Self-recording of relaxation and subjective evaluation
Scenes audio
1. Generalized Anxiety Disorder and Virtual Reality
The main objective in the treatment of generalized anxiety disorder (GAD) is to get the complete and prolonged remission of symptoms, as well as the restoration of the operational level of presymptomatic (Dilbaz, Cavus Y Darcin, 2011). However, not all patient respond well to treatment of choice: Cognitive Behavioural Therapy. Which can be combined with training on relaxation techniques and/or pharmacological treatment.
Research conducted about this topic shows that treatment with virtual reality (VR) is a good alternative for people with GAD (Gorini & Riva, 2008). Mainly because it eases the learning process as well as the creation of a relaxing mood. particularly complicated in people with chronically raised voltage as in the case of this disorder.
Moreover, Psious virtual environments specially designed for the treatment of GAD, are very useful as the therapist can carry out exposure to the patient’s worrying in two different environments: a house and subway
2. Psious – based treatment protocol
Protocol
In the following lines, a treatment protocol using Psious virtual environments is offered as an example.
However, it is noteworthy that this tool should accommodate the cognitive behavioural therapeutic framework used by the therapist, and combining it with techniques such as cognitive restructuring, training in problem solving and worry exposure. It must adapt to the needs and particularities of the patient.
On the other hand, for training in relaxation techniques, Psious has specific environments that will facilitate their learning.
The suggested protocol is an adaptation of the intervention protocol of Brown, O’Leary and Barlow (2001) for GAD.
Our proposal has a total of ten sessions instead of the 13 of the original, as VR facilitates the therapeutic process compared to the imagination (Both in the exposure and learning relaxation techniques), so the treatment’s duration is reduced.
Treatment session description
SESSION 1 PSYCHOEDUCATION
Information relating to GAD is given ( origin, maintenance and demonstration in the triple system: cognitive, physiological and conductual).
The role and origin of anxiety and worries are explained.
General information about treatment (for example importance of self-Assessment and homework).
Treatment techniques to be used are explained (emphasizing exposure by Virtual Reality).
Homework:
Self-Assessment daily levels of worrying and mood through self-reports provided ( see Annexes 5.1.)
SESSION 2 INTRODUCTION TO RELAXATION
Discuss self-reports with the patient, as well as what was commented about anxiety on the first session.
Physiological aspect of anxiety and GAD’s maintenance factors are explained..
Familiarization with Psious platform
Homework:
Self-Assessment daily levels of worrying and mood through self-reports provided (Annexes 5.1.)
SESSION 3 RELAXATION
Discuss self-reports with the patient, possible questions are resolved.
The patient learns and practises two types of relaxation techniques: diaphragmatic breathing and progressive muscle relaxation. (to do this, specific relaxation environments can be used for the training with the available audio).
Homework:
Daily practise of relaxation techniques and self-reports (Annexes 5.1 and 5.4)
SESSION 4 INTRODUCTION TO THE COGNITION’S ROLE
Discuss self-reports with the patient, possible questions are resolved.
Introduction to cognition’s role in persistent anxiety (for example, automatic thoughts) and cognitive distortions.
Explain how to use cognitive self- assessment form (annexes 5.2)
It starts to work on automatic thoughts using VR set in the home environment and go writing down these thoughts,
Practise of relaxation techniques in relaxation environment with the available audio.
Homework:
Daily practise of relaxation techniques and self-reports (Annexes 5.1, 5.2. and 5.4)
SESSION 5 EXPLORATION OF THE COGNITIVE DISTORTIONS
Discuss self-reports with the patient, possible questions are resolved.
Cognitive distortions in GAD are discussed and strategies to counter them are offered (alternative thinkings)
Overestimation of probabilities is explained.
Explain what catastrophizing is.
Exposure to house scene playing the indicated debate on TV ( depending on the characteristics of the patient)
During the exposure, the patient must verbalize his or her thoughts aloud, so it would be possible to explore these distortions.
Practise relaxation techniques in relaxation environment with the available audio
Homework:
Daily practise of relaxation techniques and self-reports (Annexes 5.1, 5.2. and 5.4)
SESSION 6 INTRODUCTION TO WORRY EXPOSURE
Discuss self-reports with the patient, possible questions are resolved.
It is explained what it is worry exposure and a hierarchy of exposure is done.
Gradual and systematic worry exposure begins on the virtual environments. Throughout all sessions of exposure, Virtual Reality is combined with techniques such as diaphragmatic breathing and progressive muscle relaxation when the therapist deems it necessary.
Practise relaxation techniques in relaxation environment with the available audio
Homework:
Daily practise of relaxation techniques, self-reports and daily worry exposure (Annexes 5.1, 5.2, 5.3 and 5.4)
SESSION 7 VR EXPOSURE
Discuss self-reports with the patient, possible questions are resolved.
Worry exposure on the house environments playing the audio
Practise relaxation techniques in relaxation environment with no audio
Homework:
Daily practise of relaxation techniques, self-reports and daily worry exposure (Annexes 5.1, 5.2, 5. 3 and 5.4)
SESSION 8 RELAXATION AND WORRYING PREVENTION
Discuss self-reports with the patient, possible questions are resolved.
It is explained what it is the prevention to worrying conducts. A list of worries with strategies to prevent them is elaborated.
Exposure to the VR environment of the house or the subway. The patient must propose strategies to prevent the worries in situ.
Practise relaxation techniques in relaxation environment with no audio.
Homework:
Daily practise of relaxation techniques, self – reports and daily worry exposure ( Annexes 5.1, 5.2, 5.3 and 5.4) and the prevention of worrying conducts must be applied.
SESSION 9 TIME MANAGEMENT AND PROBLEM SOLVING
Discuss self-reports with the patient, possible questions are resolved.
Time management and problem solving are discussed.
Exposure to the subway virtual environment to implement what has been said in the previous point.
Practise relaxation techniques in the same exposure environment.
Homework:
Daily practise of relaxation techniques, self – reports and daily worry exposure ( Annexes 5.1, 5.2, 5.3 and 5.4) and the prevention of worrying conducts must be applied.
SESSION 10 REVISION OF SKILLS AND TECHNIQUES
Discuss last session and self-reports with the patient, possible questions are resolved.
Skills and learned techniques during the treatment are discussed.
The therapeutic process is evaluated. Future tasks of self-exposure and reinforcement sessions are scheduled.
3. Use recommendations
Use recommendations
n these environments, with the aim of enhancing the effectiveness of the VR, the therapist plays a very important role with regard to the patient’s suggestion, as by specific comments, may put the patient in situation before starting the exposure. This will enhance the patient ’s sense of presence, strengthen the subjective feeling that he is in the virtual environment.
It is therefore important to use real elements of everyday life of the patient in order to build a story as close as possible to reality, as this will help the virtual environment to be more significant from the patient’s viewpoint and can generate an emotional attachment to perform worry exposure.
For the first four scenes, the therapist should explain to the patient that he or she is at home and depending on which scene the therapist should emphasize some stressors elements.
For example, for the first scene, before reproducing the debate, the therapist can ask the patient to imagine that he or she has just put the baby to sleep and that the intercom is on the coffee table with him or her activated to be aware of the baby.
With this, the patient whose concern is that something wrong may happen to their children, will start building an emotional bond from the beginning, associating the simulation to real life. So once the patient will realize they are talking about babies on the television, his or her anxious reaction will be probably stronger.
For the second scene, it is also important to create the emotional bond by making the patient to pay attention to the elements of the scene indicating that a child lives in that house (a toy, a ball..). This scene is also designed for people with an excessive worrying for their children, in this case that something bad may occurs to them by leaving them in the care of others.
As for the third scene, as in the television they are giving the weather forecast and talking about heavy rains , may be of interest to previously indicate the patient that it is the time when his or her partner comes home from work, coming by car, etc. Therefore, you will work on the concern that something bad happens to a loved one, thus using actual data that the patient has provided the therapist previously, his or her worrying will be increased, as well as his or her reaction.
For the fourth scene, the importance lies in making the patient to notice what is on the table: a medical report and a bottle of pills . To do this , we can start commenting that a few days ago the patient went to the doctor to get some recognition or analysis (add more information depending on the patient ) and has already collected the results.
This will make when the patient will hear on television talking about a disease, for example cancer, to react with a higher level of worrying and excessive anxiety. So, we can work on excessive worrying of having a medical condition or deadly disease and overestimation of probabilities.
Finally, in the fifth scene, the therapist can tell the patient he or she is going to take the subway to go at work (or to go to an important event…), so he or she must be punctual.
The fact that the subway will remain stopped for a while will be stressing by itself, so influencing him or her will reinforce the worry.
5. Recommended bibliography
Bados, A. (2005). Trastorno de ansiedad generalizada. Recuperado de la web del dipósito digital de la Universidad de Barcelona: http:// diposit.ub.edu/dspace/bitstream/2445/357/1/116.pdf
Bastida de Miguel, A.M. (2012). Tratamiento cognitivo-conductual aplicado a un caso de insomnio severo comórbido con ansiedad generalizada. Revista de Psiquiatria, 16(3), 2-36. Recuperado de http://www.psiquiatria.com/revistas/index.php/psiquiatriacom/ article/viewFile/1395/1266/
Brown, T.A., O’Leary, T.A. y Barlow, D.H. (2001). Generalized Anxiety Disorder. En D.H. Barlow (Ed.), Clinical Handbook of Psychological Disorders: A Step-by-Step Treatment Manual (pp. 154-208). Nueva York: The Guilford Press.
Dilbaz, N., Cavus, S.Y. y Darcin, A.E. (2011). Treatment resistant Generalized Anxiety Disorder. En S. Selek (Ed.), Different views of Anxiety Disorders (pp. 219-232). Rijeka: InTech.
Gorini, A., Pallavicini, F., Algeri, D., Repetto, C., Gaggioli, A. y Riva, G. (2010). Virtual Reality in the treatment of Generalized Anxiety Disorders. En B.K. Wiederhold, G. Riva y S.I. Kim (Eds.), Annual Review of Cybertherapy and Telemedicine (pp. 39-43). Amsterdam: IOS Press. Wittchen, H.U. y Hoyer, J. (2001). Generalized Anxiety Disorder: nature and course. Journal of Clinical Psychiatry, 62(11), 15-19. Recuperado de http://psychologie.tu-dresden.de/i2/klinische/mitarbeiter/ publikationen/hoyer/Pdf/504.pdf
Wittchen, H.U. (2002). Generalized Anxiety Disorder: prevalence, burden, and cost to society. Depression and Anxiety, 16(4), 162-171. doi: 10.1002/da.10065
5. Annexes
5.1 Weekly self – recording of anxiety and depression (Barlow)
Date
Average Anxiety (0-8)
High Anxiety (0-8)
Average Depression media (0-8)
Medium positive affect (0-8)
Percent of daily worrying
5.2 Self – Assessment cognitive form (Barlow)
Trigger or event
Automatic Thought
Anxiety (0-8)
Probabilities (0-100)
Alternative explanation
Realistic probabilities(0-100)
Anxiety (0-8)
5.3 Daily self – recording of worrying exposure (Barlow)
Begin and end time:
Anxiety (0-8)
Symptoms during the exposure
Worrying Content
Possible worst result feared
Anxiety (0-8)
Possible alternatives
Anxiety (0-8)
5.4 Self – recording of relaxation and subjective evaluation
Used time (start – end)
Subjective assessment of the physical condition before starting
Subjective assessment of the physical condition at the end
Some useful instruments for the evaluation of fear of public speaking
Creation of the hierarchy of exposure to Psious’ environments
Example of intervention in fear of public speaking
Recommendations for use
Recommended bibliography
Appendix
Preparation for an oral presentation in public
1. The fear of public speaking
In the current mental health diagnostic system, fear of public speaking is classified as a social phobia. Nevertheless, it is important to emphasise that only 29% of cases can be diagnosed like this. Recent data indicates that 34% of the population may have anxiety problems when facing the public, which generally has negative repercussions in the academic or professional future of the person who is suffering.
The treatment of choice for this type of phobia is usually based on exhibition techniques combined with relaxation techniques, cognitive restructuring and, in certain cases, training in public speaking skills. However, as it can be difficult to provide a suitable space and a specific audience, it is complicated to carry out live exhibition sessions. Also, parameters such as control over the audience’s reactions, and others that generally depend on factors outside of the therapist’s control increase the complexity of making a live exhibition in the case of social phobia.
For a long time, the investigation that has been done into virtual reality as a tool to treat the fear of public speaking has been very extensive, and largely coincides with not only its therapeutic efficacy, but also its potential to integrate different techniques and permit greater context control (Safir et al, 2012). It is for this reason that the Psious virtual platform has established itself as an especially suitable tool for conducting exhibition sessions and/or training within a secure and prescribed context.
2. Protocol for psychological evaluation/intervention proposed by Psious
All the information contained in this section is a guideline. Psious’s environments are therapeutic tools that should be used by health professionals within a process of evaluation and intervention designed according to the characteristics and needs of the user. Remember also that you have available the General Clinic Guide in which you have more information about how to adapt the techniques of psychological intervention (exposure, systematic desensitisation, cognitive restructuring, data economy) to Psious’s environments
2.1 Evaluation fear of public speaking
2.1.1. Objectives of evaluation
To evaluate the presence and comorbidity of other emotional disorders, especially social phobia, anxiety disorders or other phobias
To evaluate anxiety associated with components: speaking in front of an audience, whether in a formal way (such as an oral presentation in an academic environment) or more informal (such as making a toast at a birthday party), being the centre of attention in a social situation, receiving a potential negative evaluation from an audience.
To define configurations of stimulated fears by the patient and in what degree. Creation of hierarchy of exposure.
To evaluate the presence of distorted thoughts: being embarrassed in a social situation, being criticised for everything they say, not being capable of coordinating their thoughts, not knowing how to behave themselves in an appropriate way…
2.1.2. Some useful instruments for the evaluation of
fear of public speaking
Bearing in mind the objectives for evaluation we will list some tools and instruments that can be useful for obtaining information relevant to the characteristics of your user. Remember that a good definition of objectives, characterisation of the patient and plan for intervention are important for therapeutic efficiency and efficacy, as well as for the satisfaction of your patients. In the bibliography, you will find articles in which the characteristics of the instruments proposed are reviewed below.
For a complete evaluation of the problem a combination of the following instruments will be used:
Open or semi-structured interview
Structured interview: Interview for Anxiety Disorders according to the DSM-IV
Observation and self-observation (with self-report):
Behavioural approximation test live and/or through virtual reality
List of Appropriate Behaviours at the Beginning and End of a Talk
Scale of Qualification of Social Performance
Self-reports:
State Speech Anxiety Inventory (SSAI)
Self-Statement During Public Speaking Scale (SSPSS)
Speech Anxiety Thoughts Inventory (SATI)
Personal Report of Confidence as a Speaker (PRCS)
Psious self-reports for the creation of the hierarchy
2.1.3. Creation of the hierarchy of exposure to Psious’s environments:
Once we have the information from the evaluation we can proceed to create the hierarchy of exposure. For this, as well as using the data obtained through the initial assessment, we can ask a series of questions (e.g. What level of discomfort, on a scale of 0 to 100, does holding a conversation with a group of four people give you? What level of discomfort, on a scale of 0 to 100, does having to make an oral presentation for 10 minutes give you?, Do you think that there is something that could make you feel even more discomfort?…) directed at planning the intervention through virtual reality.
