Final Blog Post: TETRIS and Other Videogames’ Effects on PTSD

PTSD words on skull_101982913love_for_tetris_by_cookiemagik

Early in the term we watched Jane McGonigal’s TED talk entitled “Gaming Can Make a Better World” (2010). Her presentation focused on harnessing gamers’ inherent cooperative and decision making skills in order to solve the problems of the world, arguing that games can have an a beneficial impact on society. Others in the class have blogged about the role games play in advancing scientific research supporting McGonigal’s idea, but no one has yet to mention how games themselves can be therapeutic. Casual games such as Bejeweled have been found to decrease levels of depression and now research suggests that Tetris, the beloved king of the causal gaming industry, may be able to intervene in the earliest stages of Post-Traumatic Stress Disorder (Holmes, James, Coode-Bates, & Deeprose, 2009; Russoniello, O’Brien, & Parks, 2009).

Post-Traumatic Stress Disorder, or PTSD, is a psychiatric anxiety disorder where patients often develop unwanted and intrusive flashbacks of a traumatic event (Holmes et al., 2009). Unfortunately, the disorder cannot be clinically diagnosed until at least a month after the trauma occurs at which point the frequency of the flashbacks may already be tremendously high. Patients have no control over when these horrible memories will replay in their minds and are often forced to mentally relive the worst moments of a traumatizing event over and over.

Dr. Barbara Rothbaum, Director of the Trauma and Anxiety Recovery Program at the Emory University School of Medicine, gives a brief overview of PTSD.

Dr. Emily Holmes, currently a visiting professor in clinical psychology at the University of Oxford, has been working over the years to develop a “cognitive vaccine” that could be used as an early intervention tool to minimize the build-up of flashbacks (Holmes et al., 2009; Lilley, Andrade, Turpin, Sabin-Farrell, & Holmes, 2009; Holmes, James, Kilford, & Deeprose, 2010). Her treatment of choice? Tetris.

Clinical Psychology who studied the effect of Tetris on PTSD

Fig 1. Emily Holmes. Clinical Psychology who studied the effect of Tetris on PTSD.

Alexey Pajtnov is recognized as a renowned game designer for creating Tetris on the Electronica 60 in 1984. Tetris quickly spread across the Soviet Union once it became available on the PC. In 1988 Henk Rogers discovered the game at a Las Vegas trade show and fell instantly in love with the game. He soon released Tetris for both PC and Nintendo Entertainment System (NES) in Japan through his company, Bullet-Proof Software (Tetris ®, 2013). After gaining the rights to Tetris, Rogers licensed the game to Nintendo. This was a major step in how Tetris became a world renowned game. Because of the popularity of the game many different versions for various gaming platforms were created as well as imitations by amateur developers. In order to ensure that the quality of the Tetris experience remains consistent and pleasurable the Tetris Guidelines were created which includes the game’s distinctive logo, modeled after the tetrominos, or blocks, used to play the game.

In 1994, before Holmes et al. (2009) began studying the effects of Tetris on PTSD, the game was already being recognized for cognitively affecting its players. In fact, Wired writer Jeffrey Goldsmith asked Pajitnov point blank if the game actually was a pharmatronic, a software which produces drug like effects in the mind. Pajitnov said no, but recognized how addicting the game is saying, “For me, Tetris is some song which you sing and sing inside yourself and can’t stop” (Goldsmith, 1994).

The game Tetris has an interesting effect on players. First of all it is addicting as Pajitnov stated.  There are endless stories of people who play for hours before realizing what has happened to the time. In a particular article, A Metaphor for Life, the author bought the game for her children, but ended up playing the game for five hours straight (Coffin 1990). However, often times the game does not end when it is powered off and the Tetris Effect takes over. This is when a person’s brain continues to play Tetris even though they are no longer physically playing it. There can be many different versions of this effect. For instance, a person can imagine the tetrominos continually falling from the sky, simulating the actual playing field. The Tetris Effect can also spill out into the real world as people will convert everything from cars to cereal boxes into blocks that need to be grouped and organized after extended hours of play. It is not known if people feel the need to physically alter the items on the shelves or if it is simply in their minds. The Tetris Effect has never really been studied, but when talking to anyone that has played Tetris before, it is known to be present.

