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Military Behavioral Health

ISSN: 2163-5781 (Print) 2163-5803 (Online) Journal homepage: http://www.tandfonline.com/loi/umbh20

Eye Movement Desensitization and Reprocessing
(EMDR) as Treatment for Combat-Related PTSD: A
Meta-Analysis
Sietse Verstrael , Peter van der Wurff & Eric Vermetten
To cite this article: Sietse Verstrael , Peter van der Wurff & Eric Vermetten (2013) Eye
Movement Desensitization and Reprocessing (EMDR) as Treatment for Combat-Related PTSD:
A Meta-Analysis, Military Behavioral Health, 1:2, 68-73, DOI: 10.1080/21635781.2013.827088
To link to this article: http://dx.doi.org/10.1080/21635781.2013.827088

Accepted author version posted online: 01
Aug 2013.

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meta-analysis. 2009). Utrecht.S.vermetten@mindef. Bryant. but other therapeutic approaches such as narrative exposure therapy (NET) and brief eclectic psychotherapy for PTSD (BEPP) are also starting to gain momentum. Several possible explanations are given. military. National Institute for Health and Clinical Excellence [NICE]. however. considered to be evidence based. 2010). illustrating some divergence from the NICE guidance and evidence of professionals within specialized settings tailoring therapeutic practices to the perceived needs of individual clients. The Netherlands Eric Vermetten Downloaded by [89. & Cohen. EMDR as treatment of choice for combat-related PTSD should be used only if other treatment protocols have proven unsuccessful. however. The Netherlands.nl in the treatment guidelines by the International Society for Traumatic Stress Studies (Foa.MILITARY BEHAVIORAL HEALTH. not been validated for the military population. EMDR is being piloted in disorders beyond PTSD and other anxiety disorders. & Tarrier. Ministry of Defence. Leiden.2013. The Netherlands Although the symptom presentation of post-traumatic stress disorder (PTSD) in the general and military population is very similar.g. 1: 68–73.. TF-CBT has been proven effective in the treatment of PTSD in the general population (Bisson & Andrew. Many favor the explanation that EMDR is based on the working memory theory. psychotherapy. Among these types. These irrationalities are then replaced by corrective thoughts that are more balanced. combat-related PTSD is typically thought to be more severe due to repeated and prolonged exposure to traumatic events.1080/21635781. the U. Military Mental Health-Research. which states that working memory has limited resources.141. A meta-analysis was carried out on literature ranging back to 1987. combat. 2011). Utrecht. 2012). see Harvey. and the American Psychiatric Association (APA. eye-movement desensitization and reprocessing (EMDR) has. 2005). Ministry of Defence. Keane. Keywords: PTSD. of which the limited number of well-designed randomized controlled trials (RCTs) seems to be the most important one. 3500 EZ.136. Both tf-CBT and EMDR therapies are.172] at 01:51 21 October 2015 Military Mental Health Research.827088 Eye Movement Desensitization and Reprocessing (EMDR) as Treatment for Combat-Related PTSD: A Meta-Analysis Sietse Verstrael and Peter van der Wurff Military Rehabilitation Center. CBT. One of the treatments of choice. traumafocused cognitive behavioral therapy (tf-CBT) and eyemovement desensitization and reprocessing (EMDR) are considered to be the first-line therapies of choice (e. LLC Copyright  ISSN: 2163-5781 / 2163-5803 online DOI: 10. E-mail: hgjm. EMDR. treatment BACKGROUND It is generally believed and empirically supported that exposure-based therapies are most effective in treating combat-related post-traumatic stress disorder (PTSD) (Sharpless & Barber. RCT. Until more research is done. Arq Psychotrauma Expert Group. The analysis thus far resulted in a failure to support the effectiveness of EMDR in treating PTSD in the military population.. Doorn. TF-CBT is a so-called talking therapy. EMDR has further been recommended Address correspondence to Prof dr Col Eric Vermetten. Ministry of Defense. ranging from psychosis (Van den Berg & van der Gaag. 2004). The Netherlands. Goodson et al. Friedman. Lundlaan 1. 2009) as well as the military population (for a review. Department of Veterans Affairs/Department of Defense (Management of Post-Traumatic Stress Working Group. and Leiden University Medical Center. 2011). If a dual task uses some of those . No single theory has explained the effectivity of EMDR. 2003. 2013 C Taylor & Francis Group. in which patients are encouraged to search for irrational and distressing thoughts and feelings about the event. 2012) to borderline personality disorder (Mosquera & Gonzalez-Vazquez.

