The Effectiveness of Eye Movement Desensitization and Reprocessing Therapy (EMDR) on Post-Traumatic Stress Disorder Symptoms and Diagnostic Status in Patients with a Personality Disorder: A Randomized Controlled Trial (The Effectiveness of Eye Movement Desensitization and Reprocessing Therapy on Post-Traumatic Stress Disorder Symptoms and Diagnostic Status in Patients with a Personality Disorder: A Randomized Controlled Trial)

Journal: Psychotherapy and Psychosomotics. 2025 Jul 25. doi: 10.1159/000547622

Authors: Laurian Hafkemeijer 1, Simon Hofman 2, Ad de Jongh 3 4 5 6 7, Dorien de Roos 1, Maaike van Velzen 1, Annemieke Starrenburg 1, Karin Slotema 2 8

1- GGZ Delfland, Delft, The Netherlands.

2- Department of Personality Disorders, Parnassia Psychiatric Institute, The Hague, The Netherlands.

3- Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University, Amsterdam, The Netherlands.

4- Research Department, PSYTREC, Bilthoven, The Netherlands.

5- School of Health Sciences, Salford University, Manchester, UK.

6- Institute of Health and Society, University of Worcester, Worcester, UK.

7- School of Psychology, Queen's University, Belfast, UK.

8- Department of Psychology, Education and Child Studies, Erasmus School of Social and Behavioral Sciences, Erasmus University Rotterdam, Rotterdam, The Netherlands.

 

Translated by: Specialist Psychologist Elena Gizem Pozam

 

Abstract

Introduction: Individuals with a personality disorder (PD) frequently report high levels of exposure to adverse life events. Given the strong association between adverse life events and PD pathology, evaluating trauma-focused treatments in this population is essential. This study evaluated the effectiveness of Eye Movement Desensitization and Reprocessing (EMDR) therapy compared with a waiting list group in reducing post-traumatic stress disorder (PTSD) symptoms and diagnostic status, distinguishing between patients with and without a PTSD diagnosis. Second, it examined the effects of EMDR therapy on memories of adverse life events that both met and did not meet Criterion A for PTSD.

Method: Participants (n = 159) were randomly assigned to EMDR therapy or a waiting list group. PDs were assessed using the Structured Clinical Interview for DSM-5. PTSD symptoms and diagnoses were assessed using the Clinician-Administered PTSD Scale for DSM-5. Secondary analyses examined the effectiveness of EMDR on various types of memories.

Results: Significant group-by-time interactions indicated a greater reduction in PTSD symptoms in the EMDR therapy group, regardless of baseline PTSD diagnosis. Large effects were found in patients with PTSD at post-treatment ($d = 1.26$; control: $d = 0.28$) and follow-up ($d = 1.5$; control: $d = 0.69$). In patients without PTSD, moderate to large effects emerged at post-treatment ($d = 0.77$; control: $d = 0.18$) and follow-up ($d = 1.09$; control: $d = 0.46$). EMDR therapy reduced symptoms associated with Criterion A trauma and other adverse life events. After treatment, 65.5% of EMDR patients no longer met the criteria for a PTSD diagnosis, increasing to 73.1% at follow-up.

Conclusion: EMDR effectively reduced PTSD symptoms in individuals with PD, regardless of PTSD diagnosis, and also demonstrated effectiveness for memories that did not meet Criterion A.

Keywords: Adverse life events; Eye movement desensitization and reprocessing; Personality disorders; Post-traumatic stress disorder; Trauma.

 

Introduction

Individuals with a personality disorder (PD) experience high levels of distress that significantly affect multiple areas of their lives . Although various treatments have been shown to be effective in individuals with PD, they are generally long-term and resource-intensive , highlighting the need to develop therapeutic options for this patient group.

Levels of exposure to adverse (childhood) life events are high, with 73% reporting abuse and 82% reporting neglect . In addition, comorbid post-traumatic stress disorder (PTSD) is common, with 20–56% of patients meeting PTSD criteria . A substantial body of research links distressing and traumatic life events, such as non-Criterion A events including physical abuse, emotional abuse, and neglect, to the development of all types of PD [5, 6]. However, trauma-focused treatments are not routinely provided to this population .

Potential barriers to trauma-focused care for this patient group include the frequent underdiagnosis of PTSD [7, 8], which may be partly attributable to severe difficulties with affect (emotion) regulation, such as suicidal behavior and intense emotional reactions that can mask underlying trauma symptoms [9, 10]. However, even in the absence of a formal PTSD diagnosis, untreated memories of adverse events appear to contribute to the exacerbation and maintenance of PD pathology [5, 11], such as low self-esteem, relationship difficulties, and emotional dysregulation [12, 13]. Trauma-focused therapy may therefore be beneficial for this patient group.

