012: Let’s Talk Brain-Gut Connection, IBS and Anxiety

Transcript

Karen Conlon, LCSW:

Hello, hello and welcome to the, So, How’s Therapy? Podcast. A podcasts that works to demystify, debunk, and de-stigmatize what happens in the therapy space. I’m your host, Karen Conlon, and I’m super excited today to have our guests, Tamara Duker Freuman. She is a registered dietician, a published author, and her book, The Bloated Belly Whisperer, has become a source for so many people who are struggling with digestive issues. Tamara, welcome. Thank you so much for coming.

Tamara Duker Freuman, MS, RD, CDN:

Thank you for having me.

Karen Conlon, LCSW:

Please tell us a little bit about yourself. I’d love to know a little bit about what got you into this work and where you are now.

About Tamara Duker Freuman, MS, RD, CDN:

Tamara Duker Freuman, MS, RD, CDN:

So I am a registered dietician and I have worked in gastroenterology practices for over a decade in New York City. I’m currently with New York Gastroenterology Associates. Dietetics is really a second career for me. And so I came into dietetics, just kind of being really interested in general in health nutrition, and kind of that food connection.

Maybe like a year and a half into my graduate studies, I kind of really became captivated by the digestive system. As I learned more about how it worked, I started to really see it as sort of like this roadmap and different things are happening at different points along the way. And just this really intimate connection between what we eat, and how we eat, and how that would express itself and manifest itself in terms of digestive symptoms.

And just this really powerful feedback loop that people with digestive problems can get between their food choices and their feelings of wellbeing or not wellbeing. And that potential to make such a big impact on people’s quality of life, was really what drew me to gastroenterology. And I got my graduate degree, I got my credential and right out of school, I started working in gastroenterology and I’ve really never looked back.

Karen Conlon, LCSW:

That’s just an amazing journey that you’ve made from maybe starting off thinking, “Okay, this is something I’m really interested in, and food and nutrition,” and then starting to notice really how deeply impactful it is for people to not just have the right nutrition, because this is way beyond the right nutrition, right?

What you’ve discovered here, you and everyone that is invested in this world of the mind-gut connection is really what you talked about here, is that very intimate connection. And I love that you used that because it is such an intimate connection. And it’s one that so many people do not know about, but yet they’re walking around impacted every day, in so many different aspects of their lives.

One of the things that I’d love to maybe talk about today is that connection, that intimate connection between the brain, the gut, and later on some of that IBS and anxiety, and let’s just piece it all together for people in easy to understand terms. Let’s start off with that, disorders of the gut-brain interaction, DGBI. That’s a really long word, but can you tell us a little bit more about that, DBGIs.

Brain-Gut Connection and DGBIs

Tamara Duker Freuman, MS, RD, CDN:

Yeah. DGBIs, disorders of the gut-brain interaction, is a relatively new term that’s being used to describe a variety of what used to be called functional GI disorder. And what separates DGBI from other types of digestive diseases is that on the surface of things, we can’t actually see the sickness.

We can’t see the pathology right? There is pain in the stomach or pain in the intestine, and when you actually look in there with an endoscope, or a colonoscope, or a CT scan, or some type of imaging, there’s nothing that we can see visually that should account for that pain. There’s no active inflammation, there’s no ulcers, there is no infection and yet the pain is very real. Or people will have issues with motility.

Things are really slow or things are really fast. And again, there’s no organic disease that we can see or measure with blood work or stool samples that should account for these things. And yet they’re very real and they’re really happening. And so this collection of GI disorders that meet those criteria, really we’re learning have a lot to do with the interaction for how the brain and the gut are cross-talking, and how the brain is regulating sensation, motility.

Symptoms and the characteristics of these disorders are really kind of originating from that crosstalk between the brain and the gut. And that’s where this acronym came from.

How The Brain And Gut Communicate: The Brain-Gut Connection

Karen Conlon, LCSW:

In terms of what separates these types of conditions, these GI conditions, you were talking about the connection between the brain and the gut, and there’s a bi-directional communication that’s going on, how does that happen?

Tamara Duker Freuman, MS, RD, CDN:

So there’re several ways that the brain and the gut can communicate, and I think some are more well understood than others. I think one that is more widely understood and researched is the role of neuro-transmitters, which are chemical signalers that our body produces. And one of them we’ve probably all heard of in this space is called serotonin. So 95% of the serotonin in our body resides in the gut.

Some of our gut cells make serotonin, we have receptors in the gut that take it out of the gut and bring it back into the body. And in the psychology space, we always think about a feel good chemical, but in the gut, it also has roles in secretions of fluids in the gut. And it has a role in motility and things moving forward. And so the amount of serotonin you have in your gut or the length that’s sitting around in your gut once it’s made, can impact motility and your secretions, which can be really altered and irregular in people who have irritable bowel syndrome.

And then I think another way that is being researched now is the gut microbiome. So the microbiome produces all sorts of chemicals when we feed it fiber and food. And we’re starting to really understand that some of these byproducts, these chemicals that the microbiome produces, can also be involved in communication with the brain. And so things that we have historically thought of as originating in the brain, pain perception, or mood, or anxiety or depression that some of these seem to be associated with the state of the microbiome.

And it’s not really clear where these things originate. Do they originate in the brain and then influence the gut, do they originate in the gut and influence the brain?

So I think there’s a lot of research that’s going on, but I think the bottom line is that your brain and your gut are in constant communication with one another and in the GI space, and in the GI nutrition space, really what we’re focused on is how do we influence that communication, both through what we eat and how we eat, also through medications that can influence that communication signals and also through behavioral therapies, where we can kind of influence how that communication takes place.

And so there’s a lot of really great, impactful interventions that are now available to treat disorders of the gut brain interaction that target all of those areas.

Brain-Gut Connection: Your Gut Houses an Ecosystem

I always think about it as an ecosystem, because it really is an ecosystem, right? And so if you think about, like the Amazon rainforest, right? Think about the biodiversity in a rainforest, there’s thousands and thousands of species, and they’re completely interdependent and symbiotic.

They are a tightly knit ecosystem and different creatures have different roles, and in different ecosystems. So your microbiome might be an Amazon rainforest and my microbiome might be a Northeast deciduous forest. But there are still organisms that are playing similar roles, there’s organisms that take carbon dioxide out of the air and turn it into oxygen.

Maybe a different set of trees in your ecosystem than in mine, but they’re doing a similar role, certain types of decomposers that take all the organic matter and decompose it in a rainforest.

And there’s different species in my Northeastern forest, but they’re different roles. And so all of our inner ecosystems are unique, as unique to us as our footprint, but there are common sets of organisms that are performing similar role. And things can be off balance, in an Amazon rainforest, if somebody comes in and starts logging, all of a sudden the whole ecosystem is thrown off.

The same can be said with, you take a course of antibiotics and things get thrown off, or you follow a particular type of diet that is very, very low in fiber, or very, very narrow and not diverse. And it is not optimally nourishing the microbiome.

And so if you think about your microbiome as a really complex ecosystem, you can understand why the research into this is sort of still very much trickling out, and we don’t fully understand how to actually completely manipulate it to our ends because everybody’s is completely different. And we’re still trying to figure out exactly what everyone in there is doing and whether we can manipulate it. And if so, how? So, it is very much a field of emerging research.

Karen Conlon, LCSW:

And I love the way that you describe it as an ecosystem. It makes so much sense. When things are thrown off, we have the development of different types of DGBIs. Can you tell us a little about some of the ones that you see most commonly in your practice?