Below there is a series of items that can be used to create a suitable hierarchy for treating fear of public speaking with Psious. It must be borne in mind that we might be able to ask the patient about the anxiety that these items create, and after that, start grading the different elements of the hierarchy.
Being in an auditorium alone preparing for a presentation that will be given in a few minutes (environment of fear of public speaking, auditorium)
Having a job interview (environment of fear of public speaking, office)
Presenting a new project to a small group of work colleagues (environment of fear of public speaking, office)
Giving a talk that will be broadcast on television and seeing that the audience is listening attentively (environment of fear of public speaking, Broadcast conference)
Giving a talk in an auditorium full of people (environment of fear of public speaking, auditorium)
To be giving a conference and hear laughter from the audience (environment of fear of public speaking, audience)
In a work meeting a colleague makes a critical remark to you (environment of fear of public speaking, office)
2.2 Example of intervention in fear of public speaking
Session 1
Inform the patient about the fear of public speaking (causes, symptoms, prevalence…)
Present and justify the techniques that will be used throughout the treatment: exposure to virtual reality and live exposure
Creation of a hierarchy of exposure and exposure to items on the 20-30 USA’s hierarchy (example)
Begin hierarchy of exposition with an item from the 30 USAs. The main objective will be to familiarise the patient with virtual reality and the dynamics of work.
Item
Environment
Configuration
Event
Be in the office alone, preparing the meeting that you will shortly have with some colleagues
Fear of speaking in public
Office, none, easy
No Event
Be in a meeting with one colleague and they are listening attentively to you
Fear of speaking in public
Office, minimum, easy
No Event
Be alone in a conference room, preparing a talk that you will give in a few minutes
Fear of speaking in public
Audience, none, easy
No Event
Be in a meeting with few colleagues and when speaking they give you positive feedback
Fear of speaking in public
Office, medium, easy
Positive remark
They ask you to give an example of something that you have explained in a job interview
Fear of speaking in public
Office, minimum, easy
Neutral remark
Session 2
Review the previous session achievements and establish objectives for the session: You are speaking in a meeting with several work colleagues and you receive a negative remark
After the second session of treatment, it is recommended to start the gradual and systematic exposure to the virtual reality environments. Cognitive restructuring, if applicable.
Show clinical advances, through reports on the platform, to the patient.
Exercises for home:
Live exposure by preparing some type of talk as if later they would have to present it in a meeting, and also they can practice this talk with a very close person
Item
Environment
Configuration
Event
Be in a meeting with few colleagues and while you are talking a mobile telephone rings
Fear of public speaking
Office, medium, easy
Office, medium, easy
Be explaining a project to a lot of work colleagues and someone comes in interrupting the meeting
Fear of public speaking
Office, maximum, easy
Distraction (person comes in)
Be in an auditorium alone, preparing a talk that you are going to give in a few minutes
Fear of public speaking
Auditorium, none, easy
No Event
Have a meeting with several colleagues and when you finish your talk they make a critical remark
Fear of public speaking
Office, maximum, difficult
Negative remark
Session 3
Review the previous session achievements and establish objectives for the session: in a meeting with work colleagues who are not very interested, a mobile telephone rings and a negative remark is made
Gradual and systematic exposure to the virtual reality environments. Cognitive restructuring, if applicable.
Show clinical advances, through reports on the platform, to the patient.
Exercises at home:
Concealed exposure at home reviewing the process followed in consultation with the imagination + live exposure preparing a talk (although later they do not say it)
Item
Environment
Configuration
Event
Be about to give a talk in a room that is not very big with few people and the public applauds you
Fear of public speaking
Audience, few, easy
Applause
Be in a meeting with quite a lot of colleagues who are not interested, and then another person comes in and interrupts
Fear of public speaking
Office, maximum, difficult
Distraction (person comes in)
Be giving a talk with few people and one of the audience asks you a question that seems easy to answer
Fear of public speaking
Audience, minimum, easy
Easy question
Be in a meeting with work colleagues who do not show much interest. A mobile telephone rings and they make a negative remark
Fear of public speaking
Office, maximum, difficult
Distraction (telephone) + negative remark
Session 4
Review previous session achievements and establish objectives for the session: prepare a talk that is going to be given shortly and will be seen on television
Gradual and systematic exposure in the virtual reality environments. Cognitive restructuring, if applicable.
Show clinical advances, through reports on the platform, to the patient
Exercises at home:
Live exhibition doing some meeting at work + covert exposure at home, reviewing the
process followed in consultation by imagination
Item
Environment
Configuration
Event
Be giving a talk with quite a lot of people and hear a mobile telephone ring
Fear of public speaking
Audience, medium, easy
Distraction (mobile)
Be in a conference room with a lot of people and see that they are not paying much attention
Fear of public speaking
Audience, maximum, difficult
No event
Be preparing a talk that is going to be broadcast on television
Fear of public speaking
Broadcast conference, none, easy
No event
Session 5
Review previous session achievements and establish objectives for the session: Be giving a conference that is going to be broadcast on television and the audience is paying attention
Gradual and systematic exposure in the virtual reality environments. Cognitive restructuring, if applicable.
Repeat each one of the exercises twice
Show clinical advances, through reports on the platform, to the patient
Exercises at home:
Concealed exposure at home, reviewing the objectives of the sessions and the process followed in consultation
Item
Environment
Configuration
Event
After answering an easy question from a member of the audience at the conference today, see that there are people talking amongst themselves
Fear of public speaking
Audience, medium, difficult
Difficult question + people talking
Be giving a talk in an auditorium full of people, and also see that they are not paying much attention, hear a yawn from the audience
Fear of public speaking
Auditorium, maximum, difficult
Distraction (yawn)
Be giving a talk that is being broadcast on television and see that the audience is paying attention
Fear of public speaking
Broadcast conference, medium, difficult
Go to the stage and then no event
Session 6
Review previous session achievements and establish objectives for the session: Give a conference that is broadcast on TV and a listener asks a difficult question
Gradual and systematic exposure in the virtual reality environments. Cognitive restructuring, if applicable
Repeat each one of the exercises twice
Show clinical advances, through reports on the platform, to the patient
Exercises at home:
Imaginal exposure at home reviewing the process following the consultation
Item
Environment
Configuration
Event
Be in a room full of people giving a talk, see that the audience is not showing much interest and that one of them leaves the room
Fear of public speaking
Audience, maximum, difficult
Person leaves
Be giving a talk in a room full of people, with the lights down and television cameras and hear laughing in the background
Fear of public speaking
Broadcast conference, many, easy
Difficult question
Be giving a talk in a room full of people, with the lights down and television cameras and hear laughing in the background
Fear of public speaking
Broadcast conference, many, easy
Distraction (laughs)
Be holding a conference that is going to be broadcast on television and a person from the audience asks you a question that is difficult to answer
Fear of public speaking
Broadcast conference, maximum, difficult
Difficult question
3. Recommendations for use:
It is important to accompany exposure with remarks, questions or statements so that the patient can put themselves further into the situation and experience the exposure in a more realistic way.
These are your bosses/teachers/interviewers… You have to give a talk/do an oral exam/ do an interview…
What did the woman in front suggest to you? What do you think that she thinks of you?
If you had to have a second meeting with one of them alone, who would you prefer it to be? Who makes you most nervous?
What impression do you think that you have given them with your proposal?
Now you have to ask them a favour. Whose face are you going to look at while you do it?
Of those that are listening to you, who do you think has the most power within the company?
A man in the audience just raised his hand. What type of question do you think he is going to ask you? Do you think that he will embarrass you with his question?
With which of those would you speak after the conference?
4. Recommended bibliography
Anderson, P.L., Price, M., Edwards, S.M., Obasaju, M.A., Mayowa, A., Schmertz, S.K., Zimand, E. & Calamaras, M.R. (2013). Virtual reality exposure therapy for social anxiety disorder: A randomized controlled trial.
Journal of Consulting and Clinical Psychology, 81(5), 751.760. Bados López, A. (2006). Fobias específicas.
Bados, A. (2009). Miedo a hablar en público: naturaleza, evaluación y tratamiento. Barcelona: Publicacions i Edicions de la Universitat de Barcelona.
Cho, Y., Smits, J.A.J. y Telch, M.J. (2004). The Speech Anxiety Thoughts Inventory: Scale development and preliminary psychometric data. Behaviour Research and Therapy, 42, 13-25.
Fawcett, S.B. y Miller, L.K. (1975) Training public-speaking behavior: An experimental analysis and social validation. Journal of Applied Behavior Analysis, 8, 125-135.
Fydrich, T., Chambless, D.L., Perry, K.J., Buergener, F. y Beazley, M.B. (1998). Behavioral assessment of social performance: A rating scale for social phobia. Behaviour Research and Therapy, 36, 995-1010.
Gega, L., White, R., Clarke, T., Turner, R. & Fowler, D. (2013). Virtual environments using video capture for social phobia with psychosis. Cyberpsychology, Behavior, and Social Networking, 16(6), 473-479
Hofmann, S.G. y DiBartolo, P.M. (2000). An instrument to assess selfstatements during public speaking: Scale development and preliminary psychometric properties. Behavior Therapy, 31, 499-515.
Lamb, D.H. (1972) The Speech Anxiety Inventory: Preliminary test manual for Form X. Normal, IL: Illinois State University.
Moldovan, R. & David, D. (2014). One session treatment of cognitive and behavioral therapy and virtual reality for social and specific phobias. Preliminary results from a randomized clinical trial. Journal of EvidenceBased Psychotherapies, 14(1), 67-83.
Paul, G.L. (1966) Insight vs. desensitization in psychotherapy. Stanford, California: Stanford University Press.
Safir, M.P., Wallach, H.S. & Bar-Zvi, M. (2012). Virtual reality cognitivebehavior therapy for public speaking anxiety: One-year follow-Up. Behavior Modification, 36(2), 235-246.
5. Appendix
5.1. Preparation for an oral presentation in public
If there is nothing insisted upon, select a general topic for their presentation. Choose a topic that they have a good command of and thainterests them.
Summarize the previous topic, focusing on some aspect of it. For this, bear in mind, on one hand, the interests, attitudes and knowledge of the audience and, on the other, the occasion (reason for the meeting in public, moment in which they will speak, available time).
Determine the objective that they want to achieve with their presentation (informing, persuading, making the audience think, calling to action, entertaining).
Make a short preliminary outline that includes basic ideas and points on the topic and that serves as a guide to searching for information on the topic.
Collect pertinent information. Possible material to be collected may include examples, explanations, demonstrations, analogies, numeric data, quotes, testimonies, graphics and visual aids.
Make an outline of the body of the presentation in which the ideas to be presented can be organised coherently. It should contain the simple numbering of the main ideas about which they want to speak (no more than 4-5) and, under each of these, the secondary ideas that are going to be developed. They can also include essential information (examples, statistics, quotes), the time assigned to each main idea and the moment in which they will use each audio-visual aid, if there are any.
If they want more information than that given by the outline, they can prepare some numbered notes written on only one side of paper in which they can briefly develop the ideas to present. However, if they use a lot of notes, these can be difficult to manage and they run the risk of looking more at the notes than the audience or ending up reading the presentation.
Anticipate possible questions, objections or interruptions and prepare appropriate responses.
If it is the case, prepare a limited number of audio-visual aids to support or clarify their presentation. These aids should be easily understood, clearly visible and/or audible and preferably graphic in nature. As technology can fail, be prepared to do the presentation without them.
Prepare the introduction and check that it is clearly connected to the body of the presentation. The introduction should follow: a) earning the attention of the audience and motivating them for the presentation; and b) informing them of the topic of the presentation, the main points that it will cover. The introduction should be short and not cover more than 5-10% of the available time.
Prepare the conclusion and check that it is clearly connected to the body of the presentation. A presentation can be concluded by: a) reaffirming its main points; b) making a short summary of the main ideas presented; and c), if it is the case, prompting to carry out a specific action. The conclusion should not take up more than 10% of the available time.
It is useful to make a short mental essay on the introduction, main points and conclusion. If they are a beginner, frightened or usually have problems managing time, it is advisable to do a real rehearsal alone or in front of some collaborators. Think that the real presentation usually lasts around 10-20% longer than the private rehearsal.
Virtual environments of Psious for the treatment of blood phobia
Treatment protocol based on Psious
Comments
Recommended bibliography
1. Blood phobia
The fear of blood is a phobia classified on current mental disorders diagnosis systems as aspecific Blood-Injection-Injury type of phobia (BII). Some sort of fear towards blood is common and, in fact, it is considered that the amount of people that experience this fear may exceed 10%. Yet recent studies point out that about 2-3% of the population suffers from BII phobia.
This data is significant; not only because of its prevalence, but also due to the negative consequences that blood phobia can have on the quality of life of those who suffer from it. These people tend to avoid medical interventions that are key to health or pregnancies, as well as quitting on graduate school (e.g. medical school, nursing school), or avoid visiting hospitalized relatives, and so on.
Blood phobia, unlike the rest of phobias, is characterized by a biphasic anxiety response. That is to say, even though during the first seconds of exposure to the feared stimulus an elevated physiological activity takes place (tachycardia, palpitations, sweating, etc.), immediately followed by a rapid drop (blood pressure drops, cardiac rhythm can drop to between 35 to 40 beats per minute, etc). This can lead to dizziness, pallor, and, sometimes, even fainting.
In regard to the treatment of blood phobia, it is not usually recommended to use relaxation techniques during the exposure to the feared situation (though these are useful during the first phase of the biphasic response). On the contrary, it is considered more adequate to use Applied Tension techniques, with the aim of balancing out the physiological drop and so preventing fainting.
In the last few years, Virtual Reality (VR) and Augmented Reality (AR) have shown great clinical efficiency in the treatment of specific phobias. These technologies provide the ideal context to play the situations feared by the patient , in a controlled safe way. In the case of blood phobia, for instance, these technologies allow for blood analysis to be carried out any day of the year, without prior appointment, and offer the chance to set the parameters that are considered suitable and without even leaving the practice.
2. Virtual environments of Psious for the treatment of blood phobia
The Psious platform currently features one Virtual Reality scene (a hospital with its waiting and extraction rooms) and a video (images of a real blood extraction). Furthermore the therapist can combine, in both the video and the scenario, the Virtual Reality with traditional treatments, such as “Relax”
3. . Treatment protocol based on Psious
The following is an example of a protocol treatment in which Psious is combined with other psychotherapeutic techniques for the treatment of blood phobia. Despite this, it is recommended that each therapist integrate VR technologies into the protocols they usually use in their clinical practice, in addition to adapting the sessions to the rhythm and characteristics of the patient.
The proposed treatment protocol consists of 8 weekly treatment sessions lasting approximately one hour.
SESSION 1: PSYCHOEDUCATION + APPLIED TENSION
Information about blood phobia is provided (origin, maintenance and biphasic anxiety response).
Treatment techniques that will be used throughout the protocol are presented and justified: exposure to Virtual and Augmented Reality environments, applied tension technique.
Introduction and practice of the applied tension technique.
Homework:
Practice of the applied tension technique and filling out the associated self-recording (see Annex 6.1).
SESSION 2-3: PROGRESSIVE MUSCLE RELAXATION
The technique of applied tension continues.
The use of Jacobson’ s progressive muscle relaxation is introduced.
Familiarization accompanied by Psious platform. The patient learns how use the VR headphones and navigate within virtual environments
Homework:
Practice of applied tension and Jacobson progressive muscle relaxation. Applied tension (see Annex 6.1) and relaxation (see Annex 6.2) self-recording.
