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Claustrophobia Manual

Index Manual Distraction

  1. Claustrophobia and Virtual Reality
  2. Psychological evaluation/intervention protocol proposed by Psious
    1. Claustrophobia evaluation (including MRI)
      1. Evaluation objectives
      2. Some useful tools in the evaluation of claustrophobia
      3. Exposure Hierarchy Development with Psiousʼ environments
        1. HierarchyExample
    2. Intervention example in Claustrophobia
    3. Intervention example in Claustrophobia / Magnetic Resonance Imaging (MRI)
      1. Short case introduction
      2. Example of intervention planning 
  3. Usage Recommendations
  4. Recommended bibliography
  5. Appendix
    1. Magnetic Resonance Imaging informed consent
    2. Claustrophobia hierarchy self-report 
    3. Magnetic Resonance Imaging hierarchy selfreport
    4. Room in the basement hierarchy self-report

1. Virtual Claustrophobia and virtual reality

According to the American Psychiatric Association, claustrophobia is the fear of being enclosed in small spaces or the feeling of enclosure and/or the fear of not being able to flee. Symptoms are similar to those experienced in a panic Virtual Claustrophobia and virtual reality attack or similar manifestations (dizziness, falls, vomiting, cardiac discomfort, etc). As a consequence, the person tries to avoid these situations limiting their daily lives. With reference to the differential diagnosis, it is important to evaluate (Rachman, S., & Taylor, S.,1993), the fear of immobility and/or running out of breath, or in other words, the oxygen in the space where the person is located runs out (e.g an elevator).

Furthermore, cognitive behavioral therapy relies upon vast observational evidence in terms of evaluating and intervening in this type of psychopathology (Öst, L.-G., et al., 1982; McIsaac, H.K. et al., 1998; Öst, L.-G., et al., 2001 y Thorpe, S. et al. 2008). Nonetheless, ongoing fundamental research continues (Stella F.et al., 2011) seeking explanations as to what the causes of claustrophobia may be.

Virtual reality is an effective alternative tool to the traditional techniques used in the treatment of emotional disorders, including claustrophobia (Botella, C. et al. 1998; Botella, C. et al., 2000; M Krijn et al., 2004; Botella et al., 2012). Virtual reality allows standardization and control over the parameters in exposure sessions. Moreover, it is particularly useful for repeating the exposure to feared situations as many times as needed, providing flexibility and customized therapeutic procedures.

Psious’ environments facilitate the use of multiple psychological intervention techniques: exposure, cognitive reconstruction, systematic desensitization, social skills training… in order to achieve better results, use the most suitable technique that best suits the patient’s characteristics and base your intervention on those techniques with more empirical support.

2. Psychological evaluation/ intervention protocol proposed by Psious

All the information contained in this section is intended as a guideline. Psious’ environments are therapeutic tools which must be used by health professionals in an evaluation process and interventions devised in accordance with the characteristics and needs of the user. There is also a General Clinical Guide available for your reference where you will find further information on how to adapt the psychological intervention techniques to Psious’ environments (exposure, systematic desensitization, cognitive reconstruction).

2.1. Claustrophobia evaluation (including MRI)

2.1.1  Evaluation objectives 

  • Evaluate particular agoraphobia, panic attacks, amongst other phobias the presence and comorbidity of other emotional disorders, in particular agoraphobia, panic attacks, amongst other phobias.
  • Evaluate anxiety associated with components: asphyxiation and restriction (lack of control).
  • Set the feared stimulative settings for the patient and define to what extent. Exposure hierarchy development 
  • Evaluate the presence of distorted thoughts. In the case of NMR, in particular concerning asfixia, possible damage caused by the machine and the fear of losing control

2.1.2  Some useful tools in the evaluation of 

claustrophobia

Taking the evaluation objectives into account let’s proceed onto listing some tools that can be useful in gathering relevant information on your user characteristics. Always remember that good goal setting, patient characterization and intervention planning are important in effective and efficient therapies, as that for your patients’ satisfaction. In the bibliography you will find some articles where you can refer to see the characteristics of the instruments proposed below: 

  • Semi structured or open interview.
  • Structured interview: ADIS-IV (panic differential , agoraphobia…)

Self-reports: 

