The Gut Health Podcast

Tests Say Normal, IBS Symptoms Say Otherwise

• Kate Scarlata and Megan Riehl • Episode 29

Share episode

Use Left/Right to seek, Home/End to jump to start or end. Hold shift to jump forward or backward.

0:00 | 57:16

Tired of hearing “it’s just stress”?  IBS experts Drs. Laurie Keefer and Darren Brenner join Kate Scarlata and Dr. Megan Riehl to set the record straight on irritable bowel syndrome.

IBS is a real, biologically based disorder involving the gut–brain axis, the microbiome, immune function, and nervous system signaling. Understanding how these systems interact reshapes how we diagnose, personalize treatment, and support long-term symptom relief.

If you’ve felt dismissed, confused, or stuck in trial-and-error care, this episode will help you feel validated, informed, and empowered with a clearer, science-backed path forward.

Together we break down:

  • The value of a positive diagnosis (not endless testing)
  • The impact of trauma and adverse childhood experiences (ACEs) on gut sensitivity 
  • Using diet to support symptom relief without unnecessary food restriction
  • How to comprehensively match treatment to your triggers

Support & Professional Resources

If you’ve experienced ACEs or trauma and want support from a GI psychologist or trauma-informed provider, these directories can help: 

Partnering with a clinician trained in gut–brain disorders and trauma-informed care can safely address both physical symptoms and nervous system patterns. 

This episode is sponsored by Ardelyx. 

Learn more about Kate and Dr. Riehl:

Website: www.katescarlata.com and www.drriehl.com
Instagram: @katescarlata @drriehl and @theguthealthpodcast

Order Kate and Dr. Riehl's book, Mind Your Gut: The Science-Based, Whole-body Guide to Living Well with IBS.

The information included in this podcast is not a substitute for professional medical advice, examination, diagnosis or treatment. Always seek the advice of your physician or other qualified health care provider before starting any new treatment or making changes to existing treatment.

Welcome & Why Gut Health Matters

Dr. Megan Riehl

This podcast has been sponsored by Ardelyx.

Kate Scarlata, MPH, RDN

Maintaining a healthy gut is key for overall physical and mental well-being. Whether you're a health-conscious advocate, an individual navigating the complexities of living with GI issues, or a healthcare provider, you are in the right place. The Gut Health Podcast will empower you with a fascinating scientific connection between your brain, food, and the gut. Come join us. We welcome you. Hello, friends, and welcome to The Gut Health Podcast. We are your hosts. I'm Kate Scarlata, a GI dietitian.

IBS Reframed As Gut-Brain Disorder

Dr. Megan Riehl

And I'm Dr. Megan Riehl, a GI psychologist. Today we are diving into a condition that affects millions worldwide, yet is still widely misunderstood. That is irritable bowel syndrome. IBS is so complex. Once dismissed as a disorder of, can you believe this, hysterical women? It's now recognized as a multifactorial disorder of gut-brain interaction. Current evidence shows IBS arises from a combination of altered gut barrier function, microbiome shifts, low-grade inflammation, heightened visceral pain sensitivity, genetic susceptibility, and disrupted brain-gut communication. So this is not in your head, though the head is involved, as we'll talk about. Far from benign, IBS can profoundly impair quality of life and places a substantial burden on both patients and healthcare systems. And for many people, the pathway to diagnosis or even lack of diagnosis is fraught with frustration. Today, we're cutting through that with two leading experts in the field.

Kate Scarlata, MPH, RDN

That's right, Megan. We are. And I'm first up, and I'm going to introduce Dr. Darren Brenner. He is a professor of medicine and gastroenterologist at Northwestern University. His patients absolutely adore him, and he's widely known for his deep appreciation of the lived experience of GI disorders. He lectures internationally on disorders of gut brain interaction, including IBS, and is recognized for his expertise in GI motility and pelvic floor disorders. He's also an accomplished researcher advancing how we understand and treat IBS. Darren, thank you for joining us once again.

Meet The Experts: Brenner And Kiefer

Dr. Megan Riehl

And I have the pleasure of introducing my friend and first mentor in this field, Dr. Lori Kiefer. Dr. Kiefer is a GI psychologist at Mount Sinai in New York City, an internationally recognized leader in psychogastroenterology. She is the chief executive officer of the Rome Foundation and founded the first international gastropsych organization. She has dedicated her career to integrating behavioral medicine into gastronenterology care, advancing evidence-based brain gut behavioral therapies through numerous, numerous highly funded research projects, and reshapes how we understand the role of stress, trauma, and the nervous system. Thank you so much for joining us. We are excited to dive into this. So, Laurie, we are going to start with you with our first myth. What is a common myth about IBS that you would love to bust for our listeners?

Busting Myths About IBS And Psychology

Dr. Laurie Keefer

I think my favorite myth to bust is that if somebody refers you to a gastropsychologist, it's not because you have a psychological problem. In fact, I always like to say if you're being referred, it's probably your GI symptoms that are distressing you, and the psychologist might be able to help with that. But I think the biggest myth is that, you know, referring a patient to a psychologist means that you think the problem is caused by psych.

Kate Scarlata, MPH, RDN

That's right. That's a good one. I like that. So, Darren, how about you? What's your common myth about IBS that you'd like to bust with our audience?

Dr. Darren Brenner

I don't know if it's as much a myth as kind of a misnomer the way that this disorder is presented to people. But one of my biggest issues is that we always hear that irritable bowel syndrome is not a quote-unquote organic disorder, which leads right into what Lori said, right? If it's not organic, it has to be into your head. But the reality of the situation is everything that goes on in your body is organic. It is all part of your life. The gut and the brain talk to each other all day, every day from the moment you're born until probably a couple minutes after you're presumed dead. So the reality is there are, and I know we'll get into this a little bit later, multiple different things that lead to the symptoms of irritable bowel syndrome, and they are all 100% organic.

Dr. Laurie Keefer

Yeah, it's funny. I actually was thinking about my myths. The other myth I was gonna say is that the mind and body are somehow separate, right? So it's like to your point, yeah.

Kate Scarlata, MPH, RDN

Yeah, they're a little connected. I know I always think it's funny. This is a little going off grid here, but like we have special insurance for our teeth and special insurance for our eyes. And it's like, shouldn't it just be what we do?

