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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: A.M.Danckwerts@xtra.co.nz.

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
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2003 Plenum Publishing Corporation

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

1993. Uddo et al. Cambodia.. assault) and in cases where the survivor had coma and or extended posttraumatic amnesia (PTA) and has no specific memory for the event (e. McFarlane. 1995. 2002). were estimated at 17. for example. Folkman et al.. and highlight the importance of stressor severity and subjective appraisal of the traumatic threat and/or danger (Jones and Barlow. Foy et al. 1993. 1993. the more that an event is perceived by the victim to be adverse. stressor severity per se)..8. 28.. 1994).4.g.. The second is the subjective severity of the exposure to the stressful event. 1995) and/or specific. respectively (de Jong et al. 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. SAMPLING AND METHODOLOGICAL PROBLEMS Generalizations are sometimes inappropriately made to the general population when sampling confounds have not been recognised. van der Kolk. that is.. Schneider and Levenson. The same holds for emotion. uncontrollable. and Algeria. 1986. it is unclear whether a similar link exists between the gravity of the actual exposure to a stressful event.Cognitive Function After PTSD 223 Fig. the subjective severity of the incident. such as rape. 1989. Bremner et al. and severity of specific cognitive difficulties.. Recent postconflict rates in Gaza. Factors influencing the link between cognition and PTSD. and/or unpredictable. In the PTSD literature. this can occur when sample size is small (e. and 37. 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.4%. 1984). military and veterans populations that differ . Yehuda et al. natural disasters. 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. Bryant..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.. or terrorist attacks. and subjective severity of the traumatic incident if true cognitive (dis)functioning of those with PTSD is to be explicated. 1990. Although there is a clear link between gravity and subjective severity of the traumatic incident and PTSD symptomatology. 2001). 1. 2001). These findings hold for combat situations as well as for victims of traumatic experiences.g.

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. affective. 1995). Bremner et al. 1990. anxiety/panic disorder. anxiety. Hoffman and Sasaki. recurrent thoughts of death. 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. Goldstein et al. and Phobias (APA-TR. Generalized Anxiety Disorder (GAD). 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. The effect of depressed mood and other emotional conditions on neuropsychological functioning is well known (Parker. Barrett et al. or substance use disorders predating the assault.224 from civilian PTSD groups in that they tend to be older. That is not to say that cognition cannot be compromised by emotional as well as physical factors.g. (1998. predominantly male.. and higher executive function. Kudler et al. cognitive deficits in the areas of visual and verbal memory and executive functioning were reported. care should . COMORBIDITY PTSD is associated with increased rates of Major Depressive Disorder (MDD).. learning. 1991) highlight the complex interplay between emotional and physical states. schizophrenia spectrum.. 1998. 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. Nevertheless. information processing. McFarlane. 465). This suggests that cognitive impairments in such studies should be interpreted cautiously. 1989. the mean onset of comorbid disorders usually occurs later than PTSD symptoms (Mellman et al. 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. 1999). Indeed.. where studies 1– 10 focus on PTSD-diagnosed military and war veterans. intrusive memories may be so crippling to the sufferer as to undermine normal cognitive tasks (Wolfe and Schlesinger.. 1997). whereas brain impairment causes a different set of cognitive difficulties particularly with the acquisition of new memories.. as the findings leave open the question as to whether deficits are attributable to PTSD per se or other uncontrolled factors. identification of time lapsed since the original trauma may be important to elucidating the cognitive deficits in those with PTSD. Agoraphobia.. Moreover. 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. but although results showed a clear trend towards lower performance by those with PTSD. 1997.. Panic Disorder.. 1987. anxiety/panic disorders (Davidson. 1994). 1992). 1987). Danckwerts and Leathem rologic. whereas studies 11–15 have been conducted on civilian PTSD victims. 1994). sleep difficulties. 1997. Reports on the outcomes of neuropsychological assessment of cognitive function in those with PTSD without comorbid psychiatric difficulty is very limited (Everly and Horton. 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. Gilbertson et al. and to have been traumatised by different events (Breslau et al. Thus. 1992). Accordingly. Substance Related Disorders. Zalewski et al. Kessler et al. 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.. Synder and Nussbaum. Despite the fact that PTSD symptoms almost always surface soon after exposure to trauma. Most of the research examining the cognitive status of PTSD groups has been conducted on groups with coexisting psychiatric conditions (e.. 1990). One of the few PTSD studies using nonveteran participants (Gil et al. 1997). 2000. these participants may have acquired comorbid conditions posttrauma. 1992). Obsessive-Compulsive Disorder. 1993.. and detachment from others (Karam. Intrusive memories are a PTSD-specific set of “cognitive difficulties” that have an emotional basis. 1992. memory.. Jenkins et al.. 1992. and substance abuse (Foy. studies that have controlled for comorbid conditions have reported cognitive deficits suggesting that PTSD per se does contribute to observed group differences. 1995b. Therefore. p. or substance abuse. 1996. The latter issue is highlighted in Table I. Krishnan et al. Many prior studies have not utilized stringent criteria to exclude these and other potential comorbid confounds. Further. although there was no significant difference between the PTSD group and a group of participants with a variety of other psychiatric diagnoses. 1992). 1990. Hickling and Blanchard. Gil et al..

