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418
Eating Disorders, 16:418–427, 2008
Copyright © Taylor & Francis Group, LLC
ISSN: 1064-0266 print/1532-530X online
DOI: 10.1080/10640260802370598
UEDI1064-02661532-530XEating Disorders, Vol. 16, No. 5, August 2008: pp. 1–17Eating Disorders A Randomized Experimental Test
of the Efficacy of EMDR Treatment
on Negative Body Image in Eating
Disorder Inpatients
Efficacy of EMDR for Eating DisordersA. Bloomgarden and R. M. Calogero
ANDREA BLOOMGARDEN
Private Practice, Philadelphia, Pennsylvania, USA
RACHEL M. CALOGERO
University of Kent, Canterbury, Kent, United Kingdom
Eye Movement Desensitization and Reprocessing (EMDR) therapy
is being used by some clinicians to treat eating disorders. Although
there is anecdotal and case study data supporting its use, there are
no controlled studies examining its effectiveness with this population.
This study examined the short and long-term effects of EMDR in a
residential eating disorders population. A randomized, experi-
mental design compared 43 women receiving standard residential
eating disorders treatment (SRT) to 43 women receiving SRT and
EMDR therapy (SRT+EMDR) on measures of negative body image
and other clinical outcomes. SRT+EMDR reported less distress
about negative body image memories and lower body dissatisfaction
at posttreatment, 3-month, and 12-month follow-up, compared to
SRT. Additional comparisons revealed no differences between the
conditions pre to posttreatment on other measures of body image
and clinical outcomes. The empirical evidence reported here suggests
that EMDR may be used to treat specific aspects of negative body
image in conjunction with SRT, but further research is necessary
We would like to acknowledge the therapists, all of whom provided the EMDR treat-
ment on a purely volunteer basis: Andrea Bloomgarden, Ellen Ostroff Cohen, Pat Duffy,
Harin Feibish, Carol Gantman, Rachel Kalan, Elizabeth Kleber, and Rosemary Mennuti. Many
thanks to Frankie Klaff and William Zangwill who provided additional consultation, and to
Barbara Parrett for conducting fidelity checks. We extend our gratitude both to the Renfrew
Center and the residents who volunteered their participation, for making this study possible.
Address correspondence to Andrea Bloomgarden, 2130 Pine Street, Philadelphia, PA
19103. E-mail: ABloomgard@aol.com
Efficacy of EMDR for Eating Disorders 419
to determine whether or not EMDR is effective for treating the variety
of eating pathology presented by eating disorder inpatients.
Eye movement desensitization and reprocessing (EMDR) is a psychotherapeutic
treatment that was originally developed in the 1980’s to treat post-traumatic
stress disorder (PTSD) (Shapiro, 1989a; 1989b). While the unique effects of
EMDR treatment remain controversial (DeBell & Jones, 1997; DeRubeis & Crits-
Christoph, 1998; Perkins & Rouanzoin, 2002), several distinguished organiza-
tions have acknowledged it as a useful form of treatment for PTSD (Chambless,
et al., 1998; Chemtob, Tolin, van der Kolk, & Pitman, 2000). An accumulation of
anecdotal and case study evidence suggests that EMDR is effective for the treat-
ment of eating disorders (e.g., Cooke & Grand, 2006; Freedland, 2002; York,
2000), despite the fact that there has been no experimental examination of the
use of EMDR in this clinical population. The purpose of the present study was
to examine the efficacy of EMDR in the treatment of eating disorders.
Researchers have warned that particular characteristics of the EMDR proto-
col may produce some risks when applied to individuals with eating disorders,
such as the search for traumatic memories (Hudson, Chase, & Pope, 1998; Pope
& Hudson, 1996). We selected negative body image memories as the treatment
target for EMDR for three reasons. First, negative body image is clearly associ-
ated with the core pathology of eating disorders (American Psychiatric Associa-
tion [APA], 1994; Deter & Herzog, 1994). Second, negative body image is
experienced as aversive but does not directly imply a causal relationship
between trauma and eating disorders (Hudson et al., 1998). Third, negative
body image is less likely to be associated with secondary gain (DeBell & Jones,
1997). In addition, negative body image continues to affect one to two thirds of
individuals after treatment even with apparently successful cognitive-behavioral
treatments (Rosen, 1990, 1996). The severity and unremitting nature of negative
body image in eating disorders suggests that other treatments should be exam-
ined, and thus the risk of randomly assigning individuals to a suboptimal treat-
ment for the purposes of testing a potential treatment may be warranted.
