The following peer reviewed articles are available on the internet or on this website, when possible. Links are provided. The annotated bibliography was peer reviewed by the ISSTD and represents a thoughtful summary of what are believed to be salient information in the articles noted. If you have questions or comments about this material, then please contact the website editor. Some of the articles go to links at one of the outstanding sites on the internet that has a collection of articles related to trauma and dissociation, David Baldwins site: Trauma Information Pages. His site is linked from additional areas on this site. We are grateful to David for his outstanding work, which has been ongoing for many years.
What is a trauma?
What are the types of traumatic events?
What is acute stress disorder, ASD?
What is post-traumatic stress disorder, PTSD?
What is complex PTSD?
What is the spectrum of trauma related disorders?
Trauma, Dissociation, and the Child
Neurobiology, Somatization and Affect Dysregulation
Traumatic Reactions in Acute and Chronic or Multiple Traumatizations
|Briere, J. & Elliott, D.|
Breslau , N.
Brewin, Andrews, et.al.
Classen, Koopman, Spiegel
Heffernan, K. & Cloitre, M.
Pimlott-Kubiak, S. & Cortina, L.M.
van der Kolk, B.A, et.al (1)
van der Kolk, B.A., et.al (2)
What is a trauma?
Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults.
J Consult Clin Psychol. 2000 Oct;68(5):748-66
Brewin CR, Andrews B, Valentine JD.
Subdepartment of Clinical Health Psychology, University College London, England. firstname.lastname@example.org
Annotated Abstract: Brewin et al use meta-analysis to explore which of 14 risk factors for PTSD are most linked with the likelihood of getting the disorder. The pre trauma risk factors the examined were: civilian/military status, gender, age at trauma, race, education, previous trauma, and general childhood adversity, psychiatric history, reported childhood abuse, and family psychiatric history these latter three had more uniform predictive effects. The peri and post trauma risk factors studies were the severity of the trauma, lack of social support following the traumatic event and additional life stress and these tended to have stronger predictive effects than the pretrauma factors. The finding that events following the trauma are most predictive of PTSD may not be as clear as it first appears, proximal variables such as psychiatric history or a history of childhood abuse may effect the distal risk factors of support and continuing adversity. For instance some folk may have more difficulty because of their past in finding or asking for help. This is a very important study about which clinicians should know.
Kessler, R.C., Sonnega, A., Bromet, E, Hughes, M. & Nelson, C.B. (1995). Posttraumatic stress disorder in the National Comorbiditiy Survey. Archives of General Psychiatry, 52, 1048-1063.
This study is a large probability study (N = 5877) of men and women between 15-54 years; part of National Comorbidity Study. PTSD rates: Lifetime prevalence for PTSD: 10% women, 5% men. Women had more than twice the rate of PTSD than did men (10.4% vs. 5%). Trauma rates: Lifetime prevalence of trauma exposure for men was 60.7% and women were 51.2%, which is significantly different. The majority of people with some type of lifetime trauma had actually experienced two or more trauma. Most common traumas for whole sample: witnessing someone be injured or killed, being in a natural disaster, and being in a life-threatening accident.
Gender differences : Men were significantly more likely to experience each of those last 3 traumas, as well as physical attacks, combat experience, and being threatened with a weapon, held captive or kidnapped. Women were more likely to report higher rates of rape, sexual molestation, childhood parental neglect, and childhood physical abuse. Rape was most common trauma to be associated with PTSD for both men and women, after which the most traumatic events for men: combat, childhood neglect and childhood physical abuse; versus sexual molestation, physical attack, being threatened with a weapon, and childhood physical abuse among women
A Conceptual Framework for the Impact of Traumatic Experiences
Trauma, Violence, & Abuse, Vol. 1, No. 1, 4-28 (2000)
Eve B Carlson, National Center for PTSD, Palo Alto VA Health Care System
Constance J. Dalenberg, California School of Professional Psychology-San Diego
This conceptual framework for the effects of traumatic experiences addresses what makes an experience traumatic, what psychological responses are expected following such events, and why symptoms persist after the traumatic experience is over. Three elements are considered necessary for an event to be traumatizing: The event must be experienced as extremely negative, uncontrollable, and sudden. The initial core responses to trauma include reexperiencing and avoidance symptoms that occur across four modes of experience. Explanations of how each response is theoretically linked to traumatic events are offered to clarify how the responses reflect the natural human response to uncontrollable, negative, and sudden events. The framework delineates the behavioral learning and cognitive processes that elucidate the persistence of the initial response to trauma. Five factors are proposed that influence the response to trauma, including biological factors, developmental level at the time of trauma, severity of the stressor, social context, and prior and subsequent life events. Finally, secondary and associated responses to trauma are discussed that are common across many types of traumatic experience. These include depression, aggression, substance abuse, physical illnesses, low self-esteem, identity confusion, difficulties in interpersonal relationships, and guilt and shame.
What are the types of traumatic events?
Terr, L. C. (1991).Childhood traumas: an outline and overview. American Journal of Psychiatry, 148(1), 10-20.
Childhood psychic trauma appears to be a crucial etiological factor in the development of a number of serious disorders both in childhood and in adulthood. Like childhood rheumatic fever, psychic trauma sets a number of different problems into motion, any of which may lead to a definable mental condition. The author suggests four characteristics related to childhood trauma that appear to last for long periods of life, no matter what diagnosis the patient eventually receives. These are visualized or otherwise repeatedly perceived memories of the traumatic event, repetitive behaviors, trauma-specific fears, and changed attitudes about people, life, and the future. She divides childhood trauma into two basic types and defines the findings that can be used to characterize each of these types. Type I trauma includes full, detailed memories, "omens," and misperceptions. Type II trauma includes denial and numbing, self-hypnosis and dissociation, and rage. Crossover conditions often occur after sudden, shocking deaths or accidents that leave children handicapped. In these instances, characteristics of both type I and type II childhood traumas exist side by side. There may be considerable sadness. Each finding of childhood trauma discussed by the author is illustrated with one or two case examples.
What is Acute Stress Disorder?
Brewin, C. R., Andrews, B., Rose, S., & Kirk, M. (1999). Acute stress disorder and posttraumatic stress disorder in victims of violent crime. American Journal of Psychiatry, 156(3), 360-366.
OBJECTIVE: In a group of crime victims recruited from the community, the authors investigated the ability of both a diagnosis of acute stress disorder and its component symptoms to predict posttraumatic stress disorder (PTSD) at 6 months. METHOD: A mixed-sex group of 157 victims of violent assaults were interviewed within 1 month of the crime. At 6-month follow-up 88% were reinterviewed by telephone and completed further assessments generating estimates of the prevalence of PTSD. RESULTS: The rate of acute stress disorder was 19%, and the rate of subsequent PTSD was 20%. Symptom clusters based on the DSM-IV criteria for acute stress disorder were moderately strongly interrelated. All symptom clusters predicted subsequent PTSD, but not as well as an overall diagnosis of acute stress disorder, which correctly classified 83% of the group. Similar predictive power could be achieved by classifying the group according to the presence or absence of at least three reexperiencing or arousal symptoms. Logistic regression indicated that both a diagnosis of acute stress disorder and high levels of reexperiencing or arousal symptoms made independent contributions to predicting PTSD. CONCLUSIONS: This exploratory study provides evidence for the internal coherence of the new acute stress disorder diagnosis and for the symptom thresholds proposed in DSM-IV. As predicted, acute stress disorder was a strong predictor of later PTSD, but similar predictive power may be possible by using simpler criteria.
Classen C, Koopman C, Hales R, Spiegel D. (1998). Acute stress disorder as a predictor of posttraumatic stress symptoms. American Journal of Psychiatry, 155, 620-624.
OBJECTIVE: Using the DSM-IV diagnostic criteria for acute stress disorder, the authors examined whether the acute psychological effects of being a bystander to violence involving mass shootings in an office building predicted later posttraumatic stress symptoms. METHOD: The participants in this study were 36 employees working in an office building where a gunman shot 14 persons (eight fatally). The acute stress symptoms were assessed within 8 days of the event, and posttraumatic stress symptoms of 32 employees were assessed 7 to 10 months later. RESULTS: According to the Stanford Acute Stress Reaction Questionnaire, 12 (33%) of the employees met criteria for the diagnosis of acute stress disorder. Acute stress symptoms were found to be an excellent predictor of the subjects posttraumatic stress symptoms 7-10 months after the traumatic event. CONCLUSIONS: These results suggest not only that being a bystander to violence is highly stressful in the short run, but that acute stress reactions to such an event further predict later posttraumatic stress symptoms.
What is Post-traumatic Stress Disorder?
Breslau , N., Chilcoat, H.D., Kessler, R.C., & Davis , G.C. (1999). Previous exposure to trauma and PTSD effects of subsequent trauma: Results from the Detroit Area Survey of Trauma. American Journal of Psychiatry, 156, 902-907.
This is a representative sample of 2,181 adults in Detroit interviewed by phone. PTSD was assessed in regard to a randomly selected trauma from their list of life time traumas. Controlled for sex and type of index trauma. Having experienced multiple previous traumatic events had a stronger effect than a single previous event.
The effects of assaultive violence persisted almost unchanged despite the passage of time. Those who�d experienced multiple events of assaultive violence in childhood were more likely to have PTSD from trauma in adulthood. In fact, �a history of two or more traumatic events involving assaultive violence in childhood was associated with a nearly fivefold greater risk that a traumatic event in adulthood would lead to PTSD (p. 905)�. But even a single previous event of assaultive violence, whether in childhood or adulthood, was associated with a higher risk of PTSD in adulthood.
There was no evidence that a trauma in childhood was associated with a higher risk of PTSD than a trauma that occurred later. Age at exposure was not related to the risk of PTSD. Rather, assaultive violence seems to have a unique status in terms of the risk of PTSD that it engenders.
�The results presented here indicate that women�s higher risk of PTSD is not attributable to sex differences in history of previous exposure to trauma.�(p. 906). They think that the enduring vulnerability to anxiety disorders that starts with childhood trauma may involve �cognitive predispositions, such as helplessness and that �experiences in childhood may set up some long-term sensitization to danger� (p. 905-6).� They conclude that these findings are consistent with a �sensitization hypothesis� which was first discussed by researchers who found that Vietnam vets who�d experienced childhood trauma were more vulnerable to developing PTSD from adult trauma than those with no previous trauma.
McFarlane, A.C. (2000). Posttraumatic stress disorder: A model of the longitudinal course and the role of risk factors. Journal of Clinical Psychiatry, 61 Suppl 5, 15-20.
Posttraumatic stress disorder (PTSD) differs from other anxiety disorders in that experience of a traumatic event is necessary for the onset of the disorder. The condition runs a longitudinal course, involving a series of transitional states, with progressive modification occurring with time. Notably, only a small percentage of people that experience trauma will develop PTSD. Risk factors, such as prior trauma, prior psychiatric history, family psychiatric history, peritraumatic dissociation, acute stress symptoms, the nature of the biological response, and autonomic hyperarousal, need to be considered when setting up models to predict the course of the condition. These risk factors influence vulnerability to the onset of PTSD and its spontaneous remission. In the majority of cases, PTSD is accompanied by another condition, such as major depression, an anxiety disorder, or substance abuse. This comorbidity can also complicate the course of the disorder and raises questions about the role of PTSD in other psychiatric conditions. This article reviews what is known about the emergence of PTSD following exposure to a traumatic event using data from clinical studies.
What is complex PTSD?
van der Kolk, Bessel A.; Roth, Susan; Pelcovitz, David;Disorders of Extreme Stress: The Empirical Foundation of a Complex Adaptation to Trauma. Journal of Traumatic Stress, Vol 18(5), Oct 2005. pp. 389-399.
Children and adults exposed to chronic interpersonal trauma consistently demonstrate psychological disturbances that are not captured in the posttraumatic stress disorder (PTSD) diagnosis. The DSM-IV (American Psychiatric Association, 1994) Field Trial studied 400 treatment-seeking traumatized individuals and 128 community residents and found that victims of prolonged interpersonal trauma, particularly trauma early in the life cycle, had a high incidence of problems with (a) regulation of affect and impulses, (b) memory and attention, (c) self-perception, (d) interpersonal relations, (e) somatization, and (f) systems of meaning. This raises important issues about the categorical versus the dimensional nature of posttraumatic stress, as well as the issue of comorbidity in PTSD. These data invite further exploration of what constitutes effective treatment of the full spectrum of posttraumatic psychopathology. (PsycINFO Database Record (c) 2007 APA, all rights reserved)(from the journal abstract)
Ford, Julian D.; Stockton, Patricia; Kaltman, Stacey (2006) Disorders of Extreme Stress (DESNOS) Symptoms Are Associated With Type and Severity of Interpersonal Trauma Exposure in a Sample of Healthy Young Women. ; Journal of Interpersonal Violence, Vol 21(11), pp. 1399-1416.
