Question 1

Can psychological interventions help alleviate the physical symptoms of digestive disease or just teach people better coping mechanisms?

Laurie Keefer · Accepted Answer

I think the answer here is both.  The brain and the gut are intricately connected and digestive symptoms, even in people without coping skills deficits, can experience motility disturbances, nausea/vomiting or abdominal discomfort under stress.  Our brain-gut psychotherapies have shown repeatedly in RCTs that the physical symptoms of GI disorders are improved with treatment, specifically GI motility (how fast or slowly food and waste move through the GI tract) and abdominal pain. Acid secretion and chemical sensitivity in the esophagus has been shown to be altered with hypnosis!

Remember, the gut has its own nervous system, the enteric nervous system which connects to the  central/autonomic nervous system through the vagus nerve. Any techniques that seek to alter the sympathetic-parasympathetic pathway are likely to drive the efficiency of the GI tract (think Rest and Digest) which is why most brain-gut psychotherapies incorporate a relaxation strategy (breathing, progressive muscle relaxation, meditation, etc).  Similarly, brain imaging research has shown that changes in both the frontal cortex, where sensations are perceived and the limbic system, where symptoms are interpreted change with brain-gut interventions.  Certainly, psychological interventions also address acceptance, avoidance and other coping mechanisms since these conditions are often incurable, but I would not write off the strong physiological impact of brain-gut psychotherapies!

Question 2

What are the indicators of psychological distress in a patient with a digestive disorder?

Laurie Keefer · Accepted Answer

Patients with digestive disorders are at increased risk for psychological distress, particularly anxiety and depression. Depending on the condition, rates of mental health comorbidities are as high as 40-60%. That said, there is debate about whether it is of value to formally screen GI patients for mental health disorders in the clinic setting, versus a more holistic approach to care that promotes a "well-being review of symptoms" at each GI visit.  The latter is my preference because it is not always mental health comorbidity that we worry about in our GI patients- well-being can be reduced due to embarrassment and stigma around symptoms; worry, isolation and avoidance of situations that trigger symptoms or somehow restrict access to bathrooms (e.g. eating, going to restaurants, concerts or soccer games); fatigue and sleep disturbances.  Cognitive-affective processes also can develop quite easily with chronic digestive symptoms in the absence of frank psychopathology, including pain catastrophizing, fear of symptoms (vomiting, diarrhea or incontinence) or superstitious/hypervigilant behavior focused on preventing symptoms or situations in which they occur.

Question 3

What clinical interventions are effective for gut visceral hypersensitivity response?

Laurie Keefer · Accepted Answer

Visceral hypersensitivity is a perturbation of brain-gut interaction that occurs after the gut has sustained injury, infection or inflammation.  Basically, it means that the brain continues to send out false alarms of threat/pain long after the gut damage has healed.  Therefore, the best clinical interventions are those that target the brain-gut pathway, calming down the short-circuiting that occurs in the absence of true threat.  I often tell patients that in visceral hypersensitivity, the brain acts like your smartphone- keeping all of your background apps running and app notifications on, depleting your batteries and pinging you unnecessarily.  I would recommend something like gut-directed hypnotherapy or either a tricyclic antidepressant or SNRI (if pain is also present) to reverse this dysregulation.  The good news is that visceral hypersensitivity often decreases over time, even on its own.

Question 4

Can anxiety cause Crohn's?

Laurie Keefer · Accepted Answer

There is no evidence to suggest that anxiety, depression or stress CAUSE Crohn's Disease or ulcerative colitis, although comorbidity is as high as 40-60%.  It is more likely that there is a bi-directional pathway between the two, affected by genetic overlap (similar genes cause both), inflammation overlap (similar inflammatory cytokines found in both) and of course behavioral overlap- mental health distress can exacerbate GI symptoms and GI symptoms can exacerbate mental health distress.  Many patients are very hard on themselves, particularly after a new diagnosis of Crohn's Disease, thinking that recent stress or trauma they underwent caused the disease. While stress never really HELPS anything, that belief that IBD develops after a recent loss (psychosomatic hypothesis) has been debunked.  However,it is important that IBD patients recognize they must be more proactive than the average citizen in managing their mental health given the bi-directional pathway between the brain and the gut and the impact of mental and physical health on their overall well-being.

