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Index Agoraphobia Manual 

1. Agoraphobia and Virtual Reality
2. Psious-based Treatment/Evaluation Protocol
   1. Agoraphobia evaluation
      1. Goals of evaluation
      2. Some useful tools for evaluating agoraphobia 
      3. Elaboration of the exhibition hierarchy with Psious environments
   2. Example of intervention in agoraphobia
      1. Example of intervention in agoraphobia with 360º videos
3. Use recommendations
4. Recommended bibliography
5. Annexes
   1. Diary of Anxiety and Panic Attacks
   2. Relaxation self-recording
   3. Underground hierarchy self-recording
   4. 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.

Index Manual Acrophobia 

1. Phobia of heights
2. Virtual environments of Psious
   1. Videos
3. Treatment Protocol based on Psious
4. Comments for suggestion 
5. Recommended bibliography

1. Phobia of heights

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

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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.

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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)

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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)

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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..

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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.

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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.

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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.

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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.

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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.

Chatting at the bar

The patient is with his/her friends in a pub, having a casual conversation.
Throughout the conversation they will be talking about different topics: cinema, travel, having children, sports and schedules. The avatars talk about one of these topics for a while, and if no event is activated at the end it changes the subject.

On the other hand, if the healthcare professional activates one of the events, then at the end of that event, the topic of conversation is changed even if it has not ended.

SETTINGS VARIABLES

• Type response
  • Happy: the friends and waitress will be nice and attentive.
  • Angry: the friends and waitress will be distant and will answer negatively to the patient’s interventions.

EVENTS

• Make an order (Call waitress)
  The mates request the patient to make the order (“can you order? you can see the waitress better than us, etc”). The patient should call the waitress to make the order.

• Ask for the bathroom (Call waitress)
  The waitress will approach the table and the patient can then ask where the toilet is. The waitress will answer and leave.

• Regulate the temperature (Call waitress)
  The mates complain about the cold and tell the patient to ask the waitress to adjust the temperature.

• Change drink (Call waitress)
  The mates request the patient to call the waitress to ask for a change of drink.

• Goodbye (Call waitress)
  All the friends except two who will stay with the patient, will say goodbye and leave. Note: this event is not interactive.

Keep in mind that the purpose of this environment is to work on the exposure to social skills. Therefore, the healthcare professional can modulate the behaviors before the exposure to the VR environment. Once the exposure has finished, the healthcare professional can give feedback of the session and repeat the exposure if necessary.

ATTENTION!  

Before starting the exposure, inform the patient what kind of questions he/she should ask and give an insight on how the session is going to develop. Specifically, the order of events must be emphasized in order for the patient to differ between the events. 

Progressive muscle relaxation

This environment will help patients practice Jacobson’s muscular relaxation technique. It is recommended to previously teach the patient of the difference between tension and relaxation by simply tensing an arm and afterwards proceeding to perform this relaxation exercise. 

When launching this environment, the patient will find himself sitting in an empty room and this is when the therapist must put him in context before starting the relaxation exercise.

SETTINGS VARIABLES

• Show Teacher
  The relaxation exercise can be performed with the presence of a virtual trainer that serves as a visual guide for the patient, as it is in accordance with the audio (if activated).

EVENTS

• Introduction
  A brief explanation is played in the audio (previously activated) to remind the patient what the exercise is about. 

• Arms
  The exercise regarding the tension/ relaxation of the hand and arm muscles starts. 

• Neck
  The tension/relaxation intervals involving the neck and shoulders area take place.

• Face
  Tension and relaxation of the face muscles begins.

• Torso
  Allows for the start of the tension/ relaxation exercise regarding the trunk area. It includes the abdomen and back muscles.

• Legs
  The relaxation exercise part involving the legs takes place. Including knee joint, legs, toes and gluteus movements.

• Final
  The audio indicates the patient to start a mental journey through each of their body parts, while slowly breathing and feeling how relaxed they feel by the end of the exercise. The complete relaxation exercise is considered done. 

• Ambient Music
  Allows the exercises to be performed with background music. keep in mind that in the default option this option is disabled, so if you want to use it you must press on before the exercise.

Diaphragmatic breathing underwater in the ocean

In this environment, the patient will be at the under the sea, surrounded by a water area, which will help induce the desired state of relaxation.

SETTINGS VARIABLES

• Introduction
  This will be reproduced when the exercise starts. It is recommended that in the first session the optional introduction is activated so that the patient understands the importance of correct breathing and the methodology of the exercise.

• Visual reference
  The patient can also select his favorite 3D object in order to carry out the breathing exercises:
  • Seahorse
  • Jellyfish
  • Pufferfish

• Music
  Allows you to perform the exercises with background music. Note that in the default option this option is activated.

• Inhale/exhale duration
  Adjust the duration of the exercise by clicking on Exhalation or Inhalation from 3 to 12 seconds.

• Audio guide
  Allows you to choose whether the audio guide is a female or male voice.

EVENTS

• Inhale/exhale duration
  Adjust the duration of the exercise by clicking on Exhalation or Inhalation from 3 to 12 seconds.