The Psychology Behind Functional GI Disorders: Interview with Dr Drossman

Welcome everybody. Today we have with us Dr. Douglas A. Drossman, who is Professor Emeritus of Medicine, Psychiatry and Gastroenterology at the University of North Carolina School of Medicine, where he specializes in functional gastrointestinal disorders and psychosocial and psychosomatic medicine. He's also president of the Center for Education and Practice of Biopsychosocial Patient Care. He has a private practice named Drossman Gastroenterology out of Chapel Hill, North Carolina, and he's also president of the Rome Foundation and former director of the U.N. Center for Functional Gastrointestinal and Motility Disorders. He has published over 500 articles and received over $15 million in federal and pharmaceutical research. Educational and clinical interests relate to the psychosocial and behavioral aspects of patient care. He also facilitates workshops for health professionals to develop skills in patient communication. We're delighted to have you here today and thank you for meeting with us, Dr. Drossman. Thank you, John. Nice to be here. Hope I can help. Imagine a bit about functional gastroenterology disorders and also about the brain-gut connection. So perhaps you can tell us a little bit. You've been involved in a lifetime research and patient functional GI disorders, so maybe we can start at the beginning. Can you tell us how that began and a little bit about what you've done for that field? Sure. Well, I think starting in med school, I wasn't sure if I wanted medicine or psychiatry, and I think that was a prelude back in the 60s to what later became the concept of mind-body connection or mind-gut connection. So I went into medicine and I went into gastroenterology because I thought that wasn't where the mind and body were most connected and they are than other organ systems. And I went into gastroenterology as in my training, but also took some time to learn about what at the time was called psychosomatic medicine or the relation of mind to body. Now it's called biopsychosocial medicine because it's integrated looking at not just the psyche, but also biology, spirit, and the like. So it's an integrative type of medicine. And my present research has standing relationship looking at the psychological aspects of how stress can affect GI functioning. We all know that someone can get cramps and diarrhea before an exam or get constipated when they travel or get abdominal pain when under stress. So that was what I was really looking at. And in the course of my work and my research, I became very interested in how to best obtain that information from patients. And that led to an understanding of communication skills. How do you really actively listen to the patient? How do you provide patient-centered care? And as I did that, I learned more and more information about patients in ways that most doctors didn't do. They asked about the symptoms and then gave them a treatment, but I was understanding their life history. And that led me to do some research in areas like how stress affects it. We were the first to report how histories of abuse, sexual or physical abuse in childhood could lead to development of GI conditions. We also looked at outcomes, how stresses and quality of life can affect how you do. So it's not just the symptoms and the condition, it's the whole mind-body interface. So I started to teach that as well. And then in the course of doing the research and teaching, my practice started to grow. I was at UNC for 35 years. I've since retired, but I'm actually more active now in a specialized practice dealing with functional GI disorders. And I'm also president of the Rome Foundation, founder and president of an organization that develops, that helps gastroenterologists make diagnosis and do proper treatment. Fascinating. Now, when you say social, I immediately think of a community and interrelationships. Is that a part of this too? You mentioned a little bit about lifestyle there. Is environment and social a part of the work that you do? Absolutely. We're talking about even the fact of early family environment and how it affects illness later. We know that, for example, that when someone grows up in a family where a great deal of attention is paid to the illness, almost too much attention, then the child learns to communicate through illness and then to go to the doctors more often when they're older. That's an example of the family environment. We also understand it in terms of cultural. One of the things with the Rome Foundation is understanding cross-cultural differences. We know that in Western cultures, bloating is a big common finding. Well, it turns out that in Asia, it's a huge finding. It's very, very common. But in Latin America, there's not even a word for bloating. They call it inflammata and they don't understand it the same way. So cultures can affect how people experience symptoms. In China, people often think about their GI symptoms in terms of temperature, whether they feel hot or cold. That's not a typical finding in Western cultures. Yeah. And certainly in Ayurveda, we have a bit of that as well. We have this concept of food heating up the digestive or cooling the digestive tract. So that is terminology that an Ayurveda would be familiar with, but certainly not something that the average Western person is familiar with. So this sounds complex. We have the cultural aspect, the social aspect, the mental aspect, and then all the biology of it. It sounds like it could very well be the subject of a life's work to try to sort all of that out. So perhaps you could tell us a little bit more about your current