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1 Application of EMDR in the Treatment of Major Depressive Disorder: A Case Study Running title: EMDR treatment for major depressive disorder No. of table: 1, No. of Figs.:4 Dr. Usha Verma Srivastava* Dr. A. Mukhopadhyay** -------------------------------------------------------------------------------------------*Consultant Clinical psychologist, The Apollo Clinic, B-38/46-H, Raman Niwas, Mahmoorganj, Varanasi. Ph.+91 9838045292, e-mail: [email protected] **Professor, Dept. of Psychology, MMV . BHU. Application of EMDR in the Treatment of Major Depressive Disorder: A Case Study 2 Abstract This article presents a case study applying Eye Movement Desensitization and Reprocessing in major depressive disorder. The study describes the application of Shapiro’s Adaptive Information Processing (AIP) model in the treatment of major depressive disorder and explores the use of EMDR with a 30 year old woman experiencing depressive symptoms with 3 suicidal attempts in 5 years. Due to strong negative reactions to psychiatric medicines, her treatment was discontinued several times and she was referred for psychotherapeutic intervention. After 9 EMDR treatment sessions, her depression was completely cured; her coping improved and other symptoms of anxiety and social withdrawal were completely controlled. Effects were checked and found maintained up to 6 months follow up. The clinical implications of application of EMDR have been explored. Key words: EMDR, depression, eye movements, bilateral stimulation, adaptive information processing, somatic symptoms. Application of EMDR in the Treatment of Major Depressive Disorder: A Case Study INTRODUCTON 3 Depression is a serious medical condition that affects thoughts, feelings, and the ability to function in everyday life. Depression is a disorder of high prevalence and moderate to high severity. Depression can occur at any age. Although available therapies alleviate symptoms in over 80 percent of those treated, less than half of people with depression get the help they need (Regier, Narrow, & Rae, 1993; National Advisory Mental Health Council, 1993). Despite the enormous advances in brain research in the past 20 years, depression often goes undiagnosed and untreated; depression produces far more morbidity in the community. In addition, because suicide is a far greater risk in depression, the depressive disorder has a greater impact on premature mortality. Depressed patients suffer as much disability and distress as patients with chronic medical disorders such as high blood pressure, diabetes, coronary artery disease, and arthritis. Recovery from individual episodes of depression is readily stimulated by appropriate treatment, but relapse is common and care over the long-term is essential. Depression runs in families, reflecting an inherited vulnerability. There is equally strong evidence, however, that childhood experiences, such as loss of a parent also produce vulnerability to depression, and the losses experienced in adulthood can also precipitate depressive episodes. Depression is thus both biological and social in its origin. In spite of the considerable evidence about the general social correlates of, and the psychosocial risk factors for depression, we do not know the specific causal pathways that transform social experiences into psychopathology. Major depressive disorder is a common costly and disabling condition affecting 4.9%-17.9% of the population in a life time. From 20%-30% of effected persons suffer a chronic, relapsing course. Many medications and several time limited psychotherapies has shown establishing efficacy in randomized controlled trials. Among outpatients with major depressive disorders, treated for the first time, about 50% responded positively (i.e. exhibited a clinically significant symptom reduction). However of these “responders” only 50%-70% achieve symptom remission, which since remission is associated with the best day to day functioning and best prognosis, is the goal of treatment (Rush, Trivedi, & Fava, 2003; Parker, Roy, & Eyer, 2003). EMDR is a psychotherapeutic approach that was developed by Shapiro (1989, 2001) to resolve symptoms resulting from disturbing and unresolved life experiences. It 4 is based on a theoretical information processing model, which posits that symptoms arise when events are inadequately processed and may be eradicated when the memories are fully processed and integrated. Shapiro further maintains that a negative sense of self, inappropriate emotional responses, and self-destructive behaviors are also manifestations of inadequately processed material, and that processing the etiological experiences underlying these current dysfunctions will transform them, allowing new selfperceptions, emotions, and behaviors to emerge. In addition, new experiences are targeted, processed, and incorporated into memory in order to overcome developmental and skills deficits. EMDR is an integrative therapy, synthesizing elements of many traditional psychological orientations, such as psychodynamic, cognitive behavioral, experiential, physiological, and interpersonal therapies (Shapiro, 2001, 2002; Shapiro & Maxfield, 