Eye Movement Desensitization and Reprocessing (EMDR) Therapy

Number: 0583

Policy

  1. Aetna considers eye movement desensitization and reprocessing (EMDR) therapy medically necessary for the treatment of post-traumatic stress disorder (PTSD).

  2. Aetna considers EMDR therapy experimental and investigational for all other indications (including those listed below) because its effectiveness for indications other than PTSD has not been established:

    • Prevention of PTSD
    • Treatment of addiction
    • Treatment of chronic pain including chronic back pain and chronic phantom limb pain 
    • Treatment of methotrexate intolerance
    • Treatment of panic and anxiety disorders including generalized anxiety disorder, panic disorder, dental phobia and social phobia (other than PTSD)
    • Treatment of post-operative pain
    • Treatment of other psychiatric and behavioral disorders (e.g., anger, bipolar disorder, de-personalization de-realization disorder, depression, dissociative disorders, eating disorders, guilt, obsessive-compulsive disorder, phobias, psychogenic non-epileptic seizures, psychotic disorders, and somatoform disorders (also known as somatic symptom disorders and somatization disorders))
    • Treatment of substance use disorders.

Background

Eye movement desensitization and reprocessing (EMDR) therapy is a complex method of psychotherapy that combines a range of therapeutic approaches with eye movements or other forms of rhythmical stimulation (e.g., sound and touch) in ways that stimulate the brain's information processing system.  Eye movement desensitization and reprocessing was introduced in 1989 as a treatment for post-traumatic stress disorder (PTSD).  Since then, it has been proposed as a treatment of various psychiatric and behavioral disorders including phobias, panic and anxiety disorders, as well as eating disorders.

Guidelines on PTSD from the National Institute for Clinical Excellence (NICE, 2005) state that all people with PTSD should be offered a course of trauma-focused psychological treatment (trauma-focused cognitive behavioral therapy (CBT) or EMDR).  National Institute for Clinical Excellence guidelines note that these treatments should normally be provided on an individual outpatient basis.

Guidelines on PTSD from the American Psychiatric Association (APA, 2004) stated that CBT and EMDR have been shown to be effective for core symptoms of acute and chronic PTSD.  These guidelines note, however, that no controlled studies of EMDR have been conducted that would establish data-based evidence of its efficacy as an early preventive intervention for PTSD.  The APA guidelines state that stress inoculation, imagery rehearsal, and prolonged exposure techniques may also be indicated for treatment of PTSD and PTSD-associated symptoms such as anxiety and avoidance.  The APA guidelines observe that the shared element of controlled exposure of some kind may be the critical intervention.

In reviewing the evidence supporting EMDR, the APA found that, like many of the studies of other cognitive behavior and exposure therapies, most of the well-designed EMDR studies have been small, but several meta-analyses have demonstrated efficacy similar to that of other forms of cognitive and behavior therapy.  The AAP noted that studies also suggest that the “eye movements are neither necessary nor sufficient to the outcome, but these findings remain controversial.”  “Although it appears that efficacy may be related to the components of the technique common to other exposure- based cognitive therapies, as in the previously described cognitive behavior therapies, further study is necessary to clearly identify the effective subcomponents of combined techniques.  Follow-up studies are also needed to determine whether observed improvements are maintained over time” (APA, 2004).

Advocates of EMDR therapy state that it is a specialized approach and method that requires supervised training for full therapeutic effectiveness and client safety.  Training is considered mandatory for appropriate use.  However, a meta-analysis of the literature on EMDR by Davidson and Parker (2001) found that the effectiveness of EMDR was not affected by whether the therapist providing the treatment was trained by the EMDR Institute.

There are insufficient data to support the use of EMDR in the treatment of other psychiatric and behavioral disorders including anger, guilt, phobias, dissociative disorders, eating disorders, and panic and anxiety disorders other than PTSD.  In a randomized study on the effectiveness of EMDR treatment on negative body image in eating disorder inpatients, Bloomgarden and Calogero (2008) conclued that further research is needed to determine whether or not EMDR is effective for treating the variety of eating pathology presented by eating disorder inpatients.

In a case series, Schneider et al (2008) assessed EMDR therapy for patients with chronic phantom limb pain (PLP).  A total of 5 subjects with PLP ranging from 1 to 16 years were included in this study.  All patients were on extensive medication regimens prior to EMDR therapy; 3 to 15 sessions of EMDR were used to treat the pain and the psychological ramifications.  Patients were measured for continued use of medications, pain intensity/frequency, psychological trauma, and depression.  Treatment with EMDR resulted in a significant decrease or elimination of PLP, reduction in depression and PTSD symptoms to sub-clinical levels, and significant reduction or elimination of medications related to the PLP and nociceptive pain at long-term follow-up.  The authors concluded that the overview and long-term follow-up indicate that EMDR therapy was successful in the treatment of both PLP and the psychological consequences of amputation.  The latter include issues of personal loss, grief, self-image, and social adjustment.  These results suggest that
  1. a significant aspect of PLP is the physiological memory storage of the nociceptive pain sensations experienced at the time of the event, and
  2. these memories can be successfully reprocessed.
They stated that further research is needed to explore the theoretical and treatment implications of this information-processing approach.

