Gut Directed Behavior

Podcast Introduction 0:00

Welcome to Doctor Talks, the podcast where every episode leads to a healthier you. Join us as we navigate the world of optimal health, uncovering groundbreaking strategies to conquer chronic disease. In each episode, we'll bring you the latest insights from leading health experts, medical innovators, and wellness warriors. If you're seeking to transform your health journey, or if you're looking for answers to burning questions, you've come to the right place. Get ready to unlock the secrets of lifelong health and vitality.

This is Doctor Talks, real talk from real doctors on the issues that matter to you most. Today I'm here with Doctor Megan Real. She's a clinical psychologist who specializes in gastrointestinal issues. Things like IBS, but also inflammatory bowel disease. I'm so excited to have you on today, Megan. Thank you. Pleasure to be here. And we have something to celebrate because you just launched a book, which is incredible. And we're going to talk a little bit about the contents of the book today. But really, one's fired you and Kate to.

Right? Mind your gut. Yeah. So first, thank you for acknowledging the book. It is. We are celebrating.

Introducing Mind Your Gut 1:23

It just came out, early this year, so, it really was inspired by the idea that, you know, a lot of people don't have access to a strong multidisciplinary approach to specific this diagnosis, IBS. Though, you know, the number is about 45 million Americans have IBS. A huge number. And I always say that's probably underestimated because a lot of people don't want to talk about these symptoms. Abdominal pain, diarrhea, congestive ation. You know, the number of times patients will say to me, I'm really embarrassed to tell you about this.

And I'm just like, stop. It's okay. Like, I talk about poop and, you know, physical symptoms all day long. This is a safe space. So, you know, I work at, a tertiary care center where our gastroenterologists have access to registered dietitians. Our behavioral medicine program has three GI psychologists. We have pelvic floor physical therapists. And, you know, when patients get to me and we start to create, you know, behavioral health plan to help them with their IBS or whatever their GI condition may be.

So many times I hear this is so helpful. I never understood, the strong connection between my brain and my gut and my lifestyle and my stress and my mood. And in a relatively short period of time, I feel more confident to manage my symptoms. And I'm shocked that just nobody ever gave me this opportunity. And our GI dietitians hear very similar things. And so, you know, when you hear that as a practitioner, when you hear the same things over and over and over, I just felt compelled to, you know, reach out to Salata, who was, you know, just an expert, world renowned, GI dietitian in the space.

And I was like, have an idea? What about if we create this toolbox for patients that is 100% based in science so that, you know, and this is what I appreciate so much about, you know, so that we are really cutting through the snake oil out there and, we're giving people a roadmap that either have seen a doctor and received a diagnosis, or maybe they've been googling and, and hopefully our book comes to the top, to help guide them. What's next? Steps. Yeah. Amazing. I mean, this was so needed to my knowledge.

What IBS Is and How Itu2019s Diagnosed 4:08

I mean, I'm in the world too, right? There's not a go to book for disorders of the gut brain axis or IBS in general. And so I think it's going to be such a gift to the population to have something that's so accessible because you and I have talked where, GI psychologists are not, like, abundant in nature, it's hard to find somebody to work one on one with. So just to have something that is scalable and accessible for the general population, I mean, I think it's going to really do a lot for improving quality of life.

So thank you for birthing it into the world. Yeah. And you know, we really we talk about a dream team approach. So this this book is not meant to number one replace medical care. So it's incredibly important for people to receive an accurate diagnosis. But it also highlights that often times one provider can't do it all, especially in America where you might get 15 minutes with your your MD, you know, and then it's like, okay, here's a one pager on nutrition or, you know, really work with you on your stress that's, you know, and people walk out and they're like, oh my gosh, I get it.

I get that nutrition and my stress. But what do I do from here? And and so it really highlights this integrative team approach that, it really makes a difference for people. Absolutely. Yeah. And that's such an important point in terms of there is no substitution for working one on one with a practitioner and getting the care that you need. But just getting the word out, I think is going to be so impactful for these types of conditions. And I want to kind of get into some of the weeds here, I think, to to lay the foundation for this discussion.

Let's just talk about what is irritable bowel syndrome is a complex diagnosis. Just so people have an idea when we say that what we actually mean. Yeah. So IBS means that you have abdominal pain for three months. And then in addition to that abdominal pain you either have frequent diarrhea constipation or it can go back and forth. And so that's kind of a very basic, description of IBS. And and sometimes I think, and this is where a doctors workup is really important, where you may have, you may think you have constipation, and you're, or you might think, I'm sorry, you might think that you have diarrhea, but you actually have constipation because of fecal loading.

