Helping Patients Manage COVID-19-Induced Stress

Podcast Transcript

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

Hi everyone. Welcome again to Butts & Guts. I'm your host, Scott Steele, the Chairman of Colorectal Surgery here at Cleveland Clinic in beautiful Cleveland, Ohio. And today I'm very pleased to have Dr. Stephen Lupe who's a clinical health psychologist and associate staff for the Department of Gastroenterology within DDSI [Digestive Disease & Surgery Institute]. He's also an assistant professor of medicine at the Cleveland Clinic Lerner College of Medicine at Case Western Reserve University.

And today we're going to focus specifically on this entire process that maybe doesn't get as much press, and that's helping patients manage during this time of a pandemic with COVID-19 induced stress. Stephen, thanks so much for joining us at Butts & Guts.

Stephen Lupe: Hey, happy to be here.

Scott Steele: As a little bit of background, could you first tell us a little bit about yourself, where you're from? Where did you train and how did come to the point that you're here at the Cleveland Clinic?

Stephen Lupe: Sure. I grew up in Toledo, Ohio, and gradually made my way south, did my undergraduate education in Missouri at Central Missouri State University then became a paramedic for 10 years actually, took a break from school and at the end to being a paramedic, I got really into trying to understand the lifestyle behavioral aspects of health. I'd see patients all the time who were taking their medication and doing the right thing from a medical standpoint, then you go look in their pantry and their pantry was stocked with Oreos and there was Coca-Cola and the cigarettes. And I really wanted to help people change that part of it and improve health. So I went back to graduate school at the Florida Institute of Technology and got my doctorate in clinical psychology, and did my internship at the University of Florida Health Center. And then my postdoc in clinical health psychology at the University of Florida Health Center.

And I got into working with particularly pain patients, patients who had chronic pain and condition. And all of our patients with inflammatory bowel disease were referred down into our pain clinic to work on the pain aspects. So I started doing some work there with patients who had chronic gastrointestinal diseases that they couldn't manage the discomfort and ended up here at the Cleveland Clinic. It's actually my first job post doc at Cleveland Clinic.

Scott Steele: Well, we're really pleased to have you here and I should set the tone for what we're going to talk about today and I think we all understand that coronavirus has disrupted many of our listeners daily lives. It's uncertain, stressful times, for a lot of people. And I guess my goal today is hoping that we'll provide listeners with a little bit of ways that they can manage and cope their stress. And I should start off by saying thank you to all the listeners who are not only working in health care, but all of their communities and helping out those in need. And as COVID-19 continues to evolve, I just would like to remind all of listeners that the Cleveland Clinic facilities and emergency departments, we're open, we're committing to keeping our patients safe, both with mental health and physical health and all of your needs, and having our hospitals be amongst the safest places in the world to go to get your treatment. So let's dive into it with that as the canvas, if you will, what are the stages of stress?

Stephen Lupe: I just helped co-author an article where we came to discuss this in relation to COVID-19. So when we look at stress, when we look at the traditional idea of stress, there's three stages that came out of what was the founder of the idea of stress on Hans Selye's research. There was alarm, resistance and exhaustion. So alarm, his initial phase, he got this from doing some experiments on some animals. He was a physician and physiologist and realized that when animals were exposed to some noxious stimuli, they went through these stages. Alarm is the fight or flight response. So that's the body's sympathetic, the gas pedal, kind of like getting you ready to either fight, flight, or freeze. And it dumps a whole bunch of chemicals and gets our body ready for that. Resistance is after that our body, when the stressor doesn't go away, our body adapts to it for a while. It is able to cope with the stressor, it's pretty adaptive.

But then if the stressor doesn't go away after that, and the body eventually loses its ability to cope and starts to break down and that's the exhaustion phase. So he saw that in animals and we see it in humans too, to some extent, but then on top of that with humans, we also got to take in the cognitive pieces and there's some pieces because we're thinking organism, complicate that a little more beyond that because we have the ability to plan and judge come up with coping mechanisms. But those are generally thought of as the stages of stress.

Scott Steele: So as we take stress and especially in these times, how can stress affect a person's digestive issues or otherwise health in general?

Stephen Lupe: It's really interesting when we look at human beings and the connection between the brain in the gut and how our gut responds to stress, they're hard wired together, the brain and the gut. And actually some people would argue our gut experiences emotions before the brain. They're hard wired together and, like I said, the sympathetic and parasympathetic nervous system, that's called the brain-gut axis. And now it's actually being extended to be called the brain-gut microbial axis. But what goes on is, because they're hard wired together, when that sympathetic nervous system starts going in the alarm phase, it starts to change the way the gut functions.

So that set up to direct blood away to the major organs when something bad is going on a major stressor. And when that happens, the upper gut starts delaying the gastric emptying. We see the gut motility start to slow down in the colon, speeds up the motility. And so you can see that it actually changes physical functioning. But beyond that, we also know then that with pain and the uncomfortable sensations, stress amplifies them. So stress kind of like is dumping gasoline on some of the fires for some of our patients who have gastrointestinal disorders, it ups pain, it exacerbates everything that's there.

