EMDR TREATMENT
OF PHOBIC
SYMPTOMS
IN MULTIPLE
PERSONALITY
DISORDER
Walter C. Young, M.D.
Walter C. Young, M.D., is Medical Director of the National
Treatment Center for Traumatic and Dissociative Disorders
at Del Amo Hospital, 23700 Camino del Sol, Torrance,
California 90505
For reprints write Walter C. Young, M.D., Medical Director,
National Treatment Center for Traumatic and Dissociative
Disorders, Del Amo Hospital, 23700 Camino del Sol,
Torrance, CA 90505.
ABSTRACT
Two multiple personality disorder patients with severe, persistent
phobias were treated usingEyeMovementDesensitization/Reprocessing
(EMDR). Both patients achieved significantly beneficial results with
a single session in one patient and two sessions in another. Each
patient confronted the previously phobic object successfully showing
an objective measure ofsuccess and results were maintained at six
months follow-up. Caution should be exercised from generalizing
the use ofEMDR for specific target symptoms to using it as a total
treatment technique. Further research is needed to determine the effi-
cacy ofEMDR as a treatment procedure in general and its role in
the overall treatment ofdissociative conditions.
INTRODUCTION
In recent years a new treatment technique known as Eye
Movement Desensitization/Reprocessing (EMDR) has
emerged following two reports of the successful treatment
of traumatic memories in brief therapeutic interventions
(Shapiro 1989a, 1989b) .Since that time additional and some-
times contradictory reports have been published regarding
the effectiveness of this technique. Despite some negative
reports, sufficient positive anecdotal literature and verbal
reports of treatment successes suggest the need for further
evaluation ofEMDRwith traumatic disorders. Due to the reg-
ular and extreme nature of traumatic reports by patients
with dissociative disorders, especially those with Multiple
PersonalityDisorder (MPD), a trial ofEMDRwas used in treat-
ing resistant phobic symptoms in two patients diagnosed
with MPD.
REVIEW
Shapiro (1989a, 1989b) originally described dramatic
change in 22 patients with PTSD symptoms. Results occurred
in one to two sessions which coupled imaging of the trau-
matic memory with saccadic eye movements guided by the
therapist. A control group narrated their traumatic memo-
ries and were subsequently treated with EMDR, with similar
results.
The mechanism ofEMDR is not understood, and all pos-
tulated hypotheses are admittedly speculative. For example,
the role of the eye movements has been compared to REM
sleep processing. Shapiro (in press) postulates accelerated
information processing (AlP) occurs that may be facilitated
by saccadic eye movements among other possible mecha-
nisms.
A number of clinicians have described favorable results
with EMDR. Page and Crino (1993) reported success in treat-
ing the victim ofan armed robbery. Pellicer (1993) described
its successful use in the recurrent nightmares of a ten-year-
old girl. Puk (1991) reported success in two patients. Wolpe
and Abrams (1991) used EMDR with traditional desensiti-
zation techniques and achieved good results. Marquis (1991)
used EMDR on 78 subjects, but their use ofa variety ofother
therapies makes the interpretation of the role of EMDR dif-
ficult. McCann (1992) successfully treated recurrent intru-
sive memories in a severe burn patient with bilateral above
the elbow amputations, deafness, and severe scarring.
Boudewyns, Stwertka, Hyer, Albrecht and Sperre (1993)
reported success when comparing EMDR to simple imaging
of the traumatic event. Wernick (1993) suggested that com-
bining EMDR with other techniques may be effective in sex
therapy. Spector and Huthwaite (1993) achieved relief in a
patient who had suffered a severe automobile accident.
On the other hand, others using EMDR have not repli-
cated such optimistic reports. Lipke and Botkin (1992) sug-
gested that positive results may require longer treatment
among veterans with chronic character pathology. This was
echoed by Boudewyns, Stwertke, Hyer, Albrecht, and Sperre
(1993), who compared positive verbal reports to more lim-
ited documented gains in situations where disability may
involve a secondarygain that overrides overall improvement.
They also questioned the role of placebo effects.
Pitman, Orr, Altman, Longpre, Poire, and Lasko (1993)
used a crossover design in 17 patients where patients main-
tained eye fixation, and failed to show that the eye move-
ments were essential. They found that global improvement
of PTSD in general did not occur. Lohr et al. (1992) criti-
cized methodologic flaws in Shapiro's study. Herbert and
Mueser (1992) also raise methodologic concerns including
a lack of baseline measures, and the use of subjective self-
assessment ratings. They also questioned whether Shapiro
129
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DISSOCL-\TIO:'\. \'01. \11. :'\0. 2.June 1994
EMDR TREATMENT OF PHOBIC SYMPTOMS IN MPD
,vas treating subjeCls with subclinical syndromes.
