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Social Anxiety Disorder in Second Life

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Erica Yuen's masters thesis defense on the use of Second Life to treat Social Anxiety Disorder at Drexel University.

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Social Anxiety Disorder in Second Life

  1. 1. Cognitive Behavioral Therapy for Social Anxiety Disorder in Second Life Master’s Defense Meeting September 29, 2009 Presented by Erica Yuen
  2. 2. Social Anxiety Disorder (SAD) <ul><li>Definition: excessive fears of being embarrassed and negatively evaluated by other people </li></ul><ul><li>Significant Costs (relationships, career, quality of life, etc.) </li></ul>
  3. 3. Social Anxiety Disorder (SAD) <ul><li>Lifetime Prevalence Rate: 5% to 12% </li></ul><ul><li>12 month Prevalence Rate: 3% to 7% </li></ul><ul><li>Onset: 5 years old or younger & 13-15 years old </li></ul><ul><li>Mean age for first receiving treatment: 27.2 years </li></ul>
  4. 4. Treatment of SAD <ul><li>Components of Cognitive Behavioral Therapy (CBT) </li></ul><ul><ul><li>Exposure </li></ul></ul><ul><ul><li>Social skills training </li></ul></ul><ul><ul><li>Cognitive restructuring </li></ul></ul><ul><li>Exposure is the key component </li></ul>
  5. 5. Treatment of SAD <ul><li>CBT Protocols </li></ul><ul><ul><li>Cognitive Behavioral Group Therapy (CBGT) </li></ul></ul><ul><ul><li>Comprehensive Cognitive Behavioral Therapy (CCBT) </li></ul></ul><ul><ul><li>Acceptance Based Behavior Therapy (ABBT) </li></ul></ul><ul><li>Individual and group modalities are equally effective </li></ul><ul><li>Pharmacological treatments - high rates of relapse </li></ul>
  6. 6. Barriers to receiving CBT <ul><li>More than 80% of people with SAD do not receive any type of treatment </li></ul><ul><li>Reasons for not seeking treatment: </li></ul><ul><ul><li>Financial barriers </li></ul></ul><ul><ul><li>Uncertainty about where to seek help </li></ul></ul><ul><ul><li>Fear of negative evaluation </li></ul></ul><ul><ul><li>Limited availability of CBT therapists </li></ul></ul>
  7. 8. Internet Based Self-Help Therapy <ul><li>Nearly three-quarters of Americans have internet access in their homes; 55% of households have broadband connection </li></ul><ul><li>Online self–help treatment programs increase the availability of CBT </li></ul><ul><li>Main Disadvantages: limited therapist interaction & no in-session exposures </li></ul>
  8. 9. Telephone Therapy <ul><li>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 </li></ul><ul><li>Main Disadvantages: </li></ul><ul><ul><li>lack of visual feedback </li></ul></ul><ul><ul><li>limited opportunities for in-session exposure exercises </li></ul></ul>
  9. 10. Virtual reality therapy (VRT) <ul><li>Interaction with virtual people produces social anxiety </li></ul><ul><li>CBT with VRT is equally effective as standard CBT without VRT in treating SAD </li></ul>
  10. 11. Second Life <ul><li>Users create avatars and maneuver them through the online virtual environment </li></ul><ul><li>Communication possible through voice conversations and typing </li></ul><ul><li>Over 15.4 million users </li></ul>
  11. 12. Current Study <ul><li>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 </li></ul><ul><li>Manualized treatment: Acceptance Based Behavior Therapy for SAD (ABBT). </li></ul>
  12. 13. Hypotheses <ul><li>Hypothesis 1: Participants and therapists will rate this treatment of SAD in Second Life as acceptable and feasible. </li></ul><ul><li>Hypothesis 2: Symptoms of social anxiety and other psychopathology will improve from pre- to post-treatment. </li></ul><ul><li>Hypothesis 3: Psychosocial functioning and quality of life will improve from pre- to post-treatment. </li></ul><ul><li>Hypothesis 4: Theoretically relevant process variables will change from pre- to post-treatment. </li></ul><ul><li>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. </li></ul><ul><li>Hypothesis 6: Baseline levels of theorized moderators of treatment will be associated with treatment outcome. </li></ul>
  13. 14. Participants <ul><li>Inclusion criteria: </li></ul><ul><ul><li>Ages 18 – 65 </li></ul></ul><ul><ul><li>Generalized SAD as primary Axis I disorder </li></ul></ul><ul><ul><li>No changes in medication during study participation </li></ul></ul><ul><ul><li>No other therapy during study participation </li></ul></ul><ul><ul><li>Access to technical requirements (computer, broadband connection, VoIP headset) </li></ul></ul><ul><li>Exclusion criteria: </li></ul><ul><ul><li>Psychotic symptoms </li></ul></ul><ul><ul><li>Acute suicide potential </li></ul></ul><ul><ul><li>History of substance dependence within past six months </li></ul></ul><ul><ul><li>Mental retardation </li></ul></ul><ul><ul><li>Pervasive developmental disorder </li></ul></ul>
