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Appendix

Self-report for Contamination OCD

ITEM	LEVEL OF DISCOMFORT (0-100)
Being in front of a clean public toilet’s door.
I stand in front of a toilet cubicle door of a clean public toilet.
Enter the cubicle and stare at the toilet.
Standing in front of a clean public toilet, I touch the wall with my left hand.
I’m inside a clean public toilet cubicle, I grab paper and I throw it in the trash.
I touch the brush of a clean public toilet.
I lower the lid of a clean public toilet.
I sit on a clean public toilet.
Sitting on a clean public toilet, I touch the wall with my left hand.
I flush the toilet after having used a clean public toilet.
I stand in front of a sink in a clean public toilet.
I wash my hands in a clean public toilet after using the toilet, without touching the faucet, soap and hand dryer.
I wash my hands in a clean public toilet after using the toilet, without touching the faucet, soap and hand dryer.
I’m outside a clean public toilet, I open the door, I stand in front of the toilet cubicle, I open the door, I stand in front of the cubicle, I lower the lid and I sit on it.
I’m sitting on a clean public toilet, I grab paper, I stand up, I flush the toilet, I stand in front of the sink, I wash my hands without touching the faucet, the soap or the hand dryer.
I’m sitting on a clean public toilet, I grab paper, I stand up, I flush the toilet, I stand in front of the sink, I wash my hands touching the faucet, the soap or the hand dryer
I’m outside a clean public toilet, I open the door, I stand in front of the cubicle, I open the door, I stand in front of the toilet, I lower the lid, I sit on the toilet, I grab paper, I flush the toilet, I stand in front of the sink, I wash my hands without touching the faucet, soap or hand dryer.
I’m outside a clean public toilet, I open the door, I stand in front of the cubicle, I open the door, I stand in front of the toilet, I lower the lid, I sit on the toilet, I grab paper, I flush the toilet, I stand in front of the sink, I wash my hands touching the faucet, soap or hand dryer.
Being in front of a dirty public toilet’s door.
I enter a public toilet that stinks and has paper all over the floor and I stand in front of the toilet cubicle.
I enter a cubicle in a smelly and dirty public toilet and the toilet has urine drops.
I touch the walls of a cubicle in a smelly and dirty public toilet.
I touch the brush inside the cubicle of a dirty public toilet.
I grab paper inside the cubicle of a dirty public toilet and I throw it in the trash.
I lower the lid of a dirty public toilet.
Sitting on a dirty public toilet
Touching the wall of the cubicle with my left hand sitting on a dirty public toilet
I flush a dirty public toilet after using it and at the same time it smells bad.
I stand in front of the sink of a dirty and smelly public toilet.
I wash my hands in a dirty public toilet, without touching the faucet, soap or hand dryer, but they’re next to me.
I use the sink of a dirty public toilet after using the toilet, touching the faucet, soap and hand dryer.
I’m outside a dirty public toilet, I open the door, I stand in front of the toilet cubicle, I open the door, I stand in front of the cubicle, I lower the lid and I sit on it.
I’m sitting on a dirty public toilet, I grab paper, I stand up, I flush the toilet, I stand in front of the sink, I wash my hands without touching the faucet, the soap or the hand dryer.
I’m sitting on a dirty public toilet, I grab paper, I stand up, I flush the toilet, I stand in front of the sink, I wash my hands touching the faucet, the soap or the hand dryer.
I’m outside a clean public toilet, I open the door, I stand in front of the cubicle, I open the door, I stand in front of the toilet, I lower the lid, I sit on the toilet, I grab paper, I flush the toilet, I stand in front of the sink, I wash my hands without touching the faucet, soap or hand dryer.
I’m outside a dirty public toilet, I open the door, I stand in front of the cubicle, I open the door, I stand in front of the toilet, I lower the lid, I sit on the toilet, I grab paper, I flush the toilet, I stand in front of the sink, I wash my hands touching the faucet, soap or hand dryer.
What discomfort level does it produce you, at the present moment, to be in a public toilet? (doesn’t belong to the hierarchy)
Other situations:

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Bibliography

• American Psychiatric Association. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Arlington, VA: American Psychiatric Association, 2007.

