EMDR Scripted Protocols - M. Luber

Acute Stress Reaction &
Acute Stress Disorder

to treat-or not to treat
Gary Quinn, M.D.

Clinical Assistant Professor of Psychiatry Ohio State University
The Jerusalem Stress and Trauma Institute
Man Made to Natural Disasters
Raped or Sexually abused
Violent crime
Airplane or Car Crash
War
Terrorist Attack
Hurricane
Tornado
Fire
Illness
Gary Quinn, M.D., The Jerusalem Stress & Trauma Institute 2008
Damage & Death Toll
Angola from 1975 16 year civil war 3 of 10.5 million
displaced or directly affected
Bangladesh Flood 1998 2/3 of country underwater 30
million people affected over 9 weeks
Venezuela 1999 mud slides 30,000 80,000 affected
Earthquake Turkey 1999 45,000 350,000 homeless
Tsunami 2004 226,408
China earthquake 2008 69,016 dead, 368,545
(injured)18,830 (missing) 19th deadliest earthquake
World 1991-2000 211 million killed or affected
annually from natural disaster (IRF-CRCS 2001)
Acute Stress Reaction Definition
ICD-10
Transient disorder of significant severity which
develops in an individual without any other
apparent mental disorder in response to
exceptional physical and/or mental stress and
which usually subsides within hours or days. The
stressor may be an overwhelming traumatic
experience involving serious threat to the
security or physical integrity of the individual or
of a loved person(s)
ASR Definition
The symptoms usually appear within minutes of
the impact of the stressful stimulus or event, and
disappear within 2-3 days (often within hours).
Partial or complete amnesia for the episode may
be present.
There must be an immediate and clear temporal
connection between the impact of an
exceptional stressor and the onset of symptoms;
onset is usually within a few minutes, if not
immediate.
ASR Definition
In addition, the symptoms:

A.Show a mixed and usually changing
picture; in addition to the initial state
of "daze", depression, anxiety, anger,
despair, overactivity, and withdrawal
may all be seen, but no one type of
symptom predominates for long;
ASR Definition
B.Resolve rapidly (within a few hours at
the most) in those cases where removal
from the stressful environment is possible;
in cases where the stress continues or
cannot by its nature be reversed, the
symptoms usually begin to diminish after
24-48 hours and are usually minimal after
about 3 days.
The ICD-10 Classification of Mental and Behavioural Disorders is copyright of the
World Health Organisation 1992
Neurobiological Pathways
Sensory system
Seeing
Hearing
Smelling
Touching
Tasting
Thalamus
Amygdala and the Prefrontal cortex
Neurophysiology
Amygdala
Compares the information it to past events on an
emotional level
decides if it is important for the brain and body to pay
attention or not.
In trauma it is recognizing danger and alerting the body
When in danger or perception of
danger
Perceived as dangerous
Activate
Adrenergic system (Sympathetic Nervous System-SNS)
Locus coeruleus & Reticular activating system
Norepinephrine (fight, flight, freeze)
Glucocorticoid system
Hypothalamus release Corticotropin Releasing Factor (CRF)
Pituitary release Adrenocoritcotropin Hormone (ACTH)
Adrenals
Cortisol - Immune response & Stress response
Hormones During Stress
Norepinephrine / Epinephrine
Fight , Flight, Freeze
Encode memory stay away from a dangerous situation
Cortisol with Neuropeptide Y (NPY)

Brakes to SNS (turns it off)
Inhibits excessive retrieval of traumatic memories
Hypothalamic- Pituitary-Adrenal
Axis
Hypothalamus produces
Corticotropin releasing
factor/hormone
Pituitary produces
Adrenocorticotropic
hormone
Adrenals produce cortisol
Negative feedback loop
regulates the system
Amygdala, hippocampus and
hypothalamus connected
Jonathan I Bisson Department of Psychological

Medicine,Cardiff University
Cortisol
Hormone
Impact on memory
Inhibits excessive retrieval
of traumatic memories
Facilitates extinction
through reduced retrieval
and reconsolidation
Jonathan I Bisson Department of

