The Effectiveness of EMDR for Medically Unexplained Symptoms: A Systematic Literature Review

Amelia Staton; Sarah Wilde; David L Dawson

doi:10.1891/EMDR-2022-0017

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Abstract

Introduction: It has been hypothesized that certain persistent physical symptoms (PPS) may be linked to unresolved traumatic or distressing somatic-symptom related memories. EMDR intervention targets and reintegrates distressing memories, thus reducing the re-experiencing of physical sensations. The primary aim of this review was to examine effectiveness of EMDR for PPS. Secondary aims were to investigate effectiveness of EMDR on secondary outcomes (post-traumatic stress, anxiety, and depression), and to evaluate the acceptability of EMDR for this client group. Method: Six electronic databases (PsycInfo, PsycArticles, CINAHL, MEDLINE, Web of Science and SCOPUS) were searched for peer-reviewed literature, with no restrictions on publication dates. Twenty-eight studies met inclusion criteria. Studies were included if the primary aim of EMDR intervention was to reduce intensity, frequency or reported distress associated with PPS. Studies were quality appraised using the MMAT tool prior to narrative synthesis of key findings. Results: Studies varied in design and included RCT, UCT, case study and case series. EMDR treatment length varied between studies; 1–20 sessions. All studies reported significant improvement in PPS at post-test. Effect sizes were available to report in five studies and ranged from moderate to large. Improvement in secondary outcomes were reported in all repeated measure studies. Where available, large effect sizes were reported for reduction in anxiety and depression. Overall drop-out rates in studies with representative samples was low (10.6%). Quality of research varied; low (42.8%), medium (21.4%), and high (35.7%). Conclusions: There is promising emerging evidence for effectiveness and acceptability of EMDR for a range of PPS. However, firm conclusions on efficacy cannot be made. While comparisons between PPS presentations cannot be drawn due to methodological differences, the findings for pain and tinnitus are the most compelling due to methodological quality. High-quality sufficiently powered RCTs are recommended to determine efficacy.

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Figure 1.

PRISMA flowchart of study selection process.

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Tables

Database	Coverage
PsycINFO	1806 to present
PsycArticles	1935 to present
CINAHL	1982 to present
MEDLINE	1946 to present
Web of Science	1900 to present
SCOPUS	1788 to present

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Inclusion criterion	Rationale
All empirical studies	Due to limited studies published in this area, inclusion of all studies widens the scope of the review
Primary aim of EMDR intervention to reduce intensity, frequency, or reported distress associated with “medically unexplained symptom”	Primary focus of review
Adult participant sample characterized by persistent physical symptoms in which onset or maintenance is not better explained by biological factors	Primary focus of review and theoretically consistent with adaptive information processing (AIP) model that underpins hypothesized mechanisms of EMDR
Peer-reviewed	To provide a measure of quality control
All studies available in English language	Translation resources not available

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Critical Appraisal of the Included Studies Based on the MMAT Tool

