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EMDR TREATMENTOF PHOBICSYMPTOMS
IN MULTIPLEPERSONALITY
DISORDER
Walter C. Young, M.D.
Walter C. Young, M.D., is Medical Director of the NationalTreatment Center for Traumatic and Dissociative Disordersat Del Amo Hospital, 23700 Camino del Sol, Torrance,California 90505
For reprints write Walter C. Young, M.D., Medical Director,National Treatment Center for Traumatic and DissociativeDisorders, Del Amo Hospital, 23700 Camino del Sol,Torrance, CA 90505.
ABSTRACT
Two multiple personality disorder patients with severe, persistentphobias were treated usingEyeMovementDesensitization/Reprocessing(EMDR). Both patients achieved significantly beneficial results witha single session in one patient and two sessions in another. Eachpatient confronted the previously phobic object successfully showingan objective measure ofsuccess and results were maintained at sixmonths follow-up. Caution should be exercised from generalizingthe use ofEMDR for specific target symptoms to using it as a totaltreatment technique. Further research is needed to determine the efficacy ofEMDR as a treatment procedure in general and its role inthe overall treatment ofdissociative conditions.
INTRODUCTION
In recent years a new treatment technique known as EyeMovement Desensitization/Reprocessing (EMDR) hasemerged following two reports of the successful treatmentof traumatic memories in brief therapeutic interventions(Shapiro 1989a, 1989b) .Since that time additional and sometimes contradictory reports have been published regardingthe effectiveness of this technique. Despite some negativereports, sufficient positive anecdotal literature and verbalreports of treatment successes suggest the need for furtherevaluation ofEMDRwith traumatic disorders. Due to the regular and extreme nature of traumatic reports by patientswith dissociative disorders, especially those with MultiplePersonalityDisorder (MPD), a trial ofEMDRwas used in treating resistant phobic symptoms in two patients diagnosedwith MPD.
REVIEW
Shapiro (1989a, 1989b) originally described dramaticchange in 22 patients with PTSD symptoms. Results occurredin one to two sessions which coupled imaging of the trau-
matic memory with saccadic eye movements guided by thetherapist. A control group narrated their traumatic memories and were subsequently treated with EMDR, with similarresults.
The mechanism ofEMDR is not understood, and all postulated hypotheses are admittedly speculative. For example,the role of the eye movements has been compared to REMsleep processing. Shapiro (in press) postulates acceleratedinformation processing (AlP) occurs that may be facilitatedby saccadic eye movements among other possible mechanisms.
A number of clinicians have described favorable resultswith EMDR. Page and Crino (1993) reported success in treating the victim ofan armed robbery. Pellicer (1993) describedits successful use in the recurrent nightmares of a ten-yearold girl. Puk (1991) reported success in two patients. Wolpeand Abrams (1991) used EMDR with traditional desensitization techniques and achieved good results. Marquis (1991)used EMDR on 78 subjects, but their use ofa variety ofothertherapies makes the interpretation of the role of EMDR difficult. McCann (1992) successfully treated recurrent intrusive memories in a severe burn patient with bilateral abovethe elbow amputations, deafness, and severe scarring.Boudewyns, Stwertka, Hyer, Albrecht and Sperre (1993)reported success when comparing EMDR to simple imagingof the traumatic event. Wernick (1993) suggested that combining EMDR with other techniques may be effective in sextherapy. Spector and Huthwaite (1993) achieved relief in apatient who had suffered a severe automobile accident.
On the other hand, others using EMDR have not replicated such optimistic reports. Lipke and Botkin (1992) suggested that positive results may require longer treatmentamong veterans with chronic character pathology. This wasechoed by Boudewyns, Stwertke, Hyer, Albrecht, and Sperre(1993), who compared positive verbal reports to more limited documented gains in situations where disability mayinvolve a secondarygain that overrides overall improvement.They also questioned the role of placebo effects.