Blake et al. Afterward.g. Several meta-analyses have shown the effectiveness of EMDR in the general population (e.136. Primary outcome measures are used to identify and evaluate PTSD symptomatology. Van Etten & Taylor. 2001. Brooks. The PS score was used to calculate the weight of the study for use in a cumulative meta-analysis. with only combat-related PTSD and using standardized PTSD-specific measures were of interest for this analysis. In two articles (Silver. Bisson & Andrew. see Albright & Thyer. still unclear (for a review. & Taylor. 2013. 1998). Macklin et al. Van den Hout et al. 2004) score was calculated. 2003).172] at 01:51 21 October 2015 EMDR AS TREATMENT FOR COMBAT-RELATED PTSD resources. Articles that did not meet these criteria are not reported here. It is generally believed that eye movement is essential to the therapy (Jeffries & Davis. Garvey. Materials For all studies. Primary Measures The Clinician-Administered PTSD Scale (CAPS. and this was within a single item. After this meeting. & Propper. 2000) was written in Japanese and was therefore excluded. Authors of these studies were contacted in order to receive additional data. Compared to TF-CBT. The effectiveness of EMDR in the military population is. Included studies are listed in Table 1. Phaneuf. Russell. However. PTSD in the military population is believed to be markedly different from PTSD in other populations. Goodson et al. Only articles with original data. bilateral stimulation has been demonstrated to have a positive effect on the retrieval of episodic memories (Christman.Downloaded by [89. no meta-analysis on the effectiveness of EMDR in this population has been published to date. In EMDR. The Platinum Scale is an instrument that evaluates the study on criteria such as the use of the original EMDR protocol.141. Some therapists believe this is the result of the imagined exposure and the cognitive behavioral components of EMDR and not of the bilateral stimulation. The Mississippi Scale for Combat-Related PTSD (MPTSD. all raters judged the articles independently.. This is especially notable because PTSD as a disorder was first conceptualized to be a syndrome most applicable to war veterans. The VoC scale is a self-rated measure of the validity of one’s thoughts (whether or not the thoughts are true).. 2010. EMDR is more debated—mostly because it is still uncertain whether the effects of EMDR are due to the unique therapy approach (for an overview. 1988) is a 35-item .. Keane. the Cochrane Library. 2003. This form of PTSD is more commonly known as combat-related PTSD. Hertlein & Ricci. but no response was obtained. Despite several research studies on the applicability and therapeutic effect of EMDR in cases of combat-related PTSD dating back to 1995. PS scores indicate how well the study was designed and performed. and Utrecht University’s Omega were used to search for relevant articles. 2011). and one article (Wada. METHODS Study Selection PubMed. appropriate training of the therapist and assessors. This is performed in repeating cycles lasting for the duration of a therapy session. then afterward a consensus meeting was held. the patient is instructed to identify distressing thoughts and feelings about this event and rate them on a Validity of Cognitions (VoC) scale. such as depression. the patient is typically instructed to imagine a distressing event and to rate how distressing the event is on a Subjective Units of Distress (SUD) scale. Search Results Only seven articles met the inclusion criteria. The ratings in Table 1 represent the score the majority of raters (2 out of 3) agreed with. which is again followed by bilateral stimulation. The PS score was calculated by three raters. & Obenchain. These tests can be divided into primary and secondary outcome measures. 2009. however. and other factors. due to the prolonged and repeated exposure to the traumatic events that occur during combat.. There is some evidence that it is useful but not nearly enough to be considered evidence based. see Sikes & Sikes. using the following search parameters: the terms (“PTSD” or “posttraumatic stress disorder”) AND (“EMDR” or “eye move- 69 ment desensitization and reprocessing”) AND (“veteran” or “soldier” or “military personnel” or “combat” or “war”). The ratings are given based on the month prior to assessment.. with several characteristics. In EMDR this dual task consists of bilateral stimulation. 2012). First. The sections that follow present very short descriptions of the tests used in the included studies. Davidson & Parker. 2008). Measures PTSD symptoms are often measured using a variety of tests. Caddell. A type of rapidly alternating and bilateral stimulation is given when the affect is maximal (in most cases the subject is invited to follow a horizontally moving object with the eyes). 1995. with higher scores indicating better study designs. whereas secondary measures are used to identify and evaluate non-PTSDspecific symptoms. a Platinum Scale (PS. between 1987 (start of EMDR) and March 2012. only 2 of 156 scores (13 PS items × 4 articles × 3 raters) were debated. This article is aimed at filling that gap by conducting a metaanalysis on published studies on this topic. spanning a publication date range of 25 years. 2000) insufficient data were presented to calculate effect sizes. less will be available for memory processes so the recollection of memories will be less vivid and less emotional. 1995) is a structured interview in which the criteria from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) relating to PTSD are assessed and the severity of both frequency and intensity are rated by the interviewer on a 5-point Likert scale.

