Biological Psychology 127 (2017) 108–122

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Biological Psychology
journal homepage: www.elsevier.com/locate/biopsycho

Information Processing of the Rorschach's Traumatic Content Index in MARK

Trauma-exposed Adults: An Event Related Potential (ERP) Study
⁎
Gil Zukermana, , Esther Ben - Itzchaka,1, Leah Fosticka,2, Rinat Armony-Sivanb,3
a
Department of Communication Disorders, School of Health Sciences, Ariel University, Ariel, Israel
b
Department of Psychology, Ashkelon Academic College, Ashkelon, Israel

A R T I C L E I N F O A B S T R A C T

Keywords: PTSD elicits hypervigilance to trauma-related stimuli. Our novel research examined event-related potentials
Post traumatic stress disorder from Blood, Anatomy, and Morbid content derived from the Rorschach's traumatic content index (TCI).
Event related potentials Participants included: 16 with PTSD, 24 trauma-exposed without PTSD (non-PTSD), and 16 non-traumatized
P3 Controls. P3 oddball paradigms were used with TCI-derived Distractors and neutral Targets/Standards. We
Oddball distractor paradigm
predicted larger P3 amplitudes in the context of TCI-related Distractors among trauma-exposed participants.
Rorschach inkblot test
Significant interaction of Group and Distractor type was found for P3 amplitude. PTSD and non-PTSD groups
Traumatic content index
exhibited larger P3 amplitudes from Blood and Anatomy Distractors, and attenuated amplitudes from Morbid;
the reverse pattern was found among Controls. A late negative component was observed, denoting a significantly
larger area under the curve (AUC) among the PTSD group for Anatomy and Blood Distractors. Larger AUC's were
observed for Distractors among the PTSD group, and Targets among Controls. The findings concur with the
neurocircuitry model of PTSD and suggest impairment in cerebral suppression of attention to stimuli that may
have been perceptually primed with trauma.

1. Introduction
An exposure to a life-threatening event is sometimes followed by an
elevation of psychological distress due to the development of such
symptoms as intrusive memories, hyper-arousal, and avoidance of
trauma-related stimuli. These post-traumatic stress (PTS) symptoms
are usually followed by a feeling of constant threat to the individual's
well-being (Ehlers & Clark, 2000) and the perception of the environ-
ment as unstable and dangerous (Janoff-Bulman, 1989). In some cases,
severe PTS symptom prevalence beyond one month may lead to the
clinical diagnosis of a post-traumatic stress disorder (PTSD) (DSM-5,
American Psychiatric Association, 2013).
1.1. ERP studies in PTSD
Event-related potential (ERP) studies have been used to compare
information-processing patterns of individuals diagnosed with PTSD to
healthy controls (Felmingham, Bryant, Kendall, & Gordon, 2002;
Galletly, Clarc, McFarlane, & Weber, 2001; McFarlane, Weber, & Clark,
1993). Among several ERP components, the P3, a centro-parietal
positive component occurring around 300 ms after stimulus onset, has
been widely used to examine trauma-related changes in attention (for
review, see Javanbakht, Liberzon, Amirsadri, Gjini, & Boutros, 2011;
Johnson, Allana, Medlin, Harris, & Karl, 2013). The P3 is commonly
elicited by a three-stimuli oddball paradigm, in which the participants
are requested to respond to a low frequency target stimulus presented
amongst high frequency, repetitive standard stimuli and low frequency
salient distractors they must ignore; the stimuli are referred to as
Target, Standard, and Distractor stimuli. It has been previously reported
that when individuals with PTSD are presented with an oddball
paradigm that includes trauma-related Distractors, the P3 amplitude
in response to Targets and Distractors (also known as P3b and P3a,
respectively) is enhanced, while in the context of neutral (not trauma-
related) Distractors, the response to either Target and Distractor stimuli
is reduced (Karl, Malta, & Maercker, 2006; Javanbakht et al., 2011;
Johnson et al., 2013). PTS symptom severity has also been associated
with P3 amplitudes (Lobo et al., 2015). These findings suggest that,
compared to healthy controls, individuals diagnosed with PTSD exhibit
attentional alterations: allocating more attention to stimuli perceived to
be threatening or trauma-related, while reducing attention to neutral

⁎
Corresponding author. Tel./Fax: +972 39765755; Mobile: +972 547702468.
E-mail addresses: gilzu@ariel.ac.il (G. Zukerman), benitze@ariel.ac.il (E.B.-. Itzchak), leah.fostick@ariel.ac.il (L. Fostick), rinatsivan@gmail.com (R. Armony-Sivan).
1
Tel./Fax: +972 39765755.
2
Tel./Fax: +972 39765755.
3
Tel./Fax: +972 86789273.

