Table 2.

Role-play case 2.

A successful role-play should start by explaining the rationale and procedure of symptom provocation (points 1 and 2 described above for Case 1). Next, the following topics should be covered:

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 L.: “Sure, I am 25 years-old and I live nearby with my parents and my younger brother. I started studying Agronomy, but I had to quit university due to my symptoms.” TMS technician: “How did your disease make you quit university? Patient L.: ”I started being really afraid of offending or hurting someone when I was around other people, and these thoughts were particularly intense when I was around people outside my family, particularly people that I admired and respected, like some teachers or close friends. Consequently, I started avoiding leaving my place and eventually I was not able to go out to the university.”

4. Explore obsessive symptoms:

TMS technician: “Can you tell me more about those thoughts?” Patient L.: “I just can't avoid thinking that I will offend or hurt these people in a violent way. I don't think I want to do it, but I just can't avoid thinking about it.”

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

TMS technician: “When you feel afraid of offending someone, do you think there is a risk of actually doing it?” (Internal provocation) Patient L.: “I don't know. On one hand I have these thoughts all the time and I have never offended any of these people. On the other, I just can't avoid thinking about it so I would say that the risk can't be zero.” TMS technician: “From a scale from 0 to 10, how much distress do you feel when thinking about that possibility?” Patient L.: “Maybe a 3. As my psychologist told me, thinking something is not the same as doing it.”

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: “You told me that you were also afraid of hurting someone. Can you tell me more about these thoughts?” Patient L.: “Yes, I keep thinking that I can be really aggressive to some of these people that I admire. Often, I even have images coming to my mind of violent aggressions in which I am hurting these people very badly.” TMS technician: “Can you describe these images in detail?” (Internal provocation) Patient L.: “I frequently think of strangling them with my own hands. It's horrible, I know.” TMS technician: “That must be very distressing for you. From a scale from 0 to 10, how distressing are these thoughts?” Patient L.: “A 5, these thoughts and images are just awful.”

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.