Hypotheses
The present study addressed three open questions about the efficacy of
EMDR in eating disorders populations. First, does EMDR reduce distress about
NBIMs among eating disorders patients beyond standard residential treatment
(SRT)? We predicted that participants who received SRT + EMDR would
report significantly less distress about negative body image memories
(NBIMs) at posttreatment compared to participants who received SRT only.
We also predicted that SRT + EMDR would report significantly less distress
about NBIMs at 3-month and 12-month follow-up compared to SRT. Second,
does targeting NBIMs with EMDR improve other dimensions of negative body
420 A. Bloomgarden and R. M. Calogero
image (e.g., beliefs about attractive people, desire to harm vs. pamper one’s
body) compared to SRT? We predicted that SRT + EMDR would report signifi-
cantly less distress on other dimensions of negative body image compared to
SRT. Third, does targeting NBIMs with EMDR improve other clinical outcomes
(e.g., depression, eating symptoms) compared to SRT? We predicted that SRT
+ EMDR would not significantly differ from SRT on other clinical outcomes.
METHOD
Participants
Participants were 86 women admitted to a residential eating disorders treat-
ment program over an 18-month period. Women were assessed by senior
staff psychiatrists at a residential eating disorders center, and diagnosed
using a semi-structured interview based on criteria from the Diagnostic and
Statistical Manual of Mental Disorders, 4th edition (APA, 1994). The eating
disorders distribution in the present study was: anorexia nervosa-restricting
subtype (AN; n = 27), bulimia nervosa (BN; n = 23), and eating disorder not
otherwise specified (EDNOS; n = 36). For the total sample, mean BMI was
20.05 (SD = 5.30) and the mean age was 24.59 (SD = 8.48). Ninety-four per-
cent of the women were European American, 2.0% Asian American, 1.0%
African American, and 3.0% Hispanic American.
STANDARD RESIDENTIAL TREATMENT (SRT)
The standard residential treatment provided individual, group, and family
therapy seven days a week conducted by trained eating disorders therapists.
Therapeutic approaches incorporate a variety of cognitive, behavioral, and
experiential techniques. Women assigned to SRT were ostensibly placed on
a waiting list for participation.
EMDR TREATMENT (SRT+EMDR)
The EMDR treatment followed standard protocols described in detail else-
where (Shapiro, 1995, 2001). After an initial assessment and orientation to
EMDR, a specific body image memory was selected as the treatment target
from the Body Image Memory Questionnaire described below. To initiate the
actual desensitization and reprocessing, patients visually tracked a light bar for
approximately 15 to 20 seconds, referred to as bilateral stimulation. Women
assigned to the SRT + EMDR condition received one or two 60-minute EMDR
sessions per week during their treatment stay. Licensed eating disorders thera-
pists completed Level II EMDR training prior to their participation in the study.
An independent rater performed fidelity checks on recorded sessions to verify
Efficacy of EMDR for Eating Disorders 421
therapists’ adherence to EMDR protocol. Based on a random review of 20
EMDR sessions the fidelity checks demonstrated an 80% compliance rate.
Measures
NEGATIVE BODY IMAGE MEMORIES
The Body Image Memory Questionnaire (BIM) was adapted from Shapiro
(1995, 2001) to measure subjective distress associated with specific body
image memories. Participants recorded their earliest, worst, and most recent
BIM and then rated each memory based on how disturbing it felt to them from
0 (not disturbing at all) to 10 (worst you can imagine). Internal reliability for
these NBIMs was high (α = 0.76 to 0.89).
