Dr. Kim Bullock 

Hello, and welcome back to Psychiatry XR. I'm joined by my cohost, Faaizah Arshad.

Faaizah Arshad 

Hi, Kim.

Dr. Kim Bullock 

Hi, Faizzah. So, today we're so excited to have guest Dr. Carolyn Rodriguez join our conversation. Dr Rodriguez is an MD, PhD, full professor of psychiatry at Stanford University and director of the Stanford Translational OCD Research Program.  Her lab utilizes an interdisciplinary approach to gain an understanding of OCD at multiple levels, from molecules to circuits to behavior in order to develop novel treatments, and she has won several national awards, including the Presidential Early Career Award for Scientists and Engineers and the Dolores Shockley Diversity and Inclusion Advancement Award from the American College of Neuropsychopharmacology. And she is co-author of Hoarding Disorder, a comprehensive clinical guide published by APA publishing. Recently, she has been exploring the use of virtual reality to augment behavioral treatments for hoarding disorder. In October of 2023, she published a feasibility study in the Journal of Psychiatric Research on nine older adults with hoarding disorder during an eight-week VR intervention, which showed very promising results. Welcome Caroline,

Dr. Carolyn Rodriguez 

Such a pleasure to be here. Thank you so much for having me.

Dr. Kim Bullock 

Thank you. We're so honored to have you, and maybe we could just start off with the basics, like how you got involved with studying OCD, maybe how OCD and hoarding are related, and then how you stumbled into thinking about VR in this space.

Dr. Carolyn Rodriguez 

Yeah, absolutely happy to. So, I think, you know, for me one of the things that really drew me to obsessive compulsive disorder and hoarding disorder is the remarkable suffering that you see with patients that is often done privately. And for me, there was one patient who was so debilitated by having to wash his hands over and over and having to basically wear gloves when he was outside for fears of contamination, that when, you know, he actually did remove his gloves, I was really distressed to see how red and cracked his hands were, and it just really struck me. Again, you don't see the suffering. It's mental, and it really takes a toll on people. So, as a clinician, you know, there are first-line treatments for obsessive compulsive disorder, but not everybody has help. And so I really wanted to do my part, not only in the clinical realm, but also in the research realm, to help those individuals.  In terms of your second question about hoarding disorder, traditionally, hoarding disorder was thought to be part of OCD, and it wasn't until 2013 where the American Psychiatric Association Diagnostic Manual for Disorders (the DSM) basically depicted and sort of highlighted that hoarding disorder was a distinct disorder with its own criteria. And so I was fascinated by both of these things, and it ended up, actually, in 2013 becoming two different disorders. So happy to contribute on both sides.

Dr. Kim Bullock 

Yeah, and it was such serendipity. We actually met before either of us was working in VR because my parents were working in the community on hoarding disorder, and you came to the department. So, it's so funny how life kind of connects us all. So what was your rationale and thinking into the VR space?

Dr. Carolyn Rodriguez 

Yes, no, definitely. So, you know, just to take a step back, what is hoarding disorder, right? Which, there's a lot of common depictions that we see in the media, but per the DSM Criteria, the thing that is really the core and key of what hoarding disorder is, is very, very strong attachment to objects, so much so that, for the Criteria, there's persistent difficulty in letting go, parting with possessions regardless of their actual value. And so that, along with the stress associated with letting go of items, makes up the core of what hoarding disorder is.  And then the criteria about clutter is basically a manifestation of that drive to keep things and distress of letting go and clutter in order to meet criteria for hoarding disorder, has to congest the living spaces to the extent where you can't sleep in the bed, you can't cook in the kitchen, so it's really disrupting the intended purpose of the rooms. And similar to the other diagnostic criteria, you know, it can't be due to a medical condition. Like, if you've had a stroke or something that prevents you from actually getting things outside of the house and to the curb or to recycling, or whatever it means to part with those possessions and not better accounted for another disorder. So, it can't actually be due to OCD. So, if you have intrusive thoughts of contamination preventing you from touching items, and that's sort of leading to accumulation, then that wouldn't be hoarding disorder. Or if you're feeling so depressed that it's like hard to get energy to do that.  And so the treatments for hoarding disorder, primarily right now, consist of cognitive behavioral therapy for hoarding disorder. So, cognitive strategies for helping to learn to let go of items, to thinking about where these thoughts come from, and also doing like practice exercises, right? Like going to flea markets and practicing not acquiring items as well. So a lot of the traditional CBT but applied to hoarding disorder.  Now, what we find is that the prevalence is common; it's around 2.5% and it's debilitating, especially in older adults. And sometimes, what we found is that when we were going into homes to help people practice sorting and discarding and doing the really tough work of that, it was unfeasible for a number of reasons, either the location was difficult to get to, it was hard for people to come to the clinic, or the clutter was stacked so high that it was dangerous for a team to go inside. And so we really wanted to think of creative ways and creative solutions and talked a lot about could VR be helpful?

