EMDR for treatment of anxiety disorders in a patient with intellectual disability - A case report
Description
Background:
Eye movement desensitization and reprocessing (EMDR) is a structured, eight-phase psychotherapeutic approach, developed to resolve symptoms resulting from disturbing and unprocessed life experiences. EMDR is well known for the treatment of Post-Traumatic Stress Disorder (PTSD). However, modified protocols have been developed for the treatment of other anxiety and mood disorders specially if rooted from a traumatic experience in the past. People with intellectual disability (ID) are more likely to suffer from adverse experiences in their lives and psychiatric consequences are common among them. In addition, they are more likely to have difficulty in verbal communication which is more important in other psychological interventions but less in EMDR. These all point out towards EMDR as a potential adds-on tool should it’s effectivity in this group of client is proven. Unfortunately there are only few but encouraging case reports about the use of EMDR in people with ID. In this manuscript, I report the successful use of EMDR for the treatment of PTSD and then Obsessive Compulsive Disorder (OCD) in a patient with moderate ID. Patient has given consent for reporting his case.
Case Presentation:
Mr. X is a 35 year old gentleman with moderate ID and long history of depression, anxiety and severe OCD. When I took over his care in August 2013, he was staying on a coach under a duvet for most of the day. He was unable to move around the house due to lengthy rituals when passing a door and each shower took five hours. He misused alcohol to be able to socialise and go to sleep. In return alcohol would make him more depressed, suicidal and occasionally aggressive toward others. He would respond partially to Fluoxetine 60mg but he was unable to tolerate that dose due to side effects. The initial assessment revealed presence of flash-backs and nightmare of a bullying event happened when Mr. X was 15. After building up a therapeutic rapport and motivating him to cut his alcohol use, he was considered a suitable candidate for EMDR. He received five sessions of EMDR from April to May 2014. During treatment the memory of bullying at age 15 was processed by standard 8-phase protocol and rapid eye movements. Flashbacks and nightmare disappeared during treatment. Quality of sleep, mood and general well being all improved. He stopped misusing alcohol and binge drinking as well but no significant change in the severity of OCD. His pre-treatment Hamilton Anxiety and Depression Scale* (HADS) were 14 (Depression) and 16 (Anxiety) and they dropped to 4 and 12 respectively after treatment. Given the encouraging response of PTSD to EMDR, it was agreed to give another sets of EMDR for his OCD and anxiety in due course. He continued to do well and improvement in his HADS score sustained. It was 4 (Depression) and 8 for anxiety in October 2014. OCD was still present. He scored 55 out of maximum of 72 and cut-off of 21 on Obsessive Compulsive Inventory _ Revised (OCI-R) scale which suggested severe OCD. His main problems were long shower, counting before doing certain functions, obsessive slowness and fear of contamination. He could not remember how the illness started. Mr. X received another 6 weekly session of EMDR between Oct 2014 and January 2015. During this treatment the touchstone memory was identified by float-back technique. He remembered for the first time that his illness started after a high fever and being sick when he was 10 years old. He felt for the first time in his delirious state that his face is dirty because of vomiting and he has to wash it constantly. His OCD remained with him after that however the presentations and rituals have changed slightly during years. An anxiety protocol was used and his touchstone memory, the worst memory, the current triggers and future template were processed by rapid eye movements. Mr X reported progressive improvement in his anxiety and rituals. He stopped counting from the third session and he was able to clean the house and cook at his kitchen at the end. The shower time reduced to two hours. HADS and OCI-R were repeated in January 2015. He scored 3 (Depression) and 7 (Anxiety) on HADS and 32 on OCI_R.
Discussion and recommendations:
EMDR seem to be a useful and effective adds-on method of treatment of psychiatric disorders in people with ID especially if the problem started after a traumatic experience. Relatively short duration of intervention, minimal reliance on the verbal abilities and absence of interaction with other psychiatric interventions could be considered as its advantages for using in this group of client. However, its effectivity still needs to be proven in controlled studies but nevertheless it could be a viable option in a case which has exhausted other pharmacological and psychological interventions. A proper assessment of suitability, building up therapeutic relation with patient and creativity in using the standard protocols to adapt to specific needs of patients with ID would improve the chance of a successful use. *0-7 (Normal), 8-10 (Borderline) and 11-21 (Abnormal)
Eye movement desensitization and reprocessing (EMDR) is a structured, eight-phase psychotherapeutic approach, developed to resolve symptoms resulting from disturbing and unprocessed life experiences. EMDR is well known for the treatment of Post-Traumatic Stress Disorder (PTSD). However, modified protocols have been developed for the treatment of other anxiety and mood disorders specially if rooted from a traumatic experience in the past. People with intellectual disability (ID) are more likely to suffer from adverse experiences in their lives and psychiatric consequences are common among them. In addition, they are more likely to have difficulty in verbal communication which is more important in other psychological interventions but less in EMDR. These all point out towards EMDR as a potential adds-on tool should it’s effectivity in this group of client is proven. Unfortunately there are only few but encouraging case reports about the use of EMDR in people with ID. In this manuscript, I report the successful use of EMDR for the treatment of PTSD and then Obsessive Compulsive Disorder (OCD) in a patient with moderate ID. Patient has given consent for reporting his case.
