I. Behav. Ther & Exp. Psvchiat. Printed in Great Britain.
TREATMENT
Vol. 23. No. 1. pp. 4S49,
1992 0
OF POSTI’RAUMATIC STRESS DISORDER MOVEMENT DESENSITIZATION RONALD Department
lMK&7916/92 65.M + 0.M IYY? Pergamon Press Ltd
WITH EYE
A. KLEINKNECHT
of Psychology,
MARK
Western
Washington
University
P. MORGAN
The Martin Center,
Bellingham,
Washington
Summary - This case report describes the successful treatment of a posttraumatic stress disorder (PTSD) using eye movement desensitization (EMD). The client, a 40-year-old male, presented with an &year history of PTSD following an incident in which he was shot with a hand gun and left dying. Using EMD treatment, this trauma was quickly desensitized. Two earlier traumas with similar themes then emerged and they too were desensitized. Test results, taken pretreatment and posttreatment, along with the client’s verbatim account of cognitive and behavioral changes 8 months later, converged to document the successful treatment outcome.
Theoretical structures continue to evolve to foster understanding of fear-related conditions such as posttraumatic stress disorder (PTSD) and to advance rational treatment approaches (Chemtob, Roitblat, Hamada, Carlson, & Twentyman, 1988; Foa & Kozak, 1988; Rachman, 1990). Despite these efforts and their resultant treatment advances, PTSD remains one of the more recalcitrant of the anxiety disorders. However, a new treatment procedure, Eye movement Desensitization and Reprocessing (EMD) applicable to anxiety appears to hold great promise if upheld on more rigorous experimental scrutiny. This procedure, developed by Shapiro, (1989a, 1989b, 1991a), appears to have profound antianxiety effects on trauma and anxiety related disorders (Lipke & Botkin, in press; Marquis, 1991; Puk, 1991; Shapiro, 1989a, 1991a; Wolpe & Abrams, 1991). The present report describes a case of PTSD of 8 years duration that was successfully treated using EMD. This case is presented to Requests for reprints should be addressed to Ronald University, Bellingham, WA 98225, U.S.A.
illustrate the potential that this procedure appears to have for alleviating such previously refractory conditions as PTSD. Further, this case would appear to involve largely a “pure” EMD treatment in that it was used from the outset as the treatment modality. Treatment effects are substantiated with test data obtained at pretreatment, at 4 and 8 months posttreatment and client self-statements concerning his observed changes in behavioral, affective, and cognitive functioning.
Case Description The client, Jim, was a 40-year-old white male who holds a Masters degree in Counseling Psychology and is currently employed as a family and adolescent counselor. The traumatic episode that precipitated the PTSD symptoms occurred 8 years prior to his seeking the current treatment. However, as will be descri-
A. Kleinknecht,
43
Department
of Psychology,
Western
Washington
44
RONALD
A. KLEINKNECHT
bed, previous significant life traumas may well have predisposed the client to developing the full PTSD syndrome at this time. Jim observed a house burglary taking place and gave chase to the suspects. Having caught up with one of them on a small knoll, he took his eyes off the suspect for an instant as he looked around for help. When he looked back the suspect held a hand gun which he fired at Jim, hitting him three times. One bullet severed the right femoral artery, two others struck his left leg. When the gun was empty, the assailant ran away. leaving Jim alone in a deserted parking lot. unable to move until passers by found him.
and MARK
P. MOR(;AN
A .s.se.s.sm en ts
At intake. the following standardized tests were administered: the Brief Symptom Inventory, (BSI; Derogatis & Spencer, IY82); the State Trait Anxiety Inventory (STAI-Trait. Form Y; Spielberger, Gorsuch. Luschcnc. Vagg, Kc Jacobs. lYX3); the Center for Epidemiological Studies - Depression Scale (CESD; Weissman, Sholomkas, Pottenger, Prusoff. CycLocke, 1977). Test scores were taken pretreatment and at 4 and X months posttreatment.
PTSD Symptoms Experienced Treatment Being shot and left for dead is clearly beyond the range of usual human experience (APA. 1987). This trauma resulted in dreams involving either a gun barrel or the staring face of an “uncaring, killer-type of person,” recurring approximately once per month for X years. Significant psychological distress was evoked by the sight and sound of ambulances. loud noises. media depictions of violent assaults. or the sight of handguns. Cold. damp weather. reminiscent of the autumn ground on which he lay wounded also triggered PTSD symptoms. He systematically avoided movies with violent themes. Restimulation of the shooting trauma triggered depressive episodes lasting from days to weeks. Further PTSD symptoms included difficulties with concentration and memory, hypervigilance, restless, scanning his environment for signs of danger. He responded explosively to unexpected physical contact and was highly reactive to sharp sounds and stimuli associated with the trauma. The present treatment was sought due to the continuing state of high anxiety, hypervigilance, feelings of emotional detachment and distance from others, recurrent thoughts of the assault, a pressing need to &‘tell the story.” nightmares with violent themes, and episodic depressive episodes.
proccdurcs
The first two sessions involved intake and history taking along with some discussion of relaxation. deep breathing techniques, and anxiety coping procedures of which the client, due to his training and previous treatments was familiar. Also discussed at the second session was the rationale for using the EMD procedure. At the third session, EMD treatment procedures were followed as described by Shapiro. (lY8Ya; 1YYla). Treatment included identifying the central traumatic scene, the associated belief connected to the scene and alternative. positive beliefs that the client would prefer to hold in this context. The client chose a scene representing the most traumatic part of the experience in which the assailant stood on a knoll above him, approximately 30 feet away and shot him several times despite Jim’s pleas to stop. While Jim held the shooting image, he exhibited rapid, shallow breathing and his face turned red. At this point we established his SUD rating of anxiety as ‘$5 on a 0 to 100 scale. As the client visualized the scene, he was instructed to follow the therapist’s finger with his eyes to induce lateral eye movements. (See Shapiro, lY8Ya. 1YYla.)
