Laurie Keefer, PhD, on Brain-Gut Behavioral Therapy

In this podcast, Dr Keefer discusses how different types of behavioral therapies can help in the management of disorders of gut-brain interaction, such as irritable bowel syndrome.

Laurie Keefer, PhD, is professor of medicine and a GI health psychologist at the Icahn School of Medicine at Mt. Sinai, in New York City.
 

For more insights from experts like Dr Keefer, click here.

TRANSCRIPT:

Gastroenterology Learning Network:  Hello, and welcome to another podcast from the Gastroenterology Learning Network. I'm your moderator, Rebecca Mashaw. I'm here today with Laurie Keefer, who is a professor of medicine and a GI health psychologist at the Icahn School of Medicine at Mt. Sinai, in New York City.

She's going to be talking with us about the Rome Working Team Report on brain-gut behavior therapies for disorders of gut-brain reaction. This report has just been published in the "Journal of Gastroenterology." We're delighted to have you here. Thanks for joining us, Dr. Keefer.

Dr. Laurie Keefer:  Yeah, thanks as always for having me talk about something you know I'm very passionate about.

GLN:  Let's start with an overview of disorders of gut-brain interaction. What exactly does that term mean, and what conditions are classified as disorders of gut-brain interaction?

Dr. Keefer:  That's a great question. They were formerly known as functional GI disorders; we've made a conscious effort during Rome IV, and this will continue into Rome V in the next few years, to classify disorders based on their pathophysiology.

Instead of saying functional, meaning your GI tract doesn't function, which isn't helpful to anybody, we're saying that there is a problem with the way in which your gut and your brain are interacting.

These are real symptom-based disorders. They cut across the entire digestive tract, so you have upper disorders of a gut-brain interaction, such as reflux, GERD, dyspepsia. You have disorders in the midrange—irritable bowel syndrome, sphincter of Oddi. You have disorders of anorectal concern—dyssynergic defecation and constipation.

All of these disorders are very well characterized now. They are all considered to have at least some element of gut-brain dysregulation, some more than others. For some there's other factors—inflammation, microbiome deficiencies—but they all have some element of this miscommunication that goes on between the brain and the gut.

GLN:  Tell us a little bit about the Rome Foundation Working Team. What inspired the creation of this team and the report, and what kinds of professionals participated in its creation?

Dr. Keefer:  Rome Working Team Reports have been a huge part of the Rome Foundation for many years. When I joined the Rome board back in 2018, we talked about what my contribution might be as a board member. At the time, we were ripe for discussing these brain-gut behavior therapies amongst physicians.

Psychologists talk about these. We know these interventions. We know why they work. We understand a lot of the pros and cons, tinkering with them and making them better. There's enough of an appetite now amongst gastrointestinal providers to understand them in a deeper way than they used to as well.

We thought, let's get together an international group of psychologists, psychiatrists, nurse scientists, to come together and explain the mechanistic basis for these brain-gut behavior therapies, as well as how physicians and advanced practitioners can explain to their patients why they're referring, what the benefits are, and how to integrate these behavior therapies into intervention care.

GLN:  What can you tell us about those mechanistic factors? What causes these kinds of disorders?

Dr. Keefer:  It's interesting. When I first started in this, 25 years ago in graduate school, we focused on irritable bowel syndrome. We focused on it being a psychosomatic condition, one that had a physical manifestation of chronic worry.

That was how we developed our causative behavior therapy program. We focused on relaxation training, all of those kinds of things, and for a subset of patients, that worked, because obviously, worry doesn't help the bowels. Stress doesn't help the bowels.

We've now, with brain imaging research, with a whole group of experimental psychology research approaches, we're able to much more precisely state what's going on in the brain when a patient is experiencing a GI symptom.

How do the brains of patients with disorders of gut-brain interaction differ from the brains of "healthy controls"? How do signals arising from the gut get interpreted, or misinterpreted, by the brain? Then, even more exciting, in the last 10 years, we now have data showing not only what happens to create these symptoms based on cognitive and affective principles, we can also see how things like cognitive behavior therapy, gut-directed hypnotherapy, mindfulness stress reduction, changed the brain and the ability of the guts brain interaction. Now we're more sure than ever that brain-gut behavior therapies operate on the mechanism of brain-gut dysregulation.

We're no longer just saying, "Oh, well psychological stress could be helpful, to manage IBS in particular is stress-mediated, so do stress management." Now we know fear of symptoms, amplification of symptoms, emotional interpretation of symptoms at the level of the brain derives the symptom experience in ways that we previously didn't target.

