Attention may be compromised in people with PTSD. Several tasks have been developed to assess attention. The most common task is The Stroop Colour Word Test, which presents colour names printed in an ink congruent to the colour name (e.g. blue), or incongruent to the colour name (e.g. blue). Participants are asked to either read the word or name the ink colour. A Stroop interference index is calculated by subtracting response times in the colour-naming condition from those in the incongruent condition. This serves as a measure of the attentional engagement, with more engagement indicating an attentional bias. The emotional Stroop task replaces colour-words with neutral and emotionally loaded stimuli (e.g., the word “violence” painted in blue compared to a neutral word in the same colour). Other tasks include the Continuous Performance Test that uses both visual and auditory stimuli and requires participants to respond to targets and ignore distractors. Also, the Trail Making Test requires participants to connect, in order, letters and/or numbers as quickly as possible.

What is the evidence for attention in people with PTSD?

Moderate to high quality evidence finds medium-sized effects of poorer attention in people with PTSD than in healthy controls (people not exposed to trauma and those without PTSD). Similar findings were apparent in both children and adults. People with PTSD had greater attentional interference with PTSD-relevant stimuli and with emotionally positive stimuli than with emotionally neutral stimuli. In sexual victimisation survivors with or without PSTD, a small effect showed more attentional bias for sexual threat stimuli in those with PTSD.

August 2021

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Cognitive failures or “slips” are experienced by everyone from time to time and represent a brief lapse in concentration in real world settings. They are influenced by factors such as personality, mood, stress, and time of day. People with psychological disorders are thought to be more vulnerable to cognitive failures, possibly due to increased problems with related cognitive processing such as attention.

Several self-report tools have been developed to measure cognitive failures. One common tool is the Cognitive Failures Questionnaire (CFQ), which requires individuals to indicate how frequently they have experienced a list of minor perceptual, memory, and action failures in everyday life.

What is the evidence for cognitive failures in people with PTSD?

Moderate quality evidence finds increased severity of PTSD symptoms is related to more cognitive failures.

August 2021

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Episodic future thinking may be disrupted in people with PTSD. It refers to thought processes that contribute to the mental construction, imagination, or simulation of possible future events. Episodic future thinking plays a role in planning, problem-solving, coping, regulating emotional states and goal-motivated behaviour.

What is the evidence for episodic future thinking in people with PTSD?

Moderate to low quality evidence found no differences in episodic future thinking between people with PTSD and people without PTSD.

August 2021

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Executive functions are a group of cognitive processes including control, mental flexibility, planning, inhibition, decision-making, initiation, abstraction, self-monitoring, and pursuit of goals. Executive functions are important in situations involving error correction and behaviour evaluation in response to environmental feedback.

What is the evidence for executive functioning?

Moderate to high quality evidence found poorer executive functioning in adults and children with PTSD compared to people without the disorder who were, or who were not, exposed to trauma. There were no significant associations between symptom severity and executive functioning.

August 2021

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Overall cognitive functioning may be disrupted in people with PTSD. Intelligence quotient (IQ) is derived from standardised tests used to measure general cognitive functioning. IQ is most commonly measured using the Wechsler Adult Intelligence Scale (WAIS). The WAIS is designed to measure all aspects of cognitive functioning and is divided into subtests measuring verbal IQ (verbal comprehension and working memory) and non-verbal IQ (perceptual organisation and processing speed). Other tests used to assess IQ include the Mini-Mental State Examination (MMSE), which assesses cognitive impairment; the National Adult Reading Test (NART), which assesses premorbid intelligence; the Wide Range Achievement Test (WRAT), which assesses both verbal and mathematic ability; and the Raven’s Progressive Matrices, which assesses general intelligence.

What is the evidence for general cognition in people with PTSD?

High quality evidence finds a medium-sized effect of poorer general intelligence in people with PTSD than people without PTSD. Moderate quality evidence finds a large effect of poorer general intelligence in traumatised children with PTSD compared to non-traumatised children, and a small effect when compared to traumatised children without PTSD.

August 2021

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Information processing may be disrupted in people with PTSD. It can be assessed using various tests that assess general processing and speed.

The Wechsler Adult Intelligence Scale (WAIS) digit symbol coding test presents participants with paired numbers and symbols and when shown several numbers, participants must write down the missing corresponding symbols as quickly as possible.

The Wisconsin Card Sorting Task (WCST) requires an ability to shift cognitive sets; participants are told to match stimulus cards containing varying coloured shapes, based first on colour, then quantity, then design. The participant is then given additional cards and asked to match each one without being told any matching rules, so participants usually match according to the previous rule. Feedback is provided as to whether their match was correct or incorrect, based on a new and undisclosed matching rule, that changes during the task.

The Trail Making Test (TMT) requires participants to connect, in order, letters and/or numbers as quickly as possible.

The Stroop Colour Word Test (SCWT), presents colour names printed in an ink congruent to the colour name (e.g. blue), or incongruent to the colour name (e.g. blue). Participants are asked to either read the word or name the ink colour.

Category fluency (e.g. animal naming) is an oral test that requires participants to name as many of a category (e.g. types of animals) in one minute.

The Stockings of Cambridge (SOC) planning task requires participants to mentally plan a sequence of moves needed to complete a task in the fewest number of moves before beginning the task.

