Memory functioning in adult women traumatized by childhood sexual abuse

Association of childhood trauma with cognitive domains in adult patients with mental disorders and in non-clinical populations: a systematic review

Although the association between cognitive performances and the onset of psychiatric disorders has been widely investigated, limited research on the role of childhood trauma or early life stress (CT/ELS), and whether this role differs between clinical and non-clinical cohorts is available. This systematic review aims at filling this gap, testing whether the occurrence of CT/ELS and its subtypes are associated with cognitive domains (general cognitive ability, executive functions, working memory, attention, processing speed, verbal/visual memory) in patients with psychiatric disorders and in non-clinical populations. This study followed the PRISMA 2020 guidelines and the Newcastle-Ottawa scale for quality assessment. The search was performed until May 2022. Seventy-four studies were classified as eligible. The graphical representations of the results reported an association between exposure to CT/ELS and worse general cognitive ability, verbal/visual memory, processing speed and attention in patients affected by anxiety, mood and psychotic disorders, and that specific CT/ELS subtypes (physical neglect, physical/sexual abuse) can differentially influence specific cognitive abilities (executive functions, attention, working memory, verbal/visual memory). In non-clinical cohorts we found associations between CT/ELS exposure and impairments in executive functions, processing speed and working memory, while physical neglect was related to general cognitive ability and working memory. Concerning the emotional abuse/neglect subtypes in both populations, the results indicated their involvement in cognitive functioning; however, the few studies conducted are not enough to reach definitive conclusions. These findings suggest an association of CT/ELS with specific cognitive deficits and psychopathology.

Learning to forget: Hippocampal-amygdala connectivity partially mediates the effect of sexual trauma severity on verbal recall in older women undiagnosed with posttraumatic stress disorder

Verbal learning deficits are common among sexually traumatized women who have not been formally diagnosed with posttraumatic stress disorder (PTSD). Aberrant resting-state functional connectivity (rsFC) of the amygdala and hippocampus are implicated in PTSD and verbal memory impairment. We tested rsFC between bilateral dentate gyrus (DG) and both centromedial (CM) and basolateral (BL) nuclei of the amygdala as statistical mediators for the effect of sexual trauma-related symptom severity on delayed verbal recall performance in 63 older women (age: 60-85 years) undiagnosed with PTSD. Participant data were drawn from the NKI-Rockland Study. Individuals completed a 10-min resting-state scan, Rey Auditory Verbal Learning Test (RAVLT), and the Sexual Abuse Trauma Index (SATI) from the Trauma Symptom Checklist. Z-scores indicating rsFC of DG with BL and CM amygdala seeds were evaluated in two separate mediation models. Higher SATI scores were associated with lower RAVLT after controlling for age, β = -.23, 95% CI [.48, .03], p = .039. This effect was negated upon adding a negative path from SATI to rsFC of left DG and right CM, β = -.29, 95% CI [-.52, -.02], p = .022, and a positive path from that seed pair to RAVLT List A recall, β = .28, 95% CI [.03, 0.48], p = .015. Chi-square fit indices supported partial mediation by this seed pair, p = .762. In the absence of PTSD sexual trauma symptoms partially relate to verbal learning deficits as a function of aberrant rsFC between left hippocampus DG and right amygdala CM nuclei.

Functional Alterations and Cerebral Variations in Humans Exposed to Early Life Stress

Early life stress can be caused by acute or chronic exposure to childhood events, such as emotional, physical, sexual abuse, and neglect. Early stress is associated with subsequent alterations in physical and mental health, which can extend into adolescence, adulthood, and even old age. The effects of early stress exposure include alterations in cognitive, neuropsychological, and behavioral functions, and can even lead to the development of psychiatric disorders and changes in brain anatomy. The present manuscript provides a review of the main findings on these effects reported in the scientific literature in recent decades. Early life stress is associated with the presence of psychiatric disorders, mainly mood disorders such as depression and risk of suicide, as well as with the presence of post-traumatic stress disorder. At the neuropsychological level, the involvement of different mental processes such as executive functions, abstract reasoning, certain memory modalities, and poor school-skill performance has been reported. In addition, we identified reports of alterations of different subdomains of each of these processes. Regarding neuroanatomical effects, the involvement of cortical regions, subcortical nuclei, and the subcortical white matter has been documented. Among the telencephalic regions most affected and studied are the prefrontal cortex, the hippocampus, the amygdala, and the anterior cingulate cortex. Understanding the impact of early life stress on postnatal brain development is very important for the orientation of therapeutic intervention programs and could help in the formulation and implementation of preventive measures as well as in the reorientation of research targets.

Cognitive Training for Mild Traumatic Brain Injury and Posttraumatic Stress Disorder

Although there is evidence of mild cognitive impairments for many individuals with mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD), little research evaluating the effectiveness of cognitive training interventions has been conducted. This randomized controlled trial examined the effectiveness of a 9-h group cognitive training targeting higher-order functions, Strategic Memory Advanced Reasoning Training (SMART), compared to a 9-h psychoeducational control group in improving neurocognitive functioning in adults with mTBI and PTSD. A sample of 124 adults with histories of mild TBI (n = 117) and/or current diagnoses of PTSD (n = 84) were randomized into SMART (n = 66) or Brain Health Workshop (BHW; n = 58) and assessed at three time points: baseline, following training, and 6 months later. Participants completed a battery of neurocognitive tests, including a test of gist reasoning (a function directly targeted by SMART) as well as tests of verbal, visual, and working memory and executive functioning, functions commonly found to be mildly impaired in mTBI and PTSD. The two groups were compared on trajectories of change over time using linear mixed-effects models with restricted maximum likelihood (LMM). Contrary to our hypothesis that SMART would result in superior improvements compared to BHW, both groups displayed statistically and clinically significant improvements on measures of memory, executive functioning, and gist reasoning. Over 60% of the sample showed clinically significant improvements, indicating that gains can be found through psychoeducation alone. A longer SMART protocol may be warranted for clinical samples in order to observe gains over the comparison group.