Question 5

Are there recommended evidenced based treatments to help clients manage chronic anxiety and pain related to severe IBS?

Are there recommended career counseling resources to assist individuals with severe IBS find sustainable employment?

Laurie Keefer · Accepted Answer

By the sound of your question, the severe IBS may have morphed into a Centrally Mediated Abdominal Pain Syndrome in which traditional IBS triggers such as food, bowel movements, stress or menstrual cycle trigger are no longer as clearcut. If this is the case (see attached Rome IV criteria for CAPS), you will definitely want to take a multidisciplinary "rehab" approach focused on acceptance, promotion of goals/values despite pain (working, parenting) etc. and probably a combination of neuromodulators and behavior therapy. If the patient uses opioids, you must immediately assess for Narcotic Bowel Syndrome which can often paradoxically worsen pain and anxiety and requires detoxification before pain can begin to abate.  At the core of the treatment approach for CAPS (or severe IBS) is the therapeutic relationship, which is one of boundaries, mutual goal setting and expectancies and often involvement of caregivers.  Be careful of your own burnout and I would encourage you have team meetings/peer supervision to support you with this type of case.

I am not aware of vocational services, although I would imagine your local pain rehab centers may have some recommendations.

Question 6

How does one get expertise in CBT for IBS? Can you translate a skill set from CBT for chronic pain or anxiety to this condition?

Laurie Keefer · Accepted Answer

Yes, many GI psychologists started out in other fields of health psychology including chronic pain or oncology.  Strong skills in CBT and evidence-based practice within medical settings is a great pre-cursor to being able to treat a range of digestive disorders.  I would recommend you look into joining our internationally based Rome GastroPsych group which offers professionals training seminars, therapist and patient handouts and an active listserv to familiarize yourself more with the field!  Visit www.romegipsych.org for more details.

Question 7

What is the best training pathway to become a GI Psychologist?

Laurie Keefer · Accepted Answer

I am so glad you asked! We have assembled an international group of GI psychologists through www.romegipsych.org and I would highly encourage you to become a member, where you can access materials, listserv and educational webinars.  There are also opportunities through this foundation to train (as a postdoc or at the visiting faculty level) with GI Psychologist experts in the US and AUS.  Several GI Psychologists have contributed to the first ever handbook for psychogastroenterology professionals which I would highly recommend (shameless plug!).  https://www.routledge.com/Psychogastroenterology-for-Adults-A-Handbook-for-Mental-Health-Professionals/Knowles-Keefer-Mikocka-Walus/p/book/9780367196561

Question 8

Hi Dr Keefer, what interventions do you use to target the fatigue and mood problems that people with GI disorders experience? Thank you

Laurie Keefer · Accepted Answer

Great question!  First, fatigue is likely an extraintestinal manifestation of GI disorders that can occur even when GI symptoms are under control.  Mood problems can be both a consequence and cause of fatigue.  Assessment of fatigue is very important as it is often multifactorial and you must address all contributors to see a true benefit.  Check out the role that each of the following play in fatigue: 1) Mood, anxiety; 2) Activity level; 3) Sleep; 4) Presence of restorative activities; 5) Screen time; 6) Diet; 7) Over-extension. I often like to reference "spoon theory" to patients- how many spoons are they spending versus recuperating each day.  Mood will often improve with fatigue management unless it is the primary driver of fatigue, at which point treatments for depression and mood are probably helpful.

Question 9

When would you choose gut-directed hypnotherapy over CBT for gastrointestinal conditions?

Laurie Keefer · Accepted Answer

Great question, and an anecdotal answer I am afraid as no comparative effectiveness research has been conducted to date (hint hint those of you emerging gastropsych scientists).  I tend to choose CBT over hypno when there are clear signs of pain catastrophizing, symptom-based fear or avoidance behaviors or the presence of worry, intolerance of uncertainty, perfectionism or depression.  Hypnosis I like to use with patients who have clear arousal symptoms, several somatic complaints in addition to digestive symptoms, post-infectious IBS symptoms that are lingering, or patients who have developed hypervigilance or visceral hypersensitivity in response to symptoms. Ultimately, these are evidence based therapies and you can combine them, rely on client preference in the absence of contraindications (e.g. dissociative disorders for hypnosis).

Question 10

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