GSJP Volume 16 final Graduate Student Journal of Psychology 2015, Vol. 16 Copyright 2015 by the Department of Counseling and Clinical Psychology Teachers College, Columbia University 63 An Exploratory Study of Posttraumatic Stress Disorder, Sleep Disturbances, and Executive Functioning in Veterans Shannon Edwards, M.A. The Chicago School of Professional Psychology Laurie Benton, PsyD Associate Professor The Chicago School of Professional Psychology Anne Germain, PhD Assistant Professor University of Pittsburgh James Iaccino, PhD Associate Professor The Chicago School of Professional Psychology Introduction: Hypervigilance, hyperarousal, and sleep disturbances are components in the diagnosis and treatment of Posttraumatic Stress Disorder (PTSD) and other trauma-related diagnoses. The current study explores the relationships between PTSD, sleep, and executive functioning among military veterans. Method: The Immediate Post-concussion Assessment and Cognitive Testing Battery (ImPACT) is uti- lized to examine the cognitive performance of 18 veterans. Dependent measures included composite scores of verbal memory, visual memory, processing speed, and reaction time from the ImPACT comput- erized test battery, as well as total symptom scores from the Clinician Administered PTSD Scale (CAPS), the Pittsburgh Sleep Quality Index, and the Pittsburgh Sleep Quality Index – Addendum for PTSD (PSQI-A). 5HVXOWV�� � 9HWHUDQV� VKRZHG� VLJQLÀFDQW� GHÀFLWV� LQ� YHUEDO� PHPRU\� DQG� VORZHU� UHDFWLRQ� WLPHV� UHODWLYH� WR� QRU- mative data. The veterans did not differ from the normative group on visual memory and process- LQJ� VSHHG� LQGLFHV�� $IWHU� DGMXVWLQJ� IRU� VOHHS� GLVWXUEDQFHV�� UHDFWLRQ� WLPH� UHPDLQHG� VLJQLÀFDQWO\� FRUUHODWHG� ZLWK� 376'� V\PSWRP� VHYHULW\� LQ� YHWHUDQV�� &RQFOXVLRQV�� ([HFXWLYH� IXQFWLRQLQJ� GHÀFLWV� LQ� YHUEDO� PHPRU\� and reaction time are detectable in veterans who endorse clinical and subthreshold symptoms of PTSD. Trauma and the Military Researchers have estimated that 50-60% of indi- viduals will experience a type of serious trauma (via military combat, sexual assault, perceived horror or threat, or another major accident) during their life- time. Additionally, 5-10% of individuals have been estimated to develop symptomology which quali- ÀHV� WKHP� IRU� D� FOLQLFDO� GLDJQRVLV� RI � 3RVWWUDXPDWLF� Stress Disorder (PTSD) (Aupperle, Melrose, Stein, & Paulus, 2011). Furthermore, Aupperle et al., have suggested that neuropsychological approaches to research, which address the frontal lobe or exec- utive function/dysfunction, may offer addition- al insight regarding cognitive processes that could potentially be affected by traumatic events and PTSD. To date, much of the research has focused on learning and memory, which may not necessari- ly have the same impact on PTSD susceptibility, re- siliency, and development as executive functioning. The prevalence of traumatic brain injury (TBI), its relationship to veterans diagnosed with PTSD, and its impact on frontal lobe or executive functioning is also a presently debated topic. Data from a Veteran Affairs Polytrauma Rehabilitation Facility involving OEF/OIF Veterans receiving care was studied in which the VA research group compared combat-re- lated TBI (74%) to noncombat TBI (71%). Veterans with combat-exposed TBIs reported higher sleep dis- turbances (>50% vs. <30%) and symptoms of acute stress reaction or PTSD (Taber & Hurley, 2010). � 7KH� FRQÁLFWV� LQ� $IJKDQLVWDQ� �2SHUDWLRQ� (Q- during Freedom [OEF]) and Iraq (Operation Iraqi Freedom [OIF]) have resulted in the highest rates of military troop mobilization and deployment since the Contact: sme1724@ego.thechicagoschool.edu 64 Vietnam War (Gewirtz, Polusny, DeGarmo, Khaylis, & Erbes, 2010). An exceptional amount of reliance is also being placed on National Guard/Reserve (NG/R) groups. Service members returning from OEF/OIF have been shown to be at greater risk for developing or presenting with mental health issues �)UXHK��*UXEDXJK��(OKDL�� �%XFNOH\���������6SHFLÀ- cally, TBI, PTSD, and Major Depressive Disorder are distinct post-combat health outcomes (Ozer, Best, Lipsey, & Weiss, 2003). Additionally, research revealed self-reports from the NG/R troops of mental health issues (depression, relational