Attentional bias in post-traumatic stress disorder diminishes after symptom amelioration

Predicting Post-Traumatic Stress Disorder Treatment Response Using Heart Rate Variability to Virtual Reality Environment and Modified Stroop Task: An Exploratory Study

Predicting treatment response can inform treatment decisions, expectations, and optimize use of mental health treatment resources. This study examined heart rate (HR), heart rate variability (HRV), and a modified Stroop task (mStroop) to predict post-traumatic stress disorder (PTSD) treatment response. We report on an observational, longitudinal study with 45 U.S. veterans in outpatient PTSD care, who had deployed to Iraq or Afghanistan. HR and HRV were collected before, during, and after virtual reality (VR) combat and civilian scenes. HRV recovery was defined as HRV after a 3-minute VR simulation minus HRV during a VR scene. mStroop threat variables included index scores for combat and general threat. Self-report data were collected at baseline and 6 months later. The outcome variable was the 17-item Clinician Administered PTSD Scale (CAPS). Controlling for baseline CAPS and number of combat experiences, the following baseline HRV recovery variables were significant predictors of 6-month CAPS: standard deviation of normal beat to beat interval (SDNN) after combat scene minus SDNN during combat scene and low-frequency (LF HRV) after civilian scene minus LF during civilian scene. HRV at rest, HR reactivity, HR recovery, and mStroop scores did not predict treatment response. In conclusion, HRV recovery variables in the context of a standardized VR stressor were significant predictors of PTSD treatment response after controlling for baseline CAPS and number of combat experiences. The direction of this relationship indicates that greater baseline HRV recovery predicts lower 6-month PTSD symptom severity. This was an exploratory study in need of replication.

P3a amplitude to trauma-related stimuli reduced after successful trauma-focused PTSD treatment

An elevated P3a amplitude to trauma-related stimuli is strongly associated with posttraumatic stress disorder (PTSD), yet little is known about whether this response to trauma-related stimuli is affected by treatment that decreases PTSD symptoms. As an analysis of secondary outcome measures from a randomized controlled trial, we investigated the latency and amplitude changes of the P3a in responses in a three-condition oddball visual task that included trauma-related (combat scenes) and trauma-unrelated (threatening animals) distractors. Fifty-five U.S. veterans diagnosed with combat-related PTSD were randomized to receive either active or sham repetitive transcranial magnetic stimulation (rTMS). All received cognitive processing therapy, CPT+A, which requires a written account of the index trauma. They were tested before and 6 months after protocol completion. P3a amplitude and response time decreases were driven largely by the changes in the responses to the trauma-related stimuli, and this decrease correlated to the decrease in PTSD symptoms. The amplitude changes were greater in those who received rTMS + CPT than in those who received sham rTMS + CPT, suggesting that rTMS plays beneficial role in reducing arousal and threat bias, which may allow for more effective engagement in trauma-focused PTSD treatment.

The effects of bilateral stimulation using eye movements on sexual fantasies with follow-up

BACKGROUND AND OBJECTIVES

Sexual fantasies represent a common aspect of human sexuality that can support sexual well-being but also contribute to psychopathology. The latter warrants intervention and bilateral stimulation with eye movements (EMs) may be a suitable intervention for impairing mental imagery of sexual fantasies. This study aimed to evaluate the effect of multiple rounds of EMs on sexual fantasies, gauge the effect over time with a one-week follow-up, and assess how impaired sexual imagery may influence behaviour and behavioural intention.

METHODS

Twenty-eight participants (14 male, Mage = 44.10, SDage = 9.77) selected a favoured sexual fantasy and engaged in five repeated rounds of an EM task, either face-to-face or via telehealth. Baseline phenomenological characteristics of sexual fantasies were compared against repeated measures after each round of EMs and at one-week follow-up, as well as hypothetical behavioural intention and frequency of fantasy masturbation.

RESULTS

All sexual fantasy characteristics (e.g., vividness, sensations, arousal, believability) diminished progressively between each round of EMs. These characteristics increased from round five to follow-up. However, they remained significantly reduced compared to baseline. Participants' hypothetical behavioural intention and frequency of masturbation associated with their sexual fantasies also reduced post-EM task.

LIMITATIONS

Use of self-report measures; participants' mental imagery could not be measured directly; and no comparison groups were included.

CONCLUSIONS

As an imagery impairing task, bilateral stimulation with EMs is effective for diminishing the phenomenological properties of sexual fantasies, extending upon extant literature. Collectively, the progressive research regarding EMs and sexual fantasies encourages replication in specific populations (e.g., individuals with problematic or harmful sexual fantasies).

Neuronal underpinnings of the attentional bias toward threat in the anxiety spectrum: Meta-analytical data on P3 and LPP event-related potentials

BACKGROUND

This systematic review analyzes brain responses at later stages of neuronal processing (P3 at 300-500 ms, and LPP at 300-700 ms). Both P3 and LPP are implicated in attentional threat bias in disorders grouped into fear and distress dimensions of the anxiety spectrum described by the Hierarchical Taxonomy Model of Psychopathology (HiTOP), but there are no consistent findings so far.

METHOD

Meta-analyses with between- (32 studies, n = 1631) and within-groups design (31 studies, n = 1699) were performed for assessing P3 and LPP modulation in negative, positive, and neutral stimuli, while also considering differences between controls and anxious individuals. Relevant moderators (e.g., age, sex, task) were controlled for and negative stimuli were further decomposed in terms of category (Relevant, Fear/Threat, or Unpleasant).

RESULTS

Increased P3 and LPP amplitudes were found for negative and positive stimuli, when compared to neutral stimuli (within-subjects analysis), confirming that both components are elicited by emotionally arousing information. Within-effects for negative and positive stimuli were higher for the anxious groups. Nonetheless, between-groups analyses showed that attentional threat bias occurs only in anxious groups when negative, personally relevant-threat information is presented. The HiTOP fear dimension moderated the findings.

LIMITATIONS

Potential missed studies; ERPs time windows' heterogeneity; adult sample only; the uneven number of computed effects; categorical analyses.

CONCLUSION

Attentional bias toward disorder-congruent threatening cues can be a transdiagnostic mechanism of HiTOP fear disorders, clustered within the anxiety spectrum.

