Month: July 2020

Agoraphobia and Panic
and virtual reality

WHAT IS PSYCHOEDUCATION?

In the last few decades, psychoeducation has come up as a useful and effective mode of psychotherapy for persons with mental illness. It has been found to be fruitful in both clinical and community settings.

Psychoeducation combines the elements of cognitive-behavior therapy, group therapy, and education. The basic aim is to provide the patient and families knowledge about various facets of the illness and its treatment so that they can work together with mental health professionals for a better overall outcome.

Barker, in the Social Work Dictionary, defined psychoeducation as the “process of teaching clients with mental illness and their family members about the nature of the illness, including its etiology, progression, consequences, prognosis, treatment, and alternatives.”

GENERAL GOALS OF PSYCHOEDUCATION

• To ensure basic knowledge and competence of patients and their relatives about the illness

• To provide insight into the illness 

• To promote relapse prevention

• Engaging in crisis management and prevention

Adapted from: Sarkhel, S., Singh, O., & Arora, M. (2020). Clinical Practice Guidelines for Psychoeducation in Psychiatric Disorders General Principles of Psychoeducation. Indian Journal of Psychiatry, 62(8), 319. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_780_19

PANIC ATTACKS

People with panic disorder have recurrent unexpected panic attacks. Panic attacks are sudden periods of intense fear that come on quickly and reach their peak within minutes. Attacks can occur unexpectedly or can be brought on by a trigger, such as a feared object or situation.

During a panic attack, people may experience:

• Heart palpitations, a pounding heartbeat, or an accelerated heart rate

• Sweating

• Trembling or shaking

• Sensations of shortness of breath, smothering, or choking

• Feelings of impending doom

• Feelings of being out of control

People with panic disorder often worry about when the next attack will happen and actively try to prevent future attacks by avoiding places, situations, or behaviors they associate with panic attacks. Worry about panic attacks, and the effort spent trying to avoid attacks, cause significant problems in various areas of the person’s life, including the development of agoraphobia 

The psychoeducational Psious’ environments will help you understand the basics of panic and agoraphobia and how to manage those.

Source: https://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml

Appendix

VR Metro Hierarchy: Self Recording

ITEM	LEVEL OF MALAISE (0-100)
I’m walking in a square heading towards the subway, which is close to home.
I walk through the corridors of the station to head towards the platform and I realize the station is pretty clean. There is no one around me. When I reach the platform, I stop near the entrance.
I’m inside a train with a few people. When I get to my stop, I get off the train and leave the platform.
I’m standing on the platform with no one around me. The subway arrives, but I do not get in. I wait for the next one instead.
When entering the station, I see there is nobody inside and that the station seems to be quite clean
I am standing on the subway platform (which is quite dirty) with no one next to me. I enter the train when it arrives, but I stay close to the wagon door.
I’m in the middle of a subway wagon surrounded by a few people. I still have 3 stops left on my itinerary so when we reach the next stop, I do not get off. I decide to continue forward with my journey for the remainder of the stops.
I’m in an empty square and I’m about to cross it to enter the subway station
I’m inside a subway wagon with plenty of people. When we get to the next stop, I get off to leave the train
I’m inside a subway wagon with a few people. When it reaches the next stop, I do not get off since I still have 5 stops left on my itinerary
I’m walking through the halls of the station heading towards the platform . There is one around me, and I notice that the station is quite dirty. When I get to the platform, I stop near the entrance.
I’m in a subway with few people around me when the train comes to an unexpected stop. A breakdown has occurred.
I’m in the middle of a crowded subway wagon. When it reaches the next stop, I do not get off, as I still have 2 stops left. I continue forward to my destination.
I’m standing on a platform with people around me. The subway arrives, but I do not get on. I watch it depart from the platform.
I’m standing on the platform (which is quite dirty) with no one around me. The subway arrives and I sit down.
When I enter the lobby of the subway station, I notice that nobody is there. The atmosphere looks dirty and dark.
I’m standing on the platform (which is quite dirty) with no one around me. The subway arrives and I sit down.
When I enter the lobby of the subway station, I notice that nobody is there. The atmosphere looks dirty and dark.
I’m in the middle of a subway wagon with a lot of people. When it reaches the next stop, I do not get off. I still have 7 stops left on my itinerary so I continue on to my destination.
I walk through the corridors of the station and start heading to the platform. I see plenty of people around and the station is a bit dirty and looks dark. When I get to the platform, I stop to wait for the train.
When I enter the station lobby, I notice it is full of people and that the station seems to be quite clean.
I am standing on the subway platform (which is quite clean) with no one around me. When the train arrives, I enter.
I’m in a subway wagon with many people on it. When it reaches the next stop, I do not get off. I have 5 stops left, so I continue on until I reach my destination.
I’m standing on the subway platform (which is quite clean) with a few people around me. When the train arrives, I get in.
I’m inside the subway wagon with a lot of other people. When we reach the next stop, I do not get off.I have 7 stops left, so I continue on until I reach my destination.
I’m walking through the halls of the station heading towards the platform . There is no one around me and the station looks quite clean. When I get to the platform, I stop to wait for the train.
When I enter the lobby of the station, I see that it is full of people. I also notice that the station is dirty and dark.
I’m standing on the subway platform (which is quite clean) with people around me. When the subway arrives, I sit down instead of getting on it.
I’m standing on the platform (which is quite dirty) with a few people around me . When the subway arrives, I enter it.
I’m standing on the platform (which is quite clean) with no one around me. When the subway arrives, I sit down instead of getting on it.
I’m in a subway wagon with a lot of people around me. The train suddenly stops. It seems there has been a breakdown.

