EMDR as Treatment Option for Conditions Other Than PTSD: A Systematic Review

Abstract

Eye Movement Desensitisation and Reprocessing (EMDR) is a treatment for post-traumatic stress disorder (PTSD). The technique is known to facilitate reprocessing of maladaptive memories that are thought to be central to this pathology. Here we investigate if EMDR therapy can be used in other conditions. We conducted a systematic literature search on PubMed, ScienceDirect, Scopus, and Web of Science. We searched for published empirical findings on EMDR, excluding those centred on trauma and PTSD, published up to 2020. The results were classified by psychiatric categories. Ninety articles met our research criteria. A positive effect was reported in numerous pathological situations, namely in addictions, somatoform disorders, sexual dysfunction, eating disorders, disorders of adult personality, mood disorders, reaction to severe stress, anxiety disorders, performance anxiety, Obsessive-Compulsive Disorder (OCD), pain, neurodegenerative disorders, mental disorders of childhood and adolescence, and sleep. Some studies reported that EMDR was successful in usually uncooperative (e.g., Dementia) or unproductive cases (e.g., aphasia). Moreover, in some severe medical conditions, when psychological distress was an obstacle, EMDR allowed the continuation of treatment-as-usual. Furthermore, the effects observed in non-pathological situations invite for translational research. Despite a generally positive outlook of EMDR as an alternative treatment option, more methodologically rigorous studies are needed. We discuss the advantages and limitations and possible implications for the hypothesised mechanisms of action.

Full text

SYSTEMATIC REVIEW
published: 20 September 2021
doi: 10.3389/fpsyg.2021.644369
Frontiers in Psychology | www.frontiersin.org 1September 2021 | Volume 12 | Article 644369
Edited by:
Sara Carletto,
University of Turin, Italy
Reviewed by:
Markus Stingl,
University of Giessen, Germany
Georgios Demetrios Kotzalidis,
Sapienza University of Rome, Italy
Christopher William Lee,
University of Western
Australia, Australia
*Correspondence:
Charles Scelles
cscelles@lametairie.ch
Luis Carlo Bulnes
luis.carlo.bulnes@vub.be
†These authors have contributed
equally to this work
Specialty section:
This article was submitted to
Psychology for Clinical Settings,
a section of the journal
Frontiers in Psychology
Received: 21 December 2020
Accepted: 24 August 2021
Published: 20 September 2021
Citation:
Scelles C and Bulnes LC (2021)
EMDR as Treatment Option for
Conditions Other Than PTSD: A
Systematic Review.
Front. Psychol. 12:644369.
doi: 10.3389/fpsyg.2021.644369
EMDR as Treatment Option for
Conditions Other Than PTSD: A
Systematic Review
Charles Scelles 1,2,3
*†and Luis Carlo Bulnes 4
*†
1Adult Psychiatry Department, Université Catholique de Louvain – Saint Luc University Hospital, Brussels, Belgium, 2La
Métairie Clinic, Nyon, Switzerland, 3Adult Psychiatry Department, Geneva University Hospital, Geneva, Switzerland, 4Brain,
Body and Cognition Research Group, Vrije Universiteit Brussel, Brussels, Belgium
Eye Movement Desensitisation and Reprocessing (EMDR) is a treatment for
post-traumatic stress disorder (PTSD). The technique is known to facilitate reprocessing
of maladaptive memories that are thought to be central to this pathology. Here
we investigate if EMDR therapy can be used in other conditions. We conducted a
systematic literature search on PubMed, ScienceDirect, Scopus, and Web of Science.
We searched for published empirical findings on EMDR, excluding those centred on
trauma and PTSD, published up to 2020. The results were classified by psychiatric
categories. Ninety articles met our research criteria. A positive effect was reported
in numerous pathological situations, namely in addictions, somatoform disorders,
sexual dysfunction, eating disorders, disorders of adult personality, mood disorders,
reaction to severe stress, anxiety disorders, performance anxiety, Obsessive-Compulsive
Disorder (OCD), pain, neurodegenerative disorders, mental disorders of childhood and
adolescence, and sleep. Some studies reported that EMDR was successful in usually
uncooperative (e.g., Dementia) or unproductive cases (e.g., aphasia). Moreover, in
some severe medical conditions, when psychological distress was an obstacle, EMDR
allowed the continuation of treatment-as-usual. Furthermore, the effects observed in
non-pathological situations invite for translational research. Despite a generally positive
outlook of EMDR as an alternative treatment option, more methodologically rigorous
studies are needed. We discuss the advantages and limitations and possible implications
for the hypothesised mechanisms of action.
Keywords: mental health, systematic review, trauma, EMDR, eye movements desensitisation and reprocessing
INTRODUCTION
Eye-Movement Desensitisation and Reprocessing (EMDR) is a psychotherapeutic approach,
initially destined for the treatment of Post-Traumatic Stress Disorder (PTSD) (Shapiro, 1989).
During a therapeutic session, patients with PTSD had to perform a series of eye movement
alternations sequentially and at different times. The symptoms subsided. The technique is
articulated around several clinically relevant practises and procedures, such as relaxation
techniques, installation and bolstering of inner resources, and training to face internal difficulties.
EMDR follows an eight-phase protocol (see Table 1).
The therapist decides when is the right moment to proceed from one phase to another
and is, therefore, able to decide to deepen a certain phase when judged necessary. During the

Scelles and Bulnes Eye Movement Desensitisation Reprocessing
TABLE 1 | Eight-phase protocol of EMDR according to Shapiro (1989, 2001,
2007).
Phase Action
1 History and treatment plan
2 Introduction to EMDR protocol, and development of coping strategies
3 Evaluation of the treatment targets
4 Desensitisation and reprocessing
5 Incorporation of positive cognitions
6 Body scan (and reprocess of any remaining bodily negative sensation)
7 Relaxation (re-establish emotional stability if distress has been
experienced and for use between sessions)
8 Re-evaluation
desensitisation phase, the patient is asked to attend
simultaneously to the chosen target (e.g., a traumatic memory)
and to an alternative visual, auditory, or tactile bilateral
stimulus (BLS). He is then asked to take a deep and slow breath
and to briefly report whatever comes up, mostly sensations,
memories or thoughts (Shapiro, 2001). BLS-sets, followed by
these spontaneous associations, are repeated until the discomfort
associated with the memory dissipates. The therapy can therefore
vary, from the target that is chosen (e.g., a memory, a sensation,
a feared situation), to the lengths or type of BLS applied, or the
interventions that are made by the therapist between the sets
(Tarquinio et al., 2017).
The therapy follows the Adaptative Information Processing
Model (AIP) (Shapiro, 1994, 2001, 2007). This model postulates
that the brain possesses an innate information processing
system that assimilates new experiences by storing them into
memory networks. These networks will therefore constitute
the perceptions, negative beliefs, affects, and body sensations
linked to the initial event. For instance, information that is
inadequately processed in traumatic situations leads to the
emergence of manifestations observable in post-traumatic stress.
Bilateral Stimulation is supposed to facilitate the reprocessing of
the maladapted information.
The underlying mechanisms of action are a topic of ongoing
scientific debate. Theories are heterogeneous and broadly fall
into three categories: Psychological, Psychophysiological, and
Neurobiological. We briefly outline the main tenets of each (for a
review, see Landin-Romero et al., 2018).
The first psychological model is based on the Orienting
Response (OR) phenomenon, described by Pavlov in 1927. In the
face of threat or novelty, a set of behavioural and physiological
changes prepare to respond to danger. If no real threat is
experienced, a relaxation response takes place. According to
some authors, this relaxation response can desensitise traumatic
memories by suppressing its associated disturbance. The dual
attention task during the BLS seemingly activates the OR reflex
(Armstrong and Vaughan, 1996) creating a “dearousal” effect,
by which changes between sympathetic and parasympathetic
responses should happen, triggered by an attention attracting
stimulus (Söndergaard and Elofsson, 2008). However, the
psychophysiological underpinnings of these responses have not
been fully supported in the past (Söndergaard and Elofsson,
2008).
A second psychological model focuses on the Working
Memory account, in which the crucial element is the competition
between the vividness of traumatic memories and the BLS due
to limited-capacity working memory resources. The competition
leads to a decrease in the vividness of the treatment target
(Andrade et al., 1997). However, demanding tasks during recall
has been shown to reduce the vividness of emotional memories
(Engelhard et al., 2010; de Jongh et al., 2013).
Psychophysiological approaches focus on the ability of BLS-
sets to trigger specific changes associated with desensitisation.
These changes occur as an increase of autonomic activity,
coupled with an increase in respiratory rate during BLS, thus
excluding the effect of a mere relaxation-response (Elofsson
et al., 2008; Schubert et al., 2011, 2016). Conversely, a distinct
psychophysiological model hypothesises that ocular BLS induces
a REM-Sleep-like brain state. Because REM is characterised by
burts of eye Movements, reduction of temperature regulation,
alpha waves on EEG and activation within eye nuclei in the
brain (Söndergaard and Elofsson, 2008), BLS seems to fit similar
activity patterns. Because REM bolsters memory consolidation
via the integration of emotionally charged autobiographical
memories into general semantic networks (Born et al., 2006), BLS
may help process memories similarly as well.
Finally, the neurobiological accounts have focused on changes
and activation in the thalamocortical connexions (Llinas et al.,
2002) and in the mediodorsal thalamus-Superior Colliculus-
Amygdala circuits (Bergmann, 2008; Baek et al., 2019). Bilateral
sensory stimulation has been shown to promote the attenuation
of fear via a pathway mediated exclusively by the superior
colliculus. Sustained stimulation of this pathway was necessary
and sufficient to prevent reversal of fear extinction (Baek
et al., 2019). The general view of these accounts is that BLS
facilitates associative and episodic memory processing and
retrieval crucially attenuating traumatic memories. In concert
with an extinction-related response, the Reciprocal Inhibition
Hypothesis, based on the incompatibility between anxiety and
parasympathetic states (e.g., relaxation, feeding, sexual states),
postulates that induction of a parasympathetic state, should
induce extinction of anxiety. As such, eye movements are thought
to induce such states (Söndergaard and Elofsson, 2008).
The clinical efficiency of EMDR in trauma-related disorders
has been demonstrated in numerous meta-analysis (Davidson
and Parker, 2001; Seidler and Wagner, 2006; Chen et al., 2015;
Moreno-Alcázar et al., 2017), leading to its recommendation as a
first-line treatment for PTSD by the World Health Organization
(2013). However, it has yet not been included in therapeutical
guidelines for any other medical conditions, certainly due to the
sparsity of studies of EMDR outside PTSD. Still, the techniques’
official training manuals as well as EMDR textbooks (Tarquinio
et al., 2017), describe possible adaptations of the protocol to
treat conditions such as addiction, distress reaction to severe
medical conditions, depression, and anxiety disorders. Moreover,
the recent evolution in the definition of trauma and its causes,
as described in the DSM diagnostic manual (North et al., 2016),
the criticism of the categorical approach as diagnostic criteria
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Scelles and Bulnes Eye Movement Desensitisation Reprocessing
(Vanheule et al., 2019), and the implication of distressing life
events in numerous psychiatric conditions (Kim and Lee, 2016;
Copeland et al., 2018,Overstreet et al., 2017), make the efficiency
of EMDR outside PTSD plausible. It would indeed be surprising
for a therapeutic tool to be only effective in treating one specific
disorder. We, therefore, performed this systematic review, aimed
at investigating the evidence of the use and efficacy of EMDR in
other conditions than PTSD by using the PRISMA guidelines for
transparent reporting of reviews and meta-analyses. A previous
similar work (Valiente-Gómez et al., 2017) searched for this in
specific conditions, and only included RCTs.