And so, you know, we might do, ultrasound or an X-ray, or maybe even introducing the idea of a colonoscopy, depending on your age and other symptoms. So IBS can be diagnosed by just talking through your, symptoms with a provider. And then they might start the treatment plan. But other times it might include, you know, labs or a colonoscopy, especially as you know, we think about colorectal cancer screening. If you are 45 or older, you and you haven't had a colonoscopy, that's an incredibly important, diagnostic screening tool.

That's that's important. So, you know, a lot of times the people that have an IBS diagnosis of probably had a colonoscopy, but it's not 100% necessary to get that diagnosis. Yeah, absolutely. And, a lot of people come to us, we're kind of similar to you guys in terms of people. I've typically seen a lot of different practitioners before they end up seeing us, and even then, some people still don't know what their diagnosis is when they come. And I think I think it's two part I don't know if you've seen this too, where I think some people just don't understand that IBS is a diagnosis.

So that is something that you are being diagnosed with, right there. And then I think some people may not want the diagnosis too, but then I think some people just haven't been given the diagnosis yet. Maybe they saw somebody and didn't follow through with the workup or what have it. And we see this as, you know, such a foundation of moving forward with the diagnosis that you have to have a definitive diagnosis. So if you're a practitioner out there that's listening to this, it's it's important to deliver that diagnosis with confidence.

Because if you're somebody that has been suffering with IBS, let's say, for 20 years,

Understanding the Gut-Brain Connection 8:34

and you know, when it's finally gotten to the point where they're now going to the doctor, maybe it's impacting their quality of life, maybe it's impacting their ability to get to school or work. If as a provider, you're like, pretty sure this is IBS, watch what you eat. What's your stress? You know, I'll see you back in a year. Yeah. That person is going to keep looking. They're going to go to the next doctor. They're going to ask for more workups. And instead of that we really focus on you have IBS.

It's complex. Your brain and your gut are interconnected and are at play here, but so are several other factors which make it kind of a tricky diagnosis. However, I have a lot of different strategies that are evidence based that we can talk about together to kind of guide where we go next. And I'm very confident that we can get you feeling better. I love that, I really, really love that. And I'm going to come back to that definitive diagnosis towards the end. Once we kind of get through the gut brain axis, we have some more, stuff to, to, to play with.

But I think it's such an important point because it is like 80% of the time people come to see us and they want a different answer. They're still searching for that answer. And I think that's a large part of the problem that that still exists. Before we get into that, let's talk about what is the gut brain connection and what role does it have in things like IBS. So it's something we all have. So we all have a gut brain connection. And I think, a pretty easy way to explain it is to think about it like a bidirectional superhighway.

So your gut is constantly sending signals up to your brain via our nervous system. And our, sympathetic system kind of can drive that, our central nervous system. So there's a lot of brain interaction here that's happening. So our gut sends signals up to the brain and the brain sending signals down, and also kind of saying like, hey, I felt that. Yeah, you felt it. Want me to turn it up now that you're really paying attention to it? And it starts the cycle where we have dysregulation between our brain and fat in somebody that has IBS.

So the the person that's living with IBS that goes out to eat first, they probably had anxiety about going out to eat. What am I going to eat? How's it going to impact me? What if I need to go to the bathroom but stop doing. It's ramping up your sympathetic system. Your heart rate's increased your breathing to getting shorter and shallower. Your muscles are tensing and clenching. You might already then start to have some GI distress and associated with just thinking about this activity that you're going to do.

So then you go and you start to eat something. You might feel this gurgle, cramps, spasm. Somebody that doesn't have IBS is going to be like, oh, okay, whatever. Like move onward. I go with the yeah. They're like, you know, they might even fart right there in the table. And like, they're like, it's a loud restaurant. Nobody's going to know what I'm doing. And they feel better and they move on. But somebody that's living with IBS is going to feel that more intensely, not because they're making it up, but because of something called visceral hypersensitivity, where the nerves are sending those signals up to the brain along that superhighway.

And the brain is saying, yep, I felt that now I'm really going to feel it. And so the brain has a hard time down regulating those signals from the gut. And this is also kind of where helping people to understand that gut brain access and that it's a real saying, your pain is real. You're not making any of this up can start to destigmatize some of maybe what they've been told in the past that, you know, IBS is a throw away diagnosis or, God forbid, you know, your symptoms are in your head and get over it.

So I like to explain that process in our body between our brain and our gut to people to really validate their experience with their symptoms and also to provide some hope that our brain gut behavioral therapy is that we're going to talk probably a little bit about, are really effective at addressing that pathway and kind of restoring the communication that's taking place there. The biggest thing that I think people, you know, when I'm suggesting somebody go see somebody like yourself, like a clinical psychologist, the biggest pushback I get is, so you think it's all in my head.

