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)
Andreski, P., Chilcoat, H., & Breslau, N. (1998). Post-traumatic stress disorder and somatization symptoms: A prospective study. Psychiatry Research, 79, 131–138. DOI: https://doi.org/10.1016/S0165-1781(98)00026-2
Backryd, E. (2017). Evidence of both systemic inflammation and neuroinflammation in fibromyalgia patients, as assessed by a multiplex protein panel applied to the cerebrospinal fluid and to plasma. Journal of pain research, 10: 515–525. DOI: 10.2147/JPR.S128508
Behnam, M. & Salehian, T. (2014). The effect of eye movement desensitization and reprocessing on phantom limb pain in patients with amputation. Life Science Journal 2014;11(9s):519-522].
Blore, D., & Holmshaw, M. (2009). EMDR "blind to therapist protocol". In M. Luber (Ed.), Eye movement desensitization and reprocessing (EMDR) scripted protocols: Basics and special situations (pp. 233-240). New York, NY: Springer Publishing Co
Carlson, E. & Putnam, F. (1993). An Update on the Dissociative Experiences Scale. Dissociation: Progress in the Dissociative Disorders (DES-II). 6. 16-27. http://hdl.handle.net/1794/1539 (no DOI)
Clauw DJ. Fibromyalgia: a clinical review. JAMA 2014;311(15):1547–1555. DOI:10.1001/jama.2014.3266
Cohen, H., Neumann, L., Haiman, Y., Matar, M. A., Press, J., & Buskila, D. (2002). Prevalence of posttraumatic stress disorder in fibromyalgia patients: Overlapping syndromes or post-traumatic fibromyalgia syndrome? Seminars in Arthritis and Rheumatism, 32, 38–50
Chrousos, G. & Gold, P. (1992) The concepts of stress and stress system disorders: overview of physical and behavioral homeostasis. JAMA 267, 1244–1252. DOI:10.1001/jama.1992.03480090092034
Chrousos, G. P. The hypothalamic–pituitary–adrenal axis and immune mediated inflammation. N. Engl. J. Med. 332, 1351–1362(1995). DOI: 10.1056/NEJM199505183322008
Chrousos, G. (2009). Stress and disorders of the stress system, Nature Reviews Endocrinology, online vol. 5: 374, Nature Publishing Group. DOI:10.1038/nrendo.2009.106
Doering S, Ohlmeier MC, de Jongh A, Hofmann A, Bisping V. (2013). Efficacy of a trauma‐focused treatment approach for dental phobia: a randomized clinical trial. Eur J Oral Sci; 121: 584–593. DOI: 10.1111/eos.12090
Ehlert U, Gaab J, Heinrichs M. (2001). Psychoneuroendocrinological contributions to the
etiology of depression, posttraumatic stress disorder, and stress-related bodily disorders: the role of the hypothalamuspituitary-adrenal axis. Biol Psychol.;57:141–152. https://doi.org/10.1016/S0301-0511(01)00092-8
Felitti, V., Anda, R., Nordernberg, D., Williamson, D., Spitz, A., Edwards, V., Koss, M., & Marks, J. (1998) Relationship of childhood abuse to many of the leading causes of death in Stabilization of Complex PTSD adults: The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 14, 245–258. DOI: 9635069
Friedberg, F. (2004). Eye movement desensitization in fibromyalgia: A pilot study. Complementary Therapies in Nursing and Midwifery, 10, 245–249. DOI:10.1016/j.ctnm.2004.06.006
Gunter R. W., Bodner G. E. How eye movements affect unpleasant memories: Support for a working-memory account. Behaviour Research and Therapy. 2008;46:913–931. https://doi.org/10.1016/j.brat.2008.04.006
Hannibal, K., & Bishop, M. (2014). Chronic stress, cortisol dysfunction, and pain: A psychoneuroendocrine rationale for stress management in pain rehabilitation. Physical Therapy, 94(12), 1816-25. https://doi.org/10.2522/ptj.20130597
Hänsel, A., Hong, S., Camara, R. & von Känel, R. (2010) Inflammation as a psychophysiological biomarker in chronic psychosocial stress, Neuroscience & Biobehavioral Reviews, volume 35, Issue 1, 2010, Pages 115-121, ISSN 0149-7634, https://doi.org/10.1016/j.neubiorev.2009.12.012.
