ExPhobia: A mHealth Technology based on Augmented Reality for

Support the Treatment of Arachnophobic Stimulus

Fabiana Neiva Veloso Brasileiro

, Tauily Claussen D’Escragnolle Taunay

José Eurico de Vasconcelos Filho

, Manuela Melo Santana

and Ântonio Plínio Feitosa Bastos

Laboratório de Investigações em Análise do Comportamento, Universidade de Fortaleza,

Ave. Washington Soares, Fortaleza-CE, Brazil

Graduação em Psicologia, Centro de Ciências da Saúde, Universidade de Fortaleza,

Ave. Washington Soares, Fortaleza-CE, Brazil

Núcleo de Aplicação em Tecnologia da Informação, Universidade de Fortaleza,

Ave. Washington Soares, Fortaleza-CE, Brazil

Keywords: Arachnophobia, Augmented Reality, Systematic Desensitization, mHealth.

Abstract: Anxiety disorders attack a significant part of the population and have been treated, mainly, by

pharmaceuticals or psychotherapies. Augmented Reality technologies have gotten some space in the

treatment of these diseases, with promising results. The current paper presents the prototype ExPhobia that

holds concepts and tools from the mHealth and Augmented Reality areas for the support to the facing of

arachnophobia. We have as a main goal the development and the performing of the initial tests of ExPhobia

for the systemic desensitization on levels of anxiety and escape/dodge in people with arachnophobia. The

used methodology for the development of ExPhobia contemplates a laboratorial phase for the conception of

this functional prototype, supported by the stages of the interaction design and, after the initial tests, the

program is being planned in a way that a research in a method almost experimental can be done, with only

one individual, applying the ABA designing. For measuring the levels of anxiety and phobia of the

participants in scales, inventories and questionings, in addition to the heart frequency measuring. It is a

hypothesis that can be used in the Augmented Reality as a technique of systematic desensitization, from an

analytic-behavioral perspective, the positive and viable results for the treatment of specific phobias.

1 INTRODUCTION

Anxiety disorders, based on DSM-V (APA, 2013),

are differentiated from adaptive anxiety or fear

because they persist beyond normal time and are

excessive, in other words, disproportionate to reality,

occurring with a frequency greater than expected

and often compromising the quality of life of the

individual. Phobias are considered a type of anxiety

disorder and one of its subdivisions includes specific

phobias, among them arachnophobia, which is the

object of study of this work and corresponds to the

disproportionate and excessive fear of spiders.

According to Zaminagni and Banaco (2005) and

with most of the current literature on the subject,

from an analytic-behavioral perspective, the

behavioral pattern characteristic of anxiety disorders

is phobic avoidance, that is, the individual will emit

a response that softens, defer or eliminate (escape /

dodge) an aversive event, that is, a threatening or

uncomfortable event.

Treatment for anxiety is usually performed with

psychological, pharmacological or both intervene-

tions, but drug use is not always necessary (Haydu et

al., 2014). Within psychology, some techniques can

be used so that anxiety disorder or, more

specifically, exacerbated and irrational fear (phobia),

can be minimized or eliminated. Among the possible

strategies, systematic desensitization (SD) is a very

effective procedure for the treatment of specific

phobias. It has been proven in several studies, such

as those shown in the literature review by Turner

(Caballo, 1996).

Technological advances have provided new

possibilities and benefits in the use of high

technology in the field of mental health (MH),

contributing favourably to new forms of interaction

(Wrzesien et al., 2013). Among the developed

474

Brasileiro, F., Taunay, T., Filho, J., Santana, M. and Bastos, Â.

ExPhobia: A mHealth Technology based on Augmented Reality for Support the Treatment of Arachnophobic Stimulus.

DOI: 10.5220/0007580604740480

In Proceedings of the 12th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2019), pages 474-480

ISBN: 978-989-758-353-7

technologies, some stand out as a very useful tool

for psychologists in interventions to treat specific

phobias, which are Virtual Reality (VR) and

Augmented Reality (AR) (Tsai et al., 2018; Opris et

al., 2012; Juan and Pérez, 2010). Studies suggest the

efficacy of VR and IR in the treatment of specific

phobias, however, many of them point out the need

for more research in the field and, therefore, to

support the use of these technologies as a

complementary and facilitative form of therapeutic

interventions (Haydu et al., 2016).

