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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.”

Test Anxiety Evaluation

Evaluation Objectives 

• Evaluate the presence and comorbidity of other emotional disorders, especially anxiety disorders such as social phobia.

• Evaluate anxiety associated with components: perform a test, have to study, go to class on a test day…

• Define the patient’s fear configurations and their degree. Elaborate a hierarchy of exposure.

• Evaluate the presence of distorted thoughts such as being totally blank, not having learned anything after having studied, not showing up at exams, always failing…

• Evaluate which component of test anxiety is the one that concerns the patient the most: a, b, c, d

• Evaluate which style of coping characterizes the patient, whether it is more (a) task-oriented, focusing on the pursuit of (b) social support, or is (c) avoidance.

Some useful tools for evaluating Test Anxiety

Taking into account the evaluation objectives we will list some tools that may be useful to obtain relevant information about the characteristics of your user. Remember that a good definition of objectives, patient characterization and intervention planning are important for the therapeutic efficiency and effectiveness, as well as for the satisfaction of your user. In the bibliography you will find the articles that will serve you to review the characteristics of the tools proposed below: 

• Open or semi-structured interview 

• Structured Interview: ADIS-IV

SELF-REPORTS

• One-dimensional
  • Test Anxiety Scale

• Multidimensional
  • Test Anxiety Questionnaire (TAQ)
  • Test Anxiety Inventory (TAI) 
  • German Test Anxiety Inventory (TAI-G) 
  • Test Anxiety questionnaire
  • Anxiety and performance questionnaire

• Psious self-reports for the elaboration of the hierarchy 

Elaboration of the exposure hierarchy with Psious environments

Once we have the information from the evaluation we can proceed to elaborate the exposure hierarchy. In order to do this, we can ask a series of questions (e.g., what level of discomfort, on a scale from 0 to 100, does it generate you to study for a test?, What level of discomfort, on a scale from 0 to 100, would it generate to you having to do an admission test for the university?, Do you think there is something that can generate an even greater discomfort?) aimed at planning the intervention through virtual reality

Hierarchy Examples 

In the annex you will find a self-report tool to get the hierarchy of action using Psious environments.

Test anxiety
and virtual reality

Test anxiety has been defined as the emotional, physiological and behavioral responses that occur around the potential consequences of negative evaluations or a future test or exam (Zeidner, 1998)

Spielberg and Vagg (1995) have described test anxiety as an element of general anxiety which is composed of processes of cognitive attention that interfere with performance in academic situations or tests. Like Sapp, Durand and Farrel (1995) who consider it as a case of general anxiety disorder related to being tested. Studies about the start, prevalence and incidence indicate that the start of the problem may be very early (7 years), although the major manifestations occur in adolescence. Von Der Embse, N., Barterian, J., & Segool, N. (2013) estimate that between 10 and 40% of the child/adolescent population may suffer from it. Other studies indicate a high incidence, around 48%, in university students (Kavakci, O., Semiz, M., Kartal, A., Dikici, A., & Kugu, N., 2014).

Systematic desensitization (SD) through exposure is shown to be effective 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 anxiety before the test (Talbot, 2016).

The virtual reality environments are capable of generating the anxious response that appears because of the test to be able to perform the gradual exposure. In addition, virtual reality is equally effective as exposure by imagination and achieves a greater reduction of avoidance behaviors than exposure by imagination (Gutiérrez-Maldonado, Alsina, Carvallo, Letosa & Magallón, 2007). This may be because virtual reality allows a greater generalization of the coping response learned.

Psious environments allow you to use different techniques of psychological intervention: exposure, cognitive restructuring, systematic desensitization, training in social skills…, use those that are more appropriate to the characteristics of your patient and build on those with greater empirical support to get better results.

