FearSome

Do the Eyes Have It?

Sybil Lockhart, Ph.D. — Tue, 16 Jun 2009 17:21:13 +0000

A few years ago, my friend Ally, who had a somewhat unwarranted confidence in my knowledge of Things Psychological, asked if I knew anything about EMDR; she had suffered some severe childhood trauma, and was thinking of trying it. "EMDR?" I asked, "Is that a new street drug?" I guess that showed her what I knew. She explained that her therapist had suggested this relatively new technique, Eye Movement Desensitization and Reprocessing, that had been shown to ease symptoms of Post Traumatic Stress Disorder (PTSD) in soldiers and rape victims. From what she understood, the therapist would help her to focus on her devastating memories of childhood abuse while directing her eyes to twitch rapidly from side to side. This, according to her shrink, would help her to better "process" her memories. "Sounds like hypnotism," I expertly analyzed. "Who knows, maybe it will work." More recently, when I wrote here about the neurobiological advantages of emotionally "finding a safe place," several readers also wrote in to ask me about EMDR. Now I understand why people want an expert opinion (and I'm no expert, by the way): a heap of controversy surrounds this popular technique.

The guiding principle of EMDR proposes that normally as we store new memories, they are integrated into memory networks, connected to previous experiences, and attached to related thoughts, emotions, sensations or images, so they can be used in later situations. . Distressing experiences, however, are ill-processed, improperly stored in an "isolated memory network," according to the model.

These bad memories are stored exactly as they were perceived, along with the distorted thoughts and perceptions that occurred at the time, disconnected from relevant current information. Thus instead of simply remembering, the client has the sensation of actually re-experiencing the trauma, with intense emotional and sensory immediacy, long after the event; for example, a mugging victim, when a friend grabs her gently from behind, might experience intrusive images and sensations of the attack. In theory this happens when the unprocessed visual and sensory elements of her experience are conjured without any related information to temper them; she re-experiences her terror to its fullest degree. In EMDR, rapidly moving one's gaze from side to side and/or receiving other dual-attention stimuli (like bilateral tones or hand-tapping) is believed to enhance information processing in the patient's brain, so she becomes desensitized to the traumatic memory.

EMDR's creator, Francine Shapiro, stumbled upon the idea one day in the mid-1980's, when she took a walk in the park and had some disturbing thoughts. She noticed that her eyes were making spontaneous saccadic bursts upwards and to the right as she walked, and it occurred to her that these movements might be linked to the relief she subsequently felt; she hypothesized that the eye movements had helped her somehow to reprocess the information that had been troubling her. Shapiro's supporters see this intuitive and personal method of discovery as proof of her involvement in her work, whereas her critics find it less inspiring. At the time, Shapiro was searching for a dissertation topic, and she later earned her doctorate at the Professional School of Psychological Studies, which was never accredited and no longer exists. This is also seen by her detractors as a bit of a red flag. Yet she went on to develop a technique that has really caught on.

After her flash of insight, Shapiro tested her theory on her own patients, instructing them to conjure an image, negative thought, or bodily sensation associated with a traumatic memory and simultaneously shift their gaze, following her two fingers as she rapidly moved them from left to right. In 1989 she published her results, which she eventually developed into an eight-phase therapeutic treatment for trauma patients that integrates elements of many other psychotherapies with her eye-movement ideas, all with the aim of essentially pulling up a memory, reprocessing it, and properly integrating it in a memory network . During the key processing phases of this therapy, the patient pays attention to a disturbing memory in sets of 15 to 30 seconds while simultaneously following the dual attention stimulus (eyes following therapist's fingers, ears following tones, or alternate hand-tapping). After each set, the patient tells the therapist "what came up," and often makes this new material the focus of the next set. This process is repeated several times in succession.

Like many people before me, reading about this I scratched my head and wondered what evidence there was of these memory networks, isolated or otherwise. What proof was there that jerking our eyes back and forth would yank out the poorly processed memory and give us a re-do?

One researcher believed that EMDR could induce a physiological state similar to Rapid Eye Movement (REM) sleep, which has been shown to play an important role in memory consolidation. That sounded plausible. But more than anything, I wanted a some physiological evidence. What's actually happening in the brain and body while patients undergo this therapy? And the bottom line: Do the eye movements really make a difference?

