Irritable Bowel Syndrome Podcast

How to Provide Biopsychosocial IBS Care in Your Clinic

Lin Chang, MD; Douglas A. Drossman, MD


April 19, 2023

This transcript has been edited for clarity. For more episodes, download the Medscape app or subscribe to the podcast on Apple Podcasts, Spotify, or your preferred podcast provider. 

Lin Chang, MD: Hello. I'm Dr Lin Chang and welcome to Medscape's InDiscussion series on irritable bowel syndrome, or IBS. Today we'll be discussing a few topics, including the history of IBS; the gut-brain axis; the biopsychosocial approach; and the role of early life, adversity, and stress with our guest, Dr Doug Drossman. Dr Drossman is professor emeritus of medicine and psychiatry at the University of North Carolina School of Medicine, where he was on staff from 1977 through 2011. He was founder and co-director of the UNC Center for Functional Gastrointestinal and Motility Disorders, is president emeritus and chief executive officer of the Rome Foundation, and is president of Drossman Center for the Education and Practice of Biopsychosocial Care. Welcome to InDiscussion.

Douglas A. Drossman, MD: Thank you, Lin. Nice to be here.

Chang: It's an honor to speak with you today because we've been colleagues for many years. You're a mentor of mine, so it's really a pleasure. I wanted to start the discussion by you telling us about yourself and how you became interested in IBS.

Drossman: Thank you. Well, I'm married. I have two children and 10 grandchildren. In my work world, I've always been interested in medicine and psychiatry/psychosocial factors. In fact, I didn't even know if I wanted to go into medicine or GI. I decided to go into medicine and then GI rather than psychiatry because I wanted to treat patients, but I always had that interest. After my medical training, I went into a psychiatry psychosomatic program with George Engel, who coined the term "biopsychosocial model." From the very beginning of my training, I was integrating medicine and psychiatry or psychosomatic medicine. That got me interested in the disorders of gut-brain interaction. When I was a fellow in 1977, Don Powell, who was my division chief, got a request to do a review for a series that was coming out in General Gastroenterology. He asked me if I could do it with him, and I said, "Yeah, let's do irritable bowel syndrome," which had not been out there that much. So, we wrote that article, which combined the psychologic, the motility, and the treatment aspects. That became very popular, and that's where I first got started.

Chang: You really are one of the pioneers in the field of IBS. Our understanding of IBS has evolved over the years, and you've seen that evolution over time. Can you describe how IBS was perceived in the past and how it's changed over time up to the present day?

Drossman: Before the 20th century, the entity didn't exist as a diagnosis, as much as a collection of symptoms. In fact, I remembered reviewing that in the 1840s, there was a doctor named Cummings who may have [coined] the first description. He said, These are patients who can have diarrhea and constipation at the same time. How is that imaginable? That was one of the earlier ones, but they were a collection of symptoms. Beginning around the 1940s, there were physiologists from New York and Cincinnati and other places who started to do physiology research. They were looking at motility. They would put tubes down and measure pressures. This got into the idea of motility. One of my mentors was Tom Albee, who did research early in the late 1940s and early 1950s. He even did an experiment with medical students where he put up a sigmoidoscope in the medical student's colon and pretended that he saw cancer while he was observing the pressure generated in this rectum sigmoid. That was, of course, before Institutional Review Boards (IRBs), but then it got more sophisticated. From the 1940s until the 1980s, physiology really dominated it. It was thought that diarrhea and constipation were caused by physiologic motility dysfunction. Looking at symptoms like pain and nausea, they tried to explain it based on these pressure-generated waves, but they couldn't explain it. I think a paradigm shift happened in 1990 when two things happened. One was when the Rome Foundation developed diagnostic criteria, which allowed people to have consistency in research so patients could be studied around the world, and they would be the same group, phenotypically. In addition, work was being done on visceral hypersensitivity, which was different than motility. Bill Whitehead did it in the bowel. Joel Richter did it in the esophagus. There was now evidence that, independent of motility, you could generate hypersensitivity where distension of the bowel would lead to higher levels of pain reporting by these patients. I think those two factors led to this tension between physiologic explanations and what we later called "symptom-based diagnoses" using Rome Foundation criteria for functional GI disorders. The good thing about using the criteria is it opened the door to more research. If you trace the last 30 years since 1990, you're seeing less physiology to explain everything, but it is a component. What we see more is the microbiome, gut mucosal immune function, brain-gut interactions, and the like.