Posttraumatic stress disorder and psychiatric co-morbidity: symptoms in a random sample of female Bosnian refugees

Objectives

This study investigated psychological symptoms in Bosnian women 3–4 years after their arrival in Sweden.

Methods

A simple random sample of 163 Bosnian women aged 19–59 was drawn from the Swedish populations register in 1996. The control group consisted of 392 Swedish-born women. Data were collected in face-to-face interviews. The Hopkins Symptom Checklist 25 (HSCL-25) and the Posttraumatic Symptom Scale (PTSS-10) were used to measure psychological symptoms of depression, anxiety, psychological distress, and posttraumatic stress disorder (PTSD). Unconditional logistic regression was used to estimate odds ratios (OR) for psychological symptoms after adjustment for age, country of birth, education, marital status, economic difficulties, social network, and feeling secure.

Results

The prevalence of symptoms of PTSD was 28.3% among the Bosnian women. Bosnian women had significantly higher risks of symptoms of depression, anxiety, and psychological distress than Swedish-born women. For depression the odds ratio was 9.50 among Bosnian women.

Conclusions

Psychiatric community interventions need to target Bosnian refugee women. Awareness among health-care workers who encounter these women in a clinical setting should be improved.

Increased recruitment of cognitive control in the presence of traumatic stimuli in complex PTSD

A neurocircuitry model of post-traumatic stress disorder (PTSD) suggests increased amygdala responses to emotional stimuli, coupled with hypoactivation of prefrontal regions associated with cognitive control. However, results are heterogenous across different subsamples of PTSD as well as different paradigms. We investigated cognitive control in a classic and emotional Stroop task in 28 female patients with complex PTSD (cPTSD), 28 female trauma-exposed healthy controls (TCs) and 28 female non-trauma-exposed healthy controls (HCs) using functional neuroimaging. Afterwards, we assessed memory function in a spontaneous free recall and recognition task. Patients with cPTSD displayed significantly greater Stroop interference with trauma-related words (as reflected in slower reaction times and increased errors) compared to the other conditions and compared to the TC and HC groups. Moreover, patients with cPTSD showed increased activation in the context of trauma-related words in brain regions associated with cognitive control (dlPFC, vmPFC, dACC) compared to both control groups, and a trend for increased activation in the insula compared to the HC group. Increased recruitment of regions contributing to cognitive control in patients with cPTSD, together with a lack of amygdala response may point to efforts to compensate for emotional distraction caused by the trauma-related words.

Sexual abuse but not posttraumatic stress disorder is associated with neurocognitive deficits in South African traumatized adolescents

OBJECTIVES

Neurocognitive impairments are commonly observed in adults suffering from posttraumatic stress disorder (PTSD). The picture is less clear in adolescents. Childhood sexual abuse (CSA) may have an independent influence on neuropsychological test performance and provide partial explanatory power of the inconsistent findings. We hypothesized that adolescents with PTSD who have also suffered sexual abuse would have most pronounced deficits on neurocognitive testing.

METHODS

In a cross-sectional design, 105 traumatized South African adolescents, of whom 52 fulfilled criteria of PTSD and 34 reported CSA, were studied. A comprehensive neurocognitive battery including tests of memory, executive functioning, and language was used to analyze the associations of neurocognitive impairments with PTSD and CSA.

RESULTS

Adolescents reporting CSA manifested impairments in proactive and retroactive interference tasks on the Rey Auditory Verbal Learning test and in the copy condition of the Rey Osterrieth figure test, indicating deficits in attention and working memory. Against our hypothesis, no independent effects of PTSD were found on neurocognitive performance. Results were independent of comorbid psychiatric diagnoses.

CONCLUSIONS

Sexual abuse seems to have an independent influence on attention and working memory. This could be an early sign of hippocampal impairment.

Dissociation between working memory performance and proactive interference control in post-traumatic stress disorder

Deficits in working memory (WM) and cognitive control processes have been reported in post-traumatic stress disorder (PTSD), in addition to clinical symptoms such as hypervigilance, re-experiencing, and avoidance of trauma reminders. Given the uncontrollable nature of intrusive memories, an important question is whether PTSD is associated with altered control of interference in WM. Some studies also suggest that episodic memory shows a material-specific dissociation in PTSD, with greater impairments in verbal memory and relative sparing of nonverbal memory. It is unclear whether this dissociation applies to WM, as no studies have used identical task parameters across material. Here we tested 29 combat Veterans with PTSD and 29 age-matched control Veterans on a recent probes WM task with words and visual patterns in separate blocks. Participants studied four-item sets, followed by a probe stimulus that had been presented in the previous set (recent probe) or not (nonrecent probe). Participants with PTSD made more errors than controls, and this decrement was similar for verbal and visual stimuli. Proactive interference from items recently presented, but no longer relevant, was not significantly different in the PTSD group and showed no relationship to re-experiencing symptom severity. These results demonstrate that PTSD is not reliably associated with increased intrusions of irrelevant representations into WM when non-emotional stimuli are used. Future studies that use trauma-related material may provide insight into the flashbacks and intrusive thoughts that plague those with PTSD.

Reversal learning deficits in criminal offenders: Effects of psychopathy, substance use, and childhood maltreatment history

Deficits in reinforcement learning are presumed to underlie the impulsive and incorrigible behavior exhibited by psychopathic criminals. However, previous studies documenting reversal learning impairments in psychopathic individuals have not investigated this relationship across a continuous range of psychopathy severity, nor have they examined how reversal learning impairments relate to different psychopathic traits, such as the interpersonal-affective and lifestyle-antisocial dimensions. Furthermore, previous studies have not considered the role that childhood maltreatment and substance use may have in this specific cognitive deficit. Using a standard reversal learning task in a sample of N = 114 incarcerated male offenders, we demonstrate a significant relationship between psychopathy severity and reversal learning errors. Furthermore, we show a significant interaction between psychopathy and childhood maltreatment, but not substance use, such that individuals high in psychopathy with an extensive history of maltreatment committed the greatest number of reversal learning errors. These findings extend the current understanding of reversal learning performance among psychopathic individuals, and highlight the importance of considering childhood maltreatment when studying psychopathy.

