Reduced Alpha Wave EEG Measures in PTSD After Narrative Virtual Reality Art Making

Abstract

The purpose of this study is to examine the relationship between the use of therapeutic visual-motor activity in narrative virtual reality art making and the reduced alpha wave EEG levels in post-traumatic stress disorder patients. These measured effects on alpha waves present in Functional Connectivity (FC) within the cortical brain network appear when reactivation occurs. Since the relationship between the use of therapeutic visual-motor activity in narrative virtual reality art making (using technology) has been seen as having a correlation to the reduced alpha wave EEG levels in post-traumatic stress disorder patients, a research study can be implemented in phases to develop a scheme for introducing PTSD patients to this therapy. The measured effects on alpha waves during activation of FC within the cortical brain network may be used to finally measure improvement of a condition after art making has occurred. This would be a significant measure since scoring perception of improvement has been hypothetical up until recent investigations.

Full text

RUNNUNG HEAD: REDUCED ALPHA WAVE EEG IN PTSD AFTER
VIRTUAL REALITY ART MAKING
Reduced Alpha Wave EEG Measures in PTSD
After Narrative Virtual Reality Art Making
A research proposal prepared
in partial fulfillment of the requirements for the
Master’s Degree in Art Therapy Counseling
at
Edinboro University of Pennsylvania
Prepared by
Sandra Lee Gaskell

REDUCED ALPHA WAVE EEG IN PTSD AFTER
VIRTUAL REALITY ART MAKING
Abstract
The purpose of this study is to examine the relationship between the use of therapeutic
visual-motor activity in narrative virtual reality art making and the reduced alpha wave EEG
levels in post-traumatic stress disorder patients. These measured effects on alpha waves present
in Functional Connectivity (FC) within the cortical brain network appear when reactivation
occurs. Since the relationship between the use of therapeutic visual-motor activity in narrative
virtual reality art making (using technology ) has been seen as having a correlation to the reduced
alpha wave EEG levels in post-traumatic stress disorder patients, a research study can be
implemented in phases to develop a scheme for introducing PTSD patients to this therapy. The
measured effects on alpha waves during activation of FC within the cortical brain network may
be used to finally measure improvement of a condition after art making has occurred. This would
be a significant measure since scoring perception of improvement has been hypothetical up until
recent investigations.

REDUCED ALPHA WAVE EEG IN PTSD AFTER
VIRTUAL REALITY ART MAKING

REDUCED ALPHA WAVE EEG IN PTSD AFTER
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Table of Contents
Table of Contents i
Introduction 1
Statement of Problem 4
Purpose of the Study 9
Research Question 9
Significance of the Study 10
Theoretical Framework 11
Definition of Terms 12
Literature Review 22
Posttraumatic Stress Disorder 23
Cortical Brain Network 25
Functional Connectivity 26
Fear Emotions Memory Activation 29
EEG 31
Alpha Waves 33
Graphic Narratives 35
Art Materials 2-Dimensional 36
Virtual Reality 37
Standardized Assessments: Psychological and Art Therapy 49
Art Materials Virtual 41
Methodology 43
Research Design 43
Sample 44
Procedures 46
Data 47
Limitations 48
References 49

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CHAPTER ONE
Introduction
Art making that decreases the symptoms of a person suffering from Posttraumatic Stress
Disorder (PTSD) may be measured to show improvement. When changes of cortical activity
after art making is measured in isolation it can provide proof of a method for reducing
reactivation of traumatic memories. To date, measuring the results of art making when compared
to rote motor tasks has isolated cortical network electrical evidence (King, Knapp, Shaikh, LI,
Sabau, Pascuzzi, and Osburn, 2017). Identifying the cortical brain networks, the source of a
reactivation event in PTSD, and the use of art making to reduce the symptoms of PTSD are
proposed as a viable method of reducing the elevated alpha waves in PTSD resting state. It has
been shown that cortical activity change after art making can be measured when compared to
basic rote motor tasks with the ability to isolate this activity (King, et al., 2017). The cortical
brain networks related to the activation of the brain during episodes of post-traumatic stress
disorder have also been mapped using electroencephalogram (EEG), and in recent studies, this
pathway has been roughly defined as using Functional Connectivity (FC) of the cortical brain
network activated during trauma (Shim, Im, and Lee, 2017).
Within the studies of patients suffering from PTSD the causes of the disorder and the
types of trauma experienced have been hypothesized to be a determining factor in the pathway or
network activation that the response takes. In order to measure the improvement of a PTSD cycle
of reactivation, there are a number of factors which need to be explored. In the DSM V there are
specific types of PTSD, there are entry points for the triggering information (hearing, vision, or a
set of circumstances), there are genetic or chemical features, there are levels of memory and
attention. The main feature of PTSD is the activation of the hyperarousal and hypervigilance

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response exhibited through startle response and a heightened fear potential. The most disturbing
factors to the patient suffering from PTSD are that the memory of the incidence is buried deep in
memory, sometimes subconsciously, with no certainty of when the reaction will be triggered. For
each type of trauma experienced by the individual, there have been a number of treatments
developed to reduce the impact of the disorder.
Some of the earliest art therapy during psychological evaluation has been used to unlock
memory. During early research, Wadeson (2016) described how patients suffering from trauma
“evidenced a significant decrease in activation in Broca’s area of the frontal lobe” during an
exercise in recalling traumatic experiences (Gussak and Rosal, 2016, p. 123). According to
Howie (2016), the nature of the traumatic memories “exist as dissociated emotional perceptual,
or sensory fragments” meaning that the patient has tremendous difficulty pulling together a
“coherent trauma narrative” using verbal responses (Gussak and Rosal, 2016, p. 375). These
memories, though fragmented due to the difficulties of short term memory to encode, appear as a
series of disjointed pictures and create an inability to reconstruct a declarative description of the
memory.
Theoretical frameworks in art therapy had their beginnings within psychological
projective assessments shortly after the World Wars with art being a component of psychological
rehabilitation. In the 1970s an art therapist Vija B. Lusebrink in the Bay Area of California was
working with hospital psychiatric patients and began noting the correlation between the tactile
qualities and the responses of the patients during therapy. Using the foundations of theories
found in the dynamically oriented art therapy (Naumburg, 1953, 1966), and Gestalt Art Therapy
(Rhyne, 1973), Lusebrink (2004) was able to lend an explanation to the changes in patient
behaviors during art therapy based in brain neuroplasticity. Many of her patients were suffering

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from non-verbal disorders due to brain injury or psychological disorders such as PTSD. The
theoretical approach known as the Expressive Therapies Continuum is based on a continuum
between two opposite poles having three levels reflecting a progression from simple to complex
levels of information processing. These three polar opposite levels play a balancing act of
function and expression to where the center line between the poles represents balance, or
creativity of the individual (Lusebrink, 2010).
The central feature of the levels of the Expressive Therapies Continuum (ETC) is that the
levels reflect an outward demonstration of the internal synapsing of the cortical brain network in
a FC as a patient works through a disorder. The sequence of the three levels a)
kinesthetic/sensory, b) perceptual/affective, and c) cognitive/symbolic relate to how an art
medium affects the brain while using the material. After understanding the effects textures,
colors, fluidity, and all of the properties of an art material, a methodology for determining how
an individual will interact with an art medium can be understood through the Media Dimensions
Variable (MDV) which over the years has defined how each element of the materials will impact
the patient (Lusebrink, 1990). Each material affects or stimulates a particular part of the brain;
therefore it is necessary to have an in-depth knowledge of neuroscience to be able to judge how
the properties of art therapy affect the symptom load of the person with PTSD. This is an
understanding of how a texture or image can ignite a startle response symptom in a patient with
PTSD, or to initiate a response based upon a texture or property. We know through experimental
studies that auditory and visual stimulus has been measured using EEG as triggering such
symptoms. Although this is true, we have not truly isolated a pathway for a cure.
The National Institute of Health (NIH.gov, 2018) summarizes the current treatments
available for the list of symptoms. Symptoms appear during and following a traumatic or fearful

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event when the autonomic response to flee or fight has been triggered causing the response to the
fear. This response is characterized by a series of elevated blood pressure, a startle reflex, and
depending on the type of incident, there could be physical injury culminating in a memory of a
horrific event that may be blocked. Over the following weeks, sleeplessness, bad dreams,
flashbacks, physical symptoms of racing heart or sweating, and many times a lack of the memory
of the reason for these symptoms. Trouble remembering the traumatic event but not
understanding why the individual has these negative feelings begins to compound over time and
cause cognition and mood problems. New research in neuropathology has shown some
indications of brain injury if cycling persists.
Statement of the Problem
The Topic. Questions relating to the relationship between the subconscious regions of
the brain may be answered through looking at the current treatment approaches used by
psychologists and therapists. During activation, the alpha waves have been used as a baseline
measure of the various brain networks which have been uncovered. Having reviewed the
literature regarding the non-verbal aspects of the dysregulation, and some progress has been
made when using therapies such as; exposure therapy (visual), Graphic Narrative Processing
(motor and visual), cognitive processing, prolonged exposure, virtual reality art therapy, eye
movement desensitization for reprocessing, stress inoculation training or medications, the
combination of motor activity, visual exposure, and memory regression used singularly or in
combination during art making.
Art therapy counseling has been effective in treating PTSD. Standardization in traditional
artistic media use during art making has been collected over the historic development of the
psychological use of art making. Over the years, two assessments have garnered the most

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objective measures for differential diagnosis in the field of art therapy known as the Diagnostic
Drawing Series (Cohen, 1986/1994), and the Person Picking an Apple From a Tree (PPAT) with
the scoring mechanism, the Formal Elements Art Therapy Scale (FEATS) (Gantt, 1998). With
the advent of digital media, the new artform began to change the way art was produced and
broadened the range and use of computer technology in therapy (Malchiodi, 2017). When
animation and filmmaking advanced with the first virtual reality goggles (Lanier, 1987) and then
using blue screen and special effects, the utilitarian purposes behind virtual reality became
modified for use as a therapeutic tool. Although both of these artistic mediums are used in
narrative art making and art therapy, the implicit spatial differences in attributes between the two
artforms create comparable impressions of neural responses. One can provide distance and
weightlessness in space (Lohrius, 2018), while the other is grounded in reality and gravity with
true tactile qualities (Moon, 2010).
The prevalence of posttraumatic stress disorder according to the National Center for
PTSD of the U.S. Department of Veterans Affairs (https://www.ptsd.va.gov/public/PTSD-
overview/basics/how-common-is-ptsd.asp, 2018) is more common than believed since it can
occur after an accident, physical assault, a natural disaster such as a forest fire or flood, from
combat or by witnessing a death or violent incident. For men there can be six out of every ten
men, and for women it can be five out of every ten women who have experienced some
symptoms of PTSD. Over a lifetime, ten out of every hundred women and four out of every
hundred men will experience PTSD at one time in their lives. The epidemiology of PTSD shows
a higher likelihood of men in the military with various measures depending on which war or
theatre the veteran experienced.