Dr. Kim Bullock 

Yeah, yeah, it's this enhancement of procedural skills, because discarding is, in a sense, an exposure, but it's also kind of a skill building. So yeah, it made total sense. So there's probably a lot of us psychiatrists or providers or innovators out there wanting to enhance evidence-based treatments with VR. Were there particular challenges in creating this and doing this pilot study or any methodology or framework that guided you?

Dr. Carolyn Rodriguez 

Yeah, absolutely. And I think you know, going into it, we didn't know what to expect, so the challenges sort of unfolded, and you helped us lose out a lot of things. So what we wanted to do was test like a novel eight week intervention where we had group cognitive behavioral therapy and then we did VR uncluttering exercises. And so in order to do that, to make it as realistic as possible, we needed to basically create a VR space that mirrored the individual's home. So we had the individual send pictures of their living room, and then we worked with programmers to get like, the rug and the artwork and everything. And then we had them scan 30, you know, actual possessions. And one of the challenges was like, how to make them three dimensional. We ended up going with, like, a more of a billboarding design, so that, like, it was the picture, and then we could, like, kind of project that and map that on to the objects. And so that was kind of like a solution to kind of overcome that problem of, like, how can we sort of get this kind of 3D perspective?  And we asked individuals to take photos of things of increasing degrees, like some things were easy to part with, like empty containers and some things that were a lot harder, like souvenirs or things that had a particular emotional valence. But then once we had that, we were actually surprised that it was like pretty easy to navigate in the space, pretty easy for folks to kind of manipulate those objects. And what we ended up doing was to have three containers where people are kind of sorting, for example, so something I'm going to keep, something I'm going to discard, something I'm going to recycle. And then once the sorting happened, we had a garbage truck simulation where, you know, then the participant would go to the curb, and you would see the curb, and you would see the garbage truck like, and the sounds of it like kind of going off into the distance.  Some cool things that we didn't realize were that this environment allows you to practice discarding things over and over, which you can't do in real life. You know, you put it in the trash and it actually goes away. And so what it ended up being is, like, really a stepping stone for people who weren't ready to let go to like, do kind of a pre-practice for letting go of items. The other thing that we were really struck with, and Kim, I'd love to get your perspective on this, which was just the attachment is for the same reason that all of us keep things-so either it's like emotionally significant, like prom dress or something like that, right? Or it's, you know, I'm going to hang on to this because it could be useful later, or just esthetically, like these beautiful seashells I found on the seashore, right? But it's just kind of that amplified, and sometimes people don't get, you know, this is, like, kind of meaningless. Why are you hanging on to this? So other people kind of have that sensation. But what I try and say to people, just to give them a perspective, so like, have you guys ever heard a song that reminds you of a time and a place, and sometimes you even get, like, goosebumps, or you can kind of visualize so much. Sometimes you get like smells of what that time and place was. So, that feeling, that all encompassing feeling, and maybe you feel like a little heart racing, or, depending on what the situation was, the totality of that experience could be what individuals are experiencing that they're so attached to items. And so when they're with their items in real life, in their homes, there's the tactile part, right? There's the smell of it. And in VR you don't have that. It's just cognitively looking at this, trying to fit it in the bookcase, like does it fit in here? You don't have all those other sensations. So again, could be that this is a stepping stone to kind of circumvent that full sensory experience and extreme attachment that people have.

