Trauma, treatment and Tetris: video gaming increases hippocampal volume in male patients with combat-related posttraumatic stress disorder

 

Since there is a 23% chance of stroke survivors getting PTSD what is your doctor's prevention plan; not treatment plan, PREVENTION!

Trauma, treatment and Tetris: video gaming increases hippocampal volume in male patients with combat-related posttraumatic stress disorder

Oisin Butler ¹, Kerstin Herr ¹, Gerd Willmund ¹, Jürgen Gallinat ¹, Simone Kühn ^1,*,✉, Peter Zimmermann ^1,*

PMCID: PMC7828932  PMID: 32293830

Abstract

Background

Tetris has been proposed as a preventive intervention to reduce intrusive memories of a traumatic event. However, no neuroimaging study has assessed Tetris in patients with existing posttraumatic stress disorder (PTSD) or explored how playing Tetris may affect brain structure.

Methods

We recruited patients with combat-related PTSD before psychotherapy and randomly assigned them to an experimental Tetris and therapy group (n = 20) or to a therapy-only control group (n = 20). In the control group, participants completed therapy as usual: eye movement desensitization and reprocessing (EMDR) psychotherapy. In the Tetris group, in addition to EMDR, participants also played 60 minutes of Tetris every day from onset to completion of therapy, approximately 6 weeks later. Participants completed structural MRI and psychological questionnaires before and after therapy, and we collected psychological questionnaire data at follow-up, approximately 6 months later. We hypothesized that the Tetris group would show increases in hippocampal volume and reductions in symptoms, both directly after completion of therapy and at follow-up.

Results

Following therapy, hippocampal volume increased in the Tetris group, but not the control group. As well, hippocampal increases were correlated with reductions in symptoms of PTSD, depression and anxiety between completion of therapy and follow-up in the Tetris group, but not the control group.

Limitations

Playing Tetris may act as a cognitive interference task and as a brain-training intervention, but it was not possible to distinguish between these 2 potential mechanisms.

Conclusion

Tetris may be useful as an adjunct therapeutic intervention for PTSD. Tetris-related increases in hippocampal volume may ensure that therapeutic gains are maintained after completion of therapy.

Introduction

Recent work has provided evidence for the utility of the visuospatial video game Tetris as an early therapeutic intervention for posttraumatic stress disorder (PTSD).^1–3 Holmes and colleagues have shown that playing Tetris directly after trauma exposure can reduce subsequent intrusive memories of the traumatic event, and they have demonstrated the efficacy of this “cognitive vaccine” in both experimental¹ and real-world settings.^2–4

Following exposure to an event, the memory trace of that event must be consolidated into long-term memory for it to be accessible for later recall.⁵ Shortly after the event, the memory trace remains in a labile state as it is consolidated, and it is susceptible or vulnerable to interference.⁶ Performing an unrelated task while the memory for an event is in a labile state can reduce subsequent retrieval.⁷ In addition, it has been proposed that following reactivation, a memory again enters a labile state and must be reconsolidated into long-term memory.⁸ During this reconsolidation process, the memory trace is also vulnerable to interference. Holmes and colleagues¹ have proposed that by completing a demanding visuospatial task during memory consolidation or reconsolidation for a traumatic event, the memory trace is weakened because of competition for the cognitive resources required for consolidation.

To date, work using Tetris as an intervention has focused mainly on attempting to disrupt consolidation of the traumatic memory within the first 6 hours after the trauma exposure, ^1–3 or reconsolidation of the traumatic memory the next day.⁸ However, playing a video game in the direct aftermath of a traumatic event is neither practical nor possible in every case. It is estimated that approximately 8 million adults have PTSD in the United States alone.⁹ As such, interventions for those who are already experiencing posttraumatic symptoms are sorely needed.

One study to date has assessed a Tetris intervention in people with existing PTSD.⁴ In this study, specific intrusions were targeted based on the concepts of “concurrent task interference and memory reconsolidation.” After a reminder for a specific intrusive memory, patients played 25 minutes of Tetris. The authors found that after completion of the study, the frequency of targeted intrusions was lower than that of nontargeted intrusions. In the current study, we investigate the utility of Tetris as an adjunct therapeutic intervention for people with current PTSD.