  1. Unidimensional
  1. Claustrophobia Scale (CS) 
  1. Multidimensional
  1. Claustrophobia Questionnaire (CLQ) – Adaptación española
  2. Claustrophobia Situations Questionnaire (CSQ)
  3. Claustrophobia General Cognitions Questionnaire (CGCQ).
  1. Psious self-report for hierarchy development

2.1.3 Exposure Hierarchy Development with Psiousʼ 

environments

Once we have the evaluation information we can then proceed on to developing the hierarchy exposure. We can carry out a series of questions, (for example: what level of discomfort is generated, on a scale of 0 to 100, when left waiting for an elevator on a landing? What level of discomfort is generated, on a scale of 0 to 100, when left enclosed in a small elevator full of people due to abreakdown? Can you think of anything else that would generate even more discomfort?) all geared at the planning of the intervention via the virtual reality. 

2.1.3.1  Hierarchy Example

In the appendix you will find a self-report measure to obtain the exposure hierarchy using Psious’s environments. 

2.2 Intervention example in Claustrophobia

SESSION 1 

  • Inform the patient about claustrophobia (Causes, symptoms, prevalence…)
  • Present and show sufficient grounds for the techniques that are used overtime in the treatment: virtual reality exposure and exposure in vivo… 
  • Exposure hierarchy development and hierarchy item exposure from 20-30 USA’s (Example)
  • Start exposure hierarchy with an item close to USA’s 30. The main objective is to familiarize the patient with the virtual reality and the working dynamics
ÍtemVRConfigurationEvent
Standing on landing waiting for (large) elevator in anoffice building ClaustrophobiaBig elevatorNo event
Entering a large empty elevator ClaustrophobiaLarge elevator, nobody Enter elevator
Standing on landing waiting for (small) elevator inoffice building ClaustrophobiaLarge elevator, nobodyNo event
Entering a large empty elevatorClaustrophobiaLarge elevator, nobody Enter elevator
Watching the doors close ClaustrophobiaLarge elevator, nobody Enter elevator

Sesión 2 

  • Review achievements from previous session and and set objectives for current session: see a lot of people in a small elevator when the doors open. 
  • From the second session onwards, commencing the systematic and gradual exposure in virtual reality environments is recommended. Cognitive restructuring, if necessary 
  • Demonstrate clinical progress to the patient, using the platform reports 

Exercises at home: Short journeys with exposure in vivo in empty elevators (1 or 2 floors)

ÍtemVRConfigurationEvent
Hear the MRI precautions whilst changingClaustrophobiaNuclearGo to the changing room and precautions
Ascending in the elevator after leaving a small basementClaustrophobiaRoomExit basement 
Ascending in an elevator with a few people and the elevator starts to moveClaustrophobiaSmall Elevator – minimum peopleEnter elevator + go to another floor
The doors in a small elevator open and there are a lot of people ClaustrophobiaSmall Elevator – maximum peopleEnter elevator

SESSION 3 

  • Review achievements from previous session and and set objectives for current session: Alone in a small elevator when a short breakdown occurs 
  • Systematic and gradual exposure in virtual reality environments. Cognitive restructuring, if necessary. 
  • Demonstrate clinical progress to the patient, using the platform report 

Exercises at home: Short journey with in vivo exposure in empty elevators with a few people + covert exposure of the session using their imagination at home. 

ÍtemVRConfigurationEvent
Ascend two floors with a few people in a large elevatorClaustrophobiaLarge elevator, a few  Go to another floor and immediately exit the elevator  
Ascend 2 floors in a large elevator with quite a few peopleClaustrophobiaLarge elevator, maximumGo to another floor and immediately exit the elevator 
A short breakdown occurs in the small empty elevatorClaustrophobiaSmall elevator, nobody breakdown

SESSION 4 

  • Review achievements from previous session and and set objectives for current session: Be present in a pretty small changing room and the door shuts suddenly. 
  • Systematic and gradual exposure in virtual reality environments. Cognitive restructuring, if necessary. 
  • Demonstrate clinical progress to the patient, using the platform reports. 

Exercises at home: Covert exposure at home revising the session using their imagination. 

