Pergamon

Journal of Anxiety Disorders, Vol. 13, No. 12, pp. 159172, 1999
Copyright 1999 Elsevier Science Ltd
Printed in the USA. All rights reserved
0887-6185/99 $see front matter

PII S0887-6185(98)00045-0

What Psychological Testing and

Neuroimaging Tell Us about the
Treatment of Posttraumatic Stress
Disorder by Eye Movement
Desensitization and Reprocessing
Patti Levin, licsw, psy.d.
Boston University Medical School, Boston, Massachusetts, USA

Steven Lazrove, m.d.

Yale University School of Medicine, New Haven, Connecticut, USA

Bessel van der Kolk, m.d.

Boston University Medical School, Boston, Massachusetts, USA

AbstractTo better understand the pathophysiology and treatment of Posttraumatic

Stress Disorder (PTSD), standard psychological testing, Rorschach Ink Blot testing,
and neuroimaging using Single Photon Emission Computed Tomography (SPECT)
were administered to subjects with PTSD prior to and following three sessions of Eye
Movement Desensitization and Reprocessing (EMDR). Using this within-subject design, data from one of six subjects in our series is presented as a case report. Following
EMDR, the subject experienced improvement in his level of distress, which correlated
with decrements in PTSD and depressive symptomatology on psychological testing.
Analysis of the Rorschach data corroborated these changes. Among other findings, the
Hypervigilance Index went from positive to negative, indicating that the subject was
spending less time scanning the environment for threats, and available ego resources
also increased, as measured by the Experience Actual variable. Upon recall of the traumatic memory during SPECT scanning, two areas of the brain were hyperactive postEMDR treatment relative to pretreatment: the anterior cingulate gyrus and the left

Requests for reprints should be sent to Patti Levin, LICSW, Psy.D., 315 Whitney Avenue, New Haven, CT 06511.

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P. LEVIN, S. LAZROVE, AND B. VAN DER KOLK

frontal lobe. These changes were consistent with summed data from four out of six subjects in the ongoing study. An important implication of these findings is that successful
treatment of PTSD does not reduce arousal at the limbic level, but instead, enhances the
ability to differentiate real from imagined threat. The psychology and neurophysiology
of PTSD are discussed in greater detail. 1999 Elsevier Science Ltd. All rights reserved.

THE PSYCHOLOGICAL PROCESSING OF

TRAUMATIC EXPERIENCE
When people receive sensory input they generally automatically synthesize
this incoming information into the large store of pre-existing information. If
the event is personally significant, they generally transcribe these sensations
into a narrative, without conscious awareness of the processes that translate
sensory impressions into a personal story. As human beings, we are meaningmaking creatures: As we develop, we organize our world according to a personal theory of reality, some of which may be conscious, but much of which is
an unconscious integration of accumulated experience (Horowitz, 1986).
Thus, cognitive schemata allow people to make sense out of emotionally
arousing experiences, and serve as buffers against becoming overwhelmed
(Epstein, 1991; Janoff-Bulman, 1992). These internal schemata also function
as filters that select the relevant perceptual input for further encoding and categorization and thus constitute the pathways along which people analyze ongoing experiences (van der Kolk & Ducey, 1989). Our previous research has
shown that, in contrast to the way people seem to process ordinary information, traumatic experiences are imprinted initially as sensations or feeling
states, and are not collated and transcribed into personal narratives. Traumatic memories often are retrieved as sensory and emotional representations,
with impaired expression in communicable language. While transformation of
memories of day-to-day experiences is the norm, the flashbacks and other sensory re-experiences of Posttraumatic Stress Disorder (PTSD) seem not to be
updated or attached to other experiences. These unbidden recollections, combined with this fragmentation or disorganization of memory, seem to interfere
with the evaluation, classification, and contextualization of the experience.
Triggered by a reminder, the past can be relived with an immediate sensory
and emotional intensity that is similar to that experienced during the trauma.
Thus, a victim may feel as if the event were occurring all over again. In PTSD,
fragmented or misclassified sensations are reactivated in state-dependent
fashion, in the form of flashbacks and nightmares characteristic of PTSD.
After having been traumatized, these different elements often remain detached from other elements, so that traumatized people may experience a
bodily sensation, a smell, or a fear reaction, without simultaneously evoking a