interference. SCID Guard volunteers c. visual reproduction Executive function Category Test12 Wisconsin card sorting test (WCST)3 Sutker et al. (1995) (MMPI)-derived PTSD Scale 108 POW survivors PTSD associated with cognitive deficits Yehuda et al. recall. active interference from information relevant and nonrelevant to previous learning. Mississippi Scale for Combat-Related PTSD d. trauma delayed recall CVLT17 Intelligence WAIS-R Attention. Clinical history NS Intelligence WAIS16 2 NS attention. (MMPI)-derived PTSD 1) 16 PTSD veterans Scale6 2) 15 non-PTSD National b. 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. Mississippi Scale for Combat-Related PTSD2 PTSD < controls on logical (verbal) tests of memory (immediate & delayed) NS NS PTSD < controls across all learning trials. GAD. Mississippi Scale for 2) 12 healthy volunteers Combat-Related PTSD c. and/or substance abuse 2) 128 PTSD veterans with MDD. (1996) National Institute of Mental Health Diagnostic Interview Schedule 18 1) 236 PTSD veterans without MDD. Clinical Interview (SCID)1 1) 26 PTSD veterans 2) 15 non-PTSD volunteers b. GAD. perseverance errors. visual memory Trailmaking tests A and B11 Learning and memory WMS-R: logical memory.835 healthy veterans 225 . Characteristics of Studies of Cognitive Deficits in PTSD Study PTSD measure NS Participants Measures Outcomes Study Bremner et al. (1993) a. Clinician Administered PTSD Scale15 d. PTSD < controls retroactive interference. (1995) a. vocabulary. vis-spatial. 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. retroactive interference. picture arrangement. (1993) a. and/or substance abuse 3) 1. STM.Table I. 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. cumulative learning Memory Initial attention and immediate (STM) memory. Combat Exposure Scale14 1) 20 PTSD veterans b. memory for cumulative learning. proactive interference PTSD < control immediate recall NS delayed recall Intelligence WAIS-R3 : arithmetic.

(1987) a. DSM-III PTSD criteria b. computational ability Paced auditory serial addition test (PASAT)26 Visual-spatial perception. MMPI a. but reports of subjective cognitive difficulties Goldstein et al. follow-up contact d. 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. delayed] Visuospatial RCFT Executive function WCST No particular cognitive domains tested. 2 and 3 on all measures Danckwerts and Leathem . Record review.226 Table I. 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. capacity sustained effort. (1998) Gilbertson et al. visual. Structured Clinical Interview for DSM-III-R23 b. Semistructured interview b. (1994) Attention. Clinician Administered PTSD Scale PTSD < non-PTSD attention. concentration. Mental speed and control. memory NS NS Intelligence WAIS-R Attention WAIS-R: digit-span Trail-making test Symbol digit modalities Memory WMS24 [verbal. (1997) a. nonverbal concept formation WAIS-R: block design Memory for visual material RCFT Verbal memory (immediate [STM] and delayed) CVLT NS Groups 1. DSM-III PTSD criteria c. (Continued) PTSD measure SCID Participants Measures Outcomes PTSD < controls Intrusion errors PTSD < controls acquisition. 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.

