Category: Uncategorized

Stress & trauma,
and virtual reality

Trauma and Stress-related disorders include disorders in which exposure to a traumatic or stressful event is listed explicitly as a diagnostic criterion. These include reactive attachment disorder, disinhibited social engagement disorder, posttraumatic stress disor­der (PTSD), acute stress disorder, and adjustment disorders (APA, 1994). 

Posttraumatic stress disorder (PTSD) is a psychiatric disorder that can occur in people who have experienced or witnessed a traumatic event such as a natural disaster, a serious accident, a terrorist act, war/combat, rape or other violent personal assault. People with PTSD have intense, disturbing thoughts and feelings related to their experience that last long after the traumatic event has ended. They may relive the event through flashbacks or nightmares; they may feel sadness, fear or anger; and they may feel detached or estranged from other people. People with PTSD may avoid situations or people that remind them of the traumatic event, and they may have strong negative reactions to something as ordinary as a loud noise or an accidental touch. A diagnosis of PTSD requires exposure to an upsetting traumatic event. However, exposure could be indirect rather than first hand. For example, PTSD could occur in an individual learning about the violent death of a close family. It can also occur as a result of repeated exposure to horrible details of trauma such as police officers exposed to details of child abuse cases (adapted from: https://www.psychiatry.org/patients-families/ptsd/what-is-ptsd). 

A World Health Organization study found a lifetime prevalence of PTSD in upper-middle income and lower-middle income countries of 2.3 and 2.1 percent respectively (Koenen KC et al., 2017 ). 

Virtual Reality (VR) was proposed over two decades ago (Rothbaum et al., 1995) as a potentially useful tool to assist in the activation of the fear structure given its ability to present customizable visual, auditory, tactile, or olfactory stimuli. VR-based improvements to emotional engagement could overcome barriers in activation of the fear structure, such as avoidance (Foa, Huppert, & Cahill, 2006) and improved clinical outcomes. Studies of VR exposure (VRE) therapy for PTSD have repeatedly demonstrated reductions in PTSD symptoms following treatment (Difede et al., 2007, 2014; Reger et al., 2011; Rizzo, Difede, Rothbaum, & Reger, 2010; Rothbaum, Hodges, Ready, Graap, & Alarcon, 2001; Rothbaum et al., 2014).

This manual describes different Psious tools designed  to help healthcare professionals on assessment and treatment in general and work related-stress and post-traumatic stress disorder. 

Appendix

Conversations: Patient response options and companion avatar dialogs.

https://docs.google.com/spreadsheets/d/1WuBHNleWMoBvJfSnH-WlrqRogyA-U8O07cSD7fPq6B0/edit#gid=0

Dialog reference:

https://docs.google.com/spreadsheets/d/1WuBHNleWqMoBvJf0SDU8O07cSD7fPq6B2 # gid = 0 Please

Note the following for dialogue references:

• The color red represents the accompanying phrases.
• The blue color represents the phrases that the user can say.

Communication styles to decline consumption: Options that the patient can choose from

https://docs.google.com/spreadsheets/d/1WuBHNleWMoBvJfSnH-WlrqRogyA-U8O07cSD7fPq6B0/edit#gid=1565071000

AGGRESSIVE	PASSIVE	ASSERTIVE
No! (Dry)	No, no thanks	No, thanks, it doesn’t make me
Ostia, how do you want me to say no?	No, I do not want to.	Please do not insist, I’m leaving it.
It’s okay, you don’t find out about anything, right?	Well, no, I shouldn’t.	Sorry, I don’t do it anymore.
Leave me already, heavy!	Hmm, I don’t know … well, better not,	I’m sorry. I want to be sober.
Read my lips, no.	Do you want to? I should not?	Sorry, but you know that no, I no longer drink.
Leave me! Don’t offer me again!	Better than not.	Very kind, but no thanks. I have things to do.do
In’t want to get involved. I’ve already told you!	I shouldn’t, it doesn’t suit me	Thank you, you know I’ve left it, don’t ask any more.
What do you think of a no?	Thanks but I’m fine.	No, thank you very much, I don’t want to go back to it.
No, not now, not ever.	I don’t know, I shouldn’t, you know it doesn’t suit me, better No.	You already know it doesn’t, right? Please don’t insist
Not at all	Better than not	I do not want anything, thank you