Case Presentation:
Mr. X is a 35 year old gentleman with moderate ID and long history of depression, anxiety and severe OCD. When I took over his care in August 2013, he was staying on a coach under a duvet for most of the day. He was unable to move around the house due to lengthy rituals when passing a door and each shower took five hours. He misused alcohol to be able to socialise and go to sleep. In return alcohol would make him more depressed, suicidal and occasionally aggressive toward others. He would respond partially to Fluoxetine 60mg but he was unable to tolerate that dose due to side effects. The initial assessment revealed presence of flash-backs and nightmare of a bullying event happened when Mr. X was 15. After building up a therapeutic rapport and motivating him to cut his alcohol use, he was considered a suitable candidate for EMDR. He received five sessions of EMDR from April to May 2014. During treatment the memory of bullying at age 15 was processed by standard 8-phase protocol and rapid eye movements. Flashbacks and nightmare disappeared during treatment. Quality of sleep, mood and general well being all improved. He stopped misusing alcohol and binge drinking as well but no significant change in the severity of OCD. His pre-treatment Hamilton Anxiety and Depression Scale* (HADS) were 14 (Depression) and 16 (Anxiety) and they dropped to 4 and 12 respectively after treatment. Given the encouraging response of PTSD to EMDR, it was agreed to give another sets of EMDR for his OCD and anxiety in due course. He continued to do well and improvement in his HADS score sustained. It was 4 (Depression) and 8 for anxiety in October 2014. OCD was still present. He scored 55 out of maximum of 72 and cut-off of 21 on Obsessive Compulsive Inventory _ Revised (OCI-R) scale which suggested severe OCD. His main problems were long shower, counting before doing certain functions, obsessive slowness and fear of contamination. He could not remember how the illness started. Mr. X received another 6 weekly session of EMDR between Oct 2014 and January 2015. During this treatment the touchstone memory was identified by float-back technique. He remembered for the first time that his illness started after a high fever and being sick when he was 10 years old. He felt for the first time in his delirious state that his face is dirty because of vomiting and he has to wash it constantly. His OCD remained with him after that however the presentations and rituals have changed slightly during years. An anxiety protocol was used and his touchstone memory, the worst memory, the current triggers and future template were processed by rapid eye movements. Mr X reported progressive improvement in his anxiety and rituals. He stopped counting from the third session and he was able to clean the house and cook at his kitchen at the end. The shower time reduced to two hours. HADS and OCI-R were repeated in January 2015. He scored 3 (Depression) and 7 (Anxiety) on HADS and 32 on OCI_R.
Discussion and recommendations:
EMDR seem to be a useful and effective adds-on method of treatment of psychiatric disorders in people with ID especially if the problem started after a traumatic experience. Relatively short duration of intervention, minimal reliance on the verbal abilities and absence of interaction with other psychiatric interventions could be considered as its advantages for using in this group of client. However, its effectivity still needs to be proven in controlled studies but nevertheless it could be a viable option in a case which has exhausted other pharmacological and psychological interventions. A proper assessment of suitability, building up therapeutic relation with patient and creativity in using the standard protocols to adapt to specific needs of patients with ID would improve the chance of a successful use. *0-7 (Normal), 8-10 (Borderline) and 11-21 (Abnormal)
Format
Conference
Language
English
Original Work Citation
Shaddel, F. (2015, May). EMDR for treatment of anxiety disorders in a patient with intellectual disability - A case report. Presentation at the Faculty of Intellectual Disability Psychiatry Spring Conference, Royal College of Psychiatrists, London, UK. doi:10.13140/RG.2.1.4713.0723
Citation
“EMDR for treatment of anxiety disorders in a patient with intellectual disability - A case report,” Francine Shapiro Library, accessed May 6, 2024, https://francineshapirolibrary.omeka.net/items/show/24444.