Speaking AnxietySocial CommunicationGeneralization

First long-term (4-6 year) follow-up of VR exposure therapy and exposure group therapy for social anxiety disorder: durable gains, with 54% no longer meeting diagnostic criteria

Anderson PL et al. · 2017 · Cognitive Therapy and Research · Experimental · n = 28 · Adults with social anxiety disorder, 4-6 years post-treatment · DOI
Evidence certainty: Moderate certainty
How this was rated

Long-term follow-up (mean 6 years) of a previously published RCT (Anderson et al. 2013) is rare and clinically valuable. Twenty-eight of the original RCT participants were assessed. Peer-reviewed in Cognitive Therapy and Research (Springer, established peer-reviewed psychology journal). Limitations: attrition over the long follow-up window means the sample assessed is a subset of the original RCT; participants who were doing worse may have been less likely to engage with follow-up assessment (a positive-skew bias). The within-subjects pre-to-follow-up improvement is robust, but the comparison between VRET and exposure group therapy at follow-up is underpowered to detect small differences. Diagnostic interviews and behavioral speech tasks add objectivity beyond self-report alone.

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Twenty-eight participants from the Anderson et al. 2013 RCT of VR exposure therapy (VRET) vs exposure group therapy for DSM-diagnosed social anxiety disorder were re-assessed a mean of 6 years (range 4-6) after treatment completion. Self-report measures, behavioral speech tasks, and diagnostic interviews all showed statistically significant improvement from pre-treatment to long-term follow-up. The majority (54%) no longer met diagnostic criteria for SAD; 68% rated themselves 'very much' or 'much' improved. With one exception, there were no differences between VRET and exposure group therapy at follow-up - both produce durable long-term benefits, consistent with the broader CBT-for-SAD evidence base.

Clinical bottom line

The first published long-term (4-6 year) follow-up of VRET for social anxiety disorder. Gains from the 8-session treatment (originally reported in Anderson et al. 2013) were maintained, with the majority of participants no longer meeting SAD diagnostic criteria and the vast majority rating themselves substantially improved. VRET and exposure group therapy were equivalently effective at long-term follow-up. For clinicians considering VRET as an alternative or adjunct to group therapy for SAD/PSA, this study provides the strongest available long-term durability evidence. Important caveat: this is a follow-up of treatment completers, not all originally randomised participants - attrition over 4-6 years limits generalization.

Key findings

  • First long-term (mean 6 years, range 4-6 years post-treatment) follow-up of VRET for SAD - a rare and clinically valuable design
  • 28 participants from the original Anderson et al. 2013 RCT (which compared VRET vs exposure group therapy across 8 sessions for DSM-diagnosed SAD with public speaking fears) were re-assessed
  • Statistically significant improvement from pre-treatment to long-term follow-up on ALL self-report measures of public speaking anxiety and fear of negative evaluation
  • Diagnostic interviews showed 54% no longer met DSM diagnostic criteria for SAD - a clinically meaningful proportion given the durable, distressing nature of untreated SAD
  • Self-rated global improvement: 68% rated themselves 'very much' or 'much' improved
  • Behavioral speech task: all participants completed it (with two exceptions: one declined, one completed by phone) - persistence of the treatment-target behavioral skill
  • VRET vs exposure group therapy: with one exception, no significant differences at follow-up across self-report, clinician-rated, and behavioral data
  • Sample at follow-up: ethnically diverse, middle-aged (mean age 42), 71% female

Background

Anderson and colleagues published a landmark RCT in 2013 (in Journal of Consulting and Clinical Psychology) comparing 8-session virtual reality exposure therapy (VRET) to 8-session exposure group therapy for adults with DSM-diagnosed social anxiety disorder (SAD) including public speaking fears. The 2013 paper established VRET as a credible alternative to group exposure therapy for SAD on short-term outcomes. However, the long-term durability of VRET-driven gains had not been tested - this is the standard question for any evidence-based psychotherapy.

Twenty years earlier, Cognitive Therapy and Research published Heimberg et al.’s 5-year follow-up of cognitive-behavioral group therapy for SAD, which remains a benchmark for long-term SAD treatment outcomes. The present study extends this paradigm to VRET.

What the researchers did

Twenty-eight participants from the Anderson et al. 2013 RCT were re-assessed a mean of 6 years (range 4-6) after treatment completion. The original RCT had allocated participants to either VRET or exposure group therapy, both delivered across 8 sessions according to a treatment manual. The follow-up assessment included:

The sample at follow-up was ethnically diverse, middle-aged (mean age 42), and 71% female.

What they found

Why this matters

For clinicians considering VRET as an alternative or adjunct to group therapy for SAD or PSA, this study answers the key durability question: 8-session gains are largely maintained at 4-6 years. The 54% diagnostic-remission figure is comparable to long-term outcomes reported for traditional CBT-for-SAD. VRET produces durable change, not just short-term anxiety-management effects.

For PWS with social anxiety comorbidity (a common clinical pattern), this long-term durability matters because stuttering-associated social anxiety is itself durable. However, the original RCT and this follow-up are in SAD-with-PSA samples, not specifically PWS - direct generalization to stuttering populations requires PWS-specific long-term data.

Limitations

Implications for practice

For clinicians considering VRET as an alternative or adjunct to group therapy for SAD or public speaking anxiety, this study answers the key durability question: gains made during 8 sessions of either VRET or exposure group therapy are largely maintained 4-6 years later. The 54% who no longer meet SAD criteria at long-term follow-up is a clinically meaningful figure, comparable to long-term outcomes reported for traditional CBT-for-SAD. VRET is not merely a short-term anxiety-management trick - it can produce durable change. For PWS with social anxiety comorbidity, this long-term durability is particularly relevant given that stuttering-associated social anxiety is itself durable and benefits from interventions with carryover. Caveat: this follow-up is in a SAD-with-PSA sample, not specifically PWS - direct generalization to stuttering populations requires PWS-specific long-term data.

