Traumatic Imagery Research Articles

Discrete and Recurrent Traumatization in PTSD: Fear vs. Anxious Misery

Discrete and Recurrent Traumatization in PTSD: Fear vs. Anxious Misery

Effect of Acute Posttrauma Propranolol on PTSD Outcome and Physiological Responses During Script‐Driven Imagery

Animal and human research suggests that the development of posttraumatic stress disorder (PTSD) may involve the overconsolidation of memories of a traumatic experience. Previous studies have attempted to use pharmaceutical agents, especially the β-adrenergic blocker propranolol, to reduce this overconsolidation. In this randomized, placebo-controlled study of the efficacy of propranolol in reducing the development of PTSD, we optimized dosages and conducted both psychophysiological and clinical assessments 1 and 3 months after the traumatic event. Forty-one emergency department patients who had experienced a qualifying acute psychological trauma were randomized to receive up to 240 mg/day of propranolol or placebo for 19 days. At 4 and 12 weeks post-trauma, PTSD symptoms were assessed. One week later, participants engaged in script-driven imagery of their traumatic event while psychophysiological responses were measured. Physiological reactivity during script-driven traumatic imagery, severity of PTSD symptoms, and the rate of the PTSD diagnostic outcome were not significantly different between the two groups. However, post hoc subgroup analyses showed that in participants with high drug adherence, at the 5-week posttrauma assessment, physiological reactivity was significantly lower during script-driven imagery in the propranolol than in the placebo subjects. The physiological results provide some limited support for a model of PTSD in which a traumatic conditioned response is reduced by posttrauma propranolol. However, the clinical results from this study do not support the preventive use of propranolol in the acute aftermath of a traumatic event.

Trauma, Imagery and the Therapeutic Relationship: Langu's story

This paper, a phenomenological case study, describes the psychotherapy of Langu (pseudonym), a 21-year-old student, who presented with Acute Stress Disorder following a series of motor accidents that affected him and his family. Langu’s most distressing experience was having to identify his brother’s mutilated and severely burned body. Because of the intensity of the intrusive re-experiencing of traumatic imagery and the degree of dissociative numbing, Langu participated in four intensive guided imagery sessions, which involved reliving the incident, and imaginal dialogues with his dead brother. Session records and supervision notes from the therapy process that unfolded over 22 sessions served as the basis for a thematically selective case narrative. Additional material was obtained from several research interviews with Langu over the following months. The narrative highlights the impact of the imagery work as well as relational aspects of the therapy. The case narrative provides a source for examining many aspects of the psychological impact of trauma and the path to healing, as well as the dilemmas and challenges faced by therapists working with traumatised individuals.

Aversive Imagery in Posttraumatic Stress Disorder: Trauma Recurrence, Comorbidity, and Physiological Reactivity

Posttraumatic stress disorder (PTSD) is characterized as a disorder of exaggerated defensive physiological arousal. The novel aim of the present research was to investigate within PTSD a potential dose-response relationship between past trauma recurrence and current comorbidity and intensity of physiological reactions to imagery of trauma and other aversive scenarios. A community sample of principal PTSD (n = 49; 22 single-trauma exposed, 27 multiple-trauma exposed) and control (n = 76; 46 never-trauma exposed, 30 trauma exposed) participants imagined threatening and neutral events while acoustic startle probes were presented and the eye-blink response (orbicularis occuli) was recorded. Changes in heart rate, skin conductance level, and facial expressivity were also indexed. Overall, PTSD patients exceeded control participants in startle reflex, autonomic responding, and facial expressivity during idiographic trauma imagery and, though less pronounced, showed heightened reactivity to standard anger, panic, and physical danger imagery. Concerning subgroups, control participants with and without trauma exposure showed isomorphic patterns. Within PTSD, only the single-trauma patients evinced robust startle and autonomic responses, exceeding both control participants and multiple-trauma PTSD. Despite greater reported arousal, the multiple-trauma relative to single-trauma PTSD group showed blunted defensive reactivity associated with more chronic and severe PTSD, greater mood and anxiety disorder comorbidity, and more pervasive dimensional dysphoria (e.g., depression, trait anxiety). Whereas PTSD patients generally show marked physiological arousal during aversive imagery, concordant with self-reported distress, the most symptomatic patients with histories of severe, cumulative traumatization show discordant physiological hyporeactivity, perhaps attributable to sustained high stress and an egregious, persistent negative affectivity that ultimately compromises defensive responding.

