Diminished rostral anterior cingulate cortex activation during trauma-unrelated emotional interference in PTSD
© Offringa et al.; licensee BioMed Central Ltd. 2013
Received: 12 February 2013
Accepted: 15 April 2013
Published: 14 May 2013
Previous research suggests that individuals with posttraumatic stress disorder (PTSD) preferentially attend to trauma-related emotional stimuli and have difficulty completing unrelated concurrent tasks. Compared to trauma-exposed control groups, individuals with PTSD also exhibit lower rostral anterior cingulate cortex (rACC) activation during tasks involving interference from trauma-related stimuli. However, it is not clear whether relatively diminished rACC activation in PTSD also occurs during interference tasks involving trauma-unrelated emotional stimuli. The present study employed functional magnetic resonance imaging (fMRI) and an interference task that involves emotional facial expressions and elicits rACC activation in healthy participants.
While performing a trauma-unrelated emotional interference task, participants with PTSD (n=17) showed less rACC activation than trauma-exposed non-PTSD (TENP; n=18) participants. In the PTSD group, rACC activation was negatively correlated with the severity of re-experiencing symptoms. The two groups did not significantly differ on behavioral measures (i.e., response times and error rates).
These findings suggest that relatively diminished rACC activation in PTSD can be observed in interference tasks involving trauma-unrelated emotional stimuli, indicating a more general functional brain abnormality in this disorder. Future neuroimaging studies need not employ trauma-related stimuli in order to detect rACC abnormalities in PTSD.
KeywordsfMRI Stroop Posttraumatic stress disorder Anterior cingulate Interference Trauma
Posttraumatic stress disorder (PTSD) is a debilitating psychiatric disorder that occurs in 9-20% of individuals following a traumatic event . Those with PTSD have difficulty suppressing trauma-related thoughts and suffer from persistent re-experiencing symptoms [2, 3]. Such symptoms have been studied in the laboratory with interference tasks in which participants are asked to ignore trauma-related information (e.g., words) while performing an unrelated cognitive task (such as naming the color or number of the words). Indeed, individuals with PTSD have difficulty performing such tasks and show impaired behavioral performance (e.g. [3–5]) and relatively diminished activation in the rostral anterior cingulate cortex (rACC) [6, 7]. The rACC is a brain structure that is thought to resolve emotional conflict  and/or “decrease the ‘weighting’ of affective information in the service of optimizing cognitive performance” . Relatively diminished rACC function in PTSD may reflect a failure to (1) appropriately “weight” distracting emotional information and (2) inhibit the amygdala (e.g. ). In fact, activation of the rACC has been found to negatively correlate with PTSD symptom severity (e.g. [11, 12]).
Previous neuroimaging studies that found reduced rACC activation in PTSD during interference tasks have used trauma-related words as stimuli [6, 7]. If the same rACC abnormality could be demonstrated using trauma-unrelated emotional stimuli, it would suggest the presence of a more global emotional and attentional dysfunction in PTSD, as opposed to a deficit specific to trauma-related stimuli. Two recent studies examined rACC activation in participants with PTSD during trauma-unrelated emotional interference [13, 14] but yielded conflicting results.
In the current experiment, we used functional magnetic resonance imaging (fMRI) to study rACC activation in individuals with PTSD and trauma-exposed non-PTSD (TENP) participants during the performance of an interference task using trauma-unrelated emotional stimuli (i.e., faces and words) [8, 15]. We hypothesized that the PTSD group would exhibit diminished rACC activation relative to the TENP group when comparing high-interference to low-interference conditions. Given previous findings (e.g., [11–13]), we also hypothesized that, for the PTSD group only, rACC activation would inversely correlate with PTSD symptom severity.
We recruited 42 right-handed participants who had been exposed to criterion A traumatic events (e.g., assault, motor vehicle accidents, abuse, and witnessing serious injury/death). Of these, 21 had current PTSD and 21 never developed PTSD. Within the PTSD group, two participants were removed due to excessive movement during the scan, one participant stopped the scan before the task began, and one participant failed to respond to an adequate number (75%) of trials. Within the TENP group, two participants were excluded due to a button box malfunction, and one participant was excluded due to excessive errors (greater than 25%). A total of 17 PTSD (14 female) and 18 TENP (13 female) participants were included in the final analyses.
