The Use of Mind Body Medicine in Patients with
Celiac Disease, Non Celiac Gluten Sensitivity
and Irritable Bowel Syndrome
MARK A. SALVATORE, MD, MS
THE CENTER FOR CELIAC RESEARCH AND
TREATMENT
MASSACHUSETTS GENERAL HOSPITAL FOR
CHILDREN
APRIL 11, 2015
Financial Disclosures
 I have no relevant financial disclosures
Mind Body Medicine
Learning Objectives:
(1) Discuss the principles of Mind Body medicine,
specifically how the Relaxation Response counteracts
stress and builds resiliency
(2) Discuss the Resiliency Building program at the
Benson-Henry Institute for Mind Body Medicine
(3) Discuss the application of a Resiliency Building
Program in patients with Celiac Disease, Non Celiac
Gluten Sensitivity and Irritable Bowel Syndrome
Mind Body Medicine: Principles
• What is Stress?
• Stress is the perception of a threat to the physical
and psychological well-being and the perception
that the individual’s responses are inadequate to
cope with the threat
• Stress elicits the flight or fight response
• How stress affects the body
Mind Body Medicine: Principles
Somatic Motor System
Tension
Jaws Clench
Body Braces for Action
Autonomic Nervous System
Central Nervous System
Perception - Narrowed
Memory - Coarse, Imprecise
Learning - Blocked
Conditioning - Defense
Expectancies – Negative
Heart rate increases
Blood pressure increases
Breathing rate increases
Blood sugar increases
Adrenalin flows
Digestive tract shuts down
Blood to muscles
Blood vessels constrict in hands
Mind Body Medicine: Principles
• The stress response is an adaptive response built to
ensure our survival, but a chronic stress response is
maladaptive and can lead to symptoms of anxiety,
depression, fatigue, hopelessness, difficulty sleeping,
etc.
• Stress Disinhibition Effect
• As stress increases, so does likelihood of stress
reduction behaviors, including drinking, drug use,
overeating and other maladaptive behaviors
Mind Body Medicine: Principles
Arousal Reaction
In the adaptive person, the arousal reaction return to normal after the
stressor is dealt with.
In maladaptive person, the arousal reaction continues even after the
stressor has been dealt with. The set point or baseline of arousal reactions
steadily moves upward.
Maladaptive
Adaptive
stressor
stressor
stressor
Mind Body Medicine: Relaxation Response
The Relaxation Response is opposite of the Stress Response
Described by Dr. Herbert Benson in the mid 1970s
Stress Response
All Increase
CHANGES
Metabolism
Heart Rate
Blood Pressure
Breathing Rate
Muscle Tension
Relaxation Response
All Decrease
Mind Body Medicine: Relaxation Response
• Basic Elements for eliciting the RR:
•
A comfortable position in a quiet environment
•
The repetition of a simple sound, word, phrase or movement
•
The passive (nonjudgmental) return to the repetition when
other thoughts intrude
• Ways to elicit the RR include meditative techniques such as
mindfulness, guided imagery, repetitive prayer, progressive
muscle relaxation, diaphragmatic breathing, yoga, tai chi,
among others
• Benefits seen when performed 1-2x daily for 15-20 minutes
Mind Body Medicine: Relaxation Response
• Benefits of eliciting the RR:
•
Reduces muscle tension, heart rate, and blood pressure
•
Quiets the mind, increases ability to focus and promotes
creative problem solving
•
Breaks one from conditioned responses
•
Reduces the physical and emotional impact of stress
through building resiliency
• Resiliency is the ability to properly cope with, adapt
to and overcome stress and adversity
Mind Body Medicine: Resiliency Program
Mind Body Medicine: Resiliency Program
• Benson-Henry Institute for Mind Body Medicine at
MGH was founded in 1988
• The Relaxation Response is the foundation of the
Clinical Programs
• Clinical Programs include Cancer, Cardiac Wellness,
Fertility, Chronic Pain/Chronic Fatigue Syndrome,
Stress Management and Resiliency Training
(SMART), among others
• Researchers have published > 50 peer reviewed
articles showing the benefits of resiliency training in
various fields of medicine
Mind Body Medicine: Resiliency Program
• Curriculum usually consists of 8-10 weekly sessions
• Three Essential Components to all Programs:
• Relaxation Response. A multitude of meditative
techniques that elicit the RR are taught
• Stress Awareness. The different ways in which stress
affects an individual (cognitively, emotionally, physically,
behaviorally, relationally, spiritually) are explored
• Adaptive Strategies. Adaptive strategies to respond to
stressful situations are taught. Strategies are grouped into
four categories: reappraisal and coping, positive perspectives,
healthy lifestyle behaviors, and social connectedness
Mindy Body Medicine: Mindfulness
• What is Mindfulness?
