Journal of Behavior Therapy and Experimental Psychiatry
Is it mere distraction? Peri-traumatic verbal tasks can increase analogue flashbacks but reduce voluntary memory performance☆
Introduction
‘Flashbacks’ are a hallmark symptom of post-traumatic distress disorder (PTSD; American Psychiatric Association, [APA], 1994). In PTSD, vivid, intrusive, negative images of excerpts from a traumatic event “pop” into consciousness, apparently spontaneously, causing distress. The encoding stage has been deemed critical for the subsequent occurrence of flashbacks (for a review see Brewin & Holmes, 2003). Both contemporary theories of PTSD and cognitive memory models conceptualise flashbacks and intrusive memories as reflecting instances of ‘faulty information processing’ at the time of the trauma i.e. peri-traumatically. Such models include Ehlers and Clark's (2000) cognitive theory of PTSD, dual representation theory (DRT; Brewin, 2001, Brewin, 2003, Brewin et al., 1996), and Conway's model of autobiographical memory (Conway et al., 2004, Conway and Pleydell-Pearce, 2000), see also Dalgleish (2004). Whilst these theories differ in other respects, in relation to intrusion formation they make similar predictions (see Holmes et al., 2004, Holmes and Bourne, 2008): that is, extreme emotional responses at points in a traumatic event can cause a shift in processing style away from “conceptual” or “verbal” processing of events (focussing on the situation's meaning) towards more “data-driven”, “sensory-perceptual”, or “visuospatial” processing (focussing on sensory impressions). This peri-traumatic shift in processing style is theorized to cause those events encoded relatively more perceptually/visuospatially to become intrusive.
The view we describe above leads to two interesting predictions, which we shall refer to as the “modality” hypotheses. First, peri-traumatic disruptions to conceptual/verbal processing should increase later flashbacks. Second, peri-traumatic disruptions to sensory/visuospatial processing should reduce later flashbacks. While there is now accumulating evidence for the latter prediction, evidence for the former is sparse.
The experimental method used to investigate the impact of peri-traumatic processing on subsequent flashbacks is the trauma film paradigm (for a review see Holmes & Bourne, 2008). Healthy individuals are exposed to an event analogous to trauma, namely a film depicting stressful or traumatic events such as actual or threatened death or serious injury (PTSD Criterion A; APA, 1994). Any analogue flashbacks to the film (that is, intrusive image-based memories) are recorded in a diary. Participants sometimes find that verbal thoughts about the film may also intrude (Hagenaars, Brewin, van Minnen, Holmes, & Hoogduin, 2010). However our primary interest concerns intrusive images, as an analogue of the vivid, sensory nature of clinical flashbacks. It is the image-based memories in the diary that are analysed accordingly in this study, and referred to henceforth as intrusions. Predictions about impact on intrusion frequency can be tested by manipulating conditions at encoding, for example by using modality specific dual tasks.
Several studies have shown that peri-traumatic visuospatial tasks reduce the frequency of later intrusions. Complex spatial key tapping was used in Holmes et al. (2004, Expts. 1 & 2) and Brewin and Saunders (2001), and clay modelling in Stuart, Holmes, and Brewin (2006). Moreover, such tasks have also been shown to be effective soon post-trauma (Holmes, James, Coode-Bate, & Deeprose, 2009). In contrast, only one study has shown that a peri-traumatic verbal-interference task can increase later intrusions. Holmes et al. (2004, Expt. 3) found that counting out-loud backwards in threes increased the number of intrusions relative to a no-task control group. However, Krans, Naring, and Becker (2009) found that a similar task decreased rather than increased intrusions. According to a general attention and memory approach, it is possible that any dual task at encoding will interfere with film processing and thereby simply reduce intrusions by distraction (see Gunter and Bodner, 2008, Krans et al., 2009). This alternative account we shall refer to as the “distraction” hypothesis.
It should be noted that Gunter and Bodner (2008) used a different experimental paradigm in which (non-clinical) participants were asked to recall unpleasant autobiographical memory concurrent to eye movements (see also: Andrade et al., 1997, Kavanagh et al., 2001, van den Hout et al., 2001). Two visuospatial tasks (eye movements as well as a drawing task) and an auditory shadowing task led to reductions in vividness and emotionality. Gunter and Bodner suggested that any distractor task that taxes the central executive could produce benefits when simultaneously holding a memory in mind irrespective of the specific modality of the task. In contrast, results in PTSD patients indicated that modality may be important since concurrent eye movements reduced emotionality and vividness of recalled trauma images relative to no task whereas a verbal counting task did not (Lilley, Andrade, Turpin, Sabin-Farrell, & Holmes, 2009). In the current paper we are interested in the encoding rather than the recall stage, but a similar argument can be posited for distraction versus modality views (Baddeley and Andrade, 2000, Kemps and Tiggemann, 2007).