http://dx.doi.org/10.1016/j.biopsycho.2017.05.002
Received 10 July 2016; Received in revised form 1 April 2017; Accepted 1 May 2017
Available online 10 May 2017
0301-0511/ © 2017 Elsevier B.V. All rights reserved.
G. Zukerman et al.
stimuli (Johnson et al., 2013; Karl et al., 2006). This pattern of cerebral
response was conceptualized at the cognitive level by the “resource
allocation” model of PTSD (Ehlers & Clark, 2000). According to this
model, trauma facilitates the development of a “fear network”, leading
to an attentional bias to trauma-related stimuli at the expense of neutral
stimuli. These assertions also align with the “neurocircuitry” model of
PTSD that associates PTSD-related information processing changes and
interaction patterns of cerebral structures (Rauch, Shin, Whalen,-
& Pitman, 1998). According to this neurocognitive model, PTSD
involves impaired prefrontal cortex (PFC) top-down regulation of
hyper-responsivity within the amygdala, along with alterations in
hippocampal activity that lead to deficits in contextual conditioning
(Rauch, Shin, & Phelps, 2006). PFC deficit, particularly in the ventral/
medial PFC, which is thought to impair suppression of attention to
trauma-related stimuli, might be expressed by larger P3 amplitudes to
trauma-related stimuli. Both models are supported by the clinical
manifestation of PTSD that includes hypervigilance to trauma-related
stimuli, exaggerated startle response and concentration difficulties
(DSM-5, APA, 2013). Additionally, although most studies have reported
on significant P3 differences between participants diagnosed with PTSD
and either non-PTSD traumatized participants or Control subjects with
no previous traumatic history (Johnson et al., 2013), recent research
findings suggest that P3 alterations might be found among individuals
with previous traumatic exposure even without meeting clinical criteria
for PTSD diagnosis (Kimble, Fleming, Bandy, & Zambetti, 2010).
Most conceptualizations of PTSD characterize the condition as
hyper-responsivity to incoming stimuli that has been coupled with
traumatic experience. However, the nature of these associations and the
mechanism by which some inputs become “trauma-related stimuli” is
still not clear. Previous research findings suggest that those with PTSD
exhibit elevated cerebral responses to stimuli that are associated with
their specific traumatic experience, such as combat- or earthquake-
related stimuli, but not to trauma-irrelevant stimuli (Attias, Bliech,
Furman, & Zinger, 1996a; Attias, Bliech, & Gilat, 1996b; Stanford,
Vasterling, Mathias, Constans, & Houston, 2001; Zhang, Kong, Han,
Najam Ul Hasan, & Chen, 2014; Zhang, Kong, Hasan, Jackson, & Chen,
2015). Other authors have hypothesized that cognitive alterations
related to PTSD are not limited to increased attention to specific
trauma-associated stimuli but to a general increased expectancy of
threat, resulting in elevated sensitivity to threat-related cues
(Engelhard, de Jong, van den Hout, & van Overveld, 2009; Kimble
et al., 2010). Though some research suggests that PTSD-related
hypersensitivity to threat exists even at earlier, subliminal levels, this
attentional bias to threat was postulated to mainly occur in later, post-
recognition stages of information processing (Buckley, Blanchard,-
& Neill, 2000). The hypothesis of general sensitivity to threat is also
supported by the expression of PTSD symptoms that frequently include
a constant search for a wide variety of threats in the everyday
environment, beyond those related to the original trauma. However,
ERP studies that have used threatening stimuli not directly related to
the participants’ traumatic experiences have found reduced threat
processing, possibly due to an increased expectancy of threatening
information or, alternatively, as an adaptive response aimed at reducing
emotional arousal (Kimble, Batterink, Marks, Ross, & Fleming, 2012;
MacNamara, Post, Kennedy, Rabinak, & Phan, 2013).
Some previous research, however, suggest that those with PTSD
may possess a general sensitivity that is not limited to perceived threat.
Research findings demonstrating greater PTSD-related cerebral re-
sponses to unpleasant/negative stimuli (not considered threatening or
trauma-related) have caused some authors to suggest the existence of a
PTSD-related hypervigilant pattern of information processing; such a
pattern, they suggest, is characterized by an elevated response to
negative emotional stimuli, regardless whether or whether not it
contains threatening content (Blomhoff, Reinvang, & Malt, 1998; Lobo
et al., 2014, Saar-Ashkenazy et al., 2015). However, valence effects
were also found in ERP studies among participants with no trauma
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Biological Psychology 127 (2017) 108–122
history, and have been associated with selective attention to negative
stimuli; this has been postulated to represent a general “negativity bias”
among the general population (Olofsson, Nordin, Sequeira, & Polich,
2008). Therefore, it is not clear whether this increase in cerebral
response to negative stimuli can be attributed solely to PTSD.
A common denominator of previous hypotheses is that patients with
PTSD may be hypervigilant to the conceptual aspects of threatening
stimuli, in which association with the traumatic event is achieved via
meaning (for example, when a rape victim encounters the word
“helplessness”). An alternative approach suggests that trauma-exposed
participants may be highly responsive to the perceptual properties of
stimuli (Ehlers et al., 2002), in which an association between stimuli
and the traumatic event is made through perceptual priming (for
example, seeing headlights leads to accelerated heart rate because they
were previously encountered during a nighttime head-on collision). The
perceptual priming approach postulates that the traumatic experience
leads to data-driven processing (i.e. focusing on the perceptual and
sensory impression of an event rather than on its meaning). This results
in a strong perceptual priming of the various stimuli encountered in
temporal proximity to the traumatic experience (Christianson, 1992;
Halligan, Clark, & Ehlers, 2002; Kindt, van den Hout, Arntz, & Drost,
2008; Van der Kolk & van der Hart, 1989; Wing Lun, 2008). These
primed stimuli, when identified in the everyday environment, are then
perceived as a warning signal of impending danger and may lead to a
rapid, vivid recollection of the traumatic event, experienced as a
“flashbacks.” This approach is supported by behavioral research studies
which indicate that, in comparison to the general population, trauma-
tized individuals who develop PTSD symptoms are more likely to
associate stimuli characterized by salient perceptual properties with
trauma-related information (Halligan et al., 2002; Kindt et al., 2008;
Lin, Hofmann, Qian, & Li, 2015). Accordingly, war veterans with PTSD
have been found to demonstrate heightened physiologic arousal,
expressed by higher skin conductance and elevated heart rate, when
perceiving Rorschach Inkblots as being related to autobiographical
images of combat trauma. The authors postulated that this heightened
physiologic arousal to the Rorschach inkblots corresponds to the
development of intrusive symptoms that occur when encountering a
stimulus with perceptual similarity to those encountered at the time of
trauma (Goldfinger, Amdur, & Liberson, 1998). Since the Rorschach is
considered primarily a perception test (Blatt, 1990), this finding
suggests that perceptual properties of inkblots may trigger a condi-
tioned response mediated by altered information processing patterns.
In summary, current cognitive and neurocircuitry models suggest
that PTSD involves directing more attention to stimuli that were
previously associated with traumatic experience. This was believed by
some authors to reflect a deficit in PFC top-down regulation of hyper-
reactivity within the amygdala to trauma-related stimuli (Rauch, Shin,
et al., 1998, Rauch, Shin, & Phelps, 2006). ERP research demonstrating
larger P3 amplitudes to trauma-related stimuli among individuals with
PTSD supports this theory. While some authors have suggested that the
association between incoming stimuli and traumatic experience is
achieved via meaning (through direct association with a specific
traumatic experience) or via other conceptual properties of the stimuli
(level of threat or level of negativity), others have suggested that the
association of stimuli with the traumatic event is made through
perceptual priming.
1.2. The Rorschach inkblot test and PTSD
The Rorschach is a psychological test intended for evaluation of
perception along with cognitive function and personality characteristics
(Blatt, 1990; Exner, 2001). The Rorschach examines the individual's
perception of 10 inkblots printed on cards, and is widely used by clinical
psychologists for assessment and intervention planning (Weiner & Greene,
2007). Exner (1974) developed a comprehensive system for analyzing
responses to the Rorschach test, currently the most frequently used method
G. Zukerman et al.
for applying the Rorschach in research and clinical practice. An accumulat-
ing body of empirical evidence derived from research in recent years
suggests the Rorschach is a valid tool for the assessment of the traumatic
experience, and can provide valuable information regarding traumatic
imagery and cognitive avoidance strategies among trauma-exposed indivi-
duals (Brand, Armstrong, & Loewenstein, 2006; Brand, Armstrong,
Loewenstein, & McNary, 2009; Holaday, 2000; Katsounari & Jacobowitz,
2011; Opaas & Hartmann, 2013; Sloan, Arsenault, & Hilsenroth, 2002;
Tibon, Rothschild, Appel, & Zeligman, 2011; Viglione, Towns, & -
Lindshield, 2012).
Based on Exner's comprehensive system, the analysis of the indivi-
dual's set of responses (the individual's “protocol”) on the Rorschach
provides several indicators of mental function. Some of these indices
are specifically associated with PTSD, including those that tap into
proneness to psychopathology, hypervigilant processing style, thought
disturbances and impairment in stress tolerance (Tibon et al., 2011;
Viglione et al., 2012). Among these indices, the traumatic content index
(TCI) is a constellation of several themes more frequently reported in
Rorschach protocols of individuals diagnosed with PTSD, and are
considered related to personal traumatic history (Armstrong-
& Lowenstein, 1990). The TCI consists of the number of Rorschach
responses in which an individual identifies inkblot percepts as relating
to one of following thematic categories: 1) blood (Blood), 2) internal
organs such as liver, bones or intestines (Anatomy), 3) sexual organs or
sexual acts and behaviors (Sex), 4) objects described as torn, broken,
ruined, dead or attributed with dysphoric feeling (Morbid) and 5)
aggressive acts (Aggressive Movement). The TCI is calculated by the
sum of TCI responses divided by the total number of responses in a
Rorschach protocol (Tibon et al., 2011).
Over the past 25 years, an extensive body of research has shown that,
compared to individuals with no traumatic history, the Rorschach protocols
of participants who report diverse interpersonal and non-interpersonal
traumatic experiences are characterized by elevated frequency of the five
themes of the TCI (Armstrong & Lowenstein, 1990; Burch, 1993; Goldfinger
et al., 1998; Kamphuis, Kugeares, & Finn, 2000; Min, Lee, Kim, & Sim, 2011;
Opaas & Hartmann, 2013; Smith, Chang, Kochinski, Patz, & Nowinski, 2010;
Sloan, Arsenault, Hilsenroth, Handler, & Harvill, 1996; Van der
Kolk & Ducey, 1989; for review see Viglione et al., 2012). It has been
suggested that the ambiguous nature of the Rorschach promotes the
breakthrough to consciousness of traumatic imagery. According to this
idea, the appearance of traumatic content in the individual's response
reflects perception of the inkblot as related to specific themes associated
with their traumatic experience through meaning (Viglione et al., 2012). For
example, a response indicating perception of Blood content may be related
to a previous trauma by being a likely symbol of danger and injury to the
human body experienced at the traumatic situation, while a response
indicating Morbid content such as “rotten apple” may represent a sense of
damaged or injured self-esteem and feeling of incompleteness related to the
traumatic event (Meloy & Genoco, 1997; Viglione et al., 2012). However,
the high frequency with which TCI related themes are reported on
Rorschach protocols by individuals with PTSD may be explained in other
ways than trauma-related association; for example, Morbid responses can
indicate, according to Rorschach conceptualization, negative feelings
