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Neuropsychology Review, Vol. 13, No.

4, December 2003 ( C 2003)

Questioning the Link Between PTSD and Cognitive Dysfunction
Angela Danckwerts1,2 and Janet Leathem1

Posttraumatic stress disorder (PTSD) has been linked with impairment in cognitive functioning, but anomalies appear to arise on several levels, masking the true nature of the relationship. On one level, there is a blurring of the emotional and physical causes of cognitive dysfunction, especially with memory problems that are similar to those due to neurological disorders. At other levels, problems are evident due to issues such as overgeneralizing from specific populations to the general population, and the use of narrow-focused neuropsychological assessment instruments that neither dissociate among precise memory components nor relate to everyday situations. In this review we highlight methodological problems and concerns, and make suggestions to establish valid links between PTSD and cognitive dysfunction.
KEY WORDS: PTSD; memory; Cognition.

Posttraumatic Stress Disorder (PTSD) develops after a person has been exposed to an extreme traumatic stressor such as a car accident, rape, natural disaster, violent, or terrorist attack in which they or others were threatened with death or serious injury, and to which they responded with fear, helplessness, or horror. The condition is a relatively common and predictable psychological syndrome (Miller, 1999) and is characterised by a diagnostic triad consisting of reexperiencing of the trauma through intrusive memories, avoidance behaviors, and heightened arousal. The full symptom picture must have been present for more than 1 month and must also cause clinically significant distress, or impairment in social, occupational, and other areas of functioning (American Psychiatric Association [APA-TR], 2000). The psychological consequences of the events of September 11th, 2001, highlighted PTSD as an increasingly important health issue worldwide, and in addition established that more than those directly involved in the traumatic experience run the risk for PTSD sequelae. Significant others and professional helpers have also been shown to be susceptible to PTSD symptomatology af1 Massey

University, Auckland, New Zealand.

2 To whom correspondence should be addressed at School of Psychology,

Massey University, Albany Campus, P.B. 102 904, North Shore Mail Centre, Auckland, New Zealand; e-mail:

ter close association with horrific events (e.g., Lindeman et al., 1996). As a rule of thumb 75% of the general population are likely to experience a traumatic experience that is capable of precipitating PTSD (Green et al., 1994), and a quarter (25%) to a third (33%) of those exposed will go on to develop PTSD symptoms (McCarroll et al., 1997; Yehuda et al., 1992). Research has found the most commonly reported symptom is that of intrusive recollections or reexperiencing memories of the event through recurrent dreams of the event, hallucinations, and dissociative flashbacks. These intrusive recollections are different from the recurrent intrusive thoughts experienced by in those with Obsessive-Compulsive Disorder (OCD). Although OCD intrusive recollections are inappropriate and not related to an experienced traumatic event, PTSD recollections may include intrusive thoughts, images, or perceptions, or acting or feeling that the traumatic event is recurring, and are generally triggered automatically by cues relating to the traumatic experience. The individual will also try to avoid stimuli associated with the original trauma. Efforts to evade people, places, feelings, thoughts, conversations, or participation in activities that arouse recollections of the trauma are common. The person may feel numb, experience flat affect, feel detached from others, and have a sense of foreshortened future. At the same time they may show 221

