Kim Bullock, MD

All Publications

• Bringing Virtual Reality From Clinical Trials to Clinical Practice for the Treatment of Eating Disorders: An Example Using Virtual Reality Cue Exposure Therapy. Journal of medical Internet research Brown, T., Nauman Vogel, E., Adler, S., Bohon, C., Bullock, K., Nameth, K., Riva, G., Safer, D. L., Runfola, C. D. 2020; 22 (4): e16386

  Abstract

  Novel treatment options for eating disorders (EDs) are critically needed to enhance treatment outcomes and reduce the rates of treatment dropouts. On average, only 50% of individuals receiving evidence-based care remit, whereas 24% drop out before treatment completion. One particularly promising direction involves integrating virtual reality (VR) with existing evidence-based treatments (EBTs) such as cue exposure therapy (CET). Across psychiatric disorders, VR-based interventions are demonstrating at least preliminary efficacy and noninferiority to traditional treatments. Furthermore, VR technology has become increasingly portable, resulting in improved acceptance, increased access, and reductions in cost. However, more efficient research processes may be needed to uncover the potential benefits of these rapid technological advances. This viewpoint paper reviews existing empirical support for integrating VR with EBTs (with a focus on its use with EDs) and proposes key next steps to more rapidly bring this innovative technology-based intervention into real-world clinic settings, as warranted. VR-CET for EDs is used to illustrate a suggested process for developing such treatment enhancements. We recommend following a deployment-focused model of intervention development and testing to enable rapid implementation of robust, practice-ready treatments. In addition, our review highlights the need for a comprehensive clinical protocol that supports clinicians and researchers in the implementation and testing of VR-CET and identifies key missing protocol components with rationale for their inclusion. Ultimately, this work may lead to a more complete understanding of the full potential of the applications and integrations of VR into mental health care globally.

  View details for DOI 10.2196/16386

  View details for PubMedID 32324145

• Case Report: Virtual Reality Behavioral Activation as an Intervention for Major Depressive Disorder. JMIR mental health Paul, M., Bullock, K., Bailenson, J. 2020

  Abstract

  Major depressive disorder (MDD) is a global problem with an increasing incidence and prevalence. There has additionally been an increase in depression due to the COVID-19 pandemic. Behavioral activation is considered an evidence-based treatment for MDD. However, there are many barriers that could hinder one's ability to engage in behavioral activation, with COVID-19 "shelter-in-place" and social distancing orders being current and large impediments. Virtual reality has been successfully used to help treat a variety of mental health conditions, but it has not yet been used as a method of administering behavioral activation to a clinical population. Using virtual reality to engage in behavioral activation could eliminate barriers that pandemic precautions place and help decrease symptoms of depression that are especially exacerbated in these times.The following case report examines the feasibility, acceptability, and tolerability of virtual reality behavioral activation for an adult with MDD during a global pandemic. This participant was part of a larger pilot study and the case serves as a description of the VR intervention.The participant engaged in a weekly 50-minute psychotherapy Zoom session for four weeks, in which a modified behavioral activation protocol was administered using a virtual reality headset. Data on mood ratings, homework compliance, and headset use were obtained from the headset. Acceptability, tolerability, and depression symptoms were obtained using self-report rating scales.The intervention was feasible, acceptable, and tolerable, as reported by this participant. The participant's depressive symptoms decreased by five-points on the PHQ-9 over a month, with a beginning score of a 10 (moderate depression) and a final score of a 5 (mild depression).The implications of these findings for future research are discussed.Clinicaltrials.gov NCT04268316.

