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Cited by 355Anxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesVirtual Reality Applications and ImpactsDigital Mental Health Interventions

Virtual reality compared with in vivo exposure in the treatment of social anxiety disorder: A three-arm randomised controlled trial

Open access
Bouchard, Stéphane, Dumoulin, Stéphanie, Robillard, Geneviève, Guitard, Tanya, Klinger, Évelyne, Forget, Hélène, Loranger, Claudie, Roucaut, François Xavier·2017·British Journal of Psychiatry
DOI 10.1192/bjp.bp.116.184234
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Abstract

Background: People with social anxiety disorder (SAD) fear social interactions and may be reluctant to seek treatments involving exposure to social situations. Social exposure conducted in virtual reality (VR), embedded in individual cognitive–behavioural therapy (CBT), could be an answer. Aims: To show that conducting VR exposure in CBT for SAD is effective and is more practical for therapists than conducting exposure in vivo. Method: Participants were randomly assigned to either VR exposure ( n = 17), in vivo exposure ( n = 22) or waiting list ( n = 20). Participants in the active arms received individual CBT for 14 weekly sessions and outcome was assessed with questionnaires and a behaviour avoidance test. (Trial registration number ISRCTN99747069.) Results: Improvements were found on the primary (Liebowitz Social Anxiety Scale) and all five secondary outcome measures in both CBT groups compared with the waiting list. Conducting exposure in VR was more effective at post-treatment than in vivo on the primary outcome measure and on one secondary measure. Improvements were maintained at the 6-month follow-up. VR was significantly more practical for therapists than in vivo exposure. Conclusions: Using VR can be advantageous over standard CBT as a potential solution for treatment avoidance and as an efficient, cost-effective and practical medium of exposure.

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Crossref · 10.1192/bjp.bp.116.184234

Cites

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Claims the paper makes

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  • Findingown data
    § Results

    Improvements were maintained at the 6-month follow-up.

    “Improvements were maintained at the 6-month follow-up.”
    Quote in the paperSubstantial claim
  • Findingown data
    § Clinical outcome measures

    Time-by-conditions interactions and contrasts revealed that cognitive-behavioural therapy with in virtuo exposure was more effective at follow-up on the Liebowitz Social Anxiety Scale-Self Reported version only.

    “The time6 conditions interactions and contrasts revealed that CBT with in virtuo exposure was more effective at follow-up on the LSAS-SR only (Fig. 2).”
    Quote in the paperSubstantial claim
  • Findingown data
    § Results

    Virtual reality was significantly more practical for therapists than in vivo exposure.

    “VR was significantly more practical for therapists than in vivo exposure.”
    Quote in the paperNot a substantial claim
  • Findingcitation
    § Findings from previous studies and comparison with our findings

    The advantage of in virtuo exposure that we found on certain measures was not observed in earlier social anxiety disorder trials.

    “The superiority of in virtuo exposure that we observed on some of the measures has not been found in these previous studies on SAD 21,23,24”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [21] source

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    • cites [23] source

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    • cites [24] source

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  • Findingown data
    § Implications

    Treatment credibility was not a significant predictor.

    “while treatment credibility was not a significant predictor.”
    Quote in the paperNot a substantial claim
  • May combine two claims. 35
  • Classified as probably not a substantial claim. 39

  • May combine two claims.

    Findingown data
    § Clinical outcome measures

    At the 6-month follow-up, there was a significant time effect across all outcomes from pre-treatment to follow-up, and no significant change between post-treatment and follow-up.

    “As regards the 6-month follow-up analyses, there was a significant time effect across all outcomes from pre-treatment to follow-up, and no significant change between post-treatment and follow-up (Table 4).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data
    § Clinical outcome measures

    Planned contrasts revealed significantly decreased scores in the active treatment conditions compared with the waiting list, and no differences between cognitive-behavioural therapy conditions across all outcomes except the Liebowitz Social Anxiety Scale-Self Reported version and the Social Phobia Scale, where in virtuo exposure was more effective than in vivo exposure.

    “Planned contrasts revealed significantly decreased scores in the active treatment conditions compared with the waiting list, and no differences between CBT conditions across all outcomes except the LSAS-SR and the SPS, where CBT with in virtuo exposure was more effective than CBT with in vivo exposure.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data
    § Results

    Conducting exposure in virtual reality was more effective at post-treatment than in vivo exposure on the primary outcome measure and on one secondary measure.