• Kim, K., Kim, Ch. H., Kim, S. Y., Roh, D., Kim., S. I. (2009). Virtual Reality for Obsessive-Compulsive Disorder: Past and the Future. Official Journal of Korean Neuropsychiatric Association, 6, 115-121

• Ortiz, J. F. (2002). Trastorno obsesivo-compulsivo (TOC). Acta Neurol Colomb, 18 (1), 51-65.

• Reid, J.M., Storch, E.A. & Murphy, T.K. (2011). Clinical Correlates and Treatment Response of the Yale-Brown Obsessive Compulsive Scale Auxiliary Items. Cognitive Therapy and Research, 35, 404-413 

• Bejerot, S., Edman, G., Anckarsäter, H., Berglund, G., Gillberg, C. et al. (2014). The Brief Obsessive-Compulsive Scale (BOCS): a self-report scale for OCD and obsessive-compulsive related disorders. Nordic Journal of Psychiatry, 68(8), 549-559. http://dx.doi.org/10.3109/08039488.2014.884631 

• Freeman, J., Flessner, Ch. A,. y Garcia, A. (2011). The Children’s YaleBrown Obsessive Compulsive Scale: Reliability and Validity for Use Among 5 to 8 Year Olds with Obsessive- Compulsive Disorder. J Abnorm Child Psychol, 39, 877-883.

• Steketee, G., Chambless, D. L., Tran, G. Q., Worden, H., y Gillis. M. M. (1996). Behavioral Avoidance Test for Obsessive Compulsive Disorder. Behaviour Research and Therapy, 34 (1), 73-83. http://dx.doi.org.sire.ub.edu/10.1016/0005-7967(95)00040-5

• Sánchez, J., López, J. A., López, J. A., Marín, F., Rosa, A. I., y Gómez. A. (2011). The Maudsley Obsessive-Compulsive Inventory: A reliability generalization meta-analysis. International Journal of Clinical and Health Psychology ,11(3), 473-493.

• Bamber, D., Tamplin, A., Park, R. J., Kyte, Z. A., Goodyer, I. M. (2002). Development of a Short Leyton Obsessional Inventory for Children and Adolescents. Journal of the American Academy of Child & Adolescent Psychiatry 41 (10), 1246-1252. http://dx.doi.org.sire.ub.edu/10.1097/00004583-200210000-00015

• Obsessive-compulsive disorders; research conducted at mental health institute has provided new information about obsessive compulsive disorders. (2014). Mental Health Weekly Digest, , 31. Retrieved from https://search-proquest-com.sire.ub.edu/ docview/1516545423?accountid=15293

• Gorrindo, T., y Parekh, R. (2015). What Is Obsessive-Compulsive Disorder?. American Psychiatric Association. https://www.psychiatry.org/patients-families/ocd/what-is-obsessivecompulsive-disorder

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.”

SESSION 1

Psychoeducation: inform the patient about OCD. What are the causes, symptoms, prevalence, and definition.

• Explain which techniques will be used during the treatment: in anxiogenic situations and in others where relaxation techniques and mindfulness can be used.

• An exposure hierarchy will be elaborated.

• The exposure will be carried out with items that are around the 30 USAs, to familiarize the patient with VR.

The main objective will be familiarizing the patient with virtual reality and the work dynamics.

ITEM	SUD’s	ENVIRONMENT	CONFIGURATION	EVENT
Be at a public toilet’s door	20	OCD	Clean	Outside the toilet
I place myself in front of a public clean toilet cubicle’s door.	30	OCD	Clean	Inside the toilet
After entering a clean public toilet, I enter the toilet cubicle and look at the toilet.	35	OCD	Clean	Standing inside the cubicle

SESSION 2

• Revision of the past session’s achievements and establishing of objectives of the actual session: Lower a public toilet’s lid to sit down.

• We begin with gradual exposure and systematic response prevention with virtual reality. Cognitive restructuring, if necessary.

• The reports should be shown to the patient so they can see their clinical progress.

HOMEWORK
Live exposure entering clean public toilets, enter the cubicle and sit on the toilet. Use relaxation if necessary.

