# Çocuklukla ilişkili TSSB: EMDR ve imgeleme ile yeniden senaryolaştırmada bilişlerin rolü (Childhood-related PTSD: the role of cognitions in EMDR and imagery rescripting)

- URL: https://alisanburak.com/en/cocuklukla-iliskili-tssb-emdr-ve-imgeleme-ile-yeniden-senaryolastirmada-bilislerin-rolu-childhood-related-ptsd-the-role-of-cognitions-in-emdr-and-imagery-rescripting
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- Last updated: 2026-08-15
- Page title: Çocuklukla ilişkili TSSB: EMDR ve imgeleme ile yeniden senaryolaştırmada bilişlerin rolü (Childhood-related PTSD: the role of cognitions in EMDR and imagery rescripting) | Assoc. Prof. Dr. Alişan Burak Yaşar

> Authors: Nele Assmann, Sophie A. Rameckers, Anja Schaich, Christopher W. Lee, Katrina Boterhoven de Haan, Marleen M. Rijkeboer, Arnoud Arntz & Eva Fass

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# Çocuklukla ilişkili TSSB: EMDR ve imgeleme ile yeniden senaryolaştırmada bilişlerin rolü (Childhood-related PTSD: the role of cognitions in EMDR and imagery rescripting)

September 28, 2024Recent Articles

**Authors:** Nele Assmann, Sophie A. Rameckers, Anja Schaich, Christopher W. Lee, Katrina Boterhoven de Haan, Marleen M. Rijkeboer, Arnoud Arntz & Eva Fassbinder

**Translated by:** Specialist Psychologist Gizem Pozam

**ABSTRACT**

**Background:** The relationship between negative trauma-related cognitions and symptoms of posttraumatic stress disorder (PTSD) has been studied extensively. Studies of different psychotherapeutic treatments have found that negative trauma-related cognitions mediate symptom reduction, but this relationship has never been studied in imagery rescripting (ImRs) or eye movement desensitization and reprocessing (EMDR).

Objective of this study: To analyze the role of negative trauma-related cognitions in the treatment of childhood trauma-related PTSD with EMDR and ImRs.

**Method:** N = 155 patients: N = 155 patients with childhood trauma-related PTSD, aged between 18 and 65 years (M = 38.54), participated in a randomized clinical trial and were treated with EMDR or ImRs between October 2014 and June 2019 in Australia, Germany, and the Netherlands. The relationship between PTSD symptoms (Clinician-Administered PTSD Scale for DSM-5, CAPS-5, and Impact of Event Scale–Revised; IES-R, completed twice, for the index trauma and all other traumas) and negative trauma-related cognitions (Posttraumatic Cognitions Inventory, PTCI) was analyzed using Granger causality analyses with linear mixed models on person-centered variables. Assessments were conducted before treatment, after treatment (12 sessions over 6 weeks), eight weeks after treatment, and one year after the pretreatment assessment.

**Results:** Changes in negative cognitions (PTCI) preceded changes in PTSD symptoms (unidirectionally), as measured by the CAPS and the IES-R for the index trauma. For the IES-R relating to all other traumas, a unidirectional relationship was found in which changes in PTSD symptoms preceded changes in negative cognitions. No moderating effect of treatment was found. At the level of the PTCI subscales, only changes in cognitions about the self preceded changes in PTSD symptoms.

**Conclusions:** The results support the notion that negative trauma-related cognitions play a general role in PTSD treatment. The analyses should be replicated with more frequent assessments.

1. **Background**

Negative trauma-related cognitions are a central component of posttraumatic stress disorder (PTSD) and have been included in the DSM-5 diagnostic criteria for PTSD (American Psychiatric Association, 2013; Kip et al., 2023). These negative cognitions may concern the self (e.g., 'I am damaged'), others (e.g., 'No one can be trusted'), or the world (e.g., 'The world is dangerous'). Explanatory models of different therapeutic approaches (e.g., cognitive therapy, cognitive behavioral therapy, prolonged exposure, eye movement desensitization and reprocessing) regard these cognitions as important factors maintaining PTSD symptoms (Ehlers and Clark, 2000; Foa and Kozak, 1986; Resick et al., 2016; Shapiro and Forrest, 2001). Indeed, the relationship between negative trauma-related cognitions and PTSD symptoms has been found in many studies (see Gómez de La Cuesta et al., 2019, for an overview).

