# data[].attributes.headline
Podcast Interview with Dr. Mariel Buqué about Intergenerational Trauma

# data[].attributes.subject
Podcast Interview with Dr. Mariel Buqué about Intergenerational Trauma

# data[].attributes.body
Dr. Mariel Buqué is a first-generation Black Dominican psychologist, an intergenerational trauma expert, and author of "Break the Cycle: A Guide to Healing Intergenerational Trauma."

# data[].attributes.attachment_link.title
How to Break Family Cycles: Dr. Mariel Buqué

# data[].attributes.attachment_link.description
Podcast Episode · We Can Do Hard Things · 09/17/2024 · 1h 8m

# data[].attributes.headline
PTSD and the Developing Adolescent Brain

# data[].attributes.subject
PTSD and the Developing Adolescent Brain

# data[].attributes.body
The effects of trauma on adolescent brains show an increase in amygdala activity, yet there is a lack of research on the biological effects specifically on the adolescent brain. Most models for treating PTSD in adolescents rely on research on the effect in adult brains. In the face of this paucity of research, this study proposes a biopsychosocial model of adolescent PTSD. This model considers vulnerability factors, the trauma, and the biological factors and how they influence the functional domains of adolescents. It emphasizes the contributing factors of caregiver and peer influence on the perception of the trauma, and therefore, the biological effects. Rather than proposing a finished model, the study posits that treatments for PTSD for adolescents need to be developed for their age group and identifies domains that should be targeted for research.

# data[].attributes.attachment_link.readable_text
. Author manuscript; available in PMC: 2022 Jan 15.

Abstract

PTSD in adolescents is common and debilitating. In contrast to adult PTSD, relatively little is known about the neurobiology of adolescent PTSD, nor how current treatments may alter adolescent neurodevelopment to allow recovery from PTSD. Improving our understanding of biological mechanisms of adolescent PTSD, taken in the context of neurodevelopment, is crucial for developing novel and personalized treatment approaches. In this review, we highlight prevailing constructs of PTSD and current findings on these domains in adolescent PTSD. Notably, little data exist in adolescent PTSD for prominent adult PTSD constructs, including threat learning and attentional threat bias. Most work to date has examined general threat processing, emotion regulation, and their neural substrates. These studies suggest that adolescent PTSD, while phenomenologically similar to adult PTSD, shows unique neurodevelopmental substrates which may impair recovery, but could also be targeted in the context of adolescent neuroplasticity to improve outcomes. Both cross-sectional and longitudinal data suggest abnormal frontolimbic development compared to typically developing youth, a pattern which may differ from resilient youth. Whether current treatments such as trauma-focused psychotherapy engage these targets and restore healthy neurodevelopment remains an open question. We end our review by highlighting emerging areas and knowledge gaps that could be addressed to better characterize the biology underlying adolescent PTSD. Emerging studies in computational modeling of decision making, caregiver-related transmission of traumatic stress, and other areas may offer new targets which could harness adolescent neurobehavioral plasticity to improve resilience and recovery for some of our most vulnerable youth.

Keywords: trauma, PTSD, neurodevelopment, adolescence, neuroimaging, resilience

Introduction

Approximately two-thirds of youth are exposed to trauma by late adolescence, and many develop PTSD as a result ( 1). By age 18, 8% of traumatized youth have met criteria for a diagnosis of PTSD, with numbers rising up to 40% in cases of sexual abuse and assault ( 1). In addition to the psychological suffering imposed, PTSD is associated with lower academic achievement and high rates of comorbidity including anxiety and depressive disorders ( 2). Strikingly, PTSD carries the highest risk of all mental illnesses for first suicide attempt in adolescents and young adults ( 3). Childhood trauma and PTSD also impart tremendous societal cost in terms of health care utilization and financial outlay, costing the United States an estimated $2 trillion annually ( 4, 5). Current treatments for adolescent PTSD, which rely primarily on trauma-focused cognitive therapy, achieve only small to moderate effect sizes ( 6, 7), leaving many youth unrecovered even if they are able to access skilled therapists. Remarkably, there are currently no evidence-based pharmacological options for treating adolescent PTSD. While the aforementioned therapies target presumed domains of dysfunction in adolescent PTSD, advancing our neurobiological understanding of the illness will be critical for tailoring current treatments and developing novel interventions for affected adolescents.

In this review, we aim to summarize our current understanding of the neurodevelopmental substrates of adolescent PTSD. However, PTSD is not a biological construct in and of itself. Thus, dysfunction is best understood across a constellation of cognitive, emotional, and biological systems. Accordingly, we focus the review on neurodevelopment in systems most commonly implicated in PTSD (e.g., emotion regulation). We also discuss emerging areas of study, including large-scale neural network approaches, computational modeling of decision making and caregiver transmission of traumatic stress. Finally, we consider how findings in these domains may inform the prevention and treatment of adolescent PTSD. We also refer readers to Supplement, which contains expanded discussion of prominent constructs and emerging areas implicated in adolescent PTSD.

Developmental considerations: Adolescence as a period of biological change and reorganization

Adolescence is characterized by dramatic changes in physiological and neuroendocrine systems, along with reorganization of neural systems subserving executive function, socioemotional processing, and emotion regulation. A more complete discussion of normative physiological change can be found elsewhere in this special issue ( 8). Pubertal onset is known to be associated with altered sensitivity of subcortical regions, notably the amygdala and striatum, to emotional stimuli albeit with mixed findings ( 9, 10). This, coupled with the more prolonged development of frontoparietal regions involved in cognitive control and emotion regulation, is thought to underlie, in part, the rapid increase in affective disorders in adolescence ( 11). PTSD is no exception, in that it shows a marked increase in prevalence through adolescence ( 12). However, this has been difficult to separate from the concomitant increase in trauma exposure in adolescence ( 1, 13), which may itself be driven in part by social reorienting to peers and increased social risk taking [see this issue ( 8, 14)]. Sex hormones also influence the development of circuitry underlying cognitive-emotional interactions, though in nuanced ways ( 15, 16), and which may contribute to the characteristic greater PTSD prevalence (2-3 fold) in adolescent females compared to males. As we explore neurodevelopmental substrates implicated in adolescent PTSD, we attempt to incorporate both age and pubertal influences on these systems in ways that may heighten PTSD risk, contribute to sex differences, and impact potential treatment response for adolescent PTSD.

Neural correlates of PTSD in adolescents

In this section, we briefly summarize neuroimaging findings in adolescent PTSD with an emphasis on neurodevelopment in emotion processing circuitry. However, an important question remaining in the field is whether these alterations represent transdiagnostic risk mechanisms for trauma-induced psychopathology, or whether certain neural substrates are specific to adolescent PTSD. We refer readers to recent reviews on this topic ( 17- 19). While we focus here mainly on univariate investigations of brain function, recent studies have begun characterizing network-level alterations in pediatric PTSD (see Supplement).

The prefrontal cortex, amygdala, and hippocampus are implicated in numerous cognitive processes, but in the context of trauma and PTSD have largely been investigated with respect to constructs of threat learning and extinction, threat reactivity, and emotion regulation (see Supplement). As noted above, relative delays in prefrontal versus subcortical maturation ( 20, 21) are thought to underlie, in part, the tendency for increased emotional reactivity in adolescence. Structural studies show relatively early maturation of amygdala and hippocampus which nonetheless continue into adolescence ( 21, 22). However, prefrontal cortical regions show structural maturation well into adolescence and early adulthood, characterized by cortical thinning ( 20). Accordingly, functional imaging studies show that amygdala reactivity to negative faces and images decreases with age in adolescence ( 23- 27), and is accompanied by greater structural and functional connectivity with the medial prefrontal cortex (mPFC) in particular ( 23, 24, 27). These normative patterns likely underlie, in part, decreased reactivity to negative content and enhanced emotion-regulation capacity through adolescence ( 17). Notably, these neurodevelopmental patterns are embedded in the larger process of adolescent brain remodeling characterized by changes in association, limbic, and subcortical circuits subserving higher order processes (e.g., executive function, social cognition, and mentalizing) ( 28, 29).

Structural brain studies most consistently show reduced gray matter volume in the ventromedial (vm)PFC, and either reduced or age-related decline in hippocampal volume in adolescent PTSD ( 30, 31). In contrast, traumatized adolescents without PTSD show increased hippocampal volume and maintained vmPFC volume ( 32). In a longitudinal extension of our prior work, we examined structural brain development over one year in adolescents with PTSD compared to typically developing (TD) adolescents. Here, we found stable reductions in vmPFC and ventrolateral (vl)PFC volume in adolescent PTSD ( 33). The vmPFC has diverse functions, and in the context of PTSD, is notable for its role in stimulus valuation and inhibition of threat responses and amygdala reactivity ( 34). The vlPFC has also been heavily implicated in emotion regulation through its role in attentional control, response inhibition, and emotion perception ( 35- 37), and has direct anatomical connections to the amygdala ( 38). Notably, reduced volume in both vmPFC and vlPFC were associated with greater symptom severity in adolescents with PTSD. Finally, we found evidence of abnormal development in the dorsolateral (dl)PFC, characterized by a normative decrease in volume in TD youth, but absence of decline in adolescents with PTSD. Given the role of the dlPFC in emotion regulation and particularly reappraisal ( 37, 39), the lack of dlPFC volume change could represent delayed development contributing to the persistence of PTSD. Alternatively, absent dlPFC volume change could serve to maintain plasticity in this key regulatory region while illness is ongoing. Further studies will be needed to better understand the functional and behavioral correlates of abnormal gray matter structure and development in adolescent PTSD, and whether such patterns differ by sex and pubertal stage.

In functional brain studies in adolescent trauma and PTSD, most work has focused on general threat processing and reactivity, with some additional study under resting state conditions. As noted in prior reviews ( 17, 40, 41), childhood trauma and adversity are broadly associated with increased amygdala reactivity to negative stimuli and decreased resting functional coupling between the amygdala, hippocampus and vmPFC irrespective of PTSD status ( 42, 43). Such changes may serve an adaptive response allowing, for example, enhanced threat detection and learning ( 17). Conversely, maintained or enhanced coupling between the amygdala and dorsal/lateral prefrontal regions involved in emotional appraisal and regulation may be an important factor for resilience in trauma-exposed adolescents ( 44, 45). Supporting this notion, childhood trauma is associated with increased prefrontal recruitment and amygdala-prefrontal coupling during emotion regulation in healthy adolescents or when adjusting for affective symptoms ( 44, 46- 49). In contrast, adolescents with PTSD show reduced prefrontal engagement, as well as reduced coupling between regulatory prefrontal regions (vlPFC, dorsomedial [dm]PFC) and amygdala ( 17).

Importantly, adolescence may be a key period determining risk and resilience trajectories of prefrontal-amygdala and -hippocampal development. In our prior work, we identified age-related abnormalities in prefrontal-amygdala function in adolescent PTSD. Specifically, while TD adolescents exhibit decreased amygdala reactivity and increased amygdala-vmPFC coupling to emotional stimuli with age, adolescents with PTSD show the reverse pattern ( 17), exhibiting a neural profile similar to adult PTSD by late adolescence. Our recent longitudinal extension further supports the notion of abnormal prefrontal-amygdala and -hippocampal development in adolescent PTSD. Specifically, while TD adolescents show increased connectivity between vmPFC-amygdala, vlPFC-amygdala, and dlPFC-hippocampus over one year, adolescents with PTSD show the reverse pattern and independent of pubertal stage ( 33).

Declining dlPFC-hippocampus connectivity was further associated with greater symptom severity, suggesting that ongoing disruptions in prefrontal-amygdala and -hippocampal development may contribute to persistence or worsening of PTSD in adolescence. We next discuss how these circuits may be involved in treatment and remission in adolescent PTSD.