Related Studies

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Anderson PL et al. · 2013 Read Summary
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Pre-registered three-arm RCT: CBT with VR exposure was superior to in-vivo exposure on the primary social-anxiety outcome - and more practical for therapists

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Bouchard S et al. · 2017 Read Summary
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Sixty participants diagnosed with social anxiety disorder were randomly assigned to individual virtual reality exposure therapy (VRET), individual in-vivo exposure therapy (iVET), or a waiting-list control. Both treatments improved social anxiety symptoms, speech duration, perceived stress, and avoidant-personality-disorder beliefs versus waitlist. However, iVET (but NOT VRET) also improved fear of negative evaluation, speech performance, general anxiety, depression, and quality of life. iVET was superior to VRET on social anxiety symptoms at post and follow-up and on avoidant-PD beliefs at follow-up. At follow-up, almost all improvements remained significant for iVET; for VRET only the perceived-stress effect held.

Kampmann IL et al. · 2016 Read Summary
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First RCT (n=25+25) showing that consumer VR hardware and software can deliver effective one-session VRET for public speaking anxiety - both therapist-led (d=1.67) and self-led at home (d=1.35), with gains maintained at 6 and 12 months

Twenty-five participants were randomised to one-session therapist-led VR exposure therapy for public speaking anxiety using consumer VR hardware and software, followed by a 4-week internet-administered VR-to-in-vivo transition program; another 25 served as a waiting-list. Therapist-led VRET produced a very large effect on self-reported PSA (within Cohen's d = 1.67). The waiting-list then received internet-administered, SELF-LED VRET at home, followed by the same transition program - producing a large effect (d = 1.35). Results were maintained or improved at 6-month and 12-month follow-ups. This is the first published RCT demonstrating that off-the-shelf consumer VR hardware and software can deliver effective PSA exposure therapy in both clinician-supervised and home-based formats.

Lindner P et al. · 2019 Read Summary
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VR exposure equals traditional CBT for public-speaking anxiety, with lower dropout

In an 88-person RCT, VR-based cognitive-behavioral therapy for public-speaking anxiety produced anxiety reductions equivalent to traditional CBT and significantly larger than waitlist, with notably fewer participants dropping out of the VR arm.

Wallach HS et al. · 2009 Read Summary
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Pilot RCT (n=44) of brief self-guided virtual reality exposure therapy for social anxiety disorder: moderate-to-large effects on SAD severity, job interview fear, and trait worry, maintained at 3 and 6 months

Forty-four community-dwelling or undergraduate adults diagnosed with social anxiety disorder (SAD) using the Mini International Neuropsychiatric Interview were randomly assigned to a self-directed VR exposure intervention (designed to last four sessions or more; n=26) or a waitlist control (n=18). Outcomes measured at baseline, post-treatment, 3-month follow-up, and 6-month follow-up. VR exposure produced moderate-to-large reductions in SAD symptom severity, job interview fear, and trait worry (Hedges' g = 0.54 to 1.11). Although between-group differences in depression were not significant, the VR arm reduced depression while waitlist did not. Gains were maintained at 3- and 6-month follow-up. Self-reported presence increased during treatment (g = 0.36 to 0.45); cybersickness decreased (g = 0.43).

Zainal NH et al. · 2021 Read Summary

Cite this study

If you reference this study in your work, the canonical citation formats are:

APA 7th
Anderson, P. L., Edwards, S. M., & Goodnight, J. R. (2017). Virtual Reality and Exposure Group Therapy for Social Anxiety Disorder: Results from a 4–6 Year Follow-Up. Cognitive Therapy and Research. https://doi.org/10.1007/s10608-016-9820-y.
AMA 11th
Anderson PL, Edwards SM, Goodnight JR. Virtual Reality and Exposure Group Therapy for Social Anxiety Disorder: Results from a 4–6 Year Follow-Up. Cognitive Therapy and Research. 2017. doi:10.1007/s10608-016-9820-y.
BibTeX
@article{anderson2017,
  author = {Anderson, P. L. and Edwards, S. M. and Goodnight, J. R.},
  title = {Virtual Reality and Exposure Group Therapy for Social Anxiety Disorder: Results from a 4–6 Year Follow-Up},
  journal = {Cognitive Therapy and Research},
  year = {2017},
  doi = {10.1007/s10608-016-9820-y},
  url = {https://withvr.app/evidence/studies/anderson-2017}
}
RIS
TY  - JOUR
AU  - Anderson, P. L.
AU  - Edwards, S. M.
AU  - Goodnight, J. R.
TI  - Virtual Reality and Exposure Group Therapy for Social Anxiety Disorder: Results from a 4–6 Year Follow-Up
JO  - Cognitive Therapy and Research
PY  - 2017
DO  - 10.1007/s10608-016-9820-y
UR  - https://withvr.app/evidence/studies/anderson-2017
ER  -

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Funding & independence

Affiliations: lead author at Georgia State University (per Anderson 2013 RCT origin). Funding sources for the follow-up not extracted in detail; the original RCT was NIH-funded. Peer-reviewed in Cognitive Therapy and Research (Springer). No withVR BV involvement in funding, study design, or authorship. Summary prepared independently by withVR using the published peer-reviewed paper. The VR system used in the original RCT and described in this follow-up is NOT Therapy withVR or Research withVR; it was the era-appropriate research VRET system used by the Anderson group.

Last reviewed: 2026-05-17 Next review due: 2027-05-17 Reviewed by: Gareth Walkom