Study	Qualitative MMAT item
Study	1.1. Is the qualitative approach appropriate to answer the research question?	1.2. Are the qualitative data collection methods adequate to address the research question?	1.3. Are the findings adequately derived from the data?	1.4. Is the interpretation of results sufficiently substantiated by data?	1.5. Is there coherence between qualitative data sources, collection, analysis and interpretation?
Kelley and Benbadis (2007) Gupta and Gupta (2002) Grant (2000) Hughes (2014) Proudlock (2015) Royle (2008)	Unclear Unclear Unclear Unclear Unclear Unclear	No No No No No No	Unclear Unclear Unclear Unclear Unclear Unclear	Unclear Unclear Unclear Unclear Unclear Unclear	No No No No No No
Study	Quantitative randomized controlled MMAT item
Study	2.1. Is randomization appropriately performed?	2.2. Are the groups comparable at baseline?	2.3. Are there complete outcome data?	2.4. Are outcome assessors blinded to the intervention provided?	2.5 Did the participants adhere to the assigned intervention?
Demirci et al. (2017)	Unclear	Yes	Unclear	Unclear	Yes
Gerhardt et al. (2016) Luyten et al. (2020) Marcus (2008)	Yes Yes Unclear	Yes Yes Yes	Yes Yes Yes	Yes Yes No	Yes Yes Yes
Rostaminejad et al. (2017) Suárez et al. (2020)	Yes Yes	Yes Yes	Yes Yes	Unclear Unclear	Yes Yes
Study	Quantitative non-randomized MMAT item
Study	3.1. Are the participants representative of the target population?	3.2. Are measurements appropriate regarding both the outcome and intervention (or exposure)?	3.3. Are there complete outcome data?	3.4. Are the confounders accounted for in the design and analysis?	3.5. During the study period, is the intervention administered (or exposure occurred) as intended?
De Roos et al. (2010) Konuk et al. (2011) Phillips et al. (2019) Mazzola et al. (2009) Ray and Page (2002) Rikkert et al. (2018)	Yes No Yes Yes Unclear Yes	Yes Yes Yes Yes Unclear Yes	Yes Yes Yes Yes Yes Yes	Unclear No Unclear Unclear Unclear Unclear	Yes Yes Yes Yes Yes Yes
Study	Quantitative descriptive MMAT item
Study	4.1. Is the sampling strategy relevant to address the research question?	4.2. Is the sample representative of the target population?	4.3. Are the measurements appropriate?	4.4. Is the data complete?	4.5. Is the statistical analysis appropriate to answer the research question?
Altunbaş (2018) Brennstuhl et al. (2015) Chemali and Meadows (2004) Cope (2020) Grant and Threlfo (2002) Russell (2008) Schneider et al. (2008) Silver et al. (2008) Wilensky (2006)	Unclear Yes Unclear Unclear No Unclear Unclear Unclear Yes	Unclear Yes Unclear Unclear No Yes Unclear Unclear Unclear	Yes Yes Yes Yes Yes Yes Yes Yes Yes	Unclear Yes No Yes Unclear Yes Yes Yes No	Unclear Unclear Unclear Unclear Yes No Yes No Unclear

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Characteristics and Key Findings of Studies