Psychological Medicine,Cardiff
University
Hypothalamic- Pituitary-Adrenal
Axis in PTSD
? enhanced negative
feedback in the HPA axis
Low cortisol levels in
PTSD sufferers
CRF increases locus
ceruleus firing and
noradrenaline release
Jonathan I Bisson Department of

Psychological Medicine,Cardiff
University
Pertinent Neurobiological Factors
Initial adrenergic surge may be associated with
the consolidation of traumatic memories
Low endogenous cortisol levels may
promote development and symptomatology of
PTSD by a disinhibition of traumatic memory
retrieval
fail to contain the sympathetic stress response

PET Scans van der Kolk EMDR
Script of trauma vs. neutral memory
Intense right limbic system
Including visual area
Lower or off
Left prefrontal cortex
Brocas area- silent terror
After successful EMDR treatment

Return to normal
Acute Stress Disorder (ASD)
A. The person has been exposed to a traumatic
event in which both of the following were
present
1. the person experienced, witnessed or was
confronted with an event or events that involved
actual or threatened death or serious injury, or a
threat to the physical integrity of self or others.
2. the persons response involved intense fear,
helplessness or horror.
ASD definition
B. Either while experiencing or after
experiencing the distressing event, the individual
has three (or more) of the following dissociative
symptoms:
1. A subjective sense of numbing, detachment, or
absence of emotional responsiveness
2. A reduction in the awareness of his or her
surroundings ( being in the daze)
3. Derealization
4. Depersonalization
5. Dissociative amnesia(i.e. inability to recall an

important aspect of the trauma
ASD definition
C. The traumatic event is persistently
reexperienced in at least one of the following
ways: recurring images, thoughts, dreams,
illusions, flashback episodes, where sense of
reliving the experience: or distress on exposure
to reminders of the traumatic event
ASD definition
D. Mark avoidance of stimuli that arouse
recollections of the trauma (e.g. thoughts,
feelings, conversations, activities, places, people)
E. marked symptoms of anxiety or increased
arousal (e.g. difficulty sleeping, irritability, poor
concentration, hypervigilance, exaggerated
startle response, major restlessness)
ASD definition
F. The disturbance causes clinically significant
distress or impairment in social, occupational, or
other important areas of functioning or impairs
the in individuals ability to pursue some
necessary task, such as obtaining necessary
assistance or mobilizing personal resources by
telling family members about the traumatic
event
ASD definition
G. The disturbance last for a minimum of two
days and a maximum of four weeks and occurs
within four weeks of the traumatic event
H. The disturbance is not due to the direct
physiological effects of a substance( e.g. a drug
of abuse, medication) or a general medical
condition, is not that are accounted for by brief
psychotic disorder and is not merely an
exacerbation of a pre-existing axis I axis II
disorder
Not treating ASR
Most people recover
Incidence PTSD after Traumatic Event
Men 8-13%
Woman 20-30%
National Institute for Clinical Excellence

(N.I.C.E.)UK Clinical Guidelines (2005)
ASD often leads to PTSD
80 % of those whose symptoms are initially
severe enough to meet criteria for ASD will have
PTSD 6 months later
60-70 % will have PTSD 2 years following the
event ( Bryant & Harvey , 2000 ).
John N. Briere, Catherine Scott. Principles of Trauma Therapy: A Guide to

Symptoms, Evaluation, and Treatment. (Sage Publications, Inc, 2006). Page
166.
Prevent PTSD?
Likely those with severe ASR ones who develop
ASD
It is possible if we can help reduce strong
reactions in susceptible individuals with ASR
may prevent later development of ASD and
PTSD
Current Acute Treatments
Cognitive-Behavioral Intervention
Empirical evidence can reduce trauma and PTSD (Bryant ,
Moulds , & Nixon , 2003 ; Bryant , Sackville , Dang ,
Moulds , & Guthrie , 1999 ; Echebur a , De Corral ,
Sarasua , & Zubizarreta , 1996 ; Foa , Hearst-Ikeda , &
Perry , 1995 )
John N. Briere, Catherine Scott. Principles of Trauma Therapy: A Guide to Symptoms,

