“Toda la información contenida en este apartado es de carácter orientativo. Los entornos de Psious son herramientas de apoyo terapéutico que deben ser utilizadas por el profesional de la salud dentro de un proceso de evaluación e intervención diseñado según las características y necesidades del usuario.
Recuerda además que dispones de la Guía Clínica General en la que tienes más información sobre cómo adaptar las técnicas de intervención psicológica (exposición, desensibilización sistemática, reestructuración cognitiva, economía de fichas…) a los entornos de Psious.”
Evaluación del TOC
Objetivos de evaluación
Evaluar presencia y comorbilidad con otros trastornos emocionales.
Evaluar la presencia de obsesiones, compulsiones y neutralizaciones.
Definir configuraciones estimulares ansiógenas por parte del paciente y en qué grado. Elaboración jerarquía de exposición.
Evaluar la presencia de pensamientos distorsionados. En el caso de TOC, aquellos asociados a las obsesiones y compulsiones.
Algunos instrumentos útiles para la evaluación del TOC
Teniendo en cuenta los objetivos de evaluación pasamos a enumerar algunas herramientas que pueden serte útiles para obtener información relevante sobre las características de tu usuario. Recuerda que una buena definición de objetivos, caracterización del paciente y planificación de la intervención son importantes para la eficiencia y eficacia terapéutica, así como para la satisfacción de tu usuario. En la bibliografía encontrarás los artículos en los que revisar las características de los instrumentos propuestos a continuación:
The Maudsley Obsessive-Compulsive Inventory (MOCI).
Leyton Obsessional Inventory (LOI).
Autoinformes Psious para la elaboración de la jerarquía.
Tests de aproximación conductual
Behavioral avoidance test for obsessive compulsive disorder (BATs).
Elaboración de la jerarquía de exposición con entornos de Psious
Una vez que tenemos la información de la evaluación podemos proceder a elaborar la jerarquía de exposición. Para ello, podemos realizar una serie de preguntas (ej. ¿Qué nivel de malestar, en una escala de 0 a 100, te genera estar sentado en la taza del váter, ¿Qué nivel de malestar, en una escala de 0 a 100, te generaría no poder lavarte las manos?, ¿Crees que hay algo que pueda generarte un malestar aún mayor?) dirigidas a planificar la intervención mediante la realidad virtual (y/o entorno 360º).
According to the American Psychiatric Association, the obsessive compulsive disorder is an anxiety disorder in which people have undesirable thoughts, ideas or sensations (obsessions), which carry out ritualized behaviors (compulsions) or repetitive thoughts (neutralizations). These behaviors, such as washing hands, checking or cleaning, interfere in a significant way with the daily activities and social relationships of a person. (Gorrindo, T., Parekh, R., 2015)
For OCD’s differential diagnosis obsessions and/or compulsions that consume a lot of time (more than one daily hour), cause stress, harm work and social relationships, as well as other important areas must be present. (APA, 2007). The cognitive-behavioral therapy, the treatment with medication, apart from other somatic therapies of cerebral stimulation, have been until now the most effective alternatives to treat this disorder (APA, 2007).
Virtual Reality appears as a good alternative tool to the traditional techniques used in mental disorder treatments and in obsessive compulsive disorders among others. Virtual Reality allows the standardization and the control on the parameters of the exposure sessions. Likewise, it turns out to be very useful to repeat the exposure to the fear or anxiogenic situations as many times as necessary, making the customization and flexibilization of the therapeutic process much easier.
Psious’s environments allow the use of diverse psychological intervention techniques: exposure, cognitive restructuring, systematic desensitization, training in social skills… Use the most adapted characteristics of the patient and use those with major empirical support to obtain better results.
Según la Asociación Americana de Psiquiatría, el trastorno obsesivo-compulsivo es un trastorno de ansiedad en el cual las personas tienen pensamientos recurrentes e indeseables, ideas o sensaciones (obsesiones) que comportan, habitualmente, que lleven a cabo conductas ritualizadas (compulsiones) o pensamientos repetitivos (neutralizaciones). Estos comportamientos, tales como lavarse las manos, hacer revisiones o limpiar, pueden interferir de manera significativa con las actividades cotidianas y las relaciones sociales de una persona (Gorrindo, T., Parekh, R., 2015).
