eye movement desensitization and reprocessing ... - emdr · sitization and reprocessing...

ORIGINAL ARTICLE

Eye Movement Desensitization and Reprocessing VersusCognitive-Behavioral Therapy for Adult Posttraumatic

Stress DisorderSystematic Review and Meta-Analysis

Ling Chen, MD,* Guiqing Zhang, PhD,† Min Hu, MD,† and Xia Liang, MD†

Abstract: Posttraumatic stress disorder (PTSD) is a relatively common mentaldisorder, with an estimated lifetime prevalence of ~5.7%. Eye movement desen-sitization and reprocessing (EMDR) and cognitive-behavioral therapy (CBT) arethe most often studied and most effective psychotherapies for PTSD. However,evidence is inadequate to conclude which treatment is superior. Therefore, weconducted a meta-analysis to confirm the effectiveness of EMDR compared toCBT for adult PTSD. We searched Medline, PubMed, Ebsco, Proquest, andCochrane (1989–2013) to identify relevant randomized control trials comparingEMDR and CBT for PTSD. We included 11 studies (N = 424). Although allthe studies had methodological limitations, meta-analyses for total PTSD scoresrevealed that EMDR was slightly superior to CBT. Cumulative meta-analysisconfirmed this and a meta-analysis for subscale scores of PTSD symptoms in-dicated that EMDR was better for decreased intrusion and arousal severity com-pared to CBT. Avoidance was not significantly different between groups. EMDRmay be more suitable than CBT for PTSD patients with prominent intrusion orarousal symptoms. However, the limited number and poor quality of the originalstudies included suggest caution when drawing final conclusions.

Key Words: Posttraumatic stress disorder, eye movement desensitization andreprocessing, cognitive-behavioral therapy, meta-analysis

(J Nerv Ment Dis 2015;203: 00–00)

P sychological crises caused by previous trauma or disaster may haveserious and lasting effects on individuals and cause stress-related

disorders. Stress-related disorders are mental disorders caused by envi-ronmental risk factors and include acute stress reactions, adjustmentdisorders, dissociative disorders, and posttraumatic stress disorders(PTSD; Friedman et al., 2011). A serious consequence of PTSD is achange in thinking, emotional expression, value orientation, life beliefs,and perceptions of life value. PTSD, caused by dangerous and devastat-ing psychological trauma, is also referred to as delayed psychogenic re-action (Kekelidze and Portnova, 2011). The associated mental disordersmay appear long after the precipitating event. Three core symptoms ofPTSD (Hyman, 2010) are (a) intrusion (flashbacks), (b) avoidance(avoidance behavior and numbing of general responsiveness), and(c) increased arousal. PTSD is now a common mental disorder, withan estimated lifetime prevalence of ~5.7% (Kessler et al., 2012). PTSDaffects interpersonal communication, work, and life and is often associ-ated with substance abuse, depression, anxiety disorders, and phobias,

*School of Medicine and †Departments of Rehabilitation and Psychology, the FirstAffiliated Hospital of School of Medicine, Shihezi University, Shihezi, China.

Send reprint requests to Guiqing Zhang, PhD, Departments of Rehabilitation andPsychology, the First Affiliated Hospital of School of Medicine, ShiheziUniversity, Shihezi 832008, China. E-mail: [email protected].

The work of the paper is supported by the fund of Xinjiang Production andConstruction Corp Science-Technology Project (2012BA023).

Supplemental digital contents are available for this article. Direct URL citations appearin the printed text and are provided in the HTML and PDF versions of this articleon the journal’s Web site (www.jonmd.com).

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.ISSN: 0022-3018/15/20306–0000DOI: 10.1097/NMD.0000000000000306

The Journal of Nervous and Mental Disease • Volume 203, Number 6

Copyright © 2015 Wolters Kluwer Health, Inc. Unaut

which decrease the quality of life (Ginzburg et al., 2010). Studies(e.g., Bonanno, 2004) suggest that experiencing a traumatic event is afactor for PTSD. Brewin’s group (Brewin et al., 2000) identified severalrisk factors influencing PTSD including female gender, previoustrauma, psychiatric history, childhood adversity, life stress, poor socialsupport, and limited education. In addition, a meta-analysis (Steel et al.,2009) indicated that poor living conditions and methodological factors(e.g., non-random sampling, small sample sizes, and use of self-reportquestionnaires) generate higher PTSD prevalence rates.

