Index OCD Manual
- OCD and Virtual Reality
- Psychological Evaluation/Intervention protocol proposed by Psious
- OCD Evaluation
- Evaluation Objectives
- Useful tools for the OCD evaluation
- Exposure hierarchy elaboration with Psious’ environments
- OCD intervention example
- OCD Evaluation
- Use recommendations
- Recommended Bibliography
- Annexe
1. OCD and Virtual Reality
According to the American Psychiatric Association, the obsessivecompulsive disorder is an anxiety disorder in which people have undesirable thoughts, ideas or sensations (obsessions), which carry out ritualized behaviors (compulsions) or repetitive thoughts (neutralizations). These behaviors, such as washing hands, checking or cleaning, interfere in a significant way with the daily activities and social relationships of a person. (Gorrindo, T., Parekh, R., 2015)
For OCD’s differential diagnosis there must be presence of obsessions and/or compulsions that consume a lot of time (more than one daily hour), which cause stress, harm work and social relationships, as well as other important areas. (APA, 2007). The cognitive-behavioral therapy, the treatment with medication, apart from other somatic therapies of cerebral stimulation, have been till now the most effective alternatives to treat this disorder (APA, 2007).
Virtual reality appears as a good alternative tool to the traditional techniques used in mental disorder treatments and in obsessive compulsive disorders among others. Virtual Reality allows the standardization and the control on the parameters of the exposure sessions. Likewise, it turns out to be very useful to repeat the exposure to the fear or anxiogenic situations as many times as necessary, making the customization and flexibilization of the therapeutic process much easier.
Psious’s environments allow you the use of diverse psychological intervention techniques: exposure, cognitive restructuring, systematic desensitization, training in social skills… Use the most adapted characteristics of the patient and use those with major empirical support to obtain better results.
2. Psychological evaluation/ intervention protocol
All the information in this section is indicative. Psious’ environments are therapeutic tools that must be used by the sanitary professional inside an evaluation and intervention process designed according to the characteristics and needs of the user.
Remember that you have a General Clinical Guide where you will find more information on how to adapt the psychological intervention techniques (exposure with response prevention, cognitive restructuring…) to Psious’ environments.
2.1 OCD Evaluation
2.1.1 Evaluation objectives
- Evaluate presence and comorbidity with other emotional disorders.
- Evaluate the presence of obsessions, compulsions and neutralizations.
- Define anxiogenic stimular settings on the side of the patient and in what degree. Elaboration hierarchy of exposure.
- evaluate the presence of distorted thoughts. In case of OCD, those associated to obsessions and compulsions.
2.1.2 Useful tools for the OCD evaluation
Considering the evaluation objectives, we will enumerate some of the tools that can be useful to obtain relevant information about the characteristics of your user. Remember that good objectives definitions, patient characterization and planification of the intervention are important for the therapeutical efficiency and effectiveness just like the user satisfaction. In the bibliography you will find articles where you can revise the characteristics of the proposed tools:
- Open or semi-structured interview.
- Structured interview ADIS-IV
Self-report:
- Obsessive Beliefs Questionnaire (OBQ-44)
- The Brief Obsessive–Compulsive Scale (BOCS)
- Yale-Brown Obsessive-Compulsive Scale (Y-BOCS)
- Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS)
- The Maudsley Obsessive-Compulsive Inventory (MOCI).
- Leyton Obsessional Inventory (LOI).
- Psious self-reports for the elaboraton of the hierarchy.
Tests for behavioral approach:
- Behavioral avoidance test for obsessive compulsive disorder (BATs).
2.1.3 Exposure hierarchy elaboration with Psious’ environments:
Once we have all the evaluation information we can proceed to elaborate an exposure hierarchy. For that, we need to make some questions made to plan the intervention with virtual reality: e.g. what level of discomfort, on a scale from 0 to 100, does it cause you to be sitting on a toilet? What level of discomfort from 0 to 100 does it cause you to wash your hands? Do you think there’s something that can cause you even more discomfort than that?
2.2 OCD intervention example
SESSION 1
Psychoeducation: inform the patient about OCD. What are the causes, symptoms, prevalence, and definition.
- Explain which techniques will be used during the treatment: in anxiogenic situations and in others where relaxation techniques and mindfulness can be used.
- An exposure hierarchy with be elaborated.
- The exposure will be carried out with items that are around the 30 USAs, to familiarize the patient with VR.
The main objective will be familiarizing the patient with virtual reality and the work dynamics.
