EUROPEAN JOURNAL OF
PSYCHOTRAUMATOLOGY æ
REVIEW ARTICLE
The impact of cultural differences in self-representation
on the neural substrates of posttraumatic stress disorder
Belinda J. Liddell1* and Laura Jobson2,3
1
School of Psychology, University of New South Wales Australia, Sydney, Australia; 2School of Psychological
Sciences, Monash University, Clayton, Australia; 3Monash Institute of Cognitive and Clinical Neurosciences,
Clayton, Australia
A significant body of literature documents the neural mechanisms involved in the development and
maintenance of posttraumatic stress disorder (PTSD). However, there is very little empirical work considering
the influence of culture on these underlying mechanisms. Accumulating cultural neuroscience research clearly
indicates that cultural differences in self-representation modulate many of the same neural processes proposed
to be aberrant in PTSD. The objective of this review paper is to consider how culture may impact on the
neural mechanisms underlying PTSD. We first outline five key affective and cognitive functions and their
underlying neural correlates that have been identified as being disrupted in PTSD: (1) fear dysregulation; (2)
attentional biases to threat; (3) emotion and autobiographical memory; (4) self-referential processing; and (5)
attachment and interpersonal processing. Second, we consider prominent cultural theories and review the
empirical research that has demonstrated the influence of cultural variations in self-representation on the
neural substrates of these same five affective and cognitive functions. Finally, we propose a conceptual model
that suggests that these five processes have major relevance to considering how culture may influence the
neural processes underpinning PTSD.
Keywords: Culture; self-construal; self-representation; individualist; collectivisit; individualistic; collectivistic; posttraumatic
stress disorder; PTSD; trauma; neurocircuitry; emotion; attention; memory; self; attachment; interpersonal
Highlights of the article
Cultural variations in individualistic-collectivistic self-representation modulate many of the same neural and
psychological processes disrupted in PTSD.
“ These commonly affected processes include fear perception and regulation mechanisms, attentional biases (to
threat), emotional and autobiographical memory systems, self-referential processing and attachment systems.
“ A conceptual model is proposed whereby culture is considered integral to the development and maintenance of
PTSD and its neural substrates.
“
*Correspondence to: Belinda J. Liddell, School of Psychology, UNSW Australia, Sydney, NSW, 2052,
Australia, Email: b.liddell@unsw.edu.au
This paper is part of the Special Issue: The neurobiology of PTSD. More papers from this issue can be found
at www.ejpt.net
For the abstract or full text in other languages, please see Supplementary files under ‘Article Tools’
Received: 19 November 2015; Revised: 12 May 2016; Accepted: 14 May 2016; Published: 13 June 2016
esearch indicates that posttraumatic stress disorder (PTSD) is a universal phenomenon observed
cross-culturally (Figueira et al., 2007; Foa, Keane,
Friedman, & Cohen, 2009). However, it remains unknown
as to whether the processes implicated in the development,
maintenance, and treatment of PTSD are culturally
similar. This limitation extends to our current understanding of the neural mechanisms underpinning PTSD.
There is currently an impressive body of literature documenting the neural substrates of PTSD, yet there is very
R
little empirical work investigating the impact of culture on
these systems. The importance of considering cultural
influences is strengthened by research emerging from the
field of cultural neuroscience that clearly indicates culture
modulates many of the same neural and psychological
processes aberrant in PTSD. This review will first provide a
focused overview of the current understanding regarding
core neural mechanisms underpinning PTSD. Second, we
will consider prominent cultural theories. Third, a summary of investigations into how culture modulates neural
European Journal of Psychotraumatology 2016. # 2016 Belinda J. Liddell and Laura Jobson. This is an Open Access article distributed under the terms of the Creative
Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or
format, and to remix, transform, and build upon the material, for any purpose, even commercially, under the condition that appropriate credit is given, that a link to the license
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Citation: European Journal of Psychotraumatology 2016, 7: 30464 – http://dx.doi.org/10.3402/ejpt.v7.30464
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Belinda J. Liddell and Laura Jobson
correlates relevant to the key processes affected in PTSD is
presented. Finally, we will develop a model that can be
used to guide future empirical work in the domain of
PTSD.
