174 Journal of EMDR Practice and Research, Volume 9, Number 4,.docx

174 Journal of EMDR Practice and Research, Volume 9,
Number 4, 2015
© 2015 EMDR International Association
http://dx.doi.org/10.1891/1933-3196.9.4.174
of 5.7 years (Security Public Secretariat, 2010). The
National Report on Violence and Health (Secretariat
of Health, 2006) indicated that between 55% and 62%
of boys and girls had suffered some kind of mistreat-
ment (physical, emotional, or sexual) at some time in
their lifetime. Unfortunately, Mexico has a lack of of-
ficial and specific data about sexual violence against
children, but it is considered that for every case known
by authorities, there are 100 cases more that went un-
reported (Security Public Secretariat, 2010).
Sexual abuse can have substantial detrimental im-
pacts, affecting the child’s development in various
ways (Hornor, 2010; Ito, Teicher, Glod, & Ackerman,
1998; Navalta, Polcari, Webster, Boghossian, &
Teicher, 2006; Tyler, 2002). Jenkins, Langlais, Delis,
and Cohen (1998, 2000) found that learning and mem-
ory were affected among women who experienced
sexual assault and who presented with posttraumatic
stress disorder.
R
esearch has shown that posttraumatic stress
disorder (PTSD) is associated with structural
brain alterations (Kühn & Gallinat, 2013) and
multiple cognitive deficits (Scott et al., 2015). Neuro-

cognitive deficits include impaired verbal learning and
verbal memory, slowed information processing, and
impaired attention and working memory. Although
the treatment implications of these deficits are con-
cerning, very few studies have specifically examined
the effect of treatment on neurocognitive deficits. In
this case study, we examined several neurocognitive
variables before and after eye movement desensitiza-
tion and reprocessing (EMDR) therapy that focused
specifically on the traumatic memories of a young
woman who had experienced childhood sexual abuse.
Childhood Sexual Abuse
Mexico has high rates of childhood sexual abuse; girls
are the principal victims (77%) with an average age
Neuropsychological and Physiological Outcomes Pre- and
Post-EMDR Therapy for a Woman With PTSD: A Case Study
Benito Daniel Estrada Aranda
Nathalí Molina Ronquillo
María Elena Navarro Calvillo
Autonomous University of San Luis Potosí, Mexico
This article provides a comprehensive review of the literature
on the neurocognitive impact of posttraumatic
stress disorder (PTSD) and reports on a quantitative single-case
study, which investigated whether eye
movement desensitization and reprocessing (EMDR) therapy
would change the neuropsychological and
physiological responses of an 18-year-old female client
diagnosed with comorbid PTSD and major depres-
sive disorder. Eleven 90-minute weekly sessions of EMDR
therapy were provided. We used biofeedback
equipment (ProComp5 Infiniti System) to obtain records of

heart rate and conductance while the participant
was in the desensitization and reprocessing phases of EMDR
therapy. Results showed a heart rate decrease
between baselines at the beginning and end of treatment.
Neuropsychological evaluations of attention,
memory, and brain executive functions showed pretreatment
impairments in attentional processes, informa-
tion processing speed, and working memory and posttreatment
improvement of these cognitive functions,
with significant differences on the Paced Auditory Serial
Addition Test. We found a substantial posttreat-
ment decrease in mean scores on the Beck Depression
Inventory-II and the Dissociative Experiences Scale.
Furthermore, the patient showed no signs of PTSD after the
intervention, based on the Posttraumatic Stress
Global Scale. At 1-year follow-up, the participant reported
maintenance of treatment effects. We discuss
how amelioration of PTSD symptoms was associated with
improved neurocognitive outcomes.
Keywords: eye movement desensitization and reprocessing
(EMDR) therapy; posttraumatic stress
disorder (PTSD); sexual abuse; neurocognitive outcomes; Paced
Auditory Serial Addition Test (PASAT)
Journal of EMDR Practice and Research, Volume 9, Number 4,
2015 175
EMDR and Neurocognitive Outcomes
stimuli. The posterior parietal area and prefrontal
cortex are activated to a lesser extent, causing a poor
performance on these patients’ working memory
(Morey et al., 2009). The possible explanation to
this is because of the inability to inhibit distracting

emotional stimuli that is because of a hyperarousal
of ventral areas (amygdala, ventromedial prefrontal
cortex).
Brain Executive Function and PTSD
Brain executive functions are essential for cogni-
tive processes of reasoning and decision making;
furthermore, they regulate impulsive behavior and
mood stability (Fuster, 1997; Polak, Witteveen,
Reitsma, & Olff, 2012). In this sense, there is evi-
dence that when brain executive functions deterio-
rate, persons may be unable to work independently,
practice self-care, or maintain interpersonal rela-
tionships (Lezack, Howieson, & Loring, 2004). Ac-
cording to Walter, Palmieri, and Gunstad (2010),
clinical observations and preliminary studies sug-
gest that persons exposed to traumatic events may
present deficits in brain executive functions (Sutker,
Winstead, Galina, & Allain, 1991; Vasterling, Brailey,
Constans, & Sutker, 1998). Brain executive func-
tions shape a capabilities system that allows regula-
tion and control of conduct and cognition (Bark ley
& Fischer, 2010, Goldberg, 2001). Also, working
memory was one of the poorer executive func-
tions seen for PTSD patients compared to trauma-
exposed controls in the Olff, Polak, Witteveen, and
Denys (2014) study.
Neurobiological Changes in PTSD
According to Nutt and Malizia (2004), there are three
areas of the brain associated with the limbic system
that are different in patients with PTSD compared
with those in control subjects: the hippocampus, the
amygdala, and the medial frontal cortex. Scott and

colleagues’ (2015) meta-analysis on functional and
structural neuroimaging research in PTSD found dys-
function in neural networks on prefrontal cortex, cin-
gulate cortex, and limbic regions, with consequences
on emotion processing and cognitive functioning, as
well as their interaction.
A recent quantitative whole-brain meta-analysis
(Kühn & Gallinat, 2013) showed brain structure defi-
cits in subjects with PTSD in comparison with control
subjects. This meta-analysis was composed of 9 studies
and 319 patients with PTSD. They identified brain re-
gions of consistent gray matter reduction in anterior
cingulate cortex, ventromedial prefrontal cortex, left
Another sexual abuse consequence in many
individuals is the development of PTSD. In the
general population, the prevalence of PTSD after
exposure to a traumatic event is placed between
5% and 24% (Bobes et al., 1999; Breslau, 2001).
Kessler et al. (1995) reported prevalence for PTSD
between 5% for men and 10% for women and also
identified rape as the traumatic event mostly likely
to result in PTSD, with rates of 65% for men and
46% for women, with childhood sexual molestation
producing PTSD rates of 27%. Rates of complex
PTSD plus PTSD were found to be high for sexu-
ally abused women (53%) and even higher for those
who had experienced both physical and sexual abuse
(74%; Roth, Newman, Pelcovitz, van der Kolk, &
Mandel, 1997).
Neurocognitive Deficits in PTSD
Several studies have examined neuropsychologi-
cal effects in PTSD (Brodman, Clark, Murrough,

