Posttraumatic stress disorder is associated with limited executive resources in a working memory task.

Patients with posttraumatic stress disorder (PTSD) can show declines in working memory. A dual-task design was used to determine whether these impairments are linked to executive control limitations. Participants performed a Sternberg memory task with either one or four letters. In the dual-task condition, the maintenance period was filled with an arrow flanker task. PTSD patients were less accurate on the working memory task than were controls, especially in the dual-task condition. In the single-task condition, both groups showed similar patterns of brain potentials from 300 to 500 ms when discriminating old and new probes. However, when taxed with an additional task, the event-related potentials (ERPs) of the PTSD group no longer differentiated old and new probes. In contrast, interference resolution processes in both the single- and dual-task conditions of the flanker task were intact. The lack of differentiation in the ERPs reflects impaired working memory performance under more difficult, dual-task conditions. Exacerbated difficulty in performing a working memory task with concurrent task demands suggests a specific limitation in executive control resources in PTSD.

Executive functioning in posttraumatic stress disorder: Understanding how inhibition, switching, and test modality affect reaction times.

OBJECTIVE: Posttraumatic stress disorder (PTSD) has been linked to deficits in executive functioning, but the literature suggests these associations are inconsistent. Results vary depending on the task used, test modality, and the specific subdomain being measured, such as inhibitory control (interference resolution, response inhibition) or set shifting (task switching, rule switching). Notably, deficits are more consistently observed in computerized tasks that measure precise reaction times (RTs) than in classic paper-and-pencil measures, but few studies have parsed specific executive functioning deficits in PTSD using detailed analyses of RT data. METHOD: The present study used a cued-switching Stroop Task to examine both interference resolution and task switching in 28 veterans with PTSD and 28 age-matched controls. Each trial required attending to a randomly presented cue and responding to the specified target while ignoring irrelevant or opposing information. Analyses of RT distributions estimated both Gaussian (normal) and ex-Gaussian (exponential) parameters. RESULTS: Veterans with PTSD had slower and more variable RTs than the controls on trials that required ignoring conflicting information (interference resolution, d' = .68). These effects were confined to the normal distribution, not to excessively slow responses (as estimated by ex-Gaussian parameters). Veterans with PTSD also showed modestly slower RTs on trials that required switching between cues, but Bayesian evidence for this was weak, and measures by ex-Gaussian parameters were not significant. CONCLUSIONS: These results highlight the importance of examining executive functioning in PTSD with a more nuanced approach, as clarity around these deficits may have important implications for future intervention and rehabilitation strategies. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Attentional bias for trauma-related words: exaggerated emotional Stroop effect in Afghanistan and Iraq war veterans with PTSD.

BACKGROUND: Post-traumatic stress disorder (PTSD) involves debilitating symptoms that can disrupt cognitive functioning. The emotional Stroop has been commonly used to examine the impact of PTSD on attentional control, but no published study has yet used it with Afghanistan and Iraq war veterans, and only one previous study has compared groups on habituation to trauma-related words. METHODS: We administered the emotional Stroop, the Beck Depression Inventory (BDI), and the PTSD Checklist (PCL) to 30 veterans with PTSD, 30 military controls, and 30 civilian controls. Stroop word types included Combat, Matched-neutral, Neutral, Positive and Negative. RESULTS: Compared to controls, veterans with PTSD were disproportionately slower in responding to Combat words. They were also slower and less accurate overall, did not show interference on Negative or Positive words relative to Neutral, and showed a trend for delayed but successful habituation to Combat words. Higher PCL and BDI scores also correlated with larger interference effects. CONCLUSIONS: Because of its specificity in detecting attentional biases to trauma-related words, the emotional Stroop task may serve as a useful pre- and post task with intervention studies of PTSD patients.

The Association Between Loneliness and Maladaptive Moods and Beliefs: A Pilot Study in U.S. Veterans.