A unifying translational framework to advance treatment research for comorbid PTSD and substance use disorders

We provide a unifying translational framework that can be used to synthesize extant lines of human laboratory research in four neurofunctional domains that underlie the co-occurrence of posttraumatic stress and substance use disorders (PTSD+SUD). We draw upon the Alcohol and Addiction Research Domain Criteria (AARDOC) to include executive functioning, negative emotionality, reward, and added social cognition from the National Institute of Mental Health (NIMH) Research Domain Criteria into our framework. We review research findings across each of the four domains, emphasizing human experimental studies in PTSD, SUD, and PTSD+SUD for each domain. We also discuss the implications of research findings for treatment development by considering new ways of conceptualizing risk factors and outcomes at the level of the individual patient, which will enhance treatment matching and advance innovations in intervention.

Forgetting Unwanted Memories: Active Forgetting and Implications for the Development of Psychological Disorders

Intrusive memories are a common feature of many psychopathologies, and suppression-induced forgetting of unwanted memories appears as a critical ability to preserve mental health. In recent years, biological and cognitive studies converged in revealing that forgetting is due to active processes. Recent neurobiological studies provide evidence on the active role of main neurotransmitter systems in forgetting, suggesting that the brain actively works to suppress retrieval of unwanted memories. On the cognitive side, there is evidence that voluntary and involuntary processes (here termed "intentional" and "incidental" forgetting, respectively) contribute to active forgetting. In intentional forgetting, an inhibitory control mechanism suppresses awareness of unwanted memories at encoding or retrieval. In incidental forgetting, retrieval practice of some memories involuntarily suppresses the retrieval of other related memories. In this review we describe recent findings on deficits in active forgetting observed in psychopathologies, like post-traumatic stress disorder, depression, schizophrenia, and obsessive-compulsive disorder. Moreover, we report studies in which the role of neurotransmitter systems, known to be involved in the pathogenesis of mental disorders, has been investigated in active forgetting paradigms. The possibility that biological and cognitive mechanisms of active forgetting could be considered as hallmarks of the early onset of psychopathologies is also discussed.

Beyond Clinical Outcomes: Posttraumatic Stress Symptoms Favor Attentional and Memory Control Abilities for Trauma-Related Words

Memory alterations and biases are core features of posttraumatic stress symptoms (PTSS). Although a large number of studies have investigated memory biases associated with PTSS, some inconsistencies remain regarding the nature of the mechanisms behind the threat-related biases observed in prior findings. The present study explored the extent to which inhibitory deficits, both for automatic and controlled processes, can account for these biases. Participants (N = 64) took part in a remember/know recognition procedure for positive, neutral, negative, and trauma-related words associated with negative priming and directed forgetting encoding. Half of the participants had high levels of PTSS (i.e., PCL-5 score > 40) and half had low levels (i.e., total PCL-5 score < 20). As both negative priming and directed forgetting effects are posited to depend on inhibitory abilities, we expected these effects to be absent for trauma-related words in participants with more severe PTSS. Replicating classic memory biases, participants with high levels of PTSS produced more "remember" recognition responses for trauma-related words, η_p ² = .10. However, contrary to our expectations, directed forgetting, η_p ² = .26; and negative priming effects were observed for trauma-related words but not for words of other valences, η_p ² = .07 and .06, respectively. Hence, rather than the expected inhibitory deficits, our results suggest that PTSS preserve the ability to inhibit trauma-related information in both attentional and memory processes. As it appears to occur at the expense of other information, this preserved cognitive functioning for trauma-related stimuli is discussed with regard to resource reallocation theories.

The Relation Between Posttraumatic Stress Symptom Severity and Startle Potentiation to Predictable and Unpredictable Threat

Aberrant threat reactivity has been implicated in the pathophysiology of posttraumatic stress disorder (PTSD); however, the literature on this association is mixed. One factor that may contribute to this inconsistent association is differences in severity of posttraumatic stress symptoms (PTSSs) across studies, but no studies have tested this hypothesis. The relation between PTSD and threat reactivity may also differ between unpredictable threats (U-threats) and predictable threats (P-threats), given burgeoning evidence to support a particular role for aberrant responding to U-threat in PTSD. The present study examined how PTSS severity relates to startle potentiation to U-threat and P-threat in a trauma-exposed community sample (N = 258). There was a negative linear, but not quadratic, relation between PTSS severity and startle potentiation to U-threat, but not P-threat. Blunted defensive responding to U-threat may therefore contribute to higher levels of PTSSs and may represent a novel treatment target for higher levels of PTSSs.

Mechanisms of change in psychological interventions for posttraumatic stress symptoms: A systematic review with recommendations

Psychological interventions can alleviate posttraumatic stress symptoms (PTSS). However, further development of treatment approaches calls for understanding the mechanisms of change through which diverse interventions affect PTSS. We systematically searched the literature for controlled studies of mechanisms of change in psychological interventions for PTSS. We aimed to detect all empirically studied mechanisms and evaluate the level of evidence for their role in the alleviation of PTSS. We identified 34 studies, of which nine were among children. We found evidence for improvements in maladaptive posttraumatic cognitions as a general mechanism of change involved in diverse interventions, among both adults and children. We also found some preliminary evidence for increases in mindfulness as a mechanism of change in mindfulness- and spiritually-oriented interventions among adults. We found scant, mixed empirical evidence for other mechanisms of change. Notably, studies on changes in traumatic memories as a mechanism of change were lacking, despite clinical emphasis on their importance. A major limitation across reviewed studies was that most could not establish temporal order of changes in mechanisms and PTSS. Including thorough analyses of mechanisms of change beyond cognitions in all future trials and improving the reporting of findings would aid the development and implementation of even more effective interventions.

Future Research: Global Implications

Therapists trained to provide eye movement desensitization and reprocessing (EMDR) therapy have a global responsibility. This article summarizes the multiple impacts of high stress events, and their long-term effects on individuals, families, communities, and nations. While it is well documented that EMDR treatment will remediate the individual symptoms of posttraumatic stress, research is still needed to determine how far-reaching such outcomes are. Future studies should determine whether treatment reverses the neurobiological changes, cognitive deficits, and affective dysregulation, which are associated with exposure to traumatic events. Research should also investigate whether successful treatment decreases high-risk and/or perpetrator behavior, and whether these effects are translated into behavioral and attitudinal changes sufficient to bring an end to intergenerational trauma and ethnopolitical conflicts. It seems self-evident that the ideal way to address pressing societal needs, on both local and global levels, is by the integration of science and practice. The article also discusses the development of nonprofit EMDR humanitarian assistance programs, and their essential work in the alleviation of suffering around the world. In addition to recommending the examination of EMDR's efficacy in treating traumatization from direct, natural, structural, and cultural causes, this article advocates that research resources be dedicated for testing interventions in the areas of the world with the greatest needs. The alleviation of suffering is the duty of our profession.