practice. In what ways are, how are you addressing some of these issues in important ways that can really help the client? How to deal with some of these cultural, social factors that are affecting the body? That's a good question. And it really gets into issues around choices that I made to leave UNC, at least in terms of the practice, not in terms of the teaching, at a time when I was really at the prime of what I'm doing. And I think the reason is that in our healthcare system, there's so much attention to doing procedures and doing tests and spending less time with the patient, seeing more patients and less time than I thought I was, not providing the quality of care that I needed to address the biopsychosocial concepts. So I went into a private practice and the way the practice is set up is I can afford more time. I, first of all, the patients I see with functional GI disorders are referred from all over from out of state. They're referred from the Cleveland Clinic, the Mayo Clinic, because at those places they do testing and send them back. So our program focuses on understanding and management. So what we can do is we can provide an hour and a half or even two hours on the first visit to get to understand all the parameters. And with that information, give a more directed type of care. And then we can continue to see the patients because I've seen them once in the office. I can do some telephone, what's called telemedicine care as well, if it's too much for them to travel. So the nature of my practice is really accommodating patients who have difficult to diagnose or difficult to manage functional GI disorders where even distance is no factor. Well, that's going to be pleasant news to many of the people listening today because our audience is spread out across the country and also across the world so that they have an opportunity to meet with you is truly going to be helpful for them. So what I gather from your answer is that it wasn't so much a systematic approach to these cultural or social or family issues that can affect digestion, but that time was the solution. That people need to talk and need that interaction with a professional that can help them sort out some of these issues. And then on top of that, we might need to address some of the physical and biological aspects perhaps with a test or perhaps with a pharmaceutical or other techniques, other remedies. Is that true? So that the starting point here really is time with the client? Time but in the context of not just the patient talking, but the doctor listening and integrating this information. And that's where doctors are not necessarily trained to do that. And that's why I had my additional training in psychosocial or biopsychosocial medicine. And that's what I teach through our center is how do you do this? How do you integrate? It's like a patchwork doing a quilt and there are pieces in different places. And if you don't get all the pieces, you can't see the whole picture. And certainly in Ayurveda, we spend a lot of time with our clients and it seems even that more and more as Ayurveda practitioners, you know, over the years that they end up talking to the patients more and more about their psychological aspects. And so this fits in very well with what, you know, what practitioners try to do with their clients. And the fact that you have formalized some of these communication components as president of the Rome Foundation and offer workshops for health professionals, you know, can probably even advance a lot of Ayurveda that are out there dealing with some of these digestive disorders. It sounds like a fascinating opportunity. Can you tell me a little bit more about what is functional GI disorders? I think that many of the people on this call are hearing that word for the first time. So maybe you can tell us a little bit more how functional GI disorders are different from other gastrointestinal problems like ulcer disease or inflammatory bowel disease. That's right. So functional GI disorders really mean disorders of gastrointestinal functioning. There is a very precise homeostasis between the mind and the gut. We know that the brain is always receiving input from the gut and registering it and regulating the bowel. The bowel has its own nervous system. And when that system is not working properly, you get a functional GI disorder. That can be in terms of patients having changes in what we call motility. That is, they can have diarrhea, constipation, or vomiting, nausea, or sensation of the gut where a little bit of food might create a greater neural response or response of the nerves of the gut to produce pain. So where you and I or people who don't have functional GI problems can eat normal meals, but if they overate, they might feel cramps and pain and feel stuffed and even have to run to the bathroom. Patients with IBS do that with just a little bit of food or no food at all, just with a stressful thought or with physical activity or a woman premenstrually. What it really is is an overreaction of the physiology of the GI tract to various factors in your environment, stress, physical activity, diet, hormonal disorders, and the like. So what we're saying here is that there's either motility problems or sensations in the gut in the absence of some physical trauma to the gut. There's not actually inflammation if you do an endoscopy and peek in there with a camera or anything physically wrong, but this is truly that the GI organs are just functioning wrong. Is that the way that people should interpret that? Yes, mostly, but there's one caveat. So yes, you do x-rays and endoscopy, you won't find any abnormalities, no structural