Episode 178

Virtual reality has the potential to be far more than fun and games.  It can be a powerful therapy to treat phobias and anxiety disorders.

This week we’re joined with a double whammy of experts:  Dr. Robert Reiner, Executive Director and founder of Behavioral Associates, and Dr. Eva Zysk, Psychology Lecturer at Nottingham Trent University.

Virtual Reality vs Augmented Reality

It seems these two terms are often used interchangeably, but they’re actually different.  Augmented reality involves looking at the world through a screen.  Through the lens of that screen, you’re looking at the real world with certain virtual elements superimposed.

Virtual reality, on the other hand, is a complete reconstruction of reality.  It’s immersive.  You’re entirely cut off from the real world and in a new, virtual world.

Of course, as Dr. Reiner points out, in a sense, all reality is virtual reality.  Our reality is just the way our brain interprets light bouncing off objects in the physical world.

Using Virtual Reality to Treat Anxiety

Social Anxiety Disorder, the fear of being negatively judged by other people, is a very hard thing to treat.  Cognitive behavioral therapy (CBT) has been fairly successful as a treatment, but it has one major limitation.

CBT involves working with a therapist to modify thoughts and beliefs.  But it also requires repeated, increasing exposure.  So a patient might start by imagining being judged by a crowd, before repeated speaking in public to lessen the anxiety response.  The anxiety will reduce over time, since our bodies can’t sustain very high levels of anxiety for long.

Here’s the rub, though:  exposure therapy for CBT requires the participation of other people.  But you can’t guarantee that the unwitting participants won’t actually negatively judge a patient, confirming their original fear and negativing the positive effects of exposure.

Enter virtual reality, which can be very very useful here.  Instead of having a patient speak in front of a group of actual humans, they can do so virtually.  We can stimulate a social environment, but control the other people’s responses.

That way a positive experience is guaranteed, and the patient’s treatment doesn’t suffer a setback.

Psst:  Interested in more on virtual reality therapies?  Check out episode 87!

Read Full Transcript

Dr. Eva Zysk: So, this is quite different if you've never experienced virtual reality.  It's not like looking at the screen and having it the way you might picture 3D.  It has a very, very high aspect of something we called "presence", which is actually like you really feel like you're in that room.  Someone could be standing next to you and talking to you, but you still feel like they're right next to you in that particular room.  So, it's really, really quite a cool effect.  What we can do with that is we can actually manipulate the things that we want to.  For example, we can have, let's say, a virtual audience and we can have the person choose, for instance, or the therapist choose whether that audience is small, medium, or large, and importantly, whether the audience is reacting positively, neutrally, or negatively depending on the level of exposure the person wishes to have, and this is exactly the kind of crux of this sort of virtual reality exposure therapy that we are investigating right now.

Jesse: There's always going to be a perfectly positive response from the audience or somebody might be a heckler or a boo'er in the virtual audience if somebody's fairly far along in their process.

Dr. Eva Zysk: Yeah, exactly.  We're not as far along with a little intricacies of it.  Right now, we've got kind of three levels over five domains that people can change.  But, as we kind of go through it, yeah, this whole dialing up or dialing down would be a great sort of way to do it.  But, in terms of the actual testing of it, we first need to be able to see does having a negative versus neutral versus positive response as a kind of a three-group comparison, does that help, for instance?

Jesse: One thing that might be worth talking about a little is just breaking apart the terms "virtual reality" versus "augmented reality".  I think those are probably used a bit interchangeably these days, and maybe we should specify what's going on there.

Dr. Robert Reiner: Big difference.  Virtual reality completely seals you off, complete reconstruction.  You put these glasses and you don't want outside light to come in, because that reduces the immersiveness of it.  So, you're entirely enclosed in augmented reality.  You see the world through a lens, but you can put windows in there.  A lot of architects like to use it because people can design a room.  You say, "How's this couch going to look over here in an empty room?" and you slide a couch in.

So, that's augmented reality.  It's, I think, in a lot of ways, more realistic because it's not as isolating as virtual reality.  Incredible how it's so much more well-known right now, and when we tell people we've been doing it since 1999, they're amazed.  They thought it was just invented two years ago because Facebook bought Oculus.  The systems have gotten much better.

Now, with cellphone technology, it changes everything in virtual reality.  That's the biggest change that I've seen.  The fact that you can plug your cellphone into an Oculus shell, whoever thought about that, first of all, it was a brilliant idea to use the gyroscope, because that's the most important and the most expensive piece of a virtual reality program is the gyroscope.  But, every cellphone that has a video camera requires a gyroscope.