AR technology is used to blend digital (virtual)

content into the real world: computer-generated

images along with relevant information are

displayed in the user's real view field. It is able to

give support to different areas and applications

satisfying the need to connect the real world with

virtual worlds (Hugues et al., 2011). It also enhances

the user experience through mobile applications

designed specifically to utilize this technology,

thereby integrating the mobile health – mHealth -

area (WHO, 2011). Analysts predict that the global

AR market will grow at an annual growth rate of

65.24% over the period 2017-2021. Treatments with

the use of Augmented Reality with exposure to

phobic stimulus prove effective not only when

compared to other treatments, but also through

measurement with well-defined inventories and

scales, as in the study by Wrzesien et al. (2013).

Considering the high prevalence of anxiety

disorders in our environment, specifically the

phobias, coupled with modernization and current

technological advances, such as Augmented Reality

was necessary, in order to corroborate the tendency

of current research, to develop a functional

prototype, using AR, that can be applied by

psychologists as an important complementary tool in

the treatment of specific phobias (eg

arachnophobia), with clinical-therapeutic purpose.

2 METHODS

Before applying and testing the prototype in

participants with arachnophobia, three phases were

performed: 1) development of the ExPhobia

prototype, 2) usability test and 3) development of an

application protocol; and a phase that is still in

progress which is: 4) intervention. In order to

perform these phases, this research had as

methodological basis the evaluation of programs,

which had been developed to support the future

application of the almost-experimental method.

The evaluation of programs "is about researches

that propose and implement programs to achieve

some positive effect on a group of individuals"

(Cozby, 2003). Within the Program Evaluation,

Rossi et al. (1999) identified five (5) types of

evaluations, namely: 1) needs assessment; 2)

evaluation of the program theory; 3) evaluation of

the process; 4) evaluation of the result and 5)

evaluation of efficiency. The present study aims the

two first evaluations, that is, the needs assessment,

based on an extensive bibliographic research, and

the evaluation of the program theory, covering

usability tests and development of a protocol.

For the future application of the prototype, the

fourth phase aims to use an almost experimental

method (Cozby, 2003) and intends to use a single

subject delineation, in which each participant will be

exposed to an Initial Bond, then the measuring for

the basis line (A), then they will pass through the

Intervention condition (B) and at the end will be

submitted to the new evaluation, in the Final Result

(A) (Sampaio et al., 2008).

For data collection, one (1) Questionnaire will be

used to measure the level of the spider phobia - Fear

of Spiders Questionnaire (FSQ), one (1) Sense

Inventory of Presence (SIP), adapted for Augmented

Reality (RA), one (1) Subjective Units of

Discomfort Scale (WASP), and a portable device to

measure heart rate (Fitbit Alta HR®).

In the initial Baseline (A) the FSQ and SUDS

questionnaire will be applied to understand the level

of phobia of the participant, in addition to exposing

the participant to the equipment that will be used

(Oculus Rift), while collecting the heart rate (Fitbit

Alta HR®) to have a base before the intervention.

The Intervention (B) does not have a necessary

number of steps to be performed per session, always

respecting the participant's time. There will be eight

(8) steps in total and each change from one stage to

the next is already pre-determined. In the final result

- Final Baseline (A) will be the reapplication of the

SUDS, ISP and FSQ tests, being the same of the

beginning of the treatment, for data collection and

comparison between the Baseline and the Final

Result; besides contrasting the data recorded in the

Fitbit Alta HR®, for physiological measurements.

For the statistical analysis of the collected data,

the IBM® SPSS program will be used. It should be

emphasized that the data of the experimental

sessions are the primary data and the questionnaire

data are secondary.

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475

2.1 Procedures

Three (3) phases were developed to achieve the

objectives of this study and one phase is still in

progress.

Phase 1 - Development of the ExPhobia

Prototype: In this first phase, the prototype Exphobia

was developed, based on Interaction Design (Preece

et al., 2015), along with the professionals and

students of each area (Psychology, Computer

Science, Design), whose objective is the treatment of

arachnophobia with use of systematic

desensitization. For this, an extensive bibliographic

review was carried out in databases available on

CAPES (PubMED, Scielo, Web for Science) and

Scholar (scholar.google.com.br) with the descriptors

"phobia", "augmented reality", "Virtual reality",

"exposure therapy" and "systematic desensitization"

and their Portuguese translations, twenty (20)

articles being selected.

