Dr Brian Lacy and Dr Laurie Keefer On Gut-Directed Behavioral Therapy

In this podcast, Dr Brian Lacy and Dr Laurie Keefer discuss gut-directed behavioral therapies to improve gastrointestinal symptoms and quality of life issues related to disorders of gut-brain interaction.

Brian Lacy, MD, is a professor of medicine at the Mayo Clinic in Jacksonville, Florida. 
Laurie Keefer, PhD, is a gastrointensitnal health psychologist and professor of medicine at the Icahn School of Medicine at Mount Sinai, New York.

TRANSCRIPT:

Dr. Brian Lacy:  Welcome to this "Gastroenterology Learning Network" podcast. My name is Brian Lacy. I'm a professor of medicine at the Mayo Clinic in Jacksonville, Florida. I am absolutely delighted to be speaking today to Dr. Laurie Keefer, who is a professor of medicine and psychiatry, and a GI health psychologist at the Icahn School of Medicine at Mount Sinai in New York City.

Our topic today is one that is important for every provider regardless of specialty, "gut-directed behavioral therapy."

Laurie, thank you so much for joining this podcast today. Let's begin simply in order to set the stage for our listeners. Behavioral therapy is a broad umbrella term. What does this really encompass?

Dr. Laurie Keefer:  Thank you so much for inviting me to talk about this topic, because I think it is something that is really relevant to all providers. You're right. Behavior therapy is a broad term. What we're talking about today at least is the application of behavioral principles to GI disorders.

The two behavioral principles that serve as the core of these gut-directed behavior therapies that we're going to talk about, the principle of self-regulation and the principle of operant conditioning. Self-regulation, as you know, is the ability to be able to soothe yourself physically and emotionally during stress that can be positive or negative.

It's about that resilience, the ability to restore yourself, your body back to homeostasis as soon as possible. Then the other behavioral principle is operant conditioning, which is the pairing of stimuli that comes from the gut with brain emotions, such as fear or anxiety, which serve to amplify symptoms at the level of the brain.

When I think about behavioral therapy for GI disorders, those are the two tenants that we're referring to.

Dr. Lacy:  Great, thank you. I like that concept of resiliency not just for patients, but providers and getting back to homeostasis. Laurie, when we think about this, and we think about these techniques which I know you're going to discuss in detail, can you tell our listeners how they might work? Do these techniques work on the brain-gut access?

Dr. Keefer:  Yes, exactly. That's why we're calling them these gut-directed behavioral therapies for patients because the gut-brain access serves as the mechanistic basis for all of our behavioral interventions.

We are there to improve GI symptoms and GI-specific quality of life. We may or may not make improvements in mental health, depression, anxiety. These are targeted towards the gut-brain access. There's a couple ways in which we are pretty confident that this is what's happening.

First, we target the gut-to-brain pathway. That's when normal sensations that are coming from the gut are transmitted to the brain in a way that are perceived as painful or unpleasant.

Many of our DGBIs or disorders of gut-brain interaction have that feature, that visceral hypersensitivity, where something that maybe started out from an infection or an injury or inflammation is now perceived, the input going up to the brain is perceived as painful. Very common in post infection IBS, post infection dyspepsia.

We also see that in nausea and bloating. The normal sensations are experienced going from the gut to the brain in this hypersensitive way. Then there are the brain-to-gut pathways, the top down. Those are dysregulated as well in patients with disorders of gut-brain interaction.

That is that after that sensory input is received from the gut, the brain is doing things that process the symptoms in an emotional or a cognitive way, which is dysregulated and can amplify symptoms.

That's things like bringing in fear or anxiety, or we talk about catastrophizing of symptoms. That's another mechanism through which the brain and the gut can become dysregulated that behavior therapy is my target. Over time, both that gut-to-brain and that brain-to-gut pathway get overworked.

