EMDR, Neurocognition & Therapy Interventions

Kayla Mann 

Southern New Hampshire University

Studies regarding neurotransmitters and their reactions in the brain, and the association to depression and perception are limited. Further research was needed to find out if therapeutic interventions had any effects on neurocognition, in which limited information was found. There was more available research on the neurocognitive and emotional benefits of therapy interventions. There was limited empirical evidence to support the bio-psychological changes that occur in the brain during therapy applications, with the use of laboratory experiments. A new research study will be proposed to address the limited laboratory evidence of neurocognitive changes during therapy.

The therapeutic intervention that current research found to produce the highest success in cognitive-emotional changes was through the use of Eye Movement Desensitization Reprocessing (EMDR) therapy. Many studies were found that used self report data to support the success of EMDR. A research gap exists for laboratory studies of this therapy method.  Another research gap was found for examining the long term cognitive-emotional effects of this therapy intervention. The longest follow up study that was found, on the effects of EMDR, was 15 months. Lack of extensive, laboratory, neurocognitive evidence and the lack of a longitudinal study greater than 15 months, presents the opportunity for a research study to address one or more of these areas. This will increase validation of the neurocognitive effects of EMDR therapy. 

The first research article that was reviewed, “An interaction between perceived stress and 5HTTLPR genotype in the prediction of stable depressive symptomatology” was looking for neurocognitive implications associated with depression. The key aspect of cognition covered in this study was the serotonin transport gene 5HTTLRP and its representation of its allele which is either short (s) or long (l). The two additional factors that were studied in this research were perceived stress and long term depression. The study looked at the correlation between the length of the allele of the serotonin transport gene 5HTTLRP and perceived stress. It also searched for an indication to predict for long term depression. This study found that people that are homozygous for the short allele have higher rates of long term depression and perceived stress. 

This study used a longitudinal correlational research design. The longitudinal approach was used to decrease the chances of error in the data collection in regards to finding a "single depression phenotype, which necessarily means that it is not as prone to random and nonrandom fluctuations as cross sectional depression scales" (Beaver et al., 2012). The researchers did not include any information on consent given to participants. They did not include an explanation of any ethical measures taken. There was sensitive information taken in this study as well as DNA samples. There were approximately 90,000 participants during all phases of the longitudinal study in which the authors should have included a short explanation of how they dealt with ethical concerns. Ethics in the field of psychology have developed over time to require informed consent, which means they must explain the research prior to the participants signing consent forms (American Psychological Association, 2017). 

The second article that was reviewed was “A review of the neurobiological effects of psychotherapy for depression” to identify current information about the neurocognitive changes present with mental health disorders and the changes found during therapy.  The key aspects of cognition covered in this literature review are the prefrontal cortex, the amygdala, hippocampus, cortisol levels, serotonin transporters, and neurotransmitters. This article discusses the effects that mental health disorders have on neurocognition. This literature review looks at the results from previous studies which found or did not find empirical evidence of changes in the neurobiological mechanisms after receiving different types of therapy. Many studies confirmed changes in the brain and body as a result of psycho-therapeutic interventions. 

In regards to depression, historical findings have shown that medications “aim to reduce depression by increasing the (low) synaptic presence of neurotransmitters” and that “psychotherapy is not commonly described as having similar effects on those organic malfunctions associated with depression” (Sharpley, 2010). This study was a meta analysis to determine if these organic functions could change during the therapy process. The studies confirmed that psychotherapy did normalize the neurobiological processes during depression. The findings ranged from cortisol levels decreasing, to normalization in amygdala & hippocampus activity, and to the increased levels of serotonin transporters (Sharpley, 2010). 

The third article “Psychoanalytic treatment: A neurobiological view” was reviewed. This study looked at the effects of psychoanalytic therapy on implicit memory, which can be an indicator of long term change outcomes. The key aspects of cognition covered in this study are implicit memory, explicit memory, and the neurobiological effects of attachment. This study reports that implicit memory is "pre-linguistic and independent of conscious experience"(Cheniaux et al., 2011), and is linked to attachment theory--which deals with attachments to parental figures early in life, before explicit memory is reached. Findings support the neurocognitive benefits of analytic therapy by turning implicit memories-which cause acting out from the unconscious- into explicit memory. The therapeutic process allows the patient and therapist to understand how the unconscious acting out is a reflection of an implicit memory. "Automatic and repetitive behaviors associated with implicit memory are transformed into explicit knowledge. Consequently, patients gain the ability to control automatic behaviors. At this time the patient is able to consciously choose more satisfying and healthier forms of relationships with others" (Cheniaux et al., 2011). 

This was a meta-analysis of current information found on the effects analytic therapy and no scientific testing was conducted in this article. Historical views of psychoanalysis state “that although the achievement of insight is essential in analytic therapy, it is not sufficient. Further accomplishments are necessary for successful treatment” (Cheniaux et al., 2011). This statement stresses the need for further empirical evidence to support the neurocognitive changes that are produced from therapy interventions. 

