Portraits in Healing:

A Clinical Study on the Neurological Outcomes of EMDR in the Treatment for Cumulative PTSD in Police Officers

 

By:  Karen Lansing, MFT, BCETS, & Daniel Amen, M.D.

 

Purpose: 

The purpose of this study was to observe the changes that occurred with five clients diagnosed with Posttraumatic Stress Disorder through an entire course of treatment that included the use of EMDR.  Special interest was given to two points of reference  (1) measurements of neurological changes (observed before, during and after EMDR through brain imaging) and, (2) the clients own self report of their symptomology before the utilization of EMDR and then at the end of the segment of their treatment which incorporated EMDR.

 

Design:

The subjects for this study were chosen from a client base comprising of police officers.  All had been involved in shootings.  Each subject was evaluated by an independent clinician who was not involved in this study before EMDR was introduced as well as at the end of the course of treatment.  The purpose for this was to confirm (or rule out) a diagnosis of PTSD and to identify the severity of each subject’s condition.  These outside evaluators each specialize in the treatment of trauma.  The Foa Posttraumatic Stress Diagnostic Scale (PDS), a standardized evaluative tool for the measurement of PTSD was used by these clinicians as well as session interviews. Several subjects had seen a psychotherapist prior to entering this study for extended periods of time while others had not received any therapy before coming into the study.

In addition to the aforementioned outside evaluations, pre and post EMDR SPECT brain images were taken of all five subjects prior to their first EMDR session and then at the end of the segment of treatment where EMDR was utilized.  Additionally four out of five subjects were given brain images during their very first EMDR sessions. 

 

Outcome:

Each of the five subjects completed therapy successfully and experienced a dramatic improvement in their symptoms.  All but one were able to return to a pre-morbid level of functioning in terms of executive functioning.  Neurological changes were seen consistently in several sectors in the brain (cingulate gyrus, basal ganglia, the deep limbic system, and the cerebellum).  Prior to the use of EMDR these sectors were overactive.  Following the utilization of EMDR these areas became less active. Additional drops in activity occurred in the Prefrontal Cortex.  All of the brain images corresponded with the standardized PDS evaluations recording the client’s own self reports in the outside clinical evaluations.  A dramatic diminishing of their PTSD symptoms was reflected in both the PDS as well as in the opinions of the outside therapist evaluators. 

 

Introduction:

Individuals in Law Enforcement experience more trauma in one month than the average citizen will see in the course of a lifetime.  Cumulative PTSD with delayed onset is the most common type of case that this population will present with.  In such cases, it’s not merely one traumatic event but numerous ones that require effective resolution.  Without complete recovery, officers can experience dramatic drops in their ability to contend with the chronic stress and dangers inherent in their jobs.  For this reason, it is imperative that those providing therapy to treat duty-induced trauma be effective.  This study observes the progress and outcomes of 5 officers involved in on-duty shootings.  All had cumulative PTSD for one year or longer by the time they entered into treatment.

 

Funding: 

Partial funding for this study was rendered by the EMDR Institute that helped to pay for 15 SPECT images.  The design of this study was formulated solely by Karen Lansing, MFT and Dr. Errore. Il segnalibro non č definito..  

 

Subject Selection:

Clients that were chosen for this study had to meet the following criteria:

  1. The prospective subjects all needed to have been in an officer involved shooting
  2. All subjects needed to have confirmed a diagnosis of PTSD
  3. If medication was being used for depression, that condition needed to have been present following the traumatic event
  4. Clients on antidepressants (there was only 1) needed to remain on that same medication for the duration of the study, and be on the same dosage for all SPECT scans.
  5. Alcohol and any other forms of substance ‘self-medication’ were not to be used for the duration of treatment
  6. A range of severity in PTSD was sought across the subject population

 

These research subjects all came in for the treatment of PTSD due to duty related trauma.  All had been in officer-involved shootings but had also accumulated at least two or more other traumatic events over the course of performing their duties. Two clients had never been in therapy before, and three clients had already been involved in treatment using talk therapy as the mode of treatment.  One of these clients had been through a complete course of treatment while the remaining two had seen a therapist and had been referred.  Talk therapy was the model of treatment with the preceding therapists in all of these cases.  Prior to entering into this research, Client #1 had been in therapy for eight months, Client #2 had been in therapy for ten months and client #4 had been in therapy for five months. Session content with the previous therapists had included discussion of their respective traumas in some detail as well as some focus on family issues.

