Research on the Treatment of Social Anxiety Disorder with EMDR: A Review

Abstract

Research shows that the core of Social Anxiety Disorder (SAD), the thirdmost mental disorder, is a negative distorted self-image, that arises by reason of dissociation. These negative self-distorted self-images were identified as maintaining factors of SAD with the implication that clients cannot habituate to them when confronted with anxiety triggering situations. Therefore, we examined whether there exist studies about treating SAD with EMDR to target negative self-images and/or social situation which cause anxiety for clients.
First, we found research on EMDR and test anxiety plus EMDR and public speaking anxiety when we searched in Pubmed/Medline, Psyndex, PsycInfo, SSCI, ERIC and at the Francine Shapiro Library, and we received studies from the IFOM Institute at University Witten-Herdecke from their Meta-Analysis on EMDR and Anxiety Disorders. From the studies we included in our review, ten showed significant results regarding positive effects of EMDR and test anxiety or public speaking anxiety with evidence grades of IIb and III. Three studies did not result in significant measures which could be caused by an incorrect use of EMDR.
Second, the first author started a case study with a female suffering from SAD. After six sessions of assessment and eight treatment session (six of them with EMDR), the client was able to deliver presentations at course of studies. Including negative self-portrayals into the three-prongued EMDR approach may be a good treatment option for SAD, a necessary topic because of the great amount of nonresponders which seem to occur at therapeutic approaches such as Cognitive Behavioural Therapy (CBT) and Psychodynamic Psychotherapy (PDP) in the treatment of SAD.

Full text

06.06.21
1
RESEARCH ON THE TREATMENT
OF SOCIAL ANXIETY DISORDER
WITH EMDR: A REVIEW
AT #E MD RVI RT UA L2 02 1
Dipl.-Psych. Anna-Konstantina Richter
Psychologist, Psychotherapist
EMDR Consultant, CBT Supervisor
Zentrum für psychologische Beratung und
Training Richter & Kemeny (ZpBT)
Marburg/Germany
1
Introduction of the
Co-Authors of the Review
Franziska Beham
Dipl.-Psych. Anna-Konstantina Richter, Private Practice,
Marburg, Germany
Ferdinand Horst (EMDR practitioner)
Department of Psychiatry, St. Elisabeth Hospital, Tilburg,
Netherlands
André Maurício Monteiro (EMDR trainer)
Ed. Brasilia Medical Center, Brasilia, Brazil
Günter H. Seidler (EMDR consultant)
Ruprecht-Karls-Universität Heidelberg, Germany
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Content of this Lecture
•1. Theoretical update on Social Anxiety Disorder (SAD)
regarding EMDR
•2. Review on the research about EMDR and SAD
•3. Literature
3
ICD-10: F40.1 Social Phobias
•Fear of scrutiny by other people leading to
avoidance of social situations. More pervasive
social phobias are usually associated with low
self-esteem and fear of criticism. They may
present as a complaint of blushing, hand
tremor, nausea, or urgency of micturition, the
patient sometimes being convinced that one of
these secondary manifestations of their anxiety is
the primary problem. Symptoms may progress
to panic attacks.
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DSM V: Social Anxiety Disorder (1)
•A. A persistent fear of one or more social or performance
situations in which the person is exposed to unfamiliar
people or to possible scrutiny by others. The individual
fears that he or she will act in a way (or show anxiety
symptoms) that will be embarrassing and humiliating.
•B. Exposure to the feared situation almost invariably
provokes anxiety, which may take the form of a
situationally bound or situationally pre-disposed Panic
Attack.
•C. The person recognizes that this fear is unreasonable
or excessive.
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DSM V: Social Anxiety Disorder (2)
•D. The feared situations are avoided or else are
endured with intense anxiety and distress.
•E. The avoidance, anxious anticipation, or
distress in the feared social or performance
situation(s) interferes significantly with the
person's normal routine, occupational (academic)
functioning, or social activities or relationships, or
there is marked distress about having the phobia.
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Epidemiology
•Lifetime prevalence (Demyttenaere et al., 2004, McEvoy,
Grove, & Slade 2011, quoted from McEvoy et al., 2018):
•USA 18,2 %
•Australia 8,4 %
•Europe 5,8 –12 %
•Africa (e.g. Nigeria) 3,3 %
•Asia 2,4 –5,3 %
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Why EMDR could be a good choice
in the treatment of SAD (1)
•In a multicenter publication, the nonresponderrate of CBT
was 40 %, psychdynamic psychotherapy was 48 %
(Leichsenring et al., 2013).
•Adolescent clients with SAD show a worse response on
CBT treatment (Leigh & Clark, 2016).
