trauma has an important but poorly understood relationship with diet. Thus, we performed a cross-sectional study of the association of ACEs and adult diet quality in the Southern Community Cohort Study, a largely low-income and racially diverse population in the southeastern United States. We used ordinal logistic regression to estimate the association of ACEs with the Healthy Eating Index-2010 (HEI-10) score among 30 854 adults aged 40-79 enrolled from 2002 to 2009. Having experienced any ACE was associated with higher odds of worse HEI-10 among all (odds ratio (OR) 1⋅22; 95 % confidence interval (CI) 1⋅17, 1⋅27), and for all race-sex groups, and remained significant after adjustment for adult income. The increasing number of ACEs was also associated with increasing odds of a worse HEI-10 (OR for 4+ ACEs: 1⋅34; 95 % CI 1⋅27, 1⋅42). The association with worse HEI-10 score was especially strong for ACEs in the household dysfunction category, including having a family member in prison (OR 1⋅34; 95 % CI 1⋅25, 1⋅42) and parents divorced (OR 1⋅25; 95 % CI 1⋅20, 1⋅31). In summary, ACEs are associated with poor adult diet quality, independent of race, sex and adult income. Research is needed to explore whether trauma intervention strategies can impact adult diet quality.

Coronavirus Disease 2019 Emergency and Remote Eye Movement Desensitization and Reprocessing Group Therapy With Adolescents and Young Adults: Overcoming Lockdown With the Butterfly Hug

The coronavirus disease 2019 (COVID-19) pandemic has represented an individual and collective trauma with an impact on mental health. Restrictive measures such as lockdowns have increased risk factors for the development or triggering of various psychopathologies. Timely psychological intervention has constituted a protective factor that has been indicated as a form of prevention. The main objective of this study was to measure changes in the levels of traumatic stress and anxiety in a clinical population of adolescents and young adults aged 13 to 24 years – already assisted by the local primary and specialty care services before the pandemic – following a trauma-focused psychotherapeutic group intervention according to the eye movement desensitization and reprocessing protocol, conducted remotely before the end of the first lockdown. The Impact of Event Scale-Revised (IES-R), State-Trait Anxiety Inventory (STAI) scales, and the Emotion Thermometer were administered pre- and post-treatment. At the end of the treatment, the Post-Traumatic Growth Inventory (PTGI) questionnaire was administered. The results show that there was a significant improvement pre- and post-intervention in the scores of the scales STAI, IES-R, and Emotion Thermometer with a reduction in post-traumatic symptoms related in particular to the domains of intrusiveness and hyperarousal. The domain of avoidance was less significantly modified by therapy. This overall clinical improvement did not correlate with any of the demographic variables of the sample. In addition, the results show a significant positive global perceived change (PTGI) that did not correlate with the reduction of anxiety or post-traumatic symptoms measured by the other self-report scales. The explored use of telemedicine has revealed a valuable clinical opportunity.

EMDR for Depression: A Meta-Analysis and Systematic Review

The literature on the efficacy of eye movement desensitization and reprocessing (EMDR) for treating depression is heterogeneous due to research design, quality issues, and trials methodology. The current meta-analysis seeks to examine EMDR for depression with the aim of answering the aforementioned limitations. Thirty-nine studies were included for analysis after a review of the relevant literature. Univariate meta-regressions were run to examine dose-response and the effect of moderating variables. Subanalysis for primary and secondary depression showed a large, significant, and heterogeneous effect-size estimates, where EMDR significantly improved symptoms of depression in contrast to all control types. At post hoc, data were reexamined and a significant and large, yet heterogeneous, effect-size estimate emerged between the EMDR and control arm after the removal of two outliers [Hedges' g = 0.70, 95% CI =0.50–0.89, p-value < .01, I2 = 70%, K = 37]. This is the first meta-analysis examining for the effect of EMDR comparing to various control modalities on depression with dose-response. We found (a) that studies were balanced at onset in terms of depression severity, and (b) a large and significant effect of EMDR on depression at the end of trials. Additionally, the significance of the aggregate effect-size estimate at the end of trials was unchanged by the intake of psychotropic medications, reported demographic variables, or EMDR methodology.

