LEARNING OBJECTIVES

After reading this article you will be able to:

• • list the variety of mental illnesses for which strong evidence exists to support the use of EMDR

• • understand the specific applications of EMDR in affective, anxiety, psychotic and somatic disorders

• • identify the areas in which further evidence is still needed to support the use of EMDR.

In our previous article in BJPsych Advances (Udo Reference Udo, Javinsky and Awani2022) we presented the process of conducting eye movement desensitisation and reprocessing (EMDR) therapy and discussed the approved indications for its use and evidence supporting EMDR for post-traumatic stress disorder (PTSD). In the present article, we discuss the various mental and associated physical health conditions for which EMDR may be useful. A key element of EMDR is that it views psychopathology through the adaptive information processing model, which suggests that mental illness can result from improperly processed trauma memories (Solomon Reference Solomon and Shapiro2008). EMDR is therefore a transdiagnostic intervention that can be used in many psychiatric disorders. The conditions chosen for discussion in this article are those underpinned by randomised controlled trials (RCTs) or where EMDR is included in treatment guidelines. It is hoped that readers will become aware that, apart from PTSD, EMDR may be used to improve the quality of treatment in various other conditions, both mental and physical. There are other conditions with only lower-level evidence, such as case reports, case series or expert opinions, but these are not the subject of this review.

Anxiety disorders

Obsessive–compulsive disorder

EMDR has not been recommended as a treatment for obsessive–compulsive disorder (OCD) in any major guidelines, and research into its use is still in its early stages. Marsden et al (Reference Marsden, Lovell and Blore2018a) performed an RCT comparing EMDR and the recommended treatment, CBT. Their study randomised 55 individuals to each treatment. Both treatments had comparable completion rates and clinical outcomes, with no significant differences between the groups. Participants were recruited from a primary care mental health service that routinely offered 16–20 sessions of CBT, suggesting that their psychopathology may not have been severe. The basis for the application of EMDR was Marr's (Reference Marr2012) hypothesis that it can be used to process the fears and obsessive behaviours of OCD, thereby reducing distress in the present. He also hypothesised that EMDR could be used to process emotions associated with the trigger event or underlying event linked to the onset of illness. Marsden et al followed Marr's EMDR sequential protocol, which involved processing current triggers for obsessions and compulsions, generating a psychological belief of future success and then processing any past disturbing events. Their study is limited by its sample size and a brief follow up period of 6 months.

Nazari et al's (Reference Nazari, Momeni and Jariani2011) RCT compared EMDR with treatment using citalopram, a selective serotonin reuptake inhibitor (SSRI). In their study, 90 individuals were randomly assigned to the two groups and received the interventions for 12 weeks. Comparisons were made before and after, which showed a significant post-treatment drop in symptoms in the EMDR group compared with the citalopram group. The authors concluded that both methods brought about improvement in obsessive–compulsive symptoms, with short-term EMDR having better outcomes. Their study was limited by a short follow-up of participants, low dose of citalopram (20 mg daily) and no record of side-effects of interventions. In addition, 17 participants from the citalopram group and 13 from the EMDR group were lost to follow-up and not included in the final analysis. The range or median number of sessions required for EMDR therapy was not clear.

Böhm (Reference Böhm2019) carried out a narrative review of studies of EMDR treatment of OCD. It included the two studies above as the only randomised trials available at the time. In addition, case studies were reviewed which showed the successful integration of EMDR with CBT strategies for treatment of refractory OCD. Furthermore, a small study by Keenan et al (Reference Keenan, Farrell and Keenan2018) showed that EMDR was effective in treating people with OCD who were still symptomatic after having previously undergone CBT. Eight patients who had not benefitted from exposure and response prevention therapy completed eight sessions of EMDR, after which they demonstrated a decrease in their OCD symptoms both 1 and 3 months later; however, the authors did not do any formal statistical testing to be able to comment on significance.

Marsden et al (Reference Marsden, Teahan and Lovell2018b) considered the experiences of a sample of 24 participants in their above-mentioned RCT comparing EMDR and CBT (Marsden Reference Marsden, Lovell and Blore2018a). A thematic analysis of interviews showed that half of the 14 in their sample who had received EMDR struggled to recall the name of the treatment and its rationale; however, many felt that the preparatory phases before actual processing were of good use. Some of the EMDR participants were able to work satisfactorily with the bilateral stimulation device, but some complained of experiencing drowsiness, exhaustion and nausea. Other difficulties that EMDR participants encountered were inability to locate an OCD trigger memory, inability to relive real-world anxiety in the therapy space and exacerbation of checking behaviours after finishing therapy. Difficulties described by participants in the CBT group included problems performing exposures at the beginning of therapy and during graded activities; finding the sessions too structured and inflexible; and inability to express their feelings, leading to eventual drop out from CBT. The authors thought that the acceptability and tolerability of treatment methods depended largely on how credible patients found the rationale behind each treatment. In his seminal book Persuasion and Healing: A Comparative Study of Psychotherapy, Frank (Reference Frank1961) asserts that one of the common characteristics of efficacious psychotherapies is the use of rationales that provide reasonable explanations for patients’ symptoms and proposes procedures for resolving them.

