Eur Arch Psychiatry Clin Neurosci (2013) 263:575583
DOI 10.1007/s00406-013-0394-3
ORIGINAL PAPER
Regional cerebral changes and functional connectivity
during the observation of negative emotional stimuli
in subjects with post-traumatic stress disorder
Monica Mazza Daniela Tempesta
Maria Chiara Pino Alessia Catalucci
Massimo Gallucci Michele Ferrara
Received: 12 September 2012 / Accepted: 18 January 2013 / Published online: 6 February 2013
Springer-Verlag Berlin Heidelberg 2013
Abstract Patients with post-traumatic stress disorder
(PTSD) exhibit exaggerated brain responses to emotionally
negative stimuli. Identifying the neural correlates of emotion
regulation in these subjects is important for elucidating the
neural circuitry involved in emotional dysfunction. The aim of
this study was to investigate the functional connectivity
between the areas activated during emotional processing of
negative stimuli in a sample of individuals affected by PTSD
compared to a group of healthy subjects. Ten subjects with
PTSD (who survived the LAquila 2009 earthquake) and ten
healthy controls underwent fMRI during which the partici-
pants observed 80 images: 40 pictures with negative emo-
tional valence and 40 neutral (scrambled) stimuli. A higher
activation was found in the left posterior (LP) insula for PTSD
group and in the ventromedial prefrontal cortex (vmPFC) for
the healthy group. Two sets of Granger causality modeling
analyses were performed to examine the directed influence
from LP-insula and vmPFC to other brain regions. Activity in
the vmPFC in the healthy group while observing negative
stimuli predicted activity in several subcortical regions and
insula, while in the PTSD group the LP-insula exerted a
positive directed influence on several cortical regions. The
hyperactivation in PTSD subjects of subcortical areas such as
the insula would underlie the emotional, social, and relational
difficulties of PTSD patients.
M. Mazza (&)
D. Tempesta
M. C. Pino
M. Ferrara
Department of Life, Health and Environmental Sciences,
University of LAquila, Via Vetoio, Localita` Coppito,
67100 LAquila, Italy
e-mail: monica.mazza@cc.univaq.it
A. Catalucci
M. Gallucci
Department of Neuroradiology, San Salvatore Hospital,
LAquila, Italy
Keywords Granger causality modeling (GCM)
Emotion
regulation
Ventromedial prefrontal cortex
Insula