Conducted structured interviews of 345 college women. Most (84%) had experienced at least one traumatic event but DESNOS syndrome was rare (1% prevalence). However, DESNOS symptoms were reported by a majority of participants. After controlling for PTSD, other anxiety disorders, and affective disorders, DESNOS symptom severity was associated in a dose-response manner with a history of one-time interpersonal trauma and with more severe interpersonal trauma. Noninterpersonal trauma was correlated with PTSD and dissociation but not with DESNOS severity.
Zlotnick, Caron; Zakriski, Audrey L.; Shea, M. Tracie; The long-term sequelae of sexual abuse: Support for a complex posttraumatic stress disorder. Journal of Traumatic Stress, Vol 9(2), Apr 1996. pp. 195-205.
This study examined the relationship between childhood sexual abuse and symptoms of a newly proposed complex posttraumatic stress disorder (PTSD) or disorder of extreme stress not otherwise specified (DESNOS). Compared to 34 women without histories of sexual abuse, 74 survivors of sexual abuse showed increased severity on DESNOS symptoms of somatization, dissociation, hostility, anxiety, alexithymia, social dysfunction, maladaptive schemas, self-destruction, and adult victimization. In addition, a logistic regression found that a complex of symptoms representing DESNOS was significantly related to a history of sexual abuse. Consistent with other studies, the results of this study provide support for the idea that symptoms of DESNOS characterize survivors of sexual abuse. (PsycINFO Database Record (c) 2006 APA, all rights reserved)(from the journal abstract
What is the spectrum of trauma related disorders?
Moreau, C., & Zisook, S. (2002). Rationale for a posttraumatic stress spectrum disorder. Psychiatric Clinics of North America, 25, 775-790.
An understanding of PTSD and stress-related conditions is in its infancy. This is not surprising given the fact PTSD was not recognized as a distinct diagnostic entity until 1980. Since that time, the diagnostic classification has undergone continuous change as our understanding of PTSD is refined. The authors believe that PTSD can be best understood through a dimensional conceptualization viewed along at least three spectra: (1) symptom severity, (2) the nature of the stressor, and (3) responses to trauma. Along the severity spectrum, studies that review diagnostic thresholds reveal significant prevalence of PTSD symptoms and impairment that results from subthreshold conditions. Comorbidity patterns suggest that when PTSD is associated with other psychiatric illness, diagnosis is more difficult and the overall severity of PTSD is considerably greater. With regard to a stressor criteria spectrum, the diagnostic nomenclature initially only recognized severe forms of trauma personally experienced. More recently, however, the persons subjective response and events occurring to loved ones were included. This has greatly broadened the stressor criteria by leading to an appreciation of the range of precipitating stressors and the potential impact of "low-magnitude" events. Given that responses to trauma vary considerably, another possible spectrum includes trauma-related conditions. Traumatic grief, somatization, acute stress disorder and dissociation, personality disorders, depressive disorders, and other anxiety disorders all have significant associations with PTSD. Further research is needed to clarify and expand the current understanding of PTSD and other trauma-related conditions. Consideration of the severity of symptoms and the range of stressors coupled with the various disorders precipitated by trauma should greatly influence scientific research. The future undoubtedly will bring a refinement of the current understanding of PTSD and improved treatments.
Yen, S., Shea, M.T., Battle, C.L., Johnson, D.M., Zlotnick, C., Dolan-Sewell, R., Skodol, A.E., Grilo, C.M., Gunderson, J.G., Sanislow, C.A., Zanarini, M.C., Bender, D.S., Rettew, J.B., & McGlashan, T.H. (2002). Traumatic exposure and posttraumatic stress disorder in borderline, schizotypal, avoidant, and obsessive-compulsive personality disorders: Findings from the collaborative longitudinal personality disorders study. Journal of Nervous and Mental Disease, 190(8), 510-518.
The association between trauma and personality disorders (PDs), while receiving much attention and debate, has not been comprehensively examined for multiple types of trauma and PDs. The authors examined data from a multisite study of four PD groups: schizotypal, borderline (BPD), avoidant, and obsessive-compulsive, and a major depression comparison group. Rates of traumatic exposure to specific types of trauma, age of first trauma onset, and rates of posttraumatic stress disorder are compared. Results indicate that BPD participants reported the highest rate of traumatic exposure (particularly to sexual traumas, including childhood sexual abuse), the highest rate of posttraumatic stress disorder, and youngest age of first traumatic event. Those with the more severe PDs (schizotypal, BPD) reported more types of traumatic exposure and higher rates of being physically attacked (childhood and adult) when compared to other groups. These results suggest a specific relationship between BPD and sexual trauma (childhood and adult) that does not exist among other PDs. In addition, they support an association between severity of PD and severity of traumatic exposure, as indicated by earlier trauma onset, trauma of an assaultive and personal nature, and more types of traumatic events
McDowell, D.M., Levin, F.R., & Nunes, E.V. (1999). Dissociative identity disorder and substance abuse: The forgotten relationship. Journal of Psychoactive Drugs, 31, 71-83.
The treatment and research of dissociative disorders, particularly dissociative identity disorder (DID), are hampered by professional skepticism and diagnostic uncertainties. Almost always associated with severe and sustained childhood trauma, its chief manifestations are at least two distinct and separate identities which have an independent manner of existing in the world. It is also associated with a high degree of psychiatric comorbidity. Among the most frequent diagnoses found in patients with DID are substance use and dependence. For a variety of reasons there has been little dialogue among the disciplines that study patients with trauma and those that study and treat substance abuse. Clinicians dealing with a primarily substance-abusing population are likely to encounter but not recognize these patients. The authors present several representative cases illustrative of features of patients with DID. The epidemiology, phenomenology and presentation of DID, as well as its relation to posttraumatic stress disorder are discussed. Little systematic investigation exists on the treatment of DID in general, and substance abuse in DID in particular. The authors draw upon the existing literature, and their experience to discuss treatment strategies aimed at treating patients with both diagnoses. Ignoring either diagnosis is likely to be detrimental to patients; both disorders and their coexistence need to be addressed.
McClellan, J., Adams, J., Douglas, D., McCurry, C., & Storck, M. (1995). Clinical characteristics related to severity of sexual abuse: A study of seriously mentally ill youth. Child Abuse & Neglect, 19, 1245-1254.
OBJECTIVE: In this study we examined demographic, social, and clinical variables related to sexual abuse histories in a sample of severely mentally ill youth. METHOD: Data were collected via a retrospective chart review of all patients treated over a 5-year period (1987-1992) at a tertiary care public sector psychiatric hospital. The sample was divided into four groups: no history of sexual abuse (n = 226); isolated events (n = 62); intermittent abuse (n = 61); and chronic (n = 150). RESULTS: Youth with sexual abuse histories were more often female, had higher rates of social chaos and associated physical abuse and neglect, and had higher rates of post-traumatic stress disorder (PTSD) and substance abuse disorders. Chronically abused subjects came from the most chaotic and abusive backgrounds; were younger when first abused; had the highest number of abusers; were more likely to have been molested; and were more often abused by their father/stepfather and/or their mother/stepmother. Using logistic regression analyses, sexual abuse histories were predicted by sexually inappropriate behaviors, symptoms of PTSD and borderline personality disorders, dissociative symptoms, substance abuse and animal cruelty. CONCLUSION: Sexual abuse histories were quite common in this sample. Sexually abused subjects had increased rates of inappropriate sexual behaviors, substance abuse, and post-traumatic reactions; and were frequently exposed to other confounding environmental risk factors, including physical abuse, family problems and social chaos.
Janssen, I., Krabbendam, L., Hanssen, M., Bak, M., Vollebergh, W., de Graaf, R. et al. (2005). Are apparent associations between parental representations and psychosis risk mediated by early trauma? Acta Psychiatrica Scandinavica, 112, 372-375.
OBJECTIVE: It was investigated whether the reported association between representations of parental rearing style and psychosis does not represent a main effect, but instead is a proxy indicator of the true underlying risk factor of early trauma. METHOD: In a general population sample of 4045 individuals aged 18-64 years, first ever onset of positive psychotic symptoms at 3-year follow-up was assessed using the Composite International Diagnostic Interview and clinical interviews if indicated. Representations of parental rearing style were measured with the Parental Bonding Instrument (PBI). RESULTS: Lower baseline level of PBI parental care predicted onset of psychotic symptoms 2 years later. However, when trauma was included in the equation, a strong main effect of trauma emerged at the expense of the effect size of PBI low care. CONCLUSION: The results suggest that associations between representations of parental rearing style and psychosis may be an indicator of the effect of earlier exposure to childhood trauma.
Gunderson, J.G., & Sabo, A. (1993). The phenomenological and conceptual interface between borderline personality disorder and post-traumatic stress disorder. American Journal of Psychiatry, 150(1), 19-27.
OBJECTIVE: The authors explore the conceptual and phenomenological interface between posttraumatic stress disorder (PTSD) and borderline personality disorder as well as the therapeutic and research implications of this interface. METHOD: They systematically review the relevant empirical, conceptual, and clinical literature. RESULTS: These seemingly separate disorders are related. Borderline personality disorder is often shaped in part by trauma, and individuals with borderline disorder are therefore vulnerable to developing PTSD. CONCLUSIONS: The authors draw a distinction between the enduring effects that traumas can have on formation (or change) of axis II personality traits (including those found in borderline personality disorder) and acute symptomatic reactions to trauma, called PTSD, that are accompanied by specific psychophysiological correlates. They describe the implications of these conclusions for DSM-IV, therapy, and future research.
Janssen, I., Krabbendam, L., Hanssen, M., Bak, M., Vollebergh, W., de Graaf, R. et al. (2005). Are apparent associations between parental representations and psychosis risk mediated by early trauma? Acta Psychiatrica Scandinavica, 112, 372-375.
Brady, K.T. (1997). Posttraumatic stress disorder and comorbidity: Recognizing the many faces of PTSD. Journal of Clinical Psychiatry, 58(Suppl 9), 12-15.
Posttraumatic stress disorder (PTSD) commonly occurs with other psychiatric disorders. Data from a recent epidemiologic survey indicate that approximately 80% of individuals with PTSD meet criteria for at least one other psychiatric diagnosis. PTSD is particularly likely to be comorbid with affective disorders, other anxiety disorders, somatization, substance abuse, and dissociative disorders. Comorbidity may affect the presentation and clinical course of PTSD. Because of the relative frequency of traumatic events and the heterogeneity of presentation of PTSD, screening for traumatic events and PTSD should be standard in both psychiatric and primary care practice. Additionally, individuals with PTSD should be screened for psychiatric comorbidity. Accurate assessment of comorbidity may be important in determining optimal psychotherapeutic and pharmacotherapeutic treatment options for individuals with PTSD.
Zanarini, M.C., Yong, L., Frankenburg, F.R., Hennen, J., Reich, D.B., Marino, M.F., & Vujanovic, A.A. (2002). Severity of reported childhood sexual abuse and its relationship to severity of borderline psychopathology and psychosocial impairment among borderline inpatients. Journal of Nervous and Mental Disease, 190(6), 381-387.
This study has two purposes. The first purpose is to describe the severity of sexual abuse reported by a well-defined sample of borderline inpatients. The second purpose is to determine the relationship between the severity of reported childhood sexual abuse, other forms of childhood abuse, and childhood neglect and the severity of borderline symptoms and psychosocial impairment. Two semistructured interviews of demonstrated reliability were used to assess the severity of adverse childhood experiences reported by 290 borderline inpatients. It was found that more than 50% of sexually abused borderline patients reported being abused both in childhood and in adolescence, on at least a weekly basis, for a minimum of 1 year, by a parent or other person well known to the patient, and by two or more perpetrators. More than 50% also reported that their abuse involved at least one form of penetration and the use of force or violence. Using multiple regression modeling and controlling for age, gender, and race, it was found that the severity of reported childhood sexual abuse was significantly related to the severity of symptoms in all four core sectors of borderline psychopathology (affect, cognition, impulsivity, and disturbed interpersonal relationships), the overall severity of borderline personality disorder, and the overall severity of psychosocial impairment. It was also found that the severity of childhood neglect was significantly related to five of the 10 factors studied, including the overall severity of borderline personality disorder, and that the severity of other forms of childhood abuse was significantly related to two of these factors, including the severity of psychosocial impairment. Taken together, the results of this study suggest that the majority of sexually abused borderline inpatients may have been severely abused. They also suggest that the severity of childhood sexual abuse, other forms of childhood abuse, and childhood neglect may all play a role in the symptomatic severity and psychosocial impairment characteristic of borderline personality disorder.
