Impaired Response Inhibition in Veterans with Post-Traumatic Stress Disorder and Mild Traumatic Brain Injury

Abstract Combat veterans with post-traumatic stress disorder (PTSD) can show impairments in executive control and increases in impulsivity. The current study examined the effects of PTSD on motor response inhibition, a key cognitive control function. A Go/NoGo task was administered to veterans with a diagnosis of PTSD based on semi-structured clinical interview using DSM-IV criteria (n = 40) and age-matched control veterans (n = 33). Participants also completed questionnaires to assess self-reported levels of PTSD and depressive symptoms. Performance measures from the patients (error rates and reaction times) were compared to those from controls. PTSD patients showed a significant deficit in response inhibition, committing more errors on NoGo trials than controls. Higher levels of PTSD and depressive symptoms were associated with higher error rates. Of the three symptom clusters, re-experiencing was the strongest predictor of performance. Because the co-morbidity of mild traumatic brain injury (mTBI) and PTSD was high in this population, secondary analyses compared veterans with PTSD+mTBI (n = 30) to veterans with PTSD only (n = 10). Although preliminary, results indicated the two patient groups did not differ on any measure (p > .88). Since cognitive impairments could hinder the effectiveness of standard PTSD therapies, incorporating treatments that strengthen executive functions might be considered in the future. (JINS, 2012, 18, 1–10)

[1]  VA/DoD Clinical Practice Guideline for Management of Concussion/Mild Traumatic Brain Injury. , 2009, Journal of rehabilitation research and development.

[2]  Murray B Stein,et al.  Exploring the convergence of posttraumatic stress disorder and mild traumatic brain injury. , 2009, The American journal of psychiatry.

[3]  Murray B. Stein,et al.  Potential driving issues in combat returnees. , 2010, NeuroRehabilitation.

[4]  J. Lorberbaum,et al.  Potential role of the anterior cingulate cortex in PTSD: Review and hypothesis , 1999, Depression and anxiety.

[5]  S. Vrana,et al.  Selective processing of trauma-relevant words in posttraumatic stress disorder , 1995 .

[6]  P. Gordon Videos in clinical medicine. Endometrial biopsy. , 2009, The New England journal of medicine.

[7]  Kan Zhang,et al.  Response inhibition in adolescent earthquake survivors with and without posttraumatic stress disorder: A combined behavioral and ERP study , 2010, Neuroscience Letters.

[8]  Marijn C. W. Kroes,et al.  Structural brain abnormalities common to posttraumatic stress disorder and depression. , 2011, Journal of psychiatry & neuroscience : JPN.

[9]  S. Eliez,et al.  Decreased Anterior Cingulate Volume in Combat-Related PTSD , 2006, Biological Psychiatry.

[10]  Charles W Hoge,et al.  Care of war veterans with mild traumatic brain injury--flawed perspectives. , 2009, The New England journal of medicine.

[11]  A. Turken,et al.  Dissociation between conflict detection and error monitoring in the human anterior cingulate cortex , 2002, Proceedings of the National Academy of Sciences of the United States of America.

[12]  S. Rauch,et al.  Amygdala, Medial Prefrontal Cortex, and Hippocampal Function in PTSD , 2006, Annals of the New York Academy of Sciences.

[13]  Diane Swick,et al.  Are the neural correlates of stopping and not going identical? Quantitative meta-analysis of two response inhibition tasks , 2011, NeuroImage.

[14]  D. Cifu,et al.  Care of war veterans with mild traumatic brain injury. , 2009, The New England journal of medicine.

[15]  Nicholas J. Pastorek,et al.  Postconcussive Symptoms After Blast and Nonblast-Related Mild Traumatic Brain Injuries in Afghanistan and Iraq War Veterans , 2010, Journal of the International Neuropsychological Society.

[16]  S. Hansen,et al.  Executive function and memory in posttraumatic stress disorder: a study of Bosnian war veterans , 2006, European Psychiatry.

[17]  A. Turken,et al.  Left inferior frontal gyrus is critical for response inhibition , 2008, BMC Neuroscience.

[18]  T. Klingberg,et al.  Common and unique components of inhibition and working memory: An fMRI, within-subjects investigation , 2008, Neuropsychologia.

[19]  I. Robertson,et al.  `Oops!': Performance correlates of everyday attentional failures in traumatic brain injured and normal subjects , 1997, Neuropsychologia.

