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
Awad AG, Voruganti LN. (2004). Body weight, image and self-esteem evaluation questionnaire: development and validation of a new scale. Schizophr Res., 70 (1), 63-67.
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
National Institute for Clinical Excellence (NICE). (2004). Eating Disorders. Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa, and related eating disorders. London: The British Psychological Society and Gaskell.
Perpiñá, C., Botella, C., & Baños, R. M. (2003). Virtual reality in eating disorders. European Eating Disorders Review, 11, 261–278
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
Probst M, Vandereycken W, Coppenolle H, Vanderlinden J. (1995). The Body Attitude Test for patients with an eating disorder: Psychometric characteristics of a new questionnaire. Eat Disord., 3, 133-44.
Raich R, Mora M, Soler A, Ávila C, Clos I, Zapater L. (1996). Adaptación de un instrumento de evaluación de la insatisfacción corporal. Clínica y Salud, 7, 51-66.
Reilly EE, Anderson LM, Gorrell S, Schaumberg K, Anderson DA. (2017). Expanding exposurebased interventions for eating disorders. Int J Eat Disord., 00, 000–000. https://doi.org/10.1002/eat.22761
Riva, G. (2011). The key to unlocking the virtual body: virtual reality in the treatment of obesity and eating disorders. Journal of Diabetes Science and Technology, 5(2), 283–292.
Riva, G., Bacchetta, M., Baruffi, M., Rinaldi, S., & Molinari, E. (1999). Virtual reality based experiential cognitive treatment of anorexia nervosa. J Behav Ther Exp Psychiatry, 30(3), 221–230.
Rodriguez Campayo MA, Beato Fernández L, Rodriguez Cano T, Martínez-Sánchez F. (2003). Adaptación española de la escala de evaluación de la imagen corporal de gardner en pacientes con trastorno de la conducta alimentaria. Actas Esp Psiquiatr, 31(2), 59-64.
Rosen, JC, Srebnik, D, Saltzlberg, E (1991): Development of a Body Image Avoidance Questionnaire. Journal of Consulting and Clinical Psychology, 3, 32-37
Saldaña, C., Tomás, I. y Bach, L. (1997). Técnicas de intervención en los trastornos alimentarios. Ansiedad y Estrés, 3, 319-337.
Sánchez-Carracedo, D., Mora, M., López, G., Marroquín, H., Ridaura, I., & Raich, R. M. (2004). INTERVENCIÓN COGNITIVO-CONDUCTUAL EN IMAGEN CORPORAL. Psicología Conductual, 12(3), 551–576.
Shaffer D, Fisher P, Lucas CP, Dulcan MK, Schwab, ME. (2000). NIMH Diagnostic Interview Schedule for Children Version IV (NIMH DISC-IV). description, differences from previous versions, and reliability of some common diagnoses. Journal of the American academy of child and adolescent psychiatry, 39(1), 28-38.
Smith MC, Thelen MH. (1984). Development and validation of a test for bulimia. J Consult Clin Psychol., 52(5), 863-72.
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
We have 6 basic emotions: the surprise, the happiness, the disgust, the wrath, the sadness and the fear. Like the fingers of a hand, they help us in different aspects in our life: they prepare us, activating different mechanisms in our organism; they motive us, giving us energy, to get closer or away of determined situations; and finally they help us relate with other people and beings (animals, plants…) therefore, our emotions are adaptive and help us in a lot of aspects of our life
Like other elements of our body, the emotions can be “hurt”. IJust like we can get hit, make us a fissure, a sprain, a fracture in our hand…, in occasions our emotions can be malfunctioning. Then we talk about emotional disorders, that is to say, a temporal alteration of some or several of your emotions affects you in your daily life.
We professionals in mental health know and count with tools, just like a doctor use an ointment, a bandage, a temporary immobilization of the hand if it’s hurt, that will help you solve your emotional problems. One of these tools is virtual reality
How do we feel the emotions?