issues, and PTSD) are more than double those of active duty service mem- bers (42.4% versus 20.3%). NG/R troops also dou- ble the amount of mental health issues regarding (PTSD) screenings both post-deployment (12.7%) and 6 months thereafter (24.5%) when compared to active duty service members (Gewirtz et al, 2010). Statistics collected by Gewirtz et al., (2010), regard- ing active duty troops versus NG/R troops, supports ongoing research efforts which hypothesize that non-combat exposed veterans face similar traumatic and psychological risks to combat-exposed veterans. Importance of Executive Functioning Executive functioning is a set of mental process- es that helps connect past experience with present action. Individuals use executive functioning to per- form activities such as planning, organizing, strate- gizing, paying attention to and remembering details, and managing time and space (Aupperle, Melrose, Stein, & Paulus, 2011). Individuals with executive IXQFWLRQLQJ� GHÀFLWV�PD\� DOVR� KDYH� D�ZHDNQHVV�ZLWK� their working memory. Working memory is the abil- ity to actively maintain and manipulate information of one’s mind over a short period of time. Work- ing memory is an important component of execu- tive functioning, and is typically affected following a traumatic event due to the quick task demand that is necessary to encode, retrieve, and manipulate var- ious stimuli while functioning in daily life (Aupper- le et al., 2011). Samuelson et al (2006) noted that decreased performance on measures of working memory have been found in combat- and sexual as- sault- related PTSD when compared to victims with- out PTSD and non-trauma controls. Furthermore, working memory is needed to transfer information to long-term memory. When working memory is impaired, the process of transferring information is likely to be impaired as well (Brenner et al., 2010). Verbal memory refers to the memory of words and other abstractions of language, while visual memory describes the relationship between percep- tual processing and the encoding, storage, and re- trieval of the resulting neural representations (Ap- perle et al., 2011). Reaction time, also referred to as ‘mental chronometry,’ is the use of response time in perceptual-motor tasks to infer the content, duration, and temporal sequencing of cognitive operations. Processing Speed is one of the measures of cogni- WLYH� HIÀFLHQF\� RU� FRJQLWLYH� SURÀFLHQF\�� ,W� LQYROYHV� WKH�DELOLW\�WR�DXWRPDWLFDOO\�DQG�ÁXHQWO\�SHUIRUP�UHO- atively over-learned cognitive tasks, especially when KLJK�PHQWDO�HIÀFLHQF\�LV�UHTXLUHG��6WUDXVV��6KHUPDQ�� & Spreen, 2006). PTSD effects memory recall and accuracy (Lezak, 2008). While PTSD affects various areas of executive functioning, it has been shown WR�PRVW� VLJQLÀFDQWO\� DIIHFW�YHUEDO�PHPRU\� �6WUDXVV�� Sherman, & Spreen, 2006). Researchers have indi- cated that verbal memory impairment is found to be the most consistent cognitive impairment related to PTSD. Verbal memory has also been shown to be a VSHFLÀFDOO\�SURQRXQFHG�GHÀFLW� LQ�FRPSDULVRQ�WR�YL- sual memory or processing speed in individuals di- agnosed with PTSD (Johnsen & Asbjornsen, 2008). Short-term memory is another processes in- volved with working memory. Short-term memory is needed for disposal, integration, processing, and retrieval aspects of memory functioning to ensure the working memory aspect of the cognitive process is effective (Turner, Salamat, Drummond, & Brown, 2007). In the general population, the executive func- tioning component involved with working memory elicits a controlled response to stimuli (e.g., impulse control). In individuals diagnosed with PTSD, exec- utive functioning may be compromised. Individuals with PTSD may respond to stimuli with hypervigi- lance, hyperarousal, and impulsivity (Turner et al., ������� � ,QGLYLGXDOV� ZLWK� 376'�PD\� KDYH� GLIÀFXOW\� with an inability to consolidate memories due to trau- ma, which is also linked to increased autonomic arous- al and inhibition of the hippocampus (Aupperle et. EDWARDS, BENTON, GERMAIN, IACCINO 65 DO����������([HFXWLYH�IXQFWLRQLQJ�GHÀFLWV�DUH�OLNHO\�WR� affect the daily functioning of individuals with PTSD, and may also play a prominent role in sleep patterns and nightmare production (Levin & Nielsen, 