We further sought to integrate all types of studies, including
case studies. Indeed, RCTs cannot be considered as the only valid
scientific level of proof (Anglemyer et al., 2014). Including all
types of studies allows a broader overview, which seems necessary
given the urgency of knowledge in a context where psychiatric
disorders are still one of the deadliest medical conditions (Walker
et al., 2015).
METHODS
Database Search and Filtering
We conducted a systematic literature search among PubMed,
ScienceDirect, Scopus, and WebofScience similarly to those
previously used in systematic reviews related to Trauma and
PTSD (Valiente-Gómez et al., 2017;Bloomfield et al., 2020). The
studies included published works up to 2020 and are reported
following the Preferred Reporting Items for Systematic Reviews
and Meta-Analysis Guidelines (PRISMA) (Figure 1).
The first search was performed automatically by title within
each database, and included the keywords “EMDR,” “Eye-
Movement Desensitisation and reprocessing” with the Boolean
operator “OR” (e.g., “EMDR” OR “Eye-movement desensitisation
and reprocessing”). Because this review aims at reporting on the
use of EMDR procedure in cases not directly related to PTSD,
all searches within the databases were automatically filtered
excluding titles that included the terms “PTSD,” “Post-traumatic
stress,” “Posttraumatic stress” defined with Boolean operators
“AND” and “OR” (e.g., exclusion of titles with the terms “EMDR”
AND “Post-traumatic stress).”
Note that we decided not to use the term “disorder” because
many articles used the variant “post-traumatic stress symptoms,”
therefore reducing to post-traumatic stress was more efficient.
The resulting list of articles of all four databases was imported
into Mendeley Desktop. A cheque for duplicates was performed,
and duplicate articles discarded accordingly.
A second search was performed within the remaining records
based on the exclusion topics (i.e., PTSD, Post-traumatic stress,
posttraumatic stress) searched first by title, then by Keywords and
finally within each abstract. We manually discarded those articles
that were specific to the study of PTSD and trauma.
Article Selection
Articles were further scrutinised following different criteria:
(1) Articles were in full and constituted empirical findings (2)
Articles were either Group studies or Case studies. Both instances
of studies are reported. Conference proceedings, Theory or
Opinion articles were excluded. Review articles were included
for completeness, although the review articles are more general
in a given topic (e.g., pain) and did not focus on EMDR outside
trauma per se. Note that the final selection led to the systematic
exclusion of articles that mentioned that the subjects had been
exposed to trauma. Therefore, articles included had to focus on
the treatment of disorders that could not be assimilated to post-
traumatic stress or traumatic events (e.g., acute stress disorder,
violence, grief).”
All articles were selected by both authors independently, and
selections later interchanged for comparisons. Final inclusion
was achieved after mutual consensus. One of the authors (C.S)
is an EMDR trained psychiatrist.
Article Classification
Remaining articles were classified in different groups following
the ICD classification system (International Classification
of Diseases and Related Health Problems) with three
exceptions: Sleep disorders, Mental disorders of childhood
and adolescence and non-psychiatric conditions (e.g.,
Neurodegenerative disorders).
RESULTS
The results of the present review were organised in five main
sections: (1) General search results and classifications, (2)
General Studies Characteristics, (3) Overall EMDR reported
success, (4) Quality of evidence assessment of group studies, and
(5) Main findings per category. Because results and studies are
heterogenous, a meta-analysis was not considered and only a
descriptive approach was followed.
General Search Results and Classification
The database search resulted in a total of 4,129 records. The
original number was reduced to 389 records after philtres and
duplicate removal. Duplicate removal was performed manually.
After the second manual and independent screening, records
focusing on trauma or PTSD were removed based on specific
title, keyword, and abstract inspection resulting in 228 records.
A second round of inspection, independently by both authors
resulted in further 53 records excluded. A total count of 175
records were assessed for eligibility, with a total of 71 records
excluded based on the content. Papers were focused on the study
of trauma specifically or data was not available (e.g., conference
abstracts, full documents not found). From the final count of 104
papers, 90 were included as eligible research papers for review.
Thirteen reviews and one meta-analysis were also included but
will not be discussed as these included studies focusing on trauma
and are mentioned only for completeness.
Of the 90 final studies, 14 different categories of clinical
disorders were identified following the ICD classification system
with the exception of sleep disorders, Mental disorders of
childhood and adolescence and non-psychiatric conditions
(Table 2). See supplementary material for a general overview
of all the studies included in this review and their summarised
characteristics (Supplementary Tables S1–S14).
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FIGURE 1 | Flowchart depicting the search, selection, and inclusion of the items of the systematic review.
General Studies Characteristics
Design
The studies could be distinguished by several features. For
instance, the type of study design. Only 1/3 of the total amount of
studies constituted RCT’s (n=27), 24% corresponded to group-
controlled (n=10) or group studies (n=12) and nearly half
(46%) corresponded to case studies, case reports and case series
(n=41).
Protocol
The studies could further be distinguished by variations of
the EMDR protocol reported. In some instances, the specific
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TABLE 2 | Summary of the article classification and the total of sample size of
studies eligible for the systematic review.
Article categories Number of eligible studies
Mood disorders 10
Reaction to severe stress 7
Anxiety disorders 11
Performance anxiety 8
Obsessive-compulsive disorder 7
Pain 22
Somatoform disorders 4
Sexual disorders 2
Addiction 5
Eating disorders 1
Disorders of adult personality 4
Neurodegenerative disorders 2
Sleep 1
Mental disorders of childhood and adolescence 6
protocol was not specified, in which case it was considered
as “unspecified.” Twenty-two different protocols could be
identified, most were variations of the standard protocol
described by Shapiro (2001), some integrated protocols where the
standard protocol was used in tandem with other techniques or
variations corresponded to the type of targets. Moreover, results
demonstrated that some protocols were used also in different
disorder categories (e.g., Phobia protocol used in Anxiety and
OCD) and that in other instances, several different types of
protocols were utilised within one single disorder category (e.g.,
in the pain category, at least six different protocol variations
were reported). Furthermore, results showed that the standard
protocol was reported as used in all disorder categories, except
in somatoform disorders, Addictions and eating disorders for
which we did not find explicit data of the protocol used.
This suggests that there is not one specific protocol type per
disorder category, although the standard protocol remains the
most widely used. Crucially, some protocols devised for specific
disorders may also be used in other types of disorders as well.
See Supplementary Tables S15–S17 in supplementary material
for an overview of the distribution of protocol variations across
disorders categories and a distribution of studies by disorder
category and intervention protocol.
Session Number and Time
Although the number of EMDR sessions was variable (between
a single session to 72), it was possible to observe that the overall
average number of EMDR sessions is of about 7–8 sessions (M =
7.61, SD =2.11) regardless of the type of study (i.e., RTC, group-
controlled, group study, case report, case study or case series). To
estimate this, the specific reported average of number of EMDR
sessions was taken into account, when this was not possible,
the average of the min-max range of the reported number was
included (e.g., “between 1 and 24”).
In regard to the time of each EMDR session, it was observed
that on average, each EMDR session lasted about 78 min (SD =
TABLE 3 | Summary of the distribution of session number, duration, and average
sample size per study type.
Study type Sessions number Session duration Sample size
RCT 7.6 (1–24) 70.6 (38–90) 26
Control group 6.24 (1–12) 88 (60–150) 20
Group study 6 (1–10) 80 (60–90) 14
Case study/reports 10.6 (1–72)/9 (1–32) 74 (60–90) 2
The Min–Max reported range of all studies per group is shown.
8 min), ranging between 70 and 88 min, with the lowest mean
session duration reported by the RCTs group of studies (Table 3).
Overall EMDR Reported Success
Reported Success
Overall, results demonstrated that EMDR resulted un positive
outcomes in most cases, showing either improvements over time,
or better results in comparison to a control group.
We operationalised success according to (1) Success (reported
positive outcome), (2) Intermediate success (reported positive
outcome) but either not better than the comparison group or
comparison treatment or no treatment (e.g., not better than
CBT), or only partial improvement, and (3) No success (reported
lack of positive outcome or failure of treatment). We identified 76
studies reporting clear successful effects of EMDR, nine studies
showing an intermediate success and five studies reported no
positive effects or no improvement after treatment.
From the total count of studies that reported positive
outcomes, over half (58%) of the amount corresponded to
studies related to Pain, Anxiety, Mood, Stress. This suggest
that the literature about the use of EMDR outside trauma that
reported successful outcomes was higher in these categories.
When considering the proportion of studies per category (e.g.,
total count of positive outcomes/ total number of studies per
category), all categories showed high percentage of studies with
positive outcomes (>75%), with the exception of addictions
(60%; 3 out of 5) and OCD (57%; 4 out of 7). Importantly, in
some categories only one or two studies were found (i.e., Sleep,
Sexual disorders, eating disorders, neurodegenerative disorders),
therefore these results must be interpreted with caution.
See Supplementary Table S18 in supplementary material for
an overview of reported success per disorder category and
study type.
To better understand the results related to intermediate
findings and those studies that reported no-improvements, we
briefly summarise these.
Nine studies reported a positive effect, although the effects
were not distinguishable from the effects of a comparison
group or other treatment. Two RCTs studies on depression
did not find that EMDR was different or better than CBT
(Ostacoli et al., 2018; Minelli et al., 2019). It is important to
note that the study by Ostacoli et al. (2018) was the only
study included in mood disorders that used a different protocol
than the standard protocol (i.e., DeprEnd). One group study
on addictions reported that, out of eight participants included,
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three recovered during baseline period, two did not respond to
treatment, and three improved during EMDR (van Minnen et al.,
2020). Moreover, one group-controlled study on anxiety also
found that, although there was an improvement in symptoms
related to panic disorders, EMDR was not better than CBT
(Faretta, 2012). Similarly, an RCT on phobia by Goldstein et al.
(2000) found that EMDR resulted in significant reduction of
symptoms of panic disorder with agoraphobia, as compared to
a waiting list, but no difference was found compared to an
attention-placebo control group. In the same vein, a controlled
group study on performance anxiety by Brooker (2018) reported
that EMDR was equally effective to hypnotherapy in reducing
state-anxiety in musicians, with only slightly stronger statistical
effects. Similarly, a controlled group by Muris et al. (1998)
reported that only exposure in vivo alone was significantly
effective in reducing fear and avoidance self-reports on spiders
in children with spider phobia. The effects of EMDR were
positive, although only as an additive effect to exposure in vivo.
