IBS and the Gut-Brain Connection: When and How to Seek GI Psychological Support

Jessie Wong (00:00):

Welcome to the IBS Nutrition Podcast, your go-to source for navigating the complex diagnosis of irritable bowel syndrome. Here we dive deep into IBS and discover the power of diets and lifestyle to find freedom from your IBS symptoms. I’m your host, Jesse Wong, fo map dietitian and a gut expert. For years I suffered from debilitating gut symptoms that kept me out of work, feeling constant discomfort in my body and anxious around food. Today I’m in control of my IBS, able to eat the food I love, again, travel whenever I want, and spend quality time with loved ones. It is my mission to help you do the same and transform the way you live with IBS. Let’s get started. Hi everyone. Welcome to another episode of the IBS Nutrition Podcast. Today I have a very special guest here with me and that is Dr. Ellie Nadi, who is a licenced clinical psychologist and one of the founders of GI psychology, a multi-state centres specialising in helping patients with GI disorder and chronic pain. Dr. NTI oversees training and outreach at the practise. He is one of the founders and past president of the Northern Virginia Society of Clinical Hypnosis and a hypnosis trainer for I-S-S-T-D. Welcome, Dr. Navidia. I’m so happy to have you here.

Dr Ali Navidi (01:22):

Oh, thank you so much, Jesse. It’s a pleasure to be here and we’ve kind of run into each other over the years, so I’m glad that we had a chance to do this.

Jessie Wong (01:32):

Yes, yes. And I remember, I think multiple different GI conferences that we’ve met and talked and really knew each other for a few years now and working together in this space. Yes, allow. I have a few topics that we would like to talk about today. So one is explaining the gut bring connection and how it plays a role in IBS or functional gut disorders. There are so many confusing theories about the gut braining interaction and disorders of the gut brain interaction online. So having a doctor in this area, a psychologist in this area can really help us explain better what it is and maybe debunk some myths that we hear online all the time too. So that’s topic number one. Topic number two is when to seek GI psych help because we know it is extremely helpful for patients, but not all patients understand that they may benefit from going to a psychologist that specialises in gut disorders. So let’s talk about that. And number three is what do treatments look like when working with a GI psychologist? And last but not least, topic number four will be Dr. Nadi sharing a few three actionable steps for our listeners so that you can take it home. And these are actionable steps that you can use right away to help ease some of your IBS symptoms. So I’m very excited. Let’s dive into topic number one. Let’s talk about what is the gut brain connection and how it plays a role in IBS and other functional GI disorders.

Dr Ali Navidi (03:04):

Perfect. So I think the thing to understand is something you already mentioned earlier, which are disorders of gut brain interaction. And for people who are listening who don’t know, that’s a broad category of different disorders that include irritable bowel syndrome. So IBS and what we’re talking about are these disorders where they can’t find any structural problems, so they can’t find inflammation, there’s no cancer or there’s nothing they’re finding, but the symptoms are very real and they can be very intense and debilitating. So it can be very confusing what is happening here because a lot of patients get disappointed, they get tested, they get scanned, they get blood, it could go on for years and they don’t find anything. So then they start feeling kind of shamed and feel bad, but they absolutely shouldn’t because it’s not just in their head, they’re not crazy. There’s a real true disorder happening here.

(04:18)
But what’s causing it is the interaction between the nervous system and the brain and the gut. And that’s where we talk about this gut brain connection or the gut brain axis. And I don’t like to get overly technical about this. I think a lot of people will start talking about the vagus nerve and serotonin, and this isn’t like enteric nervous system. No, I don’t think that’s necessary. We’re not writing a dissertation here. We’re not like doing something fancy. I think that people just need to understand that there is a special connection between the brain and the gut. And what that means is that what happens up here affects what happens down here, and what happens down here affects what’s happening up here. And so I think that is at the minimum what they need to understand. And then we can start looking at what I like to think of as the model for these disorders. So the model for IBS, and I know I’ve been talking a lot without letting you talk so far, so I’ll pause for a second.

