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 / substance use disorders
   • Treatment of autism spectrum disorder
   • Treatment of body dysmorphic disorder
   • Treatment of borderline personality disorder
   • Treatment of chronic pain including chronic back pain, chronic phantom limb pain and rheumatoid arthritis
   • Treatment of dysmenorrhea
   • Treatment of methotrexate intolerance
   • Treatment of PANDAS/PANS syndrome
   • 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 psychosis
   • 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, schizophrenia, and somatoform disorders (also known as somatic symptom disorders and somatization disorders))
   • Treatment of tinnitus.

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.

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.

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 / Substance Use Disorder

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.

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.

Valiente-Gomez and colleagues (2019) stated that psychological trauma has a strong negative impact on the onset, course and prognosis of substance use disorders (SUD).  Few trauma-oriented treatment approaches have been trialed, but preliminary evidence exists of the efficacy of EMDR therapy in improving clinical symptoms in SUD patients.  In a phase-II, multi-center, rater-blinded RCT, these researchers will examine if EMDR therapy would lead to: reduced substance consumption; an improvement in psychopathological and in trauma-related symptoms; and an improvement in overall functioning.  They hypothesize that the EMDR group would improve in all variables when compared to the treatment as usual (TAU) group at 6 and 12-months visits.  In this trial, a total of 142 SUD patients with a history of psychological trauma will be randomly assigned to EMDR (n = 71) or to TAU (n = 71).  Patients in the EMDR group will receive 20 psychotherapeutic sessions of 60 mins over 6 months.  Substance use will be measured using the Timeline Followback Questionnaire, the Dependence Severity Scale and the visual analog scale (VAS).  Traumatic events will be measured by the Holmes-Rahe Life Stress Inventory, the Childhood Trauma Questionnaire Scale, the Global Assessment of Posttraumatic Stress Questionnaire, the Impact of Event Scale-Revised and the Dissociative Experiences Scale.  Clinical symptomatology will be evaluated using the Hamilton Depression Rating Scale, the Young Mania Rating Scale and the Brief Psychiatric Rating Scale.  Functionality will be assessed with the Functioning Assessment Short Test.  All variables will be measured at baseline, post-treatment and 12 months as follow-up.  Primary outcome: To test the efficacy of EMDR therapy in reducing the severity of substance use.  The secondary outcomes: to test the efficacy in reducing trauma-related psychological symptoms and psychopathological symptoms and in improving overall functioning in patients with co-morbid SUD and a history of psychological trauma.  The authors concluded that this study will provide evidence of whether EMDR therapy is effective in reducing addiction-related, trauma and clinical symptoms and in improving functionality in patients with SUD and a history of trauma.

In a randomized clinical trial, Markus and colleagues (2020) examined the feasibility, safety, and efficacy of addiction-focused EMDR (AF-EMDR) treatment for alcohol use disorder (AUD), as an add-on intervention to treatment as usual (TAU).  Adult out-patients with AUD (n = 109) who already received or had just started with TAU (community reinforcement approach) were recruited at 6 out-patient addiction care facilities.  They were randomly assigned to either TAU + 7 weekly 90-min sessions of AF-EMDR (n = 55) or TAU-only (n = 54).  Evaluations were made at baseline, after AF-EMDR therapy (+ 8 weeks in the TAU-only group), and at 1- and 6-month follow-up.  The primary outcomes were changes in drinking behavior as reported by the subject and biomarker indices.  Data were analyzed as ITT with linear mixed models.  Additionally, sensitivity analyses were performed.  No group or interaction effects were found for any of the outcome variables.  Only limited change over time was observed with regard to indices of personal and societal recovery and in some secondary indices of clinical recovery (craving, desire thinking, and rumination).  Reliable Change Index calculations showed that more TAU-only subjects showed clinical improvement with regard to alcohol consumption while a somewhat higher proportion of subjects in the TAU + AF-EMDR group experienced less craving.  The acceptability, safety, and feasibility of the treatments received in both groups were comparable.  The authors concluded that there was no add-on effect of AF-EMDR on TAU with regard to drinking behavior in out-patients with an AUD.  Moreover, these researchers stated that future studies should first establish proof-of-principle regarding the potential of AF-EMDR therapy to disrupt operant learning and habits relevant in addiction.

