Help Needed

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of 5.7 years (Security Public Secretariat, 2010). The National Report on Violence and Health (Secretariat of Health, 2006) indicated that between 55% and 62% of boys and girls had suffered some kind of mistreat- ment (physical, emotional, or sexual) at some time in their lifetime. Unfortunately, Mexico has a lack of of- ficial and specific data about sexual violence against children, but it is considered that for every case known by authorities, there are 100 cases more that went un- reported (Security Public Secretariat, 2010).

Sexual abuse can have substantial detrimental im- pacts, affecting the child’s development in various ways (Hornor, 2010; Ito, Teicher, Glod, & Ackerman, 1998; Navalta, Polcari, Webster, Boghossian, & Teicher, 2006; Tyler, 2002). Jenkins, Langlais, Delis, and Cohen (1998, 2000) found that learning and mem- ory were affected among women who experienced sexual assault and who presented with posttraumatic stress disorder.

R esearch has shown that posttraumatic stress disorder (PTSD) is associated with structural brain alterations (Kühn & Gallinat, 2013) and

multiple cognitive deficits (Scott et al., 2015). Neuro- cognitive deficits include impaired verbal learning and verbal memory, slowed information processing, and impaired attention and working memory. Although the treatment implications of these deficits are con- cerning, very few studies have specifically examined the effect of treatment on neurocognitive deficits. In this case study, we examined several neurocognitive variables before and after eye movement desensitiza- tion and reprocessing (EMDR) therapy that focused specifically on the traumatic memories of a young woman who had experienced childhood sexual abuse.

Childhood Sexual Abuse Mexico has high rates of childhood sexual abuse; girls are the principal victims (77%) with an average age

Neuropsychological and Physiological Outcomes Pre- and Post-EMDR Therapy for a Woman With PTSD: A Case Study

Benito Daniel Estrada Aranda Nathalí Molina Ronquillo

María Elena Navarro Calvillo Autonomous University of San Luis Potosí, Mexico

This article provides a comprehensive review of the literature on the neurocognitive impact of posttraumatic stress disorder (PTSD) and reports on a quantitative single-case study, which investigated whether eye movement desensitization and reprocessing (EMDR) therapy would change the neuropsychological and physiological responses of an 18-year-old female client diagnosed with comorbid PTSD and major depres- sive disorder. Eleven 90-minute weekly sessions of EMDR therapy were provided. We used biofeedback equipment (ProComp5 Infiniti System) to obtain records of heart rate and conductance while the participant was in the desensitization and reprocessing phases of EMDR therapy. Results showed a heart rate decrease between baselines at the beginning and end of treatment. Neuropsychological evaluations of attention, memory, and brain executive functions showed pretreatment impairments in attentional processes, informa- tion processing speed, and working memory and posttreatment improvement of these cognitive functions, with significant differences on the Paced Auditory Serial Addition Test. We found a substantial posttreat- ment decrease in mean scores on the Beck Depression Inventory-II and the Dissociative Experiences Scale. Furthermore, the patient showed no signs of PTSD after the intervention, based on the Posttraumatic Stress Global Scale. At 1-year follow-up, the participant reported maintenance of treatment effects. We discuss how amelioration of PTSD symptoms was associated with improved neurocognitive outcomes.

Keywords: eye movement desensitization and reprocessing (EMDR) therapy; posttraumatic stress disorder (PTSD); sexual abuse; neurocognitive outcomes; Paced Auditory Serial Addition Test (PASAT)

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stimuli. The posterior parietal area and prefrontal cortex are activated to a lesser extent, causing a poor performance on these patients’ working memory (Morey et al., 2009). The possible explanation to this is because of the inability to inhibit distracting emotional stimuli that is because of a hyperarousal of ventral areas (amygdala, ventromedial prefrontal cortex).

Brain Executive Function and PTSD

Brain executive functions are essential for cogni- tive processes of reasoning and decision making; furthermore, they regulate impulsive behavior and mood stability (Fuster, 1997; Polak, Witteveen, Reitsma, & Olff, 2012). In this sense, there is evi- dence that when brain executive functions deterio- rate, persons may be unable to work independently, practice self-care, or maintain interpersonal rela- tionships (Lezack, Howieson, & Loring, 2004). Ac- cording to Walter, Palmieri, and Gunstad (2010), clinical observations and preliminary studies sug- gest that persons exposed to traumatic events may present deficits in brain executive functions (Sutker, Winstead, Galina, & Allain, 1991; Vasterling, Brailey, Constans, & Sutker, 1998). Brain executive func- tions shape a capabilities system that allows regula- tion and control of conduct and cognition (Bark ley & Fischer, 2010, Goldberg, 2001). Also, working memory was one of the poorer executive func- tions seen for PTSD patients compared to trauma- exposed controls in the Olff, Polak, Witteveen, and Denys (2014) study.

Neurobiological Changes in PTSD

According to Nutt and Malizia (2004), there are three areas of the brain associated with the limbic system that are different in patients with PTSD compared with those in control subjects: the hippocampus, the amygdala, and the medial frontal cortex. Scott and colleagues’ (2015) meta-analysis on functional and structural neuroimaging research in PTSD found dys- function in neural networks on prefrontal cortex, cin- gulate cortex, and limbic regions, with consequences on emotion processing and cognitive functioning, as well as their interaction.

