Derek Rutter Wake Forest University

Derek Rutter Wake Forest University

According to a 2008 Department of Veterans Affairs (VA) study cited by Albright and Thyer (2009), from 2002 until January of 2008, the VA diagnosed 40% of OEF (Operation Enduring Freedom) and OIF (Operation Iraqi Freedom) veterans with possible mental health disorders. This number includes 60,000 veterans diagnosed with possible post-traumatic stress disorder (PTSD). By the fourth quarter of 2008, a follow-up report revealed that those numbers had grown to 44.6% of veterans with possible mental health diagnoses and 62,998 veterans with possible PTSD (Department of Veteran Affairs, 2009) This is an increase of nearly three thousand possible PTSD diagnoses in only ten months.

PTSD is defined by the DSM-IV-TR (2000) as the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury (American Psychiatric Association, p. 463) Characteristic symptoms of PTSD include intense fear, helplessness, or horror re-experiencing of the traumatic event, persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness, and persistent symptoms of increased arousal (American Psychiatric Association, 2000, p. 463). EMDR is an eight-phase psychotherapy that targets maladaptive information processing resulting from negative experiences. EMDR works on memories associated with negative experiences that have not been properly processed, so as to integrate them into greater memory and processing networks (Shapiro, 2001)

Searches were conducted through the Z. Smith Reynolds Library website as well as through Google Scholar. Research was limited to peer-reviewed journal articles and one book through Interlibrary Loan. Key words and phrases included post-combat PTSD and EMDR, post-war PTSD and EMDR, veteran PTSD and EMDR, and post-deployment PTSD and EMDR. The reference lists of pertinent articles that were discovered in early searches where examined for references not revealed through database searches. Google Scholar hits and reference list items were cross-referenced through Z.S.R. Library website.

7 case studies were examined, as well as one metaanalysis and two follow-up studies. These were chosen as they constitute the bulk of relevant research conducted since 2000. In a multiple case study utilizing EMDR, Russell (2006) offers a detailed account of administering EMDR treatment to four United States soldiers wounded in Iraq at the evacuation hospital in Rota, Spain. Impact of Events Scale (IES) and the Subjective Units of Disturbance Scale (SUDS) were also used to measure pretreatment and post-treatment symptoms and disturbance. All patients received one session of EMDR, as well as a follow-up visit to assess for future treatment. The observation that all four patients suffering from either ACD or acute PTSD could receive substantial benefit after one EMDR session indicates a potentially important addition to standard treatment for frontline personnel (Russell, 2006, p. 12).

In another case-study that focuses on early intervention with EMDR RE (a variation of EMDR protocol designed for the treatment of recent events), Wesson and Gould (2009) describe treating, John, a 27-yearold active-duty U.K. soldier while in theater. John completed four self-report questionnaires at pretreatment, post-treatment, and 18-month follow-up: the PTSD Checklist-Civilian Version (PCL-C), the Impact of Event Scale-Revised (IES-R), the Hospital Anxiety and Depression Scale (HADS), and the Beck Depression Inventory (DBI). John also rated his anxiety using the SUDS. John received four sessions of EMDR after which he reported a dramatic reduction is symptoms. These results remained consistent or improved at follow-up. In a 2008 study conducted by Silver, Rogers, and Russell, two case-studies involving the use of EMDR on post-combat veterans are investigated.

The first case involved a 22-year-old, George, who had completed two tours in Iraq and was honorably discharged after a suicide attempt. Over the course of four sessions all disturbing memories were addressed. At a 3-month follow-up George reported that he no longer experienced disturbances regarding the targeted memories. The second case involved a 73-year-old Vietnam veteran, Bob, who suffered from a number of aliments including myoclonic movements and PTSD. After two sessions of EMDR, Bob reported that his myoclonic movements and all other symptoms had ceased, which remained consistent at 1-month and 6-month follow-ups. The final case-study examined in this review is that of Russell (2008b), in which EMDR treatment was used to address combat-related PTSD with medically unexplained symptoms (MUS).

This case focused on Jerry, a 40-year-old master gunnery sergeant who served 19 years of active-duty and completed two tours in Iraq. Over the course of five sessions, all of Jerry s symptoms psychological, emotional, and physical greatly reduced. In a meta-analysis conducted by Albright and Thyer (2010), six experimental and three quasi-experimental studies were summarized and examined. The results of this meta-analysis suggest that limited evidence was discovered in support the use of EMDR in the treatment of post-combat PTSD. Macklin, Metzger, Lasko, Berry, Orr, and Pittman (2000) conducted a five-year follow-up study examining the results of 13 Vietnam combat veterans with chronic PTSD who had previously received EMDR treatment. In a separate follow-up study conducted by Zimmerman, Biesold, Barre, and Lanczik (2007), 89 German soldiers who received in-patient treatment for PTSD between 1998 and 2003 were retrospectively evaluated.

