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Developments in EMDR practiceMarbles in the elbow and other stories:
Using EMDR in the treatment of persistent pain
Helen MacdonaldDurham
7th October 2011
Developments in EMDR practice:Treatment of persistent pain
• Background and context– Impact of persistent pain– Why using EMDR can help
• Putting it into practice– Choosing targets for change– Using imagery
• Case exampleWhere losing your marbles can help
Background and context
• Why do EMDR clinicians and researchers take an interest in persistent pain– Impact of treating trauma on pain experience
• How many people we see who have persistent pain
• Impact of persistent pain on quality of life• Effectiveness of current treatments
The impact of pain: statistics• Between 10-50% of chronic pain patients
meet criteria for PTSD (Sharp 2004)
7.8 million people in the UK have a chronic pain problem - all ages
70% of sufferers are <60. 25% lose their jobs 22% develop depression
(Chronic Pain Coalition 2007)
4
What do we know about persistent pain?
• Pain: “An unpleasant sensory and emotional experience which is due to actual or potential tissue damage, or which is described in terms of such damage” Mersky and Bogduk (1994)
• Chronic pain ….duration longer than six months (DSM (iv), 1994)
• Usually refers to non-life-threatening conditions
(Cole, Macdonald & Carus 2005)
Acute pain: ‘Good’ pain
• Designed to protect the body from harm or minimise damage• Survival• It hurts.....–You stop doing it–It stops hurting–You don’t do it again
‘Bad’ Pain
• It hurts – You stop doing it– It doesn’t stop hurting– It doesn’t get better
• ?Not helping survival• E.g. The story ofPhantom Limb pain
Proposed Role of Memory in persistent pain
• Pain encoded as traumatic experience
• Pre-morbid traumas may be memory-linked to the pain (Grant, 2002)
• ‘Cognitive map’-body image and somatic experience (Lister, 2003 )
Information processing
• somatic memory of traumatic experience (pain)
chronic pain(Wilensky, 2006)
• Reprocessing the sensory experiences/ traumatic events facilitate resolution
• i.e. Re-consolidate memory as less distressing
Pain and memory
–Pain memory isolated from any potential adaptive information–Unresolved material easily triggered during
similar experiences• Intrusive thoughts • Emotions• Somatic response
Evidence
• Best evidence: Phantom Limb pain– Also:
• Aborting Migraine attacks• Headache• Medically Unexplained Symptoms (subjective
health complaints)• Fibromyalgia
Putting it into practice
• Own experience:• Current or past referral with persistent pain as
an issue• Impact on functioning• Potential targets- past, present, future?• What imagery?
Putting it into practice
• Usual assessment• Medication• Belief in person’s experience of pain• Education on the role of stress in experience
of physical symptoms• Appropriate management of other issues:– Substance misuse– Depression– Risk
Factors to consider• Investigations ( and what they mean)• Optimum management of the condition ?– E.g. Pain relief medication– Exercise/physiotherapy
• ‘Compliance’ with recommendations?• Is the person waiting for more medical input?• What does the person believe is happening?
The digestive biscuit story
Giving rationale for EMDR
• Increased coping• Changed attitude to
the pain• Reducing stress/
Relaxation• Decreased intensity• caution about
offering pain reduction as goal
Choosing a Target for EMDR: Past situations
• ‘What best represents this for you?’ • Specific image or memory– Trauma
• Pain related targets– Personal and physical constraints– Impact on life– Medical interventions
• Pain memories– Location of sensation(s)
• Responses of others
Choosing a Target for EMDR: Present situations
• Personal circumstances• Having needs met• Impact on daily life
Choosing a Target for EMDR: Future situations
• Thoughts and feelings about pain and future• Impact of pain on:– Family– Social life– Occupation– Economic circumstances
• Medical
Specific Antidote imagery: targeting the pain itself
• deRoos and Veenstra (2009)• Image of current pain sensation• Think of something that could take the pain away
or make it better – ‘antidote fantasy’• Imagery of healing• Using ‘antidote imagery’– Hoping for change in sensation
• Evidence that there are changes in image and sensation
Case example
• 47-year old man, involved in an RTA near to his workplace
• Severe damage to his arm, resulting in:– scarring– reduced function–persistent pain–Occupational and relationship changes
What could take the pain away?
• Medical treatment to make the elbow as it was before
• Antidote ‘fantasy’• Image: X-ray
Case example continued
• EMDR using the antidote image• Resources• Reduction in pain• Acceptance• Increased functioning
Developments in EMDR practice for Pain
• High level of unmet need: people in pain
• EMDR can facilitate changes in how pain is experienced somatically and emotionally.
• Specifically working with imagery and developing an ‘antidote’ can add to EMDR interventions with pain targets
Developments in EMDR practice:
• Limitations:
• Need for greater sample sizes in research• More consistent rigour in research• Need for better explanations of mechanism• Pain can get worse, particularly at first
References• Grant, M and Thelfro, C., (2002) EMDR in the treatment of chronic pain, in J. Clin. Psychol,
Dec;58(12):1505-20 • Grant, M ( 2001) Pain control with EMDR; a practitioner’s manual, New Hope• Hassard, A. (1995). Investigation of eye movement desensitization in pain clinic clients.
Behavioral & Cognitive Psychotherapy, 23 (2), 177-185.• Hekmat, H., Groth, S. & Rogers, D. (1994) Pain ameliorating effect of eye movement
desensitization. Journal of Behavior Therapy and Experimental Psychiatry, 25, 121-130• Lister, D (2003) Correcting the Cognitive Map with EMDR: A Possible Neurobiological
Mechanism, www.EMDR-practitioner.net• O’Keefe, J and Nadel L. (1978). The Hippocampus as a Cognitive Map. Oxford University Press • Rothschild, B ( 2000) The Body Remembers• Van den Hout et al (2010) Counting during recall: Taxing of working memory and reduced
vividness and emotionality of negative memories in: Applied Cognitive Psychology 24 no 3 303-311
• Van der Kolk, B, (1994) The body keeps the score. http://www.trauma-pages.com/vanderk4.htm
• Vanderlaan, L. (2000). The resolution of phantom limb pain in a 15-year old girl using eye movement desensitization and reprocessing. EMDR Clinician