Gut Check: Brian Lacy, MD, and Megan Riehl, PsyD, on Minding the Gut

Guest Megan Riehl, PsyD, discusses with Gt Check host Dr Brian Lacy how to diagnose, explain, and treat disorders of gut-brain interaction so patients feel validated and experience relief from symptoms.

Brian Lacy, MD, is a professor of medicine at Mayo Clinic-Florida in Jacksonville, Florida. Megan Riehl, PsyD, is clinical program director of the GI Behavioral Health program at Michigan Medicine in Ann Arbor, Michigan.

Any views and opinions expressed are those of the authors and or participants, and do not necessarily reflect the views, policies, or position of the Gastroenterology Learning Network or HMP Global its employees and affiliates.

Welcome to Gut Check, a podcast from the Gastroenterology Learning Network. My name is Brian Lacy. I'm a professor of medicine at the Mayo Clinic in Jacksonville, Florida, and I am absolutely delighted to be speaking today with Dr. Megan Riehl, associate professor of medicine and director of the GI Behavioral Health Program in the division of Gastroenterology at the University of Michigan in Ann Arbor. Dr. Riehl is a nationally recognized expert in the field of brain-gut behavior therapy. In addition, she just coauthored a wonderful book called “Mind Your Gut,” a clever title for an important topic, disorders of the gut-brain axis such as IBS. So Dr. Riehl welcome, what a delight to have you here. For our listeners, not quite as comfortable with the topic as you are. Let's begin really simply. What are disorders of gut-brain interaction?

Dr Riehl:

Well, thank you so much for having me today. Disorders of gut-brain interaction used to be known as functional bowel disorders, and we've transitioned that terminology in a way that I think explains them a little bit more clearly because syndromes like irritable bowel syndrome or IBS are impacted by the communication pathway between our brain and our gut. And so under that umbrella of disorders of gut-brain interaction are the traditional functional bowel disorders, IBS, functional dyspepsia. And so we utilize a variety of strategies that extend beyond just working with your medical provider in order to help people manage these tricky conditions.

Dr Lacy:

So Megan, you've nicely outlined this transition from using the term functional bowel disorders to disorders of gut-brain interaction or DGBI. Why was that important to maybe either patients or to providers when you are suffering with symptoms?

Dr Riehl:

So your diarrhea makes it difficult to get to work in the morning and abdominal pain happens throughout the day and being told after undergoing a colonoscopy or a workup or trying several different medications that you have something that's functional—it can sometimes feel like you're not being validated and heard for the symptoms that you're living and being impacted by. And the reality is that yes, it's functional, meaning there are no structural abnormalities happening in your digestive tract, so there's no cancer, there's no stricturing or ulceration, which we can identify using different medical procedures. But when you're told that after those procedures take place that everything looks good, we find that calling these what they are, which is a dysregulation between the functioning of your brain and your gut and providing patients with hope that we have a variety of strategies that will help you manage these very real symptoms, disorders of gut-brain interaction, help to validate that patient experience better.

Dr Lacy:

Absolutely. That's so important, isn't it? When we think about our understanding of the brain-gut disorders and the brain-gut axis, and we're all comfortable with this bidirectional pathway, how do you explain the brain-gut access to your patients?

Dr Riehl:

So first I normalize that we're all, nobody's immune to the brain-gut access. So if you've ever experienced butterflies in your stomach before a sporting event or giving a presentation, that is a very clear indicator of how your brain is surveying the environment and giving your body some feedback. And oftentimes once we start to engage in the activity—so you give the presentation or you are out on the field—those butterflies dissipate. And for patients that have disorders of gut-brain interaction, there is a dysregulation between what's happening with the brain and your gut, and that's along that brain-gut access. And we have different strategies to be able to help improve the functioning between the brain and gut access—the way your brain is communicating with your gut and your gut is sending signals up to the brain. And so this can be impacted by a variety of things. So childhood, your environment, your stress, your mood, your behaviors, and when we learn how we can make changes in those things or address certain aspects that are within our control, some of them are outside of our control, we can help with that functioning of the brain and the gut along that access.

