Involuntary Visual Imagery

I’ve become interested in the topic of involuntary visual imagery because of my own recent experiences. After my partner died of cancer, I’ve had periodic episodes of involuntary visual imagery (akin to flashbacks) of traumatic events leading up to her death. I’ve also had images of places appear for no apparent reason. The places themselves are neutral, but in the context of loss they become fraught with distress. {As an aside, I have vivid auditory imagery of popular songs which can play in my head with high fidelity.}

Today I was reviewing a paper, with a song playing in my mind in the background (Save a Prayer by Duran Duran, which I had heard a few days before). It’s a sad song, but I was managing the workload just fine. Then an image of driving onto the on-ramp of the Second Narrows Bridge appeared in my head and totally derailed me1. The view wasn’t from the car, like I was driving, but more from above (a bird’s eye view), like a detached observer fixed in mid-air. It reminded me of all the travel to a city I may not see again (especially of all the trips back and forth during the last months).

Last week, I was writing a report at work, and suddenly a vivid image of standing across the street from the BC Cancer Agency appeared. My partner had 6 weeks of radiation there in 2015. This was even more upsetting, for obvious reasons.2

Derealization

This isn’t a new phenomenon for me, although the current level of distress is novel. I have very strong memories of significant places, and sometimes an image of a specific location from my past springs to mind for no apparent reason. These visual images can be accompanied by a sense of derealization, a subjective alteration in my perception of the outside world. Revisiting these old places from childhood was disorienting:

I went on this trip once, back to my hometown after a long absence. Have you ever felt that your surroundings seem odd and distant, and that you’re completely detached from them? That the things and places around you aren’t real? This can happen to me, on occasion.

It did on this trip, perhaps because I’ve dreamed about those places so many times that the real places and the dream places are blurred in memory.

Visual imagery can be an elusive phenomenon to study scientifically, but there’s a solid literature that I’ll eventually review. A recent fMRI experiment examined the neural correlates of visual imagery vividnesss, and the authors reviewed 11 previous papers on the topic (Fulford et al., 2018). An early study found that visual imagery ability may be associated with flashbacks in post-traumatic stress disorder (Bryant & Harvey, 1996). I recently speculated that individuals with both (the inability to form mental images) and PTSD must not have visual flashbacks.

Seven years ago, I wrote a grant that was mercilessly rejected (one of many); the only section of the proposal that the reviewers liked was on imagery. So I’ll retrieve that file, dust off the virtual cobwebs, and perhaps look at the approach with a fresh set of eyes (so to speak). A bleary set of eyes is more a more apt description…

 

ADDENDUM Jan 17 2019 (2:22AM): I didn’t mention that the image below came to mind while I was writing this post. These sorts of situations, when you’re preoccupied with doing something else like reading and writing, aren’t the most conducive conditions to voluntarily imagining a visual scene or recalling a visual autobiographical memory. And yet there it was, Phibbs Exchange, appearing without warning or conscious thought.

Question for the readers: Do any of you experience involuntary visual imagery, whether confined to visual images alone or incorporating other sensory modalities (e.g., hearing, smell, touch)?

 

Footnotes

1 We were in a long-distance relationship that involved travel between Vancouver and California. I’ve taken great pains to find images on Google Maps that are the closest to those conjured up by my mind.

2 She was told she was “cured” several months after that, which clearly was not the case. Imaging the liver in all those subsequent CT/MRI screenings was not part of their “protocol” (despite suspicious early results, and despite the fact that the liver is the most likely site of metastasis). So you can see why imagery of staring at that building was quite upsetting.

References

Bryant RA, Harvey AG. (1996). Visual imagery in posttraumatic stress disorder. J Trauma Stress. 9(3):613-9.

Fulford J, Milton F, Salas D, Smith A, Simler A, Winlove C, Zeman A. (2018). The neural correlates of visual imagery vividness–An fMRI study and literature review. Cortex 105:26-40.

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How to Reconstruct Your Life After a Major Loss

I titled this post as if this is something I’m doing (I’m not). Or that I know how to address in a didactic way (I don’t). Some of you may know that my partner died recently. “It hasn’t been long,” you say, a little over two months. And that’s true. “Go easy on yourself.”