Dr. Kim Bullock 

Yeah, the gradualness of an exposure and you're taking components of the certain sensations, but I love what you're saying, yeah, it's kind of like throwing away a time machine, or your connection to time, and that is so difficult. You could imagine, if that's what it represents to you, how difficult that would be.

Faaizah Arshad 

I'm really curious to know how you felt, like your patients responded to the VR. So, you're seeing all of these positive effects of it, and you have experience with using cognitive behavioral therapy and how that usually turns out for patients, but I'm curious to know if your patients also felt like VR was truly helping them as well.

Dr. Carolyn Rodriguez 

Absolutely, and we assessed patients to see how acceptable, how tolerable was it, and if it was actually able to translate into people being helped by the intervention? And so what I will say is that overall, it's an eight-week VR intervention, but couched within a 16-week group treatment, and then the VR intervention. And we did assess exactly what you're saying, sort of open-ended participant responses, and then pulled out different kinds of themes.  And so objectively, like the self-reported hoarding symptoms, they decreased from the baseline to close. And it was a small pilot study so we had nine participants. So, seven out of those nine showed reliable improvement over that time frame, and none of them got worse. And overall, it showed that it was feasible to do.

Dr. Kim Bullock 

Acceptable. Yeah.

Dr. Carolyn Rodriguez 

Yeah, feasible and acceptable. What we did is that we asked participants these open-ended questions to really get at that question, how tolerated was it? And in general, what we found is that it was very well tolerated by the participants. So, it didn't make them feel sick. It didn't make them feel dizzy, and it was perceived as credible and associated with expected improvement, and they found it acceptable and useful overall. So that was very reassuring and gives us a window into, you know, this is potentially something to build upon and take it to the next step.

Dr. Kim Bullock 

Did you have any evidence of an expectancy effect or a placebo effect? I know we had that in our behavioral activation pilot, where people seem to get better, initially, more than the standard treatment, but I don't know if you're able to benchmark this pilot to that, or what your overall impressions were. Was the novelty of using this and the destigmatizing effect of having a technology made just for your mental health issue, do you think that had any impact?

Dr. Carolyn Rodriguez 

What I'll say is that this was a pilot study, so everybody got the intervention, and so we weren't able to take that part into account, which is something that we'd love to do in the future. So this one, as you know, was the sort of initial step, and then you really want to be able to do you know randomization and really account for those expectancy effects.  Another thing you can do with randomization is more assessing and probing for exactly the questions that you asked. So thank you for highlighting that. The other thing I would say is that there were some participants, just anecdotally, who did say that it was fun and that they enjoyed the process of having it be something like a skill, something like a muscle that could be trained, and so that act of practicing over and over reinforced that, as opposed to when you're in person, having these kind of more final decisions. So this felt more like a coaching experience, which is nice.

Dr. Kim Bullock 

Yeah, a little enjoyment, gamifying, maybe even, and, yeah. Well, that brings me to the next question, like, are you planning anything from now to do? Are you going to prototype this? Are you planning in an RCT or an efficacy or implementation study? Are you going to do a startup?

Dr. Carolyn Rodriguez 

Well, we would like to continue to consult with you, Kim, on next steps. But you know, just when we published the paper, one of the things, as you know, that we wrote about at the end was the possibility to make this more augmented reality, where individuals could be literally in their home, and then actually have the environment around them, and then with more augmented reality types of eyewear, or, you know, on an iPad where you can kind of project out. It would be nice now that technology is moving so quickly to be able to, like, tap on objects, manipulate them, and really do that in a person's home environment. I think we could see kind of a series of tools like you do with motivational interviewing-there's pre-contemplation, there's contemplation. So, you know, we could really use technology to titrate and make it a really nice entry into people building up their muscle to be able to make these really difficult decisions.