A recent quantitative whole-brain meta-analysis (Kühn & Gallinat, 2013) showed brain structure defi- cits in subjects with PTSD in comparison with control subjects. This meta-analysis was composed of 9 studies and 319 patients with PTSD. They identified brain re- gions of consistent gray matter reduction in anterior cingulate cortex, ventromedial prefrontal cortex, left

Another sexual abuse consequence in many individuals is the development of PTSD. In the general population, the prevalence of PTSD after exposure to a traumatic event is placed between 5% and 24% (Bobes et al., 1999; Breslau, 2001). Kessler et al. (1995) reported prevalence for PTSD between 5% for men and 10% for women and also identified rape as the traumatic event mostly likely to result in PTSD, with rates of 65% for men and 46% for women, with childhood sexual molestation producing PTSD rates of 27%. Rates of complex PTSD plus PTSD were found to be high for sexu- ally abused women (53%) and even higher for those who had experienced both physical and sexual abuse (74%; Roth, Newman, Pelcovitz, van der Kolk, & Mandel, 1997).

Neurocognitive Deficits in PTSD

Several studies have examined neuropsychologi- cal effects in PTSD (Brodman, Clark, Murrough, & Mathew, 2011; Marx, Doron-Lamarca, Proctor, & Vasterling, 2009; Parslow & Jorm, 2007). More recently, Scott et al. (2015) completed a quantita- tive meta-analysis on a sample of 60 studies total- ing 4,108 participants, including 1,779 with PTSD, 1,446 trauma-exposed comparison participants, and 895 healthy comparison participants without trauma exposure. They discovered that neuropsychological functioning in attention, verbal memory, and speed of information processing may have important impli- cations for the effective clinical management of per- sons with PTSD.

PTSD-related neuropsychological effects on sexu- ally abused survivors were examined by Jenkins et al. (2000) and Jenkins (1998), finding that learning and memory are affected among those women who survived sexual abuse and presented PTSD. Wilson (2009) studied the neuropsychological effects of PTSD in sexually abused adolescents throughout treatment and found changes in neuropsychological function- ing related to changes in behavioral and emotional functioning: Trauma-specific emotional functioning, self-report of memory functioning, and task perfor- mance of attention performance were consistently correlated.

Patients with PTSD constantly happen to relive the traumatic experience causing an alteration in the working memory and attentional system (Honzel, Justus, & Swick, 2014; Landré et al., 2012; Schweizer & Dalgleish, 2011). The hyperarousal of ventral areas (amygdala, ventromedial prefrontal cortex) may in- terfere with inhibition of distracting emotional

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individual therapies, including EMDR, produced the best results. EMDR treatment of childhood trauma can be more complicated and have a lengthier treat- ment course compared to treatment for adults with adult-onset trauma (van der Kolk et al., 2007).

Physiological Changes With EMDR Treatment

According to Söndergaard and Elofsson (2008), research investigating the physiological effects of eye movement stimulation on EMDR therapy indicate that saccadic eye movements are accompanied by specific physi- ological changes, such as alterations in respiratory pat- tern (Elofsson, von Schèele, Theorell, & Söndergaard, 2008; Sack, Lempa, Steinmetz, Lamprecht, & Hofmann, 2008; Wilson, Silver, Covi, & Foster, 1996), heart rate and heart rate variability (Elofsson et al., 2008; Frustaci, Lanza, Fernandez, di Giannantonio, & Pozzi, 2010; Sack, Hofmann, Wizelman, & Lempa, 2008; Sack, Lempa, & Lamprecht, 2007; Wilson et al., 1996), finger temperature (Elofsson et al., 2008; Wilson et al., 1996), and skin conductance (Barrowcliff, Gray, MacCulloch, Freeman, & MacCulloch, 2003; Elofsson et al., 2008; Wilson et al., 1996).

Preliminary neuroimaging EMDR research has in- vestigated the effects on the brain of this therapy. For example, Pagani et al. (2012) conducted a study using electroencephalography (EEG) to identify regions acti- vated either by the autobiographic recollection of the traumatic event (script) or during the bilateral ocular stimulation in EMDR sessions, to see the pathophysi- ological changes (monitored online). The aim of this study was to investigate possible changes in functional connectivity both as a result of EMDR therapy and by comparing patients and healthy controls. Results showed higher activity on the orbitofrontal, prefrontal, and anterior cingulate cortex during eye movement and also in frontotemporal limbic regions and right temporooccipital cortex. Limbic cortex showed maxi- mal activation on patients before trauma processing. In opinion of Pagani et al. (2012), these changes correlated significantly with changes occurred in neu- ropsychological tests observed in other studies.

Changes in PTSD Related Neurocognitive Deficits With Psychotherapy

A study done by El Khoury-Malhame et al. (2011) illustrated a deficiency in PTSD’s cognitive process- ing of emotional cues, using the emotional Stroop and detection of target (DOT) tasks, before and after sessions of EMDR therapy. They found that in both tasks, patients were slower than controls responding

temporal pole/middle temporal gyrus, and left hip- pocampus in PTSD patients compared with controls patients without PTSD. According to the authors, the deficit in gray matter correlates with brain networks of emotion processing, fear extinction, and emotion regulation known to be affected in PTSD.

