Skip to main content

Impaired Response Inhibition in Veterans with Post-Traumatic Stress Disorder and Mild Traumatic Brain Injury

  • Diane Swick (a1), Nikki Honzel (a1), Jary Larsen (a1), Victoria Ashley (a1) and Timothy Justus (a1)...

Combat veterans with post-traumatic stress disorder (PTSD) can show impairments in executive control and increases in impulsivity. The current study examined the effects of PTSD on motor response inhibition, a key cognitive control function. A Go/NoGo task was administered to veterans with a diagnosis of PTSD based on semi-structured clinical interview using DSM-IV criteria (n = 40) and age-matched control veterans (n = 33). Participants also completed questionnaires to assess self-reported levels of PTSD and depressive symptoms. Performance measures from the patients (error rates and reaction times) were compared to those from controls. PTSD patients showed a significant deficit in response inhibition, committing more errors on NoGo trials than controls. Higher levels of PTSD and depressive symptoms were associated with higher error rates. Of the three symptom clusters, re-experiencing was the strongest predictor of performance. Because the co-morbidity of mild traumatic brain injury (mTBI) and PTSD was high in this population, secondary analyses compared veterans with PTSD+mTBI (n = 30) to veterans with PTSD only (n = 10). Although preliminary, results indicated the two patient groups did not differ on any measure (p > .88). Since cognitive impairments could hinder the effectiveness of standard PTSD therapies, incorporating treatments that strengthen executive functions might be considered in the future. (JINS, 2012, 18, 1–10)

Corresponding author
Correspondence and reprint requests to: Diane Swick, VA Northern California Health Care System, Research Service (151), 150 Muir Road, Martinez, CA 94553. E-mail:
Hide All
Aron, A.R., Fletcher, P.C., Bullmore, E.T., Sahakian, B.J., Robbins, T.W. (2003). Stop-signal inhibition disrupted by damage to right inferior frontal gyrus in humans. Nature Neuroscience, 6, 115116.
Aupperle, R.L., Melrose, A.J., Stein, M.B., Paulus, M.P. (2012). Executive function and PTSD: Disengaging from trauma. Neuropharmacology, 62, 686694.
Beck, A.T., Steer, R., Gabin, M. (1988). Psychometric properties of the BDI: Twenty-five years of evaluation. Clinical Psychological Review, 8, 77100.
Belanger, H.G., Curtiss, G., Demery, J.A., Lebowitz, B.K., Vanderploeg, R.D. (2005). Factors moderating neuropsychological outcomes following mild traumatic brain injury: A meta-analysis. Journal of the International Neuropsychological Society, 11, 215227.
Blake, D.D., Weathers, F.W., Nagy, L.M., Kaloupek, D.G., Gusman, F.D., Charney, D.S., Keane, T.M. (1995). The development of a clinician-administered PTSD scale. Journal of Traumatic Stress, 8, 7590.
Blanchard, E.B., Jones-Alexander, J., Buckley, T.C., Forneris, C.A. (1996). Psychometric properties of the PTSD Checklist (PCL). Behaviour Research and Therapy, 34, 669673.
Botvinick, M.M., Cohen, J.D., Carter, C.S. (2004). Conflict monitoring and anterior cingulate cortex: An update. Trends in Cognitive Sciences, 8, 539546.
Brenner, L.A., Terrio, H., Homaifar, B.Y., Gutierrez, P.M., Staves, P.J., Harwood, J.E., Warden, D. (2010). Neuropsychological test performance in soldiers with blast-related mild TBI. Neuropsychology, 24, 160167.
Carlson, K.F., Kehle, S.M., Meis, L.A., Greer, N., Macdonald, R., Rutks, I., Wilt, T.J. (2011). Prevalence, assessment, and treatment of mild traumatic brain injury and posttraumatic stress disorder: A systematic review of the evidence. Journal of Head Trauma Rehabilitation, 26, 103115.
Chambers, C.D., Garavan, H., Bellgrove, M.A. (2009). Insights into the neural basis of response inhibition from cognitive and clinical neuroscience. Neuroscience and Biobehavioral Review, 33, 631646.
Cloitre, M., Koenen, K.C., Gratz, K.L., Jakupcak, M. (2002). Differential diagnosis of PTSD in women. In R. Kimerling, P. Ouimette, & J. Wolfe (Eds.), Gender and PTSD (pp. 117–149). New York: Guilford Press.
