A Neuroimaging Investigation of Severely Traumatised Refugees
2. Project period:
1/02-2015 – 31/1-2018
3. Investigator: Sigurd Uldall, MD, PhD Student
4. Supervisors and collaborative partners
- Jessica Carlsson Lohmann, MD, PhD (CTP)
- Birte Glenthøj, MD, DMSc (CNSR, CINS)
- Egill Rostrup, MSc, MD, DMSc (FIUNIT, Glostrup)
- Ayna Nejad, MSc (DRCMR, Hvidovre)
- Mette Ødegaard Nielsen, MD, PhD (CINS/PCG)
In addition to various pre- and post-migration stressors, some traumatised refugees have also been
subjected to the atrocity of torture. These experiences may lead to a complex form of posttraumatic
stress disorder (PTSD) which apart from the core symptoms of hyperarousal, flash-backs and anxiety
encompasses persistent and pervasive impairments in affective, self and relational functioning.
Although PTSD is not classified as a psychotic disorder in either DSM-5 or ICD-10, clinical and
epidemiological studies report that traumatised persons may even develop frank psychotic
symptoms such as auditory and visual hallucinations, delusional thinking and paranoid ideas. Until
now, very limited neuroimaging research has been done on survivors of torture who suffer from
We wish to study the neural underpinnings of psychotic symptoms, dissociative symptoms and
emotional disturbances. To this end, we will study the neural processing during reward and
emotional processing and exposure to auto-biographical trauma material. First, we will deploy a
theoretical framework developed in schizophrenia research to investigate psychotic symptoms
experienced by tortured refugees, the so-called salience hypothesis. Secondly, we will explore the
preliminary findings that dissociative experiences in persons with PTSD are linked to increased
activity of the prefrontal cortex using naturalistic emotional stimuli depicting social interactions.
The design is a cross-sectional study of 40 tortured male refugees with PTSD and 20 healthy control
refugees matched on age, ethnicity and socioeconomic status. Study participants will undergo three
days of interview and one day of neuroimaging. On day two, the investigator and the participant
will compose two individual scripts; one portraying a traumatic experience and one describing a
neutral experience from the participant’s past. Each script will be 30 seconds long and be written in
the second person, present tense. The emotional response will be employed using the Responses
to Script-Driven Imagery Scale (RSDI) and it will be assured that the trauma script triggers not more
than a state of moderate re-experiencing (a maximum score of 4 on any item on the RSDI). The
scripts-driven imagery procedures will be obtained and adapted to fMRI according to previously
MRI is a non-invasive imaging technique, which produces detailed images of the body’s internal
structure (structural MRI). Magnetic resonance imaging systems use a strong static magnetic field,
a pulsed gradient magnetic field and radiofrequency (RF) energy to obtain images of the body in
selected planes. The subject is placed in a strong magnetic field created by a superconducting
magnet surrounding the bore of a scanner. The subject, lying in the scanner, is exposed to brief
pulses of non-ionizing radiofrequency radiation from a transmission coil around the subject’s head.
The energy of a radiofrequency signal, transmitted into the brain tissue, can be absorbed by the
nuclei of its constituent hydrogen atoms. This energy is then released, and the rate at which it is
released (magnetic ‘‘relaxation’’) depends on the local molecular environment. Grey and white
matter, as well as other tissues, can therefore be distinguished with MRI. Patients and control
subjects will be scanned using a 3Tesla (T) Phillips Achieva scanner at the Danish Research Centre
for Magnetic Resonance, Hvidovre Hospital. The total scanning time will be approximately 1.5 hours.
8. Expected results
- PTSD patients will have an attenuated BOLD response during reward anticipation in the
striatum, and this attenuation will correlate with the degree of psychotic and depressive
- During outcome evaluation of a reward, patients will have an attenuated pleasure-related
BOLD response in the medial PFC when receiving a reward and this attenuation will
correlate with the degree of emotional numbness.
- During emotional stimuli viewing, PTSD subjects will display attenuated activity in brain
areas that have a key role in social perception and cognition, such as temporoparietal
junction, superior temporal sulcus, insula, anterior cingulate cortex, and inferior frontal
- An interaction effect between high vs. low dissociative trait scorers will be found in the
amygdala and medial prefrontal cortex during neutrally-primed emotional stimuli viewing.
- In the trauma-related primed emotional stimuli viewing, the prefrontal-amygdala
relationship will be differentially modulated in high vs. low dissociative scorers.
- Analysis of structural MRI data will reveal increased prefrontal volumes in high dissociative
scorers compared to low scorers.
- We expect patients with PTSD to differ in intrinsic resting-state fMRI based functional
connectivity from healthy controls, and patients with schizophrenia.
9. Dissemination of results:
Peer-reviewed international journals.