Longitudinal imaging studies examining treatment and remission of adolescent PTSD

To date, few studies have examined the neural correlates of treatment intervention or remission in adolescent PTSD. In a preliminary study of TF-CBT in adolescent girls with PTSD (N=23), we found that more differential activation of the amygdala to threat vs. neutral faces pre-treatment predicted greater symptom reduction over a 12-week course of TF-CBT ( 50). Additionally, this study showed that pre- to post-treatment change in suppression during reappraisal of negative images was associated with symptom reduction ( 51). While this study lacked a comparison group, these initial findings suggest that enhanced neural differentiation of threat-neutral content prior to treatment may allow for greater use of TF-CBT skills including trauma narrative exposure, while functioning in this network itself may be a potential target of TF-CBT.

A more recent study examined the impact of TF-CBT on neural function in adolescents with PTSD relative to TD adolescents (N=40) at baseline and post-treatment (5 months). Using a face processing task, only the posterior cingulate/precuneus showed a group by time effect using whole-brain analysis. Here, independent of face emotion, youth with PTSD showed reduced activation over the treatment course, which further correlated with symptom reduction ( 52). In ROI-based analyses, youth with PTSD also showed reductions over time in hippocampus, amygdala, midcingulate cortex (MCC), dmPFC, and vlPFC activation to neutral faces relative to TD adolescents. Of these, change in hippocampus and MCC activation were associated with total PTSD symptom reduction. While this study lacked a PTSD treatment comparison group, these findings suggest that symptom improvement in adolescents with PTSD may be mediated in part by reduced engagement of prefrontal-amygdala and -hippocampal circuitry to neutral faces, potentially enhancing threat discrimination.

Finally, we recently reported structural brain correlates of persistence and remission of adolescent PTSD in a naturalistic longitudinal study ( 53). Here, we examined cortical morphometry and subcortical volume change in adolescents with persistent or remitted PTSD at one year relative to TD adolescents (N=55). Adolescents with persistent PTSD showed contraction of vlPFC surface area compared to both remitters and TD. In contrast, PTSD remission was associated with expansion of frontal pole surface area and vmPFC thickness over time. Across clinical groups, vmPFC thickness was inversely associated with symptom severity. While limited in sample size, these findings suggest that structural plasticity, particularly in prefrontal regions involved in emotion regulation, may be responsible for PTSD recovery in adolescents. The frontal pole and vmPFC are notable given findings in a controlled study in adult PTSD demonstrating that prolonged exposure enhanced frontopolar activation and connectivity with the vmPFC during cognitive reappraisal, which were further associated with symptom improvement ( 54). However, to more precisely define treatment and recovery substrates in adolescent PTSD, future neuroimaging clinical trials are warranted incorporating an expanded sample size, multimodal imaging, and a treatment control arm to determine treatment-specific biomarkers.

Trauma sensitive periods, stress acceleration, and implications for adolescent PTSD

At present, little is known about developmental trauma sensitive periods in risk for adolescent PTSD, nor how childhood trauma may alter the pace of brain maturation to confer such risk. This area is also confounded with increasing trauma load as youth age, leaving an open question of whether to interpret any differences as trauma sensitive periods or cumulative stress effects. However, neuroimaging studies of trauma exposure and adolescent PTSD offer potential clues to differential brain maturation with trauma and PTSD. In our prior cross-sectional work, youth with PTSD paradoxically show lower amygdala reactivity, greater dmPFC activation, and greater amygdala-vmPFC connectivity at younger ages (<15 years), a pattern which appears to reverse by late adolescence and independent of age at index trauma, PTSD duration, or pubertal stage ( 26, 55). A retrospective study in adults also found that preadolescent abuse was associated with blunting of amygdala reactivity, while adolescent abuse was associated with increased amygdala reactivity ( 56). Additionally, studies of youth exposed to environmental adversity suggest accelerated functional brain maturation including prefrontal-amygdala connectivity ( 57, 58). These findings suggest a potential stress acceleration in the development of circuitry supporting socioemotional processing and regulation ( 18). We have speculated that such compensatory neurodevelopment may be degraded by adolescence in vulnerable youth with additional trauma exposure ( 17). While further study is clearly needed to map neurodevelopmental responses to trauma and risk for adolescent PTSD, these findings raise the intriguing possibility of unique biotypes of adolescent PTSD dependent on trauma characteristics ( 19) including age of trauma exposure, cumulative stress effects, type of trauma exposure, as well as early stress acceleration responses which may alter the development of socioemotional regulatory systems.

A biopsychosocial model of adolescent PTSD: Emerging directions

The current review is by no means exhaustive, but hopefully highlights three main observations. First, there is a general lack of research specifically conducted in adolescent PTSD and an overreliance on models and findings derived from the adult PTSD literature (see Supplement). Second, most biological studies of adolescent PTSD have not been placed in the normative context of adolescent neurodevelopment, which is particularly important given the enhanced neuroplasticity characteristic of this period. Third, PTSD likely impacts multiple functional domains, yet most studies to date have focused on general threat processing and emotion regulation (see Supplement for additional constructs). The specific functional domains affected are likely to be different for each individual, underscoring the fact that PTSD itself is not a unitary or biological construct.

In Figure 1, we propose a working model of adolescent PTSD that incorporates multiple socioenvironmental influences, mediating biological systems, and functional domains relevant for understanding and treating adolescent PTSD, though it is by no means an exhaustive model. Consistent with dimensional approaches to psychopathology, we purposefully leave out a final pathway towards a diagnostic construct. Instead, we suggest that the impact of trauma and PTSD on these functional domains could be more informative for elucidating the neurobiology of adolescent PTSD and generating precision medicine approaches. In this model, known vulnerability factors such as genetic variation, low social support, female sex, or pre-existing internalizing symptoms interact (along with the type and severity of trauma) to influence an adolescent's perception of a traumatic event ( 59, 60). Further, interactive influences come from responses and modeling of caregivers (and peers) which may ameliorate or worsen an adolescent's perception of trauma. Perceived trauma may then activate multiple biological systems involved in the stress response including release of cortisol and proinflammatory cytokines ( 61), altered sleep function ( 62), and coincident epigenetic changes ( 63) that may further the stress response. Activation of these biological pathways, in turn, can negatively impact neural function and development of systems underlying emotion regulation ( 17), reward processing ( 64), learning and decision making ( 14, 64), and social cognition ( 65). Functional compromise in these domains, such as heightened threat reactivity, reduced emotion regulation and reward learning, poor extinction learning, and misinterpretation of social information may subsequently exacerbate perceived trauma/stress and negatively impact the caregiver relationship or caregiver modeling in a vicious cycle. By the same token, maintained functioning in these domains and caregiver/peer influence could serve to ameliorate the adolescent's trauma perception and hasten recovery in biological systems. We again refer readers to Supplement for expanded discussion of biological systems and functional domains implicated in the above model. While most of these sociobiological systems and functional domains have received limited or no study in adolescent PTSD, below we highlight emerging research which could offer fruitful targets for intervention and improving outcomes for adolescent PTSD.

Figure 1 :

Psychosocial and biological model linking early life trauma exposure to multiple systems and functional domains likely contributing to risk or resilience for adolescent PTSD. Pre-trauma factors such as genetic loading and social support (far left) moderate the impact of trauma (i.e. perceived trauma) on youth. In the peritraumatic period, caregiver (as well as peer) responses and emotional modeling further influence adolescent perception of the trauma and sense of safety in a reciprocal manner. The cumulative or ongoing perceived threat may then impact multiple biological systems in youth, which in turn impact neurodevelopmental processes involving multiple functional domains (far right). In an iterative feedback loop, changes in functional domains may ameliorate or exacerbate biological stress response systems such as sleep biology or inflammation, as well as caregiver and adolescent perceived threat and emotion regulation. This feedback loop may again ameliorate or exacerbate changes in biological stress response systems. With exception of emotion regulation, most of the biological systems and functional domains listed have received little study in adolescent PTSD.

Learning and decision making

Adolescence is characterized by changes in learning and decision making that may have important implications for understanding adolescent PTSD [this issue ( 14, 66)], such as increased risky decision-making during social or emotional contexts ( 67, 68). The burgeoning field of computational psychiatry may shed light on important mechanisms of learning and decision-making in early life trauma and adolescent PTSD. In contrast to standard laboratory tasks that present stimuli to which participants can only react and not interact (e.g., emotional face viewing), modeling 1) how individuals make decisions about when, whether, and how to pursue reward and avoid threat, and 2) how individuals learn from experience to update expectations about reward and threat, may provide a more realistic laboratory paradigm for understanding the development and treatment of PTSD. Mathematical modeling of decision-making during these tasks formalizes cognitive hypotheses about behavior that can be explicitly quantified and tested against alternative models. As a recent example, we demonstrated that increased trauma load in adolescent girls was associated with impaired reward learning performance, greater variability in action selection, and decreased encoding of negative reward prediction errors in the salience network during decision-making ( 69, 70). In adult PTSD, recent computational modeling work ( 71, 72) suggests that increased PTSD severity is related to heightened encoding of associability [a dynamic learning rate reflecting increased attentional salience in response to volatility in the learning context ( 73)] in the anterior insula, ventral striatum, and amygdala. It is not currently clear how this modeling work interacts with normative neurodevelopment occurring during adolescence and if similar results would be expected in adolescent PTSD. An additional domain that will be important to characterize is how adolescents with PTSD make decisions about reward in the context of threat [approach-avoidance conflict learning ( 74)]. Specifically, the mechanisms by which adolescents prioritize sacrificing reward (e.g., peer interaction) for the sake of avoiding potential threat/trauma reminders presumably involves a complex interaction between higher-order goals and beliefs, valuations of reward, and expectations for threat. Relatedly, how adolescents incorporate signals from caregivers (or peers, see also below) in their decision-making will be important for fully characterizing the mechanisms underlying development and maintenance of adolescent PTSD.

Additionally, whereas most prior work has utilized relatively simplistic models of learning (e.g., Rescorla-Wagner models), emerging work in computational neuroscience emphasizes model-based decision-making strategies ( 75- 78), in which individuals form abstract cognitive maps of a learning environment to inform prospective decision-making. Particularly relevant for treatment of PTSD with exposure therapy, classic model-free conceptualizations (e.g., Rescorla-Wagner models) do not explain return of fear following extinction ( 75, 79- 81). However, model-based theories readily explain this phenomenon and thereby implicate higher-order learning mechanisms (e.g., frontoparietal network) in threat extinction and exposure therapy. Incorporating model-based decision-making approaches into future research in adolescent PTSD may provide better characterization of nuanced biases in decision-making with potential for rapid clinical translation in this population.