We all feel, experience and express the emotions in different ways. Let’s see whats the triple answer channel of emotions:
If we imagine a television with three channels, a first way in which we feel is our body, and it is what in psychology we call physiological channel: palpitations, abdominal discomfort, headache, tremors, excessive sweating …, are examples of how we feel the emotions in our body.
A second channel is our behavior, motor channel: block us out of anguish, cry, be in bad humor, avoid or flee of determined situations are another way of fear.
In third place, but not less important, are our thoughts, cognitive channel. In this channel, we tend to anticipate the worst, we stay just with the negative part of the situation, for example, having an accident…
These three channels, unlike what can happen in a television, are perceived at the same time. That is to say, when we feel an emotion is like we are seeing the three channels at the same time. Imagine that you are watching a movie, a documental and a tennis match at the same time and in the same television… Is because of that that sometimes, is difficult to understand what is happening to us.
How the emotional disorders appear?
That a fear ends up being a psychological problem is more likely if the following conditions are met:
People who are more nervous by nature (by genetics) are more likely to have an emotional problem.
But that is not usually a sufficient condition for a fear disorder to appear. It has also been discovered that fear disorders are learned. In other words, our experiences in relation to certain situations are also very important: having a bad experience, not having done something or never or very little, having seen other people having a bad time during a particular situation, having seen or received news about a certain situation … are experiences that influence our fear.
In short, our way of being and our experiences are the most important aspects to explain why a fear disorder appears. Knowing that the origin of the fear is in our way of being and in the lived experiences, help us to explain how and why an association is made between certain situations and the appearance of fear. In addition, (as will be explained later) it will be very useful to us to understand how the fear is solved.
How is a pathological fear kept?
When we suffer from an alteration of fear, it automatically appears when faced with situations related to the fact that we fear
An usual behavior is usually to try to avoid situations in which appears our emotional discomfort (physical and / or cognitive). For example, if a person talks about flying in a conversation, the person who is afraid of flying does not participate, if we find ourselves bad in a restaurant or in the subway … we go home…
This behavior reduces fear very quickly. However, in the medium term, the avoidance is bad, because we are learning that not doing what we are afraid of eliminates feeling the fear. However, it does not make fear to be resolved once and for all.
In addition, we also learn what is good to avoid in advance. That is, the more things related to the fact that we fear we can avoid, the better. Since that way I will have less fear. However, fear is usually widespread and generalized. Every time we fear more things; Maybe initially you were only afraid of the subway, but now you have developed fear the moment you leave home, travel…
In conclusion, Avoidance, Sensitization and Generalization explain why the emotional disorders of fear do not usually disappear alone or without a change in the behaviors that a person performs to manage their fear.
How we solve emotional problems?
To solve an emotional disorder you will learn how to break the Association that has been created between the situation or conditioned situations (getting away from home, going by subway, by car …) and fear (physical sensations and unpleasant thoughts).
Psychotherapy will help you to train and perform a series of learning that will allow you to break that association: Through the exposure technique, you will face progressively, situations related to your fears, which will help you to break down and reduce the intensity of the association between your fear and those situations.
Learning how to use your breath can also be helpful in reducing the feelings of discomfort that appear when you have fear.
Finally, learning to detect negative thoughts and change them to more real and functional ones will help you in your cognitive discomfort.
With training and these lessons you can solve your fear. Cheer up!
What is an exposure hierarchy?
An exposure hierarchy is a list of things or situations that cause you disgust and/or you avoid doing because of fear.
These lists are about specific topics, for example, the fear of flying or the fear of dogs and include in an extensive and varied way the situations that cause me discomfort.
In addition, these situations are ordered from minor to major discomfort, without having to follow a normal chronological order.
How to make an exposure hierarchy?
Let’s use the example of fear of dogs:
First, list the situations that cause you discomfort. Remember that the list should include concrete and varied facts.
Once you have the list made, score on a scale of 0 to 100 the two situations on the list that lesser and greater discomfort provokes to you. Do not worry if you doubt or make any mistake, make changes as often as necessary and score all the other situations, one by one, depending on the subjective degree of discomfort that they generate to you.