The program, which aims the intervention based

on a protocol, was planned to have the inventories

and questionnaires applied in two conditions: pre-

test (baseline - before intervention) and post-test

(final result - after intervention), in addition to

measuring the participant's heart rate throughout the

session's conduction period, using the Fitbit Alta HR

® portable device (smartband), as an objective

measure of the anxiety response, from a

physiological point of view. Based on the research

done and the theoretical basis of the systematic

desensitization technique (Caballo, 1996), the

intervention has eight (8) stages (St) (table 1),

hierarchically pre-defined (a) Size (S) in three (3)

levels: small, medium, and large (S, M and L); b)

Realism (R) in three (3) levels: low (L), medium

(M) and high (H); c) Quantity (Q) of spiders, being

possible to see 1, 5 or 10; d) Movement (M),

whether static (S) or mobile (M).

Table 1: Stages of Systematic Desensitization.

(St) (S)

(R)

(Q)

(M)

1 S L 1 S

2 M L 1 S

3 M L 1 M

4 M M 1 M

5 M H 1 M

6 M H 5 M

7 L H 5 M

8 L H 10 M

* underlined items indicate which variable was changed at

step change.

Phase 2 - Usability Test (Preece et al., 2015 p

341): After the prototype was developed by students

and professionals in Computer Science and Design,

a usability test was performed with ExPhobia, which

consisted in exposing 20 typical users to use the

mobile application of the prototype, measuring their

performance on specific tasks and, at the end of the

test, collecting their impressions in a questionnaire.

Phase 3 - Development of an Application

Protocol: Based on the results of the Usability Test,

an ExPhobia Application Protocol was developed

with the objective of better delineating the use of the

product, aiming at its greater effectiveness.

Phase 4 - Intervention: After the complete

development of the prototype and initial tests, it is

planned to proceed to the intervention phase, which

should evaluate the efficacy of ExPhobia in phobic

participants, through an almost experimental, single

subject study with a design ABA.

2.2 Materials

The materials and tools needed to apply some phases

are:

 ExPhobia: functional prototype that was

developed, for which users can interact and

evaluate. Such a prototype was developed for a

responsive web platform that will pass data

from a psychologist-mediated session to a

mobile application (Android) in which the

patient visualizes the object of specific phobia

in Augmented Reality with the help of Oculus

Rift for better immersion.

 A notebook, where the psychologist controls

and follows the whole process, such as what

the client is seeing at that moment and the

stage that the client is in that session;

 A device with Android developer system (e.g.

smartphone) to use in phobic object exposure

along with Oculus Rift;

 Portable heart-monitoring device (smartband) –

Fitbit Alta HR® to record a type of

physiological change in anxiety scales before

(baseline - pre-test), during and after treatment.

2.2.1 Software

The following platforms were used for the

development of the ExPhobia prototype:

 Blender® (for the modelling of the Spider);

 Unity® (to show the Spider in the mobile

application);

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 Android Studio® (mobile application for the

client);

 Eclipse® IDE (web functions);

 Design of Alternatives: main design activity

that consists of suggesting ideas to satisfy the

requirements.

 Pencil® (for low-fidelity displays, where the

concept and the initial idea of the product are

shown);

 Photoshop® (for high-fidelity screens, which

will look similar to the final product, used for

exploration and testing).

2.2.2 Inventories and Questionnaires

For application within the provisions of the Protocol,

the following inventories and questionnaires are

required:

- Fear of Spiders Questionnaire (FSQ) consists of

eighteen (18) items graded on a Likert scale of seven

(7) points ranging from zero (0 - totally disagree) to

seven (7 - agree totally) for situations related to the

fear of spiders. The total score varies from zero (0)

to one hundred and twenty-six (126), the average of

some studies, such as Botella, Pérez-Ara, Bretón-

López, Quero, García-Palacios, and Baños (2016),

about 89.1 (DP = 19.6);

- Displacement Subjective Units (SUDS) Scale

(Wolpe, 1969) is a scale of 0 to 10 points. The

participant will indicate a reference number to the

level of anxiety / discomfort felt, with larger

numbers indicating a higher level of anxiety and 0

(zero) indicating no discomfort;

- Sensory of Presence Inventory (SPI), adapted

for Augmented Reality (AR), contains 14 statements

that describe sensations related to the augmented

reality in terms of virtual stimuli, non-virtual

environment stimuli, physiological reactions during

the exposure and behaviors presented throughout the

exhibition. Items should be answered on a five-point

Likert scale: "I totally disagree" to "I totally agree."

