Short term correlates of the Neuro Emotional Technique for cancer-related traumatic stress symptoms: A pilot case series
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- Monti, D.A., Stoner, M.E., Zivin, G. et al. J Cancer Surviv (2007) 1: 161. doi:10.1007/s11764-007-0018-x
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As many as one quarter of all cancer survivors report traumatic stress symptoms from cancer-related experiences. While the majority of these patients do not meet the criteria for posttraumatic stress disorder (PTSD), there is growing evidence that subsyndromal symptoms can significantly contribute to functional impairment and negative health outcomes. Treatment options for the hallmark symptoms of traumatic stress—unpleasant, intrusive thoughts and avoidant behaviors—have not been well investigated for the cancer survivorship population.
Materials and methods
Seven female cancer survivors with traumatic stress symptoms from cancer-related experiences and no other major psychopathology, were enrolled to receive three sessions of Neuro-Emotional Technique (NET), a brief, targeted treatment that combines traditional desensitization principles with complementary modalities.
Psychological outcome measures (Impact of Event Scale (IES) and Subjective Units of Distress (SUD) and physiological measures (Heart Rate (HR) and Skin Conductance Level (SCL) demonstrated the following changes: 71% on IES, 88% SUD, 74% on HR, and 65% on SCL following the intervention. Statistically significant changes were observed for all four parameters, and effect size g for proportion improved were 0.50 each for IES, SUD, and HR, and 0.20 for SCL.
These cases suggest feasibility of the NET intervention for cancer-related traumatic stress and the potential for change in symptoms and physiological reactivity. Further investigation is needed to determine the specific and long-term effects of such an approach.
Implications for cancer survivors
Traumatic stress from cancer-related experiences might represent a constellation of symptoms that are amenable to brief, targeted interventions.
KeywordsCancer survivorsNeuro Emotional TechniqueNETTraumatic stressDistressing recollectionsBrief psychotherapy
Receiving a cancer diagnosis can be a highly stressful event and the cancer illness experience adds many stressors. It is well documented that stress can contribute to negative health outcomes in cancer survivors; hence, addressing stress has become a priority issue in cancer treatment and research .
Traumatic stress refers to a category of conditions where a particular life threatening event or series of events causes ongoing distress beyond a certain time period from the original occurrence of the event or events. Approximately one-fourth of all cancer survivors suffer from traumatic stress symptoms . However, only a minority (3–10%) of these patients meets the criteria for posttraumatic stress disorder . Therefore, the literature has referred to the most common manifestation of traumatic stress in cancer patients as “distressing recollections” of cancer-related experiences. The “recollection” is most often related to the experience or event of receiving a cancer diagnosis or some aspect of the cancer treatment process.
The two primary psychological symptoms of distressing recollections are avoidance and intrusive thoughts. Avoidance is driven by strong, unpleasant feelings (primarily fears) that are triggered by trauma-related thoughts, places (e.g., hospitals, doctors’ offices, etc.), and any other randomly encountered cues that trigger associations to the formative traumatic events. Avoidance is manifested through staying away from and escaping these provocative cues. Examples of avoidance might include missing doctor appointments, compulsively engaging in distracting activities, and evasion of engaging in conversation that stirs associations to trauma-related cues. Intrusive thoughts are involuntary, unwanted thoughts, memories or images. These types of thoughts are usually upsetting and stressful and can indicate an ongoing coping and mental processing of a stressful event or situation.
Distressing recollections are common among people diagnosed with a variety of cancers, including breast cancer, lymphomas, and mixed cancer types [5, 6, 14, 15]. One study found that more than 20% of their breast cancer cohort experienced disturbing recollections with high levels of avoidance and intrusive thoughts , which was consistent with another study that found that 25% of their cohort of mixed cancer patients reported spontaneous, intrusive visual memories, mostly concerning illness, injury and death . The mean levels of intrusion and avoidance were equivalent to other patient populations with posttraumatic stress disorder (PTSD).
Several studies have demonstrated that patient populations with traumatic stress symptoms that do not meet the criterion for PTSD, often show clinically meaningful, functional, impairment that may be comparable to what is seen in the full syndrome [21, 25]. In addition, there is evidence that some of the neurological correlates of cancer-related distressing recollections may be similar to what has been observed in PTSD. For example, studies on PTSD from combat exposure and childhood sexual abuse have demonstrated a reduction in either right or left hippocampal brain volumes as compared to subjects without traumatic exposure [3, 4, 25]. Likewise, a study of patients with distressing cancer-related recollections showed smaller left hippocampal brain volumes as compared to patients who did not have such recollections . The study only included patients who had no major psychiatric diagnoses (including PTSD). Hence, distressing cancer-related recollections in the absence of other psychiatric pathology were associated with brain morphological abnormalities similar to those seen in patients with full PTSD.
While there are established treatments for PTSD such as cognitive-behavioral therapies  and medication , there is little data on the treatment of subsyndromal symptoms. There are no studies to date that have assessed the use of psychosocial interventions in cancer survivors who experience distressing cancer-related recollections. This case series examines the potential of a recently developed brief intervention to reduce the emotional and physiological reactions to distressing recollections in cancer patients.
Materials and methods
The report of ongoing, subjective distress from the experience, scored by the patient at a number of 7 or higher on the Subjective Units of Disturbance Scale 0–10 scale (SUDS) . The SUDS is a single item rating of distress on a 0 (not at all distressing) to 10 (extremely distressing) visual analog scale. This measurement has been correlated with physiological indicators of distress, specifically, heart rate and skin conductance .
Autonomic reactivity when visualizing the distressing event, as defined by an increase in HR of 5% (about 4 bpm) and/or a 33% increase in skin conductance, in contrast to the visualization of a neutral image. This protocol is relatively standard for determining autonomic reactivity to traumatic events , and has been used in studies as inclusion criteria for autonomic reactivity to emotional images . Heart rate and skin conductance are standard measurements of stress arousal  and they provide a non-invasive objective assessment of autonomic nervous system activity . We allowed for an increase in either parameter based upon the knowledge that various conditions and differences in individual responsiveness can affect either parameter, especially skin conductance .
The distressing experience occurred at least six months, but not more than 3 years prior to enrollment.
None of the participants had a major mental disorder, including history of PTSD, as assessed by the Structured Clinical Interview for DSM-IV—Clinician Version (SCID-CV) .
None of the participants were taking psychiatric medications.
Participants were in the age range of 27–63, with a mean age 51. The cancer diagnoses of the seven subjects were Hodgkin’s Disease , ovarian , cervical , and breast  cancer. All participants completed the informed consent process.
Procedures and measures
Each participant was instructed to provide a brief written description of her distressing cancer-related recollection and a separate brief script of a positive recollection. It is a standard psychophysiological research method to use scripts as triggering cues for eliciting traumatic stress responses . The literature does not support the notion that preparing such scripts will significantly impact (i.e., desensitize or exacerbate) the traumatic stress syndrome [7, 20].
The treatment was conducted by a psychiatrist (D.M.), who is trained in NET procedure and has expertise working with cancer survivors. The number of sessions was determined by the time required for a participant to subjectively report that the event no longer felt bothersome. In this study, this occurred in two to three sessions, each 1 h in duration. Time between sessions was approximately 5–9 days.
Assessments were made during one pre-treatment and one post-treatment session. Assessments preceded and followed treatment by one to two weeks. Pretreatment assessment included the SCID-CV as well as psychological and physiological outcome measures. Assessments were administered to each participant individually.
The Impact of Event Scale (IES)  is a widely used measure of traumatic stress, including traumatic stress from cancer-related events [1, 5]. The measure (15 items) yields two scales, “avoidance” and “intrusive thoughts” over the past 7 days. The subjective Units of Disturbance Scale (SUDS) is a commonly used 10-point self-report rating of affective distress. It has demonstrated good concordance with physiological measures of anxiety .
Mean heart rate (HR) in beats per minute (bpm) and skin conductance levels (SCL) recorded in micromohs were collected during 60 s visualizations of three images: the distressing cancer-related event, a neutral image (numbers 1 to 10) and a positive image for technical comparison. Baseline and post-treatment changes were measured by comparing responses between the distressing and neutral images. The equipment used was a J & J Engineering (Seattle, Washington) C2 unit.
The NET protocol
The focus of the treatment sessions was on the subjective experience of the distressing cancer-related recollection. One aspect of the NET protocol consists of identifying standard psychological components of the experience: (1) cognitions (identifying the nature of the thoughts and internal dialogue associated with the recollections, (2) emotions (identifying the emotions that the recollection elicits), and (3) behaviors (how the recollection affects behavior, such as, avoidance of accomplishing tasks). The intervention involves a series of steps intended to address each of these domains, which are collectively part of what is referred to as a “neuro emotional complex” in the NET paradigm. For example, the traumatic experience might be associated with the (1) cognition “I can never be safe in the world”; (2) emotion of heightened fear or fear of recurrence; and (3) avoidant behavior, such as lack of involvement in social events.
Another component of the intervention involves a light muscle-resistance feedback test (muscle test) which has been developed and tested as an indicator of emotional-cognitive congruence or incongruence to focused images and verbal statements . In the NET protocol, the muscle test is used as an aid for probing this congruence/incongruence psychophysiological response by providing physiological feedback in response to two types of prompted stimuli: (1) recalled images (e.g., aspects of a distressing recollection) and (2) cognitive statements such as, “I can be safe in the world;” “It’s fine if I go out visiting my friends,” and so on. The muscle test is performed without equipment by positioning the patients extended arm such that applying light incremental pressure distally, creates an eccentric contraction to the point of either a muscle lock (suggesting congruence), or what is referred to as muscle “give-way” (suggesting incongruence). The muscle test has been shown to have high reliability when performed in this manner .
The practitioner assists the patient in determining the emotional quality of incongruous images and self-statements. In traditional Chinese medicine, the major meridians have a specific emotional quality, such as, anger, fear or grief. Hence, the meridian pulse point associated with the emotion is utilized during the desensitization component of the procedure as described below.
