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Age effect on autobiographical memory specificity: A study on autobiographical memory specificity in elderly survivors of childhood trauma
J. Behav. Ther. & Exp. Psychiat. 54 (2017) 247e253
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Age effect on autobiographical memory specificity: A study on autobiographical memory specificity in elderly survivors of childhood trauma Charlotte E. Wittekind a, 1, Lena Jelinek a, 1, Birgit Kleim b, Christoph Muhtz c, Steffen Moritz a, Fabrice Berna a, * a
University Medical Center Hamburg-Eppendorf, Department of Psychiatry and Psychotherapy, Martinistr. 52, D-20246 Hamburg, Germany Department of Clinical Psychology and Psychotherapy, University of Zürich, Zürich, Switzerland Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf and Schoen Klinik Hamburg-Eilbek, Martinistr. 52, D-20246 Hamburg, Germany b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 20 April 2016 Received in revised form 5 August 2016 Accepted 14 September 2016 Available online 15 September 2016
Background and objectives: Post-traumatic stress disorder (PTSD) is accompanied by altered autobiographical memories (AM) of the traumatic incident itself as well as of non-trauma-related events. Several studies have shown that trauma-exposed individuals developing PTSD have a reduced capacity to access specific past events that are not related to the traumatic event compared to those who do not develop PTSD. However, one study including a group of elderly adults did not find significant differences in AM between PTSD and non-PTSD participants. The present study investigated whether PTSD is associated with impaired AM of trauma-related and non-trauma-related memories in the elderly. Method: Forty-four elderly participants, displaced during childhood from former German territories after the end of World War II (WWII), were examined. This group comprised 19 participants with and 25 participants without PTSD. These participants were compared to 23 non-traumatized non-displaced elderly participants. Results: PTSD, non-PTSD and non-traumatized participants do not differ significantly in their ability to recall specific memories of their past. Moreover, participants with PTSD did not recall more traumarelated memories than non-PTSD participants. Limitations: The traumatized participants reached for assessment might represent the most resilient individuals, which might constrain generalizability of our results to other trauma populations. Conclusions: This study confirms preliminary evidence that PTSD is not associated with AM impairment in the elderly. We suggest that aging may alter the relationship between trauma and AM impairment in traumatized participants with PTSD, which need to be confirmed by longitudinal studies. © 2016 Elsevier Ltd. All rights reserved.
Keywords: Autobiographical memory Post-traumatic stress disorder Aging Depression Trauma Older adults
1. Introduction The literature on autobiographical memory (AM) and trauma has provided converging evidence showing that post-traumatic stress disorder (PTSD) is accompanied not only by altered memories of the traumatic incident itself, but also by altered AM for nontrauma-related events (for review: Brewin, 2007; Moore & Zoellner, 2007; Williams et al., 2007; meta-analysis: Ono, Devilly,
* Corresponding author. E-mail address: [email protected] (F. Berna). 1 Shared first authorship: Charlotte Wittekind and Lena Jelinek. http://dx.doi.org/10.1016/j.jbtep.2016.09.002 0005-7916/© 2016 Elsevier Ltd. All rights reserved.
& Shum, 2016). PTSD is typically characterized by involuntary and vivid memories of the traumatic event(s) (“intrusions”, DSM-5; American Psychiatric Association, 2013). Such intrusive traumarelated memories differ from other memories in that they are experienced as mainly sensori-perceptual and include emotional details of the trauma (McKinnon et al., 2015). At the same time, individuals with PTSD display difficulty accessing unique and detailed episodes of their life and tend to recall rather overgeneral memories, particularly for positive events (McNally, Lasko, Macklin, & Pitman, 1995; McNally, Litz, Prassas, Shin, & Weathers, 1994; € nfeld, Ehlers, Bo €llinghaus, & Rief, 2007; for meta-analysis: Scho Ono et al., 2016). These memories correspond either to generic
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events that have occurred several times or to events lasting more than a day (Williams & Broadbent, 1986).
diagnostic status for both depression and PTSD.” (p. 435). 1.3. Aim of the study
1.1. Studies comparing traumatized individuals with and without PTSD The majority of studies comparing AM between traumatized individuals with and without PTSD examined samples in the context of war-related trauma (Brown et al., 2013; Kleim & Ehlers, 2008; McNally et al., 1994, 1995; Moradi, Abdi, Fathi-Ashtiani, Dalgleish, & Jobson, 2012). Moreover, these samples included mostly male participants aged between 30 and 40 years old. Other studies investigated AM in acute stress disorder in a small sample of young participants that were victims of a car accident (Harvey & Bryant, 1998), on middle-aged patients recently diagnosed with cancer (Kangas, Henry, & Bryant, 2005), or on individuals who experienced the loss of a close relative and developed complicated grief (Boelen, Huntjens, van Deursen, & van den Hout, 2010). Almost all of these studies reported a reduced capacity for individuals with PTSD to access specific past events that were not related to the traumatic event. Rubin (2011) also showed that trauma-related memories of PTSD participants contained more sensory words and non-trauma-related memories less sensory words than memories of non-PTSD participants. However, other studies did not find evidence that the coherence of trauma- and non-trauma-related memories differ between PTSD and non-PTSD participants (Rubin, 2011; Rubin et al., 2016). Furthermore, it is not clear whether these results remain true for people from other age groups, particularly elderly people, and whether remote traumatic events still exert deleterious impact on AM. 1.2. Trauma, PTSD and autobiographical memory in aging €bler, Schützwohl, & Maercker, A recent study (Kleim, Griffith, Ga 2013) provided first findings related to this question. It included elderly subjects who had experienced remote imprisonmentrelated trauma situations occurring about 35 years ago. Results showed that individuals with and without PTSD did not differ in their ability to access specific events of non-trauma-related events. The remoteness of trauma may thus potentially lower the influence of trauma on AM in elderly people. It is also possible that the decrease of AM performance that accompanies normal aging (e.g., Levine, Svoboda, Hay, Winocur, & Moscovitch, 2002; Piolino, Desgranges, Benali, & Eustache, 2002; Piolino et al., 2010) attenuates the difference observed in younger samples. Another study (Wessel, Merckelbach, & Dekkers, 2002) that included 25 traumatized elderly participants presenting with various psychopathological disorders (such as PTSD, mood, and anxiety disorders) found evidence for impaired memory specificity in traumatized individuals; however, interpretability of findings is constrained as the healthy control group was rather small (sample of 15 nontraumatized individuals) and no traumatized control group without psychopathological disorders was included. Furthermore, as both studies focused on non-trauma-related memories, it remains unknown whether findings also concern trauma-related memories, that is, whether specificity for trauma- and nontrauma-related memories differs in elderly individuals with and without PTSD. Finally, the review by Moore and Zoellner (2007) pointed out several methodological limitations of studies investigating PTSD and AM that led the authors to recommend that “an ideal autobiographical memory study would feature thorough assessment of both childhood and adulthood trauma exposure, including assessment of event severity or life threat, appropriate control groups for both trauma exposure and depression, and standardized diagnostic interviews to assess severity and
Accordingly, the aim of the present study was to investigate AM performance in a non-selected sample of elderly participants who were exposed to a trauma during childhood, here the displacement from former German territories at the end of the Second World War (WWII). Participants were displaced as children, experienced a wide range (e.g., bombardment, seeing people die, assaults) and an average of five traumatic events during their escape (Muhtz et al., 2011). We aimed to examine the ability of displaced individuals with PTSD compared to displaced individuals without PTSD and non-traumatized non-displaced individuals without trauma history to recall specific events of the past and on trauma-related (i.e., displacement-related) memories. Based on the study by Kleim et al. (2013), we predicted that AM of non-trauma-related events would not differ between elderly individuals with and without PTSD, but would differ between traumatized and non-traumatized individuals. We also predicted that participants with PTSD would recall more specific memories related to trauma than non-PTSD participants. Both predictions were implied by our hypotheses that the impact of aging on AM may not be too pronounced to mask putative differences between groups. 2. Material and method 2.1. Participants In total, 50 individuals (born between 1932 and 1941) who were forcibly displaced at the end of WWII from the former parts of Germany (e.g., Silesia, Prussia) were recruited by means of a database build up in a previous study (see Muhtz et al., 2011), notices on black boards, refugee organizations, self-help groups as well as personal contacts. For inclusion, participants had to have experienced a traumatic event according to DSM-IV during their escape (trauma criteria A1 and A2). PTSD diagnosis was based on the PTSD section of the Structured Clinical Interview (SCID; Wittchen, Wunderlich, Gruschwitz, & Zaudig, 1997) with 19 participants with and 25 participants without PTSD (2 displaced participants were excluded after the assessment [manic episode, trauma criteria not met] and data of 4 participants was not available: Autobiographical Memory Test (AMT, see below) not conducted due to exhaustion [n ¼ 1], loss of datafiles [n ¼ 2], bad audio recording [n ¼ 1]). Within the PTSD group, 10 participants met full and nine met subsyndromal PTSD criteria (Blanchard, Jones-Alexander, Buckley, & Forneris, 1996; DSM-IV criteria A, B, E, and F fulfilled and either criterion C or D); there were no significant differences between full and subsyndromal cases as to overall symptom severity as assessed with the Post-traumatic Diagnostic Scale (PDS, Foa, Cashman, Jaycox, & Perry, 1997): full PTSD: M ¼ 14.50, SD ¼ 4.90; subsyndromal PTSD: M ¼ 16.44, SD ¼ 4.61, t(17) ¼ 0.80, p ¼ 0.39. Additionally, 23 non-displaced non-traumatized individuals (not married to a person displaced during WWII) currently not meeting any psychiatric disorder were recruited (non-Trauma group). Participants with a lifetime history of psychotic symptoms, mania or bipolar disorder, substance dependence within the last year, or acute suicidal tendencies were excluded by means of the Mini International Neuropsychiatric Interview (MINI, Sheehan et al., 1998). To assess severity of PTSD symptoms, the Posttraumatic Diagnostic Scale (Foa et al., 1997) was administered to traumatized participants. Internal consistency for the German version of the PDS is excellent with a ¼ 0.94 (Griesel, Wessa, & Flor, 2006). Depression severity was assessed in all participants using
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the Hamilton Depression Rating Scale (HDRS, 17-item version; Hamilton, 1960). A multiple choice vocabulary test was used to estimate premorbid intelligence level (Mehrfachwahl-WortschatzIntelligenztest-B: MWT-B, Multiple choice vocabulary test, Lehrl, 1995). All participants had given written informed consent prior to participation. The study was approved by the Ethics Committee of the Medical Board Hamburg (Germany).
