Virtual reality in assessment and treatment of schizophrenia: a
					systematic review

Macedo, Mônica; Marques, António; Queirós, Cristina

doi:10.1590/0047-2085000000059

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Sumário

LITERATURE REVIEW • J. bras. psiquiatr. 64 (1) • Jan-Mar 2015 • https://doi.org/10.1590/0047-2085000000059 copy

Virtual reality in assessment and treatment of schizophrenia: a systematic review

Realidade virtual na avaliação e no tratamento da esquizofrenia: uma revisão sistemática

Authorship SCIMAGO INSTITUTIONS RANKINGS

Objective

To conduct a systematic review about the use of virtual reality (VR) for evaluation, treatment and/or rehabilitation of patients with schizophrenia, focused on: areas, fields and objectives; methodological issues; features of the VR used; viability and efficiency of this resource.

Methods

Searches were performed about schizophrenia and virtual reality in PsycINFO, Academic Search Complete, MEDLINE Complete, CINAHL with Full Text, Web of Science and Business Source Premier databases, using the following keywords: [“schizophrenia”] AND [“virtual reality” OR “serious game”] AND [“treatment” OR “therapy” OR “rehabilitation”]. The search was carried out between November 2013 and June 2014 without using any search limiters.

Results

A total of 101 papers were identified, and after the application of exclusion criteria, 33 papers remained. The studies analysed focused on the use of VR for the evaluation of cognitive, social, perceptual and sensory skills, and the vast majority were experimental studies, with virtual reality specifically created for them. All the reviewed papers point towards a reliable and safe use of VR for evaluating and treating cognitive and social deficits in patients with schizophrenia, with different results in terms of generalisation, motivation, assertiveness and task participation rate. Some problems were highlighted, such as its high cost and a constant need for software maintenance.

Conclusion

The studies show that using the virtual reality may streamline traditional evaluation/rehabilitation programmes, allowing to enhance the results achieved, both in the cognitive and in the social field, helping for the legitimisation of this population’s psycho-social inclusion.

Schizophrenia; virtual reality; evaluation; rehabilitation; review

Area	n	Domain	n	Objective	n
Cognitive	15	Evaluation	13	Executive functions	10
				Atention	5
				Spacial memory	4
				Visual memory	3
		Trainning	2	Cognitive skills	2
Social	14	Evaluation	10	Social interaction	5
				Social perception	3
				Emotional recognition	2
		Trainning	4	Social skills	3
		Trainning	4	Comunication skills	1
Senso-perceptual	4	Evaluation	4	Reality perception	2
				Sense of perception	1
				Auditory hallucination	1
				Delusion	1