The MET(T)A Protocol: Mindfulness and EMDR Treatment Template for Agencies

Evidence indicating the relationship between trauma and substance use disorders (SUDs), in addition to relapse and treatment retention rates for this population, suggests there is a need for a trauma-focused solution to treat SUDs. Eye movement desensitization and reprocessing (EMDR) therapy has been studied extensively as an effective approach for treating trauma and Posttraumatic Stress Disorder (PTSD). The research evaluating its treatment for other mental health disorders such as SUDs is promising. Merging mindfulness and ethical mindfulness practices with EMDR therapy lends additional evidence-based elements to make the case for this integrative system of treatment to be studied as a trauma-focused primary psychotherapy to treat SUDs. The resulting treatment, the MET(T)A Protocol (Mindfulness and EMDR Treatment Template for Agencies), has been created to address the need for a trauma-focused solution to treat SUDs. Procedures of the MET(T)A Protocol as applied in each of the 8 phases of EMDR therapy are described in detail. Clinical examples are provided to explain the application of the MET(T)A Protocol.

What You Need to Know: Eye Movement Desensitization and Reprocessing Therapy as a Path to Recovery for Patients With Substance Use Disorder

Studies show a direct correlation between traumatic experiences and the development of substance abuse disorders (SUD). Some estimating 67-92% of the patients with a SUD reported having experienced at least one traumatic event (according to the DSMIV PTSD criterion A) in their lifetime (Carletto et al., 2018). Trauma is a contributing factor inhibiting the lifelong process of recovery and its long-term goal of abstinence. Without a focus on interventions that address both the SUD and underlying trauma, health care providers may not be providing the best possible evidence-based care and limiting the chance of recovery for patients (DiPirro, 2017). EMDR is a level A trauma treatment endorsed by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the World Health Organization (WHO) as an evidence-based approach in treating those who suffer from trauma and its related symptoms. Adding EMDR methodology to treatment as usual approach {TAU) can allow for adaptive information processing to take place while reprocessing traumatic memories that may trigger maladaptive coping strategies such as overuse, and misuse of substances.

A FLASH OF HOPE: Eye Movement Desensitization and Reprocessing (EMDR) Therapy

DEPARTMENT EDITORS Julie P. Gentile, MD Professor and Chair, Department of Psychiatry, Wright State University, Boonshoft School of Medicine, Dayton, Ohio Allison E. Cowan, MD Associate Professor, Department of Psychiatry, Wright State University, Boonshoft School of Medicine, Dayton, Ohio EDITORS' NOTE The patient cases presented in Psychotherapy Rounds are composite cases written to illustrate certain diagnostic characteristics and to instruct on treatment techniques. The composite cases are not real patients in treatment. Any resemblance to a real patient is purely coincidental. ABSTRACT Eye movement desensitization and reprocessing (EMDR) is a specific treatment modality that utilizes bilateral stimulation to help individuals who have experienced trauma. This stimulation can occur in a variety of forms, including left-right eye movements, tapping on the knees, headphones, or handheld buzzers, known as tappers. This type of psychotherapy allows the individuals to redefine their self-assessment and responses to a given traumatic event in eight defined steps. While EMDR is relatively new type of psychotherapy, existing literature has demonstrated positive results using this form of therapy when treating patients with post-traumatic stress disorder (PTSD) by utilizing eye movements to detract from negative conceptualizations as a response to a specific trigger, while reaffirming positive self-assessments. Research indicates that EMDR could be a promising treatment for mental health issues other than PTSD, including bipolar disorder, substance use disorders, and depressive disorders. In this article, the eight fundamental processes of EMDR are illustrated through a composite case vignette and examined alongside relevant research regarding its efficacy in treating PTSD.

