Pet/emdr

[DD214_DOC]

So I'm currently going through a seminar to learn PET. Briefly, we also discussed EMDR/CPT/SIT. All of this stuff seems like various iterations or repackaging of nothing more than systematic desensitization/habituation. I'm convinced that the specific eye movement stuff isn't even necessary for EMDR as any form of distraction would still serve the same purpose.

I'm curious, though, if anyone is aware of any studies that combine exposure therapy with pharmacotherapy that blocks the conditioned response to the conditioned stimulus? (Such as propanolol, prazosin, benzos, stellate block, etc.) It would make sense that doing this would reduce the amount of time it takes to habituate the CR and remove the negative reinforcement of avoidance but I'm not sure if it must happen, "naturally". I'm hearing at my training site of stellate blocks, "not working" or patients requiring a long duration of treatment, but the patients getting the blocks are also not being exposed to any triggers.

I'm also annoyed that people are taking very basic principles of behavioral psychology/learning theory and making it seem like some revolutionary treatment modality.

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[Therapist4Chnge]

EMDR is marketing, not therapy. When you can only really learn it (according to the EMDR experts) after taking a pricey course...it raises a big red flag. EMDR also lacks real research to support the 'eye movement' component. It is bizarre that some VAs actually support it.

 

[LM02]

You might find the literature on d-cycloserine and exposure therapy of interest. Here is a relevant meta-analysis.

http://www.sciencedirect.com/science/article/pii/S0006322308001066

 

[DD214_DOC]

You might find the literature on d-cycloserine and exposure therapy of interest. Here is a relevant meta-analysis.

http://www.sciencedirect.com/science/article/pii/S0006322308001066

Interesting. I will have to read more at the hospital when I have unlimited access to pubmed.

To the poster above, I agree -- EMDR is stupid. But, someone is making tons of money off of it. I'm going to manualize another therapy where you have a patient tap a pattern with his fingers and dub it, "FTDR". I'll be rich!

 

[billypilgrim37]

I once told a social worker who had just done the training that EMDR was "CBT with magic sprinkles". I have never received such a devastatingly hateful look from a social worker in my life.

The one thing I've learned about therapy education is that for many therapy educators, therapy is religion. You can really raise the ire when you ask a common sense question because it rubs against the politics of the therapy. I asked my DBT instructor once about why they make a big deal about using the word splitting in treatment team. Their rational is that when you say someone is splitting, you're saying they're being mean on purpose. I pointed out, no, when I say someone is splitting, I'm saying they're using an unconscious defense mechanism (and I did NOT say it in the smug tone I'm using here). I have never seen an educator get so angry so quickly in all of residency who basically spent the next minute telling me that I was an awful therapist who hates my patients and doesn't want to help them. It was kinda amazing. I told my psychodynamic supervisor about it, and I thought blood was going to be spilled. The whole thing was kinda awesome.

 

[canarycoalmine]

I'm annoyed, too, that some people trash a method of psychotherapy without really knowing anything about it. There is well-controlled research now proving EMDR's efficacy and it is considered one of the three treatments of choice for trauma (along with CBT and PE) by organizations such as ISTSS (International Society for the Study of Trauma and Dissociation), American Psychiatric Assoc, Amer Psychological Assoc, Dept of Veteran Affairs, Dept of Defense, Departments of Health in Northern Ireland, UK, Israel, the Netherlands, France, and other countries and organizations.

See Foa, E.B., Keane, T.M., Friedman, M.J., & Cohen, J.A. (2009). Effective treatments for PTSD: Practice Guidelines of the International Society for Traumatic Stress Studies New York: Guilford Press.
EMDR was listed as an effective and empirically supported treatment for PTSD, and was given an AHCPR “A” rating for adult PTSD. This guideline specifically rejected the findings of the previous Institute of Medicine report, which had stated that more research was needed to judge EMDR effective for adult PTSD.

EMDR contains many procedures and elements that contribute to treatment effects. While the methodology used in EMDR has been empirically validated in over 24 randomized studies of trauma victims, questions still remain regarding mechanism of action. However, since EMDR achieves clinical effects without the need for homework (unlike CBT), or the prolonged focus used in exposure therapies, attention has been paid to the possible neurobiological processes that might be evoked. Although the eye movements (and other dual attention stimulation) comprise only one procedural element, this element has come under greatest scrutiny. Randomized controlled studies evaluating mechanism of action of the eye movement component include an additional 24 studies that have demonstrated positive effects for the eye movement component.

As noted in the American Psychiatric Association Practice Guidelines (2004, p.18), in EMDR “traumatic material need not be verbalized; instead, patients are directed to think about their traumatic experiences without having to discuss them.” Given the reluctance of many combat veterans to divulge the details of their experience, this factor is relevant to willingness to initiate treatment, retention and therapeutic gains. It may be one of the factors responsible for the lower remission and higher dropout rate noted in this population when CBT techniques are used.

 

[billypilgrim37]

Just because it works doesn't mean it's not dumb and a bunch of blown up marketing. I can sell "dance like a chicken for an hour a day" as a weight loss technique, and it will work, but it's still stupid. We used to have one of the training folks in town that actually did a free training for the residents, and I'm convinced EMDR works and is valuable. But every time someone starts talking about why it works, they usually make everybody in the room just a little bit more stupid than they were before they walked in the room.

