The role of EMDR in the reduction of psychological symptoms in patients with personality disorders.

Personality disorders are one of the most common psychological disorders.
Approximately 3-15% in the general population, 40-50% of the clients in health
care settings and 60-80% in forensic settings meet the diagnostic criteria
(Bamelis et al., 2014;Soeteman, Verheul & Van Busschbach, 2008).

Personality disorders are thought to be caused by a combination of genetic and
environmental influences. Negative life experiences are an example of
environmental influences and are associated with personality pathology as well
as many other psychological disorders (Kendler e.a., 2000).

According to cognitive models people with personality disorders act in
dysfunctional ways because of negative core beliefs. These core beliefs are
partially caused by negative life experiences and underlie information
processing and emotional and behavioral processes. The treatment of patients
with personality disorders generally requires an emphasis on understanding the
meaning to patients of their adverse childhood experiences; how these
experiences led to the development and maintenance of extremely strong, rigid,
global beliefs about the self, world, and others (Beck, 2005).

Evidence based psychological treatments for personality disorders are built on
the assumption that present situations provoke disturbing negative affect as
they activate previously installed detrimental reaction patterns, caused by
painful experiences. In Schema focused therapy (Young, 2003), for example,
early experiences play an important role, and techniques such as *imagery
rescripting* are used to create a new narrative of a traumatic event with a
more satisfactory outcome. In psychodynamic therapy too, present day problems
are linked to unconscious conflicts arising from past negative events (Freud,
1962).

The importance of past disturbing and painful experiences is not only
recognized in personality treatments, it is also a cornerstone of trauma
therapy. In trauma therapy an important intervention is eye movement
desensitization and reprocessing (EMDR). Since 2005 EMDR has been acknowledged
by the National Institute for Health and Clinical Excellence (NICE) as one of
the treatments of choice for post-traumatic stress disorder (PTSD) (NICE,
2005). The effectiveness of EMDR was originally researched in patients
suffering from post-traumatic stress disorder, but it has also been shown to be
effective in treating negative experiences in other patient groups, such as
patients suffering from psychosis (Van den Berg, e.a., 2015) and anxiety
disorders (De Jongh e.a., 2002). However, efficacy research on the
effectiveness of EMDR focused on negative experiences in patients with
personality disorders is missing.

Several theories have been proposed to explain the effectiveness of EMDR. In
the adaptive information processing (AIP) model the basis of clinical trauma
pathology is hypothesized to be dysfunctionally stored memories, with
therapeutic change resulting from processing these memories within larger
adaptive networks (Shapiro, 1995, 2001, 2007). Shapiro*s AIP model (2001)
posits that EMDR therapy facilitates accessing and processing traumatic
memories and other adverse life experiences enabling positive experiences and
affects to link into the traumatic network again. The AIP model suggests that
EMDR may be also beneficial to the treatment of personality disorders,
considering the association between adverse life experiences and personality
pathology. If important dysfunctional cognitions and emotions lose strength,
psychological symptoms reduce and new experiences can be gained, leaving a
better base for verbal interventions and behavioral changes.

Another benefit of using EMDR for early negative experiences in patients with a
personality disorder might be that during EMDR intense emotions are triggered
and patients experience that they are capable of coping with their emotions.
This might be an important experience, since avoidance of emotions
(experiential avoidance) is an important factor in the development of
personality pathology (Jacob et al., 2013; Berking et al., 2009). Focusing more
on diminishing experiential avoidance seems to be a promising intervention in
the treatment of personality disorders (Gratz, e.a., 2008).

In conclusion, early traumatic experiences and adverse life events contribute
to the development of personality disorders, EMDR could potentially be
beneficial to their treatment, for example bij reducing symptoms in a fast way.
EMDR could play a role in reducing both costs and therapy duration in the
treatment of personality disorders. EMDR is not yet investigated as an
intervention in the treatment of personality disorders.
The goal of this study, is to examine the effect of EMDR-treatment on
psychological symptoms and experiential avoidance in patients with a
personality disorder.

Hypothesized is that both psychological symptoms and experiential avoidance
will be less in patients receiving EMDR, compared to patients who did not
receive EMDR. We also hypothesize that patients undergoing EMDR will experience
less overall and trauma related psychological complaints.

EMDR could play a role in reducing both costs and therapy duration in the
treatment of personality disorders. The goal of this study therefore, is to
examine the effect of EMDR-treatment on psychological symptoms and experiential
avoidance in patients with a personality disorder.

If EMDR seems to have the effect as hypothesized and more studies can prove
this,
EMDR could be an inportant addition to the actual guidelines for the treatment
of personality disorders. Anyhow, it can be regcognized as an effective
intervention in the treatment of personality disorders.

The study design is a randomized controlled trial.

Patients with a personality disorder are randomly assigned to either the
experimental condition or the control group. Patients in the experimental
condition will receive four 90 minute sessions of EMDR and a session to make a
case conceptualization.

Case conceptualization will be performed by trained EMDR-practitioners. First,
all patients will be educated about the association between personality
disorders, negative experiences and core beliefs. Then, there will be an
individual analysis on how earlier life experiences play a role in actual
psychological symptoms. The EMDR-treatment will be given following the standard
protocol, added in the appendix.
EMDR will be given by therapists who received the official full 4-day training,
acknowledged by the Dutch EMDR association. After participating in the study,
all patients will receive the treatment as usual for personality disorders.

In the experimental group the questionnaires will be completed before and after
the five sessions of EMDR (on average five weeks after measurement 1).

In the control group measurement 1 will be right after randomization.
Measurement 2 will be after 5 weeks. Patients will be on a waiting list for 5
weeks (in the normal procedure they have to wait 4 weeks) and can contact GGZ
Delfland 24 hours a day if necessary.

Patients will complete three questionnaires, the Acceptance and Action
Questionnaire-II (AAQ-II), the Brief Symptom Inventory (BSI) and the Impact of
Event Scale (Schok Verwerkings Lijst). During intake a personality disorder is
diagnosed by the SCID-II.

Eye Movement Desensitization and Reprocessing is a therapy for people who as a
result of traumatic events experience psychological symptoms.It has already
proven to be effective in the treatment of a broader range of disorders.

The effectiveness of EMDR in the treatment of personality disorders has not yet
been investigated. However, a lot is written about the possible added value of
the use of EMDR in the treatment of personality disorders. Also, positive
results of EMDR have been found in vulnerable groups, such as in patients with
psychosis, without any negative side effects.
Also existing interventions in evidence based therapies for personality
disorders (such as schema focused therapy and psychodynamic therapy) are just
as trauma therapy based on the fact that present events provoke dysfunctional
emotions because they trigger earlier, painful memories. Studies show that
treating trauma in people with personality disorders is safe (Van Minnen e.a.,
2012).

After participation in this study, all patients will receive treatment as
usual for personality disorders.

After an EMDR session the effects can carry on for mostly three days and this
is a good sign. However, it could give the client the idea of having more
negative emotions, for example when new images or feelings arise. It is often
comforting to know that this usually does not last for more than three days and
after this a new balance occurs. Patients will be informed about this.