 

The choice of officers involved in on-duty shootings was made for several reasons.  First, this is a population that the treating psychotherapist specializes in.  Additionally, because police officers are highly trained, once they’ve had to revert to their training in a critical incident, they tend to dissociate from their affective reactions to things in order to survive or, protect others (i.e. they may not be aware of any sense of fear/terror/horror even though they are reacting due to such internal reactions). The fact that an officer has been in a situation that’s caused him/her to not only have drawn a weapon, but to have fired, is a confirmation that s/he was afraid for personal safety and/or for the safety of others.  Additionally, officers who have had to fire at another (always with the intent to kill), often suffer from increased risks if they remain/return to duty.  The inability to perform this same act again out on patrol  can be one deadly bi-product of such trauma but there are other debilitating after effects that can occur as well… not the leaste of which is PTSD (Grossman, 1995; Herman, 1992; van der Kolk, et al  (1996).

 

Course of treatment:

Upon entry into treatment, intake was conducted taking a family history, client history and trauma history.  These clients were then asked if they would be interested in taking part in this study.  If they were interested they were informed of what this would involve with regards to time, travel and brain imaging.  Outside clinicians conducted the following evaluations on all subjects:  The PDS was administered along with an interview, which would set out to (1) define and describe the symptoms each client was experiencing,  (2) the nature of their traumas and (3) to confirm that each had a viable case of PTSD.  If the diagnosis of PTSD was confirmed informed consent was given to each research client by the treating therapist, and a second form was included in the patient information paperwork for their review and signature at the Amen Clinic detailing the process and elements involved in receiving SPECT imaging.

 

Treatment Protocol:  Treatment format for all clients proceeded as follows:

#1. Administrative Phase: Initial intakes are done including genogram, personal history and trauma history. Coping mechanisms are taught.  These include, (1) the identification of one’s support network (or if necessary the formation of one) (2) an agreement to refrain from self medication with non-prescribed substances, (3) teaching the client how to use containment techniques when/if flashbacks and/or disturbing memories erupt, (4) a routine of stress reduction activities are initiated as well which usually include exercise on a regular basis, social interaction with friends and/or family, etc.  (5) Logging is taught whereby a client makes note of reactions s/he is experiencing (i.e. flashbacks, memories of the scene that come to mind, strong emotional responses to things, nightmares, etc.)  These are to be noted and rated on a 0-10 scale (0=no reaction---10=as extreme/intense as could be).  Additionally, the client is instructed on how to refine his ability to clearly identify underlying emotions.  For example, male clients will often times log a reaction of anger to any given distressful situation.  If asked what lies beneath the anger he may find that it is fear or sadness. This logging is preparation for EMDR which is done in the second phase.  (6) Resource Installation:  Called “Going to Baseline” whereby the client is taught to recall a good memory or event in his/her life when disturbing memories or reactions come up. 

 

Traumatic events are inventoried and ranked in intensity for later reference regarding EMDR targets in the second phase of treatment.  Additionally, client safety is evaluated regarding risk to self / others, need for medication and stability of living environment.

 

  #2. Working Phase:  Once the client has been stabilized and has been making use of the resources put in to place in Phase #1, s/he is ready to begin focused and in-depth trauma work.

 

The focal point of this segment in treatment is EMDR.  Due to the mental fatigue that this technique will cause, the frequency of EMDR sessions (which typically run from 2-3 hours in length) is dictated by the client’s individual recuperation time.  Generally, it is done three to four weeks apart.  Due to officer safety concerns, it was necessary to time EMDR sessions for the beginning of his/her three day off-duty time, and to allow for recovery from mental fatigue before going into the next EMDR session.  In the case of the one officer who was on medication while in treatment, there was a slower recovery time noted after EMDR sessions. Sessions between the EMDR sessions are one hour long and are used to facilitate any insights and connections that had been made both during and after these sessions.  Changes in the intensity and frequency of symptoms were also reviewed. 

 

At the end of Phase #2 (one month following the last EMDR session) the final SPECT was taken.  This time between the last EMDR session and final SPECT allowed the brain to recover from mental fatigue that was caused by the EMDR.


#3. Reconciliation Phase:  Due to the fact that PTSD creates difficulties for individuals in cognitive, and emotional realms this final phase of treatment focuses on re-scripting of relational patterns that may not have self-corrected once the client is de-traumatized.  Subject content in these sessions no longer include material connected to the traumatic events.   In this phase the client is also being prepared for graduation out of therapy.