Recommended protocol for the first session:
| Item | USA’s | Environment | Settings | Event |
| Be at a public toilet’s door | 20 | OCD | Clean | Outside the toilet |
| I place myself in front of a public clean toilet cubicle’s door. | 30 | OCD | Clean | Inside the toilet |
| After entering a clean public toilet, I enter the toilet cubicle and look at the toilet. | 35 | OCD | Clean | Standing inside the cubicle |
SESSION 2
- Revision of the past session’s achievements and establishing of objectives of the actual session: Lower a public toilet’s lid to sit down.
- We begin with gradual exposure and systematic response prevention with virtual reality. Cognitive restructuring, if necessary.
- The reports should be shown to the patient so they can see their clinical progresses.
Homework
- Live exposure entering clean public toilets, enter the cubicle and sit on the toilet. Use relaxation if necessary
Recommended protocol for the second session:
| Item | USA’s | Environment | Settings | Event |
| In front of a clean public toilet, I touch the wall with my left hand. | 40 | OCD | Clean | Touch the wall (standing inside the cubicle) |
| Walk through Ramblas with many people. | 40 | OCD | Dirty | Outside the toilet |
| Inside the cubicle of a clean public toilet. I grab paper and I throw it in the trash | 40 | OCD | Clean | Grab paper |
| I touch the toilet brush in a clean public toilet | 45 | OCD | Clean | Touch toilet brush |
| I lower the toilet lid in a clean public toilet to sit on it | 45 | OCD | Clean | Lower lid |
SESSION 3
- Revision of the past session’s achievements and establishing of objectives of the actual session: Place myself in front of a sink in a clean public toilet.
- We begin with gradual exposure and systematic response prevention with virtual reality. Cognitive restructuring, if necessary.
- The reports should be shown to the patient so they can see their clinical progresses.
Homework
- Live exposure by entering a cubicle in a clean public toilet, sit on the toilet, touch the wall and stand in front of the sink. Carry out relaxation exercises if necessary
Recommended protocol for the third session:
| Item | USA’s | Environment | Settings | Event |
| I sit on a clean public toilet | 50 | OCD | Clean | Sitting on the toilet |
| Sitting on a clean public toilet, I then touch the wall with my left hand | 50 | OCD | Clean | Touching the wall (sitting onthe toilet) |
| I enter a public toilet that doesn’t smell well with paper all over the floor and I place myself in front of the toilet cubicle | 50 | OCD | Dirty | Inside the toilet |
| I flush the toilet after using it (clean public toilet) | 55 | OCD | Clean | Flush the toilet |
| I place myself in front of the sink in a clean public toilet | 60 | OCD | Clean | In front of the sink |
SESSION 4
- Revision of the past session’s achievements and establishing of objectives of the actual session: Touching the walls inside a cubicle of a dirty public toilet.
- We begin with gradual exposure and systematic response prevention with virtual reality. Cognitive restructuring, if necessary.
- The reports should be shown to the patient so they can see their clinical progresses.
Homework
- Live exposure entering a clean public toilet. Use the toilet, flush it, and wash hands in a non-compulsive way. Relaxation exercises if necessary
Recommended protocol for the fourth session:
| Item | USA’s | Environment | Settings | Event |
| Standing outside a clean public toilet, I open the door, I stand in front of the cubicle, I open the door, I stand in front of the toilet, lower the lid and I sit down | 60 | OCD | Clean | From outside until sitting on the toilet |
| I enter the cubicle and it smells bad, it’s dirty and it has urine drops | 60 | OCD | Clean/Easy | Standing inside the cubicle |
| In the cubicle of a clean public toilet, I grab paper and I throw it in the trash | 65 | OCD | Clean/Easy | Washing hands |
| Sitting on a clean public toilet, I grab paper, I stand up, I flush the toilet, I stand in front of the sink, I wash my hands without touching the faucet, the soap or the dryer. | 70 | OCD | Clean/Easy | Complete |
| I touch the walls of the cubicle of a dirty and smelly toilet | 70 | OCD | Dirty | Touching the wall (standing in the toilet cubicle) |
SESSION 5
- Revision of the past session’s achievements and establishing of objectives of the actual session: Touching the brush inside the cubicle of a dirty public toilet.
- We begin with gradual exposure and systematic response prevention with virtual reality. Cognitive restructuring, if necessary.
- The reports should be shown to the patient so they can see their clinical progresses.
Homework
- Live exposure, entering a public toilet, touching several elements inside the cubicle, using the toilet, leaving and washing hands in a non-compulsive way. Relaxation exercises if necessary.