Jessie Wong (05:27):

Well, I want to recap on what you were saying. It’s not in your head. I think a lot of the times our patients go to their providers getting all the tests done, which is great and very necessary to test out other condition because all GI conditions have very similar symptoms. So it’s important to distinguish your symptoms with IBS compared to other disorders, but it’s not in people’s head because there is pain, there’s bloating, and sometimes distension. These are physical, invisible symptoms and people have to deal with them. And oftentimes it’s very debilitating. And when they hear that all the tests are normal, it’s just IBS and people feel like their doctors are saying, well, it’s just in your head now go and learn to manage it because nothing is wrong. I can’t do anything for you. That’s not true at all. And thank you for saying that. Validating what our patients experience. Yes,

Dr Ali Navidi (06:19):

I like to talk to people about a computer.

(06:23)
So imagine that you go to use your computer and it’s just not working right, and you do this and that. It’s just not working. So one thing you might do is you might check the actual hardware. Is everything plugged in? Are the monitors working? Is the CPU checking all the hardware? And if the hardware is fine, that doesn’t mean your computer’s still not working, your computer’s still not working. But the problem might be with the software, there might be one programme that’s interfering with another programme or one program’s malfunctioning somehow. So I think of IBS as a problem with software. And just because it’s a software problem, your computer still isn’t working, there’s still a serious problem happening. It’s just what is causing the problem is different than if there was a hardware problem.

Jessie Wong (07:18):

I love this energy

Dr Ali Navidi (07:20):

Analogy analogy.

Jessie Wong (07:23):

Yes, I love it. Yes, because you can’t see the visible, there’s no visible signs of anything being wrong. It’s a software problem. Well, let’s talk more about this software problem. Yeah, tell us more. What can we do?

Dr Ali Navidi (07:37):

So you’ve got this powerful connection, but if that was it, that wouldn’t be enough for IBS. So what you also have is something called vigilance.

Jessie Wong (07:49):

And

Dr Ali Navidi (07:49):

This is usually something that happens unconsciously, but the brain is always scanning the gut. And if anyone who’s experienced has had IBS, they understand this, that once you’ve had it for a little while, your brain is always checking to see how your stomach is feeling. How am I doing today? And then if it notices something that’s a little off, then it starts catastrophizing like, oh, this is going to be a bad day. Maybe I shouldn’t do the podcast with Jessie. I need to tell her that we need to put it off. I can’t take that long car trip, or I can’t go out to dinner because the brain starts just imagining all these scenarios where things could go wrong. So that combination of hypervigilance and catastrophizing, it creates all this stress and anxiety and through that gut-brain connection, all of it goes down to the gut and actually starts causing symptoms. So in a way, it’s kind of like a self-fulfilling prophecy.

Jessie Wong (08:59):

Yeah, it’s definitely a vicious cycle, maybe having mild symptoms and then the hypersensitivity, so you’re feeling all of it and your brain gets more anxious or we get more anxious and that anxiety makes our symptom worse, and it is a really difficult vicious cycle to break. Now for IBS patients, I think this is a perfect place to move into our second topic. When is a good time? If people notice that they have this vicious cycle, the anxiety driving symptoms, their symptoms getting worse and making their anxiety worse, when is the good time to say, Hey, I probably need to see somebody to help me with my psychology, to help me with my GI disorders.

Dr Ali Navidi (09:39):

So one thing we should understand right at the beginning, and I think this is no offence to doctors, but I think a lot of gastroenterologists get this wrong when they think of GI psych, they think of giving the patient someone to talk to. Oh, you’ve got IBS. Maybe you need somebody to talk to. No, that’s not what these patients need. Of course, all humans, we need someone to talk to. We need someone to listen to us, but that’s not what’s going to really help their IBS. So we’re not acting as someone to talk to. There are specific, very focused techniques that we will teach the patient that will directly help with their symptoms. And so I know this isn’t answering your question, so let me go back to your actual question is when to get that help. Well, I’m of the opinion, and some might disagree, but I think GI psych in a perfect world would be a part of every patient’s treatment once you’re diagnosed with IBS.

(10:48)
Because we know, and the research shows that it is tremendously effective. And so why would you wait? Because almost 80% of people will reach their treatment goals using these techniques from GI psych, and this is based on 40 years of research. So why would you want to wait? If you’re diagnosed with IBS, if you know it’s not Crohn’s or colitis or something like that, if I had IBS, I’m going right to it and getting that help. Now, I’m probably also going to work with someone like you, right, to help me with diet, to calm things down so that while I’m getting the GI psych treatment, my symptoms won’t be going crazy. But I think I would start right away.