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161

visual image or other orienting stimulus that would help them locate these
memories in time and place. Failure to process information on a symbolic
level, a prerequisite for proper categorization and integration with other experiences, seems to be at the very core of the pathology of PTSD. The task of
therapy then, becomes to associate the different elements of the trauma to
each other, so that the traumatized individual can start experiencing the
trauma as an integrated whole, a tragic event that happened at a particular time,
on a particular occasion, instead as a timeless emotion or bodily sensation.
It is likely that a disruption in the brains normal mode of information processing is responsible for the failure to create a coherent memory of the traumatic experience, the core PTSD symptoms. Sensory information about a
traumatic event is not linked with other stored information. Consequently,
sensory elements of the experience remain registered separately and often are
retrieved independently of the context in which the experience occurred (van
der Kolk et al., 1996). Several neuroanatomical sites have been implicated in
the integration of sensory information into mental schemata. For example, (a)
the hippocampus is thought to create a cognitive map that allows for the categorization of experience, and its connection with other autobiographical information; (b) the corpus callosum allows for the transfer of information by both
hemispheres (Joseph, 1988), integrating emotional and cognitive aspects of
the experience; (c) the cingulate gyrus is thought to play the role of both an
amplifier and a filter that helps integrate the emotional and cognitive components of the mind (Devinsky, Morrell, & Vogt, 1995); and (d) the frontal lobes
are thought to function as a supervisory system for the integration of experience. Recent neuroimaging studies of patients with PTSD have implicated all
of these brain structures in the psychobiology of PTSD (van der Kolk et al.,
1996). These studies have begun to open up new avenues for understanding
the various ways in which the central nervous system (CNS) fails to integrate
traumatic experiences and biases the traumatized individual to interpret subsequent sensory information in the direction of threat.
One particularly interesting finding from these neuroimaging studies has
been the notion that the right hemisphere is preferentially activated during
the recollection of traumatic memories, while there seems to be a relative decrease in left hemisphere functioning, particularly in the left anterior frontal
cortex: Brocas area, the brain region implicated in translating personal experience into communicable language. The left hemisphere is thought to organize problem-solving tasks into a well-ordered set of operations and to process
information in a sequential fashion. The labeling of perceptions is a left hemisphere function (Davidson & Tomarken, 1989). It is in the area of categorization and labeling of internal states that people with PTSD seem to have particular problems (Krystal, 1978; van der Kolk et al., 1996). A relative decrease in
left hemispheric representation provides an explanation of why traumatic
memories are experienced as timeless and ego-alien: The part of the brain

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necessary for generating sequences and for cognitive categorization of experience is not functioning properly. Our research (Rauch et al., 1996) indicates
that during activation of the traumatic memory, the brain is having its experience. The person may feel, see, or hear the sensory elements of the traumatic
experience, but he or she may be physiologically prevented from translating
this experience into communicable language. During the experience of traumatic recall, victims may suffer from speechless terror in which they may literally be either out of touch with their feelings or unable to understand what
is happening to them. Physiologically, such individuals may respond as if they
actually are being traumatized, but this reaction may be dissociated from subjective experience. When the victim experiences depersonalization and derealization, he or she cannot own what is happening, and thus cannot take
steps to do anything about it, to master it.
The pattern of events described in the previous paragraph could account
for the three major symptom axes in PTSD: (a) intrusive thoughts about the
trauma, (b) avoidance of reminders of the trauma, and (c) physiologic hyperarousal, via the following cascade:
A cycle of fear and traumatization is established as the trauma repeatedly comes to mind in an (unsuccessful) attempt to make meaning of a
disturbing life event (Criterion B).
While attempting to master, or make meaning of the trauma, the victim
attempts to avoid being overwhelmed by negative emotions (Criterion
C). This is the basis for the apparent paradox of simultaneously experiencing symptoms of intrusion and avoidance.
Chronic fearfulness and a high level of emotional arousal translate into
the sympathetic hyperarousal symptoms of PTSD (Criterion D).
The Trauma Center at the Human Resource Institute in Brookline, Massachusetts, under the direction of Bessel van der Kolk, M.D., has been studying
PTSD for over 10 years. As the natural extension of prior work delineating the
phenomenology, psychopathology, pathophysiology, and treatment of PTSD,
a pilot study was undertaken to determine how psychological interventions affect the biology of PTSD. It was our belief that an enhanced understanding of
the interactions between somatic and psychological processes would inform
and refine treatment strategies.
Complementing traditional psychometric instruments for assessing PTSD
and the newer neuroimaging scanning that identify brain areas activated during traumatic recall is the Rorschach Inkblot Test. The Rorschach has undergone enormous change since it was developed in 1921 by Swiss psychiatrist
Hermann Rorschach (1921). Dr. John Exner (1974) introduced the Comprehensive System in 1974, which standardized its administration and scoring,
and created a normative database for comparative analysis. Consequently, the
Rorschach is no longer the psychologists projective associations projected

