Case Report: Integration between eye movement desensitization and reprocessing and cognitive therapy for autism spectrum disorder. Novel intervention protocol based on case formulation and brief review of literature

Autism Spectrum Disorder (ASD) is a complex neurodevelopmental condition marked by distinct challenges in social communication, interaction, and the presence of restricted, repetitive behaviors and interests. While often recognized for these core features, emerging research highlights a significant, yet frequently underestimated, vulnerability among autistic individuals to psychopathological conditions, including Post-Traumatic Stress Disorder (PTSD) and trauma-related symptoms. This heightened susceptibility is compounded by increased exposure to traumatic experiences, particularly relational trauma, and a potentially autism-specific perception of the impact of certain events. A recent case report published in Frontiers in Psychology details a novel therapeutic approach, integrating Eye Movement Desensitization and Reprocessing (EMDR) therapy with cognitive therapy, specifically adapted for a young autistic woman. This innovative protocol offers a promising avenue for addressing complex trauma and comorbid conditions within the autistic population, a demographic for which existing therapeutic modalities often require significant adaptation.

The Pervasive Link Between Autism and Trauma

Autistic individuals face a disproportionately higher risk of encountering adverse situations. This vulnerability is attributed to a confluence of factors, including differences in information processing, executive functions, and emotional and sensory regulation, as noted by Marino (2024). These neurodivergent characteristics can lead to heightened stress vulnerability and a reduced capacity for coping with stressful situations, a specificity that warrants careful consideration in clinical practice (Marino, 2024; Rumball et al., 2020).

The definition of trauma itself may need to be broadened when considering autistic individuals. Rumball and colleagues (2020) suggest that events not typically classified as traumatic under current diagnostic criteria for PTSD might have a profound and lasting impact on autistic people. This expanded understanding is crucial, as it acknowledges the subjective experience and the unique neurophysiological responses of individuals on the autism spectrum. Differences in the nervous system, including autonomic functions, with a greater and more stable activation of sympathetic and parasympathetic branches and less effective ventrovagal responses, contribute to an amplified reactivity to threat signals and a persistent activation of defense systems (Inderbitzen, 2025). This can manifest as chronic tension, anxiety, and difficulty accessing physiological states of safety and connection, thereby impacting stress management and social engagement.

Consequently, autistic individuals exhibit an increased incidence of chronic stress, anxiety, and depressive symptoms, elevating the risk of re-victimization and re-traumatization (Marino, 2024; van Lobregt-Buuren et al., 2019). The high prevalence of trauma-related symptoms in ASD, coupled with these distinct regulatory mechanisms, underscores the urgent need for targeted and specialized intervention protocols.

EMDR Therapy: A Proven Modality Facing Adaptation Challenges

Eye Movement Desensitization and Reprocessing (EMDR) therapy, a structured, eight-phase protocol based on the Adaptive Information Processing Model, has demonstrated significant efficacy in treating PTSD and trauma-related conditions. It utilizes bilateral stimulation to facilitate the processing of dysfunctionally stored information. While EMDR has evolved to address a wide range of psychopathological disorders, its application within the autistic population remains limited. A primary barrier is the challenge of adapting its core techniques to the specific sensory, cognitive, and communication needs of autistic individuals.

The case report in Frontiers in Psychology addresses this gap by presenting a detailed account of a 23-year-old autistic woman with no intellectual or language impairment, who also presented with social-performance anxiety and pathogenic schemas linked to relational trauma. Her treatment involved tailored EMDR sessions, demonstrating a successful integration of this powerful therapeutic tool with strategies derived from Polyvagal Theory.

