EMDR and the Anxiety Disorders: Exploring the Current Status

Ad de Jongh University of Amsterdam and Vrije Universiteit, The Netherlands Erik ten Broeke Visie, Deventer, The Netherlands

Based on the assumptions of Shapiro’s adaptive information-processing model, it could be argued that a large proportion of people suffering from an anxiety disorder would benefi t from eye movement desen- sitization and reprocessing (EMDR). This article provides an overview of the current empirical evidence on the application of EMDR for the anxiety disorders spectrum other than posttraumatic stress disorder (PTSD). Reviewing the existing literature, it is disappointing to fi nd that 20 years after its introduction, support for the effi cacy of EMDR for other conditions than PTSD is still scarce. Randomized outcome research is limited to panic disorder with agoraphobia and spider phobia. The results suggest that EMDR is generally more effective than no-treatment control conditions or nonspecifi c interventions but less ef- fective than existing evidence-based (i.e., exposure-based) interventions. However, since these studies were based on incomplete protocols and limited treatment courses, questions about the relative effi cacy of EMDR for the treatment of anxiety disorders remain largely unanswered.

Keywords: eye movement desensitization and reprocessing (EMDR); anxiety disorders; specifi c phobia; panic disorder

he past three decades have witnessed signifi - At the end of the 1980s, the fi rst publications of a cant advances and growth in research on anxi- newly developed method, eye movement desensitiza- T ety disorders (Boschen, 2008). Growth has tion and reprocessing (EMDR), emerged. This began been strong for its treatment for which a wide array with Shapiro’s (1989) study on the effects of EMDR of behavioral and cognitive interventions have been on a single traumatic memory. After its publication, proposed and investigated. With regard to the effec- it took years before the fi rst randomized clinical trial tiveness of these procedures, the results of a recent was published that supported the notion that EMDR comprehensive meta-analysis demonstrated not only was capable of treating full-blown posttraumatic stress that cognitive behavioral interventions are particu- disorder (PTSD) within a limited number of sessions larly effi cacious but also that there are marked differ- (Wilson, Becker, & Tinker, 1995). In the years there- ences in treatment responsiveness among the different after, many other studies followed, and now, 20 years types of anxiety disorders (Hofmann & Smits, 2008). after the fi rst EMDR publication, there is enough evi- Treatment effects appear particularly large for acute dence to conclude that the method is an established, stress disorder (ASD) and obsessive-compulsive dis- time-limited treatment for PTSD (Bisson et al., 2007). orders (OCDs) but are less strong for panic disorder Based on the notion that EMDR is capable of re- and generalized anxiety disorder (GAD). The authors solving disturbing memories of traumatic events that conclude that there is still considerable room for are critical in the development and maintenance of improvement in the treatment of anxiety disorders PTSD, it could be asserted that other types of anxiety (Hofmann & Smits, 2008). disorders that developed following a distressing event

Journal of EMDR Practice and Research, Volume 3, Number 3, 2009 133 © 2009 EMDR International Association DOI: 10.1891/1933-3196.3.3.133 would also be responsive to EMDR. This notion is at From a theoretical point of view, EMDR could play the basis of Shapiro’s adaptive information-processing a role in the treatment of panic disorder, as there are (AIP) model, a framework that is considered to be indications that panic disorder and agoraphobia often helpful to therapists when developing a problem start after a stressful life event (Kleiner & Marshall, formulation in terms of a relationship between 1987). In addition, there is evidence to suggest that memories of disturbing events and clients’ current many panic patients suffer from PTSD-like symptoms anxiety symptoms and the use of EMDR for resolv- as a result of their fi rst panic attack (McNally & Lukach, ing these memories (Solomon & Shapiro, 2008). 