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

Theresa F Wechsler, Franziska Kümpers, Andreas Mühlberger, Theresa F Wechsler, Franziska Kümpers, Andreas Mühlberger

Abstract

Background: Convincing evidence on Virtual Reality (VR) exposure for phobic anxiety disorders has been reported, however, the benchmark and golden standard for phobia treatment is in vivo exposure. 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 the 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 the treatment procedures of all included studies. For quantitative synthesis, we calculated Hedges' g effect sizes for the treatment effects of VR exposure, in vivo exposure, and the comparison of VR to in vivo exposure in 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 points to the 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 be advantageous. Considering the advantages of VR exposure, its dissemination should be emphasized. Improvements in technology and procedures might even yield superior effects in the future.

Keywords: agoraphobia; anxiety disorder; exposure therapy; meta-analysis; social anxiety; specific phobia; systematic review; virtual reality.

Figures

Figure 1
Figure 1
PRISMA flow diagram (Moher et al., 2009) reporting the number of screened studies and the number of studies excluded during the screening process.
Figure 2
Figure 2
Forest plot with pre to post effect sizes for the comparison of VR exposure therapy to in vivo exposure therapy. All effect sizes are reported as Hedges' g, using a fixed-effect model or a random-effect model as stated. Negative effect sizes indicate superiority of in vivo exposure therapy, while positive effect sizes indicate superiority of virtual reality exposure therapy. Studies are sorted by the type of phobia and date of publication.
Figure 3
Figure 3
Funnel Plot for the detection of publication bias across studies with Hedges' g on the x-axis and standard errors for Hedges' g on the y-axis.

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