• Mindfulness is defined as “the awareness that
emerges by way of paying attention on purpose, in
the present moment, and non-judgmentally to the
unfolding of experience moment by moment” 1
• Paying attention to what is present in our inner and
outer experiences, including our thoughts, emotions
and sensations
• Mindfulness elicits the RR and builds self awareness
(e.g., mindful eating and drinking)
Mind Body Medicine: Guided Imagery
• Imagery is creating thoughts and pictures in one’s
•
•
•
•
mind
Imagery is most most effective when it incorporates
as many of the senses (sight, sound, smell, touch, and
taste) as possible
What is the most common form of imagery? Worry
Positive Imagery elicits the RR
All thoughts and images created by your mind affect
your body
Mind Body Medicine: Guided Imagery
Greed
Despair
Revenge
Indifference
Arrogance
Insecurity
Loss
Envy
Mistrust
Anguish
Selfishness Hopelessness
Futility
Inadequacy Confusion Fear
Frustration
Scorn
Rejection
Bitterness
Mind Body Medicine: Guided Imagery
Abundance
Hope
Vitality
Wisdom
Love
Security
Kindness
Awe
Trust
Joy
Selflessness Hope
Faith
Creativity
Clarity
Equanimity
Peace
Connection Generosity
Gratitude
Mind Body Medicine: Use in GI Disorders
• Numerous studies have shown the efficacy of a
Mind Body Program on symptom reduction in
pediatric and adult patients with IBS 2-8
• Some persons with IBS have heightened stress
perception, which adversely affects symptoms 9-12
and hypervigilance towards bodily sensations and
symptoms 13,14
• GI-specific anxiety includes the thoughts, emotions
and behaviors that stem from fear of GI sensations,
symptoms and the context in which they occur
Mind Body Medicine: Use in GI Disorders
• GI specific anxiety has been hypothesized to function
as an endogenous stressor, leading to exaggerated
autonomic responses, changes in intestinal function,
and visceral pain perception and GI symptoms 15,16
• In the context of IBS, enhanced mindfulness
decreases GI-specific anxiety by teaching techniques
that foster reappraisal of fears and beliefs related to
GI sensations 4
• Enhanced mindfulness also builds awareness of
symptom triggers while also mitigating the effects of
known triggers
Mind Body Medicine: Use in GI Disorders
• Ljotson et al. in an open pilot study of 34 subjects with IBS
showed an improvement in IBS-QOL and GI-specific anxiety
measures 6 months following a 10 week intervention specific to
IBS using mindfulness and exposure therapy 2
• In a follow up study of 86 patients randomized either to a wait
list or an online version of the same intervention, Ljotson et al.
showed a significant improvement in IBS-QOL in both 3 month
and longer term follow up (mean 16.4 months) 3,6
• In a study of 13 adults with IBS who completed a 6 week course
in Relaxation Response Meditation, Keefer and Blanchard
showed significant within-subject improvement in bloating,
belching, flatulence and diarrhea at 3 months post treatment 7
• For 10 adults who completed a 1 year follow up, improvement in
symptoms persisted 8
Mind Body Medicine: Use in GI Disorders
• Kearney et al. studied 93 adult patients with IBS who
•
•
•
•
underwent an 8-week mindfulness-based stress reduction
program 4
Participants met weekly to practice mindfulness and yoga
Intention involved bringing to mind their personal
motivation for participating in MBSR (e.g., pain control)
Sustained Attention to an aspect of their experience
(thought, emotion, bodily sensation) and flexibility of
attention (“letting go”)
Emphasized an Attitude of openness, kindness, curiosity
and nonjudging of the present moment experience
Mind Body Medicine: Use in GI Disorders
• Participants practiced daily meditation or yoga for 45
min per day, 6 days a week
• Study showed a significant improvement in IBS-QOL
(33%) and decrease in GI-specific anxiety (40%) at 6
months post treatment
• There was a significant correlation between the
change in GI-specific anxiety and attainment of
mindfulness skills
Mind Body Medicine: Celiac Disease and NCGS
 Being evaluated for (doctor visits, blood draws,
endoscopies) and/or diagnosed with Celiac disease
or non Celiac Gluten Sensitivity, and adjusting to a
gluten free diet can be a very stressful experience,
especially in adolescence and young adulthood
 Patients with CD and NCGS, especially in the
presence of concomitant IBS or anxiety stand to
gain benefit from a Resiliency Building program
 To date, no studies have been performed in these
patient populations, but are needed
Mind Body Medicine
References
1. Kabat-Zinn J. Commentary on Majumdar et al.: mindfulness meditation and health. J Altern Comp
Med 2002; 8: 731–5.