Neurocircuitry underpinning five key disrupted
mechanisms in PTSD
Across the spectrum of PTSD psychopathology, there are
five key affective and cognitive functions that have been
repeatedly identified as being disrupted in PTSD and have
major relevance to conceptualising how culture may influence the neural substrates of PTSD. These are: (1) fear
dysregulation; (2) attentional biases; (3) emotional memory
impairments; (4) self-referential processing deficits; and (5)
attachment and interpersonal processing alterations.
Fear dysregulation
PTSD is characterised by core disturbances in the neural
balance between prefrontal regulatory systems over fear
and arousal systems. The central neurocircuitry model of
PTSD purports that hyperactivity within fear-processing
networks (including the amygdala, insula, and hippocampus), coupled with reduced regulatory activity within
medial prefrontal cortical (MPFC) regions and cognitive
control centres (dorsolateral prefrontal cortex; DLPFC),
results in an inability to control fear responses (see reviews
by Hayes, Hayes, & Mikedis, 2012; Jovanovic & Ressler,
2010; Patel, Spreng, Shin, & Girad, 2012; Pitman et al.,
2012; Shin & Liberzon, 2010). Functionally, disruptions to
these neural systems in PTSD are reflected in a hypervigilance to threat (see ‘Attention biases’ section), compromised fear learning and extinction processes (Jovanovic
& Ressler, 2010; Milad et al., 2009), and heightened
stress sensitivity and poor regulation over strong negative emotional reactions (New et al., 2009). An alternative
dysregulation model, whereby hyperactive medial prefrontal regions overmodulate fear networks, has also
been proposed for a dissociative subtype of PTSD (Lanius
et al., 2010). This neural pattern is associated with
emotional withdrawal and numbing symptoms, deactivation of arousal systems, as well as depersonalisation and
derealisation symptoms (Lanius, 2015; Lanius, Brand,
Vermetten, Frewen, & Spiegel, 2012).
Aberrant fear extinction, perception, and regulation
processes in PTSD may also be due to problems with
contextual processing (Liberzon & Sripada, 2008). A
striking feature of PTSD is that re-experiencing symptoms
usually occur in a safe context, suggesting that those with
PTSD have difficulty updating their contextual representations of the traumatic event (Hayes et al., 2011; Van
Rooij, Geuze, Kennis, Rademaker, & Vink, 2015), as well
as generalised context-processing deficits (Van Rooij et al.,
2014). Dysregulation between MPFC and hippocampal
networks, vital to healthy contextualisation of emotional
events (Maren, Phan, & Liberzon, 2013), form the neural
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basis for poor extinction of fear memories in safe contexts
in PTSD (Jovanovic, Kazama, Bachevalier, & Davis, 2012;
Parsons & Ressler, 2013). Critically, augmented fear
responses in PTSD may reflect poor utilisation of contextual information to appropriately modulate emotional
and behavioural responses (Garfinkel et al., 2014).
Attention biases
A central feature of the aetiology of PTSD is a hypersensitivity to trauma-related stimuli that generalises to all
threat cues (Cisler & Koster, 2010), reflecting an overall
inefficiency in attentional resource allocation (Suvak &
Barrett, 2011). Three mechanisms are proposed to account
for this attentional bias in PTSD: (1) a hyperactive threat
detection system engaging the amygdala (El KhouryMalhame et al., 2011); (2) problems disengaging from
threat (Pineles, Shipherd, Mostoufi, Abramovitz, &
Yovel, 2009), associated with diminished engagement of
frontoparietal attention systems (Blair et al., 2013); and
(3) heightened avoidance of threat (Aupperle, Melrose,
Stein, & Paulus, 2012), associated with dysregulated
ventrolateral prefrontal cortical (VLPFC) and dorsal
anterior cingulate cortex (dACC) functioning (Fani et al.,
2012). In reality, it’s likely that all forms of attentional
biases operate in PTSD, with a recent study demonstrating
that attention bias variability is an important predictor of
acute PTSD symptoms (Iacoviello et al., 2014).
