Art-based, Cognitive Therapy for PTSD,
TBI and Depression

Military oriented treatment for Service Members and Veterans
Hippocampal atrophy is found in...PTSD and chronic TBI, even in cases in which the primary impact site was remote from the hippocampus.

Robert Van Boven, et al, Advances in Neuroimaging of Traumatic Brain Injury and Posttraumatic Stress Disorder, J Rehab Res and Dev, 2009

The Implications of PTSD, TBI and Depression

PTSD, TBI and depression can bring about structural changes in the brain that affect thinking, emotion and behavior.
In brain trauma or stress, the amygdala (emotion) and hippocampus (memory) (each part of the Limbic system) are among the first areas of the brain to be affected.
Damage to these areas can disrupt the brain's ability to process sensory data and impair cognitive function.
Studies in combat-related PTSD show that extended release of stress-responsive hormones damages the hippocampus [affecting mood, memory and learning] and can shrink its volume by up to 26%, an effect seen in [depression and] Alzheimer’s disease.

Bremner, 2005, Gurvits et al., 1996 [in The Invisible Wound: Veterans’ Art Therapy by Janice Lobban

How the Brain Works

Interaction with the environment requires the balance of two attentional selection mechanisms in the brain:

Bottom-Up and Top-Down
Bottom-Up (BU) -- sensory processing,
or stimulus driven attention
BU systems --
take in and process information through the senses to form a single, unified perception.

Fast reactions or quick visual identification are considered BU processes as they rely primarily on sensory information.
Top-Down (TD)   -- cognitive processing, or goal directed attention
TD systems --
provide means to interpret and understand sensory data and produce a behavioral response.

Motor control and directed attention are considered TD processes because they are goal directed.
BU systems compromise can disrupt brain function and effect changes in personality and behavior
Brain imaging studies in PTSD have implicated a circuit of brain regions, including the hippocampus, prefrontal cortex and amygdala, in the symptoms of PTSD.

Robert W. Van Boven et al., Advances in Neuro-imaging of TBI/PTSD (J Rehab Rsch and Dev, 2009).
Left untreated, PTSD, TBI and depression can have adverse, long-term effects on cognitive, physical, social and emotional functioning, and cause co-occurring problems such as substance abuse, homelessness and suicide
Picture

Consequences  of BU Deficits in Theater

  • Perceptual problems (e.g., trouble in following directions)
  • Loss of the ability to recognize, construct or manipulate objects
  • Trouble distinguishing left from right
  • Fatigue (mental and physical)
  • Emotional problems / impaired vision
  • Memory and learning problems
  • Difficulty with mathematics
  • Anxiety, depression, underachievement
  • Sleep disturbances
  • Inability to locate one's limbs in space (e.g., as in climbing stairs)
  • Inability to engage in conversation or play
  • Oversensitivity to light, sound, touch
  • Over- or under stimulation (neuro distress)
The two most common cognitive symptoms in PCS (Post Concussive Syndrome), in addition to slowed overall processing speed, are impairments in attention and memory.

A Luden, et al., Symptoms and Disability until 3 Months after mild TBI. Brain Inj 2006
Trauma to the visuo-spatial (VS) area of the brain can impair the ability to locate objects in physical space, manipulate sensory information in spatial memory, and use that information to plan a sequence of movements.

Strauss, Sherman, & Spreen, 2006
Visual motor (VM) integration deficits can lead to errors in using visual cues to form spatial maps in the brain, locate one's position in space, or solve topographical problems (eg., to determine distance or direction from Points A to B).

NAT Rehabilitates the Brain

Apart from other cognitive therapies, NAT is designed to work within the amygdala and hippocampus--primary motivators for shifts in behavior with corresponding neuroplasticity -- to build a strong foundation for attention and cognition.
The goal of rehabilitation is to stimulate the brain to re-form lost circuits.

The Brain's Amazing Potential for Recovery, Elizabeth Landau, CNN  http://www.cnn.com/2011/HEALTH/05/05/brain.plasticity.giffords/
Therapeutic, art-based process --
  • Merges therapy and practical application
  • Works within the Limbic system to reduce stress, stabilize the body’s reactions to stressful stimuli and rebuild neural networks
  • Uses visual and sensori- motor tasks to stimulate therapeutic drives within the brain
  • Utilizes the neuro aspects of art (color, line, movement) to promote visual perception, manipulation of spatial relationships, color and shape discrimination, and attention to entire visual field
  • Promotes integrated brain functioning through the use of left- and right brain modalities
  • Promotes self-efficacy and greater independence
  • Fosters a renewed sense of self, identity and wellbeing
Art therapy taps into primitive brain networks and helps to establish new neural pathways that alter function.

Dr. Lukasz Konopka, in The Invisible Wound: Veterans' Art Therapy by Janice Lobban
Benefits of NAT
  • Affords interactive, client-centered treatment to strengthen and enhance cognitive function
  • Promotes compensatory strategy development and behavioral self-regulation (in dealing with neuro distress)
  • Reinforces strategies and skills developed with occupational, physical and vocational therapists
  • Provides for measurable growth of improved cognitive function
The application of creative and expressive therapies as part of treatment plans has recently shown significant and sustained benefit at leading institutions such as Walter Reed Army Medical Center, the National Intrepid Center of Excellence, and various VA institutions across the country.

Cathy A. Malchiodi, Expressive Therapies: History, Theory and Practice
Post-deployment assessment consideration:
Performance on top-down tests should be interpreted relative to performance on more fundamental visual processing tests such as simple figure copy, visual search, judgment of line orientation, and face perception.

Strauss, Sherman and Spreen, 2006 [in Katherine Possin, Visual Spatial Cognition in Neurodegenerative Disease, NCBI, June 2010]
See also:

Invisible Wounds of War: Psychological and Cognitive Injuries and Their Consequences, and Services to Assist Recovery, Terri Tanielian and Lisa H. Jaycox, eds.
Synaptic Plasticity from Visual Cortex to Hippocampus: Systems Integration in Spatial Information Processing
Alzheimers, Anxiety, Art rehabilitation, Attention, Brain injury treatment, trauma, Cognitive rehabilitation, Dementia, Focusing, memory, Neuro distress, neuroplasticity, Depression, Stress, Stroke