This story was originally published in the June issue of the Breakthroughs Newsletter.
The Division of Gastroenterology and Hepatology at Feinberg has a distinct strength in understanding how behavior and lifestyle influence gastrointestinal (GI) health. Through its work and in collaboration with the Northwestern Medicine Digestive Health Center, the Division conducts research aimed at improving treatments for disorders of the digestive tract and related organs.
John Pandolfino, MD, is chief of the Division of Gastroenterology and Hepatology.
The direction of this research began when chief of the division, John Pandolfino, MD, ‘94, ‘96 GME, noticed that his patients were not reporting improvement in their conditions even after esophageal surgery was performed. He discussed the challenge with colleagues, including Laurie Keefer, PhD, a former associate professor of Medicine in the Division of Gastroenterology and Hepatology, to get her perspective on how to address the continuation of symptoms after the procedure was completed.
“This work was born out of necessity,” Pandolfino said. “We realized we have to address mental health to improve outcomes and help the value of our physiomarkers. We had done surgery to make things better, but the correlations with improved symptoms still weren’t there.”
Together, with additional collaborators, they started working on how to measure key psychological processes such as esophageal hypervigilance, symptom-specific anxiety, and quality of life in patients, which resulted in the development of an Esophageal Hypervigilance and Anxiety Scale (EHAS) and the Northwestern Esophageal Quality of Life Scale. These measures provide a starting point for physicians and psychologists to evaluate the potential psychological processes playing a role in patient’s symptom experience as well as a patient’s perceived quality of life, and help identify other potential treatments beyond surgery or medications.
Multiple studies coming out of the division have found that treating the GI conditions include addressing the psychological factors present that impact symptoms. The gut-brain axis — how the digestive system links with the central nervous system — has been revealed to be an important element for the treatment of many GI conditions.
Hypervigilance and its Impact on Physiology
Individuals with gastrointestinal conditions such as irritable bowel syndrome (IBS), Crohn’s disease, colitis, and other esophageal disorders may experience hypervigilance, a common process characterized by heightened bodily awareness in response to a perceived threat. In the context of esophageal disorders, this can involve increased attention to current and anticipated throat, esophagus, and chest esophageal sensations. Hypervigilance may amplify sensitivity to pressure, burning, or tightness—symptoms that can be uncomfortable, disrupt food intake, and ultimately affect nutritional status and energy balance.
Livia Guadagnoli, PhD, is research assistant professor of Medicine, and is leading research into hypervigilance to understand how psychology impacts physiology.
Livia Guadagnoli, ‘20 PhD, has been fascinated by the intersection between psychology and physiology since she began in Feinberg’s clinical psychology program as a graduate student. Now, as research assistant professor of Medicine in the Division of Gastroenterology and Hepatology, she is studying hypervigilance and its impact on GI conditions. Earlier this year, she was lead author of a study published in Gastroenterology about hypervigilance and its connection to poor treatment outcomes for those living with esophageal disorders.
She and her collaborators found that increased esophageal hypervigilance and anxiety were associated with worse post-treatment symptoms and poor quality of life in patients with achalasia, a rare esophageal motility disorder.
Using multiple data analysis techniques, the investigators found that higher baseline esophageal hypervigilance and anxiety scores predicted higher post-treatment symptom severity and lower quality of life. Interestingly, they also found that worse esophageal function at baseline was associated with higher quality of life post-treatment.
“Our hypothesis was that if someone has a really dysfunctional esophagus and they get treatment, they’re probably going to experience at least some improvement that’s going to improve quality of life,” Guadagnoli said.
Screening patients with hypervigilance and anxiety may, therefore, help indicate which patients could benefit from early psychological interventions to improve post-treatment outcomes, Guadagnoli said.
“What would be a beautiful model is if people who have achalasia are screened and those who are reporting high levels of hypervigilance and anxiety meet with a psychologist in the clinic, even just for a few sessions, to try and address the vigilance and anxiety and any other psychological processes, either before treatment or while they’re going through treatment and recovering from treatment, to hopefully prevent these processes from amplifying symptoms,” Guadagnoli said.
Guadagnoli said the next steps for this work will include investigating the underlying mechanisms of how these psychological processes interact with physiology and how that contributes to better or worse patient outcomes.
Investigators are also looking at behavioral interventions to treat GI conditions. Recently, Pandolfino received a renewal of his grant from the National Institute of Diabetes and Digestive and Kidney Diseases to study the gut-brain interactions that drive symptoms and healthcare utilization, specifically in GERD and functional heartburn.
Sara Hoffman, PhD, is assistant professor of Medicine and co-investigator on a grant to study GERD and cognitive behavioral skills.
The team is studying behavioral interventions to understand if a cognitive-behavioral skills intervention can meaningfully impact hypervigilance and physical stress response in the body (like increased heart rate or sweating) for individuals living with GERD and functional heartburn. While many studies focus on acid reduction and pharmacological treatments, the Feinberg team is looking at how the gut-brain interventions influences symptoms and quality of life.
Sara Hoffman, ‘21 PhD, assistant professor of Medicine in the Division of Gastroenterology and Hepatology, is co-investigator on this project.
“We want to empower patients to have the skills to manage symptoms and improve quality of life,” Hoffman said. “The power of the gut-brain axis is that the psychological factors impact much more than stress and mood, they impact symptoms and can change how a patient experiences their symptoms.”
Bridging Clinical Care and Research
The Division has a team of six psychologists that work closely with physicians to address how psychological challenges to impact GI health. Guadagnoli, Hoffman and Kate Tomasino, PhD, associate professor of Medicine in the Division of Gastroenterology and Hepatology, make up half of that team. They receive more than 1,300 referrals annually.
Kate Tomasino, PhD, is associate professor of Medicine and Gastroenterology and leads quality improvement research in the Digestive Health Center.
Through the Digestive Health Center, they offer group therapy, support groups and individual sessions to help patients work through psychological challenges with the goal of improving GI health. In addition to the NIH-funded research, the team is always seeking to conduct quality improvement research projects that can inform and impact how they provide care.
Tomasino said it is important to look at gaps in care and conduct research to address those gaps.
“We are asking questions like what factors we need to measure, and are the things we’re doing working?” Tomasino said. “We are learning more about medical trauma and its impact on patients.”
Future research from the Division intends to build the case for how psychology impacts physiology and the importance of behavioral treatments that ease symptom burden for individuals living with GI conditions.
“From working with patients, we know that these interventions work, but there is a lack of data to justify how behavioral interventions improve symptoms over optimizing pharmacological treatments,” Guadagnoli said. “We want to understand where in the care pathway should we insert behavioral interventions to improve care and to understand that on a mechanistic level.”
Melissa Rohman contributed to this story.