Caregiver transmission of traumatic stress

Caregiver transmission of traumatic stress to the child involves both behaviorally modeled and genetic influences. Regarding modeling, caregivers are a vital source of information on numerous domains including social cognition, emotion regulation, and threat-safety discrimination. Thus, caregiver function and modeling are likely to have a major impact on PTSD risk in adolescents. For example, parental anxiety has direct environmental transmission to their adolescent offspring ( 82), which can be mitigated by parent coaching ( 83). Parental anxious rearing also mediates the effects of stressful life events on youth anxiety through early adolescence ( 84). More specific to PTSD, parental PTSD is associated with child distress and behavior problems and altered HPA axis functioning, particularly when both parent and child have been exposed to interpersonal violence ( 85, 86). Furthermore, maternal emotion dysregulation increases risk for child PTSD symptoms ( 87), while lower levels of parent distress and PTSD following a child's trauma predict more favorable outcomes for the child ( 88). Finally, in TF-CBT, which incorporates both caregiver and child, improvements in parent distress and symptomatology mediate broad improvements in internalizing and externalizing symptoms in youth with PTSD ( 89, 90). While an early area of research, these studies suggest that caregiver modeling is likely to have a significant impact on shaping adolescent development of processes including emotion regulation and threat-safety discrimination to influence both risk for and progression of PTSD in adolescents. However, to date studies have focused primarily on correlation of caregiver-child subjective reports using cross-sectional designs. While admittedly a complex area of study, our understanding of caregiver modeling and PTSD risk in adolescence could be enhanced through longitudinal designs incorporating bidirectional influence of caregiver and child function (following prior literature examining caregiver-child interactions), and utilizing more objective measures of these functional domains to assess caregiver influence on disease course in adolescent PTSD. For example, studies could test how well psychophysiological measures of caregiver emotion regulation or threat-safety discrimination "transfer" to their adolescent, and whether these processes are maladaptive in the context of caregiver and/or child psychopathology. Finally, genetic transmission of traumatic stress has gained increasing recognition, with studies demonstrating epigenetic alterations particularly in child cortisol and glucocorticoid pathways beginning prenatally ( 91). Thus, future studies would ideally capture both parental modeling as well as genetic pathways to more fully understand intergenerational transmission of traumatic stress and risk for PTSD in adolescence.

Implications for intervention

Altogether, the studies and models posited above point to an urgent need to better understand the underlying neurobiology of adolescent PTSD and translate such knowledge into neuroscience-guided treatments. With extant studies, there are already a number of salient points regarding treatment implications for adolescent PTSD. First, neurobiological studies indicate that adolescent PTSD is not simply a recapitulation of adult PTSD - there are underlying neurodevelopmental processes such as reduced threat extinction, altered risk tolerance, and decision making that need to be considered in tailoring treatment for adolescents with PTSD. Treatments may therefore need to be properly tailored for adolescents by, for example, increasing or augmenting the number of exposure sessions in psychotherapy, increasing focus on emotion regulation capacity (e.g. CBT, mindfulness), and more explicitly incorporating peer support in treatment to enhance perceived social support. Second, PTSD itself is not a biological or unitary construct. Interventions therefore need to consider actual domains of dysfunction rather than trying to target a syndrome. Ideally, we would clinically profile an adolescent in every system/domain shown in Figure 1 and target those areas accordingly. This could mean, for example, specifically targeting the inflammatory response, augmenting sleep, and improving decision making abilities for a given youth. Third, neuroimaging studies have identified key circuits, notably the dlPFC, that could be targeted in neuromodulation trials to determine whether augmenting this circuit can improve clinical outcomes. Fourth, studies to date suggest that while adolescents with PTSD show a pernicious neurodevelopmental trajectory, they also remain in a window of increased neuroplasticity. Future trials would be warranted to examine the developmental period of intervention (e.g. early vs. late adolescence vs. adult) to determine unique developmental influences and guide treatment tailoring and policy. Fifth, and of no surprise to clinicians treating adolescents, the socioenvironmental context needs to be more fully considered in adolescent PTSD. Caregivers are key in this equation even for adolescents. Studies suggest that parenting behaviors are an important predictor of adolescent PTSD following trauma ( 92), while caregiver depression moderates psychotherapy outcomes for both adolescent depression and PTSD ( 93, 94). Social support also appears to reduce the effect that adversity has on neural indices of threat processing and emotion regulation in youth ( 95), suggesting that interventions targeting the family system could have both behavioral and neurodevelopment benefits for adolescents suffering from PTSD.

Conclusion

In summary, adolescent PTSD remains a complicated disorder affecting many adolescents and portends poor outcomes well into adulthood. Mitigating the effects of trauma and PTSD in adolescents will require further investment in longitudinal, neurobiological research assessing multiple functional domains. Given the inherent difficulties in recruiting and studying trauma-exposed youth, our field would benefit from a consortium-based approach to expand sample sizes needed to more fully address trauma heterogeneity, neurodevelopmental patterns of risk and resilience, and sensitive periods for both trauma impact and intervention. Such an effort is currently underway ( 41) and, coupled with individual research programs, promises to accelerate discovery and treatment for some of our most vulnerable youth.

Supplementary Material

Acknowledgements and financial disclosures

Dr. Herringa's research is supported by the National Institute of Mental Health R01MH117141 and R01MH115910. Prior funding for work described here also comes from the NIMH (K08MH100267), the American Academy of Child & Adolescent Psychiatry, the Brain and Behavior Research Foundation, and the University of Wisconsin Institute for Clinical and Translational Research (NIH/NCATS UL1TR000427). Dr. Cisler's research is supported by NIMH grants MH119132 and MH108753.

Footnotes

The authors report no biomedical financial interests or potential conflicts of interest.

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

References

8. Pfeifer JH (n.d.): Social development, brain development, and psychopathology in adolescence. Biological Psychiatry. [Google Scholar]

14. Somerville LH (n.d.): Risk-taking and the adolescent brain. Biological Psychiatry. [Google Scholar]

64. Stringaris A (n.d.): Reward processing and adolescent depression. Biological Psychiatry. [Google Scholar]

66. Blakemore S-J (n.d.): Cognition and adolescent brain development. Biological Psychiatry. [Google Scholar]

Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials

# data[].attributes.attachment_link.title
Posttraumatic stress disorder and the developing adolescent brain

# data[].attributes.attachment_link.description
PTSD in adolescents is common and debilitating. In contrast to adult PTSD, relatively little is known about the neurobiology of adolescent PTSD, nor how current treatments may alter adolescent neurodevelopment to allow recovery from PTSD. Improving ...

# data[].attributes.headline
Adverse Childhood Experience (ACE) Study 

# data[].attributes.subject
Adverse Childhood Experience (ACE) Study 

# data[].attributes.body
This infographic is from the CDC website, which has many resources on the ACE study.

# data[].attributes.body
This is the ACE study quiz, which is used to determine one's ACE score.

# data[].attributes.body
This fact sheet provides information on what is childhood neglect, how it impacts children, how to determine if a child is experiencing neglect, how providers can respond and support children experiencing neglect as well as their caregivers, and a few resources to find out more.

# data[].attributes.headline
How Childhood Trauma Affects Health Across a Lifetime

# data[].attributes.subject
How Childhood Trauma Affects Health Across a Lifetime

# data[].attributes.attachment_link.title
How childhood trauma affects health across a lifetime | Nadine Burke Harris | TED

# data[].attributes.headline
Photos of a Typical Developing Brain Versus the Brain of a Child Exposed to Trauma

# data[].attributes.subject
Photos of a Typical Developing Brain Versus the Brain of a Child Exposed to Trauma

# data[].attributes.attachment_link.readable_text
This can leave the child feeling unsafe, fearful, irritated, and extremely sensitive to small everyday things such as a slightly raised voice or a classroom move. They may feel numb or not in contact with the here and now, they may redouble efforts to keep themselves feeling safe by anticipating and meeting the perceived needs of important people around them.

As well as causing elevated stress responses, trauma can also change the way the prefrontal cortex (aka 'the thinking centre') functions. This can make it more difficult to concentrate, make decisions and process new information. Similarly, brains which have adapted to danger may function differently in the anterior cingulate cortex (aka 'the emotional regulation centre'), so managing strong emotions can be challenging.

Studies have also shown that trauma can impact the hippocampus - a vital part of the brain that stores and retrieves memories, as well as distinguishes between past and present events. Therefore, traumatic memories can replay in a child's mind and seem like the threat is current, even if the memory happened in the past and the child is safer now. Triggers for these memories could be anything from a sound, smell, environment or situation to an image, movement, facial expression or touch.

# data[].attributes.attachment_link.title
How Trauma Affects Child Brain Development | ISP Fostering

# data[].attributes.attachment_link.description
Sadly, many children in care with complex needs, may struggle with their emotional regulation or find it difficult to communicate. This collection is aimed at foster parents to support you when caring for children with complex needs.

# data[].attributes.body
Healing your inner child can set the foundation to becoming a better adult and foster better relationships while overcoming unwarranted childhood trauma.

# data[].attributes.attachment_link.title
How To Heal Your Inner Child | Charlie Health

# data[].attributes.attachment_link.description
Negative childhood experiences and childhood trauma can stick with you in your inner child. Here’s how to do inner child work to heal your inner child.

# data[].attributes.headline
Systemic Racism's Effect on the Developing Brain

# data[].attributes.subject
Systemic Racism's Effect on the Developing Brain

# data[].attributes.body
Systemic racism in the United States is connected to low socioeconomic status, food insecurity, and negative health outcomes. While there is ample research on the effects of adversity on the developing brain, little research exists concentrating on the damaging effects of adversity due to racism. New research is discovering these impacts on Black children in the alteration of brain development, in areas such as brain volume. This research should be utilized in how racial trauma in children is approached. It should also be a call to action to change and create policy that targets reducing systemic racism.

# data[].attributes.attachment_link.title
The Impact of Racism on the Developing Brain

# data[].attributes.attachment_link.description
New research on structural brain imaging and race-related adversity identifies key brain regions affected specifically by racial adversity.

# data[].attributes.headline
TED talk from Serene Thin Elk, Mental Health & Addiction Therapist who Specializes in Intergenerational & Collective Healing 

# data[].attributes.subject
TED talk from Serene Thin Elk, Mental Health & Addiction Therapist who Specializes in Intergenerational & Collective Healing 

# data[].attributes.body
This TED talk by Serene Thin Elk includes mention of Native collective trauma, internalized oppression, lateral oppression, epigenetics, and more.

# data[].attributes.attachment_link.title
What We Carry for Our Ancestors: Intergenerational Healing | Serene Thin Elk | TEDxSiouxFalls

# data[].attributes.body
This article explains the impact of childhood trauma and how to work with children who have experienced it.

# data[].attributes.attachment_link.readable_text
Childhood trauma involve aversive, distressing experiences that can affect a child's ability to function and cope. Unfortunately, it is all too common. An estimated 46% of children experience trauma at some point in their young lives.

While kids are resilient, they're not made of stone. Adults often say things like, 'They were so young when that happened, they won't even remember it as an adult.' However, it is important to recognize that childhood trauma can have a lifelong effect.

"As children's brains develop, they are learning how safe or unsafe the world is through their experiences," says psychotherapist Yolanda Renteria, LPC. "A child has to develop a way to protect itself from what it deems unsafe; the ways in which a child protects itself shape their adult personality."

Because of this, it's important to recognize when a child may need professional help for dealing with their trauma. Early intervention can also prevent the ongoing effects of the trauma into adulthood.

What Is Childhood Trauma?

Childhood trauma is an event experienced by a child that evokes fear and is commonly violent, dangerous, or life-threatening. Also sometimes referred to as adverse childhood experiences or ACEs, there are many different experiences that can lead to trauma.

Physical or sexual abuse, for example, can be traumatic for children. One-time events like a car accident, natural disaster (like a hurricane), the loss of a loved one, or a major medical incident can take a psychological toll on children as well.

Ongoing stress, such as living in a dangerous neighborhood or being the target of bullying, can also be traumatic for a child-even if it just feels like daily life to an adult.

Childhood trauma doesn't even have to involve experiences that occur directly to the child. Watching a loved one endure a major health issue, for instance, can be extremely traumatic for children. Violent media can have this effect too.

Childhood Trauma and PTSD

As many as 15% of girls and 6% of boys develop post-traumatic stress disorder (PTSD) following a traumatic event. Children with PTSD may re-experience the trauma in their minds over and over again. They might also avoid anything that reminds them of the trauma or re-enact the trauma in their play.

Sometimes children believe that they missed warning signs predicting the traumatic event. In an effort to prevent future traumas, they become hypervigilant in looking for signs that something bad is going to happen again.

