# Trauma, treatment and Tetris: Video gaming increases hippocampal volume in male patients with combat-related posttraumatic stress disorder Trauma, treatment and Tetris: video gaming increases hippocampal volume in male patients with combat-related posttraumatic stress disorder - URL: https://alisanburak.com/en/travma-tedavi-ve-tetris-video-oyunlari-savasa-bagli-travma-sonrasi-stres-bozuklugu-olan-erkek-hastalarda-hipokampal-hacmi-artiriyor-trauma-treatment-and-tetris-video-gaming-increases-hippocampal - Language: en - Last updated: 2026-08-15 - Page title: Trauma, treatment and Tetris: Video gaming increases hippocampal volume in male patients with combat-related posttraumatic stress disorder Trauma, treatment and Tetris: video gaming increases hippocampal volume in male patients with combat-related posttraumatic stress disorder | Assoc. Prof. Dr. Alişan Burak Yaşar > Trauma, treatment and Tetris: Video gaming increases hippocampal volume in male patients with combat-related posttraumatic stress disorder Trauma, treatmen This page was translated automatically from Turkish. [Read the original](https://alisanburak.com/travma-tedavi-ve-tetris-video-oyunlari-savasa-bagli-travma-sonrasi-stres-bozuklugu-olan-erkek-hastalarda-hipokampal-hacmi-artiriyor-trauma-treatment-and-tetris-video-gaming-increases-hippocampal) [← Back to blog](https://alisanburak.com/en/blog) # Trauma, treatment and Tetris: Video gaming increases hippocampal volume in male patients with combat-related posttraumatic stress disorder Trauma, treatment and Tetris: video gaming increases hippocampal volume in male patients with combat-related posttraumatic stress disorder November 6, 2024Recent Articles **Trauma, treatment and Tetris: Video gaming increases hippocampal volume in male patients with combat-related posttraumatic stress disorder** ***Trauma, treatment and Tetris: video gaming increases hippocampal volume in male patients with combat-related posttraumatic stress disorder*** **Authors:** Oisin Butler, PhD; Kerstin Herr, MSc; Gerd Willmund, MD, PhD; Jürgen Gallinat, MD, PhD; Simone Kühn, PhD*; Peter Zimmermann, MD, PhD* **Translated by:**Specialist Psychologist Gizem Pozam Background: Tetris has been proposed as a preventive intervention to reduce intrusive memories of a traumatic event. However, no neuroimaging study has evaluated Tetris in patients with established posttraumatic stress disorder (PTSD) or investigated how playing Tetris might 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 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 played Tetris for 60 minutes every day from the start of therapy until its completion approximately 6 weeks later. Participants underwent structural MRI and completed 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 increased hippocampal volume and reduced symptoms both immediately after completion of therapy and at follow-up. Results: Following therapy, hippocampal volume increased in the Tetris group but not in the control group. In addition, hippocampal increases were associated with reductions in PTSD, depression and anxiety symptoms between completion of therapy and follow-up in the Tetris group, but not in the control group. Limitations: Playing Tetris may function as a cognitive interference task and a brain-training intervention, but it was not possible to distinguish between these 2 potential mechanisms. Conclusion: Tetris Tetris may be useful as an adjunctive therapeutic intervention for PTSD. Tetris-related increases in hippocampal volume may help maintain therapeutic gains after completion of therapy. Introduction Recent studies have provided evidence for the utility of the visuospatial video game Tetris as an early therapeutic intervention for posttraumatic stress disorder (PTSD).1-3 Holmes and colleagues have shown that playing Tetris immediately after exposure to trauma can reduce subsequent intrusive memories of the traumatic event, demonstrating the effectiveness of this “cognitive vaccine” in both experimental1 and real-world settings.2-4 Following exposure to an event, the memory trace of that event must be consolidated in long-term memory for subsequent recall.5 Shortly after the event, the memory trace remains in a labile state while it is being consolidated and is susceptible or vulnerable to interference.6 Performing an unrelated task while the memory of an event is in a labile state can reduce subsequent recall.7 In addition, it has been proposed that, following reactivation, a memory re-enters a labile state and must be reconsolidated in long-term memory.8 During this reconsolidation process, the memory trace is also vulnerable to interference. Holmes and colleagues1 proposed that completing a demanding visuospatial task during memory consolidation or reconsolidation of a traumatic event weakens the memory trace because of competition for the cognitive resources required for consolidation. To date, studies using Tetris as an intervention have focused on disrupting the consolidation of traumatic memory within the first 6 hours after trauma exposure,1-3 or the reconsolidation of traumatic memory the following day.8 However, playing a video game immediately after a traumatic event is neither practical nor possible in every situation. In the United States alone, an estimated 8 