Enhanced priming for trauma-related material in posttraumatic stress disorder

Intrusive reexperiencing in posttraumatic stress disorder (PTSD) has been linked to perceptual priming for trauma-related material. A prospective longitudinal study (N = 69) investigated perceptual priming for trauma-related, general threat, and neutral words in assault survivors with and without PTSD, using a new version of the word-stem completion task. Survivors with PTSD showed enhanced priming for trauma-related words. Furthermore, priming for trauma-related words measured soon after the trauma was associated with subsequent PTSD severity at 3, 6, and 9 months. The enhanced priming effect was specific to trauma-related words. Enhanced perceptual priming for traumatic material appears to be one of the cognitive processes operating in PTSD.     

Is Acoustic Startle a Viable Exposure Protocol for Posttraumatic Stress Disorder? A Clinical Case Study

Exaggerated startle is a common symptom (based on Diagnostic and Statistical Manual of Mental Disorders [fourth edition] Criterion D) for many patients with posttraumatic stress disorder (PTSD). Findings from previous studies suggest that exaggerated startle may be due to trauma exposure or pretrauma vulnerability factors for PTSD development. The present clinical case study reports on a patient with PTSD characterized by a very prominent startle response and preference against standard trauma-related exposure strategies. On the basis of recent findings that interoceptive exposure exercises (e.g. shaking head side to side, hyperventilation) elicit trauma-related memories (Wald & Taylor, 2008), the authors sought to determine whether repeated application of an acoustic startle stimulus would serve to diminish the prominent startle response and facilitate exposure and overall symptom reduction by eliciting trauma-related memories. The protocol was successful in eliciting vivid and distressing trauma-related memories. Over the course of seven exposure trials, the patient demonstrated a decrease in distress elicited during the protocol, improved mood, and reduced general anxiety and trauma-related distress. He also reported significantly decreased startle response to loud noises encountered during activities of daily living. Although preliminary, these finding suggest that the acoustic startle protocol may be a viable (interoceptive) exposure strategy for individuals with PTSD, particularly those with exaggerated startle responses and those who are not amenable to standard trauma-related exposure strategies.     

Is acoustic startle a viable exposure protocol for posttraumatic stress disorder? A clinical case study

Exaggerated startle is a common symptom (based on Diagnostic and Statistical Manual of Mental Disorders [fourth edition] Criterion D) for many patients with posttraumatic stress disorder (PTSD). Findings from previous studies suggest that exaggerated startle may be due to trauma exposure or pretrauma vulnerability factors for PTSD development. The present clinical case study reports on a patient with PTSD characterized by a very prominent startle response and preference against standard trauma-related exposure strategies. On the basis of recent findings that interoceptive exposure exercises (e.g. shaking head side to side, hyperventilation) elicit trauma-related memories (Wald & Taylor, 2008), the authors sought to determine whether repeated application of an acoustic startle stimulus would serve to diminish the prominent startle response and facilitate exposure and overall symptom reduction by eliciting trauma-related memories. The protocol was successful in eliciting vivid and distressing trauma-related memories. Over the course of seven exposure trials, the patient demonstrated a decrease in distress elicited during the protocol, improved mood, and reduced general anxiety and trauma-related distress. He also reported significantly decreased startle response to loud noises encountered during activities of daily living. Although preliminary, these finding suggest that the acoustic startle protocol may be a viable (interoceptive) exposure strategy for individuals with PTSD, particularly those with exaggerated startle responses and those who are not amenable to standard trauma-related exposure strategies.     

