Re:EMDR Referral / the risks / how long before it begins to work?

Matt:

Alan Goldstein and Ulrike Feske have published a systematic series of three empirical papers on EMDR for panic disorder. The first of their three papers (Goldstein & Feske, 1994) was a case series of 7 individuals with a primary diagnosis of panic disorder, 5 of whom also had an additional diagnosis of agoraphobia. "After five sessions of EMDR, subjects reported a considerable decrease in the frequency of panic attacks, fear of experiencing a panic attack, general anxiety, thoughts concerning negative consequences of experiencing anxiety, fear of body sensations, depression , and other measures of pathology." (from the abstract)

In the second paper (Feske & Goldstein, 1997), EMDR was compared with a variation of EMDR without eye movements and with waitlist control. Participants were 43 individuals diagnosed with primary panic disorder, and all but two also had agoraphobia. Results indicated that "Posttest comparisons showed EMDR to be more effective in alleviating panic and panic-related symtpoms than the waitling-list procedure. Compared with the same treatment without the eye movement, EMDR led to greater improvement on 2 of 5 primary outcome measures at posttest. However, EMDR's advantages had dissipated 3 months after treatment, thereby failing to firmly support the usefulness of the eye movement component in EMDR treatment of panic disorder." (from the abstract) To the best of my knowledge, this is the ONLY clinical dismantling study of EMDR in which eye movements have been found to have an effect on treatment outcome measures.

In the third paper (Goldstein, de Beurs, Chambless, & Wilson, 2000), EMDR was compared with a credible attention-placebo control group that consisted of relaxation and free association and wait list. Participants were 46 individuals diagnosed with panic disorder with agoraphobia. Agoraphobic avoidance had to be of at least moderate severity for the prior six months. Results indicated that "EMDR was significantly better than waiting list for some outcome measures (questionnaire, diary, and interview measusres of severity of anxiety, panic disorder, and agoraphobia) but not for others (panic attack frequency and anxious cognitions). However, low power and, for panic frequency, floor effects may account for these negative results. Differences between EMDR and the attention-placebo control condition were not statistically significant on any measure, and, in this case, the effect sizes were generally small (eta-squared = .00 - .06), suggesting the poor results for EMDR wre not due to lack of power. Because there are established effective treatments such as cognitive-behavior therapy for PDA, these data, unless contradicted by future research, indicate EMDR should not be the first-line treatment." (from the abstract).

EMDR treatment in consisted of six 90-minute sessions (1 session for assessment and treatment planning, 5 sessions of actual EMDR) over a 2-3 week period. This research team paid close attention to the issue of treatment fidelity. (a) Both Goldstein and Feske received level II training by Shapiro. Other therapists involved in administering EMDR also had Level II training by EMDR or one of her designates. (b) Shapiro reviewed the treatment manual developed for the study and the checklist used to rate treatment integrity. Using a 0 (unacceptable) to 6 (high quality) rating scale, she assigned both of these documents a score of 5 (midway between acceptable and high quality). (c) Tapes of treatment sessions were rated for adherence to the protocol which revealed the treatments were indeed administered according to protocol.

Unfortunately, there is yet to be a direct comparison between contemporary cognitive-behavioral therapy (CBT) and EMDR, so nothing can be said with any confidence about ther relative efficacy of EMDR and CBT or whether EMDR would work when CBT failed (or vice versa for that matter). On a pragmatic level, however, there is a substantial body of research indicating that CBT is generally quite effective with panic disorder. Until such a head-to-head comparison occurs, it is probably "best practice" to utilize CBT as the first-line psychological treatment for panic.

You indicated that you have already had CBT. However, before abandoning CBT for panic, I would suggest (if you have not already done so) you first read up on cutting edge CBT for panic and evaluate whether or not you received the kind of CBT that has been demonstrated effective for panic. CBT is something of an umbrella term for a general approach to therapy, but specific problems sometimes require certain specific treatment components for optimal outcome. Specifically, what appears to be most effective for panic disorder is a combination of (a) ognitive restructuring to address panic related thoughts, (b) interoceptive exposure exercises designed to induce sensations related to panic attacks (e.g., over breathing, spinning in a chair, stair-stepping, breathing through a straw, etc.) in order to reduce fear of these sensations, and (c) in vivo exposure to reduce agoraphobic avoidance. Barlow and Craske's "Mastery of Your Anxiety and Panic" program is a good example of this type of treatment (published by Graywind Publications, there are both therapist manuals and client workbooks available). If you don't feel you received this kind of treatment, then you may want to discuss your prior treatment with a qualified CBT therapist to decide whether or not it makes sense to give it another try. Best of luck in getting effective help with your problems.

Goldstein, A. J., & Feske, U. (1994). Eye movement desensitization and reprocessing for panic disorder: Journal of Anxiety Disorders, 8, 351-362.

Goldstein, A. J., de Beurs, E., Chambless, D. L., & Wilson, K. A. (2000). EMDR for panic disorder with agoraphobia: Comparison with waiting list and credible attention-placebo control conditions. Journal of Consulting and Clinical Psychology, 68, 947-956.

Feske, U., & Goldstein, A. J. (1997). Eye movement desensitization and reprocessing treatment for panic disorder: A controlled outcome and partial dismantling study. Journal of Consulting and Clinical Psychology, 6, 1026-1035.

Replies:

Re:EMDR Referral / the risks / how long before it begins to work?, by Sandra Paulsen Inobe, PhD, 12/19/01 Re:EMDR Referral / the risks / how long before it begins to work?, by Cahill, 12/19/01

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