Dr. Megan Riehl

Like mental health insurance. You're right. It's all separate and different. And and even the nomenclature of what we've called this. Laurie, you've had some really interesting involvement in the titling and the labeling of how we think about these disorders of gut brain interaction, formerly known as functional bowel, in the future, known as who knows. And I think that's a bit confusing for our patients, and we'll help demystify a little bit of that today. Absolutely.

Kate Scarlata, MPH, RDN

Lots of good myth busting to start off our episode. So, Darren, how do you describe IBS to a patient? All their tests are negative and they're coming in to see you. How do you just break that down for them?

Explaining IBS To Patients Clearly

Dr. Darren Brenner

I think it's a difficult question to answer because it really depends on the individual. Right. You know, I always tell people one of the fascinating things and one of the things I love about treating irritable bowel syndrome is that I really think it's an N of one disorder. Everybody's cause is different. So the first question I ask is when your symptoms emerge, was there some sort of trigger? Because I'm trying to figure out which direction I'm going to go with these individuals. And then we do talk about these interactions between the gut and the brain. And a lot of times, to really simplify it, I tell my patients, look, your body, your brain, and the rest of your GI tract and your nervous system are like kids playing in a sandbox. And you're all trying to play in the same sand, but maybe one group wants more sand than the other and they're willing to fight for it. And so this becomes a little bit of a push and shove battle where people don't understand why they disagree, but they disagree and they have different philosophies. And your brain and your gut can say that they say to my patients, it can be really frustrating, right? One day maybe you feel the pain in your upper GI tract, and the next day in your lower GI tract, and the third day it manifests as nausea, and you don't know if you're coming or going. And it's this constant battle between your gut and brain where the signals can communications between the two just aren't quite right. And what we want to do is try to minimize or quiet those signals to the point where they're both happy and they can both play on opposite sides of a sandbox, and they can almost both build beautiful sand castles that everybody wants to take pictures of. Now that's a very minimalistic view. I get much more biologic than that, but that's the way to simplify it. Another thing I try to do is allay fears. I tell everybody first and foremost, this is not cancer. This will not become cancer. This will not increase your risk of cancer. This is not a quote unquote inflammatory condition like IBD, although there can be overlap. And I tell them that there are multiple different therapies now that we can use to minimize their symptoms and improve their quality of life. So that's where I start.

Dr. Megan Riehl

I like that. And you have been in very close contact in a multidisciplinary team for as long as I've known you. You've had access to dietitians and GI psychologists, and you really are the gold standard of the being the gastroenterologist that can start to discuss that gut brain connection. And then a decade ago, Lori's office was right next to yours. And so, Lori, how does the gut brain connection, once Darren does that introduction and the patient gets into your office, what does that conversation look like when you're describing the gut brain connection to a patient, especially in the context of their pain?

Pain: Sensory And Emotional Pathways

Dr. Laurie Keefer

Yeah, that's great. So, so first of all, I think you hit on one of the most important parts, which is that the GI doctor has set the stage for me, right? And I do think that that makes a big difference in terms of the patient coming in, sort of knowing that their gastroenterologist believes in the role of the gut brain axis, right? And I think it's a lot easier. So for gastroenterologists out there, being able to suggest to your patient that they may benefit from a GI psychologist is really the most predictive of the patient's uptake of that service. So kudos to people like Darren that are referring. I think that when we talk about the painful disorders of gut brain interaction, so IBS, I think we could even translate this into GERD and dyspepsia and some of these other conditions. I think of pain, and you know, pain psychologists as well will sort of talk about pain as having two components. All pain has a sensory component, and all pain has an affective component. So beginning with sensory, you think about what is the input coming in from your gut to your sensory cortex? How are you feeling and experiencing sensations arising from the gut? That is the part of your brain that's filtering out. Is this an irritant? Is this not an irritant, right? Is this disruptive or not disruptive? We know that people living with IBS can have some disruptions in how those signals are coming up to the brain, as the sandbox metaphor, right? And it's sort of saying, this is an irritant, this is disruptive, I don't like this. The second part is the affective, the emotional side of it, meaning how does that interpretation go into the limbic system? How do we look at the emotional center of the brain and can we tamp down those feelings? Brain imaging studies out of UCLA in particular have really shown that people living with IBS are different from healthy controls in that both they feel those sensations arising from the gut, but they also tend to be have difficulty tamping down those sensations and the emotional centers. So once that signal has kind of come into the brain, it gets encoded and involved. And that's actually the forms the basis, and I know we'll talk about it, but that forms the basis of our brain gut behavior therapies. But I do like to sort of talk to people about it's both sensation arising from the gut, but it's also the ability to regulate the sensation once it's in the brain.

Dr. Megan Riehl

And this is so, I hope that our listeners will like replay this in their mind and hear that language because to hear that and have that explained to you as a patient, I find is incredibly validating into again why the treatments are multidisciplinary. And that is a skill set that as a clinician that we have to develop and having that ability to talk to our patients and again validate the pain is real, but it's not something that we want to put a band-aid over. It goes a lot deeper into exactly what the brain gut access is and that bi-directional pathway.

IBS Mimickers And Pelvic Floor Clues

Kate Scarlata, MPH, RDN

Oh my goodness, that was awesome. It was such a good way to describe it to a patient, but also just for professionals that are listening to to really, really look at the different effects the pain can play in this condition for sure. So, Darren, I wanted to talk a little bit about IBS mimickers in the sense that we know that in certain conditions like bile acid diarrhea, that may co-occur with IBSD. I know SIBO and IMO are a little controversial in different areas of the country and amongst many experts because the testing isn't far from perfect, but that may play a role. When do you work with patients to maybe investigate further? Like this is IBS, but maybe there's something co-occurring with IBS, or maybe there's something that's happening that really isn't IBS. What are some of the clues and signals that you see to really push for more testing?