& Mathew, 2011; Marx, Doron-Lamarca, Proctor,
& Vasterling, 2009; Parslow & Jorm, 2007). More
recently, Scott et al. (2015) completed a quantita-
tive meta-analysis on a sample of 60 studies total-
ing 4,108 participants, including 1,779 with PTSD,
1,446 trauma-exposed comparison participants, and
895 healthy comparison participants without trauma
exposure. They discovered that neuropsychological
functioning in attention, verbal memory, and speed
of information processing may have important impli-
cations for the effective clinical management of per-
sons with PTSD.
PTSD-related neuropsychological effects on sexu-
ally abused survivors were examined by Jenkins
et al. (2000) and Jenkins (1998), finding that learning
and memory are affected among those women who
survived sexual abuse and presented PTSD. Wilson
(2009) studied the neuropsychological effects of PTSD
in sexually abused adolescents throughout treatment
and found changes in neuropsychological function-
ing related to changes in behavioral and emotional
functioning: Trauma-specific emotional functioning,
self-report of memory functioning, and task perfor-
mance of attention performance were consistently
correlated.
Patients with PTSD constantly happen to relive
the traumatic experience causing an alteration in the
working memory and attentional system (Honzel,
Justus, & Swick, 2014; Landré et al., 2012; Schweizer
& Dalgleish, 2011). The hyperarousal of ventral areas
(amygdala, ventromedial prefrontal cortex) may in-
terfere with inhibition of distracting emotional

Number 4, 2015
Aranda et al.
individual therapies, including EMDR, produced the
best results. EMDR treatment of childhood trauma
can be more complicated and have a lengthier treat-
ment course compared to treatment for adults with
adult-onset trauma (van der Kolk et al., 2007).
Physiological Changes With EMDR Treatment
According to Söndergaard and Elofsson (2008), research
investigating the physiological effects of eye movement
stimulation on EMDR therapy indicate that saccadic
eye movements are accompanied by specific physi-
ological changes, such as alterations in respiratory pat-
tern (Elofsson, von Schèele, Theorell, & Söndergaard,
2008; Sack, Lempa, Steinmetz, Lamprecht, &
Hofmann, 2008; Wilson, Silver, Covi, & Foster, 1996),
heart rate and heart rate variability (Elofsson et al.,
2008; Frustaci, Lanza, Fernandez, di Giannantonio,
& Pozzi, 2010; Sack, Hofmann, Wizelman, & Lempa,
2008; Sack, Lempa, & Lamprecht, 2007; Wilson et al.,
1996), finger temperature (Elofsson et al., 2008; Wilson
et al., 1996), and skin conductance (Barrowcliff, Gray,
MacCulloch, Freeman, & MacCulloch, 2003; Elofsson
et al., 2008; Wilson et al., 1996).
Preliminary neuroimaging EMDR research has in-
vestigated the effects on the brain of this therapy. For
example, Pagani et al. (2012) conducted a study using
electroencephalography (EEG) to identify regions acti-
vated either by the autobiographic recollection of the
traumatic event (script) or during the bilateral ocular

stimulation in EMDR sessions, to see the pathophysi-
ological changes (monitored online). The aim of this
study was to investigate possible changes in functional
connectivity both as a result of EMDR therapy and
by comparing patients and healthy controls. Results
showed higher activity on the orbitofrontal, prefrontal,
and anterior cingulate cortex during eye movement
and also in frontotemporal limbic regions and right
temporooccipital cortex. Limbic cortex showed maxi-
mal activation on patients before trauma processing.
In opinion of Pagani et al. (2012), these changes
correlated significantly with changes occurred in neu-
ropsychological tests observed in other studies.
Changes in PTSD Related Neurocognitive
Deficits With Psychotherapy
A study done by El Khoury-Malhame et al. (2011)
illustrated a deficiency in PTSD’s cognitive process-
ing of emotional cues, using the emotional Stroop
and detection of target (DOT) tasks, before and after
sessions of EMDR therapy. They found that in both
tasks, patients were slower than controls responding
temporal pole/middle temporal gyrus, and left hip-
pocampus in PTSD patients compared with controls
patients without PTSD. According to the authors, the
deficit in gray matter correlates with brain networks
of emotion processing, fear extinction, and emotion
regulation known to be affected in PTSD.
Physiological Changes in PTSD
Empirical data has demonstrated that patients with
PTSD have higher psychophysiological parameters
(heart rate and conductance) at baseline, as well as a

low threshold of reactivity (Orr & Roth, 2000). The
elevated basal heart rate that is frequently observed
in patients with PTSD is understood to reflect high
activity in the sympathetic nervous system (Hopper,
Spinazzola, Simpson, & van der Kolk, 2006). Heart
rate and skin conductance were found to increase
in the presence of stress, indicating that these physi-
ological responses are sensitive to activation of the
sympathetic nervous system (Lin, Lin, Lin, & Huang,
2011).
Eye Movement Desensitization
and Reprocessing
EMDR therapy (Shapiro, 1989, 2001) is considered an
empirically valid treatment. A recent meta-analysis
of EMDR clinical studies made by Chen et al. (2014)
shows solid scientific evidence of its efficacy in the re-
duction and elimination of PTSD symptoms among
different populations. Similar findings are reported
in other meta-analysis studies (e.g., Bisson, Roberts,
Andrew, Cooper, & Lewis, 2013). EMDR therapy is
specifically recommended by the World Health Orga-
nization (2013) for management of conditions related
to stress.
EMDR Treatment of Sexual Assault
Various studies, which explicitly investigated EMDR’s
effectiveness with survivors of sexual assault, found
support for its use with adults (Edmond, Rubin,
& Wambach, 1999; Edmond, Sloan, & McCarty,
2004; Rothbaum, 1997) and children ( Jaberghaderi,
Greenwald, Rubin, Zand, & Dolatabadim, 2004;
Jarero, Roque-López, & Gomez, 2013). EMDR also
was found to result in greater trauma resolution for