abnormalities, and that's how it differs from ulcer disease and Crohn's disease and pancreatitis and the like. Having said that, there is recent evidence that there are changes that occur, but at a very microscopic level or in terms of the signaling between the neurotransmitters. For example, one of the big issues these days is that of the microbiome or the bacteria of the gut, that there are good and bad bacteria, and bad bacteria, when they're predominant, such as after an infection, can affect the GI functioning to cause what's called the leaky gut or loss of membrane integrity, and chemicals and toxins can go down into the gut and produce mild, very mild inflammation, not like inflammatory bowel disease, but very mild, but it can lead to sensitization of the nerves. So these days, we're learning that there can be factors like an infection that can do it. I think one of the critical points that separates it from the structural diseases is the additive of patients, physicians, and society toward these conditions. They're falsely attributed to being psychiatric conditions, or that there's nothing wrong and you have to learn to relax. These are real physical conditions that are experienced quite intensely by patients, but it can be trivialized because doctors and patients keep going, looking for a structural finding, not accepting that you don't have to have a structural finding to have these symptoms. And what should a person do, then, if they have this micro-inflammation that is the legacy of a past infection, that is disrupting their gut, and we see this at our clinic all the time, this issue of a client that had an infection a long time ago, and their digestion is just disrupted since, even though they're eating, generally, a pretty healthy diet. And so how would you address that condition? Right. So about 15% of people who get acute gastroenteritis will go on to have more prolonged symptoms. And there may be, and as I explained to you, that infection causes alteration of the lining of the gut. It often happens in a combination with stressful experiences. I was part of the Institute of Medicine Committee looking at the effect of the Gulf War and Gulf veterans from Iraq and Afghanistan coming back, and many of them would get up to half, well, not up to half, would get some problem, but a good proportion would get irritable bowel syndrome and functional GI disorders. And that's because most of them got a gastroenteritis in deployment there, and it was in combination with the trauma or the stress of deployment in a war zone. So it's the combination of the two that seem to lead to the prolongation. Most people who get a gastroenteritis recover. But if you have that combination, and maybe if you have some genetic predisposition, you'll go on to develop irritable bowel syndrome or functional dyspepsia or these other functional GI disorders that could go on for years. If you have that, I think your question is, what do you do about it? Well, I think we know that with functional GI disorders, the gut overreacts to stress. So we have to try to take a good look at yourself and look at your life and see are there things you can do to reduce that, whether it's physical activity or meditation, whether it's psychological counseling, whether it's learning about cognitive behavioral therapy. There are so many ways to kind of relax the mind, to relax the body. We've done brain imaging work in patients with IBS showing that the areas of the pain control center are affected under stressful circumstances like a history of trauma or something like that. So I think practitioners who do Ayurvedic healing or other type can provide not just the practicum of the care, but the process of care, of good communication, of listening, of providing support in relaxing the mind and then relaxing their body. Now when it gets to a point, then some people, that's not enough, then they should be referred to the doctor and in particular the specialist who works in functional GI disorders like gastroenterology because there are medications and other things. There are things like probiotics that can be used, dietary factors. We have to know that a subset might have celiac disease or who might have gluten sensitivity. So that would be something to consider. Again, the caveat is that there is so much attention to this that I think it's being a little bit overplayed and people are restricting their diets to a degree that's not necessary. I've had patients come in on baby food and it's not necessary. Yeah. And that causes problems as well. Many of the clients that come to Joyful Belly have already tried modifying their diet to the point where their diet modifications are either so restrictive or so severe that it's causing more harm than good. And we've got to help the client reintroduce foods into their diet in a way that is supportive. So we see that. We see a lot of people who come to us who are restricting their diet. The psychologic concept is called effort after meaning, and what that means is when you get a condition, you get a painful episode, the mind normally says, why did this happen? And the easiest thing to do is to attribute it to something that they ate, a particular food, even the fried chicken the night before. But that's not necessary. The gut is not very intelligent in terms of what goes into it. What sometimes happens is that it's the eating of the food that stretches the stomach, releases hormones and neurotransmitters that overstimulate the bowel. So eating itself is a trigger in functional GI disorders to a response. So sometimes something as simple as smaller diets more frequently can be a treatment, not necessarily what you eat. That's