Table 1.

Role-play case 1.

1. Explaining the rationale:

TMS technician:“Symptom provocation is the intentional induction of a moderate level of self-reported obsessional distress before TMS treatment. By provoking obsessive symptoms, certain areas of your brain will be activated, which will make them more susceptible to stimulation. Despite unpleasant in the short term, this procedure aims to enhance clinical improvement”.

2. Explaining the procedure:

TMS technician: “During this procedure, we will talk about your symptoms, which were presented to me by the clinical psychologist that met with you some days ago. As I just mentioned, for this treatment it is necessary to elicit in you a certain level of distress, which shouldn't be too extreme, nor too subtle. Consequently, I will be asking you regularly, on a scale from 0 to 10, on how distressed you feel, where 0 corresponds to the absence of distress and 10 to the maximum distress that you can imagine. Higher or lower levels of distress are not necessarily better, so it is important that your answers are as precise as possible. This level of distress must be maintained during the session, which will last around 20 minutes. Symptom provocations will be organized from the least to the most distressing, and it is important that you do not perform any compulsions or behaviors to reduce distress until the end of the session. Throughout the treatment cycle, I will keep in touch with the psychologist that has interviewed you and I will be here to help you in all sessions. Do you have any questions?” Patient M.: “No, I don't.”

3. Start the treatment as a conversation to engage and find information that can be used to provoke symptoms:

TMS technician: “Before starting, I would like to know you better. Can you briefly present yourself?” Patient M.: “Yes, I'm 38-years-old. I live alone and I work as a designer. However, I stopped working a few months ago because I cannot go outside without thinking that I will get HIV if I touch anything that was touched by someone infected.” TMS technician: “So you are avoiding leaving home. Can you briefly describe a typical day for you?” Patient M.: “Before, I used to go to the office and meet some friends after work. However, in the last weeks I've been essentially in my apartment completely alone.”

4. Explore obsessive symptoms:

TMS technician: “Thinking constantly that you might be infected with HIV when you go out must be extremely distressing. Can you tell me more about that?” Patient M.: “I started thinking about this in my early 20's, after a colleague in university had been diagnosed with HIV. Since then, this fear never disappeared. Basically, I'm afraid of getting in contact with someone that has HIV or touching a surface that could have been contaminated.”

5. When appropriate, introduce the first symptom provocation and ascertain the level of distress:

TMS technician: “When was the last time you were in contact with someone you though that could have HIV?” (Internal provocation) Patient M.: “Yesterday I went to the supermarket and I was afraid that the lady in front of me had HIV. She didn't look good, and she disinfected her hands too many times.” TMS technician: “I see. From a scale from 0 to 10, how much distress do you feel when thinking about that situation?” Patient M.: “Not much, yesterday I felt quite anxious but today not that much, maybe a 2”.

6. Since a score between 4 and 7 in the Visual Analog Scale was not achieved, continue to the following symptom provocation according to the symptom provocation hierarchy:

TMS technician: “Now I would like to ask if you can look at this word.” Show the word ‘HIV' written in a paper. “From a scale from 0 to 10, how much does it bother you looking to this word?” (External provocation) Patient M.: “I would say a 3”. TMS technician: “The psychologist also told me that when you are out you check all surfaces where you touch. Did you examine every surface you touched today?” (Internal provocation) Patient M.: “Yes, I checked the seat of the taxi”. TMS technician: “Did you check it properly? Are you sure that there wasn't any blood spot in there?” Patient M.: “Well… I can't be absolutely sure…”. TMS technician: “From a scale from 0 to 10, how much distress do you feel when thinking about this?” Patient M.: “It's very distressing… probably a 5 or 6”

7. After reaching the desired level of distress (score between 4 and 7 in the Visual Analog Scale), the TMS technician should keep the conversation for some minutes to prevent patients from understanding which the required distress level is, to allow for the beginning of the treatment. Start TMS treatment:

TMS technician: “Ok, now if you're ready, I will start the treatment. Please keep in mind not to perform any compulsion or other behaviors to reduce distress until the end of the session.”

8. At certain points throughout the TMS session, the technician should engage in a similar dialogue with the patient to assess the current intensity of distress and, if needed, adjust it by using the techniques already mentioned.