Disorders of gut–brain interaction (DGBI) management strategies

Overview

• Disorders of the gut-brain interaction (DGBI) are classified as conditions with dysfunctional communication between the gut and the brain, such as IBS.
• DGBI are complex and difficult to manage, and patients benefit most from integrated care.
• Brain-gut behavioral therapies (BGBT), like gut-directed hypnotherapy, can help patients manage DGBI by regulating gut motility and reducing hypersensitivity.
• Promoting self-care practices and patient education are important aspects of DGBI management for healthcare providers.

With access to some BGBT like in-person gut-directed hypnotherapy being prohibitively expensive, along with a global shortage of trained healthcare professionals available to deliver some therapies, patients with a DGBI need to find accessible solutions to alleviate digestive symptoms and GI-induced distress.  

What are disorders of the gut-brain interaction? 

Patients with a DGBI experience disruptions along the bi-directional gut-brain axis, which communicates via neural (vagus nerve), endocrine, immune, and humoral links.

These gastrointestinal disorders are classified by GI symptoms related to any combination of:

• motility disturbance
• visceral hypersensitivity
• altered mucosal and immune function
• altered gut microbiota
• altered central nervous system (CNS) processing

Once known as functional gastrointestinal disorders (FGID), these conditions were reclassified as DGBI in recognition of the complex interplay of biological, psychological, and social factors underpinning the condition. According to the Rome Foundation, FGID is no longer used because of the false perception that ‘functional’ means less legitimate than other disorders and more undefined. 

So what conditions are impacted by the gut-brain axis? DGBI includes functional dyspepsia, reflux hypersensitivity, and functional constipation. IBS is the most common DGBI and it affects 46 million people in the US, and around 1 in 10 people globally.

These GI conditions can manifest as a range of digestive symptoms and patients may experience:

• abdominal pain 
• bloating 
• diarrhea 
• constipation
• changes in bowel habits

DGBI are diagnosed with the Rome IV criteria and classifies chronic GI symptoms where inflammation, biochemical imbalances, or structural abnormalities have been ruled out, such as an ulcer or a type of cancer.

The complexity of DGBI

DGBI are intricate, multifaceted conditions arising from the complex interplay between the gut and brain, influenced by a blend of physiological, psychological, and environmental factors like gut microbiota, stress and anxiety, or a genetic predisposition. 

While patients with a DGBI may share physiological traits, the variance in symptom location, duration, and individual experiences adds layers to their complexity. This is why managing such gut disorders necessitates a comprehensive biopsychosocial approach, tailored to each patient's nuanced experience of living with their digestive issue.

Healthcare providers specializing in gut health navigate a challenging landscape. Recent research indicates DGBI patients constitute 12% of the workload for clinicians in primary care and 30% of GI outpatient consultations. Despite this, definitive diagnostic laboratory tests or imaging studies for DGBI remain elusive, compounding the challenge of patient care.

Adding to this complexity, digestive issues are common in patients with eating disorders. Conditions like IBS might precede or perpetuate disordered eating behaviors, complicating your management approach further. While dietary interventions like the low FODMAP diet have substantial evidence for managing particular DGBI, their universal suitability remains uncertain, emphasizing the need for tailored strategies beyond dietary restrictions.

Understanding the inaccessibility of DGBI treatments 

Managing a DGBI is challenging for patients due to the restricted availability of effective treatments and affordable integrated care teams – as evidenced by the annual $21 billion cost solely for IBS management. 

Accessible solutions are vital for those grappling with the complexities of DGBI due to the profound effect they have on an individual's quality of life. IBS in particular is thought to have a low mortality rate, so it can be perceived as a low-priority disorder by some healthcare providers. Yet IBS impacts a patient’s quality of life in ways similar to ischemic heart disease. 

Additionally, managing DGBI comprehensively requires a multidisciplinary approach, involving gastroenterology, psychology, and nutrition specialists. However, the scarcity of certain specialized BGBT providers – estimated at just 400 GI psychologists worldwide – creates obstacles to quality gut-brain axis care. This scarcity often leads to prolonged suffering and frustration for those affected.

Gut-brain disorders also contribute significantly to financial strain and, as noted by leading gastroenterologist Dr. Bill Chey from the University of Michigan, "It turns out that IBS is one of the leading causes of work absenteeism, second only to the common cold." 

Furthermore, the intertwining of anxiety, stress, and depression exacerbates the struggle for individuals managing DGBI symptoms, creating a challenging patient population (though how anxiety and stress impact a person’s DGBI symptoms is on a spectrum). Naturopath Michael Smith from Planet Naturopath highlighted the rarity of relaxed patients seeking guidance for GI concerns, underscoring the psychological burden – “There are very few people who are chilled out, relaxed, and coming to me about digestion issues!” he said. 

How do you treat DGBIs?

Overcoming the accessibility challenges inherent to DGBI care requires a unified approach, and determining new collaborative frameworks could prove significantly impactful for your patients. 

At the 2023 IBS Frontiers Summit, Dr. Chey explained in detail how DGBI care models have evolved from delivering traditional care to patients exclusively via a gastroenterologist, to multidisciplinary care with a team of clinicians working individually, to the current best practice integrated model that is team-based, collaborative, and multidisciplinary. Though it must be kept in mind that a team of providers can be more expensive for DGBI patients and communication breakdowns between care teams are sometimes difficult to avoid. 