1992). Indeed, since the development of EMDR, a large Beside incidental reports of therapists suggesting number of articles have appeared, suggesting a posi- that EMDR can be successfully applied to panic disor- tive effect of EMDR on the symptoms of individuals der with agoraphobia (de Jongh & ten Broeke, 1996; suffering from various anxiety-related conditions. Be- Fernandez & Faretta, 2007), not many studies have cause anxiety symptoms are common in patients who been published, and those that have been conducted use primary and secondary mental health services, it were carried out by the same research group (Feske & is important to evaluate the potential of EMDR as a Goldstein, 1997; Goldstein, de Beurs, Chambless, & contribution to the treatment of anxiety disorders. Wilson, 2001; Goldstein & Feske, 1994). Their fi rst This article provides an overview of the current publication that concerned a series of seven persons empirical evidence on the application of EMDR for diagnosed with panic disorder yielded promising anxiety disorders beyond the typical traumatically results (Goldstein & Feske, 1994). It was found that induced conditions like PTSD and ASD. First, the most patients benefi ted signifi cantly from EMDR, key symptoms of each condition within the spectrum with reductions in number of panic attacks, sever- of anxiety disorders (i.e., panic disorder with and with- ity of anticipatory anxiety, and occurrence of general out agoraphobia, social phobia, specifi c phobia, OCD, symptoms of distress. In a subsequent randomized and GAD) are initially reviewed, as are the assumptions controlled study of the same researchers using a simi- as to why this condition may be suitable for the appli- lar treatment protocol, the effectiveness of EMDR cation of EMDR. Next, the available research is sum- was compared with a protocol in which the eye move- marized. Finally, some general conclusions are drawn. ments were omitted and a wait-list condition (Feske & Goldstein, 1997; see Table 1). EMDR appeared to be Panic Disorder With or Without more effective than both no-treatment and an EMDR Agoraphobia protocol, in which the eye movements were lacking, on a number of self-report measures. However, at The central clinical features of panic disorder are the the 3-month follow-up, these differences could not be panic attacks, the associated feelings of losing con- maintained. Four years later, the same research group trol, and the fact that these are recurrent (American published another randomized clinical trial for panic Psychiatric Association, 2000). Many panic patients disorder with agoraphobia (Goldstein et al., 2001) in suffer from agoraphobia, as they tend to avoid situa- which the effectiveness of EMDR was compared with tions from which escape might be diffi cult or in which a relaxation condition used as an attention-placebo help may not be available in the event of having a control condition (association and relaxation therapy panic attack (e.g., being outside the home alone). [ART]). The use of ART in this study appeared to be Strictly speaking, there is no indication for EMDR very similar to EMDR with the exception of EMDR’s in the treatment of panic disorder because there are distraction/bilateral stimulation component. Patients already evidence-based psychological interventions in the ART condition received 30 to 45 minutes of available with cognitive-behavioral therapy being the progressive muscle relaxation training, after which most important. A number of treatment approaches they were asked to describe the scene of their most have been established in controlled trials as being frightening panic-related memory in detail, to close effective, including exposure treatment, reduction their eyes, and to speak out loud as they followed of avoidance, and cognitive treatments focusing on themselves to associate to this image (“let come up the modifi cation of panic attacks (National Institute whatever comes up”) for about 45 to 60 minutes of for Clinical Excellence, 2004). However, the long- association. As to the results, it appeared that the cli- term outcome of these studies appears to be limited, ents in the EMDR condition did not fare better on any and the vast majority of panic disorder patients need of the measures than those who were asked to just prolonged additional treatment (van Balkom, de associate on the target memory. Conversely, EMDR Beurs, Koele, Lange, & van Dyck, 1996). appeared to be signifi cantly superior to the wait-list