I returned to work three weeks later. Was that too early? Within the first two days I was faced with e-mails and deadlines and meetings that were overwhelming, and the assumption was that I was operating at normal capacity. Far from it. I couldn’t (and still can’t) handle stress very well. I’d go home and cry, which would only worsen my grief.

Or maybe it wasn’t too early. Having structure and routine and simple tasks and a low stress environment might be a good thing. Although I’m finding it nearly impossible to keep up with the workload, I have accomplished a surprising amount. “Your resilience is inspiring,” a kind and supportive co-worker said, but they don’t see me when my grief is intolerable, because I stay home those days.

It has been exceptionally hard to write, and this has been true for over a year. My partner was diagnosed with stage 4 cancer on October 4, 2017 and died on October 2, 2018. “It was a long goodbye,” said one friend. Until it wasn’t.

My partner’s decline was precipitous and unexpected, or at least not predicted by any medical professional at the hospice. One nurse even said it was a gradual decline, which was clearly not the case, according to close observers. You see, a major issue was that we didn’t live in the same city. Although I traveled there five times in the last two months, I ended up plagued with guilt because we were supposed to have weeks together on my last visit. And we didn’t. Nothing went as planned (or at least, according to the doctors’ vague prognostic indicators…).

The National Institute of Nursing Research (NINR), part of NIH, has issued an important funding opportunity on End-of-Life and Palliative Care Approaches to Advanced Signs and Symptoms (PAR-19-045). I’ll write about that in another post. I know, I know, “out of scope” for this blog.

Grief make life seem pointless. Why go on? Why care about that grant I should be writing? It’s meaningless. When you lose everything, nothing else matters.

Derealization / Dying

Derealization is a subjective alteration in one’s perception or experience of the outside world. The pervasive unreality of the external environment is a key feature, along with emotional blunting. The world loses its vividness, coloring, and tone.

I’ve spent much of the last year walking around in a fog, hazy, underwater, under glass, where nothing is real. This isn’t happening.

My partner has end-stage cancer, and was transferred from Acute Care to the Palliative Care Ward about 3 weeks ago. I was standing there, just staring at her while she slept in a hospital bed, knowing where we were and who I was and yet, the scene was surreal. Detached from my real life. Like flowing curtains.

Then her psychiatrist walked in, and suddenly everything was real. I started sobbing at the horrible reality of what was happening, and what will happen.

People speak, I’ve no reply

I’m empty inside

But for the incessant screaming

Which refuses to subside

–Single Gun Theory, I’ve Been Dying

Less than a week later, she was transferred to hospice.

I’ve been dying a long time

Down on my knees

There’s no way out of here

I’ve been dying a long time

Can’t seem to pick up the pieces of my life

–Single Gun Theory, I’ve Been Dying

Single Gun Theory were an Australian band who sampled from myriad sources, including Robert Oppenheimer, Natalie Wood, spoken word samples recorded in India, Turkey, and Southeast Asia (e.g., Islamic call to prayer, recitation of the Qur’an, Indian female vocals), and The Twilight Zone.

Twelve months ago to the moment you destroyed yourself

Much as I told you you would

{sampled from The Silence, Season 2, Episode 25 of The Twilight Zone}

Nearly a year ago, Sandra was diagnosed with stage 4 cancer. I tried for 7 months to enroll her in a clinical trial, to no avail. I wrote about how hard that was, and what was wrong with the cancer clinical trials systems in both the US and Canada.

[That] post [was] my own personalized rant about the false promises of personalized medicine. … It [was] about oncology, for very personal reasons: misery, frustration, and grief. After seven months of research on immunotherapy clinical trials, I couldn’t find a single one in either Canada or the US that would enroll my partner with stage 4 cancer. For arbitrary reasons, for financial reasons, because it’s not the “right” kind of cancer, because the tumor’s too rare, because it’s too common, because of unlisted exclusionary criteria, because one trial will not accept the genomic testing done for another trial. Because of endless waiting and bureaucracy.