Physiological Changes in PTSD

Empirical data has demonstrated that patients with PTSD have higher psychophysiological parameters (heart rate and conductance) at baseline, as well as a low threshold of reactivity (Orr & Roth, 2000). The elevated basal heart rate that is frequently observed in patients with PTSD is understood to reflect high activity in the sympathetic nervous system (Hopper, Spinazzola, Simpson, & van der Kolk, 2006). Heart rate and skin conductance were found to increase in the presence of stress, indicating that these physi- ological responses are sensitive to activation of the sympathetic nervous system (Lin, Lin, Lin, & Huang, 2011).

Eye Movement Desensitization and Reprocessing

EMDR therapy (Shapiro, 1989, 2001) is considered an empirically valid treatment. A recent meta-analysis of EMDR clinical studies made by Chen et al. (2014) shows solid scientific evidence of its efficacy in the re- duction and elimination of PTSD symptoms among different populations. Similar findings are reported in other meta-analysis studies (e.g., Bisson, Roberts, Andrew, Cooper, & Lewis, 2013). EMDR therapy is specifically recommended by the World Health Orga- nization (2013) for management of conditions related to stress.

EMDR Treatment of Sexual Assault

Various studies, which explicitly investigated EMDR’s effectiveness with survivors of sexual assault, found support for its use with adults (Edmond, Rubin, & Wambach, 1999; Edmond, Sloan, & McCarty, 2004; Rothbaum, 1997) and children ( Jaberghaderi, Greenwald, Rubin, Zand, & Dolatabadim, 2004; Jarero, Roque-López, & Gomez, 2013). EMDR also was found to result in greater trauma resolution for sexual assault survivors than eclectic therapy (Edmond et al., 2004) and to provide similar results to prolonged exposure therapy (Rothbaum, Astin, & Marsteller, 2005). A meta-analysis of studies investigating PTSD treatment for adult survivors of childhood sexual abuse (Ehring et al., 2014) found that trauma-focused

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provided for initial evaluation and history explora- tion (Phase 1) and treatment preparation (Phase 2). The treatment phases composed of eight 90-minute sessions for trauma processing (Phases 3–8). The trained EMDR therapist with 13 years of clinical prac- tice followed the standardized protocol of EMDR and complied with the EMDR research fidelity pro- tocol provided by EMDR International Association (EMDRIA) to assure treatment integrity.

Assessment Measures

Qualitative and quantitative assessments were used to evaluate the patient’s complaints. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association [APA], 2000) was used to guide the initial qualitative assessment, includ- ing a phenomenological understanding of Sofia’s ex- perience, and lastly, to determine a diagnosis.

During the first session, the research study was explained to Sofia who signed a letter of informed consent. All assessments were conducted by the therapist (BDEA; first author). Administration of psychological tests was conducted during the first session and 1 week after the last treatment sessions. Neuropsychological testing was done during the second session and 1 week after the last treatment ses- sion. Physiological data was recorded during the first and last EMDR treatment sessions.

Psychological Measures Posttraumatic Stress Global Scale. The Posttraumatic

Stress Global Scale (PSGS; Crespo & Gómez, 2011) is a Spanish evaluation instrument that allows the di- agnostic and characterization of PTSD in adults. It consists of 62 items divided in 3 sections: the evalu- ation of traumatic events, symptomatology, and the person’s performance. Cronbach’s alpha reported for Spanish population was .92 (Crespo & Gómez, 2012) and for Mexican population was .93 (Estrada, Delgado, & Sánchez, 2015). Scores are reported in this article by stating their percentile rank as compared to the normative population with higher ranks indicat- ing greater pathology. The PSGS was administered at pretreatment during the first evaluative session and at posttreatment.

Beck Depression Inventory-II. The Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996) is a self-report instrument that evaluates the intensity of depressive symptomatology through 21 items. Total scores from 0 to 13 indicate minimal depression, 14 to 19 mild, 20 to 28 moderate, and 29 to 63 severe depres- sion. The Spanish version for Mexican population of BDI-II was applied in this study, and it has reported a

in the presence of emotionally negative words com- pared to neutral ones. This result indicated that emotional information seemed to reduce processing efficiency in PTSD and that this attentional bias in PTSD diminished after symptom removal by EMDR therapy. Similar results were reported in another study (Ribchester, Yule, & Duncan, 2010) assess- ing attentional bias, memory, and attributional pro- cess associated with PTSD on children. They found a significant trauma-specific reduction in attentional bias after EMDR. Interestingly, an earlier study in- vestigated the effects of cognitive behavioral therapy (CBT) PTSD treatment on PTSD attentional bias also using a Stroop task (Devieni, Blanchard, Hickling, & Buckley, 2004). They found that CBT treatment had no significant effect on the Stroop task.

The Current Study

This study investigated an EMDR treatment using a quantitative case study design. Grey (2011) considers that “case study evaluation of a single case can pro- vide in-depth understanding of the individual’s phe- nomenological experience within the boundaries and limitations of such design” (p. 17).

