Catherine Deeprose

Can Playing the Computer Game “Tetris” Reduce the Build-Up of Flashbacks for Trauma? A Proposal from Cognitive Science

Background Flashbacks are the hallmark symptom of Posttraumatic Stress Disorder (PTSD). Although we have successful treatments for full-blown PTSD, early interventions are lacking. We propose the utility of developing a ‘cognitive vaccine’ to prevent PTSD flashback development following exposure to trauma. Our theory is based on two key findings: 1) Cognitive science suggests that the brain has selective resources with limited capacity; 2) The neurobiology of memory suggests a 6-hr window to disrupt memory consolidation. The rationale for a ‘cognitive vaccine’ approach is as follows: Trauma flashbacks are sensory-perceptual, visuospatial mental images. Visuospatial cognitive tasks selectively compete for resources required to generate mental images. Thus, a visuospatial computer game (e.g. “Tetris”) will interfere with flashbacks. Visuospatial tasks post-trauma, performed within the time window for memory consolidation, will reduce subsequent flashbacks. We predicted that playing “Tetris” half an hour after viewing trauma would reduce flashback frequency over 1-week. Methodology/Principal Findings The Trauma Film paradigm was used as a well-established experimental analog for Post-traumatic Stress. All participants viewed a traumatic film consisting of scenes of real injury and death followed by a 30-min structured break. Participants were then randomly allocated to either a no-task or visuospatial (“Tetris”) condition which they undertook for 10-min. Flashbacks were monitored for 1-week. Results indicated that compared to the no-task condition, the “Tetris” condition produced a significant reduction in flashback frequency over 1-week. Convergent results were found on a clinical measure of PTSD symptomatology at 1-week. Recognition memory between groups did not differ significantly. Conclusions/Significance Playing “Tetris” after viewing traumatic material reduces unwanted, involuntary memory flashbacks to that traumatic film, leaving deliberate memory recall of the event intact. Pathological aspects of human memory in the aftermath of trauma may be malleable using non-invasive, cognitive interventions. This has implications for a novel avenue of preventative treatment development, much-needed as a crisis intervention for the aftermath of traumatic events.

Key steps in developing a cognitive vaccine against traumatic flashbacks: visuospatial Tetris versus verbal Pub Quiz.

Background Flashbacks (intrusive memories of a traumatic event) are the hallmark feature of Post Traumatic Stress Disorder, however preventative interventions are lacking. Tetris may offer a ‘cognitive vaccine’ [1] against flashback development after trauma exposure. We previously reported that playing the computer game Tetris soon after viewing traumatic material reduced flashbacks compared to no-task [1]. However, two criticisms need to be addressed for clinical translation: (1) Would all games have this effect via distraction/enjoyment, or might some games even be harmful? (2) Would effects be found if administered several hours post-trauma? Accordingly, we tested Tetris versus an alternative computer game – Pub Quiz – which we hypothesized not to be helpful (Experiments 1 and 2), and extended the intervention interval to 4 hours (Experiment 2). Methodology/Principal Findings The trauma film paradigm was used as an experimental analog for flashback development in healthy volunteers. In both experiments, participants viewed traumatic film footage of death and injury before completing one of the following: (1) no-task control condition (2) Tetris or (3) Pub Quiz. Flashbacks were monitored for 1 week. Experiment 1: 30 min after the traumatic film, playing Tetris led to a significant reduction in flashbacks compared to no-task control, whereas Pub Quiz led to a significant increase in flashbacks. Experiment 2: 4 hours post-film, playing Tetris led to a significant reduction in flashbacks compared to no-task control, whereas Pub Quiz did not. Conclusions/Significance First, computer games can have differential effects post-trauma, as predicted by a cognitive science formulation of trauma memory. In both Experiments, playing Tetris post-trauma film reduced flashbacks. Pub Quiz did not have this effect, even increasing flashbacks in Experiment 1. Thus not all computer games are beneficial or merely distracting post-trauma - some may be harmful. Second, the beneficial effects of Tetris are retained at 4 hours post-trauma. Clinically, this delivers a feasible time-window to administer a post-trauma “cognitive vaccine”.

Assessing mental imagery in clinical psychology: a review of imagery measures and a guiding framework.

