EMDR TREATMENTOF PHOBICSYMPTOMS

IN MULTIPLEPERSONALITY

DISORDER

Walter C. Young, M.D.

Walter C. Young, M.D., is Medical Director of the NationalTreatment Center for Traumatic and Dissociative Disordersat Del Amo Hospital, 23700 Camino del Sol, Torrance,California 90505

For reprints write Walter C. Young, M.D., Medical Director,National Treatment Center for Traumatic and DissociativeDisorders, Del Amo Hospital, 23700 Camino del Sol,Torrance, CA 90505.

ABSTRACT

Two multiple personality disorder patients with severe, persistentphobias were treated usingEyeMovementDesensitization/Reprocessing(EMDR). Both patients achieved significantly beneficial results witha single session in one patient and two sessions in another. Eachpatient confronted the previously phobic object successfully showingan objective measure ofsuccess and results were maintained at sixmonths follow-up. Caution should be exercised from generalizingthe use ofEMDR for specific target symptoms to using it as a totaltreatment technique. Further research is needed to determine the effi­cacy ofEMDR as a treatment procedure in general and its role inthe overall treatment ofdissociative conditions.

INTRODUCTION

In recent years a new treatment technique known as EyeMovement Desensitization/Reprocessing (EMDR) hasemerged following two reports of the successful treatmentof traumatic memories in brief therapeutic interventions(Shapiro 1989a, 1989b) .Since that time additional and some­times contradictory reports have been published regardingthe effectiveness of this technique. Despite some negativereports, sufficient positive anecdotal literature and verbalreports of treatment successes suggest the need for furtherevaluation ofEMDRwith traumatic disorders. Due to the reg­ular and extreme nature of traumatic reports by patientswith dissociative disorders, especially those with MultiplePersonalityDisorder (MPD), a trial ofEMDRwas used in treat­ing resistant phobic symptoms in two patients diagnosedwith MPD.

REVIEW

Shapiro (1989a, 1989b) originally described dramaticchange in 22 patients with PTSD symptoms. Results occurredin one to two sessions which coupled imaging of the trau-

matic memory with saccadic eye movements guided by thetherapist. A control group narrated their traumatic memo­ries and were subsequently treated with EMDR, with similarresults.

The mechanism ofEMDR is not understood, and all pos­tulated hypotheses are admittedly speculative. For example,the role of the eye movements has been compared to REMsleep processing. Shapiro (in press) postulates acceleratedinformation processing (AlP) occurs that may be facilitatedby saccadic eye movements among other possible mecha­nisms.

A number of clinicians have described favorable resultswith EMDR. Page and Crino (1993) reported success in treat­ing the victim ofan armed robbery. Pellicer (1993) describedits successful use in the recurrent nightmares of a ten-year­old girl. Puk (1991) reported success in two patients. Wolpeand Abrams (1991) used EMDR with traditional desensiti­zation techniques and achieved good results. Marquis (1991)used EMDR on 78 subjects, but their use ofa variety ofothertherapies makes the interpretation of the role of EMDR dif­ficult. McCann (1992) successfully treated recurrent intru­sive memories in a severe burn patient with bilateral abovethe elbow amputations, deafness, and severe scarring.Boudewyns, Stwertka, Hyer, Albrecht and Sperre (1993)reported success when comparing EMDR to simple imagingof the traumatic event. Wernick (1993) suggested that com­bining EMDR with other techniques may be effective in sextherapy. Spector and Huthwaite (1993) achieved relief in apatient who had suffered a severe automobile accident.

On the other hand, others using EMDR have not repli­cated such optimistic reports. Lipke and Botkin (1992) sug­gested that positive results may require longer treatmentamong veterans with chronic character pathology. This wasechoed by Boudewyns, Stwertke, Hyer, Albrecht, and Sperre(1993), who compared positive verbal reports to more lim­ited documented gains in situations where disability mayinvolve a secondarygain that overrides overall improvement.They also questioned the role of placebo effects.

