Alberto Spalice, MD, PhD
Department of Maternal Sciences
Child Neurology Division
University La Sapienza Roma Italy
Cristiana Alessia Guido, Psy D
Department of Maternal Sciences
Child Neurology Division
University La Sapienza Roma Italy
PANS and PANDAS: An Interview on EMDR in PANDAS
Thank you to Dr. Alberto Spalice and Dr. Christiana Alessia Guido for allowing Neuroimmune Foundation director and founder, Anna Conkey to interview them. Their full paper, Eye movement desensitization and reprocessing (EMDR) treatment associated with parent management training (PMT) for the acute symptoms in a patient with PANDAS syndrome: a case report is here.
Thank you so much for taking the time to talk to us about the use of EMDR in PANDAS. You published a case study in 2019. Can you give us an overview of the case and what you found?
The case concerned an 11-year-old boy who was diagnosed with PANDAS/PANS. The syndrome was characterized by the presence of elevated Antistreptococcal and antiDNAse titers, associated with acute onset of simple and complex motor tics, oral tics, obsessions and compulsions (fear of contamination, aggressive behaviour, superstitions, repetitive compulsions, religious compulsions, etc.), irritability and anxiety. A deterioration in writing (micrographia) was also observed.
The boy suffered from recurrent familial streptococcal infection; moreover celiac disease was also diagnosed. He had been prescribed courses of antibiotic therapy and penicillin which reduced the symptoms, however, in periods of severe stress, the tics, irritability and compulsions were exacerbated.
Investigating the environmental factors, from the anamnestic interview emerged that the patient’s father suffered from OCD and tics during childhood, while his mother suffered from thyroid cancer, Hashimoto’s thyroiditis and depression. Moreover, after PANDAS’ diagnosis the parents feared that the child might get worse to the point of generate in them an environmental hyper-control which translated into hyper-cure in medicalization with rigid impositions and consequent punishments. This important change had reduced the boy’s quality of life by inserting him in a series of adverse experiences without the possibility of expressing the emotions that had generated anger and sense of helplessness and ineffectiveness in him. Through the work with EDMR the boy showed great improvement in motor and vocal tics after treatment, as well as a marked reduction of obsessions and compulsions.
Will you describe for those unfamiliar with EMDR how the process works?
The Eye Movement Desensitization- EMDR, is based on the Adaptive Information Processing model – AIP (Shapiro, 1955), according to which the experiences processed are the basis of mental health. Unresolved trauma or loss, caused by recurrent, difficult and emotionally important childhood experiences, can inhibit the normal processing of memories by interfering with the recording and storage mechanisms of autobiographical memory. Information linked to traumatic or stressful experiences is not always fully processed, so the initial perceptions of the event and the biochemical responses elicited by it (adrenaline, cortisol, etc.) would block the brain’s innate information processing system, leaving isolated in a neurobiological stasis the information linked to the trauma. This information would remain trapped in the neural network along with the emotions, negative self-beliefs and physical sensations that existed at the time of the event. Traumatic memories therefore cause an interruption of the normal adaptive processing of information that is not processed and remains blocked in a dysfunctional way in the memory networks.
Some research has shown that EMDR favors the transition from activation from limbic regions (seat of emotions) to cortical regions (Pagani, 2012), so through a process of desensitization towards memory and cognitive modification of personal patterns, during the EMDR session, the patient distances himself from the memory and modifies the negative beliefs about himself by incorporating adequate emotions and eliminating the disturbing physical sensations.
EMDR is an integrative therapeutic approach divided into 8 phases. It starts with the conceptualization of the case and the identification of the target, that is past event that acts as a trigger for the patient’s current disorder. Emotions, negative cognitions and bodily sensations related to memory are then traced (History taking and Preparation). Through various steps (Assessment and Desensitization) in which the therapist facilitates the processing of the patient’s memory through bilateral ocular stimulation (BLS), participating in the session without interfering with the process of processing the patient’s memory, the process of adaptive information processing is it concludes with the installation of new positive self-knowledge (Installation) and monitoring of any symptoms of discomfort related to the original memory still present in the patient (Body Scan, Closure and Reassessment).
In the case you described, there was a history of trauma. Was the EMDR therapy focused solely on resolving this traumatic experience and if so, was trauma the trigger of the PANDAS symptoms?