ÍtemVRConfigurationEvent
In a pretty large storage room when the door shutsClaustrophobiaRoomClose door (size of room as large as possible) 
Ascending a lot of floors in a small elevator with a lot of people ClaustrophobiaSmall Elevator Go long to another floor ( duration long) 
Ascending a lot of floors in a large empty elevatorClaustrophobiaLarge Elevator Go long to another floor (duration long) 
Being in a pretty large storage room when the door shuts suddenly  ClaustrophobiaRoomClose the door (size or bedroom , in middle) 

SESSION 5 

  • Review achievements and objectives set in previous session: Ascending a lot of floors in a small elevator with a lot of people
  • Systematic and gradual exposure in virtual reality environments. Cognitive restructuring, if necessary. 
  • Repeat each exercise twice. 
  • Reveal clinical progress to patient, using the reports provided in the platform. 

Exercises at home: Covert exposure at home revising the session using imagination + in vivo exposure entering a storage room or other type of room. 

ÍtemVRConfigurationEvent
Ascending a lot of floors in a full small elevatorClaustrophobiaSmall elevator maximum Go long to another floor ( duration long)
In a very small storage room with the doors open quite a lot of people ClaustrophobiaRoomGo to basement (size or room minimum= 
Two-minute breakdown in a small elevator with ClaustrophobiaLarge elevator, Breakdown
Ascending a lot of floors in a small elevator with a lot of people ClaustrophobiaSmall elevator maximum Go long to another floor ( duration long) 

SESSION 6 

  • Review achievements from previous session and and set objectives for current session: Large elevator with a lot of people, long breakdown. 
  • Systematic and gradual exposure in virtual reality environments. Cognitive reconstruction, if necessary.
  • Repeat each exercise twice.
  • Reveal clinical progress to patient, using the reports provided in the platform. 

Exercises at home: In vivo exposure with elevators with quite a lot of people + covert exposure at home revising specific ítems from the session using imagination. 

ÍtemVRConfigurationEvent
In a very small storage room and the door closesClaustrophobiaRoomClose doors (in a small-sized room)
In a very small storage room that starts to shrink in size  ClaustrophobiaRoomClose doors and reduce size of bedroom
In a large elevator with a lot of people and a long breakdown occurs (more than 5 minutes) ClaustrophobiaLarge elevator, maximum, offBreakdown

2.3 Intervention example in Claustrophobia/ Magnetic Resonance Imaging (MRI)

2.3.1 Short case introduction

Case: a person who attends a consultancy due to having a fear of a nuclear magnetic resonance for a study of headaches with aura

The evaluation indicates the presence of anxietydepressive symptomatology associated with an adaptative process, due to the possible diagnosis: mild claustrophobia and slight discomfort associated with having undergone nuclear magnetic resonance

The principal fear is associated with the immobility incurred and loss/lack of control during the session. Symptomatology does not appear to be associated with asphyxia. Similarly, the user is unaware of the procedure that is used and fears that the radiation may worsen their pain and cause a secondary symptom. When intense claustrophobia is not apparent, focus the intervention on the magnetic resonance procedure. Here you will find an example of intervention planning, including exposure hierarchy.

2.3.2  Example of intervention planning

SESSION 1 

  • • Inform the patient about claustrophobia (Causes, symptoms, prevalence…) 
  • Present and show sufficient grounds for the techniques that are used overtime in the treatment: virtual reality exposure and exposure in vivo…
  • Exposure hierarchy development and item exposure development from 20-v30 USA’ example
  • Start exposure hierarchy with an item close to USA’s 30. The main objective is to familiarize the patient with the working dynamics and the virtual reality
  • Before commencing the exposure, and to facilitate the immersion, you could provide the patient with an informed consent form requesting permission to carry out the NMR (se appendix)
ÍtemVRConfigurationEvent
Just about to leave home in a taxi to have a nuclear magnetic resonance Fear of flyingAt homeGo to airport
On way to hospital in car/metro to have a magnetic resonance (select most common form of transport of patient) *AFear of drivingCity (medium, sun, day, driver, minimum)Circuit 1 
On way to hospital in car/metro to have a magnetic resonance (select most common form of transport of patient) *BAgoraphobiaMetro (maximum light, easy) Go to platform, enter, next stop, exit
In waiting room waiting to have a magnetic resonanceClaustrophobiaMagneticResonance: leg, by defect, off 
In waiting room before being briefed about the test Fear of needlesWaiting Room Read and sign the informed consent form in the appendix 
Driving through a tunnel on way to hospital in a car Fear of drying Highway ( day, sun, driver, show, hide) Type of highway tunnel
Watching a video in the waiting room explaining what nuclear magnetic resonance is. ClaustrophobiaMagnetic resonance: leg, by defect, on) Close doors (in a small-sized room) 

*Choose most common method of patient transport 

SESSION 2 

  • Review achievements from previous session and and set objectives for current session: Magnetic resonance room
  • As and from the second session in treatment, introducing the systematic and gradual exposure to virtual reality environments is recommendable. Cognitive reconstruction, if necessary.
  • Reveal clinical progress to patient, using the reports provided in the platform. 