You know, people will say that and, you know, more or fewer words where they think by just referring to somebody who specializes in psychology. Oh, people think I'm making this up or, you know, it's not a real thing. And and it's I think it's so important that we say this like, a million times on this recording, where just because behavioral interventions can be helpful does not mean that this is a symptom that is made up or in your head. And there's actually newer research that's emerging that is showing that brain, that behavioral therapy is such one of the most common and most researched as cognitive behavioral therapy or CBT can actually have an impact on our gut brain microbe microbiome interaction.

How CBT Helps GI Conditions 14:02

And so it's it is it's it's not just, okay, we're teaching people how to cope better with these symptoms. We're now showing that these types of interventions are actually changing the microbiome and what's happening in our gut brain. And so I think that that will just kind of further bolster support for these types of therapies. Though, you know, many patients are very interested in these types of therapies now, especially those that are interested in going more of the non-pharmaceutical route, or want to feel empowered that, okay, if the symptoms are happening, what do I do about that?

Right, right. Okay. Let's go into what is cognitive behavioral therapy. How does it even have a place when we have gastrointestinal conditions. Because sometimes they feel like they're so far apart. You know, we're used to talking about cognitive behavioral therapy or CBT in terms of anxiety or, you know, anything that's psychological. But what role does it play in our actual treatment of gaster intestinal conditions. Yeah. So that's such an important question. And I think I'll back up and I'll I'll add one thing before I dive into that because you're right, there's CBT that we might use for symptoms of anxiety depression trauma.

And then there's GI specific CBT. And so we do know that patients that have gastrointestinal conditions, whether it be IBS or IBD, inflammatory bowel disease, have higher prevalence rates of anxiety and depression. So if a patient maybe in your practice is coming to you and they're anxiety, depression, trauma, mood symptoms are more moderate to severe and are also related to kind of more of life psychosocial stressors outside of their GI condition. Then I would prioritize those patients with connecting with more of a general mental health provider.

Yeah. So I think that's really important just for for kind of people that are watching this, that the work that I do hones in some special specialized to really giving you tools and strategies to help with the management of your GI condition. So, and our therapies won't be as effective if those more general mood symptoms are not treated. So not uncommon, though, for patients to come to me and also have a general therapist that they're working with so they can continue to see that provider, you know, maybe things are a bit more stable, but like in today's world, who can't benefit from a therapist?

Quite frankly, we all can. So, the CBT that I utilize has been kind of reformulated in a way where we still take the basic concept of CBT. That's kind of focused on how we think impacts how we feel and how we behave. And so then we utilize various cognitive strategies, behavioral strategies, or lifestyle to give people kind of, again, some strategies and techniques to change the way they're thinking about certain stressful situations. Change the way they're thinking about their physical health. And so we have tailored CBT to some of the common GI specific anxieties.

So a lot of times patients that are living with these diagnoses start to engage in avoidant behaviors. Yes. So they're not going to, concerts anymore. They're not traveling. They don't want to get the car with somebody else. Because what if they need to use the bathroom 15 times on the drive? Food restriction is another big thing. So food avoidance, food restriction. And I always talk to people about, you know, avoidance is, anxiety, anxiety lives and things that are uncontrollable, that are unpredictable.

And so in our mind, we kind of think we're safe if we avoid those things. But the reality is, in in the world of anxiety, if you have that false sense of hope, it further just kind of strengthens the anxiety. And so, CBT is really great because it gives people an opportunity to first start to look at what are the things I'm avoiding, what are the cognitions that I have about that. And a lot of times we kind of help them identify black and white thinking, it's like I either go and I eat everything or I don't go at all, and I'm staying at home and we know that, you know, the best way to live life is it's going to be.

Yeah. And it's going to be kind of the best ways that we can kind of feel confident is knowing I've got a lot of coping strategies for the gray area. If things aren't going as well as I'd like them to kind of go. I have a whole toolbox of strategies that I can manage and muster. If things are going great, I'm going to be present and mindful about that and live with that. So that's also where we start to incorporate things like acceptance and commitment therapy or Act. Some of these third wave types of psychological therapy is so it's not about like, oh, everything's great.

You know, especially it's not if you're not feeling well, but it's I can manage how I'm feeling right now with these strategies. And I, I know it's probably going to change other changes for the good or the bad that's for us to kind of live through. But knowing that it's going to change and you can manage that. We teach that with cognitive behavioral therapy and act. Yeah, yeah. And I think this can feel a little bit intangible for people when they listen to it in terms of like, yeah, I kind of get the idea, but what does this actually look like?