Hedlund. subjects are asked to rate their “worst ever” symptomatology. & Rapee. 1998 EMDR (n = 10). REDDR (n = 16). PSS = PTSD Symptom Scale.70 S. bMean effect size. self-report measure in which PTSD symptoms and associated features are rated on a 5-point Likert scale. & Lushene. Mendelson. & Muraoka. on both primary (PTSD) measures and secondary measures (see Table 1). In the SI-PTSD. Spielberger. SI-PTSD = Structured Interview for PTSD. 1961) is the most-used test to measure depression. 1996) with 22 items was used by Rogers and colleagues (1999). Wilner. Also. Ward.and posttreatment. STAI = Spielberger’s State Trait Anxiety Index. & Gournay. Exposure (n = 6) PTSD Outcome Measurea Secondary Outcome Measurea Mean Effect Sizeb d(var) Platinum Standard Total Scorea. calculated with Hedges’ d for pre. M-PTSD = Mississippi Scale for Combat-Related PTSD. It differs from the CAPS in the time frame used.3592) 6 aSee section on measures.and posttreatment scores on the tests used in the corresponding studies.. IES = Impact of Events Scale. 1979) is a 15-item self-report measure that assesses subjective stress caused by traumatic events. Procedure All analyses were performed using MetaWin.7263 (0. Due to the low number of studies and participants. Results A total of 60 patients with combat-related PTSD received EMDR therapy. Hedlund. This was devised by the authors and should not be confused with the PTSD Symptom Scale—Self-Report version (PSS-SR) by Foa. which is a standardized mean difference that accounts for the nonequality of sampling variances. and Muraoka (1998).3562 (0. was a self-report measure with an 11-point global scale. & Erbaugh. 1994). & Alvarez. When multiple PTSD measures were used in one study. no serious . Horowitz. Chemtob. Gorsuch. The interviewer rates the severity of both frequency and intensity of these symptoms on a 5-point Likert scale. in preparation) asks subjects to identify five problems that they perceive to be interfering with their daily lives. TABLE 1 Characteristics of Studies Included in Analysis Study Carlson. A random effects model was adopted to calculate the meta-analytic effect size. Physiological measures such as heart rate are excluded.5 DSM-III-R M-PTSD PSS IES CAPS M-PTSD BDI. It also gives an indication of the overall level of anxiety and its severity. 1999 Downloaded by [89. Spence. no comparisons were made between EMDR and controls.1693) 7 DSM-III-R SI-PTSD — 1. because they are an integral part of EMDR and are used only to identify progress in the context of EMDR therapy. BDI = Beck’s Depression Inventory. CAPS = Clinician-Administered PTSD Scale. BDI −1. The Structured Interview for PTSD (SI-PTSD.172] at 01:51 21 October 2015 Sample PTSD Classification EMDR (n = 6). The Personal Problem Definition (PPD. Mock. PPD −0. Jaycox. a negative value represents a drop in the measures used and thus a decline in PTSD symptomatology. The effectsize estimate used was Hedges’ d. The PTSD Symptom Scale (PSS). 1994 Rogers et al. SUD and VoC scores are not taken into account. Care as usual (n = 16) EMDR (n = 25) Control (n = variable per measure) Jensen. Secondary Measures The State-Trait Anxiety Index (STAI. Davidson. Biofeedback (n = 13).0 (Rosenberg. 1990) assesses PTSD symptoms as described in the DSM (depending on the edition of the manual that is used by the interviewer). Rusnak. 1970) is a test that measures anxiety in two distinct ways: state (current) anxiety and trait anxiety (personal characteristic). Version 2. Adams. The Impact of Events Scale (IES. Chemtob. VERSTRAEL ET AL. Effect sizes were calculated for the means of the pre.5653 7. a fixed-effect model was adopted to estimate the mean effect size of the total study. & Smith. Bec’s Depression Inventory (BDI.3030) 10. A revised version (IES-R. Beck. as used by Carlson. Kudler. 1998 EMDR (n = 19). 1999). Although one study reported more PTSD symptoms after EMDR therapy (Jensen.7879 (0. Creamer. or between EMDR and other treatments. Devilly. & Gurevitch. PPD = Personal Problem Definition.versus immediate posttreatment in EMDR condition. whereas in the CAPS a time frame of a month is used.141. Weiss & Marmar. Cashman.5 DSM-III-R M-PTSD (only posttreatment) IES (0.b STAI. Comparisons were made on EMDR groups pre. It is composed of 21 items with a 4-point Likert scale. They then rate those problems on a 9-point Likert scale. Care as usual (n = 12) DSM-IV Devilly. and Perry (1997).1045) — −0. Note. Rusnak. It is unclear which versions were used in the included studies.136.