de Roos et al (2010) examined if a psychological treatment directed at processing the emotional and somatosensory memories associated with amputation reduces PLP.  A total of 10 consecutive participants (6 men and 4 women) with chronic PLP after leg amputation were treated with EMDR.  Pain intensity was assessed during a 2-week period before and after treatment (mean number of sessions = 5.9), and at short-term (3 months) and long-term (mean of 2.8 years) follow-up.  Multi-variate ANOVA for repeated measures revealed an overall time effect (F[2, 8] = 6.7; p < 0.02) for pain intensity.  Pair-wise comparison showed a significant decrease in mean pain score before and after treatment (p = 0.00), which was maintained 3 months later.  All but 2 subjects improved and 4 were considered to be completely pain-free at 3 months follow-up.  Of the 6 subjects available at long-term follow-up (mean of 2.8 years), 3 were pain-free and 2 had reduced pain intensity.  The authors concluded that these preliminary results suggested that, following a psychological intervention focused on trauma or pain-related memories, substantial long-term reduction of chronic PLP can be achieved.  However, they stated that larger outcome studies are needed.

In a pilot study, Sandstrom and colleagues (2008) examined the effects of EMDR in women with post-traumatic stress after childbirth.  This study consisted of a "before and after" treatment design combined with follow-up measurements 1 to 3 years after EMDR treatment.  Quantitative data from questionnaires (Traumatic Event Scale [TES]) were collected.  In addition, qualitative data from individual interviews with the participants were collected as well as data from the psychotherapist's treatment notes of the EMDR treatment sessions.  A total of 4 women with post-traumatic stress following childbirth (1 pregnant and 3 non-pregnant) were included in this study.  All participants reported reduction of post-traumatic stress after treatment.  After 1 to 3 years, the beneficial effects of EMDR treatment remained for 3 of the 4 women.  Symptoms of intrusive thoughts and avoidance seemed most sensitive for treatment.  The authors concluded that EMDR might be a useful tool in the treatment of non-pregnant women severely traumatized by childbirth; however, they stated that further research is needed.

Bae et al (2008) stated that while CBT is considered to be the first-line therapy for adolescent depression, there are limited data on whether other psychotherapeutic techniques are also effective in treating adolescents with depression.  This report suggested the potential application of EMDR for treatment of depressive disorder related, not to trauma, but to stressful life events.  At present, EMDR has only been empirically validated for only trauma-related disorders such as PTSD.  These researchers reported the findings of 2 teenagers with major depressive disorder (MDD) who underwent 3 and 7 sessions of EMDR aimed at memories of stressful life events.  After treatment, their depressive symptoms decreased to the level of full remission, and the therapeutic gains were maintained after 2 and 3 months of follow-up.  The effectiveness of EMDR for depression is explained by the model of adaptive information processing.  Given the powerful effects observed within a brief period of time, the authors suggested that further investigation of EMDR for depressive disorders is warranted.

Torun (2010) noted that vaginismus is a type of sexual dysfunction in which spasm of the vaginal musculature prevents penetrative intercourse.  The main diagnostic criterion is the presence of recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with sexual intercourse.  In many cases, associated pain or the fear of pain may contribute to its persistence.  These researchers reported 2 patients who presented with vaginismus that developed secondary to childhood sexual trauma, which was treated with the EMDR.  Randomized controlled trials with PTSD patients and with victims of sexual abuse have shown that EMDR is effective.  The standard 8-phase EMDR protocol was used in both of the presented cases.  Following 3 sessions of EMDR, the patients exhibited a substantial reduction in self-reported and clinician-rated anxiety, and a reduction in the credibility of dysfunctional beliefs concerning sexual intercourse.  The authors concluded that these findings support the notion that EMDR could be an effective treatment alternative for patients with vaginismus of traumatic etiology.  Thes preliminary results need to be validated with well-designed studies.

Landin-Romero et al (2013) noted that some functional imaging abnormalities found in bipolar disorder are state-related, whereas others persist into euthymia.  It is uncertain to what extent these latter changes may reflect continuing sub-syndromal affective fluctuations and whether those can be modulated by therapeutic interventions.  These researchers reported functional magnetic resonance imaging (fMRI) findings during performance of the n-back working memory task in a bipolar patient who showed a marked improvement in sub-syndromal affective symptoms after receiving EMDR therapy in the context of a clinical trial.  The patient's clinical improvement was accompanied by marked changes in functional imaging, as compared to 30 healthy subjects.  Changes in fMRI were noted particularly in de-activation, with failure of de-activation in the medial frontal cortex partially normalizing after treatment.  The authors concluded that this case supports the potential therapeutic overall benefit of EMDR in traumatized bipolar patients and suggests a possible neurobiological mechanism of action: normalization of default mode network dysfunction.