N	Author (year), country	Design	Sample	Medically unexplained symptom	Comorbidities	Treatment (protocol, number of sessions)	Outcome measures (primary and secondary)	Follow up		MMAT quality rating
1	Altunbaş (2018), Turkey	Case report Peer-reviewed	N = 1 Age: 35 Gender: Female White Turkish	Daytime blindness (hemeralopia)	PTSD	EMDR, 9 sessions	BAI; BDI; CAPS, IES-R	3-month	Client reported improvement in vision clarity compared to pre-treatment. Clinically significant and reliable change measured in IES-R, BAI, BDI at post-test. Maintained at 3-month follow up.	Low
2	D’Andrea et al. (2021), France	Uncontrolled Clinical Trial	N = 38 Age: Not reported Gender: Female (n = 17), Male (n = 21)	Tinnitus	Not reported	5 sessions	THI, VAS	No follow up	Statistically significant reduction in tinnitus symptoms in 78.9% patients. Significant improvement in reported quality of life and daily functioning. 86.8% participant completed EMDR.	High
3	Brennstuhl et al. (2015), France	Case study	N = 2 Age range: 48–56 Gender: Female	Phantom Breast Syndrome	Chronic pain	9–12 sessions (standard and pain protocol)	STAI, CES-D, Pain and Sensation Intensity	3–6 months	Significant decrease in phantom breast sensation and pain at post-test and maintained at follow-up. Significant decrease in depression and anxiety scores at post-test and maintained at follow up.	High
4	Chemali and Meadows (2004) North America	Case report Peer-reviewed	N = 1 Age: 48 Gender: Female Not specified	Psychogenic seizures	PTSD, Borderline Personality Disorder	EMDR, 18 months (session number not specified)	N of seizures, DES, BDI, QUOLIE-31	3-month	Client seizure free following 18 months of EMDR. Clonazepam (prescribed for seizures) reduced (dosage information not provided). Maintained at 3-month follow up.	Low
5	Cope (2020) UK	Case report Peer-reviewed	N = 2 Age range: 20–50 Gender: Female (n = 1), Male (n = 1) Not specified	Functional non-epileptic attack Functional sensory symptoms	Complex trauma Health Anxiety	EMDR, 20 sessions	BES, BIPQ, GAD-7, HAI, IES-R, MDI, PHQ-9	3-month	Reduction in frequency of FNEA and dissociative episodes. Reduction in severity of functional sensory symptoms and associated distress. Post-treatment scores in subclinical range for PHQ-9, GAD-7, IES-R. Post treatment scores in subclinical range for all subtypes of dissociation (n = 1 remained in clinical range for “emotional constriction” subtype).	Low
6	Demirci et al. (2017), Turkey	Randomised Clinical Trial Peer-reviewed	N = 31 (EMDR arm) Mean age: 27.65 Gender: Female (n = 31) Not specified	Somatic Symptom Disorder General pain	Psychological Trauma	EMDR, 6 sessions (90 mins each)	SCL-90, BAI, BDI, SF-36	No follow up	Significant improvement in somatic symptoms at post-test (n² = 0.94). Both EMDR and TAU (Duloxetine) resulted in significant decreases in SF-36, BAI, BDI at post-test. EMDR group reported larger effect size (n² = 0.94) compared to TAU (n² = 0.68).	Moderate
7	De Roos et al. (2010), Netherlands	Uncontrolled clinical trial (pre-test/post-test design) Peer-reviewed	N = 10 Mean age: 50.1 Gender: Female (n = 4), Male (n = 6) Not specified	Phantom limb pain	Psychological trauma, Obsessive Compulsive Disorder, Substance Use	EMDR, 3–10 sessions (90 mins each)	Pain rating, SCL-90, CIS-20R, IES, SIL, SF-36	26–40 month	80% of patients reported clinically significant reduction in pain at post-test (medium effect size; n² = 0.63). Maintained at follow up. Four participants reported to be “pain free” at post-test and discontinued pain medication. Significant reduction in trauma measures (IES, SIL) to subclinical range at post-test.	High
8	Gerhardt et al. (2016), Germany	Randomized controlled pilot study Peer-reviewed	N = 20 (EMDR arm) Mean age: 56.6 Gender: Female (n = 14), Male (n = 6) White German	Non-specific chronic back pain	“Experience of psychological trauma” (assessed by Structured Clinical Interview DSM-5)	EMDR standard procedure and pain protocols, 10 sessions (90 mins each)	N days with pain, NRS pain intensity, MPI-D, PGIC	6-month	45% of participants who received EMDR experienced significant reduction in pain intensity (d = 0.79) and disability (0.39) versus 0% in TAU control group. Follow up (d = 0.50). 50% of participants who received EMDR rated their condition as “much improved” (n = 8) or “very much improved” (n = 2) compared to 0% in control group (d = 1.69).	High
9	Grant (2000), Australia	Case series	N = 2 Age range: 28–40 Gender: Female	Chronic pain	Depression, PTSD	Chronic pain protocol—no. sessions not specified	Qualitative self-report	Not specified	Both clients reported marked improvement in pain symptoms, functioning and associated distress.	Low