I remember when I was interviewed probably 10 years ago when the iPhone came out about the growth of apps.  We're seeing a similar exposure right now with virtual reality.  I heard a news report this morning about it that a big problem has been people on subway platforms or train station bumping into other people.  People forget that they're completely in a different world.

Jesse: I'm hoping that that's augmented reality, if somebody's on a platform for a subway, rather than full VR, but maybe not.

Dr. Robert Reiner: That's exactly what I thought.  Maybe not is right.  These people are either misinformed or they think that they know the platform very well and they don't.  That's a good example of how virtual reality really does age with judgment.  There's a very good reason, for example.  Do you ever wonder why if light travels so much quicker than sand, they still used a starting pistol to start a race and not a flash of light?

I was puzzled by it until I did some research.  I found out that, yeah, it is true, but once information gets into our senses, our ears are so much quicker.  Our brain is picking up what's coming into our ears much quicker, almost instantaneously, whereas our eyes are relatively slow.  Now, they can't even use a starting pistol inside the ring because the person who is on the inside lane has the advantage of a few microseconds.  So, they have it behind them right now.

Jesse: So, incoming signals from those two senses - sight versus hearing - we're going to respond more quick to a sound impulse versus a light impulse?  I mean, there's not really comparison there?

Dr. Robert Reiner: Not even close.  That's right.  There was a famous case of a guy who was blinded when he was about eight years old, and he loves skiing.  Actually, he learned how to ski picking up soundwaves the way a bat does.  So, he got really good at it and when he was about 50, they had this surgery that was going to restore his eyesight and they did, and when they first took off the bandages, all of a sudden, these weird lights he couldn't figure out, he couldn't recognize his children.  Took him a while for the brain to catch up.  We take this stuff for granted.  We think the world is what we see, but it's not.  It's our brain's interpretation of it.

Dr. Eva Zysk: So one of the things we'd like to do with our virtual reality therapy app that we've got developed and we're continuing to kind of hone is actually see if we can apply this to youth who struggle with social anxiety.  So, while we haven't actually tested this in a young sample population, we have been testing it in university students and we kind of already see that it works.

Jesse: What is the current standard of care for people that are dealing with severe anxiety issues?

Dr. Eva Zysk: Probably, what is mostly recommended for people that struggle with social anxiety disorder is something called CBT, which is cognitive behavioral therapy, and that's the type of treatment which has been most researched, and we know that it works.  A lot of the time, it's quite difficult to do research about which treatment works best because just the way that research works, you put multiple treatments side by side, well they might all work to a really kind of good extent, and to be able to find meaningful differences between them, it's quite difficult if you don't have hundreds and hundreds of people, which we don't normally do clinical trials on that many, at least, in the early stages.  But CBT, we know, is much better than weight loss control, and we know it is actually better that other treatments.

Dr. Robert Reiner: The concept on why it's so effective is you know that image, if you look at the face at a particular angle, it's Marilyn Monroe, and in a different angle, it's Albert Einstein.  Do you ever wonder why you can't see in the middle and see the one or the other?  The reason has to do with our brains and how our brains organize our perception of reality.  Think about our brain.  We've got this two, three pound piece of meat, basically biological wetware, is sitting in our skull that has no contact ever with the outside world and relies solely on our senses.  That's why if you get hit in the back of the head, you'll see stars because you've activated the occipital lobe which is the vision center.  We'll talk about reality versus virtual reality.  That's a misnomer because all reality is virtual reality.  It's the way our brain interprets light bouncing off objects in the world.

Dr. Eva Zysk: Unfortunately for social anxiety disorder specifically, it's actually very, very difficult using a CBT approach at times, because first of all, over 80% of people have social anxiety disorder don't actually receive treatment.  So, they might refuse the treatment, and one underlying reason for that might be because of the specific nature of the actual fear, which is a fear of interacting with other people, and also being judged by other people as well.  Actually, we've also found that, not myself, my research group, but just in general, researchers have found that people tend to seek treatment only after about 15 to 20 years of having symptoms.  Now, we're looking at people who have really had this for a very, very long time.

This is a bit of a problem with CBT, we think, is because obviously it does have that one-on-one component, and people also know that CBT incorporates two things: one is the person works with a therapist to kind of modify their thoughts and beliefs, so potentially looking at why they might be feeling like they're being judged and actually doing some behavioral experiments about, "Are people actually judging them?  Are they actually negatively evaluating them?"