 

[SuperSoccer19]

Took courses in CPT, EMDR, and PE as a resident...did a few cases as a resident, no time as an attending, but I do supervise a few providers who do protocal therapies and here are some thoughts:

1. I cannot site articles on combining medication with therapy, but benzos and alcohol are contraindicated in all--especially PE and EMDR. No clear guidelines on the other medications you mention, but are discouraged. Part of the habituation/desensitization and the results are due to actually experiencing the anxiety--not numbing yourself to it. If you use a benzo it makes the therapy useless and is a form of avoidence. I've never tried it with a pt on benzos, but the alcohol abusers who I don't know are abusing seem to not get better--unclear if its substance induced or just leading to limited efficacy of the treatment. Would be interesting to incorperate one initially and then tapper it as the therapy progresses, but I had looked for literature on this in the past and found none.

2. I thought EMDR was a load of crap initially. I was told I had to go to the training, which was over a weekend that I had plans. However, we did it on each other and a lot of us were surprised that we actually did start to reprocess events in our life. Made me a believer. Not sure if I believe the science behind it, but in addition to the eye movements, the protocal allows for auditory ques and tapping in patients too. There are fMRI studies showing that the "trauma" changes brain region, but again, I don't know if I buy this.

3. Just my opinion, but I agree that all these therapies basically combine rudimentary psych concepts, but they have been studied more as a "protocal" then as separate steps. CPT is basically glorified CBT where you convince the patient he or she did nothing wrong and "stuck points" are more all-or-none cognitive distortions. PE you described above plus psychoeducation. EMDR I somewhat felt like I was doing CBT without using the term cognitive distortion, and various relaxation techniques.

 

[DD214_DOC]

Anyone adapting any of these techiques to decrease the number of required sessions? I'm in a busy outpatient clinic and simply do not have time in the schedule to do 10 PET sessions on more than a couple patients.

 

[Fastball32]

You might find the literature on d-cycloserine and exposure therapy of interest. Here is a relevant meta-analysis.

http://www.sciencedirect.com/science/article/pii/S0006322308001066

EMDR has always been controversial and most would think that it is the exposure part of the therapy that is doing most of the work, and not the neutral stimulus or eye movements.

Seromycin is an interesting thought. It is an old Tuberculosis medication with Glutamate enhancing properties. The theory of why it helps with therapy is that the CNS activation helps the patient form new memories when taken prior to the therapy session. We know Benzo's may worsen PTSD, so Glutamate helping is worth a shot.
Seromycin is increasingly gaining evidence for anxiety therapy, particularly Social Phobia and Panic Disorder.
There have been 2 RCT's that were published this summer, and both haven't been too impressive with PE for PTSD, however both articles are suggesting that it may help, particularly with severe forms of PTSD.

Seromycin being used as an adjunct to Anxiety therapy even made it to this year's PRITE exam!

 

[SuperSoccer19]

Anyone adapting any of these techiques to decrease the number of required sessions? I'm in a busy outpatient clinic and simply do not have time in the schedule to do 10 PET sessions on more than a couple patients.

Some patient's will show significant improvement in less then 10 sessions, but with experience it seems its often longer. Very often more traumas come up, etc. Moving too fast or starting with a higher SUDs can lead to patients discontinuing, since the treatment is anxiety provoking and uncomfortable. However, you can cut 90 minute sessions to 60 some times and there are also a lot of phone aps for PE that in the right patient might be able to eliminate session time. I've never tried that, but a lot of the protocal involves the patient doing work outside.

 

[DD214_DOC]

You might find the literature on d-cycloserine and exposure therapy of interest. Here is a relevant meta-analysis.

http://www.sciencedirect.com/science/article/pii/S0006322308001066

Some patient's will show significant improvement in less then 10 sessions, but with experience it seems its often longer. Very often more traumas come up, etc. Moving too fast or starting with a higher SUDs can lead to patients discontinuing, since the treatment is anxiety provoking and uncomfortable. However, you can cut 90 minute sessions to 60 some times and there are also a lot of phone aps for PE that in the right patient might be able to eliminate session time. I've never tried that, but a lot of the protocal involves the patient doing work outside.

Do you think with a high-functioning patient you can structure a treatment regimen with them to work on the outside, then they come in for brief sessions less frequently for the imaginal exposure?

 

[notdeadyet]

In fairness to EMDR (which sounds scary, and more than a little quacky), it has a lot more evidence behind it than some of the modalities that clinicians consider for PTSD.

 

[DD214_DOC]

In fairness to EMDR (which sounds scary, and more than a little quacky), it has a lot more evidence behind it than some of the modalities that clinicians consider for PTSD.

But the common thread of PET, EMDR, CPT, and SIT is exposure. If they all work equally well and all are different except for one specific thing (exposure), then common sense suggests that it's the exposure that is doing the work and nothing more.