[20]  M. Raichle,et al.  Detection of blast-related traumatic brain injury in U.S. military personnel. , 2011, The New England journal of medicine.

[21]  A. Simmons,et al.  Neural circuitry of PTSD with or without mild traumatic brain injury: A meta-analysis , 2012, Neuropharmacology.

[22]  T. Heeren,et al.  Association of time since deployment, combat intensity, and posttraumatic stress symptoms with neuropsychological outcomes following Iraq war deployment. , 2009, Archives of general psychiatry.

[23]  J. Jonides,et al.  Interference resolution: Insights from a meta-analysis of neuroimaging tasks , 2007, Cognitive, affective & behavioral neuroscience.

[24]  Steven Scott,et al.  Clinical practice guideline: Management of Concussion/Mild Traumatic Brain Injury , 2009 .

[25]  A preliminary study of the effect of a diagnosis of concussion on PTSD symptoms and other psychiatric variables at the time of treatment seeking among veterans. , 2011, Military medicine.

[26]  M. A. Carson,et al.  Selectively reduced regional cortical volumes in post‐traumatic stress disorder , 2003, Neuroreport.

[27]  Richard Reilly,et al.  Do antisaccade deficits in schizophrenia provide evidence of a specific inhibitory function? , 2006, Journal of the International Neuropsychological Society.

[28]  R. McNally,et al.  Selective processing of threat cues in posttraumatic stress disorder. , 1990, Journal of abnormal psychology.

[29]  T. Robbins,et al.  Stop-signal inhibition disrupted by damage to right inferior frontal gyrus in humans , 2003, Nature Neuroscience.

[30]  M. Petrides The effect of periarcuate lesions in the monkey on the performance of symmetrically and asymmetrically reinforced visual and auditory go, no- go tasks , 1986, The Journal of neuroscience : the official journal of the Society for Neuroscience.

[31]  P. Ouimette,et al.  Gender and PTSD. , 2002 .

[32]  K. Felmingham,et al.  The neural networks of inhibitory control in posttraumatic stress disorder. , 2008, Journal of psychiatry & neuroscience : JPN.

[33]  D. Forbes,et al.  The validity of the PTSD checklist as a measure of symptomatic change in combat-related PTSD. , 2001, Behaviour research and therapy.

[34]  R. Constable,et al.  Imaging Response Inhibition in a Stop-Signal Task: Neural Correlates Independent of Signal Monitoring and Post-Response Processing , 2006, The Journal of Neuroscience.

[35]  Shalanda N Gordon,et al.  No Effect of PTSD and Other Psychiatric Disorders on Cognitive Functioning in Veterans With Mild TBI , 2011, The Clinical neuropsychologist.

[36]  M. Verfaellie,et al.  Introduction–Posttraumatic stress disorder: A neurocognitive perspective , 2009, Journal of the International Neuropsychological Society.

[37]  D. Charney,et al.  The development of a Clinician-Administered PTSD Scale , 1995, Journal of traumatic stress.

[38]  M. Paulus,et al.  Executive function and PTSD: Disengaging from trauma , 2012, Neuropharmacology.

[39]  Jonathan D. Cohen,et al.  Conflict monitoring and anterior cingulate cortex: an update , 2004, Trends in Cognitive Sciences.

[40]  D. Warden,et al.  Neuropsychological test performance in soldiers with blast-related mild TBI. , 2010, Neuropsychology.

[41]  T. Kimbrell,et al.  Does PTSD impair cognition beyond the effect of trauma? , 2011, The Journal of neuropsychiatry and clinical neurosciences.

[42]  M. Hotopf,et al.  Risk factors for post-traumatic stress disorder among UK Armed Forces personnel , 2008, Psychological Medicine.

[43]  Tali Fisher,et al.  Dis-regulation of response inhibition in adult Attention Deficit Hyperactivity Disorder (ADHD): An ERP study , 2011, Clinical Neurophysiology.

[44]  Alan N. Simmons,et al.  A multimodal imaging study in U.S. veterans of Operations Iraqi and Enduring Freedom with and without major depression after blast-related concussion , 2011, NeuroImage.

[45]  J. Vasterling,et al.  Attention and memory dysfunction in posttraumatic stress disorder. , 1998, Neuropsychology.