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

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.

In a randomized study, Jahanfar and colleagues (2020) examined the efficacy of eye EMDR on the QOL in patients with MDD.  Subjects were patients who suffered from psychological trauma and were currently in a major depressive episode and had a history of depression.  A total of 70 patients with MDD were selected through convenience sampling.  Patients were then assigned to 2 groups of intervention and control (35 patients in each group).  The assignment was performed randomly.  For the intervention group, EMDR were performed in eight 90-min sessions over 3 weeks.  For the control group, no intervention was considered.  Data on the QOL were collected using the WHO Quality of Life-BREF instrument before and after the treatment, and analyzed using descriptive tests, paired t-test, independent t-test, and chi-square with SPSS v19.  This study showed that the QOL in all its domains (physical health, psychological health, social relationships and environments) was significantly improved in patients with MDD in the intervention group after 8 sessions of EMDR.  The post-treatment effect for the EMDR condition was 2.11, with a CI of 1.3 to 2.7.  Another finding of this study was that there was a statistically significant difference in the QOL scores in patients in the control group before and after the treatment; however, the mean difference in the intervention group was more than the control.  The authors concluded that the findings of this study showed that EMDR was effective on the QOL in patients with MDD, and improved individuals' QOL and all its domains.  These researchers stated that treatment team members may use this technique as an effective and supportive one to improve the QOL in patients.

The authors stated that one main drawback of this study was that all patients used drug therapy that might have influenced the results of the study, which was not under the researcher’s control.  Another limitation was that they could not evaluate affective/trauma symptoms.

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.

Autism Spectrum Disorder

Lobregt-van Buuren and colleagues (2019) examined if EMDR is a feasible therapy for adults with autism spectrum disorder (ASD) and a history of adverse events (AEs), and whether it is associated with reductions in symptoms of PTSD, psychological distress and autism.  Subjects received 6 to 8 weeks treatment as usual (TAU), followed by a maximum of 8 sessions EMDR added to TAU, and a follow-up of 6 to 8 weeks with TAU only.  Results showed a significant reduction of symptoms of post-traumatic stress (IES-R: d = 1.16), psychological distress (BSI: d = 0.93) and autistic features (SRS-A: d = 0.39).  Positive results were maintained at follow-up.  The authors concluded that the findings of this study suggested that EMDR therapy may be a feasible and potentially effective treatment for individuals with ASD who suffer from the consequences of exposure to distressing events.  These preliminary findings need to be validated by well-designed studies.

Furthermore, UpToDate reviews on “Autism spectrum disorder in children and adolescents: Overview of management” (Weissman and Bridgemohan, 2019a) and “Autism spectrum disorder in children and adolescents: Behavioral and educational interventions” (Weissman and Bridgemohan, 2019b) do not mention EMDR as a therapeutic option.

Body Dysmorphic Disorder

Kazen and colleagues (2019) examined body image representations in female patients with anorexia nervosa (AN)  and healthy controls using a size estimation with pictures of their own body.  These researchers also explored a method to reduce body image distortions through right hemispheric activation.  Pictures of participants' own bodies were shown on the left or right visual fields for 130 ms after presentation of neutral, positive, or negative word primes, which could be self-relevant or not, with the task of classifying the picture as "thinner than", "equal to", or "fatter than" one's own body.  Subsequently, activation of the left- or right hemispheric through right- or left-hand muscle contractions for 3 mins, respectively.  Finally, participants completed the size estimation task again.  The distorted "fatter than" body image was found only in patients and only when a picture of their own body appeared on the right visual field (left hemisphere) and was preceded by negative self-relevant words.  This distorted perception of the patients' body image was reduced after left-hand muscle contractions (right hemispheric activation).  The authors concluded that to reduce body image distortions it is advisable to find methods that help AN patients to increase their self-esteem.  The body image distortions were ameliorated after right hemispheric activation.  A related method to prevent distorted body-image representations in these patients may be EMDR therapy.

