Exploration of eye movement desensitization and reprocessing in treating posttraumatic stress-disorder in patients with acquired brain injury: a retrospective case series

Figures & data

Table 1. Sociodemographic and clinical characteristics of ABI patients with PTSD treated with EMDR who completed the IES.

Patient characteristics (N = 16)	Number (%)	Median (range)
Male	8 (50%)
Age in years		46 (25–68)
Outpatient	14 (88%)
Type of ABI
TBI moderate/severe	8 (50%)
Stroke	4 (25%)
Other^a	4 (25%)
Time since ABI in months		65 (5–354)
Type of index trauma for PTSD
ABI^b	9 (56%)
(Other) serious injury or death (of loved one)	2 (12.5%)
Sexual abuse	2 (12.5%)
Other	3 (19%)
Timing of index trauma (other than ABI)
Prior to ABI	2 (13%)
Post ABI	5 (31%)
PTSD main reason for care	6 (38%)
Comorbid DSM disorders and problems
(Neuro)cognitive disorder	16 (100%)
Personality change due to the ABI	6 (38%)
Mood disorder, predominantly depressive disorder	3 (19%)
Personality disorder	0 (0%)
Anxiety disorder (other than PTSD)	1 (6%)
Substance abuse disorder	1 (6%)
Epilepsy	2 (13%)
Occupational problem	6 (38%)
Relational problem	5 (31%)
Other problem related to the social environment	3 (19%)
Other problem related to psychosocial circumstances	4 (25%)
OQ45 total score pre-treatment		68 (36–105)^c
OQ45 total score above clinical cut-off	11 (85%)^c

Note: ABI = acquired brain injury; PTSD = posttraumatic stress disorder; EMDR = Eye Movement Desensitization and Reprocessing; IES = Impact of Event Scale; TBI = traumatic brain injury; ^abrain hypoxia, multiple sclerosis, (extirpation of) frontal meningioma, bifrontal cystic encephalomalacia; ^bthe event of or circumstances causing the ABI or the direct consequences of the ABI (for instance the accident/stroke, the violent assault, experiences in ambulance/hospital, or in confusional state/delirium); DSM = Diagnostic and Statistical Manual of Mental Disorders; OQ45 = Outcome Questionnaire 45; ^cdata missing n = 3.

Table 2. Treatment characteristics of ABI patients with PTSD treated with EMDR who completed the IES.

Treatment characteristics (N = 16)	Number (%)	Median (range)
Total number of EMDR sessions		7 (2–14)
Number of EMDR sessions to treat Target 1		3 (1–8)
Stimuli used in desensitization
Eye movements in all sessions	9 (60%)^a
Eye movements in part of sessions	4 (27%)^a
Only other stimuli^b	2 (13%)^a
Multiple stimuli at once	6 (40%)^a

Note: ABI = Acquired Brain Injury; PTSD = Posttraumatic Stress Disorder; EMDR = Eye Movement Desensitization and Reprocessing; IES = Impact of Event Scale; ^adata missing n = 1; ^bfor instance: auditory bilateral clicks, sensory bilateral buzzers/taps, calculations.

Figure 1. Individual IES scores of ABI patients with PTSD pre- and post-treatment with EMDR (n = 16).

Note: Plot showing the pre-treatment (X-axis) and post-treatment (Y-axis) individual patient’s Impact of Event Scale (IES) scores. The dashed lines mark the boundaries of reliable change (i.e. +/−11.31). The circle marks the mean group score pre- and post-treatment. Points above the upper boundary of reliable change represent statistically significant deterioration (i.e. reporting more symptoms after treatment as compared to before treatment), triangles within the dashed lines represent no statistically significant improvement over time and squares below the lower boundary of reliable change represent statistically significant improvement (i.e. reporting less symptoms after treatment as compared to before treatment). The dotted lines mark the IES clinical cut-off score of 26, IES scores right of and above these lines are considered clinically significant. Based on Morley and Dowzer (2014).

Table

Box 1. Dutch EMDR standard protocol Before the first treatment session the therapist discusses treatment rationale, psychoeducation, and addresses treatment planning. The next sessions focus on the patients’ traumatic memory or memories. The patient is asked to concentrate on specific aspects of the traumatic memory, particularly (1) its most distressing ‘image’ (i.e. the target); (2) the cognition associated with it, that is, the patient's negative or dysfunctional belief of him- or herself; (3) the accompanying emotions, physical responses and Subjective Units of Distress (SUD). At the core of the EMDR technique is the principle of taxing the working memory in each individual case, preferably by eye movements. This is operationalized by having the patient focus on the therapists horizontal hand movements in front of the patient at eye level or a horizontally moving light on an EMDR light bar, and/or audio tones (irregular clicks) bilaterally through headphones, and/or tactile stimuli (taps, for instance) while the patient is mentally confronting the most disturbing part of the traumatic event. The patient is asked to focus on the stimuli while holding the distressing image in mind. After about 30 s the distracting stimuli are paused and the patient is asked what comes up. The therapist lets the patient know he/she should focus on that and continues desensitization (i.e. offers working memory taxing stimuli). This is continued until there is no more change in the patient report (i.e. twice the same association in a row) or after 5–10 min. Then the image is brought into recollection and the patient assesses the SUD associated with the image. The patient is asked to focus on the image and name what is distressing in the image. The procedure then continues with desensitization. This continues until the SUD is 0. By asking questions, the therapist checks the specific memory of the patient for other distressing images, and, when present, those are also desensitized. Next, the validity of cognition (VOC) of the positive cognition in relation to the image (i.e. the counterpart of the negative cognition) is assessed (on a scale of 1 (completely false) to 7 (completely true)) and desensitization is applied until VOC is 7. When there is enough time, a body scan is done to assure there is no more distress associated with the image. In case there are other distressing memories of the event about which intrusions exist, the protocol is repeated as described above. In case there is also anticipatory fear and avoidance behaviour, for instance fear of a future debilitating stroke and avoiding being alone, a ‘flashforward’ (Logie & de Jongh, 2014) is applied. Desensitization is applied as described above on the image of the anticipatory fear as if it were a memory. When appropriate, a future template is installed of a realistic avoided situation. To help foster closure, each session ends on a positive note. Homework between sessions is not a standard part of EMDR and was not applied.

Table

Box 2. Computation of the reliable change index (RCI) for the Dutch version of the Impact of Event Scale following the method of Jacobson and Truax (1991) Step 1. Compute standard error of measurement SEm = s √ 1-rxx, with s = 20.4 and Cronbach’s α = .96 (van der Ploeg et al., 2004) SEm = 20.4√1−.96 = 4.08; Step 2. Compute Sdiff Sdiff = √ 2 (SEm2), with SEm = 4.08 Sdiff = 5.77 Step 3. Compute RCI RCI = Sdiff * 1.96, with Sdiff = 5.77 RCI = 11.31

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Data availability statement

The participants of this study did not give written consent for their data to be shared publicly, so due to the sensitive nature of the research supporting data is not available.