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Implicit and Explicit Memory for

Trauma-Related Information in
PTSD"
RICHARD J. McNALLY
Department of Psychology
Harvard University
Cambridge, Massachusetts 02138

The phenomenology of posttraumatic stress disorder (PTSD) strongly suggests that


memory abnormalities underlie many symptoms. Persons with PTSD report involuntary retrieval of homfic autobiographical memories as expressed in intrusive thoughts,
nightmares, and flashbacks. They may also experience memory deficits for either
certain aspects of traumatic events themselves or information unrelated to trauma.
Despite the prominence of self-reported memory problems in PTSD, only recently
have researchers applied the experimental paradigms of neuropsychology and cognitive psychology to elucidate these phenomena in the laboratory.'.* One potentially
useful way of organizing memory data is to distinguish between content-independent
and content-dependent abnormalities.' Content-independent abnormalities denote dysfunctions that occur irrespective of the meaning of the information processed. Studies
on short-term memory deficits: for example, exemplify this line of research. Work
in this area is in the tradition of neuropsychology.
Content-dependent abnormalities denote disturbances that arise only when individuals process information that has personal emotional significance. Studies on anxiety
disorders, including PTSD, have uncovered memory biases that are operative only
when patients process threatening or trauma-relevant input.) Work in this area is in
the tradition of cognitive experimental psychology and exemplifies the growing hybrid
domain of cognition-emotion research.
This article reviews the research on content-dependent memory abnormalities in
PTSD. Studies on explicit and implicit memory biases for trauma cues are covered.
Explicit memory is expressed on tests that require conscious recollection of previous
experiences (e.g., free recall). Implicit memory is revealed when these experiences
affect performance on a test that does not require conscious recollection (e.g., perceptual identification).

MEMORY BIASES FOR TRAUMA-RELATED INFORMATION


Intrusive symptoms imply that information about trauma is primed and readily
accessible in PTSD. If enhanced accessibility underlies these symptoms, persons with
aPreparation of this chapter was supported in part by National Institute of Mental Health grant
51927 awarded to the author.
Address for correspondence: Department of Psychology, Harvard University, 33 Kirkland Street,
Cambridge, MA 02138 (tel: (617) 495-3853; fax: (617) 495-3728; e-mail: qm@wjh.harvard.edu).

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ANNALS NEW YORK ACADEMY OF SCIENCES

PTSD should exhibit an explicit memory bias for material related to trauma under
controlled laboratory conditions. That is, they ought to show superior recollection
of words related to trauma in comparison with other words and in comparison with
trauma-exposed persons without the disorder. Consistent with this hypothesis, Vrana
et aL5reported that Vietnam combat veterans with PTSD recalled more words related
to trauma than did Vietnam combat veterans without PTSD. Litz et al.,on the other
hand, did not find enhanced recognition memory for trauma words in veterans with
combat-related PTSD relative to healthy combat veterans. This null effect may be
partly attributable to their use of a recognition rather than a recall test; the former
is seldom affected by emotional variables such as word valence or diagnostic status.)
PTSD patients describe intrusive symptoms as occumng outside their conscious
control. Such phenomenologic reports imply that mechanisms underlying the activation of these symptoms may be automatic. Accordingly, researchers have used implicit
memory tests to investigate whether PTSD is associated with automatic biases favoring
the processing of trauma-related information. In a study of Vietnam combat veterans
with and without PTSD, McNally and Amir used a perceptual identification procedure
to test for an implicit memory bias favoring trauma cues. Participants first saw a
series of trauma words, positive words, and neutral words on a computer screen. On
a subsequent perceptual identification test, they again saw these (old) words
intermixed with (new) distractor words of the same type. Each word flashed on
the screen for only 100 ms and was replaced by a visual pattern mask comprising
different characters (e.g., #%$*& #) that made it difficult to perceive the word.
Subjects attempted to identify these briefly presented words. The results revealed
that both groups accurately identified old words more often than new words, thereby
demonstrating implicit memory for the former. However, there was no evidence for
enhanced perceptual identification of trauma words in the PTSD group. Because
performance on perceptual identification tasks is influenced more by the physical
shape of words than by their meaning, it is perhaps not surprising that PTSD patients
did not exhibit an implicit memory bias for trauma cues.
To investigate implicit memory for conceptually richer materials than single
words, Amir et aL8 adapted the white noise paradigm of Jacoby et aL9 In this
experiment, Vietnam combat veterans with and without PTSD heard a series of
prerecorded trauma sentences (e.g., The chopper landed in hot LZ.) and neutral
sentences (e.g., The shiny apple sat on the table.). They later heard these old
sentences intermixed with new trauma and neutral sentences, each accompanied by
white noise of either low, medium, or high volume.
Participants were asked to judge the volume of the noise that accompanied each
sentence. Implicit memory for old sentences is revealed when individuals rate the noise
accompanying these sentences as less loud than that accompanying new sentences, and
an implicit memory bias for material related to trauma is demonstrated when the
difference between volume ratings for new minus old sentences is greater for trauma
sentences than for neutral sentences. That is, previous exposure to a sentence renders
it easier to hear when it subsequently recurs against a background of white noise;
consequently, white noise of a certain volume does not seem as loud when it accompanies a familiar sentence than an unfamiliar one. Therefore, ratings of perceived
volume serve as indices of previous exposure (i.e., memory) for the sentences they
accompany. The results indicated that PTSD patients exhibited enhanced implicit

