1. Methods
1.1. PubMed Clinical Queries: Key terms ((EMDR Therapy) OR (Trauma focused CBT) AND PTSD))
1.1.1. Clinical study categories (261 results)
1.1.2. Systematic Reviews (42 results)
1.1.3. Inclusion criteria
1.1.3.1. Full text , publication dates from 2005-2019, human species, English language
1.1.4. Exclusion criteria
1.1.4.1. Treated with pharmacokinetics and methods other than EMDR or CBT
2. Evidence Synthesis
2.1. Khan et al.’s SR/M-A of RCTs
2.1.1. MA of 11 studies showed EMDR >CBT/pharmacotherapy with fluoxetine in reducing PTSD and anxiety sx but no difference for reducing depression. Studies had high level of heterogeneity.
2.2. Chen et al.’s SR/M-A of RCTs
2.2.1. EMDR more effective than CBT to reduce PTSD, depression, anxiety symptoms with associated complex childhood trauma
2.2.1.1. EMDR dropout rates were below 10% whereas trauma-focused CBT dropout rates was 41%
2.2.1.1.1. High level of heterogeneity
2.3. Moreno-Alcázar et al.’s SR/M-A or RCTs
2.3.1. EMDR was more effective than placebo and as effective as TFCBT in reducing PTSD/Anxiety. There was no difference in depression symptom improvement.
2.3.1.1. Non-significant heterogeneity
2.4. Bisson et. al.’s SR/MA of most RCTs
2.4.1. The effectiveness of EMDR was generally supported by the M/A, but the evidence base was not as strong as that for TFCBT, both in terms of the number of trials available and the certainty with which clinical benefit was established.
2.4.2. Limited evidence that TFCBT and EMDR were superior to supportive/non-directive treatments, hence it is highly unlikely that their effectiveness is due to non-specific factors such as attention.
2.4.3. Direct comparisons of these two approaches did not reveal any significant advantages of one over the other, with respect to either treatment outcome or speed of therapeutic change (Taylor et al, 2003).
2.4.4. High level of heterogeneity between studies
2.4.5. No direct comparison btwn EMDR and TFCBT, also compared other types of therapy types.
2.4.6. Recent M/A has suggested that pharmacological interventions are unlikely to be as clinically effective as trauma-focused psychological interventions and should therefore be used as a second-line treatment (National Collaborating Centre for Mental Health, 2005).
2.4.7. Results suggest that trauma-focused psychological treatments (TFCBT or EMDR) are effective for chronic PTSD. Indeed, the effect sizes compare favourably with those found for cognitive–behavioural therapy in depressive and anxiety disorders (National Collaborating Centre for Mental Health, 2004; National Collaborating Centre for Primary Care, 2004).
2.5. Bronner et. al.’s case report
2.5.1. Case report
2.5.1.1. Sophie is a 16 year old girl who developed flashbacks, distressing memories, anxiety and severe sleeping probs at a PICU after getting a spinal cord injury secondary to diving accident during fam vacation abroad.
2.5.1.1.1. A psychologist at PICU started with four sessions of TF-CBT including stress management techniques, relaxation, psycho-education and cognitive restructuring. After these sessions Sophie’s worries and appraisals about the injury changed and she felt more secure at the PICU. However, she remained anxious, kept flashbacks and sleeping problems. This was considered as an indication for EMDR.
2.5.1.1.2. Measured progress with SUDS, CRIES score
2.5.1.1.3. Received TF-CBT initially, cannot rule out possibility CBT had contributed to efficacy of EMDR
2.6. Devilly and Spence’s Nonrandomized CT
2.6.1. Compared EMDR and a CBT variant (Trauma Treatment Protocol; TTP) in the treatment of PTSD, via a controlled clinical study using therapists trained in both procedures.
2.6.1.1. Participants
2.6.1.1.1. Measurements: STAI-Anxiety, BDI-depression, SCL-90-R-psychiatric sx , SUD-distress degree, CMS-nonverteran measure of PTSD, IES- avoidance and intrusion sx.
2.6.1.1.2. Results indicated the TTP approach to be both statistically and clinically more effective than the EMDR approach, both in the short and long term, on indices measuring PTSD symptomatology.
2.6.1.1.3. Analyses of the associated measures (depression, anxiety, global distress, and subjective ratings of personal problems and anxiety), from pre- to post- treatment, also displayed a superiority for TTP, although the effect size for the interaction of condition by time was not as large as for the PTSD measures.
2.6.1.1.4. Distress of EMDR and TTP therapy.
2.7. Santarnecchi et al.’s nonrandomized controlled trial
2.7.1. Monitored psychological and spontaneous functional connectivity fMRI patterns in two groups of PTSD patients who suffered by the same traumatic event (i.e., natural disaster), before and after a cycle of psychotherapy sessions based on TF- CBT and EMDR.