2002). During processing, a client may spontaneously move through the three cognitive and emotional plateaus (inappropriate feelings of guilt, perceived lack of safety, and helplessness) to a more mature and balanced view. The clinician can observe this movement with respect to guilt when the client shifts during a session from a negative cognition such as "I am a bad person" or "I should have done something" to a positive cognition such as "I am a good person" or "I did the best I could." In other sessions, feelings of fear and lack of safety may transform a negative cognition such as "I am in danger" into a positive one ("It's over, I'm safe now"). A client's confidence in his ability to make future choices may be reflected in the shift from the cognition "I have no control" to "As an adult, I can now choose" or "I am now in control." When spontaneous changes do not occur, the cognitive interweave introduces the appropriate plateaus. (Shapiro, 2001) A separate body of research has examined the effects of EMs on physiology and memory and cognitive processes. Barrowcliff and associates demonstrated that EMs produce relaxation effects (Barrowcliff, Gray, Freeman, & MacCulloch, 2004; Barrowcliff, Gray, MacCulloch, Freeman, & MacCulloch, 2003). The finding that EMs decrease the vividness and/or emotionality of autobiographical memories is very robust and has been reported by numerous research teams ( Andrade, Kavanagh, & Baddeley, 1997; Kavanagh, Freese, Andrade, & May, 2001; Maxfield, 2004 ; Sharpley, 5 Montgomery, & Scalzo, 1996; Van den Hout , Muris, Salemink, & Kindt, 2001). Other studies found that EMs tend to enhance retrieval of episodic memories (Christman, Garvey, Propper, & Phaneuf, 2003) and increase cognitive flexibility (Kuiken, Bears, Miall, & Smith, 2001–2002 ). Although a diversity of researchers have proposed various models to explain these effects, and the possible role of EMs in EMDR, to date, no single model has been exclusively supported. Several new neurobiological theories explain that the difference between the outcomes of EMDR and Cognitive Behaviour Therapy (CBT) is because of the differences between memory reconsolidation and extinction (Suzuki, Josselyn, Frankland, Masushige, Silva, & Kida, 2004). According to these theories, treatments that rely on extinction (such as exposure therapies) result in the formation of competing memories, rather than an alteration of the old ones. However, it may prove that EMDR’s effects are based upon a different process known as reconsolidation that would involve the change and restorage of the altered targeted memory itself. It has been posited that longer exposures result in extinction, while shorter exposures result in reconsolidation (Suzuki et al., 2004). CASE REPORT Neha was a 30 year old woman who was experiencing major depressive disorder along with suicidal ideation and uncontrolled anger out bursts towards her 4 year old girl child. She was referred to a psychiatrist but due to strong reactions to medicines, psychiatrist referred her for psychotherapeutic intervention. When came for the treatment, Neha was depressed and tearful. She tried to swallow large amount of alprozolam tablets after her mother in law again criticized and humiliated her when she was going to celebrate New Year eve party with her husband. Her husband was also concerned that since last few months, whenever angry, she used to slap her daughter. She regretted it afterwards but she told me, she was unable to control herself at that time. She is also habitual to taking alprozolam, when anxious or for 6 sleeping (not regularly). Her somatic symptoms include dizziness, headache, and weakness. She was old upper middle class house wife, living with in laws, husband and a daughter. After graduating in home science with honors, she got married to the only son of a business family. She was eldest of her one brother and one sister. The day she entered her new home, her mother in law started criticizing her every step. After 10 months of marriage she developed severe cough, which could not be cured. She got treatment of tuberculosis. Whenever the symptoms got worse, her father came and took her back to her maternal home. She admitted that the moment she stepped in the train with her father, the coughing stopped. Then it was decided to shift her in the upper floor of the house, it worked and her coughing stopped but her suicidal ideations remain the same. She tried to commit suicide 2 more times before she came for the treatment. Her anxiety peaked up whenever a guest is coming at the house because it gave her mother in law a new opportunity to criticize and humiliate her in front of the guests. Her husband always supported her but couldn’t stop his mother who is very dominating and hard to please lady. In six years of marriage, she completely lost her sense of self worth, self confidence, self efficacy compounded by the feelings of guilt, sorrow, self accusation and a sense of failure. Measures Beck Depression Inventory(BDI) (Beck, Ward, Mendelssohn, Mock, & Erbaugh, 1961).: It’s a 21 item self report rating inventory on 0-3 point scale, measuring characteristic attitudes and symptoms of depression. Reliability: Internal consistency ranges from 0.73 to 0.92. Validity : concurrent validity correlation with clinician ratings range from 0.62 to 0.66. At initial assessment Neha’s score on the Beck Depression Inventory was 39 out of 63; indicative of major depressive disorder (a score below 12 is considered to be normal). After the 9 EMDR sessions the score goes down to 13. 