de Bont and colleagues (2013) stated that trauma contributes to psychosis and in psychotic disorders PTSD is often a co-morbid disorder.  A problem is that PTSD is under-diagnosed and under-treated in people with psychotic disorders.  This study's primary goal is to examine the safety and effectiveness of prolonged exposure and EMDR for PTSD in patients with both psychotic disorders and PTSD, as compared to a waiting list.  Secondly, the effects of both treatments are determined on
  1. symptoms of psychosis, in particular verbal hallucinations,
  2. depression and social performance, and
  3. economic costs.
Thirdly, goals concern links between trauma exposure and psychotic symptomatology and the prevalence of exposure to traumatic events, and of PTSD.  Fourthly predictors, moderators, and mediators for treatment success will be explored.  These include cognitions and experiences concerning treatment harm, credibility and burden in both participants and therapists.  A short PTSD-screener assesses the possible presence of PTSD in adult patients (21 to 65 years of age) with psychotic disorders, while the Clinician Administered PTSD Scale interview will be used for the diagnosis of current PTSD.  The M.I.N.I. Plus interview will be used for diagnosing lifetime psychotic disorders and mood disorders with psychotic features.  The purpose is to include consenting participants (n = 240) in a multi-site single-blind randomized clinical trial.  Patients will be allocated to 1 of 3 treatment conditions (n = 80 each): prolonged exposure or EMDR (both consisting of 8 weekly sessions of 90 minutes each) or a 6-month waiting list.  All participants are subjected to blind assessments at pre-treatment, 2 months post-treatment, and 6 months post-treatment.  In addition, participants in the experimental conditions will have assessments at mid treatment and at 12-month follow-up.

Baslet (2012) noted that psychogenic non-epileptic seizures (PNES) can significantly affect an individual's quality of life, the health care system, and even society.  The first decade of the new millennium has seen renewed interest in this condition, but etiological understanding and evidence-based treatment availability remain limited.  After the diagnosis of PNES is established, the first therapeutic step includes a presentation of the diagnosis that facilitates engagement in treatment.  These investigators presented the current evidence of treatments for PNES published since the year 2000 and discussed further needs for clinical treatment implementation and research.  They reviewed clinical trials that have evaluated the effectiveness of structured, standardized psychotherapeutic and psychopharmacological interventions.  The primary outcome measure in clinical trials for PNES is event frequency, although it is questionable whether this is the most accurate indicator of functional recovery.  Cognitive behavioral therapy has evidence of efficacy, including 1 pilot randomized controlled trial where cognitive behavioral therapy was compared with standard medical care.  The anti-depressant sertraline did not show a significant difference in event frequency change when compared to placebo in a pilot randomized, double-blind, controlled trial, but it did show a significant pre- versus post-treatment decrease in the active arm.  Other interventions that have shown efficacy in uncontrolled trials included augmented psychodynamic interpersonal psychotherapy, group psychodynamic psychotherapy, group psychoeducation, and the anti-depressant venlafaxine.  Larger clinical trials of these promising treatments are necessary, while other psychotherapeutic interventions such as hypnotherapy, mindfulness-based therapies, and EMDR may deserve exploration.

Tesarz and associates (2013) examined if a standardized, short-term EMDR intervention added to treatment as usual (TAU) reduces pain intensity in non-specific chronic back pain (CBP) patients with psychological trauma versus TAU alone.  The study will recruit 40 non-specific CBP patients who have experienced psychological trauma.  After a baseline assessment, the patients will be randomized to either an intervention group (n = 20) or a control group (n = 20).  Individuals in the EMDR group will receive ten 90-min sessions of EMDR fortnightly in addition to TAU.  The control group will receive TAU alone.  The post-treatment assessments will take place 2 weeks after the last EMDR session and 6 months later.  The primary outcome will be the change in the intensity of CBP within the last 4 weeks (numeric rating scale 0 to 10) from the pre-treatment assessment to the post-treatment assessment 2 weeks after the completion of treatment.  In addition, the patients will undergo a thorough assessment of the change in the experience of pain, disability, trauma-associated distress, mental co-morbidities, resilience, and quality of life to explore distinct treatment effects.  To explore the mechanisms of action that are involved, changes in pain perception and pain processing (quantitative sensory testing, conditioned pain modulation) will also be assessed.  The statistical analysis of the primary outcome will be performed on an intention-to-treat basis.  The secondary outcomes will be analyzed in an explorative, descriptive manner.  The authors concluded that this study adapts the standard EMDR treatment for traumatized patients to patients with CBP who have experienced psychological trauma.  This specific, mechanism-based approach might benefit patients.

Tesarz and colleagues (2014) systematically reviewed the evidence regarding the effects of EMDR therapy for treating chronic pain.  These researchers screened MEDLINE, EMBASE, the Cochrane Library, CINHAL Plus, Web of Science, PsycINFO, PSYNDEX, the Francine Shapiro Library, and citations of original studies and reviews.  All studies using EMDR for treating chronic pain were eligible for inclusion in the present study.  The main outcomes were pain intensity, disability, and negative mood (depression and anxiety).  The effects were described as standardized mean differences.  A total of 2 controlled trials with a total of 80 subjects and 10 observational studies with 116 subjects met the inclusion criteria.  All of these studies assessed pain intensity.  In addition, 5 studies measured disability, 8 studies depression, and 5 studies anxiety.  Controlled trials demonstrated significant improvements in pain intensity with high effect sizes (Hedges' g: -6.87 [95 % confidence interval (CI95 ): -8.51 to -5.23] and -1.12 [CI95 : -1.82 to -0.42]).  The pre-treatment/post-treatment effect size calculations of the observational studies revealed that the effect sizes varied considerably, ranging from Hedges' g values of -0.24 (CI95 : -0.88 to 0.40) to -5.86 (CI95 : -10.12 to -1.60) for reductions in pain intensity, -0.34 (CI95 : -1.27 to 0.59) to -3.69 (CI95 : -24.66 to 17.28) for improvements in disability, -0.57 (CI95 : -1.47 to 0.32) to -1.47 (CI95 : -3.18 to 0.25) for improvements in depressive symptoms, and -0.59 (CI95 : -1.05 to 0.13) to -1.10 (CI95 : -2.68 to 0.48) for anxiety.  Follow-up assessments showed maintained improvements; no adverse events were reported.  The authors concluded that although these findings suggested that EMDR may be a safe and promising treatment option in chronic pain conditions, the small number of high-quality studies led to insufficient evidence for definite treatment recommendations.