GLN:  This is an interesting time because you're learning much more all the time.

Dr. Keefer:  Yeah, we are. We're also able to tell our story a little bit more clearly. One of the important goals of the working team report was to tell the story in a way that physicians could adopt it. Rather than get into the nitty-gritty of, for example, avoidance behavior is a really hot topic in psychology. It's a very important construct in GI psychology.

How do you talk to physicians about that? How do you explain what that is and why you would choose cognitive behavior therapy vs exposure-based therapy or acceptance-based therapy? Those are all nuances that in the past we've left up to the psychologist providing the services, but now we're able to talk about it in ways that physicians understand.

We can point to fear of symptoms leads to this in the brain. This is why a patient might avoid their symptoms. This is why targeting avoidance improves the symptoms. We're able to do that. The Rome Working Team Report was the first document with the physician in mind, breaking down what we view as health psychologists into something that could be explained in a medical framework.

GLN:  I note that the report specifically discusses brain-gut behavior therapies, and notes that this is the first time that a document like this has provided a framework for a gastrointestinal provider to understand the specific behavioral targets of these various therapies and the techniques that they're applying to patients who have these disorders.

Could you review the 5 existing classes of brain-gut behavior therapies and how they relate to this axis?

Dr. Keefer:  Yeah, absolutely. Just like classes of drugs work on GI symptoms, classes of behavior therapies work on brain-gut interaction. While they all have some shared elements to focus on symptom reduction, there are some nuances as to what we in psychology call the theoretical orientation where the view of the provider as to why the symptoms developed, what maintains them, and how you're going to change those factors.

That's where the classes start to differ a little bit. They all involve some form of education. They all involve doctor-patient communication and a comfortable relationship. They all involve assessment of symptoms in context with the rest of people's lives. That happens regardless of class.

Then, when you start to look at why do you think the patient developed their symptoms and what's maintaining their symptoms, you start to see differences. For example, one class is self-management, and a lot of this is done from the nursing scientists, Margaret Heitkemper, Monica Jarrett; Gisela Ringstrom was on our working team report.

The self-management view of patients develop these symptoms because they don't have confidence, the support, or the understanding of why they're having them, and that creates behaviors that make it difficult for them to manage.

If you think that your patient has self-management deficiencies— they're not getting enough sleep, they're not eating properly, they're not exercising, they have minimal confidence, they don't know anybody else who has their condition—then that class might work really well.

If you look at a patient who has a lot of evidence of cognitive, and emotional, and fear, and describes their symptoms in a catastrophic way, or has a lot of avoidance behavior, then you might be looking more at symptoms develop as a result of learned experiences where cognitive behavior therapy might be where you want to teach the patients to de-pair connections that they've made. Within CDC there's a bunch of different options.

The other big one would be gut-directed hypnotherapy, which is this idea of bypassing the conscious mind that sets up a lot of barriers and defenses to improve symptoms, targeting arousal, bringing the patient into a relaxed state, and then making suggestions as to how they might improve.

Then there's mindfulness stress reduction. Everyone knows that that's a very effective class of treatment for chronic illness more broadly but does have some impact on the GI tract.

Then, lastly, but not least, is the psychodynamic interpersonal therapy where the belief in, again, this conceptualization of how do a patient's problems start and what maintains it, is more about interpersonal factors.

It's about maybe early childhood trauma. It's about relationship issues, or the feeling of not being believed, and that the way to change that would be through this more interpersonal therapist relationship approach.

You can see they all have similar elements. What makes them a separate class, just like a separate medication, is they have slightly different frameworks for why a person develops problems.

GLN:  The working group stated that the whole purpose here was to increase the confidence of gastrointestinal providers in identifying and referring appropriate candidates for these therapies and to support clinical decision making for the mental health professionals who are providing the therapy.

In your experience, do gastroenterologists generally find it challenging to bring the subject up with their patients, to identify which patients are going to benefit most? Is that part of the job of the gastrointestinal therapist?

Dr. Keefer:  That's a great question. I'd like to say it's getting easier with the language that we're offering. Look, there's so much history, so much stigma associated with these conditions that the providers are a little bit hesitant to imply that something may be in the brain. They're afraid of pushback from the patient who's going to think that they're dismissing them, invalidating them. A lot of times, physicians avoid those conversations when they're not exactly sure how they're going to be received.

What we're trying to do here is say, you don't have to avoid the conversation. You just need to ramp up the science behind how you're describing it. We do know, and the ACG guidelines came out suggesting brain-gut behavior therapies earlier on in care as part of the whole armamentarium of treatment classes. Brain-gut behavior therapies are right along with other types of treatment.