Hassard, A. (1995). Investigation of eye movement desensitization in pain clinic patients. Behavioural and Cognitive Psychotherapy, 23, 177–185. doi:10.1017/S1352465800014429
Häuser, W. , Kosseva, M. , Üceyler, N. , Klose, P. and Sommer, C. (2011), Emotional, physical, and sexual abuse in fibromyalgia syndrome: A systematic review with meta‐analysis. Arthritis Care Res, 63: 808-820. doi:10.1002/acr.20328
Heim, C., Ehlert, U., Hellhammer, D. (2000). The potential role of hypocortisolism in the pathophysiology of stress-related bodily disorders. Psychoneuroendocrinology;25:1–35.
Henningsen, P., Zimmermann, T., & Sattel, H. (2003). Medically unexplained physical symptoms, anxiety, and depression: A meta-analytic review. Psychosomatic Medicine, 65, 528–533.
International Statistical Classification of Diseases and Related Health Problems, 11th revision (ICD-11) Kind of resource: Database URL: http://apps.who.int/classifications/icd11/browse/l-m/en (Accessed Nov 2015)
Kroenke, K., Spitzer, R., Williams, J. (2001). The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med., 200;16(9):606-13.
Linton, S. (2000). A review of psychological risk factors in back and neck pain. Spine (Phila Pa 1976). 25:1148–1156
Loggia, M. (2015). An in Vivo Investigation of Brain Inflammation in Gulf War Illness with Integrated PET/MR Imaging. Massachusetts General Hospital, Boston, U.S. Army Medical Research and Materiel Command Fort Detrick,
Logie, R. D. J., & De Jongh, A. (2014). The “flashforward procedure”: Confronting the catastrophe. Journal of EMDR Practice and Research, 8, 25–32
Marsden Z, Lovell K, Blore D, Ali S, Delgadillo J. (2018). A randomized controlled trial comparing EMDR and CBT for obsessive–compulsive disorder. Clin Psychol Psychothery;25:e10–e18. https://doi.org/10.1002/cpp.2120
Marsland A., Walsh C., Lockwood K., John-Henderson N. (2017). The effects of acute psychological stress on circulating and stimulated inflammatory markers: A systematic review and meta-analysis, Brain, Behavior, and Immunity, Volume 64, 2017, Pages 208-219, ISSN 0889-1591, https://doi.org/10.1016/j.bbi.2017.01.011.
Melzack R. The McGill Pain Questionnaire: major properties and scoring methods. Pain 1975;1:277–99
Ostacoli, L., Carletto, S., Cavallo, M., Baldomir-Gago, P., Di Lorenzo, G., Fernandez, I., Hase, M., Justo-Alonso, A., Lehnung Maria, Migliaretti G., Oliva, F., Pagani, M., Recarey-Eiris, S., Torta, R., Tumani, V., Gonzalez-Vazquez, A., Hofmann, A. (2018). Comparison of Eye Movement Desensitization Reprocessing and Cognitive Behavioral Therapy as Adjunctive Treatments for Recurrent Depression: The European Depression EMDR Network (EDEN) Randomized Controlled Trial, Frontiers in Psychology , VOL9:74 DOI=10.3389/fpsyg.2018.00074
Riva, R., Mork, P., Westgaard, R., Lundberg, U. (2012). Comparison of the cortisol awakening
response in women with shoulder and neck pain and women with fibromyalgia, Psychoneuroendocrinology. ;37:299–306. DOI: https://doi.org/10.1016/j.psyneuen.2011.06.014
Roelofs, K., & Spinhoven, P. (2007). Trauma and medically unexplained symptoms towards an integration of cognitive and neuro-biological accounts. Clinical Psychology Review, 27, 798–820.