Emotion memory
The hallmark of PTSD is the re-experiencing symptoms
that involve distressing and involuntary intrusive memories of the traumatic event (Brewin, 2015). Prominent
models of PTSD suggest that intrusions stem from
fragmented, perceptual-based representations of the trauma in memory (Brewin, 2011), resulting from a breakdown
in the hippocampalventromedial prefrontal cortex
(VMPFC) network and precuneus during the consolidation period following trauma exposure (Brewin, 2011).
Impairments in these networks intersect with the systems
governing dysregulated fear processing and learning,
including the amygdala, interfering with consolidation of
both trauma-related and new emotional memories.
Another important aspect to the remembering of
trauma is a memory trade-off, with biases towards recall
of centralised information and the ‘‘gist’’ of an event under
conditions of high arousal (McGaugh, 2013), to the
detriment of recalling peripheral or contextual information (Christianson, 1992; Labar, 2007). The encoding of
memories that are gist-based and lacking contextual
details is proposed to be associated with PTSD memory
distortions (Hayes et al., 2011; Hayes, Vanelzakker, &
Shin, 2012; Williams et al., 2007), which is governed by
significant alterations in the functional pathway between
the hippocampus and MPFC (Jin et al., 2014). Changes
in amygdala functioning, alongside the fusiform gyrus,
appear to be critically involved in enhancing memory for
Citation: European Journal of Psychotraumatology 2016, 7: 30464 – http://dx.doi.org/10.3402/ejpt.v7.30464
Impact of cultural differences in self-representation on PTSD neural substrates
central details of aversive events (Kensinger, 2009), influencing the wider hippocampusVMPFC memory network
(Waring & Kensinger, 2011). Overgeneralisation of episodic memories has also been found to be associated with
abnormalities in the connectivity between the hippocampus and the MPFC (Xu et al., 2012). We propose that preexisting biases towards attending to central or gist-based
versus contextual cues, which may have a cultural basis,
may influence how traumatic events are encoded, consolidated, and later retrieved. This will be examined in the
‘Cultural differences in attention biases’ section.
Self-referential processing
PTSD patients often exhibit disturbances in self-referential
processing, namely the manner in which an individual
evaluates the self in relation to others (Lanius, Bluhm, &
Frewen, 2011). The self-memory system model poses that
trauma represents a threat to one’s core sense of self that
is difficult to reconcile with autobiographical knowledge
(Conway, 2005). Violations to self-understanding and
worldview following trauma is reflected clinically in negative appraisals of the self, others, and the world (Ehlers
& Clark, 2000), which could be influenced by cultural
factors.
Altered self-referential processing in PTSD also appears to have a specific neural basis. In one functional
magnetic resonance imaging (fMRI) study, PTSD participants were slower to respond to self-relevant statements
and demonstrated reduced VMPFC activity when compared with healthy controls (Bluhm et al., 2011). In
another study, Frewen et al. (2011) found that women
with PTSD following abuse trauma showed abnormal
neural response patterns in the pregenual region of the
ventral anterior cingulate cortex (vACC) when viewing
their face and listening to positive trait adjectives. This
region of the brain is linked to self-referential processing,
alongside other medial prefrontal regions (Northoff et al.,
2006). Meta-analyses show that PTSD patients routinely
activate the retrosplenial cortex, precuneus (Sartory et al.,
2013), and posterior cingulate gyrus (Ramage et al., 2013)
during trauma or negative information processing*
regions that are also associated with self-referential
processing (Northoff et al., 2006). The involvement of
these neural systems in PTSD supports the notion that
functional alterations following trauma is related to selfidentity and self-concept (Brewin, 2011).
