Blocking out the pain: Tetris, trauma, and Game Transfer Phenomena

Unwanted visual intrusions are characteristic of Post-Traumatic Stress Disorder (PTSD). According to Dr. Emily Holmes and her colleagues in a 2009 paper in the journal PLoS ONE, one innovative intervention for inhibiting unwanted intrusions is playing the Tetris videogame, described as a ‘cognitive vaccine’ in preventing intrusions after traumatic events. Playing Tetris consumes heavy visuospatial working memory resources that potentially compete with cognitive resources required for elaboration of visual imagery. Since Holmes and colleagues’ study, other studies have used Tetris to inhibit intrusive imagery including more studies by Holmes and her colleagues and others by Ella James’ research group, as well as some innovative studies using Tetris to reduce drug cravings by Jessica Storka-Brown and her colleagues (see ‘Further reading’ below). However, none of these studies assessed the role of videogame content after playing in relation to Game Transfer Phenomena (GTP), an area that we have carried out a lot of research into (see ‘Further reading’ below).

GTP research has investigated non-volitional experiences (e.g., altered sensorial perceptions and automatic mental processes/behaviours) mostly experienced after gaming. Gamers often report sensorial (visual/auditory) intrusions after playing (e.g., visual and auditory imagery, hallucinations). In a survey of 2,362 gamers that we published in a 2016 issue of the International Journal of Human-Computer Interaction, most (77%) had visualized images from a variety of videogames (including tile-puzzle games) with closed-eyes, and one-third (31%) had visualized images with open-eyes. Other studies have experimentally induced videogame-related visualizations at sleep onset (including studies by Stickgold and colleagues [2000], Wamsley and colleagues [2010], Kusse and colleagues [2012] – see ‘Further reading’).

James and colleagues’ 2015 study in the journal Psychological Science was the first to make explicit reference to GTP (referred to as the ‘Tetris effect’ [TE]). In 2012, we argued the TE term is misleading as it suggests repetition is the core of transfer effects. However, other factors are involved. Research concerning GTP makes the distinction between sensorial modalities facilitating non-volitional phenomena with videogame content that occur along the continuum from mild to severe. Moreover, the descriptive constructs of GTP are empirically based on our analysis of 3,500+ gamers and have been examined via confirmatory factor analysis demonstrating good reliability and validity.

James and her colleagues tested if playing Tetris offered a protective mechanism against re-experiencing traumatic events. Healthy participants (n=56) were randomly assigned to either playing Tetris for 11 minutes, or doing nothing before exposure to a 12-minute traumatic film. Image-base memories about the film were then registered in a one-week dairy. However, playing Tetris as a proactive interference task before watching the film did not show significant results. James and colleagues offered different explanations including: (i) duration of the task in relation to film length, (ii) temporal contingencies between the tasks, (iii) differences between the task types, (iv) videogame types used, and (v) reactivation of gameplay during the film for aided interference. In a commentary paper published in a 2016 issue of Frontiers in Psychology, we discussed these findings and some of its shortcomings in relation to GTP literature.

• Duration of task in relation to film length: Playing Tetris for 11 minutes may not have been long enough to compete with the consolidation of memory of the 12-minute film. GTP are significantly more likely to occur when playing 3-6 hours. Our research reported only 4% of gamers reported GTP when playing sessions shorter than one-hour. Laboratory experiments have taken days of playing to induce game-related visualizations at sleep onset.
• Temporal contingencies between gaming and film watching: The tasks were performed minutes apart from each other. GTP mostly occur soon after stopping playing but our research has found that gamers have also reported GTP days after playing. In most cases, duration of experience is very short (seconds/minutes) but in some cases hours or longer.
• Differences between the tasks: Previous studies have demonstrated that similar tasks aid interference. However, watching a film is a passive activity while gaming is interactive requiring additional perceptual/motor skills. Therefore, it may be expected that gaming is more potent as interference task, particularly because inducing the subjective sense of presence in the virtual world may strengthen the interference.
• Type of videogame used as interference task and emotional content of film: The unrealistic (geometric) Tetris content may have been overwritten by the film’s traumatic images. Visualization of stereotypical games induced at sleep onset are characterized by lack of emotion, assuming that the amygdala and the reward system are not involved. In GTP research, emotions in tile-matching puzzle-games are incomparable to emotions in realistic videogames.
• Reactivation of gameplay during the film for aided interference: The use of cue reminders may have potential in reviving videogame content. In many cases, thoughts and altered perceptions are triggered by game-related cues. Selective attention toward game-related cues has been demonstrated in experiments. GTP have been reported in variety of videogame genres particularly those that have very realistic graphics and settings. Therefore, more realistic games may aid associations between real life stimuli and videogame content, and may be more effective in competing with memories of traumatic events.

In our Frontiers paper, we noted that playing Tetris is not only an effective visuospatial task (overloading working memory resources needed for imagery-formation while playing), but as demonstrated in our GTP studies, videogame content stays active after playing (e.g., mental imagery, sensory perceptions), and may offer additional benefits for managing unwanted intrusions. GTP may potentially strengthen effects of interference tasks but should be used cautiously, because videogame content not only targets unwanted intrusions, but also influences individual cognitions, perceptions, and behaviours in day-to-day contexts (e.g., attention bias, lack of task awareness, control inhibition failures). Moreover, our studies have shown distress and dysfunction have been reported with GTP.