Pitman, Orr, Altman, Longpre, Poire, and Lasko (1993)used a crossover design in 17 patients where patients maintained eye fixation, and failed to show that the eye movements were essential. They found that global improvementof PTSD in general did not occur. Lohr et al. (1992) criticized methodologic flaws in Shapiro's study. Herbert andMueser (1992) also raise methodologic concerns includinga lack of baseline measures, and the use of subjective selfassessment ratings. They also questioned whether Shapiro
129
-DISSOCL-\TIO:'\. \'01. \11. :'\0. 2.June 1994
EMDR TREATMENT OF PHOBIC SYMPTOMS IN MPD
,vas treating subjeCls with subclinical syndromes.Metter and Michelson (1993) found no benefilS from
EMORand urged caution againstover-zealolls reporting. Theyquestioned whether the eye movements may SCIYC as a negative reinforcer leading subjects to report lowered distresslevels. They also suggest E~lDR may be related to sequencedisruption techniques described by O'Hanlon (1987). Inthis regard fractionated abreaction facilil:aled by hypnosishas been emplo)'ed by Klllfl (1988) and Fine (1991) to allowpatients to more easily move into and out oflraumatic material to comain and control ahreactions. Lytle (1992) compared EMDR to two control groups, one a non-cye mm"cmCIll dcscnsiLi7.3tion group, and lhe second a non-directi\·ctherapy control group, and found EMDR possibly the leasteffective lechnique. Sanderson and Carpenter (1992) studied 58 subjects ..·:ith a crossover design. comparing EMDRW1m imageconfronlation, encouraging imagingfora monlhafter treatmen LThey reparl no sign ifican Idifferences EMDRin MPD in the procedures. Their sludy is SUbslalltially flawedb)' a number of"ariances from standard EMDR applicalion.The mosl significant was that EMDR "'as applied for onlyseven sets of eye movements for twenty seconds each. Thisis far less than would be given in EM DR trealment, and is nOIsufficielll to obtain optimum benefits.
In mOSI of lhe studies, especially in those where negati"'e findings are reported, there are significant limilationsin methodology, making a truly accurale comparison verydifficult. Limitations include leng!h oftrealrnent, use ofancillary Ireatments, and failure 10 use Ihe same measures ofOUIcome. E"en with lhe variations in favorable reports, negative replications need to adhere to a standardized protocolfor the rcsuhs to have meaning.
In the present report both patients responded to treatment by actually confronting the phobic situation therebyobjectively demonstrating a positive outcome, even thoughthe procedure itselfused the subjective measures in Shapiro'sreports (I989a, 1989b).
METHOD
As part ofa larger pilot study ofEl\lDR treatment in dissociative disorders, tWO female dissociative disorder patientsreportingscvere phobias wcrc studied. Talking about underlying issues had not helped either patient reduce the targelsymptoms. The subjects were selected in part because theirphobic symptoms appeared somewhat isolated from thebulk of their traumatic material and because their responses could be assessed by their ability 10 address the phobicstimuli in "h·o.
Each palienl's phobic symptom was used as Lhe largetfortreaunenl, togetherwilh heraccompa.n}1ngfeelings. bodysensations, and the negative bcliefsstemmingfrom her fear.A positive selfstatement (PSS) or belief"'as selected thai thepatielll wanted to beliC\'e. Informed conselH regarding theprocedure was obrained. The patients were then gh'en E..\1DRtreaunent according to Shapiro's protocol (1989a, 1989b)and her rC\1sed prolocols (in press). A subjecti\'e unit ofdis-tress scale (SUDS) (\Volpe. 1982) ....'as used 10 measure dis-
130
Iress where 0 was no distress and 10 was l..he maximum distress created when an imageofthe phobic event '....as recalled.A validity of cognition (VOC) sC"dlc was used to assess thepatients' leVel ofconfidence thaI they could believe in theirPSS. The VOC scale rales the patient's confidence from one(the patient has no confidence in Lhe PSS), to seven (thepatienl has lotal confidence he orshe beliC\'es or will beliC\'ca new PSS). Belie..~ng the PSS is underslood to indicale IhalIhe palient has replaced a negative beliefwith a positi..'e one.SUDS and Voc measures were reponed at the beginningand end of lhe EMI)R treaunent and illlcrmiuenlly inbclwecn.
AIter initial assessmenl, each patient ....'aS asked to bringto mind the target symptoms while the author instrucloothe patient 10 track a moving finger or object with her eyes,thereby initiating rh}'thmic saccadic eye movemelH. Thepalients were instnlcted to lei images, thoughts, sensalionsor feelings occur. Periodically Ihe author paused to inquirewhat was in the patient's mind. No interpretations were madeby Ihe aUlhorand the paticnl"''aS nOI asked to give an ongoing narrath'e of Iheir her experience. The E~IOR sessionslasled from one to one and one-halfhours. At the end, SUDSand Voc levels were oblained and the pal.ient was debriefed10 determine whatlhe procedure felt like. howil comparedto herstandard work. what problems there may have encounlered, and an}' other observations she wished to make.