134 Journal of EMDR Practice and Research, Volume 3, Number 3, 2009 de Jongh and ten Broeke TABLE 1. Randomized Clinical Trials Pertaining to EMDR’s Effectiveness on the Area of Anxiety Disorders No. (and duration of Sample sessions in Authors Year Treatment (n) Characteristics minutes) Outcome Variables Effects Panic Disorder With Agoraphobia Feske and 1997 1. EMDR (15) Panic disorder 1, 3, 4: fi vea a. Social concerns 1 > 2 (a–f ) Goldstein 2. Wait list (12) with almost all (one 120-minute and general 3 > 4 (b, d, f ) and having and four anxiety 3-month 3. EMDR (18) agoraphobia 90-minute b. Anticipated follow-up: 4. EMDR with sessions) panic and coping 1 = 2 eye movements c. Physical concerns 3 = 4 omitted (18) d. General anxiety and fear of panic e. Panic frequency f. Variety of secondary measures Goldstein, 2001 1. EMDR (18) Outpatients 1–2: four a. Panic/agorapho- 1 = 2 (a–d) de Beurs, 2. Attention- applying for (90-minute bia severity 1 > 3 (a–b) Chambless, placebo, ART treatment; panic sessions) b. Diary 1 = 3 (c–d) and Wilson (13) disorder with c. Frequency of Same results 3. Wait list (14) agoraphobia anxious for 1-month (based on cognitions follow-up Structured d. Frequency of Clinical panic attacks Interview for DSM Disorders) Specifi c Phobia Muris and 1997 1. EMDR (8) Spider-phobic 1–3: one a. Spider fear 1 > 2 (a) Merckel- 2. Imaginal adults (60 minutes) b. Approach 1 = 2 (b) bach exposure (8) 4: one behavior 4 > 1–3 3. No-treatment (150 minutes) After 4, all control groups group (8) improved to 4. All conditions an equal level were followed (a, b) with in vivo exposure Muris, 1997 1. EMDR (11) Spider-phobic 1–2: one a. Spider fear 1 = 2 (a, c) Merckelbach, 2. In vivo children (90 minutes) b. Approach 2 > 1 (b) van Haaften, exposure (11) behavior and Mayer c. Skin conductance Muris, 1998 1. EMDR (9) Spider-phobic 1–3: one a. Spider fear 1 > 3 (b) Merckelbach, 2. In vivo children (150 minutes) b. State anxiety 2 > 1 (a–c) Holdrinet, exposure (9) 4: one during After 4, all and Sijsenaar 3. Computerized (90 minutes) confrontation groups exposure (8) with spider improved to 4. All conditions c. Approach an equal level were followed behavior (a–c) with in vivo exposure

aThe treatment consisted of six sessions but included one session involving history taking.

Journal of EMDR Practice and Research, Volume 3, Number 3, 2009 135 EMDR and the Anxiety Disorders condition on panic and agoraphobia severity, albeit greatest potential risk of precipitating specifi c phobia no signifi cant change was apparent on cognitive mea- (Oosterink, de Jongh, & Aartman, 2009). Some types sures or on panic attack frequency. of specifi c phobias (e.g., those involving fear of chok- It has been argued that a longer course of prepara- ing, road traffi c accidents, and dental treatment) display tion (i.e., affect regulation) may have led to a better remarkable commonalities with PTSD, including the outcome (Shapiro, 1999). This notion is supported reoccurrence of fearful memories of past distressing by a case described by Fernandez and Faretta (2007), events that are triggered by the phobic situation or who treated a woman with panic disorder and ago- object but may also occur spontaneously (de Jongh, raphobia and used a preparation phase of six sessions Fransen, Oosterink-Wubbe, & Aartman, 2006). To prior to EMDR treatment, which lasted 15 sessions. this end, it is conceivable that EMDR may be an effective Their approach led to complete remission of symp- treatment for specifi c phobias. An important advantage toms and maintenance of positive behavioral changes of using EMDR compared to exposure-based treat- at 1-year follow-up. ments is that the use of in vivo exposure for a variety of phobias (e.g., fl ight phobia, wasp phobia) may be Social Phobia diffi cult to carry out. Although there are a large number of uncontrolled Social phobia, also known as social anxiety disorder, case studies using EMDR with specifi c phobias, only involves intense fear and avoidance of situations that two controlled case reports have been published. These are unfamiliar to the person and whereby he or she demonstrate positive effects on both fear and avoidance expects to be watched, evaluated, scrutinized, or in claustrophobia and dental phobia (de Jongh, van den embarrassed by others (American Psychiatric Asso- Oord, & ten Broeke, 2002; Lohr, Tolin, & Kleinknecht, ciation, 2000). 