The Nature of Post-Traumatic Stress Disorder - Literature review Example

Literature Review Rationale and Aims Post traumatic stress disorder (PTSD) is an anxiety disorder and it can be caused by very stressful, frighteningor distressing events (NHS, 2014). The characteristic symptoms associated with PTSD re-experiencing of trauma, trying to avoid the stimuli associated with the trauma and increased arousal symptoms (American Psychiatry Association, 2000). Thomas (2008) states that, negative feelings are a typical response that a person may feel in the wake of encountering a traumatic occasion, in any case, when the indications keep going more than a month therapeutic consideration ought to be looked for. A person that has PTSD my show side effects of; flashbacks, awful dreams about the experience, abstaining from speaking or considering knowledge, feeling numb inwardly, sadness, diminished action, crabbiness, outrage, blame, rest unsettling influence, or listening to or seeing things that are not genuine (Mayo, 2012, p.46). In case of adolescents, there are certain other symptoms which are not seen in adults like behavioral problems, developmental regression, physical symptoms and some generalized fears (Schwarz, 1994). Broadly the methods used for treating post-traumatic stress syndrome are classified as psychotherapy and medication (Ipser, Sander, &Stein, 2009). Rules on PTSD from the National Institute for Clinical Excellence (NICE, 2005) state that all individuals with PTSD ought to be offered a course of trauma-centered psychological medication (trauma-centered cognitive behavioral therapy (CBT) or EMDR). National Institute for Clinical Excellence rules note that these medicines ought to typically be given on a singular outpatient foundation (Bernard & Krupat, 1994, p.68). Since the concept is still relatively new, there is ongoing research as to what could be the best method to treat post-traumatic stress syndrome. Psychotherapy includes various methods like cognitive behavioural therapy (CBT), session therapy etc and there is no substantial proof about which therapy is the best or whether we need to provide a combination of the therapies to actually treat the symptom (Ipser, Sander, & Stein, 2009). Guidelines on PTSD from the American Psychiatric Association (APA, 2004) expressed that CBT and EMDR have been indicated to be compelling for center side effects of intense and constant PTSD (Healy, 2014). These rules note, in any case, that no controlled investigations of EMDR have been led that might build information based proof of its viability as an early preventive mediation for PTSD (Bernard & Krupat, 1994, p.76). Eye movement desensitization and reprocessing (EMDR) is one of the recommended psychotherapies and being a relatively new concept introduced by Shapiro in 1987 (Shapiro, 1995) needs research about its benefits. The most basic undertaking utilized within EMDR is side-to-side eye developments that take after the therapists finger; nonetheless, rotating hand tapping or sound-related tones conveyed through earphones might be utilized. The activities are rehashed until the customer reports no enthusiastic pain (Gray, Saggers &Steane, 2014, p.69). There have been researches that indicate the efficacy of EMDR in treatment of PTSD, but there are still doubts among therapists which need to be cleared through further research (National Collaborating Centre for Mental Health, 2005). In exploring the proof supporting EMDR, the APA found that, in the same way as other of the investigations of other cognitive conduct and presentation helps, the vast majority of the composed EMDR studies have been little; however, a few meta-examines have showed adequacy as that of different types of cognitive and conduct therapy (Healy, 2014, p.230). In order to conduct my research, I went through a large database to understand the research that has already been undertaken in regards to psychotherapies in general for treatment of post-traumatic stress syndrome. Through the study of various literatures, I try to represent here the various theories that have already been undertaken for the treatment of post-traumatic stress syndrome and the gaps left that need to be filled with further study about the subject. Literature Search Strategy A literature search was conducted into the effects of EMDR on PTSD symptoms in adolescents. The studies in computerized databases were searched first; the databases included were PsychINFO, MEDLINE, ERIC, Google Scholar, Cochrane database of systematic reviews and PILOTS. The terms used in various combinations to explore the databases were: post-traumatic stress syndrome/disorder (PTSD), PTSD in adolescents, psychotherapies for PTSD, eye movement desensitization and reprocessing (EMDR) therapy. The reference section of the selected studies was then selected if in case further doubts remained about