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There are also exposure ratings for persons experiencing the effects of the many
symptoms. When the trauma was a one-time event the severity of the event contributes to the
frequency of the symptoms. When the trauma is on-going such as physical abuse of a child or
spouse, or during a catastrophic event of war or natural disaster, the trauma creates a pattern of
survival and development of coping mechanisms. The mental health implications of the
frequency of the reactivation of the startling memories may seem to never end. The fear of the
unknown or the fear of not knowing when something will trigger a hyperarousal causing aberrant
behavior can interfere with typical functional abilities. Treatment for PTSD has become less
stigmatized with current developments in medications and psychotherapy. One aspect of PTSD
during the reactivation of a blocked memory is a phase of the reaction where verbal abilities are
blocked and the sufferer cannot explain to anyone what happened or why it happened. In these
cases, forms of talk therapy are ineffective (Talwar, 2007). Visual images or drawings made by
the PTSD sufferer have been shown to alleviate some of the symptoms (Metz, 2017).
The Problem. Common to individuals suffering from PTSD is a memory block which
can occur at any time which coincides with a period of non-verbal lack of ability to communicate
using language. In such cases the intuitive art therapist has been able to use visual means of
expression to bring out communicative ability. According to Malchiodi, “Traumatic memories
that cannot be articulated with words, remain at a symbolic level and in order to retrieve them
from implicit memory, they must be externalized in symbolic forms such as images” as seen in
art therapy (Malchiodi, 2012). The art therapy techniques which access memory at levels of the
brain affected by a traumatic event have shown improvement for patients, but this improvement
has not been measured or explained in terms of a formal standard.

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In the literature regarding the traumatic reactivation of a fearful memory and the types of
treatments available, the most effective therapies have been the treatments which afford a level
of calm or respite away from the memory of the trauma while attempting to revisit the event.
Memory recovery requires that the parasympathetic system remains lowered in order to allow
portions of the memory to surface, even if the sections of memory do not match a sequence.
When looking at the differences between the physical art medium in retrieving memories
in PTSD patients and the virtual reality tools for art making, there are various studies using art
therapy with PTSD, but there are limited accounts of using virtual reality painting tools unless
they were used in exposure therapy or video reenactment therapy. The literature to review can
show the effects of the hands-on with tactile mediums and the progress made, but with the virtual
art materials the data will show the use as a presentation model for visual stimulus during
therapy not directly related to art therapy. Since the distance and weightlessness in space
(Lohrius, 2018) is an inherent property in the virtual display of stimulus in other forms of
psychological therapy using virtual reality, there is little evidence of data reported for the results
of virtual narrative art making in treatment of PTSD. Art materials and medium grounded in
reality and gravity with differing tactile qualities have been used in previously reported
standardized art therapy assessments with patients suffering from PTSD (Moon, 2010).
Evidence of the Problem. Given the prevalence factors from the NIH and the DSM V
representing our culture attributing 80% of the general population confronting severe adverse life
events, it was estimated that of these, 7% of them over the lifetime will experience PTSD
symptoms (Bangel, Bushbach,Smit, Mazaheri, and Olff, 2017). Recent literature has provided
some evidence of possible brain injury if the PTSD goes for a prolonged period of time without
treatment where it can cause physical changes or flattening or grooves on the brain tissue. Dr.

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Daniel Perl, a military neuropathologist, has examined the brain tissue of a veteran and observed
“brown, dust-like pattern scars in areas” of the brain “corresponding to sleep and cognition” and
in another soldier’s tissues found corresponding scars in the same locations (New York Times,
2016). Evidence of the physical and psychological effects of the symptoms of PTSD have been
reported for several decades, but with current technological advances, more positive treatments
have been informed. Many treatments which are being used have little empirical evidence due to
the limited ability to measure the progress without great cost.
Deficiencies in the Evidence. Academic medical teaching institutions have access to the
equipment to perform the imaging studies of the chemical activity, blood flow movement, and
neuronal activity. The positron emission tomography (PET) scan uses radioactive special dye
contrast with radioactive tracers to measure important body functions, can locate disease in
tissues, can follow blood flow, oxygen and glucose use and absorptions. Functional magnetic
resonance imaging (fMRI) measures changes in the brain by detecting change in blood flow
patterns. The common term for what fMRI measures is BOLD; blood-oxygen-level-dependent
contrast. The technology which is the most accessible for this study is the electroencephalogram
(EEG) which can measure the voltage fluctuations emitted from ionic currents activating within
the brain neurons over a period of time and measured by many electrodes at once which can be
deciphered via computer programs and interpreted. Throughout this literature review, these three
measurement tools have been the primary method of recording brain activation.
These technologies have been used during scientific studies using exposure therapy,
cognitive behavioral therapy, prolonged exposure therapy, eye movement desensitization and
reprocessing therapy, narrative exposure therapy, and medications. Recent clinical trials for
PTSD and imaging have been studying cognitive behavioral therapy and psychopharmachology,

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the efficacy of neurobiofeedback, the pathophysiology of PTSD, panic disorder, and specific
phobia by viewing the amygdalo-cortical circuitry, and vascular inflammation of the brain, and a
series of drug studies where PTSD is the main diagnosis (ClinicalTrials.gov, 2018). Although
these ongoing studies are using imaging to determine the FC of the cortical brain network of the
activation and reactivation of the trauma in PTSD, only two were actually rating efficacy of a
therapy method, and one of them without using a psychopharmacological element.
The audience. The types of persons interested in finding a practical measure of therapy
progress of symptoms of PTSD would be the sufferers of the disorder, the providers of
treatments, and those interested in isolating the FC of the cortical brain network. The non-verbal
character of PTSD and the use of narrative virtual art therapy in dosing of therapeutic
interventions would provide valuable information to physicians and therapists working with
PTSD. The use of EEG and comparative measures in studies interested in alpha wave and the
underlying neural pathways being recorded in the frequencies (8-12 Hz) may find the results of
this study informative. Although this study does not attempt to align with fMRI during the
activation of FC occurring during traumatic reactivation therapy, there may be future potential
for incorporating added measures.
Purpose of the Study
The purpose of this study is to examine the relationship between the use of therapeutic
visual-motor activity in narrative virtual reality art making and the reduced alpha wave EEG
levels in post-traumatic stress disorder patients in their cortical brain network FC.
Research Questions
The research questions this study addresses emerged from an examination of the
problem and a review of current literature on the topic of treatments available for measuring the

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reduction of the effects of PTSD reactivation events, the use of narrative virtual reality art
making, and comparing alpha brain waves while participants move through the treatment.
Finally, what is the relationship between movement during narrative art making and traumatic
memory access as measure by the EEG alpha wave levels. The researcher formulated four
guiding questions:
1. How does the use of therapeutic visual-motor activity in narrative virtual reality art
making with post-traumatic stress disorder patients effect the EEG measured alpha waves present
in FC in the cortical brain network when reactivation occurs?
2. Does alpha wave activity in the cortical brain network provide evidence of
improvement after post-traumatic stress disorder patients participate in visual-motor narrative
virtual art making?
3. When accessing memory in survivors of PTSD through narrative virtual reality art
making is there a change in alpha wave activity using EEG at the point that the fearful memory
has been reactivated?
4. Can the cortical brain network be better explained during virtual narrative art making
when recording the alpha wave changes in the areas of the amygdala, the hippocampus, and the
thalamus of survivors of PTSD?
Significance of the Study
Information gathered during the art making process by patients suffering from traumatic
flashbacks, bad dreams, and traumatic panic responses to unresolved memory can be used to
improve the lives of these patients. In the field of Art Therapy the means for providing proof of
improvement has been in question over the decades being left to the intuition of the provider and
the patient. Only few standardized measures have been accomplished using visual stimulus in

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various forms and protocols and relating to only a hand full of DSM V disorders. By having
empirical evidence of the reduction of the alpha waves after the dosage is completed for all of
the art therapy sessions, there can be a measureable effect correlated between the activity and the
improvement.
This preliminary study can be used as a basis for increasing the comparative studies
between other methods of art therapy mediums, with the ability to compare them with each
other. During the studies of emotional response and heart rate during art therapy, Haiblum-
Itskovitch and Czamanski-Cohen (2018) were able to use EEG to measure emotional valance
while comparing the heart rate and emotion during the use of tangible art materials in art therapy.
There has not been a beginning study of virtual reality art therapy interventions in peer review
even though the medium has been available since the 1970s. With advanced and less expensive
technology creating a data trail for this medium it can be used in other forms of therapy during
art making.
Theoretical Framework
Using a systems view of the brain processes, the framework for understanding how the
human brain functions has been described as a network for information processing through an
organic spatiotemporal pathway. This conceptual framework purports that the whole brain is
interdependent, with neuronal processes responding to neurofeedback as a means of growth or
dispersion. Charting the projection of electrical current across many areas of the brain
simultaneously is also called the information theoretical framework which is now being used to
confirm processing pathways in order to define human responses (Oswald, Porcaro, Mayhew,
and Bagshaw, 2012). This theoretical framework can be aligned with the theory behind the
Expressive Arts Therapies and the implications for how the brain structures and functions can be

