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Season 4 Episode 5:

The Future of IBS Management: Elimination Diets are Out, Gut-Directed Hypnotherapy is In with Claire Hall of Nerva

Episode Summary

Can hypnotherapy really alter the physical sensations in your gut? Claire Hall, research lead at Mindset Health, joins Michelle to discuss gut-directed hypnotherapy for those with irritable bowel syndrome (IBS) and how their app, Nerva, provides an innovative management option that’s challenging traditional dietary restrictions and shaping the future of gut health management.

We discuss:

  • What is gut-directed hypnotherapy and its distinction from “stage” hypnosis [1:33]
  • IBS as a diagnosis of exclusion and its clinical definition using the Rome IV criteria [4:01]
  • The biopsychosocial model of IBS, incorporating genetics, psychological factors, and early life experiences. [4:47]
  • Comparison of hypnotherapy's effectiveness with other treatments such as the low FODMAP diet [13:22]
  • The role of relaxation in managing IBS symptoms through hypnotherapy [15:28]
  • The bi-directional relationship between the brain and the gut via the vagus nerve [16:23]
  • How Nerva was developed and its focus on clinical trials and retrospective research [33:33]
  • Potential expansion of hypnotherapy applications to other GI disorders and chronic pain [40:32]
  • Success stories and patient feedback on using Nerva for IBS management. [43:03]
  • The role of education in changing the conversation around IBS and its management [46:42]


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The Future of IBS Management: Elimination Diets are Out, Gut-Directed Hypnotherapy is In with Claire Hall


Michelle Shapiro [00:00:00]:

Claire, I am so excited to have you with us today.


Claire [00:00:03]:

Thank you so much for having me. It's great being here.


Michelle Shapiro [00:00:06]:

We are huge Nerva fans at this practice and on this podcast, so for that reason, I'm extra excited. Claire, tell us about your role within Nerva. And then of course, we're going to talk about all things stress and gut health related.


What is your role within Nerva?

Claire [00:00:19]:

Yeah, I was lucky enough to start at Nerva really very early on. So the parent company above nervous, called Mindset Health, and I linked up with Chris and Alex, who are the co founders of Mindset Health when it was them and one or two other people. So I was pretty early on in the mindset health journey and of course, Nerva was the first product and so very early on with Nerva as well. And, you know, since I've been there, my role really is to develop the research arm of the company, making sure that we have high quality products and we're really engaging in creating high quality to get clinical trials and retrospective research so we can back up what we say about these products, that they really are effective for people and push forward the research world.


What is gut directed hypnotherapy and how does it work?

Michelle Shapiro [00:01:08]:

And we're going to talk about what specific studies you've done. And I know there's a tremendous amount of research behind Nerva and I'm assuming any product that mindset health has. And so just tell us really on this very kind of high level, what is the premise of gut directed hypnotherapy? How does it work?


Claire [00:01:26]:

Yeah, so anytime anyone hears hypnotherapy, you get the eyebrow raise, like hypnosis?


Michelle Shapiro [00:01:32]:



Claire [00:01:33]:

Yes. It sounds crazy. I understand that. And it's actually so fun to work in this field because we get to do so much education and really teach people about the power of clinical hypnosis and hypnotherapy. There is that classical stage hypnosis, which is totally separate to what clinical hypnotherapy is. Got directed. Hypnotherapy is a tool that uses relaxation to get patients into a deeply relaxed state so that you can offer suggestions around the improvement of GI function and really manage those IB's symptoms from a top down approach. So I'm sure we'll get into the mechanism of the vagus nerve and that bidirectional conversation that we all have between our brain and our gut.


Claire [00:02:20]:

And hypnotherapy really helps manage that from the top down approach.


Michelle Shapiro [00:02:25]:

It's incredible. So really your goal in working with clients through this app is to intervene on the gut relationship from, like you said, the top down from the brain as it directs into the gut. There's a lot of dietitians obviously work with clients from a bottom up approach. Right. So it's like, how do we do things that will affect the gut? I love this about Nerva and I love this about hypnotherapy, that when you kind of act on one part of the body, you can affect the rest of the body.


Claire [00:02:54]:

Yeah. And it's sort of naive for us to believe that we can manage the body without looking at it holistically. And I think we can talk about having a dietitian managing from the bottom up, or having a brain gut behavioral therapy managed from the top down. And really what we know about IB's is that the best management solution is all of the above and tackling it from both angles. And really that is now the new gold standard of how to manage IB's. So it's not an either or, it's an. And I think is the best way to go about it.