Finally, Böhm and Voderholzer (2010) as well as Mazzoni et al.
(2017) described three patients each, with OCD treated with a
combination of EMDR and ERP. In both studies, all patients
improved in their symptoms at post-treatment, however, it was
not possible to determine what can be accounted for by the
EMDR procedure specifically.
Of the studies with no improvement outcomes, four were
randomised controlled trials (Carrigan and Levis, 1999; Ray
and Page, 2002; Marsden et al., 2018; Markus et al., 2020)
and one was a case report (Brennstuhl et al., 2017b). In the
study by Markus et al. (2020) on addiction, results not only
did not show significant additive effects of AF-EMDR on TAU
in drinking behaviour, but also reported that individuals in the
control group had a more positive outcome than those with
EMDR. In the study by Marsden et al. (2018) on OCD, no
significant differences between treatments at post-test were found
and only 30% of patients improved in OCD symptoms. Similarly,
Ray and Page (2002) reported that EMDR did not result in
statistically significant improvement of pain scores, only a group
receiving hypnosis statistically improved symptoms. One RCT
study related to performance anxiety had previously reported
that EMDR treatment reduced SUDs of discomfort of fearful
imagery, as well as physiological anxiety (SCL), but did not
reduce public speaking anxiety and was not different or better
than any of the other control treatments (Carrigan and Levis,
1999). Finally, a case study by Brennstuhl et al. (2017b) reported
that EMDR did not have any effects on patients with chronic
pain, although they found a tendency to decrease in scores in
all measures.
This suggests that almost 26% of all the RCT’s included (n
=27) in the review either did not find that EMDR was better
than a control condition or did not find any significant effect to
the treatment [23% if all group studies are taken into account
(n=49)].
Treatment Dropout/Adverse Events
To gauge the treatment drop-out and adverse events, we focused
on RCTs, the group-controlled and the group studies (n=49). In
total, 14 studies reported on patient drop-out. Eight RCT (out of
27), Two control-groups (out of 10) and three (out of 12) group
studies reported that patients had stopped the EMDR sessions
before completion of treatment. In particular, high levels of drop-
out in a single study were reported in the treatment of addictions
[number of dropouts, Addictions (n=19; Markus et al., 2020)],
OCD (n=17; Nazari et al., 2011), and Pain (n=12; Mazzola
et al., 2009). Overall, the reasons for drop-out, when specified
and explicitly related to the treatment, were usually because of
how hard it is to reminisce past memories, or to EMDR being
time-consuming (e.g., Markus et al., 2020).
Quality of Evidence Assessment of Group Studies
As an attempt to provide the overall quality of evidence of all
group studies, we performed an ad-hoc assessment of the group
studies’ quality, with particular focus on the controlled-group
studies. We proceeded by partially following the ad-hoc GRADE
system (Atkins et al., 2004) that considers features of each study
in a hierarchical manner (Petrisor and Bhandari, 2007). To do
so, we considered several criteria, such as the study design, the
methodological limitations (e.g., control for selection bias), the
types of controls, the outcome measures (e.g., were there multiple
baselines? Was the main outcome measured via ad-hoc measures
or were there standardised measures utilised?), the consistency
of results (e.g., results were maintained at follow-up; results
or interventions were not heterogeneous), and the precision
and success of results. The result allowed to have an overall
appraisal of the quality of evidence (see Supplementary Material
for details).
It was observed that although the level of quality by design
is considered the highest within the RCT studies, 60% of
controlled group studies also proceeded by randomisation.
Therefore, around 40% of controlled group studies presented the
limitations of selection bias. The quality of the control types (e.g.,
comparison against gold-standard treatment, waiting list or no
treatment) was also limited within the group-controlled studies.
Only 50% of studies compared against either CBT or Treatment
as usual, and only 59% within the RCT’s, thus showing that
the type of control conditions was only of moderate or average
quality within controlled groups.
Further scrutiny on the measures used for the main outcomes
revealed that only five studies used ad-hoc measures instead
of standardised psychometric tools. Given the nature of the
procedure, all studies performed a baseline measurement;
however, only six of the total count of group studies performed
multiple baseline measurements.
Conversely, a higher proportion of group-controlled studies
did perform follow-up assessment (70%), not being the case
of RCT’s, where only almost half (48%) of studies performed
follow-up measures. In regard to the outcome, all group
studies and controlled group studies reported success (see
Supplementary Table S18). However, only 50% of controlled
studies reported higher success than the control condition
(70% in the RCTs). The subsequent quality assessment focused
on heterogeneity in the results (e.g., patients still needed
antidepressant medications after EMDR; Loss of control
comparisons at follow-up, etc.), which was moderate in the case
of controlled studies (40%), with higher consistency in the case
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of RCT’s (25%, low inconsistency). Crucially, we also observed a
moderate (30%) heterogeneity in the types of interventions (e.g.,
the same patient group receives mixed therapies at the same time;
the control condition is heterogeneous).
Further inconsistency concerned the maintenance of effects
at follow-up. Only three out of six controlled studies that
reported/performed follow-up demonstrated maintenance of
effects after the post-test. In the case of the group studies or
the RCT’s, they all reported maintenance of effects at follow up
when reported.
Regarding the outcome data, while almost the totality of group
studies reported success in both the critical and the secondary
outcomes, only 70% of the controlled group studies reported on
secondary outcomes measures, of which 5/7 reported success in
both. Interestingly, the majority of the RCT’s reported success in
the critical outcome only. Finally, as previously noted, the group
and group-controlled studies were highly under-sampled (<30;
Central Limit Theory) and only about 44% of RCTs’ included
sample sizes per group of more than 30, thus not satisfying
sufficient sample sizes in any of the groups, further reducing the
quality of the evidence.
In sum, the evidence’s overall quality was moderate,
particularly in the case of the controlled group studies.
Main Findings Per Category
In the next section, main findings of all studies for each category
are presented.
Mood Disorders
Ten studies were found related to EMDR and mood disorders
identified within three categories: (1) Depression, (2) specific
aspects of depression, and (3) specific subtypes of depression (see
Supplementary Table S1).
Depression
Six RCTs evaluated the effectiveness of EMDR in Depressive
Disorders. Three compared EMDR to CBT, three EMDR to TAU.
One study performed a multicentre RCT and found EMDR to be
as effective as CBT in Recurrent Depressive Disorder (Ostacoli
et al., 2018). However, the study showed that EMDR results
appeared sooner during therapy. Another study (Hofmann et al.,
2014) found significantly higher number of remissions at post-
treatment in the adjunctive treatment of EMDR in comparison
to two randomised groups of patients with Unipolar Primary
Depression, one receiving EMDR +CBT, and one CBT only.
Similar results were observed in a study (Minelli et al., 2019)
comparing EMDR to CBT in Treatment-Resistant Depression,
finding EMDR to be as effective as CBT during hospitalisation,
and superior at follow-up. Among the studies comparing EMDR
to TAU, a recent study found EMDR to be significantly more
effective on Quality of Life in a group of 70 patients suffering from
Major Depressive Disorder (Jahanfar et al., 2020). Two other
studies similarly found good tolerance of the EMDR intervention
compared to TAU, crucially they found EMDR particularly
interesting because of the speed of its therapeutic action (Gauhar,
2016) and because the EMDR group had fewer relapses at 1-year
follow-up (Hase et al., 2015).
Specific Aspects of Depression
We found two articles dealing with more specific aspects of
depression. First, one RCT (Fereidouni et al., 2019) relating to
the severity of suicidal thoughts in MDD. This study found
a significant decrease in suicidal ideas in the EMDR group
compared to a routine treatment without intervention. In the
same vein, we found one case study that examined the effect
of EMDR on depression in three patients with specific social,
educational and professional deteriorations (Rosas Uribe et al.,
2010). Longitudinal data of the study showed a positive effect
on the subjects’ mood, in particular there was a change on
emotional-cognitive processing and conceptual organisation of
emotional representations.
Specific Subtypes of Depression
We found two studies that concern specific subtypes of
depression. One study described a clinical trial on 60 subjects
with a history of myocardial infarction (MI) (Behnammoghadam
et al., 2015). Depressive symptoms are frequent among post-
myocardial infarction patients and may cause adverse effects on
cardiac prognosis. Results demonstrated a significant reduction
in depressive symptoms (BDI) after 4 months EMDR weekly
sessions. The authors highlight that EMDR is “an effective, useful,
efficient, economical, and non-invasive” method for treatment
and reducing depression in patients with MI. In the same vein, a
case report by Guina and Guina (2018) showed successful effects
of EMDR treatment of depression in a patient suffering from
aphasia, a condition hardly accessible to psychotherapy. Therapy
improved depressive symptoms and aphasia.
In addition, we identified one review (Carletto et al., 2017)
that analysed the results of RCTs evaluating EMDR in MDD, with
some articles included in this section. The authors concluded that
literature still lacks controlled studies and those currently found
present several methodological flaws. Despite the limitations,
EMDR seems to be a promising therapy to treat depression.
Reaction to Severe Stress
Seven studies were found related to severe stress. We identified
studies related to (1) Cancer, and (2) Other issues related to severe
stress (see Supplementary Table S2).
Cancer
Four studies were found that evaluate the effectiveness of EMDR
in distress related to cancer. One group study (Borji et al., 2019)
tested the effect of only two sessions of about 1 h of EMDR
on perceived stress in patients with gastrointestinal cancer,
compared to a control group of patients receiving routine care at
home. Results demonstrated a statistically significant reduction
of stress levels. Similarly, another group study (Szpringer et al.,
2018) found comparable results in the intervention group
on anxiety, depression, and food intake in 37 patients with
Multiform Glioblastoma. Moreover, the Sense of Coherence (e.g.,
overall perception of well-being) increased in the EMDR group,
as it decreased among the controls. Furthermore, we also found
a case study (Dinapoli et al., 2019) of a man suffering from
laryngeal carcinoma who experienced a high level of distress
during his first contact with the thermoplastic mask necessary for
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radiotherapy. An association of psychiatric medication and three
sessions of EMDR resulted in a decrease of distress that allowed
to start radiotherapy with only a little delay. Finally, a case report
(Trznadel and Grzybek, 2017) showed a significant decrease of
distress in three sessions EMDR in a patient diagnosed with
malignant neoplasm of the breast. Both, negative emotions and
physical sensations decreased.
EMDR in Other Health Issues and Severe Stress
Similar positive results were found in three RCTs that reported a
decrease in anxiety and depression scores in, patients requiring
haemodialysis treatment (Rahimi et al., 2019), and in patients
suffering from spinal cord injury (Hatefi et al., 2019). In the
same vein, a group study (Zolghadr et al., 2019) found a decrease
of anxiety scores in one single session of EMDR in a group
of pregnant women with a history of stillbirth compared to a
control group.
These results support the literature review by Shapiro (2014)
that reported that EMDR is efficient in the treatment of the
psychological or physiological effects of adverse life-experiences
and has preventive and rehabilitative potentials for patients and
their families.