Mood disorders

Dissociative disorders

Guidelines published by the International Society for the Study of Trauma and Dissociation (2011) identify EMDR as one of the treatments that may be helpful in dissociative identity disorder (DID); however, this recommendation is based on limited, lower-level studies. Included in the guidelines is a paper by Lazrove & Fine (Reference Lazrove and Fine1996) which presents a comprehensive description of how EMDR may be used in DID using a case report. Twombly (Reference Twombly2000) also describes how EMDR may be adapted for people with DID. Paulsen (Reference Paulsen1995) uses cases to illustrate situations where EMDR should not be used or should be cautiously used in people with DID.

The use of EMDR in DID is highly specialised and requires specific training. The majority of evidence for treating this disorder with EMDR takes the form of expert opinions presented at conferences and in the grey literature.

Eating disorders

Traumatic life experiences are known to be one of many etiological factors that may trigger eating disorders. Thus, EMDR may have a role in the treatment of eating disorders; however, the current evidence comprises only case studies and one randomised experimental trial.

Four case studies have provided preliminary evidence supporting EMDR's use. Dziegielewski & Wolfe (Reference Dziegielewski and Wolfe2000) explored the potential of EMDR as a brief intervention for low self-esteem and body image disturbances. The authors described a young female with a history of bulimia-like behaviour who, following completion of two EMDR sessions, showed significant improvements in scores on the Self-Esteem Rating Scale and the Body Image Avoidance Questionnaire. A case study by Halvgaard (Reference Halvgaard2015) examined whether EMDR could reduce symptoms associated with emotional eating. A 55-year-old woman with problems with emotional eating and feelings of loss of control over food underwent six weekly sessions of EMDR. Her treatment followed a specialised EMDR protocol, the adjusted Desensitization of Triggers and Urge Reprocessing (DeTUR™) protocol (Popky Reference Popky and Shapiro2005). She experienced an overall positive change in eating behaviour and affect regulation during triggering situations, results that were maintained at 3- and 6-month follow-up. Zaccagnino et al (Reference Zaccagnino, Cussino and Callerame2017) described the case of a 17-year-old in-patient with unremitting anorexia nervosa who received twice-weekly EMDR sessions for 6 months, with a focus on reprocessing relational traumas. At the end of treatment, the young woman's BMI had increased from 14 to 21.5 and she no longer met criteria for anorexia nervosa. Furthermore, she reported an increase in self-confidence, with results maintained at 12- and 24-month follow-up. Lastly, Yaşar et al (Reference Yaşar, Abamor and Usta2019) summarised the cases of two young girls with avoidant/restrictive food intake disorder as a consequence of traumatic events, who were treated with seven sessions of EMDR therapy combined with nine sessions of CBT. Both girls experienced significant reductions in associated symptoms of anxiety and depression and were subsequently able to eat a greater variety of foods.

In the randomised experimental trial by Bloomgarden & Calogero (Reference Bloomgarden and Calogero2008), 43 women receiving standard residential treatment for eating disorders (SRT) were compared with 43 women receiving SRT in addition to EMDR (SRT + EMDR) on measures of negative body image and other clinical outcomes. Those in the SRT + EMDR group received one or two EMDR sessions per week during their treatment stay, with a specific focus on body image problems. Those in the SRT + EMDR group reported less distress about negative body image memories and lower body dissatisfaction at post-treatment, 3-month and 12-month follow-up, compared with the SRT only group.

Although further research is still necessary, the preliminary findings of these studies imply a promising potential for the use of EMDR in treating eating disorders.

Substance misuse and addictions

Current interventions in addictions are limited by high relapse rates and low retention numbers. They are mostly based on self-control strategies that employ cognitive–behavioural approaches. These are not always appropriate or preferred by patients and there is a need to expand treatment strategies. EMDR offers various possibilities. It can be used to treat PTSD that is comorbid with addictions or underlying traumas associated with the onset of addiction, which is referred to as trauma-focused EMDR. There is also an adaptation of EMDR to process non-trauma memory representation of the addiction, referred to as the addiction-focused approach. These two approaches can be combined.

