1. © 2008 FPCE, Universidade do Porto – ESTS, Instituto Politécnico do Porto 7 th ICDVRAT Maia, Portugal, 2008 Virtual Reality and Neuropsychology A Cognitive Rehabilitation approach for people with Psychiatric Disabilities 1 António Marques, Cristina Queirós, Nuno Rocha

2. © 2008 FPCE, Universidade do Porto – ESTS, Instituto Politécnico do Porto 7 th ICDVRAT Maia, Portugal, 2008 2 Cognitive Deficit in Schizophrenia Kraepelin believed that the cognitive deterioration was associated to the illness pathophysiology Subsequent interpretations linked cognitive dysfunction to symptomatology and neuroleptical treatment Recent studies point cognitive dysfunctions as nuclear deficits in the schizophrenia, independent of the clinical symptomatology and/or of the anti-psychotic treatment.

3. © 2008 FPCE, Universidade do Porto – ESTS, Instituto Politécnico do Porto 7 th ICDVRAT Maia, Portugal, 2008 3 Cognitive Deficit in Schizophrenia.

4. © 2008 FPCE, Universidade do Porto – ESTS, Instituto Politécnico do Porto 7 th ICDVRAT Maia, Portugal, 2008 4 General dysfunctions in cognitive functioning in all neuropsychological dimensions – even at the time of the first psychotic episode (e.g., Caspi et al., 2003). In particular, the functions related to the ‘hipofrontality’, such as executive functions, processing speed, memory (with special incidence in working memory) and attention are affected (Brazo et al., 2005). These functions seem to be related to individuals’ psychosocial functioning (Green et al., 2000). Cognitive Deficit in Schizophrenia

5. © 2008 FPCE, Universidade do Porto – ESTS, Instituto Politécnico do Porto 7 th ICDVRAT Maia, Portugal, 2008 5 Cognitive Deficit in Schizophrenia Cognitive functioning Performance in ADL Social Problem Solving Skills Acquisition

6. © 2008 FPCE, Universidade do Porto – ESTS, Instituto Politécnico do Porto 7 th ICDVRAT Maia, Portugal, 2008 6 Cognitive Rehabilitation Positive evidence Kurtz et al. (2001)Suslow et al. (2001) Krabbendam & Aleman (2003) Twamley et al. (2004) Insufficient evidence Cochrane (2001)Pilling & Bebbington (2002)

7. © 2008 FPCE, Universidade do Porto – ESTS, Instituto Politécnico do Porto 7 th ICDVRAT Maia, Portugal, 2008 7 Cognitive Rehabilitation Approaches Aim to improve cognitive functioning through a set of specified training interventions Restorative Aim to bypass or “compensate” for cognitive deficits to promote skill acquisition or functional outcome Compensatory

8. © 2008 FPCE, Universidade do Porto – ESTS, Instituto Politécnico do Porto 7 th ICDVRAT Maia, Portugal, 2008 8 Cognitive Rehabilitation Approaches Individualized and specific training for each of the cognitive functions deficit through repeated instructions and exercises, with or without guided practice Computerised methods Usually developed in group context as psychoeducative programs, targeted not only for the development of cognitive skills but also for the social functioning. Non- computerised methods

9. © 2008 FPCE, Universidade do Porto – ESTS, Instituto Politécnico do Porto 7 th ICDVRAT Maia, Portugal, 2008 9 Cognitive Rehabilitation Approaches Cognition Work Shopping Leisure Cognitive Rehabilitation

10. © 2008 FPCE, Universidade do Porto – ESTS, Instituto Politécnico do Porto 7 th ICDVRAT Maia, Portugal, 2008 10 VR and Cognitive Rehabilitation

11. © 2008 FPCE, Universidade do Porto – ESTS, Instituto Politécnico do Porto 7 th ICDVRAT Maia, Portugal, 2008 11 Purpose Verify the feasibility of a Cognitive Rehabilitation Program – using Virtual Reality and Integrated Psychological Therapy (IPT) (Brenner, 1994) - to improve cognitive functioning in people with schizophrenia.

12. © 2008 FPCE, Universidade do Porto – ESTS, Instituto Politécnico do Porto 7 th ICDVRAT Maia, Portugal, 2008 12 Study Design Material and Methods 15 participants with schizophrenia 9 month Cognitive Rehabilitation Program developed in a Competencies Development Centre (Oporto, Portugal). Individual intervention using virtual reality adapted environments with immersive equipment (eye-glasses 3D Pro and Head Tracker) Group intervention methodologically based in the Brenner’s IPT model. Cognitive assessment (pre and post – follow up measurements after 12 mouths): WCST, WAIS-III sub-tests, Stroop Test, and The Subjective Scale to Investigate Cognition in Schizophrenia.