Common Types of DBGIs

Tamara Duker Freuman, MS, RD, CDN:

Sure. I mean, probably the ones I see the most commonly are IBS, which is irritable bowel syndrome and functional dyspepsia, which is a similar type of DGBI, but it really affects the stomach and the upper GI tract, whereas IBS affects the intestines, the bowel.

Similar characteristics, in that there is sort of this, what we call a visceral hypersensitivity. And visceral hypersensitivity means that the nerves of the organs in the stomach are really extra tuned in to the presence of even normal amounts of stimuli. And so really a hallmark characteristic of all DGBIs is pain. It’s a higher amount of pain, or I guess a lower threshold of tolerance for stimuli that in somebody without a DGI wouldn’t cause an issue.

And that’s a really important distinction because our patients with IBS don’t necessarily have more gas than patients who don’t have IBS, but they feel every little gas bubble in a way that someone without IBS doesn’t.

Or someone with functional dyspepsia who has a visceral hypersensitivity in the stomach, their stomach might not empty any slower than your stomach, but they get these feelings of excessive fullness from a much smaller amount of food than you would, even though their stomach isn’t emptying any slower than yours.

And so these sort of exaggerated, hypersensitive nerve reactions to the presence of stimuli, like I said earlier, it could be food, it could be bulk texture of food, it could be fat, it could be spices, it could be gas, it could be stool. These heightened responses is really characteristic of all of these conditions.

Karen Conlon, LCSW:

To give some of the examples that I hear in practice. “I sometimes am eating, I start eating food and by my third bite, I’m feeling so full, like my stomach is going to explode. I can’t take anymore and yet I’ve only had three bites of food.” Another example is, “When I eat my food, I can literally tell you where it’s located, I can tell you when it’s up here, I can tell you when it’s down here to the right, I literally feel it go through my digestive system.”

And another one that comes in a lot as well is, “I ate just enough to feel full, but I’m always in pain and sad. I don’t really know what it’s like to feel full because I just start feeling pain.”

And the brain really should be acting as a buffer to all of that. You’re not supposed to be walking around, being able to feel that whatever it is that you ate going through the process of digestion, moving through your stomach, and then into your small bowel and, you’re not supposed to be feeling all of that.

So when there is a communication dysregulation between the brain and the gut, these are some of the things that happen, urgency, constipation, a mix of both. Do we have an idea of why some people respond one way or another?

Irritable Bowel Syndrome (IBS)

Tamara Duker Freuman, MS, RD, CDN:

In very general terms, when we study IBS and learn about IBS, there’s sort of a variety of, “Risk factors,” or predisposing factors. And so I don’t know that it’s just one thing, there are associations between childhood experiences, trauma, neglect and early childhood emotional trauma, sexual trauma. And so there does seem to be something around the developing brain and the eventuality of how the gut becomes.

But then there’s also sort of some characteristics of the gut microbiome that seem to be more common among people. And again, because all of our microbiomes are different, it’s not like, “Oh, that’s what an IBS gut looks like.” All IBS guts kind of have similar characteristics, but they’re still all different. And so it’s not like you can be like, “Oh, it’s that critter. It’s like you have that bacteria and that bacteria gave you IBS.”

If only it were so easy, right? It’s not. But there do seem to be patterns, I guess, templates or characteristics of ecosystems in someone with a DGBI that seem to differ from people without. And so it’s not entirely clear, why someone gets it, why someone doesn’t, we do see that it can run in families and there’s probably some sort of hereditary predisposition.

But again, that doesn’t mean that every child of a mother with IBS is definitely going to get IBS. And so why did that sister get it, and that sister didn’t get it. And then I guess the last one, which we do have a better handle on is post-infectious.

And then there’s just the unlucky people who were perfectly fine, and then they went on vacation and got food poisoning and then their gut was never the same. And it was some sort of gut microbiome dysregulation that was brought on by the food poisoning and then that’s it for them. So that one is very unfortunate, but probably a little bit better understood.

And so there’s a lot of reasons that people can get these conditions. Not that we’re there yet being like, “This is the cause. And therefore, this is how we’re going to reverse it.”

Karen Conlon, LCSW:

I’m glad that you said that because one of the difficulties in dealing, and having to manage, and getting care for people who are struggling with symptoms of IBS is not necessarily having that very concrete and tangible reason. If you get what you’re referring to as post-infectious IBS, okay. I can say, “Oh, you know what, I went on vacation.” Or, “I ate something, and then after that, it’s just never been the same.”

And there’s something that I need to correct. And there’s a very concrete, and obvious.and tangible reason where even when they go to their doctors or dietician, they can say, “Well, this is what happened.” And we can look in a much easier manner at the things that we need to do.

Is Knowing Why You Are Experiencing A DGBI Worth It?

Tamara Duker Freuman, MS, RD, CDN:

I do see a fair number of patients get really just bogged down and stuck in this head space around needing to know why? Why and what happened? And at least from where I am as a dietician, it doesn’t matter why.

And you may never know why, and even if we did know exactly why it wouldn’t matter, it wouldn’t affect your treatment, and it wouldn’t affect the interventions that we’re going to do. And so I get that human desire to understand, but I think it can really impede people’s ability to move forward, which is, you’re here now and even if you knew why there’s nothing you could do to reverse it, the interventions that I’m going to recommend for you, who got it after food poisoning are the same intervention for someone who has a similar symptom pattern, who might’ve always had it since childhood.

I treat based on the symptom pattern. And based on there are sort of similar archetypes that some people with IBS present, there’s some patterns that you see and I can help you identify the pattern of your triggers and intervene accordingly. Regardless of why it happened, we look at the here and now and what you’re actually experiencing and go from there.

Karen Conlon, LCSW:

Our role in the therapy space is to help people understand not only how the continuation or focusing and ruminating on the unaswerables, because you know what, some of these questions are unanswerable, we may never know. How that’s really getting in the way oftentimes, even of their treatment.

A lot of times there’s a lack of compliance because, “While we don’t really know why, then I don’t know if it makes sense for me to do what my doctor said or what my dietician said.” So in our side of treating or helping to treat the psychological space, we help clients kind of get through that and understand how their thought process might be getting in the way of what they actually want, which is to get better, right? Because they’re really stuck on these unanswerable.

Let’s shift gears a little bit. We talked about what are DGBIs, can we talk a little bit about what are not DGBIs, because again, I think that the GI world can be a little bit or a lot confusing to people. And so if we can give them some clarity about what’s not, to help people rule out.

What are NOT DGBIs?

Tamara Duker Freuman, MS, RD, CDN:

Things that are not DGBIs are sort of organic diseases that are durable. So for example, if your stomach is infected with a bacteria called H pylori, it might feel like somebody who has a DGBI called functional dyspepsia. But it’s being caused by a bacteria and when you eradicate the bacteria, the symptoms go away. That is not a DGBI.

Inflammatory bowel disease, or IBD is not a DGBI. It is being caused by your immune system actively creating inflammation and when you treat the immune system and shut down all those inflammatory signalers that it’s secreting, the inflammation goes away and the gut heals and the symptoms either go away completely or they improve substantially. But that is not a DGBI.

So bacterial infections, parasites, inflammatory conditions, something called gastroparesis, the cells that govern motility in your stomach are actually misfiring. That’s not a DGBI. So there are these sort of other types of organic diseases that can have similar symptoms as a DGBI, but are not DGBIS and they’re treated with different medications or different dietary interventions than a DGBI would.