2007). Neurobiological Aspects of Nightmares Nightmares are a core re-experiencing feature RI � 376'��1LJKWPDUHV� DUH� FOLQLFDOO\� GHÀQHG� DV� ´LQ- tensely disturbing dreams that awaken the dreamer to a fully conscious state and generally occur in the latter half of the sleep period” (Hasler & Germain, 2009, p. 2). As many as 90% of trauma-exposed individuals who develop PTSD report disturbing dreams that bear varying degrees of resemblance to the actual traumatic event (Oscar et al., 2010). Ad- ditionally, dream-related disorders such as posttrau- matic dreams, nightmares, bad dreams, and recurrent dreams are the most frequently reported and most persistent symptoms exhibited by trauma victims (Kobayashi, Boarts, & Delahanty, 2007). According to Stickgold (2005), explicit Rapid Eye Movement (REM) sleep models of the neurobiological states of nightmares potentially provide emotional pro- cessing and integration of trauma-related memories. REM sleep provides a unique neurobiological state that allows for the transfer of hippocampus-medi- ated episodic traumatic memories and related amyg- dala-dependent affect into the cortically distributed semantic networks of the brain. The amygdala is hy- perreactive to traumatic images during the sleep cycle in persons with PTSD, which then produces a night- mare as a response to the threat-related stimuli, thus interfering with the transfer of traumatic memories to higher cortical areas (Germain & Zadra, 2009). A meta-analysis of 20 PTSD studies by Ko- ED\DVKL��������IRXQG�WKDW�GLIÀFXOWLHV�IDOOLQJ�RU�VWD\LQJ� asleep were reported by 44%-90% of veterans with PTSD, and that 52%-87% reported having recurrent nightmares. Additionally, a recent study was complet- ed in which 304 of 316 veterans reported combat-re- lated nightmares (Germain & Zadra, 2009). Over half of the veterans in this sample reported realistic com- bat dreams, 21% reported conceivable war sequences they had not actually experienced, and 26% reported dreams that mention or relate to the war, but also in- cluded fantasy and everyday factors. Furthermore, only 21% of the dreams reported by veterans in the study were precise replications of their experienced trau- matic event, while the majority of dreams contained contrived distortions related to the traumatic event. The current study explores the relationships between PTSD, sleep, and executive functioning. Hypotheses The presence and severity of PTSD symptoms was assessed by the Clinician Administered PTSD Scale (CAPS), and executive functions were assessed by different modules of The Immediate Post-concus- sion Assessment and Cognitive Testing (ImPACT), and results were compared to norms from age and sex-similar groups. The hypotheses were (1) that the overall participant group, exhibiting varying symp- tom severity, would score lower on visual memory, verbal memory, reaction time, and processing speed domains compared to normative values; (2) veterans with PTSD would show greater impairments than veterans without PTSD on the ImPACT domains when respectively compared to the normative group; and 3) the relationship between PTSD severity and H[HFXWLYH� G\VIXQFWLRQV�ZRXOG� UHPDLQ� VLJQLÀFDQW� DI- ter adjusting for the severity of sleep disturbances. Method Participants Between January 2011 and January 2012, partic- ipants were actively recruited though media advertis- ing in a northwestern metropolitan area. Participants were combat-exposed military veterans diagnosed with Posttraumatic Stress Disorder (PTSD) (n = 11) and without PTSD (n = 7), all of whom had self-re- ported nightmares or nocturnal sleep disturbances. Fifteen participants were male and three were female between the ages of 18 and 50 years old (M = 24 years, SD = 2.4). The racial/ethnic composition of the participants was fairly homogenous with four- teen participants identifying as Caucasian, three as Asian-American, and one as African-American. Par- ticipants were assessed via a detailed screening process as part of a concurrent sleep study. Veterans were excluded if they were over 55 years of age, or if they had been excluded from the initial study due to med- ical conditions or medication known to affect sleep. PTSD, SLEEP DISTURBANCES, AND EXECUTIVE FUNCTIONING 66 Measures As a part of the