Using Behavioral Medicine to Manage Psychological Issues Caused By GI Disorders

Podcast Transcript

Scott Steele: Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.

Hi, everybody. Welcome back to another episode of Butts & and Guts. I'm your host, Scott Steele, the Chairman of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio.

Today, we're very glad to have Dr. Judith Scheman who is the Director of Behavioral Medicine and a Clinical Professor of Medicine in Cleveland Clinic's Digestive Disease & Surgery Institute. Also, she works very closely in our department of colorectal surgery. Today, we're going to talk about the impact of IBD and GI disorders on mental health. Judith, thanks for joining us on Butts & Guts.

Judith Scheman: Thanks for inviting me.

Scott Steele: For our listeners out there, they know we always like to start with a little bit of background about you, where you're from, where did you train, and how did it come to the point that you're here at the Cleveland Clinic?

Judith Scheman: Well, I'm originally a New Yorker. I did my bachelor's degree at University of Washington in Seattle, where I thought I was going to stay, only I came to Kent State University to get my PhD in Clinical Psychology and Behavioral Medicine, fell in love with Cleveland, and stayed.

Scott Steele: Well, that's fantastic and we're so glad to have you here. Today, we're going to talk a little bit about the impact that conditions like inflammatory bowel disease, but really all other gastrointestinal disorders can have on a person's mental health. Something that we don't talk a whole lot about, and how behavioral medicine can help. For our listeners out there, give us a high level overview about behavioral medicine. What does that mean exactly, and how is that different from seeing a psychiatrist or something for depression? What does this all mean?

Judith Scheman: Behavioral medicine is part of the integrated approach to medical and surgical care. It's following the bio-psychosocial model, because we know that those factors that make us unique individuals actually turn out to be as important. Often, more important in terms of our ability to get better than what someone else does to us. When we're talking about the gut, we're talking about this exquisite connection that we have between our gut and our brain.

As a matter of fact, the gut, the enteric nervous system is often called the second brain. The reason why it's called the second brain is because it turns out that it's responsible primarily for our mood, like depression and anxiety. When we're talking about neurotransmitters responsible for those kinds of problems, depression, let's say serotonin, it turns out that about 90 to 95% of all of our serotonin is produced by our gut, not by our brain.

So when it comes to our mood, it turns out that there's actually this six-lane highway that goes from our gut to our brain, and only a one-lane road going down. The finding of the enteric nervous system is really relatively new, but one that I think that we would have discovered a whole lot sooner if we had paid attention to how we talk about our emotions, because, what are the words we use?

We use words like gut-wrenching. That just makes me sick. That's nauseating. I find that really hard to swallow, or a kick in the gut, butterflies in my stomach. I think that we use all of these gut-related terms because that's actually where the action is.

Scott Steele: Are you saying a little bit of that we are constructed this way, or is there something that we eat or some of the diseases that we have that can have an effect on this behavioral medicine and this system in terms of our emotions?

Judith Scheman: I think the answer to that is yes. I think that the arrow of causality is bidirectional. Let me explain that. For instance, when we have inflammatory bowel disease, what patients tell me is that when we're in the middle of a flare, those symptoms can be really stressful.

In addition to that, stress often makes symptoms worse. So if we try to treat one and we don't treat the other, we're likely to be less successful. In addition to that, when we take into consideration something like anxiety and stress, our body physiologically responds to stress in the fight-flight mode.

Now, fight-flight, back in the day, prepared our bodies to kill the saber tooth tiger, or run. In order to kill the tiger or run, blood is sent preferentially to our large muscles getting us ready to kill the tiger or run. That's a really highly adaptive response if there is a tiger. PS: there are no tigers.

When blood's going to our large muscles, it's not preferentially going to our gut or to our brain, because, let's think about it, that's not the time... When you're confronted with a tiger, that's not the time to say, "You know, tiger, could you come back because like I just ate and I need to digest my food." It's also not the time that we do our best thinking, because that's also not a time when you're going to say, "Huh, I wonder how big that tiger is. Is that the tiger that ate my neighbor?"

We don't digest our food well, we don't think well when we're under stress. Blood is not going to where it needs to go. It's also associated with delayed healing. In fact, if we've had a surgery related to our IBD or whatever kind of problem we might be having, well, delayed healing is not what we want. What studies have shown is that if people practice deep relaxation three to four times a day every day after a surgery, their surgical wounds actually heal significantly faster.