Functional connectivity
Introduction
Post-traumatic stress disorder (PTSD) is a complex syndrome
that includes different symptoms: anxiety, hyperarousal and
dissociative disturbances. In particular, individuals with PTSD
experience feelings of detachment from others, disinterest in
once pleasurable activities, and a restricted range of emotions,
a class of problems referred to as emotional numbing [2].
Emotional numbing (EN) may lead to a reduction of emo-
tional ability and affective inclination for others [28] and,
generally, to a decrease of social interactions [30]. Patients with
PTSD experience intense psychological pain due to the con-
tinuous reliving of the trauma, exhibit exaggerated responses to
emotionally negative stimuli, and tend to misinterpret innocu-
ous stimuli as potential threats [46]. Identifying the neural
correlates of emotion regulation in these subjects is important to
advance our understanding of how the brain perceives, pro-
duces, and experiences emotions, as well as to elucidate the
neural circuitry involved in emotional dysfunction and
inhibition.
Several studies have shown an increase of emotional
intensity and of amygdala reactivity following the exposure
to high-intensity traumatic events [20, 41]. This exagger-
ated amygdala responsivity in PTSD seems to be accom-
panied by a diminished medial prefrontal cortex activity
during viewing of affective pictures [3, 10, 26].
Indeed, recent studies have reported an increased acti-
vation of limbic structures, such as insula and amygdala,
during emotional tasks in PTSD individuals compared to
healthy subjects [15, 16, 44].
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The observation of negative stimuli activates the medial Table 1 Socio-demographic and clinical information of participants
nociceptive system (insula, medial thalamic nuclei, and Controls PTSD (SD) U p
anterior cingulate cortex (ACC)). There is a general (SD)
agreement that emotion influences pain perception [3537].
Age (years) 24.00 (4.40) 22.02 (2.70) 98.5 0.615
In particular, functional imaging studies have allowed to
clarify the role of the medial and lateral pain system Gender 10 Females 3 M; 7 F 90 0.280
comprising insula, medial thalamic nuclei, and anterior Education (years) 16.33 (2.5) 15 (2.05) 93 0.282
cingulate cortex [9, 13]. The limbic, insular, and somato- STAI state 23.36 (11.43) 43.82 (11.43) 20 0.023
sensory cortices are part of the neural circuitry of negative STAI trait 21.81 (10.84) 43.54 (7.50) 25 0.043
emotion [9, 13, 22]. Recent functional imaging studies also BDQ 1.27 (1.27) 3.54 (1.03) 55 0.001
pointed to the involvement of the insula during the pre- CAPS total score 0 78.20 (21.18)
sentation of negative facial affects in PTSD subjects [16, CAPS intrusion 0 23.70 (7.31)
subscale
31]. Increased activity in the insula was also associated
CAPS numbing 0 34.30 (9.69)
with self-reported negative valence of emotional pictures
subscale
[1].
CAPS hyperarousal 0 24.30 (8.04)
To further delineate the neural substrate of emotion subscale
dysregulation in the PTSD syndrome, in this study, we DTS total score 33.87 (13.68) 69.70 (27.94) 7.5 0.004
investigated for the first time the effective connectivity [19] DTS intrusion 11.13 (5.51) 19.18 (8.13) 14 0.021
between the specific brain areas activated during emotional subscale
processing of negative stimuli. The study of functional DTS avoidance 8.75 (6.38) 23.18 (11.77) 13 0.016
connectivity is of fundamental importance not only in basic subscale
neuroscience but also in neurophysiopathology, because DTS hyperarousal 14.00 (6.02) 25.72 (10.12) 13.5 0.016
deficits of connectivity in PTSD patients may allow to subscale
estimate the severity of the symptoms and to direct reha- Empathy quotient 50.25 (10.89) 41.71 (17.70) 31.5 0.005
bilitative interventions on more severely impaired emo- Mean scores (and standard deviations) to the psychological tests
tional functions. Based on recent fMRI studies [31], we separately for PTSD and control subjects. The results of the statistical
hypothesized that subjects with PTSD lack the cortical comparisons (MannWhitney U test, and probability) are also shown
control of emotional processes necessary for the monitor- STAI State-Trait Anxiety Inventory, BDQ Beck Depression Ques-
tionnaire (Italian adaptation), DTS Davidson Trauma Scale, CAPS
ing and modulation of emotional responses. Clinician-Administered PTSD Scale

Materials and methods
Participants
The study included 20 participants, all survivors of the
LAquila 2009 earthquake. Ten subjects (PTSD group; 7
women and 3 men, mean age SD: 22 2.7 years) were
affected by PTSD. The remaining ten subjects (Control
group; 10 women, mean age SD: 23 4.4 years)
experienced the same traumatic event, being present in the
LAquila area during the earthquake, but they did not show
the PTSD symptoms at clinical evaluation (see below).
Socio-demographic and clinical information of all partici-
pants are summarized in Table 1.
The participants were first administered the Davidson
Trauma Scale (DTS) that comprises three sub-scales
assessing intrusion, avoidance/numbing, and hyperarousal
symptoms [12]. After this preliminary screening, all par-
ticipants underwent the Clinician-Administered PTSD
Scale (CAPS, Version DX) [6]. Participants were assigned
to the PTSD group if they met the current DSM-IV criteria
for PTSD, according to CAPS 1-2 scoring rules, which
consider a symptom suitable if it was endorsed with at least
occasional frequency and moderate intensity, and which
assign a diagnosis only if a significant impairment was
reported as well.
Individuals were excluded from the study if any of the
following applied: seizure disorder, progressive neurologi-
cal and/or systemic disorders, metallic implants, significant
unstable concurrent medical illness, hormone replacement
therapy, electroconvulsive or light therapy, administration
of concomitant medication that could alter mood or cerebral
metabolism (e.g., benzodiazepines, antidepressants, mood
stabilizers, stimulants, and steroids) within 30 days prior to
screening, family history of mental health problems or
previous traumatic events, history of any substance/alcohol
abuse or dependence within the past 6 months (nicotine
dependence was allowed), and pregnancy.
All participants underwent a further clinical evaluation
through the State-Trait Anxiety Inventory [32, 43] and the
Beck Depression Questionnaire (BDQ, Italian validation)
[47], a partially modified version of the Beck Depression
Inventory [4]. According to the normative data of the
Italian sample, six participants with PTSD (54.5 % of the