1996). As is the case for all anxiety disorders, for social Recently, a cross-sectional study was conducted in- anxiety there are treatment approaches that have vestigating the comparative effects of EMDR and trau- been found to be effective, particularly those with ma-focused cognitive-behavioral therapy (TF-CBT) a cognitive-behavioral signature (Hofman & Smits, among a sample of 184 people suffering from travel fear 2008). Although there should be good reasons to devi- and travel phobia (de Jongh, Holmshaw, & Hodder, ate from evidence-based treatment standards, EMDR 2009 ). TF-CBT consisted of imaginal exposure added could fulfi ll an additional role in resolving memories with elements of cognitive restructuring, relaxation, of past events of ridicule or rejection, particularly and anxiety management. In vivo exposure during when these are likely to be activated when the client treatment sessions was discouraged for safety and in- is confronted with a social event. Although in consul- surance reasons, but patients were expected to con- tation sessions clinicians frequently report the use of front diffi cult situations without the therapist (e.g., EMDR as remarkably effective in cases of social pho- returning to the scene of the accident, self-exposure to bia, such cases are rarely described and published. An cars, or other anxiety-provoking cues). Patients were exception is a case reported by Sun and Chiu (2006), considered to have completed treatment when it was who reported the successful treatment of a psychiatric agreed that the patients’ improvement had plateaued outpatient with long-lasting social phobia. Unfortu- or that they were unlikely to make signifi cant further nately, because EMDR treatment was combined with progress in treatment. The mean treatment course mindfulness training, it does not support the use of was 7.3 sessions. No differences were found between EMDR as a sole treatment of social phobia. both treatments. Both treatment procedures were Specifi c Phobia capable of producing equally large, clinically signifi - cant decreases on measures indexing symptoms of Specifi c phobia is a condition highly prevalent in the trauma, anxiety, and depression as well as therapist general population (American Psychiatric Associa- ratings of treatment outcome. tion, 2000) and one that amounts to an unreasonable Despite the potential of EMDR as a treatment of or irrational fear related to exposure to specifi c ob- specifi c phobias, randomized controlled outcome jects or situations. As a result, affected persons tend to research has remained limited to three studies in actively avoid direct contact with these stimuli. total. All pertained to the treatment of spider pho- With regard to the onset of phobias, it has been bia and were carried out by the same research group found that, like in cases of PTSD, particularly highly (Muris & Merckelbach, 1997; Muris, Merckelbach, disruptive emotional reactions (i.e., helplessness) dur- Holdrinet, & Sijsenaar, 1998; Muris, Merckelbach, van ing an encounter with a threatening situation have the Haaften, & Mayer, 1997; for a review, see de Jongh,

136 Journal of EMDR Practice and Research, Volume 3, Number 3, 2009 de Jongh and ten Broeke ten Broeke, & Renssen, 1999; see also Table 1). In one with EMDR are sparse, and the effects reported in the study, 24 subjects were randomly assigned to either literature show that EMDR has limited potential to EMDR treatment, imaginary exposure, or a no- contribute to the treatment of this condition (Bae, treatment control group (Muris & Merckelbach, 1997). Kim, & Ahn, 2006; Corrigan & Jennett, 2004). Both the EMDR and the imaginary exposure group received 1 hour of treatment, while the control group GAD waited for 1 hour. All procedures were followed by GAD is defi ned as excessive and uncontrollable worry in vivo exposure. Although EMDR resulted in strong about a number of different life events and accompa- changes on the Subjective Units of Distress Scale, only nying somatic symptoms of anxiety, such as agitation, the exposure group showed improvements on a mea- tiredness, trouble concentrating, irritability, muscle sure of approach behavior. In another study, one ses- tension, or sleep disturbance (American Psychiatric sion of EMDR was compared to one session of in vivo Association, 2000). GAD is considered to be a condi- exposure treatment using a crossover design with tion that loads most highly on neuroticism and for spider-phobic children (Muris et al., 1997). In vivo ex- which unique infl uences in terms of onset appear posure was found to be superior in reducing avoid- to be rare (Mineka, Watson, & Clark, 1998). How- ance behavior. The third study also focused on the ever, there is evidence to suggest that in individual effectiveness of EMDR among children by compar- cases, the specifi c cognitive dynamic of GAD could be ing the effects of EMDR with those of vivo exposure rooted in multiple disturbing experiences in a client’s and computerized exposure (Muris et al., 1998). All learning history (Roemer, Molina, Litz, & Borkovec, treatments were followed by a session of in vivo expo- 1997). When it is possible to assess memories of such sure. EMDR resulted in signifi cant