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Virtual reality in the assessment and treatment of psychosis: a systematic review of its utility, acceptability and effectiveness

Published online by Cambridge University Press:  24 July 2017

M. Rus-Calafell
King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK South London and Maudsley NHS Trust, London, UK
P. Garety
King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK South London and Maudsley NHS Trust, London, UK
E. Sason
King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
T. J. K. Craig
King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK South London and Maudsley NHS Trust, London, UK
L. R. Valmaggia*
King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK South London and Maudsley NHS Trust, London, UK
*Address for correspondence: Dr L. R. Valmaggia, Department of Psychology, King's College London, Institute of Psychiatry, Psychology and Neuroscience, PO 77, De Crespigny Park, London SE5 8AF, UK. (Email:


Over the last two decades, there has been a rapid increase of studies testing the efficacy and acceptability of virtual reality in the assessment and treatment of mental health problems. This systematic review was carried out to investigate the use of virtual reality in the assessment and the treatment of psychosis. Web of Science, PsychInfo, EMBASE, Scopus, ProQuest and PubMed databases were searched, resulting in the identification of 638 articles potentially eligible for inclusion; of these, 50 studies were included in the review. The main fields of research in virtual reality and psychosis are: safety and acceptability of the technology; neurocognitive evaluation; functional capacity and performance evaluation; assessment of paranoid ideation and auditory hallucinations; and interventions. The studies reviewed indicate that virtual reality offers a valuable method of assessing the presence of symptoms in ecologically valid environments, with the potential to facilitate learning new emotional and behavioural responses. Virtual reality is a promising method to be used in the assessment of neurocognitive deficits and the study of relevant clinical symptoms. Furthermore, preliminary findings suggest that it can be applied to the delivery of cognitive rehabilitation, social skills training interventions and virtual reality-assisted therapies for psychosis. The potential benefits for enhancing treatment are highlighted. Recommendations for future research include demonstrating generalisability to real-life settings, examining potential negative effects, larger sample sizes and long-term follow-up studies. The present review has been registered in the PROSPERO register: CDR 4201507776.

Review Article
Copyright © Cambridge University Press 2017 

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Atherton, S, Antley, A, Evans, N, Cernis, E, Lister, R, Dunn, G, Slater, M, Freeman, D (2014). Self-confidence and paranoia: an experimental study using an immersive virtual reality social situation. Behavioural and Cognitive Psychotherapy 11, 19.Google Scholar
Broome, MR, Zanyi, E, Hamborg, T, Selmanovic, E, Czanner, S, Birchwood, M, Chalmers, A, Singh, SP (2013). A high-fidelity virtual environment for the study of paranoia. Schizophrenia Research and Treatment 2013, 7.CrossRefGoogle Scholar
Chan, CLF, Ngai, EKY, Leung, PKH, Wong, S (2010). Effect of the adapted virtual reality cognitive training program among Chinese older adults with chronic schizophrenia: a pilot study. International Journal of Geriatric Psychiatry 25, 643649.Google ScholarPubMed