Before beginning, each patient ....'aS asked to assure !hatshe could maintain safety during the procedure. that heralter personalities would not obstruct eye movements, andthat she would raise a hand to indicate ifshe wanted or needed to stop the procedure.
CASE REPORTS
Patitmf #}
Ms. A isa 35-year-old single woman with a terrorofsnakes.She hadjllrnped 011 people's backs when secinga snake. Sherecalled a snake had been thrown on her when shewaseightor nine years old. After cleven years of treatment and despiteirnprovclllelll. in other areas, this symptom remained stillrefractory. Ms. A was seen in consultation lO address several issues, one of which was her se\'ere phobia ofsnakes. Shedescrihcd feeling paraIYL.cd, and unable to breathe just picturing a snake. I IeI' beliefwas that she was powerless 10 faceher fear and wished to believe she could feel in control andfeci safe around snakes. Her distress le\'eI (SUDS) was l<lledal 10 and her confidence (VOC) she could stay in controland be safe around snakes \\'as 2.
Ms. A "'as informed about the use of B·1DR and g<l\'econselll to the procedure. She ''''as asked 10 picmre herselfwith a snake with Ille associated feelings of terror and helplessness. Her associations mo,'ed from exposure 10 snakesas a child, being chased by a snake. and Lhen she reporteda new incestuous a'..~.trclless of her falller by stating, "Myfalher has a snake - it's his penis!~ This was a new connection. She continued during the session 10 feel a dramaticreduclioll in her anxiety. She t....·enlually smiled and Slatedshe was not afraid of snakes anymore. She reported a SUDS
mSSOCl\TIO\. ral. \lI. \O).!.J_l~
level of 0 and a vaG level of seven. Ms. A felt her processing of this material was rapid and far superior to her traditional efforts.
The following day Ms. A went to a pet shop where shehandled a snake withoutanxiety. She remained asymptomaticwith respect to the snake phobia six months later.
In one session Ms. A patient had a dramatic outcome,resulting in her seeking out the phobic object to test herself. She remained dissociative in those areas not addressed.
Patient #2Mrs. B is a 39-year-old married mother of three children
who had been in treatmentfor Multiple Personality for sevenyears. Her clinical course had been stormy. There were manyhospitalizations for suicide attempts, depression, severeheadaches, and self-induced injurious behavior consistingmostly ofself-lacerations following pressure from hostile innerstates. There was a history of severe child abuse by father,confirmed by her mother, and she had alleged multi-perpetrator sadistic acts which could not be verified. These factors contributed to a tumultuous course in which intrusivememories and disruptive symptoms often resulted in headbanging behavior, abreactions, or self-destructive acting out.
Mrs. B was highly motivated. She was moving graduallytoward integration and had already experienced the fusionof a number of personality states when EMDR was suggested. EMDR was proposed as a means of therapy that mightprovide her a quicker and safer approach to working throughpainful material. The patient agreed to try EMDR with twosymptoms of paralyzing phobic fear. Informed consent wasobtained after extensive explanation and discussion. Thepatient had been requested to read Shapiro's original articles (1989a, 1989b) as part ofthis process.
Mrs. B described a fear ofmoths, especially in her home.She would lose all emotional control, literally screaming andrunning out of the room if a moth appeared. She recalledhaving been molested by her father in the garage when shewas a child. She remembered moths flickering by an overhead lightand occasionallydiving toward herwhile the assaultoccurred. She would see them afterward when she was leftin the garage. Mrs. B believed that she was powerless to control moths, and lived in terror of them. She was further distressed that her daughter was also becoming frightened ofmoths. Her second phobia was of seeing a full moon outdoors. This irrationally frightened her, but to a lesser extentthan did the moths. She believed she would never enjoy amoonlit night outside.
The patient rated her first phobia at a SUDS level of 10with only a vaG level of two out of seven that she could control moths in her home. Her second phobic symptom ofseeing a full moon had a SUDS level of eight and a vaG level ofthree that she would enjoy moonlit nights safely.