INTRODUCTION: Loneliness is a powerful predictor of several medical and psychiatric conditions that are highly prevalent in Veterans, including depression and PTSD. Despite this, few studies have examined loneliness in Veterans or how best to intervene upon Veteran loneliness. Additional empirical research is needed in these areas in order to define clear intervention targets and improve Veteran care. MATERIALS AND METHODS: In this pilot study, we used 62 Veterans' self-reported loneliness and symptoms of post-traumatic stress to examine whether specific symptom clusters of post-traumatic stress were associated with greater loneliness. Post-traumatic stress was measured using the PTSD Checklist for DSM-5, and responses were further parsed into four symptom clusters: intrusions, avoidance, negative alterations in mood and cognition (excluding the social withdrawal item), and alterations in arousal and reactivity. RESULTS: Results revealed that only the negative alterations in mood and cognition symptom cluster was associated with increased Veteran loneliness, even after adjusting for sociodemographic factors, social isolation, and symptoms of depression. These analyses were also repeated using a subset of our sample (n = 29) who completed repeated measures of the PTSD Checklist. Results again revealed that the same symptom cluster predicted Veteran loneliness over 1 year later. CONCLUSIONS: This pilot study demonstrates the value of a publicly available PTSD measure for identifying lonely Veterans and highlights how reducing negative alterations in mood and cognition may serve as a potentially critical target for future Veteran loneliness interventions.

Impaired response inhibition in veterans with post-traumatic stress disorder and mild traumatic brain injury.

Combat veterans with post-traumatic stress disorder (PTSD) can show impairments in executive control and increases in impulsivity. The current study examined the effects of PTSD on motor response inhibition, a key cognitive control function. A Go/NoGo task was administered to veterans with a diagnosis of PTSD based on semi-structured clinical interview using DSM-IV criteria (n = 40) and age-matched control veterans (n = 33). Participants also completed questionnaires to assess self-reported levels of PTSD and depressive symptoms. Performance measures from the patients (error rates and reaction times) were compared to those from controls. PTSD patients showed a significant deficit in response inhibition, committing more errors on NoGo trials than controls. Higher levels of PTSD and depressive symptoms were associated with higher error rates. Of the three symptom clusters, re-experiencing was the strongest predictor of performance. Because the co-morbidity of mild traumatic brain injury (mTBI) and PTSD was high in this population, secondary analyses compared veterans with PTSD+mTBI (n = 30) to veterans with PTSD only (n = 10). Although preliminary, results indicated the two patient groups did not differ on any measure (p > .88). Since cognitive impairments could hinder the effectiveness of standard PTSD therapies, incorporating treatments that strengthen executive functions might be considered in the future. (JINS, 2012, 18, 1-10).

Are the neural correlates of stopping and not going identical? Quantitative meta-analysis of two response inhibition tasks.

Neuroimaging studies have utilized two primary tasks to assess motor response inhibition, a major form of inhibitory control: the Go/NoGo (GNG) task and the Stop-Signal Task (SST). It is unclear, however, whether these two tasks engage identical neural systems. This question is critical because assumptions that both tasks are measuring the same cognitive construct have theoretical and practical implications. Many papers have focused on a right hemisphere dominance for response inhibition, with the inferior frontal gyrus (IFG) and the middle frontal gyrus (MFG) receiving the bulk of attention. Others have emphasized the role of the pre-supplementary motor area (pre-SMA). The current study performed separate quantitative meta-analyses using the Activation Likelihood Estimate (ALE) method to uncover the common and distinctive clusters of activity in GNG and SST. Major common clusters of activation were located in the right anterior insula and the pre-SMA. Insular activation was right hemisphere dominant in GNG but more bilaterally distributed in SST. Differences between the tasks were observed in two major cognitive control networks: (1) the fronto-parietal network that mediates adaptive online control, and (2) the cingulo-opercular network implicated in maintaining task set (Dosenbach et al., 2007) and responding to salient stimuli (Seeley et al., 2007). GNG engaged the fronto-parietal control network to a greater extent than SST, with prominent foci located in the right MFG and right inferior parietal lobule. Conversely, SST engaged the cingulo-opercular control network to a greater extent, with more pronounced activations in the left anterior insula and bilateral thalamus. The present results reveal the anterior insula's importance in response inhibition tasks and confirm the role of the pre-SMA. Furthermore, GNG and SST tasks are not completely identical measures of response inhibition, as they engage overlapping but distinct neural circuits.

Stress Inoculation Training (SIT-NORCAL), Part 1: The Development and Preliminary Evaluation of a Psychological Performance Training Protocol.

