Links on this page:

            International Treatment Guidelines

            Meta-Analyses

            Randomized Controlled Trauma Studies

            Non-randomized Trauma Studies

            Information Processing, Procedures, and Mechanism of Action

            Randomized Studies of Hypotheses Regarding Eye Movements

            Additional Neurobiological Evaluations

 

 

International Treatment Guidelines

 ·              American Psychiatric Association (2004).  Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder.  Arlington, VA: American Psychiatric Association Practice Guidelines

EMDR given the same status as CBT as an effective treatment for ameliorating symptoms of both acute and chronic PTSD.

·           Bleich, A., Kotler, M., Kutz, I., & Shalev, A.  (2002). A position paper of the (Israeli) National Council for Mental Health: Guidelines for the assessment and professional intervention with terror victims in the hospital and in the community. Jerusalem, Israel.

 EMDR is one of only three methods recommended for treatment of terror victims.

·        Chambless, D.L. et al. (1998).  Update of empirically validated therapies, II. The Clinical Psychologist, 51, 3-16.

According to a taskforce of the Clinical Division of the American Psychological Association, the only methods empirically supported for the treatment of any post-traumatic stress disorder population were EMDR, exposure therapy, and stress inoculation therapy.

·           CREST (2003). The management of post traumatic stress disorder in adults.  A publication of the Clinical Resource Efficiency Support Team of the Northern Ireland Department of Health, Social Services and Public Safety, Belfast.

Of all the psychotherapies, EMDR and CBT were stated to be the treatments of choice.

·        Department of Veterans Affairs  & Department of Defense (2004). VA/DoD  Clinical Practice Guideline for the Management of Post-Traumatic Stress. Washington, DC. http://www.oqp.med.va.gov/cpg/PTSD/PTSD_cpg/frameset.htm

     EMDR was one of four therapies recommended and given the highest level of evidence.

·           Dutch National Steering Committee Guidelines Mental Health Care (2003). Multidisciplinary Guideline Anxiety Disorders. Quality Institute Heath Care CBO/Trimbos Intitute. Utrecht, Netherlands.

EMDR and CBT are both treatments of choice for PTSD

·        Foa, E.B., Keane, T.M., & Friedman, M.J. (2000). Effective treatments for PTSD: Practice Guidelines of the International Society for Traumatic Stress Studies New York: Guilford Press.

In the Practice Guidelines of the International Society for Traumatic Stress Studies, EMDR was listed as an efficacious treatment for PTSD

·           INSERM (2004). Psychotherapy: An evaluation of three approaches. French National Institute of Health and Medical Research, Paris, France.

Of the different psychotherapies, EMDR and CBT were stated to be the treatments of choice for trauma victims.

·        Sjöblom, P.O., Andréewitch, S .  Bejerot,  S.,   Mörtberg, E. ,  Brinck, U., Ruck, C., &  Körlin, D. (2003). Regional treatment recommendation for anxiety  disorders.  Stockholm: Medical Program Committee/Stockholm City Council, Sweden.
 
Of all psychotherapies CBT and EMDR are recommended as treatments of choice for PTSD.

·        Therapy Advisor (2004): http://www.therapyadvisor.com

An NIMH sponsored website listing empirically supported methods for a variety of disorders.  EMDR is one of three treatments listed for PTSD.

·           United Kingdom Department of Health (2001).  Treatment choice in psychological therapies and counselling evidence based clinical practice guideline.  London, England.

      Best evidence of efficacy was reported for EMDR, exposure, and stress inoculation

 

Meta-analyses

·           Davidson, P.R., & Parker, K.C.H. (2001). Eye movement desensitization and reprocessing (EMDR): A meta-analysis. Journal of Consulting and Clinical Psychology, 69, 305-316.

EMDR is equivalent to exposure and other cognitive behavioral treatments.  It should be noted that exposure therapy uses one to two hours of daily homework and EMDR uses none.

·       Maxfield, L., & Hyer, L.A. (2002). The relationship between efficacy and methodology in studies investigating EMDR treatment of PTSD. Journal of Clinical Psychology, 58, 23-41

A comprehensive meta-analysis reported the more rigorous the study, the larger the effect.