For the treatment of PTSD, international guidelines recommendeye movement desensitization and reprocessing (EMDR) and cognitive-behavioral therapy (CBT) as evidence-based treatments of choice fortrauma victims (Ursano et al., 2004). Antidepressants are not recom-mended as a first-line treatment for adults unless psychological treat-ments are not available or have not been effective or when peoplehave concurrent moderate to severe depression (Tol et al., 2013). Inone study (van der Kolk et al., 2007), 88 PTSD patients were randomlyassigned to EMDR, fluoxetine, or placebo and treated patients received8 weeks of treatment. Then, all patients were assessed after treatmentand at a 6-month follow-up. For adult-onset trauma survivors, EMDRwas much better than fluoxetine for achieving sustained reductions inPTSD and depression symptoms. Randomized controlled trials com-paring CBTwith antidepressants have not been retrieved.

EMDR was proposed as a psychological trauma treatment ap-proach in 1987. EMDR, developed from the observation that eye move-ments can calm negative emotions, suggests that (Shapiro, 2001) patientsshould move their eyes from right to left under the guidance of thetherapist’s hand movements. Simultaneously, patients are to focus ontraumatic events they wish to feel better about. Proponents of EMDRthink the adaptive processing of traumatic memories via desensitizationemotional pain constructs positive cognition and decreases high physi-cal arousal. It is hypothesized that PTSD patients’ focus of attention onboth the traumatic memory and repeated orienting responses may in-crease communication between both brain hemispheres (Christmanet al., 2003), thus decreasing the vividness and/or emotionality of auto-biographical memories (Maxfield et al., 2008), increasing cognitiveflexibility (Kuiken et al., 2001), and enhancing memory of the trau-matic event without arousal (Barrowcliff et al., 2004). According toGreenwald (1994), successful EMDR is not only desensitization butalso a complete reprocessing of target trauma. Although EMDR hasgained wider acceptance, it has controversial beginnings because ofthe lack of evidence confirming that eye movements and other bilateralstimulation (i.e., tones and tapping) contribute to treatment outcomes(Newcomer et al., 1999). Clinical studies to evaluate the effect of eyemovements in EMDR were inconsistent (Lee and Drummond, 2008;Pitman et al., 1996; Renfrey and Richard, 1994; Wilson et al., 1996),so the value of EMDR is unclear. The Institute of Medicine failed to ac-curately read the outcome data after reviewing some EMDR studies(Berg et al., 2008) and criticized the research on all methods as beingpotentially tainted by allegiance effects, which meant the researchersapparently hold for EMDR over others.

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Chen et al. The Journal of Nervous and Mental Disease • Volume 203, Number 6, June 2015

CBT is a structured form of psychotherapy involving cognitivetherapy and behavior therapy (Koucky et al., 2013). CBT for PTSDaims to modify behaviors and cognitions that developed into PTSD,and typically targets avoidance behavior and unrealistic or unhelpfulthinking. CBT therapists routinely orient patients about the cognitive-behavioral model and an in-depth treatment rationale to educate partic-ipants about treatment. Numerous variants of CBT for PTSD have beendeveloped, including specific manualized treatments that follow stan-dard protocols (e.g., cognitive processing therapy, prolonged exposure),and less standardized applications without structured protocols (e.g.,psychoeducation coupled with cognitive and emotional processing)(Koucky et al., 2013). Some studies offer convincing support for effi-cacy of CBT approaches based on exposure, cognition, or both. How-ever, no clear evidence supports the efficacy of any particular variantof CBT for PTSD. Foa’s group (Foa et al., 1999) reported that exposurealone was superior to exposure plus stress management skills train-ing for sexual assault survivors, whereas Bryant’s group (Bryant et al.,2003) reported that imaginal exposure plus cognitive restructuring wassuperior to imaginal exposure alone. Foa’s group (Foa et al., 1999) pro-vided a possible explanation for the counterintuitive finding. First, theexposure treatment had significantly less dropout than the exposureplus stress management skills training intervention. Second, becausethe session length was constant across treatment conditions, severalprocedures were included in the combined treatment sessions, per-haps leading to information overload for the participants. Furthermore,homework assignments in the combined treatment intervention weredouble those given in the single-component treatments. Thus, partici-pants may not have had sufficient opportunity to practice each of theprocedures included in the program. Similarly, Marks’s group (Markset al., 1998) found that exposure (alone or with cognitive restructuring)was superior to cognitive restructuring alone in a mixed civilian traumasample, but other studies reveal that that exposure and cognitive re-structuring did not differ in efficacy (Paunovic and Öst, 2001; Resicket al., 2002; Tarrier et al., 1999).

