A Randomized Controlled Trial Assessing the Efficacy of a Virtual Reality Biofeedback Video Game: Anxiety Outcomes and Appraisal Processes

This study assessed the efficacy of a virtual reality biofeedback video game (DEEP) in reducing anxiety symptoms. In addition, changes in engagement and cognitive appraisals including self-efficacy, locus of control, and threat-challenge appraisals were measured and it was explored how these factors related to anxiety regulation. Undergraduates with elevated anxiety symptoms (N = 112) were randomly assigned to four training sessions with DEEP or a smartphone-guided breathing application. Trait anxiety was measured at screening, pretest, posttest, and 3 months later. State anxiety was assessed before and after each session. In addition, engagement and appraisals were assessed in each session. Participants in both conditions showed a significant decrease in trait anxiety symptoms from pre- to posttest and this decrease remained stable at follow-up. Furthermore, all participants decreased in state anxiety from pre- to postsession, except for DEEP sessions that included exposure. DEEP users increased in self-efficacy and observed resources to cope throughout the training. In addition, DEEP users felt more engaged in initial sessions than those who used the control application, but their engagement decreased toward the final session. In contrast, participants in the control group showed no change in appraisals nor engagement. Taken together, results demonstrate the potential of digital interventions such as biofeedback games and guided relaxation applications as anxiety regulation tools and show that self-efficacy and threat-challenge appraisals in particular are potential mechanisms of change in biofeedback interventions.