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Appendix

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Bibliography

• Badia X, Muriel C, Gracia A, Núñez-Olarte J, Perulero N, Gálvez R, et al. (2003). Spanish validation of the Brief Pain Inventory questionnaire in patients with pain of neoplastic cause. Med Clin, 120, 52-9

• Beck, AT, Brown, G, Epstein, N, Steer, RA (1988). An inventory to measure 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 signs, 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 nerve or somatic lesions and development of a new diagnostic questionnaire for neuropathic pain (DN4). Pain, 114, 29-36. 10.1016 / j. Pain. 2004.12.010

• Brown, TA, Di Nardo, PA and Barlow, DH (1994). Interview schedule for anxiety disorders 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). Clinical use of virtual reality for distraction and reduction of postoperative pain in adult patients. Tesis Psicológica, July-December, 38-50.

• Carlsson, AM (1983). Assessment of chronic pain. I. Aspects of the reliability and validity of the visual analogue scale. Pain, 16, 87-101.

• Cid, J., Acuña, JP, Andrés, J., Díaz, J., and Gómer-Caro, L. (2014) What and how to assess the chronic pain patient? Assessment of the patient with chronic pain. RDO. MEDICINE. CLIN. CONDES, 25 (4), 687-697.

• Freynhagen, R., Baron, R., Gockel, U. and Tölle, TR (2006). Pain DETECT: a new screening questionnaire to identify neuropathic components in patients with back pain. Current Medical Opinion and Research, 22 (10), 1911-1920.

• Garcia-Palacios, A., Hoffman, HG, Richards, TR, Siebel, EJ, and Sharar, SR (2007). Use of virtual reality distraction to reduce claustrophobia symptoms during a simulated magnetic resonance imaging brain scan: a case report. CyberPsychology & Behavior, 10 (3), 485-488. doi: 10.1089 / cpb. 2006.9926

• Gold, JI, Kant, AJ, Kim, SH, and Rizzo, AS (2005). Virtual anesthesia: the use of virtual reality to distract pain 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.

• Hamilton M. (1959). The assessment of anxiety states by rating. Br J Med Psychology; 32, 50-55. http://dcf.psychiatry.ufl.edu/files/2011/05/HAMILTON-ANXIETY.pdf

• Jones, T., Moore, T., & Choo, J. (2016). The impact of virtual reality on chronic pain. PLoS ONE, 11 (12), 1-10.

• Julian, LJ (2011) Measures of ansiedad. Arthritis Care Res (Hoboken), 63 (11). doi: 10.1002 / acr. 20561

• Kato, J., Agalave, NM, and Svensson, CI (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, SJ and Backonja, M. (2003). Development of a neuropathic pain questionnaire. Clin J Pain, 19, 306-14.

• Melzack R and Torgerson WS. (1971). On the language of pain. Anesthesiology, 34 (1), 50-59.

• Melzack, R. and Wall, PD (1965). Mechanisms of pain: a new theory. Science, 150 (3699), 971-979.

• Monsalve V, Soriano J and De Andrés J (2006). Usefulness of the Lattinen Index (IL) in the assessment of chronic pain: relationships with coping and quality of life. Rev Soc Esp Dolor, 13, 216-29.

• Ríos, EM, Herrera, RA, and Rojas AG (2014). Dental anxiety: assessment and treatment. Advances in Odontostomatology, 30 (1), 39-46.

• Spielberger, CD, Gorsuch, RL, Lushene, RE and Cubero, NS (1999). STAI: State-Trait Anxiety Questionnaire: Manual. Madrid: TEA Ediciones.

• Tanja-Dijkstra, K., Pahl, S., White, MP, Andrade, J., Qian, C., Bruce, M.,… Moles, DR (2014). Enhancing dental experiences using distracting virtual reality: a simulation study. PLoS One, 9 (3), 1-11. Doi: http://dx.doi.org.sire.ub.edu/10.1371/journal.pone.0091276

• Zigmond, AS and Snaith, RP (1983). Hospital scale of anxiety and depression. Acta Psychiatrica Scandinavica, 67, 361-70. (Main reference).

Intervention proposal

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

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

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 (basal). 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 environments of relaxation (for ex.: cove), with abdominal breathing audio.

DURING DE 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 environments of Psious to consolidate the results achieved.

Evaluation

“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 

• Determine the presence of emotional disorders.

• Determine the presence of pain behaviors and associated distorted thoughts.