    “Conducting exposure in VR was more effective at post-treatment than in vivo on the primary outcome measure and on one secondary measure.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data
    § Clinical outcome measures

    Analyses with the waiting-list condition revealed statistically significant effects of time and time-by-condition interaction across all outcome measures.

    “Analyses with the waiting-list condition revealed statistically significant effects of time and time6condition interaction across all outcome measures (Table 3).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data
    § Results

    In both cognitive-behavioural therapy groups compared with the waiting list, improvements were found on the primary outcome measure and all five secondary outcome measures.

    “Improvements were found on the primary (Liebowitz Social Anxiety Scale) and all five secondary outcome measures in both CBT groups compared with the waiting list.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data
    § Clinical outcome measures

    The mean Specific Work for Exposure Applied in Therapy rating for practicality and effort was 15.24.

    “How practical and effortless it was for therapists conducting the exposure, as measured with the SWEAT, was rated at 15. 24”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation
    § Findings from previous studies and comparison with our findings

    Our success rates were considerably higher than those reported by Kampmann et al. and matched those of other social anxiety disorder studies.

    “the success rates were much higher and consistent with other studies on SAD than those found by Kampmann et al. 24”
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    Findingown data
    § Clinical outcome measures

    Reliable change from pre- to post-treatment was observed in 76.5% (13/17) of participants who received cognitive-behavioural therapy with in virtuo exposure, 68.3% (15/22) who received cognitive-behavioural therapy with in vivo exposure, and 30.0% (6/20) in the waiting-list condition.

    “Reliable change from pre-to post-treatment was observed in 76.5% (n = 13/17) of participants who had received CBT with in virtuo exposure, 68.3% (n = 15/22) who had received CBT with in vivo exposure, and 30.0%(n = 6/20) in the waiting-list condition (w 2 (2) = 9.78, P50.01).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data
    § Main findings

    At post-treatment, virtual reality was more effective than traditional exposure on the Liebowitz Social Anxiety Scale-Self Reported version and the Social Phobia Scale; the Social Phobia Scale difference did not reach the corrected significance level at follow-up.

    “At post-treatment, VR was more effective than traditional exposure on the main outcome measure (LSAS-SR) and one of the five secondary outcome measures (SPS, a global assessment of social anxiety).The latter difference did not reach the corrected significance level at follow-up.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data
    § Main findings

    Virtual reality was neither more nor less effective than traditional exposure on the behavioural measure and on measures of fear of social interactions, fear of negative evaluation, and depressive mood.

    “VR was neither more nor less effective than traditional exposure on the behavioural measure and on the measures of fear of social interactions, fear of negative evaluation and depressive mood.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given
    § Implications

    SWEAT results now supply this information.

    “Results on the SWEAT are now providing this information.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data
    § Main findings

    The success rate in terms of reliable change index was high and similar in both active treatment conditions.

    “The success rate in terms of reliable change index was high and similar in both active treatment conditions.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingcitation
    § Findings from previous studies and comparison with our findings

    SWEAT results indicated that exposure was easier to conduct in virtual reality, which allowed greater use of the exposure experiences.

    “First, results on the SWEAT revealed that conducting exposure was simpler in VR, making it possible to exploit the exposure experiences more.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation
    § Introduction

    Psychotherapy can be perceived by patients with social anxiety disorder as highly frightening or as a threat to their privacy.

    “Moreover, psychotherapy itself can be perceived as highly frightening or a threat to their need for privacy. 6”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [6] source

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    Study design and conductnone given
    § Method

    The trial was registered with ISRCTN: 99747069.

    “The trial was registered with ISRCTN: 99747069.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductcitation
    § Therapist intervention adherence and quality

    Treatment standardisation was maximised using treatment manuals and treatment fidelity was maximised through weekly supervisions from the principal investigator.

    “Treatment standardisation was maximised using treatment manuals 44 and treatment fidelity was maximised through weekly supervisions from the principal investigator.”
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    Study design and conductcitation
    § Therapist intervention adherence and quality

    Adherence to research protocols was assessed by independent raters who reviewed videos of therapy sessions.