The punctuation of items 3, 4, 7, 10, 11 and 14 must

be reversed in the correction. The total score

represents the level that the participant feels

involved with Augmented Reality.

3 RESULTS

The results are divided by the phases, aiming a

better explanation of what was reached.

3.1 Phases

3.1.1 Phase 1: The ExPhobia Prototype

Development

The ExPhobia system was idealized and conceived

by a multidisciplinary research team (Computer

Science, Psychology and Communication) of the

University of Fortaleza - Unifor - to be composed of

two applications:

- Mobile application: initially for Android

platform, for serving a significant portion of the

Brazilian population, about 93.2% of the national

market in 2017 (Carvalho, 2017). In the application:

- The psychologist can check the list of patients

with treatment details and obtain information. In

addition, you can allow your patient to use

appropriate glasses to initiate the RA experience

using QR Code for each step of the proposed

desensitization technique.

- Patients can follow their progress in treatment,

obtain information and train completed steps using

specific QR Code for each step already achieved,

provided by the professional, without needing any

other equipment for the RA experience.

- Web application (administrative): used only by

the professional to manage, monitor and configure

the variables of each stage. At each therapy session,

measurements and information for monitoring are

recorded manually, such as: anxiety / fear level;

heart beats; galvanic measurement, and;

observations.

Figure 1 shows the applications and tools that make

up the designed system.

Figure 1: ExPhobia architecture.

The systematic desensitization technique

proposed for the system consists of eight progressive

ExPhobia: A mHealth Technology based on Augmented Reality for Support the Treatment of Arachnophobic Stimulus

477

and gradual steps. For each step, there are variations

of the four configurable variables of the phobic

object in 3D (in this case, spider), being defined as:

 Size: shows the patient's perception of the size

of the phobic object on the screen, being small,

medium or large;

 Realism: shows the patient's perception of how

realistic the phobic object can be, pixelated

(similar to Minecraft game objects), medium-

term or realistic;

 Quantity: one, five or ten phobic objects shown

in the application, and;

 Movement: stopped or not.

The steps can be understood as:

 1st: one small spider, pixelated, stopped;

 2nd: one medium spider, pixelated, without

movement;

 3rd: one medium spider, pixelated and with

movement;

 4th: one medium spider, medium term and with

movement;

 5th: one medium spider, realistic and with

movement;

 6th: five average, realistic and with movement;

 7th: five large, realistic and with movement;

 8th: ten large, realistic and with movement.

Figure 2 shows an example of the image of one of

the steps, accessed by the professional.

Figure 2: Image accessed by the professional.

The Figure 3 shows an example of viewing of one of

the steps, accessed by the professional.

Figure 3: Step accessed by the patient.

The functional prototype of the mobile

application was developed to be accessible from

version 4.4 of the Android platform, KitKat. The

choice of the version was made to suit a large

number of users who, according to the Android

Studio platform, reached approximately 90.9% of

Android devices in November 2017. The prototype

was based on Material Design (a guide to Google's

design recommendations) that allows you to

implement the look of an application in a consistent,

simple and intuitive way (Lecheta, 2016).

3.1.2 Phase 2: Usabilty Test

With the functional prototype ready, it was possible

to perform usability tests of the mobile application.

For the patient's vision of the application, tests were

performed with 20 users (1 woman and 19 men), of

university level and adults. Of these participants,

30% knew the application, but never interacted

directly with it before the tests.

In the view of the professional, tests were carried

out with 10 users (8 women and 2 men), university

level, adults, from the psychology area who did not

know the application. Phobics were not invited for

usability tests, since the purpose of the tests is to

evaluate the usability of the technological artifact,

that is, technical questions of the technology.

Some results recorded were: 1) in the

accomplishment of tasks, some participants had

doubts because they did not know terms of the

health area; 2) as to the ease of starting and using the

augmented reality experience, the majority (55%)

had no difficulties; 3) As for the level of realism of

the spider, it has been that 7 people (35%) voted in,

between zero and five, being zero unreal and five

very real, five.

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3.1.3 Phase 3 – Development of an

Application Protocol

In order for the intervention to be carried out in a

correct and standardized manner, an application

protocol has been established which presupposes:

Initial Link: The patient will enter the application

room and will explain how the program works,

presenting the project, the objectives, the procedure

and then the interested participants and that fit the

criteria of inclusion must sign the Term of Consent

Free and Informed (TCFI).