Attachment and interpersonal processing
Trauma exposure can significantly disrupt the attachment
and interpersonal processing systems that normally
assist coping with difficult events (Charuvastra & Cloitre,
2008). Insecure adult attachment style can impact on
the ability of attachments to regulate negative emotions
and confidence in available social support (Cloitre, StovallMcClough, Zorbas, & Charuvastra, 2008), which may be
functionally related to reduced hippocampal cell density
(Quirin, Gillath, Pruessner, & Eggert, 2010). Conversely,
the presence of supportive attachment figures may be
critical to recovery from PTSD. Research has demonstrated that attachment priming can attenuate attentional
biases to threat in PTSD (Mikulincer, Shaver, & Horesh,
2006) and increase activity within safety networks during
pain exposure in healthy individuals, including the
VMPFC (Eisenberger et al., 2011)*the key region responsible for fear extinction, healthy emotion regulation,
and memory functioning. Overall, evidence of the benefit
of social support for recovery from PTSD is mixed, with
models suggesting that PTSD erodes the ability to harness
social support and attachments (Bryant, 2016). Furthermore, oxytocin*a neuropeptide with widespread targets
including the amygdala and hippocampus and important
for facilitating attachment in mammals (Meyer-Lindenburg, Domes, Kirsch, & Heinrichs, 2011)*has been found
to impact on a variety of the behavioural, neural, and
neuroendocrine dysregulations observed in PTSD (Olff,
2012). Findings suggest that oxytocin reduces the acute
stress response (Pitman, Orr, & Lasko, 1993) and improves
neural functioning in emotion regulation (Olff et al., 2015)
and reward networks (Nawijn et al., 2016) in PTSD
patients, and is currently being examined as a potential
therapeutic agent (Olff et al., 2015).
There is also a growing interest in the role of interpersonal
factors in regulating emotional responses, including extreme negative emotions that define anxiety and mood
disorders (Hofmann, 2014). A recent socio-interpersonal
model of PTSD highlights the importance of considering
the impact of interpersonal processes on the posttraumatic
experience (Maercker & Hecker, 2016; Maercker & Horn,
2012). It is proposed that relevant interpersonal processes
can be situated on three levels; (1) the individual level,
comprising social affective states that relate to others; (2) the
close relationship level, which includes attachment, social
support, and interpersonal interpretation of traumatic
events; and (3) the distant social level, which represents
culture and society. Alterations to interpersonal processing
across these three levels are proposed to predict response
trajectories to traumatic stress (Maercker & Horn, 2012).
This draws on the wider mental health literature that
highlights how sociocultural context affects the expression,
evaluation, and understanding of mental health symptoms,
including explanatory models, coping strategies, and helpseeking behaviours (Alarcon et al., 2009).
Culture and self
Culture has been conceptualised as an information system
which is shared by a group and transmitted across
generations, allowing groups to survive and derive meaning from life events (Kitayama & Juang, 2013). There is a
growing recognition in the psychological sciences that
different cultural groups differ in ways of thinking,
behaving, and engaging with the world (Henrich, Heine,
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Belinda J. Liddell and Laura Jobson
& Norenzayan, 2010). The worldview of an individual
is gradually shaped by ongoing engagement with the
reinforced practices of their cultural group, affecting the
psychological landscape of the self (Kitayama & Uskul,
2011).
Psychological work on culture has placed the self as
central in formulating models, generating research questions, and theoretically integrating a vast array of
empirical findings (Kitayama & Uskul, 2011). From these
analyses, it has emerged that people in different cultures
have strikingly different understandings of the self. In
Western, individualistic cultures, the self is perceived as an
independent, autonomous entity, which emphasises private internal aspects (i.e., thoughts, emotions) and aims
to be unique, realise internal attributes, and promote
personal goals. In contrast, collectivistic, non-Western
cultures perceive the self as an interdependent entity that
emphasises external, public aspects (such as social roles,
relationships) and social harmony (Markus & Kitayama,
2010). Such culturally divergent self-construals have been
found to impact the very nature of individual experience
and modulate brain functions governing emotional
well-being, thinking, and behaviour. Therefore, cultural
variations in self-representation can be viewed as an
important factor in preserving homeostasis in the brain
and body (Cacioppo & Bernston, 2011).
