W. Nadler Ph.D. C.Psych.
This article describes Eye Movement Desensitization and Reprocessing (EMDR), a new treatment for Panic Disorder, and gives as an example of its application, details of a recent case which resulted in alleviation of panic attacks and a significant decrease in anticipatory anxiety within two sessions. The EMDR method also brought into consciousness a nexus of underlying issues and conflicts concerning loss, separation, anger and guilt. Implications for the treatment of panic are discussed within the context of the etiology of panic including the disparate ideas of Davanloo and Clark. EMDR may possess unique features that allow for a diverse array of treatment targets ranging from conditioned interoceptive sensations and catastrophic beliefs to repressed rage and grief.
EMDR was developed by Francine Shapiro in the late 1980's following the discovery that rapid movement of the eyes in sweeps from side to side for a brief period, while maintaining attention on a traumatic experience, produces a dramatic release of painful affect and a shift in negative beliefs about the event (1989a;1989b; 1994). The initial focus of the method was on the treatment of Post Traumatic Stress Disorder and there have been a variety of case reports and some controlled studies suggesting that positive, more adaptive self-referencing beliefs emerge spontaneously accompanied by improvement in typical symptoms of PTSD including intrusive flashbacks, nightmares, dysphoria and anxieties (EMDR Institute,1995). Over time the method has been adapted and applied to other disorders including phobias, addictions, obsessions, personality disorders and pathological grief. Thus far, only Goldstein and Feske (1994) have published an application of EMDR to panic disorder and agoraphobia (PDA). They report a series of seven cases where EMDR was used by an inexperienced therapist for a total of five 90 minute treatment sessions. All patients were formally diagnosed with panic disorder and most carried additional diagnoses of agoraphobia and generalized anxiety disorder. They invoked a cognitive-behavioral rationale for applying EMDR to panic disorder, suggesting that the core of panic disorder is the learned fear of the panic experience itself which occurs because of the traumatic nature of early panic attacks. EMDR, as a treatment for trauma may therefore assist those with panic disorder where the targets are significant panic experiences. Seven measures related to panic and agoraphobia were used pre and post to evaluate degree of improvement. Most patients appeared to benefit significantly from the treatment, with reductions in number of panic attacks and anticipatory anxiety as well as a wide variety of general symptoms of stress. Interestingly, in a discussion of the process of treatment, Goldstein and Feske noted that the EMDR method brought about desensitization and cognitive shifts for some patients who remained focused on the traumatic aspects of prior panic attacks with increasing degrees of relaxation, while for other patients, the method elicited streams of associations leading to memories, frequently from childhood, dealing with issues of mistrust, helplessness and profound loneliness. The emergence of traumatic childhood memories was not entirely surprising. As use of the method continued, it became evident to Shapiro (1991) that more than desensitization was occurring in the treatment process. While in some instances, focus on a trauma or anxiety in the presence of eye movements brought about rapid relief without triggering chains of associations, at other times, initial images gave way to earlier (often childhood) memories of disturbing experiences that appeared to lay the foundation for the present difficulty. When these underlying trauma were processed with eye movements and associated painful feelings and maladaptive beliefs altered, distress associated with the original target (trauma, phobia) was also resolved. Descriptions of such cases by Shapiro are reminiscent of the brief treatments of Freud and Breuer (1895/1955) and would resonate with anyone practicing psychodynamically oriented therapy or analytic hypnotherapy in general. Shapiro (1994) has framed the process of EMDR in cognitive rather than psychodynamic language in developing an Accelerated Information Processing model, but it represents a clear departure from behavioristic principles of learning and is strikingly psychodynamic in form with some obvious humanistic influences and a rudimentary suggestion of underlying neurological mechanisms. Briefly, Shapiro suggests that information from experience is organized at the neurological level in "networks" which are complex structures encoding cognitive, sensory and affective information, not unlike Leventhal's Perceptual Motor Processing model and the concept of "emotional schemata" (Greenberg & Safran,1987,Ch.5) . In the course of living, new information and experiences are naturally linked with older neuro-networks. When trauma occurs it is processed extensively by an innate, self-directed, neurologically based system until linkages are formed with adaptive information (old or newly acquired) and integration occurs. This inherent healing process is somewhat analogous to psychodynamic concepts of "completion tendency" and "repetition compulsion", and Gestalt ideas of "pragnanz and organismic valuing". Information that is highly charged with negative emotion, such as occurs during trauma, may however, overwhelm the innate processing system and become isolated in a state specific form from interaction with other networks and new learning. Although isolated, the trauma continues to exert influence on behavior and emotional states as stimuli trigger activation of the neuro-network and generate re-experiencings or emotionally driven action tendencies. The repetitive eye movements of EMDR manually stimulates this innate processing system while some dominant aspect of the painful, unassimilated material is present and barriers that keep material isolated are overcome in part or whole (thought to be related to synaptic potentials which are a function of intensity of affect) resulting in movement towards successful integration with adaptive learnings. A study of EMDR using quantitative EEG analysis suggested that psychopathological states are typified by depressed, asynchronous hemispheric functioning and that bilateral stimulation with eye movements or other stimuli may initiate an orienting response resynchronizing the hemispheres by mimicking the innate cortical pacemaker that is somehow suppressed by trauma (Nicosia,1994). Continued stimulation in the EMDR process allows integrated information processing at an accelerated rate.