07]. DISCUSSION The research question in this study. a nonsignificant medium effect was found on the primary measures and a nonsignificant small effect was Cumulative Meta-Analysis of Studies.. The test for heterogeneity was not significant (Qt = 1.42 to 4.136.07].09 to 1. hospitalization) were reported. whether EMDR is effective in reducing problems associated with combat-related PTSD in the military population.and immediately posttreatment. with df = 3). p = 0. The test for heterogeneity was not significant (Qt = 2. . The analysis FIGURE 2 yielded an nonsignificant result.73. with the PS score used as the sorting variable. so the variance was not greater than was to be expected from sampling error. A random effects model meta-analysis (Figure 2) on the secondary measures resulted in a large nonsignificant effect size of −1.29 to 1. p = 0. with a medium effect size of −0.61 [95% CI: −2. as measured pre. Jensen (1994) and Rogers and colleagues (1999) did not report relevant secondary measures other than SUD and VoC scores and were therefore not included in this analysis. which indicated there were no irregularities.43. too few studies included to conclude that no publication bias exists. The test for heterogeneity was nonsignificant (Qt = 2.32.00. A cumulative meta-analysis was then performed on the primary outcomes. There are. with df = 3). A random model was used to assess the effect of EMDR on primary outcomes. This indicates a nonsignificant medium decrease in PTSD symptoms.48. adverse reactions (e.51 [95% confidence interval (CI): −2.05 [95% CI: −6. however. p = 0. The estimated effect size was −0. As results indicate. could be answered positively for neither primary nor secondary measures.g. A normal quantile plot (Figure 1) was created to assess publication bias.60. which implies that the variance among effect sizes was not greater than was to be expected from sampling error. df = 1).32]. with 95% Confidence Intervals.141.Downloaded by [89.172] at 01:51 21 October 2015 EMDR AS TREATMENT FOR COMBAT-RELATED PTSD FIGURE 1 71 Normal Quantile Plot.