It is noted that the present review is focused specifically
on cultural differences in representations of the self and
how such variations might influence the neural correlates
of PTSD. Indeed, the field of cultural neuroscience itself,
as will be outlined in ‘Cultural neuroscience evidence’
section, has been dominated by studies focused on cultural
differences in self-orientation as it reflects a core framework for meaning-making in the social world that has
cross-cultural relevance (Cross, Hardin, & Gercek-Swing,
2011; Oyserman, 2011). However, some commentators
argue for a broader understanding of culture in experimental psychology and neuroscience (Cohen, 2009;
Henrich et al., 2010). Indeed, it has been suggested that
self-construal itself is not entirely represented by the
independentinterdependent dichotomy but rather is a
multifactorial construct (Harb & Smith, 2008). Other
cultural dimensions have been established by pioneering
work conducted in the context of organisational psychology, which include temporal focus, indulgence-restraint
and highlow power distance (Hofstede, 2001). Cohen
(2009) argues that religion, socioeconomic status, and region
within a country are alternative factors to individualism
collectivism that critically drive cultural variations.
Unfortunately, there is very little empirical work conducted with regard to how these various cultural constructs influence brain function. As such, while this review
recognises the importance of considering other cultural
dimensions in the context of PTSD, understanding how
cultural variations in self-representation explicitly influ-
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ences the neural substrates of PTSD represents an
important first step (Oyserman, Coon, & Kemmelmeier,
2002).
Cultural neuroscience evidence
An expanding evidence base challenges the pervasive
assumption that basic cognitive, perceptual, behavioural,
and emotional processes are governed by neural systems
that function universally in all humans. Rather, cultural
theories suggest that variations in the representation of
cultural values may strengthen specific neural processes
that diverge by culture, consolidating particular behavioural response patterns, cognitions, and affective tendencies (Han et al., 2013; Han & Northoff, 2008;
Kitayama & Uskul, 2011; Markus & Kitayama, 2010).
Cultural neuroscience and psychological research demonstrates that human information processing is fundamentally shaped by culturally derived self-representations
that manifest at both the population and individual level
(Oyserman, Novin, Flinkenflögel, & Krabbendam, 2014;
Park & Huang, 2010). Neural and psychological processes
involved in fear processing and regulation, attention,
memory encoding and retrieval, self-referential attributions, and attachment style are modulated by variation in
self-representation, reflecting the same five processes that
have been identified as central to known neural substrates
of PTSD. If culture influences the neural correlates
underpinning the very processes proposed to be involved
in PTSD, this may have significance for understanding the
neural substrates of PTSD. Here, we review the cultural
neuroscience literature relating to these processes.
Cultural differences in fear neurocircuitry and
regulation of negative emotions
Culture influences the bottom-up, automatic processing
of emotion, including the perception of biological fear
signals (Adams et al., 2010). Eye-tracking studies reveal
that participants from individualistic cultural groups view
faces using an inverted triangle pattern perceptual strategy,
whereas collectivistic participants focused on the central/
eye region, resulting in miscategorisation of fear and
disgust faces (Jack, Blais, Scheepers, Schyns, & Caldara,
2009). Martinez, Franco-Chaves, Milad, and Quirk (2014)
also found cultural differences in physiological arousal
responses during the habituation phase of a fear-learning
task, suggesting differences in orienting responses to novel
stimuli. These studies indicate that cultural factors shape
important automatic emotion perception processes that
are generally considered to be universal and fixed (Jack,
Garrod, Caldara, & Schyns, 2012).
Emerging research highlights the role of culture in
modulating amygdala responsivity (Derntl et al., 2012).
Of relevance to the processing of trauma, Chiao et al.
