The Mind/Body Connection?
The use of EMDR therapy to treat chronic pain
Eye-movement desensitisation and reprocessing (EMDR) was originally developed as a treatment for post-traumatic stress disorder (PTSD) by Francine Shapiro in 1989. Since then it has become an empirically validated treatment for a wide range of psychological issues including depression (Ostacoli et al. 2018) obsessive-compulsive disorder (Marsden et al. 2018) and phobias (Doering 2013). EMDR therapy is informed by the adaptive information processing (AIP) model (Shapiro 2001), this theoretical framework posits that maladaptively processed memories from traumatic events are the cause of many psychopathologies. Unprocessed traumatic memories are thought to be stored in the ‘raw’ unintegrated form of emotions and physical sensations (Stickgold 2002) that are triggered in the present moment and cause the presenting symptoms.
The tenth international statistical classification of diseases (ICD-10; WHO 1993) classifies fibromyalgia as ‘chronic primary pain’ that is characterised by pain and fatigue resulting in ‘significant emotional distress’. Current preferred psychosocial treatment for chronic pain is cognitive behavioural therapy (CBT) which is effective in reducing catastrophizing and disability but the impact on pain intensity is negligible (Williams et al 2012). This is often combined with pain medication but both interventions focus on symptom management rather than alleviation. These treatment methods view fibromyalgia as ‘medical pain’ and it is regarded a symptom of a physical dysfunction, albeit origin unknown. Here the symptoms of fibromyalgia will be viewed from a trauma perspective, through an AIP lens and the research that validates this approach will be outlined.
The prevalence of fibromyalgia is approximately 2% worldwide (Clauw 2014) and it is more common in women. Studies have shown that there is a higher prevalence of depression and anxiety in patients with medical disorders with unknown etiology compared to patients with a diagnosis and healthy controls (Henningsen et al. 2003), suggesting that there is a relationship between medically unexplained symptoms and psychological stress. A stronger relationship has been found between PTSD and medically unexplained pain (Andreski et al. 1998) and notably a study by Cohen et al. (2002) found that 57% of a sample of fibromyalgia patients (N=77) displayed clinically significant levels of PTSD symptoms. A systemic review by Hauser et al. (2011) of 18 case-control studies (N=13095) found a significant association between fibromyalgia and childhood physical and sexual abuse but this was confounded by study quality. The relationship between fibromyalgia and trauma, specifically childhood abuse and neglect (Roelofs & Spinhoven 2007), suggests that its presenting symptoms might be the result of unresolved PTSD symptoms (van Rood & de Roos 2009).
The symptoms of fibromyalgia could be explained by the impact of chronic stress on the endocrine system and its impact on the body’s inflammatory response (Hänsel et al. 2010). Backryd et al. (2015) used multi-variate pattern analysis to reveal evidence of neuroinflammation (assessed in cerebrospinal fluid) and chronic systemic inflammation (assessed in plasma) in fibromyalgia patients. Chrousos (p375 2009) defines stress as a ‘state in which homeostasis is actually threatened or perceived to be so’ importantly, in relation to the AIP model, a perceived threat, based on a previous trauma, can induce the same response as if the threat was present. Chronic stress has repeatedly been shown to increase inflammation levels in animal models (eg. Wilson et al. 2013, Tramullas 2012) and a meta-study by Marsland et al. (2012) highlighted a clear correlation between exposure to life challenges and vulnerability to inflammatory disease in humans. Stress has a complex impact on the immune system function (Chrousos 1995) and disruption of hormone secretion activates a neurogenic inflammatory response which can result in stimulation of the sensory-afferent nervous system manifesting as hyperalgesia and fatigue (Chrousos 2009). Therefore, from an AIP perspective maladaptively stored memories from eg. sexual abuse, could trigger a physical response.
Van Rood and de Roos (2009) hypothesise that unprocessed memories maintain physically unexplained symptoms through the triggering of physical sensations that were experienced during the original traumatic event being re-experienced (van der Kolk and Fisler 1995) but I propose that the inflammatory response mechanism explained above underlies the phenomenon of fibromyalgia.
Multi-variate pattern analysis has revealed the intricate overlapping nature of the physical and social pain networks in the brain (Wagner et al 2013) and this is a key point when we hypothesise about stress being the underlying cause of fibromyalgia. It has been proposed that chronic emotional stress can cause inflammation of the ‘social pain’ networks of the brain i.e. insular, anterior cingulate, and secondary somatosensory cortices through over activation (Slavich et al. 2010). Central-sensitisation of the central nervous system (CNS) is recognised as an underlying pathophysiological mechanism in chronic pain disorders and is thought to cause pain hypersensitivity (Woolf 2011). It is feasible that chronic over activation of the social pain networks caused by external and internal stimuli triggering maladaptively stored traumatic memories, could cause an inflammatory response that spreads indiscriminately and has a negative impact on the pain networks in the brain. Therefore, from an AIP perspective the physical symptoms of fibromyalgia could be viewed as the effect of the unresolved memories on the central nervous system through activation of the overlapping social and physical pain networks. A study by DeWall and colleagues (2010) showed that the inverse of this is true when they reported that a three-week course of NSAID acetaminophen (paracetamol) diminished the effects of social pain after a social exclusion paradigm.
The use of EMDR for the treatment of fibromyalgia
EMDR is now recognised as a standard treatment for PTSD but its wider applications are now becoming clear and it has proven effective as a treatment for chronic back pain (Tesarz et al. 2013) as well as phantom limb pain (Behnam & Salehain 2014). The role of the stress response in exacerbation of the pain experience and development of chronic symptoms makes a good argument for the use of EMDR therapy as a valid intervention for pain management. The different stages of EMDR therapy could independently have a positive impact on chronic pain. The preparation phases of EMDR therapy (phases 1-3) could potentially lower background anxiety and redress the balance of an endocrine system that has been damaged because of chronic stress. The reduction of inflammation should reduce the fibromyalgia symptoms as well as comorbid MUS such as irritable bowel syndrome and dysmenorrhea (Wolfe et al 1990). Secondly, the reprocessing of traumatic memories that are linked to the genesis of fibromyalgia symptoms has been shown to lower the subjective level of pain (SUP) ratings of the client (Tesarz et al. 2014).
If you would like more information about EMDR or treating fibromyalgia please contact me on 07454533341 or via the contact form below-->>
(I currently have appointments in Cardiff on Wednesday and Thursday evenings., but can travel to you if between Cardiff - Barnstable- Bristol)
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