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changed when exposed to art media based in the idea of the neuroplasticity of the brain
(Lusebrink, 2010).
Definition of Terms
The researcher has included more complex associations for the definitions in order to
explain the processes of PTSD and the re-experiencing traumatic events as a background for
describing how brain FC can be used to measure improvement of condition. The researcher
gathered information regarding these DSM V classifications: a) Posttraumatic Stress Disorder
(309.81 )(F43.10); b) Acute Stress Disorder (308.3 )(F43.0); c) Panic Disorder (300.01 )(F41.0) ;
d) Selective Mutism (312.23)(F94.0) ; e) Specific Phobia (300.29)(F40.298) ; which were
referenced as diagnoses throughout the literature review.
The researcher retrieved nomenclature for descriptions from related reference materials.
The following terms provide a definition of the terms used in this study so that the understanding
in context is clearly defined:
Acute Stress Disorder. is characterized by the development of severe anxiety,
dissociation, and other symptoms that occurs within one month after exposure to an extreme
traumatic stressor (e.g., witnessing a death or serious accident). As a response to the traumatic
event, the individual develops dissociative symptoms.(DSM V)
Alpha waves. are a type of brain wave that occur when a person is relaxed, but still
awake. Alpha waves typically occur when you are falling asleep, as you pass from wakefulness
into sleep (from wake into stage 1 sleep). Alpha waves have a frequency band of 8-13Hz and
although they are present since birth as your brain is developing, the earliest they are detected is
at 4 months old. They do not mature (10 waves per second) until the age of three, reaching

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maximum frequency (13 waves per second) in adolescence, and begin to gradually decrease after
young adulthood. (https://study.com/academy/lesson/alpha-waves-definition-lesson-quiz.html)
Art Materials. Traditional fine arts materials consist of any substance or compound that
is used in creating a visual image or a three dimensional item of self-expression. The most
common materials are watercolor paints, acrylic paint, colored pencils, markers, photography,
pencils, collage, and clay. Media Dimensions Variables are used to determine which level or
quality will evoke the correct response during therapy. (Moon, 2010, pg 4-5; Gussak and Rosal,
2016, p. 146-148).
Art Medium. Art medium can be used in the context of explaining the type of art being
made such as painting, drawing, printmaking or sculpture. In this explanation, art medium refers
to the category of art. Further to this broad definition, the term art medium can also apply to a
subset of art mediums. For example, if a group of acrylic painters is discussing the art mediums
they use, they can safely assume they are all referring to acrylic paints, gessos, gel mediums etc.
(https://arttherapyresources.com.au/art-mediums/)
Art Therapy Counseling. Art therapy is a form of expressive therapy that uses the
creative process of making art to improve a person’s physical, mental, and emotional well-being.
(http://www.arttherapyblog.com/what-is-art-therapy/#definition)
Blocked memory. A memory that is repressed because of the anxiety it engenders. An
event that occurred in a subject's past, the memory of which was actively repressed often because
of the psychologically devastating impact of that memory–eg, childhood abuse, rape,
molestation. (https://medicaldictionary.thefreedictionary.com/repressed+memory)
Chemical features. Psychopharmacology is the study and use of medications that affect
thought or behavior. The benefit sought from prescription psychoactive agents is the lessening in

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symptoms of mental or mood disorders, whether acute or chronic in nature. Chemical signatures
in the brain and the therapeutic use of drugs follows a classification system found in the
Anatomical Therapeutic Chemical Classification System.
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3957075/)
Cognitive processing. Cognitive processing therapy (CPT) is a specific type of cognitive
behavioral therapy that has been effective in reducing symptoms of PTSD that have developed
after experiencing a variety of traumatic events including child abuse, combat, rape and natural
disasters. CPT is generally delivered over 12 sessions and helps patients learn how to challenge
and modify unhelpful beliefs related to the trauma. In so doing, the patient creates a new
understanding and conceptualization of the traumatic event so that it reduces its ongoing
negative effects on current life. This treatment is strongly recommended for the treatment of
PTSD. (https://www.apa.org/ptsdguideline/treatments/cognitive-processing-therapy.aspx)
Cortical brain networks. FC in some brain regions, including the amygdala, anterior
cingulate cortex (ACC) and medial prefrontal cortex in patients with PTSD are the cortical brain
network elements related to people with sufferers of PTSD.
(https://www.nature.com/articles/tp2017200). PTSD has been associated with hyperactivity of
limbic brain regions, such as the amygdala, and hypo-activity of brain areas involved in emo-
tional regulation, such as the ventromedial prefrontal cortex (vmPFC); (Liberzon and Sripada,
2007; Rauch et al., 2006). After literature review showed numerous pathways within this
topology range, the cortical brain networks may be different in various types and severity of the
types of PTSD.

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Diagnostic Drawing Series. this art therapy assessment was designed to link picture
analysis to DSM VI diagnoses. It assesses an individual’s response to structured and unstructured
drawing tasks with the interpretation was based on a rating guide 23 categories for rating.
Digital media. Digitized content (text, graphics, audio, and video) that can be transmitted
over internet or computer networks. (http://www.businessdictionary.com/definition/digital-
media.html)
Dosing.
A specified quantity of a therapeutic agent, such as a drug, prescribed to be taken
at one time or at stated intervals. (http://www.dictionary.com/browse/dosing)
Electroencephalogram (EEG). is a test that detects electrical activity in your brain using
small, metal discs (electrodes) attached to your scalp. Your brain cells communicate via
electrical impulses and are active all the time, even when you're asleep. This activity shows up as
wavy lines on an EEG recording. (https://www.mayoclinic.org/tests-procedures/eeg/about/pac-
20393875)
Exposure therapy. Practice guidelines have identified that trauma-focused
psychotherapies have the most evidence for treating PTSD. Prolonged Exposure (PE) is one type
of trauma-focused psychotherapy. PE teaches you to gradually approach trauma-related
memories, feelings, and situations that you have been avoiding since your trauma. By
confronting these challenges, you can decrease your PTSD symptoms. People with PTSD often
try to avoid anything that reminds them of the trauma. This can help you feel better in the
moment, but not in the long term. Avoiding these feelings and situations actually keeps you from
recovering from PTSD. PE works by helping you face your fears. By talking about the details of
the trauma and by confronting safe situations that you have been avoiding, you can decrease your

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symptoms of PTSD and regain more control of your life.
(https://www.ptsd.va.gov/public/treatment/therapy-med/prolonged-exposure-therapy.asp)
Eye movement desensitization for reprocessing. It is a nontraditional form of
psychotherapy designed to diminish negative feelings associated with memories of traumatic
events. Unlike most forms of talk therapy, EMDR focuses less on the traumatic event itself and
more on the disturbing emotions and symptoms that result from the event. Treatment includes a
hand motion technique used by the therapist to guide the client’s eye movements from side to
side, similar to watching a pendulum swing. The goal of EMDR is to fully process past
experiences and sort out the emotions attached to those experiences. Negative thoughts and
feelings that are no longer useful are replaced with positive thoughts and feelings that will
encourage healthier behavior and social interactions. Ultimately, clients learn to handle stressful
situations themselves. (https://www.psychologytoday.com/us/therapy-types/eye-movement-
desensitization-and-reprocessing-therapy)
Formal Elements Art Therapy Scale. The Formal Elements Art Therapy Scale
(FEATS) is a rating system designed to measure global variables in a specific drawing. This
chapter provides an overview of the FEATS and its key principles, and describes some recent
projects. The FEATS has 14 equal-appearing interval scales for rating a "Person Picking an
Apple from a Tree" (PPAT). The scales measure global variables, some of which can be applied
to other drawings, and several that are specific to the PPAT. Other variables can be measured on
nominal scales such as colors used for particular elements, clothing of the person, and action of
the person. The key principles of FEATS: numbers can be applied to drawings with considerable
precision; art tracks psychological states; and information is obtained from structure. FC. FC
refers to the functionally integrated relationship between spatially separated brain regions. FC is

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usually measured during resting state fMRI and is typically analyzed in terms of correlation,
coherence, and spatial grouping based on temporal similarities. (Power, Fair, Schlaggar, and
Peterson, 2011) (https://www.ncbi.nlm.nih.gov/pmc/articl
Functional magnetic imaging (fMRI). magnetic resonance imaging used to detect
physical changes (as of blood flow) in the brain resulting from increased neuronal activity —
called also functional MRI. (https://www.merriamwebster.com/dictionary/fMRI)
Graphic Narrative Processing. A graphic narrative processing sequence is a group of
drawings or art work used as part of a trauma drawing series. This is used to assist the patient in
reconstructing a chronological sequence of fragmented memory. (Brooke, 2006, pg 43) Creative
Arts Therapies Manual, ISBN-13: 978-0398076214 Charles Thomas publishers Springfield Ill
Hyperarousal. Medical definition is excessive arousal : an abnormal state of increased
responsiveness to stimuli that is marked by various physiological and psychological symptoms
(such as increased levels of alertness and anxiety and elevated heart rate and respiration)
(https://www.merriam-webster.com/dictionary)
Hypervigilance. is an enhanced state of sensory sensitivity accompanied by an
exaggerated intensity of behaviors whose purpose is to detect activity. An extreme or excessive
vigilance : the state of being highly or abnormally alert to potential danger or threat. A person
suffering from PTSD may have sleep disturbances, irritability, hypervigilance, heightened startle
responses and flashbacks of the original trauma. (https://www.merriam-
webster.com/dictionary/hypervigilance)
Implicit memory. Is defined as preferences, skills, and activities that can be acted on or
performed without conscious thought; motor memories of tasks that can be performed without

