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Observational Study
. 2018 Jun 11;8(6):e021448.
doi: 10.1136/bmjopen-2017-021448.

Observational Study of Associations Between Visual Imagery and Measures of Depression, Anxiety and Post-Traumatic Stress Among Active-Duty Military Service Members With Traumatic Brain Injury at the Walter Reed National Military Medical Center

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Free PMC article
Observational Study

Observational Study of Associations Between Visual Imagery and Measures of Depression, Anxiety and Post-Traumatic Stress Among Active-Duty Military Service Members With Traumatic Brain Injury at the Walter Reed National Military Medical Center

Girija Kaimal et al. BMJ Open. .
Free PMC article

Abstract

Objectives: The study aimed tocompare recurring themes in the artistic expression of military service members (SMs) with post-traumatic stress disorder (PTSD), traumatic brain injury and psychological health (PH) conditions with measurable psychiatric diagnoses. Affective symptoms and struggles related to verbally expressing information can limit communication in individuals with symptoms of PTSD and deployment-related health conditions. Visual self-expression through art therapy is an alternative way for SMs with PTSD and other PH conditions to communicate their lived experiences. This study offers the first systematic examination of the associations between visual self-expression and standardised clinical self-report measures.

Design: Observational study of correlations between clinical symptoms of post-traumatic stress, depression and anxiety and visual themes in mask imagery.

Setting: The National Intrepid Center of Excellence at the Walter Reed National Military Medical Center, Bethesda, Maryland, USA.

Participants: Active-duty military SMs (n=370) with a history of traumatic brain injury, post-traumatic stress symptoms and related PH conditions.

Intervention: The masks used for analysis were created by the SMs during art therapy sessions in week 1 of a 4-week integrative treatment programme.

Primary outcomes: Associations between scores on the PTSD Checklist-Military, Patient Health Questionnaire-9 and Generalized Anxiety Disorder 7-item scale on visual themes in depictions of aspects of individual identity (psychological injury, military symbols, military identity and visual metaphors).

Results: Visual and clinical data comparisons indicate that SMs who depicted psychological injury had higher scores for post-traumatic stress and depression. The depiction of military unit identity, nature metaphors, sociocultural metaphors, and cultural and historical characters was associated with lower post-traumatic stress, depression and anxiety scores. Colour-related symbolism and fragmented military symbols were associated with higher anxiety, depression and post-traumatic stress scores.

Conclusions: Emergent patterns of resilience and risk embedded in the use of images created by the participants could provide valuable information for patients, clinicians and caregivers.

Keywords: anxiety; depression; military; post traumatic stress; traumatic brain injury; visual imagery.

Conflict of interest statement

Competing interests: None declared.

Figures

Figure 1
Figure 1
Psychological injury (depiction of psychological struggles with sadness, anger, inability to verbalise and social isolation).
Figure 2
Figure 2
Identification with military unit (depiction of sense of belonging to a military unit, for example, explosive ordnance disposal badge, also known as the ‘crab’).
Figure 3
Figure 3
Use of fragmented military symbols (depiction of fragmented symbols associated with the military such as flags, camouflage fabric and dog tags).
Figure 4
Figure 4
Metaphors (depiction of inner psychological states through a visual image).
Figure 5
Figure 5
Colour symbolism (specific individual colours as metaphorical representations of experiences and emotions).
Figure 6
Figure 6
Cultural or historical characters (depiction of characters from history, films and literature).
Figure 7
Figure 7
Sociocultural symbols (inclusion of images from objects commonly seen in society).
Figure 8
Figure 8
Nature images (inclusions of images from nature in mask).

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References

    1. U.S. Government Accountability Office. VA mental health: Number of veterans receiving care, barriers faced, and efforts to increase access (GAO-12-12) [PDF file]. 2011. http://www.gao.gov/products/GAO-12-12 (accessed 4 May 2018).
    1. Defense and Veterans Brain Injury Center. DoD worldwide numbers for TBI [PDF file]. Falls Church, VA: Department of Defense 2018. http://dvbic.dcoe.mil/dod-worldwide-numbers-tbi (accessed May 4 May 2018).
    1. Blakeley K, Jansen DJ. Post-traumatic stress disorder and other mental health problems in the military: oversight issues for congress. Washington DC: Library of Congress, Congressional Research Service, 2013.
    1. Tanielian T, Jaycox L. Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery. Pittsburgh, PA: RAND Corporation, 2008.
    1. Dolan S, Martindale S, Robinson J, et al. Neuropsychological sequelae of PTSD and TBI following war deployment among OEF/OIF veterans. Neuropsychol Rev 2012;22:21–34. 10.1007/s11065-012-9190-5 - DOI - PMC - PubMed

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