•Hackmann, Clark & McManus (2000) suggest that the
core of pathology of clients with social anxiety disorder is
a negative deformed picture from an observer
perspective that occures in a situation that triggers
fright, that is stable over a period of time and which is
connected with awkward social events, that happened
about the time the disorder started. Beck et al. (1985)
state that you cannot change a picture with words.
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Why EMDR could be a good choice
in the treatment of SAD (2)
•CBT improved the responderrates with implementing
Imagery Rescripting into the CBT treatment (e.g. Wild,
Hackmann & Clark, 2008, basic model of Arntz &
Weertman, 1999, McEvoy et al., 2018)
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Etiology: dissociation of self
Moscovitch et al., 2011
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Psychoanalytic alterity theory
(Seidler, 1990) predicts this dissociation
Formation of a negative distorted self-image refering to the psychoanalytic alterity
theory by Seidler (1990, 2000)
!
Intrapsychic!Dissociation!
!
!
Experiencing!self!
Observing!self!
Shame,!delevoping!
from!the!comparison!
with!the!internalized!
ideal!self!
Ideal!self!(internalized!ideal!
counterpart)!
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Assumption No. 1 in the Treatment of SAD
Treat the negative distorted self image,
the consequence of a social traumatic
dissociation
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Assumption No. 2 in the Treatment of SAD:
Ta r ge t the Flashforward of the patients (1)
!
CS
CR
SHAME
FEAR
Exams
Eating in public
Party
Date
School
Work
Presentation
+
FLASHFORWARD
US
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Assumption No. 2 in the Treatment of SAD:
Ta r ge t the Flashforward of the patients (2)
The term „Flashforwards“ was used originally by
Engelhard et al. (2011): „... fear of future danger
is common after a threatening event, and may
take the form of future-oriented mental images.
These may appear like ‚Flashforwards’, echoing
‚flashbacks“ in posttraumatic stress disorder
(PTSD) and possess sensory qualities, being
vivid, compelling, and detailed.“ (Engelhard et
al., 2011, S. 599, quoted by Logie, undated
presentation).
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AIP model for Social Anxiety Disorder
(Richter, 2018b, 2018d and 2019b)
a) Triggers (speech, flirting, meeting others, groups,
introducing oneself) and
b) Flashforwards (what catastrophy could happen?)
a) Memories about past stressful events where
patients felt humiliated, social traumas
b) Negative distorted self image that results from
these social traumas
Future template and Flashforward procedure for future
worries and catastrophies regarding social situations
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EMDR worksheet for SAD page 1
!
1!
EMDR worksheet Social Anxiety Disorder page 1
Richter, A.-K. (2018) www.zpbt-marburg.de
Name/Code: Age: Date:
Test and interview alternatives and results:
Interviews
Diagnosis
Date
Tests and
cut-offs
Score, Date
(Pre)
Score, Date
(Post)
SCID-5
SPIN (≥19)
ADIS-5
SPS (≥24)
SIAS (≥36)
AUDIT
Alcohol
screening
(≥8, ≥13 f,
≥15 m*)
BDI-II (≥10,
≥16, ≥20,
≥30, ≥40,
>40†)
LSAS (≥30
SAD, ≥60
GSAD)
Targets 1: Past (keystone) memories:
Experience
Age
SUD
SUD-
Control
1.
2.
3.
Negative distorted recurrent image of one’s public self
from an observer perspective (referred to negative
mental images measured with the WIMI by Moscovitch
2011). „How do you perceive others see you?“
Memory linked to the recurrent
image (referred to Hackmann,
Clark & McManus, 2000), e.g.
„Let’s link this to one of your
memories“
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
* (≥8 harmful drinking, alcohol dependence likely: ≥13 female, ≥15 male)
†!(≥10!normal,!≥16!mild,!≥20!borderline!clinical!depression,!≥30!moderate,!≥40!severe,!
>40!extreme)!
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2nd part: Review on the Research
Te st Anxiety (1)
•Bauman & Melnyk (1994), n=30 students, two treatment
groups EMD with eye movement and tapping. Evidence
grade III = no suffient evidence, yet.
•Gosselin & Matthews (1995), N=41 students with test
anxiety, two groups eye movement vs. no eye movement,
and high vs. low expectation of the intervention. Evidence
grade IIb = possible evidence.
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2nd part: Review on the Research
Te st Anxiety (2)
•Hampel (1997), n=32 students, treatment group and
waiting control group: „results suggest that EMDR is more
effective and requires less time than other test anxiety
treament strategy“. Evidence grade IIb = possible
evidence.