Faaizah Arshad 

I also wonder that, since the population in the pilot study was more older adults. Do you see yourself doing this study with younger individuals who might have hoarding disorder, and do you suspect that the results would be different for any reason, or do you think it could still be replicated for a younger population with hoarding disorder?

Dr. Carolyn Rodriguez 

Such a great question. I think it would be really interesting, and I think just taking a hold and thinking about mental health disorders in general. Individuals with OCD and hoarding disorder, they have a trajectory, right? So 25% of OCD cases start by age 25. On average, individuals with hoarding disorders start to get symptoms around age 16 to 17. So these things are manifesting early, but it's not typically until the 50s where people are coming to treatment and more recognized. And so I think it's such a great direction. The earlier we can identify we can help people with it, we can really prevent a lot of the long term consequences, and that people basically fall off their trajectory right difficulty launching into college and different kinds of things that earlier detection would be helpful for.

Dr. Kim Bullock 

Do you think that with this launch of the Apple Vision Pro last month with this confluence of AI spatial computing and mental and behavioral health. Do you see something like the Apple Vision Pro helping in your prototyping this kind of intervention?

Dr. Carolyn Rodriguez 

Definitely. I mean anybody who wants to partner with us and is interested in this technology. And again, we really defer to you, Kim in terms of your expertise in this area, if you think that that would be a good direction for us to go, We're all ears, right? We're game to partner, because we have a deep bench of expertise in hoarding disorder, but it really needs to be that partnership with the company or the technology, and not just what is available now, but what even is possible in the future to really brainstorm together what would be the ultimate thing that could be helpful, and then even innovate more to try and get to that stage.  So, I mean, I personally think that the more realistic you can take and being able to like my wildest dreams, having a virtual therapist sit there with you, right? So you could see the virtual therapist, but the therapist is somewhere else, right? And just being able to have a conversation, seeing the object, doing those things together, I think that would be pretty amazing.

Dr. Kim Bullock 

Yeah, yeah, me too. Okay, well, then maybe we can take a bigger look at things. I know it's so nice to have a psychiatrist on board. There's so few of us that are in this space and just thinking about XR in the field of psychiatry, and how our discipline might be able to use XR or be a part of that, like what our role is, and also maybe ethics too. Some of the things, I don't know if you've heard, you know, last week about this launch of Xaia, it's a mental health product for anxiety and depression that was launched on the Apple Vision Pro after only a small feasibility study of 14 people, and they did it from Cedars-Sinai, but they're also the CEOs of the startup and releasing this to the public as a mental health product. There's ethical dilemmas, business motivations and just, do you see our role as maybe psychiatrist, as kind of being a moral compass or pushing back on things? Or do you see us as innovators? Or, yeah.

Dr. Carolyn Rodriguez 

Yeah, absolutely. Well, you know, I think it's something that for me and the work that I'm doing with ketamine and OCD, I get a question all the time, and I always feel like, at least with the ketamine and OCD, question, that my job as a researcher is to raise funding, get the data and really look as much as possible, to see if we can replicate the data and to see how that data could be translated and accessible for our patients to be able to make informed decisions.  And so my stance is always, let's get the data. Let's see what the data says. I personally don't feel like it's enough to just do a single, small, uncontrolled study because of what we had just talked about earlier, you know, that there are very real placebo, very real expectancy effects, and we want to be able to do right by individuals who are looking for care. And so we want to be able to as much as possible tell people what is the state of technology, what is the best evidence-based care? And I know there are a couple national organizations, including the American Psychiatric Association and others that provide guidance as to like level of evidence for different kinds of app-based strategies.  And so I personally think that is one service that we can do in terms of generating the data, being transparent with individuals who are patients and clients on how can we interpret that data, and also advocating to national organizations to really get that information out there.  At the same time, I think it also speaks to the real need for mental health care and how some people can't access care for a number of reasons, including, you mentioned stigma, including access, and so I do want to be optimistic and as forward-facing as possible to try and get folks with VR that aren't able to come in in person or aren't able to access care. And so it just has to be a conversation in lockstep, where we know where the evidence is and opening the dialog and transparency with patients around recommendations. '

Dr. Kim Bullock 

Well, Carolyn, I have one last question for you. I've watched your incredible leadership style with awe over the years, and...