Conceptual and perceptual priming and dissociation in chronic posttraumatic stress disorder

Cognitive models of posttraumatic stress disorder (PTSD) assert that memory processes play a significant role in PTSD (see e.g., Ehlers & Clark, 2000). Intrusive reexperiencing in PTSD has been linked to perceptual processing of trauma-related material with a corresponding hypothesized lack of conceptual processing. In an experimental study that included clinical participants with and without PTSD (N = 50), perceptual priming and conceptual priming for trauma-related, general threat, and neutral words were investigated in a population with chronic trauma-induced complaints as a result of the Troubles in Northern Ireland. The study used a new version of the word-stem completion task (Michael, Ehlers, & Halligan, 2005) and a word-cue association task. It also assessed the role of dissociation in threat processing. Further evidence of enhanced perceptual priming in PTSD for trauma stimuli was found, along with evidence of lack of conceptual priming for such stimuli. Furthermore, this pattern of priming for trauma-related words was associated with PTSD severity, and state dissociation and PTSD group made significant contributions to predicting perceptual priming for trauma words. The findings shed light on the importance of state dissociation in trauma-related information processing and posttraumatic symptoms.     

Pavlovian eyeblink conditioning in combat veterans with and without post-traumatic stress disorder

Several recent studies have investigated relationships between post-traumatic stress disorder (PTSD) and learning and memory problems. These reports have found in general that not only does PTSD affect trauma-related memories, but when patients with PTSD are compared with similar trauma patients without PTSD, general memory impairments have been found. The present paper reports a study in which associative learning, using Pavlovian eyeblink conditioning, was investigated in combat veterans with and without chronic PTSD, using interstimulus intervals of 500 and 1000 msec in two separate experiments. Although several recent reports suggest that larger-magnitude autonomic conditioned responses occur in patients with PTSD during Pavlovian conditoning, the present study found evidence of impaired Pavlovian eyeblink conditioning in combat veterans with and without PTSD, compared to non-combat veterans. Although these data suggest that combat leads to an impaired associative learning process regardless of whether PTSD is apparent, a group of community-dwelling combat veterans not under medical treatment showed normal conditioning, suggesting that variables other than prior combat must also be involved.     

Pavlovian Eyeblink Conditioning in Combat Veterans With and Without Post-Traumatic Stress Disorder

Several recent studies have investigated relationships between post-traumatic stress disorder (PTSD) and learning and memory problems. These reports have found in general that not only does PTSD affect trauma-related memories, but when patients with PTSD are compared with similar trauma patients without PTSD, general memory impairments have been found. The present paper reports a study in which associative learning, using Pavlovian eyeblink conditioning, was investigated in combat veterans with and without chronic PTSD, using interstimulus intervals of 500 and 1000 msec in two separate experiments. Although several recent reports suggest that larger-magnitude autonomic conditioned responses occur in patients with PTSD during Pavlovian conditioning, the present study found evidence of impaired Pavlovian eyeblink conditioning in combat veterans with and without PTSD, compared to non-combat veterans. Although these data suggest that combat leads to an impaired associative learning process regardless of whether PTSD is apparent, a group of community-dwelling combat veterans not under medical treatment showed normal conditioning, suggesting that variables other than prior combat must also be involved.     

Paradoxical olfactory function in combat Veterans: The role of PTSD and odor factors

Stress- and trauma-related disorders, including posttraumatic stress disorder (PTSD), are characterized by an increased sensitivity to threat cues. Given that threat detection is a critical function of olfaction and that combat trauma is commonly associated with burning odors, we sought a better understanding of general olfactory function as well as response to specific trauma-related (i.e. burning) odors in combat-related PTSD. Trauma-exposed combat Veterans with (n = 22) and without (n = 25) PTSD were assessed for general and specific odor sensitivities using a variety of tools. Both groups had similar general odor detection thresholds. However, the combat Veterans with PTSD, compared to combat Veterans with comparable trauma exposure but without PTSD, had increased ratings of odor intensity, negative valence, and odor-triggered PTSD symptoms, along with a blunted heart rate in response to burning rubber odor. These findings are discussed within the context of healthy versus pathological changes in olfactory processing that occur over time after psychological trauma.     

Trauma-related sequelae in individuals with a high level of dental anxiety. Does this interfere with treatment outcome?