Many systematic analyses of PTSD have compared EMDR withCBTand the first published meta-analysis (Davidson and Parker, 2001)confirmed no differences between EMDR and exposure-based treat-ments, but not all study analyses were randomized controlled trials.Similarly, Bradley and colleagues (Bradley et al., 2005) found no differ-ences in direct comparative studies and conceded that there were toofew studies to justify definitive conclusions. Then, Seidler and Wagner(2006) compared studies of EMDR and CBT to treat PTSD and con-cluded that neither EMDR nor CBT was superior. Benish and col-leagues (Benish et al., 2008) reported no differences in efficacy among“bona fide” psychotherapies. Bisson and Andrew (2009) found thattrauma-focused CBT (TFCBT) and EMDR were superior to stressmanagement in 2- to 5-month follow-up comparisons, and that TFCBTand EMDRwere more effective than other therapies for treating PTSD.Ho and Lee (2012) compared EMDR and TFCBT for PTSD and foundno difference between EMDR and TFCBT for PTSD, except that EMDRmay deduce depression. Watts and colleagues (Watts et al., 2013) con-cluded that TFCBTand EMDRwere the most effective and most often-studied types of PTSD psychotherapy.

An earlier meta-analysis revealed that EMDR and CBT werecomparably effective and superior to other PTSD interventions. Morerandomized controlled trials comparing EMDR with CBT for PTSD(Capezzani et al., 2013; Nijdam et al., 2012) have been published sincethe study by Watts and colleagues (Watts et al., 2013). In addition, allconclusions of earlier meta-analyses depended on total scores ofclinician-rated or self-rated PTSD scales which consisted of intrusion,avoidance, and arousal subscales. The lack of difference between totalscores did not suggest differences among subscales. Considering this,our meta-analysis of PTSD treatment studies evaluated the efficacy ofEMDR versus CBT. We sought to specifically examine randomizedcontrol studies with rigorous criteria and to apply statistical methods

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that could resolve conflicting perspectives of past analyses. We also in-vestigated differences in effectiveness between the two treatments forPTSD symptoms (intrusion, avoidance, and arousal).

METHODSOur meta-analysis followed the Preferred Reporting Items

for Systematic Reviews and Meta-Analyses (PRISMA) statement(Liberati et al., 2009). Appendix S1 (Supplemental Digital Content 1,http://links.lww.com/JNMD/A6) summarizes the PRISMAprocedures used.

Search StrategyWe searched Medline, PubMed, Ebsco, Proquest, and Cochrane

for randomized control trials of the efficacy of EMDR compared toCBT for PTSD, focusing on studies published between 1989 (whenEMDRwas first defined) and 2013. Search termswere as follows: post-traumatic stress disorder/stress disorder; treatment/psychotherapy; eyemovement desensitization and reprocessing/EMDR; CBT/cognitive be-havioral therapy; randomized trials (see Appendix S2 (SupplementalDigital Content 2, http://links.lww.com/JNMD/A7) for search strategy).We also searched reference lists of retrieved articles, recently publishedtextbooks, and review articles.