The AMT (Williams & Broadbent, 1986) was used and adapted for the present study. Forty-eight words were rated in a pilot study by 20 psychologists in an online survey with 12 trauma-related (i.e., displacement-related) words, 12 positive, 12 negative, and 12 neutral words. Trauma-related words were selected from a pool of words that was generated for an emotional Stroop task of a previous study (Wittekind, Jelinek, Kellner, Moritz, & Muhtz, 2010) and all other word types were selected from previous AMT studies and Celex (Baayen, Piepenbrock, & Gulikers, 1995). Words were rated as to imageability (1 ¼ not imageable at all to 7 ¼ very imageable), concreteness (1 ¼ not concrete at all to 7 ¼ very concrete), frequency (1 ¼ not frequent at all to 7 ¼ very frequent), ease to generate a memory (1 ¼ very easy, 2 ¼ easy, 3 ¼ not easy), and valence (1 ¼ positive, 2 ¼ positive and displacement-relevant, 3 ¼ neutral, 4 ¼ negative and displacement-relevant, 5 ¼ negative). For selection, valence of trauma-related words had to vary between 3.5 and 4.5, valence of positive words was <1.5, of negative words >4.5, and of neutral words between 2.5 and 3.5. For each condition, words were selected such that words were comparable as to imageability, concreteness, frequency, and easiness of memory retrieval. However, it was impossible to select five traumarelated and neutral words that were comparable to positive and negative words on the five dimensions. Consequently, neutral words were excluded and trauma-related words were finally not parallelized leaving 15 cue words in total (each five positive [friendliness, kindness/goodness, success/achievement, luck, humor], negative [failure, anger, humiliation/hurt, doubts, sadness], and trauma-related words [loss, hunger/starve, trek, camp, expulsion]). Trauma-related words have several meanings in German language (homonym) so that they could also cue memories not related to displacement (i.e., non-trauma related memories) in participants without history of displacement. The characteristics of word ratings are reported in Table 1. Words were presented in pseudo-randomized order. Each word was written on a card and given orally by the experimenter. Three practice words (sickness, love, and sports) were used to ensure task comprehension. It was ensured that a specific memory was generated for each practice word before the experimental task was
Table 1 Characteristics of word ratings: means and standard deviations. Positive 3.44 3.63 5.07 1.70 1.29
(0.43)a (0.34)b (1.19)c (0.51)d (0.09)e
started. Participants were asked to generate a specific memory in response to each cue word and were allowed 60 s for each response. If the first response was not a specific memory, participants were prompted again to retrieve a specific memory (‘Can you think of a specific time/episode?’). This prompting procedure was repeated until a specific memory was retrieved or the response time was exceeded. All memories were narrated out loud by the participants and recorded in order to be later transcribed verbatim for analysis. 2.3. Scoring
2.2. Autobiographical memory task (AMT)
Imageability Concreteness Frequency Ease to access a memory Valence
249
Negative
Trauma
3.54 3.76 5.02 1.60 4.62
4.59 4.52 3.81 2.26 4.01
(0.60) (0.58) (0.59) (0.25) (0.09)
(0.50) (0.71) (1.12) (0.62) (0.27)
Note. a 1 ¼ not imageable at all to 7 ¼ very imageable. b 1 ¼ not concrete at all to 7 ¼ very concrete. c 1 ¼ not frequent at all to 7 ¼ very frequent. d 1 ¼ very easy, 2 ¼ easy, 3 ¼ not easy. e 1 ¼ positive, 2 ¼ positive and displacement-related, 3 ¼ neutral, 4 ¼ negative and displacement-related, 5 ¼ negative.
An independent rater (FB) who was blind to group status coded verbatim responses for specificity and relation to trauma. Responses were rated as “specific” if they referred to an event lasting less than 24 h that would have occurred on a particular day at a particular time and place (e.g., a specific incidence on the wedding day), “categorical” if they referred to either repeated events (e.g., ‘times I've gone jogging’), “extended”, if they referred to events lasting more than 24 h (e.g., ‘our holiday in Spain last year’), “thought” if they did not refer to a memory. Omissions were coded when no response was given by the participant. Finally, given that trauma-related cuewords may lead to the recall of memories not relating to trauma itself, memories were coded as relating to trauma if their main topic referred to displacement and/or time of war. A second independent rater (LJ) coded 20% of responses for specificity, valence, and relation to trauma. The kappa coefficient revealed good inter-rated agreement for specificity (0.78) and for relation to trauma (0.92). 2.4. Statistical analyses Separate analyses of variance (ANOVAs) were performed on the proportion of specific and trauma-related memories in each category of memories with Group (PTSD, non-PTSD, non-Trauma) as a between-subject factor and Category of memories (positive, negative, trauma) as a within-subject factor. Post-hoc analyses with Bonferroni correction were performed when a significant main effect or interaction was observed. Correlational analyses were performed using Pearson coefficient correlation in order to examine the influence of depression and severity of PTSD symptoms on the specificity of AMs. Effect sizes (h2p) were calculated for ANOVAs following Kinnear and Gray (2008) conventions for small: h2p z 0.01, medium: h2p z 0.06, and large: h2p z 0.14, effects. 3. Results 3.1. Demographical and clinical variables (see Table 2) The three groups (traumatized PTSD, traumatized non-PTSD, non-traumatized control group) did not differ in terms of age and sex ratio. Traumatized participants with PTSD had significantly lower years of formal school education than non-traumatized participants; importantly, groups did not significantly differ as to verbal intelligence. Severity of depressive symptoms (HDRS) differed significantly across groups (see Table 2). Post-hoc analyses showed that traumatized participants with PTSD had significantly higher levels of depression than the two other groups. Traumatized participants without PTSD also had more depressive symptoms than non-traumatized participants, but the difference was not significant (p ¼ 0.10). As expected, the severity of PTSD symptoms was significantly higher in the PTSD vs. non-PTSD group. 3.2. Autobiographical memory task To ensure that trauma-related cue-words effectively prompted
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Table 2 Demographic, clinical, and autobiographical memory data. Non-traumatized (NT)
Traumatized without PTSD (NP)
n ¼ 23
Age Sex (male) Years of schooling Verbal intelligence (MWT-B) HDRS PDS Proportion of specific memoriesa Positive Cue-Words (Pos) Negative Cue-Words (Neg) Trauma-related Cue-Words (TR) Proportion of trauma-related memoriesb Positive Cue-Words (Pos) Negative Cue-Words (Neg) Trauma-related Cue-Words (TR) Proportion of specific memories in trauma-related memories overall (T)b in non-trauma-related memories overall (NT)b
Traumatized with PTSD (P)
n ¼ 25
Statistics
n ¼ 19
M
SD
M
SD
M
SD
F
p
h2p
73.78 7 10.78 118.0 2.36
(2.92) (30.4%) (2.07) (11.2) (2.57) (0.20) (0.25) (0.26) (0.31) (0.13) (0.10) (0.07) (0.34)
(1.86) (32.0%) (1.98) (11.7) (5.06) (5.18) (0.24) (0.27) (0.30) (0.33) (0.10) (0.07) (0.15) (0.26)
72.58 2 9.11 113.8 11.84 15.42 0.53 0.61 0.49 0.49 0.27 0.06 0.04 0.83
(2.22) (10.5%) (2.58) (10.3) (6.21) (4.74) (0.21) (0.25) (0.29) (0.31) (0.09) (0.13) (0.08) (0.19)
1.56 c2 ¼ 3.1 3.39 1.16 21.20 34.87 8.09
0.22 0.21 0.04 0.321 <0.001 <0.001 0.006
0.05
0.45 0.57 0.38 0.38 0.18 0.03 0.03 0.54
72.84 8 9.56 118.7 5.35 6.44 0.54 0.58 0.50 0.53 0.24 0.03 0.06 0.73
404.2
12.83 0.29 0.53
(0.31) (0.22)
0.47 0.59
(0.37) (0.22)
0.48 0.59
(0.32) (0.21)
0.10
NT > P
0.40 0.45 0.11
NT < NP < P NP < P Pos > Neg,TR
<0.001
0.86
Pos,Neg < TR
0.001
0.18
NT > T
Note: HDRS¼Hamilton Depression Scale, PDS¼Post-traumatic Diagnostic Scale, MWT-B ¼ Mehrfachwahl-Wortschatz-Intelligenztest-B (Lehrl, 1995). a According to Williams and Broadbent (1986). b As rated by the experimenter.
trauma-related memories, we first calculated the proportion of trauma-related memories given by the participants for each trauma-related cue word. Overall, 61.5% memories were considered trauma-related prompted by the word “Hunger”, 82.8% by “Trek”, 67.7% by “Camp”, 79.7% by “Expulsion”, and 9.4% by “Loss”. We then decided to remove the responses obtained with the word “Loss” as prevalence of trauma-related memories was low. 3.2.1. Specific memories A significant effect of category was found, F (2,63) ¼ 8.09, p ¼ 0.006, h2p ¼ 0.112, that was explained by a higher proportion of specific memories associated with positive cue-words in comparison to negative and trauma-related cue-words (p ¼ 0.001, and p ¼ 0.007, respectively). The proportion of specific memories did not differ significantly between negative and trauma-related categories (p ¼ 0.87). Group effect and interaction were not significant, F (2,63) ¼ 1.32, p ¼ 0.27, h2p ¼ 0.04 and F (4,128) ¼ 0.65, p ¼ 0.63, h2p ¼ 0.02, respectively.2 3.2.2. Trauma-related memories A significant effect of category was found, F (2,63) ¼ 404.2, p < 0.001, h2p ¼ 0.86, due to a higher proportion of trauma-related memories in the category trauma-related compared to the other two categories. A significant group effect was found, F (2,63) ¼ 4.82, p ¼ 0.01, h2p ¼ 0.13, that was explained by a higher proportion of trauma-related memories in the traumatized PTSD vs. nontraumatized group. Traumatized non-PTSD participants had more trauma-related memories than non-traumatized participants but this difference was not significant (p ¼ 0.10)3. Finally, a significant interaction between group and category was found, F (4,128) ¼ 5.45, p ¼ 0.007, h2p ¼ 0.15. Post-hoc analyses showed that
2 More omissions were observed in the trauma-related category compared to positive and negative cue-words (p ¼ 0.01, h2p ¼ 0.15). However, the group effect and interaction between group and category were not significant (p ¼ 0.14, h2p ¼ 0.004; p ¼ 0.54, h2p ¼ 0.024, respectively). 3 We remind that as stated above in 2.2., trauma-related memories correspond here to memories relating to displacement and not to other traumatic experiences unrelated to displacement.