McNALLY: IMPLICIT AND EXPLICIT MEMORY

221

memory for trauma sentences than for neutral sentences, whereas healthy combat
veterans exhibited the opposite pattern. Although findings were similar across the
three noise levels, the effect was statistically significant only at the loudest volume.
In summary, some data suggest that explicit memory for trauma-related material
is enhanced in persons with PTSD relative to trauma-exposed persons without the
disorder. There is provisional evidence of enhanced implicit memory for conceptually
complex input related to trauma in PTSD as well.

DIRECTED FORGETTING AND CHILDHOOD SEXUAL ABUSE


Some experts believe that children traumatized by sexual abuse develop a dissociative encoding style that enables them to disengage attention from temfying stimuli
during abuse episodes and to redirect it elsewhere.lO,llPresumably, attending to
innocuous cues (e.g., wallpaper patterns) blunts an otherwise overwhelmingly frightening experience.I2
McNally et ~ 1 . used
l ~
a directed forgetting paradigm to test for a possible dissociative encoding style in women with histories of childhood sexual abuse with and
without PTSD. Participants viewed a series of trauma words (e.g., abused), positive
words (e.g., celebrate), and neutral words (e.g., mailbox) that appeared one at a time
on a computer screen. Each word was immediately followed by an instruction either
to remember or to forget the word. Participants later received free recall, cued recall,
and recognition tests for all words irrespective of original instructions. Cognitive
psychologists have shown that most individuals exhibit a directed forgetting effect
whereby they recall words that they were instructed to remember better than words
they were instructed to forget.I4Moreover, superior recall for remember-words relative
to forget-words is attributable to better initial encoding of remember-words rather than
to inhibition (repression) of forget-words. Therefore, if psychiatrically impaired
survivors of childhood sexual abuse are especially adept at disengaging attention
from trauma cues, they ought to show memory deficits for trauma-remember words
relative to positive-remember and neutral-remember words.
The results were wholly inconsistent with this dissociative encoding hypothesis.
Impaired survivors did, indeed, exhibit memory deficits, but only for positive-remember and neutral-remember words, not for trauma-remember words. Furthennore, they
tended to remember trauma words they were supposed to forget. Healthy survivors
exhibited typical directed forgetting effects: they recalled remember-words better
than forget-words regardless of word valence. There was no difference in memory
performance between those who reported having recovered memories of trauma and
those who had always remembered their abuse.
Taken together, these data suggest that people with PTSD readily encode and
therefore recall trauma-related material and that persistent rumination about trauma
may disrupt encoding for nontraumatic material. To the extent that intrusive thoughts
impair concentration, it should be difficult for survivors with PTSD to encode and
recall the nontrauma words they are supposed to remember. Although these findings
are clearly inconsistent with the dissociative encoding hypothesis, they do not establish
that impaired survivors did not dissociate during abuse episodes in childhood.