Trauma, Dissociation, and the Child
The human face of the diagnostic controversy. By Joy Silberg
An optimistic look at dissociation. By Joy Silberg
When treatment fails with traumatized children�why? By Fran Waters
Recognizing dissociation in preschool children by Fran Waters
Atypical DID adolescent case. by Fran Waters
Commentary: This short series of articles by Joy Silberg and Fran Waters are useful to read as a short series and help orientate and illustrate many of the issues relevant to children and adolescents who have suffered experiences which result in an un-integrated sense of themselves. Both Joy and Fran have been presidents of ISSTD, and both are child psychologists.
Joy�s reflection as President of ISSTD in �The human face of the diagnostic controversy� describes clearly the problems a child faces following a combination of abuse and neglect within his or her home. She notes how difficult but how necessary it is for health care workers to read and recognize the symptoms, inhibitions, behaviours and responses of the child as communications about their past.
Joys President�s column: �An optimistic look at dissociation� again takes a clinical case of child but this time the child is observed intermittently overtime by Dr Silberg to show us the presentation of a traumatized child progressing through developmental stages to adulthood.
�When treatment fails with traumatized children�why?� written by Fran Waters is a poignant but helpful look at why many child therapists lack even a minimal understanding of the impact of trauma on a child�s identity and development. She names several of the major issues: therapists can lack sight of the big picture, do an inadequate trauma assessment, misunderstand the encoding of trauma, ignore the significance of early attachment relationships especially to their abusive biological parents, have an exclusive focus on alleviation of symptoms and fail to identify the triggers of disturbed behaviors and affect, ignore multiple diagnoses and derailed treatment, employ poly-pharmacy with minimal efficacy, and exclusively use of talk/cognative behvioral therapies, with an overall lack of understanding of dissociative processes or states. By naming these common errors she briefly draws our attention to the suffering these failures can cause.
�Recognizing dissociation in preschool children� by Fran Waters describes the vulnerability of very young children to caregivers who are frightening or inadequately responsive. She briefly reviews the relevant literature and describes manifestations of dissociation in this population. She uses a beautifully describes young patient�s difficulties to illustrate her points and emphasises the need for proper recognition and treatment of dissociative symptoms in preschool children. Fran�s article �Atypical DID adolescent case� uses a detailed description of an adolescent girl to shed light on the sudden onset of a set of dissociative symptoms following treatment for her eating disorder. The phenomenology and assessment process is notes as well as the necessity for family intervention. This case highlights critical factors in treating adolescents such as early recognition and intensive treatment. The essential ingredient of a positive transference to the therapist and exploration of impaired parent-child attachment relationships as a �precursor� or proclivity to dissociate should be analyzed. The paper by Joy Silbery called �Parenting the dissociative child� is a short and helpfully optimistic essay identifying the salient features of working with families who have a dissociative child. In it she realistically notes key ideas and possible warning signs of a worsening situation with brief phrases that illustrate a practical point. Her understanding of both the child and the parents help the reader imagine how to work within the family and not feel alienated and judgmental.
Neurobiology, Somatization and Affect Dysregulation
Schore, A.N. (2001).The effects of early relational trauma on right brain development, affect regulation, and infant mental health. Infant Mental Health Journal, 22(1-2), 201-269.
A primary interest of the field of infant mental health is in the early conditions that place infants at risk for less than optimal development. The fundamental problem of what constitutes normal and abnormal development is now a focus of developmental psychology, infant psychiatry, and developmental neuroscience. In the 2nd part of this sequential work, the author presents interdisciplinary data to more deeply forge the theoretical links between severe attachment failures, impairments of the early development of the right brains stress coping systems, and maladaptive infant mental health. He comments on topics such as the negative impact of traumatic attachments on brain development and infant mental health, the neurobiology of infant trauma, the neuropsychology of a disorganized/disoriented attachment pattern associated with abuse and neglect, the etiology of dissociation and body-mind psychopathology, the effects of early relational trauma on enduring right hemispheric function, and some implications for models of early intervention. These findings suggest direct connections between traumatic attachment, inefficient right brain regulatory functions, and both maladaptive infant and adult mental health.
van der Kolk, B.A.,Pelcovitz, D., Roth, S., Mandel, F.S., MacFarlane, A., & Herman, J.L. (1996). Dissociation, somatization, and affect dysregulation: the complexity of adaptation to trauma. American Journal of Psychiatry, 153 , (7), pp. 83-93.
This study investigated the relationships between exposure to extreme stress, the emergence of PTSD and symptoms of dissociation, somatization and affect dysregulation. The PTSD field trial for the DSM-IV studied 395 traumatized treatment-seeking subjects and 125 non-treatment-seeking subjects who had also been exposed to traumatic experiences. Subjects were assessed by the High Magnitude Stressor Events Structured Interview, the NIMH Diagnostic Interview Schedule PTSD module, the PTSD module of the Structured Clinical Interview of the DSM-III (SCID). Affect dysregulation, dissociation and somatization were measured with the Structured Interview for Disorders of Extreme Stress (SIDES, an instrument designed specifically for the study). In order to examine the correlations between PTSD, somatization, dissociation, and affect dysregulation (or associated features), subjects were divided into two groups: those with and those without lifetime PTSD. Groups were compared for endorsement of associated features. To examine the relationship between current and lifetime PTSD, no PTSD, and the presence/absence of associated features, the authors divided the subjects into 3 groups � those with current PTSD, those with lifetime PTSD but not currently meeting the criteria for it, and those who have never had PTSD. A third division of subjects was made in order to study the effects of age at onset and the nature of the trauma � early-onset interpersonal trauma, late-onset interpersonal trauma, and disaster trauma.
PTSD, dissociation, somatization and affect dysregulation were found to be highly interrelated, tending not to occur in isolation but rather co-occurring in the same person. It appears that co-occurrence is related to their age when the trauma took place and the nature of the event. �The occurrence of pure PTSD is the exception, rather than the rule.� (p. 89). Subjects who were diagnosed with current PTSD endorsed symptoms of dissociation, somatization and affect dysregulation at much higher rate than those who once but no longer met criteria for PTSD. However, these individuals still had much higher levels of endorsement of these associated features than subjects who never met the criteria for PTSD. Interestingly, those who no longer suffered from PSTD still reported suffering from high levels of dissociation, somatization and affect dysregulation. This suggests it is important to inquire about past trauma and make the association between trauma history and current symptomatology. The study also supports results from precious studies that indicate that the age of onset and nature of the traumatic experience affect the �complexity of the clinical outcome.� Those who had experienced abuse at or before 14, ended up with significantly more dissociative problems, trouble managing anger as well as self-destructive and suicidal behaviors as compared with those who were older when the trauma occurred or were victims of a disaster.
Golier, J., Yehuda, R., & Bierer, L.M. (2003). The Relationship of Borderline Personality Disorder to Posttraumatic Stress Disorder and Traumatic Events. American Journal of Psychiatry, 160(11), 2018-2024.
The authors examined the relationship of borderline personality disorder to posttraumatic stress disorder (PTSD) with respect to the role of trauma and the timing of trauma exposure.
The Trauma History Questionnaire and the PTSD module of the Structured Clinical Interview for DSM-III-R were administered to 180 male and female outpatients with a diagnosis of one or more DSM-III-R personality disorders. Path analysis was used to evaluate the relationship between borderline personality disorder and PTSD.
High rates of early and lifetime trauma were found for the subject group as a whole. Compared to subjects without borderline personality disorder, subjects with borderline personality disorder had significantly higher rates of childhood/adolescent physical abuse (52.8% versus 34.3%) and were twice as likely to develop PTSD. In the path analysis of the relationship between borderline personality disorder and PTSD, none of the different types of paths (direct path, indirect paths through adulthood traumas, paths sharing the antecedent of childhood abuse) was significant. The associations with both trauma and PTSD were not unique to borderline personality disorder; paranoid personality disorder subjects had an even higher rate of co-morbid PTSD than subjects without paranoid personality disorder, as well as elevated rates of physical abuse and assault in childhood/adolescence and adulthood.
The associations of personality disorder with early trauma and PTSD were evident, but modest, in borderline personality disorder and were not unique to this type of personality disorder. The results do not appear substantial or distinct enough to support singling out borderline personality disorder from the other personality disorders as a trauma-spectrum disorder or variant of PTSD.
Heffernan, K. & Cloitre, M. (2000). A comparison of posttraumatic stress disorder with and without borderline personality disorder among women with a history of childhood sexual abuse: Etiological and clinical characteristics. Journal of Nervous and Mental Disease, 188(9), 589-595.
The study examined etiological variables and current functioning among 2 groups of outpatient women with a history of childhood sexual abuse: those with PTSD only (n=45) and those with PTSD and BPD (n=26).
Subjects were recruited through local newspaper ads and word-of-mouth. Subjects were given standardized interview set that included the Child Maltreatment Interview, Sexual Assault History Initial Interview Schedule, SCID I & II, the PTSD Symptom Scale-Self Report, BDI, STAI, Dissociative Experiences Scale, Brief Symptom Inventory, the Family Environment Scale, the Inventory of Interpersonal Problems, and the Health Services Utilization Form.
Findings: The groups did not differ in severity, frequency, or number of perpetrators of their childhood sexual abuse, or whether the perpetrator was a family member or not. The additional diagnosis of BPD was associated with earlier age of abuse onset and significantly higher rates of physical and verbal abuse by mother. Severity and frequency of PTSD symptoms were not affected by BPD diagnosis, suggesting that the personality disorder and PTSD are independent symptom constructs. The PTSD+BPD group scored higher on several other clinical measures including anger, dissociation, anxiety, and interpersonal problems. They did not differ in their frequency of use of mental health services but tended to be less compliant in their treatment.
Limitations: compliance results were available for only a small subset of the sample (PTSD-only n=20; PTSD+BPD n=10). It did reveal a trend of the PTSD-only group to be more compliant than the PTSD+BPD group (90% versus 60% respectively reporting excellent compliance with the remaining 10% and 40% of each reporting partial to adequate compliance. p < .08) The relatively weak findings here may be due to the use of a self-report measure to assess compliance or to the small size of the subset. The authors suggest that clinical reports or other objective sources of compliance reporting beside the patient may produce different results.
Traumatic Reactions in Acute and Chronic or Multiple Traumatizations
Green, B.L., Goodman, L.A. , Krupnick, J.L., Corcoran, C.B, Petty, R.M., Stockton, P. & Stern , N.M. (2000). Outcomes of single versus multiple trauma exposure in a screening sample. Journal of Traumatic Stress, 13(2), 271-286.
Studied 1909 sophomore women with only 24% response rate from surveys mailed to home. Gathered data from students at 6 D.C. colleges/universities. Used Stressful Life Events Questionnaire, which doesnt specifically ask about child sexual abuse, though does use word "molestation".
Found: 68% of the women reported at least one or more traumatic event; 38% reported two or more events. "Molestation" was 19%, sexual penetration was 14%, attempted rape was 12%. Child physical abuse or assault was 17%. (p. 277). Very few experienced only one particular event alone (less than 1 - 4% per event).
Non-interpersonal only was not associated with elevated current trauma-related symptoms. Multiple interpersonal traumas were associated with the highest risk for current trauma-related symptoms. They found evidence that multiple events have worse outcomes than single or no events. Also, interpersonal trauma, especially involving different forms of trauma (e.g., not just ongoing sexual abuse, but different perpetrators), were more distressed than those experiencing only non-interpersonal trauma.
Messman-Moore, T.L., Long, P.J. & Siegfried , N.J. (2000). The revictimization of child sexual abuse survivors: An examination of the adjustment of college women with child sexual abuse, adult sexual assault, and adult physical abuse. Child Maltreatment, 5(1), 18-27.
Studied 633 undergraduate women. Found 20.1% reported childhood sexual abuse; 27% reported unwanted sexual intercourse during adulthood; 33.2% reported physical abuse by dating partner or husband. More than half (57%) reported at least 1 trauma.
Found that cumulative trauma was more damaging than single exposure to trauma but did not find differential effects for child to adult revictimization versus multiple adult victimization. Women with revictimization and women with multiple adult assaults displayed similar levels of impaired psychological functioning.
Women with multiple adult victimizations had more depression, PTSD symptoms, interpersonal sensitivity and hostility than revictimized women. Revictimized women had more somatization and anxiety than women with multiple adult victimizations. Both of these groups of women reported more difficulties with functioning than those who had only one form of adult abuse or those without a history of trauma. The women with multiple traumas experienced more distress than women with child sexual abuse only, though these differences werent found in all areas. Women with single adult abuse did not have more distress than those with no abuse.