sexual assault survivors than eclectic therapy (Edmond
et al., 2004) and to provide similar results to prolonged
exposure therapy (Rothbaum, Astin, & Marsteller,
2005). A meta-analysis of studies investigating PTSD
treatment for adult survivors of childhood sexual
abuse (Ehring et al., 2014) found that trauma-focused
2015 177
provided for initial evaluation and history explora-
tion (Phase 1) and treatment preparation (Phase 2).
The treatment phases composed of eight 90-minute
sessions for trauma processing (Phases 3–8). The
trained EMDR therapist with 13 years of clinical prac-
tice followed the standardized protocol of EMDR
and complied with the EMDR research fidelity pro-
tocol provided by EMDR International Association
(EMDRIA) to assure treatment integrity.
Assessment Measures
Qualitative and quantitative assessments were used
to evaluate the patient’s complaints. The Diagnostic
and Statistical Manual of Mental Disorders (DSM-IV-TR;
American Psychiatric Association [APA], 2000) was
used to guide the initial qualitative assessment, includ-
ing a phenomenological understanding of Sofia’s ex-
perience, and lastly, to determine a diagnosis.
During the first session, the research study was
explained to Sofia who signed a letter of informed
consent. All assessments were conducted by the

therapist (BDEA; first author). Administration of
psychological tests was conducted during the first
session and 1 week after the last treatment sessions.
Neuropsychological testing was done during the
second session and 1 week after the last treatment ses-
sion. Physiological data was recorded during the first
and last EMDR treatment sessions.
Psychological Measures
Posttraumatic Stress Global Scale. The Posttraumatic
Stress Global Scale (PSGS; Crespo & Gómez, 2011) is
a Spanish evaluation instrument that allows the di-
agnostic and characterization of PTSD in adults. It
consists of 62 items divided in 3 sections: the evalu-
ation of traumatic events, symptomatology, and the
person’s performance. Cronbach’s alpha reported
for Spanish population was .92 (Crespo & Gómez,
2012) and for Mexican population was .93 (Estrada,
Delgado, & Sánchez, 2015). Scores are reported in this
article by stating their percentile rank as compared to
the normative population with higher ranks indicat-
ing greater pathology. The PSGS was administered at
pretreatment during the first evaluative session and at
posttreatment.
Beck Depression Inventory-II. The Beck Depression
Inventory-II (BDI-II; Beck, Steer, & Brown, 1996) is a
self-report instrument that evaluates the intensity of
depressive symptomatology through 21 items. Total
scores from 0 to 13 indicate minimal depression, 14 to
19 mild, 20 to 28 moderate, and 29 to 63 severe depres-
sion. The Spanish version for Mexican population of
BDI-II was applied in this study, and it has reported a
in the presence of emotionally negative words com-

pared to neutral ones. This result indicated that
emotional information seemed to reduce processing
efficiency in PTSD and that this attentional bias in
PTSD diminished after symptom removal by EMDR
therapy. Similar results were reported in another
study (Ribchester, Yule, & Duncan, 2010) assess-
ing attentional bias, memory, and attributional pro-
cess associated with PTSD on children. They found
a significant trauma-specific reduction in attentional
bias after EMDR. Interestingly, an earlier study in-
vestigated the effects of cognitive behavioral therapy
(CBT) PTSD treatment on PTSD attentional bias also
using a Stroop task (Devieni, Blanchard, Hickling, &
Buckley, 2004). They found that CBT treatment had
no significant effect on the Stroop task.
The Current Study
This study investigated an EMDR treatment using a
quantitative case study design. Grey (2011) considers
that “case study evaluation of a single case can pro-
vide in-depth understanding of the individual’s phe-
nomenological experience within the boundaries and
limitations of such design” (p. 17).
The purpose of this study was to determine if
EMDR therapy would change the neuropsychological
and physiological responses of an 18-year-old female
client, “Sofia,” who had PTSD related to childhood
sexual abuse. Assessments were conducted before, dur-
ing, and after the EMDR therapy. Neuropsychological
measures were used to evaluate attentional process,
and brain executive functions and physiological
changes were measured by tracking heart rate and
skin conductance. Psychological inventories were
used to triangulate these results, evaluating the wom-

an’s symptoms of PTSD, depression, and dissociation
and to assess the effectiveness of EMDR therapy
(Shapiro, 2001) in the treatment of this young woman.
Method
Participant
The participant was an 18-year-old woman, single,
and of Mexican origin named Sofia. She was referred
for EMDR therapy to address emotional and behav-
ioral distress related to sexual abuse by a family mem-
ber. Details follow later in “The Case” section.
EMDR Treatment Schedule
Sofia received 11 weekly sessions. The treatment fol-
lowed the established eight-phase and three-pronged
protocol of the EMDR therapy. Three sessions were
Number 4, 2015
Aranda et al.
record lasted 5 minutes. The second stage was during
Phases 4 and 5 of EMDR treatment; these two records
lasted for 30 minutes with recording continued until
Sofia reported no distress about the targeted memory.
Scores are reported in this article by stating her heart
rate and skin conductance average during the targeted
memory before the treatment as compared with the
heart rate and skin conductance average during the
targeted memory after the treatment.