ASSERTIVE Striped Disc	ASSERTIVE Fog bank	ASSERTIVE For you, for me	ASSERTIVE Sandwich	ASSERTIVE Postponement	ASSERTIVE Agreement	ASSERTIVE Possitive
Do not want any thanks forinterest, but do not want anything.	It’s okay, thanks for your interest! I just don’t want to.	For you it may be cool, but for me it is not, it gives me problems	Thank you for asking, but I don’t want to, if you want to go ahead	I think now is not the time to talk about whether or not I have problems. We will discuss it at another time.	Well, I don’t know if many people do it, nor do I think I’m better, do you want to talk about that? I don’t feel like it.	I don’t want to, thank you
No thanks, I don’t want to, please don’t insist on me, I don’t want to	Yes, I may be a little sad and that would make me happy. But I don’t want to thank you.	Maybe something’s wrong with you. For me it’s just that I don’t want to cheer up like that.	I’m sorry to upset you, but I don’t want anything, excuse me.	It’s true I think I’m not well. Shall we save it for another time, please?		Thanks, no problem
	You may be right, but I don’t feel like it	For you it may be an edge, I prefer not to push my luck, that’s how I’m fine	Yes, I know a lot of people do it, but I don’t want to thank you, yes to you Do you feel like it, no problem?			Okay, thank you
	Yes, things are not going the way I would like, thanks for your interest, but I don’t want anything, I’m better that way.					Sounds good to me, thank you.
	No, everything is fine, thank you. You are very kind but I don’t want anything.					Ok, ok.
	You may be right and sometimes I behave selfishly. But I don’t want to thank you.
	The truth is, I’m not in the mood. Please do not insist, I am leaving
	It is possible that everyone will take them, but I do not want to
	It may be a very good plan but I do not feel like it, but I appreciate it

[ DISCLAIMER: This document has been automatically translated using Google Translate. ]

Download appendix

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[ DISCLAIMER: This document has been automatically translated using Google Translate. ]

Recommendations for use

It is always interesting and positive to try to complement the Virtual Reality experience with comments, questions or indications to make it easier for the patient to get into the situation and feel a greater immersion in the environment. 

Some examples could be: “Imagine that these are your friends, with whom you usually consume or have used in the past”… “How do you feel when you see them?” “What do you think they think of you?” “Which one do you feel most uncomfortable with and why?” “Which one generates more impulse of consumption?” “Which one do you trust or give you more security?” “Do they make you nervous?” etc.

At the same time, it is highly recommended to try to keep the patient in the same body position as the protagonist of the scene (in this case, sitting at the classroom desk).

In the same way, it can be useful to add any element of the scene or the context where the events take place. In this case, preparing some air freshener, incense…, with a smell similar to the substance (tobacco, cannabis, beer…), having a bottle and / or a can that the patient can touch…, can help make the immersion more effective and provide the patient with the sensations and emotions of the environment. In these environments, the use of tactile, olfactory and gustatory stimulation complementary to virtual reality will be of special importance.

It is also recommended that during the conversations between patient and avatars within the virtual environment, the patient says aloud the answer he is selecting to communicate with the avatar with whom he is interacting.