Chang: I think it's a really important point that there's been different pathophysiologic mechanisms attributed to IBS, one of them being motility. It's much more than that. It's a complex condition. IBS has been redefined from a functional gastrointestinal disorder to a disorder of a gut-brain interaction, and scientific evidence has supported that redefinition. How would you describe the gut-brain axis to patients and clinicians? What do you find are the most important aspects of gut-brain axis that are applicable to patient care?

Drossman: One reason we changed the term from functional GI to disorder of gut-brain interaction is because we had learned from our surveys of the American Gastroenterological Association (AGA) and by talking to patients that it's a very stigmatizing term. It often leads to the implication that if there's nothing found, then it must be psychiatric. The real entity of functional GI was meant to be a disorder of function, but it never came across that way. With the science that was evolving in the 1990s to the 2000s, and now the gut-brain axis, I tell patients that the brain and the gut are in constant communication to regulate bowel functioning: pain, motility, sensations like nausea, and the like. This is based on a hard-wired connection between the gut and the brain. The brain and the gut don't work independently in terms of these sensations. An example of the gut-brain axis is if you're running a race, and you sprain your ankle. You may not feel the pain because the attention on the race is downregulating or blocking the signals coming from your foot. Another example is if you see a car accident, you might get nauseated and throw up. The brain and the gut are dysregulated. The good part about this dysregulation is that it opens the door to treatment, which can open up looking at neuromodulators and brain-gut behavioral treatments, in addition to peripheral neuromodulators treating the gut alone. I tell patients that it's a logical explanation for their symptoms because there's no structural findings. These patients are struggling with What do I have?, and nobody can really tell them because the studies are negative from the dualistic model. The last 20 or 30 years have led to an explosion of understanding of brain-gut dysregulation and treatments to regulate it. In a sense, I'm giving patients a greater sense of understanding and hope by using the gut-brain axis.

Chang: I think that even though we intrinsically know that symptoms can be generated by physiologic changes within our body or within the gut-brain axis, sometimes we tend to think a little more concretely. We're expecting to see a structural or anatomic abnormality that is contributing to the symptoms. I do agree that it's important to discuss that with your patients and teach that to clinicians. You mentioned having acute stimulus where you don't feel the pain; the brain is also activating descending pain inhibitory pathways to dampen that at that moment. With a chronic stimulus, the pain gets actually enhanced. That's due to that two way highway between the brain and the gut.

Drossman: Yeah, you can have visceral hypersensitivity in the gut even when normal regulatory activity could be signaled to be experienced by the brain. In addition, you get a failure of the brain to downregulate those signals, so patients get a double dose in pain.

Chang: I think a good example of that is post-infection IBS, where patients have no IBS symptoms but get an infection, so they clearly have some insult to the gastrointestinal tract. The infection goes away, but then they get chronic symptoms of IBS. That's really due to the dysregulation of the gut-brain axis. It really starts in the gut.

Drossman: It starts in the gut. You can get what some people call "leaky gut," which is a media term, but we're talking about a loss of mucosal integrity. You can get transmigration of products that can sensitize the nerves. Secondarily, in a setting of stress, such as deployment in a war zone, getting an infection can give war veterans post-infection IBS because the stress is also affecting that permeability. It's a failure to block the signals coming up.

Chang: The role of stress is an important topic that we're going to get to. I wanted to talk first about the biopsychosocial model that you brought into this field, and you mention about the OMNI study where you can get a distressing type of experience that could change the physiology of your gut. Can you describe the biopsychosocial model as it pertains to IBS and how you use this approach in taking care of patients?

Drossman: Sure. I was very fortunate to have my mentor write the seminal publication in Science in 1977 when I was a GI fellow, and I carried it through my whole career. He wrote that in real life, illness and disease are not the products of biologic dysfunction alone. Other factors, including the gut-brain axis or psychosocial factors, can affect the clinical expression and even the causation of the condition in many ways. It replaces the mind-body dualistic model because sometimes you don't see something structural, but you know there must be something there. The biopsychosocial model brings that understanding — the psychologic factors that are part of the way patients experience illness. Symptoms of pain or motility are modified by psychosocial factors. As I said before, this opens the door to better treatments.

Chang: That's important to not just recognize the symptoms but pay attention to how patients are managing their symptoms. What environmental factors can impact how well they're doing or how they're managing their symptoms? How do you apply that when you're seeing a patient? Are you thinking about all the different factors — biologic, physiologic, psychosocial — that play a role in that patient's presentation? Do you describe that to the patient? How do you put it in play when you're taking care of patients?

