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Purpose of review: This review examines the current knowledge on public-speaking anxiety, that is, the fear of speaking in front of others. This article summarizes the findings from previous review articles and describes new research findings on basic science aspects, prevalence rates, classification, and treatment that have been published between August 2008 and August 2011.

Recent findings: Recent findings highlight the major aspects of psychological and physiological reactivity to public speaking in individuals who are afraid to speak in front of others, confirm high prevalence rates of the disorder, contribute to identifying the disorder as a possibly distinct subtype of social anxiety disorder (SAD), and give support to the efficacy of treatment programs using virtual reality exposure and Internet-based self-help.
Summary: Public-speaking anxiety is a highly prevalent disorder, leading to excessive psychological and physiological reactivity. It is present in a majority of individuals with SAD and there is substantial evidence that it may be a distinct subtype of SAD. It is amenable to treatment including, in particular, new technologies such as exposure to virtual environments and the use of cognitive–behavioral self-help programs delivered on the Internet.

Introduction
Public-speaking anxiety, also termed fear of speaking in public, fear of public speaking, or fear of speaking in front of others, is a highly prevalent disorder. The fear causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
This article reports on the recent data concerning the psychological and physiological reactivity to public speaking in individuals who are afraid of speaking in front of others, prevalence rates, the position of the disorder as a possibly distinct subtype of social anxiety disorder (SAD), and the development of new treatment modalities, including, in particular, exposure in virtual reality environments and Internet-based self-help programs

Method
PubMed was systematically searched for research studies published between August 2008 and September 2011 using the search words 'public speaking anxiety', 'fear of public speaking', 'fear of speaking in public', 'fear of speaking in front of others', 'SAD', and 'social phobia'. In addition, a similar search was conducted for review articles published on the topic prior to August 2008

Basic Science Aspects
Recent studies have focused on the various aspects of psychological and physiological reactivity in individuals suffering from fear of public speaking before, during, and after speaking in public.

Physiological Reactivity
Palatini et al. [1] have investigated the blood pressure (BP) reaction to public speaking performed according to different emotionally distressing scenarios in stage 1 hypertension. They assessed hypertensive and normotensive individuals who performed three speech tasks with neutral, anger, and anxiety scenarios. For all types of speech, the systolic BP response was greater in hypertensive than in normotensive individuals. For the diastolic BP response, the between-group difference was significant for the task involving an anxiety scenario.
Stevens et al. [2] investigated differences in heartbeat perception as a proxy of interoception in individuals with high and low social anxiety at baseline and while anticipating a public speech. Results revealed lower error scores for high fearful participants both at baseline and during speech anticipation, indicating that perceived physical arousal is likely to be accurate rather than false alarm in socially anxious individuals.
Cornwell et al. [3] have investigated startle reactivity in individuals before, during, and after they delivered a short speech in a virtual reality environment. The virtual reality environment simulated standing at the center of a stage before a live audience. Startle eye-blink responses were elicited periodically by white noise bursts presented during anticipation, speech delivery, and recovery in virtual reality. Analyses of startle reactivity revealed a robust group difference during speech anticipation in virtual reality, specifically as audience members directed their eye gaze and turned their attention toward participants.
Moscovitch et al. [4] investigated the patterns of synchrony in repeated measures of heart rate, skin conductance levels, negative affect and positive affect in individuals with SAD, and nonanxious controls during a speech task. Individuals with SAD showed overall stronger levels of synchrony between increased heart rate and increased negative affect and between increased skin conductance and both increased negative and positive affect.
Carroll et al. [5] found a positive association between increases of anger and anxiety and serum levels of the proinflammatory cytokine interleukin (IL)-6 in individuals who completed a speech test, suggesting that individuals who exhibit angry or anxious responses to acute challenge are more vulnerable to stress-related increases in markers of systemic inflammation.
Miskovic et al. [6•] found distinct patterns of frontal brain oscillatory coupling during resting baseline and the anticipation of a public speaking task in high socially anxious individuals. In particular, highly anxious individuals showed significantly greater slow wave–fast wave coupling than low socially anxious individuals in the right, but not in the left, frontal electrode sites. Additionally, the low socially anxious group showed a decrease in delta power from baseline to speech anticipation.
In individuals with social phobia undergoing a stressful public-speaking task, Ahs et al. [7] have found a positive correlation between stress-induced regional cerebral blood flow (rCBF) and high-frequency heart rate variability (HF-HRV) in the right supra genual anterior cingulate cortex Brodmann's area 32, the right head of the caudate nucleus, and bilaterally in the medial prefrontal cortex (Brodmann's area 10), extending into the dorsolateral prefrontal cortex (Brodmann's area 46) in the left hemisphere.

