Isr J Psychiatry Relat Sci - Vol. 48 - No. 2 (2011) HELENE S. Wallach ET AL. Virtual Reality Exposure versus Cognitive Restructuring for Treatment of Public Speaking Anxiety: A Pilot Study Helene S. Wallach, PhD, 1 Marilyn P. Safir, PhD, 1 and Margalit Bar-Zvi, MD2 1 Department of Psychology, University of Haifa, Haifa, Israel 2 Out-Patient Psychiatry, Ziv Hospital, Safed, Israel The gold standard treatment for phobias is Cognitive ABSTRACT Behavior Therapy (CBT) which combines both behav- Objectives: To determine the utility of Virtual Reality ioral and cognitive elements (1-4). Although numerous Exposure Therapy (VRE) in comparison with Cognitive studies have been conducted to examine the necessity Therapy (CT) and with Cognitive-Behavior Therapy (CBT). of employing both cognitive and behavioral elements in therapy, it remains unclear whether it is sufficient to Method: Subjects suffering from public speaking anxiety deliver cognitive therapy (CT) alone, behavior therapy (PSA) were randomly allocated to VRE and CT, and (BT) alone or if both need to be employed (5-8). In received 12 therapy sessions, employing standardized recent years, Virtual Reality Exposure (VRE) has been treatment manuals. Outcome (questionnaires, observer utilized for the BT (exposure) component of CBT. and self ratings of a behavioral task) was compared to Therefore, for this pilot study, we compared VRE to CT results of subjects in a previous study CBT and Wait in an attempt to examine the relative efficacy of each List Controls who were not significantly different on component independently, and in comparison with the demographic data. combined treatment. Results: CT was not superior to VRE on cognitive measures, but was superior to VRE on one behavioral SOCIAL PHObias measure (LSAS fear). VRE was superior to CT on one Social phobia is defined as a fear of and desire to avoid behavioral measure (fear reduction on a behavioral a situation in which the individual may come under task). No differences were found between either TC , or scrutiny by others and fears he/she may act in ways that VRE, and CBT and all were superior to WL. may be humiliating or embarrassing (9). Social phobia affects school performance, ability to create social net- Limitations: Subject group was small and homogeneous. works and intimate relationships as well as work perfor- It appeared advisable to increase number of therapy mance, is the most common anxiety disorder, and the sessions. third most common psychiatric disorder (10, 11). In the Conclusions: VRE and CT proved to be equally effective present study we focused on a non-generalized social to CBT in reducing PSA relative to a control group, with phobia - public speaking anxiety. Public speaking anxi- minimal differential effects between them. Therefore, ety (PSA) is the most common social phobia, afflicting employing either one may be satisfactory and sufficient. 40% of all those who suffer from social phobia (11). VirtUAL REALITY EXPOSURe (VRE) foR SOCIAL PHOBIA Exposure is presumed to extinguish maladaptive con- ditioning (phobic object = fear) through anxiety reduc- tion, and to shape new conditioned responses (neutral or adaptive responses to the formally phobic object). Address for Correspondence: Helene S. Wallach PhD, Department of Psychology, University of Haifa, Haifa, 31905, Israel [email protected] 91 VIRTual REALITY EXPOSURE VERSUS COGNITIVE RESTRUCTURING This occurs as the client experiences both a reduction compare VRE to both CT and to the gold standard in anxiety during the exposure (habituation) and the treatment for PSA, namely CBT. absence of the catastrophic event he/she anticipated (extinction) (1, 12, 13). VR is defined as a situation in which sensory information is generated by a com- METHODS AND EXPERIMENtaL DESIGN puter rather than by the natural environment (e.g., 14). ParticipaNTS During the exposure stage in VR, the client puts on a Twenty subjects who suffered from PSA were recruited helmet which is connected to a computer. The helmet for this study. Candidates suffering from a psychotic provides both visual and audio input. The therapist disorder, drug or alcohol abuse, or epilepsy, or who were employs a special computer program enabling her/ in psychotherapy for this problem, or were taking psy- him to change various elements in the virtual environ- chotropic medication were excluded. Epilepsy may be ment, thus providing the client with gradual exposure aggravated by the use of VR, and therefore this served to aversive stimuli. The therapist views exactly what the as an exclusion criteria. Subjects were young (average client views in the helmet, on the computer screen. The age 28), were mostly Jewish (85%) and single (75%) client’s head movements change the environment, just (Table 1). In addition, their results were compared with as they would in the real world, hence increasing the data from a recent study that employed CBT (28 par- sense