What is the evidence for information processing in people with PTSD?

Moderate quality evidence finds medium-sized effects showing people with PTSD had poorer information processing than controls without PTSD.

August 2021

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Language may be altered in people with PTSD. Tasks designed to assess language ability include letter fluency tasks that assess the ability to generate words starting with a particular letter. Category fluency tasks assess the ability to name words within a specified category. Working memory is needed for both letter and category fluency as participants must organise and retrieve relevant information.

Other tests designed to assess language include: Boston Naming task; Wechsler Adult Intelligence Scale (WAIS) comprehension (including the subtest information, similarities and vocabulary), WAIS verbal memory, verbal fluency, National Adult Reading Test (NART)/ Wide Range Achievement Test (WRAT), Controlled Oral Word Association Test (COWA), Category Instance Generation Test (CIGT), Multiple Choice Vocabulary Test (MWT-B), Hopkins Verbal Learning Test (HVLT), California Verbal Learning Test (CVLT), Rey Auditory Verbal Learning Test (AVLT), semantic priming tasks and Lexical Decision Task and the Peabody Individual Achievement reading comprehension (PIAT). Latent Semantic Analysis (LSA) is used to determine the degree of incoherence in language.

What is the evidence for language alterations in people with PTSD?

Moderate to low quality evidence finds medium-sized effects showing children and adults with PTSD had poorer language ability than people without PTSD. There were no differences between adults aged over 65 years.

August 2021

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Learning is the ability to acquire, or change existing knowledge, behaviours, or skills. This process may be disrupted in people with PTSD. There are two distinct forms of learning. The first is explicit (or declarative) learning, which occurs during a high level of consciousness regarding specific learnt content, for example, memorising information for an exam. The second is Implicit (or procedural) learning, which is less conscious and refers to learning that is gained from task performance, for example, juggling. Explicit verbal learning can be measured with the Hopkins Verbal Learning test, the California Verbal Learning test and verbal list-learning. The Brief Visuospatial memory test, the Rey design learning test, the Rey complex figure test, and visual reproduction all measure explicit visual learning. Implicit learning can be measured using the Serial Reaction Time task where learning is inferred from reduced reaction time to stimuli.

What is the evidence for learning ability?

Moderate to low quality evidence finds a medium-sized effect showing traumatised children with PTSD had poorer learning ability than controls who were not exposed to trauma or PTSD. This was not found when compared to trauma-exposed controls (without PTSD).

Moderate to high quality evidence found small to medium-sized effects of poorer learning ability in adults with PTSD than in trauma-exposed or non-exposed controls.

August 2021

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Memory involves encoding, storage and retrieval of information. Short-term memory is the ability to remember information after several seconds or minutes; and long-term memory is the ability to remember information over a longer duration. Semantic memory is memory for general facts, episodic memory is memory for personal events, prospective memory is memory for future actions, and retrospective memory is memory for past events. Working memory involves information being temporarily held as well as manipulated.

What is the evidence for memory in PTSD?

Moderate quality evidence finds small to medium-sized effects of poorer memory in people with the disorder than in controls. This was found for both episodic and prospective memory. There were also medium to large effects of poorer verbal episodic and working memory, with similar effects found in children and adults. Visual episodic memory was impaired only in children.

Moderate to low quality evidence finds large deficits in autobiographical memory in people with PTSD. Review authors explain an autobiographical memory deficit in PTSD as having difficulty recalling specific details of personal events and a tendency to recall an overall, general impression of events instead.

August 2021

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Social cognition may be disrupted in people with PTSD. It describes the ability to understand the actions and intentions of other people; the cognitive processes underlying social interactions that are used to guide behaviour. Social cognition is crucial for effective communication and relates to social competence and may predict work functioning.

Aspects of social cognition may be altered in people with a mental illness, including theory of mind, social perception, emotion processing, emotion regulation, and empathy. Theory of mind refers to the ability to infer the mental states of other people. Social perception is an awareness of social cues and norms that dictate social interactions. Emotion processing is the ability to perceive emotional cues, such as the emotional content of facial expressions or vocal inflections (prosody). Emotion regulation is the conscious or unconscious effort to affect the likelihood, intensity, or duration of an emotion. Empathy involves showing concern for others, understanding their perspective, experiencing distress when exposed to others’ negative events, and having the ability to place oneself into fictional situations and empathically relate to the characters (‘fantasy’).

What is the evidence for social cognition in people with PTSD?

Moderate quality evidence found the emotional and affective aspects of theory of mind (but not cognitive aspects) were disturbed in people with PTSD. Most people with PTSD also exhibit altered perception of emotions, including difficulty processing threatening expressions and a reduction in the perception of positive emotions such as happiness. There were disturbances in affective empathy, from emotional resonance to compassionate feelings. Finally, social behaviour is disturbed in individuals with PTSD, which damages interactions within the family circle. Anger, impulsivity, and physical and verbal aggression underpin these difficulties.

There was a medium to large association between increased emotion regulation and increased PTSD symptoms. Small to medium-sized associations were also found with experiential avoidance, expressive suppression, rumination, thought suppression, and worry. There were no associations between reappraisal and acceptance and PTSD symptoms.

August 2021

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