Does developmental timing of exposure to child maltreatment predict memory performance in adulthood? Results from a large, population-based sample

Although maltreatment is a known risk factor for multiple adverse outcomes across the lifespan, its effects on cognitive development, especially memory, are poorly understood. Using data from a large, nationally representative sample of young adults (Add Health), we examined the effects of physical and sexual abuse on working and short-term memory in adulthood. We examined the association between exposure to maltreatment as well as its timing of first onset after adjusting for covariates. Of our sample, 16.50% of respondents were exposed to physical abuse and 4.36% to sexual abuse by age 17. An analysis comparing unexposed respondents to those exposed to physical or sexual abuse did not yield any significant differences in adult memory performance. However, two developmental time periods emerged as important for shaping memory following exposure to sexual abuse, but in opposite ways. Relative to non-exposed respondents, those exposed to sexual abuse during early childhood (ages 3-5), had better number recall and those first exposed during adolescence (ages 14-17) had worse number recall. However, other variables, including socioeconomic status, played a larger role (than maltreatment) on working and short-term memory. We conclude that a simple examination of "exposed" versus "unexposed" respondents may obscure potentially important within-group differences that are revealed by examining the effects of age at onset to maltreatment.

Chronic stress and brain plasticity: Mechanisms underlying adaptive and maladaptive changes and implications for stress-related CNS disorders

Stress responses entail neuroendocrine, autonomic, and behavioral changes to promote effective coping with real or perceived threats to one's safety. While these responses are critical for the survival of the individual, adverse effects of repeated exposure to stress are widely known to have deleterious effects on health. Thus, a considerable effort in the search for treatments to stress-related CNS disorders necessitates unraveling the brain mechanisms responsible for adaptation under acute conditions and their perturbations following chronic stress exposure. This paper is based upon a symposium from the 2014 International Behavioral Neuroscience Meeting, summarizing some recent advances in understanding the effects of stress on adaptive and maladaptive responses subserved by limbic forebrain networks. An important theme highlighted in this review is that the same networks mediating neuroendocrine, autonomic, and behavioral processes during adaptive coping also comprise targets of the effects of repeated stress exposure in the development of maladaptive states. Where possible, reference is made to the similarity of neurobiological substrates and effects observed following repeated exposure to stress in laboratory animals and the clinical features of stress-related disorders in humans.

Avoidance symptoms and delayed verbal memory are associated with post-traumatic stress symptoms in female victims of sexual violence

BACKGROUND

Victimization by sexual violence is strongly associated with the development of posttraumatic stress disorder (PTSD). While several psychological and cognitive factors are known to be associated with PTSD prognosis, multivariable analysis is scarce. This study examined factors affecting the severity of PTSD symptoms in early stage of traumatic experience of sexual violence, including initial post-traumatic symptoms and cognitive characteristics.

METHODS

Participants were recruited from the center for women and children victims of violence in a university hospital. Thirty-four sexual assault victims were assessed at the baseline and the second visit one to five months after the baseline. At the baseline, an array of posttraumatic symptoms and cognitive functions were measured: at follow-up, PTSD symptoms were determined by Clinician Administered PTSD Scale.

RESULTS

Stepwise multiple regression showed that avoidance symptoms (β = 0.551, P < 0.01) and delayed verbal memory (β = -0.331, P < 0.05) at early stage of trauma predicted the severity of PTSD symptoms one to five month later. The regression model, factoring in avoidance and delayed verbal memory, showed a 34.9% explanatory power regarding the PTSD symptom severity.

CONCLUSION

This study suggests that avoidance symptoms and verbal memory at the early stage of trauma are associated with later PTSD symptoms. It is also suggested that early intervention targeting avoidance symptoms may be beneficial in decreasing PTSD symptoms.

Neuropsychological findings in pediatric maltreatment: relationship of PTSD, dissociative symptoms, and abuse/neglect indices to neurocognitive outcomes

Maltreated (n = 38), maltreated + posttraumatic stress disorder (PTSD; n = 60), and control youth (n = 104) underwent comprehensive neuropsychological testing. The two maltreated groups performed significantly lower on IQ, academic achievement, and nearly all of the neurocognitive domains than controls. Maltreated + PTSD performed significantly worse than maltreated youth without PTSD on a task in the visuospatial domain that assessed higher order visuoconstructive abilities. No group differences were evident on the fine motor domain. PTSD diagnosis duration negatively correlated with the visuospatial, and dissociation negatively correlated with the attention domain. Cumulative lifetime maltreatment types experienced negatively correlated with academic achievement. Sexual abuse negatively correlated with language and memory functions after controlling for other maltreatment types. These data support the adverse effects of maltreatment on neuropsychological functions in youth and suggest that all child protective services identified youth should be comprehensively examined for the integrity of their neuropsychological functioning and academic skills, regardless of the presence or absence of mental health symptoms.

Post-traumatic stress disorder and declarative memory functioning: a review

Declarative memory dysfunction is associated with post-traumatic stress disorder (PTSD). This paper reviews this literature and presents two frameworks to explain the nature of this dysfunction: that memory deficits are a product of neurobiological abnormalities caused by PTSD andlor that pre-existing memory deficits serve as a risk factor for the development of PTSD following trauma exposure. Brain regions implicated in declarative memory deficits include the hippocampus and prefrontal cortex, and imaging and biochemistry studies as they relate to memory dysfunction are described. Prospective and twin studies provide support for a risk factor model.

Hippocampal dysfunction effects on context memory: possible etiology for posttraumatic stress disorder

Hippocampal volume reductions and functional impairments are reliable findings in posttraumatic stress disorder (PTSD) imaging studies. However, it is not clear if and how hippocampal dysfunction contributes to the etiology and maintenance of PTSD. Individuals with PTSD are often described as showing fear responses to trauma reminders outside of contexts in which these cues would reasonably predict danger. Animal studies suggest that the hippocampus is required to form and recall associations between contextual stimuli and aversive events. For example, the hippocampus is critical for encoding memories in which a complex configuration of multiple cues is associated with the aversive event. Conversely, the hippocampus is not required for associations with discrete cues. In animal studies, if configural memory is disrupted, learning strategies using discrete cue associations predominate. These data suggest poor hippocampal function could bias the organism toward forming multiple simple cue associations during trauma, thus increasing the chances of fear responses in multiple environments (or contexts) in which these cues may be present. Here we will examine clinical and preclinical literature to support a theory of hippocampal dysfunction as a primary contributory factor to the etiology of PTSD, and discuss future research required to test these hypotheses. This article is part of a Special Issue entitled 'Post-Traumatic Stress Disorder'.

