Question 1

Where can I train in gut-directed hypnotherapy?

Laurie Keefer · Accepted Answer

Gut-directed hypnotherapy is one of the most efficacious psychotherapies available for IBS with promise in GERD, Dyspepsia, IBD and pediatric abdominal pain. If you are in the United States, I would recommend you undergo basic and intermediate training in hypnosis from the American Society of Clinical Hypnosis (www.ASCH.net) and then request access to one of the evidence-based protocols from Olafur Palsson, PsyD at the University of North Carolina.  If you are in Europe, Peter Whorwell's group at the University of Manchester also offers training and certification.  A caveat though- please make sure you feel comfortable treating these GI conditions without hypnotherapy.  In other words, this is one treatment modality but not a solution for all and your training in the digestive disorder itself is critical in your decision making.

Question 2

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 3

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 4

How do you treat what I've heard referred to as "food PTSD" - fear of eating, avoidance of certain foods, restricted food intake not related to weight/shape concerns but to manage GI symptoms such as abdominal pain, bloating etc?

Laurie Keefer · Accepted Answer

Unfortunately, fear and avoidance of food and eating is all too common among patients with GI symptoms.  What starts out as a reasonable reaction to avoid food to prevent symptoms of pain and bloating can become overly restrictive and a source of high anxiety. For many GI patients, it is less about WHAT they eat than it is their EATING BEHAVIOR.  Now that ARFID is in the DSM-V as an eating disorder that does not require symptoms related to weight/shape, we are seeing an increased prevalence of this comorbidity in our practices and recommend screening.  Again, when present ARFID, clinical or subclinical, benefits from a multidisciplinary approach including exposure therapy, speech therapy if issues with texture/gagging/aversion are present, and sometimes psychotropics. Some patients will even use an anxiolytic before meals if traditional breathing exercises do not work.

Question 5

Is there an overlap between GI symptoms and disordered eating?

Laurie Keefer · Accepted Answer

There is growing evidence that Avoidant-Restrictive Food Intake Disorder is prevalent in tertiary GI referral practices.  Prior, less robust research has also supported  GI motility disturbances resulting in constipation, bloating and abdominal pain among patients with Anorexia Nervosa.  The upper GI motility disorder Gastroparesis is also commonly comorbid with disordered eating and should be screened for routinely.

The overlap between disordered eating and GI symptoms is likely a chicken v. egg phenomenon.  Overlap may be due to shared psychological processes between the two conditions such as cognitive inflexibility, perfectionism or somatization. Overlap could also be as simple (or complex as) as a conditioned reaction/consequence to the experience of food triggering GI symptoms.  Fear of food, food aversions to textures, color or smells are also common in the GI population and this is an important differential when disordered eating is present.

Either way, it is important to identify these disordered eating behaviors early and exposure therapy is often required, testing the cognitions that certain foods cause symptoms and should be avoided at all costs.  Working with a nutritionist can be helpful here to improve patient self-efficacy and ensure a balanced diet.  It is also helpful to have a pathway created between your GI Psych practice and an eating disorder program in case escalation is needed.

Question 6

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 7

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 8

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 9

Does ulcerative colitis effect mental health?

Laurie Keefer · Accepted Answer

Yes! The impact of ulcerative colitis on mental well-being has been well established. When disease is active, rates of depression and anxiety can be as high as 60%.  This is not surprising given the symptoms of active disease are embarrassing, isolating and disruptive.  Many patients are forced to avoid situations where bathrooms aren't readily available, are afraid to travel, and are very bothered by urgent, bloody diarrhea.  Fatigue is also common, both during active and inactive disease.  As an incurable chronic illness, mental health must be continuously addressed as when mental health comorbidity occurs in UC, disease outcomes are worse.

Question 10

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 11

Is crohn's disease psychosomatic?

Laurie Keefer · Accepted Answer

The psychosomatic hypothesis for Crohn's disease was popular in the 1930s-1950s with the view that the disease could be linked to a recent loss or trauma.  Current research has shown that many patients perceive stress to be the catalyst for the onset of their disease, Crohn's disease, is more likely to develop from a genetic X environmental pathway, of which stress may only be one part.  The onset of Crohn's disease is most often between ages 15 and 25; the tumultous time of adolescence, both psychologically and physiologically (think onset of puberty, increased exposure to environmental pathogens, nutritional changes) may hold some clues.  In other words, the psychosomatic hypothesis for Crohn's disease has since been disproven, both with the advent of effective therapies, better criteria to differentiate Crohn's disease from other less malignant diseases such as irritable bowel syndrome and a deeper appreciation of the bi-directional communication that occurs between the brain and gut/microbiome.

Question 12

Client does not have a clear diagnosis with abdominal pain. There is a correlation between his stress/anxiety &  pain with marked spikes in levels. We have tried deep breathing techniques & meditation; he indicates they don't work. Distraction helps somewhat. What else can we try?