·           Van Etten, M., & Taylor, S. (1998). Comparative efficacy of treatments for post-traumatic stress disorder: A meta-analysis.  Clinical Psychology and Psychotherapy, 5, 126-144.

This meta-analysis determined that EMDR and behavior therapy were superior to psychopharmaceuticals.  EMDR was more efficient than behavior therapy, with results obtained in one-third the time.

 

Randomized Clinical Trials

·        Carlson, J., Chemtob, C.M., Rusnak, K., Hedlund, N.L, & Muraoka, M.Y. (1998).  Eye movement desensitization and reprocessing (EMDR): Treatment for combat-related post-traumatic stress disorder. Journal of Traumatic Stress, 11, 3-24

Twelve sessions of EMDR eliminated post-traumatic stress disorder in 77% of the multiply traumatized combat veterans studied.  Effects were maintained at follow-up.  This is the only randomized study to provide a full course of treatment with combat veterans.  Other studies (e.g., Pitman et al./Macklin et al.) evaluated treatment of only one or two memories, which, according to the International Society for Traumatic Stress Studies Practice Guidelines, is inappropriate for multiple-trauma survivors. The VA/DoD Practice Guideline also indicates these studies (often with only two sessions) offered insufficient treatment doses for veterans.

·        Chemtob, C.M., Nakashima, J., & Carlson, J.G. (2002). Brief-treatment for elementary school children with disaster-related PTSD: A field study. Journal of Clinical Psychology, 58, 99-112.

EMDR was found to be an effective treatment for children with disaster-related PTSD who had not responded to another intervention.  This is the first controlled study for disaster-related PTSD, and the first controlled study examining the treatment of children with PTSD.

·        Edmond, T., Rubin, A., & Wambach, K. (1999). The effectiveness of EMDR with adult female survivors of childhood sexual abuse.  Social Work Research, 23, 103-116.

EMDR treatment resulted in lower scores (fewer clinical symptoms) on all four of the outcome measures at the three-month follow-up, compared to those in the routine treatment condition.  The EMDR group also improved on all standardized measures at 18 months follow up (Edmond & Rubin, 2004, Journal of Child Sexual Abuse).

·         Edmond, T., Sloan, L., & McCarty, D. (2004). Sexual abuse survivors’ perceptions of the effectiveness of EMDR and eclectic therapy: A mixed-methods study. Research on Social Work Practice, 14, 259-272.

Combination of qualitative and quantitative analyses of treatment outcomes with important implications for future rigorous research. Survivors’ narratives indicate that EMDR produces greater trauma resolution, while within eclectic therapy, survivors more highly value their relationship with their therapist, through whom they learn effective coping strategies.

·              Ironson, G.I., Freund, B., Strauss, J.L., & Williams, J. (2002).  Comparison of two treatments for traumatic stress: A community-based study of EMDR and prolonged exposure. Journal of Clinical Psychology, 58, 113-128.

Both EMDR and prolonged exposure produced a significant reduction in PTSD and depression symptoms. Study found that 70% of EMDR participants achieved a good outcome in three active treatment sessions, compared to 29% of persons in the prolonged exposure condition.  EMDR also had fewer dropouts.

·        Jaberghaderi, N., Greenwald, R., Rubin, A., Dolatabadim S., & Zand, S.O. (In press).  A comparison of CBT and EMDR for sexually abused Iranian girls. Clinical Psychology and Psychotherapy.

Both EMDR and CBT produced significant reduction in PTSD and behavior problems.  EMDR was significantly more efficient, using approximately half the number of sessions to achieve results.

·        Lee, C., Gavriel, H., Drummond, P., Richards, J. & Greenwald, R. (2002). Treatment of post-traumatic stress disorder: A comparison of stress inoculation training with prolonged exposure and eye movement desensitization and reprocessing. Journal of Clinical Psychology, 58, 1071-1089.

Both EMDR and stress inoculation therapy plus prolonged exposure (SITPE) produced significant improvement, with EMDR achieving greater improvement on PTSD intrusive symptoms. Participants in the EMDR condition showed greater gains at three-month follow-up.  EMDR required three hours of homework compared to 28 hours for SITPE.