The longer you have these disorders of gut-brain interaction, the easier and easier it becomes to get those signals from the gut to the brain and the brain to the gut. If we could call that central sensitization, which now it doesn't even require a gut input for you to experience that same level of pain or discomfort.

Dr. Lacy:  I like that whole concept of thinking about the emotional aspect of our patients as we try to improve their quality of life and that concept of catastrophizing too, that everything is horrible. When we think about, let's take IBS as an example, and we think about some of our IBS patients, we know they have alterations in the hypothalamic pituitary adrenal axis.

We know that others again, IBS, as an example have changes in the autonomic nervous system, especially heightened sympathetic nervous system tone. Do you think that gut-directed behavioral therapies can influence these systems as well?

Dr. Keefer:  Yes, absolutely. This goes back to that self-regulatory component, that restoring homeostasis. The gut's enteric nervous system is obviously innervated by the autonomic nervous system.

I tell my patients, "You have to be more proactive than the average citizen about managing your stress and restoring homeostasis because you have this GI condition, and it doesn't take much to throw you off." Basically, when we think about autonomic nervous system arousal, with our patients, we want to limit the time that their bodies spend in fight or flight mode.

There's no adaptive reason anymore to be in fight or flight unless you are in a true emergency. Most of us do not have true emergencies on a day-to-day basis. We might be perceiving things as dangerous or threatening and spend time in fight or flight. It's not necessary or helpful.

We want to help our patients decrease the amount of time they spend in that fight-or-flight mode, that flipping the switch on and off all day with stressors and increase the time that they spend in the opposite of that, which is our parasympathetic nervous system, or what we call rest and digest.

The more time you spend in rest and digest, the more you're resting and digesting. The more your motility is going to be normalized, the less likely you are to experience that heightened arousal from pain or input coming from the gut.

Most of our brain, our behavioral therapies for GI disorders include some modification of arousal, whether that's a relaxation training, whether that's in-the-moment parasympathetic nervous system activation, so diaphragmatic breathing, which I know you're familiar with, or something that keeps the autonomic nervous system in balance throughout the day.

Those might be things like guided imagery, meditation. We're going to talk about hypnosis, all of those things are targeting that autonomic nervous system and HPA axis.

Dr. Lacy:  You just educated us in so many ways. For our listeners here today, that's a great phrase is maybe tell your patients, "We're going to try to get you away from that fight or flight. We're going to try to get you to the rest and digest." I like that already. Let's think now a little bit about CBT, or cognitive behavioral therapy.

I know that many patients and providers and our listeners are comfortable with the term CBT, but may not exactly know what it is. Could you give us a good definition of exactly what CBT is and how it's performed?

Dr. Keefer:  Yep, that's a great point. I see all the time, "Refer for CBT." I always wonder why. What was the reason for that referral? Cognitive Behavioral Therapy is a theoretical orientation.

A clinician who's trained in mental health will view people's problems, particularly their GI problems in this case, regardless of how they started as maintained by thoughts, feelings, and behaviors that have become maladaptive. Often in response to GI symptoms, it makes sense to avoid food or avoid travelling because you're afraid you're going to have diarrhea.

That's not adaptive, you can't live your life like that. That's not sustainable. People develop problems based on their reaction to their GI symptoms that interfere with their life. The CBT is that belief that you can unlearn some of these habits that you've developed in reaction to your symptoms and replace them with new behaviors that are going to make it a lot easier for you to cope.

That's the most important part. There are a lot of CBT techniques that you might find on an app, or you might find online in a self-help book, things like self-monitoring, challenging your thoughts. All of those are great CBT techniques. I do like to differentiate for the providers and for patients, that it's less about those techniques. Those are important ingredients.

What's the most important is this understanding that your GI symptoms are exacerbated now by learned behaviors that were maybe initially adaptive, but are no longer helpful and that CBT is going to help you relearn how to cope.

Dr. Keefer:  Great way to explain it to patients is, "Let's get you to unlearn maladaptive behaviors and learn new positive proactive behaviors."