SESSION 4: RV EXHIBITION TRADITIONAL TECHNIQUES
From the fourth session on , the gradual and systematic exposure to virtual environments begins. Throughout the exposure sessions , according to the characteristics of each patient, the VR is combined by the applied tension and progressive muscle relaxation techniques.
The patient is exposed to:
A Waiting room as a companion.
An extraction room as a companion
Homework:
Self-exposure to stimuli related to a feared situation. Applied tension and progressive muscle relaxation practice.
SESSION 5: EXHIBITION RV + TRADITIONAL TECHNIQUES
Homework review
The patient is exposed to:
The waiting room + interoceptive exposure elements.
Self-exposure to stimuli related to the feared situation. Practice of applied tension and progressive muscular relaxation.
SESSION 6: EXHIBITION RV + TRADITIONAL TECHNIQUES
Homework review.
The patient is exposed to:
Extraction room with a finger prick.
Extraction room with easy extraction.
Homework:
Practice of relaxation techniques and self-exposure to needle-related stimuli.
SESSION 7: VR EXPOSURE + TRADITIONAL TECHNIQUES
Homework review.
The patient is exposed to:
Waiting room with interoceptive exposure.
Extraction room with hard extraction and/or Injection + a real extraction video.
Homework:
Practice of relaxation techniques and self-exposure to stimuli related to needles.
SESSION 8: RELAPSE PREVENTION
The therapeutic process is evaluated and future self-exposure tasks and reinforcement sessions are programmed.
Management and prevention of future relapses
4. Comments
It is important to complement the exposure with comments, questions or indications, so that the patient can get more in touch with the situation and experience the exposure in a more realistic way.
Some suggestions for blood phobia are:
At the waiting room:
You are attending a blood extraction on your own. Do you think you would have felt better if someone had come with you?
What does the person getting out of the extraction room cause in you? Does he/she make you more nervous? Or does he/she soothe you?
Do you think the extraction is going to hurt?
How do you think the person sitting next to you feels? Is he/she nervous or calm?
How do you feel about that personʼs state?
At the extraction room:
How many years of experience do you think this nurse has?
Does this nurse make you feel safe?
When you are ready, look at the needle which the extraction will be performed with.
Look at the bloodstained cotton over the small table.
5. Recommended bibliography
Chapman, L. K., & DeLapp, R. C. (2013). Nine session treatment of a blood–injection–injury phobia with manualized cognitive behavioral therapy: An adult case example. Clinical Case Studies. Retrieved October 26, 2014, from http://ccs.sagepub.com/content/ early/2013/10/28/1534650113509304
Wiederhold, B.K., Mendoza, M., Nakatani, T. Bulinger, A.H. & Wiederhold, M.D. (2005). VR for blood-injection-injury phobia. Annual Review of CyberTherapy and Telemedicine, 3, 109-116.
Wolf, J.J. & Symons, F.J. (2013). An evaluation of multi-component exposure treatment of needle phobia in an adult with autism and intellectual disability. Journal of Applied Research in Intellectual Disabilities, 26(4), 344-348.
Ritz, T.M., Meuret, A.E. & ALvord, M.K. (2014). Blood-injection injury-phobia. In Grossman, L. & Walfish, S. (Ed.): Translating psychological research into practice (pp. 295-301). New York, NY, US: Springer Publishing Co, 609.
Auto-report hierarchy waiting room and extraction room Psious environments
Ítem
(Level of discomfort 0-100)
I just had a blood draw and the nurse tells me there’s another one left.
I went into the extraction room and then the nurse pricked my finger to draw a drop of blood.
I am in a hospital waiting room accompanying a friend for a blood test.
I am in the waiting room and I am going to have a blood test soon.
I am standing in an extraction room and my friend is sitting on a stool. The nurse proceeds to give him an injection.
While my friend is sitting in the extraction room, I am standing because I accompany him. The nurse explains that she is going to do a small blood draw and proceeds to do it.
I am home a few hours before I go for a blood test.
The nurse starts to perform a blood test that lasts a long time, makes a considerable extraction.
I am in the waiting room and they’ re gonna give me an injection shortly.
I entered the extraction room accompanying a friend and then the nurse pricked his finger to draw a drop of blood.
While I am waiting with a friend to be called in for a blood test, the nurse calls someone else into the extraction room.
I see a video in which they do a blood draw on me.
am in the extraction room ready for my blood work. The nurse starts and ends right away, because the extraction has been small.
I am driving to the hospital because I’ m getting tested today.
I am in the hospital waiting room with my partner, who’ s coming in for a blood test. We are talking and then the nurse appears and calls him, so we enter the extraction room.
After I went into the extraction room, the nurse gave me an injection.
I find myself in the waiting room of the hospital, and then the nurse appears, who calls me and makes me go to the extraction room.
While my partner is in the extraction room, I see how the nurse starts doing a long blood draw, so the procedure takes a while.
I have been waiting a while to get into the extraction room. Then the nurse appears and calls another patient to come in.
I am copilot in a friend’ s car because I am escorting him for a blood test.
Virtual Reality (VR) is a less complex, cheaper alternative to in vivo exposure for 2.2. Going to the airport 2.3. Boarding Gate 2.4. The Plane the treatment of flying phobia. This technology does not require a high imagination capacity on the patient as the case of the typical exposure techniques. Also, the exposure can be modified to the patients needs when using VR, as the therapist can control different parameters such as duration of the flight, weather conditions, people on the flight,etc
Many studies demonstrate the efficiency of VR as a treatment for specific phobias. A systematic review about the use of VR as a treatment of flying phobia showed that Cognitive Behavioral Therapy (CBT) combined with relaxation techniques and VR exposure is effective for the treatment of flying phobia ( Costa et al. 2008). Also, a study by Botella ( 2004), demonstrated the efficiency of VR as the only line of treatment for flying phobia at short and long term.
2. PSIOUS-BASED TREATMENT PROTOCOL
A treatment protocol is shown below in which Psious is combined with traditional treatment techniques. However, it is recommended that each psychotherapist adapt and implement VR strategies to the treatment protocols they already use in their clinical practice. Similarly, exposure sessions should progress at their own pace and according to the needs of each patient. The proposed treatment protocol consists of 13 weekly sessions lasting approximately one hour.
Description of treatment sessions
SESSION 1: PSCOEDUCATION
Information about flying phobia is provided (origin, upkeep and appearance the triple system cognitive, physiological and motor).
Information about the functioning and safety of planes.
Treatment techniques that will be used throughout the protocolare explained (emphasizing the exposure to the Virtual Reality environments).
Homework:
Hand out of the Psychoeducation file (see annex 5.1).
SESSION 2- 3: RELAXATION
The patient learns and practices two types relaxation techniques: controlled breathing and Jacobsons progressive muscular relaxation.
Familiarization with the Psious platform. The patient learns to use the VR helmets and navigate inside the virtual scenes.
Homework:
Daily practice of relaxation techniques. The self-registers of relaxation and negative thoughts are completed (see annex 5.2)
SESSION 4: COGNITIVE RESTRUCTURING
Revision and adjustment of the patients negative thoughts.
Cognitive restructuring for each of the negative thoughts. Two kinds of cognitive therapy may b used: the one proposed by Beck or the one belonging to Ellis.
Homework:
Daily practice of relaxation technique Self-registers of relaxation and negative thoughts are completed (see annex 5.2).
SESSION 5: VR EXPOSURE + TRADITIONAL TECNIUES
As of the fifth session of treatment the gradual and systematic exposure to the virtual environments begins. Throughout all exposure sessions, VR is combined with techniques of relaxation and cognitive restructuring.
The patient is exposed to:
Patients house on a sunny day (the news is on TV).
Taxi ride on a sunny day (the news is on the radio).
Boarding gate on a sunny day.
Homework:
Daily practice of the relaxation techniques and tasks of self-exposure to stimulus related to planes.
SESSION 6: VR EXPOSURE + TRADITIONAL TECHNIQUES
Homework review.
The patient is exposed to
Taxi ride on a sunny day
Boarding gate on a sunny day. The display with the flight schedule is shown, also the window with planes taking off and landing.
Plane take-off on a sunny day.
Homework:
Daily practice of relaxation techniques and tasks of self-exposure to stimulus related to planes.
SESSION 7: VR EXPOSURE + TRADITIONAL TECHNIQUES
Homework review.
The patient is exposed to:
Boarding gate on a sunny day and with comments from other passengers. The screen with the flight schedule and the window with planes taking off and landing are observed.
Plane take-off on a sunny day.
) Flight situation. Elements of internal sense exposure are introduced.
Homework:
Daily practice of relaxation techniques and self-exposure tasks to stimuli related to planes.
SESSION 8: VR EXPOSURE + TRADITIONAL TECHNIQUES
Homework review.
The patient is exposed to:
Plane take-off on a sunny day. Turn on comments.
Flight situation and short turbulence. Internal sense exposure.
Landing.
Homework:
Daily practice of relaxation techniques and self-exposure tasks to stimulus related to planes.
SESSION 9 VR EXPOSURE + TRADITIONAL TECHNIQUES
As of the ninth session of treatment the exposure is re-started to the virtual environments but with a higher level of difficulty. Like in the rest of the exposure it is used in combination with relaxation and cognitive restructuring.
The patient is exposed to:
At home on a rainy day (the news is on TV).
Taxi ride on a rainy day (the news is on the radio).
Boarding gate on a rainy day.
Homework:
Daily practice of relaxation techniques and self-exposure tasks to stimulus related to planes.
SESSION 10 VR EXPOSURE + TRADITIONAL TECHNIQUES
The patient is exposed to:
Taxi ride on a rainy day with the radio on. Elements of internal sense exposure are introduced.
Boarding gate on a rainy day. The screen with the flight schedule and window with planes landing and taking off is observed.
Plane take-off on a rainy day.
Homework:
Daily practice of relaxation techniques and self-exposure tasks related to planes.
SESSION 11 VR EXPOSURE + TRADITIONAL TECHNIQUES
Homework revision.
The patient is exposed to:
Boarding gate on a rainy day. Elements of internal sense exposure are introduced.
Plane take-off on a rainy day. Elements of internal sense exposure are introduced.
Flight situation on a rainy day with comments. Elements of internal sens exposure are introduced.
Homework:
Daily practice of relaxation techniques and self-exposure tasks to stimulus related to planes.
SESSION 12 VR EXPOSURE + TRADITIONAL TECNIUES
Homework review
The patient is exposed to:
Plane take-off on a rainy day. Turbulence appears.
Flight situation on a rainy day with turbulence. Elements of internal sense exposure plus comments
Landing on a rainy day with turbulence.
Homework:
Daily practice of relaxation techniques and tasks of self-exposure to flight-related stimuli.
SESSION 13: VR EXPOSURE + TRADITIONAL TECHNIQUES
The therapeutic process is evaluated and future self-exposure tasks are programmed, as well as booster sessions.
Relapse management and prevention.
3. USE RECOMMENDATIONS
It is important to support the exposure with comments, questions or indications, in order for the patient to enhance their immersion, and to provide them with a more realistic experience. Some suggestions for flying phobia are:
Waiting at home, or in the taxi:
Today you are going to catch a flight to (choose a city). The plane leaves at 6 a.m., but we should be at the boarding gate by 11.15 a.m. Also, we have to go through the security controls… It is now 10 a.m., and the taxi will come pick you up in 5 minutes.
Would you want to watch the weather news before we leave home?
They just said that it is rainy. Does that make you more anxious? Can toy tell me why?
You have to be aware that, even though it is raining, the taxi is still going to come pick you up to take you to the airport.
You are going to catch a plane by yourself. hen was the last time you flew lone?
At the Gate area, or during the flight:
Now we are going to watch the planes taking off through the window. In a while you are going to be inside one of those planes.
What does the person beside you/in front of you evoke in you?
Now we are going to look at the displays where the boarding gates are indicated.
Do you think your mate is nervous?
Would you ask the lady sitting next to you for help if you felt an increase in your levels of anxiety?
Its been a while since you last saw a flight attendant in the aisle. Does that make you feel more insecure?
(In the middle of a turbulence) ould you like to call the flight attendant in a Versión de Prueba moment like this?
4. RECOMMENDED BIBLIOGRAPHY
Botella, C., Osma, J., García-Palacios, A., Quero, S. & Baños, R.M. (2004). Treatment of Flying Phobia using Virtual Reality: Data from a 1-Year Follow-up using a Multiple Baseline Design. Clinical Psychology & Psychotherapy, 11(5), 311-323.
Da Costa, R.T., Sardinha, A. & Nardi, A.E. (2008). Virtual reality exposure in the treatment of fear of flying. Aviation, Space, and Environmental Medicine, 79(9), 899-903.
Hirsch, J.A. (2012). Virtual reality exposure therapy and hypnosis for flying phobia in a treatmentresistant patient: A case report. American Journal of Clinical Hypnosis, 55(2), 168-173.
Wallach, H.S. & Bar-Zvi, M. (2007). Virtual-reality-assisted treatment of flight phobia. Israel Journal of Psychiatry and Related Sciences, 44(1), 29-32.
Wiederhold, B.K., Jang, D.P., Gervirtz, R.G., Kim, S.I., Kim, I.Y. & Wiederhold, M.D. (2002). The Treatment of Fear of Flying: A Controlled Study of Imaginal and Virtual Reality Graded Exposure Therapy. IEEE Transactions on Information Technology in Biomedicine, 6(3), 218-223.
Fear of Driving is defined in the current mental disorders classification system as a situational phobia within specific phobias. It is characterized by an intense and persistent fear that increases with the anticipation or exposure to the driving stimuli. Recent studies have shown that the prevalence of this phobia is of 4% of the population, although the percentage of people with some type of driving-related fear could raise up to 22%. The symptoms of this phobia can cause significant discomfort and serious interference with the daily lives of the patients.
Certain factors affect the intensity of the patient’s emotional reaction to driving. The typical and most important ones are: speed, weather, amount of traffic, distance to be covered, time of day, characteristics of the road, type of car, if they are driving alone or with company, where the patient is driving through, etc.
Virtual reality has been proved to be a good alternative to traditional exposure techniques in the treatment of driving phobia. This technology is especially useful in repeating the exposure as many times as necessary in order to recreate the unpredictable circumstances that occur in the real situation. Moreover, VR naturally eliminates the chances of suffering an accident and the therapist has total standardization and control over the exposure session parameters.
2. PSIOUS-BASED CLINICAL PROTOCOL
A proposal for a treatment protocol that includes the Psious tool is described below. It is recommended to combine virtual reality with traditional techniques, such as relaxation or cognitive restructuring.
Session description
SESSION 1: PSYCHOEDUCATION
Information about driving phobia: origin and manifestations (cognitive, physiological, and behavioral).
Treatment protocol explanation. The patient should understand the applicability of virtual reality and relaxation techniques.
SESSION 2 + 3: RELAXATION
Training of two relaxation techniques: Deep breathing and Progressive Muscular Relaxation.
Patient’s familiarization with VR: Use of neutral environments (e.g., environments for other phobias).
Homework:
Practice of the relaxation techniques. Relaxation diary (see annex 6.2)
SESSION 4: VIRTUAL EXPOSURE + RELAXATION
Virtual exposure + Relaxation:
1- City without cars, during the day when it’s sunny. Track 1.
2- City with cars, during the day when it’s sunny. Combine track 1 and 2 with traffic jam, slowdown and horn situations.
3- City with cars, during a rainy day + interoceptive exposure (blurry vision)
Homework:
Practice relaxation and self exposure. Relaxation and driving phobia diary (see annex 6.2).