Homework: Exposure in vivo to a hospital close by and expose them to being present in the MRI waiting room, asking them, to observe a person entering the changing room and to imagine they are doing so themselves. 

ÍtemVRConfigurationEvent
Whilst being informed on how to collect the results, the MRI technician tells me that the test has terminated whilst I notice the bed moving out of the tube ClaustrophobiaMagnetic resonance – leg, by defect, on. Terminate resonance
On my way to get changed, before doing the magnetic resonance ClaustrophobiaMagnetic resonance – leg, by defect, on. Go to changing room
Whilst in changing room I am informed on the precautions that need to be taken into account, before entering the nuclear magnetic resonance: do not enter with metallic objects, notify if wearing a pacemaker… ClaustrophobiaMagnetic resonance – leg, by defect, offPrecautions
On entering the magnetic resonance room, I see the machine where the test will be taken, with the leg coil setup, and I am informed on the test procedure and not to move during the magnetic resonanceClaustrophobiaMagnetic resonance – leg, by defect, off–
On entering the magnetic resonance room, I see the machine where the test will be taken, with the abdomen and chest coil set up, and I am informed on the test procedure ClaustrophobiaMagnetic resonance – , torso by defect, off–

SESSION 3 

  • Review achievements from previous session and and set objectives for current session: Changing room and lie down on treatment bed. 
  • Systematic and gradual exposure in virtual reality environments. Cognitive reconstruction,if it’s necessary.
  • Reveal clinical progress to patient, using the reports provided in the platform.

Homeworks: Covert exposure at home repeating the procedure worked on in the consultancy using imagination. 

ÍtemVRConfigurationEvent
Entering the room to leave metallic objects, you hear the door close and are left in the room, with no windows, and all the doors are closed from the inside. ClaustrophobiaMagnetic resonance – leg, by defect, ofGo to changing room
At home after making magnetic resonance appointment on the telephoneGeneralized anxietyWorried about infectious diseases –
On entering the magnetic resonance room, I see the machine where the test will be taken, with the head coil set up, and I am informed of the test procedure ClaustrophobiaMagnetic resonance – head, by defect, off–
Lying down, facing upwards, foot immobilized, before entering the magnetic resonance tube. ClaustrophobiaMagnetic resonance – leg, by defect, offLie down

SESSION 4 

  • Review achievements from previous session and and set objectives for current sessio. Lying immobile on the treatment bed.
  • Systematic and gradual exposure in virtual reality environments. Cognitive reconstruction, if it’s necessary.
  • Reveal clinical progress to patient, using the reports provided in the platform.

Homework: Covert exposure and make an MRI appointment on the telephone (even if they already have made an appointment) 

ÍtemVRConfigurationEvent
Before leaving the room, Before leaving the room, tells me to lie down on the treatment bed and that the test with begin shortly: the leg coil is already in place ClaustrophobiaMagnetic resonance – leg , by defect, offLie down
Lying down on the treatment bed the medical technician places the coil on my chest, whilst explaining what is going to happen, and then exitsClaustrophobiaMagnetic resonance – torso, by defect, offLie down
On the treatment bed looking at the ceiling and the coil on my chest, before being placed all the way into the magnetic resonance machine ClaustrophobiaMagnetic resonance – torso, by defect, offLie down
Whilst on the treatment bed the medical technician stops moving my head to start the test when finished he/she goes to the control room. ClaustrophobiaMagnetic resonance – head, by defect, offLie down

SESSION 5 

  • Review achievements from previous session and set objectives for current session, Immobility lying down on treatment bed inside the NMR tube (asphyxia) 
  • Systematic and gradual exposure in virtual reality environments. Cognitive reconstruction, if necessary. 
  • Reveal clinical progress to patient, using the reports provided in the platform.