Patient: Sarah, in her late 20's, was referred by her family MD with a diagnosis of panic disorder having rejected anxiolytics because they made her stuporous. She reported that a few months prior she experienced an unexpected "attack" at the hairdressers during which she felt dizzy and lightheaded, began shaking, found it hard to breathe, felt sick to her stomach and was seized with an overwhelming sense of fear that she might collapse or lose control, thus fulfilling DSM IV criteria for a panic attack (American Psychiatric Association,1994). Thereafter, she felt very tense most of the time and was vigilant for signs of dizziness, fearing that this indicated the onset of another attack. She frequently felt sick to her stomach, had trouble sleeping and became so uncomfortable being alone that she went out of her way to insure someone was with her most of the time. She also began to curtail many of the sports in which she had been previously active. In spite of efforts to calm herself, she experienced numerous partial panic attacks usually typified by lightheadedness, rapid heart beat, shakiness and the fear that she might collapse. Sarah was fully investigated medically with no significant findings. It was judged by the author that she met DSM IV criteria for panic disorder having experienced one major and numerous partial panic attacks along with the development of persistent concern about having additional attacks to the point of altering her usual independent behavior to insure that she was rarely alone. Her agoraphobic tendencies might best be considered subclinical. She experienced increased anxiety being anywhere by herself but without significant avoidance of situations. If alone, she carried on, enduring anxiety and was not particularly sensitive to situations from which escape might have been difficult. Sarah had experienced a similar attack a year ago when traveling abroad. She believed that one of her siblings might also be anxious but was unaware of any other psychopathology in the family. The context of Sarah's attack was her father's imminent remarriage, starting a new and "important" job and preparing for final exams. She described an idyllic early childhood with rather strict but not overprotective parents. She was the youngest of four, did well socially, was a good student and had been a healthy child. She was closer to her mother who developed a deteriorating illness when Sarah was quite young. In spite of the illness, the family functioned well and when the mother passed away in Sarah's adolescence, the siblings grieved together and the father was rather isolated. Sarah stated that she missed her mother and worried that her father's new marriage would disrupt things at home. Sarah was at a loss to explain her panic attacks except as a stress response. Sarah stated that she was reading a book on panic and thought it would help her cope. She asked to be seen as needed and wanted to master the panic on her own. Nothing was heard from Sarah for nearly a month, at which point she called saying her anticipatory anxiety had not abated, she had experienced a number of partial panic attacks and had been acutely anxious for the past few days. We discussed then implemented treatment with EMDR. EMDR Treatment: The rationale for using EMDR in this case flowed from the observation that the method seems to unlock memories and conflicts related to the target experience in a rapid manner. Sarah did not appear to have been traumatized by the panic itself and in spite of her assertions of confidence, her life experiences seemed prime for repressed feelings of loss and fears of imminent independence which would evoke unresolved attachment issues. Separation anxiety is considered one central factor in the development of PDA by numerous psychodynamic theorists (cf. Bowlby,1973; Nemiah,1988;Shear et.al.,1993) In particular, Davanloo has focused on the dynamics of PDA and asserts that there is a central conflict surrounding attachment and that real or perceived rejection or trauma within the process mobilizes reactive sadism which becomes deeply repressed along with extreme guilt and grief (Davanloo,1990;Kahn,1990). Although therapists may hold various hypotheses concerning the origin of patient symptoms, these actually influence the course of EMDR treatment in a minimal way. Material emerges spontaneously from the patient. The patient is asked to describe in detail the difficult experience or situation during which the target symptom arises. An image associated