EMDR for Combat PTSD 1

EMDR for Combat PTSD

Daniel R. Gaita, MA, MSWi

April 17, 2017

Abstract

Since the onset the US led wars in Iraq and Afghanistan in response to the terrorist

attacks of September 11th, 2001, rates of combat related Post Traumatic Stress Disorder

(PTSD) have escalated. This observation has led to an ongoing national multi-billion dollar

investment into research and treatment covering a wide range of evidenced based interventions

(EBIs). One such EBI gaining popularity is Eye Movement Desensitization and Repossessing

(EMDR). Despite its initially slow acceptance by mental health professionals and veterans

agencies, EMDR is providing results that are either equal to or far greater than previously

popular modalities. This work presents an analysis of EMDR for PTSD, allowing for greater

understanding of the treatment, why it works, and the challenges and successes of its

implementation with respect to micro, mezzo and macro factors.

Keywords: Eye Movement Desensitization and Reprocessing, EMDR, Combat, PTSD

EMDR for Combat PTSD 2

EMDR for Combat PTSD

Background

America has engaged in her longest consistent period of war, while doing so on multiple

battlefronts and with diminishing funding and resources following the economic collapse of

2008. Since then our service men and women have endured repeated and long duration exposure

to combat trauma coupled with depleted resources (Eckardt, 2017; Venable, 2016; Gertz, 2015)

that would normally enable active duty service members to effectively process those traumas.

As a result weve witnessed a spike in the number of combat veterans experiencing PTSD (VA,

2016; Kemp & Bossarte, 2012).

The research connecting combat to development of PTSD is widely available (McClean

& Foa, 2011; Nacasch, Hupport, Tzur et al., 2011; Tuerk, Yoder, Grubaugh et al., 2011; Yarvis,

2011). The environment contained in combat operations provides the armed forces member with

many opportunities to experience and witness traumatic events that when left unresolved or not

processed effectively can manifest into the many outcomes symptomatic of PTSD. Specifically,

desperation, hopelessness, depression, deeply rooted anxiety, guilt, or shame (Kaplan & Tolin,

2011), isolation, hypervigilence, recklessness, disturbances with sleep, problems with

concentration, dissociation and avoidance which commonly lead to substance use and or abuse

(APA, 2013).

PTSD

As the area of PTSD has gained attention and funding for research, modifications from

the DSM-IV now appear in the DSM V. Rather than discuss the variations in diagnosis from IV
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to V, this work provides the direct text as appearing in the DSM-5.

DSM-V PTSD Specifics

Whereas PTSD is identified as a trauma and stressor related disorder with a diagnostic

code of 309.81, (F43.10) (APA, 2013):

A. Diagnostic Features- Applies to adults, adolescents, and children older than 6

a. Exposure to actual or threatened death, serious injury, or sexual violence, in

one (or more) or the following:

i. Directly experiencing traumatic event(s)

ii. Witnessing, in person, the event(s) as it occurred to others

iii. Learning the traumatic event(s) occurred to a close family member or

close friend. In cases of actual or threatened death of a family

member or friend, the event(s) must have been violent or accidental

iv. Experiencing repeated or extreme exposure to aversive details of the

traumatic event(s) (Does not apply to exposure through electronic

media, television, movies, or pictures, unless this exposure is work

related)

b. Presence of one (or more) of the following intrusion symptoms associated

with the traumatic event(s), beginning after the traumatic event(s) occurred:

i. Recurrent, involuntary, and intrusive distressing memories of the

traumatic event(s)
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ii. Recurrent distressing dreams in which the content and/or affect of the

dream are related to the traumatic event(s)

iii. Dissociative reactions (flashbacks) in which the individual feels or

acts as if the traumatic event(s) were recurring.