A Young Woman’s Journey Through Trauma and Healing

The patient, diagnosed with ASD, a Specific Learning Disorder, executive control deficits, and pronounced socio-performance anxiety, entered therapy during adolescence. Her intellectual quotient was within the normal range, assessed via Raven’s Matrices (IQ=96). Initial therapeutic efforts focused on establishing a strong alliance, identifying core beliefs and pathogenic patterns, and defining long-term life objectives centered on acceptance, inclusion, spontaneous expression, autonomy, and self-efficacy. A crucial component of her early treatment involved psychoeducation about her neurodivergence and the development of specific management strategies, acknowledging these as significant variables influencing her internal experience of the disorder. The therapeutic team adopted person-first language, referring to her as an "autistic person" in line with the biopsychosocial model of neurodiversity.

The patient’s psychological profile revealed that her reactions to social and performance situations were mediated by numerous dysfunctional cognitive biases and processes. These were underpinned by deeply ingrained negative schemas and beliefs related to self-defectiveness, unlovability, safety, control, and autonomy. A cyclical pattern of severe self-criticism and a perceived helplessness contributed to somatic symptoms and a depressed mood. The initial psychotherapy aimed to reduce anxiety, depression, and avoidance behaviors through cognitive restructuring and gradual exposure with response prevention. Simultaneously, the intervention progressively integrated work on her neurodivergent characteristics, specifically addressing metacognitive, interoceptive, sensory, and executive processes that impacted her emotional regulation and social interactions.

The Turning Point: Clinical Worsening and the Shift to EMDR

The integration of EMDR therapy became necessary following a clinical worsening characterized by acute anxiety and behavioral dysregulation. This deterioration was triggered by a work experience requiring her to relocate abroad. The situation provoked a significant anxious reaction, marked by dysfunctional control behaviors, difficulty managing unforeseen events, and the deployment of maladaptive coping strategies. Upon her return, the patient demonstrated a remarkable capacity for self-reflection, critically assessing her reactions and identifying contributing factors such as sensory overload and a diminished sense of security when confronting new experiences. However, she also reported feeling overwhelmed by emotions so intense that her previously learned coping strategies were ineffective. This critical juncture suggested the presence of underlying traumatic elements, prompting a shift towards a more bottom-up, experiential approach utilizing the EMDR protocol.

Tailoring EMDR: A Protocol Adapted for Neurodiversity

The therapeutic intervention was meticulously explained to the patient in all its phases. The EMDR protocol was strategically adapted, drawing upon principles from Polyvagal Theory to address her heightened tension and hyperarousal, which persisted even in safe environments. These adaptations were crucial for fostering a sense of safety, a prerequisite for effective trauma processing, particularly for individuals with altered threat perception and a tendency toward chronic anxiety.

To achieve this stabilization, a range of techniques were employed: identifying sensory activation markers, breathing exercises, body awareness practices, accessing internal resources through guided imagery, and mindfulness exercises. These interventions helped the patient restore a greater sense of safety and remain within her "window of tolerance," a concept central to emotional regulation (Siegel, 2021).

The EMDR treatment itself was then further customized to the patient’s specific metacognitive and sensory characteristics, always prioritizing the maintenance of an optimal activation state within her tolerance window. The floatback technique was employed to identify past relational events with traumatic valence, with simplified and adapted assessments to prevent patient overload. Two primary targets were identified, stemming from childhood family experiences:

1. Family Episodes of Childhood: These involved a perceived physiological incompetence during childhood, linked to fear, a lack of control, and an inability to rely on a safe reference (her mother, who was herself experiencing distress and seeking help from the child). This experience fostered a belief system connecting incompetence with fear and helplessness.

2. Spontaneous Behavior and Unpredictable Reactions: This target highlighted the connection between her spontaneous actions and unpredictable, angry reactions from others. This conditioned her beliefs about control and safety, leading to an excessive fear of uncertain situations and irrational expectations regarding personal competence and autonomy. This fear hindered her ability to experience unforeseen events and errors with a sense of potential for repair and learning.

A significant adaptation involved tolerating the coexistence of multiple negative cognitions during target definition, rather than rigidly adhering to the classic protocol’s demand for isolating a single cognition. This decision was driven by the need to maintain a balance between emotional and cognitive load and the fluidity of information processing essential for effective EMDR work, thereby mitigating potential stress.