Chan, RC, Shum, D, Toulopoulou, T, Chen, EY (2008). Assessment of executive functions: review of instruments and identification of critical issues. Archives of Clinical Neuropsychology 23, 201216.CrossRefGoogle ScholarPubMed
Craig, TK, Rus-Calafell, M, Ward, T, Fornells-Ambrojo, M, Mccrone, P, Emsley, R, Garety, P (2015). The effects of an Audio Visual Assisted Therapy Aid for Refractory auditory hallucinations (AVATAR therapy): study protocol for a randomised controlled trial. Trials 16, 349.CrossRefGoogle ScholarPubMed
da Costa, RM, de Carvalho, LA (2004). The acceptance of virtual reality devices for cognitive rehabilitation: a report of positive results with schizophrenia. Computer Methods and Programs in Biomedicine 73, 173182.CrossRefGoogle ScholarPubMed
Dickinson, D, Bellack, AS, Gold, JM (2007). Social/communication skills, cognition, and vocational functioning in schizophrenia. Schizophrenia Bulletin 33, 12131220.CrossRefGoogle Scholar
Dyck, M, Winbeck, M, Leiberg, S, Chen, Y, Mathiak, K (2010). Virtual faces as a tool to study emotion recognition deficits in schizophrenia. Psychiatry Research 179, 247252.CrossRefGoogle Scholar
Eichenberg, C, Wolters, C (2012). Virtual realities in the treatment of mental disorders: a review of the current state of research. In Virtual Reality in Psychological, Medical and Pedagogical Applications (ed. C. Eichenberg), pp. 35–64. InTech .Google Scholar
Fajnerova, I, Rodriguez, M, Levcik, D, Konradova, L, Mikolas, P, Brom, C, Stuchlik, A, Vlcek, K, Horacek, J (2014). A virtual reality task based on animal research – spatial learning and memory in patients after the first episode of schizophrenia. Frontiers in Behavioral Neuroscience 8.CrossRefGoogle ScholarPubMed
Fornells-Ambrojo, M, Barker, C, Swapp, D, Slater, M, Antley, A, Freeman, D (2008). Virtual reality and persecutory delusions: safety and feasibility. Schizophrenia Research 104, 228236.CrossRefGoogle ScholarPubMed
Fornells-Ambrojo, M, Elenbaas, M, Barker, C, Swapp, D, Navarro, X, Rovira, A, Sanahuja, JM, Slater, M (2016). Hypersensitivity to contingent behavior in paranoia: a new virtual reality paradigm. The Journal of Nervous and Mental Disease 204, 148152.CrossRefGoogle ScholarPubMed
Fornells-Ambrojo, M, Freeman, D, Slater, M, Swapp, D, Antley, A, Barker, C (2015). How do people with persecutory delusions evaluate threat in a controlled social environment? A qualitative study using virtual reality. Behavioural and Cognitive Psychotherapy 43, 89107.CrossRefGoogle Scholar
Freeman, D (2008). Studying and treating schizophrenia using virtual reality: a new paradigm. Schizophrenia Bulletin 34, 605610.CrossRefGoogle ScholarPubMed
Freeman, D, Bradley, J, Antley, A, Bourke, E, Deweever, N, Evans, N, Cernis, E, Sheaves, B, Waite, F, Dunn, G, Slater, M, Clark, DM (2016). Virtual reality in the treatment of persecutory delusions: randomised controlled experimental study testing how to reduce delusional conviction. British Journal of Psychiatry 209, 6267.CrossRefGoogle ScholarPubMed
Freeman, D, Dunn, G, Murray, RM, Evans, N, Lister, R, Antley, A, Slater, M, Godlewska, B, Cornish, R, Williams, J, Di Simplicio, M, Igoumenou, A, Brenneisen, R, Tunbridge, EM, Harrison, PJ, Harmer, CJ, Cowen, P, Morrison, PD (2015). How cannabis causes paranoia: using the intravenous administration of 9-tetrahydrocannabinol (THC) to identify key cognitive mechanisms leading to paranoia. Schizophrenia Bulletin 41, 391399.CrossRefGoogle ScholarPubMed
Freeman, D, Evans, N, Lister, R, Antley, A, Dunn, G, Slater, M (2014). Height, social comparison, and paranoia: an immersive virtual reality experimental study. Psychiatry Research 218, 348352.CrossRefGoogle ScholarPubMed