iv. Intense or prolonged psychological distress at exposure to internal or

external cues that symbolize or resemble an aspect of the traumatic

event(s)

v. Marked physiological reactions to internal or external cues that

symbolize or resemble as aspect of the traumatic event(s)

c. Persistent avoidance of stimuli associated with the traumatic event(s),

beginning after the traumatic event(s) occurred, as evidenced by one or both

of the following:

i. Avoidance of or efforts to avoid distressing memories, thoughts, or

feelings about or closely associated with the traumatic event(s)

ii. Avoidance of or efforts to avoid external reminders (people, places,

conversations, activities, objects, situations) that arouse distressing

memories, thoughts, or feelings about or closely associated with the

traumatic event(s)

d. Negative alterations in cognitions and mood associated with the traumatic

event(s), beginning or worsening after the traumatic event(s) occurred, as

evidenced by two (or more) of the following:

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i. Inability to remember an important aspect of the traumatic event(s)

ii. Persistent and exaggetated negative beliefs or expectations about

oneself, others, or the world

iii. Persistent, distorted cognitions about the cause or consequences of

the traumatic event(s) that lead the individual to blame

himself/herself or others

iv. Persistent negative emotional state

v. Markedly diminished interest or participation in significant activities

vi. Feelings of detachment or estrangement from others

vii. Persistent inability to experience positive emotions

e. Marked alterations in arousal and reactivity associated with the traumatic

event(s), beginning or worsening after the traumatic event(s) occurred, as

evidenced by two (or more) of the following:

i. Irritable behavior and angry outbursts typically expressed as verbal or

physical aggression toward people or objects

ii. Reckless or self-destructive behavior

iii. Hypervigilance

iv. Exaggerated startle response

v. Problems with concentration

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vi. Sleep disturbance

f. Duration of the disturbance (b, c, d, e) is more than 1 month

g. The disturbance causes clinically significant distress or impairment in social,

occupational, or other important areas of function

h. The disturbance is not attributable to the physiological effects of a substance

or another medical condition

Specify if: With dissociative symptoms.

In addition to meeting criteria for diagnosis, an individual experiences high levels

of either of the following in reaction to trauma-related stimuli:

1.Depersonalization: experience of being an outside observer of or detached from

oneself (e.g., feeling as if "this is not happening to me" or one were in a dream).

2.Derealization: experience of unreality, distance, or distortion (e.g.,

"things are not real").

Specify if: With delayed expression.

Full diagnosis is not met until at least six months after the trauma(s), although onset

of symptoms may occur immediately (APA, 2013).

Biological/Neurobiological

PTSD is correlated with structural deficits in brain development via reductions in

amygdala and hippocampal volume due to reduction in size, impacting memory and well being,

as well as problems with affect regulation and cognitive processing (Cozolino, 2010). Such

structural malformations also lead to ineffective processing of psychological responses via the
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interruption of normal modulation, while amplifying stress related anxiety (Badenoch, 2008).

Research typically credits this structural phenomenon to the impact caused by excess and

long duration release and processing of the neurochemical, cortisol, which gets released during

stressful events and in higher amounts during traumatic periods of high stress (Applegate &

Shipiro, 2005). The result can be the weakening of the immune system via the prevention of T-

cell proliferation and disruption of protein synthesis, which halts neural growth, and actually

kills neural circuits. (Cozolino, 2010). Ironically, this is also correlated with why those with

PTSD also exhibit dissociation from social engagement, emotional blunting, depersonalization

and derealization (Badenoch, 2008; Solomon & Siegal, 2003).

Prevalence of PTSD

Recent study data has provided a greater understanding of PTSD prevalence across broad

population variations.

Nationally. The National Comorbidity Survey Replication (NCS-R), conducted between

February 2001 and April 2003, estimated an approximate 7% prevalence of PTSD amongst

Americans aged 18 years and older (Kessler, Berglund, Delmer et al., 2005; Kessler, Chiu,

Demier et al., 2005; NCS, 2005). These findings nearly replicate earlier studies (Kessler,

Sonnerga, Bromet et al., 1995) Adolescent rates were about half (Kilpatrick, Ruggiero, Acierno

et al. 2003).