But somehow, I’ll have to go on without her. Sandra was very active in suicide prevention efforts on social media, as @unsuicide and with her Online Suicide Help wiki so there you go.

September 10 was World Suicide Prevention Day, and Dr. Erin Michalak of CREST.BD wrote a touching tribute to Sandra’s work.

Sandra Dawson’s Legacy

. . .

Most significantly, Sandra created the Unsuicide directory of online and mobile crisis supports, as well as a popular corresponding Twitter feed (@Unsuicide) with close to 25,000 followers. Her Unsuicide online supports are authentically grounded in her lived experience of bipolar disorder, but also unfailingly focused on helping people, regardless of their geography, to access credible and safe online and mobile support tools. In 2016, she was awarded the Sovereign’s Medal for Volunteers from the Governor General of Canada in acknowledgement of the impact of her work as an advocate for people facing mental health challenges and in suicide prevention.

Samuel Beckett, The Unnameable

It will be I? It will be the silence, where I am? I don’t know, I’ll never know: in the silence you don’t know.

You must go on.

I can’t go on.

I’ll go on.

Opium for Separation Distress in Victorian-era Infants

Infant's Delight Mother's Joy

“I haven’t heard that morphine or buprenorphine is recommended for human babies who cry persistently and excessively,” I declared in a post about Opioid Drugs for Mental Anguish on my main blog.

Silly me! In a comment on the post, Ray Davis said…

An earlier generation of field-researchers found it quite (and sometimes permanently) effective: http://www.victorianweb.org/science/health/health4.html

The article on Opium and Infant Mortality states:

Medical officers were convinced that one of the major causes of infant mortality was the widespread practice of giving children narcotics, especially opium, to quieten them. At 1d an ounce laudanum was cheap enough — about the price of a pint of beer — and its sale was totally unregulated unitl late in the century.

Indeed, the New York Times of 1879 reported a terrible opium poisoning that caused the death of a one year old child.

Opium - The Cause of a Child's Death

 

There were other dangerous “soothing” products of the day with quaint and reassuring ads. One can imagine that administration of these potions was not limited to teething and bowel complaints. The U.S. National Library of Medicine has a lovely collection of these.

Baby Ease

 

The Quack Doctor has a great post on Atkinson & Barker’s Royal Infants’ Preservative, which “has been acknowledged the best medicine in the world.” Ingredients included 1 dr. Laudanum, an old-timey tincture of opium.

Atkinson's and Barker's Royal Infants Preservative

Six drops of this fine medicine was enough to kill a six week old baby in 1886.

Lest you think that in the modern era, we know better than to poison our children with such foolish remedies, there was a recall of a dangerous product in 2009. The recall was “in response to a reported case of potassium bromide poisoning in an infant, associated with the use of a locally purchased teething product.”

The name of this product? Monell’s Teething Cordial (Cordial de Monell para la Dentición).

Monell's teething cordial 2009

I’m a Lumberjack

Image

The eighth and final season of the hit series Dexter took a scientific look at serial killers. Dr. Evelyn Vogel, a neuropsychiatrist who wrote the definitive book on the brains of psychopaths, consulted with Miami Metro Homicide on a series of unusual cases. The killer would saw open the skull and scoop out the “empathetic” part of the brain (the anterior insula) with a melon baller. The most brutal of these murders occurred while the victim was alive and awake.

Dr. Vogel was ultimately killed by the “Brain Surgeon” who turned out to be her own psychopathic son (presumed dead for over 25 years; he faked his death by starting a fire in the asylum where he was housed).

But now the show has ended in a most unsatisfying way. The reasons for this are succinctly captured in the tweet below. Our favorite serial killer lives on, but in an unexpectedly isolated and self-punishing way after (you guessed it) faking his own death and moving far away from his son and girlfriend.

In an interview, Jennifer Carpenter, the actress who played Dexter’s sister Deb, had this to say about the end of the series (where her character dies due to a horrible mistake in her brother’s judgment):

“I’m picturing an older model television where you have to get up to turn the TV off and then it slips into that tiny little dot until it’s all gone — that’s what I feel like is happening to me.”