Markus & Hornsveld (Reference Markus and Hornsveld2017) performed a broad critical review of the literature on how EMDR is used in addictions. Their review comprised 18 studies of varying types, which are mostly lower-quality evidence, but include one RCT. They state that the current literature shows that EMDR's use in addictions is promising, but note that despite 20 years of research and development, addiction-focused EMDR approaches are still largely under-researched. In particular, they felt that EMDR may be useful in reducing the intensity of substance misuse-related imagery and craving.

Included in Markus & Hornsveld's review is Hase et al's (Reference Hase, Schallmayer and Sack2008) RCT, in which 34 individuals with alcohol dependence were randomised to treatment as usual (TAU) or treatment as usual plus EMDR (TAU + EMDR). EMDR treatment focused on the addiction memory, which includes preparatory behaviour, substance effects (substance use) and loss of control. The TAU + EMDR group showed a significant reduction in alcohol craving post-treatment and at 1-month follow-up, whereas the TAU group did not. A specialised EMDR protocol, the craving extinguished (CravEx) protocol, was used.

Meysami-Bonab et al (Reference Meysami-Bonab, Abolghasemi and Sheikhian2012) conducted an RCT on individuals with drug addictions attending an ‘addiction treatment camp’, in which 30 participants were randomised to either eight sessions of EMDR or no treatment. They had completed a period of detoxification before the interventions. They were assessed, using a questionnaire, for emotion regulation and emotion recognition. Those who received EMDR were found to have increased positive emotion regulation and emotion recognition in the post-test phase and their scores for negative emotion regulation were significantly improved. Their study was limited by lack of follow-up and the use of a single therapist and assessor. However, the finding of increased positive emotion regulation and recognition increases the possibility of recovery.

Sleep disturbances

EMDR is a recommended treatment in the best practice guide for the treatment of nightmare disorder in adults (Aurora Reference Aurora, Zak and Auerbach2010) commissioned by the American Academy of Sleep Medicine. This review of evidence recognises that it is based on two lower-level studies (Silver Reference Silver, Brooks and Obenchain1995; Raboni Reference Raboni, Tufik and Suchecki2006). It is thought that the efficacy of EMDR in nightmare disorder is based on its ability to induce the processing of disturbing memories and experiences by stimulating neural mechanisms that are similar to those activated during rapid eye movement (REM) sleep (Stickgold Reference Stickgold2008; Aurora Reference Aurora, Zak and Auerbach2010).

Psychosis

Although EMDR may not cure psychosis, it may have a role in ameliorating psychotic symptoms. Adams et al (Reference Adams, Ohlsen and Wood2020) performed a comprehensive systematic review of the use of EMDR in psychosis. They found six studies: one RCT, two case series, one case report and two pilot studies, one of which used an RCT design and the other an open trial with one arm. Their total sample comprised 236 adults, with individual study sample size ranging from 27 to 155. Participants had a range of psychotic disorders: schizophrenia, schizoaffective disorder, delusional disorders (including olfactory reference syndrome), bipolar disorder with psychotic features, and psychosis not otherwise specified. The number of EMDR sessions received ranged from one to ten. The authors found that the application of EMDR in psychosis was associated with reductions in delusional thinking and negative symptoms of psychosis, as well as improved social and general functioning, longer remission, fewer readmissions to hospital, reduction in use of mental health services and reduction in use of medications. These benefits were maintained at 10-year follow-up. There were mixed findings for the management of auditory hallucinations and paranoid thinking.

Conversely, in a study involving 40 individuals with schizophrenia, Kim et al (Reference Kim, Choi and Kim2010) found that EMDR was no more effective in reducing symptoms associated with schizophrenia, anxiety and depression than progressive muscle relaxation (PMR) therapy or treatment as usual. However, effect size for negative symptoms was large for the EMDR group compared with the control groups (ES = 0.60 for EMDR, ES = 0.39 for PMR and ES = 0.21 for treatment as usual).

Of note, a Japanese researcher (Kikuchi Reference Kikuchi2008) published the earliest peer-reviewed article detailing the application of EMDR therapy to schizophrenia. This work has not yet been published in English. Its model and concepts have borrowed much from how CBT is applied in schizophrenia. These are described by Miller (Reference Miller2015).