toward oneself that may stem from general feelings of inadequacy and
blame, or even be a reaction to being tested in a psychological setting.
1.3. This study
This study proposed to examine the electrophysiological response of
trauma-exposed participants to an oddball paradigm in which
Distractor stimuli consisted of two-word phrases derived from the TCI
(Armstrong & Lowenstein, 1990). Target and Standard stimuli were
comprised of two-word neutral phrases derived from neutral content
categories of the Rorschach. While it has been postulated that the
identification of a Rorschach inkblot with traumatic content represents
an activation of traumatic imagery via semantic or meaning-based
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Biological Psychology 127 (2017) 108–122
associations (Viglione et al., 2012), the neural correlates of such
processes have never been explored by ERP analysis. The advantage
of utilizing ERP, in contrast to other neuroimaging techniques such as
fMRI and PET, is its ability to provide excellent time resolution
especially suitable for examining rapid processing of potentially
threatening stimuli (LeDoux, 2000).
The neurocircuitry model proposes that PTSD is associated with an
impaired PFC suppression of attention to trauma-related stimuli (Rauch
et al., 2006). This understanding is supported by ERP research
indicating an attentional bias toward threat/trauma-related stimuli
resulting in larger P3 amplitudes. If TCI-related contents indeed
facilitate activation of traumatic imagery, as was previously suggested
(Viglione et al., 2012), then the exposure of participants with trauma
history to such contents would result in P3 alteration. Consequently, we
hypothesized that:
1. Compared to non-traumatized Controls, participants with PTSD
would exhibit larger P3 amplitudes in the context of TCI-related
Distractors.
2. Exposure to TCI-related content would be followed by increased P3
amplitudes in both the trauma-exposed groups (PTSD and non-
PTSD), compared to healthy control participants.
3. When exposed to TCI-related contents, participants with previous
traumatic exposure would exhibit increased P3 amplitudes only in
response to Target and Distractor stimuli. If such hypothesis were to
be confirmed, it may suggest the existence of increased cerebral
reactivity to either target realted/trauma related stimuli among
trauma-exposed participants, along with intact ability to discard
non-relevant (Standard) stimuli.
In addition to the formal hypotheses delineated above, we also
considered the potential effects of TCI categories on responsivity. Since
the TCI consists of five distinct content categories, it is possible that
Distractors from various categories of the TCI facilitate different
cerebral responses. Accordingly, the current study examined participant
cerebral response by using three oddball paradigms, each containing
Distractors from only one of the Anatomy, Blood, and Morbid TCI
categories. Due to the novelty of the current research, we had no
preliminary hypothesis regarding the nature of cerebral response
associated with each of the TCI categories; however, by using this
experimental design, we intended that the current study not only shed
light on potential mechanisms by which TCI-related stimuli affects
information processing, but also whether this mechanism differs in
response to various TCI categories.
2. Materials and methods
2.1. Participants
Overall, the total sample consisted of 56 participants (mean
age = 24.20; SD = 2.39). Trauma-exposed participants were recruited
through local university advertisement boards and flyers posted at the
university's student counseling center and various local medical centers,
requesting individuals who have experienced severe negative life events
to participate in our study. Forty participants (26 females) reported a
previous traumatic history that included at least one traumatic event in
accordance with DSM-5 “criterion A” for PTSD diagnosis (APA, 2013).
These participants were divided into two groups. The first group, the
“PTSD” group, consisted of 16 participants (12 females) who met clinical
criteria for PTSD and had scores of at least 40 or greater on the Clinician-
Administered PTSD Scale (CAPS) (mean = 50.67; SD = 9.53); a CAPS
score of 40 and greater is postulated to indicate moderate to severe PTSD
symptoms (MacNamara et al., 2013). The second group, the “non-PTSD”
group, included 24 participants (14 females) that had been exposed to
one or more trauma-related events, but did not meet clinical criteria for
the diagnosis of PTSD at the time of testing. The average CAPS score for
G. Zukerman et al.
21 subjects of this group (mean = 26.00; SD = 9.92) showed subthres-
hold PTSD (Weathers, Keane, & Davidson, 2001); three additional sub-
jects with no CAPS score were included in this group based on their PDS
(Posttraumatic Diagnostic Scale) score that indicated a subthreshold,
mild level of PTSD. The average PDS score (mean = 10.21; SD = 7.11)
for all 24 “non-PTSD” participants indicated a subthreshold, mild PTSD
(McCarthy, 2008).
The Control group consisted of 16 university students (14 females),
recruited through local university advertisements, with no previous
traumatic history. None of the participants reported any medical
problems, being in psychological or psychiatric treatment or the use
of any medication. All participants provided signed informed consent
and were compensated for their time. The study was approved by the
university ethics committee.
2.2. Measures and procedures
All questionnaire administration and interviews were performed by
a licensed clinical psychologist who was trained to evaluate PTSD
symptoms.
2.2.1. Trauma History Questionnaire (THQ)
The THQ is a 24-item self-report questionnaire developed to
measure exposure to potentially traumatic events included in the “A1
criteria” of DSM-IV for PTSD and acute stress disorder (Hooper,
Stockton, Krupnick, & Green, 2011). The events may include crime-
related events (e.g. robbery, mugging), general disaster and trauma
(e.g. injury, natural disaster, witnessing death), and unwanted physical
and sexual experiences. For each of the items, the participant indicates
whether or not he or she experienced the event, and if so, the number of
times and approximate age(s) of occurrence. The THQ has been widely
used to measure previous traumatic history among clinical (PTSD) and
non-clinical (non-PTSD) samples. Moderate to high test-retest reliability
and validity have been reported (Hooper et al., 2011). In the current
study, a trauma history score was calculated by adding the number of
traumatic events reported by the participant. Thus, a higher score
indicates a higher rate of traumatic event exposure. This measure was
administered to all the participants in the study.
2.2.2. Posttraumatic Diagnostic Scale (PDS)
The PDS is a 49-item self-rating scale developed to assess PTSD
diagnosis according to DSM-IV criteria (Foa, 1995). The first section of
the questionnaire includes a short checklist that identifies potentially
traumatizing events experienced by the respondent. Next, in the case of
more than one traumatic experience, the participant is asked to choose
one single traumatic experience “that currently bothers you the most”
(major event). Then, with regard to the major event, the participant is
asked to use a 4-point scale to rate the frequency with which he or she
has experienced each one of 17 PTSD symptoms over the previous two
weeks; the 17 items measure thought intrusion (re-experiencing),
avoidance and arousal symptoms. Finally, a PTSD symptom severity
score is calculated; a cutoff score of 11 and above has been suggested to
reflect a moderate level of PTSD (McCarthy, 2008). Previous research
findings have demonstrated high internal consistency and test-retest
reliability as well as a satisfactory agreement with PTSD-related
diagnostic interviews such as the Structural Clinical Interview for
DSM Disorders - SCID (Foa, Cashman, Jaycox, & Perry, 1997). This
measure was administered to all the participants in the study.
2.2.3. Clinician-Administered PTSD Scale (CAPS)
.The CAPS is a semi-structured interview for PTSD diagnosis
according to DSM-IV criteria (Blake et al., 1995). The CAPS is
considered a “gold standard” in PTSD assessment. It provides informa-
tion regarding the intensity and frequency of PTSD symptoms in
response to traumatic experience. A total severity score is calculated
by adding the intensity and frequency scores of 17 4-point scale items
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Biological Psychology 127 (2017) 108–122
that relate to one of three subscales: intrusion (re-experiencing),
avoidance and numbing, and hyper-arousal. The CAPS has demon-
strated high reliability and validity ratings across various studies (Pupo
et al., 2011; Weathers et al., 2001). This measure was administered only
in the trauma-exposed groups (PTSD and non-PTSD).
2.2.4. Beck Depression Inventory-II (BDI-II)
The BDI-II is a 21-item self-report measure assessing cognitive,
affective and behavioral outcomes of depression (BDI-II, Beck,
Steer, & Brown, 1996) The BDI is widely used and has high reliability
and validity as a measure of depression (Beck et al., 1996). This
measure was administered to all the participants in the study.
2.2.5. Other medical or psychological/psychiatric conditions
Finally, participants from all groups (PTSD, non-PTSD and Control)
were asked whether they suffer from any major health problems, were
taking prescribed medication (including psychiatric medication) or
were receiving psychotherapy.
2.3. Oddball paradigm with Rorschach's traumatic content index
Distractors
All participants’ brain activity was recorded via EEG while perform-
ing these paradigms. The oddball paradigms used in this study
contained 250 two-word phrases of visual stimuli of three Trial
Types: 1) Target stimuli consisting of a specific neutral phrase (e.g.
“silver fish”) that related to Rorschach's Animal content category; these
stimuli appeared 50 times (20% of all stimuli shown in the task),
presented randomly, and participants were asked to press a joystick
button when detecting such a phrase; 2) Distractor stimuli consisting of
10 different phrases related to three of Exner's content categories
included in the TCI (Anatomy, Blood, or Morbid); each phrase was
repeated five times resulting in 50 phrases (20% of all stimuli)
presented randomly; and 3) Standard (non-target) stimuli consisting
of 30 different phrases of domestic items related to Rorschach's
Household content category (Exner, 2001), such as “desk lamp”, “wall
clock” or “kitchen cupboard”; each phrase was repeated five times,
resulting in 150 phrases presented randomly (60% of all stimuli).
Each participant was presented with three experimental paradigms
that were identical except for the type of Distractor stimuli: Anatomy,
Blood, and Morbid. Since each TCI content category may have a
different effect on cerebral response, the experimental design included
three runs, each employing Distractors from a different TCI category.
The Anatomy paradigm included Distractors that were comprised of
phrases related to skeletal, muscular, and internal anatomy such as
“two lungs”, “pair of ribs”, or “brain tissue.” The Blood paradigm
included Distractors that were comprised of phrases related to blood
content such as “red blood”, “fresh blood”, or “a pond of blood.” The
Morbid paradigm included Distractors that were comprised of phrases
related to dead objects (“a baby's body”), destroyed, ruined, spoiled,
damaged or broken objects (“broken toy”) or objects attributed with a
dysphoric feeling (“depressed woman”). The content category classifi-
cation for the phrases used as stimuli was evaluated separately by two
licensed clinical psychologists trained in Exner's comprehensive system
of Rorschach scoring; inter-rater reliability was high (Kappa = 0.90).
Fig. 1 presents the experimental paradigm. At this study, we used three
paradigms, each relating to different TCI content category (Anatomy/
Blood/Morbid), though the TCI contains five content categories.
Distractors from the two additional content categories (Sex and
Aggressive movement) were not used mainly due to time considera-
tions; each paradigm took as long as eight minutes and we estimated
the using the all five categories would reduce the participant interest
and motivation in completing the task.
2.3.1. Distractors: evaluating emotional valence and threat level
Since PTSD has previously been associated with increased respon-
G. Zukerman et al.
Fig. 1. Experimental paradigm. Each subject participated in three experimental paradigms that included Target stimuli (animal-related content such as “silver fish”), Distractor stimuli