Anxiety Disorders
Eleven studies were found related to anxiety disorders. We
identified studies related to (1) Panic disorders, and (2) Phobia
(see Supplementary Table S3).
Panic Disorder
A first case series (Goldstein and Feske, 1994) found an effect
of EMDR after five sessions in seven subjects suffering from
panic disorder, reporting a considerable decrease in the frequency
of panic attacks, fear of experiencing a panic attack, general
anxiety, and thoughts concerning the negative consequences
of experiencing anxiety. An RCT by same author (Goldstein
et al., 2000) found no statistical difference between control and
experimental group in patients who have panic disorder with
agoraphobia, concluding that “EMDR should not be the first-line
treatment for this disorder.”
In the same vein, another RCT (Faretta, 2012) found that
EMDR had similar effects to CBT after twelve sessions, although
with faster progress in the EMDR group. Interestingly, a number
of sessions superior to 10, with at least three sessions of
preparation were also needed in two case studies (Fernandez and
Faretta, 2007; Bhagwagar, 2016) before observing a therapeutic
effect of EMDR in cases of panic disorder with agoraphobia.
Finally, a more recent case study (Nicolas and Vautier, 2017)
reported that one patient recovered from panic disorder after one
single session of EMDR. Seemingly, EMDR specifically benefited
the retrieval of non-identified memories that could then be
targeted in therapy.
Phobia and Other Anxiety Disorders
Three case studies, in arachnophobia (Muris and Merckelbach,
1995), aviophobia (Lapsekili and Yelboga, 2014), and
emetophobia (de Jongh, 2012), met our research criteria.
All three reported a good tolerance and positive effect of EMDR
in a maximum of four sessions, with remission of phobic
behaviour maintained at follow up. When no behavioural change
was observed, EMDR seems to have allowed the patient to
beneficiate from exposure therapy. Furthermore, we also found a
pilot-study in General Anxiety Disorder (Farima et al., 2015) and
a case study in Social Anxiety Disorder (Sagaltici and Demirci,
2019), both similarly demonstrating positive effects of EMDR in
terms of efficacy in reducing pathological worry symptoms and
maintenance of results.
In addition, our review identified two reviews and one recent
meta-analysis on EMDR in Anxiety Disorders. The meta-analysis
of RCTs evaluated the effectiveness of EMDR in anxiety disorder,
in a total of 17 trials with 647 patients (Yunitri et al., 2020).
Results demonstrated that EMDR is successful in the reduction of
anxiety, panic, phobia, and behavioural/somatic symptoms. Both
reviews (Faretta and Leeds, 2017; Faretta and Farra, 2019) found
that EMDR is an effective therapy for panic disorder although
there is a clear need for more controlled studies. Furthermore,
EMDR therapy effectiveness suggests that its efficacy may not
be restricted to panic disorder in general but for other specific
phobias as well.
Performance Anxiety
Our review identified seven group studies and one case
series related to performance anxiety and EMDR. We could
distinguish between studies related to (1) Public speaking, (2)
Physical performance, (3) Learning, and (4) Test anxiety (see
Supplementary Table S4).
For instance, the first RCT that we identified (Foley and
Spates, 1995) described a study where college students suffering
from public speaking followed either a standard EMDR protocol,
an EMDR protocol with moving audio stimulus instead of eye
movements, an EMDR protocol with the eyes resting on the
hands, or a no-treatment control condition. Although all EMDR
treatments were more beneficial compared to the no treatment
group, they reported no difference between EMDR treatments,
both, at post-test and follow-up. Crucially, the improvements
were specific to subjective reports of communication anxiety
but failed to improve subjective reports of public speaking
anxiety measures and their behavioural assessment. Furthermore,
no significant psychophysiological changes were reported. The
results of this study suggest that the EMDR effects were related
to subjective and general aspects of communication rather than
specific fears. A similar study (Carrigan and Levis, 1999) assessed
the effects of EMDR on fear and confidence reports of public
speaking. Participants expressing fear of public speaking were
assigned to four different protocols: (1) Eye movements and
fear-relevant imagery, (2) Eye movement and relaxing imagery,
(3) No Eye movement and fear-relevant imagery, and (4) No
Eye movement and relaxing-imagery. The protocol focused
on memories associated with fear of public speaking. The
results specifically failed to reveal any substantial effect of eye
movements on the outcome variables and only demonstrated that
the subjective units of discomfort, as well as skin conductance
values, were overall lower in the relaxing-imagery conditions.
The authors suggested that the only beneficial effects of EMDR,
may thus be merely related to the therapist-cued visualisations
of fearful images, because exposure, even at an imaginal level,
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is beneficial. Thus, further supporting the view that exposure
therapy may be a critical prophylactic to fear-related distress.
Interestingly, a more recent study (Aslani et al., 2014) found
opposing results. In this study, speech anxious students followed
either a standard protocol or no treatment. However, the protocol
did not focus on any memory specifically related to speech.
Instead, participants were invited to imagine any disturbing
situation to which subsequent eye movements followed. Results
showed significant reductions of Confidence of speaker measures
as well as speech anxiety at post-treatment in the EMDR group,
but no difference observed in the control group. Interestingly,
while this study suggests that EMDR may be beneficial for
speech anxiety, it is difficult to gauge the specific benefits of eye
movements to speech anxiety per se. Participants were tested on
unspecific imagery; as such, it could be that they were simply
more relaxed in general after the procedure and not actual
“reprocessing” occurred.
In regard to physical performance and EMDR, three studies
were found. One study (Rathschlag and Memmert, 2014)
used an advanced version (Wingwave method) of EMDR to
reduce anxiety in a group of non-pathological participants.
This method combines standard EMDR and a muscle test
(BDORT). Subjects were assigned to an EMDR group or a no-
treatment control group. In the experimental group, participants
were asked to self-generate any memory that they judged
to be anxiogenic and were later assessed in their subjective
reports of anxiety, and their physical performance in the
pulling-force test (i.e., finger muscle contraction). A crucial
element of this technique is that after EMDR if this technique
is useful, there should be more muscle strength because of
overall muscle relaxation allowing for enhanced control of
movement. Their results demonstrated that all anxiety measures
significantly decreased at post-treatment in the experimental
group, and as expected, the mean strength rating for the finger
pulling measurement was significantly increased. These results
suggest that EMDR did have anxiolytic and relaxing effects.
In the same vein, a clinical study on the effects of EMDR on
musical performance (Brooker, 2018) demonstrated the effects
of two sessions of either hypnotherapy or EMDR on objective
performance and performance-anxiety within advanced pianists
suffering from music performance anxiety. Both therapies were
significantly effective in reducing state-anxiety from a short
non-public baseline performance (2 min) to a post-treatment
performance (2 min). However, a self-report assessment on
perceived anxiety revealed that all treatments significantly
reduced the participants’ perception of anxiety immediately
after the performance, with the EMDR group producing
slightly stronger effects. Crucially, the assessment of their
actual performance increased after hypnotherapy and EMDR,
suggesting that both psychotherapies were similarly successful
in reducing acute anxiety related to music performance. In the
same vein, a case series (Falls et al., 2018) targeted prospective
imagery on competitive golfers instead of focusing on past
memories. Results demonstrated how anxiety and negative
cognitions about future-oriented imagery were reduced with
EMDR, further demonstrating a positive impact on performance
as well.
Finally, we found two group studies related to testing
anxiety and learning. One study (Maxfield and Melnyk, 2000)
reported beneficial effects of EMDR on prospective test-related
anxiety in test-anxious university students. In their study, one
single session was sufficient to produce significant reductions
in several measures of anxiety scores immediately after the
EMDR treatment (vs Waitlist), with the treatment having lasting
effects previous to examinations. More recently, another study
(Vauthier et al., 2019) extended the EMDR beneficial findings to
learning, specifically in mathematics, a well-known anxiogenic
subject for university students required to pass a mandatory
high-level mathematics contest. One single session of EMDR,
focusing on past anxiogenic experiences related to learning
mathematics revealed significant effects in reducing the negative-
emotion bias related to mathematics in general. It resulted in an
improvement of self-efficacy scores in mathematics at post-test.
These results suggest that one-shot, short EMDR sessions are
advantageous on anxiogenic experiences related to past as well
as prospective memories.
Obsessive-Compulsive Disorder
We found seven studies related to Obsessive-Compulsive
disorders (OCD). Five studies were case reports, and only
two were group studies. It was possible to identify (1) studies
reporting comparisons between CBT with exposure therapy
(ERP) and EMDR, (2) studies comparing EMDR to medication,
and (3) studies assessing variations of the standard EMDR
protocol (see Supplementary Table S5).
Among the studies comparing CBT with exposure therapy and
EMDR, an early report (Böhm and Voderholzer, 2010) described
three patients with OCD diagnosis (e.g., obsessions of control,
sexual and aggressive obsessions, washing habits) that in addition
to exposure therapy (ERP) received EMDR in three different
modalities (i.e., patient 1: EMDR first and then ERP, patient 2:
ERP first and then EMDR, and patient 3: alternations of ERP and
EMDR). Results demonstrated that all three patients presented
a clear reduction in their obsessive-compulsive scores, and this
was maintained at follow-up. Similar findings were reported in a
case report (Mazzoni et al., 2017) with three patients presenting
similar behaviours (e.g., washing obsession, fear of aggression,
and aggressive obsessions), also presented with a combination of
ERP therapy and EMDR. Results showed that all OCD symptom-
scores were reduced irrespective of modality at post-treatment.
Interestingly, dissociative scores were also modulated by the
therapeutic protocol. Along with trauma, dissociative symptoms
constitute underlying mechanisms of PTSD, and according to
the authors this element could help elucidate the mechanisms
by which EMDR help improve OCD symptoms; possibly because
OCD and PSTD could share overlapping processes. Because these
studies used combined protocols of either therapy, it is difficult
to assess, however, the precise contribution of either technique
specifically. More recently, however, another study (Marsden
et al., 2018) shed some light on the benefits of combining EMDR
and CBT therapy based on exposure and response prevention
(ERP). In their RCT, two groups of patients with OCD were
assigned either to an EMDR or a CBT. They reported no
significant differences between the groups at post-treatment or
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6-month follow-up, challenging the idea that exposure can make
people feel worse.
From the studies comparing EMDR to medication, one
group study (Nazari et al., 2011) compared standard EMDR
to treatment with the antidepressant (SSRI) citalopram 20 mg
for 12 weeks. Crucially they report a reduction of obsessive-
compulsive symptom scores in both groups; however, the
reduction of scores in the EMDR group was significantly higher
than with citalopram. In the same vein, we found a case report
(Corrigan and Jennett, 2004) of an OCD patient that was not
responsive to CBT nor to a series of antidepressants (Fluoxetine,
Paroxetine, Clomipramine and Amitriptyline), although he was
under fluvoxamine (300 mg/d) at the time of referral. They
report that the patient felt so well after only two sessions of
EMDR that she decided to stop taking fluvoxamine, alas bringing
back her depressive state. EMDR was re-established after her
recovery and was finished in five sessions while fluvoxamine
was reduced to 50 mg a day. Interestingly, the patient reported a
complete relapse 9 months later after having ingested one single
capsule of an herbal product containing 3 mg ephedra alkaloids,
a catecholamine release stimulant. Although the authors do not
comment on this issue, EMDR might act by mediating changes
through this same pathway. Results thus suggest a cooperative
effect of EMDR to medication.