The purpose of this study was to determine if EMDR therapy would change the neuropsychological and physiological responses of an 18-year-old female client, “Sofia,” who had PTSD related to childhood sexual abuse. Assessments were conducted before, dur- ing, and after the EMDR therapy. Neuropsychological measures were used to evaluate attentional process, and brain executive functions and physiological changes were measured by tracking heart rate and skin conductance. Psychological inventories were used to triangulate these results, evaluating the wom- an’s symptoms of PTSD, depression, and dissociation and to assess the effectiveness of EMDR therapy (Shapiro, 2001) in the treatment of this young woman.

Method

Participant

The participant was an 18-year-old woman, single, and of Mexican origin named Sofia. She was referred for EMDR therapy to address emotional and behav- ioral distress related to sexual abuse by a family mem- ber. Details follow later in “The Case” section.

EMDR Treatment Schedule

Sofia received 11 weekly sessions. The treatment fol- lowed the established eight-phase and three-pronged protocol of the EMDR therapy. Three sessions were

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record lasted 5 minutes. The second stage was during Phases 4 and 5 of EMDR treatment; these two records lasted for 30 minutes with recording continued until Sofia reported no distress about the targeted memory. Scores are reported in this article by stating her heart rate and skin conductance average during the targeted memory before the treatment as compared with the heart rate and skin conductance average during the targeted memory after the treatment.

Physiological signals were registered through a biofeedback device named ProComp5 Infiniti System, and they were sent to a computer to be analyzed with the Multimedia Biofeedback Software. To record heart rate, EKG sensors (P/N: SA9306M) were placed in the triangular area over the heart for coracoid and xiphoidal processes to reduce artifacts: The measure- ment unit is millivolts (mV). Heart rate reflects blood volume, which increases with anxiety, thus showing the activity of the sympathetic nervous system (S. B. Miller & Ditto, 1989). To register skin conductance, the SC-Flex/Pro (SA309M) sensor was used, and sensors were placed on the index and ring fingers, measurement units were microsiemens (mS). Skin conductance has been shown to increase in stressful situations (Fowles et al., 1981).

The Case

Sofia, an 18-year-old, single woman, was referred for treatment to address emotional and behavioral distress related to sexual abuse by a family member. Following her recent disclosure of the abuse and her parents’ dis- belief and lack of support, Sofia had moved out of her parents’ home to live with extended family in another city. She had dropped out of high school, choosing to attend technical classes instead.

Sofia’s History and Problem Presentation

Sofia was the youngest of four siblings. Prior to her disclosure, she lived with her parents in a small city in central Mexico, where she was attending high school. She began drinking alcohol heavily at the age of 15 years as well as showing risky conduct such as going out with her friends at night and returning home late. This resulted in many conflicts with her parents, who were also concerned about her anorexic behavior. Cognitive complaints were observed before treatment and included problems with focused atten- tion, poor concentration in class, and memory issues such as forgetfulness.

Sofia reported that she had been sexually abused by an adult male, a family member, when she was 15 years old. Before this, at the age of 12 years, this

good reliability index with a Cronbach’s alpha of .91 (Estrada, Delgado, Landero, & González, 2015). The BDI-II was administered at pretreatment during the first evaluative session and at posttreatment.

Dissociative Experiences Scale. The Dissociative Ex- periences Scale (DES; Bernstein & Putnam, 1986) is a self-administered, 28-item questionnaire, in which the client indicates the frequency (percentage of time) at which they experience an item. The DES is a screen- ing instrument that evaluates different types of dis- sociative symptomatology and their frequency. Total scores more than 30% suggest clinical dissociation. A Cronbach’s alpha of .96 was reported for the Mexi- can population (Robles, Garibay, & Páez, 2006). The DES was administered at pretreatment during the first evaluative session and at posttreatment.

Neuropsychological evaluation. The neuropsycho- logical evaluation was conducted at pretreatment, during the second evaluative session, and at posttreat- ment. The following tests were administered to evalu- ate brain executive functions.

Rey Osterrieth Complex Figure Test. The Rey Oster- rieth Complex Figure Test (Rey, 2003) evaluates visual memory, visuospatial organization, and brain ex- ecutive functions. There are three components. The participant is first asked to copy the figure, then to immediately reproduce it from memory. After 20–30 minutes, the participant is again asked to reproduce the figure. Scores are reported in this article by stating their percentile rank as compared to the normative population.

Paced Auditory Serial Addition Test. The Paced Au- ditory Serial Addition Test (Gronwall, 1977) assesses working memory, sustained attention, divided atten- tion, estimate, and speed of information processing. Participants are given a number every 3 seconds in the first part, and in the second part every 2 seconds, and asked to add that number to the number that pre- ceded it. Scores are reported in this article by stating their percentile rank as compared to the normative population.

Trail Making Test, Part B. The Trail Making Test, Part B (Reitan, 1958) assesses visual search, processing speed, mental flexibility, and working memory. The participant is asked to draw a line connecting labeled dots on a piece of paper, alternating consecutive num- bers and letters (i.e., 1, A, 2, B) as quickly as possible.