However, through collective action, healthcare providers can champion increased awareness, heightened research funding, and enhanced access to BGBT for individuals trying to manage DGBI. This concerted effort holds the promise of fostering the development of more accessible and efficacious treatments, while also paving the way for the implementation of comprehensive management strategies tailored to those afflicted by DGBI.

How to incorporate BGBT to address DGBI

Brain-gut behavioral therapies (BGBT) are a pivotal tool in the arsenal of healthcare providers dedicated to addressing DGBI. These therapies address the bi-directional relationship between the brain and gut, emphasizing the profound impact of behavioral and psychological factors on DGBI symptoms. 

BGBT encompasses a spectrum of evidence-based techniques and tools, including:

• gut-directed hypnotherapy
• cognitive behavioral therapy (CBT) 
• mindfulness-based stress reduction (MBSR) and relaxation techniques

Gut-directed hypnotherapy 

Targeting underlying DGBI mechanisms, gut-directed hypnotherapy empowers individuals to self-manage symptoms and mitigate flare-ups effectively. Dr. Simone Peters’ research study from Monash University found that the durable effects of gut-directed hypnotherapy were similar to those of the low FODMAP diet, and of the 71% of patients who responded to gut-directed hypnotherapy, 81% maintained their improvements over time (read more below about why app-delivered gut-directed hypnotherapy is a first-line option). 

Cognitive behavioral therapy (CBT)

CBT is a widely recognized BGBT technique that helps patients identify and modify negative thoughts and behaviors associated with their DGBI. By challenging unhelpful beliefs and developing more adaptive coping strategies, patients can reduce symptom severity and improve their overall well-being. 

Mindfulness-based stress reduction (MBSR) and relaxation techniques

These techniques focus on cultivating present-moment awareness and acceptance. It’s an effective way to help your patients get their stress under control. Relaxation exercises, such as deep breathing and progressive muscle relaxation, can also be incorporated into BGBT to promote relaxation and alleviate symptoms.

Healthcare providers can guide patients toward therapists proficient in BGBT techniques or recommend accessible on-demand digital programs like Nerva. Integrating BGBT into treatment plans offers a holistic approach, addressing both the physiological and psychological facets of DGBI. This comprehensive strategy often leads to significant improvements in symptom management, elevating quality of life, and fostering long-term self-management skills.

Managing DGBI with gut-directed hypnotherapy

Gut-directed hypnotherapy employs relaxation techniques and focused attention to induce a deeply relaxed state, enabling patients to access their subconscious mind and explore, modify, and manage thoughts, emotions, and behaviors contributing to DGBI symptoms. 

By regulating gut motility, reducing visceral hypersensitivity, and modulating the brain's stress and pain responses, it significantly diminishes symptom severity and uplifts overall well-being.

Moreover, as a BGBT, gut-directed hypnotherapy can help patients with self-regulation and symptom control, fostering an active and empowered role in managing their condition.

While it can be costly and difficult to access a qualified specialist able to deliver gut-directed hypnotherapy in person, there are digitally delivered BGBT programs, such as Nerva, which target the miscommunication along the gut-brain axis underlying DGBI. The Nerva program was developed from Dr. Peters’ protocol that established gut-directed hypnotherapy had superior efficacy to the low FODMAP diet on psychological indicies, making it an accessible first-line option for clinicians to recommend. 

Clinical guidelines for gut-directed hypnotherapy 

For patients with IBS specifically, gut-directed hypnotherapy is recommended in clinical practice guidelines by leading GI clincial protocols, including: 

• The American College of Gastroenterology (ACG)
• The British Society of Gastroenterology (BSG)
• National Institute for Health and Care Excellence (NICE)
• The Gastroenterological Society of Australia (GESA)
• Healthify (the New Zealand government’s health guidelines platform)

These organizations attest that gut-directed hypnotherapy is highly effective in managing both the physical and psychological aspects of IBS flare-ups in the vast majority of people with IBS.

Helping patients move to self-managing DGBI

Healthcare providers play a pivotal role in facilitating patient self-management and symptom control in DGBI cases. 

According to the British Society of Gastroenterology's IBS management guidelines, patients seek increased empathy and comprehensive information from their healthcare providers, not only about the nature of their condition but also regarding viable symptom management avenues.

Empowering patients through education and support enables them to assume an active role in their care. Here are some strategies you can implement:

1. Empower through education: Educate patients about DGBI, including the nature of the condition, potential triggers, and the available treatment options. This helps patients understand their condition and make informed decisions about their care.
2. Advise on lifestyle modifications: Guide patients in adopting lifestyle changes that positively influence DGBI, encompassing dietary adjustments (if suitable), regular exercise, stress-reduction techniques, and chat to them about the importance of adequate sleep.
3. Help them self-manage stress: Stress is well-known to exacerbate DGBI symptoms. Talk to your patients about stress-management techniques, such as deep breathing exercises, mindfulness, and relaxation techniques, to help them reduce symptom flare-ups. If you feel like this out of scope, consider referring them to Nerva. The program guides patients through breathing exercises alongside comprehensive gut-directed hypnotherapy to address gut-brain miscommunications.
4. Check-in regularly: Maintain regular check-ins with patients to monitor progress, adjust your treatment plans as necessary, and provide ongoing support and guidance.
5. Refer to supportive resources: Refer patients to support groups, online communities, and educational platforms focused on DGBI, such as Matter. This is where they’ll find practical information on everything from yoga for IBS to cognitive defusion, expert advice on calming symptoms, and the best dietary therapies for their condition.

Implementing these strategies will help your patients with a DGBI learn to take back control of their condition with new self-management skills that will enhance their quality of life.