Negative cognitions also seem likely to play an important role in PTSD treatment. Although only some therapeutic approaches focus directly on negative trauma-related cognitions, there appears to be a general relationship between these cognitions and PTSD symptoms (Kangaslampi & Peltonen, 2022). A recent review of the role of negative trauma-related cognitions in PTSD treatment reported that several studies identified a simultaneous reduction in PTSD symptoms and negative cognitions, regardless of the therapeutic approach (Brown et al., 2019). An important question is whether reductions in negative trauma-related cognitions and PTSD symptoms occur together during treatment or whether reductions in negative trauma-related cognitions precede reductions in PTSD symptoms. Several studies addressing this question were also summarized in a review (Brown et al., 2019), which reported that nine out of twelve studies found that changes in negative trauma-related cognitions preceded changes in PTSD symptoms. In addition, two recent studies not included in the review also found that changes in negative trauma-related cognitions preceded symptom reduction (Kooistra et al., 2023; Schumm et al., 2023). On the other hand, a total of six studies (those published before 2019 were included in Brown et al., 2019) did not find the hypothesized relationship between PTSD symptoms and negative cognitions, instead finding a bidirectional relationship (Dillon et al., 2019; Held et al., 2022; McLean et al., 2015; Trachik et al., 2018), simultaneous reductions in symptoms and cognitions (Lee et al., 2021), or a reverse relationship (changes in PTSD symptoms preceding changes in negative cognitions) (Hagenaars et al., 2010). Thus, although most studies indicate that changes in negative trauma-related cognitions precede changes in PTSD symptoms, the findings are mixed.

One study that found a reciprocal relationship was based on a sample with comorbidity (alcohol dependence), which may explain the result. Another possible explanation for the conflicting results may be the operationalization of trauma-related cognitions. For example, guilt (Trachik et al., 2018) and blame (Dillon et al., 2019) captured narrowly defined trauma-related cognitions compared with the broader definition used in the Posttraumatic Cognitions Inventory (PTCI) (Foa et al., 1999), which includes self, world, and self-blame subscales. The PTCI has been used in many studies of negative trauma-related cognitions. Studies analyzing negative trauma-related cognitions at the level of the PTCI subscales have found differences between the subscales in their relationships with PTSD symptoms (see Brown et al., 2019, for an overview). Correlational studies have found a strong cross-sectional relationship between negative self-related cognitions and PTSD symptoms or symptom reduction (Foa and Rauch, 2004; Karl et al., 2009; Long et al., 2011). Of three studies examining the relationship between specific trauma-related cognitions and changes in PTSD symptoms over time, two found that cognitions about the self were significant predictors of changes in PTSD symptoms over time (Kumpula et al., 2017; Schumm et al., 2015), whereas one found a strong relationship between self-related cognitions and PTSD symptoms, but changes in cognitions did not predict symptom changes (Hagenaars et al., 2010). Nevertheless, negative trauma-related cognitions, particularly those concerning the self, may be an important predictor of changes in PTSD symptoms (Brown et al., 2019). This is also consistent with recent findings on the effectiveness of PTSD treatment in reducing negative self-concept (Banz et al., 2022).