2003 Plenum Publishing Corporation

This can be compared with the risk for PTSD to those exposed to extremely high stressful events such as combat. Any of these traumatic experiences may predispose or contribute to the development of PTSD symptoms. and is strongly influenced by the degree of attention and organization. 1991). This is because the disorder affects Danckwerts and Leathem nondeclarative and declarative memory processes in different ways (Brewin. 1993). 1995.. However. 1992. C. intrusive thoughts. Bryant and Harvey. and have difficulty in falling asleep (APA-TR. MEMORY DISTINCTIONS It is important when discussing memory dysfunction in those with PTSD.222 persistent signs of hypervigilance or increased arousal. although lawyers and treating therapists routinely assume that beneath PTSD symptoms the disorder lurks. and those focusing on intrusive memory for trauma-related stimuli or autobiographical memory of the individual are not examined. Knowlton. Davidson and Faribank. Zeitlin and McNally. Instead. Implicit memory is not conscious. Studies that report those with PTSD show an attentional bias towards such threatening or traumarelated stimuli are demonstrating implicit memory processes (e. The type of memory disturbance in those with PTSD is concerned with impaired memory functioning due to diminished encoding. that these memories can influence ongoing emotions and behaviors (Hamner et al. difficulty concentrating.. information may come to mind or influence current behavior even when a person has no awareness or recollection of the prior occurrence. The paper is limited to studies using standard neuropsychological assessment instruments. declarative or explicit memory refers to the ability to remember and reproduce events and memory related facts. most individuals in the general population can easily see themselves as having symptoms described in the DSM-IV-TR PTSD criteria B. storage. and vivid images of the accident. Squire. Elzinga and Bremner. and Musen. There needs to be some recognition of the possibility that some experience PTSD symptoms without full-blown Criterion A criteria. 1986. COGNITIVE FUNCTIONING In addition to the emotional sequelae. The concept of memory is also frequently explained on a continuum from short-term memory (STM) to longterm memory (LTM. For instance. bombing. 1991. and PTSD symptoms are not specific to the 75% of the population who experience a true Criterion A traumatic event. and offers suggestions for clarifying that link. irritability or outbursts of anger. McNally. and being the brunt of chronic harassment. The first is the extent or gravity of the actual exposure to a stressful event per se. like a door slamming. Squire.. 1997. 1999: Schacter et al. 1989). at one time or another without a definitive Criterion A stressor. 1993). or mass violence who can have incidences of PTSD as high as 20–40% (Breslau et al. 2000).g. Yet despite the acceptance of memory dysfunctions as a symptom of PTSD. and aside from the intrusive memories of the past that intrude into the present. and D. reflecting the importance of the depth of processing for setting up memory structures that are accessible to retrieval. and/or retrieval abilities. There is substantial evidence that memories can be encoded outside awareness. getting fired. Included among possible precursors to potential PTSD symptomatology are experiences such as divorce. this is not necessarily always the case. that a distinction is made between nondeclarative (sometimes termed implicit or procedural) and declarative (explicit) memory processes (Baddeley. SEVERITY OF PTSD SYMPTOMATOLOGY There are two factors that are reported to greatly influence the severity of PTSD symptomatology. For instance. 1). the crackle of thunder. is concerned with reduced memory functioning due to impaired encoding or retrieval abilities. facts or lists). or the sight of a person in paramedic uniform..3% for triggering PTSD (Breslau et al. may evoke autonomic arousal. failure to receive tenure. 2001). disturbed cognitive functions in the form of deficits in declarative memory (remembering events. 1995. . Even the most inconsequential of triggers. loss of income or lifestyle. Squire. and refers to impairments among the processes that are critical to achieving these fundamental procedures successfully.. Having a diagnosis according to strict DSM-IV-TR diagnosis and experiencing PTSD symptomatology are not necessarily equivalent. have been listed as an integral component of PTSD since the inception of DSM criteria in 1980 (Pitman. The literature suggests that implicit memory is related to automatic priming of trauma-related material and underlies fear conditioning or conditioned emotional responses. a common trauma such as the sudden unexpected death of a loved one carries a risk of 14. On the other hand. the specific nature of the reported disturbances remains unclear. such as the persistent intrusive reexperiencing of the traumatic event in PTSD (Charney et al. 1992). 1998). 2001). This paper highlights pertinent inconsistencies and anomalies occurring at several levels in the relationship between PTSD and cognitive dysfunction (see Fig. This type of memory is typically accompanied by conscious awareness. 1997..

SAMPLING AND METHODOLOGICAL PROBLEMS Generalizations are sometimes inappropriately made to the general population when sampling confounds have not been recognised. Cognitive problems may be compounded by the fact that there is often insufficient data to determine that the memory problem resulted from the supposed event and was not preexisting. 1995) and/or specific. 2001). or terrorist attacks.. Bryant. 2002).g.g. Foy et al. 1993. for example. 1984). the more that an event is perceived by the victim to be adverse. Uddo et al. that is.8. 1989. Many also argue the case for PTSD after traumatic brain injury (TBI) where the event is often a relatively frequent occurrence (minor motor vehicle accident. Schneider and Levenson. 1993.. This highlights the importance of taking into account the individual’s prior cognitive and emotional functioning as well as conducting current cognitive and emotional assessments. and severity of specific cognitive difficulties. Cambodia. 1993. Bremner et al. 1990. These findings hold for combat situations as well as for victims of traumatic experiences. natural disasters. stressor severity per se). uncontrollable. and highlight the importance of stressor severity and subjective appraisal of the traumatic threat and/or danger (Jones and Barlow.4%.Cognitive Function After PTSD 223 Fig. were estimated at 17. respectively (de Jong et al. and subjective severity of the traumatic incident if true cognitive (dis)functioning of those with PTSD is to be explicated. Recent postconflict rates in Gaza.. and/or unpredictable.. 28.. McFarlane. Yehuda et al. such as rape. this can occur when sample size is small (e.. the more likely it is to elicit higher levels of PTSD (Blanchard et al. It is therefore important to delineate both the gravity (i... it is unclear whether a similar link exists between the gravity of the actual exposure to a stressful event. 1.. 1995. 2001). Folkman et al. In the PTSD literature. military and veterans populations that differ . assault) and in cases where the survivor had coma and or extended posttraumatic amnesia (PTA) and has no specific memory for the event (e. and 37.e. The second is the subjective severity of the exposure to the stressful event. van der Kolk. 1986. The same holds for emotion. Although there is a clear link between gravity and subjective severity of the traumatic incident and PTSD symptomatology. the subjective severity of the incident.4. Factors influencing the link between cognition and PTSD. and Algeria. 1994)..

