Posttraumatic stress disorder (PTSD) involves four main symptom clusters, namely (i) intrusion, (ii) avoidance, (iii) negative cognition and emotion, and (iv) hyperarousal. Although focus has traditionally been on emotional symptoms, there is an increasing interest in neurocognitive impairments that are often found among individuals with PTSD. It is important to recognize these impairments associated with PTSD, as neurocognitive impairments have direct implications for recovery, adequate daily life function, and the duration and severity of the disorder (Bisson Desrochers et al., 2021).
One seminal work that introduced the often-neglected intersection of neuropsychology and psychological trauma to a wider audience is Neuropsychology of PTSD: Biological, Cognitive, and Clinical Perspectives, edited by Vasterling and Brewin (2005). This work explored how individuals with PTSD experience neurocognitive impairments when exposed to both emotionally valent and emotionally neutral stimuli. Individuals with PTSD often attended to trauma-related cues more than emotionally neutral stimuli. Yet, when they complete emotionally neutral neuropsychological assessments, they tend to perform worse on measures of attention, processing speed and executive functioning. At the time, there was still much to be understood regarding memory encoding, processing and retrieval in the context of how stress impacts interactions within the limbic system (i.e., between the hippocampus and amygdala) and between the limbic system and hypothalamic-pituitary-adrenal axis. Additionally, it was still unclear whether these impairments were (i) a consequence of developing PTSD, (ii) a predisposition to developing PTSD or (iii) a mixture of both.
Thankfully, there have been advances in research on the neurocognitive impairments associated with PTSD since 2005. Domains that are commonly associated with PTSD symptomatology include (working) memory, attention, information processing speed, verbal learning and executive function (Bisson Desrochers et al., 2021; Jacob et al., 2019; Scott et al., 2015). Recent research highlights the importance of continuing to integrate the neuroscientific understanding of fear-processing networks (i.e., amygdala-hippocampus-medial prefrontal cortex circuit) to our conceptualization of how PTSD influences learning and memory (Ressler et al., 2022).
Memory deficits
The altered function of memory in individuals with PTSD appears paradoxical: on the one hand, they often experience difficulties with recalling coherent memories from the traumatic event. Yet, on the other hand, detailed involuntary intrusions of the trauma occur. This appears to be caused by impaired emotional memory encoding and retrieval that contributes to dysregulated fear extinction abilities (Ressler et al., 2022; Sep et al., 2021). Memory deficits can vary depending on several considerations, including the (i) type of traumatic event, (ii) timing of traumatic event (i.e., occurrence during childhood (de Bellis et al., 2013; Malarbi et al., 2017), adolescence, adulthood, late life (Schuitevoerder et al., 2013), (iii) number of traumatic events, (iv) features of the event that remain relevant and salient to the person and (v) inherited genetic predispositions to developing trauma symptomatology (i.e., diathesis-stress model of PTSD; McKeever & Huff, 2003). These considerations also impact how the person consciously and unconsciously coped with the trauma during and after the traumatic event (i.e., hypervigilance, dissociation): integral details that need to be considered when attempting to recognize and understand a person’s trauma-related memory deficits.
However, it is not only the trauma-related memory that is affected. Studies consistently show that individuals with PTSD also experience memory impairments for emotionally neutral information (Brewin et al., 2007; Johnsen & Asbjørnsen, 2008). Difficulties in memory are often an apparent complaint from those with PTSD, as it impacts other cognitive abilities and highly affects daily life function. But it is important to establish whether observed memory difficulties in individuals with PTSD are due to primary memory deficits or deficits in integral components of memory encoding, such as attention.
Attention deficits
Attention deficits have, in the context of PTSD, predominantly been related to impaired fear inhibition and threat-related attention bias. At-risk professionals, like police and military, benefit from a certain level of threat-related attention bias, which can be lifesaving during deployment. Yet, it is similarly crucial that the level of attention bias reduces after deployment because a constant vigilance for threat-related cues is no longer needed. However, it is especially this level of heightened attention bias that is associated with PTSD (Metcalf et al., 2022).
