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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
  1. Girija Kaimal1,
  2. Melissa S Walker2,
  3. Joanna Herres3,
  4. Louis M French2,4,
  5. Thomas J DeGraba2
  1. 1 Creative Arts Therapies, Drexel University College of Nursing and Health Professions, Philadelphia, Pennsylvania, USA
  2. 2 National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
  3. 3 Department of Psychology, The College of New Jersey, Stockton, New Jersey, USA
  4. 4 Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
  1. Correspondence to Dr. Girija Kaimal; gk27{at}


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.

  • traumatic brain injury
  • post traumatic stress
  • military
  • visual imagery
  • depression
  • anxiety

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  • Contributors All the authors contributed to the study as follows: GK led the study and conducted the review of the masks with MSW. JH conducted the statistical data analysis. LMF and TJD helped with manuscript review, including the discussion and implications sections. TJD designed the database protocol from which the clinical data for the analysis were used and patient consents were obtained.

  • Funding We are grateful to the National Endowment for the Arts’ Creative Forces: The NEA Military Healing Arts Network for providing funding to support this study.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval The study was conducted with approval from the Walter Reed National Military Medical Center (Bethesda, Maryland, USA) institutional review board, in accordance with all federal laws, regulations and standards of practice, as well as those of the Department of Defense and the Departments of the Army, Navy and Air Force and the partnering university.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The raw data were shared between the institutions as part of a data-sharing agreement. These data are not available for public sharing.

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