Scott Steele: So truth or myth, stress can cause digestive issues (a) like ulcers and (b) can stress cause IBD?

Stephen Lupe: Common myth. Let's start with the inflammatory bowel disease. When we talk about stress and inflammatory bowel disease, we know that stress exacerbates it. Like I said, when I talk to my patients, I'm very clear. I don't want anybody to have the message that this is all in your head. Stress really is, like I said, dumping kind of like gasoline on the fire. It does not cause gastrointestinal disorders, but it does exacerbate them. We're not actually really clear on the exact cause of inflammatory bowel disease. We know it's a big combination of environmental and immune factors that come together and lead to this. But when I start explaining it to patients, it's like, there's lots of factors out there. And stress is one of those factors and it's a factor we have some control over. So we tend to spend a lot of time working on it.

Because like I said, we know what exacerbates the symptoms, it can lead to other mental health problems and that makes it much harder to cope with a lot of the symptoms. And if you look at something like an ulcer or inflammatory bowel disease or any of the gastrointestinal disorders, we know that they can be very hard to live with. And if you have a bunch of stress and then that makes it much more difficult. Like when I talked to my patients, I can make the jokes. Sometimes I go, "Is it easier to have all your symptoms and pain when you're sitting on the beach relaxing or when you've got a thousand things going on and you're under a lot of stress?" And they all laugh and say, "The beach because we know that it's just much easier to cope with them when we reduce stress." But it does not. It is not the specific cause of gastrointestinal disorders.

Scott Steele: So when you talk about patients or the public in general, in terms of, how do you manage and cope with these times? I mean, what are some techniques that can help patients and again, public in general with just managing during these stressful times?

Stephen Lupe: And this is something I spend a lot of time talking to people about because it is stressful right now. And we look for the simple things we can do. So one of the things I talk to people about a lot of, what are the factors that we actually have control over? Well, we all have this problem solving mind and it can tell us stories and it sets up between news and talks all day. But when we look at things, what are the things we actually have control over? So we'll work on even little things like turning off the news and not watching the news 24/7 even though we want to know what's going on and that's our mind looking for information so we can plan and make some choices, spending time with the people we love.

That's something we've got some control over and it tends to be very helpful. Doing exercise, making sure we're being physically active, even though that's hard in times of stress, we know it's very useful. And then, like I said, engaging the parasympathetic nervous system, we can do that pretty easily. That's the braking system through some breathing techniques. So making sure we're doing good diaphragmatic breathing, taking some time to actually, when we breathe, poke out, make sure the belly comes out. When I'm working with kiddos, I teach them to inflate the beach ball and then breathe out all the way and taking some time for that. Mindfulness meditation has been shown to be pretty helpful with this. So there's lots of things we can do that are pretty simple to help in, especially that first the alarm stage. So the alarm stage, we're trying to bring down the sympathetic nervous system and activate the parasympathetic.

So that's the calming systems. So it's controlling the environment in doing some diaphragmatic breathing, relaxation, and then the resistance phase going to doing some things to try to normalize everything that's going on. So maybe some mindfulness meditation, more relaxation, spending time with family and friends. And we've got to modify some of this right now because of COVID. It's easy to say, "Go spend time with family and friends." I work with patients who a lot of times are, "How can we do that and be socially distant and wear our masks and be safe. Are we doing FaceTime calls with our family and friends or are we doing it outside on a patio where we sit on one end and the other people said the other end?" But doing these things tend to help a lot with the stress that goes along with something like COVID or any other stressors that are happening in the environment.

Scott Steele: So one of the hardest things that people sometimes have to do is admit that they're stressed for whatever reason. And then to seek out treatment where some of the techniques that you just talked about, maybe they don't implement them or they don't work as well. And so let's just say that they have a visit to Cleveland Clinic's Behavioral Medicine Program. What could a patient expect just in a rough overview during that time?

Stephen Lupe: So we're a little different at Cleveland Clinic. We have psycho-gastroenterologists who are integrated into the care. So I am right there with all the physicians. And that's nice because when a patient comes in, any of the physicians they can see him and that could be a colorectal surgeon, or it could be a gastroenterologist treating IBS, or gastroenterologists treating someone for inflammatory bowel disease condition. If they see something that signals to them, that behavioral health could be helpful. I'm right there. And they can make a referral over to me. If someone gets referred to me, usually they'll get contacted by me first and I introduce myself. When they come in for the first visit, I introduce myself, go over what I do, who I am.

And then we really spend a lot of time. I want to understand what that patient has been through. What's going on with them, what they've tried so far, what they've done as far as treatment and then we start working on looking at exactly what we're talking about. How much are you exercising? What is your sleep look like? What does diet look like? What are you doing to manage stress? Are there any stressors going on right now that are pushing over the edge and really trying to provide them the support, but then also figuring out, are there things in this picture of what's going on with this whole human being that we can change and help with?