So can we go through some of the most common things that you see in people with IBS in terms of like, I'll give it one example where it's like somebody comes in and they're like, hey, you know, Doctor Mary, I feel fine as long as I eat chicken breasts and sweet potatoes. And I can also eat kiwis. So I eat those three foods. And then, you know, I'm pretty much okay. But like other. So that would be an example of, like, a very controlling behavior or a restrictive behavior. But other examples of these controlling avoidant kind of or even checking behaviors that we often associate with IBS.

Yeah. So my trackers, the ones that are coming in with every bowel movement tract when they felt that cramp, what they ate down to like the teaspoon. And the research shows like tracking probably longer than about two weeks is just going to further perpetuate your anxiety. So as we do a really thorough clinical interview with people the first time we meet them, and I'm asking them about their GI history, their other medical history, their psych history, nutrition behaviors, lifestyle, social history, really getting a clear picture of this person.

Have they ever worked with a mental health provider? And, and then I start to kind of describe ways in which our behaviors impact our bowels, our digestive tract that, you know,

Common Avoidance and Tracking Behaviors 21:08

gut health matters to all of us. And, and so a lot of times, as we are exploring their lifestyle and like for the people that are only eating 3 to 5 foods a day, what kind of stress does that cause? How is that impacting? What might they be motivated to like? Why are they motivated to be in your office? Or, you know, if they're doing that and probably still intermittently having symptoms, it kind of shows us that what you're doing is not actually working. Yeah. And doing that in a very gentle way is also critical.

Bedside manner, I think, matters a lot with our patients because they're being vulnerable. They're telling us about like basically their innermost workings and how we start to build that rapport to talk about the treatment plan and validate, like things aren't going to get better overnight. I'll acknowledge that we're not going to go from like 3 to 5 foods to eating everything overnight. But what we can start to do is look at what where is your stress coming from? How are you thinking about your symptoms?

Are you kind of are there catastrophic thoughts that are happening? We start to point out some of the avoidant behaviors, and then what that's costing them. And also the, the toll that that can take on your body, sometimes people are restricting so much that that's going to cause either, you know, they're not going to poop as much. But that's going to have tremendous effects potentially on their pelvic floor. The progression of that, it impacting malnutrition. And so again, we can kind of highlight, look, where we are right now is okay.

And we can help you get better if you stay where you're at. I'm very concerned about the progression of potentially this going from restrictive, disordered kind of eating where you've got some control over it to a full blown eating disorder, where the consequences of that are going to be catastrophic. And so let's kind of pare down to where we're at right now. So that example is one of the more extremes, right? When, when people have restricted that much. But I think with CBT, one of the things that I teach everybody, we are what we call kind of modifications of arousal, which basically is relaxation and diaphragmatic breathing, is one of the techniques that I teach everyone.

And a lot of times people are like, oh yeah, I had a therapist that taught me that one zero. I learned that in yoga, and I get that. But I'll talk about like when your heart rate starts to increase because you're wondering where the nearest bathroom is, or you're sitting on the toilet for 30 minutes trying to poop and you're straining and you're tense, all of that escalation of your sympathetic system is working against you. It's time to poop more, have more urgency, or you're going to continue to not be able to poop.

Diaphragmatic breathing actually starts to massage those intestinal organs, which can help and urgency and can also help, especially if you're in more proper pooping position, on the toilet using a squatty potty. Leaning forward about 35 degree angle straight spine. If you engage diaphragmatic breathing, you're able to have a more complete bowel movement. So the first like session that I have with people, I'll give them that as something to turn to in times of anxiety. Have them practice for two weeks and almost everyone comes back and they're like, yeah, I tried it in the car and I was it, you know, I was able to make it to the bathroom or I changed the way I was pooping on the potty.

And why didn't nobody ever teach me that? Like, this is such a basic thing. I've been pooping for 40 years. Why is nobody taught me proper pooping position? So we incorporate those behavioral strategies, and getting that buy in and starting to kind of improve confidence really makes way for some of our other behavioral strategies. And those changes in cognitions that you're absolutely right. We've been thinking one way for your whole life. We're not going to just change that immediately, but we can help you.

Yeah, absolutely. Diaphragmatic breathing has one has been one of the biggest game changers, I think, for, for a lot of my patients. Such a simple tool, but like a great way to shift out of that sympathetic nervous system response into a more relaxation response, which is how our digestive system really function as well. Yeah. Okay. When we talk about the gut, we almost always talk about the gut microbiome. And it has a ton of attention on it right now over the last few years. But what is the importance with IBS specifically when we talk about these gut bugs?