Evaluation, and Treatment. (Sage Publications, Inc, 2006). Page 170
Cognitive-Behavioral Intervention (cont.)
Victims motor vehicle trauma: industrial accidents -
Bryant , Harvey , Dang , & Sackville ( 1998 )
5 sessions
Psychoeducation
Prolonged exposure
In vivo exposure
Cognitive therapy
Control supportive counseling
Varied nonsexual trauma (Bryant et al. 1999)

Lower % PTSD then supportive counseling
20% drop out rate
Cognitive-Behavioral Intervention (cont.)
Follow up two groups (Bryant et al. 2003)
Evaluated 42 participants 4 years later
Supportive : CBT 3:1 greater PTSD
Motor Vehicle Accidents (Ehlers et al.2003)
CBT vs self help booklet
6 months
CBT 11% PTSD
Self help 61% PTSD
Repeat assessment only 55% PTSD
Early Pharmacological Interventions
Propranolol versus placebo (two studies)
No convincing evidence of benefit
Gabapentin versus placebo (one study)
Hydrocortisone versus placebo (one study)
limited evidence favouring hydrocortisone over placebo
Temazepam versus placebo (one study)
Escitalopram versus placebo (one study)

Pharmacology intervention studies equivocal
Critical Incident Stress Debriefing
Mitchell 1983: rescuers, first responders
Group setting structured
10-20 people
1-3 hours session within week of trauma

Group sharing
Normalization
Coping strategies
Psychoeducation
Future consequences
Evaluation, and Treatment. (Sage Publications, Inc, 2006). Page 167.
CISD (cont.)
Two recent meta-analyses indicated that single-session
debriefing does not protect against the development of
PTSD ( Rose , Bisson , & Wesley , 2002 ; van Emmerik
, Kamphuis , Hulsbosch , & Emmelkamp , 2002
Potentially detrimental effect , with higher rates of
PTSD at long-term follow-up ( Mayou , Ehlers , &
Hobbs , 2000 ).

Reconsider CISD
CISD has generated much criticism, mainly because
of its application to non-helpers and its use by
nonprofessionals.
Based on a study of a large database of CISD
studies, reviewers concluded that most CISD
criticism is based on practices that do not follow the
rigorous procedures and criteria of the original
Mitchell model; for example, single sessions were
held with no follow-up, encounters were too short,
or groups were much larger than recommended.
(Everly& Mitchell, 2000)
Roseenfeld, L.B.,Caye, J.S., Ayalon,O., Lahad,M., When their world falls apart, Helping families and
children manage the effects of disaster.(NASW Press, 2005) Page 445
Proximity, Immediacy and Expectancy (PIE)
Military to return injured soldiers to front line
In Israel some success 1982 Lebanon War ( Solomon &
Benbenishty , 1986 )
Vietnam not as successful (Shalev, 2002)
overwhelmed by events , who lack sufficient affect regulation
skills , or who have a biological vulnerability to stress , such
reexposure may in fact be retraumatizing and harmful. Jones
and Wessely ( 2003 )
John N. Briere, Catherine Scott. Principles of Trauma Therapy: A Guide to

Symptoms, Evaluation, and Treatment. (Sage Publications, Inc, 2006). Page 169.
Defusing
Brief (10-30 minutes)
Conversational -informal
Support, reassurance, and information
Little research
Swedish peacekeepers Bosnia helpful

Psychological First Aid (PFA)
PFA Field Operations Guide (Hurricane Katrina)
Not a specific therapeutic
intervention
Modular framework give to individuals for
Natural disasters
Terrorisms
Mass trauma
Goal decrease initial distress
Nonintrusive, compassionate attitude of therapist