This study assessed trauma-related sequelae of 56 highly anxious patients attending a dental fear clinic. It was also examined whether such symptomatology interferes with anxiety reduction in response to a cognitive-behavioral treatment approach. About 34 patients (59%) indicated that they had experienced one or more aversive dental events that could explain the onset of their dental anxiety. There was no difference between the dental anxiety scores of patients who reported such a background and those who did not. Severity of trauma-related symptomatology was indexed by the Impact of Event Scale (IES). The mean IES score of patients with a traumatically induced dental fear was remarkably high (33.0; SD=19.7). Furthermore, there was a strong direct relationship between severity of trauma-related symptomatology and severity of dental anxiety (shared variance was 38%). Two patients (10%) met all DSM-IV diagnostic criteria for Posttraumatic Stress Disorder (PTSD) on the basis of the Self-Rating Scale for PTSD. However, no evidence was found to suggest that either a traumatic background, or level of trauma-related symptomatology, has a negative effect on treatment outcome.     

Reward Processing and Decision-Making in Posttraumatic Stress Disorder

Theory suggests that, in those with posttraumatic stress disorder (PTSD), positive emotion is likely dampened due to reexperiencing of trauma-related stimuli. Prior research has extended positive emotion experiencing to reward processing research but has not yet examined how trauma cues affect reward processing (i.e., the anticipation of and satisfaction with reward) and decision-making in individuals with PTSD. We compared 24 individuals diagnosed with PTSD to 29 trauma-exposed controls in passive and decision-making phases of a wheel-of-fortune task, following both neutral and trauma inductions. Three types of spinners were used in the task: spinners that were obviously advantageous spinners, obviously disadvantageous spinners, and ambiguously advantageous spinners with outcomes averaging to a net gain. We hypothesized that the PTSD group would report lower reward expectation and lower outcome satisfaction and make less advantageous decisions, differences that would be exacerbated following a trauma prime. The PTSD group reported lower reward expectation than controls for the ambiguous spinners only, suggesting that the reduced anticipation of reward associated with PTSD may be specific to ambiguous stimuli. Reward expectation was not affected by the type of prime. Outcome satisfaction was not affected by PTSD or type of prime. Although only marginally significant, the PTSD group played the ambiguous spinners less often than controls, and played the obviously disadvantageous spinners significantly less often than controls, suggesting that those with PTSD are more aversive to loss. Our findings suggest that PTSD-related deficits are more robust for reward expectation than outcome satisfaction, and support future research examining the role of reward-related decision-making in PTSD.     

Specificity of episodic and semantic aspects of autobiographical memory in relation to symptoms of posttraumatic stress disorder (PTSD)

Two studies examined the relationship between the ability to access specific autobiographical material in memory and presence/symptoms of posttraumatic stress. In Study 1, a sample of refugees with a diagnosis of posttraumatic stress disorder (PTSD) completed the Autobiographical Memory Test (AMT) in which they had to generate specific episodic autobiographical memories in response to emotion-related cue words. Results showed that reduced specificity of memories on the AMT was associated with an increased frequency of trauma-related flashbacks but with reduced use of effortful avoidance to deal with trauma-related intrusions in the day-to-day. Study 2 examined retrieval of semantic autobiographical information from previous lifetime periods in groups of cancer survivors with posttraumatic stress and healthy controls. The cancer survivors were able to generate fewer specific semantic details about the personal past compared to the controls. The more symptomatic survivors showed the greatest memory impairment. The data from both studies are discussed in terms of compromised access to specific autobiographical material in distressed trauma survivors reflecting a process of affect regulation.     

Attentional biases in PTSD: More evidence for interference

Attentional biases to trauma-related stimuli have been widely demonstrated in individuals with posttraumatic stress disorder (PTSD). However, the majority of these studies used methods not suited to differentiating difficulty disengaging attention from threatening stimuli (interference) from facilitated detection of threat. In the current study, a visual search task (VST) with a lexical decision component was used to differentiate between attentional interference and facilitation. Forty-six sexual assault survivors with High PTSD or Low PTSD symptoms completed the VST with three types of stimuli (trauma-related, general threat-related, and semantically-related neutral words), to examine the specificity of attentional biases associated with PTSD symptoms. High PTSD participants showed increased interference to trauma-related words relative to Low PTSD participants. Furthermore, the increased attentional interference in High PTSD participants was specific to trauma-related stimuli. No evidence was found for facilitated detection of threatening stimuli in PTSD. These results provide additional support for attentional biases in PTSD relating to attentional interference with trauma-related cues rather than facilitated detection of threat. The implications for this pattern of results are discussed in relation to anxiety disorders that are characterized by rumination and/or intrusions (e.g., PTSD, GAD) rather than those more circumscribed to fight or flight response (e.g., phobias).     