Jessie Wong (11:36):

Yeah, I love that you’re saying that because again, oftentimes dietitian or psychologists are not in the treatment picture when a patient talks to a gastroenterologist, rarely they refer out. But getting help from both these two specialties is extremely helpful. We actually refer a lot of patients, your clinic, especially when they’re very anxious, we know that it’s affecting their daily life, that maybe having another person join the care team will be extremely helpful. And another scenario we really love referring outs to you guys is also when patients are very afraid of food. Because with GI disorders, they come to us wanting to reintroduce more food, but they have so much fear sometimes that they can’t even start the reintroduction process. And again, I think if somebody has caught it earlier on and noticing the anxiety, the nervousness, and maybe even starting to develop an eating disorder or disordered eating, they should refer it out as soon as possible instead of waiting or letting the patient stay on this anxious cycle, right, this vicious cycle for prolonged periods because it can do a lot more harm. I agree with you. I think at GI Psych onto your care team, like anybody else listening here, add to your care team as soon as possible, maybe create some plans. Or even just getting an assessment can be tremendously helpful to see what treatment may look like.

(13:01)
But yeah. Okay. Well, now let’s talk about treatment options, right? When it comes to GI psych, I think maybe talk about two things. What does assessment look like and what does treatment look like for different types of patients? What are the options? Let’s start with assessment.

Dr Ali Navidi (13:19):

So let’s say we have a very straightforward case of just IBS. That’s it. And there’s no comorbid mental health concerns. There’s no history of trauma, there’s no other medical conditions. I’m saying all this because most of our patients are much more complex, but let’s say we have this very straightforward, simple case only IBS. We would assess for all these other conditions to make sure that they don’t have them going on anxiety disorders or depression or trauma. And then we’d look at the big picture. Do they have chronic pain? How’s their life? Are there relationships? And if it’s just IBS, no other things, then what does treatment look like? It looks like two different modalities that have been shown to be effective, and that is specific kind of cognitive behavioural therapy and specific types of clinical hypnosis. The CBT most people have heard of. And the idea is that it’s not standard CBT.

(14:40)
And this is where a lot of patients can get disappointed because their providers will say, oh, you have IBS, we’ve heard that CBT can be helpful, so go see a CBT practitioner. And so they go, they do it, and that practitioner doesn’t know how to adapt CBT to help someone with IBS. And so they don’t really get much benefit out of it. So that would be one. And then the other is clinical hypnosis. And I think most people maybe avoid that because what they know about hypnosis is just entertainment hypnosis. They understand the movies and the stage shows and mind control and magic. And what they don’t know is clinical hypnosis, which is research-based. They’ve been studying it again for 40 years and is extremely effective and powerful tool for patients with IBS.

Jessie Wong (15:39):

So two main tools, right? Cognitive behavioural therapy that is focused on the gut GI disorders, and then also gut directed hypnotherapy.

Dr Ali Navidi (15:48):

Exactly,

Jessie Wong (15:49):

Yes. Now when working with psychologists in the GI field, how often, so after an assessment, do patients go into treatments right away in the second or the third session, or do you start treatments in the first session? What does it look like?

Dr Ali Navidi (16:04):

I would say interestingly, what happens in the first is mainly assessment, but there’s also psychoeducation. And I would say good psychoeducation is actually an intervention because once people begin to understand the nature of the problem, and they can see that it’s this interaction through the gut brain axis with hypervigilance and catastrophizing, and then there’s this, and we didn’t really talk about this, but there’s this visceral hypersensitivity that is happening that creates this nasty feedback loop that really can make people miserable Once they understand that, that actually demystifies, they understand what’s happening to them, and that actually makes people feel better once they understand. So I think treatment starts the minute we start doing education. And then the second session is usually when we get started. And those sessions are typically like a mixture of cognitive behavioural therapy and clinical hypnosis. And usually there’s some homework from the cognitive behavioural therapy, and they’ll make a recording for the hypnosis for the patient to listen to between sessions. And usually sessions are once a week. And the good news is the course of treatment is not very long. We’re talking about between eight to 12

Jessie Wong (17:31):

Sessions,

Dr Ali Navidi (17:34):

So maybe around three months or so someone could be done with treatment.

Jessie Wong (17:40):

That’s wonderful. And as they are working on different tools, cognitive behaviour therapy, these are thinking processes to help them get out of the negative feedback loop. Is that correct?

