American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. Arlington, VA: American Psychiatric Association.
Kroenke, K. (2007). Efficacy of treatment for somatoform disorders: A review of randomized controlled trials. Psychosomatic Medicine, 69(9), 881–888. https://doi.org/10.1097/PSY.0b013e31815b00c
Bauer, M., Hersey, D., Kasuba, J., Lauridsen, A., Stewart, A., B. (2014). Somatic symptom disorder: Effective techniques for diagnosing and managing this complex condition in primary care practices. Consultant, 54(9), 1–12.
Fjorback, L. O., Arendt, M., Ørnbøl, E., Walach, H., Rehfeld, E., Schröder, A., & Fink, P. (2013). Mindfulness therapy for somatization disorder and functional somatic syndromes – Randomized trial with one-year follow-up. Journal of Psychosomatic Research, 74(1), 31–40. https://doi.org/10.1016/j.jpsychores.2012.09.006
Hedman, E., Axelsson, E., Andersson, E., Lekander, M., & Ljótsson, B. (2016). Exposure-based cognitive–behavioural therapy via the internet and as bibliotherapy for somatic symptom disorder and illness anxiety disorder: randomised controlled trial. British Journal of Psychiatry, 209(5), 407–413. https://doi.org/10.1192/bjp.bp.116.181396
Hinz, A., Ernst, J., Glaesmer, H., Brähler, E., Rauscher, F. G., Petrowski, K., & Kocalevent, R. D. (2017). Frequency of somatic symptoms in the general population: Normative values for the Patient Health Questionnaire-15 (PHQ-15). Journal of Psychosomatic Research, 96, 27–31. https://doi.org/10.1016/j.jpsychores.2016.12.017
Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2002). The PHQ-15: Validity of a new measure for evaluating the severity of somatic symptoms. Psychosomatic Medicine, 64(2), 258–266. https://doi.org/10.1097/00006842-200203000-00008
Salkovskis, P.M., Rimes, K.A., Warwick, H.M.C. & Clark, D. . (2002). The Health Anxiety Inventory: development and validation of scales for the measurement of health anxiety and hypochondriasis. Psychological Medicine, Vol. 32, 843-853. Psychological Medi, 843-853, 843–853.
Carry out a clinical assessment of your patient’s condition before starting the intervention. Use the data obtained in the evaluation to establish therapeutic goals and choose the most appropriate intervention strategies.
Use Psious tools to optimize the intervention and adjust them to the patient’s needs. Evaluate, periodically, the therapeutic process and, if necessary, adjust it. Somatic disorders are of great heterogeneity and variability: always use digital tools as a system to improve the intervention and not as a technique in itself.
“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.”
Somatic disorders Evaluation
In this section we propose different strategies and tools on how to evaluate somatic disorders
OBJECTIVES
The patient has one or more somatic symptoms — for example, pain or fatigue — that are distressing or cause problems in his/her daily life
The patient has excessive and persistent thoughts about the seriousness of the symptoms, The patient has a persistently high level of anxiety about health or symptoms, or devote too much time and energy to the symptoms or health concerns
The patient continues to have symptoms that concern, typically for more than six months, even though the symptoms may vary.
Comorbidity with Anxiety Disorders (especially Panic disorder and anxiety disorder), mood disorders (major depressive disorder) and Post-traumatic stress disorder.
Useful tools for Somatic Symptoms 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
SELF-REPORT INSTRUMENTS
Patient Health Questionnaire 15-Item (PHQ-15) Somatic Symptom Severity Screener
Somatic Symptom Disorder (SSD) includes the diagnosis of somatic symptom disorder, illness anxiety disorder, conversion disorder (functional neurological symptom disorder), psychological factors affecting other medical conditions, factitious disorder and other related disorders. It is important to note that some other mental disorders may initially manifest with primarily somatic symptoms (e.g., major depressive disorder, panic disorder). Such diagnoses may account for the somatic symptoms, or they may occur alongside one of the somatic symptoms and related disorders. (adapted from APA, 2013).