360º Hierarchy Environments: Self-Recording

ITEM	LEVEL OF MALAISE (0-100)
Now I’m outside of the market. I can see people going in and coming out.
I’m in the hall of my apartment and I’m about to start my journey to the mall.
I’m inside an elevator going from the top floor to the ground floor because I’m leaving the mall.
I’m at the entrance of thee subway because I am on my way to the mail, I see people exiting the platform and going out to the street
I’m at the entrance of the subway because I am on my way to the mall. I see people exiting the platform and going out to the street.
I enter the mall elevator. I am standing next to four people. I am going up to the second floor
I’m standing in a very busy mall. I can see plenty of people walking and shopping around me.
After leaving the mall, I stop outside for a moment to observe people walking around and cars driving in the area.
I’m inside the mall on the first floor. I am far from the exits, but I can see them in the distance.
I’m in a mall waiting for the elevator to go up to the first floor. There are a few people next to me.
As I’m approaching the subway station to head home, I can see people exiting the station
I’m in the corridor of the subway station exit watching people coming and going. I am on my way to the mall and I know it will be very crowded
I’m on the first floor of the mall and I can see the escalators that I need to take to the top floor in the distance.
I’m on the top floor of the mall waiting for the elevator. I need to take it to the ground floor in order to get to the exit.

Download appendix

Bibliography

• Bados López, A. (2009). Agoraphobia and panic: Nature, evaluation and treatment. (http://hdl.handle.net/2445/6261)
  
• Botella, C., García-Palacios, A., Villa, H., Baños, R., Quero, S., Alcañiz, M., & Riva, G. (n.d.). Virtual Reality Exposure In The Treatment Of Panic Disorder And Agoraphobia: A Controlled Study. Clinical Psychology & Psychotherapy, 164-175.
  
• 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.
  
• Bullinger, A. (n.d.). Computer generated (virtual reality) three dimensional exposure as a tool in behavioral therapy of agoraphobia. European Psychiatry, 102s-102s.
  
• Cárdenas, G., Muñoz, S., González, M., & Uribarren, G. (n.d.). Virtual Reality Applications to Agoraphobia: A Protocol. CyberPsychology & Behavior, 248-250.
  
• Chambless, D. L., Caputo, C., Bright, P. and Gallagher, R. (1984). Assessment of fear of fear in agoraphobics: The Body Sensations Questionnaire and the Agoraphobic Cognitions Questionnaire. Journal of Consulting and Clinical Psychology, 52, 1090-1097.
  
• Chambless, D. L., Caputo, G. C., Jasin, S. E., Gracely, E. J. and Williams, C. (1985). The Mobility Inventory for Agoraphobia. Behavior Research and Therapy, 23, 35-44.
  
• Echeburúa, E., de Corral, P., García Bajos, E., Páez, D. and Borda, M. (1992). A new inventory of agoraphobia (AI). Analysis and Modification of Conduct, 18, 101-123.
  
• J., C. (n.d.). A Randomized Controlled Study of Virtual Reality Exposure Therapy and Cognitive-Behavior Therapy in Panic Disorder with Agoraphobia. Frontiers in Neuroengineering.

Intervention proposal

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

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

Intervention example on agoraphobia

SESSION 1 

• Inform the patient about agoraphobia (causes, symptoms, prevalence…)

• Present and justify the techniques that will be used throughout the treatment: the exposure with virtual reality and live exposure.

