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Bremner, J. D., E. Vermetten, M. Vythilingam, N. Afzal, C. Schmahl, B. Elzinga and D. S. Charney (2004). "Neural correlates of the
classic color and emotional stroop in women with abuse-related posttraumatic stress disorder." Biol Psychiatry 55(6): 612-620.
(ISSN) 0006-3223 (Print) 0006-3223 (Linking)
BACKGROUND: The anterior cingulate and medial prefrontal cortex play an important role in the inhibition of responses, as
measured by the Stroop task, as well as in emotional regulation. Dysfunction of the anterior cingulate/medial prefrontal
cortex has been implicated in posttraumatic stress disorder (PTSD). The purpose of this study was to use the Stroop task as
a probe of anterior cingulate function in PTSD. METHODS: Women with early childhood sexual abuse-related PTSD (n = 12)
and women with abuse but without PTSD (n = 9) underwent positron emission tomographic measurement of cerebral blood
flow during exposure to control, color Stroop, and emotional Stroop conditions. RESULTS: Women with abuse with PTSD
(but not abused non-PTSD women) had a relative decrease in anterior cingulate blood flow during exposure to the emotional
(but not color) classic Stroop task. During the color Stroop there were also relatively greater increases in blood flow in nonPTSD compared with PTSD women in right visual association cortex, cuneus, and right inferior parietal lobule.
CONCLUSIONS: These findings add further evidence for dysfunction of a network of brain regions, including anterior
cingulate and visual and parietal cortex, in abuse-related PTSD.
Buckley, T. C., T. Galovski, E. B. Blanchard and E. J. Hickling (2003). "Is the emotional Stroop paradigm sensitive to malingering? A
between-groups study with professional actors and actual trauma survivors." J Trauma Stress 16(1): 59-66. (ISSN) 0894-9867 (Print)
0894-9867 (Linking)
Six professional actors, trained by psychologists and acting coaches to feign PTSD, were covertly enrolled into a treatment
outcome study for PTSD with the aim of investigating malingering. During pretreatment assessment, individuals completed
an emotional Stroop task. Vocal response latencies to different classes of stimuli were examined for sensitivity to
malingering. Actor response latencies were compared to those of 6 nonlitigant PTSD patients and 6 nonanxiety controls. The
actor/dissimulation group was able to feign an overall slowing of response latency across stimulus types, similar to the PTSD
group. However, they were unable to modulate response latency as a function of stimulus content, a pattern that
characterized the PTSD group. The use of information-processing paradigms to detect dissimulation is discussed.
Cisler, J. M., K. B. Wolitzky-Taylor, T. G. Adams, Jr., K. A. Babson, C. L. Badour and J. L. Willems (2011). "The emotional Stroop
task and posttraumatic stress disorder: a meta-analysis." Clin Psychol Rev 31(5): 817-828. (ISSN) 1873-7811 (Electronic) 02727358 (Linking)
Posttraumatic stress disorder (PTSD) is associated with significant impairment and lowered quality of life. The emotional
Stroop task (EST) has been one means of elucidating some of the core deficits in PTSD, but this literature has remained
inconsistent. We conducted a meta-analysis of EST studies in PTSD populations in order to synthesize this body of
research. Twenty-six studies were included with 538 PTSD participants, 254 non-trauma exposed control participants (NTC),
and 276 trauma exposed control participants (TC). PTSD-relevant words impaired EST performance more among PTSD
groups and TC groups compared to NTC groups. PTSD groups and TC groups did not differ. When examining within-subject
effect sizes, PTSD-relevant words and generally threatening words impaired EST performance relative to neutral words
among PTSD groups, and only PTSD-relevant words impaired performance among the TC groups. These patterns were not
found among the NTC groups. Moderator analyses suggested that these effects were significantly greater in blocked designs
compared to randomized designs, toward unmasked compared to masked stimuli, and among samples exposed to
assaultive traumas compared to samples exposed to non-assaultive traumas. Theoretical and clinical implications are
discussed.