Appendix

Self-report hierarchy bar in group settings Psious

ITEM	LEVEL OF DISCOMFORT (0-100)
I called the waitress to ask for the drink and in addition to coming very quickly she asked me what we wanted very kindly
My colleagues talked about the sport, and then that I have given my opinion, one of them makes a negative comment
I meet in a bar with some friends and it seems that they are angry with me and distant
I meet in a bar with some friends and they kindly ask me to order the drink at Waitress
While we’re having a drink, my friends ask me curtly to tell the waitress to turn down the air conditioning
When my friends are talking about movies, they ask for my opinion
A colleague just paid the bill, so I appreciate it
When the waitress it approaches our table, I wonder where is the bathroom and responds nicely
One of my colleagues asked me a little angry to ask the waitress drink
While we are taking some two friends say goodbye and leave the bar
One of my friends tells me, in an unkind way, to ask the waitress to change our drink
A colleague has started a conversation about travel and asks me what I think about it
One of my friends He asks me to call the waitress and ask her to lower the air, because it is quite cold.
I am in a bar with a few friends and they all talk about various topics.
After some colleagues have left, I stay with a couple of friends, who they are distant and unfriendly
I have called the waitress to ask for the drink, and although she comes very quickly she speaks to me in an unpleasant and hurried way
My friends ask me to ask the waitress for the account
My colleagues have asked me if I could notify the Waitress to change our drink, so I should call her and ask her
When I ask the waitress to tell me where the bathroom is, she responds but in an unkind way
I call the waitress since my friends have asked me unkindly to ask for the account
After making a comment on the issue of children, one of my friends flatters my opinion
I am in a bar with friends and one of them only makes unpleasant comments
The waitress is very kind to give us the account, says he hopes we will come back soon
After calling the waitress to ask where the bathroom is, I hear how one of my colleagues says why don’t I go look at where it is

[ DISCLAIMER: This document has been automatically translated using Google Translate. ]

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Bibliography

• García-López, L. J., Olivares, J., Hidalgo, M. D., Beidel, D. C., & Turner, S. M. (2001). Psychometric properties of the social phobia and anxiety inventory, the Social Anxiety Scale for Adolescents, the Fear of Negative Evaluation Scale, and the Social Avoidance and Distress Scale in an adolescent Spanish-speaking sample. Journal of Psychopathology and behavioral assessment, 23(1), 51-59.

• Gebara, C., Barros-Neto, T., Gertsenchstein, L., Lotufo-Neto, F. (2015). Virtual reality exposure using three-dimensional images for the treatment of social phobia. 

• Hartanto, D., Kampmann, I.L., Morina, N., Emmelkamp, P.G., Neerincx, M.A. y Brinkman, W. (2014). Controlling social stress in virtual reality environments. PLos ONE, 9(3), 1-17-. doi: 10.1371/journal. pone.0092804

• Herbelin, B., Vexo, F. y Thalmann, D. (2002). Sense of presence in virtual reality exposure therapy. Virtual Reality Laboratory, Federal Institute of Technology (EPFL). Recuperado de: http://citeseerx.ist.psu. edu/viewdoc/download?doi=10.1.1.9.9590&rep=rep1&type=pdf

• Klinger, E., Bouchard, S., Légeron, P., Roy, S., Lauer, F., Chemin, I. y Nugues, P. (2005). Virtual Reality Therapy versus Cognitive Behavior Therapy for Social Phobia: A preliminary controlled study. CyberPsychology & Behavior, 8(1):76-88. DOI: 10.1089/cpb.2005.8.76 

• McNeil, D.W. y Randall, C.L. (2014). Conceptualizing and describing Social Anxiety and its disorders. En S.G. Hofmann y P.M. DiBartolo (Eds.), Social Anxiety. Clinical, developmental, and social perspectives (pp. 3-21). Londres: Elsevier.

• Morrison, J. (2015). DSM-5: Guía para el diagnóstico clínico. México, D.F.: El Manual Moderno

• Nichols, A. L., & Webster, G. D. (2015). Designing a brief measure of social anxiety: Psychometric support for a three-item version of the Interaction Anxiousness Scale (IAS-3). Personality and Individual Differences, 79, 110-115.

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.”

Example of intervention in Social Anxiety

The general work dynamics for VR sessions in social anxiety and Social Skills problems (HHSS) are presented below:

• The  healthcare professional presents the situation / environment to the patient: “You are in a bar with some friends speaking of various topics, you can intervene at certain times by giving your opinion… ”It is positive to carry out a simulation in consultation, where the  healthcare professional encourages the patient to talk about a specific topic (better if it is one of the topics that will be discussed in the environment) and where the  healthcare professional offers an assertive model of behavior (give an opinion, make a request, etc.)  

• The exposure begins and in this way the patient can reproduce what he has observed in the model.

• After the exposure, the healthcare professional gives feedback to the patient about his execution: positive reinforcement of behaviors and proposals for improvement with forms of alternative models that the patient can rehearse in the consultation, repeating the event of VR and at home.

• The exposure and the work dynamics of the modeling are repeated.

SESSION 1 

Psychoeducation: Inform the patient about social 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 of 20-30 USA’s (example)

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

ITEM	SUD’s	ENVIRONMENT	CONFIGURATION	EVENT
Being in a bar with some lifelong friends and listening to how they talk	20	Bar in a group	Friendly	No Events
Have the waitress bring the bill and thank you kindly	25	Bar in a group	Friendly	Ask for a bill
Say goodbye to two friends who They leave the bar	30	group bar	Friendly	Farewell
Thank a colleague who pays the bill	40	group bar	Friendly	Request account

SESSION 2

• Review of achievements in the previous session and goal setting for the current session: Call the waitress to order the drink.