Michelle Shapiro [00:03:32]:

Absolutely. Yeah. And I mean, in any functional dietitian practice, we really hope, and I know certainly for our practice, that every single person is targeting every part of the body because all of them are so connected in their work. And I have hope that every dietitian is and focusing on stress, and we'll talk about what stress really means. Walk us all the way back, Claire. How would you even define IB's in what we would think of it in clinical terms and maybe how you think of it a little bit differently?


How do you define IBS?

Claire [00:04:01]:

Yeah. So Ib's is a diagnosis of exclusion. So basically, you know, it's a diagnosis that, that comes about when you rule a bunch of other things out. And then it's diagnosed using the roam four criteria, which is four questions long. And really is just ascertaining the amount of abdominal pain for a length of time and sort of the stool consistency that goes along with that. But again, it's not something that's diagnosed with a blood test or a scan, it's that diagnosis of exclusion. I think that's very much used in a research setting and it's also used sometimes in a clinical setting, but not always very strictly. I think you have to look at IB's more holistically.


Claire [00:04:47]:

And the way that we prefer to look at it is through the biopsychosocial model. So the biopsychosocial model, long tongue twister of a word. But really it looks at genetics and early life factors and how they play in. And then also the interplay between psychological factors, stress, anxiety, depression and also, gi, you know, IB's can start with an infection in the gut and then manifest into something longer. And so it's looking at these three factors and how they all play together. And so I think that's why when you have an IB's patient sitting in front of you, it's not ever the same story of how they've arrived with these symptoms, how they've arrived with this diagnosis. And looking at it from the lens of, okay, we know this biopsychosocial model is at play for every patient, but the exact picture of what that looks like is going to vary so much from patient to patient and really getting to the bottom of where that dysfunction is coming from and then addressing that for that patient. I think when you look at the four questions of the roam criteria, it doesn't even scratch the surface of really what's underlying IB's.


Michelle Shapiro [00:05:59]:

Absolutely. And for you, would you say there are people who have perhaps more in one category than another, like they have more of a biological issue, they have more of a social issue? Is that what you see, where the balances can be very different from person to person?


Claire [00:06:17]:

Yeah, it definitely can. You know, so many IB's patients are told, and we're working relentlessly to change this conversation, but so many IB's patients are told that it's all in their head or it's all stress related, and that can be so alienating and understandably, I mean, the symptoms are so real and so painful for patients. And, you know, I think that the old sort of notion that it's all in your head is obviously, we know now, very wrong, and it really can be a spectrum for people. So there is people that have really strong food triggers or, you know, really strong GI triggers, and then there's patients that have more psychological triggers, and it's a spectrum along those two categories. However, I will say when we think about the role of the psychological factor in IB's that it's more of a cycle. And so we call it the IB's stress cycle, and that even if it is more food trigger based for patients, the actual symptoms themselves can cause stress and anxiety. If you're constantly out and about and scanning for the nearest toilet, that itself causes stress and anxiety, and that can play into the symptoms. So even if it is 100% food triggers for patients, which I would argue it's not always 100% food triggers, but for the sake of the argument, we'll say it's 100% food triggers, that even the symptoms themselves cause stress and anxiety that play into that it's.


Claire [00:07:52]:

It's a spectrum of where people sit between the food triggers or psychological triggers, but they both play a role.


How does the perpetual cycle of anticipating symptoms affect individuals?

Michelle Shapiro [00:08:00]:

Absolutely, yeah. And I think not only do the symptoms create new anxiety, like, oh, my gosh, why is this happening to me? I'm so frightened by this. Is this going to keep happening? Where's a bathroom? How am I going to get through this? In addition, it then sets people in the perpetual cycle of anticipating symptoms, even when they're out of flares, which then plays into that kind of limbic system, nervous system involvement. Can we speak into that a little bit as well?


Claire [00:08:26]:

Yeah, absolutely. They're one of the main CBT terms that are used in our psychoeducation in the nerve. But really, in any CBT based education for IB's patients, you're taught a lot about hypervigilance and catastrophizing of symptoms. The hypervigilance that's built around having long term IB's symptoms is very real. The slightest gurgle in your digestion is going to set you into being so vigilant about what that is and chronically having to think about it. Check for toilets, check for where you are. Stress about, you know, if you're going to have access to a toilet. And so that thought pattern absolutely leads into creating more symptoms.


Claire [00:09:11]:

But it's such a difficult thing to get to break out of because, you know, oftentimes that gurgle could actually be an IB's flare. And you do really have to plan for these things. And so it's about, you know, we talk about teaching about these things, but then you really do. It's not enough to just teach them. You have to get those symptoms under control for then patients to feel like they can they, they have any control over this catastrophizing or hypervigilance.