  14. 15. Procedure <ul><li>Online message boards, website, referrers to the SATP </li></ul><ul><li>Telephone screen (15 minutes) </li></ul><ul><li>Structured Clinical Interview (SCID) over the telephone (1.5 - 2 hours) </li></ul><ul><li>Second Life Lesson (30 minutes) </li></ul><ul><li>Online psychoeducational readings and quiz </li></ul>
  15. 16. Procedure <ul><li>12 one-hour sessions of weekly therapy in Second Life (using ABBT protocol) </li></ul><ul><ul><li>In-session exposures & homework in vivo exposures </li></ul></ul><ul><ul><li>ACT concepts (willingness, acceptance, mindfulness, values, etc.) to help participants engage in exposure more fully </li></ul></ul>
  16. 17. Treatment Room
  17. 18. Assessment Schedule <ul><li>Pre-treatment </li></ul><ul><ul><li>Initial SCID meeting </li></ul></ul><ul><ul><li>Pre-tx questionnaire packet </li></ul></ul><ul><li>Mid-treatment (6 weeks ) </li></ul><ul><ul><li>Mid-tx assessment meeting (20 minutes) </li></ul></ul><ul><ul><li>Mid-tx questionnaire packet </li></ul></ul><ul><li>Post- treatment (12 weeks) </li></ul><ul><ul><li>Post-tx assessment meeting (20 minutes) </li></ul></ul><ul><ul><li>Post-tx questionnaire packet </li></ul></ul>
  18. 19. Measures <ul><li>Screening Measures: </li></ul><ul><ul><li>Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) </li></ul></ul><ul><li>- Primary Treatment Outcome Measures: </li></ul><ul><ul><li>Social Phobia and Anxiety Inventory (SPAI) </li></ul></ul><ul><ul><li>Liebowitz Social Anxiety Scale (LSAS) </li></ul></ul><ul><ul><li>Brief Version of the Fear of Negative Evaluation Scale (Brief FNE) </li></ul></ul><ul><ul><li>Beck Depression Inventory-II (BDI-II) </li></ul></ul><ul><ul><li>Clinical Global Impression Scale (CGI) </li></ul></ul><ul><li>Psychosocial Functioning and Quality of Life Measures: </li></ul><ul><ul><li>Quality of Life Inventory (QOLI) </li></ul></ul><ul><ul><li>Sheehan Disability Scale (SDS) </li></ul></ul>
  19. 20. Measures <ul><li>Process Variable Measures: </li></ul><ul><ul><li>Acceptance and Action Questionnaire-II (AAQ-II) </li></ul></ul><ul><ul><li>Drexel Defusion Scale (DDS) </li></ul></ul><ul><ul><li>Philadelphia Mindfulness Scale (PHLMS) </li></ul></ul><ul><li>Acceptability & Feasibility Measures: </li></ul><ul><ul><li>Reaction to Treatment Questionnaire (RTQ) </li></ul></ul><ul><ul><li>Client Satisfaction Survey (CSS) </li></ul></ul><ul><ul><li>Post-Treatment Therapist Survey </li></ul></ul><ul><li>Other: </li></ul><ul><ul><li>Demographics Questionnaire </li></ul></ul>
  20. 21. Data Analysis <ul><li>Results equivalent for ITT and completer analyses; therefore only ITT results are reported. </li></ul><ul><li>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. </li></ul>
  21. 22. Results - Hypothesis 1 <ul><li>Hypothesis 1: Participants and therapists will rate this treatment of SAD in Second Life as acceptable and feasible. </li></ul><ul><li>Attrition rate: 14% </li></ul><ul><li>93% were very or mostly satisfied with treatment </li></ul><ul><li>100% were completely or mostly satisfied with their therapist </li></ul><ul><li>86% strongly agreed or agreed that treatment decreased social fears </li></ul><ul><li>72% strongly agreed or agreed that treatment decreased social avoidance </li></ul>
  22. 23. Results – Hypothesis 1 <ul><li>79% of clients thought receiving treatment through Second Life was very or fairly easy </li></ul><ul><li>All therapists thought delivering treatment in Second Life was fairly feasible </li></ul>
  23. 24. Results – Hypothesis 1 <ul><li>39% of sessions had moderate or severe technical problems </li></ul><ul><ul><li>21% - inability to transmit/receive sound through headset </li></ul></ul><ul><ul><li>17% - poor sound quality </li></ul></ul><ul><ul><li>27% - telephone used instead of headsets </li></ul></ul><ul><ul><li>6% - hardware / internet connection problems </li></ul></ul>
  24. 25. Results – Hypothesis 2 <ul><li>Hypothesis 2: Symptoms of social anxiety and other psychopathology will improve from pre- to post-treatment </li></ul><ul><li>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). </li></ul><ul><ul><li>SPAI-SP [ t (13)=4.62, p <.001, Cohen’s d =1.44] </li></ul></ul><ul><ul><li>LSAS-F [ t (13)=3.24, p =.006, Cohen’s d =1.06] </li></ul></ul><ul><ul><li>LSAS-A [ t (13)=3.04, p =.009, Cohen’s d =0.91] </li></ul></ul><ul><ul><li>Brief-FNE [ t (13)=4.38, p =.001, Cohen’s d =1.19] </li></ul></ul><ul><ul><li>CGI-Severity [ t (13)=5.34, p<.001, Cohen’s d =1.56 </li></ul></ul><ul><ul><li>BDI-II [ t (13)=4.32, p =.001, Cohen’s d =0.72] </li></ul></ul>
