Elke GERAERTS a 1 and Tim BRENNEN b aDepartment of Experimental Psychology, Maastricht University, The Netherlands b Department of Psychology, University of Oslo, Norway
Abstract. Over the past decade, researchers have increasingly drawn upon concepts and methods developed in cognitive psychology to reveal cognitive processes underlying symptoms of Posttraumatic Stress Disorder (PTSD). These studies have shown that individuals with PTSD display difficulties retrieving specific autobiographical memories in response to cue words, instead recalling overgeneral memories. Moreover, they exhibit difficulty forgetting trauma-related words during directed forgetting, and exhibit enhanced false memory effects for trauma-related material. Such findings suggest that experimental methods can supplement conventional self-report inventories to elucidate cognitive abnormalities underlying PTSD symptomatology. However, to reach a better understanding of the phenomenon, one should also take symptom overreporting into account.
Keywords. Posttraumatic Stress Disorder, cognitive processes, false memories, malingering
Some people who are exposed to terrible events persist in reexperiencing these events in flashbacks, nightmares, and intrusive recollections, often qualifying for a diagnosis of Posttraumatic Stress Disorder (PTSD). Other people exposed to equally shocking events
Corresponding Author: Elke Geraerts, Department of Experimental Psychology, Maastricht University, PO Box 616, 6200 MD, Maastricht, The Netherlands. Tel.: +31-433882468; fax: +31433884196. E-mail: [email protected].
only show this distress for a short period of time, after which they recall these experiences in a relatively normal manner. This diversity in response to trauma entails that people differ in the way they process these incidents. The continuing involuntary and intrusive cognitive phenomena imply dysfunctions in the mechanisms of memory.
Indeed, among the anxiety syndromes, PTSD is the one that can most correctly be characterised as a disorder of memory . That is why, during the last decade, researchers have begun to employ paradigms of cognitive psychology to characterise mental abnormalities in PTSD patients. Besides this line of research, increasingly sophisticated theories have been developed that endeavored to keep pace with new findings while at the same time remaining anchored in basic psychological research .
The aim of this chapter is to describe how cognitive processes underlying PTSD symptoms can be revealed, by providing a review of prior research and focusing on recently conducted studies with survivors of war and childhood sexual abuse. Finally, we will discuss topics related to the overreporting of PTSD symptoms.
1. Prior Research
Since it has recently been argued that PTSD can be seen as a disorder of memory, several studies have explored the connection between PTSD symptoms and memory processes. For instance, a series of studies has shown a connection between overgeneral memory and PTSD [3-4]. In one study, Vietnam combat veterans with PTSD, relative to healthy combat veterans, had difficulty recalling specific personal memories in response to cue words with either a positive (e.g., kindness), negative (e.g., panic) or neutral (e.g., appearance) meaning . Despite having been trained to retrieve specific autobiographical memories, PTSD participants tended to slide back into an overgeneral retrieval style during the experiment. Patients with PTSD who had been emotionally primed by viewing a combat-related videotape, had more difficulties accessing specific memories than those who had viewed a videotape related to a neutral theme (i.e., furniture).
In a further study , Vietnam combat veterans with and without PTSD were asked to retrieve specific personal memories illustrating traits indicated by positive (e.g., loyal) and negative (e.g., guilty) cue words. Veterans with PTSD, relative to healthy veterans, exhibited difficulties retrieving specific autobiographical memories, especially in response to positive cue words. That is, while PTSD patients showed equivalent rates of specific memory retrieval for positive and negative cues, healthy veterans found it easier to think of episodes when they had exhibited positive traits than when they had exhibited negative traits.
Besides research concerning autobiographical memory, cognitive psychologists have tested controversial hypotheses by using traumatised populations. Some authors state that certain experiences may be so traumatic that victims deal with them in an avoidant-dissociative way . For instance, this style would enable survivors of childhood sexual abuse (CSA) to disengage attention from threatening stimuli and would result in impoverished, i.e. repressed or dissociated, autobiographical memories of traumatic events . Although possibly adaptive under the circumstances of chronic abuse, this encoding style presumably puts people at risk for developing subsequent psychiatric problems.