parent study, participants also completed the Clinician-Administered PTSD Scale (CAPS; Blake, Weathers, Nagy, Kaloupek, Gusman, Charney & Keane, 1995), the Pittsburgh Sleep Quali- ty Index (PSQI; Buysse, Reynolds, Monk, Berman & Kupfer, 1989) and the Pittsburgh Sleep Quality Index Addendum (PSQI-A; Germain, Hall, Krakow, Shear, & Buysse, 2005). The Clinician-Administered PTSD Scale (CAPS) is a structured interview that measures severity of symptomology and diagnosis of PTSD. The CAPS assesses the frequency and intensity of seventeen symptoms using standard questions and behaviorally anchored rating scales. Questions in- clude assessing for nightmares associated with PTSD. The CAPS is considered to be the gold standard in PTSD assessment (Blake et al., 1995). The inter-rater reliability of the CAPS is high, ranging from 0.92 to 1.00 for “Frequency” and 0.93 to .98 for “Intensity” ratings with the global severity correlation equating 0.89. The CAPS test-retest reliability ranges from .77- .96 for the three symptom clusters and from .90-.98 for the 17-item core symptom scale (Blake et.al, 1995). The Pittsburgh Quality Sleep Index (PSQI) was employed as a measure of disturbing nocturnal be- havior (sleep disturbances). The PSQI has ten ques- WLRQV�� DQG� LV� D� ÀOO�LQ�WKH� EODQN� TXHVWLRQQDLUH�� 7KH� PSQI was developed to qualitatively measure sleep quality during the previous month. The instrument also discriminates between good and poor sleepers. 7KH�364,�KDV�D�JOREDO�VFRUH�FRUUHODWLRQ�FRHIÀFLHQW� for test-retest reliability of (.87). Similarly, The Pitts- burgh Quality Sleep Index Addendum (PSQI-A) is a self-report instrument designed to assess the frequen- cy of seven disruptive nocturnal behaviors (DNB) or sleep disturbances commonly associated with PTSD. Participants completed the Immediate Post-con- cussion Assessment and Cognitive Testing (Im- PACT), which is a computerized neuropsycho- logical test (Iverson, Lovell, & Collins, 2003). The ImPACT measures several executive func- tioning composite index scores. This study made use of four: Verbal Memory, Visual Memory, Pro- cessing Speed, and Reaction Time. The compos- ite scores are made up of six modules designed to test verbal recognition, visual memory, process- ing speed, impulse control, and working memory. � ,QWUDFODVV� FRUUHODWLRQ� FRHIÀFLHQWV� IRU� WKH� ,P- PACT include processing speed (.85), reaction time (.76), visual memory (.70), and verbal memory (.62) (Elbin, Schatz, Covassin, 2011). Resch et.al (2013) compared two performance groups, with the sec- ond group also completing a test of effort. The researchers found that composite score intraclass FRUUHODWLRQ� FRHIÀFLHQWV� UDQJHG� IURP� ���� WR� ���� IRU� the 4 scores in Group 1 and .37 to .76 in Group 2. For the current study, data was automatically scored with the computerized structure within the ImPACT, which provided composite scores for each category (Verbal Memory, Visual Memory, Processing Speed, and Reaction Time). The ImPACT generated the particular composite scores for the present study by comparing scores from university male participants to individuals in the overall normative sample, and provided composite scores. The primary populations studied for ImPACT research are typically that of VSRUWV�UHODWHG�LQMXULHV��ZKLFK�VXSHUÀFLDOO\�DSSHDUHG�WR� differ from our sample of combat-exposed injuries. However, the ImPACT has been investigated within the military population and yielded a .80-.89 test-re- test reliability score (Cole et al., 2013). Individuals in the PTSD group met full diagnostic criteria for symp- tomology as indicated by the CAPS. The nPTSD group, while self-reporting some symptomology, did not reach criteria threshold for a clinical diagnosis of PTSD. The two veteran groups were separately com- pared to the normative sample from the ImPACT. Procedures One-sample t-designs were used to analyze the composite scores of each subtest score generated from the ImPACT, and were then compared to the mean composite score of the normative sample. The chosen comparison was used due to none of the par- ticipants in the current study presenting completely free of symptomology and therefore, they were un- able to be utilized as part of a control group. Fur- ther, the normative group from