Is 3MDR a more effective treatment for combat veterans with Post Traumatic Stress Disorder than EMDR? Flashcards
STRUCTURE
1) what is PTSD?/complex PTSD?
2) what is EMDR
3) EMDR theory
4) EMDR not v effective
5) Problems with EMDR
6) 3MDR - what?
7) Sendentary EMDR
8) Lack of presence in EMDR
9) Early drop out in EMDR
10) comparison studies
11) Problems with 3MDR
1) what is PTSD?
- PTSD is a mental health problem that some people develop after experiencing or witnessing a life-threatening event, like combat, a natural disaster, a car accident, or sexual assault (victimisation). NOT ATTRIBUTABLE TO SUBSTANCE USE
- 4 main symptoms
a) reliving the event
b) increased arousal
c) Reduced responsiveness
d) avoidance
COMBAT PTSD
- More complex than PTSD in the general population due to the prolonged and repeated exposure of events
***These rates will vary though with the methodology, war looked at/the type of warfare used & time looked at BUT
- Among soldiers returning from Iraq and Afghanistan, rates range from point prevalence = 9% shortly after returning from deployment AND 31% a year after deployment. (Raleviski et al. 2014)
- Whereas in the general population = Current past year PTSD prevalence was estimated at 3.5%.
- 50% dont seek treatment
- Around 1/3 drop out of treatment (group had a higher rate than individual therapy) (Goetter et al. 2015)
2) what is EMDR
- Shapiro in 1980’s
- Alters the way these traumatic memories are stored; making them easier to manage and causing you less distress.
- basis premise of the therapy: to follow the therapists fingers from side to side & keep the memory in mind while doing following their fingers
3) EMDR theory REM + eval
REM account:
- Stickgold (2002) EMDR reduces PTSD symptoms by transforming emotionally charged autobiographical memories into a more generalized semantic form
- REM sleep known for memory consolidation
- They said that the Ems physiological profile fits well with the REM account, even though REM sleep does not have a well defined static autonomic profile
EVAL
a) there is a lack of phenomenological correspondence between the rhythmic eye movements induced by EMDR and the spontaneous, arrhythmic, non-saccadic eye movements that occur during REM sleep
b) Doesn’t account for why bilateral stimulation i.e. hand tapping works/ auditory tones
c) OR drawing a complex figure
d) OR why vertical eye movements also work
** may be dual attention that’s the crucial comp not EM’s**
3) EMDR theory WM + eval
Dual attention approach:
- EM + bilateral tapping + auditory tones
- performance is degraded when doing tasks that compete for the same WM resources
Maxfield et al. 2008
- bringing the memory into consciousness and the eye movements = both use the VSSP –> WM is taxed
- When someone engages in EM while simultaneously focusing on a memory image (I.E. their WM is taxed) the quality of that image deteriorates; it becomes less vivid and less emotional (the saem way it degrades performance)
EVAL
- some say that it might be the therapists’ instructions given to the individual to rouse the memory may be causing the effects of EMDR (i.e. before any eye movement) (Lee et al. 2006)
- ** Another study was carried out without Ems but the same therapist instructions: the therapists’ instructions had no effect on the outcome, EM was found to result in a significant reduction in distress at the end of the session and at 1 week followup. There was no decrease in vividness for the No-EM conditions (Lee & Drummond, 2008)
- memories are not only blurred during the eye movements (e.g., Kavanagh et al., 2001), but also during recollections immediately after the eye movements session + one week later
WHY DOES DEGRADING THE MEMORY WORK IN PTSD?
1) Helps to shift beliefs about the dangerousness of experiencing painful memories and associated affect, which may enable reprocessing to occur (Gunter & Bodner, 2008)
2) reduce salience & let it be incorporated with episodic memories
EMDR and not v effective
- It is effective for PTSD generally (i.e. for sexual assault victims) BUT maybe not as clear for PTSD vets
- Albright & Thyer (2010) The evidence supporting the use of EMDR to treat combat veterans suffering from PTSD is ambiguous
- The finding that studies including only Vietnam veterans produced worse responses to EMDR (compared with other samples) suggests that Vietnam veterans are a particularly difficult population to treat (Bisson et al. 2007)
- Church et al. 2017 – only 10% of practitioners found the most beneficial in practice
Problems with EMDR
- Sedentary
- Lack of presence
- Not going in the first place due to avoidance
3MDR - what?
