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EMDR Scripted Protocols - M. Luber
EMDR Scripted Protocols - M. Luber
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
ASR Definition
The symptoms usually appear within minutes of
the impact of the stressful stimulus or event, and
disappear within 2-3 days (often within hours).
Partial or complete amnesia for the episode may
be present.
There must be an immediate and clear temporal
connection between the impact of an
exceptional stressor and the onset of symptoms;
onset is usually within a few minutes, if not
immediate.
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
ASR Definition
Smelling
Touching
Tasting
Thalamus
Amygdala and the Prefrontal cortex
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Neurophysiology
Amygdala
Compares the information it to past events on an
emotional level
decides if it is important for the brain and body to pay
attention or not.
In trauma it is recognizing danger and alerting the body
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
When in danger or perception of
danger
Perceived as dangerous
Activate
Adrenergic system (Sympathetic Nervous System-SNS)
Locus coeruleus & Reticular activating system
Norepinephrine (fight, flight, freeze)
Glucocorticoid system
Hypothalamus release Corticotropin Releasing Factor (CRF)
Pituitary release Adrenocoritcotropin Hormone (ACTH)
Adrenals
Cortisol - Immune response & Stress response
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Hormones During Stress
Norepinephrine / Epinephrine
Fight , Flight, Freeze
Encode memory stay away from a dangerous situation
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Hypothalamic- Pituitary-Adrenal
Axis
Hypothalamus produces
Corticotropin releasing
factor/hormone
Pituitary produces
Adrenocorticotropic
hormone
Adrenals produce cortisol
Negative feedback loop
regulates the system
Amygdala, hippocampus and
hypothalamus connected
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Pertinent Neurobiological Factors
Initial adrenergic surge may be associated with
the consolidation of traumatic memories
Low endogenous cortisol levels may
promote development and symptomatology of
PTSD by a disinhibition of traumatic memory
retrieval
fail to contain the sympathetic stress response
Lower or off
Left prefrontal cortex
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Acute Stress Disorder (ASD)
A. The person has been exposed to a traumatic
event in which both of the following were
present
1. the person experienced, witnessed or was
confronted with an event or events that involved
actual or threatened death or serious injury, or a
threat to the physical integrity of self or others.
2. the persons response involved intense fear,
helplessness or horror.
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
ASD definition
B. Either while experiencing or after
experiencing the distressing event, the individual
has three (or more) of the following dissociative
symptoms:
1. A subjective sense of numbing, detachment, or
absence of emotional responsiveness
2. A reduction in the awareness of his or her
surroundings ( being in the daze)
3. Derealization
4. Depersonalization
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
ASD definition
D. Mark avoidance of stimuli that arouse
recollections of the trauma (e.g. thoughts,
feelings, conversations, activities, places, people)
E. marked symptoms of anxiety or increased
arousal (e.g. difficulty sleeping, irritability, poor
concentration, hypervigilance, exaggerated
startle response, major restlessness)
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
ASD definition
F. The disturbance causes clinically significant
distress or impairment in social, occupational, or
other important areas of functioning or impairs
the in individuals ability to pursue some
necessary task, such as obtaining necessary
assistance or mobilizing personal resources by
telling family members about the traumatic
event
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
ASD definition
G. The disturbance last for a minimum of two
days and a maximum of four weeks and occurs
within four weeks of the traumatic event
H. The disturbance is not due to the direct
physiological effects of a substance( e.g. a drug
of abuse, medication) or a general medical
condition, is not that are accounted for by brief
psychotic disorder and is not merely an
exacerbation of a pre-existing axis I axis II
disorder
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Not treating ASR
Most people recover
Incidence PTSD after Traumatic Event
Men 8-13%
Woman 20-30%
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Prevent PTSD?
Likely those with severe ASR ones who develop
ASD
It is possible if we can help reduce strong
reactions in susceptible individuals with ASR
may prevent later development of ASD and
PTSD
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Current Acute Treatments
Cognitive-Behavioral Intervention
Empirical evidence can reduce trauma and PTSD (Bryant ,
Moulds , & Nixon , 2003 ; Bryant , Sackville , Dang ,
Moulds , & Guthrie , 1999 ; Echebur a , De Corral ,
Sarasua , & Zubizarreta , 1996 ; Foa , Hearst-Ikeda , &
Perry , 1995 )
6 months
CBT 11% PTSD
Self help 61% PTSD
Repeat assessment only 55% PTSD
John N. Briere, Catherine Scott. Principles of Trauma Therapy: A Guide to Symptoms,
Evaluation, and Treatment. (Sage Publications, Inc, 2006). Page 170
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Early Pharmacological Interventions
Propranolol versus placebo (two studies)
No convincing evidence of benefit
Gabapentin versus placebo (one study)
No convincing evidence of benefit
Hydrocortisone versus placebo (one study)
limited evidence favouring hydrocortisone over placebo
Temazepam versus placebo (one study)
No convincing evidence of benefit
Escitalopram versus placebo (one study)
No convincing evidence of benefit
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Reconsider CISD
CISD has generated much criticism, mainly because
of its application to non-helpers and its use by
nonprofessionals.