Briere, J. & Elliott, D. (2003). Prevalence and psychological sequelae of self-reported childhood physical and sexual abuse in a general population sample of men and women. Child Abuse & Neglect, 27, 1205-1222.
Used a stratified random sample of 1,442 men and women from US. Sent Traumatic Events Questionnaire and Trauma Symptom Inventory in mail.
Child Sexual Abuse (CSA) Sequelae : associated with elevations on all 10 scales of the TSI, even after controlling for socio-demographic variables (sex, age, race and family income) as well as subsequent interpersonal victimization as an adult, as well as child physical abuse (CPA).
In addition to above, found women had higher rates of adult interpersonal victimization. Women also rated CSA and CPA more upsetting at the time of the event than did men.
CPA sequelae :associated with all TSI scales except those related to sexual symptoms (Sexual concerns & Dysfunctional Sexual Behavior) and Tension Reduction Behavior. The associations were not as strong as with CSA.
Effect sizes : The size of abuse-symptom relationships was relatively small. Once all the covariates were removed (which makes the following estimates very conservative and small), the additional variance in any TSI scale accounted for by CSA or CPA ranged from 6% to 10%. However, the relationship between smoking and lung cancer is r = .12, meaning 1% of variance accounted for. So this has great clinical significance, although clearly, other variables impact these symptoms.
Elliott, D.M., Mok, D.S. & Briere, J. (2004). Adult sexual assault: Prevalence, symptomatology, and sex differences in the general population. Journal of Traumatic Stress, 17, 203-211.
This is a large national stratified random sample of general population. Sample of 941 returned mail surveys using Traumatic Events Survey and Trauma Symptom Inventory (TSI). Found that women are more likely than men to experience most types of interpersonal trauma including child sexual assault, partner violence, and stalking. Men are more likely to be victims of physical assault and as likely to experience child physical abuse. Between 13-25% of women experience sexual assault at some time in the lives while between .6% and 7.2% of men experience it.
Their figure on page 207 is excellent. It shows that both females and males with adult sexual assault (ASA) are more symptomatic on all 10 scales of the TSI compared to men and women without ASA. Men fair much worse than the women with ASA on 8 of the 10 scales. These results were found despite an average of 14 years passing since the last incident of ASA.
Revictimization: women who had experienced ASA were over twice as likely to have experienced CSA as women with no experience of ASA. Men with ASA were five times more likely to have a history of CSA than men with no ASA.
Koenen, K.C. et al. (2002). A twin registry study of familial and individual risk factors for trauma exposure and posttraumatic stress disorder. Journal of Nervous and Mental Disease, 190, 209-218.
The authors looked at male twins (N=6744) from Vietnam registry to explore why familial psychopathology increased risk for PTSD among offspring. They found that those from families with psychopathology had earlier age at first trauma, exposure to multiple traumas, and a number of preexisting psychiatric conditions in the twins increased their risk of developing PTSD.
They interpret their findings as suggesting that the associations between family psychopathology and PTSD may be mediated by increased risk of traumatic exposure and by preexisting disorders in twins. The authors believe that their data support the sensitization hypothesis: multiple traumas increasing the sensitization to later traumas.
Krupnick, J.L., Green, B.L., Stockton , P., Goodman, L., Corcoran, C. & Petty R. (2004). Mental health effects of adolescent trauma exposure in a female college sample: Exploring differential outcomes based on experiences of unique trauma types and dimensions. Psychiatry, 67, 264-279.
Authors selected 209 participants from their larger study of college women who completed questionnaires. This subset came in for interviews. They selected those who reported having been abused after age 12 (to prevent confounding by developmental level). Did SCID interviews of Axis I disorders and borderline personality disorder (BPD). They didn�t find much BPD because screen out those who had earlier trauma.
They found that single traumas were not worse in terms of association with more psychiatric disorders than no trauma exposure except in the case of sexual assault. Ongoing abuse and multiple single traumas were associated with more psychological disorders including PTSD. All trauma groups had increased general distress (SCL-90-R). Almost identical rates of PTSD in the ongoing abuse and the one time sexual assault group, so they concluded that this shows that sexual assault is particularly damaging.
The authors interpret their data as supporting Janoff-Bulman�s 1992 �assertion that deliberately perpetrated traumas are more difficult to integrate than accidental/non-deliberate events, probably because they pose both a greater threat to personal safety and bodily integrity and a greater sense of betrayal� (p. 274).
Pimlott-Kubiak, S. & Cortina, L.M. (2003). Gender, victimization and outcomes: Re-conceptualizing risk. Journal of Consulting and Clinical Psychology, 71, 528-539.
This is a study with outstanding methodology. It takes on the �women are vulnerable (Breslau, Chilcoat, Kessler & Davis, 1999)� vs. �type of event makes any gender vulnerable� gender debate. Used a sample of 16,000 people from a nationally representative telephone survey. Part of the National Violence Against Women Study. Had 8,000 men and 8,000 women so could do sophisticated analyses to see if women truly are more vulnerable to impact of trauma than men. Also used a number of outcomes, not just PTSD, which they claim helps to better understand the true impact of trauma (e.g., depression, which was hypothesized, and found to be higher in traumatized and non-traumatized women; drinking was hypothesized to be higher in traumatized men and non-traumatized men). Only looked at interpersonal aggression which included adult emotional abuse and stalking.
Found NO gender effects after controlling for earlier exposure. Those with most exposure to trauma had the most psychological and health symptoms. Sexual trauma was associated with particularly severe outcomes. The authors interpret their data to refute the theory that women are more vulnerable to pathological outcomes.
Boudreaux, E., Kilpatrick, D.G., Resnick, H.S, Best, C.L, & Saunders, B.E . (1998). Criminal victimization, posttraumatic stress disorder, and co-morbid psychopathology among a community sample of women. Journal of Traumatic Stress, 11(4), 665-678.
They used criminal victimization data. Found that at a univariate level: People who were victims of violent crime were more likely than non-victims to currently suffer from depression, agoraphobia, OCD, social phobia and simple phobia
With multiple regression, PTSD was a strong mediator between victimization and many other Axis I disorders. "While demographics, victimization status, and crime factors may still have direct associations with non-PTSD Axis I disorders, the strongest and most consistent association seemed to be indirectly through their relation with PTSD" (p. 673). Completed rape was the crime most likely to be associated with having a non-PTSD Axis I disorder, which is similar to findings for PTSD (Kilpatrick et al., 1989).
Women with PTSD were at markedly elevated risk for having another Axis I disorder. At least 64% of those with PTSD had another Axis I disorder.
Research on EMDR therapy is ongoing. Trauma Recovery/HAP provides a periodically updated bibliography of research studies which can be viewed below. For a PDF of the Research List click here.
Additional information on trauma and on EMDR therapy practice and history can be found in numerous books and articles. A growing collection of these and other materials can be found at the Francine Shapiro Library.
- EMDR therapy has been listed as an effective treatment by the American Psychiatric Association, Departments of Defense and Veterans Affairs, International Society for Traumatic Stress Studies, the World Health Organization, the Substance Abuse and Mental Health Services and numerous other international agencies.
- More than a dozen studies support the use of EMDR therapy for trauma resulting from natural disaster and treatment of war- and terrorism-related trauma.
- With little modification, EMDR has been used successfully in response to a variety of mass-casualty events such as community homicide and can be integrated with educational formats.
- EMDR therapy has a positive impact on intrusive imagery (such as nightmares and flashbacks), numbing, and hyperarousal symptoms of PTSD, as well as on associated grief and depression.
- In several direct comparisons with cognitive-behavioral therapy, EMDR offers equivalent effects more quickly (fewer sessions and/or no homework), process analyses indicate less distress for individuals undergoing treatment.
Links on this page:
International Treatment Guidelines
Randomized Controlled Trauma Studies
Non-Randomized Trauma Studies
Adaptive Information Processing and EMDR Procedures
Mechanism of Action
Randomized Studies of Hypotheses Regarding Eye Movements
Additional Neurobiological Evaluations
Combat Veteran Treatment
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 is recommended as an effective treatment for trauma.
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 three methods recommended for treatment of terror victims.
California Evidence-Based Clearinghouse for Child Welfare(2010). Trauma Treatment for Children. http://www.cebc4cw.org.
EMDR and Trauma-focused CBT are considered “Well-Supported by Research Evidence.”
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 (“probably efficacious”) for the treatment of any post-traumatic stress disorder population were EMDR, exposure therapy, and stress inoculation therapy. Note that this evaluation does not cover the last decade of research.
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.
EMDR and CBT were stated to be the treatments of choice.
Department of Veterans Affairs & Department of Defense (2010). VA/DoD Clinical Practice Guideline for the Management of Post-Traumatic Stress. Washington, DC: Veterans Health Administration, Department of Veterans Affairs and Health Affairs, Department of Defense.
EMDR was placed in the category of the most effective PTSD psychotherapies. This “A” category is described as “A strong recommendation that clinicians provide the intervention to eligible patients. Good evidence was found that the intervention improves important health outcomes and concludes that benefits substantially outweigh harm.”
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 both designated as treatments of choice for PTSD.
Foa, E.B., Keane, T.M., Friedman, M.J., & Cohen, J.A. (2009). Effective treatments for PTSD: Practice Guidelines of the International Society for Traumatic Stress Studies New York: Guilford Press.
EMDR was listed as an effective and empirically supported treatment for PTSD, and was given an AHCPR “A” rating for adult PTSD. This guideline specifically rejected the findings of the previous Institute of Medicine report, which stated that more research was needed to judge EMDR effective for adult PTSD. With regard to the application of EMDR to children, an AHCPR rating of Level B was assigned. Since the time of this publication, three additional randomized studies on EMDR have been completed (see below).
INSERM (2004).Psychotherapy: An evaluation of three approaches. French National Institute of Health and Medical Research, Paris, France.
EMDR and CBT were stated to be the treatments of choice for trauma victims.
National Collaborating Centre for Mental Health(2005).Post traumatic stress disorder (PTSD): The management of adults and children in primary and secondary care. London: National Institute for Clinical Excellence.
Trauma-focused CBT and EMDR were stated to be empirically supported treatments for choice for adult PTSD.
SAMHSA’s National Registry of Evidence-based Programs and Practices (2011)http://legacy.nreppadmin.net/ViewIntervention.aspx?id=199
The Substance Abuse and Mental Health Services Administration (SAMHSA) is an agency of the U.S. Department of Health and Human Services (HHS). This national registry (NREPP) cites EMDR as evidence based practice for treatment of PTSD, anxiety, and depression symptoms. Their review of the evidence also indicated that EMDR leads to an improvement in mental health functioning.
Therapy Advisor (2004-11): 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.
World Health Organization (2013).Guidelines for the management of conditions that arespecifically related to stress. Geneva, WHO.
Trauma-focused CBT and EMDR are the only psychotherapies recommended for children, adolescents and adults with PTSD. “Like CBT with a trauma focus, EMDR aims to reduce subjective distress and strengthen adaptive cognitions related to the traumatic event. Unlike CBT with a trauma focus, EMDR does not involve (a) detailed descriptions of the event, (b) direct challenging of beliefs, (c) extended exposure, or (d) homework.” (p.1)
EMDR therapy has been compared to numerous exposure therapy protocols, with and without CT techniques. It should be noted that exposure therapy uses one to two hours of daily homework and EMDR uses none. The most recent meta-analyses are listed here.
Bisson, J., Roberts, N.P., Andrew, M., Cooper, R. & Lewis, C.(2013). Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults. Cochrane Database of Systematic Reviews 2013, DOI: 10.1002/14651858.CD003388.pub4
Research indicates that CBT and EMDR therapy are superior to all other treatments.
Bradley, R., Greene, J., Russ, E., Dutra, L., & Westen, D. (2005). A multidimensional meta-analysis of psychotherapy for PTSD. American Journal of Psychiatry, 162, 214-227.
EMDR is equivalent to exposure and other cognitive behavioral treatments and all “are highly efficacious in reducing PTSD symptoms.”
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 therapy is equivalent to exposure and other cognitive behavioral treatments.
Lee, C.W. & Cuijpers, P. (2013). A meta-analysis of the contribution of eye movements in processing emotional memories. Journal of Behavior Therapy & Experimental Psychiatry, 44, 231-239.
“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).”
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.
Rodenburg, R., Benjamin, A., de Roos, C, Meijer, A.M., & Stams, G.J. (2009). Efficacy of EMDR in children: A meta – analysis. Clinical Psychology Review, 29, 599-606.
