Speaking AnxietyEcological Validity

Three-arm RCT (n=51) of stand-alone 360° video VR exposure therapy for public speaking anxiety: both audience-content and empty-room content produced significant pre-to-post reductions (partial η² up to .90) versus no-treatment control

Reeves R et al. · 2021 · Journal of Anxiety Disorders · RCT · n = 51 · Adults with high public speaking anxiety · DOI
Evidence certainty: Moderate certainty
How this was rated

Pre-specified three-arm RCT with formal randomisation, five-timepoint outcome measurement, mixed-ANOVA and within-group follow-up analyzes. n=51 total (17+16+18) is small for a three-arm comparison but consistent with the SAD/PSA RCT literature. Peer-reviewed in Journal of Anxiety Disorders (Elsevier, established peer-reviewed venue). The large partial η² values (.90, .71, .49, .39, .59, .43) are notable - VRET effects in this design were unusually pronounced. Possible reasons: high baseline PSA selection, structured five-session protocol, novel 360° video content. Limitations: within-group effects dominate the interpretation; between-active-group comparison (audience vs empty room) is underpowered to detect small differences; no clinician-rated or behavioral outcomes prominent in the abstract excerpt; 10-week follow-up window is moderate, not long-term.

Ratings use a simplified four-tier scheme (High, Moderate, Low, Very Low) informed by the GRADE working group. Learn more about how studies are rated.

Fifty-one participants with high public speaking anxiety were randomly allocated to one of three conditions: 360° video VRET incorporating audience stimuli (n=17), 360° video VRET incorporating empty-room stimuli (n=16), or no-treatment control (n=18). Outcomes measured at five timepoints. Mixed-ANOVA revealed a significant time × intervention-group interaction for PSA, social anxiety, and fear of negative evaluation (FNE). Both 360° VRET groups showed large pre-to-post reductions; for PSA, partial η² = .90 (audience) and .71 (empty room). Active intervention participants showed continued significant improvement out to 10-week follow-up. The study also addresses whether 360° video content (audience vs empty room) affects VRET outcomes - both worked.

Clinical bottom line

A three-arm RCT (n=51) demonstrating that stand-alone 360° video VRET is an efficacious intervention for public speaking anxiety, with both audience-stimuli and empty-room-stimuli formats producing significant pre-to-post reductions across PSA, social anxiety, and fear of negative evaluation. 360° video is a meaningfully different VR modality from computer-generated environments (lower production cost, real human stimuli, fixed perspective) - and this RCT establishes that the modality works clinically. For clinicians considering 360° video VRET as a lower-cost or more naturalistic alternative to CGI VRET, this is the foundational efficacy evidence. The finding that empty-room content also worked is methodologically important: the audience component is not strictly required for therapeutic effect.

Key findings

  • First RCT examining whether stand-alone 360° VIDEO VRET is an effective PSA intervention - filling a gap in the predominantly CGI-based VRET literature
  • n=51 randomised to one of three arms: 360° video VRET with AUDIENCE stimuli (n=17), 360° video VRET with EMPTY-ROOM stimuli (n=16), no-treatment control (n=18)
  • Participants had HIGH baseline PSA - the sample is selected for elevated anxiety, not subclinical
  • Significant TIME × INTERVENTION-GROUP interaction for PSA, social anxiety, and fear of negative evaluation (FNE) - the active groups improved differentially from control
  • Within-group pre-to-post effects (audience / empty-room 360°): PSA partial η² = .90 / .71 (p<.001); social anxiety .49 / .39 (p=.002 / .009); FNE .59 / .43 (p<.001 / .006)
  • Active intervention participants showed CONTINUED significant improvement from pre-intervention to 10-week follow-up across measures
  • Both 360° AUDIENCE and 360° EMPTY-ROOM formats worked - the audience component is not strictly required for therapeutic effect, which has implications for content creation cost and ethical considerations (consent, deepfake, identifiability)
  • The 360° video modality is methodologically distinct from CGI VRET - real human and environmental stimuli, fixed-perspective playback rather than free head-tracked exploration

Background

By 2021, most published VRET-for-PSA trials had used computer-generated (CGI) virtual environments with animated avatars. A parallel and lower-cost VR modality - 360° video - had emerged in consumer use but had not been tested in a stand-alone VRET RCT for PSA. 360° video is methodologically distinct from CGI: real human and environmental stimuli, fixed-perspective playback rather than head-tracked free exploration, lower production cost, and a different presence profile.

Two adjacent questions also remained underexplored: (1) does 360° video VRET work as a STAND-ALONE intervention without CBT integration? (2) does the 360° video CONTENT - specifically, whether the recorded scene includes an audience or just an empty room - drive the therapeutic effect?