An UpToDate review on “Treatment of depersonalization derealization disorder” (Simeon, 2015) states that “Eye movement desensitization and reprocessing (EMDR), a form of CBT that incorporates saccadic eye movements during exposure, has also been proposed for use in the treatment of DDPD in conjunction with hypnosis”.  Its effectiveness need to be ascertained in well-designed studies.

An UpToDate review on “Treatment of myofascial pelvic pain syndrome in women” (Moynihan and Elkadry, 2015) states that “Eye movement desensitization and reprocessing -- Eye movement desensitization and reprocessing (EMDR) is a psychotherapy technique that was initially developed to treat people with post-traumatic stress disorder.  Over time, it has been used to treat people with other trauma-related conditions, including chronic pain.  The goal of EMDR is to guide patients to process memories or experiences that are contributing to pain and to use these past experiences to create positive experiences in the future.  EMDR is conducted one-on-one by a therapist who has specific training in the process.  Clinical studies of EMDR in women with MPPS are lacking”.

An UpToDate review on “Psychotherapy for specific phobia in adults” (McCabe and Swinson, 2015) states that “Eye movement desensitization and reprocessing -- Eye movement desensitization and reprocessing (EMDR) is a psychotherapeutic approach initially developed to treat post-traumatic stress disorder.   EMDR is a variation of exposure that incorporates exposure to traumatic memories with simultaneous focus on external stimuli such as therapist-directed bilateral eye movements, hand-tapping, or audio stimulation.  A trial comparing EMDR to a waitlist control condition in 31 patients with dental phobia found that EMDR focused on processing traumatic dental memories reduced dental anxiety and avoidance behavior compared to the control group after one year.  Additional research is needed to confirm these findings and to determine whether EMDR offers incremental benefit over imaginal or in vivo exposure”.

Bandelow et al (2015) stated that no previous meta-analysis has attempted to compare the efficacy of pharmacological, psychological and combined treatments for the 3 main anxiety disorders (panic disorder, generalized anxiety disorder and social phobia).  Pre-post and treated versus control effect sizes (ES) were calculated for all evaluable randomized-controlled studies (n = 234), involving 37,333 patients.  Medications were associated with a significantly higher average pre-post ES [Cohen's d = 2.02 (1.90 to 2.15); 28,051 patients] than psychotherapies [1.22 (1.14 to 1.30); 6,992 patients; p < 0.0001].  Effect sizes were 2.25 for serotonin-noradrenaline reuptake inhibitors (n = 23 study arms), 2.15 for benzodiazepines (n = 42), 2.09 for selective serotonin reuptake inhibitors (n = 62) and 1.83 for tricyclic anti-depressants (n = 15).  Effect sizes for psychotherapies were mindfulness therapies, 1.56 (n = 4); relaxation, 1.36 (n = 17); individual cognitive behavioral/exposure therapy (CBT), 1.30 (n = 93); group CBT, 1.22 (n = 18); psychodynamic therapy 1.17 (n = 5); therapies without face-to-face contact (e.g., Internet therapies), 1.11 (n = 34); EMDR, 1.03 (n = 3); and inter-personal therapy 0.78 (n = 4).  The ES was 2.12 (n = 16) for CBT/drug combinations.  Exercise had an ES of 1.23 (n = 3).  For control groups, ES were 1.29 for placebo pills (n = 111), 0.83 for psychological placebos (n = 16) and 0.20 for wait-lists (n = 50).  In direct comparisons with control groups, all investigated drugs, except for citalopram, opipramol and moclobemide, were significantly more effective than placebo.  Individual CBT was more effective than waiting list, psychological placebo and pill placebo.  When looking at the average pre-post ES, medications were more effective than psychotherapies.  Pre-post ES for psychotherapies did not differ from pill placebos; this finding cannot be explained by heterogeneity, publication bias or allegiance effects.  However, the decision on whether to choose psychotherapy, medications or a combination of the two should be left to the patient as drugs may have side effects, interactions and contraindications.

Addiction

Little et al (2016) conducted 2 proof-of-principle studies to examine if EMDR can reduce the sensory richness of substance-related mental representations and accompanying craving levels. These researchers investigated the effects of EMDR on
  1. vividness of food-related mental imagery and food craving in dieting and non-dieting students, and
  2. vividness of recent smoking-related memories and cigarette craving in daily smokers.
In both experiments, participants recalled the images while making EM or keeping eyes stationary.  Image vividness and emotionality, image-specific craving and general craving were measured before and after the intervention.  As a behavioral outcome measure, participants in study 1 were offered a snack choice at the end of the experiment.  Results of both experiments showed that image vividness and craving increased in the control condition but remained stable or decreased after the EMDR; EMDR additionally reduced image emotionality (experiment 2) and affected behavior (experiment 1): participants in the EMDR group were more inclined to choose healthy over unhealthy snack options.  The authors concluded that these data suggested that EMDR can be used to reduce intensity of substance-related imagery and craving.  Moreover, they stated that although long-term effects are yet to be demonstrated, the current studies suggested that EMDR might be a useful technique in addiction treatment.