“Results indicate efficacy of EMDR when effect sizes are based on comparisons between EMDR and non-established trauma treatment or no-treatment control groups, and incremental efficacy when effect sizes are based on comparisons between EMDR and established (CBT) trauma treatment.”
Seidler, G.H., & Wagner, F.E. (2006). Comparing the efficacy of EMDR and trauma-focused cognitive-behavioral therapy in the treatment of PTSD: a meta-analytic study. Psychological Medicine, 36, 1515-1522.
“Results suggest that in the treatment of PTSD, both therapy methods tend to be equally efficacious.”
Watts, B.V. et al. (2013). Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. Journal of Clinical Psychiatry, 74, e541-550. doi: 10.4088/JCP.12r08225
“CBT and eye movement desensitization and reprocessing were the most often-studied types of psychotherapy. Both were effective.”
Randomized Clinical Trials
Abbasnejad, M., Mahani, K. N., & Zamyad, A. (2007). Efficacy of “eye movement desensitization and reprocessing” in reducing anxiety and unpleasant feelings due to earthquake experience. Psychological Research, 9, 104-117.
“EMDR is effective in reducing earthquake anxiety and negative emotions (e.g. PTSD, grief, fear, intrusive thoughts, depression, etc) resulting from earthquake experience. Furthermore, results show that, improvement due to EMDR was maintained at a one month follow up.”
Ahmad A, Larsson B, & Sundelin-Wahlsten V. (2007). EMDR treatment for children with PTSD: Results of a randomized controlled trial. Nord J Psychiatry, 61, 349-54.
“Post-treatment scores of the EMDR group were significantly lower than the WLC indicating improvement in total PTSS-C scores, PTSD-related symptom scale, and the subscales re-experiencing and avoidance among subjects in the EMDR group, while untreated children improved in PTSD-non-related symptom scale.”
Arabia, E., Manca, M.L. & Solomon, R.M. (2011). EMDR for survivors of life-threatening cardiac events: Results of a pilot study. Journal of EMDR Practice and Research, 5, 2-13.
“Forty-two patients undergoing cardiac rehabilitation . . . were randomized to a 4-week treatment of EMDR or imaginal exposure (IE). . . . EMDR was effective in reducing PTSD, depressive, and anxiety symptoms and performed significantly better than IE for all variables. . . Because the standardized IE procedures used were those employed in-session during [prolonged exposure] the results are also instructive regarding the relative efficacy of both treatments without the addition of homework.”
Capezzani et al. (2013). EMDR and CBT for cancer patients: Comparative study of effects on PTSD, anxiety, and depression. Journal of EMDR Practice and Research, 5, 2-13.
This randomized pilot study reported that after eight sessions of treatment, EMDR therapy was superior to a variety of CBT techniques. “Almost all the patients (20 out of 21, 95.2%) did not have PTSD after the EMDR treatment.”
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 77.7% of the multiply traumatized combat veterans studied. There was 100% retention in the EMDR condition. 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., Boudewyns/Devilly/Jensen/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 (2000), is inappropriate for multiple-trauma survivors. The VA/DoD Practice Guideline (2004) also indicates these studies (often with only two sessions) offered insufficient treatment doses for veterans. EMDR therapy is listed as an “A” level treatment in the VA/DoD Practice Guideline (2004, 2010).
Chemtob, C.M., Nakashima, J., & Carlson, J.G. (2002). Brief-treatment for elementary school children with disaster-related PTSD: A field study. Journalof 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.
Cvetek, R. (2008). EMDR treatment of distressful experiences that fail to meet the criteria for PTSD. Journal of EMDR Practice and Research, 2, 2-14.
EMDR treatment of disturbing life events (small “t” trauma) was compared to active listening, and wait list. EMDR produced significantly lower scores on the Impact of Event Scale (mean reduced from “moderate” to “subclinical”) and a significantly smaller increase on the STAI after memory recall.
de Bont, P. A., van den Berg, D. P., van der Vleugel, B. M., de Roos, C., de Jongh, A., van der Gaag, M., & van Minnen, A. M. (2016). Prolonged exposure and EMDR for PTSD v. a PTSD waiting-list condition: effects on symptoms of psychosis, depression and social functioning in patients with chronic psychotic disorders. Psychological medicine, 1-11.
“In patients with chronic psychotic disorders PE and EMDR not only reduced PTSD symptoms, but also paranoid thoughts. Importantly, in PE and EMDR more patients accomplished the status of their psychotic disorder in remission.”
Diehle, J., Opmeer, B. C., Boer, F., Mannarino, A. P., & Lindauer, R. J. (2014). Trauma-focused cognitive behavioral therapy or eye movement desensitization and reprocessing: What works in children with posttraumatic stress symptoms? A randomized controlled trial. European Child & Adolescent Psychiatry, 226, 227-236.
A mixed sample of full and partial PTSD was evaluated. “[B]oth treatments are effective in children with PTSS in an outpatient setting. Results on both child and parent measures support this conclusion.”
de Roos, C. Greenwald, R., den Hollander-Gijsman, M, Noorthoorn, E., van Buuren, S. & de Jongh, A. (2011). A randomised comparison of cognitive behavioural therapy (CBT) and eye movement desensitisation and reprocessing (EMDR) in disaster exposed children. European Journal of Psychotraumatology, 2: 5694 – DOI: 10.3402/ejpt.v2i0.5694
“Children (n=52, aged 4-18) were randomly allocated to either CBT (n=26) or EMDR (n=26) in a disaster mental health after-care setting after an explosion of a fireworks factory. . . Both treatment approaches produced significant reductions on all measures and results were maintained at follow-up. Treatment gains of EMDR were reached in fewer sessions.”
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, T., & Rubin, A. (2004). Assessing the long-term effects of EMDR: Results from an 18-month follow up study with adult female survivors of CSA. Journal of Childhood Sexual Abuse, 13, 69–86.
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.
Hogberg, G. et al., (2007). On treatment with eye movement desensitization and reprocessing of chronic post-traumatic stress disorder in public transportation workers: A randomized controlled study. Nordic Journal of Psychiatry, 61, 54-61.
Employees who had experienced “person-under-train accident or had been assaulted at work were recruited.” Six sessions of EMDR resulted in remission of PTSD in 67% compared to 11% in the wait list control. Significant effects were documented in Global Assessment of Function (GAF) and Hamilton Depression (HAM-D) score. Follow-up: Högberg, G. et al. (2008). Treatment of post-traumatic stress disorder with eye movement desensitization and reprocessing: Outcome is stable in 35-month follow-up. Psychiatry Research. 159, 101-108.
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. This is the only research comparing EMDR and exposure therapy that added in vivo homework to the EMDR condition. The study found that 70% of EMDR participants achieved a good outcome in three active treatment sessions, compared to 17% of persons in the prolonged exposure condition. EMDR also had fewer dropouts (0 v 30%).
Jaberghaderi, N., Greenwald, R., Rubin, A., Dolatabadim S., & Zand, S.O. (2004). A comparison of CBT and EMDR for sexually abused Iranian girls. Clinical Psychology and Psychotherapy, 11, 358-368.
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.
Jarero, I., Artigas, L., & Luber, M. (2011). The EMDR protocol for recent critical incidents: Application in a disaster mental health continuum of care context. Journal of EMDR Practice and Research, 5, 82-94.
Participants were treated two weeks following a 7.2 earthquake in Mexico. “One session of EMDR-PRECI produced significant improvement on symptoms of posttraumatic stress for both the immediate-treatment and waitlist/delayed treatment groups, with results maintained at 12-week follow-up, even though frightening aftershocks continued to occur frequently.”
Jarero, I., & Uribe, S., Artigas, L., Givaudan, M. (2015). EMDR protocol for recent critical incidents: A randomized controlled trial in a technological disaster context. Journal of EMDR Practice and Research, 9, 166–173.
Evaluation of co-workers 10 days after they witnessed seven people killed in an explosion revealed a mean of 22 on the SPRINT, indicating severe PTSD symptoms. After two consecutive-day 60-minute EMDR sessions the mean SPRINT scores for immediate and delayed treatment groups declined to equally low levels on both posttest and follow-up.
Kemp M., Drummond P., & McDermott B. (2010). A wait-list controlled pilot study of eye movement desensitization and reprocessing (EMDR) for children with post-traumatic stress disorder (PTSD) symptoms from motor vehicle accidents. Clinical Child Psychology and Psychiatry, 15, 5-25.
“An effect for EMDR was identified on primary outcome and process measures including the Child Post-Traumatic Stress – Reaction Index, clinician rated diagnostic criteria for PTSD, Subjective Units of Disturbance and Validity of Cognition scales. All participants initially met two or more PTSD criteria. After EMDR treatment, this decreased to 25% in the EMDR group but remained at 100% in the wait-list group.”
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 condition used 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 Permanente. Results show that 100% of single-trauma and 77% 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 Permanente, follow-up evaluation indicates that a relatively small number of EMDR sessions result in substantial benefits that are maintained over time.
Nijdam, M.J., Gersons, B.P.R, Reitsma, J.B., de Jongh, A. & Olff, M.(2012). Brief eclectic psychotherapy v. eye movement desensitisation and reprocessing therapy in the treatment of post-traumatic stress disorder: Randomised controlled trial. British Journal of Psychiatry, 200, 224-231.
A comparison of “the efficacy and response pattern of a trauma-focused CBT modality, brief eclectic psychotherapy for PTSD, with EMDR . . . Although both treatments are effective, EMDR results in a faster recovery compared with the more gradual improvement with brief eclectic psychotherapy.”
Novo, P. et al. (2014). Eye movement desensitization and reprocessing therapy in subsyndromal bipolar patients with a history of traumatic events: A randomized, controlled pilot-study. Psychiatry Research, 219, 122-128.
“Although preliminary, our findings support the utility of this treatment approach and suggest that Eye Movement Desensitization and Reprocessing therapy could be a promising and safe therapeutic strategy to reduce trauma symptoms and stabilize mood in traumatized bipolar patients with subsyndromal symptoms.”
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 social functioning, and required fewer treatment sessions. Subsequent reevaluation of the data indicated that “For pre- to post-treatment IES mean change score, EMDR patients also appeared to have had better treatment outcome than E+CR patients” and EMDR therapy was a predictor of positive outcome: Karatzias, A., Power, K.,McGoldrick, T., Brown, K., Buchanan, R., Sharp, D. & Swanson, V. (2006). Predicting treatment outcome on three measures for post-traumatic stress disorder. Eur Arch Psychiatry Clin Neuroscience, 20, 1-7.
Rothbaum, B. O. (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.
Rothbaum, B.O., Astin, M.C., & Marsteller, F. (2005). Prolonged exposure versus eye movement desensitization (EMDR) for PTSD rape victims. Journal of Traumatic Stress, 18, 607-616.
In this NIMH funded study both treatments were effective: “An interesting potential clinical implication is that EMDR seemed to do equally well in the main despite less exposure and no homework. It will be important for future research to explore these issues.” (p. 614)
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 in traumatized adolescents/ young women and brought scores within one standard deviation of the norm.
Shapiro, E., Laub, B. (2015). Early EMDR intervention following a community critical incident: A randomized clinical trial. Journal of EMDR Practice and Research, 9, 17-27.
“At 1 week posttreatment, the scores of the immediate treatment group were significantly improved on the IES-R compared to the waitlist/delayed treatment group, who showed no improvement prior to their treatment. At 3 months follow-up, results on the IES-R were maintained and there was a significant improvement on PHQ-9 scores.”
Shapiro, F. (1989). Efficacy of the eye movement desensitization procedure in the treatment of traumatic memories. Journal of Traumatic Stress, 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 behavioral 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 at 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 some measures. 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.
van den Berg, D.P.G., et al. (2015). Prolonged exposure versus eye movement desensitization and reprocessing versus waiting list for posttraumatic stress disorder in patients with a psychotic disorder: A randomized clinical trial. JAMA Psychiatry, 72(3):259-267.
Standard PE and EMDR therapy protocols are effective, safe, and feasible in patients with PTSD and severe psychotic disorders, including current symptoms. Additional evaluation Indicated trauma-focused treatment was associated with significantly less exacerbation, less adverse events, and reduced revictimization compared with the WL condition: van den Berg D.P.G., et al. Trauma-focused treatment in PTSD-patients with psychosis: symptom exacerbation, adverse events, and revictimization. Schizophrenia Bulletin. doi: 10.1093/schbul/sbv172
Van der Kolk, B., Spinazzola, J. Blaustein, M., Hopper, J. Hopper, E., Korn, D., & Simpson, W. (2007). A randomized clinical trial of EMDR, fluoxetine and pill placebo in the treatment of PTSD: Treatment effects and long-term maintenance. Journal of Clinical Psychiatry, 68, 37-46.