Review of EMDR Interventions for Individuals With Substance Use Disorder With/Without Comorbid Posttraumatic Stress Disorder

A large proportion (11%–60%) of people with posttraumatic stress disorder (PTSD) also suffer from substance use disorder (SUD). As the high cooccurrence of PTSD and SUD leads to a worsening of psychopathological severity, development and evaluation of integrated treatments become highly valuable for individuals presenting with both diagnoses. Eye movement desensitization and reprocessing (EMDR) therapy may fit these needs. This article summarized all studies that investigated EMDR treatment for SUD, to clarify whether EMDR might be a useful approach. A comprehensive Title/Abstract/Keyword search was conducted on PsycInfo, PsychArticle, PubMed, and Scopus databases. A total of 135 articles were retrieved, and 8 articles met inclusion/exclusion criteria. One RCT and one case study evaluated trauma-focused EMDR; one clinical RCT, one non-clinical RCT, one cross-over study, and one case study evaluated addiction-focused EMDR; and one quasi-experimental and one multiphase case study evaluated the combination of addiction-focused and trauma-focused EMDR. Results show that EMDR treatment consistently reduces posttraumatic symptoms, but that its effects on SUD symptoms are less evident. Although EMDR should be considered as a promising tool for this population due to its possible potential to improve SUD outcomes, further research is needed to see whether EMDR therapy, either trauma-focused or addiction-focused, is effective for SUD. We conclude with suggestions for future research and clinical practice in this area.

A Multicenter Phase II Rater-Blinded Randomized Controlled Trial to Compare the Effectiveness of Eye Movement Desensitization Reprocessing Therapy vs. Treatment as Usual in Patients With Substance Use Disorder and History of Psychological Trauma: A Study Design and Protocol

Background: Psychological trauma has a strong negative impact on the onset, course and prognosis of substance use disorders (SUD). Few trauma-oriented treatment approaches have been trialed, but preliminary evidence exists of the efficacy of Eye Movement Desensitization and Reprocessing (EMDR) therapy in improving clinical symptoms in SUD patients. Objective: To assess if EMDR therapy leads to: (1) reduced substance consumption; (2) an improvement in psychopathological and in trauma-related symptoms; and (3) an improvement in overall functioning. Our hypothesis is that the EMDR group will improve in all variables when compared to the treatment as usual (TAU) group at 6 and 12-months visits. Method: In this multicenter phase II rater-blinded randomized controlled trial, 142 SUD patients with a history of psychological trauma will be randomly assigned to EMDR (n = 71) or to TAU (n = 71). Patients in the EMDR group will receive 20 psychotherapeutic sessions of 60 min over 6 months. Substance use will be measured using the Timeline Followback Questionnaire, the Dependence Severity Scale and the Visual Analog Scale. Traumatic events will be measured by The Holmes-Rahe Life Stress Inventory, the Childhood Trauma Questionnaire Scale, the Global Assessment of Posttraumatic Stress Questionnaire, the Impact of Event Scale-Revised and the Dissociative Experiences Scale. Clinical symptomatology will be evaluated using the Hamilton Depression Rating Scale, the Young Mania Rating Scale and the Brief Psychiatric Rating Scale. Functionality will be assessed with the Functioning Assessment Short Test. All variables will be measured at baseline, post-treatment and 12 months as follow-up. Primary outcome: to test the efficacy of EMDR therapy in reducing the severity of substance use. The secondary outcomes: to test the efficacy in reducing trauma-related psychological symptoms and psychopathological symptoms and in improving overall functioning in patients with comorbid SUD and a history of psychological trauma. Conclusion: This study will provide evidence of whether EMDR therapy is effective in reducing addiction-related, trauma and clinical symptoms and in improving functionality in patients with SUD and a history of trauma. Clinical Trial Registration: The trial is registered at ClinicalTrials.gov, identifier: NCT03517592.