Freeman, D, Garety, PA, Bebbington, P, Slater, M, Kuipers, E, Fowler, D, Green, C, Jordan, J, Ray, K, Dunn, G (2005). The psychology of persecutory ideation II: a virtual reality experimental study. The Journal of Nervous and Mental Disease 193, 309315.CrossRefGoogle ScholarPubMed
Freeman, D, Gittins, M, Pugh, K, Antley, A, Slater, M, Dunn, G (2008a). What makes one person paranoid and another person anxious? The differential prediction of social anxiety and persecutory ideation in an experimental situation. Psychological Medicine 38, 11211132.CrossRefGoogle Scholar
Freeman, D, Pugh, K, Antley, A, Slater, M, Bebbington, P, Gittins, M, Dunn, G, Kuipers, E, Fowler, D, Garety, P (2008b). Virtual reality study of paranoid thinking in the general population. British Journal of Psychiatry 192, 258263.CrossRefGoogle ScholarPubMed
Freeman, D, Pugh, K, Vorontsova, N, Antley, A, Slater, M (2010). Testing the continuum of delusional beliefs: an experimental study using virtual reality. Journal of Abnormal Psychology 119, 8392.CrossRefGoogle ScholarPubMed
Freeman, D, Slater, M, Bebbington, PE, Garety, PA, Kuipers, E, Fowler, D, Met, A, Read, CM, Jordan, J, Vinayagamoorthy, V (2003). Can virtual reality be used to investigate persecutory ideation? The Journal of Nervous and Mental Disease 191, 509514.CrossRefGoogle ScholarPubMed
Gega, L, White, R, Clarke, T, Turner, R, Fowler, D (2013). Virtual environments using video capture for social phobia with psychosis. Cyberpsychology, Behavior, and Social Networking 16, 473479.CrossRefGoogle ScholarPubMed
Green, MF, Kern, RS, Braff, DL, Mintz, J (2000). Neurocognitive deficits and functional outcome in schizophrenia: are we measuring the ‘right stuff’? Schizophrenia Bulletin 26, 119136.CrossRefGoogle Scholar
Green, MF, Leitman, DI (2008). Social cognition in schizophrenia. Schizophrenia Bulletin 34, 670672.CrossRefGoogle ScholarPubMed
Greenwood, KE, Morris, R, Smith, V, Jones, AM, Pearman, D, Wykes, T (2016). Virtual shopping: a viable alternative to direct assessment of real life function? Schizophrenia Research 172, 206210.CrossRefGoogle ScholarPubMed
Gutierrez-Maldonado, J, Rus-Calafell, M, Marquez-Rejon, S, Ribas-Sabate, J (2012). Associations between facial emotion recognition, cognition and alexithymia in patients with schizophrenia: comparison of photographic and virtual reality presentations. Annual Review of Cybertherapy and Telemedicine 2012, 8892.Google Scholar
Harvey, PD, Bowie, CR (2005). Late-life schizophrenia. What providers need to know. Director 13, 90, 93–94.Google ScholarPubMed
Josman, N, Schenirderman, AE, Klinger, E, Shevil, E (2009). Using virtual reality to evaluate executive functioning among persons with schizophrenia: a validity study. Schizophrenia Research 115, 270277.CrossRefGoogle ScholarPubMed
Kesting, ML, Bredenpohl, M, Klenke, J, Westermann, S, Lincoln, TM (2013). The impact of social stress on self-esteem and paranoid ideation. Journal of Behavior Therapy and Experimental Psychiatry 44, 122128.CrossRefGoogle ScholarPubMed
Kim, K, Kim, J-J, Kim, J, Park, D-E, Jang, HJ, Ku, J, Kim, C-H, Kim, IY, Kim, SI (2007). Characteristics of social perception assessed in schizophrenia using virtual reality. Cyberpsychology and Behavior 10, 215219.CrossRefGoogle ScholarPubMed
Kircher, TT, Leube, DT (2003). Self-consciousness, self-agency, and schizophrenia. Consciousness and Cognition 12, 656669.CrossRefGoogle Scholar