Metter and Michelson (1993) found no benefilS from
EMORand urged caution againstover-zealolls reporting. They
questioned whether the eye movements may SCIYC as a neg-
ative reinforcer leading subjects to report lowered distress
levels. They also suggest E~lDR may be related to sequence
disruption techniques described by O'Hanlon (1987). In
this regard fractionated abreaction facilil:aled by hypnosis
has been emplo)'ed by Klllfl (1988) and Fine (1991) to allow
patients to more easily move into and out oflraumatic mate-
rial to comain and control ahreactions. Lytle (1992) com-
pared EMDR to two control groups, one a non-cye mm"c-
mCIll dcscnsiLi7.3tion group, and lhe second a non-directi\·c
therapy control group, and found EMDR possibly the least
effective lechnique. Sanderson and Carpenter (1992) stud-
ied 58 subjects ..·:ith a crossover design. comparing EMDR
W1m imageconfronlation, encouraging imagingfora monlh
after treatmen LThey reparl no sign ifican Idifferences EMDR
in MPD in the procedures. Their sludy is SUbslalltially flawed
b)' a number of"ariances from standard EMDR applicalion.
The mosl significant was that EMDR "'as applied for only
seven sets of eye movements for twenty seconds each. This
is far less than would be given in EM DR trealment, and is nOI
sufficielll to obtain optimum benefits.
In mOSI of lhe studies, especially in those where nega-
ti"'e findings are reported, there are significant limilations
in methodology, making a truly accurale comparison very
difficult. Limitations include leng!h oftrealrnent, use ofancil-
lary Ireatments, and failure 10 use Ihe same measures ofOUI-
come. E"en with lhe variations in favorable reports, nega-
tive replications need to adhere to a standardized protocol
for the rcsuhs to have meaning.
In the present report both patients responded to treat-
ment by actually confronting the phobic situation thereby
objectively demonstrating a positive outcome, even though
the procedure itselfused the subjective measures in Shapiro's
reports (I989a, 1989b).
METHOD
As part ofa larger pilot study ofEl\lDR treatment in dis-
sociative disorders, tWO female dissociative disorder patients
reportingscvere phobias wcrc studied. Talking about under-
lying issues had not helped either patient reduce the targel
symptoms. The subjects were selected in part because their
phobic symptoms appeared somewhat isolated from the
bulk of their traumatic material and because their respons-
es could be assessed by their ability 10 address the phobic
stimuli in "h·o.
Each palienl's phobic symptom was used as Lhe larget
fortreaunenl, togetherwilh heraccompa.n}1ngfeelings. body
sensations, and the negative bcliefsstemmingfrom her fear.
A positive selfstatement (PSS) or belief"'as selected thai the
patielll wanted to beliC\'e. Informed conselH regarding the
procedure was obrained. The patients were then gh'en E..\1DR
treaunent according to Shapiro's protocol (1989a, 1989b)
and her rC\1sed prolocols (in press). A subjecti\'e unit ofdis--
tress scale (SUDS) (\Volpe. 1982) ....'as used 10 measure dis-
130
Iress where 0 was no distress and 10 was l..he maximum dis-
tress created when an imageofthe phobic event '....as recalled.
A validity of cognition (VOC) sC"dlc was used to assess the
patients' leVel ofconfidence thaI they could believe in their
PSS. The VOC scale rales the patient's confidence from one
(the patient has no confidence in Lhe PSS), to seven (the
patienl has lotal confidence he orshe beliC\'es or will beliC\'c
a new PSS). Belie..~ng the PSS is underslood to indicale Ihal
Ihe palient has replaced a negative beliefwith a positi..'e one.
SUDS and Voc measures were reponed at the beginning
and end of lhe EMI)R treaunent and illlcrmiuenlly in
bclwecn.
AIter initial assessmenl, each patient ....'aS asked to bring
to mind the target symptoms while the author instrucloo
the patient 10 track a moving finger or object with her eyes,
thereby initiating rh}'thmic saccadic eye movemelH. The
palients were instnlcted to lei images, thoughts, sensalions
or feelings occur. Periodically Ihe author paused to inquire
what was in the patient's mind. No interpretations were made
by Ihe aUlhorand the paticnl"''aS nOI asked to give an ongo-
ing narrath'e of Iheir her experience. The E~IOR sessions
lasled from one to one and one-halfhours. At the end, SUDS
and Voc levels were oblained and the pal.ient was debriefed
10 determine whatlhe procedure felt like. howil compared
to herstandard work. what problems there may have encoun-
lered, and an}' other observations she wished to make.