Dr. Keefer:  Exactly right.

Dr. Lacy:  Great. Now that we know what CBT is, and what it really can do, can you give us an example or two, maybe some data from the literature about how CBT might be used to treat a GI disorder?

Dr. Keefer:  Yeah, absolutely. Of the behavioral therapies for DGBI, CBT is probably the most well tested. There's more than 30 randomized control trials, which is our gold standard supporting its use.

If we look at the highest-level evidence of systematic reviews and meta-analyses, CBT has demonstrated both immediate efficacy and symptom improvement in IBS, but also long term, so up to five years post treatment, and probably continued because, again, these are skills, not pills, as we say. That's true for IBS.

Then there have been other smaller randomized control trials that have also demonstrated efficacy for some of our other chronic painful conditions, noncardiac, chest pain, and functional dyspepsia. Even though it hasn't necessarily been tested across all of our disorders of gut-brain interaction, these are highly personalized therapies, because again, they're about unlearning maladaptive behaviors.

It doesn't matter so much to the GI health psychologist, whether you have dyspepsia or nausea, you have maladaptive behaviors, and our job is to teach those to you.

Interestingly, when you look at mechanisms—we're fancy now, in terms of our understanding of why CBT works for IBS—it's actually the change in avoidance behaviors. It's the change in the way that patients think about their symptoms, that seems to mediate the effects of CBT on IBS symptom severity.

As opposed to some people would say, "Oh, you're just treating the anxiety disorder, you're treating the stress problem." The mechanistic data is again, going back to that brain gut. I's affecting positively those exact behaviors that are amplifying symptoms at the level of the brain.

I would also mention that when we talk about CBT, obviously, the field has tried to figure out ways to deliver this faster, better, cheaper. It's now been tested across multiple forms of delivery, minimal therapist contact, telephone, online, even digital, delivered by nurses, delivered by mental health professionals.

Trying to figure out exactly how can we get the most number of patients to experience this type of beneficial therapy.

Dr. Lacy:  Wonderful. I know you get a lot of referrals from people in the New York City for CBT. Which patient or group of patients is most likely to respond to CBT?

Dr. Keefer:  I think that the patients that I would most likely recommend CBT for are those that have already bought in to the concept of gut-brain dysregulation, preferably, their GI doctor has referred them and to explain that their condition is a disorder of gut-brain interaction. It's important. I can't stress that enough.

That often leads to patients who have some inherent motivation to change their thoughts, feelings, and behaviors. People have to be able to acknowledge that the way they're thinking about something might not be that helpful. I tend to recommend CBT in patients who can make a clear connection between stress and their symptoms, or anxiety or fear and their symptoms.

People who say that they've always been on the anxious side, and now they're spending time worrying about their GI symptoms. Then people who report clear cut fear, or they're telling you that they're avoiding certain things in response to their symptoms.

Because again, CBT is going after those maladaptive responses that were maybe initially reactive to symptoms, but are no longer helpful.

Dr. Lacy:  Maybe just as importantly, Laurie, what patients should not be referred to CBT where it may not work or may not be beneficial, and it's just a waste of time?

Dr. Keefer:  Similarly, patients that have very limited insight into the brain aspect of their condition. They're overly fixated on what caused their GI symptoms, and what's going to take their GI symptoms away, as opposed to how they can learn to cope.

It's sort of that rigidity, or that inflexibility and thinking. Patients that have that style often find CBT unhelpful or even particularly frustrating, I think.

Dr. Lacy:  It's good point too for clinicians. Many patients are fixated on why this happened. Oftentimes, we just need to move beyond that. It happened. Water under the bridge, move on, let's deal with a proactive positive approach to unlearn those bad behaviors.

Let's think a little bit about hypnotherapy. I'm sure you've heard all the myths and misperceptions that exist about hypnotherapy. Can you just tell us a few of those myths and misperceptions to set us on the right path?