Adverse childhood environment and late-life cognitive functioning

OBJECTIVE

Clinical studies suggest that childhood maltreatment may cause nervous system changes and consequent cognitive disorder. The persistence of this association in late-life is examined.

METHODS

Cognitive functioning and childhood events were examined in 1282 persons over 65 years, taking into account proximal competing causes of poor cognitive performance.

RESULTS

Ninety one per cent experienced at least one adverse childhood event, of these 14.7% severe events. Sharing of parental problems and, for women, loss of a parent were associated with poorer verbal retrieval whereas being sent to a foster home or mistreatment by schoolmates was associated with poorer visuospatial memory. Severe abuse was associated with a lower risk of cognitive impairment on some tests suggesting a resilience factor. Positive childhood environment was protective although only for non-carriers of the ApoE ε4 allele on the central executive task.

CONCLUSIONS

Some adverse childhood events continue to have a negative effect on later-life cognitive performance, while some more severe acute events may have the opposite effect, underlying the necessity to consider events individually and not as global test scores.

Longitudinal effects of PTSD on memory functioning

Numerous studies have demonstrated explicit and working memory deficits related to posttraumatic stress disorder (PTSD), but few have addressed longitudinal changes in memory functioning. There is some evidence to suggest an interactive effect of PTSD and aging on verbal memory decline in Holocaust survivors (Yehuda et al., 2006). However, the longitudinal trajectory of neuropsychological functioning has not been investigated in Vietnam veterans, a younger but substantial population of aging trauma survivors. We administered tests of visual and verbal memory, and working memory to derive different dependent measures in veterans between the ages of 41 and 63, the majority of whom served in the Vietnam War. Twenty-five veterans with PTSD and 22 veterans without PTSD were assessed over two time points (mean age at follow-up = 54.0; mean inter-test interval = 34 months). The PTSD+ group, consisting of veterans with chronic, primarily combat-related PTSD, did not show a significant change in PTSD symptoms over time. Compared to veterans without PTSD, veterans with PTSD showed a greater decline in delayed facial recognition only, and this decline was extremely subtle.

Cognitive impairment and functioning in PTSD related to intimate partner violence

Posttraumatic stress disorder (PTSD) has been associated with neuropsychological impairments across multiple domains, but consensus regarding the cognitive profile of PTSD has not been reached. In this study of women with PTSD related to intimate partner violence (n = 55) and healthy, demographically similar comparison participants (NCs; n = 20), we attempted to control for many potential confounds in PTSD samples. All participants were assessed with a comprehensive neuropsychological battery emphasizing executive functioning, including inhibition, switching, and abstraction. NCs outperformed PTSD participants on most neuropsychological measures, but the differences were significant only on speeded tasks (with and without executive functioning components). The PTSD group's mean performance was within the average range on all neuropsychological tests. Within the PTSD group, more severe PTSD symptoms were associated with slower processing speed, and more severe dissociative symptoms were associated with poorer reasoning performance. These results suggest that women with PTSD related to intimate partner violence demonstrate slower than normal processing speed, which is associated with the severity of psychiatric symptoms. We speculate that the cognitive slowing seen in PTSD may be attributable to reduced attention due to a need to allocate resources to cope with psychological distress or unpleasant internal experiences.

The posttraumatic stress disorder project in Brazil: neuropsychological, structural and molecular neuroimaging studies in victims of urban violence

BACKGROUND

Life trauma is highly prevalent in the general population and posttraumatic stress disorder is among the most prevalent psychiatric consequences of trauma exposure. Brazil has a unique environment to conduct translational research about psychological trauma and posttraumatic stress disorder, since urban violence became a Brazilian phenomenon, being particularly related to the rapid population growth of its cities. This research involves three case-control studies: a neuropsychological, a structural neuroimaging and a molecular neuroimaging study, each focusing on different objectives but providing complementary information. First, it aims to examine cognitive functioning of PTSD subjects and its relationships with symptomatology. The second objective is to evaluate neurostructural integrity of orbitofrontal cortex and hippocampus in PTSD subjects. The third aim is to evaluate if patients with PTSD have decreased dopamine transporter density in the basal ganglia as compared to resilient controls subjects. This paper shows the research rationale and design for these three case-control studies.

METHODS AND DESIGN

Cases and controls will be identified through an epidemiologic survey conducted in the city of São Paulo. Subjects exposed to traumatic life experiences resulting in posttraumatic stress disorder (cases) will be compared to resilient victims of traumatic life experiences without PTSD (controls) aiming to identify biological variables that might protect or predispose to PTSD. In the neuropsychological case-control study, 100 patients with PTSD, will be compared with 100 victims of trauma without posttraumatic stress disorder, age- and sex-matched controls. Similarly, 50 cases and 50 controls will be enrolled for the structural study and 25 cases and 25 controls in the functional neuroimaging study. All individuals from the three studies will complete psychometrics and a structured clinical interview (the Structured Clinical Interview for DSM-IV and the Clinician-Administered PTSD Scale, Beck Anxiety Inventory, Beck Depression Inventory, Global Assessment of Function, The Social Adjustment Scale, Medical Outcomes Study 36-Item Short-Form Health Survey, Early Trauma Inventory, Clinical global Impressions, and Peritraumatic Dissociative Experiences Questionnaire). A broad neuropsychological battery will be administered for all participants of the neuropsychological study. Magnetic resonance scans will be performed to acquire structural neuroimaging data. Single photon emission computerized tomography with [(99m)Tc]-TRODAT-1 brain scans will be performed to evaluate dopamine transporters.