After some investigation, I found the data to be roughly equivocal: about half the articles I read concluded that this technique works exceptionally well, and half concluded that it's not so great: either it is ineffective overall, or the eye movements are unnecessary, or it works no better than other therapies. It's a strange feeling indeed to read study after study and still come away so uncertain. I was not up to the task of doing an exhaustive analysis of the literature, so I am not about to argue it either way. Instead, I took a brief look at some work that began to address the physiological and neurological consequences of the eye movements.

One study I found particularly compelling explored whether the eye movement component of EMDR made a significant contribution to the subject's desensitization to a traumatic memory, and simultaneously monitored subjects' autonomic nervous system responses. Patients underwent regular EMDR, EMDR minus the eye movement component, or the same procedure substituting thumb-tapping for eye movement. In this case, EMDR with eye movements worked significantly better than with either thumb tapping or zero bilateral stimulation. Moreover, psychological desensitization to a traumatic memory during EMDR with eye movements was correlated with changes in patients' autonomic nervous system responses: breathing synchronized with their eye movements, heart rate slowed, blood pressure dropped, fingertips warmed, and galvanic skin response indicated relaxation. More recently another group looked at many of the same measurements plus a few more, and concluded that the eye movements during EMDR induced a nervous system response similar to that seen in REM sleep (which argues for a role in memory consolidation).

Possibly the most interesting physiological story I found was in a case study, which of course has none of the statistical power of the others. A patient whose PTSD was decreased significantly after EMDR was subjected to Single Photon Emission Computed Tomography (SPECT) before and after undergoing treatment. When he recalled the traumatic memory during brain scans, two areas of his brain lit up after EMDR relative to before: the anterior cingulate gyrus and the left frontal lobe. This is intriguing because the cingulate gyrus is thought to be involved in integrating emotional and mental components of the mind, and the frontal lobes seem to play an "executive" role in the integration of experience. I'd love to see combined scan data from 1000 PTSD patients.

Is EMDR a miracle cure? Because it is used to address isolated events rather than a patient's entire life, this technique often yields quick results, giving the impression of a particularly effective treatment, and it is now being tried for a range of complaints other than PTSD. Some physicians seem worried that this method will be mistaken for a magic bullet to replace more traditional methods of psychotherapy. But from everything I have read, no matter whether one chooses to believe the naysayer or the evangelist, EMDR appears limited in scope. My friend Ally tried it. She reported that it seemed to help with the particular memory she had focused on, but it had not resolved her issues around trauma that had been on-going over many years. She said she didn't see herself going back to address instance after instance of childhood abuse using EMDR.

If traditional psychoanalysis is akin to regular auto maintenance and quarterly tune-ups, perhaps EMDR could be compared to replacing a fuse: important and necessary, maybe even crucial, but often insufficient for long-term functioning of the entire vehicle. It is very important to address specific events, especially in the case of severe PTSD, but from here it seems that just like anti-depressant drugs, EMDR should be considered not as a universal balm, but as a handy tool to use in conjunction with traditional methods.

Early Morning Courage

Sybil Lockhart, Ph.D. — Wed, 08 Apr 2009 19:03:42 +0000

One of the reasons I decided to write a blog about fear and courage was that I kept waking up between the hours of 2 and 4 a.m. with a thumping heart, overwhelmed by the avalanche of fear I had for my children, my bank account, and my poor suffering planet. I figured that if I was afraid, others must be also. And this seemed to be true—an informal survey revealed that many of my friends awaken in the wee hours of the morning, too. Some of my female friends, who are almost all between the ages 30 and 50, figure this might be due to impending menopause, but many of the comparably aged men I know have also begun to experience early morning insomnia—so if this is peri-menopause, then there must be a male peri-menopausal correlate. What we all have in common is that we wake up suddenly, besieged by our worries, as though everything we've had to put off thinking about during our busy day has suddenly caught up with us at 3 am.