Never push for information
Practical assistance, safety
and comfort connect primary
support networks and social resources
John N. Briere, Catherine Scott. Principles of Trauma Therapy: A Guide to Symptoms, Evaluation,
and Treatment. (Sage Publications, Inc, 2006). Page 170
8 Core Actions
1. Contact and Engagement
2. Safety and Comfort
3. Stabilization (if needed)
4. Information Gathering: Current Needs & Concerns
5. Practical assistance
6. Connection with Social Supports
7. Information on Coping
8. Linkage with Collaborative Services
http://www.ncptsd.va.gov/ncmain/ncdocs/manuals/nc_manual_psyfirstaid.html
Guidelines for first encounter with an ASR
victim
ER Staff
Dr Ilan Kutz MD ,Prof. Mooli Lahad PhD
Guidelines for a talk with an ASR victim
When we help a person

suffering from ASR we must
consider a few main points:

What characterizes ASR is a feeling of loss of
control, difficulty in getting organized and
reduced functioning
Preliminary treatment should help to increase:
A feeling of internal control
Physical and emotional organization
Functioning ability
Orientation
Help in recruiting resources
Support: encouragement, contact, hugs
Making up deficiencies: Food & drink, rest & sleep
Introductions
Orientation
Allow expression without disturbance
Normalization of reactions as opposed to the
abnormality of the difficult situation the
reactions are logical and to be expected and they
should slowly fade away

Defining the situation in terms of coping and

abilities
Expectations of improvement as time goes by
and as the situation gets quieter
Activation by questions such as what can you
do for yourself and your family?
Concentrating on what helps and on getting
back to routine, including using services
No arguments pacing and leading
Try and encourage them to say what they

expect of themselves and of the environment
Remind them and encourage them to focus
on good coping in the past
Indicate possible sources of support (family
friends, neighbors, professionals,
information, faith, activities etc.)
The principle of a gradual return to

understand that sometimes it is impossible to
return immediately to the way things were
before the incident, but that it is important to
get back to normal
Avoidance as a mode of behavior is a major
step in the development of PTSD. Therefore
it is important to encourage a full return to
normal functioning
Leave time for questions and answers
An iron rule if the symptom gets worse or

does not diminish turn to professional help
The symptoms can be in the form of getting
easily annoyed a short fuse, pessimism being
under a cloud or cutting oneself off from the
outside.

8 Core Actions
1. Contact and Engagement
2. Safety and Comfort
3. Stabilization (if needed)
4. Information Gathering: Current Needs & Concerns
5. Practical assistance
6. Connection with Social Supports
7. Information on Coping
8. Linkage with Collaborative Services
http://www.ncptsd.va.gov/ncmain/ncdocs/manuals/nc_manual_psyfirstaid.html
Terrorist Attacks 2nd Intifada
September 2000
1,053 Israelis total:
- 719 Israeli civilians killed by Palestinians;
- 334 Israeli security force personnel killed by
Palestinians
Yael # 6 bus
Got off bus just before exploded

Actively hallucinating the explosion
In silent terror
EMDR
Adaptive Information Processing
As the body self heals after physical injury
The mind can also self heal
Help with correct cognitions

Responsibility
Safety/Vulnerability
Control/Choices
EMDR
Treatment validated by randomized control
studies- more than 15
Can work much more rapidly in single Incident
PTSD
CBT 12-20 sessions 100 hours homework
EMDR 1-3 ninety minute sessions no homework
(not explained with exposure model)
Bilateral Stimulation
May help link Right and Left Brain (PET scans
van der Kolk)
Dual Attention- remain in the present as access
memories of the past
Bilateral Stimulation Helps
Numerous controlled studies have also indicated that
eye movements cause a decrease in imagery vividness
and distress, as well as increased memory access.
Andrade, J., Kavanagh, D., & Baddeley, A. (1997). Eye-movement and visual
imagery: a working memory approach to the treatment of post-traumatic stress
disorder. British Journal of Clinical Psychology, 36, 209-223.
Barrowcliff, A.L., Gray, N.S., MacCulloch, S. Freeman, T.C.A., &
MacCulloch, M.J. (in press). Horizontal rhythmical eye-movements consistently
diminish the arousal provoked by auditory stimuli. British Journal of Clinical
Psychology.
Christman, S.D., Garvey, K.J., Propper, R.E. & Phaneuf, K.A. (in press).
Bilateral eye movements enhance the retrieval of episodic memories. British Journal
of Clinical Psychology, 40, 267-280.
Bilateral Stimulation Helps
Kavanaugh, D.J., Freese, S., Andrade, J., & May, J. (2001).
Effects of visuospatial tasks on desensitization to emotive
memories. British Journal of Clinical Psychology, 40, 267-280.
Kuiken, D., Bears, M., Miall, D., & Smith, L. (2002-2002).
Eye movement desensitization reprocessing facilitates attentional
orienting. Imagination, Cognition and Personality, 21, (1), 3-30.
Sharpley, C.F., Montgomery, I.M., & Scalzo, L.A. (1996).
Comparative efficacy of EMDR and alternative procedures in
reducing the vividness of mental images. Scandinavian Journal of
Behaviour Therapy, 25, 37-42.
van den Hout, M., Muris, P., Salemink, E., & Kindt, M.
(2001). Autobiographical memories become less vivid and
emotional after eye movements. British Journal of Clinical
Psychology, 40, 121-130.
Taking Pictures of Duty-Induced PTSD
& HEALING
Article:
High Resolution Brain SPECT Imaging and Eye Movement Desensitization and
Reprocessing in Police Officers With PTSD
Karen Lansing, M.F.T, B.C.E.T.S.