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163

onto the clients projective associations. The Rorschach provides information

on a number of important psychological dimensions: cognitive, ideational and
affective processes, coping styles, relationship between available resources
and stimulus demands, self-image and interpersonal perceptions. Interpretation is based on a comparison of the subjects overall scoring with the normative data in Exners database, rather than a focus on any single score or item of
content.
Levin has developed a Rorschach profile of pure PTSD based on 37
adults who were traumatized in adulthood and who had no antecedent psychiatric history (Levin, 1993; Levin & Reis, 1997). All subjects had a clinical diagnosis of PTSD made by the referring clinician and confirmed by the primary
investigator. Controls were Exners norms (Exner, 1993) created from Rorschachs on 700 adults without a history of psychiatric disease. Because the
Rorschach presumably accesses preconscious mental processing, it may yet
provide another perspective on the traumatic experience that would otherwise
be unavailable.
To study the effect of treatment on PTSD, a brief, effective therapy that
generates measurable changes within a reasonable time frame is needed.
While a number of successful strategies for treating PTSD have been developed, the consensus of the senior clinicians at the Trauma Center was that
Eye Movement Desensitization and Reprocessing (EMDR) best meets this
requirement.
EMDR was developed by psychologist Francine Shapiro and is based on
her personal observation that performing saccadic eye movements while
thinking about a disturbing thought decreased the intensity of the distress associated with that thought. Presumably, alternating left-right attention while
recalling a trauma produces a physiologic effect that permits reprocessing of
stored information about the trauma. Over the past 10 years, EMDR has
evolved into an eight-stage method of psychotherapy (Shapiro, 1995).
Controlled studies support EMDRs efficacy in civilian trauma. In a waitlistcontrolled study of 21 rape victims with PTSD, Rothbaum (1997) found
that 91% of victims no longer met criteria for PTSD following four EMDR
sessions, while no change was observed after 4 weeks in a nontreatment group.
Wilson, Becker, and Tinker (1995) recorded similar robust improvement following three sessions of EMDR in 80 psychologically traumatized individuals.
The treatment effect size for trauma-specific measures was 1.85, and the composite effect size was 0.65 and was maintained for 15 months (Wilson,
Becker, & Tinker, 1997). Two comparative-treatment studies involving
EMDR have been completed. Scheck, Ann, and Gillette (1998) compared two
sessions of EMDR with two session of active listening in young women
screened for high-risk behavior and a traumatic history and found greater improvement in the EMDR than in the active listening group (composite treatment effect size, 1.56 and 0.65, respectively). In a health-maintenance organization setting, Marcus, Priscilla, and Sakai (1997) compared EMDR with

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standard care in 67 individuals with a clinical diagnosis of PTSD. The EMDR

group showed greater and more rapid improvement on measures of PTSD,
depression, anxiety, and general symptoms, and required fewer medication
appointments and psychotherapy sessions.
Accordingly, a study was undertaken using EMDR to correlate treatmentderived changes in core and secondary symptoms of PTSD with hypothesized
changes in the processing and storage of traumatic memory in the brain recorded using Single Photon Emission Computed Tomography (SPECT)
neuroimaging. An in-depth discussion of data from one subject from that series with representative findings forms the nucleus of this article.