not to say that some people, a small proportion, could have sensitivity to gluten and things like that. But the greater response for most people is to over-interpret that finding. And really what's happening is that eating is a process that can stimulate the symptoms and you have to learn to reduce the stress, use medications that can reduce the sensitivity of the bowel and the like. Fascinating. So quantity and the timing is playing a factor here as well, not just what the person is eating. And this over-interpretation, getting anxious because a person thinks that they're intolerant to gluten is going to cause a digestive disturbance as much as the gluten itself, right? We're doing a videotape now because I want to teach that concept in a young woman who came to me six months ago who was 30 pounds less because she was obsessively preoccupied with what to eat and the anxiety around that and the eating led to the symptoms. So her treatment, in addition to some medications, was to get her to rethink what we call maladaptive thinking. I can't eat this, I can't eat that. And to gradually get a sense of control over what she can eat. And now she's 30 pounds heavier feeling, which is not overweight, she's normal now, but functioning quite normally with a better sense of her knowing herself, knowing her body and eating most everything. She made a comment that for four years I didn't eat gluten or processed foods or anything and now I can't get enough of it. I think it's a great testament to, it's really the bodies, the mind and the body affecting much of this. Yeah. Our bodies are more flexible than we think. Diet, of course, is not irrelevant, but our body does have a lot of flexibility. And the term is orthorexia, right? Orthorexia, the obsession with eating correctly, ends up that people are making decisions about food with their mind instead of letting their intuition around food lead them to a good diet. If a person wants a banana, there may be a good reason for that. And that's okay. It's okay to eat the banana when you feel like you want one and not to override that or let's get, you know, interrupt that process too much that can cause problems. Yeah. And to re-mention, the brain, the body, the gut is not that intelligent to discern what you're eating. It knows about fats and proteins and carbohydrates, but whether something has been processed or not is not something that the body really interprets. With the exception of a few people who might be gluten intolerant or lactose intolerant, but for most people, it's not going to make that much of a difference. Yeah. Now here's an area where Ayurveda places a great, more deal of attention to this concept of taste. And so, and so Ayurveda talks a lot about how the body interprets food. So maybe that is, would be a very interesting discussion to have, to hear more about is the gut intelligent or not in this, Ayurveda certainly does talk a lot about taste as having a factor. So I'm interested to hear more about that. You're also president of the Rome Foundation, and you've talked a lot about this today on our call, about the importance of communication and the doctor active, perhaps active listening. Can you tell us a little bit more about the foundation and how it helps, how it helps people communicate and why it's so critical for people who are dealing with clients that have digestive disorders to look up the Rome Foundation, to, to pay attention to it and how it can improve their practice. Okay. So let me make a distinction between the Rome Foundation and our center for biopsychosocial care. The Rome Foundation is a international nonprofit organization of experts around the world, functional GI's. So we together to produce committees that, that produce fully documented, help doctors take care of the patient. Now that involves understanding the micro flora of the gut, understanding brain gut communications, understanding the basic science of how the gut, understanding cross cultural differences. And those are publications that we produce, including criteria for diagnosis. So the scholarly component that patients can learn from there's books, we're going to have books coming out, Rome 4 books, just like in psychiatry, there's DSM 1, 2, 3, 5, there's now Rome 4 coming out after 10 years. There will be a book for primary care doctors and non gastroenterologists that patients can purchase to learn about these conditions. What the center does is it focuses more on the process of the care. So it talks about how do you best communicate with patients? How can you learn to do that? We even do it for patients. How do you best communicate with your doctor? It's a two way street. And what we're focusing on are several key principles. The doctors have to learn empathy. They have to learn about what we call patient centered care, which is participation with the patient where the patient makes decisions with the doctor, the doctor doesn't tell the patient what to do. Now, if you come in with a gallbladder attack, there's not a lot of communication that needs to go on. The doctor has to take the gallbladder out. But if you have chronic pain or functional GI disorders, there are life choices. What foods should I go to? Should I take medications? Can I work? And that's where the patient doctor has to participate. So that's involving that establishing a sense of trust and validating the symptoms. Patients come into doctors. They don't believe that doctors think that it's real. And sometimes they don't. The doctors think it's not a real condition because I can't see anything. That's the kind of communication that has to go on. Okay. That participation with patient centered