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Eye movement desensitization across subjects: Subjective and physiological measures of treatment efficacy
J. Behav. 7’her. & Exp. Psychiar. Vol. 25, No. 3. pp, 217-230. 1994. Elsevier Science Ltd Rinted in Great Britain ooo5-7916/94 $7.00 + 0.00
00057916(94)00039-5
EYE MOVEMENT DESENSITIZATION ACROSS SUBJECTS: SUBJECTIVE PHYSIOLOGICAL MEASURES OF TREATMENT EFFICACY
AND
ROBERT W. MONTGOMERY Auburn University,
Georgia State University
TEODORO
AYLLON
Georgia State University Summary - Eye movement desensitization (EMD) was investigated in an experimental multiple baseline across subjects design. Six subjects who met the diagnostic criteria for Posttraumatic Stress Disorder (PTSD) were included in the study. While the EMD technique advanced by Shapiro has been reported to be clinically effective, major methodological issues have been raised which remain to be addressed. One issue raised is whether exposure to the traumatic image is sufficient to account for the reported clinical effects of EMD or whether the addition of saccadic eye movements is central to the treatment. This study attempted to address this concern by comparing two EMD-based procedures: a Non-saccade phase (without the saccadic eye movements) which functioned as a control and a second that included saccadic eye movements. Dependent variables included selfreport information (SUDS, behavioral symptoms reports) and physiological data (heart rate and systolic blood pressure). The results showed no significant decreases in SUDS level with the EMD minus the saccadic eye movements procedure. However, five of the six subjects reported clinically significant decreases in their SUDS levels with the inclusion of the saccadic eye movements. This study appears to corroborate previous work employing single-case design as well as pre and postcomparisons.
Given that Post-Traumatic Stress Disorder (PTSD) “is the only disorder where we can clearly identify the onset” (Barlow, 1988, p. 499) and that there are no clearly identified treatments that provide consistent alleviation of the symptoms of the disorder (Fairbank & Nicholson, 1987; Pittman, Altman, & Greenwald, 1991; Solomon, Gerrity and Muff, 1992) there is a clear need for the development of a consistently effective treatment for PTSD. Eye movement desensitization [EMD] has been proposed (Shapiro, 1989a) as a new and highly efficacious treatment for PTSD. Wolpe (1990a) refers to EMD as a treatment whose confirmation “would make it a major contribution to the treatment of [PTSD]” (p. 272). In addition
to the original report in the literature by Shapiro (1989a) there have been 11 reports of case studies utilizing EMD (Hassard, 1993; Kleinknecht, 1993; Kleinknecht & Morgan, 1992; Lipke & Botkin, 1992; Marquis, 1991; McCann, 1992; Oswalt, Anderson, Hagstrom, & Berkowitz, 1993; Pellicer, 1993; Puk, 1991; Shapiro, 1989b; Wolpe & Abrams, 1991), one single-case experiment (Montgomery & Ayllon, 1994), and two group design experiments (Boudewyns, Stwertka, Hyer, Albrecht, & Sperr, 1993: which appeared in an unrefereed newsletter; and Sanderson & Carpenter, 1992). Since her initial report on EMD, Shapiro (1991a, b) has gone on to expand the field of disorders claimed as treatable by use of EMD
Requests for reprints should be addressed to Robert Montgomery,
100 Hillside Lane, Roswell, Georgia 30076-2828,
217
U.S.A.
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ROBERT W. MONTGOMERY
(now renamed EMD/R for Eye Movement Desensitization and Reprocessing) to include almost all anxiety disorders, multiple personality disorder, the unspecified issues of “adult children of alcoholics”, “dysfunctional” emotions such as excessive grief, rage, guilt, etc.” (1991 b, p. 135) and the clinically undefined area of “self-esteem issues” (Shapiro, 1992, p. 1). While a variety of presenting problems have been addressed (Marquis, 1991) and presented as appropriate for treatment utilizing EMD (Shapiro, 1992), the majority of the case reports have ad-dressed intrusive disturbing memories as a component of PTSD. Additionally, the Carpenter & Sanderson (1993) study demonstrated that Shapiro’s claims (1989a, b; 1991a, b) that the saccadic eye movements are essential for treatment efficacy are not supported in the use of EMD with simple phobias. Several reviewers (Dyck, 1993; Herbert & Mueser, 1992; Lohr et al., 1992; Wolpe, 1990a) have critiqued the current body of literature on EMD and called for experimental investigations of EMD. Herbert and Mueser (1992) point out that the literature on EMD to date is composed primarily of case studies and among their recommendations for future research is a call for intensive studies of EMD utilizing the power of single-case experimental designs (Barlow & Hersen, 1984). In addition, each of these reviews has called for more rigorous objective evaluation of patient psychopathology as a component of any future investigation, citing the lack of such diagnostic rigor as a significant failing of the literature to date. To date there have been few studies investigating the correlation of psychophysiological measures of physical reactivity to imaginal stimuli and self-report data (SUDS) of such experiences (Montgomery & Ayllon, 1994; Thyer, Papsdorf, Davis, & Vallecorsa, 1984). The EMD literature has relied almost exclusively [with the exceptions of Montgomery & Ayllon (in press), Shapiro (1989b) and Wolpe & Abrams (1991) studies] on
and TEODORO
AYLLON
self-report measures of treatment efficacy. While the subjective experience of each subject is certainly central to the evaluation of the utility of any treatment for psychopathology, reliance upon a single treatment outcome measure is a major limit to this body of literature. In view of the lack of adequately controlled investigations on the effectiveness of EMD, this study attempts to extend the preliminary findings of Montgomery and Ayllon (1994) and to investigate the role of exposure both with and without saccadic eye movements. Since that study was limited to one subject, this investigation includes six subjects and a multiple-baseline design across subjects to evaluate the role of saccadic eye movements in the EMD procedure. Further, this study includes physiological measures as an additional dependent variable to self-report as called for by Lohr et al. ( 1992). The essential questions addressed herein are: (1) does EMD provide subjective relief from PTSD symptomatology: (2) if subjects report subjective relief from such symptomatology are these reports corroborated by psychophysiological measures; (3) are there subject differences which may explain any treatment outcome differences across subjects; and (4) are the saccadic eye movements of EMD essential for any treatment gains?*
Method Subjects Six adult subjects aged between 25 and 55 were selected from referrals to the Regional Mental Health Services, a University Medical Center Adult Psychiatric Outpatient Clinic and the Adult Psychological Outpatient Clinic of the University Medical Center. Subjects were selected based on being diagnosed with PTSD [American Psychiatric Association (APA), 19871 which had been precipitated by other than military based trauma. Subjects were excluded from the study
*Our replication ot’ the EMD procedure as reported by Shapiro was enhanced by access to videotaped applications technique and discussions with Jospeh Wolpe, who also provided additional clarification on issues related to the technique.
of the
Eye Movement Desensitization
(Shapiro, 1989a, b; 1991b) if judged currently to be suffering from obsessive-compulsive disorder, substance abuse or dependence disorders, alcohol abuse or dependence, or have a history of schizophrenia, multiple personality disorder, or delusional disorder. Subjects were also excluded for history of serious cardiovascular disorders or potential for suicidal homicidal ideation. Those currently taking antipsychotic medications for any reason or receiving psychotherapy focused on the symptomatology associated with PTSD were excluded from the study. Those subjects not included were offered appropriate referral or alternative treatment. Subject number 1. A 36-year-old black female related an incident which had occurred 6 months prior to her evaluation in which her home was destroyed by tomados which had ravaged the area. Her car was buffeted and she thought that she was going to die. Upon returning to her neighborhood she discovered that her entire section of the area was decimated, and she feared that her husband was dead. The patient was reunited several hours later with her husband but did not recall their initial meeting following the event. She was diagnosed as suffering from PTSD and depression. The patient had received 3 months of supportive therapy prior to her entry into the current investigation. She was not receiving any other form of therapy at any point during the current investigation. Subject number 2. A 41-year-old white male also related an incident which had occurred 6 months prior to his evaluation in which his home was destroyed by tornados. The image which continued to intrude on the subject’s thoughts was of the funnel cloud approaching his home across a small pond while he watched in fascination as his neighbors’ houses were destroyed. The subject reported that he knew that he and his family were going to die when the tornado hit his home. It changed course at the last possible instant and did not hit the subject’s home. The patient had received pharmacotherapy for his PTSD symptoms for 2 months prior to entry into the investigation.
Across Subjects
219
Subject number 3. A 40-year-old white male reported that he had recurrent intrusive thoughts and dreams of an incident which occurred to him at the age of 17. The incident involved his father loading a shotgun in the subject’s presence, chambering the shotgun shell, placing the barrel of the weapon to the subject’s head and pulling the trigger. The shell which had been loaded had been previously fired and was inert; however, the subject was unaware of this fact at the time of the incident. His clearest image was of looking up the barrel of the shotgun as his father pulled the trigger. In psychological evaluations the subject was diagnosed as suffering from PTSD, mild depression, and dependent personality disorder with a history of both cannabis and alcohol dependence. The patient had received 28-day inpatient 12-Step treatment for his substance dependence and was continuing to attend outpatient 12-Step group meetings on a weekly basis. He was adjudged, by the attending psychiarist, to have been substance free for over 2 years at the time of entry into this study. Study number 4. A 25-year-old white male had both recurrent intrusive thoughts and dreams of an incident which occurred to him at the age of 22. The patient reported that while in prison he was beaten, knifed, and left for dead by other inmates. He reported that his intrmive thoughts were of the three inmates cornering him in the toilet/shower area, grabbing him, gagging him and assaulting him. His clearest image was of the light glinting off the polished metal of the handmade knife as it was initially plunged into his body. In psychological evaluations the subject was diagnosed as suffering from PTSD, mild depression, and a history of alcohol dependence. The patient had received 28-day inpatient 12-Step treatment for his alcohol dependence and was adjudged to have been alcohol free for over 3 years at the time of entry into this study. Subject number 5. A 36-year-old white male had related an incident which occurred almost two years prior to his interview, in which he had been attacked and almost killed by three pitbull terriers.