Mental imagery is an under-explored field in clinical psychology research but presents a topic of potential interest and relevance across many clinical disorders, including social phobia, schizophrenia, depression, and post-traumatic stress disorder. There is currently a lack of a guiding framework from which clinicians may select the domains or associated measures most likely to be of appropriate use in mental imagery research. We adopt an interdisciplinary approach and present a review of studies across experimental psychology and clinical psychology in order to highlight the key domains and measures most likely to be of relevance. This includes a consideration of methods for experimentally assessing the generation, maintenance, inspection and transformation of mental images; as well as subjective measures of characteristics such as image vividness and clarity. We present a guiding framework in which we propose that cognitive, subjective and clinical aspects of imagery should be explored in future research. The guiding framework aims to assist researchers in the selection of measures for assessing those aspects of mental imagery that are of most relevance to clinical psychology. We propose that a greater understanding of the role of mental imagery in clinical disorders will help drive forward advances in both theory and treatment.

Mood stability versus mood instability in bipolar disorder: A possible role for emotional mental imagery

A cognitive model of bipolar disorder suggests that mental imagery acts as an emotional amplifier of mood and may be heightened in bipolar disorder. First, we tested whether patients with bipolar disorder would score higher on mental imagery measures than a matched healthy control group. Second, we examined differences in imagery between patients divided into groups according to their level of mood stability. Mood ratings over approximately 6-months, made using a mobile phone messaging system, were used to divide patients into stable or unstable groups. Clinician decisions of mood stability were corroborated with statistical analysis. Results showed (I) compared to healthy controls, patients with bipolar disorder had significantly higher scores for general mental imagery use, more vivid imagery of future events, higher levels of intrusive prospective imagery, and more extreme imagery-based interpretation bias; (II) compared to patients with stable mood, patients with unstable mood had higher levels of intrusive prospective imagery, and this correlated highly with their current levels of anxiety and depression. The findings were consistent with predictions. Further investigation of imagery in bipolar disorder appears warranted as it may highlight processes that contribute to mood instability with relevance for cognitive behaviour therapy.

Cognitions in bipolar affective disorder and unipolar depression: imagining suicide.

Hales SA, Deeprose C, Goodwin GM, Holmes EA. Cognitions in bipolar affective disorder and unipolar depression: imagining suicide. u2028Bipolar Disord 2011: 13: 651–661.

An exploration of prospective imagery: the impact of future events scale.

BACKGROUNDnMental imagery of the future has clear clinical importance, although little is known about intrusive, prospective imagery of personally-relevant events. Currently, no measure is available to assess this.nnnAIMSnThe Impact of Future Events Scale (IFES) was created to assess the impact of intrusive, prospective, personally-relevant imagery. It was examined in relation to predictions about dysphoria.nnnMETHODnTo form the IFES, the IES-R (a measure of the impact of a past traumatic event on posttraumatic stress disorder symptomatology such as intrusive re-experiencing) was adapted item-by-item to assess intrusive pre-experiencing and imagery of specific, future events. Participants (N = 75) completed the IFES and assessments of depression, anxiety and general imagery use.nnnRESULTSnAs predicted, the IFES significantly and positively correlated with depression scores. Analyses using subgroups of non-dysphoric and mild-dysphoric participants confirmed that the mild-dysphoric group reported significantly higher IFES scores, indicating higher levels of pre-experiencing of the future and related hyperarousal and avoidance.nnnCONCLUSIONSnIFES provides a measure of the impact of pre-experiencing in the form of intrusive prospective, personally-relevant imagery, with sensitivity to group differences on the basis of depression scores. Further research is required to extend these finding into clinical depression and other psychopathological conditions.

Mental imagery and emotion in treatment across disorders: using the example of depression.

Abnormalities in mental imagery have been implicated in a range of mental health conditions. Imagery has a particularly powerful effect on emotion and as such plays a particularly important role in emotional disorders. In depression, not only is the occurrence of intrusive negative imagery problematic, but also the lack of positive (in particular, future-directed) imagery is important. The authors suggest that, in depression, imagery can exacerbate the effects of interpretation bias. This article outlines an experimental psychopathology subcomponents model of depression that focuses specifically on the role of imagery and interpretation bias in the maintenance of the disorder. The authors propose that negative intrusive imagery, a lack of positive imagery, and negative interpretation bias serve both independently and interactively to maintain depressed mood. Finally, the authors consider the implications of this imagery-based approach for the development of new cognitive treatments in this area.