Para el diagnóstico diferencial de TOC debe haber presencia de obsesiones y/o compulsiones que consuman mucho tiempo (más de una hora diaria), que provocan estrés, y perjudican el trabajo, las relaciones sociales y otros ámbitos importantes. (APA, 2007). La terapia cognitivo-conductual, el tratamiento mediante fármacos, a parte de otras terapias somáticas de estimulación cerebral, han sido hasta ahora las alternativas más eficaces para tratar este trastorno (APA, 2007).
La Realidad Virtual se presenta como una buena herramienta alternativa a las técnicas tradicionales empleadas en el tratamiento de los trastornos mentales, entre ellos el trastorno obsesivo compulsivo (Kim, K., et al., 2009). La Realidad Virtual permite la estandarización y el control sobre los parámetros de las sesiones de exposición. Así mismo, resulta muy útil para repetir la exposición a las situaciones temidas o ansiógenas las veces que sea necesario, facilitando la personalización y flexibilización del proceso terapéutico.
Los entornos de Psious te permiten la utilización de diversas técnicas de intervención psicológica: exposición, reestructuración cognitiva, desensibilización sistemática, entrenamiento en habilidades sociales… Utiliza las más adecuadas a las características de tu paciente y básate en aquellas con mayor apoyo empírico para obtener mejores resultados.
I am at home a few days before performing an important test
All students are in class today performing a very short test of anxiety
While I’m alone in the hallway, the teacher is going to question me, and with a friendly voice, he invites me to go to the classroom
The test that I’m doing today is quite long, and the class I’m in is very full
I find myself in the hallway with several classmates who seem calm although we have a test. The teacher comes to the classroom with a very serious look and asks us to come in
I am alone in the classroom with the teacher, who seems quite friendly, waiting for the test anxiety to start
I’m waiting in the hallway for the teacher to start the test today, and there are many people who also wait and seem quite anxious
I’m alone in the hallway, waiting for the teacher to start a test
I and a few of my classmates are about to start the Science Test, they all seem pretty calm and the teacher is relaxed
I’m alone in the classroom with a very serious teacher who seems to be watching me, waiting for the anxiety test to start
I’m with a lot of people in the hallway waiting for the teacher to start the test today, and I can see how the others are quite calm
I’m just sitting in the classroom, waiting for the teacher, who seems quite friendly, to start the history test
At the end of the test I have been doing, the teacher shows me the result on a screen
I find myself in the hallway with a few classmates who seem quite nervous, and we are waiting for a test
As the test will begin, the murmur of the classmates goes down until nothing is heard
I and a few classmates are waiting for the teacher to start a test, and it seems that they are relaxed and calm
I’m in class about to perform an anxiety test, in the class there are enough people who are very uneasy and also the teacher seems very serious and fairly controlling
While I am in the middle of the test, one of my colleagues announces aloud that he is finished
After waiting for a while alone in the hallway, the teacher appears and tells me to go to class very seriously
I’m the only student in class and I am doing a science test
I find myself in class with many classmates, and we are doing a brief history test
I’m in the hallway with several classmates who seem quite nervous. Suddenly the teacher appears and kindly tells us that we can go to the classroom
I’m alone in the classroom with the teacher, who is quite serious, waiting for the start of the natural sciences test
While I and some of my classmates were waiting quietly for the teacher to arrive, he appeared and kindly told us to go to class
I’m alone in a classroom doing an anxiety test
I’m in the history classroom, and I find myself doing a brief test on this topic with many classmates
While I and some colleagues who look very anxious are waiting for the teacher, he comes and tells us in a friendly way that we can go to the classroom
In the class where the history test is done, we are just me and the teacher, who seems very serious
I’m in class about to take a history test. The classroom is full of people who seem very calm, and the history teacher is calm and friendly
I find myself doing a long anxiety test, and the class is quite full
I’m alone in the classroom with the teacher, who seems very calm, waiting for the start of the natural sciences test
I’m inside the subway, because I’m going to do the test I have today
I meet many classmates in the classroom where the natural sciences test will start, the teacher seems very serious and the students are nervous
I’m in class about to do an anxiety test, the class is full of people who are quite calm and also the teacher is very kind
I find myself alone with the history teacher, doing a test