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

• The reports are shown to the patient to see the clinical progress.

TASKS FOR HOME
Live exhibition meeting a couple of friends and listening to them talk.

ITEM	SUD’s	ENVIRONMENT	CONFIGURATION	EVENT
A friend makes a positive comment about what I just said	45 Group	Bar	Friendly	No Events
Have your friends ask you to give your opinion on what they are talking about	50 Group	Bar	Friendly	No Events
Tell the waitress what Do you want to drink	55 Group	Bar	Friendly	Order a drink
Call the waitress to order a drink	60 Group	Bar	Friendly	Order a drink

SESSION 3

• Review the achievements of the previous session and goal setting for the current session: having to call the waitress to change the drinks he had already brought.

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

• The reports are shown to the patient to see the clinical progress.

TASKS FOR HOME
Live exhibition in a place known to the patient, talking and listening to a couple of friends; if you feel comfortable, order the drink.

ITEM	SUD’s	ENVIRONMENT	CONFIGURATION	EVENT
Ask the waitress where the bathroom is and to answer you very cordiallyAsk	60 Group	Bar	Friendly	Bathroom
you to call the waitress to ask for the bill	65 Group	Bar	Friendly	Ask for account
They ask you to call the waitress to change the drink	70 Group	bar	Kind	Drink change

SESSION 4

• Review of the achievements of the previous session and goal setting of the current session: Call the waitress and be unkind.

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

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

TASKS FOR HOME
Live exhibition calling a waitress to ask where the bathroom is, the bill, etc. + covert exposure at home repeating the process worked in consultation through imagination.

ITEM	SUD’s	ENVIRONMENT	CONFIGURATION	EVENT
Being in a bar with friends who are angry and distant	70	Bar in a group	Unfriendly	Bathroom
Hearing that a friend only makes negative comments about what others say	75	Bar in a group	Unfriendly	Ask for an account
Call the waitress to order the drink and be unkind	80 Group	bar	Unfriendly	Drink change

SESSION 5

• Review of the achievements of the previous session and goal setting of the current session: They ask you for your opinion on a topic that you do not master. 

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

• Repeat 2 times each of the exercises.

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

TASKS FOR HOME
Covert exhibition reviewing the process followed in the session.

ITEM	SUD’s	ENVIRONMENT	CONFIGURATION	EVENT
Having to call the waitress because they have asked you unkindly to lower the air conditioning	80	Bar in a group	Unfriendly	Temperature
That after asking the waitress where the bathroom is, he answers you in a bad way	85	Bar in a group	Unkind	Bathroom
Being asked for your opinion on a topic that you do not dominate in a brusque and unkind way	90 Group	bar	Unfriendly	No event

SESSION 6

• Review of achievements in the previous session and goal setting for the current session: Hear negative comments from a friend after asking the waitress where the bathroom is.

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

• Repeat 2 times each of the exercises

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

TASKS FOR HOME
Imaginal exhibition reviewing the process followed in consultation.

ITEM	SUD’s	ENVIRONMENT	CONFIGURATION	EVENT
Call the waitress to change your drink and make it seem like she responds angrily	90 Group	bar	Not friendly	Drink change
Have a friend give you a critical comment after you comment on the topic of conversation	95 Group	bar	Unfriendly	No event
After asking the waitress where the bathroom is, hearing a friend comment that why don’t I go and see where it is instead of bothering the waitress	100 Group	bar	Unfriendly	Bathroom

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.“

Social Anxiety Assessment

As mentioned above, this environment not only serves for exposure, but is also useful for assessment.

Activate the environment having given minimal instructions about what the patient will see. 

During playback, you will be able to evaluate the patient’s behavior, both on a non-verbal level, if he continues the conversation, seeking eye contact, if he orients his body, if he makes gestures that accompany his speech, and on a verbal level, that is, how he intervenes, if it is fluid, with adequate volume, etc.

Later, by asking the patient, you can also evaluate what happened at a cognitive level.

Evaluation objectives

• To evaluate the presence and comorbidity of other emotional disorders, especially other anxiety disorders.

• Evaluate anxiety associated with components: being in a social situation or performance where one is exposed to evaluation by others.

• Define stimulus configurations feared by the patient and to what degree. Elaboration of the exposure hierarchy.