10	Grant and Threlfo (2002), Australia	Case series	N = 3* Age range: 27–54 Gender: Female	Chronic pain	Depression, Fatigue	Chronic pain protocol—9 weekly sessions	SFMPQ, CSQ, VOC, Qualitative self-report	2 months	Significant decrease in pain and distress for all participants. Marked increase in perceived ability to cope with pain and reported daily functioning.	Low
11	Gupta & Gupta (2002), Canada	Case series	N = 4 Age range: 22–43 Gender: Female (n = 3), Male (n = 1)	Dermatologic Disorders	Anxiety, Complex Trauma	3–6 sessions	VOC, Qualitative self-report	6–12 months	All patients reported significant improvement in symptoms. Maintained at follow-up.	Low
12	Hughes (2014), Canada	Case study	N = 1 Age: 35 years Gender: Female	Complex regional pain	Depression, Fatigue, Trauma	16 sessions	Qualitative Self-Report	8 months	Client reported decreased pain, decreased substance use and improved mood at post-test. Maintained at follow up. Client reported improvement in daily functioning and perceived ability to cope with chronic pain.	Low
13	Kelley and Benbadis (2007) North America	Case series Peer-reviewed	N = 8 Mean age: 37.1 Gender: Female (n = 4), Male (n = 4) White American	Psychogenic non-epileptic seizures	PTSD, Complex Trauma, Depression, Obsessive Compulsive Disorder, Dissociative Disorder, Anxiety, Substance Use, Psychosis, Traumatic Brain Injury	Counselling sessions followed by EMDR, 0–7 sessions EMDR protocol	VOC, N of psychogenic seizures	18-month	Two out of three participants who received EMDR were seizure free following 6–7 sessions of intervention. Maintained at follow up. 12.5% reported being seizure free after consult only (n = 1) 12.5% declined treatment after consult (n = 1) 25% dropped out after 2–3 counselling sessions prior to receiving EMDR (n = 2)	Low
14	Konuk et al. (2011), Turkey	Uncontrolled clinical trial	N = 11 Age range: 18–50 Gender: Female (n = 9), Male (n = 2)	Migraines	Trauma related to headaches	8 sessions	NRS, SA-45, WHQ	3 months	Statistically significant decreases in frequency and duration of headaches. Frequency of headaches increased during intervention but decreased post-treatment. No reductions in reported pain intensity. Significant decrease in pain medication and number of medical visits. Maintained at follow up.	Moderate
15	Luyten et al. (2020), Belgium	RCT	N = 46 (EMDR arm) Mean age: 47.87 Gender: Female (n = 26), Male (n = 63)	Chronic Subjective Tinnitus	Anxiety, Depression	5 sessions EMDR (plus Tinnitus Retraining Therapy)	TFI, VAS, TQ, HADS, HQ	3 months	TRT/EMDR showed clinically significant reduction in tinnitus symptoms compared to TRT/CBT. Both TRT/EMDR and TRT/CBT showed significant decrease in tinnitus complaints, hyperacusis, anxiety and depression. Maintained at follow up.	High
16	Marcus (2008), North America	RCT	N = 21 (Integrated EMDR arm) Mean age: 38.33 Gender: Female (n = 41), Male (n = 2)	Migraine	Not reported	1 session (60 minutes) EMDR with diaphragmatic breathing and cranial compression	SPL, MIDAS, HDI	1, 2, 7 days	Both the integrated EMDR and TAU (pain medication) groups reported reduced migraine pain posttreatment. Integrated EMDR group showed significantly greater improvements in rapidity of pain reduction. Maintained at follow up.	Moderate
17	Mazzola et al (2009), Argentina	Uncontrolled clinical trial	N = 38 Age: Not specified Gender: Female (n = 32), Male (n = 6)	Chronic pain 30 (79%) headaches; 4 (10.5%) fibromyalgia; 4 (10.5%) neuropathic pain	Personality disorder, Depression, Anxiety	12 weekly sessions	SF-36, STAI, BDI, SCID-II, VAS	No follow-up	Significant reduction in pain levels resulting in reduction of medication (e.g., benzodiazepines, opioids). EMDR resulted in significant decrease in BDI and STAI at post-test. Statistically significant positive change in perceptions of quality of life (SF-36).	High
18	Phillips et al. (2019), UK	Uncontrolled clinical trial	N = 14 Mean age: 57.2 Gender: Female (n = 7), Male (n = 7)	Tinnitus	Anxiety, Depression	3–10 sessions	THI, BDI, BAI	6 months	Statistically significant improvement in tinnitus symptoms in “majority of participants.” Marked decrease in depression and anxiety at post-test. Results maintained at 6 month follow up.	High
19	Proudlock (2015) England	Case report, Peer-reviewed	N = 1 Age: “Late 50s” Gender: Male White British	Abdomen pain	Psychological trauma, Anxiety	EMDR plus “principles of SLT and CBT,” 20 sessions	IES	6-month	Client reported reduction in frequency and severity of pain. Client reported improvement in depressed mood. At 6 month follow up, client required 6 additional sessions to manage pain associated with recurrent bladder infections.	Low