Physiological signals were registered through a
biofeedback device named ProComp5 Infiniti System,
and they were sent to a computer to be analyzed with
the Multimedia Biofeedback Software. To record
heart rate, EKG sensors (P/N: SA9306M) were placed
in the triangular area over the heart for coracoid and
xiphoidal processes to reduce artifacts: The measure-
ment unit is millivolts (mV). Heart rate reflects blood
volume, which increases with anxiety, thus showing
the activity of the sympathetic nervous system (S. B.
Miller & Ditto, 1989). To register skin conductance,
the SC-Flex/Pro (SA309M) sensor was used, and
sensors were placed on the index and ring fingers,
measurement units were microsiemens (mS). Skin
conductance has been shown to increase in stressful
situations (Fowles et al., 1981).
The Case
Sofia, an 18-year-old, single woman, was referred for
treatment to address emotional and behavioral distress
related to sexual abuse by a family member. Following
her recent disclosure of the abuse and her parents’ dis-
belief and lack of support, Sofia had moved out of her
parents’ home to live with extended family in another
city. She had dropped out of high school, choosing to
attend technical classes instead.
Sofia’s History and Problem Presentation
Sofia was the youngest of four siblings. Prior to her
disclosure, she lived with her parents in a small city
in central Mexico, where she was attending high
school. She began drinking alcohol heavily at the age
of 15 years as well as showing risky conduct such
as going out with her friends at night and returning

home late. This resulted in many conflicts with her
parents, who were also concerned about her anorexic
behavior. Cognitive complaints were observed before
treatment and included problems with focused atten-
tion, poor concentration in class, and memory issues
such as forgetfulness.
Sofia reported that she had been sexually abused
by an adult male, a family member, when she was
15 years old. Before this, at the age of 12 years, this
good reliability index with a Cronbach’s alpha of .91
(Estrada, Delgado, Landero, & González, 2015). The
BDI-II was administered at pretreatment during the
first evaluative session and at posttreatment.
Dissociative Experiences Scale. The Dissociative Ex-
periences Scale (DES; Bernstein & Putnam, 1986) is a
self-administered, 28-item questionnaire, in which the
client indicates the frequency (percentage of time) at
which they experience an item. The DES is a screen-
ing instrument that evaluates different types of dis-
sociative symptomatology and their frequency. Total
scores more than 30% suggest clinical dissociation. A
Cronbach’s alpha of .96 was reported for the Mexi-
can population (Robles, Garibay, & Páez, 2006). The
DES was administered at pretreatment during the first
evaluative session and at posttreatment.
Neuropsychological evaluation. The neuropsycho-
logical evaluation was conducted at pretreatment,
during the second evaluative session, and at posttreat-
ment. The following tests were administered to evalu-
ate brain executive functions.
Rey Osterrieth Complex Figure Test. The Rey Oster-

rieth Complex Figure Test (Rey, 2003) evaluates visual
memory, visuospatial organization, and brain ex-
ecutive functions. There are three components. The
participant is first asked to copy the figure, then to
immediately reproduce it from memory. After 20–30
minutes, the participant is again asked to reproduce
the figure. Scores are reported in this article by stating
their percentile rank as compared to the normative
population.
Paced Auditory Serial Addition Test. The Paced Au-
ditory Serial Addition Test (Gronwall, 1977) assesses
working memory, sustained attention, divided atten-
tion, estimate, and speed of information processing.
Participants are given a number every 3 seconds in
the first part, and in the second part every 2 seconds,
and asked to add that number to the number that pre-
ceded it. Scores are reported in this article by stating
their percentile rank as compared to the normative
population.
Trail Making Test, Part B. The Trail Making Test,
Part B (Reitan, 1958) assesses visual search, processing
speed, mental flexibility, and working memory. The
participant is asked to draw a line connecting labeled
dots on a piece of paper, alternating consecutive num-
bers and letters (i.e., 1, A, 2, B) as quickly as possible.
Physiological Recordings. The physiological testing
was done on two occasions—during the first and last
EMDR sessions—and in two stages. The first stage
was the baseline when Sofia was asked to remain
quiet and focus on a point placed in front of her; this

2015 179
and (d) physical violence (attacks, robberies, mistreat-
ment). She indicated that the most severe symptoms
were about the rape/sexual abuse and described flash-
backs and intrusive thoughts (for instance, when she
was bathing she had the feeling that she was being
observed by her abuser).
Depression at Pretreatment. Sofia obtained a score
of 29 points on the BDI-II, representing a serious de-
pression level. Items with higher intensity were changes
in sleep pattern, irritability, suicidal thoughts, weeping,
worthlessness feelings, concentration problems, tired-
ness, or fatigue. It is important to mention that the item
evaluating symptom intensity over “thoughts or suicide
desires,” her answer was “I would like to commit sui-
cide.” The therapist asked Sofia to rate her risk of cur-
rent suicide on the Suicide Risk scale question (where 0
represents no current risk of suicide and 10 maximum
risk), adapted from de Shazer (1985). Sofia identified
her suicide risk at Level 4. Given these responses and
her history of 10 suicide attempts, we proceeded to
make a behavioral agreement in writing (Méndez &
Olivares, 2001). A diagnostic interview confirmed that
her presentation met DSM-IV criteria for a diagnosis of
major depressive disorder.
Dissociation at Pretreatment. Sofia’s score on the
DES was 50.35 indicating the presence of patho-
logical dissociation. DES evaluates through its items
three dissociative symptoms: amnesia, absorption,
as well as depersonalization/derealization. In Sofia’s
case, Sofia reported greater occurrence frequency for

absorption with an average score of 64 followed by
the items of depersonalization/derealization with an
average score of 46.7. During the interview, she re-
ported depersonalization and/or derealization symp-
toms (she felt as if she were not the same person, she
looked in the mirror and felt unusually different) as
well as some memory lapses.
Sofia described various somatic symptoms, all
of which began in junior high school. She indicated
that for several years, she had chronic headaches
that were not relieved with analgesics sold over the
counter; furthermore, she experienced knee pain.
Sleeping problems included nightmares or noctur-
nal dread.
Executive Function at Pretreatment. The Rey Oster-
rieth Figure Test (Rey, 2003) evaluates visual memory,
visuospatial organization, and brain executive func-
tions. Sofia’s above average score placed her at the
80th percentile, indicating that her constructive praxis
and spatial organization processes were not affected
by PTSD. On the other hand, her score on the im-
mediate recall task was well below the norms for her
man started with sexual harassment behavior toward
her, such as staring while she was swimming or bath-
ing, and using harassing words. At the age of 12 years,
she began cutting her arms with a sharpener blade
and the first suicide attempt happened, coinciding
with the harassment. Sofia informed that there she
made 10 identical suicide attempts, tying her shoe-
laces around the bathroom’s shower faucet at home;
she hanged herself and immediately stood up as soon
as she felt asphyxia.