BACKGROUND: Stress inoculation training (SIT) interventions have demonstrated promise within military contexts for human performance enhancement and psychological health applications. However, lack of manualized guidance on core content selection, delivery, and measurement processes has limited their use. PURPOSE: The purpose of this study was to develop and evaluate a comprehensive SIT intervention protocol to enhance the performance and health of military personnel engaged in special warfare and first-response activities. METHODS: Multidisciplinary teams of subject matter experts (n = 19) were consulted in protocol generation. The performance improvement/human performance technology (HPT) model was used in the selection, refinement, and measurement of core skills. The protocol was trialed and refined (44 cohorts, n = =300; 2013-2020) to generate the results. RESULTS: Four primary aims were achieved: (1) The generation of a flexible, evidence-based/evidence-driven psychological performance and health sustainment hybrid, SIT-NORCAL. (2) Manualized content and process guidance. (3) The creation of multimedia materials using evidence-based methodologies. (4) The design of initial measurement systems. Preliminary quality improvement analysis demonstrated positive results using standard-of-care and performance enhancement assessments. CONCLUSION: Hybridized human performance and psychological health sustainment protocols represent a paradigm shift in the delivery of psychological performance training with the potential to overcome barriers to success in traditional care. Further study is needed to determine the effectiveness and reach of SIT-NORCAL.

Stress Inoculation Training (SIT-NORCAL), Part 2: A Pilot Study Among Explosive Ordnance Disposal Special Warfare Enablers.

BACKGROUND: Despite being a well-supported strategy, Stress Inoculation Training (SIT) has not been fully incorporated in the advancement of human performance among most military personnel. The RAND Study recommendations for maximizing SIT's potential within high-risk/ high-intensity occupational groups were used in designing the Core Training protocol targeting psychological performance, SIT-NORCAL (Part 1). PURPOSE: The current project (Part 2) sought to further develop the protocol as a health and human performance hybrid through quality improvement analysis of the content, process, and measurement elements for use in the human performance context. METHODS: Evidence-based/evidence-driven methodologies were used in collaborative design tailored to the unique needs of special warfare enablers specializing in Explosive Ordnance Disposal (n = 17). The resultant three-phase training was conducted with a novice group (n = 10) using standardized measurements of collaboration, human performance, and adaptive capabilities on identified training targets. RESULTS: Process elements demonstrated high feasibility, resulting in high collaboration and trainee satisfaction. Significant improvements in psychological performance targets were observed pre- to post-training, and during an Adaptive Environmental Simulation designed by unit members. Two weeks post-training, unit members (n = 5) responded to an actual crash of an F-16 aircraft; measurements indicated maintenance of skill set from training to real-world events. CONCLUSION: Deployment of the elements in the SIT-NORCAL protocol demonstrated early feasibility and positive training impact on occupationally relevant skills that carried over into real-world events.

The Specificity of Inhibitory Control Deficits in Post-Traumatic Stress Disorder: A Dissociation Between the Speed and Reliability of Stopping.

Inhibitory control over thoughts, emotions, and actions is challenging for people with Post-Traumatic Stress Disorder (PTSD). Whether specific aspects of inhibitory control are differentially affected in PTSD remains an open question. Here we examined performance on two popular response inhibition tasks in 28 combat Veterans with PTSD and 27 control Veterans. We used a Hybrid variant that intermixed 75% Go trials, 12.5% NoGo trials, and 12.5% Stop trials. Parameters from an ex-Gaussian race model (Matzke et al., 2017) provided estimates of stopping speed (µ Stop) and stopping variability (τ Stop). Participants with PTSD had higher error rates on NoGo trials, replicating previous results. The estimated probability of "trigger failures" (failures to launch inhibitory control) on Stop trials was also higher in PTSD patients, suggesting that sustained attention was a common deficit in the two tasks. Stopping variability was also increased in participants with PTSD, which supports a difficulty with maintaining task goals. Conversely, stopping speed did not differ between patients and controls, suggesting that core inhibitory processes were intact. These results demonstrate a dissociation between the speed and reliability of motor response inhibition in PTSD, and suggest that top-down inhibitory control was deployed less consistently in participants with PTSD.

Consequences of emotional stimuli: age differences on pure and mixed blocks of the emotional Stroop.

