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ABSTRACTBackground:The evidence for the effectiveness of online EMDR for PTSD is scarce.Objective:This service evaluation aimed to assess how online EMDR compared to in-person EMDR, in terms of its potential effectiveness and acceptability to therapists and patients.Method:The evaluation was carried out in the Cardiff and Vale University Health Board Traumatic Stress Service. We compared the outcome of therapy (PTSD scores at end of treatment), number of sessions, drop-out rate, and adverse events using linear/logistic regression in those receiving online EMDR over a 12-month period with those who had received in-person therapy in the year previous to that. Interviews with therapists and clients who had provided or undertaken online EMDR explored their views and experiences of treatment. Interviews were analysed thematically.Results:33 people received in-person EMDR (15.3 sessions, SD = 1.4), and 45 received online EMDR (12.4 sessions, SD = 0.9). 24 individuals completed therapy in-person, and 32 online. There was no evidence of a difference in therapy completion, drop-out rates or adverse events between the two delivery modes. There was weak evidence that those who completed EMDR online and had available data (N = 29), had slightly lower PTSD scores at the end of therapy compared to those who received in-person EMDR (N = 24) (17.1 (SD = 3.2) versus 24.5 (SD = 3.0), mean difference = 7.8, 95% CI −0.3, 15.9, p = .06). However, groups were not randomised and only those who completed treatment were analysed, so estimates may be biased. 11 patients and five therapists were interviewed. Overall, both therapists and clients viewed online EMDR as safe and effective. Benefits mentioned by clients included feeling more in control and not having to travel. Clients’ concerns related to lack of privacy and ‘transition time/space’ between therapy and their daily lives.Conclusion:Results suggest that online EMDR is an acceptable, safe and effective alternative to in-person EMDR for PTSD in this service.

ObjectiveFunctional neurological disorder (FND) is characterised by unexplained neurological symptoms, including movement, seizures or sensory symptoms that are unrelated to an underlying neurological disorder. As FND presents as ∼16% cases in neurology clinics (Stone et al, 2010) and the current understanding of its aetiology is limited, research into the neural disturbances present in this group is critical. FND subjects have been shown to display enhanced amygdala activity to arousing stimuli (Voon et al, 2010), however delineation of the roles of each subnuclei have not yet been achieved. In this study, we examined the response of FND subjects to fear conditioning and their sensitivity to loss.Method25 FND and 20 healthy volunteers (HV) were conditioned to aversive/negative affective (CS+) or neutral (CS-) stimuli. During functional MRI, subjects performed a two-choice learning task to avoid monetary loss. The stimuli used in the two-choice task included the previously conditioned stimuli and were associated with a greater likelihood of a loss outcome.ResultsFND patients were more impaired at learning to avoid losses. Using reinforcement learning modelling, we show that FND subjects had a more negative valuation of the CS+ and greater noisy choice behaviours in the context of the CS+. Compared to HV, FND patients showed enhanced Centromedial amygdala responses to loss compared to neutral feedback in the context of the negative/aversive CS+, which correlated with greater impairments in avoidance learning.ConclusionThe findings show that although FND patients have enhanced sensitivity to negative outcomes, this fails to be adaptive, and is not used to guide avoidance learning. We show no evidence for greater harm avoidance but rather a generalised impairment in the capacity to use negative outcomes to guide behaviours. Furthermore, fearful learned contexts enhance the randomness of choice behaviours, thus highlighting a potential mechanism by which negative contexts interfere with adaptive behaviours. Our findings further detail the aetiology of a common but elusive disorder and highlight the potential utility of interventions targeting the salience of negative stimuli.