Comparing the efficacy of virtual reality and flat screen delivery of breath control training for anxiety management
Abstract
Game-based biofeedback offers a promising approach for learning and practising breath control techniques to manage anxiety and stress. Traditionally known as a response-modulation emotion regulation strategy, biofeedback operates through a closed-loop system that measures and feeds back real-time physiological information for users to monitor and subsequently manage their bodily responses. Few studies, however, have directly compared breath control training integrated with game-based biofeedback across two-dimensional flat screen display and three-dimensional immersive environment. It remains unclear whether differences in realism and immersiveness might influence the efficacy of breath control training. The present study investigated training effectiveness and user evaluation of a novel biofeedback-based breath control game among forty-five healthy adolescents. The breath control training was delivered in both virtual reality (VR) and flat screen modalities in a randomised and counterbalanced order using a within-subject study design. Consistent with hypotheses, the biofeedback game significantly improved both subjective and physiological (standard deviation of normal-to-normal intervals (SDNN) and heart rate) markers of anxiety. While the two modalities indicated comparable intervention efficacy, the VR biofeedback game contributed added benefits in increasing SDNN, a physiological indicator of stress that reflects overall autonomic nervous system activity, as well as facilitating greater levels of interest and enjoyment, as indicated by ratings of intrinsic motivation to engage in the self-regulation training. These findings suggest that VR-based breath control training may enhance engagement and specific physiological responses, with implications for the design, development and evaluation of VR games for improving anxiety and stress.
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BibTeX
@misc{leung2026comparing,
title = {{Comparing the efficacy of virtual reality and flat screen delivery of breath control training for anxiety management}},
author = {Grace Y.S. Leung and Naresh Subramaniam and Benjamin Cook and Lucie Daniel-Watanabe and Johanna Finnemann and Toby Woolley and Craig Powell and Sergey Sitnikov and Paul Fletcher},
howpublished = {PsyArXiv},
year = {2026},
month = oct,
doi = {10.31234/osf.io/9tcre_v1},
url = {https://osf.io/preprints/psyarxiv/9tcre_v1/},
note = {CC BY 4.0},
}
RIS
TY - UNPB
TI - Comparing the efficacy of virtual reality and flat screen delivery of breath control training for anxiety management
AU - Grace Y.S. Leung
AU - Naresh Subramaniam
AU - Benjamin Cook
AU - Lucie Daniel-Watanabe
AU - Johanna Finnemann
AU - Toby Woolley
AU - Craig Powell
AU - Sergey Sitnikov
AU - Paul Fletcher
PY - 2026
DA - 2026/10/01
PB - PsyArXiv
DO - 10.31234/osf.io/9tcre_v1
UR - https://osf.io/preprints/psyarxiv/9tcre_v1/
AB - Game-based biofeedback offers a promising approach for learning and practising breath control techniques to manage anxiety and stress. Traditionally known as a response-modulation emotion regulation strategy, biofeedback operates through a closed-loop system that measures and feeds back real-time physiological information for users to monitor and subsequently manage their bodily responses. Few studies, however, have directly compared breath control training integrated with game-based biofeedback across two-dimensional flat screen display and three-dimensional immersive environment. It remains unclear whether differences in realism and immersiveness might influence the efficacy of breath control training. The present study investigated training effectiveness and user evaluation of a novel biofeedback-based breath control game among forty-five healthy adolescents. The breath control training was delivered in both virtual reality (VR) and flat screen modalities in a randomised and counterbalanced order using a within-subject study design. Consistent with hypotheses, the biofeedback game significantly improved both subjective and physiological (standard deviation of normal-to-normal intervals (SDNN) and heart rate) markers of anxiety. While the two modalities indicated comparable intervention efficacy, the VR biofeedback game contributed added benefits in increasing SDNN, a physiological indicator of stress that reflects overall autonomic nervous system activity, as well as facilitating greater levels of interest and enjoyment, as indicated by ratings of intrinsic motivation to engage in the self-regulation training. These findings suggest that VR-based breath control training may enhance engagement and specific physiological responses, with implications for the design, development and evaluation of VR games for improving anxiety and stress.
ER -