Treatment
Treatment
Responses
Truumu One After the first set of 30 arcs, Jim reported that the previously vivid and anxiety-producing image had faded and he could no longer generate it. Most of the anxiety sensations associated with it had also dissipated. A second set of eye movements focused on the lingering sensations. Within a few seconds the image was gone altogether and he could not retrieve it. However, the image he had at that point was of the therapist erasing his, (Jim’s) memory with his hand as one would use an eraser on a chalkboard! He was then unable to reconstruct the shooting image. Try as he might, he could not form a coherent image, nor could he generate any anxiety from the fragmented pieces that he could visualize. With the eradication of this image, Jim described a feeling of loss. Using this sense of loss as a starting point, a third set of eye movements was begun that resulted in a profound sense of sadness that came from the recall of a prior significant trauma that became the next target of our EMD procedure. Trauma Two The deep sadness that welled up at the termination of the initial shooting scene described above came from a prior trauma involving an auto accident in which Jim’s second wife and their unborn child died. This accident occurred 4 years prior to the shooting (12 years prior to the present treatment). The second EMD/R session focused on the auto accident. The EMD procedure began with Jim visualizing the sequence of the accident while continuing a series of eye movements. This scene began with he and his wife driving in the country on a winter’s day. They came up a hill shaded from the sun that had melted the ice from most of the open road. As they entered the shade on the hill, the car hit ice; he lost control of the vehicle, and collided broad-side
of PTSD
45
with a car coming over the crest of the hill. In the first session dealing with this image, the fourth session overall, the desired cognition he wished to associate with this scene involved his personal safety and the fact that he had indeed survived the crash. Sensations initially associated with this image were described as an extreme “adrenaline rush,” with hyperalertness. This session of EMD began with a replay of this image while following the therapist’s moving finger. As the scene began, Jim reported feeling as if he were going from light (out in the sun) into a wall of darkness (shaded hill) and was being drawn in against his will and without control (sliding on ice). With continued eye movements and replaying this scene, the image evolved into one in which, as he entered the darkness, a ray or tunnel of light shone through and safely escorted him out of the darkness so that he side-stepped the crash. A replay of the original scene found the images unclear and out of focus. Attempts to regenerate this scene were associated with a sense that he did not need to replay it any more since it was over and he was safely through it. He felt that he had “. . side-stepped death.” After this initial crash scene was desensitized and had an associated safety cognition. the immediate post-crash devastation and trauma was dealt with. In the next scene the crash was over, Jim had hit his chest into the steering column and cut his eye. Then, realizing that he had survived, he climbed out of a broken window and stood by the car feeling great relief that he survived. Glancing back into the car he saw his wife in the passenger seat, not moving. He experienced deep grief at this point as he instantly knew that she and the unborn child were dead. Another series of eye movements with this scene resulted in his feeling that, as with the crash itself, it was over and it was not happening now. He no longer needed to replay it. On a final rerunning of this post-crash scene with eye movements, Jim had the sensation of observing it in all of its minute details. However, he experienced the scene as happening
46
RONALD
A. KLEINKNECHT
off to his right side with him as an observer rather than as a participant. Although his negative affect associated with this tragedy was diminished, it did not diminish his concern or caring, but now he felt it had happened in the past, and was over. Traumu Three Following the desensitization of the above two traumas, Jim had a perception of fear and aloneness. A continuation of this sensation, with eye movements, brought up images of when he was 18 years old. His father had died suddenly, leaving him and the family devastated and alone. At this time, the late 196Os, Jim had also become eligible for the military draft for the Viet Nam war. However. Jim had decided that he was a Conscientious Objector (CO) and could not in good conscious, enter the military. His unpopular stand on the war was not supported by his family members, friends, or by his parish priest. After formally refusing induction, he was picked up by the FBI and taken to jail as a “draft dodger” at IX years of age. Although booked as a draft evader, he was shortly released pending trial. However, for 1.5 years, he anticipated that he would yet go to prison. His fear of being confined in a prison led to Jim developing claustrophobia during that time. Finally, the judge hearing his case reviewed his file and concluded that he was indeed a CO and sentenced Jim to 2 years of alternative community service. He chose child care as his community service, a position that ultimately led to his current position as family counselor with a social service agency. Reenacting these scenes with eye movements led from an unresolved sense of rejection and aloneness to a feeling of resolution that he had indeed dealt with these early traumatic times and he had done so with a sense of commitment and resolve to achieve what he felt was right. At this point, there were no more traumatic, affect-laden scenes to be dealt with. Applica-
and MARK
P. MORGAN
tion of these new feelings of resolution, personal empowerment, and “I’m safe and OK” were discussed with respect to feelings at home and at work.
