Posttraumatic Stress Disorder 519
Clinician Guideline 12.15
Modification of dysfunctional beliefs about a vulnerable self, dangerous world, expectation
of future threat, and alienation from others is the primary emphasis in cognitive therapy of
PTSD.Hypothesis 3
Individuals with PTSD will exhibit an automatic attentional bias for information
representing a threat to personal safety.
An early review of information- processing studies of PTSD concluded that evidence
for an automatic processing bias for threat cues was mixed but the findings were more
consistent for a strategic or elaborative attentional bias for trauma- relevant stimuli
(Buckley, Blanchard, & Neill, 2000). Most studies have employed the modified Stroop
task and investigated attentional bias only at the elaborative stage of information pro-
cessing. In one of the first studies, Vietnam combat veterans with PTSD showed a sig-
nificant interference effect that was specific to combat- relevant words but not OCD,
positive, or neutral words (McNally, Kaspi, et al., 1990). This supraliminal Stroop inter-
ference effect for trauma information has been replicated with motor vehicle accident
survivors with PTSD (e.g., J. G. Beck et al., 2001; Bryant & Harvey, 1995), rape victims
with PTSD (e.g., Cassiday, McNally, & Zeitlin, 1992), and crime victims with acute
PTSD (Paunovic, Lundh, & Öst, 2002). However, some studies have found that color-
naming interference may not be specific to trauma stimuli but sensitive to all emotional
stimuli (Vrana et al., 1995; see also Paunovic et al., 2002) and that the attentional bias
may be evident only at the elaborative processing stage (Buckley et al., 2002; McNally,
Amir, & Lipke, 1996; Paunovic et al., 2002). Finally, attentional bias for trauma may be
related to severity of reexperiencing intrusions but not avoidance symptoms (Cassiday
et al., 1992).
Findings from other studies also suggest that the attentional bias for threat in PTSD
may not be as straightforward as predicted by the cognitive model. Employing a dot
probe detection task, individuals with PTSD did not evidence an attentional bias for
trauma- relevant pictures compared to nonclinical controls even though they had accel-
erated heart rate to the trauma- related stimuli (Elsesser, Sartory, & Tackenberg, 2004).
Based on a visual search task involving threat and nonthreat target words and distrac-
tors, Vietnam veterans with high PTSD symptoms showed attentional interference but
not facilitation for threat words (Pineles, Shipherd, Welch, & Yovel, 2007). This finding
is consistent with the Stroop interference studies and suggests that the attentional bias
in PTSD reflects difficulty disengaging from threat- relevant cues. It is also apparent that
the attentional bias for trauma is more transient than enduring as the effect appears to
wane with repetition (McNally et al., 1996) or can be suppressed when individuals with
PTSD anticipate exposure to a mildly threatening situation (Constans et al., 2004).
In summary there is considerable empirical support for attentional bias for trauma-
related information in PTSD. However, there has been little support for a preconscious
(but probably involuntary) attentional bias and it is unclear whether the bias is content-
specific to trauma. More research is needed using experimental tasks other than the