SUBJECTS AND METHODS

Subjects
Subjects were volunteers who were referred to the Trauma Clinic or who
answered a recruitment advertisement for subjects for inclusion in this study.
A research assistant screened prospective subjects, administered the psychological instruments, and obtained the trauma script (see below). Inclusion criteria were adults aged 18 to 65 years, with a diagnosis of PTSD (score . 50) on
the Clinician-Administered PTSD Scale (CAPS; Blake et al., 1995). Exclusion
criteria were active psychosis; a dissociation score over 25 on the Dissociative
Experience Scale (DES; Bernstein & Putnam, 1986); ophthalmologic problems, excluding errors of refraction; and medical conditions considered potentially hazardous during emotional arousal (e.g., heart disease, lung disease,
and pregnancy). Current involvement in legal proceedings related to the traumatic event(s), including matters related to disability benefits, was also exclusionary. Subjects were allowed to remain in psychotherapy and/or to take psychoactive medication as long as the treatment had been ongoing for at least 3
months prior to enrollment and was continued for the duration of the study
period.
Psychological measures. Subjects underwent a comprehensive initial assessment prior to treatment (baseline) and following treatment (posttreatment).
This assessment included the following measures: CAPS, DES, Hamilton Psychiatric Rating Scale for Depression (Hamilton, 1967), Davidson Self-Rating
PTSD Scale (Davidson, Smith, & Kudler, 1989), Impact of Event Scale (IES;
Horowitz, Wilmer, & Alvarez, 1979), Traumatic Memory Inventory, Short
Form (TMI-Short; B. A. van der Kolk, unpublished data), and the Structured
Clinical Interview for the DSM-III-R (SCID; Spitzer, Williams, Gibbon, &
First, 1990) to determine comorbid diagnoses. Following each EMDR session,
the Davidson Self-Rating PTSD Scale and the IES were administered.

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165

The Rorschach Inkblot Test was given prior to and following EMDR treatment by two experienced testers and the scoring was checked by one of the authors (P.L.). Administration and scoring adhered to Exners Comprehensive
System.
Script-driven imagery. Because of the ways that neural nets link information between the different nodes of the memory structure in the CNS, activation of a traumatic memory spreads from one sensory element, feeling state,
or thought structure to another. When people are presented with a sufficient
number and intensity of internal and environmental stimuli, such as smells,
bodily sensations, or physical postures, that match a critical number of elements of a particular event, other sensory, emotional, or cognitive elements of
the trauma are activated. In this way, the information network related to an
intense emotional experience is usually processed as a unit. For purposes of
this study, we composed an individualized script portraying the most traumatic experience that the subject can recall after the method of Langs (1979)
group. The neutral script is a generic script of getting up in the morning and
brushing ones teeth. The subjects were asked to describe the traumatic experience in writing on a script preparation form and then to select, from a
menu of subjective visceral and muscular reactions, those that he/she remembered as having accompanied the experience. The research assistant and
subject then jointly composed a script approximately 30 seconds in duration
that portrays the experience in the second person, present tense, incorporating five different visceral and muscular reactions, or as many as the subject selects. The script was audiotaped by the research assistant and played to the
subject during neuroimaging.
Neuroimaging
Neuroimages of the brain indicating what brain regions are activated during the recall of a traumatic memory were obtained via SPECT at the Beth Israel Deaconess Neuroimaging laboratory, using the same protocol on the
study of traumatic memory using Positron Emission Tomography (PET) imaging developed by Rauch et al. (1996). The image obtained during auditory
exposure to a script of the trauma, generated by the subject during the baseline evaluation, was digitally subtracted from the image obtained during exposure to the script of a neutral event (e.g., a description of brushing ones teeth).
The resultant image indicates what areas of the brain are hyper- and/or hypoactive during activation of a traumatic memory, relative to normal recall. The
provocation of PTSD responsiveness was monitored by physiological reactivity using electrocardiogram and blood pressure. Subjects were scanned on
three occasions: (a) prior to treatment with exposure to the neutral script, (b)
prior to treatment with exposure to the traumatic script, and (c) once following EMDR treatment with exposure to the traumatic script.

