Kim Bullock: XR Wearables for Treating Mental Illnesses (Current Uses and Barriers)

In this episode, Kim Bullock M.D. discusses the evolution, current uses, and barriers of using XR wearables in psychiatric care, including for anxiety disorders.

The following is a transcript of the episode:

Kim Bullock

So Hi there and welcome back to Psychiatry XR, where we're on a mission to inspire worldwide conversations and innovation around the use of extended reality and psychiatric care. I'm your host, Kim Bullock, and I'm a clinical professor and XR researcher in Stanford School of Medicine. I'm board certified in psychiatry, behavioral neurology and neuropsychiatry as well as lifestyle medicine. Thanks for joining me on this journey as we are discovering together how XR technology is influencing the field of psychiatry and mental and behavioral health care. Please note that this podcast is distinct from my own clinical, teaching, and research roles and the information provided is not medical advice and should not be considered or taken as replacement for medical advice.

I'm so excited to talk to you about wearables in the treatment of mental illness using extended reality. So I'm a clinical professor, and I direct the virtual reality and immersive technology program and clinic here at Stanford in the Department of Psychiatry. And so we mostly enhance evidence based psychotherapies using these wearables. And if if you want to check out in further depth, if you if you put in Google Search virtual reality in Stanford, you'll find our clinic quite easily. Most people are not really aware of how much and how long XR and wearables have been being used in mental and behavioral health. Virtual reality is actually just an umbrella term for all the realities, any spatial computing technologies. That's what the x represents. So it can include the future. So it's, it's now being used as sort of an umbrella term. So the definition, usually it's a computer generated image that's 3D, can be interacted with, is head mounted, incorporates all this sensations, usually majorly visual and audio feedback, and it really brings you an illusion of being somewhere or being someplace. And for virtual reality, it completely replaces the user's real-world environment and replaces it with a simulated. So that's the definition we'll be using for virtual reality here. And there's been a big boom in the last 10 years because this became more ubiquitous and disseminable and available to most of us on our mobile phone now. In all of these VR technologies, there's a synthetic sense of being there, which is considered the ecological validity. So the robustness of bringing somebody to a place where it can trigger emotions and belief, and it can be divided into social, spatial and self. And the term immersion is the capacity to be there, and it can take as little as five to six seconds. It's, it's amazing. It can not only change one's cognitions, and emotions, but it can actually create sensations because movement and sensation are intimately linked. But really the first time we harnessed this for medicine was using mirror therapy. It's an embodied virtual reality in a sense, and it is used for unilateral a motor and sensory symptom and problems, usually neurological, but it can have psychological origins. And I see quite a few people with somatic symptom related disorders that are kind of at the interface of both neurology and behavioral and mental health. And so I was trying to create a mere visual feedback for those people with one sided symptoms and worked with Jeremy Bailenson and his graduate student and we were the first people that I know of that took an HTC Vive, a common a gaming device and put it into my office and helped patients actually do mirror visual feedback. And we had some remarkable results. XR experiences, virtual reality in particular, can force a person to see a different perspective. You can have an egocentric point of view where you're seeing things from your first person, have a second person seeing how the other person is experiencing you— this is quite important for things like theory of mind. And then you can also see things from the third person perspective, which is often quite helpful for people that are very emotional about a trauma that has happened that taking the third person point of view can help one with emotion regulation.

So how is it actually being used in psychiatry currently? And what evidence do we have? Well, there's kind of four different types of actual uses and I would classify them as exposure, distraction, training and research. So exposure is cue desensitization— people might be afraid of something like a spider, and they need frequent repetitive contact with that object and the VR can stimulate that. It can help prevent people's fear responses and get them ready and help people desensitize to that; distraction for both pain and emotional distress; it can still be used for stimulation when there's sensory deprivation; can be used to automate training experiences and standardize those in muscle relaxation, diaphragmatic breathing, mindfulness, meditation, things like that. It's currently being used in psychoeducation. And then for research quite a bit in standardizing experiences, creating cues that can be replicated, and then for measurement for eye tracking, and capturing behavioral movement and arousal. And so there's been multiple randomized controlled trials in a variety of diagnoses: trauma, anxiety, addiction, pain, eating disorders, autism, schizophrenia, and palliative care, but limited in the realm of mood disorders. One generalization that could be made right now is clinical trials do not show that VR enhanced psychotherapies are superior to their equivalents. There's mostly a noninferiority trend, but that does not mean they're not of value, because I think what they're where the value is, is it enhances the implementation of evidence based psychotherapy. And then the other nice thing about this is it now, it can be also, since the pandemic most of the companies have been helping clinicians to deliver this remotely through the applications mostly through phones, but now recently through actually the Quest 2 and 5 and so what's it's being treated most for, especially in our clinics is anxiety disorders.

