FPIN's Clinical Inquiries

Virtual Reality in the Treatment of Generalized Anxiety Disorder


Am Fam Physician. 2021 Dec ;104(6):638-640.

Clinical Question

Does therapy with virtual reality decrease generalized anxiety in adults?

Evidence-Based Answer

Virtual reality does not appear to be effective and should not be used in the treatment of generalized anxiety disorder (GAD). (Strength of Recommendation [SOR]: B, based on randomized controlled trials [RCTs].) In trials including anxiety disorders such as phobias and fear of flying, virtual reality may be better than no treatment, but it is not superior to traditional behavioral therapy or cognitive behavior therapy (CBT). (SOR: B, based on meta-analysis of RCTs.)

Evidence Summary

A 2019 meta-analysis of nine RCTs (N = 371) analyzed the treatment of specific phobias, social phobias, and agoraphobia when using virtual reality exposure therapy (VRET) compared with in vivo exposure therapy.1 VRET included a computer-generated presentation that provided input to the user's sensory system via specific glasses with a head-mounted display or through a projection system in an enclosed room. In vivo exposure involves the patient being exposed to their phobia in real live exposures that gradually increase in intensity each time the person has a lessened reaction to the previous exposure. When comparing these treatments for a specific phobia, there was no difference in symptom improvement between VRET and in vivo exposure therapy (four trials; n = 153; effect size [ES] = −0.15; 95% CI, −0.47 to 0.16). When examining trials treating social phobia, there was a small ES favoring in vivo exposure (three trials; n = 148; ES = −0.50; 95% CI, −0.83 to −0.16). Examining agoraphobia specifically, the result was also nonsignificant (two trials; n = 70; ES = −0.01; 95% CI, −0.47 to 0.45).

A 2012 meta-analysis of 21 RCTs (N = 803) evaluated VRET combined with traditional behavioral therapy or CBT to treat various anxiety disorders including fear of flying, panic disorder, agoraphobia, social phobia, posttraumatic stress disorder, arachnophobia, and acrophobia.2 The VRET groups were compared

Address correspondence to Corey Lyon, DO, at corey.lyon@cuanschutz.edu. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

Copyright © Family Physicians Inquiries Network. Used with permission.


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1. Wechsler TF, Kümpers F, Mühlberger A. 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. Front Psychol. 2019;10:1758....

2. Opriş D, Pintea S, García-Palacios A, et al. Virtual reality exposure therapy in anxiety disorders: a quantitative meta-analysis. Depress Anxiety. 2012;29(2):85–93.

3. Wang TC, Tsai CL, Tang TW, et al. The effect of cycling through a projection-based virtual environment system on generalized anxiety disorder. J Clin Med. 2019;8(7):973.

4. Repetto C, Gaggioli A, Pallavicini F, et al. Virtual reality and mobile phones in the treatment of generalized anxiety disorders: a phase-2 clinical trial. Pers Ubiquit Comput. 2011;17(2):253–260.

5. Gorini A, Pallavicini F, Algeri D, et al. Virtual reality in the treatment of generalized anxiety disorders. Stud Health Technol Inform. 2010;154:39–43.

Clinical Inquiries provides answers to questions submitted by practicing family physicians to the Family Physicians Inquiries Network (FPIN). Members of the network select questions based on their relevance to family medicine. Answers are drawn from an approved set of evidence-based resources and undergo peer review. The strength of recommendations and the level of evidence for individual studies are rated using criteria developed by the Evidence-Based Medicine Working Group (https://www.cebm.net).

The complete database of evidence-based questions and answers is copyrighted by FPIN. If interested in submitting questions or writing answers for this series, go to http://www.fpin.org or email: questions@fpin.org.

This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

A collection of FPIN's Clinical Inquiries published in AFP is available at https://www.aafp.org/afp/fpin.



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