    “Adherence to research protocols was also assessed by independent raters who reviewed videos of therapy sessions based on a grid used in previous CBT studies. 45”
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    • cites [45]

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    Premisereasoning
    § Introduction

    Using virtual reality with social anxiety disorder requires a larger range of scenarios, cues eliciting social fears, and virtual environments than with specific phobias.

    “Compared with phobias, using VR with SAD requires a larger range of scenarios, cues eliciting social fears and virtual environments.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation
    § Conclusions

    Therapists can vary the context of immersion without leaving the office, allowing complete confidentiality and maximising generalisation of inhibitory learning.

    “Therapists also have the possibility of varying the context of immersion (for example shops, restaurants) without ever leaving the office, allowing for complete confidentiality and maximising the generalisation of inhibitory learning. 15”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [15] source

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  • Classified as probably not a substantial claim. May combine two claims.

    Premisereasoning
    § Introduction

    In vivo exposure exercises raise issues regarding arousal and loss of privacy and may be cumbersome for therapists.

    “However, in vivo exposure exercises (for example asking for the time on the street, browsing in a shop) raise the same issues regarding arousal and loss of privacy as CBT in a group format and may be cumbersome for therapists”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation
    § Introduction

    Social anxiety disorder remains largely undertreated despite being frequent, severe, and having effective treatments available.

    “Paradoxically, despite its frequency, severity and the existence of effective treatments, SAD remains largely undertreated. 2,3”
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    Premisecitation
    § Introduction

    People with social anxiety disorder tend to avoid healthcare services in the same way they avoid other social interactions.

    “Patients with SAD seem to avoid healthcare services like they do other social interactions. 3,4”
    Quote in the paperNot a substantial claim0 of 2 sources checked
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    Study design and conductnone given
    § Method

    The institutional review board approved the protocol and all patients provided written informed consent after receiving a complete description of the study.

    “The institutional review board approved the protocol and all patients provided written informed consent after receiving a complete description of the study.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § Introduction

    Individual cognitive-behavioural therapy can overcome the limits of the group format.

    “Therapy in an individual setting can be an alternative to the group format that overcomes those limits. 11”
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    Study design and conductnone given
    § Statistics

    Intent-to-treat analyses based on all participants who completed the baseline assessment were conducted using last-observation carried-forward for those who did not complete treatment.

    “Intent-to-treat analyses based on data from all participants who completed the baseline assessment (Fig. 1) were conducted using the last-observation carried-forward for those who did not complete treatment.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation
    § Introduction

    Patients with social anxiety disorder often wait many years before consulting, by which time complications have already occurred.

    “Patients with SAD often wait many years while their symptoms evolve before consulting, by which time complications have already occurred. [2][3]][4]”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [2][3]][4]

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  • Classified as probably not a substantial claim.

    Interpretationreasoning
    § Conclusions

    The use of virtual scenarios allows for controlled, manageable and reproducible social exposure.

    “The use of virtual scenarios allows for controlled, manageable and reproducible social exposure.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation
    § Introduction

    Virtual reality technologies have been used extensively with specific phobias, but their applications now extend to more complex disorders.

    “These technologies have been used extensively with specific phobias (such as fear of flying) but their applications now extend to more complex disorders (for example obsessive-compulsive disorder, generalised anxiety disorder). 13”
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    Study design and conductnone given
    § Selection criteria

    All diagnoses were reviewed and confirmed by a second assessor.

    “all diagnoses were reviewed and confirmed by a second assessor”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data
    § Systematic assessment

    The speech behaviour was evaluated by three independent assessors masked to hypotheses and treatment conditions.

    “The speech was video recorded and the patients' behaviour was evaluated using the Social Performance Rating Scale (SPRS) 32 by three independent assessors, masked to hypotheses and treatment conditions.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [32] source

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  • May combine two claims.

    Interpretationreasoning
    § Conclusions

    Using virtual reality can be advantageous over standard cognitive-behavioural therapy as a potential solution for treatment avoidance and as an efficient, cost-effective and practical medium of exposure.

    “Using VR can be advantageous over standard CBT as a potential solution for treatment avoidance and as an efficient, cost-effective and practical medium of exposure.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisereasoning
    § Introduction

    Virtual reality or in virtuo exposure can overcome the drawbacks of standard cognitive-behavioural therapy.

