Innovations In Clinical Neuroscience

JAN-FEB 2018

A peer-reviewed, evidence-based journal for clinicians in the field of neuroscience

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C A S E R E P O R T 46 ICNS Innovations in Clinical Neuroscience • January–February 2018 • Volume 15 • Number 1–2 Philomela resumed socializing and stroke- related therapies (including 7 more months of speech therapy, which resulted in some improvement in using a speech-generating device), but she continued to experience severe expressive aphasia. However, depression insidiously returned, culminating in a serious suicide attempt. Bupropion was started to augment escitalopram and because it lacks anticholinergic activity. This resulted in modest improvements. Additional therapies (e.g., psychotherapy, music, art, yoga, cognitive rehabilitation) were recommended but difficult to find or inappropriate due to limitations, so EMDR was suggested. Measures . All measures were clinician- administered due to aphasia. Depression severity was assessed using the Patient Health Questionnaire (PHQ-9), a commonly used 0 to 27 scale. EMDR's standard assessment tools assessed progress: Subjective Units of Disturbance (SUD), a 0 to 10 scale with 10 indicating the worst distress; Validity of Cognition (VOC), a 1 to 7 scale with 7 indicating the strongest belief in a positive cognition; and Body Scan, which systematically attends to body parts for sensations. Treatment . EMDR began 24 months post-stroke with weekly one-hour sessions. The first three sessions involved history-taking, preparation/education, and assessment (identifying images, positive/negative cognitions, emotions, VOC, SUD, and bodily sensations associated with target memories). These were greatly aided by her husband (whom she requested to be at all sessions) and with lists of cognitions/emotions. She selected three target events to process using desensitization (reducing distress with sets of BLS) with cognitive interweaves (brief clinician statements/questions between BLS), and installation (enhancing positive self- referencing beliefs using BLS). Using a biopsychosocial formulation based on history-taking/assessment, the clinician generally could hone guesses that Philomela would confirm/deny. It was important not to rush offering alternatives even after an emotion/cognition was agreed with (i.e., she would often identify better words to describe what she was feeling/thinking). Nevertheless, occasionally Philomela's thoughts could not be communicated/guessed. Two target memories were identified—stroke and suicide attempt—but a third event remained elusive, even after listing potential traumas/stressors and administering the Adverse Childhood Experienc e Questionnaire. 19 The unidentified event was narrowed to occurring "25 years ago," which became its cue phrase. It was harder to guess related cognitions/emotions, but she acknowledged having the words in her mind that could be cued (e.g., "negative belief "). As recommended in B2T, where the therapist cannot assess "change," Philomela was taught the nature of change in EMDR and was instructed to use nods/shakes or yes/no similar to a case report involving stuttering. 12 Desensitization was initially difficult: she required frequent reminders about the nature of change, feedback was often stalled by aphasia, and it became clear that high numbers of rapid BLS passes were necessary for change (she reported no change with too slow/few, 50 were generally sufficient following positive changes, but 100 were needed otherwise). When she could not verbalize feedback, she was reassured that EMDR can work even with internal processing without the clinician knowing specifics. Gradually, the process became more familiar, and the clinician became more attuned, leading to better guesses. A workable pattern developed in which the following steps were repeated again and again: 1. BLS 2. Deep breath 3. Time to respond 4. If unable to verbalize, "is it a feeling?… thought?… image?… or body sensation?" 5. "Is it positive or negative?" 6. Clinician guesses 7. Whether or not the change could be identified, BLS resumed +/- cognitive interweave. Results . Table 1 displays how the rate of progress improved exponentially, resulting in improved depression. When processing stalled, cognitive interweaves became very effective (e.g., "Can someone require a lot of help and still be a worthwhile person?"; "If your child was in a wheelchair, would you still think they were a worthwhile person?"; "Even if your stroke symptoms never improve can you still live a good life?"; "Can you have physical limitations and still be loved and important to others?"). Philomela often gave surprisingly negative responses to cognitive interweaves, but with continued BLS and returns to target, positive changes eventually occurred and became sustained. At four months post-EMDR, depression remained remitted with her return to a full social life and enjoyable activities, reinventing her life within her physical/speech limitations TABLE 1. Patient's improvement in SUD (0–10), VOC (1–7), Body Scan (+ = positive for bodily sensations; - = clear body scan), and PHQ-9 (0–27) EVENT/SCALE ASSESSMENT SESSION 1 SESSION 2 SESSION 3 SESSION 4 SESSION 5 1 SUD VOC Body Scan 9 2 + 3 - - 1 - - 0 7 - - - - - - - 2 SUD VOC Body Scan 7 4 + - - - - - - - - - 0 7 - - - - 3 SUD VOC Body Scan 3 6 + - - - - - - - - - - - - 0 7 - PHQ-9 (severity of depression) 24 (severe) - - - - - - - - 5 (minimal) SUD: Subjective Units of Disturbance; VOC: Validity of Cognition; PHQ-9: Patient Health Questionnaire

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