the proportion of trauma-related memories was higher in the traumatized PTSD and traumatized non-PTSD group than in the non-traumatized group, but the difference was significant only for the comparison between traumatized PTSD and non-traumatized groups (p ¼ 0.004 and p ¼ 0.066, respectively). When traumatized PTSD and traumatized non-PTSD groups were compared, the difference was not significant (p ¼ 0.72). Moreover, the proportion of trauma-related memories associated with either positive or negative cues did not differ significantly between groups (ps > 0.47). In order to further examine the specificity of trauma-related memories, secondary ANOVAs were performed that compared the proportion of specific memories among the memories coded as trauma-related by the experimenter (that is, whatever the category of cue-words) to the proportion of specific memories among memories coded as non-trauma-related. This analysis showed a significantly higher proportion of specific memories in nontrauma-related memories than in trauma-related memories, F (2,63) ¼ 12.83, p ¼ 0.001, h2p ¼ 0.18. Neither the group effect, F (2,63) ¼ 2.00, p ¼ 0.14, h2p ¼ 0.062, nor the group by category interaction, F (4,128) ¼ 0.83, p ¼ 0.44, h2p ¼ 0.027, were significant. 3.3. Correlation analyses Correlation between PTSD severity and memory specificity was not significant for both traumatized groups, jrsj < 0.31, ps > 0.20. Correlation between depression scores and memory specificity were not significant for all groups, jrsj < 0.39, ps > 0.10. A significant negative correlation between memory specificity and depression score was observed only in the trauma-related category and in the traumatized PTSD group, r ¼ 0.54, p ¼ 0.02, but this correlation was no longer significant after correction for multiple testing (see Table 3). 4. Discussion The present study extended previous AM specificity studies by investigating impairment of trauma-related and non-traumarelated AMs in a unique sample of elderly participants exposed
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Table 3 Correlation coefficients between scores of depression (HDRS), severity of symptoms of posttraumatic stress disorder (PDS) and characteristics of autobiographical memories.
% Specific memoriesa Positive Cue-Words (Pos) Negative Cue-Words (Neg) Trauma-related Cue-Words (TR) % Trauma-related memoriesb
Non-traumatized (NT)
Traumatized without PTSD (NP)
Traumatized with PTSD (T)
Total sample
n ¼ 23
n ¼ 25
n ¼ 19
n ¼ 67
n ¼ 44
HDRS
HDRS
PDS
HDRS
PDS
HDRS
PDS
0.30 0.22 0.18 0.26 0.01
0.04 0.10 0.06 0.11 0.28
0.26 0.21 0.16 0.26 0.09
0.39& 0.09 0.21 0.54* 0.19
0.24 0.31 0.25 0.004 0.28
0.04 0.04 0.02 0.08 0.17
0.19 0.14 0.16 0.16 0.15
Note: *p < 0.05, & p < 0.10. HDRS¼Hamilton Depression Scale, PDS¼Post-traumatic Diagnostic Scale. a According to Williams and Broadbent (1986). b As rated by the experimenter.
to an early trauma during childhood, hence also expanding previous studies by providing information on a sample of war survivors that is usually not often studied. This study was the first to compare trauma-related and non-trauma-related memories and to include a comparison group composed by nontrauma exposed individuals who had no trauma experience in their life, all groups being from the same culture and native German-speaking people. Our results show that traumatized PTSD, traumatized non-PTSD, and non-traumatized participants did not differ significantly in their ability to recall specific memories of their past. Moreover, participants with PTSD did not recall more trauma-related memories than traumatized participants without PTSD. 4.1. Trauma, PTSD and AM in aging Our findings provide new evidence challenging the view that PTSD in general is associated with a reduced capacity to access specific memories of past events (e.g., Brown et al., 2013; Kleim & Ehlers, 2008; McNally et al., 1994, 1995; Moradi et al., 2012). They are in line with a previous study suggesting that PTSD in elderly people exposed to a trauma occurring more than 30 years ago may no longer influence the ability to recall specific events (Kleim et al., 2013) and extend these findings to trauma-related memories. It would thus be tempting to suggest that aging alters the effect of PTSD on AM. However, as no measures of AM performance were used when our participants were around 30e40 years old, we cannot draw this conclusion. Longitudinal studies are needed to investigate whether AM specificity alters during aging. With regard to trauma-related memories, our results are in contrast to that reported by McKinnon et al. (2015) who found that memories of personal trauma (flight accident), in comparison to non-personal trauma (9/11 attack), contained more perceptual and emotional details relating to core events. However, this study differs from our study on several points. Firstly, McKinnon et al. (2015) counted the number of memory details and did not assess the specificity of the events themselves. Secondly, the trauma investigated in McKinnon and colleagues’ study was a single trauma that had taken place 10 years before assessment. In contrast, traumatized participants in our study experienced multiple and various types of trauma during displacement (mean of five traumatic events according to Muhtz et al., 2011), which occurred more than 65 years before testing, this increasing the propensity for traumatized participants to recall repeated events instead of unique (specific) events in our AM task. Given the type of traumatic events under the scope of our study, our results may not be confined to our specific population but might be transferred to other refugee populations.
4.2. Cognitive and affective mechanisms These results raise the question of the cognitive and affective mechanisms at play in AM for trauma-related and non-traumarelated events in aging. In fact, Williams et al. (2007) have shown that executive functions and emotional regulation factors are directly involved when people try to access specific memories. Executive functions are implicated in the strategic retrieval of memories and their impairment (that accompanies normal aging) is causally involved in the difficulty accessing specific memories in the elderly (Piolino et al., 2010). Executive functions also entail inhibitory processes that prevent intrusive trauma-memories to arise, when provoked by trauma-related cues. Emotional regulation factors are engaged to avoid the activation of unpleasant emotions when accessing memories. Thus, the absence of difference observed for memory specificity across our groups suggests that executive function did not differ dramatically between our groups and this is corroborated by the non-significant difference observed between traumatized participants with and without PTSD with regard to the proportion of trauma-related memories.4 Furthermore, previous studies did not find clear evidence for an alteration of executive functions due to PTSD in elderly (Green, Fairchild, Kinoshita, Noda, & Yesavage, 2016; Jelinek, Wittekind, Moritz, Kellner, & Muhtz, 2013; Schuitevoerder et al., 2013). Moreover, Dalgleish, Rolfe, Golden, Dunn, and Barnard (2008) demonstrated that the capacity to access specific memories depends less on executive function in patients with PTSD and more on emotional regulation factors. Another hypothesis is that emotional regulation processes were rather preserved in PTSD participants although these participants presented with depressive and PTSD symptoms. In support for this hypothesis, PTSD participants as well as participants from the two other groups, recalled more specific memories in response to positive than to negative and trauma-related cue-words. This effect is usually attenuated or absent in PTSD and depression (Ono et al., 2016; Williams et al., 2007), in particular due to a mood congruency effect (that is, an easier access to specific memories with a valence matching the current emotional state). However, this effect was still observed in our PTSD participants although they had higher level of depressive symptoms. Moreover, we did not find significant correlations between the levels of depressive and/or PTSD symptoms and memory specificity for non-trauma-related memories in all groups. This result is in contrast to previous results obtained in
4 Additionnally, although we did not explicitly assess executive functioning in the present study, an emotional Stroop task incorporating the classic Stroop condition (i.e., incongruent color words), which is considered a measure of inhibitory control, was also administered (Wittekind, Muhtz, Moritz, & Jelinek, 2016). Groups did not differ significantly regarding reaction times towards incongruent color words.
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younger samples of traumatized individuals (e.g., McKinnon et al., 2015; McNally et al., 1995, 1994), but again it also confirms Kleim et al. (2013) findings from their study of elderly traumatized participants. Kleim and colleagues demonstrated that other factors than depression or PTSD symptoms were significantly associated with memory specificity in their sample such as, for instance, characteristics of the traumatic events and the coping strategies developed by the participants. These factors were not investigated in our study.
4.3. Limitations Some limitations of our study should be mentioned with regard to the selection of our non-displaced control group. In fact, the events targeted here concerned all German citizens more or less directly in the period following the end of WWII. Displaced participants were forced to leave their home, but non-traumatized participants were virtually all directly in contact with displaced people as displaced people represented about 20% of the German population at that time (Kossert, 2008). Consequently, nontraumatized participants may have been marked by this historical event and also able to retrieve vivid (but not traumatic) memories from that time. Moreover, our sample size was rather small making it more difficult to detect subtle differences. However, as traumatization dates back more than 65 years, many of the individuals affected might not be available for assessment as traumatization and PTSD in particular are associated with higher morbidity and mortality (Boscarino, 2006; Glaesmer, Br€ ahler, Gündel, & RiedelHeller, 2011). In consequence, only the most resilient individuals might have been reached for assessment. Thus, the sample under investigation represents a specific population and it remains to be tested whether findings can be transferred to other trauma populations. For example, PTSD participants in the present sample reported a rather low level of intrusions (M ¼ 1.11, SD ¼ 1.10, with a rating of ‘1’ corresponding to “Once a week or less/one in a while”) as assessed with item #1 of the PTSD (“Having upsetting thoughts or images about the traumatic event that came into your head when you didn't want them to”). Thus, PTSD participants in the present study are not as chronically troubled by flashbacks as are recent trauma victims. Finally, given that all trauma-related memories referred to events occurring during childhood, these events were more remote than those cued with positive and negative words. It is also hard to tease apart if results here relate to old age or temporarily remote traumatization.
5. Conclusions The present results confirm preliminary evidence that PTSD in aging individuals is not associated with AM impairment. One may thus hypothesize that aging may alter the relationship between trauma and AM impairment in traumatized participants with PTSD, but longitudinal studies are necessary to examine the persisting effect of trauma on memory at different time points.
Declaration of interest Authors declare no conflicts of interest.
Funding source The present study was supported by a PhD scholarship of the University of Hamburg granted to C.E.W.