    “These drawbacks of standard CBT can be overcome with an alternative medium of exposure: virtual reality (VR) or in virtuo exposure”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation
    § Introduction

    People with social anxiety disorder feel ashamed of their symptoms and fear discussing them with others, including healthcare professionals.

    “They feel ashamed of their symptoms and fear discussing them with others, including healthcare professionals. 5”
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    Premisecitation
    § Introduction

    The consensus in psychotherapy for social anxiety disorder calls for cognitive-behavioural therapy in either individual or group format.

    “The consensus in the field of psychotherapy calls for cognitive-behavioural therapy (CBT) either in an individual or group format. 9,10”
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    • cites [9]

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    Premisecitation
    § Introduction

    Group cognitive-behavioural therapy has limitations: treatment may be less individualised and exposure may be difficult for the therapist to manage.

    “Because of the need to manage a whole group of people, treatment may be less individualised and exposure difficult to handle for the therapist.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [11]

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    Study design and conductcitation
    § Statistics

    A power analysis was conducted using effect sizes from previous studies.

    “When planning the study, a power analysis was conducted using effect sizes from previous studies. 11,18,23”
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    • Rests on an assumption: In vivo exposure is the gold-standard condition for cognitive-behavioural therapy in social anxiety disorder.

  • Classified as probably not a substantial claim.

    Study design and conductnone given
    § Selection criteria

    Random assignments were generated with a random numbers table prior to recruitment.

    “Random assignments were generated with a random numbers table prior to recruitment.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data
    § Systematic assessment

    The primary outcome was identified before the study began as the total score on the Liebowitz Social Anxiety Scale-Self Reported version.

    “The primary outcome was identified before the study began as the total score on the Liebowitz Social Anxiety Scale-Self Reported version (LSAS-SR)”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § Introduction

    Effective treatments for social anxiety disorder rely on medication or psychotherapy.

    “There are effective treatments for SAD that rely on medication or psychotherapy. [7][8]8][9]”
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    • cites [7][8]8][9]

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    Study design and conductown data
    § Recruitment and attrition

    None of the paired t-tests suggested a significant increase in Simulator Sickness Questionnaire scores across sessions.

    “Paired t-tests were conducted for each session and none suggested a significant increase in SSQ scores (statistics not reported, all P40.2).”
    Quote in the paperNot a substantial claim

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    Study design and conductnone given
    § Selection criteria

    Assignments were concealed until the first therapy session began.

    “Assignments were concealed until the first therapy session began.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductreasoning
    § Therapy

    Cognitive-behavioural therapy with in virtuo exposure followed the same methodology as cognitive-behavioural therapy with in vivo exposure, with the only difference being that it exclusively used virtual reality immersion to conduct exposure and no in vivo exposure.

    “CBT with in virtuo exposure followed the same methodology as CBT with in vivo exposure, with the only difference that it exclusively used VR immersion to conduct exposure (i.e.no in vivo exposure).”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Participants in the in virtuo condition complied with the instruction not to engage in any in vivo exposure.

  • May combine two claims.

    Interpretationown data
    § Main findings

    Results confirmed both hypotheses: conducting cognitive-behavioural therapy with in virtuo exposure was effective and more practical for therapists than cognitive-behavioural therapy with in vivo exposure.

    “Results confirmed both hypotheses: conducting CBT with in virtuo exposure was effective and more practical for therapists than CBT with in vivo exposure.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: In vivo exposure is the gold-standard condition for cognitive-behavioural therapy in social anxiety disorder.

  • May combine two claims.

    Study design and conductown data
    § Limitations

    Behavioural assessments were used instead and corroborated the self-report findings.

    “Behavioural assessments were chosen instead and support results found with self-reports.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning
    § Findings from previous studies and comparison with our findings

    The restriction of exposure to conversations with virtual characters, together with the lack of a cognitive component, could account for the lower effectiveness of in virtuo exposure compared with other trials.

    “Limiting exposure to talking to virtual characters and the absence of a cognitive component that facilitates how exposure is mentally processed by patients may explain why in virtuo exposure was less effective than in other published trials.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation
    § Findings from previous studies and comparison with our findings

    In Anderson et al, patients improved significantly with treatment and improvements were maintained after 1 year.