Evidence of Cognitive, Affective. and Behavior Change Test Results The results of the standardized instruments reflect the subjective scribed above by the client.
assessment changes dc-
State-trait arzxiety ittvetltory (STAI). The initial administration of the trait portion of the STAI resulted in a raw score of 51, corresponding with the 64th percentile of psychiatric outpatients and the 94th percentile of 40-year-old adult men. (Spielbergcr, ct al. 1983). Posttreatment testing at 4 months revealed a score of 3X, (a decrease of 1.5 standard deviations), only three points above the mean of 35 for his age group and the 26th percentile of psychiatric patients. On the X month posttest. Jim scored 42 (36th percentile of patients, 76th of likeaged adults). Cettter for epidetrtiologic studies - cleprcssion .scu/~.Initial administration of the CES-D revealed a score of 9 which is below the normative level of 16, indicative of clinical depression (Weissman. et al. 1977). Although Jim was not clinically depressed at the outset. he did report some dcprcssive symptoms. At the two follow-up testings. his scores diminished considerably to I and 4. respectively. Briej’ Symptom Invct~tory (BSI). Scores on the BSI declined on all dimensions with the largest changes occurring on those scales relevant to this client’s PTSD symptoms. As can be seen in Figure I, his highest pre-test Tscores were on Somatization, (SOM). Anxiety. (ANX) and Phobic Anxiety (PHOB) scales. These scales along with Depression (DEP) showed a posttreatment change of nearly 2 standard deviations. Smaller changes were
Treatment Brief symptom inventory
’
’
’
’
*
’
’
’
SOM O-C IS. DEP ANX b
$
::
2
’
’
’
PAR & GSI 0.
Clinical scales
. pre
+ post 4 mos Figure
47
have had no depressive episodes in the 8 months since initial treatment. Visual images of the events are diffused and lack the previous emotional impact. The memories are there to be called up, but I now have no compulsion to replay them. Life feels more normal and there is not a catastrophic overlay to all of my activities. I have an increased sense of personal power and confidence to deal with adversity. I no longer feel like a victim or a target who’s unable to fight back or respond appropriately. I have a wonderful feeling of satisfaction and relief when the (trauma-related) stimuli occur and the old responses no longer follow.
65
35L’
of PTSD
* post 8 mos
1
seen on less relevant dimensions of Psychoticism (PSY), and Paranoia (PAR), both of which were below the mean of psychiatric patients. Over all, his scores on the nine clinical scales had a mean T-score of 52.78 using norms for male psychiatric outpatients (see Figure 1). Thus, before EMD treatment, he scored slightly above the mean for male psychiatric outpatients. At the first posttreatment testing, the mean T-score of the clinical scales was 44.56. At this point, none of the clinical or summative scales reached the 50th percentile whereas prior to treatment, six had exceeded the mean T-score of 50 for psychiatric patients. On the second posttest, only one scale, SOM, reached a T-score of 51. The Global Symptom Index to be the most sensitive (GSI), considered scale to assess patient distress, can be seen to decline progressively. Client’s Statement of EMD Effects The following paragraph was written by the client to describe the changes he experienced following EMD/R treatment: Nightmares with violence have ceased while dreams with overtones of violence are rare. Hypervigilance has greatly decreased. particularly at work. I am able to relax and enjoy work more. I have increased contact with others and I am less guarded and self-protective. I
Criteria for Successful Emotional Processing Rachman (1990) discussed four indices reflective of satisfactory emotional processing of fear stimuli. Following, we have compared the client’s progress on these four indices. Test probes fail to elicit disturbance. Direct exposure to the sites of the traumas elicit no negative emotional reaction. Both sites (parking lot and highway) were tested in vivo during therapy. Seeing movies with scenes depicting a person being shot in cold blood with a hand gun and viewing “Terminator II” were well tolerated and elicited no undo anxiety response. Decline of Emotional Disturbance. The SUDS rating change from 95 at the outset to 10 at termination, indicates a clinically relevant decrease in emotional disturbance. Decline of Disturbed Behavior. There have been no nightmares in the 8 months since treatment of the shooting scene, the pressure to tell the story repeatedly is gone, and no depressive episodes have been experienced subsequent to treatment. Return of routine behaviors. Jim has resumed greater physical activity that had been deferred because sensations triggered anxiety and panic. He feels an increased personal and professional confidence and increased concentration at work. These indices of satisfactory emotional processing along with the above test results,
3x
RONALD
A. KLEINKNECHT
suggest that these traumas have been desensitized and reprocessed and this appears to have resulted in significant and meaningful cognitive, affective, and behavioral change that has been sustained now for 8 months.