Tetris also has other effects that have been observed by players. Similar to other games, Tetris brings out one’s competitive side. However, this competition is solely within the player. This is because players feel the need to succeed, but to what degree this need is and what success means is dependent on the player. The game itself sets goals for each level, but a player may also set a separate individual goal, such as getting past level ten or creating a “tetris.” A tetris is achieved when a player is able to clear four lines all at once. This is only achievable with the one-by-four unit straight tetromino. With that in mind, Tetris is a not a very forgiving game. It is a decision-based game where a single mistake will be costly. Only with the right series of decisions can the mistake be fixed because one is limited to using the seven distinctly shaped tetrominos. Banking on getting a certain block can be detrimental to your play. As media reviewer, Deborah Coffin states, in “Tetris there is no opportunity to dwell on misfortune. It is a game that demands constant decision-making” (1990).

TETRIS

The pressure demanding characteristics of the game eats up the brain’s glucose supply, the brain’s currency for getting work done. Interestingly, players become more efficient at playing the game over time as cortical thickness increases and their cerebral glucose metabolic rate returns back to normal (Goldsmith, 1994; Haier, Karama, Leyba, & Jung, 2009). As Dr. Richard Haier, one of the principal investigators on a Tetris study measuring increased cortex in adolescent girls, points out, “It requires many cognitive processes like attention, hand/eye co-ordination, memory and visual spatial problem solving all working together very quickly. It’s not surprising that we see changes throughout the brain” (The Mind Research Network, 2009).

Given these effects, Tetris makes a great intervention game when it comes to PTSD because it competes for cognitive resources such as attention and information processing. When competition for resources occurs, a patient cannot focus to the same degree on traumatic scenes whilst playing the game, minimizing the intensity of a traumatic memory.

After trauma occurs there is a six hour window to disrupt memory consolidation from short term memory to long term memory (Holmes et al., 2009). This process is facilitated by what is known as working memory, which is the capacity to hold and manipulate multiple bits of information in one’s head at a given time. By overloading working memory with competing information, one minimizes the chances for traumatic scenes to be strongly transferred into long term memory. Weaker images in long term memory means that the frequency of traumatic flashbacks may decrease because it is harder to retrieve the information. Additionally, the memories themselves may be less intense in terms of vividness and emotion due to degraded encoding of the traumatic images. For this to work, the competing information must be of the same medium as the traumatic information to disrupt the consolidation process (Holmes, James, Kilford, & Deeprose, 2010; Kemps & Tiggemann, 2007; Stuart, Holmes, Brewin, 2004). In other words, traumatic images can be displaced with other visuals such as falling tetriminos and auditory information can be dislodged by the Tetris theme song.

Participants in Holmes et al.’s (2009) study who played Tetris as opposed to sitting quietly not only reported fewer flashbacks of a traumatic film watched 30 minutes prior to testing, they also reported significantly less flashbacks over the course of a week. This means that playing Tetris was successful in disrupting post-traumatic memories and limited the number of flashbacks participants had even up to a week later. While obviously more testing needs to be done to see how long the effects last, and if the same results will hold for a clinical population, the study opens up the doors to a potentially widespread and affordable “cognitive vaccine” as per Holmes et al.’s (2009) hope.

Previous research suggests that following visual objects with one’s eyes, counting aloud, or playing with clay during traumatic events can decrease vividness and emotionality of the events when they are later recalled (Stuart, Holmes, Brewin, 2004; Kemps & Tiggemann, 2007; Lilley, Andrade, Turpin, Sabin-Farrell, & Holmes, 2009). In comparison to participants who visually followed a single letter around a computer screen, playing Tetris leads to decreased emotionality, but not vividness of negative images which may help patients better process and come to terms with their trauma (Engelhard, van Uijen, & van den Hout, 2010). This shows that Tetris can hold its own against current intervention methods.

As noted before, it is important that the intervention tool be of the same modality as the information it is trying to compete against. If modalities are not matched, flashback frequencies can be made even worse (Holmes et al., 2010). In other words, Tetris works not just because it is an engaging game, but because it is a challenging visual game that requires players’ constant attention. Games that are word based, such as Pub Quiz, have been found to actually increase the frequency of flashbacks within the course of a week after a traumatic film (Holmes et al., 2010).