    “Patients improved significantly with treatment and improvements were maintained after 1 year.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [21] source

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    Premisecitation
    § Implications

    New virtual environments can depict more complex social interactions and use virtual characters with promising artificial intelligence.

    “New virtual environments can now depict more complicated social interactions 15 and rely on virtual characters with promising artificial intelligence. 24”
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  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing). May combine two claims.

    Interpretationreasoning
    § Implications

    Since virtual reality exposure is less cumbersome and becoming more affordable, acceptance of the technology should increase.

    “Because conducting exposure in VR is less cumbersome and rapidly becoming more affordable, there should be an increase in acceptance of this technology.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Virtual reality is rapidly becoming more affordable.

  • Classified as probably not a substantial claim.

    Interpretationnone given
    § Implications

    A key contribution of this study is its use of a measure that assesses the burden, challenges and costs of conducting exposure.

    “One important contribution of this study is the use of a measure assessing the burden, challenges and costs of conducting exposure.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationreasoning
    § Findings from previous studies and comparison with our findings

    Lack of direct therapist support may have harmed the therapeutic alliance and thereby lowered the effectiveness of in virtuo exposure.

    “The absence of direct support from the therapist might have had a negative impact on the therapeutic alliance and thus might have reduced the efficacy of in virtuo exposure.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § Findings from previous studies and comparison with our findings

    Previous studies have shown that giving a speech in front of a virtual audience can elicit distress and physiological arousal in patients with social anxiety disorder.

    “Previous studies have shown that giving a speech in front of a virtual audience can elicit distress and physiological arousal in patients with SAD. 17”
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    Premisecitation
    § Findings from previous studies and comparison with our findings

    Numerous studies have shown the efficacy of in virtuo exposure for treating fear about public speaking.

    “Numerous studies have also shown the efficacy of in virtuo exposure for treating fear about public speaking. [18][19]9][20]”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [18][19]9][20]

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  • May combine two claims.

    Interpretationown data
    § Findings from previous studies and comparison with our findings

    Because therapeutic alliance predicted outcome, the therapist's role in delivering exposure is important.

    “Second, the importance of the therapeutic alliance in predicting outcome highlights the importance of the therapists in conducting exposure.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § Findings from previous studies and comparison with our findings

    In Anderson et al, the quality of the working alliance was not different between the two treatment conditions.

    “Furthermore, the quality of the working alliance was not different in the two treatment conditions. 22”
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    • cites [22] source

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    Premisecitation
    § Findings from previous studies and comparison with our findings

    Kampmann et al's randomised controlled trial found that participants in both treatment conditions improved from pre- to post-assessment on social anxiety, avoidance, speech duration during a behavioural assessment task, perceived stress, and avoidant personality disorder related beliefs compared with the waiting-list control group.

    “Results revealed that participants in both treatment conditions improved from pre-to postassessment on social anxiety, avoidance, speech duration during a behavioural assessment task, perceived stress, and avoidant personality disorder related beliefs when compared with the waiting-list control group. 24”
    Quote in the paperSubstantial claim0 of 1 sources checked
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    Interpretationreasoning
    § Limitations

    An RCT in which all stimuli were perfectly matched across conditions would have greater validity.

    “Nevertheless, conducting an RCT with all stimuli perfectly matched between conditions would increase the validity of the trial.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning
    § Limitations

    The absence of independent, masked clinical assessors raises concerns about the objectivity of questionnaire-based clinical assessments.

    “First, the lack of clinical evaluations by independent assessors masked to the study raises the potential issues of the objectivity of clinical assessments using questionnaires.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation
    § Main findings

    These results support what has been found with other anxiety disorders and show that cognitive-behavioural therapy combined with exposure in virtual reality is an effective and efficient alternative to classical individual cognitive-behavioural therapy, acutely and in the long term.

    “These results support what has been found with other anxiety disorders 13 and show that CBT combined with exposure in VR is an effective and efficient alternative to classical individual CBT, acutely and in the long term.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [13]

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  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based). May combine two claims.

    Interpretationnone given
    § Limitations

    Individual virtual reality exposure may appeal more to patients who avoid social exposure or who require strict confidentiality about their disorder.