SESSION 5: VIRTUAL EXPOSURE + RELAXATION
Virtual exposure + Relaxation:
1- City with cars during a rainy night. Combine track 1 and 2 with the above mentioned situations.
2- City with cars during a rainy night + interoceptive exposure (blurry vision → tunnel vision + hyperventilation)
3- Road without cars during the day. Low, mid and high speed.
Homework:
Practice relaxation and self-exposure. Relaxation register and driving phobia diary (see annex 6.2).
SESSION 6: VIRTUAL EXPOSURE + RELAXATION
Virtual exposure + Relaxation:
1- Highway with cars during a sunny day. Mid speed combined with some type of distractor
2- Highway with cars during a rainy day. Sections of tunnels and bridges. Highway with cars during a rainy day.
3- Sections with tunnels and bridges. Add curves and combine with accidented car. High speed.
Homework:
Practice relaxation and self-exposure. Self Recording of relaxation and driving phobia diary (see annex 6.2).
SESSION 7: VIRTUAL EXPOSURE + RELAXATION
Virtual exposure + relaxation
1- Road with cars during a rainy day. Tunnels and bridges. High speed. Combine last session settings and the use of some type of distractor
2- Road with cars during a rainy night. Combine the different elements and add interoception effects.
Homework:
Practicing relaxation and self-exposure. Self Recording of relaxation and driving phobia diary (see annex 6.2).
SESSION 8: CONCLUSIONS AND RELAPSE PREVENTION
Evaluation of the treatment.
Future self-exposure planning.
Tools for future relapse prevention.
3. TIPS FOR IMMERSION
It is important to accompany the exposure with comments, questions or indications. This is beneficial to the treatment because it helps the patient to become more involved in the situation and the exposure.
Some options for driving phobia:
You are driving along a highway and there is still an hour left of driving
It will take two more hours to get to our destination and it’s 8 in the evening. It’s getting dark…
Now the highway has curves and slopes. Are you scared? Of what?
You are about to get into the car to go to work and the day is very rainy.
Today we will drive around the town. You know that in towns there are many / a lot of cars. In addition, today we have to go by in rush hour. And by the way, your cellphone battery is dead, so you can’t call anyone to calm you down neither before nor during the trip.
Imagine you are alone in the car. Today we will travel for 4 minutes/10 minutes/30 minutes…
Picture yourself driving and that someone is recording you in case you need to get points taken off.
We are driving down a road packed with trucks. Yes, and you know that trucks sometimes overtake each other.
In this section, you must go 62m/h because if you go over this speed, you will obstruct traffic.
Now we are going to enter a tunnel. How long do you think the tunnel is? What do you feel when you see that the tunnel is longer than you expected?
If the car in front of you were to derail, do you think you would have time to react?
4. RECOMMENDED BIBLIOGRAPHY
Da Costa, R.T., de Carvalho, M.R. & Nardi, A.E. (2010). Virtual reality exposure therapy in the treatment of driving phobia. Psicologia: Teoria e Pesquisa, 26(1), 131-137.
Kraft, T. & Kraft, D. (2004).Creating a virtual reality in hypnosis: A case of driving phobia. Contemporary Hypnosis, 21(2), 79-85.
Wald, J. & Taylor, S. (2000). Efficacy of virtual reality exposure therapy to treat driving phobia: A case study. Journal of Behavior Therapy and Experimental Psychiatry, 31(3-4), 249-257.
Wald, J. & Taylor, S. (2003). Preliminary research on the efficacy of virtual reality exposure therapy to treat driving phobia. CyberPsychology & Behavior, 6(5), 459-465.
Wald, J. (2004). Efficacy of virtual reality exposure therapy for driving phobia: A multiple baseline across-subjects design. Behavior Therapy, 35(3), 621-635.
Walshe, D.G., Lewis, E.J., Kim, S.I., O’Sullivan, K. & Wiederhold, B.K. (2003). Exploring the use of computer games and virtual reality in exposure therapy for fear of driving following a motor vehicle accident. CyberPsychology & Behavior, 6(3), 329-334.
4. ANNEXES
4.1 Fear of driving diary
AVOID DRIVING:
To what degree would you avoid driving today according to the scale indicated below?
0
1
2
3
4
5
6
7
8
I wouldn’t avoid it
I would avoid it a bit
I would avoid it quite a bit.
I would avoid it a lot
I would completely avoid it
STATE OF DRIVING PHOBIA SYMPTOMS:
How do you assess your driving phobia symptoms today?
Useful tools for fear of darkness and or storm evaluation (children and adults)
Hierarchy preparation/development and exposure with Psious environments
Exposure Hierarchy Development with Psious environments
Intervention example and fear of darkness in children
Intervention example and fear of storms in children
Usage Recommendations
Recommended bibliography
Appendix
1. Fear of darkness and storms
This Psious virtual reality environment (VR) will assist you in the intervention and evaluation of children and adults who are showing signs of fear of darkness and or storms. With the help of the events and the environment settings provided in the platform each environment can be adapted to the therapeutic procedure requirements. For example, a behavioral approach test or alike, can be carried out (Orgilés, Méndez y Espada, 2005) or the psychological intervention through procedures that have demonstrated stronger observational, in this instance multicomponent programs (systematic desensitization, exposure, modelling, token economy approach, parents training…). Amongst them, one worthy of mention is that of Mikulas y Coffman (1989) and the “emotive performances technique” ( EPT) by Méndez (1986) that suggested using EPT as an alternative to emotive imagery by Lazarus y Abramovitz (1979). Furthermore, an environment can be used to carry out gradual exposure, psychoeducation, cognitive reconstruction, relaxation…
Lastly, let’s focus on the advantages that VR brings to this type of intervention and denote that VR has already demonstrated to be very effective as a treatment in phobias (Capafons, J.I, 2001). With respect to darkness phobia in children, as already indicated, multicomponent programs have shown greater effectiveness than other intervention techniques. For example, in the emotive performances technique counterconditioning components are clearly combined (a child being introduced to a game should be sufficiently attractive to offset the effects of the feared stimulus) with other operant conditioning techniques, not only the strengthening of approach behaviors to the phobic stimulus, but also the elimination of possible conduct behaviors that parents or adults involved in the treatment could apply.The control that the therapist acquires in addition to the gradual process that patients undergoes, on the one hand, facilitates the transition from the simulated environment to the real environment, delivering greater levels of accuracy, and on the other hand, due to the fact that this type of coaching encourages acceptance of the intervention. Thereby, favoring the coaching of parents through observation during the visit and lastly, allowing us to easily “gamify” the intervention.
When it comes to storm phobias, VR provides the solution to solving one of the major drawbacks to in vivo exposure: unpredictability and the lack of frequency. Exposures in Psious can be exposed to patients systemically and the levels of anxiety can be adjusted accordingly to the degree of: night or day, amount of light, intensity of rain or storms.
Ultimately, it combines your knowledge with the tools that you are provided with by Psious, thus enhancing user experiences and achieving better results.
2. Evaluation Protocol/ Psychological Intervention 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 designed according to the characteristics and needs of the user. There is also a General Clinical Guide available for your attention where you will find further information on how to adapt the psychological intervention techniques in environments with Psious (exposure, systematic desensitization, cognitive reconstruction, token economy approach…).
2.1 Fear of darkness and storms evaluation
2.1.1. Evaluation Objectives:
Evaluate the presence and comorbidity of other emotional disorders, in particular anxiety from separation, night terrors, sleep alterations, other phobias…
Evaluate anxiety associated with dimensions:
Darkness:
personal safety (eg. rapture, robbers)
loss or separation (eg. in children, their parents)
nightmares
imaginary creatures
darkness
Storms:
personal safety/damage
intense sounds
Set the feared stimulative settings for the patient and define to what extent. Exposure hierarchy development, assess if there is only fear of darkness or storms or both collectively.
Measure the presence of distorted thoughts, monsters, robbers, lightning coming through the windows…
2.1.2. Some useful instruments for fear of darkness and/or storms evaluation (children and adults)
Taking the evaluation objectives into account let’s proceed onto listing some tools and devices that can be useful in gathering relevant information on the user characteristics. Always remember good goal setting, patient characterization and intervention planning are important in effective and efficient therapies, as that of your patients’ satisfaction. The following are the articles you will find in the bibliography where you can refer to the proposed tool characterization:
Child evaluation:
Interviews
Structured interview: ADIS-IV:C (Children)
Interview with one or both parents: education background, coping with fear…
Natural observation procedures for parents (similar to Orgilés proposal, Méndez y Espada, 2005): Register of Behavior to Darkness and Register at Bedtime.
Artificial observation procedures for parents (based on Orgilés, Méndez y Espada, 2005): behavioral approach test to darkness and darkness tolerance test.
Fear level thermometer for children applicable to the observation procedures.
Bedtime register (BD)
Self-reporting :
General diagnosis examination questionnaire for parents: e.g CBCL.
General questionnaire of fears for children: e.g FSSC-R
Fear of Darkness assessment scale (EMO)
Electromyography biofeedback. Set the baseline in neutral environment.
Evaluation in Adults:
Structured interview: ADIS-IV
Behavioral approach test/behavior avoidance (in vivo or with virtual reality)
Self-reporting:
Fear Survey Schedule FSS-III (Fear Survey Schedule)
Electromyography biofeedback. Set the baseline in neutral environment.
2.1.3 Exposure Hierarchy development with Psious environments:
Once we have received the evaluation information we can then proceed to develop the hierarchy exposure. To do this, in addition to using the data obtained during the initial evaluation, we can carry out a series of questions, (e.g What level of discomfort is generated, on a scale of 0 to 100, when left alone without any light in the living room? What level of discomfort is generated, on a scale of 0 to 100, when left alone without any light in this bedroom? Can you think of anything else that would generate even more discomfort?…) all geared at the planning of the intervention via the virtual reality
2.2 An example of the Fear intervention to darkness in children
Example protocol designed to be applied on a biweekly or weekly basis, made up of 8 to 12 sessions, lasting 30-45 minutes. A follow-up in 3 to 6 months is recommended.
Session 1
POn introducing the virtual reality, show a neutral environment such as an island or underwater in the sea
The objective in the opening session is to create a game where the child feels relaxed and is willing to participate. Explain to the child that he is going to meet Psicobot, the teleportation who he/she can use for help when needed, be shown the rooms in the house which they can visit, and gain tokens for exploring the house, which the child can exchange for prizes at the end of the session (in the case of using token economy)…
When using the token economy, clarify the operating rules before starting the virtual session. Get the child to interact with the environment and collect tokens easily and exchange the tokens for prizes (in the case of using token economy) at the end of the session .
Introduction Teleportation (on child’s request) Help (on child’s request) Ambient light)
Session 2
Review achievements from the last session and the objectives set in the session: Continue exploring the house to gain tokens and carry out missions with levels of less lighting.
To favor confrontation and, in particular in the case of implementingemotive performances techniques, games (counterconditioning) could be introduced in the individual spaces. For example, count the number of vases there there are in the living room (5), the number of pictures on the wall in the training zone and in the living room (7)…count the windows in the house, find the contingency/tokens table (bedroom wall) where you can take note of the tokens obtained.
If you use gradual exposure, playing games or distracting is not recommended, use the tokens as a confrontational reinforcement and repetition as a strategy in promoting the bedroom and end to the conditioned biofeedback. As and from the second session in treatment, introducing the systematic and gradual exposure to the distinct spaces in the house is recommendable. In function with the minor’s progress, reduce the light intensity progressively.
• Use the cognitive reconstruction, if necessary.
Remember you have been given TOKENS, set up a token economy, if need be, so that confrontational behavior can be positively reinforced. In the beginning, exchanging tokens for prizes is recommendable at the end of the session
Exercises at home:
Programme activities to be carried out with the parents and the minor between sessions. These activities should be similar to the ones carried out by the consultant via VR. For example, when it’s night-time, using enough lighting, go through the individual rooms in the house, and play teleportation, looking for a specific toy that has been previously hidden by the parents. If you using the token economy, using tokens at home is also recommendable: for finding toys and exploring the rooms. Teach the parents never to force the child to do something he/she does not want to do. Whether scenes such as those which are used in gradual exposure are applied, it would also be a good idea for the parents to be present for the sessions so they can see how the coping develops during the VR sessions.
Teleportation (on child’s request) Help (on child’s request) Lying down on bed (on child’s request) Ambient light 75%
Session 3 to SessionN
Review achievements from the last session, go over the activities done at home and objectives set in the last session: Continue exploring the house to gain tokens and carry out missions.
Emotive performance techniques/Gradual and systematic exposure to the distinct spaces in the house. In function with the minor’s progress, gradual light intensity reduction. REMEMBER BY SETTING THE TOKENS CONFIGURATION SETTINGS (Easy, Medium, Difficult) YOU WILL IN TURN INCREASE THE TIME SPENT IN GAINING TOKENS.
Cognitive reconstruction, if necessary.
To favor confrontation and, in particular in the case of implementing emotive performances techniques, games (counterconditioning) could be introduced in the individual spaces. Be creative by offering a variety of games, get the child to make suggestions….
If you use gradual exposure playing games or distracting the child will not be necessary, use the tokens system as a confrontational reinforcement and repetition as a strategy in promoting the bedroom and end to the conditioned response.
• If you have used a token economy, within the last 2-3 sessions schedule a fading to the token economy: the exchanging of tokens for prizes becomes further apart and reinforcement becomes more social, from the environment itself (child’s autonomy) and self-administered.
Exercises at home:
When based on the emotive performance technique, continue with the kitchen, which will not be accessible, will also be visible from the zones described above, starting at the training zone.
Final session
Review achievements and objectives set from previous session. Lie down on bed with the light turned off (to proceed use rain and even storms if needed).
Systematic and Gradual exposure/Emotive performances techniques to distinct spaces in the house.”Tokens” configuration settings in difficult mode and lights offs. Cognitive reconstruction, and proceed.
If you have used environment tokens to carry out a token economy, make sure it is has been completely withdrawn: behaviors are maintained from natural and social effort and not from exchanging tokens.
Teleportation (on child’s request) Help (on child’s request) Lying down on bed (on child’s request) Ambient Light 25-0%
PLEASE REFER TO OUR CLINICAL GUIDE ON OBSERVATIONAL EVIDENCE THERAPEUTIC PROCEDURES AND HOW TO ADAPT THE INTERVENTION TO VIRTUAL REALITY ENVIRONMENTS WITH PSIOUS
2.3 An example of Fear Intervention to storms in adults
Example protocol designed to be applied on a biweekly or weekly basis, made up of 6 to 8 sessions, lasting 30- 45 minutes. A follow-up in 3 to 6 months is recommended.
Session 1
Inform the patient about fear of storms (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 development from 20-30 USA’s
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.
Review achievements and objectives set from previous session: reduce light in the environments and increase rain intensity.
From the second treatment session, it is recommended to start systematic and gradual exposure in light of virtual reality environments. Cognitive reconstruction, if applicable.
Show clinical progress to patient, using the reports provided in the platform.Reveal clinical progress to patient, using the reports provided in the platform.
Exercises at home:
Covert and/or assisted exposure by computer to the sound of rain (light-moderate) with heavy overcast imaging. Foster in vivo exposure
Lying down on bed Ambient light 25-0% Rain intensity 90%-100
Sesion 6 & 7
Review achievements from previous session and and set objectives for current session: generalization and overlearning
Systematic and gradual exposure in light of virtual reality environments. Cognitive reconstruction, and proceed.
Repeat each exercise twice, in function with levels of discomfort.