Michelle Shapiro [00:09:37]:

Absolutely, because there's an automatic reaction to it and we have some control over it, but the automatic reaction changes over time, which is a lot of the work that you're doing and a lot of the goal of the work that you're doing. But the problem is that when you have that initial trigger of an uncomfortable sensation, there is some reaction that might happen. I think, where people can take control is either doing things like you're doing so beautifully subconsciously by rerouting the brain's reaction or having different languages, working with ifs with a psychologist or something on ifs with a psychologist, there's ways to do that too. But certainly it's very hard for people to believe that stress legitimately causes gut issues. Why do you think it's so hard for people to believe that?


Claire [00:10:25]:

I think it's hard for people to believe because the symptoms are so real for them. And, you know, you think about stress, stress and anxiety and how that manifests in the body feels very abstract. It's not concrete. And you, you don't see the direct link between it a lot of times, and most people resonate with having food triggers because they'll eat a meal and they'll be able to pinpoint and identify the exact food trigger. Sometimes it's working with a dietitian, sometimes they can come to you knowing some of the exact triggers. And so it's just more abstract for people to actually see the link between their symptoms and psychological factors. I think once you're sort of more educated about IB's and educated about the vagus nerve and really how the body affects the brain in many other ways, that you start to sort of have a. You start to gain a better understanding of how it works, and then, you know, you move away from, okay, it's not all in my head.


Claire [00:11:29]:

It can certainly be food triggers, it can be other things, but this might play a role. And once you've had that shift, then you can really start to make headway in managing that aspect of it.


Michelle Shapiro [00:11:41]:

Absolutely. This idea that stress is non tangible or intangible versus the fact that our symptoms are so tangible, I think that is the divide. That's such a beautiful way of phrasing it, too, because we can't believe that something abstract is causing something real for us, that we almost put stress into the category of something spiritual or unmeasurable. And I think what makes that also uncomfortable for people to target is that generally they are not able to tangibly target stress. So it's hard for people. They can target their inputs for stress, but they can't target stress being actually lower. So I think a lot of people feel like if I'm doing hypnosis or I'm doing meditation, it's not doing the thing I need it to do because I need right now, you know, it doesn't register as being anything more than unmeasurable for people, I think.


Claire [00:12:36]:

Yeah, and I totally agree with that. The one thing I will say, and I'll push back on a little bit around putting hypnotherapy in the same bucket as meditation or any sort of other stress reducing tool. We actually study gut directed hypnotherapy almost exactly as we. The way we study the low FODMAp diet or the way we study a drug intervention for IB's, we study with the primary endpoint being abdominal pain reduction. So it's not. I always have to reframe this. That gut directed hypnotherapy is actually not a stress reduction tool. It is specifically targeting abdominal pain and targeting that visceral hypersensitivity.


Claire [00:13:22]:

There is the peripheral benefit of stress reduction, anxiety reduction, reduction and depression, but we don't see it have the same effect as meditation or cognitive behavioral therapy or other sort of coping tools and stress management tools. It is a specific tool targeted towards that visceral hypersensitivity, which is kind of interesting. It puts it in a slightly different category, but of course, there is at that peripheral benefit of reduction in anxiety, stress, depression as well.


Michelle Shapiro [00:13:56]:

Yeah, I'm not a huge fan of recommending meditation for people with gut symptoms that are very active, because generally being really present inside of the gut symptoms can then create more symptoms and more discomfort. That awareness is actually quite uncomfortable. So thank you for that divide. And I just. I've seen it with thousands of clients before. That divide is really important to just say, just relax and sit with your symptoms. Just breathe. It's actually more dismissive than what you're talking about is that gut directed hypnotherapy is not an indirect approach to healing the gut or working with IB's or managing IB's symptoms.


Michelle Shapiro [00:14:34]:

It's actually directly working on the gut. So it is a top down approach, but it's actually working directly there, as opposed to an indirect effect of, if you de stress, then the gut will come together, basically.


Claire [00:14:46]:

Yep, absolutely. There was this great study that was done a number of years ago now that was actually a balloon distension study. I'm not sure if you're familiar with it, but it was looking at visceral hypersensitivity. So those overactive nerves that line the gut lining, and really, that's what is one of the main causes of IB's symptoms, is this visceral hypersensitivity. And in the study, they looked at patients with IB's and then patients who did not have a history of IB's, and they actually inserted a small balloon in the patient's rectum, which it's not a pretty study, but we're all used to that.