ITEM	SUD’s	ENVIRONMENT	CONFIGURATION	EVENT
In front of a clean public toilet, I touch the wall with my left hand.	40	OCD	Clean	Touch the wall (standing inside the cubicle)
Walk through Ramblas with many people.	40	OCD	Dirty	Outside the toilet
Inside the cubicle of a clean public toilet. I grab paper and I throw it in the trash	40	OCD	Clean	Grab paper
I touch the toilet brush in a clean public toilet	45	OCD	Clean	Touch toilet brush
I lower the toilet lid in a clean public toilet to sit on it	45	OCD	Clean	Lower lid

SESSION 3

• Revision of the past session’s achievements and establishing of objectives of the actual session: Place myself in front of a sink in a clean public toilet.

• We begin with gradual exposure and systematic response prevention with virtual reality. Cognitive restructuring, if necessary.

• The reports should be shown to the patient so they can see their clinical progress.

HOMEWORK
Live exposure by entering a cubicle in a clean public toilet, sit on the toilet, touch the wall and stand in front of the sink. Carry out relaxation exercises if necessary.

ITEM	SUD’s	ENVIRONMENT	CONFIGURATION	EVENT
I sit on a clean public toilet	50	OCD	Clean	Sitting on the toilet
Sitting on a clean public toilet, I then touch the wall with my left hand	50	OCD	Clean	Touching the wall (sitting onthe toilet)
I enter a public toilet that doesn’t smell well with paper all over the floor and I place myself in front of the toilet cubicle	50	OCD	Dirty	Inside the toilet
I flush the toilet after using it (clean public toilet)	55	OCD	Clean	Flush the toilet
I place myself in front of the sink in a clean public toilet	60	OCD	Clean	In front of the sink

SESSION 4

• Revision of the past session’s achievements and establishing of objectives of the actual session: Touching the walls inside a cubicle of a dirty public toilet.

• We begin with gradual exposure and systematic response prevention with virtual reality. Cognitive restructuring, if necessary.

• The reports should be shown to the patient so they can see their clinical progress. 

HOMEWORK
Live exposure entering a clean public toilet. Use the toilet, flush it, and wash hands in a non-compulsive way. Relaxation exercises if necessary.

ITEM	SUD’s	ENVIRONMENT	CONFIGURATION	EVENT
Standing outside a clean public toilet, I open the door, I stand in front of the cubicle, I open the door, I stand in front of the toilet, lower the lid and I sit down	60	OCD	Clean	From outside until sitting on the toilet
I enter the cubicle and it smells bad, it’s dirty and it has urine drops	60	OCD	Clean/Easy	Standing inside the cubicle
In the cubicle of a clean public toilet, I grab paper and I throw it in the trash	65	OCD	Clean/Easy	Washing hands
Sitting on a clean public toilet, I grab paper, I stand up, I flush the toilet, I stand in front of the sink, I wash my hands without touching the faucet, the soap or the dryer.	70	OCD	Clean/Easy	Complete
I touch the walls of the cubicle of a dirty and smelly toilet	70	OCD	Dirty	Touching the wall (standing in the toilet cubicle)

SESSION 5

• Revision of the past session’s achievements and establishing of objectives of the actual session: Touching the brush inside the cubicle of a dirty public toilet.

• We begin with gradual exposure and systematic response prevention with virtual reality. Cognitive restructuring, if necessary.

• The reports should be shown to the patient so they can see their clinical progress.

HOMEWORK
Live exposure, entering a public toilet, touching several elements inside the cubicle, using the toilet, leaving and washing hands in a non-compulsive way. Relaxation exercises if necessary.

ITEM	SUD’s	ENVIRONMENT	CONFIGURATION	EVENT
I use the sink in a public toilet after using the toilet. I touch the faucet, the soap and the hand dryer	75	OCD	Clean/Difficult	Washing hands
Sitting on a clean public toilet, I grab paper, I stand up, I flush the toilet, I stand in front of the sink and I use it touching faucet, soap and hand dryer	75	OCD	Clean/Difficult	From sitting on the toilet to washing hands
I´m outside a clean public toilet, I open the door and I stand in front of the cubicle. I open the door and I stand in front of the toilet. I lower the lid, I sit on the toilet, I grab paper, I stand up, I flush the toilet and I stand in front of the hand dryer. I wash my hands without touching the faucet, soap or hand dryer.	75	OCD	Clean/Easy	Complete
I grab paper from the cubicle in a dirty public toilet and I then throw it in the trash	75	OCD	Dirty	Grabbing paper
I touch the toilet brush inside a cubicle of a dirty public toilet	80	OCD	Dirty	Touching toilet brush

SESSION 6

• Revision of the past session’s achievements and establishing objectives of the actual session: Standing outside a dirty public toilet, I open the door, I stand in front of the cubicle, I open the door, I stand in front of the toilet, I lower the lid and sit on the toilet.

