Virtual Reality and Schizophrenia

The immersion of VR makes this technology an excellent aid for the assessment of cognitive and social functions also in people with pathologies such as schizophrenia.


Advertising message We’ve probably all heard of Virtual Reality (RV) by now, a digital world that is attracting increasing interest and enthusiasm from clinicians and researchers. Let’s briefly see what it is and how it works.

RV is a simulated 3D environment with which the subject can interact through the help of particular “input” (position sensors and / or gloves / overalls equipped with sensors) and “output” systems (helmet with LCD monitor), integrated and updated by a computer, which builds and returns in real time images and sounds of the scenario in which the user is immersed.

VR offers a wide range of applications: from architecture to video games, from medicine to art, from psychology to sport.

Being the RV scenario a realistic simulation of a likely environment and, at the same time safe and controlled by the clinician in a laboratory setting, it allows to minimize the costs and dangers related to situations that could be potentially dangerous in the field experience (or experience in vivo). Furthermore, given the high level of involvement, interaction and participation, it seems to promote the patient’s motivation for treatment (Baker Ek. Et al., 2006).

For these reasons, the application of this technology, in the context of clinical psychology, is a valid support tool for cognitive behavioral psychotherapy.

VR exposure is effective in scientific research, in the identification and treatment of eating disorders and anxiety disorders (G. Riva, 2005).

Although the amount of research shows the effectiveness of the application of immersive technologies to these types of ailments, only recently have surprising results emerged in the context of schizophrenia.

DSM-5 (APA, 2013) defines it as a chronic psychotic disorder characterized by positive (delusions, hallucinations, disorganized thinking and agitation) and negative symptoms (coerced affectivity, poverty of thought, social isolation, emotional flattening, apathy and anhedonia) that cause a strong personal and social compromise. Furthermore, impairment of the cognitive sphere is a central feature of schizophrenia.

According to a review published in 2010 (La Barbera D. et al., 2010) the research, with the help of RV, mainly dealt with:

Daniel Freeman (who will be a guest at Digital Perspectives in Psychology 2021), professor of clinical psychology and researcher at the University of Oxford, has devoted much of his research to the knowledge and treatment of paranoia. Together with his research team, he assessed the potentially predictive factors of paranoid symptoms, exposing a group of as many as 200 non-clinical subjects to neutral virtual environments (2008). The virtual settings, a simulation of the London Underground and a common library, were populated by avatars created to be as neutral as possible. The avatars moved randomly in the environment and showed a neutral facial expression, never clearly friendly or hostile. Of all the subjects, previously subjected to a series of psychological evaluations on the “predisposition to paranoia”, only a small portion declared persecutory thoughts and moods connected to the experience. These experiences were statistically predicted by previously measured constructs such as: anxiety, worry, perceptual anomalies and cognitive rigidity.

Banks and his research team (2004), on the other hand, helped by a group of patients suffering from schizophrenia, have created real hallucinatory experiences in the laboratory, with the aim of measuring their neurophysiological and psychological correlates. Using VR, the researchers exposed healthy subjects to audio-visual stimuli attributable almost perfectly to the common hallucinations experienced by psychotic subjects. The experiences, which consisted of sounds or voices, at the appearance of words like “death” intermittently between the headlines of a newspaper or the vision of the Virgin Mary, seemed to activate particular areas of the brain and induce specific emotional responses. The results of measurements with functional magnetic resonance imaging indicated an increase in the work of the auditory secondary cortex in the left secondary planum. Furthermore, the subjects seemed to experience significant emotional activation when they were exposed to auditory hallucinations with accusatory semantic content. From this they found, therefore, that it is precisely the meaning rather than the frequency, the volume or the duration of the hallucinations, to induce unpleasant experiences.

The immersion of the VR makes this technology also an excellent aid for the assessment of cognitive and social functions. Many evaluation tools, which traditionally consisted in the administration of tests or in observation in the natural environment, find today an incredible turning point in terms of costs and effectiveness with VR.

Between 2003 and 2006, several research groups proposed RV versions of some neuropsychological tests (Ku J. et al., 2003; Ku J. et al., 2004; Sorkin A. et al., 2005; Sorkin A . et al., 2006).

Sorkin and colleagues (2006) have demonstrated, through the immersion of schizophrenic patients in a virtual environment inspired by the Wisconsin Card Sorting Test (Heaton RK et al., 2000), the effectiveness of this technology in measuring frontal functions. The subject’s task was to overcome a maze by going through a series of doors distinguished by color, shape and sound. The data produced by moving the subject produced incredibly accurate measurements in terms of abstract reasoning skills and cognitive strategies.

