In this environment, the patient will find himself in the middle of a relaxing meadow where he will be able to practice the body scan, one of the most important techniques in relaxation programs based on Mindfulness. It consists of mentally going through all the parts of one’s body so that a full consciousness develops. Through this exercise, the patient will notice the tensions and pains that are in their body so they can correct them.
This environment can also be used to perform a Relaxation by induction within the program of Jacobson’s progressive relaxation, with a mental path through the body, but with the difference that one does not practice the part of voluntary tension and relaxation of the muscles.
To start the exercise, the healthcare professional should select the Play button and an audio will be played with instructions on the parts of the body to focus attention on. In addition, the patient will be able to observe that both in the human figure and in his own avatar, a light will appear illuminating the part of the body to which attention is directed.
In this scenario, the patient finds themselves sitting inside an office. In front, they find different virtual characters sitting around a table. It is a virtual environment in which, depending on the needs of each patient, different types of situations can be represented: a job interview, a presentation in front of work colleagues, an oral exam, etc.
SETTINGS VARIABLES
Amount of people
None
Minimum (1 person)
Medium (3 people)
Maximum (6 people)
Difficulty.
Low (audience that listens attentively and with approval)
High (audience that is more distracted or disinterested)
EVENTS
Distraction. Choice of a series of distractions:, a Skype call coming through on the patient’s laptop, a mobile telephone ringing when it receives a message (short sound), one of the audience receiving a phone call (in this case one of the colleagues tells the patient not to pay attention to the telephone, as they know they are in a meeting), or someone interrupting the meeting.
Positive remark
Neutral remark
Negative remark
Therapeutic remark This event is useful for the healthcare professional to make a remark to the patient while they find themselves within the immersive environment, so as to avoid breaking the dynamics of the session.
This environment consists of a blood extraction located in a real scenario. Initially the patient will be in a waiting room and after a few seconds the nurse will call him to enter the room where the extraction will take place.
This environment can be very useful for the exploration of the patient’s current state and its anxiogenic configuration in the face of the feared situation. For example, by putting the patient in a situation, negative thoughts or physiological reactions can be analysed (if biofeedback equipment is available).
The patient is sitting inside the taxi and heading towards the airport terminal.
SETTINGS VARIABLES
Time Day / Night
Weather Clear/ Rainy
EVENTS
Radio News about the weather will be heard. During flight. The news varies according to the chosen climate.
Go to final The taxi ride does not have a specific duration, it is the healthcare professional who decides when to arrive. This allows the exposure to be adapted to the needs and pace that the patient needs.
This is a scenario aimed at the treatment of anticipatory anxiety, which is an essential component of flight phobia. In this scene, the patient is at home and is about to leave on a trip and must wait for the taxi that will take him to the airport.
SETTINGS VARIABLES
Time Day / Night
Weather Clear/ Rainy
EVENTS
TV weather report News about the weather forecast are shown on TV. The news vary according to the weather conditions previously selected.
TV crash report News about a plane accident are shown on TV.
Taxi arrives Upon enabling this setting, the taxi driver arrives to pick up the patient and make their way to the airport.
Thunders Activates the sound of thunder outside the house.
The highway virtual environment displays a three-lane road with straight sections and curves. In this environment, the healthcare professional can manipulate specific variables in order to design a personalized exposure hierarchy for each patient.
SETTINGS VARIABLES
Cars in road None / Full
Passengers None / Full
Patient position Driver / Passenger
Time Day / Night
Weather Clear/ Rainy
EVENTS
Turn left
Turn right
Accelerate To regulate the speed of the car. The speedometer will respond according to the selected speed changes. If the vehicle is travelling at the maximum speed (5/5) on the left lane and returns to the center lane, the speed will be reduced to 4 to avoid colliding with the vehicle ahead.
Distraction
Telephone: the driver receives a call.
Passenger: a passenger distracts the driver with his mobile.
Radio: the co-pilot plays loud music.
Type Road: Tunnel / Bridge / Highway (Please note that these are infinite stages, so the selected stage will go on until another option is selected.)
Curve Straight / Mixed / Curves
Accident Displays a broken car on the right side of the road.
Broken engine Causes the car to slow down and an error signal appears on the car’s controls.
This route reproduces a car journey through a city. Includes clinically relevant elements such as straight streets, corners, traffic signs, stop lights and cars moving through the streets.
SETTINGS VARIABLES
Number of cars Regulates if the car ride takes place with or without cars on the road. Choose among three traffic flow options: none, minimum, medium and maximum.