(either Anatomy, Blood or Morbid related content) and Standard stimuli (two-word phrases of household-related content). Subjects were asked to press a button on a joystick when they
identified the Target stimuli. The order of the three experimental paradigms was counterbalanced across participants.
sivity to negative emotional stimuli (Blomhoff et al., 1998; Saar-
Ashkenazy et al., 2015) as well as increased responsivity to threatening
stimuli (Engelhard et al., 2009; Kimble et al., 2012), we evaluated: 1)
the emotional valence of the Distractor stimuli used in this study and 2)
the perceived level of threat of Distractors in this study.
In order to evaluate the emotional valence of the Distractor stimuli,
a separate group of 49 age-matched undergraduate students who did
not participate in the ERP portion of the study (46 females, mean
age = 22) were asked to rate Distractor phrases on a nine-point Likert
scale from 1 (“exceptionally negative”) to 9 (“exceptionally positive”).
Participants’ responses were analyzed with a repeated measure analysis
of variance (ANOVA) with three content categories (Anatomy, Blood,
Morbid) containing 10 phrases in each category (3 × 10). The results
indicated significantly different negative ratings by content category, F
(2, 26) = 240.36, p < .00, ηp2 = 0.91. Bonferroni post hoc tests re-
vealed that phrases in the Morbid category were perceived as signifi-
cantly more negative (M = 2.58, SE = 0.05) than phrases from the
Anatomy (M = 3.98, SE = 0.07) and Blood (M = 3.35, SE = 0.09)
categories. Significant differences were also found between the Blood
and Anatomy categories, p < .00, denoting that anatomy Distractors
were perceived as more negative then Distractors at the Blood category.
In order to evaluate the perceived level of threat of Distractor
stimuli, an additional 24 age-matched undergraduates students who did
not participate in the ERP procedure (23 females, mean age = 22) were
asked to rate the Distractor phrases on a 6-point Likert scale from 0
(“not threatening”) to 5 (“very threatening”). Participant responses
were analyzed with a repeated measure analysis of variance (ANOVA)
with three content categories (Anatomy, Blood, Morbid) containing 10
phrases in each category (3 × 10). The results indicated significantly
different threat ratings by content category, F(2, 22) = 17.30, p < .00,
ηp2 = 0.61. Bonferroni post hoc tests revealed that Blood (M = 3.19,
SE = 0.19) and Morbid (M = 3.15, SE = 0.11) Distractors were rated
as significantly more threatening than Anatomy Distractors (M = 2.07,
SE = 0.17). No significant differences were found between Blood and
Morbid Distractors.
Target, Standard, and Distractor stimuli were presented in random
order. The order of the three experimental paradigms (Anatomy, Blood,
and Morbid) was counterbalanced across participants. Chi-square
analysis indicated no significant group differences in paradigm pre-
sentation order, χ2(4, 56) = 0.64, p > .05). Stimuli were presented as
white letters on a black background computer screen. Times New
Roman font size 88 letters were used. Each stimulus duration was
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Biological Psychology 127 (2017) 108–122
300 ms and interstimulus fixed intervals were 1700 ms, thus, stimuli
were presented every 2 s.
Participants were seated in a comfortable armchair, told that they
would see all kinds of phrases on the computer monitor and were asked
to press a button on a joystick when they identified the Target stimuli
(“silver fish”). The computer monitor was located 100 cm from the
participant's head.
2.4. Electrophysiological testing and measures
The EEG was recorded in a room free of noise and electromagnetic
fields. Continuous EEG was recorded using a Micromed SD 64 channel
system and a Neuroscan 64 channel elastic cap with electrode locations
based on the 10/20 system. All electrodes were referenced to an
electrode located at the tip of the nose. A ground electrode was placed
on the right mastoid. A vertical electrooculogram (EOG) was recorded
using two electrodes, one located above and one below the right eye.
The impedance measure for each electrode was always below 5 kΩ.
Raw data were continuously recorded with a 16-bit A/D and a band
pass filter of 0.15–463 Hz and a sampling rate of 1024 Hz.
All data were analyzed using BPM software (Brain Performance
Measurement: Orgil Medical Equipment, Inc.). EEG Recordings were
segmented into time intervals that were time-locked to the stimuli, and
extended from 200 ms pre-stimulus to 2000 ms post-stimulus. An eye
movement correction procedure was performed offline using an eye
movement correction algorithm. The algorithm detects an epoch with
ocular artifacts by comparing the signals recorded from above and
below the eye. In a second step, a correction is performed for each
record and each channel separately. Additionally, EEG signals were
visually scored on a high resolution computer monitor, and portions of
the data containing eye movement, muscle movement or other sources
of artifact were removed. Baseline correction for each trial was
performed using the 200 ms prior to stimulus onset for each channel
separately. Amplitude rejection had been applied to the data prior to
averaging. Records with amplitude higher than 250 microvolts (even in
a single channel) were excluded. For each participant, all trials were
averaged per stimulus type (Target, Distractor, and Standard). In the
final stage of averaging, the data were filtered using a 6 Hz low-pass
filter.
Global field power (GFP) was calculated across all 12 electrodes,
Groups (PTSD, non-PTSD, Control), Paradigm type (Anatomy, Blood,
G. Zukerman et al.
Morbid) and Trial type (Target, Distractor, Standard). The GFP was
calculated by the root mean square (RMS) of the grand average
waveform (Murry, Brunet, & Michel, 2008) thus obtaining positive
components that indicate the strength of the potential being recoded.
The GFP provides a reference–independent measure of response
strength (Murry et al., 2008). Reviewing the GFP identified two main
components. The first component was identified as P3, denoting a
positive deflection at mid-latency time intervals and a second, late
negative component (LNC). The P3 component was quantified in terms
of peak amplitudes (maximum positive amplitude from baseline in
microvolts) and latency (time interval from stimulus onset to peak
amplitude in milliseconds) between 300 and 750 ms. The second
component was evident between 950 and 1500 ms with no defined
peak. Thus, we calculated the area under the curve (AUC) (Luck, 2014)
by advancing along the time axes between the two time points (1 ms
differentiates each successive sampling at a sampling rate of 1 KHz).
The AUC is defined by the area between the curve and a baseline level,
which was calculated by using the more positive amplitude of two time
points (950 and 1500 ms). The AUC measurement, expressed in
μv × ms units, has been associated with total activity of the underlying
neural substrate (Pratt, Mittelman, Bleich, & Laufer, 2004). Fig. 2
presents the GFP. The GFP, derived from the mean square, produced
positive values for both positive and negative components. Thus,
although the GFP values for the second component were positive, it is
presented in its initial negative format.
2.5. Statistical analysis
Analyses were conducted by using SPSS version 21 (Armonk, N.Y.;
IBM Corp., 2013). For comparison of demographics and behavioral
assessment measures (THQ, PDS, BDI) one-way analysis of variance
(ANOVA) with Group (PTSD, non-PTSD, Controls) as an independent
variable was used. An independent t-test was used to track group
differences (PTSD vs non-PTSD) on the CAPS assessment. A non-
parametric Chi-square test was conducted to compare gender differ-
ences among the three groups.
P3 amplitude and latency as well as AUC comparisons were
conducted by a repeated measure analysis of variance (ANOVA) with
Group (PTSD, non-PTSD, Control) as a between-factor and Paradigm
type (Anatomy, Blood, Morbid) X Trial type (Target, Distractor,
Standard) X Electrode Midline site (Prefrontal, Frontal, Central,
Parietal) X Electrode Side site (Left, Midline, Right) as within-factors.
Greenhouse Geisser corrections were applied as necessary for violations
of sphericity, and partial eta square (ηp2 ) served as an estimate for effect
size of the ANOVA's. Bonferroni post hoc tests have been used to
examine group differences, while contrast analysis was used to examine
interaction effects for the P3 component analysis. Data were obtained
from 12 electrodes (PF1, PFz, PF2, F3, Fz, F4, C3, Cz, C4, P3, Pz, P4)
Fig. 2. Grand average global field power. GFP was calculated by the root mean square
(RMS) of the grand averages waveform resulting in two components that were identified
as positive P3 component and LNC, respectively.
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Biological Psychology 127 (2017) 108–122
that were divided between two location factors. Given that the P3
response of different locations may represent divergent cognitive
processes (Katayama & Polich, 1998), we assigned each electrode to a
four-level Midline Site factor denoting Prefrontal (PF1, PFZ, PF2),
Frontal (F3, Fz, F4), Central (C3, Cz, C4) and Parietal (P3, Pz, P4) Sites.
Additionally, since the oddball paradigms used in this study included
two-word phrases, and based on a well-established concept that the left
hemisphere is associated with more efficient processing of verbal
information (Dickson & Federmeier, 2014; Selpien et al., 2015), elec-
trodes were also divided into a three-level Side Site factor denoting Left
(PF1, F3, C3, P3), Middle (PFz, Fz, Cz, Pz) and Right (PF2, F4, C4, P4)
sites. This categorization of the electrodes into two factors is in
accordance with previous research (Kimble, Kaloupek, Kaufman,-
& Deldin, 2000).
All analyses were performed with and without gender and depres-
sion levels as covariates. Gender was selected as a covariate factor since
numerous studies have reported that females are more likely to develop
intense PTS symptoms, as well as meet criteria for PTSD (for review, see
Tolin & Foa, 2006). Depression was selected as a covariate factor since
comorbidity between PTSD and major depressive disorder is common
(Stander, Thomsen, & Highfill-McRoy, 2014) and lower P3 amplitudes
have been reported among depressed individuals (Iv, Zhao, Gong,
Chen, & Miao, 2010). In all analyses, no significant effects for either
of the covariates were found. Therefore, results are reported only for
analyses with no covariates.
3. Results
3.1. Participant characteristics
No significant gender differences were found between groups, χ2(2,
N = 56) = 4.14, p > .05, in spite of female predominance. No sig-
nificant group differences in age were found. On the PDS, the majority
of the participants in trauma-exposed groups (PTSD and non-PTSD)
reported motor vehicle accidents (62.5%) as their major traumatic
experience, 12.5% war or combat related traumatic experiences, 5.0%
sexual assaults and 5.0% the loss of a family member. Most participants
described a history of multiple types of trauma. The distribution of
types of “main traumatic event” as well as types of overall traumatic
event distribution, as reported on the PDS, is presented in Table 1. No
significant statistical differences were found in the distribution of the
main traumatic event type between the PTSD and non-PTSD groups, χ2
(6, N = 40) = 4.47, p > .05.
Data for age, THQ, PDS, and BDI indices are presented in Table 2. A
significant effect of Group on the level of previous traumatic exposure
in the THQ was found. Bonferroni post hoc tests revealed significantly
higher rates of previous traumatic exposure among participants in the
PTSD and non-PTSD groups. No significant difference in trauma history
levels between PTSD and non-PTSD groups, as reported at the THQ, was
observed. A significant effect of Group on the level of post-traumatic
symptoms, as indicated by the PDS, was found. As expected, Bonferroni
post hoc tests have indicated that, in comparison to the Control group
who reported no traumatic symptoms, PTSD and non-PTSD group
participants reported significantly higher levels of traumatic symptoms.
Table 1
Trauma type distribution among 40 subjects with traumatic history.
Trauma type Major traumatic event Any traumatic event
Motor vehicle accident 25 (62.5%) 26 (65%)
War- or combat-related 5 (12.5%) 17 (42.5%)
experience
Sexual assault 2 (5%) 5 (12.5%)
Loss of family member 2 (5%) 3 (7.5%)
Other 6 (15%) 19 (47%)
Note: Trauma type distribution as reported at the posttraumatic diagnostic scale (PDS).
G. Zukerman et al. Biological Psychology 127 (2017) 108–122