BACKGROUND: Studies of aging and emotion suggest that older adults show diminished responsiveness to negative information, possibly resulting from increased emotion regulation, but the mechanisms accounting for this effect are uncertain. METHODS: To examine whether aging affects the allocation of attention to negative stimuli, we compared 20 younger and 20 older adults on 2 versions of the emotional Stroop task: "pure blocks," in which all words in each block were either emotional or neutral, and "mixed blocks," a pseudorandomized design in which either a negative emotional or a neutral category word was always followed by six neutral words. The emotional Stroop task typically elicits slower reaction times for naming the font color of negative emotional words compared to neutral, but no studies have examined the effects of aging on the immediate and sustained components of the emotional Stroop effect. RESULTS: Both groups showed an emotional Stroop effect on pure blocks manifest as slower RTs on the emotional, relative to the neutral, block. However, only younger adults showed persistent slowing that carried over from emotional words onto subsequent neutral words in mixed blocks. CONCLUSION: These results suggest that the consequences of emotional stimuli may differ with age. Younger and older adults showed equivalent interference from the emotional words themselves, but older adults did not show a sustained effect of negative information.

An Event-Related Potential Study of Cross-modal Morphological and Phonological Priming.

The current work investigated whether differences in phonological overlap between the past- and present-tense forms of regular and irregular verbs can account for the graded neurophysiological effects of verb regularity observed in past-tense priming designs. Event-related potentials were recorded from sixteen healthy participants who performed a lexical-decision task in which past-tense primes immediately preceded present-tense targets. To minimize intra-modal phonological priming effects, cross-modal presentation between auditory primes and visual targets was employed, and results were compared to a companion intra-modal auditory study (Justus, Larsen, de Mornay Davies, & Swick, 2008). For both regular and irregular verbs, faster response times and reduced N400 components were observed for present-tense forms when primed by the corresponding past-tense forms. Although behavioral facilitation was observed with a pseudopast phonological control condition, neither this condition nor an orthographic-phonological control produced significant N400 priming effects. Instead, these two types of priming were associated with a post-lexical anterior negativity (PLAN). Results are discussed with regard to dual- and single-system theories of inflectional morphology, as well as intra- and cross-modal prelexical priming.

Angry and Fearful Face Conflict Effects in Post-traumatic Stress Disorder.

In the presence of threatening stimuli, post-traumatic stress disorder (PTSD) can manifest as hypervigilance for threat and disrupted attentional control. PTSD patients have shown exaggerated interference effects on tasks using trauma-related or threat stimuli. In studies of PTSD, faces with negative expressions are often used as threat stimuli, yet angry and fearful facial expressions may elicit different responses. The modified Eriksen flanker task, or the emotional face flanker, has been used to examine response interference. We compared 23 PTSD patients and 23 military controls on an emotional face flanker task using angry, fearful and neutral expressions. Participants identified the emotion of a central target face flanked by faces with either congruent or incongruent emotions. As expected, both groups showed slower reaction times (RTs) and decreased accuracy on emotional target faces, relative to neutral. Unexpectedly, both groups showed nearly identical interference effects on fearful and neutral target trials. However, post hoc testing suggested that PTSD patients showed faster RTs than controls on congruent angry faces (target and flanker faces both angry) relative to incongruent, although this finding should be interpreted with caution. This possible RT facilitation effect with angry, but not fearful faces, also correlated positively with self-report measures of PTSD symptoms. These results suggest that PTSD patients may be more vigilant for, or primed to respond to, the appearance of angry faces, relative to fearful, but further study is needed.

Stress inoculation training outcomes among veterans with PTSD and TBI.

OBJECTIVE: Stress inoculation training (SIT) is a cognitive-behavioral treatment that has demonstrated potential as a nontrauma based intervention for veterans with posttraumatic stress disorder (PTSD). The purpose of this study was to explore the efficacy of a novel 3-phase group formulation of SIT applied to a naturalistic population of veterans with PTSD and traumatic brain injury (TBI). The goals were to reduce symptoms of PTSD and depression, improve perceived functioning, and increase treatment initiation among veterans who were reticent to initiate established evidence-based and trauma-focused therapies. METHOD: A program development and evaluation archival analysis of 65 veterans engaged in SIT over an 18-month period at an outpatient VA PTSD clinic was conducted. Participants completed baseline self-report measures of PTSD and depression symptoms, substance use, and perceived performance. RESULTS: Paired samples t tests were used to evaluate pre- to posttreatment gains and demonstrated significant reductions in PTSD (PTSD Checklist, d = 0.66) and depression symptoms (Beck Depression Inventory, d = 0.67), increases in aspects of perceived stress tolerance and performance in multiple life domains, as well as improvements in both social and occupational functioning (Situational Adaptation to Stress Scale, d = 1.26). Eighty-eight percent of the intent-to-treat sample followed through with the recommended follow-up treatment. CONCLUSIONS: The results of this study provide preliminary support for the use of this SIT protocol in reducing symptoms of PTSD and depression, improving performance, and increasing rates of treatment initiation in evidence-based and trauma-focused treatments. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Left inferior frontal gyrus is critical for response inhibition.