Psychological Reactivity
Kocovski et al. [8] have investigated the effect of rumination and distraction periods immediately following a speech task on subsequent postevent processing. At high levels of social anxiety, the distraction condition led to more positive thoughts compared with the guided negative rumination condition, whereas at low levels of social anxiety, conditions were similar with respect to positive thoughts.
Amir et al. [9] have found that an attention modification program (AMP) can be effective in reducing anxiety response and improving performance on a public-speaking challenge in socially anxious participants. Participants in an AMP group showed significantly less attention bias to threat after training and lower levels of anxiety in response to a public-speaking challenge than did the participants in an attention control condition group.
Blöte et al. [10] have investigated the reaction of adolescents towards their socially anxious classmates in relation to their social performance, speech quality, and nervousness during a speech task in front of the class. Social performance of socially anxious students was a predictor of class behavior, whereas their overt nervousness was not. The quality of their speech was negatively related to class behavior.

Cognitive Models of Fear of Public Speaking
Cognitive models attribute fear of speaking in public to an essentially negative-biased perception of individuals with regard to their social performance. According to these models, negative self-imagery has a causal role in the development and maintenance of the disorder. Recent studies provide support for this model.
In a study by Beard and Amir,[11] socially anxious undergraduates completed self-report measures of social anxiety and interpretation bias, and 2 days later they completed an impromptu speech. Mediational analyses support the hypothesis that interpretation bias mediates the effect of social anxiety on state anxiety in response to the speech.
Orr and Moscovitch[12] have examined whether video feedback with cognitive preparation could be optimized through the addition of a post-video feedback cognitive review. In comparison with individuals in a control group, patients in the cognitive preparation plus video feedback plus cognitive review condition demonstrated significant improvements in self-perception and performance expectations.
In a study by Hirsch et al.,[13] low public-speaking anxious volunteers rehearsed a negative self-image, a positive self-image, or a control image prior to giving a speech. The negative image group felt more anxious, believed they performed less well and reported more negative thoughts than the positive image group. The negative image group also reported more anxiety than the control group.
Berry et al. [14] have tested the assumption that extinction retention (which comprises the amount of fear reduction that is retained between two exposure sessions) is important to the outcome of exposure-based therapy. Participants in two separate studies received three sessions of repeated exposure to public speaking and provided ratings of peak fear during exposure treatment. According to the authors, the findings suggest that the consolidation of extinction learning into long-term memory is associated with improvements in fear and avoidance related to social situations following exposure therapy.
Voncken and Bögels[15] have investigated the relative importance of underestimation of social performance (defined as the discrepancy between self-perceived and observer-perceived social performance) versus actual (observer-perceived) social performance. Individuals with SAD were compared with normal controls during a speech and a conversation. In comparison with the control participants, individuals with SAD underestimated their social performance during the two interactions, but primarily during the speech. Observed social performance deficits were clearly apparent in the conversation but not in the speech.

