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Eye Movement Desensitization And Reprocessing Treatment İn Sexual Trauma With Dissociative Symptoms: A Study Of Three Cases
MAKALE #16921 © Yazan Dr.Onur Okan DEMİRCİ | Yayın Temmuz 2016 | 2,631 Okuyucu
INTRODUCTION: Individuals who exposed to psychological trauma may live highest levels of fear and desperation. If an individual cannot give an appropriate biological or psychological response to the threat then psychological traumatization occurs1. Exposing to sexual trauma is very common in all communities. In a study, the ratio of adult women who exposed to sexual trauma was shown as 39.9%2. The most common reason of post traumatic stress disorder (PTSD) in women is sexual traumas3. In a study has shown that 57.1% of individuals were exposed to sexual trauma who had been diagnosed dissociative disorder diagnosis4.
Dissociation is collapsing in integrity of sense, identity, memory and environment sensations of an individual. Generally, occurs after PTSD as a defensive mechanism. Dissociative disorders were classified as a main topic first time in DSM-III5.
Although dissociative disorders are classifying as an apart class in DSM-V, there is also a subtype of PTSD named ‘PTSD with dissociative symptoms’6.
Eye Movement Desensitization and Reprocessing (EMDR) is a kind of therapy method that includes some techniques belongs to psychodynamic, cognitive and behavioural approaches
In this study, I aim that to share the results of EMDR treatment in three women who had dissociative symptoms after exposed to sexual trauma in their adult life.
Dissociative Experiences Scale (DES), Somatoform Dissociation Questionnaire (SDQ) and PTSD Checklist-Civilian Version (PCL-C) were performed to the patients before, 3 months after and 6 months after the EMDR treatment7,8,9, (Table I, Table II, Table III).
Case 1: A.G., a 31 years old female patient who graduated from high school and unemployed was consulted to psychiatry for amnesia, behavioural changes, sense of changing body parts and astonishment plaints. The plaints have been started about a year ago and no medical treatment was applied before. All medical examination results including blood tests, electroencephalography(EEG), magnetic resonance imaging (MRI) and consultations were normal. When the plaints were questioned in detail, the patient said that they were started after molestation of her boss in the office where the patient worked before. As a result of detailed examinations, PTSD with dissociative symptoms diagnosis was diagnosed to the patient according to the DSM-V. Standard 8 staggered EMDR protocol was applied to the patient. First session started with two recent distressed memories that belongs to patient which have ‘3’ and ‘4’ on a ‘10’ points of Subjective Units of Disturbance (SUD) scale. At that first memories SUD levels regressed to ‘0’ point easily. The session proceeded with the distressed memory that concerned with molestation. For this memory, she determined her negative cognition(NC) as ‘I am stupid’ and positive cognition (PC) that she wants to believe as ‘I am smart and I can learn’. She determined ‘fear’ as an emotion. She specified stomach-ache and dyspnoea as physical symptoms. She indicated ‘10’ points of score in SUD scale. In Validity of Cognition (VOC) scale which evaluates the belief to the PC, the patient determined ‘1’ on a ‘7’ points. The eye movement desensitization process was started for this memory. During the process she had amnesic situations a few times. She remembered some molestation memories during onwards sessions that belongs to the childhood of the patient which were not fully clear. EMDR was applied for all the distressed memories that the patient remembered. Dissociative symptoms were also treated with EMDR. At the end of total 8 sessions of EMDR treatment, all symptoms were regressed significantly.
Case 2: F.A., a 24 years old female patient who graduated from college and working as a teacher was consulted to psychiatry for amnesia, failure in teaching, irritability, feeling herself as another person and anxiety plaints. The plaints had been started about 9 months ago and escitalopram 20 mg/day treatment was applied before during 4 months. She quit medication a month ago because of no improvement in her plaints. All medical examination results including blood tests, EEG, MRI and consultations were normal. When the plaints were questioned in detail, the patient said that 9 months ago she had been stalked by someone until the front door of her house at midnight. After that, a fear emotion and thought about being followed by someone had been started. She told that, one day she was stalked again and the man who followed the patient attempted molestation this time. As a result of detailed examinations, PTSD with dissociative symptoms diagnosis was diagnosed to the patient according to the DSM-V. Standard 8 staggered EMDR protocol was applied to the patient. First session started with a recent distressed memory that belongs to patient which have ‘4’ on SUD scale. At that first memory SUD levels regressed to ‘0’ point easily. The session proceeded with the distressed memories that concerned with stalking and molestation. For this memories, she determined her NC as ‘I am in danger’ and she couldn’t determine any PC at he beginning. She determined ‘fear’ as an emotion. She specified palpitation and dyspnoea as physical symptoms. She indicated ‘10’ points of score in SUD scale. During the eye movement desensitization processes, she was talking about her fear and anxiety levels frequently. Especially in early on sessions, she was talking about feelings about watching herself as outside. During the session she indicated ‘I am going to fail’ and ‘I am powerless’ as NC lots of times. All memories which related with stalking fear were processed with EMDR. After she found a PC as ‘its over, I am safe now’, she relaxed significantly. EMDR was applied for all the distressed memories that the patient remembered. Dissociative symptoms were also treated with EMDR. At the end of total 7 sessions of EMDR treatment, all symptoms were regressed significantly.