• Determine the presence of anxiety and associated thoughts.

Useful tools for the evaluation of Chronic Pain and 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

SELF-REPORTS

Regarding Chronic Pain, there are specific scales to measure it:

•  One-dimensional 
  1.  VAS (Visual Analogue Scales) (Carlsson, 1983) 
  2. Numeric Scale 
  3.  Facial Pain Scale 
     
• Multidimensional 
  1. McGill Pain Questionnaire, MPQ (Melzack & Torgerson, 1971) 
  2.  Lattinen Index, IL (Monsalve, Soriano and De Andrés, 2006) 
  3. Brief Pain Inventory, BPI (Badia et al, 2003) 

• Neuropathic Pain Rating Scales
  1.  The LANSS Pain Scale (Bennett, 2001) 
  2.  The Neuropathic Pain Questionnaire (NPQ) (Krause & Backonja, 2003) 
  3. Neuropathic pain in 4 questions (DN4) (Bouhassira et al, 2005) 
  4.  PainDETECT (Freynhagen et al, 2006) 

• Regarding Anxiety, there are specific measurement scales
  1. Hamilton Anxiety Rating Scale (HAM-A) (Hamilton, 1959) 
  2. The State-trait Anxiety Inventory (STAI) (Spielberger et al, 1999) 
  3. Beck Anxiety Inventory (BAI) (Beck et al, 1998) 
  4. Hospital Anxiety And Depression Scale- Anxiety (HADS-A) (Zigmond & Snaith, 1983)

Pain management
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 quality life. 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.

Pain Management therapeutic area includes different VR environments for patients with chronic pain, acute pain, or anxiety for medical procedures, 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 Central Nervous System activities, especially attention, emotion and memories related to previous experience, play a fundamental role in sensory perception (Gold, et al, 2005).  Empirical evidence indicates that the use of virtual reality allows, in case of achieving a high immersion in the scene, the distraction of painful and anxious sensations in a very effective way (Jones, T., et al, 2016).

Appendix

Claustrophobia hierarchy Self-report

ITEM	LEVEL OF MALAISE (0-100)
I’m on the landing of a small elevator and there’s no one next to me. The elevator doors are closed and I’m waiting for him to arrive.
I find myself climbing several floors in a large elevator that is very crowded
I get on a rather small elevator with few people, then the doors close and we start to move.
I get on a big elevator with no one else inside and press the button to get on.
The elevator arrives, the doors open and I see that it is quite small and that there is no one inside. I get ready to go up
There is a momentary malfunction (approximately 1 minute) inside a large elevator while I go in it with no one else.
I just got into a small elevator with a lot of people, and the doors are still open
When the elevator arrives its doors open, I see that it is quite small and that there are not many people inside (3 people).
I’m going up a lot of floors in a big elevator that doesn’t get a lot of people.
There is a long breakdown (approximately 5 minutes) inside a large elevator while I am in it with many people.
I’m in a small elevator with a lot of people and we’re going up a couple of floors
I’m climbing several floors in a big elevator with no people inside.
There is a momentary malfunction (approximately 1 minute) inside a small elevator while I am in it with few people.
There is a long breakdown (approximately 5 minutes) inside a small elevator while I go in it with a lot of people.
I’m going up a couple of floors in a big elevator where there are few people
I get into a small elevator with no one else inside, the doors are still open.
I’m going up several floors in a small elevator that’s empty.
There is a long breakdown (approximately 5 minutes) inside a large elevator while I go in it with no one else.
I get on a big elevator with a lot of people, the doors are still open.
I climb a small elevator with a lot of people, the doors close and we start to move
Coming out of a big elevator where he traveled with a few people.
I get on a small elevator with no one else inside and press the button to get on
I find myself climbing many floors in a small elevator with few people.
I’m on the landing of a big elevator (mall type) with no people by my side. The elevator doors are closed and I’m waiting for it to arrive.
I’m going up a lot of floors in a big elevator that’s totally empty.
I’m in a small elevator with few people in it, and we’re going up a couple floors
I walk into a big elevator with a few people, and the doors are still open.
A large elevator arrives at the landing, the doors open and it is very full. There’s still room for me to go up.
There is a momentary malfunction (approximately 1 minute ) inside a small elevator while I go in it with no one else.
I’m coming out of a small elevator where I traveled with few people.
I’m going up a lot of floors in a small elevator with no one else.
While I am in a large elevator with few people, a momentary breakdown occurs (approximately 1 minute).
I find myself in a small elevator that is very full, and we go up many floors
I enter a small elevator with few people, and the doors remain open.
There is a long breakdown (approximately 5 minutes) inside a small elevator while I go in it without anyone else.
I get on a big elevator that’s very full, the doors close and we start moving.
I’m coming out of a big elevator where I was traveling unaccompanied.
I come out of a small elevator where I traveled with a lot of people.
The doors of a large elevator open and there are few people (3 people) inside
I’m climbing some floors in a big elevator with no people inside.
There is a momentary malfunction (approximately 1 minute) inside a small elevator while I am in it with a lot of people.
I walk into a big elevator with no one else inside, the doors are still open
I find myself in a large elevator that is quite empty, and suddenly there is a breakdown that lasts about 5 minutes.
I’m coming out of a big elevator where I was traveling with a lot of people
There is a long breakdown (approximately 5 minutes) inside a small elevator while I am in it with few people.
The doors of a big elevator open and I see there’s no one inside. I’m getting ready to go up.
I am coming out of a small elevator in which I was travelling unaccompanied.
I’m going up a lot of floors in an elevator that’s really big and full of people
There is a momentary malfunction (approximately 1 minute ) inside a large elevator while I am in it with a lot of people.
A small elevator arrives at the landing, the doors open and it is very full. There is room for me to go up.
I get on a big elevator with a few people, the doors close and we start moving.

