De rationale voor de behandeling van PTSD
met EMDR en andere interventies.
Theoretische overwegingen
en experimentele bevindingen
Marcel van den Hout (UU)
4 april 2014
KP/KNP congres, Utrecht
Vooraf: Psychologische behandeling van angststoornissen
1) Behandeling: Exposure (Exp) en cognitieve therapie (CT) effectief
2) Rationale straightforward: Extinctie door exposure (cf. dier studies)
3) CS
Dus:
Activatie
representatie US
Angst response
Paniekstoornis: hartkloppingen  hartinfarct
OCD
: vieze handen
 verspreiden ziekte
Vliegangst : vliegtuig
 crash
Sociale fobie : Blozen
 sociale uitsluiting
4) PTSD: Exp en CT ook effectief
5) Echter: Andere angststoornissen: Exp en CT doorbreken CSUS
verwachting.
PTSD: aard/aanwezigheid CSUS verwachting onduidelijk
6) Bovendien: EMDR ook effectief; even sterk als CT en Exp.
(en alle 3 veel beter dan andere interventies)
Bradley et al. (2005).A multidimensional meta-analysis of psychotherapy for PTSD.
American Journal of Psychiatry, 162, 214-227.
Seidler & Wagner (2006) Comparing the efficacy of EMDR and trauma focussed CBT
in the treatment of PTSD. Psychological Medicine, 36, 1515-1522
Bisson and Ehlers, et al . (2007). Psychological treatments for chronic PTSD:A systematic review
and meta-analysis. British Journal of Psychiatry, 190, 97-104.
7) Cruciaal probleem: Hoe werken Exp., CT en EMDR bij PTSD?
Te bespreken:
A) Exposure en PTSD
B) CT en PTSD
C) EMDR en PTSD
Exposure behandeling van EMDR: ‘Imaginaire exposure”
Hoe werkt exp. bij PTSD? 1) Extinctie
Als bij andere angststoornissen, ook bij PTSD doorbreken US verwachting
(= extinctie)
NB: Mentale vermijding definierend kenmerk PTSD
Verwachting PTSD patient: Bij recall trauma  controleverlies e.d.
Dus: Paniekstoornis: hartkloppingen  hartinfarct
OCD
: vieze handen  verspreiden ziekte
Vliegangst : vliegtuig
 crash
PTSD
: trauma recall  Controle verlies etc
Schematisch:
Schematisch: Exposure werkt (ook bij PTSD) via extinctie
CS
(reminder)
Activatie US representatie
(trauma-recall)
Emotionele
response
Verwachting ctrl verlies
e.d.
Hoe werkt exp. bij PTSD? 2): habituatie
Theoretisch/empirisch onderscheid: habituatie en extinctie
Schematisch: Exposure werkt via habituatie in PTSD:
CS
(reminder)
Activatie US representatie
(trauma-recall)
Emotionele
response
NB: Dat exposure werkt bij PTSD is evident:
bijdrage extinctie en/of habituatie onduidelijk
B) Hoe werkt CT bij PTSD?
Procedure CT
B) Hoe werkt CT bij PTSD?
Procedure CT
Correctie (mis)interpretatie antecedenten
en consequenten van trauma
CS
(reminder)
Activatie US representatie
(trauma-recall)
Emotionele
response
Verwachting ctrl verlies
e.d.
C) EMDR als behandeling van PTSD
Terzijde: scepsis over EMDR ongegrond
Meta-analyses: EMDR as effective as CBT, and far more than e.g.
psychodynamic, client centered etc. approaches
Bradley et al. (2005).A multidimensional meta-analysis of psychotherapy for PTSD. American
Journal of Psychiatry, 162, 214-227.
Seidler & Wagner (2006) Comparing the efficacy of EMDR and trauma focussed CBT
in the treatment of PTSD. Psychological Medicine, 36, 1515-1522
Bisson and Ehlers, et al . (2007). Psychological treatments for chronic PTSD:A systematic review and meta-analysis. British
Journal of Psychiatry, 190, 97-104.
Effecten EMDR bij PTSD: groot en snel
Changes in post-traumatic stress disorder (PTSD) scores on the Impact of Event Scale – Revised
for intent-to-treat analysis.
Nijdam M J et al. BJP 2012;200:224-231
©2012 by The Royal College of Psychiatrists
C) EMDR als behandeling van PTSD
Cruciaal element van procedure: oogbewegingen tijdens trauma-recall
Hoe werkt EMDR bij PTSD?