Although the evidence that negative trauma-related cognitions change before PTSD symptoms do is mixed, the finding of such an effect in exposure-based therapy as well as cognitive therapy may indicate a general mechanism of change that is not specific to particular (cognitive) therapeutic approaches. To investigate this assumption further, it is important to analyze the role of negative trauma-related cognitions in various PTSD treatments. One treatment that has been shown to be effective and stands alongside CBT as a strongly recommended treatment for PTSD is EMDR (Lewis et al., 2020; Mavranezouli et al., 2020). Another promising treatment is imagery rescripting (ImRs) (Arntz and Weertman, 1999), for which there is some evidence of effectiveness in treating PTSD in general (see Kip et al., 2023) and childhood trauma-related PTSD in particular (Boterhoven de Haan et al., 2020; Raabe et al., 2022). In EMDR, negative trauma-related beliefs are targeted directly, and following desensitization, the therapist repeatedly pairs positive beliefs with the trauma memory (Shapiro and Forrest, 2001). ImRs addresses negative trauma-related cognitions more indirectly by changing the meaning of an event through imagining corrective experiences, meeting needs, and psychoeducation. Thus, both therapeutic approaches aim to address and modify negative trauma-related cognitions in different ways and may differ in the impact of cognitive changes on PTSD symptoms. An earlier analysis of the mechanisms of action of ImRs and EMDR, using the same dataset as our study, found that changes in distress and the idiosyncratic encapsulated belief relating to the index trauma predicted changes in PTSD severity during ImRs, but not during EMDR (Rameckers et al., 2024). Some studies have shown simultaneous reductions in negative trauma-related cognitions and PTSD symptoms from before to after EMDR treatment (Brown et al., 2019).

To our knowledge, no study to date has investigated the effect of general negative trauma-related cognitions (e.g., as measured by the PTCI) on treatment outcomes in EMDR or ImRs. To gain insight into the role of (general) negative trauma-related cognitions in ImRs and EMDR treatment, we used data from a randomized trial comparing EMDR and ImRs as treatments for childhood trauma-related PTSD (Boterhoven de Haan et al., 2020) to analyze the temporal order of changes in negative trauma-related cognitions and PTSD symptoms using Granger causality analysis (Granger, 1969). This analysis allows the examination of time-lagged relationships between variables and provides insight into the direction of changes in negative cognitions and PTSD symptoms. We hypothesize that (i) changes in negative trauma-related cognitions precede changes in PTSD symptoms, thereby providing some evidence for a mechanism of change. We also investigated whether the effects differed by treatment condition. Given the findings on negative self-related cognitions, we hypothesize that (ii) only changes in this subscale precede changes in PTSD symptoms.

1. **Methods**

2.1. Study design

This study is a subanalysis of data from an international multicenter randomized clinical trial (IREM-RCT) comparing EMDR and ImRs at seven sites in Australia, Germany, and the Netherlands (Boterhoven de Haan et al., 2020). The study was registered with the Australian New Zealand Clinical Trials Registry (ref. no. ACTRN12614000750684). The study was approved by all local institutional review boards, and patients provided written informed consent. Detailed information on the study characteristics can be found in the IREM design paper (Boterhoven de Haan et al., 2017); a brief description of the study design follows below.

2.2. Participants

Patients were included if they (1) had a primary diagnosis of PTSD based on an index trauma occurring before the age of 16, with symptoms present for at least three months, (2) were between 18 and 65 years of age, (3) could attend sessions twice a week, and (4) agreed to maintain stable medication use (or no medication use) throughout the six-week treatment phase and eight-week follow-up phase. Exclusion criteria were (1) acute suicide risk, (2) a lifetime diagnosis of a psychotic disorder, (3) a lifetime diagnosis of bipolar I disorder, (4) acute substance dependence, (5) PTSD related to trauma occurring within the past six months, (7) an IQ below 80, (8) any PTSD-focused treatment within the past three months, and (9) benzodiazepine medication. Participation was possible after discontinuing these medications for two weeks.

2.3. Randomization and masking

Participants were randomized to EMDR or ImRs by an independent research assistant after the pretreatment assessment using block randomization (n = two, four, and six per block, with randomized block size), stratified by gender to control the distribution per treatment at each site. All assessments were conducted by trained research assistants blinded to treatment condition.

2.4. Procedures

Between October 2014 and June 2019, participants were recruited at seven mental health and specialist services in Australia, Germany, and the Netherlands. Because the Structured Clinical Interview for DSM-5 (First et al., 2015) was not available at the start of the study, potential participants were screened for psychiatric disorders using either the Mini International Neuropsychiatric Interview (Sheehan et al., 1998) or the Structured Clinical Interviews for DSM-IV-TR (First et al., 2002), depending on site preferences. Trauma history was assessed using the Life Events Checklist for DSM-5 (Weathers et al., 2013). Outcome assessments were conducted before treatment, midway through treatment (self-report only, no interview), after treatment, eight weeks after treatment (follow-up 1), and one year after the pretreatment assessment (follow-up 2).

