Inferiority or Even Superiority of Virtual Reality Exposure Therapy in Phobias?—A Systematic Review and Quantitative Meta-Analysis on Randomized Controlled Trials Specifically Comparing the Efficacy of Virtual Reality Exposure to Gold Standard in vivo Exposure in Agoraphobia, Specific Phobia, and Social Phobia
Open accessAbstract
Background: Convincing evidence on Virtual Reality (VR) exposure for phobic anxiety disorders has been reported. However, the benchmark for phobia treatment is in vivo exposure as gold standard. For direct treatment comparisons, the control of confounding variables is essential. Therefore, the comparison of VR and in vivo exposure in studies applying an equivalent amount of exposure in both treatments is necessary. Methods: We conducted a systematic search of reports published until June 2019. Inclusion criteria covered diagnosis of Specific Phobia, Social Phobia, or Agoraphobia, and a randomized-controlled design with an equivalent amount of exposure in VR and in vivo. We qualitatively reviewed participants’ characteristics, materials, and treatment procedures of all included studies. For quantitative synthesis, we calculated Hedges’ g effect sizes for treatment effects of VR exposure, in vivo exposure, and the comparison of VR to in vivo exposure over all studies and separately for studies on each diagnosis. Results: Nine studies (n = 371) were included, four on Specific Phobia, three on Social Phobia, and two on Agoraphobia. VR and in vivo exposure both showed large, significant effect sizes. The comparison of VR to in vivo exposure revealed a small, but non-significant effect size favoring in vivo (g = –0.20). Specifically, effect sizes for Specific Phobia (g = –0.15) and Agoraphobia (g = –0.01) were non-significant, only for Social Phobia we found a significant effect size favoring in vivo (g = –0.50). Except for Agoraphobia, effect sizes varied across studies from favoring VR to favoring in vivo exposure. Conclusions: We found no evidence, that VR exposure is significantly less efficacious than in vivo exposure in Specific Phobia and Agoraphobia. The wide range of study specific effect sizes especially in Social Phobia indicates a high potential of VR, but also a need for a deeper investigation and empirical examination of relevant working mechanisms. In Social Phobia, a combination of VR exposure with cognitive interventions and the realization of virtual social interactions targeting central fears might have advantages. Considering the advantages of VR exposure, its dissemination should be emphasized. Improvements in technology and procedures might even yield superior effects in future.
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VRET, when properly developed, is a more accessible, affordable, and potentially exploitable choice for mental health practitioners and patients.
“while VRET (when properly developed) remains as a more accessible, affordable, and potentially exploitable choice for mental health practitioners and patients (Wechsler et al., 2019).”
From Virtual reality and psychedelics for the treatment of psychiatric disease: A systematic literature review (2020) · cites this paper as Wechsler et al., 2019
The Introduction (Rationale; page unavailable) says VR can reduce the time and cost of changing exposure contexts. The Discussion (Conclusions; page unavailable) describes VRET as time-effective, requiring less organizational effort, and potentially extending treatment to more patients. These passages support accessibility and some cost advantages, but do not establish that VRET is affordable overall or explain what makes it a 'potentially exploitable' choice when properly developed. (LLM, conf=0.84)
Experimental — accuracy not yet measurediVR technology allows a novel controlled exposure that provides the possibility of confronting the phobia in a safe setting and achieving clinically relevant results.
“iVR technology allows a novel controlled exposure that provides the possibility of confronting the phobia in a safe setting and achieving clinically relevant results [22], with evidence showing substantial improvements in therapeutic outcomes [23].”
From SAFEvR MentalVeRse.app: Development of a Free Immersive Virtual Reality Exposure Therapy for Acrophobia and Claustrophobia (2024) · cites this paper as [22]
Results of VRET seem comparable to those found in in vivo exposure.
“results seem to be comparable to the ones found in in vivo exposure (Wechsler et al., 2019).”
From An Internet-based treatment for Flying Phobia using 360° images: Study protocol for a feasibility pilot study (2021) · cites this paper as Wechsler et al., 2019
Meta-analyses show no significant difference between in-vivo exposure therapy and VRET.
“Meta-analyses have shown that no significative difference exists between in-vivo ET and VRET”
From Virtual reality and psychedelics for the treatment of psychiatric disease: A systematic literature review (2020) · cites this paper as Wechsler et al., 2019
In several non-ICU-related mental health disorders, VR exposure is accepted as an effective treatment and user-friendly modality.
“In several non-ICU–related mental health disorders, VR exposure is accepted as an effective treatment and user-friendly modality (14, 15).”
From Virtual Reality to Improve Sequelae of the Postintensive Care Syndrome: A Multicenter, Randomized Controlled Feasibility Study (2021) · cites this paper as [15]
Virtual reality exposure therapy (VRET) is an efficacious treatment of anxiety disorders.
“Virtual reality exposure therapy is an efficacious treatment of anxiety disorders”
From Experiences of gamified and automated virtual reality exposure therapy for spider phobia: qualitative study (2020) · cites this paper as [6]
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- Authors
- Wechsler, T. F., Kümpers, F., & Mühlberger, A.
- Affiliations
- University of Regensburg (DE)
- Corresponding author
- Wechsler, Theresa F.
- Venue
- Frontiers in Psychology
- Publisher
- Frontiers Media SA
- Published
- 2019-09-10
- Volume
- 10
- Pages
- 1758-1758
- ISSN
- 1664-1078 (ISSN-L)
- PMC
- PMC6746888
- OpenAlex
- W2959888472
- Cited by
- 282
- References
- 113
- Citations by year
- 2026: 33 · 2025: 29 · 2024: 50 · 2023: 60 · 2022: 41 · 2021: 46 · 2020: 23
- FWCI
- 2.44
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- Frontiers in Psychology (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- University of Regensburg Publication Server (University of Regensburg) (acceptedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Topics
- Physical Sciences › Computer Science › Human-Computer Interaction › Virtual Reality Applications and Impacts
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Keywords
- virtual reality exposure therapy, in vivo exposure, phobia treatment, agoraphobia, specific phobia, social anxiety disorder, anxiety disorders, treatment efficacy comparison, exposure therapy, cognitive intervention
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