Index Generalized Anxiety Manual
- Generalized anxiety disorder
- Psious-based treatment protocol
- Use recommendations
- Recommended bibliography
- Annexes.
- Weekly self-recording of anxiety and depression.
- Self-Assessment cognitive form
- Daily self-recording of worrying exposure.
- Self-recording of relaxation and subjective evaluation
- Scenes audio
1. Generalized Anxiety Disorder and Virtual Reality
The main objective in the treatment of generalized anxiety disorder (GAD) is to get the complete and prolonged remission of symptoms, as well as the restoration of the operational level of presymptomatic (Dilbaz, Cavus Y Darcin, 2011). However, not all patient respond well to treatment of choice: Cognitive Behavioural Therapy. Which can be combined with training on relaxation techniques and/or pharmacological treatment.
Research conducted about this topic shows that treatment with virtual reality (VR) is a good alternative for people with GAD (Gorini & Riva, 2008). Mainly because it eases the learning process as well as the creation of a relaxing mood. particularly complicated in people with chronically raised voltage as in the case of this disorder.
Moreover, Psious virtual environments specially designed for the treatment of GAD, are very useful as the therapist can carry out exposure to the patient’s worrying in two different environments: a house and subway
2. Psious – based treatment protocol
Protocol
In the following lines, a treatment protocol using Psious virtual environments is offered as an example.
However, it is noteworthy that this tool should accommodate the cognitive behavioural therapeutic framework used by the therapist, and combining it with techniques such as cognitive restructuring, training in problem solving and worry exposure. It must adapt to the needs and particularities of the patient.
On the other hand, for training in relaxation techniques, Psious has specific environments that will facilitate their learning.
The suggested protocol is an adaptation of the intervention protocol of Brown, O’Leary and Barlow (2001) for GAD.
Our proposal has a total of ten sessions instead of the 13 of the original, as VR facilitates the therapeutic process compared to the imagination (Both in the exposure and learning relaxation techniques), so the treatment’s duration is reduced.
Treatment session description
SESSION 1 PSYCHOEDUCATION
- Information relating to GAD is given ( origin, maintenance and demonstration in the triple system: cognitive, physiological and conductual).
- The role and origin of anxiety and worries are explained.
- General information about treatment (for example importance of self-Assessment and homework).
- Treatment techniques to be used are explained (emphasizing exposure by Virtual Reality).
Homework:
Self-Assessment daily levels of worrying and mood through self-reports provided ( see Annexes 5.1.)
SESSION 2 INTRODUCTION TO RELAXATION
- Discuss self-reports with the patient, as well as what was commented about anxiety on the first session.
- Physiological aspect of anxiety and GAD’s maintenance factors are explained..
- Familiarization with Psious platform
Homework:
Self-Assessment daily levels of worrying and mood through self-reports provided (Annexes 5.1.)
SESSION 3 RELAXATION
- Discuss self-reports with the patient, possible questions are resolved.
- The patient learns and practises two types of relaxation techniques: diaphragmatic breathing and progressive muscle relaxation. (to do this, specific relaxation environments can be used for the training with the available audio).
Homework:
- Daily practise of relaxation techniques and self-reports (Annexes 5.1 and 5.4)
SESSION 4 INTRODUCTION TO THE COGNITION’S ROLE
- Discuss self-reports with the patient, possible questions are resolved.
- Introduction to cognition’s role in persistent anxiety (for example, automatic thoughts) and cognitive distortions.
- Explain how to use cognitive self- assessment form (annexes 5.2)
- It starts to work on automatic thoughts using VR set in the home environment and go writing down these thoughts,
- Practise of relaxation techniques in relaxation environment with the available audio.
Homework:
Daily practise of relaxation techniques and self-reports (Annexes 5.1, 5.2. and 5.4)
SESSION 5 EXPLORATION OF THE COGNITIVE DISTORTIONS
- Discuss self-reports with the patient, possible questions are resolved.
- Cognitive distortions in GAD are discussed and strategies to counter them are offered (alternative thinkings)
- Overestimation of probabilities is explained.
