EMDR IN THE TREATMENT OF CHRONIC PAIN
A naturalistic design study is currently underway involving a number of EMDR-trained therapists in Australia and New Zealand. The aim of this study is to evaluate EMDR in the treatment of chronic pain in out-patient chronic pain sufferers. It is hypothesized that EMDR will lead to decreased pain, anxiety (including PTSD), depression and disability and decreased reliance on medication. The need for this study stems from the limitations of current psychological approaches. For example, The Cochrane Library review concluded that CBT can help reduce mood problems and disability associated with pain but that it has “weak effects” in improving pain (Eccleston, Williams & Morley, 2009).
EMDR started out as a treatment for Posttraumatic Stress Disorder (Shapiro, 1989) and rapidly reached the status of an empirically validated treatment (Chambless, 1998, American Psychiatric Association, 2004, Foa, Keane & Friedman, et al, 2009). EMDR also appears to have some advantages over more traditional approaches. Schubert & Lee (2009) found that EMDR requires significantly fewer sessions and less homework than exposure therapy for PTSD.
EMDR is founded on a different conceptualization to CBT, reflecting its origins as a treatment for PTSD. The Adaptive Information Processing model (AIP) posits that psychological problems occur when a person’s information processing system fails to assimilate experience into existing memory networks where it is ideally stored in an adaptive way (Shapiro, 2007). The aim of EMDR treatment is to facilitate adaptive information processing such that traumatic memories are integrated with pre-existing knowledge and experience, ie; no longer distressing (Shapiro, 2001).
Rome and Romes’ (2000) Limbically Augmented Pain Syndrome theory describes how the AIP model might apply to chronic pain and its treatment. They suggest that repeated exposure to painful stimuli and/or traumatic experiences may induce a complex series of neuroplastic processes at corticolimbic levels that are able to transduce information coming from the inside the body or from the environment into cellular memory. Consequently, previous traumatic or painful memories may result in an augmented pain response to future stimuli, even though these are not painful in nature. This model is consistent with the Central Sensitization theory of pain, which posits that a continuous flow of pain signals into the pain mediating pathways of the dorsal horn of the spinal cord alters those pathways through physiological processes such as neuroplasticity (Gudin, 2004). Ray & Zbik (2001) have also speculated about why EMDR should be considered as a treatment for pain. They note that EMDR separates and permanently “de-augments” the affective component of traumatic memories, unless the individual suffers another later trauma. They suggest that this gives EMDR an added dimension to more traditional CBT approaches, which may improve a person’s perception of pain and quality of life, but don’t offer a permanent change in the affective dimension of pain.
The methods of action of EMDR have been the subject of much debate. EMDR has been found to stimulate various physiological and psychological processes including changes in heart rate variability, decreased physiological arousal, a relaxation effect, a distancing effect and free association (Shapiro, 2001, Elofsson, von Scheele, & Theorell, et al, 2007; Lee, Taylor & Drummond 2006; Schubert, Lee & Drummond, 2008). In the treatment of PTSD it has been proposed that these changes facilitate the transfer of information from episodic to semantic memory (Stickgold, 2002). In the treatment of trauma-related pain it has been proposed that these changes alter the sensory component of traumatic memories (de Roos, Veenstra, den Hollander-Gijsman, et al, 2006, Grant, 1999). In the treatment of non-traumatic pain it has been proposed that these changes reduce the contribution of physical and emotional tension to pain,
In addition to its efficacy with PTSD, EMDR has shown some promise in the treatment of chronic pain patients including CLPB (Grant & Threlfo, 2002), Headaches and fibromyalgia (Mazzola et al, 2009, Ray & Page, 2002), and Phantom Limb Pain (Wilson, Tinker & Becker, 2000; de Roos Veenstra, Holllander-Gijsman et al, 2006; Schneider, Hofman, Rost and Shapiro, 2008). A systematic review of EMDR treatment of Medically Unexplained Symptoms found that the method seemed to facilitate greater relief in Phantom Limb Pain sufferers (n=21) than a more mixed pain group (n=58). The authors speculated that this might be because of the methods proven efficacy with trauma (van Rood & de Roos, 2009). At this stage, the small number of subjects makes it difficult to draw any firm conclusions about what kinds of pain populations EMDR might be most efficacious with.