Finally, sort the list according to the score that you have assigned to each of its elements (from minor to major discomfort or score).
Congratulations, you already have your exposure hierarchy ready!
Elaboration of the exhibition hierarchy with Psious environments
Example of intervention in agoraphobia
Example of intervention in agoraphobia with 360º videos
Use recommendations
Recommended bibliography
Annexes
Diary of Anxiety and Panic Attacks
Relaxation self-recording
Underground hierarchy self-recording
Videos 360º hierarchy self-recording
1. Agoraphobia and Virtual Reality
According to Bados (2006), the problems with panic and agoraphobia are very frequent in clinical practice; specifically, these are the anxiety problems which people consult about most and they constitute around 50-60% of the phobia cases attended in the clinic (Bados, 2009). In general, if data of population of primary health care is analyzed, numbers will show a higher prevalence than in the general population.
Virtual reality (VR) seems to be a good alternative regarding traditional techniques of exposure in the treatment of agoraphobia. Unlike in vivo exposure, virtual reality allows standardization and control over the exposure session parameters. Moreover, this technology is particularly useful for repeating the exposure of the feared situations as many times as necessary (Botella et al, 2004). It also prevents panic attacks, losing the risk of reinforcing the existing fear.
2. Psious-based Treatment/ Evaluation Protocol
All the information in this section is designed to provoke an indicative nature. Psious environments are therapeutic tools that should be used only by healthcare professionals experienced in the evaluation and intervention processes according to the characteristics of their patient’s needs.
There is a General Clinical Guide that contains more information on how to adapt the techniques of psychological intervention (exposure, systematic desensitization, cognitive reorganization, chip economy…) to Psious environments at your disposal if needed.
2.1 Agoraphobia evaluation
2.1.1 Goals of evaluation
To evaluate the presence and comorbidity of other emotional disorders, especially panic disorder, anxiety disorders and other phobias.
Evaluate component-related anxiety: being in a public place with many people, feelings of distress and thoughts about not being able to escape.
Define stimulating configurations feared by the patient and the degree of it. Elaboration Hierarchy of Exposure.
Evaluate the presence of distorted thoughts: losing control and not being able to escape the situation, suffer a panic attack.
2.1.2 Some useful tools for evaluating agoraphobia
In consideration to the evaluation objectives, we will provide a list of some tools that can be useful to obtain relevant information and characteristics about your patient. Remember that a good definition of objectives, characterization of the patient and planning of the intervention are important for the efficiency and efficacy of the therapy, as well as for satisfaction of your patients. In the bibliography, you will find articles to review the characteristics of the instruments proposed below. A combination of the following tools will be used for a complete evaluation of the problem.
Open or semi-structured interview.
Structured interview: Interview for the Anxiety disorders According to DSM-IV (ADIS-IV)
Observation and self-observation (with auto-registration)
Diary of anxiety and panic attacks
Auto-registration of relaxation
Behavioral approach Test in vivo and/or through virtual reality
Auto – reports
Mobility Inventory for agoraphobia: to evaluate the avoidance of situations and places
Body Sensation Questionnaire: to evaluate the fear of various body sensations
Questionnaire of agoraphobic cognitions: to evaluate the catastrophic thoughts and physical feelings of anxiety
Agoraphobia Inventory
Psious Auto-Reports for the elaboration of the hierarchy
2.1.3 Elaboration of the exhibition hierarchy with Psious environments
Once we have the information from the evaluation, we can proceed to develop the exposure hierarchy. In addition to using the data obtained during the initial assessment, we can make a series of questions (for example: on a scale from 0-100, what level of discomfort would you feel being on a platform waiting for the underground?, a scale from 0 to 100, what level of discomfort would you feel going to shop at a mall with a lot of people?, do you think there is anything that can generate a higher discomfort?…) aimed at planning the intervention through virtual reality.
