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PSYM214, Student Number570020329, Word Count 3844.

that is able to reorganise and change its original


structure and functionality in response to damage

POSTNOTE
April

Post-traumatic Stress Disorder, Neuroimaging,


and Criminal Behavior
Overview
Background
Post-traumatic stress disorder (PTSD) is
an anxiety disorder induced by the
experience ofcing traumatic events. It has
a lifetime prevalence of 6.8%.1. Common
causes include personal assault,
prolonged abuse, the witnessing of
violent deaths, and military combat.
Symptoms include nightmares,
flashbacks, startle responses, difficulty
concentrating, guilt, and feelings of
isolation.2.
PTSD and Crime
The PTSD literature reveals suggests a
link between traumatic experiences and
criminal behavior.3. Crime rates average
around 8% in PTSD samples, compared
withto 2% in the general population.4.
Further, the frequency number and severity
of PTSD symptoms are positively
correlated with the likelihood of arrest or
incarceration.5.
This association appears to occurs
regardless of stressor the type of stressor.
Early traumas in during childhood often
lead to PTSD, and increasinge the
likelihood of antisocial behavior and
arrest later in life.6,7. Whilst R rates of
violent crime following dismissal from the
military are 30% higher amongst PTSD
veterans than non-PTSD veterans.79.
PTSD and Sentencing
Given this association, diagnoses of
PTSD have been presentedused in courts
as both a defence and an argument for
reduced sentencing. It has been received

PTSD is an anxiety disorder caused by


traumatic events, and is associated with
criminal behavior.
The use of PTSD as a defense in court is
controversial due to low diagnostic
consensus amongst experts.
It has been proposed that neuroimaging
may be used as a diagnostic tool to
improve the reliability of PTSD
defences, and address court bias
regarding stressor type.
Although neuroimaging studies have
shown neural differences between PTSD
and control groups, they have yet to
identify reliable biomarkers or
demonstrate clear links between
specific activity and criminal behavior.
Limitations and implications of the
research are discussed, and
recommendations for future research
with mixed support in the judicial system
and its use is considered controversial.810.
A review of the legal literature reveals
several deficienciesissues with its use.
First, changes to diagnostic criteria may
render previously accepted legal
precendentprecedents for PTSD defences
inadmissible. Second, compared withto
other mental health conditions, PTSD has
relatively low inter-rater reliability among
psychiatric experts.912. Hamner attributes
this to the subjective nature of a
diagnosis based on self-reporting.s1013 and
that, Ttogether, he claims, these problems
undermine the objectivity of PTSD
defences.
Third, courts are more likely to accept a
defence of PTSD when the defendant is a
military veteran, as contrasted with other
populations at risk of psychological
trauma.114. Grey argues that this greater

leniency for military PTSD defences


reflects a bias towards for trauma caused
by socially approved stressors. Military
personnel are considered deserving
victims whilst individuals traumatized by
imprisonment or participation in gang
violence, for example, do not receive
similar considerations.
Both Hamner and Grey propose that
neuroimaging techniques could be
employed to ensureable a fairer legal
process. Hamner argues that such
techniques would strengthen the
reliability of PTSD diagnoses by making
them more objective, whilst Grey states
that demonstrating the influence of
trauma on criminal behavior, regardless of
the nature of the stressor, would address
court bias.

The neuroimaging literature implicates


three areas of the brain involved in PTSD;
the amygdala, the hippocampus, and the
medial prefrontal cortex (mPFC). This
section provides a brief review of the
research on each of these areas in turn
and explores their association with
criminal behaviour.

pairing the presentation of a blue square


with the administration of an electric
shock. Following this conditioning phase,
participants were repeatedly shown the
square in isolationon its own as part of
anthe extinction phase. Positron emission
tomography (PET) scans showed that the
PTSD sample demonstrated had higher
amygdala activity when presented with
the square on its ownin isolation several
days after the fear conditioning. This
indicates towards a reduced extinction
capacityability for individuals with PTSD, a
known risk factor for criminal behavior.18
(Gao, 2010).
Kouyri-Malhame and colleagues
exploreded the correlation ofbetween
threat-related amygdala activity withand
attention bias in PTSD samples.19.
Participants completed two tasks:an
emotional face matching, task and an
detection of target detection, simultaneously
task whilst undergoing fMRI. Amygdala
activity was higher in the PTSD group and
was positively correlated with distraction
from the detection task when presented
with negative emotional faces. These
results suggest imply an attentional
orientation to threat in PTSD individuals - ,
which is a significant predictor of criminal
behavior.201,22.