224 from civilian PTSD groups in that they tend to be older. recurrent thoughts of death. Hoffman and Sasaki. 1992. 1994). schizophrenia spectrum.. Generalized Anxiety Disorder (GAD).. information processing.. Danckwerts and Leathem rologic. This suggests that cognitive impairments in such studies should be interpreted cautiously.. 1997. Nevertheless.. Therefore.. anxiety. Moreover. memory.. imaging techniques that have demonstrated alterations in brain structures including the hippocampus in long-term sufferers of mood disorders such as depression (Axelson et al. 465). 2000) included in their exclusionary criteria the existence of neu- BLURRING OF COGNITIVE DIFFICULTIES Cognitive difficulties associated with PTSD further highlight the interplay between emotional and physical states. Despite the fact that PTSD symptoms almost always surface soon after exposure to trauma. studies that have controlled for comorbid conditions have reported cognitive deficits suggesting that PTSD per se does contribute to observed group differences. Kudler et al. Intrusive memories are a PTSD-specific set of “cognitive difficulties” that have an emotional basis. That is not to say that cognition cannot be compromised by emotional as well as physical factors. 1992. 1987. 1987). Gilbertson et al. 1992). 1992). Synder and Nussbaum. these participants may have acquired comorbid conditions posttrauma. 1990. 1995). p. Barrett et al. Kessler et al. 1990). Further. as the findings leave open the question as to whether deficits are attributable to PTSD per se or other uncontrolled factors.. whereas brain impairment causes a different set of cognitive difficulties particularly with the acquisition of new memories. identification of time lapsed since the original trauma may be important to elucidating the cognitive deficits in those with PTSD. and detachment from others (Karam. 1997). Many prior studies have not utilized stringent criteria to exclude these and other potential comorbid confounds. 1990. COMORBIDITY PTSD is associated with increased rates of Major Depressive Disorder (MDD). Zalewski et al. 1998. and Phobias (APA-TR. affective. (1998. 1999). 1992). or substance abuse. Panic Disorder. 1997. Jenkins et al. McFarlane. Bremner et al. Reports on the outcomes of neuropsychological assessment of cognitive function in those with PTSD without comorbid psychiatric difficulty is very limited (Everly and Horton. it is not clear if there are similarities or differences in the cognitive deficits reported for those presenting with PTSD alone and those presenting with PTSD and at least one other psychiatric complaint such as depression. 1991) highlight the complex interplay between emotional and physical states. anxiety/panic disorder. 2000. The latter issue is highlighted in Table I. with as many as 80% of those diagnosed with PTSD likely to present in clinical settings with one or more other psychiatric diagnoses (Zalewski et al. and substance abuse (Foy. One of the few PTSD studies using nonveteran participants (Gil et al. sleep difficulties.. Goldstein et al. 1996. predominantly male.. learning. Agoraphobia. This means that neuropsychological complaints assessed in PTSD are likely to coexist with and be influenced by features such as depression: markedly diminished interest in activities.. 1997)... or substance use disorders predating the assault. 1993. 1989. where studies 1– 10 focus on PTSD-diagnosed military and war veterans. 1994). Substance Related Disorders. 1995b. and higher executive function. The effect of depressed mood and other emotional conditions on neuropsychological functioning is well known (Parker.. Obsessive-Compulsive Disorder. anxiety/panic disorders (Davidson. and to have been traumatised by different events (Breslau et al. the mean onset of comorbid disorders usually occurs later than PTSD symptoms (Mellman et al. but although results showed a clear trend towards lower performance by those with PTSD. cognitive deficits in the areas of visual and verbal memory and executive functioning were reported. Krishnan et al. Accordingly. It is just that it is important to emphasise that the cognitive difficulties referred to in most of the studies purporting to examine the cognition/ PTSD link are those involving acquisition and recall in the cognitive domains of attention. Gil et al. it has been suggested that the comorbidity course-of-illness onset of PTSD may be different to other psychiatric conditions such as generalized anxiety disorder and past substance abuse. Hickling and Blanchard. whereas studies 11–15 have been conducted on civilian PTSD victims. 1992). Most of the research examining the cognitive status of PTSD groups has been conducted on groups with coexisting psychiatric conditions (e. Indeed.g. Thus. care should . intrusive memories may be so crippling to the sufferer as to undermine normal cognitive tasks (Wolfe and Schlesinger.. The danger in not recognising these sampling confounds is that findings from veteran’s studies are generalized to civilian populations when the extent to which this is appropriate is unclear (Norris. although there was no significant difference between the PTSD group and a group of participants with a variety of other psychiatric diagnoses.