Borderline Personality Disorder

In a single-case report, Momeni Safarabad and colleagues (2018) examined the effect of the 3-phase model of EMDR in the treatment of a patient with borderline personality disorder (BPD).  A 33-year old woman, who met the DSM-IV-TR criteria for BPD, received a 20-session therapy based on the 3-phase model of EMDR.  Borderline Personality Disorder Checklist (BPD-Checklist), Dissociative Experience Scale (DES-II), Beck Depression Inventory-II-second edition (BDI-II), and Anxiety Inventory (BAI) were filled out by the patient at all treatment phases and at the 3-month follow- up.  According to the obtained results, the patient's pre-test scores in all research tools were 161, 44, 37, and 38 for BPD-Checklist, DES-II, BDI-II, and BAI, respectively.  After treatment, these scores decreased significantly (69, 14, 6 and 10, respectively).  The patient exhibited improvement in BPD, dissociative, depression and anxiety symptoms, which were maintained after the 3-month follow-up.  The authors concluded that although the findings of this study were promising for BPD patients, more research should be done with larger sample sizes and with experimental and control groups to evaluate the positive effects of EMDR on BPD patients.  They also noted that more studies should be conducted to compare this phasic model of treatment with other phase-oriented treatments, such as CBT, dialectic behavior therapy (DBT), and psychodynamic.

The authors stated that although the this study was the first one evaluating the effects of phasic model of EMDR on improving BPD, dissociation, anxiety, and depression symptoms through comparing the effects of each phase, the results should be interpreted discreetly as the study was carried out only on 1 patient, who may not represent the whole population of BPD patients.  Additionally, 1 therapist delivered the treatment program.  Thus, the characteristic of therapists rather than the treatment may affect the results.  Finally, extended follow- up interval (12 month or longer) are needed to evaluate the sustainability of treatment gains, as duration of follow- up in the present study was short (3 months).

Childhood Trauma

Chen and colleagues (2018) noted that survivors of complex childhood trauma (CT) such as sexual abuse show poorer outcomes compared to single event trauma survivors.  A growing number of studies examined EMDR therapy for PTSD, but no systematic reviews have focused on EMDR treatment for CT as an intervention for both adults and children.  These investigators reviewed all RCTs evaluating the effect of EMDR on PTSD symptoms in adults and children exposed to CT.  Databases including PubMed, Web of Science, and PsycINFO were searched in October 2017; RCTs that recruited adult and children with experience of CT, which compared EMDR to alternative treatments or control conditions, and which measured PTSD symptoms were included.  Study methodology quality was evaluated with Platinum Standard scale.  A total of 6 eligible RCTs (251 subjects) were included in this systematic review.  The results indicated that EMDR was associated with reductions in PTSD symptoms, depression and/or anxiety both post-treatment and at follow-up compared with all other alternative therapies (cognitive behavior therapy, individual/group therapy and fluoxetine) and control treatment (pill placebo, active listening, EMDR delayed treatment, and treatment as usual).  However, studies suffered from significant heterogeneity in study populations, length of EMDR treatment, length of follow-up, comparison groups, and outcome measures.  One study had a high risk of bias.  The authors concluded that the findings of this systematic review suggested that there is growing evidence to support the efficacy of EMDR in treating CT in both children and adults.  However, conclusions were limited by the small number of heterogenous trials.  These researchers stated that further RCTs with standardized methodologies, as well as studies addressing real world challenges in treating CT are needed.

Chronic Pain Associated with Rheumatoid Arthritis

Nia and colleagues (2018) stated that previous studies reported the reduction of pain following EMDR and guided imagery; however, the effectiveness of these modalities was not compared.  In a RCT, these researchers compared the effects of EMDR and guided imagery on pain severity in patients with rheumatoid arthritis (RA).  A total of 75 patients were selected using non-random method, and then allocated into 2 intervention groups and 1 control group.  Interventions were conducted individually in 6 consecutive sessions for the intervention groups.  The Rheumatoid Arthritis Pain Scale was used for data collection before and after the interventions.  Collected data were analyzed with descriptive and inferential statistics in SPSS; significance level was considered at p < 0.05.  The post-intervention mean scores of physiological, affective, sensory-discriminative, and cognitive pain sub-scales for patients in guided imagery group were 16.3 ± 2.2, 13.9 ± 2.2, 30.6 ± 3.4, and 23.2 ± 3, respectively.  The post-intervention mean scores of these sub-scales in the EMDR group were 22 ± 1.5, 18.1 ± 1.8, 39.6 ± 2.8, and 29 ± 1.8, respectively.  A significant difference was observed in the mean pain score between EMDR and guided imagery groups, and also between each intervention group and the control group (p = 0.001).  The authors concluded that guided imagery and EMDR could reduce pain in RA, but pain reduction was more following the EMDR than guided imagery.  These researchers stated that given that the simplicity, cost-effectiveness, and non-aggressiveness of such interventions, healthcare workers might consider these interventions once the approval of their effectiveness is provided.