Reveal clinical progress to patient, using the reports provided in the platform.
Foster in vivo exposure and set follow-up at 3-6 months.
Item
Environment
Scene/setting
Event
At home watching television and it’s raining. One family member is not at home
Generalized Anxiety
Concerns about family
Reproduce
At home, just on way to do some errands. TV weather forecast warns of storms
Fear of flying
At home: daytime, rain
Forecast
Driving in the city at night in a storm.
Fear of driving
City: night, rain, maximum, driving, minimum
Circuit 1
Driving on the road at night in a storm
Fear of driving
Road, night, rain, driver, show, hide.
Highway, Medium speed,Bends
Taking a taxi by day in a storm
Fear of flying
On the way to the airport: day, rain.
Weather forecast on radio
At the airport, going to travel in bad weather
Fear of flying
Boarding area:day, rain, maximum
Window, Boarding call
Traveling on a plane in bad weather
Fear of flying
Plane:maximum day, rain, window,middle,off
Traveling on a plane in bad weather
Fear of flying
Plane:maximum, storm,- day window, behind,off
Taxi, Landing
Traveling on a plane in bad weather
Fear of flying
Plane: maximum, storm,day window, behind,off
Flight, Take-off, Light,Turbulences
3. Usage Recommendations
INTERVENTION IN CHILDREN:
When using emotive performances techniques, do remember to give a good introduction making it feel like a game. Psicobot will naturally give a clear explanation on how to “play” but don’t forget to give him a brief introduction. You could let the child meet Psicobot in video format, let him watch a Thor or Star Trek clip showing the child who teleportation is. Practise using the reinforcement “gesture” and say “Teleportation to…”: You could get the child to look at the mobile at the same time (before putting on the virtual reality glasses) so that the child already knows what movement he needs to make. Also practise naming the places the child can go to before beginning the game (training room, living room, bathroom, hall, bedroom).
Adapt the room to each session where the intervention is carried out. In general, feeling disorientated is common when wearing the glasses and feeling familiar with the room is always advisable, for example touch the seat with their calves when standing up. When using the emotive performances technique with children this is of utmost importance: getting them to play out “superhero” will make them get into the role in a jiffy!
Asking for a brief summary on what the child has understood is advisable, after listening to Psicobot’s instructions, and before beginning “the game”. Clarify and doubts or misunderstandings at this point.
If a child asks why he/she cannot go to the kitchen, bathroom or attic, tell him/her that these zones have a force field that is blocking teleportation, and Psicobot is looking for ways to unblock them…
If at any time the child plays a game “unenthusiastically” or is not “motivated”, let the child know they are not concentrating. And as a result that the counterconditioning is not working properly. Tell the child to copy the gesture they practised at the beginning of the session better to make it work.
The effect of the teleportation will be fascinating to the the child when he/she looks up down and down. Try to make sure the child looks up or down when making the “lively” movement associated with teleportation.
Make up games you can use during VR that parents can practise in vivo at home. For example finding a hidden object without them knowing (“Do not turn on lights!”), counting the objects in the rooms where it’s getting darker and darker, finding an object that we have requested, starting in the training area (e.g the tokens chart), playing hide and seek: where the child hides in one of the rooms (e.g lying down on the bed) asking them questions and he/she responds with hot or cold until we guess correctly. Try to be imaginative and let the child suggest the activities of interest.
If you use the token economy don’t forget to plan the intervention well which will in turn be very useful in setting the objectives between the work done at the consultation and the work done at the home of the minor.
INTERVENTION IN ADULTS:
Help the patient by introducing the items you are going to work on, before you start to work on the VR, is always a good way of starting the activation, and thus stimulates a sense of presence. Tell you patient that they are going to work at night, at home, in a storm and that they will sometimes be situated close to the window in the living room.
Remember the general sound in the platform will help you adjust the exposure. For example, you can lower the sound to lower the storm intensity in the case of storms.
Be imaginative! Use the different environments that Psious provides with the climate configuration settings (driving, generalized anxiety, travelling on a plane) to promote the generalized habituation.
GENERAL:
You can use the environments such as the house “travelling on a plane” so as to gain more flexibility in situations. You could also work bad weather and night in this situation. The generalized anxiety environment and, concerns for families will also enable you to work on the bad weather exposure, particularly, in managing cognitive distortions.
You can use the relaxation environments (diaphragmatic breathing and/or Jacobson) and mindfulness as a counterconditioning tool to promote the reciprocal inhibition procedure, if you use systematic desensitization in adults and emotive performance scenes in children.
You can use the fear of dark environment to help train diaphragmatic breathing lying down on the bed, at night to the sound of rain.
The electrodermal definition register will help you show your patient how physiological discomfort will vary during the sessions.
4. Recommended Bibliography
Antony, M.M., Craske, M.G. y Barlow, D.H. (2006). Mastering your fears and phobias: Client workbook (2a ed.). Londres Oxford University Press.
Arrindell, W. A. Dimensional structure and psychopathology correlates of the fear survey schedule (FSS-III) in a phobic population: A factorial definition of agoraphobia, Behaviour Research and Therapy, Volume 18, Issue 4, 1980, Pages 229-242, ISSN 0005-7967
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.http://www.libreriaolejnik.com/ventana. php?codig=31669
Carrobles, J.A. (1986). Cuestionario de Temores de Wope y Lang, FSS-III-122. En J.A.I. Carrobles, P. Bartolomé, P.T. Costa y T del Ser. La práctica de la terapia de conducta: Valencia: Promolibro.
Craske, M.G., Antony, M.M. y Barlow, D.H. (2006). Mastering your fears and phobias: Therapist guide (2a ed.). Londres: Oxford University Press.
Gutiérrez, C. et al.(2012): Características psicométricas del inventario de Miedos de Ollendick. CUaDERNos HisPaNoaMERiCaNos DE PsiCología, Vol 12 No 1, 85-93
Mikulas, W. L. y Coffman, M. G. (1989). Home-based treatment of children’s fear of the dark. En C.E. Schaefer y J.M. Briesmeister (Eds.), Handbook of parent training (pp. 179-202). Nueva York: John Wiley and Sons.
Matesanz, L. (2006): Datos para la adaptación castellana de la Escala de Temores (FSS). Análisis y Modificación de Conducta. Vol. 32, Nº 144.
Méndez, X. , Orgilés, A. y Espada, J.P. (2003). Escenificaciones emotivas para la fobia a la oscuridad: un ensayo controlado. International Journal of Clinical and Health Psychology. ISSN 1697-2600 2004, Vol. 4, No 3, pp. 505-520
Méndez, X. , Orgilés, A. y Rosa, A. I. (2005). Los tratamientos psicológicos en la fobia a la oscuridad: Una revisión cuantitativa. Anales de psicología. Vol. 21, no 1 (junio), 73-82
Muris, P., Merckelbach, H., Ollendick, T. H., King, N. J., & Bogie, N. (2001). Children’s nighttime fears: Parent-child ratings of frequency, content, origins, coping behaviors and severity. Behaviour Research and Therapy, 39(1), 13-28. doi: 10.1016/S0005-7967(99)00155-2
Lazarus, A. y Abramovitz, A. (1979). The use of “emotive imagery” in the treatment of children ́s phobias. En H.J. Eysenck (Ed.), Experimentos en terapia de conducta: experimentación con niños (vol. 3) (pp. 37-45). Madrid: Fundamentos
Olivares, J., Y Méndez, F.X. (2001).Técnicas de modificación de conducta. Madrid: Biblioteca Nueva.
Ollendick, T. H. (1979). Fear reduction techniques with children. En M. Hersen, R. M. Eisler y P. M. Miller (Eds.), Progress in behavior modification: Vol. 8 (pp. 127-168). Nueva York: Academic Press.
Ollendick, T. H. (1983). Reliability and validity of the revised fear survey schedule for children (FSSC-R), Behaviour Research and Therapy
Orgilés, A., Méndez, X. , y Espada, J.P. (2005)Tratamiento de la fobia a la oscuridad mediante entrenamiento a padres. Psicothema. Psicothema 2005. Vol. 17, no 1, pp. 9-14
Sardinero, E., Pedreira J.L. y Muñiz J.: El cuestionario CBCL de Achenbach: Adaptación española y aplicaciones clínico-epidemiológicas: http://www.copmadrid.org/webcopm/publicaciones/clinica/1997/Vol8/Arti3. Htm
Silverman, W.K, M, Albano, A.M y Sandín, B (2003): ADIS-IV: Centrevista para el diagnóstico de los trastornos de ansiedad en niños según el DSMIV : entrevista para el niño = (anxiety disorders interview schedule for DSM-IV: child version : child interview shedule). Ed. Klinik, 2003. España
5. Appendix
5.1. Token economy contingency table
5.2. Psicobot tokens
5.3 Hierarchy darkness and storms self-reporting (adults)
5.4 Hierarchy darkness and storms self-reporting (children)
. Psychological evaluation/intervention protocol proposed by Psious
PTSD Evaluation
Evaluation Objectives
Useful tools for PTSD evaluation
Usage Recommendations
Recommended Bibliography
1. Introduction to EMDR
EMDR is a bilateral simulation technique where, on the one hand ocular movements are being carried out, and on the other hand the disturbing thought is kept in mind. (Marín, C., Guillen, A. I., Vergara, S., 2016).
This technique was thought for patients with post traumatic stress disorder (PTSD), for having lived traumatic experiences such as natural disasters, assaults, sexual abuse, etc. Saphiro(2001) differentiated between two types of trauma: “T” type, that corresponds to traumas with danger of death and “t” type, that corresponds to those situations with chronicity, like school bullying situations. According to Saphiro (2001), nearly all disorders can have a traumatic origin, so the use of EMDR is justified in other problems, such as: phobias, addictions, depressive disorders, generalized anxiety, OCD, body image in eating disorders, personality disorders and behavioural problems among others. The EMDR Virtual Reality environment will favor the spacious effect and relaxation due to the patient’s situation which will be at the top of a hill surrounded by trees and mountains. Also, the fact that the therapist doesn’t have to go with the ocular movements can favor and help the patient by the evocation of the disturbing thoughts.
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. PTSD Evaluation
In this section we propose different strategies and tools on how to evaluate TEPT, as a previous step to using the EMDR technique.
2.1.1 Evaluation objectives
Evaluating the presence and comorbidity with other emotional disorders.
Evaluating the presence of reexperimentation, avoidance and activation increase.
Defining anxiogenic stimuli configurations and in what grade.
Evaluating presence of distorted thoughts.
2.1.2 Useful tools for the Posttraumatic stress disorder
(PTSD) 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
CAPS-DX interview
Scale (TOP-8)
Índice Global de Duke DGRP
Self-report:
PTSD Symptom Scale
Impact of Event Scale (IES)
MMPI PTSD Subscale
PTSD Symtom Scale (PSS)
Child PTSD Symptom Scale (CPSS)
Traumatic Events Questionnaire (TEQ)
Davidson Trauma Scale (DTS)
Mississippi Scale for Combat-Related
The critical war zone experiences (CWE) scale
3. Usage Recommendations
The environment for EMDR will be used to alleviate the symptomatology caused by one or several traumatic situations. For that, the idea is that the the patient, immersed in the scene, feels a certain relaxation feeling caused by the landscape and the environmental sounds. Then, the element that will guide the ocular movements will be introduced, and the speed and direction will be adapted depending on the objectives and characteristics of the subject. Remember that you can also add auditory stimuli that go together with the visual ones.
To favor a better sense of presence, the therapist can contribute with comments encouraging the patient to remember, and this way make the patient re-live the traumatic situation at a cognitive level.
4. Recommended Bibliography
Marín, C., Guillén, A. I., y Vergara, S. (2016). Nacimiento, desarrollo y evolución de la desensibilización y el reprocesamiento por medio de movimientos oculares (EMDR). Clínica de Salud, 27 (3), 101-114. http://dx.doi.org.sire.ub.edu/10.1016/j.clysa.2016.09.001
Echeburúa, E., de Corral, P., Amor, P. J., Zubizarreta, I., y Sarasua, B. (1997). Escala de gravedad de síntomas del Trastorno de Estrés Postraumático: Propiedades Psicométicas. Análisis y Modificación de Conducta, 23 (90), 503-526. http://zutitu.com/FitxersWeb/20/ARTICULO10.pdf
Bustos, P., Rincón, P., y Aedo, J. (2009). Validación Preliminar de la Escala Infantil de Síntomas del Trastorno de Estrés Postraumático (Child PTSD Symptom Scale, CPSS) en Niños/as y Adolescentes Víctimas de Violencia Sexual. PSYKHE , 18 (2), 113-126. http://dx.doi.org/10.4067/S0718-22282009000200008
Bobes, J., Calcedo, A., García, M.,François, M., Rico, F., González, M. P., Bascarán, M. T., y Bousoño, M. (2000). Actas Esp Psiquiatr, 28 (4), 207- 218. https://www.researchgate.net/profile/Julio_Bobes/ publication/229011090_Evaluacion_de_las_propiedades_ psicometricas_de_la_version_espanola_de_cinco_cuestionarios_ para_la_evaluacion_del_Trastorno_de_Estres_Postraumatico/ links/54a7a5740cf267bdb90a16b2/Evaluacion-de-las-propiedadespsicometricas-de-la-version-espanola-de-cinco-cuestionarios-para-laevaluacion-del-Trastorno-de-Estres-Postraumatico.pdf
Kimbrel, N. A., Evans, L. D., Patel, A. B., Wilson, L. C., Meyer, E. C., Gulliver, S. B., Morissette, S. B. (2014). The critical warzone experiences (CWE) scale: Initial psychometric properties and association with PTSD, anxiety, and depression. Psychiatry Research, 220 (3), 1118-1124. http://dx.doi.org.sire.ub.edu/10.1016/j.psychres.2014.08.053
Disorders of the Eating Behavior and Virtual Reality
Psychological evaluation/intervention protocol proposed by Psious
Evaluation of the Eating Behavior Disorders
Proposal of Intervention in the presence of Eating Disorders
Recommendations for use
Recommended Bibliography
Annexes
Self-registration of body image (situation/thought/emotion)
Self-report hierarchy for Eating Disorders: Restaurant (Psious)
1. Disorders of the Eating Behavior and Virtual Reality
Virtual Reality (VR) is a beneficial tool for the treatment of Eating Disorders, also known as Eating Behavior Disorders (EBD), especially Bulimia Nervosa (BN), Nervous Anorexia (AN) and Binge Eating Disorder (BED).
Several studies demonstrate the effectiveness of VR as an exposure therapy to reduce the desire or impulse towards food and to normalize eating patterns, as well as to help patients to be aware of their distortion of their own body image, to confront and correct such distortion, get a more realistic perception and reduce dissatisfaction with one’s own body (Gutiérrez-Maldonado et al., 2016; Lafond, Riva, Gutierrez-Maldonado, & Wiederhold, 2016; Lozano et al, 2002; Marco, Perpiñá & Botella, 2013; Manzoni et al, 2013; Manzoni et al, 2016; Perpiñá, Botella & Baños, 2003; Perpiñá et al., 2013; Pla-Sanjuanelo et al., 2015; Riva, 2011: Riva et al, 1999; Wiederhold, Riva, & GutiérrezMaldonado, 2016).
2. Psychological evaluation/ intervention protocol proposed by Psious
*All the information contained in this section is indicative. The Psious environments are therapeutic tools that must be used by the healthcare professional within a process of evaluation and intervention designed according to the characteristics and needs of the user. Also remember that you have the General Clinical Guide where you have more information on how to adapt psychological intervention techniques (exposure, DS, cognitive restructuring, etc.) to Psious environments.