Discussion This case illustrates rapid and clinically significant changes that can occur with EMD. At this point in the development of EMD, little empirical evidence exists to document its efficacy as a procedure for facilitating cognitive and behavioral change. At the time of writing, there are relatively few cases published using EMD procedures (Lipke & Botkin, in press; Marquis, 1991; Puk, 1991; Shapiro, 1989a; 1989b; 1991a; Wolpe & Abrams, 1991). A significant addition is the report by Marquis (1991) in which all of 16 cases of PTSD recovered at a mean of 2.9 on a scale of 0 to 3.0. Although our standardized test results, along with specific verbatim statements by the client describing his perceptions of change suggest a highly positive outcome, as with all nonspecific therapeutic such case studies, effects can never be ruled out as alternative explanations for observed changes. However, the similarities between the processes described here and those described independently by others lend some credence to the validity of the effects in this case. The initial trauma scene of the shooting was desensitized within about 3 minutes. From the time of the first series of 30 eye movements, Jim has been unable to generate the specific shooting scene and he cannot to this date, 8 months later, generate a negative affective response from it. It now appears to him as simply a historical occurrence. Further, all of the PTSD symptoms described at the outset, are now remitted. The large post-treatment changes shown in the BSI and STAI-trait are consistent with this dissipation of symptoms.
and MARK
P. MORGAN
A second element of note here is the phenomenon of unlayering of successive traumas whose memories provoke significant negative affect. Desensitizing one trauma may reactivate earlier thematically related traumas. Here, some elements from the loss of his wife and unborn child were still highly sensitive. Desensitization of this trauma seemed to trigger the third trauma associated with death of his father and the threat of imprisonment for refusing military induction. Similar phenomena have been described in other trauma related treatments (Levis, 1991). It is also of interest that the PTSD symptoms only occurred after the shooting trauma, not after the accident that involved death. It may be that the later trauma precipitated PTSD because it had been predisposed by the two earlier thematically similar traumas. Individually, the traumas may not have been sufficient to elicit such intense, long-standing symptoms. However, the continued threats to life and security were sufficient to trigger the syndrome and to cast it into a chronic disorder of 8 years standing. The sequential elicitation of these three traumas suggests that they were cognitively linked in a memory network and that the entire network was involved in the PTSD. Based on the current case along with other recent reports, the EMD procedure appears to hold promise as another treatment modality, effective for treating anxiety and traumarelated disorders. (Lipke & Botkin, in press; Puk, 1991; Marquis, 1991; Shapiro, 1989a, 1991a; Wolpe & Abrams, 1991). Further, EMD, by its ability to activate a series of related memories, may also be a valuable tool for studying the conditions responsible for the onset and maintenance of such disorders. Given the positive accounts of the effectiveness of EMD, efforts toward more extensive placebo-controlled outcome research would seem justified, as would experimental investigations into the mechanisms by which this rapid desensitization process works.
Treatment
References American Psychiatric Association (1987). Dingnosticand statistical manual of mental disorders (3rd ed., revised). Washington. D.C. Chemtob. C., Roitblat, H. Hamada, R.. Carlson, J., & Twentyman, C. (1988). A cognitive action theory of posttraumatic stress disorder. Journal of Anxiety Disorders. 2, 253-275. Dcrogatis, L. R. & Spencer. P. M. (1982). The Brief Symptom Inventory: administration, scoring & procedures manual - I. Baltimore: Clinical Psychometric Research. Foa, E.. 6i Kozak, M. (1988). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin 99. 2C35. Levis, D. J. (1991). Memory reactivation in the treatment of trauma. In T. M. Keane (Chair) Treatingpsvchological trauma: comprehensive treatment of chrome PTSD. Symposium conducted at the meetings of The Association for Advancement of Behavior Therapy. New York. Lipke, H. & Botkin, A. Brief case studies of eye movement desensitization and reprocessing (EMD/R) with chronic post-traumatic stress disorder. Psychotherapy. (in press) Marquis, J. N. (1991). A report on seventy-eight cases treated by eye movement desensitization. Journal of Behavior Therapy and Experimental Psychiatry. 22, 1X7192. Puk, G. (1991). Treating traumatic memories: A case
of PTSD
49
report on the eye movement desensitization procedure. Journal of Behavior Therapy and Experimental Psychiatry, 22, 149-151. Rachman. S. J. (1990). Fear and courage. (2nd edition). San Francisco: W. Freeman & Co. Shapiro, F. (1989a). Eye Movement Desensitization: A new treatment for post-traumatic stress disorder. Journal of Behavior Therapy and E.xperimental Psychiatry. 20, 211-217. Shapiro, F. (198%). Efficacy of the eye movement desensitization procedure in the treatment of traumatic memories. Journal of Traumatic Stress, 2. 199-223. Shapiro, F. (1991a). Eye movement desensitization & reprocessing procedure: From EMD to EMD/R - A new treatment model for anxiety and related traumata. The Behavior Therapist, 14. 133-135, 128. Shapiro, F. (1991b). Eye movement desensitization and reprocessing: A cautionary note. The Behavior Therapist. 14, 188. Spielberger, C., Gorsuch. R. L.. Luschene, R., Vagg, P. R.. & Jacobs. G. A. (1983). Manualfor the State-Trait Anxiety Inventory (STAI (Form Y)). Palo Alto, CA: Consulting Psychologist Press. Weissman, M., Sholomkas, D., Pottenger. M., Prusoff. B.. & Locke, B. (1977). Assessing depressive symptoms in five psychiatric populations: A validation study. American Journal of Epidemiology, 106, 203-214. Wolpe, J. & Abrams, J. (1991). Post-traumatic Stress Disorder overcome by eye-movement desensitization: A case Report. Journal of Behavior Therapy and Experimental Psychiatry, 22, 39-43.