Holmes et al. (2010) results

Holmes et al. (2010) result

Given these results, and due to the high occurrence of PTSD within soldiers, it is not surprising that the Pentagon has been looking at ways to use videogames in diagnosing and treating PTSD. While it is not known if they have been utilizing Holmes et al.’s results, it is not surprising that they would look towards technology as a possible solution because of the wide range of remedies they have previously used to treat PTSD, such as medical marijuana and Reiki.

While not looking directly at Tetris, the Pentagon has begun research on how to use the brain’s gray matter, or neural cell bodies, to control videogames and subsequently treat PTSD (Drummond, 2012). Known as neurofeedback (NF), electrodes are attached to patients’ heads so that brain waves can be monitored as they play a particular game. In these specially designed games, on-screen movements are controlled by the type of activity that is happening in the brain. Calm and steady brain activity results in an “enhanced performance” where in a racing game for instance, the car is able to move smoothly and quickly (Drummond, 2012). Whereas less controlled brain activity due to anxiety, panic, etc. would cause uncontrollable movements and potentially a car crash. Dr. Siegfried explains how this works by stating, “When the brain sees itself interacting with the world, it becomes interested in that,” and this in turn allows patients to learn how to control their anxiety as they retrain their brains.

Racing gam

Another avenue of research the Pentagon is pursuing is the use of virtual worlds. As we have discussed multiple times through Tom Boellstorff’s chapter Coming of Age in Second Life in the book Personhood, there are many benefits of virtual realities. Second Life offers a space for players to create a life that is entirely different than their actual real world one. This is possible because of the anonymity that is present within the game. With this key element in mind, the T2 Virtual PTSD Experience was unveiled by the Department of Defense in January 2011 (Ashton, 2011). Developed by Joint Base Lewis-McChord, the project allows “users [to] explore the causes and symptoms of combat trauma.” In this virtual space, players are able to access mental health services which are typically shied away from because of the “fear of social and professional repercussions.” Not only is there an emphasis on utilizing mental health services, there is also interactions within the game that help encourage soldiers to return to civilian life such as walking through a mall.

Second Life

Second Life

This past example is a more positive route to help soldiers with PTSD as opposed to using virtual realities that stimulate experiences that can occur in a war zone (Moore, 2010).  These experiences are “used as a means to facilitate a highly effective treatment for PTSD called exposure therapy.”  Exposure therapy is when soldiers are re-exposed to an event that is associated with either trauma or stress. The purpose is to desensitize the individual to the “emotional and physical distress that is associated with the event.” This method is only as effective as participants make it to be.

In taking a step towards new developments, it has been reported that the Army has invested sums around $100,000 each into three different private companies (Vista Life Sciences, Empirical Technologies, and Aptima Inc.) to develop an app that can be downloaded onto smartphones (Plackett, 2012). Ideally the app would be available for soldier before deployment so that the mental state of an individual can be charted and monitored from the beginning. The challenge is for the game to be engaging enough for soldiers to want to continue to play it throughout their deployment. This, however, is a lofty goal since we have all experienced becoming bored of a game within a couple of weeks. Because PTSD is such a serious disorder you can’t help but want to hope for this game to be effective.

The Army’s heavy investment and the scholarly work that is being done in using new technologies to aid treatment of PTSD demonstrates the influential role technology can play in our lives. While Pajitnov originally laughed when asked if his game was a pharmatronic, it has been found that games such as Tetris and others can effectively influence one’s psychological state. Videogames are no longer just for fun as they can produce serious effects that can help individuals combat very debilitating psychological disorders. No longer are patients solely reliant on brain altering chemicals to control their anxiety or depression. While some scholars like Sherry Turkle voice their fears that technology is tearing our society apart, this research proves, if anything, that technology can be used to actually better our lives. Through continued research and development of therapeutic games, we are moving towards a future where mental health care is affordable and non-stigmatized.

Works Cited

Ashton, A. (2011, Jan. 31). For post-traumatic stress victims, Pentagon video game may help healing. The Washington Post. Retrieved March 18, 2013, from http://www.washingtonpost.com/wp-dyn/content/article/2011/01/31/AR2011013101528.html

Boellstorff, T. (2008). Coming of Age in Second Life. Personhood. Princeton: Princeton             University Press.

Coffin, D. C. (1990). TETRIS. ETC: A Review of General Semantics Spring, 47(1), 72.