Exercises at home: Covert Exposure 

ÍtemVRConfigurationEvent
Lying down, facing upwards, head immobilized, before entering the magnetic resonance tube and I see the medical technician in the control room in the coil mirror ClaustrophobiaMagnetic resonance – head, by defect, offLie down
The test starts: entering cramped magnetic resonance tube to the waist point, leg immobile due to the coil and hear the sounds of the machine for the first time ClaustrophobiaMagnetic resonance – leg , by defect, offStart resonance 
The test starts and I notice my immobile body, due to the coil, sliding to the inside of the magnetic resonance tube. Small space. ClaustrophobiaMagnetic resonance – torso , by defect, offStart resonance 

SESSION 6 

  • Review achievements from previous session and and set objectives for current session.: Immobility lying down on treatment bed inside the NMR tube (asphyxia).
  • Systematic and gradual exposure in virtual reality environments. Cognitive reconstruction, if necessary. 
  • Reveal clinical progress to patient, using the reports provided in the platform.

Exercises at home: General guidelines for coping with the NMR test in vivo. 

ÍtemVRConfigurationEvent
Hear the technician’s voice a short while after entering saying we are about to start Entire body enters the magnetic RMN tube, head immobilized from coil, watching how the technician controls the machine through the little mirror. ClaustrophobiaMagnetic resonance – head , by defect, offStart resonance
Whilst placed inside the machine, I hear how the sound of the magnetic resonance changes. ClaustrophobiaMagnetic resonance – head , by defect, offNoise
Noticing how the sound of the magnetic resonance machine becomes deeper ClaustrophobiaMagnetic resonance – head , by defect, offGeneral volumeregular

PLEASE REFER TO OUR GENERAL CLINICAL GUIDE FOR INFORMATION ON THERAPEUTIC PROCEDURES WITH EMPIRICAL EVIDENCE AND HOWTO ADAPT THEM TO THE INTERVENTION WITH PSIOUSʼ VIRTUAL REALITY ENVIRONMENTS.

3. Usage Recommendations

The therapist can contribute by making comments that will help the the patient immerse in the simulation context.

For example, in the Room environment

  • “You need to go to the basement because you left the car keys there (or some other important object), so you will need to take the elevator from your block and descend to the last floor” 
  • “The elevator in your block is quite old and narrow, but it is the only way you can get down to the basement, since there are no stairs to the last floor.” 
  • “Once the door closes, remember you will encounter a floor below the first floor and the only way to go back up will be by the way you came.”
  • “The elevator door has closed, and it may head up since other neighbors may have called the elevator, so if you wish to return, you will not be able to use it immediately,”
  • “The basement is at the end of quite a narrow hall, the walls are quite dirty so best not to touch them.”

Other example: Elevator environments: 

  • “Going to the ninth floor, so the stairs is not an option, you will have to take the elevator.”
  • “You will Ascend in the elevator with other neighbours, so staying calm would be a good option so as to avoid an awkward situation”.
  • “¿How do you feel when you know there are other people in the elevator? ¿Do you become more aggravated or it is calming to know you will be accompanied?”
  • (Inside the elevator) “Some neighbors in the lobby mention the elevator has been having problems of recent, and the service technician was on holidays ” (this gives rise to the breakdown event activation).

4. Recommended bibliography

Botella, C. et al. (1998). Virtual reality treatment of claustrophobia: a case report. Behaviour research and therapy, 36(2), 239-246. 

Botella, C. et al (2000): Virtual reality in the treatment of claustrophobic fear: A controlled, multiple-baseline design, Behavior Therapy, Volume 31, Issue 3, Pages 583-595, ISSN 0005-7894, http://dx.doi.org/10.1016/S0005-7894(00)80032-5

Botella et al. (2012): La realidad virtual para el tratamiento de los trastornos emocionales: una revisión. Anuario de psicología clínica y de la Salud. Volumen 08 • Pág. 7 a 21 

Brown, T. A., DiNardo, P. A., & Barlow, D. H. (1994). Anxiety disorders interview schedule for DSM-IV (ADIS-IV), adult version. Albany (NY): Graywind Publications Inc.

Febbraro, G.A.R. y Clum, G.A. (1995). A dimensional analysis of claustrophobia. Journal of Psychopathology and Behavioral Assessment, 17, 335-351.