The other component and this the part which can be a little bit tricky is that people with social anxiety disorder, or any other kind of anxiety disorder, would be working with the therapist to do kind of repeated exposure trials.  Let's just say a very simple analogy is people with spider phobia.  They might first be exposed to a picture of a spider, and then maybe play with a plastic spider, and then maybe watch a little spider walking around, and then maybe handle that spider, and then the spider might get bigger.

This is quite similar with social anxiety and exposure therapy for that where people would be placed in social situations to be able to see that nothing bad happens, and over time, their anxiety would just go down, because as our bodies, we can't sustain a high state of anxiety for a long, long period of time.  However, the problem with that is we can't actually control, we can't influence what happens on the other side of that.  We can put people in these situations, but we can't guarantee the patient that others won't judge them, or that others won't react negatively to them, which can be, obviously, a little bit of a problem if it does happen that way, and then that can actually confirm the person's original fear.  This is where virtual reality exposure therapy can be very, very useful where we can actually stimulate a social environment through having people be immersed in kind of a virtual world.

Jesse: Have you had equal levels of success with most people with virtual reality therapy, or are there some people that, for some reason, they don't buy into it or it doesn't feel real enough to them?

Dr. Eva Zysk: One is something called "presence", and we do find that virtual reality tends to have very high presence, and this is kind of across all age groups.  What can people do with it afterwards.  So, basically, are the benefits just in the actual virtual reality environment.  Yes, they might decrease, over time, in terms of their social anxiety whilst they might be doing a public speech in a virtual reality environment, but does that actually translate to the real world?

So, that's the kind of follow-up questions that we'll need to be asking in our upcoming study, anyways.  We'll be able to get those answers to you as soon as we know.  But, off-hand, quotes just from students emailing us and saying, "You know, this has really worked.  This has really helped with my assessment for one student who had an assessment that was an oral presentation just after." So, it is very heartening, and we think it might translate, but we do need to be able to test that.

There are other people getting treated with virtual reality for things like post-traumatic stress disorder, which can affect people of all ages, and we were asking, "Do people buy into it?" Well, some age group might so more so than others.  But also, because a lot of the time, it's still on kind of getting tested phases, we're only going to be attracting patients or participants who are actually interested in having VR intervention to begin with.  So, we don't know if we roll it out in the UK, for instance, and NHS, if it's going to attract all sorts of people, but it does give people who are interested in it that kind of a tool, and it might particularly engage people that might actually be quite difficult engage in the first instance, such as young people.  So, youth and university students and people of kind of a younger age group.

Jesse: Tell me, in the last couple of years, some of the protocol changes that you've been able to make to your therapeutic practice based on these new technologies.

Dr. Robert Reiner: There are feedbacks, for example.  We are able, now, to give people home practice devices.  In ADD cases, they're producing too many slow theta waves and not enough beta waves.  Beta waves are required when we concentrate.  If you want to do an interesting experiment on this, if you put your thumb on your carotid artery - that's the artery going to your brain - and you take your pulse and then you do some complex math, start subtracting 7 from a 1,000, you'll notice your pulse increases to your brain because the brain requires blood.

The brain is an incredible organ, but it requires 20-25% of our blood, and even then, you can tell what part of the brain the person is using by where there blood is.  Let's say we're dealing with somebody with ADD who has trouble concentrating, and we're giving him neurofeedback to try to produce more beta waves, and we're having him suppress theta waves.  The beta-theta ratio is very important.  Well, back in the old days, all we can do is either offers them to stimulant medication when there was feedback, but there are home devices now that can be used.  There's an excellent app in the Android world called Brain Waves that produces an audio signal that causes your brain to move into that area, meaning you'll flood it with beta waves.

The human brain is a copy machine, basically, in a lot of ways.  If you send in audio or visual frequency at, say, 16 hertz, which is the beta range, those waves begin to dominate in the human brain.  We now have the ability for an app that doesn't cost any money at all to alter brainwaves, and we can confirm this with a neurofeedback device.  I'll put an EEG scanner on my own head and put headphones on, and sure enough, those waves began to dominate.

Jesse: They've got some interesting technologies that essentially can hide those frequency fluctuations in music and things like that so it doesn't sound like you're listening to a sine wave either.

