Cognitive Behavioral Therapy Cognitive Behavioral Therapy for Social Anxiety Disorderfor Social Anxiety Disorder

in Second Lifein Second Life

Master’s Defense MeetingMaster’s Defense MeetingSeptember 29, 2009September 29, 2009

Presented by Erica YuenPresented by Erica Yuen

Social Anxiety Disorder (SAD)Social Anxiety Disorder (SAD)

• Definition: excessive fears of being embarrassed and negatively evaluated by other people

• Significant Costs (relationships, career, quality of life, etc.)

Social Anxiety Disorder (SAD)Social Anxiety Disorder (SAD)

• Lifetime Prevalence Rate: 5% to 12%

• 12 month Prevalence Rate: 3% to 7%

• Onset: 5 years old or younger & 13-15 years old

• Mean age for first receiving treatment:27.2 years

Treatment of SADTreatment of SAD

• Components of Cognitive Behavioral Therapy (CBT)– Exposure– Social skills training– Cognitive restructuring

• Exposure is the key component

Treatment of SADTreatment of SAD

• CBT Protocols– Cognitive Behavioral Group Therapy (CBGT)– Comprehensive Cognitive Behavioral Therapy

(CCBT)– Acceptance Based Behavior Therapy (ABBT)

• Individual and group modalities are equally effective

• Pharmacological treatments - high rates of relapse

Barriers to receiving CBTBarriers to receiving CBT

• More than 80% of people with SAD do not receive any type of treatment

• Reasons for not seeking treatment:– Financial barriers– Uncertainty about where to seek help– Fear of negative evaluation– Limited availability of CBT therapists

Internet Based Self-Help TherapyInternet Based Self-Help Therapy

• Nearly three-quarters of Americans have internet access in their homes; 55% of households have broadband connection

• Online self–help treatment programs increase the availability of CBT

• Main Disadvantages: limited therapist interaction & no in-session exposures

Telephone TherapyTelephone Therapy

• Therapist contact in telephone therapy may provide greater structure, accountability, and motivation to complete in vivo exposure assignments, compared to self-help internet-based treatment

• Main Disadvantages:– lack of visual feedback– limited opportunities for in-session

exposure exercises

Virtual reality therapy (VRT)Virtual reality therapy (VRT)

• Interaction with virtual people produces social anxiety

• CBT with VRT is equally effective as standard CBT without VRT in treating SAD

Second LifeSecond Life• Users create avatars and maneuver them through the

online virtual environment

• Communication possible through voice conversations and typing

• Over 15.4 million users

Current StudyCurrent Study

• Uncontrolled pilot study to assess the feasibility, acceptability, and initial efficacy of an acceptance-based CBT intervention in Second Life to treat adults with generalized SAD

• Manualized treatment: Acceptance Based Behavior Therapy for SAD (ABBT).

•

HypothesesHypotheses• Hypothesis 1: Participants and therapists will rate this treatment of SAD in Second Life

as acceptable and feasible.

• Hypothesis 2: Symptoms of social anxiety and other psychopathology will improve from pre- to post-treatment.

• Hypothesis 3: Psychosocial functioning and quality of life will improve from pre- to post-treatment.

• Hypothesis 4: Theoretically relevant process variables will change from pre- to post-treatment.

• Hypothesis 5: Changes in theoretically relevant process variables from pre-treatment to mid-point will predict change in social anxiety symptoms from mid-point to post-treatment.

•Hypothesis 6: Baseline levels of theorized moderators of treatment will be associated with treatment outcome.