2.1. Evaluation of the Eating Behavior Disorders
2.1.1 Objectives of the evaluation
Evaluate the concern for body image, eating habits, diet and physical exercise, the perception of one’s body figure, self-image and self-esteem.
Evaluate the presence of altered eating behaviors (food restriction, binge eating, compensatory behavior…).
Evaluate the presence of distorted thoughts in relation to food / body image.
Evaluate possible comorbidities (depression, anxiety, self-injurious behavior, etc.).
Define stimulation configurations feared by the patient and to what degree: Elaboration of the exposure hierarchy.
2.1.2 Some useful instruments for the Eating Behavior
Disorders evaluation
Taking into account the objectives of the evaluation, we will list some tools and instruments that may be useful to obtain relevant information about the characteristics of your user. Remember that a good definition of objectives, characterization of the patient and planning of the intervention are important for the efficiency and therapeutic efficacy, as well as for the satisfaction of your patients. In the bibliography you will find the articles in which to review the characteristics of the instruments proposed below:
Structured Clinical Interview for disorders of Axis I of the DSM-IV (First, Spitzer, Williams, Gibbon, 1997)
Diagnostic Interview for Children and Adolescents (Shaffer, Fisher, Lucas, Dulcan, Schwab, 2000; Bravo et al, 2001; Ezpeleta L, et al., 1997)
Autoreports:
Body Image:
Gardner’s Body Image Evaluation Scale (Gardner, Stark, Jackson, Friedman, 1999).
Eating Attitudes Test (EAT-40) (Garner and Garfinkel, 1979; Castro, Toro, Salmero, Guimera, 1991).
Eating Disorders Exam – Quetionnaire (EDE-Q) (Fairburn y Beglin, 1994; Elder y Grilo, 2007).
Edinburgh Bulimia Test (BITE) (Henderson and Freeman, 1987).
Bulimia Test (BULIT) (Smith and Thelen, 1984; Vázquez-Morejón et aL, 2007)
Desire / impulse towards food
State and Trait Food Cravings Questionnaires (FCQ-S, FCQ-T)(Cepeda et al, 2000).
Motivation for the treatment
Attitudes Questionnaire against Change in Eating Disorders (ACTA) (Beato Fernández, Rodríguez Cano, 2003).
3.2. Proposal of Intervention in the presence of Eating
Disorders
It is important to note that in this section we will only show and suggest some points to guide the intervention with our patient through the two virtual environments available to Psious for the treatment of EDs. However, we must not forget that the intervention proposal presented below only shows a part of it, because the full treatment of the EDs also requires other procedures (diagnostic interview, psychometric evaluation, structuring of dietary guidelines, prevention of relapse, etc.) and will be more extensive.
SESSIONS TO WORK ON THE DISTORTION OF THE BODY IMAGE: “DRESSING ROOM” SCENE
The intervention sessions described below do not necessarily have to be consecutive, but may be spaced throughout the treatment according to the phase of the treatment (at the beginning, in the middle and at the end). This is so because the perception of one’s body image is hardly going to be modified week by week, so it would make more sense to evaluate their changes according to the phase of treatment in which the patient is located.
SESSION 1: At the beginning of the therapy process
Provide the necessary basic information on concepts related to body image (ideal of beauty, how it has evolved throughout history …).
Ask the patient to what degree (from 0 to 10) he is satisfied with his body in general, with which parts of it he is most dissatisfied and which ones he likes the most.
Assess the fear / discomfort felt by the patient before having to see his own body and to what extent he would avoid it (or feel the need to do so) if this were possible.
Present and justify the use of VR in this context. Give instructions on how the environment works and let the patient become familiar with the tool.
Start experience through VR:
Measure the patient’s BMI and select the corresponding category for each part of the body (“slim”, “very slim”, etc.) according to the table of equivalences provided in this handbook.
Ask the patient to adjust the dimensions of each part of the body of the avatar that appears in the VR glasses, as perceived by himself. You may ask: “What parts of your body do you perceive as different from those of the avatar and, therefore, are you going to modify?”
When the patient has established the dimensions of the avatar, we can formulate and record the answers to the following questions:
“Is this how you see yourself?”
“What is your level of discomfort with this image (from 0 to 10)?”
“What is your level of satisfaction with this image (from 0 to 10)?”
“To what degree do you think your body is really like that (from 0 to 10)?”
“To what degree do you think others see you this way too (from 0 to 10)?”
Activate the event “Avatars comparison”.
Discuss with the patient the distortion of his own image, which he can now observe objectively through the real silhouette. This will lead to a process of cognitive restructuring. We can ask questions like:
“This is your real body, what do you think?”
“What is your level of discomfort with this image (from 0 to 10)?”
“What is your level of satisfaction with this image (from 0 to 10)?”
“Are both figures (avatar and silhouette) the same?”
“What differences do you see between the two?”, “What body parts do you have distorted?”
“What makes you believe that you / they (to mention the distorted part of the body) are / are bigger / bigger than they really are / are?”
“How does this affect you emotionally?”
“How does this affect your behavior (avoidance, diets …)?”
“To what degree do you accept that you overestimate the dimensions of your body and that your perception of your own body image is different from that of your real body (from 0 to 10)?”
“Could we assume that the parts of your body that least match reality are those that dislike you the most?”
“What have you learned or what conclusions have you drawn today?”
Explain how to perform a self-registration of situations, thoughts and emotions related to body image (see appendix) (ex .: Situation: “I went to buy clothes and there were no pants of my size.” Thought: “Surely not they make fat pants like me.” Emotion: “Frustration, anger, shame”).
Explain, if deemed necessary, how to practice a guided SD with an audio tape to work the exposure in imagination to bodily areas (to reduce discomfort to one’s body).
Tasks between sessions:
Do daily self-registration of situations, thoughts and emotions related to body image.
Practice the guided SD with an audio tape to work the exposure in imagination to corporal areas, if applicable.
SESSION 2: Around the halfway of the therapy process
Review the daily self-registrations made to date and perform the relevant cognitive restructuring.
Ask the patient to what degree (from 0 to 10) he is satisfied with his body in general, with which parts of it he is most dissatisfied, and which ones he likes the most, at this moment of treatment.
Assess the fear / discomfort felt by the patient in this phase of treatment before having to see his own body and to what extent he would avoid it (or feel the need to do so) if this were possible
Start the experience by VR following the same steps described above in points 5 and 6 of Session 1. Note: In this phase of treatment it is possible that the actual body size of the patient has changed (whether the patient has gone up or down in weight, etc.). If so, the patient’s current BMI should be taken into account to introduce the new dimensions of each part of the body to the platform, in order to generate its new real silhouette.
Tasks between sessions:
Continue with self-registration of situations, thoughts and emotions related to body image.
Continue practicing the SD guided with an audio tape to work the exposure in imagination to corporal areas, if necessary.
SESSION 3: At the end of the therapy process
Review the daily self-registrations made to date and perform the relevant cognitive restructuring
Ask the patient to what degree (from 0 to 10) he is satisfied with his body in general, with which parts of it he is most dissatisfied, and which ones he likes the most, at this moment of treatment.
Assess the fear / discomfort felt by the patient in this phase of treatment before having to see his own body and to what extent he would avoid it (or feel the need to do so) if this were possible.
Start the experience by VR following the same steps described above in points 5 and 6 of Session 1. Note: In this phase of treatment it is possible that the actual body size of the patient has changed (whether the patient has gone up or down in weight, etc.). If so, the patient’s current BMI should be taken into account to introduce the new dimensions of each part of the body to the platform, in order to generate its new real silhouette. The final objective will be for the patient to adjust as much as possible the estimated figure (avatar with subjective measures) to his real measures (silhouette with real measurements).
Emphasize and reinforce the improvements achieved: Reduction of distortion (show how the avatar with the subjective measures of the patient and the real silhouette have increasingly seemed more) and decrease in levels of anxiety / discomfort (SUDs), if proceeds.
Tasks:
Follow with self-registration of situations, thoughts and emotions related to body image, with the aim that the patient himself who from now on is able to restructure their own thoughts / emotions about it. the learned.
Continue practicing the SD guided with an audio tape to work the exposure in imagination to corporal areas, if it continues to agree.
SESSIONS TO WORK ON THE EXPOSURE TO THE FOOD:
“RESTAURANT” SCENE
SESSION 1:
The objective of this first session will be to present and justify the use of VR in the treatment, and for the patient to get used to the tool.
Present and justify the techniques that will be used throughout the treatment: exposure with VR and live exposure, etc.
Show the VR “Restaurant” environment, explain how it works, and what will the work’s dynamics be like.
Elaborate an exposure hierarchy (see appendix) ordered by Subjective Units of Distress (SUDs) from 0 to 100. Note:
If we wish to work on the fear of consuming certain foods: Elaborate a hierarchy considering feared or “forbidden” foods and the situations that accompany 18 Eating Disorders Handbook them (eating with people, eating alone, etc.), arranging the items from those producing lesser anxiety to those generating more anxiety.
. If we wish to work on the intake control (desire/”craving” or impulse towards food): Build a hierarchy considering foods and situations that produce a greater desire/impulse to eat, arranging the items from those which cause less urgency/impulse to those causing more urgency/impulse.
Begin the gradual and systematic exposure to the “Restaurant” environment: Propose to begin by exposing the patient to one of the hierarchy’s items that is close to 20-30 SUDs (see example of items below).
Explain that the same will be done in the following sessions, progressively increasing the difficulty (advancing in the hierarchy’s items):
For fear of consuming certain foods: Trying foods and situations that produce greater fear
To control the intake and compensatory behaviors: Trying foods and situations that produce a greater desire or impulse to eat, without the possibility of binge eating or compensatory behavior.
Note: From now on, using the present intervention example, we will work on a hypothetical case of exposure due to fear of consuming certain foods (option “a”).
Item
SUDs
Configuration V.:
Event
At the restaurant, alone, eating the diuretic/hypocaloric menu:
20
Company: Alone
Menu + Menu 2 (diuretic)/ Menu 4 (hypocaloric)
At the restaurant, accompanied, eating the diuretic/hypocaloric menu, while talking about a neutral topic:
25
Company: Accompanied. Conversation: Neutral (examples of phrases: “I have a lot of free time lately, and I like to use it to watch movies, one of my favorite hobbies”; “Yesterday, I saw a movie I really liked, I think it was called The Magic of Belle Island”).
Menu + Menu 2 (diuretic)/ Menu 4 (hypocaloric)
At the restaurant, accompanied, eating the diuretic/hypocaloric menu, while they are silent:
30
Company: Accompanied Conversation: Silence
Events: Menu + Menu 2 (diuretic)/ Menu 4 (hypocaloric)
SESSION 2:
Review the achievements of the previous session and establish objectives for this session: To be in the restaurant, accompanied, eating the diuretic/hypocaloric menu, while talking about topics related to food/physical appearance.
Continue with the gradual and systematic exposure to the “Restaurant” environment: Expose the patient to any of the hierarchy’s items close to 35-50 SUDs (see example item below). Cognitive restructuring, if applicable: while the patient is being exposed, ask him/her about his/her thoughts, emotions and the difficulties he/she is experiencing (e.g., “I will not be able to eat,” “to talk about these subjects while eating generates a lot of anxiety for me”…).
Using the platform reports, show the patient the clinical advances achieved
Homework between sessions: Try to eat together with other people (friends, coworkers, family…), even if the patient still does not dare to eat a normalized diet with them.
ítem
USAs
V. Configuración
Evento
At the restaurant, accompanied, eating the diuretic/hypocaloric menu, while talking about topics related to food/physical appearance:
50
Company: Accompanied Conversation: Uncomfortable (examples of phrases: “Mmmm… how good is this!”; “You know that I brought you here because I’ve been told you can eat very well in this restaurant.”)
Event: Menu + Menu 2 (diuretic)/ Menu 4 (hypocaloric)
SESSION 3:
Review the achievements of the previous session and establish objectives for this session: To be in the restaurant, accompanied, eating the standard menu, while talking about a neutral topic.
Continue with the gradual and systematic exposure to the “Restaurant” environment: Expose the patient to any of the hierarchy’s items close to 55-70 SUDs (see example items below). Cognitive restructuring, if applicable: while the patient is being exposed, ask him/her about his/her thoughts, emotions and the difficulties he/she is experiencing (e.g., “I will not be able to eat this”…).
Using the platform reports, show the patient the clinical advances achieved
Homework between sessions: Try to eat together with other people (friends, coworkers, family…) dishes and quantities belonging to a normalized diet (without restrictions or consuming low-calorie foods only).
ítem
USAs
V. Configuración
Evento
At the restaurant, alone, eating the standard menu:
65
Company: Alone
Menu + Menu 3 (standard)
At the restaurant, accompanied, eating the standard menu, while talking about a neutral topic:
70
Company: Accompanied Conversation: Neutral (examples of phrases: “I like films a lot, almost all genres, and even though I watch many movies at home, I believe there is nothing quite like going to the movies”; “I think a movie they have been promoting for some time will be released this weekend, I don’t remember what it’s called, but I think it’s a scary one”).
Menu + Menu 3 (standard)
SESSION 4:
Review the achievements of the previous session and establish objectives for this session: To be at the restaurant, accompanied, eating the standard menu, while talking about topics related to food/physical appearance.
Continue with the gradual and systematic exposure to the “Restaurant” environment: Expose the patient to any of the hierarchy’s items close to 75-80 SUDs (see example items below). Cognitive restructuring, if applicable: while the patient is being exposed, ask him/her about his/her thoughts, emotions and the difficulties he/she is experiencing (e.g., “I will not be able to eat this,” “to talk about these subjects while eating generates a lot of anxiety for me”…).
Using the platform reports, show the patient the clinical advances achieved.
Homework between sessions: Try to eat together with other people (friends, co-workers, family…) dishes and quantities belonging to a normalized diet (without restrictions or consuming low-calorie foods only), while the patient start (if not done by others) a talk regarding physical appearance/food topics that generates some discomfort (e.g., “What is your favorite food? I have always liked macaroni with tomato”, etc.) with the aim of talking about these topics normally and without feeling so much anxiety
ítem
USAs
V. Configuración
Evento
: At the restaurant, accompanied, eating the standard menu, while silent:
75
Company: Accompanied Conversation: Silence
Event: Menu + Menu 3 (standard)
At the restaurant, accompanied, eating the standard menu, while talking about topics related to food/physical appearance:
80
Company: Accompanied Conversation: Uncomfortable (examples of phrases: “Now that I think about it, maybe tomorrow afternoon I won’t be able to meet you because I want to go to the gym, I have not been there for days…”; “I believe I haven’t told you I’m thinking of going to the Islands in summer… I would have to buy a new swimsuit, but I can’t find one that I like how it makes me look…”).
Events: Menu + Menu 3 (standard)
SESSION 5:
Review the achievements of the previous session and establish objectives for this session: To be at the restaurant, accompanied, eating the hypercaloric menu, while talking about a neutral topic.
Continue with the gradual and systematic exposure to the “Restaurant” environment: Expose the patient to any of the hierarchy’s items close to 85-90 SUDs (see example items below). Cognitive restructuring, if applicable: while the patient is being exposed, ask him/her about his/her thoughts, emotions and the difficulties he/she is experiencing (e.g., “I will not be able to eat this,” “this food has a lot of fat,” “I feel I’m going to put on weight if I eat this,” “if there is someone with me, I get more distracted while I eat, but if I’m alone, I’m more focused on the food…”).