7 Psychological General Well Being Schedule (PGWBS)(Dupuy, 1984): It’s a 22 item questionnaire designed to measure self representations of interpersonal affective or emotional status, reflecting a sense of subjective well being or distress. A 6 point Likert type scale measures six affective states, namely, anxiety, depressed mood, positive well being, self control, general health and vitality. Reliability: Internal consistency alpha coefficient =0.92 (range 0.90-0.94) Validity : Cross national studies and community based investigations show validity of 90.2 to 95.1. Psychological well being schedule was administered to assess overall well being of the client and scores indicate increase in low tension, relaxed and not anxious state of mind as well as low depressed mood state (Decrease in tension and anxiety as well as depressed mood). An increase in positive well being, self control, general health and vitality is also indicated. Stress Resistant Cognitive Behavioral Coping Pattern Scale (SRCBCP S)(Srivastava, 1995): It consists 53 items, measuring cognitive coping (problem focused), behavioural coping (emotion focused) and cognitive with behavioural coping with a response pattern of 5 point scale. Reliability: Split half reliability =0.67 Test retest reliability= 0.88 SRCBCPS was used in order to assess the coping pattern of client. It showed an increase in cognitive (problem focused) coping and cognitive with behavioural coping pattern and a decrease in behavoiural (emotion focused) coping pattern, as lower scores denote better coping style. Rathus Assertiveness Scale (RAS) ( Hindi adaptation, Shukla, 1988): It’s a 28 item, self report measure of assertive behaviour. Reliability and Validity: Split half coefficient =0.631 Test retest (after 8 weeks) =0.661 Concurrent validity =0.53 8 Rathus assertiveness scale was administered to measure the assertiveness of the client . Case Formulation EMDR treatment was conceptualized according to adaptive information processing (AIP) model proposed by Shapiro (2001, 2002). AIP model posits that the emotions and physical sensations inherent in the unprocessed event and stored inappropriately in memory are the foundation of the current pathology. (Ray & Zabik, 2001; Shapiro, 1995, 2001; Stickgold, 2002) In Neha’s case her mother in law was critical about her every action, her cooking, her style of dressing, her gifts, her handling home appliances and humiliated her in front of everyone. When Neha found it beyond her tolerance, she developed cough so severe that she was unable to control her bladder. The symptoms disappear as soon as she was out of the house and on her way to her mom’s home. When she started living separately but in the same home, she recovered her bronchial symptoms but she has completely lost her self confidence, her urge to live and enjoy life, her sense of self worth and self efficacy. She felt anxiety attacks whenever a guest or relative came home or planned to visit them, and she had to go down to meet them, or any festive occasion when she had to confront her mother in law for rituals. She stopped going out of the house for any reason because for that she had to ask or inform her mother in law, who never let her go without tormenting her even when her husband was with her. She became very submissive and never retaliated to her mother in law’s behaviour, introjected her anger within herself and sunk into deep state of depression. She started avoiding people, mostly relatives, thinking that she is a failure in her marriage and has made everyone’s life hell. She is a disappointment to her mother and father and her perception changed completely negative. The AIP model assumes that processing of the traumatic events have the effect of integrating the problematic memory with the larger non dysfunctional memory networks, thereby facilitating the patient’s sense of self confidence, self worth and ameliorating the overt symptoms. 9 The comprehensive EMDR treatment of Neha’s clinical complaints included processing memories and current triggers that contributed to the suicidal attempts, depression and anger outbursts towards her daughter as well as strengthening the positive resources she needed to adjust to the life like introducing better defenses and coping strategies and increasing assertiveness. Intervention After the diagnostic session, Neha participated in 9, once in a week EMDR session. The first session included the preparation phase started with the strengthening of some important emotional resources through a combination of imagery and bilateral stimulation. These resources are unconditional love, security and understanding of her husband, parents and her daughter, and then her belief in her own abilities, education and strength. She was asked to think of memories associated with her parents, her husband and daughter