VRET Clinical Case Vignettes: Phobias, Social Anxiety, PTSD
By Equipo clínico VRET
The three vignettes below are composite cases built from the clinical patterns commonly seen in practice, not identifiable real cases. We cover the typical course of a VRET protocol in dog phobia, social anxiety, and PTSD: session counts, reading the SUDS curve, discharge criteria, early dropout, and practical workflow notes. The goal is to complement meta-analyses with the clinical texture that rarely appears at conferences, always with the methodological caveat that no individual case is generalizable.
Preliminary Methodological Notice and GDPR Considerations
Before reading the vignettes, an explicit notice is important: the three cases described are composite, not real cases. They reflect clinical patterns commonly seen in VRET practice, as they appear in the literature, in supervision, and in the sessions of the clinicians we work with, but they do not correspond to specific individuals. Any resemblance to an actual patient is coincidental, not documentary.
This is not a rhetorical caveat. Publishing clinical cases in a blog, on professional networks, or at conferences raises serious ethical and legal requirements in Spain and the European Union. Under the GDPR, any information about the mental health of an identifiable person is a special category of data, and simply combining three or four variables (exact age, specific profession, small town) can allow reidentification even without a name. The ethical codes of Spain’s General Council of Psychology and the Madrid Official College of Psychologists require, among other things, specific informed consent for dissemination, effective (not merely cosmetic) anonymization, and proportionality between scientific interest and the patient’s exposure.
Accordingly, what we publish here is not clinical information about real people. It is a didactic construct that reflects the pattern observed in practice without compromising anyone. If you want to document your own cases for publication, it is worth reviewing the procedure against your licensing board’s own regulations and, where applicable, with your practice’s or center’s data protection officer.
Composite Case 1 — Dog Phobia Following a Childhood Bite
The patient we describe could be a woman between thirty and forty years old, a healthcare professional with no further detail, with a history of being bitten by a medium-sized dog around age seven or eight. She presents with a phobia specific to dogs (dog phobia) meeting DSM-5-TR criteria, with marked avoidance in everyday life: she avoids parks with dogs, crosses the street, and has stopped visiting relatives who own pets. Initial SUDS for visual approach to a medium-sized dog: around 80-90 out of 100. the dog phobia exposure scenario the dog phobia exposure scenario the dog phobia exposure scenario
After assessment, clinical formulation, and psychoeducation, a progressive VR exposure protocol is agreed upon. A six-step hierarchy is built: a calm small dog at a distance, a calm small dog at medium distance, a medium-sized dog lying down far away, a medium-sized dog standing nearby, a medium-sized dog approaching, and a medium-sized dog interacting with the virtual clinician present. The protocol calls for eight to ten weekly sessions of about forty-five effective minutes each.
The typical course for this profile follows an observable pattern. The first two sessions usually require more time for psychoeducation and framing, with peak SUDS close to the initial level. From the third or fourth session onward, the within-session SUDS curve begins to show habituation (from 80 down to 40-50 by the end of the exposure) and between-session habituation (initial SUDS decrease week by week). By session six or seven, the typical patient reports functional changes: she no longer crosses the street, she agrees to visit relatives who have a dog, and she is surprised by spontaneous reactions of lower activation.
Discharge from the protocol usually includes gradual in vivo exposure, in parks near the practice or in controlled settings. The final session consolidates the full hierarchy with a combined exercise. Follow-up at three and six months shows maintained change in most cases. When partial relapses occur, they tend to relate to general stressful situations that reduce coping resources.
Composite Case 2 — Social Anxiety in a Young Professional
The second composite case could be a professional between twenty-five and thirty-five years old, with a social anxiety disorder meeting DSM-5-TR criteria, focused especially on public speaking and work meetings with superiors. Initial SUDS for imagined exposure to presenting in front of a group: around 75-85. He seeks treatment because he has started avoiding meetings that affect his professional performance.
The protocol combines VR exposure with cognitive work on automatic interpretations (inner criticism, negative anticipation, self-focused attention). The virtual scenario allows presenting to graduated audiences: one person, a small group with neutral faces, a medium group with neutral faces, a group asking questions, and a group with one actively critical member. Ten to twelve sessions, weekly or biweekly.