20	Ray and Page (2002), Australia	Non-randomized Trial	N = 17 Mean age: 36.8 Gender: Female (n = 7), Male (n = 10)	Chronic pain	PTSD, Depression	1 session of EMDR followed by 1 session hypnosis or 1 session hypnosis followed by EMDR (randomly assigned)	MPQ	<1 month	Non-significant reduction in self-reported pain in EMDR condition. Statistically significant pain reduction reported in hypnosis condition. 86.7% reported preference for hypnosis over EMDR post-treatment.	Low
21	Rikkert et al. (2018), Netherlands	Within-groups design	N = 35 Mean age: 49.2 Gender: Female (n = 16), Male (n = 19)	Tinnitus	Sleeping difficulties, pain, trauma, other somatic complaint not otherwise specified	6 sessions	TFI, Mini TQ, SCL-90, SRIP	3 months	Significant reduction in tinnitus distress at post-test compared to passive control condition. Medium effect size observed (d = .72). Almost 1 in 2 participants reported benefiting from EMDR. Results maintained at follow up.	High
22	Rostaminejad et al. (2017) Iran	Randomized controlled trial, Peer-reviewed	N = 30 (EMDR arm) Mean age: 42.8 Gender: Female (n = 9), Male (n = 21) Not specified	Phantom limb pain	Psychological trauma related to amputation	EMDR, 12 sessions (60 mins each)	VOC, Pain rating scale	24-month	At post-test, 86% of participants who had received EMDR reported being “almost or completely pain free.” Maintained at follow up. Statistically significant reduction in pain intensity and associated distress at post-test (P < .001). Effect size calculated for purpose of review (d = 3.23). In comparison, 96.3% of control group (allocated to routine care) reported no reduction in pain in same period.	High
23	Royle (2008), UK	Case report, Peer reviewed	N = 1 Age: 49 Gender: Male Not specified	Chronic fatigue	Anxiety, depression, work related stress	EMDR, 9 sessions	VOC, Qualitative self-report	6, 12-month	Significant decrease in fatigue which allowed client to return to employment and other daily activities. Reduction in symptom-perpetuating maladaptive cognitions. Maintained at 12 month follow up.	Low
24	Russell (2008), Japan	Case report, Peer-reviewed	N = 1 Age: 40 Gender: Male Not specified	Exaggerated startle response, chronic pain, somatic symptoms	Combat related trauma	EMDR, 5 sessions	IES, BDI, Health Status	1, 3, 6-month	Marked improvement in health status self-report at post-test. Maintained at 6 month follow up. Clinically significant and reliable change in IES and BDI scores at post-test. Scores in non-clinical range. Maintained at follow up.	Low
25	Schneider et al., (2008), Germany	Case series, Peer-reviewed	N = 5 Mean age: 49.2 Gender: Female (n = 1), Male (n = 4) Not specified	Phantom limb pain	PTSD	EMDR, 3–15 sessions	IES, BDI, Faces pain scale	12–24 month	Complete elimination of phantom limb pain in two cases. Maintained at follow up. Reduction in pain in three cases. At follow up, one case (who did not complete full protocol due to relocation) reported “rebound in pain frequency.” At post-test and follow up, two clients reduced pain medication (e.g., morphine) and discontinued Diazepam. Average IES and BDI scores in subclinical range at post-test and follow up.	Moderate
26	Silver,et al. (2008), North America & Japan	Case report, Peer-reviewed	N = 1 Age: 73 Gender: Male Not specified	Myoclonic movements (upper body shaking & jerking)	Combat related PTSD	EMDR, 2 sessions	IES, BDI, BHS	1, 6-month	Clinically significant and reliable change in IES, BDI and BHS scores at post-test. No longer in clinical ranges. Maintained at follow up. Client reported complete elimination of myoclonic movements. Maintained at 6 month follow up.	Moderate
27	Suárez et al. (2020), Spain	RCT Pilot	N = 14 (EMDR arm) Age range: 49–60 Gender: Female (n = 22), Male (n = 6)	Chronic Pain	Depression, Anxiety	12 sessions	VAS, PDI, EDQ-5D-5L, HADS	3 months	EMDR+TAU group reported significant improvement in pain intensity, anxiety and depression scores at post-test when compared to TAU. Results from EMDR maintained at follow up.	High
28	Wilensky (2006), Canada	Case series, Peer-reviewed	N = 5 Mean age: 45.6 Gender: Female (n = 1), Male (n = 4) Not specified	Phantom limb pain	Psychological trauma	EMDR, 3–9 sessions	IES, BDI, PDI, TSI	1, 3-year (two clients only)	Four of the five clients completed planned protocol and reported complete elimination or marked reduction in pain. One client stopped treatment after reducing reported pain by 50%. Significant reduction in BDI and PDI scores at post-test. Significant reduction in IES scores at post-test. One client no longer scoring in clinical range. Three clients lost to follow up.	Moderate