Recommended protocol for the fifth session:
| Item | USA’s | Environment | Settings | Event |
| I use the sink in a public toilet after using the toilet. I touch the faucet, the soap and the hand dryer | 75 | OCD | Clean/Difficult | Washing hands |
| Sitting on a clean public toilet, I grab paper, I stand up, I flush the toilet, I stand in front of the sink and I use it touching faucet, soap and hand dryer | 75 | OCD | Clean/Difficult | From sitting on the toilet to washing hands |
| I´m outside a clean public toilet, I open the door and I stand in front of the cubicle. I open the door and I stand in front of the toilet. I lower the lid, I sit on the toilet, I grab paper, I stand up, I flush the toilet and I stand in front of the hand dryer. I wash my hands without touching the faucet, soap or hand dryer. | 75 | OCD | Clean/Easy | Complete |
| I grab paper from the cubicle in a dirty public toilet and I then throw it in the trash | 75 | OCD | Dirty | Grabbing paper |
| I touch the toilet brush inside a cubicle of a dirty public toilet | 80 | OCD | Dirty | Touching toilet brush |
SESSION 6
- Revision of the past session’s achievements and establishing of objectives of the actual session: Standing outside a dirty public toilet, I open the door, I stand in front of the cubicle, I open the door, I stand in front of the toilet, I lower the lid and sit on the toilet.
- We begin with gradual exposure and systematic response prevention with virtual reality. Cognitive restructuring, if necessary.
- The reports should be shown to the patient so they can see their clinical progresses.
Homework
- Live exposure, entering a public toilet, touching several elements inside the cubicle, using the toilet, leaving and washing hands in a non-compulsive way. Relaxation exercises if necessary.
Recommended protocol for the sixth session:
| Item | USA’s | Environment | Settings | Event |
| Standing outside a dirty public toilet, I open the door, I stand in front of the cubicle I open the door, I stand in front of the toilet, I lower the lid and sit on the toilet, I grab paper, I stand up, I flush the toilet and I stand in front of the sink. I wash my hands, I touch the faucet, soap and hand dryer | 80 | OCD | Clean/Difficult | Complete |
| Lower the lid of a dirty public toilet | 85 | OCD | Dirty | Lower the lid of a dirty public toilet |
| Sitting on a dirty public toilet | 90 | OCD | Dirty | Sitting on the toilet |
| While I’m sitting on a dirty public toilet, I touch the wall with my left hand | 90 | OCD | Dirty | Touching the wall (sitting on the toilet) |
| I’m standing outside a dirty public toilet, I open the door, I stand in front of the cubicle, I open its door, I stand in front the toilet, I lower the lid and I sit on it. | 90 | OCD | Dirty | From standing outside until sitting on the toilet |
SESSION 7
- Revision of the past session’s achievements and establishing of objectives of the actual session: Make a complete sequence, in a dirty public toilet with easy settings.
- We begin with gradual exposure and systematic response prevention with virtual reality. Cognitive restructuring, if necessary.
- The reports should be shown to the patient so they can see their clinical progresses.
Homework
- Live exposure, entering a public toilet, touching several elements inside the cubicle, using the toilet, leaving and washing hands in a non- compulsive way. Relaxation exercises if necessary.
Recommended protocol for the seventh session:
| Item | USA’s | Environment | Settings | Event |
| I flush a dirty public toilet and it smells bad after having used it | 95 | OCD | Dirty | Flushing toilet |
| I stand in front of the sink of a public toilet that stinks | 95 | OCD | Dirty | In front of the sink |
| I wash my hands in a dirty public toilet without touching the faucet, soap or hand dryer. | 95 | OCD | Dirty/Easy | Washing hands |
| I’m standing outside a dirty public toilet, I open the door, I stand in front of the cubicle, I open the door, I standing front of the toilet, I lower the lid, I sit down, I grab paper, I stand up, I flush the toilet, I stand in front of the sink and I wash my hands without touching the faucet, soap and hand dryer. | 95 | OCD | Dirty/Easy | Complete |
SESSION 8
- Revision of the past session’s achievements and establishing of objectives of the actual session: Complete sequence, dirty environment and difficult level.
- We begin with gradual exposure and systematic response prevention with virtual reality. Cognitive restructuring, if necessary.
- The reports should be shown to the patient so they can see their clinical progresses.
Homework
- Live exposure by entering both dirty and clean public toilets, enter the toilet cubicle and sit on the toilet, use the sink in a non-compulsive way. relaxation exercises if necessary.