EMDR was superior to both control conditions in the amelioration of both PTSD symptoms and depression. Upon termination of therapy, the EMDR group continued to improve while Fluoxetine participants again became symptomatic.
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 (albeit non-significant) 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.
Wanders, F., Serra, M., & de Jongh, A. (2008). EMDR Versus CBT for children with self-esteem and behavioral problems: A randomized controlled trial. Journal of EMDR Practice and Research, 2, 180-189.
Twenty-six children (average age 10.4 years) with behavioral problems were randomly assigned to receive either 4 sessions of EMDR or CBT. Both were found to have significant positive effects on behavioral and self-esteem problems, with the EMDR group showing significantly larger changes in target behaviors.
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.
Aduriz, M.E., Bluthgen, C. & Knopfler, C. (2009). Helping child flood victims using group EMDR intervention in Argentina: Treatment outcome and gender differences. International Journal of Stress Management. 16, 138-153.
A comprehensive group intervention with 124 children, who experienced disaster related trauma during a massive flood utilizing a one-session group protocol. Significant differences were obtained and maintained at 3-month follow up.
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.
This study found CBT superior to EMDR. The research is marred by higher expectations in the CBT condition: Treatment was delivered in both conditions by the developer of the CBT protocol.
Fernandez, I. (2007). EMDR as treatment of post-traumatic reactions: A field study on child victims of an earthquake. Educational and Child Psychology. Special Issue: Therapy, 24, 65-72.
This field study explores the effectiveness of EMDR and the level of post-traumatic reactions in a post-emergency context on 22 children victims of an earthquake. The results show that EMDR contributed to the reduction or remission of PTSD symptoms and facilitated the processing of the traumatic experience
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.
Hensel, T. (2009). EMDR with children and adolescents after single-incident trauma an intervention study. Journal of EMDR Practice and Research, 3, 2-9.
36 children and adolescents ranging in age from 1 year 9 months to 18 years 1 month were assessed at intake, post-waitlist/pretreatment, and at follow up. EMDR treatment resulted in significant improvement, demonstrating that children younger than 4 years of age showed the same benefit as the school-age children.
Jarero, I., & Artigas, L. (2010). The EMDR integrative group treatment protocol: Application with adults during ongoing geopolitical crisis. Journal of EMDR Practice and Research, 4, 148-155.
“In this study, the EMDR-IGTP was applied during three consecutive days to a group of 20 adults during ongoing geopolitical crisis in a Central American country in 2009. . . Changes on the IES were maintained at 14 weeks follow-up even though participants were still exposed to ongoing crisis.”
Jarero, I., Artigas, L., & Hartung, J. (2006). EMDR integrative group treatment protocol: A post-disaster trauma intervention for children and adults. Traumatology, 12, 121-129.
A study of 200 children treated with a group protocol after a flood in Mexico indicates that one session of treatment reduced trauma symptoms from the severe range to low (subclinical) levels of distress. Data from successful treatment at other disaster sites are also reported.
Jarero, I., Artigas, L., Lopez-Lena, M. (2008). The EMDR integrative group treatment protocol: Application with child victims of mass disaster. Journal of EMDR Practice and Research, 2, 97-105.
“In this study the EMDR-IGTP was used with 16 bereaved children after a human provoked disaster in the Mexican State of Coahuila in 2006. Results showed a significant decrease in scores on the Child’s Reaction to Traumatic Events Scale that was maintained at 3-month follow-up.”
Jarero, I., Artigas, L., Uribe, S., García, L. E., Cavazos, M. A., & Givaudan, M. (2015). Pilot research study on the provision of the eye movement desensitization and reprocessing integrative group treatment protocol with female cancer patients. Journal of EMDR Practice and Research, 9(2), 98-105.
“EMDR-IGTP intensive therapy was administered for 3 consecutive days, twice daily. . . . Results also showed an overall subjective improvement in the participants.”
Jarero, I., Roque-López, S., & Gomez, J. (2013). The provision of an EMDR-based multicomponent trauma treatment with child victims of severe interpersonal trauma. Journal of EMDR Practice and Research, 7(1), 17-28.
“Results showed significant improvement for all the participants on the Child’s Reaction to Traumatic Events Scale (CRTES) and the Short PTSD Rating Interview (SPRINT), with treatment results maintained at follow-up.”
Jarero, I. & Uribe, S. (2011). The EMDR protocol for recent critical incidents: Brief report of an application in a human massacre situation. Journal of EMDR Practice and Research, 5, 156-165.
“Each individual client session lasted between 90 and 120 minutes. Results showed that one session of EMDR-PRECI produced significant improvement on self-report measures of posttraumatic stress and PTSD symptoms for both the immediate treatment and waitlist/delayed treatment groups.” There were no dropouts during treatment.
Jarero, I. & Uribe, S. (2012). The EMDR protocol for recent critical incidents: Follow-up report of an application in a human massacre situation. Journal of EMDR Practice and Research, 6, 50-61.
“Follow-up scores showed that the original treatment results were maintained, with a further significant reduction of self-reported symptoms of posttraumatic stress and PTSD between posttreatment and follow-up. . . . [S]cores of all participants were far below PTSD cutoff levels.”
Konuk, E., Knipe, J., Eke, I., Yuksek, H., Yurtsever, A., & Ostep, S. (2006). The effects of EMDR therapy on post-traumatic stress disorder in survivors of the 1999 Marmara, Turkey, earthquake. International Journal of Stress Management, 13, 291-308.
Data reported on a representative sample of 1500 earthquake victims indicated that five sessions of EMDR successfully eliminated PTSD in 92.7% of those treated, with a reduction of symptoms in the remaining participants. Gains were maintained at 6-month follow-up.
McLay, R. N., Webb-Murphy, J. A., Fesperman, S. F., Delaney, E. M., Gerard, S. K., Roesch, S. C., Nebeker, B. J., Pandzic, I., Vishnyak, E. A., & Johnston, L. (2016, March 10). Outcomes from eye movement desensitization and reprocessing in active-duty service members with posttraumatic stress disorder. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. http://dx.doi.org/10.1037/tra0000120
“Results indicated that patients receiving EMDR had significantly fewer therapy sessions over 10 weeks but had significantly greater gains in their PCL–M scores than did individuals not receiving EMDR.”
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.
Ribchester, T., Yule, W., & Duncan, A. (2010). EMDR for childhood PTSD after road traffic accidents: Attentional, memory, and attributional processes. Journal of EMDR Practice and Research, 4, 138-147.
“EMDR was used with 11 children who developed posttraumatic stress disorder (PTSD) after road traffic accidents. All improved such that none met criteria for PTSD on standardized assessments after an average of only 2.4 sessions. . .Treatment was associated with a significant trauma-specific reduction in attentional bias on the modified Stroop task, with results apparent both immediately after therapy and at follow-up.”
Russell, M.C., Silver, S.M., Rogers, S., & Darnell, J. (2007). Responding to an identified need: A joint Department of Defense-Department of Veterans Affairs training program in eye movement desensitization and reprocessing (EMDR) for clinicians providing trauma services.International Journal of Stress Management, 14, 61-71.
72 active-duty military personnel were treated with EMDR therapy by nine different therapists in actual clinic settings.Results indicated that “the disturbance associated with the targeted traumatic memories had been largely eliminated and a new more positive perspective had developed. These changes were corroborated with the IES-R and BDI scores falling from the severe range to the mild or subclinical range.” Average treatment time: 8.50 sessions if wounded and 3.82 sessions if nonwounded.
Schubert, S.J., Lee, C.W., de Araujo, G., Butler, S.R., Taylor, G. & Drummond, P. (in press). The effectiveness of eye movement desensitization and reprocessing (EMDR) therapy to treat symptoms following trauma in Timor Leste. Journal of Traumatic Stress.
“These findings suggest that benefits can be achieved with EMDR therapy for decreasing PTSD symptoms in a post-war, cross-cultural setting in a relatively short period (on average 4 treatment sessions over 13 days).”
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.
The analysis of an inpatient veterans’ PTSD program (n=100) found EMDR to be superior to biofeedback and relaxation training.
Silver, S.M., Rogers, S., Knipe, J., & Colelli, G. (2005). EMDR therapy following the 9/11 terrorist attacks: A community-based intervention project in New York City. International Journal of Stress Management, 12, 29-42.
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 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. Positive recall of the deceased was significantly greater post treatment in the EMDR condition.
Wadaa, N. N., Zaharim, N. M., & Alqashan, H. F. (2010). The use of EMDR in treatment of traumatized Iraqi children. Digest of Middle East Studies, 19, 26-36.
“Our findings are consistent with the conclusion . . . that EMDR is effective for civilian PTSD, and it applies its treatment in a user-friendly manner . . . The results of the study demonstrated the effectiveness of EMDR in the treatment of PTSD in the experimental group compared to the control group.”
Zaghrout-Hodali, M., Alissa, F. & Dodgson, P.W. (2008). Building resilience and dismantling fear: EMDR group protocol with children in an area of ongoing trauma. Journal of EMDR Practice and Research, 2, 106-113.
Results indicate that the EMDR approach can be effective in a group setting, and in an acute situation, both in reducing symptoms of posttraumatic and peritraumatic stress and in “inoculation” or building resilience in a setting of ongoing conflict and trauma.
Adaptive Information Processing and EMDR Procedures
The Adaptive Information Processing model (Shapiro, 2001, 2002, 2007, 2014) is used to explain EMDR’s clinical effects and guide clinical practice. This section includes literature to provide an overview of the model and procedures, as well as selected research and case reports that demonstrate the predictive value of the model in the treatment of life experiences that appear to underlie a variety of clinical complaints.
Afifi, T.O., Mota, N.P., Dasiewicz, P., MacMillan, H.L. & Sareen, J. (2012). Physical punishment and mental disorders: Results from a nationally representative US sample. Pediatrics, 130, 184-192.
“Harsh physical punishment [i.e., pushing, grabbing, shoving, slapping, hitting] in the absence of [more severe] child maltreatment is associated with mood disorders, anxiety disorders, substance abuse/dependence, and personality disorders in a general population sample.”
Allon, M. (2015). EMDR group therapy with women who were sexually assaulted in the Congo. Journal of EMDR Practice and Research, 9, 28-34.
Rape victims were successfully treated within three sessions using both individual and group protocols. They reported the simultaneous remission of back and abdominal pain. These processing results are consistent with the reported remission of PLP with EMDR therapy.
Arseneault, L., Cannon, M, Fisher, H.L. Polanczyk, G. Moffitt, T.E. & Caspi, A. (2011). Childhood trauma and children’s emerging psychotic symptoms: A genetically sensitive longitudinal cohort study. Am J Psychiatry, 168, 65–72.
“Trauma characterized by intention to harm is associated with children’s reports of psychotic symptoms. Clinicians working with children who report early symptoms of psychosis should inquire about traumatic events such as maltreatment and bullying.”
Bae, H., Kim, D. & Park, Y.C. (2008). Eye movement desensitization and reprocessing for adolescent depression. Psychiatry Investigation, 5, 60-65.
Processing of etiological disturbing memories, triggers and templates resulted in complete remission of Major Depressive Disorder in two teenagers. Treatment duration was 3-7 sessions and effects were maintained at follow-up.
Behnam Moghadam, M., Alamdari, A.K., Behnam Moghadam, A. & Darban, F. (2015). Effect of EMDR on depression in patients with myocardial infarction Global Journal of Health Science, 7, 258-262.
In this randomized study, the mean depression level in experimental group significantly decreased following the intervention. These changes were significantly greater compared to the control group. Conclusion: “EMDR is an effective, useful, efficient, and non-invasive method for treatment and reducing depression in patients with MI.” A 12-month follow-up reported maintenance of treatment effects: Behnam, M. M., Behnam, M. A., & Salehian, T. (2015). Efficacy of eye movement desensitization and reprocessing (EMDR) on depression in patients with myocardial infarction (MI) in a 12-month follow up. Iranian Journal of Critical Care Nursing, 7, 221-226
Brown, K. W., McGoldrick, T., & Buchanan, R. (1997). Body dysmorphic disorder: Seven cases treated with eye movement desensitization and reprocessing. Behavioural and Cognitive Psychotherapy, 25, 203–207.
Seven consecutive cases were treated with up to three sessions of EMDR. Complete remission of BDD symptoms were reported in five cases with effects maintained at one- year follow-up.
Brown, S. & Shapiro, F. (2006). EMDR in the treatment of borderline personality disorder. Clinical Case Studies, 5, 403-420.