• Evaluate the presence of distorted thoughts: believe that others are observing you excessively and that they are going to evaluate you negatively, underestimate your own abilities, evaluate excessively negatively your own social performance, think that if you make a mistake, everyone will laugh …

Some useful instruments for the evaluation of social anxiety

Taking into account the evaluation objectives, we will now list some tools and instruments that may be useful to obtain relevant information about the characteristics of your user. Remember that a good definition of objectives, characterization of the patient and planning of the intervention are important for the efficiency and therapeutic efficacy, as well as for the satisfaction of your patients. In the bibliography you will find the articles in which to review the characteristics of the instruments proposed below:

For a complete evaluation of the problem, a combination of the following instruments will be used:

• Open or semi-structured interview.

• Structured Interview: Interview for Anxiety Disorders according to DSM-IV (ADIS-IV)

• Observation and self-observation (with self-registration):-registration

• Approach test in vivo and / or through virtual reality

• Self-report Relaxation

• Scale TOP-8

• Global Index of Duke DGRP

SELF-REPORTS

• Anxiety and Social Avoidance Scale (SADS) 

• Anxiety and Social Phobia Inventory (SPAI)

• Fear of Negative Evaluation(FNES) 

• ScaleInteraction Anxiety Scale (IAS)

• Psious Self-reports for the elaboration of the hierarchy

Some useful tools for the evaluation of social anxiety

Once we have the evaluation information we can proceed to develop the exposure hierarchy. To do this, in addition to using the data obtained during the initial assessment, we can ask a series of questions (eg, what level of discomfort, on a scale of 0 to 100, does it cause you to be in a bar talking to friends? What level of discomfort, on a scale of 0 to 100, would you have to ask a waitress to change your drink? Do you think there is something that could generate even greater discomfort? …) aimed at planning the intervention through virtual reality.

Below are a number of items that could be used to create a proper hierarchy for treating social anxiety with Psious. It must be taken into account that we could ask the patient about the anxiety that these items generate, and from this, gradually graduate the different elements of the hierarchy.

• Being in a bar with some friends.

• After making an intervention in a conversation with friends, one of them makes a critical comment.

• Having to ask where the bathroom of a bar is.

• Being unkindly asked by a friend to call the waitress.

• Having to thank your partner for paying the bill.

• Ask for your opinion about cinema.

• Receive a friendly response from the waitress when ordering the drink.

Social anxiety
and virtual reality

The fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), replaces the old term of social phobia with Social Anxiety Disorder. This modification represents a change in the conceptualization of the disorder, in which it is understood that the condition exists in a variety of social settings.

Virtual Reality (VR) is a beneficial tool for the treatment of Social Phobia, as it exposes the patient to social interactions, cognitive restructuring, social skills training and allows to train the patient on relaxation techniques. Moreover, the virtual exposure can be applied in an anxiogenic or unfavorable situation (seated, noisy, mid-conversation, etc), which is useful to design the exposure to the patient’s needs.

Appendix

Relaxation self-recording

Name:______________________________ Date:____________________

Date	Hour	Degree of relaxation (0-100) Before	Degree of relaxation (0-100) After	Used time	Comments

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Bibliography 

• Ansgar, C. & Walton, R. (2007). Muscle relaxation therapy for anxiety disorders: it works but how?. Journal of Anxiety Disorders, 21(3), 243-264. Recuperado de: http://www.sciencedirect.com.sire.ub.edu/science/article/pii/S0887618506001174 

• Mazoni, G., Pagnini, F., Castelnuovo & G., Molinari, E. (2008). Relaxation training for anxiety: a ten-years systematic review with metaanalysis. BMC Psychiatry, june. Recuperado de: http://link.springer.com/article/10.1186/1471-244X-8-41/fulltext. html#copyrightInformation

• Richard, D. & Lauterbach, D. (2007). Handbook of exposure therapies. San Diego, CA: Elsevier. 

• Serrano, V., Baños, R. & Botella, C. (2016). Virtual reality and stimulation of touch and smell for inducing relaxation: A randomized controlled trial. Computers in Human Behavior, 55(A), 1-8. Recuperado de: http://ac.els-cdn.com.sire.ub.edu/S0747563215300856/1-s2.0-S0747563215300856- main.pdf?_tid=592d5014-e60b-11e5-9676-00000aacb35e&acdnat=1457537392_38be 8d967a7bf04c27d4b027990429b4

• Spira, J.L., Pyne, J.M., Wiederhold, B., Wiederhold, M., Graap, K. & Rizzo, A. (2006). Virtual reality and other experiential therapies for combat-related posttraumatic stress disorder. Primary Psychiatry, 13(3), 58-64. Recuperado de: http://www.researchgate.net/profile/James_Spira/publication/228387636_Virtual_ reality_and_other_experiential_therapies_for_combat-related_posttraumatic_ stress_disorder/links/00463518c81d4ac9d1000000.pdf