Number of passengers:
Minimum (only the driver)
Medium (driver and front passenger)
Maximum (with passengers in the back seat)
Seat It changes the avatar position (driver/passenger).
Time Day / Night
Weather Clear/ Rainy
EVENTS
Speed The speed can be increased and decreased with a slider control.
Circuit Choose between two different routes: Track 1 (less anxiogenic. With straight roads and few curves and intersections) and Track 2 (fewer straight distances, constantly turning corners, cars coming from both ways).
Horn Reproduces the sound of a horn.
Hard brake The driver suddenly hits the brakes.
Ambulance An ambulance with its siren turned on can be heard. The car stops at a traffic light and the ambulance crosses in front.
Enable traffic jam The driver is stuck in traffic.
This virtual reality (VR) environment aims to create an ideal environment to apply the exposure technique to cockroaches. In this environment, the patient is seated and can observe a terrarium on the table in front of him.
SETTINGS VARIABLES
Number of cockroaches Allows regulating the amount of cockroaches from a minimum to a maximum (6 cockroaches).
Zone of exposition You can choose if cockroaches are on the table or inside the terrarium.
Cockroach size Choose between three sizes: small, medium and large.
EVENTS
Cockroach noise A noise is heard and the cockroach will start moving from side to side.
Near distance Position the cockroaches at a close distance from the patient.
Medium distance Position the cockroaches at an average distance from the patient.
Far distance Position the cockroaches at a far distance from the patient.
Cockroach in hand When this event is activated, cockroaches will approach and begin to walk above the avatar’s hand.
Move finger The avatar starts to move a finger. This option aims to enhance the immersion of the patient through a rhythmic movement that you will have to perform at the same time, thus facilitating the identification of the hand you are seeing as your own.
This environment simulates a restaurant where the patient can eat various menu options (hypocaloric/diuretic/standard/hypercaloric), alone or accompanied, as required by the situation. The healthcare professional will select the menu option the patient should be eating. In this environment, we mainly intend to work the anxiety towards certain foods, awareness on how good eating habits can prevent a subsequent purge/compensation, and not isolation during meals.
Exposure Therapy To reduce the anxiety caused by certain “forbidden” foods (usually, hypercaloric foods).
Exposure with Response Prevention (EPR) To be exposed to certain stimuli (food), which usually precede binge eating and/or compensatory behaviors (e.g., purge) with the aim of preventing the occurrence of such behaviors. The procedure consists of exposing the patient to foods that usually act as a trigger for binge eating. When the patient feels that he/she has broken the diet and wishes to vomit, we will try for him/her to focus on what his/her feelings and what he/she thinks, with the aim of being able to analyze and restructure it together with the therapist during the session. The aim is for the subject to verify he/she can control himself/herself and notice how anxiety, guilt, etc., can be reduced without the need to compensate (e.g., vomiting). These exposures can also work as behavioral tests through which the patient can test whether or not his/her irrational fears regarding the consequences of not compensating are met (e.g., put on a lot of weight, fat accumulation on a certain part of his/her body at once, etc.) (Saldaña, Tomás & Bachs, 1997).
CONFIGURATION VARIABLES
Companion This variable will allow choosing whether the patient eats alone or accompanied and, in that case, whether the companion is male or female. This variable should be taken into account during the exposure based on whether the patient is more or less stressed when eating alone or with a companion, and whether he/she is worried when eating with a person of the same sex (e.g., because he/she tends to compare himself/herself with them) or of the opposite sex (e.g., for fear of feeling judged):
None: The patient appears eating alone, without any companion at his/her table and with no people on the tables surrounding him/her
Female: The patient eats while accompanied by another avatar (a woman). Also, there are people eating on the tables near them.
Male: The patient eats while accompanied by another avatar (a man). Also, there are people eating on the tables near them.
Conversation In the case of the “Accompanied” configuration, the healthcare professional may choose the kind of conversation the patient’s companion will provide during the experience. It is important to keep in mind that this conversation will not be activated if there is no food on the table. In fact, it will not consist of a conversation per se (there will be no exchange), but only the companion will issue sentences/comments. However, the idea is to simulate a real situation in which a conversation takes place during a meal. The subject of said conversation may be:
None: In this option, the companion will not make any comments and will remain silent.
Neutral: In this modality, the companion will issue phrases regarding a neutral subject, such as the movies (going to the movies, favorite movies, upcoming releases…).