TREATMENT
Vol. 23. No. 1. pp. 4S49,
1992 0
OF POSTI’RAUMATIC STRESS DISORDER MOVEMENT DESENSITIZATION RONALD Department
lMK&7916/92 65.M + 0.M IYY? Pergamon Press Ltd
WITH EYE
A. KLEINKNECHT
of Psychology,
MARK
Western
Washington
University
P. MORGAN
The Martin Center,
Bellingham,
Washington
Summary - This case report describes the successful treatment of a posttraumatic stress disorder (PTSD) using eye movement desensitization (EMD). The client, a 40-year-old male, presented with an &year history of PTSD following an incident in which he was shot with a hand gun and left dying. Using EMD treatment, this trauma was quickly desensitized. Two earlier traumas with similar themes then emerged and they too were desensitized. Test results, taken pretreatment and posttreatment, along with the client’s verbatim account of cognitive and behavioral changes 8 months later, converged to document the successful treatment outcome.
Theoretical structures continue to evolve to foster understanding of fear-related conditions such as posttraumatic stress disorder (PTSD) and to advance rational treatment approaches (Chemtob, Roitblat, Hamada, Carlson, & Twentyman, 1988; Foa & Kozak, 1988; Rachman, 1990). Despite these efforts and their resultant treatment advances, PTSD remains one of the more recalcitrant of the anxiety disorders. However, a new treatment procedure, Eye movement Desensitization and Reprocessing (EMD) applicable to anxiety appears to hold great promise if upheld on more rigorous experimental scrutiny. This procedure, developed by Shapiro, (1989a, 1989b, 1991a), appears to have profound antianxiety effects on trauma and anxiety related disorders (Lipke & Botkin, in press; Marquis, 1991; Puk, 1991; Shapiro, 1989a, 1991a; Wolpe & Abrams, 1991). The present report describes a case of PTSD of 8 years duration that was successfully treated using EMD. This case is presented to Requests for reprints should be addressed to Ronald University, Bellingham, WA 98225, U.S.A.
illustrate the potential that this procedure appears to have for alleviating such previously refractory conditions as PTSD. Further, this case would appear to involve largely a “pure” EMD treatment in that it was used from the outset as the treatment modality. Treatment effects are substantiated with test data obtained at pretreatment, at 4 and 8 months posttreatment and client self-statements concerning his observed changes in behavioral, affective, and cognitive functioning.
Case Description The client, Jim, was a 40-year-old white male who holds a Masters degree in Counseling Psychology and is currently employed as a family and adolescent counselor. The traumatic episode that precipitated the PTSD symptoms occurred 8 years prior to his seeking the current treatment. However, as will be descri-
A. Kleinknecht,
43
Department
of Psychology,
Western
Washington
44
RONALD
A. KLEINKNECHT
bed, previous significant life traumas may well have predisposed the client to developing the full PTSD syndrome at this time. Jim observed a house burglary taking place and gave chase to the suspects. Having caught up with one of them on a small knoll, he took his eyes off the suspect for an instant as he looked around for help. When he looked back the suspect held a hand gun which he fired at Jim, hitting him three times. One bullet severed the right femoral artery, two others struck his left leg. When the gun was empty, the assailant ran away. leaving Jim alone in a deserted parking lot. unable to move until passers by found him.
and MARK
P. MOR(;AN
A .s.se.s.sm en ts
At intake. the following standardized tests were administered: the Brief Symptom Inventory, (BSI; Derogatis & Spencer, IY82); the State Trait Anxiety Inventory (STAI-Trait. Form Y; Spielberger, Gorsuch. Luschcnc. Vagg, Kc Jacobs. lYX3); the Center for Epidemiological Studies - Depression Scale (CESD; Weissman, Sholomkas, Pottenger, Prusoff. CycLocke, 1977). Test scores were taken pretreatment and at 4 and X months posttreatment.
PTSD Symptoms Experienced Treatment Being shot and left for dead is clearly beyond the range of usual human experience (APA. 1987). This trauma resulted in dreams involving either a gun barrel or the staring face of an “uncaring, killer-type of person,” recurring approximately once per month for X years. Significant psychological distress was evoked by the sight and sound of ambulances. loud noises. media depictions of violent assaults. or the sight of handguns. Cold. damp weather. reminiscent of the autumn ground on which he lay wounded also triggered PTSD symptoms. He systematically avoided movies with violent themes. Restimulation of the shooting trauma triggered depressive episodes lasting from days to weeks. Further PTSD symptoms included difficulties with concentration and memory, hypervigilance, restless, scanning his environment for signs of danger. He responded explosively to unexpected physical contact and was highly reactive to sharp sounds and stimuli associated with the trauma. The present treatment was sought due to the continuing state of high anxiety, hypervigilance, feelings of emotional detachment and distance from others, recurrent thoughts of the assault, a pressing need to &‘tell the story.” nightmares with violent themes, and episodic depressive episodes.
proccdurcs
The first two sessions involved intake and history taking along with some discussion of relaxation. deep breathing techniques, and anxiety coping procedures of which the client, due to his training and previous treatments was familiar. Also discussed at the second session was the rationale for using the EMD procedure. At the third session, EMD treatment procedures were followed as described by Shapiro. (lY8Ya; 1YYla). Treatment included identifying the central traumatic scene, the associated belief connected to the scene and alternative. positive beliefs that the client would prefer to hold in this context. The client chose a scene representing the most traumatic part of the experience in which the assailant stood on a knoll above him, approximately 30 feet away and shot him several times despite Jim’s pleas to stop. While Jim held the shooting image, he exhibited rapid, shallow breathing and his face turned red. At this point we established his SUD rating of anxiety as ‘$5 on a 0 to 100 scale. As the client visualized the scene, he was instructed to follow the therapist’s finger with his eyes to induce lateral eye movements. (See Shapiro, lY8Ya. 1YYla.)