[46]  G. McCarthy,et al.  Neural systems for executive and emotional processing are modulated by symptoms of posttraumatic stress disorder in Iraq War veterans , 2008, Psychiatry Research: Neuroimaging.

[47]  R. Yoash-Gantz,et al.  Relationship Between Processing Speed and Executive Functioning Performance Among OEF/OIF Veterans: Implications for Postdeployment Rehabilitation , 2009, The Journal of head trauma rehabilitation.

[48]  J. Patton,et al.  Factor structure of the Barratt impulsiveness scale. , 1995, Journal of clinical psychology.

[49]  R. Ruff,et al.  Mild traumatic brain injury in U.S. soldiers returning from Iraq. , 2008, The New England journal of medicine.

[50]  A. Etkin,et al.  Functional neuroimaging of anxiety: a meta-analysis of emotional processing in PTSD, social anxiety disorder, and specific phobia. , 2007, The American journal of psychiatry.

[51]  M. Bellgrove,et al.  Insights into the neural basis of response inhibition from cognitive and clinical neuroscience , 2009, Neuroscience & Biobehavioral Reviews.

[52]  S. Johnstone,et al.  A meta-analysis of response inhibition and Stroop interference control deficits in adults with traumatic brain injury (TBI) , 2011, Journal of clinical and experimental neuropsychology.

[53]  G. Larson,et al.  Prospective analysis of psychiatric risk factors in marines sent to war. , 2009, Military medicine.

[54]  E. Blanchard,et al.  Psychometric properties of the PTSD Checklist (PCL). , 1996, Behaviour research and therapy.

[55]  J. Ghajar Traumatic brain injury , 2000, The Lancet.

[56]  Jin Fan,et al.  The activation of attentional networks , 2005, NeuroImage.

[57]  Stewart H. Mostofsky,et al.  Response Inhibition and Response Selection: Two Sides of the Same Coin , 2008, Journal of Cognitive Neuroscience.

[58]  P. White,et al.  Attentional networks reveal executive function deficits in posttraumatic stress disorder. , 2007, Neuropsychology.

[59]  Mieke Verfaellie,et al.  Mild traumatic brain injury and posttraumatic stress disorder in returning veterans: perspectives from cognitive neuroscience. , 2009, Clinical psychology review.

[60]  E. Miller,et al.  An integrative theory of prefrontal cortex function. , 2001, Annual review of neuroscience.

[61]  B. Renneberg,et al.  Response Inhibition in Borderline Personality Disorder: Performance in a Go/Nogo Task , 2007, Psychopathology.

[62]  Shuhei Yamaguchi,et al.  The Key Locus of Common Response Inhibition Network for No-go and Stop Signals , 2008, Journal of Cognitive Neuroscience.

[63]  J. Whyte,et al.  Measuring sustained attention after traumatic brain injury: Differences in key findings from the sustained attention to response task (SART) , 2006, Neuropsychologia.

[64]  M. J. Emerson,et al.  The Unity and Diversity of Executive Functions and Their Contributions to Complex “Frontal Lobe” Tasks: A Latent Variable Analysis , 2000, Cognitive Psychology.

[65]  A. Beck,et al.  Psychometric properties of the Beck Depression Inventory: Twenty-five years of evaluation , 1988 .

[66]  Glenn Curtiss,et al.  Factors moderating neuropsychological outcomes following mild traumatic brain injury: A meta-analysis , 2005, Journal of the International Neuropsychological Society.

[67]  T. Shallice,et al.  Effects of focal frontal lesions on response inhibition. , 2006, Cerebral cortex.

[68]  E. Bigler,et al.  Neuropsychological and information processing deficits following mild traumatic brain injury , 2004, Journal of the International Neuropsychological Society.

[69]  P. Siddall,et al.  Biopsychosocial perspective on a mechanisms-based approach to assessment and treatment of pain following spinal cord injury. , 2009, Journal of rehabilitation research and development.

[70]  Zac E. Imel,et al.  Posttraumatic stress disorder as a risk factor for suicidal ideation in Iraq and Afghanistan War veterans. , 2009, Journal of traumatic stress.

[71]  Nina A. Sayer,et al.  Prevalence, Assessment, and Treatment of Mild Traumatic Brain Injury and Posttraumatic Stress Disorder: A Systematic Review of the Evidence , 2011, The Journal of head trauma rehabilitation.