I am with many colleagues doing a long test of natural sciences
I’m in class about to take a history test. The classroom is full of people who seem very nervous, and the teacher is a bit serious and not very kind
Estoy en casa unos días antes de realizar un examen importante
Todos los alumnos estamos hoy en clase realizando un examen muy corto de ansiedad
Mientras estoy solo en el pasillo, aparece el profesor que me va a examinar, y con gesto y voz amable, me invita a pasar al aula
El examen que estoy haciendo hoy es bastante largo, y la clase en la que me encuentro está muy llena
Me encuentro en el pasillo con varios compañeros que parecen tranquilos aunque tenemos un examen. El profesor llega al aula con un aspecto muy serio y nos dice que pasemos
Estoy yo solo en el aula con el profesor, que parece bastante amistoso, esperando a que dé comienzo el examen de ansiedad
Estoy esperando en el pasillo a que llegue el profesor para poder empezar el test de hoy, y hay mucha más gente que también espera y parece bastante ansiosa
Estoy solo en el pasillo, esperando a que llegue el profesor para empezar un examen
Yo y unos cuantos compañeros estamos a punto de empezar el examen de ciencias, todos parecen bastante calmados y el profesor se muestra relajado
Estoy yo solo en el aula con un profesor muy serio y que parece que me vigila, esperando a que dé comienzo el examen de ansiedad
Estoy con mucha gente esperando en el pasillo a que llegue el profesor para poder empezar el test de hoy, y puedo ver como los demás están bastante tranquilos
Estoy solo sentado en la clase, esperando a que el profesor, que parece bastante amistoso, dé comienzo el examen de historia
Al terminar el examen que he estado haciendo, el profesor me muestra el resultado en una pantalla
Me encuentro en el pasillo con unos pocos compañeros que parecen bastante nerviosos, y estamos esperando para realizar un examen
Como el examen va a empezar, el murmullo de los compañeros va bajando hasta que no se oye nada
Yo y unos cuantos compañeros estamos esperando al profesor para poder empezar un examen, y parece que ellos están relajados y tranquilos
Estoy en clase a punto de realizar un examen de ansiedad, en la clase hay bastante gente que se muestra muy intranquila y además el profesor parece muy serio y bastante controlador
Mientras estoy a mitad del examen, uno de mis compañeros anuncia en voz alta que ya ha terminado
Después de esperar un rato solo en el pasillo, aparece el profesor y me dice que pase a la clase de forma muy seria
Soy el único alumno en clase y estoy realizando un examen de ciencias
Me encuentro en clase con muchos compañeros, y estamos haciendo un breve examen de historia
Estoy en el pasillo con varios compañeros que parecen bastante nerviosos. De pronto aparece el profesor y nos indica de forma amable que ya podemos pasar al aula
Estoy yo solo en el aula con el profesor, que está bastante serio, esperando a que dé comienzo el examen de ciencias naturales
Mientras yo y algunos compañeros esperamos tranquilamente a que llegue el profesor, este aparece y nos dice amablemente que vayamos pasando a la clase
Estoy solo en una aula haciendo un examen de ansiedad
Estoy en el aula de historia, y me encuentro haciendo un breve examen de esta materia junto a muchos compañeros
Mientras yo y algunos compañeros que parecen muy ansiosos esperamos al profesor, éste llega y nos dice de forma amigable que ya podemos ir pasando al aula
En la clase donde se hace el examen de historia solo estamos yo y el profesor, que parece muy serio
Estoy en clase a punto de hacer un examen de historia. El aula está llena de gente que parece muy calmada, y el profesor de historia se muestra tranquilo y amigable
Me encuentro haciendo un largo examen de ansiedad, y la clase está bastante llena
Estoy yo solo en el aula con el profesor, que parece muy tranquilo, esperando a que dé comienzo el examen de ciencias naturales
Me encuentro dentro del metro, porque estoy yendo a hacer el examen que tengo hoy
Me encuentro con muchos compañeros en el aula donde va a dar comienzo el examen de ciencias naturales, el profesor parece muy serio y los alumnos están nerviosos
Me encuentro en clase a punto de realizar un examen de ansiedad, la clase está llena de gente que se muestra bastante tranquila y además el profesor es muy amable
Me encuentro a solas con el profesor de historia haciendo un examen
Estoy junto con muchos compañeros realizando un largo examen de ciencias naturales
Estoy en clase a punto de hacer un examen de historia. El aula está llena de gente que parece muy nerviosa, y el profesor se muestra un poco serio y no muy amable
Ali, M. S., & Mohsin, M. N. (2013). Test Anxiety Inventory (TAI): Factor analysis and psychometric properties. Journal of Humanities and Social Science, 8(1), 73-81
Alsina, I., Carvallo, C. y Gutiérrez-Maldonado, J. (2007). Validity of virtual reality as a method of exposure in the treatment of test anxiety. Behavior Research Methods, 39 (4), 844-851. R
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.