Recent studies have found that eye movement desensitization and reprocessing (EMDR) therapy, a first-line evidence-based trauma-focused therapy, is effective in individuals with PD and comorbid PTSD [4, 15]. Knowledge about trauma-focused psychotherapy in PD patients without PTSD is limited. However, several case studies [16–18] and a randomized controlled trial (RCT) have yielded promising results. In the latter RCT, EMDR therapy targeted unprocessed memories of adverse events, most of which did not meet Criterion A, that contributed to current symptoms and dysfunctional behavioral patterns; it demonstrated positive effects on psychological symptoms and personality functioning. The theoretical framework for this approach is based on the Adaptive Information Processing (AIP) Model, which proposes that unprocessed memories of adverse events can be triggered and drive current psychopathological symptoms [13, 20]. Furthermore, research has shown that non-Criterion A events, such as emotional neglect and emotional abuse, are highly likely to trigger PTSD symptoms of similar severity [21, 22] and are associated with the development of PDs . Despite the potential benefits of trauma-focused treatment, no previous study has specifically examined its effectiveness in PD patients while distinguishing between those with and without a PTSD diagnosis.

The primary aim of this RCT is to evaluate the effectiveness of EMDR therapy compared with a waiting list control in reducing PTSD symptoms and diagnostic status in PD patients, distinguishing between those with and without PTSD. This study also examined how EMDR therapy affects various types of memories, including memories of events that do not meet Criterion A. It was hypothesized that EMDR therapy would yield positive outcomes even when focusing on memories of events that do not meet Criterion A for PTSD and in the absence of a comorbid PTSD diagnosis. This study provides valuable insights into the potential of trauma-focused treatment for PD patients and may contribute to improving treatment outcomes in this population.

Method

This study was part of the Trauma-Focused EMDR for Personality Disorders among Outpatients (TEMPO) study . In this single-blind, multicenter RCT (Randomized Controlled Trial), EMDR therapy was compared with a waiting list. Participants in the EMDR group received ten EMDR sessions, twice weekly over 5 weeks. Assessments were conducted at baseline (before randomization, T0), post-treatment (after 5 weeks, T1), and at 3-month follow-up (T3). Demographic data were collected at baseline. All researchers were blinded to the randomization process. The study was approved by the Medical Research Ethics Committee (MREC) of Erasmus Medical Center in Rotterdam (number MEC-2020-0583).1 This study was conducted and reported in accordance with CONSORT guidelines. The completed CONSORT checklist is available in the Supplementary Material. The original (planned) outcomes were retained throughout the study.

Participants

Participants were recruited from the outpatient clinics of two mental health institutions in the Netherlands, GGZ Delfland and Parnassia Psychiatric Institute. Recruitment and follow-up ran from December 2020 until the third follow-up in February 2025. Patients were eligible (for the study) if they were aged 18 or older and had a PD diagnosis confirmed by the Structured Clinical Interview for DSM-5 Personality Disorders (SCID-5-PD). Participants with a diagnosis of "other specified" PD were required to exhibit at least ten PD symptoms. Exclusion criteria were insufficient proficiency in Dutch and an estimated IQ of <70. A power analysis determined the sample size to be 159 participants .

Interventions

After baseline measurements, participants were randomly assigned in a 1:1 ratio to EMDR therapy or the waiting list group using a randomization table in Data Manager.2 This study was a parallel-design, randomized controlled superiority trial. A case report form is created in Data Manager without blocking. The unblinded researcher reveals the participant's assigned group via the randomization button and informs participants by telephone or video call. The principal investigator (K.S.) has access to all allocations, ensuring that unblinding is never required. Further details of the randomization process have been published previously .

EMDR Therapy

Half of the participants received a total of ten 90-minute EMDR sessions, delivered twice weekly. EMDR therapy is a trauma-focused treatment in which attention is sequentially directed to a distressing memory while the patient simultaneously engages in another task requiring dual attention [14, 20]. First, patients were given information about EMDR therapy. A case conceptualization (formulation) was then developed based on the patient's symptoms (such as intrusions) and the current core symptoms of their PD. All memories thought to play an important role in patients' current core symptoms were identified and processed. These included memories related to Criterion A events and other adverse experiences, such as emotional abuse, neglect, the death of a loved one, or illness. A detailed case example and the theoretical framework for this approach have been published previously .

Waiting List

The remaining half were assigned to the waiting list control group. Patients in this group received neither EMDR therapy nor any other PD treatment. They were informed of their allocation and invited to the post-treatment assessment (T1). At the 3-month follow-up (T3), participants from both groups met with their original diagnosing therapists to determine the most appropriate treatment as usual for PD.