Theorie in schema:
CS
(reminder)
Activatie US representatie
(trauma-recall)
Emotionele
response
Verwachting ctrl verlies
e.d.
Hoe werkt EMDR bij PTSD?
Theorie in schema:
Reductie levendigheid/emotionaliteit
van trauma herinnering
CS
(reminder)
Activatie US representatie
(trauma-recall)
Emotionele
response
Verwachting ctrl verlies
e.d.
Maar hoe zou EMDR levendigheid/emotionaliteit van
trauma-herinnering reduceren?
Reductie levendigheid/emotionaliteit
van trauma herinnering
CS
(reminder)
Activatie US representatie
(trauma-recall)
Emotionele
response
Verwachting ctrl verlies
e.d.
Maar hoe zou EMDR levendigheid/emotionaliteit van
trauma-herinnering reduceren?
Recall: episodisch geheugen ‘labiel’
Vergelijk: Concentratie op herinnering en “imagination inflation”
Imagination inflation
100
80
60
Vividness
40
20
0
Recall
PRE Imag
Recall
DURING
Imag
Recall
POST
Imag
Imagination inflation
100
80
60
Vividness
40
20
0
Recall
PRE Imag
Recall
DURING
Imag
Recall
POST
Imag
Imagination inflation
100
concentration
80
60
Vividness
40
20
0
Recall
PRE Imag
Recall
DURING
Imag
Recall
POST
Imag
Imagination inflation
100
80
60
Vividness
40
20
0
Recall
PRE Imag
Recall
DURING
Imag
Recall
POST
Imag
Imagination deflation
100
80
60
Vividness
40
20
0
Recall
PRE Imag
Recall
DURING
Imag
Recall
POST
Imag
Imagination deflation
100
80
60
Vividness
40
20
0
Recall
PRE Imag
Recall
DURING
Imag
Recall
POST
Imag
Imagination deflation
100
80
60
Vividness
40
20
0
Recall
PRE Imag
Recall
DURING
Imag
Recall
POST
Imag
Imagination deflation
100
80
60
blurring
Vividness
40
20
0
Recall
PRE Imag
Recall
DURING
Imag
Recall
POST
Imag
Imagination deflation
100
80
60
Vividness
40
20
0
Recall
PRE Imag
Recall
DURING
Imag
Recall
POST
Imag
Theory:
1) EMDR exploits memory lability during recall.
2) EMDR serves as the inverse of imagination inflation:
it deflates the vividness of memories by taxing of Working Memory during recall
3) Reconsolidation of memory affected by Recall+WM episodes
Typical preparation of lab studies on EMDR
1) Healthy volunteers retrieve aversive memories
2) Pre-test: memories scored in terms of vividness/adversity
3) Interventions: during recall a) Recall + Eye movements
or
b) Recall only
4) Post test: recall and scored in terms of vividness/adversity
Exposure Theories: Recall only = Recall + EM’s (EM’s irrelevant)
Januari 2011: at least 14 experiments
Author
Outcome
Adrade et al.,
(1997)
Van den Hout et al., (2001)
Kavanagh et al.,
(2001)
Kemps et al.,
(2007)
Maxfield et al.,
(2008)
Expt. 1
Expt. 2
Gunter & Bodner (2008)
Expt. 1
Expt. 2
Expt. 3
Lilley et al.
(2009)
Van den Hout et al. (2010)
Engelhard et al.
(2010 a-b)
Hornsveld et al.
(2010)
Van den Hout et al. (2011)
Van den Hout et al. (2011)
Expt 1
Expt 2
Expt 3
Recall Only
0
0
0
0
Recall + EM’s
+
+
+
+
0
0
+
+
0
0
0
0
0
0
0
0
+
+
+
+
+
+
+
+
0
0
0
+
+
+
Effects not confined to self reports.
1) Argument: Decision whether painting fragments are/are not
part of Rembrand’s ‘Nightwatch’: activation memory
Vivid memory?
Fast Y/N response
Blurred memory? Slow Y/N response
2) Method: a) Encode complex picture
b) Recall picture + EM’s (vs. ctrl. condition)
c) Decide whether fragments are/are not part of picture
d) Prediction: slow decision after recall + EM’s
Picture
In mind
EM’s
No EM’s
Prediction:
slow Y/N
recognition
Not in mind
Van den Hout et al., 2012. Cognition & Emotion, in press
Conclusie: EM’s  negatieve herinneringen:
a) Minder levendig
b) Minder emotioneel
c) Minder toegankelijk
Wordt werkgeheugen echt belast door EM’s?