It’s a great interview from an actress who got better and better as the series progressed. I always thought of Deb as the most traumatized woman on television.

Finally, here’s an alternate ending from an executive producer who left the show after four seasons:

“In the very last scene of the series,” Philips explained, “Dexter wakes up. And everybody is going to think, ‘Oh, it was a dream.’ And then the camera pulls back and back and back and then we realize, ‘No, it’s not a dream.’ Dexter’s opening his eyes and he’s on the execution table at the Florida Penitentiary. They’re just starting to administer the drugs and he looks out through the window to the observation gallery.

“And in the gallery are all the people that Dexter killed—including the Trinity Killer and the Ice Truck Killer (his brother Rudy), LaGuerta who he was responsible killing, Doakes who he’s arguably responsible for, Rita, who he’s arguably responsible for, Lila. All the big deaths, and also whoever the weekly episodic kills were. They are all there.

“That’s what I envisioned for the ending of Dexter. That everything we’ve seen over the past eight seasons has happened in the several seconds from the time they start Dexter’s execution to the time they finish the execution and he dies.  Literally, his life flashed before his eyes as he was about to die. I think it would have been a great, epic, very satisfying conclusion.”

The Melancholia of Kirsten Dunst and Lars von Trier

Melancholia_gray_wool_dunst

“Gray wool, clinging to my legs, it’s heavy to carry along”

The disastrous wedding reception of the severely depressed Justine precedes the end of the world, depicted as a highly stylized and artistic event feared by some but welcomed by others. Kirsten Dunst plays the role of von Trier‘s own melancholia, which was the inspiration for his film.

The image above occurred out of context, at the very beginning, during the bombastic Wagnerian apocalyptic prelude to Part One, “Justine” and Part 2, “Claire.” We don’t hear Justine say those words until later, when she had lost the ability to care for herself. “She should be hospitalized,” I thought at the time, and wondered why no one was getting her psychiatric help. But then we wouldn’t have a movie that deals with internal struggle and suffering.

Melancholia is also the name of the giant blue planet that destroys the Earth.

Melancholia_the_planet

A beautiful movie about the end of the world

DIRECTORS STATEMENT

It was like waking from a dream: my producer showed me a suggestion for a poster. “What is that?” I ask. ”It’s a film you’ve made!” she replies. ”I hope not,” I stammer. Trailers are shown … stills … it looks like shit. I’m shaken.

Don’t get me wrong … I’ve worked on the film for two years. With great pleasure. But perhaps I’ve deceived myself. Let myself be tempted. Not that anyone has done anything wrong … on the contrary, everybody has worked loyally and with talent toward the goal defined by me alone. But when my producer presents me with the cold facts, a shiver runs down my spine.

This is cream on cream. A woman’s film! I feel ready to reject the film like a wrongly transplanted organ.

But what was it I wanted? With a state of mind as my starting point, I desired to dive headlong into the abyss of German romanticism. Wagner in spades. That much I know. But is that not just another way of expressing defeat? Defeat to the lowest of cinematic common denominators? Romance is abused in all sorts of endlessly dull ways in mainstream products.

Lars von Trier, Copenhagen, April 13, 2011.

 

Melancholia_movie_poster

Celebration of Trauma

Series2_jts
“here’s the plan: don’t go out of your backyard”

 

Why do people memorialize individual grief and collective tragedy? A father’s death, the national trauma of 9/11, your anniversary with an ex, an unfortunate medical diagnosis, the date of a breakup or a betrayal. 

tempting to finish this disaster under midnight sun
hope, gin

so you’re not lucky
you look a little thin
burdened

your courage wasted time
your courage and mine

lay down your arms
you were plenty strong

i’ve heard enough of your howling
say you succumb
are you completely numb?

your gentle aftershock shock
your fragile aftershock shock

-Kristin Hersh, Ginhttps://www.kristinhersh.com/gin/

The Journal of Traumatic Stress has a special 10 year issue on “9/11 trauma studies”:

Special Section: The September 11, 2001 Terrorist Attacks: Ten Years After

  1. Media use by children and adolescents from New York City 6 months after the WTC attack
  2. Shared traumatic stress and the long-term impact of 9/11 on Manhattan clinicians
  3. Predictors of the impact of the September 11th terrorist attacks on victims of intimate partner violence
  4.  PTSD and alcohol use after the World Trade Center attacks: A longitudinal study
  5.  Adolescent exposure to the World Trade Center attacks, PTSD symptomatology, and suicidal ideation
  6. Alterations in affective processing of attack images following September 11, 2001
Editorial by Daniel S. Weiss

The September 11, 2001 terrorist attacks: Ten years after 

This issue of the Journal of Traumatic Stress contains a special section on the consequences of the terrorist attacks on the World Trade Center (WTC) in New York City and the Pentagon in Washington, DC that occurred on Tuesday, September 11, 2001 (9/11). It is a truism to note that this man-made terrorist disaster fundamentally, and permanently, altered the world view of the citizens of the United States, at least those who were old enough to appreciate its meaning. For the latter, however, their world view has always included the reality of the collapsing WTC towers and its horrible aftermath. It is also fair to say that the world view of citizens of many other countries around the world was also fundamentally and permanently altered. Victims of 9/11 came from over 70 countries. As well , 9/11 propelled emergency services workers (e.g., police, firefighters, and search and rescue personnel) and the role they play in disasters into the forefront of associations with 9/11. The 9/11 attacks also increased public awareness of the psychological processes that are required to adapt to and recover from exposure to traumatic stress (e.g., Weiss, 1993) and that such processes can be, blocked, derailed, or overwhelmed.

The first article published in the Journal of Traumatic Stress that mentions the WTC appeared in the February issue of Volume 15, which was published in 2002 (Koplewicz, Vogel, & Gallagher); ironically it was a study of the impact on children and parents of the 1993 bombing of the WTC, gathering data 3 and 9 months following exposure. The findings of this study were prescient for what was to follow involving the WTC only 8 years later. Exposed children reported symptoms of posttraumatic stress disorder (PTSD) and disaster-related fears; their parents reported their own symptoms of PTSD. The children did not report a decrease in symptoms at 9 months, although their parents did. The initial distress of the children was predictive of the parents’ status at 9 months.

The first paper about 9/11 published in JTS appeared 21 months after the attacks themselves (Boscarino, Galea, Ahern, Resnick, & Vlahov, 2003). Since then, there have 27 other papers in JTS describing the etiology, prevention, risk or protective factors, epidemiology, course, treatment, and recovery from exposure to 9/11, not including those in the special section. The scientific literature on 9/11 is large. As of June 2011, the PILOTS (Published International Literature on Traumatic Stress) database of the National Center for PTSD lists 518 peer-reviewed entries, and 788 of all types. The earliest are reviews, case studies, editorials, and public service and health presentations (e.g., Stephenson, 2001). It is not until the beginning of 2002 that empirical papers appeared (e.g., Galea et al., 2002).

The articles in the special section build on that legacy, and will be part of a major expansion of the 9/11 literature as many other journals will be publishing special sections or issues commemorating the 10th anniversary of 9/11. It will be of interest to observe how large that contribution will be. The content in the special section is diverse, comprising among others, the impact of potential genetic vulnerability (Holman, Lucas-Thompson, & Lu, this issue), longitudinal findings for disaster workers (Cukor et al., this issue), suicidal ideation in children (Chemtob, Madan, Berger, & Abramovitz, this issue), and exploration of trauma response using evoked potentials (Tso, Chiu, King-Casas, & Deldin, this issue).

It would be a failure of compassion and empathy not to take note of the impact that the 10th anniversary of 9/11 will almost certainly have on the families, friends, coworkers, and acquaintances of those whose lives were lost or altered by injury or illness as a consequence of exposure to the attacks. Though it is well established that acute responses ebb over time, it is also well established that anniversaries are times when the pain of loss is more sensitive. One of the most well-established findings in the PTSD literature is the positive role of social support (e.g., Ozer, Best, Lipsey, & Weiss, 2003). As we consider what we have learned from the study of the consequences of 9/11, we might well consider providing support to those who could benefit from it.