Veterans. Prevalence of PTSD varies slightly across conflicts. However rates overall

tend to be about double the civilian population. Vietnam veterans have a rate of about 15%

(Kulka, Schlenger, Fairbanks et al., 1990); Gulf War veterans 12% (Kang, Natelson, Mahan et

al., 2003); Iraq and Afghanistan (OIF/OEF) veterans about 14% (Tanielian & Jaycox, 2008; VA,

2017,1).
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Assessment for PTSD

Ideally, upon or prior to initial meeting, all participants shall be or have been assessed

for prevalence and severity of PTSD symptoms through self-reporting on the military version

of the standard PTSD checklist (PCL-M) or by way of the Clinician Administered PTSD

Scale (CAPS)

CAPS. The Clinician Administered PTSD Scale (CAPS) serves as the standard in the

evaluation of treatment efficacy and determination of a diagnosis of PTSD. The CAPS is a 30-

item scale, measures the existence and intensity of 17 symptoms, and is completed by a mental

health professional interviewing the subject (Blake, Weathers, Nagy et al., 1995). Severity scores

of 0-19 = asymptomatic/few symptoms, 20-39 = mild PTSD/sub threshold, 40-59 = moderate

PTSD/threshold, 60-79 = severe PTSD symptomatology, and > 80 = extreme PTSD

symptomatology," (Weathers, Keane, & Davidson, 2011). When utilized to determine treatment

efficacy, a decrease or increase in CAPS scores ranging from 10 to 15 have been recommended

or used as interpretations of clinical significance (Weathers et al, 2011; Ready, Thomas, Worley,

Backscheider, Harvey, Baltzell, & Rothbaum, 2008).

PCL-M. The PTSD Checklist is a much shorter and less intrusive with only 17

questions. Additionally, its self-administered and demonstrates reliability with relation to

CAPS diagnoses (Weathers, Litz, Herman, Huska, & Keane, 1993; Weathers et al., 2011).

EMDR

Eye Movement Desensitization and Reprocessing is a dynamic, integrative approach

which brings together an alchemy of psychodynamic, cognitive behavioral, person-centered,

and body-based therapies in structured procedures and protocols which take place over eight

phases and incorporate past, present and future aspects of the clients presenting problem
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(Solomon & Siegel, 2003). Another often preferred aspect of EMDR that differs from previous

cognitive processing therapy models is that the client is not required to fully engage in the

verbal reliving of the traumatic episode(s) (Van der Kolk, 2002).

Since its inception, the name has created confusion. To simplify this title, conceptualize

EMDR as a more dynamic form of reprocessing therapy, or EMDR as Emotional and Mental

Development and Reorganization (Solomon & Siegel, 2003). EMDR utilizes the Adaptive

Information Processing model (AIP), which posits that memory is associated with experiences,

thus learning occurs through the creation of new associations by way of cognitive reprocessing.

While similar in context, to CBTs Cognitive Processing Therapy, EMDR differs in

application. While both CBT and EMDR allows one to target and connect unprocessed traumatic

memories to the more adaptive information located in other memory networks and thus reprocess

the memory to result in a reduction of symptoms, EMDR accomplishes this objective with

different treatment mechanics which work on a more subconscious level (Solomon & Siegel,

2003; Van der Kolk, 2002; Van der Kolk, 2003).

Frequency & Duration

EMDR typically occurs along a two-three month treatment period with the client meeting

weekly for 50-90 minute sessions (VA, 2017, 2).

Evaluation of Efficacy

A broad range of research on EMDR (Solomon & Siegel, 2003; Van der Kolk, 2002; Van

der Kolk, 2003) has resulted in promising findings specific to treatment efficacy across a broad

range of trauma related diagnosis. Several studies have reported 77-90% remission of PTSD in

single-trauma victims in as few as five hours of treatment of EMDR (Solomon & Siegel, 2003,

pg. 197).
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Seventeen previous studies covered in a recent critical review showed strong efficacy for

Cognitive Processing Therapy (CPT) when compared with Exposure Therapy, Present Centered

Therapy, Skill Building, Focused Cognitive Behavioral Therapy (CBT), and Multimodal

Therapy (Dworkin, 2011). Surprisingly, EMDR was not included in those comparisons, but has

been since by the VA.