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sample) had comorbid high statetrait anxiety levels. None
of the participants had comorbid depression.
The study was conducted at the San Salvatore Hospital
of LAquila, Italy. The protocol of the study was approved
by the local Institutional Ethical Committee, and the par-
ticipants gave their written informed consent, according to
the Declaration of Helsinki.
Social cognition measure
Empathy Quotient (EQ) [11]. The EQ was designed to
examine empathy competences. It is composed of 60
questions: 40 questions eliciting empathy and 20 filler
items. The EQ has a forced choice format and can be self-
administered.
Experimental design: stimuli and paradigm
In this experimental protocol, we assessed cerebral reac-
tivity to images with highly negative emotional valence (40
stimuli) selected from the International Affective Picture
System (IAPS) [27] and contrasted to neutral stimuli (40
scrambled stimuli). The negative pictures included scenes
of war, wounds, and grief. Mean rating for the selected
pictures in the IAPS database was 2.63 (SD:.94) for
valence and 5.56 (SD:.67) for arousal.
Negative and neutral pictures were separately presented
in 8 blocks (5 pictures each). Each picture, presented for
1.6 s, was alternated with a 1.2-s control state with a fix-
ation cross. After two alternating blocks of negative and
scrambled images, a resting phase with a fixation point
lasting 14 s was provided. The order of conditions was
maintained fixed. Within each run, images were presented
in a randomized order with no repetition of the same
image. At the beginning of each session, 5-s visual
instructions informed the volunteers about the upcoming
task. The stimuli were displayed on a screen with a black
background and made visible by a mirror mounted on the
interior of the head coil. Participants were asked to observe
all images carefully. At the end of the fMRI session, par-
ticipants evaluated the valence of each image on the Self-
Assessment Manikin scale (SAM). The SAM valence scale
consists of a cartoon-type figure in which nine human
emotional expressions, ranging from smiling and happy to
frowning and unhappy, are represented on a nine-point
scale [7].
Image acquisition
All participants were scanned with a General Electric 1.5 T
whole-body scanner (GE HD), at the Department of Neu-
roradiology, San Salvatore Hospital of LAquila, Italy. dure resulted in a normalized four-dimensional data rep-
To scan whole-brain structural volumes, we used a
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T1-weighted 3D FSPGR sequence on sagittal plane (slice
thickness 1 mm; voxel size 1 mm3; FOV 260 mm; matrix
256 9 256; TR 8.7 ms; TE 4.2 ms, flip angle 15). The
blood oxygen leveldependent (BOLD) signal was
obtained using echoplanar imaging (EPI) sequences (23
contiguous transversal slices, covering both the cerebral
hemispheres; slice thickness 4.4 mm; FOV 280 mm;
matrix 64 9 64; TR 2,000 ms; TE 60 ms; flip angle 60).
fMRI data preprocessing
Preprocessing and statistical analysis of the fMRI data
were performed using Brain Voyager QX 4.6 software.
Due to T1 saturation effects, the first three scans of each
run were discarded from the analysis. Preprocessing of
functional scans included motion correction and removal of
linear trends from voxel time series. A three-dimensional
motion correction was performed by means of a rigid body
transformation to match each functional volume to the
reference volume (the fourth volume) estimating three
translation and three rotation parameters.
These parameters were stored in log files and inspected
to check that estimated head movement was not larger than
approximately half a voxel (2 mm) for the functional run
and that no task-correlated movement had occurred [18].
Spatial normalization was performed for structural and
functional datasets. The spatial normalization of the
structural volumes was performed in two steps. The first
step consisted in aligning the 3D MPRAGE dataset of each
subject with the stereotactic axes. For this step, the location
of the anterior commissure (AC), the posterior commissure
(PC), and two rotation parameters for midsagittal align-
ment were specified manually in the 3D dataset. In the
second step, the extreme points of the cerebrum were
specified. These points, together with the AC and PC
coordinates, were then used to scale the 3D datasets into
the dimensions of the standard brain of the Talairach and
Tournoux atlas [45] using a piecewise affine and continu-
ous transformation.
The co-registration transformation in BrainVoyager QX
was determined by concatenating an initial alignment
matrix obtained using the position parameters of the
functional and structural images with a fine tuning align-
ment matrix obtained by means of an intensity-driven
alignment algorithm.
The alignment between functional and anatomical scans
was finally checked by means of a thorough visual
inspection. Then, the rigid body AC-PC transformation
matrix and the piecewise affine Talairach grid scaling
transformation performed for the 3D anatomical dataset
were applied to co-registered functional data. This proce-
resentation (volume time course) for each functional run. In
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order to avoid quality loss due to successive data sampling,
spatial normalization was actually performed using a single
transformation matrix obtained by combining the different
spatial transformations described.
A random effect-group analysis was performed using
the general linear model [18]. One predictor of interest
(picture blocks) was considered, whereas baseline cor- Y, given that all other sources of influence have been taken
responded to the cross fixation blocks. The anatomical and
functional series were then co-registered in order to map
the fMRI activations on a high-resolution image.
The next phase was characterized by the application of
the Cluster-Level Statistical Estimator Threshold, an
algorithm which, through a Monte Carlo simulation, allows
the identification of the most likely clusters. The Cluster
Threshold plug-in allows a correction for multiple mea-
surements using the cluster size as a threshold value. It
represents a complementary method to the correction of
multiple measurements using as a threshold the intensity of
voxels (Bonferroni correction, a = .05) which is based on
the fundamental assumption that the activated areas tend to
show the signal changes on groups of spatially contiguous
voxels rather than in isolated groups [17]. We proceeded
then with an interpolation of tabular data to define an
acceptable threshold on the cluster size. Three-dimensional
statistical maps were overlaid on the Talairach-transformed
Montreal Neurological Institute T1-weighted brain tem-
plate (http://www.brededatabase.com). Activated areas
were obtained from the group activation maps of the
whole-brain analysis considering those voxels showing a
significant response (p \ .05 corrected) in the experimental
condition. The mean time course of the fMRI signal from
voxels belonging to a given activated area was analyzed for
each subject, and the individual BOLD responses to the
different stimulation conditions were characterized by the
BOLD signal intensity variation in each activated area.
Granger causality modeling analyses
Taking into account the anatomical variation across sub-
jects, the subject-specific peak voxel and ROI were defined
on individual maps. The selected ROIs were restricted to
the activated voxels detected by the group analysis in the
previous step. For each subject, the ROI was a 6-mm-
radius sphere centered on the peak activation coordinate,
identified as the voxel with the highest positive t-value.
The mean time course of the ROI for each subject was
calculated by averaging the time series of all voxels in the
ROI. Granger causality maps (GCM) were computed for a
given reference (ROI) by computing the influence mea-
sures Fx?y, Fy?x, and Fx
y, for every voxel, from the
average time course of the voxels in the ROI (as x) and the
voxel time course (as y). In accordance with the results
from the simulations, the influence difference term
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Eur Arch Psychiatry Clin Neurosci (2013) 263:575583
(Fx?y - Fy?x) was then computed for every voxel to form
the difference-GCM (dGCM), mapping influence to and
from the ROI over the brain. As defined by the Granger
causality theory, a discrete time series X[t] is said to
Granger cause a discrete time series Y[t] if the past
values of X improve the prediction of the current value of
into account [39].
Granger causality modeling analyses were performed
using the Brain Voyager Granger Causality Mapping plug-
in. The algorithms implemented in this program are
described in more detail by Goebel [21]. Briefly, Granger
causality modeling is used to examine directed influences
between brain regions. A small reference region, referred
to as a seed region, is defined as a set of voxels. The
average time course of activation across these voxels is
compared to the time course of activation in all other
voxels in the brain via a vector autoregressive algorithm.
This allows the identification and mapping of two kinds of
directed effect: regions that are influenced by the reference
region (that is, regions in which later activation can be
predicted by earlier activation in the reference region,
abbreviated as Ref2Vox) and regions that influence the
reference region (that is, regions in which earlier activation
can predict later activation in the reference region, abbre-
viated as Vox2Ref). Granger causality modeling does not
require any assumptions about the underlying anatomical
or functional connectivity between regions. The most
unbiased measure of directed influence is achieved by
taking the difference between the two measures of directed
influence, Ref2Vox-Vox2Ref, in which a positive differ-
ence is interpreted as directed influence onto the seed
region, and a negative difference as directed influence from
the seed region.
The Ref2Vox-Vox2Ref measurement is calculated sep-
arately at each voxel outside of the reference region, and
the voxelwise measures are used to form maps that are
overlaid on the anatomical images. Maps were defined on
an individual subject basis and then combined across
subjects via a voxelwise t test identifying voxels in which
activity was significantly different from zero. The analyses
were performed using preprocessed data, which included
spatial smoothing.
Two sets of Granger causality modeling analyses were
performed. The first set examined directed influence from
vmPFC identified individually for each healthy control
subject using the localizer scan. The second set examined
directed influence onto/from left posterior (LP) insula
region identified individually for patients with PTSD. The
vmPFC and LP-insula reference regions were defined using
region growing algorithms implemented in Brain Voyager.
The seed regions for the connectivity analyses were
chosen according to two criteria. The first was the maximal
Eur Arch Psychiatry Clin Neurosci (2013) 263:575583 579