Two months before the first therapy session, Sofia
told her parents about being sexually abused by the
family member. Her disclosure generated a major
family conflict because they initially did not believe
her. Instead of offering support and caring, her par-
ents mistreated her with physical and verbal abuse
(beatings and insults). After this, she began showing
behavioral problems at school, and she stopped eat-
ing and going out with friends. After 2 months, she
decided to leave home and moved to another city to
live with a family member.
Pretreatment Assessment
Posttraumatic Stress Disorder at Pretreatment. PTSD
was evaluated with the PSGS and with a diagnostic in-
terview. Her presentation met PTSD diagnostic criteria
according to Diagnostic and Statistical Manual of Mental
Disorders (4th ed., text rev., DSM-IV-TR; APA, 2000). Al-
though her assessment was conducted prior to DSM-5
(APA, 2013) criteria, it is noted that her identification
of nine other subjective clinical symptoms meant that
her presentation fulfilled DSM-5 criteria for PTSD as
well. She was diagnosed with chronic PTSD because
the symptoms had lasted more than 3 months.
A comparison of her PSGS scores with the Mexican
normative sample (Estrada, Delgado, & Sánchez,
2015) showed that most scores were at a high level
and consistent with those of people exposed to trau-
matic events, placing her at the 85th–99th percentile.
The only exceptions were on the Hyper-arousal scale
with a medium-high level (at the 80th percentile),
and the Functioning scale with a medium-high level
(70th percentile). However, it is important to indicate
that in relation to functioning, her current symptoms

were interfering in six of the seven PSGS areas (doc-
tor’s appointments; alcohol or drugs intake; work and
academic life; her social, family, or partner relation-
ships; and any other important aspect of her life).
Sofia listed four traumatic events on the PSGS ques-
tionnaire: (a) transport accidents, (b) rape/abuse or
sexual attack, (c) harassment (sexual, at work, in pre-
vious relationships) or psychological mistreatment,
Number 4, 2015
Aranda et al.
EMDR Treatment
Phases 1 and 2
Phases 1 and 2 of the EMDR protocol were provided
during Sessions 1, 2, and 3. The problem history was
collected and the pretreatment assessment (using
psychological instruments and neuropsychological
tests) was conducted during Sessions 1 and 2. Prepa-
ration for trauma processing was also provided. Sofia
showed a lot of anxiety and insecurity; therefore,
the preparation phase included instruction in self-
control, self-care, and confidence strategies. Some
breathing techniques and the safe place exercise were
applied. During the third session, Sofia and the thera-
pist worked together to develop the target-sequencing
plan for past memories, present triggers, and future
desired outcomes.
Case Conceptualization and
Target-Sequencing Plan

EMDR therapy is theoretically grounded in the adap-
tive information processing (AIP) model (Shapiro,
2001). This model posits that memories stored in
dysfunctional manner are the basis of clinical pa-
thology (Solomon & Shapiro, 2008). Sofia’s present-
ing complaints were manifested in cognitive themes
related to overresponsibility and incompetence. The
self-referencing negative cognition that structured the
treatment was “I am a bad person” and the target-
sequencing plan was developed with six memories
(targets). The AIP/EMDR approach recommends that
the EMDR therapist begin with the target-sequencing
plan and earliest memories. In Sofia’s case, harass-
ment was the target to start with. Each memory
was rated by Sofia using the SUDS. Sofia rated the
six memories with SUDS scores ranging from 3 to 7.
Like other studies, these target-sequencing plans were
used as self-report tools to check Sofia’s experimental
progress (Grey, 2011). Sofia identified several present
age, placing her at the 1st percentile, suggesting pos-
sible deficits in attentional processes. Likewise, in the
delayed recall task, her score was at the 1st percentile,
indicating poor consolidation affected by attentional
processes.
The Trail Making Test, Part B (Reitan, 1958) assesses
visual search, processing speed, mental flexibility, and
working memory. Although Sofia completed the test
without errors, it took her an estimated time of 88
seconds, which is longer than expected for someone
her age. This indicates difficulties with processing
speed and verbal working memory, constructs that
are linked to attentional processes.

The Paced Auditory Serial Addition Test (Gronwall,
1977) assesses working memory, sustained attention,
divided attention, estimate, and speed of informa-
tion processing. Her performance in the two parts of
the test (in the first part, the numbers appear every
3 seconds and in the second part, every 2 seconds)
was below expectations for her age. Attentional pro-
cesses and working memory are required for this task,
indicating difficulties in these neuropsychological
functions.
Physiological Recordings. Physiological recordings
were conducted in the first trauma processing session
(the fourth session). Sofia was connected to the bio-
feedback equipment named ProComp5 Infiniti System
and asked to think of the first target memory (base
event) while a physiological baseline was recorded
collecting measurements of heart rate and skin con-
ductance for 5 minutes. Then treatment began, with
Phases 3, 4, and 5 of the EMDR protocol related to
the targeted memory. Sofia remained connected to
the equipment, and recordings continued until Sofia
reported a score of 0, on the Subjective Units of Dis-
turbance Scale (SUDS), where 0 5 no disturbance and
10 5 worst possible (Shapiro, 2001).
Results of the recording of the first baseline and
the first target memory are shown in Tables 1 and 2.
TABLE 1. Results of Physiological Recording of
Baseline Pretreatment
Virtual Channel Description Value
A: EKG HR mean (beats/min) 92.83