• Elaboration of the hierarchy of exposure and exposure to items from the hierarchy of 20-30 USA’s (example)

• Start exposure hierarchy with an item close to 30 USA’s. The main objective will be the patient’ s familiarization with the virtual reality and the work dynamics

ITEM	SUD’s	ENVIRONMENT	CONFIGURATION	EVENT
Being in the square next to your house with few people	20	Square
Take a walk on the beach with few people	20	Video Environment “The beach”
Drive around the city during hightraffic hours	25	City	Sun, day, driver, minimum	Circuit 1
Drive on the highway	30	Highway	Sun, day, driver, show, hide	Tunnel

SESSION 2

• Review achievements from the previous session and setting objectives of the actual session: entering an elevator

• Starting with the second session of the treatment, we recommend to start the exposure gradually and systematically to environments of virtual reality. If it’s necessary, perform a cognitive restructuring.

• Show clinical advances to the patient, through platform reports.

HOMEWORK
Live exposure to streets away from home, or go out for a drive through the city.

ITEM	SUD’s	ENVIRONMENT	CONFIGURATION	EVENT
Being in a square near home with plenty of people	40	Square	Maximum
Walking along a very crowded boulevard	45	Environment Very Crowded Boulevard
Being alone at home	50	Home
Take a walk along the port	55	Environment walk
Entering an elevator	60	Small elevator

SESSION 3

• Review achievements from previous sessions and establish new objectives for this: Being in the underground entrance when there is people there.

• Gradual and systematic exposure to virtual reality environments. Cognitive restructuration, if it’s necessary.

• Show clinical advances to the patient through platform reports.

HOMEWORK 
Live exposure by going out for a walk in a busy street, being alone at home or entering an elevator (if you have too much anxiety you can do imagery at home, imagining the situations treated in the session).

ITEM	SUD’s	ENVIRONMENT	CONFIGURATION	EVENT
Be in the waiting room of a hospital	60	Magnetic resonance imaging		Waiting room
Go into the elevator	65	Big elevator	Maximum	Into the elevator
Being in the entrance of the Metro without people	70	Metro	Non, clean
Being in the entrance of the Metro surrounded by people	70	Metro	Maximum, clean

SESSION 4

• Review the achievements from the previous session and setting new goals: Being on the underground platform

• Gradual and systematic exposure to virtual reality environments. Cognitive restructuration if it’s necessary.

• Show clinical advances to the patient, through platform reports.

HOMEWORK
Live exhibition in the underground, you can start at the entrance and walk down stairs to the ticket machines or do the same with imaginary exposure at home.

ITEM	SUD’s	ENVIRONMENT	CONFIGURATION	EVENT
Very crowded boulevard.	70	Very crowded boulevard
Underground entrance	75	Metro	Maximum, dirty
Environment Crowded market	75	Video crowded market
Go to the underground platform	80	Metro	Maximum, dirty	Platform

SESSION 5

• Review of previous session achievements and establish the new objective of the session: Enter the underground train

• Gradual and systematic exposure to virtual reality environments. Cognitive restructuration if it’s necessary.

• Repeat each one of the exercises twice.

• Show clinical advances to the patient, through platform reports.

HOMEWORK
Live exposure in crowded streets (if reducing anxiety levels is required, the patient can be accompanied), start to enter into the underground (can be done at timetables when there is not many people)

ITEM	SUD’s	ENVIRONMENT	CONFIGURATION	EVENT
Exit from the underground where there is not many people	80	Metro	None, dirty	Activate “metro” (if you want to be inside) and then click on “leave metro” ( without being a inside for very long)
See how the train arrives without getting in it and waiting for another	80	Metro	None, dirty	No event (do not look at the input viewer)
Exit a subway where there is plenty of people	85	Metro	Maximum, dirty	Activate “metro” (to be inside) and then click on “ leave metro” (without being inside for very long)
Enter a plane and close the doors	90	Plane	Maximum, sun, day, window, non, off	Taxi
Being in the subway near the door	90	Agorafobia	Maximum, dirty	“Metro arrival” (and enter with the viewer)

SESSION 6

• Review of previous session achievements and establish the new objective of the session: Be inside a subway wagon with many people when a breakdown occurs.

• Gradual and systematic exposure to virtual reality environments. Cognitive restructuration if necessary

• Repeat each one of the exercises twice

• Show clinical advances to the patient, through platform reports.

HOMEWORK
Live exposure in the subway, you can start with a small amount of people in the station and increase the level of crowdedness. First, the patient stands near the door, gets into the subway and takes it until the next stop. Gradually increase the exposure as the session progresses.