Devineni, T., E. B. Blanchard, E. J. Hickling and T. C. Buckley (2004). "Effect of psychological treatment on cognitive bias in motor
vehicle accident-related Posttraumatic Stress Disorder." J Anxiety Disord 18(2): 211-231. (ISSN) 0887-6185 (Print) 0887-6185
(Linking)
The modified or "emotional" Stroop paradigm has been frequently employed in previous evaluations of information
processing models of Posttraumatic Stress Disorder (PTSD) and other anxiety disorders. These studies have frequently
documented an attentional bias to trauma-specific threatening stimuli in PTSD patients. However, the response of the Stroop
color-naming interference effect to psychological treatment has yet to be tested in a trauma population. The present study
evaluated the effects of three treatment conditions on the Stroop interference effect in motor vehicle accident (MVA)
survivors with PTSD. Following treatment, participants were classified as either treatment responders or nonresponders.
Participants named the color of three types of stimuli: MVA trauma-specific words, neutral words, and nonwords. Results
showed that change in selective color-naming interference for trauma cues was unrelated to treatment response or modality
at either posttreatment or follow-up. Findings cast doubt on the clinical utility of the modified Stroop test as a measure of
treatment outcome in this population.
El Khoury-Malhame, M., L. Lanteaume, E. M. Beetz, J. Roques, E. Reynaud, J. C. Samuelian, O. Blin, R. Garcia and S. Khalfa
(2011). "Attentional bias in post-traumatic stress disorder diminishes after symptom amelioration." Behav Res Ther 49(11): 796-801.
(ISSN) 1873-622X (Electronic) 0005-7967 (Linking)
BACKGROUND: Avoidance and hypervigilance to reminders of a traumatic event are among the main characteristics of
post-traumatic stress disorder (PTSD). Attentional bias toward aversive cues in PTSD has been hypothesized as being part
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of the dysfunction causing etiology and maintenance of PTSD. The aim of the present study was to investigate the cognitive
strategy underlying attentional bias in PTSD and whether normal cognitive processing is restored after a treatment
suppressing core PTSD symptoms. METHODS: Nineteen healthy controls were matched for age, sex and education to 19
PTSD patients. We used the emotional stroop and detection of target tasks, before and after an average of 4.1 sessions of
eye movement desensitization and reprocessing (EMDR) therapy. RESULTS: We found that on both tasks, patients were
slower than controls in responding in the presence of emotionally negative words compared to neutral ones. After symptoms
removal, patients no longer had attentional bias, and responded similarly to controls. CONCLUSION: These results support
the existence of an attentional bias in PTSD patients due to a disengagement difficulty. There was also preliminary evidence
that the disengagement was linked to PTSD symptomatology. It should be further explored whether attentional bias and
PTSD involve common brain mechanisms.
Fleurkens, P., M. Rinck and A. van Minnen (2011). "Specificity and generalization of attentional bias in sexual trauma victims
suffering from posttraumatic stress disorder." J Anxiety Disord 25(6): 783-787. (ISSN) 1873-7897 (Electronic)
0887-6185 (Linking)
The present study investigated specificity of attentional biases for trauma-related stimuli using an Emotional Stroop Task.
Participants were 14 women suffering from posttraumatic stress disorder (PTSD) who had experienced a sexual trauma and
24 healthy non-traumatized women. They were asked to name print colors of 4 different word types: threatening sexual
violence words and non-threatening sexual words, threatening accident trauma words, and positive words. Compared to
control participants, PTSD patients displayed increased interference by threatening trauma-related, but not by accident
trauma and positive words. Interference by non-threatening sexual words occurred as well, but only in those patients who
suffered from more severe PTSD arousal symptoms. These findings suggest graded generalization of the attentional bias
across stimuli of varying emotional valence, but specificity regarding the trauma topic. Results are discussed in light of
current cognitive models of PTSD, and clinical implications are suggested.