and her own abilities in past when she was managing her own life while completing her graduation living in hostel, and focused on them while engaging in bilateral stimulation. The emphasis on positive states is consistent with the use of EMDR for the activation of resources in patients with compromised affect tolerance (Korn& Leeds, 2002) Progressive muscular relaxation and safe place exercise was also taught to the client to manage the anxiety. In safe lace exercise, she was asked o close her eyes and imagine herself in a place where she felt sheltered, safe and protected. She found it in her bedroom with curtains down, door shut and TV on. Bilateral stimulation was given by tapping her knees. She could successfully manage the practice of safe place in only two sets of bilateral stimulation. Preparation phase increases the patients’ access to positive memories and affect if needed during subsequent processing. At the next meeting, the author initiated the EMDR standard protocol for treating traumatic memories (Shapiro, 2001).This was the first of the 5 processing sessions directed at various memories associated with Neha’s conditions. The traumatic memory reported by Neha, was her experience which she remembered that just after 3 days of her marriage, her mother in law had to go to her sister’s place due to some medical emergency. She was left at home on her alone, only a maid to tell her how to carry on. When her mother in law returned, she scolded her saying that that she had 10 messed up everything of the house. Neha was shocked and failed in all her efforts to please her. Her first visit with her husband and the gifts purchased for all the members of family could not satisfy her mother in law. She asked to her son-“what happened to your taste, it was never so bad before?” and she looked at Neha with accusing eyes. The memory was very distressing for Neha. Her negative cognition (NC) was “I am worthless”. Her SUDs [Subjective Units of Disturbance scale (Shapiro, 1989; Wolpe, 1958) ], was 8. Emotion felt was of helplessness. Location of body sensation was, she felt cold, shivering all over and her hands were shaking. Her positive cognition (PC) was “I am worthy and I can be myself, (I can do whatever I please)”. Desensitization was done with the help of eye movements (EMs). Checked SUDs which after 6 bilateral stimulations (BLs) became 0. Then installation was done similarly with BLs and with the selected PC till the VoC {Validity of Cognition scale (VoC; Shapiro, 1989, 2001)} became 7. Body scan was done for any tension, tightness or unusual sensation and reprocessed. Then session was closed. IIIrd session included processing her memory of her wedding lahanga for which her mother in law told her that she felt insulted and humiliated in front of all relatives for such cheap and ugly looking dress. In IVth session she recalled her memory of a trip to hill station with whole family, where her mother in law created a scene in front of several guests disrespecting her saying that her bad luck has giver her such a daughter in law. During Vth session she recalled her memories of last Karwa chauth puja, when a daughter in law gives offerings to mother in law and accept her blessings for long life of her husband. But when she offered her offerings to her mother in law, she refused to take it saying that she is only showing off it and the fact is she dose not need them or their blessings and dose not respect them. VIth and last EMDR session was processing of a very traumatic memory after which she tried to attempt suicide. It was new year eve and her husband and his group of friends were throwing a party, and when she was going to attend the party with her husband and daughter, her in laws created a very ugly scene that a daughter in law of a reputed family was going out at night to attend a party and it was her low class 11 upbringing which also influenced their only son in doing such disrespectable things. She cried and SUDs was 10 which became 0 after 12 sets of BLs and her VoC, “I do not need approval of my in laws for anything I do”, became 7. Table 1indicates the session by session goals and course of Neha’s progress . Neha was also asked to use log chart including, Trigger, Image, Cognition, Emotions and Sensation and SUDs (TICES), reporting her emotions and reactions to the events of the week. Memories that emerged during the EMDR processing sessions included her feelings of hopelessness, worthlessness, guilt and inability to control the situation and most of all a sense of failure and disappointment for her parents. As the processing progressed session by session, her feelings of guilt and worthlessness decreased. She started realizing that it was not at all her inability but it was her mother in law’s possessive feelings for her only son and also that she was scared of loosing her power and position after the marriage of her son. Neha also realized that her marriage is not unsuccessful because despite all odds in their life, her husband never blamed her and strictly told his own mother that he can not even think of divorcing Neha. Similarly she realized her daughter needs her love and caring and her suicidal thoughts completely