The authors stated that although the findings of this study indicated pain reduction in patients with RA following EMDR and guided imagery interventions, this study was associated with several drawbacks that should be considered in the generalization of finding.  First, the severity of pain in patients with RA in remission phase may be less than in patients with RA in the relapsing phase of the disease.  Thus, it was recommended to examine the effect of these interventions on the severity of pain in patients with RA in the relapsing phase.  Second, subjects of this study were selected using non-random sampling or convenience method due to the limited study population, so random sampling method was impossible, and the sample size of this study was small (n = 75).  These investigators stated that further investigation with larger sample size and random sampling method was suggested to examine the effects of these interventions.

Post-Partum Post-Traumatic Stress Disorder

Furuta and colleagues (2018) noted that approximately 3 % of women in community samples develop PTSD following childbirth.  Higher prevalence rates are reported for high risk samples.  Post-partum PTSD can adversely affect women's well-being, mother-infant relationships and child development.  These researchers examined the effectiveness of trauma-focused psychological interventions (TFPT), for post-natal women.  They conducted a systematic review and meta-analysis including all clinical trials that reported post-traumatic stress symptoms for both the intervention and control groups or at least 2 time-points, pre- and post-intervention.  These investigators searched 4 databases: Central, Medline, PsycINFO, and OpenGrey.  Screening of search results, data extraction, and risk of bias assessment were undertaken independently by 2 reviewers.  A total of 11 studies, reported in 12 papers, involving 2,677 post-natal women were included.  All were RCTs, bar 1 case series.  Interventions varied in modality, duration and intensity, and included exposure therapy, trauma-focused cognitive behavioral therapy, EMDR and other psychological approaches.  Participants had experienced uncomplicated births, emergency cesarean sections and/or pre-term births.  Results suggested that TFPT were effective for reducing PTSD symptoms in the short-term (up to 3 months post-partum [4 RCTs, n = 301, standardized mean difference [SMD] = -0.50, 95 % CI: -0.73 to -0.27]), and medium-term (i.e., 3 to 6 months post-partum [2 RCTs, n = 174, SMD = -1.87, 95 % CI: -2.60 to -1.13]).  However, there was no robust evidence to suggest whether TFPT could also improve women's recovery from clinically significant PTSD symptoms.  The authors concluded that further larger studies, distinguishing between low- and high-risk groups, and with longer-term follow-up, are needed to establish which TFPT are most effective and acceptable for treating post-partum PTSD.

Schizophrenia

Yasar and colleagues (2018) stated that being exposed to traumatic experiences is rather common in patients with schizophrenia.  Adverse experiences may induce the onset of psychotic symptoms or trigger current symptoms to be exacerbated.  Eye Movement Desensitization Reprocessing is an effective therapy in the treatment of incidences with underlying traumatic experiences, thus, it can be conducted on various cases in addition to other treatments such as psycho-medication or another therapy method.  It was developed by Shapiro in 1980s.  Although desensitization is widely applied on patients with PTSD, it is unusual for EMDR therapy to be safely and effectively performed in the treatment of psychotic disorders or symptoms.  In this single-case study, these investigators discussed EMDR treatment process and course of psychiatric state in a patient with history of child hood abuse and forced psychiatric residency.  The patient had a diagnosis of schizophrenia for 8 years and was treated with anti-psychotic treatment as well as 2 sessions of EMDR, and as a result, a positive change was observed in her general clinical course.  The authors concluded that their thoughts on this phenomenon were that EMDR treatment was a safe, effective, and short-term intervention in the co-morbidity of PTSD and psychotic disorders.  However, the literature regarding the place of EMDR in the treatment of schizophrenia is rather limited and much more research is needed.