Cunha, M., & Paiva, M. J. (2012). Text Anxiety in Adolescents: The role of self-criticism and acceptance and mindfulness skills. The Spanish journal of psychology, 15(2), 533
Kavakci, O., Semiz, M., Kartal, A., Dikici, A., & Kugu, N. (2014). Test anxiety prevalence and related variables in the students who are going to take the university entrance examination. Dusunen Adam, 27(4), 301.
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)
Liebert, R. M., & Morris, L. W. (1967). Cognitive and emotional components of test anxiety: A distinction and some initial data. Psychological reports, 20(3), 975-978.
Mandler, G and Sarason, S B, (1952). A study of anxiety and learning. Journal of Abnormal and Social Psychology, 47, 166–173
Gutiérrez-Maldonado, J., Alsina-Jurnet, I., Carvallo-Becíu, C., Letosa Porta, A., y Magallón-Neri, E. (2007). Aplicaciones clínicas de la realidad virtual en el ámbito escolar. Cuadernos de medicina psicosomática y psiquiatría de enlace, 82, 32-51.
Heredia, D., Piemontesi, S., Furlan, L., y Pérez, E. (2008). Adaptación de la Escala de Afrontamiento ante la ansiedad e incertidumbre pre examen:(COPEAU). Avaliação psicológica, 7(1), 1-9.
Hembree, R. (1988). Correlates, causes, effects, and treatment of test anxiety. Review of educational research, 58(1), 47-77.
Hodapp, V., Glanzmann, P., y Laux, L. (1995). Theory and measurement of test anxiety as a situation-specific trait. En Charles Spielberger (Ed). Test anxiety: Theory, assessment, and treatment, (47-58). Philadelphia: Taylor & Francis.
Rodríguez, J. O., Alcázar, A. I. R., Caballo, V. E., García-López, L. J., Amorós, M. O., y López-Gollonet, C. (2003). El tratamiento de la fobia social en niños y adolescentes: una revisión meta-analítica. Psicología Conductual, 11, 599-622.
Sapp, M., Farrell, W., y Durand, H. (1995). The effect of mathematics, reading, and writing tests in producing worry and emotionality test anxiety with economically and educationally disadvantaged college students. College Student Journal, 29, 122–125.
Sarason, I. G. (1972). Experimental approaches to test anxiety: Attention and the uses of information. Anxiety: Current trends in theory and research, 2, 383-403.
Spielberger, C. D & Vagg, P.R. (1995). Test Anxiety: Theory Assessment and Treatment Washington D.C. Taylor Francis, 3-14.
Talbot, L. (2016). Test Anxiety: Prevalence, Effects, and Interventions for Elementary School Students. James Madison Undergraduate Research Journal (JMURJ), 3(1), 5.
Valero, L. (1999). Evaluación de ansiedad ante exámenes: Datos de aplicación y fiabilidad de un cuestionario CAEX. Anales de psicología, 15(2), 223-231.
Von Der Embse, N., Barterian, J., & Segool, N. (2013). Test anxiety interventions for children and adolescents: A systematic review of treatment studies from 2000–2010. Psychology in the Schools, 50(1), 57-71.
Zeidner, M. (1998). Test anxiety: The state of the art. Springer Science & Business Media.