2.5. Outcomes

PTSD symptom severity was measured using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) (Weathers et al., 2018). The CAPS-5 is a well-validated semistructured diagnostic interview for assessing the severity of PTSD symptoms over the preceding month. It consists of 30 items corresponding to DSM-5 PTSD symptoms and rates PTSD severity over the past month on a scale of 0–80 (total score, with higher scores reflecting greater severity). For our analysis, criteria D2 and D3 were removed from the CAPS total score because these criteria assess negative cognitions and feelings of guilt and therefore overlap with PTCI items. The internal consistency of these CAPS scores for each assessment ranged from a = .892 to .922. Self-reported PTSD symptoms were measured using the Impact of Event Scale–Revised (IESR) (Weiss, 2007). The IES-R consists of 22 items assessed for the past seven days and is sensitive to change. Participants were asked to rate the items twice: once for the trauma identified as central at intake (index trauma) (a ranging from .877 to .972), and then for all other traumas excluding the index trauma (a ranging from .927 to .973). The Posttraumatic Cognitions Inventory (PTCI) was used to assess trauma-related cognitions (Foa et al., 1999). The PTCI is a 33-item self-report instrument with three subscales (negative cognitions about the self, negative cognitions about the world, and self-blame), has good psychometric properties, and is frequently used in studies of negative trauma-related cognitions. We analyzed the PTCI total score as well as its three subscales. In our data, the internal consistency of the PTCI total score was high/excellent, ranging from .928 to .978. The internal consistency of the three subscales across assessments was also high (a = .919 to .973 for the PTCI Self-Blame scale, a = .850 to .964 for the PTCI World scale, and .802 to .935 for the PCTI self-blame scale).

To limit the number of analyses, we used only the primary outcome (CAPS) to analyze the PTCI subscales.

2.6. Treatment

Briefly, the study treatment consisted of twelve 90-minute sessions of ImRs or EMDR, delivered twice weekly over a six-week period, with up to eight weeks allowed, based on standardized treatment manuals (Arntz & Weertman, 1999; Shapiro & Forrest, 2001). The first session introduced the treatment rationale and established an overview of the trauma memories to be addressed during treatment. A pilot rescripting exercise was conducted in the ImRs condition, while preparation for the procedure and affect tolerance training, including a safe-place exercise, were provided in the EMDR condition. From the second treatment session onward, each session involved trauma reprocessing in the assigned treatment condition. Study therapists were licensed psychologists, psychotherapists, psychiatrists, and a psychiatric nurse with advanced mental health qualifications, trained in one or both treatment conditions. Details on treatment, training, supervision, and adherence can also be found in the study protocol and the publication on the clinical effectiveness of the IREM trial (Boterhoven de Haan et al., 2017; Boterhoven de Haan et al., 2020).

2.7. Statistical analysis

To examine the relationships between PTCI and PTSD symptoms over time, we conducted Granger causality analyses (Granger, 1969) using linear mixed models. We performed the analyses in RStudio using the NLME package (Pinheiro et al., 2020). We conducted separate analyses for each PTSD measure (i.e., IES-R Index Trauma, IES-R All Other Traumas, and CAPS-5). First, we centered the data at the participant level. Second, we examined whether PTCI scores at assessment i predicted PTSD symptoms at assessment i + 1, also including PTSD symptoms at assessment i as a predictor to control for autocorrelation. We tested reverse effects by examining whether CAPS-5 scores at assessment i predicted PTCI scores at assessment i + 1. Because changes over time could also occur due to nonspecific treatment effects, and because we expected a nonlinear time trend, we controlled for the effect of time by adding a natural time spline with two degrees of freedom using the splines package (R Core Team, 2020). Finally, we also included a random effect of time (using the same splines) if this improved model fit.

All model comparisons were based on log-likelihood, the Bayesian Information Criterion (BIC), and the Akaike Information Criterion (AIC). The alpha threshold for all analyses was .05. We defined outliers as residuals with an absolute value greater than 3 (Blatná, 2006). If any outliers were identified, they were removed, and the number of outliers removed was reported. The Results section reports results based on data excluding outliers.