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conscious awareness of what is necessary to perform them. Synonym(s): nondeclarative
memory, unconscious memories. (https://medicaldictionary.thefreedictionary.com)
Mobile brain mapping. Mobile Brain / Body Imaging (MoBI) is a new imaging
modality, employing mobile brain imaging methods like the electroencephalogram (EEG) or
near infrared spectroscopy (NIRS) synchronized to motion capture and other data streams to
investigate brain activity while participants actively move in and interact with their environment.
Mobile Brain / Body Imaging allows to investigate brain dynamics accompanying more natural
cognitive and affective processes as it allows the human to interact with the environment without
restriction regarding physical movement. http://mobi2018.bpn.tu-berlin.de/
Neurobiofeedback. a technique, for dealing with brain-based functional disorders
without the use of medication or invasive procedures, in which brain activity is recorded using
electrodes and presented visually or audibly so that the patient can know the state of the function
he or she is trying to control. (https://www.collinsdictionary.com/us/dictionary/english)
Neuropathologist. Medical Definition of Neuropathologist. Neuropathologist: A
pathologist who specializes in the diagnosis of diseases of the brain and nervous system by
microscopic examination of the tissue and other means.
(
https://www.medicinenet.com)
Non-verbal. Transmission of information from person to person without the use of
words, as by gesture, bodily attitude, expression, exclamation, and so on.
(
https://medical-
dictionary.thefreedictionary.com/non-verbal+communication)
Panic disorder. anxiety disorder characterized by repeated panic attacks that leads to
persistent worry and avoidance behaviour in an attempt to prevent situations that could
precipitate an attack. Panic attacks are characterized by the unexpected, sudden onset of intense
apprehension, fear, or terror and occur without apparent cause. Panic attacks often occur in

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people with breathing disorders such as asthma and in people experiencing bereavement or
separation anxiety. (https://www.britannica.com/science/panic-disorder)
Parasympathetic system. Substances that are foreign to the atmosphere or that are
present in the natural atmosphere in concentrations that may result in adverse effects on humans,
animals, vegetation, and or materials.
Person Picking An Apple From a Tree. see The Formal Elements Art Therapy Scale
(FEATS)
Positron emission tomography (PET). Positron emission tomography, also called PET
or a PET scan, is a diagnostic examination that uses small amounts of radioactive materials
called radiotracers, a special camera and a computer to help evaluate your organ and tissue
functions. By identifying body changes at the cellular level, PET may detect the early onset of
disease before it is evident on other imaging tests.
(
https://www.radiologyinfo.org)
Posttraumatic stress disorder. Post-traumatic stress disorder (PTSD) is a mental health
condition that's triggered by a terrifying event — either experiencing it or witnessing it.
Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable
thoughts about the event. Most people who go through traumatic events may have temporary
difficulty adjusting and coping, but with time and good self-care, they usually get better. If the
symptoms get worse, last for months or even years, and interfere with your day-to-day
functioning, you may have PTSD.
(
https://www.mayoclinic.org/diseases-conditions/post-
traumatic-stress-disorder/symptoms-causes/syc-20355967)
Psychological assessments. Psychological assessment is a process of testing that uses a
combination of techniques to help arrive at some hypotheses about a person and their behavior,
personality and capabilities. Psychological assessment is also referred to as psychological

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testing, or performing a psychological battery on a person. Psychological testing is nearly always
performed by a licensed psychologist, or a psychology trainee (such as an intern). Psychologists
are the only profession that is expertly trained to perform and interpret psychological tests.
(
https://psychcentral.com/lib/what-is-psychological-assessment/)
Psychopharamacological agent. See chemical feature
Reactivation. Memory reactivation is an important process resulting from reexposure to
salient training-related information whereby a memory is brought from an inactive to an active
state. Reactivation is the first stage of memory retrieval but can result from the exposure to
salient cues without any behavioral output. Gisquet-Verrier P , Riccio DC (2012) Memory
reactivation effects independent of reconsolidation. Learn Mem 19:401–409 ,
doi:10.1101/lm.026054.112 , pmid:22904371.
Repressed memory. Is defined as past, the memory of which was actively repressed
often because of the psychologically devastating impact of that memory–eg, childhood abuse,
rape, molestation.
(
https://medical-dictionary.thefreedictionary.com/repressed+memory)
Specific phoba. DSM-5 Category: Anxiety Disorders. Introduction. Specific phobia is a
DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th ed.) diagnosis assigned to
individuals who suffer from intense fear or anxiety when exposed to specific objects or
situations.
Stress inoculation training. Therapy (SIT) is a psychotherapy method intended to help
patients prepare themselves in advance to handle stressful events successfully and with a
minimum of upset. Stress Inoculation Training is a cognitive-behavioral approach providing
people with added psychological resilience against the effects of stress through a program of

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managed successful exposure to stressful situations. The approach was developed by Donald
Meichenbaum.
(
https://www.mentalhelp.net/articles/stress-inoculation-therapy/)
Traumatic memories. the ability of the body to store memories unconsciously. It has a
sensory recollection of traumatic experiences related to pain, discomfort, tension, and arousal.
The hypothesis is that, despite infantile amnesia, the body itself experiences a sensorimotor
encoding of each traumatic event, or sensorimotor encoding.
(https://psychologydictionary.org/body-memory/)
Virtual reality. It is an artificial environment which is experienced through sensory
stimuli (such as sights and sounds) provided by a computer and in which one's actions partially
determine what happens in the environment; also : the technology used to create or access a
virtual reality. (https://www.merriam-webster.com/dictionary/virtual%20reality)
Virtual Reality Art Therapy. VR art making provides an infinite canvas of possibilities
to explore both creatively and therapeutically. As the ubiquity of digital natives becomes more
pronounced in our world, adding VR art tools to our studios and offices offers clients a medium
they can feel natural, familiar, and competent in. The ability for the virtual world to immerse you
in your art including full body gestural movement opens up realms of increased physicality,

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CHAPTER 2
LITERATURE REVIEW
During research into the possible pitfalls of this approach to recovery from PTSD,
questions arose in various areas that complicated the ability to formulate a methodology to
follow in order to have a specific approach to be able to define the reactivation and the levels of
alpha waves. Studies show that there is a common thread of activation following a pathway of
the FC of the cortical Brain network. They also show that certain triggers affect both Type I and
Type II of PTSD patients by a reactivation process affecting emotion and memory. There are few
studies where the wave lengths of EEG have been differentiated to show the alpha wave as the
elevating or reducing factor during and after a reactivation event. As research advances in the
study of the disorder of PTSD the disease is becoming better understood. Studies incorporate
measurements of heart rate along with other physiological factors when measuring alpha wave
brain activity.
While researching the FC of the segments of the brain that communicate during a PTSD
event, the disruptions in the normal patterns of synapsing have become better understood. Some
of the methods to reduce the severity of the disruptive events such as virtual reality, art therapy,
narrative writing and art making, and talk therapy have been used to describe the symptoms of
fear, anxiety, emotional; disturbance and memory loss. Although the symptomology of PTSD
has made progress in the description of the disorder, the limitations of the ability to assess
improvement has led to the use of differing psychological assessments, psychological
questionnaires, art therapy assessments, and narrative art making activities using scoring
mechanisms in order to interpret how the sufferer of PTSD perceives their healing. With the
ability to provide evidence of a reduced or stabilized alpha wave in FC during cortical brain

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network activity and then confirming this through further studies with fMRI to view the synapse
activity in real time, a process of therapy may be identified.
Posttraumatic Stress Disorder
Understanding the disorder named PTSD, the causes and the symptoms for the disease
began historically with military mental disorders going largely undetected until there were more
severe psychological difficulties. In the Diagnostic and Statistical Manual of Mental Disorders,
5
th
Edition (2013), PTSD is part of the classification for trauma and stress related disorders. This
category includes other disorders with a similar causation of an exposure to a traumatic event
resulting in a symptom cluster variable based upon the type of exposure. The symptom class
which includes anxiety-fear related defenses are mainly identified in relations to PTSD, but the
“most prominent clinical characteristics are anhedonic and dysmorphic symptoms, externalizing
angry aggressive symptoms, or dissociative symptoms” when describing the patients, DSM V
(2013, p. 265).
The specific diagnostic code for PTSD is 309.81 (F43.10) with descriptive criteria for
adults, adolescents, and children (DSM V, p. 271-274). The type of exposure and length or
severity of the exposure will determine the amount of distress experienced as symptoms develop
after the traumatic event. Whether it is psychological abuse over time, or a psychological trauma
experienced because of a catastrophe, disaster, accident, physical abuse or traumatic event
repeatedly experienced, the anticipation of the event can bring on various symptoms. According
to Yang, Oathes, Linn, Bruce, Satterthwaite, Cook, Satchell, Shou, and Sheline (2018), the
underlying neural dysfunction can lead to chronic illness and cognitive problems which have up
until now been identified as only a psychological disorder, but their findings have shown that the
biological phenomena overlap psychiatric disorders (Yang et al, 2018, p. 311). In epigenetic

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research by Ferrufino (2018) gene expression can shift when influenced by environmental stress
in animal studies, linking them to certain enzymes, and are researching proclivity toward
epigenetic prediction for symptoms of PTSD in persons, expanding research to epigenetic
enzymes which might ease anxiety or even erase traumatic memories. Ferrufino also reported
about an identified area of the “stress response pathway” the hypothalamic-pituitary-adrenal
(HPA) being influenced by reduced methylation of the glucocorticoid receptor in the peripheral
blood of veterans with PTSD which may be used to alter the trauma response.
Hyper-reactivation is a random event triggered by many factors. When this occurs, the
alpha level appears heightened. Measurements taken during recall treatment may record evidence
of improvement of severity and frequency of a trauma reactivation. The activity involved in
virtual reality narrative art making can occur in many forms through readily available device
APPs, or computer programs in conjunction with the participant wearing electrodes in a
prescribed scalp placement array for recording the alpha waves.
In order to understand the relevancy of the use of art medium realia at physical sensory
levels found in the use of traditional artistic media when compared with the new technological
features found in virtual reality, a literature review of narrative art therapy will be reviewed from
post-traumatic stress disorder treatment recorded studies. This study will begin to examine the
effect that the activity of art making over time during narrative art therapy can reduce the
symptom load of individuals experiencing the reactivation of traumatic memory, and begin to
manage the episodes of traumatic memory retrieval. The human brain experiences these memory
events in a way to cause chemical grooves to become deeper as the reactivations occur. Studies
have shown that there are physical signs on portions of the brain indicating the injury caused by
the recurrent cortisol releases during fearful reenactments.