difference of the intensity of activation measured in terms of
beta values observed between the two groups. The beta value
can be interpreted as the slope in a linear regression model; it
is, by definition, the change in y for a unit change in the
corresponding x. Therefore, vmPFC has been selected
because it was significantly more active in healthy subjects
compared to PTSD patients. Similarly, in the PTSD group,
LP-insula was chosen because it shows the largest activation
difference in the contrast between the two groups, as indi-
cated by Cluster Threshold plug-in analysis. The second
criterion implied the selection of brain areas previously found
to be particularly involved in tasks of emotional evaluation.
The size of each ROI was constrained to be between 100
and 200 voxels. With both the localizer-based reference
regions (vmPFC and LP-insula), we calculated positive and
negative influence during picture blocks viewing, com-
paring emotional versus neutral (scrambled) stimuli.
Results
valence evaluation (mean SD, PTSD: 2.78 .80; healthy
controls: 2.61 .69; t = .81, p = .42).
Emotional pictures versus neutral stimuli
From the analysis of the Cluster Threshold plug-in, we
identified the areas showing the highest number of active
voxels during the task. In the emotional versus scrambled
pictures contrast, a higher activation in PTSD was found in
the right precentral gyrus (t = -4.38; p \ .001), left pos-
terior insula (t = -4.59; p \ .001), right anterior insula
(t = -4.52; p \ .001), and in the parietal lobe, in partic-
ular in the right intraparietal sulcus (t = -4.26; p \ .001,
see Table 2). In the healthy control group compared to
PSTD group, we observed a higher activation in the frontal
lobe, in particular in the right superior frontal gyrus (t =
-4.44; p \ .001), in the ventromedial prefrontal cortex
(t = 4.92; p \ .001), and in the parietal cortex, in partic-
ular in bilateral inferior parietal lobe (left t = -5.46;
p \ .001; right t = -4.04, p \ .001, see Table 2).