Kalnin, A. J., C. R. Edwards, Y. Wang, W. G. Kronenberger, T. A. Hummer, K. M. Mosier, D. W. Dunn and V. P. Mathews (2011).
"The interacting role of media violence exposure and aggressive-disruptive behavior in adolescent brain activation during an
emotional Stroop task." Psychiatry Res 192(1): 12-19. (ISSN) 0925-4927 (Print) 0925-4927 (Linking)
Only recently have investigations of the relationship between media violence exposure (MVE) and aggressive behavior
focused on brain functioning. In this study, we examined the relationship between brain activation and history of media
violence exposure in adolescents, using functional magnetic resonance imaging (fMRI). Samples of adolescents with no
psychiatric diagnosis or with disruptive behavior disorder (DBD) with aggression were compared to investigate whether the
association of MVE history and brain activation is moderated by aggressive behavior/personality. Twenty-two adolescents
with a history of aggressive behavior and diagnosis of either conduct disorder or oppositional-defiant disorder (DBD sample)
and 22 controls completed an emotional Stroop task during fMRI. Primary imaging results indicated that controls with a
history of low MVE demonstrated greater activity in the right inferior frontal gyrus and rostral anterior cingulate during the
violent word condition. In contrast, in adolescents with DBD, those with high MVE exhibited decreased activation in the right
amygdala, compared with those with low MVE. These findings are consistent with research demonstrating the importance of
fronto-limbic structures for processing emotional stimuli, and with research suggesting that media violence may affect
individuals in different ways depending on the presence of aggressive traits.
Metzger, L. J., S. P. Orr, N. B. Lasko, R. J. McNally and R. K. Pitman (1997). "Seeking the source of emotional Stroop interference
effects in PTSD: a study of P3s to traumatic words." Integr Physiol Behav Sci 32(1): 43-51. (ISSN) 1053-881X (Print) 1053-881X
(Linking)
We investigated the source of emotional Stroop interference effects in posttraumatic stress disorder (PTSD) by measuring
reaction times and P3 latencies and amplitudes to personal traumatic, personal positive, and neutral words in a modified
Stroop paradigm. Individuals with PTSD were slower to indicate word color, especially for traumatic words, thereby
replicating emotional Stroop interference in PTSD. Individuals with PTSD also had significantly reduced and delayed P3
components across word types. Across diagnostic groups, frontal P3 amplitudes were larger to personal positive and
traumatic words compared to standard neutral words. However, the absence of Diagnosis x Word Type interactions for P3
measures suggests that individuals with PTSD do not differ from individuals without PTSD in the encoding and recognition of
the color of traumatic relative to nontraumatic words, and that Stroop interference does not occur during these early stages
of processing.
Mueller-Pfeiffer, C., C. Martin-Soelch, J. R. Blair, A. Carnier, N. Kaiser, M. Rufer, U. Schnyder and G. Hasler (2010). "Impact of
emotion on cognition in trauma survivors: what is the role of posttraumatic stress disorder?" J Affect Disord 126(1-2): 287-292.
(ISSN) 1573-2517 (Electronic) 0165-0327 (Linking)
BACKGROUND: Cognitive theories of anxiety disorders postulate an increased attentional bias to environmental cues
associated with threat that underlies the exaggerated fear response. The role of trauma, which may represent strong
competitive advantage for attention, remains unclear. We investigated the influence of trauma exposure and the presence of
anxiety/stress disorders on the impact of emotional distractors on cognitive performance. METHODS: Fourteen traumaexposed subjects with PTSD, 12 trauma-exposed subjects with anxiety disorders other than PTSD, 12 trauma-exposed
healthy subjects and 19 non-trauma-exposed healthy controls participated in this study. The impact of emotion on cognition
was determined by the Affective Stroop task that measures the effect of irrelevant emotional distractors on the speed of
operant responding. RESULTS: The speed of cognitive performance was significantly reduced in the presence of negative
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distractors versus neutral or positive distractors in subjects with PTSD, while there was no significant influence of the
distractor type on performance in the other diagnostic groups (diagnosis-by-distractor type interaction, p<0.001). While
negative distractors induced the same levels of anxiety and depersonalization in subjects with PTSD and subjects with other
anxiety disorders, distractor-induced depersonalization was associated with slowing of cognitive performance in PTSD
(p=0.02) but not in other groups. LIMITATIONS: Different types of anxiety disorders in the non-PTSD group might reduce the
selectivity of the results; some subjects received medication possibly impacting on their cognitive functioning.