    “However, individual exposure with VR may be more enticing to patients disinclined from social exposure or sensitive to strict confidentiality concerning their disorder.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation
    § Findings from previous studies and comparison with our findings

    Kampmann et al found cognitive-behavioural therapy with in vivo exposure superior to cognitive-behavioural therapy with in virtuo exposure on multiple variables such as social anxiety and personality disorder related beliefs.

    “However, CBT with in vivo exposure was found superior to CBT with in virtuo exposure on multiple variables (such as social anxiety, personality disorder related beliefs).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [24] source

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    Premisecitation
    § Limitations

    That study concerned specific phobia of heights, and its exposure scenarios were limited to three situations.

    “However, this was a study on the specific phobia of heights, the exposure scenarios were limited to three situations”
    Quote in the paperNot a substantial claim0 of 1 sources checked
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61 of 61

  • The paper relies on this without support.

    In vivo exposure is the gold-standard condition for cognitive-behavioural therapy in social anxiety disorder.

    “large with the gold-standard condition (i.e.Cohen's f of 0.4, for a total n of 78).”

  • The paper relies on this without support.

    Participants in the in virtuo condition complied with the instruction not to engage in any in vivo exposure.

    “Participants in the in virtuo condition were instructed not to engage in any exposure in vivo.”

  • The paper relies on this without support.

    Group CBT is as effective as individual CBT and is widely used.

    “although the group format is equally effective and widely used”

  • The paper relies on this without support.

    Therapists may be reluctant to adopt virtual reality.

    “Therapists may be reluctant to use VR”

  • The paper relies on this without support.

    Virtual reality is rapidly becoming more affordable.

    “rapidly becoming more affordable”
5 of 5

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Cognitive-behavioral therapy (CBT) with exposure in virtual reality (VR) is a promising intervention for treating speaking anxiety in pediatric populations.

    “Cognitive-behavioral therapy (CBT) with exposure in virtual reality (VR) emerges as a promising intervention for treating speaking anxiety in pediatric populations.”

    From Speaking face-to-face with a virtual avatar to reduce anxiety in students who stutter: Tool development and pilot study results. (2026) · cites this paper as Bouchard et al., 2017

    The Results report improved social-anxiety outcomes with CBT using VR exposure, and the In virtuo exposure section includes speaking before a virtual audience. But the Selection criteria limit participants to ages 18–65, so the study does not establish effectiveness in pediatric populations; it also evaluates social anxiety disorder rather than speaking anxiety alone. Page numbers were not available in our copy. (LLM, conf=0.90)

    Experimental — accuracy not yet measured

  • Therapists have no control over in vivo treating context, which can elevate patient arousal and raise privacy issues.

    “In addition, therapists have no control over in vivo treating context, which can elevate patient arousal and raise privacy issues (Bouchard et al., 2017; Stangier et al., 2003).”

    From Speaking face-to-face with a virtual avatar to reduce anxiety in students who stutter: Tool development and pilot study results. (2026) · cites this paper as Bouchard et al., 2017

    The opening discussion of CBT limitations says in vivo exposure can raise arousal and privacy concerns. But “no control” over the treatment context is too absolute: the In vivo exposure section describes therapist-guided exercises adjusted to patients’ needs, while the Conclusions contrast these with the greater control offered by virtual scenarios. Page numbers are not available in the supplied passages. (LLM, conf=0.85)

    Experimental — accuracy not yet measured

  • Virtual reality treatment for anxiety-related disorders is effective and particularly useful for social anxiety.

    “The virtual reality method of treating anxiety-related disorders is effective and especially useful for tackling social anxiety.”

    From Fear and Anxiety in COVID-19: Preexisting Anxiety Disorders (2021) · cites this paper as Bouchard et al., 2017

    Experimental — accuracy not yet measured

  • In an RCT in SAD patients, both CBT with VRET and CBT with exposure in vivo significantly reduced self-reported SAD symptoms compared to waitlist, and VRET exceeded in vivo on the primary outcome measure.

    “While both exposure conditions were of comparable efficacy regarding most outcome measures, VRET exceeded the in vivo condition in the primary outcome measure, with significantly greater symptom reductions in patients receiving exposure in virtuo.”