Tinnitus

Rikkert and associates (2018) stated that while normal tinnitus is a short-term sensation of limited duration, in 10 to 15 % of the general population it develops into a chronic condition.  For 3 to 6 % it seriously interferes with many aspects of life.  These investigators examined the effectiveness of EMDR in reducing tinnitus distress.  This study consisted of 35 adults with high levels of chronic tinnitus distress from 5 general hospitals in the Netherlands; subjects served as their own controls.  After pre-assessment (T1), subjects waited for a period of 3 months, after which they were assessed again (T2) before they received six 90-min manualized EMDR treatment sessions in which tinnitus-related traumatic or stressful events were the focus of treatment.  Standardized self-report measures, the Tinnitus Functional Index (TFI), Mini-Tinnitus Questionnaire (Mini-TQ), Symptom Checklist-90 (SCL-90) and the Self-Rating Inventory List for Post-traumatic Stress Disorder (SRIP), were completed again halfway through treatment (T3), post-treatment (T4) and at 3 months' follow-up (T5).  Repeated measures analysis of variance revealed significant improvement after EMDR treatment on the primary outcome, TFI.  Compared to the waiting-list condition, scores significantly decreased in EMDR treatment [t(34) = -4.25, p < 0.001, Cohen's dz  = 0.72].  Secondary outcomes, Mini-TQ and SCL-90, also decreased significantly.  The treatment effects remained stable at 3 months' follow-up.  No adverse events (AEs) or side effects were noted in this trial.   The authors concluded that this was the first study to suggest that EMDR was effective in reducing tinnitus distress; they stated that RCTs are needed.

Luyten and co-workers (2019) noted that patients suffering from chronic, subjective tinnitus are on a quest to find a cure or any form of alleviation for their persistent complaint.  Current recommended therapy forms provide psychotherapeutic interventions that are intended to train the patient how to deal with the tinnitus sound.  Pharmaceutical managements are used to reduce secondary effects of the tinnitus sound such as sleep deprivation, emotional and concentration difficulties, but these treatments do not cure the tinnitus.  Recent studies have shown that tinnitus retraining therapy (TRT) significantly improved the QOL for tinnitus patients.  Furthermore, several studies have reported that CBT relieved a substantial amount of distress by changing dysfunctional cognitions.  However, when the tinnitus causes great interference with daily functioning, these treatment methods are not always sufficiently effective.  Recent insights showed that EMDR is a highly effective therapy for medically unexplained symptoms such as chronic pain and phantom pain.  In scientific research, tinnitus is compared to phantom limb pain.  Starting from tinnitus as a phantom percept , these researchers aim to demonstrate that the operating mechanisms of EMDR may also be an effective treatment method for patients with subjective tinnitus.  The aim of this RCT with blind evaluator is to examine the effect of EMDR compared to CBT in chronic tinnitus patients.  A total of 166 patients with subjective, chronic, non-pulsatile tinnitus will be randomized to 2 treatment groups: TRT + CBT versus TRT + EMDR.  The experimental group will receive the bi-modal therapy TRT/EMDR and the active control group will receive the bi-modal therapy TRT/CBT.  Evaluations will take place at baseline before therapy, at the end of the treatment, and 3 months after therapy.  The score on the Tinnitus Functional Index (TFI) will be used as the primary outcome measurement.  Secondary outcome measurements are the VAS of loudness, Tinnitus Questionnaire (TQ), Hospital Anxiety and Depression Scale (HADS), Hyperacusis Questionnaire (HQ), psycho-acoustic measurements and event-related potentials (ERP).  The objective is to examine if the bi-modal therapy TRT and EMDR could provide faster and/or more relief from the annoyance experienced in chronic tinnitus patients' daily lives compared to the bi-modal therapy TRT and CBT.  So far there has been no prospective RCT with blind evaluator that compares CBT and EMDR as a treatment for tinnitus.

