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 By
Robert Evans
(WebMD/Healtheon)
-- Every night, insomnia and nightmares; every
day, panic, anxiety, depression. These were the
ruins of childhood and adolescence for Donna Bowers
of Placentia, California, who was abused for 19
years by a close relative. Ten years of psychotherapy
did little to ease her symptoms, the classic signs
of post-traumatic stress disorder (PTSD).
"My therapist admitted we had hit a wall
and couldn't move past it," says Bowers,
44. "He referred me to a doctor who had just
started using a new therapy called Eye Movement
Desensitization and Reprocessing (EMDR). Within
the first six sessions of EMDR, all of my symptoms
left and haven't returned in eight years."
Though skeptics still criticize this unusual treatment,
in which therapists wave their fingers in front
of their patients' eyes, EMDR is gaining acceptance
in the psychotherapy community. The approach was
first developed by psychologist Francine Shapiro,
Ph.D., of the Mental Research Institute in Palo
Alto, California.
While walking in a park in 1987, Shapiro noticed
that when her eyes moved in a "rapid, ballistic,
flicking" motion, unhappy thoughts became
less disturbing to her. She soon began experimenting
with ways of producing the same effect in trauma
victims.
PTSD occurs after frightening experiences such
as combat, rape, physical assault, natural disasters
or automobile accidents. The principal method
of treatment until now has been cognitive behavior
therapy, which involves gradual exposure to circumstances
reminiscent of the trauma, slowly reducing the
fears in the patient. This approach usually takes
months or even years to relieve symptoms.
Psychotherapy is not the only treatment for PTSD.
In December, the U.S. Food and Drug Administration
gave its first approval to a medication for the
disorder. But this antidepressant, Zoloft (sertraline
hydrochloride), works only as long as patients
take it, and it suppresses only the symptoms of
the illness rather than addressing their cause.
Eye movements
Treatment with EMDR involves elements of several
therapeutic methods, including behavioral, cognitive,
and even Freudian ideas, but in addition, the
EMDR therapist induces rapid eye movements in
the patient by asking him to follow the movements
of a finger waved in front of his face. At the
same time, the patient is encouraged to think
and talk about the original stressful event. According
to Shapiro, after three 90-minute sessions, at
least 84 percent of trauma victims improve so
much that their symptoms no longer fit the definition
of PTSD.
The effect of EMDR is so rapid and dramatic that
when he first read about it in a professional
journal 10 years ago, Steven Silver, Ph.D., a
U.S. Department of Veterans Affairs PTSD specialist,
was skeptical. "I remember calling up the
editor," he says, "and telling him that
we were the victim of some kind of hoax."
Silver now uses EMDR in his practice.
It's unclear how the treatment might work. Some
experts have speculated that the eye movements
restore activity in a part of the brain that was
shut down as a result of the trauma. Others believe
that EMDR is simply behavior therapy dressed up
as something novel. They point out that similar
results have been produced by using finger and
hand taps, or repeated auditory tones, instead
of finger movements.
"What is new is not effective," says
James Herbert, Ph.D., associate professor of psychology
at M.C.P. Hahnemann University in Philadelphia,
"and what is effective is not new."
But recent research has begun to convince such
mainstream organizations as the American Psychological
Association and the International Society of Traumatic
Stress Studies, both of which approved EMDR in
1999. One of the most impressive studies was published
in the Journal of Traumatic Stress in 1998. Sixty
traumatized young women in Colorado Springs, Colorado,
were randomly assigned to either EMDR or "active
listening" therapy. After only two sessions,
the EMDR patients had markedly fewer symptoms
of PTSD than the active-listening group.
For Donna Bowers, herself a psychotherapist, EMDR
is nothing short of a miracle. "It opened
up the entire world for me without the panic and
fear that I'd had for 16 years," she says.
"It gave me back my life."
SPECULATIONS ON HOW EMDR MIGHT WORK TO ALLEVIATE
PAIN
Mark Grant M.A.