• We begin with gradual exposure and systematic response prevention with virtual reality. Cognitive restructuring, if necessary.

• The reports should be shown to the patient so they can see their clinical progress.

HOMEWORK 
Live exposure, entering a public toilet, touching several elements inside the cubicle, using the toilet, leaving and washing hands in a non-compulsive way. Relaxation exercises if necessary.

ITEM	SUD’s	ENVIRONMENT	CONFIGURATION	EVENT
Standing outside a dirty public toilet, I open the door, I stand in front of the cubicle I open the door, I stand in front of the toilet, I lower the lid and sit on the toilet, I grab paper, I stand up, I flush the toilet and I stand in front of the sink. I wash my hands, I touch the faucet, soap and hand dryer	80	OCD	Clean/Difficult	Complete
Lower the lid of a dirty public toilet	85	OCD	Dirty	Lower the lid of a dirty public toilet
Sitting on a dirty public toilet	90	OCD	Dirty	Sitting on the toilet
While I’m sitting on a dirty public toilet, I touch the wall with my left hand	90	OCD	Dirty	Touching the wall (sitting on the toilet)
I’m standing outside a dirty public toilet, I open the door, I stand in front of the cubicle, I open its door, I stand in front the toilet, I lower the lid and I sit on it.	90	OCD	Dirty	From standing outside until sitting on the toilet

SESSION 7

• Revision of the past session’s achievements and establishing of objectives of the actual session: Make a complete sequence, in a dirty public toilet with easy settings.

• We begin with gradual exposure and systematic response prevention with virtual reality. Cognitive restructuring, if necessary.

• The reports should be shown to the patient so they can see their clinical progress.

HOMEWORK
Live exposure, entering a public toilet, touching several elements inside the cubicle, using the toilet, leaving and washing hands in a non- compulsive way. Relaxation exercises if necessary. 

ITEM	SUD’s	ENVIRONMENT	CONFIGURATION	EVENT
I flush a dirty public toilet and it smells bad after having used it	95	OCD	Dirty	Flushing toilet
I stand in front of the sink of a public toilet that stinks	95	OCD	Dirty	In front of the sink
I wash my hands in a dirty public toilet without touching the faucet, soap or hand dryer.	95	OCD	Dirty/Easy	Washing hands
I’m standing outside a dirty public toilet, I open the door, I stand in front of the cubicle, I open the door, I standing front of the toilet, I lower the lid, I sit down, I grab paper, I stand up, I flush the toilet, I stand in front of the sink and I wash my hands without touching the faucet, soap and hand dryer.	95	OCD	Dirty/Easy	Complete

SESSION 8

• Revision of the past session’s achievements and establishing of objectives of the actual session: Complete sequence, dirty environment and difficult level. 

• We begin with gradual exposure and systematic response prevention with virtual reality. Cognitive restructuring, if necessary.

• The reports should be shown to the patient so they can see their clinical progress.

HOMEWORK
Live exposure by entering both dirty and clean public toilets, enter the toilet cubicle and sit on the toilet, use the sink in a non-compulsive way. relaxation exercises if necessary.

ITEM	SUD’s	ENVIRONMENT	CONFIGURATION	EVENT
I use the sink in a dirty public toilet, touching the faucet, soap and hand dryer	95	OCD	Dirty/Difficult	Washing hands
Sitting on a dirty public toilet, I grab paper, I stand up, flush the toilet, I stand in front of the sink, and I wash my hands without touching the faucet, soap or hand dryer	95	OCD	Dirty/Easy	From sitting down until washing hands
Sitting on a dirty public toilet, I grab paper, I stand up, flush the toilet, I stand in front of the sink, and I wash my hands touching the faucet, soap and hand dryer	100	OCD	Dirty/Difficult	From sitting down until washing hands
I find myself outside a dirty public toilet, I open the door, I stand in front of the cubicle, I open the door, I stand in front of the toilet, I sit on the toilet, I grab paper, I flush the toilet, I stand in front of the sink and i wash my hands touching faucet, soap and hand dryer.	100	OCD	Dirty/Difficult	Complete

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.”