Test: vertraging op Reactie Tijd taak t.g.v. EM’s
Van den Hout, Engelhard et al., 2011, Behav Res Ther,
Traditional EMDR theory:
EMDR effects depend on Left-Right alternation
of EM’s.
Implication:
Horizontal EM’s > Vertical EM’s
Alternative theory: (memory deflation):
Horizontal EM’s = Vertical EM’s
Eyes stationary
Eye Movements
Horizontal
Pre-to-post
decreases
Vertical
Vividness
From: Gunter & Bodner, 2008
Emotionality
Completeness
Theorie:
ook memory deflation t.g.v. “Recall + andere duale taak die WG belast
Technique
Author
Outcome
Recall
only
Vertical EM’s (Gunter & Bodner, 2008)
Drawing
( idem)
Shadowing (idem)
Tetris
(Engelhard et al, 2011)
Counting
(van den Hout et al., 2010)
(Engelhard et al., 2010)
7) Articulatory
suppresion (Kemps et al., 2007)
8) Attentional
breathing
(van den Hout et al., 2010)
1)
2)
3)
4)
5)
Recall +
WM taxing
0
0
0
0
0
0
+
+
+
+
+
+
0
+
0
+
Replacing EM’s by bilateral beeps
1) > 50% of actual EMDR sessions presently with beeps
instead of EM’s (Cf. interhemisphere theory of EMDR)
2) No studies on clinical effects of beeps
3) Do bilateral beeps tax WM?
4) Beeps effective in blurring memory?
400
350
Reaction
300
times
(Msec)
250
200
150
Van den Hout, Engelhard et al., 2011, Behav Res Ther.
Eye Movements
Binaural
stimulation
No dual task
400
350
Reaction
300
times
(Msec)
250
200
150
Eye Movements
Binaural
stimulation
No dual task
400
350
Reaction
times
300
(Msec)
250
Eye Movements
?
200
150
Van den Hout, Engelhard et al., 2011, Behav Res Ther.
Binaural
stimulation
No dual task
400
350
Reaction
300
times
(Msec)
250
200
150
Van den Hout, Engelhard et al., 2011, Behav Res Ther
Eye Movements
Binaural
stimulation
No dual task
Do beeps blur memory like EM’s do?
1,6
1,2
Eye movements
Drop
0,8
in
scores
Binaural
stimulation
No dual task
0,4
0
Vividness
Van den Hout, Engelhard et al., 2011, Behav Res Ther.
1,6
1,2
Eye movements
Drop
0,8
in
scores
Binaural
stimulation
No dual task
0,4
0
Vividness
Van den Hout, Engelhard et al., 2011, Behav Res Ther.
1,6
1,2
Eye movements
Drop
in
scores
0,8
0,4
Binaural
stimulation
No dual task
?
0
Vividness
Van den Hout, Engelhard et al., 2011, Behav Res Ther.
1,6
1,2
Eye movements
Drop
0,8
in
scores
Binaural
stimulation
No dual task
0,4
0
Vividness
Van den Hout, Engelhard et al., 2011, Behav Res Ther.
Theory and data suggest:
Beeps inferior to EM’s
Objection: Experimental model = clinical reality
1) Students had no PTSD
2) “Unpleasant memory” = trauma
Question: How do real PTSD patients respond
to beeps and EM’s?
Clinical study; n= 12 PTSD
(Rape (5 X), war + rape, years of sexual/physical abuses etc)
6 recalls during session 1: 2 X EM’s
2 X Beeps
2 X Recall only
Order of interventions:
Balanced
Dependant variables :
Vividness
Emotionality (SUDS)
Hout, M.A. van den et al., (2012). Tones inferior to eye movements in the EMDR treatment of PTSD.
Behaviour Research and Therapy, 50, 275-279
2,5
2
1,5
Drop
in
scores
EM's
Beeps
Recall only
1
0,5
0
-0,5
Emotionality
Vividness
2,5
2
1,5
Drop
in
scores
EM's
Beeps
Recall only
1
0,5
0
-0,5
Emotionality
Van den Hout et al, Behav Res Ther, 2012
Vividness
2,5
2
1,5
Drop
in
scores
EM's
Beeps
Recall only
1
0,5
0
-0,5
Emotionality
Van den Hout et al, Behav Res Ther, 2012
Vividness
2,5
2
?