Dimoska-Di Marco, A., McDonald, S., Kelly, M., Tate, R., Johnstone, S. (2011). A meta-analysis of response inhibition and Stroop interference control deficits in adults with traumatic brain injury (TBI). Journal of Clinical and Experimental Neuropsychology, 12, 115.
Donohoe, G., Reilly, R., Clarke, S., Meredith, S., Green, B., Morris, D., Robertson, I.H. (2006). Do antisaccade deficits in schizophrenia provide evidence of a specific inhibitory function? Journal of the International Neuropsychological Society, 12, 901906.
Etkin, A., Wager, T.D. (2007). Functional neuroimaging of anxiety: A meta-analysis of emotional processing in PTSD, social anxiety disorder, and specific phobia. American Journal of Psychiatry, 164, 14761488.
Falconer, E., Bryant, R., Felmingham, K.L., Kemp, A.H., Gordon, E., Peduto, A., Williams, L.M. (2008). The neural networks of inhibitory control in posttraumatic stress disorder. Journal of Psychiatry & Neuroscience, 33, 413422.
Fan, J., McCandliss, B.D., Fossella, J., Flombaum, J.I., Posner, M.I. (2005). The activation of attentional networks. Neuroimage, 26, 471479.
Fisher, T., Aharon-Peretz, J., Pratt, H. (2011). Dis-regulation of response inhibition in adult Attention Deficit Hyperactivity Disorder (ADHD): An ERP study. Clinical Neurophysiology, 122, 23902399.
Forbes, D., Creamer, M., Biddle, D. (2001). The validity of the PTSD checklist as a measure of symptomatic change in combat-related PTSD. Behaviour Research and Therapy, 39, 977986.
Gordon, S.N., Fitzpatrick, P.J., Hilsabeck, R.C. (2011). No effect of PTSD and other psychiatric disorders on cognitive functioning in veterans with mild TBI. Clinical Neuropsychology, 25, 337347.
Hamner, M.B., Lorberbaum, J.P., George, M.S. (1999). Potential role of the anterior cingulate cortex in PTSD: Review and hypothesis. Depression and Anxiety, 9, 114.
Hoge, C.W., Goldberg, H.M., Castro, C.A. (2009). Care of war veterans with mild traumatic brain injury--flawed perspectives. New England Journal of Medicine, 360, 15881591.
Hoge, C.W., McGurk, D., Thomas, J.L., Cox, A.L., Engel, C.C., Castro, C.A. (2008). Mild traumatic brain injury in U.S. Soldiers returning from Iraq. New England Journal of Medicine, 358, 453463.
Iversen, A.C., Fear, N.T., Ehlers, A., Hacker Hughes, J., Hull, L., Earnshaw, M., Hotopf, M. (2008). Risk factors for post-traumatic stress disorder among UK Armed Forces personnel. Psychological Medicine, 38, 511522.
Jakupcak, M., Cook, J., Imel, Z., Fontana, A., Rosenheck, R., McFall, M. (2009). Posttraumatic stress disorder as a risk factor for suicidal ideation in Iraq and Afghanistan War veterans. Journal of Traumatic Stress, 22, 303306.
Koso, M., Hansen, S. (2006). Executive function and memory in posttraumatic stress disorder: A study of Bosnian war veterans. European Psychiatry, 21, 167173.
Kroes, M.C., Rugg, M.D., Whalley, M.G., Brewin, C.R. (2011). Structural brain abnormalities common to posttraumatic stress disorder and depression. Journal of Psychiatry & Neuroscience, 36, 256265.
Larson, G.E., Booth-Kewley, S., Highfill-McRoy, R.M., Young, S.Y. (2009). Prospective analysis of psychiatric risk factors in marines sent to war. Military Medicine, 174, 737744.
Leskin, L.P., White, P.M. (2007). Attentional networks reveal executive function deficits in posttraumatic stress disorder. Neuropsychology, 21, 275284.
Lew, H.L., Amick, M.M., Kraft, M., Stein, M.B., Cifu, D.X. (2010). Potential driving issues in combat returnees. Neurorehabilitation, 26, 271278.
Li, C.S., Huang, C., Constable, R.T., Sinha, R. (2006). Imaging response inhibition in a stop-signal task: Neural correlates independent of signal monitoring and post-response processing. Journal of Neuroscience, 26, 186192.
Lippa, S.M., Pastorek, N.J., Benge, J.F., Thornton, G.M. (2010). Postconcussive symptoms after blast and nonblast-related mild traumatic brain injuries in Afghanistan and Iraq war veterans. Journal of the International Neuropsychological Society, 16, 856866.