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Cortical Brain Network
When Shim (2017) describes the symptoms of PTSD as re-experiencing, avoiding
triggers and experiencing hyperarousal, the brain regions are listed as abnormal function in the
amygdala, prefrontal cortex, anterior cingulate cortex, hippocampus, and parahippocampus. The
whole brain networks of “FC” coined by Shim have been mapped using EEG in resting state in
the brains of PTSD sufferers (Shim, et. al, 2017). Volumetric studies of some of the regions of
the brain using MRI imaging and EEG in epilepsy showed measurable atrophy and lateralization
of signal (Cendes, 1993). Amygdala asymmetry and enlargement was observed in a study where
eleven patients underwent video EEG showing amygdala enlargement during epileptic seizures,
confirming the use of EEG signals to report specific size regions of brain activity. The brain
activity of a strong sequence of synapses is a negative thing, but at these high levels the electrical
currents within the pathway of PTSD reactivation will lend power to determining the FC of the
brain pathway (McNerney, et al., 2018). McNerney et al (2018) also proposed in the results of
the neuroimaging and epigenetic study that the hippocampal volume of the specific promoter
region of the synapses of methylation biochemical analysis was a predictor of PTSD.
By tracking blood flow in PTSD brain activity, Etkin of Stanford University had 66
participants enrolled into exposure therapy with fMRI scans showing changes in activation
nearest the front of the cortex and showed a connection between the frontopolar cortex to two
other brain regions ( Fonzo, et al., 2017). When Dr. Daniel Perl the military neuropathologist
observed the “brown, dust-like pattern scars in areas” of the brain “corresponding to sleep and
cognition” in two harvested soldier’s brain tissues, they were near the prefrontal cortex showing
a biological lesion or brain injury (New York Times, 2016).

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Functional Connectivity
In the study by Shim, et al (2017) it examined the source-level cortical brain networks of
post-traumatic stress disorder (PTSD) based on the graph theory using electroencephalography
(EEG). This study was done using a quantitative research design with correlational analysis
performed to investigate the relationship between the network index and symptom severity
scores. The differences in cortical network characteristics at the global level between PTSD and
healthy controls (HC) were investigated for each frequency band by using independent t-tests.
The participants were 78 patients with PTSD (29 were male and 49 were female) and 58 HCs (30
males and 28 females) which were screened with the Structured Clinical Interview for DSM-IV
Axis I Psychiatric Disorders by a psychiatrist. The instrumentation for the EEG signals were
recorded using a NeuroScan SynAmps2 amplifier (CompumedicsUSA, El Paso, Tx) from 62
AG/AgCl scalp electrodes that were evenly mounted on a QuickCap according to the extended
international 10-20 system. The results of the experiment concluded that the global level indices
of strength (clustering coefficient and path lengths) showed significant differences between the
PTSD patients and the HCs in theta and low beta bands. The study identified dysfunctional
characteristics of cortical networks in patients with PTSD by using resting–state EEG. These
study results showed the ability to correlate significant differences in the brain FC in patients
with PTSD when compared to healthy participants.
This brain activation network has appeared in many studies containing varying parts of
the brain as the prefrontal cortex-amygdala ( Bina and Langevin 2018; Grupe et al, 2018; Fonzo
et al, 2017; and Bradshaw, 2018), and as the dimensional change in the hippocampus
(McNerney, Tong, Nechvatal, Lee, Lyons, Soman, Liao, O’Hara, Hallmayer, Taylor, Ashford,
Yesavage, and Adamson, 2018; Fragkaki, Thomaes, and Sijbrandij, 2016; Ferrufino, 2018; and

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Queensland Brain Institute, 2018), and as the anterior cingulate cortex with prefrontal cortex and
thalamus network (Lau, 2017; Brenner, 2018), and as the change in size of the amygdala
(Cendes, Anderman, Gloor, Evans, Jones-Gotman, Watson,Melanson, Oliver, Perters, and
Leroux, 1993;
S
him, Im, and Lee, 2017). The FC of the cortical brain network pathway reveals
itself during activation, with a proven ability to be identified and measured (King, et al, 2017).
The means by which this activation has been measured also showed a significant range of change
when measuring the alpha waves during the investigations (Bangel et al, 2017; Lau, 2017;
Sanders, 2018; Newsom, 2018, and in Applied Psychophysical Biofeedback, 2013).
Shim has strength in looking at the psychological assessment scores against the EEG
results, the relationships between the altered networks and anxiety-related symptom scores in the
low beta bands. This band has been related to anxiety disorders and the findings showed an
overall decrease in connectedness with increased local clustering and connection strength.
Although there are other studies using measures of alpha waves, this study is significant to this
study due to the methods and analysis as well as the results showing a difference between
healthy people and PTSD patients.
The existence of “distinct underlying cortical activations in multiple regions of the
brain” were explained in a study by Greeshma, Gramann, Chandra, Singh, and Mittal (2017)
through an experiment to identify the FC network in the theta and alpha frequency bands. Fifty
young healthy male participants were chosen for this quantitative study to undergo a virtual
navigation task which would be performed both egocentric and allocentric applications. The
EEG data was gathered using a EMOTIV EPOC system with 14 electrodes with specific
sampling procedures and filters. This study demonstrates important information regarding the
encoding of memory following a model where the hippocampus acts as a central hub sharing a

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neural mechanism recruited based upon the activity of navigation. This navigation network
includes cognitive processes causing neural activity in a distributed cortical network recorded in
EEG. While comparing good and bad navigators, the EEG alpha band data indicated evidence to
support which were good and bad, or elevated alpha bands in specific regions. The findings of
this study showed more FC in the brain networks of individuals with good navigation skills.
Maquire and Mullaly (2013) shared evidence of how the hippocampus participated in a cortical
brain network.
Lusebrink (2010) developed a process of assessment and therapeutic application of the
Expressive Therapies Continuum (ETC) while working over decades in the medical setting. The
hypothesis explains implications for brain structures and functions in case studies and
longitudinal art therapy applications. In the 1970s Lusebrink, was working with hospital
psychiatric patients and began noting the correlation between the tactile qualities and the
responses of the patients during therapy. Using the foundations of theories found in the
dynamically oriented art therapy (Naumburg, 1966), and Gestalt Art Therapy (Rhyne, 1973).,
Lusebrink (2004) was able to lend an explanation to the changes in patient behaviors during art
therapy based in brain neuroplasticity. Many of her patients were suffering from non-verbal
disorders due to brain injury or psychological disorders such as PTSD.
The theoretical approach known as the ETC is based on a continuum between two
opposite poles having three levels reflecting a progression from simple to complex levels of
information processing. These three polar opposite levels play a balancing act of function and
expression to where the center line between the poles represents balance, or creativity of the
individual (Lusebrink, 2010). The central feature of the levels of the expressive therapies
continuum (ETC) is that the levels reflect an outward demonstration of the internal synapsing of

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the cortical brain network in a FC as a patient works through a disorder. The sequence was
described earlier (p. 3).
Fear Emotions Memory Activation
In a recent literature review of PTSD by Bina and Langevin (2018), the aim was to
compile a group of affective strategies for intervention where many DSM V diagnostic
categories have a feature of a dysfunctional interpretation of facial affective cues. The authors
reviewed 1460 articles to find 162 articles which contained information pertinent to PTSD. The
articles looked at deep brain stimulation, at the hyper-activation of the nodes in the network such
as the prefrontal cortex (learning context) hippocampus (memory) and the basolateral nucleus of
the amygdala (where extinction cells and fear encoding exist). Biomarkers and neurotransmitters
were identified in studies, autonomic activation of increased heart rate, and during fMRI studies
the fear circuit in articles showed that dysfunctional study participants presented with poor
responses with facial recognition tasks. The EEG articles were summarized as holding promise
for identifying a network response to facial expressions in order to evoke emotional responses in
individuals who were unable to decode facial expression simulations.
Understanding why traumatic memories recur in PTSD patients was discussed by Marek
(2018) sharing how activation is context dependent causing difficulty in the use of extinction
therapy. The extinction treatment method does not erase the traumatic memories, it just reduces
the reactivity when the memory returns. The therapy depends upon reactivation, and in the
clinical setting it is contrived, whereas in the everyday lives the activation is random and
unexpected. When Amit Etkin (Fonzo, et al., 2017) required 66 PTSD subjects to undergo
exposure therapy to self-regulate their emotions over 12 sessions brain scans were conducted,
and scheduled a follow-up session. Four weeks after the therapy concluded the brains were