 

Study Protocol:

Each of the subjects had gone through initial intake, the complete course of education and training listed in Phase #1 and the outside clinical evaluation prior to their first SPECT scan.  The outside evaluations were done anywhere from 1-42 days prior to the SPECT scan.  The two clients with the most severe PTSD symptomology were purposefully put on extreme ends of this timeline to see if Phase #1 could drop their symptom intensity and overactive neurological conditions.   SPECT scans still indicated a high degree of PTSD induced over activity in both of these clients.  While all five of the clients following Phase #1 were more able to mediate their symptom clusters and had more skills to make use of for self-care, their symptomology had not abated measurably.  Dramatic drops in symptomology as well as changes in brain function occurred after the clients had completed the second phase of treatment where EMDR had been used (when final SPECT images were taken). 

The choice was made to have the Connor CPT Concentration Test utilized for the “at concentration” pre and post EMDR SPECT images.  This was in the interest of (1) having the subjects engaged in a uniform activity, and (2) to insure that they were not thinking about their traumatic events during the imaging.  This allowed the view of PTSD “running in the background” when the thoughts/images of their incidents were not foremost in their minds.  More importantly, was the goal to “render no harm” to these officers as we observed their progress through treatment.  The SPECT images cannot be taken any sooner than 30 hours apart (due to the half life of the ink which is injected).  As it was, the pre and during EMDR brain images were done one week apart.  There were concerns that in doing an initial SPECT image that required the subjects to recall their shootings, or to have them listen to the dispatch tapes of their incidents, this could intensify their PTSD conditions.  Not all of these officers were on disability leave and so were still working out on patrol with guns.      

EMDR was conducted according to the techniques taught through the EMDR Institute.  The use of the TheraTapper during EMDR segments allowed the subjects to go through the traumatic scenes with their eyes closed.  Even so, it was noted that at various times all subject’s eyes would move back and forth even though they remained closed.  These subjects were unaware of this when asked about it.

 

Brain Imaging Parameters:

The brain SPECT studies were performed in the following manner.  The subject was placed in a dimly lit, quiet room.  Intravenous access was obtained via small gauge butterfly.  The subject remained quiet for several minutes with his/her eyes open to allow his/her mental state to acclimate to the environment. 

For both the pre and post EMDR brain images, the subject was given a standardized concentration test to perform.   The Conner’s Continuous Performance Task is a 15 minute computerized test of attention.  Three minutes into performing the task HMPAO was injected into the I.V. port.  The subject then completed the task. 

In the “during” EMDR brain images, the Conner’s Continuous Performance Task was replaced by EMDR.  Subjects were set up with the Iv port prior to commencement of EMDR.  Once EMDR was under way, the injection was given (always during the first review of the traumatic scene).  

In all cases, a tomographic brain image was then performed approximately 45 minutes later using a high resolution Picker Prism 3000 gama camera with fan beam collimators.  Data was acquired in 128 X 128 matrices.  One hundred twenty images with 3 degrees of separation spanning 360 degrees rotation were obtained.  The data was prefiltered using a low pass filter with a high cutoff.  Attenuation correction was performed using a linear method.  Coronal, sagittal and transaxial tomographs were parallel to the orbitalmeatal line. 

The tomographs were displayed using a standardized linear color scale.  The studies were read by visual inspection in all three planes and in 3 dimensional surface brain maps (looking at the most active 45% of brain activity) and 3 dimensional active brain maps (comparing average activity with the most active 15% of brain activity).  All of the brain areas were rated on a scale of 0 (normal activity) to 4 (+) increased or 4 (-) decreased activity.  

 

EMDR Protocol:

Eye Movement Desensitization and Reprocessing (Shapiro, 1989, 1995) is a treatment modality that combines key aspects of major theoretical orientations (e.g. cognitive behavioral, psychodynamic, client-centered and interactional) along with bi-lateral stimulation.  This technique can be integrated into a comprehensive treatment plan by appropriately trained clinicians in order to address and neutralize the effects of distressing life events and traumas.  EMDR consists of a procedural protocol including eight phases designed to address specific complaints that bring clients in for treatment (i.e. mood disturbances, insomnia/hypersomnia, increased anger, depression, isolation, avoidant behaviors, panic/anxiety attacks, etc.).  Initially eye movement was the modality used to accomplish the increased vivification of scenes that were disturbing.  Over the course of time, it has been discovered that various other types of bi-lateral stimulation (i.e. tapping or tones) can also effectively work. 