The Predictive Processing Model of EMDR

Eye Movement Desensitization and Reprocessing Therapy (EMDR) is an effective treatment for Post-traumatic Stress Disorder (PTSD). The Adaptive Information Processing Model (AIP) guides the development and practice of EMDR. The AIP postulates inadequately processed memory as the foundation of PTSD pathology. Predictive Processing postulates that the primary function of the brain is prediction that serves to anticipate the next moment of experience in order to resist the dissipative force of entropy thus facilitating continued survival. Memory is the primary substrate of prediction, and is optimized by an ongoing process of precision weighted prediction error minimization that refines prediction by updating the memories on which it is based. The Predictive Processing model of EMDR postulates that EMDR facilitates the predictive processing of traumatic memory by overcoming the bias against exploration and evidence accumulation. The EMDR protocol brings the traumatic memory into an active state of re-experiencing. Defensive responding and/or low sensory precision preclude evidence accumulation to test the predictions of the traumatic memory in the present. Sets of therapist guided eye movements repeatedly challenge the bias against evidence accumulation and compel sensory sampling of the benign present. Eye movements reset the theta rhythm organizing the flow of information through the brain, facilitating the deployment of both overt and covert attention, and the mnemonic search for associations. Sampling of sensation does not support the predictions of the traumatic memory resulting in prediction error that the brain then attempts to minimize. The net result is a restoration of the integrity of the rhythmic deployment of attention, a recalibration of sensory precision, and the updating (reconsolidation) of the traumatic memory. Thus one prediction of the model is a decrease in Attention Bias Variability, a core dysfunction in PTSD, following successful treatment with EMDR.

Gender Differences in Threat Biases: Trauma Type Matters in Posttraumatic Stress Disorder

Women are diagnosed with posttraumatic stress disorder (PTSD) at twice the rate of men. This gender difference may be related to differences in PTSD experiences (e.g., more hypervigilance in women) or types of trauma experienced (e.g., interpersonal trauma). We examined whether attentional threat biases were associated with gender, PTSD diagnosis, and/or trauma type. Participants were 70 civilians and veterans (38 women, 32 men; 41 with PTSD, 29 without PTSD) assessed with the Clinician Administered PTSD Scale for DSM-IV who completed a facial dot-probe attention bias task and self-report measures of psychiatric symptoms and trauma history. Factorial ANOVA and regression models examined associations between gender, PTSD diagnosis, index trauma type, lifetime traumatic experiences, and attentional threat biases. Results revealed that compared to women without PTSD and men both with and without PTSD, women with PTSD demonstrated attentional biases toward threatening facial expressions, d = 1.19, particularly fearful expressions, d = 0.74. Psychiatric symptoms or early/lifetime trauma did not account for these attentional biases. Biases were related to interpersonal assault index traumas, η_p ² = .13, especially sexual assault, d = 1.19. Trauma type may be an important factor in the development of attentional threat biases, which theoretically interfere with trauma recovery. Women may be more likely to demonstrate attentional threat biases due to higher likelihood of interpersonal trauma victimization rather than due to gender-specific psychobiological pathways. Future research is necessary to clarify if sexual assault alone or in combination with gender puts individuals at higher risk of developing PTSD.

Inhibitory control of threat remembering in PTSD

Intrusive traumatic recollections suggest an inability in Posttraumatic Stress Disorder (PTSD) to control and notably to inhibit memories for trauma-related information. Supported by inhibitory deficits found on experimental settings in PTSD, memory functioning and memory biases in the disorder were usually explained through inhibitory and control deficits in the processing of trauma-related information. The present study aimed to directly assess this hypothesis by investigating memory control abilities for emotional information in PTSD. For this purpose, 34 patients diagnosed with PTSD were compared to 37 non-PTSD controls on an item-cued directed forgetting paradigm for emotional words combined with a Remember/Know recognition procedure. Results revealed enhanced amounts of Remember recognitions for trauma-related words in PTSD. Moreover, we replicated findings of memory control impairments in the disorder. However, such impairments only occurred for non-trauma-related words. Accordingly, it appeared that PTSD patients presented preserved memory control abilities for trauma-related words, at the expenses of other emotional valences. Surprisingly, PTSD patients presented a preserved ability to control and notably to inhibit their memory functioning for trauma-related material. In addition to potential theoretical and clinical relevance, these results are discussed in the light of resource reallocation hypotheses and vigilant-avoidant theories of information processing in PTSD.

Eye movement desensitization and reprocessing for post-traumatic stress disorder from the perspective of three-dimensional model of the experiential selfhood

Eye Movement Desensitization and Reprocessing (EMDR) therapy is included in many international trauma treatment guidelines and is also shortlisted as an evidence-based practice for the treatment of psychological trauma and Post-Traumatic Stress Disorder (PTSD). However, its neurobiological mechanisms have not yet been fully understood. In this brief article we propose a hypothesis that a recently introduced neurophysiologically based three-dimensional construct model for experiential selfhood may help to fill this gap by providing the necessary neurobiological rationale of EMDR. In support of this proposal we briefly overview the neurophysiology of eye movements and the triad selfhood components, as well as EMDR therapy neuroimaging studies.

Neural Mechanisms of Spatial Attention Deficits in Trauma

BACKGROUND

Survival requires effective shifting of attention from one stimulus to another as goals change. It has been consistently demonstrated that posttraumatic stress disorder (PTSD) is associated with both faster orienting of attention toward and slower disengagement of attention from affective stimuli. Prior work, however, suggests that attention abnormalities in PTSD may extend beyond the affective domain.

METHODS

We used the Attention Network Test-modified to include invalid spatial cues-in conjunction with functional magnetic resonance imaging to examine the neurocognitive underpinnings of visuospatial attention in participants with PTSD (n = 31) and control participants who were (n = 20) and were not (n = 21) exposed to trauma.