Drossman: Getting a history is the first thing I do, and this gets into some of the work on communication. In getting the history, I allow the patient to speak, because they tell the story. That's what Osler said, right? I don't interrupt, and I give them the time. Healthcare providers worry about that, but it usually only takes 2 or 3 minutes before most patients stop. Patients tell their story in a psychosocial context. If they're saying to me, "I got my pain while driving to the office," a follow-up question might be, "Then what happened? Tell me about the pain." I might continue to ask, "What type of work do you do? Was there anything going on at the office at the time?" I use the time where they bring up something else of a psychosocial nature to have them elaborate on it. Then I bring them back to the story because you take the history through what's called a narrative thread from beginning to end of the symptom of pain. I also try to get certain questions answered even on the first visit. "What brought you here today? What do you think is going on?" This is their illness schema. That's a way to get psychosocial information. I ask, "How can I be helpful to you?" These are the kind of questions that clarify the psychosocial context of what's going on. I work on integrating that information. If I were to find out that the illness began on the anniversary of the father's death from esophageal cancer, and they're talking about chest pain, I can bring them back to that story and say, "It's really interesting that it happened on an anniversary. Maybe you were thinking about that at that time." That helps me decide how attuned the patient is to understanding that issue. Now, if they were to say, "Well, that has nothing to do with me," then I take that as data and won't pursue it, but I'll keep it in the back of my mind. If they say, "Oh yeah, that might make a difference," that opens the door to talking about brain-gut therapies. I'm constantly gathering information, integrating it, and trying to play it back to the patient to see their response. That really is the biopsychosocial model, right?

Chang: That's the approach I also take. I think it's really important to listen to the patient and convey it back to them. It helps to bring the whole story together from a biopsychosocial standpoint. A lot of times, patients have the bits and pieces but not really collected.

Drossman: You're absolutely right. Remember medical school training? History of the present illness, past medical history, and social factors — they're totally different, and we tend to partition them in medical school. We have to reverse that. We have to let the patient tell their story. We call it patient-centered care, where we are the experts who put it all together and give it back to them.

Chang: As the fellowship training program director at UCLA, I've noticed that when fellows are they're taking care of inpatients and there's a GI bleed, the questions are often like a checklist because they're trying to get the history and determine the urgency. Outpatient care is different. You must have a different thought process and framework for how you ask questions. I feel it isn't so difficult to make the diagnosis of IBS if you have some experience or knowledge of it, but it's really determining all the factors that play a role in that patient's presentation and their understanding of how they manage their symptoms. I want to discuss the role of stressful life events in childhood or adulthood, such as abuse. You've studied this a lot. Can you elaborate on the association of chronic stress and the development of IBS and the role of stress for symptom flares?

Drossman: I've always been interested in medicine, in psychiatry, or psychosomatic medicine or biopsychosocial medicine. That was the beginning of my research, too. I was interested in looking at the role of stress and psychosocial factors. We're talking the 1980s now, right after I finished my fellowship. One of the questions that struck me when we were looking at IBS was that people looked at it in two ways due to that physiology-psychosocial split. One camp thought that patients with IBS were stressed because they had severe motility disturbance, and that's why they had it. The other camp was saying that these are psychiatric disorders like somatization. I tried to study that by creating this model of looking at people with IBS who were patients, people who weren't patients, and people who were healthy. I looked at them medically, physiologically in terms of sensation threshold with Bill Whitehead, and in terms of their psychosocial parameters. What we found was the psychologic distress or disturbance was greater in the patients than they were in people with IBS who didn't go to the doctor. The ones who didn't go to the doctor were not statistically different from normal. What that told me was that healthcare seeking was a factor associated with more psychologic difficulties or distress. As the symptoms became more severe, there was more psychologic disturbance. I saw it as an interacting factor between the brain and the gut. The stressful factors can enable the phenotypic expression of their symptoms. That was the first part. Because of Engel's training and my interviewing, I started to pay more attention to listening to patients. I found at my GI clinic that everybody coming to me had a history of trauma and abuse. I didn't understand that. The first thing we did was to survey the GI clinic — not just my clinic, which was getting all the IBS people, but the whole GI clinic. We gave them a survey with Jane Leserman, who was a colleague of mine on abuse. We also later got a National Institutes of Health (NIH) grant to study it with more detail and with interviews. The bottom line is we found about 50% of the women going to the GI clinic had a history of ongoing or early sexual or physical abuse. That led us to get the grant. With the further work of the grant, we began to see that this had significant impact on health status — their psychologic scores, their quality of life, their healthcare utilization, even the propensity to have surgery. A patient with abuse and IBS was more likely to get surgery than patients with just IBS, and that surgery was not necessarily indicated. We then looked at brain imaging and found that the pain scores to rectal distension was higher and the sensitivity of the rectal distension was less in those with abuse who had IBS than those who didn't have IBS. I think the greatest part about that is that there's been even greater elaboration of these early factors. Lin, you've done work with deprivation and many other factors. It's been really exciting to see what's carried on since my work in the 1990s.