Finally, remember that in Psious you have a wide variety of environments with which you can complement the work in relation to substance-related disorder. We present some examples below:

Therapeutic area	Environments	Scene	Therapeutic objective
Social Anxiety	Group in the Bar	Bar	Evaluation and management of Craving (alcohol, tobacco and cannabis)General EEHHSS
Fear of the dark	Fear of the dark	House alone	Evaluation and management of Craving ( alcohol, tobacco and cannabis)
Fear of driving	City	Driving at night in the city
Fear of flying	Boarding gate	Before boarding
Airplane	Flight
Anxiety about exams	Institute	Before entering the exam and After the exam
University
Fear of speaking in public	All	Before and after of the execution of the speech
Relaxation	Diaphragmatic breathing	Under the sea or Grassland	Management of physiological activation
Jacobson relaxation Jacobson	relaxation
Mindfulness	Conscious walk	All	Attention management
Spring-Summer	All	Management of attention and thoughts
Psychoeducation	Anxiety	All	Conceptualization of emotional responses
Stress	All	Conceptualization of stress response

[ DISCLAIMER: This document has been automatically translated using Google Translate. ]

Intervention proposal

“All the information contained in this section is for guidance only. Psious environments are therapy supporting tools that must be used by the healthcare professional within an evaluation and intervention process designed according to the characteristics and needs of the user.

Also remember that you have the General Clinical Guide in which you have more information on how to adapt psychological intervention techniques (exposure, systematic desensitization, cognitive restructuring, chip economy…) to Psious environments.”

Objectives of the environment Bar Terrace

Bar Terrace focuses on the work of craving alcohol, tobacco and cannabis. The main intervention objectives of this environment will be twofold. The first of them, framed in the mode of passive exposure, is the extinction of the consumption impulse associated with the conditioned stimuli, key or signals related to the substance. The second, within the active strategies, is training in social skills in general and in negative and positive assertiveness, in particular. These therapeutic objectives will mainly be carried out in two moments of the intervention, related to the state of change (Prochaska JO and Prochaska JM, 1993). On the one hand, when the patient is in the action stage, the can be worked on management of craving, and on the other hand, when the user is already in the maintenance phase, it can be used to prevent relapse (Sánchez-Hervás et al. 2004).

1. Training in the management of craving through the Bar Terrace environment

Regarding psychological strategies, the Bar Terrace environment allows to work on Signal Exposure Therapy (Cue Exposure Therapy, CET) and Systematic Desensitization (SD) through virtual reality. Likewise, the environment is designed for Social Skills Training (SST), especially to practice negative assertiveness (refusal of consumption) and positive assertiveness.

The first two techniques, CET and SD, favor the extinction of the relationship between conditional stimuli, signals or cues (for example being in a bar, getting bored, looking at cigarette papers…) and the conditioned response (physiological, cognitive and / or or motor related to the consumption of the substance). Remember that both CET andSD are only two of the multiple strategies (pharmacological, psychological and psychosocial) that can be used in the management of craving (see Castillo, II, and Bilbao, NC, 2008, Hone-Blanchet, A., 2014 ). The SST, for its part, will be essential in managing risk situations, especially those in social interaction. 

The environment allows the three techniques, CET, SD and SST, in an ecological situation and with different degrees of difficulty: combining configuration variables (paraphernalia, substance) and events (emotional craving, short / long conversation).

2. Extinction of conditioned responses through the Bar Terrace environment The

The goal of TSC is to decrease the conditioned relationship between a substance-related signal and the physiological response by systematically matching them in a treatment environment. The constant combination of a conditioned stimulus with a conditioned response in the absence of the substance reduces the physiological reactivity to the signal. With this process, an extinction of the signal-response association will be favored and, therefore, the reactivity to signals, keys related to the substance and that are responsible for craving, will decrease (Hone-Blanchet, A., 2014). In the case of SD, termination will occur through the counter-conditioning procedure. In this case, it will associate a deactivation response to the signals or keys, thus achieving the extinction of stimuli and conditioned responses. Remember, that in case of applying the extinction procedure using SD, you can use the progressive muscle relaxation and diaphragmatic breathing environments to train the patient and to apply the technique during the procedure itself.