Dr Lacy:

Wonderful. And I like the way you started by saying none of us are immune to this, and I think that probably is reassuring to some patients as well. So before we start discussing specific treatments, how do you approach the topic of using brain-gut behavioral therapies for patients with DGBIs— disorders of gut-brain interaction? Aren't a lot of patients resistant to this concept because they think you're just telling them that they're anxious or depressed?

Dr Riehl:

Yeah, I'm fortunate that I work within a team setting. So my clinic is based within the division of gastroenterology and in working with my colleagues gastroenterologists over the years, we really coach and work together that when you're talking to your patients about a referral to GI Behavioral Health, it's helping the patient to understand that it's not that we think your symptoms are made up or in your head as unfortunately so many patients with DGBIs have maybe heard or experienced in the past. We help them to understand that the psychological therapy is available, evidence-based, meaning that there's now been years of research supporting the efficacy and the use of these interventions. And they also can be created as a part of the treatment plan. So you may work with your gastroenterologist for medication management or maybe referred for pelvic floor physical therapy or to a registered dietician who's expert in GI and the GI psychologist is another team member that can teach additional tools and strategies for the management of your condition. So we talk openly about this as a part of a multidisciplinary team, which research now shows is kind of the gold standard for patients with DGBI.

Dr Lacy:

I like that whole concept of this multidisciplinary team. And again, that may be reassuring to patients. And so that's a great segue when we start thinking about treatment and a treatment plan, when do we introduce this to patients? Should brain-gut behavioral therapies be the first step for every patient or is this just for the most severe patient or somebody who's very anxious or depressed?

Dr Riehl:

It's a really great question and one that I'm not sure I'm going to have a clear-cut answer to because access to GI psychologists is still pretty limited. So while I think most people with IBS would love to be considered for some of these interventions if they haven't had success with medication or nutrition, getting access to a GI psychologist is a bit limited. So we want to think strategically about how we refer, but I think starting to differentiate if a patient has more moderate to severe anxiety or depression symptoms outside of their GI condition, you might want to prioritize that patient first to a general mental health provider. And if you're a gastroenterologist or a physician who is seeing a lot of these patients, you want again to highlight that your anxiety and depression are not necessarily the root cause of your GI condition, but they can exacerbate it.

And therefore, while I continue to work with you to stabilize your GI symptoms, working to stabilize your mood symptoms is also an important part of our treatment plan. And so helping a patient to understand that their mental health is important in also the management of their GI condition, again, you're validating their experience. Now, the patient that has anxiety or mood symptoms that's really driven by their GI symptoms, that patient you might want to prioritize to a GI psychologist because we can help to address the GI specific anxieties like catastrophizing about your symptoms or a lot of avoidant behaviors because of again, trying to avoid those symptoms or prevent those symptoms. And if you don't have access to a GI psychologist, you might start to think about some of the digital behavioral therapies that are emerging specifically for GI conditions, and we might be able to talk a little bit more about that.

Dr Lacy:

Wonderful. Lots of great teaching points in there. And I like the point, especially if somebody is so severely anxious or so depressed they're not functioning, that mental health provider first before you start attacking GI symptoms and using behavioral therapies. And so what are some of the key steps to integrate this type of health care into a treatment plan? You've mentioned a few little roadblocks. Do I just give somebody a pamphlet or do I just send them a link to go online? What do I do?

Dr Riehl:

Yeah, I think as you start to ask your patients about their symptoms or a simple question of do you feel like stress impacts your symptoms? And if their answer is yes, then that might be a good kind of introductory opportunity to talk a little bit about the role of stress on the immune system and on their digestive tract and helping them to understand that by optimizing stress management and reducing physiological tension in the body that can help with the management of their GI symptoms. It's something tangible again, that the patient can identify as well. That doesn't sound like I sit on a couch and receive therapy. It sounds like there's some pretty actionable things that you would be learning. I think that that's really important piece of making that referral to a GI mental health provider is that it's an active therapy. You're learning about your diagnosis. So psychoeducation is a big part of that, helping patients to feel like they understand the different components of their lifestyle that can impact their symptoms. And then going through the different types of therapy, whether it be cognitive behavioral therapy or gut-directed hypnosis, there's investment on the patient's time because ultimately we're working to adjust the way the brain and the gut are functioning. And that does take some time and effort.