·        Marcus, S., Marquis, P. & Sakai, C. (1997).  Controlled study of treatment of PTSD using EMDR in an HMO setting.  Psychotherapy, 34, 307-315

Funded by Kaiser Permanent. Results show that 100% of single-trauma and 80% of multiple-trauma survivors were no longer diagnosed with post-traumatic stress disorder after six 50-minute sessions.

·        Marcus, S., Marquis, P. & Sakai, C. (2004).  Three- and 6-month follow-up of EMDR treatment of PTSD in an HMO setting.  International Journal of Stress Management, 11, 195-208.

Funded by Kaiser Permanent, follow-up evaluation indicates that a relatively small number of EMDR sessions result in substantial benefits that are maintained over time.

·        Power, K.G., McGoldrick, T., Brown, K., et al. (2002). A controlled comparison of eye movement desensitization and reprocessing versus exposure plus cognitive restructuring, versus waiting list in the treatment of post-traumatic stress disorder.  Journal of Clinical Psychology and Psychotherapy, 9, 299-318.

Both EMDR and exposure therapy plus cognitive restructuring (with daily homework)  produced significant improvement.  EMDR was more beneficial for depression and required fewer treatment sessions.

·        Rothbaum, B. (1997).  A controlled study of eye movement desensitization and reprocessing in the treatment of post-traumatic stress disordered sexual assault victims. Bulletin of the Menninger Clinic, 61, 317-334.

Three 90-minute sessions of EMDR eliminated post-traumatic stress disorder in 90% of rape victims.

·        Scheck, M., Schaeffer, J.A., & Gillette, C. (1998).  Brief psychological intervention with traumatized young women: The efficacy of eye movement desensitization and reprocessing. Journal of Traumatic Stress, 11, 25-44.

Two sessions of EMDR reduced psychological distress scores in traumatized young women and brought scores within one standard deviation of the norm.

 

·           Shapiro, F. (1989). Efficacy of the eye movement desensitization procedure in the treatment of traumatic memories. Journal of Traumatic Stress Studies, 2, 199–223.
 

Seminal study appeared the same year as first controlled studies of CBT treatments.   Three-month follow-up indicated substantial effects on distress and behavioural reports. Marred by lack of standardized measures and the originator serving as sole therapist. 

 

·        Soberman, G. B., Greenwald, R., & Rule, D. L. (2002). A controlled study of eye movement desensitization and reprocessing (EMDR) for boys with conduct problems. Journal of Aggression, Maltreatment, and Trauma, 6, 217-236.

The addition of three sessions of EMDR resulted in large and significant reductions of memory-related distress, and problem behaviors by 2-month follow-up.

·        Taylor, S. et al. (2003).  Comparative efficacy, speed, and adverse effects of three PTSD treatments: Exposure therapy, EMDR, and relaxation training. Journal of Consulting and Clinical Psychology, 71, 330-338.

The only randomized study to show exposure statistically superior to EMDR on two subscales (out of 10).  This study used therapist assisted “in vivo” exposure, where the therapist takes the person to previously avoided areas, in addition to imaginal exposure and one hour of daily homework (@ 50 hours).  The EMDR group used only standard sessions and no homework. 

·        Vaughan, K., Armstrong, M.F., Gold, R., O'Connor, N., Jenneke, W., & Tarrier, N. (1994).  A trial of eye movement desensitization compared to image habituation training and applied muscle relaxation in post-traumatic stress disorder.  Journal of Behavior Therapy & Experimental Psychiatry, 25, 283-291.

All treatments led to significant decreases in PTSD symptoms for subjects in the treatment groups as compared to those on a waiting list, with a greater reduction in the EMDR group, particularly with respect to intrusive symptoms.  In the 2-3 weeks of the study, 40-60 additional minutes of daily homework were part of the treatment in the other two conditions.

·        Wilson, S., Becker, L.A., & Tinker, R.H. (1995).  Eye movement desensitization and reprocessing (EMDR): Treatment for psychologically traumatized individuals. Journal of Consulting and Clinical Psychology, 63, 928-937.