•Ten Cate (1998), N=18 students, three groups: EMDR,
Rational Emotive Behaviour Therapy and Bibliotherapy.
No evidence was found.
•Stevens & Florell (1999), n=62 students, EMDR lowered
distress at posttest more than RET and information only.
•No evidence was found.
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2nd part: Review on the Research
Te st Anxiety (3)
•Maxfield & Melnyk (2000), n=17 psychology students with
test anxiety, significant improvement on all scales of the
TAI. Evidence grade IIb = possible evidence.
•Enright, Baldo & Wykes (2000), n=35 college students in
a treatment or delayed treatment control group: EMDR
reduced overal test anxiety, emotionality and worry
components of test anxiety.
Evidence grade IIb = possible evidence.
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2nd part: Review on the Research
Te st Anxiety (4)
•Cook-Vienot & Taylor (2011), RCT with n=30 students with
test anxiety: EMDR reduced text anxiety significanty and
outperformed the biofeedback/stress inoculation training
condition. Evidence grade IIb = possible evidence.
•Munshi & Mehrotra (2014), n=61 12 grade students with
test anxiety, significantly different TAI scores after EMDR
treatment. Evidence grade IIb = possible evidence.
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2nd part: Review on the Research
Public Speaking Anxiety (1)
•Foley & Spates (1995), RCT, N=40 students with speech
anxiety, three groups: EMD, focussing on the hands in the
lap, control group. Evidence regarding the self measuring
of the participants. Evidence grade IIb = possible
evidence.
•Carrigan & Levis (1999), RCT, N=71 psychology students.
No significant results of EMDR intervention, which was
probably applied to shortly.
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2nd part: Review on the Research
Public Speaking Anxiety (1)
•Aslani, Miratashi & Aslani (2014), quasi-experimental
design, n=30 students with speech anxiety, 7 sessions
EMDR showed: EMDR reduced public speaking anxiety.
„These results suggest that treatment of eye movement
desensitization and reprocessing is effective on reducing
physiological symptoms of speech anxiety and increasing
the speaker’s confidence.“Evidence grade IIb = possible
evidence.
•Brooker (2017), RCT, EMDR group, hypnotherapy group,
control group, Evidence grade III = no suffient evidence,
yet.
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2nd part: Review on the Research
Social Phobia, SAD (1)
•Sun & Chiu (2006), single case study, male with long-term
social phobia, treatment: EMDR and Mindfulness
Meditation, BAI scores changed from high „mild-
moderate“ to „normal“ and BDI scores changed from
„moderate“ to „minimal“.
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2nd part: Review on the Research
Social Phobia, SAD (1)
0
5
10
15
20
25
30
BAI BDI
Case Study SAD Treatment with EMDR,
MBSR and Medication (Sun & Chiu, 2005)
Prä Post
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2nd part: Review on the Research
Social Phobia, SAD (2)
•Shawky, Hazem (2015). The Effectiveness of Eye
Movement Desensitization and Reprocessing Therapy
(EMDR for Reducing Social Anxiety Disorder Among
College Students.
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2nd part: Review on the Research
Social Phobia, SAD (2)
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We recommend for Future Research:
•Select full profile Social Anxious patients (not only students with test
anxiety or public speaking anxiety), e.g. with the ADIS-5 interview (in
German: DIPS-OA download for free)
•Use modern test measures like SPIN, SPS, SIAS, LSAS to identify
social anxious patients (in German: SOZAS-Skalen).
•Use the NSPS (Moscovitch & Huyder, 2012) to identify negative
distorted self-images (download for free, in German: NSBS, download
for free).
•Ask the patients about their Flashforwards for additional targets with
the Flashforward-Procedure by Logie & de Jongh (2014, 2015).
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Download the EMDR worksheet for
SAD for free here:
•Use the EMDR worksheet for SAD and download for free
here:
•ResearchGate
https://www.researchgate.net/publication/327208005_EMD
R_worksheet_for_Social_Anxiety_Disorder_SAD
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Literature
•American Psychiatric Association (1980) . Diagnostic and
statistical manual of mental disorders (3rd ed .).
Washington, DC: Author.
•Arntz, A., & Weertman, A. (1999). Treatment of childhood
memories: theory and practice. Behaviour Research and
Therapy. 37 (1999) 715-740.
•Aslani, J., Miratashi, M., & Aslani, L. (2013). Effectiveness
of Eye Movement Desensitization and Reprocessing
Therapy on Public Speaking Anxiety of University
Students. Zahedan Journal of Research in Medical …,
29–32. Retrieved from
http://www.zjrms.ir/browse.php?a_code=A-10-2235-
1&slc_lang=en&sid=1
29
Literature
•Bauman, W., & Melnyk, W. T. (1994). A Controlled
Comparison of the Eye Movements and Finger Tapping in
the Treatment of Test Anxiety. J. Behav. Ther. & Exp.