VA Studies. Following an evaluation of clinician administered PTSD Scale (CAPS)

scores, pre and post treatment, (EMDR), demonstrated a 53% rate of success in resolving PTSD

symptoms, which was equally as effective as both Cognitive Behavioral Therapy (CBT)

modalities of Cognitive Processing Therapy (CPT), and Prolonged Exposure Therapy (PE).

Additionally, EMDR demonstrated greater efficacy than Stress Inoculation Training

(SIT), which has a success rate of 20%. Furthermore, EMDR appears to outperform the

commonly prescribed Selective Serotonin Reuptake Inhibitors (SSRI) and Serotonin-

Norepinephrine Reuptake Inhibitors (SNRI) which demonstrate a 42% success rate (VA, 2017

,2).

For a full breakdown and delineation of principals, protocols, and procedures see Shapiro

(2001).

Phases of Treatment - Eight-Phase Approach

Phase 1.

history taking, evaluation, and treatment planning. This phase, while similar to

traditional psychotherapy, also works to identify key life events for further targeting and

processing. While additionally considering present situations interfering with adaptive functions

causing distress(Shapiro, 2001; Solomon & Siegel, 2003; Van der Kolk, 2002; Van der Kolk,

2003). Whereas other treatment modalities fixate on the here-and-now environment to work
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through reforming cognitive maladaptations, EMDR takes a more holistic approach inclusive of

the myriad of biopsychosocial factors impacting the clients psyche.

Phase II.

preparation. Herein, the client is educated and prepared for possible symptoms of

treatment and provided some levels of progress expectation while establishing a therapeutic

alliance with the mental health practitioner (Solomon & Siegel, 2003).

Phase III-VI

processing. Phases three-through six involve processing distressing memories, and

present triggers in an effort to mobilize the information and facilitate connections with other

adaptive information. The goal of each phase is to mobilize the materiel and facilitate its linkage

with other adaptive information (Shapiro, 2001).

Phase VII.

closure. This phase provides feedback via an evaluation of processing along with self-

calming interventions from phase two. Additionally, the client monitors intersession responses

using a log while also implementing self-control techniques (Shapiro, 2001).

Phase VIII.

reevaluation. Herein evaluation of previous work is conducted at the beginning of each

session. Throughout this phase, various EMDR protocols are utilized to address specific clinical

complaints (Shapiro, 2001).

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Barriers to Treatment

Apparent disconnects between effective evidence based interventions and combat

veterans that are ambivalent, reluctant, or resistant to utilize them is not simply due to the

perceived stigma associated with seeking mental health services. It is also a component of access

or lack thereof due to availability of resources and status of service members discharge from

military service.

Access to Resources

Veterans that have earned an Honorable discharge and served during a combat period can

access the wide array of available VA services and programs such as education, disability

compensation, medical and mental health services. Conversely, those that have not served their

full term of duty due to disciplinary action and premature discharge under less than honorable

conditions are effectively locked out of the resource loop.

Discharge Status. Up until recently, the status of discharge of an armed forces veteran

had not been a matter of either comprehension or concern. However, recent data demonstrates

that 70% of suicides are committed by veterans that never used the VA (Kemp and Bossarte,

2012; VA, 2016; Thompson 2016). Furthermore, the highest risk factor for veteran suicide is

amongst the veteran population that has been discharge under less than honorable circumstances

(Reger, Smolenski, skopp et al., 2015).

Many in this population have been discharged due to the behavioral outcomes resulting

from mental health problems (PTSD) that were neither properly diagnosed nor treated while the

service member was still actively serving. Worse, upon discharge, they are no longer eligible for

VA services or mental health care.