Epidemiology and Nosology
Recent studies confirm that fear of public speaking is a frequent feature of SAD, but that it may also be present in the absence of any or most of the other features of SAD. On the whole, there seems to be substantial, although not conclusive, evidence that the disorder may be a specific subtype and not just a minor form of SAD.
Tillfors and Furmark[16] found a point prevalence of social phobia among Swedish university students of 16.1%. In most individuals, SAD was associated with the use of dysfunctional avoidant strategies in anticipation of public speaking.
The literature available up to 2008 on public-speaking anxiety and its relation with SAD has been reviewed by Blöte et al..[17] The authors analyzed 16 empirical studies on public-speaking anxiety, including studies on qualitative or quantitative aspects of subtype differences, involving clinical or community samples and focusing on characteristic behavioral symptoms or not. They conclude that there is significant evidence supporting the premise that public-speaking anxiety is a distinct subtype of SAD that is qualitatively and quantitatively different from other subtypes of the disorder.
Bögels et al. [18] reviewed the literature on SAD up to 2010, including the literature on specifiers related to performance fears, social interaction fears, observation fears, and fears of displaying visible signs of anxiety. They conclude that there is a moderate level of evidence that individuals with an isolated fear of speaking in front of others are qualitatively different from other persons with SAD. In particular, they develop the fear later, they are less characterized by childhood factors, they are not shy or behaviorally inhibited, their fear is not familial, they have stronger psychophysiological responses, and they are more likely to respond to beta-blockers.
Fear of public speaking is often associated with test anxiety. In their review of the literature on specific phobia, LeBeau et al. [19] examined the nosological position of test anxiety and concluded that 'more studies are warranted to differentiate test anxiety from social phobia and generalized anxiety disorder'.
Knappe et al. [20] compared different social fears and social phobia subtypes among community youths. They paid particular attention to clinical factors including age of onset, avoidance, impairment, and comorbidities and vulnerability factors involving behavioral inhibition, parental psychopathology and parental rearing among community youth. Except for fear of taking tests and public speaking, social fears rarely occurred in isolation. Fear of speaking in front of others occurred in 70.3% of individuals with SAD, in combination with other feared situations and in 6.5% of individuals as an isolated fear.
Beidel et al. [21] have investigated whether patients with the nongeneralized subtype of SAD display social skills deficits in social interactions. Adults with SAD completed an extensive behavioral assessment of social skills and social anxiety. Individuals with either subtype of SAD reported equal distress and displayed similar rates of avoidance during an Impromptu Speech Task. Adults with the nongeneralized subtype had fewer deficits in social skills than those with the generalized subtype.
The relationship between social phobia and shyness has been examined by Heiser et al..[22] The authors have examined the characteristics of highly shy persons with social phobia, highly shy persons without social phobia, and nonshy persons. The social phobia group reported similar levels of anxiety as the shy without social phobia during analog conversation tasks, but they reported more anxiety during a speech task. In addition, the social phobia group performed less effectively across tasks than those without social phobia.
Finally, Iverach et al. [23] have found 16-fold to 34-fold increased odds of meeting Diagnostic and Statistical Manual of Mental Disorders-IV or International Classification of Disorders-10 criteria for SAD in individuals seeking speech therapy for stuttering.

Treatment
Recent studies confirm that public-speaking anxiety is amenable to cognitive–behavioral therapy (CBT) programs that include novel ways of exposure to the feared situations, including exposure to virtual reality environments and exposure to video-taped audiences on the Internet. Recent studies also suggest that there are additional treatment modalities, such as the administration of drugs prior to exposure, which might enhance the efficacy of currently available CBT programs.

Exposure to Virtual Reality Environments
Exposure to virtual audiences offers many advantages over traditional exposure modalities such as exposure in imagination or exposure to live audiences. In particular, the therapist can control the exposure, the patient does not have to imagine an audience, and there is no loss of confidentiality.
Wallach et al. [24] randomly assigned participants with public-speaking anxiety to either CBT with exposure to virtual reality (VRCBT), CBT with exposure to traditional environments, or a wait-list control (WLC). VRCBT and CBT were significantly more effective than WLC in anxiety reduction on four of five anxiety measures, and on individuals' self-rating of anxiety during a behavioral task. No significant differences were found on observer ratings of the behavioral task. However, twice as many participants dropped out from CBT as from VRCBT.
In an open clinical trial, Anderson et al. [25] tested a cognitive–behavioral treatment for public-speaking anxiety involving exposure therapy in virtual reality. Treatment consisted of eight individual therapy sessions, including four sessions of anxiety management training and four sessions of exposure therapy using a virtual audience. Participants were asked to give a speech to an actual audience before and after treatment. Results showed decreases on all self-report measures of public-speaking anxiety from before to after treatment, which were maintained at follow-up. However, participants were no more likely to complete a speech after treatment than before treatment.
Robillard et al. [26] randomly assigned individuals with SAD including fear of public speaking to traditional CBT with in-vivo exposure, CBT combined with exposure in virtual reality, or a waiting list. Results show significant reduction of anxiety on all questionnaires as well as statistically significant interactions between both treatment groups and the waiting list.

Internet-delivered Treatments
Tillfors et al. [27] have investigated the efficacy of an Internet-based self-help program with minimal therapist contact via e-mail for Swedish university students with social phobia and public-speaking fears. The main objective was to test whether the Internet-based self-help program would be more effective if five live group exposure sessions were added both after test and at 1-year follow-up. The results suggest that the Internet-based self-help program on its own was efficient and that adding group exposure sessions did not improve the outcome significantly.
Botella et al. [28••] have developed an Internet-based, self-administered program called 'Talk to me' for the treatment of fear of public speaking that includes exposure and cognitive approaches. In a randomized controlled study, the authors compared the efficacy of 'Talk to me' with the same program applied by a therapist and a waiting-list control group. Both treatment conditions were equally efficacious and more efficacious than the waiting-list condition and the treatment gains were maintained at 1-year follow-up.