anything. The search came up with approximately 2410 hits which were then carefully scrutinized to get relevant information about EMDR as a method of treatment for PTSD. For inclusion, the studies had to meet following criteria: (1) the EMDR treatment was based on the Shapiro’s (1995) standard protocol. (2) diagnosis of PTSD based on standard criteria as suggested by NICE (2005) or DSM-IV-TR. (3) the age group was 10-19 or the patients were subjected to trauma in their childhood. (4) post-treatment information was given clearly. Considering the above considerations in mind primary studies were selected. However, four meta-analytical studies were also included that were highly credible because of their own extensive research and I also wanted to include what other meta-analytical studies about EMDR had suggested. Critical appraisal skills programme (CASP, 1999) and CONSORT guidelines were utilized in selecting the studies as well in critiquing the studies. A total of 10 studies were selected based on the inclusion criteria. Methodological quality of the studies was checked based on the gold standards suggested by Foa & Meadows (1997). Review of selected literature In reviewing the literature that I selected for my research I will be undertaking a chronological approach and henceforth the discussion will be in accordance to the date of publication of the articles. EMDR integrates various aspects of psychodynamic, behavioral, cognitive and experiential therapies along with bilateral stimulation using eye or hand movements or other methods (Korn & Leeds, 2002, p. 4). Korn & Leeds (2002) suggest that EMDR when integrated with Resource development and installation (RDI) is effective in treatment of complex post traumatic stress disorder. Their work deals with the complex form of disorder which is also known as DESNOS. Even though the work mainly focuses on the complex post traumatic stress disorder but as they explain that the symptoms are the same as has been classified under DSM-IV criteria for post traumatic stress disorder (Korn & Leeds, 2002). Hence the work holds critical importance for post traumatic stress disorder and its treatment. Their work becomes especially important since it especially focuses on adolescents when they start showing symptoms of post-trauma having been exposed to the trauma of sexual abuse as a child. Also since I have tried to include the disorder in its entirety and hence I had wanted to include various literatures that discussed the various reasons for the disorder and the research by Korn & Leeds (2002) helped me fulfill that objective. RDI is a set of EMDR-related protocols that focuses more on stimulating the “positive” networks in order to spare the patient of reliving the traumatic experience (Korn & Leeds, 2002, p. 5). The paper is commendable for its work on trying to find ways to improve the established technique. However, due to the narrow structure of the research that includes just two patients does not generalize the concept and leaves space for further research. Edmond, Sloan & McCarty’s (2004) is like an extension of the work by Korn & Leeds (2002) that discusses the similar trauma experience but do not consider it as another category of post traumatic stress syndrome and the treatment is within the criteria for post traumatic stress disorder. Their work is of importance because as they explain that there has been relatively less qualitative research about the effectiveness of treatments for post-traumatic stress disorder and a mixed approach using both qualitative and quantitative methods has not been used for evaluating the effectiveness of EMDR and their research uses a mixed approach (Edmond, Sloan & Mc Carty, 2004). The researchers found that EMDR had a deeper effect in resolving the issue in that it directly resolved the core of the issue rather than dealing with the outer manifestations of the issue as is the case with most traditional therapies which take a longer duration than EMDR in treating post traumatic stress syndrome (Edmond, Sloan & McCarty, 2004, p.267). The findings of the research by Edmond, Sloan & McCarty reveal that in comparison to other therapy (the one discussed by them was eclectic therapy) EMDR required less interference by the clinician and allowed the patients to deal with the issue on their own (Edmond, Sloan & McCarty, 2004, p. 269). This finding is specially important because they support their data with the perceptions of the patient which gives a better insight about the effectiveness of the treatment. The only problem with the research is that the method suggested is good for comparative studies but intervention studies require more substantial quantitative data. Bradley et al. (2005) performed a multi-dimensional meta-analysis of psychotherapy for PTSD. The meta-analysis by Bradley et al. (2005) found that all psychotherapies are useful in