vanished. After 3 months, she came for a follow up. She was happy and in good mood. She told me that her 2 sister in laws are coming to spend the vacation of one month with their families, and will go after celebrating her daughter’s birthday. She was slightly worried but we revised her coping mechanism, safe place and relaxation exercises to cope with the stress. We also used role play, and she declared that now she is ready for the encounter. After one and a half month, her husband took her to the clinic. She was tearful and unable to speak. Her husband described that even his sisters and mother criticized and harassed her continuously, she spend the whole month very bravely, facing them, of course without replying them for their nasty comments. But on the birthday of her daughter, when they started it again, she breakdown. She was taking alprozolam for three or four days for sleeping, which she has stopped previously after the first 6 sessions of treatment. Her husband was adamant to leave the home to live separately, without his 12 parents’ interference. But Neha refused it. She said they are old and deserve the support of their son at this stage of life. She can not live with the guilt that they lost their son because of her. So next three sessions were planned to increase her assertiveness and coping, because if she can not leave them she should face the bull by the horns. She was asked what could help her to restore her belief in her abilities to cope, her strength to fight and win over the situation and live her life fully (Schneider, Hofmann, Rost, & Shapiro, 2008). She described an image of hers living peacefully without feeling any negative emotions for her in laws’ comments. She was asked “where do you feel it in your body”? She answered “in my heart”, then she was asked to focus on that image and the body feeling while simultaneously following the eye movements. With brief sets of EMs her beliefs in her abilities increased which were then strengthened with another set of EMs. She became calmer and realized that life doesn’t end up with her in laws disapproval, she is capable and deserve a lot better, that she is in control now. She still couldn’t reply to her mother in law to stop insulting her but she could stop reacting to her, emotionally. Her SUD was 8 and become 0 after processing. But in the next (IX) session, when we went through the previous session her VoC again declined to 5, so the processing was done again with SUD 6 which declined to 0 after processing. Accepting her own efficacy, capacity, ability and her assertion is itself a cognition which she finally realized, asserted and succeded. Table 2 indicates the psychometric measures at pre- nd post treatment phase. After 3 months follow up, standardized measures indicate, no depression, healthy well being, problem focused coping and increased assertiveness. She started actively participating with her husband’s social activities along with her husband and even kept arranging business meetings and functions on behalf of her husband. DISCUSSION All humans are understood to have a physiologically-based information processing system. This can be compared to other body systems, such as digestion in which the body extracts nutrients for health and survival. The information processing system processes the multiple elements of our experiences and stores memories in an accessible and useful form. Memories are linked in networks that contain related 13 thoughts, images, emotions, and sensations. Learning occurs when new associations are forged with material already stored in memory. When a traumatic or very negative event occurs, information processing may be incomplete, perhaps because strong negative feelings or dissociation interfere with information processing. This prevents the forging of connections with more adaptive information that is held in other memory networks. It is not only major traumatic events, or “large-T Traumas” that can cause psychological disturbance. Sometimes a relatively minor event from childhood, such as being teased by one’s peers or discouraged by one’s parent, may not be adequately processed. Such “small-t traumas” can result in personality problems and become the basis of current dysfunctional reactions. Shapiro proposes that EMDR can assist to successfully alleviate clinical complaints by processing the components of the contributing distressing memories. These can be memories of either small-t or large-T traumas. Information processing is thought to occur when the targeted memory is linked with other more adaptive information. Learning then takes place, and the experience is stored with appropriate emotions, able to appropriately guide the person in future. Implications The usefulness of EMDR has been demonstrated in this case of major depressive disorder, following 5 years of unsuccessful treatment efforts, 9 EMDR sessions eliminated Neha’s depression. EMDR was also used to address her anxiety and social withdrawal symptoms. She renewed her ability to enjoy her life and to explore new ways to utilize her intelligence, education, energy and time. The AIP model posits that the emotions and physical sensations inherent in the unprocessed event and showed stored inappropriately in the memory are the foundation of current pathology (Ray & Zbik, 2001; Shapiro, 1995, 2001; Stickgold, 2002). Neha’s symptoms of dizziness, headache and fatigue were due to her painful memories of humiliation and criticism of her mother in law, every time there is an audience present. The memories were comprehensively processed and resolved ecologically, including a realistic perception on coping with her weaknesses (her lack of assertiveness, her submissive and suppressive nature). 