The patient began EMDR with the moth fear for two sessions, then decided to wait two months until moths were "inseason." Mter two sessions her SUDS level was only mildlyreduced (to eight) but she felt increasingly confident thatshe could manage mothswithout becoming hysterical despiteher fear (VaG 5). Her associations moved from images of
her assault in the garage to moths in the night flying aroundthe light, and eventually to the spots on their wings thatreminded her of eyes looking at her. While she never overtly switched during the procedure, she was aware of experiencing a variety of feelings (such as fear, guilt, and beingugly and bad) which were affects associated with alter personalities she had encountered. The patient used part of athird session to use EMDR on her fear of the moon. Sherecalled the garage light had been suspended beneath awhite metal shield that diffused the lighting in the garage,and that it had seemed moon-like to her. There were further associations to moths under the light from the first twosessions.
Treatment had to be suspended for several weeks whenMrs. B was called out of town. When she returned, mothswere outin large numbers, and she requested EMDR to desensitize herself to them. Halfway into this session Mrs. B suddenly exclaimed she was no longer afraid of the moon. Shehad recalled an assault during a moonlit night in a field onher childhood farm home. She felt dramatic relief and wasconfident she could manage to be outside at night. Recallof the target full moon was not distressing (SUDS 0) and herconfidence she was through the fear was high (VaG 6-7).Further work on the target symptom of moths resulted inonly a modest reduction in fear (SUDS 8) but a vaG level of6 that she could manage with moths.
The following week the patient announced proudly thatwhen she saw moths at home she had remained calm andplaced a flat dish of soapy water under a light on the tableas she had seen her mother do when she was a child. Themoths flitted about the light and its reflection, and wouldbounce into the soapy water where they got stuck. Then shethrew them out. Due to other concerns, work proceeded inanother direction. Mrs. B commented she felt the procedure was very helpful, much faster than our previous work,and that somehow her work on the material treated withEMDR seemed more finished than her work with other memories. She felt it was not like hypnotic work, and was pleasedit had not resulted in abreactions or destructive impulses.She described an awareness of feeling states characteristicof some of her other alter personalities giving her anincreased sense ofher own range ofreactions. Her work alsodemonstrated a generalization effect when work with hermemory involving moths spilled over to a related memoryof the moon and relieved her distress there as well. Whileher target symptom remained high for moths, she felt successful with both fears. If further work had been attemptedshe might well have lowered her SUDS level to moths. At sixmonths she continued to feel confident in her progress onthese two areas.
RESULTS
Both Ms. A and Mrs. B demonstrated rapid reductionin distress levels that persisted at six months follow-up. Thesecond patient's distress over moths was reduced less, buther confidence that she could take effective action resultedin a sense of mastery with regard to the moths. She enjoyed
131DISSOCLUIQ:\. \'01. \11. :\0. 2.June 1994
EMDR TREATMENT OF PHOBIC SYMPTOMS IN MPD
the additional benefit of her second phobic symptom (thefull moon) spontaneously dissipating rcmiuingduring treatment for the first
Little narrative or interpretation was made by the author.Still the patients improved. During the n.WR treatmentseach patientreporlcd seeing material rapidly passing throughher mind that appeared related through associations to thetarget symplOm. In Mrs. A there was an awareness of incestand a teenage sexual assault. Mrs. B recalled the circularspots on the moths' wings and the overhead light in hergarage where insects gathered as she recalled being molest~
ed. These and other associations were related to symptomrelief. This factor suggests thatimprovcment was nOlsimplya matterofsystematic desensitization or the hierarchical ordering of anxiety producing elements. This more closely fitsShapiro's (in press) concept that EM OR induces accelerated information processing (AlP). It further would seem tocontradict the thesis put forward by Metter and Michelson(1993) that results occur secondary to sequence disruptionor negative reinforcement from the eye movements.
On the other hand this report does not establish thatthe eye movements themselves constitutes the mechanismbywhich AlP occurs (or, indeed, thatAJPoccurs). What doesseem clear is there was rapid relief of symptoms related toreduced fears ofthe target phobias, and that this reliefoccurredwhile traumatic materiafwas being internally processed. Morewas occurring through simple desensitization or relaxation.Both patients demonstrated early distress when focusing onthe target symptom initially; it was rapidly reduced as theEMDR progressed.