care, then it means that the that the patient gets to participate in deciding what choices they're going to make with the with the advice of the doctor that the doctor is saying, here are some things that can help you. Which of these can you do? Which of these can you integrate into your life? Is that the is that the idea? Absolutely. Because if the doctor says, I want you to do this, a patient either doesn't understand it or may, for whatever reason, not agree with it, they're probably the adherence rate is going to be very low. They're probably not going to take it and they may not even tell the doctor. But if a doctor says, well, here's this treatment, here are the side effects, here are the potential benefits, here's this treatment, which one does appeals to you or do you have any questions about it? They get in a dialogue where the patient can make an intelligent decision with the doctor acting as a kind of a coach and they're more likely to stay with it. Yeah. It's something that they can integrate into their life. Finding things that people can do because, you know, the doctor has has a lot of experience with so many different clients and has a lot of ideas that the clients may not have thought of. And the client knows what they can change in their life and what they can't. They may have to go to their their job at which is at odd hours or places a lot of stress on their body. Well, how can they improve their quality of life despite that? That limitation, despite the thing that they can't change. And it goes both ways. There is a partnership here in the sense that these days, very few patients, the doctor without having read the Internet about this treatment or that treatment, the doctor has to educate. They have to be willing to listen and educate because, you know, coconuts or lots of things get played out in almost like a meme. It's almost like a viral attention to a particular product and it may have no scientific value and the doctor has to help provide that guidance. Yeah. Health fads. One food being better than another food, you know, it almost takes on a moral or ethical quality. Some of these foods that people are thinking, this is healthy. That's not healthy. And Ayurveda certainly doesn't subscribe to that. In Ayurveda, it's very much on the basis of the individual. We have to look at the client. It's not that coconuts are better than bread or bread is better than coconuts. But you see that kind of thinking. It's pervasive and we'll use those kinds of fads to make lots of money, but it's not necessarily helping the client. So there's more to the story. Now, so going back to the Rome Foundation, which you said was different from the center, the Rome Foundation, is that a means for functional GI doctors to make sure they're providing comprehensive care, that they're not leaving diagnostic questions unasked, that they're making sure that they have looked under every stone and every nook and cranny? Is that what that's about? So the Rome Foundation began about 25 years ago, when there was no way to categorize patients with these conditions. They were just symptoms and in order to understand these symptoms better, we had to develop categories or criteria for diagnosis so that some patient might have abdominal pain with diarrhea and others abdominal pain with constipation. We call that IBS. But by using criteria, these patients could be studied so that a patient population in North Carolina would be the same as in England or China. And by that, we were able to collate information. So we started by developing criteria for research to make the diagnosis. And over the years, we started to provide educational materials about that research and to the point of going through Rome 1, 2, 3, and 4, now 25 years later, we have basically an encyclopedia of functional GI disorders with diagnosis and treatment. And in addition, we have additional books such as algorithms. The patient comes to you with nausea and vomiting. What workup should you do? What diagnostic should you do? And then we have what's called the MDCP, which is a treatment program, multidimensional clinical profile. That's biopsychosocial, where we look not just at the symptoms and the diagnosis, but what's the impact on their disease, their quality of life? What stresses are they experiencing? What physiologic abnormalities do they have, incontinence or gastroparesis? And putting that together, we make treatment recommendations. So we're comprehensively looking at ways to help doctors with those diagnoses and treatments. And one of the more exciting things we're doing now is we're developing intelligent software where, after looking at thousands and thousands of these patients in the pathways for diagnosis and treatment, the program develops a brain where the doctor can put in the symptoms and through a series of questions, it tells them what to do in diagnosis and treatment. Fascinating. So the fruits of a lifetime of dedication to this field, it's incredible all of what you've managed to put together on several levels here as a ... I'm very interested to hear about this intelligent software because I certainly do believe that there's a lot of opportunity there for ... There's so much data sometimes, so much information. It can overwhelm the doctor, I'm sure, and to have the help of intelligent computer software to sort through all that data, that's been done in marketing. Why can't it be done to the body? Let's do it with the body as well. It's much harder. Yes. Yes, of course. It must be. But there's still some opportunity there for improvement, which you've identified, and that's fascinating. And you've brought this up a lot also in our