Acknowledgements gionale de Sante , Ho ^ pitaux We are grateful to the Agence Re Universitaires de Strasbourg and the Fondation FondaMental that financially supported FB's post-doctoral position in Hamburg. References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, fifth edition (DSM-5) (5th ed.). Washington, DC: American Psychiatric Association. Baayen, R., Piepenbrock, R., & Gulikers, L. (1995). CELEX2 LDC96L14. Web download. Philadelphia: Linguistic Data Consortium, 1995. 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(8), 669e673. Boelen, P. A., Huntjens, R. J. C., van Deursen, D. S., & van den Hout, M. A. (2010). Autobiographical memory specificity and symptoms of complicated grief, depression, and posttraumatic stress disorder following loss. Journal of Behavior Therapy and Experimental Psychiatry, 41(4), 331e337. http://dx.doi.org/10.1016/ j.jbtep.2010.03.003. Boscarino, J. A. (2006). Posttraumatic stress disorder and mortality among U.S. Army veterans 30 years after military service. Annals of Epidemiology, 16(4), 248e256. http://dx.doi.org/10.1016/j.annepidem.2005.03.009. Brewin, C. R. (2007). Autobiographical memory for trauma: Update on four controversies. Memory, 15(3), 227e248. http://dx.doi.org/10.1080/ 09658210701256423. Brown, A. D., Root, J. C., Romano, T. A., Chang, L. J., Bryant, R. A., & Hirst, W. (2013). Overgeneralized autobiographical memory and future thinking in combat veterans with posttraumatic strdss disorder. Journal of Behavior Therapy and Experimental Psychiatry, 44(1), 129e134. http://dx.doi.org/10.1016/ j.jbtep.2011.11.004. Dalgleish, T., Rolfe, J., Golden, A.-M., Dunn, B. D., & Barnard, P. J. (2008). Reduced autobiographical memory specificity and posttraumatic stress: Exploring the contributions of impaired executive control and affect regulation. Journal of Abnormal Psychology, 117(1), 236e241. http://dx.doi.org/10.1037/0021843X.117.1.236. Foa, E. B., Cashman, L., Jaycox, L., & Perry, K. (1997). The validation of a self-report measure of posttraumatic stress disorder: The Posttraumatic Diagnostic Scale. Psychological Assessment, 9(4), 445e451. http://dx.doi.org/10.1037/10403590.9.4.445. €hler, E., Gündel, H., & Riedel-Heller, S. G. (2011). The association of Glaesmer, H., Bra traumatic experiences and posttraumatic stress disorder with physical morbidity in old age: A German population-based study. Psychosomatic Medicine, 73(5), 401e406. http://dx.doi.org/10.1097/PSY.0b013e31821b47e8. Green, E., Fairchild, J. K., Kinoshita, L. M., Noda, A., & Yesavage, J. (2016). Effects of posttraumatic stress disorder and metabolic syndrome on cognitive aging in veterans. The Gerontologist, 56(1), 72e81. http://dx.doi.org/10.1093/geront/ gnv040. Griesel, D., Wessa, M., & Flor, H. (2006). Psychometric qualities of the German version of the posttraumatic diagnostic scale (PDS). Psychological Assessment, 18(3), 262e268. http://dx.doi.org/10.1037/1040-3590.18.3.262. Hamilton, M. (1960). A rating scale for depression. Journal of Neurology, Neurosurgery, and Psychiatry, 23(1), 56e62. Harvey, A. G., & Bryant, R. A. (1998). The relationship between acute stress disorder and posttraumatic stress disorder: A prospective evaluation of motor vehicle accident survivors. Journal of Consulting and Clinical Psychology, 66(3), 507e512. http://dx.doi.org/10.1037/0022-006X.66.3.507. Jelinek, L., Wittekind, C. E., Moritz, S., Kellner, M., & Muhtz, C. (2013). Neuropsychological functioning in posttraumatic stress disorder following forced displacement in older adults and their offspring. Psychiatry Research, 210(2), 584e589. http://dx.doi.org/10.1016/j.psychres.2013.06.037. Kangas, M., Henry, J. L., & Bryant, R. A. (2005). The course of psychological disorders in the 1st year after cancer diagnosis. Journal of Consulting and Clinical Psychology, 73(4), 763e768. http://dx.doi.org/10.1037/0022-006X.73.4.763. Kinnear, P. R., & Gray, C. D. (2008). SPSS 16 made simple. New York: Psychology Press, Hove. Kleim, B., & Ehlers, A. (2008). Reduced autobiographical memory specificity predicts depression and posttraumatic stress disorder after recent trauma. Journal of Consulting and Clinical Psychology, 76(2), 231e242. http://dx.doi.org/10.1037/ 0022-006X.76.2.231. €bler, I., Schützwohl, M., & Maercker, A. (2013). The impact Kleim, B., Griffith, J. W., Ga of imprisonment on overgeneral autobiographical memory in former political prisoners. Journal of Traumatic Stress, 26(5), 626e630. http://dx.doi.org/10.1002/ jts.21849. Kossert, A. (2008). Kalte Heimat - Die Geschichte der deutschen Vertriebenen nach 1945 [Cold homeland e The history of displaced Germans after 1945]. Munich, Germany: Siedler. Lehrl, S. (1995). Mehrfachwahl-wortschatz-intelligenztest: MWT-B [Multiple choice vocabulary test] (3rd ed.). Balingen: PERIMED-spitta. Levine, B., Svoboda, E., Hay, J. F., Winocur, G., & Moscovitch, M. (2002). Aging and autobiographical memory: Dissociating episodic from semantic retrieval.
C.E. Wittekind et al. / J. Behav. Ther. & Exp. Psychiat. 54 (2017) 247e253 Psychology and Aging, 17(4), 677e689. http://dx.doi.org/10.1037//08827974.17.4.677. McKinnon, M. C., Palombo, D. J., Nazarov, A., Kumar, N., Khuu, W., & Levine, B. (2015). Threat of death and autobiographical memory: A study of passengers from flight AT236. Clinical Psychological Science, 3(4), 487e502. http:// dx.doi.org/10.1177/2167702614542280. McNally, R. J., Lasko, N. B., Macklin, M. L., & Pitman, R. K. (1995). Autobiographical memory disturbance in combat-related posttraumatic stress disorder. Behaviour Research and Therapy, 33(6), 619e630. http://dx.doi.org/10.1016/00057967(95)00007-K. McNally, R. J., Litz, B. T., Prassas, A., Shin, L. M., & Weathers, F. W. (1994). Emotional priming of autobiographical memory in post-traumatic stress disorder. Cognition and Emotion, 8(4), 351e367. http://dx.doi.org/10.1080/ 02699939408408946. Moore, S. A., & Zoellner, L. A. (2007). Overgeneral autobiographical memory and traumatic events: An evaluative review. Psychological Bulletin, 133(3), 419e437. http://dx.doi.org/10.1037/0033-2909.133.3.419. Moradi, A. R., Abdi, A., Fathi-Ashtiani, A., Dalgleish, T., & Jobson, L. (2012). Overgeneral autobiographical memory recollection in Iranian combat veterans with posttraumatic stress disorder. Behaviour Research and Therapy, 50(6), 435e441. http://dx.doi.org/10.1016/j.brat.2012.03.009. Muhtz, C., Godemann, K., von Alm, C., Wittekind, C., Goemann, C., Wiedemann, K., et al. (2011). Effects of chronic posttraumatic stress disorder on metabolic risk, quality of life, and stress hormones in aging former refugee children. Journal of Nervous and Mental Disease, 199(9), 646e652. http://dx.doi.org/10.1097/ NMD.0b013e318229cfba. Ono, M., Devilly, G. J., & Shum, D. H. (2016). A meta-analytic review of overgeneral memory: The role of trauma history, mood, and the presence of posttraumatic stress disorder. Psychological Trauma: Theory, Research, Practice, and Policy, 8(2), 157e164. http://dx.doi.org/10.1037/tra0000027. , A.-L., Quinette, P., Guillery-Girard, B., et al. Piolino, P., Coste, C., Martinelli, P., Mace (2010). Reduced specificity of autobiographical memory and aging: Do the executive and feature binding functions of working memory have a role? Neuropsychologia, 48(2), 429e440. http://dx.doi.org/10.1016/ j.neuropsychologia.2009.09.035. Piolino, P., Desgranges, B., Benali, K., & Eustache, F. (2002). Episodic and semantic remote autobiographical memory in ageing. Memory, 10(4), 239e257. http:// dx.doi.org/10.1080/09658210143000353. Rubin, D. C. (2011). The coherence of memories for trauma: Evidence from
253
posttraumatic stress disorder. Consciousness and Cognition, 20, 857e865. http:// dx.doi.org/10.1016/j.concog.2010.03.018. Rubin, D. C., Deffler, S. A., Ogle, C. M., Dowell, N. M., Graesser, A. C., & Beckham, J. C. (2016). Participant, rater, and computer measures of coherence in posttraumatic stress disorder. Journal of Abnormal Psychology, 125, 11e25. http://dx.doi.org/ 10.1037/abn0000126. €nfeld, S., Ehlers, A., Bo € llinghaus, I., & Rief, W. (2007). Overgeneral memory and Scho suppression of trauma memories in post-traumatic stress disorder. Memory, 15(3), 339e352. http://dx.doi.org/10.1080/09658210701256571. Schuitevoerder, S., Rosen, J. W., Twamley, E. W., Ayers, C. R., Sones, H., Lohr, J. B., et al. (2013). A meta-analysis of cognitive functioning in older adults with PTSD. Journal of Anxiety Disorders, 27(6), 550e558. http://dx.doi.org/10.1016/ j.janxdis.2013.01.001. Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim, P., Janavs, J., Weiller, E., et al. (1998). The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59(S20), 22e33. Wessel, I., Merckelbach, H., & Dekkers, T. (2002). Autobiographical memory specificity, intrusive memory, and general memory skills in Dutch-Indonesian survivors of the World War II era. Journal of Traumatic Stress, 15(3), 227e234. http://dx.doi.org/10.1023/A:1015207428675. Williams, J. M. G., Barnhofer, T., Crane, C., Herman, D., Raes, F., Watkins, E., et al. (2007). Autobiographical memory specificity and emotional disorder. Psychological Bulletin, 133(1), 122e148. http://dx.doi.org/10.1037/0033-2909.133.1.122. Williams, J. M., & Broadbent, K. (1986). Autobiographical memory in suicide attempters. Journal of Abnormal Psychology, 95(2), 144e149. http://dx.doi.org/ 10.1037/0021-843X.95.2.144. Wittchen, H.-U., Wunderlich, U., Gruschwitz, S., & Zaudig, M. (1997). Strukturiertes €rungen [Structured clinical klinisches interview für DSM-IV. Achse I: Psychische Sto interview for the DSM-IV. Axis I: Psychiatric disorders]. Goettingen: Hogrefe. Wittekind, C. E., Jelinek, L., Kellner, M., Moritz, S., & Muhtz, C. (2010). Intergenerational transmission of biased information processing in posttraumatic stress disorder (PTSD) following displacement after World War II. Journal of Anxiety Disorders, 24(8), 953e957. http://dx.doi.org/10.1016/j.janxdis.2010.06.023. Wittekind, C. E., Muhtz, C., Moritz, S., & Jelinek, L. (2016). Performance in a blocked versus randomized emotional Stroop task in an aged, early traumatized group with and without posttraumatic stress symptoms. Journal of Behavior Therapy and Experimental Psychiatry, 54(3), 35e43. http://dx.doi.org/10.1016/ j.jbtep.2016.06.003.