visual reproduction Executive function Category Test12 Wisconsin card sorting test (WCST)3 Sutker et al. active interference from information relevant and nonrelevant to previous learning. GAD. interference. motor skills RCFT CVLT Executive functioning WCST NS Groups 1 and 2 on all measures Groups 1 and 2 < Group 3 on all measures Barrett et al. PTSD < controls retroactive interference. STM. visual memory Trailmaking tests A and B11 Learning and memory WMS-R: logical memory. cumulative learning Memory Initial attention and immediate (STM) memory. (1993) a. block design Verbal memory WMS-R4 : logical memory Selective reminding test (SRT)5 Visual memory WMS-R: figural memory SRT Cognitive Function After PTSD Uddo et al. memory for cumulative learning.835 healthy veterans 225 . (1996) National Institute of Mental Health Diagnostic Interview Schedule 18 1) 236 PTSD veterans without MDD. and/or substance abuse 3) 1. Characteristics of Studies of Cognitive Deficits in PTSD Study PTSD measure NS Participants Measures Outcomes Study Bremner et al. (1995) a. proactive interference PTSD < control immediate recall NS delayed recall Intelligence WAIS-R3 : arithmetic. Mississippi Scale for Combat-Related PTSD2 PTSD < controls on logical (verbal) tests of memory (immediate & delayed) NS NS PTSD < controls across all learning trials. Personal and demographic information interview Intelligence WAIS-R or Shipley Institute of Living Scale7 Verbal memory Auditory verbal learning test (AVLT)8 WMS-R: digit-span Visual memory Complex figure test (RCFT)9 WMS-R: visual memory-span Executive function Controlled oral word association test (COWAT)10 PTSD < control Attention and mental tracking WMS-R: digit-span. recall. and/or substance abuse 2) 128 PTSD veterans with MDD. (1995) (MMPI)-derived PTSD Scale 108 POW survivors PTSD associated with cognitive deficits Yehuda et al. perseverance errors. Clinician Administered PTSD Scale15 d. vis-spatial. vocabulary. Combat Exposure Scale14 1) 20 PTSD veterans b. Mississippi Scale for 2) 12 healthy volunteers Combat-Related PTSD c. Clinical Interview (SCID)1 1) 26 PTSD veterans 2) 15 non-PTSD volunteers b. Clinical history NS Intelligence WAIS16 2 NS attention. trauma delayed recall CVLT17 Intelligence WAIS-R Attention. Mississippi Scale for Combat-Related PTSD d. picture arrangement. (MMPI)-derived PTSD 1) 16 PTSD veterans Scale6 2) 15 non-PTSD National b. retroactive interference.Table I. (1993) a. SCID Guard volunteers c. GAD.

(1994) Attention. (Continued) PTSD measure SCID Participants Measures Outcomes PTSD < controls Intrusion errors PTSD < controls acquisition. delayed] Visuospatial RCFT Executive function WCST No particular cognitive domains tested. (1997) a. follow-up contact d. Diagnostic Interview Schedule25 1) 241 veterans with PTSD no GAD 2) 241 veterans with GAD no PTSD 3) 241 healthy veterans 1) “Half” of 41 veterans with PTSD 2) Other “half” of veterans without PTSD Most PTSD < non-PTSD Zalewski et al. Record review. 2 and 3 on all measures Danckwerts and Leathem . capacity sustained effort. (1987) a. concentration.226 Table I. Structured Clinical Interview for DSM-III-R23 b. but reports of subjective cognitive difficulties Goldstein et al. DSM-III PTSD criteria b. Clinician Administered PTSD Scale PTSD < non-PTSD attention. Semistructured interview b. MMPI a. nonverbal concept formation WAIS-R: block design Memory for visual material RCFT Verbal memory (immediate [STM] and delayed) CVLT NS Groups 1. retroactive interference NS memory recall or proactive interference Study 1) 19 PTSD Gulf War recruits Attention 2) 24 healthy recruits Letter cancellation19 Stroop color-word test20 Continuous performance test21 Verbal memory WAIS-R: digit-span. (1998) Gilbertson et al. arithmetic AVLT Visual memory Continuous visual memory test (CVMT)22 Executive function WCST 1) 19 veterans with PTSD 2) 14 healthy veterans Vasterling et al. visual. memory NS NS Intelligence WAIS-R Attention WAIS-R: digit-span Trail-making test Symbol digit modalities Memory WMS24 [verbal. DSM-III PTSD criteria c. computational ability Paced auditory serial addition test (PASAT)26 Visual-spatial perception. Mental speed and control.