2. Ljotsson B, Andre´ewitch S, Hedman E, Ruck C, Andersson G, Lindefors N. Exposure and mindfulness
based therapy for irritable bowel syndrome – an open pilot study. J Behav Ther Exp Psychiatry 2010; 41:
185–90.
3. Ljotsson B, Falk L, Vesterlund AW, et al. Internet-delivered exposure and mindfulness based therapy
for irritable bowel syndrome – a randomized controlled trial. Behav Res Ther 2010; 48: 531–9.
4. Kearney DJ, McDermott K, et al. Association of participation in a mindfulness programme with bowel
symptoms, gastrointestinal symptom-specific anxiety and quality of life. Aliment Pharmacol Ther 2011;
34: 363-373
5. Psychosocial interventions can improve pain and symptoms in children with IBS (Youssef NN, et al,
Aug 2004: American Academy of Peds Subcommittee on Chronic Abdominal Pain. Chronic abdominal
pain in children. Pediatrics. 2005)
6. Ljotsson B, Hedman E, Lindfors P, et al. Long-term follow-up of internet-delivered exposure and
mindfulness based treatment for irritable bowel syndrome. Behav Res Ther 2011; 49: 58–61.
7. Keefer, L and Blanchard, EB. "The effects of relaxation response meditation on the symptoms of
irritable bowel syndrome: results of a controlled treatment study." Behav Res Ther 2001; 39(7): 801-11.
8. Keefer, L and Blanchard, EB. "A one year follow-up of relaxation response meditation as a treatment for
irritable bowel syndrome." Behav Res Ther 2002; 40(5): 541-6.
9. Murray CD, Flynn J, Ratcliffe L, Jacyna MR, Kamm MA, Emmanuel AV. Effect of acute physical and
psychological stress on gut autonomic innervation in irritable bowel syndrome. Gastroenterology 2004;
127: 1695–703.
10. Whitehead WE, Crowell MD, Robinson JC, Heller BR, Schuster MM. Effects of stressful life events on
bowel symptoms: subjects with irritable bowel syndrome compared with subjects without bowel
dysfunction. Gut 1992; 33: 825–30.
References
11. Bennett EJ, Piesse C, Palmer K, Badcock CA, Tennant CC, Kellow JE. Functional gastrointestinal
disorders: psychological, social, and somatic features. Gut 1998; 42: 414–20.
12. Bennett EJ, Tennant CC, Piesse C, Badcock CA, Kellow JE. Level of chronic life stress predicts clinical
outcome in irritable bowel syndrome. Gut 1998; 43: 256–61.
13. Gibbs-Gallagher N, Palsson OS, Levy RL, Meyer K, Drossman DA, Whitehead WE. Selective recall of
gastrointestinal sensation words: evidence for a cognitive-behavioral contribution to irritable bowel
syndrome. Am J Gastroenterol 2001; 96: 1133–8.
14. Gomborone JE, Dewsnap PA, Libby GW, Farthing MJ. Selective affective biasing in recognition
memory in the irritable bowel syndrome. Gut 1993; 34: 1230–3.
15. Labus JS, Mayer EA, Chang L, Bolus R, Naliboff BD. The central role of gastrointestinal-specific
anxiety in irritable bowel syndrome: further validation of the Visceral Sensitivity Index. Psychosomatic
Medicine 2007; 69: 89–98.
16. Ballenger JC, Davidson JRT, Lecrubier Y, et al. Consensus statement on depression, anxiety, and
functional gastrointestinal disorders.