DEPRESSION AND ANXIETY 22:156–158 (2005)

Brief Report

COGNITIVE BEHAVIORAL THERAPY FORPUBLIC-SPEAKING ANXIETY USING VIRTUAL REALITY

FOR EXPOSURE

Page L. Anderson, Ph.D.,1� Elana Zimand, Ph.D.,2 Larry F. Hodges, Ph.D.,3 and Barbara O. Rothbaum, Ph.D.4

This study used an open clinical trial to test a cognitive-behavioral treatment forpublic-speaking anxiety that utilized virtual reality as a tool for exposuretherapy. Treatment was completed by participants (n 5 10) meeting theDiagnostic and Statistical Manual of Mental Disorders (DSM)-IV criteria forsocial phobia, or panic disorder with agoraphobia in which public speaking wasthe predominantly feared stimulus. Treatment was conducted by a licensedpsychologist in an outpatient clinic. Treatment consisted of eight individualtherapy sessions, including four sessions of anxiety management training andfour sessions of exposure therapy using a virtual audience, according to astandardized treatment manual. Participants completed standardized self-report questionnaires assessing public-speaking anxiety at pre-treatment, post-treatment, and 3-month follow-up. Participants were asked to give a speech toan actual audience at pre- and post-treatment. Results showed decreases on allself-report measures of public-speaking anxiety from pre- to post-treatment,which were maintained at follow-up (n 5 8; all Po.05). Participants were nomore likely to complete a speech post-treatment than at pre-treatment. Thisstudy provides preliminary evidence that a cognitive-behavioral treatment usingvirtual reality for exposure to public speaking may reduce public-speakinganxiety and suggests that further research with a controlled design is needed.Depression and Anxiety 22:156–158, 2005. & 2005 Wiley-Liss, Inc.

Key words: public-speaking anxiety; cognitive behavior therapy; virtualreality; treatment

INTRODUCTIONFear of public speaking (FOPS) is common andconsequential in clinical samples [Mannuzza et al,1995] and in general; one community study found thatFOPS was associated with lower income, decreasededucation, and increased unemployment [Stein et al.,1994].

Cognitive-behavioral therapy (CBT) is effective fortreatment of social phobia, with good long-termfollow-up [Fava et al., 2001]. Exposure to public-speaking fears is feasible in group therapy [e.g.,Heimberg et al., 1990]; however, if groups are notavailable or patients are unwilling, arranging andconducting exposure is challenging [Butler, 1985].Common barriers to treatment include uncertaintyover where to go and fear of what others might think

Published online 17 October 2005 in Wiley InterScience (www.

interscience.wiley.com).

DOI 10.1002/da.20090

Received for publication 28 December 2004; Revised 25 May

2005; Accepted 15 June 2005

Contract Grant sponsor: National Institutes of Mental Health;

Grant number: R41 MH60506-01.

�Correspondence to: Page Anderson, Ph.D., Department of

Psychology, Georgia State University, P.O. Box 5010, Atlanta,

GA 30302-5010. E-mail: panderson@gsu.edu

1Georgia State University, Atlanta, Georgia2Virtually Better, Decatur, Georgia3University of North Carolina–Charlotte, Charlotte, North

Carolina4Emory University School of Medicine, Atlanta, Georgia

rr 2005 Wiley-Liss, Inc.

[Olfson et al., 2000], so alternative treatments mayimprove treatment utilization among social phobics.

Virtual reality (VR) technology may offer an alter-native for exposure therapy for FOPS. Two controlledstudies support the use of VR in treating specificphobias (heights and flying) with good long-termfollow-up [Emmelkamp et al., 2002; Rothbaum et al.,2000, 2002]. Using VR to treat FOPS is a greaterchallenge, as it must elicit an interpersonal fear. Twocase studies utilizing VR for FOPS treatment showedclinical improvement [Anderson et al., 2003].

The current study describes an open clinical trialusing a treatment manual, homogenous inclusion/exclusion criteria, independent assessment, and abehavioral avoidance test to examine a treatment forFOPS that uses VR for exposure (VRE). The studyprotocol and informed consent process was approvedand monitored by Emory University’s InstitutionalReview Board.

SUBJECTS AND METHODSThe sample (n 5 10) was predominantly female

(80%), married (90%), well-educated (mean years ofeducation 5 17), and middle-to-upper class (90%).Participants self-identified as either Caucasian (70%)or African-American (30%). All participants met currentcriteria for social phobia (n 5 8) or panic disorder withagoraphobia (n 5 2), in which public speaking was thepredominantly feared stimulus, as determined by theStructured Clinical Interview for the Diagnostic andStatistical Manual of Mental Disorders (DSM)-IV(SCID) [First et al., 1995]. Most (70%) met criteriafor another anxiety disorder (specific phobia, n 5 4;generalized anxiety disorder, n 5 2; posttraumatic stressdisorder, n 5 1). The SCID was administered by alicensed psychologist not involved with treatment; asecond psychologist rated half of the interviews, with100% agreement for the primary diagnosis.