DISCUSSION

This study protocol will be informative for researchers and clinicians interested in considering, designing and/or conducting translational research in the field of trauma and posttraumatic stress disorder.

Neuropsychological performance is related to current social and occupational functioning in veterans with posttraumatic stress disorder

BACKGROUND

Several studies have reported deficits in both immediate and delayed recall of verbal memory in patients with posttraumatic stress disorder (PTSD). However, most of these studies had several methodological disadvantages. None of these studies assessed parameters related to social or occupational functioning.

METHODS

Fifty Dutch veterans of UN peacekeeping missions (25 with PTSD and 25 without PTSD) were assessed with a comprehensive neuropsychological test battery consisting of four subtests of the Wechsler Adult Intelligence Scale-III, California Verbal-Learning Test, and the Rey Auditory Verbal-Learning Test. Veterans with PTSD were free of medication and substance abuse.

RESULTS

Veterans with PTSD had similar total intelligence quotient scores compared to controls, but displayed deficits of figural and logical memory. Veterans with PTSD also performed significantly lower on measures of learning and immediate and delayed verbal memory. Memory performance accurately predicted current social and occupational functioning.

CONCLUSIONS

Deficits of memory performance were displayed in a sample of medication- and substance abuse-free veterans with PTSD. Deficits in memory performance were not related to intelligence quotient, length of trauma exposure, or time since trauma exposure. This study showed that cognitive performance accurately predicted current social and occupational functioning in veterans with PTSD.

Consistent impaired verbal memory in PTSD: a meta-analysis

BACKGROUND

Qualitative review papers have indicated that verbal memory impairment is found to be the most consistent cognitive impairment related to PTSD. These review papers have used qualitative methods to describe the effects, and consequently they have not been able to estimate the strength of the memory-PTSD association.

METHODS

This meta-analysis of 28 studies examined the empirical evidence for this relationship, and factors affecting the results.

RESULTS

Overall, the results showed medium effect sizes in patients with PTSD compared to controls on verbal memory across studies. Marked impairment was found in the patient groups compared to healthy controls, while modest impairment was found compared to exposed non-PTSD controls. Meta-analyses found strongest effects in war veterans compared to sexual and physical assault related PTSD. Rather unexpectedly no effect was found for the sexually abused PTSD groups compared to exposed controls. The analyses further showed that the effect was dependent on the test procedures used. The studies using WMS and AVLT had stronger effects than studies using CVLT.

LIMITATIONS

Insufficient data were available to analyze a more complete attention-memory profile.

CONCLUSIONS

This meta-analysis confirms that verbal memory impairment is present in adults with PTSD, and they are consistent across studies. This impairment should be the focus of work in clinical settings.

Low plasma brain-derived neurotrophic factor and childhood physical neglect are associated with verbal memory impairment in major depression--a preliminary report

BACKGROUND

Early life stress has been suggested to mediate vulnerability to affective disorders. Animal models of repeated maternal separation have shown reduced brain-derived neurotrophic factor (BDNF) levels in specific brain regions implicated with hypothalamic-pituitary-adrenal axis and memory formation. In addition, BDNF levels are also reduced in major depressive disorder (MDD) and bipolar disorder. The aim of this study was to investigate whether childhood physical neglect (CPN) and plasma BDNF levels would impact on memory performance in adult female subjects with recurrent major depression.

METHODS

Recurrent female MDD outpatients with CPN (MDD + CPN, n = 17) and without CPN (MDD, n = 17) and healthy control subjects (n = 15) were assessed for plasma BDNF content and verbal memory performance. Memory was assessed through the logical memory component of the Weschler Memory Scale-Revised for immediate and delayed recall. Brain-derived neurotrophic factor was assessed with enzyme-linked immunosorbent assays (ELISAs).

RESULTS

Major depressive disorder patients showed lower plasma BDNF concentrations than healthy control subjects (p < .001). Major depressive disorder + CPN had even lower BDNF levels compared with control subjects and MDD (p < .05). Brain-derived neurotrophic factor levels were negatively related to psychological morbidity and positively correlated to memory performance. Regression models showed that severity of self-reported CPN and low plasma BDNF predicted impairment on immediate verbal recall. Delayed recall impairment was predicted by severity of CPN and depression and memory retention by posttraumatic stress disorder (PTSD) severity symptoms.

CONCLUSIONS

Our data suggest that CPN and plasma BDNF are important factors associated with depression and verbal memory performance, particularly with encoding processes.

Traumatic stress: effects on the brain

Brain areas implicated in the stress response include the amygdala, hippocampus, and prefrontal cortex. Traumatic stress can be associated with lasting changes in these brain areas. Traumatic stress is associated with increased cortisol and norepinephrine responses to subsequent stressors. Antidepressants have effets on the hippocampus that counteract the effects of stress. Findings from animal studies have been extended to patients with post-traumatic stress disorder (PTSD) showing smaller hippocampal and anterior cingulate volumes, increased amygdala function, and decreased medial prefrontal/anterior cingulate function. In addition, patients with PTSD show increased cortisol and norepinephrine responses to stress. Treatments that are efficacious for PTSD show a promotion of neurogenesis in animal studies, as well as promotion of memory and increased hippocampal volume in PTSD.

PTSD psychiatric patients exhibit a deficit in remembering

This study investigated the effects of PTSD on levels of awareness in a recognition memory task. A group of PTSD psychiatric patients and a control group without any traumatic experience were compared in remembering (R) versus knowing (K) recognition using non-trauma-related words. Results showed that overall recognition did not differ between the two groups, but in the PTSD group a significantly different pattern of Remember and Know responses was produced, indicating a shift from remembering to knowing. However, this shift from remembering to knowing in individuals with PTSD is associated with modifications in the trait anxiety level. These results are interpreted within theoretical frameworks in which R responses could be associated with distinctiveness (Rajaram, 1996) and conceptual processing (Ehlers & Clark, 2000). These collective findings would suggest the possibility that a poor general ability in the formation of source memory may eventually be a common characteristic across different types of PTSD.

Is posttraumatic stress disorder associated with specific deficits in episodic memory?