20 EMDR sessions that focused on reprocessing the memories seemingly at the foundation of the pathology, along with triggers and future templates resulted in a complete remission of BPD, including symptoms of affect dysregulation, as measured on the Inventory of Altered Self Capacities.
de Roos, C., Veenstra, A.C, et al. (2010). Treatment of chronic phantom limb pain (PLP) using a trauma-focused psychological approach. Pain Research and Management, 15, 65-71.
10 consecutive cases of phantom limb pain were treated with EMDR resulting in the reduction or elimination of pain in all but two cases. Results were maintained at 2.8-year follow-up.
Doering, S., Ohlmeier, M, de Jongh, A., Hofmann, A., & Bisping, V. (2013). Efficacy of a trauma-focused treatment approach for dental phobia: A randomized clinical trial. European Journal of Oral Sciences, 121, 584–593.
Three sessions of EMDR therapy memory processing resulted in remission of dental phobia. “After 1 yr, 83.3% of the patients were in regular dental treatment (d = 3.20). The findings suggest that therapy aimed at processing memories of past dental events can be helpful for patients with dental phobia.”
Faretta, E. (2013). EMDR and cognitive behavioral therapy in the treatment of panic disorder: A comparison. Journal of EMDR Practice and Research, 7, 121-133.
As predicted by AIP, the processing of etiological events, triggers and memory templates was sufficient to alleviate the diagnosis without the use of treatment specific homework in contrast to the CBT group. In this study, there was “a continuing decrease in frequency of panic attacks for participants with PD or PDA in the EMDR condition at follow-up that was significantly greater than that found in the CBT treatment group.”
Felitti, V. J., et al. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine,14, 245–258.
“We found a strong dose response relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.”
Fernandez, I., & Faretta, E. (2007). EMDR in the treatment of panic disorder with agoraphobia. Clinical Case Studies, 6, 44-63.
As predicted by AIP, the processing of etiological events, triggers and memory templates was sufficient to alleviate the diagnosis without the use of therapist-assisted in vivo exposure.
Gauvreau, P. & Bouchard, S. (2008) Preliminary evidence for the efficacy of EMDR in treating generalized anxiety disorder. Journal of EMDR Practice and Research, 2, 26- 40.
Four subjects were evaluated using a single case design with multiple baselines Results indicate that subsequent to targeting the experiential contributors, at posttreatment and at 2 months follow-up, all four participants no longer presented with GAD diagnosis.
Gold, S. D., Marx, B. P., Soler-Baillo, J. M., & Sloan, D. M. (2005). Is life stress more traumatic than traumatic stress?. Journal of Anxiety Disorders, 19, 687-698.
“[The non-Criterion A] group reported significantly greater severity of PTSD symptomatology than those who reported a Criterion A1 PTSD event. In addition, significantly more people in the DSM trauma-incongruent group met criteria for PTSD than those in the DSM trauma-congruent group.”
Heim, Plotsky & Nemeroff (2004). Importance of studying the contributions of early adverse experience to neurobiological findings in depression. Neuropsychopharmacology, 29, 641–648.
“The available data suggest that (1) early adverse experience contributes to the pathophysiology of depression, (2) there are neurobiologically different subtypes of depression depending on the presence or absence of early adverse experience, likely having confounded previous research on the neurobiology of depression, and (3) early adverse experience likely influences treatment response in depression.”
Heins et al. (2011). Childhood trauma and psychosis: A case-control and case-sibling comparison across different levels of genetic liability, psychopathology, and type of trauma. Am J Psychiatry, 168, 1286-1294.
“Discordance in psychotic illness across related individuals can be traced to differential exposure to trauma. The association between trauma and psychosis is apparent across different levels of illness and vulnerability to psychotic disorder, suggesting true association rather than reporting bias, reverse causality, or passive gene-environment correlation.”
Madrid, A., Skolek, S., & Shapiro, F. (2006) Repairing failures in bonding through EMDR. Clinical Case Studies. 5, 271-286.
EMDR processing of experiential contributors to bonding disruption, in addition to current triggers, and a memory template of an alternative/problem free pregnancy and birth resulted in the repair of maternal bonding, analogous to the positive findings with the repair of disrupted attachment.
McGoldrick, T., Begum, M. & Brown, K.W. (2008). EMDR and olfactory reference syndrome: A case series. Journal of EMDR Practice and Research 2, 63-68.
EMDR treatment of four consecutive cases of ORS whose pathological symptoms had endured for 8–48 years resulted in a complete resolution of symptoms in all four cases, which was maintained at follow-up.
Mol, S. S. L., Arntz, A., Metsemakers, J. F. M., Dinant, G., Vilters-Van Montfort, P. A. P., & Knottnerus, A. (2005). Symptoms of post-traumatic stress disorder after non-traumatic events: Evidence from an open population study. British Journal of Psychiatry, 186, 494–499.
Supports a basic tenet of the Adaptive Information Processing model that “Life events can generate at least as many PTSD symptoms as traumatic events.” In a survey of 832 people, “For events from the past 30 years the PTSD scores were higher after life events than after traumatic event.”
Nazari, H., Momeni, N., Jariani, M., & Tarrahi, M. J. (2011). Comparison of eye movement desensitization and reprocessing with citalopram in treatment of obsessive-compulsive disorder. International Journal of Psychiatry in Clinical Practice, 15, 270-274.
“There was significant difference between the mean Yale –Brown scores of the two groups after treatment and EMDR was more effective than citalopram in improvement of OCD signs.”
Obradovic´, J., Bush, N.R., Stamperdahl, J., Adler, N.E. & Boyce, W.T. (2010). Biological sensitivity to context: The interactive effects of stress reactivity and family adversity on socioemotional behavior and school readiness. Child Development, 1, 270–289.
“A substantive body of work has established that environmental adversity can have a deleterious effect on children’s functioning” “Exposure to adverse, stressful events . . .has been linked to socioemotional behavior problems and cognitive deficits.”
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, and theory.
Raboni, M.R., Tufik, S., & Suchecki, D. (2006). Treatment of PTSD by eye movement desensitization and reprocessing improves sleep quality, quality of life and perception of stress. Annals of the New York Academy of Science, 1071, 508-513.
Specifically citing the hypothesis that EMDR induces processing effects similar to REM sleep (see also Stickgold, 2002, 2008), polysomnograms indicated a change in sleep patterns post treatment, and improvement on all measures including anxiety, depression, and quality of life after a mean of five sessions.
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.
The authors note that the application of EMDR guided by the Adaptive Information Processing model appears to afford benefits to chronic pain patients not found in other treatments.
Read, J., Fosse, R., Moskowitz, A., & Perry, B. (2014). The traumagenic neurodevelopmental model of psychosis revisited. Neuropsychiatry, 4(1), 65-79.
“[C]ontrary to long-held beliefs among biologically oriented researchers and clinicians, the etiology of psychosis and schizophrenia are just as socially based [e.g., early-life adversity] as are nonpsychotic mental health problems, such as anxiety and depression.”
Ricci, R. J., Clayton, C. A., & Shapiro, F. (2006). Some effects of EMDR treatment with previously abused child molesters: Theoretical reviews and preliminary findings. Journal of Forensic Psychiatry and Psychology, 17, 538-562.
As predicted by the Adaptive Information Processing model the EMDR treatment of the molesters’ own childhood victimization resulted in a decrease in deviant arousal as measured by the plethysmograph, a decrease in sexual thoughts, and increased victim empathy. Effects maintained at one year follow up.
Robinson, J. S. & Larson, C. (2010). Are traumatic events necessary to elicit symptoms of posttraumatic stress? Psychological Trauma: Theory, Research, Practice, andPolicy, 2, 71-76.
Research data “indicated similar levels of posttrauma symptom severity for all three symptom clusters among people who had endorsed the experience of only a traumatic type event and people who had reported the experience of only stressful negative life events [e.g., loss of job, problems with school or work, or change in financial status]”
Russell, M. (2008). Treating traumatic amputation-related phantom limb pain: a case study utilizing eye movement desensitization and reprocessing (EMDR) within the armed services. Clinical Case Studies, 7, 136-153.
“Since September 2006, over 725 service-members from the global war on terrorism have survived combat-related traumatic amputations that often result in phantom limb pain (PLP) syndrome. . . . Four sessions of Eye Movement Desensitization and Reprocessing (EMDR) led to elimination of PLP, and a significant reduction in PTSD, depression, and phantom limb tingling sensations.”
Schneider, J., Hofmann, A., Rost, C., & Shapiro, F. (2008). EMDR in the treatment of chronic phantom limb pain. Pain Medicine, 9, 76-82.
As predicted by the Adaptive Information Processing model the EMDR treatment of the event involving the limb loss, and the stored memories of the pain sensations, resulted a decrease or elimination of the phantom limb pain which maintained at 1-year follow-up.
Schneider, J., Hofmann, A., Rost, C., & Shapiro, F. (2007). EMDR and phantom limb pain: Case study, theoretical implications, and treatment guidelines. Journal of EMDR Science and Practice, 1, 31-45.
Detailed presentation of case treated by EMDR that resulted in complete elimination of PTSD, depression and phantom limb pain with effects maintained at 18-month follow-up.
Shapiro, F. (2001).Eye movement desensitization and reprocessing: Basic principles, protocols and procedures (2nd 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 and an elucidation of the guiding Adaptive Information Processing model.
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.
Shapiro, F. (2006). EMDR and new notes on adaptive information processing: Case formulation principles, scripts and worksheets. Camden, CT: EMDR Humanitarian Assistance Programs (http://www.emdrhap.org)
Overview of Adaptive Information Processing model, including how the principles are reflected in the procedures, phases and clinical applications of EMDR. Comprehensive worksheets for client assessment, case formulation, and treatment as well as scripts for various procedures.
Shapiro, F. (2007). EMDR, adaptive information processing, and case conceptualization. Journal of EMDR Practice and Research, 1, 68-87.
Overview of EMDR treatment based upon an Adaptive Information Processing case conceptualization. Early life experiences are viewed as the basis of pathology and used as targets for processing. The three-pronged protocol includes processing of the past events that have set the foundation for the pathology, the current triggers, and templates for appropriate future functioning to address skill and developmental deficits.
Shapiro, F. (2012). EMDR therapy: An overview of current and future research. European Review of Applied Psychology, 62, 193-195.
“Research findings indicate that EMDR therapy and TF-CBT are based on different mechanisms of action in that EMDR therapy does not necessitate daily homework, sustained arousal or detailed descriptions of the event, and appears to take fewer sessions. EMDR is guided by the adaptive information processing model, which posits a wide range of adverse life experiences as the basis of pathology.”
Shapiro, F. (2014). The role of eye movement desensitization & reprocessing (EMDR) therapy in medicine: Addressing the psychological and physical symptoms stemming from adverse life experiences. The Permanente Journal, 18, 71-77.
An overview of the substantial body of research demonstrating that adverse life experiences contribute to both psychological and biomedical pathology, as well as the research demonstrating the clinical effects of EMDR therapy as guided by the Adaptive Information Processing model.
Shapiro, F., Kaslow, F., & Maxfield, L. (Eds.) (2007).Handbook of EMDR and Family Therapy Processes. Hoboken, NJ: Wiley.
Using an Adaptive Information Processing conceptualization a wide range of family problems and impasses can be addressed through the integration of EMDR and family therapy techniques. Family therapy models are also useful for identifying the targets in need of processing for those engaged in individual therapy.
Simhandl, C., Radua, J., König, B., & Amann, B. L. (2014). The prevalence and effect of life Events in 222 bipolar I and II patients: A prospective, naturalistic 4 year follow-up study. Journal of Affective Disorders.
“Our data suggest a high and continuous number of life events prior to affective episodes. Life events after the index episode worsened the course of bipolar I patients with more depressive episodes. This underlines the importance of detection and treatment of emerging life events.”
Solomon, R. M. & Shapiro, F, (2008). EMDR and the adaptive information processing model: Potential mechanisms of change. Journal of EMDR Practice and Research, 2, 315-325.
This article provides a brief overview of some of the major precepts of the Adaptive Information Processing model, a comparison and contrast to extinction-based information processing models and treatment and a discussion of a variety of mechanisms of action.
Teicher, M.H., Samson, J.A., Sheu, Y-S, Polcari, A. & McGreenery, C.E. (2010). Hurtful words: Association of exposure to peer verbal abuse with elevated psychiatric symptom scores and corpus callosum abnormalities. Am J Psychiatry, 167, 1464 – 1471.
“These findings parallel results of previous reports of psychopathology associated with childhood exposure to parental verbal abuse and support the hypothesis that exposure to peer verbal abuse is an aversive stimulus associated with greater symptom ratings and meaningful alterations in brain structure.”