Karen Conlon, LCSW:

For those of you who are hearing certain words for the first time, certain technical words, such as motility, motility refers to movement. So in gastro-paresis, for example, you might have food that is sitting in your stomach longer than it should, and not moving through the digestive process. And a lot of times when people are experiencing gastro-paresis one of the things that they experience can be nausea, for example, and there are other symptoms you want to check with your doctor and make sure that you are getting cared for, but we just want to give you some examples and explain some of this technical language that we’re using today.

I wanted to also mention in terms of the IBD, there is the possibility, there are a percentage of people who have IBD with overlapping IBS, and normally the way to really rule that out, or kind of know that this is the path that you’re on is if you have inflammatory bowel disease and you are in remission and in remission means that your inflammatory markers are down, and your gut is looking well, not just medically, but physically, right?

I mean, your doctor’s checking your lining, everything is looking great. And you’ve been in remission for quite a while. Your symptoms have reduced or gone away disappeared. And yet you’re still feeling a lot of the same sensations, right?

That might be a clue that you have overlapping IBS. DGBIs, we’ve talked about some of the ways that they come about. Are there any DGBIs that are rooted in psychological issues or physiological issues or both? Can we have a combination of both? And I know we’ve touched on that a little bit.

What have you seen in your practice as a dietician that you… I guess, I’m thinking as a dietician, you’re not just looking obviously at diet. I mean, you’re hearing stories, right? You’re hearing ways that people cope and ways that people function and their understanding of like, “Oh, well this is when they started.” Are you noticing any patterns or any commonalities in some of the stories that you hear?

How Stress/Anxiety can Affect IBS

Tamara Duker Freuman, MS, RD, CDN:

Yeah, for sure. I mean, the stories that we hear really correlate with what the research shows, right? I mean, there’s nothing that I’ve seen that hasn’t been very well documented. All of our IBS patients often will have symptoms, even when things are going well, and they’re not stressed and they’re calm. And so I think it really ruffles people’s feathers when the doctors are like, “Oh, you’re getting stomach aches, do yoga, go relax.”

Because they can also have symptoms when they’re not stressed. However, excess stress can absolutely and often does aggravate symptoms. And again, we talked about serotonin a lot, but there’s other hormones in our body. Cortisol has a very big impact on the intestine, and when cortisol levels are high it can, in a lot of our IBS patients, it can cause terrible diarrhea.

And that’s actually why a lot of IBS patients have their worst symptoms in the morning, because your cortisol levels are highest between 4:00 AM and 10:00 AM. And that’s often when your bowel is most active. And so stress hormones absolutely affect bowel function and so any kind of stressful life situation, our IBS constipated patients feel like their constipation is worse, our IBS diarrhea patients feel like their diarrhea is worse.

I think the one that we really haven’t spoken about, which shame on me for not bringing it up sooner is, patients who struggle with disordered eating, which is a psychiatric disorder, anorexia, bulimia, binge eating disorder.

The data suggests that our patients who struggle with these issues have almost universal GI symptoms, especially if they’ve been dealing with them for a prolonged period of time. Specifically, a lot of DGBIs, and so a ton of IBS and functional dyspepsia are so incredibly prevalent in these conditions.

And it can be really, really tricky because the GI symptoms can then really interfere with treatment to get over the eating disorder, because if it physically hurts to eat, what is my incentive to eat? And so it can be really tricky, both for our behavioral health specialist, and our psychiatrist, and our psychologist, and our mental health professionals, as well as for dieticians and nutritionists, working with our patients who are trying to recover from disordered eating behaviors who want to recover and are really putting in the work and trying to recover.

But they’re not being rewarded for their efforts by feeling good. And that is really, really tricky and really where a great gastroenterologist and someone like me, and GI nutritionist can come in handy, which is we have to manage the GI symptoms so that it doesn’t hurt to eat and to eat healthfully and to eat in a way that is more regulated, and more nourishing, and more healthy. That’s tricky.

Karen Conlon, LCSW:

Especially when you are talking about eating disorders, disordered eating, if you look at what starts at all, there’s usually a need for controlling something in your environment. And if that’s not possible, we internalize that. We’re trying to find a way of finding stability and control about something in our environment. And so it’s a really tricky situation when, like you said, if I am trying to control and manage this pain, but then the treatment causes me pain, we need all hands on deck to help someone really increase their resilience around what they can do.

How Medication Can Help with IBS and DGBIs

Tamara Duker Freuman, MS, RD, CDN:

Yeah. And also to give them, I think in many cases, both behavioral health tools, right? And so there’s a lot of interventions around there, but also pharmacological tools. Medication can be really, really helpful for patients. And I think often patients can be resistant, “I don’t want to take medications.”

There were some really great tools available and it can be very frustrating sometimes. And I hear it all the time that patients will go see a doctor and the doctor does all these workups and they’re like, “Great news. It’s just IBS.” And then sends them on their way. Where really the conversation is, “Okay. It looks like there’s IBS. There are so many ways that we could try treating that, pick your poison.

You want to do first with diet, you want to work with medication, you want to try behavioral health, you want to try all three? What is your orientation because we have a lot of evidence-based interventions that are medicine, dietary, and behavioral health.” These are treatable conditions. Nobody should be sent on their way and told, “You’ll just have to live with it or go do some yoga.” That is not acceptable in this day and age with everything that we know about DGBIs and all of the treatments that are available.

Communication with Healthcare Providers

Karen Conlon, LCSW:

I’m so glad you brought that up. “Good news, it’s just IBS,” because for some people that is actually the beginning of the most difficult parts of their journey, that diagnosis that on the one hand brings clarity and at least explain something about what’s going on, but it’s also for so many people, it’s not the answer. It’s just the beginning of a very, very difficult journey of feeling invalidated and feeling not listened to.

And again, the struggle with not being satisfied with not having very specific and tangible and concrete responses as to why did this happen, how do I prevent it, what can I do? And so, one of the things, again, that we see in practice is a lot of high alert around certain language. It’s not uncommon for us to see people say, “I’ve been to six doctors and three nutritionists or dieticians and everybody tells me it’s in my head.” Or maybe that’s what they’re hearing.

That’s the other part too, because sometimes we filter things out. And once we hear something that strikes a chord, we don’t hear anything else. And so taking a focus on IBS in terms of triggers and those types of triggers, that trigger the brain’s alarm system. In practice and therapy, what we see a lot of is, those verbal cues that trigger the brain’s alarm system and right away send people into a spin or a thought process of.

“That’s it, I’m not being listened to.” And maybe they don’t hear anything else of what you have to stay. Tell me a little bit about what your thoughts are and how you describe that alarm system going off in terms of your practice or from your lens.

Your Brain’s Thermostat

Tamara Duker Freuman, MS, RD, CDN:

So the analogy and I learned this from my colleague, one of my gastroenterologist colleagues, this is his analogy that he uses, but I find it really helpful. Is he talks about the brain’s pain thermostat being set too high, right? And so that we all sort of have this thermostat and when you have DGBI or something like IBS, thermostats end up being set to like 70 degrees, which is room temperature or 68 degrees, your thermostat is set to like a hundred degrees.