Eligibility CriteriaRandomized control trials that met the following criteria were

included: (a) study participants were 18 years of age or older; (b) par-ticipants’ diagnoses used established standards for PTSD (which wereDSM-III [American Psychiatric Association, 1980], DSM-III-R[American Psychiatric Association, 1987], DSM-IV [American Psy-chiatric Association, 1994], DSM-IV-TR [American Psychiatric Asso-ciation, 2000], and ICD-10 [World Health Organization, 1992]);(c) EMDR and CBT (manualized treatment or less standardized ap-plication) were the main interventions; (d) studies reported pre- andposttreatment measures of PTSD recorded in mean scores and stan-dard deviations. We excluded letters, reviews, editorials, and open clin-ical trials. Titles and abstracts were separately screened by twoinvestigators and full papers of eligible studies trialswere retrieved. Dis-agreements about inclusion were resolved by discussion with anotherinvestigator.

Data ExtractionWe organized patient information and study parameters, includ-

ing sample size, location, gender, trauma type, variants of CBT, andoutcome measures. We used Review Management (RevMan) 5.0 soft-ware (provided by the Cochrane collaboration; Higgins and Green,2008) to extract information on treatment effectiveness (e.g., differ-ences in posttreatment symptoms total scores and subscores betweencomparison groups). We extracted clinician-rated severity of PTSDsymptoms where possible. Otherwise, we used self-reported severityof PTSD symptoms. Additionally, we contacted authors for missingdata. Rothbaum (see Rothbaum et al., 2005) provided uswith additionalinformation, but we failed tomake contact Devilly (Devilly and Spence,1999), Taylor (Taylor et al., 2003), Arabia (Arabia et al., 2011), andNijdam (Nijdam et al., 2012).

Quality AssessmentWe assessed methodological quality using the Cochrane Collab-

oration tool (Higgins et al., 2011), which includes random sequencegeneration, allocation concealment, blinding of outcome assessment,intention-to-treat analysis, selective reporting, and other potential bias.Data extraction and quality assessment were independently accom-plished by two investigators. Any disagreement was resolved by discus-sion with another investigator when necessary.

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TABLE

1.Cha

racteristicsof

theInclud

edStud

ies

Stud

yLocation

N(EMDR/CBT)Females/M

ales

Age

inYears

aRan

gean

d/or

Mean±SD

Traum

aTyp

eVariantsof

CBT

Clin

ician-Rated

Measuresb

Self-R

ated

Measuresb

Vaughan

etal.,1994

Australian

12/13

Not

reported

20–78(32±14.7)

Mixed

IHT

SI-PTSD

—Devilly1999

Australian

11/12

15/8

37.96±12.82

Mixed

TTP

PTSD

-I—

Rogers1999

US

6/6

0/12

47–53

Com

batv

eterans

Exposure

—IES

Power

2002

UK

27/21

20/28

EMDR:3

8.6±11.8;C

BT:4

3.2±11

Mixed

E+CR

SI-PTSD

—Ironson2002

US

10/9

17/5

16–62

Rapeandcrim

evictim

sPE

—PS

S-SR

Lee

etal.,2002

Australian

12/12

11/13

35.3

Mixed

SITPE

SI-PTSD

—Taylor

2003

UK

15/15

Not

reported

37±10

Mixed

Exposure

CAPS

—Rothbaum

2005

US

20/20

40/0

33.8±11.0

Rapevictim

sPE

CAPS

—Arabia2011

Italy

21/21

14/28

34–79(63.48

±10.32)

Cardiac

eventssurvivors

IE—

IES-R

Nijd

am2012

Netherlands

70/70

79/61

EMDR:3

7.7±10.6;C

BT:5

2.7±8.68

Mixed

BEP

SI-PTSD

—Capezzani

2013

Italy

11/10

19/2

52.7±8.68

Cancerpatients

Lessstandardized

CBTc

—IES-R

IHT,im

agehabituationtraining;T

TP,traumatreatm

entprotocol;E+CR,exposureplus

cognitive

reconstructio

n;PE

,prolonged

exposure;S

ITPE

,stressinoculationtraining

with

prolongedexposure;IE,imag-

inalexposure;B

EP,briefeclectic

psychotherapies;SI-PTSD

,StructuredInterviewforP

TSD

;IES,

Impactof

EventScale;IES-R,Impactof

EventScale-Revised;P

TSD

-I,P

TSD

Interview;P

SS-SR,P

TSD

Symp-

tom

ScaleSelf-Report;CAPS

,Clin

ician-Adm

inisteredPT

SDScale.