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W. MONTGOMERY
The dogs ran him down, harried him, nearly severed his left arm at the shoulder, and only left when the subject lost consciousness due to loss of blood. The subject’s clearest and most disturbing image of the event was of being on his back on the ground holding the largest of the pitbulls off by grasping its fur around the neck as the dog lunged at his face. The patient was diagnosed as suffering from PTSD, panic disorder with agoraphobia, and mild depression. The patient was receiving 5 mg of Valium daily prior to going to sleep each night. Medication was provided on a weekly basis and maintained at pre-investigation levels throughout all phases of the investigation. Subject number 6. A 38-year-old white female related an incident which had occurred 6 months prior to her evaluation in which her home and automobile were destroyed by tornados. The subject reported hearing a loud roaring sound, feeling her home shake, grabbing her 3-year-old child and heading for a culvert down the street from her home. While in the culvert she looked up and saw a funnel of the tornado heading straight for where she and her child were lying. When she looked up again her home and automobile were destroyed, the car was on its side against a tree and her home was obliterated. The patient also reported not being able to recall what occurred to her from the time when she looked up and saw her devastated home and when she was sitting in her husband’s pickup truck over an hour later. The patient was diagnosed as suffering from PTSD, storm phobia, and panic disorder with agoraphobia. The patient had received no therapy for her condition. Apparatus and Measurements
Subjects were screened using: the Structured Clinical Interview for The DSM-III-R (SCID: Spitzer, Williams, Gibbon, & First, 1990); the Structured Clinical Interview for the DSM-III-R for Personality disorders (SCID-II: Spitzer, Williams, & Gibbon, 1987); Beck Depression Inventory (BDI: Beck, Ward, Mendelsohn, Mock & Erbaugh, 1961); Anxiety Disorders Interview
and TEODORO
AYLLON
Schedule-Revised (ADIS-R: DiNardo et al., 1985); a brief biographical/clinical history questionnaire; the revised Betts Questionnaire on Mental Imagery (QMI: Sheenan, 1967); The Fear Survey Schedule (Wolpe & Lang 1969); and the Subjective Anxiety Scale (SUDS: Wolpe, 1982, 1990). In addition a clinical interview covering those areas of concern to the subject centering on their traumatic memories was conducted. Physiological data were collected using the Omron HEM-8 15F Automatic Oscillometric Electronic Digital Blood Pressure & Pulse Monitor (Shigemi et al., 1990). Measures of “belief” in selfstatements centering on the disturbing images were taken (as in Shapiro, 1989a) using a 7-point semantic differential scale (1 = completely untrue; 7 = completely true) to assess changes in the belief in the alternative to the irrational belief theorized to underlie the traumatic memory/image. The initial and weekly subsequent interviews included questions regarding the frequency and disruptive effects of such presenting problems as flashbacks, intrusive thoughts, and sleep disturbances. General Procedures
As a condition of the multiple baseline design across subjects, assessment, baseline, non-saccade treatment, EMD treatment, and follow-up for subjects were run in tandem, and sessions were run so that sessions across baselines were within a day of each other. Subjects attended sessions on an average of twice a week throughout the active phases of the study and once weekly during the follow-up phase. Times of the day and day of the week were kept as consistent as possible across subjects throughout this study. Baseline data were collected during initial intake assessments. During sessions both self-report and physiological data were collected concurrently. Decisions concerning inclusion/exclusion in the investigation were made using both medical records and data collected during this initial intake/baseline period. Each session lasted approximately 75 minutes and began with a general explanation of the agenda for the session. The dependent variables were subjective anxiety level (as measured by the
Eye Movement Desensitization
SUDS), presenting complaints surveyed weekly severity and frequency of flashbacks, (e.g., intrusive memories/images, and sleep disturbances: including sleep hygiene and nightmares) and physiological measures of anxiety. Physiological measures were taken prior to each session and concurrently with each self-report of subjective anxiety (SUDS). Following each administration of non-saccade or EMD treatment protocol each subject was asked to report their subjective distress (SUDS) and cognitive shifts (as developed by Shapiro, 1989a) using a 7-point Semantic Differential scale while physiologic measures were recorded. As in Shapiro (1989a, b), self-statements concerning the patients’ beliefs around the traumatic image were solicited and each patient was asked to rate the degree of the strength of their belief in those self-statements on a bipolar adjective anchored Likert type seven point scale. Subjects were asked to wait quietly in the treatment room for 5 minutes prior to any assessments in an effort to assure that the stability of the psychophysiological measures was not effected by physical exertion or ambient heat differentials. Following this acclimation period data was collected according to the parameters of the applicable protocol then in effect. Baseline Procedures During the baseline condition (Phase A) subjects were asked to fill out several assessment and history questionnaires while data concerning their intrusive image and the anxiety surrounding that image were collected. At five points, once approximately every 1.5 minutes, subjects were directed to imagine both the traumatic scene and the words of the self-statements that best fit the image (as in Shapiro, 1989a). They were then asked verbally to assign a subjective level of distress (SUDS) rating to the scene. Blood pressure and heart rate data were collected concurrently with the assignment of a SUDS rating to the disturbing image utilizing the Omron HEM-8 1.5F Automatic Oscillometric Electronic Digital Blood Pressure & Pulse Monitor (Shigemi et al., 1990).
Across Subjects
221
After determining the level of distress experienced (via self-report and physiological measurements), each subject was then asked to state how they would like to feel instead and to supply a new selfstatement to reflect the desired feeling. The subject was then asked verbally to report (on a 7point Semantic Differential Scale) how true the new statement was for them (as in Shapiro, 1989a). Non-Saccade
Procedure
Following the baseline condition of the experiment, a brief control for the presence of saccadic eye movements in the full “Shapiro” condition was implemented with each subject (Phase B). The non-saccade procedure presented all aspects of the EMD treatment procedure to the subject except for the saccadic eye movements which characterized Shapiro’s (1989a, b) procedure and characterized as operative in EMD. The following intervention is taken directly from Shapiro (1989a). Subjects were told that: What we will be doing is often a physiological check. I need to know from you exactly what is going on with as clear feedback as possible. Sometimes things will change and sometimes they won’t. I may ask you if the picture changes - sometimes it will change and sometimes it won’t. I’ll ask you how you feel from 0 to IO - sometimes it will change and sometimes it won’t. 1 may ask if something else comes up - sometimes it will and sometimes it won’t. There are no ‘supposed to’s’ in this process. So just give as accurate feedback as you can as to what is happening without judging whether it should be happening or not. Just let whatever happens, happen. (p. 204)
Following the initial anxiety rating, each subject was asked to sit upright in a chair in a relaxed posture and look straight ahead. The subject was then asked to stare at a fixed point while imagining the disturbing scene for 30 seconds. This procedure was repeated 20 times during each non-saccade session with approximately 1 minute breaks between each “treatment” thus generating data on an average of every three minutes throughout each session. The non-saccade condition continued for three sessions at the conclusion of which the EMD treatment condition was implemented.
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ROBERT W. MONTGOMERY and TEODORO AYLLON
All standard measures (SUDS, HR, BP, semantic differential, etc.) were taken during the non-saccade condition EMD Treatment
EMD treatment procedure was terminated after six sessions, and with one subject after three sessions when the SUDS level was at an average of 1 (on a l-10 scale).
Procedure Follow-Up
As in the non-saccade condition, during the EMD treatment phase (B + C Phase) each subject was asked to provide initial anxiety ratings (SUDS) prior to treatment. Subjects were then instructed to visualize the traumatic scene/image, rehearse the negative self-statement (upon which semantic differential reports were taken), and provide a SUDS rating of the anxiety (during which physiological measures of anxiety were taken). The investigator then caused (as described in Shapiro, 1989a, b; 199 1b; Wolpe, 1990b) the subject to generate a series of voluntary, bilateral, rhythmic saccadic eye movements by moving a stimulus (an upraised index finger) rapidly back and forth across their field of vision (approximately two sweeps per second). The stimulus was located 12-16 inches from the face of the subject and was moved from the extreme left of the field of vision to the extreme right of the visual field and back again (as in Shapiro, 1989a, b; Wolpe, 1990b). The distance of one such sweep was approximately 12-18 inches. Twenty such sweeps were administered during each set. After each set the subject was asked to: “blank it (the image) out, and take a deep breath.” (Shapiro, 1989a, p. 205) He was then asked to bring up the image and self statement again, to concentrate on the anxiety level generated, and to provide a SUDS level rating (during which additional physiological measures were taken). Subjects were then asked: (1) “Did the picture change?“, and (2) “Does anything else come up?” in order to track that the image stated at the outset of the set was the image imagined during the procedure. As in the non-saccade condition, if the subject’s SUDS level was reduced the subject’s belief in the validity of the new desired self statement (or as Shapiro refers to it: “Belief system”) was assessed by asking “How do you feel about the statement from ’ 1’ - completely untrue to ‘7’ - completely true” (p. 205). The
Initial follow-up was done at one week following EMD treatment completion. Such interviews involved history taking of PTSD symptoms (e.g., sleep disturbances, flashbacks, frequency of intrusive thoughts, instances of aggressive episodes), physiological monitoring of anxiety around the treated image, and reports by the subject on SUDS level and belief in selfstatements (on the 7-point semantic differential scale) investigated during the active phases of the study as in the baseline phase of the investigation. Additional follow-up sessions were conducted as possible on a weekly basis for as many weeks as possible with each subject.
Results Within Session
Data
The t-test for dependent samples (Shavelson, 1981; Kazdin, 1983) was used to examine the data for statistical significance. Shavelson (198 1) points out that, the t-test for dependent samples is designed to take the fact that within subject data is correlated into account. While general downward slope of the data were noted in each of the measures of within session distress, statistical significance was demonstrated in only the overall decreases in Subjective Units of Distress (to,,<= 5.24, p < .005). Subjective units of distress. An overall summary of the SUDS data is presented in Table 1. During baseline subjects generally had a steady level of subjective distress without great variance throughout this phase of the investigation (see Figures l-3). While there was a slight fluctuation in the SUDS reports during Phase B (NonSaccade), variance was limited and the range was
Eye Movement Desensitization
223
Across Subjects
Table 1 Mean Subjecfive Unirs ofDisrress*t
1
2
3
4
5
6
Mean
10.0 9.4 7.7 3.7
8.0 8.0 1.4 1.3
8.9 7.9 5.2 2.1
7.8 6.4 I .5
7.0 7.4 6.1 7.3
7.9 8.1 2.5 1.4
8.27 7.82 4.21 2.74
Subject Baseline Non-Saccade EMD TX Follow-Up
(based upon self-report:N = 6)
1.4
* = (rob\= 5.24, p < 005). tThe r-test for dependent samples (Shavelson, 1981; Kazdin, 1984) was used to examine throughout the study. All r-scores reported represent tests for dependent samples. narrow
and not clinically
significant. SUDS the EMD Treatment Phase (B + C). Within the initial session of EMD treatment variance was lowest and was greatest within the last EMD treatment session. Decreases in subjective distress were generally demonstrated throughout the Follow-up Phase. decreased
steadily
during
Systolic blood pressure. An overall summary of systolic blood pressure (SBP) for each subject is presented in Table 2. The changes in systolic blood pressure recorded across phases of this investigation did not achieve statistical significance. However, general decreases in most of the subjects in recorded SBP are noted (Mean change from Baseline to EMD Treatment is 19.7 mm Hg). Heart rate. An overall summary of heart rate data is presented in Table 3. The changes in heart rate recorded across phases of this investigation failed to achieve statistical significance. However, general decreases in most of the subjects’ recorded heart rates are noted (mean change from Baseline to EMD Treatment is 6.2 bpm).
the data for statistical
significance
Between session data. Initially flashbacks were conceived of as an additional measure of treatment efficacy, however, flashbacks were not reported by any of the six subjects of this study and therefore, are not reported upon herein. Data on both intrusive thoughts and disturbing dreams was recorded on a weekly basis during each phase of this investigation. Intrusive thoughts. Without exception there was no statistical difference between Baseline (A) and Non-Saccade (B) Phases for any of the six subjects for intrusive thoughts. The rate of days per week reported as having had intrusive thoughts occur dropped from a pretreatment (Baseline and NonSaccade phases) mean of 5.57 to a mean of 2.55 during the EMD Treatment (B + C) Phase and further to 1.88 days per week during the follow-up period. This represents a decrease of 66% from baseline to follow-up levels (see Table 4). Statistical significance, between Phases A and B and EMD Treatment (B + C) levels, was achieved for intrusive thoughts (to,,,= 5.67, p < .005). Dreams.