Michelle Shapiro [00:15:26]:

We really hope those reimbursements were high for this year.


Claire [00:15:28]:

I know. I really do hope so as well. But in the. You know, they actually inflated the balloon the exact same amount in both cohorts of patients and in the patients with IB's they reported feeling more pain and more discomfort than patients without IB's. And so it's such a great way to actually visualize what's happening in these patients that it's not, you know, there's not a different amount of pressure in the digestion of these patients. It's just that these oversensitive nerves are reacting more strongly. And so the target of gut directed hypnotherapy is calming those nerves specifically. And I think when you think about it like that feels less like we were talking about before, less abstract, less stress reduction, and more, really a targeted management tool.


Michelle Shapiro [00:16:20]:

The nerve therapy, you could almost say.


Claire [00:16:22]:



What is the relationship between the gut and the stomach?

Michelle Shapiro [00:16:23]:

Well, it is a nerve therapy. Tell us also, walk us way back if anyone's listened to an episode of this podcast. The vagus nerve has been mentioned, but I always like to hear how you would define it and how you would present it. Talk to us about this relationship between the gut and the stomach through either the vagus nerve or any other mechanisms. I'd love to hear.


Claire [00:16:41]:

Yeah. So the gut brain axis is multi pronged. The biggest portion of it is this vagus nerve, which is the biggest nerve we have, and it runs from our brain to different organs. And also, you know, is the main communication channel between the gut and the brain. And it's bi directional, so it flows both directions. So information is sent from the gut up to the. Up to the brain, and from the brain back down to the gut. And, you know, the classic example of experiencing this, if you don't have IB's, is feeling butterflies in your stomach before you go on stage for something.


Claire [00:17:17]:

You know, there is this conversation that's happening when you do feel nervous. You can actually experience gut symptoms and vice versa. And so there is this conversation along the vagus nerve. There's also, you know, that's not the. We often talk about that like, it's the only part of the gut brain axis. The microbiome is a big part of the gut brain axis, and also the immune system is implicated. So we talk about it oftentimes, and I think for many reasons, it is a massively important part. But there is other parts of the gut brain axis that get looked over sometimes as well.


Michelle Shapiro [00:17:53]:

Yeah, I mean, even the fact that the cephalic phase begins in the mouth, that our digestion begins when we first see food, that's gut brain access. If we think about the delivery of nutrients through blood flow that goes into the gut, that's directed by the brain. And really there's that command center that's going to tell the body. Where should we send an immune response here? What should we do? I like that you stated this, too. It's really always bi directional. Any relationship with our gut goes back up to the brain and the brain going back down to the gut and all other parts of our body as well, usually when it comes to those major players in the body. And tell us how that vagus nerve piece and that gut brain axis fits in with this visceral hypersensitivity, which seems to be a really key piece of how nerva targets IB's symptoms.


How does the vagus nerve and gut brain axis fit into all of this?

Claire [00:18:44]:

Yeah, so the visceral hypersensitivity. So when you have. We'll talk about that balloon study again. You know, when those balloons are inflated and in the IB's patients and that pain, that patient is starting to feel pain, that information is sent up to the brain. So those nerves that are lining the gut send information along the vagus nerve back up to the brain. And the brain really is where we feel pain in our body. But pain is actually created in our brain. And that's not to say pain is all in your head, but pain is.


Claire [00:19:18]:

The information is sent to the brain, and the brain is the deciding factor of, okay, we're feeling this pain because we have to do something about it. So that information is sent along the vagus nerve and what we're doing, what we're really targeting. And I'll be completely honest that the actual mechanism of how this works is not understood, and it's something that we definitely need more research into. But what we believe is happening is that those pain signals are able to be modulated through hypnotherapy. And so we're able to better decipher what is actually dangerous pain and what is visceral hypersensitivity pain. Really learning to modulate the pain signals that are visceral hypersensitivity and still accepting the pain signals that are signals that really do need a reaction out of us as well.


Michelle Shapiro [00:20:15]:

What percentage of pain are you finding in research? This also might not be quantifiable. Is visceral hypersensitivity perceived pain versus, like, pain pain? If that makes sense?


Claire [00:20:28]:

Yeah, it's not really quantifiable, to be honest. We know in IB's it most of the time is visceral hypersensitivity sensitivity with IB's symptoms. You know, if. If someone with IB's breaks their foot, though, that it's absolutely not visceral hypersensitivity pain. And same thing, you know, if you have a GI infection or, you know, you can have co concurrent things. And we certainly don't want to be modulated, modulating pain signals that are advantageous for us to feel. And so it's about just sort of having a better, better control of that visceral hypersensitivity. Again, we can't really quantify what percentage is visceral hypersensitivity.