a Som

estudiesreported

ranges

ormeans

orboth

forallp

articipantsor

each

group.

b Outcomemeasuresthatserved

forthepresentm

eta-analysiswereextracted.

c Itincludesmajor

elem

entsof

CBT,

such

aspsychoeducation,cognitive

thoughts,g

radualand/or

prolongedexposure.

The Journal of Nervous and Mental Disease • Volume 203, Number 6, June 2015 Eye Movement Desensitization



Statistical Analysis

The meta-analysis summarized and pooled statistics usingRevMan 5.0 software and the Stata software package (version 12.0). Ef-fect sizes were expressed as standard mean differences (SMD) with95% confidence intervals (CIs). Differences were considered statisti-cally significant at the p < 0.05 level. To track effect differences overtime, a cumulative meta-analysis was performed to calculate pooledSMDs and CIs at the end of each year, according to the temporal se-quence in which the studies were published.

FIGURE 1. Risk of bias summary: review authors’ judgments about eachrisk of bias item for each included study.

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FIGURE 2. Risk of bias graph: review authors’ judgments about each risk of bias item presented as percentages across all included studies.


Statistical HeterogeneityBoth I2and χ2 tests (Higgins and Thompson, 2002) (a = 0.05)

were used to evaluate data heterogeneity from different studies: I2

<30% defined mild heterogeneity and a fixed effects model was car-ried out to pool the data; I2 >50% indicated substantial heterogene-ity and a random effects model was used to synthesize the results;30% ≤ I2 ≤ 50% was considered moderate heterogeneity. The χ2 testof heterogeneity was simultaneously used to confirm a fixed effectsmodel. Sensitivity analysis based on blinding of outcome measurementwas used to assess the pooled SMD stability. Meta-regression analy-sis explored heterogeneity sources. Subgroup analysis was predefinedand performed to assess the influence of form of CBT. Funnel plots,Begg’s tests, and Egger tests were used to estimate potential publicationbias (Begg and Mazumdar, 1994; Egger et al., 1997).

RESULTS

Study Selection and Characteristics of Eligible StudiesThe initial search yielded 502 studies. Of those, we identified

108 papers as possibilities after screening the title and abstract. Afteran evaluation by two reviewers, 11 studies (N = 424) met the inclu-sion criteria and 97 studies were excluded (Figure S1, SupplementalDigital Content 3, http://links.lww.com/JNMD/A8). Table 1 depictstrial characteristics.

Quality AssessmentFigure 1 and Figure 2 depict the quality assessment proce-

dures applied to the sampled random control trials. A double blind

FIGURE 3. A Forest plot of meta-analysis of the total scores of PTSD symptom

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methodology is difficult or impossible for psychotherapy, as the thera-pist would know which therapeutic method is employed and the pa-tients know why they receive treatment and what that treatment is.Seven trials (63.6%) stated that an intention-to-treat analysis was used.Losses to follow-up of >20% occurred in five trials (45.5%). Six trials(54.5%) appeared to report potential biases. Studies by Rothbaum et al.(2005), Nijdam et al. (2012), Rogers et al. (1999), Ironson et al. (2002),and Power et al. (2002) were significantly different at baseline on PTSDscale or subscale scores. No fidelity checks for treatment sessions wereperformed and the same therapist carried out both treatment types inthe study by Capezzani et al. (2013). Bias risk was from randomizationprocedures. Risk of selection bias was not apparent across studies; mostdescribed blinding techniques.

Effects of Intervention: Meta-AnalysisComplete results are summarized in Figures 3–6.

