Running Head: TREATING SOCIAL ANXIETY IN TEENAGE GIRLS
Treating Social Anxiety in Teenage Girls Using Theory-Driven Game Design
Katie Dobruse
Michigan State University
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Abstract
For healthy individuals, anxiety is a normal reaction to stressful situations. While a certain
amount of anxiety is perfectly normal, those who suffer from anxiety disorders find their daily
lives disrupted by the severity of their worries and fears. Anxiety occurs significantly more often
in women than men, and this disparity arises during adolescence. Anxiety is frequently
associated with depression, and in teenagers both are associated with suicidal thoughts/behaviors
and substance abuse. Because of the increased frequency of anxiety disorders in teenage girls
relative to teenage boys, as well as the social, emotional, and physical risks that they face, the
goal of this project is to design a serious game aimed at teenage girls with anxiety disorders as
part of a Cognitive-Behavioral Therapy treatment program.
Keywords: anxiety, Cognitive-Behavioral Therapy, Theory of Planned Behaviors, SocialCognitive Theory
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Treating Social Anxiety in Teenage Girls Using Theory-Driven Game Design
Problem
Incidence
According to the National Institute of Mental Health, anxiety disorders affect 40 million
American adults each year with female sufferers being 60% more likely than male (“Anxiety
Disorders,” n.d.). Approximately 8% of teenagers 13–18 suffer from anxiety disorders;
treatment can involve medication, psychotherapy, or a combination thereof (“Anxiety
Disorders,” n.d.). If left untreated, the consequences of anxiety can be severe, yet only 18% of
teens 13-18 with anxiety disorders receive treatment (“Anxiety Disorders,” n.d.). The high cost
of prescription medication and cognitive-behavioral therapy (one of the most effective treatments
for anxiety disorders) means that many patients who would benefit from treatment do not have
access to it (“Low-Cost Treatment,” n.d.).
Science is only beginning to understand why there is such a marked gender disparity. In
children, incidence of anxiety is not significantly different, but from 13 to 26 years of age
anxiety sharply spikes in females, while the increase for males is much less significant (Beesdo,
Knappe, and Pine, 2011). Part of this is thought to due to the changes adolescent brains undergo
during puberty: “Brain scans of teens sizing each other up reveal an emotion circuit activating
more in girls as they grow older, but not in boys. This finding highlights how emotion circuitry
diverges in the male and female brain during a developmental stage in which girls are at
increased risk for developing mood and anxiety disorders” (“Anxiety Disorders in Children,”
n.d.).
Consequences
TREATING SOCIAL ANXIETY IN TEENAGE GIRLS
Teenage sufferers of severe anxiety also exhibit a host of physical symptoms, including
“muscle tension and cramps, stomachaches, headaches, pain in the limbs and back, fatigue, or
discomforts associated with pubertal changes. They may blotch, flush, sweat, hyperventilate,
tremble, and startle easily” (Pruitt, 2000). A major consequence of severe anxiety in teenagers,
especially severe social anxiety, is school avoidance. The physical symptoms these teens
experience, along with the original anxiety, can keep them from attending classes or taking part
in school activities. Consequently, both their academic performance and self-esteem deteriorate
(Pruitt, 2000). More than classroom learning is harmed by school avoidance; adolescence is a
critical period for social learning, which suffers when anxiety prevents a student from attending
school (Steingard, 2013).
Even more serious are the increases in suicidal thoughts/behaviors and substance abuse,
both of which are closely tied to depression and anxiety in teenagers. Suicide ranks as the third
highest cause of death among 15 to 24 year olds, and the majority of these victims also suffer
from a mental illness (Steingard, 2013). By that same token, anxiety and depression are the two
most common psychiatric disorders associated with substance abuse in teens, which account for
the majority of cases (Steingard, 2013).