'Enhanced' Cognitive–behavioral Therapy Treatments
During the past 3 years, several authors have published studies attempting to enhance traditional CBT treatment programs.
Rubin et al. [29] have investigated four different exposure modalities: a prolonged exposure condition, a positively enhanced dosed exposure (PDE) condition, a dosed-only exposure condition, and a negatively supplemented dosed exposure (NDE) condition. Both the PDE and dosed-only exposure conditions produced less measured aversive arousal and significantly more rapid arousal reduction than the tested alternatives.
Rapee et al. [30] randomly allocated individuals with social phobia to one of three treatments: standard cognitive restructuring plus in-vivo exposure, an 'enhanced' treatment that augmented the standard program with several additional treatment techniques (e.g., performance feedback and attention retraining), and a nonspecific (stress management) treatment. The enhanced treatment demonstrated significantly greater effects on diagnoses, diagnostic severity, and anxiety during a speech. The enhanced treatment also showed significantly greater effects than standard treatment on two putative process measures: cost of negative evaluation and negative views of one's skills and appearance.
In a randomized, double-blind, placebo-controlled trial, Guastella et al. [31] administered 24 IU of oxytocin or a placebo in combination with exposure therapy to participants with a primary diagnosis of SAD. Participants administered oxytocin showed improved positive evaluations of appearance and speech performance as exposure treatment sessions progressed. These effects did not, however, generalize to improve the overall treatment outcome from exposure therapy. Participants who received oxytocin or placebo reported similar levels of symptom reduction following treatment across symptom severity, dysfunctional cognition, and life-impairment measures.
Borgeat et al. [32] have compared the effect of two group treatments at eight weekly sessions: Self-Focused Exposure Therapy, which is based essentially on prolonged exposure to public speaking combined with positive feedback, and a more standard cognitive and behavioral method encompassing psychoeducation, cognitive work, working through exposure hierarchies of feared situations for exposure within and outside the group. The results indicate that positive cognitive change can be achieved more rapidly with noncognitive methods, while avoidance decreases more reliably with a standard approach rather than an approach with an exclusive focus on exposure.
Donahue et al. [33] have investigated the effect of a single dose of 25 mg of quetiapine in individuals with SAD 1 h before they were exposed to a 4-min virtual reality public-speaking challenge. A parallel exposure challenge occurred 1 week later using a counter-balanced cross-over (within individual) design for the medication–placebo order between the two sessions. The results showed no significant drug effect for quetiapine on the primary outcome measures, suggesting that a single dose of 25 mg quetiapine is not effective in alleviating SAD symptoms in individuals with fears of public speaking.
Guastella et al. [34] have confirmed the findings of Hofmann et al. [35] concerning the effect of short-term dosing of D-cycloserine (DCS) as an adjunctive intervention to exposure therapy for SAD. In a randomized, double-blind, placebo-controlled trial, participants administered DCS prior to exposure reported greater improvement on measures of symptom severity, dysfunctional cognitions, and life-impairment from SAD in comparison with placebo-treated participants.
Bergamaschi et al. [36] have compared the effects of a single dose of cannabidiol (CBD) versus placebo administered 1 h and a half before a speech test. Pretreatment with CBD significantly reduced anxiety, cognitive impairment, and discomfort in individuals' speech performance, and significantly decreased alert in their anticipatory speech.

Correspondence Between Neural and Behavioral Functioning
Miskovic et al. [37] have provided the evidence of concomitant improvement in neural and behavioral functioning among socially anxious adults undergoing psychotherapy. The authors used a double-baseline, repeated measures design, in which adults with a principal diagnosis of SAD completed 12 weekly sessions of standardized group cognitive–behavioral therapy and four electroencephalogram (EEG) assessments: two before treatment, one in the middle of treatment, and one after treatment. Treatment was associated with reductions in symptom severity across multiple measures and informants, as well as with reductions in delta–beta coupling at rest and during speech anticipation. In addition, the EEG cross-frequency profiles in the clinical group normalized by the posttreatment assessment.

Discussion
A considerable number of studies have been published on various aspects of public-speaking anxiety during the past 3 years, including studies on physiological and psychological reactivity to public speaking, the nosological position of public-speaking anxiety with regard to other manifestations of SAD, and the efficacy of various treatment modalities, either as stand-alone treatments, combination treatments, or enhanced standard treatments. The studies show that significant advances have been made in the understanding as well as in the treatment of the disorder.

Conclusion
Public-speaking anxiety is a highly prevalent and disabling disorder. It is present in most individuals who suffer from the generalized type of SAD and it also occurs in the absence of other manifestations of SAD. It is amenable to treatment, in particular to CBT focusing upon cognitive restructuring and graded exposure to the feared environments. Recent treatment modalities involve the use of new technologies, such as virtual reality and the Internet.

 

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