Based on a study of a large database of CISD
studies, reviewers concluded that most CISD
criticism is based on practices that do not follow the
rigorous procedures and criteria of the original
Mitchell model; for example, single sessions were
held with no follow-up, encounters were too short,
or groups were much larger than recommended.
(Everly& Mitchell, 2000)
Roseenfeld, L.B.,Caye, J.S., Ayalon,O., Lahad,M., When their world falls apart, Helping families and
children manage the effects of disaster.(NASW Press, 2005) Page 445
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Current Acute Treatments
Proximity, Immediacy and Expectancy (PIE)
Military to return injured soldiers to front line
In Israel some success 1982 Lebanon War ( Solomon &
Benbenishty , 1986 )
Vietnam not as successful (Shalev, 2002)
overwhelmed by events , who lack sufficient affect regulation
skills , or who have a biological vulnerability to stress , such
reexposure may in fact be retraumatizing and harmful. Jones
and Wessely ( 2003 )
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Current Acute Treatments
Defusing
Brief (10-30 minutes)
Conversational -informal
Little research
Swedish peacekeepers Bosnia helpful
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Current Acute Treatments
Psychological First Aid (PFA)
PFA Field Operations Guide (Hurricane Katrina)
Not a specific therapeutic
intervention
Modular framework give to individuals for
Natural disasters
Terrorisms
Mass trauma
Goal decrease initial distress
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Guidelines for first encounter with an ASR
victim
ER Staff
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Guidelines for a talk with an ASR victim
Introductions
Orientation
Allow expression without disturbance
Normalization of reactions as opposed to the
abnormality of the difficult situation the
reactions are logical and to be expected and they
should slowly fade away
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Guidelines for a talk with an ASR victim
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Terrorist Attacks 2nd Intifada
September 2000
1,053 Israelis total:
- 719 Israeli civilians killed by Palestinians;
- 334 Israeli security force personnel killed by
Palestinians
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Yael # 6 bus
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
EMDR
Adaptive Information Processing
As the body self heals after physical injury
The mind can also self heal
Control/Choices
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
EMDR
Treatment validated by randomized control
studies- more than 15
Can work much more rapidly in single Incident
PTSD
CBT 12-20 sessions 100 hours homework
EMDR 1-3 ninety minute sessions no homework
(not explained with exposure model)
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Bilateral Stimulation
May help link Right and Left Brain (PET scans
van der Kolk)
Dual Attention- remain in the present as access
memories of the past
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Bilateral Stimulation Helps
Numerous controlled studies have also indicated that
eye movements cause a decrease in imagery vividness
and distress, as well as increased memory access.
Andrade, J., Kavanagh, D., & Baddeley, A. (1997). Eye-movement and visual
imagery: a working memory approach to the treatment of post-traumatic stress
disorder. British Journal of Clinical Psychology, 36, 209-223.
Barrowcliff, A.L., Gray, N.S., MacCulloch, S. Freeman, T.C.A., &
MacCulloch, M.J. (in press). Horizontal rhythmical eye-movements consistently
diminish the arousal provoked by auditory stimuli. British Journal of Clinical
Psychology.
Christman, S.D., Garvey, K.J., Propper, R.E. & Phaneuf, K.A. (in press).
Bilateral eye movements enhance the retrieval of episodic memories. British Journal
of Clinical Psychology, 40, 267-280.
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Bilateral Stimulation Helps
Kavanaugh, D.J., Freese, S., Andrade, J., & May, J. (2001).
Effects of visuospatial tasks on desensitization to emotive
memories. British Journal of Clinical Psychology, 40, 267-280.
Kuiken, D., Bears, M., Miall, D., & Smith, L. (2002-2002).
Eye movement desensitization reprocessing facilitates attentional
orienting. Imagination, Cognition and Personality, 21, (1), 3-30.
Sharpley, C.F., Montgomery, I.M., & Scalzo, L.A. (1996).
Comparative efficacy of EMDR and alternative procedures in
reducing the vividness of mental images. Scandinavian Journal of
Behaviour Therapy, 25, 37-42.
van den Hout, M., Muris, P., Salemink, E., & Kindt, M.