BACKGROUND: Lesion studies in human and non-human primates have linked several different regions of prefrontal cortex (PFC) with the ability to inhibit inappropriate motor responses. However, recent functional neuroimaging studies have specifically implicated right inferior PFC in response inhibition. Right frontal dominance for inhibitory motor control has become a commonly accepted view, although support for this position has not been consistent. Particularly conspicuous is the lack of data on the importance of the homologous region in the left hemisphere. To investigate whether the left inferior frontal gyrus (IFG) is critical for response inhibition, we used neuropsychological methodology with carefully characterized brain lesions in neurological patients. RESULTS: Twelve individuals with damage in the left IFG and the insula were tested in a Go/NoGo response inhibition task. In alternating blocks, the difficulty of response inhibition was easy (50% NoGo trials) or hard (10% NoGo trials). Controls showed the predicted pattern of faster reaction times and more false alarm errors in the hard condition. Left IFG patients had higher error rates than controls in both conditions, but were more impaired in the hard condition, when a greater degree of inhibitory control was required. In contrast, a patient control group with orbitofrontal cortex lesions showed intact performance. CONCLUSION: Recent neuroimaging studies have focused on a highly specific association between right IFG and inhibitory control. The present results indicate that the integrity of left IFG is also critical for successful implementation of inhibitory control over motor responses. Our findings demonstrate the importance of obtaining converging evidence from multiple methodologies in cognitive neuroscience.

Hemispheric asymmetries in the perceptual representations of words.

The representation of words in sentences can involve the activation and integration of perceptual information. For example, readers who are asked to view pictures of objects relating to a word in a sentence are influenced by perceptual information in the sentence context-readers are faster to respond to a picture of a whole apple after reading, "There is an apple in the bag," than after reading, "There is an apple in the salad." The purpose of this study was to examine how the two cerebral hemispheres use perceptual information about words as a function of sentence context. Patients who had damage to the left or right hemisphere and age-matched control participants read sentences that described, but did not entail, the shape or state of an object. They then made recognition judgments to pictures that either matched or mismatched the perceptual form implied by the sentence. Responses and latencies were examined for a match effect -- faster and more accurate responses to pictures in the match than mismatch condition -- controlling for comprehension ability and lesion size. When comprehension ability and lesion size are properly controlled, left-hemisphere-damaged patients and control participants exhibited the expected match effect, whereas right-hemisphere-damaged participants showed no effect of match condition. These results are consistent with research implicating the right hemisphere in the representation of contextually relevant perceptual information.

The effect of orbitofrontal lesions on the error-related negativity.

Current theories of orbitofrontal cortex (OFC) function suggest that this region should participate in the generation of error-related signals associated with the outcomes of actions. We investigated the impact of lesions to OFC on the error-related negativity (ERN), an electrophysiological marker of performance monitoring. Four OFC patients and eight control subjects participated in a manual Stroop task while brain electrical activity was recorded. We found that the ERN was attenuated in the patient group. Three of the patients also had impaired error correction performance, but all showed normal post-error slowing. These findings suggest OFC involvement in monitoring and evaluation of ongoing performance.

Enhanced Attentional Bias Variability in Post-Traumatic Stress Disorder and its Relationship to More General Impairments in Cognitive Control.