Total Scores of PTSD SymptomsEMDRwas slightly better than TFCBT. All 11 studies (N = 424)

included comparable measures of severity of PTSD symptoms. TheSMDwas −0.43 (CI, −0.86 to−0.01), indicating a slight, but significant,difference between studies (z = 1.99; p = 0.05). Heterogeneity was high(I2 = 75%; Fig. 3).

Subscales Scores of PTSD Symptoms

IntrusionEMDRwas beneficial compared to CBT in intrusion. Six studies

(N = 170) included comparable measures of severity of PTSD intrusion

s comparing EMDR group with CBT group.



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FIGURE 4. A Forest plot of meta-analysis of the subscales scores of PTSD intrusion symptoms comparing EMDR group with CBT group.


symptoms. The SMD significantly favored the EMDR group (SMD,−0.37; CI, −0.68 to −0.06; z = 2.36; p = 0.02; Fig. 4). Heterogeneity wasmoderate (I2 = 49%).

AvoidanceWhen EMDR was compared to TFCBT for avoidance symp-

toms, neither was clearly better. Six studies (N = 170) included compa-rable measures of severity of PTSD avoidance symptoms. The SMDwas −0.42 (CI, −0.92 to 0.08), indicating no statistically significantdifference between studies (z = 1.64; p = 0.1). Heterogeneity was high(I2 = 59%; Fig. 5).

ArousalFor arousal, EMDR was better than CBT. Five studies (N = 146)

included comparable measures of severity of PTSD arousal symptoms.The SMD significantly favored the EMDR group (SMD, −0.34; CI,−0.68 to −0.01; z = 2.02; p = 0.04; Fig. 6). Heterogeneity wasmoderate (I2 = 42%).

Analysis: Cumulative Meta-Analysis, Sensitivity,Meta-Regression, and Subgroup

Analyses for the total scores of PTSD symptoms indicated that(cumulative meta-analysis) the pooled SMD achieved significancewhen the last study published in 2013 was included (p = 0.05), and thatEMDR was better than CBT as published data accumulated (Fig. 7).

The leave-one-out sensitivity analysis indicated that three studieswere the main source of heterogeneity (Fig. 8). Excluding these threestudies removed heterogeneity (χ2 = 4.19; p = 0.76; I2 = 0) and in-creased the pooled SMD (SMD, −0.83; CI, −1.08 to −0.58). After sen-sitivity analyses, for which a single study at a time was removed andthe remaining eight studies were analyzed, the pooled SMDs rangedfrom −1.17 to −0.49, indicating that the pooled estimate was robustand stable.

FIGURE 5. A Forest plot of meta-analysis of the subscales scores of PTSD avoi



Comparing the three studies removed in the sensitivity analysisto others, we observed that the study conducted by Rothbaum et al.(2005), which influenced the overall pooled estimates most, differedwith regard to gender and trauma type (all were female and had experi-enced sexual assault). To determine if treatment effects varied by gender,we performed a meta-regression analysis (50% as boundary) to assessheterogeneity. Data show that neither gender (adjusted p = 0.533) nortrauma type (adjusted p = 0.557) was a significant source of heteroge-neity between studies.

Subgroup analysis of variants of CBT (exposure alone, exposurecombined with cognitive restructuring and/or stress inoculation train-ing) showed no significant association among variants of CBT andthe pooled effect sizes (SMD, −0.32; CI, −0.96 to 0.32 and SMD, −0.57;CI, −1.15 to 0.01, respectively; see Fig. 9).

Publication BiasPublication bias was explored using funnel plots, Begg’s ad-

justed rank correlation test, and the Egger regression test. After testingtotal scores of PTSD symptoms from EMDR versus CBT, no evidencewas found of funnel plot asymmetry (Begg’s test continuity correctedz = 0.31, p = 0.76; Egger test t = 0.69, p = 0.51; Fig. 10), suggestingno publication bias between these studies.