OCD Evaluation

Evaluation objectives 

• Evaluate presence and comorbidity with other emotional disorders.

• Evaluate the presence of obsessions, compulsions and neutralizations.

• Define anxiogenic stimular settings on the side of the patient and in what degree. Elaboration hierarchy of exposure.

• evaluate the presence of distorted thoughts. In case of OCD, those associated with obsessions and compulsions.

Useful tools for the OCD 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

• Obsessive Beliefs Questionnaire (OBQ-44) 

• The Brief Obsessive–Compulsive Scale (BOCS)

• Yale-Brown Obsessive-Compulsive Scale (Y-BOCS)

• Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS)

• The Maudsley Obsessive-Compulsive Inventory (MOCI).

• Leyton Obsessional Inventory (LOI).

• Psious self-reports for the elaboration of the hierarchy.

TEST FOR BEHAVIORAL APPROACH

• Behavioral avoidance test for obsessive compulsive disorder (BATs).

Exposure hierarchy elaboration with Psious’ environments

Once we have all the evaluation information we can proceed to elaborate an exposure hierarchy. For that, we need to make some questions made to plan the intervention with virtual reality: e.g. what level of discomfort, on a scale from 0 to 100, does it cause you to be sitting on a toilet? What level of discomfort from 0 to 100 does it cause you to wash your hands? Do you think there’s something that can cause you even more discomfort than that?

OCD and virtual reality

According to the American Psychiatric Association, the obsessive compulsive disorder is an anxiety disorder in which people have undesirable thoughts, ideas or sensations (obsessions), which carry out ritualized behaviors (compulsions) or repetitive thoughts (neutralizations). These behaviors, such as washing hands, checking or cleaning, interfere in a significant way with the daily activities and social relationships of a person. (Gorrindo, T., Parekh, R., 2015)

For OCD’s differential diagnosis obsessions and/or compulsions that consume a lot of time (more than one daily hour), cause stress, harm work and social relationships, as well as other important areas must be present. (APA, 2007). The cognitive-behavioral therapy, the treatment with medication, apart from other somatic therapies of cerebral stimulation, have been until now the most effective alternatives to treat this disorder (APA, 2007).

Virtual Reality appears as a good alternative tool to the traditional techniques used in mental disorder treatments and in obsessive compulsive disorders among others. Virtual Reality allows the standardization and the control on the parameters of the exposure sessions. Likewise, it turns out to be very useful to repeat the exposure to the fear or anxiogenic situations as many times as necessary, making the customization and flexibilization of the therapeutic process much easier.

Psious’s environments allow the use of diverse psychological intervention techniques: exposure, cognitive restructuring, systematic desensitization, training in social skills… Use the most adapted characteristics of the patient and use those with major empirical support to obtain better results.