Ku, J, Cho, W, Kim, JJ, Peled, A, Wiederhold, BK, Wiederhold, MD, Kim, IY, Lee, JH, Kim, SI (2003). A virtual environment for investigating schizophrenic patients’ characteristics: assessment of cognitive and navigation ability. Cyberpsychology and Behavior 6, 397404.CrossRefGoogle Scholar
Ku, J, Jang, HJ, Kim, KU, Park, SH, Kim, JJ, Kim, CH, Nam, SW, Kim, IY, Kim, SI (2006). Pilot study for assessing the behaviors of patients with schizophrenia towards a virtual avatar. Cyberpsychology and Behavior 9, 531539.CrossRefGoogle ScholarPubMed
Kurtz, MM, Baker, EK, Astur, RS (2006). Virtual reality assessment of medication compliance in patients with schizophrenia. Cyberpsychology & Behavior 9, 224229.Google Scholar
Landgraf, S, Krebs, M-O, Olie, J-P, Committeri, G, Van Der Meer, E, Berthoz, A, Amado, I (2010). Real world referencing and schizophrenia: are we experiencing the same reality? Neuropsychologia 48, 29222930.CrossRefGoogle ScholarPubMed
Leff, J (2013). Computer-assisted therapy for medication-resistant auditory hallucinations (vol 202, pg 428, 2013). British Journal of Psychiatry 203, 313313.Google Scholar
Leff, J, Williams, G, Huckvale, MA, Arbuthnot, M, Leff, AP (2013). Computer-assisted therapy for medication-resistant auditory hallucinations: proof-of-concept study. British Journal of Psychiatry 202, 428433.CrossRefGoogle ScholarPubMed
Liddle, PF (1987). Schizophrenic syndromes, cognitive performance and neurological dysfunction. Psychological Medicine 17, 4957.CrossRefGoogle ScholarPubMed
Madary, M, Metzinger, TK (2016). Real virtuality: a code of ethical conduct. Recommendations for good scientific practice and the consumers of VR-technology. Frontiers in Robotics and AI 3, 123.CrossRefGoogle Scholar
Moritz, S, Voigt, M, Köther, U, Leighton, L, Kjahili, B, Babur, Z, Jungclaussen, D, Veckenstedt, R, Grzella, K (2014). Can virtual reality reduce reality distortion? Impact of performance feedback on symptom change in schizophrenia patients. Journal of Behavior Therapy and Experimental Psychiatry 45, 267271.CrossRefGoogle ScholarPubMed
Nuechterlein, KH, Green, MF, Kern, RS, Baade, LE, Barch, DM, Cohen, JD, Essock, S, Fenton, WS, Frese, FJ III, Gold, JM, Goldberg, T, Heaton, RK, Keefe, RS, Kraemer, H, Mesholam-Gately, R, Seidman, LJ, Stover, E, Weinberger, DR, Young, AS, Zalcman, S, Marder, SR (2008). The MATRICS consensus cognitive battery, part 1: test selection, reliability, and validity. American Journal of Psychiatry 165, 203213.CrossRefGoogle ScholarPubMed
Olivera, TA, Maranghello, N, Silve, ACR, Pereira, AS (2016). Virtual laboratories development using 3D environments. Handbook of Research on 3-D Virtual Environments and Hypermedia for Ubiquitous Learning. Hershey, PA, USA: IGI Global.Google Scholar
Olton, DS, Becker, JT, Ge, H (1979). Hippocampus, space and memory. The Behavioral and Brain Sciences 2, 313322.CrossRefGoogle Scholar
Park, IH, Kim, JJ, Ku, J, Jang, HJ, Park, SH, Kim, CH, Kim, IY, Kim, SI (2009a). Characteristics of social anxiety from virtual interpersonal interactions in patients with schizophrenia. Psychiatry 72, 7993.CrossRefGoogle Scholar
Park, K, Ku, J, Choi, S, Jang, H, Park, J, Kim, SI, Kim, J (2011). A virtual reality application in role-plays of social skills training for schizophrenia: a randomized, controlled trial. Psychiatry Research 189, 166172.CrossRefGoogle ScholarPubMed
Park, SH, Ku, J, Kim, JJ, Jang, HJ, Kim, SY, Kim, SH, Kim, CH, Lee, H, Kim, IY, Kim, SI (2009b). Increased personal space of patients with schizophrenia in a virtual social environment. Psychiatry Research 169, 197202.CrossRefGoogle Scholar