As with intrusive
thoughts,
without
Table 2 Mean Systolic Blood Pressure*
Subject Baseline Non-Saccade EMD TX Follow-Up
(N = 6)
I
2
3
4
5
6
Mean
182.1 167.4 146.0 130.7
151.9 142.8 122.5 124.6
157.9 153.6 143.5 129.4
154.1 141.8 128.0 125.8
145.3 141.3 147.5 153.3
134.5 134.9 120.3 119.6
153.8 145.8 135.9 130.8
*Did not achieve statistical significance.
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ROBERT W. MONTGOMERY
and TEODORO
FollowUp
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Sessions Figure 1. Subjective Units of Distress (SUDS) for Subject 1 (36 yr, female, Tornado victim) and Subject 2 (41 yr, Male, Tornado victim) across Baseline (A); Non-Saccade (B); EMD Treatment (B + C); and Follow-Up.
exception there was no statistical difference between Baseline (A) and Non-Saccade (B) Phases for any of the six subjects for dreams (See Table 5). Additionally, there was found to be no statistical difference between reported rates of
intrusive thoughts or dreams between EMD Treatment (B + C) and follow-up. The rate of days per week reported for dreams dropped from a baseline mean of 3.92 to a mean of 2.13 during the EMD Treatment (B + C) Phase. Reported dreams
Table 3 Mean Heart Rote c~cmw Subjem Subject Baseline Non-Saccade EMD TX Follow-Up
and Cortdition.s* (IV = 6)
1 85.2 83.5 79.7 75.5
*Did not achieve statistical significance.
2
3
4
5
6
Mean
74.5 75.2 73.8 73.0
83.5 81.3 77.3 72.3
82.2 77.2 72.9 72.5
76.8 16.7 71.1 75.6
78. I 74.1 68.8 69.X
80.3 77.6 74.4 72.7
Eye Movement Desensitization
Across Subjects
225 Follow-Up
B+C
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1
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Sessions Figure 2. Subjective Units of Distress (SUDS) for Subject 3 (40 yr, male, Shotgun victim) & Subject 4 (25 yr, male, Knife victim) across Baseline (A); Non-Saccade (B): EMD Treatment (B + C); and Follow-Up.
continued to drop following termination of active treatment to a mean of 1.20 during follow-up. This drop in dreams across pretreatment (Baseline and Non-Saccade Phases) to treatment/ follow-up represents a drop in disturbing dreams of 2.0 dreams per week or a 5 1% decrease in the rate of disturbing dreams. Statistical significance, between Baseline and EMD Treatment (B + C) levels, was achieved for dreams (fobs= 12.71, p < .005). Depression. Scores reported for the Beck Depression Inventory (BDI) were recorded during intake/initial assessment and during the Follow-
Up Phase of the investigation. Pretreatment BDI levels were predominately in the mildly depressed range (BDI range 11-17) with one exception (Subject 1: BDI = 24) reporting moderate levels of depression (Steer & Beck, 1988). Each of the subjects answered fewer questions in the storable direction at the posttreatment measurement. The single largest drop in reported depression was for subject one, whose BDI dropped 9 points from pre to posttreatment measurement. Posttreatment BDI levels demonstrated a mean drop of 4.0 (See Table 6) over pretreatment levels, which is statistically significant (tabs= 8.22, p < .005).
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ROBERT W. MONTGOMERY
and TEODORO
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Sessions Figure 3. Subjective Units of Distress (SUDS) for Subject 5 (36 yr, Male, Pitbull victim) & Subject 6 (38 yr, female, Tornado victim) across Baseline (A); Non-Saccade (B); EMD Treatment (B + C); and Follow-Up.
Table 4
Table S
Mean Number of Days per Week of Intrusive Subject and Experimental Condition
Thoughts
by
Mean Number of Days per Week with Disturbing Across Subjects and Experimental Condition
Days with Intrusive Thoughts/Week Subject/phase
A
B
I
7.0 3.7 5.7 6.7 5.0 5.7 5.63
7.0 4.0 5.0 6.0 5.0 6.0 5.50
2 3 4 5 6 Mean*
B+C 1.I 2.0 2.3 1.7 4.6 3.0 2.55
* = (to&= 5.67, p < ,005). A = Baseline Phase; Saccade Phase; B + C = EMD Treatment Phase
Follow-Up
I .o I .5 0.8 2.0 5.0
1.o 1.88 B = Non-
Days with Disturbing Subject/Phase
A
B
I
3.5 1.0 3.0 5.3 7.0 3.7 3.92
3.5 I .5 3.0 3.5 5.0 4.0 3.42
2 3 4 5 6 Mean*
*=(I<,~,= 12.7l,p<.OO5). A = Baseline Phase; B = Non-Saccade Treatment Phase.
Dreams/Week
B+C 1.3 0.8
1.7 3.0 4.0 2.0 2.13
Dreams
Follow-Up 0.0 0.0 0.7 0.8 5.3 0.4 1.20
Phase; B + C = EMD
Eye Movement Desensitization Table 6 Beck Depression Inventory Scores* Subject
I 2 3 4 5 6 Mean *=
Pretreatment
Posttreatment
24 16 14 14 12 14 15.7
17 12 12 11 9 9 11.7
Change I 4 2 3 3 5 4.0
(toha = 8.22, p < .005).
Discussion Given the paucity of outcome research in the treatment or PTSD (Solomon, Gerrity & Muff, 1992), any methodologically sound experimental investigation of treatment outcome for PTSD is an addition to the literature. This study investigated Eye Movement Desensitization as a treatment for PTSD in a non-combat trauma population. In an effort to address criticisms made of the EMD literature to date (Herbert & Mueser, 1992; Lohr et al., 1992) and limitations in the PTSD treatment outcome literature more broadly, a single-case experimental design (Barlow & Hersen, 1984) was used to evaluate treatment efficacy. Partial dismantling of the EMD treatment was conducted by the addition of a Non-Saccade (B) Phase wherein subjects received all components of Shapiro’s (1989b, 1991b) treatment package minus the saccadic eye movements. Following this Non-Saccade phase, the EMD treatment protocol as presented by Shapiro was conducted. As noted in the Introduction, the essential questions addressed herein are: (1) does EMD provide subjective relief from PTSD symptomatology; (2) if subjects report subjective relief from such symptomatology are these reports corroborated by psycho-physio-logical measures; (3) are there subject differences which may explain any treatment outcome differences across subjects; and (4) are the saccadic eye movements of EMD essential for any treatment gains? In addressing the first question, “does EMD
Across Subjects
227
provide subjective relief from PTSD symptomatology”: the findings of this study are generally positive. The self-report data, both within sessions and across sessions (i.e., SUDS, Intrusive Thoughts, Dreams, BDI score), to a limited extent support the data as presented by Shapiro (1989a, b; 199 lb) and others (Kleinknecht & Morgan 1992; Lipke & Botkin, 1992; Marquis, 1991; McCann, 1992; Pellicer, 1993; Puk, 1991; Shapiro, 1989b; Wolpe & Abrams, 1991) on the efficacy of EMD. A significant exception to these results was Subject 5. While the self-report data are clinically significant (a reported decrease in SUDS, with the exclusion of Subject 5, of 6.54 from a baseline mean of 8.52 to a follow-up mean of 1.98), the treatment gains are not as immediate nor as profound as those reported elsewhere in the literature (i.e., Shapiro, 1989a, b; Lipke & Botkin, 1992; Marquis, 1991; McCann, 1992; Puk, 1991). Additionally, these treatment gains, with the exception of Subject 6, were achieved over the course of six EMD treatment sessions not the one or two previously reported by Shapiro. The second question, “if subjects report subjective relief from such symptomatology are these reports corroborated by psychophysiological measures”, is less clearly answered by the data. Attempts were made to correlate the self-report measures of treatment efficacy with more objective measures of any changes in anxiety levels. While there were not statistically significant changes in the anticipated direction for either systolic blood pressure or heart rate, there were consistent decreases in both physiological measures. Systolic blood pressure decreased an average of 22.99 mm Hg from baseline through follow-up. Heart rate dropped from a mean of 80.29 bpm during baseline to 72.69 bpm during the follow-up (an average drop of 7.6 bpm). Reports of decreases across psychophysiological measures were more pronounced (28.7 mm Hg and 8.9 bpm) for the subjects who reported positive treatment effects (excluding Subject 5). These findings can be viewed as supporting the self-report data on clinically relevant decreases in situational anxiety surrounding the disturbing images investigated.