And so it is just so finely, finely tuned. It is so finely honed that your brains thermostat is sensing these very, even minor stimuli coming out of the digestive tract. And again, we kind of go back to the idea about just as you described the patient who feels like every little bit of food moving throughout the body and how the brains thermostat, the sensors are so finely sensitive that they’re perceiving all of these stimuli coming out of the gut.

So you and I might be sitting in a restaurant, and we’re eating the same exact salad for lunch. It’s a nice, big, bulky kale salad, we’re chewing it, but it probably isn’t pureed in our mouth. So probably still taking up some space even when we swallow it. I eat this salad, it starts emptying my stomach and entering into my bowel.

My stomach is stretching, it feels this larger salad coming in, sends a message to the brain, “Oh, salad coming through, carry on.” Salad starts emptying. You eat that salad, your stomach stretches the same amount that my stomach stretched from that bulk of the solid and those mechanical receptors on the outside of the stomach that sends stretch, send a message to your brain that says, “Hey, we just stretched from a salad.”

And the brain sends back a message like, “Oh my God, the biggest salad of all time is about to enter the GI tract, tell the colon, ‘Make room, big, giant salad coming down.'” And the colon gets a message, “Oh my God, I have to make room for the salad. There’s a little bit of stool in me right now, what if there’s not room for this big salad? Spasm, spasm, get this stool out, make room for this big salad.” And all of a sudden we’re sitting at lunch and you have to run to the bathroom with diarrhea because your colon just got a five alarm fire message from the brain that the mother of all salads is coming down the pipeline.

That’s that finely tuned thermostat that is just over sensationalizing normal amounts of stimuli from the gut. That’s called the gastrocolic reflex or an accelerated gastrocolic reflex, because the nerve signal for the colon to move when we eat is normal.

Many people poop after they eat and many people might prove me like an hour or so after they have a big salad, that’s not abnormal. But when you don’t have IBS, you might be sitting at your desk an hour, maybe two hours after you ate that salad and kind of start to feel, “Oh, I think I might have to poop. Let me finish this email, and then I’ll mosey on over to the bathroom at my leisure, and I’ll have a nice, normal, wonderful poop.” So the nerve reflex is not abnormal, but the intensity, the quickness that severity of the nerve reflex, that hyper reaction, that’s IBS.

And I’ll explain that to my patient and it really resonates with their experience and they can understand sort of what is happening, where that dysfunction lies that it’s not that they have too much stool or too much gas, or that they’re allergic to the greens or salads, but rather it’s this overreaction to stimuli that is really underlying their symptoms.

And that lays the groundwork for what I’m about to recommend, which is how do we reduce the stimuli that we are introducing to the gut so that your brain doesn’t have something to overreact to? And that really is the crux of most dietary interventions for DGBIs, which is, “I’m trying to figure out which stimuli your brain is particularly overreacting to.”

Is it bulky refugee foods, is it fat, is it spice, is it gas in the bowel from gassy foods? What is it that your brain really overreacts to and how do we work to minimize those stimuli in your body so that you can have a more calm, predictable day of GI experiences.

Karen Conlon, LCSW:

That is such a great visual, what a great way of explaining it. And I just want to remind everyone that you will have the opportunity, not only to re-listen to this as many times as you want, but you can go to the show notes afterwards, if you want to just take that read it, copy and paste this, so you can remember it.

Whatever’s going to help you to remember this explanation, because this is the crux of what we’re talking about here. It is the brain, misunderstanding the signal. And then because it misunderstands the signal, it also sends down faulty signals back. That’s where that two way bi-directional communication continues on its loop until there are interventions that help you figure out which one of those things are the things that are causing the issues for you. IBSs mimickers. Tell me about those. What are those?

IBS Mimickers

Tamara Duker Freuman, MS, RD, CDN:

Yeah. So there’s a bunch of conditions that someone could have that produce symptoms that are similar to IBS, but they are actually caused by some sort of disease or other phenomenon that is not that disordered gut brain interaction. And a lot of these patients will have been given a diagnosis of IBS by somebody at some point, whether they had an extensive workup or they just went in and the doctor’s like, “Honestly, you’ve got IBS,” and they don’t do any testing.

So I’ve had patients in both camps, but what ends up happening with these patients is they’ve tried a lot of the IBS interventions. Here’s the thing about IBS interventions. There are many different types of medications, many categories of medications, and there’s a few different types of dietary approaches and a couple of supplements. There are behavioral health interventions, cognitive behavioral therapy, and hypnotherapy and things like that.

And so what’ll happen is these patients who have like an IBS mimicking condition will have tried a whole bunch of medications and they’ll have tried the diet and they’ve gone to the therapies and nothing is better. And then at certain point you have to start wondering, I know that it looks like IBS, and it sounds like IBS, and it smells like IBS, but it’s not acting like IBS.

Because most people with IBS will respond at least somewhat to some of these interventions. Maybe not be a hundred percent perfect all the time, but almost all of our IBS patients get better, to a significant degree. And if you are not responding to any IBS interventions, you have to step back and wonder, is this really IBS?

Karen Conlon, LCSW:

So are there questions that people can ask their doctors if they want to learn how to advocate for themselves? Are there any ways that you can recommend for people to ask the question, if it’s starting to feel like, “I’ve done all of this and I’m still having this.”

Tamara Duker Freuman, MS, RD, CDN:

Yeah. I mean, look, the point about some of the IBS mimickers is that they’re not always obvious at the outset, right? And so the day that you get your diagnosis is probably not the day that you’re going to ask a doctor, “Could it be one of these other things that are a lot less common than IBS?” Look, IBS is pretty common, right?

And so the day of your diagnosis is not the time that you’re asking the doctor for an exploratory laparoscopic surgery to see if you have endometriosis. That’s not probably the time and the place for that conversation because chances are, it may actually be IBS more so than some of these other things.

However, if you have really been with this doctor for some time, and this doctor has thrown a bunch of medications at you, and you’ve seen the dietician and you’re really not responding. I mean, I think that it’s very appropriate to say, “Listen, are there other conditions that present like IBS that you’ve had other patients have that turned out not to be IBS? What were those conditions and were there other symptoms that were associated?”

And so some of the IBS mimickers have symptoms that are not classic IBS. And so for example, we have patients who have disorders mediated by histamine, having too much histamine in the body, right? Histamine is that sort of inflammatory chemical that gives us those allergic symptoms, like runny noses and itchy eyes and hives and things like that.

It can also cause GI symptoms that look like IBS, but IBS doesn’t cause rashes, IBS doesn’t cause hives, IBS doesn’t cause acid reflux, right? That’s your stomach. That’s not your bowel IBS doesn’t cause your heart to race, or IBS doesn’t cause migraines. And so if your GI symptoms travel with other symptoms that aren’t really classic IBS symptoms, that’s a great thing to mention to the doctor. And sometimes it may be coming from the patient, right?

Like I think sometimes if a patient goes to a gastroenterologist you think, “This guy or girl, just wants to hear about my gut problems, why would I mention that I have hives? Or why would I mention that I have a runny nose to a GI doctor, they’re the gut doctor.”

And so I also think it’s great advice for a patient, if you have other symptoms that travel hand-in-hand with your GI symptoms, every time I have diarrhea, my heart is racing or I have a migraine. That is relevant information because that might actually help a GI doctor identify an IBS mimicker earlier. Or for women, they have a lot of bloating and distension around the time of their period or patients who felt worse on the low FODMAP diet that is really, really helpful for most people with IBS.