In a prospective, single-site, interventional clinical trial, Phillips and colleagues (2019) examined the effectiveness of EMDR for the treatment of tinnitus.  Subjects were provided with tEMDR, which was a bespoke EMDR protocol that was developed specifically to treat individuals with tinnitus.  Subjects received a maximum of 10 sessions of tEMDR.  Outcome measures including tinnitus questionnaires and mood questionnaires were recorded at baseline, discharge, and at 6 months post-discharge.  Tinnitus Handicap Inventory (THI) and Beck Depression Inventory (BDI) scores demonstrated a statistically significant improvement at discharge following EMDR intervention (p = 0.0005 and p = 0.0098, respectively); this improvement was maintained at 6 months post-discharge.  There was also a moderate but not significant (p = 0.0625) improvement in Beck Anxiety Inventory (BAI) scores.  The authors concluded that this study has demonstrated that the provision of tEMDR has resulted in a clinically and statistically significant improvement in tinnitus symptoms in the majority of subjects who participated.  Furthermore, the treatment effect was maintained at 6 months after treatment ceased.  This study was of particular interest, as the study protocol was designed to be purposefully inclusive of a diverse range of tinnitus patients.  However, as a small uncontrolled study, these results did not consider the significant effects of placebo and therapist interaction.  These researchers stated that larger high-quality studies are needed to validate these preliminary findings.  Level of Evidence = IV.

Dysmenorrhea

Valedi and colleagues (2019) stated that unpleasant experience with the previous menstruation can increase the sensitivity to pain that may lead to moderate-to-severe pain in patients with dysmenorrhea.  These researchers designed the protocol of a RCT to examine the effect of EMDR therapy on pain intensity in patients with dysmenorrhea.  This trial protocol was designed in compliance with the Consolidated Standards of Reporting Trials (CONSORT).  Female students who have moderate-to-severe primary dysmenorrhea (based on a VAS score of at least 4 for 2 consecutive months) and who live in dormitories at Qazvin University of Medical Sciences in Qazvin, Iran will be invited to participate in the study.  The total sample size will be 88 girls, who will be randomly assigned to intervention (n = 44) and control (n = 44) groups.  EMDR therapy will be performed for the intervention group, while the control group can use sedative or other pain relief methods.  There will be 6 treatment sessions, which will be held twice-weekly.  The duration of each session is 30 to 90 mins, according to the convenience of each participant.  The data will be collected using the demographic characteristics questionnaire, the VAS, the Subjective Units of Anxiety or Distress Scale (SUD), and the Validity of Cognition Scale (VOC).  The data on pain intensity due to primary dysmenorrhea in both groups will be collected at 1 and 2 months before the intervention (to identify eligible participants) and 1 and 2 months after the intervention (follow-ups).  Data will be analyzed by using SPSS version 25 software and analysis of variance (ANOVA) with repeated measures with appropriate post-hoc tests.  A p value of less than 0.05 will be considered significant.  The authors stated that the findings are expected to provide the information on the efficacy of EMDR therapy to manage moderate-to-severe pain in patients with primary dysmenorrhea.

PANDAS / PANS Syndrome

Guido and colleagues (2019) presented the results of EMDR therapy associated with parent management training (PMT) in a child with pediatric autoimmune neuropsychiatric disorder associated with streptococcus (PANDAS), who had previously only been treated with pharmacological treatment.  The case entailed a 11-year old boy who presented with simple and complex vocal tics, motor tics, obsessive-compulsive traits and irritability from the age of 6 years, in addition to a positive result for streptococcal infection.  The course of symptoms followed a relapsing-remitting trend with acute phases that were contingent on the infectious episodes.  The authors concluded that these findings suggested that EMDR may be used in patients with PANDAS/PANS syndrome, together with PMT.  Moreover, these researchers stated that additional studies examining the application of these therapies in a larger population are needed.

Psychosis

Adams and colleagues (2020) noted that there is increasing evidence suggesting that trauma can play a pivotal role in the development and maintenance of psychosis; EMDR is an effective treatment for trauma and could be a vital addition to the treatment of psychosis.  These researchers examined the evidence for EMDR as a treatment for psychosis, focusing on the safety, effectiveness and acceptability of this intervention for this population.  A total of 4 data-bases (Cochrane, Embase, Medline, and PsychINFO), as well as the Francine Shapiro Library were systematically searched, along with grey literature and reference lists of relevant papers.  No date limits were applied as this is an area of emerging evidence.  Studies were screened for eligibility based on inclusion and exclusion criteria.  The included studies were quality assessed and data were extracted from the individual studies, and synthesized using a narrative synthesis approach.  A total of 6 studies met the inclusion criteria (1 RCT, 2 pilot studies, 2 case series and 1 case report).  Across the studies EMDR was associated with reductions in delusional and negative symptoms, mental health service and medication use.  Evidence for reductions in auditory hallucinations and paranoid thinking was mixed.  No AEs were reported, although initial increases in psychotic symptoms were observed in 2 studies.  Average drop-out rates across the studies were comparable to other trauma-focused treatments for PTSD.  The acceptability of EMDR was not adequately measured or reported.  The authors concluded that EMDR appeared a safe and feasible intervention for people with psychosis.  The evidence is currently insufficient to determine the effectiveness and acceptability of the intervention for this population.  These researchers stated that larger confirmative trials are needed to form more robust conclusions.

