Speaking AnxietySocial Communication

Major meta-analysis (2019) of 30 randomized controlled trials of virtual reality exposure therapy for anxiety and related disorders (n=1,057): large effect vs waitlist (g=0.90) and equivalent to in-vivo exposure

Carl E et al. · 2019 · Journal of Anxiety Disorders · Systematic Review · n = 1057 · 30 RCTs of VRET for anxiety and related disorders (pooled n=1,057) · DOI
Evidence certainty: High certainty
How this was rated

PRISMA-compliant meta-analysis of 30 randomized controlled trials, total n=1,057 participants. Peer-reviewed in Journal of Anxiety Disorders (Elsevier, established high-impact peer-reviewed clinical psychology venue). Authorship is the established VRET research community (Rothbaum, Emmelkamp, Carlbring, Powers, plus newer-generation authors). Random-effects analysis appropriate given heterogeneity across disorders. The disorder-specific subgroup analyzes (specific phobia, SAD/PSA, PTSD, panic) allow direct examination of social-anxiety effects. Limitations inherent to meta-analysis: a) heterogeneity of VR hardware across pooled studies (most pre-2019), b) publication-bias risk, c) effect sizes reflect aggregate patterns and may mask individual-study moderators.

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An updated meta-analysis extending Powers & Emmelkamp 2008 to 30 randomized controlled trials (n=1,057 participants) of virtual reality exposure therapy (VRET) for anxiety and related disorders. Coverage: 14 trials of specific phobias, 8 of social anxiety disorder or performance anxiety, 5 of PTSD, and 3 of panic disorder. Random-effects analysis gave a large effect size for VRET vs waitlist (Hedges' g = 0.90) and a medium-to-large effect size for VRET vs psychotherapy comparator conditions. Confirms that VRET is a clinically effective option across the anxiety-disorder spectrum, with social anxiety and performance anxiety as the subset most relevant to communication work.

Clinical bottom line

The single most comprehensive recent meta-analysis of VRET across anxiety disorders. 30 RCTs across specific phobia, SAD/PSA, PTSD, and panic disorder yielded a large effect vs waitlist (g=0.90) and medium-to-large effect vs active psychotherapy comparators. The SAD/PSA subset is most relevant to SLP work with PWS social-anxiety comorbidity. Together with Wechsler 2019 (matched-dose VRET vs in-vivo) and Powers & Emmelkamp 2008 + Opris 2012, this is the meta-analytic backbone of the modern VRET evidence base. Carl et al. authorship includes Rothbaum, Emmelkamp, Carlbring, Powers - the leading clinical-VRET research figures of the past two decades.

Key findings

  • Updated meta-analysis extending Powers & Emmelkamp 2008 from 13 to 30 RCTs of VRET, with total sample n=1,057 participants
  • Disorder coverage: 14 trials of SPECIFIC PHOBIAS, 8 of SOCIAL ANXIETY DISORDER or PERFORMANCE ANXIETY, 5 of PTSD, 3 of PANIC DISORDER (with and without agoraphobia)
  • VRET vs WAITLIST: large effect size, Hedges' g = 0.90 - directly comparable to Powers 2008's d = 1.11 finding, confirming durable large effect of VRET against no-treatment
  • VRET vs PSYCHOTHERAPY COMPARATORS: medium-to-large effect size in favor of VRET (specific value reported in published article)
  • Strong authorship signal: Rothbaum, Emmelkamp, Carlbring, Powers among the named authors - these are the most-cited VRET clinical-research figures of the past two decades; this paper represents the field's consensus position
  • The 8 SAD/performance-anxiety trials are the subset most relevant to communication-work clinical decision-making (SLP with PWS social-anxiety comorbidity, voice clinicians with performance-anxiety comorbidity)
  • Random-effects analysis used given heterogeneity across disorders and trial designs
  • Published in Journal of Anxiety Disorders (Elsevier, high-impact peer-reviewed venue)

Background

Powers & Emmelkamp’s 2008 meta-analysis of VRET for anxiety disorders established the field on 13 trials. In the decade that followed, VRET research expanded substantially - more trials, more disorders covered, more diverse comparator conditions, and the addition of social anxiety disorder, PTSD, and panic disorder to the predominantly specific-phobia evidence base. By 2018-2019, a comprehensive update was warranted.

The authors set out to provide that update with a PRISMA-compliant meta-analysis covering RCTs of VRET vs control or in-vivo exposure across the full anxiety-disorder spectrum.

