Virtual reality exposure therapy for anxiety and trauma-related disorders: clinical evidence, behavioral sensing, and implementation priorities

Virtual reality exposure therapy (VRET) provides a controlled environment for delivering exposure to feared cues. Evidence supports benefit over inactive controls for selected specific phobias and social-anxiety presentations, but nonsignificant differences from active treatment do not establish equivalence. This critical narrative review integrates systematic reviews, representative randomized trials, mechanistic studies, and measurement and implementation frameworks. We distinguish diagnosed social anxiety disorder from performance-focused and symptom-selected samples, and exposure-based treatment from VR distraction or relaxation. PTSD findings require particular caution because military cohorts, trauma cues, and treatment histories may not represent civilian clinical populations. Behavioral and physiological signals are examined at four levels: technical capture, experimental association, clinical validity, and incremental clinical utility. Feasible recording and associations with arousal or attention do not establish that a signal measures therapeutic learning or improves treatment decisions. We propose a clinician-governed precision VRET loop as a conceptual framework requiring prospective evaluation, rather than a clinically validated adaptive intervention. Research priorities include appropriately designed comparative trials, explicit diagnostic characterization, standardized intervention and hardware reporting, purpose-specific measurement validation, systematic harms assessment, longer follow-up, and implementation and economic evaluation. VRET should be evaluated as a defined exposure intervention for a specified population and care setting, with patient choice and accountable clinical oversight.