OTHER BODY IMAGE OUTCOMES
The Body Investment Scale (BIS; Orbach & Mikulincer, 1998) is a 24-item mea-
sure of emotional investment in the body, particularly self-destructive and self-
harming tendencies, with high internal reliability across the four factors (α = 0.82
to 0.90). The Appearance Schemas Inventory (ASI; Cash & Labarge, 1996) is a
14-item measure of dysfunctional beliefs associated with physical appearance,
including body image vulnerability, self-investment, and appearance stereotyp-
ing, with high internal reliability across the three factors (α = 0.86 to 0.95). The
Body Dissatisfaction subscale of the EDI-2 (EDI-BD) is a widely used 9-item
measure of degree of satisfaction with various parts and regions of the body
such as waist, hips, and thighs (Garner, 1991), with high internal reliability (α =
0.92). The Sociocultural Attitudes toward Appearance Questionnaire – Revised
(SATAQ-R; Heinberg, Thompson, & Stormer, 1995) is a 14-item measure of
awareness and acceptance of culturally sanctioned standards of appearance,
with high internal reliability across the two factors (α = 0.80 to 0.89).
OTHER CLINICAL OUTCOMES
The Eating Attitudes Test-26 (EAT-26; Garner, Olmsted, Bohr, & Garfinkel,
1982) is a widely used 26-item measure of eating attitudes and behaviors,
with high internal reliability (α = 0.89). The Beck Depression Inventory (BDI;
Beck, Steer, & Garbin, 1988) is a widely used 21-item measure of depressive
symptoms, with high internal reliability (α = 0.95). The Dissociative Experi-
ences Scale (DES; Bernstein & Putnam, 1986) is a 28-item measure of the
percentage of time an individual has dissociative experiences, with high
internal reliability (α = 0.82). Finally, participants reported the age of eating
disorder onset, number of times previously hospitalized, and satisfaction
with current weight. Admission weight and height measured by a nurse
practitioner were used to calculate body mass index (BMI).
422 A. Bloomgarden and R. M. Calogero
Procedure
Eligibility of women who expressed interest in participation was determined
using the EMDR clinical guidelines (Shapiro, 1995, 2001). Women were ineligi-
ble if they met any of the following criteria: (a) diagnosed with a dissociative
disorder or reported a score greater than 30 on the DES, (b) actively suicidal or
attempted suicide in the past month, (c) on any form of bed rest, (d) have a
history of or active seizure disorder, or (e) actively psychotic. Eligible women
were randomly assigned to SRT or SRT+EMDR by a research assistant masked
to the hypotheses of the present study using a random number table. Partici-
pants were randomly assigned to one of the available therapists who were not
also the participants’ individual or family therapist. There were no significant
differences in the number of SRT+EMDR participants assigned to each EMDR
therapist over the course of the study, χ2 (6) = 10.540, p = .104. Due to the con-
straints imposed by unexpected discharges, a minimum number of completed
EMDR sessions were not required, which allowed more women to be included
in the study. Participants provided informed consent prior to beginning the
study, and completed self-report questionnaires at admission (pretreatment),
discharge (posttreatment), 3-month follow-up, and 12-month follow-up. The
follow-up packets included a cover letter, the questionnaires anonymously
coded, and a self-addressed stamped envelope to return the completed packet.
The return rate at 3-month follow-up was 93% for SRT+EMDR participants and
95% for SRT participants. The return rate at 12-month follow-up was 79% for
SRT+EMDR participants and 74% for SRT participants.
RESULTS
A one-way MANOVA revealed no significant differences between SRT+EMDR
and SRT in age, age of eating disorder onset, number of times previously hos-
pitalized, satisfaction with current weight, BMI, depression, dissociation, eating
attitudes, or body dissatisfaction (p’s ranged from .17 to .99). There were also
no significant differences in the proportion of each eating disorder diagnosis
represented in each condition, χ2 (2) = 2.74, p = .25. These results indicate no
systematic differences at pretreatment between conditions on relevant partici-
pant characteristics. At posttreatment, a significant difference was observed in
length of treatment stay, F(1,84) = 4.08, p = .02, with a slightly longer length of
treatment stay for SRT+EMDR (M = 23.25, SD = 9.77) than SRT (M = 19.94, SD
= 10.49). Mean number of EMDR sessions was 4.31 (SD = 1.96).
Negative Body Image Memories
Table 1 displays the means for the three NBIMs at each assessment point.