Using the platform reports, show the patient the clinical advances achieved.
Homework between sessions: Try to eat, both alone and with other people (friends, co-workers, family, both at home and at a family/friends meal…), some “forbidden” foods (with higher caloric content) that generate discomfort (e.g., pizza, pasta, chocolate, soft drinks with high sugar content…).
ítem
USAs
V. Configuración
Evento
At the restaurant, alone, eating the hypercaloric menu
85
Menu + Menu 1 (hypercaloric)
At the restaurant, accompanied, eating the hypercaloric menu, while talking about a neutral topic
90
Company: Accompanied Conversation: Neutral (examples of phrases: “Next month, there will be a 2×1 promo in all the city’s cinemas, I saw it on the internet”; “I’ve noticed that the more films I watch, the more I notice the amount of good stories you can write about”).
Menu + Menu 1 (hypercaloric)
SESSION 6:
Review the achievements of the previous session and establish objectives for this session: To be at the restaurant, accompanied, eating the hypercaloric menu, while talking about topics related to food/physical appearance.
Continue with the gradual and systematic exposure to the “Restaurant” environment: Expose the patient to any of the hierarchy’s items close to 95-100 SUDs (see example items below). Cognitive restructuring, if applicable: while the patient is being exposed, ask him/her about his/her thoughts, emotions and the difficulties he/she is experiencing (e.g., “I will not be able to eat this,” “this food has a lot of fat,” “I feel I’m going to put on weight if I eat this,“” if there is someone with me, I get more distracted while I eat, but if I’m alone, I’m more focused on the food “, ”when somebody tells me I look better, I think it’s because I gained weight right away”…).
Show the clinical advances achieved using the platform reports, analyze the improvements achieved (reduction of anxiety when compared to the first exposures), and provide the final feedback to the patient regarding the results obtained.
Homework: Eat together with other people (friends, coworkers, family, both at home and at a family/friends meals…) some “forbidden” foods (with higher caloric content) that generate discomfort (e.g., pizza, pasta, chocolate, soft drinks with high sugar content…), while the patient start (if not done by others) a talk regarding physical appearance/food topics that generates some discomfort (e.g., “What is your favorite food? I have always liked macaroni with tomato”, etc.) with the aim of talking about these topics normally and without feeling so much anxiety, while being capable of incorporating previously “forbidden” foods to his/her diet.
ítem
USAs
V. Configuración
Evento
At the restaurant, accompanied, eating the hypercaloric menu, while silent:
95
Company: Accompanied Conversation: Silence
Menu + Menu 1 (hypercaloric)
At the restaurant, accompanied, eating the hypercaloric menu, while talking about topics related to food/physical appearance:
100
Company: Accompanied Conversation: Uncomfortable (examples of phrases: “You know, I think you look much better”; “Oh! I forgot to tell you that we have organized a barbecue next week, I’m counting on you to come…”).
Carta + Menu + Menu 1 (hypercaloric)
3. Recommendations for use
It is important to accompany the exhibition with comments, questions or indications so that the patient becomes more in a situation and experiences the exhibition more realistically. For example, in the Dressing Room scene, comments like “Imagine that this is your real body, that you are the one in this costume right now,” etc. as they could be useful. In the Restaurant scene, we could also make interventions such as “Try to imagine you are eating these foods as if they were real, try to focus on their flavor, texture, temperature…”, “What thoughts come to your mind when you eat in this restaurant while surrounded by other people?”, etc.
4. Recommended Bibliography
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Beato Fernández L, Rodríguez Cano T. (2003). Attitudes towards change in eating disorders (ACTA). Development and psychometric properties. Actas Esp Psiquiatr, 31(3), 111-119.
Bravo M, Ribera J, Rubio-Stipec M, Canino G, Shrout P, Ramírez R, Fábregas L, Chavez L, Alegría M, Bauermeister JJ, Martínez Taboas A. (2001). Test-retest reliability of the Spanish version of the Diagnostic Interview Schedule for Children (DISC-IV). J Abnorm Child Psychol, 29(5), 433-44.
Cardi, V., Krug, I., Perpiñá, C., Mataix-Cols, D., Roncero, M., & Treasure, J. (2012). The use of a nonimmersive virtual reality programme in Anorexia nervosa: A single case-report. European Eating Disorders Review, 20(3), 240–245. https://doi.org/10.1002/erv.1155
Castro J, Toro J, Salmero M, Guimera E. (1991). The Eating Attitude Test: validation of the Spanish version. Psychol Assess, 7, 175-190.
Cepeda-Benito, D.H. Gleaves, M.C. Fernández, J. Vila, T.L. Williams, J. Reinoso. (2000). The development and validation of Spanish versions of the State and Trait Food Cravings Questionnaires. Behavior Research and Therapy, 38, 1125-1138.
Cooper P, Taylor M. (1988). Body image disturbances in bulimia nervosa. Br J Psychiatry., 153(Suppl 2), 32-36
Elder KA, Grilo CM. (2007). The Spanish language version of the Eating Disorder Examination Questionnaire: comparison with the Spanish language version of the eating disorder examination and test-retest reliability. Behav Res Ther, 45(6), 1369-1377.
Ezpeleta L, Osa N de la, Júdez J, Doménech JM, Navarro JB, Losilla JM. (1997). Fiabilidad testretest de la adaptación española de la Diagnostic Interview Children and Adolescent- DICA-R. Psichothema, 9(3), 529-39.
Fairburn CG, Beglin SJ. (1994). Assessment of eating disorders: interview or self-report questionnaire? Int J Eat Disord., 16(4), 363-70.
First MB, Spitzer RL, Williams JB, Gibbon, M. (1997). Entrevista Clínica Estructurada para los trastornos del Eje I del DSM-IV, Versión Clínica (SCID-I-VC). Barcelona: Masson.
Gardner RM, Stark K, Jackson NA, Friedman BN. (1999). Development and validation of two new scales for assessment of body-image. Percept Mot Skills, 89 (3 Pt 1), 981-93.
Garner, D. M. (2004). Eating Disorder Inventory-3. Professional Manual. Lutz, FL: Psychological Assessment Resources, Inc.
Garner DM, Garfinkel PE. (1979). The Eating Attitudes Test: an index of the symptoms of anorexia nervosa. Psychol Med, 9, 273-279.
Gila A, Castro J, Gómez MJ, Toro J, Salamero M. (1999). The Body Attitude Test: validation of the Spanish version. Eat Weight Disord., 4(4),175-8.
Gutiérrez-Maldonado, J., Pla-Sanjuanelo, J., & Ferrer-García, M. (2016). Cue-exposure software for the treatment of bulimia nervosa and binge eating disorder. Psicothema, 28(4), 363–369. https://doi.org/10.7334/psicothema2014.274
Gutiérrez-Maldonado, J., Wiederhold, B. K., & Riva, G. (2016). Future Directions: How Virtual Reality Can Further Improve the Assessment and Treatment of Eating Disorders and Obesity. Cyberpsychology, Behavior, and Social Networking, 19(2), 148–153. https://doi.org/10.1089/cyber.2015.0412
Henderson M, Freeman CP. (1987). A self-rating scale for bulimia. The ‘BITE’. Br J Psychiatry, 150, 18 -24.
Lafond, E., Riva, G., Gutierrez-Maldonado, J., & Wiederhold, B. K. (2016). Eating Disorders and Obesity in Virtual Reality: A Comprehensive Research Chart. Cyberpsychology, Behavior and Social Networking, 19(2), 141–147. https://doi.org/10.1089/cyber.2016.29026.ela
Lozano, J. A., Alcaniz, M., Gil, J. A., Moserrat, C., Juan, M. C., Grau, V., & Varvaro, H. (2002). Virtual food in virtual environments for the treatment of eating disorders. Stud Health Technol Inform, 85, 268–273.
Manzoni, G. M., Cesa, G. L., Bacchetta, M., Castelnuovo, G., Conti, S., Gaggioli, A., … Riva, G. (2013). Virtual reality for enhancing the cognitive behavioral treatment of obesity with binge eating disorder: randomized controlled study with one-year follow-up. Journal of Medical Internet Research, 15, e113. https://doi.org/http://dx.doi.org/10.2196/jmir.2441.
Manzoni, G. M., Cesa, G. L., Bacchetta, M., Castelnuovo, G., Conti, S., Gaggioli, A., … Riva, G. (2016). Virtual reality for enhancing the cognitive behavioral treatment of obesity with binge eating disorder: randomized controlled study with one-year follow-up. Journal of Medical Internet Research, 19(2), 134–140. https://doi.org/10.1089/cyber.2015.0208
Marco, J. H., Perpiñá, C., & Botella, C. (2013). Effectiveness of cognitive behavioral therapy supported by virtual reality in the treatment of body image in eating disorders: One year followup. Psychiatry Research, 209, 619–625. https://doi.org/10.1016/j.psychres.2013.02.023
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Perpiñá, C., Roncero, M., Fernández-Aranda, F., Jiménez-Murcia, S., Forcano, L., & Sánchez, I. (2013). Clinical validation of a virtual environment for normalizing eating patterns in eating disorders. Comprehensive Psychiatry, 54, 680–686. https://doi.org/10.1016/j.comppsych.2013.01.007
Pla-Sanjuanelo, J., Ferrer-Garcia, M., Gutiérrez-Maldonado, J., Vilalta-Abella, F., Andreu-Gracia, A., Dakanalis, A., … Sánchez, I. (2015). Trait and State Craving as Indicators of Validity of VR-based Software for Binge Eating Treatment. Studies in Health Technology and Informatics, 219, 141–146
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Vázquez Morejón, A. J. , Jiménez García-Bóveda,R., Vázquez-Morejón Jiménez, R. (2007). Psychometric characteristics of Spanish adaptation of a Test for Bulimia (BULIT). Actas Españolas de Psiquiatría, 35 (5), 309-314
Wiederhold, B. K., Riva, G., & Gutiérrez-Maldonado, J. (2016). Virtual Reality in the Assessment and Treatment of Weight-Related Disorders. Cyberpsychology, Behavior and Social Networking, 19(2), 67–73. https://doi.org/10.1089/cyber.2016.0012
5. Annexes
5.1 Self-registration of body image
(situation/thought/emotion)
Date/Time
Situation
Thought
Emotion
5.1 Self-report hierarchy for Eating Disorders: Restaurant
(Psious)
ÍTEM
Anxiety/Urgency Level (0-100)
Being in a restaurant, alone, drinking a green tea and eating green salad and a fruit (e.g., kiwi) as desert.
Being in a restaurant, alone, drinking water and eating grilled chicken breast with a salad, and natural yogurt as dessert.
Being in a restaurant accompanied (by a friend, family member, partner…) where there are more tables with people surrounding me, and I am drinking green tea and eating a green salad and a fruit (e.g., kiwi) as desert, while my companion and I remain silent.
Being in a restaurant accompanied (by a friend, family member, partner…) where there are more tables with people surrounding me, and I am drinking green tea and eating a green salad and a fruit (e.g., kiwi) as desert, while my companion talks to me about topics that have nothing to do with food or physical appearance (e.g., films).
Being in a restaurant accompanied (by a friend, family member, partner…) where there are more tables with people surrounding me, and I am drinking green tea and eating a green salad and a fruit (e.g., kiwi) as desert, while my companion talks to me about topics that are more directly or indirectly related to food and physical appearance (e.g., going to the gym, buying clothes, organizing a barbecue…).
Being in a restaurant accompanied (by a friend, family member, partner…) where there are more tables with people surrounding me, and I am drinking water and eating grilled chicken breast with a salad, and natural yogurt as dessert, while my companion and I remain silent.
Being in a restaurant accompanied (by a friend, family member, partner…) where there are more tables with people surrounding me, and I am drinking water and eating grilled chicken breast with a salad, and natural yogurt as dessert, while my companion talks to me about topics that have nothing to do with food or physical appearance (e.g., films).
Being in a restaurant accompanied (by a friend, family member, partner…) where there are more tables with people surrounding me, and I am drinking water and eating grilled chicken breast with a salad, and natural yogurt as dessert, while my companion talks to me about topics that are more directly or indirectly related to food and physical appearance (e.g., going to the gym, buying clothes, organizing a barbecue…).
Being in a restaurant, alone, drinking water and eating a tortilla as a first course, a dish of steamed vegetables as second course, and natural yogurt as dessert.
Being in a restaurant accompanied (by a friend, family member, partner…) where there are more tables with people surrounding me, and drinking water and eating a tortilla as a first course, a dish of steamed vegetables as second course, and natural yogurt as dessert, while my companion and I remain silent.
Being in a restaurant accompanied (by a friend, family member, partner…) where there are more tables with people surrounding me, and drinking water and eating a tortilla as a first course, a dish of steamed vegetables as second course, and natural yogurt as dessert, while my companion talks to me about topics that have nothing to do with food or physical appearance (e.g., films).
Being in a restaurant accompanied (by a friend, family member, partner…) where there are more tables with people surrounding me, and drinking water and eating a tortilla as a first course, a dish of steamed vegetables as second course, and natural yogurt as dessert, while my companion talks to me about topics that are more directly or indirectly related to food and physical appearance (e.g., going to the gym, buying clothes, organizing a barbecue…).
Being in a restaurant, alone, having a soft drink (e.g., Coca-Cola) and eating a hamburger with chips and a piece of cake as dessert.
Being in a restaurant accompanied (by a friend, family member, partner…) where there are more tables with people surrounding me, and I am having a soft drink (e.g., Coca-Cola) and eating a hamburger with chips and a piece of cake as dessert, while my companion and I remain silent.
Being in a restaurant accompanied (by a friend, family member, partner…) where there are more tables with people surrounding me, and I am having a soft drink (e.g., Coca-Cola) and eating a hamburger with chips and a piece of cake as dessert, while my companion talks to me about topics that have nothing to do with food or physical appearance (e.g., films).
Being in a restaurant accompanied (by a friend, family member, partner…) where there are more tables with people surrounding me, and I am having a soft drink (e.g., Coca-Cola) and eating a hamburger with chips and a piece of cake as dessert, while my companion talks to me about topics that are more directly or indirectly related to food and physical appearance (e.g., going to the gym, buying clothes, organizing a barbecue…).
Psychological evaluation/intervention protocol proposed by Psious
Pain and Anxiety Evaluation
Evaluation objectives
Some useful tools for the evaluation of Chronic Pain and Anxiety
Intervention on Pain and Anxiety
Intervention with virtual reality proposal to reduce the pain during diagnostic tests
Use Recommendations
Recommended Bibliography
1. Distraction and Virtual Reality
Pain, despite being an unpleasant sensation, is a vital alarm system of the body since it allows the individual to recognize some stimulus harmful to the body tissue. Acute pain, because of its short duration, ends once the cause is resolved. However, chronic pain loses the alarm function to become an obstacle to achieve the life quality. This pain can be caused by various conditions, and is resistant to standard treatments (Kato, J., Agalave, N. M., and Svensson, C.I., 2016). Some of the causes are burns, cancer, fibromyalgia, among others.
In relation to anxiety, it is a normal reaction to stress. It serves to help a person with a difficult situation and to enable them to deal with it. This type of anxiety is adaptive, but when it becomes excessive it can manifest itself as an anxiety disorder.
The Distraction scene is presented as a good option for patients with chronic pain, acute pain, or anxiety, who have to undergo processes such as hemodialysis, endoscopies, chemotherapy, visits to the dentist, magnetic resonance, etc., in order to decrease the painful sensations or anxiety by focusing the attention on the virtual environment.