13. © 2008 FPCE, Universidade do Porto – ESTS, Instituto Politécnico do Porto 7 th ICDVRAT Maia, Portugal, 2008 13 Study Design Intervention - IPT

14. © 2008 FPCE, Universidade do Porto – ESTS, Instituto Politécnico do Porto 7 th ICDVRAT Maia, Portugal, 2008 14 Study Design Intervention - VR Interaction Immersion Presence Properties Integrated Virtual Environment for Cognitive Rehabilitation Rio de Janeiro Federal University, Brasil (Costa & Carvalho, 2004) Virtual Environments for Panic Disorder Auxiologic Italian Institute (Vincelli et al., 2000) Virtual environments Attention, Working Memory, and Processing speed Executive Functioning Targeted functions

15. © 2008 FPCE, Universidade do Porto – ESTS, Instituto Politécnico do Porto 7 th ICDVRAT Maia, Portugal, 2008 15 Study Design Intervention - VR

16. © 2008 FPCE, Universidade do Porto – ESTS, Instituto Politécnico do Porto 7 th ICDVRAT Maia, Portugal, 2008 16 Study Design Intervention - VR

17. © 2008 FPCE, Universidade do Porto – ESTS, Instituto Politécnico do Porto 7 th ICDVRAT Maia, Portugal, 2008 17 Study Design Intervention - VR

18. © 2008 FPCE, Universidade do Porto – ESTS, Instituto Politécnico do Porto 7 th ICDVRAT Maia, Portugal, 2008 18 Study Design Cognitive Techniques Errorless learning and scaffolding Massed practiceInformation processing strategies

19. © 2008 FPCE, Universidade do Porto – ESTS, Instituto Politécnico do Porto 7 th ICDVRAT Maia, Portugal, 2008 19 Results WAIS - III ItemStagexsp Picture Completion Pre18,143,94 0,013 * Post20,642,30 Vocabulary Pre39,7112,49 0,030 * Post44,1415,27 Digit Symbol - Coding Pre48,9312,66 0,116 NS Post50,1417,96 Similarities/Differences Pre16,366,50 0,015 * Post20,297,01 Block Design Pre34,6412,99 0,002 ** Post42,2912,70 Arithmetic Pre9,294,68 0,007 ** Post12,074,71 Matrix Reasoning Pre12,145,54 0,004 ** Post16,865,92

20. © 2008 FPCE, Universidade do Porto – ESTS, Instituto Politécnico do Porto 7 th ICDVRAT Maia, Portugal, 2008 20 Results WAIS - III ItemStagexsp Information Pre13,716,17 NS Post14,795,94 Picture Arrangement Pre10,435,95 0,048* Post12,435,69 Comprehension Pre16,867,75 0,306 NS Post17,718,76 Digit span Pre15,793,36 0,011 * Post19,074,50 Symbol Search Pre24,576,64 0,008 ** Post28,365,33 Letter-Number Sequencing Pre8,142,88 0,040 * Post10,073,54 Object Assembly Pre30,6410,52 0,32 NS Post34,009,58

21. © 2008 FPCE, Universidade do Porto – ESTS, Instituto Politécnico do Porto 7 th ICDVRAT Maia, Portugal, 2008 21 Results WCST ItemStagexsp Number of Errors Pre45,8618,84 0,007** Post31,7920,18 Perseverative answers Pre32,7119,87 0,030* Post19,9315,17 Non-perseverative errors Pre21,438,62 0,140 NS Post17,2912,07 Perseverative errors Pre24,4315,41 0,033* Post14,6411,26 Categories Pre4,211,67 0,016* Post5,291,64

22. © 2008 FPCE, Universidade do Porto – ESTS, Instituto Politécnico do Porto 7 th ICDVRAT Maia, Portugal, 2008 22 Results Stroop Test ItemStagexsp Word Pre33,438,82 0,008 ** Post39,147,85 Color Pre34,937,44 0,571 NS Post36,006,42 Word-Color Pre33,076,34 0,001 ** Post39,367,74 Interference Pre48,798,44 0,834 NS Post49,438,92

23. © 2008 FPCE, Universidade do Porto – ESTS, Instituto Politécnico do Porto 7 th ICDVRAT Maia, Portugal, 2008 23 Results SSTICS ItemStagexsp Total Score Pre55,933.83 0,003** Post47,293.06 Working Memory Pre5.861.29 0.026* Post4.791.19 Explicit Memory Pre21.213.83 0.006** Post18.503.06 Attention Pre15.863.18 0.016* Post13.212.99 Executive Functioning Pre8.642.50 0.043* Post7.071.63 Language Pre3.000.96 0.020* Post2.210.80 Praxia Pre2.000.96 NS Post1.640.93

24. © 2008 FPCE, Universidade do Porto – ESTS, Instituto Politécnico do Porto 7 th ICDVRAT Maia, Portugal, 2008 24 Results and Conclusion Results identified significant differences (p<0.05) between pre and post tests in the subjective and objective assessed cognitive dimensions. Relapse and re-hospitalized rate (6,7%), drop out rate (0%), attendance rate (91%), and punctuality rate (85%) verified are the example of the high level of participants motivation and satisfaction The results point out that virtual reality technology and IPT may be a significant resource and intervention methodology in the promotion of cognitive competencies in people with psychiatric disabilities. However, considering that this research represents only a pilot study,it is essential that further investigation is made on this field Results identified significant differences (p<0.05) between pre and post tests in the subjective and objective assessed cognitive dimensions. Relapse and re-hospitalized rate (6,7%), drop out rate (0%), attendance rate (91%), and punctuality rate (85%) verified are the example of the high level of participants motivation and satisfaction The results point out that virtual reality technology and IPT may be a significant resource and intervention methodology in the promotion of cognitive competencies in people with psychiatric disabilities. However, considering that this research represents only a pilot study,it is essential that further investigation is made on this field

25. © 2008 FPCE, Universidade do Porto – ESTS, Instituto Politécnico do Porto 7 th ICDVRAT Maia, Portugal, 2008 Virtual Reality and Neuropsychology A Cognitive Rehabilitation approach for people with Psychiatric Disabilities 25 ajmarques@estsp.ipp.pt, cqueiros@fpce.up.pt, nrocha@estsp.ipp.pt