Treatment
One of the most effective forms of therapy for anxiety disorders is Cognitive-Behavioral
Therapy (“Anxiety Disorders,” n.d.). CBT teaches patients to understand the thought processes
that underlie their fears, both to understand the impact that this anxiety has on them and to
prepare themselves to encounter the source(s) of their anxiety; this in turn allows patients to
prepare their reactions to specific anxiety-producing circumstances (Pruitt, 2000). Often this
involves exposure to the fear in a controlled setting to prove that the fear is not as severe as the
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patient’s anxiety makes it seem: CBT teaches patients “to challenge those negative thoughts, to
recognize the pattern and train themselves to think outside it” (Steingard, 2013).
Solution
I’m proposing a game version of CBT for teenage girls with severe social anxiety. The
player will have to navigate social situations given a series of scripted dialogues to choose from.
In part this will help patients by giving them default language to use to handle situations they
find awkward or uncomfortable. Ideally, the game would involve speech-recognition software
and eye-tracking software. The former would require the player to practice actually saying the
dialogue out loud; the latter would be used to ensure that players kept eye-contact with the
computer-player. The environment is a safe, controlled one, so if the player selects a socially
inappropriate answer, the consequences would be minor, and at least they would learn what not
to say. I would expect this to take place as part of a therapy program with a psychiatrist,
psychologist, or other certified mental health professional. This would benefit from partnerships
with local schools, to integrate this into their counseling resources. Another benefit of this would
be to make treatment more accessible: girls could play the game multiple times per week in the
counselor’s office and space out visits with a CBT therapist to more affordable intervals.
Theory
The first theory I plan to utilize to construct this project is Social Cognitive Theory
(SCT). SCT posits that the chances of someone making a change to a health behavior are
determined by three factors: “(1) self-efficacy, (2) goals, and (3) outcome expectancies” (US
Department of Health, 2005, p. 20). An important part of any effective therapy program is the
patient’s sense of self-efficacy: she needs to be able to believe in her own ability to overcome the
challenges in her life in order to get better. Players would work with their therapist to set
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personal goals for what they wanted to achieve by playing this game. For some, it might be
speaking up when talking with another person; for others, it might be maintaining eye-contact
while speaking. The point is for patients to have a stake in their own recovery and to believe that
recovery is in fact possible for them.
I will also use the Theory of Planned Behaviors (TPB) to shape players’ perceptions of
social norms. Since individual’s intentions are the most important part of TPB, the focus of the
game’s CBT will be to encourage players to want to make changes in their behaviors. The goal
will be to take a three-pronged approach. For example, the player’s attitude toward the
behavior (say, making small talk) will be changed so that it seems like a less intimidating
activity. Then, by establishing baselines for conversation topics, the game will help re-establish
subjective norms for those who feel like they can’t tell what those are (i.e., those with social
anxiety). This in turn will affect the player’s perceived control over social interactions, making
them seem less intimidating.
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References
Anxiety disorders. (n.d.). Retrieved September 21, 2013, from National Institute of Mental
Health website: http://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml
Anxiety disorders in children and adolescents (fact sheet). (n.d.). Retrieved September 21, 2013,
from National Institute of Mental Health website:
http://www.nimh.nih.gov/health/publications/anxiety-disorders-in-children-andadolescents/index.shtml
Beesdo, K., Knappe, S., & Pine, D. S. (2011). Anxiety and anxiety disorders in children and
adolescents: Developmental issues and implications for DSM-V. Psychiatric Clinics of
North America, 32(3), 483-524. http://dx.doi.org/10.1016/j.psc.2009.06.002
Low-Cost treatment. (n.d.). Retrieved September 22, 2013, from Anxiety and Depression
Association of America website: http://www.adaa.org/finding-help/treatment/low-costtreatment
Pruitt, D. (Ed.). (2000). Your adolescent: Emotional, behavioral, and cognitive development
from early adolescence through the teen years. New York, NY: HarperCollins.
Steingard, R. J. (2013, January 22). Mood disorders and teenage girls: Why they are more
vulnerable than boys, and what signs and symptoms you should look for. Retrieved
September 21, 2013, from http://www.childmind.org/en/posts/articles/mood-disordersteenage-girls-anxiety-depression
US Department of Health and Human Services National Institutes of Health. (2005). Theory at a
glance: A guide for health promotion practice (B. K. Rimer & K. Glanz, Authors).