Yeah. So as as simple as possible I like to keep this because it just again, you can do a deep dive into the literature here. And you're got all kinds of hard to pronounce, bugs that, that are out there. But the reality is, and we'll keep with the example of the person that's having 3 to 5 foods. The reality is you're limiting your gut microbiome when you restrict your food. And we all benefit from, you know, natural ways of getting, diverse microbiome. And that's through our food. However, things like stress, anxiety, sleep, our lifestyle have a profound impact on how our microbiome is, is behaving and kind of how it's fed is a good way to like, look at that.

So I think that why it's important for somebody with IBS is, you know, the reality that if our gut microbiome is being impacted

Microbiome, Diet, and Health Anxiety 26:48

by our lifestyle choices or, you know, such a restrictive food kind of pattern, that's going to impact how our digestive system functions and, and so, you know, some of these kind of concepts of eating the rainbow, like, is great because in the variety of fruits and vegetables and make it as simple as possible. Right. So I live in Michigan right now. It's typically not sunny. Getting fresh fruits and vegetables is much more difficult, than maybe somebody living in a sunny state, like you. And, and I think if you can find frozen fruits and vegetables, like, eat those, that's fine.

You're still going to get good kind of benefits from those, those fruits and vegetables, regardless of whether they're frozen or not. So I think just keeping that in mind that, so much can impact our microbiome, it's going to have an impact on your gut health. And our goal is to keep things as diverse and happy. The happy bugs, going so that your pooping and kind of it can affect your upper GI symptoms too. So, basically your overall gut health. Yeah. I mean, the fact that, you know, the more we are stressing about what we're doing for our health, almost like this health anxiety around our health and trying to be healthier and the healthiest, you know, that I can actually have a detrimental effect on your overall health and your gut microbiome specifically.

So what we're trying to do is sometimes what we're end up not actually doing. That's right. And along the same category, I see a lot of, you know, either strict eating disorders or disordered eating patterns in our practice. I think orthorexia is becoming more and more prominent, especially with the rise of, yeah, to be totally honest, like biohacking. And you know, these things where it's like track, track, track, do everything right and keep everything in a really kind of regimented routine. And I think some people do okay with variations of that, but I think a lot of people can easily fall into the path of extremes, and it becomes something that can, like really take over a lot of their thought process.

I, I ask patients all the time, like, how much of your day do you spend thinking about your health? And it's not uncommon that I here oh, actually, the majority of my day or over half of my day, I think about tracking and and my general health. And so when we, when we see kind of patterns like that, how do you think that could actually impact somebody that has IBS when they're, you know, using all the the sleep trackers and the Apple Watches or the aura rings or all of the other things, even if they're not directly related to their GI health.

Yeah. I think what you hit on is basically, is it helping you? Is it doing what you're trying to accomplish and moderation. Right. So like I've got an Apple Watch, I like it. It's easy for me to see my text messages. I'm not obsessing over when it clicks on my watch at ten minutes to the hour to tell me I haven't moved yet, like, I, I know that I'm at work. Apple Watch. Like I get that I'm going to exercise later. So I that's a good example of that doesn't cause me distress. But to your point, you know, when I have a patient that's coming in and they're showing me this tracked sleep pattern and, you know, and what this means and how they're assessing, I'm like just assessing all of that is going to impact your sleep.

So I think similar to the conversation I have with patients around like supplements and probiotics, I'm like, if it's not giving you the answers that you're looking for, if you've been doing it for a month, right, whether it be if you've been tracking for a month in your sleep, is it better if you've been, you know, tracking your food and you're not achieving the goals that you want around a healthy lifestyle? You've been taking this for a month and you're not getting better again. What is better?

Better is you are living the life that you want, and your quality of life has improved and what you're doing is sustainable. That's where we're where we found a sweet spot. If you've been doing that for 4 to 6 weeks and you're not there yet, then we've got to pivot. We've got to look someplace else. And and I think orthorexia is complicated, right? Because people are like, Now I'm being healthy. It's everybody else that like they're the ones that are killing themselves with everything that they're eating and, you know, and so again, we'll talk about, has this progressed to a stage of eating disorder where we really need to include an eating disorder specialist.

Yeah. And and that again is a very gentle conversation. Because I think that, people can feel like they're so well-intentioned and that they're not doing anything all that bad. But I'll say, you know, what are your friends think about this? You know, are they concerned about your family? Concerned? Are you are you not spending as much time with friends and family anymore because of these lifestyle choices? And as we tease some of that apart, I think it highlights that, you know, maybe this isn't sustainable or maybe it's not as healthy as we think it is.