Other research appears relevant to this debate. A more perceptual encoding style predicted increased intrusions after a film relative to a more conceptual encoding style (Halligan, Clark, & Ehlers, 2002), with related results via a manipulation of these processing styles post-trauma (Kindt, van den Hout, Arntz, & Drost, 2008). A verbal distraction condition post-film (a semantic naming task which could be thought of as interrupting conceptual processing) led to more intrusions than concrete thinking (Ehring, Szeimies, & Schaffrick, 2009). Also, increased conceptual processing has been related to improved outcome in PTSD patients following therapy (Kindt, Buck, Arntz, & Soeter, 2007). However, studies are lacking which compare manipulations of both perceptual versus conceptual processing at encoding to test impact on later intrusions.
Returning to trauma encoding, according to a “distraction hypothesis”, the modality of the peri-traumatic dual task would be irrelevant to its effect on intrusions. However, in contrast, our formulation of PTSD theories suggests that peri-traumatic tasks interfering specifically with sensory/visuospatial processing would selectively protect against later intrusions, whereas other tasks would not. We therefore sought to test, within the same experiment, whether a visuospatial, but not a non-visuospatial task, would reduce later intrusions of a trauma film. In a second study, we sought to test the stronger prediction that a verbal/conceptual interference task rather than being distracting would actually increase (not decrease) intrusions.
Section snippets
Experiment 1
Three peri-traumatic experimental groups were compared for their impact on later intrusions of a traumatic film: (1) a complex visuospatial tapping task; (2) a verbal counting task and (3) a no-task control condition. Identical tasks were used as in Holmes et al. (2004). However, rather than the impact of each task being tested separately against a control condition, in the current study they were compared within a single experiment. It was predicted first, that the visuospatial group would
Experiment 2
This experiment compared a new Verbal Interference condition with a no-task Control condition. The Verbal Interference dual task required participants to count out-loud backwards in sevens, a cognitive load task used by Wegner and Ansfield (1993) (as cited in Wegner, 1994). This is thought to be incrementally more demanding than counting backwards in threes. We extended the trauma film from 13 to 21.5 min and projected it on a video screen (rather than via TV) to maximise the impact of the
General discussion
The importance of peri-traumatic processing on later PTSD symptoms has long been emphasised (American Psychiatric Association, 2000, Ozer et al., 2003), but is still little understood at a cognitive level. We propose that what people do cognitively during trauma may be critical for later flashbacks. We tested the impact of differences in peri-traumatic processing using dual task methodology. Our results are in line with a “modality hypothesis” rather than a “distraction hypothesis” concerning
Acknowledgements
This research was supported by a Royal Society Dorothy Hodgkin Fellowship to Emily A. Holmes, by a Medical Research Council Studentship to Corin Bourne whilst Francisco Frasquilho and Anthony D. Roth were supported by Camden and Islington Mental Health and Social Care Trust. We would also like to thank the providers of the film clips used in these studies, including LyleBailie International, Kino International and the National Archives.
References (55)
A cognitive neuroscience account of posttraumatic stress disorder and its treatment
Behaviour Research and Therapy
(2001)- et al.
Psychological theories of posttraumatic stress disorder
Clinical Psychology Review
(2003) - et al.
A cognitive model of posttraumatic stress disorder
Behaviour Research and Therapy
(2000) - et al.
An experimental analogue study into the role of abstract thinking in trauma-related rumination
Behaviour Research and Therapy
(2009) - et al.
How eye movements affect unpleasant memories: support for a working memory account
Behaviour Research and Therapy
(2008) - et al.
Cognitive processing, memory, and the development of PTSD symptoms: two experimental analogue studies
Journal of Behavior Therapy and Experimental Psychiatry
(2002) - et al.
Inducing and modulating intrusive emotional memories: a review of the trauma film paradigm
Acta Psychologica
(2008) - et al.