Sachinvala et al. nonabused adults Intelligence WAIS-R: arithmetic. Diagnosis of depression allowed 2) 18 healthy employees Vets Administration Attention.1976)30 NS Groups 1 and 2 on all measures Groups 1 and 2 < Group 3 on all measures Bremner et al. Foa. Early Trauma Inventory (ETI) b. words. block design. (1995b) a. picture arrangement Verbal short-term memory WMS: logical SRT Visual short-term memory WMS: figural SRT PTSD < non-PTSD on verbal STM. DSM-III PTSD criteria b. all function tests. Hamilton-D Depression Rating Sale (1960)21 1) 12 PTSD civilians 2) 12 non-PTSD psychiatric patients 3) 12 healthy civilians Intelligence WAIS-R “Organicity” Bender–Gestalt31 Verbal new learning WMS Mental control Nonverbal memory RCFT Benton visual reproduction test (form c)32 Executive function COWAT Hebrew letter test33 Remote memory Famous Events Questionnaire34 Self-report Subjective memory disturbance NS 1) 36 veterans with PTSD. and reaction time Cognitive Function After PTSD Gil et al. functional capacities. Axis I disorder (semistructured interview) c. PTSD Diagnostic Sale (PDS. (2000) a. 1995)27 b. numbers. short-term memory. immediate. Guy. extended memory tests. Severity of psychiatric disturbance scored on Clinical Global Impression Scale (CGI. vocabulary. and delayed recall NS 227 . Schedule for Affective Disorders and Schizophrenia—Life version (SADS-L)35 All patients met criteria for PTSD 1) 21 PTSD adult survivors of severe childhood physical/sexual abuse “many” with comorbid disorders 2) 21 Healthy. extended memory Cognitive Evaluation Scale29 PTSD patients < controls on all attention tests. (1990) a.

. 30 Clinical Global Impression Scale (Guy.. 1935). number of words CVLT learned but results NS Jenkins et al. (1984).. 37 Beck Depression Inventory (BDI. Endicott and Spitzer. 1948. Walker. 1978). 1995). Michigan Alcoholism Sreening Test (MAST)38 1) 15 PTSD rape victims 2) 16 non-PTSD rape victims 3) 16 nontraumatised healthy controls Verbal memory PTSD rape < other groups on delayed free (immediate free recall. 1947). 2000). divided attention. 1944.. 1985). 1988). 1990). 21 Continuous Performance Test (CPT.. Reitan. 40 Continuous Performane Test (CPT. 1990). and Rafal. 1965). 1977). Lezak. meaning-related. 1967). Mock. (2000) PTSD group < other groups Digit span backward PTSD < other groups PTSD < other groups PTSD > omission errors than other groups Trails B PTSD < other groups NS a. 1988).. Conners. 26 Paced Auditory Serial Addition Test (PASAT. 1988). 1944). modified c. Weschler. 1984).S. Spitzer et al.. 17 CVLT (Delis et al. DSM-III-R PTSD criteria b. (Continued) PTSD measure DSM-III-R PTSD criteria 14 clinical PTSD patients Verbal memory Four word short-term memory test (Ryan and Butters. 33 Hebrew Letter Test (see Gil et al. 1981). 1978). 16 Wechsler Adult Intelligence Scale (Wechsler and Stone. 1945). 9 Rey Complex Figure Test (RCFT. Beck Depression Inventory(BDI)37 e. 1 Structured Clinical Interview for DSM-III-R(SCID. 1976). Heaton. Michigan Alcoholism Sreening Test (MAST)38 Sustained and focused attention PASAT39 WAIS-R: digit-span. Trahan and Larrabee.228 Table I. DSM-III-R PTSD criteria b. 34 Famous Events Questionnaire (see Gil et al. 1987). Department of War. short. 1961). Beck. 32 Benton Visual Reproduction Test (form c). 39 PASAT (Levin et al. Osterreith. 20 Stroop Color-Word Test (Stroop. sustained. 24 Wechsler Memory Scale (Weschler and Stone. Berg. of encoding) on immediate free recall. digit symbol Sustained attention for visual stimuli Continuous performance test (CPT)40 Psychomotor processing speed. 1955). 1980). 42 Posner Visual Selective Attention Task (Posner. 1964).. 38 Michigan Alcoholism Sreening Test (MAST. 1985). 14 Combat Exposure Scale (Laufer et al. 1980)36 PTSD < normative group Participants Measures Outcomes Study Everly and Horton (1989) Jenkins et al. 6 (MMPI)-derived PTSD Scale of Keane et al. Friedrich. 1987). 19 Letter cancellation (Tailland. Danckwerts and Leathem . 1967). 1995). recall recognition. 13 Wisconsin Card Sorting Test (WCST.. 25 Diagnostic Interview Schedule (Robins and Helzer. Beck Depression Inventory(BDI)37 e. SCID d. Mendelson. 1985). 28 Hamilton-D Depression Rating Sale (Hamilton. 1960). long delay recall.. 7 Shipley Institute of Living Scale (Shipley. 4 Wechsler Memory Scale—Revised (WMS-R. 15 Clinician Administered PTSD Scale (Black et al. 1974). Mississippi Scale for Combat-related PTSD. switch cognitive sets Trail-making tests A and B41 Covert shifting of attention Posner visual selective attention task42 Note. SCID d. McGuire et al. 1987).. 23 DSM-III-R criteria (American Psychiatric Association. 31 Bender–Gestalt (Hutt. 1981). 36 Four Word Short-Term Memory Test (Ryan and Butters. (1998) 1) 15 PTSD rape victims 2) 16 non-PTSD rape victims 3) 16 nontraumatised healthy controls a. Westmayer and Neider. 12 Category Test (Halstead. 1987). 35 Schedule for Affective Disorders and Schizophrenia—Life version (SADS-L. U. 11 Trailmaking Tests Parts A and B (Army Individual Test Battery. 1987). modified c. Loong. Ward. 10 Controlled Oral Word Association Test (COWAT. 29 Cognitive Evaluation Protocol (CEP. 1983. and Erbaugh. 3 Wechsler Adult Intelligence Scale—Revised (Weschler. 1992). 1988). 8 Rey Auditory Verbal Learning Test (AVLT. 41 Trailmaking Test A and B (TMT-A and TMT-B. Gronwall and Sampson. 18 National Institute of Mental Health Diagnostic Interview Schedule (Robins et al. Rey. Benton and Hamsher. Foa. Mississippi Scale for Combat-Related PTSD. 27 Posttraumatic Stress Diagnostic Scale (PDS. see Sutker et al. 1981). 1990). Adjutant General’s Office.. 2 Mississippi Scale for Combat-Related PTSD (Keane et al. 5 Selective Reminding Test (Hannay and Levin. 22 Continuous Visual Memory Test (CVMT. serial clustering PTSD rape < non-PTSD rape plus controls.