Dr. Darren Brenner

It's a great question, Kate. I think it differs on the IBS-D from the IBS -C side. I think in clinical practice, we're seeing more on the IBS -C side because people have become very good at identifying the mimickers of IBS-D, like you mentioned bile acid diarrhea, SIBO, exocrine pancreatic insufficiency, inflammatory bowel disease. So obviously it goes back to what we all learned initially in medical school, which is the history and the physical exam. And we're looking for alarm signs or symptoms. Age plays a role. Are you bleeding, anemic? Are there nocturnal symptoms? Is there unintentional weight loss? Has there been an acute shift? Somebody who has irritable bowel syndrome for a long time can literally my chart call or come to the office and say, I know my symptoms well, and these are not them. I want to look elsewhere. And more times than not, they're correct. So we have to listen to our patients. It's not one of those, oh, so-and-so's calling again. So I'm just gonna, you know, brush this off. When they say there's something different, in most cases there are. And that's where we can go sleuthing. I think we see more in clinical practice on the IBS C side because people assume that constipation is just constipation. And so I tell my patients, constipation plus laxative does not always equal cure, because that's what they get. Two, three, four, five stack laxatives, and they say, I don't understand why things aren't working. Which is why when we write the guidelines, we were very finite, right, Laurie? Yeah. If you get treated for IBS -C and it does not work, look at the function of the pelvic floor because your skeletal muscles will not respond to laxatives. So in many cases, I'll have a conversation with my patients about their constipation, and their first question is, well, is this just IBS-C then? And I'll say, no, you may have a component of IBS -C, but it is not the rate limiting step. And that's the key take-home message for the patients that are listening to this podcast and the practitioners. If you're giving laxatives, if you're giving FDA approved therapies for IBS -C and they are not responding, look at their pelvic floor. I don't care how quickly you can get food from mouth to rectum to anus, if the door at the bottom doesn't open, and that is a group of skeletal muscles, your medications will never, ever work. So that's where we have to start looking at these mimickers, and that's where the vast majority of my patient practice comes from. So a difference between the different subtypes, but really I want to focus on that constipation side because these are the people who suffer for 40, 50, 60 years. We were told they had spastic colon, inflammatory colon, leaky gut syndrome, atonic colon, dead colon, and they have a perfectly functioning colon, but they've got pelvic floor musculature that doesn't work.

Kate Scarlata, MPH, RDN

So glad you brought that up because the majority of my patients have constipation predominance IBS, and they may even present with diarrhea initially, and that's the diagnosis, and it's an overflow situation where constipation's driving it. And pelvic floor physical therapists have been such a, I mean, I've been referring for years. Once I saw what they were doing, and I think the other piece of this too is that not only did the laxatives not work, they might make things worse because you're adding all this fluid to the bottom of the colon and that door is tight. So that's another red flag to kind of be thinking about too, right?

Diet, Bloating, And Multidisciplinary Care

Dr. Darren Brenner

Right. And it leads to fecal incontinence. And this is where that, like you said, multidisciplinary model comes into play because we need those pelvic floor physical therapists. And sometimes it takes multiple conversations. We hear from patients all the time I tried this laxative, I tried that laxative, I'm waiting to see the physical therapist. Fix me while I'm waiting for the physical therapist. And politely have to say there's a reason why you're waiting for the physical therapist. But getting back to what Laurie does, that brings in the chronic cognitive portion, right? Now you've opened two doors. Number one, I'm angry because I don't have just irritable bowel syndrome. I've been told by many practitioners this is what it is, and it actually what it isn't, or maybe it's just a portion. And then number two, there's the chronic illness component. I have been suffering. I have not been able to leave my house. I'm chained to my toilet, which can actually further affect those pelvic floor muscles and make them worse. So you still need that brain-gut connection to be dealt with to actually improve the patient's symptom profile. So never, I want to tell the audience, forget that piece too, because if your pelvic floor therapy is failing, it may not be the patient or the therapist. It may still be part of that mind-gut connection, which we need to address to actually open up the muscles of the pelvic floor. It's very Freudian, but it's very true.

Kate Scarlata, MPH, RDN

No, I agree. And we can't forget diet too. Too much fiber when the door's not opening is like adding cars to a traffic jam, right? So that cannot sometimes be a problem. And then there are things that we can do with the diet, like two green kiwi fruit or adding prunes if they're not sensitive to them from a FODMAP standpoint. Things that the diet piece can just also add a little bit of help as well, right?

Dr. Darren Brenner

Especially for the bloating distention component, right? Every constipated patient gets that back up. It's the abdominal symptoms that drive a lot of the referrals to practitioners, like all of us. So absolutely, if we can minimize that piece with diet, it just goes further for giving that person improved quality of life.

Dr. Megan Riehl

And so for those that they suffer, and also it can take a long time to get into the right team. And so when Laurie and I end up getting connected with a patient, there tends to be this frustration, overwhelm, feeling like they've been dismissed for years. Again, they're bringing like a pile in some cases of workups and they're willing to do any and everything moving forward to feel better. And so, Laurie, how do you take patients when you're being introduced to their treatment team, teaching them how to advocate for themselves in these scenarios?

Empowering Patients And The Positive Diagnosis

Dr. Laurie Keefer

Yeah, I think that's so important. And so much of what we have to do, right? Especially because they've been sort of mistreated all along the way, is re-empower the patient. I think a lot of times that helplessness has taken over and then you become almost hyper-vigilant to everything the doctors say, and it's hard to take the forest for the trees. So, you know, I think one reason that patients feel dismissed is the assumption that nobody's been able to find something, and so they don't have anything. And that is really, I mean, something that we've really tried to work with. And in the ACG IBS guidelines, right? One of the first things we talk about is receiving a clear positive diagnosis. We do know what you have. You have something called irritable bowel syndrome. Your subtype is this. This is what you have. These are all of these tests, all these workups may have been helpful, may not have been, frankly, but we know what you have, and we need to move past the assessment towards an intervention, right? And to getting you to feel better. And unfortunately, the longer you go before somebody diagnoses you positively, the more you've sort of fell into this helplessness trap and the idea that you've received this wastebasket diagnosis. The second, I think, thing, in addition to not receiving the positive diagnosis up front, is not buying into or not understanding the pathophysiology, right? One of the reasons, and Megan, to your point earlier about the nomenclature, one of the reasons we changed functional to disorders of gut-brain interaction was to really reflect that these are disorders of gut brain interaction, so that there's no question as to the pathophysiology. The degree to which it's gut, the degree to which it's brain may vary for every individual person, but the underlying pathophysiology is the interaction between these two. And so I think it's really important to help our patients advocate for themselves to buy into that. And I often have my patients sort of start out with what's your elevator pitch? What do you have? How do you manage it? How does it show up in your life, right? And you'd be surprised. A lot of times people aren't able to say that. And I think it really speaks to that helplessness feeling of, I don't know what I have, I have stomach issues. No, I have irritable bowel syndrome. It's a disorder of gut-brain interaction. It's actually very common. I have to sometimes take medications for it and I modify my diet. And sometimes I may have to cancel on you because I don't feel well, right? That's your elevator pitch, but it makes it so much easier to talk about then. And I think that helps that when you go to the doctor, you can tell the doctor what your elevator pitch is, you can tell your friends and your family, and you can buy into the treatment a little bit better.