Introduction:
EMDR (Eye Movement Desensitization & Reprocessing)
EMDR is a new psychological therapy that utilizes
a combination of focused attention and bilateral
eye movements to help "reprocess" traumatic
memories and/or unpleasant thoughts and feelings.
EMDR often facilitates profound change in the
affect, including physical sensations that accompany
distressing situations or memories. Despite having
more research than any other trauma treatment,
the efficacy of EMDR continues to be debated.
There is also a debate as to whether EMDR represents
something new, or is just a clever re-packaging
of existing techniques. (Devilly, 1996) For the
purposes of this paper, EMDR is treated as a single
distinct approach, incorporating different elements
from existing methods, with the addition of innovative
elements.
Although EMDR began as a treatment of trauma,
clinicians soon it found it effective in the treatment
of other problems including addictions, anxiety,
and pain. Despite a number of case studies and
conference presentations, there have only been
two studies into the efficacy of EMDR as a treatment
for pain, (Hekmat Groth & Rodgers, 1994, Wilson
Tinker & Becker, 1997 - unpublished pilot
study). It seems that the pattern of use of EMDR
with pain will follow that of trauma with research
support lagging far behind clinical application.
Meanwhile, clinicians have to justify what they
are doing and why. Often the fact that what they're
doing seems to work is not enough. In this early
stage of research and development, this paper
aims to provide support, for clinicians who are
using EMDR in the treatment of pain by drawing
together what is known about how psychological
treatments work, and recent neurobiological discoveries.
It is also hoped to stimulate that most important
of scientific attributes, curiosity and highlight
directions for research.
The mechanisms by which EMDR might work are the
subject of much debate and research. Dr Francine
Shapiro, the originator of EMDR, has stated that
perhaps EMDR is harnessing some kind of innate
information processing ability, similar to what
is might operate during REM sleep. What this information
processing capacity is and how it works are only
dimly understood. Other theorists have suggested
that EMDR is just a very effective way to unblock
energy locked in our body. All we can say, maybe,
is that EMDR seems to be activating unconscious
capabilities for transducing information in the
form of thoughts and feelings.
There is no general agreement as to what constitutes
this information processing mechanism. However,
recent research into the neurobiology of emotions
and trauma has made possible some understanding
of how emotions and thoughts are 'processed' by
the brain and body. (Le Doux, 1996. Van der Kolk,
1996). These discoveries have been summarized
in the popular best seller 'Emotional Intelligence'
(Daniel Goleman, 1996). One interesting finding
is that the brains of people who have suffered
trauma are different from those of none-traumatized
persons. (Le Doux etc, ibid).
Consequently, there is curiosity about whether
psychotherapy might reverse or alleviate these
abnormalities, (Goleman, 1995) including EMDR.
(Bergmann, 1996) and also how. EMDR seems to be
effective in reducing the emotional component
of some problems, (Shapiro, 1989, 1995, Wilson
Tinker & Becker, 1995). Chronic pain is a
problem with a significant affective component
so it should be amenable to this form of treatment.
To try and talk about how EMDR might alleviate
pain however is a formidable task indeed. Pain
is a very complex problem, medicated by a huge
array of variables. While there is research support
for the efficacy of traditional approaches such
as relaxation, even hypnosis, there are only hypotheses
as to how these interventions might actually mediate
the pain response. Most of these hypotheses are
really couched in terms of psychological processes,
eg; relaxation response, and don't include investigation
of neurological phenomena. It must be said that
at this stage, no psychotherapy or method could
survive the burden of proof that an understanding
of its biological underpinnings would demand.
EMDR, because of its unusual characteristics,
the speed at which change occurs etc, demands
a thorough explanation. Thus this discussion will
focus on both psychological and neurological processes,
but with an emphasis on the latter. Increasing
knowledge about neurological correlates of emotions,
trauma and even pain make it possible to attempt
to explain psychotherapy in terms of both mental
and neurobiological processes. For example, Goleman
recently described psychotherapy as a kind of
"emotional tutorial" wherin the successful
patient is one who has learned to control their
"overactive amygdala." (1996, p213).