Here are some items that could be used to create an appropriate hierarchy for treating agoraphobia with Psious. It must be noted that we should ask the patient about the anxiety generated by these situations, and based on this, note and grade the different elements of the hierarchy.
Driving around the city during low-traffic hours
Driving around the city during high-traffic hours ( Environment fear to driving, city)
Highway travel
Being alone at home (Generalized Anxiety Environment, concern…)
Going inside an elevator (Claustrophobic environment, Small elevator)
Being in the Underground entrance (Agoraphobia environment, Metro)
Being at the platform (Agoraphobia environment, Metro)
Getting on a plane and closing the doors (Environment fear of flying, Plane)
Being in the subway wagon with a lot of people (Environment agoraphobia, Metro)
Being on the street away from home with few people (Environment agoraphobia, Square, Boulevard…)
2.2 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
USA’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 “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.
Exercises to do at home:
Exercises to do at home: Live exposure to streets away from home, or go out for a drive through the city.
Item
USA’s
Environment
Configuration
Event
Being in a square near home with plenty of people
40
Square
Maximum
Walking along a very crowded boulevard
45
Video Very Crowded Boulevard
Being alone at home
50
Home
Take a walk along the port
55
Video 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.
Exercises to do at home:
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
USA’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.
Exercises to do at home:
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
USA’s
Environment
Configuration
Event
Very crowded boulevard.
70
Very crowded boulevard
Underground entrance
75
Metro
Maximum, dirty
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.
Exercises to do at home:
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
USA’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.
Exercises to do at home:
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
USA’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”
2.2.1 Intervention Example on Agoraphobia with 360º Format Videos
In addition to virtual environments and normal videos, the agoraphobia scene has several 360º format videos that will allow you to make a more effective intervention. The videos 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 videos can be used: The video with the stair landing (leaving the house), the one in the subway (going to the market), the market videos (ground floor) and the one in the mall (elevator, first floor, second floor…) The use of different videos can be used to create a hierarchy of exposure that will help the patient become used to visiting a mall or a market.
SSESION 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
USA’s
Environment
After having left the mall , he/she is out on the street surrounded by people and cars
20
360º video outside the mall
On the elevator, going from the last floor to the ground floor to leave the mall.
25
360º video inside the elevator
Waiting for the elevator to leave the top floor of the mall.
30
360º video waiting for the elevator.
Being at the market’s exit, observing people come in and out.
40
360º video entering a crowded market.
SESIÓN 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.
Exercises to do at home:
Live exposure, going out into the street and going to a market or a mall. The patient doesn’t have to enter it.
Ítem
USA’s
Entorno
Observe people leaving the subway station, right before entering it to go home.
40
360º Video Subway Exit
Being in the entrance hall of their own home after coming back from the mall.
50
360º Video Hall
Being out on the street , observing (from a distance) the mall he/she intends to go to.
55
360º Video 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 Video Ground Floor
SESIÓN 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.
Exercises to do at home:
Live exposure, going to market that isn’t as crowded or just standing outside a mall to observe + image exposure to review session goals.
Ítem
USA’s
Entorno
Taking a slightly crowded elevator to go up to the second floor of the mall
65
360º Video inside the elevator
Waiting to take an elevator to the first floor at a market surrounded by a few people.
70
360º Video waiting for the elevator
On the first floor of a mall with the exit in view in the far distance.
75
360º Video inside the mall. Vídeos
SESIÓN 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.
Exercises to do at home:
Live exposure going to a crowded market or to a busy mall.
Ítem
USA’s
Entorno
Watching people (in the hall of the subway exit) coming in and out of the subway before entering a busy market.
80
360º Video 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 Video 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 Video 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 Video Second Floor
3. Recommended Use
It is important to include comments, questions or indicators in the exposure session (to immerse the patient in the situation) so the experience seems more realistic.
Some suggestions for agoraphobia are:
You are leaving home and you remember you will have to cross a square full of protesters.
Today we are going to take the underground after work during rush hour. Does it produce anxiety in you? Why?