EMDR seems particularly well-suited for treating PTSD in combat soldiers and veterans for a number of reasons: 1. the immediacy of results 2. the lack of necessary self-disclosure during treatment 3. the lack of homework 4. the ability to be used in a variety of settings, including in-theater 5. the application to recent and distant-past trauma 6. the application to single and multiple-trauma disturbances (Department of Veterans Affairs and Department of Defense, 2010; Russell, 2006; Wesson & Gould, 2009).

While the case-studies examined in this review predominantly demonstrate the efficacy of EMDR, generalizability cannot be assumed from these studies alone. There is a lack of consistency regarding evaluative inventories and treatment protocol.

Future research comparing EMDR treatments of Vietnam veterans to veterans of more recent conflicts may offer valuable insight into populations best served by EMDR. The work of Russell (2006) points out a need for future investigation into the variable of time and type of trauma in regards to combat PTSD as treated by EMDR. As Wesson and Gould (2009) illustrate, EMDR has potential for successful use within a variety of venues, including in theater, and future research may benefit from comparing the success of different therapeutic contexts. Shapiro (2009) notes that except for a one one-session process analysis, there have been no randomized studies directly comparing EMDR and CBT treatments with U.S. combat veterans (p. 226). Shapiro (2009) also states that few studies conducted have used the standard number of EMDR treatments dictated by protocol.

Albright, D. L., & Thyer, B. (2010). Does EMDR reduce post-traumatic stress disorder symptomatology in combat veterans? Behavioral Interventions, 25(1), 1 19. American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders (4 th ed., Text Revision). Washington, DC: Author. Department of Veterans Affairs. (2009). VHA office of public health and environmental hazards, analysis of VA health care utilization among US global war on terrorism (GWOT) veterans: Operation Enduring freedom, Operation Iraqi Freedom, January 2009. Retrieved from http://www.networkofcare.org/library/gwot_4th%20qtr%20fy08%20hcu.pdf Department of Veterans Affairs and Department of Defense. (2010). VA/DoD clinical practice guideline for the management of post-traumatic stress. Version 1.0. Washington, DC: Department of Veterans Affairs and Department of Defense. Retrieved from http://www.healthquality.va.gov/ptsd/ptsd_full.pdf Luber, M., & Shapiro, F. (2009). Interview with Francine Shapiro: Historical overview, present issues, and future directions of EMDR. Journal of EMDR Practice & Research, 3(4), 217 231. doi:10.1891/1933-3196.3.4.217 Macklin, M. L., Metzger, L. J., Lasko, N. B., Berry, N. J., Orr, S. P., & Pitman, R. K. (2000). Five-year follow-up study of eye movement desensitization and reprocessing therapy for combat-related posttraumatic stress disorder. Comprehensive Psychiatry, 41(1), 24 27. doi:10.1016/s0010-440x(00)90127-5 Russell, M. C. (2006). Treating combat-related stress disorders: A multiple case study utilizing eye movement desensitization and reprocessing (EMDR) with battlefield casualties from the Iraqi war. Military Psychology, 18(1), 1 18. doi:10.1207/s15327876mp1801_1 Russell, M. C. (2008b). War-related medically unexplained symptoms, prevalence, and treatment: Utilizing EMDR within the armed services. Journal of EMDR Practice & Research, 2(3), 212 225. doi:10.1891/1933-3196.2.3.212 Shapiro, F. (2001). Eye movement desensitization and reprocessing : basic principles, protocols, and procedures (2nd ed.). New York, NY: Guilford Press. Silver, S. M., Rogers, S., & Russell, M. (2008). Eye movement desensitization and reprocessing (EMDR) in the treatment of war veterans. Journal of clinical psychology, 64(8), 947 957. doi:10.1002/jclp.20510 Wesson, M., & Gould, M. (2009). Intervening early with EMDR on military operations. Journal of EMDR Practice & Research, 3(2), 91 97. doi:10.1891/1933-3196.3.2.91 Zimmermann, P., Biesold, K. H., Barre, K., & Lanczik, M. (2007). Long-term course of post-traumatic stress disorder (PTSD) in German soldiers: Effects of inpatient eye movement desensitization and reprocessing therapy and specific trauma characteristics in patients with non-combat-related PTSD. Military medicine, 172(5), 456 460.