Johnsen, B, et al. (1990): Fear questionnaires for simple phobias: Psychometric evaluations for a norwegian sample. Scandinavian Journal of Psychology, 31, 42-48

M Krijn, et al. (2004) Virtual reality exposure therapy of anxiety disorders: A review, Clinical Psychology Review, Volume 24, Issue 3, Pages 259-281, ISSN 0272-7358, http://dx.doi.org/10.1016/j. cpr.2004.04.001. (http://www.sciencedirect.com/science/article/pii/ S0272735804000418)

Martínez Valls, M.A. et al. (2003): Propiedades psicométricas del cuestionario de claustrofobia en población española. Psicothema 2003. Vol. 15, nº 4, pp. 673-678

McIsaac, H.K. et al. (1998). Claustrophobia and the Magnetic Resonance Imaging Procedure. Journal of Behavioral Medicine, 21, 255-268. 

Öst, L.-G., Alm, T., Brandberg, M. & Breitholtz, E. (2001). One vs five sessions of exposure and five sessions of cognitive therapy in the treatment of claustrophobia. Behaviour Research and Therapy, 39(2), 167-183.

Öst, L.-G., Johansson, J., & Jerremalm, A. (1982). Individual response patterns and the effects of different behavioral methods in the treatment of claustrophobia. Behaviour Research and Therapy, 20, 445–460.

Stella F. Lourenco, Matthew R. Longo, Thanujeni Pathman. Near space and its relation to claustrophobic fear. Cognition, (2011); 119 (3): 448 DOI: 10.1016/j.cognition.2011.02.009

Rachman, S., & Taylor, S. (1993). Analyses of claustrophobia. Journal of Anxiety Disorders, 7, 281–291. Rachman, S.J. (1997). Claustrophobia. En G.C.L. Davey (Ed.), Phobias. A Handbook of Theory, Research and Treatment (pp. 163-182). Chichester:Wiley

Thorpe, S. et al. (2008): Claustrophobia in MRI: the role of cognitions, Magnetic Resonance Imaging, Volume 26, Issue 8, October 2008, Pages 1081-1088, ISSN 0730-725X http://dx.doi.org/10.1016/j. mri.2008.01.022 – http://www.sciencedirect.com/science/article/pii/ S0730725X0800043X