predominantly combat veterans” (p. however. L. and all included small groups of participants. It is therefore of utmost importance that this topic is further investigated. & Taylor.5).136. 1744). it is clear that more sessions are needed in most cases. Does EMDR reduce post-traumatic stress disorder symptomatology in combat veterans? Behavioral Interventions.172] at 01:51 21 October 2015 72 S. 25. training and using EMDR does not serve the best interest of science and beneficiaries. no research articles on the use of EMDR in the military population that met our criteria were found published after the year 2000. The only included study in this analysis that does not support EMDR effectiveness is the Jensen (1994) study. One can hypothesize that more severely afflicted individuals were affected less (or more) by EMDR than those with less severe PTSD. Also. . the results of our meta-analyses tended to indicate a medium to large symptom-reducing effect. 2004). This is not the case in this meta-analysis. Due to the use of different tests. because combat veterans with PTSD often have been exposed to a greater number of traumas than civilians with PTSD.0 to 10. Hawthorne. It is clear that more research is needed before any hard conclusions about its effectiveness can be made. This is an important notion. There are several possible explanations for this result.43 (Bradley.51 (Bisson & Andrew. Russell (2008) identified several reasons for and ways in which there is scientific resistance to properly research EMDR.g. many of whom have been living with persistent symptoms of PTSD for decades. With chronicity. VA: Author.. 2010). which indicates that the methodological strength was not comparable. Although some articles claim very significant improvements after only a few sessions (e. He states that “continued resistance to fully researching. D. so their symptoms may be more resistant to treatment.Downloaded by [89. One could wonder what the reason for this finding is. It could. This is a remarkable result. however. Dutra. Russell. which found that symptoms increased after therapy. 2009). see Albright & Thyer. VERSTRAEL ET AL. Greene. to conclude that EMDR is a treatment of choice for returning veterans affected by PTSD seems premature. mean that if more methodologically rigorous studies are included. tf-CBT) have been proven unsuccessful or until larger and more rigorous EMDR studies have yielded positive results in this population. Another explanation is that PTSD severity could have been a factor that caused differences in the effect EMDR had on the patients. a predecessor of the Platinum Standard) report larger effect sizes. American Psychiatric Association. while the effectiveness of EMDR according to evidencebased standards is not yet proven. Arlington. & McHugh. 2006). Is it because EMDR is already accepted as a proper treatment? Is it because there was no more funding? It is to the possible detriment of this veteran population that research on this subject has been particularly lacking in the past decade. the number of studies was very low. Symptom severity is known to be a marker of poorer outcome in psychotherapy (Goodson et al. This explanation. Russ. 2003). with reported effect sizes of −1. Disease chronicity may also be particularly relevant to Vietnam veterans. Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. which may pose additional treatment challenges (Forbes. 1998). These reported effect sizes are much larger than those found in this meta-analysis. treatment of veterans with combat-related PTSD may be hindered by factors specific to such combat-related trauma as guilt and shame about their combat-related actions. 2005) and −1. A problem with Jensen’s study is that only two EMDR sessions were provided. because meta-analyses on EMDR in the general population tend to support its effectiveness.g. Future studies should therefore be as rigorous as possible. Based on these results. This analysis thus fails to support the effectiveness of EMDR in the treatment of combat-related PTSD in the military population. B. in which 12 sessions were administered. In our search.. especially because Maxfield and Hyer (2002) found that more methodologically rigorous studies (as rated on the Gold Standard. (2010). it could be that EMDR really is not effective in the military population. although not significant. it is not possible to compare the severity of the PTSD in the samples of the included studies. 1–19. (2004). rendering symptoms less amenable to treatment interventions (Foa & Meadows. Creamer. It is indeed a problem that so few studies have been conducted on the use of EMDR in this population. to give a better estimate of the real effectiveness of EMDR. Chronicity of disease associated with combat-related PTSD may also adversely affect veterans’ responses to treatment. 2011). REFERENCES Albright. 1997). veterans with PTSD are also more likely to present with comorbid physical and psychiatric conditions. This could have contributed to the result of this analysis. Furthermore. Also. The Platinum Scale guideline is that 11 or more EMDR sessions are needed to fully study its effects (Hertlein & Ricci. & Thyer. determined on the secondary measures. Finally. despite the fact that larger RCTs on this topic are very much needed. & Westen.. The included studies varied widely on the Platinum Standard scores (range 6. Use of EMDR with veterans suffering from combatrelated PTSD should be postponed as treatment of choice until other treatment protocols (e. it is quite remarkable that the included studies were all published between 1994 and 1999. the effect sizes would be larger. The notion that combat-related PTSD may be different from “normal” PTSD still holds.24 (Van Etten. The other included studies also used sessions numbers that would be considered too few. does not align with the results of most experimental studies (e.. in that combat-related PTSD is more difficult to address. Allen. −1. It thus remains speculation whether this factor could have had an impact on the effectiveness of EMDR. First.g. probably because of the lower occurrence of random errors.. with the exception of the Carlson and colleagues (1998) study.141.

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