And they actually had worse diarrhea. That might tell a doctor, “What were you eating more of on your low FODMAP diet that you should feel worse?” And all of a sudden that could lead them to test you for sucrose intolerance, that you don’t have enough enzyme for sucrose, sugar, which is sort of the primary sugar in a low FODMAP diet.

So these types of clues, when things have been better, when things have been worse, what types of symptoms travel with your GI symptoms, may help your doctor identify things that look like IBS, but are not necessarily IBS.

Karen Conlon, LCSW:

Being able to give people this language and this way of communicating to their providers will really help them to advocate for themselves in a much healthier way.

Descriptions and Details in Diagnosis

Tamara Duker Freuman, MS, RD, CDN:

Yeah. I think the patients who get the best outcomes or the fastest diagnoses, or the fastest route to treatments are the ones who come with really detailed descriptions of their experiences and their symptoms. I think that the example you gave about a lot of people are doing their own research online. I’m certainly guilty of it. I mean, I can’t say how many times I went to my kid’s pediatrician and said, “My kid has scarlet fever.”

And the doctor’s like, “Your kid does not have scarlet fever. Why do you think that?” But the right question for a doctor to say, if a patient does come with a belief and a diagnosis is, “What makes you think you have that? What are the symptoms you’re experiencing that led you to that conclusion?”

So my philosophy and I hope, I think the right philosophy is, we always should believe our patient’s symptoms and experiences, but it’s okay to question their extrapolation or their conclusions of what those symptoms mean. Maybe they get the diagnosis wrong, because they read online this diagnosis and then kind of attached to it and they think they have that, but their belief or their conclusion is based on a very real set of experiences and symptoms.

And that’s what I want to hear about. I want to hear what’s happening in your body and maybe let’s just put aside for a moment why you think that’s happening. I might come to the same exact conclusion that you do. In fact, often I do.

I will end the conversation, I’m like, “Yeah, I agree with you. It sounds like you do have bacterial overgrowth (SIBO),” or, “Yeah, I agree with you. It really does sound like you have a histamine intolerance.” But I want to get there based on the data collection and my assessment of your symptoms without being too prejudiced going into it with this being a foregone conclusion.

And sometimes my patients will be very vague with their symptoms, “I get kind of bloated.” I’m like, “I want to know what that means. Is bloating something we see, does your belly actually protrude and stick out?”

And so don’t assume that we’re all sharing terminology. Don’t assume that anything you say to a doctor, especially a gastroenterologist could even remotely gross them out because they have seen things and heard things, nothing that you say to them is new or gross. You can not gross us out. The devil is always in the details. The diagnosis is always in the details. All the diagnosis comes from things that my patients tell me, I get the diagnosis from you. So I need you to tell me every single gory detail. And I will tell you if it’s too much.

Shame and GI Conditions

Karen Conlon, LCSW:

There’s so much shame wrapped around GI conditions because it has to do with bowel movements. There is a lot of ambivalence, oftentimes around getting treatment. There’s definitely a lot of resistance around talking about it because of that shame that is correlated with it. So we want to know, we want to know more.

We want to know all of it and the therapy side of it, in this headspace, I want to know all of the too. Because the other thing too, is that timing, like you said, when we were talking about the IBS mimickers, there is a certain amount of time and patience that needs to be had while figuring this out. And people are going to experience discomfort, both physical and emotional, and even psychological discomfort. So there is a certain amount of tolerance and patience that needs to be a part of the treatment.

Tamara Duker Freuman, MS, RD, CDN:

Yeah, absolutely. Sometimes we don’t nail it on the first try, sometimes we try a diet, we give it two weeks and it doesn’t make a patient better. And one thing I didn’t do well when I first started out in practice that I think I’m much better at now is I didn’t give my patients the roadmap on day one. So I would recommend something and then it might not have worked.

And then the patient kind of, after two weeks of trying what I said and it didn’t work, they never heard from me, “Hey, if it doesn’t work, come back and see me because we’re going to learn as much about you from what doesn’t work as from what does work and if plan A doesn’t work, this is plan B.” And when I didn’t say that in the beginning, I think my patients would probably end up going off, feeling really discouraged or frustrated and disappointed like, “Oh, I saw another dietician and she told me to try this and it didn’t work so nobody can help me.”

And I think that it’s really important for as a clinician and for clinicians in general, to help our patients understand that it is a process. And sometimes the first thing we try may not be the thing that helps. Sometimes we’re lucky. And as we get more experienced as clinicians, we usually get the right answer faster. But sometimes the first thing we try doesn’t help.

I always tell my patients, if this doesn’t work, then I’m going to learn a lot about what’s going on with you, even if it doesn’t work. And then we’re going to take this totally different direction. And that’s really important for our patients to here’s what they understand that we are partners with them on a journey. And the end goal is your quality of life.

And that is an iterative process, and it can be a multi-factoral process. Sometimes it’s just diet, sometimes it’s diet plus supplements, or diet plus medication, or medication plus therapy without diet. There is a constellation of solutions and sometimes it’s a little bit of trial and error until we figure out the exact optimized combination of interventions that’s going to work for your IBS.

Karen Conlon, LCSW:

Thank you for that visual. That’s so helpful. And again, think for a lot of people who really… they’re tired of reading. They spend so much time looking at their test results and their blood work and trying to figure it out and sometimes we just need a little visual of what can happen and what this can look like. So I love that you’re doing that and setting that expectation.

Can You Get Better From IBS?

Tamara Duker Freuman, MS, RD, CDN:

The hope I think is a really big piece of it. I can’t tell you how many times patients have asked me like, “Have you had patients that get better from this?” And I’m like, “Almost every single one of my patients with IBS has gotten substantially better, and if they didn’t get better, then they probably didn’t have IBS.

And then we had to figure out what it was.” And so I think patients really need hope, and I always get feedback. Like, “Thank you so much.” Before they even tried anything, they’ll say, “I feel so much more optimistic, understanding that someone’s got a plan, someone’s got a vision.

Someone has sort of a process that has gotten other people to that destination, that optimism, that knowing that even though I still feel really crappy now, and it might take a couple of weeks or even a couple of months, I feel optimistic that I’m going to get to a better place.”

And I think that that is also hugely important and that’s often missing from medical interactions where someone is given a diagnosis as if the diagnosis is why the patient is there. The patient is there because they want to feel better, not because they want the intellectual knowledge of knowing that they have IBS. And sometimes the diagnosis of IBS can feel like the end of the road, at least the way that it is presented to a patient.

Like, “We’ve gotten it. Here’s the diagnosis, you have IBS.” And that is not the end of the road. To your point earlier, that is the beginning of the journey. “Okay. We’re getting off the highway on the IBS exit. Now we have a new road to navigate the destination of actually feeling human.” And that is the next destination. And if your doctor isn’t the one who is going to partner with you and take you on that journey, you need someone who will, because you can’t do it alone.

Karen Conlon, LCSW:

The diagnosis is not something that is finite, right? I mean, that’s really what we want to make sure that people understand. This is not it. This is the beginning.

Tamara Duker Freuman, MS, RD, CDN:

It’s the beginning. It has to be the beginning. Because again, you’re not there because you’re intellectually curious why your stomach hurts every time you eat. You’re there because you don’t want your stomach to hurt every time you eat. Being told the diagnosis, isn’t the end of the conversation or it shouldn’t be the end of the conversation.