  View details for DOI 10.2196/24331

  View details for PubMedID 33031046

• Virtual Reality-Delivered Mirror Visual Feedback and Exposure Therapy for FND: A Midpoint Report of a Randomized Controlled Feasibility Study. The Journal of neuropsychiatry and clinical neurosciences Bullock, K., Won, A. S., Bailenson, J., Friedman, R. 2019: appineuropsych19030071

  Abstract

  OBJECTIVE: The aim was to provide preliminary feasibility, safety, and efficacy data for a personalized virtual reality-delivered mirror visual feedback (VR-MVF) and exposure therapy (VR-ET) intervention for functional neurological disorder (FND).METHODS: Midpoint results of a single-blind, randomized controlled pilot are presented. Fourteen adults were randomly assigned to eight weekly 30-minute VR sessions-seven in the treatment arm and seven in the control arm. The treatment arm consisted of an immersive avatar-embodied VR-MVF treatment, plus optional weekly VR-ET starting at session 4 if participants had identifiable FND triggers. The control arm received equally immersive nonembodied sessions involving exploration of a virtual interactive space. Feasibility was measured by acceptability of randomization, completion rates, side effects, adverse events, and integrity of blinding procedures. Exploratory primary and secondary outcome measures were weekly symptom frequency and the Oxford Handicap Scale, respectively.RESULTS: Two early dropouts occurred in the treatment arm, resulting in an 86% completion rate (N=12/14). No side effects or adverse events were reported. Blind assessment at study end indicated that two of the seven treatment arm and three of the seven control arm participants incorrectly guessed their assignment. Changes in mean symptom frequency and disability were reported, but data will not be statistically analyzed until study end.CONCLUSIONS: This study is the first to report on MVF and VR for treatment of FND. Results generated thus far support feasibility and justify continuation of the study and further investigation into the efficacy of VR interventions for FND.

  View details for DOI 10.1176/appi.neuropsych.19030071

  View details for PubMedID 31687867

• Recommendations for Methodology of Virtual Reality Clinical Trials in Health Care by an International Working Group: Iterative Study. JMIR mental health Birckhead, B., Khalil, C., Liu, X., Conovitz, S., Rizzo, A., Danovitch, I., Bullock, K., Spiegel, B. 2019; 6 (1): e11973

  Abstract

  Therapeutic virtual reality (VR) has emerged as an efficacious treatment modality for a wide range of health conditions. However, despite encouraging outcomes from early stage research, a consensus for the best way to develop and evaluate VR treatments within a scientific framework is needed.We aimed to develop a methodological framework with input from an international working group in order to guide the design, implementation, analysis, interpretation, and communication of trials that develop and test VR treatments.A group of 21 international experts was recruited based on their contributions to the VR literature. The resulting Virtual Reality Clinical Outcomes Research Experts held iterative meetings to seek consensus on best practices for the development and testing of VR treatments.The interactions were transcribed, and key themes were identified to develop a scientific framework in order to support best practices in methodology of clinical VR trials. Using the Food and Drug Administration Phase I-III pharmacotherapy model as guidance, a framework emerged to support three phases of VR clinical study designs-VR1, VR2, and VR3. VR1 studies focus on content development by working with patients and providers through the principles of human-centered design. VR2 trials conduct early testing with a focus on feasibility, acceptability, tolerability, and initial clinical efficacy. VR3 trials are randomized, controlled studies that evaluate efficacy against a control condition. Best practice recommendations for each trial were provided.Patients, providers, payers, and regulators should consider this best practice framework when assessing the validity of VR treatments.

  View details for PubMedID 30702436

  View details for PubMedCentralID PMC6374734

• Key Considerations for Incorporating Conversational AI in Psychotherapy. Frontiers in psychiatry Miner, A. S., Shah, N., Bullock, K. D., Arnow, B. A., Bailenson, J., Hancock, J. 2019; 10: 746

  Abstract

  Conversational artificial intelligence (AI) is changing the way mental health care is delivered. By gathering diagnostic information, facilitating treatment, and reviewing clinician behavior, conversational AI is poised to impact traditional approaches to delivering psychotherapy. While this transition is not disconnected from existing professional services, specific formulations of clinician-AI collaboration and migration paths between forms remain vague. In this viewpoint, we introduce four approaches to AI-human integration in mental health service delivery. To inform future research and policy, these four approaches are addressed through four dimensions of impact: access to care, quality, clinician-patient relationship, and patient self-disclosure and sharing. Although many research questions are yet to be investigated, we view safety, trust, and oversight as crucial first steps. If conversational AI isn't safe it should not be used, and if it isn't trusted, it won't be. In order to assess safety, trust, interfaces, procedures, and system level workflows, oversight and collaboration is needed between AI systems, patients, clinicians, and administrators.