Three sessions of EMDR produced clinically significant change in traumatized civilians on multiple measures.

·        Wilson, S., Becker, L.A., & Tinker, R.H. (1997).  Fifteen-month follow-up of eye movement desensitization and reprocessing (EMDR) treatment of post-traumatic stress disorder and psychological trauma. Journal of Consulting and Clinical Psychology, 65, 1047-1056.

Follow-up at 15 months showed maintenance of positive treatment effects with 84% remission of PTSD diagnosis.

Non Randomized Studies

·     Devilly, G.J., & Spence, S.H. (1999). The relative efficacy and treatment distress of EMDR and a cognitive behavioral trauma treatment protocol in the amelioration of post-traumatic stress disorder. Journal of Anxiety Disorders, 13, 131-157.

The only EMDR research study that found CBT superior to EMDR.  The study is marred by poor treatment delivery and higher expectations in the CBT condition.  Treatment was delivered in both conditions by the developer of the CBT protocol.

·        Fernandez, I., Gallinari, E., & Lorenzetti, A. (2004). A school- based EMDR intervention for children who witnessed the Pirelli building airplane crash in Milan, Italy.  Journal of Brief Therapy, 2, 129-136.

A group intervention of EMDR was provided to 236 schoolchildren exhibiting PTSD symptoms 30 days post-incident.  At four-month follow up, teachers reported that all but two children evinced a return to normal functioning after treatment.

·        Grainger, R.D., Levin, C., Allen-Byrd, L. , Doctor, R.M. & Lee, H. (1997).  An empirical evaluation of eye movement desensitization and reprocessing (EMDR) with survivors of a natural catastrophe. Journal of Traumatic Stress, 10, 665-671.

A study of Hurricane Andrew survivors found significant differences on the Impact of Event Scale and subjective distress in a comparison of EMDR and non-treatment condition

·         Puffer, M.; Greenwald, R. & Elrod, D. (1997). A single session EMDR study with twenty traumatized children and adolescents. Traumatology-e, 3(2), Article 6.

In this delayed treatment comparison, over half of the participants moved from clinical to normal levels on the Impact of Events Scale, and all but 3 showed at least partial symptom relief on several measures at 1-3 m following a single EMDR session.

·      Silver, S.M., Brooks, A., & Obenchain, J. (1995). Eye movement desensitization and reprocessing treatment of Vietnam war veterans with PTSD: Comparative effects with biofeedback and relaxation training. Journal of Traumatic Stress, 8, 337-342.

One of only two EMDR research studies that evaluated a clinically relevant course of EMDR treatment with combat veterans (e.g., more than one or two memories; see Carlson et al., above). The analysis of an inpatient veterans’ PTSD program (n=100) found EMDR to be vastly superior to biofeedback and relaxation training on seven of eight measures.

·   Silver, S.M., Rogers, S., Knipe, J., & Colelli, G. (in press). EMDR therapy following the 9/11 terrorist attacks: A community-based intervention project in New York City. International Journal of Stress Management.

Clients made highly significant positive gains on a range of outcome variables, including validated psychometrics and self-report scales.  Analyses of the data indicate that EMDR is a useful treatment intervention both in the immediate aftermath of disaster as well  as later.

·        Solomon, R.M. & Kaufman, T.E. (2002). A peer support workshop for the treatment of traumatic stress of railroad personnel: Contributions of eye movement desensitization and reprocessing (EMDR). Journal of Brief Therapy, 2, 27-33,

60 railroad employees who had experienced fatal grade accident crossing accidents were evaluated for workshop outcomes, and for the additive effects of EMDR treatment.  Although the workshop was successful, in this setting, the addition of a short session of EMDR (5-40 minutes) led to significantly lower, sub clinical, scores which further decreased at follow up 

·        Sprang, G. (2001). The use of eye movement desensitization and reprocessing  (EMDR) in the treatment of traumatic stress and complicated mourning:  Psychological and behavioral outcomes. Research on Social Work Practice, 11, 300-320.