All of these pathways increase the confidence of the clinician to be able to bring it up. The best way to get a patient to get brain-gut behavior therapy is for the physician to refer. We psychologists can talk till we're blue in the face about the brain-gut connection, but if the patient's doctor says to them, "Hey, I think brain-gut behavior therapy is a treatment that you might want to add to a complement of other things that we're working on," the uptake, the receptivity is so much higher.

One thing that physicians and other GI, I say physicians, but any GI provider, the other thing that they tend to get afraid to do or don't have confidence in, is deciding which class. Physicians and other professionals are used to picking out which drug you're going to give to the patient and why, instead of just saying this whole class of drugs might work.

Being comfortable saying, "I don't know which of these brain-gut behavior therapists is going to be best for you. We're going to let the psychologist decide that, but there's several of them," is sufficient.

Just getting people out of the habit of feeling like, "I don't know whether hypnosis or CBT is appropriate, then I shouldn't say anything." We wanted to build that confidence that you can refer in the context of a strong relationship.

GLN:  With medication, sometimes there'll be an algorithm that shows that if these factors are in place, then this class of drugs is probably your best bet, and maybe this particular therapeutic is going to be best.

It's not as clear cut for the clinician to refer in terms of types of behavioral therapies. Again, as you said, they simply refer to the professionals who can do that.

Dr. Keefer:  Yeah. I would say that maybe as of now. Where the field is going—we were talking earlier, before the show, a little bit about the availability of these providers, of GI psychologists, and how do you improve access.

One way to improve it is to get algorithms that allow the GI providers, the medical providers, to be able to prescribe therapies. There's some digital therapeutics available that could offset the patients who don't necessarily need to meet with a GI psychologist because it's more straightforward, but we have to get those algorithms a little bit more thought out.

You don't want patients to have a bad experience with a brain-gut behavior therapy. You don't want to give them something and have them think you're telling them it's in their head, that you're giving them something that doesn't work for them, and then they write off the whole intervention.

In the future, 10 years from now, if you have me back, I may be talking about an algorithm to decide if and whether you prescribe cognitive behavior therapy, or mindfulness-based, or hypnosis, or what have you. That's an area that this working team report will drive some of the research on.

GLN:  Is this going to be a good application for telehealth, since there aren't as many GI psychologists as there are gastroenterologists, and because there are gastroenterologists practicing not in academic centers, but in smaller cities and towns where they don't have easy access to a therapist? Is this a promising field for the application of telehealth?

Dr. Keefer:  Yeah, absolutely. First of all, most of what we do, even hypnosis now, Peter Whorwell has a study showing that hypnosis over Skype was basically as good as hypnosis in person. He's pretty old-school around this, so that's pretty amazing.

Absolutely, access, licensure of GI psychologists, so being able to see somebody across...Now that there's COVID, I can see people all the way up in Albany, Buffalo, and Rochester, even though I'm in New York City. You can see people more frequently via telehealth.

I'm sure you're familiar with "GI OnDEMAND" which is trying to work on connecting those community gastroenterologists with these types of resources. Then, obviously the Rome GastroPsych group also has a membership.

They have a searchable directory to find a provider in your state, and with telemedicine, that has increased access. There's still not enough, but at least now you can see that academic gastropsych person even if you live 500 miles from where they practice due to telemedicine.

GLN:  Do you have any last thoughts that you'd like to pass on to those clinicians out there about approaching, identifying, and referring patients who might benefit from behavioral therapy?

Dr. Keefer:  I really recommend that you, as a GI provider, come up with a couple of elevator pitches or metaphors that you like to use related to what the brain-gut behavior therapy is and why you're referring.

In the heat of the moment, sometimes it's easier to just avoid, but if you have a couple of good examples and have mastered your language, because these terms don't roll off your tongue—"catastrophizing” and “acceptance-based.” Taking a few extra minutes to read through this report, go through and come up with an example or a phrase that you particularly like, and practice that routinely, that makes the referral all the more easy.

GLN:  Thank you for joining us today. This has been really interesting. I'm sure we're going to be checking back with you to see what's new in this very interesting field.

Dr. Keefer:  My pleasure. Thanks for having me, as always.

Reference:

Keefer L, Ballou SK, Drossman DK, Ringstrom G, Elsenbruch, Ljótsson B. A Rome Working Team report on brain-gut behavior therapies for disorders of gut-brain interaction. Gastroenterology. 2022;162(1); 300-325