Neural correlates of reexperiencing, avoidance, and dissociation in PTSD: Symptom dimensions and emotion dysregulation in responses to script‐driven trauma imagery

Research suggests that responses to script-driven trauma imagery in posttraumatic stress disorder (PTSD) include reexperiencing and dissociative symptom subtypes. This functional magnetic resonance imaging (fMRI) study employed a dimensional approach to characterizing script-driven imagery responses, using the Responses to Script-Driven Imagery Scale and correlational analyses of relationships between severity of state posttraumatic symptoms and neural activation. As predicted, state reexperiencing severity was associated positively with right anterior insula activity and negatively with right rostral anterior cingulate cortex (rACC). Avoidance correlated negatively with rACC and subcallosal anterior cingulate activity. In addition, as predicted, dissociation correlated positively with activity in the left medial prefrontal and right superior temporal cortices, and negatively with the left superior temporal cortex. Theoretical and clinical implications are discussed, particularly with respect to an emotion-dysregulation account of PTSD.

Effects of psychotherapy on regional cerebral blood flow during trauma imagery in patients with post-traumatic stress disorder: a randomized clinical trial

Functional brain-imaging studies in post-traumatic stress disorder (PTSD) have suggested functional alterations in temporal and prefrontal cortical regions. Effects of psychotherapy on these brain regions have not yet been examined. Twenty civilian PTSD out-patients and 15 traumatized control subjects were assessed at baseline using psychometric ratings. Cerebral blood flow was measured using trauma script-driven imagery during 99mtechnetium hexamethyl-propylene-amine-oxime single-photon emission computed tomography scanning. All 20 out-patients were randomly assigned to treatment or wait-list conditions. Treatment was brief eclectic psychotherapy (BEP) in 16 weekly individual sessions. At baseline, greater activation was found in the right insula and right superior/middle frontal gyrus in the PTSD group than in the control group. PTSD patients treated with BEP significantly improved on all PTSD symptom clusters compared to those on the waiting list. After effective psychotherapy, lower activation was measured in the right middle frontal gyrus, compared to the PTSD patients on the waiting list. Treatment effects on PTSD symptoms correlated positively with activation in the left superior temporal gyrus, and superior/middle frontal gyrus. BEP induced clinical recovery in PTSD patients, and appeared to modulate the functioning of specific PTSD-related sites in the prefrontal cortical regions.

Effect of post-retrieval propranolol on psychophysiologic responding during subsequent script-driven traumatic imagery in post-traumatic stress disorder

The β-adrenergic blocker propranolol given within hours of a psychologically traumatic event reduces physiologic responses during subsequent mental imagery of the event. Here we tested the effect of propranolol given after the retrieval of memories of past traumatic events. Subjects with chronic post-traumatic stress disorder described their traumatic event during a script preparation session and then received a one-day dose of propranolol ( n = 9) or placebo ( n = 10), randomized and double-blind. A week later, they engaged in script-driven mental imagery of their traumatic event while heart rate, skin conductance, and left corrugator electromyogram were measured. Physiologic responses were significantly smaller in the subjects who had received post-reactivation propranolol a week earlier. Propranolol given after reactivation of the memory of a past traumatic event reduces physiologic responding during subsequent mental imagery of the event in a similar manner to propranolol given shortly after the occurrence of a traumatic event.

Trauma, imagery and the therapeutic relationship: Langu's story

This paper, a phenomenological case study, describes the psychotherapy of Langu (pseudonym), a 21-year-old student, who presented with Acute Stress Disorder following a series of motor accidents that affected him and his family. Langu's most distressing experience was having to identify his brother's mutilated and severely burned body. Because of the intensity of the intrusive re-experiencing of traumatic imagery and the degree of dissociative numbing, Langu participated in four intensive guided imagery sessions, which involved reliving the incident, and imaginal dialogues with his dead brother. Session records and supervision notes from the therapy process that unfolded over 22 sessions served as the basis for a thematically selective case narrative. Additional material was obtained from several research interviews with Langu over the following months. The narrative highlights the impact of the imagery work as well as relational aspects of the therapy. The case narrative provides a source for examining many aspects of the psychological impact of trauma and the path to healing, as well as the dilemmas and challenges faced by therapists working with traumatised individuals. Keywords: acute stress disorder, case narrative, case study, cognitive therapy, guided imagery, post-traumatic stress disorder, psychotherapy, therapeutic relationshipJournal of Psychology in Africa 2005, 15(2): 185–195

Heart Rate Responsivity to Script-Driven Imagery in Posttraumatic Stress Disorder: Specificity of Response and Effects of Psychotherapy