We examined the influence of all data points by inspecting Cook's distance for each point. For each of the models, all Cook's distance values were small and below the threshold of 1 (Cook & Weisberg, 1982).

1. **Results**

3.1. Participants

Data from all participants in the IREM trial (N = 155) across three countries were included: the Netherlands (n = 92), Germany (n = 22), and Australia (n = 41). Participants were allocated to EMDR (n = 81) or ImRs (n = 74). Women accounted for 77% of the sample, and the mean age of participants was 38.54 years. Most participants had experienced their index trauma more than once (93.2% of ImRs participants, 79.0% of EMDR participants), with a mean index trauma duration of 7.6 (SD = 5.2) years for ImRs and 6.8 years (SD = 4.6) for EMDR. The most common index trauma was sexual abuse (48.6% ImRs, 67.9% EMDR), followed by physical abuse (20.3% ImRs and 19.8% EMDR), and the mean age at the time of the index trauma was 7.77 years (SD = 4.21) for ImRs and 8.12 years (SD = 4.16) for EMDR. Most participants had received higher education/vocational training (56.8% in both groups), but fewer than half were employed (39.2% ImRs, 42.0% EMDR), and approximately one-third were receiving a disability pension (37.9% ImRs and 32.0% EMDR). Further details on the study sample can be found in the primary publication of the IREM trial (Boterhoven de Haan et al., 2020).

3.2. Granger causality

For the main analysis (see Table 1 and Figure 1a), we tested Granger causality for each of the three PTSD outcomes (i.e., CAPS-5, IES-R Index Trauma, and IES-R Other Trauma). We also explored interactions with treatment. Autocorrelations were significant and negative in all analyses. The number of outliers removed per analysis is reported in Table 1.

3.2.1 PTCI total score with CAPS-5

Changes in PTCI preceded CAPS-5 scores at the next assessment (β = .085, p < .05), whereas CAPS-5 did not significantly predict subsequent PTCI scores (i.e., the reverse test) (β = .005, p > .05). The relationship between PTCI and subsequent CAPS scores was not moderated by treatment (b = 0.028, t(285) = 1.546, SE = 0.018, p = .123), and the same was true for the reverse relationship (b = -0.010, t(288) = -0.065, SE = 0.153, p = .948). We repeated the analyses excluding criterion D4 from the CAPS-5 score because this criterion included negative emotions and therefore might have some overlap with the PTCI, but this did not change the results.

3.2.2 PTCI at the subscale level with CAPS

The results of the analyses at the PTCI subscale level are reported in Table 1 and Figure 1b. PTCI negative cognitions about the self scores positively predicted and preceded changes in subsequent CAPS-5 scores (β = .132, p < .05), whereas CAPS-5 scores did not predict changes in PTCI negative cognitions about the self scores (β = .001).

PTCI negative cognitions about the world scores did not predict changes in CAPS scores at the next assessment (β = .058, p > .05), whereas CAPS scores positively predicted subsequent changes in PTCI negative cognitions about the world (β = .170, p < .05).

PTCI self-blame scores were not associated with CAPS-5 scores at the next assessment (β = .032, p > .05), and CAPS-5 scores did not predict subsequent PTCI self-blame scores (β = .025, p > .05).

3.2.3 PTCI total score with IES-R Index Trauma.

PTCI scores predicted subsequent IES-R Index Trauma scores (β= -.088, p < .05), whereas scores on the IES-R Index Trauma scale did not predict PTCI scores at the next assessment (β= .080, p > .05). The effects were not moderated by treatment: PTCI as predictor, b = 0.052, t(408) = 1.515, SE = 0.035, p = .131; IES-R Index Trauma scores as predictor, b = 0.061, t (420) = 0.614, SE = 0.010, p = .539.

3.2.4 PTCI total score with IES-R Other Traumas.

PTCI scores did not predict IES-R Other Trauma scores at the next assessment (β = .056, p > .05), whereas the effect of IES-R Other Trauma scores on PTCI scores at the next assessment was significant (β = .102, p < .05). Thus, changes in IES-R Other Trauma scores preceded changes in PTCI scores. Again, there was no moderation by treatment for PTCI, b = -0.004, t(400) = -0.126, SE = 0.033, p = .900, or IES-R Other Traumas, b = 0.096, t(417) = 0.859, SE = 0.111, p = .391.