Claire [00:21:09]:

It really is the felt experience of the patient. Absolutely.


Michelle Shapiro [00:21:13]:

Drugs like Pepto Bismol that people take when they're having IB's symptoms, they seem to alleviate symptoms in some capacity. Is it believed that potentially those are affecting the visceral hypersensitivity as well, or is it just affecting the inflamed area or something like that?


Claire [00:21:30]:

So I don't exactly know the mechanism of pepto Bismol specifically. I can speak a little bit to something like the low fOdmap diet, where in a limited diet, where really the low foDMap diet, these FoDMaps are broken down in our bodies and are specific carbohydrates that produce gas. And so the idea with the low FODMAp diet is if you're producing less gas, you're actually putting less pressure on those nerves lining the gut. And so if you actually think about the low five amp diet, which is an effective tool for a lot of patients, I think there's some problems with it. But I think the premise of it really is that it's supposed to be short term, and it's really a way for you to be able to reset those nerves and give them a little break so they're not constantly having pressure on them and then being able to reset and have them sort of start acting appropriately. The reason why the low FODMAp diet is not meant to be a long term solution is that these fodmaps are not bad for us. They're actually really, when you're cutting out all fodmaps, you're cutting out a lot of nutrients in the diet. You really want to be careful to reintroduce as many of those foods as you possibly can.


Claire [00:22:54]:

But it's actually working on the same mechanism of putting less pressure on those visceral hypersensitivity of those nerves lining the gut so that they can sort of have a break and reset and start sort of sending appropriate pain signals.


Michelle Shapiro [00:23:07]:

And is that pressure that can be on the nerves both physical, or it can be a mental pressure? Or is it literally that they're pressing on the nerves with distension?


Claire [00:23:18]:

So it's actually quite, quite literally physical pressure on the nerves. You know, we see that with the balloon study I was talking about, actual pressure on the. On the nerves is causing pain signals. It absolutely can be, like I said, a psychological, if that is part of it, then the visceral hypersensitivity can come around from psychological factors, stress, anxiety. But again, it's sort of on that spectrum we were talking about, and we.


Can someone be predisposed to developing IBS?

Michelle Shapiro [00:23:44]:

Don'T know, again, there's no quantifiable number for each person has x amount of things. Do you think that someone who has a strong biological disposition for IB's or other gut conditions, and I'm putting IB's in quotes because again, it's a diagnosis through exclusion, of course. Do you think that someone who has that through having managed the psychosocial component of it throughout their lives or just not having major trauma inputs throughout their lives may go on to not develop ib's in the first place?


Claire [00:24:18]:

So it's hard to say. Right. It's really subjective.


Michelle Shapiro [00:24:22]:

It's a really hard subjective question.


Claire [00:24:24]:

Yeah, it's really hard to say. And, you know, we don't have a good answer for that. It's. There's certain things that we are now seeing that may predispose you to developing ib's. So early life trauma is one of them, and. But I think it's hard to say the other way of, you know, is.


Michelle Shapiro [00:24:43]:

What would have been, you know. Yeah, who knows what would have been. So this idea I have about elimination diets, and I'm really glad you brought up a low fodmap diet too, is that if we think of the gut as being kind of like on fire and your nerves are on fire, it's. You never want to pour fuel on that fire. And then once the fire is doused, if you could put a little fire in and there's no oil there, so it doesn't matter. And that's kind of the visual I have for these. And also in the work that we do, that's really important because long term elimination diets have psychological consequences, physiological consequences, and are not something that we recommend. Although it's confusing for people because they do feel a lot better on those diets to begin with, and then they can develop fears of bringing those foods back in.


Claire [00:25:29]:

Yeah, it's. It's all too common. And there's a whole new category of eating disorders that have come about because of elimination diets, which is Arfid, which is avoidant restrictive food intake disorders. And it's exactly that. What you're talking about of people do feel way better when they're cutting out foods that are causing symptoms. And then there's this long term fear of reintroducing foods. And you have people who are just not getting enough nutrients in their diet because they're afraid to reintroduce foods. And so I think specifically in cases of people who do feel symptom improvement when they're cutting out and eliminating different foods, it's important that you're able to manage those symptoms in other ways and work with the dietitian, reintroduce foods, try to get variety back in the diet.