Physiological Recordings. The physiological testing was done on two occasions—during the first and last EMDR sessions—and in two stages. The first stage was the baseline when Sofia was asked to remain quiet and focus on a point placed in front of her; this

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and (d) physical violence (attacks, robberies, mistreat- ment). She indicated that the most severe symptoms were about the rape/sexual abuse and described flash- backs and intrusive thoughts (for instance, when she was bathing she had the feeling that she was being observed by her abuser).

Depression at Pretreatment. Sofia obtained a score of 29 points on the BDI-II, representing a serious de- pression level. Items with higher intensity were changes in sleep pattern, irritability, suicidal thoughts, weeping, worthlessness feelings, concentration problems, tired- ness, or fatigue. It is important to mention that the item evaluating symptom intensity over “thoughts or suicide desires,” her answer was “I would like to commit sui- cide.” The therapist asked Sofia to rate her risk of cur- rent suicide on the Suicide Risk scale question (where 0 represents no current risk of suicide and 10 maximum risk), adapted from de Shazer (1985). Sofia identified her suicide risk at Level 4. Given these responses and her history of 10 suicide attempts, we proceeded to make a behavioral agreement in writing (Méndez & Olivares, 2001). A diagnostic interview confirmed that her presentation met DSM-IV criteria for a diagnosis of major depressive disorder.

Dissociation at Pretreatment. Sofia’s score on the DES was 50.35 indicating the presence of patho- logical dissociation. DES evaluates through its items three dissociative symptoms: amnesia, absorption, as well as depersonalization/derealization. In Sofia’s case, Sofia reported greater occurrence frequency for absorption with an average score of 64 followed by the items of depersonalization/derealization with an average score of 46.7. During the interview, she re- ported depersonalization and/or derealization symp- toms (she felt as if she were not the same person, she looked in the mirror and felt unusually different) as well as some memory lapses.

Sofia described various somatic symptoms, all of which began in junior high school. She indicated that for several years, she had chronic headaches that were not relieved with analgesics sold over the counter; furthermore, she experienced knee pain. Sleeping problems included nightmares or noctur- nal dread.

Executive Function at Pretreatment. The Rey Oster- rieth Figure Test (Rey, 2003) evaluates visual memory, visuospatial organization, and brain executive func- tions. Sofia’s above average score placed her at the 80th percentile, indicating that her constructive praxis and spatial organization processes were not affected by PTSD. On the other hand, her score on the im- mediate recall task was well below the norms for her

man started with sexual harassment behavior toward her, such as staring while she was swimming or bath- ing, and using harassing words. At the age of 12 years, she began cutting her arms with a sharpener blade and the first suicide attempt happened, coinciding with the harassment. Sofia informed that there she made 10 identical suicide attempts, tying her shoe- laces around the bathroom’s shower faucet at home; she hanged herself and immediately stood up as soon as she felt asphyxia.

Two months before the first therapy session, Sofia told her parents about being sexually abused by the family member. Her disclosure generated a major family conflict because they initially did not believe her. Instead of offering support and caring, her par- ents mistreated her with physical and verbal abuse (beatings and insults). After this, she began showing behavioral problems at school, and she stopped eat- ing and going out with friends. After 2 months, she decided to leave home and moved to another city to live with a family member.

Pretreatment Assessment

Posttraumatic Stress Disorder at Pretreatment. PTSD was evaluated with the PSGS and with a diagnostic in- terview. Her presentation met PTSD diagnostic criteria according to Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev., DSM-IV-TR; APA, 2000). Al- though her assessment was conducted prior to DSM-5 (APA, 2013) criteria, it is noted that her identification of nine other subjective clinical symptoms meant that her presentation fulfilled DSM-5 criteria for PTSD as well. She was diagnosed with chronic PTSD because the symptoms had lasted more than 3 months.

A comparison of her PSGS scores with the Mexican normative sample (Estrada, Delgado, & Sánchez, 2015) showed that most scores were at a high level and consistent with those of people exposed to trau- matic events, placing her at the 85th–99th percentile. The only exceptions were on the Hyper-arousal scale with a medium-high level (at the 80th percentile), and the Functioning scale with a medium-high level (70th percentile). However, it is important to indicate that in relation to functioning, her current symptoms were interfering in six of the seven PSGS areas (doc- tor’s appointments; alcohol or drugs intake; work and academic life; her social, family, or partner relation- ships; and any other important aspect of her life). Sofia listed four traumatic events on the PSGS ques- tionnaire: (a) transport accidents, (b) rape/abuse or sexual attack, (c) harassment (sexual, at work, in pre- vious relationships) or psychological mistreatment,

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EMDR Treatment

Phases 1 and 2

Phases 1 and 2 of the EMDR protocol were provided during Sessions 1, 2, and 3. The problem history was collected and the pretreatment assessment (using psychological instruments and neuropsychological tests) was conducted during Sessions 1 and 2. Prepa- ration for trauma processing was also provided. Sofia showed a lot of anxiety and insecurity; therefore, the preparation phase included instruction in self- control, self-care, and confidence strategies. Some breathing techniques and the safe place exercise were applied. During the third session, Sofia and the thera- pist worked together to develop the target-sequencing plan for past memories, present triggers, and future desired outcomes.