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EMDR
EMDR was administered using the standard protocol for trauma developed by Shapiro (1995). The research therapists were two senior psychologists
with 2 and 5 years of experience using EMDR. Sessions were videotaped and
random tapes were reviewed by another senior EMDR clinician to insure
treatment fidelity. Subjects received three to four 90-minute sessions, based
on response to treatment.
Case report. A 36-year-old, married, White, professional man presented to
the Trauma Clinic specifically for inclusion in the SPECT research study. He
complained of feelings of constant dread, panic, and anxiety. He gave a history
of having an abusive childhood, witnessing violence between his parents and
occasionally being beaten. He described his experience of childhood as being
one of constant terror. The subject had been in psychotherapy for approximately 10 years and was taking sertraline for depression. The target memory
was chosen by the subject and represents one of many traumatic images from his
childhood. He received three 90-minute sessions of EMDR at 1-week intervals.
The following is this subjects traumatic script:
You are 6 years old and getting ready for bed. You hear your mother and father yelling at each other. You are frightened and your stomach is in a knot.
You and your younger brother and sister are huddled at the top of the stairs.
You look over the banister and see your father holding your mothers arms
while she struggles to free herself. Your mother is crying, spitting, and hissing like a primitive animal. Your face is flushed and you feel hot all over.
When your mother frees herself, she runs to the dining room and breaks a
very expensive Chinese vase. You yell at your parents to stop, but they ignore you. Your mom runs upstairs and you hear her breaking the TV. Your
little brother and sister try to get her to hide in the closet. Your heart pounds
and you are trembling.

RESULTS
Upon entry into this study, the subject met criteria for PTSD from the Diagnostic and Statistical Manual of Mental Disorders, third edition, revised
(DSM-III-R; American Psychiatric Association, 1987). Given the long evaluation interval, the pretreatment battery of psychological tests was administered
on two occasions to ensure that the baseline was stable. As shown in Table 1,
there was a decrease in the intensity of PTSD symptomatology as measured by
three separate instruments: CAPS, Davidson, and IES. The subject no longer
met criteria for the diagnosis of PTSD posttreatment (CAPS , 50). There was
no change in the Hamilton Psychiatric Rating Scale for Depression, but the
subject had not been depressed at the outset of this study (score , 10), and he

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TABLE 1
Sequential Changes in Psychometric Parameters Prior to and
Following Three Sessions of Eye Movement Desensitization and
Reprocessing (EMDR) in a Patient with Chronic Posttraumatic
Stress Disorder (PTSD)

CAPS
Reexperiencing
Avoidance
Hyperarousal
Davidson
Hamilton
IES
SUDS

Pretreatment

Pretreatment

Posttreatment

62
2
4
5
57
5
33

64
3
3
4
69
5
46
7

31
0
2
2
30
6
13
0

Note. CAPS, Davidson, Hamilton, and IES are reported as total score.
Reexperiencing, Avoidance, and Hyperarousal are reported as number of
symptoms endorsed on the CAPS (Frequency 1 Intensity . 3). PTSD
caseness.
CAPS 5 Clinician-Administered PTSD Scale; Davidson 5 Davidson SelfRating PTSD Scale; Hamilton 5 Hamilton Depression Scale; IES 5 Impact of Event Scale; SUDS 5 Subjective Units of Disturbance Scale.

remained on antidepressant medication throughout the study. These objective

measures correlated with subjective improvement as measured by the decrement in the Subjective Units of Disturbance Scale (SUDS; Wolpe, 1956) during EMDR treatment.
Upon recall of the traumatic memory during SPECT scanning, two areas of
the brain were hyperactive post-EMDR treatment relative to pretreatment:
the anterior cingulate gyrus and the left frontal lobe. These changes were consistent with summed data from four out of six subjects in the ongoing study.
Analysis of the Rorschach data corroborated changes observed on psychometric testing and neuroimaging. The Hypervigilance Index went from positive to negative, showing the cessation of hypervigilance. In addition, there
was an increase in available ego resources measured by the Experience Actual
(EA) variable. This ratio sums the number of human movement and weighted
color responses. The number of Texture (T) responses increased from 0 to 1,
animal movement (FM) responses increased from 2 to 4, and the Lambda
value decreased from 1.10 to .30, bringing all three determinants into the normative range.