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scanned again where the ability of the subjects to reinterpret emotionally charged stimuli and
they were able to change their emotional response levels.
In a study conducted by Kim, Dager, and Lyoo (2012) the amygdala again was
considered the hub of the fear response in patients experiencing panic disorder. Through
literature review, a network sequence was identified within the amygdala as follows: “ the lateral
subgroup recieves information from the cortical and subcortical areas, the basal subgroup inter-
connects the lateral and central subgroups, and sends the output to the cortical areas, and the
central subgroup conveys…the information to the hypothalamus and periaqueductal grey…the
laterobasal and central subgroups are also connected with bed nucleus of the stria terminalis
which projects to the hypothalamus, cerebellum, and brain stem areas” (Kim, Dager, and Lyoo,
2012, p. 20). Volume and areas of the amygdala during a fear event changes in size and the
locations of the reactivation is in the right amygdala processing acquired fear, and the left
amygdala involved in processing innate fear, this was found in three of the author’s research
articles. The volume of the amygdala was also found to reduce in both short term and long term
traumatic injury. When looking at symptom provocation paradigms, when reactivity occurred
there was an increased regional cerebral blood flow.
Emotional reactivity and regulation has been the focus of treatments for PTSD. In a
group study by Fonzo, et al. (2017) 66 participants underwent fMRI while completing three tasks
and recording the reactions. Using fMRI to see how the baseline brain function is affected by
treatment. These three responses were observed as symptoms appeared and treated: greater
dorsal prefrontal activation, less left amygdala activation during emotional reactivity, better
inhibition of left amygdala with pulses of TMS to right dorsolateral prefrontal cortex, and greater
ventromedial prefrontal/ventral striatal activation during emotional conflict resolution. These

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cortical brain networks show the FC of the fear response and the ability to modulate the strength
of the reactivations. Measuring the effects of Cognitive Behavioral Therapy a group of thirty-
four adolescent girls with PTSD related to physical and sexual assault was done through
administering a baseline response analysis of faces depicting fearful and neutral expressions.
According to Cisler, Sigel, Kramer, Smitherman, Vanderzee, Pemberton, and Kitts (2015) the
individuals with less symptom reduction showed greater amygdala activations to both types of
images, but the individuals with greater symptom reduction showed amygdala activation only to
the threatening images of faces.
EEG
This study by King, Knapp, Shaikh, Sabau, Pascuzzi, and Osburn, (2017) was performed
as an EEG quantitative attempt to explore the differences in cortical activation patterns of
subjects immediately following art making and following rote motor tasks. The hypothesis was
that there was a significant difference in the cortical activation pattern of art making as compared
to baseline. Participants were ten consenting study subjects participated in baseline EEG
measures prior, during and after tasks which was used to compare to measures following art
making activity. The instrumentation of the study was recorded using a Nihon Kohden EEG-
1200 with a low frequency filter of 0.16 seconds and a high frequency filter of 70 Hz. There
resulting findings of significant difference with persistent changes following art making in both
hemispheres. The strengths in this study is that it used brain based theoretical construct that
applies certain functional areas of the brain with certain artistic activities. This study used art
making as a basis for relating regions of the brain for emotion, cognition, and intelligence, into
narrative virtual reality art making. King et al (2017) looked at hemispheric activation divided
into four quadrants, whereas other studies were able to differentiate the cortical brain networks

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of specific regions by using specific electrode arrays of scalp placements. Although the study
was hemispheric, the activities and procedures can be adapted for a more localized distribution
of effects.
According to Belkofer and Vaughn (2014) their study was performed, because there is
little empirical evidence that exists as to how materials used in art therapy affect the brain and its
neurobiological function. This pre/post with-in group study utilized the quantitative EEG to
measure residual effects in the brain after 20 minutes of drawing. EEG recordings were
conducted before and after the participants created a drawing with oil pastels. The recruitment
resulted in 30 possible participants, but after attrition there were ten participants. The
convenience sample consisted of six art therapists and four non-artists. The instrumentation was
a 64-channel net recorded a continuing resting EEG amplified and sampled at 1000Hz on a
Netamps 300 (Electrical Geodesics). Using an international electrode placement system , the
readings were digitally converted into quantitative EEG using Neurospan software and
referenced with a Laplacian montage. The statistical analysis was performed on all of the
electrode EEG epochs and plotted to compare the averages of the data in the pre/post while
computing to determine the amplitudes and mapped to show electrical activity statistical values.
The results confirmed the hypothesis that drawing produced significant different between the
pre/post EEG readings. The self-regulating behaving was proven through increased alpha waves
in the spatially rotational visual processing networks of the brain. The strengths of the study were
the readings for the alpha wave significance, yet the weakness in the findings is that regions
indicated here for understanding the FC of the cortical brain network were not refined. This
study also confirmed early in 2014 that alpha waves can be a source of information to predict
influences in the brain. This study was a simple study, but at a time when efficacy in art therapy

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was under represented, it began a sequence of EEG studies. There are items in methodology and
reporting findings that can be used to inform the current study.
While investigating resting state EEG of PTSD sufferers, Newman (2018) found that the
PTSD individuals had more suppressed alpha activity when compared to healthy individuals. In a
study of 13 PTSD sufferers, they were exposed to loud or disturbing auditory signal where
involuntary attention to an unexpected event produced a hypervigilant state resulting in
differences in resting state alpha wave records. Looking at alpha asymmetry compared to delta-
beta currency expression in people suffering from social anxiety, Harrewijn, Van der Molen, and
Westenberg (2016) isolated brain networks into FC regions mainly as frontal alpha asymmetry.
EEG was used by Sperl, Panitz, Rosso, Dillon, Kumar, Hermann, Whitton, Hermann, Pizzagalli,
and Mueller (2018) when comparing the signals to fMRI imaging of frontomedial and amygdala
to identify how the regions communicate with each other. During fear conditioning, the therapy
was for providing extinction versus fear recall in this case measuring theta waves. Mental stress
was studied by Subhani, Xia, and Malik (2011) where a coorelation between mental stress and
suppression of alpha waves with improved theta waves showing that the alpha waves were more
active in occipital and frontal regions of the brain. Alpha waves lower during stress and elevate
during calm.
Alpha Waves
The study by Wahbeh and Oken (2013) was performed to find an effective biofeedback
therapy by assessing respiration, electroencephalography (EEG) and heart rate variability (HRV)
as potential indicators as biofeedback parameters. The study was done using a quantitative
research design. The subjects were 57 male veterans with a diagnosis of PTSD and a control
group of 29 typical males veterans with no diagnosis. The instrumentation EEG data were

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processed offline using Brain Vision Analyzer Version 2.0 (Brain Products GmbH, Inc.,
Gilching, Germany). Data were digitally filtered with 1 Hz high pass, 70 Hz low pass and 60 Hz
notch filters. The delta, theta, alpha, and beta amplitude, frontal alpha symmetry, and peak alpha
frequency measures were used for establishing the biofeedback parameters. The findings of the
study were to assess the measures of the peak frequencies of alpha for sensitivity to PTSD status
and relationship to the symptoms. The peak alpha frequencies were higher in the PTSD group
although the peak high-frequency HRV was lower in the PTSD group. All other wave
frequencies were not different between the groups. A strength of the study showed the
significance that the anterior, posterior, right, and left peak alpha frequency were all higher in the
PTSD group. Since peak alpha frequency was sensitive to PTSD status and symptoms the
measure is valid for use to determine for this study its use for developing a biofeedback
treatment. The findings helpful to my proposal was For our study of the use of narrative virtual
reality art therapy alpha wave levels may be a good approach for measuring the effects on PTSD
patients. Of the alpha waves examined in this study, the frontal alpha frequency amplitude
showed no differences between the PTSD group whereas the other wave signals showed
differences. This may be significant because other studies referenced here showed peak alpha
frequency associated with higher intelligence and improved cognitive performance. Since people
with PTSD have a higher peak alpha frequency compared the control group, it is a stable
measure of EEG and shows potential for use in the examination of other methods of treating
PTSD such as the proposed study of narrative virtual reality art therapy.
Descriptions of the types of waves and their locations in the brain were detailed by
Sanders (2018) when discussing the deep brain components where slower more goal directed
waves may be a mixture of beta and alpha waves. The waves active in memory storage were

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named as the gamma and beta waves. Auditory unexpected signals were used by Bangel,
Bushbach, Smit, Mazaheri, and Olff, (2017) in order to record how patients who had PTSD
increased theta and stronger suppression of upper alpha activity (13-15 Hz) after presented with
the deviant auditory tones. Bremner (2018) was reporting on the use of transcranial magnetic
stimulation (TMS) to treat the brain networks in people suffering from PTSD and Major
Depression. The use of TMS was introduced in order to change the signals and shift the pathway
of the brain network in order to alter the firing of the hypervigilant reactivation. In Bremner’s
article the network is referenced as the Executive Control Network (ETN) as compared to the use
of FC of the cortical brain network. Haiblum-Itskovitch, Czamanski-Cohen, and Galili (2018)
described the emotional response and changes in heart rate variability following art-making with
three different art materials. This preliminary study can be used as a basis for increasing the
comparative studies between other methods of art therapy mediums, with the ability to compare
them with each other. During the studies of emotional response and heart rate during art therapy,
Haiblum-Itskovitch and Czamanski-Cohen were able to use EEG to measure emotional valance
while comparing the heart rate and emotion during the use of tangible art materials in art therapy.
Measures of improvement in participants of therapeutic interventions has been largely a
subjective measure in art therapy.
Graphic Narratives
Art therapy relies upon the expressive arts such as when using graphic narratives during
counseling with individuals with limited oral expression capabilities. Therapy using visual art
has been constructed over many decades and compiled into applications of verbal instruction and
client action. Evidence has been gathering over the years from assessments like the House-Tree-
Person assessment (Buck, 1987), the Kinetic Family Drawing (Burns and Kaufman, 1972), the