McNally and colleagues  reasoned that a particular variant of directed forgetting paradigm would be well-suited to testing whether psychiatrically impaired adults with histories of childhood sexual abuse are indeed characterised by an avoidant encoding style. In an item-specific directed forgetting paradigm, participants are presented with words one at a time. Immediately after each word appeared, participants are instructed either to remember or to forget that particular word. After this encoding phase, memory for both the to-be-remembered (TBR) and the to-be-forgotten (TBF) words is tested, and the standard result in this paradigm is that when participants are given a surprise recall of the entire set of stimuli, they recall fewer TBF words than TBR words . The key mechanism behind this directed forgetting effect is presumed to be encoding activities, because better recall of TBR words can be explained by the fact that participants terminate encoding and rehearsal processes as soon as the forget instruction follows a TBF word . Accordingly, if psychiatrically impaired survivors of childhood sexual abuse develop an ability to avoid encoding trauma-related material, they should show memory deficits for trauma-related TBR words relative to neutral and positive TBR words. Put another way, for such a group, directed forgetting ought to be observed only for neutral (e.g., mailbox) and positive (e.g., celebrate) material but not for trauma-related material (e.g., incest). McNally et al. tested this with three groups of participants: The first group comprised women reporting histories of childhood sexual abuse and who were diagnosed with PTSD; the second group comprised women with similar abuse histories but no PTSD. Finally, the third group included women without abuse histories and without PTSD. Contrary to the avoidant encoding hypothesis, participants with PTSD only displayed overall memory deficits compared to the other groups for neutral and positive words, which they were supposed to remember equally well. Additionally, they remembered trauma-related words very well, including those they were instructed to forget. In contrast, healthy survivors and participants with no history of childhood abuse recalled TBR words better than TBF words, irrespective of word valence. Taken together, these data imply that individuals with PTSD easily encode and recall trauma-related material, and that persistent trauma-related thoughts may undermine the encoding of material that is not related to the trauma.
It can be seen that cognitive research on PTSD has depicted cognitive processes that may figure in the source of certain symptoms of the disorder. Results of the studies described above can be clearly linked to classic symptoms of PTSD like intrusions and avoidance. Studies imply, for example, that enhanced accessibility and failure of inhibition are candidates for the mechanism underlying the phenomenon of intrusive recollection. This evident link between PTSD symptoms and underlying cognitive deficits displayed in these studies, underlines the importance of research investigating the cognitive patterns in PTSD patients and trauma-exposed controls.
Besides research exploring these cognitive abnormalities underlying PTSD, several models of cognitive functioning in PTSD have been proposed [10-12]. The model of Ehlers and Clark , for example, describes a network of cognitive processes, including strategies that the person chooses to use that lead from the traumatic situation itself to the maintenance of persistent PTSD. The model reflects the notion that strategies with which the person attempts to keep unpleasant mental intrusions to a minimum may paradoxically make their elimination more difficult. Implicit in this and other models is that trauma exposure per se is not enough to produce and maintain PTSD: amongst other variables, particular cognitive strategies that only arise in a subset of trauma-exposed people are necessary to produce that. Furthermore, in the models, the cognitive differences between people with PTSD and trauma-exposed people are predicted to be most marked for trauma-related material. That is, PTSD is assumed to have effects on cognitions thematically-related to the traumatising event, and therefore a general prediction of the framework is that, compared to trauma-exposed controls, PTSD patients should have worse performance on tests of trauma-related cognition but not on tests with neutral stimuli.
The Deese-Roediger-McDermott (DRM) task is a laboratory paradigm that is very effective in eliciting false memories [13-14]. In it, participants study a list of words that are strong semantic associates of a word not presented on the list - the critical lure. For example, participants may study words like bed, rest, awake, tired, and so forth, all of which are strongly related to the nonpresented critical item, sleep. On a subsequent test, participants often falsely recall and recognise the critical lure (in this case, sleep).