You should be leaving for work now since it’s getting late
If you suffered a panic attack right now, would you be able to manage it?
You should take the underground because if you walk, you won’t get to your destination on time.
Right now, you are in the middle of a protest with a lot of people around you. How do you feel?
Today we will go for a walk from your house to your parents’/friend’s/ girlfriend’s or boyfriend‘s house. This walk will last 10/15/20/”x amount” of minutes.
Imagine that, upon entering the underground station, your phone runs out of battery.
On this occasion you find yourself walking through a(n) empty/ moderately busy/extremely busy – street. How do you feel?
Would you feel any different if you were alone in this situation?
4. Recommended Bibliography
Bados López, A. (2009). Agorafobia y pánico: Naturaleza, evaluación y tratamiento. (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 behavioural 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. y 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. y Williams, C. (1985). The Mobility Inventory for Agoraphobia. Behaviour Research and Therapy, 23, 35-44.
Echeburúa, E., de Corral, P., García Bajos, E., Páez, D. y Borda, M. (1992). Un nuevo inventario de agorafobia (IA). Análisis y Modificación de Conducta, 18, 101-123.
J., C. (n.d.). A Randomized Controlled Study of Virtual Reality Exposure Therapy and Cognitive-Behaviour Therapy in Panic Disorder with Agoraphobia. Frontiers in Neuroengineering.
5. Annexes
5.1 Diary of Anxiety and Panic Attacks
Time and Date
Activity conducted
Sensations
Intensity of the Sensations (0-10)
Alone or in company
Before
During
After
5.2 Relaxation: Self-Recording
Date
Time
Level of relaxation before (0-100)
Level of relaxation after (0-100)
Time
Comments
5.3 Underground Hierarchy: Self Recording
Item
Discomfort Level (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 and 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.
5.4 360º Hierarchy Videos: Self-Recording
Item
Discomfort Level (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.
Fear of heights —also known as acrophobia— is a condition that affects 3–5% of 1. Phobia of heights 1. Phobia at heights Manual Acrophobia the general population. It is not necessarily pathologic, and it only implies a problem if the anxiogenic response is uncontrollable, if it can drive the patient into a panic attack or into suffocation sensations, etc. This phobia belongs to the category of “specific phobias”, which may provoke an intense and anxious response to a specific stimulus —in this case, when people are exposed to heights.
Fear of heights is considered natural, even adaptative, since the avoidance response could be positive when people feel they are in a risk environment.
There are several agents implied in the development and maintenance of this phobia and Coelho, Waters, Hine and Wallis (2009) consider both non associative —hereditary— and associative —conditioned— factors in their model. So, it is considered as a multi-causal phenomena because not all the patients that seem tosuffer this phobia have developed it in a conditioned or learned way. Moreover, it was found in a longitudinal study realized by Poulton , Davies, Menzies, Langley and Silva (1998) that those who took part in the study and suffered significant lesions and falls before the age of 9 do not show a phobic response when they are 18.
However, some people manifest a phobic behavior pattern when they are exposed to heights, such as feeling anxious or even presenting panic attacks. In these cases, treating the patient is essential since it is shown a high level of acrophobia, so one could try to avoid any place not situated at ground level. The avoidance response intensity depends on the patient’s particular condition but it is particularly important to understand how the avoidance response intensity manifests itself through a continuum, which is a scale of high positions going from climbing up stairs to situate the patient on a cli. This is an important indicator and it has to be taken into account not just when analyzing the impact and the relevancy of the disorder but when the stage.
Finally, it is worth mentioning that Virtual Reality is a good alternative compared to traditional exposure techniques in the treatment of acrophobia because of several reasons.
Firstly, the therapist holds greater control of exposure variables, as opposed to the difficulty of obtaining an optimal environment to treat this phobia.
