The Efficacy of Eye Movement Desensitization and Reprocessing (EMDR) in Patients With Post Traumatic Stress Disorder in Multiple Sclerosis. A Randomized Controlled Trial.

Multiple Sclerosis (MS) is a chronic neurological disease of the Central Nervous System (CNS) that affects both the brain and the spinal cord by destroying the myelin sheath that protects the nerve fibers, leaving plaques or scars on the damaged sites. MS shows a wide range of psychological and psychological-related symptoms, including psychiatric aspects, fatigue and cognitive deficits. In particular, there is a strong evidence of psychiatric disorders associated with MS, the most common being depression, adjustment disorder and anxiety. These occur more frequently at the time of diagnosis communication, during the earlier phases of development of the disease and during relapse episodes. Some studies report a significant association between stressful life-events and relapses, in some cases pointing to frequency and number of stressors as an enhancing factor that can predict a relapsing episode.

The patients may experience distress not only in association with external stressors, but also in relation to the onset or the progression of the disease itself. Diagnosis, relapsing episodes and a worsening of physical functioning may be perceived as traumatic events and may give rise to physiological and emotional posttraumatic symptoms and, in some cases, to Post Traumatic Stress Disorder (PTSD). According to the DSM IV-TR, PTSD is a clinical condition characterised by "the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury or other threat to physical integrity. The person's response to the event must involve intense fear, helplessness. The characteristic symptoms resulting from the exposure to the extreme trauma include persistent re-experiencing of the traumatic event, persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness and persistent symptoms of increased arousal. The full symptom picture must be present for more than one month and the disturbance must cause clinically significant distress or impairment in social, occupational or other important areas of functioning" [DSM IV]. Many psychological treatments are available for PTSD, ranging from individual therapy to family therapy and support groups together with interpersonal, relational and psychodynamic psychotherapies; their focus is to desensitise the trauma memory and the meaning of the trauma as well as its power to affect relationships. Among these therapies, the two elective treatments according to international guidelines are the Trauma-focused Cognitive-Behavioural Therapy(CBT-TF) and Eye Movement Desensitisation and Reprocessing (EMDR). CBT-TF focuses on thoughts and beliefs helping people to overcome fear about their painful memories by talking about the trauma repeatedly or by imagining the situation that is realistically safe although still frightening. EMDR is based on the accelerated information processing model integrating elements of different psychotherapies and it is applied through an eight-phase approach. In the EMDR, the patient is induced to focus on his/her negative thoughts, image and body sensation while receiving an "alternate stimulus" (such as eye movements, hand taps or sounds). This procedure leads to desensitisation and emotional reprocessing.

The aims of the study are aim to evaluate whether a treatment based on the EMDR protocol can resolve PTSD or reduce PTS symptoms, also improving the PTS-associated symptoms, such as anxiety and depression. Primary objective : to evaluate the efficacy of the treatment with EMDR on the PTSD in MS. Secondary objectives : To evaluate whether after treatment with EMDR there is an improvement in PTS-associated symptoms of anxiety and depression and an improvement in quality of life.

The recruitment of the patients proceed with a two-step screening: 1) the Impact of Event Scale Revised (IES-R) will be administered to consecutive patients corresponding to the neurological inclusion and exclusion criteria, specifying in the instructions that they consider only the illness as the traumatic event. 2) Patients with scores above the cut off of 33 will be assessed with the SCID in order to confirm diagnosis of PTSD. The research protocol will be proposed to patients with PTSD who meet the inclusion/exclusion criteria, with an explanation of the aims of the study, its relevance for MS patients and the possibility that they may be included, by random assignment, in the treatment or control group for the period of the study, with the same timing and assessment tools. If they agree, they sign the informed consent. Patients will be randomised to the intervention (A) or control (B) group using a block-wise randomisation sequence (block size of 10). Assessment Measures: All patients are evaluated by neurologists with the Expanded Disability Status Scale (EDSS).

The psychological assessment of the patients entering the study will be performed at T0 (baseline evaluation), at T1 (post-treatment evaluation after 12 weeks) and at T2 (follow up evaluation six months later) to determine the reliability of the results.