Parsons, TD, Carlew, AR, Magtoto, J, Stonecipher, K (2017). The potential of function-led virtual environments for ecologically valid measures of executive function in experimental and clinical neuropsychology. Neuropsychological Rehabilitation 27, 777807.CrossRefGoogle ScholarPubMed
Pot-Kolder, R, Veling, W, Geraets, C, Van Der Gaag, M (2016). Effect of virtual reality exposure therapy on social participation in people with a psychotic disorder (VRETp): study protocol for a randomized controlled trial. Trials 17, 25.CrossRefGoogle ScholarPubMed
Rizzo, AA, Buckwalter, JG (1997). Virtual reality and cognitive assessment and rehabilitation: the state of the art. Studies in Health Technology and Informatics 44, 123145.Google ScholarPubMed
Rizzo, AS, Buckwalter, JG, Forbell, E, Reist, C, Difede, J, Rothbaum, BO, Lange, B, Koenig, S, Talbot, T (2013). Virtual reality applications to address the wounds of war. Psychiatric Annals 43, 123138.CrossRefGoogle Scholar
Rus-Calafell, M, Gutierrez-Maldonado, J, Ribas-Sabate, J (2014). A brief cognitive-behavioural social skills training for stabilised outpatients with schizophrenia: a preliminary study. Schizophrenia Research 143, 327336.CrossRefGoogle ScholarPubMed
Ruse, SA, Harvey, PD, Davis, VG, Atkins, AS, Fox, KH, Keefe, RS (2014). Virtual reality functional capacity assessment in schizophrenia: preliminary data regarding feasibility and correlations with cognitive and functional capacity performance. Schizophrenia Research: Cognition 1, e21e26.CrossRefGoogle Scholar
Shaikh, M, Ellett, L, Dutt, A, Day, F, Laing, K, Kroll, J, Pterella, S, Mcguire, P, Valmaggia, L (2016). Perceived ethnic discrimination and persecutory paranoia in individuals at ultra-high risk for psychosis. Psychiatry Research 241, 309314.CrossRefGoogle Scholar
Slater, M (2004). Presence and emotions. Cyberpsychology and Behavior 7, 121; author reply 123.CrossRefGoogle ScholarPubMed
Smith, MJ, Fleming, MF, Wright, MA, Roberts, AG, Humm, LB, Olsen, D, Bell, MD (2015). Virtual reality job interview training and 6-month employment outcomes for individuals with schizophrenia seeking employment. Schizophrenia Research 166, 8691.CrossRefGoogle ScholarPubMed
Sorkin, A, Weinshall, D, Modai, I, Peled, A (2006). Improving the accuracy of the diagnosis of schizophrenia by means of virtual reality. American Journal of Psychiatry 163, 512520.CrossRefGoogle Scholar
Sorkin, A, Weinshall, D, Peled, A (2008). The distortion of reality perception in schizophrenia patients, as measured in Virtual Reality. Studies in Health Technology and Informatics 132, 475480.Google ScholarPubMed
Spieker, EA, Astur, RS, West, JT, Griego, JA, Rowland, LM (2012). Spatial memory deficits in a virtual reality eight-arm radial maze in schizophrenia. Schizophrenia Research 135, 8489.CrossRefGoogle Scholar
Stinson, K, Valmaggia, LR, Antley, A, Slater, M, Freeman, D (2010). Cognitive triggers of auditory hallucinations: an experimental investigation. Journal of Behavior Therapy and Experimental Psychiatry 41, 179184.CrossRefGoogle Scholar
Synofzik, M, Thier, P, Leube, DT, Schlotterbeck, P, Lindner, A (2010). Misattributions of agency in schizophrenia are based on imprecise predictions about the sensory consequences of one's actions. Brain 133, 262271.CrossRefGoogle ScholarPubMed
Thomas, BH, Ciliska, D, Dobbins, M, Micucci, S (2004). A process for systematically reviewing the literature: providing the research evidence for public health nursing interventions. Worldviews on Evidence Based Nursing 1, 176184.CrossRefGoogle ScholarPubMed
Tsang, MM, Man, DW (2013). A virtual reality-based vocational training system (VRVTS) for people with schizophrenia in vocational rehabilitation. Schizophrenia Research 144, 5162.CrossRefGoogle ScholarPubMed