The mode of exposure (live, in imagination, photographs, videos, virtual reality, etc.) largely determines the ability of stimuli to produce desire for consumption and for habituation or extinction responses to generalize outside of the therapeutic context . A recent field of research is interested in the development of new exposure procedures using advanced technologies such as virtual reality. The main advantage of this over other presentation methods is that the subjects do not have the sensation of being external observers, but rather of being part of the surroundings, thus increasing the sensation of realism. Despite being a relatively recent field of study, the research published to date has provided reasonably positive expectations about the usefulness of this tool for improving key exposure techniques (Kuntze et al., 2001; Saladin et al. ., 2006; Bordnick et al., 2009; Ferrer-García et al., 2010).

The following is a proposed procedure for the CET (Vallejo, MA and Comeche, MI, 2016) :

1. Individual selection of the keys to which each subject will be exposed based on their consumption history and / or preferences.

2. Elaboration of an exposure hierarchy starting with the stimuli or situations that produce less desire and following in ascending order.

3. Selection of the type of response that will be taken into account to evaluate reactivity. In general, the patient’s subjective desire for consumption or craving is used. For example, using a Visual Analogue Scale (EVA or Visual Analogue Scale)

4. Selection of the extinction criterion based on the baseline measurement and the reactivity that the keys produce, for example, changes in the conductance measurement of the skin, basal level of desire to consume before the stimulus.

5. Exposure to the items of the hierarchy with the corresponding procedure (live, photographs, videos, virtual reality, etc.).

6. The exposure can be totally passive, in which they only seek habituation responses, or active, where the exposure is accompanied by previously trained coping strategies, for example, training in social skills to reject consumption.

7. During the exposure, it is necessary to guarantee that the patient does not have escape behaviors, fundamentally, of inattention to the stimulus.

8. Homework is used in which a live exposure is scheduled with response prevention.

3. Training in Social Skills (SST) with the Bar Terrace  environment The Bar Terrace

environment has the substance configuration variable (alcohol, tobacco or cannabis) and the conversation event (short or long) to favor the SST, especially in relation to refusal assertiveness:consumer rejection. 

The intervention dynamics will allow us to configure one of the Substances (alcohol, tobacco or cannabis) and graduate the level of difficulty by selecting the level of Paraphernalia (low / medium / high) before launching the scene. Once the scene is configured and activated, the start of the Talk event will determine the therapeutic goal. The selection of the Short Conversation will allow us to evaluate the communicative style of the patient (aggressive, passive, assertive) and / or to intervene in the training for the use of more assertive responses. It should be noted that, in all cases, the response that the patient can give to the offer of consumption is negative and what the patient can select only refers to the communicative style. The response options for the patient are very varied, both in verbal, non-verbal and paraverbal content and will alternate to avoid a learning effect.  

In the case of the Long Conversation, the therapeutic objective will be training in negative assertiveness and emotional management. The accompanying avatar will insist repeatedly to incite consumption, using both insistence and even personal “attack” on the patient, to convince him to accompany him in the consumption of the substance selected in the initial configuration. The patient will be able to choose response options, again assertive, passive or aggressive. A decision algorithm will reward, making the conversation shorter and more pleasant, or it will punish, making the conversation more insistent and tense, according to the patient’s selection criteria: If you choose assertive options, the accompanying avatar will insist less, give more support and understanding. If the patient chooses passive or aggressive options, the accompanying avatar will be more insistent and unpleasant. For more detail of the algorithm, the review of the section:is recommended Events-Long-Conversation. 

Each of the response options that the patient can choose represents a negative assertive strategy: Say no (“No, thanks”, “Very good, but I don’t want to…”), Scratched record (“Sorry, I’m not interested…” , “I’m sorry, I’m not interested…”), For you, for me (“Maybe something’s wrong with you. For me, it’s just that I don’t want to cheer up like that”), Fog bank (“It may be that you right, but I’d rather not ”)…, In appendix 6.2 you will find a description of the options available to the patient, classified according to the type of negative assertiveness used.