The inclusion of knowledge about neurobiology
into our explanations of psychological processes
makes for a more substantive and verifiable explanation.
Psychological Processes:
As I have already stated, understanding how psychological
interventions affect pain is difficult. Some of
the variables which are known to influence the
outcome of pain interventions include different
measurement criteria, different types of pain,
the personality of the pain sufferer, the gender
of the pain sufferer etc. Nevertheless, based
on what is known about how other psychological
approaches alleviate pain, we can make a number
of relatively general suppositions about how EMDR
might help alleviate pain. The effects EMDR might
have on pain can be described in terms of the
traditional psychological processes and outcomes;
relaxation, distraction, stimulation of release
of natural opioids, and even placebo effects.
For example, distraction is a well-documented
pain-management strategy. (Clum et al, 1982, Scott
& Barber, 1977). The bilateral stimulation
used in EMDR might simply work as a kind of distraction,
providing relief by taking the sufferers attention
away from the pain.
EMDR probably also works by stimulating a relaxation
response. Hedstrom (1991) found that bilateral
stimulation can stimulate relaxation. The bilateral
stimulation might also work to by stimulating
the release of endorphins. Many psychological
pain-management techniques are thought to work
this way, including hypnosis and placebo effects.
Goleman (1985) has written of the "pain-numbing"
response when endorphins are released enabling
us to ignore pain when our survival depends on
it.
Placebo undoubtedly accounts for some treatment
effect in any psychological intervention. Estimates
of the size of placebo effect range between a
low of 12% and a high of 35% of treatment effect.
(Simmonds & Kumar, 1994, Gaupp Flinn &
Weddige, 1989)
All these hypotheses are attempts to explain how
EMDR might alleviate pain in terms of traditional
psychological processes, and hypotheses. We are
using accepted hypothetical constructs and terms
to 'explain' a noticeable effect, with only a
limited understanding of how that effect is produced
in the body.
Neurobiological processes:
Most of the research about EMDR has been in its
applications to trauma and the reduction of associated
distressing thoughts and feelings. Most of the
research about the neurological correlates of
psychological problems has been with trauma. Thus,
any discussion of how EMDR might work to "reprocess"
pain must begin with identifiable neurological
parallels between pain and trauma, and the scant
information that exists about how EMDR might influence
neurological processes.
Much of what is known about the emotional brain
comes from studies of trauma, although knowledge
about the effects of chronic pain on the brain
is increasing. Some of the significant parts of
the Central Nervous System (CNS) that are involved
in the experience of both pain and trauma are;
the Prefrontal Cortex, the Amygdala and the Cingulate
system.
The amygdala regulates the emotional state of
the brain. We know from trauma research that the
amygdala mediates the fear response. The amygdala
has also been implicated in the production of
natural opioids. (Manning & Mayer 1995)
The Cingulate gyrus is the part of your brain
that allows you to shift your attention from one
thing to another, from one idea to another. Most
pain sufferers probably employ their Cingulate
system, in conjunction with their pre-frontal
cortex, when they use distraction to take their
mind off the pain. Problems in the Cingulate system
can lead to getting 'stuck' on certain thoughts
or behaviors, aggressiveness, compulsivity, which
is seen in chronic pain sufferers and trauma victims.
The functions of the Prefrontal cortex include
modulating concentration and attention and the
ability to feel and express emotions.
The Central Nervous System is not 'hard-wired'
but kept in a stable state by elaborate control
mechanisms. If these control mechanisms become
unstable, as a result of say prolonged stress,
symptoms such as found in trauma and chronic pain
can result. For example, Chronic pain is known
to lead to over-sensitivity in spinal cord and
Central Nervous System, ('Central Sensitization'Devor,
1996) and drug therapy is aimed at "turning
down the volume" on that sensitization. Chronic
Pain Sufferers also experience high levels of
stress. Stress is known to lower Seratonin and
low Serotonin is known to increase sensitivity
to pain. Seratonin is an "anti-stress"
chemical that inhibits transmission of nociception.