Clinical measures Directed influence from vmPFC region in healthy

Between-groups differences for all the clinical variables
were assessed by means of MannWhitney U test (see
Table 1). PTSD subjects showed higher scores compared
to healthy controls in the Davidson Trauma Scale total
score, as well as in the three subscales (Intrusion, Avoid-
ance, and Hyperarousal). PTSD subjects also reported
significantly higher state and trait anxiety than controls.
According to the Italian normative data, 6 PTSD partici-
pants (85.7 % of the sample) had comorbid statetrait
anxiety disorder. None of the participants had comorbid
depression. The PTSD sample also showed lower Empathy
Quotient scores compared to healthy controls.
subjects
We selected the region (vmPFC) that was significantly
more active in the healthy subjects compared to PTSD, and
we examined positive directed influence from the reference
region to other brain regions (see Fig. 1a). Activity in the
vmPFC region in healthy subjects while observing negative
emotional stimuli predicted activity in right putamen
(x = 24; y = 13; z = -8), left putamen (x = -22; y = 15;
z = 0), left-mid/anterior insula (x = -34; y = -4; z = 0),
left posterior insula (x = 44; y = -8; z = 6), middle tem-
poral gyrus (x = 41; y = -69; z = 17), and occipital tem-
poral junction (x = -48; y = -58; z = 17).