4. Relapse prevention

One of the times in which the management of craving in a substance-related disorder is of special relevance is during the maintenance of abstinence. The prevention of relapses is one of the aspects of vital importance in the work of this psychopathology. Following the guidelines of the relapse prevention strategies of Witkiewitz and Marlatt (2007), we present a proposal adapted for the Bar Terrace environment:

Relapse prevention strategies	Therapeutic objective	Configuration / Events
Psychoeducation: teaching about relapse concepts / fall, identification of early warning signs, general intervention treatment plan.
Enumeration of high-risk situations and strategies for managing them.  The therapist should show models to do this during the session (role play).	Use the environment to obtain ecological information, in situ / virtuous, on the level of craving generated by certain Signals / Keys. It accompanies VR without and with tactile stimuli (a bottle, cigarette paper…) and olfactory (a candle, incense…) related to substances to graduate the intensity of the impulse to consume. Before performing the intervention by VR, it is advisable to explain the basic concepts of Craving and SST to the patient. Likewise, it will be important to offer examples and models of the different communication styles (passive-assertive-aggressive).	Graduate the presentation of the scenes from least to greatest number of paraphernalia and with the absence or presence of emotional craving.
Acquisition of cognitive skills: it is important to set limits in interpersonal relationships.  Patients must also acquire the skill of negative assertion communication.	During the intervention process in SST it is recommended to follow the process:  a) Establishment of objectives (eg evaluation of communication style, training in saying no…) b) Modeling (eg assertive style, aggressive style, passive style or negative assertiveness) c ) Live behavior rehearsal (eg, substance rejection role playing) d) Feedback on the behavior rehearsal e) Repetition of role playing if relevant. f) Introduction of the virtual scene and virtual conduct rehearsal g) Feedback on the virtual conduct rehearsal h) Repetition of the virtual scene if applicable i) Establishment of objectives and homework.	Use the substance configuration variable to work with a specific Signal (alcohol, tobacco, or cannabis). You can also modulate the difficulty using the different levels of the Paraphernalia configuration variable.The Conversation Event: short / long will allow you to focus more on the detection of the communicative style or on the SST: negative assertiveness / rejection of consumption.
Realize the emotions themselves and management of the reactions resulting from them.	The emotional responses as modulators of both craving and the correct use of SST will be a relevant objective in relapse prevention.	The Emotional Craving event is specially designed for the work of identification and emotional management of craving.
Understand the desire to consume: deal with craving and exercise to regain control.	Craving management will be important both in the cessation process and in the maintenance and prevention of relapses.  La Terraza makes it possible to evaluate craving and social skills at different moments of the therapeutic process. The environment will also help you to intervene to extinguish signals related to craving and increase the SST to reject consumption, favoring in both cases a better management of the consumption impulse.	The configuration variables, especially Paraphernalia and substance, will allow you to adjust the scene to the needs of your patient and the therapeutic moment.
Learning of cognitive distortions and setbacks: helping the patient to modify cognitive perspectives to prevent relapse.	La Terraza will help to evaluate and intervene in cognitive processes, perception, attention (heat maps), thoughts (cognitive evaluation during execution of the virtual scene) and memory (extinction of conditioned stimuli). All this aimed at increasing the resources of your patient in the management of Craving. Ask your patient what they are thinking during the scene (via viewer communication) after launching a specific event. Get information about what they are thinking when they see a specific Sign in the scene or for example what they are thinking after rejecting a consumer offer.	Use the different possibilities of the environment, configuration variables (Paraphernalia, Substance…), events (Emotional Craving, Conversation…) and tools (timeline, galvanic response log, heat maps…) to
assess other comorbid conditions and situations specials. The health professional must consider the possible risks of the presence of dual pathologies and psychopathology.

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