ParticipantsParticipants• Inclusion criteria:

– Ages 18 – 65– Generalized SAD as primary Axis I disorder– No changes in medication during study participation– No other therapy during study participation– Access to technical requirements (computer, broadband

connection, VoIP headset)

• Exclusion criteria:– Psychotic symptoms– Acute suicide potential– History of substance dependence within past six months– Mental retardation– Pervasive developmental disorder

ProcedureProcedure• Online message boards, website, referrers to the

SATP

• Telephone screen (15 minutes)

• Structured Clinical Interview (SCID) over the telephone (1.5 - 2 hours)

• Second Life Lesson (30 minutes)

• Online psychoeducational readings and quiz

Procedure

• 12 one-hour sessions of weekly therapy in Second Life (using ABBT protocol)

– In-session exposures & homework in vivo exposures

– ACT concepts (willingness, acceptance, mindfulness, values, etc.) to help participants engage in exposure more fully

Treatment RoomTreatment Room

Assessment ScheduleAssessment Schedule• Pre-treatment

– Initial SCID meeting– Pre-tx questionnaire packet

• Mid-treatment (6 weeks )– Mid-tx assessment meeting (20 minutes)– Mid-tx questionnaire packet

• Post- treatment (12 weeks)– Post-tx assessment meeting (20 minutes)– Post-tx questionnaire packet

MeasuresMeasures

• Screening Measures:– Structured Clinical Interview for DSM-IV Axis I Disorders (SCID)

• - Primary Treatment Outcome Measures:– Social Phobia and Anxiety Inventory (SPAI)– Liebowitz Social Anxiety Scale (LSAS)– Brief Version of the Fear of Negative Evaluation Scale (Brief

FNE)– Beck Depression Inventory-II (BDI-II)– Clinical Global Impression Scale (CGI)

• Psychosocial Functioning and Quality of Life Measures:– Quality of Life Inventory (QOLI) – Sheehan Disability Scale (SDS)

MeasuresMeasures• Process Variable Measures:

– Acceptance and Action Questionnaire-II (AAQ-II) – Drexel Defusion Scale (DDS)– Philadelphia Mindfulness Scale (PHLMS)

• Acceptability & Feasibility Measures: – Reaction to Treatment Questionnaire (RTQ)– Client Satisfaction Survey (CSS)– Post-Treatment Therapist Survey

• Other:– Demographics Questionnaire

Data AnalysisData Analysis

• Results equivalent for ITT and completer analyses; therefore only ITT results are reported.

• G*power calculated a power of .93 for a large effect size (Cohen’s d = 1.00) at α = .05 and n=14 for a paired samples t test.

Results - Hypothesis 1 Results - Hypothesis 1 Hypothesis 1: Participants and therapists will rate this treatment of

SAD in Second Life as acceptable and feasible.

• Attrition rate: 14%

• 93% were very or mostly satisfied with treatment

• 100% were completely or mostly satisfied with their therapist

• 86% strongly agreed or agreed that treatment decreased social fears

• 72% strongly agreed or agreed that treatment decreased social avoidance

Results – Hypothesis 1Results – Hypothesis 1

• 79% of clients thought receiving treatment through Second Life was very or fairly easy

• All therapists thought delivering treatment in Second Life was fairly feasible

Results – Hypothesis 1Results – Hypothesis 1

• 39% of sessions had moderate or severe technical problems21% - inability to transmit/receive sound through

headset17% - poor sound quality27% - telephone used instead of headsets6% - hardware / internet connection problems

Results – Hypothesis 2Results – Hypothesis 2

Hypothesis 2: Symptoms of social anxiety and other psychopathology will improve from pre- to post-treatment

• T-tests comparing pre- to post-treatment scores were significant for measures of social anxiety (SPAI-SP, LSAS, Brief-FNE, CGI-Severity) and depression (BDI-II).– SPAI-SP [t(13)=4.62, p<.001, Cohen’s d=1.44]– LSAS-F [t(13)=3.24, p=.006, Cohen’s d=1.06]– LSAS-A [t(13)=3.04, p=.009, Cohen’s d=0.91]– Brief-FNE [t(13)=4.38, p=.001, Cohen’s d=1.19]– CGI-Severity [t(13)=5.34, p<.001, Cohen’s d=1.56– BDI-II [t(13)=4.32, p=.001, Cohen’s d=0.72]

Results – Hypothesis 2Results – Hypothesis 2

Hypothesis 2: Symptoms of social anxiety and other psychopathology will improve from pre- to post-treatment

• 64% no longer met criteria for SAD at post-treatment

• 57% were very much or much improved at post-treatment (CGI-Improvement)

Results – Hypothesis 3

Hypothesis 3: Psychosocial functioning and quality of life will improve from pre- to post-treatment.