It should be noted that the successful results claimed forthe patients relates to their phobic target symptoms alone.No effort was made to measure global hmctioning in otherareas. Much of their clinical pictures deriving from chronic traumatization needed ongoing work. Based on their successful usc of EMDR for the symptoms under discussion it ispossible that their therapies may include the judicious useofadditional EMDR treatments in the future. Chronic trauma patients may turn out to require more inteillention fortarget symptoms than thesinglesession treatment ofepisodesof trauma described in Shapiro's early work (1989a, 1989b).In some, the impact of characterologic overlay or chronicdisability may impede the effectiveness of any therapeuticefforts, includingL\ltDR, because ofthe secondarygain involved(Boudewyns et al., 1993, Lipke & Botkin 1992). The potential for generalizing from relief ofaspecific trauma by EMDRto relief of other traumatic materials has been suggested,and may find support in Mrs. B's sudden relief of her fearof the moon. The issues raised here will need further study.
DISCUSSION
While tllis report describes a positive outcome with EMDRin twO patients with dissociative disorders, it isstill necessaryto be aware of the limitation of case reports in evaluatingEMDR and all psychotherapy in general. Adequate standardized, baseline assessments, follow-up assessments andcontrol studies are clearly indicated.
132
EMDR is still new. Both it.<; potential applications and thecautionsand complications that may surface as it el"U0Yswiderusage need further study. The author is aware of potentialpitfalls in the us~ of El\IllK, such as premature nooding,increased escalation of angry impulses, and the failure tomobilize affect. He also is aware that its benefits need further study if accurate assessment of EMDR is to occur, andclear indications for the use ofEMDR are to bedefined. Further,the role of the eye movement itself remains to be clarified.
A number of limitations in this case report study needto be acknowledged. The two patients came to the authorexpecting positive results despite low confidence levels. Thiswas partly due to an informed consent process duringwhichShapiro's articles were provided, partly because the authorwas seen in consultation for this procedure (implying positive expecLtncy), and partly because these patients were onan inpatient unit where other patienL~ had discussed positive results coming from another EM DR pilot study inprogress. Expectancy may prove to h,\\'c exerted a morepositive impact than did thc EMDR itself.
The potential for contamination by hypnosis is important. Dissociative patients may bring their own autohypnotic talents to bear, augmenting the impact ofthe EMDR. Recentarticles have described fractionated abreactions, usi ng a hypnotic technique ofmoving in and out of trance states to pacethe intensity ofabreactive work (Fine, 1991; KIuft, 1988). IfEMDR is, in fact, related to hypnotic processes, one wouldexpect to find highly positive response patterns in a highlyhypnotizable populations and poor responsitiviry in low hypnotizable populations. This has not been seen to be the casein the author's experience with anecdotal reporL~ in whichEMDR outcomes are discussed. In this study, neitllCr patientfelt that the impact of the procedure was similar to formalhypnosis. Theydid feel subjectivclythat information was processed more quickly, more completely, and differently inEMOR as compared to hypnosis.
Clearly, controlled studies are going to be required toaddress many of the above concerns, and these studies willneed to address more than single symptom inteillentions.They will also need to see whether EMDR as a major treatment modality can demonstrably shorten treatment inchronically traumatized individuals with dissociative conditions, or whether EMOR, if shown to bc effective, can andshould be introduced at judicious, clinically defined pointsin treatment. Controlled studies also need to study patientstreated with more traditional therapeutic int.en'cntions, EMOR,and other "special" techniques designed to clarify the roleofeye movement itself, in addition to the other factors thatconfound treatment outcome. The use of raters other thanthe treating clinician will be essential.
A current problem in evaluating reports on the efficacyof EMDR relatcs to the variety of dHferent treatment protocols that are being described by the term EMDR. Many ofthese formats not only fail to adhere to Shapiro's (1989a,I989b) protocol butoften are used in cOI"Uunction with othertreatment techniques. Baseline measures to standardize treatment protocols, outcome, and provide consistent criteriafor positive results have to be applied in future study.
DlSSOCLI.T[O~, \'01. \11, ~o. 2,june 1994
Despite the present problems assessing the efficacy andunderlying mechanisms of EMDR, results to date suggestenough clinicians are finding positive outcomes in theirworkwith this technique towarrantfurther study. The rapid responseto EMDR of the two dissociative patients reported here support the need for further study ofEMDR in dissociative populations to see whether this modality can contribute to thedeve10pment ofan effective, less painful, and more controlledand cost-efficient treatment technique for dissociative disorder patients. •
REFERENCES
Boudewyns, PA, Stwertka, SA, Hyer, L.A, Albrecht,].W., & Sperre,E.Y. (1993). Eye movement desensitization for PTSD of combat:A treatment outcome pilot study. The Behavior Therapist, 16,30-33.
