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 47 ICNS Innovations in Clinical Neuroscience • January–February 2018 • Volume 15 • Number 1–2 While our target had been depression, there were subjective (i.e., reported by patient, family, and clinician) improvements in aphasia, initiation, and verbal apraxia. She started using multisyllabic words (e.g., "heaviness," "positive," "emotional," and "contentment," the latter being said without first being said by the clinician, astounding herself and her husband), verbalized things the clinician had been unable to guess (e.g., the third event) and, in her last session, she said her husband's name for the first time in two years. He admitted being skeptical of EMDR originally but happily said, "she made more progress in two months with this than in over a year of speech therapy." DISCUSSION In Greek mythology, Philomela was raped and her tongue was cut out to keep her silent. Rendered unable to speak, she wove a tapestry of her story and was turned into a nightingale by the gods to escape her tormentor (while male nightingales sing, females are mute). Like the Greek Philomela, our case involved a woman who was rendered unable to speak. Through EMDR, she was able to process her story nonverbally and was able to take flight into a worthwhile life. While known to be effective for depression, we can only speculate how EMDR helped this specific patient. EMDR activates the frontal lobe, 20,21 which might explain its utility for PSD and, perhaps, the surprising improvement in aphasia. Stress-induced deactivation in Broca's area has been repeatedly implicated in the difficulty that trauma survivors have when discussing traumas. 22–25 It is conceivable that EMDR and antidepressants enhanced frontal lobe activation and neuroplasticity. Table 2 summarizes considerations for EMDR with aphasia. Anticipatable issues include regularly explaining change, trouble identifying cognitions, and more time needed in all phases. While initially distracting, the husband's presence was likely beneficial as he provided collateral information, improved guesses, and was able to bear witness to her struggles and successes. Helpful preparation included consultation, literature searches, and organizing visual scales and lists of emotions/cognitions. It should be noted that our patient had only expressive aphasia, as her comprehension issues had been successfully treated by a speech-language pathologist; EMDR might lack utility for those with receptive aphasia. As a single case report, further research is required to determine EMDR efficacy for mental disorders with comorbid aphasia. Not expecting speech improvements, we did not use objective measures as we did with depression, so the aphasia findings are anecdotal. It is possible that aphasia seemed to improve because the therapist became more familiar with her, or only secondary to reduced depression (e.g., perhaps it was not the "aphasia" that improved but rather the patient's ability to connect with others due to remission of depression), or that symptoms improved because of the husband's presence (e.g., his attention helped lift her depression), but the clinical observations warrant further research. Irrespective of aphasia, this study indicates that EMDR can be effective for PSD TABLE 2. EMDR phases with recommendations for aphasia patients General • Empathize and reassure patient about speech limitations and EMDR • Establish safe and non-judgmental setting regarding speech limitations • Build rapport by normalizing common feelings associated with aphasia • Emphasize collaborative process to problem solve and communicate • Encourage/praise verbalizing but reassure/move on when unable to verbalize • Use closed-ended questions to speculate and deduce patient's thoughts • Supply likely emotions and cognitions based on formulation and assessment • Guess by following the affect, and looking for themes or incongruences • Expect a slow process and take all the time that is necessary History taking • Determine communication capabilities, and factors that may help or worsen • Determine memory, attention or other deficits that may impact treatment • Determine realistic prognosis of stroke-related deficit recovery • Obtain collateral history from trusted friends/family with patient permission • Utilize validated questionnaires to illicit unapparent symptoms/history • Develop a coherent formulation of symptoms and underlying factors Preparation • Educate about nature of change and self-assessment of change • Agree upon verbal and non-verbal signals for change • Determine if motor/sensory deficits could impede bilateral stimulation • Consider use of communication devices, pictures or symbols Assessment • Educate the difference between emotions, cognitions, sensations and images • Utilize lists of emotions and cognitions to improve guessing • Agree upon cue words/phrases for thoughts that cannot be verbalized • Use visual scales for SUD and VOC Desensitization/ Installation/ Body Scan • Empower patient-centered setting • Patient may require slower or faster passes depending on deficits • Check-in about level of arousal since affect may be masked by motor deficits • Continuously educate about nature of change and self-assessment of change • Utilize lists to help deduce blocking beliefs • Utilize formulation to target cognitive interweaves • Use closed-ended Socratic questions • Consider stroke-related ecological validity (e.g., realistic expectations about full neurological recovery, body sensations that are unlikely to resolve) Closure • Summarize changes • Debrief about patient experience using closed-ended questions • Validate/affirm/reinforce strengths and gains • Consider ending with safe place (which requires no verbalization) Reevaluation • Determine if memory deficits necessitate repeating past processing EMDR: Eye Movement Desensitization and Reprocessing; SUD: Subjective Units of Disturbance; VOC: Validity of Cognition

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