Appendix

Self-report Hierarchy Test Anxiety

ITEM	LEVEL OF DISCOMFORT (0-100)
I am at home a few days before performing an important test
All students are in class today performing a very short test of anxiety
While I’m alone in the hallway, the teacher is going to question me, and with a friendly voice, he invites me to go to the classroom
The test that I’m doing today is quite long, and the class I’m in is very full
I find myself in the hallway with several classmates who seem calm although we have a test. The teacher comes to the classroom with a very serious look and asks us to come in
I am alone in the classroom with the teacher, who seems quite friendly, waiting for the test anxiety to start
I’m waiting in the hallway for the teacher to start the test today, and there are many people who also wait and seem quite anxious
I’m alone in the hallway, waiting for the teacher to start a test
I and a few of my classmates are about to start the Science Test, they all seem pretty calm and the teacher is relaxed
I’m alone in the classroom with a very serious teacher who seems to be watching me, waiting for the anxiety test to start
I’m with a lot of people in the hallway waiting for the teacher to start the test today, and I can see how the others are quite calm
I’m just sitting in the classroom, waiting for the teacher, who seems quite friendly, to start the history test
At the end of the test I have been doing, the teacher shows me the result on a screen
I find myself in the hallway with a few classmates who seem quite nervous, and we are waiting for a test
As the test will begin, the murmur of the classmates goes down until nothing is heard
I and a few classmates are waiting for the teacher to start a test, and it seems that they are relaxed and calm
I’m in class about to perform an anxiety test, in the class there are enough people who are very uneasy and also the teacher seems very serious and fairly controlling
While I am in the middle of the test, one of my colleagues announces aloud that he is finished
After waiting for a while alone in the hallway, the teacher appears and tells me to go to class very seriously
I’m the only student in class and I am doing a science test
I find myself in class with many classmates, and we are doing a brief history test
I’m in the hallway with several classmates who seem quite nervous. Suddenly the teacher appears and kindly tells us that we can go to the classroom
I’m alone in the classroom with the teacher, who is quite serious, waiting for the start of the natural sciences test
While I and some of my classmates were waiting quietly for the teacher to arrive, he appeared and kindly told us to go to class
I’m alone in a classroom doing an anxiety test
I’m in the history classroom, and I find myself doing a brief test on this topic with many classmates
While I and some colleagues who look very anxious are waiting for the teacher, he comes and tells us in a friendly way that we can go to the classroom
In the class where the history test is done, we are just me and the teacher, who seems very serious
I’m in class about to take a history test. The classroom is full of people who seem very calm, and the history teacher is calm and friendly
I find myself doing a long anxiety test, and the class is quite full
I’m alone in the classroom with the teacher, who seems very calm, waiting for the start of the natural sciences test
I’m inside the subway, because I’m going to do the test I have today
I meet many classmates in the classroom where the natural sciences test will start, the teacher seems very serious and the students are nervous
I’m in class about to do an anxiety test, the class is full of people who are quite calm and also the teacher is very kind
I find myself alone with the history teacher, doing a test
I am with many colleagues doing a long test of natural sciences
I’m in class about to take a history test. The classroom is full of people who seem very nervous, and the teacher is a bit serious and not very kind

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Bibliography

• Ali, M. S., & Mohsin, M. N. (2013). Test Anxiety Inventory (TAI): Factor analysis and psychometric properties. Journal of Humanities and Social Science, 8(1), 73-81

• Alsina, I., Carvallo, C. y Gutiérrez-Maldonado, J. (2007). Validity of virtual reality as a method of exposure in the treatment of test anxiety. Behavior Research Methods, 39 (4), 844-851. R

• 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.

• Cunha, M., & Paiva, M. J. (2012). Text Anxiety in Adolescents: The role of self-criticism and acceptance and mindfulness skills. The Spanish journal of psychology, 15(2), 533

• Kavakci, O., Semiz, M., Kartal, A., Dikici, A., & Kugu, N. (2014). Test anxiety prevalence and related variables in the students who are going to take the university entrance examination. Dusunen Adam, 27(4), 301.

• 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)

• Liebert, R. M., & Morris, L. W. (1967). Cognitive and emotional components of test anxiety: A distinction and some initial data. Psychological reports, 20(3), 975-978.

• Mandler, G and Sarason, S B, (1952). A study of anxiety and learning. Journal of Abnormal and Social Psychology, 47, 166–173

• Gutiérrez-Maldonado, J., Alsina-Jurnet, I., Carvallo-Becíu, C., Letosa Porta, A., y Magallón-Neri, E. (2007). Aplicaciones clínicas de la realidad virtual en el ámbito escolar. Cuadernos de medicina psicosomática y psiquiatría de enlace, 82, 32-51.

• Heredia, D., Piemontesi, S., Furlan, L., y Pérez, E. (2008). Adaptación de la Escala de Afrontamiento ante la ansiedad e incertidumbre pre examen:(COPEAU). Avaliação psicológica, 7(1), 1-9.

• Hembree, R. (1988). Correlates, causes, effects, and treatment of test anxiety. Review of educational research, 58(1), 47-77.

• Hodapp, V., Glanzmann, P., y Laux, L. (1995). Theory and measurement of test anxiety as a situation-specific trait. En Charles Spielberger (Ed). Test anxiety: Theory, assessment, and treatment, (47-58). Philadelphia: Taylor & Francis.