improvement on a specifi c experiences, theoretically EMDR could de- measure of self-reported fear and appeared to be sig- liver a contribution to a general cognitive-behavioral nifi cantly more effective than the computerized ex- treatment plan. posure treatment. However, in vivo exposure was The only example in this area evaluating the po- found to produce superior treatment results with tential effectiveness of EMDR is a study among four regard to approach behavior. clients using a multiple-baseline-across-participants de- sign (Gauvreau & Bouchard, 2008). This study, which OCD included 15 treatment sessions of EMDR, showed that EMDR treatment was effective in reducing worry and OCD is characterized by recurrent obsessional rumi- associated anxiety. Self-report measures and clinician- nations, images, or impulses or recurrent physical administered measures indicated that after EMDR or mental rituals that are distressing and time con- treatment and at 2 months follow-up, all participants suming and that cause interference with social and no longer met the diagnostic criteria of GAD, two of occupational function (American Psychiatric Associ- which were in full remission. ation, 2000). Common obsessions relate to contami- nation, accidents, and religious or sexual matters; Discussion common rituals include washing, cleaning, checking, and counting. Based on the assumptions of Shapiro’s AIP model, it As research shows that clients with OCD respond could be argued that if EMDR is capable of acceler- relatively well to cognitive-behavioral interventions ating recovery from pathology that have arisen from (i.e., exposure and response prevention and cognitive disturbing life events, a large proportion of individu- therapy) EMDR will generally not play an important als suffering from an anxiety disorder may benefi t role in the treatment of OCD. However, there may be from EMDR. To this end, it remains unfortunate to exceptions. For example, there is evidence to suggest note that, now, 20 years after its introduction, sup- that stressful events precipitate this disorder and that port for EMDR’s effi cacy for other conditions than in some cases a causal link between severe trauma PTSD is still scarce. There is randomized outcome and the onset of OCD can be identifi ed (see De research for panic disorder and specifi c (i.e., spider) Silva & Marks, 1999). Therefore, it could be argued phobia, but for the other anxiety disorders (i.e., so- that if the condition has a direct and known onset and cial phobia, OCD, and GAD), well-designed clinical the client’s memory of that event is still emotionally trials or even less rigorous forms of outcome research charged, it may be helpful to desensitize the memory are completely lacking. The results of the studies that and to evaluate its effect on the client’s symptomatol- have been conducted look promising but are cer- ogy. However, case reports on the treatment of OCD tainly not convincing. It would seem that EMDR is

Journal of EMDR Practice and Research, Volume 3, Number 3, 2009 137 EMDR and the Anxiety Disorders generally more effective than no-treatment control as the occurrence of emotionally laden memories may conditions or nonspecifi c interventions but less ef- have exerted negative effects on patients’ functioning fective than existing evidence-based interventions. after therapy. In addition, it is diffi cult to understand Regarding the treatment of spider-phobic children, why a treatment course as short as four sessions in for instance, one long-session EMDR has been found total was chosen, as Feske and Goldstein themselves to be signifi cantly more effective than computerized stated that even 10 to 16 sessions of the most powerful exposure treatment but also less effective than an in treatments rarely result in positive outcomes in cases vivo exposure. Concerning panic and agoraphobia where panic disorder is complicated with agorapho- severity, EMDR appeared to be signifi cantly more bia (Feske & Goldstein, 1997). Indeed, according to effective than a wait-list control condition, but with the international guidelines on the treatment of panic regard to panic attack frequency, no differences could disorder, a typical treatment course of panic disorder be detected. A limitation of the studies on panic disor- should consist of approximately 16 to 20 hours and der is the lack of an empirically supported intervention include supervised “homework” sessions lasting ap- as a control condition. Therefore, it is not clear how proximately 4 months (National Institute for Clinical EMDR would compare with, for instance, a