ITEM	SUD’s	ENVIRONMENT	CONFIGURATION	EVENT
See how the train arrives without getting on it	85	Metro	Maximum, dirty	“Metro arrival ” and not entering ( let 30 seconds pass)
Entering the train with few people	90	Metro	None, dirty	“Metro arrival” (and enter with the viewer)
Enter the train full of people	95	Metro	Maximum, dirty	“Metro arrival” (and enter with the viewer
Entering the train and staying inside for a few stops	100	Metro	Maximum, dirty	“Inside the metro” and “next station” (several stops)
Being on a full train while a breakdown occurs	100	Metro	Maximum, dirty	“Inside Metro” and “Breakdown”

Intervention Example on Agoraphobia with 360º Format Environments

In addition to virtual environments, the agoraphobia scene has several 360º format environments that will allow you to make a more effective intervention. The environments described previously can be used to create a storyline for the agoraphobic patient that are similar to situations that he/she could be experiencing in their everyday life. Gradually increasing the level of difficulty of each of these situations will allow the patient to progressively confront and overcome their fears at a much quicker rate. For example, storylines that can be created are prompting a patient to go inside a market (ground floor) and then having them go inside a mall (first and second floor).

To create this storyline, the following environments can be used: The environment with the stair landing (leaving the house), the one in the subway (going to the market), the market environments (ground floor) and the one in the mall (elevator, first floor, second floor…) The use of different environments can be used to create a hierarchy of exposure that will help the patient become used to visiting a mall or a market.

SESSION 1

• Inform the patient about agoraphobia (Causes, symptoms, prevalence…)

• Discuss the techniques that will be used throughout the treatment: Exposure with virtual reality and live exposure.

• Prepare the exposure hierarchy and the 20-30 USA’s hierarchy  item exposure. (example)

• Initiate exposure hierarchy with an item close to 30 USA’s. The main goal will be to make sure the patient gets comfortable with the virtual reality and the dynamics of the work.

Item	SUD’s	Environment
After having left the mall, he/she is out on the street surrounded by people and cars.	20	360º environment outside the mall
On the elevator, going from the last floor to the ground floor to leave the mall.	25	360º environment inside the elevator
Waiting for the elevator to leave the top floor of the mall.	30	360º environment waiting for the elevator
Being at the market’s exit, observing people come in and out.	40	360º environment entering a crowded market

SESSION 2

• Review the achievements from the previous session and establish session goals: Be on the ground floor of a very crowded market, and watch people shop and walk.

• From the second session onwards, it is highly recommended to begin the gradual and systematic exposure to virtual reality environments. Do cognitive restructuring, if necessary.

• Show clinical advances to the patient through platform reports.

HOMEWORK
Live exposure, going out into the street and going to a market or a mall. The patient doesn’t have to enter it.

Item	SUD’s	Environment
Observe people leaving the subway station, right before entering it to go home.	40	360º environment Subway Exit
Being in the entrance hall of their own home after coming back from the mall.	50	360º environment Hall
Being out on the street , observing (from a distance) the mall he/she intends to go to.	55	360º environment Outside the Mall
Being on the ground floor of a crowded market to observe the massive amount of people shopping and walking around.	60	360º environment Ground Floor

SESSION 3

• Review achievements from the previous session and establish session goals: To be on the first floor of a mall and see the exit doors from a distance.

• Gradual and systematic exposure to virtual reality environments. Use cognitive restructuring, if necessary.

• Show clinical advances to the patient, through platform reports.

HOMEWORK
Live exposure, going to market that isn’t as crowded or just standing outside a mall to observe + image exposure to review session goals.

Item	SUD’s	Environment
Taking a slightly crowded elevator to go up to the second floor of the mall	65	360º environment inside the elevator
Waiting to take an elevator to the first floor at a market surrounded by a few people.	70	360º environment waiting for the elevator
On the first floor of a mall with the exit in view in the far distance.	75	360º environment inside the mall. Vídeos

SESSION 4

• Review achievements from the previous session and establish session goals : To be on the first floor of a market to observe people walk around with city buildings in view in the background. 

• Gradual and systematic exposure to virtual reality environments . Use cognitive restructuring, if necessary.

• Show clinical advances to the patient through platform reports.

HOMEWORK
Live exposure going to a crowded market or to a busy mall.

Item	SUD’s	Environment
Watching people (in the hall of the subway exit) coming in and out of the subway before entering a busy market.	80	360º environment Subway Exit
At the subway entrance on the way to the market and watching people enter and leave the platform to go out into the street	80	360º environment Subway Exit
On the first floor of a mall with escalators in the distance (use them to go up to the last floor).	90	360º environment Inside the Mall Vídeos
At the roof terrace (on the top floor of the mall), observing people wandering around with buildings in view in the background.	100	360º environment Second Floor