  25. 26. Results – Hypothesis 2 <ul><li>Hypothesis 2: Symptoms of social anxiety and other psychopathology will improve from pre- to post-treatment </li></ul><ul><li>64% no longer met criteria for SAD at post-treatment </li></ul><ul><li>57% were very much or much improved at post-treatment (CGI-Improvement) </li></ul>
  26. 27. Results – Hypothesis 3 <ul><li>Hypothesis 3: Psychosocial functioning and quality of life will improve from pre- to post-treatment. </li></ul><ul><li>T -tests on pre- to post-treatment scores were significant for measures of: </li></ul><ul><ul><li>disability (SDS) [ t (13)=5.97, p <.001, Cohen’s d =1.45] </li></ul></ul><ul><ul><li>quality of life (QOLI) [ t (13)=-7.61, p <.001, Cohen’s d =0.86]. </li></ul></ul>
  27. 28. Results – Hypothesis 4 <ul><li>Hypothesis 4: Theoretically relevant process variables will change from pre- to post-treatment. </li></ul><ul><li>T -tests on pre- to post-treatment scores were significant for measures of: </li></ul><ul><ul><li>Psychological flexibility (AAQ-II) [ t (13)=-6.17, p <.001, Cohen’s d =0.84] </li></ul></ul><ul><ul><li>Defusion (DDS) [ t (13)=-4.77, p <.001, Cohen’s d =1.35] </li></ul></ul><ul><ul><li>Acceptance (PHLMS-Acceptance) [ t (13)= -3.48, p =.004, Cohen’s d =0.74] </li></ul></ul><ul><li>But not significant for: </li></ul><ul><ul><li>Awareness (PHLMS-Awareness) [ t (13)= 0.34, p =.739, Cohen’s d =0.07] </li></ul></ul>
  28. 29. Results – Hypothesis 5 <ul><li>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. </li></ul><ul><li>Low power for correlation analyses </li></ul><ul><li>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 </li></ul><ul><ul><li>No significant results </li></ul></ul><ul><li>2) Correlations between pre- to post-tx residual gain in hypothesized process variables and pre- to post-tx residual gain in social anxiety </li></ul><ul><ul><li>An increase in PHLMS-Acceptance residual gain scores was significantly associated with a decrease in Brief-FNE scores ( r =-.541, p =.046). </li></ul></ul><ul><ul><li>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) </li></ul></ul><ul><ul><li>Opposite pattern observed with awareness; pre- to post-tx increase in awareness associated with pre- to post-tx increase in social anxiety. </li></ul></ul>
  29. 30. Results – Hypothesis 6 <ul><li>Hypothesis 6: Baseline levels of theorized moderators of treatment will be associated with treatment outcome. </li></ul><ul><li>Low power for correlation analyses </li></ul><ul><li>Correlations between baseline levels of theorized moderators of treatment (mindfulness, defusion, psychological flexibility) and residual change in social anxiety symptoms </li></ul><ul><ul><li>Higher baseline PHLMS-Acceptance scores associated with greater reduction in LSAS-Total scores ( r =-.472, p =.088) </li></ul></ul><ul><ul><li>Higher baseline AAQ-II scores associated with greater reduction in LSAS-Total scores ( r =-.486, p =.078) </li></ul></ul><ul><ul><li>Overall pattern observed: higher baseline levels of theorized moderators (acceptance, defusion, and psychological flexibility, but not awareness) moderately correlated with better treatment outcome </li></ul></ul>
  30. 31. Discussion <ul><li>Treatment delivered through Second Life appears feasible and acceptable </li></ul><ul><li>Treatment outcome appears comparable to in-person treatment </li></ul><ul><li>Acceptance, defusion, and psychological flexibility are possible mechanisms of change; less likely the case for awareness </li></ul><ul><li>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 </li></ul>
  31. 32. Discussion <ul><li>Strengths: User-friendly and easily accessible application </li></ul><ul><li>Weakness: therapists, clients, and role-players could not see each other in real life </li></ul><ul><li>Implications: </li></ul><ul><ul><li>Remote treatment may be a viable treatment modality </li></ul></ul><ul><ul><li>Remote treatment increases accessibility of CBT to individuals unable to see a therapist in person, or unwilling due to severity of symptoms </li></ul></ul><ul><li>Future Directions: videoconferencing, handheld devices </li></ul>
  32. 33. <ul><li>Committee Discussion </li></ul>

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