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ANNALS NEW YORK ACADEMY OF SCIENCES

AUTOBIOGRAPHICAL MEMORY DISTURBANCE


While investigating mood and memory in depressed and suicidal patients, Williams and his c~lleaguesl~~~
discovered that these individuals had great difficulty
accessing specific personal memories in response to cue words. Unlike nondepressed
individuals, these patients tended to retrieve overgeneral memories, especially in
response to positive cues. Thus, in response to words such as happy, healthy control
participants easily remembered specific events (e.g., the day we left to go on
holiday), but depressed participants usually retrieved a categoric memory that did
not refer to any specific episode despite instructions to retrieve a specific memory
(e.g., when I play squash).Is
Difficulties in retrieving specific personal memories strongly predicts failure to
recover from major depre~sion.~
This memory abnormality is also associated with
poor problem-solving skills.18Most probably, difficulty remembering specific details
regarding how one attempted to deal with problems in the past hampers ones ability
to learn from experience.
Several experiments have uncovered a link between overgeneral memory and a
history of trauma in general and PTSD in particular.2@22
In the f i s t experiment,
Vietnam combat veterans with PTSD, relative to healthy combat veterans, exhibited
difficulties recalling specific personal memories in response to cue words having
either neutral (e.g., appearance), positive (e.g., kindness), or negative (e.g., panic)
emotional meaning. Although they had been trained to retrieve specific episodes
in response to cue words, PTSD subjects reverted to an overgeneral mode of retrieval
as the experiment progressed. PTSD patients who had been exposed to reminders of
trauma (i.e., a combat audio-videotape) had more difficulty accessing specific memories than did those who had been exposed to an emotionally neutral videotape. This
suggests that reminder-induced preoccupation with traumatic events may consume
attentional resources to such an extent that PTSD patients have little remaining
capacity to search memory effortfully in tasks requiring accessing of specific autobiographical episodes.
In the second experiment,*I Vietnam combat veterans with and without PTSD
attempted to retrieve specific autobiographical memories exemplifying traits denoted
by negative (e.g., guilty) and positive (e.g., loyal) cue words. Healthy veterans had
little problem accessing specific memories, especially in response to positive cues.
In contrast, those with PTSD had difficulty accessing specific memories to both kinds
of cues. These overgeneral memory problems were far more marked in PTSD
subjects who arrived at the laboratory wearing Vietnam War regalia (e.g., POW/
MIA buttons, fatigues, and a loaded gun) than in those who did not. Healthy combat
veterans never wore regalia. Regalia-wearing PTSD participants disproportionately
retrieved memories from the war, unlike other subjects who overwhelmingly recalled
specific memories from the last few weeks. The striking self-presentational style of
wearing ones military regalia in everyday life is not only emblematic of psychological
fixation to a war fought more than two decades ago, but also a marker for autobiographical memory disturbance. The overgeneral memory problems evident in PTSD patients
who are still in Vietnam may underlie their difficulties envisioning the future, as
reflected in the symptom of future foreshortening. Difficulty remembering the
past may render it difficult to envision the future.

McNALLY: IMPLICIT AND EXPLICIT MEMORY

223

Kuyken and BrewinZ2reported further evidence linking autobiographical memory


dysfunction to a history of trauma. They found that depressed women who had
been sexually abused as children exhibited difficulties retrieving specific personal
memories in response to cue words, whereas depressed women who had not been
abused did not. These researchers, however, did not assess for PTSD.
Difficulties in retrieving specific autobiographical memories converge with findings showing diminished hippocampal volume in PTSD.23Individuals with compromised anatomical structures that support autobiographical memory may have especial
difficulty retrieving details of their past.

SUMMARY
Experiments on content-dependent memory abnormalities in PTSD suggest several conclusions. First, PTSD patients exhibit enhanced recall of words related to
trauma relative to trauma-exposed persons with the disorder. Recognition tests, however, appear insensitive to these effects.
Second, PTSD patients do not exhibit implicit memory biases for trauma cues on
implicit memory tasks that are strongly influenced by perceptual (e.g., orthographic)
aspects of input. They may, however, exhibit enhanced implicit memory for traumarelated material on conceptually more complex tasks.
Third, directed forgetting research suggests that adult survivors of childhood
sexual abuse who have PTSD exhibit memory deficits only for neutral and positive
material, not for material related to their abuse. Psychiatrically healthy survivors
exhibit normal memory performance in this paradigm.
Fourth, autobiographical memory research indicates that trauma survivors, especially those with PTSD, are characterized by difficulties retrieving specific memories
from their past in response to cue words. These findings are especially dramatic in
Vietnam combat veterans whose self-presentational style suggests a fixation to the
war and a failure of their autobiography to unfold.
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