APPLICATION

Preliminary Baseline (A):

First, the FSQ and SUDS questionnaires will be

applied to understand the level of phobia of the

participant.

After that, the patient will be presented and

experiment the Oculus Rift to know the tool and the

scenario, but without the phobic stimulus (spider in

augmented reality).

During the presentation the patient will be

connected to the Fitbit Alta HR® device to heart rate

monitoring. The heart rate data will be collected 40

seconds before the start of the session and will

continue for another 40 seconds after the end of the

session, so that the physiological data can be

measured throughout the process. The objective is to

measure the data before the intervention in order to

effectively compare the variation during the session,

reducing the probability of foreign variables.

Intervention (B):

There are no pre-determined number of sessions

in the intervention, varying according to each

patient's response.

Each session has 8 stages (previously defined

hierarchically), already mentioned before. Each

stage will have 3 equal repetitions of exposure (1-

adaptive, 2- real, 3-confirmatory) of 20 seconds,

with an interval of 1 minute between one exposure

and another and 1 minute for other issues

(equipment setting, some necessary break), totaling

about 5 minutes.

Every new stage requires a baseline (BL per

stage), which refers to: 1) the patient will be asked if

he feels comfortable moving to the next stage. If

'yes', the patient goes to the next stage after 5

minutes (interval between one stage and another); If

‘no', there will be a 5 minute stop, the equipment

will be removed and there will be some relaxation

exercise, after the procedure, the question will be

redone and, if it persists, there is the postponement

or end of the intervention; 2) The heart rate will be

checked, if it is above 120bpm, it will be

recommended to repeat the stage or pause the

intervention; 3) Application of the SUDS discomfort

level scale (range ranging from 0-10).

Throughout the procedure, the patient may want

to stop the stimulus to the phobic object and, for

this, it will be agreed that it is sufficient to raise the

hand that, immediately, the exposure will be

suspended. Raising the hand is the escape for the

exposed patient.

Final Baseline (A):

After the intervention, the ISP tests will be

applied (applied only in this phase, since it is the

assessment of immersion to the prototype), SUDS

and FSQ, these being the same as the beginning of

the treatment, for data collection and comparison

between the Baseline and the Final Result; in

addition to contrasting the heart rate data recorded in

the Fitbit Alta HR®, for physiological

measurements.

ENVIROMENT

The psychologist must have a closed room to avoid

strange noises and contact with uncontrolled

variables;

- Table to support the QRcode, which should be

printed in a minimum size of 20x20cm on an acrylic

plate;

- Chair for the patient;

- The distance between the QRcode and the

patient, who will be seated, should be 1 meter;

- The QRcode should be located in front of the

patient under his direct sight, without him having to

lower or raise his head so that he can have access to

the phobic stimulus.

CLOSING

Each stage, if carried out without difficulties, has a

forecast of 5 minutes;

- Between one stage and another, if there are no

problems, there will be a break of 5 minutes;

- If there is no difficulty during the entire

intervention (exposure to the 8 steps previously

defined), the process ends in approximately 2 hours.

3.1.4 Phase 4: Intervention

This last phase is under development, however, it is

hypothesized that the use of augmented reality as a

tool to the technique of systematic desensitization,

from an analytic-behavioral perspective, elicits

ExPhobia: A mHealth Technology based on Augmented Reality for Support the Treatment of Arachnophobic Stimulus

479

positive and viable results for the treatment of

specific phobias, assumptions, given the research

conducted, as well as the various tests and protocol

established for application, that when applied to

phobic participants, the effects will be favorable.

The intervention is, in fact, the application of

ExPhobia as proposed by the Phase 3 protocol, with

the proposal to develop a research, as previously

mentioned in the methodology, which covers the

almost experimental, single subject, and ABA,

searching for relevant data and comparing, in fact,

between preintervention and postintervention.

4 CONCLUSIONS

The current paper is a tangible result of the junction

between health and technology, aiming the treatment

for the phobia of spiders (arachnophobia). The

developed prototype has as final focus the

improvement of the life quality of the participants,

but it also aims the psychologist who will work with

the technology, providing new ways of treatment.

It is understood, therefore, that new technologies,

such as augmented reality, can be combined with

health treatments; facilitating procedures or

expanding techniques.

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