Background Tetris has been proposed as a preventative 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 Emergency caesarean section (ECS) qualifies as a psychological trauma, which may result in postnatal post-traumatic stress disorder (PTSD). Maternal PTSD may not only have a significant negative impact on mother–infant interactions, but also on long-term infant development. The partner’s mental health may also affect infant development. Evidence-based early interventions to prevent the development of postpartum PTSD in mothers are lacking. Immediately after a traumatic event, memory formation is vulnerable to interference. There is accumulating evidence that a brief behavioural intervention including a visuospatial task may result in a reduction in intrusive memories of the trauma. Methods and analysis This study protocol describes a double-blind multicentre randomised controlled phase III trial testing an early brief maternal intervention including the computer game ‘Tetris’ on intrusive memories of the ECS trauma (≤1 week) and PTSD symptoms (6 weeks, primary outcome) of 144 women following an ECS. The intervention group will carry out a brief behavioural procedure including playing Tetris. The attention-placebo control group will complete a brief written activity log. Both simple cognitive tasks will be completed within the first 6 hours following traumatic childbirth. The intervention is delivered by midwives/nurses in the maternity unit. The primary outcome will be differences in the presence and severity of maternal PTSD symptoms between the intervention and the attention-placebo control group at 6 weeks post partum. Secondary outcomes will be physiological stress and psychological vulnerability, mother–infant interaction and infant developmental outcomes. Other outcomes will be psychological vulnerability and physiological regulation of the partner and their bonding with the infant, as well as the number of intrusive memories of the event. Ethics and dissemination Ethical approval was granted by the Human Research Ethics Committee of the Canton de Methods and analysis This study protocol describes a double-blind multicentre randomised controlled phase III trial testing an early brief maternal intervention including the computer game ‘Tetris’ on intrusive memories of the ECS trauma (≤1 week) and PTSD symptoms (6 weeks, primary outcome) of 144 women following an ECS. The intervention group will carry out a brief behavioural procedure including playing Tetris. The attention-placebo control group will complete a brief written activity log. Both simple cognitive tasks will be completed within the first 6 hours following traumatic childbirth. The intervention is delivered by midwives/nurses in the maternity unit. 7 10–13 PTSD is also highly comorbid with depression, for which there is substantial evidence of long-term negative effects on child development and behaviour. 14–16 Estimated economic costs of perinatal mental health problems are about £8.1 billion for each 1 year cohort of UK births, of which 72% relate to adverse impacts on the child rather than the mother. 17 In Switzerland, 16.7% of women in the perinatal period used mental health services. 18 New and innovative evidence-based interventions are, therefore, needed to reduce those costs by preventing the development of postnatal PTSD. 19 To date, research investigating PTSD symptoms in partners following ECS is missing. Evidence from laboratory-based experiments have demonstrated that a brief behavioural intervention, including a reminder cue, mental rotation and a visuospatial task (Tetris), can significantly reduce the frequency of intrusive images following exposure to traumatic film material. 85 86 One study showed that individuals who were instructed to engage in conceptually driven processing, relative to those engaged in sensory-based, data-driven processing, reported more intrusive memories to a traumatic film. 87 It has been hypothesised that tasks which interfere with data-driven processing, such as sensory-perceptual, visuospatial tasks, may reduce the occurrence of intrusive memories of an index event. 85 86 Visuospatial cognitive tasks, such as the computer game Tetris, are thought to compete for resources with visuospatial images. 88 Studies of memory consolidation have shown that human memories are likely to still be 4 In the latter study, per-protocol analyses also showed significantly lower re-experiencing symptoms at 1 week and lower rates of PTSD diagnosis at 1 month following ECS (secondary outcomes). 4 Aims of the present study The objectives of the present study are to investigate the effects of an early brief, behavioural intervention procedure (including the computer game Tetris) delivered in the hospital context within 6 hours of the trauma, on maternal mental health and infant development after a traumatic childbirth (ECS). The primary outcome measure will be the presence and the severity of maternal PTSD symptoms at 6 weeks. ECS, emergency caesarean section; PTSD, post-traumatic stress disorder. Intervention group Mothers in the intervention group will be instructed to engage in a cognitive visuospatial task, the computer game Tetris, for 15 min continuously, on a handheld gaming device (Nintendo DS) (see ref. 4 ). They are given a 3 min training in how to play the game and how to actively use mental rotation as they play the game. The intervention is delivered in the same context as that in which the trauma occurred (eg, wake-up room) so additional memory reminder cue to the trauma is not used. Primary outcome The primary outcomes are differences in the presence and severity of maternal PTSD symptoms between the intervention and the attention-placebo control group at 6 weeks post partum measured with the Clinician-Administered PTSD Scale (CAPS-5) 100 101 and the PTSD Checklist (PCL-5) for DSM-5. 102 Secondary outcomes The following outcomes will be assessed via validated assessments at different time-points (ie, ≥6 hours following ECS, ≤1 and 6 weeks and 6 months follow-up).