Treatment
Treatment
Responses
Truumu One After the first set of 30 arcs, Jim reported that the previously vivid and anxiety-producing image had faded and he could no longer generate it. Most of the anxiety sensations associated with it had also dissipated. A second set of eye movements focused on the lingering sensations. Within a few seconds the image was gone altogether and he could not retrieve it. However, the image he had at that point was of the therapist erasing his, (Jim’s) memory with his hand as one would use an eraser on a chalkboard! He was then unable to reconstruct the shooting image. Try as he might, he could not form a coherent image, nor could he generate any anxiety from the fragmented pieces that he could visualize. With the eradication of this image, Jim described a feeling of loss. Using this sense of loss as a starting point, a third set of eye movements was begun that resulted in a profound sense of sadness that came from the recall of a prior significant trauma that became the next target of our EMD procedure. Trauma Two The deep sadness that welled up at the termination of the initial shooting scene described above came from a prior trauma involving an auto accident in which Jim’s second wife and their unborn child died. This accident occurred 4 years prior to the shooting (12 years prior to the present treatment). The second EMD/R session focused on the auto accident. The EMD procedure began with Jim visualizing the sequence of the accident while continuing a series of eye movements. This scene began with he and his wife driving in the country on a winter’s day. They came up a hill shaded from the sun that had melted the ice from most of the open road. As they entered the shade on the hill, the car hit ice; he lost control of the vehicle, and collided broad-side
of PTSD
45
with a car coming over the crest of the hill. In the first session dealing with this image, the fourth session overall, the desired cognition he wished to associate with this scene involved his personal safety and the fact that he had indeed survived the crash. Sensations initially associated with this image were described as an extreme “adrenaline rush,” with hyperalertness. This session of EMD began with a replay of this image while following the therapist’s moving finger. As the scene began, Jim reported feeling as if he were going from light (out in the sun) into a wall of darkness (shaded hill) and was being drawn in against his will and without control (sliding on ice). With continued eye movements and replaying this scene, the image evolved into one in which, as he entered the darkness, a ray or tunnel of light shone through and safely escorted him out of the darkness so that he side-stepped the crash. A replay of the original scene found the images unclear and out of focus. Attempts to regenerate this scene were associated with a sense that he did not need to replay it any more since it was over and he was safely through it. He felt that he had “. . side-stepped death.” After this initial crash scene was desensitized and had an associated safety cognition. the immediate post-crash devastation and trauma was dealt with. In the next scene the crash was over, Jim had hit his chest into the steering column and cut his eye. Then, realizing that he had survived, he climbed out of a broken window and stood by the car feeling great relief that he survived. Glancing back into the car he saw his wife in the passenger seat, not moving. He experienced deep grief at this point as he instantly knew that she and the unborn child were dead. Another series of eye movements with this scene resulted in his feeling that, as with the crash itself, it was over and it was not happening now. He no longer needed to replay it. On a final rerunning of this post-crash scene with eye movements, Jim had the sensation of observing it in all of its minute details. However, he experienced the scene as happening
46
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off to his right side with him as an observer rather than as a participant. Although his negative affect associated with this tragedy was diminished, it did not diminish his concern or caring, but now he felt it had happened in the past, and was over. Traumu Three Following the desensitization of the above two traumas, Jim had a perception of fear and aloneness. A continuation of this sensation, with eye movements, brought up images of when he was 18 years old. His father had died suddenly, leaving him and the family devastated and alone. At this time, the late 196Os, Jim had also become eligible for the military draft for the Viet Nam war. However. Jim had decided that he was a Conscientious Objector (CO) and could not in good conscious, enter the military. His unpopular stand on the war was not supported by his family members, friends, or by his parish priest. After formally refusing induction, he was picked up by the FBI and taken to jail as a “draft dodger” at IX years of age. Although booked as a draft evader, he was shortly released pending trial. However, for 1.5 years, he anticipated that he would yet go to prison. His fear of being confined in a prison led to Jim developing claustrophobia during that time. Finally, the judge hearing his case reviewed his file and concluded that he was indeed a CO and sentenced Jim to 2 years of alternative community service. He chose child care as his community service, a position that ultimately led to his current position as family counselor with a social service agency. Reenacting these scenes with eye movements led from an unresolved sense of rejection and aloneness to a feeling of resolution that he had indeed dealt with these early traumatic times and he had done so with a sense of commitment and resolve to achieve what he felt was right. At this point, there were no more traumatic, affect-laden scenes to be dealt with. Applica-
and MARK
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tion of these new feelings of resolution, personal empowerment, and “I’m safe and OK” were discussed with respect to feelings at home and at work.