RESULTS

We observed deficits in the utilization of spatial information in the group with PTSD. Specifically, compared with the non-trauma-exposed group, participants with PTSD showed a smaller reaction time difference between invalidly and validly cued targets, demonstrating that they were less likely to use spatial cues to inform subsequent behavior. We also found that in both the PTSD and trauma-exposed control groups, utilization of spatial information was positively associated with activation of attentional control regions (e.g., right precentral gyrus, inferior and middle frontal gyri) and negatively associated with activation in salience processing regions (e.g., right insula).

CONCLUSIONS

This pattern suggests that both trauma exposure and psychopathology may be associated with alterations of spatial attention. Overall, our findings suggest that both attention- and salience-network abnormalities may be related to altered attention in trauma-exposed populations. Treatments that target these neural networks could therefore be a new avenue for PTSD research.

The effects of trauma on brain and body: A unifying role for the midbrain periaqueductal gray

Post-traumatic stress disorder (PTSD), a diagnosis that may follow the experience of trauma, has multiple symptomatic phenotypes. Generally, individuals with PTSD display symptoms of hyperarousal and of hyperemotionality in the presence of fearful stimuli. A subset of individuals with PTSD; however, elicit dissociative symptomatology (i.e., depersonalization, derealization) in the wake of a perceived threat. This pattern of response characterizes the dissociative subtype of the disorder, which is often associated with emotional numbing and hypoarousal. Both symptomatic phenotypes exhibit attentional threat biases, where threat stimuli are processed preferentially leading to a hypervigilant state that is thought to promote defensive behaviors during threat processing. Accordingly, PTSD and its dissociative subtype are thought to differ in their proclivity to elicit active (i.e., fight, flight) versus passive (i.e., tonic immobility, emotional shutdown) defensive responses, which are characterized by the increased and the decreased expression of the sympathetic nervous system, respectively. Moreover, active and passive defenses are accompanied by primarily endocannabinoid- and opioid-mediated analgesics, respectively. Through critical review of the literature, we apply the defense cascade model to better understand the pathological presentation of defensive responses in PTSD with a focus on the functioning of lower-level midbrain and extended brainstem systems.

Sack A, Fecteau S. Characterizing emotional Stroop interference in posttraumatic stress disorder, major depression and anxiety disorders: A systematic review and meta-analysis

BACKGROUND

Posttraumatic stress disorder is a debilitating psychiatric disorder characterized by symptoms of intrusive re-experiencing of trauma, avoidance and hyper-arousal. Diagnosis and treatment of PTSD is further complicated by concurrently occurring disorders, the most frequent being major depressive disorder and anxiety disorders. Previous research highlights that attentional processing in posttraumatic stress disorder is associated with substantial interference by emotional stimuli, a phenomenon also observed in these concurrently occurring psychiatric disorders. However, the diagnosis-relevance of this interference remains elusive. Here, we investigated the emotional Stroop interference for diagnosis-related stimuli, generally negative stimuli, and generally positive stimuli in posttraumatic stress disorder, major depressive disorder and anxiety disorders.

METHODS

We performed a systematic database search in PubMed (Medline), Cochrane Library and PsycINFO on emotional Stroop performance in individuals with a diagnosis of posttraumatic stress disorder, major depressive disorder or anxiety disorders separately. Mean effect sizes, standard errors and confidence intervals were estimated for each clinical group and healthy control group comparison using random effect models.

RESULTS

As compared to healthy control group, the posttraumatic stress disorder group displayed greater interference by diagnosis-related stimuli and positive stimuli but not for generally negative stimuli. The major depressive disorder and anxiety disorders groups showed greater interference by diagnosis-related and negative stimuli, but not by positive stimuli. The age and sex had no significant impact on interference.

CONCLUSIONS

These findings highlight the importance of diagnosis-relevant information on attentional processing in all three clinical populations, posttraumatic stress disorder, major depressive disorder and anxiety disorders. Further, the impact of generally negative stimuli but not generally positive stimuli in major depressive disorder and anxiety disorders indicate impaired attentional bias for mood-congruent stimuli but not for general stimuli. Finally, it remains to be studied whether the influence of generally positive stimuli in posttraumatic stress disorder indicate that positive stimuli are perceived as PTSD related.

Emotional Memory in Post-traumatic Stress Disorder: A Systematic PRISMA Review of Controlled Studies

Background: Emotional memory is an adaptive process that improves the memorization of emotional events or stimuli. In Post-Traumatic Stress Disorder (PTSD), emotional memory may be altered, which in turn may affect symptoms. Having a clearer view of the processes of interaction between memory and emotional stimuli in PTSD may improve our knowledge of this disorder, and could create new therapeutic management tools. Thus, we performed a systematic review of the evidence of specific emotional memory in PTSD patients. Method: Following PRISMA guidelines, a systematic review of MEDLINE, PsycInfo, and ScienceDirect was undertaken to identify controlled studies on emotional memory that used cognitive tasks on PTSD patients. The initial research was conducted from June 2017 to July 2017, and search terms included: Post-Traumatic Stress Disorder; PTSD; emotional memory; emotion; emotional; memory; and episodic memory. Results: Eighteen studies reporting on 387 PTSD patients met the eligibility criteria. Among the studies selected, 11 observed specific memory processing in PTSD patients, such as a greater memorization of negative information, or a trend to false recognition of negative information. In addition, attentional and inhibition processing seem to play an important role in emotional memory in PTSD sufferers. Furthermore, other studies that did not find behavioral differences between PTSD and control groups nevertheless showed differences in both specific cerebral activities and neurohormone levels during emotional memory tasks. Conclusion: This review has several limitations, including a limited number of controlled studies, small sample sizes, different tasks and methods. Nevertheless, the results of this systematic review provide interesting information on emotional memory for clinicians and researchers, as they seem to highlight facilitated memory processing for negative information in PTSD patients. This topic needs further controlled studies with sensitive behavioral tasks. Also, future studies may evaluate emotional memory after symptom amelioration.

Attentional avoidance in peer victimized individuals with and without psychiatric disorders

Background

Attentional biases are a relatively robust phenomenon among clinical populations but less pronounced in healthy participants. However, regarding the components of attentional biases and the directions of attention allocation, there are several inconsistencies in the literature. The present study examined whether these inconsistencies can be traced back to previous experiences of relational peer victimization in clinical populations.