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The third question, “are there subject differences which may explain any treatment outcome differences across subjects”, is more easily answered. There was only one subject (Subject 5) who did not report positive treatment gains during the EMD Treatment Phase of this investigation. During the follow-up phase it was discovered that this subject was involved in litigation seeking compensation for his claimed disability. This fact may provide some rationale for why subject 5’s reaction to the EMD technique was atypical. The subject had been declared fit for return to work by his orthopedist, physical therapist, and surgeon. His attorney was making his claim of total disability based solely upon the subject’s diagnosis of PTSD. It is therefore, possible that his reporting of subjective distress was influenced by an attempt to strengthen his legal claim to monetary compensation. The fourth question, “are the saccadic eye movements of EMD essential for any treatment gains” was addressed by the use of a Non-Saccade Phase. Since Shapiro (1989a, b; 199 1b) presented a treatment package with three identified components, the question was whether the combination of saccadic eye movements, cognitive restructuring and repeated short term exposure was necessary for treatment gains in PTSD subjects or whether the combination of cognitive restructuring and repeated exposure, without the saccadic eye movements, alone were sufficient for significant treatment gains was addressed. The data indicate that with PTSD subjects the use of short duration repeated exposure and cognitive restructuring alone were insufficient for positive treatment gain. SUDS declined non-significantly (0.45, from a mean of 8.27 to a mean of 7.82) during the Non-Saccade phase of the investigation. The addition of the saccadic eye movements to the treatment package (thereby replicating Shapiro’s original protocol) resulted in the significant decreases in self-reports of distress previously addressed. These findings are reflected by decreases in the psychophysiological measures of arousal. It appears from these data that the combination of the three components is superior to the use of only the
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repeated exposure and cognitive restructuring components alone. The present study generally supports the utility of EMD as a treatment for PTSD. While the treatment gains were neither as immediate nor as profound as those reported by Shapiro, they are of greater magnitude and occurred in a shorter treatment time than typically occurs with traditional (implosive therapy and imaginal flooding) treatment techniques for PTSD. Flooding as described by the National Center for PTSD Research at the Boston VA Medical Center (Lyons & Keane, 1989), usually lasts 2-2.5 hours per session (not all of which is devoted to reliving the traumatic scene) and is “generally continued for at least several sessions” (p. 149). The typical VA patient, being treated with implosive therapy for PTSD, will receive from 8 to 16 hours of exposure to a specific traumatic scene during the course of therapy. On the other hand, EMD subjects are exposed to 6-12 minutes of exposure following Shapiro’s protocol as originally (1989b) presented. It must, however, be noted that in the final examination, all self-report measures (for five of the six subjects of this investigation) demonstrated both clinically and statistically significant treatment gains and that all the psycho-physiological measures of treatment efficacy (for all six of the subjects) failed to demonstrate statistical significance. Future investigations of EMD should incorporate those criticisms of the literature offered by both Lohr and colleagues ( 1992) and Herbert and Mueser (1992). Continued use of single-case experimental methodology is also indicated in investigating the treatment of PTSD subjects, regardless of the treatment(s), investigation, demands emphasis on both diagnostic rigor and objective measurement of disorder sequelae (including follow-up reassessment for the presence of PTSD). Refinement of psycho-physiological measurement of levels of situational distress should play a significant role in any future investigation of EMD. Finally, objective measures of intrusive thoughts and disturbing dreams may in the future be available through anticipated advances in computer technology and neuro-imaging.
Eye Movement Desensitization Acknowledgements
- This study was funded in part through a dissertation support grant (GSU: 93-003) from the Chancellor of the University System of Georgia and matching funds from the chair of the Department of Psychology at Georgia State University. The authors thank Joseph Wolpe, Robert Brown, Walter F. Davies, Gregory Jurkovic, Sudhakar Madakasira, Michael A. Milan and Donald B. Penzien, and two anonymous reviewers.
References American
Psychiatric
statistical
manual
Association.
(1987).
of mental
disorders
Diagnostic
and
(3rd ed. rev.).
Washington, DC: Author. Barlow, D. H. (1988). Anxiety and its disorders. New York: Guilford. Barlow, D. H., & Hersen, M. (1984). Single case experimental designs; strategies for stud&g behavior change (2nd ed.). New York: Pergamon Press. Beck, A. T., Ward, C. H., Mendelsohn, M., Mock, _I., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatv,
4, 561-571.
Boudewyns, P. A., Stwertka, S. A., Hyer, L. A., Albrecht, J. W., & Sperr, E. V. (1993). Eye movement desensitization for PTSD of combat: a treatment outcome pilot study. The Behavior
Therapist,
Interview Schedule
-
Revised (AD&R).
Albany, NY: Phobia and Anxiety Disorders Clinic, State University of New York. Dyck, M. J. (1993). A proposal for a conditioning model of eye movement desensitization treatment for posttraumatic stress disorder. Journal of Behavior Therapy & Experimental
Psychiatry, 24, 201-210.
Fairbank, J. A., & Nicholson, R. A. (1987). Theoretical and empirical issues in the treatment of post-traumatic stress disorder in Vietnam veterans. Journal of Clinical Psychology,
43, 44-55.
Hassard, A. (1993). Eye movement desensitization of body image. Behavioural Psychotherapy, 21, 57-160. Herbert, J. D., & Mueser, K. T. (1992). Eye movement desensitization: a critique of the evidence. Journal of Behavior 169-174.
Therapy
& Experimental
Psychiatry,
23,
Kazdin, A. E. (1983). Statistical analyses for single-case experimental designs. In D. H. Barlow & M. Hersen (Eds.) Single case experimental designs: strategies for studing behavior change (2nd ed.). New York: Pergamon Press.
Kleinknecht, injection
R. A. (1993). Rapid treatment of blood and phobias with eye movement desensitization.
Journal of Behavior 24, 21 I-217.
Therapy
& Experimental
Psychiatry,
Kleinknecht, R. A., & Morgan, M. P. (1992). Treatment of posttraumatic stress disorder with eye movement desensitization. Journal of Behavior Therapy & Experimental
Psychiatry, 23, 43-49.
Lipke, H. J., & Botkin, A. L. (1992). Case studies of eye movement desensitization and reprocessing (EMDR) with chronic post-traumatic stress disorder. Psychotherapy, 29, 591-595.
229
Lohr, J. M., Kleinknecht, R. A., Conley, A. T., Dal Cerro, S., Schmidt, J., & Sontagg, M. E. (1992). A methodological critique of the current status of eye movement desensitization and reprocessing (EMD/R). Journal of Behavior 159-167.
Therapy
& Experimental
Psychiatry,
23,
Lyons, J. A., & Keane, T. M. (1989). Implosive therapy for the treatment of combat-related PTSD. Journal of Traumatic Stress, 2, 137-152. McCann, D. L. (1992). Post-traumatic stress disorder due to devastating burns overcome by a single session of Eye Movement Desensitization. Journal of Behavior Therapy & Experimental
Psychiatry, 23, 319-323.
Marquis, J. N. (1991). A report on seventy-eight by eye movement desensitization. Journal Therapy and Experimental
Psychiatq,
cases treated
of Behavior 187-192.
22,
Montgomery, R. W., & Ayllon, T. (1994). Eye movement desensitization across images: a single case design. Journal of Behavior 23-28.
Therapy
and Experimental
Psychiatry,
25,
Oswalt, R., Anderson, M., Hagstrom, K., & Berkowitz, B. (1993). Evaluation of the one-session eye-movement desensitization reprocessing procedure for eliminating traumatic memories. Psychological Reports, 73, 99-104. Pellicer, X. (1993). Eye movement desensitization treatment of a child’s nightmares: a case report. Journal of Behavior Therapy and Experimental
16, 29-33.
DiNardo, P. ., Barlow, D. H., Cerny, J., Vermilyea, B. B., Vermilyea, J. A., Himadi, W., & Waddell, M. (1985). Anxiety Disorders
Across Subjects
Psychiatry, 24, 73-75.
Pittman, R. K., Altman, B., & Greenwald, Psychiatric complications during flooding posttraumatic stress disorder. Journal
E. (1991). therapy for of Clinical
Psychiatry, 52, 17-20.
Puk, G. (1991). Treating traumatic memories: a case report on the eye movement desensitization procedure. Journal of Behavior 149-151.
Therapy
and
Experimental
Psychiatry,
22,
Sanderson, A., & Carpenter, R. (1992). Eye Movement Desensitization versus image confrontation: a singlesession crossover study of 58 phobic subjects, Journal of Behavior 269-275.
Therapy
& Experimental
Psychiatry,
23,
R. J. (1981). Stutisfical reasoning for the sciences. Boston: Allyn and Bacon, Inc. Shapiro, F. (1989a). Efficacy of the eye movement desensitization procedure in the treatment of traumatic memories. Journal of Traumatic Stress, 2, 199-223. Shapiro, F. (1989b). Eye movement desensitization: a new treatment for post-traumatic stress disorder. Journal of Shavelson,
behavioral
Behavior 21 l-217.
Therapy
and
Experimental
Psychiatry.
Shapiro, F. (1991a). Eye movement desensitization reprocessing: a cautionary note [Letter to the editor]. Behavior Therapist, 14, 188. Shapiro, F. (1991b). Eye movement desensitization reprocessing procedure: from EMD to EMD/R - a treatment model for anxiety and related trauma. Behavior Therapist, 14, 128, 133-135. Shapiro, F. (1992). Eye movement desensitization reprocessing:
1992 Level I basic training
schedule.
Alto, CA: EMRD. Sheenan, P. W. (1967). A shortened form Questionnaire Upon Mental Imagery. Journal Psvcholog?;,
23, 386-389.
20,
and The
and new The and
Palo
of Betts’ of Clinical
230
ROBERT W. MONTGOMERY
Shigemi, K., Takahashi, H., Hashimoto, S., Noni, S., Chihara, E., Kinoshita, T., Tanaka, Y., & Miyazaki, M. (1990). A comparative study of measurement of arterial blood pressure using HEM-802F and arterial cannulation. Journal of Anesthesiology, 4, 91-93. Solomon, S. D., Gerrity, E. T., & Muff, A. M. (1992). Efficacy of treatments for Posttraumatic Stress Disorder. Journal of the American
Medical Association,
Spitzer, R. L., Williams,
268, 633638.
J. B. W., Gibbon, M., & First, M. B.
(1990). Structured clinical interview for DSM-III-R -Nonpatient edition (SCID-NP). Washington, DC: American
Psychiatric Press. Spitzer, R. L., Williams, Structured disorders.
J. B. W., & Gibbon, M. (19X7). clinical interview for DSM-III-R - Personality New York: Biometrics Research Department of
the New York State Psychiatric Institute. Thyer, B. A., Papsdorf, J. D., David, R., & Vallecorsa,
S.
and TEODORO (1984).
AYLLON
Autonomic
correlates
of the subjective
anxiety
Journal of Behavior Therapy and Experimental Psychiatry1 15, 3-7. Wolpe, J. (1982).The practice of behuvior therapy (3rd ed.).
scale.
New York: Pergamon Press. Wolpe, J. (1990a). The practice ofbehavior therapy (4th ed.). New York: Pergamon Press. Wolpe, J. (1990b). Eye movement desensitization (Video Cassette Recording CP V 17). Phoenix, AZ: The Milton H. Erickson Foundation. Wolpe, J., & Abrams, J. (1991). Post-traumatic stress disorder overcome by eye movement desensitization: a case report. Journal of Behavior 22. 3943.
Therap.v and Experimental
Psychiatry,
Wolpe, J., & Lang, P. J. (1969). Few survey schedule. San Diego, CA: Educational and Industrial Testing Service.
