Virtual Reality Exposure Therapy for Adolescents with Public Speaking Anxiety

Bakgrunn: Presentasjonsangst er en av de vanligste fryktene blant ungdom. Angsten innebærer en redsel for å bli negativt evaluert, etterfulgt av en følelse av å bli flau eller ydmyket når man snakker foran andre. Eksponeringsterapi for presentasjonsangst er utfordrende å gjennomføre, da en trenger et reelt publikum som kan fungere som det fryktede stimuli. Virtual Reality (VR) kan være løsningen, da teknologien er i stand til å skape et virtuelt publikum, som kan oppleves som ekte. For voksne med presentasjonsangt finnes det flere randomiserte kontrollerte VR-studier som viser gode kliniske effekter, men en vet lite om effekten relatert til ungdom. Ingen studier har tidligere evaluert effekten av selvveiledet, automatiserte og spillbaserte VR-intervensjoner for ungdom med presentasjonsangst. Mål: Denne oppgaven adresserte aktuelle kunnskapshull ved å kartlegge den kliniske effekten og gjennomførbarheten av to VR-intervensjoner for ungdom med presentasjonsangst: en terapeutveiledet og en selvveiledet, automatisert og spillbasert intervensjon. Målet med Artikkel I var å undersøke gjennomførbarheten og den kliniske effekten av en terapeutveiledet, enkelt-sesjons VR-intervensjon for ungdom med presentasjonsangst. Hovedmålet med Artikkel II var å undersøke den kliniske effekten av en selvveiledet, automatisert og spillbasert VR-intervensjon sammenlignet med venteliste og en selvveiledet nettbasert intervensjon. Et sekundært mål var å undersøke om VR-intervensjonen førte til en økning i påfølgende eksponeringsøvelser under det nettbaserte eksponeringsprogrammet, sammenlignet med de som mottok nettbasert psykoedukasjons- og eksponeringsprogram. Målet med Artikkel III var å undersøke om intervensjonene rettet mot presentasjonsangst også førte til en reduksjon i symptomer på perfeksjonisme og om symptomer på perfeksjonisme modererte den kliniske effekten av intervensjonene for presentasjonsangst. Metode: To kliniske studier ga data for tre studier: en ikke-randomisert gjennomførbarhet- og pilotstudie (papir I) og en to-faset, firearmet randomisert kontrollert studie (papir II og III). Begge studiene undersøkte effekter og moderatorer av behandling: symptomer på generalisert sosial angst ved baseline og tilstedeværelse i det virtuelle miljøet (artikkel I) og om perfeksjonisme modererte behandlingsresultatet (artikkel III). Selvrapporterte symptomer på presentasjonsangst ble innhentet under intervensjons- og oppfølgingsperioden i begge studiene, i tillegg til hjertefrekvensmålinger under VR-eksponeringen i Artikkel I, selvrapporterte symptomer på generalisert sosial angst i Artikkel II og III, og perfeksjonisme i Artikkel III. Gjennomførbarhets- og pilotstudien i Artikkel I inkluderte N=27 ungdommer som deltok i en terapeutveiledet, 90-minutters VR-intervensjon på én sesjon ved klinikken. To-faset, firearmede randomiserte kontrollerte studien i Artikkel II og III inkluderte N=100 ungdommer som deltok i et seks ukers digitalt selvveiledet intervensjonsprogram. Ungdommene ble randomisert i fire grupper, med følgende fase én + fase to intervensjon; 1) Kun VR, 2) VR + nettbasert eksponeringsprogram, 3) Nettbasert psykoedukasjon + eksponeringsprogram, 4) Venteliste + nettbasert psykoedukasjonsprogram. Resultater: Resultater fra Artikkel I viste en signifikant reduksjon i presentasjonsangstsymptomer fra pre til post, og symptomene holdt seg stabile ved en og tre måneders oppfølging. Basert på tilbakemeldinger fra ungdommene, ble gjennomførbarheten av intervensjonen økt i løpet av studien, noe som resulterte i ingen manglende besvarelser ved oppfølging. Symptomer på generalisert sosial angst ved baseline og tilstedeværelse modererte ikke de kliniske effektene. Det var en liten økning i hjertefrekvensen under VR-eksponeringsoppgavene. Resultater fra Artikkel II viste en signifikant større reduksjon i presentasjonsangstsymptomer blant ungdommene som mottok VR-intervensjonen sammenlignet med ventelistegruppen. Resultatene viste også at VR + nettbasert eksponeringsprogram var like effektivt sammenlignet med kun VR og nettbasert psykoedukasjon + eksponeringsprogram. I tillegg hadde alle fire grupper en signifikant reduksjon i presentasjonsangstsymptomer. I motsetning til hypotesen fullførte ikke ungdommer som mottok VR-intervensjon et høyere antall in-vivo-eksponeringsoppgaver i løpet av nettbasert eksponeringsprogram sammenlignet med de som mottok nettbasert psykoedukasjon og eksponeringsprogram. De kliniske effektene holdt seg stabile ved tre måneders oppfølging. Resultater fra Artikkel III viste at intervensjonene ikke reduserte perfeksjonisme på gruppenivå, men det var signifikante individuelle forskjeller i endringer over tid. En nedgang i perfeksjonisme var assosiert med en større reduksjon på alle utfallsmål fra post til oppfølging. Det var ingen signifikante interaksjonseffekter mellom presentasjonsangstsymptomer og nivået av perfeksjonisme før behandling. Høye nivåer av perfeksjonisme før behandling var assosiert med dårligere langsiktige resultater for begge gruppene som mottok det nettbaserte eksponeringsprogrammet. Konklusjon: Denne oppgaven bidrar til det voksende evidensgrunnlaget for VR-eksponeringsterapi, og den første som demonstrerer potensialet til både terapeutveiledet og selvveiledet VR-behandling for ungdom generelt, og spesielt for de med presentasjonsangst. Resultatene indikerer at VR-behandling kan fungere som et indisert forebyggingsprogram for ungdom med PSA. Studiene som inngår i oppgaven er gjennomført ved hjelp av et solid design. Gjennomførbarhet og pilotering var første trinn, før man for første gang med denne målgruppen evaluerte de kliniske effektene i en randomisert kontrollert studie. I tillegg har oppgaven undersøkt relevante moderatorer av behandlinger; rollen til perfeksjonisme og hvordan den kan hindre bedring. Disse resultatene kan være veiledende for hvordan optimalisere fremtidige intervensjoner for ungdom med presentasjonsangst. Fremtidige studier bør undersøke om VR-terapi har en langsiktig forebyggende effekt på utvikling av generalisert