Just tried playing this game with a PS4 controller using DS4 Windows and the button mapping is way off. The first person controls are right stick left/right to look up and down and X is back and square is enter (among many other frustrating issues). I tried adjusting the controls in the options but for some reason you can't have one button performing multiple functions, even when they wouldn't be used in the same context.

Has anyone else had this sssue but has solved it yet?

So I'm playing this game using a DS4, but instead of using DS4 Windows I use an 8bitdo receiver in X Input mode. That being said....

If you haven't tried it yet, it may be worth to follow the guide at: www.pcgamingwiki.com/wiki/Silent_Hill_4:_The_Room#Controller_support and download XInput Plus and use that to configure the controller. (I believe DS4 Windows can be used with X Input with the correct settings)

Step 5. Assign right stick to Z Axis/Z Rot
Should actually be assigned Z Rot/ Z Axis to fix your "left/right to look up and down" issue.
(Can also invert the up/down axis after it's been set properly by choosing "Customize" too if you'd like)

'X' is enter/confirm for me by using this tool with no key rebinds.

(Thanks to this thread https://www.gog.com/forum/silent_hill_4_the_room/controller for pointing me to this resource in the first place)

Thanks for the helpful response I'll look into this right away!

I never bothered with DS4Windows; it actually performed worse.

The game recognizes the controller just fine for me, but I do have to register each button in the SH4config for it to work properly.