Claire [00:26:18]:

Because, you know, Doctor Simone Peters, who has created the protocol for the Nerva app, she always says that, and it always resonates with me that she's like, I don't have IB's, but if I were eating just rice and just dry chicken all the time, I would have got symptoms too. And so there is something to be said that, you know, even if you're eliminating foods because you feel that and it is causing less symptoms for you, if you eliminate so many foods for such a long period of time, you're going to cause other problems because of that. And so it's really important we have other management tools for IB's like hypnotherapy. You know, there's other solutions as well. And it's important that you can work with those so that to reintroduce foods into the diet.


Michelle Shapiro [00:27:04]:

And I often look at digestion as being something that, again, when the fire is burning, we don't want to pour fuel on the fire, but when the fire isn't burning, our gut likes challenge. We actually need to have some sort of work to do in the gut and some sort of challenge. So if we make our world smaller and smaller through the foods that we're eating, the activities we do, our bodies are very efficient and they will follow suit. And our capacity to digest more foods or live a bigger life gets smaller as we perceive things as being only as safe as what we're doing. Can you speak into that a little bit too?


Claire [00:27:39]:

Yeah. And, you know, our, our digestion is our, is the way that our inside actually is. It communicates with the outside world. We, you know, our immune system is built off of the foods that we're eating and the variety that we're eating. And we're fueling our microbiome. And, you know, we know our microbiome is implicated in almost everything. And so you're right that when you make your world smaller and you expose your inside world to less, you're doing a disservice to more than just your digestion and just your GI tract. You're really looking holistically at the whole person.


Claire [00:28:20]:

You're cutting down the contact with the outside world for your whole body. Oh, that was so beautiful.


Michelle Shapiro [00:28:27]:

Thank you for saying that. I don't want to cut off contact. That's the feeling I got when he said that. I don't want anyone to cut off contact with the outside world. Communicate, be connected. And we know our gut microbiome extends feet outside of us from what we understand now, too, and is literally connecting with our outside world as well. So it's so important, not to mention food is.


Claire [00:28:46]:

I mean, food is so culturally important. You know, we gain so much by, by sitting down and having a meal with friends. And I think that part is often overlooked that, you know, when, when patients are experiencing severe IB's flare ups and they're not able to eat with friends, not able to eat with family, I think there is so much negativity that comes from that that is often overlooked. You know, that's where we build relationships and maintain relationships. And, you know, taking that piece away from it is so impactful as well.


Michelle Shapiro [00:29:19]:

Especially when you're already suffering from symptoms and when for some people, Ib's can feel like it deprives us of connection, of normalcy. To add more isolation on top of it is a really rough combo.


Claire [00:29:35]:

Yeah. Some of the best responses we get, you know, we get great people that write into us at Nerva, and my absolute favorites are the ones that specifically call that out that, you know, we had one the other day that a woman wrote in and said, I've been going and playing with my grandkids more now than I have ever. And I just like, that's. Those are the things that, you know, it's those relationships that you can start to rebuild when you have more control over your symptoms that really are the things that impact you the most in life.


Michelle Shapiro [00:30:06]:

Yeah. You're not helping people to heal their guts in order to heal their digestion. You're helping them to live their lives in the way that feels the most authentic and grand for them.


Claire [00:30:16]:

Yeah. And that's, you know, that's the quality of life impact that is overlooked with IB's. That ib's. There was a study that was done looking at quality of life impact and it has a similar. Quality of life impact is something with high mortality, like ischemic heart disease. And so you look at that and it's sort of mind boggling at first that you can have the exact same quality of life impact with a disorder that has very, very low mortality like IB's, that you can with ischemic heart disease. And when you start to talk to patients and you start to understand that the experience and the impact not just in the GI tract, but also in relationships and life and work, then that starts to make more sense. But I feel from speaking to a lot of IB's patients that that piece is often overlooked in the medical community.


Michelle Shapiro [00:31:11]:

IB's as a diagnosis is so interesting and frustrating. You know, I probably got diagnosed with IB's the first time when I was like 14. But that's like a light diagnosis compared to what most of my clients have, will ultimately have gone through. And for some reason, that one hurt me the most of all the diagnoses that I've collected over the years from all these symptoms that doctors didn't understand until I started to really work with myself in a lot of ways and really, really good practitioners. But because it's an exclusionary diagnostic diagnosis, it's very, it feels very hopeless is the word I would use for people, because it feels like, oh, you don't have IBD. There's this experience, Claire, where some of my clients are upset when they get diagnoses that aren't heavy hitting. And I know people who are not chronically ill find that very hard to believe. They're like, wouldn't you want a less scary diagnosis? And it's like, honestly, no, because at least there's a pathway forward.