5. Anexos

5.2 Autoinforme jerarquía Ascensores

ÍtemNivel malestar (0-100)
Estoy en el rellano de un ascensor pequeño y no hay nadie a mi lado. Las puertas del ascensor están cerradas y estoy esperando a que llegue
Me encuentro subiendo diversos pisos en un ascensor grande que está muy lleno
Subo a un ascensor bastante pequeño con poca gente, entonces las puertas se cierran y empezamos a movernos
Subo a un ascensor grande sin que haya nadie más dentro y pulso el botón para subir
Llega el ascensor, se abren las puertas y veo que es bastante pequeño y que no hay nadie dentro. Me dispongo a subir 
Se produce una avería momentánea (aproximadamente 1 minuto) dentro de un ascensor grande mientras voy en él sin nadie más
Acabo de subir a un ascensor pequeño con mucha gente, y las puertas continúan abiertas
Cuando llega el ascensor se abren sus puertas, veo que es bastante pequeño y que no hay mucha gente en su interior (3 personas) 
Estoy subiendo muchos pisos en un ascensor grande en el que no va mucha gente
Se produce una avería larga (de aproximadamente 5 minutos) dentro de un ascensor grande mientras voy en él con mucha gente
Me encuentro en un ascensor pequeño con mucha gente y estamos subiendo un par de pisos
Estoy subiendo diversos pisos en un ascensor grande sin gente dentro
Se produce una avería momentánea (aproximadamente 1 minuto) dentro de un ascensor pequeño mientras voy en él con poca gente
Se produce una avería larga ( aproximadamente 5 minutos) dentro de un ascensor pequeño mientras voy en él con mucha gente
Estoy subiendo un par de pisos en un ascensor grande en el que hay poca gente
Subo a un ascensor pequeño sin que haya nadie más dentro, las puertas continúan abiertas
Voy subiendo diversos pisos en un ascensor pequeño que va vacío
Se produce una avería larga (de aproximadamente 5 minutos) dentro de un ascensor grande mientras voy en él sin nadie más
Subo a un ascensor grande con mucha gente, las puertas continúan abiertas.
Subo a un ascensor pequeño con mucha gente, las puertas se cierran y empezamos a movernos
Saliendo de un ascensor grande en el que viajaba con poca gente
Subo a un ascensor pequeño sin que haya nadie más dentro y pulso el botón para subir.
Me encuentro subiendo muchos pisos en un ascensor pequeño con poca gente
Estoy en el rellano de un ascensor grande (tipo centro comercial) sin gente a mi lado. Las puertas del ascensor están cerradas y estoy esperando a que llegue
Voy subiendo muchos pisos en un ascensor grande que va totalmente vacío
Estoy en un ascensor pequeño con poca gente en él, y vamos subiendo un par de pisos
Entro en un ascensor grande con poca gente,y las puertas continúan abiertas
Un ascensor grande llega al rellano, se abren las puertas y está muy lleno. Queda espacio para que yo suba
Se produce una avería momentánea (aproximadamente 1 minuto) dentro de un ascensor pequeño mientras voy en él sin nadie más
Voy saliendo de un ascensor pequeño en el que viajaba con poca gente
Estoy subiendo muchos pisos en un ascensor pequeño sin nadie más
Mientras estoy en un ascensor grande con poca gente, se produce una avería momentánea (aproximadamente 1 minuto)
Me encuentro en un ascensor pequeño que está muy lleno, y vamos subiendo muchos pisos 
Entro en un ascensor pequeño con poca gente, y las puertas continúan abiertas.
Se produce una avería larga ( aproximadamente 5 minutos) dentro de un ascensor pequeño mientras voy en él sin nadie más
Subo a un ascensor grande que está muy lleno, las puertas se cierran y empezamos a movernos
Estoy saliendo de un ascensor grande en el que viajaba sin acompañantes
Salgo de un ascensor pequeño en el que viajaba con mucha gente
Se abren las puertas de un ascensor grande y hay poca gente (3 personas) en su interior
Estoy subiendo algunos pisos en un ascensor grande sin gente dentro 
Se produce una avería momentánea (aproximadamente 1 minuto) dentro de un ascensor pequeño mientras voy en él con mucha gente
Entro en un ascensor grande sin que haya nadie más dentro, las puertas continúan abiertas
Me encuentro en un ascensor grande que está bastante vacío, y de repente se produce una avería que dura unos 5 minutos
Estoy saliendo de un ascensor grande en el que viajaba con mucha gente
Se produce una avería larga ( aproximadamente 5 minutos) dentro de un ascensor pequeño mientras voy en él con poca gente
Se abren las puertas de un ascensor grande y veo que no hay nadie dentro. Me dispongo a subir.
Estoy saliendo de un ascensor pequeño en el que viajaba sin acompañantes
Voy subiendo muchos pisos en un ascensor que es muy grande y está lleno de gente
Se produce una avería momentánea (aproximadamente 1 minuto) dentro de un ascensor grande mientras voy en él con mucha gente
Un ascensor pequeño llega al rellano, se abren las puertas y está muy lleno. Queda espacio para que yo suba
Subo a un ascensor grande con poca gente, las puertas se cierran y empezamos a movernos

