Psychological Effects of GI Disorders

Podcast Transcript

Dr. Scott Steele: Butts and Guts, a Cleveland Clinic Podcast, exploring your digestive and surgical health from end to end. Hi again everyone, and welcome to another episode of Butts and Guts. I'm your host, Dr. Scott Steele, the chair of colorectal surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. And today I'm very pleased to have our expert, Dr. Madison Simons here, who is a GI psychologist in the Department of Gastroenterology, Hepatology, and Nutrition here at the Cleveland Clinic. Madison, welcome to Butts N' Guts.

Dr. Madison Simons: Thank you so much for having me.

Dr. Scott Steele: So as all our listeners know out there, we always like to start out with the overview of you. Tell us a little bit about yourself. Where were you born, where did you train, and how did you come to come to the point that you're here at the Cleveland Clinic?

Dr. Madison Simons: I was born in West Michigan in Grand Rapids, went to undergrad at University of Michigan, and then applied for a graduate school in psychology. I did my doctorate at Regent University in Virginia Beach, and they're specialized in health psychology. But it was there that I was introduced to the field of nutritional psychology, how our nutrients affect mental and physical health. And I thought with that I might do weight management or something of that sort, management of chronic illness. So I did a pre-doctoral internship in health psychology at Jesse Brown VA in downtown Chicago and was introduced to the of the field of GI psychology.

I had the fortune of training under Dr. Tiffany Taft and John Pandolfino at Northwestern University and did a two-year postdoctoral fellowship in GI psychology specifically. And there we were studying the role of hypervigilance to physical sensation and symptoms specific anxiety in the esophagus, and how those played out with a person's symptom severity.

My particular interest in nutrition have been a mesh with psychology then in GI. And so a lot of my work now clinically focuses on the relationship between mental health, nutrition, and gastroenterology. And so I was brought to Cleveland Clinic to then build a behavioral medicine program in our motility clinics.

Dr. Scott Steele: That's a tremendous amount of training. I hope today you can tell me what those Sour Patch Kids do for my attitude. So today we're going to talk a little bit about the psychological effects of GI disorders. And so to start, can you share a little about your role within that multidisciplinary team on the GI team?

Dr. Madison Simons: I specialize in treating motility disorders, and within that I bridge two different clinics. I spend the majority of my time in our gastroparesis center where we have a multidisciplinary clinic involving a physician, surgeon, and myself, and really provide collaborative care for patients, that when they come for their initial visit, they're doing their testing and they're meeting with all three of us, one right after another, so that we recognize that we're not treating just a stomach on its own; we're treating a whole person. That team-based approach works well for patients that we can care for every part of their experience.

I also see patients with a broad range of disorders of gut-brain interaction that affect the esophagus all the way down to the rectum, and so see all organs of the GI tract.

Dr. Scott Steele: Many of our listeners may be out there kind of familiar with the idea you got a couch and a psychiatrist or psychologist. How does your specialty, that GI psychologist, differ from the general psychologist that people may be more familiar with?

Dr. Madison Simons: Yeah, absolutely. As a GI psychologist, I focus mostly on where your GI symptoms are the primary source of your distress as opposed to treating a person's underlying anxiety, depression, or other mental health conditions. I'm specifically focused at the ways that your GI symptoms affect your quality of life, and that other elements of your life affect your GI tract.

Dr. Scott Steele: Let's dig into it a little bit more. Why do patients with GI conditions often experience psychological challenges?

Dr. Madison Simons: Many of the patients that I see are receiving increased input from their GI tract to their brain, whether that's related to an organic pathology or it's related to increased nerve communication coming out of the gut. When the brain is receiving more input from a particular area of the body, it's the natural response for the brain to start to pay attention to that area more. We use the term their hypervigilance to physical sensation.

When my brain starts to monitor that area of the body more, I can develop anxiety about what's causing that or what might be the result of that, what's going to be the future of these symptoms. We use the term there symptom anxiety for it. And our research has consistently shown that across areas of the GI tract, hypervigilance to physical sensation and symptoms specific anxiety are some of the biggest predictors of a person's symptom severity. And so my role really comes in in how can I help you decrease anxiety about symptoms by creating more flexibility. And then can we help your brain decrease the sense of monitoring that it does around your GI organs?

Dr. Scott Steele: Now I'm very much hoping that you tell me that hangry is a real term, but what are some of the more common symptoms that you help patients with? You mentioned anxiety and everything, but what are some of the more common ones?

Dr. Madison Simons: There are three main areas that I in particular help work with patients. One is when we're getting that increased communication out of the gut, we use the term visceral sensitivity to describe this. We might use strategies like gut directed hypnotherapy to try to turn down the volume signal on those nerve communications coming from the gut.

I also work to help people reduce the distress associated with symptoms. So we're going to help you reengage in life around what's happening to you and pursue those activities that are valuable to you.

And lastly, I help people the most probably with food-related anxiety. When we have severe symptoms after eating, it's natural for our brain to have a very fear-based response to the act of food and eating. And so we're working with the brain to help create positive experiences and safety and security around food.

Dr. Scott Steele: That's fantastic. If I'm listening at home, how do I tell that it might be important for me to reach out to a GI psychologist like yourself?

Dr. Madison Simons: I would say I'm the most helpful for people when your GI symptoms are the biggest source of distress that you experience. But even in that case, our work is going to be the most effective if your mental health is otherwise stabilized. And so that might mean that you're working with a general therapist alongside of myself, or seeing a psychiatrist as well. But if you're seeking to treat your regular anxiety and depression, working with a general therapist is going to be the way to go. When GI symptoms are your primary source of distress, that's when I come in.