By means of perceptive inconsistency tasks, the research group (2008), on the other hand, assessed the reality test. These tasks consisted of recognizing perceptual anomalies such as, for example, a barking cat or a tree with blue leaves. Almost 90% of the patients had very low scores in these tasks, making this characteristic index of the disorder and the test an excellent psychodiagnostic screening tool.

Advertising message In 2006 what was originally a test to measure spatial memory and learning abilities in mice expanded the target audience for humans, through a virtual version, which in a traditional laboratory environment would have been difficult to be implemented (Hanlon FM. et al., 2006). The subject is virtually immersed in a pool of opaque water, just as it happened for the mouse, with the task of identifying and getting on a platform. This first test is then repeated with a higher water level, such as to hide it. Despite the use of environmental reference points, such as the virtual examiner or objects placed beyond the edges of the pool, schizophrenic subjects took longer than healthy subjects to locate the platform.

In addition to the application of VR in the evaluation of cognitive functions, virtual social environments are useful for understanding the social functioning of the individual and his ways of relating to others. To evaluate this, Ku J. and his research team (2007) asked a group of patients with schizophrenia to interact virtually with avatars. This experiment produced interesting results regarding the relationship between social factors and the negative symptoms of schizophrenia. It has been shown that patients with a greater compromise in terms of negative symptoms tended to maintain greater interpersonal distance during interactions. This index, which emerged through the use of immersive technologies, highlights a further peculiarity of the disease,

In order to improve the social functioning of people with schizophrenia, VR has become part of the social skill training programs. By comparing the standard role playing protocols with the simulations of virtual social situations, the latter demonstrated far greater evidence of effectiveness, particularly in general social skills and conversation skills (Ku J. et al., 2007).

To date, there is not a large number of cognitive rehabilitation protocols in VR. A protocol devised in Brazil by Costa and Carvalho (2004) appears to be effective in cognitive rehabilitation of various ailments as with brain-damaged patients. The two researchers created a virtual space called “Integrated Virtual for Cognitive Rehabilitation” (AVIRC), that is a city consisting of a square, houses, a library, a church and a supermarket. The aim of the researchers was to enable the user to train in the presence of typical situations of daily life. Some of the tasks that the user had to complete were: answering passers-by questions regarding time and date, interacting with common objects such as radios or lamps, dialing previously stored telephone numbers or recognizing passers-by faces.

In addition, VR has also found use in improving compliance and the management capacity of drug therapy, another problem related to the decline of the intellectual abilities of subjects with schizophrenia. American researchers (Kurtz MM. Et al., 2007) virtually recreated an apartment, equipped with various rooms, within which the patient was trained to correctly take drug therapy in terms of dosage and timing, with the help of external environmental aids such as the wall clock or post-it. The use of this technology has proved effective both in identifying problems relating to self-management of therapy and in its implementation.

Schizophrenia is madness for the collective imagination. By its nature the schizophrenic experience is commonly thought of as something unknowable, mysterious and terrifying. This is why the severity of the stigma that afflicts people with this pathology cannot be compared to any other psychiatric or medical condition. It is possible, however, through simulation workshops of the hallucinatory experience, to immerse yourself in the everyday life of these people for a few minutes and live an experience that has the aim of raising awareness of these conditions. Yellowlees and colleagues (2006) worked for this, making this experience available on a gigantic digital platform produced by the American company Linden Lab, called “Second Life”.

The experience consisted in the simulation of a series of hallucinatory and delusional experiences in environments of daily life and ended with the entry on the scene of an avatar with friendly features, evocative of the underlying message of the experience itself, that is, awareness of social support .

In conclusion, the scientific evidence taken into consideration sees RV aimed purely at patients at risk of psychosis and without current positive symptoms. It has been seen that through the fictitious reproduction of real-life contexts and situations, it is possible not only to obtain a reliable evaluation of the main cognitive functions, to facilitate the evaluation of what are the psychopathological symptoms of social anxiety or persecutory ideation, but also decrease the stigma and sensitize with respect to the schizophrenic experience.

Although the scientific literature shows that some subjects (people suffering from serious cardiac pathologies, epilepsy, drug addicts, and with problems regarding the perception of reality) show very intense reactions to simulated environments (Wiederhold B. et al., 2003), the possibilities application of this tool and possible future developments are inevitably interesting.

So extending research in this field seems to be an extremely interesting, topical and fundamental objective for the future to date.