Valmaggia, LR, Day, F, Garety, P, Freeman, D, Antley, A, Slater, M, Swapp, D, Myin-Germeys, I, Mcguire, P (2015a). Social defeat predicts paranoid appraisals in people at high risk for psychosis. Schizophrenia Research 168, 1622.CrossRefGoogle Scholar
Valmaggia, LR, Day, F, Rus-Calafell, M (2016a). Using virtual reality to investigate psychological processes and mechanisms associated with the onset and maintenance of psychosis: a systematic review. Social Psychiatry and Psychiatric Epidemiology 51, 921936.CrossRefGoogle ScholarPubMed
Valmaggia, LR, Day, FL, Kroll, J, Laing, J, Byrne, M, Fusar-Poli, P, Mcguire, P (2015b). Bullying victimisation and paranoid ideation in people at ultra high risk for psychosis. Schizophrenia Research 168, 6873.CrossRefGoogle Scholar
Valmaggia, LR, Freeman, D, Green, C, Garety, P, Swapp, D, Antley, A, Prescott, C, Fowler, D, Kuipers, E, Bebbington, P, Slater, M, Broome, M, Mcguire, PK (2007). Virtual reality and paranoid ideations in people with an ‘at-risk mental state’ for psychosis. British Journal of Psychiatry 191, s63-s68.CrossRefGoogle Scholar
Valmaggia, LR, Latif, L, Kempton, MJ, Rus-Calafell, M (2016b). Virtual reality in the psychological treatment for mental health problems: an systematic review of recent evidence. Psychiatry Research 236, 189195.CrossRefGoogle ScholarPubMed
Veling, W, Brinkman, WP, Dorrestijn, E, Van Der Gaag, M (2014a). Virtual reality experiments linking social environment and psychosis: a pilot study. Cyberpsychology, Behavior and Social Networking 17, 191195.CrossRefGoogle ScholarPubMed
Veling, W, Moritz, S, Van Der Gaag, M (2014b). Brave new worlds – review and update on virtual reality assessment and treatment in psychosis. Schizophrenia Bulletin 40, 11941197.CrossRefGoogle ScholarPubMed
Veling, W, Pot-Kolder, R, Counotte, J, Van Os, J, Van Der Gaag, M (2016). Environmental social stress, paranoia and psychosis liability: a virtual reality study. Schizophrenia Bulletin 42, 13631371.CrossRefGoogle ScholarPubMed
Weniger, G, Irle, E (2008). Allocentric memory impaired and egocentric memory intact as assessed by virtual reality in recent-onset schizophrenia. Schizophrenia Research 101, 201209.CrossRefGoogle ScholarPubMed
Westermann, S, Kesting, M-L, Lincoln, TM (2012). Being deluded after being excluded? How emotion regulation deficits in paranoia-prone individuals affect state paranoia during experimentally induced social stress. Behavior Therapy 43, 329340.CrossRefGoogle ScholarPubMed
Wilkins, LK, Girard, TA, King, J, King, MJ, Herdman, KA, Christensen, BK, King, J (2013a). Spatial-memory deficit in schizophrenia spectrum disorders under viewpoint-independent demands in the virtual courtyard task. Journal of Clinical and Experimental Neuropsychology 35, 10821093.CrossRefGoogle ScholarPubMed
Wilkins, LK, Girard, TA, Konishi, K, King, M, Herdman, KA, King, J, Christensen, B, Bohbot, VD (2013b). Selective deficit in spatial memory strategies contrast to intact response strategies in patients with schizophrenia spectrum disorders tested in a virtual navigation task. Hippocampus 23, 10151024.CrossRefGoogle Scholar
Wykes, T, Spaulding, WD (2011). Thinking about the future cognitive remediation therapy-what works and could we do better? Schizophrenia Bulletin 37, S80S90.CrossRefGoogle ScholarPubMed
Yeh, SC, Lee, SH, Chan, RC, Chen, S, Rizzo, A (2014). A virtual reality system integrated with robot-assisted haptics to simulate pinch-grip task: motor ingredients for the assessment in chronic stroke. NeuroRehabilitation 35, 435449.Google ScholarPubMed