1. **Discussion**

This is the first study to examine the role of negative trauma-related cognitions other than encapsulated beliefs in PTSD symptoms during treatment with EMDR and ImRs in patients with childhood trauma-related PTSD.

Consistent with our hypothesis, we found that changes in negative trauma-related cognitions preceded changes in PTSD symptoms for two of the three outcomes. For IES-R Index Trauma and CAPS, changes in negative trauma-related cognitions preceded changes in PTSD symptoms, but the reverse was not found. This unidirectional relationship provides some evidence of causality between negative trauma-related cognitions and PTSD symptoms and resembles the findings of several previous studies by supporting the notion that changes (i.e., reductions) in cognitions precede reductions in PTSD symptoms (Brown et al., 2019). For the third outcome, IES-R Other Traumas, only the reverse relationship (changes in PTSD symptoms preceding changes in negative trauma-related cognitions) was significant. One reason for this may be that the index trauma was addressed early in treatment (right at the beginning in EMDR and within the first six sessions in ImRs), whereas other traumas were addressed later in treatment. Perhaps the reduction in negative cognitions associated with other traumas resulted from a generalization effect of treatment experiences and therefore followed the reduction in PTSD symptoms.

Only changes in the PTCI subscale measuring negative cognitions about the self preceded reductions in PTSD symptoms. These findings support our second hypothesis that reductions in negative trauma-related cognitions are particularly important for improvement in PTSD symptoms in our patient group (childhood trauma-related PTSD). This is consistent with previous findings indicating the importance of such cognitions (Foa and Rauch, 2004; Karl et al., 2009; Kumpula et al., 2017; Long et al., 2011). Our findings are also consistent with previous findings suggesting that negative cognitions about the self and self-blame may be particularly important among survivors of (sexual) violence (Beck et al., 2016; Littleton et al., 2012; Pence et al., 2014). In our sample, the index trauma involved sexual, physical, or mixed abuse or domestic violence for 92.9% of all participants (Boterhoven de Haan et al., 2020). The findings are also consistent with a meta-analysis reporting that psychological interventions for PTSD improve negative self-concept with moderate to large controlled effect sizes (Banz et al., 2022).

The predictive relationship between negative trauma-related cognitions and PTSD symptoms did not differ by treatment condition, suggesting that the role of cognition may be similar in EMDR and ImRs. This contrasts with an earlier analysis of this study, which showed that changes in the idiosyncratic encapsulated belief about the index trauma preceded symptom reduction only in the ImRs condition (Rameckers et al., 2024). The difference may be explained by the fact that our analysis refers to general negative cognitions, whereas the study by Rameckers and colleagues addressed an individual belief relating to a specific situation within the index trauma. On the other hand, the absence of a moderating effect of treatment is consistent with previous studies identifying a mediating effect of negative trauma-related cognitions on treatment outcomes across different therapeutic approaches (Brown et al., 2019). Despite differences in treatment models (Cooper et al., 2017), this may indicate a general mechanism of change in PTSD treatment; that is, different interventions may share common pathways of change. Our findings are consistent with previous studies in which changes in negative trauma-related cognitions preceded changes in PTSD symptoms across different trauma-focused treatments, such as PE (e.g., Kumpula et al., 2017; McLean, Yeh et al., 2015; Zalta et al., 2014), CPT (Schumm et al., 2015), and trauma-focused CBT (Kleim et al., 2013; Zoellner et al., 2011). This, in turn, is consistent with several established explanatory models of PTSD in which trauma-related cognitions play a central role (Ehlers and Clark, 2000; Foa and Kozak, 1986; Resick et al., 2016; Shapiro and Forrest, 2001). However, it should also be noted that several studies have not found this temporal association, particularly for PE (Hagenaars et al., 2010; McLean, Su et al., 2015) and CPT (Dillon et al., 2019; Held et al., 2022; Lee et al., 2021).