Treatment Training and Integrity

Protocol adherence and treatment fidelity were ensured in this study. EMDR therapy was provided by certified therapists who had completed Dutch Basic EMDR training and attended a 1-day workshop delivered by an EMDR Europe-accredited trainer to ensure standardization. Therapists received monthly supervision from EMDR Europe-approved consultants. All case conceptualizations and session reports were submitted to supervisors. Session recordings were used to provide feedback on technique and protocol adherence, and a subset was assessed by blinded raters for therapist competence and protocol compliance.

Outcome Measures

Structured Clinical Interview for DSM-5 Personality Disorders

The SCID-5-PD is a diagnostic instrument used to assess DSM-5 PDs .3 It rates each PD symptom on a 3-point scale to determine its presence or absence . The interview includes 135 questions, some of which overlap to capture different aspects of a symptom. Because it requires clinical expertise, only trained clinicians should administer the SCID-5-PD. Raters were trained accordingly. Although Dutch reliability and validity data are not available, they are expected to match those of the nearly identical preceding version, the SCID-II , which demonstrates substantial to almost perfect interrater reliability (κ = 0.78–0.98) [28, 29].

Clinician-Administered PTSD Scale for DSM-5

The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) is a structured diagnostic instrument designed to assess the severity of PTSD symptoms according to DSM-5 criteria .4 It rates 20 PTSD symptoms according to the four main DSM-5 criteria: Criterion A (exposure to traumatic events), Criterion B (intrusive symptoms, such as flashbacks and nightmares), Criterion C (avoidance of reminders), Criterion D (negative alterations in mood and cognition), and Criterion E (arousal symptoms, such as irritability, sleep disturbances, and hypervigilance [heightened arousal/alertness]). These symptoms were rated on a scale of 0–5, with total scores reflecting overall PTSD severity. In addition, ten questions addressed symptom duration, functional impairment, and dissociative symptoms. Psychometric evaluations demonstrated strong internal consistency (α = 0.90) and excellent interrater reliability (ICC = 0.98) . Raters were trained in administering the CAPS-5.

Childhood Trauma Questionnaire – Short Form

The Childhood Trauma Questionnaire – Short Form (CTQ-SF) is used to screen for childhood trauma in both clinical and general populations . Participants rate 25 statements about their childhood experiences using a five-point Likert scale (e.g., "I had to wear dirty clothes"). The questionnaire contains five subscales: physical neglect, emotional neglect, and physical, emotional, and sexual abuse. The Dutch version, which demonstrates strong to excellent internal consistency (α = 0.89–0.95), will be used, although the physical neglect subscale shows lower reliability (α = 0.63) .

Statistical Analysis

Baseline differences were assessed using parametric tests. Outcome comparisons followed the intention-to-treat principle and included all participants. A linear mixed model (LMM) examined the fixed effects of time (baseline, post-treatment, and follow-up), group (EMDR vs. control), PTSD diagnosis, and their interactions. Since baseline PTSD symptom severity was expected to explain a substantial proportion of the error variance, it was categorized¹ and included in the model as a covariate to increase statistical power. The LMM included two levels. Level 1 examined within-person changes in CAPS-5 scores, including fixed effects for PTSD severity, group, and diagnosis, as well as random slopes for individual variation. Level 2 modeled between-person differences with random intercepts and slopes for baseline scores and rates of change. Cohen’s d was calculated to quantify effect size, providing a standardized measure for easier interpretation and comparison with other studies. It was calculated by dividing the mean difference (within and between groups) by the pooled standard deviation. Effect sizes were categorized as small (0.2), medium (0.5), or large (0.8). A second LMM analyzed the effects of EMDR on memory types (emotional abuse, physical abuse, and others), using time and memory type as fixed effects and including their interactions. A Type I error rate of 0.05 was maintained using two-tailed tests. Data were analyzed using SPSS 27 and R 4.4.2 (with the nlme package).

 

Results

Patient Flow and Sample Characteristics

Table 1 presents baseline demographic and clinical characteristics, including PTSD symptom severity and diagnostic status, by treatment group. No significant differences between groups were found in any baseline characteristics.

Figure 1 shows participant flow throughout the study. No adverse events were reported. Missing post-treatment CAPS-5 data were more frequent in the control group (18 versus 7 in the EMDR group; $p = 0.01$), and a larger proportion of the missing cases were PTSD patients with higher baseline scores. Since the data were missing not at random (MNAR), case-wise deletion was applied.