Dr. Carolyn Rodriguez 

The feeling is mutual, Kim.

Dr. Kim Bullock 

Well, I think you have a particular strength in one area that I'd love both personally to get your tips on, but I think our audience would as well about getting buy in from high levels despite being part of an underrepresented group, especially yourself from multiple underrepresented groups, you're even more inspiring. I see that you have this secret skill and attribute to your success, where you have the ability to collaborate and inspire powerful people and organizations to support you and your projects. Do you have any tips for for the rest of us in that realm?

Dr. Carolyn Rodriguez 

Yeah, well, I would say, I mean, I think you and I share this, which is, you know to really know where your sort of home base is within you. And for me, it really is like wanting to advocate and wanting to help patients. And so everything sort of comes back to if I get rejected, or if I don't do stuff like centering on that mission and just kind of speaking in that way. And not everybody's going to want to support you and advocate for you. And so it's just about trying to have clarity in what you want, what are you aiming for, and people want to be helpful. You know, who doesn't want to help patients? Especially now, you know, post-COVID, there's a big need and such a landscape to help people. There isn't a single person who isn't touched by a family, loved one and acquaintance that is struggling right now. And so really being able to invest in resources and support people who are on this mission, I think, is important and helpful and will make other people feel good, right? It's just such a position when you have a loved one that is suffering to feel like you can't do anything, but if you can contribute and be a part of a collaboration or a research effort that is trying to make a difference, it can also be be very helpful.

Dr. Kim Bullock 

Yeah, stay mindful of your mission and your passion and just don't get distracted. And I love that.

Dr. Carolyn Rodriguez 

Exactly, exactly. I mean, you know, we all get rejected, it's okay, keep going.

Dr. Kim Bullock 

Yeah, try not to take it personally. And yes, all right.

Faaizah Arshad 

This was so informative.

Dr. Kim Bullock 

Yeah.

Faaizah Arshad 

Thank you so much.

Dr. Carolyn Rodriguez 

Oh, my pleasure. Thank you guys for getting the word out. You know, I think you guys are at the cutting edge of our field, and I think as a field, we don't even know what we don't know. And so having this podcast to really kind of go behind the scenes, and I love that question, like, what are the challenges, or what things you didn't foresee? I think that's really helpful for data sharing. I feel like, if I can enter this space and Kim, you were such an ally, I feel like other people have great ideas and to just, you know, go for it and come to the group. Like you're still collaborative. So

Dr. Kim Bullock 

Yeah, yeah, all right. Well, thank you so much for joining us. Dr Rodriguez, it's been such a pleasure speaking with you, and that's it for this episode of Psychiatry XR. We hope you gained a new perspective on using extended reality in healthcare, and thank you for listening.  This episode was brought to you by Psychiatry XR, the psychiatry podcast about immersive technology and mental health. And for more information about Psychiatry XR, please visit our website at psychiatryxr.com and be sure to subscribe to the podcast and tune in again next month to hear from another guest about XR use in psychiatric care.  You can also join monthly on Apple podcast, Twitter, Spotify, or wherever you get your podcast. Psychiatry XR was produced by myself, Kim Bullock, Faaizah Arshad, and Jessica Hagen, and please note that the podcast is distinct from my own clinical teaching and research roles at Stanford University. The information provided is not medical advice and should not be considered or taken as replacement for medical advice. This episode was edited by David Bell and music and audio produced by Austin Hagen. See you next time you.