Children with PTSD may also:

Act younger than they are (such as by sucking their thumb)

Experience trouble focusing

Feel more depressed or anxious

Find it difficult to be affectionate with others

Have increased anger and aggression

Have issues in school

Have trouble sleeping

Lose interest in activities they once enjoyed

Lose touch with reality

Seem detached, numb, or non-responsive

Worry about dying young

Even children who don't develop PTSD may still exhibit emotional and behavioral issues following a traumatic experience. Here are some things to watch for during the weeks and months after an upsetting event:

Anger issues

Attention problems

Changes in appetite

Development of new fears

Increased concerns about death or safety

Irritability

Loss of interest in normal activities

Problems sleeping

Sadness

School refusal

Somatic complaints like headaches and stomachaches

Impacts of Childhood Trauma

Traumatic events can affect how a child's brain develops, which can have lifelong consequences for them physically, mentally, and socially.

Physical Health Impacts

When a child experiences a traumatic event, it can impair their physical development. The stress can impair the development of their immune and central nervous systems, making it harder to achieve their full potential.

Specifically, it notes that exposure to repeated trauma increases a child's risk of developing:

A 2019 review of 134 different research-based articles adds that exposure to adverse experiences as children increases the risk of developing several different conditions-such as autoimmune diseases, pulmonary disease, cardiovascular disease, and cancer-in adulthood, as well as increasing levels of pain.

Mental Health Impacts

Childhood trauma can also have an impact on mental health. Psychological effects of traumatic experiences can include:

Children exposed to complex traumas may even become disassociated. Dissociation involves separating themselves from the experience mentally. They might imagine that they are outside of their bodies and watching it from somewhere else or they may lose memory of the experience, resulting in memory gaps.

Research published in Psychiatric Times further notes that the prevalence of suicide attempts is significantly higher in adults who experienced traumas such as physical abuse, sexual abuse, and parental domestic violence as a child.

Relationship Impacts

A child's relationship with their caregivers-whether they be parents, grandparents, or other familial or non-familial adults-is vital to their emotional and physical health. The attachment children have with their caregivers can help them learn to trust others, manage emotions, and positively interact with the world around them.

When a child experiences a trauma that teaches them that they cannot trust or rely on that caregiver, they're likely to believe that the world around them is a scary place and people are dangerous. This lesson makes it incredibly difficult to form relationships throughout their childhood and into their adult years.

Children who experience trauma are also likely to struggle with romantic relationships in adulthood. A 2017 study in the Journal of Family Psychology found that spouses with a history of child abuse tend to have less satisfying marriages, even when still in the newlywed phase.

Renteria notes that the lasting effects of trauma often depend on the nature and severity of the event. In some cases, it may lead to feelings of anxiety or avoidance coping that some partners may find frustrating or confusion.

Yolanda Renteria, LPC

She also explains that some common relationship struggles that can stem from such trauma include:

Difficulty trusting

Being physically and verbally distant

Defensiveness

Difficulty being vulnerable

Difficulty giving their partner the benefit of the doubt

Difficulty with communication skills

Difficulty seeing their partner as their ally

Other Impacts

Sometimes the impact of childhood trauma extends beyond physical or mental health and relationships. For instance, some studies have connected adverse childhood experiences with an increased risk of becoming a criminal offender by the age of 35, oftentimes committing offenses that are serious and violent.

Additional impacts can include:

Being easily "set off" and having more intense reactions

Engaging in high-risk behaviors (such as driving at high speeds or unsafe sex)

Inability to plan ahead or prepare for the future

Increased risk of self-harm

Lack of impulse control

Low self-esteem

Trouble problem-solving or reasoning

Children experiencing traumatic events may also have a reduced ability to parent their own kids later in life.

Untreated Childhood Trauma

How to Help Children Who Have Experienced Trauma

Social support can be key to reducing the impact trauma has on a child, even as far as reducing their risk of suicidal ideation. Here are some ways to support a child after an upsetting event:

Encourage the child to talk about their feelings and validate their emotions.

Help them understand that they are not at fault.

Answer their questions honestly.

Reassure the child that you'll do everything you can to keep them safe.

Stick to a daily routine as much as possible.

Be patient as each child recovers at their own pace.

Depending on the child's age and needs, they may be referred for services such as cognitive behavioral therapy, play therapy, or family therapy. In some cases, such as when there is a diagnosis of PTSD, medication may also be an option to help treat their symptoms.

How to Heal From Your Own Childhood Trauma

If you experienced trauma as a child and still have some healing to do, there are several actions you can take to help you better cope. Among them are:

Talking to a mental health professional can also help you start to heal. Therapeutic options may include a number of trauma-informed therapies, such as cognitive processing therapy (CPT), trauma-focused cognitive behavioral therapy (TF-CBT), eye movement desensitization and reprocessing (EMDR), and acceptance and commitment therapy (ACT), among others.

You may also want to reach out to reputable organizations able to help childhood trauma survivors. The Disaster Distress Helpline offered by the Substance Abuse and Mental Health Services Administration (SAMHSA) is one option. If you prefer to communicate via text, the Crisis Text Line is another.

A Word From Verywell

While it's normal to have some level of distress following a traumatic event, it's not out of the question that children can return to a healthy state of functioning-and some kids are less affected by their circumstances than others.

If childhood trauma has created negative effects, it is never too late to get help. Whether you've adopted a teenager who was abused over a decade ago or you've never received help for the traumatic experiences you endured 40 years ago, trauma treatment can still be effective and beneficial.

# data[].attributes.attachment_link.description
The effects of childhood trauma can be debilitating and last a lifetime without early intervention. Here's how to recognize the signs of trauma and get help.

# data[].attributes.attachment_link.title
Discovering you're still dealing with trauma and PTSD, much later in life (full segment) | The Drum

# data[].attributes.headline
Connecting Older Adults with Services for Trauma

# data[].attributes.subject
Connecting Older Adults with Services for Trauma

# data[].attributes.attachment_link.title
Recognizing Trauma and Connecting Older Victims with Services

# data[].attributes.body
This article details what is trauma, different types of trauma, and ways to treat it.

# data[].attributes.attachment_link.description
Trauma can stem from many different experiences. And even though your brain holds onto it, there are ways to heal from emotional trauma.

# data[].attributes.headline
Types of Trauma: Impacts and Paths to Healing

# data[].attributes.subject
Types of Trauma: Impacts and Paths to Healing

# data[].attributes.body
This article includes information about different types of trauma, coping strategies, and resources.

# data[].attributes.attachment_link.title
Types of Trauma Unraveled: Types, Impacts, and Paths to Healing - Groundbreaker Therapy | Dr. Matthew G. Mandelbaum, Phd, Msed, Ma

# data[].attributes.attachment_link.description
There are many types of trauma. Understanding trauma is the first step toward healing. It’s a brave and empowering decision to explore the complexities of

# data[].attributes.headline
Three Types of Trauma: Acute, Chronic, and Complex Developmental Trauma

# data[].attributes.subject
Three Types of Trauma: Acute, Chronic, and Complex Developmental Trauma

# data[].attributes.attachment_link.title
Types Of Trauma | Acute, Chronic, and Complex Developmental Trauma (CDT) | Complex PTSD

# data[].attributes.body
This article lays out the bare bones of symptoms and treatments for the effects of trauma in adolescents. While it does not break the mold in any sense, it offers a warning for the increased chance of self-harm in teens that experience trauma.

# data[].attributes.attachment_link.title
Trauma in Adolescents: Symptoms, Causes, Trauma-Informed Care, and Healing Techniques - Bright Path Adolescent Mental Health

# data[].attributes.attachment_link.description
Trauma in adolescents refers to the emotional and psychological distress experienced as a result of deeply disturbing or overwhelming events. It can stem from

# data[].attributes.headline
Trauma, Adolescence, and the Developing Brain

# data[].attributes.subject
Trauma, Adolescence, and the Developing Brain

# data[].attributes.attachment_link.title
Trauma, Adolescence, and the Developing Brain - thewaveclinic.com

# data[].attributes.attachment_link.description
This blog explores the different ways that trauma may affect the adolescent brain, mind, body, and behaviours.

# data[].attributes.body
This article explains what causes intergenerational trauma and how to treat it.

# data[].attributes.attachment_link.title
Intergenerational Trauma: What You Need To Know

# data[].attributes.attachment_link.description
Intergenerational trauma is passed from one generation to the next. Learn how it is defined, what causes it, and how people with this type of trauma can get support.

# data[].attributes.body
Nora McInerny discusses society's reluctance to address grief and loss in a realistic and helpful manner. Grief is not something we move through and finish, but something we carry with us forever. It can be honored by normalizing and incorporating it in our daily lives. Like those that are still with us, our loved ones that have passed can be celebrated and remembered, not left behind.

# data[].attributes.attachment_link.title
We don't "move on" from grief. We move forward with it | Nora McInerny | TED

# data[].attributes.body
Eye Movement Desensitization and Reprocessing (EMDR) has faced a copious amount of scrutiny. While every intervention should be thoroughly researched, there is no denying the healing capabilities of this treatment that helps process unprocessed memories of trauma, lessening their impact, in a relatively brief amount of time. The heart of the treatment is bilateral stimulation, like eye movements and hand taps. This stimulation resembles REM sleep, which aids the brain in processing traumatic memories. By integrating these memories, it releases it. These memories are no longer “stuck,” negatively affecting daily functioning, informing thoughts, and inducing unpleasant physical sensations. This is a powerful treatment in any trauma-informed therapist’s care.

# data[].attributes.attachment_link.readable_text
A substantial body of research shows that adverse life experiences contribute to both psychological and biomedical pathology. Twenty-four randomized controlled trials support the positive effects of eye movement desensitization and reprocessing therapy in the treatment of emotional trauma and other adverse life experiences relevant to clinical practice. Twelve randomized studies of the eye movement component noted rapid decreases in negative emotions and/or vividness of disturbing images.

Abstract

Background:

A substantial body of research shows that adverse life experiences contribute to both psychological and biomedical pathology. Eye movement desensitization and reprocessing (EMDR) therapy is an empirically validated treatment for trauma, including such negative life experiences as commonly present in medical practice. The positive therapeutic outcomes rapidly achieved without homework or detailed description of the disturbing event offer the medical community an efficient treatment approach with a wide range of applications.

Methods:

All randomized studies and significant clinical reports related to EMDR therapy for treating the experiential basis of both psychological and somatic disorders are reviewed. Also reviewed are the recent studies evaluating the eye movement component of the therapy, which has been posited to contribute to the rapid improvement attributable to EMDR treatment.

Results:

Twenty-four randomized controlled trials support the positive effects of EMDR therapy in the treatment of emotional trauma and other adverse life experiences relevant to clinical practice. Seven of 10 studies reported EMDR therapy to be more rapid and/or more effective than trauma-focused cognitive behavioral therapy. Twelve randomized studies of the eye movement component noted rapid decreases in negative emotions and/or vividness of disturbing images, with an additional 8 reporting a variety of other memory effects. Numerous other evaluations document that EMDR therapy provides relief from a variety of somatic complaints.

Conclusion:

EMDR therapy provides physicians and other clinicians with an efficient approach to address psychological and physiologic symptoms stemming from adverse life experiences. Clinicians should therefore evaluate patients for experiential contributors to clinical manifestations.

Introduction

Eye movement desensitization and reprocessing (EMDR) is an empirically validated psychotherapy approach that medical personnel can employ to treat the sequelae of psychological trauma and other negative life experiences. Its ability to rapidly treat unprocessed memories of these adverse experiences has important implications for the medical community, as they appear to be the foundation for an array of clinical symptoms. Clinical applications of EMDR include a wide variety of psychological problems affecting patients and family members, as well as stress-induced physical disorders and medically unexplained symptoms. The frequent ability of EMDR to bring about substantial improvement in short periods of time has relevance to major current problems in medical practice such as increasing patient load and the cost of medical care. The therapy procedures can be used by qualified medical personnel to improve comfort levels and functionality in managing some of their most difficult cases in everyday practice.