Table 2
Traumatic history and symptoms reported among all groups.

Control non-PTSD PTSD

Mean (SD) n Mean (SD) n Mean (SD) n F/t p

Age 23 1.96 15 24.63 2.48 24 24.69 2.38 16 2.57 ns

THQ scores 0 0 16 5.00 1.87 22 4.81 2 16 40.59 < 0.01
PDS scores 0 0 16 10.21 7.11 24 21.25 8.14 16 44.37 < 0.01
Total CAPS scores 26 9.92 21 50.75 9.22 16 −7.96 < 0.01
BDI scores 1.07 1.38 15 6.75 7.9 24 9.00 7.73 15 5.66 < 0.01

Note: THQ = Trauma History Questionnaire, PDS = Posttraumatic Diagnostic Scale, CAPS = Clinician Administered PTSD Scale, BDI = Beck Depression Inventory.

In accordance with PDS norms (McCarthy, 2008) the levels of traumatic
symptoms matched “mild” and “moderate to severe” levels of traumatic
symptoms among the non-PTSD and PTSD groups, respectively. The
difference in the level of traumatic symptoms reported by the PTSD and
the non-PTSD groups was also statistically significant, indicating a
higher level of traumatic symptoms among the PTSD group. Addition-
ally, a significant difference in reported levels of depression, as
indicated by the BDI, was found, with higher levels of depressive
symptoms reported among those with PTSD, as compared to non-PTSD
and Control participants. Nevertheless, the average score of each group
indicated non-depression (BDI score < 13) (Beck et al., 1996, Dozois,
Dobson, & Ahnberg, 1998; Kendall, Hollon, Beck, Hamenn, & Ingram,
1987; Whisman & Richardson, 2015).
3.2. ERP component analysis
3.2.1. P3 amplitude and latency
The grand averages of the ERP waveforms can be seen in Fig. 3 for
Target stimuli and Fig. 4 for Distractor and Standard stimuli. Visual
inspection of the waveforms suggests that, across trials, the trauma-
exposed groups (PTSD and non-PTSD) were characterized by larger P3
amplitudes for the Anatomy and Blood paradigms compared to the
Morbid paradigm, while the Control group was characterized by larger
P3 amplitudes for the Morbid paradigm compared to the Anatomy and
Blood paradigms. The results of the analysis of P3 amplitude and
latency are provided below.
3.2.1.1. P3 amplitude. A Group (PTSD, non-PTSD, Control) X Paradigm
Type (Anatomy, Blood, Morbid) X Trial Type (Target, Distractor,
Standard) X Electrode Midline Site (Prefrontal, Frontal, Central,
Parietal) X Electrode Side Site (Left, Middle, Right) repeated
measures ANOVA was conducted in order to assess P3 peak
amplitude levels.
Results indicated a significant Group X Paradigm Type crossover
interaction, F(3.43, 91.11) = 3.19, p < .05, ηp2 = 0.11. A secondary
contrast analysis revealed that the combined effect of Group and
Paradigm Type was significantly different for the Anatomy and Blood
paradigms, compared to the Morbid paradigm, F(2, 53) 5.22, p < .01,
ηp2 = 0.17; F(2, 53) = 3.59, p < .05, ηp2 = 0.12 , respectively. This points
out differences in cerebral activation patterns in response to the various
paradigms between study groups: participants in the PTSD and non-
PTSD groups exhibited higher P3 amplitudes for the Anatomy and the

Fig. 3. Grand average ERP's for electrodes Fz and Cz in response to Target stimuli across the three experimental paradigms (Anatomy, Blood, Morbid) among the three study groups
(PTSD, non-PTSD, C ontrol). Shaded areas correspond to the time window for P3 (300–750 ms) and late negative component (LNC) (950–1500 ms).

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Fig. 4. Grand average ERP's for electrodes Fz and Cz in response to Distractor (a) and Standard (b) stimuli for the three experimental paradigms (Anatomy, Blood, Morbid) among the
three study groups (PTSD, non- PTSD and Control) Shaded areas correspond to the time window for P3 (300–750 ms) and late negative component (LNC) (950–1500 ms).

