Posted by Toby on July 27, 1999, at 13:02:01
In reply to Re: EMDR and sleep, posted by Elizabeth on July 22, 1999, at 23:18:27
> Perhaps I did not make myself clear. I do not need to see *all* the studies of EMDR; I can do a Medline search if I want that. I wanted a pointer to perhaps three of them that you consider to be among the better-designed and -executed.
There are actually 13 controlled trials using EMDR for PTSD, whereas there are only 6 other controlled trials using other forms of therapy (excluding medications) in all the literature. The three best would probably be these: 1) Freund, Ironson and Williams (1998) which compared EMDR and prolonged imaginal exposure therapy. Both showed positive effects. The drop-out rate was less in the EMDR group. Further, EMDR proved more efficient: 7 out of 9 clients were successfull treated in the 3 active sessions of EMDR versus 2 out of 7 for prolonged exposure. 2) Vaughan, Armstron, et al (1994) which studies 36 subjects with PTSD randomly assigned to treatments of imaginal exposure, applied muscle relaxation, or EMDR. Treatment consisted of four sessions, with 60 and 40 minutes of additional daily homework over a 2 to 3 week period for the image exposure and muscle relaxation groups, respectively, and no additional homework for the EMDR group. All treatments led to significant decreases in PTSD symptoms for subjects in the treatment groups as compared to those on a waiting list, with a greater reduction in the EMDR group, particularly with respect to intrusive symptoms. 3) Rothbaum (1997) which studied single trauma rape victims and found that after three EMDR treatment sessions, 90 percent no longer met full criteria for PTSD.
> One criticism I've heard and read is that EMDR is just exposure therapy ("DR") wearing a funny hat; i.e., that they eye movements don't have any specific effect. This is based on dismantling studies that compared cognitive-behavior therapies with EMDR; at best, EMDR equalled the other therapy.The Meta-analysis study published by van Etten and Taylor (1997) showed that EMDR is equally effective to behavior therapy, although EMDR takes significantly less time to achieve results. For example, controlled studies of exposure therapies with single trauma victims take 25-50 hours of combined treatment and expusre (Foa et al, 1991; Richards, Lovell and Marks, 1994), while EMDR takes three ninety minute sessions to eliminate 84-100 percent of the diagnoses (Marcus, Marquis and Sakai, 1997; Scheck, Schaeffer and Gillette, 1997; Wilson, Becker and Tinker, 1995). The unfortunate aspect of the meta-analysis is that it included EMDR studies conducted by researcher who had not been trained or who reported negative fidelity checks (how well the researcher performed the method), along with the studies by competent researchers. Even with this drawback, however, EMDR was termed equally efficacious.
> I'd like to know, as well, how one decides by reading a study whether or not EMDR was "done right" in that study - other than that the researchers studied EMDR without the aid of Dr. Shapiro and colleagues? That is, what leads you to the conclusion that they did it wrong?Indeed, EMDR is not just "hand waving," it is a series of 8 steps, an entire protocol that is addressed to the PTSD and now there are even specific protocols for specific problems such as substance abuse, phobias, OCD and eating disorders. These more complicated disorders require more complex treatment protocols. It is NOT just the eye movements, but it does seem that the eye movements are what speeds up the effects. I say this because the specific protocols I mentioned incorporate (usually) several different techniques borrowed from CBT, Neuro Linguistic Therapy, psychoanalysis, supportive therapy, dialectical behavioral therpy, educational therapy, etc. And those therpies do work, obviously, but adding the eye movements makes it go faster. But back to your question: The researchers that I disparage for "doing it wrong" were not trained in EMDR, they didn't follow a protocol, we don't know how long they "waved their hand" or if they talked to the patient during the sessions or exactly what all they did do. So, basically, they weren't doing EMDR anymore than Dear Abby is doing therapy.
> It's an interesting hypothesis you offer about an association between EMDR and REM sleep. Perhaps I will ask one of my teachers about this (they run a sleep lab at Mass. Mental Health Center and have done quite a bit of research on sleep). To tell you the truth, though, it sounds like hand waving. My understanding of current thought on the subject is that rapid eye movements are not what drives REM/desynchronized sleep, but rather are a byproduct of it, so that forcing eye movements that mimick those of REM sleep will not induce a state of "waking REM." Have there ever been any polysomnographic studies of EMDR? If what you are claiming were true, then such studies would show some rather extraordinary things that would not be found with ordinary desensitization therapy.Am not aware of any PSG studies published, though I don't know if any are being done now. I am aware that some studies are being conducted using PET and SPECT to study brain changes before and after EMDR and I think also in a controlled study comparing exposure to EMDR using PET scans. It may not be feasible to study EMDR using PSG due to movement artifact, but not sure.
> As for dreaming and associative memory, two of the main things that are hypothesized (and not without good reason) to occur during REM sleep are (1) episodic memories are incorporated into a "network" of associative memories; and (2) forgetting (taking out the garbage, as it were) takes place. Regardless of self-image, the predominant emotions in REM sleep dreams are anxious ones, with little depressive or shameful feeling.Exactly how it is hypothesized that EMDR works.
> Posttraumatic dreams, incidentally, are not like normal REM sleep dreams, perhaps because of a (dare I say it?) chemical imbalance, namely in the interaction between norepinephrine and acetylcholine. As a result, you get nonbizarre dreams that replay the memory verbatim rather than incorporating it with other memories in unpredicted ways.
But is it a chemical imbalance that causes the nightmares or the vulnerability to PTSD or is it the degree of trauma that inhibits resolution fo the event and then leads to the chemical imbalance? One small correction is that PTSD memories are not consistently verbatim forever and ever but do tend to incorporate other events into them and also insinuate themselves into other types of dreams.
> It should be noted that NREM/synchronized sleep is also apparently required for learning to take place.No argument here.
> I think perhaps the problem people have with EMDR not having a theoretical basis is that they are not convinced that it works, practically speaking, either. CBT is pretty much common sense, while psychoanalytic psychotherapy is subject to many of the same criticisms as EMDR is.
I think the problem people have with not believing the EMDR works on a practical level is that they haven't seen any patients who have had EMDR. And I don't think seeing just one patient is such a mind-changer because after all, that could just be a fluke of nature, or an easily suggestible person. But see several people and you begin to say, hmmmmmmm. Then experience it on yourself and you say, whoa, I'm not that suggestible, I'm a skeptic of this whole process, I'm actively resisting this, where did THIS come from? Then you compare your response rate of the patients with PTSD going out the door smiling and sleeping for the first time in months or years with the patients you work with for months on relaxation therapy and CBT and exposure therapy who feel better and don't worry so much but in whom a relapse and flashbacks can still be triggered with the right stimulus and you say, OK, I don't know exactly how it works, but I don't know how relaxation or CBT or hypnosis or exposure works either, but the EMDR patients are better faster, to a greater degree and with longer lasting and more generalized results. Which treatment am I going to use? Hmmmmmmm.
> I doubt it bothers people that EMDR is being claimed useful for non-trauma-related disorders in particular; rather, it's that it's being claimed useful for disorders that don't respond to "DR," though EMDR has not been proven to be any more effective than "DR."I don't know which disorders those might be that don't respond to "DR" but that EMDR is claiming efficacy for.
poster:Toby
thread:8171
URL: http://www.dr-bob.org/babble/19990829/msgs/9271.html