EMDR therapy was introduced in 1989 with the publication of a randomized controlled trial (RCT) evaluating its effects with trauma victims. The same year, the first RCTs on trauma-focused cognitive behavioral therapy (CBT) and psychodynamic therapy were published., In 2008, an Institute of Medicine report stated that more research was needed to determine the efficacy of EMDR, cognitive therapy, and pharmacotherapy in the treatment of posttraumatic stress disorder (PTSD); psychodynamic therapy and hypnotherapy were not considered because of the paucity of relevant evidence (one study each). However, since that time additional EMDR therapy RCTs with PTSD participants have been published, and this therapy is recommended as an effective treatment for trauma victims by numerous organizations, including the American Psychiatric Association, Department of Defense, and World Health Organization. Although meta-analyses report comparable effect sizes for CBT and EMDR therapy, and both are considered "highly efficacious in reducing PTSD symptoms," 10p225 there are significant differences between the two treatments. As noted in the World Health Organization's 2013 Guidelines for the Management of Conditions That Are Specifically Related to Stress, whereas both therapies are recommended for PTSD treatment in children, adolescents, and adults, "Like CBT with a trauma focus, EMDR therapy aims to reduce subjective distress and strengthen adaptive cognitions related to the traumatic event. Unlike CBT with a trauma focus, EMDR does not involve a) detailed descriptions of the event, b) direct challenging of beliefs, c) extended exposure, or d) homework." 8p1

Twenty-nine RCTs have evaluated EMDR therapy as a trauma treatment. Excluding 4 RCTs determined by the International Society for Traumatic Stress Practice Guidelines Taskforce to have provided insufficient treatment doses, fidelity, or both, the remaining 25 studies have created a strong knowledge base. Twenty-four RCTs support the use of EMDR therapy with a wide range of trauma populations (see meta-analyses cited above for a comprehensive listing of most studies and critiques). Seven of 10 RCTs have indicated that EMDR therapy is more rapid or otherwise superior to CBT, ⁻ and only 1 has reported superior effects for CBT on some measures. The latter is likewise the only RCT (of 25) to report a control condition superior to EMDR. Whereas the EMDR therapy involved only 8 standard sessions and no homework, the CBT treatment was vastly more complex and entailed 4 sessions of imaginal exposure (describing the trauma) and 4 sessions of therapist-assisted in vivo exposure (physically going to a disturbing location) plus approximately 50 hours of combined imaginal exposure and in vivo exposure homework. The EMDR therapy condition involved only 8 standard sessions and no homework. Of particular note with respect to general clinical practice is a study conducted at Kaiser Permanente, that reported that 100% of single-trauma victims and 77% of multiple-trauma victims no longer had PTSD after a mean of six 50-minute EMDR therapy sessions, demonstrating a large and significant pretreatment versus posttreatment effect size (Cohen's δ = 1.74). This is consistent with 2 other RCTs that found that 84% to 90% of single-trauma victims no longer had PTSD after three 90-minute EMDR sessions. ⁻ Most recently, a study funded by the National Institute of Mental Health evaluated the effects of 8 sessions of EMDR therapy compared to 8 weeks of treatment with fluoxetine. EMDR was superior for the amelioration of both PTSD symptoms and depression. Upon termination of therapy, the EMDR group continued to improve, whereas the fluoxetine participants who had reported as asymptomatic at posttest again became symptomatic. At follow-up, 91% of the EMDR group no longer had PTSD, compared with 72% in the fluoxetine group.

EMDR therapy is an eight-phase treatment approach composed of standardized protocols and procedures. The eight phases and three-pronged protocol facilitate a comprehensive evaluation of the clinical picture, client preparation, and processing of a) past events that set the foundation for pathology, b) current disturbing situations, and c) future challenges ( Table 1).

Table 1.

History taking

Obtain background information
Identify suitability for EMDR treatment
Identify processing targets from events in client's life according to standardized three-pronged protocol

Standard history-taking questionnaires and diagnostic psychometrics
Review of selection criteria
Questions and techniques to identify 1) past events that have laid the groundwork for the pathology, 2) current triggers, and 3) future needs

Preparation

Prepare appropriate clients for EMDR processing of targets

Education regarding the symptom picture
Metaphors and techniques that foster stabilization and a sense of personal control

Assessment

Access the target for EMDR processing by stimulating primary aspects of the memory

Elicit the image, negative belief currently held, desired positive belief, current emotion, and physical sensation and baseline measures

Desensitization

Process experiences toward an adaptive resolution (no distress)

Standardized protocols incorporating eye movements (taps or tones) that allow the spontaneous emergence of insights, emotions, physical sensations, and other memories

Installation

Increase connections to positive cognitive networks

Enhance the validity of the desired positive belief and fully integrate the positive effects within the memory network

Body Scan

Complete processing of any residual disturbance associated with the target

Concentration on and processing of any residual physical sensations

Closure

Ensure client stability at the completion of an EMDR session and between sessions

Use of guided imagery or self-control techniques if needed
Briefing regarding expectations and behavioral reports between sessions

Reassessment

Ensure maintenance of therapeutic outcomes and stability of client

Evaluation of treatment effects
Evaluation of integration within larger social system

One of the components used during the reprocessing phases is composed of dual attention stimuli in the form of bilateral eye movements, taps, or tones. The eye movements have been the subject of great scrutiny and were called into question a decade ago by a meta-analysis of studies evaluating treatment effects with and without this component. However, guidelines published by the International Society for Traumatic Stress Studies indicated that no conclusions were possible because the studies evaluated in the meta-analyses were fatally flawed owing to the use of inappropriate populations, insufficient treatment doses, and lack of power. In contrast, since that time, 20 RCTs have indicated positive effects of the eye movement component. Twelve RCTs demonstrate an immediate decrease in arousal, negative emotions, and/or imagery vividness,, and the remainder report additional memory effects, including increased attentional flexibility, memory retrieval, and recognition of true information. A recent meta-analysis has reported that significant outcomes are evident in both clinical studies, with a moderate effect size (Cohen's δ = 0.41), and laboratory experiments, with a large effect size (Cohen's δ = 0.74). Three dominant hypotheses regarding proposed mechanisms of action of EMDR therapy that have been supported by research ⁻ include that the eye movements a) tax working memory, b) elicit an orienting response, and c) link into the same processes that occur during rapid eye movement sleep.

Experiential Contributors to Pathology

EMDR therapy is guided by the adaptive information processing (AIP) model. Developed in the early 1990s, this concept posits that, except for symptoms caused by organic deficits, toxicity, or injury, the primary foundations of mental health disorders are unprocessed memories of earlier life experiences. It appears that the high level of arousal engendered by distressing life events causes them to be stored in memory with the original emotions, physical sensations, and beliefs. The flashbacks, nightmares, and intrusive thoughts of PTSD are prime examples of symptoms resulting from the triggering of these memories. However, as indicated in the AIP model, a wide range of adverse life experiences can also be stored in a dysfunctional manner, providing the basis for diverse symptomology that include negative affective, cognitive, and somatic responses. Sufficient processing of those accessed memories within the standard three-pronged EMDR therapy protocol brings about adaptive resolution and functioning. It is conjectured that processing the targeted experiences transfers them from implicit and episodic memory to explicit and semantic memory systems., The originally experienced negative emotions, physical sensations, and beliefs are altered as the targeted memory is integrated with more adaptive information. What is useful is learned and stored with appropriate affective, somatic, and cognitive concomitants. Consequently, the disturbing life experience becomes a source of strength and resilience.

Support for the AIP tenets positing the primacy of life experiences to pathology comes from research showing that general life experiences (eg, relational problems, problems with study or work) can be the source of even more posttraumatic stress symptoms than major trauma. Hence, patients presenting with anxiety, depression, hypervigilance, frequent anger, etc, should be evaluated for adverse experiences contributing to current dysfunction. Two RCTs have demonstrated the effectiveness of EMDR therapy in treating distressing life experiences that do not meet the criteria for traumatic events in the diagnosis of PTSD.,, Both trials reported positive treatment effects within 3 sessions. One of the studies using a mixed sample, reported comparable decreases in symptoms whether or not the participant met all criteria for PTSD. The 3 sessions of EMDR therapy resulted in an 84% remission of PTSD diagnosis with a large and significant pretreatment versus posttreatment effect size (Cohen's δ = 1.69).

The ability of EMDR therapy to rapidly treat unprocessed memories of distressing life experiences has multiple applications in medical practice, as such memories have been identified as the basis for a wide variety of clinical symptoms. Research has revealed widespread mental health treatment implications. For instance, "Harsh physical punishment [ie, pushing, grabbing, shoving, slapping, hitting] in the absence of [more severe] child maltreatment is associated with mood disorders, anxiety disorders, substance abuse/dependence, and personality disorders in a general population sample." 42p1 Additional research demonstrates that "Exposure to adverse, stressful events ... has been linked to socioemotional behavior problems and cognitive deficits." 43p270 These studies highlight the significance of carefully evaluating patients for a history of adverse life experiences. It is particularly important in the treatment of children to identify interpersonal experiences, including household dysfunction, bullying, and humiliation, that may be contributing to problems such as anxiety, lack of focus, angry outbursts, inattention, and impulsivity issues that might otherwise be incorrectly diagnosed as attention deficit hyperactivity disorder., A course of EMDR therapy treatment can be used to alleviate the effects of experiential contributors and to evaluate whether or not medication is actually needed. Reports of insomnia, nightmares, and night terrors should be similarly evaluated, as memory processing alone can improve the quality of sleep.

Although these studies have contributed greatly to our knowledge base, the most important research underscoring the importance of experiential contributors to both physical and mental health problems is the Adverse Childhood Experiences (ACE) Study. This study examined more than 17,000 adult members in the Kaiser Permanente Medical Care Program and "... found a strong dose-response relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults." 47p251 The implications for combined medical and psychological treatment are relevant to both prevention and remediation. In this regard, the use of EMDR therapy to treat the patient and to identify the adverse life experiences that contribute to current symptoms, and processing the memories to an adaptive resolution, can significantly contribute to efficient clinical practice.,,

EMDR Therapy Approach

According to the AIP model, current experiences link into already established memory networks and can trigger the unprocessed emotions, physical sensations, and beliefs inherent in earlier-stored adverse life experiences. In this way, when the past becomes present and patients react in a dysfunctional manner, it is because their perceptions of current situations are colored by their unprocessed memories. The AIP conceptualization provides the basis for a comprehensive evaluation of the clinical picture, the targets selected for treatment, and the procedures used during reprocessing.,,, Unlike CBT, which involves extended focused attention on the disturbing event, EMDR reprocessing sessions promote an associative process that clearly reveals the intricate connections of memories that are triggered by current life experiences. The transcript of a patient who requested treatment for PTSD following an earthquake reveals the experiences of household dysfunction that set the foundation for her current symptoms (see Sidebar: Partial Transcript of EMDR Therapy Session, available online at: www.thepermanentejournal.org/files/Winter2014/EyeMovement.pdf). Note the spontaneous emergence of insight that ties together both past and present trauma, as well as the rapid change in affect and cognitive response. Also of note is the recognition of childhood feelings of powerlessness that provide the foundation for psychosomatic problems. Such rapid decline in subjective distress during a single EMDR therapy session has been reported in a number of RCTs.,, A short course of EMDR therapy has also been found to successfully treat cases of perceived neuropathy as well as stress-related dermatologic disorders such as atopic dermatitis, psoriasis, acne excoriee, and generalized urticaria.