Imagery in the aftermath of viewing a traumatic film: Using cognitive tasks to modulate the development of involuntary memory

Background and objectives Involuntary autobiographical memories that spring unbidden into conscious awareness form part of everyday experience. In psychopathology, involuntary memories can be associated with significant distress. However, the cognitive mechanisms associated with the development of involuntary memories require further investigation and understanding. Since involuntary autobiographical memories are image-based, we tested predictions that visuospatial (but not other) established cognitive tasks could disrupt their consolidation when completed post-encoding. Methods In Experiment 1, participants watched a stressful film then immediately completed a visuospatial task (complex pattern tapping), a control-task (verbal task) or no-task. Involuntary memories of the film were recorded for 1-week. In Experiment 2, the cognitive tasks were administered 30-min post-film. Results Compared to both control and no-task conditions, completing a visuospatial task post-film reduced the frequency of later involuntary memories (Expts 1 and 2) but did not affect voluntary memory performance on a recognition task (Expt 2). Limitations Voluntary memory was assessed using a verbal recognition task and a broader range of memory tasks could be used. The relative difficulty of the cognitive tasks used was not directly established. Conclusions An established visuospatial task after encoding of a stressful experience selectively interferes with sensory-perceptual information processing and may therefore prevent the development of involuntary autobiographical memories.

Prospective mental imagery as its link with anxiety and depression in prisoners.

Mental imagery is known to play a key role in the development and maintenance of depression and anxiety. Prisoners commonly experience psychological distress, but interventions to address this are currently lacking. We aimed to examine the link between prospective mental imagery and anxiety and depression among prisoners. One hundred twenty-three male prisoners from a Category C prison in southwest England participated in the study. They completed the Centre for Epidemiologic Studies Depression Scale (CES-D) and the General Anxiety Disorder Scale (GAD-7) to measure whether they experience depression and/or anxiety symptoms. Furthermore, they completed additional questionnaires to evaluate their prospective mental imagery. Results showed that 67.5% of prisoners presented with more depression symptoms and 27.7% with more anxiety symptoms. Supporting earlier findings, our data revealed that some dimensions of prospective mental imagery were significantly related with increased anxiety and depression symptoms in prisoners. Namely, intrusive negative personally relevant imagery was a positive predictor and likelihood of positive events a negative predictor of both anxiety and depression symptoms. The perceived likelihood of negative events was a positive predictor of depression. Intrusive verbal thought was a positive predictor of anxiety. The obtained results suggest the need to develop interventions not only targeting the reduction of prospective negative imagery but also the enhancement of positive mental imagery.

Voluntary and Involuntary Imagery in Social Anxiety.

BACKGROUNDnNegative mental imagery is ubiquitous in cognitive models of social anxiety and in the social anxiety literature. Previous research has shown that it is causal of increased anxiety, lower social performance ratings and lower implicit self-esteem. Despite its prevalence, few studies have investigated this imagery directly.nnnAIMSnThis study aimed to provide an in-depth analysis of the phenomenology of negative imagery experienced by socially anxious individuals, and to compare recurrent and intrusive images with images deliberately generated by participants during the study.nnnMETHODnThirty-eight undergraduate students screened to be above average in social anxiety scores completed a computerized imagery questionnaire adapted from previous qualitative work.nnnRESULTSnThematic analyses revealed four major image themes for intrusive images and three for deliberately generated images including interacting with others and anxiety symptoms. Most intrusive images were based on negative episodic memories and were experienced at least fortnightly. Images were primarily visual, auditory and somatic but could involve any sensory modality. Depression anxiety stress scale (DASS-21) scores were higher in participants who experienced intrusive imagery and increased with the frequency of intrusions. Emotionality was generally higher in intrusive images than generated images.nnnCONCLUSIONSnThe phenomenology of negative imagery experienced by socially anxious individuals is idiosyncratic and may be inherently different from images generated for use in experimental research. Theoretical and clinical implications are discussed.