Self-report measures with adequate reliability andvalidity were used, including the Personal Report ofConfidence as a Speaker [Paul, 1966], Personal Reportof Communication Apprehension [McCroskey, 1978],and Self-Statements During Public Speaking, positive

and negative subscales [Hofmann and DiBartolo,2000]. Client ratings of improvement were assessedusing the Clinical Global Improvement–Patient Ratingscale [Guy, 1976].

Participants were asked to give a speech to anaudience (n 5 5–9) based on a standardized behavioralavoidance test (BAT) [Beidel et al., 1989] before andafter treatment. Audience members rated the patients’level of anxiety and performance on a scale of 0–10, withhigher numbers indicating higher anxiety and betterperformance. Participants who did not complete theBAT before treatment (n 5 4) did so during Session 1 infront of the therapist and videocamera to equalizepractice effects across participants at post-treatment andto use the video as a part of treatment. Participants gavespeeches on different topics at each assessment point.

Participants received individual treatment for eightsessions according to a treatment manual. Treatmentconsisted of four sessions of anxiety managementtraining (breathing retraining, cognitive restructuring,and behavioral experiments to challenge cognitions)followed by four sessions of VRE. During VRE, theparticipant wore a head-mounted display that presenteda computer-generated environment including a virtualpodium, upon which the text of their speech may bedownloaded. A virtual curtain opened to show either 5people around a conference table or of 22 people in anauditorium. The audience consisted of high-resolutiondigital video of actual people embedded within thevirtual environment. During exposure therapy, thetherapist controlled the audience’s reactions (e.g.,interested, bored, applause), communicated with thepatient via a microphone, and encouraged therapeuticexposure to feared situations according to a fearhierarchy developed for each person.

RESULTSRepeated-measures analysis of variance (ANOVA)

was used to compare baseline scores to post-treatmentand follow-up. Scores on all FOPS measures improvedsignificantly from pre- to post-treatment and thesegains were maintained at follow-up (Table 1). Therewere no differences between scores between post-

TABLE 1. Mean scores at pre-, and post-treatment, and 3-month follow-upy

Questionnaire Pre-treatment Post-treatment 3-month follow-up

Public-speaking fearsPRCS 21.40 (5.89) 12.00�� (6.32) 13.00�� (5.41)SSPS-positive 9.40 (5.32) 15.40� (4.88) 15.50�� (6.23)SSPS-negative 15.80 (5.37) 8.30�� (5.10) 8.50�� (6.05)PRCA 36.30 (9.97) 27.20�� (5.49) 28.13� (10.19)

yMean scores are presented for the all available data at pre-treatment (n 5 10), post-treatment (n 5 10), and follow-up (n 5 8). Standard deviationsfor mean scores are in parentheses. PCRS, Personal Report of Confidence as a Speaker. SSPS, Self-Statements during Public Speaking; PRCA,Personal Report of Communication Apprehension.�Po.05; ��Po.01. Statistical differences are based on repeated-measures ANOVA, with Bonferroni correction for the pre–post comparison (basedon n 5 10) and the pre–follow-up comparison (based on n 5 8).

157Brief Report: Public-Speaking Anxiety and Virtual Reality

treatment and follow-up. Effect sizes (Cohen’s d) forFOPS measures were large at post-treatment (1.1–1.5)and at 3-month follow-up (0.8–1.5).

Defining treatment response as a 30% reduction onFOPS measures, most participants improved on at leasthalf the measures at post-treatment (80%) and follow-up (75%).

The percentage of participants who completed theBAT did not change from pre- (60%) to post-treatment(70%; w2 [1] 5 .18, P 5 67). Among participants whocompleted the pre- and post-BAT (n 5 4), audiencemembers rated them as performing better (pre 5 6.62;post 5 8.45) and less anxious (pre 5 6.06; post 5 2.88)at post-treatment, relative to pre-treatment (all Po.05).

At post-treatment, all participants reported that theyfelt improved ‘‘very much’’ (n 5 1), ‘‘much’’ (n 5 7), or‘‘minimally’’ (n 5 2). Participants said the quality ofservice was ‘‘excellent’’ (n 5 9) or ‘‘good’’ (n 5 1), andwere ‘‘extremely’’ (n 5 10) satisfied.

Finally, pre- and post-treatment scores on the PRCSand SSPS in the current study are comparable to pre-and post-treatment scores from another 8-week beha-vioral treatment of public-speaking fears [Newmanet al., 1994].

DISCUSSIONCBT using VR for exposure may reduce FOPS.