In the case we discussed, the trauma was not the trigger of the PANDAS symptoms, but in contrast, the onset of Pandas was a traumatic event for both the boy and his family. EMDR therapy was used with the dual objective of treating both the change generated with the onset of the disease as a traumatic event and the attachment relationship between child and parent which presented some problematic aspects from early childhood. These aspects were further compromised with the onset of the disease. According to this perspective, we can therefore say that the symptoms related to the syndrome (irritability, obsessive-compulsive traits, sense of inadequacy and helplessness), were amplified by the negative cognitions that the boy had developed about himself as an effect of the dysfunctional relationship with the father. For this reason, the EMDR treatment was accompanied by sitting parent training aimed at the boy’s parents, showing high efficacy in reducing symptoms. A factor that favored the resolution of the problem was in fact constituted by the reduction of the relational conflict between father and son and the acquisition of more mature strategies in the parents to deal with the sudden behavioral changes of the boy. Through parent training, parents have reduced over-control over the child and modified symptom containment strategies. Through Emdr the boy installed new positive knowledge about himself and new resources that led to more effective coping strategies.
Does EMDR therapy have a possible application in PANDAS where there is no history of trauma?
EMDR can be considered by therapists as a useful tool to use in situations where observable symptoms are the product of negative experiences that disorganize the person’s neurobiological system and impact on his identity by involving his emotions, beliefs and feelings. Therefore, the assessment phase with the patient is a very important moment for planning the therapeutic treatment deemed most suitable for the individual case.
In the case presented, as described above, the dysfunctional management of the boy’s pathology by the family members did not favor the containment of symptoms by subjecting the patient to negative experiences that exacerbated a relational conflict already present from childhood.
Instead, where a less complex situation arises, the scientific community has shown that Cognitive-Behavioural Therapy – CBT, represents the most effective treatment for Pandas / Pans (Swedo SE, Frankovich J, Murphy TK. Overview of treatment of pediatric acute-onset neuropsychiatric syndrome. J Child Adolesc Psychopharmacol. 2017; Sep;27(7):562–5.) The clinician must therefore identify, according to his experience, the most appropriate treatment methodology.
In what ways can EMDR therapy help with OCD, intrusive thoughts, repetitive loops, etc?
EMDR should be used when the patient with OCD does not respond to standard treatment with CBT (exposure with prevention of response – ERP). According to some authors, traumatic life experiences may be the explanation for the development of acute and chronic OCD, as something comes from 82% of therapy-incident patients have experienced trauma and 50% meet the criteria for post-traumatic stress disorder (PTSD; Gershuny, Baer, Parker, Gentes, Infield and Jenike 2007). Research shows that to achieve optimal progress in OCD treatment, use an integrated approach traetment (ERP Therapy and EMDR) both desensitization in vivo and past events associated with OCD (Luber 2017). Through the EMDR the patient takes the attention that the disorder / symptom is a way of coping, of managing stress. The work on the events that make up the history of the disorder and on the triggers, together with the installation of new coping strategies (protocol of the future) leads the patient to face the trigger situations (CRSP, Fernandez 2016).
Can EMDR help resolve rage, anxiety, or other troublesome symptoms?
There are specific protocols for the treatment of various problems including anxiety and mood disorders. In general, EMDR working on events related to the onset of the symptom favors its reduction or extinction.
It has been about a year since you published the case study. Can I ask how this young man is doing today and if his gains from EMDR therapy have stuck?
The boy was monitored over time through interviews with his parents. Since the end of EMDR therapy, parents have observed periods of increased irritability and the presence of mild tics in the child that have never reached acute stages. The periods indicated correspond to changes in the boy’s routines (return to school, interruptions of some activities) or with requests for results from outside (music or school exams). In the rest of the time the symptoms were not present. Parents also have access to having reduced the overcontrol on the child who was exercised with the imposition of rigid rules and also administered with an excess of medical visits or drugs. The same have in fact understood the psychological aspect can determine the exacerbation or the reduction of the symptoms therefore they have adopted more flexible behavioral strategies giving more autonomy to the child.
The boy also definitively stopped penicillin therapy which he had also used for years for prevention purposes.
Thank you so much for your time Dr. Spalice and Dr. Guido. This was really interesting.
An EMDR webinar is available to members of the Community Room