Availability. Lack of proper funding has had negative impacts on access to treatment and
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resources. Impacts from the 2008 economic collapse had long lasting deteriorating effects across

the VA and Department of Defense. (Eckardt, 2017; Venable, 2016; Gertz, 2015) As evidenced

by the spike in veteran suicides following 2008 despite previously lowering rates of suicide

between 1999-2007 (Kemp and Bossarte, 2012; VA, 2016). In addition, drastic budget cuts

resulted in outdated processes, understaffed and underfunded DOD and VA systems, which were

unable to handle the demand, and were not equipped to adequately address the surge in need for

mental health services. (Garske, 2011; Jaeger, Echiverri, Zoellner, Post, & Feeny, 2009; Hoge,

Terhakopian, Castro, Messer, & Engel, 2007).

Thankfully, leading up to and since the release of the 2012 VA suicide report (Kemp and

Bossarte, 2012) billions of dollars have poured into VA and DOD programs for services,

research, and outreach (Thompson, 2016; Garske, 2011; Gros et al., 2011). Mental health

professionals specializing in combat related trauma are now available in combat areas

implementing preventative measures, screenings and treatment following combat-related events

thus working to prevent these issues from becoming chronic (Gros et al., 2011; Garske, 2011).

Cost. Unfortunately, EMDR is not widely available through VA facilities (VA, 2017, 2)

thus veterans are required to pay out of pocket cost for the treatment which, in most cases, is a

primary deterrent.

Combat Masculine Warrior Paradigm

The term Combat Masculine Warrior Paradigm (Dunvin, 1997) articulates our social and

cultural model of the combat fighter as one whose core activity is the preparation for and conduct

of war. The social and cultural ideal of a combat veteran swirls around the expectation of traits of

courage and strength. Such constructs are historically in conflict with the thought of seeking

help. Moreover, mental health treatment requires self-reporting. However, mission readiness and
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peer pressure often result in underreporting symptoms (Hoge et al., 2007). Consciously, the

combat veteran may be aware that he needs treatment, but other factors tend to permeate.

Internal Bias. Our unconscious and conscious tendencies are often times unreasoned

opinions and prejudices about other social groups or individuals based formed via life

experiences (Robbins, Chatterjee & Canda, 2011). Based on their training alone its obvious that

combat veterans have a drastically counterintuitive internal bias toward mental health treatment.

The concept is subconsciously contradictory to the established norms of the warrior mentality.

Transference. Of additional consideration and having similar effects as internal bias is

the subconscious phenomenon of transference, representing our unconscious tendency to project

onto others both feelings and attitudes that were formed early on in life or even later on in life

through traumatic episodes such as combat (Robbins et al., 2011).

Cognitive Dissonance. Also compounding the masculine warrior paradigm is our

internal attitudes and beliefs, which are continually shaped and formed throughout the life cycle

creating cognitive dissonance. The thought of therapy creates conflict because it is not consistent

with the combat veterans indoctrinated beliefs. The result is commonly irrational and sometimes

maladaptive behavior due to an internal clash, which creates unpleasant tension (Festinger,

1957).

Conclusion

With a prevalence rate double the civilian population, combat veterans will benefit from

the growing popularity and acceptance of EMDR as an evidence based best practice in the

treatment of PTSD. Primary barriers that are of greatest concern will rely upon legislative and

institutional actions at the macro and mezzo levels in order to open access to both availability

and eligibility of EMDR utilization by combat veterans.

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Furthermore, emphasis on training and certification in EMDR modalities can foster

solutions to both affordability and accessibility. It would seem that EMDR, while in its

receptive infancy stage, may very well be an area where military and family mental health

social work practitioners find exciting opportunities for growth and professional development.

Simultaneously, EMDR appears set to offer our combat veterans an improved quality of life

through relief of the myriad of symptom that accompany PTSD.

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