2.7.1.1. Thirty-seven (37) PTSD patients were enrolled from a larger sample of people exposed to a single, acute psychological stress (i.e., 2002 earthquake in San Giuliano di Puglia, Italy). Patients were randomly assigned to TF-CBT (n = 14) or EMDR (n = 17) psychotherapy.
2.7.1.1.1. All patients underwent a fMRI data acquisition session before and after treatment, aimed at characterizing their functional connectivity (FC) profile at rest, as well as potential connectivity changes associated with the clinical impact of psychotherapy.
2.7.1.2. Philips Intera whole-body MRI scanner
2.7.2. In 2002, a devastating earthquake caused, among other tragedies, the collapse of an elementary school (1st–5th grade) in San Giuliano di Puglia (Campobasso, Italy).
2.7.2.1. Patients were screened at the Department of Psychiatry
2.7.2.2. EMDR followed Shapiro's 2014 standard EMDR protocol
2.7.2.3. TF-CBT
2.7.2.4. Assessments: CAPS, DTS, WSAS Scores
2.7.2.4.1. CAPS
2.7.2.4.2. DTS
2.7.2.4.3. WSAS Scores
2.7.2.4.4. Conclusion: Even though no statistically significant differences in clinical improvement between EMDR/TF-CBT were observed (except for the WSAS), different therapy-specific rearrangements of FC could have supported the observed clinical improvement.
2.7.2.5. As a result, 27 children and a schoolteacher died.
2.7.2.5.1. For the present study, 31 PTSD patients were recruited among the population affected by the earthquake, including survivors of the building collapse and victim’s family members (parents, siblings).
2.7.3. Conclusions
2.7.3.1. EMDR patients with decreased FC between the precuneus and visual regions seem to display a greater benefit in terms of pre–post changes at CAPS [F(1,29) = 3.58, p < 0.023]. Interestingly, patients showing a benefit at CAPS (after both EMDR and TF-CBT) showed a stronger positive connectivity between theright inferior frontal gyrus (pars triangularis) and regions of the temporal lobe (for EMDR) and somatosensory cortex (for TF-CBT) [F(1,29) = 3.49, p < 0.019].
2.7.3.2. While both EMDR and TF- CBT exerted a beneficial effect on PTSD symptomatology, the two psychotherapeutic approaches displayed both common and dissociable effects on brain connectivity, with the overlap being represented by decreased connectivity between visual cortex andemporal lobe regions in the left hemisphere, and increased connectivity between bilateral superior frontal gyrus and right temporal pole regions.
2.7.3.3. No significant differences were observed in the impact of EMDR and TF-CBT on PTSD symptomatology, except for a significantly greater improvement in work and social impairment following TF-CBT intervention as compared to EMDR. This is in line with existing literature, showing no evidence of greater efficacy for a specific psychotherapeutic approach in the treatment of PTSD patients (Bradley et al., 2005), especially when therapies including elements of exposure such as TF-CBT and EMDR are compared
2.7.3.4. That being said, a difference in the effectiveness of the two interventions in terms of dose-response seems present, with EMDR and TF-CBT eliciting similar results at both the clinical and neuroimaging level even though EMDR included half the number of treatment sessions (4 weekly sessions ±2) compared to TF-CBT (10 weekly sessions ±2) and an overall shorter treatment period. The present data are not suitable for a proper analysis of dose-response effects across the two approaches, but results provide an interesting insight into this matter that should be considered in future studies.
2.7.3.5. The analysis of functional connectivity changes induced by EMDR and TF-CBT revealed both common and dissociable correlates for symptoms improvement recorded at the different various clinical scales. In general, both therapies seem to induce two main patterns of connectivity changes, pointing to a reduction of connectivity between regions of the visual cortex and of the left temporal pole, as well as an increase in connectivity between the superior frontal gyrus and right temporal pole. Interestingly, such changes characterize a decrease in CAPS scores in both patient groups, possibly due to the aforementioned methodological overlap between EMDR and TF-CBT for PTSD (Bradley et al., 2005).
2.7.3.6. In general, the changes in connectivity patterns highlight the involvement of the bilateral temporal pole. Changes in these structures have been extensively documented in PTSD patients (Shin, 2006; Cheng et al., 2015; Meng et al., 2016), including recent results about changes in hippocampal volume induced by EMDR treatment (Bossini et al., 2017).
2.8. Diehle et al.’s RCT
2.8.1. Partipants
2.8.1.1. Forty-eight children (8-18 yo) randomly assigned to 8 sessions of TF-CBT or EMDR.
2.8.1.1.1. TF-CBT
2.8.1.1.2. EMDR
2.8.1.1.3. Randomization was performed with an allocation ration 1:1 using block randomization stratified by age.
2.8.1.1.4. Conclusions
2.9. Jeffries and Davis’ SR
2.9.1. Advantage of EMDR over CBT
2.9.1.1. No need for the client to describe the trauma as the procedure involves the client holding it in mind rather than verbalizing their experience.