  View details for DOI 10.3389/fpsyt.2019.00746

  View details for PubMedID 31681047

• Role-Play SUPERVISION IN PSYCHIATRIC PRACTICE: PRACTICAL APPROACHES ACROSS VENUES AND PROVIDERS Bullock, K. D., DeGolia, S. G., Corcoran, K. M. 2019: 69–77

  View details for Web of Science ID 000550978200007

• Psychiatric Factors in Psychogenic Nonepileptic Seizures Psychogenic Nonepileptic Seizures: Towards the Integration of Care edited by Dworetzky, B., Baslet, G. Oxford University Press. 2017; 1
• Group Psychotherapy Treatment for Psychogentic Nonepileptic Seizures Gates and Rowan’s Non-Epileptic Seizures edited by Schachter, S. C., LaFrance, C. Cambridge Press. 2017; 4
• Documentation Bias in Functional Neurological Symptom Disorder: Comparing the Prevalence and Documentation of Functional Neurological Symptom Disorder and Parkinson's Disease Leaver, K., Yi, E., Evans, B., Bullock, K., Dearlove, J. LIPPINCOTT WILLIAMS & WILKINS. 2016

  View details for Web of Science ID 000411328602166

• Obsessive-Compulsive Disorder Presenting as Gender Dysphoria/Gender Incongruence: A Case Report and Literature Review AACE Clinical Case Reports Safer, D. L., Bullock, K. D., Safer, J. D. 2016; Summer 2016, 2 (3): e268-e271

  View details for DOI 10.4158/EP161223.CR

• Group Dialectical-Behavior Therapy Skills Training for Conversion Disorder With Seizures. journal of neuropsychiatry and clinical neurosciences Bullock, K. D., Mirza, N., Forte, C., Trockel, M. 2015; 27 (3): 240-243

  Abstract

  Neuroimaging evidence suggests deficits in affective regulation in conversion disorder (CD). Dialectical-behavior therapy skills training (DBT-ST) was developed to target emotion dysregulation. This study was aimed to test the feasibility of stand-alone DBT-ST for CD using Linehan's manual for borderline personality disorder. In a prospective naturalistic design, 19 adult outpatients diagnosed with video EEG-confirmed seizure type CD were recruited and received weekly group DBT. Seventeen out of 19 subjects finished an average of 20.5 weeks of treatment. The mean seizure rate decreased by 66%. Cessation of seizures occurred in 35% of the sample. Completion rates reached 90%.

  View details for DOI 10.1176/appi.neuropsych.13120359

  View details for PubMedID 25959039

• Ethical Considerations in Caring for People Living with Addiction Applied Ethics in Mental Health Care, An Interdisciplinary Reader Sisti, . A. MIT Press. 2013
• Ethical Considerations in Caring for People Living with Addictions APPLIED ETHICS IN MENTAL HEALTH CARE: AN INTERDISCIPLINARY READER Roberts, L., Bullock, K., Sisti, D. A., Caplan, A. L., RimonGreenspan, H. 2013: 223–28