sosial angst da dette fortsatt er uklart for denne aldersgruppen.Background: Public Speaking Anxiety (PSA) is one of the most common fears reported by adolescents. PSA involves the fear of being negatively evaluated, followed by a feeling of being embarrassed or humiliated when speaking in front of others. Providing state-of-the-art in-vivo exposure therapy for PSA is difficult due to the logistics of recruiting an actual audience trained to act as the feared stimuli. An attractive way of resolving this obstacle is through Virtual Reality (VR) technology, which is capable of creating an immersive experience of being in front of a virtual audience, as if it was real. Although there are several randomized controlled trials demonstrating the clinical efficacy of VR exposure therapy for adults with PSA, little is known about its clinical effects on adolescents. Moreover, no past study has evaluated self-guided and automated VR interventions for adolescents with PSA. Aims: This thesis addressed these key knowledge gaps by exploring the clinical effects and feasibility of both therapist-guided and self-guided, and automated VR interventions for adolescents with PSA. The aim of Paper I was to investigate the feasibility and the clinical effects of a therapist-guided, single-session VR-intervention for adolescents with PSA, using low-cost consumer VR hardware. The primary aim of Paper II was to investigate the clinical efficacy of a self-guided, automated, and gamified VR intervention compared with waitlist and self-guided online programs. A secondary aim was to explore whether the VR intervention led to an increase in subsequent exposure tasks during the online exposure program compared to those receiving the online psychoeducation and exposure program. The aim of Paper III was to investigate whether interventions targeting PSA also led to a reduction in symptoms of perfectionism and whether symptoms of perfectionism moderated the clinical efficacy of self-guided interventions for PSA. Methods: Two clinical trials provided data for three studies: one non-randomized feasibility and pilot study (Paper I) and a two-phased, four-armed randomized controlled study (Paper II and III). Both trials investigated effects and moderators of treatment: baseline generalized social anxiety symptoms and presence in the virtual environment (Paper I) and whether perfectionism moderated treatment outcome (Paper III). Self-reported PSA were assessed during the intervention and follow-up period in both studies, in addition to heart rate measurements during the VR exposure in Paper I, self-reported symptoms of generalized SAD in Paper II and III, and perfectionism in Paper III. The non-randomized feasibility and pilot study in Paper I included N=27 adolescents who participated in a therapist-guided, 90-minutes single-session VR intervention at the clinic. The two-phased, four-armed randomized controlled study in Paper II and III included N=100 adolescents who participated in a six weeks digital self-guided interventions program. The adolescents were randomized into four groups, with the following phase one + phase two intervention; 1) VR only, 2) VR + online exposure program, 3) Online psychoeducation + exposure program, 4) Waitlist + online psychoeducation program. Results: Results from Paper I revealed a significant decrease in PSA symptoms from pre to post, and symptoms remained stable at one- and three-month follow-up. Based on feedback from the adolescents, the feasibility of the intervention was increased during the trial, resulting in no missing data. Baseline generalized social anxiety symptoms and presence did not moderate the clinical effects. There was a small increase in heart rate during the VR exposure tasks. Results from Paper II revealed a significantly greater reduction in PSA symptoms among the adolescents who received the VR intervention compared to the the waitlist group. The results also demonstrated that VR + online exposure program was as equally effective as compared to VR only and online psychoeducation + exposure program. Moreover, all groups had a significant reduction in PSA symptoms. Contrary to the hypothesis, adolescents who received VR training did not complete a higher number of in-vivo-exposure tasks during the online exposure program compared to those receiving online psychoeducation and exposure program. The clinical effects remained stable at three-month follow-up. Results from Paper III revealed that the interventions did not reduce perfectionism at a group level, however, there were significant individual differences in changes over time. A decrease in perfectionism was associated with a larger reduction on all outcome measures from post to follow-up. There were no significant interaction effects between PSA symptoms and the pre-treatment level of perfectionism. High pre-treatment levels of perfectionism was associated with poorer long-term outcomes for both groups receiving the online exposure program. Conclusions: In sum, this thesis contributes to the growing evidence base for VR exposure therapy, and is among the first to demonstrate the potential of both therapist-guided and self-guided, VR interventions for adolescents in general and with PSA in particular. The results indicate that VR may serve as an indicated prevention program for adolescents with PSA. The studies included in the thesis is conducted through a strong design with feasibility and piloting as a first step before evaluating, for the first time with this target group, the clinical effects in a randomized controlled trial. Moreover, the thesis has investigated relevant moderators of treatments, specifically the role of perfectionism and how it may hinder treatment improvement. These results can provide guidance on how to optimize future interventions for the large group of adolescents with PSA. Future studies should investigate whether VR interventions have a long-term preventive effect on the development of generalized social anxiety as this remains unclear for this age group.Doktorgradsavhandlin

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