Dr. Megan Riehl

Starts to give you some tangible things that, you know, giving some control in what feels like a very uncontrollable medical condition, you're starting to take some ownership of this.

Dr. Laurie Keefer

Yeah, even symptoms. Like, I mean, how many times? I mean, Megan and I used to joke, you know, you'd spend like an hour with someone, and by the end, it was so confusing, even for the clinician to understand, you know, does a patient have diarrhea? Do they have constipation? I'm not sure. Do they have dyspepsia or IBS? Because it's so overwhelming, right? And so I do think that it can be helpful for everybody, the clinicians and the patients, to really be able to explain this in a more concise way, right?

Kate Scarlata, MPH, RDN

Yeah, I used to do the elevator pitch for the low FODMAP diet during the holiday times. Just like this is what it is, this is why I need to be on it, this is not an allergy. But these foods can really cause me pain. And it is, it's sometimes easy for us. We've been doing this for a while, right? We can say, oh, this is what it is in a nut, right? But the patient doesn't really have those like simple, doesn't want to spend three hours describing their health history. What is that quick elevator pitch for whatever it is can really help them advocate for themselves and get involved in life again, right?

Dr. Megan Riehl

Like that's part of our goal is we know that patients that are living with IBS, their life becomes very isolated, afraid to leave, wanting to be near a bathroom. So giving a skill set and some cognitive strategies around how to get back involved in some of these things that you've been avoidant of, that helps to reduce the anxiety associated with this condition.

Treatment Triage And Shared Decisions

Dr. Darren Brenner

It normalizes it too, right? I mean, if people go home and they look up IBS, the internet, if it can do one thing, can you know normalize this disorder. It's a very common disorder. We've all heard this. What I'm gonna tell you, you've probably never heard before. It's the strangest thing, and all of us are thinking in the back of our heads, you're gonna tell me the same thing I've heard other times already. But it's okay because it's abnormal for you. But by, like you said, not marginalizing this, saying it's more the rule than the exception, that really does take that stress level down a notch. And we've all heard it, right? We've all had patients leave our office and say, I feel so much better. At least I know there's something going on, I can move forward from here. So that's a great thing.

Kate Scarlata, MPH, RDN

That is a great thing. Giving them hope and direction and being part of it. That's it's such a need to have for these patients to have a lot of different helpers and different corners and different disciplines. And I know that's been proven through the research, but you know, having this multidisciplinary team is just so key. And that really brings me to my question for Darren. And that is, you know, when I started, and I I'll be honest, you know, I'd look at my patient profiles for the day and I'd see IBS, and I'd be like, oh, what am I gonna do with this patient? Of course, this is nearly, you know, 35 years ago. And to just see this whole growth and research and interest in IBS finally, I can remember the transition to being like, oh, it's IBS. I can do that. You know, I have a lot of different tools in my toolbox. And so we do have this expanding toolkit for our patients. How do you decide? Like, this one's probably gonna need, let's do diet first. Or, you know, I know in my practice I have people waiting for a long time and they come in and I'm like, they need a GI psychologist. So, you know, I might give them some modifications slightly in their diet, but I'm like, you know what? I really want to connect you with this provider. So, how do you handle that in your practice? And then a second question to this is just, you know, what are your go-to therapies, or are there some emerging therapies that are like, this is really exciting in this area that you want to share?

Dr. Darren Brenner

Yeah, you know, it's it's a very difficult question. I could probably answer this for the next two hours.

Sponsor Message: IBS-C Therapy

Kate Scarlata, MPH, RDN

I know. Well, just high level, elevator pitch, elevator pitch.

Trauma, ACEs, And The Nervous System

Dr. Darren Brenner

High level is is what I say to everybody, and they laugh. I make this comment, you know, to my colleagues in my audiences, and they laugh because it's common sense, but then people don't go back and actually do it. And it goes back to my first question: what was your trigger, right? What caused the onset of your symptoms or an exacerbation? And if somebody says to me, I went to Mexico and I drank some water and I've been sick ever since, that's completely different than the person that says to me, My symptoms flare because I've been the caretaker for my mother for the last 10 years and she passed away two weeks ago. Or if a person says, every time I eat food X, I get sick. So it's not a one-size-fits-all disorder. And so we really have to listen to our patients and hear them because if somebody has, I'll call it Montezuma's revenge, we can all relate to that, then I'm probably using something more traditional pharmaceutical. If somebody's mom passed away, I'm probably immediately referring to Megan or Laurie, one of my colleagues at Northwestern, Kate or Anjali. If somebody says to me every time I eat food, it makes me sick and I'm food avoidant, I'm getting ARFID or I've xetophobia, fear of eating, then obviously I'm referring to, you know, you, Kate and Beth and Kristen at Northwestern. So it really does matter. But if I can't tease that out, I think one thing that has kind of shifted the pyramid. I used to say going towards diet was the peak of the pyramid. Now, Kate, unfortunately, you're the base of my pyramid.

Kate Scarlata, MPH, RDN

Yeah. No, I agree.

Dr. Darren Brenner

You know, right? Most patients can identify a food, and most practitioners have bought into this. This is your data, you know, published in the Red Journal a couple of years ago. Practitioners believe diet can be as good as pharmaceuticals, and they think people can get better from a symptom and quality of life standpoint by seeing a dietitian. So, really, I start there and I try to tease through that process. And you mentioned it. For many people, it isn't an allergy, and maybe it's a sensitivity, but all of our labs aren't doing confocal laser microscopy to prove that. So we have to go and pick them and again listen to the patient and hear what they have to say. Now, if people say everything I put in my mouth makes me sick, then I talk more about the process of eating than the particular foods. But if they can isolate food categories, I'll go there. You're right. We have lots of medications differentiated between IBS -C and IBS-D and IBS-M. So we can tease those out. And I can't design an algorithm because I talk about the different therapies that are out there. I talk about the risks, the benefits, the costs, the effects, the side effects. And then it really does become shared decision making. Where do you want to go and what do you want to do? And yes, I've had patients who come up with the craziest ideas. I'll say, well, maybe that's not the direction I would take. But nine times out of 10, I'm comfortable with the patient's decision because the outcomes are always better. But I will stress this the best outcomes always occur in my ivory towers, Megan mentioned earlier, multidisciplinary therapy, absolutely within pseudo therapist.