And you might need to kind of explore this a little bit more with somebody who specializes in this.

Eating Disorders, ARFID, and Restrictive Diets 32:18

Yeah, no, I think it's a great point, and I'm sure you see a lot of it as well too, because eating disorders can sometimes present exactly like IBS, as well as the fact that IBS and eating disorders have a huge overlap, between the two of them. So people with unique disorders have a really high prevalence of IBS, but also people can be experiencing bloating, constipation specifically, and it's due to the eating disorder itself versus an actual condition of IBS, which may or may not resolve with re feeding and things like that.

That's right. And a condition called avoidant restrictive food intake disorder, or our fed is really kind of a new hot area of research in the GI space because this type of disordered eating is different from our, you know, traditional anorexia or bulimia, where we're restricting food for body image, concern for weight loss. Our food is more so I'm restricting food because it hurts. I'm restricting food because I'm afraid of how it's going to impact my symptoms. And so this is a really important screening opportunity for physicians out there to ask all of your patients.

And again, we can't screen eating disorders based on a body type. Right. So you know I think that sometimes we we can stigmatize this. So all people, regardless of their body size, need to be asked, you know, what is your relationship with food when they're presenting with a GI condition. Because they might not be, you know, restricting food because they're trying to lose weight. And I've had a lot of patients actually, where they've been in a hospital misdiagnosed with anorexia, when really it was our fed and it was completely related to their GI condition, and it set them on two very different treatment paths that further kind of stigmatized the GI condition when they're labeled with anorexia.

Yeah, really, really important. Our food was talked about a lot of a couple of years ago. And I think it's something that we're not screening enough for in medicine. But in both of these populations where we have the disordered eating, you know, whether it's a strict eating disorder or not, as well as are often the last thing we would want to do for these people is to put them on a restrictive diet where what, even if it's a low Fodmap diet and it could potentially be indicated we have to proceed with such caution.

And these individuals where it may be perpetuating the the actual disorder. Yeah. So if you have a patient or you are a patient that has had a history of eating disorder, even if it's been in remission. Interesting research, kind of put, the low Fodmap diet versus gut directed hypnotherapy for patients with IBS. And the outcome when people were randomized in that study was that the outcomes are very similar, regardless of whether you had low Fodmap or gut directed hypnosis. Not surprised. Only those that had gut directed hypnosis had a reduction in anxiety symptoms a little bit more than those that just did the diet.

But I think this this really highlights that there are alternatives. Like it doesn't have to be an, low Fodmap diet for people that have IBS. And even though access to GI psychologists and maybe people that are trained in gut directed hypnotherapy, can be quite limited, the digital therapeutic space is really opening up for patients. So the Nerva app, is available for download and I don't have any. I'm not getting paid by Nerva to say this in any capacity, but they're using the evidence based scripts that I use with my own practice, tailored a little bit, but basically the same kind of concept.

And so, I think it's a really important kind of basically opening up treatment options for people, especially those that are our, restrictive diet is contraindicated in. Yeah, absolutely. What is gut directed hypnotherapy for those people who are now thinking you're making people like, quack like a doc and do funny things like stage hypnotherapy, what's the difference there? Yeah. So the biggest difference is that it's evidence based. And, and it's been backed by over 40 years of research in the GI space.

And so, the strategies that we're using with gut directed hypnotherapy are, again, helping with those modifications of arousal. So teaching people how to deeply relax their body and, and what makes it hypnosis is that when people are in a very focused state and we guide them into that, we utilize very specific suggestions about the calming and soothing and restoration of that brain that dysregulation and research has shown that these protocols are more effective than any of the pharmaceuticals out there, patients that have failed.

Or I'll reframe that as our treatments have failed the patient and we've not found adequate relief for that patient. We do tend to find relief with gut directed hypnotherapy and anywhere from about 66 to 80% of patients. So it's an extremely effective, protocol. In my practice, it's about seven sessions spread out over about four months. And at the conclusion of that, a lot of times you can continue to do kind of self hypnotherapy or use the audio recordings that I provide for patients. But if they're having a complete resolution of their symptoms, I talk to them about, all right, you've carved out this time for home practice.

Now save that save that for ongoing stress management. Save that for meditation. Save that for, you know, time for 20 minutes to yourself for self-care. And and that way it's long term. It's long term health practices for stress management, relaxation and meditation. So there's no ball going off and clucking like a chicken. It's Evidence-Based.

Gut-Directed Hypnotherapy and Supplements 38:30

It's been around for a long time, and if people can kind of have it introduced in a way that is, hey, this is science backed, this is effective, this is, you know, something that can really give you an empowered sensation to, to manage your symptoms. More time than not, people are willing to give it a try. Yeah. We use normal in our practice all the time as well as there's a prescription one now called, I think regular IRA that your doctors prescribe for you. And obviously referring to practitioners like yourself to do it one on one.