• Rodríguez, J. O., Alcázar, A. I. R., Caballo, V. E., García-López, L. J., Amorós, M. O., y López-Gollonet, C. (2003). El tratamiento de la fobia social en niños y adolescentes: una revisión meta-analítica. Psicología Conductual, 11, 599-622.

• Sapp, M., Farrell, W., y Durand, H. (1995). The effect of mathematics, reading, and writing tests in producing worry and emotionality test anxiety with economically and educationally disadvantaged college students. College Student Journal, 29, 122–125.

• Sarason, I. G. (1972). Experimental approaches to test anxiety: Attention and the uses of information. Anxiety: Current trends in theory and research, 2, 383-403.

• Spielberger, C.D. (1980). Test Anxiety Inventory Palo Alto, C.A: Consulting Psychologists Press.  

• Spielberger, C. D & Vagg, P.R. (1995). Test Anxiety: Theory Assessment and Treatment Washington D.C. Taylor Francis, 3-14.

• Talbot, L. (2016). Test Anxiety: Prevalence, Effects, and Interventions for Elementary School Students. James Madison Undergraduate Research Journal (JMURJ), 3(1), 5.

• Valero, L. (1999). Evaluación de ansiedad ante exámenes: Datos de aplicación y fiabilidad de un cuestionario CAEX. Anales de psicología, 15(2), 223-231.

• Von Der Embse, N., Barterian, J., & Segool, N. (2013). Test anxiety interventions for children and adolescents: A systematic review of treatment studies from 2000–2010. Psychology in the Schools, 50(1), 57-71.

• Zeidner, M. (1998). Test anxiety: The state of the art. Springer Science & Business Media.

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.”

Systematic desensitization (SD) through exposure is shown to be effective by itself to reduce test anxiety (Hembree, 1988) in addition to having a positive effect on academic results and a decrease in overall anxiety and trait status.

The therapeutic approaches that combine SD with cognitive restructuring and study techniques are the ones that show a greater reduction of the test anxiety (Talbot, 2016). Remember that exposure is an equally effective but more efficient technique than SD and that, in addition, virtual reality exposure is equally effective as exposure by imagination and achieves a greater reduction of avoidance behaviors than exposure by imagination (GutiérrezMaldonado, Alsina, Carvallo, Letosa & Magallón, 2007). 

In terms of study techniques, it can be taught the importance of properly managing time and planning, understanding that in order to optimize the study, it is necessary to plan short-, medium- and long-term objectives. Techniques may also be used for the control of activation such as relaxation in case of having a patient with excessive physiological activation. 

Another useful technique in these cases is cognitive restructuring, especially in those patients with excessive concern and with distorted thoughts centered on the negative consequences of not being successful in the test. During the preparation for the test, the student can be told to analyze the rationality of his/her thoughts, to think about which ones he/she habitually has and how they can interfere with his/her performance. In addition to this, you can tell the patient to draw up a list of alternative thoughts (self instructions) so they can choose one of them when their mind focuses on a negative thought while they are doing a test. Remember that the patient can practice using all these strategies in the virtual reality environment.

Below is the hierarchy example to use with the Psious environment. In this case the scene used is the university, but the same example could be used with the school environment.

SESSION 1

Psychoeducation: Inform the patient about the test anxiety (causes, symptoms, prevalence…).

• Present and justify the techniques that will be used throughout the treatment: exposure with virtual reality and live exposure…

• Elaboration of the exposure hierarchy and exposure to items of the hierarchy with 20-30 SUD’s (example)

• Start exposure hierarchy with an item close to 30 SUD’s.

The main objective will be to familiarize the patient with virtual reality and the work dynamic. 

ITEM	SUD’s	ENVIRONMENT	CONFIGURATION	EVENT
Being at home a few days before an important test	20	Home	Sun, Day
Being on the subway before doing a test	25	Metro	Illuminated, easy	Enter
Being alone in the hallway, waiting for the teacher to arrive and start the test	35	University	Easy, alone
Being with a few classmates in the hallway before a test while they look very calm	40	University	Easy, few students

SESSION 2

• Review of the previous session achievements and establishment of the objectives of the session: Waiting for the teacher with a few classmates who seem quite nervous.