As a child, I was a solid sleeper, and as a teenager, I loved sleep more than almost anything else. Sleep was a beautiful, simple pleasure to me—a yummy, sensual experience. I relished Saturdays, when I could stay there for ages, pulling the covers over my head when the sunlight hit my pillow, and sinking down to re-immerse myself in the pure, enveloping sweetness of dreams. (I had vivid, insanely adventurous dreams, dreams of flying and high-speed chases, in color, with beautiful music and delicious food.) My mother and sister got upset when I slept in past 1 pm—they thought I was depressed—but I didn't use sleep as an escape; I was just taking advantage of one of life's greatest pleasures. Since then, psychologists have decided that teenagers just have a different sleep cycle, and that this late-shifted behavior is physiologically normal for them.

The first time I experienced disrupted sleep was late in my first pregnancy, when I arose every 3 to 5 hours for a sleepwalk to the ladies room and back—a lightweight prelude to nursing every 2-3 hours in the months that followed. Nursing required a bit more attention, but still I always fell back to sleep immediately. And up until recently, I had rarely spontaneously awoken in the middle of the night to have coherent thoughts I actually consciously processed.

When it started, I was alarmed; I thought, wow, I must be really stressed right now. But when I looked at what was expected for my age group, I found that my new pattern of sleeping fewer hours and waking up earlier in the morning is not so unusual—although the medical community seems rather intent on pathologizing it. One study showed that sometime between the ages of 35 and 60, most healthy adults begin to experience a reduced need for sleep. This is not a sleep disorder; it's just a reduction in the maximal capacity for sleep, and a shift toward earlier bedtime and earlier rise time. But even this study, which considered only healthy adults, carried the subtitle, "implications for insomnia."

Much of the work done on peri-menopausal and post-menopausal women has the same tendency to define differences as problems. For example, when one group found that hormone replacement therapy didn’t help with insomnia, the authors proceeded to speculate that the insomnia might reflect an independent sleep disorder or "unresolved grief" from going through menopause! But why insist that a period of nighttime wakefulness at this life stage be viewed as problematic? Why do we think we need to replace hormones to "fix" it? As the previously-mentioned study on healthy sleep pointed out, failure to recognize our reduced need for sleep may lead us to stay in bed longer than necessary—and then complain of troubled sleep and early awakening. This might in turn lead physicians to label our sleep patterns "disordered" or "disturbed." What if, instead, we presumed these patterns physiologically normal, perhaps even adaptive, and set about making good use of them?

I've begun to try out this idea myself when I wake up at 2 am. I know this may be the hormones waking me up, so I ask, is this a hot flash? (So far, no.) I consider how I feel in that moment (not as worried as I thought). And I pay attention to all the issues that are coming up for me—that upcoming job interview, the book readings, the kids' birthday parties, the class I have to teach Monday afternoon. Instead of worrying, I hold each item in my mind. Sometimes I ask for help: "Please help me figure this out," I say to the Powers That Be. I have come to respect this time, this still, dark, calm pool of night I find myself in, as a respite. No one will interrupt me to ask if I'll make them mac and cheese; my cell phone won't ring. This is my time—usually about 10-20 minutes of it—to line up my ducks, to consider any unresolved issues from the previous day, to open my mind to the possibilities for tomorrow.

I find when I handle it this way, I often go back to sleep and dream rich and vibrant dreams in my remaining one or two hours of sleep. This is reassuring, because maybe it means I'm not losing out on that crucial Rapid Eye Movement sleep some researchers believe to be necessary for memory consolidation. In fact, maybe part of what my brain processes during those final dreams is the very material that I just produced: the solutions. Midlife is a time of wisdom and power. Maybe we don’t have the opportunity or the physiological predisposition to sleep in until noon, but embracing our early morning thoughts, instead of worrying that we are worried or panicking that we are panicked, may just be the developmentally appropriate response for a busy grown-up on the go.

Blind Terror Meets Bunny Empathy

Sybil Lockhart, Ph.D. — Wed, 25 Mar 2009 21:15:56 +0000

Our first born, who has asked to be called Alice, started out as a dog lover. In fact, she took her first steps in pursuit of three frolicking pups. She fearlessly toddled to the panting dogs, giggling with delight when they swiped at her cheeks with their long pink tongues. We thought that was it; she'd be a dog lover for life. But around age four, she began to recoil when dogs jumped to greet her; suddenly she seemed to perceive their open mouths and high energy as threatening. By third grade her terror had deepened to the point where even a small dog trotting down the opposite side of the street could send her leaping into my arms with a shriek. She had developed a terror, a real phobia, that has persisted through most of sixth grade, though it has begun to diminish. I have some new thoughts about how to approach this old fear.