Dr Lacy:

I like so much of what you said, but especially the part that not only do these programs help people better understand their condition, but it really is an active process that's not passive. And I think that's so important for patients to be involved. So we've kind of danced around the issue a little bit. Let's drill down now to the different types of brain-gut behavioral therapies. As an example. People use the term CBT, cognitive behavioral therapy, in different ways. What is CBT and how do you employ this in your practice?

Dr Riehl:

Cognitive behavioral therapy or CBT is a well-established type of therapy in health care settings. And then over the last several decades, we've modified aspects of CBT to home in on specific characteristics related to patients with GI conditions. So those avoidant behaviors catastrophizing the physiological arousal that can come with stress and anxiety, and we apply different aspects of CBT for our patients. With IBS it is the most well-researched with the best outcomes. I like to think about CBT as helping patients to identify that how we think impacts how we feel and how we behave. And sometimes the way we've been thinking is the way we've been thinking since we were kids. And so it's again, an act type of therapy where we're identifying our thought patterns and making modifications to them. So we call that cognitive reframing and thinking about more adaptive helpful ways of living life and of managing a medical condition. CBT is kind of, again, a cognitive focus, but under that umbrella we're teaching different relaxation strategies. So teaching patients diaphragmatic breathing, again, also looking at their overall lifestyle and helping them to recognize that many of these strategies that you're learning for your IBS or whatever it is that we're treating are going to help with your overall functioning in general life as well. But we're going to home it in from a GI perspective.

Dr Lacy:

Wonderful. Hypnosis—some patients and some providers believe that hypnosis is when you put somebody in a trance or you make them do things they wouldn't ordinarily do. And we've all seen those silly shows and programs, but that of course is not true. Can you clarify what gut directed hypnosis is and how you use it in your practice?

Dr Riehl:

Yes. If you would've told me many, many, many years ago when I was in graduate school that I would be doing hypnosis as a clinical psychologist in my day-to-day practice, I would've really been perplexed. But in the world of GI gut-directed hypnosis, when we think about numbers needed to treat, that's something we're looking at. Our number is about 4, meaning that we deliver this intervention to 4 people and somebody is going to have a clinical response—that's better than any medication out there. And this type of intervention is able to really help restore the way the brain and gut are communicating and functioning. It can address motility and visceral nerve sensitivity. And patients, we typically are using a protocol that's been researched for many, many years over the course of 7 sessions.

And over that time the patient is in a way in a trance. That's what aspects of that make it hypnotherapy. But there's no bell going off and clucking like a chicken. I'm not implanting suggestions regarding any aspect of something that would be unethical and not right. But I'm giving subtle and also very specific suggestions about the calming, the soothing of the digestive tract. And the way I'll explain this to patients is that if they've ever done guided imagery, guided meditation, if they've done the Calm app or Headspace and they enjoy that kind of practice, that meditative practice, this is very similar to that. We're just using very targeted suggestions to help with the functioning of their digestive tract and make improvements in their IBS symptoms.

Dr Lacy:

And your point about the number needed to treat is so important because this is better than almost every medication we can think of for IBS. So this is a nice segue, too, to the concept of mindfulness. And mindfulness can be described as a willingness to remain in contact with a present moment. How do you use mindfulness for the treatment of disorders of gut-brain interaction?