Treatments for DGBIs

Karen Conlon, LCSW:

Absolutely not. So wanting to take off on that, let’s talk a little bit now about treatments. We’ve talked a little bit about the role of diet. Can you give us some more specifics? Can you talk to us a little bit about some of the dietary considerations that people might want to think about regardless of where they’re at?

Tamara Duker Freuman, MS, RD, CDN:

Yeah, I mean, there’s probably, I think in preparation of this conversation, I kind of sat down and really thought about, what are the types of categories of diet interventions. And I think there’s like six types of interventions and they’ll often be modular, I’ll layer them with each other, so they’re not all mutually exclusive. But one really big area of interventions is around your fiber balance, high fiber versus low fiber, but also what type of fiber?

So different types of fiber behave really differently in the gut. So kind of that bulky roughagey type of fiber is called insoluble fiber. And that behaves really differently in the intestine than the type of fiber called soluble fiber, which absorbs water and gets gooey, and gummy, and viscous, and shape-shifting and not so bulky.

And they can affect your stool form, the stool hardness softness, liquidness, bulkiness gearing our diets towards different types of fiber, maybe limiting one type and skewing your intake more towards the other type. And so we can do a lot with the amount of fiber and also the types of fiber and the ratio between the two is something I do a lot of.

I do a lot of meal size and meal spacing interventions. Going back to that example I gave around, when the stomach starts to perceive stretch and a big meal, how it can overreact and sort of send spasms signals to the colon. And so meal size can be a really big factor in IBS symptoms or functional dyspepsia symptoms.

And so we talk a lot about rather than eating two meals a day. So some of our patients who want to do intermittent fasting might only be eating lunch and dinner sort of in a six hour window of each other and then going really long periods without eating sometimes dumping all that volume on a DGBI body doesn’t always feel great. And so we talk about meal size and spacing as a potential intervention for some people. We talk a lot about volume at night and how much we eat at night. In our society, there’s a lot of breakfast skipping and dinner as this main meal. And then we’re watching TV and we’re snacking in front of the TV.

And when you are someone who’s prone to really delicate, sensitive mornings, your cortisol is a super spiky in the morning and you’re back and forth to the toilet a hundred times and you can’t get out of the house and get to work, because you keep having to go back to have another poop, eating a lot at night and eating late at night can really aggravate that because all of that volume is hitting your bowel in the morning, which is your most sensitive time.

We talk about fat, and so fat can stimulate hormonal signals in the GI tract that also affect the colon’s motility and can cause spasms.

And so similar to how that salad can kind of tell the colon, “Five alarm fire,” greasy foods, fatty foods, rich creamy foods, high fat foods can have a similar effect. And so we talk about fat intake, but we can also use the fat intake as a benefit for a constipated patients. If I know that fat stimulates the colon, I might want you to eat more fat if you’re constipated.

Whereas if you’re diarrhea prone, I might pull back. And so we can manipulate these things more or less, depending on what your symptoms are. A lot of our IBS patients have heard of the low FODMAP diet. And so FODMAP is an acronym for different types of sugars and carbohydrates that are fermentable, that’s what the F and FODMAP is, and that create gas.

Our patients who have a lot of visceral hypersensitivity to gas and have gas pain, and bloating and gaseous discomfort, we’re trying to reduce the amount of gas that is in their bowel because lots of gas hurts them.

And so we might manipulate the amount or the type of FODMAPs in their diet to see if we can get them some relief in terms of that gas pain, and the bloating and the discomfort. And then the last area is dietary supplements. And so there’s not a ton of dietary supplements that are really evidence-based for IBS, but there are some that are cheap and easy to find and can be incredibly helpful.

Our constipated patients who can’t poop every day, and so there are probably in pain and cramping and miserable and bloated every single night because they’re not emptying well, a lot of them do great with just a little bit of magnesium, which you can get in any drugstore. Diarrhea prone patients who can’t get out of the house in the morning, because they’re back and forth hooping these tiny little dribs and drabs of incomplete, soft crampy poop.

Sometimes they’ll take a soluble fiber supplement at night and then in the morning they get two gorgeous, complete consolidated bowel movements and they’re out of the house.

Some enzymes, so if beans are really gassy for you, but you’re a vegetarian and they cause you horrible distress, there’s an enzyme that makes beans less gassy. And so there’s some very easy, I call them cheap and cheerful interventions. It’s not high science, it’s not a proprietary 50 pill regimens, but these are just drug store staples that can be incredibly helpful and incredibly easy to include into your life. And so that is the realm of my toolkit for most of my IBS patients.

And like I said, if literally I’m going through this list and nothing is working, I am then stepping back at a certain point and being like, “This may not actually be IBS. Let me look at you with fresh eyes, let’s reassess understanding that maybe this is an IBS and we’re going to try something completely different.”

How Diet Can Impact DGBI Symptoms

Karen Conlon, LCSW:

When you were describing all these, the word that came to me was education. Really important for you to educate yourself, so you’re seeking these treatments out. So for example, when you were talking about the low FODMAP diet, I thought about how many foods on that list are actually considered to be very healthy and they are healthy. And you might be eating them all the time because you are trying to lead a very healthy lifestyle, or perhaps in your culture there are foods that are on this list, which are just kind of a staple in the diet, right?

I mean, for me, it’s garlic and onions, right? I mean, my household doesn’t exist without garlic and onions. But if you getting better is something that requires a lifestyle change and adaptation. And you know what, sometimes it may mean doing something or making changes that feel like they’re very much against the grain of how you grew up or of your beliefs.

That is something that needs to be talked through and discussed so that you can process it and come to a place where you can feel better. You can feel better about your decisions so that you’re not feeling guilty or ashamed of what you need to do. And also finding a way of talking to your family, to your loved ones, so that you can actually get the support that you need.

I mean, I’m thinking holiday season, I’m thinking all these summer barbecue, all these different situations, going to a restaurant to hangout with friends or family, all these situations where food is the main thing or the main source of get togethers, right? I mean, it’s like the food that’s bringing us together and being able to feel confident and at peace with, if you need to, or if you want to explaining your food choices, because this is a lifestyle change that we’re talking about.

How Influencer Culture Can Negatively Impact Those With DGBIs

Tamara Duker Freuman, MS, RD, CDN:

Yeah, definitely. I think that’s a huge piece of it and I think the ancillary piece, I mean, you’ve really focused on sort of cultural traditions and family dynamic, but there’s also just sort of online influencer culture. And so stuff that, “Everyone says is healthy,” and I should be eating kale salads, or I should be eating raw date energy balls.

My trainer said, I should be eating this. So I think that there’s also this very pervasive wellness culture online, on Instagram in particular, which I think is particularly problematic. There’s a lot of tribalism now around diet, keto, vegan, and everyone’s sort of proselytizing, almost like a diet is like a religion and an identity. And everyone has to be plant-based, or vegan, or keto is the only way and it’s unnatural for humans to eat milk.

Whatever the religious beliefs that you are encountering online, it can be really hard for a lot of my patients to come to terms with the fact that those diets feel horrible for them. “I want to be vegan, I feel like I should be vegan. Everyone says fiber is so good and fiber are so helpful and I need to have as much fiber as I can possibly eat.” “Yeah. But my dear, your pelvic floor muscles are really screwed up and you’re only able to poop once a week.

So how’s it going to feel when you’re eating 50 grams of fiber per day and pooping out zero grams of fiber per day, how’s that going to feel for you? There are so many shoulds when it comes to diet, but how’s it going to feel for you if you’re eating 50 grams of fiber a day and you can only poop out zero grams of fiber a day?”