Case Conceptualization and Target-Sequencing Plan

EMDR therapy is theoretically grounded in the adap- tive information processing (AIP) model (Shapiro, 2001). This model posits that memories stored in dysfunctional manner are the basis of clinical pa- thology (Solomon & Shapiro, 2008). Sofia’s present- ing complaints were manifested in cognitive themes related to overresponsibility and incompetence. The self-referencing negative cognition that structured the treatment was “I am a bad person” and the target- sequencing plan was developed with six memories (targets). The AIP/EMDR approach recommends that the EMDR therapist begin with the target-sequencing plan and earliest memories. In Sofia’s case, harass- ment was the target to start with. Each memory was rated by Sofia using the SUDS. Sofia rated the six memories with SUDS scores ranging from 3 to 7. Like other studies, these target-sequencing plans were used as self-report tools to check Sofia’s experimental progress (Grey, 2011). Sofia identified several present

age, placing her at the 1st percentile, suggesting pos- sible deficits in attentional processes. Likewise, in the delayed recall task, her score was at the 1st percentile, indicating poor consolidation affected by attentional processes.

The Trail Making Test, Part B (Reitan, 1958) assesses visual search, processing speed, mental flexibility, and working memory. Although Sofia completed the test without errors, it took her an estimated time of 88 seconds, which is longer than expected for someone her age. This indicates difficulties with processing speed and verbal working memory, constructs that are linked to attentional processes.

The Paced Auditory Serial Addition Test (Gronwall, 1977) assesses working memory, sustained attention, divided attention, estimate, and speed of informa- tion processing. Her performance in the two parts of the test (in the first part, the numbers appear every 3 seconds and in the second part, every 2 seconds) was below expectations for her age. Attentional pro- cesses and working memory are required for this task, indicating difficulties in these neuropsychological functions.

Physiological Recordings. Physiological recordings were conducted in the first trauma processing session (the fourth session). Sofia was connected to the bio- feedback equipment named ProComp5 Infiniti System and asked to think of the first target memory (base event) while a physiological baseline was recorded collecting measurements of heart rate and skin con- ductance for 5 minutes. Then treatment began, with Phases 3, 4, and 5 of the EMDR protocol related to the targeted memory. Sofia remained connected to the equipment, and recordings continued until Sofia reported a score of 0, on the Subjective Units of Dis- turbance Scale (SUDS), where 0 5 no disturbance and 10 5 worst possible (Shapiro, 2001).

Results of the recording of the first baseline and the first target memory are shown in Tables 1 and 2.

TABLE 1. Results of Physiological Recording of Baseline Pretreatment

Virtual Channel Description Value

A: EKG HR mean (beats/min) 92.83

A: EKG LF/HF (means) 2.26

E: Skin conductance mean (mS) 1.90

Note. EKG HR mean 5 mean of heart rate per minute; EKG LF/HF 5 heart rate means of low frequency/high frequency. A 5 heart frequency channel; EKG 5 electrocardiogram; HR 5 heart rate; LF 5 low frequency; HF 5 high frequency; E 5 conductance channel.

TABLE 2. Results Physiological Recording of Target Memory Pretreatment

Virtual Channel Description Value

A: EKG HR mean (beats/min) 92.83

A: EKG LF/HF (means) 1.71

E: Skin conductance mean (mS) 4.38

Note. EKG HR mean 5 mean of heart rate per minute; EKG LF/HF 5 heart rate means of low frequency/high frequency. A 5 heart frequency channel; EKG 5 electrocardiogram; HR 5 heart rate; LF 5 low frequency; HF 5 high frequency; E 5 conductance channel.

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& Flick, 1988). In the case of Mexican population, the average score in BDI-II gotten by Estrada, Delgado, Landero, et al. (2015) was 9.1. This result indicates that Sofia’s posttreatment score shows a clinically sig- nificant recuperation from depression.

Neuropsychological Changes

At pretreatment, Sofia’s performance on copying the Rey Osterrieth Figure Test (Rey, 2003) was above aver- age, but her scores on immediate and delayed recall tasks placed her at the 1st percentile. At posttreat- ment, her scores on immediate and delayed recall tasks improved at the 25th percentile. These changes were not statistically significant because of low power with only one participant. However, the results sug- gest that the patient got better on attentional pro- cesses that contribute in the recall of information.

At pretreatment, Sofia’s performance on the Trail Making Test, Part B (Reitan, 1958) was longer than expected for someone her age. At posttreatment, she improved in the task and her time of execution was better, indicating an improvement in the processing speed with an impact on working memory.

Sofia’s pretreatment performance on the Paced Auditory Serial Addition Test (Gronwall, 1977) was below expectations for her age. At posttreatment, a profound improvement on the Paced Auditory Serial Addition Test (PASAT) was found obtaining a statisti- cally significant in the t test between the performance pretreatment and posttreatment (p 5 .042). For this task, different processes are necessary: working mem- ory, sustained attention, divided attention, estimate, and speed of information processing. The patient’s statistically significant improvement shows that the EMDR treatment had a positive effect on the neu- rocognitive processes that had been impaired by the PTSD (Table 3).