Chang: I found that studying the role of early life adversity and stress is so relevant to patients. It isn't just abuse; it could be a general adversity like mental illness in the household growing up. I wanted to talk about your role as a leader in the patient-provider relationship. I know that's something you're very passionate about. It's very valuable. Can you address the importance of good communication to optimize the patient-provider relationship?

Drossman: The thing that makes my situation unique is from the very moment I started working in GI, after meeting with Engel, I was interested in the history. When I was a fellow doing endoscopy in the days when we did three or four a day, I would get patient histories and would predict who would have the ulcer, IBD, or a normal study with pretty good accuracy because I was getting the psychosocial data. I made that a part of my career in teaching, when I was giving grand rounds, or when I was doing visiting professorship. I always integrated it. If we look at the modern times, I think a pivotal moment, Lin, was the paper you and I did and several others in 2021 where we did an evidence-based review to show that good communication skills or the training of communication skills was predictive of reduction of health outcomes, reduction in symptoms, increased satisfaction of the doctor and the patient, reduced procedures, and even a reduction in healthcare costs. We have the science now to justify it. The passion now comes because I've been a firm believer in collaborative patient-centered care. I work with Johannah Ruddy, who was a patient and is a patient advocate. We do communication skills workshops to talk about the value of the patient. This weekend, we're going to do a train-the-trainer session with some key leaders in the field, teaching them how to run workshops and how to improve their skills. I think it's helped me be a good teacher, to tell people what it's really like because it's very valuable to watch them use these skills and then come back to me and say, "I saw this patient, I did it this way, and now they're better." I feel good about it.

Chang: I've definitely benefited from learning from you. My whole approach of taking care of patients really changed after I started seeing patients with you many years ago. Thank you for that. We're about out of time, but is there any key message of IBS you'd like to convey to the audience?

Drossman: IBS and the other disorders of the gut-brain interaction are the most challenging, exciting, and enjoyable areas in gastroenterology. I don't want to demean other specialties, but what more can you do for GERD? There are things you can do, but here we're building on the knowledge and creating new treatments through basic and translational research in the microbiome and brain-gut interactions. We didn't talk much about neuromodulators and brain-gut treatments, including new agents on the enteric nervous system and the brain. I think we're finally opening up the opportunities to help patients who have never felt health before. We are dealing with a cohort who are dissatisfied with their care, and we can do something about it.

Chang: Those are all wonderful comments. This has been a great foundation for our series on IBS. Today we've had Dr Doug Drossman discussing the history of IBS, the gut-brain axis, the biopsychosocial approach and the role of stress in early life adversity, and the patient-provider relationship. Thank you so much for joining us. This is Dr Lin Chang for InDiscussion.


IBS and Chronic Constipation

The Need for a New Medical Model: A Challenge for Biomedicine

The Irritable Bowel Syndrome

Rome IV Criteria

William E. Whitehead, PhD

Program Treats Complex GI and Swallowing Disorders

Post-infection Irritable Bowel Syndrome

Psychosocial Factors in Gastrointestinal Illness

To Be a Great Physician, You Must Understand the Whole Story

Validation of Symptom-Based Diagnostic Criteria for Irritable Bowel Syndrome: A Critical Review

Effect of Abuse History on Pain Reports and Brain Responses to Aversive Visceral Stimulation: An FMRI Study

Toward a Biobehavioral Model of Visceral Hypersensitivity in Irritable Bowel Syndrome

A Review of the Evidence and Recommendations on Communication Skills and the Patient-Provider Relationship: A Rome Foundation Working Team Report

Rome Foundation — Johannah's Story

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