treatment of symptoms of PTSD. Symptoms are greatly improved from the baseline on applying both EMDR and CBT. This study compares the efficacy of CBT to that of EMDR. Since CBT is a widely accepted therapy method, hence this gives credibility to the use of EMDR as a method of therapy for PTSD. However, the study remains unclear about those who suffered repeated childhood traumas or who did not respond to the treatment or who were not included in the study like substance abusers (Bradley et al., 2005). The researchers also state that despite their efforts the meta-analytical study has some limitations like the “file drawer” problem where most unpublished reports are not taken into account and also it has been suggested that statistical analysis holds advantage over judgments made in qualitative literature reviews (Bradley et al., 2005). Even though there are limitations associated with the study, but the research provides substantial results about the efficacy of EMDR in treating PTSD symptoms. Scheck et al. (2005) in their research about the efficacy of eye movement and reprocessing therapy among young women found that EMDR had a very good effect on the victims in controlling the symptoms of the disorder. “The post treatment outcome variable means of EMDR –treated participants compared favorably with non patient or successfully treated norm groups on all measures” (Scheck et al., 2005, p. 26). The results also indicated that EMDR had better efficacy than active listening (AL) (Scheck et al., 2005). Their study is important in understanding the efficacy of EMDR in treatment for rape victims. Since the study was specific for women traumatized by rape and all of the participants were adolescents, hence it can be said that the study specified EMDR as a mode of treatment for adolescents especially girls. However, the study has its limitations in that no follow up was done and just two sessions of the therapies were undertaken to check which of the two methods is better (Scheck et al., 2005). Despite the limitations, the study was the first to specifically deal with adolescent girls dealing with the trauma of rape and showed the efficacy of EMDR as an intervention for post-traumatic stress syndrome. The methodology can be extrapolated to other forms of traumatic experiences and can be checked for individual responses to EMDR. Rothbaum et al. (2005) also discuss the role of EMDR for PTSD rape victims and compare the relative efficacy of Prolonged Exposure (PE), eye movement desensitization and reprocessing (EMDR) to a no-treatment wait-list. The results showed that there was improvement in PTSD symptoms, anxiety, dissociation and depression in both PE and EMDR as compared to the waitlist group (Rothbaum et al., 2005, p. 608). “PE and EMDR did not differ significantly for change from baseline to either post treatment or 6-month follow-up measurement for any quantitative scale” (Rothbaum et al., 2005, p. 608). The results are important as a means of comparison from the research by Scheck et al. (2005) as this research suggests that other psychotherapy like PE holds the same efficacy as EMDR. Even so, the importance of EMDR in treating the symptoms of PTSD is only strengthened by this research as well. The research also has its limitations in that being a completely quantitative methodology based research the qualitative aspects of the experience are missed out. Also since the results are after a six month follow up, hence EMDR’s exact value as a short duration therapy cannot be judged in the research. The research is important in that it pits EMDR in the same level as other psychotherapies for treatment of PTSD. Seidler & Wagner (2006) in their meta-analytic study about the efficacy of EMDR in treatment of PTSD found that the efficacy of other treatments is the same as EMDR. The importance of this research to my paper was that a meta-analytic study as suggested by Seidler & Wagner (2006, p. 7) does not really differentiate the results of a treatment from one to another and hence should not taken as a proof for comparative studies. They say that the major reason for this is due to the lack of inadequate data and I think this happens because not enough research has been done about EMDR. Seidler & Wagner (2006, p. 7) through their analysis discard the dismantling studies that the eye movement is small or non-existent. They confirm that eye movement has a critical role to play in EMDR therapy however the question of how eye movement affects the patient remains to be solved. Despite the extensive analysis of their chosen resources, there is a large restriction in such studies due to lack of high quality research and that results are based entirely on computer analyses of the data. Seidler & Wagner (2006, p. 7) suggest that further research is required with regards how different experiences affect the symptoms and how the individual