Demographic and psychometric data
PTSD Mean (SD)
TENP Mean (SD)
Stimuli and procedures
Participants completed four runs (6 minutes and 40 seconds each), but fMRI (and behavioral) analyses included only the first two runs to avoid decrements in anterior cingulate activation that are known to occur with extended task performance . Face stimuli were displayed using MacStim Carbon 3.2.1 and projected via a Sharp Notevision6 (XG-NV6XU) LCD projector (Osaka, Japan). Participants used a button box to indicate whether faces were happy or afraid. Button assignments for “happy” and “afraid” were counterbalanced across subjects.
Participants were scanned using a Symphony/Sonata 1.5T whole body high-speed imaging device, equipped for echo planar imaging (Siemens Medical Systems, Iselin, NJ) with a 3-axis gradient head coil. First, we collected an automated scout image and shimmed . Next, we collected two high-resolution three-dimensional magnetization prepared rapid acquisition gradient echo (MPRAGE) sequences (TR/TE/Flip angle=2730 ms/3.39 ms/7°) with 1.33 mm slice thickness. We acquired fMRI blood-oxygen-level dependent (BOLD) signal images  using gradient echo T2*-weighted sequences (TR/TE/Flip angle=2000 ms/40 ms/90°) in 22 coronal slices, (thickness=7 mm, 1 mm gap), with interleaved excitation order and foot-to-head phase encoding. To allow longitudinal magnetization to reach equilibrium, four images were acquired and discarded before the start of each functional scan.
Response times were averaged across correct trials within each condition. Separate 2 (Group: PTSD, TENP) × 2 (Condition: Incongruent, Congruent) analyses of variance (ANOVA) were used to analyze response time and error rate data. With regard to error rates, we examined both errors of commission (incorrect response) and errors of omission (failure to respond) in separate ANOVAs.
We performed all fMRI statistical analyses using SPM 2.0 software (Wellcome Department of Cognitive Neurology, London, UK). Functional images were slice-time and motion corrected (realigned to the first volume in the time series), co-registered to structural images, spatially normalized into a standard stereotactic space (Montreal Neurological Institute [MNI] template), and smoothed with a Gaussian filter set at 7mm full width at half maximum.
Voxelwise Incongruent vs. Congruent (IvC) contrast images were created for each participant. These contrast images were then submitted to a second-level random effects model to assess differences between groups (PTSD vs. TENP). Trials involving either errors of commission or omission were excluded from all contrasts.
Statistical parametric maps were inspected for activations in rACC and dorsal anterior cingulate cortex (dACC) that exceeded a significance threshold of p<0.001 (one-tailed), uncorrected. We included the dACC as a secondary region of interest because previous studies have shown relatively greater dACC activation in PTSD versus non-PTSD groups (e.g., [6, 14, 24, 25]). Consistent with previous research, the rACC was defined as the region superior/anterior to the corpus callosum and inferior to the cingulate sulcus, with a y coordinate greater than +30 . The dACC was defined as the region superior to the corpus callosum and inferior to the cingulate sulcus, with a y coordinate between 0 and +30 [25–27]. Activations observed outside of these predefined regions of interest (ROIs) were subjected to the more conservative threshold of p<0.00001, uncorrected. Data from clusters exceeding these thresholds were extracted using MarsBaR (MRC Cognition and Brain Sciences Unit, Cambridge, United Kingdom).
Voxelwise whole brain correlations
To assess the relationship between current CAPS scores and IvC signal change in the PTSD group, we conducted the following voxelwise whole brain correlational analyses. First, we computed the IvC contrast within each participant in the PTSD group and correlated those contrast images with total CAPS scores. Because IvC activation could be related differently to different types of PTSD symptoms, we also ran correlations with CAPS-B (re-experiencing), CAPS-C (avoidance/numbing) and CAPS-D (hyper-arousal) subscale scores. We then inspected our regions of interest for significant clusters using the same p-value thresholds as described above.