The potential role of cognitions in PTSD treatment may be of interest for our understanding of nonresponse. If a reduction in negative trauma-related cognitions is necessary for a reduction in PTSD symptoms, a lack of change in cognitions may partly explain nonresponse; this could then prompt the therapist to focus more on cognitive interventions. This may provide an argument for session-level assessment of cognition in EMDR and ImRs treatments as well, as has been proposed for PE (Kooistra et al., 2023).

However, it should also be noted that changes in negative trauma-related cognitions may not be the only mechanism of change in PTSD treatment, as there is evidence that belief change plays a similar role in CBT more generally (e.g., Garratt et al., 2007; Lorenzo Luaces et al., 2015).

4.1 Limitations and strengths

The main limitation of our analysis is that we had limited process data. CAPS and PTCI were assessed at baseline, after treatment, and at the 8-week and 1-year follow-ups, whereas IES-R was assessed at every session, and IES-R and PTCI were additionally assessed between sessions 6 and 7. More assessment points during treatment would be valuable for obtaining more reliable evidence on processes of change. Furthermore, because our study included patients with childhood trauma-related PTSD, our results are limited to this patient group. All other limitations of the IREM trial also apply to this analysis (Boterhoven de Haan et al., 2020), including the presence of two active treatment arms and the absence of a control condition.

This is the first study to analyze the relationship between general negative trauma-related cognitions and changes in PTSD symptomatology in patients treated with EMDR and ImRs. Moreover, this relationship was investigated for the first time in adult patients experiencing childhood trauma-related PTSD. The study thus supported a general mechanism of change across different PTSD treatment modalities and different types of trauma. Treatment delivered by trained therapists and evaluated through adherence checks, together with data assessment involving self-reports and interviews conducted by trained blinded assessors, supports the high quality of the IREM-RCT. Given that there has been only one study comparing EMDR and ImRs to date, further studies are needed to replicate the results and gain more insight into their mechanisms of action.

4.2 Conclusion

In conclusion, our study showed that the role of negative trauma-related cognitions in treatment with EMDR and ImRs is similar to their role in other PTSD treatments, such as cognitive processing therapy (CPT), CT, and PE. Changes in negative trauma-related cognitions preceded changes in PTSD symptoms in both EMDR and ImRs treatment. To further validate our findings and improve generalizability, the analyses should be replicated with more frequent assessments (e.g., weekly during treatment) and in a sample with adulthood trauma.

Acknowledgments

We thank all patients, therapists, and research assistants who participated in this study.

Disclosure statement

No potential conflict of interest was reported by the author(s). Declaration of interests: C.W.L. reported receiving a grant from the EMDR Research Foundation during the conduct of the study and personal fees from Psychology Training outside the submitted work. A.A. publishes scientific articles and book chapters on ImRs and occasionally conducts workshops on this treatment. The financial remuneration he receives goes to the University of Amsterdam to support research. E.F. reports personal fees from workshops and lectures on ImRs and PTSD treatment and grants from the University of Lübeck (Habiliationsförderung für Wissenschaftlerinnen, Sektion Medizin) outside the submitted work. The other authors declared that they had no conflicts of interest.

Funding

This study was supported by the Anxiety Disorders Foundation of Western Australia (grant number PG51012100); the EMDR Research Foundation (ref: PG10400309); and the Commonwealth Government through the 'Australian Government Research Training Program Fees Offset'. We acknowledge the financial support provided by the State of Schleswig-Holstein through the 'Open Access Publikationsfond' funding program.

Author contributions

Conceptualization, A.A., C.W.L., M.R. and E.F.; Methodology, A.A. and C.W.L.; Software, A.A. and S.R.; Formal analysis, A.A. and S.R.; Investigation, N.A., E.F., A.S., C.W.L., K.B.d.H., M.R. and A.A.; Resources, E.F., C.W.L., M.R. and A.A.; Data curation, S.R. and K.B.d.H.; Writing - original draft preparation, N.A.; Writing - review and editing, N.A., E.F., A.S., C.W.L., K.B.d.H., M.R. and A.A.; Revision following feedback and submission: N.A.; Visualization, S.R.; Supervision, C.W.L., M.R. and A.A.; Project administration, C.W.L., K.B.d.H. and A.A.; Funding acquisition, C.W.L. and K.B.d.H. All authors have read and agreed to the published version of the manuscript.

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