response to a treatment may vary and hence there is a need for optimizing the treatment according to the response of the patient to the treatment. Van der Kolk et al. (2007) in their research about comparison between efficacy of EMDR and medication found that EMDR has a greater efficacy than medications like fluoxetine and placebo effect. EMDR has been found to have better effect in reduction of symptoms of post-traumatic stress disorder compared to SSRI (serotonin reuptake inhibitor) fluoxetine and was also helpful in controlling associated depression (Van der Kolk, 2007). However, the results were not replicated when the trauma was induced during childhood. EMDR was also more effective in reduction of symptoms of PTSD compared to placebo effect while fluoxetine had the same effect as placebo effect (Van der Kolk, 2007, p. 5). According to the research after a prolong treatment with drugs, the patient’s response to further drug therapy and placebo remains the same (Van der Kolk, 2007, p. 9). The study provides important results about the effectiveness of EMDR and being an extensive study that has a follow up period of 6 months and eighty eight study subjects, the results from the study can be said to be highly credible. They leave the scope for further study, as the results regarding childhood trauma are still unclear and hence more research is required about this (Van der Kolk, 2007). The other limitation of the study can be that since it is a randomized trial, and as other studies suggest that individual response to treatment can be different hence individual specific response should have been studied. Even so due to the large data collected and the long duration for which the study was conducted provides credibility to the results. Rodenberg et al. (2009) in their meta-analytic study found that EMDR has incremental efficacy. EMDR has high efficacy in treatment of post traumatic stress disorder but this improvement does not necessarily lead to “a non-clinical status” and can be further studied (Rodenberg et al., 2009, p. 605). The meta-analytic study by Rodenberg et al. is important because theirs is the first research that discusses the incremental efficacy of EMDR bringing our attention to not just the efficacy of a treatment during the initial stage but also during the later stages so as to check the efficacy of the treatment in completely treating the disorder. The study also provides evidence about the importance of bilateral movement in the therapy. The proof of incremental efficacy of EMDR also provides evidence that the hypothesized mechanism of bilateral stimulation for the working of EMDR is true and needs more research (Rodenber et al, 2009, p. 604). Rodenberg et al. (2009, p. 605) like Seidner & Wagner (2006) believe that the treatment with EMDR should be focused based on the traumatic experience of the individual. However, the study has limitations of considering only seven sources for their study and has the same limitations of a meta-analytical study. The meta-analytical but helps to concise, compare and relate other studies that have researched EMDR’s efficacy (Rodenberg et al., 2009, p. 606). Field & Cottrell (2011, p. 385) in their research about the use of EMDR as a method of treatment for PMTD in children and adolescents found that EMDR is a better therapy for reducing the symptoms of post-traumatic stress disorder and even treated some other effects associated with post-trauma like depression and anxiety. “It is also suggested that there is a greater impact for EMDR on the cognitive re-experiencing subgroup than on the behavioural avoidance subgroup of symptoms” (Field & Cottrell, 2011, p. 386). The research by Field & Cottrell (2011) provide specific evidence for the age group concentrated in my study about the significance of EMDR as a therapy option. It is further suggested by them that even though eventual results for EMDR or CBT may not be different but there is a considerable difference in the duration in which the treatment yields its result. EMDR takes a shorter duration to achieve the same results as CBT and hence is more efficacious than CBT in terms of duration (Field & Cottrell, 2011, p. 386). Even though their research leads us to such important findings but it has its own shortcomings. As the researchers themselves point out, the research lacks credibility because of the limited number of articles that were included for the research (Field & Cottrell, 2011, p. 384). With every such study there is a limitation of excluding out important sources because of the inclusion and exclusion criteria applied for the study. Hence, even though the researchers are thorough in the study of the resources they used but this leaves out many other resources which also speak about effect of EMDR. They also pint to other limitation of the study that due to use of waiting list, there is a chance that