Article summary with Imagery rescripting and eye movement desensitisation and reprocessing for treatment of adults with childhood trauma-related post-traumatic stress disorder: IREM study design by Boterhoven de Haan a.o. - 2020

What is EMDR and ImRs?

Trauma-focused cognitive behaviour therapy (Tf-CBT) and eye movement desensitization and reprocessing (EMDR) have been identified as the most efficacious post-traumatic stress disorder (PTSD) treatments. Compared to other treatment modalities like pharmacotherapy, and to non-trauma-focused approaches, EMDR and Tf-CBT interventions have been identified as more effective at reducing PTSD symptom severity. The research on treatments for adults with childhood trauma-related PTSD (Ch-PTSD) has suggested that this population is difficult to treat due to the additional symptom complexity that can develop as a consequence of early trauma experiences.

Three main approaches for treatment of Ch-PTSD were outlined by Ehring and colleagues. One approach suggests that the aim of treatment should be on improving functioning through skill building, rather than focusing on trauma reprocessing. Secondly, there is the phase-based approach which incorporates skill building with trauma reprocessing techniques like prolonged exposure. The third approach uses trauma-focused treatments without any modifications to protocol. Treatments are categorized as trauma focused when they specifically target processing of trauma memories and their meaning.

There is much debate regarding the appropriateness of trauma-focused interventions, and some have argued that treatments which primarily focus on trauma reprocessing, are inappropriate for the Ch-PTSD population. Other trauma-focused treatments like EMDR and Imagery Respricting (ImRs) have been proposed for Ch-PTSD. EMDR and ImRs share similarities with prolonged exposure techniques by activating imagery, emotions and cognitions related to the trauma memory and providing corrective information.

EMDR asks individuals to recall their trauma experience in their mind while tracking the back-and-forth movement of the therapist’s finger. The dual attention focus facilitates reconsolidation of the original trauma memory so that it is less vivid and less distressing.

ImRs involves the individual imagining a different ending to a trauma experience. Individuals are encouraged to recall a memory in the first person, present tense as their child self. The memory is then rescripted, by imagining a different course of events, which helps to satisfy the needs of the person.

What is the aim of this study?

This article describes the study design of IREM, an international, multi-center randomized clinical trial (RCT) whose primary objectives are to compare the effectiveness of EMDR and ImRs in the treatment of Ch-PTSD and to test whether different mechanisms of change are involved. Various additional sub-studies will be performed which include investigating the participant and therapists’ perspectives of treatment, assessing the effects of treatment integrity, prediction of drop out and changes in how trauma memories are stored following treatment.

What method was used?

IREM is an international multicenter randomized controlled trial involving seven sites across Australia, Germany, and the Netherlands. We aim to recruit 142 participants who were randomly assigned to treatment conditions. Assessments were conducted before treatment until 1-year follow-up. assessments before and after the waitlist assessed change in time only.

The primary outcome measure was change in PTSD symptom severity from pre-treatment to 8-weeks post-treatment. Secondary outcome measures include change in severity of depression, anger, trauma-related cognitions, guilt, shame, dissociation, and quality of life. Underlying mechanisms of treatment will be assessed on changes in vividness, valence, and encapsulated belief of a worst trauma memory. Additional sub-studies will include qualitative investigation of treatment experiences from the participant and therapists’ perspective, change in memory and the impact of treatment fidelity on outcome measures.

Taking into account all the data collected, a mixed regression model was used to analyze the data. This identified any fixed or random effects resulting from the treatment and changes over time. A mixed logistic regression analysis was used for diagnostic outcomes. A mixed gamma regression was used for skewed distributions. Poisson or negative binomial regression as used for analyzing medication use and other count data. Analysis included an intent-to-treat sample.

The mechanism test was done by advance medication tests, using multiple assessments of dependent variables (CAPS-5, IES-R) and variables representing indices that should predict change in symptoms (imagery interview-based ratings of vividness, valence, and encapsulated beliefs of the primary trauma memory).  Secondary investigations were performed as additional sub-studies to explore and further the authors’ understanding of the effectiveness of EMDR and ImRs in the treatment of Ch-PTSD.

What conclusions were made and discussed?

This study described the study design of IREM, an international multicenter RCT comparing the effectiveness of EMDR and ImRs for treatment of Ch-PTSD. this RCT and the additional sub-studies broadened the understanding of the effectiveness of these approaches in Ch-PTSD treatment and help furthering our understanding of their underlying mechanisms of change.

The evidence from this RCT will contribute to clinical decisions on whether to use trauma-focused approaches for the sequela associated with Ch-PTSD. while the primary aims of this study were to compare EMDR and ImRs treatments on PTSD symptom severity and to clarify whether or not different mechanisms of change are involved, secondary outcome measures will assess some disturbances associated with Ch-PTSD such as guilt, shame, anger, and dissociation. EMDR and ImRs might more directly target change through cognitive and experiential mechanisms, thus having a greater impact on a wider range of symptoms than just PTSD.

This study contributes to the growing evidence for the efficacy of trauma-focused treatment for Ch-PTSD. the documented lack of implementation of trauma-focused approaches has highlighted the need to explore treatments, which will be accepted to both participants and therapists. A large issue for treating Ch-PTSD is the perception that individuals won’t be able to tolerate treatment. However, it is unclear if the reluctance to engage in trauma-focused treatment is a shared view as it is suggested that avoidance of the therapist is a much greater barrier. This RCT will be able to contribute to our knowledge of participants’ capacity to engage in treatment. The exploration into therapist and participants’ perspective will help to identify barriers and issues with the implementation of treatment.

Taken together, findings from this RCT will make a significant contribution towards developing best practice for treating PTSD caused by childhood experiences. Both EMDR and ImRs hold promise as being efficacious treatments for Ch-PTSD and the sequela of symptoms associated with this disorder.