Effect sizes were reported for all analyses, indexed by r (Rosnow &
Efficacy of EMDR for Eating Disorders 423
Rosenthal, 1996), and corrected for potential bias (Becker, 1988). Because
of the number of between group comparisons on the NBIMs, the Bonferroni
correction was used to reduce the likelihood of Type I errors (i.e., p values
were set at .014 or .05/√12). A one-way MANOVA indicated that SRT + EMDR
and SRT did not significantly differ at pretreatment on ratings of the NBIMs.
A series of 2 (Condition: SRT + EMDR vs. SRT) × 4 (Time: pretreatment vs.
posttreatment vs. 3-month vs. 12-month) repeated-measures ANCOVA models
were conducted to test the primary hypotheses for the NBIMs. Length of
treatment stay and pretreatment scores were entered as covariates in all anal-
yses. Results revealed Time × Condition interactions for the earliest memory,
F(3,252) = 7.27, p < .01, r = .17, and worst memory, F(3,252) = 6.78, p < .014,
T
ABLE 1 Between Group Differences for Body Image Memories at Each Assessment Point
Body Image
Memories
SRT + EMDR SRT r b
(95% CI)nMSDnMSD F a
Earliest
Pretreatment 43 6.09 3.05 43 5.56 3.16 0.638 .008
(−.19, .21)
Posttreatment 43 3.56 2.30 43 5.28 3.07 14.47*** .382
(.17, .59)
3-Month 40 3.33 2.36 41 5.05 2.97 9.939** .333
(.18, .54)
12 – month 34 4.49 2.59 32 5.06 2.44 0.369 .008
(−.23, .24)
W
orst
Pretreatment 43 8.42 2.20 43 8.49 2.11 0.023 .001
(−.23, .23)
Posttreatment 43 5.21 2.68 43 7.30 2.68 12.480*** .362
(.13, .60)
3-Month 40 4.23 3.15 41 7.02 2.72 11.722*** .357
(.12, .59)
12-month 34 5.26 3.05 32 7.13 2.08 6.226** .296
(.03, .56)
Most Recent
Pretreatment 43 6.84 2.89 43 6.58 2.56 0.189 .004
(−.29, .30)
Posttreatment 43 5.26 2.74 43 6.30 2.65 3.940* .211
(−.08, .51)
3-Month 40 4.18 3.16 41 5.73 3.08 3.523* .206
(−.10, .51)
12-month 34 5.49 3.34 32 5.75 2.97 0.063 .003
(−.33, .34)
N
ote. SRT+EMDR = standard residential treatment plus EMDR; SRT = standard residential treatment.
aF-values indicate between group differences at each assessment point. bEffect sizes (r) refer to between
group differences.
*p <.05. **p <.01. ***p <.001.
424 A. Bloomgarden and R. M. Calogero
r = .16, but not the most recent memory, F(3,252) = 4.58, p < .03, r = .13.
Follow-up repeated measures ANCOVA models tested for differences
between conditions at each time of assessment compared to pretreatment
(see Table 1). SRT + EMDR reported significantly less distress than SRT at
posttreatment for the earliest and worst memory, but not for the most recent
memory. These effects remained significant at 3-month follow-up, but only for
the worst memory at 12-month follow-up. Together, these results indicate that
SRT + EMDR reduced distress about earliest and worst NBIMs more than SRT
alone at posttreatment, 3-month, and 12-month follow-up (worst BIM only).1
Other Body Image and Clinical Outcomes
Because of the number of between group comparisons on the other body
image and clinical outcomes, the Bonferroni correction was used to reduce
the likelihood of Type I errors (i.e., p values were set at .011 or .05/√24). A
series of 2 (Condition: SRT + EMDR vs. SRT) × 4 (Time: pretreatment vs.
posttreatment vs. 3-month vs. 12-month) repeated-measures ANCOVA mod-
els revealed no significant differences between SRT + EMDR and SRT on the
BIS, ASI, SATAQ-R, EDI-BD, depression, dissociative symptoms, or disor-
dered eating attitudes.