Ali, M. S., & Mohsin, M. N. (2013). Test Anxiety Inventory (TAI): Factor analysis and psychometric properties. Journal of Humanities and Social Science, 8(1), 73-81
Alsina, I., Carvallo, C. y Gutiérrez-Maldonado, J. (2007). Validity of virtual reality as a method of exposure in the treatment of test anxiety. Behavior Research Methods, 39 (4), 844-851. R
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.
Cunha, M., & Paiva, M. J. (2012). Text Anxiety in Adolescents: The role of self-criticism and acceptance and mindfulness skills. The Spanish journal of psychology, 15(2), 533
Kavakci, O., Semiz, M., Kartal, A., Dikici, A., & Kugu, N. (2014). Test anxiety prevalence and related variables in the students who are going to take the university entrance examination. Dusunen Adam, 27(4), 301.
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)
Liebert, R. M., & Morris, L. W. (1967). Cognitive and emotional components of test anxiety: A distinction and some initial data. Psychological reports, 20(3), 975-978.
Mandler, G and Sarason, S B, (1952). A study of anxiety and learning. Journal of Abnormal and Social Psychology, 47, 166–173
Gutiérrez-Maldonado, J., Alsina-Jurnet, I., Carvallo-Becíu, C., Letosa Porta, A., y Magallón-Neri, E. (2007). Aplicaciones clínicas de la realidad virtual en el ámbito escolar. Cuadernos de medicina psicosomática y psiquiatría de enlace, 82, 32-51.
Heredia, D., Piemontesi, S., Furlan, L., y Pérez, E. (2008). Adaptación de la Escala de Afrontamiento ante la ansiedad e incertidumbre pre examen:(COPEAU). Avaliação psicológica, 7(1), 1-9.
Hembree, R. (1988). Correlates, causes, effects, and treatment of test anxiety. Review of educational research, 58(1), 47-77.
Hodapp, V., Glanzmann, P., y Laux, L. (1995). Theory and measurement of test anxiety as a situation-specific trait. En Charles Spielberger (Ed). Test anxiety: Theory, assessment, and treatment, (47-58). Philadelphia: Taylor & Francis.
Rodríguez, J. O., Alcázar, A. I. R., Caballo, V. E., García-López, L. J., Amorós, M. O., y López-Gollonet, C. (2003). El tratamiento de la fobia social en niños y adolescentes: una revisión meta-analítica. Psicología Conductual, 11, 599-622.
Sapp, M., Farrell, W., y Durand, H. (1995). The effect of mathematics, reading, and writing tests in producing worry and emotionality test anxiety with economically and educationally disadvantaged college students. College Student Journal, 29, 122–125.
Sarason, I. G. (1972). Experimental approaches to test anxiety: Attention and the uses of information. Anxiety: Current trends in theory and research, 2, 383-403.
Spielberger, C. D & Vagg, P.R. (1995). Test Anxiety: Theory Assessment and Treatment Washington D.C. Taylor Francis, 3-14.
Talbot, L. (2016). Test Anxiety: Prevalence, Effects, and Interventions for Elementary School Students. James Madison Undergraduate Research Journal (JMURJ), 3(1), 5.
Valero, L. (1999). Evaluación de ansiedad ante exámenes: Datos de aplicación y fiabilidad de un cuestionario CAEX. Anales de psicología, 15(2), 223-231.
Von Der Embse, N., Barterian, J., & Segool, N. (2013). Test anxiety interventions for children and adolescents: A systematic review of treatment studies from 2000–2010. Psychology in the Schools, 50(1), 57-71.
Zeidner, M. (1998). Test anxiety: The state of the art. Springer Science & Business Media.
To increase the sense of immersion in Virtual Reality, you can include comments, questions or ideas in the session so the experience will seem more realistic to your patient.
Some examples are:
You are at home watching TV a few days before having a test, how do you feel without studying?
You are going to high school/university, since today you are going to have to do a test
You are only waiting for the teacher to arrive, and you no longer have time to review more because he will arrive at any moment
You can hear your classmates talking a lot but you can’t understand them, however they seem pretty calm. How does it make you feel?
How do you think you would feel if instead of being surrounded by people who seem nervous, you were alone just waiting for the teacher?
The teacher appears and tells you that you can come in a very serious way, do you think he will make the test very difficult?
How do you feel right now, how do you think the test you are about to do is going?
