Search

Intensive care unit (ICU) staff continue to face recurrent work-related traumatic events throughout the COVID-19 pandemic. Intrusive memories (IMs) of such traumatic events comprise sensory image-based memories. Harnessing research on preventing IMs with a novel behavioural intervention on the day of trauma, here we take critical next steps in developing this approach as a treatment for ICU staff who are already experiencing IMs days, weeks, or months post-trauma. To address the urgent need to develop novel mental health interventions, we used Bayesian statistical approaches to optimise a brief imagery-competing task intervention to reduce the number of IMs. We evaluated a digitised version of the intervention for remote, scalable delivery. We conducted a two-arm, parallel-group, randomised, adaptive Bayesian optimisation trial. Eligible participants worked clinically in a UK NHS ICU during the pandemic, experienced at least one work-related traumatic event, and at least three IMs in the week prior to recruitment. Participants were randomised to receive immediate or delayed (after four weeks) access to the intervention.Primary outcome was the number of IMs of trauma during week 4, controlling for baseline week. Analyses were conducted on an intention-to-treat basis as a between-group comparison. Prior to final analysis, sequential Bayesian analyses were conducted (n=20,23,29,37,41,45) to inform early stopping of the trial prior to the planned maximum recruitment (n=150). Final analysis (n=75) showed strong evidence for a positive treatment effect (Bayes factor, BF=1.25 × 106): the immediate arm reported fewer IMs (median=1, IQR=0-3) than the delayed arm (median=10, IQR=6-16.5). With further digital enhancements, the intervention (n=28) also showed a positive treatment effect (BF=7.31). Sequential Bayesian analyses provided evidence for reducing IMs of work-related trauma for healthcare workers. This methodology also allowed us to rule out negative effects early, reduced the planned maximum sample size, and allowed evaluation of enhancements. Trial RegistrationNCT04992390(www.clinicaltrials.gov).

BACKGROUND Many Intensive Care Unit (ICU) staff experience intrusive memories following work-related traumatic events, which can lead to long-term mental health outcomes and impact work functioning. There is a need for interventions that target intrusive memories in this population, however, factors such as mental health stigma and difficulty fitting interventions into busy schedules can pose barriers. The GAINS study tested a brief, digital imagery-competing task gameplay intervention with the aim to reduce and prevent the recurrence of intrusive memories which holds particular promise for overcoming some of these barriers. This paper presents a sub-study exploring the acceptability of the intervention. OBJECTIVE To explore barriers and facilitators to the uptake and practical usage of the intervention in ICU staff, alongside its acceptability; To iteratively explore the impact of intervention optimisations to further refine the intervention. METHODS The GAINS Study is a randomised controlled trial (RCT) of access to a brief digital imagery-competing task intervention for 4 weeks versus usual care (followed by delayed access to the intervention). Participants were ICU staff who worked through the COVID-19 pandemic and experienced intrusive memories. All participants were sent a bespoke questionnaire 4-weeks after the first intervention session to gather data about intervention acceptability. Nested within the RCT, a subset of 16 participants were interviewed and data analysed using thematic analysis drawing from a framework approach. RESULTS Quantitative and qualitative data both point towards high acceptability of the intervention. Intervention usage data shows that, on average, staff were able to target around 73% of their intrusive memories and used the intervention for the full 20 minutes per session. Overall, on the acceptability questionnaire, the staff found the intervention easy-to-use, helpful and highly acceptable. Four themes were generated from the interviews: Approach to Intervention, Positives of Intervention, Negatives of Intervention, Improvements and Optimisations. The findings highlighted barriers that ICU staff experienced when approaching the intervention: stigma, feeling weak for seeking help, not wanting colleagues to know they were struggling, scepticism. However, they provided suggestions for how these barriers could be overcome and discussed advantages of the intervention when compared to other existing treatments. Whilst participants described many positives of the intervention, such as it being easy-to-use, enjoyable and leading to a reduction in frequency or intensity of intrusive memories, they also raised practical issues to be considered for implementation. CONCLUSIONS The intervention has the potential to overcome stigma and reduce the frequency of intrusive memories after traumatic events in ICU staff. There is scope for further refinement to improve adoption and reach of this intervention for ICU staff. A limitation is that we could not interview NHS staff who were unable or unwilling to take part in the trial. CLINICALTRIAL The trial is registered at ClinicalTrials.gov (NCT04992390).

This study aimed to develop empirically grounded recommendations and a coherent model of psychological care derived from the experiences and psychological care needs of COVID-19 frontline doctors, using semi-structured interviews and thematic analysis. Participants were UK frontline doctors specialising in Emergency Medicine, Anaesthetics, or Intensive Care (n = 31) purposively sampled for maximum variation on gender, specialty, ethnicity, and trauma-related distress, most worked in ICU during the pandemic (71%). Four themes were derived: (1) ‘coping strategies’, participants used many, including exercise, mindfulness, and “wait until it gets really bad”, (2) ‘sources of support’, participants valued embedded psychological support, digital services, and informal conversations with colleagues or family, though there was little opportunity, (3) ‘organisational influences on wellbeing’, participants reported a love–hate relationship for concepts like ‘wellbeing’, seen as important but insulting when basic workplace needs were unmet, (4) ‘improving engagement with support’, analysis suggests we must reduce physical and psychological barriers to access and encourage leaders to model psychologically supportive behaviours. Doctors’ frontline COVID-19 working experiences shine a ‘spotlight’ on pre-existing problems such as lack of physical resources and access to psychological care. Empirically grounded recommendations and a model of incremental psychological care are presented for use in clinical services.

Objective This randomised controlled trial (RCT) aimed to investigate the effects of a simple cognitive task intervention on intrusive memories ("flashbacks") and associated symptoms following a traumatic event. Patients presenting to a Swedish emergency department (ED) soon after a traumatic event were randomly allocated (1:1) to the simple cognitive task intervention (memory cue + mental rotation instructions + computer game "Tetris" for at least 20 min) or control (podcast, similar time). We planned follow-ups at one-week, 1-month, and where possible, 3- and 6-months post-trauma. Anticipated enrolment was N = 148. Results The RCT was terminated prematurely after recruiting N = 16 participants. The COVID-19 pandemic prevented recruitment/testing in the ED because: (i) the study required face-to-face contact between participants, psychology researchers, ED staff, and patients, incurring risk of virus transmission; (ii) the host ED site received COVID-19 patients; and (iii) reduced flow of patients otherwise presenting to the ED in non-pandemic conditions (e.g. after trauma). We report on delivery of study procedures, recruitment, treatment adherence, outcome completion (primary outcome: number of intrusive memories during week 5), attrition, and limitations. The information presented and limitations may enable our group and others to learn from this terminated study. Trial registration ClinicalTrials.gov: NCT04185155 (04-12-2019)

Intrusive memories are common after trauma, and can cause significant distress. Interventions to prevent/reduce the occurrence of this core clinical feature of posttraumatic stress disorder are needed; they should be easy to deliver, readily disseminated and scalable. A novel one-session intervention by Iyadurai et al. 2018, Molecular Psychiatry, resulted in intrusion reduction over the subsequent week. Its feasibility in a different setting and longer-term effects (>1 month) need investigation. We conducted an exploratory open-label pilot randomised controlled trial (RCT) to investigate the feasibility and effects of a brief behavioural intervention to reduce intrusive memories in trauma-exposed patients in a Swedish hospital emergency department (ED). Participants (final N = 41) were randomly allocated to either intervention (including memory reminder cue then visuospatial cognitive task “Tetris” with mental rotation instructions) or active control (podcast) condition within 72 h of presenting to the ED (both conditions using their smartphone). Findings were examined descriptively. We estimated between-group effect sizes for the number of intrusive memories post-intervention at week 1 (primary outcome) and week 5 (secondary outcome). Compared to the control condition, participants in the intervention condition reported fewer intrusive memories of trauma, both at week 1 and week 5. Findings extend the previous evaluation in the UK. The intervention was readily implemented in a different international context, with a mixed trauma sample, with treatment gains maintained at 1 month and associated with some functional improvements. Findings inform future trials to evaluate the capacity of the cognitive task intervention to reduce the occurrence of intrusive memories after traumatic events.

Background The current study explored how to recruit patients soon after a traumatic event, to deliver a novel intervention in a new emergency department in Sweden. This brief behavioral intervention aims to prevent intrusive memories and is delivered soon after trauma in the emergency department. In the UK, it has shown promising results. Traumatic events resulting in admission to the emergency department (e.g., road traffic accidents) may result in subsequent mental health problems such as post-traumatic stress disorder, where intrusive memories of the trauma constitute a core clinical feature. Early interventions that prevent intrusive memories after psychological trauma are lacking. Specific aims were to explore identification of eligible patients (aim 1), fitting in with emergency department staff routines to deliver the study protocol (aim 2), and using the patients’ own smartphones to deliver intervention/control task (aim 3). Two changes to the previous study were (i) extending the trauma types included (ii) a new control condition, also by smartphone. Methods This is an explorative observational study. Data was both analyzed descriptively and using the Framework method. Results We identified several possible ways to recruit patients, and establish a sense of embeddedness in the Swedish emergency department context and a positive appreciation from staff. The study protocol was tested with 8 participants. Tasks both in the intervention and control condition were readily delivered via patients’ own smartphones. Conclusion Recruitment of patients and smartphone delivery of the intervention indicates initial feasibility. Researcher presence and administration of study procedures was successfully fitted to emergency department routines and well received by staff. Further pilot work is warranted, underscoring the importance of our collaboration between nursing and psychology.

Background:Even in cases with complexity, simple techniques can be useful to target a specific symptom. Intrusive mental images are highly disruptive, drive emotion, and contribute to maintaining psychopathology. Cognitive science suggests that we might target intrusive images using competing tasks.Aims:We describe an imagery competing task technique within cognitive behavioural therapy (CBT) with a patient with bipolar disorder and post-traumatic stress disorder (PTSD) symptoms. The intervention – including Tetris computer game-play – was used (1) to target a specific image within one therapy session, and (2) to manage multiple images in daily life.Method:A single case (AB) design was used. (1) To target a specific image, the patient brought the image to mind and, after mental rotation instructions and game-play practice, played Tetris for 10 minutes. Outcomes, pre- and post-technique, were: vividness/distress ratings when the image was brought to mind; reported intrusion frequency over a week. (2) To manage multiple images, the patient used the intervention after an intrusive image occurred. Outcomes were weekly measures of: (a) imagery characteristics; (b) symptoms of PTSD, anxiety, depression and mania.Results:(1) For the target image, there were reductions in vividness (80% to 40%), distress (70% to 0%), and intrusion frequency (daily to twice/week). (2) For multiple images, there were reductions from baseline to follow-up in (a) imagery vividness (38%), realness (66%) and compellingness (23%), and (b) PTSD symptoms (Impact of Events Scale-Revised score 26.33 to 4.83).Conclusion:This low-intensity intervention aiming to directly target intrusive mental imagery may offer an additional, complementary tool in CBT.

Preventative psychological interventions to aid women after traumatic childbirth are needed. This proof-of-principle randomized controlled study evaluated whether the number of intrusive traumatic memories mothers experience after emergency caesarean section (ECS) could be reduced by a brief cognitive intervention. 56 women after ECS were randomized to one of two parallel groups in a 1:1 ratio: intervention (usual care plus cognitive task procedure) or control (usual care). The intervention group engaged in a visuospatial task (computer-game ‘Tetris’ via a handheld gaming device) for 15 min within six hours following their ECS. The primary outcome was the number of intrusive traumatic memories related to the ECS recorded in a diary for the week post-ECS. As predicted, compared with controls, the intervention group reported fewer intrusive traumatic memories (M = 4.77, SD = 10.71 vs. M = 9.22, SD = 10.69, d = 0.647 [95% CI: 0.106, 1.182]) over 1 week (intention-to-treat analyses, primary outcome). There was a trend towards reduced acute stress re-experiencing symptoms (d = 0.503 [95% CI: −0.032, 1.033]) after 1 week (intention-to-treat analyses). Times series analysis on daily intrusions data confirmed the predicted difference between groups. 72% of women rated the intervention “rather” to “extremely” acceptable. This represents a first step in the development of an early (and potentially universal) intervention to prevent postnatal posttraumatic stress symptoms that may benefit both mother and child. Clinical trial registration ClinicalTrials.gov, www.clinicaltrials.gov, NCT02502513., Highlights • An intervention to reduce traumatic memories in mothers after ECS was tested. • We compared usual care plus visuospatial cognitive task with usual care. • After 1 week, the intervention group reported fewer intrusive traumatic memories. • They also showed a trend towards reduced acute stress re-experiencing symptoms after 1 week. • This early game-based computerized intervention may benefit both mother and child.

Study objectives Intrusive memories of psychological trauma are a core clinical feature of posttraumatic stress disorder (PTSD), and in the early period post-trauma may be a potential target for early intervention. Disrupted sleep in the weeks post-trauma is associated with later PTSD. The impact of sleep and intrusive memories immediately post-trauma, and their relation to later PTSD, is unknown. This study assessed the relationship between sleep duration on the first night following a real-life traumatic event and intrusive memories in the subsequent week, and how these might relate to PTSD symptoms at 2 months. Methods Patients (n = 87) recruited in the emergency department completed a sleep and intrusive memory diary from the day of their trauma and for the subsequent week, with optional actigraphy. PTSD, anxiety, and depression symptoms were assessed at 1 week and 2 months. Results A U-shaped relationship was observed between sleep duration on the first night and intrusive memories over the subsequent week: sleeping “too little” or “too much” was associated with more intrusive memories. Individuals who met Clinician-Administered PTSD Scale (CAPS) criteria for PTSD at 2 months had three times more intrusive memories in the first week immediately post-trauma than those who did not (M = 28.20 vs 9.96). Post hoc analysis showed that the absence of intrusive memories in the first week post-trauma was only observed in those who did not meet CAPS criteria for PTSD at 2 months. Conclusions Monitoring intrusive memories and sleep in the first week post-trauma, using a simple diary, may help identify individuals more vulnerable to later psychopathology.

Intrusive memories of a traumatic event can be distressing and disruptive, and comprise a core clinical feature of post-traumatic stress disorder (PTSD). Intrusive memories involve mental imagery-based impressions that intrude into mind involuntarily, and are emotional. Here we consider how recent advances in cognitive science have fueled our understanding of the development and possible treatment of intrusive memories of trauma. We conducted a systematic literature search in PubMed, selecting articles published from 2008 to 2018 that used the terms "trauma" AND ("intrusive memories" OR "involuntary memories") in their abstract or title. First, we discuss studies that investigated internal (neural, hormonal, psychophysiological, and cognitive) processes that contribute to intrusive memory development. Second, we discuss studies that targeted these processes using behavioural/pharmacological interventions to reduce intrusive memories. Third, we consider possible clinical implications of this work and highlight some emerging research avenues for treatment and prevention, supplemented by new data to examine some unanswered questions. In conclusion, we raise the possibility that intrusive memories comprise an alternative, possibly more focused, target in translational research endeavours, rather than only targeting overall symptoms of disorders such as PTSD. If so, relatively simple approaches could help to address the need for easy-to-deliver, widely-scalable trauma interventions.

Background:Despite the global impact of bipolar disorder (BD), treatment success is limited. Challenges include syndromal and subsyndromal mood instability, comorbid anxiety, and uncertainty around mechanisms to target. The Oxford Mood Action Psychology Programme (OxMAPP) offered a novel approach within a cognitive behavioural framework, via mental imagery-focused cognitive therapy (ImCT).Aims:This clinical audit evaluated referral rates, clinical outcomes and patient satisfaction with the OxMAPP service.Method:Eleven outpatients with BD received ImCT in addition to standard psychiatric care. Mood data were collected weekly from 6 months pre-treatment to 6 months post-treatment via routine mood monitoring. Anxiety was measured weekly from start of treatment until 1 month post-treatment. Patient feedback was provided via questionnaire.Results:Referral and treatment uptake rates indicated acceptability to referrers and patients. From pre- to post-treatment, there was (i) a significant reduction in the duration of depressive episode relapses, and (ii) a non-significant trend towards a reduction in the number of episodes, with small to medium effect size. There was a large effect size for the reduction in weekly anxiety symptoms from assessment to 1 month follow-up. Patient feedback indicated high levels of satisfaction with ImCT, and underscored the importance of the mental imagery focus.Conclusions:This clinical audit provides preliminary evidence that ImCT can help improve depressive and anxiety symptoms in BD as part of integrated clinical care, with high patient satisfaction and acceptability. Formal assessment designs are needed to further test the feasibility and efficacy of the new ImCT treatment on anxiety and mood instability.

After psychological trauma, recurrent intrusive visual memories may be distressing and disruptive. Preventive interventions post-trauma are lacking. Here we test a behavioural intervention after real-life trauma derived from cognitive neuroscience. We hypothesized that intrusive memories would be significantly reduced in number by an intervention involving a computer game with high visuospatial demands (Tetris), via disrupting consolidation of sensory elements of trauma memory. The Tetris-based intervention (trauma memory reminder cue plus c. 20 minute game play) versus attention-placebo control (written activity log for same duration) were both delivered in an Emergency Department within 6 hours of a motor-vehicle accident. The randomized controlled trial compared the impact on the number of intrusive trauma memories in the subsequent week (primary outcome). Results vindicated the efficacy of the Tetris-based intervention compared to the control condition: there were fewer intrusive memories overall, and time-series analyses showed intrusion incidence declined more quickly. There were convergent findings on a measure of clinical post-trauma intrusion symptoms at one week, but not on other symptom clusters or at one month. Results of this proof-of-concept study suggest that a larger trial, powered to detect differences at one month, is warranted. Participants found the intervention easy, helpful and minimally distressing. By translating emerging neuroscientific insights and experimental research into the real world, we offer a promising new low-intensity psychiatric intervention that could prevent debilitating intrusive memories following trauma.

Mental imagery involves having an experience like perception but in the absence of a percept. We frequently have mental images such as when we remember an event or imagine the future. In psychological disorders, emotional mental images can flash to mind and be highly distressing, including traumatic memories or simulations of feared future events. However, emotional images have been neglected in research and therapy. This entry combines perspectives from cognitive science (mental imagery) and clinical psychology (psychological disorders). Cognitive science suggests that compared to verbal thoughts, mental imagery has a more powerful impact on emotion. Therefore, it is useful to ask about imagery in clinical assessment of emotional disorders. However, this approach has been largely restricted to PTSD (posttraumatic stress disorder). First, we illustrate that emotional mental imagery occurs across a wide variety of disorders. Second, by mapping the nature of imagery in disorders where it has been neglected (e.g., bipolar disorder), we may be able to import existing imagery therapy techniques (e.g., from PTSD) to improve treatment. Third, by drawing on cognitive science, we can capitalize on the properties inherent to mental imagery to suggest novel techniques. For example, maladaptive imagery may be reduced by cognitive tasks, which interfere with holding an image in mind. Also, adaptive imagery may be boosted by computerized training in generating positive imagery. Intriguingly, this opens the possibility of cognitively informed and computerized psychological treatments that may look rather different from traditional talking therapies. Keywords: mental imagery; psychological disorders; experimental psychopathology; imagery rescripting; emotion; trauma; bipolar disorder; depression; posttraumatic stress; cognitive science; cognitive behavior therapy; cognitive therapy

Mental imagery is increasingly recognized as having an important role in relation to autobiographical memory and psychopathology. Autobiographical memories frequently take the form of mental images (Conway & Pleydell-Pearce, 2000; Tulving, 1984) and, as mentioned in Bernsten (Chapter 9) can be recalled both voluntarily or involuntarily as a normal part of everyday life (see also Berntsen, 1996; 2010). Autobiographical memory for most individuals demonstrates a positivity bias. For example, more positive memories are recalled than negative ones; individuals perceive a greater number of positive events than negative events as occurring in their lives; and the emotional affect of negative memories fades faster than for positive ones (Walker et al., 2003b). However, in psychopathology this bias can be disrupted. After trauma, involuntary mental images and memories, for example, of an intrusive image of a car crash or assault, can be distressing and disruptive. In depressed individuals it can become difficult to recall positive memories, creating an automatic bias toward more negative information and increasing negative affect. Mental imagery offers a possible route to alleviating distress in psychopathology by reducing the occurrence of negative imagery or boosting positive imagery and biases toward positive imagery and information.

Recent elegant research has raised the salient issue of altering traumatic memories and its treatment implications. Kindt et al [1][1] suggest that ‘if emotional memory could be weakened or even erased, then we might be able to eliminate the root of many psychiatric disorders, such as post