Importantly, while CBT trauma treatments involve one to two hours of daily homework to achieve positive effects, EMDR therapy uses none. As reported in a controlled study funded by the National Institute of Mental Health, "An interesting potential clinical implication is that EMDR seemed to do equally well in the main despite less exposure [to the trauma memory] and no homework." 54p614 Rapidly attained treatment effects and the absence of homework make EMDR therapy highly amenable to physical rehabilitation services. An RCT with patients suffering from PTSD following a life-threatening cardiovascular event compared eight sessions of EMDR therapy to imaginal exposure therapy (which involves concentrating on the trauma memory and repeatedly describing it in detail). EMDR therapy resulted in greater reductions on all measures posttest, indicating a rapid decline in trauma symptoms, depression, and anxiety. Of note, significant improvement in trait anxiety was also reported and maintained. No such improvement was reported for imaginal exposure therapy. The authors reported that EMDR therapy was initially posited to be more "gentle" and therefore amenable for this debilitated population because "distancing" rather than reliving has been found to be correlated with treatment effects, and the eye movements used in EMDR appear to immediately cause parasympathetic activation, resulting in physiologic calming.,, Further, RCTs of initial treatment sessions indicate that the subjective distress of patients decreases with EMDR therapy, whereas it increases with exposure therapy.,

... EMDR therapy was initially posited to be more "gentle" and therefore amenable for this debilitated population because "distancing" rather than reliving has been found to be correlated with treatment effects,⁵⁵ and the eye movements used in EMDR appear to immediately cause parasympathetic activation, resulting in physiologic calming.

Rehabilitation services can benefit from EMDR therapy to support both patient and family members. The traumatic impact of dealing with life-threatening, incapacitating disease can be mitigated by incorporating relatively few memory-processing sessions to address distressing medical experiences, current situations, and fears of the future. As reported by Gattinara, 58p170-1

"Using this approach in the field of neuromuscular disease is useful on three levels:

1. It can facilitate the processing of the traumatic event in the patient and the whole family.

2. It can rapidly reestablish a secure interpersonal context between the patient and his or her caregiver by reducing the high arousal level.

3. It can transform the health service into a network of support for patient and family, offering help in managing the emotional vulnerability connected with physical vulnerability, thus buffering the adverse impact of worsening clinical conditions."

In addition, because EMDR therapy requires no homework, it can be used on consecutive days, allowing rapid completion of treatment. The cost implications are obvious.

EMDR therapy can also be used to help support family members dealing with the death of a loved one. The results of both prolonged debilitation and sudden death can involve trauma symptoms that include distressing intrusive images of the suffering patient. The family member is often unable to retrieve positive memories of the deceased, which further exacerbates and complicates the grieving process. As indicated in a nonrandomized multisite study, EMDR therapy reduced symptoms significantly more rapidly than the CBT on behavioral measures and on 4 of 5 psychosocial measures. EMDR was more efficient, inducing change at an earlier stage and requiring fewer sessions (6.2 vs 10.7 sessions). Positive recall of the deceased was significantly greater (twice the frequency) posttreatment with EMDR.

A wide range of patients suffering from debilitating medical conditions can also benefit from EMDR therapy. For instance, the utility of psychological services for burn victims has been reported, with EMDR therapy specifically recommended on the basis of both effectiveness and brevity of treatment. As indicated previously, three to six sessions are generally sufficient to alleviate symptoms from a single trauma. Of particular note is the elimination of both PTSD and somatic symptoms in a burn victim who had been severely debilitated for almost a decade. The rapid alleviation of the patient's symptoms and return to independent functioning are consistent with the AIP model, which posits that the feelings of helplessness and hopelessness are the result of unprocessed memories of the trauma that contain the perceptions experienced at the time of the event.,,

These findings have important implications for the medical community in that many chronic pain patients may actually be debilitated by unprocessed memories encoded with the original somatic perceptions. As noted by Ray and Zbik, whereas CBT treatments address chronic pain through cognitive interventions that can reduce distress, EMDR therapy can result in the elimination of the pain sensations. For instance, a number of researchers have reported positive outcomes of EMDR therapy for the treatment of phantom limb pain. The 4 evaluations of patients published to date ⁻ indicate an aggregate 80% success rate as defined by complete elimination or substantial reduction of pain sensations. According to the AIP model, the phantom pain is caused by the unprocessed memory of the experience during which the limb was damaged. This unprocessed memory contains the physical sensations experienced at the time of the event. EMDR processing of the memory results in a simultaneous shift in emotions, physical sensations, and beliefs., Completed processing is posited to involve an alteration of the originally stored memory through a process of integration and reconsolidation., The change in the targeted memory results in an elimination of those pain sensations that are not caused by physical nerve damage. Successful elimination and/or reduction of pain to tolerable levels has been reported after 2 to 9 EMDR therapy sessions. Therefore, when no neuropathy is observed in chronic pain patients it is often beneficial to explore the potential results of a short course of memory processing., In addition, EMDR therapy has been reported to be beneficial in the treatment of migraine headaches in an open trial and an RCT.

Potential Neurobiologic Concomitants

The different treatment outcomes and the procedural differences between EMDR therapy and CBT indicate potentially diverse underlying neurobiologic mechanisms. For instance, trauma-focused CBT exposure therapies entail extended, detailed repetitions of the disturbing event that are repeated during both sessions and homework. Research has indicated that prolonged exposures, as used in CBT, result in extinction, whereas brief exposures as used in EMDR therapy trigger memory reconsolidation. These differences have significant neurobiologic and clinical implications. As noted by Craske et al, 74p6 "... recent work on extinction and reinstatement ... suggests that extinction does not eliminate or replace previous associations, but rather results in new learning that competes with the old information." This mechanism is posited to account for relapse. Further, "Extinction is conceptualized as the development of a second context-specific inhibitory association that, in contrast to fear acquisition, does not easily generalize to new contexts." 74p12 These factors may account for differences in treatment time, with EMDR therapy reported to be more rapid than CBT in five RCTs, ⁻,⁻ as well as reported positive effects obtained with EMDR treatment that have not been reported with CBT (eg, elimination of phantom limb pain, increased positive recall of the deceased). The fact that CBT exposure therapies are posited to leave the original memory intact may be the reason these beneficial results have not been reported with CBT. Likewise, a recent pilot study indicated that six sessions of EMDR therapy with patients with psychosis and PTSD also resulted in "a positive effect on auditory verbal hallucinations, delusions, anxiety symptoms, depression symptoms, and self-esteem." 75p664 By contrast, successful CBT has resulted in a continuation of auditory hallucinations that the patient experiences, but with less distress. In the EMDR study, the majority of participants who had initially experienced auditory hallucinations reported that these had disappeared. The findings that " ... childhood adversity is strongly associated with increased risk for psychosis" 76p2 suggest the need for additional rigorous research evaluating the effects of memory processing with this population.

Future Research

The ACE Study conducted at Kaiser Permanente provides an ideal platform for future research to evaluate the effects of EMDR therapy for a wide range of psychological and physical problems pertinent to medical practice. Some of the conditions found in the ACE Study to be correlated with exposure to adverse life experiences in childhood are alcoholism, drug abuse, severe obesity, depression, and suicide attempts. These conditions would lend themselves well to rigorous RCTs in which integrated EMDR therapy protocols that include processing the disturbing memories are compared to current standard care. Both immediate and long-term follow-up of at least a year's duration to evaluate maintenance of treatment gains would greatly inform current medical practices.

Of equal importance is the finding in the ACE Study that ACEs result in the increased incidence of physically debilitating conditions such as ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease. Rigorous longitudinal studies to evaluate the utility of EMDR therapy for preventive care would provide the medical community an important opportunity to determine whether processing the memories of adverse experiences can ameliorate these detrimental effects. The social policy and financial implications of such studies underscore their importance in providing optimal care.

For any of the suggested studies, it is vital that clinical personnel with appropriate treatment fidelity carefully assess the nature of the disturbing events in the patient's history and allocate adequate treatment time to process a sufficient number of memories to potentially achieve asymptomatic status. As reported in the ACE Study, there is a "strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults." 47p245 As indicated previously, a short course of EMDR therapy may be sufficient to eliminate a variety of psychological and somatic conditions. However, patients who have been serially abused throughout childhood will generally need more treatment time to achieve comprehensive adaptive resolution., Given that EMDR treatment effects generalize to similar memories, it is unnecessary to process each disturbing event. However, sufficient time should be provided to process the relevant memories within the various categories of adverse experiences.

For all the suggested studies, the inclusion of procedures to identify epigenetic and neurophysiologic changes subsequent to treatment also opens the door to potentially important assessment possibilities. Since EMDR therapy can be provided on consecutive days, successful treatment can be accomplished over a matter of weeks, rather than months, which can reduce time confounds and provides both efficient and cost-effective research opportunities.

Conclusions

A substantial amount of research indicates that adverse life experiences may be the basis for a wide range of psychological and physiologic symptoms. EMDR therapy research has shown that processing memories of such experiences results in the rapid amelioration of negative emotions, beliefs, and physical sensations. Reports have indicated potential applications for patients with stress-related disorders, as well as those suffering from a wide range of physical conditions. The medical community can also benefit from the use of EMDR therapy for prevention and rehabilitative services to support both patients and family members. A thorough assessment of potential experiential contributors can be beneficial. If relevant, EMDR therapy can allow medical personnel to quickly determine the degree to which distressing experiences are a contributing factor and to efficiently address the problem through memory processing that can help facilitate both psychological and physical resolution. Rigorous research of the use of EMDR therapy with patients suffering from the conditions identified in the ACE Study can further contribute to our understanding of the potential for both remediation and preventive care.

Acknowledgments

Leslie Parker, ELS, provided editorial assistance.

Eye

For the eye altering alters all.

- The Mental Traveller, William Blake, 1757-1827, English poet, painter, and printmaker

References

62. McCann DL. Post-traumatic stress disorder due to devastating burns overcome by a single session of eye movement desensitization. J Behav Ther Exp Psychiatry. 1992 Dec;23(4):319-23. doi: 10.1016/0005-7916(92)90055-n. [DOI] [PubMed] [Google Scholar]

Articles from The Permanente Journal are provided here courtesy of Kaiser Permanente

# data[].attributes.attachment_link.title
The Role of Eye Movement Desensitization and Reprocessing (EMDR) Therapy in Medicine: Addressing the Psychological and Physical Symptoms Stemming from Adverse Life Experiences

# data[].attributes.attachment_link.description
A substantial body of research shows that adverse life experiences contribute to both psychological and biomedical pathology. Twenty-four randomized controlled trials support the positive effects of eye movement desensitization and reprocessing ...

# data[].attributes.body
Elders that learn how to acknowledge and move past trauma that has affected their life overall have a better quality of life and psychological wellbeing

# data[].attributes.attachment_link.title
Quality-of-life in older adults: its association with emotional distress and psychological wellbeing - BMC Geriatrics

# data[].attributes.attachment_link.description
Background There is consistent evidence of the impact of depression and health on Quality of Life in older adults. However, the influence of anxiety or psychological wellbeing aspects has been less extensively studied. This study aims to assess the association between quality of life and sociodemographic characteristics (gender, age), levels of health, emotional distress (anxiety and depression) and psychological wellbeing (personal growth and purpose in life). Methods The survey was conducted with 361 older adults (mean age = 68.44 years) This study was of cross-sectional design. Results We found that the older adults’ quality of life increased when increased the levels of health, personal growth and purpose in life and when there were lower scores in anxiety and depression. This model explained 63.2% of variance. In contrast, sociodemographic characteristics did not show any association with quality of life. Conclusions A better understanding of the factors associated with quality of life could help health professionals to develop interventions that enhance it. Efforts to address older adults’ quality of life focusing on older adults’ perceived health and emotional status should be considered.