In a multi-site study, EMDR significantly reduced symptoms more often than the CBT treatment on behavioral measures, and on four of five psychosocial measures.  EMDR was more efficient, inducing change at an earlier stage and requiring fewer sessions.

Information Processing, Procedures, and Mechanism of Action

EMDR contains many procedures and elements that contribute to treatment effects.  While the methodology used in EMDR has been extensively validated (see above), questions still remain regarding mechanism of action.  An information processing model (Shapiro, 2001, 2002) is used to explain EMDR's clinical effects and guide clinical practice. This model is not linked to any specific neurobiological mechanism since the field of neurobiology is as yet unable to determine the neurobiological concomitants of any form of psychotherapy (nor of many medications). However, since EMDR achieves clinical effects without the need for homework, or the prolonged focus used in exposure therapies, attention has been paid to the possible neurobiological processes that might be evoked. Although the eye movements (and other dual attention stimulation) comprise one only one procedural element, this element has come under greatest scrutiny. Controlled studies evaluating mechanism of action of the eye movement component follow this section.

·        MacCulloch, M. J., & Feldman, P. (1996). Eye movement desensitization treatment utilizes the positive visceral element of the investigatory reflex to inhibit the memories of post-traumatic stress disorder: A theoretical analysis. British Journal of Psychiatry, 169, 571–579.

One of a variety of articles positing an orienting response as a contributing element (see Shapiro, 2001 for comprehensive examination of theories and suggested research parameters).  This theory has received controlled research support (Barrowcliff et al., 2003, 2004).

·           Perkins, B.R. & Rouanzoin, C.C. (2002).  A critical evaluation of current views regarding eye movement desensitization and reprocessing (EMDR): Clarifying points of confusion. Journal of Clinical Psychology, 58, 77-97.

Reviews common errors and misperceptions of the procedures, research, theory.

·           Ray, A. L. & Zbik, A. (2001). Cognitive behavioral therapies and beyond. In C. D. Tollison, J. R. Satterhwaite, & J. W. Tollison (Eds.) Practical Pain Management (3rd ed.; pp. 189-208). Philadelphia: Lippincott.

Note that the application of EMDR guided by its information processing model appears to afford benefits to chronic pain patients not found in other treatments.

·        Stickgold, R. (2002). EMDR: A putative neurobiological mechanism of action. Journal of Clinical Psychology, 58, 61-75.

Comprehensive explanation of the potential links to the processes that occur in REM sleep.  Controlled studies have evaluated these theories (see below; Christman et al., 2004; Kuiken et al. 2001-2002

·           Rogers, S., & Silver, S. M. (2002). Is EMDR an exposure therapy? A review of trauma protocols. Journal of Clinical Psychology, 58, 43-59.

Theoretical, clinical, and procedural differences referencing two decades of CBT and EMDR research.

·           Shapiro, F. (2001).  Eye movement desensitization and reprocessing: Basic principles, protocols and procedures (2^nd ed.).  New York: Guilford Press.

EMDR is an eight-phase psychotherapy with standardized procedures and protocols that are all believed to contribute to therapeutic effect.  This text provides description and clinical transcripts.

·           Shapiro, F. (2002). (Ed.). EMDR as an integrative psychotherapy approach: Experts of diverse orientations explore the paradigm prism. Washington, DC: American Psychological Association Books.

EMDR is an integrative approach distinct from other forms of psychotherapy.  Experts of the major psychotherapy orientations identify and highlight various procedural elements.

Randomized Studies of Hypotheses Regarding Eye Movements

A number of International Practice Guideline committees have reported that the clinical component analyses reviewed by Davidson & Parker (2001) are not well designed (International Society for Traumatic Stress Studies/ISTSS; DoD/DVA). Davidson & Parker note that there is a trend toward significance for eye movements when the studies conducted with clinical populations are examined separately.  Unfortunately even these studies are flawed.  As noted in the ISTSS guidelines (Chemtob et al., 2000), since these clinical populations received insufficient treatment doses to obtain substantial main effects, they inappropriate for component analyses.  However, as noted in the DoD/DVA guidelines, the eye movements used in EMDR have been separately evaluated by numerous memory researchers. These studies have found a direct effect on emotional arousal, imagery vividness, attentional flexibility, and memory association. 