Before beginning, each patient ....'aS asked to assure !hat
she could maintain safety during the procedure. that her
alter personalities would not obstruct eye movements, and
that she would raise a hand to indicate ifshe wanted or need-
ed to stop the procedure.
CASE REPORTS
Patitmf #}
Ms. A isa 35-year-old single woman with a terrorofsnakes.
She hadjllrnped 011 people's backs when secinga snake. She
recalled a snake had been thrown on her when shewaseight
or nine years old. After cleven years of treatment and despite
irnprovclllelll. in other areas, this symptom remained still
refractory. Ms. A was seen in consultation lO address sever-
al issues, one of which was her se\'ere phobia ofsnakes. She
descrihcd feeling paraIYL.cd, and unable to breathe just pic-
turing a snake. I IeI' beliefwas that she was powerless 10 face
her fear and wished to believe she could feel in control and
feci safe around snakes. Her distress le\'eI (SUDS) was l<lled
al 10 and her confidence (VOC) she could stay in control
and be safe around snakes \\'as 2.
Ms. A "'as informed about the use of B·1DR and g<l\'e
conselll to the procedure. She ''''as asked 10 picmre herself
with a snake with Ille associated feelings of terror and help-
lessness. Her associations mo,'ed from exposure 10 snakes
as a child, being chased by a snake. and Lhen she reported
a new incestuous a'..~.trclless of her falller by stating, "My
falher has a snake - it's his penis!~ This was a new con-
nection. She continued during the session 10 feel a dramatic
reduclioll in her anxiety. She t...·enlually smiled and Slated
she was not afraid of snakes anymore. She reported a SUDS
mSSOCl\TIO\. ral. \lI. \O).!.J_l~
level of 0 and a vaG level of seven. Ms. A felt her process-
ing of this material was rapid and far superior to her tradi-
tional efforts.
The following day Ms. A went to a pet shop where she
handled a snake withoutanxiety. She remained asymptomatic
with respect to the snake phobia six months later.
In one session Ms. A patient had a dramatic outcome,
resulting in her seeking out the phobic object to test her-
self. She remained dissociative in those areas not addressed.
Patient #2
Mrs. B is a 39-year-old married mother of three children
who had been in treatmentfor Multiple Personality for seven
years. Her clinical course had been stormy. There were many
hospitalizations for suicide attempts, depression, severe
headaches, and self-induced injurious behavior consisting
mostly ofself-lacerations following pressure from hostile inner
states. There was a history of severe child abuse by father,
confirmed by her mother, and she had alleged multi-per-
petrator sadistic acts which could not be verified. These fac-
tors contributed to a tumultuous course in which intrusive
memories and disruptive symptoms often resulted in head-
banging behavior, abreactions, or self-destructive acting out.
Mrs. B was highly motivated. She was moving gradually
toward integration and had already experienced the fusion
of a number of personality states when EMDR was suggest-
ed. EMDR was proposed as a means of therapy that might
provide her a quicker and safer approach to working through
painful material. The patient agreed to try EMDR with two
symptoms of paralyzing phobic fear. Informed consent was
obtained after extensive explanation and discussion. The
patient had been requested to read Shapiro's original arti-
cles (1989a, 1989b) as part ofthis process.
Mrs. B described a fear ofmoths, especially in her home.
She would lose all emotional control, literally screaming and
running out of the room if a moth appeared. She recalled
having been molested by her father in the garage when she
was a child. She remembered moths flickering by an over-
head lightand occasionallydiving toward herwhile the assault
occurred. She would see them afterward when she was left
in the garage. Mrs. B believed that she was powerless to con-
trol moths, and lived in terror of them. She was further dis-
tressed that her daughter was also becoming frightened of
moths. Her second phobia was of seeing a full moon out-
doors. This irrationally frightened her, but to a lesser extent
than did the moths. She believed she would never enjoy a
moonlit night outside.
The patient rated her first phobia at a SUDS level of 10
with only a vaG level of two out of seven that she could con-
trol moths in her home. Her second phobic symptom ofsee-
ing a full moon had a SUDS level of eight and a vaG level of
three that she would enjoy moonlit nights safely.