Participants showed significant improvement on self-report measures, were satisfied with treatment, andmaintained gains at follow-up. There was no differ-ence, however, on BAT participation, which is criticalas self-reported changes should be related to real-worldbehavioral changes. Qualitative feedback suggests therewere real-life changes after treatment; one patientinterviewed and accepted a job as a teacher, andanother took a leadership role in an organizationrequiring public speaking.

These results are encouraging but quite preliminary.Future studies should compare VRE to a control groupand should not include individuals whose primarydiagnosis is panic disorder. Addition of physiologicalmonitoring would improve the assessment. Futurework could isolate the effect of VR on treatmentresponse. These findings extend past work using VREfor treatment of specific phobia with powerful physicalcues (e.g., heights, flying), and suggest that VR mayalso be a potent interpersonal stimulus. If replicated incontrolled trials, the use of VR as an interpersonalstimulus extends its potential mental health applica-tions. Disadvantages include cost and the inability ofthe VR to match the idiosyncratic fears or elicit anxietyfor some patients. Potential advantages of VRE includegreater control, convenience, confidentiality, and per-haps patient acceptance.

Acknowledgments. This study was supported bythe National Institutes of Mental Health, Washington,DC (grant R41 MH60506-01 to L.H.).

DISCLOSURE OF INTERESTS AND AF-FILIATIONS. Drs. Rothbaum and Hodges receiveresearch funding and are entitled to sales royalty fromVirtually Better, Inc., which is developing productsrelated to the research described in this article. Inaddition, the investigators serve as consultants to andown equity in Virtually Better, Inc. The terms of thisarrangement have been reviewed and approved byEmory University and Georgia Institute of Technologyin accordance with its conflict of interest policies.

REFERENCESAnderson P, Rothbaum BO, Hodges LF. 2003. Virtual reality in the

treatment of social anxiety: two case reports. Cogn Behav Pract10:240–247.

Beidel DC, Turner SM, Jacob RG, Cooley MC. 1989. Assessment ofsocial phobia: reliability of an impromptu speech task. J AnxietyDisord 3:149–158.

Butler G. 1985. Exposure as a treatment for social phobia: someinstructive difficulties. Behav Res Ther 23:651–657.

Emmelkamp PM, Krijin M, Hulsbosch L, de Vries S, Schuemie MJ,van der Mast CA. 2002. Virtual reality treatment versus exposure invivo: a comparative evaluation in acrophobia. Behav Res Ther40:509–516.

Fava GA, Grandi S, Ranfanelli C, Runni, Conti C, Belluardo S. 2001.Long-term outcome of social phobia treated by exposure. PsycholMed 31:899–905.

First MB, Spitzer RL, Gibbon M, Williams JB. 1995. StructuredClinical Interview for DSM-IV Axis I Disorders–Patient Edition(SCID). New York: Biometrics Research Dept., New York StatePsychiatric Institute, Biometrics Institute.

Guy W. 1976. ECDEU Assessment Manual for Psychotherapy–Re-vised (DHEW Publication No. ADM 76-338). Bethesda, MD:National Institute of Mental Health. p 217–222.

Heimberg RG, Dodge CS, Hope DA, Kennedy CR, Zollo L, BeckerRE. 1990. Cognitive behavioral treatment of social phobia:comparison to a credible placebo control. Cogn Ther Res 14:1–23.

Hofmann SG, DiBartolo PM. 2000. An instrument to assessself-statements during public speaking: scale developmentand preliminary psychometric properties. Behav Ther 31:499–515.

Mannuzza S, Schneider FR, Chapman TF, Liebowitz MR, Klein DF,Fyer AJ. 1995. Generalized social phobia: reliability and validity.Arch Gen Psychiatry 52:230–237.

McCroskey JC. 1978. Validity of the PRCA as an index of oralcommunication apprehension. Commun Monogr 45:192–203.

Newman D, Hofmann SG, Trabert W, Roth WT, Taylor CB. 1994.Does behavioural treatment of social phobia lead to cognitivechanges? Behav Ther 25:503–517.

Olfson M, Guardino M, Struening E, Schneier FR, Hellman F, KleinDF. 2000. Barriers to the treatment of social anxiety. Am JPsychiatry 157:521–527.

Paul G. 1966. Insight vs. desensitization in psychotherapy. Stanford,CA: Stanford University Press.

Rothbaum BO, Hodges LF, Smith S, Lee JH, Price L. 2000. Acontrolled study of virtual reality exposure therapy for the fear offlying. J Consult Clin Psychol 68:1020–1026.

Rothbaum BO, Hodges LF, Anderson P, Smith S, Lee JH, Price L.2002. 12-month follow-up of virtual reality and standard exposuretherapies for the fear of flying. J Consult Clin Psychol 70:428–432.

Stein MB, Walker JR, Forde DR. 1994. Public-speaking fears in acommunity sample. Prevalence, impact on functioning, anddiagnostic classification. Arch Gen Psychiatry 53:169–174.

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