Reference (year)	Country	Field	Objective	Type of study	Assessments and measurements	Total sample/CG [M age (SD)]	VR Programs	Presence	VR Usability, Feasibility and Safety in schizophrenia patients
I. Cognition Abilities
Ku et al. (2003)³⁴	Korea	A	EF	ES	EF: (WCST) Intelligence: (SPM)	13 patients [30(2.5)] 13 healthy controls [27.8(3.4)]	Virtual Environment based on WCST – designed for research	I	Parameters in VR correlate to WCST and SPM. This allows verifying how distracters influence cognitive skills. It also allows identifying perseverance behaviours that are specific to the pathology
Ku et al. (2004)³⁵	Korea	A	EF	ES	EF: (WCST) Intelligence: (SPM)	15 patients [n.i.] 18 healthy controls [n.i]	Virtual Environment based on WCST – designed for research	I	Parameters in VR correlate to WCST and SPM. This allows verifying how distracters influence cognitive skills. It also allows identifying perseverance behaviours that are specific to the pathology
Costa and Carvalho (2004)¹⁴	Brazil	A	Cognitive Training Program	PS	Direct observation Questionnaire	4 patients [45.2(8.6)] No CG	Ambiente Virtual Integrado para Reabilitação Cognitiva (AVIRC)	I	The technology is safe and efficient for cognitive training. The immersive mode promotes greater attention and motivation by users
St. Germain and Kurtz (2004)³⁶	USA	A	Attention Work Memory Visual Perception	ES	Number of erros	11 individuals [34.9(11.2)] 15 healthy controls [24,1(5,4)]	Virtual Driving Simulator	NI	The technology allows analysing the task of driving safely, in order to identify the driver’s difficulties
Sorkin et al. (2005)²⁷	Israel	A	Work Memory	ES	Symptoms: (PANSS) 26 parameters for subjects performance divided in 3 groups: work-memory and integration, navigation, strategy	39 patients [n.i.] 21 healthy controls matched by age	Virtual Maze – designed for research	I	VR allows collecting multiple metrics on complex behaviours, including multi-modal interactions (working memory), widening the spectrum of the cognitive evaluation. It improves the participant’s motivation and attention
Sorkin et al. (2006)³⁷	Israel	A	EF	ES	Symptoms: (PANSS) 26 parameters for subjects performance divided in 3 groups: work-memory & integration, navigation & strategy	39 patients [32.3(7.9)] 21 healthy controls matched by age	Virtual Environment based on WCST – designed for research	I	VR allows collecting multiple metrics on complex behaviours, including multi-modal interactions (working memory), widening the spectrum of the cognitive evaluation. It improves the participant’s motivation and attention
Baker et al. (2006)²²	USA	A	Medication Compliance Behavior	ES	Attention: (CPT ) Cognition: (SCT) Memory (HVLT-R ) Symptoms: (PANSS) Number of errors Time discrepancy Number of clock/reminder checks	25 participants [n.i.] No CG	Virtual Apartment – designed for research	NI	It enables ecological assessment. It demonstrates predictive power over adherence to medication. It has major potential in the field of evaluation of cognitive skills
Kurtz et al. (2007)³⁸	USA	A	Medication Management Skills	PS	Attention: (CPT) Cognition: (SCT) Memory: Test (HVLT) Medication Management Ability Assessment (MMAA) Symptoms: (PANSS) Number of errors (quantitative and qualitative) Time discrepancy Total distance travelled	25 patients [42.1(10.5)] 18 healthy controls [39.1(11)]	Virtual Reality Apartment Medication Management Ability Assessment (VRAMMA)	NI	The technology is well tolerated and efficient for the evaluation of cognitive skills. It allows simulating a multi-modal environment, in order to recruit a range of neurocognitive a sensory-motor skills
Weniger and Irle (2008)³⁹	Germany	A	Spatial Memory	ES	Intelligence: (WAIS-R) Memory: (WMS-R) Outcomes: (CGI), (GAF) Symptoms: (SANS), (SAPS) Number of errors Questionnaire about navigation strategies	25 inpatients [30(10)] 25 healthy controls [32(10)]	Park and Virtual Maze – design for research	NI	It is an adequate, practical and cost-efficient technology for evaluating spatial capacity. It does not cause side effects
Josman et al. (2009)⁴⁰	Israel	A	EF	ES	EF: (BADS) Symptoms: (PANSS)	30 individuals [46.7(10.5)] 30 healthy controls [47.7(12.4)]	Virtual Action Plan-Supermarket (VAP-S)	NI	It is an ecologically valid technology for EF evaluation tools. It enables the inclusion of independence and participation measurements, according to WHO recommendations
