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

  • Stéphane Bouchard (a1), Stéphanie Dumoulin (a2), Geneviève Robillard (a3), Tanya Guitard (a3), Évelyne Klinger (a4), Hélène Forget (a3), Claudie Loranger (a5) and François Xavier Roucaut (a6)...

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.


To show that conducting VR exposure in CBT for SAD is effective and is more practical for therapists than conducting exposure in vivo.


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.)


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.


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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Corresponding author
Stéphane Bouchard, PhD, Université du Québec en Outaouais, Département de psychoéducation et de psychologie, CP 1250, Succ Hull, Gatineau, Québec, Canada. Email:
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See editorial, pp. 245–246, this issue.

Declaration of interest

S.B. and G.R. are consultants to and own equity in Cliniques et Développement In Virtuo, which develops virtual environments; however, Cliniques et Développement In Virtuo did not create the virtual environments used in this study. The terms of these arrangements were reviewed and approved by Université du Québec en Outaouais, in accordance with its policy on conflicts of interest.

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

  • Stéphane Bouchard (a1), Stéphanie Dumoulin (a2), Geneviève Robillard (a3), Tanya Guitard (a3), Évelyne Klinger (a4), Hélène Forget (a3), Claudie Loranger (a5) and François Xavier Roucaut (a6)...
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Virtual reality compared with in vivo exposure… – A reply to Verma and Verma.

Stéphane Bouchard, Full professor, UQO
12 June 2018

First, we want to thank Verma and Verma (2018) for their review, and comment and thus the use of only self-report is not “acknowledged by the authors”. Patient’s performance in an impromptu speech was recorded and rated by independent assessors. Results on the BAT support results from self-reports.

To clarify the randomization procedure that was used, as stated in the article, we used a table of random numbers. Following the procedures and table from Kirk (1982), before starting recruitment we created a list of which condition participants would be randomly assigned to. When a participant met the selection criteria, he or she was assigned to the next available slot on the list, with number 1, 2 or 3 corresponding to the experimental conditions.

As for the potential effect of self-exposure at home, it is indeed a potential limitation of the study. Care was taken to limit self-exposure with anti in vivo exposure instructions given to participants in the in virtuo condition and no homework given to all participants. Self-exposure, intended or unintended by participants, remains a possibility. But it is doubtful the success of in virtuo exposure, especially when it was superior to in vivo, could be attributed to this limitation.

Verma and Verma mentioned relevant limitations associated with the use of a waiting list compared to a placebo control condition. But when designing a clinical study, these limitations must be carefully weighed against ethical and practical considerations, especially when a gold-standard control condition is also included in the research design. Using Solomon’s 4-group design is indeed a very effective solution to control for the effect of assessment.

In conclusion, it is interesting to highlight one of the findings of the study which might have not caught the attention of Verma and Verma. When it comes to cost / effectiveness, our results showed that using VR to conduct exposure was at least as effective as in vivo, and more effective on some measures such as the LSAS, but also less costly in terms of efforts and financial burden based on the SWEAT.


Kirk, R. .E. (1982). Experimental design (2nd Edition). Brooks/Cole Publishing.

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Conflict of interest: Prof Bouchard is the leading author of the article reviewed by Verma and Verma.

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Virtual reality compared with in vivo exposure in the treatment of social anxiety disorder

Rohit Verma, Assistant Professor of Psychiatry, All India Institute of Medical Sciences New Delhi India
Kamini Verma, Junior Resident, All India Institute of Medical Sciences New Delhi India
05 April 2018

The current article builds upon many facets of methodological deficiencies in previous literature on the issue of utility of virtual reality (VR) therapies in managing social anxiety disorder (SAD).

Positive critique -

The study used multiple scales for assessing various facet of SAD and therapy that usually is lacking in studies utilizing psychotherapies (in particular VR/ computer stimulated therapies) such as measure for assessing burden, challenges and costs of conducting exposure, measures to assess the component of how feasible it is for the therapist to perform the therapy and scales for unwanted negative side-effects induced by immersions in VR (cyber sickness). The study made the sample more similar to real-world setting by including patients with other comorbities like depression, generalized anxiety disorder, panic attacks, and substance use which increases the generalizability of findings. It also described the cognitive behavior therapy in somewhat detail which usually is lacking in psychotherapy studies.

The study also reported on the consistency in findings measured by follow up at 6 months. Moreover, it used both performance and non-performance social situations in the treatment of SAD with VR increasing the importance of findings.

Negative critique -

The findings are based only on self-reports (as acknowledged by authors too) restricting its firm conclusions. The information regarding randomization process was not mentioned, although the authors did mention that therapist and patient were concealed of which group they belong till the first therapy session begin.

A possible bias could have arisen due to the fact that individuals receiving in-virtuo CBT after first 7 sessions of cognitive therapy would have gone out in real world and may have experienced real in-vivo exposures which might create bias in outcome by rendering the differences attributable not just solely on basis of in-virtuo exposure.

The researchers used wait-list as controls, which has been reported in psychotherapy literature to be acting not as placebo but rather as a nocebo (Hart et al, 2008). Effect size using a waiting list has been reported to be more as compared to using placebo. Psychological placebo is associated with a significantly greater reduction of symptoms than placement on a waiting list, possibly due to effects of anticipation, hope, or faith. Also, there was no independent, blinded investigator to assess the outcome.

Another facet of consideration in such psychotherapeutic studies is the recognition of the Solomon 4 group design effect as assessments may interact with interventions to either strengthen or weaken the observed effects producing biased estimates of effects (McCambridge et al, 2011).

Overall, the study paves way towards strengthening of the evidence towards utility of VR applications in psychiatric conditions for a positive outcome.


Hart T, Fann JR, Novack TA. The dilemma of the control condition in experience-based cognitive and behavioural treatment research. Neuropsychol Rehabil. 2008 Jan;18(1):1-21.

McCambridge J, Butor-Bhavsar K, Witton J, Elbourne D. Can research assessments themselves cause bias in behaviour change trials? A systematic review of evidence from solomon 4-group studies. PLoS One. 2011;6(10):e25223.
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Conflict of interest: None declared

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