Kate Scarlata, MPH, RDN

That was perfect. Yeah.

Advertisement

When it comes to irritable bowel syndrome with constipation or IBS-C, there's no one size fits all treatment. If you're not satisfied with your current IBS-C medication, it may be time to try something different. Ibsrela (Tanapenor) is a prescription medicine used to treat adults with IBS-C. Ibsrela works differently to help relieve the constipation and abdominal symptoms of IBS-C and could be the right option for you. Ready to try something different for your IBS- C symptoms? Ask your doctor about Ibs rela. Do not give Ibsrela to children less than six years of age. You should not give Ibsrela to children six to less than 18 years. It may harm them. The most common side effect is diarrhea, sometimes severe, and your child could get severe dehydration. Stop taking Ibsrela and call your doctor if you develop severe diarrhea. Do not take Ibsrela if you have a bowel blockage. Tell your doctor if you are pregnant or breastfeeding and about the medications you take. Other common side effects include swelling or a feeling of fullness or pressure in your abdomen, gas or dizziness. Learn more at ibsrela.com/PI or call 1-844-Ibsrela and press option 4.

Dr. Megan Riehl

And we've highlighted it's kind of an N of one diagnosis, and life experiences can really have a profound impact on a diagnosis of IBS as well as chronic pain and numerous other health conditions. And something called adverse childhood experiences or ACEs are associated with roughly doubling the risk of developing IBS in both men and women. And anxiety seems to explain a large portion of that connection, while resilience may also serve as a protective factor. And we've seen this in research, particularly in women. And so, Laurie, can you help us understand a little bit around how early life stress and trauma can shape our nervous system and then the influence that has on GI symptoms, as well as how does this impact how we encourage patients to seek treatment?

Advocacy, Boundaries, And Trauma-Informed Care

Dr. Laurie Keefer

Yes, that's a great question. And I think it's something that, you know, a lot of us are uncomfortable talking about, right? And so I think I'm really glad you asked that. Like you said, you know, ACEs, which you know can mean anything from, you know, severe sexual trauma to, you know, an incarcerated parent or a mentally ill parent growing up in that environment, are more common in people with chronic health conditions, including IBS. And there's, you know, been a couple studies that have shown that IBS patients are indeed twice as likely to go on to develop IBS if they have ACEs. But like you said, resilience and also confiding in somebody at the time of your adverse life event can often be the differentiator. And so, you know, I think we have to keep that in mind. For many of us clinicians, we're the first person that a patient has told about an adverse childhood experience. And so we really need to honor that opportunity to have them just tell us and confide. But in terms of you know, the impact of the nervous system, I think it's, you know, it's increasingly we're seeing more and more, not just the fact that there's psychological sequelae of an adverse environmental, you know, adverse childhood experiences, there may even be microbiome impact, right? Growing up in poverty, growing up in, you know, Annie Church's work at UCLA has really shown that discrimination experiences, living in communities, can really affect brain gut signaling, what foods we crave, you know, how we handle pain and discomfort, and all of that, you know, I think sets the context of piling on additional adverse life experiences can really kind of set people up for risk for these disorders. So I think that the data is really starting to show that we do need to be thinking about that context, early life microbiome development in the first three years of life is influenced by some of these adverse childhood experiences. If you think about it, you know, more top-down and you think about the job of the body to maintain homeostasis, right? Keep us safe. Keep us safe. Our job is really, you know, if you think about the the role that that early life experience has in your ability to detect potential threats, right? I always say, you know, are you somebody that grew up kind of sleeping with one eye open? Did you grow up, you know, wondering how a parent was going to come home drunk or not? You know, how attuned to your environment are you and how much does it take to activate your sympathetic nervous system? And from a GI standpoint, on always turning on and off that switch, right? There's a saber-toothed tiger about to eat me, you know, there's a my boss is about to come down and yell at me. You know, if you're doing that all day long and you're not bouncing back because your nervous system is so sort of overdriven, anyways, you're really going to start to see the impact on the gut, right? Nobody stops to rest and digest during the middle of an emergency. The other thing I'll say is in addition to sympathetic nervous system arousal associated with chronic and even acute stress and early life experiences, you also have behaviors. When you're under stress, what are you doing? You're skipping the gym. You're maybe just grabbing a snack instead of eating a meal, you're not sleeping as well, maybe you're not taking care of yourself as much as you want. And so I think that also can play a role in that process.

Smart Second Opinions Without Chaos

Dr. Darren Brenner

I'm gonna stress for the the audience, both the patients and the practitioners. The patients don't understand that these early life events, traumas can lead to these jail illnesses. They're not making the links. And the practitioners, in 20 years of practice, I can count on one hand the number of times I've seen a history that's asked about trauma, stress, or PTSD. So please, please, please, for the audience, if you're a practitioner, ask. If you're a patient, tell. Because this will send us in a completely different direction that will not only improve your symptoms and quality of life exponentially if we have access to people that can help, but also get you there faster. Because what we don't know and what we don't ask can't help.

Dr. Megan Riehl

And you don't have to detail it, right? So speaking about your trauma with a new provider, we completely understand the difficulty of that sometimes. But letting Dr. Brenner know, you know, I have a history of sexual trauma from childhood, period. And now his entire, you know, I think again, we're we're with an expert here that as a GI doctor is going to come from a trauma-informed lens. But to your point, Darren, not everybody does.

Kate Scarlata, MPH, RDN

Right.

Dr. Megan Riehl

So as a patient, that we get how difficult that can feel. But also what we're trying to highlight is that that's going to get you better care, better access, better resources.

Dr. Darren Brenner

And it can be just a binary yes or no. Have you had yes, no, yes is enough for us to take that in a different direction.