Dr. Robert Reiner: They call it entrainment devices right now, and they're commercially available.  You put on glasses and your headphones, and you'll get flashing lights at a particular frequency and sound to match it, but you can embed the sound and music that you like.  You can now, for neurofeedback, watch a movie, and kids really love this because they don't even know they're being trained.  When your brain gets to the right spot, the movie gets bigger and brighter and dominates the screen.  When your brain goes into a place that's undesirable like producing theta waves in ADD, the movie gets smaller.  So, kids get to pick out their own movie and it works just as well.

Jesse: I'm wondering about the correlation, if any, between introversion and extroversion and social anxiety disorder.  Intuitively, it seems like it would be the introverted people that are going to have social anxiety problems.  But, is that always the case?  Are there such things as extroverts that have social anxiety issues?

Dr. Eva Zysk: No, it's quite a complex thing, so it's very hard to almost have these kind of blanket statements of any sort, which does make it quite interesting for us, as researchers, to research, to look into.  Some of the research that we're doing, we've got one part of it where we're looking at predictors of social anxiety, and while we're not quite looking at introversion-extroversion, we know that introversion does predict social anxiety, but that doesn't mean that one equals one.  So, if one person has it, that means that they automatically will have this or not have that.

There are other elements to it.  For instance, having a lot of, maybe, social support can allow extroverts who might have had social anxiety to some extent maybe not develop the disorder.  There might be, as you were saying, extroverts who might actually just be very good at covering up their social anxiety, or they might have social anxiety but in other areas.  For instance, eating in public, writing in public, things that they can actually hide, but they might be fairly good at giving presentations or having one-on-one discussions.  We can't always say that extroverts don't necessarily have it because that isn't always the case.

Jesse: Since there's different modalities that a person could use to do brain entrainment, let's say that you're doing this with audio, does that start in the audio portions of the brain and kind of percolate out from there, or does it hit the whole thing simultaneously?

Dr. Robert Reiner: That's a good question.  I don't know the answer.  I think next time I put an EEG scanner on, I'll be able to check.  But, there are other devices that we use at home right now because it turns out that that entrainment device I'm talking about, there's another way to do it with glasses that you can see through.  This was initially used for golfers.  One of the enemies of any golfers is the yips when you putt.  We all know, for a big putt, you get a little shaky and you're not quite as confident.  Well, your brainwave actually changes.  So, you can send in the proper brainwaves to practice while you're putting.  We talked about it before, augmented reality and virtual reality.  Well, now entrainment, you can actually see the world, and that's a big break.  Kids can do their own feedback and get a little bit of a boost by doing entrainment at the same time.

Jesse: It's really interesting to think about performance-enhancing drugs and things that are illegal in the Olympics and baseball, but we could be using a light as a performance-enhancing drugs, things like that don't fall into our normal definitional categories.

Dr. Robert Reiner: Actually, the 2008 Canadian Winter Hockey, they won the Olympics that year.  I believe they got the gold.  They were trained in neurofeedback.  The company that we buy it from donated a bunch of equipment and they were trained to produce, rapidly changing neurological states, which is very good for a hockey player.  Can’t say, for sure, that it made them won the Olympics, but it doesn't seem to hurt them.

Jesse: Yeah, and there's lots of applications, things in real life that nobody would think to consider it cheating, basically, unless it's for a competitive sport-type scenario.

Dr. Robert Reiner: You know, you just made a really good point, which is why is it that taking a chemical is called cheating, but having light or sound coming is not, but if that's our culture.

Jesse: Yeah.  Unfortunately, there's a lot of armchair referees out there that enjoy that sport quite a bit as well.  I think it's probably more likely that more things will be considered cheating rather than less.

Dr. Robert Reiner: I mean, what if the neurofeedback is still good that there's a marked difference between people that are using it, as there is with drugs, for example.  We know if you give somebody Ritalin, anybody, they're going to perform better.  Baseball players used to use it in the 70s.  They called them "greenies".  The only reason there was not a lot of attention given to them, and there was no punishment was because it didn't improve performance that much.  It made you a little more alert, but we didn't see 75 home runs being hit.

Jesse: Would you say that social anxiety disorder is something where we're failing really at the educational level for kids, that we should be identifying kids earlier that, "Hey, this kid doesn't like speaking in front of their peer group," rather than waiting until it's 20 years down the road and somebody has to seek out a psychologist for themself?