cognitive- Excellence, 2004). behavioral treatment approach. An intriguing result A more general question is why EMDR proponents was that with regard to treatment effi cacy, EMDR and have not been able to demonstrate the additional value those who were asked to just associate on the target of EMDR over and above alternative (i.e., cognitive- memories of earlier signifi cant panic experiences in a behavioral) treatment approaches. It would certainly relaxed state (ART condition) did equally well. How- come as no surprise if the disappointing results of the ever, since there is evidence that a greater reduction controlled outcome research have led many people in physiological dearousal during confrontation with (including grant providers) to believe that EMDR has a traumatic memory is signifi cantly associated with a no additional value in the treatment of anxiety disor- positive treatment outcome (Sack, Hofman, Wizel- ders. The question is whether the latter is true. For man, & Lempa, 2008), it is questionable whether the example, when considering the literature on specifi c use of ART, as applied in this study, was a credible phobia, it is surprising to note that while in vivo ex- attention-placebo control condition as was stated by posure generally is considered to be the treatment of the authors. choice for specifi c phobia, empirical evidence on the One of the explanations for the suboptimal results long-term outcome is weaker than many of us believe of the randomized clinical trials is that these studies had (Choy, Fyer, & Lipsitz, 2007). Of the total of 14 con- many limitations in terms of shortcomings in adher- trolled studies that have been carried out, only eight ing to the EMDR protocol (de Jongh et al., Shapiro, included a control condition, and these addressed 1999). These include the lack of a number of elements only a very limited array of phobia subtypes (i.e., key to EMDR, such as the “future template” and the animal phobia, water phobia, height phobia, fl ying preparation of clients for future interactions with poten- phobia, and claustrophobia; Choy et al., 2007). While tially anxiety-eliciting stimuli or situations. In addition, some types of phobia have proven to be remarkably it is not clear whether, within the limited number of responsive to a primarily cognitive-behavioral treat- sessions, more than one target was processed and thus ment approach, other phobia subtypes appear to be as- whether the lack of improvement could be explained sociated with a high dropout rate and low treatment by the limited amount of treatment time spent on the acceptance. Based on these discrepant fi ndings, it has adequate processing of relevant memories and related been hypothesized that when participants display a affective material. To this end, treatment may have relatively low level of anxiety, in vivo exposure would provoked chains of associations, emergence of child- be the best treatment alternative, while for phobias hood memories, and a release of painful affect that with a traumatic background or a high initial level of could not subsequently be processed. For example, anxiety, EMDR may be more profi table (de Jongh & Goldstein and Feske (1994) indicate that on some occa- ten Broeke, 2007 ). The latter would, for instance, sions following a session, patients reported an increase generally be the case in dental phobia or choking in stress: “Typically, this followed a session in which phobia (see de Jongh & ten Broeke, 2007; de Roos & new and upsetting material arose near the end of a de Jongh, 2008). It would certainly be enlightening to session and could not be processed during that ses- test these hypotheses in controlled outcome studies. sion” (p. 360). Unfortunately, they failed to explain Given the dearth of controlled outcome research how they dealt with such complications in case this on the application of EMDR for anxiety disorders happened at the end of the fourth treatment session, and the limitations of these studies, questions about