Psychiat., 25(1), 29–33.
•Beck, A.T., Emery, G. & Greenberg, R.L. (1985) Anxiety
Disorders and Phobias: A Cognitive Perspective. New
York: Basic Books.
•Brooker, E. (2017). Music performance anxiety: A clinical
outcome study into the effects of cognitive hypnotherapy
and eye movement desensitization and reprocessing in
advanced pianists. Psychology of Music, 46(1), pp. 107-
124.
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Literature
•Carrigan, M.H., & Levis, D. J. (1999). The contributions of
eye movements tot he efficacy of brief exposure treatment
for reducing fear of public speaking. Journal of Anxiety
Disorders; 13(1-2): 101–18.
•Cook-Vienot, R., & Taylor, R. J. (2012). Comparison of
Eye Movement Desensitization and Reprocessing and
Biofeedback/Stress Inoculation Training in Treating Test
Anxiety. Journal of EMDR Practice and Research, 6(2),
62–72. https://doi.org/10.1891/1933-3196.6.2.62
31
Literature
•Engelhard, I. M., van den Hout, M. A., Dek, E. C. P., Giele,
C. L., van der Wielen, J.-W., Reijnen, M. J., & van Roij, B.
(2011). Reducing vividness and emotional intensity of
recurrent “flashforwards” by taxing working memory: An
analogue study, 25(4), 599–603.
https://doi.org/10.1016/j.janxdis.2011.01.009
•Enright, M., Baldo, T. D., & Wykes, S. D. (2000). The
Efficacy of Eye Movement Desensitization and
Reprocessing Therapy Technique in the Treatment of Test
Anxiety of College Students. Journal of College
Counseling. Retrieved from
http://search.ebscohost.com/login.aspx?direct=true&db=a
9h&AN=5188741&site=ehost-live
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Literature
•Foley, T., Spates, C. R. (1995). Eye Movement
Desensitization of public-speaking anxiety: A partial
dismantling. Journal of Behavior Therapy and
Experimental Psychiatry, 26(4), pp. 321-329.
•Gosselin, P., & Matthews, W. J. (1995). Eye Movement
Desensitization and Reprocessing in the Treatment of
Test Anxiety: A Study of the Effects of Expectancy and
Eye Movement. Journal of Behavior Therapy and
Experimental Psychiatry, 26(4), 331–337.
33
Literature
•Hackmann, A., Clark, D. M., & McManus, F. (2000).
Recurrent images and early memories in social phobia.
Behaviour Research and Therapy, 38(6), 601–610.
•Hampel, J. C. (1997). The Effects of Eye Movement
Desensitization and Reprocessing (EMDR) on Self-
Reported Test Anxiety in College Students. Western
Michigan University Kalamazoo, Michigan. Dissertations.
1634. https://scholarworks.wmich.edu/dissertations/1634
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Literature
•Leichsenring, F., Salzer, S., Beutel, M. E., Herpertz, S.,
Hiller, W., Hoyer, J., … Leibing, E. (2013). Psychodynamic
therapy and cognitive-behavioral therapy in social anxiety
disorder: A multicenter randomized controlled trial.
American Journal of Psychiatry, 170(7), 759–767.
https://doi.org/10.1176/appi.ajp.2013.12081125
•Leigh, E., & Clark, D. (2016). Cognitive Therapy for Social
Anxiety Disorder in Adolescents: A Development Case
Series. Behavioural and Cognitive Psychotherapy, 44(1),
1-17. doi:10.1017/S1352465815000715.
35
Literature
•Logie, R., de Jongh, A. (2014). The “Flashforward
Procedure”: Confronting the Catastrophe. Journal of
EMDR Practice and Research, 8(1), 25–32.
https://doi.org/http://dx.doi.org/10.1891/1933-3196.8.1.25
•Logie, R., & de Jongh, A. (2015). The Flashforward
Procedure. In M. Luber (Ed.), EMDR Scripted Protocols
and Summary sheets. Treatin g Anxiety, Obsessive-
compusive, and Mood-Related Conditions.(pp. 81–90).
New York: Springer Publishing Company.
•Maxfield, L., & Melnyk, W.T. (2000). Single Session
Treatment of Test Anxiety with Eye Movement
Desensitization and Reprocessing (EMDR). International
Journal of Stress Management. 7(2), 87-101.
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Literature
•McEvoy, P. M., Saulsman, L. M., & Rapee, R. M. (2018).