Trauma-related and neutral false memories in war-induced Posttraumatic Stress Disorder

Recent models of cognition in Posttraumatic Stress Disorder (PTSD) predict that trauma-related, but not neutral, processing should be differentially affected in these patients, compared to trauma-exposed controls. This study compared a group of 50 patients with PTSD related to the war in Bosnia and a group of 50 controls without PTSD but exposed to trauma from the war, using the DRM method to induce false memories for war-related and neutral critical lures. While the groups were equally susceptible to neutral critical lures, the PTSD group mistakenly recalled more war-related lures. Both false and correct recall were related more to depression than to self-rated trauma. Implications for accounts of false memories in terms of source-monitoring are discussed.     

Emotion regulation difficulties in trauma survivors: the role of trauma type and PTSD symptom severity

Two different hypotheses regarding the relationship between emotion regulation and PTSD are described in the literature. First, it has been suggested that emotion regulation difficulties are part of the complex sequelae of early-onset chronic interpersonal trauma and less common following late-onset or single-event traumas. Second, PTSD in general has been suggested to be related to emotion regulation difficulties. Bringing these two lines of research together, the current study aimed to investigate the role of trauma type and PTSD symptom severity on emotion regulation difficulties in a large sample of trauma survivors (N=616). In line with the hypotheses, PTSD symptom severity was significantly associated with all variables assessing emotion regulation difficulties. In addition, survivors of early-onset chronic interpersonal trauma showed higher scores on these measures than survivors of single-event and/or late-onset traumas. However, when controlling for PTSD symptom severity, the group differences only remained significant for 2 out of 9 variables. The most robust findings were found for the variable "lack of clarity of emotions." Implications for future research, theoretical models of trauma-related disorders, and their treatment will be discussed.     

Is the concept of "repression" useful for the understanding chronic PTSD?

Theories concerning the value of avoiding versus attending to trauma-related thoughts provide mixed support for specific coping strategies such as repression. The goal of this study is to examine the usefulness of the concept of repression in understanding chronic Posttraumatic Stress Disorder (PTSD). One hundred and fifty individuals who had been in a motor vehicle accident were included. Participants were classified into four groups (repressors, low anxious, high anxious, and defensively high anxious) based on methodology introduced by Weinberger et al. [J. Abnormal Psychol. 88 (1979) 369]. These four groups were compared on measures of PTSD symptomatology, anxiety, depression, and where appropriate, perceived pain and disability. Results revealed a fairly consistent pattern of group differences such that repressors reported fewer PTSD symptoms, fewer additional anxiety disorders, less depression, and less physical disability due to pain relative to the high anxious and defensively high anxious groups. Regression analyses examining the separate and interactive effects of anxiety and social desirability to predict PTSD symptomatology showed that the majority of the variance was explained by anxiety. In many respects, these data suggest that repression may not be a useful concept for understanding chronic PTSD.     

Cognitive therapy for post-traumatic stress disorder: development and evaluation

The paper describes the development of a cognitive therapy (CT) program for post-traumatic stress disorder (PTSD) that is based on a recent cognitive model (Behav. Res. Therapy 38 (2000) 319). In a consecutive case series, 20 PTSD patients treated with CT showed highly significant improvement in symptoms of PTSD, depression and anxiety. A subsequent randomized controlled trial compared CT (N = 14) and a 3-month waitlist condition (WL, N = 14). CT led to large reductions in PTSD symptoms, disability, depression and anxiety, whereas the waitlist group did not improve. In both studies, treatment gains were well maintained at 6-month follow-up. CT was highly acceptable, with an overall dropout rate of only 3%. The intent-to-treat effect sizes for the degree of change in PTSD symptoms from pre to post-treatment were 2.70-2.82 (self-report), and 2.07 (assessor-rated). The controlled effect sizes for CT versus WL post-treatment scores were 2.25 (self-report) and 2.18 (assessor-rated). As predicted by the cognitive model, good treatment outcome was related to greater changes in dysfunctional post-traumatic cognitions. Patient characteristics such as comorbidity, type of trauma, history of previous trauma, or time since the traumatic event did not predict treatment response, however, low educational attainment and low socioeconomic status were related to better outcome.     