Exposure to Adverse Life Events

Table 2 shows the frequency of specific adverse events reported at baseline in patients across different PD clusters, categorized by the presence or absence of PTSD. No significant differences in trauma exposure were observed between the EMDR therapy and control groups. Emotional neglect (94.7%) and emotional abuse (89.5%) were the most frequently reported adverse events, with similar distributions across the groups with and without PTSD. Physical abuse (37.9%), physical neglect (60.8%), and sexual abuse (36.5%) were also commonly reported.

Effectiveness of EMDR in Reducing PTSD Symptoms

Table 3 shows mean scores at baseline, post-treatment, and follow-up, as measured by the CAPS-5, by assigned group for those with and without a PTSD diagnosis. Figure 2 illustrates changes in PTSD symptoms for both the EMDR and control groups, differentiated by baseline PTSD status.

Table 4 presents LMM estimates examining the effects of group allocation, time, and PTSD status on CAPS-5 scores. There was no significant main effect of group, indicating that baseline differences between the EMDR therapy and control groups were not statistically significant. PTSD diagnosis and symptom severity were significant predictors of baseline CAPS-5 scores. Significant group-by-time interactions at post-treatment and follow-up indicated that the EMDR group exhibited greater symptom reduction over time than the control group. Interactions involving PTSD status were not significant ($p > 0.05$), indicating that treatment effectiveness did not differ significantly depending on the presence or absence of a baseline PTSD diagnosis.

Change in PTSD Diagnostic Status

After treatment, 65.5% of patients in the EMDR group no longer met the criteria for a PTSD diagnosis, increasing to 73.1% at follow-up. In the control group, 27.8% no longer met PTSD diagnostic criteria after treatment, increasing to 40.0% at follow-up; a significant difference between groups over time was found ($p = 0.03$).

Within-Group and Between-Group Effect Sizes

Within-Group Effect Sizes of EMDR Therapy on PTSD Severity

For the entire sample in the EMDR group, a within-group effect size of Cohen’s $d = 0.60$ (95% CI [0.36, 0.84]) was found at post-treatment, increasing further at the 3-month follow-up ($d = 0.85$, 95% CI [0.60, 1.09]). In patients with PTSD, EMDR therapy significantly reduced PTSD severity at post-treatment (EMDR: Cohen’s $d = 1.26$, 95% CI [0.70, 1.80]; control: $d = 0.28$, 95% CI [−0.31, 0.86]), with effects maintained at the 3-month follow-up (EMDR: $d = 1.5$, 95% CI [0.90, 2.06]; control: $d = 0.69$, 95% CI [0.10, 1.26]). No significant difference was found between patients with and without PTSD. EMDR also reduced PTSD severity in patients without PTSD (EMDR: $d = 0.78$, 95% CI [0.34, 1.20]; control: $d = 0.18$, 95% CI [−0.23, 0.59]), with effects maintained at follow-up (EMDR: $d = 1.09$, 95% CI [0.64, 1.53]); control: $d = 0.46$, 95% CI [0.03, 0.89]).

Between-Group Effect Sizes of EMDR Therapy on PTSD Severity

For the entire sample, a between-group Cohen’s $d$ effect size of −0.53 (95% CI [−0.88, −0.18]) was found at post-treatment, with effects maintained at the 3-month follow-up ($d = −0.60$, 95% CI [−0.96, −0.24]). In the PTSD group, the between-group effect sizes comparing EMDR therapy with the control group were Cohen’s $d$ = −1.04 (95% CI [−1.64, −0.39]) at post-treatment and −0.93 (95% CI [−1.52, −0.20]) at follow-up. For the non-PTSD group, the effect sizes were −0.49 (95% CI [−0.92, −0.06]) at post-treatment and −0.51 (95% CI [−0.96, −0.06]) at follow-up.

Differential Effectiveness of EMDR Therapy across Memory Types

Among the 77 patients who received EMDR therapy, the memories most frequently addressed involved physical abuse (29.9%), emotional abuse (28.6%), and other adverse life events (37.7%). Sexual abuse was not analyzed because it was the most frequently addressed trauma in only three patients ($n = 3$; 3.9%). Figure 3 shows the mean differences in CAPS-5 scores for each memory type measured over time. Table 5 presents the statistics from the LMM analysis of patients' memory types related to adverse life events. The intercept represents the mean baseline score for emotional abuse. Significant reductions in PTSD symptoms were found for memories related to emotional abuse ($p < 0.001$), with no significant differences between memory types.