What the researchers did

Fifty-one participants with high baseline PSA were randomly allocated to one of three arms:

  1. 360° Audience VRET (n=17) - 360° video content depicting an audience
  2. 360° Empty Room VRET (n=16) - 360° video content depicting an empty room (no audience)
  3. No-treatment control (n=18)

Outcomes were measured at five timepoints, including a 10-week follow-up after intervention completion. Statistical analysis used mixed-ANOVA with Greenhouse-Geisser correction.

What they found

Why this matters

For clinicians considering VRET for PSA, 360° video is now established as a clinically effective alternative to CGI VRET. Practical implications:

For PWS with PSA comorbidity, 360° video VRET expands the available delivery modes - particularly useful in low-resource clinical settings or self-administered home programs.

Limitations

Implications for practice

For clinicians considering VRET for PSA, this RCT establishes 360° video as a clinically effective modality alongside computer-generated VRET. Practical implications: 360° video has lower production cost than CGI environments (a phone or 360 camera plus a recording session) and uses real human stimuli rather than avatars. The finding that EMPTY-ROOM 360° content also worked is significant - clinicians without ethics-approved 360° audience footage can use empty-room footage and still produce therapeutic effect. For PWS with PSA comorbidity, this expands the available VRET delivery modes; 360° video could be especially useful in low-resource settings or for self-administered home programs. Caveat: 360° video VRET works best as adjunct or stand-alone exposure delivery; it does NOT replace CBT or stuttering-specific cognitive work.

Related Studies

Social CommunicationSpeaking AnxietyGeneralization

VR exposure is as effective as in vivo exposure group therapy for public-speaking-focused social anxiety, with lasting results

In a randomized controlled trial of 97 adults with social anxiety disorder whose primary fear was public speaking, eight sessions of virtual reality exposure were as effective as eight sessions of manualized in vivo exposure delivered in groups. Both active treatments outperformed waitlist on self-report and on a behavioral speech task, and improvements were maintained at 12-month follow-up.

Anderson PL et al. · 2013 Read Summary
Speaking AnxietySocial CommunicationGeneralization

Pre-registered three-arm RCT: CBT with VR exposure was superior to in-vivo exposure on the primary social-anxiety outcome - and more practical for therapists

A pre-registered three-arm RCT randomized 59 adults with DSM-5 social anxiety disorder to 14 weekly sessions of CBT with VR exposure (n=17), CBT with in-vivo exposure (n=22), or waitlist (n=20). The pre-specified superiority hypothesis was confirmed: VR exposure was significantly more effective than in-vivo exposure on the LSAS-SR primary outcome at post-treatment and at 6-month follow-up, and significantly less cumbersome for therapists (SWEAT: 15.24 vs 24.46). Reliable change: 76.5% VR, 68.3% in vivo, 30.0% waitlist.

Bouchard S et al. · 2017 Read Summary
Speaking AnxietySocial Communication

Pilot pre-post + waitlist study of four brief VR therapy sessions for public speaking anxiety in university students: reductions in self-report and heart-rate measures

Eight university students with public speaking anxiety completed four brief VR therapy sessions (~15 minutes each, weekly), with six waitlist-control students completing post-testing only. Self-report inventories, Subjective Units of Discomfort during exposure, and heart-rate measurements during speaking tasks were used. Results showed reductions on self-report measures and physiological indices for the VR group, supporting brief VRT as a workable PSA intervention. Small samples and pre-post-with-waitlist (not full RCT) design limit certainty - this is foundational pilot evidence rather than definitive efficacy data.

Harris SR et al. · 2002 Read Summary
Speaking AnxietySocial Communication

Three-arm RCT (n=60) of stand-alone VR exposure therapy vs in-vivo exposure vs waiting-list for social anxiety disorder: in-vivo exposure was superior to VRET on multiple secondary outcomes - the opposite pattern to Bouchard 2017

Sixty participants diagnosed with social anxiety disorder were randomly assigned to individual virtual reality exposure therapy (VRET), individual in-vivo exposure therapy (iVET), or a waiting-list control. Both treatments improved social anxiety symptoms, speech duration, perceived stress, and avoidant-personality-disorder beliefs versus waitlist. However, iVET (but NOT VRET) also improved fear of negative evaluation, speech performance, general anxiety, depression, and quality of life. iVET was superior to VRET on social anxiety symptoms at post and follow-up and on avoidant-PD beliefs at follow-up. At follow-up, almost all improvements remained significant for iVET; for VRET only the perceived-stress effect held.