• Exposure begins with prevention of gradual and systematic response to virtual reality. Cognitive restructuring, if appropriate.

• Reports are shown to the patient to see clinical progress.

HOMEWORK
Imagination exposure at home reviewing the objectives covered in the session + live exposure going to university even if you don’t have a test.

ITEM	SUD’s	ENVIRONMENT	CONFIGURATION	EVENT
Being alone waiting for the teacher, and when he arrives he nicely ask you to come in	40	University	Easy, alone	Teacher appears
Being with a lot of people in the hallwaybefore an exam and they seemvery quiet	45	University	Easy, a lot of students
Being with a few classmates in the hallway, and when the teacher appears he asks you to come in	50	University	Easy, Few students	Teacher appears
Waiting for the teacher with some classmates that seem very nervous	60	University	Hard, Few students

SESSION 3

• Review the achievements of the previous session and establish the objectives of the current one: Being in class about to start a test and the classmates are very calm. 

• Exposure begins with prevention of gradual and systematic response to virtual reality. Cognitive restructuring, if appropriate.

• Reports are shown to the patient to see clinical progress.

HOMEWORK
Imagination exposure reviewing the process followed in consultation.

ITEM	SUD’s	ENVIRONMENT	CONFIGURATION	EVENT
Waiting for the teacher with a lot of people in the hallway, and they are very nervous and agitated	60	University	Hard, A lot of students	No event
Be with some classmates waiting in the hallway, the teacher appears and tells you to come in very seriously	65	University	Difficult, Few students	Teacher appears
Being in class about to start a test, the classmates seem calm	70	University	Easy, Few students	Enters the classroom

SESSION 4

• Review the achievements of the previous session and establish the objectives of the current one: See that the classmates are very nervous while waiting to start the test. 

• Exposure begins with prevention of gradual and systematic response to virtual reality. Cognitive restructuring, if appropriate.

• Reports are shown to the patient to see clinical progress.

HOMEWORK
Imagination exposure at home, reviewing previous session.

ITEM	SUD’s	ENVIRONMENT	CONFIGURATION	EVENT
To see the result after doing a test	70	University	Easy, Few students	Finish the test
Being alone with the teacher while he seems very serious	75	University	Hard, Alone	Enters the classroom and then, No event
Waiting for the test to begin and see that the large number of colleagues around you seem very nervous	80	University	Hard, A lot of students	Enters the classroom and then, No event

SESSION 5

• Review of the previous session achievements and establishment of the objectives of the session: Note that the teacher watches a lot while doing a short test.

• Exposure begins with prevention of gradual and systematic response to virtual reality. Cognitive restructuring, if appropriate.

• Repeat twice each one of the exercises.

• Reports are shown to the patient to see clinical progress.

HOMEWORK
Imagination exposure at home reviewing the objectives discussed in the session.

ITEM	SUD’s	ENVIRONMENT	CONFIGURATION	EVENT
Be alone with the teacher and start the test	80	University	Easy, Alone	Start the exam
Doing a short test in a crowded classroom	85	University	Easy, A lot of students	Start the exam
Doing a short test and notice that the teacher is watching a lot	90	University	Hard, A lot of students	Start the exam

SESSION 6

• Review of the previous session achievements and establishment of the objectives of the session: Performing a long test while several classmates are saying aloud that they have already finished

• Exposure begins with prevention of gradual and systematic response to virtual reality. Cognitive restructuring, if appropriate.

• Repeat twice each one of the exercises

• Reports are shown to the patient to see clinical progress.

HOMEWORK
Imagination exposure at home, reviewing the previous session.

ITEM	SUD’s	ENVIRONMENT	CONFIGURATION	EVENT
The class murmur is being reduced and the teacher starts the test	90	University	Easy, Few students	Start the exam
Be doing a very long test and the teacher is watching you a lot	95	University	Hard, A lot of students	Start the exam
Doing a long test and several classmates are announcing aloud that they have already finished	100	University	Hard, A lot of people	Start the exam (some time has to pass)

Remember that you can use the clinical guide to inform you of the therapeutic procedures with empirical evidence and how to adapt them to the intervention with the Psious virtual environments.