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 Psicométricas. 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
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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 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 healthcare professional can contribute with comments encouraging the patient to remember, and this way make the patient re-live the traumatic situation at a cognitive level.
“All the information contained in this section is for guidance only. Psious environments are therapeutic tools that must be used by the healthcare professional within an evaluation and intervention process designed according to the characteristics and needs of the user.
Also remember that you have the General Clinical Guide in which you have more information on how to adapt psychological intervention techniques (exposure, systematic desensitization, cognitive restructuring, chip economy…) to Psious environments.”
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.
Evaluation objectives
Evaluating the presence and comorbidity with other emotional disorders.
Evaluating the presence of re-experimentation, avoidance and activation increase.
Defining anxiogenic stimuli configurations and in what grade.
Evaluating presence of distorted thoughts.
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 therapeutic 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 Symptom 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
Introduction to EMDR
Eye Movement Desensitization and Reprocessing (EMDR) therapy (Shapiro, 2001) was initially developed in 1987 for the treatment of posttraumatic stress disorder (PTSD) and is guided by the Adaptive Information Processing model (Shapiro 2007). EMDR is an individual therapy typically delivered one to two times per week for a total of 6-12 sessions, although some people benefit from fewer sessions. Sessions can be conducted on consecutive days.
The Adaptive Information Processing model considers symptoms of PTSD and other disorders (unless physically or chemically based) to result from past disturbing experiences that continue to cause distress because the memory was not adequately processed. These unprocessed memories are understood to contain the emotions, thoughts, beliefs and physical sensations that occurred at the time of the event. When the memories are triggered these stored disturbing elements are experienced and cause the symptoms of PTSD and/or other disorders.
Unlike other treatments that focus on directly altering the emotions, thoughts and responses resulting from traumatic experiences, EMDR therapy focuses directly on the memory, and is intended to change the way that the memory is stored in the brain, thus reducing and eliminating the problematic symptoms.
During EMDR therapy, clinical observations suggest that an accelerated learning process is stimulated by EMDR’s standardized procedures, which incorporate the use of eye movements and other forms of rhythmic left-right (bilateral) stimulation (e.g., tones or taps). While clients briefly focus on the trauma memory and simultaneously experience bilateral stimulation (BLS), the vividness and emotion of the memory are reduced.
The treatment is conditionally recommended for the treatment of PTSD.
Using EMDR to Treat PTSD
EMDR therapy uses a structured eight-phase approach that includes:
· Phase 1: History-taking
· Phase 2: Preparing the client
· Phase 3: Assessing the target memory
· Phases 4-7: Processing the memory to adaptive resolution
· Phase 8: Evaluating treatment results
Processing of a specific memory is generally completed within one to three sessions. EMDR therapy differs from other trauma-focused treatments in that it does not include extended exposure to the distressing memory, detailed descriptions of the trauma, challenging of dysfunctional beliefs or homework assignments.
The Phases of EMDR
History-taking and Treatment Planning
In addition to getting a full history and conducting appropriate assessment, the therapist and client work together to identify targets for treatment. Targets include past memories, current triggers and future goals.
Preparation
The therapist offers an explanation for the treatment, and introduces the client to the procedures, practicing the eye movement and/or other BLS components. The therapist ensures that the client has adequate resources for affect management, leading the client through the Safe/Calm Place exercise.
Assessment
The third phase of EMDR, assessment, activates the memory that is being targeted in the session, by identifying and assessing each of the memory components: image, cognition, affect and body sensation.
Two measures are used during EMDR therapy sessions to evaluate changes in emotion and cognition: the Subjective Units of Disturbance (SUD) scale and the Validity of Cognition (VOC) scale. Both measures are used again during the treatment process, in accordance with the standardized procedures:
Validity of Cognition (VOC) scale
The clinician asks, “When you think of the incident, how true do those words (repeat the positive cognition) feel to you now on a scale of 1-7, where 1 feels completely false and 7 feels totally true?”
Completely false
1
2
3
4
5
6
7
Completely true
Subjective Units of Disturbance (SUD) scale
After the client has named the emotion he or she is feeling, the clinician asks, “On a scale of 0-10, where 0 is no disturbance or neutral and 10 is the highest disturbance you can imagine, how disturbing does it feel now?”
No disturbance
0
1
2
3
4
5
6
7
8
9
10
Worst possible
Desensitization
During this phase, the client focuses on the memory, while engaging in eye movements or other BLS. Then the client reports whatever new thoughts have emerged. The therapist determines the focus of each set of BLS using standardized procedures. Usually the associated material becomes the focus of the next set of brief BLS. This process continues until the client reports that the memory is no longer distressing.
Installation
The fifth phase of EMDR is installation, which strengthens the preferred positive cognition.
Body Scan
The sixth phase of EMDR is the body scan, in which clients are asked to observe their physical response while thinking of the incident and the positive cognition, and identify any residual somatic distress. If the client reports any disturbance, standardized procedures involving the BLS are used to process it.
Closure
Closure is used to end the session. If the targeted memory was not fully processed in the session, specific instructions and techniques are used to provide containment and ensure safety until the next session.
Re-evaluation
The next session starts with phase eight, re-evaluation, during which the therapist evaluates the client’s current psychological state, whether treatment effects have been maintained, what memories may have emerged since the last session, and works with the client to identify targets for the current session.
EMDR is a bilateral stimulation 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.
Self-report hierarchy for Eating Disorders: Restaurant (Psious)
ITEM
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…).
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To increase the sense of immersion in Virtual Reality, you can include comments, questions or ideas in the session so the experience will seem more realistic to your patient.
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.
“All the information contained in this section is for guidance only. Psious environments are therapy supporting tools that must be used by the healthcare professional within an evaluation and intervention process designed according to the characteristics and needs of the user.
Also remember that you have the General Clinical Guide in which you have more information on how to adapt psychological intervention techniques (exposure, systematic desensitization, cognitive restructuring, chip economy…) to Psious environments.”
It is important to emphasise that in this section we will only show and suggest some points to guide the intervention with our patient using the two virtual environments available to Psious for tackling EDCs.
However, we must not forget that the intervention proposal presented below only shows a part of it, as the full treatment of EDs also requires other procedures (diagnostic interview, psychometric assessment, structuring eating patterns, relapse prevention, 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 they do not make pants for fats 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).
HOMEWORK
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.
HOMEWORK
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.
HOMEWORK
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, they 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 the work’s dynamics will 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
SUD’s
CONFIGURATION
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 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.
ITEM
SUD’s
CONFIGURATION
EVENT
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 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).
ITEM
SUD’s
CONFIGURATION
EVENT
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 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
ITEM
SUD’s
CONFIGURATION
EVENT
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 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…).
ITEM
SUD’s
CONFIGURATION
EVENT
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.
ITEM
SUD’s
CONFIGURATION
EVENT
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…”).
“All the information contained in this section is for guidance only. Psious environments are therapy supporting tools that must be used by the healthcare professional within an evaluation and intervention process designed according to the characteristics and needs of the user.
Also remember that you have the General Clinical Guide in which you have more information on how to adapt psychological intervention techniques (exposure, systematic desensitization, cognitive restructuring, chip economy…) to Psious environments.”
Objectives
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.
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).
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, to get a more realistic perception and to 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).