Methods

Participants were subjects with a diagnosed psychiatric disorder (n = 30) and healthy controls (n = 31). Additionally, the sample was divided into two subgroups according to the participants’ reports of previous relational peer victimization (high peer victimization: n = 28; low peer victimization: n = 33). Attentional biases were measured by the Emotional Stroop task and a dot-probe task.

Results

In both samples, peer victimized participants showed delayed response times when color-naming negative and positive compared to neutral adjectives in the Emotional Stroop task. Likewise, the dot-probe task indicated attentional avoidance of both negative and positive words in peer victimized participants with and without a psychiatric disorder. Interestingly, presence of a psychiatric disorder did not have a significant effect on attentional biases.

Conclusion

Both tasks could detect that attentional processes were linked to the experience of peer victimization rather than to the current diagnostic status of the participants. Attentional avoidance of emotional stimuli may prevent victimized individuals from responding adequately to environmental stimuli, which may increase the risk for the development of psychopathology.

PTSD symptoms and overt attention to contextualized emotional faces: Evidence from eye tracking

Abnormal patterns of attention to emotional faces and images are proposed by theories of posttraumatic stress disorder (PTSD), and this has been demonstrated empirically. However, few studies have examined how PTSD symptoms are associated with attention to emotional faces in the context of emotional background images. Eye tracking data were collected from seventy-eight undergraduates with a history of experiencing at least one traumatic event as they completed the Contextual Recognition of Affective Faces Task (CRAFT; Milanak and Berenbaum, 2014), which requires subjects to identify the emotion depicted by faces superimposed on an emotional background image. Greater PTSD symptom severity was associated with more time spent looking at background contexts and less time looking at target faces. This is consistent with greater susceptibility to distraction by task-irrelevant emotional stimuli. The duration of each gaze fixation upon fear faces was shorter for those with greater PTSD symptoms, and this pattern was marginally significant for disgust faces. These findings suggest that PTSD symptoms may relate to greater attention toward non-facial background scenes and less attention toward facial stimuli, especially when conveying a fear or disgust expression.

How Does Eye Movement Desensitization and Reprocessing Therapy Work? A Systematic Review on Suggested Mechanisms of Action

Background: Eye movement desensitization and reprocessing [EMDR] is an innovative, evidence-based and effective psychotherapy for post-traumatic stress disorder [PTSD]. As with other psychotherapies, the effectiveness of EMDR contrasts with a limited knowledge of its underlying mechanism of action. In its relatively short life as a therapeutic option, EMDR has not been without controversy, in particular regarding the role of the bilateral stimulation as an active component of the therapy. The high prevalence of EMDR in clinical practice and the dramatic increase in EMDR research in recent years, with more than 26 randomized controlled trials published to date, highlight the need for a better understanding of its mechanism of action.

Methods: We conducted a thorough systematic search of studies published until January 2018, using PubMed, ScienceDirect, Web of Knowledge and Scopus databases that examined the mechanism of action of EMDR or provided conclusions within the framework of current theoretical models of EMDR functioning.

Results: Eighty-seven studies were selected for review and classified into three overarching models; (i) psychological models (ii) psychophysiological models and (iii) neurobiological models. The evidence available from each study was analyzed and discussed. Results demonstrated a reasonable empirical support for the working memory hypothesis and for the physiological changes associated with successful EMDR therapy. Recently, more sophisticated structural and functional neuroimaging studies using high resolution structural and temporal techniques are starting to provide preliminary evidence into the neuronal correlates before, during and after EMDR therapy.

Discussion: Despite the increasing number of studies that published in recent years, the research into the mechanisms underlying EMDR therapy is still in its infancy. Studies in well-defined clinical and non-clinical populations, larger sample sizes and tighter methodological control are further needed in order to establish firm conclusions.

Consistency of Recall for Deployment-Related Traumatic Brain Injury

OBJECTIVE

To examine the temporal consistency of self-reported deployment-related traumatic brain injury (TBI) and its association with posttraumatic stress disorder (PTSD) symptom severity.

SETTING

In-person interviews at US Army installations (postdeployment); phone interviews (long-term follow-up).

PARTICIPANTS

A total of 378 US Army soldiers and veterans deployed to Iraq; 14.3% (n = 54) reported TBI with loss of consciousness during an index deployment.

DESIGN

Participants were evaluated after returning from deployment and again 5 to 9 years later.

MAIN MEASURES

Temporal consistency of TBI endorsement based on TBI screening interviews; PTSD Checklist, Civilian Version.

RESULTS

The concordance of deployment-related TBI endorsement from the postdeployment to long-term follow-up assessment was moderate (κ = 0.53). Of the 54 participants reporting (predominantly mild) TBI occurring during an index deployment, 32 endorsed TBI inconsistently over time. More severe PTSD symptoms at postdeployment assessment were independently associated with discordant reporting (P = .0004); each 10-point increase in PCL scores increasing odds of discordance by 69% (odds ratio = 1.69; 95% confidence interval, 1.26-2.26).

CONCLUSIONS

Deployment-related TBI may not be reported reliably over time, particularly among war-zone veterans with greater PTSD symptoms. Results of screening evaluations for TBI history should be viewed with caution in the context of PTSD symptom history.

Serum levels of interleukins IL-6 and IL-10 in individuals with posttraumatic stress disorder in a population-based sample

To evaluate the serum levels of IL-6 and IL-10 anti-inflammatory interleukins in individuals with post-traumatic stress disorder (PTSD) in a population-based study. This is a paired study nested in a cross-sectional population-based study. All individuals who presented PTSD and did not present major depressive disorder, diagnostic by interview--Mini International Neuropsychiatric Interview were selected. From these, 41 healthy controls were matched by sex and age. Serum levels of IL-6 and IL-10 were measured by the ELISA, using commercial kits. The group of individuals with PTSD showed a significant increase in the serum levels of IL-6 and IL-10. Our results suggest that individuals with PTSD may present an activation of the immune system, which may lead to neuroinflammation.

Age As Moderator of Emotional Stroop Task Performance in Posttraumatic Stress Disorder (PTSD)

Emotional Stroop task (EST) has been extensively used to investigate attentional processes in posttraumatic stress disorder (PTSD). Even though aging significantly changes the dynamics of emotion-cognition interactions, very little is known about its role in shaping EST performance in PTSD patients. In the present study we tested a uniquely large sample of motor vehicle accident victims. Data of 194 participants (75.3% female; mean age = 36.64 years, SD = 12.3) were included in the analysis, out of which 136 (70.1%) were diagnosed with PTSD. Prior to the psychiatric assessment, participants completed the pictorial version of EST (neutral, positive, negative, and accidents photos were presented). Comparison of the PTSD and control groups revealed a specific increase in reaction times (RTs) related to the exposure of trauma-related material. At the same time, previously unreported, moderating effects of age were also discovered. Older participants, in contrast to the younger group, showed no increase in RTs and interference scores in trials where accident photos were presented. Our study points to the key role of age as a previously understudied factor modifying EST performance in PTSD patients.