138 Journal of EMDR Practice and Research, Volume 3, Number 3, 2009 de Jongh and ten Broeke the relative effi cacy of EMDR for the treatment of Bae, H., Kim, D., & Ahn, J. (2006). A case series of post- anxiety disorders remain largely unanswered. The traumatic obsessive compulsive disorder: A six month contrast between the lack of empirical evidence on follow-up evaluation. Journal of the Korean Neuropsychiatric the one hand and the promise that EMDR could ele- Association, 45, 476–480. gantly fi t into a therapeutic plan aimed to treat anxiety Bisson, J. I., Ehlers, A., Matthews, R., Pilling, S., Richards, on the other is striking. Yet the future of EMDR as a D., & Turner, S. (2007). Psychological treatments for chronic post-traumatic stress disorder: Systematic re- therapeutic method will for an important part de- view and meta-analysis. British Journal of Psychiatry, 190, pend on the research that it initiates. To this end, 97–104. exactly 10 years ago, after having reviewed the lit- Boschen, M. J. (2008). Publication trends in individual anxi- erature on specifi c phobia, de Jongh et al. (1999) ety disorders: 1980–2015. Journal of Anxiety Disorders, 22, concluded, “The empirical support for EMDR with 570–575. specifi c phobias is still meager; therefore, one should Choy, Y., Fyer, A. J., & Lipsitz, J. D. (2007). Treatment of remain cautious. However, given that there is insuf- specifi c phobia in adults. Clinical Psychology Review 27, ficient research to validate any method for complex 266–286 or trauma related phobias, that EMDR is a time- Corrigan, F. M., & Jennett, J. (2004). Ephedra alkaloids and limited procedure, and that it can be used in cases brief relapse in EMDR-treated obsessive compulsive dis- for which an exposure in vivo approach is difficult order. Acta Psychiatrica Scandinavica, 110, 158. to administer, the application of EMDR with spe- de Jongh, A., Fransen, J., Oosterink-Wubbe, F., & Aart- cific phobias merits further clinical and research at- man, I. H. A. (2006). Psychological trauma exposure and trauma symptoms among individuals with high and low tention” (pp. 69–70). Now, 10 years later, not much levels of dental anxiety. European Journal of Oral Sciences, seems to have changed, and it has become even 114, 286–292. clearer that these conclusions pertain not only to de Jongh , A., Holmshaw, M., & Hodder, K. (2009). Treat- specific phobia but also to the full spectrum of anxi- ment of travel phobia resulting from road traffi c accidents: ety disorders, except PTSD. Effi cacy of two trauma-focused psychological therapies. Man- Clearly, it is of utmost importance that advocates uscript submitted for publication. of EMDR become more aware of the need of pub- de Jongh, A., & ten Broeke, E. (1996). Eye movement lishing their cases, and researchers should put more desensitization and reprocessing (EMDR): Een proce- effort in applying for grants on research evaluating dure voor de behandeling van aan trauma gerelateerde the effectiveness of EMDR in relation to other em- angst [Eye movement desensitization and reprocess- pirically validated treatments in terms of outcome ing (EMDR): A procedure for the treatment of trau- and patient satisfaction. Research should focus on an- ma-related anxiety]. Tijdschrift voor Psychotherapie, 22, swering the question whether there are any anxiety 93–114. de Jongh, A., ten Broeke, E., & Renssen, M. R. (1999). Treat- disorders that are more amenable to EMDR than to ment of specifi c phobias with eye movement desensiti- exposure treatments. Further, research hypotheses zation and reprocessing (EMDR): Protocol, empirical could be that relapse rates are lower after an initial status, and conceptual issues. Journal of Anxiety Disorders, treatment with EMDR in which emotionally charged 13, 69–85. targets are desensitized prior to the beginning of a reg- de Jongh, A., van den Oord, H. J. M., & ten Broeke, E. ular cognitive behaviorally based intervention and that (2002). Effi cacy of eye movement desensitization and such a combination of EMDR and CBT is associated reprocessing (EMDR) in the treatment of specifi c pho- with greater effi ciency than either treatment given bias: Four single-case studies on dental phobia. Journal of alone. However, only careful treatment delivered by Clinical Psychology, 58, 1489–1503. suitably trained people who able to demonstrate that de Roos, C. J. A. M., & de Jongh, A. (2008). EMDR treat- their clinical practice adheres to the treatment proto- ment of children and adolescents with a choking phobia. cols and using thoughtful case conceptualizations and Journal of EMDR Practice and Research, 2, 201–211. desensitization of all targets that are needed to fully de Silva, P., & Marks, M. (1999). The role of traumatic expe- riences in the genesis of obsessive-compulsive disorder. resolve the disturbing material could address these Behaviour Research and Therapy, 37, 941–951. issues appropriately. Fernandez, I., & Faretta, E. (2007). Eye movement desen- sitization and reprocessing in the treatment of panic dis- References order with agoraphobia. Clinical Case Studies, 6, 44–63. Feske, U., & Goldstein, A. (1997). Eye movement desensiti- American Psychiatric Association. (2000). Diagnostic and sta- zation and reprocessing treatment for panic disorder: A tistical manual of mental disorders (4th ed., text revision). controlled outcome and partial dismantling study. 