Self-Guided Virtual-Reality Exposure Therapy For Social Anxiety

Exposure therapy is a cognitive-behavioral treatment that involves gradually confronting feared stimuli to reduce anxiety. For social anxiety, this may include speaking in front of others or attending social events.

While exposure therapy is effective for social anxiety, many individuals may be reluctant to seek in-person treatment due to fear of social situations or stigma.

Self-guided or virtual reality exposure therapy (VRET) offers a promising alternative by allowing individuals to practice exposures in a controlled, private setting at their own pace.

By providing a safe and accessible way to challenge fears, self-guided exposure and VRET may increase treatment engagement and effectiveness for social anxiety.

Premkumar, P., Heym, N., Brown, D. J., Battersby, S., Sumich, A., Huntington, B., Daly, R., & Zysk, E. (2021). The effectiveness of self-guided virtual-reality exposure therapy for public-speaking anxiety. Frontiers in psychiatry, 12, 694610. https://doi.org/10.3389/fpsyt.2021.694610

Key Points

1. The main findings of this study on self-guided virtual reality exposure therapy (VRET) for public speaking anxiety (PSA) are:

• Participants gradually increased their exposure to virtual social threats like audience size, audience reaction, and self-salience during the self-guided VRET sessions.
• This increased exposure led to reductions in anxiety, arousal, and heart rate within the virtual environment.
• Self-guided VRET improved PSA post-treatment and at 1-month follow-up.
• In-session anxiety reduction correlated with improvements in fear of negative evaluation post-treatment and at follow-up.

2. While the study provides promising evidence for the feasibility and effectiveness of self-guided VRET for PSA, it has certain limitations, such as lacking a control group and having a predominantly subclinical sample.
3. The research highlights the potential of self-guided VRET as an accessible and efficacious intervention for individuals with PSA.

Rationale

Public speaking anxiety (PSA) is a common variant of social anxiety disorder that affects up to 77% of the general population (Fumark et al., 1999) and impairs academic and occupational functioning (Beidel & Turner, 2007).

Cognitive-behavioral therapy with exposure is the most evidenced treatment for social anxiety (Kaplan et al., 2018), but many individuals do not seek treatment due to fear of social situations (Chartier-Otis et al., 2010).

Virtual reality exposure therapy (VRET) offers a promising solution by allowing individuals to encounter social threats in a controlled virtual environment (Botella et al., 2017).

While therapist-led VRET has shown efficacy for social anxiety (Carl et al., 2019), self-guided VRET is an emerging advance that could enhance treatment accessibility and engagement (Lindner, 2020).

This study aimed to test the feasibility of self-guided VRET for PSA by examining whether it enables gradual exposure to virtual social threats, reduces anxiety and arousal, and improves PSA outcomes.

Method

Procedure

This pilot study involved 32 university students with high self-reported PSA attending two weekly self-guided VRET sessions.

Each session required participants to deliver a 20-minute speech in a virtual classroom, divided into four 5-minute blocks.

During 1-minute intervals between blocks, participants could manipulate their exposure to virtual social threats, including audience size, audience reaction, number of speech prompts, and self-salience.

Sample

Participants (27 completers) were predominantly female (84.4%), Caucasian (84.4%), and undergraduate students (87.5%) with a mean age of 21.4 years. Most (84%) had never been diagnosed with social anxiety disorder.

Measures

• Speech Anxiety Thoughts Inventory (SATI): The SATI is a 23-item self-report questionnaire that assesses negative thoughts related to speech anxiety, such as prediction of poor performance and fear of negative evaluation by the audience.
• Public Speaking Anxiety Scale (PSAS): The PSAS is a 17-item scale that measures the cognitive, behavioral, and physiological dimensions of public speaking anxiety, with items rated on a 5-point scale.
• Personal Report of Confidence as a Speaker—Short Form (PRCS-SF): The PRCS-SF is a 12-item self-report measure that evaluates an individual’s behavioral and affective responses to public speaking situations, with items scored as either “true” or “false.”
• Liebowitz Social Anxiety Scale (LSAS): The LSAS is a 24-item clinician-administered scale that assesses fear and avoidance of social interaction and performance situations, providing subscale scores for each domain.
• Brief Fear of Negative Evaluation Scale (BFNE): The BFNE is a 12-item self-report questionnaire that measures apprehension and distress related to perceived negative evaluation from others, which is a core feature of social anxiety.
• Subjective Units of Distress Scale (SUDS) for anxiety and arousal: The SUDS is a self-reported rating scale, typically ranging from 0 to 100, that quantifies an individual’s subjective experience of anxiety and arousal in real-time, with higher scores indicating greater distress or physiological activation.
• Heart rate was also measured.

Statistical Analysis

Repeated measures ANOVAs examined changes in exposure levels, anxiety, arousal, heart rate, and PSA measures over time.

Correlations assessed relationships between in-session anxiety reduction and PSA outcomes.

Results

As hypothesized, participants gradually increased their exposure to audience size, audience reaction, and self-salience within and across the two VRET sessions (p < .005).

This increased exposure coincided with significant reductions in anxiety (p < .001), arousal (p = .003), and heart rate (p = .002) during the sessions.

PSA measures (SATI, PSAS, PRCS-SF, LSAS, BFNE) showed significant improvements from pre-treatment to post-treatment and 1-month follow-up (p < .005).