Can you speak about the experience of patients with IBS feeling like they aren't being taken seriously?

Michelle Shapiro [00:32:09]:

At least people will take you seriously. I notice a lot with IB's that people do not feel like they're being taken seriously. Have you seen that, too?


Claire [00:32:17]:

Yeah, absolutely. That is so common across IB's and the experience of patients. And it's so sad because we do have options now. And I think the, it's, you know, we do so much work in trying to educate healthcare providers, educate gps, educate gastroenterologists that, you know, there are good options now. And it doesn't have to be this diagnosis where you get diagnosed and then it's, you're fine, you know, you know, you're not going to die, go on your way. And that's, that's, that you can understand why that feels like absolutely tragic to people because, again, the symptoms are so very real.


Michelle Shapiro [00:32:59]:

Yeah. And the perception also of someone with IB's is like, well, your symptoms are either like everyone else's or you're being, like, dramatic, but it's really not that you're being dramatic. It's that kind of your nerves and your gut are being a little bit dramatic. And that's okay.


Claire [00:33:15]:

It's okay.


Michelle Shapiro [00:33:16]:

By the way, I love dramatic people. I think it's a wonderful. I'm very dramatic.


Claire [00:33:19]:

I'm dramatic, exactly.


Michelle Shapiro [00:33:20]:

Yeah, we're dramatic. Exactly. It's good. But it really is that if you're having and hearing that experience, I want people to hear that there is actually a dramatic response happening, but it's very real and very physical.


Claire [00:33:31]:

Yeah, absolutely.


Michelle Shapiro [00:33:33]:

Tell us, like Claire, walk us through Nerva and walk us through some of the research you've done after. But first tell us what is Nerva?


What is Nerva?

Claire [00:33:40]:

Yeah, so Nerva. We created Nerva because there is amazing research that has been done in gut directed hypnotherapy. Going back to the first clinical trial was done in the 1980s, and there's been 15 or more since then. And, you know, it has amazing results. It was first studied in severe refractory cases of IB's and has since been studied in a very general IB's population. And the problem with it really, until about five years ago, was that it was completely inaccessible for patients. There's no providers who are offering it. There's about 400 GI psychologists in the world.


Claire [00:34:20]:

So it's something that is very inaccessible. Even though the research was very strong. I know in the US the term hypnotherapist is also unregulated. So it's difficult to know what you're getting when you're going to a hypnotherapist. But, you know, we partnered with Doctor Simone Peters, who is the clinical content creator for nervous. She ran a clinical trial out of Monash University and developed the protocol and partnered with her to actually deliver it via a mobile app. Hypnotherapy is all script based, and so it's actually a great candidate to be delivered via nap because you can actually just record the audio of it. And it's the exact same thing that is delivered in clinical trial in person.


Claire [00:35:06]:

And so the app itself is six weeks long. So exactly the same that is delivered in clinical trial in person every day for six weeks. There's about a 15 minutes hypnotherapy recording, a five minute psychoeducation reading, and then there's also a diaphragmatic breathing exercise. So it's sort of, you know, it is gut directed hypnotherapy based. That is the main therapeutic element. But the psychoeducation has a lot of CBT involved. Then, of course, the diaphragmatic breathing is a great way to really engage the parasympathetic nervous system and sort of lower the set point with some practice of that as well. So it's a little bit more holistic than just got directed hypnotherapy, though, that is the main therapeutic component.


Claire [00:35:53]:

So that was a lot of information, I know, but it's basically the six week program is app delivered, and we know that patients really see great success with it. 89% of our patients self report reduction, self report better management of their symptoms, and 64% see a clinically significant ability to manage their abdominal pain specifically.


Michelle Shapiro [00:36:18]:

And does that line up against some IB's drugs? Like, is there as it compares to drugs or anything like that? Have you ever looked at those numbers? I'm sure you have, yeah.


Claire [00:36:28]:

So there was a head to head study. Doctor Peters actually ran a head to head study comparing it to a low FODMAP diet specifically. And both patient groups saw there was no statistical difference between the groups. So both groups actually improved almost identically, and that improvement was maintained out to six months. So we know it's as effective as a low FODMAp diet on its own. It's never been run in a head to head trial compared to any drugs for IB's. However, I will say just the rates of efficacy for any commercially available drug for IB's have never been even close to what is published for a low FODMAp diet or gut directed hypnotherapy, of course.