Bad: In this case, the companion will issue phrases related to physical appearance, food, social events where eating while with a group of people is included, etc. That is, subjects that often cause anxiety (or discomfort) to this type of patients.
EVENTS
Choose menu In this events, will appear the following menu options for the patient to take:
Hypocaloric: Menu consisting of foods with a low fat content: Water + grilled chicken breast together with a salad + natural yogurt.
Diuretic: Menu consisting of foods that help the elimination of liquid (urine), often eaten by people who wish to lose weight: Green tea + salad (lettuce, beet, and carrot) + Fruit (kiwi).
Standard: A normal diet’s menu: Water + Steamed vegetables + Omelette with tomato slices + Natural yogurt.
Hypercaloric: Menu including foods with higher fat content: 1 soft drink (Coca-Cola) + Hamburger with French fries + Pie.
View menu The patient (and the companion, if also present) will have a menu in their hands with different menu options. However, the healthcare professional will be the one to choose the patient’s menu, by selecting the event described below.
The healthcare professional can make the avatar (patient) hold the menu in his/her hands for as long as he/she wants. When the healthcare professional wants the avatar to start eating, he/she must select the kind of menu to which he/she wishes to expose the patient from the “Menu” event.
Once the menu option is selected, the menu will automatically disappear and the first course of the chosen menu option will be displayed. Once the patient finishes the dish, the second course will appear (if there is one), and finally the dessert
Once the configuration/event variables have been selected and the patient has the corresponding course in front of him/her, he/she should pretend to eat the food by staring at the dish until the little circle that appears on the goggles is completed. Each time the patient stares at the dish, the avatar will ingest a portion of the food, until the food is finished (approximately, 7-10 bites). However, if the patient takes too long to perform this action, the system will automatically simulate a mouthful intake after approximately 30 seconds. The drinking action can also be activated by looking at the glass with the goggles. When finishing each course, the avatar will leave the cutlery on the plate. When the full menu is finished, the scene will return to its initial state, and the option to choose another menu will be available
In order for the healthcare professional to receive a more accurate feedback of the patient’s behavior during the experience, some signs will appear on the platform viewer notifying him/her of each time the patient ingests a portion of food, whether the patient has decided to eat it voluntarily, or if the system has automatically simulated the intake after 30 seconds, etc. The different signs (feedbacks) that will appear will be the following ones:
Initial state: Informs that the avatar is at the table, without the menu or the food, still in “standby mode”
Showing menu: Informs that the avatar (patient) is looking at the menu
Changing menu: A brief fade to black will be shown on the goggles at that moment, and immediately after it, the menu selected by the therapist will appear.
Menu [kind of menu] – [course]: Signals the kind of menu and the specific course the avatar (patient) is eating. Example, “Hypercaloric menu-Hamburger”
Eating portion [number] of [number], voluntarily: Informs that the patient is currently taking a bite and what bite number it is (for example, 3 of 8 would inform the patient is eating the third bite of a total of 8 bites in which the course can be eaten), and also that he/she has voluntarily decided to eat it (it has been the patient who, using the goggles, has deliberately selected the action of eating that bite).
Eating portion [number] of [number], automatically: Informs that the patient is currently taking a bite and what bite number it is (for example, 3 of 8 would inform the patient is eating the third bite of a total of 8 bites in which the course can be eaten), but that the bite has not been voluntary (i.e., that 30 seconds have passed without the patient deciding to take a bite, and the system has performed the action automatically).
Menu [kind of menu] – Drinking: Informs that the patient has directed the goggles towards the drink to take a sip at that moment.
Finished course: Informs that the patient has finished the dish he/she was eating at that time.
Changing course: When the patient has finished a dish, a brief fade to black is shown on the goggles, and the next course of the menu will appear immediately afterwards.
Menu [kind of menu] – Completed: Informs the patient has just finished eating the full menu (after eating the dessert). Example, “Hypercaloric menu – Completed”.
If the healthcare professional wants to expose the patient to the plate but not to eat it (that is, to watch the plate), it is sufficient for the patient to place the pointer of the viewer outside the plate (e.g. on the table) and, keeping your head in that position, lower your gaze to the plate (only with your eyes, otherwise you would place the pointer again on top of the food and the intake would begin).
REFERENCES
Saldaña, C., Bach, L., & Tomás, I. (1997). Técnicas de intervención en los trastornos del comportamiento alimentario – Dialnet. Aniedad y Estrés, 3(2–3), 319–337.