Does PTSD have a visual shadow?

Gisbi Susan Shaji ⁽¹⁾, Research Fellow;

Pragati Gupta ⁽²⁾, PhD Student

International Institute of Information Technology, Hyderabad, India

Visual manifestations in psychological disorders are complex phenomena with diverse origins and implications. Involuntary and distressing visual memories are linked to disorders like Post Traumatic Stress Disorder (PTSD), anxiety, and depression, highlighting the neural underpinnings involving prefrontal and parietal cortices. ⁽¹⁾

The primary area for processing visual information is the primary visual cortex (V1). The ventral stream in the temporal lobe processes object identity and is essential for recognising and remembering visual features. The hippocampus encodes new visual information into long-term memory. The prefrontal cortex is often used to retrieve visual memories and maintain attention to visual stimuli.

When a person experiences a traumatic event, it often gets encoded into memory with strong emotional associations. These memories can later be re-triggered through visual images or cues, which bring back the feelings of fear or panic associated with the event. The amygdala processes emotions, especially fear. ⁽²⁾ During a traumatic event, the amygdala attaches strong emotional significance to that event and the visual cortex processes sensory input including visual information. These visual images (such as a specific place, object, or face) become associated with the emotional experience and are stored in long-term memory. The hippocampus then stores these visual elements with emotional associations. In the case of anxiety or panic attacks, the brain can recognise visual cues (such as certain environments, faces, or even specific colours or objects) that are linked to the original traumatic or stressful event. The brain essentially “relives” the emotional intensity of the past event when the visual cue is perceived. When a person encounters a visual trigger, the brain activates the same neural circuits that were involved during the original experience. This is a form of sensory re-experiencing. The visual memory brings back not just the image but also the accompanying feelings of fear, panic, or distress. ⁽³⁾

Miller said from a neuro-ophthalmologic point of view that in any psychogenic disease five areas can be affected: Vision (including visual acuity and visual field), ocular motility and alignment, pupillary size and reactivity, eyelid position and function, and hypersensitivity or anaesthesia of corneal and facial sensation. ⁽⁴⁾ Anxiety and stress elevate cortisol levels, causing an imbalance in the sympathetic branch of the autonomic nervous system (ANS). The sympathetic branch of the ANS has been identified as playing a role in accommodation and pupillary changes. Longer duration of near work (around 7 h/day) together with the effects of stress and anxiety on the ANS, can affect visual functions. ⁽⁵⁾ Chronic psychological stress can lead to neuroplastic changes in the brain, affecting areas responsible for visual processing and emotional regulations which manifest in these visual symptoms.

The cognitive model of PTSD by Ehlers and Clars explains the triggers and emotional responses. ⁽⁶⁾ Studies have recorded those individuals with PTSD reporting abnormalities in visual imagery, especially with the vividness of visual imagery being associated with the incidence of flashbacks and nightmares, there are also reports on hallucinatory- like visual images and sensory flashbacks. ⁽⁷⁾

A comprehensive visual examination that includes pupillary evaluations, ocular movements, visual field, and binocular vision tests can be performed by optometrists, who can also offer recommendations based on the results. Environmental modifications and coping mechanisms, such as the 20-20-20 rule to reduce visual stress or avoiding certain lighting or visual patterns. Light sensitivity can be addressed with specific tints. A thorough history and if these signs are evident, please direct them to a licensed psychologist for further evaluation.

Visual manifestations during traumatic psychological events can significantly impact an individual’s mental health and daily life. Intrusive imagery causes unwelcome and distressing thoughts especially in cases where memory processing is altered, leading to persistent, involuntary recall of the traumatic event. The resulting emotional distress and behavioural changes can interfere with daily activities, highlighting the importance of effective treatment. Psychotherapy, such as Cognitive Behavioural Therapy (CBT) and Eye Movement Desensitisation and Reprocessing (EMDR), alongside management of primary symptoms can help overall improvement in the quality of life.

References:

1. Brewin, C. R., Gregory, J. D., Lipton, M., & Burgess, N. (2010). Intrusive images in psychological disorders: characteristics, neural mechanisms, and treatment implications. Psychological review, 117(1), 210–232. https://doi.org/10.1037/a0018113.
2. Phelps E. A. (2004). Human emotion and memory: interactions of the amygdala and hippocampal complex. Current opinion in neurobiology, 14(2), 198–202. https://doi.org/10.1016/j.conb.2004.03.015.
3. Brewin, C. R., Gregory, J. D., Lipton, M., & Burgess, N. (2010). Intrusive images in psychological disorders: characteristics, neural mechanisms, and treatment implications. Psychological review, 117(1), 210–232. https://doi.org/10.1037/a0018113.
4. Miller N. R. (2006). Neuro-ophthalmologic manifestations of psychogenic disease. Seminars in neurology, 26(3), 310–320. https://doi.org/10.1055/s-2006-945517.
5. Ortiz-Peregrina, S., Ortiz, C., Casares-López, M., Martino, F., Granados-Delgado, P., & Anera, R. G. (2023). The Relationship between Anxiety, Visual Function, and Symptomatology in University Students. Journal of Clinical Medicine, 12(20), 6595. https://doi.org/10.3390/jcm12206595.
6. Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour research and therapy, 38(4), 319–345. https://doi.org/10.1016/s0005-7967(99)00123-0.
7. Bryant, R. A., & Harvey, A. G. (1996). Visual imagery in posttraumatic stress disorder. Journal of traumatic stress, 9(3), 613–619. https://doi.org/10.1007/BF02103670.