In both trauma and chronic pain there is increased
activity in the right hemisphere. This is the
hemisphere involved in expression and comprehension
of global non-verbal emotional material. The activity
of the anterior cingulate and the frontal cortex
is altered during both pain and trauma.
In both trauma and chronic pain there is usually
disruption to REM sleep. In trauma at least, this
is known to be as a result of too much norepeniphrine.
(Henry, 1994 ) NB: REM sleep is known to be necessary
for information processing.
Trauma victims, who were treated with EMDR and
later given a SPECT brain scan, showed reduction
in some of the neurological abnormalities associated
with their condition. Specifically, the anterior
cortex of the cingulate gyrus was activated, and
the left hemisphere (Broca's area) became reactivated.
Nicosia (1994) found that examination of EMDR
clients by electroencephalography (QEEG) revealed
a normalization in the slower brain wave activity
of the two cortical hemispheres.
Summary & Discussion:
An increasing number of clinicians are employing
EMDR in the treatment of chronic pain. There is
little research evidence to support EMDR as a
treatment for chronic pain, but what research
does exist is favourable. The parallels between
the processes of EMDR and other psychological
methods, which even EMDR's detractors acknowledge,
also lend support to its clinical application
in this way.
Some processes by which EMDR might alleviate pain
were identified. These are the same processes
thought to be responsible for effects observed
following traditional psychological pain-management
interventions. Eg; relaxation, distraction, placebo
effects, stimulation of natural endorphins etc.
Parallels between neurological changes associated
with pain and trauma were also identified. These
were noted as lateralization effects, raised seratonin
levels, alterations in activity level of the anterior
cingulate and the frontal cortex, disruption of
REM sleep. We speculated about how EMDR might
effect the neurological processes underlying the
experience of pain.
Neurological changes following EMDR treatment
of trauma, include a resynchronizing of the two
hemispheres. It has been suggested that the bilateral
stimulation resynchronises the activity of the
two hemispheres, perhaps because the repetitive
alternating stimuli mimics the activity of the
pacemaker mechanism. (Nicosia, ibid). If this
is so, it means that at least the emotional component
of trauma and probably pain too, can be 'reprocessed'
with EMDR. This alone can lead to a significant
reduction in suffering.
Speculating about the effects of EMDR on trauma,
Bergmann has suggested that EMDR dampens down
an overactive amygdala, allowing greater neocortical
activity concerning the presenting problem, leading
to greater integration of thoughts and feelings.
In addition to its role in mediating the fear
response, the amygdala has been implicated in
the production of natural opiates. (Manning &
Meyer, ibid). A hypothesis that would be worth
investigating is the possibility that EMDR stimulates
the amygdala to produce natural opiates.
The parallels between neurobiological abnormalities
associated with pain and trauma, and the changes
observed following EMDR treatment of trauma, invite
speculation regarding the mechanisms by which
EMDR might facilitate correction of the neurological
processes associated with pain. There is enough
tantalizing evidence to suggest that similar processes
may be at work in both cases. Some of the neurological
changes that occur following EMDR treatment of
trauma involve the same neurological processes
that are involved in the experience of pain. (eg;
lateralization effects, changes in the cingulate
gyrus, changes in brain wave activity.) We can
hypothesize that these changes are triggered in
part by bilateral stimulation, leading to neurologicaal
effects responsible for alterations in the way
pain is experienced.
Clinical use of EMDR in this area seems justified,
but widespread acceptance of this application
of EMDR obviously awaits the results of more research.
Specifically, research is needed into the mechanisms
by which EMDR can effect pain, as well as charting
associated neurobiological changes.
References:
Bergmann, Uri (1996) Speculations on the Neurobiology
of EMDR. Unpublished monograph.