Case 3: N.G., a 36 years old female patient who graduated from elementary school and unemployed was consulted to psychiatry for amnesia, irritability, onset insomnia, night terrors, difficulties in recognition of her relatives and suicidal thoughts. The plaints have been started about 3 years ago. She had been stayed in psychiatry clinic once before because of suicide attempt. All medical examination results including blood tests, EEG, MRI and consultations were normal. When the plaints were questioned in detail, the patient said that 3 years ago, she had a sexual assault and raped by a friend of her husband. As a result of detailed examinations, PTSD with dissociative symptoms diagnosis was diagnosed to the patient according to the DSM-V. She refused to take medical treatment. Standard 8 staggered EMDR protocol was decided for the treatment. First session started with a recent distressed memory that belongs to patient which have ‘3’ on SUD scale. Dissociative symptoms were aggravated during the sessions, even in distressed memories which had low levels of SUD. Because of this, advanced levels of EMDR was performed frequently. The session proceeded with the distressed memories that concerned with the sexual attack. For this memories, she determined her NC as ‘this is all my fault’ and she determined PC as ‘I am innocent’. She determined ‘shame’ as an emotion. She specified nauseating and contraction on her legs as physical symptoms. She indicated ‘10’ points of score in SUD and ‘1’ point in VOC scale. During processing of these memories, the patient had pseudoseizures frequently which look like absence seizures. She told that, she couldn’t remember the face of the hostile and she said ‘the victim doesn’t seem like me’. At this point, ‘confrontation with the hostile’ method as an imagination was used to exceed the process. In this method, an imaginary unbreakable glass was put between the hostile and victim. Thus, possibility of scourging of the hostile was prevented. After these interventions, the process proceeded again. EMDR was applied for all the distressed memories that the patient remembered. Dissociative symptoms were also treated with EMDR. At the end of total 12 sessions of EMDR treatment, all symptoms were regressed significantly.
DISCUSSION: PTSD is classifying under the main topic of ‘Trauma and Stress Related Disorders’ in DSM-V. PSTD can be occur via directly confronting the trauma, witnessing the trauma or learning a traumatic event that belongs to someone else. Flashbacks, continuous negative cognitions, avoiding reactions, attention deficit, sleeping disorders, irritability and anxiety symptoms are some components of PTSD. Some individuals who have PTSD also may have depersonalisation and derealisation symptoms6. EMDR may reveals dissociative symptoms in some of patients who haven’t before10.
In this study, all three cases were providing PTSD criteria and also had dissociative symptoms simultaneously. Some of these dissociative symptoms were exist before the treatment and some of them were occurred during EMDR sessions. When considered from this point of view, while performing EMDR treatment in patients who have highly risk of occurring dissociative symptoms, therapists should be careful. This shows us, EMDR treatment should perform by experienced clinicians. EMDR may reveals dissociative symptoms as it can be used in the treatment also.
At the present time only approved area of EDMR is PTSD treatment. But there are articles and case reports about usage of EMDR in other diagnosis of psychiatry like specific phobias, social phobias and vaginismus. In literature, there are very few researches about usage of EMDR in dissociation disorders. The data about usage of EMDR in patients who have PTSD with dissociative symptoms is also limited.
CONCLUSIONS: In these cases, by courtesy of EMDR treatment, there was significant decrease in DES, SDQ and PCL-C scores, PTSD symptoms and dissociative symptoms even in 6th month control examination. Consequently, EMDR can be an effective method in the long-term treatment of PTSD with dissociative symptoms and a good alternative to other treatment methods.
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Dr.Onur Okan DEMİRCİ
İstanbul
Doktor "Ruh sağlığı ve hastalıkları - Psikiyatri"
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