2000).. Viguier et al. in adults with a history of childhood abuse and PTSD (Bremner et al. Furthermore. MRI studies have reported evidence of decreased hippocampal volume in veterans with combatrelated PTSD (Bremner et al. Discrepancy between self-report and formal assessment of cognitive difficulty has been noted after traumatic brain injury (TBI.. it is entirely possible that cognitive difficulty. the research literature does not support a one-to-one relationship between structural change and predictable change on neuropsychological assessment measures (Stein et al. as well as problems with new learning and recall (Archibald and Tuddenham.g. of the studies listed in Table I.. Barret et al. 1996. but when items focused on real life. Further. Bennett-Levy et al.. measures borrowed from clinical neuropsychology have quantified the difficulties. but also reported increased fatigue. empirical research that connects subtle alterations in hippocampal brain structures to quantifiable cognitive changes in those diagnosed with PTSD victims is limited (Wolfe and Schlesinger. 1989). or the Rivermead Behavioral Memory Test (RBMT. However. Thus. As its name suggests. 1995a. as can be seen in Table I. and one study found decreased hippocampal volume in breast-cancer patients diagnosed with PTSD (Kato et al. which may better match the patients’ self-reports of attention. other researchers (sometimes using the same assessment measures) just as commonly report negative findings. the importance of excluding coexisting emotional states is crucial. anxiety. 1991..g. and orientation for time and place. 1991). it is not clear if cognitive problems are related to a continuum of severity of PTSD and a continuum of tissue damage. Wolfe and Charney. Sutker et al. there were significant correlations between subjective and objective measurement measures. These discrepancies have received little attention in the PTSD literature. 1997) especially as these relate specifically to PTSD. an appointment. (1994) reported no differences. Ponsford et al. 1965. For example. If there is structural damage secondary to PTSD (possibly due to biochemical changes in the brain associated with chronic arousal that leads to tissue damage). when significant results are reported... 1996). Self-reported complaints of memory difficulties associated with PTSD generally highlight lower concentration and attention.. “everyday” memory skills. White. 229 mood disorders (Branca et al. and memory disturbance. Future research should employ more tests of “everyday” of cognitive functioning such as the Everyday Memory Scale (Crook and Larrabee.. . Furthermore. the RBMT includes practical. The fact that self-report of cognitive changes is not always associated with corresponding changes on formal neuropsychological assessment. Ravdin et al. Ravdin and associates reported that Lyme borreliosis patients rated their subjective memory as more impaired than objective memory scores implied. However. For instance. 1990).TBI patients. (1996) reported immediate and delayed verbal memory differences between those with PTSD and healthy controls whereas Zalewski et al. 1995. or brain structure has been frequently reported in the research literature. When the means by which cognitive difficulties have been identified are quite different.. 2000).. especially in the hippocampal area. concentration. there is a danger in assuming that the entity so identified is the same in each case. Notwithstanding that self-report validity may be confounded by motivational factors such as the tendency for some to underestimate their symptoms (e. 2001). or the tendency for others to overestimate their symptoms when there is litigation involvement (Kay. Wilson et al. and those with PTSD self-report cognitive difficulties as they relate to the everyday situation. relevant tests of everyday functioning such as remembering: a name associated with a photograph. 1999). or fatigue.g. Prigatano. although structural changes appear to be linked with cognitive difficulties. and various other disorders affecting cognitive functioning (e. 1995. Gurvits et al. 1983. In addition. Miller.Cognitive Function After PTSD be taken when reading the PTSD research literature to ensure that it is clear which of the two subsets of cognitive difficulties is being referred to. Roca and Freeman.. delivering a message. the literature suggests self-report of impaired memory performance may be confounded by mood states such as depression.. 1997). as with other disorders.. As the hippocampal area appears to be responsible for declarative (explicit) memory processing (Tranel and Damasio. 1995) it could be concluded (on the basis of neuroimaging) that the cognitive impairments associated with PTSD are associated with subcortical damage. 1980). 1996). that is. 2001). IDENTIFICATION OF COGNITIVE FUNCTION The cognitive difficulties associated with PTSD have been identified from three sources: structural changes are reported on MRI in areas of the brain traditionally associated with memory. 1997). the difficulties reported in this everyday sense are not always confirmed on formal neuropsychological assessment (e. a new route. identified by one source may not be identified in either of the other two. (1980) initially reported that laboratory tasks and self-report of memory complaints had low correlation. the importance of item content of self-report measures must also be stressed. less than 30% include self-report to check for everyday interactions relative to environment or other ecological validity.