Dr. Laurie Keefer

Right. It doesn't mean you haven't coped with it, you haven't dealt with it, you haven't moved on from it. It just means that it may inform the way your gut and brain are communicating. And we need to address, we need to consider that as part of the context of treatment.

Dr. Megan Riehl

So this is something we also see where Lori, patients come to us and they're like, I've powered through months, years, chronic stress. I was fine, fine, quote, air quotes. And now, you know, my life is good. I'm I'm high functioning, I've got a job that I love, my family is supportive. Like I've done a 360 in terms of what my life was. And what the heck is going on with my gut now? Like, why this delayed response and why does the body hold on? How do you tell patients and describe that to them?

Labels Versus Root Causes In Care

Dr. Laurie Keefer

Yeah, it's a I hear that all the time, right? And I think it's really that, you know, they've been operating on fight or flight successfully because it is adaptive to mount a stress response in your body when you're under stress, right? Like there is a reason why our bodies still go into fight or flight mode to conquer stress. And so, but what we're sacrificing the longer we're in that fight or flight mode is time and rest and digest mode. And I think that that's where once you finally kind of make it, right? Your body has to adjust to being, and I always tell my patients, you know, you we're also adjusting to being well, right? Like, what does that feel like? What do I actually do with that sensation of not having to run after the latest, you know, stressor or emergency or dramatic person in my life? What do I do when I actually just like can live? And I think that's where a lot of these other skills come from, which is, you know, how do I adjust to rest and digest? How do I live in terms of my lifestyle going forward without all of these emergency situations? Again, though, you know, to my point earlier, when you're in these fight or flight responses and you're often not seeing the consequences of skipping gym and diet and sleep until afterwards, right? They kind of build up. And so you may have periods of time after a stressor is over in which you have to kind of rebuild some of those lifestyle patterns to see an impact on your gut.

Dr. Megan Riehl

And it's not going to be a light switch where, like, okay, I've been exercising regularly. I've been, we always talk about the longer-term expectations of this implementation. And that can be a bit frustrating for some because they're like, I just suffered for all of this time and I just want to feel better. So we do have to kind of cultivate a sense of reasonability with the implementation of everything. And I do want to hit on you've been instrumental in research around resilience for both patients with IBS as well as patients with inflammatory bowel disease. What's your elevator pitch on why resilience is first modifiable? And we can teach this and hone this, but what do you want people to know about resilience in their healthcare?

Mindset Shifts: Catastrophizing To Grace

Dr. Laurie Keefer

Yeah, thank you. I think the term, unfortunately, because of everything going on with COVID and you know, we're throwing out the word resilience all the time. Like you have a resilient economy, you have a resilient army, you know. But you know, when we talk about it scientifically, we really are talking about the body's ability to physically recover and move past stress and the mindset that people have in being able to recover and move past adversity, right? And the beauty of resilience is that everyone is resilient. Humans by nature are resilient. So our resilience gets challenged during adversity, and all we have to do is rise to the occasion. And sometimes we need skills to be able to do that. So this isn't psychopathology, this isn't a lack of resilience, right? This doesn't mean that you can't manage things. It just means that there are strategies that we can do to help you bounce back quicker and move on further. And that might be what we call our resilience five, which is acceptance of the situation that you're in, even if you don't approve. Second is having that optimism that not taking things personally, pervasive, or permanently. The third is having the ability to regulate and do hard things, even if they're hard, you're still able to push through and challenge yourself, have that courage. The fourth is the confidence to do whatever needs to be done. If you need to learn how to swallow pills, if you need how to learn how to cook gluten-free, you can do it. And then the last and probably maybe the most important is community, right? Being able to leverage your social support system long-term around your health and well-being. And so we call that those are the five modifiable resilience, five characteristics, but I do think it's so relevant to our IBS and IBD patients.

Dr. Megan Riehl

Again, it gives a framework. It gives people something to say, like, oh, well, I'm not the greatest at my coping skills for this. And great, we can work on that. Talking about what true acceptance is. I've had sometimes patients that are like, well, I don't like that. And I'm like, well, that's okay. You don't have to like this, but we're gonna work on accepting it so that we can move forward in terms of next steps.

Kate Scarlata, MPH, RDN

Yeah, I definitely see that with IBS. The I don't want to accept this diagnosis, keep looking, keep looking, keep looking. And new doctors, new doctors, new doctors. And it just gets them into such a you're the my last ditch effort, and you're like, uh, you need to stay with the team that we're gonna put together for you and stop jumping because that is so important.

Dr. Laurie Keefer

It's the ability to do the hard things, right? To tolerate side effects potentially of a medication that eventually will work for you, but right now you're on the upstart. It's it's being able to regulate and persist despite obstacles, is what resilience is. And that's what the team can help with, right?

Kate Scarlata, MPH, RDN

Exactly. And I also just want to go back a little bit because these adverse childhood events that are, you know, can really increase this risk of IBS. And I think of patients seeing a gastroenterologist and there may be a rectal exam and how to navigate that if that's something of concern. And again, speaking to Darren's comment, we really all should be asking these questions. And maybe patients don't want to divulge fully. That's absolutely their right. But it's also their right to say, I don't want that exam too. And so just as a reminder to listeners out there that, you know, if something's uncomfortable for you, you can say no.

Dr. Megan Riehl

And that really, really is key. Yeah, if there's something you've been avoiding because of a trauma history, a colonoscopy, or an exam, communicating with your team about that, there will be no judgment. If you've experienced shame because of that, then you need to find a new provider. And we'll help you with that. Reach out to me. I'll help you find a good gastroenterologist. But we don't want you to avoid your care, especially when we hear about colon cancer being on the rise and in younger adults. We don't want you missing out on a important medical exams and tests because of fear and past negative experiences. Absolutely.

Speed Round: Trends, Tools, And Hope

Kate Scarlata, MPH, RDN

So for those patients that have persistent symptoms, really just not feeling well, how do you help them navigate getting a second opinion? We don't like people jumping and jumping and jumping, but sometimes they need a second opinion. How do you help them navigate that, Dr. Brenner?