00057916(94)00039-5
EYE MOVEMENT DESENSITIZATION ACROSS SUBJECTS: SUBJECTIVE PHYSIOLOGICAL MEASURES OF TREATMENT EFFICACY
AND
ROBERT W. MONTGOMERY Auburn University,
Georgia State University
TEODORO
AYLLON
Georgia State University Summary - Eye movement desensitization (EMD) was investigated in an experimental multiple baseline across subjects design. Six subjects who met the diagnostic criteria for Posttraumatic Stress Disorder (PTSD) were included in the study. While the EMD technique advanced by Shapiro has been reported to be clinically effective, major methodological issues have been raised which remain to be addressed. One issue raised is whether exposure to the traumatic image is sufficient to account for the reported clinical effects of EMD or whether the addition of saccadic eye movements is central to the treatment. This study attempted to address this concern by comparing two EMD-based procedures: a Non-saccade phase (without the saccadic eye movements) which functioned as a control and a second that included saccadic eye movements. Dependent variables included selfreport information (SUDS, behavioral symptoms reports) and physiological data (heart rate and systolic blood pressure). The results showed no significant decreases in SUDS level with the EMD minus the saccadic eye movements procedure. However, five of the six subjects reported clinically significant decreases in their SUDS levels with the inclusion of the saccadic eye movements. This study appears to corroborate previous work employing single-case design as well as pre and postcomparisons.
Given that Post-Traumatic Stress Disorder (PTSD) “is the only disorder where we can clearly identify the onset” (Barlow, 1988, p. 499) and that there are no clearly identified treatments that provide consistent alleviation of the symptoms of the disorder (Fairbank & Nicholson, 1987; Pittman, Altman, & Greenwald, 1991; Solomon, Gerrity and Muff, 1992) there is a clear need for the development of a consistently effective treatment for PTSD. Eye movement desensitization [EMD] has been proposed (Shapiro, 1989a) as a new and highly efficacious treatment for PTSD. Wolpe (1990a) refers to EMD as a treatment whose confirmation “would make it a major contribution to the treatment of [PTSD]” (p. 272). In addition
to the original report in the literature by Shapiro (1989a) there have been 11 reports of case studies utilizing EMD (Hassard, 1993; Kleinknecht, 1993; Kleinknecht & Morgan, 1992; Lipke & Botkin, 1992; Marquis, 1991; McCann, 1992; Oswalt, Anderson, Hagstrom, & Berkowitz, 1993; Pellicer, 1993; Puk, 1991; Shapiro, 1989b; Wolpe & Abrams, 1991), one single-case experiment (Montgomery & Ayllon, 1994), and two group design experiments (Boudewyns, Stwertka, Hyer, Albrecht, & Sperr, 1993: which appeared in an unrefereed newsletter; and Sanderson & Carpenter, 1992). Since her initial report on EMD, Shapiro (1991a, b) has gone on to expand the field of disorders claimed as treatable by use of EMD
Requests for reprints should be addressed to Robert Montgomery,
100 Hillside Lane, Roswell, Georgia 30076-2828,
217
U.S.A.
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ROBERT W. MONTGOMERY
(now renamed EMD/R for Eye Movement Desensitization and Reprocessing) to include almost all anxiety disorders, multiple personality disorder, the unspecified issues of “adult children of alcoholics”, “dysfunctional” emotions such as excessive grief, rage, guilt, etc.” (1991 b, p. 135) and the clinically undefined area of “self-esteem issues” (Shapiro, 1992, p. 1). While a variety of presenting problems have been addressed (Marquis, 1991) and presented as appropriate for treatment utilizing EMD (Shapiro, 1992), the majority of the case reports have ad-dressed intrusive disturbing memories as a component of PTSD. Additionally, the Carpenter & Sanderson (1993) study demonstrated that Shapiro’s claims (1989a, b; 1991a, b) that the saccadic eye movements are essential for treatment efficacy are not supported in the use of EMD with simple phobias. Several reviewers (Dyck, 1993; Herbert & Mueser, 1992; Lohr et al., 1992; Wolpe, 1990a) have critiqued the current body of literature on EMD and called for experimental investigations of EMD. Herbert and Mueser (1992) point out that the literature on EMD to date is composed primarily of case studies and among their recommendations for future research is a call for intensive studies of EMD utilizing the power of single-case experimental designs (Barlow & Hersen, 1984). In addition, each of these reviews has called for more rigorous objective evaluation of patient psychopathology as a component of any future investigation, citing the lack of such diagnostic rigor as a significant failing of the literature to date. To date there have been few studies investigating the correlation of psychophysiological measures of physical reactivity to imaginal stimuli and self-report data (SUDS) of such experiences (Montgomery & Ayllon, 1994; Thyer, Papsdorf, Davis, & Vallecorsa, 1984). The EMD literature has relied almost exclusively [with the exceptions of Montgomery & Ayllon (in press), Shapiro (1989b) and Wolpe & Abrams (1991) studies] on
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self-report measures of treatment efficacy. While the subjective experience of each subject is certainly central to the evaluation of the utility of any treatment for psychopathology, reliance upon a single treatment outcome measure is a major limit to this body of literature. In view of the lack of adequately controlled investigations on the effectiveness of EMD, this study attempts to extend the preliminary findings of Montgomery and Ayllon (1994) and to investigate the role of exposure both with and without saccadic eye movements. Since that study was limited to one subject, this investigation includes six subjects and a multiple-baseline design across subjects to evaluate the role of saccadic eye movements in the EMD procedure. Further, this study includes physiological measures as an additional dependent variable to self-report as called for by Lohr et al. ( 1992). The essential questions addressed herein are: (1) does EMD provide subjective relief from PTSD symptomatology: (2) if subjects report subjective relief from such symptomatology are these reports corroborated by psychophysiological measures; (3) are there subject differences which may explain any treatment outcome differences across subjects; and (4) are the saccadic eye movements of EMD essential for any treatment gains?*
Method Subjects Six adult subjects aged between 25 and 55 were selected from referrals to the Regional Mental Health Services, a University Medical Center Adult Psychiatric Outpatient Clinic and the Adult Psychological Outpatient Clinic of the University Medical Center. Subjects were selected based on being diagnosed with PTSD [American Psychiatric Association (APA), 19871 which had been precipitated by other than military based trauma. Subjects were excluded from the study
*Our replication ot’ the EMD procedure as reported by Shapiro was enhanced by access to videotaped applications technique and discussions with Jospeh Wolpe, who also provided additional clarification on issues related to the technique.
of the
Eye Movement Desensitization
(Shapiro, 1989a, b; 1991b) if judged currently to be suffering from obsessive-compulsive disorder, substance abuse or dependence disorders, alcohol abuse or dependence, or have a history of schizophrenia, multiple personality disorder, or delusional disorder. Subjects were also excluded for history of serious cardiovascular disorders or potential for suicidal homicidal ideation. Those currently taking antipsychotic medications for any reason or receiving psychotherapy focused on the symptomatology associated with PTSD were excluded from the study. Those subjects not included were offered appropriate referral or alternative treatment. Subject number 1. A 36-year-old black female related an incident which had occurred 6 months prior to her evaluation in which her home was destroyed by tomados which had ravaged the area. Her car was buffeted and she thought that she was going to die. Upon returning to her neighborhood she discovered that her entire section of the area was decimated, and she feared that her husband was dead. The patient was reunited several hours later with her husband but did not recall their initial meeting following the event. She was diagnosed as suffering from PTSD and depression. The patient had received 3 months of supportive therapy prior to her entry into the current investigation. She was not receiving any other form of therapy at any point during the current investigation. Subject number 2. A 41-year-old white male also related an incident which had occurred 6 months prior to his evaluation in which his home was destroyed by tornados. The image which continued to intrude on the subject’s thoughts was of the funnel cloud approaching his home across a small pond while he watched in fascination as his neighbors’ houses were destroyed. The subject reported that he knew that he and his family were going to die when the tornado hit his home. It changed course at the last possible instant and did not hit the subject’s home. The patient had received pharmacotherapy for his PTSD symptoms for 2 months prior to entry into the investigation.
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Subject number 3. A 40-year-old white male reported that he had recurrent intrusive thoughts and dreams of an incident which occurred to him at the age of 17. The incident involved his father loading a shotgun in the subject’s presence, chambering the shotgun shell, placing the barrel of the weapon to the subject’s head and pulling the trigger. The shell which had been loaded had been previously fired and was inert; however, the subject was unaware of this fact at the time of the incident. His clearest image was of looking up the barrel of the shotgun as his father pulled the trigger. In psychological evaluations the subject was diagnosed as suffering from PTSD, mild depression, and dependent personality disorder with a history of both cannabis and alcohol dependence. The patient had received 28-day inpatient 12-Step treatment for his substance dependence and was continuing to attend outpatient 12-Step group meetings on a weekly basis. He was adjudged, by the attending psychiarist, to have been substance free for over 2 years at the time of entry into this study. Study number 4. A 25-year-old white male had both recurrent intrusive thoughts and dreams of an incident which occurred to him at the age of 22. The patient reported that while in prison he was beaten, knifed, and left for dead by other inmates. He reported that his intrmive thoughts were of the three inmates cornering him in the toilet/shower area, grabbing him, gagging him and assaulting him. His clearest image was of the light glinting off the polished metal of the handmade knife as it was initially plunged into his body. In psychological evaluations the subject was diagnosed as suffering from PTSD, mild depression, and a history of alcohol dependence. The patient had received 28-day inpatient 12-Step treatment for his alcohol dependence and was adjudged to have been alcohol free for over 3 years at the time of entry into this study. Subject number 5. A 36-year-old white male had related an incident which occurred almost two years prior to his interview, in which he had been attacked and almost killed by three pitbull terriers.