[i] BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory; CAPS = Clinician-Administered Post-traumatic stress disorder Scale; IES-R = Impact of Events Scale Revised; BES = Beliefs About Emotions Scale; BIPQ = Brief Illness Perception Questionnaire; GAD-7 = Generalized Anxiety Disorder Scale; HAI = Health Anxiety Inventory; IMDI = Multiscale Dissociation Inventory; PHQ-9 = Patient Health Questionnaire; CIS-R = Checklist Individual Strength Revised; SCL-90 = Symptom Checklist; SIL = Self-Inventory List; SF-36 = Short Form Health Survey; NRS Pain = Numeric Pain Rating Scale; MPI-D = Multi-dimensional Pain Inventory (Dutch Version); PGIC = Patient Global Impressions of Change; VOC = Validity of Cognition; BHS = Beck’s Hopelessness Scale; PDI = Peters’ Delusions Inventory; TSI = Trauma Symptom Inventory; SFMPQ = Short-Form McGill Melzack Pain Questionnaire; CSQ = Coping Skills Questionnaire; VAS = Visual Analog Score; WHQ = Weekly Headache Questionnaire; SA-45 = Symptom Assessment 45 Questionnaire; SCID = Structured Clinical Interview for DSM; STAI = State Trait Anxiety Inventory; CES-D = Centre for Epidemiologic Studies—Depression; EQ-5D-5L = EuroQol 5 Dimensions Quality of Life; TFI = Tinnitus Functional Index; Mini TQ = Mini Tinnitus Questionnaire; SRIP = Self-Rating Inventory List for Post-Traumatic Stress Disorder; THI = Tinnitus Handicap Inventory; HQ—Hyperacusis Questionnaire; CTQ = Childhood Trauma Questionnaire; ADES = Adolescent Dissociative Experiences Scale; SPL = Subjective Pain Level; HDI = Headache Disability Inventory; MDAS = Migraine Disability Assessment Scale.

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The Effectiveness of EMDR for Medically Unexplained Symptoms: A Systematic Literature Review

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