with the worst moment is identified along with a currently held negative self-referencing belief (such as "I'm to blame" or "I'm helpless"). Body sensations associated with negative affect are located and subjective units of distress (SUD) are estimated. A more positive, affirming belief is also generated. Once some aspect of the maladaptive material is in consciousness, eye movements are initiated in sets, approximately 20 seconds in length. At the end of a set, patients are simply asked what they are aware of at that moment. Further sets of eye movements are then implemented in successive waves as patients process more information and access memories or reorganize their perceptions spontaneously. The therapist provides little or nothing except for a holding environment unless the patient is obviously stuck in an unchanging feeling or memory. At that point, the therapist may "interweave" some bit of information that should help the patient move further along towards integration (Shapiro,1994). In Sarah's case, the scene was a moment at the office when she felt light-headed and then had a wave of fear. The belief was that she might collapse and be helpless and alone. Eye movements were then initiated. The first few sets produced increasing discomfort in the chest. When the focus moved directly to these sensations Sarah started to cry and speak of missing her mother. Further sets produced strong sobbing and then, haltingly, the belief that she had somehow caused her mother to die by not being good enough. This evolved with repeated sets into an expression of tearful rage with her mother who from infancy had expected Sarah to be perfect and adultlike, frequently punishing her through withdrawal of love for expressions of neediness. Sarah felt she was bad for crying or wanting comfort. Sarah then had the thought, along with waves of guilt, that she was actually glad her mother was dead. As processing continued there was a flood of memories of her mother's stiffness or rejecting behavior. With further sets, guilt diminished and she had the insight that she had never really been bad. Her needs had been those of a normal child. She now saw that her mother had always suppressed her own needs and that inside she felt bad the way Sarah was made to feel bad. Further sets produced increasing calm and a sense of herself as an adult. A check of her fear of the light-headed sensations indicated a reduction of SUDs to 1 from 9 (10 point scale). A second session was held two weeks later. Sarah reported significant relief after the first EMDR session with only a few odd sensations at work. These were then targeted with EMDR. It emerged that she loathed her job and had only taken it to please her father. This brought up anger with him, historically for being distant and currently for abandoning her by remarrying. She also realized that her current symptoms were an appeal to him to look after her and that as a child she had found physical illness the only reliable way to gain attention. Further, she realized that she had adopted her mother's martyrdom, suffering in "silence" but with numerous displays of her "suffering" as indirect recriminations. With continued processing Sarah realized that she needed to speak to her father, allowing herself to feel her anger directly and channeling it into action with regard to her home situation and plans for her future. She felt and sounded much less helpless.
Results: Sarah did not experience further panic attacks for the next six months during our occasional contact. Her anticipatory anxiety fell significantly except for a brief increase when she felt a surge of unnamed feelings and was afraid of being overwhelmed. Further EMDR processing brought feelings of sadness and being trapped at home into awareness, related to escalating conflict with the stepmother, and she realized it was time to leave. It was judged that the two initial EMDR sessions brought about significant symptomatic improvement. Sarah also had a greatly enhanced awareness of central conflicts that appear to have been the foundation of the panic problem. There was an improvement in her characterological style of generating somatic concerns to express emotional need and automatically repressing difficult emotions. This is not to say that there was a complete restructuring of her defenses or character, rather her presenting complaint was treated successfully with the additional benefit that she was now dealing more overtly with unresolved and emotionally charged issues.