Pitman, Orr, Altman, Longpre, Poire, and Lasko (1993)used a crossover design in 17 patients where patients main­tained eye fixation, and failed to show that the eye move­ments were essential. They found that global improvementof PTSD in general did not occur. Lohr et al. (1992) criti­cized methodologic flaws in Shapiro's study. Herbert andMueser (1992) also raise methodologic concerns includinga lack of baseline measures, and the use of subjective self­assessment ratings. They also questioned whether Shapiro

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EMDR TREATMENT OF PHOBIC SYMPTOMS IN MPD

,vas treating subjeCls with subclinical syndromes.Metter and Michelson (1993) found no benefilS from

EMORand urged caution againstover-zealolls reporting. Theyquestioned whether the eye movements may SCIYC as a neg­ative reinforcer leading subjects to report lowered distresslevels. They also suggest E~lDR may be related to sequencedisruption techniques described by O'Hanlon (1987). Inthis regard fractionated abreaction facilil:aled by hypnosishas been emplo)'ed by Klllfl (1988) and Fine (1991) to allowpatients to more easily move into and out oflraumatic mate­rial to comain and control ahreactions. Lytle (1992) com­pared EMDR to two control groups, one a non-cye mm"c­mCIll dcscnsiLi7.3tion group, and lhe second a non-directi\·ctherapy control group, and found EMDR possibly the leasteffective lechnique. Sanderson and Carpenter (1992) stud­ied 58 subjects ..·:ith a crossover design. comparing EMDRW1m imageconfronlation, encouraging imagingfora monlhafter treatmen LThey reparl no sign ifican Idifferences EMDRin MPD in the procedures. Their sludy is SUbslalltially flawedb)' a number of"ariances from standard EMDR applicalion.The mosl significant was that EMDR "'as applied for onlyseven sets of eye movements for twenty seconds each. Thisis far less than would be given in EM DR trealment, and is nOIsufficielll to obtain optimum benefits.

In mOSI of lhe studies, especially in those where nega­ti"'e findings are reported, there are significant limilationsin methodology, making a truly accurale comparison verydifficult. Limitations include leng!h oftrealrnent, use ofancil­lary Ireatments, and failure 10 use Ihe same measures ofOUI­come. E"en with lhe variations in favorable reports, nega­tive replications need to adhere to a standardized protocolfor the rcsuhs to have meaning.

In the present report both patients responded to treat­ment by actually confronting the phobic situation therebyobjectively demonstrating a positive outcome, even thoughthe procedure itselfused the subjective measures in Shapiro'sreports (I989a, 1989b).

METHOD

As part ofa larger pilot study ofEl\lDR treatment in dis­sociative disorders, tWO female dissociative disorder patientsreportingscvere phobias wcrc studied. Talking about under­lying issues had not helped either patient reduce the targelsymptoms. The subjects were selected in part because theirphobic symptoms appeared somewhat isolated from thebulk of their traumatic material and because their respons­es could be assessed by their ability 10 address the phobicstimuli in "h·o.

Each palienl's phobic symptom was used as Lhe largetfortreaunenl, togetherwilh heraccompa.n}1ngfeelings. bodysensations, and the negative bcliefsstemmingfrom her fear.A positive selfstatement (PSS) or belief"'as selected thai thepatielll wanted to beliC\'e. Informed conselH regarding theprocedure was obrained. The patients were then gh'en E..\1DRtreaunent according to Shapiro's protocol (1989a, 1989b)and her rC\1sed prolocols (in press). A subjecti\'e unit ofdis-­tress scale (SUDS) (\Volpe. 1982) ....'as used 10 measure dis-

130

Iress where 0 was no distress and 10 was l..he maximum dis­tress created when an imageofthe phobic event '....as recalled.A validity of cognition (VOC) sC"dlc was used to assess thepatients' leVel ofconfidence thaI they could believe in theirPSS. The VOC scale rales the patient's confidence from one(the patient has no confidence in Lhe PSS), to seven (thepatienl has lotal confidence he orshe beliC\'es or will beliC\'ca new PSS). Belie..~ng the PSS is underslood to indicale IhalIhe palient has replaced a negative beliefwith a positi..'e one.SUDS and Voc measures were reponed at the beginningand end of lhe EMI)R treaunent and illlcrmiuenlly inbclwecn.

AIter initial assessmenl, each patient ....'aS asked to bringto mind the target symptoms while the author instrucloothe patient 10 track a moving finger or object with her eyes,thereby initiating rh}'thmic saccadic eye movemelH. Thepalients were instnlcted to lei images, thoughts, sensalionsor feelings occur. Periodically Ihe author paused to inquirewhat was in the patient's mind. No interpretations were madeby Ihe aUlhorand the paticnl"''aS nOI asked to give an ongo­ing narrath'e of Iheir her experience. The E~IOR sessionslasled from one to one and one-halfhours. At the end, SUDSand Voc levels were oblained and the pal.ient was debriefed10 determine whatlhe procedure felt like. howil comparedto herstandard work. what problems there may have encoun­lered, and an}' other observations she wished to make.