Uribe, M. E. R., & Ramirez, E. O. L. (2006). The effect of EMDR therapy on the negative information processing on patients who suffer depression. Revista Electrónica de Motivación y Emoción (REME), 9, 23-24.
The study evaluated the impact of EMDR treatment on bias mechanisms in depressed subjects in regard to negative emotional valence evaluation. “The results indicated that it generated important cognitive emotional changes in such mechanisms.” Priming tests indicated changes in the negative valence evaluation of emotional information indicative of recovery with decreased reaction times in the neutral and positive stimuli processing.”
van den Berg, D.P.G. & van den Gaag, M. (2012). Treating trauma in psychosis with EMDR: A pilot study. Journal of Behavior Therapy & Experimental Psychiatry, 43, 664-671.
“This pilot study shows that a short EMDR therapy is effective and safe in the treatment of PTSD in subjects with a psychotic disorder. Treatment of PTSD has a positive effect on auditory verbal hallucinations, delusions, anxiety symptoms, depression symptoms, and self-esteem.”
Varese, F., Smeets, F., Drukker, M., Lieverse, R., Lataster, T., Viechtbauer, W., et al. (2012). Childhood adversities increase the risk of psychosis: a meta-analysis of patient-control, prospective-and cross-sectional cohort studies. Schizophrenia Bulletin, 38(4), 661-671.
“These findings indicate that childhood adversity is strongly associated with increased risk for psychosis.”
Wesselmann, D. & Potter, A. E. (2009). Change in adult attachment status following treatment with EMDR: Three case studies. Journal of EMDR Practice and Research, 3, 178-191.
Subsequent to EMDR treatment “all three patients made positive changes in attachment status as measured by the [Adult Attachment Inventory], and all three reported positive changes in emotions and relationships.”
Wilensky, M. (2006). Eye movement desensitization and reprocessing (EMDR) as a treatment for phantom limb pain. Journal of Brief Therapy, 5, 31-44.
“Five consecutive cases of phantom limb pain were treated with EMDR. Four of the five clients completed the prescribed treatment and reported that pain was completely eliminated, or reduced to a negligible level. . . The standard EMDR treatment protocol was used to target the accident that caused the amputation, and other related events.”
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. 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 only one procedural element, this element has come under greatest scrutiny. Randomized controlled studies evaluating mechanism of action of the eye movement component follow this section.
De Jongh, A., Ernst, R., Marques, L., & Hornsveld, H. (2013). The impact of eye movements and tones on disturbing memories of patients with PTSD and other mental disorders. Journal of Behavior Therapy andExperimental Psychiatry, 44, 447–483.
“The findings provide further evidence for the value of employing eye movements in EMDR treatments. The results also support the notion that EMDR is a suitable option for resolving disturbing memories underlying a broader range of mental health problems than PTSD alone”.
El Khoury-Malhame, M. et al. (2011). Attentional bias in post-traumatic stress disorder diminishes after symptom amelioration. Behaviour Research and Therapy 49, 796-801.
“Attentional bias toward aversive cues in PTSD has been hypothesized as being part of the dysfunction causing etiology and maintenance of PTSD. The aim of the present study was to investigate the cognitive strategy underlying attentional bias in PTSD and whether normal cognitive processing is restored after a treatment suppressing core PTSD symptoms.” An average of 4.1 EMDR sessions resulted in remission of PTSD. Post treatment “similarly to controls, EMDR treated patients who were symptom free had null e-Stroop and disengagement indices.”
Elofsson, U.O.E., von Scheele, B., Theorell, T., & Sondergaard, H.P. (2008). Physiological correlates of eye movement desensitization and reprocessing. Journal of Anxiety Disorders, 22, 622-634.
Changes in heart rate, skin conductance and LF/HF-ratio, finger temperature, breathing frequency, carbon dioxide and oxygen levels were documented during the eye movement condition. It was concluded the “eye movements during EMDR activate cholinergic and inhibit sympathetic systems. The reactivity has similarities with the pattern during REM sleep.”
Hornsveld, H. K., Landwehr, F., Stein, W., Stomp, M., Smeets, S., & van den Hout, M. A. (2010). Emotionality of loss-related memories is reduced after recall plus eye movements but not after recall plus music or recall only. Journal of EMDR Practice and Research, 4, 106-112.
“Recall-plus-music was added to investigate whether reductions in emotionality are associated with relaxation. . .Participants reported a greater decline in emotionality and concentration after eye movements in comparison to recall-only and recall-with-music. It is concluded that eye movements are effective when negative memories pertain to loss and grief.”
Kapoula Z, Yang Q, Bonnet A, Bourtoire P, & Sandretto J (2010). EMDR effects on pursuit eye movements. PLoS ONE 5(5): e10762. doi:10.1371/journal.pone.0010762
EMDR treatment of autobiographic worries causing moderate distress resulted in an “increase in the smoothness of pursuit [which] presumably reflects an improvement in the use of visual attention needed to follow the target accurately. Perhaps EMDR reduces distress thereby activating a cholinergic effect known to improve ocular pursuit.”
Kristjánsdóttir, K. & Lee, C. M. (2011). A comparison of visual versus auditory concurrent tasks on reducing the distress and vividness of aversive autobiographical memories. Journal of EMDR Practice and Research, 5, 34-41.
“Results showed that vividness and emotionality ratings of the memory decreased significantly after eye movement and counting, and that eye movement produced the greatest benefit. Furthermore, eye movement facilitated greater decrease in vividness irrespective of the modality of the memory. Although this is not consistent with the hypothesis from a working memory model of mode-specific effects, it is consistent with a central executive explanation.”
Lee, C.W., Taylor, G., & Drummond, P.D. (2006). The active ingredient in EMDR: Is it traditional exposure or dual focus of attention? Clinical Psychology and Psychotherapy, 13, 97-107.
This study tested whether the content of participants’ responses during EMDR is similar to that thought to be effective for traditional exposure treatments (reliving), or is more consistent with distancing which would be expected given Shapiro’s proposal of dual focus of attention. Greatest improvement on a measure of PTSD symptoms occurred when the participant processed the trauma in a more detached manner, which indicates the underlying mechanisms of EMDR and exposure therapy are different.
Leer, A., Engelhard, I. M., & van den Hout, M. A. (2014). How eye movements in EMDR work: changes in memory vividness and emotionality. Journal of behavior therapy and experimental psychiatry, 45, 396-401.
“[T]his study provides corroborating evidence that EM during recall causes reductions in memory vividness and emotionality at a delayed post-test and that the magnitude of these effects is related to intervention duration.”
Lilley, S.A., Andrade, J., Graham Turpin, G., Sabin-Farrell, R., & Holmes, E.A. (2009). Visuospatial working memory interference with recollections of trauma. British Journal of Clinical Psychology, 48, 309–321.
Tested patients awaiting PTSD treatment and demonstrated that the eye movement condition had a significant effect on vividness of trauma memory and emotionality compared to counting and exposure only. In addition, “the counting task had no effect on vividness compared to exposure only, suggesting that the eye-movement task had a specific effect rather than serving as a general distractor” (p. 317)
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).
Propper, R., Pierce, J.P., Geisler, M.W., Christman, S.D., & Bellorado, N. (2007). Effect of bilateral eye movements on frontal interhemispheric gamma EEG coherence: Implications for EMDR therapy. Journal of Nervous and Mental Disease, 195, 785-788.
“Specifically, the EM manipulation used in the present study, reported previously to facilitate episodic memory, resulted in decreased interhemispheric EEG coherence in anterior prefrontal cortex. Because the gamma band includes the 40 Hz wave that may indicate the active binding of information during the consolidation of long-term memory storage (e.g., Cahn and Polich, 2006), it is particularly notable that the changes in coherence we found are in this band. With regard to PTSD symptoms, it may be that by changing interhemispheric coherence in frontal areas, the EMs used in EMDR foster consolidation of traumatic memories, thereby decreasing the memory intrusions found in this disorder.”
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.
Rogers, S., Silver, S., Goss, J., Obenchain, J., Willis, A., & Whitney, R. (1999). A single session, controlled group study of flooding and eye movement desensitization and reprocessing in treating posttraumatic stress disorder among Vietnam war veterans: Preliminary data. Journal of Anxiety Disorders, 13, 119–130.
This study was designed as primarily a process report to compare EMDR and exposure therapy. A different recovery pattern was observed with the EMDR group demonstrating a more rapid decline in self-reported distress.
Sack, M., Hofmann, A., Wizelman, L., & Lempa, W. (2008). Psychophysiological changes during EMDR and treatment outcome. Journal of EMDR Practice and Research, 2, 239-246.
During-session changes in autonomic tone were investigated in 10 patients suffering from single-trauma PTSD. Results indicate that information processing during EMDR is followed by during-session decrease in psychophysiological activity, reduced subjective disturbance and reduced stress reactivity to traumatic memory.
Sack, M., Lempa, W. Steinmetz, A., Lamprecht, F. & Hofmann, A. (2008). Alterations in autonomic tone during trauma exposure using eye movement desensitization and reprocessing (EMDR) – results of a preliminary investigation. Journal of Anxiety Disorders, 22, 1264-1271.
The psycho-physiological correlates of EMDR were investigated during treatment sessions of trauma patients. The initiation of the eye movements sets resulted in immediate changes that indicated a pronounced de-arousal.
Servan-Schreiber, D., Schooler, J., Dew, M.A., Carter, C., & Bartone, P. (2006). EMDR for PTSD: A pilot blinded, randomized study of stimulation type. Psychotherapy and Psychosomatics. 75, 290-297.
Twenty-one patients with single-event PTSD (average IES: 49.5) received three consecutive sessions of EMDR with three different types of auditory and kinesthetic stimulation. All were clinically useful. However, alternating stimulation appeared to confer an additional benefit to the EMDR procedure.
Stickgold, R. (2002). EMDR: A putative neurobiological mechanism of action. Journal of Clinical Psychology, 58, 61-75.
Stickgold, R. (2008). Sleep-dependent memory processing and EMDR action. Journal of EMDR Practice and Research, 2, 289-299
Comprehensive explanations of mechanisms and the potential links to the processes that occur in REM sleep. Controlled studies have evaluated these theories (see next section; Christman et al., 2003; Kuiken et al. 2001-2002).
Suzuki, A., et al. (2004). Memory reconsolidation and extinction have distinct temporal and biochemical signatures. Journal of Neuroscience, 24, 4787– 4795.
The article explores the differences between memory reconsolidation and extinction. This new area of investigation is worthy of additional attention. Reconsolidation may prove to be the underlying mechanism of EMDR, as opposed to extinction caused by prolonged exposure therapies. “Memory reconsolidation after retrieval may be used to update or integrate new information into long-term memories . . . Brief exposure … seems to trigger a second wave of memory consolidation (reconsolidation), whereas prolonged exposure . . leads to the formation of a new memory that competes with the original memory (extinction).”
van den Hout, M., Engelhard. I.M. Marleen M., Rijkeboer, M.M., Koekebakker, J., Hornsveld, H., Leer, A.,et al. (2012). EMDR: Tones inferior to eye movements in the EMDR treatment of PTSD. Behaviour Research and Therapy, 50, 275-79.
“EMs outperformed tones while it remained unclear if tones add to recall only. . . EMs were superior to tones in reducing the emotionality and vividness of trauma memories. [I]n contrast to EMs, tones hardly tax working memory and induce a smaller reduction in emotionality and vividness of aversive memories. Interestingly, patients’ preferences did not follow this pattern: the perceived effectiveness was higher for tones than for EMs. . . . Clearly, the superior effects of EMs on emotionality and vividness of trauma memories were not due to demand characteristics.”
Wilson, D., Silver, S. M., Covi, W., & Foster, S. (1996). Eye movement desensitization and reprocessing: Effectiveness and autonomic correlates. Journal of Behaviour Therapy and Experimental Psychiatry, 27, 219–229.
Study involving biofeedback equipment has supported the hypothesis that the parasympathetic system is activated by finding that eye movements appeared to cause a compelled relaxation response. More rigorous research with trauma populations is needed.
Randomized Studies of Hypotheses Regarding Eye Movements
Numerous memory researchers have evaluated the eye movements used in EMDR therapy. A recent meta-analysis of the eye movement research has reported positive effects (Lee & Cuijpers, 2013) in both clinical and laboratory trials (see above). It is hypothesized that a number of mechanisms interact synergistically. The following studies have tested specific hypotheses regarding mechanism of action and found a direct effect on emotional arousal, imagery vividness, attentional flexibility, retrieval, distancing 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.