So it is, anxiety disorders are the most common, with 33% of us being affected at some time in our life. The mainstay for treatment is psychotherapy, it's the first line— as far as durability, it outperforms medications. The therapy itself involves actual disrupting the conditioning and the pathways that sustain anxiety and fear, which are safety and avoidance behaviors. So as one actually has anxiety, one usually avoids the thing they're afraid of, but the more that they avoid it, there's a positive feedback loop that then makes the anxiety go up, the more the anxiety goes up, the more avoidance and safety behaviors. So it's this positive feedback loop, this vicious cycle that creates more and more fear, more and more anxiety. And the way to disrupt that is to get into a virtuous cycle where you have people let go of their safety behaviors, let go of avoidance, and that is called exposure therapy. Repetitive use over time, and the more frequency and the intensity, the more quickly a person recovers. And so what VR does for anxiety disorders is makes it more comfortable. So it may not increase the outcome if somebody is engaging in it. But it might make it less likely that the person drops out of therapy because of it being uncomfortable, because these are very uncomfortable treatments— kind of like chemotherapy, people can feel like they're going to die before they get better. Being able to use a simulated exposure before doing the actual feared stimulus can make it a lot more comfortable and help the desensitization process. And I think that's where the real enhancement for exposure comes in, and we call this in virtuo. People's stimuli and the things that they're afraid of are so idiosyncratic. But definitely there are still barriers to XR development: security concerns, problems with not having all stakeholders at the table when prototyping and designing especially behavioral health experts, and side effects including cyber sickness and postural instability, lucid dreaming. One has to be careful about that — that we still have limited number of minutes that people can stay or feel comfortable being in cyberspace, as we call it— but there are techniques and the technology is improving to decrease the cyber sickness.

Kim Bullock

And thanks so much for listening. This episode was brought to you by Psychiatry XR, the psychiatry podcast about immersive technology and mental health. For more information about Psychiatry XR, visit our website at www.psychiatryxr.com. Make sure to subscribe to the podcast and tune in again next month. You can join us monthly on Apple Podcast, Twitter, Spotify, or wherever you get your podcast. Kim Bullock produced this podcast with the help of Faaizah Arshad and Jessica Hagen, and we credit are grateful to Austin Hagen for music and audio production. See you next time.

BIO

Kim Bullock, M.D. is the founder of SPIT-C and a diplomat in the subspecialties of Psychiatry, Behavioral Neurology and Neuropsychiatry, and Lifestyle Medicine. She's a Clinical Professor in the Department of Psychiatry and Behavioral Sciences within Stanford University's School of Medicine. She's also founder and director of Stanford's Neurobehavioral Clinic and the Virtual Reality & Immersive Technologies (VRIT) program and laboratory. Dr. Bullock currently sees patients, teaches, and engages in research. She takes a holistic, customized, and personal approach to each client and encourages family and community involvement in the treatment process. In addition to medication management, she is intensively trained and teaches cognitive behavior therapy (CBT) and dialectical behavior therapy (DBT). She runs weekly DBT groups for friends and family, neuropsychiatric patients, and DBT graduates and delivers individual comprehensive DBT and CBT and virtual reality (VR) psychotherapies. She presents and speaks on VR and DBT/CBT both internationally and locally. She has published many peer-reviewed journals and is a Cambridge and Oxford Press author. To help expand awareness of medical XR's clinical benefits, Dr. Bullock cofounded Psychiatry XR.