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Solving the Mystery of Intrusive Flashbacks in Posttraumatic Stress Disorder: Comment on Brewin 2014)

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In the light of current controversy about the nature of intrusions in posttraumatic stress disorder (PTSD), the review by Brewin (2014) is timely and important. It will undoubtedly stimulate further research and guide researchers' quests for understanding the nature of flashbacks in PTSD. In this commentary, I briefly summarize and discuss key points made by Brewin and elaborate on some of the reasons behind the controversy. For example, the terms involuntary autobiographical memories, intrusive memories, and flashbacks are often used interchangeably. I propose a taxonomy revealing the key differences across these forms of memory. If flashbacks are characteristic of patients with PTSD only, it is essential that more research targeting this population is conducted with a variety of methods. Finally, some new avenues for research to study intrusive memories and flashbacks in PTSD, using a diary method and modified trauma film paradigm, are described. (PsycINFO Database Record (c) 2013 APA, all rights reserved).
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COMMENT
Solving the Mystery of Intrusive Flashbacks in Posttraumatic Stress
Disorder: Comment on Brewin (2014)
Lia Kvavilashvili
University of Hertfordshire
In the light of current controversy about the nature of intrusions in posttraumatic stress disorder (PTSD),
the review by Brewin (2014) is timely and important. It will undoubtedly stimulate further research and
guide researchers’ quests for understanding the nature of flashbacks in PTSD. In this commentary, I
briefly summarize and discuss key points made by Brewin and elaborate on some of the reasons behind
the controversy. For example, the terms involuntary autobiographical memories, intrusive memories, and
flashbacks are often used interchangeably. I propose a taxonomy revealing the key differences across
these forms of memory. If flashbacks are characteristic of patients with PTSD only, it is essential that
more research targeting this population is conducted with a variety of methods. Finally, some new
avenues for research to study intrusive memories and flashbacks in PTSD, using a diary method and
modified trauma film paradigm, are described.
Keywords: involuntary autobiographical memories, intrusive memories, flashbacks, hotspots, posttrau-
matic stress disorder
Research on posttraumatic stress disorder (PTSD) has yielded
important insights over the past 10 years, especially with respect to
intrusive memories and flashbacks, which constitute a key symp-
tom of this debilitating disorder. Given the complexity of the
phenomenon, a variety of approaches and methods has been used,
ranging from interview/questionnaire studies of intrusive memo-
ries in clinical and nonclinical samples to analysis of trauma
narratives in patients with PTSD and experimental analogue stud-
ies in nonclinical samples (trauma-film paradigm). This re-
search has been instrumental in testing and developing influ-
ential theories, enhancing understanding of mechanisms
involved in the formation and maintenance of recurrent intru-
sions in PTSD, and contributing to various therapeutic ap-
proaches in clinical practice.
In parallel, independent of this research, remarkable progress
has been achieved in a new area of cognitive psychology on
involuntary (nonintrusive) autobiographical memories in
mostly nonclinical populations, with numerous publications and
several books on the topic since the publication of a pioneering
study by Berntsen (1996). Researchers of involuntary autobio-
graphical memory and mainstream cognitive psychology have
recently started to question some of the findings and theoretical
assumptions of clinical research on intrusive memories in
PTSD.
In the light of current controversy about the nature of intru-
sive memories in PTSD, the review article by Brewin (2014) is
both important and timely. The major contribution of this
review to the literature on intrusive memories and more gener-
ally to cognitive psychology, as I see it, is (a) making a very
strong and convincing case for the existence of a perceptually
based memory representation system that can be accessed both
nonconsciously (implicitly) and consciously (explicitly) and (b)
situating research on intrusive phenomena and their theoretical
explanations within the context of normal cognitive processes.
It is essential, however, as pointed out by Brewin (2014), that
researchers “consider how ordinary memory mechanisms may
operate under usual and unusual circumstances” (p. 90). In
other words, researchers need to explore the variables that
modulate the operation of these normal processes in response to
extreme levels of stress experienced by patients during trau-
matic events to explain the highly intrusive and repetitive
nature of flashbacks and other clinical phenomena, such as
nightmares, hypervigilance, and partial and/or temporary am-
nesia for details of the traumatic event, as described in clinical
cases. They also need to explain why repeated exposure to these
highly distressing memories results in disappearance rather than
increase of intrusions and other symptoms of PTSD.
My aim is to briefly summarize the key points of Brewin (2014),
elaborate on reasons behind the controversy, discuss some of the
challenges faced by research on intrusive memories in general and
PTSD in particular, and outline possible avenues for future re-
search in this area.
This commentary has benefited from discussions with Jamie Hacker
Hughes on intrusive memories and from useful comments by Diana Korn-
brot on a draft of the manuscript.
Correspondence concerning this article should be addressed to Lia
Kvavilashvili, Department of Psychology, University of Hertfordshire,
College Lane, Hatfield, Hertfordshire AL10 9AB, United Kingdom.
E-mail: L.Kvavilashvili@herts.ac.uk
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Psychological Bulletin © 2014 American Psychological Association
2014, Vol. 140, No. 1, 98–104 0033-2909/14/$12.00 DOI: 10.1037/a0034677
98
Summary of Key Points
Long-Term Perceptual Memory System
Brewin (2014) brings together several different streams of re-
search within cognitive and clinical psychology to support the
existence of a long-term memory system that automatically en-
codes sensory perceptual information and that may sometimes
operate separately from the more language-based episodic and
autobiographical memory systems postulated by current theories
of memory. Although the existence of implicit memory and prim-
ing and its underlying perceptual representation memory system is
now textbook material in cognitive psychology, the basic assump-
tion, until recently, has been that this system manifests itself
nonconsciously (implicitly) in behavioral responses (e.g., reaction
times or word stem completions) and that its effects are relatively
short lived, not lasting longer than few minutes, hours, or days,
depending on the tasks and materials used. However, evidence
reviewed by Brewin provides support for the idea that not only
does the encoding of low-level perceptual minutiae occur auto-
matically but that this information can subsequently be retrieved in
the form of conscious intrusive images and memories in the
presence of some potent cues, even after long periods of delay.
Evidence emerging from SenseCam research concerning long-
term retention of everyday minutiae—including one’s own
thoughts (which are notoriously difficult to remember; e.g.,
Brewer, 1988)—is promising and can potentially change current
theories of episodic and autobiographical memories (see, e.g.,
Conway, 2009). Further evidence, not reviewed in the target arti-
cle, comes from initial research on involuntary semantic memo-
ries, or mind-pops, in both clinical and nonclinical samples. The
research shows that even briefly encountered novel information
(e.g., a street name seen in passing) may later pop into one’s mind,
sometimes even without one’s conscious knowledge that this in-
formation had been encountered (Elua, Laws, & Kvavilashvili,
2012;Kvavilashvili & Mandler, 2004). Such memory representa-
tions were referred to as “free radicals” by Tulving (1983), who
proposed that they had not been integrated into either episodic or
semantic memory systems and, hence, represented more of an
anomaly than a standard mode of operation. In contrast, Brewin
(2014) proposed the existence of a long-term perceptually based
memory system that is crucial in the production of various con-
sciously experienced involuntary phenomena, including the intru-
sive memories and flashbacks in PTSD.
Dissociation Between Long-Term Perceptual and
Language-Based Memory Systems
Dissociations between implicit and explicit memory are well
documented in cognitive memory research. Brewin (2014) re-
viewed additional evidence from cognitive psychology that shows
dissociations between the two systems (e.g., on verbal overshad-
owing or using SenseCam). In relation to PTSD intrusions, Brewin
summarized findings from both experimental and correlational
studies, which have used the trauma-film paradigm asking partic-
ipants to record subsequent intrusions and testing participants’
episodic memory for scenes in the trauma film. Meta-analysis of
these studies revealed that the number of recorded film intrusions
do not correlate with performance on episodic memory tasks,
which measure the retention of film content. Furthermore, al-
though manipulations of concurrent activities during the film af-
fected the number of recorded intrusions, the group differences
were not usually mirrored by similar differences in episodic mem-
ory tasks, as shown in Brewin’s Tables 2, 3, and 4 (for a partic-
ularly interesting dissociation, see Krans, Näring, Holmes, &
Becker, 2009).
Nature of Voluntary (Narrative) Memory of
Traumatic Events in PTSD
A review of the literature, presented by Brewin (2014),on
impaired voluntary memory for trauma (one of the key symptoms
of PTSD, according to the Diagnostic and Statistical Manual of
Mental Disorders criteria) showed that all those studies in which
trauma narratives were independently judged by raters provide
support for clinical observations of increased fragmentation or
disorganization of trauma narratives. In contrast, those studies that
asked participants themselves to rate these aspects of their trauma
memory (using one or two items in a questionnaire) did not find
any such effects. Brewin therefore concluded that the results
obtained will depend on the method used and that the judges’
ratings are more objective than and preferable to participants’ own
ratings. It is, however, obvious that it will be very difficult to
achieve consensus on this contentious issue. Indeed, it is difficult
to study empirically the type of disorganization/fragmentation and
partial or even complete amnesia for aspects of trauma event
reported in clinical case studies of PTSD, especially if researchers
use nonclinical or non-PTSD populations, which do not experience
such symptoms.
Effects of Visuospatial and Verbal Concurrent Tasks
on Subsequent Intrusions
The dual representation theory assumes two separate and rela-
tively independent routes to the formation and recall of trauma
memories: the long-term perceptually based visuospatial represen-
tation system and the language-based conceptual memory system
(Brewin, Dalgleish, & Joseph, 1996). It is assumed that concurrent
visuospatial and verbal tasks at the time of encoding tap into these
two systems separately and produce modality-specific interference
with contrasting effects on subsequent intrusions and flashbacks.
In particular, if a person engages in a secondary task taxing his or
her visuospatial system, this performance will interfere with the
automatic formation of perceptual images of trauma and result in
reduction of subsequent trauma-related intrusions. In contrast,
engagement in a concurrent verbal activity would interfere with
the processes occurring in the language-based memory system.
Although logically this should lead to some impairment of the
person’s voluntary narrative of the trauma event (perhaps making
it less coherent and/or incomplete), the main and somewhat coun-
terintuitive prediction of the theory is that concurrent verbal tasks
enhance processing in visuospatial perceptual system, which will
result in an increased number of subsequent intrusions compared
to no task control.
Brewin (2014) provided a comprehensive review of empirical
studies that directly test the key predictions of the dual represen-
tation theory using traumatic film clips and manipulating the
nature of concurrent tasks in nonclinical samples. He provided
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99
INTRUSIVE FLASHBACKS IN PTSD
strong support for the idea that visuospatial tasks presented during
or after the trauma film, such as the complex tapping task or the
game Tetris, reliably reduce the number of recorded film intrusions
in comparison to control conditions (without or with other con-
current tasks). Of particular interest are recent studies that man-
aged to obtain these results by engaging participants in visuospa-
tial tasks 30 minutes or several hours after watching the film
(Deeprose, Zhang, DeJong, Dalgleish, & Holmes, 2012;Holmes,
James, Kilford, & Deeprose, 2010).
However, one problem is that the majority of relevant studies
have used relatively complex visuospatial tasks, which should also
engage, to a certain degree, the central executive component of
working memory system. Hence, it is not entirely clear whether the
reduction of intrusions is due to selective engagement of the
visuospatial sketchpad, the central executive, or both. For exam-
ple, growing research examining the role of eye movements, while
a person holds an image of negative and/or intrusive memory in
mind, shows that engaging the visuospatial system in this way has
beneficial effects in the direction predicted by the dual represen-
tation theory (Gunter & Bodner, 2008;Lilley, Andrade, Turpin,
Sabin-Farrell, & Holmes, 2009). However, this research has also
shown that eye movements tax the central executive by reducing
performance on a concurrent reaction time task (van den Hout et
al., 2011). Could it be, therefore, that asking participants to gen-
erate random numbers, a task that taps primarily into central
executive resources, will produce the same amount of reduction in
intrusions as the complex tapping task or the Tetris game? Recent
findings by Pearson and Sawyer (2011) seem to provide initial
support for this conjecture, even though they used emotional
pictures instead of a trauma film (which could have affected the
results, as pointed out by Brewin, 2014). However, Isaacs (2004)
has reported similar results using the so-called numerical distrac-
tion therapy with 26 patients with PTSD, who, as part of their
therapy session, had to hold in mind their intrusive images while
simultaneously completing a demanding counting task (counting
backward in 2 s from 10 to 0 and then up to 10 again). It is clear
that more systematic research is needed to address this important
question.
In contrast to research on concurrent visual tasks, evidence
concerning concurrent verbal tasks within the trauma film para-
digm is mixed and appears to depend on the nature of concurrent
tasks used. Two separate analyses were reported by Brewin
(2014). The analyses of seven studies that used counting backward
in 3 s or 7 s showed that the concurrent verbal task resulted in a
statistically significant increase in the number of film intrusions in
two studies, a nonsignificant trend in the predicted direction in
three studies, and a nonsignificant trend in the opposite direction
(verbal task reducing intrusions in comparison to no task control)
in two other studies. Although the overall effect, using meta-
analytic procedures on these seven studies, came out as significant,
it is obvious that the findings are not as straightforward as they
have been with concurrent visuospatial tasks. Moreover, a separate
but similar analysis of those five studies that used different verbal
tasks (e.g., simple counting or remembering a 9-digit number)
resulted in nonsignificant effects.
It is interesting that simple counting or holding a 9-digit number
engages primarily the phonological loop, whereas counting back-
ward by 3 s and 7 s requires additional central executive resources,
as they impair performance on simple reaction time tasks (van den
Hout et al., 2010). Therefore, it is unclear to what extent the effects
predicted by the dual representation theory concerning concurrent
verbal tasks also relate to engaging the central executive in addi-
tion to modality specific verbal processes within the phonological
loop. It is also interesting that more cognitively based theories
would predict that engaging verbal processes and counting back-
ward in 3 s and 7 s should decrease rather than increase subsequent
intrusions and distress associated with them, as was indeed re-
ported by Isaacs (2004; see also Pearson & Sawyer, 2011;van den
Hout et al., 2010). It is therefore important that future research
systematically compares the predictions of the dual representation
theory and general theories of cognitive load and working mem-
ory, using a trauma-film paradigm with both analogue and clinical
samples (see below). One potential issue that arises in relation to
this paradigm, as with research on involuntary phenomena in
general, is that there is a large variability in the number of recorded
film intrusions, which can range from 0 to over 30 per participant
(see, e.g., Holmes, Brewin, & Hennessy, 2004). The data are
therefore non-normally distributed and may be affected by one or
two outliers in some but not other conditions. Consequently, it is
important to examine such data for outliers and, if necessary,
exclude them from analyses or use statistical procedures that are
sensitive to the (almost always) non-normal distribution of intru-
sion errors.
Reasons Behind the Controversy
Several important reasons underlying the nearly continuous
debates between clinical and cognitive psychologists were dis-
cussed by Brewin (2014). Here, I would like to elaborate on
several additional issues, which in my view have also contributed
to the controversy and confusion about intrusive memories in
PTSD.
Problems With Terminology and Definition of
Intrusive Memories
A key problem is confusion about the terminology used and
what is actually studied: involuntary autobiographical memories,
intrusive memories, or flashbacks. These terms are often used
interchangeably, even though they refer to different phenomena.
According to the Diagnostic and Statistical Manual of Mental
Disorders (4th ed.; DSM–IV;American Psychiatric Association,
1994; p. 209), the PTSD diagnosis requires that “the traumatic
event is persistently re-experienced” (Criterion B), which may
consist of “recurrent and distressing recollections of the event”
(B1), and/or “acting or feeling as if the traumatic event was
recurring (includes the sense or reliving the experience, illusions,
hallucinations and dissociative flashback episodes)” (B3). From
this description, it is obvious that the types of intrusive recollec-
tions described as B1 and B3 are quite different. Although B1
refers to what is typically called “intrusive memories,” which are
also experienced by the general population and people with clin-
ical disorders (e.g., patients with depression), B3 refers to a very
special type of intrusive phenomena, associated with an intense
sense of current threat (as if the trauma is recurring) and involves,
in extreme cases, complete loss of sense of current reality and
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100 KVAVILASHVILI
control of one’s situation.
1
These flashbacks appear to be a key
characteristic feature of PTSD only (Brewin, Dalgleish, & Joseph,
1996;Reynolds & Brewin, 1998).
Despite these important differences between intrusive memories
and flashbacks, many published studies use these terms inter-
changeably. The situation is exacerbated by the fact that in some
studies researchers have started using the term involuntary auto-
biographical memory when referring to intrusive memories and
vice versa (e.g., Brewin, 1998;Bywaters, Andrade, & Turpin,
2004;Deeprose et al., 2012), presumably because intrusiveness is
equated with the spontaneity of recall.
By clear definition of each of these concepts, confusion and
controversy can be greatly reduced. Indeed, involuntary autobio-
graphical memories are memories of past events that pop into mind
unexpectedly without any attempt to recall anything, often in
response to external or internal triggers. They may affect one’s
current mood (Berntsen & Hall, 2004;Kvavilashvili & Schlagman,
2011). They may refer to positive, negative, or completely neutral
events, such as remembering one’s first romantic kiss, a car
accident, or bumping into a neighbor at a supermarket. In contrast,
intrusive memories are spontaneous involuntary memories of a
(mostly) negative event that repeatedly intrude upon conscious-
ness, often against one’s will; they are hard to control and may
disrupt one’s ongoing activities. These intrusive memories may
sometimes be of positive events (e.g., Brewin, Christodoulides, &
Hutchinson, 1996;Bywaters et al., 2004), but they are predomi-
nantly negative and disturbing.
Although ordinary involuntary autobiographical memories and
intrusive memories are similar in terms of their spontaneous na-
ture, they are different in a number of ways. Indeed, everyday
involuntary autobiographical memories are random, one-off mem-
ories, which pop into mind only once or twice and may never again
be recalled, whereas the key feature of intrusive memories is their
repetitive nature, so that a particular memory or image keeps
coming back and disturbing the individual. Moreover, everyday
involuntary autobiographical memories, even if negative, do not
normally disrupt ongoing activities. Often, it is hard to even notice
them, as they form part of a normal stream of consciousness and
do not stay in mind for longer than a few seconds. Of importance,
they do not involve active avoidance attempts, which is one of the
key features of intrusive memories.
It is even more important to distinguish clearly intrusive mem-
ories and trauma flashbacks in PTSD (see Brewin, Dalgleish, &
Joseph, 1996;Reynolds & Brewin, 1999). Although intrusive
memories can in principle be about a positive or a negative event,
this is not the case for flashbacks, which by definition refer to
traumatic events involving high levels of intense fear, helpless-
ness, and horror (e.g., when being threatened by a knife and raped,
witnessing death, or causing someone’s death). The most impor-
tant difference between the two lies in the nature of reliving of the
event in memory. Even though intrusive memories often induce
bodily reactions and feelings associated with the original event, the
person is still aware of this being a recollective experience or
“mental time travel” that is characteristic of autobiographical
memories in general. In contrast, the reexperiencing in flashbacks
is different from reliving in intrusive memories, as it involves an
overwhelming sense of “nowness” accompanied by a strong startle
response and high degrees of physiological arousal. As a result,
Brewin, Dalgleish, and Joseph (1996) characterized flashbacks
more as spontaneous reenactments than as just reliving of trauma
(p. 671). One of the difficulties of distinguishing intrusive mem-
ories from flashbacks is that flashbacks can vary “from relatively
mild (there is a transient sense of event re-occurring in the present)
to severe (the person loses all connection with his or her current
self and surroundings while re-experiencing the memory)”
(Brewin, Gregory, Lipton, & Burgess, 2010, p. 211).
The three types of memories described above can be presented
on a continuum with involuntary autobiographical memories and
flashbacks occupying its opposite poles and intrusive memories in
the middle, sharing some features with each (see Figure 1). The
important question that arises is whether the difference between
intrusive memories and flashbacks (especially the relatively mild
ones with only transient sense of nowness) is quantitative or
qualitative. According to clinical research and the dual represen-
tation theory, the difference is qualitative, whereas cognitive psy-
chologists argue that it is quantitative (Berntsen, 2001;Rubin,
Boals, & Berntsen, 2008). Answering this important question is
difficult but not impossible. It may require more targeted behav-
ioral studies on participants with PTSD (see below) as well as
input from fMRI and lesion studies (e.g., Koenigs & Grafman,
2009;Whalley et al., 2013).
Problems With Studying PTSD Flashbacks in
Analogue Studies
Clinical observations and case studies suggest that patients with
PTSD have a small number of recurring images and/or memories
about their trauma, only a few of which have the qualities of
flashback type reenactment/reexperiencing that is specifically
characteristic of PTSD (e.g., Holmes, Grey, & Young, 2005).
Therefore, the existing controversy may also be related to the
implicit assumption that the dual representation theory was pro-
posed to explain all intrusions in PTSD rather than a relatively
small subset of them (i.e., flashbacks).
However, Brewin, Dalgleish, & Joseph, (1996) clearly distin-
guished two types of intrusive memories in PTSD. Intrusive mem-
ories are essentially part of the normal autobiographical memory
system and can be recalled both deliberately in the form of trauma
narrative and as recurrent intrusive memories (see also Reynolds &
Brewin, 1999). Such intrusive memories are often associated with
secondary emotions of sadness, anger, or guilt and can occur in the
general population and other clinical samples (e.g., people with
depression). In contrast, flashbacks can only be recalled involun-
tarily, in response to internal or external triggers, and consist
predominantly of visual perceptual images.
If intrusive trauma memories and flashbacks are distinguished in
this way, there appears to be no real contradiction between general
cognitive theories of autobiographical memory and the dual rep-
resentation theory, as they are simply trying to explain different
types of phenomena. This formulation, however, contains para-
doxes that should be addressed and clarified. First, if flashbacks
1
It is important that, in the Diagnostic and Statistical Manual of Mental
Disorders (5th ed.; DSM–5;American Psychiatric Association, 2013), a
similar distinction is drawn between B1 and B3. There, B1 is defined as
“Recurrent, involuntary, and intrusive memories” and B3 is defined as
“Dissociative reactions (e.g., flashbacks) which may occur on a continuum
from brief episodes to complete loss of consciousness.”
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101
INTRUSIVE FLASHBACKS IN PTSD
are a special form of intrusive memories, based entirely on the
long-term perceptual representation system, then analogue re-
search with nonclinical samples cannot be generalized to flash-
backs occurring in PTSD. Instead, as pointed out by Brewin
(2014), research on flashbacks should be conducted on patients
with PTSD who are actually suffering from these flashbacks. The
second paradox revolves around the assumption that patients’ most
disturbing and intrusive flashbacks cannot be accessed voluntarily.
This is strange, given that in therapy, patients are asked to delib-
erately recall the most distressing parts of their trauma memory,
which patients appear to be able to do (e.g., Isaacs, 2004; see also
Brewin, Huntley, & Whalley, 2012;Holmes et al., 2005). If
patients cannot voluntarily access their flashback, this would mean
that they have no conscious awareness of it after they cease
experiencing it. In other words, inability to voluntarily recall a
particular flashback would imply the existence of amnesia for the
content of this flashback until a person encounters a potent cue that
spontaneously triggers the memory. Although patients have been
reported to have amnesia for some details of the traumatic event,
in the course of therapy they are normally able to provide some
description of their most disturbing and recurring flashback type
intrusions. Moreover, several studies have asked participants with
PTSD to provide a written narrative of their trauma event and then
to retrospectively indicate which parts of the trauma narrative
elicited flashback experience(s). Participants were able to do so
(see Brewin et al., 2012;Hellawell & Brewin, 2002,2004). Having
indicated such places in their narrative, patients should be able to
deliberately bring into their mind the same flashbacks, if re-
quested. In light of this evidence, it would be important to have
some discussion in the literature about this aspect of trauma
flashback—including whether it manifests in therapy and in ev-
eryday life as specified by the dual representation theory.
Avenues for Future Research
These are clearly interesting times for research on intrusive
memories and flashbacks in PTSD. The growing number of em-
pirical studies and theorizing in this field, as well as the contro-
versy between clinical and more cognitively oriented researchers,
indicate that researchers may be on a verge of important break-
throughs and developments in near future. The key to these de-
velopments, in my view, is adopting a broader approach, as advo-
cated by Brewin (2014), and bringing together various strands of
research that have been developing relatively independently. These
include research on involuntary autobiographical memories, on the
one hand, and research on intrusive memories and flashbacks, on
the other. In addition, there is growing research situated within the
working memory model examining the effects of concurrent verbal
and visuospatial tasks on the vividness and emotionality of nega-
tive memory images (mostly in nonclinical samples). Below, I
conclude by outlining some additional avenues for future research.
Studying Flashbacks in Patients With PTSD
Irrespective of the methodology used and of researchers’ orien-
tation (clinical or cognitive), future studies should concentrate to a
greater degree on clinical samples with PTSD to study the actual
phenomenon in question: the flashbacks. There is already evidence
that it is possible to do so; for example, by asking patients with
PTSD to provide a detailed written trauma narrative and retrospec-
tively indicate which parts of the narrative (called hotspots)
brought about uncontrollable visual flashbacks when writing the
narrative (e.g., Holmes et al., 2005). Two studies have used inter-
esting variations of this method. Brewin et al. (2012) exposed
patients with PTSD to words and phrases from their own or other
patients’ trauma narratives and examined which cues elicited
flashback intrusions. Michael, Ehlers, Halligan, and Clark (2005)
used the so-called intrusion provocation task by exposing assault
victims to pictures depicting various assaults (bought from press
agencies) and then assessing whether these pictures elicited intru-
sive memories from their own assault. Both methods elicited
reports of flashbacks in patients. This indicates that intrusive
flashbacks, despite their unpredictable nature, can be studied in
patients with PTSD in much more focused and systematic fashion
than previously thought.
Moreover, the success of these methods indicates that the pre-
dictions of the dual representation theory can be directly tested on
patients with PTSD, in addition to analogue samples, by using a
modified version of a trauma-film paradigm. Indeed, trauma film
clips can be tailored in such a way that they depict several different
Figure 1. Schematic representation of different types of involuntary memories presented on a continuum and
their characteristics. PTSD posttraumatic stress disorder.
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102 KVAVILASHVILI
incidents that are thematically similar to the patient sample’s own
trauma (e.g., road traffic accidents vs. assaults, depending on a
composition of the sample tested). Immediately after watching the
film, participants report which parts of the film elicited flashbacks
or intrusions of their own trauma, if any, and briefly describe the
content of these flashbacks. In the subsequent week, participants
with PTSD keep a diary of their own (and/or film) intrusions
elicited by the film, and the effects of concurrent tasks during
and/or after the film can be assessed. Of particular interest would
be examining whether the completion of concurrent visual tasks
during the film reduces the likelihood of experiencing one’s own
trauma flashbacks and the concurrent verbal tasks increase the
chances of such flashbacks (cf. Hellawell & Brewin, 2002).
Diary Studies of Intrusive Memories and
Flashbacks in PTSD
Research on intrusive memories and flashbacks can benefit from
use of a diary method. It is one of the key methodological tools in
research on involuntary autobiographical memories and has con-
sistently produced valid and replicable findings (Berntsen, 2010;
Schlagman & Kvavilashvili, 2008). Its use should enable the
gathering of comparable data on intrusive memories and flash-
backs. One important task is examining the nature of ordinary
(nontrauma) involuntary autobiographical memories, repetitive in-
trusive (but non flashback) memories of trauma, and trauma flash-
backs in patients with PTSD by asking them to keep a diary of
these memories (using a within- or between-subjects design). It is,
for example, unclear what role ordinary involuntary autobiograph-
ical memories play in the maintenance of PTSD symptoms. Is it
possible that they are likely to be linked (remotely or indirectly) to
the traumatic event (e.g., Berntsen, 2001), and could this further
enhance negative mood or elicit intrusions about the trauma itself?
Another interesting issue that this research could clarify is to
examine whether the same memory image can sometimes occur as
an intrusive memory (without the sense of nowness) and as a
full-blown flashback reenactment, in which the patient feels as if
the traumatic event is happening again.
Comparing Predictions of Dual Representation Theory
and Working Memory Model
It is particularly urgent to systematically investigate and com-
pare the contrasting predictions of dual representation theory and
working memory model in order to answer the following question:
Are there modality-specific interference effects on the number of
reported intrusions with concurrent visuospatial and verbal tasks,
or are the obtained effects at least partly due to more general
interference by taking up some central executive resources, as
initially demonstrated by Pearson and Sawyer (2011)? Or are both
modality- specific and general interference at play (Kemps &
Tiggemann, 2007)? Another important task is to find whether the
effects of concurrent tasks are mediated by working memory span
of participants. For example, is it possible that the interference
effects with concurrent tasks are more likely to occur in partici-
pants with low rather than high working memory span (e.g.,
Gunter & Bodner, 2008)? All these interesting questions await
further investigation, and the review of Brewin (2014) will un-
doubtedly inform and stimulate this future research conducted by
both clinical and cognitive psychologists. Together, researchers
can solve the mystery of intrusive flashbacks in PTSD.
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Received July 16, 2013
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Accepted August 7, 2013
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104 KVAVILASHVILI
... However, what appears to distinguish intrusive memories in PTSD from intrusive memories in other psychiatric disorders is that they are reexperienced as if re-living the traumatic moment in the here and now (Bryant, O'Donnell, Creamer, McFarlane, & Silove, 2011;Kleim, Graham, Bryant, & Ehlers, 2013). Re-experiencing is thought to exist on a continuum with mild to moderate levels of re-experiencing characterising intrusive memories and more intense forms of re-living leading to dissociative experiences characterising flashbacks (American Psychiatric Association, 2013;Kvavilashvili, 2014). A more detailed description of the phenomenology and development of intrusive memories following trauma will be provided later in this chapter. ...
... Secondly, intrusive memories tend to be relatively brief, sensory-based, vivid, and detailed "snapshots" representing moments of the trauma rather than the entire traumatic event (Ehlers, Hackmann, & Michael, 2004;Hackmann et al., 2004;Speckens, Ehlers, Hackmann, Ruths, & Clark, 2007). An additional characteristic that is thought to distinguish intrusive memories from more common involuntary autobiographical memories is their high level of repetition, whereby the same "snapshot" is re-experienced over and over again (Kvavilashvili, 2014). Individuals can remember with great accuracy smells, sounds, and especially sights they perceived during the trauma. ...
... Indeed, defined flashbacks as actual re-enactments of the trauma rather than simple cases of reliving. Importantly, while intrusive memories can be experienced by both individuals with and without PTSD, flashbacks appear to be unique to individuals with PTSD (Kvavilashvili, 2014). Due to the focus in the current thesis on a non-clinical population of disaster survivors, we will focus on intrusive memories of the traumatic event experienced by individuals with and without PTSD rather than limiting the investigation to flashbacks experienced only among individuals with PTSD. ...
Conference Paper
Full-text available
Intrusive memories represent a hallmark symptom of post-traumatic stress disorder (PTSD). Cognitive theories of PTSD hypothesize that intrusive memories result from disruptions in information processing during traumatic memory encoding. The affective, cognitive, and behavioural reactions taking place during trauma have been termed peritraumatic reactions. These include reactions such as peritraumatic dissociation and tonic immobility. Experimental evidence has supported the theoretical claims concerning the role of peritraumatic reactions in the development of intrusive memories. This literature, however, presents a number of limitations. First, it relies on a conceptualisation of peritraumatic reactions based largely on quantitative measures with a large degree of conceptual overlap. Secondly, the identification of peritraumatic reactions has relied on clinical expertise, theory, and animal models, rather than on systematic investigations of survivors’ lived experience. Finally, studies on peritraumatic reactions and intrusive memories, have generally assessed peritraumatic reactions for the entire trauma rather than for the specific moments experienced as intrusive memories. This thesis set out to address these limitations. Firstly, I investigated the factorial structure of the six most widely used peritraumatic measures. This led to the identification of a psychometrically validated model comprising five distinct peritraumatic reactions. Secondly, I explored using a largely inductive analytical framework the lived experienced of peritraumatic reactions spontaneously reported in interviews. Finally, building on these findings, I confirmed the theory-informed claims that the specific moments of a trauma experienced as intrusive memories would be characterised by higher levels of peritraumatic reactions compared to moments from the same trauma that did not intrude. All research was conducted among earthquake survivors. The current findings hold various implications for the conceptualisation of peritraumatic reactions and intrusive memories. Additionally, they have a number of practical implications for the prevention and management of intrusive memories as well as for the wellbeing of disaster survivors more generally.
... Unlike most diary studies of involuntary retrieval, which only establish a lack of clear intention to retrieve a memory (warranting the phrase "non-intentional"), counter-intentional retrievals justify the use of the phrase "involuntary". Counter-intentional retrievals may provide an informative laboratory model of the retrieval processes that underlie intrusive memories, which are involuntary retrievals that are both unwanted and potentially disruptive (Kvavilashvili, 2014). In line with their counter-intentional nature, we therefore refer to the involuntary retrievals reported by our participants as "intrusions" (Levy & Anderson, 2012) that may be relevant to clinical reports of intrusive memories. ...
... Van Schie and Retrieval suppression focuses on how we suppress unwanted involuntary retrievals, and addresses intrusive memories per se, a subclass of involuntary memories that are both unwanted and perseverative (Kvavilashvili, 2014): intrusion ratings are a suitable way to track intrusions over the course of the TNT phase. ...
Thesis
The flow of human thoughts is frequently plagued by unwanted cognitive activity, which has the unfortunate power to interfere with task performance, planning, social behaviour, and many other aspects of our lives. Importantly, repetitive negative thoughts and memories play a major role in psychopathology and represent a fundamental transdiagnostic process which deserves experimental and clinical attention. Inhibitory deficits on the one hand and metacognitive beliefs on the other are thought to play a key role in maintaining intrusive repetitive memories and thoughts in a variety of mental health difficulties (Major Depressive Disorder, Post-Traumatic Stress Disorder, Obsessive-Compulsive Disorder, Generalized Anxiety Disorder). This thesis argues against Daniel Wegner’s Ironic Process Theory (Chapter 1) and examines the impact of thought suppression on intrusive Autobiographical Memories with two studies: an fMRI study (Study 1, Chapter 2), and a behavioural study (Study 2, Chapter 3). These two studies represent the first attempt to employ the Autobiographical Think/No-Think task (ATNT), a novel version of the Think/No-Think task solely based on autobiographical memories provided by each participant. In particular, Study 1 investigates the neural correlates of the ATNT task using functional Magnetic Resonance Imaging, and Study 2 explores the introduction of trial-by-trial intrusion ratings in the ATNT task and considers the affective consequences of thought suppression using Skin Conductance Response (SCR). This thesis also probes for the first time the relationship between metacognitive beliefs, intrusive memories, and thought control abilities using the standard Think/No-Think paradigm and manipulating participants’ metacognitive beliefs about the usefulness and the uncontrollability of repetitive intrusive thinking (Study 3, Chapter 4). After a general discussion (Chapter 5), this thesis reflects on the philosophical and ethical implications of forgetting, from a personal, psychological, and historical point of view (Chapter 6).
... In line with this reasoning, one may argue that if inhibitory control did mattereven if in a rather limited and narrow sub-class of circumstancesthen it should predominantly matter in relation to intrusive memories and thoughts. As suggested by Kvavilashvili (2014), intrusive memories and flashbacks should be treated as a separate sub-category of involuntarily retrieved autobiographical memories (but see Berntsen & Nielsen, 2021). Briefly, Kvavilashvili (2014) proposed a continuum with IAMs and trauma re-experiencing in the form of flashbacks at opposite poles and intrusive memories in the middle. ...
... As suggested by Kvavilashvili (2014), intrusive memories and flashbacks should be treated as a separate sub-category of involuntarily retrieved autobiographical memories (but see Berntsen & Nielsen, 2021). Briefly, Kvavilashvili (2014) proposed a continuum with IAMs and trauma re-experiencing in the form of flashbacks at opposite poles and intrusive memories in the middle. While all these memories are spontaneously retrieved, they may also be treated as different from each other. ...
Article
The present study focused on involuntary thoughts about personal past events (i.e., involuntary autobiographical memories; IAMs), and involuntary thoughts about future events and plans (i.e., involuntary future thoughts; IFTs). The frequency of these involuntary thoughts is influenced by cognitive demands of ongoing activities, but the exact underlying mechanism(s) has yet to be revealed. The present study tested two possible explanations: (1) the special inhibitory mechanism switches on when one is engaged in attentionally demanding activities; (2) different levels of cognitive load interfere with cue-noticing that act as triggers for IAMs and IFTs. We report a study with pre-selected groups of participants that differed in terms of their individual level of inhibitory control capacity (high vs. low), and completed both standard and attentionally demanding versions of a laboratory vigilance task with irrelevant cue-words to trigger IAMs and IFTs, and random thought-probes to measure their frequency. To examine the level of incidental cue-noticing, participants also completed an unexpected cue-recognition task. Despite large differences between groups in inhibitory control capacity, the number of IFTs and IAMs, reported in the attentionally demanding condition, was comparable. In addition, high cognitive load reduced the number of IAMs, but not IFTs. Finally, the recognition of incidental cues encountered in the vigilance task was reduced under high cognitive load condition, indicating that poor cue-noticing may be the main underlying mechanism of cognitive load effect rather than the lack of inhibitory resources needed to suppress involuntary retrieval. This and other possible mechanisms and avenues for future research are discussed.
... Considerable AM research in PTSD has focused on memories that arise spontaneously, namely, involuntary AMs, intrusive AMs, and flashbacks. Although these terms are often used interchangeably in research studies, recent attempts to create a taxonomy have been employed to study potentially distinct phenomena associated with these processes (Kvavilashvili, 2014). For instance, Kvavilashvili suggests that involuntary AMs arise spontaneously without attempt at recall; may occur in response to internal and external triggers; and can be positive, negative, or neutral in valence (e.g., Berntsen and Hall, 2004). ...
... For example, Schönfeld and Ehlers (2017) found that compared to individuals without PTSD, traumatic AM's appeared more specific, as they were experienced more vividly and were associated with a subjective sense of "nowness." However, the group with PTSD perceived their traumatic memories as less intentional, indicating that while traumatic and nontraumatic memories may be similarly involuntary post-trauma, individuals with PTSD may overestimate the frequency of trauma-related involuntary memories because they are noticed more often than non-trauma related involuntary memories (Kvavilashvili, 2014). By contrast, nontraumatic memories in the group with PTSD were associated with reduced continuity between past self and present self; and were less specific (Schönfeld and Ehlers, 2017). ...
... IAMs have been differentiated from intrusive memories and flashbacks byKvavilashvili (2014). She proposes a continuum with IAMs and flashbacks on opposite poles and intrusive memories in the middle. ...
Article
Involuntary autobiographical memories (IAMs) and déjà vu are phenomena that occur spontaneously in daily life. IAMs are recollections of the personal past, whereas déjà vu is defined as an experience in which the person feels familiarity at the same time as knowing that the familiarity is false. We present and discuss the idea that both IAMs and déjà vu can be explained as natural phenomena resulting from memory processing and, importantly, are both based on the same memory retrieval processes. Briefly, we hypothesise that both can be described as ‘involuntary’ or spontaneous cognitions, where IAMs deliver content and déjà vu delivers only the feeling of retrieval. We map out the similarities and differences between the two, making a theoretical and neuroscientific account for their integration into models of memory retrieval and how the autobiographical memory literature can explain these quirks of daily life and unusual but meaningful phenomena. We explain the emergence of the déjà vu phenomenon by relating it to well-known mechanisms of autobiographical memory retrieval, concluding that IAMs and déjà vu lie on a continuum.
... However, intrusion cannot be simply equated with flashback which is one of the core symptoms of PTSD. Between these two, there are obvious differences in emotional value, distress and re-experiencing the traumatic event now (Kvavilashvili, 2014). In other words, although the intrusive imagery collected in studies using analogue trauma includes real "flashback" (i.e., painful imagery that is repeatedly intruded involuntarily), for PTSD researches, there are still inevitable limitations. ...
Article
Full-text available
Trauma-related flashback (also called intrusive imagery) is one of the most typical re-experience symptoms of acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) and has important impacts on the development of PTSD. The cognitive model of PTSD and the dual representation theory of PTSD both emphasize the effects of abnormal peritraumatic cognitive processing (i.e., data-driven processing or sensational representation being strengthened while conceptual processing or contextual representation being weakened). Some vulnerable personality traits of PTSD and working memory abilities are also focused in studies of analogue and real trauma, and are considered as risk factors and protective factors respectively. This study aimed to examine the effects of vulnerable personality traits of PTSD, working memory abilities and peritraumatic cognitive processing on flashbacks in different periods after analogue trauma. A total of 159 healthy college students (38 males; age = 17~26 ys, M = 20.44 ± 1.80) participated in the study, who were screened by a self-designed health status questionnaire (e.g., “Did you receive psychotherapy or psychopharmaceutical treatment in recent two years?”), Beck Depression Inventory-II (BDI-II), and Self-report Anxiety Scale (SAS). In the laboratory, they were asked to watch a 14’34’’ long Road Traffic Accidents (RTAs) film alone. Trait anxiety, trait dissociation, neuroticism and attentional control were measured before watching the film respectively by State-trait Anxiety Inventory-Trait version (STAI-T), Dissociative Experiences Scale-II (DES-II), the revised Eysenck Personality Questionnaire Short Scale for Chinese (EPQ-RSC), and Attentional Control Scale (ACS), while working memory capacity was tested by a revised Operation Span Task (OSPAN) seven days later. Immediately after the film, data-driven processing and conceptual processing were measured by Thoughts and Feelings Questionnaire-Chinese Revised (TFQ-CR). Five minutes after the film, participants firstly read a standardized description about the film-related flashback until they fully understood it with the help of the experimenter, and then reported immediate flashback (number, vividness and distress level). In the following week after the laboratory portion, participants independently reported flashback at three regular time points every day through WeChat or QQ. Upon coming back to the laboratory, they reported the frequency of posttraumatic symptoms through the Impact of Event Scale-Revised (IES-R) and triggered flashback after finishing a single-blind fake task assessing the degree in which they liked (10 relevant to the film). Structural equation model (SEM) and Bootstrap method were mainly adopted in the statistical analyses. Results showed that data-driven processing positively predicted the number, vividness and distress level of all three kinds of flashbacks (i.e., immediate, one-week and triggered) and one-week frequency of intrusion; higher neuroticism predicted higher distress level of triggered flashback; attentional control and working memory capacity both negatively predicted one-week frequency of intrusion. Conceptual processing played a mediating role between attentional control and distress level of immediate flashback. Furthermore, attentional control was positively associated with conceptual processing, whereas conceptual processing negatively predicted distress level of immediate flashback. These findings suggest that data-driven processing is the main factor influencing flashbacks in different periods after trauma; conceptual processing mainly affects the early acute stress response, while attentional control functions as a protective factor; neuroticism and working memory ability have long-term effects on flashback, and working memory ability serves as a protective factor.
... Cognitive models of intrusive memory development also suggest that the disruptions in memory encoding experienced during the peritraumatic phase are responsible for the highly affective nature of intrusive memories. In particular, intrusive memories are posited to be accompanied by strong emotions that were experienced at the time of the trauma (Brewin et al., 1996;Kvavilashvili, 2014). This contributes to the feeling of re-experiencing (Bryant et al., 2011) and to the maintenance of a sense of current threat (Ehlers & Clark, 2000). ...
Article
Full-text available
Cognitive theories of posttraumatic stress disorder (PTSD) suggest that intrusive memories result from disrupted information processing during traumatic memory encoding and are characterized by fear, helplessness, and horror at recall. Existing naturalistic studies are limited by the absence of direct comparisons between specific moments that do and do not correspond to intrusive memories. We tested predictions from cognitive theories of PTSD by comparing peritraumatic responses during moments experienced as intrusive memories versus distressing moments of the same traumatic event from the same individual not experienced as intrusive memories. A further comparison was with highly distressing moments experienced during the same event by individuals without intrusive memories. We utilized a psychometrically generated model to distinguish different peritraumatic reactions. Moments experienced as intrusive memories were characterized by higher peritraumatic distress, immobility, cognitive overload, and somatic dissociation when compared both to distressing moments from the same individual that did not intrude and to the most distressing memories of individuals without intrusions. Exploratory analyses indicated that at recall, intrusive memories were characterized by higher levels of primary traumatic emotions such as anxiety, fear, and helplessness in comparison with nonintrusive memories. Findings from this novel naturalistic design support predictions made by cognitive theories of PTSD and have implications for research and preventative interventions targeting intrusive memories. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
... Intrusive memories are spontaneous, involuntary memories of a negative event (mostly) that repeatedly intrude upon consciousness, often against one's will (Kvavilashvili, 2014). They are associated with various psychiatric disorders, such as posttraumatic stress disorder (PTSD; , major depressive disorder (MDD; Brewin et al., 1996), social phobia (Wild et al., 2008), personality disorders (Arntz, 2011), chronic pain (Philips & Samson, 2012), obsessive compulsive disorder (Veale et al., 2015), and psychosis (Ison et al., 2014). ...
Article
We applied two sessions of memory rescripting in routine cognitive behavioural therapy (CBT) practice for MDD and measured its effectiveness. We also examined the content of intrusive memories and rescripted memories. Sixteen patients with MDD were asked to identify intrusive memories and rate their vividness, distress, interference with daily life, and uncontrollability before and after memory rescripting. As a result, memory rescripting significantly reduced the intrusive memory index. With one exception, memory rescripting created an image containing compassionate imagery, mastery imagery, or both elements. These results suggest that two sessions of memory rescripting could be incorporated into traditional CBT to improve distress caused by intrusive memories experienced by patients with MDD.
Article
Full-text available
Intrusive memories of a traumatic event can be reduced by a subsequent interference procedure, seemingly sparing voluntary memory for that event. This selective-interference effect has potential therapeutic benefits (e.g., for emotional disorders) and legal importance (e.g., for witness testimony). However, the measurements of intrusive memory and voluntary memory typically differ in the role of associations between a cue and the emotional memory “hotspots.” To test this, we asked participants to watch a traumatic film followed by either an interference procedure (reminder plus Tetris) or control procedure (reminder only). Measurement of intrusions (using a laboratory task) and voluntary memory (recognition for film stills) were crossed with the presence or absence of associative cues. The reminder-plus-Tetris group exhibited fewer intrusions despite comparable recognition memory, replicating the results of prior studies. Note that this selective interference did not appear to depend on associative cues. This involuntary versus voluntary memory dissociation for emotional material further supports separate-trace memory theories and has applied advantages.
Article
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The present study investigated the predictive power of trait dissociation on the development of intrusive images and the mediating role of peritraumatic state dissociation and horror in this relationship. An observational quasi-experimental design was used with an aversive film to model a traumatic experience. Participants (N = 99) were exposed to a 10-minute trauma film after completing the Dissociative Experiences Scale C. After the film participants completed the Dissociative States Subscale and indicated their subjective horror. Intrusive images of the film were recorded in the subsequent week using an intrusion diary Results showed that trait dissociation predicted intrusion frequency This effect disappeared after controlling for peritraumatic horror, suggesting that state horror could have mediated the trait dissociation intrusion relationship. State dissociation was associated with intrusion frequency in univariate, partial correlations but not in the final model including horror. The results underscore the importance of peritrauma emotions in the prediction of PTSD and as a possible explaining factor of the predictive power of dissociation.
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Flashbacks are a defining feature of posttraumatic stress disorder (PTSD), but there have been few studies of their neural basis. We tested predictions from a dual representation model of PTSD that, compared with ordinary episodic memories of the same traumatic event, flashbacks would be associated with activity in dorsal visual stream and related areas rather than in the medial temporal lobe. Participants with PTSD, with depression but not PTSD, and healthy controls were scanned during a recognition task with personally relevant stimuli. The contrast of flashbacks versus ordinary episodic trauma memories in PTSD was associated with increased activation in sensory and motor areas including the insula, precentral gyrus, supplementary motor area, and mid-occipital cortex. The same contrast was associated with decreased activation in the midbrain, parahippocampal gyrus, and precuneus/posterior cingulate cortex. The results were discussed in terms of theories of PTSD and dual-process models of recognition.
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Current cognitive theories of posttraumatic stress disorder (PTSD) have attributed the development of memory intrusions to specific peritraumatic visuospatial processing that occurs within working memory. Empirical support has been provided by analogue trauma studies that find intrusion frequency in nonclinical participants can be significantly reduced by performance of dual tasks that place cognitive demands on the resources of visuospatial working memory (VSWM). However, it remains unclear the extent to which these reported reductions result from genuine modality-specific interference effects. The results of two experiments are reported which examine this issue using reported intrusions for affective images selected from the International Affective Picture System (IAPS). In Experiment 1 it was found that a verbal random number generation task significantly reduced the frequency of intrusions for IAPS images to the same extent as a complex visuospatial tapping task. In Experiment 2 both the modality of the dual tasks (verbal or visuospatial) and their executive load were manipulated. Only high executive load tasks were found to significantly reduce intrusion development, with no significant effect of task modality. These findings do not support an interpretation of dual task effects on intrusion development in terms of modality-specific interference occurring within VSWM. Implications for current cognitive theories of PTSD and the treatment of intrusive traumatic memories are discussed.
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Involuntary autobiographical memories are memories of personal experiences that come to mind spontaneously—that is, with no preceding attempt at retrieval. They were one of Ebbinghaus’s (1885/1964) three basic kinds of memory but have been ignored by modern cognitive psychology. Recent work suggests that involuntary memories are a basic mode of remembering that operates on the same episodic memory system as voluntary (strategic) remembering and thus follows the same rules of encoding and maintenance. Due to their associative and unplanned retrieval, involuntary memories differ from voluntary memories by being more specific, by being less relevant to one’s life story and identity, and by involving more emotional reaction at the time of recall. Research on involuntary autobiographical memories has important implications for the understanding of intrusive memories in posttraumatic stress disorder (PTSD).
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