Augmenting self-guided virtual-reality exposure therapy for social anxiety with biofeedback: a randomised controlled trial

Introduction: Self-guided Virtual Reality Exposure Therapy (VRET) previously improved public speaking anxiety (PSA) and reduced heart rate. Because elevated heart rate characterizes social anxiety, continuous biofeedback on physiological arousal during VRET may help individuals manage anxiety. This study tested whether biofeedback enhances responsiveness to self-guided VRET in socially anxious individuals. Methods: Seventy-two participants with high self-reported social anxiety were randomized to VRET plus biofeedback (n=38; 25 completers) or VRET alone (n=35; 25 completers). Three hour-long VRET sessions were delivered across three weeks. Each session included a 20-minute public speech in a virtual lecture hall. The biofeedback group received real-time feedback on heart rate and frontal alpha asymmetry (FAA) within the VR environment and were instructed to lower arousal. Psychometric assessments of social anxiety were completed after each session and at one-month follow-up. Results: PSA improved by end of treatment and overall social anxiety improved at one-month follow-up across both groups. The biofeedback group showed a steadier reduction in FAA in the first VRET session and a greater reduction in self-reported arousal across sessions than the VRET-alone group. Conclusion: Biofeedback can steady physiological arousal and lower perceived arousal during exposure. Self-guided VRET benefits for social anxiety were sustained one month after therapy.