1,5
Drop
in
scores
EM's
Beeps
Recall only
1
0,5
0
-0,5
Emotionality
Van den Hout et al, Behav Res Ther, 2012
Vividness
2,5
2
1,5
Drop
in
scores
EM's
Beeps
Recall only
1
0,5
0
-0,5
Emotionality
Van den Hout et al, Behav Res Ther, 2012
Vividness
2,5
2
1,5
Drop
in
scores
EM's
Beeps
Recall only
1
0,5
0
-0,5
Emotionality
Van den Hout et al, Behav Res Ther, 2012
Vividness
2,5
2
1,5
Drop
in
scores
EM's
Beeps
Recall only
1
0,5
0
-0,5
Emotionality
Vividness
2,5
?
2
1,5
Drop
in
scores
EM's
Beeps
Recall only
1
0,5
0
-0,5
Emotionality
Vividness
2,5
2
1,5
Drop
in
scores
EM's
Beeps
Recall only
1
0,5
0
-0,5
Emotionality
Vividness
Hout, M.A. van den et al., (2012). Tones inferior to eye movements in the EMDR treatment of PTSD. Behaviour Research and Therapy, 50,
275-279
What about patient’s opinions about
1) Recall only?
2) Recall+ beeps?
3) Recall+ EM’s?
“How would you prefer to continue?”
8
7
6
5
EM's
Beeps
Recall only
4
3
2
1
0
Patients preference
8
7
6
5
EM's
Beeps
Recall only
4
3
2
1
0
Patients preference
8
7
6
5
EM's
Beeps
Recall only
4
3
2
1
0
Patients preference
8
7
6
5
4
3
?
2
1
0
Patients preference
EM's
Beeps
Recall only
8
7
6
5
EM's
Beeps
Recall only
4
3
2
1
0
Patients preference
Hout, M.A. van den et al., (2012). Tones inferior to eye movements in the EMDR treatment of PTSD. Behaviour Research and Therapy, 50, 275279
8
7
6
5
EM's
Beeps
Recall only
4
3
2
1
0
Patients preference
EM’s superior,
But patients preferred beeps.
Clinicians may infer effectivity from patients’ preference.
Tijdens EMDR: ook recall positieve herinneringen + EM’s
“Resource Development and Installation” (RDI)
according to EMDR protocol
Activation of “positive, functional and resourceful memories”
and simultaneous EM’s
Experiment: RDI (positive memories!!) under three conditions:
a) Traditional
(with horizontal EM’s)
b) Alternative
(with vertical EM’s)
c) Crucial Alternative (without EM’s)
Vividness
Pleasantness
0
Horizontal
Vertical
Horizontal
Mean Difference scores (in VAS Rating)
Mean Difference scores (in VAS Rating)
-0,2
-0,4
-0,6
-0,8
-1
-1,2
-1,4
-1,6
Vertical
-0,2
-0,4
-0,6
-0,8
-1
-1,2
-1,8
Conditions
Hornsveld et al, 2011
0
Recall-only
Conditions
Recall-only
Indication EMDR (evidence based):
PTSD (trauma memories)
Clinical practice (non-evidence based): Eating disorders, addiction,
chronic pain, sexual problems etc.
Theory suggests: also flash forwards (prospective memory)
80
80
75
75
70
70
Emotionality
Vividness
Change in “flash forwards” 1
65
60
65
60
55
55
50
50
45
45
pre-test
eye movement
post-test
just retrieval
pre-test
eye movement
post-test
just retrieval
Engelhard, van den Hout, Janssen & van der Beek, 2010 ( Behav Res Ther)
Change in “flash forwards” 2
(Engelhard, van den Hout et al., 2011)
Samengevat
* Imaginaire exposure, CT en EMDR: effectief bij PTSD
*Imaginaire exposure: Extinctie en/of habituatie
* CT: Correctie interpretatie antecedenten en consequenten trauma
* EMDR: Deflatie trauma memory door “Recall + EM’s”
Besproken data mbt EMDR
1) EM (zeer) effectief in lab
2) Niet alleen EM’s ook andere WG belasting effectief
3) Piepjes: Minimale WM belasting, minimale geheugeneffecten
4) Ook bij positieve herinneringen: deflatie na “recall + EM’s
5) Flash forwards als ander indicatiegebied?
Theoretical issue:
Noradrenaline and Emotion in memory effects of recall + EM
Van den Hout et al., 2012, submitted
1
2
WM span
3
4
WM load of
dual task
WM load
provided
by memory
The end
EMDR: tijdens (trauma) recall vervagen van herinnering
door simultane oogbewegingen
Verwachting: imagination “deflation”