Dr. Eva Zysk: Yeah, so in a way CBT usually kind of looks at the symptoms right then and there, and this anxiety disorders, generally, that I'm speaking about now that it actually doesn't even matter how long you've had some anxiety disorders, that you can still be very, very successful with your CBT if you just address the current symptoms you have.  But, actually, we do kind of know that the longer someone has a disorder, the more likely they are to even do things like hide some of their symptoms or not even realize that some of their symptoms are symptoms of the disorder, and they actually think that it's part of their personality or their characteristics.

Nowadays, we are more looking at early interventions.  In the UK, for instance, there's been a huge drive to be able to identify and treat people very, very early on.  So sometimes even at the point before something gets to a clinical disorder.  So, this one of the reasons why having interventions aren't necessarily like CBT.  In the UK, we've got the NHS, which is the National Healthcare Service, and basically, what that does is it allows mental health treatment and physical treatment, as well, for free to the UK public, but it's very, very costly on the taxpayers.

Now, we're kind of looking at it as, "Well, what can we do before that, before we need to send patients to receive cognitive behavioral therapy by therapists whether they are clinical psychologist or IAP practitioners, which is this new initiative by the government which is improving access to psychological therapies?  What if we do that earlier on?" So, as you're saying, what if we identify this in children and young people before it gets to be a diagnosable problem?  This is some of the conferences and things that are happening right now is the kind of, "What can we do and how well would it work, and what are the long-term effects of this?"

Jesse: We've talked a little bit about entrainment glasses and the devices that, I assume, would have been cost-prohibitive to send home with people previously, but now at-home devices for therapy are becoming a reality.  What other changes are you seeing?

Dr. Robert Reiner: This is not neurofeedback as much as general biofeedback called heart rate variability.  Turns out that if you put a strain gauge in the diaphragm, you can measure respiration, and this is basically a polygraph, or a lie detector.  There's no direct human expression of lying.  The device is measuring three things: heart rate, respiration rate, and something called galvanic skin resistance, or GSR, which you put electrodes on the fingertips, and the moment before you actually perspire, tiny amounts of fluid are released under the pads of your fingers.  Well because fluid is a better conductor of electricity in the skin tissue, the change in resistance is picked up and amplified directly via computer.  So, we can tell when someone is a little bit anxious about something, and sure enough, this thing is sensitive to thoughts that produce the anxiety.

The problem is, and this is why lie detectors should not be admissible in court, is that the very people who are most likely to commit crimes, psychopaths, have no guilt at all about this stuff.  In fact, very often, they believe the lies.  So, they beat a polygraph every time.  Turns out heart rate variability, when you get into phase between your respiration and your heart rate -- let me explain what that means.

If you ask people to take about five seconds to breathe in and five seconds to breathe out, that's six breaths per minute, which is not a normal way to breathe.  Now, I recommend that you do this all the time and you'd faint.  But, if you do it for, say, 10 or 15 minutes, after about five minutes something really interesting happens.  Your heart rate begins to rise when you inhale and drop when you exhale.  So, you're getting sympathetic arousal, the on system goes on when you inhale, and the parasympathetic system which is the relaxing system drops when you exhale.

Jesse: Are those two systems normally associated with inhalation or exhalation or does that sync-up only happen at this rhythmic breathing?

Dr. Robert Reiner: I think it’s much more pronounced.  I don't think each time you breathe in and out, you activate sympathetic and parasympathetic arousal.  I think it has to be slow deliberate diaphragmatic breathing.  That's my understanding of it.  Say your resting pulse is 70, and it climbs to 90 when you inhale, and it drops down to 60 when you exhale.  You've got a 30-point swing.  Let's say at six and a half breaths a minute, you get a 38-point swing, and that's the biggest one you can get.  We call that the person's sweet spot.  We're going to train him at six and a half breathes a minute, and every smartphone has a voice recorder now.

So, our custom make a breathing exercise at the exact rate we determine that sweet spot to be so they can practice this at home whatever they want, and that puts you -- it's a drug-like state.  You feel like you've been injected IM with valium, which is why we use it for sleep problems, and we strongly recommend that people never do it when they're driving a car because it does make you very sleepy.  But, it also causes very deep relaxation by suppressing the sympathetic branches of the nervous system.  It's extremely relaxing.  It temporarily disables by fight or flight activity, so it's impossible to get anxious when you're doing this.

Jesse: If this is so effective with 5 to 10 minutes of calming people down, why is everybody not doing this before they go to bed every night?  I mean, it seems like this would be a relatively easy thing to figure out for any given person and kind of put yourself in a really mellow state before you got to sleep.