Dr. Darren Brenner

It's a good question. I'm usually the second opinion or ninth opinion or tenth opinion. I know. That cycle, quite honestly. First and foremost, you know, understand the role of the patient. Don't take it personally. So as a practitioner, I think there are a lot of people who will say, you don't need a second opinion. I'm right. And if you want to go see somebody else, don't come back to my office. I've heard that over and over again. That's when the Kleenex boxes start coming up. We've all heard it. Don't be shy about it. I will block, or I won't say block, it's a bad term. I will suggest against third, fourth, fifth, ninth, tenth, twelfth opinions. I have had too many cooks in the pot conversations. I've had the we went down the Alice in Wonderland rabbit hole because if you run a million tests, you will find something to chase, which probably has nothing to do with anything we're discussing with regards to your initial symptoms. But that second opinion is okay. I ask individuals, be honest about why you want the second opinion. I'm uncomfortable with this, or I'm sure we haven't addressed. You may be able to address that issue, allay their fears, and then they don't need the second opinion. But importantly, especially at my level, if you want a second opinion, tell us, because we want to get you to the right person. And I'm not going to name names, but I have people who will go off, not tell me that. They want second opinions. And then they'll see a resident or a fellow in another program and bring back this laundry list of things that they want to do. And it's backtracking and saying, okay, I appreciate what they said. I appreciate what they did. They may not have the same experience or knowledge. So let's go through this, let's walk through this and see what really needs to be done, why these things would be useful, why they may be completely irrelevant, and what we want to do as a team. So I ask patients, be honest, frank, and upfront about it. We'll get you to the right people, the people we can work with and communicate with to get that second opinion. And then you still have that team focus as opposed to somebody we don't know or as somebody far, far away where we can't have those interactions. And now you're stuck on that teeter-totter trying to balance who do I believe for what part, where do I go, and what's right. Let us help you in that process.

Kate Scarlata, MPH, RDN

It is awful for patients. And sometimes they will jump to a physician, you know, across the country, get a completely different diagnosis and plan. And I say, that is like the worst case scenario for you because you're just there's no continuity of care here. And even the hospitals, you know, being private practice, I'm always reaching out to the gastroenterologist, like, can we have the same messaging? Let's agree on what we both agree on. And that's what we're going to work on initially, because it can be terrifying, exhausting, and complicating for patients and expensive and expensive.

Dr. Darren Brenner

Right. And forget the treatment. If you don't agree on the diagnosis, the treatment becomes irrelevant because you're recommending completely different things. So you have to agree, especially in a patient with IBS, that it's IBS. The minute, like Lori, I think mentioned, you open that door to the possibility of something else, then to Megan's point, here comes the litany of diagnostic tests. And I can guarantee you, if you give me enough tests, I will find an abnormality. So we have to break that cycle.

Kate Scarlata, MPH, RDN

And I think they need to know that you can have IBS and something else too. It's not like IBS is still here, but you also have that. Sorry, it's two. It's two for one. So I think too, it's not going to discount or throw out the IBS because we found something else that you can have two things at the same time.

Closing Thoughts And Community CTA

Dr. Megan Riehl

And I love Laurie's opinion on this, but I mean, not to toot our own horns, but when we think about some of the nuances of these different diagnoses, IBS, SIBO, leaky gut, I'll tell patients that once you're in our office, our treatments are going to be getting at that root that will help you with the management. In a lot of cases, it doesn't matter what we label it.

Dr. Laurie Keefer

Yes.

Kate Scarlata, MPH, RDN

Good point.

Dr. Laurie Keefer

No, that's exactly right. And because we are targeting the beauty of what GI psychologists get to do is we get to target the gut brain axis, which is the underlying framework for all of these conditions. And so so many patients have comorbidities, they have dyspepsia and IBS, they have pelvic floor dysfunction and reflux, you know, it's just which organs are involved in the GI tract.

Kate Scarlata, MPH, RDN

Absolutely. So, Dr. Brenner, if you could offer one mindset shift for patients navigating their chronic gut symptoms and the setting of normal tests, what would it be? Give an example. What's a good mindset shift?

Dr. Darren Brenner

I think we want to minimize the catastrophization. I'm always afraid to throw that term out there, especially in the initial visit, because we can make the diagnosis in a couple of minutes, right? We all know that. An accurate diagnosis with just a few different questions. So it's to minimize that catastrophization. I have, in the era that we live in now with telemedicine, I don't let patients get away with it anymore. If they're not there for their visits, we call and I ask, you had an appointment this morning, you waited six months for that. I know that because I can look in the records. Why are you not here? Because I was afraid this morning that I may have diarrhea and the Eden's Expressway is jammed with traffic, and I just bought this brand new car that I love and I don't want to soil it. That's an honest answer. I've heard that over and over again. They are not there. And I'll say, well, when was the last time that happened? Did that happen when you went grocery shopping last night? Did it happen when you went to the movie with your husband last week? It's never happened before. So I try from a cognitive standpoint to minimize the burden of this illness. I'm honest. I'm completely honest. I say to people, you'll love me or you'll hate me, but I will always be honest with you. And I start out by saying, I, nor do any of my colleagues in 99% of cases, because I'm not God, I'm never 100%, I'm not black or white, but 99% have no cure for this disorder. So you're gonna have good days and you're gonna have bad days. And I want to make it so there's more good days than bad days, but I'll never get there. If every morning, when you wake up in the morning, the first thing you think is, Whoa is me, how is my body going to beat my head down today? Where am I gonna be and how am I gonna not function? So I try to tell them you want to get up every morning with the idea of to the point that we mentioned earlier, I control my life, I will tell my symptoms I can get around this, I can be better with my resilience, and I'm gonna move on with my day, and my day will be better than the day before. That's really where I want to focus the attention on a day-by-day basis from a brain gut standpoint. Perfect.

Dr. Megan Riehl

Laurie, I would love to hear your perspective as well. What is the mindset shift that you you wish patients could have?

Dr. Laurie Keefer

Yeah, I mean, I think it is a lot of what Darren's saying, I would look at it also from the more the positive side of, you know, which is that A, you can give yourself some grace, right? I think a lot of our patients are very perfectionistic. And if they don't feel perfect, if they can't bring their whole selves to every event, then they don't want to go at all. And so I think a lot of this is to Darren's point, you've got to go about your life. You may wake up, you might have symptoms, there is no cure. I don't have to be perfect. I can give myself the grace to go and not feel 100% and still do what I want to do. Right. And I think a lot of our patients, I wish more people would feel that it's okay to have this and that you don't have to be perfect all the time.