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The dogs ran him down, harried him, nearly severed his left arm at the shoulder, and only left when the subject lost consciousness due to loss of blood. The subject’s clearest and most disturbing image of the event was of being on his back on the ground holding the largest of the pitbulls off by grasping its fur around the neck as the dog lunged at his face. The patient was diagnosed as suffering from PTSD, panic disorder with agoraphobia, and mild depression. The patient was receiving 5 mg of Valium daily prior to going to sleep each night. Medication was provided on a weekly basis and maintained at pre-investigation levels throughout all phases of the investigation. Subject number 6. A 38-year-old white female related an incident which had occurred 6 months prior to her evaluation in which her home and automobile were destroyed by tornados. The subject reported hearing a loud roaring sound, feeling her home shake, grabbing her 3-year-old child and heading for a culvert down the street from her home. While in the culvert she looked up and saw a funnel of the tornado heading straight for where she and her child were lying. When she looked up again her home and automobile were destroyed, the car was on its side against a tree and her home was obliterated. The patient also reported not being able to recall what occurred to her from the time when she looked up and saw her devastated home and when she was sitting in her husband’s pickup truck over an hour later. The patient was diagnosed as suffering from PTSD, storm phobia, and panic disorder with agoraphobia. The patient had received no therapy for her condition. Apparatus and Measurements
Subjects were screened using: the Structured Clinical Interview for The DSM-III-R (SCID: Spitzer, Williams, Gibbon, & First, 1990); the Structured Clinical Interview for the DSM-III-R for Personality disorders (SCID-II: Spitzer, Williams, & Gibbon, 1987); Beck Depression Inventory (BDI: Beck, Ward, Mendelsohn, Mock & Erbaugh, 1961); Anxiety Disorders Interview
and TEODORO
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Schedule-Revised (ADIS-R: DiNardo et al., 1985); a brief biographical/clinical history questionnaire; the revised Betts Questionnaire on Mental Imagery (QMI: Sheenan, 1967); The Fear Survey Schedule (Wolpe & Lang 1969); and the Subjective Anxiety Scale (SUDS: Wolpe, 1982, 1990). In addition a clinical interview covering those areas of concern to the subject centering on their traumatic memories was conducted. Physiological data were collected using the Omron HEM-8 15F Automatic Oscillometric Electronic Digital Blood Pressure & Pulse Monitor (Shigemi et al., 1990). Measures of “belief” in selfstatements centering on the disturbing images were taken (as in Shapiro, 1989a) using a 7-point semantic differential scale (1 = completely untrue; 7 = completely true) to assess changes in the belief in the alternative to the irrational belief theorized to underlie the traumatic memory/image. The initial and weekly subsequent interviews included questions regarding the frequency and disruptive effects of such presenting problems as flashbacks, intrusive thoughts, and sleep disturbances. General Procedures
As a condition of the multiple baseline design across subjects, assessment, baseline, non-saccade treatment, EMD treatment, and follow-up for subjects were run in tandem, and sessions were run so that sessions across baselines were within a day of each other. Subjects attended sessions on an average of twice a week throughout the active phases of the study and once weekly during the follow-up phase. Times of the day and day of the week were kept as consistent as possible across subjects throughout this study. Baseline data were collected during initial intake assessments. During sessions both self-report and physiological data were collected concurrently. Decisions concerning inclusion/exclusion in the investigation were made using both medical records and data collected during this initial intake/baseline period. Each session lasted approximately 75 minutes and began with a general explanation of the agenda for the session. The dependent variables were subjective anxiety level (as measured by the
Eye Movement Desensitization
SUDS), presenting complaints surveyed weekly severity and frequency of flashbacks, (e.g., intrusive memories/images, and sleep disturbances: including sleep hygiene and nightmares) and physiological measures of anxiety. Physiological measures were taken prior to each session and concurrently with each self-report of subjective anxiety (SUDS). Following each administration of non-saccade or EMD treatment protocol each subject was asked to report their subjective distress (SUDS) and cognitive shifts (as developed by Shapiro, 1989a) using a 7-point Semantic Differential scale while physiologic measures were recorded. As in Shapiro (1989a, b), self-statements concerning the patients’ beliefs around the traumatic image were solicited and each patient was asked to rate the degree of the strength of their belief in those self-statements on a bipolar adjective anchored Likert type seven point scale. Subjects were asked to wait quietly in the treatment room for 5 minutes prior to any assessments in an effort to assure that the stability of the psychophysiological measures was not effected by physical exertion or ambient heat differentials. Following this acclimation period data was collected according to the parameters of the applicable protocol then in effect. Baseline Procedures During the baseline condition (Phase A) subjects were asked to fill out several assessment and history questionnaires while data concerning their intrusive image and the anxiety surrounding that image were collected. At five points, once approximately every 1.5 minutes, subjects were directed to imagine both the traumatic scene and the words of the self-statements that best fit the image (as in Shapiro, 1989a). They were then asked verbally to assign a subjective level of distress (SUDS) rating to the scene. Blood pressure and heart rate data were collected concurrently with the assignment of a SUDS rating to the disturbing image utilizing the Omron HEM-8 1.5F Automatic Oscillometric Electronic Digital Blood Pressure & Pulse Monitor (Shigemi et al., 1990).
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221
After determining the level of distress experienced (via self-report and physiological measurements), each subject was then asked to state how they would like to feel instead and to supply a new selfstatement to reflect the desired feeling. The subject was then asked verbally to report (on a 7point Semantic Differential Scale) how true the new statement was for them (as in Shapiro, 1989a). Non-Saccade
Procedure
Following the baseline condition of the experiment, a brief control for the presence of saccadic eye movements in the full “Shapiro” condition was implemented with each subject (Phase B). The non-saccade procedure presented all aspects of the EMD treatment procedure to the subject except for the saccadic eye movements which characterized Shapiro’s (1989a, b) procedure and characterized as operative in EMD. The following intervention is taken directly from Shapiro (1989a). Subjects were told that: What we will be doing is often a physiological check. I need to know from you exactly what is going on with as clear feedback as possible. Sometimes things will change and sometimes they won’t. I may ask you if the picture changes - sometimes it will change and sometimes it won’t. I’ll ask you how you feel from 0 to IO - sometimes it will change and sometimes it won’t. 1 may ask if something else comes up - sometimes it will and sometimes it won’t. There are no ‘supposed to’s’ in this process. So just give as accurate feedback as you can as to what is happening without judging whether it should be happening or not. Just let whatever happens, happen. (p. 204)
Following the initial anxiety rating, each subject was asked to sit upright in a chair in a relaxed posture and look straight ahead. The subject was then asked to stare at a fixed point while imagining the disturbing scene for 30 seconds. This procedure was repeated 20 times during each non-saccade session with approximately 1 minute breaks between each “treatment” thus generating data on an average of every three minutes throughout each session. The non-saccade condition continued for three sessions at the conclusion of which the EMD treatment condition was implemented.
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All standard measures (SUDS, HR, BP, semantic differential, etc.) were taken during the non-saccade condition EMD Treatment
EMD treatment procedure was terminated after six sessions, and with one subject after three sessions when the SUDS level was at an average of 1 (on a l-10 scale).
Procedure Follow-Up
As in the non-saccade condition, during the EMD treatment phase (B + C Phase) each subject was asked to provide initial anxiety ratings (SUDS) prior to treatment. Subjects were then instructed to visualize the traumatic scene/image, rehearse the negative self-statement (upon which semantic differential reports were taken), and provide a SUDS rating of the anxiety (during which physiological measures of anxiety were taken). The investigator then caused (as described in Shapiro, 1989a, b; 199 1b; Wolpe, 1990b) the subject to generate a series of voluntary, bilateral, rhythmic saccadic eye movements by moving a stimulus (an upraised index finger) rapidly back and forth across their field of vision (approximately two sweeps per second). The stimulus was located 12-16 inches from the face of the subject and was moved from the extreme left of the field of vision to the extreme right of the visual field and back again (as in Shapiro, 1989a, b; Wolpe, 1990b). The distance of one such sweep was approximately 12-18 inches. Twenty such sweeps were administered during each set. After each set the subject was asked to: “blank it (the image) out, and take a deep breath.” (Shapiro, 1989a, p. 205) He was then asked to bring up the image and self statement again, to concentrate on the anxiety level generated, and to provide a SUDS level rating (during which additional physiological measures were taken). Subjects were then asked: (1) “Did the picture change?“, and (2) “Does anything else come up?” in order to track that the image stated at the outset of the set was the image imagined during the procedure. As in the non-saccade condition, if the subject’s SUDS level was reduced the subject’s belief in the validity of the new desired self statement (or as Shapiro refers to it: “Belief system”) was assessed by asking “How do you feel about the statement from ’ 1’ - completely untrue to ‘7’ - completely true” (p. 205). The
Initial follow-up was done at one week following EMD treatment completion. Such interviews involved history taking of PTSD symptoms (e.g., sleep disturbances, flashbacks, frequency of intrusive thoughts, instances of aggressive episodes), physiological monitoring of anxiety around the treated image, and reports by the subject on SUDS level and belief in selfstatements (on the 7-point semantic differential scale) investigated during the active phases of the study as in the baseline phase of the investigation. Additional follow-up sessions were conducted as possible on a weekly basis for as many weeks as possible with each subject.
Results Within Session
Data
The t-test for dependent samples (Shavelson, 1981; Kazdin, 1983) was used to examine the data for statistical significance. Shavelson (198 1) points out that, the t-test for dependent samples is designed to take the fact that within subject data is correlated into account. While general downward slope of the data were noted in each of the measures of within session distress, statistical significance was demonstrated in only the overall decreases in Subjective Units of Distress (to,,<= 5.24, p < .005). Subjective units of distress. An overall summary of the SUDS data is presented in Table 1. During baseline subjects generally had a steady level of subjective distress without great variance throughout this phase of the investigation (see Figures l-3). While there was a slight fluctuation in the SUDS reports during Phase B (NonSaccade), variance was limited and the range was
Eye Movement Desensitization
223
Across Subjects
Table 1 Mean Subjecfive Unirs ofDisrress*t
1
2
3
4
5
6
Mean
10.0 9.4 7.7 3.7
8.0 8.0 1.4 1.3
8.9 7.9 5.2 2.1
7.8 6.4 I .5
7.0 7.4 6.1 7.3
7.9 8.1 2.5 1.4
8.27 7.82 4.21 2.74
Subject Baseline Non-Saccade EMD TX Follow-Up
(based upon self-report:N = 6)
1.4
* = (rob\= 5.24, p < 005). tThe r-test for dependent samples (Shavelson, 1981; Kazdin, 1984) was used to examine throughout the study. All r-scores reported represent tests for dependent samples. narrow
and not clinically
significant. SUDS the EMD Treatment Phase (B + C). Within the initial session of EMD treatment variance was lowest and was greatest within the last EMD treatment session. Decreases in subjective distress were generally demonstrated throughout the Follow-up Phase. decreased
steadily
during
Systolic blood pressure. An overall summary of systolic blood pressure (SBP) for each subject is presented in Table 2. The changes in systolic blood pressure recorded across phases of this investigation did not achieve statistical significance. However, general decreases in most of the subjects in recorded SBP are noted (Mean change from Baseline to EMD Treatment is 19.7 mm Hg). Heart rate. An overall summary of heart rate data is presented in Table 3. The changes in heart rate recorded across phases of this investigation failed to achieve statistical significance. However, general decreases in most of the subjects’ recorded heart rates are noted (mean change from Baseline to EMD Treatment is 6.2 bpm).
the data for statistical
significance
Between session data. Initially flashbacks were conceived of as an additional measure of treatment efficacy, however, flashbacks were not reported by any of the six subjects of this study and therefore, are not reported upon herein. Data on both intrusive thoughts and disturbing dreams was recorded on a weekly basis during each phase of this investigation. Intrusive thoughts. Without exception there was no statistical difference between Baseline (A) and Non-Saccade (B) Phases for any of the six subjects for intrusive thoughts. The rate of days per week reported as having had intrusive thoughts occur dropped from a pretreatment (Baseline and NonSaccade phases) mean of 5.57 to a mean of 2.55 during the EMD Treatment (B + C) Phase and further to 1.88 days per week during the follow-up period. This represents a decrease of 66% from baseline to follow-up levels (see Table 4). Statistical significance, between Phases A and B and EMD Treatment (B + C) levels, was achieved for intrusive thoughts (to,,,= 5.67, p < .005). Dreams.