This manual describes different Psious tools designed to help healthcare professionals on assessment and treatment in SSD and more specifically for Somatic Symptoms (headache, chronic fatigue, irritable colon…) and illness anxiety disorder (IAD).
Somatic symptom disorder (SSD) is characterized by an extreme focus on physical symptoms — such as pain or fatigue — that causes major emotional distress and problems functioning. The patient may or may not have another diagnosed medical condition associated with these symptoms, but the person’s reaction to the symptoms is excessive. People diagnosed with IAD strongly believe they have a serious or life-threatening illness despite having no, or only mild, symptoms. Yet IAD patients’ concerns are to them very real. Even if they go to doctors and no illnesses are found, they are generally not reassured, or they only do it for a short time, and their obsessive worry continues. IAD can also trigger worries in people who do have a physical illness that they are sicker than they really are. The disorder is not about the presence or absence of illness, but the psychological reaction (adapted from Mayo and Cleveland Clinics).
Cognitive Behavior Therapy (CBT) is the best established treatment for a variety of somatoform disorders, with some benefit also demonstrated for a consultation letter to the primary care physician ( Kroenke, K., 2007).
Psious’ “Somatic and Related” therapeutic area tools were grouped to help healthcare professionals on somatic symptoms assessment and treatment, especially for somatic symptoms and illness anxiety disorders. These tools can help for somatic symptomatology treatment using CBT evidence-based techniques: exposure and response prevention (Hedman, E., et al 2016 ), relaxation training and cognitive–behavioral therapy (Bauer, M.,et al 2014), Mindfulness (Fjorback, L. O.,et al 2013, Hedman, E., et al 2016 ).
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. Arlington, VA: American Psychiatric Association.
Bastien CH, Vallières A, Morin CM. Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Medicine. 2001;2(4):297–307.
Chung KF, Ho FYY, Yeung WF. Psychometric comparison of the full and abbreviated versions of the dysfunctional beliefs and attitudes about sleep scale. J Clin Sleep Med. 2016;12(6):821–828. doi:10.5664/jcsm.5878
Davidson, J. R., Dickson, C., & Han, H. (2019). Cognitive behavioural treatment for insomnia in primary care : British Journal of General Practice.
de Bruin, E. J., Meijer, A. M., & Bögels, S. M. (2020). The Contribution of a Body Scan Mindfulness Meditation to Effectiveness of Internet-Delivered CBT for Insomnia in Adolescents. Mindfulness, 11(4), 872–882. https://doi.org/10.1007/s12671-019-01290-9
Doris, J.D.S (2015). Effectiveness of Virtual Reality Therapy Upon Stress Among Nurses. In Dissertation. Retrieved from http://repository-tnmgrmu.ac.in/id/eprint/1780
Espie, C. A. (2009). “Stepped care”: A health technology solution for delivering cognitive behavioral therapy as a first line insomnia treatment. Sleep, 32(12), 1549–1558. https://doi.org/10.1093/sleep/32.12.1549
Horsch, C., Lancee, J., Beun, R. J., Neerincx, M. A., & Brinkman, W. P. (2015). Adherence to technology-mediated insomnia treatment: A meta-analysis, interviews, and focus groups. Journal of Medical Internet Research, 17(9), e214. https://doi.org/10.2196/jmir.4115
Johnson JA, Rash JA, Campbell TS, et al. (2016) A systematic review and meta-analysis of randomized controlled trials of cognitive behavior therapy for insomnia (CBT-I) in cancer survivors. Sleep Med Rev 27: 20–28.