But we get really good results with people who actually commit to doing it, which is with everything. You know, it has to be done to get the actual effects from it. But it's such a such a useful tool for people. I want to go back and talk about the supplements piece really quick because you said that and I'm like, oh, wow, we really have to talk about this, even if it's just for a short period of time, because it is not uncommon for people to come to us and they're on a list of 20 supplements, honestly, not that uncommon.

And a lot of the times what I see is people saying, yeah, sometimes I'll take this, but if I have this symptom, then I'm gonna, you know, say I'm bloated than I take this or if I'm constipated, then I go over here and take this. And, you know, I've been playing around with the dosage of that. So they do what I call tinkering and, and I think tinkering, it's it's basically like being your own, pharmacist, right, where you're just kind of mixing potions together. And sometimes I see it prescribed actually by a practitioner where it's like all of these things and it's so intricate and it has to be taking up a lot of mind space as well.

But can you talk to us from like, a psychology standpoint, how that could potentially affect somebody with a disorder of the gut brain axis like IBS? Yeah. So I'll start with a very similar clinical picture of the patient that will send me on their patient portal. The the workup of the labs that they've had done by somebody where, where, you know, this bacteria has been identified and this bug and this stuff. And what I'll say is that I don't believe most practitioners are doing this maliciously or with ill intent in any capacity.

The problem is we just don't have the science yet to do much with it. Yeah, it's interesting thing to identify it all, but we all kind of have back to it. We all have our microbiome as we talked about, that has bacteria and bugs and you know, some things that are going to be in our body that, you know, once you uncover it, there's not much that we can do about it. And so then oftentimes what comes with that panel of, of labs and stool tests is the wide supplement regimen. Right. And again, I think that that can work for some people.

But the problem is let's say you and I present with the exact same symptoms to the same doctor, and we have the same stool stuff. That's and maybe it pops up the same. But your microbiome, no matter what, is different from my microbiome, which may respond differently to the supplements and therefore I might have wonderful results. And I'm willing to shell out that $1,500 because my quality of life is worth it. I'll put it on a credit card, I don't care. I've been suffering. You might not have the same results.

And you're like, well, I'll go back for that second month. I'll try it the third month. Maybe it's the fourth month. I think maybe my symptoms are like a smidge better. That's that anxiety that starts to creep in that says, like, if you stop this now, you're this far in you know, all could be lost. And and so I think that it goes back to another kind of instruction that I'll talk with patients about. It's like if you've been trying something for a good like if you've given it the good old college, try for 4 to 6 weeks and you're not seeing any improvements that are enough that you wouldn't go back to your doctor, then it's probably not the right thing for you.

And so I think the long winded answer to this is just our science isn't quite there yet, and therefore, should we just not try at all? I don't think so. I think we should try. I think there are some, especially for like experts like you that are very pragmatic about things. You're using the science. If a patient can ask their provider, what's the science behind this, this recommendation, tell me a little bit about what you are targeting here. How long should I try it? What should I expect if you if that provider can answer those questions, that's going to go a long way in managing the anxiety as opposed to, you know, this is really scary.

Look at all these things that popped up on here. And now we're going to like, you know, we're going to look at this and try these different things. That's that's really I think you just have to really ask and get the science and that the answers and, and also what's the black and white. What's the I'm willing to try this with you. I think this is what's reasonable based on kind of your presentation. But we're going to back off, you know, if we hit x, Y and Z here. Yeah. I think you're spot on. I'm glad you brought the stool test, too.

If anybody watches my Instagram, I, rag on comprehensive stool analysis is all the time for that exact reason where we just don't know yet. I think there may be a time where we do now and there's. Yeah, it's slow, but we're not there yet. And so to do them now is, is really just you're just trying to, you know, throw spaghetti at the wall and hoping something sticks and not not following the science. And a lot of times people are paying out of pocket for like, you know, insurance company is covering this.

So that's the other side of this is that, you know, when you don't feel well, you become more desperate to try any and everything. And I think it's our job as medical professionals to, you know, again, that comes back to that definitive diagnosis. This is what you have. This is what we've identified. These are the evidence based strategies that can unfold based on what you're interested in. And unfortunately, you know, all of these kind of conglomeration of things that you're trying to do right now.

You're here because they're not working. So so that's like I think sometimes you have to step in and almost be like a hard line in the sand for people. And they're either going to respond to that with like, oh my God, somebody that like knows what they're doing and is willing to like take the reins here and guide me or they're going to be like, nope, never mind not coming back to you. And, you know, I my heart breaks for those people. And I try to fill them with as much information as I can as they're on their way out.