Blood paradigms, in comparison to the Morbid paradigm. In contrast,
Control participants exhibited lower amplitudes for the Anatomy and
Blood paradigms in comparison to the Morbid paradigm. Fig. 5
illustrates this disordinal interaction pattern between Group and
Paradigm Type on P3 amplitude across Trial Type (Target, Distractor,
Standard), averaged for all 12 electrodes. No other significant main
effects or interactions involving the Group factor were found. Table 3
displays the group averages for the P3 analysis.
A significant main effect of Trial Type was found F(1.54, 81.91)
= 58.13, p < .01, ηp2 = 0.52 . Follow-up Bonferroni post hoc tests
revealed a significant difference in amplitudes elicited by Target stimuli
(M = 10.82, SE = 0.65) in comparison to Distractor (M = 6.40,
SE = 0.43, p < .00) and Standard stimuli (M = 5.40, SE = 0.42;
p < .00). The difference between amplitudes elicited by Distractor
and Standard stimuli was also significant, p < .05.
Additionally, a significant effect of Electrode Side Site was found, F
(1.40, 74.63) = 34.34, p < .00, ηp2 = 0.39. Bonferroni post hoc testing
revealed a significant difference in amplitudes elicited by electrodes at
the Left (M = 7.79, SE = 0.43) in comparison to the Right (M = 7.14,
SE = 0.39, p < .00). No other significant main effects were found for
peak amplitude.
3.2.1.2. P3 latency. A Group (PTSD, non-PTSD, Control) X Paradigm
Type (Anatomy, Blood, Morbid) X Trial type (Target, Distractor,
Standard) X Electrode Midline Site (Prefrontal, Frontal, Central,
Parietal) X Electrode Side Site (Left, Middle, Right) repeated
measures ANOVA was conducted in order to assess differences in P3
peak latencies.
A significant main effect for Midline Site was observed, F(1.65,
87.47) = 10.35, p < .01, ηp2 = 0.16 . Bonferroni post hoc tests have

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For the Anatomy Paradigm, a significant Group X Trial interaction

Fig. 5. P3 amplitudes for Group (PTSD, non-PTSD, Control) and Paradigm Type
(Anantomy, Blood, M orbid) averaged for 12 electrodes. Means and standard errors of
means are presented.
indicated that this effect was due to significantly longer latencies at
Prefrontal sites (M = 495.32, SE = 6.70) in comparison to Frontal
(M = 483. 97, SE = 6.78, p < .01), Central (M = 481.93, SE = 6.64,
p < .01) and Parietal (M = 481.55, SE = 6.43, p < .05) Sites. No
other significant effects of Paradigm Type, Trial Type, or Electrode Side
Site on latency time were observed.
3.2.2. Late negative component (LNC) AUC
A Group (PTSD, non-PTSD, Control) X Paradigm Type (Anatomy,
Blood, Morbid) X Trial type (Target, Distractor, Standard) X Electrode
Midline Site (Prefrontal, Frontal, Central, Parietal) X Electrode Side Site
(Left, Middle, Right) repeated measures ANOVA was conducted in order
to assess differences in the AUC at the 950–1500 ms time points. (See
Figs. 3 and 4 for grand averages of ERP waveforms).
A significant two-way interaction of Group X Trial Type was
observed, F(4, 102) = 6.61, p, < .01, ηp2 = 0.21. Additionally, a four-
way interaction of Group X Paradigm type X Trial type X Electrode Side
was found, F(7.79, 206.55) = 2.00, p = .05, ηp2 = 0.07. No other
significant main effects or interactions involving the Group factor were
found.
In order to probe the four-way interaction, Group (PTSD, non-PTSD,
Control) X Trial type (Target, Distractor, Standard) X Electrode Side
(Left, Middle, Right) repeated measures ANOVA's were conducted,
separately for each Paradigm Type (Anatomy, Blood, Morbid).
was observed F(3.01, 79.88) = 3.73, p < .05, ηp2 = 0.12 . To probe the
interaction, repeated measure ANOVA's were conducted for each Trial
Type. Results indicated a significant effect of Group on AUC values for
only the Distractor Trial Type F(2, 53) = 3.35, p < .05, ηp2 = 0.11.
Bonferroni post hoc tests revealed significantly larger AUC values for
the PTSD (M = 2412.78, SE = 231.54) compared to the Control group
(M = 1566.51, SE = 231.54, p < .05). No other main effects of
interactions involving the Group Factor were observed. Fig. 6 illustrates
the AUC values for the three experimental paradigms (Anatomy, Blood,
Morbid) as function of Trial Type (Target, Distractor, Standard) for the
three study groups (PTSD, non-PTSD, Control), averaged for all 12
electrodes.
For the Blood Paradigm, a significant effect of Group was observed F
(2, 53) = 3.37, p < .05, ηp2 = 0.11. Bonferroni post hoc tests revealed
significantly larger AUC values for the PTSD (M = 2034.75,
SE = 176.15) as compared to the non-PTSD (M = 1472.40,
SE = 143.82, p < .05). Additionally, a significant Trial Type and
Group interaction was observed F(3.47, 92.19) = 4.11, p < .01,
ηp2 = 0.13. In order to probe the interaction, repeated measures
ANOVA's analyses, separate for each Trial Type (Target, Distractor,
Standard) were conducted. For Target Trial Type, a significant effect of
Group was observed F(2, 53) = 3.60, p < .05, ηp2 = 0.12 . Bonferroni
post hoc tests revealed significantly smaller AUC values for the non-
PTSD group (M = 1659.48, SE = 212.54) as compared to the Control
group (M = 2546.53, SE = 260.30, p < .05). For Distractor Trial type,
a significant effect of Group was observed F(2, 53) = 5.00, p = .01,
ηp2 = 0.16 . Bonferroni post hoc tests revealed significantly larger AUC
values for the PTSD group (M = 2575.98, SE = 236.73) compared to
the non-PTSD (M = 1643.88, SE = 193.29, p < .01) and Control
(M = 1775.33, SE = 236.73, p < .05) groups. No significant main
effects or interactions involving the Group factor were observed for
Standard Trial Type (Fig. 6).
For the Morbid Paradigm, a significant Group X Trial Type X
Electrode Side interaction was observed F(4.75, 125.96) = 3.17,
p < .05, ηp2 = 0.11. Probing the interaction by separate repeated
measures ANOVA's for each Trial Type have indicated a significant
Group X Electrode Side interaction for Target Trial Type F(2.55, 66.82)
= 4.47, p < .01, ηp2 = 0.14 . Probing this interaction by repeated
measures ANOVA's, separated for each side, indicated a significant
effect of Group only for Right Side electrodes F(2, 53) = 3.18, p = .05,

Table 3
Means and standard errors of P300 amplitude (μV) and late negative component (LNC) area under the curve (μV*ms) values for the study groups across all paradigms and trial types.

PTSD Non-PTSD Control

Mean SE Mean SE Mean SE

P300
Anatomy Target 12.37 1.26 10.82 1.03 11.04 1.26
Distractor 6.13 1.00 7.05 0.82 5.10 1.00
Standard 5.28 0.85 5.34 0.69 4.62 0.85
Blood Target 11.83 1.58 9.25 1.29 10.55 1.58
Distractor 7.08 1.17 7.60 0.95 6.65 1.17
Standard 6.69 1.02 5.87 0.83 4.03 1.01
Morbid Target 9.68 1.48 9.28 1.20 12.54 1.48
Distractor 4.32 1.23 6.17 1.00 7.46 1.23
Standard 5.31 0.86 5.61 0.70 5.84 0.86
LNC
Anatomy Target 2195.93 268.46 1963.34 239.17 2486.35 268.46
Distractor 2412.78 231.54 1944.48 189.05 1566.51 231.54
Standard 1232.13 151.46 1240.05 123.66 1175.05 151.46
Blood Target 2162.08 260.30 1659.48 212.54 2546.53 260.30
Distractor 2575.98 236.73 1643.88 193.29 1775.33 236.73
Standard 1366.21 159.53 1113.85 130.25 1271.69 159.53
Morbid Target 2268.73 242.07 1798.68 197.64 2382.37 242.07
Distractor 2027.85 239.17 1876.22 195.28 1750.50 239.17
Standard 1298.07 238.30 1154.52 194.57 1666.70 238.30

Note: All values are averaged for 12 electrodes.