Magnetic Resonance Imaging hierarchy Self-report

ITEM	LEVEL OF MALAISE (0-100)
As I enter the MRI room, I see the machine on which I will be tested, with the head coil ready, and I am told what the testing process will be like.
As I enter the MRI room, I see the machine on which I will be tested, with the chest and abdomen coil ready, and I am informed of how the testing process is going to be.
As I enter the MRI room, I see the machine on which I will be tested, with the leg coil ready, and I am told what the testing process is going to be like and that I should not move during the MRI.
Before entering the MRI machine I am lying face up with my head immobilized and I see the technician inside the control room through the mirror of the coil.
When I enter the room to leave the metal objects, I hear the door close and I am left inside the room, without windows, and with all the doors closed inside.
On the way to the hospital I go through a tunnel with my car.
The technician tells me that we started and I notice how my body, motionless by the coil, moves completely to the inside of the magnetic resonance tube. I see it’s a small space.
The technician tells me that the test is over and I notice how the stretcher is coming out of the MRI tube, while they tell me how to collect the results.
The technician, before leaving the room, tells me that I must lie down on the stretcher to start the test and that we will start shortly: I already have the coil of the leg in place.
In a box after making an appointment by phone for an MRI.
In the waiting room I see an informative video of what an MRI is.
I’m in the waiting room before I have an MRI.
I’m in the waiting room before they inform me of the test I have to take.
I’m on the stretcher looking at the ceiling and seeing the coil on my chest before entering, completely, the MRI machine.
Just before I left home to go, by taxi, to get an MRI
While I’m inside the machine, I hear the sound of the MRI machine change.
While I’m on the stretcher the technician finishes immobilizing my head to prepare me for the test. At the end he goes to the control room.
While I am in the changing room I am informed of the precautions to take into account, not to enter with metallic objects, to warn if I have a pacemaker…, before entering the room of the nuclear magnetic resonance
I notice how the sound of the MRI machine is more intense than before.
Shortly after entering the control room I hear the technician’s voice indicating that we are starting: I enter completely into the MRI tube, with my head immobilized by the coil as I watch through the mirror of the coil as the technician controls the machine.
The test begins: with the leg immobile by the coil my body enters up to the waist inside the reduced space of the tube of the magnetic resonance equipment and I hear the first noises of the machine.
Lying on my back on the stretcher, leg immobilized, before entering the MRI tube
Lying on the stretcher, the technician finishes placing the coil on my chest while explaining to me, before leaving, what will happen next.
I’m on my way to the room to change, before going in to have an MRI.
I’m on my way to the hospital by subway/car for an MRI. (choose most common method of transport)
Other situations:

Room in the basement hierarchy Self-report

ITEM	LEVEL OF MALAISE (0-100)
I’m on the landing of my flat waiting for the elevator to arrive to go to the basement.
After walking through the basement corridor, I reach the storeroom, open the door and enter the room, which is quite large, and leave the door open.
The elevator arrives and when the doors open I see that it is empty. I get ready to go up to it and I start to go down to the basement.
I’m walking down a very narrow hallway that’s going to take me to the basement storeroom.
I’m coming out of an elevator, I stop for a moment at the basement landing, and in the distance I can see the door to the storeroom
I’m standing in the middle of a very narrow corridor. On my back I have the storage room I just left and in front of me I see the elevator that will take me to the surface.
I’m walking down the hall and I’m heading for the basement storeroom, and then I stop walking for a moment.
I’m in an elevator after I’ve been in the storeroom, and I’m going up from the basement floor to another floor.
When I get to the storeroom, I open the door and enter the room, which is not very big but not very small either. The door is still open
While I’m in a pretty big storeroom, the door closes.
I reach the basement storeroom, open the door and enter the room leaving the door open. The room is very small, it seems that I fit in it and little more.
I’m in the middle of a pretty big storeroom, and suddenly the room starts to get smaller.
While I’m in a medium storage room, neither too big nor too small, the door closes.
I’m walking down a very narrow corridor that will take me to the elevator, so I’ll leave the floor where the basement is.
While I’m in a very small storeroom, the door closes.
I get ready to leave the storage room in the basement, so I turn, open the door and go.

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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 la 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). Analysis 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

Intervention proposal

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

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

Intervention example 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

ITEM	ENVIRONMENT	CONFIGURATION	EVENT
Standing on landing waiting for (large) elevator in an office building	Claustrophobia	Big elevator	No event
Entering a large empty elevator	Claustrophobia	Large elevator, nobody	Enter elevator
Standing on landing waiting for (small) elevator in an office 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

SESSION 2 

• Review achievements from previous sessions and set objectives for the 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 

HOMEWORK 
Short journeys with exposure in vivo in empty elevators (1 or 2 floors)

ITEM	ENVIRONMENT	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 sessions and set objectives for the 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 

HOMEWORK 
Short journey with in vivo exposure in empty elevators with a few people + covert exposure of the session using their imagination at home. 

ITEM	ENVIRONMENT	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 sessions and set objectives for the 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. 

HOMEWORK 
Covert exposure at home revising the session using their imagination. 

ITEM	ENVIRONMENT	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 the patient, using the reports provided in the platform. 

HOMEWORK 
Covert exposure at home revising the session using imagination + in vivo exposure entering a storage room or other type of room. 

ITEM	ENVIRONMENT	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 sessions and set objectives for the 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 the patient, using the reports provided in the platform. 

HOMEWORK 
In vivo exposure with elevators with quite a lot of people + covert exposure at home revising specific ítems from the session using imagination. 

ITEM	ENVIRONMENT	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

Intervention example in Claustrophobia/ Magnetic Resonance Imaging (MRI)

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 anxiety-depressive symptomatology associated with an adaptive 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.

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)

ITEM	ENVIRONMENT	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)

SESSION 2 

• Review achievements from previous sessions and set objectives for the 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 the 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. 

ITEM	ENVIRONMENT	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 the changing room I am informed of 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 sessions and set objectives for the current session: Changing room and lying down on the treatment bed. 

• Systematic and gradual exposure in virtual reality environments. Cognitive reconstruction,if it’s necessary.

• Reveal clinical progress to the patient, using the reports provided in the platform.

HOMEWORK
Covert exposure at home repeating the procedure worked on in the consultancy using imagination. 

ITEM	ENVIRONMENT	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 sessions and set objectives for the current session. Lying immobile on the treatment bed.

• Systematic and gradual exposure in virtual reality environments. Cognitive reconstruction, if it’s necessary.

• Reveal clinical progress to the 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) 

ITEM	ENVIRONMENT	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 the 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 the patient, using the reports provided in the platform.

HOMEWORK 
Covert Exposure 

ITEM	ENVIRONMENT	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 sessions and set objectives for the current session. Immobility lying down on a treatment bed inside the NMR tube (asphyxia).

• Systematic and gradual exposure in virtual reality environments. Cognitive reconstruction, if necessary. 

• Reveal clinical progress to the patient, using the reports provided in the platform.

HOMEWORK 
General guidelines for coping with the NMR test in vivo. 

ITEM	ENVIRONMENT	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 the 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 HOW TO ADAPT THEM TO THE INTERVENTION WITH PSIOUSʼ VIRTUAL REALITY ENVIRONMENTS.