Recommended protocol for the eighth session:
| Item | USA’s | Environment | Settings | Event |
| I use the sink in a dirty public toilet, touching the faucet, soap and hand dryer | 95 | OCD | Dirty/Difficult | Washing hands |
| Sitting on a dirty public toilet, I grab paper, I stand up, flush the toilet, I stand in front of the sink, and I wash my hands without touching the faucet, soap or hand dryer | 95 | OCD | Dirty/Easy | From sitting down until washing hands |
| Sitting on a dirty public toilet, I grab paper, I stand up, flush the toilet, I stand in front of the sink, and I wash my hands touching the faucet, soap and hand dryer | 100 | OCD | Dirty/Difficult | From sitting down until washing hands |
| I find myself outside a dirty public toilet, I open the door, I stand in front of the cubicle, I open the door, I stand in front of the toilet, I sit on the toilet, I grab paper, I flush the toilet, I stand in front of the sink and i wash my hands touching faucet, soap and hand dryer. | 100 | OCD | Dirty/Difficult | Complete |
4. Use recommendations
To favor a better immersion, the therapist can contribute adding comments.
For example:
- “The patient is going to enter the cubicle of a public toilet. Many other people have already entered it and touched the walls.”
- “The patient will touch the toilet brush, water could’ve splashed on the brush stick”
- “The patient will sit on the toilet; many people have been sitting there previously.”
- “The patient will flush the toilet. Many people have been touching that without washing their hands.”
- “He/she finds himself in front of the sink with dirty hands after touching the objects inside the cubicle.”
- “Feels the need of doing compulsions while washing hands.”
- “He/she will use the sink for 10 seconds and that will be enough to clean them.”
5. Recommended bibliography
American Psychiatric Association. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Arlington, VA: American Psychiatric Association, 2007.
Kim, K., Kim, Ch. H., Kim, S. Y., Roh, D., Kim., S. I. (2009). Virtual Reality for Obsessive-Compulsive Disorder: Past and the Future. Official Journal of Korean Neuropsychiatric Association, 6, 115-121
Ortiz, J. F. (2002). Trastorno obsesivo-compulsivo (TOC). Acta Neurol Colomb, 18 (1), 51-65.
Reid, J.M., Storch, E.A. & Murphy, T.K. (2011). Clinical Correlates and Treatment Response of the Yale-Brown Obsessive Compulsive Scale Auxiliary Items. Cognitive Therapy and Research, 35, 404-413
Bejerot, S., Edman, G., Anckarsäter, H., Berglund, G., Gillberg, C. et al. (2014). The Brief Obsessive-Compulsive Scale (BOCS): a self-report scale for OCD and obsessive-compulsive related disorders. Nordic Journal of Psychiatry, 68(8), 549-559. http://dx.doi.org/10.3109/08039488.2014.884631
Freeman, J., Flessner, Ch. A,. y Garcia, A. (2011). The Children’s YaleBrown Obsessive Compulsive Scale: Reliability and Validity for Use Among 5 to 8 Year Olds with Obsessive- Compulsive Disorder. J Abnorm Child Psychol, 39, 877-883.
Steketee, G., Chambless, D. L., Tran, G. Q., Worden, H., y Gillis. M. M. (1996). Behavioral Avoidance Test for Obsessive Compulsive Disorder. Behaviour Research and Therapy, 34 (1), 73-83. http://dx.doi.org.sire.ub.edu/10.1016/0005-7967(95)00040-5
Sánchez, J., López, J. A., López, J. A., Marín, F., Rosa, A. I., y Gómez. A. (2011). The Maudsley Obsessive-Compulsive Inventory: A reliability generalization meta-analysis. International Journal of Clinical and Health Psychology ,11(3), 473-493.