People with PTSD often report difficulties remembering day to day information unrelated to their traumatic episode. In addition, structural and functional imaging techniques have identified abnormalities in the brains of people with PTSD in regions known to be important for memory functioning. Nevertheless, studies investigating cognitive functioning in people with PTSD have reported widely varying results. The aim of this review is to investigate studies reporting performance on tests of episodic memory. Specifically, papers were examined in relation to the hypothesised memory functions of the frontal lobes, the hippocampus and the amygdala. It is concluded that while there is reasonable evidence of frontal lobe involvement, memory deficits caused by hippocampal involvement have been more difficult to detect. There are no published studies looking at the involvement of the amygdala although preliminary evidence suggests that people with PTSD do have memory deficits resulting from dysfunction of this structure. Reasons for the inconclusiveness of the results are discussed.

Neuropsychological functioning in posttraumatic stress disorder and alcohol abuse

Studies have shown differences in neuropsychological functioning between groups with posttraumatic stress disorder (PTSD) and control participants. Because individuals with PTSD often have a history of comorbid alcohol abuse, the extent to which an alcohol confound is responsible for these differences remains a concern. The current study compares neuropsychological testing scores in 4 groups of veterans with and without PTSD (PTSD+ and PTSD-, respectively) and with and without a history of alcohol abuse (ETOH+ and ETOH-, respectively): n for PTSD+/ETOH- = 30, n for PTSD+/ETOH- = 37, n for PTSD-/ETOH+ = 30, and n for PTSD-/ETOH- = 31. Results showed that PTSD, when alcohol, educational level, vocabulary, and depression are controlled for, was associated with decreased verbal memory, attention, and processing speed performance. Alcohol abuse history was associated with decreased visual memory performance. By controlling for alcohol and depression, the authors can more conclusively demonstrate that verbal memory and attention differences are associated with PTSD.

Memory performance in older trauma survivors: implications for the longitudinal course of PTSD

Impaired declarative memory performance and smaller hippocampal volume have been observed in young and middle-aged adults with chronic posttraumatic stress disorder (PTSD). These alterations may put trauma survivors with PTSD at greater risk for cognitive decline in later life. This article focuses on the emerging literature on neuropsychological impairment in aging trauma survivors, in particular, elderly combat veterans and survivors of the Holocaust. In veterans and in Holocaust survivors, PTSD was associated with substantial impairments in learning, free and cued recall, and recognition memory compared to the respective nonexposed subjects; however, in neither group was PTSD associated with impaired retention or "rapid forgetting." Additionally, PTSD was not associated with smaller right or left hippocampal volume in either cohort. PTSD is associated with considerable cognitive burden with age. Longitudinal studies of older subjects are warranted to examine whether PTSD is associated with accelerated aging or progressive memory loss.

IQ and posttraumatic stress symptoms in children exposed to interpersonal violence

BACKGROUND

The literature is mixed as to the relationship between intelligence quotient (IQ) and Posttraumatic Stress Disorder (PTSD) symptomatology in adult populations. Even less is known about the relationship in children who have been traumatized.

METHODS

Fifty-nine children and adolescents (mean age = 10.6) with a history of interpersonal violence were evaluated with respect to PTSD symptomatology, number of traumas, and estimated Verbal, Performance and Full scale IQ scores. PTSD symptomatology included symptom levels for cluster B (re-experiencing), cluster C (avoidance and numbing), and cluster D (Hypervigilance) and criterion F, functional impairment.

RESULTS

Results indicated that Full scale and Verbal IQ were significantly associated with the number of traumas, re-experiencing symptoms, and impairment. Performance IQ was only associated with impairment. Regression analyses suggested that together PTSD symptomatology predicted Full scale and Verbal IQ but nor Performance IQ and impairment was the single best predictor of IQ generally.

CONCLUSIONS

Findings provide support for an association between PTSD symptoms and IQ, particularly verbal IQ. Two possible reasons for this relationship are that higher levels of Verbal IQ may serve as a premorbid protective factor against the development of re-experiencing symptoms, or performance on post-trauma Verbal IQ measures may be negatively impacted by expression of PTSD symptoms. Longitudinal studies are needed to clarify which of these two possibilities explains the association.

The relationship between cognitive and brain changes in posttraumatic stress disorder

Preclinical studies show that stress is associated with changes in structure of the hippocampus, a brain area that plays a critical role in memory, inhibition of neurogenesis, and memory deficits. Studies in animals showed that both serotonin reuptake inhibitors (SSRIs) and the epilepsy medication phenytoin (dilantin) block the effects of stress on the hippocampus. Imaging studies in posttraumatic stress disorder (PTSD) have found smaller volume of the hippocampus as measured with magnetic resonance imaging (MRI) in patients with PTSD related to both combat and childhood abuse. These patients were also found to have deficits in memory on neuropsychological testing. Functional imaging studies using positron emission tomography (PET) found decreased hippocampal activation with memory tasks. In an initial study, we found that a year of treatment with paroxetine led to a 5% increase in hippocampal volume and a 35% increase in memory function. A second study showed that phenytoin was efficacious for symptoms of PTSD and led to a significant 6% increase in both right hippocampal and right whole brain volume, with no significant change in memory. These studies suggest that medications may counteract the effects of stress on the brain in patients with PTSD.

Learning and memory in aging combat veterans with PTSD

The California Verbal Learning Test (CVLT) was administered to examine learning and memory performance in aging combat veterans with (n = 30) and without PTSD (n = 20), and veterans unexposed to combat (n = 15). Combat veterans with PTSD (PTSD+) showed many impairments compared to non-exposed veterans, but only long-delay free recall consistently discriminated the PTSD+ group from combat-exposed subjects without PTSD (PTSD-), when data were corrected for subscale scores on the WAIS (Vocabulary, Block Design). Alterations in total learning were associated with PTSD when controlling for substance abuse and depression. Two contrast measures, proactive interference and recognition hits, distinguished combat from noncombat veterans, and may be related to trauma exposure. Impairments in total learning are similar to what has been observed in Holocaust survivors. However, increased severity of rapid forgetting may be a specific alteration in older combat veterans, likely reflecting aspects of both combat exposure and aging.