14 In cognitive therapies, like in exposure therapy, high level of emotional engagement or “reliving” is encouraged, which is very different from EMDR where, the client engages in a dual-attention task, which results in the client “distancing” from the memory—that is, maintaining present-day attention while simultaneously focusing on the memory. (Jaycox, Foa, & Morral, 1998). A study by Lee, Taylor, and Drummond (2006) coded clients’ responses during an EMDR session according to whether the responses were consistent with reliving, distancing, or focusing on other associated material. They found that distancing was associated with the greatest improvement on a measure of PTSD symptoms, demonstrating support for this EMDR treatment component and supporting the concept that EMDR is distinct from exposure therapy. They also suggested that “distancing may be partly facilitated by the distraction of the eye movement task”. This case illustrates how the patient’s own cognitive, emotional, and somatic associations during EMDR can lead to an accelerated learning experience that results in both a remediation of symptoms and an enhanced sense of self-efficacy (Shapiro & Forrest, 1997). Conclusion It is not unusual for EMDR processing to result in new insights and an enhanced sense of self, with the desire to make the painful experience fruitful and to help others. When the sense of a positive future is lacking, comprehensive treatment is incomplete, and greater attention should be directed to potential targets manifested in the premorbid history (Shapiro, 2001). Ultimately, overt symptom reduction, such as pain elimination, dizziness and fatigue is only one element in the comprehensive clinical picture. As indicated by Shapiro ( Shapiro, 2001; Shapiro & Forrest, 1997), the treatment of somatic problems involves not only physical but also psychological and existential issues. It is the “psychological tension or self identification as a helpless victim that can be the most debilitating factor” (Shapiro, 2001). It is important to remember that cases of depression involve the issues of self-worth, self-efficacy, and unresolved feelings of loss of identity, social status, and an active, positive future. Thus, in the present case the first step of processing the memories of the past not only consisted of processing the traumatic events itself, but additional memories involving sense of 15 failure, loss, shame, anger at maltreatment, and so forth. These were all necessary for a permanent elimination of the depression. It is vital to take a comprehensive history of the case to explore contributing factors, as they may not always emerge during processing itself. Other targets involving present triggers, and future templates and the material associated with them should address most of the clinical picture. The outcome of an EMDR session indicates the linkup of the two networks; an assimilation of the painful material into its proper perspective (i.e., that it belongs to the past); and a discharge of the dysfunctional affect, with generalization of the adaptive conditions through the hitherto isolated material. Thus, after the treatment of a trauma the client is able to bring up earlier memories that are now fully integrated into the more adaptive perspective. Along with this new perspective comes the ability to act in a more appropriate and empowered way. REFERENCES Andrade, J., Kavanagh, D., & Baddeley, A. (1997). 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Stanford, CA: Stanford University Press. 19 Table I Pre and Post – treatment assessment: session-wise treatment goals Sessions I II III IV V VI Target Preparation Mother Mother Mother Mother Mother in cognitions for EMDR in law ‘s in law’s in law in law ‘s law’s reprosessed sessions. criticism criticism insulting refusal of gifts of in wedding public dress VII VIII IX Strengthening Strengthening daughter’s Of coping Of coping blame for birthday resources resources to accept low class party puja upbringing Insult in offerings Pre -SUD 8 7 8 9 10 10 8 6 Post-SUD 0 0 0 0 0 0 0 0 20 Table 2 Pre and Post – treatment psychometric measures Measures Pre treatment scores Post-treatment scores Beck Depression 39 13 Inventory Psychological General Well- Being Schedule Anxiety/relaxed 2 13 Depressed/elated 1 12 Negative/positive 3 12 mood well being Uncontrolled/self 1 10 control General 6 12 3 14 sickness/health Lethargy/vitality Stress Resistant Cognitive Behavioural coping Pattern Scale. Problem focused 41 24 21 coping Emotion focused 46 70 coping Problem with 21 12 emotion focused coping Rathus Assertiveness Scale Positive 32 48 28 22 assertiveness traits Negative assertiveness traits 22