Journal of Behavior Therapy and Experimental Psychiatry 64 (2019) 31–35 Contents lists available at ScienceDirect Journal of Behavior Therapy and Experimental Psychiatry journal homepage: www.elsevier.com/locate/jbtep Preventive efforts in the aftermath of analogue trauma: The effects ofTetris T and exercise on intrusive images ∗ Antonia Brühla, , Nina Heinrichsa, Emily E. Bernsteinb, Richard J. McNallyb a University of Braunschweig, Department of Psychology, Institute of Clinical Psychology, Psychotherapy and Assessment, Humboldtstr. 33, 38106, Braunschweig, Germany b Harvard University, Department of Psychology, 1230 William James Hall, 33 Kirkland Street, Cambridge, MA, 02138-2044, USA ARTICLE INFO ABSTRACT Keywords: Background and objectives: Efficacious interventions soon after trauma exposure to prevent posttraumatic stress Posttraumatic stress disorder disorder (PTSD) are scarce. Evidence suggests that post-trauma, reminder cues to reactivate trauma memory Intrusive memories followed by a cognitive visuospatial task, such as Tetris, reduce later intrusive images. Furthermore, studies Trauma film indicate that aerobic exercise may reduce PTSD symptoms. The present study aimed to test whether playing Aerobic exercise Tetris, without prior reminder cues, after an experimental trauma limits the development of analogue symptoms Visuospatial cognitive task and to compare Tetris to aerobic exercise, which could plausibly alter cognitive-affective processing of the trauma as well. Methods: Participants (N = 71) watched a distressing film and were randomly assigned to either playing Tetris, cycling, or remaining sedentary for 25 min without prior reminder cues. Intrusive images and co-occurring distress were recorded in a diary during the following week. After one week, participants completed a re- cognition test to assess voluntary memories of the film. Results: Neither Tetris nor exercise, without prior memory reactivation, reduced intrusive images and associated distress nor impeded voluntary memory compared to the control condition. There were no effects of physical fitness level at baseline or voluntary exercise during the subsequent week on analogue symptoms. Limitations: Although participants were instructed to record intrusions as they occurred in diaries, they did not receive additional reminders throughout the follow-up period. Conclusions: Our findings suggest that neither a single bout of aerobic exercise, nor playing Tetris without prior memory reactivation, after an analogue trauma reduces stress symptoms. Potential explanations and clinical implications are discussed. 1. Introduction over a 6-h period (Walker, Brakefield, Hobson, & Stickgold, 2003). Yet limits in cognitive capacity mean that visual trauma images may Intrusive images of a trauma are sensory-based re-experiencing compete for resources that support concurrent cognitive visual tasks symptoms characteristic of posttraumatic stress disorder (PTSD; during consolidation (Holmes, Brewin, & Hennessy, 2004). Therefore, a Brewin, Gregory, Lipton, & Burgess, 2010; Creamer, O'Donnell, & visuospatial cognitive task performed during consolidation of a trauma Pattison, 2004) that are key targets for preventive efforts. Although memory may interfere with the latter's consolidation, thereby reducing evidence-based treatments for PTSD are available, early interventions the frequency of later intrusive images. Consistent with these hy- that prevent the development of such symptoms following trauma ex- potheses, studies have shown that individuals who played Tetris soon posure are scarce (Roberts, Kitchiner, Kenardy, & Bisson, 2009; after watching a distressing film reported fewer intrusive images inthe Sijbrandij, Kleiboer, Bisson, Barbui, & Cuijpers, 2015). One preventive following week relative to subjects who performed no task (Holmes approach is the use of visuospatial cognitive tasks, such as the computer et al., 2010; Holmes, James, Coode-Bate, & Deeprose, 2009). Holmes game Tetris, that may inoculate against the emergence of intrusive et al. (2010) had participants watch a distressing film for 21 min before images (Holmes, James, Kilford, & Deeprose, 2010). Following en- performing filler tasks for 30 min and viewing a reminder of thefilm(a coding of new information, memories are consolidated and malleable brief memory reactivation task). Immediately thereafter, participants ∗ Corresponding author. E-mail addresses: [email protected] (A. Brühl), [email protected] (N. Heinrichs), [email protected] (E.E. Bernstein), [email protected] (R.J. McNally). https://doi.org/10.1016/j.jbtep.2019.01.004 Received 8 June 2018; Received in revised form 16 January 2019; Accepted 17 January 2019 Available online 18 January 2019 0005-7916/ © 2019 Elsevier