Previous psychophysiological studies of posttraumatic stress disorder (PTSD) have found heightened physiological responsivity to trauma-specific stimuli, but mostly in combat veterans with high comorbidity rates and with psychiatric medication. Our aim was to investigate psychophysiological responses in two new populations while excluding those confounding influences and to assess the effects of psychotherapy on such responses. Thirty-nine subjects with PTSD (24 civilian outpatients and 15 police officers) and 15 trauma-exposed, non-PTSD control subjects underwent psychophysiological assessment while listening to neutral, stressful, and trauma scripts. Psychophysiological measures were heart rate (HR) and blood pressure in combination with subjective anxiety ratings. In a randomized clinical trial, 20 of the civilians were then assigned to treatment or waitlist groups. Psychophysiological assessment was repeated on them after the treatment stage. Both civilians and police with PTSD showed significantly higher HR responses to trauma scripts than the control subjects. After successful psychotherapy with the civilians, HR responsivity to the trauma scripts was significantly reduced, and it correlated positively with PTSD clinical symptoms. We confirmed previous findings of heightened psychophysiological responses in PTSD for two new populations while minimizing comorbidity and medication as confounding factors. Successful psychotherapy normalized HR response to trauma imagery.

Preliminary evidence for lymphocyte distribution differences at rest and after acute psychological stress in PTSD-symptomatic women

This study investigated circulating natural killer (NK), CD4+ and CD8+ cells in response to acute psychological challenge among mothers of child cancer survivors with and without posttraumatic stress symptoms (PTSS). Control mothers of healthy children ( n = 9) were compared to 17 cancer mothers with (PTSS: n = 9) and without PTSS (No PTSS: n = 7) under conditions of rest, after a generic stressor (MAT: mental arithmetic task) and a personalized stressor (script-driven trauma imagery), and after recovery from each stressor. Results indicate the PTSS group had higher percentage CD4+ and lower CD8+ levels than non-symptomatic women and blunted NK reactivity to generic challenge. Multiple regression analyses indicated PTSS effects were independent of self-reported distress. Contrary to expectations, cancer mothers without PTSS were not significantly different from controls on tonic or phasic immune outcomes. Also unlike predictions, reactivity to challenge was greatest to the non-social MAT stressor compared to the personalized challenge for all groups. Conclusions are constrained by study limitations (e.g., small sample size and potential phase order effects). Nonetheless, results are consistent with an emerging literature on PTSS-associated immune differences and further suggest these effects may be distinct from that associated with subjective distress more generally.

Regional cerebral blood flow in the amygdala and medial prefrontal cortex during traumatic imagery in male and female Vietnam veterans with PTSD.

Theoretical neuroanatomic models of posttraumatic stress disorder (PTSD) and the results of previous neuroimaging studies of PTSD highlight the potential importance of the amygdala and medial prefrontal regions in this disorder. However, the functional relationship between these brain regions in PTSD has not been directly examined. To examine the relationship between the amygdala and medial prefrontal regions during symptom provocation in male combat veterans (MCVs) and female nurse veterans (FNVs) with PTSD. Case-control study. Academic medical center. Volunteer sample of 17 (7 men and 10 women) Vietnam veterans with PTSD (PTSD group) and 19 (9 men and 10 women) Vietnam veterans without PTSD (control group). We used positron emission tomography and the script-driven imagery paradigm to study regional cerebral blood flow (rCBF) during the recollection of personal traumatic and neutral events. Psychophysiologic and emotional self-report data also were obtained to confirm the intended effects of script-driven imagery. The PTSD group exhibited rCBF decreases in medial frontal gyrus in the traumatic vs neutral comparison. When this comparison was conducted separately by subgroup, MCVs and FNVs with PTSD exhibited these medial frontal gyrus decreases. Only MCVs exhibited rCBF increases in the left amygdala. However, for both subgroups with PTSD, rCBF changes in medial frontal gyrus were inversely correlated with rCBF changes in the left amygdala and the right amygdala/periamygdaloid cortex. Furthermore, in the traumatic condition, for both subgroups with PTSD, symptom severity was positively related to rCBF in the right amygdala and negatively related to rCBF in medial frontal gyrus. These results suggest a reciprocal relationship between medial prefrontal cortex and amygdala function in PTSD and opposing associations between activity in these regions and symptom severity consistent with current functional neuroanatomic models of this disorder.

HOMICIDE BEREAVEMENT COUNSELING: A SURVEY OF PROVIDERS

The opinions of 116 homicide bereavement caregivers of interventions recommended for survivors were solicited. Presenting problems, optimum treatment framework, and reasons for treatment failure were also surveyed. Respondents preferred methods associated with crisis intervention and grief counseling. Other clinical techniques were rated as moderately helpful, except family therapy, which was highly rated. Suppression of trauma imagery was deemed harmful to survivors, though diversion was recommended often in cases of complicated grief. Caregivers who are themselves survivors appeared more sensitive to some of the emotional aspects of homicide bereavement, such as the potential for retraumatization in therapy.