Fine, C.G. (1991). Treatment stabilization and crisis prevention:Pacing the therapy of the multiple personality disorder patient.Psychiatric Clinics North America, 14,661-676.
Herbert,].D., & Mueser, K.T. (1992). Eye movement desensitization: A critique of the evidence. Journal of Behavioral Therapy andExperimental Psychiatry, 23, 169-174.
Kluft, RP. (1988) On treating the older patient with multiple personalitydisorder: 'Race against time' or 'make haste slowly'?" AmericanJournal Clinical Hypnosis, 30, 257-266.
Lipke, Hl-, & Botkin, AL. (1992). Case studies of eye movementdesensitization and reprocessing (EMDR) with chronic post-traumatic stress disorder. Psychotherapy, 29, 591-595.
Lohr,].M., Kleinknecht, RA, Conley, AT., Dal Cerro, S., Schmidt,]., & Sonntag, M.E. (1992). A methodological critique of the current status of eye movement desensitization (EMD). Journal ofBehavioral Therapy and Experimental Psychiatry, 23, 159-167.
Lytle, R (1992). An investigation ofeye movement desensitization reprocessing: Failure to replicate Shapiro's claims. The Pennsylvania StateUniversity, Department of Psychology, unpublished manuscript.
Marquis,].N. (1991). A report on seventy-eight cases treated by eyemovement desensitization. Journal of Behavioral Therapy andExperimental Psychiatry, 22, 187-192.
McCann, D.L. (1992). Post-traumatic stress disorder due to devastating burns overcome by a single session of eye movement desensitization. Journal Behavioral Therapy and Experimental Psychiatry, 23,319-323.
Metter,]., & Michelson, L.K. (1993). Commentary: Theoretical,clinical research, and ethical constraints ofthe eye movementdesensitization reprocessing technique.Journal ofTraumatic Stress, 6,413416.
•O'Hanlon, W.H. (1987). Taproots: Underlying principals of MiltonErickson's therapy and hypnosis. orton & Co.; ew York.
Page, A.C., & Crino, RD. (1993). Eye-movement desensitization:Asimple treatment for post-traumatic stress disorder? Australia andNew ZealandJournal ofPsychiatry, 27, 288-293.
Pellicer, X. (1993). Eye movement desensitization treatment of achild's nightmares: A case reportJournal ofBehavioral Therapy andExperimental Psychiatry, 24, 73-75.
Pitman, RK., Orr, S.P., Altman, B., Longpre, RE., Poire, RE., &Lasko, .G. (1993). A controlled study of eye movement desensitization/processing (EMDR) treatment for post-traumatic stress disorder.Unpublished Manuscript. Presented at American PsychiatricAssociation Annual Meeting, Washington, D.C.
Puk, G. (1991). Treating traumatic memories: A case report on theeye movementdesensitization procedure.journalofBehavioral Therapyand Experimental Psychiatry, 22, 149-151.
Sanderson, A., & Carpenter, R (1992). Eye movement desensitization versus image confrontation: A single session cross-over studyof 58 phobic subjects. Journal ofBehavioral Therapy and ExperimentalPsychiatry, 23, 264-275.
Shapiro, F. (1989a). Efficacy of the eye movement desensitizationprocedure in the treatmentoftraumatic memories.journalofTraumaticStress, 2, 199-223.
Shapiro, F. (1989b). Eye movement desensitization: A new treatment ofpost-traumatic stress disorder.Journal ofBehavioral Therapyand Experimental Psychiatry, 20, 211-217.
Shapiro, F. (in press). Eye movement desensitization and reprocessing:Basic principles, protocols and procedures. New York: Guilford.
Spector,]., & Huthwaite, M. (1993). Eye movement desensitization to overcome post-traumatic stress disorder. British Journal ofPsychiatry, 163, 106-108.
Wernik, U. (1993). The role of the traumatic component in theetiology of sexual dysfunctions and its treatment with eye movement desensitization procedure.JournalofSexEducation and Therapy,19,212-222.
Wolpe,]., & Abrams,]. (1991) A post-traumatic stress disorder overcome by eye movement desensitization: A case report. JournalBehavioral Therapy and Experimental Psychiatry, 22, 39-43.
Wolpe,j. (1982). Thepractice ofbehaviortherapy, ewYork: PergamonPress.
133D1SS0CLmo:\. Yol. m :\0. 2. June 1994