the results are affected by a placebo effect or due to contact with the therapist (Field 7 Cottrell, 2011, p. 384). Despite the limitations of the study, does provide important evidence about the significance of EMDR as a method of treatment in adolescents. Gillies et al. (2012) in their research about psychological therapies for treatment of post-traumatic stress syndrome in adolescents provide a platform where all the psychological therapies can be compared. Their meta-analytical study concludes that EMDR had similar result when compared with other psychological therapies in the treatment of PTSD (Gillies et al, 2012, p. 12). The results for CBT were much better than EMDR which suggested that CBT was a better treatment method than EMDR. However, the re-experiencing scores were significantly lower suggesting that the when it came to re-experiencing EMDR worked better than CBT (Gillies et al, 2012, p. 15). The study also found that EMDR did not work effectively on associated depression and anxiety (Gillies et al., 2012, p. 16). The results of the study are important since they present such a different picture from other researches. The research is significant in that it drew its result from fourteen independent studies and it was a high level research where the biases that result from such studies were reduced to a large extent. Even so, the study cannot be said to lack the methodological biases completely and hence the results cannot be considered as the only proof. Also, the sources for studying EMDR were limited to just two of which only one was actually used to provide the results (Gillies et al, 2012). The number of resources for analyzing the effectiveness of CBT was higher and hence the deviation in the results compared to other studies can be understood. Synthesis and strength of evidence Methods used by the selected studies Four of the ten sources were meta-analytical studies namely papers by Bradley et al. (2005), Seidler & Wagner (2006), Rodenburg et al. (2009), & Gillies et al. (2012). All the meta-analytical had the limitation of being limited by certain inclusion criteria and not being able to access unpublished work. Seidler & Wagner’s (2006) and work by Rodenburg et al. (2009) were also limited because of review of fewer resources. The others were quantitative researches that were tested in comparison with waiting list controls and none dealt with a single case study. With respect to the selection of patients, the study population varied widely and was difficult to compare. The sample size was also variable from a minimum of 11 to a maximum of 68. The training and experience of the therapists or clinicians involved in the studies was not mentioned and none of the therapists claimed to have held advanced knowledge about EMDR. Efficacy of EMDR in the studies All the articles that were discussed provided favorable reviews in regards to the use of EMDR as a method of treatment for adolescents. EMDR was found to be wither having comparative efficacy as other psychotherapies (Korn & Leeds, 2002; Edmond, Sloan & McCarty, 2004; Bradley et al., 2005; Scheck et al., 2005; Rothbaum et al., 2005; Seidler & Wagner, 2006; Rodenburg et al., 2009). It was considered as a better method of treatment by Field & Cottrell (2011) and was said to be better than medication and placebo effect by Van der Kolk et al. (2007). There was only a single research that found CBT to be a better psychotherapy than EMDR (Gillies et al., 2012). Family context of EMDR The research showed that EMDR can be treated as an individual therapy and does not necessitate the help of the therapists or family (Edmond, Sloan & McCarty, 2004). It is based on the individual’s ability. However, some of the researchers think that a family-based approach is helpful for children and adolescents as adolescents feel more secure when family is around and can trust their therapists more (Field & Cottrell, 2011;Gillies et al., 2012). The suggestions by the researchers are in line with the suggestion of others like Tinker & Wilson (1999) who have been advocating family-based psychotherapeutic approach for children and adolescents. Strength of evidence This literature review among set of other meta-analytical studies holds importance because it specifically focuses on EMDR as a technique that needs more attention and has a lot of scope among other psychotherapies in treating the symptoms of PTSD. Adolescence is a critical age and exposure to trauma is heightened at this stage, hence there is a need to find the best therapy for intervention during adolescence (Nooner et al., 2012). The review shows that the efficacy of EMDR as a method of intervention cannot be doubted, there are certain factors that need to be consider and have to be further studied but further research about effective use of EMDR will help in treating PTSD. Nooner et al. (2012) bring our attention to