DISCUSSION
The present study examined the effects of adding EMDR to standard residen-
tial eating disorders treatment on a variety of body image and clinical out-
comes. Consistent with predictions, SRT + EMDR participants reported less
distress about their NBIMs compared to SRT participants at posttreatment and
3-month follow-up. Consistent with meta-analytic results on the effectiveness
of EMDR (Davidson & Parker, 2001), effect sizes for these group differences
were medium to large for the earliest and worst memory, and small for the
most recent memory. SRT + EMDR participants reported less distress about
the worst BIM compared to SRT participants at 12-month follow-up; however
the effects on the earliest and most recent memory faded over the 12 months,
with effect sizes hovering around zero. An average of four EMDR sessions
appeared to be sufficient to reduce distress up to 3 months and up to 12
1 We did not have a theoretical rationale for predicting differences between eating disorder
diagnoses on the negative body image memories. However, because of the absence of any empirical
evidence on the efficacy of EMDR treatment for eating disorders, a series of 3 (Diagnosis: AN-R vs. BN
vs. EDNOS) × 4 (Time: pretreatment vs. posttreatment vs. 3-month vs. 12-month) repeated-measures
ANCOVA models were conducted to test for potential differences on the body image memories by
eating disorder diagnosis. Results revealed no significant Diagnosis × Time interactions for the earliest,
F(6,249) = 0.873, p = .459, r = .101, worst, F(6,249) = 0.437, p = .727, r = .007, or the most recent,
F(6,249) = 0.987, p = .404, r = .108, memory.
Efficacy of EMDR for Eating Disorders 425
months for the worst memory. However, four sessions of EMDR was not suf-
ficient to sustain a permanent reduction in distress about these memories, or
to generalize to other body image and clinical outcomes. It is possible that to
generalize these effects would require more than four EMDR sessions, further
processing of other targets, and/or the building of new skills to lead to
improved body image overall. It may be reasonable to incorporate EMDR into
treatment to reduce distress about specific traumatic body image-related
experience, but processing these memories will not necessarily bring about a
broader change in body image or eating disorder pathology.
It appears that selecting negative body image as the treatment target for
EMDR was appropriate in a sample of women with eating disorders. The
risk for memory fabrication in the recall of trauma among eating disorders
patients should have been minimized because negative body image events
have been related consistently to the development and maintenance of eat-
ing disorders (Rosen, 1990; Smolak & Levine, 2001). However, the accuracy
of participants’ recall of prior body image-related events remains debatable.
Memories tend to fade or become distorted over time (Roediger & McDer-
mott, 2000; Schacter, 1995), and other research suggests that vividly imagin-
ing an object leads to falsely remembering what was actually seen versus
what was only imagined (Gonsalves et al., 2004). This is important because
if the body image memories were not particularly accurate, this may be one
explanation for why the EMDR therapy did not generalize beyond the mem-
ories to participants’ actual body images. Although EMDR treats the subjec-
tive experience of the memory regardless of the actual veracity of the
memory, this possibility should be subjected to further scrutiny.
Several limitations of the present study should be considered. First, it is
unclear how EMDR therapy would have compared to a supportive listening
condition targeting the same body image memories. There is considerable
uncontrolled “extra” therapy inherent in the residential treatment setting; thus, it
is worth acknowledging that the effects observed on the NBIMs with EMDR
therapy were quite robust considering the comprehensive SRT that it was com-
pared against. Second, a comparison of treatment conditions that experienced
the same length of treatment stay would provide a more stringent test of the
effects of EMDR. Third, participants were not blind to receiving the EMDR treat-
ment or being on a wait list, and future experimental designs should address
this potential contamination effect. Finally, the present findings cannot be gen-
eralized to AN-purging subtype because this diagnosis was not represented in
the final sample, or to outpatients, men, and other types of memories.
To conclude, the intent of the present research was not to support or
discredit EMDR per se, but rather to test the efficacy of EMDR therapy for
treatment with a severely eating disordered population. A randomized,
experimental study with long-term follow-up was conducted to test the
effectiveness of EMDR for the treatment of eating disorders. The evidence
reported here suggests that EMDR can reduce distress about specifically
426 A. Bloomgarden and R. M. Calogero
targeted negative body image memories, but more research is needed to
determine its effectiveness on broader eating disorders pathology.
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