Mathias, J.L., Beall, J.A., Bigler, E.D. (2004). Neuropsychological and information processing deficits following mild traumatic brain injury. Journal of the International Neuropsychological Society, 10, 286297.
Marx, B.P., Brailey, K., Proctor, S.P., Macdonald, H.Z., Graefe, A.C., Amoroso, P., Vasterling, J.J. (2009). Association of time since deployment, combat intensity, and posttraumatic stress symptoms with neuropsychological outcomes following Iraq war deployment. Archives of General Psychiatry, 66, 9961004.
Matthews, S.C., Strigo, I.A., Simmons, A.N., O'Connell, R.M., Reinhardt, L.E., Moseley, S.A. (2011). A multimodal imaging study in U.S. veterans of Operations Iraqi and Enduring Freedom with and without major depression after blast-related concussion. Neuroimage, 54, S69S75.
Mac Donald, C.L., Johnson, A.M., Cooper, D., Nelson, E.C., Werner, N.J., Shimony, J.S., Brody, D.L. (2011). Detection of blast-related traumatic brain injury in U.S. military personnel. New England Journal of Medicine, 364, 20912100.
McNab, F., Leroux, G., Strand, F., Thorell, L., Bergman, S., Klingberg, T. (2008). Common and unique components of inhibition and working memory: An fMRI, within-subjects investigation. Neuropsychologia, 46, 26682682.
McNally, R.J., Kaspi, S.P., Riemann, B.C., Zeitlin, S.B. (1990). Selective processing of threat cues in posttraumatic stress disorder. Journal of Abnormal Psychology, 99, 398402.
Miller, E.K., Cohen, J.D. (2001). An integrative theory of prefrontal cortex function. Annual Review of Neuroscience, 24, 167202.
Miyake, A., Friedman, N.P., Emerson, M.J., Witzki, A.H., Howerter, A., Wager, T.D. (2000). The unity and diversity of executive functions and their contributions to complex “Frontal Lobe” tasks: A latent variable analysis. Cognitive Psychology, 41, 49100.
Morey, R.A., Petty, C.M., Cooper, D.A., Labar, K.S., McCarthy, G. (2008). Neural systems for executive and emotional processing are modulated by symptoms of posttraumatic stress disorder in Iraq War veterans. Psychiatry Research, 162, 5972.
Mostofsky, S.H., Simmonds, D.J. (2008). Response inhibition and response selection: Two sides of the same coin. Journal of Cognitive Neuroscience, 20, 751761.
Nee, D.E., Wager, T.D., Jonides, J. (2007). Interference resolution: Insights from a meta-analysis of neuroimaging tasks. Cognitive, Affective, & Behavioral Neuroscience, 7, 117.
Nelson, L.A., Yoash-Gantz, R.E., Pickett, T.C., Campbell, T.A. (2009). Relationship between processing speed and executive functioning performance among OEF/OIF veterans: Implications for postdeployment rehabilitation. Journal of Head Trauma Rehabilitation, 24, 3240.
Patton, J.H., Stanford, M.S., Barratt, E.S. (1995). Factor structure of the Barratt impulsiveness scale. Journal of Clinical Psychology, 51, 768774.
Petrides, M. (1986). The effect of periarcuate lesions in the monkey on the performance of symmetrically and asymmetrically reinforced visual and auditory go, no-go tasks. Journal of Neuroscience, 6, 20542063.
Picton, P.W., Stuss, D.T., Alexander, M.P., Shallice, T., Binns, M.A., Gillingham, S. (2007). Effects of focal frontal lesions on response inhibition. Cerebral Cortex, 17, 826838.
Qureshi, S.U., Long, M.E., Bradshaw, M.R., Pyne, J.M., Magruder, K.M., Kimbrell, T., Kunik, M.E. (2011). Does PTSD impair cognition beyond the effect of trauma? Journal of Neuropsychiatry and Clinical Neurosciences, 23, 1628.
Rauch, S.L., Shin, L.M., Segal, E., Pitman, R.K., Carson, M.A., McMullin, K., Makris, N. (2003). Selectively reduced regional cortical volumes in post-traumatic stress disorder. Neuroreport, 14, 913916.
Rentrop, M., Backenstrass, M., Jaentsch, B., Kaiser, S., Roth, A., Unger, J., Renneberg, B. (2008). Response inhibition in borderline personality disorder: Performance in a Go/Nogo task. Psychopathology, 41, 5057.
