Neural basis of PTSD and Eye Movement Desensitization &

Reprocessing (EMDR) therapy

Felix Bacigalupo
Escuela de Psicología, Facultad de Ciencias Sociales
Departamento de Psiquiatría, Facultad de Medicina
Centro Interdisciplinario de Neurociencia
Pontificia Universidad Catolica de Chile
Neural basis of PTSD and Eye Movement Desensitization &
Reprocessing (EMDR) therapy
Outline

• 1. Post-tratumatic Stress Disorder (PTSD)

• 2. Efficay of EMDR: Meta-analytic data
• 3. EMDR and clinical guidelines for PTSD treatment
• 4. Memory and traumatic memory
• 5. Proposed mechanisms of action of EMDR therapy: REM & sleep,
working memory
• 6. Neurobiology background: superior colliculi, thalamus and amygdala
• 7. Baek et al., 2019: methods, results and conclusions
Trauma
www.heroesmile.com
PTSD symptoms and brain function

Yehuda et al., 2015

Neural basis of PTSD and Eye Movement Desensitization &
Reprocessing (EMDR) therapy
Outline

• 1. Post-tratumatic Stress Disorder (PTSD)

• 2. Efficay of EMDR: Meta-analytic data
• 3. EMDR and clinical guidelines for PTSD treatment
• 4. Memory and traumatic memory
• 5. Proposed mechanisms of action of EMDR therapy: REM & sleep,
working memory
• 6. Neurobiology background: superior colliculi, thalamus and amygdala
• 7. Baek et al., 2019: methods, results and conclusions
Francice Shapiro: Eye Movement Desensitization (and
Reprocessing)
• In 1987, Francine Shapiro was walking in
the park when she realized that eye
movements appeared to decrease the
negative emotion associated with her own
distressing memories.
• She assumed that eye movements had a
desensitizing effect, and when she
experimented with this, she found that
others also had the same response to eye
movements. It became apparent however
that eye movements by themselves did not
create comprehensive therapeutic effects
and so Shapiro added other treatment
elements, including a cognitive
component, and developed a standard
procedure that she called Eye Movement
Desensitization (EMD).
www.emdr.com
The eight phases of EMDR

www.emdria.org
Shapiro, 1989
EMDR and SUDs reduction

Shapiro, 1989
EMDR and VOC increase

Shapiro, 1989
EMDR and VOC increase

Shapiro, 1989
EMDR and symptom reduction

Shapiro, 1989
EMDR decreases PTSD, depressive and anxiety symptoms in patients with PTSD

Chen et al., 2014

EMDR decreases PTSD, depressive and anxiety symptoms in patients with PTSD

Chen et al., 2014

EMDR decreases PTSD, depressive and anxiety symptoms in patients with PTSD

Chen et al., 2014

EMDR decreases subjective distress in patients with PTSD

Chen et al., 2014

EMDR with vs. without eye movements

Lee & Cuijpers, 2013

Chen et al., 2015
Neural basis of PTSD and Eye Movement Desensitization &
Reprocessing (EMDR) therapy
Outline

• 1. Post-tratumatic Stress Disorder (PTSD)

• 2. Efficay of EMDR: Meta-analytic data
• 3. EMDR and clinical guidelines for PTSD treatment
• 4. Memory and traumatic memory
• 5. Proposed mechanisms of action of EMDR therapy: REM & sleep,
working memory
• 6. Neurobiology background: superior colliculi, thalamus and amygdala
• 7. Baek et al., 2019: methods, results and conclusions
PTSD treatment recommendations

Yehuda et al., 2015

Neural basis of PTSD and Eye Movement Desensitization &
Reprocessing (EMDR) therapy
Outline

• 1. Post-tratumatic Stress Disorder (PTSD)

• 2. Efficay of EMDR: Meta-analytic data
• 3. EMDR and clinical guidelines for PTSD treatment
• 4. Memory and traumatic memory
• 5. Proposed mechanisms of action of EMDR therapy: REM & sleep,
working memory
• 6. Neurobiology background: superior colliculi, thalamus and amygdala
• 7. Baek et al., 2019: methods, results and conclusions
Pavlovian classical conditioning