Finally, our review identified two case studies using variations
of the phobia EMDR protocol that included a “(mental)video
playback,” where the crucial element is to address current
obsessions, instead of past negative experiences For instance,
Marr (2012) showed preliminary research on patients that
have either not been responsive to CBT or were reluctant to
CBT because their symptoms were exacerbated by exposure.
Irrespective of the protocol used, all four patients presented
a net decrease of the obsessive-compulsive scores at post-
treatment and at follow up 4–6 months later. Similarly, using
the same protocol, Marsden (2016) later reported three cases
of female patients with similar improvement in all obsessive-
compulsive measures.
Pain
Twenty-two studies were related to EMDR and pain
management. To better assess these, we organised the studies
based on the aetiology of the pain symptoms, namely: (1)
Chronic pain, (2) Phantom pain, (3) Fibromyalgia, (4) Migraine,
and (5) Acute pain/experimental (see Supplementary Table S6).
Chronic Pain
Seven studies were related to EMDR and chronic pain
management. We identified five group studies. The first group
study we could trace compared the effects of EMDR to hypnotic
suggestion (Ray and Page, 2002). In this RCT, participants were
randomly assigned either to an EMDR group or a hypnosis
group. Perception of pain was assessed within each therapeutic
session as well as between sessions (e.g., different times of the
day, each day for seven days). Crucially, the authors report
that although both types of treatment resulted in numerical
declines of perceived pain, only the hypnotic group reached
significant levels, suggesting that hypnosis was more useful
in reducing pain than EMDR during the treatment session.
In another study (Mazzola et al., 2009), a mixed sample
of patients suffering from chronic pain took place on a 12
weekly 90-min session of an adapted EMDR protocol that
focused on the pain sensations. Their results showed significant
decreases in scores in all of the different health and mental
health assessments (e.g., SF-36 functioning survey, Anxiety,
Depressive symptoms, and pain perception), demonstrating an
efficacious effect of EMDR, despite the heterogeneous aetiologies
of their sample. Interestingly they reported that among all the
personality assessments, the most prominent one was obsessive-
compulsive symptoms, present mostly in the headache patients
who were in the majority. A later group study (Brennstuhl
et al., 2016) compared two different EMDR protocols [i.e.,
Standard protocol (Group 1), Pain protocol (Group 2)] to a
control group that followed classical psychotherapy (Group
3) on multidimensional components of pain perception (e.g.,
sensorial, cognitive, behavioural, emotional, PCL checklist, pain
perception). The standard protocol was the most effective of
all, and this already after five sessions. Interestingly, although
no statistical group differences were determined in the PCL-
checklist, the control group got worse, while the two EMDR
groups ameliorated in their subjective report of traumatic
experiences. Despite the fact this study focused on pain and not
trauma per se, the results shed some light on the fact that chronic
pain may have an underlying aetiology specifically related to
traumatic experiences, which are therefore best approached
with the standard protocol. Furthermore, two group studies on
chronic pain have tested the effects of EMDR in patients with
rheumatoid arthritis, both in the adult and the young. In the
adults’ study (Ghanbari Nia and Behnammoghadam, 2018) the
authors compared an EMDR protocol with guided imagery and
a waitlist control group. Scores on pain perception were all
significantly reduced both in the EMDR and the imagery groups;
however, the EMDR decrease of pain severity was even lower,
suggesting that the EMDR group rated significantly less pain than
the guided and the waiting list groups. Similar positive results
were reported in the juvenile group suffering from idiopathic
arthritis (Höfel et al., 2018). Young patients suffering from this
condition may sometimes be intolerant to methotrexate (MTX),
a drug usually prescribed to treat arthritis. Here, the authors
showed that EMDR followed in eight sessions over 2 weeks was
sufficient to improve the intolerance symptoms as well as the
reported Quality of Life of the sufferers. The authors point out
that many negative feelings in this condition might be related
to anticipation (e.g., suggestion) of the adverse effects of MTX.
Therefore, anticipation and/or suggestion (see Ray and Page,
2002) seems key to understanding pain management.
Finally, we identified two case studies. The first one assessed
chronic pain with a dedicated pain protocol (Brennstuhl et al.,
2017b). In this study no significant results were found after five
sessions with EMDR, although pain scores showed a tendency
to decrease, in all measures (e.g., pain perception, sensory
and emotional aspects of pain). The second case study used a
mixture of standard/pain protocol (Grant and Threlfo, 2002).
Here, however, all patients were relieved from pain and the
positive effects were maintained after 2 months post-treatment.
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Crucially, results showed an improvement in the patients’
negative construals, which the authors suggest may be related to
(de)conditioning effects of EMDR.
Phantom Limb
Three group studies and one pilot study were related to phantom
pain sensations. The first three concerned limb amputations. For
instance, one study (De Roos et al., 2010) described a group of
patients that underwent an EMDR treatment after amputation
between 1 and 39 years before treatment. They administered a
combined protocol (standard and pain) during an average of 6
sessions, showing that the overall effect of time of a decrease
in pain intensity was significant, and this effect was maintained
still 3 months later. In the same vein, another study (Sinici,
2016) demonstrated a significant improvement in several pain
perception and mood scales, with a positive outlook still 3 months
after treatment. Crucially, in their study, the EMDR protocol
was applied right 1 week after amputation, suggesting that an
early EMDR procedure is beneficial in the control of phantom
pain. More recently, an RCT comparing EMDR vs. routine
care of patients that had undergone amputation of lower limb
(Rostaminejad et al., 2017), demonstrated that a standard EMDR
intervention applied as early as 2 months post-amputation has
significant long-lasting effects on phantom limb pain (PLP)of up
to 24 months post-treatment. One pilot study (Brennstuhl et al.,
2017a) extended the limb-related finding with patients having
undergone mastectomies. Using a mixture of standard and pain
protocol, the authors report that between 5 and 10 EMDR
sessions were sufficient to significantly decrease the phantom
breast sensations and pain of the patients, as well as improve
their scores in anxiety and depression questionnaires with results
stable of up to 6 months post-treatment. These authors suggest
that EMDR may target not only pain perception alone but also
many other non-specific memories, such as traumatic memories.
Complementary to these group studies, five case reports were
found, all of which equally report on positive outcomes after
EMDR. For instance, three studies report positive results of
patients having suffered from upper and lower limb amputations
(Willensky, 2006; Schneider et al., 2008; Flik and De Roos,
2010). Similarly, another study reported on two patients suffering
from phantom breast symptoms (Brennstuhl et al., 2015).
However, although both patients reported experiencing positive
psychological impacts after EMDR (i.e., anxiety, depression),
only one of them experienced a reduction in pain sensation.
Finally, we found one case study of a patient with paraparesis
after trauma of the spinal cord (Oledzka et al., 2016). Crucially,
the patient had significant improvements after 6 weeks of EMDR,
both, in mood scales and the perception of pain. These studies
highlight the positive effects of EMDR in amputees’ pain and
mood perception, irrespective of the cause of amputation or its
anatomical level.
Fibromyalgia
Our review identified only one group study and one case series
report, on the effects of EMDR in the treatment of fibromyalgia.
The group study tested the effects of EMDR on the fibromyalgia
impact questionnaire, as well as on reports of fatigue, anxiety
and depression (Friedberg, 2004). The authors also assessed
thermal biofeedback and pain ratings. Their results indicated a
decrease in all the measures after EMDR treatment, and these
effects were still valid after 3 months follow up. The thermal
biofeedback revealed an average increase in hand temperature
right after treatment, which indexes a relaxing effect of the
procedure, therefore suggesting a clear somatic and autonomic
effect of EMDR. In the same vein, the case series reported the
effects of EMDR in seven patients diagnosed with fibromyalgia
(Kavakci et al., 2012). Their key finding was a specific decrease
in tender points after treatment and the decrease in scores in
different variables, including anxiety, depression and trauma-
related ratings. Of interest, after treatment, six out of seven
patients did not meet the FMS classification criteria, suggesting
that EMDR not only helped to decrease symptoms but also was
effective to the extent patients no longer met diagnostic criteria.
Migraine and Headache
Two group studies were related to migraine headaches. In one
of the studies (Marcus, 2008), migraine patients were assigned to
either a group that received an integrated EMDR procedure or to
a standard care medication group. Participants took part in either
treatment during the mild to a late stage of an acute migraine
episode. The integrated EMDR consists in first starting the
unique 1 h-session with diaphragmatic breathing and craniofacial
compression, and in a second time within the same session
submitting the patients to eye-movements in a figure of eight
patterns in blocs of 30–90 s. Patients were assessed immediately
1 h after treatment in the EMDR group or about 4 h after taking
medications. The authors demonstrated that 95% of the EMDR
patients had reached a score of zero in the SPL scale after 1 h,
and only 5% of the medicated group reached the zero SPL
score of no pain in the same time. No other difference was
found 24, 48 h, or 7 days after treatment between groups. Thus,
suggesting that the integrated EMDR protocol helped reduce or
eliminate migraine faster, in a short time window immediately
after treatment. In the second group study (Konuk et al., 2011),
patients suffering from chronic migraine followed an EMDR
headache protocol that targets disturbing events related to the
headache episodes. After an average of eight sessions of EMDR,
there was a significant decrease in headache frequency, but no
reduction of pain intensity. These effects lasted after 3 mo follow
up. In sum, these studies highlight how EMDR may be useful in
the treatment of migraine, either as a prophylactic procedure or
a treatment for acute migraine episodes.
Acute Pain
We identified two group studies related to acute pain and EMDR.
The first study (Hekmat et al., 1994) with an experimental
design, tested the hypothesis that EMDR could modulate the
pain threshold, pain tolerance and endurance after participants
had received noxious stimulations with ice. Two groups received
either only EMDR or EMDR and music in comparison to a
no EMDR control. Both procedures were similarly effective
in changing the pain threshold, and both were better than
the control condition. Pain tolerance, however, resulted in
being higher in the EMDR and Music group, suggesting that
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music has additive effects on EMDR. Note that eye movements
were manipulated with a moving dot on a computer screen.
The second group study (Maroufi et al., 2016) reported on
the effects of EMDR on postoperative pain in adolescents
undergoing surgery. In this study, patients admitted for
emergency abdominal surgery were allocated either to an EMDR
group or a Non-EMDR control group.
Right after surgery and as soon as they had recovered
consciousness, the patients started baseline tests and
subsequently had a one 60 min EMDR or No-EMDR session.