A: EKG LF/HF (means) 2.26
E: Skin conductance mean (mS) 1.90
Note. EKG HR mean 5 mean of heart rate per minute; EKG
LF/HF 5 heart rate means of low frequency/high frequency.
A 5 heart frequency channel; EKG 5 electrocardiogram;
HR 5 heart rate; LF 5 low frequency; HF 5 high frequency;
E 5 conductance channel.
TABLE 2. Results Physiological Recording of Target
Memory Pretreatment
Virtual Channel Description Value
A: EKG HR mean (beats/min) 92.83
A: EKG LF/HF (means) 1.71
E: Skin conductance mean (mS) 4.38
Note. EKG HR mean 5 mean of heart rate per minute; EKG
LF/HF 5 heart rate means of low frequency/high frequency.
A 5 heart frequency channel; EKG 5 electrocardiogram;
HR 5 heart rate; LF 5 low frequency; HF 5 high frequency;
E 5 conductance channel.
2015 181
& Flick, 1988). In the case of Mexican population, the
average score in BDI-II gotten by Estrada, Delgado,
Landero, et al. (2015) was 9.1. This result indicates

that Sofia’s posttreatment score shows a clinically sig-
nificant recuperation from depression.
Neuropsychological Changes
At pretreatment, Sofia’s performance on copying the
Rey Osterrieth Figure Test (Rey, 2003) was above aver-
age, but her scores on immediate and delayed recall
tasks placed her at the 1st percentile. At posttreat-
ment, her scores on immediate and delayed recall
tasks improved at the 25th percentile. These changes
were not statistically significant because of low power
with only one participant. However, the results sug-
gest that the patient got better on attentional pro-
cesses that contribute in the recall of information.
At pretreatment, Sofia’s performance on the Trail
Making Test, Part B (Reitan, 1958) was longer than
expected for someone her age. At posttreatment, she
improved in the task and her time of execution was
better, indicating an improvement in the processing
speed with an impact on working memory.
Sofia’s pretreatment performance on the Paced
Auditory Serial Addition Test (Gronwall, 1977) was
below expectations for her age. At posttreatment, a
profound improvement on the Paced Auditory Serial
Addition Test (PASAT) was found obtaining a statisti-
cally significant in the t test between the performance
pretreatment and posttreatment (p 5 .042). For this
task, different processes are necessary: working mem-
ory, sustained attention, divided attention, estimate,
and speed of information processing. The patient’s
statistically significant improvement shows that the
EMDR treatment had a positive effect on the neu-
rocognitive processes that had been impaired by the

PTSD (Table 3).
Regarding Sofia’s physiological responses, signifi-
cant pre- and posttherapy differences were found in
heart rate during the baseline (p 5 .022) and during
EMDR treatment (p 5 .027). Significant differences
were not found for conductance before and after the
treatment (Table 2). It is important to mention that
during the last therapy session (between Sessions 10
and 11, Sofia focused on abuse target) where heart
rate was registered during EMDR, Sofia was able to
stabilize such frequency. It lets us know of an im-
provement activating the parasympathetic. Therefore,
excitability reduces when facing the stressing memo-
ries. Through this, we proved that Sofia was able to
have a more adaptive process in her physiological re-
sponses when evoking the stressful event (Table 4).
triggers, including being stared at, family swimming
pool parties, hearing someone talking about the per-
son who had abused her, being in the place where
the abuse happened, and movies about sexual abuse.
Her future desired outcomes were to be independent,
have social interaction with friends, and have a good
relationship with both parents.
EMDR Treatment, Phases 3–8
Sessions 4 through 11 focused on reprocessing each
one of Sofia’s traumatic memories, addressing cur-
rent triggers, and working on the future template.
Standard EMDR procedures were followed through-
out, using EMDR Phases 3–8.
In Session 4, physiological recordings were made
while Sofia processed her first target. The EMDR

therapist and Sofia then reevaluated the SUDS scores
for the remaining targets on the target-sequencing
plan. In the following sessions, Sofia reprocessed all
memories listed on the target-sequencing plan. There
were six memories related to the negative cognition
(NC) “I’m a bad person.” Memories linked to this
NC were the sexual harassment, sexual abuse experi-
ence, and her silence about this matter. The NC was
transformed into a new positive cognition for each
target, such as “I am brave,” “I am strong,” which
Sofia endorsed with a validity of cognition score of
7 on a scale where 1 5 completely false and 7 5 totally
true. After this, reprocessing was also needed for two
present triggers. One of them was a friend from her
job who looks like the abuser. Another one was a
cousin of the abuser. Finally, the future template was
installed.
Posttreatment Assessment and Results
Psychological Measures
At the end of the treatment sessions (after Session
11), the psychological measures were again adminis-
tered. Sofia’s scores on the PSGS had decreased from
moderate/high levels at pretreatment to low at post-
treatment. Her presentation no longer met PSGS nor
DSM-5 criteria for PTSD. Likewise, her dissociative
symptoms were greatly reduced, with a posttreat-
ment score on the DES of 6.8 points, placing her in
the normal range.
Her depressive symptoms were alleviated. This
was reflected by a score on the BDI-II of 4 points
(minimum level). According to Sanz, Perdigón, and
Vázquez (2003), depression recuperation can be de-

fined as a similar or lower score than the average
standard of a sample of general population (Hollon
Number 4, 2015
Aranda et al.
to evaluate the effectiveness of a psychotherapeutic
treatment (e.g., Boudewyns & Hyer, 1990; Shalev,
Orr, & Pitman, 1992), as well as to provide detailed
and contextual information about the treatment re-
sponse of individual patients (e.g., Blanchard et al.,
1996; Shalev et al., 1998).
In this study, the neuropsychological and psy-
chophysiological measure were very important to
examine the effect of the treatment in a patient with
PTSD and to understand the improvement in her life
after the treatment. At pretreatment, the patient had
PTSD-related difficulties in attentional processes, in-
formation processing speed, and working memory.
When the patient finished treatment, there were sub-
stantial improvements in cognitive function and in all
areas of her life.
Physiological Changes
Heart rate decrease between the baseline at the begin-
ning and the baseline at the end of the treatment pro-
vides evidence of the EMDR treatment effectiveness.
Follow-Up
One year later, after completing the EMDR therapy, we

saw Sofia again in a follow-up session. No formal testing
was conducted. She was stable, attending school, and
working with no more cognitive complaints. She was
still living independently (she was not living with her
parents but their relationship was stable), she had found
a job that made her feel good about herself. She had
gone back to her high school studies and she had plans
to attend university, with an improvement in her capac-
ity of concentration, speed processing of information,
and attentional processing that helped in her school ac-
tivities. She was not drinking alcohol in an uncontrolled
manner. She did not show any PTSD symptoms. Her
self-esteem and trust were visible in her attitude and in
her academic, work, and social accomplishments.
Discussion
This study is consistent with the idea of using psy-
chophysiological and neuropsychological estimates
TABLE 3. Comparison of Neuropsychological Test Results
Before and After Eye Movement Desensitization and
Reprocessing Treatment
Test Value 5 0
t df Sig. (Two-Tailed) Mean Difference
95% Confidence Interval of the Difference
Lower Upper
FR_meminm 5.600 1 .112 14.000 217.7655 45.7655
FR_memdif 4.077 1 .153 13.250 228.0452 54.5452