Enhanced priming for trauma-related words predicts posttraumatic stress disorder

There is preliminary evidence that enhanced priming for trauma-related cues plays a role in posttraumatic stress disorder (PTSD). A prospective study of 119 motor vehicle accident survivors investigated whether priming for trauma-related stimuli predicts PTSD. Participants completed a modified word-stem completion test comprising accident-related, traffic-related, general threat, and neutral words at 2 weeks post-trauma. Priming for accident-related words predicted PTSD at 6 months follow-up, even when initial symptom levels of PTSD and depression and priming for other words were controlled. The results are in line with the hypothesis that enhanced priming for traumatic material contributes to the development of chronic PTSD.     

Posttraumatic Stress Disorder and Chronic Pain Arising from Motor Vehicle Accidents: Efficacy of Interoceptive Exposure Plus Trauma-Related Exposure Therapy

Preliminary data are presented on the pattern of treatment response of combining interoceptive exposure (IE) with trauma-related exposure therapy (TRE) in five female patients with posttraumatic stress disorder (PTSD) and comorbid chronic musculoskeletal pain originating from motor vehicle accidents. Treatment consisted of four sessions of IE followed by eight sessions of TRE. Four participants reported a reduction in PTSD symptoms after completing treatment, and three no longer met diagnostic criteria for PTSD. Although both interventions were associated with reductions in PTSD symptoms, TRE was associated with greater reductions in PTSD symptoms than IE and was particularly effective at reducing avoidance. IE was associated with larger reductions in anxiety sensitivity than TRE. Pain symptoms lessened slightly during IE and then worsened following TRE. Anxiety decreased after completing treatment, whereas panic and depressive symptoms responded less so. Three individuals completed a 3-month follow-up assessment. There was no change in their PTSD diagnostic status, and all experienced a slight loss of pre–post gains, particularly involving the return of pain. Clinical and research implications are discussed.     

From Survivor to Thriver: A Pilot Study of an Online Program for Rape Victims

Approximately 15% to 20% of women have been victims of rape and close to a third report current rape-related PTSD or clinically significant depression or anxiety. Unfortunately, very few distressed rape victims seek formal help. This suggests a need to develop alternative ways to assist the many distressed victims of sexual violence. Online treatment programs represent a potentially important alternative strategy for reaching such individuals. The current paper describes a pilot evaluation of an online, therapist-facilitated, self-paced cognitive behavioral program for rape victims. Five college women with current rape-related PTSD were recruited to complete the From Survivor to Thriver (S to T) program in a lab setting over the course of 7 weeks. After completing the program, 4 participants reported clinically significant reductions in PTSD symptoms and no longer met criteria for PTSD. All participants reported clinically significant reductions in vulnerability fears and 4 reported significant reductions in negative trauma-related cognitions. Implications of the results for further development of the S to T program and how clinicians could utilize this program in treating rape-related PTSD are discussed.     

Acceptance and Commitment Therapy for Treatment-Resistant Posttraumatic Stress Disorder: A Case Study

An adult woman with chronic posttraumatic stress disorder (PTSD) and major depressive disorder who was nonresponsive to 20 sessions of cognitive behavior therapy (CBT) is presented in this case study. Two months after her CBT trial, she was treated with 21 sessions of Acceptance and Commitment Therapy (ACT) for PTSD. Measurements of PTSD severity, depression, anxiety, psychological flexibility and trauma-related thoughts and beliefs were taken at pretreatment, after Sessions 8 and 16, and at posttreatment. Results showed significant reduction on all measures throughout treatment, except for trauma-related thoughts and beliefs, which did not decrease until near the end of treatment. Strengths, limitations, and future directions are discussed.