Imagery-Enhanced CBT for Social Anxiety Disorder (1st
ed.). New York: Guilford Press.
•Moscovitch, D. A., Gavric, D. L., Merrifield, C., Bielak, T.,
& Moscovitch, M. (2011). Retrieval properties of negative
vs. positive mental images and autobiographical
memories in social anxiety: outcomes with a new
measure. Behaviour Research and Therapy, 49(8), 505–
517.
https://doi.org/http://dx.doi.org/10.1016/j.brat.2011.05.009
37
Literature
•Moscovitch, D.A., & Huyder, V. (2012). Negative Self-
Protrayal Scale (NSPS). Measurement Instrument
Database for the Social Science. Retrieved from
www.midss.ie
•Munshi, C., & Mehrotra, S. (n.d.). A Study of EMDR as a
Strategy for Reducing High Test Anxiety in Students (12th
Grade) (pp. 1–17).
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Literature
•Richter, A.-K. (2018b). EMDR worksheet for Social
Anxiety Disorder (SAD). Berlin: ResearchGate. Online
publication. DOI: 10.13140/RG.2.2.32944.20480
•Richter, A.-K. (2018d). Vernachlässigte Folgen sozialer
Traumatisierung: Soziale Angststörung – „Stiefkind“ in der
psychotherapeutischen Versorgung. (English: Social
Anxiety Disorder: A Blind Spot in Psychotherapeutic Care.
Consequences of social traumatisation frequently
overlooked). Stuttgart: Trauma & G ewalt 12, 334–344.
DOI 10.21706/TG-12-4-334, https://elibrary.klett-
cotta.de/article/10.21706/tg-12-4-334
39
Literature
•Richter, A.-K. (2018c). NSBS: Negatives Selbstbild-Skala.
1. Arbeitsversion. Deutsche Bearbeitung von Moscovich,
D.A., & Huyder, V. (2012). Negative Self-Portrayal Scale
(NSPS). Berlin: ResearchGate. Online publication.
DOI:10.13140/RG.2.2.19103.00165/1
•Richter, A.-K. (2019b). EMDR bei Sozialen
Angststörungen. Stuttgart: Klett-Cotta. ISBN: 978-3-608-
96388-5
•Richter, A.-K., Beham, F., Horst, F., Monteiro, A.M., &
Seidler, G.H. (submitted). EMDR in the Treatment of
Social Anxiety Disorder, Test Anxiety, and Public Speaking
Anxiety: A Review.
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Literature
•Stevens, M. J., & Florell, D. W. (1998). EMDR as a
treatment for test anxiety. Imagination, Cognition and
Personality, 18(4), 285–296.
https://doi.org/http://dx.doi.org/10.2190/FJWQ-HKQQ-
UEJW-6VLH
•Seidler, G. H. (1990). Rumpelstilzchen auf der Couch –
ein Ensemble von Scham-, Identitäts- und Vaterthematik.
Praxis der Kinderpsychologie und Kinderpsychiatrie. 39;
261-266.
41
Literature
•Shawky, Hazem. (2015). The Effectiveness of Eye
Movement Desensitization and Reprocessing Therapy
(EMDR for Reducing Social Anxiety Disorder Among
College Students
•Sun, T.-F. , &Chiu N.-M. (2006, September). Synergism
between mindfulness meditation training, and eye
movement desensitization and reprocessing in
psychotherapy of social phobia. Chang Gung Medical
Journal, 29(4), 1-4
•Ten Cate, H. (1998). Eye Movement Desensitization and
Reprocessing (EMDR) Facilitating Rational Emotive
Behaviour Therapy (REBT) in the Treatment of Test
Anxiety. University of Stellenbosch.
42

06.06.21
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Literature
•WHO/Dilling, H ., Mombour, W . & Schmidt, M . H .
(Hrsg.). (1991). Internationale Klassifikation psychischer
Störungen, ICD-10 Kapitel V (F). Bern: Huber.
•Wild, J., Hackmann, A., & Clark, D. M. (2008). Rescripting
early memories linked to negative images in social
phobia: a pilot study. Behavior Therapy. 39(1):47-56. doi:
10.1016/j.beth.2007.04.003.
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Contact
Anna-Konstantina Richter, EMDR Consultant
(EMDR Hellas, EMDRIA Germany)
richter@zpbt-marburg.de
Visit our websites
http://www.zpbt-marburg.de
http://www.emdr.africa and http://www.emdr.ae
Dr. André Maurício Monteiro, EMDR Trainer‘s Trainer
(EMDR Brasil, EMDR-Portugal)
andrefocus@hotmail.com
https://www.espacodamente.com/our_team/andre-
monteiro/
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