Drummond, K. (2012, July 3). Pentagon’s Brain-Powered Videogames Might Treat PTSD. Wired. Retrieved March 18, 2013, from http://www.wired.com/dangerroom/2012/07/neurofeedback/

Engelhard, I. M., Van Uijen, S. L., & Van den Hout, M. A. (2010). The impact of taxing working memory on negative and positive memories. Journal of AESTHETICS & CULTURE, 1(0). doi:10.3402/ejpt.v1i0.5623

Goldsmith, J. (1994, May). This Is Your Brain on Tetris. Wired. Retrieved March 16, 2013, from http://www.wired.com/wired/archive/2.05/tetris.html

Haier, R. J., Karama, S., Leyba, L., & Jung, R. E. (2009). MRI assessment of cortical thickness and functional activity changes in adolescent girls following three months of practice on a visual-spatial task. BMC Research Notes, 2(1), 174. doi:10.1186/1756-0500-2-174

Hellerstein, J.D. (2012, March 27). Can TETRIS Prevent PTSD? Psychology Today. Retrieved February 2, 2013, from http://www.psychologytoday.com/blog/heal-your-brain/201203/can-tetris-prevent-ptsd-0

The History of Tetris. (2013). Retrieved February 2, 2013, from http://www.tetris.com/history/index.aspx

Holmes, E. A., James, E. L., Coode-Bate, T., & Deeprose, C. (2009). Can Playing the Computer Game “Tetris” Reduce the Build-Up of Flashbacks for Trauma? A Proposal from Cognitive Science. PLoS ONE, 4(1), 1–6.

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. (K. Hashimoto, Ed.) PLoS ONE, 5(11), e13706. doi:10.1371/journal.pone.0013706

Holmes, E. A., & Mathews, A. (2010). Mental imagery in emotion and emotional disorders. Clinical Psychology Review, 30(3), 349–362. doi:10.1016/j.cpr.2010.01.001

Kavanagh, D. J., Freese, S., Andrade, J., & May, J. (2001). Effects of visuospatial tasks on desensitization to emotive memories. British Journal of Clinical Psychology, 40(3), 267–280. Retrieved from http://onlinelibrary.wiley.com/doi/10.1348/014466501163689/abstract

Lilley, S. A., Andrade, J., Turpin, G., Sabin-Farrell, R., & Holmes, E. A. (2009). Visuospatial working memory interference with recollections of trauma. British Journal of Clinical Psychology, 48(3), 309–321. doi:10.1348/014466508X398943

McGonigal, J. (2010). Gaming Can Make a Better World. Ted Talk. Retrieved from http://www.ted.com/talks/jane_mcgonigal_gaming_can_make_a_better_world.html

Moore, B.A. (2010, May 24). Video Game or Treatment for PTSD?. Psychology Today. Retrieved March 18, 2013, from http://www.psychologytoday.com/blog/the-camouflage-couch/201005/video-game-or-treatment-ptsd

Russoniello, C.V.,  O’Brien, K.,  & Parks, J.M. (2009). The effectiveness of casual video games in improving mood and decreasing stress. Journal of CyberTherapy & Rehabilitation, 2(1), 53-66. Retrieved from http://www.ecu.edu/cs-hhp/rcls/biofeedback/upload/The-Effectiveness-of-Casual-Video-Games-in-Improving-Mood-and-Decreasing-Stress.pdf

Stafford, T. (2012, Oct. 12). The psychology of Tetris. BBC. Retrieved February 2, 2013, from http://www.bbc.com/future/story/20121022-the-psychology-of-tetris

Turkle, S. (2011). Introduction. Alone Together: Why We Expect More from Technology   and Less from Each Other. 

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One Response to Final Blog Post: TETRIS and Other Videogames’ Effects on PTSD

  1. cstabile says:

    As I was reading this well-researched and provocative example of therapeutic effects of videogames, I was reminded of the intersections between war and technological advances. It seems ironic, doesn’t it, that games could at once celebrate the kinds of activities that result in PTSD while at the same time providing treatment for the disorder? Puts me in mind of Donna Haraway’s cyborg.

    What I liked best about this post, M&V, is that it provides such a smart and compelling instance of the potential of video games without making any McGonigal-like grand claims and by really grounding your argument in research. Very nicely don.

    Loved The Simpsons clip, btw!

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