Evidence of Cognitive, Affective. and Behavior Change Test Results The results of the standardized instruments reflect the subjective scribed above by the client.
assessment changes dc-
State-trait arzxiety ittvetltory (STAI). The initial administration of the trait portion of the STAI resulted in a raw score of 51, corresponding with the 64th percentile of psychiatric outpatients and the 94th percentile of 40-year-old adult men. (Spielbergcr, ct al. 1983). Posttreatment testing at 4 months revealed a score of 3X, (a decrease of 1.5 standard deviations), only three points above the mean of 35 for his age group and the 26th percentile of psychiatric patients. On the X month posttest. Jim scored 42 (36th percentile of patients, 76th of likeaged adults). Cettter for epidetrtiologic studies - cleprcssion .scu/~.Initial administration of the CES-D revealed a score of 9 which is below the normative level of 16, indicative of clinical depression (Weissman. et al. 1977). Although Jim was not clinically depressed at the outset. he did report some dcprcssive symptoms. At the two follow-up testings. his scores diminished considerably to I and 4. respectively. Briej’ Symptom Invct~tory (BSI). Scores on the BSI declined on all dimensions with the largest changes occurring on those scales relevant to this client’s PTSD symptoms. As can be seen in Figure I, his highest pre-test Tscores were on Somatization, (SOM). Anxiety. (ANX) and Phobic Anxiety (PHOB) scales. These scales along with Depression (DEP) showed a posttreatment change of nearly 2 standard deviations. Smaller changes were
Treatment Brief symptom inventory
’
’
’
’
*
’
’
’
SOM O-C IS. DEP ANX b
$
::
2
’
’
’
PAR & GSI 0.
Clinical scales
. pre
+ post 4 mos Figure
47
have had no depressive episodes in the 8 months since initial treatment. Visual images of the events are diffused and lack the previous emotional impact. The memories are there to be called up, but I now have no compulsion to replay them. Life feels more normal and there is not a catastrophic overlay to all of my activities. I have an increased sense of personal power and confidence to deal with adversity. I no longer feel like a victim or a target who’s unable to fight back or respond appropriately. I have a wonderful feeling of satisfaction and relief when the (trauma-related) stimuli occur and the old responses no longer follow.
65
35L’
of PTSD
* post 8 mos
1
seen on less relevant dimensions of Psychoticism (PSY), and Paranoia (PAR), both of which were below the mean of psychiatric patients. Over all, his scores on the nine clinical scales had a mean T-score of 52.78 using norms for male psychiatric outpatients (see Figure 1). Thus, before EMD treatment, he scored slightly above the mean for male psychiatric outpatients. At the first posttreatment testing, the mean T-score of the clinical scales was 44.56. At this point, none of the clinical or summative scales reached the 50th percentile whereas prior to treatment, six had exceeded the mean T-score of 50 for psychiatric patients. On the second posttest, only one scale, SOM, reached a T-score of 51. The Global Symptom Index to be the most sensitive (GSI), considered scale to assess patient distress, can be seen to decline progressively. Client’s Statement of EMD Effects The following paragraph was written by the client to describe the changes he experienced following EMD/R treatment: Nightmares with violence have ceased while dreams with overtones of violence are rare. Hypervigilance has greatly decreased. particularly at work. I am able to relax and enjoy work more. I have increased contact with others and I am less guarded and self-protective. I
Criteria for Successful Emotional Processing Rachman (1990) discussed four indices reflective of satisfactory emotional processing of fear stimuli. Following, we have compared the client’s progress on these four indices. Test probes fail to elicit disturbance. Direct exposure to the sites of the traumas elicit no negative emotional reaction. Both sites (parking lot and highway) were tested in vivo during therapy. Seeing movies with scenes depicting a person being shot in cold blood with a hand gun and viewing “Terminator II” were well tolerated and elicited no undo anxiety response. Decline of Emotional Disturbance. The SUDS rating change from 95 at the outset to 10 at termination, indicates a clinically relevant decrease in emotional disturbance. Decline of Disturbed Behavior. There have been no nightmares in the 8 months since treatment of the shooting scene, the pressure to tell the story repeatedly is gone, and no depressive episodes have been experienced subsequent to treatment. Return of routine behaviors. Jim has resumed greater physical activity that had been deferred because sensations triggered anxiety and panic. He feels an increased personal and professional confidence and increased concentration at work. These indices of satisfactory emotional processing along with the above test results,
3x
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A. KLEINKNECHT
suggest that these traumas have been desensitized and reprocessed and this appears to have resulted in significant and meaningful cognitive, affective, and behavioral change that has been sustained now for 8 months.