of immersion. The therapist monitors the client’s ticipants) for PSA using similar protocols and a wait list Subjective Units of Discomfort (SUD) and thus con- control (WL) (30 participants) condition (16). Subjects trols the fear level of the environment. Thus, VRE is in the previous study were also primarily Jewish (89%, superior to conventional exposure for people who have 90%), young (average age 28, 25) and single (75%, 93%) difficulty imagining situations vividly, for those who and not significantly different on these variables from avoid remaining in the imagined fearful situation, and the subjects in the present study (Table 1). for those who are unable to control their imagination and flood themselves with higher levels of anxiety than Table 1. Demographic Variables are produced by the hierarchy. In addition, the drop-out Family rate from VRE has been found to be much lower than situation Age Sex Single Ethnicity the drop-out rate from traditional BT (15, 16). N M Sd M F Other Maj.a Min.b VRE 10 27.50 7.85 5 5 9 1 8 2 COGNITIVE THErapy FOR SOCIAL PHOBIA CT 10 28.11 1.69 4 6 6 4 9 1 Cognitive factors are especially obvious in social phobia CBT 28 28.18 7.97 5 23 21 7 25 3 (6, 17, 18). Socially anxious individuals over-estimate WL 30 25.29 2.62 9 21 28 2 27 3 the threat of public criticism, scrutiny or embarrassment (17). They also have negative and distorted images of how Note. aMaj=Majority; bMin=Minority others view them (19, 20). In addition, clients exagger- ate the “social cost” of their performance (21). This leads MEasURES to the perception of social situations as dangerous, to an 1. Liebowitz Social Anxiety Scale (LSAS) (26) includes increase in anxiety relevant physical sensations when 24 questions. For each question, the participant rates encountering feared situations, to hyper vigilance to the the amount of fear experienced (answered on a 4-point environment and to bodily sensations and to avoidance Likert scale from 0 – “not at all” to 3 – “very much”) of feared social situations or the use of “safety” behav- and the amount of avoidance experienced (rated on a iors. Therefore, faulty cognitions develop, maintain and 4-point Likert scale from 0 – “never, 0%” to 3 – “usually, increase social phobia (18, 20). However, therapy that 68%-100%”). This scale has high reliability (Cronbach α challenges these cognitions was found to be beneficial .90-.95). It also has good validity (high correlations with and crucial in the treatment of PSA (2, 22, 23). other anxiety measures, e.g., Social Interaction Anxiety Scale – fear scale .72, avoidance scale .68; Social Phobia COGNITIVe-BehaviOR THErapy FOR PHObias Scale – fear scale .64, avoidance scale .59). The combination of Cognitive and Behavior Therapies 2. Self Statements During Public Speaking (SSPS) (27). (CBT) has been reported to be the treatment of choice This 10-item measure assesses fearful thoughts dur- for phobias (e.g., 23-25). Thus this pilot attempted to ing public speaking. It consists of two subscales: posi- 92 HELENE S. Wallach ET AL. tive and negative self-statements. This scale has high our subjects met the formal criterion for PSA. However, reliability (.78-0.80 & .80-.86, respectively). It also they volunteered for this study, reporting that they suf- has good validity (discriminates between social pho- fered from PSA, and would like treatment. Additionally bics and the general population; correlates with other their pre-therapy scores were similar to those of indi- anxiety scales: e.g., Personal Report of Confidence as viduals suffering from social phobia in previous stud- a Speaker .67; Fear of Negative Evaluation .49; Social ies. For example, mean LSAS Fear scores ranged from Phobia and Anxiety Inventory .48. For the positive 28.18-34.80 in this study which is higher than mean scale, higher scores indicate less anxiety. scores found in a previous studies (18.92 and 24.9), 3. Fear of Negative Evaluation (FNE) (28) includes 30 mean LSAS Avoidance scores ranged from 24.46-27.97 yes/no questions. The questions relate to cognitive in this study which is also higher than 18.20 and 16.7 aspects of the phobic experience – fear of criticism found in a previous studies (29, 30). Mean FNE scores or negative evaluation. FNE has high reliability (.78- ranged from 20.07-21.80 in this study which is similar .94), and good validity (e.g., correlations with Taylor’s to mean FNE scores (23.14-25.04) found in previous Manifest Anxiety -.60, social and evaluative parts of studies (29, 31). Mean SSPS positive scores ranged the Endler-Hunt S-R -.47). from 10.18-13.90 in this study similar to the score of 4. Behavioral Task: Upon completion of treatment, par- 9.4 found in a previous study, while mean SSPS negative ticipants presented a 10-minute talk on a topic they scores ranged from 11.64-13.10 in this study compared choose (standing, and without notes) in front of a to mean of 15.80 in a previous study (32).