  View details for Web of Science ID 000327644300020

• Ethics Commentary: Ethical Considerations in Caring for People Living With Addictions Focus Laura Weiss Roberts 2011; 9: 66-69
• Group Psychotherapy Treatment for Psychogentic Nonepileptic Seizures Gates and Rowan’s Non-Epileptic Seizures, Third Edition Schachter, . C., LaFrance Jr, . Cambridge University Press. 2010; 3rd
• Group therapy for patients with psychogenic nonepileptic seizures: A pilot study 58th Annual Meeting of the American-Epilepsy-Society Barry, J. J., Wittenberg, D., Bullock, K. D., Michaels, J. B., Classen, C. C., Fisher, R. S. ACADEMIC PRESS INC ELSEVIER SCIENCE. 2008: 624–29

  Abstract

  Great advances have been made in the diagnosis of people with psychogenic nonepileptic seizures (PNES) since the advent of video/EEG monitoring. However, treatment options for this population have lagged significantly. This pilot study was undertaken to evaluate whether group therapy done with a psychodynamic focus would offer a useful intervention. Twelve patients entered the study and seven completed at least 75% of the 32 weekly sessions. The Beck Depression Inventory and the Global Severity Index of the Symptom Checklist-90 showed improvement as well as an overall decrease in PNES frequency. The data suggest that group therapy focusing on interpersonal issues may benefit patients with PNES.

  View details for DOI 10.1016/j.yebeh.2008.06.013

  View details for Web of Science ID 000260701500008

  View details for PubMedID 18621147

• Double-blind treatment with oral morphine in treatment-resistant obsessive-compulsive disorder JOURNAL OF CLINICAL PSYCHIATRY Koran, L. M., Aboujaoude, E., Bullock, K. D., Franz, B., Gamel, N., Elliott, M. 2005; 66 (3): 353-359

  Abstract

  Obsessive-compulsive disorder (OCD) often responds inadequately to serotonin reuptake inhibitors (SRIs). A case series reported substantial response to once-weekly oral morphine. We conducted a placebo-controlled, double-blind trial to investigate whether once-weekly oral morphine is effective in SRI-resistant OCD.Subjects with DSM-IV-defined OCD for > or =3 years who had failed > or =2 adequate SRI trials and had a Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score of > or =20 were recruited. Current medications were continued. Subjects were randomly assigned to random-order, 2-week blocks of once-weekly morphine, lorazepam, and placebo. Week 2 dosage was increased, decreased, or maintained depending on response and side effects.We enrolled 23 subjects, who had failed 2 to 6 SRI trials. The median screening Y-BOCS score was 29. The median Y-BOCS score after morphine (highest dose) was 25 (median decrease = 13%). Seven subjects (30%) were responders (Y-BOCS decreases > or =25%). The median Y-BOCS score after lorazepam (highest dose) was 27 (median decrease = 6%). Four subjects (17%) responded to lorazepam; 1 was a morphine responder. The median Y-BOCS score after placebo (highest dose) was 27 (median decrease = 7%), and no subject responded. Responses differed significantly among the 3 conditions (Friedman 2-way analysis of variance, chir(2) = 13.92, df = 2, p = .01). Wilcoxon matched-pairs signed-rank tests (T = 56.5, p = .05) showed significance for morphine versus placebo but not lorazepam versus placebo.Our results support the hypothesis that once-weekly oral morphine can reduce symptoms in some treatment-resistant OCD patients. The mechanism of action is unknown. Further studies of mu-agonists and glutamate antagonists are warranted.

  View details for PubMedID 15766302

• Current status of the utilization of antiepileptic treatments in mood, anxiety and aggression: Drugs and devices CLINICAL EEG AND NEUROSCIENCE Barry, J. J., Lembke, A., Bullock, K. D. 2004; 35 (1): 4-13

  Abstract

  Interventions that have been utilized to control seizures in people with epilepsy have been employed by the psychiatric community to treat a variety of disorders. The purpose of this review will be to give an overview of the most prominent uses of antiepileptic drugs (AEDs) and devices like the Vagus Nerve Stimulator (VNS) and Transcranial Magnetic Stimulation (TMS) in the treatment of psychiatric disease states. By far, the most prevalent use of these interventions is in the treatment of mood disorders. AEDs have become a mainstay in the effective treatment of Bipolar Affective Disorder (BAD). The U.S. Food and Drug Administration has approved the use of valproic acid for acute mania, and lamotrigine for BAD maintenance therapy. AEDs are also effectively employed in the treatment of anxiety and aggressive disorders. Finally, VNS and TMS are emerging as possibly useful tools in the treatment of more refractory depressive illness.