million adults have PTSD.9 Interventions for those already experiencing posttraumatic symptoms are therefore urgently needed. One study to date has evaluated a Tetris intervention in people with established PTSD.4 This study targeted specific intrusions based on the concepts of “concurrent task interference and memory reconsolidation.” After a reminder of a specific intrusive memory, patients played Tetris for 25 minutes. Following completion of the study, the authors found that the frequency of targeted intrusions was lower than that of nontargeted intrusions. In the present study, we investigate the utility of Tetris as an adjunctive therapeutic intervention for people with established PTSD. Current therapeutic interventions for PTSD have several limitations concerning response rates and long-term effectiveness. A substantial minority of people with PTSD will not show significant symptom improvement immediately after treatment; some studies estimate nonresponse rates as high as 35% to 50%.10-12 In addition, the long-term prognosis for PTSD is poor: most people continue to experience symptoms for months or years after the initial diagnosis, and a substantial proportion never fully recover.13 There is therefore a considerable need for additional therapeutic interventions that can act as adjuncts to conventional psychotherapy for nonresponders and support the long-term maintenance of therapy-related gains for responders. The most widely used and effective interventions for PTSD are psychotherapies such as trauma-focused cognitive behavioral therapy (CBT) and eye movement desensitization and reprocessing (EMDR) therapy. These therapies target memories of the traumatic event and the person's cognitive and emotional interpretations of the event. EMDR therapy is of particular interest because it differs from other psychotherapies in incorporating a visual-sensory attention component.14 There are some inconsistencies in the literature on EMDR, particularly regarding the therapeutic contribution of the visual-sensory component:15 although reviews of studies comparing trauma-focused CBT and EMDR have not demonstrated that one is more effective than the other,10,15 separate reviews have provided evidence that adding eye movements produces significant improvements in treatment outcomes.16,17 Thus, although EMDR is a widely used therapeutic intervention for PTSD, the precise mechanisms underlying its effectiveness remain somewhat unclear. In this study, we investigated the use of Tetris as an adjunct to EMDR. Each EMDR session involved selecting a traumatic memory to work on. Given the visual-sensory attention component of EMDR, we reasoned that Tetris might complement EMDR better than other psychotherapeutic interventions such as CBT. At the neuroanatomical level, adult PTSD populations are characterized by smaller volumes in the hippocampus and prefrontal regions, including the ventromedial prefrontal cortex and anterior cingulate cortex.18-20 The hippocampus is hypothesized to play a key role in PTSD symptomatology: smaller hippocampal volumes have been associated with increased risk and poorer prognosis and poorer prognosis in PTSD.21-25 In addition, increases in hippocampal gray matter volume have been observed in response to psychological therapy, including EMDR26,27 and pharmacological interventions, and increases in hippocampal volume have been associated with improvements in memory.28 Training studies have shown that increases in hippocampal volume can be produced by a wide range of interventions,29,30 including video game interventions.31 We therefore hypothesized that the Tetris video game intervention would increase hippocampal volume, which in turn would reduce PTSD symptomatology. Smaller prefrontal regions have also been widely observed in people with PTSD.18-20 Prefrontal regions have also been shown to increase in response to video game interventions.31 We therefore hypothesized that prefrontal regions in PTSD populations would also increase in response to therapeutic interventions, although most studies on neuroplasticity and PTSD have demonstrated effects in the hippocampus rather than prefrontal regions. In this study, we used a prospective design to investigate the structural and behavioral effects of a Tetris intervention in people with PTSD undergoing psychotherapy. We recruited people with combat-related PTSD and assessed them before and immediately after EMDR therapy, as well as at follow-up approximately 6 months later. We proposed that playing Tetris after therapy, while the reactivated traumatic memory was in a labile state, would weaken reconsolidation and aid recovery.8 Playing Tetris has been shown to reduce the vivid, intrusive elements of a traumatic memory, but not declarative memory.1 We therefore expected that Tetris would not affect memory of the therapy sessions or interfere with the clinical effectiveness of EMDR. In addition, spatial memory training and video games are linked to increases in hippocampal volume,31 and increases in hippocampal volume have been associated with improvements in memory and reductions in symptoms in PTSD.32 We therefore expected Tetris to aid recovery from PTSD by weakening the memory of the traumatic event and increasing hippocampal volume. We hypothesized that the Tetris group would show increased hippocampal volume and reduced symptoms — immediately after completion of therapy and at follow-up. Methods Participants We recruited 40 participants with combat-related PTSD from the German Federal Armed Forces before they began therapy. All participants were inpatients at the German Military Hospital in Berlin, Germany. All participants were male and had been deployed to overseas conflict zones. For inclusion criteria, participants were screened by clinical psychologists and psychiatrists for deployment-related trauma within the previous 2 years and a current diagnosis of PTSD according to ICD-10 criteria. For exclusion criteria, participants were screened for current or previous comorbid psychosis or substance dependence, psychotropic medication use, a history of concussion or traumatic brain injury, and contraindications to MRI. Patients were assessed against the inclusion and exclusion criteria and then randomly assigned to the experimental Tetris group (n = 20) or the control group (n = 20). The local ethics committee of Charité University Hospital (Berlin, Germany) approved the study, and we obtained written informed consent from each participant before study entry in accordance with the Declaration of Helsinki. Participants in both groups completed EMDR therapy.14,33 Participants in the control group completed EMDR therapy only, while participants in the experimental Tetris group also played the video game Tetris for 60 minutes daily from the start to the completion of therapy, for approximately 6 weeks. Following completion of therapy, all participants returned for neuroimaging and questionnaire assessment. Approximately 6 months after completion of therapy, participants also completed a questionnaire-only assessment. Four participants, 2 in the Tetris group and 2 in the control group, did not complete the 6-month follow-up assessment. Psychotherapy intervention All participants completed EMDR therapy, one of the most common therapeutic interventions for PTSD34 and known to effectively reduce symptoms in most individuals immediately after completion of therapy.14,15,33 Psychotherapists and senior psychiatrists specializing in psychotherapy administered EMDR in individual sessions. Treatment followed the standard EMDR protocol. A 1-week stabilization and preparation phase was followed by a 4-week exposure phase, with an average of 2 sessions per week, each lasting 60 to 90 minutes. Participants completed an average of 7.2 ± 1.8 sessions over approximately 6 weeks (duration 39.9 ± 4.8 days). When the number of sessions could not be obtained from clinical records (n = 3), we used participants' self-report data. Each EMDR session involved selecting a memory to work on. The selected memory was then reactivated, during which the individual briefly attended to specific elements of the memory while simultaneously performing a periodic series of eye movements by focusing on a moving visual stimulus controlled by the therapist. Tetris intervention Participants in the Tetris group were given a Nintendo DS XL console and the computer game Tetris. Participants were asked to play for 60 minutes per day. Participants reported playing for an average of 61 ± 14.6 minutes per day (data unavailable for 2 participants) and missing an average of 1 ± 1.2 days (data unavailable for 2 participants). On days when participants completed an EMDR therapy session, they were required to play Tetris within 6 hours of completing therapy. Questionnaires To assess participants' military deployment duration and experiences during deployment, we asked them to complete the German version of the Combat Experiences Scale,35 a 33-item questionnaire assessing the type and frequency of combat-related events during military deployment, and a study-specific questionnaire containing items on the number and duration of military deployments. To assess psychological symptoms, participants also completed the German versions of the following self-report questionnaires before each neuroimaging session: the Posttraumatic Diagnostic Scale (PDS), the Beck Depression Inventory II (BDI-II) and the State-Trait Anxiety Inventory (STAI). The PDS36,37 is designed to aid the diagnosis of PTSD and assess symptom severity. As part of the PDS, participants rate 17 items representing the main symptoms of PTSD experienced within the previous 30 days, using a 4-point scale ranging from 0 (“not at all or only once”) to 3 (“5 or more times a week or almost always”). The BDI-II38,39 is a 21-item inventory assessing the characteristic behaviors and symptoms of depression experienced by participants within the previous 2 weeks, using a 4-point scale ranging from 0 (“I do not feel sad”) to 3 (“I am so sad or unhappy that I cannot stand it”). The STAI40,41 consists of 2 forms assessing state anxiety experienced at the present time (Form X-1) and trait anxiety experienced in general (Form X-2). In this study, we used the trait anxiety subscale of the STAI (Form X-2) because we were interested in assessing changes in enduring rather than transient states of anxiety and stress. In Form X-2, individuals rate 20 statements describing feelings of stress and worry using a 4-point scale ranging from 1 (“almost never”) to 4 (“almost always”). MRI scanning procedure We acquired structural images using a 3 T Magnetom Tim Trio MRI scanner system (Siemens Medical Systems) and a 12-channel radiofrequency head coil. We acquired images using a 3-dimensional T1-weighted magnetization-prepared gradient echo (MPRAGE) sequence based on the Alzheimer's Disease Neuroimaging Initiative protocol (www.adni-info. org; repetition time 2500 ms, echo time 4.77 ms, inversion time 1100 ms, acquisition matrix 256 × 256 × 176, flip angle 7°, voxel size 1 × 1 × 1 mm3 ). MRI data analysis We processed structural data using the computational anatomy toolbox (CAT12; http://dbm.neuro.uni-jena.de/cat/) and statistical parametric mapping (SPM12; http://www.fil. ion.ucl.ac.uk/spmb), with default parameters, running on MATLAB 9.1 (Mathworks). We used voxel-based morphometry to estimate the local amount or volume of gray matter. Voxel-based morphometry is a neuroimaging analytical technique that allows investigation of focal differences in brain anatomy based on statistical parametric mapping of structural images. It includes bias correction, tissue classification and affine registration. We normalized images to Montreal Neurological Institute (MNI) space using the ICBM152 template42 and segmented them into gray matter, white matter and cerebrospinal fluid using default parameters. We applied modulation to preserve the volume of a given tissue within a voxel by multiplying voxel values in the segmented images by the Jacobian determinants obtained from the spatial normalization step. We smoothed images with an 8 mm full width at half maximum (FWHM) kernel. We computed a whole-brain voxel-wise factorial analysis. We included age and total intracranial volume as covariates of no interest and applied an absolute gray matter probability threshold of 0.2 (CAT12 manual, http://dbm.neuro.uni-jena. de/cat12/CAT12-Manual.pdf). We thresholded the resulting maps at p < 0.001 at the voxel level and applied a cluster-extent threshold of 100 voxels per cluster to control type I error. We also performed a region-of-interest (ROI) analysis in the hippocampus, a region commonly implicated in adult PTSD.19,25 We defined a bilateral anatomical hippocampal mask using the automated anatomical labeling (AAL)43 template. We defined a PTSD-specific hippocampal mask using the hippocampal cluster identified in a previous meta-analysis of whole-brain neuroimaging studies.20 We used the Region of Interest Extraction (REX) toolbox to extract gray matter volumes from the identified clusters and then entered the extracted volume values into a repeated-measures analysis of variance. We also assessed the relationship between increases in hippocampal volume and reductions in symptoms. We calculated hippocampal change using the cluster identified in the whole-brain analysis and subtracting pretreatment hippocampal gray matter volume from posttreatment hippocampal gray matter volume; positive values indicated an increase in hippocampal volume following completion of treatment. We also calculated symptom change by subtracting follow-up PDS, BDI-II and STAI scores from posttreatment scores; negative values indicated a reduction in symptoms from completion of treatment to follow-up. We then correlated these change scores separately for each group. Results Participants The Tetris and control groups did not differ in age, sex, duration of military deployment, combat exposure, number of EMDR sessions or time between assessments (Table 1). Neuroimaging analyses The whole-brain analysis revealed a significant increase in gray matter volume in a cluster in the right hippocampus after treatment in the Tetris group (k = 150, x = 27, y = -33, z = -3, p < 0.001 at the voxel level; and k > 100, nonisotropic smoothness correction at the cluster level; Table 2 and Figure 1), compared with the control group. In addition, the ROI analysis of the hippocampus revealed a significant group × time interaction. Compared with the control group, we found larger volumes after therapy in the Tetris group in the hippocampal cluster identified in a meta-analysis of PTSD neuroimaging studies20 comparing patients with PTSD with trauma-exposed controls (F1,38 = 4. 42, p = 0.042, ηp 2 = 0.10) and in the bilateral anatomical hippocampus defined using the AAL template (F1,38 = 7.07, p = 0.011, ηp 2 = 0.16; Table 2 and Appendix 1, Figure S1, available at jpn.ca/190027-a1).43 We also performed ROI analyses on clusters in the ventromedial prefrontal cortex and anterior cingulate cortex identified in the aforementioned meta-analysis of PTSD neuroimaging studies20 and on the bilateral anatomical amygdala defined using the AAL template.43 However, we observed no significant results (Appendix 1, Table S1). Psychological questionnaire analyses Repeated-measures analysis of variance revealed a main effect of time, with significant reductions in PTSD symptoms (PDS: F2,68 = 7.19, p = 0.001, ηp 2 = 0. 17) and trait anxiety (STAI Form X-2: F2,68 = 3.64, p = 0.033, ηp 2 = 0.09). 17) and trait anxiety (STAI Form X-2: F2,68 = 3.64, p = 0.031, ηp 2 = 0.09) showed significant reductions, whereas depression symptoms did not (BDI: F2,68 = 2.67, p = 0.076, ηp 2 = 0.07). The group × time interaction was not significant for PDS (F2,68 = 0.27, p = 0.76, ηp 2 = 0.01) or BDI (F2,68 = 0.27, p = 0.765, ηp 2 = 0.01), but we found a significant interaction for STAI (F2,68 = 3.15, p = 0.049, ηp 2 = 0.08). We then performed post hoc paired-samples t tests to compare pretherapy symptom levels with those at the 6-month follow-up. Both groups continued to show significant improvement in PTSD symptoms at the 6-month follow-up relative to pretreatment levels (PDS Tetris t17 = 1.93, p = 0.036; PDS control t17 = 3.39, p = 0.002; 1-tailed significance). Only the Tetris group continued to show a significant reduction in anxiety symptoms (STAI Tetris t17 = 1.93, p = 0.035; STAI control t17 = 0.57, p = 0.29; 2-tailed significance), but there was no significant reduction in depression symptoms (BDI Tetris t17 = 1.00, p = 0.165; BDI control t17 = 0.24, p = 0.41; 1-tailed significance) at the 6-month follow-up (Figure 2A). To investigate relationships between neural and clinical change, we correlated changes in hippocampal volume with changes in psychological symptoms. Using the cluster identified in the whole-brain analysis, we found that increased hippocampal volume after therapy was associated with further symptom reductions between completion of therapy and follow-up in the Tetris group, but not in the control group (Figure 2B). Discussion We found evidence that completing a visuospatial video game intervention during psychological therapy for PTSD led to increased hippocampal volume and maintenance of a broader range of therapy-related gains, and that increases in hippocampal volume were associated with further symptom reductions at the 6-month follow-up. At the level of brain structure, we found larger hippocampal volumes in the Tetris group in both whole-brain and ROI analyses. At the psychological level, both groups showed reductions in PTSD, depression and anxiety symptoms immediately after therapy. At the 6-month follow-up, both groups continued to show reductions in PTSD symptoms, but only the Tetris group continued to show reductions in anxiety symptoms. In addition, increases in hippocampal gray matter during therapy were associated with further reductions in PTSD, depression and anxiety symptoms from discharge to follow-up in the Tetris group, but not in the control group. We observed increased volume in the hippocampus in both whole-brain and ROI analyses, but not in prefrontal regions such as the ventromedial prefrontal cortex and anterior cingulate cortex. The hippocampus is involved in memory, learning and fear extinction,44 whereas the ventromedial prefrontal cortex and anterior cingulate cortex are involved in emotional and cognitive processing and the regulation of fear expression.45 Smaller hippocampal volumes have been associated with increased risk for PTSD25 and poorer prognosis;21-24 smaller volumes in the prefrontal cortex may represent a more general effect of stress exposure.46,47 At the structural level, the hippocampus is one of the most plastic regions of the human brain; it is rich in glucocorticoid receptors, making it highly sensitive to the effects of stress. In addition, reduced glucocorticoid receptor function can lead to hyperactivity of the hypothalamic–pituitary–adrenal axis, resulting in increased glucocorticoid levels and further reductions in hippocampal volume.48 Stress has been shown to cause dendritic atrophy and reduced neurogenesis in the hippocampus,49 and stress-induced changes in the hippocampus have been associated with reduced memory and cognition50 and increased anxiety-related behavior.51 Conversely, training studies have shown that increases in hippocampal volume can be produced by a wide range of interventions,29,30 including video game interventions.31 The hippocampus is also involved in spatial orientation and navigation, and spatial learning has been associated with increases in hippocampal volume.52 Thus, sustained focus on a demanding visuospatial task such as Tetris may produce increases in hippocampal volume, driven in part by increased neurogenesis. In animal models, hippocampal neurogenesis has been shown to mediate forgetting and support new learning.53 Newly formed neurons compete with existing neurons for connections, and these newly formed connections may replace older ones, weakening existing memories and strengthening new ones.53 We therefore propose that video game-related increases in hippocampal neurogenesis may lead to subsequent reductions in PTSD symptoms by weakening memories of the traumatic event and strengthening memories formed during therapy. Tetris offers a promising therapeutic intervention for several practical reasons. The required video game consoles are inexpensive and portable and can be reused multiple times. Tetris does not require a clinician to administer it; it can even be self-administered. Tetris produces no side effects and is enjoyable to play, so adherence is likely to be high. Tetris is also adaptive; as a person continues to play, the difficulty level (the speed at which blocks fall) automatically increases until the game ends (the blocks fill the screen), at which point the game restarts at the lowest difficulty level. In this way, adapting the difficulty level to the player's skill makes it possible to minimize the frustration of the game being too difficult and the boredom of it being too easy, and to keep the player engaged. This study builds on previous studies that used Tetris as the visuospatial task of choice.1-4 However, other demanding visuospatial working-memory tasks, including other video games, may also be used successfully for PTSD. Attention and engagement with a task are known to be key factors in achieving training-related gains at both behavioral and neural levels.54 Offering a range of games for a person to choose from may help maintain motivation and adherence, particularly for those outside a clinical setting. In the present study, we assessed young adult men who had been exposed to combat. Trauma type, age, sex and military status may mediate the effect of the video game intervention on the brain. Sex and age have been shown to play a role in stress resilience49 and hippocampal neuroplasticity;55 military and civilian PTSD populations have also been shown to differ in risk factors56 and response to psychotherapy.11 Future studies could explore the utility of video game interventions for female and civilian PTSD populations. Limitations At the time the study was initiated, no study had attempted to use Tetris as an intervention targeting memory reconsolidation or for people with established PTSD. We considered Tetris a promising adjunct to EMDR therapy, both as a cognitive interference task targeting the reconsolidation of traumatic memories after their reactivation during therapy and as a brain-training intervention targeting the hippocampus. We consider the present results an initial proof of concept for the utility of Tetris as an adjunctive therapeutic intervention. However, the current design did not allow us to distinguish the cognitive interference elements of the Tetris intervention from its brain-training elements. In addition, given the novel nature of this study, we used a standard-of-care control group. A standard-of-care control group is a widely accepted approach to evaluating the effectiveness of a new therapeutic intervention in conditions for which therapeutic interventions already exist. Future studies could use a gaming active control group to test whether the observed effects are specific to Tetris and to distinguish potential brain-training effects from cognitive interference effects. In addition, patients with PTSD may show signs of cognitive impairment,57 and increases in hippocampal volume have been associated with increases in cognitive performance after PTSD treatment.28 Future studies could investigate whether Tetris-related changes in hippocampal volume are associated with improvements in cognitive performance in patients with PTSD. It should be noted that more conservative approaches could have been adopted for the neuroimaging analyses. However, the present sample size was small because of the considerable difficulty of recruiting this patient population. Therefore, to balance concerns about type I and type II errors in our analysis, we applied the less conservative approach of a voxel-level threshold of p < 0.005 combined with cluster-size correction; this method has been accepted and published.47,58 In contrast, we also note that we did not observe effects in the prefrontal cortex, despite reductions in these regions in PTSD populations18-20 and evidence that they respond to video game interventions.31 The time course of changes in the hippocampus and prefrontal cortex may differ; the prefrontal cortex shows a period of renormalization following an initial period of expansion.59 Future studies could use multiple neuroimaging assessments over the course of treatment to assess the rate and pattern of neural changes. Alternatively, because of the small sample size, the present study may have been underpowered to detect changes in the prefrontal cortex. At the behavioral level, we observed an interesting trend toward reduced depression symptoms in the Tetris group at the 6-month follow-up, but this finding was not statistically significant. As noted previously, we consider the present results an initial proof of concept. However, future studies with larger sample sizes are needed to explore the utility of Tetris as an adjunctive therapeutic intervention and the underlying neural mechanisms. Conclusion Current interventions for PTSD have several limitations in terms of response rates and long-term effectiveness, and there is a considerable need for additional therapeutic interventions that can act as adjuncts to conventional psychotherapy. We provide evidence that Tetris may be useful as an intervention alongside EMDR psychotherapy for people with established PTSD. Following completion of psychotherapy, symptoms decreased in all participants, and both groups continued to show reductions in PTSD symptoms at the 6-month follow-up. However, only the Tetris group continued to show reductions in anxiety symptoms and a trend toward reduced depression symptoms at the 6-month follow-up. Playing Tetris was associated with increases in hippocampal volume, and hippocampal increases were associated with continued reductions in PTSD, depression and anxiety symptoms between completion of treatment and the 6-month follow-up. Thus, playing Tetris may support the maintenance of a broader range of symptom improvements after therapy through increases in hippocampal volume. 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