Laurie Keefer · Accepted Answer

What a clinical challenge that so many of us face!  First, I would wonder if the patient met criteria for Centrally-Mediated Abdominal pain syndrome (CAPS), which can be diagnosed through the Rome IV criteria and when shared with the patient, can help patients move past the "assessment phase of why I have pain" towards an intervention phase focused on acceptance and pain distress tolerance.  I like the idea of using deep breathing and meditation as distress tolerance techniques and, since most GI conditions benefit from re-balancing of the autonomic nervous system, relaxation techniques of any sort should be part of any intervention you offer.

You could potentially approach this as a combination therapy- gut-directed hypnotherapy is particularly effective for abdominal pain syndromes given the effect of hypnosis on emotional arousal circuits in the brain. It often takes 4 sessions before one starts to see a benefit however, so set expectations upfront and encourage practice between sessions for faster relief.

If there are other factors however that seem to be maintaining the pain, 2nd wave behavior therapies such as CBT focused on reducing pain catastrophizing or avoidance behavior or 3rd wave behavior therapies incorporating acceptance and mindfulness are also reasonable. Finally, many of our refractory abdominal pain patients benefit from a combination of brain-gut psychotherapy and a central neuromodulator (e.g. an SNRI).

Question 13

Any suggestions for patients with unexplained cyclic vomiting who have had full GI workup?

Laurie Keefer · Accepted Answer

Great question! There has been an increase in the presentation of unexplained cyclic vomiting syndrome (CVS), chronic nausea and vomiting syndrome (CNVS) and Cannabinoid hyperemesis syndrome (CHS) and I encourage you to look at the Rome IV criteria is differential diagnosis can really inform your approach (attached).  Gut-directed hypnotherapy focused on nausea/prevention of vomiting can be helpful, CBT can also work well if triggers associated with the cycle are known. Patients should also be encouraged to stay hydrated, cool and engage in diaphragmatic breathing routinely.  I will also say that neurologists can also be quite helpful in the medical management of CVS- if your patient hasn't seen one, this could be a worthwhile consult.

Question 14

I have a 17yo female client who reports that she wakes up at 5AM and begins vomiting for hours. Medical tests rule out any organic problems and there is no disordered eating so it appears to be anxiety. Any interventions to suggest?

Laurie Keefer · Accepted Answer

This is an all too common condition we see in our practice of teens and young adults.  Chronic nausea/vomiting syndrome (CNVS- see Rome IV Criteria attached plus differentials) is increasingly common among young people and can definitely be related to sleep disturbances, anxiety about the day/school or school refusal, or excessive cannabis use.  I would also confirm there is no binge eating that happens in the evening since many of these patients will not eat most of the day due to the morning vomiting, and then overeat at night (especially when cannabis is used).

I agree with you that focusing on anxiety management is appropriate in this situation- given the severity and impact, I would probably recommend a combination of central neuromodulators (atypical antipsychotics can work well) PLUS a brain-gut psychotherapy, either/or CBT for anxiety or gut-directed hypnosis focused on nausea/inhibition of vomiting reflex.

If possible, the patient may also benefit from a nutritional consult.  Electrolytes should also be routinely monitored-- even if you do not find this to be an eating disorder, the frequency of vomiting is concerning for electrolyte disturbance as well as concerns about mouth and teeth inflammation - she should consult with a dentist if she hasnt already.

Finally, the patient may also benefit from distress tolerance around nausea, which you didn't mention but I presume is a trigger for vomiting? Is she able to better tolerate the nausea without throwing up?  Sometimes the vomiting becomes self-soothing (rids you from nausea) and habit reversal techniques can be helpful.

Question 15

There are newer deferential diagnosis's for IBS that I have recently seen as EPI and GSID. I am curious if there is 1, misdiagnosis happening primarily for IBS as it has a mixed bag of symptoms, & 2 if any evidence-based psychological interventions are recommended if GSID and/or EPI is present?

Laurie Keefer · Accepted Answer

You are correct in that Irritable Bowel Syndrome is a real, diagnosed disorder of gut-brain interaction that is best understood through a multi-factorial model.  It is a heterogeneous condition with 4 subtypes, IBS-diarrhea predominant, IBS-constipation predominant, IBS-Mixed type and IBS-Undetermined.  As such, exocrine pancreatic insufficiency (EPI) or Genetic Sucrase-Isomaltase Deficiency (GSID), might mimic IBS-diarrhea type., much like in the older days we worried about lactose intolerance and Celiac Disease being misdiagnosed as IBS. That said, EPI and GSID are substantially rarer conditions than IBS, which is as prevalent as 15% in the Western world, suggesting that a horses not zebras approach is reasonable. Furthermore, because IBS is NO LONGER a disorder of exclusion (we used to think there could be no other possible explanation for the symptoms), it is completely possible to have IBS with EPI or GSID.  Treatment for moderate to severe IBS of any subtype still requires a comprehensive approach including medication management, nutritional management and behavioral/lifestyle management and therefore patients are still likely to benefit from evidence-based psychological interventions even when absorptive issues as you discussed are present.

Question 16

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 17

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 18

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!

Evidence-Based Psychological Interventions for Digestive Disorders