Effectiveness of Eye Movement Desensitization and Reprocessing on Post Traumatic Stress Disorder in persons with mild intellectual disability and psychosis: A multiple baseline study

Persons with mild intellectual disabilities (ID) and borderline intellectual
functioning (IF) have 2 to 4 times more chances of developing psychiatric
disorders (Dekker, Koot, Van der Ende, & Verhulst, 2002; Neijmeijer, et al.,
2013) as ptss (Mevissen & De Jongh , 2010; Didden et al., 2016; Wielland et
al., 2014) a psychosis (see eg, Cooper et al., 2007; Welch et al., 2011; Morgan
et al., 2008; Zammit et al. 2004). Although PTSD is common in psychosis, few
studies have been conducted on effective treatment methods in non-disabled with
comorbid PTSD and psychosis. Past or present comorbid psychotic disorder is the
highest criterion for exclusion in random clinical PTSD outcomes studies
(Bradley, Green, Russ, Dutra, & Westen, 2005; Powers, Halpern, Ferenschak,
Gillihan, & Foa, 2010; Ronconi, Shiner, & Watts, 2014; Spinazzola, Blaustein &
Van der Kolk, 2005). Research shows that 87% of clinicians see comorbid
psychosis as a contraindication for psychotherapeutic intervention, such as
long-term exposure (PE) (Becker, Zayfert, & Anderson, 2004). They feared
failure or symptom aggravation or the induction of false memories in this
vulnerable group (Becker et al., 2004; Van Minnen, Hendriks, & Ollf, 2010,
2010; Read, Hammersley & & Rudegeair, 2007). It is very important to
investigate effective treatments for individuals with a mild ID to borderline
IF and comorbid PTSD and psychosis. Since cognitive behavioral therapy mainly
includes verbal interventions, homework assignments and exercises outside the
sessions, this treatment seems less suitable for this target group. Treatment
studies in persons with mild ID and borderline IF are limited (Gilderthorp,
2014; Mevissen & De Jongh, 2010; Mevissen, Lievegoed & De Jongh, 2011; Mevissen
et al., 2016; Mevissen, 2016). Jowett and colleagues (2016) conclude from a
literature review of 6 case studies that there are sufficient indications that
EMDR is a safe intervention for this group of patients in the intellectual and
adaptive skills of persons with a mild ID and borderline IF.
Researchers of this current research are not aware of (published) studies on
the effectiveness of EMDR on PTSD in persons with mild ID and borderline IF and
psychosis. In studies in the general population it appears that EMDR is a safe
and effective method and even positively affects psychotic symptoms (see, for
example, De Fur, Van Minnen, De Jongh, 2013, De Bont, Van den Berg, Van der
Vleugel, & De Roos, 2016; Van den Berg & Van der Gaag, 2012).

The main purpose of this study is to find out whether EMDR is a safe and
effective treatment to reduce the symptoms of PTSD in people with mild
intellectual disability and borderline intellectual functioning.
In addition, it is expected to reduce the severity of symptoms of PTSD in
people who have a slight identifier to the F-boundary and psychosis after edder
treatment. In addition, it is expected that Amdere will also improve overall
performance and reduce mental complaints: hallucinations and hallucinations.
(Psi) and General

The present study uses a multiple baseline across subjects design. When
patients are eligible, they will be randomly allocated to different baseline
(B) lengths (a-e). The start of the therapy will be randomized over 3-7 weeks
of the baseline phase. Studies comparable to the proposed research (See de
Bont, et al., 2013, de Bont et al., 2016; Verhagen et al., in preparation) have
similar baseline lengths. For each baseline phase, two participants will be
randomly assigned. Participants will be weekly assessed with primary measures
during baseline (B), treatment (T) and post-treatment (P). Secondary measures
in order to measure auditory hallucinations, delusions and general
psychopathology will be applied at three time points (t1-t3). That is, before
and after treatment and at follow-up (FU), three months after the end of
treatment (Table 1).

Table 1 Planning of measurements

Baseline a : t1 BBB TTTTTTTTTTTTt2 PPPPPPP t3 FU
Baseline b : t1 BBBB TTTTTTTTTTTTt2 PPPPPP t3 FU
Baseline c : t1 BBBBB TTTTTTTTTTTTt2 PPPPP t3 FU
Baseline d : t1 BBBBBB TTTTTTTTTTTTt2 PPPP t3 FU
Baseline e : t1 BBBBBBB TTTTTTTTTTTTt2 PPP t3 FU


t1= baseline B= baseline 3-7 weeks T=treatment 12 weeks, P=post treatment 2-6
weeks, t2= post treatment measurement, t3 FU= follow up after 3 months.