Perceptual and conceptual processing as predictors of treatment outcome in PTSD
Journal of Behavior Therapy and Experimental Psychiatry
(2007) - et al.
The influence of data-driven versus conceptually-driven processing on the development of PTSD-like symptoms
Journal of Behavior Therapy and Experimental Psychiatry
(2008) - et al.
Hyperarousal and dissociation: a study of novice skydivers
Behaviour Research and Therapy
(2002)
The influence of a visuospatial grounding task on intrusive images of a traumatic film
Behaviour Research and Therapy
Diagnostic and statistical manual of mental disorders
Diagnostic and statistical manual of mental disorders
Eye-movements and visual imagery: a working memory approach to the treatment of post-traumatic stress disorder
British Journal of Clinical Psychology
Working memory and the vividness of imagery
Journal of Experimental Psychology-General
Manual for the beck depression inventory-II
Involuntary memories of emotional events. Do memories of traumas and extremely happy events differ?
Applied Cognitive Psychology
The reappearance hypothesis revisited: recurrent involuntary memories after traumatic events and in everyday life
Memory & Cognition
Posttraumatic stress disorder: Malady or myth?
Autobiographical memory for trauma: update on four controversies
Memory
Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults
Journal of Consulting and Clinical Psychology
A dual representation theory of posttraumatic stress disorder
Psychological Review
The effect of dissociation at encoding on intrusive memories for a stressful film
British Journal of Medical Psychology
Differential effects of worry and imagery after exposure to a stressful stimulus: a pilot study
Behavioural and Cognitive Psychotherapy
Sensory-perceptual episodic memory and its context: autobiographical memory
Philosophical Transactions of the Royal Society of London Series B-Biological Sciences
Images and goals
Memory
The construction of autobiographical memories in the self- memory system
Psychological Review
Cited by (48)
A systematic review and meta-analysis of the effect of cognitive interventions to prevent intrusive memories using the trauma film paradigm
2023, Journal of Psychiatric ResearchLifetime adversity interacts with peritraumatic data-driven processing to predict intrusive memories
2022, Journal of Behavior Therapy and Experimental PsychiatryVisuospatial computer game play after memory reminder delivered three days after a traumatic film reduces the number of intrusive memories of the experimental trauma
2020, Journal of Behavior Therapy and Experimental PsychiatryAllocentric spatial memory performance predicts intrusive memory severity in posttraumatic stress disorder
2019, Neurobiology of Learning and MemoryCitation Excerpt :Researchers have used the trauma film paradigm to manipulate trauma processing either before, during, or after encoding of the traumatic material. Relevant for the present work are findings showing a decrease of intrusive images by deploying a visuospatial task either during encoding (Bourne, Frasquilho, Roth, & Holmes, 2010; Brewin & Saunders, 2001; Holmes, Brewin, & Hennessy, 2004) or directly thereafter (Holmes, James, Coode-Bate, & Deeprose, 2009; Holmes, James, Kilford, & Deeprose, 2010), with preliminary translational evidence in survivors of a motor vehicle accident (Iyadurai et al., 2017). A possible explanation is that visuospatial tasks compete for perceptual resources, which leads to an attenuation of the sensory representation and thus to fewer intrusive memories (cf. Brewin, 2014; Stuart, Holmes, & Brewin, 2006).
Imagining trauma: Memory amplification and the role of elaborative cognitions
2018, Journal of Behavior Therapy and Experimental PsychiatryPlaying the computer game Tetris prior to viewing traumatic film material and subsequent intrusive memories: Examining proactive interference
2016, Journal of Behavior Therapy and Experimental PsychiatryCitation Excerpt :The estimates of effect size for each intrusion measure were small, as shown by the size of the Cohen's d statistic. Thus, current results using a proactive interference design stand in contrast to the large effect sizes found in concurrent/retroactive interference studies with a trauma film paradigm (Bourne et al., 2010; Holmes et al., 2009). While it is possible there is a small effect of Tetris on reducing diary intrusions when played before the trauma film, corresponding to our d value of 0.26, future studies would be required to test this a priori.
- ☆
Corin Bourne and Emily A. Holmes are at the Department of Psychiatry, University of Oxford, UK. Francisco Frasquilho works for The East London NHS Foundation Trust and was previously at the Sub-Department of Clinical Psychology, University College London. Anthony D. Roth is at the Sub-Department of Clinical Psychology, University College London, UK.