1 2

3 4
Associative learning: aversive conditioning and extinction

Lonsdorf & Merz, 2017

Associative learning: aversive conditioning and extinction

Lonsdorf & Merz, 2017

Conditioning and extinction are independent learning & memory processes

Britton et al., 2014; Vervliet et al., 2013

Conditioning and extinction are independent learning & memory processes

1 Conditioning

1
Extinction

2
2 Extinction

Conditioning

Britton et al., 2014; Vervliet et al., 2013

The fear response

Kozlowska et al., 2015

The fear response: Arousal

Kozlowska et al., 2015

The fear response: Flight or Fight

Kozlowska et al., 2015

The fear response: Freezing

Kozlowska et al., 2015

The fear response: Tonic immobility

Kozlowska et al., 2015

The fear response: Collapsed immobility

Kozlowska et al., 2015

Neural threat-processing circuit

Ross et al., 2017

Neural threat-processing circuit

Ross et al., 2017

Evolution of the amygdala across species

Janak & Tye, 2015

Aversive (fear) conditioning paradigm

Milad et al., 2011

Extinction memory effect

Milad et al., 2011

Lashley, Hebb and the memory trace (the engram)

Takamiya et al., 2019

The mechanisms of memory: Karl Lashley
The mechanisms of memory: Karl Lashley, the engram and the
principle of mass action
The mechanisms of memory: Karl Lashley, the engram and the
principle of mass action
The mechanisms of memory: the role of the hippocampus
The mechanisms of memory: H.M., William Scoville and Brenda Milner

William Scoville

Brenda Milner
Scoville & Milner, 1957
Scoville & Milner, 1957
The mechanisms of memory: Consolidation theory

Sakaguchi & Hayashi, 2012

The mechanisms of memory: explicit vs. implicit memory

Squire & Zola-Morgan, 1991

The mechanisms of memory: explicit vs. implicit memory

Squire & Zola-Morgan, 1991

The memory engram

Josselyn et al., 2015

Dynamics of memory engrams

Takamiya et al., 2019

Dynamics of memory engrams

Takamiya et al., 2019

Traumatic memory engram plasticity

Maddox et al., 2019

Factors involved in threat memories

Maddox et al., 2019

Threat memory: conditioning and extinction

Maddox et al., 2019

Threat memory: relapse

Maddox et al., 2019

Threat memory engram: hippocampus and amygdala
Threat memory engram: hippocampus and amygdala
Threat memory engram manipulation (optogenetics,
medication…psychotherapy?)
Neural basis of PTSD and Eye Movement Desensitization &
Reprocessing (EMDR) therapy
Outline

• 1. Post-tratumatic Stress Disorder (PTSD)

• 2. Efficay of EMDR: Meta-analytic data
• 3. EMDR and clinical guidelines for PTSD treatment
• 4. Memory and traumatic memory
• 5. Proposed mechanisms of action of EMDR therapy: REM & sleep,
working memory
• 6. Neurobiology background: superior colliculi, thalamus and amygdala
• 7. Baek et al., 2019: methods, results and conclusions
Memory consolidation and sleep
The stages of sleep

Reeve and Bailes, 2010

The stages of sleep
Sleep and PTSD: insomnia, nightmares, memory disruption

Stickgold, 2022
Slow wave sleep and memory consolidation

Girardeau & Lopes dos Santos, 2022

Pagani et al., 2017
The working memory model

• Although eye movements are often considered its most distinctive

element, EMDR therapy is not a simple procedure dominated by the
use of eye movements. It is a complex psychotherapy, containing
numerous components that are considered to contribute to
treatment effects. Eye movements are used to engage the client’s
attention to an external stimulus, while the client is simultaneously
focusing on internal distressing material.
• Shapiro describes eye movements as “dual attention stimuli,” to
identify the process in which the client attends to both external and
internal stimuli. Therapist directed eye movements are the most
commonly used dual attention stimulus but a variety of other
stimuli including hand-tapping and auditory stimulation are often
used. The use of such alternate stimuli has been an integral part of
the EMDR protocol for more than 10 years (Shapiro 1991, 1993).

Baddeley & Hitch, 1974; Kuehn, 2009; Chai, 2018, www.emdr.com

The working memory model

Baddeley & Hitch, 1974; Kuehn, 2009; Chai, 2018

Taxing working memory could improve desensitization

Calancie et al., 2018

Neural basis of PTSD and Eye Movement Desensitization &
Reprocessing (EMDR) therapy
Outline

• 1. Post-tratumatic Stress Disorder (PTSD)

• 2. Efficay of EMDR: Meta-analytic data
• 3. EMDR and clinical guidelines for PTSD treatment
• 4. Memory and traumatic memory
• 5. Proposed mechanisms of action of EMDR therapy: REM & sleep,
working memory
• 6. Neurobiology background: superior colliculi, thalamus and amygdala
• 7. Baek et al., 2019: methods, results and conclusions
Neural threat-processing circuit

Maddox et al., 2019

Eye movements and the limbic system: Superior Colliculus, Thalamus and Amygdala

Thalamus

Amigdala Superior Colliculus

 Eye movements and the limbic system: Superior Colliculus, Thalamus and Amygdala

Thalamus

Amigdala Superior Colliculus

 Eye movements and the limbic system: Superior Colliculus, Thalamus and Amygdala

Thalamus

Amigdala Superior Colliculus

 Eye movements and the limbic system: Superior Colliculus, Thalamus and Amygdala

Thalamus

Amigdala Superior Colliculus

 Eye movements and the limbic system: Superior Colliculus, Thalamus and Amygdala

Thalamus

Amigdala Superior Colliculus

Output

Input
 Eye movements and the limbic system: Superior Colliculus, Thalamus and Amygdala

Thalamus

Amigdala Superior Colliculus

Output

Input
Eye movements and the limbic system: Superior Colliculus, Thalamus and Amygdala
Neural basis of PTSD and Eye Movement Desensitization &
Reprocessing (EMDR) therapy
Outline

• 1. Post-tratumatic Stress Disorder (PTSD)

• 2. Efficay of EMDR: Meta-analytic data
• 3. EMDR and clinical guidelines for PTSD treatment
• 4. Memory and traumatic memory
• 5. Proposed mechanisms of action of EMDR therapy: REM & sleep,
working memory
• 6. Neurobiology background: superior colliculi, thalamus and amygdala
• 7. Baek et al., 2019: methods, results and conclusions
Baek et al., 2019
 Aversive Conditioning Paradigm

US CS US CS
 Aversive Conditioning and Extinction Paradigm
CS US
Conditioning

Extinction: 3 conditions
1. Continuous stimulation
2. Intermittent stimulation
3. Sequential stimulation
(alternating bilateral sensory stimulation; ABS)

Baek et al., 2019

ABS during extinction decreases freezing behavior

CS US CS CS

Context A Context B Context B

Baek et al., 2019
ABS during extinction decreases freezing behavior

CS CS

Context B Context B Context C

SR: Spontaneous Recovery Baek et al., 2019
ABS during extinction increases superior colliculus responses

Baek et al., 2019

ABS during extinction increases superior colliculus responses

Baek et al., 2019

ABS during extinction increases superior colliculus responses and prevents return of
fear

Baek et al., 2019

ABS during extinction increases medial-dorsal thalamus responses

Baek et al., 2019

ABS during extinction increases medial-dorsal thalamus responses

Baek et al., 2019

ABS during extinction increases medial-dorsal thalamus responses and prevents
return of fear

Baek et al., 2019

Optogenetics
Electromagnetic energy spectrum

ChR2 NpHR
Inhibition of SC-MD pathway supressed extinction

Baek et al., 2019

Activation of SC-MD pathway increased extinction

Baek et al., 2019

SC-MD pathway is necessary and sufficient for fear extinction

CS CS

Context B Context B Context C

Baek et al., 2019
ABS pairing induces sustained baso-lateral amygdala inhibition

Output

Input

Baek et al., 2019

ABS pairing induces sustained baso-lateral amygdala inhibition and reduces
fear responses (freezing)

Output

Input

Baek et al., 2019

Mediodorsal thalamus – basolateral amygdala pathway underlies ABS effects

CS CS

Context B Context B Context C

Baek et al., 2019

Conclusions

Baek et al., 2019

Future directions

Fenster et al., 2018

Thanks!