Regarding Sofia’s physiological responses, signifi- cant pre- and posttherapy differences were found in heart rate during the baseline (p 5 .022) and during EMDR treatment (p 5 .027). Significant differences were not found for conductance before and after the treatment (Table 2). It is important to mention that during the last therapy session (between Sessions 10 and 11, Sofia focused on abuse target) where heart rate was registered during EMDR, Sofia was able to stabilize such frequency. It lets us know of an im- provement activating the parasympathetic. Therefore, excitability reduces when facing the stressing memo- ries. Through this, we proved that Sofia was able to have a more adaptive process in her physiological re- sponses when evoking the stressful event (Table 4).

triggers, including being stared at, family swimming pool parties, hearing someone talking about the per- son who had abused her, being in the place where the abuse happened, and movies about sexual abuse. Her future desired outcomes were to be independent, have social interaction with friends, and have a good relationship with both parents.

EMDR Treatment, Phases 3–8

Sessions 4 through 11 focused on reprocessing each one of Sofia’s traumatic memories, addressing cur- rent triggers, and working on the future template. Standard EMDR procedures were followed through- out, using EMDR Phases 3–8.

In Session 4, physiological recordings were made while Sofia processed her first target. The EMDR therapist and Sofia then reevaluated the SUDS scores for the remaining targets on the target-sequencing plan. In the following sessions, Sofia reprocessed all memories listed on the target-sequencing plan. There were six memories related to the negative cognition (NC) “I’m a bad person.” Memories linked to this NC were the sexual harassment, sexual abuse experi- ence, and her silence about this matter. The NC was transformed into a new positive cognition for each target, such as “I am brave,” “I am strong,” which Sofia endorsed with a validity of cognition score of 7 on a scale where 1 5 completely false and 7 5 totally true. After this, reprocessing was also needed for two present triggers. One of them was a friend from her job who looks like the abuser. Another one was a cousin of the abuser. Finally, the future template was installed.

Posttreatment Assessment and Results

Psychological Measures

At the end of the treatment sessions (after Session 11), the psychological measures were again adminis- tered. Sofia’s scores on the PSGS had decreased from moderate/high levels at pretreatment to low at post- treatment. Her presentation no longer met PSGS nor DSM-5 criteria for PTSD. Likewise, her dissociative symptoms were greatly reduced, with a posttreat- ment score on the DES of 6.8 points, placing her in the normal range.

Her depressive symptoms were alleviated. This was reflected by a score on the BDI-II of 4 points (minimum level). According to Sanz, Perdigón, and Vázquez (2003), depression recuperation can be de- fined as a similar or lower score than the average standard of a sample of general population (Hollon

182 Journal of EMDR Practice and Research, Volume 9, Number 4, 2015 Aranda et al.

to evaluate the effectiveness of a psychotherapeutic treatment (e.g., Boudewyns & Hyer, 1990; Shalev, Orr, & Pitman, 1992), as well as to provide detailed and contextual information about the treatment re- sponse of individual patients (e.g., Blanchard et al., 1996; Shalev et al., 1998).

In this study, the neuropsychological and psy- chophysiological measure were very important to examine the effect of the treatment in a patient with PTSD and to understand the improvement in her life after the treatment. At pretreatment, the patient had PTSD-related difficulties in attentional processes, in- formation processing speed, and working memory. When the patient finished treatment, there were sub- stantial improvements in cognitive function and in all areas of her life.

Physiological Changes

Heart rate decrease between the baseline at the begin- ning and the baseline at the end of the treatment pro- vides evidence of the EMDR treatment effectiveness.

Follow-Up

One year later, after completing the EMDR therapy, we saw Sofia again in a follow-up session. No formal testing was conducted. She was stable, attending school, and working with no more cognitive complaints. She was still living independently (she was not living with her parents but their relationship was stable), she had found a job that made her feel good about herself. She had gone back to her high school studies and she had plans to attend university, with an improvement in her capac- ity of concentration, speed processing of information, and attentional processing that helped in her school ac- tivities. She was not drinking alcohol in an uncontrolled manner. She did not show any PTSD symptoms. Her self-esteem and trust were visible in her attitude and in her academic, work, and social accomplishments.

Discussion

This study is consistent with the idea of using psy- chophysiological and neuropsychological estimates

TABLE 3. Comparison of Neuropsychological Test Results Before and After Eye Movement Desensitization and Reprocessing Treatment

Test Value 5 0

t df Sig. (Two-Tailed) Mean Difference

95% Confidence Interval of the Difference

Lower Upper

FR_meminm 5.600 1 .112 14.000 217.7655 45.7655

FR_memdif 4.077 1 .153 13.250 228.0452 54.5452

PASAT_total 15.222 1 .042 68.500 11.3221 125.6779

TMT_B 7.800 1 .081 78.000 249.0620 205.0620

Note. FR_meminm 5 immediate memory Rey figure; FR_memdif 5 deferred memory Rey figure; PASAT 5 Paced Auditory Serial Addition Test; TMT_B 5 Trail Making Test Part B.