CONCLUSIONS: The cognitive impairments in the presence of negative distractors specifically found in PTSD call for
research into novel psychotherapeutic approaches, e.g. attentional training, for PTSD.
Schlosser, N., C. Mensebach, N. Rullkotter, C. Schaffrath, M. Driessen, T. Beblo and K. Wingenfeld (2011). "Selective attention in
depression: influence of emotionality and personal relevance." J Nerv Ment Dis 199(9): 696-702. (ISSN) 1539-736X (Electronic)
0022-3018 (Linking)
Selective attention to negative stimuli has been discussed as being an essential characteristic of depressive disorder.
Theories and empirical data, however, are contradictory. The present study addressed the question of whether depressive
patients selectively attend to negatively valenced and personally relevant or irrelevant stimuli and whether they habituate to
these stimuli. Thirty-one inpatients with major depressive disorder and 37 healthy controls participated in the study. They
underwent a modification of the emotional Stroop paradigm. The results indicated that personally relevant stimuli evoked
more pronounced Stroop interference than did stimuli without personal relevance in all subjects. Furthermore, habituation to
personally relevant negative stimuli was seen in both depressive patients and control subjects. The present findings question
a generally negative attentional bias as being a specific characteristic of depressive disorder. Furthermore, as depressed
patients habituated to personally relevant negative stimuli, exposure therapy might be suitable for the treatment of
depressive disorder.
Shin, L. M., P. J. Whalen, R. K. Pitman, G. Bush, M. L. Macklin, N. B. Lasko, S. P. Orr, S. C. McInerney and S. L. Rauch (2001). "An
fMRI study of anterior cingulate function in posttraumatic stress disorder." Biol Psychiatry 50(12): 932-942. (ISSN) 0006-3223 (Print)
0006-3223 (Linking)
BACKGROUND: Several recent neuroimaging studies have provided data consistent with functional abnormalities in anterior
cingulate cortex in posttraumatic stress disorder (PTSD). In our study, we implemented a cognitive activation paradigm to
test the functional integrity of anterior cingulate cortex in PTSD. METHODS: Eight Vietnam combat veterans with PTSD
(PTSD Group) and eight Vietnam combat veterans without PTSD (non-PTSD Group) underwent functional magnetic
resonance imaging (fMRI) while performing the Emotional Counting Stroop. In separate conditions, subjects counted the
number of combat-related (Combat), generally negative (General Negative), and neutral (Neutral) words presented on a
screen and pressed a button indicating their response. RESULTS: In the Combat versus General Negative comparison, the
non-PTSD group exhibited significant fMRI blood oxygenation level-dependent signal increases in rostral anterior cingulate
cortex, but the PTSD group did not. CONCLUSIONS: These findings suggest a diminished response in rostral anterior
cingulate cortex in the presence of emotionally relevant stimuli in PTSD. We speculate that diminished recruitment of this
region in PTSD may, in part, mediate symptoms such as distress and arousal upon exposure to reminders of trauma.
Taylor, F. B., K. Lowe, C. Thompson, M. M. McFall, E. R. Peskind, E. D. Kanter, N. Allison, J. Williams, P. Martin and M. A. Raskind
(2006). "Daytime prazosin reduces psychological distress to trauma specific cues in civilian trauma posttraumatic stress disorder."