Dr. Scott Steele: You mentioned a little bit ago about this gut-brain connection. Can you share a little bit more about that?

Dr. Madison Simons: Yeah, absolutely. Your gut is constantly sending signals up to your brain as to how digestion is working and communicating with you signals like hunger or pain or the need to poop, and your brain is responding to that in equal parts. And so we can end up with these disorders of gut-brain interaction where really the signals coming from the gut are maybe no longer accurate and my brain cannot perceive anymore what the correct behavioral response is.

For some people, hunger is a sensation we all know. If I feel hungry, I might eat, and that's the appropriate behavioral response. In a disorder of gut-brain interaction, I may feel nausea or I may feel pain instead of hunger. And if I feel nauseous, I may not be inclined to eat. I may be inclined not to eat at all or to eat different foods. My symptoms might get worse because I've not responded behaviorally in a correct way. So the characteristics of a disorder of gut-brain interaction is that I am not always receiving accurate signals from my brain, and therefore I cannot respond correctly to those.

Dr. Scott Steele: Truth or myth. Truth or myth, certain GI conditions can trigger the body's fight or flight response which can exacerbate a patient's GI symptoms?

Dr. Madison Simons: Absolutely. Anytime your brain or body perceives a sense of threat, it can activate that fight or flight mechanism. When our body goes into this state of sympathetic arousal, the body deprioritizes digestion. It is just not important to digest your lunch if a lion has walked through our door today. So the body's going to go through natural processes. It might slow motility down, it might rapidly evacuate your bowels, you might feel nauseous or indigestion, or you may even vomit just on a product of being in that state of high arousal, and your GI symptoms can put your body into that position.

Dr. Scott Steele: So, you've diagnosed me with this, I have it. Now it's time to treat or work with some therapy. Are there pharmaceutical options? Did dietary changes help? Walk me through some of the treatments.

Dr. Madison Simons: Absolutely. If you have one of these conditions, we're probably going to take a multidisciplinary approach to your symptoms. It may involve medication, and here we're thinking about a spectrum of medication. Your physician is probably working with you on medication that treats the peripheral organs themselves, so a medication that might help your colon work better, your stomach work better.

But then we also have medications that address these symptoms from the top down or your central nervous system. We use the category there of neuromodulators. These are medications that have an impact on the brain-gut connection, and they're typically things that like antidepressants or atypical antipsychotics that actually have an effect on GI symptoms. We're using them for that purpose, not for their mental health purpose.

Alongside of that, we might use brain-gut behavior therapies, which fall into two main evidence-based categories, gut directed hypnotherapy and cognitive behavioral therapy, where we're addressing the symptoms themselves and the way that symptoms have affected your quality of life.

Beyond that, we probably will bring in a dietician, especially if your relationship with food has been affected. There might be specific dietary changes that we can make that would improve your quality of life.

Dr. Scott Steele: I'm sitting at home in Minocqua, Wisconsin where I was born, and I say, "That's great that Cleveland Clinic has GI psychologists, but we don't have them here." Are there any home treatments or any other practices they can try on their own to help with these symptoms?

Dr. Madison Simons: There are digital therapeutics that patients have access to that provide things like gut-directed hypnotherapy or cognitive behavioral therapy, and those are options. Many psychologists have the ability to see patients across state borders also, and so that may be an option to work with a psychologist even outside of your state. In addition, any small things that you can do to help cool your nervous system down and put your body into more of a parasympathetic state of relaxation, like gentle movement, spending time with loved ones, engaging in activities that are meaningful to you, all of those things are going to help your gut also.

Dr. Scott Steele: Fantastic. Petting my dog. Are there any advancements or new treatments on the horizon when it comes to helping patients address the psychological effects of GI disorders?

Dr. Madison Simons: Right now, we're piloting a virtual reality program for irritable bowel syndrome in partnership with Cedars-Sinai. And that's one of the big directions that IBS treatment is moving in, is to use other technologies to bring the treatments that we know work to more patients.

Dr. Scott Steele: Fantastic. So now it's time for our quick hitters, a chance to get to know our experts a little bit better. So first of all, what's your favorite food?

Dr. Madison Simons: My favorite food, my husband makes the best chocolate chip cookies I have ever had, so that would come at the top of the list.

Dr. Scott Steele: Fantastic. What was your first car?

Dr. Madison Simons: My first car, a black Toyota Matrix.

Dr. Scott Steele: Don't even know. I'm going to have to look that one up. Tell me about a trip that you had that sticks out in your mind, or maybe a place that you want to go.

Dr. Madison Simons: My favorite vacations have always been to the Outer Banks and spending time with family on the beach.

Dr. Scott Steele: And finally, look back to when you were a young girl. What did you think you were going to grow up to be?

Dr. Madison Simons: I don't know what I thought I was going to be at that point. I thought maybe a doctor at first, but this is a good periphery to that.

Dr. Scott Steele: That's fantastic. Why don't you give us a final take home message to our listeners regarding this whole concept of gut-brain and the psychological effects of GI disorders.

Dr. Madison Simons: It's very normal for your GI symptoms to have a devastating effect on your quality of life. I think the first place is just being aware of that impact that it's had on you and asking for help. There are people out there that can help you. But it's normal and expected that you go through part of this, and we can help your brain work around it.

Dr. Scott Steele: Great advice. To learn more or schedule an appointment with the gastroenterology team at Cleveland Clinic, please call the Digestive Disease Institute at 216.444.7000. That's 216.444.7000. You can also visit our website at clevelandclinic.org/digestive. That's clevelandclinic.org/digestive. Dr. Simons, thanks so much for joining us on Butts and Guts.

Dr. Madison Simons: Thank you for having me.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.