You are about to take a short test. Think that it will not last that long, how do you think is it going to be?
How does it make you feel that your peers are saying aloud that they are finished? Does it make you more nervous?
The mumble of the classmates is decreasing, so it seems that the test will start. Are you ready?
The test is over. How are you now, what are you thinking?
Para aumentar la sensación de inmersión en la Realidad Virtual, puede incluir comentarios, preguntas o ideas en la sesión para que la experiencia le parezca más realista a su paciente.
Algunos ejemplos son:
Estás en casa viendo la tele unos días antes de tener un examen, ¿cómo te sientes sin estar estudiando?
Te estás dirigiendo al instituto/universidad, ya que hoy vas a tener que hacer un examen
Estás solo esperando a que llegue el profesor, y ya no tienes tiempo de repasar más porque va a llegar de un momento a otro
Puedes escuchar a tus compañeros hablando mucho pero no puedes entenderles, aunque parecen bastante tranquilos. ¿Cómo te hace sentir eso?
¿Cómo crees que te sentirías si en lugar de estar rodeado de gente que parece nerviosa, estuvieras tú solo esperando al profesor?
Aparece el profesor y os dice que vayáis pasando de forma muy seria, ¿te parece que habrá puesto el examen muy difícil?
¿Cómo te sientes ahora mismo, cómo crees que irá el examen que estás a punto de hacer?
Estás a punto de realizar un breve examen. Piensa que no va a durar mucho, ¿cómo crees que irá?
¿Cómo te hace sentir que tus compañeros vayan diciendo en voz alta que han acabado? ¿Te pone más nervioso?
El murmullo de los compañeros está disminuyendo, por lo que parece que el examen va a empezar. ¿Estás listo?
El examen ya ha acabado. ¿Cómo estás ahora, en qué piensas?
“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.”
Systematic desensitization (SD) through exposure is shown to be effective by itself to reduce test anxiety (Hembree, 1988) in addition to having a positive effect on academic results and a decrease in overall anxiety and trait status.
The therapeutic approaches that combine SD with cognitive restructuring and study techniques are the ones that show a greater reduction of the test anxiety (Talbot, 2016). Remember that exposure is an equally effective but more efficient technique than SD and that, in addition, virtual reality exposureis equally effective as exposure by imagination and achieves a greater reduction of avoidance behaviors than exposure by imagination (GutiérrezMaldonado, Alsina, Carvallo, Letosa & Magallón, 2007).
In terms of study techniques, it can be taught the importance of properly managing time and planning, understanding that in order to optimize the study, it is necessary to plan short-, medium- and long-term objectives. Techniques may also be used for the control of activation such as relaxation in case of having a patient with excessive physiological activation.
Another useful technique in these cases is cognitive restructuring, especially in those patients with excessive concern and with distorted thoughts centered on the negative consequences of not being successful in the test. During the preparation for the test, the student can be told to analyze the rationality of his/her thoughts, to think about which ones he/she habitually has and how they can interfere with his/her performance. In addition to this, you can tell the patient to draw up a list of alternative thoughts (self instructions) so they can choose one of them when their mind focuses on a negative thought while they are doing a test. Remember that the patient can practice using all these strategies in the virtual reality environment.
Below is the hierarchy example to use with the Psious environment. In this case the scene used is the university, but the same example could be used with the school environment.
SESSION 1
Psychoeducation: Inform the patient about the test anxiety (causes, symptoms, prevalence…).
Present and justify the techniques that will be used throughout the treatment: exposure with virtual reality and live exposure…
Elaboration of the exposure hierarchy and exposure to items of the hierarchy with 20-30 SUD’s (example)
Start exposure hierarchy with an item close to 30 SUD’s.
The main objective will be to familiarize the patient with virtual reality and the work dynamic.
ITEM
SUD’s
ENVIRONMENT
CONFIGURATION
EVENT
Being at home a few days before an important test
20
Home
Sun, Day
Being on the subway before doing a test
25
Metro
Illuminated, easy
Enter
Being alone in the hallway, waiting for the teacher to arrive and start the test
35
University
Easy, alone
Being with a few classmates in the hallway before a test while they look very calm
40
University
Easy, few students
SESSION 2
Review of the previous session achievements and establishment of the objectives of the session: Waiting for the teacher with a few classmates who seem quite nervous.