- Explain what catastrophizing is.
- Exposure to house scene playing the indicated debate on TV ( depending on the characteristics of the patient)
- During the exposure, the patient must verbalize his or her thoughts aloud, so it would be possible to explore these distortions.
- Practise relaxation techniques in relaxation environment with the available audio
Homework:
Daily practise of relaxation techniques and self-reports (Annexes 5.1, 5.2. and 5.4)
SESSION 6 INTRODUCTION TO WORRY EXPOSURE
- Discuss self-reports with the patient, possible questions are resolved.
- It is explained what it is worry exposure and a hierarchy of exposure is done.
- Gradual and systematic worry exposure begins on the virtual environments. Throughout all sessions of exposure, Virtual Reality is combined with techniques such as diaphragmatic breathing and progressive muscle relaxation when the therapist deems it necessary.
- Practise relaxation techniques in relaxation environment with the available audio
Homework:
Daily practise of relaxation techniques, self-reports and daily worry exposure (Annexes 5.1, 5.2, 5.3 and 5.4)
SESSION 7 VR EXPOSURE
- Discuss self-reports with the patient, possible questions are resolved.
- Worry exposure on the house environments playing the audio
- Practise relaxation techniques in relaxation environment with no audio
Homework:
Daily practise of relaxation techniques, self-reports and daily worry exposure (Annexes 5.1, 5.2, 5. 3 and 5.4)
SESSION 8 RELAXATION AND WORRYING PREVENTION
- Discuss self-reports with the patient, possible questions are resolved.
- It is explained what it is the prevention to worrying conducts. A list of worries with strategies to prevent them is elaborated.
- Exposure to the VR environment of the house or the subway. The patient must propose strategies to prevent the worries in situ.
- Practise relaxation techniques in relaxation environment with no audio.
Homework:
Daily practise of relaxation techniques, self – reports and daily worry exposure ( Annexes 5.1, 5.2, 5.3 and 5.4) and the prevention of worrying conducts must be applied.
SESSION 9 TIME MANAGEMENT AND PROBLEM SOLVING
- Discuss self-reports with the patient, possible questions are resolved.
- Time management and problem solving are discussed.
- Exposure to the subway virtual environment to implement what has been said in the previous point.
- Practise relaxation techniques in the same exposure environment.
Homework:
Daily practise of relaxation techniques, self – reports and daily worry exposure ( Annexes 5.1, 5.2, 5.3 and 5.4) and the prevention of worrying conducts must be applied.
SESSION 10 REVISION OF SKILLS AND TECHNIQUES
- Discuss last session and self-reports with the patient, possible questions are resolved.
- Skills and learned techniques during the treatment are discussed.
- The therapeutic process is evaluated. Future tasks of self-exposure and reinforcement sessions are scheduled.
3. Use recommendations
Use recommendations
n these environments, with the aim of enhancing the effectiveness of the VR, the therapist plays a very important role with regard to the patient’s suggestion, as by specific comments, may put the patient in situation before starting the exposure. This will enhance the patient ’s sense of presence, strengthen the subjective feeling that he is in the virtual environment.
It is therefore important to use real elements of everyday life of the patient in order to build a story as close as possible to reality, as this will help the virtual environment to be more significant from the patient’s viewpoint and can generate an emotional attachment to perform worry exposure.
For the first four scenes, the therapist should explain to the patient that he or she is at home and depending on which scene the therapist should emphasize some stressors elements.
For example, for the first scene, before reproducing the debate, the therapist can ask the patient to imagine that he or she has just put the baby to sleep and that the intercom is on the coffee table with him or her activated to be aware of the baby.
With this, the patient whose concern is that something wrong may happen to their children, will start building an emotional bond from the beginning, associating the simulation to real life. So once the patient will realize they are talking about babies on the television, his or her anxious reaction will be probably stronger.
For the second scene, it is also important to create the emotional bond by making the patient to pay attention to the elements of the scene indicating that a child lives in that house (a toy, a ball..). This scene is also designed for people with an excessive worrying for their children, in this case that something bad may occurs to them by leaving them in the care of others.