Various theories exist regarding how and why EMDR works. Dyck (1993) correlates the EMDR protocol to that of classical conditioning.  Another theory is that eye movement or kinesthetic tapping can reduce the intensity of overpowering affective reactions when recalling a traumatic event (Commons, 2000).  

While the basal ganglia do tend to drop in over activity during EMDR the increase of fear, helplessness, horror, etc. were uniformly a part of the process in the earlier sets.  As already mentioned, the modality for bi-lateral stimulation used during EMDR was hand tapping with the “TheraTapper.”  In each set of EMDR the focus was on facilitating the most intense re-experiencing of the traumatic scene.  The clients who had previously been in talk therapy voiced concerns that they would not be able to recount their traumatic scenes fully, or experience any improvements since they had discussed them in some detail on numerous occasions with prior clinicians.  In all of these cases their concerns were unfounded.  These same subjects voiced surprise at the intensity of not only the scenes, but also their affective reactions to them (especially those of fear and sadness) as they worked through these during EMDR.  Additionally, in most cases, fragments of memory were recounted (i.e. why a gun had not fired properly, or the presence of bystanders who’d been near the line of fire that the officer had not recalled being there, or, why radio transmission had not occurred). The subjects who had not been in therapy prior to entering this study had the similar experiences as well.  

All five subjects also reported a change in the nature of their memories as the EMDR process proceeded.  Perceptive changes were noted and volunteered by the subjects where they described initially feeling as though they’d been back in the scene.   One client without realizing it, had actually lifted her hands (as though aiming her gun).  As the scene was revisited in each EMDR segment, the subjects began to experience it more as spectators watching the scene playing out.  One of the subjects who’d come into this study with severe PTSD (according to the PDS and his brain image) had never before been able to discuss his shooting without coming to tears. After the completion of his EMDR session, for the first time, he was able to tell the story from beginning to end without becoming overwhelmed.

 

Outcome:

In all of the initial brain images similar patterns of neurological activity were observed.  Over activity (to varying degrees) was found in the cingulated gyrus, the basal ganglia, the deep limbic region and in the cerebellum.  Upon completion of the second phase of treatment where EMDR was used, these regions became measurably less active or returned to normal levels of activity.  Along with this, the prefrontal cortex (PFC) was also found to drop in activity.   

Typically this PFC drop would indicate a diminishing of ability to sustain attention, to filter out distractions and a drop in cognitive function.  However, all but one subject reported marked improvements in these areas along with an increase in their sense of safety, ability and control while on duty.  Prior to EMDR all had experienced difficulties in things such as multitasking (i.e. driving out on patrol, listening to radio traffic, verbal responses on the radio and watching the activity out on the streets).  After treatment, multitasking returned to a pre-morbid level of functioning.  The one officer who was an exception to this had suffered several traumatic head injuries over the course of her career prior to treatment.   

Two officers (subjects 2 & 5) reported still having some residual anxiety in their PDS. Both saw measurable drops in neurological over activity in all the aforementioned regions of their brains with the exception of the basal ganglia.  These two officers had concerns regarding possible retribution after their respective shootings in the communities that they served. Despite that however, both felt that their anxiety was manageable while on duty.  Even so, symptoms such as nightmares, sleep disturbances, mood disruptions (i.e. disproportionate anger reactions) all disappeared.  

All subjects reported dramatic improvements in mood, sleep, and relationships in the wake of EMDR utilization.  Their brain images corresponded with their self-reports in the final PDS intakes. 

Summary:

While this study was designed as a means to observe the normal clinical progression of subjects being treated for complicated PTSD with the utilization of EMDR, the hope is that it can add to the research which has already been done.  Further studies of this type using other treatment models can only help to facilitate our understanding of what treatment modalities can best assist in the process of healing.  Even so, as is always the case, improvements in research design are always possible and this modest study is no exception.  One aspect of study along with the standardized evaluations and brain imagines that could further add to such endeavors would involved the measurements of stress hormones before, during and after EMDR has been utilized.  Due to funding restrictions this was an aspect of investigation that was not an option.  In the future perhaps this can be added to the matrix.   

 

The Pre and Post EMDR PDS Evaluation Scores: 


 

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