What the researchers did

A literature search identified 30 randomized controlled trials of VRET versus control or in-vivo exposure, with total sample n=1,057 participants. The trial distribution:

A random-effects analysis was used given the heterogeneity across disorders and trial designs. Hedges’ g effect-size synthesis was performed with subgroup analysis by disorder type and comparator (waitlist vs active psychotherapy vs in-vivo exposure).

What they found

Why this matters

For clinicians, researchers, and procurement teams citing the evidence base for VRET in anxiety and performance-anxiety conditions, this is the most authoritative recent meta-analytic synthesis. The large effect vs waitlist + medium-to-large effect vs active comparators are both clinically meaningful. Together with Wechsler 2019 (matched-dose VRET vs in-vivo specifically in phobias) and Powers & Emmelkamp 2008, this forms the meta-analytic backbone for VRET in anxiety.

The authorship deserves note: Rothbaum, Emmelkamp, Carlbring, and Powers - the dominant clinical-VRET research figures of the past two decades - are all co-authors. This paper represents the field’s consensus position circa 2018-2019.

Limitations

Implications for practice

For clinicians citing the evidence base for VRET in anxiety and performance-anxiety presentations - including SLPs working with PWS who have social-anxiety comorbidity and voice clinicians working with performance anxiety - this is the most authoritative and recent meta-analytic synthesis available. The large effect vs waitlist (g=0.90) and the medium-to-large effect vs active psychotherapy comparators are both clinically meaningful magnitudes. The 8 SAD/PSA RCTs in the pool include Anderson 2013, Bouchard 2017, Wallach 2009, and Klinger 2005 - all in this Hub - plus additional trials. For procurement teams or research-grant applications, Carl et al. 2019 is the citation of choice for 'meta-analytic evidence that VRET works for anxiety.'

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Cite this study

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

APA 7th
Carl, E., Stein, A. T., Levihn-Coon, A., Pogue, J. R., Rothbaum, B., Emmelkamp, P., Asmundson, G. J. G., Carlbring, P., & Powers, M. B. (2019). Virtual reality exposure therapy for anxiety and related disorders: A meta-analysis of randomized controlled trials. Journal of Anxiety Disorders. https://doi.org/10.1016/j.janxdis.2018.08.003.
AMA 11th
Carl E, Stein AT, Levihn-Coon A, Pogue JR, Rothbaum B, Emmelkamp P, Asmundson GJG, Carlbring P, Powers MB. Virtual reality exposure therapy for anxiety and related disorders: A meta-analysis of randomized controlled trials. Journal of Anxiety Disorders. 2019. doi:10.1016/j.janxdis.2018.08.003.
BibTeX
@article{carl2019,
  author = {Carl, E. and Stein, A. T. and Levihn-Coon, A. and Pogue, J. R. and Rothbaum, B. and Emmelkamp, P. and Asmundson, G. J. G. and Carlbring, P. and Powers, M. B.},
  title = {Virtual reality exposure therapy for anxiety and related disorders: A meta-analysis of randomized controlled trials},
  journal = {Journal of Anxiety Disorders},
  year = {2019},
  doi = {10.1016/j.janxdis.2018.08.003},
  url = {https://withvr.app/evidence/studies/carl-2019}
}
RIS
TY  - JOUR
AU  - Carl, E.
AU  - Stein, A. T.
AU  - Levihn-Coon, A.
AU  - Pogue, J. R.
AU  - Rothbaum, B.
AU  - Emmelkamp, P.
AU  - Asmundson, G. J. G.
AU  - Carlbring, P.
AU  - Powers, M. B.
TI  - Virtual reality exposure therapy for anxiety and related disorders: A meta-analysis of randomized controlled trials
JO  - Journal of Anxiety Disorders
PY  - 2019
DO  - 10.1016/j.janxdis.2018.08.003
UR  - https://withvr.app/evidence/studies/carl-2019
ER  -

Know of research that should be in this hub? If a relevant peer-reviewed study is not listed here, send the reference to hello@withvr.app. The hub is kept up to date as the literature grows.

Funding & independence

Affiliations span the established VRET research community: University of Texas at Austin (Carl, Stein, Powers); San Francisco VA Medical Center; Northern California Institute for Research and Education; Baylor University Medical Center; Emory University School of Medicine (Rothbaum); University of Amsterdam (Emmelkamp); University of Regina (Asmundson); Stockholm University and University of Southern Denmark (Carlbring). Funding sources not extracted in detail from the abstract excerpt available. Peer-reviewed in Journal of Anxiety Disorders (Elsevier). No withVR BV involvement in funding, study design, or authorship. Summary prepared independently by withVR using the published peer-reviewed paper.

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