Dr Riehl:

First, I correct any misconceptions or stigma about mindfulness. I think sometimes people feel like, well, if I'm practicing mindfulness, I'm at peace and I'm at calm and everything's great. And that's really hard to be in that state when you have IBS. And so thank you for providing the definition because in our present moment, we always don't feel great. There may be moments where we do feel at peace and at ease and we feel wonderful and thankful and accepting. And then there may also be times where our stomach is cramping and we need to get our kids to school or show up for an event and you don't feel very good. But we recognize that emotionally how we respond to that present moment can impact us physically. And so I'll talk with patients about the good thing about mindfulness is recognizing that whether it be an uncomfortable or a pleasant moment, it's going to change. Learning those strategies to recognize that we feel empowered in the pleasant moments and we feel empowered in the uncomfortable moments to use our skills to manage the moment and to get through that aspect. That's where mindfulness training can kind of come in in terms of coping and managing.

Dr Lacy:

I like that a lot. I'm going to use some of those phrases in clinic tomorrow. Megan, thinking about these 3 broad categories we've talked about—CBT, hypnosis, mindfulness— can you predict the patient most likely to respond?

Dr Riehl:

When a patient is interested in any of it, that patient is going to likely have some response. And I think when I can correct the misconception, and I'll speak about IBS, but it applies to all GI conditions if they're coming into treatment expecting to never have an IBS flare up ever again, I like to frame it with, when we apply strategies and empower you with tools and resources and evidence-based interventions, our goal is to reduce the severity of your symptoms, the frequency of your symptoms, and the duration of your symptoms. And yes, you might have symptoms that come up, but when you do, it's not going to be a catastrophe anymore. It's going to be, I know what this is, I have this toolbox to utilize and I don't feel as anxious about that anymore. And so when people understand that and have a really clear expectation for what treatment will involve, we will have a treatment responder. And so those people that they believe their diagnosis, they believe they have IBS, they're not coming to me still thinking like, well, I think my doctor missed something. I'm going to have a better opportunity with those patients. And then people that are just generally interested, we just need a little buy-in and usually I can get them start to feel some wins with their symptom management.

Dr Lacy:

Great teaching points. And again, almost speaking of the concept of setting some expectations for some of these patients, which we should do routinely. You've touched on this a little bit, but I just want to come back to it again, but in a similar vein, are there patients who should not be referred to a psychologist for treatment with brain gut behavior therapy?

Dr Riehl:

Those patients that are really seeking complete resolution of their symptoms and also patients that need more comprehensive mental health treatment, they should really be prioritized to a general mental health provider or psychiatry. And again, how we explain that to patients is really important that you as their physician will remain a part of their care. And maybe working with a GI psychologist in the future would be a great idea for their treatment. But any patients with suicidality or untreated trauma, those patients, we really want them to have more stable mood and symptoms under control so that our therapies will be more effective when their other symptoms are better managed.

Dr Lacy:

Megan, this has been a wonderful conversation. You've educated me. I know you've educated any last thoughts for our listeners?

Dr Riehl:

So I just think that working together as a team is so important, and as we work to develop kind of a team approach that fits the patient's needs that can look different for each patient. And so the gastroenterologist plays a very important role in providing that definitive diagnosis. Don't be wishy-washy in how you diagnose IBS, because a patient will take that and they'll hear, I think you have IBS, and they'll hear, I don't have IBS, there's something else going on. So that definitive diagnosis really sets the stage for medication management if needed, and remaining a part of the patient's care while exploring other evidence-based options. And that can include my excellent colleagues as registered dieticians or somebody like myself who's a GI psychologist. And I feel so strongly that when a patient feels heard and validated in how we engage in shared decision making, that too is therapeutic and will impact their symptoms. And you so graciously made mention of the book that Kate Scarlata and I wrote, and that was one of the reasons we wrote the book, was to improve knowledge and access to these types of resources. And we hope that it will help patients with IBS in many different ways.

Dr Lacy:

Wonderful. And again, the name of that book is “Mind Your Gut.” So Megan, again, thank you. To our listeners on Apple, Spotify, and other streaming networks, I'm Brian Lacy, professor of medicine at the Mayo Clinic in Jacksonville, Florida, and you've been listening to Gut Check, a podcast from the Gastroenterology Learning Network. Our guest today was Dr. Megan Riehl, associate professor of medicine at the University of Michigan. I hope you found this just as enjoyable as I did, and I look forward to having you join us for future Gut Check podcasts. Stay well.