Robertson, I.H., Manly, T., Andrade, J., Baddeley, B.T., Yiend, J. (1997). ‘Oops!’: Performance correlates of everyday attentional failures in traumatic brain injured and normal subjects. Neuropsychologia, 35, 747758.
Romesser, J., Shen, S., Reblin, M., Kircher, J., Allen, S., Roberts, T., Marchand, W.R. (2011). A preliminary study of the effect of a diagnosis of concussion on PTSD symptoms and other psychiatric variables at the time of treatment seeking among veterans. Military Medicine, 176, 246252.
Shin, L.M., Rauch, S.L., Pitman, R.K. (2006). Amygdala, medial prefrontal cortex, and hippocampal function in PTSD. Annals of the New York Academy of Sciences, 1071, 6779.
Sigford, B., Cifu, D.X., Vanderploeg, R. (2009). Care of war veterans with mild traumatic brain injury. New England Journal of Medicine, 361, 536; author reply 537–538.
Simmons, A.N., Matthews, S.C. (2012). Neural circuitry of PTSD with or without mild traumatic brain injury: A meta-analysis. Neuropharmacology, 62, 598606.
Stein, M.B., McAllister, T.W. (2009). Exploring the convergence of posttraumatic stress disorder and mild traumatic brain injury. American Journal of Psychiatry, 166, 768776.
Swick, D., Ashley, V., Turken, A.U. (2008). Left inferior frontal gyrus is critical for response inhibition. BMC Neuroscience, 9, 102.
Swick, D., Ashley, V., Turken, A.U. (2011). Are the neural correlates of stopping and not going identical? Quantitative meta-analysis of two response inhibition tasks. Neuroimage, 56, 16551665.
Swick, D., & Turken, A. U. (2002). Dissociation between conflict detection and error monitoring in the human anterior cingulate cortex. Proceedings of the National Academy of Sciences of the United States of America, 99, 16354–16359.
The Management of Concussion/mTBI Working Group (2009). VA/DOD clinical practice guideline for management of concussion/mild traumatic brain injury (mTBI). Journal of Rehabilitation Research Development, 46, CP1CP68.
Vasterling, J.J., Brailey, K., Constans, J.I., Sutker, P.B. (1998). Attention and memory dysfunction in posttraumatic stress disorder. Neuropsychology, 12, 125133.
Vasterling, J.J., Verfaellie, M. (2009). Introduction-posttraumatic stress disorder: A neurocognitive perspective. Journal of the International Neuropsychological Society, 15, 826829.
Vasterling, J.J., Verfaellie, M., Sullivan, K.D. (2009). Mild traumatic brain injury and posttraumatic stress disorder in returning veterans: Perspectives from cognitive neuroscience. Clinical Psychology Review, 29, 674684.
Vrana, S.R., Roodman, A., Beckham, J.C. (1995). Selective processing of trauma-relevant words in posttraumatic stress disorder. Journal of Anxiety Disorders, 9, 515530.
Weathers, F.W., Litz, B.T., Huska, J.A., Keane, T.M. (1994). PTSD Checklist—Military Version (PCL-M) for DSM-IV. Boston: National Center for PTSD—Behavioral Science Division.
Wechsler, D. (2001). Wechsler Test of Adult Reading. San Antonio, TX: Harcourt Assessment, Inc.
Whyte, J., Grieb-Neff, P., Gantz, C., Polansky, M. (2006). Measuring sustained attention after traumatic brain injury: Differences in key findings from the sustained attention to response task (SART). Neuropsychologia, 44, 20072014.
Woodward, S.H., Kaloupek, D.G., Streeter, C.C., Martinez, C., Schaer, M., Eliez, S. (2006). Decreased anterior cingulate volume in combat-related PTSD. Biological Psychiatry, 59, 582587.
Wu, J., Ge, Y., Shi, Z., Duan, X., Wang, L., Sun, X., Zhang, K. (2010). Response inhibition in adolescent earthquake survivors with and without posttraumatic stress disorder: A combined behavioral and ERP study. Neuroscience Letters, 486, 117121.
Zheng, D., Oka, T., Bokura, H., Yamaguchi, S. (2008). The key locus of common response inhibition network for no-go and stop signals. Journal of Cognitive Neuroscience, 20, 14341442.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Journal of the International Neuropsychological Society
  • ISSN: 1355-6177
  • EISSN: 1469-7661
  • URL: /core/journals/journal-of-the-international-neuropsychological-society
Please enter your name
Please enter a valid email address
Who would you like to send this to? *



Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed