Transcription:
GI Psychology and the Brain-Gut Connection

Melanie Cole, MS: Emerging research is showing that our brains and our gastrointestinal systems may be connected much more so than we previously thought, potentially influencing mood and even mental health. This exciting new frontier of scientific knowledge is being examined in more detail. Welcome to Better Edge a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And we have a panel here today to discuss GI psychology and the brain gut connection. Joining me is Dr. Anjali Pandit. She's an assistant professor of medicine in the divisions of gastroenterology, hepatology, and psychiatry. And she's the co-director of behavioral medicine for digestive health program at Northwestern.

Dr. Tiffany Taft, she's an associate professor of medicine in the divisions of gastroenterology, hepatology, medical, social sciences, and psychiatry at Northwestern Medicine. And Dr. Kathryn Tomasino. She's an assistant professor of medicine in the divisions of gastroenterology, hepatology, and psychiatry. She is also co-director of the behavioral medicine for digestive health program at Northwestern. Doctors. I'm so glad to have you with us today. What an amazing topic this is. I'm looking so forward to a lively discussion and Dr. Taft, I'd like to start with you, please tell us a little bit for other providers. This is a relatively new field. So what is GI psychology? What is the brain gut connection?

Dr. Tiffany Taft: Yeah. Thank you so much for having us on to talk about this. GI psychology really got going about 15 to 20 years ago, so it isn't as new as. It seems, even though it really hasn't started catching on, I would say until the last five years or so more in clinical practice, and it is the intersection of the social and emotional and psychological processes that we all experience with our digestive system all the way from the top all the way through to the bottom. So we focus in on any condition that affects the gut from the esophagus.

So things like Astro, esophageal, reflux disease eosinophilic esophagitis, and then down through inflammatory bowel disease. Irritable bowel syndrome. So we really work with the whole gamut of digestive conditions and we focus in on that brain gut connection that you mentioned, which is a pretty intricate system. Now, also involving the microbiome of the gut where the brain is communicating. With the gut pretty constantly through the vagus nerve and the autonomic nervous system.

And then also we are learning more recently. I think the newer stuff that you're thinking of is the gut microbiome is communicating back up to the brain and it's being implicated in all sorts of things, including mood and anxiety and other psychological conditions. So it's a really complex system that we really are getting into some really cool stuff and starting to understand.

Melanie Cole, MS: It is some cool stuff. It is amazing. And I'm looking so forward to this as we learn more. Dr. Tomasino, there are many conditions and mood disorders where this connection is being closely looked at. Yes. Schizophrenia bipolar, depression. What are the diagnoses or reasons for referral for the patients you typically see and what kind of demand is there for this type of treatment? I would imagine it's huge.

Dr. Kathryn Tomasino: Yes. Thank you again for having a phone today. So we talk about the impact of the brain gut connection on some of those psychiatric conditions that you mentioned. But the types of patients who we see in the referrals that we receive are more for some of the conditions that Dr. Taft was mentioning, and those are the GI conditions. So actually within our clinic, we don't see patients with The psychiatric conditions that you were speaking, unless they're co-occurring with a gastrointestinal condition. And we also see in the majority of our patients are seen for gastrointestinal conditions.

We just provide psychological and behavioral treatments that through the brain gut connection can help improve the symptoms of their GI tract. So those include things like IBS, as Tiffany mentioned, inflammatory bowel disease, GERD, AIA, gastroparesis, chronic abdominal pain really across the whole digestive tract.

Melanie Cole, MS: Thank you, Dr. Tomasino for that. And Dr. Pandit, what do you do in a typical session? So as the interest in this topic is pretty high right now, as Dr. Tomasino was saying, do you do anything other than one to one therapy in terms of patient care? Tell us a little bit for referring physicians, what they can tell their patients to expect?

Dr. Anjali Pandit: Absolutely. So, yeah, again, thanks so much for having us. We love to talk about the gut brain connection, the brain gut connection. So first, when a patient's referred, we do a very comprehensive evaluation. So we look and ask questions, not only about the GI condition, but their impact on the patient's quality of life. We do look at things like mental health and whether a mood might be Influencing symptoms and vice versa, as well as social support, health habits, kind of a big picture of how the patient is doing. And then if they seem to be a good candidate for our clinic, as Dr. Tomasino mentioned, we're really focused in, on the GI condition themselves.

So. We are trained as clinical psychologists, but are specifically working with patients on their GI conditions. But we use a lot of different kinds of therapies to help patients. So a typical session might look like doing relaxation strategies with patients to teach them ways to calm their fight or flight response. It could also look like examining a patient's interpretation of their symptom. And helping the patient to use evidence to reinterpret their symptoms in a more helpful and potentially more logical way. And it also could look like things like talking to patients about accepting or coping with some of their symptoms in order to focus on more value life activities.

We also offer gut directed hypnosis because that is a really good evidenced intervention for many symptoms of the GI tract. So a session that might look like that, we really take a tailored case by case approach. We typically do see patients in that one-on-one therapy, like you mentioned, but we do have several groups in classes too. So support groups for. Are internal. So Northwestern patients with inflammatory bowel disease can attend our monthly support group and also have a support group that runs every few months for patients with gastroparesis and that's open to patients anywhere.

And they don't have to be a Northwestern patient. And then also have some new programs and Group therapy to focus in on hypnosis. So delivering hypnosis in a group format so we can reach more patients. Since, as you mentioned, the need for this service is so high and also offering more education about what the brain gut connection is.

Melanie Cole, MS: Isn't this fascinating, Dr. Tomasino. I'd like you to follow up on what Dr. Pandit just said and what distinguishes the work you do from a typical therapist one might refer to?

Dr. Kathryn Tomasino: Absolutely. So I think Dr. Pandit did a really nice job of explaining what we do in a typical session. And the target of that is really to influence that interaction between the brain and the gut. So we are trying to target in the typical session brain based factors that might be influencing the GI symptoms that the patient is coming in with. And so that really does distinguish us from what a patient would be doing in a typical session. She mentioned a couple of specific interventions, but a lot of these fall under the broad category of cognitive behavioral therapy.

And while a patient might receive cognitive behavioral therapy for something like depression or anxiety, or a whole host of other conditions, we are really targeting it at the GI tract. So what distinguishes it is when we are talking about how the relaxation strategy will be beneficial. For example, diaphragmatic breathing is one strategy that we're teaching. We are helping patients learn how to calm down their autonomic nervous system specifically to make sure that they're activating the parasympathetic side to that vagus nerve.

But we're talking about how that's then affecting their motility, how that's affecting how things are moving through their digestive tract, how it might be affecting their pain response. And we also know that diaphragmatic breathing, as an example, can help influence things like belching and reflux through its effect on the lower esophageal sphincter. So we wouldn't be talking about that in a typical one to one session on depression, right? We wouldn't be talking about the impact of breathing on the lower esophageal sphincter, but in our types of therapy, using the gut brain connection, we're talking about our digestive tract specifically.

Melanie Cole, MS: Dr. Tomasino. I'd like to stick with you for a second then. So this work that you're doing, how is this affected treatment options? If there's clearly a bidirectional connection, as you were just describing, then can we expect that treating those gastrointestinal issues may also improve mood disorder symptoms and go back and forth?

Dr. Kathryn Tomasino: Yeah. So, a number of patients with gastrointestinal conditions have co-occurring depression or anxiety. The majority of those treatments might help with mood and anxiety that are co-occurring particularly if the reason that they're experiencing depression or anxiety is because of the impact of the medical condition on their life and ability to participate in meaningful life activities. So for example, if someone is having constant abdominal pain and then they're canceling plans and not able to do the things that they enjoy and then the treatments that we are working with them on improve their abdominal pain and improve their willingness to engage in some activities with maybe some mild discomfort, then that is likely going to improve mood and anxiety as well.

If the anxiety is stemming from the GI condition and nervousness about those symptoms, then we are targeting that anxiety specifically, and that might improve generalized anxiety. So certainly, engaging in some of these treatments can help, but we wouldn't claim that just helping treat the disorder of gut brain interaction or the pain condition or the GI condition that the patient is coming in with will help necessarily address a major depressive disorder. For example, it might improve mood and might improve anxiety, but it would be going beyond the scope of what we do to say that we're treating that at the same time.

Melanie Cole, MS: Thank you for making that clear and for making that point. So Dr. Pandit, is there anything you wish MDs would tell their patients when making this kind of.

Dr. Anjali Pandit: Absolutely. Yeah. So, I think in light of everything that we've talked about earlier today that there is this strong evidence that the brain gut connection is very real. And therefore if a physician is referring their patients to our service, it's not because they think that the symptoms are in the patient's head, that fewer and fewer patients are coming in with that kind of preconception, but maybe emphasizing that, Hey, your symptoms may be because of a disruption in communication between your brain and your gut. There's a real science here.

And so let me refer you to a provider who has the skills and training to address the symptoms that you're experiencing. And also I think mentioning that we are in, we're housed within the GI department. there's several of us psychologists available to treat patients with GI conditions. So, there's certainly a need here and we're embedded within Northwestern as well.

Dr. Kathryn Tomasino: I'd like to add if I can that, just speaking to what Dr. Panda mentioned, there is a lot of evidence, not only for the brain gut connection, but for the types of treatments that we provide. There's Been studies as Dr. Taft mentioned for the past 15 to 20 years, this has been around and research has been done to demonstrate the effectiveness of cognitive behavioral therapy got directed hypnosis and some other treatments for GI conditions themselves. And for the associated distress that it can cause. And so if they could provide that to their patients, I think that would be a better sell if you will, when making the referral.

Melanie Cole, MS: What a great topic we are discussing today. It's so informative. And Dr. Taft, what is your current research focus?

Dr. Tiffany Taft: Right now I'm focusing on a couple different things. The first target that we're looking at is medical trauma or medical post-traumatic stress, post-traumatic stress disorder in patients with inflammatory bowel disease. And this is actually a relatively new area of research. But I think if you talk to any patient with IBD or even other chronic. digestive conditions that necessitate some pretty intensive testing, workup potential for feeling like their life, maybe in danger because of their body or because of their medical condition.

So Patients would tell you they've been experiencing this for a long time, but we've only identified it within the last few years, putting out four research papers so far, looking at the rates of medical trauma and post-traumatic stress in patients with inflammatory bowel disease. And unfortunately, that number is around 25 to 30% report, what we would call moderate to severe symptoms of post traumatic stress because of their disease. So this isn't from other experiences. We usually think of post traumatic stress disorder as a thing that people who have been in combat or victims of a crime live with.

And so we are now seeing that. Have identified that and are talking about it in these patients. And we are hoping to do now some treatment studies to see if we can help folks because post-traumatic stress disorder is a chronic lifelong condition that simply does not go away on its own. And can really have the potential to impact patient lives, patient outcomes, and how they're even presenting in their with physicians. So if you suspect post-traumatic stress disorder in one of your patients, it's important to follow up on that.

The other line of research that we're doing is in esophageal conditions. Looking at the psychophysiology of the brain gut with the esophagus, which hasn't gotten as much attention as the lower parts of the digestive system in this space. So we're really excited to be looking at that in conditions like GERD and Achalasia and EOE and looking at things like heart rate variability as a marker of the brain gut function. Looking at symptom specific anxiety and hypervigilance to esophageal sensations. And so we're finding some really interesting stuff.

And we're hoping, to continue with this line, this is all a lot NIH funded research. So, what we're doing, I think people are finding to be really important. And so we're really excited to be doing this work here.

Melanie Cole, MS: It is exciting work. And I'd like to give you each a chance for a final thought here. So Dr. Taft sticking you with you for just a minute, and thank you for telling us about your really interesting research. How have you seen this research that you've done affect patient care and gastroenterology take us from bench to bedside. And where do you see this going and helping patients in their journey with their gastrointestinal issues?

Dr. Tiffany Taft: Yeah, that's a great question. I'll start with the. Symptom specific anxiety and hypervigilance. I really have to implore to the folks who are listening that hypervigilance and anxiety about pain and discomfort, difficulty swallowing is a natural response. So I'm not talking necessarily about pathological over the top, anxiety that doesn't make sense considering the situation I really need to say this, because I do hear from patients that they're hearing from some of their physicians, well, this is anxiety. And if you didn't have anxiety, you wouldn't feel so sick. And that is about the worst thing you can say to somebody.

So really focusing in on a lot of the involuntary ways that anxiety happens. Our fight or flight system is not only controlled by conscious thinking, right? It's very automatic. And if we had to think about it, when the, protective responses needed immediately, we wouldn't survive. So these are normal natural responses. And so by trying to understand them, we can help patients also understand what's going on, normalize that anxiety, normalize that hyper vigilance, but also through the techniques that Dr. Pandit and Dr. Thomasino talked about, help the patients adjust.

Because even though the anxiety is normal, and is supposed to be protective. It prevents them from really living the life that they would like, because these are chronic conditions that aren't going to necessarily go away. They might get better with medical treatment, but if that threat response is kicked into high gear, We need to help them turn that down, even though it's a natural response to something like pain. And then on the PTSD side simply recognizing and starting to talk about that.

This is a thing I think has been where we're at right now and now we're looking at, okay, how do we treat post-traumatic stress in patients with inflammatory bowel disease? Because it is a stressful treatment, there are already treatments out there for PTSD that the veterans administration uses, but we're like, we don't know if we should just apply those here because it's a little bit different than combat related trauma or the like. And also causing a lot of stress through that treatment could exacerbate or make cause a flare up of the disease.

So we're trying to figure out the safest way to work with patients on PTSD, so that hasn't been done yet. So really right now, the translation is recognition and conversation with patients about that, and then trying to connect them skilled therapists who can work with people experiencing post traumatic stress.

Melanie Cole, MS: The work you all are doing is so important and needed right now. Dr. Pandit, can you just take one minute to tell us about this holistic model of care that recognizes the complexity of these inflammatory bowel diseases and the evolving role of diet and stress? And Dr. Taft was talking about PTSD and just this role as you are all looking at it through the therapist's lens and through the gastroenterology lens, that the role that the stress and all of diet plays in flareups for their diseases?

Dr. Anjali Pandit: It's a great question. And I think a great question for panel too, because we're all health psychologists. So, we really look at all of our patients in a very holistic lens, true believers in the mind body connection, but also that all these different areas that you mentioned of a patient's life influence each other. So, it's what we call a bio psychosocial approach to looking at patients. So we tend to ask a lot of questions about the patient's diet or pattern of eating, or have a cope with stress, or what kinds of medications are you taking?

Where do you turn to for educating yourself about your condition who is in your social support network? It all really matters. Because this is a real person who's coping with this whether it's inflammatory bowel disease or another GI condition and having to live their life at the same time. So making a change in one area may make a significant change to their symptoms or their quality of life. And so, how people cope with stress is a huge part of what we do.

Just because we do know that stress can predispose or kind of make someone more vulnerable to an IBD flare up or an IBS flare up, or make someone predisposed to developing some GI conditions is something that we ask about all the time. And a lot of our interventions are really directed towards helping someone better manage their stress.

Melanie Cole, MS: Wow. And Dr. Tomasino last word to you for referring physicians, what would you like them to know about referring to the specialists at Northwestern Medicine in behavioral medicine for digestive health program and everything that we're talking about today. I'd love for you to just give us a quick summary?

Dr. Kathryn Tomasino: Well, we'd really like people to know that if they have patients with these gastrointestinal conditions, they think they could benefit from the types of treatments that we provide. They could certainly refer to the Northwestern Medicine, gastroenterology department, which offers this whole host of services, including working with. A psychologist, like one of us, we actually will have up to five psychologists on board come 2023 who are in the clinic side in addition to Dr. Taft on the research side.

And we also have medical nutrition services and then the wonderful quality of care from our gastroenterologists and other medical providers here. So a referral just to gastroenterology will allow them then to have the option of all of the different treatments we have over here.

Melanie Cole, MS: Thank you doctors for joining us today and sharing your incredible expertise. Fascinating topic. What a good podcast interview this was. So thank you so much for joining us to refer your patient or for more information, head over to our website at breakthroughsforphysiciansd.nm.org/gastro, to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine Podcast for Physicians. I'm Melanie Cole.