The amygdala

The medial prefrontal cortex

The amygdala is implicated in the


detection of, and response to, threats, as
well as the formation of emotional,
particularly fear-related, memories.127.
Given the association ofbetween PTSD
withand heightened rates of fear
conditioning and vigilance, it has been
hypothesized that individuals with the
disorder experience hyperactivation in the
amygdala. Indeed, recent neuroimaging
studies have supported this. Several studies
have found higher amygdala activity in
PTSD groups compared withto non-PTSD
groups in response to traumatic13 (Shin,
2004), emotional14 (Rauch, 2000), and
neutral stimuli15 (Semple, 2000), and also
when at rest.16 (Chung).
A study by Bremner and colleagues
explored the process of fear conditioning
in a PTSD sample.17. A fear association
was conditioned in the participants by

The mPFC is implicated in the process


of extinction21 (Milad & Quirk, 2002) and
the regulation of amygdala fear
responses224. Individuals with PTSD
exhibit diminished extinction ability and
prolonged fear associations,
suggestingimplying a disruption of the
mPFC. ManyMany studies provide
evidence for lower mPFC activity in
individuals with PTSD in response to
traumatic23 (Shin, 1997), emotional24 (Shin,
2005), and neutral (Semple15, 2000) stimuli
and during the recollection of traumatic
events.25 (Bonne et al, 2001).
A study by Britton and colleagues
exposed combat veterans to script-driven
traumatic imagery.26 PET scans revealed
that mPFC deactivation in response to
these images was greater in the PTSD
group than the non-PTSD control group. It
was also found that greater mPFC

PTSD and Neuroimaging

deactivation was correlated with greater


severity of PTSD symptoms. This
couldmay partially explain the link between
PTSD and crime as , as low mPFC activity
is associated with impulsive and
aggressive behaviour (Raine, 1998).27
Inversed correlation between activity in
the amygdala and the mPFC in individuals
with PTSD was demonstrated in another
PETA study withof Vietnam veterans
demonstrated an inversed correlation
between activity in the amygdala and the
mPFC in individuals with PTSD25, gesturing
toindicating a failure of higher level neural
processes in the suppression ofng
amygdalal activity.1326. It is suggested that
this suppression leads to a threat-oriented
bias in the interpretation of ambiguous
stimuli, which in turn provokingcauses PTSD
hyperarousal and distress among
iindividuals with PTSD in response to to
respond with hyperarousal and distress to
stimuli that would otherwise be considered
unthreatening1927.
It should be noted that there are several
studies which do not indicate PTSDspecific hypoactivation in the mPFC.
Using single-photon emission computed
tomography (SPECT), Liberzon found
similar mPFC activation in PTSD and nonPTSD veterans, as well as non-combat
controls.28. Results may depend on which
area in this region is scanned, as most of
the studies showing hypoactivation focus
on the ventral areas of the mPFC. Studies
focusing on the dorsal mPFC show typical
or increased activation in response to
emotional stimuli (Milad.29, 2009).

The hippocampus
The hippocampus is part of the limbic
system and is associated with the
formation and contextualizing of
memories. Neurological findings for this
region have been mixed. The majority of
PTSD studies demonstrate suppressed
hippocampal activity during stressful
periods and following exposure to
emotional stimuli (Bremner, et al., 1999).30
However, several studies indicate
increased hippocampal activity when
encoding and recollecting traumatic
stimuli (Werner et al., 2009).31 Therefore,
the direction of hippocampal activity may

depend on the type of task ands well as the


method used.32 (Shin & Handwerger, 2009).
Hayes and colleagues aimed to examined
hippocampal activity during trauma
encoding amongin combat veterans.33
PTSD and non-PTSD groups were
exposed to trauma-related and neutral
stimuli. Participants returned a week later
for a memory recognition test whilst
undergoing fMRI. Individuals with PTSD
had lower hippocampus activity and
reported higher rates of false recognition
(believing to have already seen novel
stimuli) for traumatic but not neutral
stimuli. This . iIndicatesing poorer memory
encoding for PTSD individuals when
stressed.
Another common finding with PTSD is
reduced hippocampal volume (Karl, et al.
2006).34 An MRI study demonstrated a 12%
reduction in hippocampal size in
individuals with PTSD compared to
controls3029, with that a greater reduction
of 20% for combat veterans
experiencingwith PTSD.258. This is believed
suggested to be caused by prolonged
exposure to heightened levels of
cortisol.350.
Given the importance of the
hippocampus for distinguishing between
past and present memories, its reduced
activity and volume in individuals with
PTSD may explain the occurrence of
traumatic flashbacks, usually of the trauma,
which often resulting in violent behavior361.
It is hypothesized that when individuals
with PTSD are presented with traumarelated stimuli, they often believe the
event is happening again, having been
unable to consolidate the initial memory
in their past17.