    From Virtual Reality exposure therapy in the treatment of public speaking anxiety and social anxiety disorder (2024) · cites this paper as Bouchard et al., 2017

  • Exposure-based interventions addressing social fears can be resource-intensive and time-consuming.

    “Exposure-based interventions addressing social fears can be resource-intensive and time-consuming due to the need to facilitate exposure exercises often outside the safety of a standardized, closely measured and accompanied environment (Reeves et al., 2022; Bouchard et al., 2017).”

    From Virtual Reality exposure therapy in the treatment of public speaking anxiety and social anxiety disorder (2024) · cites this paper as Bouchard et al., 2017

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

  • In-vivo addiction percentage is incorrect

    Minor

    Two participants in the in-vivo group of 22 represent 9.1%, not the reported 3.4%.

    Reported 3.4 · recomputed 9.090909

  • White participants' overall percentage is too high

    Minor

    The table reports 55 White participants out of a total sample of 59. That is 93.2%, not 94.8%.

    Reported 94.8 · recomputed 93.220339

  • Low-income percentage does not match the count

    Minor

    Sixteen of the 59 participants is 27.1%, rather than the reported 21.1%.

    Reported 21.1 · recomputed 27.118644

  • Medication percentage does not match the sample size

    Minor

    The reported nine participants represent 15.3% of the stated total sample of 59, not 16.7%.

    Reported 16.7 · recomputed 15.254237

  • Addiction count does not equal the group counts

    Minor

    The three group counts for addiction add to four participants, whereas the total column reports five.

    Reported 5 · recomputed 4

5 of 5

Cites

Flagged first, then by citations

1 of the 45 references couldn’t be matched to a known paper.

Research works printed but not linked: 6

  1. Bouchard, 2001, Exploring new dimensions in the assessment of virtual reality induced side effects, J Computer Inform Techn, 1, 20
  2. Bouchard, 2009, Side effects of immersions in virtual reality for anxious people, J Cyber Ther Rehabil, 2
  3. Tisseau, 2008, 1st Workshop on SMA in Biology at meso or macroscopic scales, Paris, July 2, 2008
  4. Bouchard, 2014, Advances in Virtual Reality and Anxiety Disorders.
  5. First, 2002, Structured Clinical Interview for DSM-IV Axis I Disorders (Research edn).
  6. Bouchard, 2007, Revising the factor structure of the Simulator Sickness Questionnaire, Ann Rev Cyberther Telemed, 5

Cited by

Sorted by citations

Related

Authors
Bouchard, S., Dumoulin, S., Robillard, G., Guitard, T., Klinger, É., Forget, H., Loranger, C., & Roucaut, F. X.
Affiliations
Université du Québec en Outaouais (CA)
Corresponding author
Bouchard, Stéphane
ORCID
Venue
British Journal of Psychiatry
Publisher
Royal College of Psychiatrists
Published
2017-04
Volume
210
Issue
4
Pages
276-283
ISSN
  • 0007-1250 (ISSN-L)
  • 1472-1465
DOI
10.1192/bjp.bp.116.184234
OpenAlex
W2565451694
Cited by
354
References
45
Citations by year
2026: 28 · 2025: 38 · 2024: 45 · 2023: 48 · 2022: 39 · 2021: 51 · 2020: 39 · 2019: 31 · 2018: 25 · 2017: 10
FWCI
31.23
Type
journal article
Language
en
Open access
Licence
www.cambridge.org/core/terms (unspecified, 276 d)
Locations
  • The British Journal of Psychiatry (publishedVersion)
  • PubMed (publishedVersion)
Funders
  • Canada Research Chairs (950-10762)
  • Social Sciences and Humanities Research Council of Canada (10762)
Topics
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
  • Physical Sciences › Computer Science › Human-Computer Interaction › Virtual Reality Applications and Impacts
  • Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
Keywords
social anxiety disorder, virtual reality exposure, in vivo exposure, cognitive behavioral therapy, exposure therapy, treatment avoidance, maintenance therapy, cost-effectiveness
MeSH terms
Phobia, Social, Adult, Female, Humans, Implosive Therapy, Male, Middle Aged, User-Computer Interface, Cognitive Behavioral Therapy, Outcome Assessment, Health Care

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-05.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-05.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

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