Neuropsychological measurement of inhibitory control in posttraumatic stress disorder: An exploratory antisaccade paradigm

OBJECTIVE

The aim of the study was to uncover inhibitory control dynamics and assess antisaccade eye-tracking tasks for relevance in a veteran posttraumatic stress disorder (PTSD) population.

METHOD

Participants were 36 veterans enrolled at the Washington DC Veterans Affairs Medical Center. The groups (PTSD diagnosed vs. controls) did not vary between age and sex. Participants completed a testing battery of clinical neuropsychological measures and two different eye-tracking conditions, one that utilized face stimuli and one with standard shape stimuli, which test pro- (PS) and antisaccade (AS) eye movements.

RESULTS

Veterans with PTSD, t(33) = 2.2, p = .04, took longer to respond than controls in the standard condition AS. In the face condition, a group by task interaction was seen with increased latency for PTSD veterans in the AS versus PS task, F(3, 33) = 3.99, p = .05, with a large overall effect (Hedges' g = 1.18, p < .001) compared to controls. After controlling for depression, analyses suggested that only the face condition AS task significantly predicted dimensions of PTSD symptomology measured by the Clinician Administered PTSD Scale (CAPS) for veterans with PTSD.

CONCLUSIONS

This is the first study to extend AS findings to PTSD and suggests a specific capability to measure inhibitory control using eye-tracking technology. We discuss the notion that reduced capacity to regulate facial-related processing affects cognitive and attentional control networks of PTSD patients, potentially representing a core cognitive deficit.

Performance in a blocked versus randomized emotional Stroop task in an aged, early traumatized group with and without posttraumatic stress symptoms

BACKGROUND AND OBJECTIVES

Attentional biases (AB) for trauma-related stimuli have been examined in many studies assessing different trauma samples. In emotional Stroop tasks (EST), blocked and single-trial formats are used almost interchangeably in clinical research. There is reason to believe that different designs yield different results and assess different processes, which, however, has been hardly examined in studies. Furthermore, there is a dearth of information about AB in older trauma survivors with posttraumatic stress symptoms.

METHODS

Older adults with (n = 20) and without PTSD symptoms (n = 26) as well as non-traumatized controls (n = 21) completed an EST, in which words were presented both blocked and randomized.

RESULTS

Analyses revealed that individuals with PTSD symptoms showed AB for trauma- and depression-related words; however, mode of administration did not significantly influence reaction times.

LIMITATIONS

The emotional Stroop task cannot disentangle the underlying cognitive mechanism (i.e., facilitation, interference, avoidance).

CONCLUSIONS

PTSD symptoms in older trauma survivors are associated with AB. Overall, participants with PTSD symptoms did not show greater impairment of cognitive control in comparison to both control groups. Results also illustrate that methodological differences between task versions need to be considered more thoroughly.

Examining Cognitive Processes and Drinking Urge in PTSD

Despite their centrality to learning theories, strikingly little attention has been paid to the role of cognitions in efforts to understand associations between posttraumatic stress disorder (PTSD) and alcohol drinking. In the present study, we sought to examine information processing pathways for trauma and alcohol information, and the effects of posttraumatic stress and trauma cue exposure on these pathways. Participants were college students (N = 232; 49% female; Mage = 19.56,SD = 1.44) categorized into three diagnostic groups based on current PTSD status determined by structured clinical interview. These students then were exposed to a personalized trauma or neutral cue script, followed by a Stroop task modified to include trauma, alcohol, and contrast words. Indices of mood and urge to drink alcohol were administered throughout the task. Findings revealed that those with PTSD who were exposed to the personalized trauma cue showed a general response slowing across all stimuli types on the Stroop task. Intriguingly, this slowing effect was significantly associated with urge to drink alcohol for only those PTSD participants who were exposed to the trauma cues. In contrast, we did not find support for the hypothesis that trauma cues would lead to attention bias to trauma and alcohol specific Stroop stimuli among participants with PTSD, nor did slower RT for specific word types predict unique variance in urge to drink alcohol. Findings suggest that individual (PTSD) and environmental (cue) circumstances may work conjointly to precipitate changes in cognitive processing - changes that may have implications for drinking motivation. Given the importance of cognition in the etiology of both PTSD and drinking, this is a mechanism that warrants further investigation.

Behavior, neuropsychology and fMRI

Cognitive neuroscientists in the late 20th century began the task of identifying the part(s) of the brain concerned with normal behavior as manifest in the psychological capacities as affective powers, reasoning, behaving purposively and the pursuit of goals, following introduction of the 'functional magnetic resonance imaging' (fMRI) method for identifying brain activity. For this research program to be successful two questions require satisfactory answers. First, as the fMRI method can currently only be used on stationary subjects, to what extent can neuropsychological tests applicable to such stationary subjects be correlated with normal behavior. Second, to what extent can correlations between the various neuropsychological tests on the one hand, and sites of brain activity determined with fMRI on the other, be regarded as established. The extent to which these questions have yet received satisfactory answers is reviewed, and suggestions made both for improving correlations of neuropsychological tests with behavior as well as with the results of fMRI-based observations.