Behavioral data: picture valence ratings Directed influence from LP-insula in PTSD

We used unpaired Students t test to compare valence ratings We examined directed influence from LP-insula to other
of the emotional stimuli in the two groups. PTSD and Control brain regions, chosen because it shows the largest activa-
groups did not show significant differences in the picture tion difference in the contrast between the two groups, as

Table 2 Activations for

Brain region Controls PTSD X Y Z Voxels t
contrast emotional versus
Beta value
scrambled pictures contrast
Right intraparietal sulcus -0.234 0.253 45 -28 49 270 -4.26
Right inferior parietal lobule -0.434 0.168 45 -34 37 290 -4.03
Left inferior parietal lobule -0.294 0.251 -51 -40 52 229 -5.46
Right precentral gyrus -0.166 0.302 33 -19 37 238 -4.38
Right superior frontal gyrus -0.312 0.180 24 -7 55 293 -4.44
Right anterior insula -0.216 0.233 24 17 -2 290 -4.52
Left posterior insula -0.191 0.307 -39 -22 25 281 -4.60
Ventromedial prefrontal cortex 0.373 -0.203 0 68 16 487 0,230556

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Fig. 1 Regions shown in green

have significantly positive
influence difference terms and
are thus indicated to be sources
of influence to the reference
ROI. Regions shown in blue
have significantly negative
influence difference terms and
are thus indicated to be targets
of influence from the reference
ROI. a Granger causality
analysis in healthy controls
from seed ROI in vmPFC,
negative versus scrambled
picture contrast: the vmPFC
influence over insula activity.
b In PTSD, left insula had
stronger influence over vmPFC
activity during the observation
of negative emotion images
compared with scrambled
stimuli

indicated by Cluster Threshold plug-in analysis (see
Fig. 1b).
In the PTSD group, the results show that LP-insula
exerted a positive directed influence on several cortical
regions: right posterior cingulate cortex (x = 11; y = 34;
z = 25), left posterior cingulate cortex (x = -9; y = -59;
z = 28), right thalamus (x = 4; y = -25; z = 0), right
medial prefrontal cortex (x = 8; y = 60; z = 11), middle
frontal gyrus (x = -34; y = 40; z = 17), frontal gyrus
(x = -56; y = -8; z = 11), and superior temporal gyrus
(x = 51; y = -17; z = 5).
Discussion
In the present study, we reported that subjects who devel-
oped a PTSD after the 2009 LAquila earthquake show a
higher reactivity to negative emotional stimuli in limbic
brain regions such as the insula. More importantly, the
application of Granger causality modeling allowed us to
show that PTSD is characterized by a modification of the
fronto-limbic functional connectivity. Such a dysfunction,
which leads to a reduced cortical control of limbic areas
that, in turn, result hyperactivated, may be the substrate of
the peculiar emotional symptoms of PTSD.
Our data are consistent with recent studies in subjects
who survived to the China earthquakes reporting functional
and structural alterations in frontal-limbic structures [29]
and, in particular, an exaggerated activation in amygdala
and insula, together with a reduced response in prefrontal
cortex. A stronger activation of the limbic areas in indi-
viduals with PTSD in the presence of emotionally negative
stimuli could lead the subjects to enact coping strategies
aimed at protecting themselves from the re-experience of
pain related to traumatic events [8, 40].
We also found a strong activation of frontal areas in
healthy subjects, which does not occur in subjects with
PTSD. The reduced activation of the frontal areas and the
high activation of the limbic areas in PTSD patients are
compatible with some neurophysiological evidence sug-
gesting that the limbic pathways evaluate emotional stimuli
very quickly and allow an immediate response without the
involvement of more complex information processing
systems, such as frontal and prefrontal cortex [9]. When
exposed to reminders of traumatic events, PTSD subjects
seem to recruit limbic regions, while exhibiting a decreased

