Using virtual reality to evaluate the difference between pathological and healthy responding to anxiety

Anxiety is an adaptive emotional state which can become problematic and lead to anxiety disorders. It is unclear how healthy and pathological anxiety is differentially triggered and regulated. Virtual reality (VR) can simulate anxiety-provoking situations to evaluate response. This study explores the feasibility of a novel remote anxiety-inducing VR paradigm, comparing self-reported and physiological anxiety response between patients and healthy controls. One hundred and twenty patients with anxiety disorders and 120 healthy controls experienced two VR conditions, one mildly anxiety-inducing and one neutral, at home using a cardboard VR headset with a smartphone, guided over videoconference. Anxiety was assessed using the State-Trait Anxiety Inventory (STAI-State), with heart rate variability (HRV), heart rate (HR), and electrodermal activity (EDA) collected using a wearable device. The anxiety VR condition increased STAI-State and EDA compared to the neutral, with patients and controls showing similar differences, though patients rated both conditions as more anxiety provoking. Patients showed no HRV/HR modulation between conditions. Controls showed a trend toward HRV increase and significant HR decrease in the anxiety condition. This study highlights the value of this remote VR paradigm to study anxiety. The absence of HRV/HR alterations in patients is consistent with a blunted physiological reactivity pattern potentially reflecting constrained autonomic flexibility, while the HR decrease and trend-level HRV increase in controls may indicate improved emotion regulation, though these patterns warrant replication. This study emphasizes the potential to leverage VR for real-time exposure assessments of physiological and self-reported anxiety, particularly in remote settings to diversify studied populations.