Secondly, it is less expensive in terms of logistics, treatment time and effort because it does not require the patient and therapist to move around to find suitable places for in vivo exposure: the situation is modeled in a virtual environment . And, last but not least , there are fewer probabilities of the patient not wishing to be exposed to this treatment. Moreover, the use of VR exposure as a technique is at least equally efficient as in vivo exposure treatment (Emmelkamp, & cols; 2002).
2. Virtual environments of Psious
Psious currently offers three scenarios and nine videos for treating acrophobia. In 2.1 New York The patient is located in the highest part of a skyscraper. Furthermore, thanks to RV viewer and to Psious platform, the patient can look around a 360 degrees angle. Moreover, the therapist can control exposure to anxiogenic interoceptive sensations (Figure 2) two of them, the patient is placed at the top of a building: the first one is New York (figure 1) and the second one is Barcelona (figure 1).
Both environments are thought to work on the cognitive aspect, hence the lack of events. On the other hand, if the therapist wants to proceed with gradual exposure, there is a third environment: an Elevator (figure 1).
On the other hand, the videos depict different places located at a certain height: a castle’ s moat, a ferris wheel in an amusement park, a ferris wheel in the city, a fifth floor balcony, an Indoor glass elevator, an outdoor glass elevator, train bridge anda cliff (figure 1)
These virtual environments are very useful for the examination of the patientʼs current state as well as their anxiety response when facing a feared situation.
Figure 1
HOW TO APPLY COGNITIVE BEHAVIORAL TECHNIQUES WITH PSIOUS?
The virtual reality environments and especially the last two can be used for verbal and behavioral questioning of the negative thoughts of the patient.
The fact of being in the situation will facilitate the evocation of recurrent thoughts that it produces. Thus, the therapist will be able to question them and the patient will internalize the procedure, which he will be able to apply more easily when in his real life he finds himself facing the feared situation. In the same way, the patient will be able to test the most feared consequences of the situation, previously discussed with the therapist, and verify that they are not being complied with.
For example, the therapist has an acrophobic patient who believes that if his or her eyesight is clouded, he or she will probably faint, fall and eventually die. In this case, patient and therapist can prove repeatedly in the virtual environment ( New York or Barcelona) that in spite of experiencing these sensations, they are controllable, and their predictions are erroneous and are not fulfilled.
3. Treatment Protocol based on Psious
As detailed below, a treatment protocol is offered as an example. It includes the SESSION 1: PSYCHOEDUCATION SESSION 2 and 3 : RELAXATION SESSION 4: COGNITIVE RESTRUCTURING 3. Treatment protocol based on Psious Manual Acrophobia use of Psious combined with traditional techniques, nevertheless we recommend the therapist to adjust the VRʼs strategies to the techniques he already uses in his clinic practice. Moreover, the techniques will have to be adjusted to the needs and evolution of the patient, but especially to the exposure hierarchy, which therapist and patient should elaborate in the first session
SESSION 1: PSYCHOEDUCATION
Information about acrophobia is provided (origin, upkeep and appearance the triple system cognitive, physiological and motor).
Treatment techniques that will be used throughout the protocol are explained (emphasizing the exposure to the VirtualReality environments).
An exposure hierarchy is elaborated.
SESSION 2 and 3 : RELAXATION
The patient learns and practices two types of relaxation techniques: controlled breathing and Jacobson’s progressive muscular relaxation.
Familiarization with the Psious platform. The patient learns touse 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 6.2)
SESSION 4: COGNITIVE RESTRUCTURING
Revision and adjustment of the patient’s negative thoughts.
Cognitive restructuring for each of the negative thoughts. Two kinds of cognitive therapy may be used: the one proposed by Beck or the one belonging to Ellis.
Homework: Daily practice of relaxation techniques. Self-registers Versión de Prueba of relaxation and negative thoughts are completed (see annex 6.2)
SESSION 5: VIRTUAL EXHIBITION + RELAXATION
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:
Bridge and/or Cliff
Getting to the second level of the crystal elevator
Homework: Daily practice of the relaxation techniques, selfregister of relaxation and negative thoughts and tasks of self exposure to stimulus related to heights..