Post-intervention results indicated a significant difference
between groups, mostly due to a decrease in pain intensity scores
for the EMDR group and an increase in pain intensity in the
No-EMDR group, suggesting that EMDR administered at the
earliest has immediate positive effects on pain perception, and
no intervention allows an increase in pain instead. In sum, this
study highlights how the EMDR can counter the encoding of a
traumatic, painful experiences at the earliest onset.
In addition, our search identified three reviews related to
EMDR and Chronic pain management (Tesarz et al., 2014; Tefft
and Jordan, 2016; Wicking et al., 2017) and one review related
to Phantom limb (Niraj and Niraj, 2014). Only one of these
reviews (Wicking et al., 2017) focused on EMDR in chronic
pain by patients who do not suffer from PTSD. Note that
some of the studies we found on chronic pain, were included
in previous reviews, although, our review differs in the sense
that it focuses on studies not specifically studying trauma or
PTSD per se, independently of whether the patients presented
symptoms related to PTSD and of whether this was assessed
or not. In general, all reviews in the matter converge in that
EMDR is a safe and effective alternative to usual treatments
or other psychotherapeutic approaches in the management of
chronic pain.
Somatoform Disorders
Four studies were identified that were not related to
specific psychiatric conditions. We identified studies on (1)
Tinnitus, (2) somatic symptoms disorder and (3) conversion
hysteria/dissociative symptoms (see Supplementary Table S7).
In the first study described in the literature testing EMDR
in tinnitus (Rikkert et al., 2018), patients suffering from
tinnitus followed a composite EMDR procedure where they
had first to elaborate on disturbing memories (Tinnitus and
past experiences) and focussed on tinnitus only at a later
session. Results demonstrated that the distress related to tinnitus
experience was significantly lower right after treatment compared
to a waiting list. In the same vein, a more recent smaller study
(Phillips et al., 2019) showed that a combination of standard
and a specific Tinnitus EMDR protocols is effective in reducing
the perceived extent of the handicap caused by tinnitus (THI)
and depressive symptoms while showing no effects on anxiety.
However, because participants were submitted to two EMDR
protocols sequentially they were not all naïve to the EMDR
procedure. As such, it is difficult to gauge the additive effects of an
immediately previous EMDR protocol on tinnitus management.
Relative to somatic disorders, one group study (Demirci
et al., 2017) compared the administration of Duloxetine vs. six
weekly sessions of 90 min EMDR in patients diagnosed with
Somatic Symptoms Disorder (SSD). Results showed that both
groups significantly improved on all measures, however, the
improvement was higher in the EMDR group compared to
Duloxetine, suggesting that EMDR may be considered as a first-
line treatment in SSD. Furthermore, one case study (Chemali
and Meadows, 2004) related to dissociative symptoms reported
the case of a patient suffering from 3 years of daily psychogenic
seizures. After EMDR, the patient experienced fewer events
shortly after the beginning of the treatment and was seizure-free
after 18 months, with results maintained at 3-months follow-up.
Finally, one review was identified dealing with Functional
Neurological Disorders (Cope et al., 2018), finding that EMDR
was successful in treating symptoms in four out of a total of five
patients that followed EMDR in three studies.
Sexual Disorders
We found two case reports on sexual disorders (see
Supplementary Table S8). The first study described two cases
of vaginismus successfully treated after only three sessions of
EMDR (Torun, 2010). The results were maintained at 2 months
follow-up. The second report (Gaboraud, 2018) highlights a case
of paedophilia in which the introduction of EMDR after 8 years
of psychotherapy successfully reduced the patients’ paraphilias
and was associated with subjective mood improvement.
Addiction
Five studies were found in total related to (1) Alcohol
dependence, (2) substance abuse and (3) pathological gambling
(see Supplementary Table S9).
A recent RCT tested the adjunction of EMDR in addition to
TAU in a randomised group of adult patients with alcohol use
disorder (Markus et al., 2020). The study failed to demonstrate
any additive effects in the TAU+EMDR group; possibly due
to the population tested being chronic poly-morbid patients
with poor social support. Another group study (Hase et al.,
2008) compared alcohol cravings measured with the Obsessive-
Compulsive Drinking Scale (OCDS) in two non-randomised
groups. One group received TAU and the experimental group
received TAU+two sessions EMDR. The therapy target
was addiction memories. Results demonstrated a statistically
significant effect on craving as on depressive symptoms, with the
maintenance of that difference at 6 months follow-up. Authors
note that targeting the addiction memory in EMDR did not lead
to a destabilisation of patients.
Furthermore, one case study (Qurishi et al., 2017) on
substance abuse found a successful treatment of a Gamma-
HydroxyButyric Acid (GHB) addict with EMDR in a few weeks,
with effects maintained after 6 months of follow-up.
Finally, we found one group study (van Minnen et al., 2020)
and a case series (Bae et al., 2015) on pathological Gambling.
Despite their small sample size, they both found a potentially
positive effect of EMDR as a treatment in this condition, in
particular with positive effects still observed at 6 months-follow-
up (Bae et al., 2015). Overall, the treatment was well-tolerated,
and its efficacy appeared in a short period of time.
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In addition to these studies, two reviews were identified on
addiction (Pilz et al., 2017; Markus and Hornsveld, 2019). Both
found that EMDR has a high therapeutic potential in the field of
addictions, although the conditions by which EMDR operates in
addiction remains unclear.
Eating Disorders
Only one case study related to eating disorders could be identified
(Yasar et al., 2019). This study applied a combination of EMDR
and CBT in an intermingled manner (EMDR-CBT-EMDR) to
two young adult patients suffering from restrictive food intake
disorder. Results showed positive results on depressive and
anxiety scales, but also on food habits, that were reported as back
to normal after treatment (see Supplementary Table S10).
In addition, two reviews 20 years apart were identified. The
first found EMDR to be ineffective and risky because it could
trigger false traumatic memories and would only delay the use
of proven-effective therapies (Hudson et al., 1997). Conversely,
a more recent review (Balbo et al., 2017) found the approach
beneficial as a complement to standard treatment.
Disorders of Adult Personality
Four case studies reported on EMDR and disorders of adult
personality (see Supplementary Table S11).
A first case report documented a case of a female patient
presenting symptoms of Borderline Personality Disorder (BPD),
and major depression and anxiety (Brown and Shapiro, 2006).
Results demonstrated a clinically significant effect after 20
sessions of EMDR during 6 months with improvements in BPD
symptoms, overall functionality and affect.
Similarly, the same number of sessions were later used in
another BPD case study (Safarabad et al., 2018) demonstrating
positive effects on BPD symptoms, dissociation scores and affect.
One case report on attachment disorder (Wesselmann and
Potter, 2009), showed that patients suffering from relational and
interpersonal functioning improved in their cognitions about
their relationships. Crucially, the EMDR therapy helped the
patients shift toward a more positive attachment status. The
therapies, however, were highly spaced in time (over a year) and
EMDR was coupled to talk therapy as well. As such, it remains
difficult to gauge the exact additive effects of the procedure.
Finally, we found a case report on a patient detained in a
high-secured hospital that followed EMDR targeting triggers of
the urge to self-injury (Annesley et al., 2019). Eighteen EMDR
sessions were to reduce the urge to self-inf-jury to zero. The
authors also reported a benefit on other mental health indicators,
such as mood, thinking, sleep, concentration, memory, and the
experiencing of flashbacks.
Neurodegenerative Disorders
We found two case studies related to neuropsychiatric disorders
(see Supplementary Table S12).
One study (Amano and Toichi, 2015) reported on the
reduction of erratic behaviour in the elder with dementia.
Three patients diagnosed with dementia (vascular and/or AD)
were administered an “on the spot” EMDR protocol. Because
of memory and behavioural issues, the standard protocol
was shortened, and the report came from hetero anamnesis.
Crucially, the target of the disturbing episodes concerned the
patients’ erratic behaviour (i.e., wandering, screaming). For
instance, past memories were assumed to be relived through the
behavioural disturbances and were considered as the target of the
desensitisation process. The beneficial effects of the procedure
were still reported by their caregiver at 6 mo follow-up in various
behavioural changes, such as less cursing, reduced restlessness,
and more smiling. More recently, another study (Van Der Wielen
et al., 2019) reported a patient diagnosed with AD at the early
stages. The patient suffered from distressful memory flashbacks.
Results demonstrated that one single session of EMDR was
sufficient to reduce the distress related to the flashbacks,
although there was no difference in measures of depression
and anxiety 3 months after the intervention. Importantly
her neuropsychological assessments had not changed between
assessments and follow-up, suggesting that one single EMDR
session had effectively helped the patient in her subjective
experience of distressful perceptions and memories.
Sleep
Only one study related to sleep met our inclusion criteria (Nia
et al., 2019). In this RCT, 75 subjects with rheumatoid arthritis
experiencing insomnia were assessed on the insomnia severity
index. The study showed that EMDR and Guided Imagery were
significantly effective in reducing insomnia in those patients.
However, the effects of EMDR were significantly better than those
of guided imagery (see Supplementary Table S13).
Mental Disorders of Childhood and Adolescence
A total of six studies in children and adolescents were
identified; two are already discussed within pain management for
conceptual reasons. Among these, we could distinguish between
studies on (1) anxiety disorders, (2) mood disorders, and (3)
autoimmune disorders (see Supplementary Table S14).
For instance, two group studies report on EMDR in phobia.
In the first study (De Jong et al., 1997) a small group of young
girls were assessed for spider phobia and disgust before and after
one single EMDR session. The post-treatment values of spider
phobia and disgust had significantly decreased. Interestingly,
results also showed a significant disgust bias in phobic children,
as compared to the controls. Crucially, a disgust bias was found
also in the parents of phobic children who found spiders more
fearful in general, and at the same time their mothers found
spiders more disgusting than the parents of the control group.
The second study on phobia (Muris et al., 1998) reported a
group study on spider phobia comparing EMDR to exposure
in vivo and a computerised exposure control group. A second
phase was added where all patients received one session of
exposure in vivo to gauge the extent to which any of the
conditions at phase one could potentiate the effects of exposure
in vivo. Results demonstrated that only exposure in vivo had
significant effects in reducing fear and avoidance self-reports of
spiders (e.g., SPQ, -C, SAM., BAT). EMDR was only effective
alone to reduce non-verbal reports of fear of spiders and had
significant additive effects at phase 2 to exposure in vivo, only
in measures of avoidance. These authors suggest that exposure in
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vivo remains the best protocol to treat spider phobia in children.
It is worth noting, however, that both group studies included
very small samples, their statistical inferences should thus be
taken cautiously.
Further evidence related to anxiety disorders in the paediatric
population comes from a recent group study (Mariani Wigley
et al., 2019) reporting that one single EMDR session before
invasive and painful surgical procedures had significant effects
in preventing anxiety in children. Children following EMDR
complementary to non-pharmacological treatment were
significantly less anxious before the procedure. Note that a
similar group study was later reported (Höfel et al., 2018)
in young patients suffering arthritis and being intolerant to
methotrexate. However, we discussed this study in the section for
chronic pain for conceptual reasons. Another study on EMDR in
post-operative pain in adolescents (Maroufi et al., 2016) was also
discussed in the section for pain for the same reasons.