Single photon emission computed tomography in posttraumatic stress disorder before and after treatment with a selective serotonin reuptake inhibitor

Background: Posttraumatic stress disorder (PTSD) is recognized as a disorder mediated by specific neurobiological circuits. Functional imaging studies using script-driven trauma imagery and pharmacological challenges have documented altered cerebral function (activation and deactivation) in several brain regions, including the amygdala, hippocampus, prefrontal cortex and anterior cingulate. However, the neural substrates of PTSD remain poorly understood and the effect of selective serotonin reuptake inhibition on regional cerebral activity is deserving of further investigation. Methods: Eleven adult patients (seven men, four women) (mean age+S.D.=33.6±9.2 years) with a DSM-IV diagnosis of PTSD, as determined by the Structured Clinical Interview for DSM-IV (SCID-I) and the Clinician-Administered PTSD Scale (CAPS), underwent single photon emission computed tomography (SPECT) with Tc-99m HMPAO pre- and post-8 weeks of treatment with the selective serotonin reuptake inhibitor, citalopram. Symptoms were assessed at baseline and at 2-week intervals with the Clinician-Administered PTSD Scale (CAPS), Montgomery–Asberg Depression Rating Scale (MADRS), and the Clinical Global Impression Scale (CGI). Image analysis of baseline and post-treatment scans was performed using Statistical Parametric Mapping (SPM). Results: Treatment with citalopram resulted in significant deactivation in the left medial temporal cortex irrespective of clinical response. On covariate analysis, a significant correlation between CAPS score reduction and activation in the left paracingulate region (medial prefrontal cortex) was observed post-treatment. No significant pre-treatment differences were observed between responders and non-responders in anterior cingulate perfusion. Conclusions: These preliminary findings are consistent with clinical data indicating temporal and prefrontal cortical dysfunction in PTSD and preclinical data demonstrating serotonergic innervation of these regions. However, further studies, in particular in vivo receptor imaging studies, are needed to confirm whether these regional abnormalities correlate with clinical features and treatment response.

Psychophysiological reactivity in female sexual abuse survivors.

This study examined psychophysiological reactivity in 37 female childhood sexual abuse (CSA) survivors. After assessment of posttraumatic stress disorder (PTSD), psychiatric comorbidity, and trauma history, we conducted a psychophysiological assessment of forehead muscle tension, electrodermal activity, and heart rate during a mental arithmetic task and4 script-driven imagery tasks (neutral, consensual sex, pleasant, and trauma). PTSD symptom severity correlated positively with psychophysiologic changes and negative emotions during the trauma imagery task. During mental arithmetic, PTSD symptom severity correlated negatively with autonomic changes and positively with negative emotions. These results extend earlier PTSD research showing trauma-specific increased psychophysiological reactivity related to CSA in women with PTSD. They further suggest a negative association between PTSD severity and autonomic reactions to mental arithmetic.

Regional Cerebral Blood Flow During Script-Driven Imagery in Childhood Sexual Abuse-Related PTSD: A PET Investigation

The purpose of this study was to determine whether anterior limbic and paralimbic regions of the brain are differentially activated during the recollection and imagery of traumatic events in trauma-exposed individuals with and without posttraumatic stress disorder (PTSD). Positron emission tomography (PET) was used to measure normalized regional cerebral blood flow (CBF) in 16 women with histories of childhood sexual abuse: eight with current PTSD and eight without current PTSD. In separate script-driven imagery conditions, participants recalled and imagined traumatic and neutral autobiographical events. Psychophysiologic responses and subjective ratings of emotional state were measured for each condition. In the traumatic condition versus the neutral control conditions, both groups exhibited regional CBF increases in orbitofrontal cortex and anterior temporal poles; however, these increases were greater in the PTSD group than in the comparison group. The comparison group exhibited regional CBF increases in insular cortex and anterior cingulate gyrus; increases in anterior cingulate gyrus were greater in the comparison group than in the PTSD group. Regional CBF decreases in bilateral anterior frontal regions were greater in the PTSD group than in the comparison group, and only the PTSD group exhibited regional CBF decreases in left inferior frontal gyrus. The recollection and imagery of traumatic events versus neutral events was accompanied by regional CBF increases in anterior paralimbic regions of the brain in trauma-exposed individuals with and without PTSD. However, the PTSD group had greater increases in orbitofrontal cortex and anterior temporal pole, whereas the comparison group had greater increases in anterior cingulate gyrus.