Shapiro F. (1989). Eye movement desensitization: A new treatment for post-traumatic stress disorder. J Behav Ther Exp Psychiatry ;20:211–7. DOI: https://doi.org/10.1016/0005-7916(89)90025-6
Shapiro, F. (1989). Efficacy of the eye movement desensitization procedure in the treatment of traumatic memories. Journal of Traumatic Stress Studies, 2, 199–223.
Slavich GM, Way BM, Eisenberger NI, Taylor SE. Neural sensitivity to social rejection is associated with inflammatory responses to social stress. Proc. Natl Acad. Sci. USA. 2010;107(33):14817–14822. DOI: https://doi.org/10.1073/pnas.1009164107
Spitzer, R., Kroenke, K., Williams, J., Löwe B. (2006). A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med., New York State Psychiatric Institute, New York.
Stickgold, R. (2002). EMDR: A putative neurobiological mechanism of action. Journal of Clinical Psychology, 58, 61–75. DOI: https://doi.org/10.1002/jclp.1129
Teneycke, T. (2012). Utilizing the Standard Trauma-Focused EMDR Protocol in Treatment of Fibromyalgia. (Electronic Thesis or Dissertation). Retrieved from https://etd.ohiolink.edu/
Tesarz, J., Gerhardt, A., Leisner, S., Janke, S., Hartmann, M., Seidler, G. H., & Eich, W. (2013). Effects of eye movement desensitization and reprocessing (EMDR) on non-specific chronic back pain: A randomized controlled trial with additional exploration of the underlying mechanisms. BMC Musculoskeletal Disorders, 14(1), 256. doi:10.1186/1471-2474-14-256
Tesarz, J., Leisner, S., Gerhardt, A., Janke, S., Seidler, G. H., Eich, W., & Hartmann, M. (2014). Effects of eye movement desensitization and reprocessing (EMDR) treatment in chronic pain patients: A systematic review: Systematic review: EMDR in chronic pain. Pain Medicine, 15(2), 247-263. doi:10.1111/pme.12303
Tramullas, M. (2012). Chronic psychosocial stress induces visceral hyperalgesia in mice. Stress (Amsterdam, Netherlands), 15(3), 281-292.doi:10.3109/10253890.2011.622816
van Rood, Yanda R.; de Roos, C. (2009). EMDR in the Treatment of Medically Unexplained Symptoms: A Systematic Review, Journal of EMDR Practice and Research, Volume 3, Number 4, 2009, pp. 248-263(16). DOI: 10.1891/1933-3220.127.116.11
Williams, A., Eccleston, C, Morley S. (2012). Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev;11:1–102 DOI: 10.1002/14651858.CD007407.pub3
Wilson CB, McLaughlin LD, Nair A, Ebenezer PJ, Dange R, et al. (2013) Inflammation and Oxidative Stress Are Elevated in the Brain, Blood, and Adrenal Glands during the Progression of Post-Traumatic Stress Disorder in a Predator Exposure Animal Model. PLOS ONE 8:10: e76146. DOI: https://doi.org/10.1371/journal.pone.0076146
Woolf C. (2011). Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011;152(3 Suppl):S2–S15. DOI: https://doi.org/10.1016/j.pain.2010.09.030
Wolfe, F., Smythe, H., Yunus, M., Bennett, R., & Bombardier C. (1990). Criteria for the classification of fibromyalgia. The American College of Rheumatology, Arthritis Rheum 1990; 33:160–72. https://doi.org/10.1002/art.1780330203
World Health Organization. (1990). Major depressive disorder. In International statistical classification of diseases and related health problems (10th ed.). Retrieved from http://apps.who.int/classifications/icd10/browse/2010/en#/F32 (accessed 5.4.18)