Document 7 from FOI23.24 1400 Disclosure log documents.pdf

FOI 23/24- 1400
DOCUMENT 7
Research paper
OFFICIAL
For Internal Use Only
Eye movement desensitisation and response
therapy for people with Autism Spectrum
Disorder and Obsessive Compulsive Disorder
The content of this document is OFFICIAL.
Please note:
The research and literature reviews collated by our TAB Research Team are not to be shared
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accurate & up-to-date snapshot of these matters
Research question: Can eye movement desensitisation and response therapy improve the
functional capacity of people with autism spectrum disorder and obsessive compulsive
disorder?
Date: 01/11/2022
Requestor: Abby Lam
Endorsed by: Naomi Rowler
Researcher: Aaron Harrison
Cleared by: Stephanie Pritchard
Review date: n/a
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1.  Contents
Eye movement desensitisation and response therapy for people with Autism Spectrum
Disorder and Obsessive Compulsive Disorder ........................................................................... 1
1.
Contents ....................................................................................................................... 2
2.
Summary ...................................................................................................................... 2
3.
ASD, OCD and trauma ................................................................................................. 2
4.
EMDR for people with OCD .......................................................................................... 3
4.1
OCD treatment guidelines ......................................................................................... 4
5.
EMDR for people with ASD ........................................................................................... 4
6.
References ................................................................................................................... 5
2. Summary
Eye movement desensitisation and response therapy (EMDR) is most often used in the
treatment of post-traumatic stress disorder (PTSD), though evidence for its efficacy in other
conditions is growing. There is some evidence that EMDR can improve symptoms associated
with obsessive compulsive disorder (OCD) and autism spectrum disorder (ASD). However, the
evidence base for its efficacy in both conditions is small. There are 3 randomly controlled trials
offering preliminary support for the use of EMDR in OCD. There is so far only one non-
randomised group trial looking into the efficacy of EMDR for ASD. There are problems with all
studies including small samples, high drop out rate and failure to identify what was producing
the therapeutic effect.
No clinical guidelines were found which recommend use of EMDR for OCD or ASD.
3.  ASD, OCD and trauma
Between 4% and 17% of people with ASD are likely to meet criteria for a diagnosis of OCD
(Elliot et al, 2021; Avasthi et al, 2019). One large sample study showed people diagnosed with
ASD are twice as likely as the general population to go on to receive a diagnosis of OCD. The
same study showed people with a first diagnosis of OCD have a four times higher chance of
going on to receive a diagnosis of ASD (Elliot et al, 2021).
In addition, people diagnosed with ASD are more likely to experience traumatic events and
show symptoms of trauma than the general population (Volkmar, 2021; Lobregt-van Burren et
al, 2019). People presenting with OCD symptoms often do so after a traumatic event. PTSD
and OCD also share some symptoms such as intrusive thoughts, anxiety and avoidant
behaviour (Talbot, 2021). Those diagnosed with PTSD are at a ten times higher risk of
developing OCD compared to those without PTSD (Sarichloo et al, 2020).

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4.  EMDR for people with OCD
Two reviews (Talbot, 2021; Scelles & Bulnes, 2021) identified 10 papers in total investigating
the use of EMDR for OCD published between 2004 and 2020. Seven of the published studies
are case studies or case reports with small sample sizes (1 study of 8 people and 6 studies of
under 4 people). Three of the published studies are randomly controlled trials with sample
sizes between 30 and 60 participants.
There are inconsistencies in and between both reviews. Talbot (2021) reports that randomly
controlled trials from Nazari et al (2011) and Marsden et al (2018) had sample sizes of 45 and
29 respectively. Scelles and Bulnes (2021) give the sample sizes as 60 and 55 for the same
studies. Nazari et al (2011) report their sample size as 90. Marsden et al (2018) report their
sample size as 55. Talbot (2021) states that all studies reviewed found positive results for
EMDR on symptoms of OCD. Despite majority overlap in studies reviewed, Scelles and Bulnes
(2021) state only half of the studies reviewed found positive results. Talbot (2021) did not
describe their review procedure and their paper is published in the Journal of EMDR Practice
and Research, which is the journal of the international peak body of EMDR researchers and
clinicians. Both reviews note that heterogeneity of treatment protocols limits what can be
concluded from the current research.
The first randomly controlled trial into the use of EMDR for OCD compares EMDR with
citalopram in 90 OCD patients. They found significant reduction in symptoms for both
treatment groups, but the effect was larger for EMDR (Nazari et al, 2011). Marsden et al
(2018) compared EMDR with cognitive behavioural therapy (CBT) following the exposure and
response prevention (ERP) model and found no significant differences in effects between
treatments. Sarichloo et al (2020) compared ERP with ERP + EMDR in 60 patients. They
found greater therapeutic effect and higher completion rates for the combined therapy.
However, this study specifically recruited for participants with OCD and a history of traumatic
life experiences. This is significant as it may be difficult to separate the effects of EMDR on
core OCD symptoms from its effects on symptoms of trauma due to negative life experiences
of people with mental health conditions such as OCD (Scelles & Bulnes, 2021).
There is inconsistency in effect sizes between Marsden et al (2018) and Sarichloo et al (2020).
Mean scores on the Yale-Brown Obsessive Compulsive Scale for patients receiving just ERP
were about 2 points higher pre-treatment in Marsden et al’s sample compared to Sarichloo et
al’s. The difference grew to 10 points post-treatment. This means two groups receiving the
same treatment showed dramatically different results.
Sample sizes and drop-out rates of all three randomly controlled trials means more subtle
effects of different therapies may not have been picked up (Nazari et al, 2011; Marsden et al,
2018; Sarichloo et al, 2020). In addition, it is possible symptom reduction can be explained by
several common factors of CBT, CBT with ERT and EMDR, such as the empathetic
therapeutic relationship, putting the patient at ease, enhancing their expectations, motivating
them to change their behaviour. CBT, CBT with ERP and EMDR also involve some measure