the ImPACT used for comparison was comprised of university males, which was the group which most closely matched the current study’s participant sample. While not ide- EDWARDS, BENTON, GERMAIN, IACCINO 67 al, the limitations with power and sample size were recognized and results were interpreted with caution. The ImPACT was administered via computer by the primary investigator while being supervised by a Ph.D. clinician, the primary investigator of the concurrent sleep study. Participants were informed WKH� VWXG\� ZDV� LQ� SDUWLDO� IXOÀOOPHQW� RI � D� GRFWRUDO� dissertation. The participants navigated through six modules. The ImPACT took approximately thirty WR� IRUW\�ÀYH� PLQXWHV� WR� DGPLQLVWHU��:KHQ� WKH� ,P- PACT concluded, participants were afforded time WR� DVN� TXHVWLRQV�� DV�ZHOO� DV� JLYHQ�GHEULHÀQJ� VKHHWV� Results The ImPACT computer-generated printout pro- vided descriptive statistics for each composite score based on their overall normative group of university students. Verbal memory composite score (M = 88.2, SD = 12.4), Visual Memory composite score (M = 72.3, SD = 14.9), Processing Speed composite score (M = 35.6, SD = 8.3), and Reaction Time compos- ite score (M = 0.58, SD = .12) averages and stan- dard deviations were all provided to the investigators. H1: The entire sample of veterans showed VWDWLVWLFDOO\� VLJQLÀFDQW� LPSDLUPHQWV� FRPSDUHG� to the normative data for IMPACT, on the ver- bal memory composite score (t (17) = -2.737, p = .014; M = 81.72). Reaction time composite scores among participants were also slower than nor- mative data, t (17) = 2.837, p = .011; M = .61. H2: The verbal memory composite score was VLJQLÀFDQWO\� ORZHU� LQ� YHWHUDQV�ZLWK�376'� (t (11) = -3.001, p = .013; M = 78.73), but not in veterans without PTSD t (6) = -.658, p > .05, M = 86.43. Each group was compared to the ImPACT norma- tive group, respectively. Further, when compared to the ImPACT normative group, individuals diagnosed ZLWK�376'�KDG�VLJQLÀFDQWO\�VORZHU�UHDFWLRQ�WLPHV� t (10) = 2.610, p = .026; M = .62, indicating they re- sponded less quickly to tasks that were construct- HG� WR�PHDVXUH� VSHHG� DQG� HIÀFDF\�� � ,Q� FRPSDULVRQ�� veterans without PTSD responded as quickly as the normative sample t (6) = 1.224, p > .05; M = .59. Both visual memory and processing speed had QRQ�VLJQLÀFDQW�ÀQGLQJV� LQ�WKH�RYHUDOO�VDPSOH�JURXS� (t (17) = -.948, p > .05; M = 74.72 and t (17) = -.946, p > .05; M = 35.22), when compared to the ImPACT normative group. Additionally, the PTSD JURXS� KDG� QRQ�VLJQLÀFDQW� ÀQGLQJV� t (10) = -1.070, p > .05; M = 73.28 and t (10) = -2.229, p > .05; M = 32.36 when compared to the ImPACT norma- tive group, as did the PTSD group t (6) = -.148, p > .05; M = 77.00 and t (6) = .650, p > .05; M = 39.72 when compared to the ImPACT normative group. H3: Lastly, results indicated that verbal memory DQG�UHDFWLRQ�WLPH�ZHUH�VLJQLÀFDQWO\�FRUUHODWHG�ZLWK�WKH� PSQI-A (r = .033, p = < .05) and (r = .031, p = < .05), re- spectively, when adjusting for sleep symptom severity. Conclusion The results of the current study coincide with ex- isting research regarding verbal memory impairments in individuals diagnosed with PTSD. The term verbal memory encompasses both encoding and retrieval of information. Verbal memory is necessary for the processing of traumatic memories when consider- ing hyperarousal and the inability to quickly encode and retrieve responses concerning external stimuli (McClincy, Lovell, Pardini, Collins, & Spore, 2006). 'LIÀFXOW\�ZLWK�HQFRGLQJ�DQG�SURFHVVLQJ�YLVXDO�VWLP- uli can lead to increased or prolonged hyper-aroused states, increased physiological responses (high blood pressure), and other psychological symptoms such as increased levels of anxiety (Frueh, et al., 2007). Reac- tion time appears to be another area of functioning affected in individuals with PTSD symptompology. Research has suggested that individuals diagnosed with PTSD, or individuals with symptoms related to traumatic memories, have slower reaction times, which could be a vicarious consequence of decreased executive functioning (Johnsen & Asbjornsen, 2008). Decreased reaction time can lead to slowed response to external stimuli, reduced agility in response to physical responsibilities, and possibly psychomotor