As for the third scene, as in the television they are giving the weather forecast and talking about heavy rains , may be of interest to previously indicate the patient that it is the time when his or her partner comes home from work, coming by car, etc. Therefore, you will work on the concern that something bad happens to a loved one, thus using actual data that the patient has provided the therapist previously, his or her worrying will be increased, as well as his or her reaction.
For the fourth scene, the importance lies in making the patient to notice what is on the table: a medical report and a bottle of pills . To do this , we can start commenting that a few days ago the patient went to the doctor to get some recognition or analysis (add more information depending on the patient ) and has already collected the results.
This will make when the patient will hear on television talking about a disease, for example cancer, to react with a higher level of worrying and excessive anxiety. So, we can work on excessive worrying of having a medical condition or deadly disease and overestimation of probabilities.
Finally, in the fifth scene, the therapist can tell the patient he or she is going to take the subway to go at work (or to go to an important event…), so he or she must be punctual.
The fact that the subway will remain stopped for a while will be stressing by itself, so influencing him or her will reinforce the worry.
5. Recommended bibliography
Bados, A. (2005). Trastorno de ansiedad generalizada. Recuperado de la web del dipósito digital de la Universidad de Barcelona: http:// diposit.ub.edu/dspace/bitstream/2445/357/1/116.pdf
Bastida de Miguel, A.M. (2012). Tratamiento cognitivo-conductual aplicado a un caso de insomnio severo comórbido con ansiedad generalizada. Revista de Psiquiatria, 16(3), 2-36. Recuperado de http://www.psiquiatria.com/revistas/index.php/psiquiatriacom/ article/viewFile/1395/1266/
Brown, T.A., O’Leary, T.A. y Barlow, D.H. (2001). Generalized Anxiety Disorder. En D.H. Barlow (Ed.), Clinical Handbook of Psychological Disorders: A Step-by-Step Treatment Manual (pp. 154-208). Nueva York: The Guilford Press.
Dilbaz, N., Cavus, S.Y. y Darcin, A.E. (2011). Treatment resistant Generalized Anxiety Disorder. En S. Selek (Ed.), Different views of Anxiety Disorders (pp. 219-232). Rijeka: InTech.
Gorini, A., Pallavicini, F., Algeri, D., Repetto, C., Gaggioli, A. y Riva, G. (2010). Virtual Reality in the treatment of Generalized Anxiety Disorders. En B.K. Wiederhold, G. Riva y S.I. Kim (Eds.), Annual Review of Cybertherapy and Telemedicine (pp. 39-43). Amsterdam: IOS Press. Wittchen, H.U. y Hoyer, J. (2001). Generalized Anxiety Disorder: nature and course. Journal of Clinical Psychiatry, 62(11), 15-19. Recuperado de http://psychologie.tu-dresden.de/i2/klinische/mitarbeiter/ publikationen/hoyer/Pdf/504.pdf
Wittchen, H.U. (2002). Generalized Anxiety Disorder: prevalence, burden, and cost to society. Depression and Anxiety, 16(4), 162-171. doi: 10.1002/da.10065
5. Annexes
5.1 Weekly self – recording of anxiety and depression (Barlow)
| Date | Average Anxiety (0-8) | High Anxiety (0-8) | Average Depression media (0-8) | Medium positive affect (0-8) | Percent of daily worrying |
5.2 Self – Assessment cognitive form (Barlow)
| Trigger or event | Automatic Thought | Anxiety (0-8) | Probabilities (0-100) | Alternative explanation | Realistic probabilities(0-100) | Anxiety (0-8) |
5.3 Daily self – recording of worrying exposure (Barlow)
Begin and end time:
| Anxiety (0-8) | Symptoms during the exposure | Worrying Content | Possible worst result feared | Anxiety (0-8) | Possible alternatives | Anxiety (0-8) |
5.4 Self – recording of relaxation and subjective evaluation
| Used time (start – end) | Subjective assessment of the physical condition before starting | Subjective assessment of the physical condition at the end |