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Bender Gastalt II (1938), the Person Picking an Apple from a Tree (Gantt and Tabone, 1990), the
Silver Drawing Test Assessment (Silver, 2002), the Face Stimulus Assessment (Betts, 2001),
Diagnostic Drawing Series (Cohen, 1986), which employ an auditory instruction and certain art
making media provided. Of the approximately 20 two-dimensional drawing assessments only
about three of them have a scoring mechanism (Moon, 2010).
A graphic narrative art making task is one where the individual is given directions and
then the person is asked to interpret the art work themselves without any prompting from the art
therapist that may influence the definitions. The ETC is an assessment tool that attempts to blend
the artistic response to mental processing areas, and employs an interpretive rubric to attempt to
isolate health of the individual state of mind. All art media and application of the motor skills
and use of the elements of art and design were also summarized in the scoring rubric of the
Formal Elements of Art Therapy Scale (Gantt and Tabone, 1990). Whether the verbal instruction
is to tell the client to draw whatever they feel like drawing with whatever medium they want, or
the detailed instructions for drawing what the assessment requires, there are cognitive and motor
neuron activity occurring in the brain. The complexity of the processes involved in the chain of
decision- making tell us much about the person being assessed. But all of the motor and
cognitive decisions are subject to the response of the participant to the textures, colors, in other
words the elements of art therapy where the therapist is mitigating direction of the process. These
mental activities and physical movements are emitting the electrical currents being picked up
during EEG of art making in the studies of King, et.al (2017) and Belkofer, et. al (2014).
Art Materials 2-Dimensional
According to the research of Talwar (2007), accessing traumatic memory through art
making can be done by following free flowing art making which calms and relaxes the client.

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The fear of the unknown or the fear of not knowing when something will trigger a hyperarousal
that causes aberrant behavior can interfere with typical functional abilities. Treatment for PTSD
has become less stigmatized with current developments in medications and psychotherapy. One
aspect of PTSD during the reactivation of a blocked memory is a phase of the reaction where
verbal abilities are blocked and the sufferer cannot explain to anyone what happened or why it
happened. In these cases, forms of talk therapy are ineffective (Talwar, 2007, p. 27). The use of
art making in memory activation has been documented in many cases for emotional regulation,
improving attention, and reducing anxiety.
Different methods have been used for improving mood as explained by Drake, Coleman,
and Winner (2011) as they researched their use for creating a study where 40 participants were
involved in measuring the two dimensions of mood using the Affect Grid. The two dimensions
of mood are valance, ranging from pleasantness to unpleasantness and arousal, as ranging from
activation to deactivation (2011, p.27). Mood ratings were taken after visual input of a horrible
movie clip and in that way using the responses as a rating. After this, there were two groups, one
was asked to write whatever they liked, and a drawing group using a black marker and a white
sheet of paper. Thirteen out of the 40 used the expressive art to vent their sad feelings, eighteen
used expression to distract them from what they had seen. A measure of mood by using valance
is one way to rate how expressive art making can reduce anxiety.
Virtual Reality
With the advent of digital media, the new artform began to change the way art was
produced and broadened the range and use of computer technology in therapy. According to
Malchiodi, “Traumatic memories that cannot be articulated with words, remain at a symbolic
level and in order to retrieve them from implicit memory, they must be externalized in symbolic

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forms such as images” as seen in art therapy (Malchiodi, 2017). The art therapy techniques
which access memory at levels of the brain affected by a traumatic event have shown
improvement for patients, but this improvement has not been measured or explained in terms of a
formal standard. One way to use virtual digital art is through creating narratives in filmmaking.
The animation project was begun by Kavitski (2017) where computer generated animation can
be created through a process of designing by first making a storyboard ((Kavitski, 2017, p. 184-
186) sequence of events and then using other mechanisms such as rigging a virtual skeleton.
Since the human eye can perceive motion at 24 frames per second, a sequence of events can
develop to explain a set or situation to build a story or narrative of an event similar to the triggers
of a response in a patient suffering from PTSD. Software is readily available now, and there are a
variety of interventions developed for PTSD such as the group therapy practice called The
Animation Project (TAP) (Kavitski, 2017, p. 179-182).
With the advent of telehealth, the use of technology to administer therapy over the
internet on secured lines; it became possible to participate in art therapy remotely. Examples of
telehealth in art therapy were described by Walls (2018) where Creative Forces, a military
healing therapy program that uses community based arts opportunities over a range of expressive
arts therapies. Access ease for therapeutic interventions has been increased by using remote
access abilities in telehealth technology. Bravemind is described by Walls as “a virtual reality
application that builds resilience in combat veterans with PTSD” and is highly engaging during
exposure therapy (Walls, 2018, p. 162-163). Roleplay during virtual art narrative video places
the PTSD patient into the actual event like a video game. Elements in the simulation can be used
to allow the person to be immersed into a scenario that corresponds to their traumatic event. The
theory is that by re-exposing the PTSD patient to the traumatic event as a form of desensitization

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to the event. After treatment using Bravemind, Rizzo and Shilling (2017) reported that three case
studies showed improvement of condition as well as large scale trials on returning veterans.
Although the desensitization might reduce the reactivation to the event, there is not a way to
determine if the severity of the reaction reduces over time, or if the reactivations will stop
randomly occurring given the right triggers. Interactive video game style art therapy is personal,
but there is still the computer screen separating the individual from the true threat.
Digital art is not new, but the proof of the value during therapy has begun to be
recognized according to McNiff (2018) as he has been developing a research practice to seek
legitimatization of the use of the medium in art therapy. Art-based research contributes where
“artistic expression offers modes of communication and understanding that are inaccessible to
linear and logical reason and language” meaning that art speaks for itself (McNiff, 2018, p. 329).
During art therapy it is not the therapist that interprets the art making but it is the art maker, with
their own interpretations experiencing an event in a non-threatening way. The art itself cannot be
measured as the visualization of the patients progress, but using other assessments, the
improvement of the individual condition can be pre- and –post tested using psychological exams.
Standardized Assessments: Psychological and Art Therapy
Pre-and Post-testing of the subjects participating in various studies that were performed
on PTSD patients can accompany physiological testing as with the alpha wave levels and heart
rate elevation measures. During the screening process for test participants, the use of
psychological and art therapy based standardized assessments can be administered in order to
validate findings of improvement of condition. In art therapy rating instruments have been
normed on patients suffering from Major Depression, Bipolar Disorder, Mania, Schizophrenia,
Delerium, Dementia, Amnestic and other Cognitive Disorders (Gantt and Tabone, 1998),

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through a review of the graphic equivalent of symptoms using a Likert Scale and giving
thousands of examples of drawings paired with diagnosis. The Diagnostic Drawing Series (DDS)
and the Descriptive Assessment of Psychiatric Artwork (DAPA) also follow scales using a
measurement of a ratio showing absence or exaggerated use of any of the elements of the art
making being assessed (Betts, 2006). For this study the classifications: a) Posttraumatic Stress
Disorder (309.81 )(F43.10); b) Acute Stress Disorder (308.3 )(F43.0); c) Panic Disorder (300.01
)(F41.0) ; d) Selective Mutism (312.23)(F94.0) ; e) Specific Phobia (300.29)(F40.298) should be
the central focus related to PTSD.
Psychological assessments and PTSD checklists used in the pre-and post-testing in
previous studies with PTSD consisted of: the Clinical Administered PTSD Scale (CAPS), the
Wechsler Adult Intelligence Scale, the Beck Depression Inventory II, the Wechsler Memory
Scale Revised, the Combat Exposure Scale,
Selective Reminding Test SRT, and the PTSD
Checklist Scale. The Clinical Administered PTSD Scale (CAPS) was developed over time
beginning with Blake, Weathers, Nagy, Kaloupek, Gusman, Charney, and Keane (1995) and
modeled after the Hamilton Depression Scale (HDRS) which follows after the DSM V criterions.
The HDRS has a high test-retest reliability based upon time intervals, and can only be used in
one trauma meaning a Criterion A traumatic event. This assessment tracks frequency of
unwanted memories and dreams over a month, and whether they are able to remove the memory
from current activity and move away from the bad thoughts.
The Wechsler Adult Intelligence Scale assesses intellectual ability and cognitive ability
in adults and adolescents (Wechsler, 1955) where work on a fifth edition began in 2016 to revise
the test. Wechsler developed the assessment in order to “assess the global capacity of a person to
act purposely, to think rationally, and to deal effectively with his environment” with a verbal and

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non-verbal component which applies to traumatic event reactivation affecting the language
center. The Beck Depression Inventory II (BDI II) was developed by Aaron Beck (1972) consists
of 21 questions used for self-reporting the severity of depression where an individual can rate the
aspects of depression. This can relate to negative thoughts, fear of the future or no idea about the
future, discouragement, and other symptoms of mood disorder and depression. For veterans, the
Combat Exposure Scale (CES) uses a seven item self-report to define using a weighted light-to-
heavy score so that by using this method the level of exposure to danger and harm can be
determined.
The Selective Reminding Test (SRT) by Buschke (1973) uses verbal learning and
memory tasks in order to measure how memory works during encoding, storage, and retrieval
activities. Memory is a primary function affected during PTSD exposures where memories have
been buried deep without being able to be accessed. The PTSD Checklist Scale (PCL-C) rates a
person according to the responses to 17 questions. There is a military and a civilian version
which can be used in the case of various other traumas besides military. It rates how severe a
person feels his symptoms are over a period of a month.
Art Materials Virtual
The use of three dimensional computer-generated interactive visual art making in therapy
allows for manipulation of the environment to immerse the participant into the artwork. There is
an absence of the physicality of the art medium, but a larger presence where the participant is
inside the artwork with little problem with responses to tactile or sensory input. Types of virtual
reality in literature are storyboarding, clay models, flight simulation, exposure therapy
environments, position tracking headsets with hand presence in 3-dimensions, Tilt Brush, group
art making inside Tilt Brush, art making in 360 degree volumetric space, scale adjusted figure to

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ground, the ability to move around an object, and “playing with the laws of nature” to heighten
awareness or to be a third person actor in a personal trauma (Lohrius and Malchiodi, 2018).
Virtual reality art making is similar to 2-dimensional sensory art making except without
the sensory input of standard materials. The technology needed to create art making
environments for therapeutic experiences has become readily available and can be used with
internet wifi access when given the amount of storage memory to operate the system chosen.
Headmounted display (HMD) sensors, hand presence controllers such as the Oculus Rift as seen
on the Oculus Connect site can be used with the mobile brain mapping equipment for measuring
brain activity while performing art making. Other APPs and software are Google Cardboard,
Tilt Brush, Quill, Blocks and Medium, AnimVR, Tvori, Mindshow, and Embodyme are some of
the technology used for art making purposes.
To summarize the literature where PTSD has been viewed through EEG studies, and how
forms of art making have influenced the healing process, there is evidence to support the
hypothesis that the elevation or reduction of the alpha wave in the cortical brain network FC may
hold value in defining a scoring mechanism. The properties of neuroplasticity and the ability of
the memory to float to the surface after being buried because of a traumatic event coincide with
psychological principles of healing.