Hypervigilance towards threat is one of the defining features of post-traumatic stress disorder (PTSD). This symptom predicts that individuals with PTSD will be biased to attend to potential dangers in the environment. However, cognitive tasks designed to assess visual-spatial attentional biases have shown mixed results. A newer proposal suggests that attentional bias is not a static phenomenon, but rather is characterized by fluctuations towards and away from threat. Here, we tested 28 combat Veterans with PTSD and 28 control Veterans on a dot probe task with negative-neutral word pairs. Combat-related words and generically negative words were presented in separate blocks. Replicating previous results, neither group showed a bias to attend towards or away from threat, but PTSD patients showed greater attentional bias variability (ABV), which correlated with symptom severity. However, the cognitive processes indexed by ABV are unclear. The present results indicated that ABV was strongly correlated with standard deviation at the reaction time (RT) level and with excessively long RTs (ex-Gaussian tau) related to cognitive failures. These findings suggest an overall increase in response variability unrelated to threat-related biases in spatial attention, and support a disruption in more general cognitive control processes in PTSD.

Dissociation between working memory performance and proactive interference control in post-traumatic stress disorder.

Deficits in working memory (WM) and cognitive control processes have been reported in post-traumatic stress disorder (PTSD), in addition to clinical symptoms such as hypervigilance, re-experiencing, and avoidance of trauma reminders. Given the uncontrollable nature of intrusive memories, an important question is whether PTSD is associated with altered control of interference in WM. Some studies also suggest that episodic memory shows a material-specific dissociation in PTSD, with greater impairments in verbal memory and relative sparing of nonverbal memory. It is unclear whether this dissociation applies to WM, as no studies have used identical task parameters across material. Here we tested 29 combat Veterans with PTSD and 29 age-matched control Veterans on a recent probes WM task with words and visual patterns in separate blocks. Participants studied four-item sets, followed by a probe stimulus that had been presented in the previous set (recent probe) or not (nonrecent probe). Participants with PTSD made more errors than controls, and this decrement was similar for verbal and visual stimuli. Proactive interference from items recently presented, but no longer relevant, was not significantly different in the PTSD group and showed no relationship to re-experiencing symptom severity. These results demonstrate that PTSD is not reliably associated with increased intrusions of irrelevant representations into WM when non-emotional stimuli are used. Future studies that use trauma-related material may provide insight into the flashbacks and intrusive thoughts that plague those with PTSD.

Source memory retrieval is affected by aging and prefrontal lesions: behavioral and ERP evidence.

Age-related deficits in source memory have been attributed to alterations in prefrontal cortex (PFC) function, but little is known about the neural basis of such changes. The present study examined the time course of item and source memory retrieval by recording event-related potentials (ERPs) in patients with focal lesions in lateral PFC and in healthy older and young controls. Both normal aging and PFC lesions were associated with decrements in item and source memory. However, older controls showed a decrease in item hit rate with no change in false alarms, whereas patients showed the opposite pattern. Furthermore, ERPs revealed notable differences between the groups. The early positive-going old/new effect was prominent in the young but reduced in patients and older adults, who did not differ from each other. In contrast, older adults displayed a prominent left frontal negativity (600-1200 ms) not observed in the young. This left frontal effect was substantially smaller and delayed in the patients. The current results provide novel insights into the effects of aging on source memory and the role of the lateral PFC in these processes. Older controls appeared to adopt alternate memory strategies and to recruit compensatory mechanisms in left PFC to support task performance. In contrast, the lateral frontal patients were unable to use these mechanisms, thus exhibiting difficulties with strategic memory and monitoring processes.

Intact error monitoring in combat Veterans with post-traumatic stress disorder.

The error-related negativity (ERN) is a neuroelectric signature of performance monitoring during speeded response time tasks. Previous studies indicate that individuals with anxiety disorders show ERN enhancements that correlate with the degree of clinical symptomology. Less is known about the error monitoring system in post-traumatic stress disorder (PTSD). PTSD is characterized by impairments in the regulation of fear and other emotional responses, as well as deficits in maintaining cognitive control. Here, combat Veterans with PTSD were compared to control Veterans in two different versions of the flanker task (n=13 or 14 per group). Replicating and extending previous findings, PTSD patients showed an intact ERN in both experiments. In addition, task performance and error compensation behavior were intact. Finally, ERN amplitude showed no relationship with self-reported PTSD, depression, or post-concussive symptoms. These results suggest that error monitoring represents a relative strength in PTSD that can dissociate from cognitive control functions that are impaired, such as response inhibition and sustained attention. A healthy awareness of errors in external actions could be leveraged to improve interoceptive awareness of emotional state. The results could have positive implications for PTSD treatments that rely on self-monitoring abilities, such as neurofeedback and mindfulness training.