1) This treatment incorporated self-selected photographs and music, treadmill walking, and known therapeutic elements from Virtual Reality Exposure therapy and EMDR.
2) Walking on a treadmill through virtual reality tunnels & opening doors and seeing images of their trauma
3) Red ball = bilateral stimulation the whole time; working memory is taxed.
Sedentary
- “not only does it challenge WM more during dual tasks
- Walking on a treadmill is not sedentary – which a lot of combat vets find hard with EMDR; “restless energy”
a) Restless leg syndrome: often comorbid with PTSD (Talbot et al. 2018) military mental health guide - Increases presence (Bernhard et al. 2015) = sense of ‘being there’
Lack of presence
- some people (combat vets) have difficulty imagining/immersing themselves in the traumatic event (due to avoidance) (Botella et al. 2015)
- this will affect their sense of “being there” (presence) - presence contributes to the amount of anxiety felt during exposure…
& thus have difficulty emotionally engaging w the memory –> more drop out (ref the %) (Foa et al. 2013)
- emotional engagement is necessary for good treatment outcomes (Jaycox et al. 1997)
^^ DOES DEP ON THE EMOTION
a) most studies have used the SUD (subjective units of distress) scale to look @ emotional engagement & this measures fear/anxiety and discomfort. It seems this is related to effective outcomes.
BUT
b) PTSD veterans & anger. Anger can prevent activation of the fear structure (Adolphs, 2013) –> & thus affect ex therapy which relies on anxiety
**pretreatment anger = worse outcomes from exposure therapy (Foa 1995) & more drop out (Rizvi, 2009)
SOOOO
- VR good for emotional engagement &; eliminates a barrier for those who have difficulty with imagining or visualising. MAKES PEOPLE FEEL THEYRE ACTUALLY IN THE ENVIRONMENT (presence)
- Multimodal stimuli (smell, sound etc) all contribute to presence (González-Franco et al., 2010)
Presence –> Emotional engagement –> good outcomes bc they feel like it’s real**
Not going in the first place
- Due to cognitive avoidance
- Been likened to phobias who have a serious avoidance of a specific thing; many link the two (Ressler, 2018)
a) In a big sample of people with specific phobias the refusal rate for VR was much lower than for other Tx (Botella et al. 2007)
b) This has also been found in PTSD veterans with an increased satisfaction for VRE. EG In a sample of 352 post-9/11 US soldiers, the majority reported that they would be willing to use most of the technology-based approaches for mental health care included in the survey (e.g., VR). ALSO found that 20% of those who wouldn’t talk to a counsellor would use an alternative VR approach = addresses some barriers to treatment
(Wilson, 2008)
EMDR vs 3MDr comparison studies
Jetley (2017)
- Eight CAF members with cr-PTSD volunteered to participate in this study//chronic cr-PTSD (symptoms > 3 months) who were non-responders to at least one type of trauma-focused psychotherapy (EMDR) Overall, participants demonstrated modest gains, which were expected since study participants had chronic symptoms of PTSD, and had tried and failed conventional therapy.
- Depression, anger, and substance abuse do not appear to be adversely affected by the VR treatment, as has sometimes been the case with exposure therapy for Vietnam veterans (i.e. other complications can come up from it) (Pitman et al., 1991) – VR exposure therapy + PTSD study (Rothbaum et a. 1991)
- ^ good bc anger has been implicated as an impediment to successful emotional processing (Foa & Kozak, 1986)
Problems with 3MDR
- Lack of RCT involving complex trauma and 3MDR – this may lead to a overestimation of effect sizes (Shultz, 1995) – still somewhat ambigious (even for EMDR) – need more in the field.
- Fredman (2014) suggested that the effects of Tx are mediated somewhat by social support network, If not including this network then might be going home to stressful household.
- ALSO common for PTSD vets to get divorced/ relationship problems/caregiver burden