Daniel G. Amen, M.D.
Chris Hanks, Ph.D
Lisa Rudy, B.A.
QuickTime and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Published in the Jrnl of Neuropsychiatry Clinical Neuroscience17:4, Fall 2005

Yael #6 Emergency Response
Procedure (ERP)
Bilateral stimulation
You are safe in the ER
That explosion is in the past
You are here
Repeat often
Take a deep breath, Let it all go, What are you
noticing? (took time before she could answer)
Yael #6 after ERP
Talked about the event (narrative)
Debriefed regarding expected normal reactions
to trauma
Gave referral if before follow up visit needed to
consult
Came in 1 week later with no ASD
ERP
Currently experimental and not validated by

controlled research (F)
Research proceeding with ambulance workers
ERP
Timing: Within hours of traumatization
Indication: Silent terror or highly agitated
state
ERP initial preparation
Normalization while uncontrollable shaking and
overwhelmed: This is the bodys normal
healthy way of dealing with a dangerous
situation.
ERP preparation
Brief explanation describing EMDR: I will be
using a procedure based on the natural state
of dreaming when your eyes move rapidly
back and forth. This can help you learn new
things and be calm. It will also help you
come back to the present.
I am going to ask you to follow my fingers
with your eyes or with your permission, I am
going to tap on your hands.
ERP assessment
No formal assessment as already accessing
memory
Assumed initial NC: I am in danger
PC : I am safe now from that event
ERP desensitization
Begin bilateral stimulation.
You are in the emergency room (or current
location) and you are safe. That event is over
and out there. You are here, safe in the
emergency room (repeat several times).
Take a breath, Let it go, What are you
noticing
At first there can be re experiencing of trauma
followed by calming and ability to communicate
ERP completion
Narrative of event
And/or EMDR (if time)
At times another negative cognition is active
such as a false sense of responsibility
ERP closure
You may still have a day or two of anxiety,