Dr Ali Navidi (17:53):

That’s part of it. And

(17:55)
The other part is there’s often a lot of avoidance happening in patients with IBS. So you spoke about food avoidance, and so that actually avoiding these foods actually works to maintain the anxiety about foods. And so there often needs to be this structured programme of exposure that is paired with reframing negative thoughts. But then there’s also other types of avoidance. There’s avoidance of situations and places. Some people don’t go on long car rides, they don’t travel by. There’s a lot of things they end up avoiding that make their lives very limited. So working on that avoidance. And then finally, there’s something called interceptive avoidance. So meaning they begin to become anxious about their own internal bodily feelings, and that also adds to that anxiety spiral. So these are the levels of avoidance that we work on as well as the negative thinking that you are talking about.

Jessie Wong (19:06):

Oh, wow. That is amazing. And these are giving patients the tools so that when they’re in certain situations, they can pull the tool cell and not be afraid of it. And of course, every time I think we hear this from patients when they talk about food is I go out to eat. I don’t have symptoms. That really builds to the confidence. And you’re talking about situations. It’s the same thing. Once you created the tool, they know how to use it. They go out into adventures that they might have been afraid of every time they do it again, it builds up to the confidence that I’m actually, okay, I can do this again. I can do this freely. And then after a few times say, their confidence really comes back.

Dr Ali Navidi (19:43):

And that’s why you see with patients that have completed treatment treatments, done, let’s say here,

Jessie Wong (19:50):

Their

Dr Ali Navidi (19:50):

Progress actually continues to improve. Versus if they’re taking a drug, they finish treatment, boom, and they kind of collapse. And the reason it improves is because they’ve learned skills. They’ve learned self-hypnosis. They’ve learned how to identify and challenge their negative thinking. They learned how to challenge that avoidance in a structured way. These are all things they learn in treatment, and they can take them with them for the rest of their

Jessie Wong (20:21):

Life. I love that. Yes, it is so helpful, and it sounds like we all should go and see a psychologist right away for everything in life. But no, we are talking about specifically GI disorders, gastrointestinal disorder treatments that is very specific for patients with GI disorders. Yeah. Oh, that’s amazing. Okay, so thank you for sharing that with us. When to seek GI psych, we think go right away as soon as you’ve been diagnosed because nothing else is quite wrong. So let’s work on the software and see if we can get you to a better

Dr Ali Navidi (20:55):

Place. Yeah.

Jessie Wong (20:56):

Now, last but not least, can you share three actionable steps for our listeners? So actionable items that they can do rights now, so that they can start feeling better?

Dr Ali Navidi (21:07):

I think the first step would be get really educated and really understand and get your education from reputable places, right?

Jessie Wong (21:17):

Yes, absolutely. So

Dr Ali Navidi (21:19):

Go to Jesse’s website, check things out, go to our website, gi psychology.com. Megan Real, Dr. Real,

Jessie Wong (21:30):

I see the book behind you.

Dr Ali Navidi (21:31):

Oh, yeah, yeah, yeah.

Jessie Wong (21:32):

Yes. And mine copy is right here too.

Dr Ali Navidi (21:35):

Perfect. Yes. Yeah. Read this book, get really into it. Understand the problem, because the more you understand this problem, the less scary it becomes. The other thing then is I would recommend some sort of practise that does some kind of affect regulation. So what do I mean that calms you down? That teaches you a skill to reduce anxiety when you need it. So you can learn breathing techniques, you can learn what’s called progressive muscle relaxation. There’s visualisation techniques. There’s various things out there that you can learn that can calm yourself down, but just realise you need to practise. You can’t just do it once and say, oh, I know how to do that. No, this is a physical skill. You got to practise. Right? So that would be number two. And then the last one would be begin to understand your own thinking. Begin to kind of identify this hypervigilance and this catastrophic thinking, because I’m like everybody else.

(22:50)
I’m kind of focused on what I’m doing in the day. I’m not thinking about my own thinking. Most people don’t do that, and that’s normal. But if you want to change the way you’re thinking, then you need to become more aware of it. And so you could do something like keeping a journal or even a little log. And anytime you feel anxious, just write down your thinking. You could do what’s called mindfulness meditation, where you just sit with your thoughts and just observe them. There’s a lot of different things that you can do, but the third is doing something to become more aware of your thinking patterns.