Chan et al. (2009)²³	China	T	Attention Memory Orientation	ES	Cognition: (Cognistat) Side effects: (SSQ) Volition: (VQ)	12 individuals [66.4(6.2)] 15 individuals schizophrenia disorder [65.8(5.5)]	VR Program adapted from IREX® - Interactive Rehabilitation Exercise System	NI	It is efficient in cognitive functioning and volition training. It does not cause side effects
Han et al. (2012)⁴¹	Korea	A	EF – Cognitive flexibility	ES	Intelligence: (K-WAIS) Sense of Presence: (ITQ), (PQ), (VRQ) Social Problem Solving: (SPSI) Symptoms: (PANSS)	30 patients [30(4.9)] 30 healthy controls [29.5(4.9)]	Virtual Environment designed for research	NI	It allows for safe evaluation, through stimuli, in environments similar to reality, with the advantage of not being limited time or space
Spieker et al. (2012)¹⁰	USA	A	Spatial Learning Spatial Memory	ES	Cognition: (RBANS) Symptoms: (BPRS), (SANS)	33 outpatients [40 (11.9)] 39 healthy controls [40.5(11.4)]	Radial Arm Maze (RAM) adapted for a virtual environment	NI	The VR paradigm can provide information on the effects of cognitive training on the improvement of the pre-frontal cortex and hippocampus functions
Tsang and Man (2013)²⁶	China	T	Attention Memory EF	RCT	Attention: (DVT) Cognition: (BNCE), (VCRS) EF: (WCST) Memory: (RBMT) Self-designed checklist - sales performance Self-efficacy performance scale	25 inpatients [39.6(7.9)] 50 inpatients TAG (n=25) [40.7(9.1)]; CG (n=25) [41.56(9.9)]	Virtual Reality-Based Vocational Training System (VRVTS)	NI	It enables the restoration of cognitive skills and enhances vocational training. The technology requires constant technical support and side effect monitoring
Zawadzki et al. (2013)⁴²	Canada	A	Spatial Learning Spatial Memory	ES	Cognition: (RBANS) Intelligence: (K-WAIS) Quality of life: (QLS) Symptoms: (SAPS)	33 outpatients [40 (10.9)] 39 healthy controls [43 (11.3)]	Virtual Environment designed for research	NI	The results obtained at VR environment are correlated with classical assessments (e.g. Repeatable Battery for the Assessment of Neuropsychological Status). The using of naturalistic virtual environment is supported as a measure of cognitive functioning
II. Social Abilities
Kim et al. (2005)⁴³	Korea	A	Social Perception	ES	Intelligence: (K-WAIS) Sense of Presence: (ITQ), (PQ), (VRQ) Symptoms: (PANSS) Verbal/non-verbal social cue Happy/sad/angry situation Emotional recognition Interpretation of relevant cue	17 inpatients [30.4(5.3)] 17 healthy controls [30.05(6)]	Virtual Reality Behavior & Facial Data Base (VRBFDB)	NI	The application of the evaluation in virtual mode is faster and easier, and it also allows to quickly change facial parameters, thereby creating variability in the interactions proposed
Jang (2005)⁴⁴	Korea	A	Social Interaction Social Anxiety	ES	Anxiety: (SAQ)	15 inpatients [28.6(7)] 15 healthy controls [25.1(1.5)]	Virtual environment designed for research	I	VR technology (ecological model) is a safe option for experimenting emotions in induced social situations and can be used for coping training in a safe environment
Ku et al. (2005)⁴⁵	Korea	A	Social Interaction	ES	Symptoms: (PANSS) Interpersonal distance Verbal response time	11 inpatients [29.5(8.9)] No CG	Virtual environment designed for research	NI	The technology allows social interaction responses that are similar to those of a real context
Ku et al. (2006)⁴⁶	Korea	A	Social Interaction	PS	Symptoms: (PANSS) Interpersonal distance Verbal response time	11 inpatients [29.5(8.9)] No CG	Virtual environment designed for research	NI	The technology allows social interaction responses that are similar to those of a real context
Kim et al. (2007)⁴⁷	Korea	A	Social Perception	ES	Intelligence: (K-WAIS) Sense of Presence: (ITQ), (PQ), (VRQ) Symptoms: (PANSS) Verbal/non-verbal social cue Happy/sad/angry situation Emotional recognition Interpretation of relevant cue	30 inpatients [29.6(4.9)] 30 healthy controls [29.5(5.3)]	Virtual environment designed for research	NI	It is a potential tool for evaluating social perception, problem solving ability and assertiveness skills, as well as for training social skills
Ku et al. (2007)²⁸	Korea	T	Conversational Skills	ES	Symptoms: (PANSS) Verbal response time Questionnaire about general options, usability and presence	10 patients [28.8(9)] No CG	Virtual environment designed for research	I	It is an efficient technique for conversation training. It provides objective clinical metrics. Its application can be limited by pathology-specific conditions (negative symptoms)