Biol Psychiatry 59(7): 577-581. (ISSN) 0006-3223 (Print) 0006-3223 (Linking)
BACKGROUND: Persons with posttraumatic stress disorder (PTSD) whose trauma-related nightmares improve or resolve
with bedtime administration of the alpha-1 adrenergic antagonist prazosin often continue to experience PTSD symptoms
during the day. This study addressed whether daytime prazosin compared to placebo would alleviate psychological distress
provoked experimentally by a trauma-related word list included in the emotional Stroop (E-Stroop) paradigm. METHODS:
Eleven persons with civilian trauma PTSD who continued to experience daytime PTSD symptoms despite a stable bedtime
prazosin dose that suppressed trauma-related nightmares were studied. Prazosin and placebo were administered on two
different occasions in the early afternoon followed two hours later by the E-Stroop. Effects of drug on psychological distress
were assessed by the Profile of Mood States (POMS). RESULTS: POMS total score and an "emotional distress" POMS
subscale score following trauma-related words were significantly lower in the prazosin than placebo condition. There were
no treatment effects on E-Stroop completion time. In 10 subjects who continued open label daytime prazosin, there was a
reduction in global PTSD illness severity at 2-week follow-up. CONCLUSIONS: Daytime prazosin pretreatment reduced
psychological distress specifically to trauma cues. Adding daytime prazosin to bedtime prazosin may further reduce overall
PTSD illness severity and distress.
Thomaes, K., E. Dorrepaal, N. Draijer, M. B. de Ruiter, B. M. Elzinga, A. J. van Balkom, J. H. Smit and D. J. Veltman (2012).
"Treatment effects on insular and anterior cingulate cortex activation during classic and emotional Stroop interference in child abuserelated complex post-traumatic stress disorder." Psychol Med: 1-13. (ISSN) 1469-8978 (Electronic) 0033-2917 (Linking)
BACKGROUND: Functional neuroimaging studies have shown increased Stroop interference coupled with altered anterior
cingulate cortex (ACC) and insula activation in post-traumatic stress disorder (PTSD). These brain areas are associated with
error detection and emotional arousal. There is some evidence that treatment can normalize these activation
patterns.MethodAt baseline, we compared classic and emotional Stroop performance and blood oxygenation leveldependent responses (functional magnetic resonance imaging) of 29 child abuse-related complex PTSD patients with 22
non-trauma-exposed healthy controls. In 16 of these patients, we studied treatment effects of psycho-educational and
cognitive behavioural stabilizing group treatment (experimental treatment; EXP) added to treatment as usual (TAU) versus
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TAU only, and correlations with clinical improvement. RESULTS: At baseline, complex PTSD patients showed a trend for
increased left anterior insula and dorsal ACC activation in the classic Stroop task. Only EXP patients showed decreased
dorsal ACC and left anterior insula activation after treatment. In the emotional Stroop contrasts, clinical improvement was
associated with decreased dorsal ACC activation and decreased left anterior insula activation. CONCLUSIONS: We found
further evidence that successful treatment in child abuse-related complex PTSD is associated with functional changes in the
ACC and insula, which may be due to improved selective attention and lower emotional arousal, indicating greater cognitive
control over PTSD symptoms.
Wingenfeld, K., R. Bullig, C. Mensebach, W. Hartje, M. Driessen and T. Beblo (2006). "Attention bias towards personally relevant
stimuli: the individual emotional Stroop task." Psychol Rep 99(3): 781-793. (ISSN) 0033-2941 (Print) 0033-2941 (Linking)
The emotional Stroop task is a widely used method for investigating attentional bias towards stimuli due to mood or affect. In
general, standardized stimuli are used, which might not be appropriate when investigating individual contextual frameworks.