The fourth research study that was reviewed was from the article “On the neural basis of EMDR therapy: Insights from qEEG studies.” The key aspects of cognition studied in this research were: the amygdala, hippocampus, greater hippocampal system, prefrontal cortex, alpha-amino-3-hydroxy-5-methyl-4-isoxazole (AMPA) receptors, short wave sleep (SWS), rapid eye movement sleep (REM), synaptic depotentiation, and fear memory. The study reports that with the use of the therapeutic application of eye movement desensitization and reprocessing (EMDR) that the intensity of the fear memory can be decreased. The study describes that the emotion of fear in the amygdala is unable to properly be processed due to the high level of intensity which is unable to integrate properly into the hippocampus and prefrontal cortex for memory storage. In the study they use qEEG to show the change in intensity during EMDR. This change in intensity is associated with the AMPA receptors, which mediate fear memories. 

The researchers chose to use an experimental design because due to the nature of the information needed, laboratory equipment had to be used. To study the internal workings of the brain, qEEG was used, while the participants were given bilateral brain stimulation (bilateral stimulation is the technique used in EMDR therapy), in order to record changes in electrical activity. The researchers touched ethics by describing animal studies which prelude the research methods used to determine potentiation of electrical impulses in the amygdala and hippocampus. Study participants were screened for childhood sexual abuse history, extreme disorders of stress, or chronic PTSD. If found, “these volunteers were given names of relevant practitioners and were advised to seek treatment” (Harper, Rasolkhani-Kalhorn, and Drozd, 2009). This research study shows that ethics were considered prior to beginning. Ethics in psychology have developed over time and require that “psychologists take steps to protect the prospective participants from adverse consequences” (American Psychological Association, 2017).

The fifth study reviewed was the article “Case studies of eye movement desensitization and reprocessing (EMDR) with chronic post-traumatic stress disorder.” This was a case study of five combat veterans who suffer from chronic PTSD. Initially, study participants had only one EMDR session and this study was conducted over a 10 week or more treatment period. Changes were given from self report questionnaires and clinical observation. Aspects of cognition that were covered in this study were the psychological effects of chronic PTSD. Primary presenting problems included flashbacks, intrusive thoughts, sleep disturbances, and intimacy problems (Lipke & Botkin, 1992). Measures of subjective units of disturbance (SUDS) and measurements of "gut level" believability of a positive self-statement (PSS) were used in the study to report changes during and after EMDR treatment sessions (Lipke & Botkin, 1992).  The study found that SUDS decreased and PSS increased after just 12 EMDR treatments in patients with chronic PTSD. This study conducted a three month follow up which reported that results stayed the same or improved. 

History has shown that PTSD self report scores are highly resistant to change in combat survivors (Lipke & Botkin, 1992). A case study was used likely due to the limited research on EMDR in 1992. This gave researchers a foundational place to start due to the lack of research on EMDR at the time. Researchers addressed ethics by informing patients that they were being asked to try a new treatment for PTSD symptoms and that they could end the treatment at any time (Lipke & Botkin, 1992). Psychological research ethics require that “psychologists provide a prompt opportunity for participants to obtain appropriate information about the nature, results, and conclusions of the research” (American Psychological Association, 2017). 

The sixth article, “Three- and 6-month follow-up of EMDR treatment of PTSD in an HMO setting” is about the effects of EMDR versus standard care, three and 6 months after treatment. The aspects of cognition that are covered in this study were traumatic memories, bilateral stimulation, PTSD, anxiety, depression and general psychological symptoms (Marcus, Marquis & Sakai, 2004). This study found that EMDR was more effective in decreasing symptoms than standard care therapy techniques. There were two control groups in this study- the EMDR treatment group and the standard care group. The standard care group received individual psychotherapy (cognitive, psychodynamic, or behavioral) with the possible addition of medication and/or group therapy (Marcus, Marquis & Sakai, 2004). 

Participants from the EMDR group had lower symptom measurement ratings throughout both current and follow up data collection. The EMDR group required less treatment sessions and less need for medication modifications which indicate positive treatment outcomes. The study was conducted in an HMO setting, which is limited to 20 outpatient mental health visits (Marcus, Marquis, & Sakai, 2004). This outcome is important when treating patients with a limited amount of time to make therapeutic improvements. Results for both groups continued to improve at the three month follow up. “The standard care group means were slightly higher at 6 months than at 3 months, suggesting that treatment effects may be deteriorating, nearly all of the EMDR treatment means were lower at 6 months than at 3 months” (Marcus, Marquis, & Sakai, 2004). 

This was a longitudinal correlational study which took measures at the initial treatment period, at three months and at 6 months post treatment. History demonstrates "considerable controversy about EMDR" and its effectiveness (Marcus, Marquis, & Sakai, 2004). A correlational study facilitates data analysis between the two control groups and over time. 

Important ethical considerations were not discussed. The article does not mention if participants were notified of the study that took place at an HMO outpatient clinic. The control groups had different therapy interventions and different results. The standard care group had decreased longevity for symptom relief. This was the hypothesized outcome, therefore it was unethical not to notify the clients about this or inform readers about how they addressed ethical concerns before or after the study. The American Psychological Association (2017) ethical code of conduct states that psychologists should explain any deception that is an integral feature of the design and conduct of an experiment to participants as early as is feasible, preferably at the conclusion of their participation, but no later than at the conclusion of the data collection, and permit participants to withdraw their data.”