A phobia is a severe fear reaction that occurs in situations that aren't really dangerous. People develop phobias of many things: needles, heights, public speaking, flying, and small animals are all common phobias. Some people believe these irrational fears are the result of conditioning; for example, a highly traumatic experience with a dog could have conditioned Alice's fear of dogs, or she might have observed another person's extremely fearful response, with the same effect. But, as is often the case, there was no precipitating event that we are aware of; she just got scared.

Many people think the best way to counter a phobia is to decondition the patient, or train her to react more appropriately. This is achieved by very gradual exposure (sometimes called in vivo exposure) to the thing she fears, allowing her to experience the fear and stay with it, so she becomes desensitized to the horrible anxiety (and less likely to suddenly leap into a loved one's arms on the side walk).

Alice was partially deconditioned by two Welsh Corgis named Sachmo and Nelly, frequently tethered outside the girls' school. Kind and mellow, these two did not chase or slather, and rarely barked; they merely lifted their weary heads to be petted as the children filed past. After months of acute avoidance, Alice followed her little sister's lead—I'll call her Chloe; four years younger, she was a steadfast dog lover—and tentatively patted them; these daily safe encounters added up, and eventually Alice became quite fond of Sachmo and Nelly. But now, at almost twelve, she still gets flighty around canines. Some part of her still can't quite distinguish between a friendly animal and serious threat.

Almost-eight-year-old Chloe would have had her first puppy years ago if it hadn't been for landlords and her dad's and sister's allergies. She can't have a dog, but this week she finally received her first furry pet: a foster rabbit named Mister Bubbles. The addition of this timid little cream-colored Netherlands Dwarf, this four-pound weakling with his quick-beating heart and soft, quiet hop, has transformed our household.

Each of us reacts differently to his gentle presence in our home. Chloe is his official guardian: she changes his litter, refreshes his water, and feeds him a morning carrot chip to be sure his appetite is up. He climbs on her lap and follows her around the room, and she repeats longingly, "I love him so much," as if she just can't believe she has feelings this strong for him so soon. Late at night my husband Pat lies on the floor to watch TV, while Mister Bubbles roams companionably around the living room. I sneak down at the crack of dawn to commune with him while I drink my morning coffee. And when Alice returns from school, she climbs into his cage, quietly approaches, and very gently strokes his silky ears.

Watching her with the bunny, I've been thinking about Alice's dog phobia. I see an opportunity for something more like cognitive therapy (replacing anxious thoughts with more realistic ones). It begins with the fact that Alice has empathy for the bunny. Mister Bubbles is about as scared a little individual as ever there was. Next to him, Alice, always a small kid, is suddenly the big, threatening beast. He goes all fluttery when she touches him; now she is the dog. But she understands the bunny.

I think this empathy might allow her to see her fear of dog-animals in a new light. Mister Bubbles is not a lesser version of a dog (a small puppy, or a faraway dog) for deconditioning; he is the picture of her normal state. And now in a position of scaring him, she can see there is no reason for him to be afraid of her; she's nice; she's safe. So she experiences, on a gut level, the fact that there are trustworthy large beasts, and that if a bunny can just learn to identify them, if she doesn't generalize unduly, she will be safe.

This empathy for another soul is what allows us to walk down the street alongside people who may scare us—maybe they resemble someone who once hurt us—and understand that although they appear to be similar, they are not necessarily dangerous; that there are fine criteria upon which we may judge a potential threat; that making broad generalizations like "all dogs are scary" can even make us more vulnerable.

Alice aches to confront that bunny's fear with reason: learn that I am a nice person who will take care of you, she urges him (learn that I am a safe, friendly dog). Will this empathy with the bunny help her learn to differentiate between safe and dangerous dogs? Will it extinguish the last bits of dog-fear lodged in her soul? That remains to be seen. But I am willing to bet that it has moved her forward a notch. And I'll be interested to see how her progress in dog phobia deconditioning will be enhanced by Bunny Empathy.