2.9.1.1.1. EMDR may therefore improve treatment compliance as this has been suggested as a possible cause of treatment drop-out (e.g. Kilpatrick and Best, 1984).
2.9.2. Conclusion
2.9.2.1. Choice of EMDR over trauma-focused CBT should therefore remain a matter of patient choice and clinician expertise; it is suggested, however, that some evidence suggests EMs may be more effective at reducing distress and thereby allow other components of treatment to take place.
2.10. Mello et al.’s SR/MA of RCTs
2.10.1. Participants: n=2713; Male=851 and female=1853; mean age 39.49 years
2.10.1.1. Conclusions
2.10.1.1.1. Results of studies comparing CBT with EMDR favored the latter, which indicates a need to investigate further the comparative benefits of this treatment for PTSD.
2.10.1.1.2. Past reviews found no differences between EMDR and trauma-focused CBT].
2.10.1.1.3. On the other hand, the meta-analysis by Watts et al. found stronger effect sizes in favor of CBT and its individual components.
2.10.1.1.4. We suggest that more follow-up trials with those treatments be conducted and reviewed in order to evaluate how outcomes compare between both strategies.
2.11. Roos et al.’s RCT
2.11.1. Participants: Children age 4-18 yo, randomly allocated to CBT n=26 and EMDR n=26
2.11.1.1. A large fireworks factory exploded in Enschede, the Netherlands on May 13, 2000 killing 22 people, injuring many, destroying more than 500 houses, and damaging 1,500 more. In total about 10,000 people were affected, of which the number of children and adolescents is un- known.
2.11.1.1.1. Children received up to 4 individual tx sessions over 48 week period
2.11.1.1.2. This field study was initiated 6 months after the fireworks factory exploded and ran from 2001 to 2004 at the disaster mental health after-care centre Mediant in Enschede, the Netherlands.
2.11.1.1.3. One-third of the affected area’s inhabitants were first- and second-generation immigrants mostly of Turkish origin (Committee Oosting, 2001
2.12. Wilson et. al.’s systematic narrative review
2.12.1. Depression sx tx
2.12.1.1. EMDR therapy as significantly reducing symptoms of depression.
2.12.2. PTSD associated anxiety sx
2.12.2.1. PTSD anxiety-related symptoms reduced significantly with EMDR.
2.12.3. PTSD sx
2.12.3.1. EMDR therapy significantly improved PTSD diagnosis (Carletto et al., 2016)
2.12.3.2. Significantly reduced symptoms of PTSD (Chen et al., 2014, 2015; Acarturk et al., 2016; Carletto et al., 2016), and other trauma symptoms (ter Heide et al., 2016)
2.12.4. EMDR dropout rates
2.12.4.1. Low drop-out rates across all studies indicates EMDR therapy is well tolerated by clients, including in comparison to prolonged exposure.
2.12.5. Conclusion
2.12.5.1. EMDR therapy is an effective treatment to improve diagnosis of PTSD, and reduce symptoms of PTSD, and other trauma-related symptoms.
2.12.5.2. More RCT evidence is required to further enhance our collective understanding of PTSD and co-morbid symptoms.
3. Conclusions
3.1. Future directions
3.1.1. Need more data on if eye movements are necessary/effective for EMDR therapy.
3.2. PTSD and Anxiety related symptoms
3.2.1. Overall, EMDR therapy has greater clinical efficacy than trauma-focused CBT in reducing symptoms of PTSD and related anxiety.
3.3. Depression sx
3.3.1. EMDR therapy did not show convincing evidence that it is effective in reducing PTSD depressive symptoms.
3.4. Eye movement use in EMDR
3.4.1. Most data supports use of eye movements for EMDR therapy.
4. Introduction
4.1. Prevalence
4.1.1. Gore’s narrative clinical review
4.1.1.1. In the United States, as many as 50% of women and 60% of men have experienced a traumatic event during their lifetime.
4.1.2. Khan et al.’s SR/M-A of RCTs
4.1.2.1. The lifetime prevalence of PTSD among adults is estimated to be 8.3% in the United States.
4.2. Therapies for PTSD
4.2.1. Pharmacotherapies vs psychotherapies
4.2.1.1. FDA approved pharmacotherapies
4.2.1.1.1. Sertraline and Paroxetine
4.2.1.2. Trauma focused CBT
4.2.1.2.1. Seidler et al.’s SR/M-A of RCT and CT studies
4.2.1.3. EMDR therapy
4.2.1.3.1. Chen et al.’s SR/M-A of RCTs
4.3. Pathophysiology of PTSD
4.3.1. Santarnecchi et al.’s nonrandomized controlled trial
4.3.1.1. PTSD-related brain changes, morphometric and functional brain abnormalities in PTSD patients have been shown to follow different patterns for specific types of trauma as well (Meng et al., 2016).