BACKGROUND AND OBJECTIVES Efficacious interventions soon after trauma exposure to prevent posttraumatic stress disorder (PTSD) are scarce. Evidence suggests that post-trauma, reminder cues to reactivate trauma memory followed by a cognitive visuospatial task, such as Tetris, reduce later intrusive images. Furthermore, studies indicate that aerobic exercise may reduce PTSD symptoms. The present study aimed to test whether playing Tetris, without prior reminder cues, after an experimental trauma limits the development of analogue symptoms 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 recognition 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.

Abstract Background Playing Tetris is a relatively new concept when considering how to treat or prevent post-traumatic stress symptoms (PTSS). Benefits have been identified regarding how playing the game can influence traumatic memory processing and storage. However, the concept is under-explored and can potentially help populations who are at risk of and are known to experience post-traumatic stress, such as parents of preterm infants in the Neonatal Unit. The aim of the review was to establish if preterm parents playing Tetris was a feasible option to potentially minimise PTSS. Method A scoping review was conducted using PRISMA-ScR guidance. Databases searched were Cinahl, Medline and PsychInfo, over a 20 year period (2003-2023). Titles and abstracts were screened before analysis of full-text articles. A variety of clinical and experimental studies were examined, with differing trauma exposure experienced by participants. Results Thirteen articles were reviewed and four common themes identified. These were memory consolidation, playing Tetris and its effect on intrusive memories (IMs), the effect on the brain and the acceptability as a technique to minimize PTSS in clinical trials. Conclusion Tetris, in theory, is a first-aid intervention and has the potential to minimise the impact of trauma. Based on the findings of the review, Tetris has been effective in other clinical areas and deemed acceptable by participants. Therefore, Tetris is worthy of consideration for use in the population of preterm parents. The theory that Tetris can minimize intrusive memories / flashbacks [ 2 , 5 ] could potentially help many parents who struggle with PTSS long after their baby has been discharged from the NNU. Post-traumatic stress symptoms (PTSS) Post-traumatic stress symptoms can lead to the development of post-traumatic stress disorder (PTSD), but not in all cases. PTSS can occur 3-4 weeks after the traumatic event [ 4 , 11 ]. These symptoms include intrusive memories (flashbacks) and avoiding triggering reminders of the trauma including people and places. Other symptoms are negative thoughts including fear and guilt, and hyperarousal such as irritability and anger, and sleep disturbance [ 12 , 13 ]. Dual activities compete for the working memory capacity in the brain and reduce the vividness of the memory [ 14 ]. If the brain is unable to process the traumatic effects of the event experienced or observed, then the memory becomes less vivid and flashbacks occur less often [ 47 ]. Memory consolidation takes place within 6 hours [ 16 , 23 , 39 ]. Up to that point the memory is labile and as such the traumatic effect of the memory can be minimized through the technique of playing Tetris. However, for those with established PTSD, this window of opportunity has long since passed, yet the need for treatment remains [ 2 , 39 ]. The key is to recall the memory, reactivating it as such. When considered separately, playing Tetris without recall of a traumatic memory, or recalling the memory alone will not reduce the incidence of IMs – it is the considered theory that the combination of recall and reconsolidation interferes with IM consolidation [ 14 , 39 , 44 ]. It is important to note that the accuracy of the memory remains intact [ 43 ]. Only the negative connotations associated with the recalled memory are affected when the gaming occurs prior to the reconsolidation phase of memory processing and storage [ 43 ]. They also hypothesized that hippocampal volume would increase through gaming, and this was found to be the case - as observed in MRI scans of participants who played Tetris. This increase in hippocampal volume coincided with a reduction in PTSD symptoms, possibly due to the hippocampus being the brain centre for memory consolidation and learning [ 39 ]. Stress has also been linked to glucocorticoid receptor activation which reduces the hippocampal volume, and a reduction in neurogenesis or neuron synthesis. Tetris can influence neurogenesis, which may aid a reduction in PTSS through the synthesis of new neurons. Kessler et al.’s study highlighted that at present copyright laws did not affect the use of the Tetris game in studies concerning PTSD, but if the game should revolutionize the treatment of PTSS, then this may become an issue [ 2 ]. Discussion The scoping review met the aim of the literary search: What is known from existing literature about Tetris and minimizing post-traumatic stress symptoms? Key factors associated with the concept were identified and examined [ 29 ]. Playing Tetris, as described, affects how traumatic memories are stored. Using the visuospatial working memory to play the game, while the brain tries to store the memory is considered a dual task. If the parents were encouraged to play Tetris early after preterm delivery, and when they felt stressed during their NICU stay, they potentially could reduce the number of IMs. As stated by Deforges et al. (2022), Butler et al. (2020) and Horsch et al. (2017), memory is labile for up to six hours after experiencing trauma [ 16 , 23 , 39 ]. Herein lies the window of opportunity to minimize the effect of the trauma by applying a first aid intervention. The relentless nature of stress in NICU would necessitate the parent playing Tetris Computer Game Play Reduces Intrusive Memories of Experimental Trauma via Reconsolidation-Update Mechanisms. Psychol Sci. 2015;26(8):1201–15. Article PubMed Google Scholar Holmes EA, James EL, Coode-Bate T, Deeprose C. Can Playing the Computer Game “Tetris” Reduce the Build-Up of Flashbacks for Trauma? A Proposal from Cognitive Science. One. 2009;4(1):e4153. Available at: https://doi.org/10.1371/journal.pone.0004153 Article Google Scholar Deforges C, Fort D, Stuijfzand S, Holmes EA, Horsch A. Reducing childbirth-related intrusive memories and PTSD symptoms via a single-session behavioural intervention including a visuospatial task: A proof-of-principle study. J Affect Dis. 2022;303:64–73.

Background: Flashbacks (intrusive memories of a traumatic event) are the hallmark feature of Post Traumatic Stress Disorder, however preventative interventions are lacking. Tetris may offer a ‘cognitive vaccine’ [1] against flashback development after trauma exposure. We previously reported that playing the computer game Tetris soon after viewing traumatic material reduced flashbacks compared to no-task [1]. However, two criticisms need to be addressed for clinical translation: (1) Would all games have this effect via distraction/enjoyment, or might some games even be harmful? (2) Would effect We previously reported that playing the computer game Tetris soon after viewing traumatic material reduced flashbacks compared to no-task [1] . However, two criticisms need to be addressed for clinical translation: (1) Would all games have this effect via distraction/enjoyment, or might some games even be harmful? (2) Would effects be found if administered several hours post-trauma? Accordingly, we tested Tetris versus an alternative computer game – Pub Quiz – which we hypothesized not to be helpful (Experiments 1 and 2), and extended the intervention interval to 4 hours (Experiment 2). Methodology/Principal Findings The trauma film paradigm was used as an experimental analog for flashback development in healthy volunteers. In both experiments, participants viewed traumatic film footage of death and injury before completing one of the following: (1) no-task control condition (2) Tetris or (3) Pub Quiz. Flashbacks were monitored for 1 week. Experiment 1 : 30 min after the traumatic film, playing Tetris led to a significant reduction in flashbacks compared to no-task control, whereas Pub Quiz led to a significant increase in flashbacks. Thus, the trauma field is in critical need of easily accessible treatment innovations to reduce PTSD symptoms in the immediate aftermath of trauma. A ‘cognitive vaccine’ against flashbacks via visuospatial computer games such as Tetris: a treatment rationale from cognitive science We proposed the development of computerized, low intensity, intervention against PTSD flashbacks for use as a preventative mental health strategy [1] . Specifically, we proposed that playing computer games such as Tetris post-trauma may offer a ‘cognitive vaccine’ to inoculate against the build-up of flashbacks. Interestingly, a counter argument to a “distraction account” is that according to the theory from cognitive science outlined in points 6–7 above, a comparison task such as a computer game requiring verbal processing should not only be ineffective but may even be harmful in increasing the development of later flashbacks. “Pub Quiz” [31] - a general knowledge, verbal computer game was used to specifically test these opposing hypotheses. (1) Would the beneficial effects of playing Tetris on flashbacks be sustained if administered several hours post-trauma? A second limitation of our 2009 study was that we only tested the intervention soon after trauma, whereas in the real world people may not have access to an intervention for several hours. Thus in Experiment 2, we considerably extended the time frame from 30 min to 4 hours post trauma to explore the impact of playing the computer games after a significant interval on the development of flashbacks. In summary, we predicted that: Experiment 1: playing the computer game Tetris 30 min after a traumatic film would significantly reduce flashbacks over 1-week compared to no-task control. There were no baseline differences between the three groups in terms of age, number of previous traumatic events, depressive symptoms or trait anxiety ( Table 1 ). Mood was equivalent between conditions pre-film, and as predicted, all conditions experienced comparable mood deterioration post-film ( Table 2 ). Figure 1 Experiment 1 study design overview. Participants completed the trauma film paradigm, a well established experimental analog for PTSD. All participants viewed a traumatic film followed by a 30-min structured break. Participants were then allocated to one of three experimental conditions [Tetris vs. no-task control vs. Pub Quiz] which they completed for 10 min. Flashbacks are the hallmark feature of PTSD, thus offering an important target for intervention. At present, preventative interventions for PTSD remain lacking. Following our recent finding that playing Tetris post-trauma compared to no-task may reduce the development of flashbacks [1] , the current experiments provide important steps in translating this intervention for clinical real-world application. First, the current experiments provide the first evidence that different computer games have differential effects on the development of flashbacks post-trauma. Playing Tetris after viewing traumatic material reduced later flashbacks compared to no-task control (Experiment 1 and 2), whereas the computer game Pub Quiz did not. In fact, Pub Quiz even worsened these post-trauma symptoms in Experiment 1. This was the case despite the games being rated as equally as enjoyable and as of similar difficulty. There is increasing interest in using computer games as novel psychological interventions in healthcare [32] but our data suggest that in the field of trauma, not all computer games are beneficial or even merely distracting - some may even be harmful. Implications and limitations of findings The insights arising from these two studies support the possibility that tasks such as Tetris (a simple visuospatial task) may be developed as a post-trauma intervention to reduce the flashback symptoms of PTSD, and administered up to 4 hours post-trauma. Such an approach would provide a novel alternative to drug treatment or counseling. Current clinical treatment reviews suggest that an existing counseling early intervention for trauma - “critical incident stress debriefing” - may worsen rather than improve PTSD symptoms [44] , and that there are no drugs yet shown to be effective.

Post-traumatic stress disorder (PTSD) is often debilitating, with current treatments limited by low adherence, high costs, and accessibility issues. Innovative technologies such as virtual reality (VR), augmented reality (AR), and therapeutic video games provide immersive environments that may improve treatment outcomes. This systematic review and meta-analysis evaluated the efficacy of these approaches and explored their potential advantages over traditional methods. A comprehensive search of PubMed, PsycINFO, CINAHL, Web of Science, and Cochrane identified relevant studies. Two reviewers independently screened articles, extracted data, and assessed quality using the Mixed Methods Appraisal Tool (MMAT). A random-effects model was used to calculate pooled effect sizes (Hedges' g), and heterogeneity was evaluated with the <i>Q</i> test and <i>I</i>² statistic. Publication bias was examined with funnel plots, Egger's, and Begg's tests. Analyses were performed in Stata version 17.0. From 480 records, 21 studies were included in the review and 12 in the meta-analysis. VR-based treatments yielded a pooled effect size of -0.35 (95% CI [-0.57, -0.13]), indicating a small-to-moderate reduction in PTSD symptoms. The effect was statistically significant (<i>z</i> = -3.13, <i>P</i> < .01), with moderate heterogeneity (<i>I</i>² = 46.28%, <i>P</i> = .03). Funnel plots and statistical tests suggested minimal publication bias. Meta-regression showed no moderating effect of gender. Subgroup analyses indicated significant benefits in male-only samples, participants aged 20 to 30 and over 40, and studies with follow-up periods ≤7 months. Larger effects were observed in studies with 15 to 30 participants. VR, AR, and video game interventions significantly reduce PTSD symptoms and may enhance accessibility and engagement compared to traditional treatments. These findings support the integration of immersive technologies into therapeutic practice to improve outcomes for individuals with PTSD.