But, I think that, you know, a lot of times it's doing more harm than good. Yeah, I totally agree. And and I do think some people are just not there yet. Right. Like I was in this patient scenario when I was younger. And if you had told me to see a psychologist, I would have been like, you are crazy. Absolutely not. So I get it from from both sides. But I think it's so important when people like you are talking about how this is not saying that everything is in your head. We're using very science based approaches to actually change the physiology

Closing Thoughts and Where to Find the Book 45:48

in your body based on changing parts and behavioral patterns and even beliefs around what's going on, which is really, really it's empowering because I think people end up leaving with a better understanding of what's actually going on and that things aren't happening all the time. By chance. You know, sometimes our actual behaviors are perpetuating our symptoms versus making them better and understanding how to navigate that using the tools that you've mentioned today, which are really invaluable.

And the durability of cognitive behavioral therapy for GI conditions in terms of GI, CBT is one of the most impressive things that I see here, which when we talk about durability, I mean that once you finish sessions with, you know, say yourself, you can maintain those benefits even after you stop the sessions, which you can't say that about any medication on the market, really, I'm trying to think of. There may be any, but and not to mention that you're addressing the global symptoms of IBS and not just constipation and diarrhea, right?

Where most of the medications out there are addressing the constipation, the diarrhea, they're not addressing the abdominal pain, the bloating. The more global symptoms that arise with this. That's right. You mentioned something earlier about the patient that just doesn't want this diagnosis. They'd rather it be something else. And I think you know that's that hits on. I'll tell people you know, the reality of this is I'm not going to cure your IBS. You're still going to be, you know, potentially like no matter what, we're all susceptible to a GI bug here and there, like getting the flu.

I have little kids. So like, that stomach bug comes through, like at least once a year and it hits everybody. And it sucks. However, when somebody with IBS gets that, it like ramps that anxiety right back up of oh my gosh, here we go again. And so I'll tell you that, you know, when you feel comfort in about you, you've got gut directed hypnosis as a strategy. You've got those CBT skills. What that's going to do is that's going to likely prevent, the, the duration of that episode of symptoms becomes shorter.

How frequently you experience symptoms is lasts, and the severity of those symptoms is significantly less. And so yes, you might get a bout of symptoms, but it might last 12 hours or 24 hours as opposed to like a month long of a flare. And and when people kind of buy into that and they're like, oh, I can manage that, I've got that. That's where we know we've really hit the nail on the head with their treatment. Yeah, yeah, I think it's really important to to put that expectation. We, we work with marketers, you know, in terms of our actual business structure.

And they want to say things like, you will cure your IBS or it'll be gone. Or I'm like, I you cannot say that. And I think that anybody that is saying it is really, playing around with integrity at a level that's not helpful for anybody. But I think most people want their quality of life back. Like, that's really what they're looking for is to have their quality of life back, to have more understanding around what's going on and and just to feel more at ease in their own body, which is something that a lot of these get directed behavioral therapies can help so much with.

You've got it. That's exactly at. Thank you so much. I wish we had a whole nother hour. There's like a whole other thing that I want to get into with you. So maybe another time. But where can people find mind your gut, how can they read it and just tell us a little bit about it? Yeah. So it's available online, Amazon bookstores, wherever you buy your books, you can find us on Mind Your Gut official on Instagram. And my coauthor, Kate and I also have a podcast called the Gut Health Podcast. And, we do new episodes every month.

It features, a variety of, of health practitioners. So maybe we'll have to have you out in the future. And, and, and it's available wherever you get your podcasts too. So we hope that you will, by mind your gut and and enjoy it, share it with your friends, family. And and thank you so much for the opportunity to come on and chat tonight. Thank you. And I'm I'm halfway through it. I'm on audible with it. So it does have an audible version for those of us who don't pick up real books anymore. And, and it's wonderful.

It's really thorough. You guys not only go to the cognitive behavioral side of things, but also touching on nutrition and lifestyle and, and everything in between. So I'm really impressed with it. And I'm so excited that the world now has this resource. So thank you for creating it. And thanks for joining me today. Thank you. Thank you for tuning in to Doctor Talks. We hope today's episode has enlightened and inspired you on your path to optimal health. Each day is a new opportunity to make choices that empower your well-being.

For more insights and strategies, subscribe to our podcast and visit our website w ww di doctor Talksport.com. Stay connected, stay healthy and join us next time on Doctor Talks. Real talks from real doctors on the issues that matter to you most.