Response time (RT) and error rate (ER) results
Group x Condition
Incongruent vs. Congruent (IvC) contrast within PTSD and TENP groups
Activation in PTSD group
Activation in TENP group
6, 32, 36
16, 36, 34
12, 4, 42
−4, 34, 42
16, 46, 2
−10, 42, 32
−12, 4, 44
−14, 20, 32
Between-group comparison of the IvC contrast
Activation greater in PTSD group
Activation greater in TENP group
18, 32, 32
Discussion and conclusion
In support of our primary hypothesis, the PTSD group exhibited lower rACC activation to trauma-unrelated interference, as compared to the TENP group. These results are consistent with those of Kim and colleagues  and suggest that diminished rACC function may reflect a more general abnormality in processing emotional material in PTSD.
We did not find any significant between-group differences on response times or error rates. It is possible that rACC dysfunction in PTSD is not behaviorally apparent until stimuli are more salient (trauma-related). Indeed, a recent meta-analysis has suggested that trauma-unrelated emotional word stimuli do not elicit greater behavioral interference in PTSD participants, as compared to controls . However, previous studies that used trauma-related stimuli also failed to find significant behavioral impairment despite showing diminished rACC activation in PTSD [6, 7]. It should be noted, however, that the latter study measured only accuracy (not response times) and the former study did report greater group differences in behavioral interference than the current study. Thus, it remains possible that behavioral evidence of rACC dysfunction is stronger when the stimuli are more salient. Regardless, the lack of behavioral differences in the present study suggests that our neuroimaging results cannot be attributed to group differences in behavioral performance.
Consistent with previous research, we found a trend toward a negative correlation between total symptom severity and activation in the rACC proper [11–13]. We also found significant negative correlations between total symptom severity and activation of structures adjacent to the rACC: the MFG and the dACC. Previous studies have revealed negative correlations between symptom severity and MFG activation (e.g., [29, 30]). The observed dACC cluster lies 6mm away from the rACC boundary as defined herein. Given the smoothing kernel (7 mm), this cluster could reflect function of the rACC. Importantly, we also found that only re-experiencing symptom severity (CAPS-B) was significantly negatively correlated with activation in rACC proper. That the degree of diminished rACC activation during emotional interference may reflect the severity of re-experiencing symptoms per se makes sense given that emotional interference tasks were originally intended to tap into the cognitive processes underlying re-experiencing symptoms of PTSD .
If the rACC deficit in PTSD is more general (i.e., not specific to trauma-related material), then rACC activation to emotional interference should correlate negatively with PTSD symptom severity regardless of whether the emotional stimuli are trauma-related. Consistent with this hypothesis, Kim et al.  found that rACC activation to trauma-unrelated emotional stimuli is negatively correlated with PTSD symptom severity. In addition, we found a similar negative correlation in the current study between rACC activation and CAPS-B re-experiencing symptoms. Unfortunately, correlations between brain activation and symptom severity were not reported in other previous neuroimaging studies of emotional interference in PTSD [6, 7, 14].
In summary, our findings suggest that relatively diminished rACC function in PTSD may reflect a more generalized abnormality that can be observed even when emotional stimuli are unrelated to trauma. This finding also has implications for the planning of future neuroimaging studies that examine rACC function in groups with diverse trauma histories. Individually tailoring stimuli to match each participant’s traumatic event may not be necessary as emotional interference tasks need not contain trauma-related stimuli in order to reveal rACC abnormalities in PTSD.
Analysis of variance
Blood oxygenation level dependent
Clinician administered PTSD scale
Dorsal anterior cingulate cortex
Diagnostic and statistical manual of mental disorders, fourth edition
Functional magnetic resonance imaging
Incongruent versus Congruent contrast
Major depressive disorder
Medial frontal gyrus
Magnetic resonance imaging
Posttraumatic stress disorder
Rostral anterior cingulate cortex
Regions of interest
Structured clinical interview for the DSM-IV
The authors would like to thank Mary O’Hara and Larry White of the Martinos Center for their technical assistance. This study was supported by funding from Tufts University.
