When Dysphagia Is Not Psychogenic: An Atypical Presentation of Schatzki Ring in a Patient With Schizophrenia.

Specific phobias are among the most common mental disorders, with lifetime prevalence estimates ranging from 7.7% to 12.5% among adults []. Individuals with specific phobias experience intense, irrational fear responses and exhibit avoidance behavior toward a specific object or situation []. Exposure therapy, particularly in vivo treatment, is the preferred method for helping individuals replace maladaptive fear responses with adaptive reactions []. Exposure therapy for specific phobias typically begins with psychoeducation, during which patients learn how phobias develop and persist through avoidance behavior, and which fears are rational or irrational [,]. Patients are then systematically confronted with the feared object or situation, enabling cognitive restructuring by reducing maladaptive behaviors and replacing irrational fear responses with more adaptive interpretations [,,]. Despite the proven effectiveness of exposure therapy [], fewer than 8% of individuals with specific phobias seek treatment []. Barriers include the unpredictability of exposure, challenges in implementing therapy, and a shortage of mental health care providers [,,]. An alternative approach, known as in virtuo treatment, uses virtual reality (VR) to address many of these barriers. VR enables users to experience computer-generated environments that can evoke a strong sense of presence or "sense of being there," which is commonly attributed to the replacement of real-world sensory input with computer-generated stimuli []. Through this effect, the user cognitively knows that the world around them is unreal, yet experiences a perceptual illusion that makes the brain and the body automatically react to sensory cues []. This characteristic of VR allows patients to repeatedly confront realistic phobic stimuli in a manner comparable with traditional in vivo exposure conducted in real-life settings. But in contrast to real-world exposure, virtual reality exposure therapy (VRET) allows therapists to precisely control and gradually adjust exposure intensity according to individual patient needs, offering high repeatability and flexibility while maintaining a sense of safety for the patient []. This controlled environment may reduce barriers to treatment and encourage engagement with exposure exercises that might otherwise be avoided in real-life situations. Several meta-analyses have reported greater patient willingness to engage in VRET compared with in vivo exposure [-], which has frequently been attributed to the perceived safety and controllability of the virtual environment. The findings of a more recent meta-analysis on VRET for specific phobias, which reported no significant differences between VRET and traditional in vivo exposure at posttreatment or follow-up [], together with the inclusion of VRET in the American Psychological Association guidelines for empirically supported treatments, demonstrate the effectiveness of VRET for specific phobias []. Furthermore, VRET can expand access to treatment for individuals who face barriers to traditional methods, such as limited facilities, practitioner shortages, cultural disparities, or life circumstances []. One possible approach is the use of automated interventions, also referred to as guided self-help [], which have recently been shown to achieve substantial symptom reductions []. However, findings from internet-based mental health interventions have suggested that maintaining treatment adherence can be challenging, particularly in unguided approaches []. This raises the question of how therapeutic guidance, psychoeducation, and emotional support can be delivered in the absence of a physically present therapist, for example, through virtual therapists that serve as a functional analog to human therapists during exposure exercises [,].