Aims of this study
This study seeks to investigate the efficacy of EMDR treatment of chronic pain in a general outpatient chronic pain population with a diagnosis of either; a pain disorder, somatization disorder or conversion disorder. Patients are accepted into the study on the basis of being assessed as suitable for EMDR after having been referred to an EMDR-trained therapist with specialist training in the application of EMDR to pain. It was decided not to adopt a randomized control (RCT) design. Although the RCT is generally viewed as the ‘gold standard’ for research purposes, it has also been criticized for lacking external validity because of the significant differences between real world clinical practice and RCT design (Hotopf, 2002, Clay, 2010, Williams, 2010). For example, in RCT’s patients with comorbid medical or psychiatric disorders are often excluded whereas in clinical practice most patients actually have comorbid disorders. In RCT’s treatment is assigned randomly whereas in clinical practice treatment is assigned on the basis of individual assessment, clinical judgement and negotiation with the patient.
Participants were outpatient chronic pain sufferers, aged between 18 and 80, suffering from either trauma-related pain (ie; arising from a life-threatening event) or non-traumatic pain (ie; arising from non-life-threatening injury or illness). Subjects received 10 x one-hour sessions of EMDR treatment, or less as required. Treatment was delivered from a variety of private practice settings, in an attempt to reach patients who are more likely to be representative of the population of patients with long-standing persistent pain (Turk & Rudy, 1990). All therapists had to be experienced in the treatment of chronic pain. The EMDR therapists followed Grants (2001) treatment manual for chronic pain, which incorporates a modified version of the Shapiro’s basic trauma protocol, plus psychoeducation (explanation of pain in terms of AIP model), pain-control skills based on EMDR (self-use of DAS/Bls) and general support and advice. All participants are given a range of self-report tests designed to evaluate the psychological and affective dimensions of their pain problem at the following four points; 1) prior to treatment, 2) mid-way through treatment, 3) after treatment and 4) at 12 months follow-up. Since participants included patients suffering from both trauma-related and non-trauma related pain, all participants were given a PTSD questionnaire (the PCL-C). Participants are also assessed regarding whether they were suffering from a conversion disorder, a somatization disorder or a chronic pain disorder, using DSM IV criteria.
Treatment consists of approximately ten weekly sessions, lasting one hour, with an EMDR trained therapist with extensive experience with chronic pain. The EMDR sessions are administered according to Grant’s (1999) treatment manual. This manual integrates the five tasks of the EMDR Chronic Pain Protocol (Grant, 1999) with Shapiro’s (1995) basic EMDR protocol for traumatic memories. The main difference between the pain protocol and the trauma protocol is the option of targeting present pain in addition to unresolved traumatic memories, the use of continuous Bilateral Stimulation (Bls) and the teaching of self-use of Bls to people whose pain cannot be completely resolved.
If you would like to participate in this study, please contact me at email@example.com
Note: This study will end in August 2013.
EcclestonC. Williams AC de C, Morley S. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database of Systematic Reviews 2009, issue 2. Art.No.:CD007407:DOI:10:1002/14651858.CD007407.pub2..
Elofsson, U. O., von Scheele, B., Theorell, T., & Sondergaard, H. P. (2007). Physiological correlates of eye movement desensitization and reprocessing. Journal of Anxiety Disorders (in print).
Grant, Mark (1999). Pain Control with EMDR. Createspace.
Grant, M. & Threlfo, C. (2002). EMDR in the treatment of chronic pain.
Journal of Clinical Psychology, 58(12), 1505-1520.