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Age effect on autobiographical memory specificity: A study on autobiographical memory specificity in elderly survivors of childhood trauma Charlotte E. Wittekind a, 1, Lena Jelinek a, 1, Birgit Kleim b, Christoph Muhtz c, Steffen Moritz a, Fabrice Berna a, * a
University Medical Center Hamburg-Eppendorf, Department of Psychiatry and Psychotherapy, Martinistr. 52, D-20246 Hamburg, Germany Department of Clinical Psychology and Psychotherapy, University of Zürich, Zürich, Switzerland Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf and Schoen Klinik Hamburg-Eilbek, Martinistr. 52, D-20246 Hamburg, Germany b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 20 April 2016 Received in revised form 5 August 2016 Accepted 14 September 2016 Available online 15 September 2016
Background and objectives: Post-traumatic stress disorder (PTSD) is accompanied by altered autobiographical memories (AM) of the traumatic incident itself as well as of non-trauma-related events. Several studies have shown that trauma-exposed individuals developing PTSD have a reduced capacity to access specific past events that are not related to the traumatic event compared to those who do not develop PTSD. However, one study including a group of elderly adults did not find significant differences in AM between PTSD and non-PTSD participants. The present study investigated whether PTSD is associated with impaired AM of trauma-related and non-trauma-related memories in the elderly. Method: Forty-four elderly participants, displaced during childhood from former German territories after the end of World War II (WWII), were examined. This group comprised 19 participants with and 25 participants without PTSD. These participants were compared to 23 non-traumatized non-displaced elderly participants. Results: PTSD, non-PTSD and non-traumatized participants do not differ significantly in their ability to recall specific memories of their past. Moreover, participants with PTSD did not recall more traumarelated memories than non-PTSD participants. Limitations: The traumatized participants reached for assessment might represent the most resilient individuals, which might constrain generalizability of our results to other trauma populations. Conclusions: This study confirms preliminary evidence that PTSD is not associated with AM impairment in the elderly. We suggest that aging may alter the relationship between trauma and AM impairment in traumatized participants with PTSD, which need to be confirmed by longitudinal studies. © 2016 Elsevier Ltd. All rights reserved.
Keywords: Autobiographical memory Post-traumatic stress disorder Aging Depression Trauma Older adults
1. Introduction The literature on autobiographical memory (AM) and trauma has provided converging evidence showing that post-traumatic stress disorder (PTSD) is accompanied not only by altered memories of the traumatic incident itself, but also by altered AM for nontrauma-related events (for review: Brewin, 2007; Moore & Zoellner, 2007; Williams et al., 2007; meta-analysis: Ono, Devilly,
* Corresponding author. E-mail address: [email protected] (F. Berna). 1 Shared first authorship: Charlotte Wittekind and Lena Jelinek. http://dx.doi.org/10.1016/j.jbtep.2016.09.002 0005-7916/© 2016 Elsevier Ltd. All rights reserved.
& Shum, 2016). PTSD is typically characterized by involuntary and vivid memories of the traumatic event(s) (“intrusions”, DSM-5; American Psychiatric Association, 2013). Such intrusive traumarelated memories differ from other memories in that they are experienced as mainly sensori-perceptual and include emotional details of the trauma (McKinnon et al., 2015). At the same time, individuals with PTSD display difficulty accessing unique and detailed episodes of their life and tend to recall rather overgeneral memories, particularly for positive events (McNally, Lasko, Macklin, & Pitman, 1995; McNally, Litz, Prassas, Shin, & Weathers, 1994; € nfeld, Ehlers, Bo €llinghaus, & Rief, 2007; for meta-analysis: Scho Ono et al., 2016). These memories correspond either to generic
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events that have occurred several times or to events lasting more than a day (Williams & Broadbent, 1986).
diagnostic status for both depression and PTSD.” (p. 435). 1.3. Aim of the study
1.1. Studies comparing traumatized individuals with and without PTSD The majority of studies comparing AM between traumatized individuals with and without PTSD examined samples in the context of war-related trauma (Brown et al., 2013; Kleim & Ehlers, 2008; McNally et al., 1994, 1995; Moradi, Abdi, Fathi-Ashtiani, Dalgleish, & Jobson, 2012). Moreover, these samples included mostly male participants aged between 30 and 40 years old. Other studies investigated AM in acute stress disorder in a small sample of young participants that were victims of a car accident (Harvey & Bryant, 1998), on middle-aged patients recently diagnosed with cancer (Kangas, Henry, & Bryant, 2005), or on individuals who experienced the loss of a close relative and developed complicated grief (Boelen, Huntjens, van Deursen, & van den Hout, 2010). Almost all of these studies reported a reduced capacity for individuals with PTSD to access specific past events that were not related to the traumatic event. Rubin (2011) also showed that trauma-related memories of PTSD participants contained more sensory words and non-trauma-related memories less sensory words than memories of non-PTSD participants. However, other studies did not find evidence that the coherence of trauma- and non-trauma-related memories differ between PTSD and non-PTSD participants (Rubin, 2011; Rubin et al., 2016). Furthermore, it is not clear whether these results remain true for people from other age groups, particularly elderly people, and whether remote traumatic events still exert deleterious impact on AM. 1.2. Trauma, PTSD and autobiographical memory in aging €bler, Schützwohl, & Maercker, A recent study (Kleim, Griffith, Ga 2013) provided first findings related to this question. It included elderly subjects who had experienced remote imprisonmentrelated trauma situations occurring about 35 years ago. Results showed that individuals with and without PTSD did not differ in their ability to access specific events of non-trauma-related events. The remoteness of trauma may thus potentially lower the influence of trauma on AM in elderly people. It is also possible that the decrease of AM performance that accompanies normal aging (e.g., Levine, Svoboda, Hay, Winocur, & Moscovitch, 2002; Piolino, Desgranges, Benali, & Eustache, 2002; Piolino et al., 2010) attenuates the difference observed in younger samples. Another study (Wessel, Merckelbach, & Dekkers, 2002) that included 25 traumatized elderly participants presenting with various psychopathological disorders (such as PTSD, mood, and anxiety disorders) found evidence for impaired memory specificity in traumatized individuals; however, interpretability of findings is constrained as the healthy control group was rather small (sample of 15 nontraumatized individuals) and no traumatized control group without psychopathological disorders was included. Furthermore, as both studies focused on non-trauma-related memories, it remains unknown whether findings also concern trauma-related memories, that is, whether specificity for trauma- and nontrauma-related memories differs in elderly individuals with and without PTSD. Finally, the review by Moore and Zoellner (2007) pointed out several methodological limitations of studies investigating PTSD and AM that led the authors to recommend that “an ideal autobiographical memory study would feature thorough assessment of both childhood and adulthood trauma exposure, including assessment of event severity or life threat, appropriate control groups for both trauma exposure and depression, and standardized diagnostic interviews to assess severity and
Accordingly, the aim of the present study was to investigate AM performance in a non-selected sample of elderly participants who were exposed to a trauma during childhood, here the displacement from former German territories at the end of the Second World War (WWII). Participants were displaced as children, experienced a wide range (e.g., bombardment, seeing people die, assaults) and an average of five traumatic events during their escape (Muhtz et al., 2011). We aimed to examine the ability of displaced individuals with PTSD compared to displaced individuals without PTSD and non-traumatized non-displaced individuals without trauma history to recall specific events of the past and on trauma-related (i.e., displacement-related) memories. Based on the study by Kleim et al. (2013), we predicted that AM of non-trauma-related events would not differ between elderly individuals with and without PTSD, but would differ between traumatized and non-traumatized individuals. We also predicted that participants with PTSD would recall more specific memories related to trauma than non-PTSD participants. Both predictions were implied by our hypotheses that the impact of aging on AM may not be too pronounced to mask putative differences between groups. 2. Material and method 2.1. Participants In total, 50 individuals (born between 1932 and 1941) who were forcibly displaced at the end of WWII from the former parts of Germany (e.g., Silesia, Prussia) were recruited by means of a database build up in a previous study (see Muhtz et al., 2011), notices on black boards, refugee organizations, self-help groups as well as personal contacts. For inclusion, participants had to have experienced a traumatic event according to DSM-IV during their escape (trauma criteria A1 and A2). PTSD diagnosis was based on the PTSD section of the Structured Clinical Interview (SCID; Wittchen, Wunderlich, Gruschwitz, & Zaudig, 1997) with 19 participants with and 25 participants without PTSD (2 displaced participants were excluded after the assessment [manic episode, trauma criteria not met] and data of 4 participants was not available: Autobiographical Memory Test (AMT, see below) not conducted due to exhaustion [n ¼ 1], loss of datafiles [n ¼ 2], bad audio recording [n ¼ 1]). Within the PTSD group, 10 participants met full and nine met subsyndromal PTSD criteria (Blanchard, Jones-Alexander, Buckley, & Forneris, 1996; DSM-IV criteria A, B, E, and F fulfilled and either criterion C or D); there were no significant differences between full and subsyndromal cases as to overall symptom severity as assessed with the Post-traumatic Diagnostic Scale (PDS, Foa, Cashman, Jaycox, & Perry, 1997): full PTSD: M ¼ 14.50, SD ¼ 4.90; subsyndromal PTSD: M ¼ 16.44, SD ¼ 4.61, t(17) ¼ 0.80, p ¼ 0.39. Additionally, 23 non-displaced non-traumatized individuals (not married to a person displaced during WWII) currently not meeting any psychiatric disorder were recruited (non-Trauma group). Participants with a lifetime history of psychotic symptoms, mania or bipolar disorder, substance dependence within the last year, or acute suicidal tendencies were excluded by means of the Mini International Neuropsychiatric Interview (MINI, Sheehan et al., 1998). To assess severity of PTSD symptoms, the Posttraumatic Diagnostic Scale (Foa et al., 1997) was administered to traumatized participants. Internal consistency for the German version of the PDS is excellent with a ¼ 0.94 (Griesel, Wessa, & Flor, 2006). Depression severity was assessed in all participants using
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the Hamilton Depression Rating Scale (HDRS, 17-item version; Hamilton, 1960). A multiple choice vocabulary test was used to estimate premorbid intelligence level (Mehrfachwahl-WortschatzIntelligenztest-B: MWT-B, Multiple choice vocabulary test, Lehrl, 1995). All participants had given written informed consent prior to participation. The study was approved by the Ethics Committee of the Medical Board Hamburg (Germany).