To further accommodate her attentional and sensory needs, the standard bilateral eye movement stimulation was replaced with tapping (administered by the clinician) alternated with the "butterfly hug" (self-administered by the patient). This modification addressed the attentional focus and sensory load that eye movements could impose. Physical distance and the type of bilateral stimulation were consistently negotiated with the patient, ensuring both her well-being and the clinical efficacy of the treatment.

The integration of EMDR led to a profound modification of sensations and emotions associated with unprocessed relational trauma, directly impacting her core schemas of autonomy, competence, control, and safety. This integrated approach resulted in overall improvements in the patient’s perceived sense of efficacy and a reduction in anxiety symptomatology.

Specific adjustments were also made to the EMDR protocol’s phases. In Phase 1 (client history), salient life episodes were integrated within her psychological functioning, and Phase 2 (preparation) was significantly expanded. This extended preparatory phase provided ample time for psychoeducation, allowing the patient to gain mastery and familiarity with the process, thereby reducing anxiety and enhancing her sense of agency. Visual materials, such as graphic sheets and maps, were utilized to support her processing capacity during moments of increased load.

Throughout the protocol, EMDR stimulation sessions were alternated with conversational "commentary" sessions. This allowed for cooperative monitoring of the emotional, cognitive, and sensory load, enabling timely integrative interventions. Session by session, the Subjective Units of Disturbance (SUD) scores decreased, reaching minimal levels, while the Validity of Cognition (VOC) scores increased, indicating a significant resolution of distress. The patient demonstrated excellent compliance, with no adverse reactions, blockages, shutdowns, or meltdowns reported. Stabilizing practices, managed by the patient, were instrumental in handling increased emotional, cognitive, and sensory overload.

Broader Implications and Future Directions

The successful adaptation of EMDR therapy for this autistic individual highlights critical insights for the field. The integration of Polyvagal Theory-informed strategies, coupled with specific EMDR protocol modifications addressing sensory and metacognitive characteristics, proved clinically effective. This approach aligns with the Adaptive Information Processing (AIP) theory underpinning EMDR and underscores the necessity of ensuring adequate safety levels for functional information processing.

While research on EMDR for autistic individuals is growing, it remains limited, with many studies being small and uncontrolled. Previous research has indicated potential benefits in areas like communication and social awareness, often assessed by parents (Leuning et al., 2023). A recent Delphi Consensus identified barriers to EMDR treatment for autistic people, including patient-specific characteristics (communication difficulties, emotional regulation issues) and therapist factors (lack of confidence) (Fisher et al., 2023).

This case report contributes by emphasizing a structured, neurodivergence-informed approach. The sequence of interventions—prioritizing awareness work on autism and individual characteristics before introducing EMDR, and integrating autonomic modulation exercises for stabilization—is a novel heuristic. The use of visual aids and the flexible approach to negative cognitions and SUD scores represent further advancements.

The patient’s perspective underscores the profound impact of this integrated therapy. She reported a fundamental internal shift, a reduction in feelings of loneliness and helplessness, and an increased capacity to attend to past fearful memories as distinct from present experiences. This has translated into greater tranquility, more flexible coping strategies, and a reduction in avoidance and hyper-control behaviors. Her statement, "Now I no longer feel alone and helpless… something has fundamentally changed inside me. The best feeling is being more secure, capable of reacting. It’s a beautiful achievement for me," powerfully illustrates the transformative potential of tailored therapeutic interventions.

The authors advocate for continued research with larger clinical samples and pre- and post-treatment parameters to establish robust intervention protocols. This case report serves as a vital step in paving the way for more accessible and effective trauma-informed care for individuals on the autism spectrum, acknowledging their unique vulnerabilities and strengths. The findings suggest that with thoughtful adaptation, evidence-based therapies like EMDR can be powerfully leveraged to promote healing and well-being in this population.