4.3.1.2. Several studies have examined resting brain activity in PTSD patients (for a review see Wang et al., 2016), revealing significantly different spontaneous activity in cortical regions [e.g., superior temporal gyrus, medial prefrontal cortex (mPFC), inferior parietal lobule and middle occipital gyrus], limbic areas (e.g., the amygdala, hippocampus, insula, thalamus, and ACC), and even in the cerebellum. However, results are somehow inconsistent.
4.3.1.3. Studies on the impact of PTSD on regions such as the amygdala usually report a strong support in the notion of PTSD being driven by hyper-excitability of such structure, but at the same time neglect potential changes in other structures yet to be included in models and theories (e.g., cerebellum, motor system, and thalamus).
4.3.1.3.1. The vast majority of studies reporting amygdala-related alterations in PTSD are based on a priori defined ROI analysis (for a few example seeShin et al., 2005, 2009; Fonzo et al., 2010; Linnman et al., 2011; Sripada et al., 2012; Bruce et al., 2013; Stevens et al., 2013), i.e., they are explicitly looking just at the fMRI signal from the amygdala both during an emotion-provoking task or resting-state, neglecting activity in the rest of the brain.
4.4. Clinical presentation of PTSD
4.4.1. Bronner et. al.’s case report
4.4.1.1. Young children
4.4.1.1.1. Young children may report generalized fears, separation anxiety, sleep disturbances, agitated behaviour and posttraumatic play.
4.4.1.1.2. Young children may lose acquired developmental skills (e.g. independent toileting skills).
4.4.1.2. School aged children
4.4.1.2.1. May describe persistent reliving of the stressful event in vivid memories and nightmares.
4.4.1.2.2. They can also experience symptoms of increased arousal, such as sleeping or concentration problems, accompanied by physical symptoms.
4.4.1.2.3. School aged children can avoid situations or places that remind them of the stressful event or may become less responsive emotionally, depressed and withdrawn socially.
4.4.1.3. Adolescents
4.4.1.3.1. show similar stress reactions, but they are more likely to exhibit impulsive and aggressive behaviours in comparison to younger children [4,12]. Comorbidity may become manifest, e.g. anxiety, substance abuse and depression [13].
4.4.2. Gore’s narrative clinical review
4.4.2.1. Adults
4.4.2.1.1. Individuals affected by PTSD suffer from cognitive and mood symptoms, hyperarousal symptoms, avoidance symptoms and reexperiencing events.
4.5. Theoretical model of EMDR
4.5.1. Bronner et. al.’s case report
4.5.1.1. This approach is based on a theoretical model of incomplete information processing.
4.5.1.1.1. In this model, it is assumed that trauma causes a blockade in the natural physiological information-processing system, because the system gets overwhelmed by trauma- related information.
4.5.2. Essential of eye movements in EMDR for PTSD tx
4.5.2.1. Jeffries and Davis’ SR
4.5.2.1.1. some evidence was found suggesting bilateral stimulation first increases access to episodic memories; and second that it could act on components of working memory which makes focusing on the traumatic memories less unpleasant and thereby improves access to these memories.
4.5.2.1.2. Clinical research evidence is contradictory as to how essential EMs are in PTSD treatment.
4.5.3. Jeffries and Davis’ SR
4.5.3.1. According to this model, humans have an innate information processing system that processes our experiences and stores them in an adaptive state (Shapiro, 2002).
4.5.3.1.1. Memory networks link the thoughts, images, emotions and sensations associated with experiences.
4.5.4. Santarnecchi et al.’s nonrandomized controlled trial
4.5.4.1. EMDR vs Gold standard for PTSD tx
4.5.4.1.1. Diverse pharmacological and psychotherapeutic approaches for PTSD treatment have been suggested, with psychotherapy being considered the gold standard, whereas pharmacological treatment is conceptualized as a form of symptoms control.
4.5.4.2. Despite differences in session-to-session patient management and behavioral techniques, TF-CBT, EMDR and ET all focus on re-elaborating traumatic events or memories, favoring the emergence of new positive attitudes at the behavioral and cognitive level, leading to fear extinction and habituation.
4.5.4.2.1. In particular, TF-CBT and EMDR further stress the cognitive component of therapeutic process, strengthening top-down cognitive control (Robertson et al., 2004).
4.5.4.3. Differences of EMDR and TF-CBT
4.5.4.3.1. TF-CBT
4.5.4.3.2. EMDR