The relationship between social anxiety and the perception of depth-ambiguous biological motion stimuli is mediated by inhibitory ability

Orthographically projected biological motion stimuli are depth-ambiguous. Consequently, their projection when oriented towards the viewer is the same as when oriented away. Despite this, observers tend to interpret such stimuli as facing the viewer more often. Some have speculated that this facing-the-viewer bias may exist for sociobiological reasons: Mistaking another human as retreating when they are actually approaching could have more severe consequences than the opposite error. An implication of this theory is that the facing-towards percept may be perceived as more threatening than the facing-away percept. Given this, as well as the finding that anxious individuals have been found to display an attentional bias towards threatening stimuli, we reasoned that more anxious individuals might have stronger facing-the-viewer biases. Furthermore, since anxious individuals have been found to perform poorer on inhibition tasks, we hypothesized that inhibitory ability would mediate the relationship between anxiety and the facing-the-viewer bias (i.e., difficulty inhibiting the threatening percept). Exploring individual differences, we asked participants to complete anxiety questionnaires, to perform a Go/No-Go task, and then to complete a perceptual task that allowed us to assess their facing-the-viewer biases. As hypothesized, we found that both greater anxiety and weaker inhibitory ability were associated with greater facing-the-viewer biases. In addition, we found that inhibitory ability significantly mediated the relationship between anxiety and facing-the-viewer biases. Our results provide further support that the facing-the-viewer bias is sensitive to the sociobiological relevance of biological motion stimuli, and that the threat bias for ambiguous visual stimuli is mediated by inhibitory ability.

EMDR therapy for PTSD after motor vehicle accidents: meta-analytic evidence for specific treatment

Motor vehicle accident (MVA) victims may suffer both acute and post-traumatic stress disorders (PTSD). With PTSD affecting social, interpersonal and occupational functioning, clinicians as well as the National Institute of Health are very interested in identifying the most effective psychological treatment to reduce PTSD. From research findings, eye movement desensitization and reprocessing (EMDR) therapy is considered as one of the effective treatment of PTSD. In this paper, we present the results of a meta-analysis of fMRI studies on PTSD after MVA through activation likelihood estimation. We found that PTSD following MVA is characterized by neural modifications in the anterior cingulate cortex (ACC), a cerebral structure involved in fear-conditioning mechanisms. Basing on previous findings in both humans and animals, which demonstrate that desensitization techniques and extinction protocols act on the limbic system, the effectiveness of EMDR and of cognitive behavioral therapies (CBT) may be related to the fact that during these therapies the ACC is stimulated by desensitization.

Depression, not PTSD, is associated with attentional biases for emotional visual cues in early traumatized individuals with PTSD

Using variants of the emotional Stroop task (EST), a large number of studies demonstrated attentional biases in individuals with PTSD across different types of trauma. However, the specificity and robustness of the emotional Stroop effect in PTSD have been questioned recently. In particular, the paradigm cannot disentangle underlying cognitive mechanisms. Transgenerational studies provide evidence that consequences of trauma are not limited to the traumatized people, but extend to close relatives, especially the children. To further investigate attentional biases in PTSD and to shed light on the underlying cognitive mechanism(s), a spatial-cueing paradigm with pictures of different emotional valence (neutral, anxiety, depression, trauma) was administered to individuals displaced as children during World War II (WWII) with (n = 22) and without PTSD (n = 26) as well as to non-traumatized controls (n = 22). To assess whether parental PTSD is associated with biased information processing in children, each one adult offspring was also included in the study. PTSD was not associated with attentional biases for trauma-related stimuli. There was no evidence for a transgenerational transmission of biased information processing. However, when samples were regrouped based on current depression, a reduced inhibition of return (IOR) effect emerged for depression-related cues. IOR refers to the phenomenon that with longer intervals between cue and target the validity effect is reversed: uncued locations are associated with shorter and cued locations with longer RTs. The results diverge from EST studies and demonstrate that findings on attentional biases yield equivocal results across different paradigms. Attentional biases for trauma-related material may only appear for verbal but not for visual stimuli in an elderly population with childhood trauma with PTSD. Future studies should more closely investigate whether findings from younger trauma populations also manifest in older trauma survivors.

Neuropsychological and Physiological Outcomes Pre- and Post-EMDR Therapy for a Woman With PTSD: A Case Study

This article provides a comprehensive review of the literature on the neurocognitive impact of posttraumatic stress disorder (PTSD) and reports on a quantitative single-case study, which investigated whether eye movement desensitization and reprocessing (EMDR) therapy would change the neuropsychological and physiological responses of an 18-year-old female client diagnosed with comorbid PTSD and major depressive disorder. Eleven 90-minute weekly sessions of EMDR therapy were provided. We used biofeedback equipment (ProComp5 Infiniti System) to obtain records of heart rate and conductance while the participant was in the desensitization and reprocessing phases of EMDR therapy. Results showed a heart rate decrease between baselines at the beginning and end of treatment. Neuropsychological evaluations of attention, memory, and brain executive functions showed pretreatment impairments in attentional processes, information processing speed, and working memory and posttreatment improvement of these cognitive functions, with significant differences on the Paced Auditory Serial Addition Test. We found a substantial posttreatment decrease in mean scores on the Beck Depression Inventory-II and the Dissociative Experiences Scale. Furthermore, the patient showed no signs of PTSD after the intervention, based on the Posttraumatic Stress Global Scale. At 1-year follow-up, the participant reported maintenance of treatment effects. We discuss how amelioration of PTSD symptoms was associated with improved neurocognitive outcomes.

Attachment-security priming attenuates amygdala activation to social and linguistic threat

A predominant expectation that social relationships with others are safe (a secure attachment style), has been linked with reduced threat-related amygdala activation. Experimental priming of mental representations of attachment security can modulate neural responding, but the effects of attachment-security priming on threat-related amygdala activation remains untested. Using functional magnetic resonance imaging, the present study examined the effects of trait and primed attachment security on amygdala reactivity to threatening stimuli in an emotional faces and a linguistic dot-probe task in 42 healthy participants. Trait attachment anxiety and attachment avoidance were positively correlated with amygdala activation to threatening faces in the control group, but not in the attachment primed group. Furthermore, participants who received attachment-security priming showed attenuated amygdala activation in both the emotional faces and dot-probe tasks. The current findings demonstrate that variation in state and trait attachment security modulates amygdala reactivity to threat. These findings support the potential use of attachment security-boosting methods as interventions and suggest a neural mechanism for the protective effect of social bonds in anxiety disorders.

EMDR Therapy Humanitarian Assistance Programs: Treating the Psychological, Physical, and Societal Effects of Adverse Experiences Worldwide

The negative effects of trauma and other adverse life experiences have been shown to interfere with individual, family, and societal functioning. Eye movement desensitization and reprocessing (EMDR) therapy is empirically supported and recommended as a frontline treatment for psychological trauma in numerous practice guidelines. It provides both effective and efficient treatment without the need for detailed descriptions of the disturbing event or homework. This allows field teams to provide culturally sensitive therapy on consecutive days for those in remote areas and in crisis situations. Humanitarian assistance organizations have conducted projects internationally to provide EMDR therapy after both natural and manmade disasters and have helped develop sustainable mental health resources worldwide. This brief introduction provides an overview of current programs, treatment rationale, and a call for future action.