Limitations
A review of the literature reveals that the
atypical neural activity observed in PTSD
samples may be associated with
behaviours and mental states thatwhich
increase the likelihood of criminal
behaviour. However, there are several
limitations to these studies thatwhich
should first be considered.
First, neuroimaging research only
demonstrates correlational patterns, they
do not provide evidence for causal

relationships between neural activity and


criminal behaviour. The observed atypical
activity may be a necessary but not a
sufficient condition or causal factor for
aggressive behavior. For example,
Grantedgiven that it is rare to have
baseline measures of an individuals
neuroanatomy prior to trauma, for
example, it is not known if reduced
hippocampal volume is a result of PTSD
or a risk factor for its development.37 (van
Rooij et al, 2014).
Second, there are significant gaps in the
neuroimaging literature when it
comesconcerning to PTSD and crime.33
(Ardino). Although Grey argues that a
better understanding of PTSD through via
neuroimaging may give more legitimacy
to defence claims of PTSD in court, her
review is deficientlacking in specific linkings
between the disorder and criminal
behaviourx.11 In fact, no studies were
found which sought to examine the link
between PTSD and crime using
neuroimaging. Whilst studies have
observed atypical neural activity in PTSD
samples, and others have found
correlations between similar activity and
crime-related behavior, neuroimaging
research has not yet studied PTSD
samples specifically in relation to crime.
It is important to remember that violent
behavior is not in and of itself an symptom
peculiar toof PTSD. In fact, whilst violent
and criminal behaviours are more
prevelant in PTSD samples, most
individuals with PTSD do not have a
criminal record or a history of violent
behavior. As such, diagnoses of PTSD
alone are insufficient in explaining
criminal behavior and are rarely influential
as defences without a link between
specific symptoms and behaviours being
demonstrated (Hamner).10
Third, there are many factors which may
account for the association between PTSD
and crime for which neuroimaging
research does not account for. Factors
such as comorbidity with other
disorders38, combat addiction, substance
use, anger problems39, and the desire to
reenact trauma40 may also be implicated.. A
model proposed by Ardino to explain the
association between PTSD and crime,
describes the symptoms of PTSD leading
to both neurobiological and cognitive

deficits, both of which disrupt selfregulation.34. What Hamner may refer to as


the weakness of subjectivity10 is in fact
necessary to understand the full breadth
of PTSD. Arguably, neuroimaging is also
subject to subjectivity given that there
are many inferential steps taken between
the brain and raw data, and the data and
the published image .41(Roskies, 2004) and
Nneuroimaging data may, then, be
misinterpreted.42 (Ackerman, 2004).
Fourth, neuroimaging research has yet
to identify a reliable biomarker for PTSD.
Whilst many studies demonstrate neural
differences between PTSD and control
populations, others do not.43 (Liberzon
and Garfinkel, 2009) and Oof those that do,
most report some degree of overlap
amongbetween the scores of both groups.
Shin and Handwerger attributes this to the
inherent variability ofin neuroimaging
methodology, due to the comparatively
low temporal and spatial resolution of
techniques such as PET.32 This may also
result from Hughes and Shin (2011) argue
that this may be due to reduced activation
following continued response to the same
stimuli in a prolongedlengthy experiment.
When these readings are averaged out
over several minutes the chances of
detecting a signal are reduced.44
Fifth, many of the neural findings of
PTSD are also implicated in other
conditions such asincluding generalised
anxiety disorder and phobias (Etkin &
Wager). If neuroimaging were to be
considered as a diagnostic tool for PTSD,
other conditions would also need to have
been thoroughly researched in orderso as
to distinguish eachthem from theeach
other. However,Still, many mental health
conditions are still remain
underrepresented in the neuroimaging
literature.45 (Etkin & Wager, 2007).
Sixth, the association between PTSD
and criminal behavior has primarily been
researched with veteran samples35.11 This
may limit the generalizability of results to
other populations. For example,
individuals with combat experience have
higher levels of PTSD-related hostility
than those who developed the disorder
from other stressors.4637 . This
overrepresentation of military groups in
the literature may also contribute to the