the fact that if intervention is not made during adolescence then it leads to further problems later on in life. Hence, this study that focuses on treating the symptoms in adolescence holds an important place in providing a comprehensive look into what other researchers working on EMDR think about it as a method of treatment for PTSD in adolescents. I hope that this review will stimulate others to research more about EMDR. Limitations of the study Even though this research takes the study on EMDR a step forward but it has its limitations. Being a qualitative study that only reviews the literature already available, the selection of literature can have its limitations. The inclusion criteria could have been too broad, and there could have been omission of some significant research made in the field. Since the study focuses on the recent developments of EMDR and hence the research was limited to studies beyond 2000, this could have also led to missing out on the researches before that could have proved more helpful. Further in such qualitative reviews there’s the problem that the study is marked by limitations of the parent studies. Despite the limitations, the study helps in collecting the latest information about EMDR and the developments that have been made since the idea was first brought by Shapiro. Implications for Practice, Policy and Research Following are the suggestions that I would like to give to the practitioners: As adolescents are a high risk group they should be checked for symptoms of PTSD. Continuous support of parents mean a lot to children and the clinicians should not just treat the symptoms through therapies but there is a need to connect with the patient on an emotional level. EMDR’s efficacy should be considered while opting for the best method of treating PTSD. The clinician should keep in mind individual’s personality, the type of traumatic experience, intensity of the trauma, family background of patient, and gender of the patient before choosing a therapy for the patient. EMDR has not been well researched and even in the meta-analytical studies I studied it was clear that studies about EMDR have not been conducted to the same extent as other studies for other psychotherapies (Gillies et al., 2012). However, the studies conducted do provide a positive review for EMDR. Hence it has been recommended that the clinicians should try to integrate EMDR completely or in part or in some particular period of the therapy to help the patient recover from the symptoms of PTSD (Field & Cottrell, 2011). The study will also be of help for further researches. The study pointed out that EMDR is efficacious in treatment of PTSD symptoms but there are questions that remain about whether a combination of therapy is required and if EMDR can be generalized as a method of therapy for all patients. Also there’s question about comparison of efficacy of CBT and EMDR, there are researches that indicate both have same efficacy while others suggest CBT is better. Hence in order to make EMDR a more acceptable method of intervention by therapists, more research is required. The research by Rothbaum et al (2005) indicate the significance of both qualitative and quantitative methods in such studies, hence I would also like to suggest that further researches about EMDR should take into account both methods to come up with a more holistic result. There have been researches that consider EMDR to be a ‘pseudoscience’ and ‘poorly understood’ but the results of the studies I have studied suggest otherwise (Fletcher, 1996; Herbert et al. 2000; Metter and Michelson, 1993). The researches I studied did not suggest that the efficacy of EMDR is in any ways less than other psychotherapies. There’s lack of high level research in the field and hence some of the discrepancies can be understood but that does not mean one should completely neglect EMDR as a method of treatment. There is inadequate information to help the utilization of EMDR in the medication of other psychiatric and behavioral issue including resentment, blame, fears, dissociative issue, dietary problems, and frenzy and anxiety issue other than PTSD (Healy, 2014, p.231). But some studies have suggested that associated depression and anxiety has been also reduced. Hence there’s also confusion in that aspect and should be researched further. I believe that EMDR has not been completely explored and further research about EMDR can help us in establishing a method of treatment that is suitable for post-traumatic stress disorder patients. REFERENCES 1. KORN, D. & LEEDS, A. (2002) Preliminary evidence of efficacy for EMDR Resource Development and Installation in the stabilization phase of treatment of complex post traumatic stress disorder. Journal of clinical psychology. 58(12), 1465-1487. 2. EDMOND, T., SLOAN, L., & McCARTY, D. 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