Trauma has been shown to be a significant predictor of psychosis (Read Reference Read, van Os and Morrison2005; Shevlin Reference Shevlin, Dorahy and Adamson2007), meaning that screening and treatment of trauma symptoms should be an important consideration in individuals with psychotic disorders. To this end, two studies have examined the safety and efficacy of using EMDR to treat PTSD in patients with psychosis. In a feasibility study, de Bont et al (Reference de Bont, Van Minnen and De Jongh2013) found that 7 of 10 individuals treated with either EMDR or prolonged exposure therapy no longer met the diagnostic criteria for PTSD at follow-up. No serious adverse events were reported and participants did not exhibit any worsening of delusions, hallucinations, general psychopathy or social functioning. However, participants were followed up for only 3 months, the sample was small, and the study focused on auditory hallucinations, not including other types of hallucination. The study was also limited by the lack of a control group and the use of clinical chart diagnosis to determine lifetime diagnosis. An RCT by van den Berg et al (Reference van den Berg, de Bont and van der Vleugel2015) also suggested that EMDR is safe and effective in treating PTSD in people with psychosis. They randomised 155 patients to receive either prolonged exposure therapy or EMDR or to a waiting list. Participants in both treatment conditions experienced greater reductions in PTSD symptoms than those on the waiting list. Importantly, no severe adverse events occurred as a result of the interventions. In their 12-month follow-up study, van den Berg et al (Reference van den Berg, de Bont and van der Vleugel2018) showed that positive effects were maintained for reductions in PTSD symptoms, depression and paranoid-referential thinking and for remission from schizophrenia in both treatment groups. The authors therefore concluded that their results suggested that trauma-focused therapies such as EMDR have long-term neutral to positive effects on symptoms of PTSD, depression and psychosis in people with psychotic disorders.

The specific ways in which EMDR was employed in the treatment processes described above were to target and process the traumatic memories that caused comorbid PTSD (van den Berg Reference van den Berg and van der Gaag2012; de Bont Reference de Bont, Van Minnen and De Jongh2013; Laugharne Reference Laugharne, Marshall and Laugharne2014; Adams Reference Adams, Ohlsen and Wood2020), to target and process hallucinations associated with negative beliefs about self and others (Kratzer Reference Kratzer, Heinz and Schennach2017) and to target life experiences that triggered olfactory reference syndrome (McGoldrick Reference McGoldrick, Begum and Brown2008).

Despite this exciting potential for the application of EMDR in psychosis, existing studies are limited by lower sample sizes and power, with their study designs making the overall quality of evidence low. Preliminary guidelines on the skilled use of EMDR in the management of psychosis have been published by a team of subject experts (van den Berg Reference van den Berg, van der Vleugel and Staring2013).

Somatoform disorders, including chronic pain syndromes

Summary and conclusions

Apart from its approved use for treating PTSD, EMDR has been shown to be useful in the treatment of a variety of affective and non-affective conditions. Specifically, this review has presented high-quality evidence supporting the use of EMDR in the management of panic disorder, specific phobia, OCD and major depressive disorder. It has been shown to be potentially useful in the management of bipolar affective disorder, although more evidence is needed. Moreover, its usefulness is not limited to these conditions. Early evidence points to the potential usefulness of EMDR in the management of eating disorders and substance misuse. EMDR is recommended, by subject experts, for the treatment of dissociative identity disorder and nightmare disorder. It has also been found to be helpful for individuals suffering from complex disorders such as somatoform disorders and chronic pain syndromes. The mechanisms by which it helps in these latter conditions are less clear, but they appear to require an increased number of sessions and a longer duration of treatment compared with PTSD.

Although EMDR used to be considered unsuitable for psychosis, evolving evidence supports its safe use in some cases. This use of EMDR is based on several concepts. The adverse early childhood experiences of many people with psychosis constitute unresolved trauma. This trauma is often an important aspect of their illness, including triggers for the onset of psychosis, the resolution of which improves symptoms. Furthermore, the events of having a psychotic breakdown and/or being treated in mental health services are potentially traumatic in themselves and may in some cases lead to post-traumatic stress symptoms. It is now acknowledged that psychoses and PTSD may occur comorbidly, influencing one another and leading to ongoing traumatisation (Marconi Reference Marconi and Polidoro2018).

The evidence supporting the use of EMDR in treating PTSD is incontrovertible, especially in adults, but this review highlights areas where further research is needed. Furthermore, there is a sense of urgency, given the ubiquity of mental illnesses such as anxiety and depressive disorders and the complexity of disorders such as eating, substance use and somatoform disorders. The outcomes of studies presented in this review are indeed encouraging. Hence, there is promise that treatment guidelines may be expanded and it is our hope that this article enlightens clinicians to consider these possibilities and advocate for services that can deliver these interventions for the good and well-being of patients.