Kampmann IL et al. · 2016 Read Summary
Speaking AnxietyImplementation

First RCT (n=25+25) showing that consumer VR hardware and software can deliver effective one-session VRET for public speaking anxiety - both therapist-led (d=1.67) and self-led at home (d=1.35), with gains maintained at 6 and 12 months

Twenty-five participants were randomised to one-session therapist-led VR exposure therapy for public speaking anxiety using consumer VR hardware and software, followed by a 4-week internet-administered VR-to-in-vivo transition program; another 25 served as a waiting-list. Therapist-led VRET produced a very large effect on self-reported PSA (within Cohen's d = 1.67). The waiting-list then received internet-administered, SELF-LED VRET at home, followed by the same transition program - producing a large effect (d = 1.35). Results were maintained or improved at 6-month and 12-month follow-ups. This is the first published RCT demonstrating that off-the-shelf consumer VR hardware and software can deliver effective PSA exposure therapy in both clinician-supervised and home-based formats.

Lindner P et al. · 2019 Read Summary
Speaking AnxietyGeneralization

VR exposure equals traditional CBT for public-speaking anxiety, with lower dropout

In an 88-person RCT, VR-based cognitive-behavioral therapy for public-speaking anxiety produced anxiety reductions equivalent to traditional CBT and significantly larger than waitlist, with notably fewer participants dropping out of the VR arm.

Wallach HS et al. · 2009 Read Summary
Speaking AnxietySocial CommunicationImplementation

Pilot RCT (n=44) of brief self-guided virtual reality exposure therapy for social anxiety disorder: moderate-to-large effects on SAD severity, job interview fear, and trait worry, maintained at 3 and 6 months

Forty-four community-dwelling or undergraduate adults diagnosed with social anxiety disorder (SAD) using the Mini International Neuropsychiatric Interview were randomly assigned to a self-directed VR exposure intervention (designed to last four sessions or more; n=26) or a waitlist control (n=18). Outcomes measured at baseline, post-treatment, 3-month follow-up, and 6-month follow-up. VR exposure produced moderate-to-large reductions in SAD symptom severity, job interview fear, and trait worry (Hedges' g = 0.54 to 1.11). Although between-group differences in depression were not significant, the VR arm reduced depression while waitlist did not. Gains were maintained at 3- and 6-month follow-up. Self-reported presence increased during treatment (g = 0.36 to 0.45); cybersickness decreased (g = 0.43).

Zainal NH et al. · 2021 Read Summary

Cite this study

If you reference this study in your work, the canonical citation formats are:

APA 7th
Reeves, R., Elliott, A., Curran, D., Dyer, K., & Hanna, D. (2021). 360° Video virtual reality exposure therapy for public speaking anxiety: A randomized controlled trial. Journal of Anxiety Disorders. https://doi.org/10.1016/j.janxdis.2021.102451.
AMA 11th
Reeves R, Elliott A, Curran D, Dyer K, Hanna D. 360° Video virtual reality exposure therapy for public speaking anxiety: A randomized controlled trial. Journal of Anxiety Disorders. 2021. doi:10.1016/j.janxdis.2021.102451.
BibTeX
@article{reeves2021,
  author = {Reeves, R. and Elliott, A. and Curran, D. and Dyer, K. and Hanna, D.},
  title = {360° Video virtual reality exposure therapy for public speaking anxiety: A randomized controlled trial},
  journal = {Journal of Anxiety Disorders},
  year = {2021},
  doi = {10.1016/j.janxdis.2021.102451},
  url = {https://withvr.app/evidence/studies/reeves-2021}
}
RIS
TY  - JOUR
AU  - Reeves, R.
AU  - Elliott, A.
AU  - Curran, D.
AU  - Dyer, K.
AU  - Hanna, D.
TI  - 360° Video virtual reality exposure therapy for public speaking anxiety: A randomized controlled trial
JO  - Journal of Anxiety Disorders
PY  - 2021
DO  - 10.1016/j.janxdis.2021.102451
UR  - https://withvr.app/evidence/studies/reeves-2021
ER  -

Know of research that should be in this hub? If a relevant peer-reviewed study is not listed here, send the reference to hello@withvr.app. The hub is kept up to date as the literature grows.

Funding & independence

Affiliations: Queen's University Belfast (UK); Northern Health and Social Care Trust (UK). Funding sources not extracted in detail from the abstract excerpt. Peer-reviewed in Journal of Anxiety Disorders (Elsevier). No withVR BV involvement in funding, study design, or authorship. Summary prepared independently by withVR using the published peer-reviewed paper. The VR system used was a 360° video-based platform, NOT Therapy withVR or Research withVR (Therapy withVR uses computer-generated environments, a different modality).

Last reviewed: 2026-05-17 Next review due: 2027-05-17 Reviewed by: Gareth Walkom