Johns MW. Sleepiness in different situations is measured by the epworth sleepiness scale. Sleep. 1994;17(8):703–710. doi:10.1093/ sleep/17.8.703
Luyster, F. S., Choi, J., Yeh, C.-H., Imes, C. C., Johansson, A. E. E., & Chasens, E. R. (2015). Screening and evaluation tools for sleep disorders in older adults. Applied Nursing Research, 28(4), 334–340. https://doi.org/10.1016/j.apnr.2014.12.007
Manber, R., & Simpson, N. (2016). Dissemination of CBT for Insomnia. Current Sleep Medicine Reports, 2(3), 136–141. https://doi.org/10.1007/s40675-016-0048-x
Morin CM, Belleville G, Bélanger L, Ivers H, (2011): The insomnia severity index: psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep.34(5):601–608.
Pallesen S, Bjorvatn B, Nordhus IH, Sivertsen B, Hjornevik M, Morin CM (2008). A new scale for measuring insomnia: the bergen insomnia scale. Percept Mot Ski. 107(3):691–706. doi:10.2466/ pms.107.3.691-70
Pigeon, W. R., Funderburk, J. S., Cross, W., Bishop, T. M., & Crean, H. F. (2019). Brief CBT for insomnia delivered in primary care to patients endorsing suicidal ideation: A proof-of-concept randomized clinical trial. Translational Behavioral Medicine, 9(6), 1169–1177. https://doi.org/10.1093/tbm/ibz108
Sandlund C, Hetta J, Nilsson GH, et al.(2017): Improving insomnia in primary care patients: a randomized controlled trial of nurse-led group treatment. Int J Nurs Stud 2017; 72: 30–41
Weaver TE, Chasens ER, Ratcliffe SJ (2009): Development of the FOSQ-10:a short version of the functional outcomes of sleep questionnaire. Sleep.32(7):915–919. doi:10.1093/sleep/32.7.915
Wong SY, Zhang DX, Li CC, et al..(2017): Comparing the effects of mindfulness-based cognitive therapy and sleep psycho-education with exercise on chronic insomnia: a randomised controlled trial. Psychother Psychosom 2017; 86(4): 241–253.
Yeh ZT, Chiang RP, Kang SC, Chiang CH. Development of the insomnia screening scale based on ICSD-II. Int J Psychiatry Clin Pr. 2012;16(4):259–267. doi:10.3109/13651501.2011.640938
Yüksel, D., Goldstone, A., Prouty, D., Forouzanfar, M., Claudatos, S., Lee, Q., de Zambotti, M. (2020). 0916 The Use of Immersive Virtual Reality and Slow Breathing to Enhance.
The cognitive part of CBT-I teaches the patient to recognize and change beliefs that affect your ability to sleep. This type of therapy can help you control or eliminate negative thoughts and worries that keep you awake. The behavioral part of CBT-I helps the patient to develop good sleep habits and avoid behaviors that keep you from sleeping well.
Depending on patients needs, the healthcare professional may recommend some of these CBT-I techniques:
Stimulus control therapy This method helps remove factors that condition your mind to resist sleep. For example, the patient might be coached to set a consistent bedtime and wake time and avoid naps, use the bed only for sleep and sex. The patient must leave the bedroom if he/she can’t go to sleep within 20 minutes, only returning when he or she is sleepy.
Sleep restriction Lying in bed when the patient is awake can become a habit that leads to poor sleep. This treatment reduces the time that patient spends in bed, causing partial sleep deprivation, which makes you more tired the next night. Once your sleep has improved, your time in bed is gradually increased.
Sleep hygiene This method of therapy involves changing basic lifestyle habits that influence sleep, such as smoking or drinking too much caffeine late in the day, drinking too much alcohol, or not getting regular exercise. It also includes tips that help you sleep better, such as ways to wind down an hour or two before bedtime.
Sleep environment improvement This offers ways that you can create a comfortable sleep environment, such as keeping your bedroom quiet, dark and cool, not having a TV in the bedroom, and hiding the clock from view.
Relaxation training This method helps you calm your mind and body. Approaches include meditation, imagery, muscle relaxation and others.
Remaining passively awake Also called paradoxical intention, this involves avoiding any effort to fall asleep. Paradoxically, worrying that you can’t sleep can actually keep you awake. Letting go of this worry can help you relax and make it easier to fall asleep.