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G. Zukerman et al.
Fig. 6. Late negative component area under the curve (AUC) for each of the experimental
paradigms Anatomy (a), Blood (b), Morbid (c), as function of Trail Type (Target,
Distractor, Standard) for the three study groups (PTSD, non-PTSD and control), averaged
for all 12 electrodes. (* p < 0.05). For the Morbid paradigm, significant effect was
restricted to the Right Side electrodes. Means and standard errors of means are displayed.
ηp2 = 0.11. Bonferroni post hoc tests revealed significantly smaller AUC
values for the non-PTSD group (M = 1679.36, SE = 204.37) compared
to the Control (M = 2469.20, SE = 250.30, p = .05) group (Fig. 6).
We also probed the two-way Group X Trial Type interaction by
separate repeated measures ANOVA's for each Trial type. Results
indicated a significant effect of Group on AUC values for Targets F(2,
53) = 4.65, p < .05, ηp2 = 0.15. Bonferroni post hoc tests revealed
significantly smaller AUC for the non-PTSD (M = 1807.17,
SE = 141.20) compared to Control participants (M = 2471.75,
SE = 172.94). Results also indicated a significant effect of Group on
AUC values for Distractors F(2, 53) = 4.20, p < .05, ηp2 = 0.13.
Bonferroni post hoc tests revealed significantly larger AUC values for
the PTSD group (M = 2338.87, SE = 168.45) compared to the Controls
(M = 1697.44, SE = 168.45). A marginally significant difference be-
tween the PTSD compared to the non-PTSD group (M = 1821.53,
SE = 137.54, p = .06) was also observed.
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Biological Psychology 127 (2017) 108–122
In summary, our findings indicate that for the Anatomy and Blood
paradigms, when subjects observed Distractors with Anatomy (“a pair
of ribs”) or Blood (“red blood”) contents, the PTSD group responded
with significantly larger AUC values compared to the non-PTSD group.
For the Blood and Morbid paradigms, the response to neutral Target
stimuli was significantly larger among Control subjects, compared to
the non-PTSD group (although this effect was restricted to the Right
Side electrodes and only for the Morbid paradigm). Table 3 displays
group averages for the LNC analysis. Beyond Paradigm Type, our
findings also showed a significantly smaller AUC among non-PTSD
participants for Target Trials, compared to Controls, and larger AUC
values among the PTSD group compared to Controls in response to
Distractor Trials.
A significant main effect of Trial type was observed F(2, 52)
= 87.10, p < .05, ηp2 = 0.77. Bonferroni post hoc tests revealed larger
AUC values for Targets (M = 2153.78, SE = 94.14) as compared to
AUC values elicited in response to Distractors (M = 1939.00,
SE = 92.80, p < .05) as well as Standard stimuli (M = 1275.70,
SE = 78.69, p < .01). The difference in AUC values for Distractors
and Standard Trials was also significant (p < .01).
Finally, a significant main effect of Midline Electrode Site on AUC
vales was observed F(1.34, 71.05) = 5.42, p < .05, ηp2 = 0.09.
Bonferroni post hoc tests revealed larger AUC values at the Prefrontal
Electrode Site (M = 1888.64, SE = 94.83) as compared to AUC values
at Frontal Site (M = 1733.70, SE = 74.34, p < .01). No other sig-
nificant main effects or interactions involving the Group factor were
observed.
4. Discussion
This is the first ERP study to examine the cerebral response to
Rorschach's Traumatic Content Index among a sample of trauma-
exposed participants diagnosed with PTSD, trauma-exposed partici-
pants not meeting clinical criteria for PTSD, and Control participants
unexposed to trauma. Our study found that trauma-exposed partici-
pants (PTSD and non-PTSD) exhibited different cerebral activation
patterns in the presence of Anatomy, Blood and Morbid contents, than
did Control participants. This finding indicates that, when faced with
some TCI-related traumatic themes (Anatomy and Blood), trauma-
exposed participant ERP's will exhibit increased P3 amplitudes.
5. Allocation of attention
Larger P3 amplitudes have been postulated to indicate an allocation
of greater attention (Polich & McIssac, 1994). Thus, our findings
indicate an allocation of more attention to some TCI-related stimuli
among trauma-exposed participants. This concurs with the resource
allocation model of PTSD (Ehlers & Clark, 2000) as well as with the
neurocircuitry model of PTSD, denoting a deficit in PFC suppression of
attention to trauma-related stimuli (Rauch et al., 1998, Rauch et al.,
2006). Specifically, the results indicate that, in comparison to Control
participants, trauma-exposed participants demonstrated an attentional
bias toward Distractor phrases related to Anatomy and Blood, while
their reaction to phrases related to torn, broken, or dysphoria-related
objects (Morbid content) was characterized by reduced attention. Thus,
the finding regarding Anatomy and Blood content supports our first
hypothesis (i.e. participants with PTSD would exhibit larger P3
amplitudes in the context of TCI-related Distractors compared to non-
traumatized Controls), while the Morbid content finding does not.
The elevated P3 response in both trauma-exposed groups (PTSD and
non-PTSD) to Anatomy and Blood contents (but not Morbid) also
supports our second hypothesis, which indicated that exposure to
TCI-related content would be followed by increased P3 amplitudes in
both the trauma-exposed groups (PTSD and non-PTSD), compared to
the Control participants. These findings concur with the growing
literature suggesting that attentional bias after an exposure to trauma
G. Zukerman et al.
are also found among participant that do not meet clinical criteria for
PTSD (Kimble et al., 2010; Thomas, Goegan, Newman, & Arndt, 2013)
6. General hypervigilance pattern
In contrast to previous findings (Karl et al., 2006; Johnson et al.,
2013) and to our third hypothesis (i.e. that participants with previous
traumatic exposure would exhibit increased P3 amplitudes only in
response to Target and Distractor stimuli), our findings showed that an
increase in P3 amplitude to Anatomy and Blood content among trauma-
exposed participants (PTSD and non-PTSD) was evident for all Trial
types (Target, Distractor, Standard). This finding may be characterized
as a general hypervigilant pattern, and may suggest impaired stimulus
filtering. A recent magnetoencephalography (MEG) study of partici-
pants with PTSD found dorsolateral prefrontal-related hyperactivity to
standard stimuli in the presence of threatening Distractors (Herz et al.,
2016). While the Herz study's results seem to provide some support for
the current findings, further research is needed to examine a possible
pattern of general hypervigilance among trauma-exposed individuals.
In summary, our ERP findings indicate that there is an attentional
bias to the Anatomy and Blood TCI subjects among trauma-exposed
participants, thus complementing the cognitive resource allocation
model (Ehlers & Clark, 2000) as well as the neurocognitive neurocir-
cuitry model (Rauch et al., 1998, Rauch et al., 2006) of PTSD. The
findings support the explanation that the relatively high frequency of
TCI responses in the Rorschach protocols of trauma-exposed individuals
can be explained, at least in part, by activation of the individual's
traumatic imagery. This mechanism may be restricted to Anatomy and
Blood contents, since the cerebral response to Morbid content among
the trauma-exposed groups was attenuated.
7. Responsivity to different TCI categories
Beyond the above findings, this study also showed that trauma-
exposed participants had higher cerebral responsivity to Anatomy and
Blood Distractors (“a pair of ribs” or “a drop of blood”, respectively)
along with attenuated responses to Morbid Distractors (“a baby's
body”). These differences can be explained neither by differences in
level of perceived threat among Distractors of the three paradigms
(Kimble et al., 2010) nor by PTSD-related sensitivity to negative
emotional valance of the stimulus (Blomhoff et al., 1998; Saar-Askenazy
et al., 2015). This position is informed by our study findings from two
separate groups of age-matched undergraduate students who were
asked to rate the threat and negativity levels of the TCI phrases. These
groups rated the Anatomy phrases as significantly less threatening than
Blood and Morbid phrases, while rating Blood and Anatomy as less
negative than Morbid phrases
A higher cerebral responsivity to Anatomy and Blood Distractors
might be related to trauma-exposed participants’ high responsiveness to
stimuli that bear perceptual similarities to stimuli encountered during
the trauma itself. These perceptual properties acquire the status of a
warning signal through perceptual priming (Ehlers et al., 2002; Ehlers,
Hackmann, & Michael, 2004). It has also been suggested that partici-
pants exposed to trauma focus on the central perceptual properties of
an object rather than on its meaning due to narrow attention during the
traumatic experience (Christianson, 1992; Ehlers & Clark, 2000; Ehlers
et al., 2004; Sundermann, Hauschildt, & Ehlers, 2013; Van der
Kolk & Fisler, 1995; Wing Lun, 2008). It might be that Anatomy and
Blood Distractors used in the current study contained more perceptual
information (like “smelly skull” or “red blood”) than Morbid Distractors
that contained more affective and symbolic data (“depressed woman”,
“broken toy”). These possible differences between TCI categories are
also acknowledged by the Rorschach interpretive conceptualization in
which Anatomy and Blood content is thought to reflect preoccupation
with concrete bodily injury (Bohm, 1958; Meyer & Viglione, 2008)
while Morbid content is thought to symbolize wounded self-image and
118
Biological Psychology 127 (2017) 108–122
relates to a general sense of inadequacy (Exner, 2001; Hartmann,
Halvorsen, & Wang, 2013; Meyer & Viglione, 2008). Thus, it is possible
that these differences may have triggered larger P3 in response to
Anatomy and Blood than to Morbid Distractors. Notwithstanding,
Distractors were not rated according to their level of perceptual/
conceptual information within this study; furthermore, other explana-
tions can be suggested for the current findings. For example, it is
possible that the Anatomy and Blood Distractors were more concep-
tually related to the content of the participants’ primary traumatic
event (Zhang et al., 2015), the vast majority of which were motor
vehicle accidents or war/combat. Therefore, it is our recommendation
that perceptual and conceptual levels of incoming stimuli on informa-
tion processing among trauma-exposed individuals should be explored
in future studies, in light of this novel finding.
8. Late negative component
This study's findings extend beyond the P3 component. Although we
had no preliminary hypothesis regarding possible effects of trauma
exposure on later ERP components, evaluation of the grand averages of
ERP waveforms and the resulting statistical analysis have revealed that
the elevated P3 response of the PTSD group to Anatomy and Blood
Distractors was followed by a significantly larger AUC values in the