I think the same is true with other therapies. When psychodynamic therapy was compared to CBT in various studies, the outcomes were not any different, despite both modalities being near opposites of each other. However, all modalities have one thing in common - the necessary and sufficient conditions and the therapeutic alliance. That's probably really all you need, and the technique of what you do is probably not that important. (Which Rogers basically stated). I have no idea what I'm doing in therapy, but all my patients seem to improve and really enjoy coming to their sessions. I think it's just because I'm likeable, easy to talk to, supportive and empathic. I provide psychoeducation, CBT, interpretations, etc., but I'm sure none of it really matters in the end.

 

[notdeadyet]

I have no idea what I'm doing in therapy, but all my patients seem to improve and really enjoy coming to their sessions. I think it's just because I'm likeable, easy to talk to, supportive and empathic. I provide psychoeducation, CBT, interpretations, etc., but I'm sure none of it really matters in the end.

So basically your technique plan as a physician is to be a swell guy? And post-military, why could 90% of your job not be done by a social worker or life coach?

 

[DD214_DOC]

So basically your technique plan as a physician is to be a swell guy? And post-military, why could 90% of your job not be done by a social worker or life coach?

Because 90% of my job is not therapy.

I'm not sure what you're trying to get at? You do realize that psychologists and social workers also do therapy, right? Psychologists also get much more training in therapy than we do.

You should refresh your memory with the necessary and sufficient conditions as postulated by Rogers. I have implemented different techiques with patients as well as no techique and have found little difference in the efficacy and outcomes thus far. My point is that the common thread amongst all of these, "equipotent and equally efficacious" therapies is the relationship between patient and therapist.

 

[notdeadyet]

You should refresh your memory with the necessary and sufficient conditions as postulated by Rogers. I have implemented different techiques with patients as well as no techique and have found little difference in the efficacy and outcomes thus far.

This is what I meant by the "swell guy" comment. If what you say here is right and no technique has the same efficacy and outcome as the rest of your psychotherapy modalities, the implication is that it's just lending an ear that is helping (or as you said it, being "likable, easy to talk to, supportive and empathetic"). And you don't need a psychiatrist (or psychologist or social worker or therapist) for this.

Sorry if I ruffled your feathers. That wasn't my intent. Personally, I question some of the efficacy of stuff, as some of the research people point to are studies that compare a form of psychotherapy with no psychotherapy. Unless you compare it to a control sham, I question the results. But I think believing that psychotherapy serves no purpose other than being a good listener might be throwing the baby out with the bathwater.

 

[DD214_DOC]

This is what I meant by the "swell guy" comment. If what you say here is right and no technique has the same efficacy and outcome as the rest of your psychotherapy modalities, the implication is that it's just lending an ear that is helping (or as you said it, being "likable, easy to talk to, supportive and empathetic"). And you don't need a psychiatrist (or psychologist or social worker or therapist) for this.

Sorry if I ruffled your feathers. That wasn't my intent. Personally, I question some of the efficacy of stuff, as some of the research people point to are studies that compare a form of psychotherapy with no psychotherapy. Unless you compare it to a control sham, I question the results. But I think believing that psychotherapy serves no purpose other than being a good listener might be throwing the baby out with the bathwater.

Well, I don't think it's possible to do, "no therapy" in a session, because the session and relationship themselves are therapeutic. I agree that we need some validated RCT comparing specific therapies to sham, made-up therapy and no therapy at all and see the prospective results. My guess is that the, "therapy" groups would all show very similar effect when compared to the control group.

A colleague did once tell me of a study where they read names from a phonebook to patients after some sort of standard session everyone received. The other group received some sort of manualized treatment after the standard supportive session. In the end, there was no significant difference between the phone book group and the other group. Unfortunately, I cannot recall the details or name of the study.

 

[AcronymAllergy]

Well, I don't think it's possible to do, "no therapy" in a session, because the session and relationship themselves are therapeutic. I agree that we need some validated RCT comparing specific therapies to sham, made-up therapy and no therapy at all and see the prospective results. My guess is that the, "therapy" groups would all show very similar effect when compared to the control group.

A colleague did once tell me of a study where they read names from a phonebook to patients after some sort of standard session everyone received. The other group received some sort of manualized treatment after the standard supportive session. In the end, there was no significant difference between the phone book group and the other group. Unfortunately, I cannot recall the details or name of the study.

The RCTs for many of the manualized treatments out nowadays (e.g., CBT for depression, PE and CPT for PTSD, ERP for OCD, exposure therapies for phobia) have generally compared the various therapies to "treatment as usual" (which is essentially what you've described--general supportive therapy that encompasses many of the common elements like empathy, unconditional positive regard, and just spending time with the patient) as well as to wait-list controls. In the end, manualized therapies produce better outcomes.

Part of the issue that comes into play is that if you're a genuinely nice guy/gal who readily establishes rapport with your patients, they're generally going to tell you that they feel better (which they might even believe themselves). However, if an uninvolved party comes in and asks them how therapy is going (either immediately afterward or further down the line), they might not report as much benefit, if any. They also might end up right back in supportive therapy with someone else soon after you've terminated, as they might be attending sessions simply for the social interaction alone (i.e., to have a "friend").