Joseph McGuire straps a virtual reality (VR) headset onto a teenage patient, and she is transported to a tropical jungle. Ahead of her, she sees six cascading waterfalls. Looking down, she sees sand and grass. Around her are palm trees and leafy plants, and behind her lies a vast jungle, with rays of sunshine beaming between trees and colorful birds flying overhead. A calm voice, speaking through the headset, guides her through a 20-minute mindfulness exercise, prompting her to be aware of her body and to let her thoughts drift in and out.

Her experience is part of a new study on how teenagers’ ability to sense signals from their body (interoception) affects conditions such as anxiety, obsessive-compulsive disorder (OCD) and eating disorders — all of which are linked to interoceptive dysfunction. “There’s no specific place that we know of in the brain where interoception lives,” McGuire says. “We’re trying to figure that out.”

McGuire, a Johns Hopkins clinical psychologist and expert in Tourette syndrome, anxiety and OCD, and his team are performing “deep phenotyping” — creating comprehensive patient profiles based on neuroimaging, physiological and behavioral responses, and self-reporting. The team, which includes co-investigators Kimberly Smith, an assistant professor of psychiatry and behavioral sciences, and Martin Lindquist, a professor of biostatistics at the Johns Hopkins Bloomberg School of Public Health, is studying the effectiveness of two VR interventions in improving interoception. Additionally, the study will use machine learning to match patient profiles to VR interventions, providing the foundation for later personalized treatments.

At her next visit, that patient will experience the second VR intervention: a deep-breathing exercise in an underwater paradise with futuristic, pop-art looking plants. She’ll hold one of the VR controllers to her belly, and will move through the virtual space as her belly inflates and deflates with her breathing. (In the study, patients receive these two interventions in different orders to determine which VR approach best improves interoception for that individual.)

McGuire says that for patients with anxiety, OCD and eating disorders, deep breathing may be a more successful intervention for some, and mindfulness exercises may be more effective for others.

“Our goal is to use patients’ behavioral and physiological responses along with their brain imaging to precisely predict which type of therapeutic approach will help improve each individual’s interoceptive deficits,” McGuire says. “This way, patients do not have to continue to try different types of therapies and delay finding the ‘right one’ that will help them feel better.”

The study, now in its early stages, is supported by a $900,000, three-year grant from the Tiny Blue Dot Foundation. It complements the team’s ongoing research that compares virtual reality exposures with real-world exposures across physiological and behavioral measures for children with OCD.

Johns Hopkins is the only center in the U.S. studying virtual reality as a therapeutic tool for children with OCD in such a comprehensive manner. In one exposure exercise, participants confront contamination obsessions by picking up and moving around virtual trash in a virtual bedroom.

“For youth with OCD, there’s a fear and distress about touching stuff that’s ‘contaminated,’” McGuire says. “In this virtual world, you pick up a dirty used cup, toilet roll and dirty dishes. While you might do something that’s going to elicit fear or distress in the real world, we find that children and adolescents don’t mind it as much in the virtual world. So while your body and mind are perceiving the exposure in the same way, it’s less distressing from the participants’ subjective perspective.”

In another VR exposure, children are asked to rearrange paintings that are hung on a wall so they aren’t straight — another activity that can be challenging for some people with OCD. In both cases, the same participants complete similar activities with real objects so researchers can compare the effectiveness of the real and virtual exposures across physiological, behavioral and subjective self-reported outcomes.

McGuire’s interest in exploring new therapeutic techniques was recently recognized when he was named the inaugural James C. Harris, M.D. Professor in Developmental Neuropsychiatry & Neurosciences Research. Harris, a child and adolescent psychiatrist who passed away in 2021, was director of the Developmental Neuropsychiatry Clinic. He made a profound impact on patients with developmental disabilities, and was a beloved mentor to many Johns Hopkins faculty members. The endowed chair was made possible by the late clinician’s wife, Catherine DeAngelis, a Johns Hopkins University distinguished service professor emerita and the first female editor-in-chief of JAMA.

In addition to the Harris professorship, McGuire was recently named associate director for research in the child and adolescent psychiatry division.

Virtual reality is not the only means through which McGuire is seeking new treatments. With a $2.9 million, five-year R01 grant from the National Institutes of Health, he and his team are now in their third year of studying how an online mindfulness-based group intervention can help adults with Tourette syndrome (TS) and related tic disorders.

While tics tend to start in childhood, they often persist into adulthood. Behavioral therapy — which does not include mindfulness-based treatment — is the first-line treatment for the management of TS. However, it is only effective for about half of children and about a third of adults. Moreover, McGuire’s prior work has shown that behavioral therapy is beneficial for patients with TS, but does not confer any added benefit to commonly co-occurring disorders such as OCD and anxiety, which affect up to 80% of individuals with TS.

“Mindfulness really treats the whole person,” McGuire says. “Our hope is that we can teach patients key mindfulness skills that not only help with managing tics, but also improve these commonly co-occurring conditions. This can lead to an improved quality of life for patients with TS.”

The study is yet another example of McGuire’s creativity in seeking better treatments.

“How do we make care better?” McGuire asks. “How do we help patients? That’s ultimately what drives me.”