SESSION 6: EXHIBITION RV + TRADITIONAL TECHNIQUES
Homework review.
The patient is exposed to:
Getting to the terrace by the crystal elevator introducing interoceptive exposure and leaning to the rail.
Getting to the terrace by the crystal elevator introducing a breakdown
Homework: Daily practice of relaxation techniques, self-registers and tasks of self-exposure to height related stimuli.
SESSION 7: EXHIBITION RV + TRADITIONAL TECHNIQUES
Homework review.
The patient is exposed to:
Getting to the terrace by the metal elevator.
Homework: Daily practice of relaxation techniques, self-registers and self-exposure tasks to height related stimuli.
SESSION 8: EXHIBITION RV + TRADITIONAL TECHNIQUES
Homework review
The patient is exposed to:
Getting to the terrace by the metal elevator introducing interoceptive exposure.
Homework: Daily practice of relaxation techniques, self-registers and self-exposure tasks to height related stimuli.
SESSION 9: EXHIBITION RV + 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. With this scenario, we propose to examine the thoughts of the patient and the achieved results. Like in the rest of the exposure it is used in combination with relaxation and cognitive restructuring.
The patient is exposed to:
New York or Barcelona.
Homework: Daily practice of relaxation techniques, self-registers and self exposure tasks to height related stimuli.
SESSION 10: RELAPSE PREVENTION
Homework review.
The therapeutic process is evaluated and future self-exposure tasks are programmed, as well as booster sessions.
Relapse management and prevention.
4. Comments for suggestion
It is important to follow the exposure with comments, questions or instructions 4. Comments for suggestion Manual Acrophobia for the patient to feel more exposed to the situation and to experience a much more realistic experience. Some suggestions for acrophobia:
Today we are going to climb up a building of 15 floors. You will be located at the balcony on the highest floor, from where you will observe the fall from above, paying attention to the movement of cars and to the ground distance.
Is it true that falling from this height could be deadly?
Do you feel that it is a risk situation?
We are now in a very high place. Do you feel anxious?
Move the head to both sides and look how we are in a very high place.
Is it hard not to look down?
Do you feel anxious or fearful looking down?
Do you feel fear? Is it more intense or less than before?
Do you feel like you are in danger right now? How real do you think it is?
(Inside the glass elevator) Notice that as the elevator goes up, the distance from the ground is increased and everything looks smaller. How does that make you feel?
5. Recommended bibliography
Antony, M., & Craske, M. (1995). Mastery of your specific phobia: Client workbook. Albany, New York: Graywind Publications.
Emmelkamp, P., Krijn, M., Hulsbosch, A. M., De Vries, S., Schuemie, M. J. & Van der Mast, C. (2002). Virtual reality treatment versus exposure in vivo: A comparative evaluation in acrophobia. Behaviour Research and Therapy. Vol. 40, 509-516.
Poulton, R., Davies, S., Menzies, R. G., Langley, J. D., & Silva, P. A. (1998). Evidence for a non-associative model of the acquisition of a fear of heights. Behaviour Research and Therapy, 36(5), 537–544.
Coelho, C., Waters, A., Jine, T. & Wallis, G. (2009). The use of virtual reality in acrophobia research and treatment. Journal of Anxiety Disorders, 23 (5), 563-574. Recuperado de http://www. sciencedirect.com.sire.ub.edu/science/article/pii/S 0887618509000280
Cohen DC. Comparison of self-report and behavioral procedures for assessing acrophobia. Behavior Therapy. 1977;8:17–23.
Self-report hierarchy elevator environments Psious:
Ítem
Level malaise (0-100)
I walk into a glass elevator and stand near the railing.
I am in a glass elevator, placed near the railing, and we go up one floor
After a long journey in the metal elevator that looks like a work of art, we reached the terrace, and to access it I have to pass through a metal bridge and uncovered
I am going up in a glass elevator , and when we’ re on the first floor there’s a breakdown, so there’ s noise and the elevator moves a little bit. 3 minutes go by and the fault remains unsolved.