Park et al. (2009)¹¹	Korea	A	Emotional Perception Emotional Response	ES	Anxiety: (STAI-Y) Intelligence: (RPM) Symptoms: (PANAS), (PANSS), (PSAS), (SAS)	27 individuals [28.5(5.7)] 27 healthy controls [26.5(4.4)]	Virtual environment designed for research	I	It is an efficient technique for evaluating social cognition. The experience causes joy, interest and emotional confrontation
Park et al. (2009)⁴⁸	Korea	A	Social Interaction – Spatial Behavior	ES	Symptoms: (PANSS) Distance from a virtual person Orientation head angle	30 individuals [28.7(5.5)] 30 healthy controls [26.3(4.3)]	Virtual environment designed for research	I	It is a safe alternative for verifying interpersonal space
Park et al. (2009)⁴⁹	Korea	A	Social Interaction	PS	Clinical: (BARS), (SARS) Social Functioning: (SBS), (RCS) Symptoms: (PANAS) (PANSS)	18 female Aripiprazole group (n = 10) [30.2(7.7)]; Risperidone group (n = 8) [29.3(6.8)] 15 healthy female [28.1(8)]	Virtual Reality Functional Skills Assessment (VRFSA)	I	It is a valid tool to measure functional skills
Dyck et al. (2010)⁶	Germany	A	Emotional Recognition	ES	Intelligence: (MWT-B) Symptoms: (PANAS), (PANSS) Questionnaire of computer game experience	20 patients [36.7(1.9)] 20 healthy controls [36.9(2.2)]	Virtual faces	I	It allows controlling animation and changing parameters in real time, which increases the number of observation/research options
Park et al. (2011)²⁴	Korea	T	Social Skills	RCT	Symptoms: (PANSS) Social Functioning: (AI),(SBS), (RAS), (RCS), (SPSI-R), (SST) Questionnaire of VR experience	33 inpatients [28.1(7.7)] 31 inpatients with schizophrenia disorder [31.2(7.7)]	VR role-playing (SST-VR)	I	It can be applied to conversation and assertiveness skill training; however, it is less effective for non-verbal skills. It allows enhancing motivation. Its usage is limited, due to the fact that it is expensive
Gutiérrez-Maldonado et al. (2012)²⁹	Spain	A	Facial Recognition	ES	Attention: (CPT), Symptom: (PANSS), (SCIP), (TAS-20)	30 outpatients [n.i.] No CG	Virtual faces	NI	It is a useful tool for evaluating emotion recognition. Its dynamic nature improves accuracy in recognising facial expressions
Rus-Calafell et al. (2012)²⁵	Spain	T	Social Skills	CS	Anxiety: (SADS) Social Functioning: (AI), (SFS) Symptom: (PANSS)	1 woman [30 year old] No CG	SOSKITRAIN - VR	NI	It allows strengthening other treatment approaches in an individualised manner and it presents a larger degree of generalisation of the gains obtained
Rus-Calafell et al. (2014)⁸	Spain	T	Social Skills	PS	Anxiety: (SADS) Social Functioning: (AI), (SFS), (SSIT) Symptom: (PANSS)	12 participants [36.5(6)] No CG	SOSKITRAIN - VR	NI	It enables treating patients who refuse to participate in group therapy; it is an ecological tool; it allows practising skills in specific social interactions; it allows for direct, real-time observation of social behaviours
III. Senso-Perceptual Abilities
Fornells-Ambrojo et al. (2008)³³	UK	A	Safety and Feasibility of Using VR Sense of Presence Delusion in VR	ES	Anxiety: (STAI) Intelligence: (WTAR) Sense of presence: (SPQ) Side Effects: (SSQ) Symptom: (PANSS), (G-PTS), (SSPS) VR semi structured interview	22 participants with early psychosis [23.5(3.1)] 20 non clinical group [25.5(4.4)]	VE designed for research	I	VE can be used safely in people with persecutory delusions
Lallart et al. (2009)⁵⁰	France	A	Sense of Presence	ES	Sense of Presence: (PQ) Symptom: (PANSS)	19 individuals [33.3(8.2)] 19 healthy controls [32.6(8)]	VE designed for research	I	VR tests can safely contribute to evaluating agency deficit
Han et al. (2012)⁵¹	Korea	A	Auditory Hallucination	ES	Cognitive Ability: (RPM) Sense of presence: (PQ), (VREQ) Side Effects: (SSQ) Symptom: (PANSS), (BAS), (SARS)	36 patients [28.9(6)] 20 healthy controls matched by age	VE designed for research	I	VR is particularly valuable in supplying objective parameters for evaluating behavioural characteristics
Moritz et al. (2014)⁵²	Germany	A	Delusion	ES	Symptom: (PANSS), (POD)	33 in-out patients [40.5 (9.9)] No CG	VE designed for research	NI	VE was safe and efficient in the evaluation of paranoid symptoms. It does not have side effects