DISCUSSION
This subjects PTSD symptomatology decreased on both subjective and objective measures. Psychometric measures, SPECT scan data, and Rorschach

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results dovetail well in describing the psychological changes in this patient

with chronic PTSD after effective EMDR treatment. The subject showed significant improvement on all three measures of PTSD used in this study, and no
longer met DSM-III-R criteria for PTSD following EMDR treatment. Subjectively, the subject reported feeling less distress (SUDS 5 0).
Having collected pre- and posttreatment standard psychometric measures,
Rorschach data, and neuroimages, it is interesting to speculate how changes in
one measure are reflected in changes in the others. In other words, having
these very different outcome measures allows us to speculate on how symptomatic, information processing, and neurobiological changes seen after effective treatment are interrelated. Since our results are based on only a single
subject, it is impossible to say to what degree the changes seen in this one subject are generalizable to other people whose PTSD improves after effective
treatment. It is tempting to say that the changes reported here are related to
an increased ability to differentiate between exposure to a real traumatic
event from a mere reminder of a shocking event that occurred many years ago.
In this one scan, improvement is reflected by increased activation of the anterior cingulate and left prefrontal cortex. This seems to indicate that, at least in
humans, one filter that ultimately interprets incoming stimuli for whether they
are traumatic or not, is not necessarily at the level of the amygdala, but in a
more frontal region of the brain. Both the anterior cingulate and the orbital
frontal cortex have been implicated in helping modulate fight/flight reactions
to perceived threats. Our preliminary scans suggest that improvement of
PTSD symptoms may not be mediated by decreased activation of the amygdala, but by an increased activation of the anterior cingulate and the prefrontal area, which become capable of distinguishing between real threats and
traumatic reminders that are no longer relevant to current experience. The activation of the prefrontal cortex may indicate the assignment of meaning to
the emotions associated with traumatic memory via the elaboration of cognitive strategies. It is in this area that the Rorschach offers the best information
about the intrapsychic state.
The changes seen in this subjects Rorschach data have been shown not to
occur in ordinary test-retest situations (Exner, 1993). Exner also derived a Hypervigilance Index (HVI) based on post-hoc statistical analyses of existing data
(Exner, 1993). In PTSD, hypervigilance is an experience akin to paranoia, in
which the individual is overly alert to the possibility of threat, is avoidant and
mistrustful of people, guarded, distant, and extremely self-protective. In this
subjects protocol, the HVI was initially positive, but disappeared after effective treatment. Levin, Errbo, and Call (1996) found that following three sessions
of EMDR, 3 of 5 subjects with adult onset PTSD went from a positive HVI to a
negative HVI, indicating the absence of hypervigilance at posttreatment.
Correlating this finding with the SPECT scan, the anterior cingulate activation has been implicated as playing a role in distinguishing between real and