Before beginning, each patient ....'aS asked to assure !hatshe could maintain safety during the procedure. that heralter personalities would not obstruct eye movements, andthat she would raise a hand to indicate ifshe wanted or need­ed to stop the procedure.

CASE REPORTS

Patitmf #}

Ms. A isa 35-year-old single woman with a terrorofsnakes.She hadjllrnped 011 people's backs when secinga snake. Sherecalled a snake had been thrown on her when shewaseightor nine years old. After cleven years of treatment and despiteirnprovclllelll. in other areas, this symptom remained stillrefractory. Ms. A was seen in consultation lO address sever­al issues, one of which was her se\'ere phobia ofsnakes. Shedescrihcd feeling paraIYL.cd, and unable to breathe just pic­turing a snake. I IeI' beliefwas that she was powerless 10 faceher fear and wished to believe she could feel in control andfeci safe around snakes. Her distress le\'eI (SUDS) was l<lledal 10 and her confidence (VOC) she could stay in controland be safe around snakes \\'as 2.

Ms. A "'as informed about the use of B·1DR and g<l\'econselll to the procedure. She ''''as asked 10 picmre herselfwith a snake with Ille associated feelings of terror and help­lessness. Her associations mo,'ed from exposure 10 snakesas a child, being chased by a snake. and Lhen she reporteda new incestuous a'..~.trclless of her falller by stating, "Myfalher has a snake - it's his penis!~ This was a new con­nection. She continued during the session 10 feel a dramaticreduclioll in her anxiety. She t....·enlually smiled and Slatedshe was not afraid of snakes anymore. She reported a SUDS

mSSOCl\TIO\. ral. \lI. \O).!.J_l~

level of 0 and a vaG level of seven. Ms. A felt her process­ing of this material was rapid and far superior to her tradi­tional efforts.

The following day Ms. A went to a pet shop where shehandled a snake withoutanxiety. She remained asymptomaticwith respect to the snake phobia six months later.

In one session Ms. A patient had a dramatic outcome,resulting in her seeking out the phobic object to test her­self. She remained dissociative in those areas not addressed.

Patient #2Mrs. B is a 39-year-old married mother of three children

who had been in treatmentfor Multiple Personality for sevenyears. Her clinical course had been stormy. There were manyhospitalizations for suicide attempts, depression, severeheadaches, and self-induced injurious behavior consistingmostly ofself-lacerations following pressure from hostile innerstates. There was a history of severe child abuse by father,confirmed by her mother, and she had alleged multi-per­petrator sadistic acts which could not be verified. These fac­tors contributed to a tumultuous course in which intrusivememories and disruptive symptoms often resulted in head­banging behavior, abreactions, or self-destructive acting out.

Mrs. B was highly motivated. She was moving graduallytoward integration and had already experienced the fusionof a number of personality states when EMDR was suggest­ed. EMDR was proposed as a means of therapy that mightprovide her a quicker and safer approach to working throughpainful material. The patient agreed to try EMDR with twosymptoms of paralyzing phobic fear. Informed consent wasobtained after extensive explanation and discussion. Thepatient had been requested to read Shapiro's original arti­cles (1989a, 1989b) as part ofthis process.

Mrs. B described a fear ofmoths, especially in her home.She would lose all emotional control, literally screaming andrunning out of the room if a moth appeared. She recalledhaving been molested by her father in the garage when shewas a child. She remembered moths flickering by an over­head lightand occasionallydiving toward herwhile the assaultoccurred. She would see them afterward when she was leftin the garage. Mrs. B believed that she was powerless to con­trol moths, and lived in terror of them. She was further dis­tressed that her daughter was also becoming frightened ofmoths. Her second phobia was of seeing a full moon out­doors. This irrationally frightened her, but to a lesser extentthan did the moths. She believed she would never enjoy amoonlit night outside.

The patient rated her first phobia at a SUDS level of 10with only a vaG level of two out of seven that she could con­trol moths in her home. Her second phobic symptom ofsee­ing a full moon had a SUDS level of eight and a vaG level ofthree that she would enjoy moonlit nights safely.