short-term memory. extended memory tests. nonabused adults Intelligence WAIS-R: arithmetic. DSM-III PTSD criteria b. Diagnosis of depression allowed 2) 18 healthy employees Vets Administration Attention. extended memory Cognitive Evaluation Scale29 PTSD patients < controls on all attention tests. 1995)27 b. all function tests.1976)30 NS Groups 1 and 2 on all measures Groups 1 and 2 < Group 3 on all measures Bremner et al. Guy. (1990) a. (2000) a. functional capacities. and reaction time Cognitive Function After PTSD Gil et al. (1995b) a. and delayed recall NS 227 . 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.Sachinvala et al. numbers. Foa. 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. Axis I disorder (semistructured interview) c. immediate. words. block design. vocabulary. Severity of psychiatric disturbance scored on Clinical Global Impression Scale (CGI. PTSD Diagnostic Sale (PDS. picture arrangement Verbal short-term memory WMS: logical SRT Visual short-term memory WMS: figural SRT PTSD < non-PTSD on verbal STM. Early Trauma Inventory (ETI) b.

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

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

1988) is essential. the importance of assessment for visual memory impairments experienced by those with PTSD should not be ignored. Vasterling et al. 1990) may be the product of mood. 1993. Of the various aspects of memory. architecture. or piloting a helicopter or an aeroplane (Shum et al. as well as information that is neither personally relevant or emotional (Yehuda et al.230 NEUROPSYCHOLOGICAL ASSESSMENT Cognitive difficulties that cannot be readily explained by the moderating effect of comorbid conditions such as mood. or fear responses and may be mistaken for brain damage The challenge lies in distinguishing between them (Rankin and Adams. 1995). This highlights once again the complex interplay between physical and psychological states. Bremner et al. driving a car. Uddo et al. there has been little examination of visual memory relating to individuals with PTSD. 2000). Nonetheless. Davis. Therefore. it is just as important to know why the individual has the difficulty performing the task.e. In addition. 1999). 1998). impaired attention prevents proper registration of information to be learned. This underscores the need to use assessment instruments that evaluate the different component processes of verbal memory and attention. LeDoux et al. It has already been established that interference conditions contribute to the memory difficulties of PTSD victims (e... Yehuda et al. there is nothing stored to remember. and/or substances.g. Here. 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. Vasterling et al. as they pertain to the self-reported problem areas as well as the functioning mediated by areas of the brain believed to be damaged. skills such as the ability to remember patterns and spatial positions are crucial in employment areas such as art and graphic design. 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). 1993. Sutker et al. anxiety. verbal memory has been highlighted as a common problem associated with PTSD. right hippocampus) produce declines in visual memory (Trennery et al.. 1992). through to encoding. 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.g.. the ability to temporarily maintain and manipulate information in order to perform cognitive tasks). causing impairments in memory for relevant. Sutker et al. although it is useful to know via psychometric measurement that a person has difficulty with a particular task. visual impairments would be supported by studies documenting that removal of portions of certain structures lying deep within the subcortical areas (e. reduced ability to absorb new information (often attributable to impaired attention) and apparent executive deficits (Gil et al.. emotion. 1995. may be insufficiently sensitive to the memory impairments reported by individuals with PTSD. It is plausible then that one-off subsets such as the Logical Memory of WMS-R in which stimuli are presented only once. However. that is. For example. 1994.. rather than a problem of memory per se (Lezak. may be due to the undermining influence of an attentional problem. 1997.. which in turn precludes consolidation and retrieval of memory. require careful examination by means of psychometric assessment. 1998. when the studies .g. 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. (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. and the need to dissociate between disruption to memory caused through mood or anxiety states and that caused by structural abnormalities. 1996).. and processing inefficiencies including sequencing and organizational skills. susceptibility to memory problems regarding relevant information may be a product of anxiety or fear responses involving the amygdala (Damasio. To begin with. However... examination of all components of a cognitive domain such as memory (from sensation and attention.. 1995). Significant differences in scoring on measures of attention have been reported for PTSD and control groups (e. Uddo et al. storage of information to subsequent recall). where stimuli not recalled are represented on multiple occasions) reported significant short-term memory (STM) deficits. 1993). 1990. (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. 1993) and/or the amygdaloid regions and their numerous projections. However.. 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. 1995). using a process approach (Kaplan. a low result on a standardised measure of memory. Perhaps even more important for those experiencing PTSD.. Findings also suggest that those with PTSD experience impairments in working memory (i... Although distraction by irrelevant stimuli can have a profound impact on memory and once again suggests frontal lobe damage (Damasio and Anderson. Tranel Danckwerts and Leathem and Damasio. In comparison to verbal memory.

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

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