# data[].attributes.headline
Statistics about People Who Have Experienced Trauma 

# data[].attributes.subject
Statistics about People Who Have Experienced Trauma 

# data[].attributes.headline
How Trauma Affects Relationships as Adults

# data[].attributes.subject
How Trauma Affects Relationships as Adults

# data[].attributes.headline
Three Generations of Intergenerational Trauma

# data[].attributes.subject
Three Generations of Intergenerational Trauma

# data[].attributes.headline
A Model of Complex PTSD with Potential General Practice Recommendations

# data[].attributes.subject
A Model of Complex PTSD with Potential General Practice Recommendations

# data[].attributes.headline
The Four F's of Trauma Response: How It Shows up and What You Can Do about It

# data[].attributes.subject
The Four F's of Trauma Response: How It Shows up and What You Can Do about It

# data[].attributes.body
II

# data[].attributes.headline
Polyvagal Theory and Fight/Flight/Freeze Trauma Response

# data[].attributes.subject
Polyvagal Theory and Fight/Flight/Freeze Trauma Response

# data[].attributes.body
The article that accompanies this infographic explores Polyvagal Theory and how it conceptualizes the physiological trauma responses of fight, flight, and freeze. The article includes some ways to improve self regulation known as "improving vagal tone."

# data[].attributes.body
Understanding what generational trauma is can be the first step to breaking it and becoming a better example for your future generations

# data[].attributes.attachment_link.title
Generational Trauma Might Explain Your Anxiety and Depression

# data[].attributes.attachment_link.description
Generational trauma passes down through generations in families. Read on to learn how trauma passes between family members and how to seek treatment.

# data[].attributes.headline
Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), a Leading Intervention for Childhood Trauma 

# data[].attributes.subject
Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), a Leading Intervention for Childhood Trauma 

# data[].attributes.body
This infographic shows the three phase process of using TF-CBT therapy as an intervention for trauma. Trainings can be found at https://tfcbt.org/training/.

# data[].attributes.body
National Center for PTSD course on PTSD and Aging (must sign up for an account to watch).

# data[].attributes.attachment_link.description
Apply for and manage the VA benefits and services you’ve earned as a Veteran, Servicemember, or family member—like health care, disability, education, and more.

# data[].attributes.body
Dr. Louise spent much of her career working with women that were widowed at a young age, but has turned her attention to the unique confluence of factors that affect women widowed later in life. Grieving the loss of their closest (and likely longest lasting) relationship can create an acute loneliness they have perhaps never felt. The death of their husbands has likely coincided or occurred after the end of their careers and social network that has only gotten smaller. Possible health and financial issues deepen the complexity of their lives. The article warns of the negative coping strategies that might develop, like substance use, and emphasizes the need for the most ameliorating factor: social connections. This article presents a “framework for renewal” for these women and offers therapists a powerful and informing view when treating these clients with competency.

# data[].attributes.attachment_link.provider_name
Interventionist | Licensed Professional Family Interventions

# data[].attributes.attachment_link.title
Beyond Loss: Insights from a Lifetime of Working with Widows - Interventionist | Licensed Professional Family Interventions

# data[].attributes.attachment_link.description
As someone who has walked the path of widowhood myself and interviewed countless women on their journeys through grief, I’ve gained unique insights into this life-altering transition. This September, I’ll be sharing these perspectives at Oxford University’s prestigious Masters Series, where I’ll address the complex intersection of widowhood, aging, and the challenges many face—including substance use and isolation. I’m especially excited to bring insights from my newly launched book, Reflections on Aging From the Sunset Marquis, to this important conversation about healing relational wounds and transforming trauma. The Evolution of My Work: From Young to Mature Widows While much of my earlier research focused on women widowed at a young age—capturing their unique challenges of raising children alone, rebuilding careers, and navigating decades of life ahead without their partners—my work has naturally evolved as I’ve aged. Now, at 78, I find myself increasingly drawn to the distinct challenges faced by mature widows. These women confront different obstacles: the loss of long-term partnerships spanning 40 or 50 years, navigating health concerns alone, reconciling with end-of-life decisions, and often combating profound isolation. The practical realities for older widows can be particularly daunting. Many have been out of the workforce for decades, leaving […]

# data[].attributes.headline
Secondary Losses Associated with the Primary Loss of Death

# data[].attributes.subject
Secondary Losses Associated with the Primary Loss of Death

# data[].attributes.headline
The 8 Phases of EMDR Therapy (Used to Treat PTSD and Trauma) from EMDRIA

# data[].attributes.subject
The 8 Phases of EMDR Therapy (Used to Treat PTSD and Trauma) from EMDRIA

# data[].attributes.body
The article that accompanies this infographic is from the official EMDR (Eye movement desensitization and reprocessing) website. It explains in detail the eight phases used in EMDR treatment. EMDR is an advanced treatment protocol that is used for processing trauma. When a client "processes" trauma, it means they are able to make sense of the experience and are no longer disturbed by it.

# data[].attributes.attachment_link.readable_text
The eight phases of EMDR therapy provide a framework to understand the treatment process. They act as a map for the EMDR therapist to follow. The names of the eight phases describe what happens during each phase and each phase focuses on a particular aspect of treatment ( Hase, 2021). All eight phases contribute to the overall effect of EMDR therapy, however, not all phases may be used in one EMDR therapy session.

The Map of EMDR Eight Phases as a Guide

The map of the EMDR eight phases acts as a guide to the goal of EMDR therapy: to "facilitate accelerated information processing" (Shapiro, 2018, p. 83). The understanding upon which EMDR therapy is built is that every person has the natural ability to heal. We all go through difficult situations in life. Often, we are able to 'process' the information (images, sights, sounds, feelings, sensations, thoughts) from these events ourselves or with the help of friends and family. To clarify, 'processing' in EMDR therapy refers to this natural ability to integrate our emotions, beliefs, and body sensations about an experience. If an experience is 'processed,' we can understand that it was a negative experience, but we can also link it to positive or useful information regarding the experience. This positive or useful material could include lessons learned, helpful shifts in feeling and body sensation, remembering how strong we are, relation to past successes, or a realization of how future actions can be guided because of the experience. In other words, 'processing' an experience means to make sense of the experience, and also no longer feel disturbed by it.

Sometimes an experience is simply too large, painful, or shocking for a person to process by themselves. So, a therapist can help 'reprocess' this experience with EMDR therapy. Maybe the experience reminds a person of similar negative experiences that have occurred in the past. The experience is overwhelming or traumatic. This is when EMDR therapy can be used to jump-start our natural processing system. EMDR therapy allows the overwhelming experiences to 'reprocess' until they no longer feel disturbing. The eight phases of EMDR therapy provide the map to guide treatment.

The Eight Phases

The eight phases are 1) history taking and treatment planning, 2) preparation, 3) assessment, 4) desensitization, 5) installation, 6) body scan, 7) closure and 8) reevaluation.

Phase 1: The first phase begins with a discussion between the therapist and client regarding what brings the client into therapy and how EMDR therapy can be used best for that client. The therapist and client develop a secure working relationship. The client's and a treatment plan is developed with attention to the pacing of therapy and the selection of traumatic events that will be part of treatment. In addition, the client's internal and external resources are assessed.

The next three phases are known as the 'reprocessing' phases and all involve dual attention bilateral stimulation (BLS). Dual attention BLS activates the client's information processing system while keeping the client anchored in the present moment. Dual attention BLS can be side to side eye movements, sounds, or taps.

Phase 4: In the fourth phase, , the side to side eye movements, sounds, or taps are begun while focusing on the traumatic event, and continue until the client's SUD reduces to zero (or 1 if appropriate). During this time, new thoughts, sensations, images, and feelings may emerge.

The last two phases ensure safety for the client both at the end of a current session and at the beginning of the next session.
8 Phases Infographic Infografía de las 8 fases 8 Phases Video Vídeo ocho fases de la terapia EMDR EMDR Therapy & Your Brain Infographic

Susanna Kaufman works with content at EMDRIA, compiling and editing Focal Point blog posts while working toward her full LPC licensure in Texas.

Hase, M. (2021). The structure of EMDR therapy: A guide for the therapist. Frontiers in Psychology, 12, 660753. Open access: https://doi.org/10.3389/fpsyg.2021.660753

Hase, M., Balmaceda, U.M., Ostacoli, L., Libermann., P., & Hofmann, A. (2017). The AIP model of EMDR therapy and pathogenic memories. Frontiers in Psychology 8: 1578. Open access: https://doi.org/10.3389/fpsyg.2017.01578

Shapiro, F. (2018). Eye Movement Desensitization and Reprocessing Therapy: Basic Principles, Protocols, and Procedures (3 ed.). New York, NY: The Guilford Press
Back to Focal Point Blog Homepage
Additional Resources

If you are a therapist interested in the EMDR training:

If you are EMDR trained:

If you are an EMDRIA Member:

# data[].attributes.attachment_link.description
The eight phases of EMDR therapy provide a framework to understand the treatment process. They act as a map for the EMDR therapist to follow.

# data[].attributes.headline
Helping Children and Adolescents Cope with Traumatic Events

# data[].attributes.subject
Helping Children and Adolescents Cope with Traumatic Events

# data[].attributes.body
When you know ways to help a child identify and cope from traumatic events, you are able to be a greater help to the community by being able to address the problem immediately.

# data[].attributes.attachment_link.provider_name
National Institute of Mental Health (NIMH)

# data[].attributes.attachment_link.title
Helping Children and Adolescents Cope With Traumatic Events

# data[].attributes.attachment_link.description
This fact sheet presents information on how children and adolescents respond to traumatic events, and what family, friends, and trusted adults can do to help.

# data[].attributes.headline
The After Effects of Stress in Trauma Patients

# data[].attributes.subject
The After Effects of Stress in Trauma Patients

# data[].attributes.body
This article details the effects of the treatments of stress in trauma patients.

# data[].attributes.attachment_link.title
The course, prediction, and treatment of acute and... : Journal of Trauma and Acute Care Surgery

# data[].attributes.attachment_link.description
and (2) which and when psychological treatments are effective. METHODS Embase, Medline, Web of Science, Scopus, PsycInfo, Cinahl, Cochrane, PubMed, and Google Scholar were searched up to September 14, 2015. Quality was assessed with STROBE and CONSORT checklists. RESULTS Overall, 45 (68%) observational studies and 21 (32%) intervention studies were included. Forty-seven (85%) were of lower (level of evidence (LoE) 3) or poor quality (LoE 4). ASD was found during hospitalization (range 1–37%) and about 30% experienced PTSD 1 month after trauma (LoE 3). The onset of PTSD was within 3 months but also up to 12 months after trauma (LoE 3). Especially in patients with ASD, patients showed PTSD symptoms after 6 years (LoE 3). ASD and PTSD were associated with sociodemographic factors (e.g., being female, younger age, financial problems, and low income), reduced cognitive functioning, and physical (e.g., pain), social (e.g., low social support), and psychological problems (e.g., hyperarousal) or disorders (e.g., ASD). Early treatment in the first weeks after trauma can be preventive for PTSD, but effective treatment for ASD is still unclear. Compared to other psychological treatments, the most effective and examined treatment for PTSD was cognitive behavioral therapy (CBT). CONCLUSIONS A large number of studies of lower or poor quality present inconsistent findings on the course of ASD and PTSD. Predictors for ASD and PTSD were identified. Early treatment can be preventive for PTSD, as CBT is the most effective treatment. However, good qualitative observational and intervention studies are lacking and needed. LEVEL OF EVIDENCE Systematic review, level III.…

# data[].attributes.body
This site details information about what child trauma is. It has treatments, resources, and screenings.

Types of trauma experienced by children on this website include bullying, sex trafficking, racial trauma, disasters, physical abuse, refugee trauma, medical trauma, sexual abuse, terrorism and violence, community violence, complex trauma, early childhood trauma, etc.