LNC. In the LNC results, participants with PTSD were characterized by
increased responsivity to Distractors derived from the TCI, while the
Controls showed increased responsivity to the Target (neutral) stimuli.
Specifically, participants with PTSD were characterized by increased
response to Distractors with Anatomy and Blood contents, as compared
to Control participants. This pattern of response in a late component has
not been previously documented.
Providing further context to this pattern is a study involving an
emotional Stroop task that suggested its finding of an increased late
(626–726 ms) negativity indicated an association between emotional
arousal and late attentional processes that enroll higher order cognitive
control mechanisms (Feroz, Liecht, Steinmann, Andreou, & Mulert,
2016). It is possible that in the present study, Anatomy and Blood
Distractors elicited higher levels of arousal among participants in the
PTSD group. Other ERP studies have related LNC to sensitivity to the
number of items that are stored in working memory, and an index of
filtering efficiency (i.e. the ability to exclude non-relevant items from
working memory storage) (Qi, Ding, & Li, 2014; Vogel & Machizawa,
2004). Highly Trait Anxious (HTA) individuals that showed large
amplitudes of LNC were suggested to allocate excessive working
memory storage to threatening Distractors, indicating inefficient filter-
ing ability (Stout, Shackman, & Larson, 2013). This might also be the
case in this study, indicating that PTSD participants who associated
Anatomy and Blood contents with traumatic experience through
perceptual priming required more working memory storage and elicited
larger late negativity. This should be further explored in future studies.
Notwithstanding the above, this study's results should be viewed
within the context of the study design, and the previous hypothesis’
relevance to the current findings should be considered with caution. In
the current study, an oddball paradigm was used, the LNC was reported
at later time intervals than in previous studies, and was calculated as a
measure of the AUC; in previous studies, other ERP paradigms were
used and the late negativity was calculated as mean amplitude (Feroz
et al., 2013; Stout et al., 2013).
Taken together, the findings for both P3 and LNC suggest a PTSD-
related information processing pattern denoting increased responsivity
to Anatomy and Blood Distractors in mid-latency time intervals
followed by later increased cerebral response. These findings may point
to impaired PFC top-down regulation influence on information proces-
sing. Another possibility is that these findings indicate a “vigilance-
avoidance” pattern of information processing among individuals with
PTSD: the increased P3 amplitude may signify an initial vigilance to
cues that were perceptually primed and associated with danger,
G. Zukerman et al.
followed by elevation of the late negativity indicating an effort to avoid
or suppress the processing of emotional stimuli. Such a response pattern
(Mathews, 1990; Mogg & Bradley, 1998) is supported by a number of
behavioral studies indicating that, among participants with High Trait
Anxiety or anxiety disorders, there is a significant initial heightened
vigilance to threatening stimuli at the first 500 ms after stimulus
presentation followed by avoidance of the aversive stimuli at very late
latencies of approximately 1500 ms after stimulus onset (Amir,
Foa, & Coles, 1998; Hermans, Vansteenwegen, & Eelen, 1999; Mogg,
Bradley, Miles, & Dixon, 2004; Rohner, 2002). In summary, this study's
findings suggest that information processing alterations among partici-
pants with PTSD may extend beyond the P3 time interval, as indicated
by the LNC alterations. Future studies should examine whether the
increase in LNC is due to hyper-responsivity to trauma-related stimuli
or reflects an attempt to avoid processing of such stimuli.
9. Study limitations
To the best of our knowledge, this is the first study examining the
cerebral response to phrases from Rorschach's Traumatic Contents
Index among participants whose levels of PTSD symptoms have been
validated by self-report questionnaires and semi-structured interviews.
Notwithstanding, the current study has several limitations.
First, the generalizability of this study might be limited since all
participants were young students, healthy, with minimal comorbidity
and “moderate to severe” level of PTSD. Despite these factors, the fact
that our results were obtained even among this selective subset of
participants indicates the strength of the findings. Nevertheless, having
a greater representation of the full range of ages and severity levels
(including participants with extremely severe PTSD symptoms) would
have increased the generalizability of our findings. Moreover, since no
formal mental health evaluation was conducted, we cannot exclude the
possible effects of undetected mental health problems on our findings.
However, considering the fact that our participants were mainly young,
high-functioning individuals, we theorize that the levels of the possible
effects would be minor.
A second limitation may be the higher representation of females as
well as an imbalanced gender ratio in some of the groups (Females
made up: 12 of 16 PTSD, 14 of the 24 non-PTSD, and 14 of the 16
Control group members). Interestingly, a higher rate of females
characterizes other related studies (Felmingham et al., 2002; Lobo
et al., 2014). Regarding gender ratio: our analyses indicated no
significant differences in male/female ratios between the study groups,
and no significant effect of gender as a covariate in any of the analyses.
Previous research also indicated negligible effects of gender on P3
characteristics (Rozenkrants & Polich, 2008). While we conclude that
the imbalance in male/female ratio had no major effect on results, we
suggest that, to some extent, this study findings may be more applicable
to women and to trauma-exposed individuals whose posttraumatic
symptom levels meets clinical criteria for PTSD.
Additionally, as noted previously, the absence of data on arousal
levels of Distractors is a possible study limitation. While Distractors
were evaluated for emotional valence and threat levels, and those
analyses demonstrate the improbability of the heightened responsivity
to Anatomy and Blood Distractors (compared to the Morbid Distractors)
due to those factors, we did not rate Distractors according to their
arousal level. Arousal may play an under-recognized role in the
heightened responsivity observed among different categories of TCI
Distractors used in this study. Even so, we believe that such possible
arousal differences cannot fully explain variances in cerebral response
within study groups. Arousal level effects have been mainly reported
among non-disordered participants (Olofsson et al., 2008); thus,
Appendix A. Appendix
Table 1A
119
Biological Psychology 127 (2017) 108–122
possible effects of arousal should be evident among Controls as well
as traumatized participants. However, the current finding indicates
significant differences between trauma-exposed and Control partici-
pants. Moreover, previous arousal research focused on evaluating
responsivity to validated visual stimuli (Rozenkrants & Polich, 2008),
while our stimuli were phrases adopted from the Rorschach, possessing
no previous norms. Nonetheless, arousal, as well as emotional valence
and level of perceived threat, should be further evaluated; we intend to
evaluate TCI-related emotional arousal levels, and their possible effect
on ERP's, in future studies.
The null effect of Trial type (Target, Distractor, Standard) in this
study may indicate a general, nonspecific hypervigilant information
processing pattern among those with PTSD. However, another possibi-
lity is that the present study's sample was underpowered to detect
subtle effects of stimulus type. Moreover, only Blood, Anatomy and
Morbid categories from the TCI were analyzed in our study. Therefore,
future research should use a larger sample size and also examine the
other two TCI categories (Sex and Aggressive Movement) to enable
additional comparisons.
10. Conclusions
The present study findings support the previously suggested hypoth-
esis that the perception of Rorschach inkblots as containing traumatic
contents represents a breakthrough of intrusive traumatic imagery
among those with PTSD (Viglione et al., 2012). Our findings also
generate additional hypotheses that should be explored in future
studies. One such hypothesis is that intrusive memories are elicited
by perceptual properties of the inkblots primed by the traumatic
experience. Another hypothesis is that phrases with Morbid content
contains less perceptual information and that the higher frequency of
Morbid responses observed in the Rorschach protocols of individuals
with PTSD may stem from another mechanism.
Previous research has mainly focused on the conceptual or semantic
associations between the traumatic experience and the processing of
incoming stimuli in a current setting, those with PTSD have been thought
to allocate attention to stimuli that were conceptually related to trauma
through meaning via explicit memory representations. Cognitive-based
intervention therapies for PTSD, such as Cognitive Processing Therapy
(Reisick, Monson, & Chard, 2007) are, in fact, based on the premise that
PTSD develops due to changes in the meaning of previous cognitions
following traumatic event exposure, such as a change from a thought that
“the world is a just place in which people get what they deserve” to “the
world is an unpredictable, chaotic environment” (Ehlers & Clark, 2000;
Janoff-Bulman, 1989). However, it is our contention that, in accordance
with an accumulating body of research in recent years, our findings suggest
the presence of another mechanism of action in PTSD: one in which
attention is elevated when encountering stimuli that have been perceptually
primed, organized in implicit memory representations, and associated with
impending danger. If confirmed in future studies, this may have significant
implications for PTSD treatment methodologies: this newly identified
mechanism may be resilient to standard psychological intervention techni-
ques that focus solely on altering conceptual, semantic-based cognition.
Development of novel methods to reduce perceptually generated
PTSDsymptoms may be warranted.
Acknowledgement
The authors would like to thank Shira Chana Bienstock for her
thorough editorial and scientific review of this manuscript. The authors
would also like to thank Mirit Mazor Hadad for her help in evaluating
the Rorschach phrases that were used in this study.
G. Zukerman et al.
Table 1A
Trauma content index distractor phrase examples.
Anatomy distractors Blood distractors
Smelly scull A pond of blood
Exposed intestine Streaming blood
Brain tissue Splashing blood
Skeleton muscle Congealed blood
A pair of ribs A bloody fluid
Spinal cord Flowing blood
Liver lobe Umbilical blood
Gall bladder Spilled blood
Tail bone Fresh blood
A pair of lungs Red blood
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