Discussion

This study demonstrated that EMDR therapy led to significant reductions in PTSD symptoms compared with a waiting list control condition, with effects maintained at follow-up. A substantial proportion of participants in the EMDR group no longer met the criteria for a PTSD diagnosis at post-treatment (65.5%) and follow-up (73.1%), and a low treatment dropout rate (5.1%) was observed. Furthermore, the results support our hypothesis that EMDR therapy is effective in reducing distress associated with various types of memories, including memories of events that do not meet Criterion A for PTSD. The results support the benefit of trauma-focused therapy for PDs even in the absence of a PTSD diagnosis.

Consistent with previous research [3, 35, 36], this study highlights the high prevalence of adverse childhood experiences across all types of PD, with emotional neglect (94.7%) and emotional abuse (89.5%) being particularly common. Importantly, although approximately 40% of participants had a PTSD diagnosis at baseline, 38.6% of patients whose index trauma did not meet Criterion A exhibited elevated PTSD symptoms across all B–E symptom clusters on the CAPS-5. These findings highlight the high prevalence of PTSD symptoms in PD patients, with or without a formal PTSD diagnosis.

Consistent with previous research [15, 37], this study confirmed the effectiveness of EMDR therapy in reducing PTSD symptoms in patients with PD and PTSD. Notably, this effect was also observed in individuals with PD but without PTSD. Although the baseline-to-follow-up effect size was higher in the PTSD group ($d = 1.5$), large effects were also observed in the non-PTSD group ($d = 1.09$), with no significant difference between these groups. These findings are consistent with an earlier RCT that demonstrated significant improvements in psychological symptoms in PD patients without PTSD by focusing on memories of events that did not meet Criterion A . Our study findings further support the view that EMDR therapy can be applied broadly and transdiagnostically and may be effective for individuals with PD both with and without a baseline PTSD diagnosis.

Supporting the AIP model [13, 20], which proposes that unprocessed memories drive psychopathological symptoms, our study results confirm that non-Criterion A events, such as emotional abuse, contribute significantly to PTSD symptoms in PD patients. In 28.6% of patients, EMDR sessions focused primarily on memories of emotional abuse, whereas memories of sexual abuse were the primary focus of processing in only three individuals. This highlights the need to address non-Criterion A memories in trauma-focused therapy. Previous studies have demonstrated a strong link between non-Criterion A memories, such as emotional abuse, and PTSD severity and PD development . Emotional abuse, which frequently leads to rumination and reduced emotional acceptance , is a common risk factor for both PTSD and PD . It may exacerbate PTSD symptoms by limiting access to support [43, 44], as also observed in the present RCT (with a lack of support frequently reported as having a greater impact than the trauma itself). In addition, other non-Criterion A events, such as neglect, reported by 94.7% of patients in this study, have also been found to be associated with both PTSD and PD; this may contribute to greater clinical severity, particularly in individuals with BPD (Borderline Personality Disorder) .

It is important to address the limitations of this study. First, the focus on PTSD-related outcome measures may have limited the generalizability of the findings to other aspects of PDs. Future studies should examine the effects of EMDR therapy on other PD-specific symptoms. This issue will be investigated further using data from the TEMPO study . Future research should assess changes in the severity of core symptoms reported at baseline to evaluate more precisely whether specific symptoms indeed decrease following EMDR therapy. The use of a waiting list control group limits insights into comparative treatment effectiveness, highlighting the need for future studies to include an active treatment group to better compare the effects of EMDR therapy. Finally, missing post-treatment data were more common in the control group, particularly among participants with higher baseline CAPS-5 scores, suggesting that the data were probably not MNAR (missing not at random). Consequently, case-wise deletion may have introduced bias and limited generalizability, as individuals with greater symptom severity, who may have been underrepresented because of dropout in the control group, may have skewed follow-up estimates. Analyses based only on complete cases assume representativeness, an assumption that may not hold under MNAR conditions. This common limitation in clinical trials calls for cautious interpretation, particularly regarding treatment effect size. Although this limitation presents methodological challenges, it also suggests that untreated patients experiencing more severe symptoms may be less likely to continue participating. In contrast, the dropout rate in the EMDR group was substantially lower, suggesting that patients were more motivated to remain in treatment. This may have been influenced by factors such as positive treatment experiences, perceived effectiveness, and the therapeutic alliance.

Despite these limitations, the relatively low overall dropout rate (16.4%) compared with other trauma-focused [4, 46] and PD studies [47, 48] enhances the internal validity of the findings. A notable strength of this multicenter study, which included participants from specialized departments, is the strong representation of clinical practice through patients with a range of PDs. In addition, this is the first study to investigate the effectiveness of EMDR therapy within a single RCT while distinguishing between individuals diagnosed with PD with and without PTSD. Future research should focus on exploring long-term effects.

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