slowing while addressing cognitive tasks in employ- ment or academic settings (Aupperle et al., 2011). Commonly, traumatic nightmares are among the most treatment-resistant symptoms of PTSD. When utilizing sleep as a correlative variable in the equa- tion, verbal memory and reaction times appeared to PTSD, SLEEP DISTURBANCES, AND EXECUTIVE FUNCTIONING 68 be non-affected in individuals with and without a di- agnosis of PTSD. It could be suggested that sleep disturbances can decrease verbal memory and reac- tion time; however, one could also infer that by in- creasing executive functioning (i.e., strengthening verbal memory and reaction time via neurocognitive therapeutic interventions), sleep disturbances may decrease and vice versa. This is particularly concern- ing within the veteran population as they are more likely to underreport psychological symptoms than the general population, which could arguably be due to the military culture and training (Port, 2001). Within the general population, executive func- tioning that is involved with working memory elic- its a controlled response to stimuli. Research has suggested that individuals diagnosed with PTSD are more likely than the general population to have compromised executive functioning (Aupperle et al, 2011) (Johnsen & Asbjornsen, 2008). Individu- DOV�ZLWK� 376'�PD\� DOVR� KDYH� GLIÀFXOW\� FRQVROLGDW- LQJ� PHPRULHV� GXH� WR� GHÀFLWV� LQ� ZRUNLQJ� PHPRU\�� which is also linked to increased autonomic arous- al and inhibition of the hippocampus (Aupperle et. DO��� ������� 7KXV�� H[HFXWLYH� IXQFWLRQLQJ� GHÀFLWV� DUH� more likely to effect the daily functioning of in- dividuals with PTSD than the general population, and may also play a prominent role in sleep patterns and nightmare production (Levin & Nielsen, 2007). Limitations The primary limitation to the study was the homogeneity of the sample, as well as the sample VL]H��:KLOH�ZH�ZHUH�DEOH� WR�REWDLQ�VRPH�VLJQLÀFDQW� results on two composite scores with a small sam- ple size, a larger sample would have allowed us to make further inferences, particularly when exam- ining the relationship with sleep disturbances. Ob- WDLQLQJ� VRPH� VLJQLÀFDQFH� LV� HQFRXUDJLQJ� IRU� IXWXUH� research, when a larger sample may be possible, as well as a more gender, ethnically diverse sam- ple. This could be sought in future studies in order to provide a broader understanding of how sleep and executive functioning may affect different so- ciocultural groups within the veteran population. Directions for Future Research The study aspired to determine if there was a re- lationship between PTSD, sleep, and executive func- tioning. While there was a power differential and our UHVXOWV�ZHUH�LQWHUSUHWHG�ZLWK�FDXWLRQ��WKH�ÀQGLQJV�GR� suggest a link between some aspects of executive func- tioning, which will likely affect individuals with PTSD symptoms. Results also suggested verbal memory and reaction times are unaffected by sleep disturbances. Future research could include the implementa- tion of an intervention, in a test-retest model, for veterans who are experiencing the aforementioned symptoms. The determination of executive func- tioning impairments could be measured via broad as- sessment and evaluation protocols (Bromberg, 2003; Rutherford et al., 2010). Rather than the unaccom- panied treatment of the psychological symptomolo- gy of PTSD with primarily trauma-based therapeu- tic interventions, the addition of a neurocognitive WKHUDSHXWLF� LQWHUYHQWLRQ�FRXOG�EH�EHQHÀFLDO� LI � WKHUH� were present executive dysfunctions to consider. Research has suggested that a multi-modal ap- SURDFK�PD\�EH�PRUH�HIÀFDFLRXV�LQ�WKH�WUHDWPHQW�RI � co-occurring PTSD and neurocognitive dysfunction (Davidson & Frances, 1999); although, at this time, there is not a substantial amount of literature that pro- vides empirically based approaches to this ideation. While Aupperle and colleagues (2011) validated that increased neuropsychological research is needed to identify the effects of treatment on cognitive function and to potentially characterize mechanisms of current PTSD treatments, the ability to identify areas of focal GHÀFLWV� LV� D� VWHS� FORVHU� WKDQ� UHVHDUFKHUV� KDYH� EHHQ� in the recent past. 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