Dr. Robert Reiner: That's a very good question.  I think a lot of people don't know about it.  I also think that, unfortunately, in Western culture, people, the first thing they think about is take a pill.  So, that's what people do, but we are pushing this stuff.  Certainly, all of my patients know about it.  How many people talk to a psychologist or a psychiatrist professionally in their lifetime?  Just a fraction.  You probably got to very person who's in psychotherapy.  You've got 100 people take medications.  It's the nature of our culture and it's written for us by the pharmaceutical industry.  That's why the drug companies are encouraging physicians, like gynecologists and internal medicine people to prescribe psychotropic medications.  Without much training, it's a concern.

Jesse: Is there anything that would be the contrapositive of that?  Maybe hyperventilating might be the answer.  But, like to get yourself into an aroused state with a certain style of breathing?

Dr. Robert Reiner: Well, if you want to get yourself anxious, I wouldn't call it arousal.  I would call it -- if you hyperventilate, it really advances sympathetic arousal.  You might induce a panic attack, but you're going to feel very jittery.  We do that very often in the office to demonstrate GSR.  The idea that you can ramp up your anxiety level or sympathetic arousal by hyperventilating, it's the opposite of what we're doing with heart rate variability.  So, to answer your question, yes, you can make yourself anxious or aroused that way, yup.

Jesse: The anxious or aroused state, would that be the opposite as far as the heart rate variability?  Would you see those two numbers come together where your inhalation-exhalation, you essentially have the same heart rate?

Dr. Robert Reiner: Well, it's very choppy.  Contrary to popular belief, your heart rate resting pulse is 72.  It's not going to stay that way all day long.  That's a good measure of cardiovascular health.  The more variable your heart rate is, the more flexible your arteries are.  Think about a garden hose that sat all summer long but at the end of the summer, it's not very flexible.  Our arteries are the same way.  We get old, they're not very flexible.  If you see not a lot of heart rate variability in a person, it means one of two things.  Either, they're very old or they've got cardiovascular disease.

Jesse: Where would you like to see the technology continue to develop?  What do you expect might be possible as either the technology gets better or maybe the price comes down and these tools become more available?

Dr. Eva Zysk: The ideal outcome for this would be to do something like use it on our weight loss control.  So, when people first enter treatment system, they'd have to wait quite a few weeks before they would actually receive the system.  While they wait, they can actually do something to be able to help themselves, and this is part of this kind of self-help initiative.  So, that would be ideal.  But, for some people, they might not actually need to receive "full-blown" treatment.  So, potentially, it might just be something like a little bit of exposure that they can work on themselves, even though ways such as gamification, which is becoming quite popular, which is making things like therapy and actually making it quite fun so people can move through levels at their own speed.

So, this could be a standalone treatment, this virtual reality exposure therapy, or it can be as something that's supplemental to therapy, or even as homework assignments.  CBT is based quite heavily around setting homework in between sessions and patients can actually do that in order to improve their outcomes and to have this exposure in between sessions as well.

Jesse: Given the assumption that things continue to get cheaper in semi-predictable advances in technology, what do you see yourself as doing differently, likely, in five years from now versus what you're doing now?

Dr. Robert Reiner: Well, I think the database will get much better for neurofeedback.  The database that we're using now, it's only been around for about 10 years.  It's very expensive to make a database, but when they do get better, I think it will make it so that people reach their goals much quicker.  Right now, we use something called a "quantitative electroencephalogram", or QEEG to "diagnose the problem, to see where the deficits are".

Based on database, meaning we know exactly what a person's brain will look like at all 88 levels, 88 sections.  They're called Brodmann areas.  The database gives us the information to every six months of life from the ages of 2 to 82.

Jesse: Do you have, maybe, an example that you could give of helping a patient to zero in on the correct brain activity, given how far off they are versus the normal range within this database?

Dr. Robert Reiner: Actually, because so many people have concentration problems just with reading, especially kids, and we're constantly training kids to get their brainwaves moving quicker when they're reading.  The patient that I'm seeing, he got Lyme disease really bad about 20 years ago, and it got into his heart and his brain, and it's really disabled him.  He's on full disability and he has trouble reading, and he's doing neurofeedback, and he's doing really well with neurofeedback.