A number of researchers have argued that susceptibility to false memories may be due to a deficit in source monitoring, i.e., incorrect judgments about the origin or source of information . On this view, the presentation of semantically associated words activates a concept that is common to all words on the list, namely the critical nonpresented lure. Thus, the DRM paradigm requires participants to differentiate between internally generated thoughts and genuine memories of the studied words .
There is reason to believe that PTSD patients may have particular problems with source-monitoring, and thus a tendency towards higher production of false memories, due to the connection between the disorder and dissociation. For instance, Bremner and colleagues  demonstrated a link between war-induced PTSD and dissociation, and Winograd and co-workers  showed that scores on dissociative scales were positively correlated with susceptibility to false memories on the DRM task. This hypothesis has been tested in two studies employing the DRM paradigm with people reporting traumatic experiences, with or without PTSD. On the one hand, Bremner et al.  studied women with memories of childhood sexual abuse who were suffering from PTSD. The authors found that these women displayed a higher frequency of false recognition than abused women without PTSD. However, there were no differences in correct recognition between the groups. Zoellner and colleagues , on the other hand, reported that victims of criminal assaults with or without PTSD did not differ on either falsely recognising critical lures or on correctly recognising presented words. When comparing the two traumaexposed groups on recall of words from DRM lists, Zoellner et al.  reported no differences in the number of correctly recalled words, whereas Bremner et al.  found that PTSD patients recalled fewer words than participants without PTSD. On numbers of critical lures mistakenly recalled, neither study reported significant differences between the two groups, and in both cases the trend was actually for non-PTSD participants to recall more lures.
The study of Brennen and colleagues  aimed at investigating the discrepancy between these results on correct recall of words from DRM lists and to shed more light on the unexpected finding in both previous studies that trauma-exposed groups have equivalent susceptibility to recall critical lures, apparently at odds with the models of cognition in PTSD. In addition, a novelty of this study was that, in addition to neutral word lists, trauma-related DRM lists were used. If PTSD patients and trauma-exposed non-PTSD patients are found to show similar patterns on trauma-related cognitive tasks, this would undermine models of cognition in PTSD, where PTSD patients are predicted to have impaired trauma-related cognition. For instance, in Ehlers and Clark's  model, several sets of factors intervene between trauma exposure and the development of persistent PTSD: besides the characteristics of the trauma and its sequelae, a person's beliefs and coping style will play a role, as well as peritraumatic processing, and of most relevance here, an individual's cognitive strategies aimed at inhibiting the reminders of the unpleasant event. In this model PTSD patients have self-reinforcing thought patterns, where their attempts at pushing thoughts of the trauma out of their mind actually have the opposite effect of making the unpleasant thoughts rebound into consciousness more often. Trauma-related cognition would thus be expected to be impaired for PTSD patients compared to traumaexposed controls.
To test this question, Brennen et al.  tested 50 participants with war-related PTSD and 50 traumatised controls without PTSD. The inducing events for the PTSD patients had occurred at least 7 years previously, during the war in Bosnia. Based on cognitive models, it was expected that war-related source-monitoring should be worse in PTSD, leading to more false recall of the war-related critical lures. The study revealed that PTSD patients did not show a higher susceptibility to falsely recalling neutral critical lures. This finding is consistent with previous results [19-20]. However, PTSD patients exhibited higher rates of false recall of war-related critical lures, while simultaneously showing a lower rate of correct recall.
In agreement with models such as Ehlers and Clark's , trauma-related source-monitoring appears to be impaired in PTSD patients, even compared to a group of traumaexposed controls. Taken together, this study provides evidence suggesting that PTSD
patients have a particular susceptibility to trauma-related false memories, but backs up previous findings of no difference for recall of neutral false memories.
By far the most controversial topic in the field of trauma concerns the accuracy of recovered memories of childhood sexual abuse. The concept of repressed and recovered memories has been deeply divisive in psychology and psychiatry and has led to the so-called 'memory wars' [22-23]. Some scholars claim that amnesia for trauma and/or subsequent recovery of traumatic memories can be demonstrated in clinical populations [5, 24], whereas others have questioned the existence of repressed and recovered memories because of the lack of solid evidence for such memories [25-26]. Moreover, skeptics have warned that memories may be susceptible to distortions  and hence that therapies intended to recover memories of childhood sexual abuse may unintentionally foster false memories of childhood sexual abuse .