Discussion This case illustrates rapid and clinically significant changes that can occur with EMD. At this point in the development of EMD, little empirical evidence exists to document its efficacy as a procedure for facilitating cognitive and behavioral change. At the time of writing, there are relatively few cases published using EMD procedures (Lipke & Botkin, in press; Marquis, 1991; Puk, 1991; Shapiro, 1989a; 1989b; 1991a; Wolpe & Abrams, 1991). A significant addition is the report by Marquis (1991) in which all of 16 cases of PTSD recovered at a mean of 2.9 on a scale of 0 to 3.0. Although our standardized test results, along with specific verbatim statements by the client describing his perceptions of change suggest a highly positive outcome, as with all nonspecific therapeutic such case studies, effects can never be ruled out as alternative explanations for observed changes. However, the similarities between the processes described here and those described independently by others lend some credence to the validity of the effects in this case. The initial trauma scene of the shooting was desensitized within about 3 minutes. From the time of the first series of 30 eye movements, Jim has been unable to generate the specific shooting scene and he cannot to this date, 8 months later, generate a negative affective response from it. It now appears to him as simply a historical occurrence. Further, all of the PTSD symptoms described at the outset, are now remitted. The large post-treatment changes shown in the BSI and STAI-trait are consistent with this dissipation of symptoms.
and MARK
P. MORGAN
A second element of note here is the phenomenon of unlayering of successive traumas whose memories provoke significant negative affect. Desensitizing one trauma may reactivate earlier thematically related traumas. Here, some elements from the loss of his wife and unborn child were still highly sensitive. Desensitization of this trauma seemed to trigger the third trauma associated with death of his father and the threat of imprisonment for refusing military induction. Similar phenomena have been described in other trauma related treatments (Levis, 1991). It is also of interest that the PTSD symptoms only occurred after the shooting trauma, not after the accident that involved death. It may be that the later trauma precipitated PTSD because it had been predisposed by the two earlier thematically similar traumas. Individually, the traumas may not have been sufficient to elicit such intense, long-standing symptoms. However, the continued threats to life and security were sufficient to trigger the syndrome and to cast it into a chronic disorder of 8 years standing. The sequential elicitation of these three traumas suggests that they were cognitively linked in a memory network and that the entire network was involved in the PTSD. Based on the current case along with other recent reports, the EMD procedure appears to hold promise as another treatment modality, effective for treating anxiety and traumarelated disorders. (Lipke & Botkin, in press; Puk, 1991; Marquis, 1991; Shapiro, 1989a, 1991a; Wolpe & Abrams, 1991). Further, EMD, by its ability to activate a series of related memories, may also be a valuable tool for studying the conditions responsible for the onset and maintenance of such disorders. Given the positive accounts of the effectiveness of EMD, efforts toward more extensive placebo-controlled outcome research would seem justified, as would experimental investigations into the mechanisms by which this rapid desensitization process works.
Treatment
References American Psychiatric Association (1987). Dingnosticand statistical manual of mental disorders (3rd ed., revised). Washington. D.C. Chemtob. C., Roitblat, H. Hamada, R.. Carlson, J., & Twentyman, C. (1988). A cognitive action theory of posttraumatic stress disorder. Journal of Anxiety Disorders. 2, 253-275. Dcrogatis, L. R. & Spencer. P. M. (1982). The Brief Symptom Inventory: administration, scoring & procedures manual - I. Baltimore: Clinical Psychometric Research. Foa, E.. 6i Kozak, M. (1988). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin 99. 2C35. Levis, D. J. (1991). Memory reactivation in the treatment of trauma. In T. M. Keane (Chair) Treatingpsvchological trauma: comprehensive treatment of chrome PTSD. Symposium conducted at the meetings of The Association for Advancement of Behavior Therapy. New York. Lipke, H. & Botkin, A. Brief case studies of eye movement desensitization and reprocessing (EMD/R) with chronic post-traumatic stress disorder. Psychotherapy. (in press) Marquis, J. N. (1991). A report on seventy-eight cases treated by eye movement desensitization. Journal of Behavior Therapy and Experimental Psychiatry. 22, 1X7192. Puk, G. (1991). Treating traumatic memories: A case
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report on the eye movement desensitization procedure. Journal of Behavior Therapy and Experimental Psychiatry, 22, 149-151. Rachman. S. J. (1990). Fear and courage. (2nd edition). San Francisco: W. Freeman & Co. Shapiro, F. (1989a). Eye Movement Desensitization: A new treatment for post-traumatic stress disorder. Journal of Behavior Therapy and E.xperimental Psychiatry. 20, 211-217. Shapiro, F. (198%). Efficacy of the eye movement desensitization procedure in the treatment of traumatic memories. Journal of Traumatic Stress, 2. 199-223. Shapiro, F. (1991a). Eye movement desensitization & reprocessing procedure: From EMD to EMD/R - A new treatment model for anxiety and related traumata. The Behavior Therapist, 14. 133-135, 128. Shapiro, F. (1991b). Eye movement desensitization and reprocessing: A cautionary note. The Behavior Therapist. 14, 188. Spielberger, C., Gorsuch. R. L.. Luschene, R., Vagg, P. R.. & Jacobs. G. A. (1983). Manualfor the State-Trait Anxiety Inventory (STAI (Form Y)). Palo Alto, CA: Consulting Psychologist Press. Weissman, M., Sholomkas, D., Pottenger. M., Prusoff. B.. & Locke, B. (1977). Assessing depressive symptoms in five psychiatric populations: A validation study. American Journal of Epidemiology, 106, 203-214. Wolpe, J. & Abrams, J. (1991). Post-traumatic Stress Disorder overcome by eye-movement desensitization: A case Report. Journal of Behavior Therapy and Experimental Psychiatry, 22, 39-43.