• T-tests on pre- to post-treatment scores were significant for measures of:– disability (SDS) [t(13)=5.97, p<.001, Cohen’s d=1.45]

– quality of life (QOLI) [t(13)=-7.61, p<.001, Cohen’s d=0.86].

•

Results – Hypothesis 4Hypothesis 4: Theoretically relevant process variables will change

from pre- to post-treatment.

• T-tests on pre- to post-treatment scores were significant for measures of:– Psychological flexibility (AAQ-II) [t(13)=-6.17, p<.001, Cohen’s

d=0.84]– Defusion (DDS) [t(13)=-4.77, p<.001, Cohen’s d=1.35]– Acceptance (PHLMS-Acceptance) [t(13)= -3.48, p=.004,

Cohen’s d=0.74]• But not significant for:

– Awareness (PHLMS-Awareness) [t(13)= 0.34, p=.739, Cohen’s d=0.07]

Results – Hypothesis 5Hypothesis 5: Changes in theoretically relevant process variables from

pre-treatment to mid-point will predict change in social anxiety symptoms from mid-point to post-treatment.

• Low power for correlation analyses

• 1) Partial correlations between pre- to mid-tx residual gain of hypothesized process variables and mid- to post-tx residual gain in social anxiety level, controlling for pre- to mid-tx residual gain in social anxiety

– No significant results

• 2) Correlations between pre- to post-tx residual gain in hypothesized process variables and pre- to post-tx residual gain in social anxiety

– An increase in PHLMS-Acceptance residual gain scores was significantly associated with a decrease in Brief-FNE scores (r=-.541, p=.046).

– Pattern observed (moderate effect sizes) between pre- to post-tx increases in acceptance, psychological flexibility, and defusion associated with pre-to post-tx reductions in social anxiety (SPAI-SP, LSAS-Total, Brief FNE)

– Opposite pattern observed with awareness; pre- to post-tx increase in awareness associated with pre- to post-tx increase in social anxiety.

Results – Hypothesis 6Hypothesis 6: Baseline levels of theorized moderators of treatment will

be associated with treatment outcome.

• Low power for correlation analyses

• Correlations between baseline levels of theorized moderators of treatment (mindfulness, defusion, psychological flexibility) and residual change in social anxiety symptoms

– Higher baseline PHLMS-Acceptance scores associated with greater reduction in LSAS-Total scores (r=-.472, p=.088)

– Higher baseline AAQ-II scores associated with greater reduction in LSAS-Total scores (r=-.486, p=.078)

– Overall pattern observed: higher baseline levels of theorized moderators (acceptance, defusion, and psychological flexibility, but not awareness) moderately correlated with better treatment outcome

DiscussionDiscussion

• Treatment delivered through Second Life appears feasible and acceptable

• Treatment outcome appears comparable to in-person treatment

• Acceptance, defusion, and psychological flexibility are possible mechanisms of change; less likely the case for awareness

• Individuals with higher baseline levels of acceptance, defusion and psychological flexibility may have better treatment outcomes; opposite may be true for higher baseline levels of awareness

DiscussionDiscussion

• Strengths: User-friendly and easily accessible application

• Weakness: therapists, clients, and role-players could not see each other in real life

• Implications:– Remote treatment may be a viable treatment modality– Remote treatment increases accessibility of CBT to individuals unable to see a

therapist in person, or unwilling due to severity of symptoms

• Future Directions: videoconferencing, handheld devices

Committee Discussion