Despite the furore surrounding recovered memories, almost no research has been conducted on the cognitive functioning of people at the heart of this debate, namely people with reported repressed and recovered memories of a trauma. This situation may have arisen because few clinicians possess expertise in laboratory research and few cognitive psychologists have access to trauma populations. In fact, Richard McNally, Susan Clancy, and their colleagues at Harvard University were the first to apply experimental methods to investigate memory functioning in people reporting repressed and recovered memories of childhood sexual abuse. More specifically, McNally and his group have been conducting studies on four groups of participants: adults who report remembering the abuse after years of not thinking about it (recovered memory group), adults who believe they were sexually abused as children but who have no explicit autobiographical memories of childhood abuse (repressed memory group), adults who have always remembered being abused (continuous memory group), and adults without a history of abuse (control group) . By using several cognitive tasks, McNally and colleagues showed that the repressed and recovered memory group did not exhibit a superior ability to forget trauma-related words on directed forgetting tasks [29-30; see also 31]. Furthermore, they showed that people with recovered memories of childhood sexual abuse are more prone to exhibit false memory effects on neutral DRM word lists .
However, no study has considered these false memory effects for trauma-related material in survivors of childhood sexual abuse. Would people with recovered memories of abuse show the same trauma-related source monitoring deficit that is seen in PTSD survivors in the study of Brennen and colleagues ? Recently, Geraerts and colleagues  addressed these questions by employing neutral and trauma-related DRM lists to traumatised individuals. They investigated whether participants who reported having recovered memories of childhood sexual abuse would display higher rates of false recall and recognition for neutral and trauma-related words relative to other participants. Following the procedure of Clancy et al. , they recruited participants through advertisements in local newspapers. In these advertisements, they invited women to come to the lab when they a) had recovered memories of childhood sexual abuse, b) believed they had been sexually abused as a child, c) had a history of sexual abuse which had never been forgotten or d) had no history of sexual abuse.
The results replicated the robust false recall and recognition effects typically found with the DRM paradigm . That is, overall, participants falsely remembered many of the critical lures. Replicating earlier findings of Clancy et al. , the results also lend support to the idea that women reporting recovered CSA memories are more susceptible than other participants to this memory illusion. More specifically, women with recovered memories of CSA exhibited higher rates of false recall and false recognition of critical lures than the other participants. This study was the first to show that this was true for both neutral and trauma-related word lists.
As already mentioned, a number of researchers have argued that susceptibility to false memories may be due to a deficit in source monitoring . The results of Geraerts et al.  suggest that women reporting recovered CSA memories may have a source monitoring deficit for all types of material, whether the content is neutral or trauma-related. It can be speculated that especially these women have difficulties with the identification of the origin of a memory and that they may have a tendency to adopt an internally generated thought as being a genuine memory. This could have serious real-life implications, both for the reliability of their autobiographical memory and for the development of their knowledge and beliefs. Additionally, it might well be the case that source monitoring confusion can produce pseudomemories. Therefore, it is very important to recognise that the influence of source monitoring on the origin of recovered memories warrants further study.
The debate about repressed and recovered memories of sexual abuse is however not the only controversy in the field of trauma. Whereas all the aforementioned studies relate to benign memory distortion, one should be aware that false claims of PTSD are a reality. For instance, Frueh and colleagues  demonstrated the problem of deliberate exaggeration of symptoms in veterans seeking to obtain a diagnosis of PTSD. Because in many countries there are civil and criminal laws that regulate financial compensation for victims of war trauma, it is obvious that, in some cases, people present themselves as victims in an attempt to profit from financial or judicial regulation.