The patient began EMDR with the moth fear for two ses­sions, then decided to wait two months until moths were "inseason." Mter two sessions her SUDS level was only mildlyreduced (to eight) but she felt increasingly confident thatshe could manage mothswithout becoming hysterical despiteher fear (VaG 5). Her associations moved from images of

her assault in the garage to moths in the night flying aroundthe light, and eventually to the spots on their wings thatreminded her of eyes looking at her. While she never overt­ly switched during the procedure, she was aware of experi­encing a variety of feelings (such as fear, guilt, and beingugly and bad) which were affects associated with alter per­sonalities she had encountered. The patient used part of athird session to use EMDR on her fear of the moon. Sherecalled the garage light had been suspended beneath awhite metal shield that diffused the lighting in the garage,and that it had seemed moon-like to her. There were fur­ther associations to moths under the light from the first twosessions.

Treatment had to be suspended for several weeks whenMrs. B was called out of town. When she returned, mothswere outin large numbers, and she requested EMDR to desen­sitize herself to them. Halfway into this session Mrs. B sud­denly exclaimed she was no longer afraid of the moon. Shehad recalled an assault during a moonlit night in a field onher childhood farm home. She felt dramatic relief and wasconfident she could manage to be outside at night. Recallof the target full moon was not distressing (SUDS 0) and herconfidence she was through the fear was high (VaG 6-7).Further work on the target symptom of moths resulted inonly a modest reduction in fear (SUDS 8) but a vaG level of6 that she could manage with moths.

The following week the patient announced proudly thatwhen she saw moths at home she had remained calm andplaced a flat dish of soapy water under a light on the tableas she had seen her mother do when she was a child. Themoths flitted about the light and its reflection, and wouldbounce into the soapy water where they got stuck. Then shethrew them out. Due to other concerns, work proceeded inanother direction. Mrs. B commented she felt the proce­dure was very helpful, much faster than our previous work,and that somehow her work on the material treated withEMDR seemed more finished than her work with other mem­ories. She felt it was not like hypnotic work, and was pleasedit had not resulted in abreactions or destructive impulses.She described an awareness of feeling states characteristicof some of her other alter personalities giving her anincreased sense ofher own range ofreactions. Her work alsodemonstrated a generalization effect when work with hermemory involving moths spilled over to a related memoryof the moon and relieved her distress there as well. Whileher target symptom remained high for moths, she felt suc­cessful with both fears. If further work had been attemptedshe might well have lowered her SUDS level to moths. At sixmonths she continued to feel confident in her progress onthese two areas.

RESULTS

Both Ms. A and Mrs. B demonstrated rapid reductionin distress levels that persisted at six months follow-up. Thesecond patient's distress over moths was reduced less, buther confidence that she could take effective action resultedin a sense of mastery with regard to the moths. She enjoyed

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EMDR TREATMENT OF PHOBIC SYMPTOMS IN MPD

the additional benefit of her second phobic symptom (thefull moon) spontaneously dissipating rcmiuingduring treat­ment for the first

Little narrative or interpretation was made by the author.Still the patients improved. During the n.WR treatmentseach patientreporlcd seeing material rapidly passing throughher mind that appeared related through associations to thetarget symplOm. In Mrs. A there was an awareness of incestand a teenage sexual assault. Mrs. B recalled the circularspots on the moths' wings and the overhead light in hergarage where insects gathered as she recalled being molest~

ed. These and other associations were related to symptomrelief. This factor suggests thatimprovcment was nOlsimplya matterofsystematic desensitization or the hierarchical order­ing of anxiety producing elements. This more closely fitsShapiro's (in press) concept that EM OR induces accelerat­ed information processing (AlP). It further would seem tocontradict the thesis put forward by Metter and Michelson(1993) that results occur secondary to sequence disruptionor negative reinforcement from the eye movements.

On the other hand this report does not establish thatthe eye movements themselves constitutes the mechanismbywhich AlP occurs (or, indeed, thatAJPoccurs). What doesseem clear is there was rapid relief of symptoms related toreduced fears ofthe target phobias, and that this reliefoccurredwhile traumatic materiafwas being internally processed. Morewas occurring through simple desensitization or relaxation.Both patients demonstrated early distress when focusing onthe target symptom initially; it was rapidly reduced as theEMDR progressed.

It should be noted that the successful results claimed forthe patients relates to their phobic target symptoms alone.No effort was made to measure global hmctioning in otherareas. Much of their clinical pictures deriving from chron­ic traumatization needed ongoing work. Based on their suc­cessful usc of EMDR for the symptoms under discussion it ispossible that their therapies may include the judicious useofadditional EMDR treatments in the future. Chronic trau­ma patients may turn out to require more inteillention fortarget symptoms than thesinglesession treatment ofepisodesof trauma described in Shapiro's early work (1989a, 1989b).In some, the impact of characterologic overlay or chronicdisability may impede the effectiveness of any therapeuticefforts, includingL\ltDR, because ofthe secondarygain involved(Boudewyns et al., 1993, Lipke & Botkin 1992). The poten­tial for generalizing from relief ofaspecific trauma by EMDRto relief of other traumatic materials has been suggested,and may find support in Mrs. B's sudden relief of her fearof the moon. The issues raised here will need further study.