It's really interesting how it happened.  He was stuck at a certain threshold.  You see, with neurofeedback, you're trying to move the threshold down.  We do something that's called Z-Score training, which relies on good old statistics.  Using the database, we know in all 88 Brodmann areas what a person brain will look like, and when it's deviant in any way.  Say, some of these two standard deviations off the mean, that means that it's in the top 5%, or bottom 5%.  If it's three standard deviations off the mean, it's 99.9, or 1 out of 1,000.

So, he was actually at four and a half standard deviations off the mean, and in critical areas of his brain, and all of a sudden, in one session, about two weeks ago, and this is the person that comes twice a week, he just kind of got it, and he couldn't explain it, but he just started advancing very quickly.  It was like the neurons restitched themselves, and believe it or not, after being stuck at four and a half standard deviations, he's now down around 1 and a quarter standard deviations off the mean.

You know that feeling you get when you're -- let's say you're having trouble falling asleep, and then you say to yourself, "Oh good, I'm falling asleep," and you can feel yourself being aware of it right before you drop off.  You can also prevent yourself from falling asleep up to a point.  If you were on the subway or train, and you don't want to fall asleep, you can say, "Well, wait a minute, I don't want to miss my stop," so you pull yourself out of it.  It's a very interesting process.

Well, that's kind of what neurofeedback is.  You can't make it happen.  You have to let it happen, but you can prevent it from happening also.  For example, I've been doing it long enough on myself to know what it feels like when I'm doing well, and it's a familiar feeling to me when I've done it that day.  It always reminds me of do you know that feeling you get when you've been driving a car for a long time, and you pull in for gas not realizing how dirty your windshield is, and the guy cleans your windshield, and you go, "Oh my god, look how clear the world is.  I had no idea." That's kind of what neurofeedback feels like.  Everything is clearer, you're more relaxed and you're more alert - you're centered.

Jesse: I'd love to go back to something you said about standard deviations there.  Maybe this ties in with the word "centered" too.  A quick into that is the implication that most of our brainwave states, the population is going to fall into these bell-shaped curves, these normal distribution curves of how one person's brain versus the next would be.  Does that bear out in the population?  Do these things fit themselves nicely into normal curves?

Dr. Robert Reiner: That's exactly what the database, the principle is made out of.  The foundation of it is the bell curve, and the acceptable rate is two standard deviations off the mean.  You see that in statistics all the time.  Probability is less than .05, or 1 in 20.  In peer-reviewed research journals, that's the acceptable rate of the chances occurring by luck, 1 out of 20 - that's what the .05 means.  It's the same thing with brainwaves.

Now, this guy was four and a half standard deviations off the mean in critical areas required for reading, and now he's 1.25, and it just happened all of a sudden.  It was the strangest thing.  He just kind of did.  Unfortunately, it hasn't generalized as well as I would like it to, because really, it's gotten much better, but not as advanced as I would hope it was based on these numbers.  Sometimes, people say, when they argue against neurofeedback, "You're making people mediocre.  Because, when you make people average, what about somebody with 130 IQ, and what?  You're going to bring him down to 100?"

Well, it's an argument I hear quite a bit, but in my experience, it's kind of like multiple personalities, Jesse.  You hear about multiple personalities, but I've never met a psychologist, and including myself, who ever met a patient who was a true multiple personality.

Jesse: Filmmakers like them a lot more than reality seems to.

Dr. Robert Reiner: Exactly.  It makes for great television, but in the real world, it just rarely exists.

Jesse: Also, I think it's a different case when somebody comes in that's clearly debilitated.  In this case, Lyme disease, reading problems.  Probably pushing them towards the normal is going to be advantageous for somebody like that.

Dr. Robert Reiner: The fact is I've never seen it make someone dumber.  Blood pressure, we know 120/80 is the norm.  Now, one day, that may change, and they decide 110/70 is more desirable, but that's considered lower blood pressure right now.

Jesse: You were talking earlier on about some of the catch-22s of somebody dealing with social anxiety disorder, and one of those being that the barrier of actually reaching out to somebody, even if that somebody is a psychologist, to deal with social anxiety, that barrier itself might seem insurmountable.  It seems like, maybe, virtual reality could even be used to solve some of those problems, sort of the onboarding process dealing with virtual chat bots, or virtual receptionists rather than a real person.