(2008) demonstrated that enhanced amygdala activation
to fear expressed by members of one’s own cultural group
Citation: European Journal of Psychotraumatology 2016, 7: 30464 – http://dx.doi.org/10.3402/ejpt.v7.30464
Impact of cultural differences in self-representation on PTSD neural substrates
when compared with fear expressed by members of
another cultural group, reflecting the amygdala’s sensitivity to detecting potential threat to self. Similarly, oxytocin
may be involved in motivating in-group favouritism by
facilitating not only the development of trust, empathy,
and prosociality but also preferential treatment of ingroup and denigration of out-group members (De Dreu
et al., 2010; De Dreu, Greer, Van Kleef, Shalvi, &
Handgraaf, 2011). These findings suggest that culture
operates on the processing of fear, which may have
implications for understanding the neural basis of traumatic stress reactions and recovery across cultural groups.
Contextual processing biases have been found to
differ between cultural groups. For instance, collectivistic
participants draw more on social-based contextual cues
to make emotional judgements of target face cues relative
to individualistic participants (Masuda et al., 2008).
These findings highlight that culturally influenced schemas influence cognitive processes, affecting attention
allocation to emotional situations and appraisals. Given
those with PTSD have been found to have deficits in
contextual processing and culture influences this contextual processing, questions arise regarding how PTSD and
culture interact to influence the perception and evaluation
of context.
Disruptions in emotional regulation play a pivotal
role in PTSD. Ford and Mauss (2015) highlight that
culture influences the employment of specific emotion
regulation strategies and the physiological consequences
of implementing these strategies, thereby shaping overall
well-being. Cultural differences have been found to automatically influence preferred regulation strategy (Mauss,
Bunge, & Gross, 2008) and the neural substrates of
emotion regulation (De Greck et al., 2012). Research has
shown that while suppression is linked with reduced wellbeing in those from individualistic cultural backgrounds,
suppression is unrelated to, or even beneficial for, the
functioning of those from collectivistic cultural backgrounds (see Ford & Mauss, 2015). This is attributed to
the collectivist view of promoting social harmony by
minimising the impact of personal distress on others
through suppressing the exhibition of strong emotions.
Moreover, culture plays a role in determining the preferred
homeostatic emotional state that regulation strategies
serve to maintain. For instance, individualist cultures
prefer high-arousal positive affective states (e.g., excitement), whereas collectivists prefer low-arousal positive
states (e.g., calmness) (Tsai, Knutson, & Fung, 2006).
Another study found that collectivistic participants preferentially activated the ventral anterior insula (related
to the autonomic modulation of internal homeostasis),
whereas an individualist group engaged the dorsal anterior insula (visceral-somatosensory/control) during evaluation of social narratives (Immordino-Yang, Yang, &
Damasio, 2014). These studies suggest that culture
impacts on the experience and neural correlates of arousal
and affective states. Further, it is suggested that cultural
attributes could play a role in modulating the nature of
disruptions to emotion regulation functioning pivotal
in PTSD.
Cultural differences in attention biases
Behavioural and cognitive studies have highlighted the
role of culture in modulating perception of the visual environment (Goh & Park, 2009; Kitayama & Uskul, 2011).
Behavioural data have shown that those from collectivist
cultures are more likely to attend to contextual and holistic
aspects of visual cues than those from individualist
cultures, who tend to fixate on object salience, localised
details, and central objects (Nisbett & Masuda, 2003; Park
& Huang, 2010). Research has demonstrated that these
cultural differences are reflected in neural activation
patterns (Park & Hwang, 2010). In one study, individualistic participants demonstrated greater selective functioning within the fusiform face area during face processing
(consistent with object perception biases) compared with
collectivistic participants, who showed a trend towards
enhanced ‘‘landmark’’ processing in the lingual gyrus to
house stimuli (Goh et al., 2010).