During the desensitization procedure to distressing recollections, participants are directed and supported to perform the following: (1) manually stimulate (via mild finger pressure) the acupuncture pulse point(s) associated with the identified emotion(s) of the experience, (2) mentally hold the image of the experience, (3) re-experience the related emotion, and (4) contemplate the negative self-statement, while simultaneously (5) consciously breathing in a deep, slow, relaxed manner. This exercise is repeated for as long as the person experiences distress or discomfort related to thinking about the event. Several repetitions may be required to allow the participant to focus on the various aspects of the experience. The intervention is complete when the patient no longer feels distressed by the experience and when the muscle test is both non-reactive to recalling the event and registers internal congruence with statements of desired behaviors, thoughts and feelings; e.g., “I am safe in the world; I can attend social events; I can do things even though I’ve had cancer,” etc. Patients generally report a sense of subjective relief following the procedure.
Cancer type, age and distressing recollection, per case
The doctor came out and told me they “found something” on the X-ray.
Feeling the spike (tumor marker) stuck into me.
He said (about docs ignoring my non-consent), “What IS your problem, Mrs. T.”
The Doctor said (so coldly), “We’re going to take your breast.”
Going through the radiation treatments (9–10 treatments).
How humiliating to go through this.
The moment he told me the diagnosis.
Subjective reports of symptoms that remitted
Thoughts of it intruded at odd times
A, B, C, G
Tried to remove it from memory
B, E, G
Trouble falling or staying asleep
B, C, E
Waves of strong feelings
A, C, E
Dreams about it
B, E, F
A, C, E
Felt it was unreal/never happened
Tried not to talk about it
B, C, E, F
Did not deal with strong feelings about it
C, E, F
Tried not to think about it
Any reminder brought back feelings
A, C, D, F, G
Numb feelings about it
Changes in physiological and subjective measures of response to events
Impact of Event Scale
Subjective Units of Distressb
Heart Rate (bpm)
Skin Conductance (micromos)
The seven cases were quite varied as to the IES distress symptoms that were initially elevated, reduced and alleviated. Most cases showed several symptoms with 1- or 2-point reductions plus one larger reduction; two cases showed larger reductions. The seven women were similar in age and initial distressing recollections, but their emotions and cognitive self-statements were highly individualized. The NET protocol moved them quickly through these stressful experiences to relative comfort by each session’s end.
Table 3 gives an indication of the relief achieved by the treatment. T-tests (for correlated means, one tail) gave p < .05 on all measures except the SCL. The p levels for IES, SUD, and HR were sufficiently below .05 that they exceeded the Bonferroni significance correction for four simultaneous t-tests (0.013). Levels of p (one-tail) for IES, SUD, and HR on binomial tests of percent cases showing notable symptom reduction were also significant beyond 0.013. Effect sizes are evaluated through the d statistic for mean differences and through g for percentage case improvements. We consider “large” any d above 0.80 and any g above 0.25. The ds and gs = 0.50. However, even SCL’s effect sizes were considerable, with d = 0.77 and g = 0.23, both effect sizes closely approaching “large.”
Several patients made strong, subjective statements at the last treatment session. For example, case G felt the distressing recollection was “more resolved” and was “grateful to be in the study.” Case F was feeling “more comfortable” about the recollection, and was now able to focus on dealing appropriately with a new important diagnosis. Case D felt that because of the prior session, she was also less reactive to a remark by her husband that “ordinarily would make me cry.”
The effect sizes generated from these seven cases provide encouraging initial data that can inform the next level of evaluation of this approach. In this small sample that was without comorbidity from other psychopathology, NET appeared to yield notable short-term relief from distressing recollections in three or less, 1-h treatments. Of particular interest, reduction in physiological arousal accompanied self-report measures of reduced distress. An expanded, controlled, study needs to be completed to clarify the potential effects of the NET intervention. This initial pilot study is presented as a case series. Case studies report on individual patient outcomes; hence, there are well known limitations of such an approach such as, a lack of control and an inability to generalize findings. The case series presented cannot determine a causal link between the intervention and outcome.
Case studies, however, can be vehicles to put forward a hypothesis that can be the basis of further research. In this particular case series, it is of interest that the approach used was associated with reduction in both subjective and physiological responsiveness to the traumatic events. Although habituation should be considered as a potential confounder, there have not been studies showing that briefly discussing prolonged traumatic memories leads to dramatic decline in their physiological and psychological impact. Nonetheless, several such potential concerns should be addressed in a randomized trial with a control group that receives equal attention from the investigative team, and follow-up assessments at time points that are distant from the time of intervention. The positive preliminary findings presented support this next level of investigation. Also important to elucidate would be the optimal timing (i.e., how soon after cancer diagnosis) and dosing of the intervention.
Implication for cancer patients
There is a dearth of studies specifically aimed at the assessment of psychosocial interventions for cancer survivors who experience some symptoms related to traumatic stress, but not clinical PTSD during the initial years post diagnosis. Validating the efficacy of an intervention that targets these symptoms, such as the one explored here, could be of benefit to cancer patients. Given that traumatic stress symptoms occur with some frequency in cancer survivors who have little other psychopathology, they may be particularly responsive to a targeted, brief intervention.