Deficits in verbal declarative memory function in women with childhood sexual abuse-related posttraumatic stress disorder

Several studies have shown deficits in verbal declarative memory function in posttraumatic stress disorder (PTSD). Most of these studies have been performed in men with combat-related PTSD compared with healthy subjects; relatively little is known about memory function in women with abuse-related PTSD, or whether these effects are specific to PTSD or are a nonspecific outcome of exposure to early abuse. The purpose of this study was to assess declarative memory function in women with and without a history of early childhood sexual abuse and PTSD. Forty-three women with and without a history of early childhood sexual abuse and PTSD underwent neuropsychological testing with subtests of the Wechsler Memory Scale--Revised for measurement of verbal and visual memory and subtests of the Wechsler Adult Intelligence Scale for measurement of IQ, and behavioral ratings of PTSD and other psychiatric symptoms. Abused women with PTSD had deficits in verbal declarative memory as measured with the subtests of the Wechsler Memory Scale--Revised compared with women with early abuse without PTSD and nonabused women without PTSD. There were no significant differences in IQ. These findings suggest that early abuse with PTSD is associated with deficits in verbal declarative memory, and that these effects are not related to the nonspecific effects of childhood abuse.

Traumatic stress, brain changes, and memory deficits: a critical note

Memory deficits are frequently observed in posttraumatic stress disorder. According to some authors, these memory impairments are a result of hippocampal damage caused by traumatic stress. This article contains a critical review of studies on changes in hippocampal volume and memory performance in posttraumatic stress disorder. We conclude that most studies in this area suffer from methodological weaknesses and therefore do no allow for firm conclusions about the causal linkage among traumatic stress, hippocampal functioning, and memory. Suggestions for future research, circumventing methodological flaws, are given.

Hippocampal function in posttraumatic stress disorder

Recent studies have reported memory deficits and reduced hippocampal volumes in posttraumatic stress disorder (PTSD). The goal of the current research was to use functional neuroimaging and a validated explicit memory paradigm to examine hippocampal function in PTSD. We used positron emission tomography (PET) and a word-stem completion task to study regional cerebral blood flow (rCBF) in the hippocampus in 16 firefighters: 8 with PTSD (PTSD group) and 8 without PTSD (Control group). During PET scanning, participants viewed three-letter word stems on a computer screen and completed each stem with a word they had previously encoded either deeply (High Recall condition) or shallowly (Low Recall condition). Relative to the Control group, the PTSD group exhibited significantly smaller rCBF increases in the left hippocampus in the High vs Low Recall comparison. However, this finding reflected relatively elevated rCBF in the Low Recall condition in the PTSD group. Collapsing across High and Low Recall conditions, (1) the PTSD group had higher rCBF in bilateral hippocampus and left amygdala than the Control group, and (2) within the PTSD group, symptom severity was positively associated with rCBF in hippocampus and parahippocampal gyrus. The groups did not significantly differ with regard to accuracy scores on the word-stem completion task. The PTSD group had significantly smaller right (and a trend for smaller left) hippocampal volumes than the Control group. The results suggest an abnormal rCBF response in the hippocampus during explicit recollection of nonemotional material in firefighters with PTSD, and that this abnormal response appears to be driven by relatively elevated hippocampal rCBF in the comparison condition.

Neuropsychological function in college students with and without posttraumatic stress disorder

Previous research on the neuropsychology of posttraumatic stress disorder (PTSD) has identified several neurocognitive deficits that co-occur with the disorder. However, it remains unclear whether these deficits are due to trauma exposure, PTSD symptomatology or psychiatric/substance abuse comorbidity. We examined trauma exposure, PTSD symptoms and neuropsychological performance in 235 undergraduate students, i.e. a non-clinical sample. The sample comprised 146 subjects with trauma exposure (38 with current PTSD and 108 without lifetime PTSD) and 89 no-trauma comparison (NC) subjects who were administered tests of attention, working memory, psychomotor speed, word generation and executive functioning. Relationships of neuropsychological functioning to measures of psychiatric symptoms and substance abuse were examined. Current PTSD (PTSD+), trauma-exposed without PTSD (PTSD-) and NC subjects did not differ significantly on the vast majority of neuropsychological tests. There were very few significant associations between neuropsychological performance and clinical variables, and those that were statistically significant were small in magnitude. The striking lack of differences in neuropsychological performance between the three groups suggests that college students with trauma exposure, regardless of the presence of PTSD symptoms, may be cognitively resilient. Neuropsychological impairment may not be an invariant feature of PTSD, but when it is present, it may be associated with poorer functional outcomes.

The accumulative effect of trauma exposure on short-term and delayed verbal memory in a treatment-seeking sample of female rape victims

The accumulative effect of prior high-magnitude trauma exposure on memory was examined in 73 rape victims, 92% of whom had current posttraumatic stress disorder (PTSD). Participants were administered the Logical Memory component of the Wechsler Memory Scale, the Quick Test to obtain an estimate of intelligence, and were assessed for prior traumatic experiences. Prior exposure to high-magnitude stressors (e.g., child rape, being kidnapped) was significantly correlated with poorer performance on the memory tasks. Regression analyses controlling for estimated IQ and psychopathology severity demonstrated that magnitude of prior trauma exposure predicted performance on the memory task, suggesting that in the current sample, deficits in verbal memory may be related (in part) to the degree of accumulative stress experienced over the lifetime.