Moreover, individualists demonstrate faster eye movements to objects (Chua, Boland, & Nisbett, 2005) and
stronger engagement in frontoparietal attention control
regions when performing a culturally non-preferred
version of a spatial judgement (Hedden, Ketay, Aron,
Markus, & Gabrieli, 2008) or global/local processing
task (Liddell et al., 2015). These biases in attention
allocation during encoding also impacts on memory
(Gutchess & Indeck, 2009): collectivist participants have
better memory for contextual information and display
difficulty recalling centrally presented information
when paired with different backgrounds (e.g., Nisbett &
Masuda, 2003).
Cultural differences in autobiographical memory
Cross-cultural research has repeatedly demonstrated
systematic cultural differences in autobiographical remembering; individualists frequently provide self-focused
accounts of specific, personal events when compared with
those from collectivistic cultures, who tend to focus on
general group activities, social interactions, and significant
others (Jobson, Moradi, Ramimi-Movaghar, Conway, &
Dalgleish, 2014; Ross & Wang, 2010). While studies have
not examined the neural mechanisms underlying these
findings, recent work investigating cultural influences on
neural processes underpinning information processing
challenge the assumption that brain processes underlying
autobiographical memories are universally similar (Ross
& Wang, 2010).
Studies have indicated that cultural variability plays
a role in the consolidation and retrieval of trauma
memories in PTSD (Jobson, 2009). For example, Jobson
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Belinda J. Liddell and Laura Jobson
and Dalgleish (2014) found that the more the trauma
memory reflected culturally appropriate remembering,
the fewer the number of intrusions. However, other
studies have recently demonstrated that trauma survivors
with PTSD from different cultural backgrounds evidence
similar disruptions in their autobiographical remembering (Jobson et al., 2014). Such findings highlight
the need for further research to investigate the influence
of culture on the neural correlates of autobiographical
memory, as central to memory disruptions in PTSD.
Cultural differences in self-referential processing
PTSD models emphasise that trauma fundamentally
affects the neural basis of self-concept (Brewin, 2011),
but the empirical basis for these assertions are largely
based on an individualistic sense of self-meaning (Jobson,
2009). Self-representations of those from both individualistic and collectivistic cultures have been traced to the
VMPFC (Ng, Han, Mao, & Lai, 2010). However, for those
from collectivist cultures the idea of self also includes
reflections of others, and consequently significant others
are also represented in the VMPFC (Ng et al., 2010). Zhu,
Zhang, Fan, and Han (2007) compared neural activity
in collectivists and individualists when making judgements
about the self versus a significant other (i.e., mother).
They found that individualistic participants showed
heightened activation in the regions of the MPFC
and pregenual area of the vACC when making judgements about themselves, and collectivistic participants recruited regions of the MPFC when making
judgements about themselves and their mothers. Another
study found that collectivists showed stronger engagement
of pain processing centres in the brain (dACC, anterior
insula) when perceiving others in emotional distress
(Cheon et al., 2013). These findings provide strong
evidence that cultural values shape neural functioning
of self-referential systems (Park & Huang, 2010). Therefore, the question arises whether culture modulates
the specific neural basis underpinning disrupted selfreferential processing in PTSD.
Cultural differences in attachment and support
Attachment is an important regulator of emotions but
cultural differences in support seeking can substantially
influence how attachment figures are utilised to cope with
stress (Sherman, Kim, & Taylor, 2009). To individualists,
the role of others is often to provide self-validation, with
freely chosen relationships a means for meeting individual
goals. Conversely, for collectivists, others are essential
to self-definition, with goals and motivations significantly
shaped and dominated by the needs of others in the
immediate family or community (Adams & Plaut, 2003;
Markus & Kitayama, 1991).
Culture has the potential to modulate two key features
of social support: the decision to seek social support and
the impact of social support seeking on health and well-
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being (Sherman et al., 2009). Research has shown that
when deciding whether to seek social support, collectivists have a greater awareness of their impact on close
others, are more sensitive to relational constraints, and
believe help-seeking can negatively affect group harmony
(Sherman et al., 2009). By contrast, individualists seem to
focus more on the problem requiring support (Kim,
Sherman, & Taylor, 2008; Sherman et al., 2009; Taylor,
Welch, Kim, &amp