There is scientific evidence that when one shifts attention from a noxious stimulus to a more pleasant one, there is a reduction in the perception and experience of pain. Melzack and Wall proposed the gate control theory, which emphasizes the relationship between the central and peripheral nervous systems, according to which only certain painful stimuli would pass to the brain. According to this theory, several CNS activities, especially attention, emotion and memories related to previous experience, play a fundamental role in sensory perception (Gold, JI, Kant, AJ, Kim, SH, and Rizzo, A., 2005)
We have empirical data in favor of the use of virtual reality in these cases (Jones, T., Moore, T., and Choo, J, 2016), since it is a system in which, if one is immersed in the scene, the distraction of painful or anxious sensations can be very high.
All information in this section is for guidance. Psious environments are therapeutic tools that must be used by the healthcare professional in an evaluation and intervention process designed according to the characteristics and needs of the user
Remember also that you have the General Clinical Guide in which you have more information on how to adapt the techniques of psychological intervention (exposure with response prevention, cognitive restructuring …) to the Psious environments.
2.1 Pain and Anxiety Evaluation
2.1.1 Evaluation objectives
Determine the presence of emotional disorders
Determine the presence of pain behaviors and associated distorted thoughts.
Determine the presence of anxiety and associated thoughts.
2.1.2 Some useful tools for the evaluation of Chronic Pain and ç
Anxiety
Taking into account the evaluation objectives, we will list some tools that may be useful to obtain relevant information about the characteristics of your user. Remember that a good definition of the objectives, a well conducted patient characterization and intervention planning are important for the therapeutic efficiency and effectiveness, as well as for the satisfaction of your user. In the bibliography you will find the articles in which to review the characteristics of the tools proposed below:
Open or semi-structured interview.
Structured interview: ADIS-IV (Brown, Di Nardo & Barlow, D, 1994)
Regarding Chronic Pain, there are specific scales to measure it:
Lattinen Index, IL (Monsalve, Soriano and De Andrés, 2006)
Brief Pain Inventory, BPI (Badia et al, 2003)
Neuropathic Pain Rating Scales
The LANSS Pain Scale (Bennett, 2001)
The Neuropathic Pain Questionnaire (NPQ) (Krause & Backonja, 2003)
Douleur neuropathique en 4 questions (DN4) (Bouhassira et al, 2005)
PainDETECT (Freynhagen et al, 2006)
Regarding Anxiety, there are specific measurement scales:
Hamilton Anxiety Rating Scale (HAM-A) (Hamilton, 1959)
The State-trait Anxiety Inventory (STAI) (Spielberger et al, 1999)
Beck Anxiety Inventory (BAI) (Beck et al, 1998)
Hospital Anxiety And Depression ScaleAnxiety (HADS-A) (Zigmond & Snaith, 1983)
2.2 Intervention on Pain and Anxiety
2.2.1 Intervention with virtual reality proposal to reduce the
pain during diagnostic tests
In order to achieve a better result, it would be advisable to perform different relaxation techniques both before and after the painful diagnostic test. It is also recommended to evaluate the levels of pain and anxiety at the previous and final moments of the process, in order to analyze the changes in these levels (Cabas Hoyos, Cárdenas López, Gutiérrez Maldonado, Ruiz Esquivel, Torres Villalobos, 2015).
Before the diagnostic test
Assessment of the level of pain and anxiety (baseline). Tools such as visual analogue scales (VAS) for pain and anxiety questionnaires (eg BAI)
Application of relaxation techniques:
Abdominal breathing through Psious virtual environments for this task (eg, diaphragmatic breathing in a meadow, diaphragmatic breathing under the sea).
Abdominal breathing through 360º videos of relaxation (for ex.: cove), with abdominal breathing audio.
During the diagnostic test
Distraction Task using the Psious virtual environment.
After the diagnostic test is done
Assessment of the level of pain and anxiety using the same instruments as in the beginning.
Imagery task through the Beach scene and/or 360º videos of Psious to consolidate the results achieved
3. Use Recommendations
It is recommended to be used on patients with chronic pain, who have to go through a painful intervention or have to undergo a therapeutic process that causes them mild anxiety (not a psychopathological type of phobia) such as an intervention at the dentist, removal of a cast… Managing the focus of attention can actually decrease the painful feeling and help in the management of mild anxiety. The therapist should explain to the patient that the environment consists of a game and encourage him to be immersed in the environment of tranquility, without thinking of anything else. Disconnecting from reality to try to achieve the goals required in the game, progress and earn rewards.
4. Recommended Bibliography
Badia X, Muriel C, Gracia A, Núñez-Olarte J, Perulero N, Gálvez R, et al. (2003). Validación española del cuestionario Brief Pain Inventory en pacientes con dolor de causa neoplásica. Med Clin, 120, 52-9.
Beck, AT, Brown, G, Epstein, N, Steer, RA (1988). An Inventory for Measuring Clinical Anxiety: Psychometric Properties. Journal of Consulting and Clinical Psychology, 56, 893-897.
Bennett, M. (2001). The LANSS Pain Scale: The Leeds assessment of neuropathic symptoms and sign, Pain, 92, 147-157
Bouhassira, D., Attal, N., Alchaar, H., Boureau, F., Brochet, B., Bruxelle, J., Cunin, G., Fermanian, J., Ginies, P., Grun-Overdyking, A., JafariSchluep, H., Lantéri-Minet, L., Laurent, B., Mick, G., Serrie, A., Valade, D., Vicaut, E. (2005). Comparison of pain syndromes associated with nervous or somatic lesions and development of a new Neuropathic pain diagnostic questionnaire (DN4). Pain, 114, 29–36. 10.1016/j. Pain.2004.12.010
Brown, T.A., Di Nardo, P.A. & Barlow, D.H. (1994). Anxity Disorders Interview Schedule for DSM-IV (ADIS-IV). San Antonio: The Psychological Corporation.
Cabas Hoyos, Kattia; Cárdenas López, Georgina; Gutiérrez Maldonado, José; Ruiz Esquivel, Fernanda; Torres Villalobos, Gonzalo; (2015). Uso clínico de la realidad virtual para la distracción y reducción del dolor postoperatorio en pacientes adultos. Tesis Psicológica, JulioDiciembre, 38-50.
Carlsson, A.M. (1983). Assessment of chronic pain. I. Aspects of the reliability and validity of the visual analogue scale. Pain, 16, 87-101.
Cid, J., Acuña, J. P., Andrés, J., Díaz, J., y Gómer-Caro, L. (2014). ¿Qué y cómo evaluar al paciente con dolor crónico? Evaluación del paciente con dolor crónico. REV. MED. CLIN. CONDES, 25(4), 687-697
Freynhagen, R., Baron, R., Gockel, U., & Tölle, T. R. (2006). Pain DETECT: a new screening questionnaire to identify neuropathic components in patients with back pain. Current medical research and opinion, 22(10), 1911-1920.
García-Palacios, A., Hoffman, H. G., Richards, T. R., Siebel, E. J., y Sharar, S. R. (2007). Use of Virtual Reality Distraction to Reduce Claustrophobia Symptoms during a Mock Magnetic Resonance Imaging Brain Scan: A Case Report. CyberPsychology & Behavior, 10(3), 485-488. doi:10.1089/cpb.2006.9926
Gold, J. I., Kant, A. J., Kim, S. H., y Rizzo, A. S. (2005). Virtual anesthesia: The use of virtual reality for pain distraction during acute medical interventions. Seminars in Anesthesia, Perioperative Medicine and Pain, 24(4), 203-210. https://doi-org.sire.ub.edu/10.1053/j.sane.2005.10.005
Jones, T., Moore, T., y Choo, J. (2016). The Impact of Virtual Reality on Chronic Pain. PLoS ONE, 11(12), 1-10
Julian, L. J. (2011) Measures of Anxiety. Arthritis Care Res (Hoboken), 63 (11). doi:10.1002/acr.20561
Kato, J., Agalave, N. M., y Svensson, C. I. (2016). Pattern recognition receptors in chronic pain: Mechanisms and therapeutic implications. European Journal of Pharmacology, 788, 261-273. http://doi.org.sire.ub.edu/10.1016/j.ejphar.2016.06.039
Krause, S.J. & Backonja, M. (2003). Development of a neuropathic pain questionnaire. Clin J Pain,19, 306–14.
Melzack R & Torgerson WS. (1971). On the language of pain. Anesthesiology, 34(1), 50–59.
Melzack, R. y Wall, P.D. (1965). Pain mechanisms: a new theory. Science, 150 (3699), 971–979.
Monsalve V, Soriano J y De Andrés J. (2006). Utilidad del Índice de Lattinen (IL) en la evaluación del dolor crónico: relaciones con afrontamiento y calidad de vida. Rev Soc Esp Dolor ,13, 216-29.
Ríos, E. M., Herrera, R. A., y Rojas A. G. (2014). Ansiedad dental: Evaluación y tratamiento. Avances en Odontoestomatología, 30(1), 39-46.
Spielberger, C. D., Gorsuch, R. L., Lushene, R. E., & Cubero, N. S. (1999). STAI: Cuestionario de Aansiedad Estado-Rasgo: Manual. Madrid: TEA Ediciones.
Tanja-Dijkstra, K., Pahl, S., White, M. P., Andrade, J., Qian, C., Bruce, M., …Moles, D. R. (2014). Improving Dental Experiences by Using Virtual Reality
Zigmond, A.S. & Snaith, R.P. (1983). The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand, 67, 361–70. (Primary reference)
Psychological evaluation/intervention protocol proposed by Psious
Claustrophobia evaluation (including MRI)
Evaluation objectives
Some useful tools in the evaluation of claustrophobia
Exposure Hierarchy Development with Psiousʼ environments
HierarchyExample
Intervention example in Claustrophobia
Intervention example in Claustrophobia / Magnetic Resonance Imaging (MRI)
Short case introduction
Example of intervention planning
Usage Recommendations
Recommended bibliography
Appendix
Magnetic Resonance Imaging informed consent
Claustrophobia hierarchy self-report
Magnetic Resonance Imaging hierarchy selfreport
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:
Claustrophobia Questionnaire (CLQ) – Adaptación española
Claustrophobia Situations Questionnaire (CSQ)
Claustrophobia General Cognitions Questionnaire (CGCQ).
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
Ítem
VR
Configuration
Event
Standing on landing waiting for (large) elevator in anoffice building
Claustrophobia
Big elevator
No event
Entering a large empty elevator
Claustrophobia
Large elevator, nobody
Enter elevator
Standing on landing waiting for (small) elevator inoffice building
Claustrophobia
Large elevator, nobody
No event
Entering a large empty elevator
Claustrophobia
Large elevator, nobody
Enter elevator
Watching the doors close
Claustrophobia
Large 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)
Ítem
VR
Configuration
Event
Hear the MRI precautions whilst changing
Claustrophobia
Nuclear
Go to the changing room and precautions
Ascending in the elevator after leaving a small basement
Claustrophobia
Room
Exit basement
Ascending in an elevator with a few people and the elevator starts to move
Claustrophobia
Small Elevator – minimum people
Enter elevator + go to another floor
The doors in a small elevator open and there are a lot of people
Claustrophobia
Small Elevator – maximum people
Enter 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.
Ítem
VR
Configuration
Event
Ascend two floors with a few people in a large elevator
Claustrophobia
Large elevator, a few
Go to another floor and immediately exit the elevator
Ascend 2 floors in a large elevator with quite a few people
Claustrophobia
Large elevator, maximum
Go to another floor and immediately exit the elevator
A short breakdown occurs in the small empty elevator
Claustrophobia
Small 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.
Ítem
VR
Configuration
Event
In a pretty large storage room when the door shuts
Claustrophobia
Room
Close door (size of room as large as possible)
Ascending a lot of floors in a small elevator with a lot of people
Claustrophobia
Small Elevator
Go long to another floor ( duration long)
Ascending a lot of floors in a large empty elevator
Claustrophobia
Large Elevator
Go long to another floor (duration long)
Being in a pretty large storage room when the door shuts suddenly
Claustrophobia
Room
Close 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.
Ítem
VR
Configuration
Event
Ascending a lot of floors in a full small elevator
Claustrophobia
Small elevator maximum
Go long to another floor ( duration long)
In a very small storage room with the doors open quite a lot of people
Claustrophobia
Room
Go to basement (size or room minimum=
Two-minute breakdown in a small elevator with
Claustrophobia
Large elevator,
Breakdown
Ascending a lot of floors in a small elevator with a lot of people
Claustrophobia
Small 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.
Ítem
VR
Configuration
Event
In a very small storage room and the door closes
Claustrophobia
Room
Close doors (in a small-sized room)
In a very small storage room that starts to shrink in size
Claustrophobia
Room
Close doors and reduce size of bedroom
In a large elevator with a lot of people and a long breakdown occurs (more than 5 minutes)
Claustrophobia
Large elevator, maximum, off
Breakdown
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)
Ítem
VR
Configuration
Event
Just about to leave home in a taxi to have a nuclear magnetic resonance
Fear of flying
At home
Go to airport
On way to hospital in car/metro to have a magnetic resonance (select most common form of transport of patient) *A
Fear of driving
City (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) *B
Agoraphobia
Metro (maximum light, easy)
Go to platform, enter, next stop, exit
In waiting room waiting to have a magnetic resonance
Claustrophobia
Magnetic
Resonance: leg, by defect, off
In waiting room before being briefed about the test
Fear of needles
Waiting 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.
Claustrophobia
Magnetic 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.
Ítem
VR
Configuration
Event
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
Claustrophobia
Magnetic resonance – leg, by defect, on.
Terminate resonance
On my way to get changed, before doing the magnetic resonance
Claustrophobia
Magnetic 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…
Claustrophobia
Magnetic resonance – leg, by defect, off
Precautions
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 resonance
Claustrophobia
Magnetic 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
Claustrophobia
Magnetic 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.
Ítem
VR
Configuration
Event
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.
Claustrophobia
Magnetic resonance – leg, by defect, of
Go to changing room
At home after making magnetic resonance appointment on the telephone
Generalized anxiety
Worried 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
Claustrophobia
Magnetic resonance – head, by defect, off
–
Lying down, facing upwards, foot immobilized, before entering the magnetic resonance tube.
Claustrophobia
Magnetic resonance – leg, by defect, off
Lie 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)
Ítem
VR
Configuration
Event
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
Claustrophobia
Magnetic resonance – leg , by defect, off
Lie 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 exits
Claustrophobia
Magnetic resonance – torso, by defect, off
Lie 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
Claustrophobia
Magnetic resonance – torso, by defect, off
Lie 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.
Claustrophobia
Magnetic resonance – head, by defect, off
Lie 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
Ítem
VR
Configuration
Event
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
Claustrophobia
Magnetic resonance – head, by defect, off
Lie 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
Claustrophobia
Magnetic resonance – leg , by defect, off
Start 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.
Claustrophobia
Magnetic resonance – torso , by defect, off
Start 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.
Ítem
VR
Configuration
Event
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.
Claustrophobia
Magnetic resonance – head , by defect, off
Start resonance
Whilst placed inside the machine, I hear how the sound of the magnetic resonance changes.
Claustrophobia
Magnetic resonance – head , by defect, off
Noise
Noticing how the sound of the magnetic resonance machine becomes deeper
Claustrophobia
Magnetic resonance – head , by defect, off
General 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
Ítem
Nivel 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
Ítem
Nivel 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
Ítem
Nivel 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