Spaced cognitive interviewing: Facilitating therapeutic and forensic narration of traumatic memories

The evolution of the cognitive interview (CI) is reviewed from the original package of memory-enhancing techniques through to the revised (or enhanced) CI, and the cognitive approach now taught to police officers in UK. Many officers are reluctant to apply CI, particularly to traumatised victims. The traumatising effects of crime are examined in terms of immediate response and the potential for an acute stress response and post-traumatic stress disorder, with subsequent re-experiencing of dissociated traumatic memories in the form of intrusive, unwanted imagery. Traumatic memories are described, particularly their accuracy, detail and persistence. The therapeutic potential of prolonged experience of distress while narrating the content of traumatic imagery is explained. An approach to maximising the disclosure of dissociated detail - spaced cognitive interviewing (SCI) - is described and case material presented illustrating its forensic and therapeutic application. The practice and practical implications of SCI are summarised.

Traumatic memories and pseudomemories in posttraumatic stress disorder

Intrusive imagery was investigated in survivors of motor vehicle accidents with (a) posttraumatic stress disorder (PTSD) and accurate recall of the trauma, (b) PTSD and amnesia of the trauma, (c) no PTSD, or (d) control participants who simulated PTSD. Imagery was precipitated by presentation of an audiotape of a motor vehicle accident. Whereas the traumatic imagery of participants who had accurate recall of their trauma was consistent with third party accounts of the trauma, the imagery of amnesic participants was inconsistent with these accounts. Participants were then interviewed about cognitive and emotional aspects of their responses. All participants with PTSD and simulators reported similar levels of imagery detail, involuntariness, re-experiencing, and emotional response, and reported higher levels than participants with no PTSD. Findings are discussed in terms of cognitive and contextual factors that can mediate accurate and inaccurate traumatic imagery. © 1998 John Wiley & Sons, Ltd.

The Contribution of Art Therapy to the Dissociative Disorders

AbstractResearch has shown that childhood trauma is a critical component in dissociative disorders (Putnam, 1989). Traumatic imagery and frightening emotions are right brain functions (Brende, 1984). In order to explore concepts of brain hemispheric lateralization and distinct right brain functioning in extensive dissociation, the Dissociative Experiences Scale (DES) scores of 114 engineering students were compared to the DES scores of 92 drawing students on a university campus. The DES measures the level of dissociative experiences. The engineering curriculum was presumed to require more analytical, left brain skills while the drawing class tasks were assumed to utilize more visual, right brain skills. The data were separated into three levels of scoring. A chi-square calculation found differences in dissociative scoring levels between the groups that approached significance at the .05 level. This suggests that brain lateralization may play a role in dissociative processes. Since art therapy may employ t...

Psychophysiologic assessment of traumatic imagery in Israeli civilian patients with posttraumatic stress disorder

This study used a script-driven imagery technique, previously used with combat veterans, to assess physiologic responses of Israeli survivors of noncombat traumas. Each subject had experienced an event meeting DSM-III-R criterion A for posttraumatic stress disorder (PTSD). The subjects were classified on the basis of the full DSM-III-R criteria into a current PTSD group (N = 13) and a non-PTSD group (N = 13). Thirty-second scripts describing each subject's personal traumatic event, as well as other events, were prepared. The scripts incorporated subjective visceral and muscular responses reported to have accompanied each experience. In the laboratory, the scripts were read one at a time to the subject, who was instructed to imagine each event portrayed as vividly as possible, while heart rate, skin conductance, and left lateral frontalis electromyogram levels were measured. Multivariate analysis of variance revealed that the physiologic responses of the PTSD subjects during imagery of their personal traumatic experiences were significantly greater than those of the non-PTSD subjects. This difference was not explained by age, gender, or rated severity of the traumatic event. A physiologic discriminant function derived from previously studied Vietnam veterans correctly classified nine of the 13 PTSD subjects (sensitivity = 69%) and 10 of the 13 non-PTSD subjects (specificity = 77%). These results replicate previous findings of heightened physiologic responses during personal combat imagery in male American war veterans and extend them to a group of male and female Israeli civilian victims of trauma, supporting the robustness of physiologic responding during personal traumatic imagery as a measure of PTSD.

The nosology of posttraumatic stress disorder

Abstract Since its introduction as a diagnostic category in DSM-III, Posttraumatic Stress Disorder has been the subject of continuing nosologic disagreement. Two theoretical perspectives—one emphasizing traumatic imagery, the other conditioned anxiety—subtly permeate the field. A sizable empirical database has also accrued. These contributions are discussed in the context of nosologic arguments endorsing the theoretical construct and the applicability of the DSM-III-R criteria set.