Sexual violence among a cohort of injection drug users

The objective of this study was to determine the prevalence of, and factors associated with, sexual violence in childhood, adolescence and adulthood, among injection drug using men and women. The Vancouver Injection Drug User Study is a prospective cohort of injection drug users (IDU) begun in 1996. The analysis included all individuals who completed the baseline questionnaire who responded to a question about sexual assault. Multivariate modeling was used to determine and to what extent a history of sexual violence at different ages is predictive of HIV risk and other health risk behaviors. HIV prevalence was calculated as the total current number of HIV-positive individuals in the cohort. Of the 1437 eligible individuals, 36% reported a lifetime history of sexual violence; 68% of women, and 19% of men (p<0.001). After adjusting for fixed sociodemographics, these individuals were more likely to have ever been in the sex trade, to knowingly share needles/rigs with HIV-positive people, to have attempted suicide, to have ever accidentally overdosed, to binge on alcohol, and to have been diagnosed with a mental disorder/disability. The prevalence of child sexual abuse in this cohort is 21%; 33% for women, and 13% for men. The data show a dose-response relationship between age at first sexual violence and most risk behaviors examined. These relationships are further mediated by gender. The prevalence of HIV among individuals who ever experienced sexual violence was 25%, compared to 19% among those who never experienced sexual violence (p=0.006). Sexual violence, and especially child sexual abuse, is highly prevalent among this cohort, particularly among women. Child sexual abuse has worse consequences for both genders than sexual violence later in life. Nevertheless, women and men are affected differently by sexual violence at different ages, and this has significant implications for health promotion programs, and specifically HIV prevention.

The relevance of differential response to trauma in an animal model of posttraumatic stress disorder

BACKGROUND

Posttraumatic stress disorder affects 20%-30% of those exposed. Clinical studies employ stringent inclusion-exclusion criteria, yet animal studies include the entire exposed population as the study population. We examined the effect of grouping prestressed rats according to magnitude of response on the statistical analysis of results.

METHOD

Response magnitude to predator exposure was assessed and used to group the animals into "diagnostic" groups. Two extremes were studied (clearly "maladapted" and clearly "well adapted" rats) using arbitrarily selected cutoff behavioral criteria (CBC). The data for the middle group were discarded for reasons of clarity. Hypothalamic-pituitary-adrenal axis and heart-rate variability were analyzed for the entire exposed population and then according to the CBC.

RESULTS

A single 10-min exposure to a predator caused fear-related behaviors in only 25.3% of exposed rats. Compared with control subjects and well-adapted exposed rats, maladapted rats exhibited significantly higher plasma corticosterone and corticotropin concentrations, increased sympathetic activity, diminished vagal tone, and increased sympathovagal balance. These differences surfaced only when data were analyzed according to CBC. Animals respond to stress heterogeneously, resembling humans. Overlooking this heterogeneity may obscure the results of data analysis.

CONCLUSIONS

Animals can be divided into distinct groups according to magnitude of response and be studied accordingly.

Neuropsychological function in female victims of intimate partner violence with and without posttraumatic stress disorder

BACKGROUND

Various aspects of neuropsychologic function have been reported to be abnormal in patients with posttraumatic stress disorder (PTSD); however, the majority of these data come from studies of seriously ill, treatment-seeking samples with substantial substance use comorbidity. Few studies have included similarly trauma-exposed subjects without PTSD, and fewer still have focused on women.

METHODS

Thirty-nine female victims of intimate partner violence (IPV; 22 without lifetime PTSD and 17 with current PTSD), and 22 nonvictimized comparison (NC) subjects were administered tests of attention, working memory, visuoconstruction, language ability, learning and memory, and executive functioning.

RESULTS

The IPV and NC subjects did not demonstrate statistically significant differences on most neuropsychologic tests, with the exception of those in the realm of working memory, visuoconstruction, and executive functioning. The IPV subjects, regardless of PTSD status, had poorer performance on tasks of speeded, sustained auditory attention and working memory (Paced Auditory Serial Addition Test) and response inhibition (Stroop). The IPV subjects with PTSD performed worse than NCs on a set-shifting task (Trail Making Test, Part B). No consistent relationships were noted between neuropsychologic functioning and severity of childhood abuse or domestic violence experiences.

CONCLUSIONS

Cognitive deficits in IPV subjects were confined to measures of working memory, visuoconstruction, and executive function; were subtle; and were not uniformly worse among those with current PTSD. This pattern, however, is consistent with frontal-subcortical dysfunction in traumatized women. The clinical significance of these findings deserves further study.

Attention, learning, and memory performances and intellectual resources in Vietnam veterans: PTSD and no disorder comparisons

Attention, learning, memory, and estimated intellectual potential were examined in 26 Vietnam veterans diagnosed with posttraumatic stress disorder (PTSD) and in 21 Vietnam veterans without mental disorders. Results revealed PTSD-associated cognitive deficits on tasks of sustained attention, working memory, initial learning, and estimated premorbid intelligence but not on measures of focus of attention, shift of attention, or memory savings. Cognitive task performances adjusted for estimated native intelligence remained negatively correlated with PTSD severity. An intellectual measure adjusted for cognitive task performances was negatively correlated with PTSD severity, even after the authors statistically controlled the level of combat exposure. Results suggested that although intellectual resources may constitute a vulnerability-protective factor for PTSD development, PTSD was associated with cognitive impairment independent of intellectual functioning.

Genetic predisposition and the development of posttraumatic stress disorder in an animal model

BACKGROUND

Exposure to extremely stressful events can lead to Posttraumatic stress disorder (PTSD). Due to the complexity of PTSD, animal models have been designed and advanced to address the role of psychosocial stressors in the etiology; however, the apparent role of genetics in susceptibility to PTSD-like behaviors in animals remains unexplored.

METHODS

An animal model of congenital learned helpless (cLH) behavior has been used to study the effects of genetic disposition as a risk factor for the development of PTSD-like behaviors. Animals were monitored for changes in pain tolerance, spatial memory and hypothalamic-pituitary-adrenal functioning after re-exposure to intermittent stress in the presence and absence of situational cues.

RESULTS

Exposure to stress resulted in an increase in pain tolerance in the cLH animals. In the spatial memory test 80% of the cLH animals manifested a decrease in performance after exposure to stress. These animals also had a blunted poststress corticosterone response.

CONCLUSIONS

The genetic learned helpless animal model exhibited physiologic symptoms of analgesia, cognitive deficits and hyporesponsivity of the hypothalamic-pituitary-adrenal axis similar to those observed in human subjects with PTSD. It is proposed that the cLH model may be a valuable tool for exploring the role of genetic predisposition in the etiology of PTSD.