During baseline, each participant will be assessed weekly for a period between
3-7 weeks on the ADIS-C-PTSD-LVB-Adult version (only the second part) and
potential/possible adverse events, and once on the AHRS, DRS, BSI and HoNOS
(t1). During the treatment phase (12 weeks) participants will be measured
weekly on the second part of the ADIS-C-PTSD-LVB-Adult version interview and
potential/possible adverse events. Participants will be assessed weekly for 3-7
weeks after the end of treatment on the ADIS-C-PTSD-LVB-Adult version (second
part) and potential/ possible adverse events. During this phase (t2) they will
also be assessed once on the AHRS, DRS, BSI and HoNOS. Three months after the
end of treatment (t3), participants will be assessed on all measures (i.e.,
ADIS-C-PTSD-LVB-Adult version (second part), AHRS, DRS, BSI and HoNOS.

EMDR is an eight-phase protocolized approach intended to resolve the symptoms
that can result from disturbing and unprocessed life experiences (Shapiro,
2001). The patient is asked to focus on an image that provides negative
emotional reaction. Then the patient is asked to call this disturbing event in
mind and focus on the most intrusive still image (called *target*), and the
negative thought about oneself (negative cognition), the negative emotion and
physical stress that is caused by the target. At the same time the patient is
asked to concentrate on a distracting task, preferably following the fingers of
the therapist moving from left to right. This is called desensitization and is
repeated until the negative charge on the target has become neutral and the
(physical) tension has decreased (Shapiro, 2001). Finally, the patient is asked
to replace his or here negative cognition with a positive cognition.
At the core of the EMDR method, the working memory taxation plays an
important role as an explanation for the treatment effects (Van den Hout &
Engelhard, 2011; Ten Broeke, De Jongh, & Oppenheim, 2012). The working memory
has a limited capacity and is therefore unable to retain the aversive memory
(target) in all its intensity while simultaneously paying attention to another
task. As a result, the memory is stored less vividly and emotionally
(Engelhard, Van den Hout, & Smeets, 2011; Gunter & Bodner, 2008; Kavanagh,
Freese, Andrade, & May, Van den Hout & Engelhard, 2011). Negative cognitions
associated with the memory of the traumatic event lose credibility and positive
cognitions become more believable (Van den Hout & Engelhard, 2011; De Jongh,
Ernst, Marques, Hornsveld, 2013; Ten Broeke et al., 2012). This leads to
changes in meaningfulness and consolidation of functional representations
(Baddeley, 2012).

The treatment as applied in this study
All participants will receive a maximum of twelve EMDR sessions of ninety
minutes. Early completion is allowed. For each participant, a case
conceptualization based upon the Two Method Approach (Ten Broeke, et al., 2012)
will be made, approved by an accredited supervisor of the Dutch EMDR
Association. After target selection, the standard EMDR-protocol in Dutch (De
Jongh & Ten Broeke, 2011) adapted from Shapiro*s (1995) work will be used.
Meanwhile all participants will continue to receive comparable treatment as
usual for psychosis delivered by multidisciplinary teams, with care usually
consisting of antipsychotic medication and treatment and/or supportive
counseling by psychiatrists, psychologists, nurses and case management.

Participants will be interviewed and tested before treatment, after treatment,
and at three months follow-up. That is a maximum of 24 times in 24 weeks. The
measurements will take approximately 360 minutes, no more than 15 minutes each
time. Participants will receive a maximum of twelve therapy sessions of
maximally 90 minutes each. A session of 90 minutes is according to the
guidelines of the general population. Early completion is allowed.
After the EMDR-sessions some participants might experience a short
increase in symptoms, which is a common response to this type of therapy. Major
adverse events are not to be expected nor have these been documented in
previous similar research with persons with or without mild ID and borderline
IF (Gilderthorp, 2014; De Bont, Minnen & De Jongh, 2013; Mevissen, Lievegoed &
De Jongh, 2011a; Mevissen, Didden, Korzilius, & De Jongh, Van den Berg et al.,
2015). Therapists are experienced in working with persons with mild ID to
borderline IF and psychosis and performing EMDR in persons with mild ID and
borderline IF and PTSD.