The authors stated that this study had several drawbacks.  This was the 1st systematic review that examined the evidence of EMDR as a treatment for psychosis.  It was important to note that the populations and focus of EMDR varied amongst the studies; 4 of the studies focused on assessing the safety of using EMDR when treating PTSD in people with a psychotic disorder.  For these studies, it was difficult to determine if EMDR was directly responsible for the reduction in psychotic symptoms, or if it was the reduction in PTSD symptoms that caused subsequent reductions in psychotic symptoms.  Furthermore, the 2 studies evaluating EMDR for the treatment of individuals with psychosis without a co-morbid PTSD were able to provide preliminary results that EMDR could be a useful treatment for psychosis, but these studies were of lower quality.

Cuijpers and associates (2020) stated that there is no comprehensive meta-analysis of randomized trials examining the effects of EMDR on PTSD and no systematic review at all of the effects of EMDR on other mental health problems.  These investigators carried out a systematic review and meta-analysis of 76 trials.  Most trials examined the effects on PTSD (62 %).  The effect size of EMDR compared to control conditions was g = 0.93 (95 % CI: 0.67 to 0.18), with high heterogeneity (I2= 72 %).  Only 4 of 27 studies had low risk of bias, and there were indications for publication bias.  EMDR was more effective than other therapies (g = 0.36; 95 % CI: 0.14 to 0.57), but not in studies with low risk of bias.  Significant results were also found for EMDR in phobias and test anxiety, but the number of studies was small and risk of bias was high.  EMDR was examined in several other mental health problems, but for none of these problems, sufficient studies were available to pool outcomes.  The authors concluded that EMDR may be effective in the treatment of PTSD in the short-term, however, the quality of studies was too low to draw definite conclusions.  They stated that the is currently inadequate evidence to advise it for the use in other mental health problems.

The authors stated that they conducted a meta-analysis according to the current standards for such studies.  However, the results of a meta-analysis could never be better than the set of selected studies.  This was clearly an issue here because the included studies had several limitations.  These investigators already mentioned the small number of studies with low risk of bias, the high heterogeneity in most comparisons, and the lack of studies examining longer-term effects.  Especially the risk for selective outcome reporting and the small number of registered trials was striking.  Another limitation was that most trials had small sample sizes, with several having less than 10 subjects in each condition.  They stated that future research should focus on high-quality, sufficiently powered, randomized trials with long-term effects.  Without such studies, the effects of EMDR will remain as uncertain as they are now.  Despite these limitations, the results of this meta-analysis aid the authors in concluding that EMDR may be effective in the treatment of PTSD in the short-term and possibly have comparable effects as other treatments.  However, the quality of studies was too low to draw definite conclusions.  Furthermore, it was evident that the long-term effects of EMDR are unclear and that there is certainly inadequate evidence to advise its use in patients with mental health problems other than PTSD.

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 "+":
Eye movement desensitization and reprocessing - no specific code:
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:
D89.89	Other specified disorders involving the immune mechanism, not elsewhere classified [PANDAS/PANS]
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
H93.11 - H93.19	Tinnitus
H93.A1 - H93.A9	Pulsatile tinnitus
M05.00 - M06.9	Rheumatoid arthritis with rheumatoid factor
M54.5	Low back pain [chronic back pain]
M54.9	Dorsalgia, unspecified [chronic back pain]
N94.4	Primary dysmenorrhea
N94.5	Secondary dysmenorrhea
N94.6	Dysmenorrhea, unspecified
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: