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44 (2013) 179e185
a r t i c l e i n f o a b s t r a c t
Article history: Background and Objectives: Intrusive images after a traumatic event, a hallmark feature of post-traumatic
Received 16 January 2012 stress disorder, are suggested to develop because the trauma memory is disorganized and not integrated
Received in revised form into autobiographical memory. Unconscious Thought Theory predicts that information can be concep-
24 July 2012
tually organized after a period of unconscious thought (UT), more so than after conscious thought (CT).
Accepted 31 August 2012
We aimed to test the hypothesis that UT decreases intrusions and increases conceptual organization in
memory.
Keywords:
Methods: Participants were shown a stressful lm and were required to perform an UT task, a CT task, or
Intrusions
Trauma lm paradigm
a distraction task. Intrusions of the lm, intrusion qualities, and sequence memory were measured
Unconscious Thought Theory afterwards.
PTSD Results: We conrmed our hypothesis that UT (versus CT or mere distraction) leads to fewer intrusions,
thereby replicating earlier research. Contrary to prediction, we found no difference between the
conditions on sequence memory. In addition, conscious thought appeared to increase intrusion nowness
and arousal.
Limitations: The analogue design and healthy participant sample prevent from generalizing results to
other populations. Intrusion frequency and qualities were assessed immediately after the lm thereby
prohibiting us from drawing conclusions about any long-term effects.
Conclusions: Engaging in unconscious thought after a stressful lm can reduce intrusion frequency. This
has potential implications for clinical interventions to prevent initial stress symptoms. The underlying
mechanism remains unclear for now and provides an avenue for future research.
2012 Elsevier Ltd. All rights reserved.
0005-7916/$ e see front matter 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jbtep.2012.08.004
180 J. Krans et al. / J. Behav. Ther. & Exp. Psychiat. 44 (2013) 179e185
Deeprose, 2009; Holmes, James, Kilford, & Deeprose, 2010). A recently supported with experimental evidence (e.g., Bos,
cognitive training towards more positive self-efcacy and meta- Dijksterhuis, & Van Baaren, 2008, 2011).
cognitive beliefs about stress symptoms after a trauma lm was Most UTT research has focused on decision-making. The
shown to reduce intrusion development compared to a training common nding is that unconscious thought leads to better deci-
towards more negative self-efcacy beliefs (Woud, Holmes, sions (Bos et al., 2008; Dijksterhuis, 2004; Dijksterhuis, Bos,
Postma, Dalgleish, & Mackintosh, 2011). Other studies have Nordgren, & Van Baaren, 2006; Dijksterhuis & Meurs, 2006; Ham,
shown that worrying or ruminating after a distressing lm Van den Bos, & Van Doorn, 2009; Lerouge, 2009), although some
increased intrusions (Butler, Wells, & Dewick, 1995; Wells & research reports failures to replicate these effects (Acker, 2008;
Papageorgiou, 1995) although others have found no signicant Calvillo & Penaloza, 2009; Gonzalez-Vallejo, Lassiter, Bellezza, &
effects (Ehring, Szeimies, & Schaffrick, 2009; Williams & Moulds, Lindberg, 2008; Newell, Wong, Cheung, & Rakow, 2009; Payne,
2007). Samper, Bettman, & Luce, 2008; Thorsteinson & Withrow, 2009;
Few studies have directly targeted the hypothesis that intru- Waroquier, Marchiori, Klein, & Cleeremans, 2009). However,
sions develop from a lack of memory organization although this is a recent meta-analysis including more than 80 studies indicated
an important claim made by models of PTSD and intrusive memory that, overall, there is a benet for unconscious thought in decision-
(Brewin et al., 1996; Ehlers & Clark, 2000). Zetsche, Ehring, and making although the overall effect size is small (for more infor-
Ehlers (2009) presented participants with a distressing lm after mation, please see Strick et al., 2011).
which they were assigned to a rumination, memory organization or Importantly for the research at hand, several experiments have
distraction condition. Intrusions were measured during a rst shown that unconscious thought can aid in organizing, clustering
session and reported in a one-week diary following the lm. and restructuring previously unorganized information in a mean-
Overall, the experimental conditions did not have a signicant ingful way (Bos et al., 2008; Dijksterhuis, 2004). For example, in the
effect on intrusion development, although, when split by gender, experiment of Dijksterhuis (2004, Experiment 5; see also Bos et al.,
men in the rumination condition reported more intrusions in the 2008; Experiment 2), participants read 18 sentences describing
rst session than men in the memory organization condition. Men behaviors (for instance: Jeroen usually gets high grades in school)
(but not women) in the memory organization condition, in turn, that related to three overarching traits (intelligence, idealism and
reported fewer intrusions than men in the distraction condition. extraversion) of a hypothetical person, presented in random order.
Despite the unexpected gender effect, this gives some credence to They were then instructed to recall these behaviors. Sequence
the idea that memory organization has an inuence on intrusion memory scores showed that participants in the unconscious
frequency. thought condition, more so than in the conscious thought condi-
In another study using an analogue trauma design, participants tion, recalled the behaviors in the order according to the over-
were shown a lm with trafc accidents, and then received a cued- arching traits rather than in the order in which they were
recognition memory test about the lm. The items were presented presented. That is, memory appeared to be more conceptually
in chronological order (Krans, Nring, Becker, & Holmes, 2009). organized after unconscious thought than after conscious thought.
Participants then reported the recurrence of intrusive images of the Unconscious thought theoretically has the potential to organize
lm in a diary during the following week. After one week they traumatic information in a more conceptual way than dealing with
returned and completed a cued-recall test for the lm. The results many overwhelming details of the event by thinking it over
showed that intrusion frequency was lower for the part of the lm consciously. Having a more structured memory of an event may
for which they had received the recognition memory test. reduce the negative effects of trauma (Ehlers & Clark, 2000).
Furthermore, distress associated with the intrusive images showed Although there have been efforts at nding conscious strategies to
a trend towards being lower for that part of the lm. This suggests aid the integration of information in memory (e.g. Michael & Ehlers,
that imposing a chronological structure to a traumatic event could 2007), this requires one to consciously revisit the negative events.
reduce the occurrence of intrusions and possibly distress associated Unconscious thought potentially offers a way to aid the integration
with the intrusions. of information in memory without consciously focusing on the
The studies described above are part of a recent surge in efforts negative event. Krans and Bos (2012) tested whether unconscious
to discover effective experimental interventions to prevent the thought after a trauma lm would be successful at reducing
initial development of intrusions. There is, however, still a lack of intrusion frequency. Participants were shown a negative lm clip
studies targeting memory organization as a possible benecial known for inducing intrusive images and were then given the
factor. Interestingly, organization of new information in memory instruction to think about the lm before a memory test (conscious
has been described by Unconscious Thought Theory (UTT; thought condition), or performed an unrelated cognitively
Dijksterhuis & Nordgren, 2006). UTT distinguishes between demanding task, which prevented conscious processing. Of the
conscious and unconscious thought, where conscious thought participants who received this distraction task, half were told that
processes are dened as schematic and top-down thinking about the experiment was over (mere distraction condition), whereas the
an object or task using conscious attention allocated to that task or other half were told that a memory test of the lm would be pre-
object. It is thought to be of limited capacity, meaning that only few sented afterwards (unconscious thought condition). Comparing the
chunks of information can be handled simultaneously (Dijksterhuis latter two conditions shows that unconscious thought is a goal-
& Nordgren, 2006). Unconscious thought processes, on the other dependent process.2 After the memory test (presented in all
hand, are dened as thought processes that operate while conditions), participants reported their intrusive images of the lm
conscious attention is directed elsewhere. For example, if people during an intrusion provocation task. This involved presenting the
are faced with a problem that requires a large amount of infor- participants with still frames from the lm that did not depict
mation to be processed, they are often advised to sleep on it (Bos, anything negative. After this presentation, participants monitored
Dijksterhuis, & Van Baaren, 2011; Dijksterhuis, 2004; Dijksterhuis,
Bos, Nordgren, & van Baaren, 2006a, 2006b, 2006c). This mode of
thought is suggested to be of high capacity and using a bottom-up 2
When participants are told the task is over, they no longer have a goal to
approach (Bos & Dijksterhuis, 2011). Importantly, unconscious process information, whereas telling the participants that the experiment will
thought is assumed to be a goal-dependent process, which distin- continue after the distraction task introduces the goal to unconsciously process the
guishes it from a mere distraction effect. This assumption has been information (Bos et al., 2008).
J. Krans et al. / J. Behav. Ther. & Exp. Psychiat. 44 (2013) 179e185 181
their thoughts for 2 min and pressed a button every time they week after the experiment. Complete data were collected from 78
experienced an intrusive image of the lm. Intrusion frequency was participants.3
signicantly lower in the unconscious thought condition than in
both other conditions. However, the free recall memory task that 2.2. Negative lm clip
was designed to measure memory organization for the lm did not
show any differences between the groups. Participants viewed an 8.42 min scene from the lm Irrversible
To summarize, unconscious thought decreased intrusion by Gaspar No (2002). The lm clip shows a violent murder in
frequency as expected, but the proposed mechanism by which this a nightclub. Participants viewed the lm on a PC with a 17 inch
was achieved remained unclear. The particular memory task may monitor and listened to the sound through headphones.
not have been sensitive enough to pick up differences in memory
organization between the three conditions. Another limitation in 2.3. Experimental conditions
the Krans and Bos (2012) study was that only intrusion frequency
was assessed. In the present study, we aimed to (a) replicate the In the conscious thought condition (CT), participants were
effect of unconscious thought, (b) measure qualities of the intrusive instructed to think about the lm for 4 min and were informed that
images to compare between conditions, and (c) measure memory they would receive a memory test afterwards. In the unconscious
organization with a different measure. thought condition (UT), participants were also informed about the
In order to address our research goals, participants were shown memory test but they were instructed to rst complete a 2-back
a negative lm clip and were then randomly assigned to one of task for 4 min (Jonides et al., 1997; Kirchner, 1958; Krans & Bos,
three conditions as in Krans and Bos (2012): conscious thought 2012). In the 2-back task, participants see a series of numbers
(thinking about the lm before a memory test), unconscious presented on the screen in rapid succession (1 s presentation time,
thought (performing a cognitively demanding task before the 0.5 s interval). Whenever the number they saw on the screen was
memory test), or mere distraction (performing the task whilst the same as two numbers before, participants were required to
being unaware of the upcoming memory test). Participants press the spacebar on the computer. This task was chosen as this is
completed a structured memory test and intrusion frequency, a highly demanding task leaving very little opportunity for
vividness, nowness and arousal were measured. conscious thinking about the lm. Participants in the mere
Based on models of PTSD (e.g., Ehlers & Clark, 2000), UTT distraction condition (MD) were informed that the 2-back task was
(Dijksterhuis & Nordgren, 2006), we predicted that (a) intrusion the end of the experiment and that they would not be questioned
frequency would be lowest in the unconscious thought condition, about the lm.
with no differences between the two other conditions, and (b) that
memory organization would be higher in the unconscious thought 2.4. Randomization, manipulation, compliance, and demand
condition than in the other two conditions. In relation to the
intrusion qualities (vividness, nowness, and arousal), we predicted Individual differences in trait anxiety were measured with the
that (c) all would be lower in the unconscious thought condition Dutch trait version of the State-Trait Anxiety Inventory (STAI-T; Van
than in the other two conditions. This prediction was based on der Ploeg, 1980). This questionnaire contains 20 items to which
models from the PTSD (e.g., Ehlers & Clark, 2000) and memory participants respond on a scale from 1 (almost never) to 4 (almost
literature (Conway & Pleydell-Pearce, 2000) proposing that- by always). Testeretest reliability (0.75) and internal consistency
denition- memory representations that are processed on a more (a 0.85) are good (Van der Ploeg, 1980).
conceptual level will be less vivid, arousing and here-and-now than To measure the emotional impact of the lm, a mood ques-
memory representations at the lowest sensory levels (i.e., tionnaire (MoodQ; Holmes, Brewin, & Hennessy, 2004; Krans,
intrusions). Nring, Speckens, & Becker, 2011) and the Dutch state version of
the State Trait Anxiety Inventory (STAI-S; Spielberger, Gorsuch,
Lushene, Vagg, & Jacobs, 1983; Van der Ploeg, 1980) were used.
2. Method
The MoodQ consists of ve items about current happiness, fear,
horror, depression and anger to which participants respond on
Approval for this study was obtained from the Ethical
a scale from 0 (not at all) to 10 (extremely). The STAI-S contains 20
Committee of the Behavioural Science Institute (BSI) of the Rad-
items and participants respond on a scale from 1 (not at all) to 4
boud University Nijmegen (number ECG 06042009), where data
(very much so). Testeretest reliability for the STAI-S has been re-
was collected.
ported at a 0.25, internal consistency at a 0.85 (Van der Ploeg,
1980).
2.1. Participants Participants rated their attention for the lm on an 11-point
scale from 0 (not at all) to 10 (completely). In addition, partici-
Participants were undergraduate students from the Radboud pants in all conditions were asked to indicate how much they had
University Nijmegen. They were recruited through an online thought about the lm during the experimental task (continuous
participation system and were rewarded with course credit. For scale from not at all to very much). Participants in the UT and MD
ethical reasons, participants were informed beforehand of the conditions were additionally asked whether their thinking of the
exclusion criteria, that they would be watching a negative lm clip, lm was deliberate or spontaneous. Lastly, participants indicated
and that they could terminate the study at any time without whether they expected their task to increase, decrease or have no
consequence for their credit. Exclusion criteria were as follows: effect on their memory and intrusions of the lm.
PTSD (current and lifetime), major depression (current and life-
time), psychotic episodes (current and lifetime), panic attacks 2.5. Experimental measures
(current), panic disorder (current), intoxication during or shortly
prior to testing, history of fainting, and having to take exams in the 2.5.1. Intrusion frequency
The intrusion provocation procedure (Lang, Moulds, & Holmes,
2009; Michael, Ehlers, Halligan, & Clark, 2005) was used to elicit
3
Data from 18 additional participants was lost due to a technical error. intrusions from the lm clip. Participants were presented with ten
182 J. Krans et al. / J. Behav. Ther. & Exp. Psychiat. 44 (2013) 179e185
still pictures from the lm representing neutral scenes that conditions. Demographic information was obtained and partici-
preceded the negative events in the lm. The pictures were pre- pants continued on the STAI-T, STAI-S, and MoodQ, after which they
sented as a slideshow with a presentation time of 4 s per picture. were shown the lm. They were instructed to completely attend to
Intrusion frequency was measured with an adapted version of the the lm as if they were a bystander and not to look away or
widely used Intrusion subscale of the Impact of Events scale (IES; disengage in any way. After the lm, the experimental instructions
Horowitz, Wilner, & Alvarez, 1980). This subscale has a good (CT, UT, MD) were given randomly with the restriction that an
internal consistency (a 0.86) and good testeretest reliability identical number of participants were allocated to each condition.
(a 0.89) (Sundin & Horowitz, 2002). The 8 items were reworded The recall task was then administered, followed by the STAI-S and
to refer to the lm and participants responded on a scale from MoodQ. Participants then completed the intrusion provocation
0 (not at all) to 4 (very much). Participants were instructed to rate task, the IQ, compliance and demand questions, and IES Intrusion
the items in terms of their appropriateness during the course of the subscale. The interval between the lm and the IES administration
present study (rather than during the last seven days as in the was approximately 12 min, depending on individual speed. Finally,
original version). they were thanked for their participation and debriefed.
Change in state anxiety from pre- to post lm was tested with In the present study, we aimed to (a) replicate the effect of
a mixed model repeated measures ANOVA, with time (pre-lm, unconscious thought on intrusion frequency, (b) extend earlier
post-lm) as the within-subjects factor, condition (CT, UT, MD) as research by including intrusion qualities, and (c) test the organi-
the between-subjects factor, and state anxiety (STAI-S scores) as zation of the trauma lm in memory with a structured recall test.
the dependent variable. There was a predicted signicant effect of The main nding was that participants who were given an
time, F(1, 48) 145.60, p < 0.001, f 1.74, indicating an overall unconscious thought instruction after viewing the trauma lm
signicant increase in state anxiety from pre- to post-lm. The reported a reduction in intrusive experiences compared to partic-
main effect of condition was not signicant, F(2, 48) 1.62, p 0.21. ipants who were instructed to think about the lm deliberately, or
There was a signicant time condition interaction, F(2, participants in the distraction control condition. This nding
48) 5.48, p 0.01, f 0.48. Pairwise comparisons of the anxiety replicates our earlier work (Krans & Bos, 2012) and supports the
change scores (post minus pre) showed that the increase in state goal-dependent asset of unconscious thought as opposed to it
anxiety was signicantly larger in the CT than in the UT condition, being a mere distraction effect (Bos et al., 2008, 2011). This time, we
p 0.01, and MD, p 0.03; whereas the latter two conditions did included a widely used and well validated measure of intrusive
not differ signicantly from each other, p > 0.99. experience, namely the Impact of Event Scale (Horowitz et al.,
The same pattern emerged for negative mood (MoodQ): there 1980). Thus, the effect of unconscious thought reducing intrusion
was a signicant main effect of time (pre- to post-lm), F(1, frequency has now been found using two difference intrusion
48) 247.25, p < 0.001, f 2.27; but no signicant main effect of measures, which increases the validity of the effect.
condition (CT, UT, MD), F(2, 48) 0.93, p 0.40. The Contrary to expectations, we did not nd an effect of uncon-
time condition interaction effect was signicant, F(2, 48) 3.51, scious thought on intrusion qualities. If anything, it appeared that
p 0.04, f 0.38, though pairwise comparisons on the change consciously thinking about the lm increased intrusion nowness
scores of negative mood (post-lm minus pre-lm) did not reach and arousal. This is in line with the nding that state anxiety and
signicance. The descriptive statistics are reported in Table 1. negative mood increased to a larger extend in the conscious
thought condition than in the other two conditions. Although this
3.5. Experimental effects was not in line with our expectations, this opens up an interesting
possibility that can be addressed in future studies. Conscious
3.5.1. Intrusion frequency and quality thought is better at encoding details than at processing the
As predicted, Helmert contrasts showed that scores on the conceptual meaning of new information (Dijksterhuis & Nordgren,
intrusion subscale of the IES were signicantly lower in the UT 2006). Intrusive images, by denition, consist mostly of sensory
condition compared to the other two conditions, p < 0.05 (one- impressions rather than more abstract representations. Thus, more
tailed). There was no signicant difference between the CT and MD conscious thought may have resulted in more arousing and here-
conditions, p 0.45 (two-tailed). and-now intrusions because of enhanced sensory encoding.
Contrary to prediction, Helmert contrasts showed no signicant As in Krans and Bos (2012), we were unable to nd differences in
difference between the UT condition and the CT and MD condition sequence memory between the three conditions despite using
on intrusion vividness, nowness or arousal, (all ps > 0.12, two- a structured recall test to measure memory organization for the
tailed). However, there was a signicant difference between the lm. According to PTSD models (Brewin et al., 1996; Ehlers & Clark,
CT and MD condition on nowness and arousal (all ps 0.02, two- 2000), intrusions occur when the trauma information is disorga-
tailed). Follow-up contrasts (two-tailed) showed a signicantly nized and not well integrated into memory. As unconscious
higher feeling of nowness in the CT than in the UT and MD, p 0.02, thought is suggested to be superior in organizing information in
and a higher arousal level in the CT condition compared to the MD a conceptual way (Dijksterhuis & Nordgren, 2006) this should have
condition, p 0.05, but not compared to the UT condition, p .18. been detected in both the intrusion and recall measure. One
possibility is that the recall measure that was used here was still
3.5.2. Sequence memory insensitive to differences in sequence memory. Another possibility
Contrary to prediction, Helmert contrasts showed no signicant is that sequence memory is not a good measure of the conceptu-
difference on sequence memory between the UT condition and the alization of the lm information. For example, asking about the
CT and MD conditions (p 0.82, two-tailed). There was no signif- meaning or general gist of the lm may have resulted in differences
icant difference between the CT and MD conditions either (p 0.88, between groups. According to UTT, unconscious thought would
two-tailed). lead to a more global assessment of meaning (e.g., vengeance)
Table 1
Means and standard deviations for control and experimental variables within and across conditions.
M SD M SD M SD M SD
STAI-T 36.06 9.58 35.53 6.72 35.53 7.80 35.71 7.96
STAI-S Pre-lm 39.59 3.78 40.18 6.26 41.12 5.75 40.29 5.30
Post-lm 55.76 5.54 49.24 7.64 50.88 5.98 51.96 6.91
MoodQ Pre-lm 11.82 3.88 12.71 4.83 14.24 5.70 12.92 4.87
Post-lm 34.88 5.84 29.59 9.36 30.24 7.01 31.57 7.68
Attention 9.00 1.37 8.82 1.29 8.65 1.46 8.82 1.35
Sequence memory 0.81 0.37 0.77 0.37 0.79 0.36 0.79 0.36
Intrusion vividness (IQ) 5.06 3.31 3.94 2.28 3.29 2.59 4.10 2.80
Intrusion nowness (IQ) 9.29 1.57 7.47 1.88 7.41 2.24 8.06 2.07
Intrusion arousal (IQ) 12.12 2.26 10.59 2.81 10.12 1.73 10.94 2.42
Post-lm intrusions (IES) 9.29 6.47 5.87 3.63 7.88 5.73 7.68 5.49
Post-lm avoidance (IES) 10.33 7.89 9.59 5.50 11.59 4.49 10.50 6.06
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