In a single-blinded, randomized controlled trial (RCT), Shafer and co-workers (2017) examined the effectiveness of EMDR in reducing PTSD symptoms in patients with substance use disorders (SUD) and PTSD.  This study included a total of 158 patients with SUD and co-morbid PTSD admitted to a German addiction rehabilitation center specialized for the treatment of patients with SUD and co-morbid PTSD.  Patients were randomized to receive either EMDR, added to SUD rehabilitation and non-trauma-focused PTSD treatment (treatment-as-usual [TAU]), or TAU alone.  The primary outcome was change from baseline in PTSD symptom severity as measured by the Clinician-Administered PTSD Scale at 6-month follow-up.  Secondary outcomes were change from baseline in substance use, addiction-related problems, depressive symptoms, dissociative symptoms, emotion dysregulation and quality of life (QOL).  Assessments were carried out by blinded raters at admission, at end of treatment, and at 3- and 6-month follow-up.  They expected that EMDR plus TAU would be more effective in reducing PTSD symptoms than TAU alone.  Mixed models would be conducted using an intention-to-treat (ITT) and per-protocol approach.  The authors concluded that this study aims to expand the knowledge about the effectiveness of EMDR in patients with SUD and co-morbid PTSD.  The expected finding of the superiority of EMDR in reducing PTSD symptoms compared to non-trauma-focused PTSD treatment may enhance the use of trauma-focused treatment approaches for patients with SUD and co-morbid PTSD.  A major drawback of this study was that patients who were younger than 18 or older than 65 years; who don’t speak German; presented acute suicidal, psychotic or severe dissociative symptoms; or showed severely cognitive impairment were excluded from this study.  Thus, these findings might not be generalized to these populations of patients with SUD and PTSD.

Post-Operative Pain

In a RCT, Maroufi et al (2016) examined the effectiveness of EMDR for post-operative pain management in adolescents.  A total of 56 adolescent surgical patients aged between 12 to 18 years were allocated to gender-balanced EMDR (treatment) or non-EMDR (control) groups.  Pain was measured using the Wong-Baker FACES Pain Rating Scale (WBFS) before and after the intervention (or non-intervention for the control group).  A Wilcoxon signed-rank test demonstrated that the EMDR group experienced a significant reduction in pain intensity after treatment intervention, whereas the control group did not.  Additionally, a Mann-Whitney U-test showed that, while there was no significant difference between the 2 groups at time 1, there was a significant difference in pain intensity between the 2 groups at time 2, with the EMDR group experiencing lower levels of pain.  The authors concluded that these findings suggested that EMDR may be an effective treatment modality for post-operative pain.  These preliminary findings need to be validated by well-designed studies.

Back Pain

In a randomized, controlled pilot study Gerhardt and colleagues (2016) estimated preliminary effectiveness of a pain-focused EMDR intervention for the treatment of non-specific CBP.  A total of 40 non-specific CBP (nsCBP) patients reporting previous experiences of psychological trauma were consecutively recruited from outpatient tertiary care pain centers.  After baseline assessment, patients were randomized to intervention or control group (1:1).  The intervention group received 10 sessions standardized pain-focused EMDR in addition to TAU.  The control group received TAU alone.  The primary outcome was preliminary effectiveness, measured by pain intensity, disability, and treatment satisfaction from the patients' perspective.  Clinical relevance of changes was determined according to the established recommendations.  Assessments were conducted at the baseline, post-treatment, and at a 6-month follow-up; ITT analysis with last observation carried forward method was used.  Estimated effect sizes (between-group, pooled SD) for pain intensity and disability were d = 0.79 (95 % CI: 0.13 to 1.42) and d = 0.39 (95 % CI: -0.24 to 1.01) post-treatment, and d = 0.50 (95 % CI: 0.14 to 1.12) and d = 0.14 (95 % CI: -0.48 to 0.76) at 6-month follow-up.  Evaluation on individual patient basis showed that about 50 % of the patients in the intervention group improved clinically relevant and also rated their situation as clinically satisfactory improved, compared to 0 patients in the control group.  The authors concluded that there is preliminary evidence that pain-focused EMDR might be useful for nsCBP patients with previous experiences of psychological trauma, with benefits for pain intensity maintained over 6 months.  They stated that these findings are promising because the treatment appeared to meet patients’ success criteria and clinically relevant changes were suggested for 50 % of the treated patients.  However, they noted that due to the pilot study design, results should be interpreted with caution.  In the next step, a methodologically more stringent RCT on EMDR in nsCBP-t with an appropriate sample size and a psychosocial comparator intervention is needed to confirm these findings.

This study had several drawbacks, which included the following -- as common for pilot studies, the study was not sufficiently powered for confirmatory decisions about the effectiveness of EMDR in nsCBP-t patients.  Moreover, EMDR was not compared to other psychotherapeutic treatments.  However, these drawbacks were accepted fitting with the proof-of-concept pilot RCT design that was not confirmatory; but aimed at a first impression of potential effects of EMDR in nsCBP-t.  Thus, these preliminary findings considering EMDR in nsCBP-t have to be replicated with larger, methodological, and more stringent trials.