Exposure begins with prevention of gradual and systematic response to virtual reality. Cognitive restructuring, if appropriate.
Reports are shown to the patient to see clinical progress.
HOMEWORK Imagination exposure at home reviewing the objectives covered in the session + live exposure going to university even if you don’t have a test.
ITEM
SUD’s
ENVIRONMENT
CONFIGURATION
EVENT
Being alone waiting for the teacher, and when he arrives he nicely ask you to come in
40
University
Easy, alone
Teacher appears
Being with a lot of people in the hallwaybefore an exam and they seemvery quiet
45
University
Easy, a lot of students
Being with a few classmates in the hallway, and when the teacher appears he asks you to come in
50
University
Easy, Few students
Teacher appears
Waiting for the teacher with some classmates that seem very nervous
60
University
Hard, Few students
SESSION 3
Review the achievements of the previous session and establish the objectives of the current one: Being in class about to start a test and the classmates are very calm.
Exposure begins with prevention of gradual and systematic response to virtual reality. Cognitive restructuring, if appropriate.
Reports are shown to the patient to see clinical progress.
HOMEWORK Imagination exposure reviewing the process followed in consultation.
ITEM
SUD’s
ENVIRONMENT
CONFIGURATION
EVENT
Waiting for the teacher with a lot of people in the hallway, and they are very nervous and agitated
60
University
Hard, A lot of students
No event
Be with some classmates waiting in the hallway, the teacher appears and tells you to come in very seriously
65
University
Difficult, Few students
Teacher appears
Being in class about to start a test, the classmates seem calm
70
University
Easy, Few students
Enters the classroom
SESSION 4
Review the achievements of the previous session and establish the objectives of the current one: See that the classmates are very nervous while waiting to start the test.
Exposure begins with prevention of gradual and systematic response to virtual reality. Cognitive restructuring, if appropriate.
Reports are shown to the patient to see clinical progress.
HOMEWORK Imagination exposure at home, reviewing previous session.
ITEM
SUD’s
ENVIRONMENT
CONFIGURATION
EVENT
To see the result after doing a test
70
University
Easy, Few students
Finish the test
Being alone with the teacher while he seems very serious
75
University
Hard, Alone
Enters the classroom and then, No event
Waiting for the test to begin and see that the large number of colleagues around you seem very nervous
80
University
Hard, A lot of students
Enters the classroom and then, No event
SESSION 5
Review of the previous session achievements and establishment of the objectives of the session: Note that the teacher watches a lot while doing a short test.
Exposure begins with prevention of gradual and systematic response to virtual reality. Cognitive restructuring, if appropriate.
Repeat twice each one of the exercises.
Reports are shown to the patient to see clinical progress.
HOMEWORK Imagination exposure at home reviewing the objectives discussed in the session.
ITEM
SUD’s
ENVIRONMENT
CONFIGURATION
EVENT
Be alone with the teacher and start the test
80
University
Easy, Alone
Start the exam
Doing a short test in a crowded classroom
85
University
Easy, A lot of students
Start the exam
Doing a short test and notice that the teacher is watching a lot
90
University
Hard, A lot of students
Start the exam
SESSION 6
Review of the previous session achievements and establishment of the objectives of the session: Performing a long test while several classmates are saying aloud that they have already finished
Exposure begins with prevention of gradual and systematic response to virtual reality. Cognitive restructuring, if appropriate.
Repeat twice each one of the exercises
Reports are shown to the patient to see clinical progress.
HOMEWORK Imagination exposure at home, reviewing the previous session.
ITEM
SUD’s
ENVIRONMENT
CONFIGURATION
EVENT
The class murmur is being reduced and the teacher starts the test
90
University
Easy, Few students
Start the exam
Be doing a very long test and the teacher is watching you a lot
95
University
Hard, A lot of students
Start the exam
Doing a long test and several classmates are announcing aloud that they have already finished
100
University
Hard, A lot of people
Start the exam (some time has to pass)
Remember that you can use the clinical guide to inform you of the therapeutic procedures with empirical evidence and how to adapt them to the intervention with the Psious virtual environments.