Scott Steele: That's such interesting stuff. Let's say, the naysayers out there, just having surgery or just being told a certain diagnosis can oftentimes create anxiety and stress. We know that anxiety and stress, as you said, can make medical problems worse, but is it true, something that makes it worse, or it's just the feeling that things are worse? You said that wounds can even not heal as well if somebody is under stress and having depression or something. Do we have any insight into why that's the case?

Judith Scheman: Yeah, we actually do. It turns out that stress produces pro-inflammatory cytokines. Those are agents that actually produce inflammation. The good news is, we know that, once again, deep relaxation actually blocks the production of those pro-inflammatory cytokines. In addition to that, when we're under stress, it doesn't do great things to our immune system either. Using, once again, relaxation, that helps boost our immune system.

Scott Steele: Dr. Scheman, let's say that I have inflammatory bowel disease or another one of these GI conditions, and I get referred to you. First of all, how do I get referred to you? Second of all, walk me through what a patient can expect when they have a meeting with you.

Judith Scheman: Well, patients get referred to me in a number of ways. I'll see patients prior to any surgery because surgery can be really stressful. In addition, I also help people with teaching them ways that they can manage their own pain, and that gives people agency to help themselves. So they'll see me if they're going to have a surgery, and the surgeon can refer me. I also see patients with other GI problems such as irritable bowel and also some functional swallowing problems.

Patients get referred to me because they can either be referred directly to me, and they can also come in with a referral from the physician for DDSI behavioral medicine.

Scott Steele: If a patient comes into your office, walk me through that visit, and what can they expect to do?

Judith Scheman: Before I actually see the patient, I take the opportunity to thoroughly review their medical records, because what I want to know is not just what they're coming in to see me for, but also what other sorts of problems they may have going on in their lives as well.

Is this somebody who not only has inflammatory bowel disease, but also has fibromyalgia, and sleep problems and chronic headache, et cetera? I'll review their chart, and then I'll just get to know people and find out what their issues are. What are their biggest concerns? What have they tried to do to help with these issues? What's helped, what hasn't helped, and what might we be able to add?

Sometimes, it's just one visit, and sometimes it's a few visits if we've identified something that they think might be valuable to work on.

Scott Steele: So a lot of people when they hear about behavioral health, they think they're going to walk in and be laying down in a couch and they're going to be talking about their past history, and their parents, and all these other things. What do you do during that visit? What do you talk about?
Let's discuss some of the different treatment options such as relaxation therapy and cognitive behavioral therapy and biofeedback. What do all those terms mean?

Judith Scheman: That's an important question. One of the first things I do is, I make the distinction between behavioral health, which is the department of psychiatry and psychology here, and behavioral medicine, because what I do is focus primarily on their medical problems. Now, cognitive behavioral therapy is just about examining, "What are our thoughts and what are our behaviors, and how do those contribute to helping us get better faster, and how might they contribute to actually making us sicker?" For instance, there's catastrophizing. Sometimes patients will come in and they will say, "I have this pain, and because I have this pain, I have to stay off of work. And if I stay off of work, I'm going to lose my job. If I lose my job, I'm going to lose my house. My spouse is going to leave me. My life is going to be destroyed and I'm going to die under the High Level Bridge in a box in a snowstorm." They do that all within 30 or 60 seconds.

That's an exaggeration of what catastrophizing is, but the fact is, is that people who catastrophize about their medical problems or about their pain actually have a much harder time recovering. That's the bad news. The good news is, if we examine those thoughts, see if they're realistic, see if maybe you're kind of jumping the gun, see if there are things that we can do and that you can do to change the behaviors that are going to turn around that entire situation.

Scott Steele: What about relaxation therapy and biofeedback?

Judith Scheman: Biofeedback is a technique where we might hook somebody up to a piece of equipment, like measuring hand temperature using just a thermometer, a digital thermometer that you can buy on the internet. It will measure, let's say, your hand temperature, and then you can notice that when you're under stress, that maybe perhaps your hand temperature drops, because, remember, the blood is going to the large muscles, the capillaries are constricting, so your fingers get cold.