In support of previous findings on anxiety, we found one
case study (Verkleij et al., 2017) reporting on an adolescent
with difficult to control asthma with exacerbations exclusively
related to the perception of shortness of breath (vs the cause
of shortness of breath). Here, the adolescent patient followed a
mixed protocol where she first received CBT therapy, and then
EMDR only at the last two sessions. Analyses using structural
break-point modelling and reliable change-index demonstrated
that results on primary outcomes were significant compared to
baseline at post-treatment and as a follow-up. Crucially, the level
and the trend of asthma exacerbations over time was significantly
reduced and there was an improvement in physical and social
activities, physical complaints and anxiety in general. However,
although the outcome measures seemed better during the EMDR
protocol, the authors did not gauge if this was either an additive
or a specific effect of EMDR.
Furthermore, our review identified one case study related
to mood disorders in the adolescent (Bae et al., 2008). The
study reported two cases of adolescents with major depressive
disorder and no history of trauma that received between
three and seven sessions of EMDR. Results demonstrated how
depressive symptoms decreased to close to zero, with a remission
maintained at follow-up after 2 months.
Finally, in one case study related to autoimmune disorders
(Guido et al., 2019), EMDR was performed in a young boy
(11 yo) with paediatric autoimmune neuropsychiatric disorder
-associated with streptococcus (PANDAS). The patient also
presented a series of motor and mood-related disorders (e.g.,
vocal tics, motor tics, irritability) comorbid with obsessive-
compulsive traits. The EMDR protocol focused on unfavourable
experiences and coping strategies improvement. Results showed
that the severity of tics and the obsessive-compulsive behaviour
had reduced after therapy, suggesting that EMDR was effective
in reducing a series of motoric-related disturbances in a very
young infant.
∗Note that during the review process it was possible to
identify three recent studies, one by Hafkemeijer et al. (2020)
on EMDR and personality disorders, one by Matthijssen et al.
(2019) on psychosis, and one by Dominguez et al. (2020) on
EMDR and depression, not included in our literature search.
In the RCT by Hafkemeijer et al. (2020) randomised controlled
trial, the intervention group received 5 90-min sessions of
EMDR and was compared to a waiting list group. Results
showed a significant improvement on psychological symptoms,
psychological distress, and personality functioning in the EMDR
group. The differences were significant between groups and
results were maintained at a 3-month follow-up. In the study
by Matthijssen et al. (2019), patients suffering with auditory
hallucinations performed an emotional memory recall task under
three conditions: a visual taxing task (EMDR steps 1, 2, and
3, Dutch protocol), an auditory taxing task (counting) and a
control task (eye fixation). Crucially, the authors reported that
both active tasks were similarly effective in reducing SUDs scores
of emotional memories. Finally, Dominguez et al. (2020) reported
a randomised controlled trial with patients showing symptoms
of depression and mostly meeting criteria for a major depressive
episode. Fortynine participants were randomly assigned to either
an EMDR group (3 sessions), an Assertiveness training group or
Treatment as usual (TAU). Specifically, no significant differences
among treatments were found at post treatment. However, the
authors stressed that the likelihood of not meeting criteria for
depression after the adjunct EMDR was higher in this group than
those following assertiveness training or TAU.
DISCUSSION
The present review aimed to investigate the uses of EMDR
outside trauma and PTSD.
To our knowledge, this is the first review on EMDR
that integrates different clinical uses of this technique and
overviews the extent of its effectiveness within and across several
pathologies. To date, the scarce literature on the subject focused
on RCTs’ only, and just a few specific major topics. Here we
present an extensive body of work on the uses of EMDR where
good care was taken to identify studies not focused on the study
of trauma and PTSD. We analysed state of the art broadly,
identifying -in a clinically relevant fashion- a series of topics to
better categorise the scope of application of EMDR. We observed
that the technique is used in many other situations beyond the
traditional guidelines, and the number of studies and research on
EMDR has consequently grown in the last 10 years.
Ninety studies met our search criteria. Results demonstrated
that EMDR is helpful in a series of conditions in which the study’s
primary purpose was not the treatment of trauma. The recent
review included all types of designs, although only one-third of
the studies were randomised controlled trials with a majority
corresponding to case studies, suggesting that systematic studies
on EMDR remain scarce.
We identified 14 different clinical disorders, and most studies
consistently reported positive outcomes in all different disorders
identified. However, the number of group studies, controlled-
group studies or RCT’s reporting either intermediate results (e.g.,
positive but no better than a control condition) or no results (i.e.,
failure of EMDR effects) corresponded to between 23 and 26%
of the literature included. Importantly, although several of the
group studies reported a significant improvement that was not
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better than the one of the comparison groups or the comparisons
treatment, the positive effects of EMDR seemed to appear faster,
as has been reported in previous reviews (cf. Pain results in a
review by Faretta and Leeds, 2017; Wicking et al., 2017).
Evidence of successful outcomes was found across all
disorders, although results were less evident in the cases of
OCD and Addiction, for which almost only half of the studies
reported clear positive results. Importantly, in some categories
that reported successful results, the evidence was also too scarce
(e.g., sleep, sexuality), thus not allowing for a generalisation
of the effectiveness of EMDR in these categories. However,
nearly half (58%) of the total number of studies included, and
that reported positive outcomes, were related to Pain, Anxiety,
Mood and Stress, suggesting that albeit the use of EMDR for
different conditions is broad, the evidence remains higher only
in these categories.
It was also possible to distinguish the use of EMDR according
to several parameters related to the protocol. For instance, the
literature on EMDR showed that at least 22 variations of the
standard protocol exist in the literature included, suggesting a
vast heterogeneity of the techniques’ procedure across clinical
uses. Interestingly, different protocols were reported within a
single category (e.g., DeTur in Addictions and Adult personality).
This suggests that there is not one specific protocol type per
disorder category and that some protocols devised for specific
disorders may be used in other conditions. Thus, results highlight
that a common mechanism underlying the effects of EMDR
may be at play across certain conditions. Moreover, the standard
protocol was used in almost all conditions, except in somatoform
disorders, sexual disorders, addiction and eating disorders.
However, not many studies were found in these categories, and
it is difficult to assess whether specific variations of the standard
protocol are more common or more effective for a particular
disorder, and more evidence is still needed in these domains.
In the same vein, results showed that the number of EMDR
sessions was variable across studies, as may be expected in
psychotherapy. However, it was possible to estimate the average
number of EMDR sessions per treatment, ranging between 7 and
8 sessions, regardless of the type of study.
Similarly, the average time per session was estimated to range
between 70 and 88 min. Both results suggest that the number of
sessions, on average, tends not to be too short (e.g., <5) and that
each session lasts almost 1 h 30 maximum but is always slightly
more than 60 min.
Although timings, as well as protocols, both depend on
the needs of the patients in the clinics, it is essential to
have a quantification of the reported parameters to understand
all factors that may play a role in the assessment of the
effectiveness of the technique. This is of particular importance
when considering randomised trials where a certain homogeneity
of parameters is of particular relevance to make the proper
statistical inferences.
Finally, the results of the review demonstrated that the
number of the reported dropout within the group studies were in
general low, with only three specific studies reporting high levels
of dropout (addictions: Markus et al., 2020; OCD: Nazari et al.,
2011; Pain: Mazzola et al., 2009). Interestingly in some instances,
the reasons for dropout were related to external causes and not
only intolerance to the EMDR procedure (e.g., work schedule
incompatibility). Thus, suggesting that overall, the use of EMDR
was well-tolerated.
Strengths and Limitations
The present review demonstrates how EMDR has a series
of beneficial aspects, although its limitations are intrinsically
related to the procedure’s implementation. For instance, the
low dropout and the reported success suggests that EMDR
is safe to use in several conditions. The estimated average
of treatment and session time was convergent among studies,
and the relatively short nature of the treatment may also
contribute to the patient’s compliance, so contributing to its
effectiveness. However, it is important to note that most of the
studies we could find reported successful findings; thus, the
relative convergence of the reports may also be affected by a
publication bias. The scarcity of literature may indeed be due
to the exclusive report of positive findings, yet even the studies
with a high level of proof (e.g., RCT’s) had several flaws. For
instance, these studies were in general relatively small (e.g.,
an average sample size of 26 patients), and some studies were
not better than a control condition, despite showing positive
outcomes. Nevertheless, most results (85/90) reported a positive
outcome, although the literature in several disorder categories
was under-represented (e.g., Eating disorders, Sexual disorders,
neurodegenerative disorders, and sleep).
Implications for the Effectiveness of EMDR
It is critical to distinguish between clinically meaningful results
and statistical comparisons between treatments. The present
review showed a discrepancy in the literature related to the effects
of EMDR in the remission of symptoms in patients and the
technique’s efficacy compared to other alternatives. In some cases,
EMDR was not better than a control group or a control treatment
(e.g., CBT). This suggests that the systematic integration of case
studies, group studies, and RCTs in future reviews is warranted.
As such, the use and efficacy of EMDR in different conditions
should be understood broadly. This further invites at making the
distinction between what is clinically relevant (e.g., symptoms
improvements) and what is an empirical issue (e.g., assessing
EMDR against other treatments). For instance, it is not enough
to report the positive outcomes; the proper and exhaustive
assessment of EMDRs’ efficacy compared to other alternatives
is needed through rigorous randomised trials with sufficient
sample sizes.
Another limitation in this regard was the inclusion of very
heterogeneous patients in RCT’s or group studies (e.g., Chronic
pain, Addiction). Several group studies included patients with all
types of complaints or aetiologies in one single group, a factor
that might affect the overall outcome and interpretation of their
trials. This might also explain specific high dropout reports, as
was the case in addictions (e.g., Markus et al., 2020). Therefore,
the effects of EMDR in sub-categories of major disorders should
be tested as well.
Timing parameters (e.g., session number) were also related to
the effectiveness of EMDR. Although an average length of therapy
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could be estimated, in some disorders, the studies were very
long (e.g., adult personality); in some other particular cases (e.g.,
migraine), EMDR was beneficial as an immediate prophylactic
procedure when applied at the earliest. Moreover, another issue
that was related to timing was the observation that in some
cases, EMDR was compared to a waiting list, thus giving the
patient more time with the therapist, an element that cannot be
disregarded as the relational aspects of EMDR are essential in the
development of the protocol and undoubtedly have an impact on
the therapy. Therefore, the effects of time should be taken into
account when assessing the efficacy of the technique and devising
trial protocols.
Furthermore, an important finding was the effectiveness
of EMDR as compared to other treatments. In some cases,
no benefit of EMDR as compared to either exposure therapy
(ERP) or CBT was found (e.g., OCD, Performance Anxiety).
However, we found reports that EMDR was beneficial in
reducing medication (e.g., citalopram and fluvoxamine) intake.
Therefore, it is vital to gauge the effects of EMDR with several
other alternatives.