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of exposure to disturbing stimuli, though the mechanism of exposure may be different in the
different therapeutic strategies (Marsden et al, 2018).
4.1  OCD treatment guidelines
The Australian OCD Clinicians network recommends following Canadian and UK treatment
guidelines (OCD Clinicians Network, n.d.). However, these guidelines were developed in 2014
and 2005 respectively. More recent evidence may affect recommendations. UK’s National
Institute for Health Care Excellence (NICE) decided to review their guidelines in 2019 and the
updating process is currently in progress (NICE, 2005).
Canadian clinical practice guidelines note that CBT on the model of ERP shows equivalent or
superior results to pharmacological treatment (usually selective serotonin re-uptake inhibitors
(SSRIs)). Some evidence shows combined psychological and pharmacological treatment is
equivalent to psychological treatment alone, but superior to pharmacological treatment alone
(Katzman et al, 2014).
NICE guidelines recommend CBT with ERP and/or a course of SSRIs for adults with moderate
to severe functional impairment as a result of OCD. For children, CBT and ERP involving
family or carers is preferred and SSRIs should be only offered if the child or family decline
psychological treatment or if psychological treatment is not benefiting the child (NICE, 2005).
More recent Indian clinical practice guidelines emphasise the need for a treatment plan
including psychological or pharmacological treatment and psychoeducation regarding OCD,
treatment options and potential side-effects of medication (Reddy et al, 2017; Avasthi et al,
2019). For adults, SSRIs are preferred as a first line treatment in Indian due to the availability
of clinical psychologists to deliver CBT (Reddy et al, 2017). For children with mild to moderate
functional impairment, CBT should be the first-line treatment. For children with severe
functional impairment, a combination of CBT and SSRIs should be preferred (Avisthai et al,
2019).
Of the 4 reviewed clinical practice guidelines, none recommend EMDR for treatment of OCD.
Only Katzman et al (2014) explicitly advise against EMDR.
5.  EMDR for people with ASD
There does not appear to be any existing studies that investigate EMDR as a tool for people
with autism separate from their traumatic experiences and symptoms.
A handful of case studies and one group study suggest that EMDR can be modified to work
effectively for children and adults with autism who have PTSD or who have experienced
traumatic events (Volkmar, 2021; Fisher et al, 2022a; Fisher et al, 2022b). One non-
randomised add-on study of 27 participants with autism and a history of trauma showed EMDR
could lead to a reduction in symptoms of trauma. It also showed a small but significant
reduction in autistic traits as measured by the Social Responsiveness Scale-Adult version.
Due to the small effect size, the small sample may not be sufficient to show a conclusive

