The role of EMDR in the reduction of psychological symptoms in patients with personality disorders.

Personality disorders are one of the most common psychological disorders.
Approximately 3-15% in the general population, 40-50% of the clients in health
care settings and 60-80% in forensic settings meet the diagnostic criteria
(Bamelis, Evers, Spinhoven, & Arntz, 2014; Soeteman, Verheul & Van Busschbach,
2008). PD*s are disorders with high individual, societal and economic burden of
disease (Soeteman, Hakkaart, van Roijen, Verheul, & Busschbach, 2008; Soeteman,
Verheul, & Busschbach, 2008).

Personality disorders are thought to be caused by a combination of genetic and
environmental influences. Negative life experiences are an example of
environmental influences and are associated with personality pathology as well
as many other psychological disorders (Kendler et al., 2000).

According to cognitive models people with personality disorders act in
dysfunctional ways because of negative core beliefs. These core beliefs are
partially caused by negative life experiences and underlie information
processing and emotional and behavioral processes. The treatment of patients
with personality disorders generally requires an emphasis on understanding the
meaning to patients of their adverse childhood experiences; how these
experiences led to the development and maintenance of extremely strong, rigid,
global beliefs about the self, world, and others (Beck, 2005).

Evidence based psychological treatments for personality disorders are built on
the assumption that present situations provoke disturbing negative affect as
they activate previously installed detrimental reaction patterns, caused by
painful experiences. In Schema focused therapy (Young, Klosko, & Weishaar,
2003), for example, early experiences play an important role, and techniques
such as *imagery rescripting* are used to create a new narrative of a traumatic
event with a more satisfactory outcome. In psychodynamic therapy too, present
day problems are linked to unconscious conflicts arising from past negative
events (Freud, 1962).

The importance of past disturbing and painful experiences is not only
recognized in personality treatments, it is also a cornerstone of trauma
therapy. In trauma therapy an important intervention is eye movement
desensitization and reprocessing (EMDR). Since 2005 EMDR has been acknowledged
by the National Institute for Health and Clinical Excellence (NICE) as a safe
and effective treatment of choice for post-traumatic stress disorder (PTSD)
(NICE, 2005). The effectiveness of EMDR was originally researched in patients
suffering from post-traumatic stress disorder, but it has also been shown to be
effective in treating negative experiences in other patient groups, such as
patients suffering from psychosis (Van den Berg, et al., 2015) and anxiety
disorders (De Jongh, Van den Oord, & Ten Broeke,2002). However, research on the
effectiveness of EMDR focused on negative experiences in patients with
personality disorders is missing.


Treatment of personality disorders is often considered to be complicated and
requires lengthy therapy (Vandereyken et al., 2008). Also, the level of
psychological symptoms seems to be higher in patients with PD*s both at the
beginning and end of therapy compared to patients without a PD (Verheul,
2013).
Since EMDR works fast to reduce symptoms, adding EMDR as pre-treatment could
help in quickly reducing psychological symptoms. The goal of this study is to
examine the effect of pre-treatment with EMDR on psychological symptoms in
patients with a PD.

The main objective of this study is to examine the effect of EMDR as
pre-treatment on psychological symptoms in patients with a PD.
The secondary objective is to examine whether pre-treatment with EMDR still has
an effect on symptoms three months after treatment as usual for PD has started.
Also weekly treatment results are monitored.

Another secundary objective is to examine the effect of EMDR on the global
level of personality functioning.

This study design is a randomized controlled trial with 2 arms, comparing
pre-treatment EMDR therapy with a WL condition.

Patients in the experimental condition will receive five weekly 90 minute
sessions of EMDR. The EMDR-treatment will be given following the standard
protocol, added in the appendix (F4).
In the waiting list condition patients receive no psychological treatment.

Benefits:
EMDR is effective in the treatment of axis 1 disorders, such as PTSD, psychosis
and anxiety disorders in reducing psychological symptoms. Clinicians already
use EMDR in the treatment of personality disorders with positive effects, but
it has never been studied. Studies show that treating PTSD in people with
personality disorders is safe (Van Minnen e.a., 2012).
A fast symptom reduction and a possibly faster treatment of the personality
disorder could be a benefit for the experimental group.

Risks: EMDR can cause intense emotions when patients are confronted with
earlier traumatic experiences. Patients can temporarily experience difficulties
in regulating their emotions or can temporarily experience an increase in their
symptoms.