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Journal of EMDR Practice and Research, Volume 3, Number 3, 2009 139 EMDR and the Anxiety Disorders Gauvreau, P., & Bouchard S. (2008). Preliminary evidence Oosterink, F. M. D., de Jongh A., & Aartman, I. H. A. (2009). for the effi cacy of EMDR in treating generalized anxiety Negative events and their potential risk of precipitating disorder. Journal of EMDR Practice and Research, 2, 26–40. pathological forms of dental anxiety. Journal of Anxiety Goldstein, A. J., de Beurs, E., Chambless, D. L., & Wilson, Disorders, 23, 451–457. K. A. (2001). EMDR for panic disorder with agorapho- Roemer, L., Molina, S., Litz, B. T., & Borkovec, T. D. (1997). bia: Comparison with waiting list and credible atten- Preliminary investigation of the role of previous expo- tion-placebo control condition. Journal of Consulting and sure to potentially traumatizing events in generalized Clinical Psychology, 68, 947–956. anxiety disorder. Depression and Anxiety, 4, 134–138. Goldstein, A., & Feske, U. (1994). EMDR treatment of panic Sack, M., Hofman, A., Wizelman, L., & Lempa, W. (2008). disorder. Journal of Anxiety Disorders, 8, 351–362. Psychophysiological changes during EMDR and treat- Hofmann, S. G., & Smits, J. A. J. (2008). Cognitive-behavioral ment outcome. Journal of EMDR Practice and Research, 2, therapy for adult anxiety disorders: A meta-analysis of 239–246. randomized placebo-controlled trials Journal of Clinical Shapiro, F. (1989). Effi cacy of the eye movement desensitiza- Psychiatry, 69, 621–632. tion procedure in the treatment of traumatic memories. Kleiner, L., & Marshall, W. L. (1987). The role of interper- Journal of Traumatic Stress Studies, 2, 199–223. sonal problems in the development of agoraphobia with Shapiro, F. (1999). Eye movement desensitization and re- panic attacks. Journal of Anxiety Disorders, 1, 313–324. processing (EMDR): Clinical and research implications Lohr, J. M., Tolin, D. F., & Kleinknecht, R. A. (1996). An of an integrated psychotherapy treatment. Journal of intensive design investigation of eye movement desen- Anxiety Disorders, 13, 35–67. sitization and reprocessing of claustrophobia. Journal of Solomon, R. M., & Shapiro, F. (2008). EMDR and the Anxiety Disorders, 10, 73–88. adaptive information processing model: Potential McNally, R. J., & Lukach, B. M. (1992). Are panic attacks mechanisms of change. Journal of EMDR Practice and Re- traumatic stressors? American Journal of Psychiatry, 149, search, 2, 315–325. 824–826. Sun, T., & Chiu, N. (2006). Synergism between mindfulness Mineka, S., Watson, D., & Clark, L. A. (1998). Comorbidity meditation training, and eye movement desensitization of anxiety and unipolar mood disorders. Annual Review and reprocessing in psychotherapy of social phobia. Chang of Psychology, 49, 377–412. Gung Medical Journal, 29, 1–5. Muris, P., & Merckelbach, H. (1997). Treating spider phobics van Balkom, A., de Beurs, E., Koele, P., Lange, A., & van with eye-movement desensitization and reprocessing: A Dyck, R. (1996). Long-term Benzodiazepine use is as- controlled study. Behavioural and Cognitive Psychotherapy, sociated with smaller treatment gain in panic disorder 25, 39–50. with agoraphobia. Journal of Nervous and Mental Disease, Muris, P., Merckelbach, H., Holdrinet, I., & Sijsenaar, M. 184, 133–135. (1998). Treating phobic children: Effects of EMDR ver- Wilson, S. A., Becker, R. H., & Tinker, R. H. (1995). Eye sus exposure. Journal of Consulting and Clinical Psychology, movement desensitization and reprocessing (EMDR) 66, 193–198. treatment for psychologically traumatized individu- Muris, P., Merckelbach, H., van Haaften, H., & Mayer, B. als. Journal of Consulting and Clinical Psychology, 63, (1997). Eye movement desensitization and reprocessing 928–937. versus exposure in vivo. British Journal of Psychiatry, 171, 82–86. Correspondence regarding this article should be directed National Institute for Clinical Excellence. (2004). The man- to Ad de Jongh, Department of Behavioral Sciences, Aca- agement of panic disorder and generalised anxiety disorder in demic Centre for Dentistry Amsterdam, Louwesweg 1, primary and secondary care. London: National Collaborat- 1066 EA Amsterdam, The Netherlands. E-mail: a.de. ing Centre for Mental Health. [email protected]

140 Journal of EMDR Practice and Research, Volume 3, Number 3, 2009 de Jongh and ten Broeke