Note 1: ID: Identification; A: Assessment; T: Training; CS: Case Study; ES: Experimental Study; PS: Pilot Study; RCT: Randomized Control Trial; I: Immersive; NI: No Immersive; CG: Control Group.
EF: Executive Functions; (AI): Assertion Inventory; (BARS): Barnes Akathisia Rating Scale; (BAS): Barnes Akathisia Scale; (BADS): Behavioral Assessment of Dysexecutive Syndrome; (BNCE): Brief Neuropsychological Cognitive Examination; (BPRS): Brief Psychiatric Rating Scale; (CGI): Clinical Global Impression Scale; (CPT): Continuous Performance Test; (DVT): Digit Vigilance Test; (GAF): Global Assessment of Functioning Scale; (G-PTS): Green et al. Paranoid Thoughts Scales; (HVLT-R): Hopkins verbal learning test; (ITQ): Immersive Tendency questionnaire; (K-WAIS): Coreia do Suln-Wechsler Adult Intelligence Scale; (MMAA): Medication Management Ability Assessment; (MWT-B): Mehrfachwahl Wortschatz Intelligenztest; (PSAS): Physical and Social Anhedonia Scale; (PANAS): Positive and Negative Affective Schedule; (PANSS): Positive and Negative Syndrome Scale; (PO): Paranoia, Obsessive-compulsive and Depression Questionnaire; (PQ): Presence Questionnaire; (QLS): Quality of Life Scale; (RAS): Rathus Assertiveness Schedule; (RCS): Relationship Change Scale; (RPM): Raven’s Progressive matrices; (RCS): Relationship Change Scale; (RBANS): Repeat Battery for the Assessment of Neuropsychological Status; (RBMT): Rivermead Behavioral Memory Test; (SANS): Scale for the Assessment of Negative Symptoms; (SAPS): Scale for the Assessment of Positive Symptoms; (SAS): Schizotypal Ambivalence Scale; (SCIP): Screen for Cognitive Impairment in Psychiatry; (SPQ): Sense of Presence Questionnaire; (SCT): Short Category Test; (SARS): Simpson Angus Rating Scale; (SSQ): Simulator Sickness Questionnaire; (SADS): Social Anxiety and Distress Scale; (SAQ): Social Anxiety Quest; (SBS): Social Behavior Scale; (SFS): Social Functioning Scale; (SPSI): Social Problem Solving Inventory; (SSIT): Simulated Social Interaction Test; (SST): Social Skill Training; (STAI): Spielberg State-Trait Inventory; (SPM): Standard Progressive Matrices; (SSPS): State Social Paranoia Scale; (STAI-Y): State-Trait Anxiety Inventory-Form Y; (TAS-20): Toronto Alexithymia Scale; (VAP-S): Virtual Action Plan-Supermarket; VE: Virtual Environment; (VREQ): Virtual Reality Experience Questionnaire; (VRFSA): Virtual Reality Functional Skills Assessment; (VRQ): Virtual Reality Questionnaire; (VCRS): Vocational Cognitive Rating Scale; (WAIS-R): Wechsler Adult Intelligence Scale-Revised; (WMS-R): Wechsler Memory Scale-Revised; (WCST): Wisconsin Card Sorting Test.

Study	VR issue	Assessment/Measuremnt	Results Mean (Standard Deviation) [Range]
Ku et al. (2007)²⁸	Usefulness	Questionnaire	6.3 (±1.6) [0-10]
Ku et al. (2007)²⁸	Interest	Questionnaire	7.3 (±2) [0-10]
Park et al. (2011)²⁴	Interest	Interest-in-Participation Questionnaire	81.5 (±10) [0-100]
Ku et al. (2007)²⁸	Volition	Questionnaire	7.5 (±2.7) [0-10]
Chan et al. (2009)²³	Volition	Volition Questionnaire	26.8 (±4.8) [15-56]
Russ-Callafel et al. (2014)⁸	Satisfaction	Satisfaction Questionnaire	8.7 (±0.3) [0-10]
Russ-Callafel et al. (2014)⁸	Acceptance	Satisfaction Questionnaire	9.2 (±0.7) [0-10]

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E-mail: editora@ipub.ufrj.br

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[1] Correspondence address to: António Marques. E-mail: ajmarques@estsp.ipp.pt