The Genetic Track2003: genetic study – A. Caspi (Science)Two variants of a gene (Polymorphism) One variant risk of depression of 10-15% If 3-4 events happened, the other variant had
a risk of 25-30% for depressionAre these genes a main cause for depression?
(Candidate Genes)Caspi et al. (2003), Science, 301:386-389
JAMA 2009
The Genetic Track
Meta-analysis of 26 studies on Serotonin transponder gene variantsNegative life eventsRisk for depression
14 250 participantsNo risk for depression related to gene
or interaction life event/geneRisk increases with number of events
Risch et al. (2009), JAMA, 2462-2471
The Genetic Track The End of the Candidate Genes 2019
Depression is the most commondocumented outcome of childhoodsexual abuse in adults(Putnam 2003)
Exposure to trauma and household dysfunction accountfor about 50% of Major Depressions and suicides(Fellitti, 2001, 2004)
Close relationship between depressive episodes andLosses, Separations andHumiliations (p<.001) Events with danger for life were onlyrelated to anxiety disorders (GAD)Depression is a stress-related disease
Kendler et al. (2003), Arch Gen Psychiatry, 60; 789-796
Life Events and Depression Summary
Depression isto a large extend
a Stress-and Traumabased Disorder
No –but many stressful life events
Is it all Trauma ?
This is where EMDR and the AIP model
come in
The AIP model of EMDR(Shapiro 1995/2018)
• Formulated to explain the clinical phenomena observed during EMDR therapy processing sessions
• Evolved from 1995 to 2018• Basis of EMDR theory of disease• Basis of treatmant planing in EMDR• Element of EMDR training
The AIP model of EMDR(Shapiro 1995/2018)
1.Stressful and traumatic life experiences
can create pathogenic memories that can lead to a number of disorders
(e.g. PTSD, Depression, Pain disorders).2.
The brain has an innate selfhealing system is able to transform these memories
Implizite Erinnerung (Phase 3)Pathogenic memories in PTSD
Pagani 2012
The selfhealing capacityof the brain
0102030405060708090
100
1Woche
2Monate
6Monate
% PTBS
Rothbaum, 1992Rothbaum 1993
The AIP model of EMDR
3.In some situations the innate information
processing system of the brain is blocked so that pathogenic memories and the symptoms persist
4.The stimulation of EMDR-therapy unblocks
the self-healing system, transforms thepathogenic memories and helps to reach
an adaptive resolution and healing. Hofmann 2020, Hase 2017
A Main Mechanism of EMDR
Explizite Erinnerung (Phase 8)Normal memory after EMDR
Pagani 2012
AIP Model and EMDR -What is the difference for patients?
• A meta-analytic study by University College of London u.a. and NHS
• In a 2020 meta-analysis and review of 90 RCTs EMDR and TF-CBT were the most effective psychotherapy treatments for PTSD
• Based on that analysis a decision analytic model was developed with a review and network analysis to find the most cost-effective of 10 interventions for PTSD
Retrospective Study (N=10 Patients)Age 52, 9 women, 1 manFive 33.2, two double depressions (MD+34.1) 3 chronic depressions (>2 years)Previous relapses ~ 6.4 (3-13) Outpatient treatment CBT or PD Treatment 60 sessions including 7.4 EMDRFollow up 3.7 years (1-6)
At follow up:9 had a complete remission (7 at end of therapy)7 patients had no more medication4-5 relapses were expected Only 1 patient relapsedTrigger: Partner got cancer3 others had significant stressors, but no relapse
Prospective controlled study withoutpatients of a CBT Training Institute
Two groups compared (N=42)CBT (47 sessions) + medication = TAU vs. TAU (45) incl. ca. 6.9 sessions EMDR
Results: BDI better in EMDR group (p=.029)Complete Remissions EMDR group >80% (vs. Tau 38%, p<.001)
EDEN Pilot 1 - Krefeld
Hofmann et al. 2014, JEMDR
Krefeld StudyResults BDI-II (N=42)
*
* = .029 Hofmann et al. 2014, JEMDR
Krefeld Study:Complete Remissions (N=42)
**
** = .001 Hofmann et al. 2014, JEMDR
EDEN Pilot 2 - Bad Bevensen
32 Inpatients (32.X and 33.X)12 women, 20 men, age: 46 yearsAll recieved group therapy plus:1. TAU (individual psychodynamic therapy)2. TAU vs. TAU+ 4-5 sessions EMDROne result: Follow up: EMDR group more
at work (N=20, p< .05)Hase et al. 2015, Brain & Behavior
82 patients with recurrent depressive disorder16 sessions of EMDR vs. CBTBaseline, + 2 weeks, after every 4 EMDR sessions,
post-treatment, follow-up after 6 monthsEMDR and CBT at least equally effective
Better reduction of BDI for the EMDR group at posttreatment p>.05
EDEN RCT Study EMDR vs CBT
EDEN RCT Study EMDR vs CBT
Complete Remissionsat post treatment in %
p < 0.05
9 RCT studies with 373 participantsanalysed Effect size of EMDR treatment high: 1,07 At follow-up (6 months): 0.62 (N=3) EMDR is at least as effective as other
active control treatments like CBT EMDR possibly leads the will lower relapse
rate
Meta-Analysis of EMDR Studies for Depression 3-2021
Get an overview: “Symptom-Event Map“ List all depressive episodes Look for trigger events of episodes Full or partial remission? Comorbid Complex PTSD or
Dissociative Disorder ?