I walk into a glass elevator and stand away from the railing.
I am in a metal elevator that looks like a work of art, placed near the railing, and we go up one floor
I am in a glass elevator, placed away from the railing, and we go up four floors
I am going up in a glass elevator, and when we’ re on the third floor there’ s a breakdown, so there’ s noise and the elevator moves a little bit. After 30 seconds the fault is solved and the elevator continues.
I am in a glass elevator, placed near the railing, and we go up two floors
I am going up in a metal elevator that looks like a building site, and when we are on the first floor there is a breakdown, so there is noise and the elevator moves a bit. After 30 seconds the fault is solved and the elevator continues.
I a m in a glass elevator, placed away from the railing, and we go up three floors.
After a long journey in the glass elevator, we arrived at the terrace, and to access it I have to pass through a covered walkway.
I am going up in a metal elevator that looks like a work of art, and when we’ re getting to the top of the whole building there’s a breakdown, so I’ m going to go up in a metal elevator that looks like a work of art.
There is noise and the elevator moves a little. 3 minutes go by and the fault remains unsolved.
I am in a glass elevator, placed away from the railing, and we go up one floor
I am going up in a glass elevator, and when we’ re getting to the top of the whole building there’s a breakdown, so there’ s noise and the elevator moves a little bit. 3 minutes go by and the fault is still not solved.
I am in a metal elevator that looks like a work of art, placed away from the railing, and we go up a floor
I am in a glass elevator, placed away from the railing, and we go up five floors
I enter a metal elevator that looks like a work of art and I stand far from the railing.
I am in a glass elevator, placed near the railing, and we go up five floors
I am going up in a metal elevator that looks like a building site, and when we’ re getting to the top of the whole building there’s a breakdown, so there’ s noise and the elevator moves a bit. After 30 seconds the fault is solved and the elevator continues.
I am in a metal elevator that looks like a building site, placed away from the railing, and we go up two floors.
I am in a glass elevator, placed near the railing, and we go up four floors
I am going up in a metal elevator that looks like a building site, and when we’ re on the third floor there’ s a breakdown, so there’ s noise and the elevator moves a bit. After 30 seconds the fault is solved and the elevator continues.
I am in a metal elevator that looks like a building site, placed near the railing, and we go up three floors
I am in a glass elevator, placed near the railing, and we go up three floors
I am in a metal elevator that looks like a construction site, placed away from the railing, and we go up five floors.
I’ m going up in a metal elevator that looks like a building site, and when we are on the first floor there is a breakdown, so there is noise and the elevator Versión de Prueba moves a bit. 3 minutes go by and the fault remains unsolved.
I am in a metal elevator that looks like a construction site, placed away from the railing, and we go up four floors.
I am going up in a glass elevator, and when we’ re on the first floor there’ s a breakdown, so there’ s noise and the elevator moves a little bit. After 30 seconds the fault is solved and the elevator continues.
I enter a metal elevator that looks like a work of art and I stand near the railing
I am in a metal elevator that looks like a construction site, placed near the railing, and we go up four floors.
I am going up in a glass elevator, and when we’ re getting to the top of the whole building there’ s a breakdown, so there’ s noise and the elevator moves a little bit. After 30 seconds the fault is solved and the elevator continues.
I am in a glass elevator, placed away from the railing, and we go up two floors.
I am in a metal elevator that looks like a construction site, placed near the railing, and we go up five floors.
I am in a metal elevator that looks like a construction site, placed away from the railing, and we go up three floors.
I am going up in a glass elevator , and when we’ re on the third floor there ‘ s a breakdown, so there is noise and the elevator moves a little bit. 3 minutes go by and the fault remains unsolved.
I am going up in a metal elevator that looks like a building site, and when we’ re on the third floor there’s a breakdown, so there’ s noise and the elevator moves a bit. 3 minutes go by and the fault remains unsolved.
I am in a metal elevator that looks like a building site, placed near the railing, and we go up two floors.