PASAT_total 15.222 1 .042 68.500 11.3221 125.6779
TMT_B 7.800 1 .081 78.000 249.0620 205.0620
Note. FR_meminm 5 immediate memory Rey figure;
FR_memdif 5 deferred memory Rey figure; PASAT 5 Paced
Auditory Serial
Addition Test; TMT_B 5 Trail Making Test Part B.
TABLE 4. Comparison of Physiological Responses Before and
After Eye Movement Desensitization and
Reprocessing (EMDR) Treatment
Test Value 5 0
t df Sig. (Two-Tailed) Mean Difference
95% Confidence Interval of the Difference
Lower Upper
FCLB 28.423 1 .022 89.675 49.5869 129.7631
FCEMDR 23.788 1 .027 89.085 41.5003 136.6697
SCLB 2.193 1 .272 1.305 26.2552 8.8652
SCEMDR 1.872 1 .312 2.855 216.5220 22.2320
Note. FCLB 5 heart frequency baseline; FCEMDR 5 heart rate
during EMDR; SCLB 5 skin conductance baseline; SCEMDR 5
skin
conductance during EMDR.

2015 183
this area have been found in studies using functional
magnetic resonance imaging with patients with PTSD
(Patel et al., 2012). This area is related to processes
such as inhibition, detection, and conflict solution as
well as regulation and attentional effort (Flores, 2006).
Cingulate cortex is activated when some tasks are car-
ried out such as error detection, divided attention as
well as detection, and conflict solution (Badgaiyan
& Posner, 1997). The PASAT was the most sensitive
one to detect improvement with EMDR treatment
in Sofia because this test does not evaluate different
cerebral mechanisms at the same time like the Rey’s
figure test and just evaluates cerebral pathways of
the prefrontal area such as attentional processes and
working memory that are impacted in patients with
posttraumatic stress.
There are several explanations of why the EMDR
therapy is useful in patients with PTSD and has an
impact in the improvement of neuropsychological
processes that are affected by the PTSD. Some have
proposed (Ioannides et al., 2004; Stickgold, 2002) that
one of EMDR’s mechanisms is its similarity to REM
sleep, which has many beneficial effects and which
is disrupted in individuals with PTSD. The constant
recall of episodic information (flashbacks) may be re-
lated to REM sleep disorders, based on the function
that this sleeping phase has in the consolidation of
these kinds of memories (Seijas, 2013).
Limitations and Recommendations

One of this study’s limitations is found in the impos-
sibility to control other variables related to Sofía’s
improvements. On the other hand, just like in other
case studies, generalization of results is limited be-
cause we only worked with Sofia. Another limitation
is that Sofia’s parents never agreed to have an appoint-
ment with the therapist. Therefore, we were unable
to gather information from third parties and confirm
Sofia’s change.
We recommend future research with larger sam-
ples. A case series providing EMDR to patients with
PTSD could investigate whether the pre- and post-
therapy neurocognitive changes shown by Sofia can
be replicated and whether the PASAT remains the
most useful test. Further research comparing a con-
trol condition with an EMDR treatment condition
could determine if neurocognitive changes can be
fully attributed to EMDR therapy and the ameliora-
tion of PTSD symptoms. It would be very valuable
to compare the neurocognitive outcomes of CBT
and EMDR treatment of PTSD, given that CBT
(Devieni et al., 2004) did not produce the changes on
These results are consistent with those found in previ-
ous studies, where EMDR treatment success was dem-
onstrated with physiological responses from patients
with PTSD (Frustaci et al., 2010; Högberg et al., 2008).
In this study, we observed an increase in heart
rate during initial EMDR application, indicating an
increase in parasympathetic activation when the
stressing situation was remembered. Then, after suc-
cessful treatment, the heart rate decreased when the
stressful event was recalled. There are at least two pos-
sible explanations. The first explanation is that after

the treatment with EMDR, the sympathetic nervous
system load decreases, allowing Sofia to face environ-
mental stimuli in an adaptive manner. This is consistent
with findings in studies done by Frustaci et al. (2010)
and the study of Sack et al. (2007). A second explana-
tion is that after treatment with EMDR, the stressful
event is no longer disturbing and there is no related
excitability of the sympathetic nervous system.
Neuropsychological Changes
The significant improvement in the PASAT confirms
EMDR treatment benefit for attentional processes
(sustained and divided attention) as well as in work-
ing memory. That confirms the works of Walter et al.
(2010), where optimal results were obtained in neu-
ropsychological processes improvement after treating
patients with PTSD. Further research is needed to
determine the relationship between improvement in
working memory and improvement in attention. We
tend to think that the improvement in Sofia’s work-
ing memory was secondary to her improvement in
attention because when she started to get better on
focusing her attention she could hold and process in-
formation. There is an alteration in the medial pre-
frontal cortex in patients with PTSD (Patel, Spreng,
Shin, & Girard, 2012), this area is related with atten-
tional process, and the cerebral mechanism for work-
ing memory depends on these attentional abilities
(Flores, 2006).
Although there was an improvement in the per-
centile on the Rey’s figure test, the difference was
not statistically significant. The reason may be be-
cause of low statistical power. Also, this test may
not be the best measure to evaluate neurocognitive

changes in treatment. It evaluates several different ce-
rebral mechanisms involved with high-level cognitive
processes such as organization, planning, spatial anal-
ysis and synthesis, perceptual organization, as well as
memory. Treatment results may be better evaluated
by tests such as the PASAT, which measure changes in
medial prefrontal area function, as notable deficits in
Number 4, 2015
Aranda et al.
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treatment outcome studies.
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Reproduced with permission of the copyright owner. Further
reproduction prohibited without
permission.
Research Evaluation Form
CCMH/525 Version 3
5
University of Phoenix Material
Research Evaluation Form
Use this form for both your individual and Learning Team
article reviews.
Name(s):
______________________________________________