The AMT (Williams & Broadbent, 1986) was used and adapted for the present study. Forty-eight words were rated in a pilot study by 20 psychologists in an online survey with 12 trauma-related (i.e., displacement-related) words, 12 positive, 12 negative, and 12 neutral words. Trauma-related words were selected from a pool of words that was generated for an emotional Stroop task of a previous study (Wittekind, Jelinek, Kellner, Moritz, & Muhtz, 2010) and all other word types were selected from previous AMT studies and Celex (Baayen, Piepenbrock, & Gulikers, 1995). Words were rated as to imageability (1 ¼ not imageable at all to 7 ¼ very imageable), concreteness (1 ¼ not concrete at all to 7 ¼ very concrete), frequency (1 ¼ not frequent at all to 7 ¼ very frequent), ease to generate a memory (1 ¼ very easy, 2 ¼ easy, 3 ¼ not easy), and valence (1 ¼ positive, 2 ¼ positive and displacement-relevant, 3 ¼ neutral, 4 ¼ negative and displacement-relevant, 5 ¼ negative). For selection, valence of trauma-related words had to vary between 3.5 and 4.5, valence of positive words was <1.5, of negative words >4.5, and of neutral words between 2.5 and 3.5. For each condition, words were selected such that words were comparable as to imageability, concreteness, frequency, and easiness of memory retrieval. However, it was impossible to select five traumarelated and neutral words that were comparable to positive and negative words on the five dimensions. Consequently, neutral words were excluded and trauma-related words were finally not parallelized leaving 15 cue words in total (each five positive [friendliness, kindness/goodness, success/achievement, luck, humor], negative [failure, anger, humiliation/hurt, doubts, sadness], and trauma-related words [loss, hunger/starve, trek, camp, expulsion]). Trauma-related words have several meanings in German language (homonym) so that they could also cue memories not related to displacement (i.e., non-trauma related memories) in participants without history of displacement. The characteristics of word ratings are reported in Table 1. Words were presented in pseudo-randomized order. Each word was written on a card and given orally by the experimenter. Three practice words (sickness, love, and sports) were used to ensure task comprehension. It was ensured that a specific memory was generated for each practice word before the experimental task was
Table 1 Characteristics of word ratings: means and standard deviations. Positive 3.44 3.63 5.07 1.70 1.29
(0.43)a (0.34)b (1.19)c (0.51)d (0.09)e
started. Participants were asked to generate a specific memory in response to each cue word and were allowed 60 s for each response. If the first response was not a specific memory, participants were prompted again to retrieve a specific memory (‘Can you think of a specific time/episode?’). This prompting procedure was repeated until a specific memory was retrieved or the response time was exceeded. All memories were narrated out loud by the participants and recorded in order to be later transcribed verbatim for analysis. 2.3. Scoring
2.2. Autobiographical memory task (AMT)
Imageability Concreteness Frequency Ease to access a memory Valence
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Negative
Trauma
3.54 3.76 5.02 1.60 4.62
4.59 4.52 3.81 2.26 4.01
(0.60) (0.58) (0.59) (0.25) (0.09)
(0.50) (0.71) (1.12) (0.62) (0.27)
Note. a 1 ¼ not imageable at all to 7 ¼ very imageable. b 1 ¼ not concrete at all to 7 ¼ very concrete. c 1 ¼ not frequent at all to 7 ¼ very frequent. d 1 ¼ very easy, 2 ¼ easy, 3 ¼ not easy. e 1 ¼ positive, 2 ¼ positive and displacement-related, 3 ¼ neutral, 4 ¼ negative and displacement-related, 5 ¼ negative.
An independent rater (FB) who was blind to group status coded verbatim responses for specificity and relation to trauma. Responses were rated as “specific” if they referred to an event lasting less than 24 h that would have occurred on a particular day at a particular time and place (e.g., a specific incidence on the wedding day), “categorical” if they referred to either repeated events (e.g., ‘times I've gone jogging’), “extended”, if they referred to events lasting more than 24 h (e.g., ‘our holiday in Spain last year’), “thought” if they did not refer to a memory. Omissions were coded when no response was given by the participant. Finally, given that trauma-related cuewords may lead to the recall of memories not relating to trauma itself, memories were coded as relating to trauma if their main topic referred to displacement and/or time of war. A second independent rater (LJ) coded 20% of responses for specificity, valence, and relation to trauma. The kappa coefficient revealed good inter-rated agreement for specificity (0.78) and for relation to trauma (0.92). 2.4. Statistical analyses Separate analyses of variance (ANOVAs) were performed on the proportion of specific and trauma-related memories in each category of memories with Group (PTSD, non-PTSD, non-Trauma) as a between-subject factor and Category of memories (positive, negative, trauma) as a within-subject factor. Post-hoc analyses with Bonferroni correction were performed when a significant main effect or interaction was observed. Correlational analyses were performed using Pearson coefficient correlation in order to examine the influence of depression and severity of PTSD symptoms on the specificity of AMs. Effect sizes (h2p) were calculated for ANOVAs following Kinnear and Gray (2008) conventions for small: h2p z 0.01, medium: h2p z 0.06, and large: h2p z 0.14, effects. 3. Results 3.1. Demographical and clinical variables (see Table 2) The three groups (traumatized PTSD, traumatized non-PTSD, non-traumatized control group) did not differ in terms of age and sex ratio. Traumatized participants with PTSD had significantly lower years of formal school education than non-traumatized participants; importantly, groups did not significantly differ as to verbal intelligence. Severity of depressive symptoms (HDRS) differed significantly across groups (see Table 2). Post-hoc analyses showed that traumatized participants with PTSD had significantly higher levels of depression than the two other groups. Traumatized participants without PTSD also had more depressive symptoms than non-traumatized participants, but the difference was not significant (p ¼ 0.10). As expected, the severity of PTSD symptoms was significantly higher in the PTSD vs. non-PTSD group. 3.2. Autobiographical memory task To ensure that trauma-related cue-words effectively prompted
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Table 2 Demographic, clinical, and autobiographical memory data. Non-traumatized (NT)
Traumatized without PTSD (NP)
n ¼ 23
Age Sex (male) Years of schooling Verbal intelligence (MWT-B) HDRS PDS Proportion of specific memoriesa Positive Cue-Words (Pos) Negative Cue-Words (Neg) Trauma-related Cue-Words (TR) Proportion of trauma-related memoriesb Positive Cue-Words (Pos) Negative Cue-Words (Neg) Trauma-related Cue-Words (TR) Proportion of specific memories in trauma-related memories overall (T)b in non-trauma-related memories overall (NT)b
Traumatized with PTSD (P)
n ¼ 25
Statistics
n ¼ 19
M
SD
M
SD
M
SD
F
p
h2p
73.78 7 10.78 118.0 2.36
(2.92) (30.4%) (2.07) (11.2) (2.57) (0.20) (0.25) (0.26) (0.31) (0.13) (0.10) (0.07) (0.34)
(1.86) (32.0%) (1.98) (11.7) (5.06) (5.18) (0.24) (0.27) (0.30) (0.33) (0.10) (0.07) (0.15) (0.26)
72.58 2 9.11 113.8 11.84 15.42 0.53 0.61 0.49 0.49 0.27 0.06 0.04 0.83
(2.22) (10.5%) (2.58) (10.3) (6.21) (4.74) (0.21) (0.25) (0.29) (0.31) (0.09) (0.13) (0.08) (0.19)
1.56 c2 ¼ 3.1 3.39 1.16 21.20 34.87 8.09
0.22 0.21 0.04 0.321 <0.001 <0.001 0.006
0.05
0.45 0.57 0.38 0.38 0.18 0.03 0.03 0.54
72.84 8 9.56 118.7 5.35 6.44 0.54 0.58 0.50 0.53 0.24 0.03 0.06 0.73
404.2
12.83 0.29 0.53
(0.31) (0.22)
0.47 0.59
(0.37) (0.22)
0.48 0.59
(0.32) (0.21)
0.10
NT > P
0.40 0.45 0.11
NT < NP < P NP < P Pos > Neg,TR
<0.001
0.86
Pos,Neg < TR
0.001
0.18
NT > T
Note: HDRS¼Hamilton Depression Scale, PDS¼Post-traumatic Diagnostic Scale, MWT-B ¼ Mehrfachwahl-Wortschatz-Intelligenztest-B (Lehrl, 1995). a According to Williams and Broadbent (1986). b As rated by the experimenter.
trauma-related memories, we first calculated the proportion of trauma-related memories given by the participants for each trauma-related cue word. Overall, 61.5% memories were considered trauma-related prompted by the word “Hunger”, 82.8% by “Trek”, 67.7% by “Camp”, 79.7% by “Expulsion”, and 9.4% by “Loss”. We then decided to remove the responses obtained with the word “Loss” as prevalence of trauma-related memories was low. 3.2.1. Specific memories A significant effect of category was found, F (2,63) ¼ 8.09, p ¼ 0.006, h2p ¼ 0.112, that was explained by a higher proportion of specific memories associated with positive cue-words in comparison to negative and trauma-related cue-words (p ¼ 0.001, and p ¼ 0.007, respectively). The proportion of specific memories did not differ significantly between negative and trauma-related categories (p ¼ 0.87). Group effect and interaction were not significant, F (2,63) ¼ 1.32, p ¼ 0.27, h2p ¼ 0.04 and F (4,128) ¼ 0.65, p ¼ 0.63, h2p ¼ 0.02, respectively.2 3.2.2. Trauma-related memories A significant effect of category was found, F (2,63) ¼ 404.2, p < 0.001, h2p ¼ 0.86, due to a higher proportion of trauma-related memories in the category trauma-related compared to the other two categories. A significant group effect was found, F (2,63) ¼ 4.82, p ¼ 0.01, h2p ¼ 0.13, that was explained by a higher proportion of trauma-related memories in the traumatized PTSD vs. nontraumatized group. Traumatized non-PTSD participants had more trauma-related memories than non-traumatized participants but this difference was not significant (p ¼ 0.10)3. Finally, a significant interaction between group and category was found, F (4,128) ¼ 5.45, p ¼ 0.007, h2p ¼ 0.15. Post-hoc analyses showed that
2 More omissions were observed in the trauma-related category compared to positive and negative cue-words (p ¼ 0.01, h2p ¼ 0.15). However, the group effect and interaction between group and category were not significant (p ¼ 0.14, h2p ¼ 0.004; p ¼ 0.54, h2p ¼ 0.024, respectively). 3 We remind that as stated above in 2.2., trauma-related memories correspond here to memories relating to displacement and not to other traumatic experiences unrelated to displacement.