The patient began EMDR with the moth fear for two ses-
sions, then decided to wait two months until moths were "in
season." Mter two sessions her SUDS level was only mildly
reduced (to eight) but she felt increasingly confident that
she could manage mothswithout becoming hysterical despite
her fear (VaG 5). Her associations moved from images of
her assault in the garage to moths in the night flying around
the light, and eventually to the spots on their wings that
reminded her of eyes looking at her. While she never overt-
ly switched during the procedure, she was aware of experi-
encing a variety of feelings (such as fear, guilt, and being
ugly and bad) which were affects associated with alter per-
sonalities she had encountered. The patient used part of a
third session to use EMDR on her fear of the moon. She
recalled the garage light had been suspended beneath a
white metal shield that diffused the lighting in the garage,
and that it had seemed moon-like to her. There were fur-
ther associations to moths under the light from the first two
sessions.
Treatment had to be suspended for several weeks when
Mrs. B was called out of town. When she returned, moths
were outin large numbers, and she requested EMDR to desen-
sitize herself to them. Halfway into this session Mrs. B sud-
denly exclaimed she was no longer afraid of the moon. She
had recalled an assault during a moonlit night in a field on
her childhood farm home. She felt dramatic relief and was
confident she could manage to be outside at night. Recall
of the target full moon was not distressing (SUDS 0) and her
confidence she was through the fear was high (VaG 6-7).
Further work on the target symptom of moths resulted in
only a modest reduction in fear (SUDS 8) but a vaG level of
6 that she could manage with moths.
The following week the patient announced proudly that
when she saw moths at home she had remained calm and
placed a flat dish of soapy water under a light on the table
as she had seen her mother do when she was a child. The
moths flitted about the light and its reflection, and would
bounce into the soapy water where they got stuck. Then she
threw them out. Due to other concerns, work proceeded in
another direction. Mrs. B commented she felt the proce-
dure was very helpful, much faster than our previous work,
and that somehow her work on the material treated with
EMDR seemed more finished than her work with other mem-
ories. She felt it was not like hypnotic work, and was pleased
it had not resulted in abreactions or destructive impulses.
She described an awareness of feeling states characteristic
of some of her other alter personalities giving her an
increased sense ofher own range ofreactions. Her work also
demonstrated a generalization effect when work with her
memory involving moths spilled over to a related memory
of the moon and relieved her distress there as well. While
her target symptom remained high for moths, she felt suc-
cessful with both fears. If further work had been attempted
she might well have lowered her SUDS level to moths. At six
months she continued to feel confident in her progress on
these two areas.
RESULTS
Both Ms. A and Mrs. B demonstrated rapid reduction
in distress levels that persisted at six months follow-up. The
second patient's distress over moths was reduced less, but
her confidence that she could take effective action resulted
in a sense of mastery with regard to the moths. She enjoyed
131
DISSOCLUIQ:\. \'01. \11. :\0. 2.June 1994
EMDR TREATMENT OF PHOBIC SYMPTOMS IN MPD
the additional benefit of her second phobic symptom (the
full moon) spontaneously dissipating rcmiuingduring treat-
ment for the first
Little narrative or interpretation was made by the author.
Still the patients improved. During the n.WR treatments
each patientreporlcd seeing material rapidly passing through
her mind that appeared related through associations to the
target symplOm. In Mrs. A there was an awareness of incest
and a teenage sexual assault. Mrs. B recalled the circular
spots on the moths' wings and the overhead light in her
garage where insects gathered as she recalled being molest~
ed. These and other associations were related to symptom
relief. This factor suggests thatimprovcment was nOlsimply
a matterofsystematic desensitization or the hierarchical order-
ing of anxiety producing elements. This more closely fits
Shapiro's (in press) concept that EM OR induces accelerat-
ed information processing (AlP). It further would seem to
contradict the thesis put forward by Metter and Michelson
(1993) that results occur secondary to sequence disruption
or negative reinforcement from the eye movements.
On the other hand this report does not establish that
the eye movements themselves constitutes the mechanism
bywhich AlP occurs (or, indeed, thatAJPoccurs). What does
seem clear is there was rapid relief of symptoms related to
reduced fears ofthe target phobias, and that this reliefoccurred
while traumatic materiafwas being internally processed. More
was occurring through simple desensitization or relaxation.
Both patients demonstrated early distress when focusing on
the target symptom initially; it was rapidly reduced as the
EMDR progressed.
It should be noted that the successful results claimed for
the patients relates to their phobic target symptoms alone.
