As you all know by now, I have always been a firm believer in the team approach concept for care of IBS patients. I truly believe that due to the complexity of IBS, patients benefit from a multi-disciplinary team. For many patients, a gastroenterologist, a dietitian and a GI psychologist is essential for managing this often debilitating condition.
This year, I spoke at the University of Michigan’s program, FOOD: The Main Course to Digestive Health conference in September 2017. One of my favorite speakers at this event was Megan E. Riehl, PsyD, Assistant Professor of Medicine and GI Psychologist, from the Division of Gastroenterology at University of Michigan. Dr. Riehl spoke about therapeutic interventions used by GI psychologists when working with IBS patients. I asked Dr. Riehl if she would kindly do a Q & A for my blog followers, and she graciously agreed. See our Q & A session below–filled with great and actionable information!
Most of us know the gut and the brain are highly connected via the gut-brain axis (GBA). The GBA is a bi-directional communication pathway between the gut and the brain. The gut and brain are derived from same tissue in utero. The GBA pathway enables gut microbes to communicate with the brain & brain with gut. The vagus nerve is a key route of communication between gut microbes & the brain.
Our gut microbes regulates/creates neurotransmitters such as: serotonin (alters precursors), GABA & dopamine. Here are a few more interesting facts about our gut nervous system and the role of microbes:
- There are over 100 million neurons in the gut (more than the spinal cord or peripheral nervous system) and many contain the exact same neurotransmitters as the brain.
- 100 trillion gut microbes mediate communication through hypothalamic-pituitary-adrenal axis (HPA).
- Psychological stress increases gut permeability; allowing bacteria to translocate & directly access immune & neural cells of the enteric nervous system (the nervous system of the gut).
- Animal studies show changes in their gut microbiome lead to changes in emotional behavior. And we are learning more about how these changes impact anxiety, depression and more in humans.
This area of research is in its infancy–but is very exciting. Many individuals with IBS experience psychological distress and a GI psychologist can offer effective strategies to improve quality of life.
Kate: I am a firm believer that IBS patients reach better therapeutic gains when they are working with a collaborative healthcare team. How does the role of a GI psychologist fit into this team approach?
MER: The team approach to IBS is essential, since this is a difficult to treat disorder. You’ve got an all-star team when a gastroenterologist, GI psychologist and dietitian come together. When the traditional medical model is not aiding in symptom improvement, a GI psychologist may work with a patient to address the role of stress, anxiety, and coping. A GI psychologist can help patients in understanding the intricacies of the brain-gut connection and how one’s body can respond to stress. People with IBS tend to have very sensitive nerve endings in the digestive system (referred to as visceral hypersensitivity) that can get irritated by daily stressors (i.e. going to school or work, wondering where a bathroom is, eating), causing worsening GI symptoms. A GI psychologist works with a patient to address GI-specific anxiety (thoughts and emotions related to the fear of GI symptoms), which can significantly impact a person’s quality of life. Treatment is short term and will typically incorporate cognitive behavioral therapy and/or gut-directed hypnotherapy. Due to time and cost, patients are encouraged to attempt one treatment approach at a time (i.e. low FODMAP or GI behavioral health). A patient who addresses their GI-specific anxiety with a GI psychologist, may be a better candidate for dietary therapy once their anxiety is better controlled.
Kate: Can you provide a short and sweet definition of gut-directed hypnotherapy and how it may help IBS patients?
MER: Hypnosis is a special mental state where a trained therapist guides a person into a focused state of awareness while feeling deeply relaxed. The technique utilizes suggestion, imagery and relaxation to produce a therapeutic effect. Gut-directed hypnotherapy for IBS uses suggestions that are aimed at calming the digestive tract and preventing unnecessary focus on discomfort in the body. Gut-directed hypnotherapy often helps patients who have failed other treatments, is one of the most successful treatment approaches (response rates of 80% or better) for IBS and results are longstanding.
Kate: What is diaphragmatic breathing and what is its role in managing IBS symptoms? Where can patients go to learn more about deep breathing techniques?
MER: Diaphragmatic breathing is one of my favorite techniques! It is a skill that takes some practice, but once you are comfortable, it can be used in so many ways. The activation of the diaphragm through diaphragmatic breathing allows for a gentle massage of the internal organs (stomach and intestines). This can aid with abdominal pain, urgency, bloating and constipation.
My instructions for diaphragmatic breathing:
- Sit or lie in a comfortable place. Close your eyes.
- Place one hand on your chest and one hand on your abdomen. Your bottom hand should do the moving. Top hand should remain still or only move as the bottom hand moves.
- Inhale through your nose for about 4 seconds, feeling your abdomen expand. You may feel slight tension during these initial inhalations.
- Hold your breath for 2 seconds.
- Then exhale through your mouth very slowly for about 6 seconds. Mouth should be relaxed with a steady, slow exhalation.
- Repeat for 5-15 minutes.
A couple of my favorite apps to learn more and practice are Belly Biofeedback and Breathe2Relax (both free!).
Kate: Suffering with chronic pain can lead to worrying and some individuals with IBS may take part in catastrophic thinking. Can you describe pain catastrophizing and how it may impact the IBS patient?
MER: We know that worry doesn’t typically help anything. Given the painful and embarrassing symptoms that an IBS patient may experience, pain catastrophizing is common. It often takes the form of negatively anticipating how the pain will impact their life and doing all they can to avoid that anticipated negative outcome. When a patient with IBS begins to experience a pain, they may experience excessive worry about what that pain may mean both at present and in the future. For example, a gentleman wakes up with a stomachache on the day he has a big date with a woman he has liked for a long time. Despite the fact that the date is several hours away, he spends the whole morning in the bathroom attempting to lessen the pain and thinking about how angry he is that his IBS is getting in the way, yet again. His pain persists and ultimately he cancels the date believing that his pain would surely get in the way of enjoying his date. In this case, of our dater’s pain catastrophizing had more to do with why he didn’t go on the date as opposed to the actual pain. Pain catastrophizing leads to negative expectations and feelings of helplessness. This causes a person to focus more on the pain they are currently feeling, which makes the pain worse, brings up unhelpful memories of past painful experiences and decreases one’s ability to cope effectively with their pain.
Kate: Cognitive behavioral therapy is another buzz term I hear that a GI psychologist may engage in with their IBS patients. What is cognitive behavioral therapy?
MER: Cognitive behavioral therapy, or CBT, is a common therapeutic approach in medical settings. It is present focused and provides patients with skills to better manage their medical problem. CBT is a collaborative effort between the therapist and patient and helps the patient to change thoughts, feelings and behaviors that may be impacting their stress response, coping and mood. CBT can provide patients with skills to decrease GI-specific anxiety, pain catastrophizing, and avoidance behaviors. Treatment will also aid patients in finding more flexible coping strategies and break the cycle of stress leading to IBS flare ups.
Interesting and informative, right? A big thank you to Dr. Riehl for taking the time to share her expertise with all of us! There are many different approaches to living your best with IBS –and the role of the GI psychologist can be very therapeutic!