Jessie Wong (23:33):

I love that. Just what you were just saying, mindfulness exercise, sitting there and just understand your thoughts. I think that can be really, really helpful for patients with IBS. Right? When they feel the cramp, they immediately think a lot of the times like, okay, is this an emergency? Do I need to run now? Or maybe stay with it and breathe, debrief.

Dr Ali Navidi (23:56):

Just breathe,

Jessie Wong (23:57):

Take a few deep breaths and feel it and see how you actually feel, right?

Dr Ali Navidi (24:03):

Yes, yes,

Jessie Wong (24:05):

Yes. And I love what you were saying, the three things that you actually just shared. One is the deep diaphragmatic breathing. Breathing, do some deep breaths. Number two is progressive muscle relaxation techniques, and the third is visualisation relaxation.

Dr Ali Navidi (24:19):

Oh, the three things you can do to calm yourself down.

Jessie Wong (24:22):

Yes.

Dr Ali Navidi (24:23):

Yeah, yeah.

Jessie Wong (24:24):

Can you say the last one again?

Dr Ali Navidi (24:26):

Well, so there are three categories, right? So it’s the first is getting good education. The second is an affect regulation technique, and those can include diaphragmatic breathing. It could include progressive muscle relaxation, it could include visualisation. There’s various types of other meditation and things like that. But anything that can shift your nervous system from fight or flight

Jessie Wong (24:58):

To

Dr Ali Navidi (24:58):

Rest and digest, right?

Jessie Wong (25:01):

Yes, absolutely.

Dr Ali Navidi (25:02):

Calm things down. And then the third would be doing things to help you understand your own thinking patterns, right? So when you get that cramp now realising, oh, listen to the thoughts that I have when I have the cramp. Wow, they’re really catastrophic, right? They’re really like, oh my God, I’m going to have to cancel everything, or I need to start sprinting to the bathroom right away. Take a pause and just notice the way you’re thinking can be incredibly helpful.

Jessie Wong (25:38):

Yeah, I love these, all three things. Well, the three big picture things, right? Then the actionable items that they can do right away. And to truly understand, well, first to calm the body down, and then also to better understand your thinking process.

Dr Ali Navidi (25:51):

Yeah.

Jessie Wong (25:52):

Oh, I love this. I love this. Well, thank you so much for joining me today. Do you have any words, any last words that you want to share with our IBS listeners who might be struggling with their pain,

Dr Ali Navidi (26:05):

With

Jessie Wong (26:05):

Their changes in bowel habits? What would you say to them?

Dr Ali Navidi (26:09):

Over the years, I’ve heard patients tell me about the messages they’ve kind of received from their doctors and other medical professionals that are along the lines of basically learn to live with it. And one of my messages I think I like to leave people with is you don’t have to live with it. There are very effective things that you can do on the diet side of things. There’s very effective things that you can do on the mind body side of things. These are not just things we’re telling you. These are things that have very good research and are effective, and so you don’t have to live with it. There’s a lot that you can do to make this

Jessie Wong (27:00):

Better. I love that. Thank you so much. Yes, there’s a lot of evidence into diet therapies and psychological therapies for patients with IBS and GI disorders in general. However, they’re not always recommended as one of the treatment options, but if you’re listening, you know that these are options that can be extremely helpful in giving you tools to manage your symptoms, preventing symptoms, and maybe get you out of the vicious cycle. Well, thank you so much, Dr. Ali Vedi. Thank you for sharing all your wisdom with our listeners, and I’m sure everyone appreciates it and finds it really helpful.

Dr Ali Navidi (27:34):

Thank you so much, Jesse. It was a pleasure.

Jessie Wong (27:36):

Thank you for tuning into the IBS Nutrition podcast. We hope today’s episode has brought you closer to understanding and managing IBS. Remember, you are not alone on this journey and finding freedom is possible for more on IBS. Make sure to follow us on your favourite podcast platforms, and please leave us a five star review. We would really appreciate that you can access links mentioned in this episode in the show notes to learn more about your type of IBS and how to identify your own food or lifestyle triggers. Register for a free IBS masterclass, three steps to IBS Relief for our proven holistic three steps approach to managing I IBS once and for all. Head to IBS dietician.com/masterclass to register. Until next time, take good care of your gut and here’s to your health and happiness.