5.3 Autoinforme jerarquía Resonancia Magnetica

ÍtemNivel malestar (0-100)
Al entrar en la sala de la resonancia magnética, veo la máquina en la que me haré la prueba, con la bobina de cabeza preparada, y me informan de cómo va a ser el proceso de la prueba.
Al entrar en la sala de la resonancia magnética, veo la máquina en la que me haré la prueba, con la bobina de pecho y abdomen preparada, y me informan de cómo va a ser el proceso de la prueba.
Al entrar en la sala de la resonancia magnética, veo la máquina en la que me haré la prueba, con la bobina de pierna preparada, y me informan de cómo va a ser el proceso de la prueba y de que no debo moverme durante la resonancia magnética.
Antes de entrar en la máquina de resonancia magnética estoy tumbado boca arriba con la cabeza inmovilizada y veo al técnico dentro de la sala de control por el espejo de la bobina.
Cuando entro en la sala para dejar los objetos metálicos, oigo cómo se cierra la puerta y me quedo dentro de la habitación, sin ventanas, y con todas las puertas cerradas por dentro.
De camino al hospital paso por un túnel con el coche.
El técnico me indica que empezamos y noto cómo mi cuerpo, inmóvil por la bobina, se desplaza por completo hasta el interior de tubo de resonancia magnética. Veo que se trata de un espacio pequeño.
El técnico me indica que la prueba ha finalizado y noto como la camilla va saliendo del tubo de resonancia magnética, mientras me indican como recoger los resultados.
El técnico, antes de marcharse de la sala, me indica que debo tumbarme en la camilla para iniciar la prueba y que empezaremos en breve: ya llevo la bobina de la pierna puesta.
En caja después de haber pedido cita por teléfono para realizarme una resonancia magnética
En la sala de espera veo un video informativo de lo que es una resonancia magnética nuclear.
Estoy en la sala de espera antes de hacerme la resonancia magnética 
Estoy en la sala de espera antes de que me informen de la prueba que tengo que hacerme.
Estoy sobre la camilla mirando al techo y viendo la bobina sobre mi pecho antes de entrar, por completo, en la máquina de resonancia magnética
Justo antes de salir de casa para ir, en taxi, a hacerme una resonancia magnética nuclear
Mientras estoy dentro de la máquina, oigo como el sonido de la máquina de resonancia magnética cambia.
Mientras estoy en la camilla el técnico termina de inmovilizarme la cabeza para prepararme para realizar la prueba. Al terminar se marcha a la habitación de control.
Mientras estoy en la sala para cambiarme me informan de las precauciones a tener en cuenta, no entrar con objetos metálicos, avisar si llevo un marcapasos…, antes de entrar en la sala de la resonancia magnética nuclear.
Noto como el sonido de la máquina de resonancia es más intenso que antes.
Poco después de entrar en la sala de control oigo la voz del técnico indicándome que empezamos: entro por completo en el tubo de la resonancia magnética, con la cabeza inmovilizada por la bobina mientras veo por el espejito de la misma como el técnico controla la máquina.
Se inicia la prueba: con la pierna inmóvil por la bobina mi cuerpo entra hasta la cintura dentro del reducido espacio del tubo del equipo de resonancia magnética y oigo los primeros ruidos de la máquina.
Tumbado boca arriba en la camilla, con la pierna inmovilizada, antes de entrar en el tubo de la resonancia magnética
Tumbado/a en la camilla el técnico termina de colocarme la bobina sobre el pecho mientras me explica, antes de marcharse, que sucederá a continuación.
Voy de camino a la sala para cambiarme, antes de entrar a hacerme la resonancia magnética 
Voy de camino al hospital en metro/coche para realizarme una resonancia magnética. (elegir método más habitual de transporte)
Otras situaciones:

5.4 Autoinforme jerarquía Habitación del sótano 

ÍtemNivel malestar (0-100)
Estoy en rellano de mi piso esperando que llegue el ascensor para dirigirme al sótano
Después de andar por el pasillo del sótano, llego al trastero, abro la puerta y entro en la habitación, que es bastante grande, y dejo la puerta abierta
Llega el ascensor y al abrirse las puertas veo que está vacío. Me dispongo a subir a él y empiezo a bajar hacia el sótano
Estoy andando por un pasillo muy estrecho que va a llevarme al trastero del sótano
Estoy saliendo de un ascensor, me paro un momento en el rellano del sótano, y a lo lejos puedo ver la puerta del trastero
Estoy parado en medio de un pasillo muy estrecho. A mi espalda tengo el trastero del que acabo de salir y delante de mí veo el ascensor que me va a llevar a la superfície 
Estoy andando por el pasillo y me dirijo hacia el trastero del sótano, y entonces paro de andar un momento
Me encuentro dentro de un ascensor después de haber estado en el trastero, y estoy subiendo desde el piso del sótano hasta otro piso
Al llegar al trastero, abro la puerta y entro en la habitación, que no es muy grande pero tampoco muy pequeña. La puerta sigue abierta
Mientras estoy en un trastero bastante grande, se cierra la puerta
Llego al trastero del sótano, abro la puerta y entro en la habitación dejando la puerta abierta. La habitación es muy pequeña, parece que en ella quepo yo y poco más
Estoy en el medio de un trastero bastante grande, y de repente la habitación empieza a hacerse más pequeña
Mientras estoy en un trastero mediano, ni muy grande ni muy pequeño, se cierra la puerta
Estoy andando por un pasillo muy estrecho que me va a llevar al ascensor, con lo que dejaré el piso donde se encuentra el sótano 
Mientras estoy en un trastero muy pequeño, se cierra la puerta
Me dispongo a salir del trastero del sótano, por lo que me giro, abro la puerta y me voy