the proportion of trauma-related memories was higher in the traumatized PTSD and traumatized non-PTSD group than in the non-traumatized group, but the difference was significant only for the comparison between traumatized PTSD and non-traumatized groups (p ¼ 0.004 and p ¼ 0.066, respectively). When traumatized PTSD and traumatized non-PTSD groups were compared, the difference was not significant (p ¼ 0.72). Moreover, the proportion of trauma-related memories associated with either positive or negative cues did not differ significantly between groups (ps > 0.47). In order to further examine the specificity of trauma-related memories, secondary ANOVAs were performed that compared the proportion of specific memories among the memories coded as trauma-related by the experimenter (that is, whatever the category of cue-words) to the proportion of specific memories among memories coded as non-trauma-related. This analysis showed a significantly higher proportion of specific memories in nontrauma-related memories than in trauma-related memories, F (2,63) ¼ 12.83, p ¼ 0.001, h2p ¼ 0.18. Neither the group effect, F (2,63) ¼ 2.00, p ¼ 0.14, h2p ¼ 0.062, nor the group by category interaction, F (4,128) ¼ 0.83, p ¼ 0.44, h2p ¼ 0.027, were significant. 3.3. Correlation analyses Correlation between PTSD severity and memory specificity was not significant for both traumatized groups, jrsj < 0.31, ps > 0.20. Correlation between depression scores and memory specificity were not significant for all groups, jrsj < 0.39, ps > 0.10. A significant negative correlation between memory specificity and depression score was observed only in the trauma-related category and in the traumatized PTSD group, r ¼ 0.54, p ¼ 0.02, but this correlation was no longer significant after correction for multiple testing (see Table 3). 4. Discussion The present study extended previous AM specificity studies by investigating impairment of trauma-related and non-traumarelated AMs in a unique sample of elderly participants exposed
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Table 3 Correlation coefficients between scores of depression (HDRS), severity of symptoms of posttraumatic stress disorder (PDS) and characteristics of autobiographical memories.
% Specific memoriesa Positive Cue-Words (Pos) Negative Cue-Words (Neg) Trauma-related Cue-Words (TR) % Trauma-related memoriesb
Non-traumatized (NT)
Traumatized without PTSD (NP)
Traumatized with PTSD (T)
Total sample
n ¼ 23
n ¼ 25
n ¼ 19
n ¼ 67
n ¼ 44
HDRS
HDRS
PDS
HDRS
PDS
HDRS
PDS
0.30 0.22 0.18 0.26 0.01
0.04 0.10 0.06 0.11 0.28
0.26 0.21 0.16 0.26 0.09
0.39& 0.09 0.21 0.54* 0.19
0.24 0.31 0.25 0.004 0.28
0.04 0.04 0.02 0.08 0.17
0.19 0.14 0.16 0.16 0.15
Note: *p < 0.05, & p < 0.10. HDRS¼Hamilton Depression Scale, PDS¼Post-traumatic Diagnostic Scale. a According to Williams and Broadbent (1986). b As rated by the experimenter.
to an early trauma during childhood, hence also expanding previous studies by providing information on a sample of war survivors that is usually not often studied. This study was the first to compare trauma-related and non-trauma-related memories and to include a comparison group composed by nontrauma exposed individuals who had no trauma experience in their life, all groups being from the same culture and native German-speaking people. Our results show that traumatized PTSD, traumatized non-PTSD, and non-traumatized participants did not differ significantly in their ability to recall specific memories of their past. Moreover, participants with PTSD did not recall more trauma-related memories than traumatized participants without PTSD. 4.1. Trauma, PTSD and AM in aging Our findings provide new evidence challenging the view that PTSD in general is associated with a reduced capacity to access specific memories of past events (e.g., Brown et al., 2013; Kleim & Ehlers, 2008; McNally et al., 1994, 1995; Moradi et al., 2012). They are in line with a previous study suggesting that PTSD in elderly people exposed to a trauma occurring more than 30 years ago may no longer influence the ability to recall specific events (Kleim et al., 2013) and extend these findings to trauma-related memories. It would thus be tempting to suggest that aging alters the effect of PTSD on AM. However, as no measures of AM performance were used when our participants were around 30e40 years old, we cannot draw this conclusion. Longitudinal studies are needed to investigate whether AM specificity alters during aging. With regard to trauma-related memories, our results are in contrast to that reported by McKinnon et al. (2015) who found that memories of personal trauma (flight accident), in comparison to non-personal trauma (9/11 attack), contained more perceptual and emotional details relating to core events. However, this study differs from our study on several points. Firstly, McKinnon et al. (2015) counted the number of memory details and did not assess the specificity of the events themselves. Secondly, the trauma investigated in McKinnon and colleagues’ study was a single trauma that had taken place 10 years before assessment. In contrast, traumatized participants in our study experienced multiple and various types of trauma during displacement (mean of five traumatic events according to Muhtz et al., 2011), which occurred more than 65 years before testing, this increasing the propensity for traumatized participants to recall repeated events instead of unique (specific) events in our AM task. Given the type of traumatic events under the scope of our study, our results may not be confined to our specific population but might be transferred to other refugee populations.
4.2. Cognitive and affective mechanisms These results raise the question of the cognitive and affective mechanisms at play in AM for trauma-related and non-traumarelated events in aging. In fact, Williams et al. (2007) have shown that executive functions and emotional regulation factors are directly involved when people try to access specific memories. Executive functions are implicated in the strategic retrieval of memories and their impairment (that accompanies normal aging) is causally involved in the difficulty accessing specific memories in the elderly (Piolino et al., 2010). Executive functions also entail inhibitory processes that prevent intrusive trauma-memories to arise, when provoked by trauma-related cues. Emotional regulation factors are engaged to avoid the activation of unpleasant emotions when accessing memories. Thus, the absence of difference observed for memory specificity across our groups suggests that executive function did not differ dramatically between our groups and this is corroborated by the non-significant difference observed between traumatized participants with and without PTSD with regard to the proportion of trauma-related memories.4 Furthermore, previous studies did not find clear evidence for an alteration of executive functions due to PTSD in elderly (Green, Fairchild, Kinoshita, Noda, & Yesavage, 2016; Jelinek, Wittekind, Moritz, Kellner, & Muhtz, 2013; Schuitevoerder et al., 2013). Moreover, Dalgleish, Rolfe, Golden, Dunn, and Barnard (2008) demonstrated that the capacity to access specific memories depends less on executive function in patients with PTSD and more on emotional regulation factors. Another hypothesis is that emotional regulation processes were rather preserved in PTSD participants although these participants presented with depressive and PTSD symptoms. In support for this hypothesis, PTSD participants as well as participants from the two other groups, recalled more specific memories in response to positive than to negative and trauma-related cue-words. This effect is usually attenuated or absent in PTSD and depression (Ono et al., 2016; Williams et al., 2007), in particular due to a mood congruency effect (that is, an easier access to specific memories with a valence matching the current emotional state). However, this effect was still observed in our PTSD participants although they had higher level of depressive symptoms. Moreover, we did not find significant correlations between the levels of depressive and/or PTSD symptoms and memory specificity for non-trauma-related memories in all groups. This result is in contrast to previous results obtained in
4 Additionnally, although we did not explicitly assess executive functioning in the present study, an emotional Stroop task incorporating the classic Stroop condition (i.e., incongruent color words), which is considered a measure of inhibitory control, was also administered (Wittekind, Muhtz, Moritz, & Jelinek, 2016). Groups did not differ significantly regarding reaction times towards incongruent color words.
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younger samples of traumatized individuals (e.g., McKinnon et al., 2015; McNally et al., 1995, 1994), but again it also confirms Kleim et al. (2013) findings from their study of elderly traumatized participants. Kleim and colleagues demonstrated that other factors than depression or PTSD symptoms were significantly associated with memory specificity in their sample such as, for instance, characteristics of the traumatic events and the coping strategies developed by the participants. These factors were not investigated in our study.
4.3. Limitations Some limitations of our study should be mentioned with regard to the selection of our non-displaced control group. In fact, the events targeted here concerned all German citizens more or less directly in the period following the end of WWII. Displaced participants were forced to leave their home, but non-traumatized participants were virtually all directly in contact with displaced people as displaced people represented about 20% of the German population at that time (Kossert, 2008). Consequently, nontraumatized participants may have been marked by this historical event and also able to retrieve vivid (but not traumatic) memories from that time. Moreover, our sample size was rather small making it more difficult to detect subtle differences. However, as traumatization dates back more than 65 years, many of the individuals affected might not be available for assessment as traumatization and PTSD in particular are associated with higher morbidity and mortality (Boscarino, 2006; Glaesmer, Br€ ahler, Gündel, & RiedelHeller, 2011). In consequence, only the most resilient individuals might have been reached for assessment. Thus, the sample under investigation represents a specific population and it remains to be tested whether findings can be transferred to other trauma populations. For example, PTSD participants in the present sample reported a rather low level of intrusions (M ¼ 1.11, SD ¼ 1.10, with a rating of ‘1’ corresponding to “Once a week or less/one in a while”) as assessed with item #1 of the PTSD (“Having upsetting thoughts or images about the traumatic event that came into your head when you didn't want them to”). Thus, PTSD participants in the present study are not as chronically troubled by flashbacks as are recent trauma victims. Finally, given that all trauma-related memories referred to events occurring during childhood, these events were more remote than those cued with positive and negative words. It is also hard to tease apart if results here relate to old age or temporarily remote traumatization.
5. Conclusions The present results confirm preliminary evidence that PTSD in aging individuals is not associated with AM impairment. One may thus hypothesize that aging may alter the relationship between trauma and AM impairment in traumatized participants with PTSD, but longitudinal studies are necessary to examine the persisting effect of trauma on memory at different time points.
Declaration of interest Authors declare no conflicts of interest.
Funding source The present study was supported by a PhD scholarship of the University of Hamburg granted to C.E.W.