- Breslau N, Kessler RC, Chilcoat HD, Schultz LR, Davis GC, Andreski P: Trauma and posttraumatic stress disorder in the community: the 1996 Detroit area survey of trauma. Arch Gen Psychiatry. 2004, 55 (7): 626-632.View Article
- First MB, Spitzer RL, Gibbon M, Williams J: Structured Clinical Interview for DSM-IV Axis I Disorders - Patient Edition (SCID-I/P Version 2.0). 1995, New York: New York State Psychiatric Institute, Biometrics Research Department
- McNally RJ: Experimental approaches to cognitive abnormality in posttraumatic stress disorder. Clin Psychol Rev. 1998, 18 (8): 971-982. 10.1016/S0272-7358(98)00036-1.View ArticlePubMed
- Foa EB, Feske U, Murdock TB, Kozak MJ, McCarthy PR: Processing of threat-related information in rape victims. J Abnorm Psychol. 1991, 100 (2): 156-162.View ArticlePubMed
- Bryant RA, Harvey AG: Processing threatening information in posttraumatic stress disorder. J Abnorm Psychol. 1995, 104 (3): 537-541.View ArticlePubMed
- Shin LM, Whalen PJ, Pitman RK, Bush G, Macklin ML, Lasko NB, Orr SP, McInerney SC, Rauch SL: An fMRI study of anterior cingulate function in posttraumatic stress disorder. Biol Psychiatry. 2001, 50 (12): 932-942. 10.1016/S0006-3223(01)01215-X.View ArticlePubMed
- Bremner JD, Vermetten E, Vythilingam M, Afzal N, Schmahl C, Elzinga B, Charney DS: Neural correlates of the classic color and emotional stroop in women with abuse-related posttraumatic stress disorder. Biol Psychiatry. 2004, 55 (6): 612-620. 10.1016/j.biopsych.2003.10.001.View ArticlePubMed
- Etkin A, Egner T, Peraza DM, Kandel ER, Hirsch J: Resolving emotional conflict: a role for the rostral anterior cingulate cortex in modulating activity in the amygdala. Neuron. 2006, 51 (6): 871-882. 10.1016/j.neuron.2006.07.029.View ArticlePubMed
- Whalen PJ, Bush G, McNally RJ, Wilhelm S, McInerney SC, Jenike MA, Rauch SL: The emotional counting stroop paradigm: a functional magnetic resonance imaging probe of the anterior cingulate affective division. Biol Psychiatry. 1998, 44 (12): 1219-1228. 10.1016/S0006-3223(98)00251-0.View ArticlePubMed
- Rauch SL, Shin LM, Phelps EA: Neurocircuitry models of posttraumatic stress disorder and extinction: human neuroimaging research–past, present, and future. Biol Psychiatry. 2006, 60 (4): 376-382. 10.1016/j.biopsych.2006.06.004.View ArticlePubMed
- Hopper JW, Frewen PA, van der Kolk BA, Lanius RA: Neural correlates of reexperiencing, avoidance, and dissociation in PTSD: symptom dimensions and emotion dysregulation in responses to script-driven trauma imagery. J Trauma Stress. 2007, 20 (5): 713-725. 10.1002/jts.20284.View ArticlePubMed
- Shin LM, Wright CI, Cannistraro PA, Wedig MM, McMullin K, Martis B, Macklin ML, Lasko NB, Cavanagh SR, Krangel TS, Orr SP, Pitman RK, Whalen PJ, Rauch SL: A functional magnetic resonance imaging study of amygdala and medial prefrontal cortex responses to overtly presented fearful faces in posttraumatic stress disorder. Arch Gen Psychiatry. 2005, 62 (3): 273-281. 10.1001/archpsyc.62.3.273.View ArticlePubMed
- Kim MJ, Chey J, Chung A, Bae S, Khang H, Ham B, Yoon SJ, Jeong DU, Lyoo IK: Diminished rostral anterior cingulate activity in response to threat-related events in posttraumatic stress disorder. J Psychiatr Res. 2008, 42 (4): 268-277. 10.1016/j.jpsychires.2007.02.003.View ArticlePubMed
- Hayes JP, Labar KS, Petty CM, McCarthy G, Morey RA: Alterations in the neural circuitry for emotion and attention associated with posttraumatic stress symptomatology. Psychiatr Res Neuroimaging. 2009, 172 (1): 7-15. 10.1016/j.pscychresns.2008.05.005.View Article