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effect. The authors suggest possible explanations for reduction in autistic traits could be the
ASD diagnosis overshadowing the symptoms of trauma or the presence of untreated trauma
symptoms exacerbating existing autistic traits (Lobregt-van Burren et al, 2019; Volkmar, 2021).
6. References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Avasthi, A., Sharma, A., & Grover, S. (2019). Clinical practice guidelines for the management
of obsessive-compulsive disorder in children and adolescents. Indian Journal of
Psychiatry, 61(Suppl 2), 306–316.
https://doi.org/10.4103/psychiatry.IndianJPsychiatry 554 18
Elliott, S. J., Marshall, D., Morley, K., Uphoff, E., Kumar, M., & Meader, N. (2021). Behavioural
and cognitive behavioural therapy for obsessive compulsive disorder (OCD) in
individuals with autism spectrum disorder (ASD). Cochrane Database of Systematic
Reviews, 9(9), CD013173. https://doi.org/10.1002/14651858.CD013173.pub2
Fisher, N., van Diest, C., Leoni, M., & Spain, D. (2022a). Using EMDR with autistic individuals:
A Delphi survey with EMDR therapists. Autism: The International Journal of Research
and Practice, 13623613221080254. https://doi.org/10.1177/13623613221080254
Fisher, N., Patel, H., van Diest, C., & Spain, D. (2022b). Using eye movement desensitisation
and reprocessing (EMDR) with autistic individuals: A qualitative interview study with
EMDR therapists. Psychology and Psychotherapy: Theory, Research and Practice, 00,
1– 19. https://doi.org/10.1111/papt.12419
Katzman, M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., Van Ameringen, M., Canadian
Anxiety Guidelines Initiative Group on behalf of the Anxiety Disorders Association of
Canada/Association Canadienne des troubles anxieux and McGill University, Antony,
M. M., Bouchard, S., Brunet, A., Flament, M., Grigoriadis, S., Mendlowitz, S., O’Connor,
K., Rabheru, K., Richter, P. M. A., Robichaud, M., & Walker, J. R. (2014). Canadian
clinical practice guidelines for the management of anxiety, posttraumatic stress and
obsessive-compulsive disorders. BMC Psychiatry, 14 Suppl 1, S1.
https://doi.org/10.1186/1471-244X-14-S1-S1
Lobregt-van Buuren, E., Sizoo, B., Mevissen, L., & de Jongh, A. (2019). Eye movement
desensitization and reprocessing (EMDR) therapy as a feasible and potential effective
treatment for adults with autism spectrum disorder (ASD) and a history of adverse
events. Journal of Autism and Developmental Disorders, 49(1), 151–164.
https://doi.org/10.1007/s10803-018-3687-6
Marsden, Z., Lovell, K., Blore, D., Ali, S., & Delgadillo, J. (2018). A randomized controlled trial
comparing EMDR and CBT for obsessive-compulsive disorder. Clinical Psychology &
Psychotherapy, 25(1), e10–e18. https://doi.org/10.1002/cpp.2120

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National Institute for Health and Care Excellence. (2005). Obsessive-compulsive disorder and
body dysmorphic disorder: treatment (CG31). https://www.nice.org.uk/guidance/cg31
Nazari, H., Nahid Momeni, Mojgan Jariani & Mohammad Javad Tarrahi. (2011). Comparison of
eye movement desensitization and reprocessing with citalopram in treatment of
obsessive–compulsive disorder. International Journal of Psychiatry in Clinical Practice,
15(4), 270-274, doi10.3109/13651501.2011.590210
OCD Clinicians Network. (n.d). Treatment Guidelines.
http://www.ocd.org.au/clinicians/treatment-guidelines
Reddy, Y. C. J., Sudhir, P. M., Manjula, M., Arumugham, S. S., & Narayanaswamy, J. C.
(2017). Clinical practice guidelines for cognitive-behavioral therapies in anxiety
disorders and obsessive-compulsive and related disorders. Indian Journal of Psychiatry,
59, 74-90. https://doi.org/10.4103/psychiatry.IndianJPsychiatry 773 19
Sarichloo, M. E., Taremian, F., Dolatshahee, B., & Haji Seyed Javadi, S. A. (2020).
Effectiveness of exposure/response prevention plus eye movement desensitization and
reprocessing in reducing anxiety and obsessive-compulsive symptoms associated with
stressful life experiences: A randomized controlled trial. Iranian Journal of Psychiatry
and Behavioral Sciences, 14(3). https://doi.org/10.5812/ijpbs.101535
Scelles, C., & Bulnes, L. C. (2021). EMDR as treatment option for conditions other than PTSD:
A systematic review. Frontiers in Psychology, 12, 644369.
https://doi.org/10.3389/fpsyg.2021.644369
Talbot, D. (2021). Examination of initial evidence for EMDR as treatment for obsessive-
compulsive disorder. Journal of EMDR Practice and Research, 15(3), 167-173.
https://doi.org/10.1891/EMDR-D-21-00004
Volkmar, F. R. (Ed.). (2021). Encyclopedia of autism spectrum disorders. Springer
International Publishing.

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