Dr. Eva Zysk: Exactly, exactly.  So, if we can do that, if we can at least engage that population who is so fearful of coming forward because of this face-to-face interaction that they are generally fearing, if we can do that, either we're successfully treating them through this exposure therapy simply in the virtual reality environment, or using that as a bridge between not getting treatment and actually being able to come in for an assessment and potentially get treatment.  Then, at the end of the day, us researchers are heading home very, very happy.

Jesse: How common is this, really?  What percentage of the population deals with the diagnosable level of social anxiety?

Dr. Eva Zysk: In terms of lifetime prevalence, because there's different types of prevalence that we can look at, but in terms of over the course of one's lifetime, anyone from a Western society, the rates are very, very high.  It's the third most common psychiatric disorder in the U.S.  for instance, and it affects about 7 to 13 percent.  So, very, very high rates of social anxiety disorder.

A student survey has found, one group of researchers, that 90% would rather do virtual reality than in Vivo Exposure Therapy, which means kind of real-life exposure therapy.  We can minimize the social threat, we can avoid things like overexposure, we can allow the patient greater control of their own environment, and of course, it doesn't necessitate this feared face-to-face contact with the therapist.

Finally, we actually found that it's just as clinically effective as CBT at times, but actually, it's a lot more cost-effective.  The thing that we actually have in place right now is an app.  We have an app developed that you can put on any smartphone.  You can buy the headset.  Something like Google Cardboard cost, I believe, 8 pounds, or in the U.S., maybe $12 or so, and basically, it's a very, very portable thing, so you can do it any time, any place, and yeah, basically receive even treatment on-the-go if you're keen to that.

Jesse: Has there ever been any concerted attempt to maybe build a database of very high-performing brains and see where maybe the standards there are a little bit different from the mean of the general population?

Dr. Robert Reiner: Not to my knowledge, but that's a great idea.  We have some ideas about what that would take.  For example, we know that being able to shift from one state to another is very important.  Let's say you're deeply relaxed.  Well, if you can rev up very quickly to very alert, a desired kind of thing.

Jesse: You could see where something like that would come in handy in the real world.  I mean, the real-world applications of being able to go from a creative state to a highly-focused state quickly when you decide on the right solution to your problem, that kind of thing could come in very handy.

Dr. Robert Reiner: They say that when people have had amazing ideas, it's been like a storm in their mind.  Apparently, when Einstein - I read his biography - he was about to give up on general relativity until it just came to him, the concept of things slowing down as they got faster.  I mean, this is 1910, I think, that he thought about this.  There was a storm in his mind for weeks as he got the formulas down, and then his wife checked all the mathematics and then he got drunk for a week.

I'll tell you something interesting that nobody has any explanation for.  It's the field of parapsychology, or being able to read minds somehow.  Well, they did a, what's called, meta-analysis.  So, imagine you take somebody, you put them in the room and have their colleague a mile away in a different room, and there's no communication between the two that we can see, yet you ask one of them to concentrate on -- you have four cards.  They're all aces.  So, you got spade, diamonds, clubs, and hearts, and you have them concentrate on one of them.  Well, the odds of getting it right, if you're the person who's supposed to be reading your friend's mind is 1 out of 4, or 25%.  Yet, in study after study, after study, after study, it's .31.  The odds of that occurring by chance are 1 in 2 million.

Jesse: Why don't we hear about that more?

Dr. Robert Reiner: I don't know.  If you YouTube it, you can certainly read about it.  There are some very well-respected college professors who are studying it.  Think about this though.  Let's go 200 years back.  If you showed somebody a smartphone that you could talk to someone in France, in real-time, and see them for free, that would be godlike, wouldn't it?

Jesse: It's funny, because, yeah, the difference between 25% and 31%, so you've got a 6% marginal difference.  You can't take that to the bank right now, but you're right.  If there's something there to work with, that's pretty amazing.

Dr. Robert Reiner: Yeah, then you think the first time the telephone signal, when he said, "Watson, come in here," Alexander Graham Bell, I'm sure it didn't sound like we sound to each other right now.  It's very, very scratchy, barely audible, and that was just 20 feet away.  So, maybe something's going on that we don't understand.

The march of science has been humbling to humanity, and you know that the acceleration is accelerating.  I read something that really hit the nail on the head.  You know how cars in rear-view mirrors, it says, "Objects are close than they seem"?  So is the future.

Written by Hannah Sabih
Hannah believes there's nothing 8 hours of sleep and some kale can't cure (yes, she's from California). She's an avid runner, reader, and traveler, who brings you the latest and greatest in neuroscience via our social media channels.
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