But by using relaxation as well as the feedback from that thermometer, you can learn what, first of all, is causing that stressful response, and then how to undo it. There are other biofeedback techniques that you might need to go see somebody who specializes in biofeedback and has their equipment in the office.

It might be galvanic skin response, it might be muscle tension. What you can do, what I've done in the past is to hook people up to biofeedback equipment, and then talk to them about things that they may not have even realized were stressful in their lives. However, when you're using the biofeedback and you start discussing maybe stresses at home, or at work, or whatever, and you can watch the muscle tension go up in somebody's back or their neck, and then you say, "Okay, well, this is how your body is responding, how can we undo that?"

Scott Steele: Many people may not understand your role in the multidisciplinary team. So when you get referred to a patient either before surgery, or after surgery, or as an inpatient, tell us about how you interact within that team to make sure that the patient has optimal results.

Judith Scheman: Well, I get the opportunity, actually the privilege of spending a great deal of time with my patients. Often, they'll talk to me about things that can be very important in terms of their recovery.

For instance, when I asked people, "How have you learned to deal with this disease?" They'll say, "Well, frankly, I've been drinking more," and, "I'm actually up to five or six drinks every night and more on weekends." Well, that can be important in terms of recovery if we're going to operate on this person and we may want to see if they can wean down from the alcohol, or just make sure after surgery that they're okay. I also ask patients about their use of opioids and benzodiazepines and I get a sense of how many they're actually taking, because those prescriptions are often written on an as-needed basis, and the patient and I will talk about, "Well, how many are you actually swallowing?"

If I'm seeing a patient prior to surgery and there's enough of a lead time, I'll explain to them the importance of possibly weaning down from or off of their opioids and benzodiazepines prior to surgery because that will make for an easier recovery. Working alongside with the surgeon and other healthcare providers, having a heads-up that this is how somebody is going to be going into surgery, or possibly there are medications that they can prescribe prior to surgery, that will be additionally helpful, particularly if we're dealing with anxiety.

Scott Steele: Judith, I've had the personal experience of being able to see the fruit of your work and how much it's really helped out my personal patients and patients within DDSI. There's no question you have a passion for this. What do you enjoy most about helping these patients who are a part of this program?

Judith Scheman: I really love watching people get better. It matters a great deal to me to help smooth out people's recovery from surgery and help them manage things on their own. When we get done talking, patients have an understanding of things that they can do to help themselves get better. I'm also part of a very fabulous team, and what I tell patients is that we're all here to help you. We work together as a team, and that as part of that team, if I can be of any assistance at all after surgery or postoperatively, that they're always welcome to come back.

Scott Steele: That's fantastic. Now, it's time for our quick hitters where we get to know our guests a little bit better. Judith, what is your favorite sport?

Judith Scheman: Well, if binge-watching Netflix doesn't count as a sport, then I would have to say hiking in the mountains.

Scott Steele: What's your favorite meal?

Judith Scheman: It's a toss-up between ribs and lobster.

Scott Steele: What's the favorite place that you've traveled to?

Judith Scheman: I'd have to say Provence.

Scott Steele: What is the last non-medical book that you've read?

Judith Scheman: The Bonesetter's Daughter by Amy Tan.

Scott Steele: I'll have to look that up. You live here in Cleveland, tell our listeners one of the things you like about Northeast Ohio here in Cleveland.

Judith Scheman: I love the Cleveland Orchestra. They're amazing.

Scott Steele: Yeah. Amen to that. Judith, final take-home messages for our listeners, and even a final take-home for the naysayers out there who may say, "Ugh, I don't know about all this stuff." What do you have to say to them?

Judith Scheman: What I would say is that there really is this indisputable connection, exquisite connection between our brain and our gut. I always talk about brain rather than mind, because frankly, I'm not really sure what mind is, but I've a pretty good idea what the brain is. What I would say to the naysayers is, look up enteric nervous system. Look up microbiome. It's really, really fascinating stuff.

Scott Steele: For more information on Cleveland Clinic's Behavioral Medicine program, please visit clevelandclinic.org/behavioralmedicine. That's clevelandclinic.org/behavioralmedicine. To speak with a specialist in the behavioral medicine program, please call (216) 445-9552. That's (216) 445-9552.

Dr. Scheman, thanks so much for joining us on Butts & Guts.

Judith Scheman: Dr. Steele, thanks so much for inviting me.

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