Quantitative study: __________
Qualitative study: _____________
Location of Researcher’s Observation or Experiment
None _________ Home ________ Clinic _________ Lab
__________
Residential facility _________ School _________ Hospital
_________ Other __________
Were children involved? Yes _____ No ______ If your answer
is yes, how many? _________
Introduction
Research hypothesis or research questions/problem behaviors:
________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
___________________
_____________________________________________________
_____________________________________________________
________________________________________________
Operational definitions:
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
___________________________________________
Consider the following questions:

Is the need for the study clearly stated in the introduction?
_____________________________________________________
________________________
Were the research questions and hypothesis clearly stated? Note
that research questions are often presented implicitly within a
description of the purpose of the study section.
Review of literature as relevant to the study:
_________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
___________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
___________________
Method
Sample size (total): ________________
Size per group or cell: _______________
Consider the following questions:
_______ Were the methods described so that the study could be
replicated without further information?
Subjects

_______ Were subject recruitments and selection methods
described?
_______ Were subjects randomly selected? Were there any
biases in sampling?
_______ Were the samples appropriate for the population to
which the researcher wished to generalize?
_______ Were characteristics of the sample adequately
described?
_______ Are two or more groups being compared? Are they
shown to be comparable on potentially confounding variables?
If they are not comparable, is this incomparability handled
properly?
_______ Was informed consent obtained?
_______ Was the size of the sample large enough for the
number of measures and for the effect being sought?
Research Design
_______ Single group, time series study
_______ Multiple baseline (sequential) design:
______________
_______ Single group, no measurement
_______ Single group with measurement: Pre ______ During
_____ Post _____
_______ Two groups classic experimental versus control group,
randomly assigned

_______ (Quasi-experimental) two groups experimental versus
control group,
not randomly assigned
_______ Correlation research, not manipulated, degree of
relationship
_______ Descriptive research (qualitative study)
_______ Natural observation
_______ Analytical research
_______ Interview research
_______ Historical study
_______ Survey research
_______ Legal study
_______ Ethnography research
_______ Policy analysis

_______ Fieldwork research
_______ Evaluation study
_______ Phenomenology
_______ Grounded theory
_______ Protocol analysis (collection and analysis of verbatim
reports)
_______ Case study, no measurement
_______ Case study, with measurement: Pre _________ During
_______ Post _________
_______ Developmental research
_______ Longitudinal (same group of subjects over a period of
time)
_______ Cross-sectional (subjects from different age groups
compared)
_______ Cross-sequential (subjects from different age groups,
shorter period of time)
_______ Correlation, more than two groups: control, treatment,
and other treatment comparisons
_______ Factorial design, two or more groups: other treatment
differences, no untreated controls
_______ Two or more dependent variables (MANOVA)

_______ Other design:
_____________________________________________________
_____
Consider the following Yes/No questions:
_______ If appropriate, was a control group used?
_______ Was the control method for the study appropriate?
_______ For what variable was being controlled?
_______ In the case of an experimental study, were subjects
randomly assigned to groups?
Measures
Type of dependent measures or instruments used:
____________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
___________________________________________
Measurement or instrument validity information:
_______________________________________
_____________________________________________________
_____________________________________________________
________________________________________________
Measurement or instrument reliability information:
_____________________________________
_____________________________________________________
_____________________________________________________
________________________________________________

_______ For all measures—measures to classify subjects,
dependent variables, and so forth—was evidence of reliability
and validity provided, either through summarizing the data or
by referring the reader to an available source for that
information?
_______ Do the reliability and validity data justify the use of
the measure? Specific evidence is particularly important if a
measure is created just for this particular study.
_______ Do the measures match the researchers questions and
hypothesis being addressed?
_______ In the case that different tasks or measures are used,
was their order counterbalanced? Do the researchers analyze for
potential order effects?
_______ Are multiple measures used, particularly those that
sample the same domains or constructs but with different
methods, such as self-report, rating scales, self-monitoring, or
direct observation?
_______ If human observers, judges, or raters were involved,
was inter-observer or inter-rater agreement (reliability)
assessed? Was it obtained for a representative sample of the
data? Did the two raters do their ratings independently? Was
their reliability satisfactory?
Independent and Dependent Variables
Independent variables:
_____________________________________________________
___
_____________________________________________________
_____________________________________________________

_____________________________________________________
_____________________________________________________
___________________
Dependent variables:
_____________________________________________________
_____
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
___________________
Data Analysis
Scales of Measurement:
Nominal _______ Ordinal _______ Interval _______ Ratio
_______
What type of statistical techniques are used?
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
___________________________________________
What type of tables and graphs are used?
_____________________________________________________
________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________

_____________________________________________________
___________________________________________
_______ Do the data fulfill the assumptions and requirements of
the statistics?
_______ Were tests of significance used and reported
appropriately, such as with sufficient detail to understand what
analysis was being conducted?
_______ In correlation studies, did the researchers interpret low
but significant correlations as though they indicated a great deal
of shared variance between the measures? Are the correlations
limited by restricted ranges on one or more measures? Are
means and standard deviations provided so that you may
determine this?
_______ Do the researchers report means and standard
deviations, if relevant, so that the reader can examine whether
statistically significant differences are large enough to be
meaningful?
Limitations of the study:
_____________________________________________________
___
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
___________________________________________
Discussion
Summary and conclusions (usefulness):
____________________________________________
_____________________________________________________

_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
___________________________________________
_______
Do the researchers discuss marginally or insignificant results as
though they were significant?
_______Do the researchers over-interpret the data? For
example, do they use casual language to integrate correlation
findings or consider self-report of behavior to be equivalent to
direct observation?
_______Do the researchers consider alternative explanations for
the findings?
_______Do the researchers have a humility section that
describes the limitations of the research?
_______Do the researchers point out aspects of subject
selection, procedures, and dependent variables that limit
generalizability of the findings?
Rate the writing style on a scale of 1 to 10:
Overall clarity?
1-------------5-------------10
Easy to read?
1-------------5-------------10
Organized?
1-------------5-------------10
Describe what you learned from the study:

_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
___________________________________________
__________________________________
________________________________
Group member
Group member
___________________________________
________________________________
Group member
Group member
___________________________________
________________________________
Group member
Group member

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