For example. the importance of assessment for visual memory impairments experienced by those with PTSD should not be ignored. that is. reduced ability to absorb new information (often attributable to impaired attention) and apparent executive deficits (Gil et al. Davis.e.. In comparison to verbal memory. anxiety... there is nothing stored to remember. which in turn precludes consolidation and retrieval of memory. These impairments that (combined with attentional difficulties) undermine scores on measures of memory have been associated with damage to the orbito-frontal (Damasio and Anderson. Here. right hippocampus) produce declines in visual memory (Trennery et al. Significant differences in scoring on measures of attention have been reported for PTSD and control groups (e. However. 1993) and/or the amygdaloid regions and their numerous projections. and the need to dissociate between disruption to memory caused through mood or anxiety states and that caused by structural abnormalities. examination of all components of a cognitive domain such as memory (from sensation and attention. skills such as the ability to remember patterns and spatial positions are crucial in employment areas such as art and graphic design. 1997. the ability to temporarily maintain and manipulate information in order to perform cognitive tasks). require careful examination by means of psychometric assessment. rather than a problem of memory per se (Lezak. may be insufficiently sensitive to the memory impairments reported by individuals with PTSD.. In addition. emotion. 1994.. 1990. 1995). Tranel Danckwerts and Leathem and Damasio. 1993.. it is just as important to know why the individual has the difficulty performing the task. Perhaps even more important for those experiencing PTSD. driving a car. To begin with. Findings also suggest that those with PTSD experience impairments in working memory (i. causing impairments in memory for relevant. It has already been established that interference conditions contribute to the memory difficulties of PTSD victims (e. This underscores the need to use assessment instruments that evaluate the different component processes of verbal memory and attention.. 1999). as well as information that is neither personally relevant or emotional (Yehuda et al. (1995) utilizing only the score on the Logical Memory component of the WMS-R to assess verbal memory deficits of PTSD victims reported no significant results. 1996). However. or fear responses and may be mistaken for brain damage The challenge lies in distinguishing between them (Rankin and Adams. using a process approach (Kaplan. Uddo et al. where stimuli not recalled are represented on multiple occasions) reported significant short-term memory (STM) deficits. and/or substances. Yehuda et al. A process approach is more likely to elucidate the focal points at which the attention/memory processes become dysfunctional as a consequence of psychological or physiological damage. although it is useful to know via psychometric measurement that a person has difficulty with a particular task. Nonetheless.. (1993) employing both the Logical Memory subtest of Wechsler Memory Scale— Revised (WMS-R) as well as the Verbal Component of Selective Reminding Test (SRT. Therefore. 2000). Vasterling et al. Uddo et al. It is plausible then that one-off subsets such as the Logical Memory of WMS-R in which stimuli are presented only once. visual impairments would be supported by studies documenting that removal of portions of certain structures lying deep within the subcortical areas (e. 1992). LeDoux et al.. through to encoding. may be due to the undermining influence of an attentional problem. This highlights once again the complex interplay between physical and psychological states.. the ability to remember visual patterns and spatial relations underpins everyday activities such as locating where one has put an article or finding one’s way in an unfamiliar environment (Mapou.g. or piloting a helicopter or an aeroplane (Shum et al. Although distraction by irrelevant stimuli can have a profound impact on memory and once again suggests frontal lobe damage (Damasio and Anderson. as they pertain to the self-reported problem areas as well as the functioning mediated by areas of the brain believed to be damaged. However. verbal memory has been highlighted as a common problem associated with PTSD. 1995). and processing inefficiencies including sequencing and organizational skills. Sutker et al. 1993). 1995.. This also supports an assessment of mood states at the time of testing as cognitive deficits including impairments in attention (particularly in the face of competing stimuli or distraction). impaired attention prevents proper registration of information to be learned. 1993. 1998.. Of the various aspects of memory. storage of information to subsequent recall). Bremner et al.g. 1995). Sutker et al.. a low result on a standardised measure of memory.. 1998). The role of the amygdala in anxiety and mood states may mean that cognitive function is impaired by the disruptive influence of heightened arousal rather than actual damage to the area.g.. Vasterling et al. 1990) may be the product of mood. susceptibility to memory problems regarding relevant information may be a product of anxiety or fear responses involving the amygdala (Damasio. 1988) is essential. architecture. when the studies . 1995). there has been little examination of visual memory relating to individuals with PTSD.230 NEUROPSYCHOLOGICAL ASSESSMENT Cognitive difficulties that cannot be readily explained by the moderating effect of comorbid conditions such as mood.