pro-military bias in accepting PTSD


claims, as noted by Greyyx . notes.11
Seventh, whilst most studies consider
the impact of PTSD on victims of trauma,
comparatively little research has been
conducted on the psychological
consequences of killing or inflicting
trauma on others-, what McNair refers to
as Perpetration-Induced Traumatic Stress
(PITS).470. Slaughterhouse workers, for
example, are at greater risk of developing
PTSD than other worker populations485,
and the higher crime rates in areas
surrounding slaughterhouses (, what
Fitzgerald refers to as the Sinclair
effeceffect)t, implies a potential relationship
between the trauma of slaughterhouse
work and criminal behaviour.496. Despite
the difference in symptom type and
severity for PITS compared to standard
PTSD471, the neural differences between
PTSD and PITS and theirhow they may
relatione to criminal behavior are poorly
understood.
Implications & Recommendations

Although it does not seem that


neuroimaging techniques, as they
stand, do not appear sufficientlyare
accurate enough to serve as the
objective diagnostic tool that
Hamner proposed, they may be
useful if when used used as one
component amongst many in a
legal defense, provideding their
limitations are acknowledged.
Similarly, introducing
neuroimaging evidence of PTSD
may address court bias given that
it does not discriminate against
particular stressors. , Hhowever,
the overrepresentation of combat
veterans in the PTSD literature
should be rememberedconsidered.
Whilst neuroimaging studies are
only correlational, by identifying
critical brain areas, they may
provide the groundwork for further
studies to examine causal
relationships. For example, Rrecent
research indicates that lesion
studies50 (Koenigs et al., 2008) and
transcranial magnetic stimulation51
(Bolu et al, 2015) hold promise for

understanding the causal


relationship between PTSD andon
crime.
Future neuroimaging research may
wish to bridge the gap between
studies of PTSD and crime, and
neurological studies of criminal
behavior.
Being As aa multi-disciplinary topic,
it is important that experts across
the relevant fields relevant to PTSD
diagnoses and defences, such as
neuroscience, sociology, and law,
collaborate on future research.
Given the similarity in neural activity
between PTSD and other anxiety
disorders, accurately distinguishing
one condition from the rest will require
continued research.Given their
overlapping neural activity, continued
research of other mental health
conditions would facilitate the
distinguishing of PTSD from them.
Future research should be more
inclusive of non-military
populations as well as groups at
risk of developing PITS. Research
ought to explore whether
individuals with PITS have are
greater likelihood ofpredisposed to a
greater or lesser extent to committing
crime than those with PTSD.

Conclusion
This note has provided a brief overview of
the neuroimaging PTSD literature, discussing
the association between the amygdala,
hippocampus and mPFC and PTSD, and
their role in criminal behaviour.
Limitations of the literature have been
highlighted, including the
overrepresentation of military personnel
in study samples. Further,
recommendations for future research
have been proposed, including the study of
the neural activity of other anxiety disorders
to facilitate the distinguishing of PTSD.
Although it appears that neuroimaging
technology is not yet accurate enough to
diagnose PTSD; through it, our
understanding of the association between
PTSD and crime may improve and its use
in litigation is likely to expand.

Supplementary Notes

Definitions

Biomarker: a measurable indicator of some biological state or condition. 52


Extinction: when a conditioned response is reduced or lost. 53
Inter-rater reliability: the degree of agreement among ratings. 54
Stressor: an external stimulus or an event that causes stress. 55

Diagnostic Criteria
PTSD: (taken from the DSM 52)

History of exposure to a traumatic event.


Intrusion symptoms
Avoidance symptoms

Negative changes in cognition and mood.


Changes in arousal and reactivity.
Symptoms last for longer than one month.
Significant symptom-related distress or functional impairment (e.g., social, occupational).
Disturbance is not due to medication, substance use, or other illness.

Neuroimaging techniques

Electroencephalography (EEG) measures voltage fluctuations resulting from ionic current


within the neurons of the brain.56
Functional Magnetic Resonant Imaging (fMRI) measures brain activity by detecting changes
associated with blood flow.57
Magnetoencephalography (MEG) maps brain activity by recording the magnetic fields
resulting from electric currents which occur in the brain.58
Positron Emission Tomography (PET) detects pairs of gamma rays emitted indirectly by a
positron-emitting radionuclide (tracer), which is introduced into the body.59

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