- Haas BW, Omura K, Constable RT, Canli T: Interference produced by emotional conflict associated with anterior cingulate activation. Cogn Affect Behav Neurosci. 2006, 6 (2): 152-156. 10.3758/CABN.6.2.152.View ArticlePubMed
- Blake DD, Weathers FW, Nagy LM, Kaloupek DG, Gusman FD, Charney DS, Keane TM: The development of a clinician-administered PTSD scale. J Trauma Stress. 1995, 8 (1): 75-90. 10.1002/jts.2490080106.View ArticlePubMed
- Beck AT, Steer RA: Manual for the revised Beck Depression Inventory. 1987, San Antonio, TX: The Psychological Corporation
- Beck AT, Steer RA: Beck Anxiety Inventory Manual. 1990, San Antonio, Tex: Psychological Corp
- Ekman P, Friesen WV: Pictures of Facial Affect. 1976, Palo Alto, CA: Consulting Psychologists Press
- The Optseq Program. http://surfer.nmr.mgh.harvard.edu/optseq/,
- Bush G, Whalen PJ, Rosen BR, Jenike MA, McInerney SC, Rauch SL: The counting stroop: an interference task specialized for functional neuroimaging–validation study with functional MRI. Hum Brain Mapp. 1998, 6 (4): 270-282. 10.1002/(SICI)1097-0193(1998)6:4<270::AID-HBM6>3.0.CO;2-0.View ArticlePubMed
- Reese TG, Davis TL, Weisskoff RM: Automated shimming at 1.5 T using echo-planar image frequency maps. J Magn Reson Imaging. 1995, 5 (6): 739-745. 10.1002/jmri.1880050621.View ArticlePubMed
- Kwong KK, Belliveau JW, Chesler DA, Goldberg IE, Weisskoff RM, Poncelet BP, Kennedy DN, Hoppel BE, Cohen MS, Turner R: Dynamic magnetic resonance imaging of human brain activity during primary sensory stimulation. Proc Natl Acad Sci U S A. 1992, 89 (12): 5675-5679. 10.1073/pnas.89.12.5675.PubMed CentralView ArticlePubMed
- Shin LM, Bush G, Whalen PJ, Handwerger K, Cannistraro PA, Wright CI, Martis B, Macklin ML, Lasko NB, Orr SP, Pitman RK, Rauch SL: Dorsal anterior cingulate function in posttraumatic stress disorder. J Trauma Stress. 2007, 20 (5): 701-712. 10.1002/jts.20231.View ArticlePubMed
- Shin LM, Bush G, Milad MR, Lasko NB, Brohawn KH, Hughes KC, Macklin ML, Gold AL, Karpf RD, Orr SP, Rauch SL, Pitman RK: Exaggerated activation of dorsal anterior cingulate cortex during cognitive interference: a monozygotic twin study of posttraumatic stress disorder. Am J Psychiatry. 2011, 168 (9): 979-985. 10.1176/appi.ajp.2011.09121812.PubMed CentralView ArticlePubMed
- Bush G, Luu P, Posner M: Cognitive and emotional influences in anterior cingulate cortex. Trends Cogn Sci. 2000, 4 (6): 215-222. 10.1016/S1364-6613(00)01483-2.View ArticlePubMed
- Bush G, Vogt BA, Holmes J, Dale AM, Greve D, Jenike MA, Rosen BR: Dorsal anterior cingulate cortex: a role in reward-based decision making. Proc Natl Acad Sci U S A. 2002, 99 (1): 523-528. 10.1073/pnas.012470999.PubMed CentralView ArticlePubMed
- Cisler JM, Wolitzky-Taylor KB, Adams TG, Babson KA, Badour CL, Willems JL: The emotional Stroop task and posttraumatic stress disorder: a meta-analysis. Clin Psychol Rev. 2011, 31 (5): 817-828. 10.1016/j.cpr.2011.03.007.PubMed CentralView ArticlePubMed
- Britton JC, Phan KL, Taylor SF, Fig LM, Liberzon I: Corticolimbic blood flow in posttraumatic stress disorder during script-driven imagery. Biol Psychiatry. 2005, 57 (8): 832-840. 10.1016/j.biopsych.2004.12.025.View ArticlePubMed
- Shin LM, Orr SP, Carson MA, Rauch SL, Macklin ML, Lasko NB, Peters PM, Metzger LJ, Dougherty DD, Cannistraro PS, Alpert NM, Fischman AJ, Pitman RK: Regional cerebral blood flow in the amygdala and medial prefrontal cortex during traumatic imagery in male and female Vietnam veterans with PTSD. Arch Gen Psychiatry. 2004, 61 (2): 168-176. 10.1001/archpsyc.61.2.168.View ArticlePubMed
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