Acknowledgements gionale de Sante , Ho ^ pitaux We are grateful to the Agence Re Universitaires de Strasbourg and the Fondation FondaMental that financially supported FB's post-doctoral position in Hamburg. References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, fifth edition (DSM-5) (5th ed.). Washington, DC: American Psychiatric Association. Baayen, R., Piepenbrock, R., & Gulikers, L. (1995). CELEX2 LDC96L14. Web download. Philadelphia: Linguistic Data Consortium, 1995. 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(8), 669e673. Boelen, P. A., Huntjens, R. J. C., van Deursen, D. S., & van den Hout, M. A. (2010). Autobiographical memory specificity and symptoms of complicated grief, depression, and posttraumatic stress disorder following loss. Journal of Behavior Therapy and Experimental Psychiatry, 41(4), 331e337. http://dx.doi.org/10.1016/ j.jbtep.2010.03.003. Boscarino, J. A. (2006). Posttraumatic stress disorder and mortality among U.S. Army veterans 30 years after military service. Annals of Epidemiology, 16(4), 248e256. http://dx.doi.org/10.1016/j.annepidem.2005.03.009. Brewin, C. R. (2007). Autobiographical memory for trauma: Update on four controversies. Memory, 15(3), 227e248. http://dx.doi.org/10.1080/ 09658210701256423. Brown, A. D., Root, J. C., Romano, T. A., Chang, L. J., Bryant, R. A., & Hirst, W. (2013). Overgeneralized autobiographical memory and future thinking in combat veterans with posttraumatic strdss disorder. Journal of Behavior Therapy and Experimental Psychiatry, 44(1), 129e134. http://dx.doi.org/10.1016/ j.jbtep.2011.11.004. Dalgleish, T., Rolfe, J., Golden, A.-M., Dunn, B. D., & Barnard, P. J. (2008). Reduced autobiographical memory specificity and posttraumatic stress: Exploring the contributions of impaired executive control and affect regulation. Journal of Abnormal Psychology, 117(1), 236e241. http://dx.doi.org/10.1037/0021843X.117.1.236. Foa, E. B., Cashman, L., Jaycox, L., & Perry, K. (1997). The validation of a self-report measure of posttraumatic stress disorder: The Posttraumatic Diagnostic Scale. Psychological Assessment, 9(4), 445e451. http://dx.doi.org/10.1037/10403590.9.4.445. €hler, E., Gündel, H., & Riedel-Heller, S. G. (2011). The association of Glaesmer, H., Bra traumatic experiences and posttraumatic stress disorder with physical morbidity in old age: A German population-based study. Psychosomatic Medicine, 73(5), 401e406. http://dx.doi.org/10.1097/PSY.0b013e31821b47e8. Green, E., Fairchild, J. K., Kinoshita, L. M., Noda, A., & Yesavage, J. (2016). Effects of posttraumatic stress disorder and metabolic syndrome on cognitive aging in veterans. The Gerontologist, 56(1), 72e81. http://dx.doi.org/10.1093/geront/ gnv040. Griesel, D., Wessa, M., & Flor, H. (2006). Psychometric qualities of the German version of the posttraumatic diagnostic scale (PDS). Psychological Assessment, 18(3), 262e268. http://dx.doi.org/10.1037/1040-3590.18.3.262. Hamilton, M. (1960). A rating scale for depression. Journal of Neurology, Neurosurgery, and Psychiatry, 23(1), 56e62. Harvey, A. G., & Bryant, R. A. (1998). The relationship between acute stress disorder and posttraumatic stress disorder: A prospective evaluation of motor vehicle accident survivors. Journal of Consulting and Clinical Psychology, 66(3), 507e512. http://dx.doi.org/10.1037/0022-006X.66.3.507. Jelinek, L., Wittekind, C. E., Moritz, S., Kellner, M., & Muhtz, C. (2013). Neuropsychological functioning in posttraumatic stress disorder following forced displacement in older adults and their offspring. Psychiatry Research, 210(2), 584e589. http://dx.doi.org/10.1016/j.psychres.2013.06.037. Kangas, M., Henry, J. L., & Bryant, R. A. (2005). The course of psychological disorders in the 1st year after cancer diagnosis. Journal of Consulting and Clinical Psychology, 73(4), 763e768. http://dx.doi.org/10.1037/0022-006X.73.4.763. Kinnear, P. R., & Gray, C. D. (2008). SPSS 16 made simple. New York: Psychology Press, Hove. Kleim, B., & Ehlers, A. (2008). Reduced autobiographical memory specificity predicts depression and posttraumatic stress disorder after recent trauma. Journal of Consulting and Clinical Psychology, 76(2), 231e242. http://dx.doi.org/10.1037/ 0022-006X.76.2.231. €bler, I., Schützwohl, M., & Maercker, A. (2013). The impact Kleim, B., Griffith, J. W., Ga of imprisonment on overgeneral autobiographical memory in former political prisoners. Journal of Traumatic Stress, 26(5), 626e630. http://dx.doi.org/10.1002/ jts.21849. Kossert, A. (2008). Kalte Heimat - Die Geschichte der deutschen Vertriebenen nach 1945 [Cold homeland e The history of displaced Germans after 1945]. Munich, Germany: Siedler. Lehrl, S. (1995). Mehrfachwahl-wortschatz-intelligenztest: MWT-B [Multiple choice vocabulary test] (3rd ed.). Balingen: PERIMED-spitta. Levine, B., Svoboda, E., Hay, J. F., Winocur, G., & Moscovitch, M. (2002). Aging and autobiographical memory: Dissociating episodic from semantic retrieval.
C.E. Wittekind et al. / J. Behav. Ther. & Exp. Psychiat. 54 (2017) 247e253 Psychology and Aging, 17(4), 677e689. http://dx.doi.org/10.1037//08827974.17.4.677. McKinnon, M. C., Palombo, D. J., Nazarov, A., Kumar, N., Khuu, W., & Levine, B. (2015). Threat of death and autobiographical memory: A study of passengers from flight AT236. Clinical Psychological Science, 3(4), 487e502. http:// dx.doi.org/10.1177/2167702614542280. McNally, R. J., Lasko, N. B., Macklin, M. L., & Pitman, R. K. (1995). Autobiographical memory disturbance in combat-related posttraumatic stress disorder. Behaviour Research and Therapy, 33(6), 619e630. http://dx.doi.org/10.1016/00057967(95)00007-K. McNally, R. J., Litz, B. T., Prassas, A., Shin, L. M., & Weathers, F. W. (1994). Emotional priming of autobiographical memory in post-traumatic stress disorder. Cognition and Emotion, 8(4), 351e367. http://dx.doi.org/10.1080/ 02699939408408946. Moore, S. A., & Zoellner, L. A. (2007). Overgeneral autobiographical memory and traumatic events: An evaluative review. Psychological Bulletin, 133(3), 419e437. http://dx.doi.org/10.1037/0033-2909.133.3.419. Moradi, A. R., Abdi, A., Fathi-Ashtiani, A., Dalgleish, T., & Jobson, L. (2012). Overgeneral autobiographical memory recollection in Iranian combat veterans with posttraumatic stress disorder. Behaviour Research and Therapy, 50(6), 435e441. http://dx.doi.org/10.1016/j.brat.2012.03.009. Muhtz, C., Godemann, K., von Alm, C., Wittekind, C., Goemann, C., Wiedemann, K., et al. (2011). Effects of chronic posttraumatic stress disorder on metabolic risk, quality of life, and stress hormones in aging former refugee children. Journal of Nervous and Mental Disease, 199(9), 646e652. http://dx.doi.org/10.1097/ NMD.0b013e318229cfba. Ono, M., Devilly, G. J., & Shum, D. H. (2016). A meta-analytic review of overgeneral memory: The role of trauma history, mood, and the presence of posttraumatic stress disorder. Psychological Trauma: Theory, Research, Practice, and Policy, 8(2), 157e164. http://dx.doi.org/10.1037/tra0000027. , A.-L., Quinette, P., Guillery-Girard, B., et al. Piolino, P., Coste, C., Martinelli, P., Mace (2010). Reduced specificity of autobiographical memory and aging: Do the executive and feature binding functions of working memory have a role? Neuropsychologia, 48(2), 429e440. http://dx.doi.org/10.1016/ j.neuropsychologia.2009.09.035. Piolino, P., Desgranges, B., Benali, K., & Eustache, F. (2002). Episodic and semantic remote autobiographical memory in ageing. Memory, 10(4), 239e257. http:// dx.doi.org/10.1080/09658210143000353. Rubin, D. C. (2011). The coherence of memories for trauma: Evidence from
253
posttraumatic stress disorder. Consciousness and Cognition, 20, 857e865. http:// dx.doi.org/10.1016/j.concog.2010.03.018. Rubin, D. C., Deffler, S. A., Ogle, C. M., Dowell, N. M., Graesser, A. C., & Beckham, J. C. (2016). Participant, rater, and computer measures of coherence in posttraumatic stress disorder. Journal of Abnormal Psychology, 125, 11e25. http://dx.doi.org/ 10.1037/abn0000126. €nfeld, S., Ehlers, A., Bo € llinghaus, I., & Rief, W. (2007). Overgeneral memory and Scho suppression of trauma memories in post-traumatic stress disorder. Memory, 15(3), 339e352. http://dx.doi.org/10.1080/09658210701256571. Schuitevoerder, S., Rosen, J. W., Twamley, E. W., Ayers, C. R., Sones, H., Lohr, J. B., et al. (2013). A meta-analysis of cognitive functioning in older adults with PTSD. Journal of Anxiety Disorders, 27(6), 550e558. http://dx.doi.org/10.1016/ j.janxdis.2013.01.001. Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim, P., Janavs, J., Weiller, E., et al. (1998). The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59(S20), 22e33. Wessel, I., Merckelbach, H., & Dekkers, T. (2002). Autobiographical memory specificity, intrusive memory, and general memory skills in Dutch-Indonesian survivors of the World War II era. Journal of Traumatic Stress, 15(3), 227e234. http://dx.doi.org/10.1023/A:1015207428675. Williams, J. M. G., Barnhofer, T., Crane, C., Herman, D., Raes, F., Watkins, E., et al. (2007). Autobiographical memory specificity and emotional disorder. Psychological Bulletin, 133(1), 122e148. http://dx.doi.org/10.1037/0033-2909.133.1.122. Williams, J. M., & Broadbent, K. (1986). Autobiographical memory in suicide attempters. Journal of Abnormal Psychology, 95(2), 144e149. http://dx.doi.org/ 10.1037/0021-843X.95.2.144. Wittchen, H.-U., Wunderlich, U., Gruschwitz, S., & Zaudig, M. (1997). Strukturiertes €rungen [Structured clinical klinisches interview für DSM-IV. Achse I: Psychische Sto interview for the DSM-IV. Axis I: Psychiatric disorders]. Goettingen: Hogrefe. Wittekind, C. E., Jelinek, L., Kellner, M., Moritz, S., & Muhtz, C. (2010). Intergenerational transmission of biased information processing in posttraumatic stress disorder (PTSD) following displacement after World War II. Journal of Anxiety Disorders, 24(8), 953e957. http://dx.doi.org/10.1016/j.janxdis.2010.06.023. Wittekind, C. E., Muhtz, C., Moritz, S., & Jelinek, L. (2016). Performance in a blocked versus randomized emotional Stroop task in an aged, early traumatized group with and without posttraumatic stress symptoms. Journal of Behavior Therapy and Experimental Psychiatry, 54(3), 35e43. http://dx.doi.org/10.1016/ j.jbtep.2016.06.003.