ARE THERE DIFFERENCES IN RATES OR TREATMENT RESPONSE BETWEEN COMBAT-RELATED AND CIVILIAN PTSD?
In this review of research on EMDR treatment for combat-related trauma, we begin with the question: Are there differences in rates or treatment response between combat-related and civilian PTSD? In a sample of nearly 500 burn unit patients, Gaylord et al. (2009 reported that “The incidence of PTSD is not significantly different in burned combat casualties and civilians treated at the same burn unit.” Is combat-related PTSD more difficult to treat than civilian PTSD? A recent meta-analysis of frontline treatments by Straud et al. (2019) found that both “combat and [civilian] assault trauma subgroups had worse treatment outcomes compared to the mixed trauma subgroup, but differences were not observed between assault and combat subgroups.” “Higher attrition rates predicted poorer treatment outcomes but did not vary between military populations and civilians.” Straud et al. recommended that “…manualized, first-line psychotherapies for PTSD should continue to be used for civilians and military populations with various trauma types. However, greater emphasis should be placed on enhancing PTSD psychotherapies for military populations and on treatment retention across populations based on findings from this metaanalysis.”
RANDOMIZED CONTROLLED TRIALS (RCTS) FOR COMBAT RELATED PTSD
RCTs remain the standard for evaluating evidence-based treatment. Out of more than 30 RCTs in which EMDR therapy has been evaluated as a treatment for PTSD, only six have examined the treatment of those with combat related PTSD. These include Ahmadi, et al. (2015), Boudewyns, et al. (1993) Carlson, et al. (1998), Devilly (1998), Jensen (1994), and Pitman et al. (1996). The Jensen, the Devilly and the Boudewyns studies provided only two sessions of EMDR therapy, which is unlikely to have been enough treatment for this multiply traumatized population whereas in the Carlson study, after 12 sessions of EMDR therapy, 78% no longer met full criteria for PTSD (Shapiro, 2018, p 389). Pitman et al. was a dismantling study of a nonstandard eye movement condition with concurrent, but non-bilateral, finger tapping versus an eye fixation condition. The authors claimed the results showed modest improvement in both groups, but data from the standardized testing were not disclosed. Independent treatment fidelity rating revealed low to moderate fidelity to standard EMDR procedures. The Ahmadi study reported a high dropout rate of 31% and evaluated eight sessions of EMDR or REM desensitization with a wait list control. Differential dropout rates by group were not disclosed. REM desensitization is a previously unpublished procedure that uses glasses that track REM sleep and plays 30 seconds of music during REM sleep. The music played had previously been paired with soothing images during awake desensitization-conditioning sessions. Ahmadi et al. reported similar symptom reduction with REM desensitization compared to the EMDR condition and both were superior to the wait list control. Thus, of these six RCTs, at best only two (Ahmadi, et al., 2015; Carlson, et al., 1998) may have specific relevance for evidence of EMDR therapy’s effectiveness with combat-related PTSD. Clearly more controlled research with combat related PTSD is needed.
THE OFFICIAL LINE: DOD/VA TREATMENT GUIDELINES
In the United States, the most recent Department of Veterans Affair and Department of Defense treatment guidelines (2010) list EMDR therapy as an effective intervention on an equal footing with other frontline treatments. The guidelines state that “The choice of a specific approach should be based on the severity of the symptoms, clinician expertise in one or more of these treatment methods and patient preference, and may include an exposure-based therapy (e.g., Prolonged Exposure), a cognitive-based therapy (e.g., Cognitive Processing Therapy), Stress management therapy (e.g., SIT) or Eye Movement Desensitization and Reprocessing (EMDR).” While that is the official line, anecdotal reports and survey data – see Russell & Silver (2007) below – suggest that availability of trauma informed care varies widely and that EMDR therapy is not universally permitted in the VA system. Prolonged Exposure (PE) Therapy and Cognitive Processing Therapy (CPT) may be more widely available within the DOD/VA system, but as Najavits (2015) makes clear, studies in real-world conditions (rather than in research settings) of patient retention (those who receive the recommended “dose” of seven sessions or more) and dropout show that most patients with PTSD do not stay in these treatments for their intended lengths. In one recent VA study by Mott et al. which she cited, “Only 11.4% (n = 91 patients) began either CPT or PE and only 7.9% (n = 59 patients) completed either CPT or PE.”
EMDR FIRST IN PRINT FOR TREATMENT FOR ACUTE STRESS DISORDER IN COMBAT EXPOSED SOLDIERS
While there are relatively few published studies on the treatment of acute stress disorder, there are two early case reports of EMDR therapy for combat-related acute stress disorder. The first by Russell (2006) discussed four combat veterans, casualties from the Iraqi war, evacuated to a field hospital in Spain and treated with a single session of EMDR which led “to significant improvement in their acute stress disorder and posttraumatic stress disorder symptoms.” Russell provided detailed descriptions of their treatment and suggests that “Compared to other early interventions, EMDR may be better suited for combat veterans.” He highlighted the need for further research. The second, by Wesson and Gould (2009), presents a single-case study on the use of the EMDR recent event protocol (Shapiro, 1995) used in theatre two weeks post trauma “with a 27-year-old active-duty U.K. soldier who was experiencing an acute stress reaction after treating a land mine casualty.” After four sessions on consecutive days, “the soldier [was] able to return immediately to frontline duties.” Four standardized measures were used at pretreatment, posttreatment, and 18-month follow-up and showed stable effects at the 18-month follow-up.
CASE STUDIES OF EMDR TREATMENT FOR COMBATRELATED PTSD
Silver, Rogers and Russell (2008) summarized EMDR treatment of two combat veterans to “illustrate the ability of EMDR to achieve symptom reduction in a variety of clinical domains (e.g., anxiety, depression, anger, physical pain) simultaneously without requiring the patient to carry out homework assignments or discuss the details of the event.” They also discussed the EMDR treatment of phantom limb pain and other somatic presentations and highlighted “The ability of EMDR to achieve positive effects without homework indicates that it can be effectively employed on consecutive days, making it especially useful during combat situations.” Russell (2008) examined the potential benefits of EMDR treatment of combat-related medically unexplained symptoms (MUS) and presented a single case study of an Iraqi war combat veteran treated with EMDR for combat-related MUS and PTSD. He emphasized the benefits of EMDR therapy which does not require the “extensive homework or self-disclosure that some military patients may resist” and called for further research. The same year Russell (2008) published a case study on the use of EMDR therapy for phantom limb pain. “One active-duty patient was referred to a military outpatient clinic for treatment of PLP and PTSD following a traumatic leg amputation from a noncombat-related motor vehicle accident. Four sessions of eye movement desensitization and reprocessing (EMDR) led to elimination of PLP and a significant reduction in PTSD, depression, and phantom limb tingling sensations.” A more recent case report by Moss (2017) described “the case narrative of a 29-year-old national guardsman, exposed to combat trauma and later to civilian trauma in public safety work.” His treatment involved a series of “multimodal interventions, beginning with self-directed behavioral changes, then the acquisition of skills (including self-hypnosis), and finally professional treatment including clinical hypnosis and EMDR.”
EMDR TREATMENT FOR NONCOMBAT, DEPLOYMENT-RELATED PTSD IN GERMAN SOLDIERS.
Zimmermann, et al. (2007) investigated inpatient EMDR treatment for German soldiers with PTSD following non-combat deployments. They reported that “The Impact of Event Scale showed that inpatient trauma therapy with eye movement desensitization and reprocessing significantly improved the course of post-traumatic stress disorder. In addition, the Impact of Event Scale indicated a significantly poorer longterm outcome for patients who had been confronted with death during their traumatic experience.” However, the authors acknowledge that their small sample size limits the generalizability of this finding. See Alliger-Horn, et al. (2015) and Köhler, et al. (2017) further below for more recent data on EMDR treatment of German soldiers.
ABSENCE OF EVIDENCE-BASED TRAINING WITHIN THE DOD/VA
Three years after the DoD/VA first released clinical-practice guidelines for posttraumatic stress disorder (CPGPTSD), Russell and Silver (2007) published a survey of 137 mental health professionals employed by the military or the VA to clarify whether they used any of the psychotherapies listed in the CPG-PTSD: cognitive therapy, eye-movement desensitization and reprocessing, exposure therapy, and stress inoculation therapy. “Ninety percent of respondents reported not using any of the 4 psychotherapies. Of those who did, most had received their training before their affiliation with the military…”
EARLY EMDR TRAINING OF CLINICIANS PROVIDING TRAUMA SERVICES FOR DOD & VA PROGRAMS
Russell, Silver, Rogers and Darnell (2007), responding to the need identified in the Russell and Silver survey (2007) cited above, described delivering a training program for EMDR therapy with the help of a non-profit agency. They presented “an evaluation of that program with rating data gathered from participants as well as treatment outcome data from the application of the training to patients.” They reported that the “program was highly rated by the participants and the impact of EMDR treatment was significant.”
SCIENTIFIC RESISTANCE TO EMDR THERAPY IN POST-WAR DISORDERS
In 2008, Russell published “Scientific resistance to research, training and utilization of EMDR therapy in treating post-war disorders.” “[An] analysis of scientists’ resistance to discoveries is examined in relation to an 18-year controversy between the dominant cognitive-behavioral paradigm or zeitgeist and its chief rival – eye movement desensitization and reprocessing (EMDR) in treating trauma-related disorders…”
EMDR ONLY AFTER OTHER METHODS FAIL FOR COMBATRELATED PTSD
As a possible example of this bias, and despite the DOD/VA treatment guidelines (2010) giving equal emphasis to TF-CBT and EMDR therapy, Verstrael et al. (2013) commented in their meta-analysis that “One of the treatments of choice, eye-movement desensitization and reprocessing (EMDR) has, however, not been validated for the military population.” Their meta-analysis reached back to 1987 and concluded that “The analysis thus far resulted in a failure to support the effectiveness of EMDR in treating PTSD in the military population.” They emphasized the limited number of “well-designed randomized controlled trials (RCTs)” and suggest that “Until more research is done, EMDR as treatment of choice for combat-related PTSD should be used only if other treatment protocols have proven unsuccessful.”
TWO EFFECTIVENESS REVIEWS EMDR THERAPY FOR ACTIVE MILITARY PERSONNEL
Brickell, et al. (2015) analyzed archival clinical outcome data from individuals treated with EMDR in U.S. military community counseling centers. They examine 99 archival cases, of which 65 were active duty military personnel. The primary diagnosis was PTSD for 65 of the clients. Of these, 42 involved combat, and 23 were noncombat related. Outcome measures after EMDR treatment showed significant improvement. McLay, et al. (2016) also investigated the efficacy of EMDR with a record review from 311 service members treated at active-duty military mental health clinics using selfreport measures of posttraumatic stress and disability. Symptom scores were compared between those who received (n = 46) or did not receive (n = 285) EMDR. “Results indicated that patients receiving EMDR had significantly fewer therapy sessions over 10 weeks but had significantly greater gains in their PCL-M scores than did individuals not receiving
EMDR.” SYSTEMATIC REVIEW AND METAANALYSIS OF PSYCHOLOGICAL THERAPIES FOR COMBAT-RELATED PTSD
Kitchener, et al., (2019) recently published a systematic review and meta-analysis of active duty and ex-serving military personnel treated with psychological therapies for post-traumatic stress disorder. Their review focused on studies with wait-list controls and considered four studies: Ahmadi et al., 2015; Carlson et al., 1998; Devilly et al., 1998; Jensen, 1994. The Devilly et al. (1998) study offered only two sessions of EMDR therapy and contained several risks of bias. Kitchener admits the Devilly “outcome data should, therefore, be treated with caution” but still includes it. Kitchener points out that the clinicians in the Jensen (1994) study had only two days of EMDR training and subjects received only two EMDR sessions, yet still includes the data in the meta-analysis. In this meta-analysis, Kitchener states that “there was no difference between EMDR and waitlist in reducing PTSD symptoms post treatment” despite the data in Figure 9 showing EMDR favored over waitlist/TAU. Kitchener did not include the RCT data from Alliger-Horn, et al. (2015) nor from Köhler, et al. (2017). Kitchener emphasizes the need for more controlled research on EMDR therapy for actively duty and former serving military personnel with PTSD that include a waitlist control condition.
ATTACHMENT STYLE MAY MEDIATE VULNERABILITY TO COMBATRELATED PTSD
Escolas, et al. (2012) examined the relationship of attachment style on self-reported PTSD symptoms in 561 active duty, post deployment service members who completed anonymous questionnaires including 2 measures of adult attachment and a military PTSD checklist. They reported that self-reported secure attachment was associated with fewer self-reported PTSD symptoms. The authors suggest a possible relationship between attachment and PTSD symptoms within a military population and call for future research in this area.
PREDICTION OF PSYCHOTHERAPY OUTCOME IN PTSD USING NEUROIMAGING DATA
This proof-of-concept study by Zhutovsky, et al. (2019) explored the use of structural and restingstate functional magnetic resonance imaging (MRI/rs-fMRI) to identify potential biomarkers for treatment response. The idea is that these rsfMRI biomarkers could enable personalized treatment of patients with PTSD. The study included forty-four male veterans with PTSD who had baseline scanning followed by treatment-as-usual consisting of TF-CBT and/or EMDR therapy. The authors concluded that “the current study shows that treatment response to trauma-focused psychotherapy can be predicted for individual patients with PTSD using machine learning analysis of rs-fMRI data.” In addition to treating only male combat veterans, the authors acknowledged that “… the treatments received by the patients represent a heterogeneous mix of different trauma-focused psychotherapies. While they are considered as first-line treatments and the fact that in realistic settings multiple treatments might be employed by therapists, the results are not specific to one particular treatment. Therefore, the current approach might obscure specific individual patient-by-treatment interactions.”
CAN INTENSIVE TREATMENT BE EFFECTIVE FOR COMBAT-RELATED TRAUMA?
Hurley (2018) provided a comparison derived from a records review between intensive daily and weekly EMDR therapy for veterans with PTSD treated at Soldier Center. Veterans in the intensive daily format received two EMDR sessions per day during a 10-day period. Those in the weekly format received one session each week. Both formats offered a total of 18-20 EMDR treatment sessions. “The results indicated that both weekly treatment and intensive daily treatment groups produced statistically significant treatment effects (p < 0.001) that were maintained at 1-year follow-up.” Thus, “The10-day EMDR intensive daily treatment (EMDR therapy twice a day for 10 days) produced a similar outcome as to that of the weekly treatment with a 1-year follow-up.” Steele, et al., (2018) summarizes a single-group assessment of Trauma and Resiliency Resources, Inc.’s intensive seven-day Warrior Camp (WC) program for treating combat-related trauma in active duty and veterans. This multi-modal program includes EMDR therapy, equine-assisted psychotherapy, yoga, and narrative writing. Change scores from prepost-assessment for 85 WC participant showed what the authors described as “statistically significant reductions in distress. The effect sizes ranged from small to large.” Self-report measures included the Mississippi Scale for Combat-related PTSD, the Patient Health Questionnaire, the Revised Adult Attachment Scales, and the Moral Injury Events Scale, Clinician-administered measures included the Davidson Trauma Scale and the Dissociative Experiences Scale. “Results suggest that WC participants experienced significant improvement in PTSD, depression, moral injury, dissociation and adult attachment.”
PREDICTING EMDR AND TFCBT RESPONSE WITH CORTISOL AWAKENING RESPONSE
Rapcencu, et al., (2017) assessed the cortisol awakening response (CAR|i|) in both PTSD (N=41) and non-PTSD (N=25) combat-exposed male subjects. Treatment included TF-CBT and EMDR as well as psychotropic medication for PTSD or for comorbid conditions. CAR|i| was assessed at the start of the study and after 6-8 months. There were two findings of note. First, CAR|i| decreased over time in both groups. This finding suggests that decreases in CAR|i| was not specific to PTSD or a result of treatment. “Second, CAR|i| prior to treatment predicted PTSD symptom reduction (CAPS score change) after treatment, and accounted for 10% of the variance, even when adjusted for changes in depressive symptoms and medication use during the study period.” The authors suggest that CAR|i| could potentially be used “as a predictive biomarker of symptom reduction in male individuals with combatrelated PTSD.”
HIPPOCAMPAL GROWTH WITH MULTIMODAL EMDR THERAPY FOR COMBAT-RELATED PTSD
Butler, et al. (2018) reported on a small pilot study which compared structural MRI images in six patients with combat-related PTSD with nine individuals in a waitlist group. Those in the treatment group received multimodal therapy including two 120-minute EMDR sessions per week for six weeks. Multimodal therapy included psychoeducation group sessions (250 min per week), occupational therapy (100 min per day), relaxation therapy (progressive muscle relaxation) (50 min per day), and physiotherapy (100 min per week). They reported that “the therapy group (n = 6) showed a significant increase in hippocampal volume and a nonsignificant trend toward an increase in amygdala volume following therapy, while no change was observed in the waiting-list group (n = 9).” While the results are promising, due to the multimodal therapy and the known role of exercise on hippocampal growth (Thomas et al., 2016), it is impossible to determine the extent to which hippocampal growth was mediated specifically by EMDR therapy or other interventions.
EMDR TREATMENT OF TRAUMATIZED GERMAN SOLDIERS
Alliger-Horn, et al. (2015) published a German language article. This brief summary is from the English abstract. In this study “the comparative effectiveness of EMDR and IRRT (Imagery Rescripting and Reprocessing Therapy) in trauma therapy was examined with 40 traumatized Bundeswehr soldiers with a PTSD diagnosis.” The authors report significant changes in “trauma complaints and comorbid symptoms” and that “The Reliable Change Index (RCI) for EMDR is 77 percent and for IRRT 67 percent.” Köhler, et al. (2017) published an inpatient, retrospective, quasiexperimental effectiveness study of EMDR therapy with 78 German soldiers and a waitlist of 18 soldiers. Those treated with EMDR received four weeks of two to three individual sessions of 90 to 100 minutes, each week. The authors concluded that “EMDR therapy is an effective treatment to reduce symptoms of PTSD and depression.” They add that “in the military context it needs to be complemented by treatment options that specifically address further conditions perpetuating the disorders.”
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