And then I work with that person to figure out what interventions might work. There's a whole toolbox full of interventions. Like I was saying, relaxation, mindfulness, cognitive behavioral therapy. So working with the thoughts, increasing behavioral things, so exercise, and we've got to work with that patient to understand how that fits in their life and which things they could do that'll be helpful for them.

And so that's what that first is about. Then I'll usually work with someone between two and six visits depending on the person, to figure out let's start implementing some of these things and seeing how they're working your life and what they're doing to symptoms, what they're doing distress. And it's kind of nice being an embedded psychologist because I never really go away. I may work with someone and we may get stress under control. And let's say six months from now, something else pops up. They can call me back and go, Dr. Lupe I'd really like a follow-up visit with you and we can start working on whatever's going on in this moment.

And on top of that, it helps to understand what's going on with the patient overall, I do a lot of talking to patients about what's going on with them affecting their life? And that really gives us a good picture of what's going on with this patient and why there may be other things that are contributing to disease processes going on? So psychosocial factors, but does the person have any social support? Are they able to make the changes? Are they being adherent to what the physician's prescribing to them? And we work on all these things to make sure that the patient's taken care of the best we can.

Scott Steele: One of the things that I was struck by was the fact that nowhere in your first set of what you went to was, "I am going to give you medications to deal with all of this stuff." That a lot of this stuff has to deal with, working on the thoughts, working on the mindfulness, working on techniques to be able to relax and to incorporate all that.

Stephen Lupe: Yeah absolutely. Like I tell my patients from the beginning, my goal is always that we learn a technique or learn a skill so you won't need me eventually. So it is definitely working on skills and lifestyle interventions. That's not to say there's not a place for medications. I work very closely with the physicians I work with and sometimes we do talk about medications, especially for modulating some of the ways that neuro-transmitters affect the gut.

The more research we do, the more we find out that the neurotransmitters that we think of in their brain, actually affect the gut and they control a lot of the functioning of the gut. And so, sometimes we'll use a medication for controlling some of that along with the benefits that gets to anxiety reduction, pressure reduction. Some of that does make it much easier for the patients I work with to do some of these lifestyle interventions as well. So there is a place for medication, but you're right. Mostly what we worked on is skills and interventions as far as lifestyle.

Scott Steele: And I think it's important to say that during this time we just talked about what to expect during a visit. It is very important to go to the doctor's office or hospitals for standard appointments and preventative screenings, taking care of yourself or critical issues. And if that is not a comfort level that you're out there and you're listening with, we absolutely do have virtual visit options that are open as well. So some great, helpful yips.

We always like to end up with some quick hitters with our guests and learn a little bit more about you. So first of all, what's your favorite food right now?

Stephen Lupe: Right now it's stir fry, I've been eating a lot of vegetables stir fried.

Scott Steele: Fantastic. What's your favorite sport?

Stephen Lupe: My favorite sport is baseball.

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

Stephen Lupe: The last nonmedical book I read was actually Born to Run.

Scott Steele: That's a great book. It's actually one of my favorite books of all time and it's... Caballo Blanco, I love it. And then you said he spent a lot of time in Florida, but what's something that you'd like about living here in the great city of Cleveland?

Stephen Lupe: I missed the seasons incredibly when I was in Florida. Florida was great for the first five years. It was summer for the first five years, but then I started missing the seasons and the leaves changing, and it actually being cool. So I very much love the seasons in Northeast Ohio.

Scott Steele: So give us a final take home message for our listeners out there regarding stress and coping mechanisms and just sums this all up.

Stephen Lupe: Sure. I think the biggest take home message that I try to drive with everybody is stress is a part of life. It's what happens. Life is stressful and there are things we can do to help with that. And especially when we talk about patients with gastrointestinal disorders, stress, like I said, is not the cause of any of this, but it is a very big contributing factor to the distress that comes along with having being diagnosed and treating a gastrointestinal disorder, make sure that you're talking to your providers, telling them what's going on because a lot of times providers will have someone like me or know of someone like me.

We do get referrals from even outside systems to me to help with some of the stress and learning some of these techniques. But it's really important. It's hard to talk about some of that stuff, and it's really important to make sure that you're telling your providers what's going on.

Scott Steele: That's fantastic and just really good sage advice there. So for more information on Cleveland Clinic's Behavioral Medicine Program, please visit clevelandclinic.org/behavioralmedicine, that's clevelandclinic.org/behavioralmedicine. And to speak with a specialist in the behavioral medicine program, please call 216.445-9552 that's 216.445.9552.

And for the most up to date information on COVID-19, including our appointment, visitor policies and a lot of great information, please visit clevelandclinic.org/coronavirus, that's clevelandclinic.org/coronavirus.

And please, again, kind of a self plug here, listen to our series on Butts & Guts podcasts on this disease. In times like these, it's more important to keep up with your medical care and rest assured here at the Cleveland Clinic, we're taking all the necessary precautions to sterilize our facilities and to protect our patients and make this the most safe place possible. Stephen, thanks so much for joining us on Butts & Guts.

Stephen Lupe: No problem. I enjoyed it.

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