Discussion: Understanding of PDA has evolved over the past decade. Early views of Klein (1981) and Sheehan , Ballenger and Jacobson (1980) that panic attacks are purely endogenous, neurophysiologically triggered phenomena were valuable in developing more effective pharmacological treatments but have given way to a number of diathesis models combining genetic and psychological dimensions. In particular, Clark (1986), Beck (1988) and Barlow (1988) from cognitive and behavioral perspectives have proposed conceptualizations emphasizing lowered alarm thresholds, constitutional neuroticism, interoceptive conditioning and the development of catastrophic beliefs concerning somatic sensations. These treatments are effective, often within 7 to 15 sessions but with reports of considerable residual anticipatory anxiety and a definite subset of patients with minimal or "low level change" (Barlow,1994;Clark,1994;Klosko et.al.,1990;Telch et.al.,1993). There are also themes of dependency conflict, immature defenses, low self-confidence and difficulty experiencing anger in the premorbid presentation of many panic patients (cf. Andrews et.al.,1990;Shear et.al.,1993;Tryer et.al.,1983) which raises the question of whether there is a responsibility or need to treat such vulnerabilities. A number of psychodynamic theorists have attempted to integrate ideas concerning biological vulnerabilities, personality development and unconscious conflicts over dependence, anger and guilt into models of PDA. Shear et.al.(1993) suggest that inborn neurophysiologic irritability predisposes certain children to experience parental behavior as abandoning or suffocating (whether real or imagined) and form object relations accordingly with threatening objects and a vulnerable, dependent self. Fantasies of being abandoned or trapped are easily activated and with a "weak" self, negative affects are generally anxiety provoking. Situations which actually or symbolically threaten security or create a sense of being trapped will trigger an alarm response as will any strong negative affect which causes somatic sensations without being consciously experienced. They argue that psychodynamic therapies could play an adjunct role with psychopharmacology and cognitive therapy in the treatment of PDA. Davanloo's Intensive Short Term Dynamic Psychotherapy (ISTDP) goes further with the view that PDA can be treated rapidly without medication or cognitive methods (Davanloo,1989a,1989b,1989c;Kahn,1990). ISTDP systematically challenges and restructures a patient's defenses to "unlock the unconscious", revealing the repressed neurotic core of guilt and grief-laden sadistic reactions to real or imagined failures of attachment figures during childhood. Bringing these feelings and impulses into consciousness is reported to dramatically reduce symptoms of panic in one or a few sessions. However, ISTDP requires years of training and supervision to learn, with real risk of harm if used improperly. It also presumes a unitary model for the development of PDA that precludes the possibility of simple cognitive or conditioned fears as an adequate explanation for some PDA and presumes that there is a specific premorbid personality for PDA which is supported to some degree (see above) but is contradicted by other studies that suggest a proportion of patients may be assertive, independent, emotionally stable and relatively fearless during periods free of PDA (Hafner,1982). Given the ubiquity of panic, numerous concomitant disorders, the low variance accounted for by inheritance (Barlow,1988), and the apparent effectiveness (and failures) of such diverse treatments as antidepressants, high potency benzodiazepines, breathing training, cognitive-behavioral therapy and ISTDP it seems plausible that there are multiple causal pathways in the etiology of PDA. Different patients may have different mixtures of neurophysiological, psychodynamic and learned factors. In this context, EMDR may offer a clinically unique treatment option or adjunct for PDA. As Goldstein found, some patients experience desensitization and the alteration of catastrophic cognitions without the emergence of underlying dynamic issues while others produce memories of earlier trauma or disturbance. In our clinic I have also found PDA patients who did not produce memories but became profoundly relaxed with an alteration of catastrophic beliefs. The present case highlights the rapid emergence of apparently unconscious conflicts over dependence, anger, grief and guilt as well as maladaptive characterological tendencies. It may be that something in the patients own process determines whether they experience desensitization or move into underlying memories/issues. Each type of patient may engage in the type of therapeutic process needed to recover. EMDR requires objective and controlled outcome and process research in its application to PDA, but case studies are at least promising. It may prove to be a truly patient-centered approach, delivering rapid symptomatic relief through desensitization and alteration of beliefs concerning symptoms in some patients while propelling those who have need along the path of more substantial personality change.
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