EMDR DeprEndStep 1
Hofmann, Hase et al. (2009)
Symptom Event Map
Hofmann et al. (2009)
Symptom-Event Mapwith 3 Components
Check for stressful or traumaticevents along timeline (with SUDs)
Check for depressive episods along the timeline, with correlating of the „dip“ with symptom severity
Result: The patient recovers her strengths and quality of life
She can go back to work The patient decides to leave management and
start something completely new She is full of energy and can sleep again Back pain is completely gone Full remission of depressive symptoms
Step 3: Episode TriggersCase Example
Reprocessing Episode Triggers
Stressful life event precedinga depressive episode (1-2 months)
Can usually be named by the patient
Mostly not criterion A (loss, shaming, humiliation, material loss)
Typically high SUDs, may be intrusive
Can be connected to old material
Hofmann, Hase et al. (2009)
EMDR DeprEndStep 3
Evolution of the Cognitions
Cognitions are more important in Depression than in PTSD !
Look for second (different) NCs in phase 3 Note them, but focus on one on phase 4 In phase 5 look again and possibly install it too Dont take a VoC of 7 as the end of instalation in
depressive patients Install as long as there is more progress in
Patient, 45-years old clerk, married, one child (13) Depressive episode after death of her mother Disease-related anxieties and somatization First Step: Working with death of mother
(episode trigger). That goes very well. Residual symptoms of sensitivity, irritability
had the feeling: “I‘m stupid“, “I‘m not okay,“ “I am unimportant.“
Proof Memories: Events of shaming in school NC: I‘m stupid, Feeling: Shame; SUD = 10 ! The memory is processed with impressive
intensity At the end of the process: SUD is 0 PC: “I am okay as I am,“ the body scan is clear
Step 4: Belief SystemCase example
The belief “I am unimportant“ is still charged
Look for a Touchstone memory with Floatback
Present trigger is a situation with the husband
Touchstone memory found with the Floatback was where she ran away from home at age 5 and feltalone and unimportant (parents had a business and little time for her)
Asking for the background of the morning low, the patient remembers that the talk with theboss happened on Monday morning
Focusing on the memory “Morning low“Image: My depressed face in the mirrorNC: I have no controlSUD=8, anger and fear –> SUD 0After EMDR: the morning low disappears
55-year old patient with severe depression First episode at 13-years of age, since then 13
other episodes, mostly in spring Other episodes and after birth of first child Depressive episodes reappear after menopause Strong suicidal impulses, several “visits“ to the
railway track (without suicide attempt) Medication and psychotherapy for many years 10 sessions psychotherapy (4 EMDR processing)
10 sessions EMDR PsychotherapyS.1-5. sessions History-Taking, Preparation and RDI
S. 6. EMDR session: Stressful image of last depressive episode (SUD 6,5 -> 0)
S. 7-8. Sessions: Two other stressful memories, connectedto episodes, processed (relief)
S. 9.EMDR session: Work with suicidal impulseImage: Railway track “Urge to kill myself“ (SUD=8) “A feeling of desperation and hopelessness“
S. 10. During EMDR a memory appears (SUD=5-6): Grandmother tells her about the war – (lost husband, the son – father of patient – came home-severelywounded home)
Step 5: Suicidal StateCase Example
The SUD comes down to 0 in asession that ends withan image of safety
Last session for closurePatient in full remission at therapy endFollow up five years later:
Two shorter depressive episodes triggered by thecancer diagnosis of her husband (citalopram 10mg for 4 months)
Present full remission, BDI II: 2In situations of former suicidality
52-year old woman living on welfarePanic attacks - many anxietiesMajor Depression, more than 10 prior
episodes (F33.2)Relationship problems and
present borderline disorder (F60.31)Past alcohol abuse and eating disorder3 suicide attempts, 5 hospital staysIntrusions of abuse age 3-10, but no PTSD
A Severe Case of Recurrent Depression
80 sessions of CBT plus (in midtherapy)Better, but no change in intrusions and shame
5 sessions of RDI (inverted Protocol)8 sessions of Standard EMDR Therapy
Broken relationship that triggered last episode(SUD: 6 down to 1) NC: “I am a failure“
Separation of her husband (SUD: 8 down to 0 in 2 sessions) PC: “It is over“ VoC: 7
“Representative memory“ of abuse by father(SUD 10) went down to 0 in two sessions
A Severe Case of Recurrent Depression
8 sessions of Standard EMDR TherapyPC after processing the abuse memory “I am
worthy of being treated lovingly“ VoC: 7Focusing on a representative “memory“ of
childhood neglectSUD of 9 came down to 0 in two sessionsPC: “I am loved“ (linked to warm body feeling) Since then no more intrusions and shame
At therapy end: Depression significantly improvedand no more borderline diagnosis
A Severe Case of Recurrent Depression
Follow up six years later:No depression relapse, full remissionNo more medicationFar better in relationshipsFounded own buisness (with employees)Recent Stressor: apartment burned down –
she managed it without decompensationBDI: 2
A Severe Case of Recurrent Depression
Take Home Message• Depression is to a large extent
a stress- and trauma-based disease• EMDR therapy for depression is at least as
effective as CBT treatment (equivalent) • Studies show that EMDR can lead to
better results and fewer relapses• If you use DeprEnd start with epidode triggers
first in outpatients and do complex PTSD patients later
Thanks to the EDEN Team Dr. Michael Hase (Germany)Prof. Luca Ostacoli (Italy)Dr. Sara Carletto (Italy)