DISCUSSION

While tllis report describes a positive outcome with EMDRin twO patients with dissociative disorders, it isstill necessaryto be aware of the limitation of case reports in evaluatingEMDR and all psychotherapy in general. Adequate stan­dardized, baseline assessments, follow-up assessments andcontrol studies are clearly indicated.

132

EMDR is still new. Both it.<; potential applications and thecautionsand complications that may surface as it el"U0Yswiderusage need further study. The author is aware of potentialpitfalls in the us~ of El\IllK, such as premature nooding,increased escalation of angry impulses, and the failure tomobilize affect. He also is aware that its benefits need fur­ther study if accurate assessment of EMDR is to occur, andclear indications for the use ofEMDR are to bedefined. Further,the role of the eye movement itself remains to be clarified.

A number of limitations in this case report study needto be acknowledged. The two patients came to the authorexpecting positive results despite low confidence levels. Thiswas partly due to an informed consent process duringwhichShapiro's articles were provided, partly because the authorwas seen in consultation for this procedure (implying posi­tive expecLtncy), and partly because these patients were onan inpatient unit where other patienL~ had discussed posi­tive results coming from another EM DR pilot study inprogress. Expectancy may prove to h,\\'c exerted a morepositive impact than did thc EMDR itself.

The potential for contamination by hypnosis is impor­tant. Dissociative patients may bring their own autohypnot­ic talents to bear, augmenting the impact ofthe EMDR. Recentarticles have described fractionated abreactions, usi ng a hyp­notic technique ofmoving in and out of trance states to pacethe intensity ofabreactive work (Fine, 1991; KIuft, 1988). IfEMDR is, in fact, related to hypnotic processes, one wouldexpect to find highly positive response patterns in a highlyhypnotizable populations and poor responsitiviry in low hyp­notizable populations. This has not been seen to be the casein the author's experience with anecdotal reporL~ in whichEMDR outcomes are discussed. In this study, neitllCr patientfelt that the impact of the procedure was similar to formalhypnosis. Theydid feel subjectivclythat information was pro­cessed more quickly, more completely, and differently inEMOR as compared to hypnosis.

Clearly, controlled studies are going to be required toaddress many of the above concerns, and these studies willneed to address more than single symptom inteillentions.They will also need to see whether EMDR as a major treat­ment modality can demonstrably shorten treatment inchronically traumatized individuals with dissociative condi­tions, or whether EMOR, if shown to bc effective, can andshould be introduced at judicious, clinically defined pointsin treatment. Controlled studies also need to study patientstreated with more traditional therapeutic int.en'cntions, EMOR,and other "special" techniques designed to clarify the roleofeye movement itself, in addition to the other factors thatconfound treatment outcome. The use of raters other thanthe treating clinician will be essential.

A current problem in evaluating reports on the efficacyof EMDR relatcs to the variety of dHferent treatment proto­cols that are being described by the term EMDR. Many ofthese formats not only fail to adhere to Shapiro's (1989a,I989b) protocol butoften are used in cOI"Uunction with othertreatment techniques. Baseline measures to standardize treat­ment protocols, outcome, and provide consistent criteriafor positive results have to be applied in future study.

DlSSOCLI.T[O~, \'01. \11, ~o. 2,june 1994

Despite the present problems assessing the efficacy andunderlying mechanisms of EMDR, results to date suggestenough clinicians are finding positive outcomes in theirworkwith this technique towarrantfurther study. The rapid responseto EMDR of the two dissociative patients reported here sup­port the need for further study ofEMDR in dissociative pop­ulations to see whether this modality can contribute to thedeve10pment ofan effective, less painful, and more controlledand cost-efficient treatment technique for dissociative dis­order patients. •

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Shapiro, F. (in press). Eye movement desensitization and reprocessing:Basic principles, protocols and procedures. New York: Guilford.

Spector,]., & Huthwaite, M. (1993). Eye movement desensitiza­tion to overcome post-traumatic stress disorder. British Journal ofPsychiatry, 163, 106-108.

Wernik, U. (1993). The role of the traumatic component in theetiology of sexual dysfunctions and its treatment with eye move­ment desensitization procedure.JournalofSexEducation and Therapy,19,212-222.

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