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.