The typical course in social anxiety is slower and less linear than in specific phobia. Cognitive changes take time, and exposure needs to be paired with between-session work. Some patients show sustained progress from the fourth session onward; others hit plateaus that call for reworking the hierarchy or digging deeper into the cognitive component. In a successful course, peak SUDS drops from the 75-85 range to the 40-55 range, with functional changes appearing from session six or seven onward.
A frequent observation: patients with social anxiety tolerate VR exposure better than in vivo exposure precisely because the environment is reversible. Knowing they can remove the headset at any time reduces the catastrophic anticipation of freezing in public, which makes it easier to enter the hierarchy. The progression to in vivo exposure then feels more natural, since patients start from a state of lower overall avoidance.
Composite Case 3 — PTSD Following a Traffic Accident
The third case could be a person between thirty-five and fifty years old, with PTSD meeting DSM-5-TR criteria, arising from a moderately severe traffic accident that occurred between eighteen and thirty-six months before consultation. Predominant symptoms: re-experiencing, marked avoidance of driving or riding as a passenger on similar routes, hyperarousal. Frequent comorbidity with mild-to-moderate depression and dissociative features at peak moments.
In PTSD, incorporating VR calls for additional caution. The protocol is structured with an emphasis on prior stabilization, clear framing, an explicit window of tolerance, and specialized clinical supervision. The VR hierarchy does not expose the patient to the original accident (which is out of scope for a generic clinical scenario) but to contextually related situations: riding as a passenger in a moving car, seeing dense traffic, hearing braking or impact sounds at progressive volume.
The course is usually longer and more irregular than in the two preceding cases. Twelve to twenty sessions is a reasonable range and not always sufficient. Patients may show transient symptom increases in early phases (sensitization before habituation), which calls for special attention to framing and dropout prevention. Peak SUDS ranges between 70 and 95, with slower session-by-session decreases.
When the protocol works, the changes are significant: reduced frequency and intensity of re-experiencing, gradual recovery of the ability to drive, normalized sleep. When it does not progress, this is usually a sign that the presentation requires a broader approach (complex trauma, significant comorbidity, need for coordination with pharmacological treatment). VR does not substitute for clinical judgment or specific training in trauma.
Cross-Cutting Patterns and Dropout in the VRET Workflow
Beyond the individual vignettes, it is worth highlighting some patterns that recur in VRET practice. Early dropout (before session four) tends to be linked to three factors: insufficient framing (the patient does not understand what is going to happen), miscalibrated expectations (expecting results right away and not getting them), or technical discomfort (cybersickness, an uncomfortable headset fit). Addressing these three factors in the first sessions significantly reduces attrition.
Late dropout (between sessions four and eight) tends to relate to two things: apparent stalling in the hierarchy (which is often a legitimate transition between phases) or the emergence of unexpected clinical material that requires reformulation. In both cases, an explicit clinical conversation about what is happening frequently restores adherence.
As for the SUDS curve, the ideal within-session habituation pattern (an initial rise followed by a sustained decline over five to fifteen minutes of maintained exposure) occurs in a significant share of patients but not all of them. Others show slower declines or need more sessions before between-session habituation shows up. SUDS is a guiding tool, not a deterministic thermometer.
An additional cross-cutting pattern is the importance of session closure and the transition back to everyday life. Removing the headset should not be abrupt; it is worth reserving five to ten minutes at the end for debriefing with the patient, reviewing what was worked on, identifying what worked and what was hardest, and preparing between-session tasks. This practice reinforces the consolidation of learning and reduces the sense of "having gone through a technical experience" rather than having done therapeutic work.
Finally, medium-term follow-up (three and six months after discharge) emerges as a relevant predictor of maintained change. Patients who stay in contact, even with spaced-out review sessions, retain improvement better than those who close treatment without any follow-up. This is not specific to VRET, but it takes on added importance in this context because, in some cases, the relative novelty of the tool can create a false sense that the problem is "solved" after the last session.
What These Vignettes Are Not, and What They Can Offer
These three vignettes are not scientific evidence. They lack the statistical power and representativeness of a clinical trial, and they do not meet the methodological criteria to claim causal conclusions. If you want empirical support on VRET efficacy, the meta-analyses by Powers and Emmelkamp 2008, Opriş 2012, and Carl et al. 2019 are the appropriate reading.