  View details for Web of Science ID 000223764000002

  View details for PubMedID 15112459

• Group psychotherpy for patients with non-epileptic seizures: a pilot study (abstract). Epilepsia Wittenberg D, Michaels J, Ford C, Bullock K, Barry JJ 2004; 45 (Suppl. 7): 57-8
• Citalopram for compulsive shopping disorder: An open-label study followed by double-blind discontinuation 40th Annual Meeting of the American-College-of-Neuropsychopharmacology Koran, L. M., Chuong, H. W., Bullock, K. D., Smith, S. C. PHYSICIANS POSTGRADUATE PRESS. 2003: 793–98

  Abstract

  Open-label trials suggested that fluvoxamine and citalopram may be effective for compulsive shopping disorder, but 2 double-blind fluvoxamine trials failed to confirm this. To test the hypothesis that citalopram is a safe, effective treatment for this disorder, we conducted a 7-week, open-label trial followed by a 9-week, double-blind, placebo-controlled discontinuation trial.From Jan. 2001 to Jan. 2002, we enrolled adult outpatients meeting diagnostic criteria suggested in a prior study for compulsive shopping disorder and having a score of >/= 17 on the Yale-Brown Obsessive Compulsive Scale-Shopping Version (YBOCS-SV). Open-label citalopram was started at 20 mg/day and increased, absent marked response and limiting side effects, to 60 mg/day. Responders (subjects rated "much improved" or "very much improved" on the Clinical Global Impressions-Improvement scale [CGI-I] and having a >/= 50% decrease in YBOCS-SV score) were randomized to double-blind citalopram treatment at the week 7 dose or placebo for 9 weeks.We enrolled 24 subjects (23 women and 1 man). Mean +/- SD YBOCS-SV scores decreased significantly from 24.3 +/- 4.6 at baseline to 8.2 +/- 8.1 at week 7 (Wilcoxon signed rank: z = 4.20, p <.001). Fifteen of 24 subjects (63%) met the responder criteria. Three subjects (13%) discontinued for adverse events (1 each for headache, rash, and insomnia). Of the 15 responders who entered the double-blind treatment phase, 5 of 8 (63%) randomized to placebo relapsed (YBOCS-SV score >/= 17 and "minimally improved" or less on the CGI-I) compared with none of 7 randomized to continue taking citalopram (Fisher exact test p =.019).Citalopram appears to be a safe and effective treatment for compulsive shopping disorder. Further trials of citalopram and other selective serotonin reuptake inhibitors are warranted.

  View details for Web of Science ID 000184233600009

  View details for PubMedID 12934980

• Psychopharmacology of compulsive buying Drugs of Today Bullock KD, Koran LM 2003; 39 (9): 695-700
• Citalopram treatment of compulsive shopping: An open-label study 41st Annual Meeting of the New-Clinical-Drug-Evaluation-Unit Koran, L. M., Bullock, K. D., Hartston, H. J., Elliott, M. A., D'Andrea, V. PHYSICIANS POSTGRADUATE PRESS. 2002: 704–8