As with intrusive
thoughts,
without
Table 2 Mean Systolic Blood Pressure*
Subject Baseline Non-Saccade EMD TX Follow-Up
(N = 6)
I
2
3
4
5
6
Mean
182.1 167.4 146.0 130.7
151.9 142.8 122.5 124.6
157.9 153.6 143.5 129.4
154.1 141.8 128.0 125.8
145.3 141.3 147.5 153.3
134.5 134.9 120.3 119.6
153.8 145.8 135.9 130.8
*Did not achieve statistical significance.
224
ROBERT W. MONTGOMERY
and TEODORO
FollowUp
B+c
A IO-
AYLLON
-
-
e67-
& e-
3
I-
94cn 3-
21 0
0
1
2
3
0
1
2
3
2 1 0 i
Sessions Figure 1. Subjective Units of Distress (SUDS) for Subject 1 (36 yr, female, Tornado victim) and Subject 2 (41 yr, Male, Tornado victim) across Baseline (A); Non-Saccade (B); EMD Treatment (B + C); and Follow-Up.
exception there was no statistical difference between Baseline (A) and Non-Saccade (B) Phases for any of the six subjects for dreams (See Table 5). Additionally, there was found to be no statistical difference between reported rates of
intrusive thoughts or dreams between EMD Treatment (B + C) and follow-up. The rate of days per week reported for dreams dropped from a baseline mean of 3.92 to a mean of 2.13 during the EMD Treatment (B + C) Phase. Reported dreams
Table 3 Mean Heart Rote c~cmw Subjem Subject Baseline Non-Saccade EMD TX Follow-Up
and Cortdition.s* (IV = 6)
1 85.2 83.5 79.7 75.5
*Did not achieve statistical significance.
2
3
4
5
6
Mean
74.5 75.2 73.8 73.0
83.5 81.3 77.3 72.3
82.2 77.2 72.9 72.5
76.8 16.7 71.1 75.6
78. I 74.1 68.8 69.X
80.3 77.6 74.4 72.7
Eye Movement Desensitization
Across Subjects
225 Follow-Up
B+C
O’,,
,,I
0
1
I
234587
e
I
I
0
io
I
I
11
12
I
I
I
13
14
15
I
16
17
ie
io
20
Sessions Figure 2. Subjective Units of Distress (SUDS) for Subject 3 (40 yr, male, Shotgun victim) & Subject 4 (25 yr, male, Knife victim) across Baseline (A); Non-Saccade (B): EMD Treatment (B + C); and Follow-Up.
continued to drop following termination of active treatment to a mean of 1.20 during follow-up. This drop in dreams across pretreatment (Baseline and Non-Saccade Phases) to treatment/ follow-up represents a drop in disturbing dreams of 2.0 dreams per week or a 5 1% decrease in the rate of disturbing dreams. Statistical significance, between Baseline and EMD Treatment (B + C) levels, was achieved for dreams (fobs= 12.71, p < .005). Depression. Scores reported for the Beck Depression Inventory (BDI) were recorded during intake/initial assessment and during the Follow-
Up Phase of the investigation. Pretreatment BDI levels were predominately in the mildly depressed range (BDI range 11-17) with one exception (Subject 1: BDI = 24) reporting moderate levels of depression (Steer & Beck, 1988). Each of the subjects answered fewer questions in the storable direction at the posttreatment measurement. The single largest drop in reported depression was for subject one, whose BDI dropped 9 points from pre to posttreatment measurement. Posttreatment BDI levels demonstrated a mean drop of 4.0 (See Table 6) over pretreatment levels, which is statistically significant (tabs= 8.22, p < .005).
226
ROBERT W. MONTGOMERY
and TEODORO
:
L
3
FollowUp
B+C
0
4
AYLLON
8
7
0
8
10
11
12
L----
85 $4 3 2 I
,
0 I-012343
13
14
13
16
17
18
Sessions Figure 3. Subjective Units of Distress (SUDS) for Subject 5 (36 yr, Male, Pitbull victim) & Subject 6 (38 yr, female, Tornado victim) across Baseline (A); Non-Saccade (B); EMD Treatment (B + C); and Follow-Up.
Table 4
Table S
Mean Number of Days per Week of Intrusive Subject and Experimental Condition
Thoughts
by
Mean Number of Days per Week with Disturbing Across Subjects and Experimental Condition
Days with Intrusive Thoughts/Week Subject/phase
A
B
I
7.0 3.7 5.7 6.7 5.0 5.7 5.63
7.0 4.0 5.0 6.0 5.0 6.0 5.50
2 3 4 5 6 Mean*
B+C 1.I 2.0 2.3 1.7 4.6 3.0 2.55
* = (to&= 5.67, p < ,005). A = Baseline Phase; Saccade Phase; B + C = EMD Treatment Phase
Follow-Up
I .o I .5 0.8 2.0 5.0
1.o 1.88 B = Non-
Days with Disturbing Subject/Phase
A
B
I
3.5 1.0 3.0 5.3 7.0 3.7 3.92
3.5 I .5 3.0 3.5 5.0 4.0 3.42
2 3 4 5 6 Mean*
*=(I<,~,= 12.7l,p<.OO5). A = Baseline Phase; B = Non-Saccade Treatment Phase.
Dreams/Week
B+C 1.3 0.8
1.7 3.0 4.0 2.0 2.13
Dreams
Follow-Up 0.0 0.0 0.7 0.8 5.3 0.4 1.20
Phase; B + C = EMD
Eye Movement Desensitization Table 6 Beck Depression Inventory Scores* Subject
I 2 3 4 5 6 Mean *=
Pretreatment
Posttreatment
24 16 14 14 12 14 15.7
17 12 12 11 9 9 11.7
Change I 4 2 3 3 5 4.0
(toha = 8.22, p < .005).
Discussion Given the paucity of outcome research in the treatment or PTSD (Solomon, Gerrity & Muff, 1992), any methodologically sound experimental investigation of treatment outcome for PTSD is an addition to the literature. This study investigated Eye Movement Desensitization as a treatment for PTSD in a non-combat trauma population. In an effort to address criticisms made of the EMD literature to date (Herbert & Mueser, 1992; Lohr et al., 1992) and limitations in the PTSD treatment outcome literature more broadly, a single-case experimental design (Barlow & Hersen, 1984) was used to evaluate treatment efficacy. Partial dismantling of the EMD treatment was conducted by the addition of a Non-Saccade (B) Phase wherein subjects received all components of Shapiro’s (1989b, 1991b) treatment package minus the saccadic eye movements. Following this Non-Saccade phase, the EMD treatment protocol as presented by Shapiro was conducted. As noted in the Introduction, the essential questions addressed herein are: (1) does EMD provide subjective relief from PTSD symptomatology; (2) if subjects report subjective relief from such symptomatology are these reports corroborated by psycho-physio-logical measures; (3) are there subject differences which may explain any treatment outcome differences across subjects; and (4) are the saccadic eye movements of EMD essential for any treatment gains? In addressing the first question, “does EMD
Across Subjects
227
provide subjective relief from PTSD symptomatology”: the findings of this study are generally positive. The self-report data, both within sessions and across sessions (i.e., SUDS, Intrusive Thoughts, Dreams, BDI score), to a limited extent support the data as presented by Shapiro (1989a, b; 199 lb) and others (Kleinknecht & Morgan 1992; Lipke & Botkin, 1992; Marquis, 1991; McCann, 1992; Pellicer, 1993; Puk, 1991; Shapiro, 1989b; Wolpe & Abrams, 1991) on the efficacy of EMD. A significant exception to these results was Subject 5. While the self-report data are clinically significant (a reported decrease in SUDS, with the exclusion of Subject 5, of 6.54 from a baseline mean of 8.52 to a follow-up mean of 1.98), the treatment gains are not as immediate nor as profound as those reported elsewhere in the literature (i.e., Shapiro, 1989a, b; Lipke & Botkin, 1992; Marquis, 1991; McCann, 1992; Puk, 1991). Additionally, these treatment gains, with the exception of Subject 6, were achieved over the course of six EMD treatment sessions not the one or two previously reported by Shapiro. The second question, “if subjects report subjective relief from such symptomatology are these reports corroborated by psychophysiological measures”, is less clearly answered by the data. Attempts were made to correlate the self-report measures of treatment efficacy with more objective measures of any changes in anxiety levels. While there were not statistically significant changes in the anticipated direction for either systolic blood pressure or heart rate, there were consistent decreases in both physiological measures. Systolic blood pressure decreased an average of 22.99 mm Hg from baseline through follow-up. Heart rate dropped from a mean of 80.29 bpm during baseline to 72.69 bpm during the follow-up (an average drop of 7.6 bpm). Reports of decreases across psychophysiological measures were more pronounced (28.7 mm Hg and 8.9 bpm) for the subjects who reported positive treatment effects (excluding Subject 5). These findings can be viewed as supporting the self-report data on clinically relevant decreases in situational anxiety surrounding the disturbing images investigated.