Moreover, research also highlights deficits in response inhibition. Response inhibition is conceptualized as the inability to restrain from irrelevant actions to novel information outside the context of fear conditioning, due to the inability to adequately distinguish between threat-related and neutral cues (Jovanovic et al., 2012; van Rooij & Jovanovic, 2019). A growing body of literature shows that attention deficits in individuals with PTSD are common and occur not only in the context of threat-related cues, but also in circumstances with emotionally neutral stimuli. The attention deficits span both basic components of attention (i.e., focused, sustained and divided attention) as well as in higher-order components (i.e., alternating and divided attention) and are positively linked with the PTSD severity (Punski-Hoogervorst et al., 2023).
A bidirectional relationship: Considerations for assessment and treatment
In addition to identifying the exact neurocognitive impairments associated with PTSD, another important question relates to the directionality between PTSD and neurocognition. Researchers from the VA Boston Healthcare System reviewed studies on PTSD and neurocognition and found that neuropsychological functioning and PTSD symptomatology maintain a bidirectional relationship (Jacob et al., 2019). Poorer cognitive abilities (i.e., memory processing, attention, executive functioning) can increase the risk of developing and maintaining PTSD symptomatology. On the other hand, traumatic experiences and PTSD can increase the likelihood of developing cognitive difficulties and increase the overall risk of cognitive decline.
Maintaining this bidirectional conceptualization could be crucial to improve the efficacy of PTSD diagnosis and treatment through its associated neurocognitive difficulties. Improvement of cognitive abilities may be relevant to increase resilience of those at risk for developing PTSD. For example, increasing cognitive abilities may improve certain coping strategies such as problem solving and cognitive appraisal (Jacob et al., 2019). Furthermore, the neurocognitive impairments developing in the course of PTSD may be used as an outcome measure of treatment efficacy, as literature suggests that these impairments are, at least to some extent, reversible (Jacob et al., 2019).
Lastly, it is well-suited to think about the implications of neurocognitive impairments for the efficacy of treatment strategies. Current cognitive-behavioral interventions rely largely on intact memory, attentional and problem-solving abilities, which are the same abilities that are often less efficient in individuals with PTSD. Future studies should relate to the benefit of both assessing and addressing neurocognitive impairments for better and more personalized treatment interventions. Studies investigating Attention Control Training (ACT) for PTSD symptoms show promising results (Metcalf et al., 2022; Segal et al., 2020).
About the authors
Sheila M. Thompson is a Filipina-American doctoral student in clinical psychology at Palo Alto University (PAU) specializing in trauma and neuropsychology. She is a research assistant in the Risk and Resilience Lab with Dr. Lisa Brown through PAU. She is also a clinical assessor for the Bonding and Attunement in Neuropsychiatric Disorders (BAND) and the Trauma and Health Research on Immunity, Vitality and Emotions (THRIVE) labs through the VA San Francisco Health Care System and University of California, San Francisco. Her dissertation investigates the associations of complex and acute traumatic stressors with stress and cognitive functioning in older adult Puerto Ricans who survived Hurricane Maria. She is the past president of PAU’s Association of Traumatic Stress Studies (ATSS) and is an affiliate of ISTSS (ISTSS Complex Trauma SIG), American Psychological Association (APA) Divisions 40 (Clinical Neuropsychology) and 56 (Trauma Psychology) and International Neuropsychological Society (INS).
Dr. Janne L. Punski-Hoogervorst is a Dutch Jewish medical doctor, currently associated as clinical researcher and doctoral candidate with the Behavioral Neurobiology Lab and Lab for Sensory Processing and Daily Function, both at the University of Haifa, Israel. Her research focuses on attentional, emotional and sensory processing dysregulations in adults with PTSD. In addition, Dr. Punski-Hoogervorst is an executive board member of the Dutch Psychotrauma Association (Nederlandstalige Vereniging voor Psychotrauma), co-chair of the ISTSS Military SIG and editor of this Biological Perspectives section of StressPoints.
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