(2001). Autobiographical memories become less vivid and
emotional after eye movements. British Journal of Clinical
Psychology, 40, 121-130.
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Taking Pictures of Duty-Induced PTSD
& HEALING
Article:
High Resolution Brain SPECT Imaging and Eye Movement Desensitization and
Reprocessing in Police Officers With PTSD
QuickTime and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Yael #6 after ERP
Talked about the event (narrative)
Debriefed regarding expected normal reactions
to trauma
Gave referral if before follow up visit needed to
consult
Came in 1 week later with no ASD
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
ERP
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
ERP
Timing: Within hours of traumatization
Indication: Silent terror or highly agitated
state
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
ERP initial preparation
Normalization while uncontrollable shaking and
overwhelmed: This is the bodys normal
healthy way of dealing with a dangerous
situation.
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
ERP preparation
Brief explanation describing EMDR: I will be
using a procedure based on the natural state
of dreaming when your eyes move rapidly
back and forth. This can help you learn new
things and be calm. It will also help you
come back to the present.
I am going to ask you to follow my fingers
with your eyes or with your permission, I am
going to tap on your hands.
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
ERP assessment
No formal assessment as already accessing
memory
Assumed initial NC: I am in danger
PC : I am safe now from that event
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
ERP desensitization
Begin bilateral stimulation.
You are in the emergency room (or current
location) and you are safe. That event is over
and out there. You are here, safe in the
emergency room (repeat several times).
Take a breath, Let it go, What are you
noticing
At first there can be re experiencing of trauma
followed by calming and ability to communicate
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
ERP completion
Narrative of event
And/or EMDR (if time)
At times another negative cognition is active
such as a false sense of responsibility
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
ERP closure
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Lebanon-Israel War 2006
3 soldiers kidnapped (2 in Lebanon)
4228 rockets fired
163 people killed
1750 physically injured
Thousands Psychologically injured
1.5 million people lived bomb shelters 33 days
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Debriefing with first responder
2 weeks after war ended (not within 72 hours)
Heterogeneous group: Police, Firemen,
Ambulance and Zaka (removal of dead) workers
Different events
Each person reported a huge amount of trauma
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
ERP with Dov
Zaka (removal of dead) worker
After hearing most of the group walked out
Said was going to bathroom
Followed him and he was in dissociated state
After hour of walking got him to sit down
ERP protocol
10 minutes responded and returned to group
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Group EMDR
EMDR Group protocol developed after Hurricane
Pauline ravaged the western coast of Mexico in 1997
By AMAMECRISIS for 200 distressed children and
adults who had lost families and homes
Artigas, Jarero, Mauer, Lpez Cano, & Alcal, 2000;
Jarero, Artigas, Lpez Cano, Mauer, & Alcal, 1999
Described for children after a natural disaster in
Argentina: MarIa Elena Aduriz, Catalina Knopfler,
Cristina Bluthgen, & Susana Maqueira)
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Group EMDR
Fernandez, Gallinari, and Lorenzetti (2004)
Alleviate symptoms for all but 2 of the 236 students
who witnessed an airplane crash in Italy.
Adriz and colleagues (in press) used the EMDR
Integrative Group Treatment protocol (EMDR-
IGTP)
220 child victims of a flood in Santa Fe, Argentina in
2003 and reported significant improvement that was
maintained at 3-month follow-up.
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Group EMDR
Sit in circle with paper and crayons, pens etc
First picture: Resource- Tap
Next Picture: Worst Picture- Tap
Next Picture: Picture what ever comes up: Tap
Continue around 4 to 5 times
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Tsunami 2004
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Group EMDR-Israel-Lebanon War-
Children not go to the exit of Bomb
Shelter 3 weeks
Combined Children and Adults
Group protocol
First picture: resource
Next picture: worst Katyushas, black sky
Next picture: no Katyushas, ground empty
Next picture: grass growing
Next picture: Sun , flowers
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Group after EMDR
For the first time in 3 weeks the children went
to and up the exit of the bomb shelter
At the top a siren started
One girl started to shake and did butterfly hug
and resolved in 10 seconds
Had to hold back children who wanted to run
out and taught them not when siren
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Conclusion
Victor Frankel: even in the worst of nightmares such as
the holocaust mankind can utilize the crisis for growth
Woman seeing terrorist blow self up killing and injuring
scores of civilians
At first I could only see the incredible amount of evil
After EMDR processing:
Now I am seeing the amazing good of so many people
coming to help. The good outweighs the evil by
thousands
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008