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Fig. 1 continued
activity within heteromodal cortical areas [38]. This
decreased cortical activity could be the basis of avoidance and
numbing symptoms, which are typical of PTSD, and could
explain the fact that patients with PTSD and with high scores
in EN subscale may show a difficulty since the earliest phases
of emotion processing. The activation of fronto-limbic circuit
only in healthy subjects suggests the lack of mediation and
cortical control during the processing of emotional stimuli in
individuals with PTSD. This results in a dysfunctional hy-
peractivation of subcortical areas, in particular of the amyg-
dala and insula, which may cause emotional distress and
impaired social relationships of PTSD patients.
In agreement with previous studies [30], our PTSD
subjects obtained higher scores in Avoidance and Numbing
subscales, and lower empathy scores [34]. Negative events
related to the most distressing memories of the trauma
bring the subjects to enact coping strategies aimed at pro-
tecting themselves from the experience of pain and from
involuntary reactivation of memories related to traumatic
experiences [8, 30]. Suppression of contagion or lower
empathy might be an unconscious coping strategy aimed at
preventing the individual from being overwhelmed by the
581
stressful experiences [34]. Some authors indeed suggested
that lower empathy (as measured before the trauma) can be
a protective factor against PTSD [14]. Since our sample
was not tested before the earthquake, the protective value
of empathy is beyond the scope of this work.
Previous human imaging studies focusing on empathy
for others pain have consistently shown activations in
regions involved in the direct pain experience, particularly
the insula [5]. Clinical studies [25] report that insula
mediates emotion feelings [23]. The increase of insula
activity in PTSD subjects is correlated with the increase of
the alert threshold that can be used as security tool against
all threatening and negative stimuli. This mechanism
explains why these people show a deterioration in their
emotional processing, with an inability to recognize the
emotions of others [24, 42]. This result could be interpreted
as a hyperactivation of this structure in response to nega-
tive stimuli, or, more in general, as an enhancement of a
frightening threshold, which inappropriately evaluates a
stimulus as more threatening than it really is [30]. This
result suggests that empathy traits may, under some con-
ditions, modulate empathic brain responses [5].
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The functional connectivity method is designed to assess
the difference in time of activation of areas involved in
emotional processing and to infer how these areas influence
each other. We observed directed effects between frontal
and limbic areas indicating that the frontal areas drive or
Granger cause activity fluctuations in specific subre-
gions of the activated limbic areas, at least in normal
controls. From our results, we assume, in agreement with
Muller and collaborators [33], that PTSD subjects show an
overall pattern of directed influence in which the subcor-
tical areas influence cortical regions, which in turn influ-
ence the anterior insula.
This pattern of directed influence can be interpreted as
the neural correlate of emotional control. More specifically,
we assume that frontal areas are involved in generating and
maintaining an appropriate self-instruction for the current
emotional mapping and that the corresponding neural
representations act upon limbic areas. The hyperactivation
in PTSD subjects of subcortical areas such as the insula
that we observed here may underlie the emotional, social,
and relational difficulties of PTSD patients. In perspective,
the understanding of the neural correlates involved in acute
and chronic stress-related response may be a valuable
diagnostic tool, helping us to design appropriate and
effective methods of intervention and rehabilitation. A
potential limitation of the study is the absence of a direct
assessment of empathy before the earthquake; whether a
deficit of this ability precedes the triggering of the distur-
bance, instead of being a consequence of it, thus remains an
open question.
Since this study examined only pictures with a negative
and neutral valence, we cannot generalize our results to all
types of highly arousing stimuli. Future studies that include
positively valenced stimuli, controlled for arousal levels,
are needed in order to ascertain whether increases in insular
activity are specific to negative emotions. In addition, our
sample size was limited to female participants. Although
this sample size was sufficiently large for our hypothesis-
driven ROI approach to have adequate power to detect a
reliable change in the insula (as indexed by the random
effects analysis), larger sample sizes would provide enough
power to allow the multiple corrections needed in order to
perform more exploratory analyses using whole-brain
parametric tests. Such analyses may reveal other brain
regions involved in emotional regulation processes. Future
studies examining the relations between changes in insula
and prefrontal activity resulting from different emotion
regulatory strategies may provide a genuine breakthrough
in understanding the pathophysiology of mood disorders.
Acknowledgments This research has been partially supported by a
grant of the Fondazione Cassa di Risparmio della Provincia del-
lAquila (CARISPAQ 2011) to Michele Ferrara.
123
Eur Arch Psychiatry Clin Neurosci (2013) 263:575583
Conflict of interest None.
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