Finally, in line with our findings, and as an addition to
our quality assessment results, several recent meta-analyses
show that, although EMDR is overall effective, the size of
the effects remain small to moderate. Two meta-analyses on
patients diagnosed with major depression (MDD) or presenting
subclinical symptoms of MDD and other depressive disorders
[Carletto et al., 2021 (n=9); Dominguez et al., 2021 (n=
10)] reported that although the effects of EMDR for depression
where large (Carletto et al., 2021), these were moderate compared
to other treatments. However, EMDR is more likely to reduce
depressive symptoms than CBT (Dominguez et al., 2021). More
recently in a meta-analysis that considered only studies with
patients formally diagnosed with MDD, Yan et al. (2021) (n=
8), EMDR was significantly more effective than CBT, further
highlighting the importance of limiting the heterogeneity of
patients in future RCT’s. The authors point out the effects of
low compliance in CBT (e.g., CBT is more time consuming) as
a possible factor that bolsters EMDR superiority. Interestingly,
a meta-analysis of studies of EMDR and anxiety by Yunitri
et al. (2020) (n=17), showed that time, duration, and
recurrence of therapy do not modulate EMDR’s effectiveness.
Crucially, EMDR was effective in the treatment of anxiety, panic
and phobia, although -surprisingly- they found no effects on
traumatic feelings. Similarly, a subsample (n=16) of a broader
meta-analysis on EMDR and mental health by Cuijpers et al.
(2020) (n=76) corroborated positive effects of EMDR on
anxiety disorders, although the effects of EMDR on PTSD were
inconclusive, primarily because of large heterogeneity of studies
included. Note that the high uncertainty of the evidence noted
by Cuijpers et al. (2020) was further exemplified by the fact
that analysis on a small subset of dismantling studies reported
no difference of effect sizes between effects of partial and full
EMDR protocols.
In sum, recent meta-analyses highlight several issues raised
about the effectiveness of EMDR also present in this review.
The heterogeneity of patients affects the outcomes. Despite the
moderate evidence, EMDR clearly has clinical benefits, and
meta-analytical findings particularly support the effectiveness of
EMDR within anxiety and depression, with emphasis on the
treatment of fear and the use of DeprEnd R
protocol, respectively.
The issue at hand regarding EMDR’s effectiveness as
compared to other therapies, may not solely be the question of
whether EMDR is better (e.g., against an alternative), or what
factors support its effectiveness (e.g., compliance) but also, the
overarching implications such as the cost-effectiveness-benefit
balance. Therefore, the economic and social impacts of EMDR
should also be considered and studied further (Carletto et al.,
2021).
Differences Between EMDR in Children and the Adult
Results were similar in both age groups, and overall, the majority
of children’s results were also related to pain, mood and anxiety.
However, contrary to studies in the adult, we did find literature
on phobia in children. The lack of studies on phobia in the adult
may be related to the fact that phobia may usually be approached
in the context of trauma in older patients and were thus not
identified and included in the present review. Crucially, results
showed that the parent-child correlation toward negative bias
in phobia is very high. It is therefore crucial that, in tandem
with the EMDR procedure, the parents of children with a phobia
be also monitored to help reduce the possible risk of relapse,
and suggests that in the adult with phobias, the context and
immediate entourage should also be explored. In all, EMDR
seems a safe procedure to use in the young, and literature showed
how EMDR is successful, particularly as an anxiolytic procedure.
Implications for EMDR Possible Mechanisms of
Action
Our review also showed that studies presented several
overlapping factors. Among these, a central element was
the nature of the targets, suggesting there is a possible common
mechanism across disorders by which EMDR is operational.
Almost all treatments reported were related to affective memory,
regardless of whether this memory was related to past memories,
remembered present or prospective memory. Indeed, affect is
indissociable from memory systems, and the interplay between
the triad of body-memory-affect is the cornerstone of affective
consciousness itself (Panksepp, 2005; Vandekerckhove et al.,
2014; Ledoux et al., 2017). EMDR seems specifically related to
how these memories become disturbing.
Interestingly, the finding that EMDR can be successful
in patients with frontal pathologies (i.e., neurodegenerative
disorders) raise questions about the possible underlying
mechanisms. During EMDR, the Prefrontal cortex (PFC) has
significant involvement in the treatment of traumatic memories
(Pagani et al., 2012) although few instances have shown opposite
results (see Landin-Romero et al., 2018). Dementia is mainly
related to disturbances of PFC (Burgmans et al., 2009). Therefore,
these results are of interest to understand how EMDR operates,
although the evidence was limited. Similarly, studies that
support other neurobiological accounts remain scarce as well
(e.g., sleep studies and similarities of EMDR with REM sleep).
Moreover, some studies reported that EMDR is not better than
a suggestion-focused therapy (i.e., hypnosis) in some cases for
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pain, so exposing an opportunity to understand the cognitive
mechanisms of action of EMDR. As such, the results invite to
elucidate the effectiveness of EMDR in relevant conditions (e.g.,
sleep, neurodegenerative disorders) and systematically compare
to other techniques (e.g., CBT, Hypnosis).
The Omnipresence of Trauma in the Literature
The operational aspects of this psychotherapy depend on how
the disturbing symptoms are conceptualised and contextualised.
The therapists’ approach to the patients’ symptoms determines
the target memories, and by doing so, the link between the
symptom and the affective memory can be brought about. For
this reason, to differentiate what is and what is not traumatic
is a very delicate endeavour and leaves open the question of
what precisely a target is and if the target memories of the
therapy are not just a product of the therapists’ desiderata. For
instance, a significant limitation of this body of work remains the
difficulty in the inclusion of research and studies not dealing with
trauma, either as the primary target or as specific comorbidity.
Almost all studies converged in the idea that negative memory
representations and their affective component were the culprits
of the negative symptoms treated by EMDR, most likely the
product of traumatic experiences. For example, both studies
on sexual disorders in their conclusions could only link the
symptomatology to traumatic experiences. Thus, making difficult
to assess the hypothesis that a particular disorder (e.g., sexual
disorders) may also be related to non-traumatic memories and
invites the question of whether it is indeed possible to understand
EMDR effects and the underlying mechanisms outside the realm
of trauma.
Together, our review suggests that despite the consistently
reported success of EMDR in the treatment of several disorders,
clearly more rigorous research is needed. Many studies do
not give sufficient details about the exact procedures they use,
insufficient information about how the target is conceptualised
and very little information about the data they collect or the
statistics they run, if any. Most studies lack sufficient information
to attempt proper scientific replicability, which hinders the
possible advantage of having those unsuccessful studies published
and fuels doubt and apprehension in the scientific community.
The major weakness remains the lack of transparency and
detailed procedures. Regarding the data and the studies, the
results of the ad-hoc quality assessment of the group studies
revealed that the overall evidence found was of weak-to-moderate
quality and any generalisation warrants precaution. The clinical
interest, however, remains at the centre of this review, and we
sketch some prudent recommendations based on the overall
findings in the next section.
Clinical Recommendations
It is critical for the practitioner and the researcher to
properly select the suitable candidates for EMDR therapy
and conceptualise their cases (e.g., choice of targets). They
should question at all times, which are the adequate protocol
adaptations, what should be the most favourable frequency of
application, the reasonable number of sessions and their length.
There was overall a high number of studies reporting positive
treatment effects in Pain, Anxiety, Mood (e.g., depression),
and Stress-related disorders suggesting that EMDR is an
appropriate treatment, at least as a complementary option. In
cases where standard care is ineffective, EMDR seems to be
a plausible alternative. Moreover, EMDR could be of interest
in populations for which classical psychotherapy using speech
and oral communication is limited or difficult (e.g., Dementia,
Aphasia). For instance, EMDR may be suitable to use when there
is a language barrier between the practitioner and the patient, also
in young infants, deafness and speech disabilities. Furthermore,
EMDR can help treat when treatment as usual (e.g., exposition
therapy, radiotherapy) cannot be followed due to psychological
reasons. Finally, due to the reported rapid action, it can also be
used as first-line treatment in migraine or acute pain situations.
Unfortunately, we did not find studies on tobacco addiction,
although very brief protocols inspired by EMDR seem to be
promising in treating relapse after tobacco cessation (Tsoutsa
et al., 2013). We believe that more studies on affect and
affective disorders, such as narcissistic personality disorder (e.g.,
Mosquera and Knipe, 2015) and antisocial personality disorder,
should also be encouraged.
Future Directions
Despite the general limitations, EMDR -as most
psychotherapeutic approaches- remains a highly personalised,
tailored therapeutic tool, and it should be understood as
such. Future research, however, should try to understand what is
operational in EMDR, mainly because of the myriad of protocols,
differences found between studies, the heterogeneity in session
length, their number and the conceptualisation of the targets.
Moreover, future research could try better ways to compare
the therapy to other alternatives and active treatments (vs
Waiting lists). A possibility is the use of a multi-methods
approach where qualitative and quantitative methods are used
across time, with the help of structural and functional imaging
techniques. Special care should be taken in future RCTs and
controlled group studies by selecting appropriate sample sizes
and systematically reporting follow-ups and dropout rates.
Limitations of the Review
The major limitation of this review remains the difficulty of
selecting studies where trauma was not measured, was not the
aim of the therapy or were patients not included based on trauma
diagnosis. Despite our careful selection of studies not focusing on
trauma, in some cases, the authors concluded that the symptoms
treated were very likely related to traumatic experiences.
Another significant limitation is that by attempting to be
highly inclusive on works on EMDR, some potentially relevant
studies were undoubtedly left out (e.g., studies using BLS only
but not the entire EMDR protocol).
CONCLUDING REMARKS
The present review found that EMDR can successfully treat
several disorders beyond PTSD and Trauma. Results shed light
on several aspects that support the interest of its practise
Frontiers in Psychology | www.frontiersin.org 17 September 2021 | Volume 12 | Article 644369

Scelles and Bulnes Eye Movement Desensitisation Reprocessing
in mental health care. Despite the clear need for more
rigorous research, our review also demonstrated that EMDR has
translational interests. The fact that this therapy could be helpful
in non-pathological situations (e.g., performance) broadens the
scope of its benefits and invites for interdisciplinary research.
Also, because of its potential advantages, we believe that EMDR
could be considered in major crisis situations, such as to alleviate
the imminent and disproportionate mental health sequelae of a
world pandemic (Ridley et al., 2020) that has left grief, despair,
frustration and affective pain.
DATA AVAILABILITY STATEMENT
The datasets presented in this study can be found in online
repositories. The names of the repository/repositories
and accession number(s) can be found in the
article/Supplementary Materials.
AUTHOR CONTRIBUTIONS
CS conceptualised the study. LB designed the study. Literature
search, analyses, and manuscript writing was done by CS and
LB. All authors contributed to the article and approved the
submitted version.
ACKNOWLEDGMENTS
The authors would like to thank Marco Pagani for his
encouragements and Serge Maman Morel for facilitating CS and
LB collaboration.
SUPPLEMENTARY MATERIAL
The Supplementary Material for this article can be found
online at: https://www.frontiersin.org/articles/10.3389/fpsyg.
2021.644369/full#supplementary-material
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