• Andrade, J., Kavanagh, D., & Baddeley, A. (1997). Eye-movements and visual imagery: a working memory approach to the treatment of post-traumatic stress disorder. British Journal of Clinical Psychology, 36, 209-223.

Tested the working memory theory. Eye movements were superior to control conditions in reducing image vividness and emotionality.

• Barrowcliff, A.L., Gray, N.S., Freeman, T.C.A., MacCulloch, M.J. (2004). Eye-movements reduce the vividness, emotional valence and electrodermal arousal associated with negative autobiographical memories. Journal of Forensic Psychiatry and Psychology, 15, 325-345.

Tested the reassurance reflex model. Eye movements were superior to control conditions in reducing image vividness and emotionality. 

• Barrowcliff, A.L., Gray, N.S., MacCulloch, S., Freeman, T. C.A., & MacCulloch, M.J. (2003). Horizontal rhythmical eye-movements consistently diminish the arousal  provoked  by auditory stimuli.  British Journal of Clinical Psychology, 42, 289-302.

Tested the reassurance reflex model. Eye movements were superior to control conditions in reducing arousal provoked by auditory stimuli. 

• Christman, S. D., Garvey, K. J., Propper, R. E., & Phaneuf, K. A. (2003). Bilateral eye movements enhance the retrieval of episodic memories. Neuropsychology. 17, 221-229.

Tested cortical activation theories.  Results provide indirect support for the orienting response/REM theories suggested by Stickgold (2002).  Saccadic eye movements, but not tracking eye movements were superior to control conditions in episodic retrieval.

• Kavanagh, D. J., Freese, S., Andrade, J., & May, J. (2001). Effects of visuospatial tasks on desensitization to emotive memories. British Journal of Clinical Psychology, 40, 267-280.

Tested the working memory theory. Eye movements were superior to control conditions in reducing within-session image vividness and emotionality.  There was no difference one-week post.

• Kuiken, D., Bears, M., Miall, D., & Smith, L. (2001-2002). Eye movement desensitization reprocessing facilitates attentional orienting. Imagination, Cognition and Personality, 21, (1), 3-20.

Tested the orienting response theory related to REM-type mechanisms.  Indicated that the eye movement condition was correlated with increased attentional flexibility. Eye movements were superior to control conditions.

• Sharpley, C. F. Montgomery, I. M., & Scalzo, L. A. (1996). Comparative efficacy of EMDR and alternative procedures in reducing the vividness of mental images. Scandinavian Journal of Behaviour Therapy, 25, 37-42.

Results suggest support for the working memory theory. Eye movements were superior to control conditions in reducing image vividness.

• Van den Hout, M., Muris, P., Salemink, E., & Kindt, M. (2001). Autobiographical memories become less vivid and emotional after eye movements. British Journal of Clinical Psychology, 40, 121-130.

Tested their theory that eye movements change the somatic perceptions accompanying retrieval, leading to decreased affect, and therefore decreasing vividness. Eye movements were superior to control conditions in reducing image vividness. Unlike control conditions, eye movements also decreased emotionality.

Additional Neurobiological Evaluations

Lamprecht, F., Kohnke, C., Lempa, W., Sack, M., Matzke, M., & Munte, T. (2004). Event-related potentials and EMDR treatment of post-traumatic stress disorder. Neuroscience Research, 49, 267-272.

Lansing, K., Amen, D.G., Hanks, C. & Rudy, L. (in press). High resolution brain SPECT imaging and EMDR in police officers with PTSD. Journal of Neuropsychiatry and Clinical Neurosciences.

Levin, P., Lazrove, S., & van der Kolk, B. A. (1999). What psychological testing and neuroimaging tell us about the treatment of posttraumatic stress disorder (PTSD) by eye movement desensitization and reprocessing (EMDR). Journal of Anxiety Disorders, 13, 159-172.

van der Kolk, B., Burbridge, J., & Suzuki, J. (1997). The psychobiology of traumatic memory: Clinical implications of neuroimaging studies. Annals of the New York Academy of Sciences, 821, 99-113.