Greater in-session anxiety reduction correlated with larger improvements in fear of negative evaluation post-treatment (r = .40) and at follow-up (r = .44).

Insight

This study provides initial evidence that self-guided VRET is a feasible and potentially effective intervention for PSA.

By enabling individuals to gradually expose themselves to fear-provoking virtual social threats, self-guided VRET may help them habituate to anxiety and challenge irrational beliefs in a controlled manner.

The findings extend previous research on therapist-led VRET for social anxiety (Kampmann et al., 2016) by demonstrating that individuals with PSA can tolerate and benefit from self-paced virtual exposure.

Importantly, the correlation between in-session anxiety reduction and improved fear of negative evaluation suggests a potential mechanism of change.

Future research could compare self-guided to therapist-led VRET, examine longer-term outcomes, and explore mediating factors like perceived control and self-efficacy.

Strengths

This study had some many methodological strengths, including:

• Novel investigation of self-guided VRET for PSA
• Inclusion of both subjective and physiological measures of anxiety and arousal
• Assessment of short-term and 1-month follow-up outcomes
• Examination of correlations between process and outcome variables

Limitations

However, this study also had some limitations, including;

• Lack of a control group, preventing conclusions about causality
• Small, predominantly female and Caucasian sample, limiting generalizability
• Predominantly subclinical sample, requiring replication in clinical populations
• Short follow-up period, necessitating examination of longer-term effects

Implications

The positive findings support the potential of self-guided VRET as a feasible and efficacious intervention for PSA.

By enabling self-paced exposure to virtual social threats, self-guided VRET may provide an accessible and engaging option for individuals reluctant to seek traditional treatment.

Clinically, self-guided VRET could be a valuable adjunct to therapist-led exposure therapy, allowing patients to practice skills between sessions.

However, the limited follow-up period and subclinical sample underscore the need for further research in clinical populations with long-term follow-up assessments.

Consideration of individual differences like perceived control and self-efficacy may help optimize self-guided VRET protocols.

Overall, this study highlights the promise of self-guided VRET as an innovative approach to treating PSA and lays the groundwork for future clinical applications.

References

Beidel, D. C., & Turner, S. M. (2007). Shy children, phobic adults: Nature and treatment of social anxiety disorder (2nd ed.). American Psychological Association. https://doi.org/10.1037/11533-000

Botella, C., Fernández-Álvarez, J., Guillén, V., García-Palacio, A., & Baños, R. (2017). Recent progress in virtual reality exposure therapy for phobias: a systematic review. Current Psychiatry Reports, 19(7), 42. https://doi.org/10.1007/s11920-017-0788-4

Carl, E., Stein, A. T., Levihn-Coon, A., Pogue, J. R., Rothbaum, B., Emmelkamp, P., Asmundson, G., Carlbring, P., & Powers, M. B. (2019). Virtual reality exposure therapy for anxiety and related disorders: A meta-analysis of randomized controlled trials. Journal of Anxiety Disorders, 61, 27-36. https://doi.org/10.1016/j.janxdis.2018.08.003

Chartier-Otis, M., Perreault, M., & Bélanger, C. (2010). Determinants of barriers to treatment for anxiety disorders. Psychiatric Quarterly, 81(2), 127-138. https://doi.org/10.1007/s11126-010-9123-5

Furmark, T., Tillfors, M., Everz, P. O., Marteinsdottir, I., Gefvert, O., & Fredrikson, M. (1999). Social phobia in the general population: prevalence and sociodemographic profile. Social psychiatry and psychiatric epidemiology, 34, 416-424. https://doi.org/10.1007/s001270050163

Kampmann, I. L., Emmelkamp, P. M., Hartanto, D., Brinkman, W. P., Zijlstra, B. J., & Morina, N. (2016). Exposure to virtual social interactions in the treatment of social anxiety disorder: A randomized controlled trial. Behaviour Research and Therapy, 77, 147-156. https://doi.org/10.1016/j.brat.2015.12.016

Kaplan, S. C., Swee, M., & Heimberg, R. G. (2018). Psychological treatments for social anxiety disorder. In G. Conway (Ed.), Oxford Research Encyclopedia of Psychology. Oxford University Press. https://doi.org/10.1093/acrefore/9780190236557.013.98

Lindner, P. (2020). Better, virtually: the past, present, and future of virtual reality cognitive behavior therapy. International Journal of Cognitive Therapy. https://doi.org/10.1007/s41811-020-00090-7

Keep Learning

Here are some reflective questions related to this study that could prompt further discussion:

1. How might the self-guided nature of the VRET protocol influence its acceptability and effectiveness compared to therapist-led VRET? What factors could moderate this relationship?
2. What are some potential mechanisms of change in self-guided VRET for PSA (e.g., perceived control, self-efficacy, habituation)? How could future studies measure and analyze these mechanisms?
3. How could self-guided VRET be integrated into traditional cognitive-behavioral therapy for social anxiety disorder? What are the benefits and challenges of a combined approach?
4. What technological advancements might enhance the realism and efficacy of VRET for PSA (e.g., real-time physiological feedback, personalized virtual audiences)? How could these be tested empirically?
5. How might individual differences (e.g., baseline anxiety severity, motivation for change, technophobia) influence engagement with and response to self-guided VRET? What screening or tailoring strategies could optimize treatment outcomes?