The Search for Non-Pharmaceutical Courage

Sybil Lockhart, Ph.D. — Thu, 19 Mar 2009 00:04:43 +0000

I'm afraid. I'm afraid the savings will run out before the husband's start-up begins to make money. I'm afraid I'll get Alzheimer's just like my mom. I'm afraid of the too-fast, un-patrolled street my 2nd grader crosses on her way to school.

This fear is so tangible, so visceral. I fear a perceived threat-the 8th grade boy who was texting my 6th grade girl the other night at bedtime-and my brain sets off a general alarm, an involuntary reaction; my nervous and endocrine systems shift into high gear. This is presumably a self-preservation mechanism, and it might be helpful if I were being attacked by a bear. I'm flooded by stress hormones and neurotransmitters like adrenaline that increase my heart rate and blood pressure, constrict my blood vessels, and tighten my muscles; they wash over my amygdala, a little brain nubbin that processes emotions, and it promptly stores an imprint of my fear deep within its cells.

What to do? I could pop a valium to sleep, take some aspirin to thin my blood, and hope for the best. Or, if I wanted to rid myself of a particular bad memory, I could try erasing it. When we revisit a painful memory, there's a special period of neurobiological flexibility before the memory is placed back into long-term storage; during this critical window if a patient is given drugs that cause amnesia, the memory—and the fear and stress that accompany it—may be diminished, or even abolished. In one study just after patients' fearful memories had been reactivated, they were given beta blockers, which interfere with the action of stress hormones on the body and brain. In this case the patients' fearful emotions were diminished, while their memory of events remained intact. Trials are underway to test whether people suffering from Post Traumatic Stress Disorder (PTSD) might benefit from these kinds of treatment.

Although these findings are certainly exciting, the idea of memory erasure raises many ethical dilemmas. Besides, most of us are not suffering from severe PTSD; the ordeals we seek to overcome are much less extreme. And for people like me, drugs just create more fear: fear of the drugs' side effects; fear that I'll become dependent on chemicals for my emotional well-being. What if I want to feel better without chemical intervention?

Since childhood I have carried an image of the king's bravest soldier, stalwart, forging ahead in a land of peril. He walks through his fear, a-sparkle in his glory: not fearless, but courageous. That soldier is really living. I want to be like him. So maybe my fear won't go away; maybe I just need help getting through it. What can I take for that?

My answer might be a disappointment to people looking for a one-drug answer. I think we're often so focused on our search for the magic pharmaceutical bullet that we fail to consider the existing solutions. Courage may lie not in a drug, but in building up our belief that we can walk through fearful situations and remain intact-the old-fashioned way.

Therapy, support groups, and spiritual and religious community can help us feel safe to persist in the face of adversity. But do they literally change our minds? Can they can fix my brain, rewrite my amygdala's deep-seated fear-based memories, tip the balance of neurotransmitters in my circuits? I like empirical evidence; I'd like to see my soldier's courage on a hi-resolution brain scan. So I was happy to read about one recent data-packed study supporting the idea that "finding a safe place" emotionally has serious neurophysiologic consequences.

In this study mice were trained to associate safety or fear with specific electronic tones: for fear conditioning, a tone was paired with a shock to the foot, and for safety conditioning another tone signaled there would be no shock. Mice that had been trained to associate a tone with assured safety were found to be significantly more resilient under adverse conditions and less depressed by stressful situations than their cell mates with no learned safety training . In other words, when they knew there was a chance to be safe, they could return to their happy place. And these effects were discernable at a neurophyiological level.

In mice trained to feel safe, levels of a growth factor called BDNF increased, causing more neurons to be born in the dentate gyrus, a brain structure that contributes to new memories.These new cells were necessary for successful safety conditioning. In the amygdala, where fear memories are thought to be stored in the brain, learned safety also ramped up key dopamine neurotransmitter and neuropeptide systems that affect learning, thought and mood. In other words, this conditioning brought about unambiguous physical and chemical changes the brain.

I find this so gratifying. When my husband quietly reminds me that things are actually okay at the moment, or when I spend time with family and friends and think my happy thoughts, maybe I'm growing myself a new lawn of dentate gyrus cells and watering it with fresh BDNF; maybe a nice batch of neurotransmitter system components is brewing in my brain. Maybe these concrete biological changes will give me concrete, biological courage. In which case I can soldier on with confidence.