228
ROBERT
W. MONTGOMERY
The third question, “are there subject differences which may explain any treatment outcome differences across subjects”, is more easily answered. There was only one subject (Subject 5) who did not report positive treatment gains during the EMD Treatment Phase of this investigation. During the follow-up phase it was discovered that this subject was involved in litigation seeking compensation for his claimed disability. This fact may provide some rationale for why subject 5’s reaction to the EMD technique was atypical. The subject had been declared fit for return to work by his orthopedist, physical therapist, and surgeon. His attorney was making his claim of total disability based solely upon the subject’s diagnosis of PTSD. It is therefore, possible that his reporting of subjective distress was influenced by an attempt to strengthen his legal claim to monetary compensation. The fourth question, “are the saccadic eye movements of EMD essential for any treatment gains” was addressed by the use of a Non-Saccade Phase. Since Shapiro (1989a, b; 199 1b) presented a treatment package with three identified components, the question was whether the combination of saccadic eye movements, cognitive restructuring and repeated short term exposure was necessary for treatment gains in PTSD subjects or whether the combination of cognitive restructuring and repeated exposure, without the saccadic eye movements, alone were sufficient for significant treatment gains was addressed. The data indicate that with PTSD subjects the use of short duration repeated exposure and cognitive restructuring alone were insufficient for positive treatment gain. SUDS declined non-significantly (0.45, from a mean of 8.27 to a mean of 7.82) during the Non-Saccade phase of the investigation. The addition of the saccadic eye movements to the treatment package (thereby replicating Shapiro’s original protocol) resulted in the significant decreases in self-reports of distress previously addressed. These findings are reflected by decreases in the psychophysiological measures of arousal. It appears from these data that the combination of the three components is superior to the use of only the
and TEODORO
AYLLON
repeated exposure and cognitive restructuring components alone. The present study generally supports the utility of EMD as a treatment for PTSD. While the treatment gains were neither as immediate nor as profound as those reported by Shapiro, they are of greater magnitude and occurred in a shorter treatment time than typically occurs with traditional (implosive therapy and imaginal flooding) treatment techniques for PTSD. Flooding as described by the National Center for PTSD Research at the Boston VA Medical Center (Lyons & Keane, 1989), usually lasts 2-2.5 hours per session (not all of which is devoted to reliving the traumatic scene) and is “generally continued for at least several sessions” (p. 149). The typical VA patient, being treated with implosive therapy for PTSD, will receive from 8 to 16 hours of exposure to a specific traumatic scene during the course of therapy. On the other hand, EMD subjects are exposed to 6-12 minutes of exposure following Shapiro’s protocol as originally (1989b) presented. It must, however, be noted that in the final examination, all self-report measures (for five of the six subjects of this investigation) demonstrated both clinically and statistically significant treatment gains and that all the psycho-physiological measures of treatment efficacy (for all six of the subjects) failed to demonstrate statistical significance. Future investigations of EMD should incorporate those criticisms of the literature offered by both Lohr and colleagues ( 1992) and Herbert and Mueser (1992). Continued use of single-case experimental methodology is also indicated in investigating the treatment of PTSD subjects, regardless of the treatment(s), investigation, demands emphasis on both diagnostic rigor and objective measurement of disorder sequelae (including follow-up reassessment for the presence of PTSD). Refinement of psycho-physiological measurement of levels of situational distress should play a significant role in any future investigation of EMD. Finally, objective measures of intrusive thoughts and disturbing dreams may in the future be available through anticipated advances in computer technology and neuro-imaging.
Eye Movement Desensitization Acknowledgements
- This study was funded in part through a dissertation support grant (GSU: 93-003) from the Chancellor of the University System of Georgia and matching funds from the chair of the Department of Psychology at Georgia State University. The authors thank Joseph Wolpe, Robert Brown, Walter F. Davies, Gregory Jurkovic, Sudhakar Madakasira, Michael A. Milan and Donald B. Penzien, and two anonymous reviewers.
References American
Psychiatric
statistical
manual
Association.
(1987).
of mental
disorders
Diagnostic
and
(3rd ed. rev.).
Washington, DC: Author. Barlow, D. H. (1988). Anxiety and its disorders. New York: Guilford. Barlow, D. H., & Hersen, M. (1984). Single case experimental designs; strategies for stud&g behavior change (2nd ed.). New York: Pergamon Press. Beck, A. T., Ward, C. H., Mendelsohn, M., Mock, _I., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatv,
4, 561-571.
Boudewyns, P. A., Stwertka, S. A., Hyer, L. A., Albrecht, J. W., & Sperr, E. V. (1993). Eye movement desensitization for PTSD of combat: a treatment outcome pilot study. The Behavior
Therapist,
Interview Schedule
-
Revised (AD&R).
Albany, NY: Phobia and Anxiety Disorders Clinic, State University of New York. Dyck, M. J. (1993). A proposal for a conditioning model of eye movement desensitization treatment for posttraumatic stress disorder. Journal of Behavior Therapy & Experimental
Psychiatry, 24, 201-210.
Fairbank, J. A., & Nicholson, R. A. (1987). Theoretical and empirical issues in the treatment of post-traumatic stress disorder in Vietnam veterans. Journal of Clinical Psychology,
43, 44-55.
Hassard, A. (1993). Eye movement desensitization of body image. Behavioural Psychotherapy, 21, 57-160. Herbert, J. D., & Mueser, K. T. (1992). Eye movement desensitization: a critique of the evidence. Journal of Behavior 169-174.
Therapy
& Experimental
Psychiatry,
23,
Kazdin, A. E. (1983). Statistical analyses for single-case experimental designs. In D. H. Barlow & M. Hersen (Eds.) Single case experimental designs: strategies for studing behavior change (2nd ed.). New York: Pergamon Press.
Kleinknecht, injection
R. A. (1993). Rapid treatment of blood and phobias with eye movement desensitization.
Journal of Behavior 24, 21 I-217.
Therapy
& Experimental
Psychiatry,
Kleinknecht, R. A., & Morgan, M. P. (1992). Treatment of posttraumatic stress disorder with eye movement desensitization. Journal of Behavior Therapy & Experimental
Psychiatry, 23, 43-49.
Lipke, H. J., & Botkin, A. L. (1992). Case studies of eye movement desensitization and reprocessing (EMDR) with chronic post-traumatic stress disorder. Psychotherapy, 29, 591-595.
229
Lohr, J. M., Kleinknecht, R. A., Conley, A. T., Dal Cerro, S., Schmidt, J., & Sontagg, M. E. (1992). A methodological critique of the current status of eye movement desensitization and reprocessing (EMD/R). Journal of Behavior 159-167.
Therapy
& Experimental
Psychiatry,
23,
Lyons, J. A., & Keane, T. M. (1989). Implosive therapy for the treatment of combat-related PTSD. Journal of Traumatic Stress, 2, 137-152. McCann, D. L. (1992). Post-traumatic stress disorder due to devastating burns overcome by a single session of Eye Movement Desensitization. Journal of Behavior Therapy & Experimental
Psychiatry, 23, 319-323.
Marquis, J. N. (1991). A report on seventy-eight by eye movement desensitization. Journal Therapy and Experimental
Psychiatq,
cases treated
of Behavior 187-192.
22,
Montgomery, R. W., & Ayllon, T. (1994). Eye movement desensitization across images: a single case design. Journal of Behavior 23-28.
Therapy
and Experimental
Psychiatry,
25,
Oswalt, R., Anderson, M., Hagstrom, K., & Berkowitz, B. (1993). Evaluation of the one-session eye-movement desensitization reprocessing procedure for eliminating traumatic memories. Psychological Reports, 73, 99-104. Pellicer, X. (1993). Eye movement desensitization treatment of a child’s nightmares: a case report. Journal of Behavior Therapy and Experimental
16, 29-33.
DiNardo, P. ., Barlow, D. H., Cerny, J., Vermilyea, B. B., Vermilyea, J. A., Himadi, W., & Waddell, M. (1985). Anxiety Disorders
Across Subjects
Psychiatry, 24, 73-75.
Pittman, R. K., Altman, B., & Greenwald, Psychiatric complications during flooding posttraumatic stress disorder. Journal
E. (1991). therapy for of Clinical
Psychiatry, 52, 17-20.
Puk, G. (1991). Treating traumatic memories: a case report on the eye movement desensitization procedure. Journal of Behavior 149-151.
Therapy
and
Experimental
Psychiatry,
22,
Sanderson, A., & Carpenter, R. (1992). Eye Movement Desensitization versus image confrontation: a singlesession crossover study of 58 phobic subjects, Journal of Behavior 269-275.
Therapy
& Experimental
Psychiatry,
23,
R. J. (1981). Stutisfical reasoning for the sciences. Boston: Allyn and Bacon, Inc. Shapiro, F. (1989a). Efficacy of the eye movement desensitization procedure in the treatment of traumatic memories. Journal of Traumatic Stress, 2, 199-223. Shapiro, F. (1989b). Eye movement desensitization: a new treatment for post-traumatic stress disorder. Journal of Shavelson,
behavioral
Behavior 21 l-217.
Therapy
and
Experimental
Psychiatry.
Shapiro, F. (1991a). Eye movement desensitization reprocessing: a cautionary note [Letter to the editor]. Behavior Therapist, 14, 188. Shapiro, F. (1991b). Eye movement desensitization reprocessing procedure: from EMD to EMD/R - a treatment model for anxiety and related trauma. Behavior Therapist, 14, 128, 133-135. Shapiro, F. (1992). Eye movement desensitization reprocessing:
1992 Level I basic training
schedule.
Alto, CA: EMRD. Sheenan, P. W. (1967). A shortened form Questionnaire Upon Mental Imagery. Journal Psvcholog?;,
23, 386-389.
20,
and The
and new The and
Palo
of Betts’ of Clinical
230
ROBERT W. MONTGOMERY
Shigemi, K., Takahashi, H., Hashimoto, S., Noni, S., Chihara, E., Kinoshita, T., Tanaka, Y., & Miyazaki, M. (1990). A comparative study of measurement of arterial blood pressure using HEM-802F and arterial cannulation. Journal of Anesthesiology, 4, 91-93. Solomon, S. D., Gerrity, E. T., & Muff, A. M. (1992). Efficacy of treatments for Posttraumatic Stress Disorder. Journal of the American
Medical Association,
Spitzer, R. L., Williams,
268, 633638.
J. B. W., Gibbon, M., & First, M. B.
(1990). Structured clinical interview for DSM-III-R -Nonpatient edition (SCID-NP). Washington, DC: American
Psychiatric Press. Spitzer, R. L., Williams, Structured disorders.
J. B. W., & Gibbon, M. (19X7). clinical interview for DSM-III-R - Personality New York: Biometrics Research Department of
the New York State Psychiatric Institute. Thyer, B. A., Papsdorf, J. D., David, R., & Vallecorsa,
S.
and TEODORO (1984).
AYLLON
Autonomic
correlates
of the subjective
anxiety
Journal of Behavior Therapy and Experimental Psychiatry1 15, 3-7. Wolpe, J. (1982).The practice of behuvior therapy (3rd ed.).
scale.
New York: Pergamon Press. Wolpe, J. (1990a). The practice ofbehavior therapy (4th ed.). New York: Pergamon Press. Wolpe, J. (1990b). Eye movement desensitization (Video Cassette Recording CP V 17). Phoenix, AZ: The Milton H. Erickson Foundation. Wolpe, J., & Abrams, J. (1991). Post-traumatic stress disorder overcome by eye movement desensitization: a case report. Journal of Behavior 22. 3943.
Therap.v and Experimental
Psychiatry,
Wolpe, J., & Lang, P. J. (1969). Few survey schedule. San Diego, CA: Educational and Industrial Testing Service.