Group Cognitive Behavioral Therapy With Virtual Reality Exposure Versus In-Vivo Exposure for Social Anxiety Disorder and Agoraphobia: Underpowered Results From the SoREAL Pragmatic Randomized Clinical Trial
Bibliographic record
Abstract
Background: Social anxiety disorder (SAD) and agoraphobia are common, impairing conditions often treated with cognitive behavioral therapy (CBT) conducted in groups. In CBT, exposure therapy is a core element. However, in-vivo exposure therapy is logistically challenging and aversive for both patient and therapist, especially in a group context, often leading to exposure being skipped altogether in clinical practice. Virtual reality exposure (VRE), in which phobic stimuli are presented through immersive virtual reality technology, has shown promise as a flexible alternative to in-vivo exposure. We thus hypothesized that using VRE would result in more overall exposure and more individualized exposure, resulting in statistically significant symptom reduction compared with a group using in-vivo exposure. Objective: This trial evaluated the efficacy of group CBT with VRE (VR-CBT) versus CBT with in-vivo exposure for treating SAD and agoraphobia in clinical settings. Methods: In this randomized, parallel-group, assessor-blinded trial, 177 participants with SAD (n=150) or agoraphobia (n=27) as a primary diagnosis were assigned to either VR-CBT (n=81) or traditional CBT (n=96) across 5 Danish mental health outpatient clinics. Both groups received 14 weekly group sessions. The difference between the 2 treatments was that the VR-CBT group received exposure therapy via head-mounted displays (HMDs) displaying 360° videos of anxiogenic situations for individuals with SAD (eg, presenting at work) and agoraphobia (eg, faulty elevator), while the CBT group conducted traditional in-vivo exposure exercises (eg, presenting to the group, using the clinic elevator). Primary outcomes were phobic anxiety reductions, measured by the Liebowitz Social Anxiety Scale and the Mobility Inventory for Agoraphobia at baseline, posttreatment, and 1-year follow-up (from baseline). Secondary outcomes included work and social functioning, depressive symptoms, and quality of life. Results: Both groups showed significant reductions in primary, secondary, and exploratory outcomes, with no significant differences between groups at posttreatment (d=-0.026) and 1-year follow-up (d=0.097). Baseline characteristics and attrition rates were balanced across the groups. Conclusions: Due to insufficient recruitment and substantial missing data, no definitive conclusions can be drawn regarding group differences between VR-CBT and traditional CBT in group settings. The feasibility issues encountered suggest that careful consideration of the benefits and limitations of VR technology is essential before implementation in clinical practice.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.017 | 0.015 |
| Meta-epidemiology (narrow) | 0.002 | 0.001 |
| Meta-epidemiology (broad) | 0.007 | 0.005 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.001 | 0.002 |
| Scholarly communication | 0.002 | 0.002 |
| Open science | 0.001 | 0.001 |
| Research integrity | 0.003 | 0.003 |
| Insufficient payload (model declined to judge) | 0.007 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".