Clum, GA, Luscomb RL & Scott L Relaxation
Training and cognitive redirection strategies
in the treatment of acute pain. Pain, 12, 175-183,
1982.
Devilly, G EMDR and PTSD: The Score at half time.
Psychotherapy in Australia, Vol 3. No 1. Nov 1996.
Gaupp, LA, Flinn, DE & Weddige RL Adjunctive
Treatment Techniques in: Handbook of Chronic Pain
Management Ed; Tollison, David. Williams &
Wilkins, 1989.
Goleman, Daniel (1985) Vital Truths, Simple Lies,
the psychology of self-deception. Bloomsbury,
UK.
Goleman, Daniel (1995) Emotional Intelligence.
Bloomsbury, UK
Hedstrom, James (1991) A Note on Eye Movements
and relaxation, Journal of behavior Therapy &
Experimental Psychiatry. 1, pp37-38
Hekmat Groth & Rodgers, (1994) Pain Ameliorating
Effect of Eye Movement Desensitization & Reprocessing.
Jnl of behavior Therapy & Experimental Psychology
p 121 - 129. Hekmat Groth & Rodgers, (1994)
Henry, S (1994) How Does EMDR Work Anyway? EMDR
Network Newsletter Issue 1, p 4-5.
Jensen T (1996) Mechanisms of Neuropathic Pain
in: 'Pain - an Updated Review'. IASP, 8th World
Congress on Pain.
Le Doux, Joseph (1996): The Emotional Brain. Simon
& Schuster, NY .
Manning, Barton H & Mayer, DJ (1995) The central
nucleus of the amygdala contributes to the production
of morphine antinociception in the formalin test.
Pain, 63 p 141-152
Nicosia, G (1994) A Mechanism for dissociation
suggested by the qualitative analysis of electroencephalography.
Paper presented at the EMDR Annual Conference,
Sunnydale, Calif
Scott DS & Barber TX (1977) Cognitive control
of pain: effects of multiple cognitive strategies,
Psychol Rec 2. P 373-383.
Shapiro, Francine (1989) Eye movement desensitization:
a new treatment for post-traumatic Stress Disorder.
Journal of Behavior Therapy and Experimental Psychiatry,
20. 211-217
Shapiro, Francine (1995) Eye Movement Desensitization
& Reprocessing New York, Guilford
Simmonds MJ & Kumar, S (1994) Pain & the
Placebo in rehabilitation using TENS and Laser.
Disability & Rehabilitation. 16; 1. P13-20
Van Der Kolk, Bessell (1996) Traumatic Stress,
the effects of overwhelming experience on mind
body and society. Guilford Press, NY.
Wilson, S Tinker, R & Becker L (1995) Eye
Movement Desensitization & Reprocessing (EMDR)
Treatment for Psychologically Traumatized Individuals.
Journal of Consulting and Clinical Psychology,
Vol 63. No 6. 928-937
Appendix A - Clinical Cautions:
There are certain conditions that must prevail
for EMDR to be effective. The pain must not be
so severe that the patient cannot concentrate.
In the initial stages, the patient must be able
to focus on both the pain and the EMDR stimulation
simultaneously. It must be stressed that once
the patient notices their pain, and attends to
the bilateral stimulation, that's all they really
have to do. Not everybody can do this easily.
A full assessment is necessary prior to attempting
to use this method with chronic pain. In addition
to the usual contraindications (severe dissociative
disorders etc) this method is not indicated where
there is significant medical mismanagement (up
to 50% of cases according to some estimates) and/or
unresolved 'secondary gain' issues.
Finally, sometimes, pain persists, the therapist
can do their best to remove blockages and stimulate
processing, but EMDR cannot remove what is ecological.
Pain can be 'necessary' for many reasons. It needs
to be remembered chronic pain often comes with
peripheral nociception, as well as neural phenomenon.
The longer pain has continued, the greater the
changes to the nervous system. Other forms of
management may need to be considered in addition
to psychological treatments such as EMDR.
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