No effort was made to measure global hmctioning in other
areas. Much of their clinical pictures deriving from chron-
ic traumatization needed ongoing work. Based on their suc-
cessful usc of EMDR for the symptoms under discussion it is
possible that their therapies may include the judicious use
ofadditional EMDR treatments in the future. Chronic trau-
ma patients may turn out to require more inteillention for
target symptoms than thesinglesession treatment ofepisodes
of trauma described in Shapiro's early work (1989a, 1989b).
In some, the impact of characterologic overlay or chronic
disability may impede the effectiveness of any therapeutic
efforts, includingL\ltDR, because ofthe secondarygain involved
(Boudewyns et al., 1993, Lipke & Botkin 1992). The poten-
tial for generalizing from relief ofaspecific trauma by EMDR
to relief of other traumatic materials has been suggested,
and may find support in Mrs. B's sudden relief of her fear
of the moon. The issues raised here will need further study.
DISCUSSION
While tllis report describes a positive outcome with EMDR
in twO patients with dissociative disorders, it isstill necessary
to be aware of the limitation of case reports in evaluating
EMDR and all psychotherapy in general. Adequate stan-
dardized, baseline assessments, follow-up assessments and
control studies are clearly indicated.
132
EMDR is still new. Both it.<; potential applications and the
cautionsand complications that may surface as it el"U0Yswider
usage need further study. The author is aware of potential
pitfalls in the us~ of El\IllK, such as premature nooding,
increased escalation of angry impulses, and the failure to
mobilize affect. He also is aware that its benefits need fur-
ther study if accurate assessment of EMDR is to occur, and
clear indications for the use ofEMDR are to bedefined. Further,
the role of the eye movement itself remains to be clarified.
A number of limitations in this case report study need
to be acknowledged. The two patients came to the author
expecting positive results despite low confidence levels. This
was partly due to an informed consent process duringwhich
Shapiro's articles were provided, partly because the author
was seen in consultation for this procedure (implying posi-
tive expecLtncy), and partly because these patients were on
an inpatient unit where other patienL~ had discussed posi-
tive results coming from another EM DR pilot study in
progress. Expectancy may prove to h,\\'c exerted a more
positive impact than did thc EMDR itself.
The potential for contamination by hypnosis is impor-
tant. Dissociative patients may bring their own autohypnot-
ic talents to bear, augmenting the impact ofthe EMDR. Recent
articles have described fractionated abreactions, usi ng a hyp-
notic technique ofmoving in and out of trance states to pace
the intensity ofabreactive work (Fine, 1991; KIuft, 1988). If
EMDR is, in fact, related to hypnotic processes, one would
expect to find highly positive response patterns in a highly
hypnotizable populations and poor responsitiviry in low hyp-
notizable populations. This has not been seen to be the case
in the author's experience with anecdotal reporL~ in which
EMDR outcomes are discussed. In this study, neitllCr patient
felt that the impact of the procedure was similar to formal
hypnosis. Theydid feel subjectivclythat information was pro-
cessed more quickly, more completely, and differently in
EMOR as compared to hypnosis.
Clearly, controlled studies are going to be required to
address many of the above concerns, and these studies will
need to address more than single symptom inteillentions.
They will also need to see whether EMDR as a major treat-
ment modality can demonstrably shorten treatment in
chronically traumatized individuals with dissociative condi-
tions, or whether EMOR, if shown to bc effective, can and
should be introduced at judicious, clinically defined points
in treatment. Controlled studies also need to study patients
treated with more traditional therapeutic int.en'cntions, EMOR,
and other "special" techniques designed to clarify the role
ofeye movement itself, in addition to the other factors that
confound treatment outcome. The use of raters other than
the treating clinician will be essential.
A current problem in evaluating reports on the efficacy
of EMDR relatcs to the variety of dHferent treatment proto-
cols that are being described by the term EMDR. Many of
these formats not only fail to adhere to Shapiro's (1989a,
I989b) protocol butoften are used in cOI"Uunction with other
treatment techniques. Baseline measures to standardize treat-
ment protocols, outcome, and provide consistent criteria
for positive results have to be applied in future study.
DlSSOCLI.T[O~, \'01. \11, ~o. 2,june 1994
Despite the present problems assessing the efficacy and
underlying mechanisms of EMDR, results to date suggest
enough clinicians are finding positive outcomes in theirwork
with this technique towarrantfurther study. The rapid response
to EMDR of the two dissociative patients reported here sup-
port the need for further study ofEMDR in dissociative pop-
ulations to see whether this modality can contribute to the
deve10pment ofan effective, less painful, and more controlled
and cost-efficient treatment technique for dissociative dis-
order patients. •
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D1SS0CLmo:\. Yol. m :\0. 2. June 1994