Bipolar Disorder

Moreno-Alcazar and colleagues (2017) noted that up to 60 % of patients with bipolar disorder (BD) have a history of traumatic events, which is associated with greater episode severity, higher risk of co-morbidity and higher relapse rates.  Trauma-focused treatment strategies for BD are thus necessary but studies are currently scarce.  The aim of this study is to examine if EMDR therapy focusing on adherence, insight, de-idealization of manic symptoms, prodromal symptoms and mood stabilization can reduce episode severity and relapse rates and increase cognitive performance and functioning in patients with BD.  This is a single-blind, randomized controlled, multi-center study in which 82 patients with BD and a history of traumatic events will be recruited and randomly allocated to 1 of 2 treatment arms:
  1. EMDR therapy, or
  2. supportive therapy.
Patients in both groups will receive 20 psychotherapeutic sessions, 60 minutes each, during 6 months.  The primary outcome is a reduction of affective episodes after 12 and 24 months in favor of the EMDR group.  As secondary outcome these researchers postulate a greater reduction in affective symptoms in the EMDR group (as measured by the Bipolar Depression Rating Scale, the Young Mania Rating Scale and the Clinical Global Impression Scale modified for BD), and a better performance in cognitive state, social cognition and functioning (as measured by the Screen for Cognitive Impairment in Psychiatry, the Mayer-Salovey-Caruso Emotional Intelligence Test and the Functioning Assessment Short Test, respectively).  Traumatic events will be evaluated by the Holmes-Rahe Life Stress Inventory, the Clinician-administered PTSD Scale and the Impact of Event Scale.  The authors stated that the results of this study will provide evidence whether a specific EMDR protocol for patients with BD is effective in reducing affective episodes, affective symptoms and functional, cognitive and trauma symptoms.

Somatoform Disorders

Somatoform disorders, also known as somatic symptom disorders and somatization disorders, are a group of psychological disorders in which a patient experiences physical symptoms that are inconsistent with or cannot be fully explained by any underlying general medical or neurologic condition.  Gielkens and colleagues (2016) noted that EMDR is a kind of psychotherapy, which is growing in popularity, particularly for treatment of PTSD.  When Shapiro first introduced EMDR in 1989, it was approached as a controversial treatment because of lack of evidence.  However, nowadays there is growing evidence for EMDR efficacy in PTSD and EMDR is recommended by international and national treatment guidelines for PTSD.  Also, research continues on effects of EMDR in addiction, somatoform disorders and psychosis.

Furthermore, an UpToDate review on “Somatization: Treatment and prognosis” (Greenberg, 2017) does not mention EMDR as a therapeutic option.

Depression

Ostacoli and colleagues (2018) stated that treatment of recurrent depressive disorders is currently only moderately successful.  Increasing evidence suggests a significant relationship between adverse childhood experiences and recurrent depressive disorders, suggesting that trauma-based interventions could be useful for these patients.  In a non-inferiority, single-blind RCT, these investigators examined the efficacy of EMDR in addition to anti-depressant medication (ADM) in treating recurrent depression.  They compared EMDR or CBT as adjunctive treatments to ADM.  Randomization was carried out by a central computer system.  Allocation was carried out by a study coordinator in each center.  Two psychiatric services, one in Italy and one in Spain.  A total of 82 patients were randomized with a 1:1 ratio to the EMDR group (n = 40) or CBT group (n = 42); 66 patients, 31 in the EMDR group and 35 in the CBT group, were included in the completers analysis.  Participants received a total of 15 ± 3 individual sessions of EMDR or CBT, both in addition to ADM.  They were followed up at 6 months.  Main outcome measure was rate of depressive symptoms remission in both groups, as measured by a BDI-II score of less than 13.  A total of 66 patients were analyzed as completers (31 EMDR versus 35 CBT).  No significant difference between the 2 groups was found either at the end of the interventions (71 % EMDR versus 48.7 % CBT) or at the 6-month follow-up (54.8 % EMDR versus 42.9 % CBT).  A RM-ANOVA on BDI-II scores showed similar reductions over time in both groups [F(6,59) = 22.501, p < 0.001] and a significant interaction effect between time and group [F(6,59) = 3.357, p = 0.006], with lower BDI-II scores in the EMDR group at T1 [mean difference = -7.309 (95 % CI: -12.811 to -1.806]), p = 0.010].  The RM-ANOVA on secondary outcome measures showed similar improvement over time in both groups [F(14,51) = 8.202, p < 0.001], with no significant differences between groups [F(614,51) = 0.642, p = 0.817].  The authors concluded that although these results can be considered preliminary only, the findings of this study suggested that EMDR could be a viable and effective treatment for reducing depressive symptoms and improving the QOL of patients with recurrent depression.

This study had several drawbacks.  First, the number of patients treated with EMDR and CBT included in the study was not large.  As this was the first study attempting to investigate the non-inferiority of EMDR compared with CBT, it was possible that actual differences between the 2 groups were not revealed due to the design and sample size of the study; future superiority clinical trials are needed to broaden this investigation.  Moreover, in this study a self-report measure (BDI-II) was used as the primary outcome measure.  Future studies should also include a clinician report measure administered by an independent rater in order to overcome this limitation.  Second, the 6-month follow-up evaluation was not long enough to examine the recurrence rate of subsequent depressive episodes.  Thus, longer follow-ups (e.g., at 1 year or longer) are needed in order to identify possible differences between the 2 interventions in reducing the risk of recurrence of depressive episodes.  The final limitation was the inclusion of intention-to-treat analysis for the primary outcome only.