disrupted sleeping and/or increase startle
reaction.
If you find these symptoms lasting longer
than that and you can seek further
treatment.
Referral numbers and fact sheet
Lebanon-Israel War 2006
3 soldiers kidnapped (2 in Lebanon)
4228 rockets fired
163 people killed
1750 physically injured
Thousands Psychologically injured
1.5 million people lived bomb shelters 33 days
Debriefing with first responder
2 weeks after war ended (not within 72 hours)
Heterogeneous group: Police, Firemen,
Ambulance and Zaka (removal of dead) workers
Different events
Each person reported a huge amount of trauma
ERP with Dov
Zaka (removal of dead) worker
After hearing most of the group walked out
Said was going to bathroom
Followed him and he was in dissociated state
After hour of walking got him to sit down
ERP protocol
10 minutes responded and returned to group
Group EMDR
EMDR Group protocol developed after Hurricane
Pauline ravaged the western coast of Mexico in 1997
By AMAMECRISIS for 200 distressed children and
adults who had lost families and homes
Artigas, Jarero, Mauer, Lpez Cano, & Alcal, 2000;
Jarero, Artigas, Lpez Cano, Mauer, & Alcal, 1999
Described for children after a natural disaster in
Argentina: MarIa Elena Aduriz, Catalina Knopfler,
Cristina Bluthgen, & Susana Maqueira)
Group EMDR
Fernandez, Gallinari, and Lorenzetti (2004)
Alleviate symptoms for all but 2 of the 236 students
who witnessed an airplane crash in Italy.
Adriz and colleagues (in press) used the EMDR
Integrative Group Treatment protocol (EMDR-
IGTP)
220 child victims of a flood in Santa Fe, Argentina in
2003 and reported significant improvement that was
maintained at 3-month follow-up.
Group EMDR
Sit in circle with paper and crayons, pens etc
First picture: Resource- Tap
Next Picture: Worst Picture- Tap
Next Picture: Picture what ever comes up: Tap
Continue around 4 to 5 times
Tsunami 2004
Group EMDR-Israel-Lebanon War-
Children not go to the exit of Bomb
Shelter 3 weeks
Combined Children and Adults
Group protocol
First picture: resource
Next picture: worst Katyushas, black sky
Next picture: no Katyushas, ground empty
Next picture: grass growing
Next picture: Sun , flowers
Group after EMDR
For the first time in 3 weeks the children went
to and up the exit of the bomb shelter
At the top a siren started
One girl started to shake and did butterfly hug
and resolved in 10 seconds
Had to hold back children who wanted to run
out and taught them not when siren
Conclusion
Victor Frankel: even in the worst of nightmares such as
the holocaust mankind can utilize the crisis for growth
Woman seeing terrorist blow self up killing and injuring
scores of civilians
At first I could only see the incredible amount of evil
After EMDR processing:
Now I am seeing the amazing good of so many people
coming to help. The good outweighs the evil by
thousands

EMDR Scripted Protocols - M. Luber

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Acute Stress Reaction &

Acute Stress Disorder

Gary Quinn, M.D.

In addition, the symptoms:

Cortisol with Neuropeptide Y (NPY)

Jonathan I Bisson Department of Psychological

Jonathan I Bisson Department of

Jonathan I Bisson Department of

Jonathan I Bisson Department of Psychological

Brocas area- silent terror

After successful EMDR treatment

5. Dissociative amnesia(i.e. inability to recall an

National Institute for Clinical Excellence

John N. Briere, Catherine Scott. Principles of Trauma Therapy: A Guide to

John N. Briere, Catherine Scott. Principles of Trauma Therapy: A Guide to Symptoms,

Varied nonsexual trauma (Bryant et al. 1999)

Jonathan I Bisson Department of Psychological

1-3 hours session within week of trauma

John N. Briere, Catherine Scott. Principles of Trauma Therapy: A Guide to Symptoms,

John N. Briere, Catherine Scott. Principles of Trauma Therapy: A Guide to

Support, reassurance, and information

John N. Briere, Catherine Scott. Principles of Trauma Therapy: A Guide to Symptoms,

Nonintrusive, compassionate attitude of therapist

Dr Ilan Kutz MD ,Prof. Mooli Lahad PhD

When we help a person

Dr Ilan Kutz MD ,Prof. Mooli Lahad PhD

Dr Ilan Kutz MD ,Prof. Mooli Lahad PhD

Defining the situation in terms of coping and

Try and encourage them to say what they

Dr Ilan Kutz MD ,Prof. Mooli Lahad PhD

The principle of a gradual return to

Leave time for questions and answers

An iron rule if the symptom gets worse or

Dr Ilan Kutz MD ,Prof. Mooli Lahad PhD

Got off bus just before exploded

Help with correct cognitions

Karen Lansing, M.F.T, B.C.E.T.S.

Published in the Jrnl of Neuropsychiatry Clinical Neuroscience17:4, Fall 2005

Currently experimental and not validated by

You may still have a day or two of anxiety,

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