Dr. Keefer:  Yeah, exactly. The main ones are that I try to be upfront with is that gut-directed hypnotherapy is medical hypnosis. It's not a magic trick. It's not something that you're going to do in Las Vegas with your friends at a bachelor party. It is a skill and much like any of our other behavioral therapies.

I think that's important and it's important because many times patients will have undergone a hypnosis session and say, "I don't know if I was hypnotized. Is that really working?" Again, it is. It's not this magic experience that it sounds like it is.

The other myth that patients are skeptical about is that they're afraid to lose control. Being under a hypnotic trance, or in the hypnotic state means that they've given up control, that the therapist can do what they want. That is a myth as well as a fully voluntary state. Patients can stop in the middle and resume activities if they wanted to. That is probably the other important myth buster.

Dr. Lacy:  That's great to bring up because I think that may be some reason why some patients don't want to be referred because of that loss of control and many of these people are so hyper vigilant anyways.

Dr. Keefer:  Exactly.

Dr. Lacy:  When you get down to the basic science, and maybe we don't know, but how do you think hypnotherapy really works?

Dr. Keefer:  Look, hypnotherapy has been used...Basically, if you think of the hypnotic trance as a way of summoning the subconscious, we put patients into this very relaxed state, a highly focused state of awareness.

It decreases all of the thoughts and feelings and behaviors that would normally be defense mechanisms, that we would just throw up. I said, "Hey, Brian, your symptoms are getting better." I can just tell. You'd be like, "She's really quaky. Has she listened to anything I said?"

If I say that to you, when you're in this subconscious state, your brain is much more open to suggestion. We're able to bypass some of these thoughts, feelings and behaviors and perception symptoms that patients may have had for a long time in that hypnotic state.

What's the most key ingredient I tell patients the hypnotic state is like the IV going into your arm. It's the way we get the intervention to you. The real therapeutic part of hypnosis is what we call the "post-hypnotic suggestions," and those scientifically have been shown to be the critical link to why somebody's symptoms might improve.

In IBS for example, we are saying to the patient, once they're in the hypnotic trance, we are pushing that dose of medication through the IV, saying, "Your brain and your gut are normalizing. You're no longer experiencing pain to the same degree." We're targeting those particular symptoms.

If I were to say, "You're smart. People like you," and "You're a great colleague," that's not going to affect your GI tract. Scientifically we know that it's really important that the hypnosis is gut-directed. When you do that, then we see actual brain changes where you see normalization of things like that visceral hypersensitivity.

That input from the gut to the brain no longer registers at the same threshold. We see improvements in motility because the muscles relax, and things balance out. There's even been studies that have shown that you can alter acid exposure from hypnosis. There's definitely something physiological going on directly related to those key suggestions that the hypnotherapist is making.

Dr. Lacy:  Great explanation. Thank you. Similar to CBT, which disorders of brain-gut interaction is hypnotherapy best suited for, do you think?

Dr. Keefer:  That's a great question. Again, because we're really targeting the brain and the gut, theoretically, any of our DGBIs would be appropriate. There's the most evidence for IBS, of course. There's also evidence from randomized control trials and things like functional abdominal pain in pediatrics, dyspepsia, duodenal ulcers, noncardiac chest pains, even ulcerative colitis.

There's been some case reports for globus. We've done some work on PPI non-responders and reflux. Again, all a matter of customizing those suggestions to the patient's primary symptom.

Dr. Lacy:  Got it. Theoretically for most of these disorders of gut-brain interaction for the right patient, it should help.

Dr. Keefer:  Yeah.

Dr. Lacy:  Similar to CBT, which patient group do you think is most likely to respond and which are least likely to respond?

Dr. Keefer:  I tend to recommend hypnosis to patients who have overlapping DGBIs, for example. They maybe have a lot of symptoms that either fall into a specific IBS, functional dyspepsia or what have you, or they have several, or patients who might have extraintestinal manifestations.