Ltd. All rights reserved. A. Brühl, et al. Journal of Behavior Therapy and Experimental Psychiatry 64 (2019) 31–35 either played Tetris, a verbal-conceptual task, or sat quietly for 10 min. that participants may cycle or engage in a less physically active task. Results showed that Tetris decreased the frequency of intrusive images Eligible participants were at least 18 years old and denied current or from the film, whereas the verbal task increased them. The authors past mental health treatment. Further exclusion criteria were possibility concluded that verbal tasks do not compete for resources requisite for of pregnancy, medical contraindications to exercise (Physical Activity consolidating visual images. James et al. (2015) expanded these find- Readiness Questionnaire; Adams, 1999), or a score above the cut-off ings by showing that 24 h after watching a trauma film, playing Tetris (> 24) on the Exercise Addiction Inventory: Short Form (EAI; Szabo & following a memory reactivation cue reduced intrusive memories in the Griffiths, 2004). The study protocol was approved by Harvard Uni- following week. Therefore, playing Tetris may disrupt not only the in- versity's Committee on the Use of Human Subjects. itial consolidation, but also the reconsolidation of trauma images. To initiate reconsolidation after 24 h, James et al. (2015) reactivated the 2.2. Procedure trauma memories by presenting reminder cues in form of film stills from the trauma film and showed that both a prior memory reactivation Participants completed two laboratory sessions, occurring seven and playing Tetris were required to reduce intrusive images. These days apart. During session 1, after providing written informed consent, findings suggest that during reconsolidation processes, explicit memory participants completed the Depression Anxiety Stress Scales short form reactivation may play an important role in this paradigm. Although (DASS-21; Lovibond & Lovibond, 1995) to assess mood and anxiety Tetris certainly constitutes an innovative intervention, replication stu- symptoms, and the George Non-Exercise Test (GNET; George, Stone, & dies from outside the Holmes research group are scarce. Given that Burkett, 1997) to assess exercise habits and fitness level. Participants' there is no effective comparator intervention directly delivered post- maximal oxygen consumption (VO2max) was estimated by using their trauma (Roberts et al., 2009), prior studies have only compared Tetris GNET responses, height, and weight. All participants then watched a to a no-task control or other cognitive tasks. Therefore, we aimed to distressing film for 21 min, including footage of car accidents andsur- partially replicate and extend previous findings (Holmes et al., 2010) by geries (as used in Holmes et al., 2010). Afterwards, participants rated comparing Tetris to a physical intervention. The duration of these ac- how closely they had attended to the film and their perceived distress tivities was extended and the 30-min post-film interval and the memory on scales from 0 (not at all) to 10 (extremely). Unlike previous studies reactivation task were omitted. (Holmes et al., 2010), we excluded the 30-min delay period after the Aerobic exercise can help people weather physical and emotional film, implemented in previous studies to approximate the average stress (Bernstein & McNally, 2016; Salmon, 2001; Zschucke, Renneberg, waiting time in an emergency department in the United States (Holmes Dimeo, Wüstenberg, & Ströhle, 2015). Moreover, it diminishes PTSD et al., 2009). Given the apparent absence of additional rationales for symptoms (Asmundson et al., 2013; Rosenbaum, Tiedemann, this delay, we omitted a delay between the film and experimental tasks. Sherrington, Curtis, & Ward, 2014) perhaps by mitigating physiological The length of this interval period has varied across studies, with in- arousal (Blumenthal et al., 1988; Glynn, Christenfeld, & Gerin, 2002; tervals of 30 min (Holmes et al., 2009; Holmes et al., 2010, Exp. 1) to Kishida & Elavsky, 2015) or decreasing vulnerability to adverse effects 4 h (Holmes et al., 2010, Exp. 2) to estimate waiting times for emer- of rumination (Bernstein & McNally, 2017; Puterman et al., 2011). gency assistance, and 24 h for targeting reconsolidation processes Additionally, neurochemical changes following exercise, such as an (James et al., 2015). In order to reactivate the trauma film memories elevated brain-derived neurotrophic factor (BDNF), that are crucial for after these interval periods, previous studies further presented reminder memory consolidation may facilitate fear extinction (Powers et al., cues in form of film stills immediately before participants played Tetris 2015). (e.g. Holmes et al., 2010; James et al., 2015).