Bamber, D., Tamplin, A., Park, R. J., Kyte, Z. A., Goodyer, I. M. (2002). Development of a Short Leyton Obsessional Inventory for Children and Adolescents. Journal of the American Academy of Child & Adolescent Psychiatry 41 (10), 1246-1252. http://dx.doi.org.sire.ub.edu/10.1097/00004583-200210000-00015
Obsessive-compulsive disorders; research conducted at mental health institute has provided new information about obsessivecompulsive disorders. (2014). Mental Health Weekly Digest, , 31. Retrieved from https://search-proquest-com.sire.ub.edu/ docview/1516545423?accountid=15293
Gorrindo, T., y Parekh, R. (2015). What Is Obsessive-Compulsive Disorder?. American Psychiatric Association. https://www.psychiatry.org/patients-families/ocd/what-is-obsessivecompulsive-disorder
6. Annexe
6.1 Hierarchy for OCD
| Item | Discomfort level (0-100) |
| Being in front of a clean public toilet’s door. | |
| I stand in front of a toilet cubicle door of a clean public toilet. | |
| Enter the cubicle and stare at the toilet. | |
| Standing in front of a clean public toilet, I touch the wall with my left hand. | |
| I’m inside a clean public toilet cubicle, I grab paper and I throw it in the trash. | |
| I touch the brush of a clean public toilet. | |
| I lower the lid of a clean public toilet. | |
| I sit on a clean public toilet. | |
| Sitting on a clean public toilet, I touch the wall with my left hand. | |
| I flush the toilet after having used a clean public toilet. | |
| I stand in front of a sink in a clean public toilet. | |
| I wash my hands in a clean public toilet after using the toilet, without touching the faucet, soap and hand dryer. | |
| I wash my hands in a clean public toilet after using the toilet, without touching the faucet, soap and hand dryer. | |
| I’m outside a clean public toilet, I open the door, I stand in front of the toilet cubicle, I open the door, I stand in front of the cubicle, I lower the lid and I sit on it. | |
| I’m sitting on a clean public toilet, I grab paper, I stand up, I flush the toilet, I stand in front of the sink, I wash my hands without touching the faucet, the soap or the hand dryer. | |
| I’m sitting on a clean public toilet, I grab paper, I stand up, I flush the toilet, I stand in front of the sink, I wash my hands touching the faucet, the soap or the hand dryer | |
| I’m outside a clean public toilet, I open the door, I stand in front of the cubicle, I open the door, I stand in front of the toilet, I lower the lid, I sit on the toilet, I grab paper, I flush the toilet, I stand in front of the sink, I wash my hands without touching the faucet, soap or hand dryer. | |
| I’m outside a clean public toilet, I open the door, I stand in front of the cubicle, I open the door, I stand in front of the toilet, I lower the lid, I sit on the toilet, I grab paper, I flush the toilet, I stand in front of the sink, I wash my hands touching the faucet, soap or hand dryer. | |
| Being in front of a dirty public toilet’s door. | |
| I enter a public toilet that stinks and has paper all over the floor and I stand in front of the toilet cubicle. | |
| I enter a cubicle in a smelly and dirty public toilet and the toilet has urine drops. | |
| I touch the walls of a cubicle in a smelly and dirty public toilet. | |
| I touch the brush inside the cubicle of a dirty public toilet. | |
| I grab paper inside the cubicle of a dirty public toilet and I throw it in the trash. | |
| I lower the lid of a dirty public toilet. | |
| Sitting on a dirty public toilet | |
| Touching the wall of the cubicle with my left hand sitting on a dirty public toilet | |
| I flush a dirty public toilet after using it and at the same time it smells bad. | |
| I stand in front of the sink of a dirty and smelly public toilet. | |
| I wash my hands in a dirty public toilet, without touching the faucet, soap or hand dryer, but they’re next to me. | |
| I use the sink of a dirty public toilet after using the toilet, touching the faucet, soap and hand dryer. | |
| I’m outside a dirty public toilet, I open the door, I stand in front of the toilet cubicle, I open the door, I stand in front of the cubicle, I lower the lid and I sit on it. | |
| I’m sitting on a dirty public toilet, I grab paper, I stand up, I flush the toilet, I stand in front of the sink, I wash my hands without touching the faucet, the soap or the hand dryer. | |
| I’m sitting on a dirty public toilet, I grab paper, I stand up, I flush the toilet, I stand in front of the sink, I wash my hands touching the faucet, the soap or the hand dryer. | |
| I’m outside a clean public toilet, I open the door, I stand in front of the cubicle, I open the door, I stand in front of the toilet, I lower the lid, I sit on the toilet, I grab paper, I flush the toilet, I stand in front of the sink, I wash my hands without touching the faucet, soap or hand dryer. | |
| I’m outside a dirty public toilet, I open the door, I stand in front of the cubicle, I open the door, I stand in front of the toilet, I lower the lid, I sit on the toilet, I grab paper, I flush the toilet, I stand in front of the sink, I wash my hands touching the faucet, soap or hand dryer. | |
| What discomfort level does it produce you, at the present moment, to be in a public toilet? (doesn’t belong to the hierarchy) | |
| Other situations: |