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169

perceived threat. Hence, our subjects data suggest that effective treatment facilitates the differentiation of real from imagined threat.
One of the most fascinating findings on the effect of EMDR on patients
with PTSD is related to the ability and/or willingness to reach out for closeness, one of the key variables in the HVI. Research has shown (van der Kolk
et al., 1996) that many individuals with PTSD have difficulty with trust in interpersonal relationships. Previous research using the Rorschach suggests that
PTSD sufferers shut off their willingness for affective interaction, as though
their experience of emotional and dependency needs had become neutralized
(Levin, 1993; Levin & Reis, 1997). On the Rorschach, the Texture response,
known in Rorschach lingo as T is an indication of interpersonal connectedness. Normatively, adults are expected to have one, and only one, texture response on the Rorschach. (More than one is reflective of significant loss.) Our
subject developed one texture response after treatment. To understand the
significance of this change, outcome research reported by Exner and others indicate that it takes an average of 9 to 15 months of psychotherapy for T-less
patients to develop the willingness for interpersonal contact and thus to grow
a T, regardless of the type of therapeutic intervention (Exner, 1993).
One of the hallmarks of PTSD is the presence of volatile, unmodulated affect, expressed both in the form of emotional flooding and as numbing, often
in the same individual. Capacity to utilize affect to plan ones actions is an important ego resource for healthy functioning. Previous research has found that
after EMDR therapy, emotions can become more modulated (Levin et al.,
1996). In this subject, affect also became more modulated, and he was less
prone to back away from affectively provocative stimuli (i.e., less avoidant). In
other words, emotion was now more comfortably experienced as a resource,
rather than as an intrusive experience. These changes may be explained by the
increased activation of the left prefrontal cortex, which is specialized for cognitive analysis and is implicated in executive function and cortical inhibition of
subcortical processes (Joseph, 1988).
In line with the increased prefrontal activation is the increase in the number of Human Movement (M) responses. M has been thought to reflect the capacity to use thought as experimental action (van der Kolk & Ducey, 1989).
Since there is no actual movement on the cards, the ability to see human
movement presumably reflects the capacity to think on ones own behalf. This
capacity is necessary to formulate decisions and initiate behavior. Incorporation of color in a response represents emotion, and form represents the cognitive envelope containing the affect. Another interpretation of this change is to
say that the subject now sees himself as an active agent in his environment.
The FM variable, or animal movement, increased following EMDR therapy, going from subnormal to normal range. This variable is related to need
states experienced as the presence of mental activity provoked by internal demand states (i.e., rumination). Test-retest data indicate that the FM variable is

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reasonably stable over time. Interestingly, the FM response is minimal or absent in eating-disordered subjects protocols (Ransom, 1991). Ransoms research hypothesized that such subjects are considered to be out of touch with
their bodies and thus with their bodies need states. Accordingly, the increase
in FM seen after EMDR may mean that subjects are more in touch with normal internal need states.
At pretreatment, this subject appeared to cope primarily through avoidance and emotional numbing, a style common to many PTSD sufferers. One
measure on the Rorschach that may reflect the psychological experience of
numbing is the Lambda. Lambda is the relationship of pure form responses to
responses that contain other determinants. Briefly, this describes the willingness and/or ability of the subject to access other resources, such as thinking
and feeling, as well as experience dysphoric affect or utilize other mental abilities. The use of pure form is not unhealthy per se, rather it is the ratio of its use
to other perceptual facilities that is significant. Post-EMDR, this subjects
Lambda moved to within normal limits: he became more able to use a fuller
range of coping resources.
The addition of the Rorschach and SPECT imaging to conventional psychometric testing of PTSD creates a rich tapestry that deepens our understanding of this complex disorder. The ability to effect changes rapidly via
EMDR and to observe that from three perspectives provides new insights into
both the pathology of and the recovery from this disorder.
Since our recent studies on trauma and memory (van der Kolk & Fisler,
1995), as well as our neuroimaging studies indicate that traumatic experiences
appear to be, in part, stored as somatic sensations and intense affect states that
may be relatively inaccessible to semantic processing, it may be important to
help individuals with PTSD process traumatic information with means that do
not primarily rely on semantic or analytical mental processes. In this process,
it seems to be important to accommodate for the fact that traumatic memories
can be primarily represented in the right hemisphere, and then in the limbic
portion of that hemisphere, which may make it difficult to process them with
verbal therapies alone. While it is unlikely that the changes seen on either the
Rorschach or the SPECT scan reflect any specific effects of EMDR as a therapeutic modality, but rather are an indication of the changes that would occur
following any form of effective treatment, it is possible that some of the newer
therapies, such as EMDR, may yield benefits that traditional insight-oriented
therapies lack.

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