It was investigated whether words chosen to be related to individuals' personal life events would produce more pronounced
Stroop interference (as an indicator of attentional bias) than stimuli without any personal relevance. Twenty-six nonclinical
subjects, 20 female and 6 male, participated in the study. Mean age was 36.1 yr. (SD = 18.1). All were recruited by means of
local advertising. Stimulus material consisted of four word types: personal words related to negative life events with and
without current personal relevance, and negative and neutral words without any personal relevance. Words were presented
in three blocks. Analysis of variance showed main effects for word type and blocks, with slower reactions in the personally
relevant conditions than in the negative, or neutral conditions, and in response to the first blocks as opposed to the last.
These findings indicate that regardless of the word valence, personally relevant stimuli evoke more pronounced Stroop
interference than do stimuli without personal relevance.
Wingenfeld, K., C. Mensebach, N. Rullkoetter, N. Schlosser, C. Schaffrath, F. G. Woermann, M. Driessen and T. Beblo (2009).
"Attentional bias to personally relevant words in borderline personality disorder is strongly related to comorbid posttraumatic stress
disorder." J Pers Disord 23(2): 141-155. (ISSN) 1943-2763 (Electronic) 0885-579X (Linking)
Current research indicates altered inhibitory functioning in borderline personality disorder (BPD). The emotional stroop task
is a widely used method for investigating inhibition of interference. In the present study we used an individualized version of
the emotional stroop task to investigate inhibitory functioning in BPD with respect not only to valence but also to personal
relevance of the stimuli. Thirty-one BPD patients and 49 healthy controls performed the individual emotional stroop task that
consisted of (1) words related to personal negative life events that were currently relevant (2) words related to personal
negative life events that were not currently relevant, (3) negative words that were not personally relevant, and (4) neutral
words. BPD patients showed greater interference only for words related to personal negative life events with current
relevance. A comparison between BPD patients with and without posttraumatic stress disorder (PTSD) revealed reduced
inhibitory functioning only in BPD patients with PTSD. Inhibition of interference in BPD patients seems not to be altered in
general but is exclusively disturbed in those with comorbid PTSD when highly relevant personal factors are the focus of
attention.
Wingenfeld, K., N. Rullkoetter, C. Mensebach, T. Beblo, M. Mertens, S. Kreisel, M. Toepper, M. Driessen and F. G. Woermann
(2009). "Neural correlates of the individual emotional Stroop in borderline personality disorder." Psychoneuroendocrinology 34(4):
571-586. (ISSN) 0306-4530 (Print) 0306-4530 (Linking)
OBJECTIVE: Emotional dysregulation is a key feature of borderline personality disorder (BPD) with altered inhibitory
functions having suggested as being crucial. The anterior cingulate cortex and further prefrontal brain regions are crucial for
response inhibition. The regulation of emotions is ensured via inhibitory control over the amygdala. The present study aimed
to investigate neural correlates of response inhibition in BPD by using an emotional Stroop paradigm extending the task to
word stimuli which were related to stressful life events. METHODS: Twenty BPD patients and 20 healthy controls underwent
functional magnetic resonance imaging (fMRI) while performing the individual emotional Stroop task. A block design was
used with the following word type conditions: neutral words, general negative words, and individual negative words. The
individual negative words were recruited from a prior interview conducted with each participant. RESULTS: While BPD
patients had overall slower reaction times in the Stroop task compared to healthy controls, there was no increased slowing
with emotional interference. Controls exhibited significant fMRI blood oxygenation level-dependent signal increases in the
anterior cingulate cortex as well as in frontal cortex contrasting generally negative vs. neutral and individual negative vs.
neutral conditions, respectively. BPD patients did not show equivalent signal changes. CONCLUSIONS: These results
provide further evidence for a dysfunctional network of brain areas in BPD, including the ACC and frontal brain regions.
These areas are crucial for the regulation of stress and emotions, the core problems of BPD patients.
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