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CHAPTER 3
METHODOLOGY
Since the relationship between the use of therapeutic visual-motor activity in narrative
virtual reality art making has been seen as having a correlation to the reduced alpha wave EEG
levels in post-traumatic stress disorder patients, a research study can be implemented in phases to
develop a scheme for introducing PTSD patients to this therapy. The measured effects on alpha
waves during activation of FC within the cortical brain network may be used to finally measure
improvement of a condition after art making has occurred. This would be a significant measure
since scoring perception of improvement has been hypothetical up until recent investigations.
Research Design
The researcher will utilize a quantitative experimental, cross-sectional, correlational
research design to examine the access to memory during narrative art making as one of the key
elements (Creswell & Kohler, 2008). This access is correlated with the reduction or elevation of
alpha wave since the traumatic memory is a random event, the feature triggers for such an event
may or may not occur during therapy. Therefore the quantitative EEG measures of the alpha
waves during the art making process used for regressive memory activation response therapy can
be tracked over time from baseline to indicate alpha wave levels.
Statistical analysis of the EEG data gathered can be analyzed in various ways after it has
been gathered. The more broad the demographics in the initial recruitment phase, the more useful
the data will be for future research. Quantitative data when used with the gender component, or
the form of trauma reported can be used to analyze how different triggers or forms of traumatic
events exhibit recovery rates. During data collection, if there is more than one trigger of a
traumatic hyperactivation, then this can be used in a comparative analysis over the course of

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treatment. The brain region of the FC of the cortical brain network can be analyzed using the
data of the group to estimate the spatial parameters of an activation event. The quantitative
experimental theoretical framework allows for real data to be gathered.
Sample
Site
The location of the study will; be at an educational institution where the psychology or
neuroscience department has the Mobile Brain Body Imaging (MoBI) facilities are available.
The physical environment required would be one where there would be ample room for mobility
of the subject through space to allow for full range of motion and a large footprint for graphic art
making. MoBI technology is based upon the idea that “cognition and brain dynamics are
embodied, and the natural cognition that makes use of physical structure” and that “movement
changes cognitive processes” thus requiring a setting with remote sensing or connectivity.
Kinesthetic qualities inherent in virtual reality art making involves EEG, virtual software, and
mobility.
Participants
Recruitment of study participants will begin through offering a written description of the
study in the form of a brochure or poster which can be distributed on campus, at the medical
institution, or at the veterans’ facilities. The target population will be individuals who have
experienced trauma and the symptoms of PTSD. It is the hope of this study to recruit individuals
who will pass the screening pre-tests during psychological testing having response results
consistent with having traumatic reactivation sequences of PTSD. Exclusion criteria may include
persons having major medical conditions, prior head injury, experiencing a seizure disorder, and
using pharmacologic interventions or drug abuse which are not part of the treatment of PTSD.

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Demographics of the population is open to all ages based upon the ability to fit into the mobile
brain mapping equipment backpack and perform the tasks wearing the proper technology to
perform the tasks. Childhood trauma, combat trauma, domestic violence trauma, accident victim
trauma, and other inclusive causes of PTSD will be screened during the intake process.
The participants will be required to respond to a survey including questions regarding
background in the use of artistic media, handedness, vision impairment, mobility issues, age,
gender, or any proclivity for motion sickness. Once the recruitment period has been closed, and
the amount and demographics of the population has been categorized, the participants will follow
a list of instructions and screenings. During the literature review, a list of assessments both
psychological assessments and PTSD checklists have been compiled consisting of : Clinical
Administered PTSD Scale (CAPS), Wechsler Adult Intelligence Scale, Beck Depression
Inventory II, Wechsler Memory Scale Revised, Combat Exposure Scale,
Selective Reminding
Test SRT, and the PTSD Checklist Scale. The assessment chosen for screening of participants
will be determined after the interview to determine the PTSD Type I or II, the type of trauma
symptoms, and other pertinent information.
Sample
Central to the use of virtual reality art making is the ability to wear and carry the MoBI
backpack while using body movement to create artwork in space. Once the participants have
been screened for determining the type of PTSD, the level of the traumatic events, and the
frequency of reactivation or triggers, the baselines from the PTSD assessments will be used to
determine which groups will be created, and the phases of investigation. The FC following a
dominant cortical brain network which can be aligned along electrode positioning standards will
be identified as the common region of measurement for the initial phase of the data collection.

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This can allow for a pre- art making and post-art making measurement of the alpha wave levels
produced by the participants. Since we now know that motor behavior influences cognitive
processing, art making and the creative process will be used to chart neural pathways and the
brain activity.
Procedures
Participants which have been screened and determined to be eligible for the study based
upon their diagnosis of PTSD will undergo a series of baseline EEG measures. Pre-testing will
occur using the Clinical Administered PTSD Scale (CAPS), Selective Reminding Test SRT, and
the PTSD Checklist Scale. The participants will follow the university standards for
confidentiality and human subjects’ participation with a full informed consent briefing before
agreeing to participate. Initially the participants will participate in a baseline of activities while
wearing the Mobile Brain Body Imaging (MoBI) apparatus (Gramann, 2014). This will be a
series of alpha wave measurements with eyes open, eyes closed, rote manual and body
movements before implementing the virtual reality art making application. Once the baselines
have been obtained, the participant will participate in a series of art making experiences with the
directive to draw a graphic narrative of your traumatic event which will be recorded as a large art
making experience encompassing the entire room with the virtual reality Tilt Brush by Google
application. While the art-making is actively produced the EEG measures will be recording the
alpha brain activity through the MoBI. A series of EEG measurements will be developed with
the encephalopathy expert in collaboration with the principal investigator. The pathway of choice
for the measurements will be determined by the EEG expert knowledge for the most feasible
electrode positions to obtain the optimum alpha wave readings. These pathways have been
described previously in the discussion of Functional Connectivity in the literature review. These

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art making experiences can be repeated over time to be used as a therapeutic intervention
culminating with a post-test of the Clinical Administered PTSD Scale (CAPS), Selective
Reminding Test SRT, and the PTSD Checklist Scale. The timing and duration of therapy plan
should coincide with collaborative psychologist or counselor on the experimental team, and the
culminating progress report should be timed to the duration and frequency of the therapy
programming.
Data
Instrument
Mobile Brain Body Imaging (MoBI) apparatus is equipment mounted in a backpack type
of assembly worn by the participant housing the EEG and the wearable headset for visual
imagery display where the individual becomes a part of the environment. Three-dimensional life
sized painting using a virtual paint brush makes a room into a large canvas where the human
body is in the center of the light and color. This is possible while wearing the Oculus Rift virtual
reality headset, a rear view control box, two Oculus touch controllers following the systems
requirements of the manufacturer which may be Intel processor or Microsoft Windows. The
three-dimensional art work is possible when the Oculus is paired with the Google Tilt Brush
application which provides varies strokes, colors, fire, light and other special effects to be used
during the art-making process.
Analysis
The statistical analysis of the EEG data gathered for the elevation or decreased elevation
of the alpha waves during three phases of the process. The first phase is the resting state with the
eyes opened and closed which can be compared to the alpha waves over the entire experiment,

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and finally the resting state alpha waves after the entire series of art-making of the graphic
narrative virtual painting. Recordings of the virtual art from the sessions will be stored and can
be used for future therapy session with that individual and remains confidential due to the nature
of the request for drawing the graphic narrative of the traumatic event. More specific measures
and statistical analysis will be defined by the EEG expert team member.
Limitations
Understanding that the human brain is each individual processes somewhat differently,
the validity of the results are dependent upon factors such as the pre-test levels of the alpha wave
in the resting state for each individual. The random order of the reactivation of a person with
PTSD may involve a certain amount of recidivism during the participation during the duration of
the study. Because of the nature of the virtual art making wearable equipment, some participants
may feel that the backpack, goggles and other sensory involvement may limit the freedom they
feel in art making. These participants may be more prone to using a two-dimensional art-making
approach. There could be an unanticipated PTSD reaction during the therapy process which may
cause some of the data to be corrupted. This study is a preliminary measure to determine the
reliability of the use of virtual reality in a graphic narrative to reduce stress, ignite the trapped
memory, and motivate the participants to practice stress reducing activities. The understanding
that the alpha wave is a reliable method to measure this reduction in activation has been reported
in other studies, and it is hoped that replicating a reduction in anxiety and stress in PTSD will be
the result.

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Appendix A