They have IBS, but they also have low back pain or fatigue or difficulty sleeping so more of those sorts of somatic complaints, and maybe less evidence of that fear conditioning, or that avoidance behavior, or that anxiety. Post infection IBS, I often can get away with as few as four sessions.

If you're not seeing fear of symptoms, and catastrophizing, you're just reprogramming that sensory input from the gut to the brain. You would not want to recommend hypnotherapy in patients who have significant concerns about control, who are inflexible or not willing to let themselves relax.

Similar to that, that would include anybody with any significant trauma history, or any dissociative qualities about them, PTSD, borderline personality disorder, mania, psychosis, that type of thing.

Dr. Lacy:  Very helpful. Laurie, as we start to wind down, could you just briefly summarize psychodynamic interpersonal psychotherapy? Again, who might you use it for? What's the concept?

Dr. Keefer:  Yep, so the concept here is a little less known. It has been tested in some trials. It's offered by highly trained psychotherapists. This is not one that you would necessarily find in an app or a behavioral tool.

It's rooted in this belief that a strong trusting collaborative relationship with a therapist who understands you and validates your concerns is your primary vehicle of change.

This is best for patients who have those severe persistent symptoms, who've created almost an identity around their illness, and have had significant interpersonal difficulties, either with their providers or their people in their life, those patients for whom the symptoms are the primary focus of their life.

They're struggling interpersonally. It also can be effective if patients do have that abuse history or that high-trauma history, because again, it's that repairing of the relationship and the experience of symptoms. It is the key ingredient.

Dr. Lacy:  Wonderful. Laurie, I know that many of our listeners are now much more comfortable using what we call neuromodulators or tricyclic antidepressant or maybe an SSRI or an SNRI.

For many of these patients with these disorders of gut-brain interaction, is it one or the other? Do you only do CBT or only use a neuromodulator? Can we use both?

Dr. Keefer:  Part of integrated GI care, all of these therapies are compatible with each other. I think of them as augmentation. You might augment CBT with an SSRI in a patient who has a comorbid anxiety disorder, and needs CBT for their GI condition. You might give a tricyclic for someone that has a lot of visceral hypersensitivity and recommend hypnotherapy at the same time.

Sometimes patients need that chemical boost from the central neuromodulator in order to engage in these big asks that come with behavior change. Sometimes patients need that help being motivated or flexible enough to make the changes that they need to. Then we taper them off over time, once they've learned the skills.

Vice versa, you might start a patient who's benefiting from an SSRI and SNRI or TCA. Then say, "You know what? You're better, but you're not quite better. Let's add on a behavioral therapy," like you'd add on a diet, or you would add on antispasmodic. These problems of gut-brain interaction are multifactorial. We have to be open to throwing the kitchen sink in if we have to. [laughs]

Dr. Lacy:  I like that whole concept of layering. Some providers still say it's got to be either A or B, or C. Many of us now recognize it's probably a little bit of A and some of B and a little bit more of C, and this additive therapy, diet, behavioral therapy, medications maybe what's necessary.

Dr. Keefer:  That's exactly right.

Dr. Lacy:  Laurie, this has been an amazing discussion. You've educated me. I know you've educated our listeners. Any last comments for listeners today?

Dr. Keefer:  No, thank you for inviting me to talk about this. I'm excited in this GI world. We've made such great strides in recognizing the importance of integrated care. This is a model for hopefully other health conditions down the road, where you have that fully integrated care, treating patients in the context of their lives and not just their symptoms.

Dr. Lacy:  Once again, I'd like to thank Dr. Laurie Keefer, Professor of Medicine in Psychiatry at the Icahn School of Medicine at Mount Sinai in New York City. Thank you to our listeners for joining in today. We look forward to having you join in for another Gastroenterology Learning Network podcast. Best wishes.