October 1, 2009
Can Eye Movement Desensitization and Reprocessing Be the Treatment of Choice for Posttraumatic Stress Disorder?
van der Kolk BA, Spinazzola J, Blaustein ME, et al. A randomized clinical trial of eye movement desensitization and reprocessing (EMDR), fluoxetine, and pill placebo in the treatment of posttraumatic stress disorder: treatment effects and long-term maintenance. J Clin Psychiatry. 2007;68(1):37-46.
Randomized, controlled clinical trial
Eighty-eight posttraumatic stress disorder (PTSD) patients diagnosed according to Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria were randomly assigned to receive eye movement desensitization and reprocessing (EMDR), the selective serotonin reuptake inhibitor (SSRI) fluoxetine, or a pill placebo. Participants underwent 8 weeks of treatment and were assessed by blind raters posttreatment and at 6-month follow-up. The primary outcome measure was the Clinician-Administered PTSD Scale, DSM-IV version, and the secondary outcome measure was the Beck Depression Inventory-II.
To compare the short-term efficacy and long-term benefit of SSRIs, EMDR, and a pill placebo in the treatment of PTSD
EMDR has been found to be an effective psychological intervention for PTSD. In fact, based on the evidence of controlled research both the practice guidelines of the American Psychiatric Association and the US Department of Veterans Affairs and Defense have placed EMDR in the highest category of effectiveness in the treatment of trauma.1 To date, this is the only study that has compared EMDR to a pharmaceutical, measuring relative short-term efficacy and long-term benefits of either intervention in the treatment of PTSD.
The theory underlying EMDR treatment is that it helps a person process distressing memories more fully, thereby deactivating the stress response and improving PTSD symptoms. The use of EMDR is based on a theoretical information-processing model that proposes symptoms arise when events are inadequately processed and that these symptoms can be adequately erased when the memory of the traumatic event is fully processed. The most unique aspect of EMDR, in comparison to other psychotherapeutic interventions, is the application of bilateral stimulation of the brain through eye movement, bilateral sound, or bilateral tactile stimulation coupled with remembering the traumatic event using guided imagery, cognition, and body sensation. EMDR also uses dual attention awareness to allow the individual to vacillate between the traumatic material and the safety of the present moment. This theoretically prevents retraumatization from activating the disturbing memory.
The psychotherapy intervention EMDR was more successful than pharmacotherapy in achieving sustained reductions in PTSD and depression symptoms, but this benefit accrued primarily for adult-onset trauma survivors. At 6-month follow-up, 75% of adult-onset vs 33.3% of child-onset trauma participants receiving EMDR achieved asymptomatic end-state functioning compared with none in the fluoxetine group. For most childhood-onset trauma patients, neither treatment produced complete symptom remission.
It is estimated that more than 25 million Americans suffer from some form of anxiety disorder, including panic, social phobia, PTSD, obsessive-compulsive disorder, and generalized anxiety.1 PTSD is a severe anxiety disorder that is characterized by a persisting pattern of reexperiencing trauma through flashbacks, recurring dreams, or intense fear. Patients with PTSD also experience symptoms of sympathetic dominance, such as increased muscular tension, high blood pressure, restlessness, tendency to startle easily, and a hypersensitivity to environmental stimuli like noise or bright lights. People who experience these trauma-related events often have little or no conscious identification with the original episode and frequently experience sensory elements of the trauma without being able to make sense out of what they are feeling or seeing. This may happen through exposure to circumstances that are reminiscent of the trauma or that seemingly have no relation at all. Furthermore, fear-related trauma is commonly associated with poor memory. Jean Martin Charcot, the French neurologist credited with being the “father of neurology” noted, “The patient. . .does not preserve any recollection, or he preserves it in a vague manner. . . .Questions addressed to him upon this point are attended with no result. He knows nothing or almost nothing.”2 Even more than just an inability to recall the specific traumatic event, PTSD patients are often forgetful, have a low attention span, and have difficulty sustaining focus.3
In patients with PTSD, we see an exaggerated activation of the amygdala in response to an emotionally charged experience. The greater the sensitivity of the amygdala to these events, the more severe the symptoms of the syndrome are for the individual.4 The medial prefrontal cortex, the part of the brain that is associated with rational thought and that can act to calm the amygdala, has also been shown to be less responsive in PTSD patients during emotional events, and there is evidence that this region of the brain is actually smaller than normal. The same is true of the hippocampus; its volume is often decreased in the PTSD brain and the integrity and function of its neurons seem to be impaired.5 This corresponds to the observation that after trauma, people are more forgetful—the hippocampus may actually be hindered in storing new information and less capable of generating memories of safety in the present moment. Thus, the PTSD brain might be described as an overly sensitive amygdala that is not properly kept in check by the other brain regions that normally mediate its sensitivity.
There is no definitive explanation for how EMDR works in the PTSD brain. Research has shown that eye movement seems to decrease the vividness and/or emotional intensity of traumatic memory, enhances the retrieval of episodic or short-term memory, produces a physiological relaxation effect, and increases cognitive ability. Although a wide range of researchers have proposed various models and theories to explain the effectiveness of EMDR and the importance of eye movement as part of the therapy, no single model or theory satisfactorily explains all of these findings.
So here we have a therapy that is well researched, safe, gentle, effective, and in keeping with naturopathic philosophies. It is well within the scope of a holistic medical practice and may provide the possibility of informing new ideas about cognitive and subcognitive processing. It is worthwhile to review these therapies at a time when PTSD and other trauma-related syndromes are on the rise—particularly as our troops return from the Middle East and our war veterans seek treatment beyond the veterans hospital. Studies show that 1 in 5 veterans returning from Iraq and Afghanistan suffer from PTSD.5 Additionally, clinical experience and contemporary literature suggest that the etiology of chronic disease is repeatedly associated with traumatic events.6 Trauma is ubiquitous in our society. From the medicalized birthing process to family separation and divorce, from neglected childhoods, overwork and disenchantment with profession, to road rage, motor vehicle accidents, and violence on TV, daily distress seems almost impossible to avoid. “All chronic ailments and most mental illness can be traced to trauma, and virtually everyone in modern society is traumatized,” writes neurologist Robert Scaer, MD, in his book The Trauma Spectrum (Haworth Medical Press, 2005).7
In the naturopathic clinic, we routinely see some of the most challenging patients. Often these individuals present with a chronic ongoing illness that has remained uncured. In naturopathic medicine, we posit that chronic disease is an indication of a maladaptive physiological process, a sign of a body that is hampered or blocked in its attempt to heal itself. Given the association of PTSD with chronic disease, particular attention should be given to therapies such as EMDR that have been proven effective in addressing these imbalances and their associated manifestations for our patients.
- EMDR clinical guidelines and insurance coverage information. EMDR International Association Web site. http://www.emdria.org/displaycommon.cfm?an=1&subarticlenbr=16. Accessed October 27, 2009.
- Scaer RC. The Body Bears the Burden: Trauma, Dissociation, and Disease. 2nd ed. New York: The Haworth Press; 2007.
- Bremner JD. The relationship between cognitive and brain changes in posttraumatic stress disorder. Ann N Y Acad Sci. 2006;1071:80-86.
- Shin LM, Rauch SL, Pitman RK. Amygdala, medial prefrontal cortex, and hippocampal function in PTSD. Ann N Y Acad Sci. 2006;1071:67-79.
- Cnnhealth.com – based on the RAND study, April 2008.
- Scaer RC. The Trauma Spectrum: Hidden Wounds and Human Resiliency. New York: Haworth Medical Press; 2005.