And so this idea that one diet fits all people and that everyone has to eat this diet or the same diet that your girlfriend eats, or your trainer eats, or your mom eats, it might not feel good in your body. We all don’t have to eat the way that an Instagram influencer eats and some foods that are objectively nutritious on paper, full of antioxidants and fiber and benefits, can still feel like garbage in your body. And you don’t have to eat foods that feel bad.

There’s stuff out there that will probably feel fine and you’re allowed to eat that and not eat something that hurts. I can’t tell you how many patients I’ve had that asked me permission to eat a bagel, grown people. They know that a bagel feels good, a plain bagel never hurts, but they feel like they’re not allowed to. They feel like they’re not supposed to because a bagels refined carbs, or a bagel is gluten, or bagel doesn’t have fiber.

Whatever it is that they’ve read that they’re not supposed to do, and so they force themselves to eat kale and eggs for breakfast, which feels horrible because they feel they need my permission. And that is so problematic with our food culture and our wellness culture and our diet culture. This idea that you can’t eat what feels good in your body without feeling shame or that you’re violating the terms of a tribal alliance of people who derive their identity from their diet.

You have not just permission to eat what feels good, but you have permission to not eat what doesn’t feel good. And you don’t have to justify that to anyone, right? My job is to help you find the healthiest diet that you can comfortably tolerate. And often I am the one taking salad away from someone other than suggesting they eat more of it. At least in my line of work, because a lot of my patients for many, many different reasons, don’t feel good when they eat raw stuff.

Karen Conlon, LCSW:

That’s so powerful. The permission that you can give yourself and fine, if you need a provider, health provider professional and an authority in the field to give you the first permission. Great. But then just know that you can take it from there, you can give yourself permission.

And giving yourself permission, you’re also going to allow yourself to start trusting that you can self evaluate, that you can start to trust your body, that your body will tell you what it needs if you allow yourself to listen and even better, if you can work with someone who can help you to confirm that what you’re hearing and that what your body’s telling you is right, because your body will always tell you.

Tamara Duker Freuman, MS, RD, CDN:

So sometimes people aren’t getting the message really clear, they feel like, “Sometimes that food’s okay, sometimes it’s not, I don’t really know what my triggers are.” But just as often my patients know exactly what foods are going to make them sick, and sometimes they eat them anyway, because they feel like they’re supposed to. How many times have I heard, “The healthier I eat, the worse I feel.” But I think that there’s a certain genre of healthy foods that feel bad for a lot of people and those are the things that we can steer you away from and help navigate you towards other options.

Karen Conlon, LCSW:

Absolutely. I feel like we can do three segments of this. This is just so much. I mean, so much that we can dig into deeper. In treating DGBIs, just generally, can you tell us, just kind of clarify for us who does what, right? If I am seeking out help, who does what in the field?

How Different Providers Can Address DGBIs

Tamara Duker Freuman, MS, RD, CDN:

So, I mean, if you think about a DGBI as being that dysfunctional connection between the brain and the gut, different practitioners will have different tools in their toolkit to either target the brain or the gut, right? And so someone like me, a dietician really focuses on the periphery, the gut, the symptoms actually in the body. And so, like I mentioned earlier, most of my tools are really aimed at reducing the stimuli within the GI tract, because I know that the brain is going to overreact to them. So I can’t really target the brain as someone who just does food, but I can target the stuff in the gut. And that’s really what I focus on.

But medical doctors have medications that can target both command central, both the brain, as well as the periphery and the gut. There’s medications that can target the pain response in the brain. So certain types of tricyclic antidepressants, and SSRI. So people often mistakenly think that if the doctor is offering them a, “Antidepressant,” it’s because the doctor thinks that it’s because you’re depressed or because you’re anxious and it’s all in your head. No, no, no, no, no. Those medications are being used off label at much lower doses than would be used to treat depression because they’re actually treating the neurotransmitters and the pain response.

There’s medications that can target the periphery, the gut. We talked about the colon spasms, colon spasms that can cause diarrhea, or colon spasms that can cause pain. There are medications that are antispasmodics, anti-spasm medications that can shut down that spasmodic motility reaction in the… there are medications that a GI doctor can prescribe to target both command central brain, as well as gut behavior in the periphery.

And then there’s people like you, GI psychologists or other types of therapists who do sort of GI targeted therapies and interventions, which again are focusing on that command central, on the brain and the pain perception and the outcroppings of chronic GI disorders like symptom hypervigilance, anticipating something is going to happen, such that it becomes a self fulfilling prophecy.

“I’m worried that I’m going to have an attack when I get on the stage.” And therefore, when I step on the stage, I precipitate that attack. And so some of the kind of patterns that our brains get us locked into that can make the pain perception worse and they can actually predispose us to having symptoms. That’s where I think the GI psychologists and therapists crew really comes in to help our patients control and redirect and retrain the brain to become a partner in the treatment rather than an adversary.

Karen Conlon, LCSW:

Absolutely, absolutely. So medication, diet, the cognitive behavioral work around thoughts and behaviors, changing thoughts, and evaluating and making changes in your thought process. Gut directed hypnotherapy is also something that the research has now lately shown more and more as being something that is incredibly efficient and helpful in treating the miscommunication that’s going on between the brain and the gut. What in your view are limitations to any of these? Do you have any thoughts around that? If any, these have their own limitations?

Limitations of Different Treatment Modalities for DGBIs

Tamara Duker Freuman, MS, RD, CDN:

I don’t know if I would say that they have limitations. It’s just certain modalities work better for certain people. I think I have some patients who I will meet with them and I will be like, I feel like 90% of their pathology is really the brain. Their symptoms are so triggered by their state of being.

And when they are in a good place, anxiety wise, or stress wise or anticipating symptom wise, they can eat anything, that their food is not really triggering. They can eat fat, they can eat FODMAPs, they could eat all fiber or no fiber, as long as they’re in a good headspace. And those patients typically aren’t responding very well to diet or meds, or certain meds, I should say. Other meds they do respond to and that is someone I might send on day one, straight to a GI psychology type of therapist.

And then some patients, it is so completely tied to food choice that if we just manipulate the diet, they don’t even need medication. They don’t need it. They follow this diet, they’re good. They take their Citrucel fiber at night and they just don’t eat too much salad and they’re great. And so sometimes you’ll kind of get a patient where you’re like, “If a doctor puts you on a medication, it probably wouldn’t do very much.”

Or, “If I put you on a diet, I don’t think it’s going to do very much.” But again, I think that when you work with someone who really is experienced with your particular type of condition, they can kind of get a feel for you within a session or two about what you’re going to respond best to. And I think it’s great if you can be open to that.

I think there’s some patients who really don’t want to take drugs and I get it. I don’t like taking pills, but sometimes it’s like, “Oh my God, I’ve seen a thousand people like you and you wouldn’t do so well with this one medication. I know it would help you so much.”

And I think sometimes it’s like, you kind of draw the line in the sand as a patient like, “I only want to do diet.” We can try, we’ll do the best we can, but you might be kind of limiting how much better you could get. Whereas if you’re open to any and all types of interventions that are really tailored to you, you might get an even better result.

Karen Conlon, LCSW:

Yeah, absolutely. And so sometimes there are benefits to addressing the different areas. And for other people it’s really about finding out one by one, maybe which one of these would work best. Okay. So now that you have a plan, you have to adhere, do you not have to adhere? How important is adherence now that there’s a plan in place?