In an experimental, case-series study, Wood and associates (2018) tested the feasibility of EMDR for the treatment of patients with long-term depression.  A total of 13 people with recurrent and/or long-term depression were recruited from primary care mental health services and given standard protocol EMDR for a maximum of 20 sessions.  Levels of depression were measured before and after treatment and at follow-up, clients also rated their mood each day; 8 people engaged with the treatment; 7 of these had clinically significant and statistically reliable improvement on the Hamilton Rating Scale for Depression.  Daily mood ratings were highly variable both during baseline and intervention.  The authors concluded that EMDR is a feasible treatment for depression; it has the potential to be a treatment for long‐term depression.  Moreover, they stated that research on treatment efficacy and effectiveness is now needed.

This study had several drawbacks.  First, this was a feasibility study involving a case series (n = 8 who received EMDR) without a control group and therefore did not aim to establish efficacy.  Second, as all the participants received EMDR, the evaluators were not blind to treatment.  Finally, the use of a predictive baseline and continuous measurement sought to partially control for the passage of time.  The length of the baseline period was determined by how quickly a therapist became available and was not randomized.  This meant it was not a true experimental design, but it was considered clinically more appropriate.

Methotrexate Intolerance

Hofel and colleagues (2018) noted that methotrexate (MTX), commonly used in juvenile idiopathic arthritis (JIA), frequently has to be discontinued due to intolerance with anticipatory and associative gastro-intestinal (GI) adverse effects; EMDR is a psychological method where dysfunctional experiences and memories are re-processed by recall combined with bilateral eye movements.  In a prospective, open, proof of concept trial, these researchers evaluated the efficacy of EMDR for treatment of MTX intolerance in consecutive JIA patients.  Intolerance was determined using the Methotrexate Intolerance Severity Score (MISS) questionnaire prior to treatment, directly after treatment and after 4 months.  Health-related QOL was determined using the PedsQL prior to and 4 months after treatment.  Patients were treated according to an institutional EMDR protocol with 8 sessions over 2 weeks.  Changes in MISS and PedsQL were analyzed using non-parametric statistics.  A total of 18 patients with MTX intolerance (median MISS at inclusion 16.5, inter-quartile range [IQR] = 11.75 to 20.25) were included.  Directly after treatment, MTX intolerance symptoms were significantly improved (median MISS 1 (IQR = 0 to 2).  After 4 months, median MISS score was at 6.5 (IQR = 2.75 to 12.25, p = 0.001), with 9/18 patients showing MISS scores of greater than or equal to 6.  Median PedsQL after 4 months improved significantly from 77.6 % to 85.3 % (p = 0.008).  The authors concluded that patients with JIA showing MTX intolerance profited significantly from EMDR treatment directly after the treatment and over a period of 4 months, allowing continuation of MTX treatment with improved QOL.  To their knowledge, this was the 1st report of an effective measure against MTX intolerance.  Moreover, they stated that further studies are needed to elucidate not only the cause of MTX intolerance, but also the exact benefits of EMDR treatment for MTX intolerance.

The authors stated that a drawback of this study was patient selection, including only patients with sufficiently severe symptoms of MTX intolerance to be willing to undergo 2 weeks of (partially in-patient) treatment.  Also, this was not a randomized trial, but a mere “proof of concept”, and there was no control group with ‘treatment as usual”.

Obsessive-Compulsive Disorder

In a pragmatic, feasibility RCT, Marsden and co-workers (2018) evaluated eye EMDR as a treatment for obsessive-compulsive disorder (OCD), by comparison to CBT based on exposure and response prevention.  This trial included 55 participants with OCD who were randomized to EMDR (n = 29) or CBT (n = 26).  The Yale-Brown obsessive-compulsive scale was completed at baseline, after treatment and at 6 months follow-up.  Treatment completion and response rates were compared using Chi-square tests.  Effect size was examined using Cohen's d and multi-level modeling.  Overall, 61.8 % completed treatment and 30.2 % attained reliable and clinically significant improvement in OCD symptoms, with no significant differences between groups (p > 0.05).  There were no significant differences between groups in Yale-Brown obsessive-compulsive scale severity post-treatment (d = -0.24, p = 0.38) or at 6 months follow-up (d = -0.03, p = 0.90).  The authors concluded that EMDR and CBT had comparable completion rates and clinical outcomes.  Moreover, they stated that future qualitative studies focusing on acceptability and investigations of mechanisms of change may help us to better understand how to maximize the effectiveness of psychological treatments for OCD.  They acknowledged the need for further replication of these findings in larger samples.  The authors noted that the main drawbacks of this feasibility study were its small sample size (n = 29) who received EMDR0 and its short-term follow-up (6 months).

Furthermore, UpToDate reviews on “Treatment of obsessive-compulsive disorder in children and adolescents” (Rosenberg, 2018) and “Psychotherapy for obsessive-compulsive disorder in adults” (Abramowitz, 2018) do not mention EMDR therapy as a therapeutic option.