interview about brain-gut interactions and the growing interest in that field, and you've talked a lot about functional GI disorders. In this brain-gut interaction, you've talked a lot about communication with the client and the doctor listening. How about microbiome? What more can we say about microbiome? There's been so much interest lately in that area. Is there any insights that all this provides with microbiome? Is brain-gut affecting the microbiome? What are some of the factors that are coming into play there? Well, I would take a leap that's evolving in that microbiome can affect the brain. We know from animal studies that the bad bacteria can create states of loss of cognition and even depressive states. So yes, there is this mind-gut connect. First of all, no other organ is as close to the brain as the GI tract. It has its own nervous system. It's what we call hardwired to the brain. And the functioning of the gut can be modified by the brain. And when it's not working well, we call it a functional GI disorders. But conversely, gut dysfunction can affect the brain. Someone who has chronic pain or diarrhea has tremendous amount of emotional distress and anxiety. They're fearful of leaving the house. They don't want to socialize. All of those kinds of things can be affected through this brain-gut connection. That's very different from other organ systems like the heart or the lungs. And the microbiome is a part of the gut, which is only beginning to be understood. Ninety-five percent of the microflora of the gut are not recognizable because there's no way to identify them. Cultures only do a small proportion. We're doing these genetic testing of these bacteria now to understand it. And the quality of the bacteria and the quantities are different across cultures, depending on what you eat. And they also are more common, abnormalities are more common in functional GI disorders. So bacteria like Firmicutes are higher, Bifidobacteria is lower in functional GI. And by that recognition, altering the bacteria of the gut, such as probiotics, or in some cases antibiotics, with the Bifidobacteria, or even these days, the possibility for fecal transplantation, are ways in which you can reestablish a more normal gut functioning. In our practice, about 30 or 40 percent of people coming with irritable bowel go on an antibiotic for treatment, a non-absorbable antibiotic that works only in the gut. And they do beautifully well for three, four, or five months, but then the bacteria come back and they have to be retreated. So it's a very intimate connection. And as I mentioned, the nature of the good and the bad bacteria can affect mental functioning as well. So it's not just about how you feel in your tummy, but digestion affects the whole nervous system and the body. So this kind of places digestion, gives digestion a more central role in a person's health on some level. Because this is affecting your mind, this is affecting the way you think, this is affecting how you feel, how you're digesting. So it really brings our attention there. Dr. Jossman, this has been a fascinating talk, and I'm sure that everyone who is listening is going to have a lot to learn from what you've shared with us today. I appreciate some of what you've given and your time, but also your commitment to this field. It's amazing. You mentioned earlier on about workshops where people can develop clinical skills. Can people learn more about this by coming to these workshops? Who can come to these workshops? Is this just for doctors? Is this for everybody? Can you tell us a little bit about what the workshops are even like? Are these one-week workshops? Are these something that people will go to for a whole year? What is the opportunity there for patients and for practitioners, even people of different ages from Western medicine, to come and learn some of the skills that you develop? This is part of the Jossman Center, and we have programs, you can go to jossmancenter.com and you can find out about it, and there are various kinds of programs. I give lectures at various communities and medical centers about communication skills. We have workshops, which can be anywhere from a day to two days, to a day and a half usually, where we would enroll people, and this could be any practitioner, whether it's a diabetic or an MD, we would tailor the training, because communication crosses all disciplines. It's present in business and law and in healthcare. So we would develop that where we do small group sessions and video demonstrations and role plays, and you can contact us through the website and we can set up workshops. The other thing we do are what are called preceptorships, where you could spend time in the practice observing what we do, and then we talk afterwards about what we did in the biopsychosocial approach to care. So those are the kind of workshops that we do for everybody. The other point is that there's the jossmangastroneurology.com, which is for treating patients. So if you work with a patient who has a very severe gastrointestinal problem, where your work is not enough, they need some medication or psychologic intervention, you can refer them to our practice. Should I give the number for referral? Sure. Yeah, given the website jossmangastroneurology.com and then jossmangastroneurology, what is the phone number that people can use? For referral, it's 919-929-7990, and we contact Dina, who's our scheduler, for an appointment. Great. So this is where people can take the next step. Thank you again so much. I really appreciate your time and what you've shared, and also, again, your contribution to this field. Thank you very much. Glad to be here.