What they can offer is the clinical texture that trials rarely show: how SUDS moves in an actual session, what kind of conversation works in session three, when it is worth pausing the hierarchy and revisiting the framing. This is information that complements the evidence base, not a substitute for it. Any psychologist planning to apply VRET should build their own clinical experience through supervision and specific training support.
If you are considering incorporating VRET into your practice, one practical recommendation: start with a well-defined specific phobia, where the evidence is strongest and the workflow’s learning curve is manageable. Once the protocol is established, extending to social anxiety or more complex presentations becomes more natural.
Conclusion and Links for Further Reading
We have reviewed three composite vignettes illustrating typical VRET clinical patterns for specific phobia, social anxiety, and PTSD. We highlighted the methodological disclaimers (these are not real cases) and the GDPR considerations that protect patients when professionals document or share clinical experiences. And we outlined dropout patterns and practical follow-up criteria.
Material like this serves two final purposes. On one hand, it offers the psychologist weighing whether to adopt VRET a realistic picture of what the work looks like in practice, beyond the elegance of meta-analyses and the spectacle of technical demonstrations. On the other, it is a reminder that clinical and ethical responsibility cannot be delegated to the tool: the headset does not formulate cases, does not build hierarchies, does not manage the therapeutic alliance, does not decide when to discharge, and does not document what happens. All of that remains the responsibility of the licensed psychologist in charge, and no tool replaces that function.
To go further, you can check out the dog phobia exposure scenario, the review on comparative efficacy of VRET and in vivo exposure, and the article on tolerance and dropout in VRET. If you want to see how all of this translates into a real-world workflow, you can book a guided demo.
This article is for informational purposes for psychology professionals. It is not clinical advice for any individual case and does not replace the judgment of the licensed psychologist in charge. VRET is professional clinical-support software, not a CE-marked medical device.
Frequently asked questions
Are the cases described in this article real?
No. These are composite cases built from the clinical patterns commonly seen in VRET practice, not identifiable real cases. Any resemblance to a specific patient is coincidental. Publishing real clinical cases requires specific informed consent, effective anonymization, and compliance with the GDPR and the ethical codes of Spain’s General Council of Psychology.
How many sessions does a VRET protocol for specific phobia usually require?
Usually between eight and ten weekly sessions of about forty-five effective minutes, depending on initial severity, the patient’s response, and the complexity of the hierarchy. For social anxiety the range rises to ten to twelve sessions, and for PTSD to twelve to twenty, always with the caveat that each case is idiosyncratic.
What should I do if a patient drops out of VRET treatment in the first sessions?
Early dropout tends to relate to insufficient framing, miscalibrated expectations, or technical discomfort (cybersickness, an uncomfortable headset). Addressing these three factors in the first two sessions significantly reduces attrition. If dropout persists, it is worth reassessing the clinical indication.
How do you anonymize a clinical case for publication?
Always use a pseudonym, an age range and a generic profession instead of exact data, and zero identifiable data (emails, national ID numbers, phone numbers, precise dates, small towns). Ideally, elements from several patients are combined to create a composite case. The procedure should be reviewed against your licensing board’s own regulations and, where applicable, with a data protection officer.
Is VR appropriate as a stand-alone intervention for PTSD?
In most cases, no. PTSD requires specific training in trauma, prior stabilization, an explicit window of tolerance, and, frequently, coordination with other treatments. VR can be integrated into the protocol, but it should not be used as a stand-alone tool absent specialized clinical supervision.
What should I do if the SUDS curve shows no habituation after several sessions?
It is worth reviewing several variables: Is presence sufficient? Is the hierarchy well calibrated? Is there unaddressed clinical material keeping activation high? SUDS is a guide, not a deterministic measure; a sustained flat pattern usually points to the need to reformulate the protocol rather than to increase exposure intensity.
Can I publish my own VRET cases on professional networks?
Only with specific informed consent for publication, effective anonymization, and compliance with your licensing board’s ethical codes and the GDPR. It is worth reviewing the procedure with a legal advisor or your practice’s data protection officer, especially if the data could allow reidentification through a combination of variables.
VRET is professional clinical-support software, not a CE-marked medical device. Clinical supervision remains with the licensed psychologist in charge.