Substance Use Disorders

Pilz and colleagues (2017) noted that EMDR is a therapeutic method that has been shown to be especially effective in traumatic disorders.  Since the concept of an addiction memory has become widely accepted, the use of EMDR also in substance use disorders (SUD) treatment might count as a separate field.  These researchers summarized the current state of research on treatment effects EMDR in SUD.  The literature search included the databases of PubMed and PsychInfo; 4 studies met the inclusion criteria.  The authors concluded that EMDR was found to be related to a decreased amount of craving, fear and depression and to an improvement of emotion regulation and management and self-esteem.  They stated that initial findings indicated a high therapeutic potential of EMDR in SUD treatment.

Carletto and associates (2018) stated that SUD are patterns of substance use leading to severe impairment on social, working and economic levels.  In-vivo and clinical findings have enhanced the role of the brain's stress-related system in maintaining SUD behaviors.  Several studies have also revealed a high prevalence of post-traumatic symptoms among SUD patients, suggesting that a trauma-informed treatment approach could lead to better treatment outcomes.  However, only few studies have evaluated the use of EMDR in SUD without consistent results.  In a pilot study, these researchers evaluated efficacy of a combined trauma-focused (TF) and addiction-focused (AF) EMDR intervention in treating post-traumatic and stress-related symptoms of patients with SUD.  A total of 40 patients with different SUD were enrolled in the study; 20 patients underwent treatment as usual (TAU), the other 20 patients were treated with TAU plus 24 weekly sessions of EMDR.  All patients were assessed before and after intervention for several psychological dimensions using specific tools (i.e., BDI-II, DES, IES-R, STAI, and SCL-90-GSI).  A repeated measure MANOVA was performed to evaluate both between groups (TAU + EMDR vs. TAU) and within group (pre- versus post-intervention) effects and interactions.  A secondary outcome was the dichotomous variable yielded by the urine drug testing immunoassay (yes/no).  The RM-MANOVA revealed both a significant pre-post main effect (p < 0.001), and a significant group-by-time main effect (p < 0.001).  Significant improvements on IES-R, DES, and SCL-90-GSI scales were shown in both groups according to time effects (p < 0.05).  However, significant greater effects were found for TAU + EMDR group than TAU group.  No differences were found between TAU and TAU + EMDR groups in terms of urine drug immunoassay results before and after the interventions.  The authors concluded that the TAU + EMDR group showed a significant improvement of post-traumatic and dissociative symptoms, accompanied by a reduction in anxiety and overall psychopathology levels, whereas TAU group showed a significant reduction only in post-traumatic symptoms.  They stated that although these findings can only be considered preliminary, this study suggested that a combined TF- and AF-EMDR protocol is an effective and well-accepted add-on treatment for patients with SUD.  Moreover, they noted that future studies would be better to examine not only the effectiveness of an EMDR add-on treatment, but also the mediators, moderators, and predictors of treatment outcome, in order to be able to delineate effective interventions for these disorders.

This study had several drawbacks.  First, the non-randomized design led to the significant differences between the 2 groups at baseline.  In fact, participants who received EMDR treatment showed higher baseline levels of symptoms compared to the group receiving only TAU treatment.  These differences at baseline could limit a conclusive interpretation of the results of the study, as the improvements obtained by the group that received EMDR in addition to TAU could also be due to a spontaneous reduction of symptoms linked to the fact that higher reductions were observed when there were higher starting levels.  Second, the findings of the present study suggested that EMDR may be more useful in subjects who experienced more adverse childhood experiences and higher levels of symptoms, in order to strengthen standard treatment that otherwise would only be partially effective, especially on withdrawal-related anxiety.  Consistent with previous literature reporting that adverse childhood events have significant implications for substance abuse treatment and that a trauma-informed approach to SUD leads to better treatment outcomes, these findings suggested that exposure to adverse childhood experiences should be routinely assessed in treatment settings, in order to provide specific interventions to reduce traumatic burden associated with SUD.  Future randomized controlled studies with larger samples should better investigate these aspects.  Finally, aspects related to craving and abstinence were not specifically investigated.  The results of this study were in line with previous studies, which showed that EMDR had beneficial effects on symptoms related to the traumatic history and only limited effects on additional outcomes.  The present study aimed to focus on post-traumatic and associated aspects linked to the relationship between addiction and traumatic burden, but future studies on similar populations should also take into account addict-related aspects.

Table: CPT Codes / HCPCS Codes / ICD-10 Codes
Code Code Description

Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":

There is no specific CPT code for eye movement desensitization and reprocessing:

Other CPT codes related to the CPB:

90832 - 90899 Psychotherapy, other psychotherapy, and other psychiatric services or procedures [not covered for eye movement desensitization and reprocessing therapy]

ICD-10 codes covered if selection criteria are met:

F43.10 - F43.12 Posttraumatic stress disorder
Z86.51 Personal history of combat and operational stress reaction

ICD-10 codes not covered for indications listed in the CPB:

F01.50 - F43.0
F43.20 - F99
Mental disorders (other than posttraumatic stress disorder)
G54.6 - G54.7 Phantom limb (syndrome)
G89.11 - G89.18 Acute pain, not elsewhere classified
G89.21 -G89.29 Chronic pain, not elsewhere classified
G89.4 Chronic pain syndrome
M54.5 Low back pain [chronic back pain]
M54.9 Dorsalgia, unspecified [chronic back pain]
R56.00 - R56.9 Convulsions [psychogenic non-epileptic seizures]
Z88.8 Allergy status to other drugs, medicaments and biological substances status [methotrexate intolerance]

The above policy is based on the following references:

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