DISCUSSIONIn summary, data show that EMDR is slightly superior to CBT

for treating adult PTSD. Because the significant difference is nearthe statistical margin (p = 0.05), more studies with larger samples, ran-dom controlled designs, and methodological rigor with respect theCONSORT standard (Schulz et al., 2010) are required to verify thisconclusion. Moreover, cultural difference comparisons would be in-teresting to include. We acknowledge that differences among national-ities might exist, but the numbers for any given country were too smallto analyze.

dance symptoms comparing EMDR group with CBT group.

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FIGURE 6. A Forest plot of meta-analysis of the subscales scores of PTSD arousal symptoms comparing EMDR group with CBT group.

FIGURE 7. A Forest plot of cumulative meta-analysis of the total scores of PTSD symptoms comparing EMDR group with CBT group.

FIGURE 8. A Forest plot of sensitivity analysis of the total scores of PTSD symptoms comparing EMDR group with CBT group.


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FIGURE 9. A Forest plot of subgroup analysis according to exposure alone (group 1) or exposure plus cognitive restructuring and/or stress inoculationtraining (group 2) of the total scores of PTSD symptoms comparing EMDR group with CBT group.

FIGURE 10. Begg’s funnel plot comparing EMDR group with CBT groupfor the total scores of PTSD symptoms with 95% confidence limits (CIs)of publication bias test.


In addition, evidence suggests that compared to CBT, EMDRmay be more effective for decreasing the severity of intrusion andarousal symptoms. Perhaps the working memory model proposed byEngelhard et al. (2011) which assumes that focusing on a distressingmemory while making eye movements can tax the working memorysystem during retrieval. Therefore, the intrusion of vividness and emo-tionality of the visual images is reduced (Elofsson et al., 2008;Engelhard et al., 2011). Other investigators (Grant and Threlfo, 2002)concluded that eye movements may activate the parasympathetic system,causing de-arousal.

Some advocates of CBT suggest that exposure has the greatestempirical support across different trauma populations (Zayfert andBecker, 2007), but others suggest exposure and cognitive restructuringis best. Still, PTSD is not eliminated by exposure alone because PTSDpatients also often present with additional problems that are obstaclesto exposure (intense anger/profound shame). We did not compare theefficacy of exposure and cognitive restructuring directly, and subgroupanalysis showed that neither exposure alone or with other forms ofCBTwas better than EMDR. That we studied 11 trials is a limitationfor this conclusion.

To our knowledge, Arabia’s group (Arabia et al., 2011), whoseparticipants were survivors of life-threatening cardiac events, andCapezzani’s group (Capezzani et al., 2013), whose participants werecancer patients, were the first to directly compare EMDR with CBT.The participants from both of the studies had trauma resulting frommedical illness, and both authors indicated that EMDR was signifi-cantly more effective than CBT in reducing PTSD symptom scores.The DSM-IV-TR criteria (APA, 2000, pp. 464) include “being diag-nosed with a life-threatening illness” as one example of a traumaticevent. Consequently, EMDR has been used effectively with patientssuffering from various diseases, including chronic pain (Grant andThrelfo, 2002; Schneider et al., 2008) and fibromyalgia (Friedberg,2004). Those examples suggest that PTSD associated with other med-ical issues (strokes/other major diseases) might be treated effectivelywith EMDR.



Our data should be interpreted with caution. First, the presentmeta-analysis included few studies and the risk of falsely rejecting thenull hypothesis (type I error) in the pool of effect sizes would be in-creased. Furthermore, many variants of CBTwere compared to EMDR.Even with subgroup analyses, the lack of homogeneity in the studiesconsidered to be CBT is a limitation. Also, study quality varied, andmost studies had small sample sizes. Some studies had methodological(or reporting) deficiencies (i.e., all patients in Capezzani et al. (2013)received their treatment from the same therapist; differences may haveresulted from differences in clinical skillwith nonspecific treatment var-iables). In general, as a recent JAMA meta-analysis of meta-analysisarticles (Dechartres et al., 2014)mentioned, estimation of treatment out-comes differed depending on the analytic strategy, our conclusionsshould be interpreted with caution because of the limited number andpoor quality of the original studies.

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DISCLOSURESThe authors declare no conflict of interest.

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