  Abstract

  Compulsive shopping, a DSM-IV impulse-control disorder not otherwise specified, is characterized by preoccupation with shopping and inability to resist buying unneeded items, with resulting marked distress, social or occupational impairment, and financial and/or familial problems. Because an open-label trial suggested that fluovaxamine, a selective serotonin reuptake inhibitor (SSRI), is effective for this disorder, we tested the effectiveness of the SSRI citalopram.We enrolled adults meeting formal diagnostic criteria (as defined by McElroy and colleagues) in a 12-week open-label trial. We excluded subjects with obsessive-compulsive disorder, bipolar disorder, substance abuse or dependence, or psychotic disorders. Citalopram treatment was begun at 20 mg/day and increased every 2 weeks by 20 mg/day, absent marked response and limiting side effects, to 60 mg/day. At endpoint, all subjects were asked to give written informed consent for follow-up telephone interviews at 3-month intervals for 12 months.We enrolled 24 subjects, 22 women and 2 men, whose mean +/- SD age was 43.7 +/- 8.1 years; most had been shopping compulsively for 2 decades or more. Citalopram (mean +/- SD endpoint dose = 35.4 +/- 21.4 mg/day) produced rapid, marked, sustained improvements on both the Yale-Brown Obsessive Compulsive Scale-Shopping Version and the Clinical Global Impressions-Improvement (CGI-I) scale in subjects with and without comorbid conditions. Seventeen subjects (71%) were responders, achieving ratings of much or very much improved on the CGI-I, including 2 of the 3 subjects who discontinued for adverse events (sedation or agitation). During a 6-month follow-up period, those continuing citalopram therapy were less likely to relapse than those discontinuing the medication.Citalopram appears to be a safe and effective treatment for compulsive shopping. Acute and long-term, double-blind, placebo-controlled trials of citalopram and other SSRIs for the treatment of this disorder are indicated.

  View details for PubMedID 12197451

• REDUCED MORTALITY RISK IN ALCOHOLICS WHO ACHIEVE LONG-TERM ABSTINENCE JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Bullock, K. D., Reed, R. J., Grant, I. 1992; 267 (5): 668-672

  Abstract

  To determine if alcoholic men who achieved stable abstinence experienced fewer deaths than those who relapsed and to develop a model predictive of premature mortality.A cohort of alcoholic men recruited into a prospective study of neurocognitive effects of alcoholism was followed up from 1 through 11 years. A demographically equated group of nonalcoholic men was also followed up. Alcoholics were classified as stable abstainers or relapsers.Alcoholics were patients or ex-patients from a Department of Veterans Affairs Alcoholism Treatment Program and/or members of local chapters of Alcoholics Anonymous.There were 234 alcoholic men who met the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, criteria for alcohol dependence. Follow-up status regarding relapse and mortality was obtained for 199 alcoholic subjects (85%). Of these, 101 had relapsed and 98 had abstained. Ninety-eight nonalcoholic controls equated for age, education, and sex also participated. Mortality status was obtained for 92 subjects in this group (94%).Major medical and psychiatric illness and history of nonalcoholic drug abuse.Death during a follow-up period of 1 through 11 years. Death was ascertained through the National Death Index, the California State Department of Health and Vital Statistics, the State Department of Motor Vehicles, and through personal contact with informants, relatives, and significant others of the subjects.There were 19 deaths among relapsed alcoholics compared with the expected number of 3.83 (99% confidence interval (CI), 9.64 to 33.38). Among abstinent alcoholics there were four deaths (expected = 3.21; 99% CI, 0.67 to 12.59). The standardized mortality ratio for relapsed alcoholics was 4.96, which significantly exceeded the expected ratio (P less than .001), whereas the standardized mortality ratio for abstinent alcoholics (1.25) was indistinguishable from the expected. Cox proportional hazards analysis was used to determine if any of several demographic, medical, cognitive, or drinking history variables (in addition to relapse) helped predict mortality among alcoholics. Only relapse was significantly related to increased mortality (chi 2 = 9.15, P = .003).Alcoholic men who achieve stable abstinence do not differ from nonalcoholic men in mortality experience; however, alcoholics who relapse die at a rate 4.96 times that of an age-, sex-, and race-matched representative sample from the US Bureau of the Census.

  View details for Web of Science ID A1992HB35400023

  View details for PubMedID 1731133