Current therapeutic interventions for PTSD have a number of limitations related to response rates and long-term efficacy. A significant minority of people with PTSD will not show significant improvement in symptoms directly following therapy, with rates of nonresponders estimated to be as high as 35% to 50% in some studies.^10–12 In addition, the long-term prognosis for PTSD is poor: a majority of people continue to experience symptoms for months or years after initial diagnosis, and a substantial number never fully recovers.¹³ As such, there is a significant need for additional therapeutic interventions that may act as an adjunct to traditional psychotherapy for nonresponders and to ensure the long-term maintenance of therapy-related gains for responders.

The most widely used and most effective interventions for PTSD are psychotherapies such as trauma-focused cognitive behaviour therapy (CBT) and eye movement desensitization and reprocessing (EMDR) therapy. These therapies target memories of the traumatic event, along with the person’s cognitive and emotional interpretation of the event. Therapy with EMDR is particularly interesting, because it differs from other psychotherapies by incorporating a visuosensory attentional component.¹⁴ There are some inconsistencies in the literature regarding EMDR, particularly the therapeutic contribution of the visuosensory component:¹⁵ although reviews of studies comparing trauma-focused CBT and EMDR have failed to demonstrate increased efficacy for one over the other,^10,15 separate reviews have provided evidence that the addition of eye movements results in significant improvements to treatment outcomes.^16,17 As such, although EMDR is a common therapeutic intervention for the treatment of PTSD, the precise mechanisms underlying its efficacy remain somewhat unclear.

In the current study, we explored the use of Tetris as an adjunct to EMDR. Each EMDR session consisted of selecting a traumatic memory to work on. Given the visuosensory attentional component of EMDR, we considered that Tetris might complement EMDR better than other psychotherapeutic interventions, such as CBT.

At the neuroanatomical level, adult PTSD populations are characterized by smaller volumes in the hippocampus and in prefrontal regions, including the ventromedial prefrontal cortex and the anterior cingulate cortex.^18–20

The hippocampus is hypothesized to play a key role in PTSD symptomatology: smaller hippocampal volumes have been associated with increased risk and poorer prognosis in PTSD, and with poorer prognosis.^21–25 In addition, increases in grey matter volume in the hippocampus have been observed in response to psychological therapy, including EMDR^26,27 and pharmacological interventions, and increases in hippocampal volume have been linked to improvements in memory.²⁸

Training studies have demonstrated that increases in hippocampal volume can be produced with a wide variety of interventions, ^29,30 including video-gaming interventions.³¹ As such, we hypothesized that the video-gaming intervention Tetris would increase hippocampal volume, which would in turn reduce PTSD symptomatology.

Smaller prefrontal regions have also been commonly observed in people with PTSD.^18–20 Prefrontal regions have also been shown to increase in response to video-gaming interventions. ³¹ We therefore hypothesized that prefrontal regions in PTSD populations would also increase in response to therapeutic interventions, although the majority of relevant work in neuroplasticity and PTSD has demonstrated effects in the hippocampus rather than the prefrontal regions.

In the current study, we investigated the structural and behavioural effects of a Tetris intervention in people with PTSD who were undergoing psychotherapy, using a prospective design. We recruited people with combat-related PTSD and assessed them before and directly after EMDR therapy, as well as at follow-up, approximately 6 months later. We proposed that playing Tetris after therapy while the reactivated traumatic memory was in a labile state would weaken reconsolidation and aid recovery.⁸ It should be noted that playing Tetris has been shown to reduce the vivid, intrusive elements of a traumatic memory, but not of a declarative memory.¹ As such, we expected that Tetris would not affect memory of the therapy sessions, or interfere with the clinical efficacy of EMDR. In addition, spatial memory training and video gaming have been linked to increases in hippocampal volume,³¹ and increases in hippocampal volume have been associated with improvements in memory and reductions in symptoms in PTSD.³² As such, we expected that Tetris would aid in recovery from PTSD by weakening the memory of the traumatic event, and by increasing hippocampal volume. We hypothesized that the Tetris group would show increases in hippocampal volume and reductions in symptoms — directly after completion of therapy and at follow-up.

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