Sparr and Pankratz  were the first to identify such false claims of PTSD in individuals reporting disability from combat in Vietnam when in fact it can be shown that the claimants had never been to that country. Until recently, such false claims remained largely ignored. Burkett and Whitley  pointed out how widespread the problem was by describing many cases where entire combat histories had been falsified. In a recent study, Kozaric-Kovacic and co-workers  explored the change in the diagnosis of PTSD which was related to the introduction of a new national regulation on compensation-seeking by Croatian war veterans. The legal regulation of compensation-seeking of these veterans was first established in 1992 within a law, including all immediate combat and civilian victims of war trauma. This regulation was extended in 2001, allowing war veterans that had not been covered by the previous law to apply for compensation due to prolonged or delayed PTSD . It was found that there were significant differences in the diagnosis of PTSD made before and after the introduction of the new law in 2001. The diagnoses made by psychiatrists changed towards the diagnoses with higher compensation rates. On a related note, it has also been shown that the details of the rules governing compensation appear to influence the way some veterans report their symptoms when they are being evaluated for PTSD .
Clinical researchers need to increase the attention given to these issues and to realise that it is essential to differentiate between malingered and genuine PTSD symptoms. Therefore, psychometric instruments for the evaluation of malingered PTSD are needed. One promising test is the Morel Emotional Numbing Test (MENT) . This is a forced-choice task to detect response bias in PTSD assessments. Updated in 2004 , it consists of 60 two-alternative items. Briefly, the test uses 20 coloured slides of 10 facial expressions posed by a man and a woman. Their expressions reflect happiness, frustration, sadness, anger, fear, calmness, surprise, shyness, confusion, and sleepiness. The slides are presented on a computer screen along with verbal labels describing emotions. The participant is instructed to identify the emotion word that best matches the expression portrayed on the slide. In a first series of 20 trials, participants see one slide on the computer screen and are asked to circle one of two words (e.g., "happy"; "surprised") describing the slide. In a second run of 20 trials, participants view two slides, but only one word and are asked to identify the slide that best matches the word. In a final run of 20 trials, participants are shown two slides and two words which have to be matched to each other. Before the task is given to participants, they are primed with the instruction that many PTSD patients suffer from emotional numbness and that this may cause them to have difficulties with the recognition of facial expressions. The idea is that individuals who tend to overreport PTSD symptoms will intentionally produce more errors on this deceptively simple test. Findings from Morel  pointed out that war veterans who were suspected for false PTSD claims made more errors on the MENT than credible claimant groups and patient groups with alcohol dependency or schizophrenia. At the moment, the MENT is being employed in a large sample of compensation-seeking Croatian war veterans. The aim of this ongoing study is to examine the possibility of distinguishing between simulated and genuine symptom presentation, based on scores on the MENT and several other diagnostic tools .
Cognitive research on PTSD has produced substantial evidence that PTSD patients show deficits in memory for trauma-related material. Studies on autobiographical memory reveal impairments in the ability of PTSD patients to access specific episodes from their past. Additionally, the hypothesis that trauma survivors, especially those with a history of childhood sexual abuse, have developed skills for expelling disturbing material from awareness has been undermined by directed forgetting methods. These methods even point in the opposite direction: trauma survivors exhibit an impaired ability to forget disturbing material. Likewise, studies using a false memory paradigm point out that PTSD patients show enhanced false memory effects for trauma-related material.
This cognitive research on PTSD is required to elucidate the information-processing characteristics associated with PTSD and to test the main tenets of psychological theories of PTSD. Furthermore, several clinical implications are suggested by this line of research. For example, problems accessing specific episodes from the past should alert clinicians to difficulties patients may come across in cognitive therapy or in other interventions that require one to access specific episodes from one's past. Furthermore, clinicians should take into account that PTSD patients are more prone to falsely recalling trauma-related material, at least in the laboratory. Additionally, one should be attentive for the relationship between source monitoring deficits and recovered memories of childhood sexual abuse. Finally, it is important to realise that a diagnosis of PTSD should not only rely on self-report inventories or other assessment procedures which may be vulnerable to symptom overreporting.
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42 Novel Approaches to the Diagnosis and Treatment of Posttraumatic Stress Disorder
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