Dr. Megan Riehl

That's right. That's right. Perfectionism is not possible. Yeah.

Dr. Laurie Keefer

And you the perfectionist is always the one that tells you that they're not perfect. So that's right. Yeah. Right. So you always have to kind of work your way back around that, right?

Kate Scarlata, MPH, RDN

Yeah. Just, you know, leaning into the imperfections of life, right? We can't control everything. And I think sometimes this patient population with trying to connect the dots and feeling somewhat confused, they're writing down every symptom and every bowel movement and every food-related connection and just constantly that hyper-vigilance. That's stressful for me to even see the logs. I'm like, oh, let's let's tone this back. And I get it, it's a complicated disease condition that's very challenging to live with. But, you know, having all of these great answers to this about mind shift is so important to getting on with living life and not expecting perfection and leaning in to the nuance of the condition can really make a difference. So, with that, we're gonna get to our fun part. We're gonna learn a little bit about you all. We're gonna do our speed round. So, this is really just fun. You've shared your brilliance with our audience, and now we're gonna get to know you. So, we're gonna start with you, Lori. What is your favorite way to spend a day off?

Dr. Laurie Keefer

I think with my kids, I have two teenagers who are actually really fun and interesting people. So I would say I love to spend my days off with them. I also enjoy traveling a lot, so I try to find something places to go to do.

Kate Scarlata, MPH, RDN

I like that. Perfect. Those are two favorites for me, too. So, what's one word or phrase patients need to hear more often? It will be okay. It will be okay. That gave me chills. I love that. What is one gut health that you're skeptical of?

Dr. Laurie Keefer

Oh microdosing of anything. And I know what that means.

Kate Scarlata, MPH, RDN

Yeah, I don't think we anyone knows what that means, but whether it's microdosing magic mushrooms or GLP1s, yeah, exactly.

Dr. Laurie Keefer

Or Prozac, whatever microdosing, yeah.

Kate Scarlata, MPH, RDN

Don't don't microdose. Okay. Something you always travel with.

Dr. Laurie Keefer

So unfortunately, I get very emotion sick, so I always bring my dramamine with me everywhere I go.

Kate Scarlata, MPH, RDN

Yeah, that's a good one. Yeah. And then what is your go-to nervous system regulator?

Dr. Laurie Keefer

So funny story. My kids laugh at me, but I have a mommy upbeat playlist in our family Spotify, and they periodically will add songs to it that help me regulate my emotions. And so sometimes if I just need a little nervous system regulator, I'd be like, what have my children added to my upbeat playlist? Oh, that's so fun.

Dr. Megan Riehl

That is fun. So yes.

Kate Scarlata, MPH, RDN

That is fun.

Dr. Megan Riehl

And your children are like approaching college age. So I bet you're really getting exposed to some interesting and culturally relevant.

Dr. Laurie Keefer

People or little bop or kids. Yeah. Yeah. Serious music. Yeah. Yes, all right. Thank you, Laurie. Darren, you are up. What's your favorite way to spend a day off?

Dr. Darren Brenner

That's why Laurie and I get along so well. They're very similar with family and friends, traveling. My wife will tell you that she says in her next life she wishes she had as much energy as I do. I always want to be on the move, seeing new things, having new experiences, and just being in different cultures. I think the best way to understand the world is to actually experience the world.

Kate Scarlata, MPH, RDN

I love that. And what's a gut health trend you are skeptical of?

Dr. Darren Brenner

Yeah. So right now, my biggest taboo, please, please, please, I won't be as polite as Laura. I'm going to be flat out honest. Do not put castor oil in your belly buttons. It does not do anything for your intestinal health. Period. Exclamation point, exclamation point, emoji sign.

Dr. Megan Riehl

Emoji sign. Okay. Well, so I won't be doing that as part of my ...

Kate Scarlata, MPH, RDN

You need to stop. Yeah. Stop doing that, Megan.

Dr. Megan Riehl

I can promise you I've never done it. So don't worry. One thing patients apologize for, but they don't need to. Contact.

Dr. Darren Brenner

Many of our patients apologize because they think they need help. And their mic charts begin with, I'm sorry for reaching out. For important realistic things, we want to be there. We want to help. We realize as practitioners that there aren't enough hours in the day. I can't see everybody that wants to be seen in clinic. And that doesn't leave a good feeling. So if there really is something going on that's concerning you, please do reach out to us and don't apologize for it.

Dr. Megan Riehl

What a great doctor.

Kate Scarlata, MPH, RDN

I know. Jeez, wish I lived in Chicago.

Dr. Megan Riehl

Go to IBS management strategy.

Dr. Darren Brenner

Yeah, I think like I mentioned before, it depends on what's wrong. I don't have a there is no one size fits all to your end of one point, Megan. It is really dependent on the patient, what that individual wants to do. What I think realized years ago is when it comes to treating irritable bowel syndrome, it's not about me. It's not about what I want. It's what the individual wants, and it's my goal to get him there.

Dr. Megan Riehl

Yep. Okay. And then what's one word or phrase patients need to hear more of?

Dr. Darren Brenner

I'm going to take a quote from Gloria Gaynor. I will survive and thrive. This illness is not the end of your life. This is not going to make it so you can't do anything anymore. Take control of your own care, take control of your own body, and just go on and live your best life. That's perfect.

Kate Scarlata, MPH, RDN

Yeah, love it. This was such a good episode. So thank you so much for the incredible conversation, sharing your brilliance and really all this real life experience that you've had working as clinicians in this area. Really, you need to be zoomed out to really see the big picture in all of this, and the best way to help our patients navigate a really challenging, often challenging, but livable condition. So there's always ways to advocate for yourself or those listening that are living with IBS and you can explore new treatments. There's lots of tools in the toolkit and build resilience along the way.

Dr. Megan Riehl

That's right. So thank you both for joining us, and thank you for listening to this episode. Thank you for joining us as we grow this gut health community. We hope you enjoyed this episode, and don't forget to subscribe, rate, and leave us a comment. You can also follow us on social media at The Gut Health Podcast, where we'd love for you to share your thoughts, questions, and experiences. Thanks for tuning in, friends.

Head Shot

Kate Scarlata

Host
Head Shot

Megan Riehl

Host