measurement of initial encoding and retention over delayed intervals. 1992). are necessary.. Shum et al. complex Chinese characters assess an individual’s ability to recognize visual patterns. it is apparent that much of the relevant information pertaining to visual memory impairments in those with PTSD is too subtle and sensitive to be elicited by imprecise assessment measures employed thus far. Stringent criteria to exclude potential preexisting. In addition. the longer the space between stimulus presentation and recall. especially concerning right temporal lobe lesions (Delaney et al. the use of more sophisticated tests that dissociate among specific memory components. all but two reported nonsignificant visual impairments. Furthermore. a visual testing instrument without a visual-constructional component such as the Shum Visual Learning Test (SVLT. attention). over one trial) that do not allow in-depth examination of diverse visual memory functions such as the rate. Of the studies reviewed. and on language-related rather than visual-related areas of the brain (De Renzi. It may simply be that isolated measures used to assess attention and memory in PTSD groups borrowed from clinical neuropsychology such as the Wechsler Memory Scales are insufficiently precise to elucidate the specific deficits likely to result from hippocampal or other structural changes. and defining relationships with the brain.g. The importance of item content of self-report measures is also stressed. Future research needs to identify both the type (i. Heilbronner (1992) suggested that the administration procedure involved with the WMS-R visual reproduction subtest confuses participants (requiring the copying of four geometric designs immediately and again after 30-min delay) in that the assessment of visual memory is contaminated by the constructional component of the task. Forthcoming research should also employ more assessment of “everyday” functioning such as RBMT that may better match the patients’ selfreports of attention. (1993). a practice deficit. These nonsignificant yet pertinent findings support an association between PTSD and visual memory impairments. Moreover. 1982). subjective severity of the traumatic incident. . concentration. as increased familiarity heightens the likelihood of the material being dependent on language-related skills rather than 231 on visual-spatial abilities. 1991). the extent to which an individual is familiar with the visual material presented is a crucial factor. and will likely confound interpretations of performance (Heilbronner. speed. and time lapsed since the original trauma if valid cognitive (dis)functioning of civilians with PTSD is to be revealed. Research findings have been confounded so far by methodological inconsistencies and flawed neuropsychological testing procedures that neither provide a comprehensive examination of memory domains. Understanding the memory processes underlying cognitive functioning in those with PTSD would provide information pertinent to lesion localization. The SVLT is a newly developed test of visual memory and learning in which unfamiliar. or time lapsed since original trauma. (2000).. visuoperceptual or visuo-spatial memory impairment. 1995) may have the power to detect visual anomalies in those with PTSD. or a blend of any of these. Generally. these findings may be due to the use of very limited visual assessment instruments (more often than not a single measure. retention of material after interference.. or degree of new learning. male. nor incorporate memory as related to everyday situations. there has also been little consideration given to the relationship between severity of the subjective response to the traumatic event experienced by those with PTSD. Clearly. and comorbid criteria. some measures (e. severity of PTSD symptomatology. gravity). instruments that allow multiple exposures of the information to be learned. Although their results did not reach significance. Support for the value of a more comprehensive examination of visual memory is provided by Bremner et al. Correspondingly. (1998). WMS-R visual memory) do not assess recognition and remote memory (Kane.g. is crucial. the more sensitive the measure may be in detecting visual memory disturbance. war veterans. and using a delay period of only 30 min may not be long enough to elicit various precise visual impairments.. Bremner and colleagues demonstrated that the lower percentage of retention for the Figural Memory subtest of WMS-R was related to greater PTSD symptom severity and Vasterling and colleagues reported impaired initial learning of visuo-spatial information in their PTSD groups. or take into account how frontal lobe tests may impact on memory (e. It is therefore likely that much of the relevant information pertaining to the relationship between visual memory and PTSD is too subtle and sensitive to be elicited by simple. However. Although most studies have focused on older. and give provisional support to the significant results of Uddo et al. Heilbronner (1992) argues that WMS-R visual reproduction tests load high on factors comprised of nonmemory measures. and their impact on formal and everyday cognitive functioning. (1993) and Vasterling et al. Eadie and Shum. unidimensional measures. 1980). and memory disturbance relative to their everyday environmental cognitive functioning. As a result an observed impairment may stem from a physiological.e. or delayed retention of information by comparing performances across trials. rehabilitation.. leading Eadie and Shum (1995) to suggest that nonsense figures may be more sensitive than geometric figures. as suggested by Shum et al.Cognitive Function After PTSD investigating the links between visual memory difficulties and PTSD are scrutinised. 1999.

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