TABLE 4. Comparison of Physiological Responses Before and After Eye Movement Desensitization and Reprocessing (EMDR) Treatment

Test Value 5 0

t df Sig. (Two-Tailed) Mean Difference

95% Confidence Interval of the Difference

Lower Upper

FCLB 28.423 1 .022 89.675 49.5869 129.7631

FCEMDR 23.788 1 .027 89.085 41.5003 136.6697

SCLB 2.193 1 .272 1.305 26.2552 8.8652

SCEMDR 1.872 1 .312 2.855 216.5220 22.2320

Note. FCLB 5 heart frequency baseline; FCEMDR 5 heart rate during EMDR; SCLB 5 skin conductance baseline; SCEMDR 5 skin conductance during EMDR.

Journal of EMDR Practice and Research, Volume 9, Number 4, 2015 183 EMDR and Neurocognitive Outcomes

this area have been found in studies using functional magnetic resonance imaging with patients with PTSD (Patel et al., 2012). This area is related to processes such as inhibition, detection, and conflict solution as well as regulation and attentional effort (Flores, 2006). Cingulate cortex is activated when some tasks are car- ried out such as error detection, divided attention as well as detection, and conflict solution (Badgaiyan & Posner, 1997). The PASAT was the most sensitive one to detect improvement with EMDR treatment in Sofia because this test does not evaluate different cerebral mechanisms at the same time like the Rey’s figure test and just evaluates cerebral pathways of the prefrontal area such as attentional processes and working memory that are impacted in patients with posttraumatic stress.

There are several explanations of why the EMDR therapy is useful in patients with PTSD and has an impact in the improvement of neuropsychological processes that are affected by the PTSD. Some have proposed (Ioannides et al., 2004; Stickgold, 2002) that one of EMDR’s mechanisms is its similarity to REM sleep, which has many beneficial effects and which is disrupted in individuals with PTSD. The constant recall of episodic information (flashbacks) may be re- lated to REM sleep disorders, based on the function that this sleeping phase has in the consolidation of these kinds of memories (Seijas, 2013).

Limitations and Recommendations

One of this study’s limitations is found in the impos- sibility to control other variables related to Sofía’s improvements. On the other hand, just like in other case studies, generalization of results is limited be- cause we only worked with Sofia. Another limitation is that Sofia’s parents never agreed to have an appoint- ment with the therapist. Therefore, we were unable to gather information from third parties and confirm Sofia’s change.

We recommend future research with larger sam- ples. A case series providing EMDR to patients with PTSD could investigate whether the pre- and post- therapy neurocognitive changes shown by Sofia can be replicated and whether the PASAT remains the most useful test. Further research comparing a con- trol condition with an EMDR treatment condition could determine if neurocognitive changes can be fully attributed to EMDR therapy and the ameliora- tion of PTSD symptoms. It would be very valuable to compare the neurocognitive outcomes of CBT and EMDR treatment of PTSD, given that CBT (Devieni et al., 2004) did not produce the changes on

These results are consistent with those found in previ- ous studies, where EMDR treatment success was dem- onstrated with physiological responses from patients with PTSD (Frustaci et al., 2010; Högberg et al., 2008).

In this study, we observed an increase in heart rate during initial EMDR application, indicating an increase in parasympathetic activation when the stressing situation was remembered. Then, after suc- cessful treatment, the heart rate decreased when the stressful event was recalled. There are at least two pos- sible explanations. The first explanation is that after the treatment with EMDR, the sympathetic nervous system load decreases, allowing Sofia to face environ- mental stimuli in an adaptive manner. This is consistent with findings in studies done by Frustaci et al. (2010) and the study of Sack et al. (2007). A second explana- tion is that after treatment with EMDR, the stressful event is no longer disturbing and there is no related excitability of the sympathetic nervous system.

Neuropsychological Changes

The significant improvement in the PASAT confirms EMDR treatment benefit for attentional processes (sustained and divided attention) as well as in work- ing memory. That confirms the works of Walter et al. (2010), where optimal results were obtained in neu- ropsychological processes improvement after treating patients with PTSD. Further research is needed to determine the relationship between improvement in working memory and improvement in attention. We tend to think that the improvement in Sofia’s work- ing memory was secondary to her improvement in attention because when she started to get better on focusing her attention she could hold and process in- formation. There is an alteration in the medial pre- frontal cortex in patients with PTSD (Patel, Spreng, Shin, & Girard, 2012), this area is related with atten- tional process, and the cerebral mechanism for work- ing memory depends on these attentional abilities (Flores, 2006).

Although there was an improvement in the per- centile on the Rey’s figure test, the difference was not statistically significant. The reason may be be- cause of low statistical power. Also, this test may not be the best measure to evaluate neurocognitive changes in treatment. It evaluates several different ce- rebral mechanisms involved with high-level cognitive processes such as organization, planning, spatial anal- ysis and synthesis, perceptual organization, as well as memory. Treatment results may be better evaluated by tests such as the PASAT, which measure changes in medial prefrontal area function, as notable deficits in

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Correspondence regarding this article should be directed to Benito Daniel Estrada Aranda, PhD, Autonomous University of San Luis Potosí. School of Psychology, Carretera Central Km. 424.5 C.P. 78390 Mexico. E-mail: [email protected]

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