Attention to threat images in individuals with clinical and subthreshold symptoms of post-traumatic stress disorder

Attention to general and trauma-relevant threat was examined in individuals with clinical and subthreshold symptoms of post-traumatic stress disorder (PTSD). Participants' eye gaze was tracked and recorded while they viewed sets of four images over a 6-s presentation (one negative, positive, and neutral image, and either a general threat image or a trauma-relevant threat image). Two trauma-exposed groups (a clinical and a subthreshold PTSD symptom group) were compared to a non-trauma-exposed group. Both the clinical and subthreshold PTSD symptom groups attended to trauma-relevant threat images more than the no-trauma-exposure group, whereas there were no group differences for general threat images. A time course analysis of attention to trauma-relevant threat images revealed different attentional profiles for the trauma-exposed groups. Participants with clinical PTSD symptoms exhibited immediate heightened attention to the images relative to participants with no-trauma-exposure, whereas participants with subthreshold PTSD symptoms did not. In addition, participants with subthreshold PTSD symptoms attended to trauma-relevant threat images throughout the 6-s presentation, whereas participants with clinical symptoms of PTSD exhibited evidence of avoidance. The theoretical and clinical implications of these distinct attentional profiles are discussed.

Neural, psychophysiological, and behavioral markers of fear processing in PTSD: a review of the literature

As presently defined, post-traumatic stress disorder (PTSD) is an amalgam of symptoms falling into: re-experiencing of the trauma, avoidance of reminders of it, emotional numbing and hyperarousal. PTSD has a well-known proximate cause, commonly occurring after a life-threatening event that induces a response of intense fear, horror, and helplessness. Much of the advancement in understanding of the neurobiology of PTSD has emerged from conceptualizing the disorder as one that involves substantial dysfunction in fear processing. This article reviews recent knowledge of fear processing markers in PTSD. A systematic search was performed of reports within the specific three-year publication time period of January 2010 to December 2012. We identified a total of 31 studies reporting fear processing markers in PTSD. We further categorized them according to the following classification: (1) neural-activation markers (n=10), (2) psychophysiological markers (n=14), and (3) behavioral markers (n=7). Across most studies reviewed here, significant differences between individuals with PTSD and healthy controls were shown. Methodological, theoretical and clinical implications were discussed.

Attentional bias for trauma-related words: exaggerated emotional Stroop effect in Afghanistan and Iraq war veterans with PTSD

BACKGROUND

Post-traumatic stress disorder (PTSD) involves debilitating symptoms that can disrupt cognitive functioning. The emotional Stroop has been commonly used to examine the impact of PTSD on attentional control, but no published study has yet used it with Afghanistan and Iraq war veterans, and only one previous study has compared groups on habituation to trauma-related words.

METHODS

We administered the emotional Stroop, the Beck Depression Inventory (BDI), and the PTSD Checklist (PCL) to 30 veterans with PTSD, 30 military controls, and 30 civilian controls. Stroop word types included Combat, Matched-neutral, Neutral, Positive and Negative.

RESULTS

Compared to controls, veterans with PTSD were disproportionately slower in responding to Combat words. They were also slower and less accurate overall, did not show interference on Negative or Positive words relative to Neutral, and showed a trend for delayed but successful habituation to Combat words. Higher PCL and BDI scores also correlated with larger interference effects.

CONCLUSIONS

Because of its specificity in detecting attentional biases to trauma-related words, the emotional Stroop task may serve as a useful pre- and post task with intervention studies of PTSD patients.

Emotion and cognition interactions in PTSD: a review of neurocognitive and neuroimaging studies

Posttraumatic stress disorder (PTSD) is a psychiatric syndrome that develops after exposure to terrifying and life-threatening events including warfare, motor-vehicle accidents, and physical and sexual assault. The emotional experience of psychological trauma can have long-term cognitive effects. The hallmark symptoms of PTSD involve alterations to cognitive processes such as memory, attention, planning, and problem solving, underscoring the detrimental impact that negative emotionality has on cognitive functioning. As such, an important challenge for PTSD researchers and treatment providers is to understand the dynamic interplay between emotion and cognition. Contemporary cognitive models of PTSD theorize that a preponderance of information processing resources are allocated toward threat detection and interpretation of innocuous stimuli as threatening, narrowing one's attentional focus at the expense of other cognitive operations. Decades of research have shown support for these cognitive models of PTSD using a variety of tasks and methodological approaches. The primary goal of this review is to summarize the latest neurocognitive and neuroimaging research of emotion-cognition interactions in PTSD. To directly assess the influence of emotion on cognition and vice versa, the studies reviewed employed challenge tasks that included both cognitive and emotional components. The findings provide evidence for memory and attention deficits in PTSD that are often associated with changes in functional brain activity. The results are reviewed to provide future directions for research that may direct better and more effective treatments for PTSD.

Emotion and cognition interactions in PTSD: a review of neurocognitive and neuroimaging studies

Posttraumatic stress disorder (PTSD) is a psychiatric syndrome that develops after exposure to terrifying and life-threatening events including warfare, motor-vehicle accidents, and physical and sexual assault. The emotional experience of psychological trauma can have long-term cognitive effects. The hallmark symptoms of PTSD involve alterations to cognitive processes such as memory, attention, planning, and problem solving, underscoring the detrimental impact that negative emotionality has on cognitive functioning. As such, an important challenge for PTSD researchers and treatment providers is to understand the dynamic interplay between emotion and cognition. Contemporary cognitive models of PTSD theorize that a preponderance of information processing resources are allocated toward threat detection and interpretation of innocuous stimuli as threatening, narrowing one's attentional focus at the expense of other cognitive operations. Decades of research have shown support for these cognitive models of PTSD using a variety of tasks and methodological approaches. The primary goal of this review is to summarize the latest neurocognitive and neuroimaging research of emotion-cognition interactions in PTSD. To directly assess the influence of emotion on cognition and vice versa, the studies reviewed employed challenge tasks that included both cognitive and emotional components. The findings provide evidence for memory and attention deficits in PTSD that are often associated with changes in functional brain activity. The results are reviewed to provide future directions for research that may direct better and more effective treatments for PTSD.