Electrodermal sensor responser This method allows you to observe biological signs such as heart rate and muscle tension and shows you how to adjust them. Your sleep specialist may have you take a biofeedback device home to record your daily patterns. This information can help identify patterns that affect sleep.
The most effective treatment approach may combine several of these methods.
“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.”
Insomnia Evaluation
In this section we propose different strategies and tools on how to evaluate Insomnia, as a previous step to using Psious’ VR tools.
OBJECTIVES
Sleep Assessment
Is this insomnia or something else (e.g., insufficient sleep syndrome)?
Even if comorbid conditions present (e.g., depression, pain), CBT-I can be beneficial.
Even if the patient is on sleep aids or wants to start taking sleep aids, this can be done in combination with CBT-I.
Patient Characteristics
Is the patient motivated to try CBT-I? Do they just want a pill?
Does the patient have sufficient intellect to benefit from CBT-I?
CBT-I is intended for adult patients
A major component of CBT-I (sleep restriction) is contraindicated for those with psychosis, bipolar disorder, untreated sleep apnea, parasomnias, and seizure disorder so CBT-I should be modified in these cases
A sleep study should be conducted in cases of suspected sleep apnea before sleep restriction started.
Useful tools for the Insomnia 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
Sleep self-record/ Sleep logs
SELF-REPORTS
Insomnia Severity Index (ISI)
Epworth Sleepiness Scale (ESS)
The Bergen insomnia scale (BIS)
Dysfunctional Attitudes and Beliefs about Sleep (DBAS-16)
Sleep-wake disorders encompass 10 disorders or disorder groups: insomnia disorder, hypersomnolence disorder… Individuals with these disorders typically present with sleep-wake complaints of dissatisfaction regarding the quality, timing, and amount of sleep. Resulting daytime distress and impairment are core features shared by all of these sleep-wake disorders.(APA, 1994). Sleep disorders are often accompanied by depression, anxiety, and cognitive changes that must be addressed in treatment planning and management. Furthermore, persistent sleep disturbances (both insomnia and excessive sleepiness) are established risk factors for the subsequent development of mental illnesses and substance use disorders. They may also represent a prodromal expression of an episode of mental illness, allowing the possibility of early intervention to preempt or to attenuate a full-blown episode (APA, 2013).
This manual describes different Psious tools designed to help healthcare professionals on assessment and treatment in sleep-wake disorders and more specifically for insomnia disorder. The essential feature of insomnia disorder is dissatisfaction with sleep quantity or quality with complaints of difficulty initiating or maintaining sleep. The sleep complaints are accompanied by clinically significant distress or impairment in social, occupational, or other important areas of functioning (APA, 2013). Insomnia is the most prevalent sleep disorder, affecting 10–15% of the adult population1 and 19–44% of primary care patients worldwide (Davidson et al., 2019)
Cognitive behavioral therapy for insomnia (CBT-I) has structured programs that help the patients to identify and replace thoughts and behaviors that cause or worsen sleep problems with habits that promote sound sleep. Nine systematic reviews or meta-analyses of CBT have been published in the past 15 years ( for example: Johnson, et al., 2016, Sandlund et al., 2017 and Wong et al., 2017). To take two examples, the American Academy of Sleep Medicine [AASM (formerly the American Sleep Disorders Association of Sleep)] task force reports (1999 and 2006) comprised 85 clinical trials (4,194 participants), and indicated that CBT was associated with im- provement in 70% of patients, that was sustained at least 6 months post-treatment (Espie, C. A., 2009).
Virtual Reality Psious tools are useful for CBT-I interventions. Different psychological techniques are the evidence base for insomnia: Relaxation training (Yüksel, D., et al. 2009), Sleep environment improvement, Sleep restriction, Sleep hygiene, Meditation, Mindfulness … Once the evaluation is done the healthcare professional adjusts, according to the needs of your patient, the virtual tools to the therapeutic goals.
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