Consequently, further research needs conducting to identify: (i) videogames that are most effective, (ii) playing duration, (iii) factors that reduce intervention efficacy and strategies to control them, and (iv) individuals that may benefit the most from such intervention. While using videogames as intervention tools for preventing unwanted imagery from traumatic experiences has potential, therapeutically it is still at an early stage.

• (Please note: This blog was co-written with Dr. Angelica Ortiz de Gortari and is based on an article we published in Frontiers in Psychology: Ortiz de Gortari, A.B. & Griffiths, M.D. (2016). Playing the computer game Tetris prior to viewing traumatic film material and subsequent intrusive memories: Examining proactive interference. Frontiers in Psychology, 7, 260. doi: 10.3389/fpsyg.2016.00260)

Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Holmes, E. A., James, E. L., Kilford, E. J., & Deeprose, C. (2010). Key steps in developing a cognitive vaccine against traumatic flashbacks: Visuospatial Tetris versus Verbal Pub Quiz. PloS ONE, 5(11), e13706.

James, E. L., Bonsall, M. B., Hoppitt, L., Tunbridge, E. M., Geddes, J. R., Milton, A. L., & Holmes, E. A. (2015a). Computer game play reduces intrusive memories of experimental trauma via reconsolidation-update mechanisms. Psychological Science. doi: 10.1177/0956797615583071

James, E. L., Zhu, A. L., Tickle, H., Horsch, A., & Holmes, E. A. (2015b). Playing the computer game Tetris prior to viewing traumatic film material and subsequent intrusive memories: Examining proactive interference. Journal of Behavior Therapy and Experimental Psychiatry. doi: 10.1016/j.jbtep.2015.11.004

Kusse, C., Shaffii-Le Bourdiec, A., Schrouff, J., Matarazzo, L., & Maquet, P. (2012). Experience-dependent induction of hypnagogic images during daytime naps: A combined behavioural and EEG study. Journal of Sleep Research, 21(1), 10-20.

Ortiz de Gortari, A. B., Aronsson, K., & Griffiths, M. D. (2011). Game Transfer Phenomena in video game playing: A qualitative interview study. International Journal of Cyber Behavior, Psychology and Learning 1(3), 15-33.

Ortiz de Gortari, A. B., & Griffiths, M. D. (2012). An introduction to Game Transfer Phenomena in video game playing. In J. I. Gackenbach (Ed.), Video Game Play and Consciousness (pp. 223-250). Hauppauge, NY: Nova Publisher.

Ortiz de Gortari, A. B., & Griffiths, M. D. (2014a). Altered visual perception in Game Transfer Phenomena: An empirical self-report study. International Journal of Human-Computer Interaction, 30(2), 95-105.

Ortiz de Gortari, A. B., & Griffiths, M. D. (2014b). Auditory experiences in Game Transfer Phenomena: An empirical self-report study. International Journal of Cyber Behavior, Psychology and Learning 4(1), 59-75.

Ortiz de Gortari, A. B., & Griffiths, M. D. (2014c). Automatic mental processes, automatic actions and behaviours in Game Transfer Phenomena: An empirical self-report study using online forum data. International Journal of Mental Health and Addiction, 12(4), 1-21.

Ortiz de Gortari, A. B., & Griffiths, M. D. (2015a). Game Transfer Phenomena and its associated factors: An exploratory empirical online survey study. Computers in Human Behavior, 51, 195-202.

Ortiz de Gortari, A.B. & Griffiths, M.D. (2016). Prevalence and characteristics of Game Transfer Phenomena: A descriptive survey study. International Journal of Human-Computer Interaction, 32, 470-480.

Ortiz de Gortari, A.B., Oldfield, B. & Griffiths, M.D. (2016). An empirical examination of factors associated with Game Transfer Phenomena severity. Computers in Human Behavior, 64, 274-284.

Ortiz de Gortari, A. B., Pontes, H. M. & Griffiths, M. D.  (2015). The Game Transfer Phenomena Scale: An instrument for investigating the nonvolitional effects of video game playing. Cyberpsychology, Behavior, and Social Networking 10, 588-594

Skorka-Brown, J., Andrade, J., & May, J. (2014). Playing ‘Tetris’ reduces the strength, frequency and vividness of naturally occurring cravings. Appetite, 76 , 161-165.

Skorka-Brown, J., Andrade, J., Whalley, B., & May, J. (2015). Playing Tetris decreases drug and other cravings in real world settings. Addictive Behaviors, 51, 165-170.

Stickgold, R., Malia, A., Maguire, D., Roddenberry, D., & O’Connor, M. (2000). Replaying the Game: Hypnagogic images in normals and amnesics. Science, 290(5490), 350-353.

Wamsley, E. J., Perry, K., Djonlagic, I., Reaven, L. B., & Stickgold, R. (2010). Cognitive replay of visuomotor learning at sleep onset: Temporal dynamics and relationship to task performance. Sleep, 1(33), 59-68.