How Important is Adherence?

Tamara Duker Freuman, MS, RD, CDN:

Adherence is important to the extent that you want reliability of symptoms. The thing about IBS is it’s not going to kill you. You’re not damaging your body if you eat something that gives you a stomach ache, it’s not like inflammatory bowel disease, where it actually inflamed, or creating ulcers or holes.

You’re not going to give yourself cancer if you eat a FODMAP. You’re not going to feel good, right? If you don’t take your magnesium at night for constipation, you start to get backed up, you’re not going to feel good, right? And I do see that a lot patients will be doing really well in their magnesium and they somehow think that their body has sort of, “Healed,” from IBS and they don’t need to take it anymore. And they stop taking and of course the symptom comes back.

And so adherence is as important as you were wanting to have consistent symptom control. And that’s important because sometimes you might eat something that you know is going to make you sick, and that is an informed decision that you make that is worth it. “I’m an Eastern European Jew, I can’t eat lactose. I have no business eating ice cream.

But you know what, I love ice cream. Sometimes it is worth it to me to eat [inaudible 01:00:30], and I know that tomorrow morning I’m going to pay a price. And sometimes it is worth it to me.” You could be someone of Puerto Rican descent who has horrible IBS and black beans are your nemesis. And nine times out of 10, you avoid them. But when you go to your grandma’s house and she makes like the best yummiest, whatever that has black beans in it, that might be worth it. You take a couple of binos and you pray and you hope for the best.

Sometimes, it’s worth it to go off your plan. But if it’s so important to you, “I have a presentation.” “I have somewhere to be.” “I have a first date.” “This is a moment in my life where I need to be on point and I need my bowel to behave.” It’s very empowering to know what you need to do to be there and to get there. That knowledge is power and you can decide how strictly or how laxly you want to follow the interventions. My job, and the doctor’s job, and the therapist’s job, is to help you crack the code on how to manage your IBS. You get to decide on whether you want to actually do that. And if so, to what extent.

Karen Conlon, LCSW:

Yeah. And that’s such an important point, right? You get to decide, you do have control over many of these aspects and you do get to decide whether you’re ready to take control of that wheel is a different story, but you do get to have that. You do have that in your power.

Tamara, let me ask you, this podcast was created because I wanted to really de-mystify, debunk and help to de-stigmatize therapy and what we talk about in therapy and what happens in a therapy space. But for you and with this work that you do, can you tell me something that you want to really share with people that you feel is a really important aspect of the treatment and of the work that you do that you want to debunk, or demystify, or de-stigmatize? What do you want to let people kind of walk away with what’s that message?

De-stigmatizing IBS and DGBIs

Tamara Duker Freuman, MS, RD, CDN:

Well, I think, I mean, the word de-stigmatize to me is probably one of the more important ones, because I do think that there is a lot of stigma around IBS and DGBIs, because of this perception that whether people came to it themselves, or projecting the other people think that this idea that it’s, “All in your head.”

That somehow it is a weakness or a moral failing that it’s just that you’re too anxious, that you’re doing this to yourself and your anxiety is causing this. And that is so stigmatizing, right? And it’s like, “Why can’t I get a handle on this, why do I have to be so anxious?”

IBS is not all in your head, you didn’t choose IBS. You’re not causing your IBS. It is not your fault that you have IBS, but all of these disorders, they may not be in your head, but they are actually in your brain, as everything is, right? It is not stigmatizing for pain to be in your brain. My pain is also in my brain, when I stub my toe, why does it hurt?

Because my brain tells me that the stubbed toe hurts. All pain originates in our brain. There’s no shame in that. My breathing and my heart rate also originate in my brain and I am very glad that they do. Your brain controls everything in your body.

And so IBS is not a moral failing, it is not a psychiatric disorder. It is a physiological disorder that has its origins in your brain. Literally everything else that happens in your body, pretty much has some connection or association with your brain playing a role. You’re human. Your brain is involved. That doesn’t mean it’s all in your head. And I think that’s so important for our patients to understand.

Karen Conlon, LCSW:

It’s the message that translates to them, right? It might not be what’s originally said, but that’s how they translate it. So really important message here. Yes, it is all in your brain, but not in your head. You’re not making this up, this is real. And we want to work with you to help you. Tamara, tell us any resources that you’d like to pass along. I’d like to recommend your book, but I might be biased, The Bloated Belly Whisperer. Are there any websites or any other resources that you’d like to share with our listeners?

Where To Learn More

Tamara Duker Freuman, MS, RD, CDN:

I mean, I’ll say the most reliable places to get information on DGBIs is the Rome Foundation and also IFFGD, the International Foundation for Functional Gastrointestinal Disorders. They’re both online, in general, be so careful about getting information about these conditions online.

The internet is not a well edited journal, it is a place where anybody with an opinion or a point of view can just post something up that looks like fact, and Instagram is a horrible place to get health information or diet information on IBS information. Social media in general, and everyone’s trying to sell something or trying to proselytize their diet or their supplements. And sometimes it’s better to just kind of stay away from those sites.

I think even well-meaning kind of Facebook support groups or people like, “This worked for me. And therefore I want to share this from a really good place in my heart. But my IBS is not your IBS and just because it works for me, it doesn’t mean it’s going to work for you.”

And so also getting medical advice from other people in your disease support groups is also a really very dicey strategy. And so just be mindful and cautious about how much you internalize from what you read online, because you could read the exact opposite things online. And they are both stated with equal amounts of seeming credibility and seeming vehemence. And they’re completely opposite of each other. Online is a tricky place for health information.

Karen Conlon, LCSW:

Yeah. And you might find yourself backed in that should space. They are better, so I should feel better also. And where can we find you? Let our listeners know please, where we can find you if they want to know more about you, if they want to reach out to you.

Tamara Duker Freuman, MS, RD, CDN:

Yeah. So I have a website it’s just, thebloatedbellywhisper.com. And also if you Google my name, you’ll find it. Tamara Freuman, F-R-E-U-M-A-N. I wrote The Bloated Belly Whisperer, you can get it very intelligent, evidence-based, wonderful books are sold. I write for U.S. News, their Eat and Run blog.

I’ve got 300 and something articles about digestive health archived since 2012. And so my byline and U.S. News is a great way to read about the stuff on digestive health that I’m thinking about and writing about. Or you can find me professionally at New York Gastroenterology Associates and that practice website where I work with a bunch of GI doctors and a couple of fellow GI dieticians as well. So I’m not hard to find.

Karen Conlon, LCSW:

Thank you so much, Tamara, for being here today. I can’t even begin to tell you how valuable and important, and I know while received all your information, all the knowledge that you shared with us today is going to be taken. And this is not an easy topic to talk about. We get it. There’s a lot of stigma around it. People don’t necessarily want to talk about poop all the time, but we do. We definitely do. So please feel free to reach out. As always, we will have all of this information in the show notes.

I know we had a couple of technical issues, but don’t worry about that. We will edit the podcast as much as possible, but if you still come across some of those, don’t worry about that. We will have all of this in the transcript in the show notes. If you want to know more about our practice, Cohesive Therapy NYC or this podcast head over to cohesivetherapynyc.com/podcast. You can check out the show notes there and listen to this again. Get in touch that way too. Thank you so much. And I look forward to seeing you the next time when I ask, “So, How’s Therapy?”