The seventh article, “Fifteen-month follow-up of eye movement desensitization and reprocessing (EMDR) treatment for posttraumatic stress disorder and psychological trauma” gave data about the longest follow up study that was found. The key aspects of cognition that were studied were psychological representations of distress found in anxiety, depression, and PTSD. The application of EMDR therapy was studied to determine if the decrease in mental health symptoms were maintained at 15 months post initial treatment. The study found that after 15 months from the original treatment with EMDR, the effects were maintained. "At a 15-month follow-up, the three 90-minute sessions of EMDR previously administered produced an 84% reduction in PTSD diagnosis and a 68% reduction in PTSD symptoms (Wilson et al., 1997). 

This study used a longitudinal correlational research design. The researchers used this method so that they could study the results over different intervals. This research method allows for consistent variables, the use of the same measurement criteria and evaluation of the data in each interval. The researchers contacted participants from the previous study to invite them back for follow up. They included information about notifying the participants about the follow up study and informing them that it would include similar testing like what they completed in the 3 month follow up (Wilson et al., 1997). 

Historically, therapies that do not include EMDR "generally demonstrated maintenance of treatment effects for periods of 3-6 months" (Wilson et al., 1997).  Many previous studies have been conducted on the beneficial effects of EMDR in reducing psychological symptoms with significant and lasting effects. There is limited research on the neurobiological findings of therapy interventions, including EMDR therapy. Additionally, limited research exists for long term follow up and retention of treatment outcomes. This is a gap in the current research that a new study will address. 

 The research question for a new hypothetical study is: are the neurological changes in the brain from therapy long lasting or short term? Do therapy interventions produce lasting changes in the neurological functions of the brain with people who have DSM-5 diagnoses? Is there empirical evidence to support long term neurobiological changes in the brain from therapy interventions?

This new study will be a longitudinal experimental study on the neurocognitive effects of EMDR therapy. It will be similar to what was conducted in Harper et al. 2009 with the use of qEEG, which measured the intensity of electrical impulses associated with memory, during therapeutic application of EMDR. An identified limitation in previous neurocognitive research on therapy is a limited number of participants in the research cohorts. This study will include 500 or more participants and there will be three follow up laboratory sessions: at one year, two years, and 4 years.

This study will address the gap in the current research that was reviewed on the neurobiological processes of the brain with mental health diagnoses and with the application of therapy interventions. This research proposal is limited in that the control of therapeutic interventions after the initial treatment stage, outside of the confines of this study, will be difficult to control in a long term study. 

Psychological research must continue to inform evidence based treatment and best care practices. There is empirical evidence to support neurocognitive changes from therapy and the strongest evidence is found in EMDR therapy. Data supports that it is the fastest treatment method, with the longest lasting therapy outcomes, as well as in the most resistant therapy groups. Continued studies should be conducted in order to gather more empirical data on this intervention. 

References 

American Psychological Association. (2017). Retrieved on April 19, 2020 from https://www.apa.org/ethics/code/

Beaver, K. M., Vaughn, M. G., Wright, J. P., & Delisi, M. (2012). An interaction between perceived stress and 5HTTLPR genotype in the prediction of stable depressive symptomatology. American Journal of Orthopsychiatry, 82(2), 260–266. doi: 10.1111/j.1939-0025.2012.01148.x

Cheniaux, E., Zusman, J. A., Freitas, S. D., Carvalho, L. A. V. D., & Landeira-Fernandez, J. (2011). Psychoanalytic treatment: A neurobiological view. Psychology & Neuroscience, 4(3), 417–427. doi: 10.3922/j.psns.2011.3.015

Harper, M. L., Rasolkhani-Kalhorn, T., & Drozd, J. F. (2009). On the neural basis of EMDR therapy: Insights from qEEG studies. Traumatology, 15(2), 81–95. doi: 10.1177/1534765609338498

Lipke, H. J., & Botkin, A. L. (1992). Case studies of eye movement desensitization and reprocessing (EMDR) with chronic post-traumatic stress disorder. Psychotherapy: Theory, Research, Practice, Training, 29(4), 591–595. doi: 10.1037/0033-3204.29.4.591

Marcus, S., Marquis, P., & Sakai, C. (2004). Three- and 6-Month Follow-Up of EMDR Treatment of PTSD in an HMO Setting. International Journal of Stress Management, 11(3), 195–208. doi: 10.1037/1072-5245.11.3.195

Sharpley, C. F. (2010). A review of the neurobiological effects of psychotherapy for depression. Psychotherapy: Theory, Research, Practice, Training, 47(4), 603–615. doi: 10.1037/a0021177

Wilson, S. A., Becker, L. A., & Tinker, R. H. (1997). Fifteen-month follow-up of eye movement desensitization and reprocessing (EMDR) treatment for posttraumatic stress disorder and psychological trauma. Journal of Consulting and Clinical Psychology, 65(6), 1047–1056. doi: 10.1037/0022-006x.65.6.1047