# data[].attributes.attachment_link.provider_name
The National Child Traumatic Stress Network

# data[].attributes.attachment_link.title
The National Child Traumatic Stress Network

# data[].attributes.attachment_link.description
CFTSI is a brief (5‐8 session), evidence‐based early intervention for children 7 to 18 years old that reduces traumatic stress reactions and the onset of PTSD. CFTSI is implemented within 30-45 days following a traumatic event or the disclosure of physical or sexual abuse.

# data[].attributes.headline
A Study Comparing Five Types of Childhood Trauma

# data[].attributes.subject
A Study Comparing Five Types of Childhood Trauma

# data[].attributes.body
This is a study that compares five different types of childhood trauma using a screening. The primary screening used was the Aggressive Behavior Questionnaire.

# data[].attributes.attachment_link.title
Five Forms of Childhood Trauma: Relationships With Aggressive Behavior in Adulthood

# data[].attributes.attachment_link.description
Objective: To examine relationships between 5 types of childhood trauma (witnessing violence, physical neglect, emotional abuse, physical abuse, and sexual abuse) and an aggression score based on 21 self-reported aggressive behaviors in adulthood.…

# data[].attributes.headline
The Impact of Trauma in Adult Development

# data[].attributes.subject
The Impact of Trauma in Adult Development

# data[].attributes.body
This article speaks on the difference between trauma and PTSD and how trauma can affect a person's adult development. It speaks on a person's ACE score as well as different developmental changes.

# data[].attributes.attachment_link.readable_text
Childhood trauma can lead to physical and mental struggles later in life

Some people assume we forget or outgrow trauma. But the truth is, if someone experiences trauma as a child, it can lead to physical and mental struggles that affect their entire life.

Thomas O'Connor, director of the Wynne Center for Family Research at the University of Rochester Medical Center, and Kristen Holderle, UR Medicine's Clinic Director of the HEAL Collaborative, share the ways in which trauma affects the brain and body, how PTSD and trauma are related, and suggestions for healing.

What is the difference between trauma and PTSD?

With trauma, a person fears for their own safety or the safety of a loved one. It can be anything from a loss of a parent, to experiencing or witnessing an assault, to being in a car accident.

Trauma can lead to PTSD (Post-traumatic stress disorder), a condition that requires professional treatment. The key sign of PTSD is that the person has difficulty doing the day-to-day things that they had done prior to a traumatic event.

Symptoms of PTSD can include:

Flashbacks

Distressing intrusive thoughts

Avoiding things that remind you of the trauma

Feeling jumpy

Difficulty concentrating

Shutting down emotionally

Lack of interest in things you enjoyed before

Not everyone will experience a traumatic event the same (even those exposed to the same traumatic event may respond differently), and a traumatic event does not necessarily lead to PTSD.

"It's normal to react deeply to a stressful event," says Holderle. "If you're having a hard time, that doesn't mean something is wrong with you. It's important to normalize big feelings and big reactions."

Several factors can determine if experiencing a trauma will become a bigger problem and require help.

How can childhood trauma impact adulthood?

The impact of childhood trauma on life as an adult can depend on the environment in which the person was raised, how they coped with the trauma and supports that were available, and when in life the trauma occurred.

To determine risks of developing mental illness, addiction, and other conditions, it is now common to ask about past traumatic events using measures like the ACE (Adverse Childhood Experience). The higher a person's ACE score, the more likely it is that they will have negative physical or mental health outcomes.

"The studies suggest that this happens because early trauma affects stress response," Holderle says. "Your flight or fight response, your neurodevelopment, gets off track. It suggests that if you can intervene early, when someone has a childhood traumatic event, it could have a huge lasting impact on their life."

The earlier the intervention, the greater chance that treatment can help, especially for trauma early in childhood.

When a person develops behaviors to deal with an early childhood trauma, changing those habits later in life can be more difficult.

Can trauma impact physical health?

Yes. In addition to affecting mental health and coping mechanisms, trauma has been proven to affect physical health as well.

"Research has shown that the experience of trauma not only influences our thinking and behavioral patterns, but also our biology," says O'Connor. "Trauma influences our stress response system and may be associated with compromised immunity and poor cardiovascular health."

URMC scientists are also investigating how the effects of trauma may be passed on, such as the ways biological changes caused by trauma affect health in pregnancy. They are also exploring epigenetics, the study of how behavior and environment can affect the way genes work.

What can help with healing?

If someone you care about has experienced trauma, it can help to offer a listening ear and encourage that person to talk about, rather than avoid, the event.

"Sometimes trauma happens, and people feel scared to talk about it because they don't want to make it worse," says Holderle. "It's important to talk about. You might not be able to fix things, and that's okay."

Therapy can help a person make sense of the experience and move forward.

The type of therapy recommended will vary, but could include:

Trauma-focused cognitive behavioral therapy

Cognitive processing therapy

Written expressive therapy

Most therapists will focus on helping individuals separate themselves from the traumatic experience.

"A lot of the work we do is trying to help people even before the story that they make of the trauma is solidified," says Holderle. "We try to help with the narrative. We can't change our past, but we can change our relationship to it."

University of Rochester Medicine Mental Health Treatment

# data[].attributes.attachment_link.description
Some people assume we forget or outgrow trauma. But the truth is, if someone experiences trauma as a child, it can lead to physical and mental struggles that affect their entire life.

# data[].attributes.headline
How to Acknowledge, Prevent, and Treat Intergenerational Trauma 

# data[].attributes.subject
How to Acknowledge, Prevent, and Treat Intergenerational Trauma 

# data[].attributes.body
This article details what is considered intergenerational trauma and how it can be transmitted generationally. It highlights preventative methods and educates the reader on treatments. It is informative on acknowledging, overcoming, and breaking the cycle.

# data[].attributes.attachment_link.description
Intergenerational trauma refers to the apparent transmission of trauma between generations of a family. People who experienced adverse childhood experiences growing up, or who survived historical disasters or traumas, may pass the effects of those traumas on to their children or grandchildren, through their genes, their behavior, or both, leaving the next generation susceptible to anxiety, depression, hypervigilance, and other emotional and mental health concerns.

# data[].attributes.headline
Groups More Likely to Have Experienced ACES

# data[].attributes.subject
Groups More Likely to Have Experienced ACES

# data[].attributes.body
This infographic displays groups of people who, research has shown, tend to have higher ACE scores (Source: CDC website.)

# data[].attributes.headline
How Childhood Trauma Affects the Brain Through Three Types of Stress

# data[].attributes.subject
How Childhood Trauma Affects the Brain Through Three Types of Stress

# data[].attributes.body
This video highlights 3 different types of stress (positive, tolerable, and toxic) and how it affects a child and rewires a brain causing damage.

# data[].attributes.attachment_link.title
Wired for Danger: The Effects of Childhood Trauma on the Brain

# data[].attributes.headline
How to Conduct a Screen for Trauma in a Child

# data[].attributes.subject
How to Conduct a Screen for Trauma in a Child

# data[].attributes.body
This video is a virtual representation of how to conduct a trauma screen. These are not actual sessions and these are actors.

# data[].attributes.attachment_link.title
Conducting a Quick Screen for Trauma - Child Interview

# data[].attributes.body
This video shows how trauma affects teens. It breaks down what trauma is and how it can affect a teen's coping mechanism regarding everyday life and their sense of safety.

# data[].attributes.attachment_link.title
Neuroscience and the Study of Intergenerational Trauma - Panel Discussion

# data[].attributes.headline
Armchair Expert with Dax Shepard: Interview with Cody Delistraty on Grief

# data[].attributes.subject
Armchair Expert with Dax Shepard: Interview with Cody Delistraty on Grief

# data[].attributes.body
Cody Delistraty, author of "The Grief Cure," talks about his mother's cancer treatment and the social function of grieving. Cody speaks about his experience of using AI to process his grief, ethics of deleting people’s traumatic memories, and laughter therapy.

# data[].attributes.attachment_link.description
Cody Delistraty (The Grief Cure) is a writer and journalist. Cody joins the Armchair Expert to discuss how art can differ between cultures, his experience with his mother’s cancer treatment, and what the social function of grieving is. Cody and Dax talk about how grief has become more public with so

# data[].attributes.headline
Armchair Expert with Dax Shepard: Interview with Gabor Maté (on Trauma & Addiction)

# data[].attributes.subject
Armchair Expert with Dax Shepard: Interview with Gabor Maté (on Trauma & Addiction)

# data[].attributes.body
Gabor Maté, author of multiple books including "The Myth of Normal," talks about the trauma's effect on the body, the importance of getting in touch with painful emotions, loving children unconditionally, and his personal experience of healing from trauma.

# data[].attributes.attachment_link.description
Dr. Gabor Maté (The Myth of Normal) is a physician and author. Gabor joins the Armchair Expert to discuss how most people exhibit addictive behaviors, how the mind is connected to physical health, and how human societies are like lab cultures. Gabor and Dax talk about why airports can be sources of

# data[].attributes.body
The window of tolerance is a concept was created by Dr. Dan Siegel. It describes the optimal state of arousal for a person to function effectively in life. For clients who have experienced trauma, it can be difficult to regulate emotions. This website explains more about the window of tolerance and gives ways clients can manage their emotions better.

# data[].attributes.attachment_link.readable_text
Our clients are best able to cope with stressors and triggers when they're operating within their window of tolerance.

But a traumatic experience can narrow our clients' window of tolerance, leading to states of either hyper- or hypo-arousal.

So we created this infographic as a tool you can share with your clients. It can help you explain what's going on when they're feeling dysregulated. Plus, this will help to support the exercises and work you do together as an important part of healing.

Click the image to enlarge

If you'd like to print a copy for yourself, just click here: Color or Print-friendly

(Please be sure to include the copyright information. We put a lot of work into creating these resources for you. Thanks!)
For more strategies you can use to help clients who've experienced trauma, be sure to check out the Treating Trauma Master Series.
You'll get insights from Bessel van der Kolk, MD; Dan Siegel, MD; Pat Ogden, PhD; Stephen Porges, PhD; Peter Levine, PhD; Allan Schore, PhD; and Ruth Lanius, MD, PhD.

Now we'd like to hear from you. How could this help you in your work? Please leave a comment below.

# data[].attributes.attachment_link.title
How to Help Your Clients Understand Their Window of Tolerance

# data[].attributes.attachment_link.description
Our clients are best able to cope with stressors and triggers when they're operating within their window of tolerance. But a traumatic experience can narrow our clients' window of tolerance, leading to states of either hyper- or hypo-arousal. So we created this infographic as a tool you can share with your clients.

# data[].attributes.headline
The Effects of Childhood Trauma on Health

# data[].attributes.subject
The Effects of Childhood Trauma on Health

# data[].attributes.body
This displays how childhood trauma affects the health of an adult.

# data[].attributes.attachment_link.title
Childhood trauma can lead to poor health later in life

# data[].attributes.attachment_link.description
More than half of Minnesota adults have had an adverse childhood experience that could be linked to poor health outcomes later in life.

# data[].attributes.headline
Aging: Will my Decisions Today Influence Potential Future Depression?

# data[].attributes.subject
Aging: Will my Decisions Today Influence Potential Future Depression?

# data[].attributes.body
This chart highlights how influences can support or cause more risk in the future of one's life.

# data[].attributes.attachment_link.title
Biological factors influencing depression in later life: role of aging processes and treatment implications - Translational Psychiatry

# data[].attributes.attachment_link.description
Translational Psychiatry - Biological factors influencing depression in later life: role of aging processes and treatment implications

# data[].attributes.attachment_caption
This chart details types of trauma according to different ages. It gives details on how the child could be affected.

# data[].attributes.body
This article details common reactions people have from disasters, helpful steps, as well as resources to recover. It covers information for children as well as adults.