Michelle Shapiro [00:37:09]:

So I'm picturing when you're doing a low FODMAp diet, like you said, it's probably just the distension that's affecting those nerves is a proposed mechanism. I know we don't know the exact mechanism, as you said, that it's almost like the hypnotherapy is communicating with the nerves to lessen their signal and lessen their response.


Claire [00:37:29]:

Yeah, it's. It's, you know, some sort of. Some sort of communication or modulation in the signal, you know, again, I wish we knew. We will. We are going to look into it, and it's certainly something that is. Is on the radar of not just us, but lots of researchers around the world. But it's hard to say exactly what's happening.


Are there studies that can show nerve activity in certain areas of the body that seems hard to measure?

Michelle Shapiro [00:37:51]:

And are you measuring in the studies the actual perceived pain that people will tell you they experience? Are you able to. Is there studies that can show nerve activity in certain areas of the body that seems hard to measure?


Claire [00:38:05]:

Yeah, so there's, there's, there. There isn't any studies that currently exist looking at that. There's a couple companies that are creating wearable devices around the Aquaman that can start to measure nerve activity. And so that's an interesting, you know, it's something that we've toyed with the idea of actually partnering with them to see if we can develop a study and look into a mechanism that way. It's not been done yet, but I think that's an interesting area we could go into.


Michelle Shapiro [00:38:36]:

I mean, I have to tell you something. If you tell me that something is effective for 89% of people and is extremely low risk and very low time or energy involvement for people, you've already sold all of us. However, I'm just interested because it would be fascinating to have the other data. I think, again, for people, it's really about drawing that connection between the intangible, which is stress, let's say, and then doing something really tangible, like Nerva, is so helpful for people, because then it's, you're saying there is a specific directed program. We understand how it impacts. You really just have to show up. And I think that makes it really easy for people. And that's accessibility, I think, is so central to your mission.


Michelle Shapiro [00:39:22]:

And I think when people are suffering from chronic illness, the last thing they want to do is think about every single thing they have to do to help their condition, because that's going to make them activated, uncomfortable, and possibly even symptomatic. So the fact that you're laying it out for people, I don't know if, you know, that's also a really big deal, is just having it laid out and say, this is exactly what you do on this day.


Claire [00:39:44]:

Yeah, and I totally agree, you know, just having, it's. It's that path that you can look, you know, exactly what you have to do every day. And also, you know, we have education in the app around this, but if you miss a day, it's not the end of the world. You know, in, in the studies we run, it's actually no, we see no difference, in effect, with patients that listen five days a week or more. And so I also think there's something to be said about giving yourself grace. If you miss a day, it's not the end of the world, and you can pick up where you left off and just keep going. You know, we, too often we beat ourselves up for not adhering perfectly to whatever the plan is. And, you know, I like that we've done the research to look into that because I think it's so important that, you know, if you do miss a day here and there, it's.


Claire [00:40:31]:

That's okay as well.


Michelle Shapiro [00:40:32]:

Absolutely. Is there any research or understanding around reflux or IBD or any other gut conditions as well.


Claire [00:40:39]:

Yeah, so there is definitely research into upper GI. So dyspepsia. We are toying with the idea of developing a program for dyspepsia. There is great research out of the University of North Carolina of Oliver Paulson's group. They've looked into hypnotherapy for dyspepsia and for upper GI conditions, and it seems to be very effective for that as well. The Nerva app specifically has lower GI focus suggestions, so at this point in time, it wouldn't be appropriate, but it's definitely something that is on our radar and I think is an option for patients that are suffering with some disorders of gut brain interaction on the upper GI end. In terms of IBD, we are actually, we've just registered a clinical trial. We're looking at.


Claire [00:41:33]:

Yes, we are looking at patients with well controlled IBD with suspected IB's overlay. So, you know, we don't believe that hypnotherapy is going to be effective in actually managing IBD flares. But a lot of patients with IBD have some IB's overlay. So even when their IBD is well controlled, they're still experiencing symptoms. And so we are designing a trial to look at that and seeing if we can manage the symptoms that are happening while their IBD is well controlled.


Michelle Shapiro [00:42:08]:

And I know hypnosis as it's directed is quite effective for pain in other parts of the body. So now I'm applying in my head this visceral hypersensitivity. I wonder if it would apply to other parts of the body, too, outside of even the gut.


Claire [00:42:22]:

Yeah, there's, you know, chronic pain generally is the area where hypnotherapy has the most research. So, you know, Ib's is a niche of that. But chronic low back pain is a big area, and we're actually developing a product for chronic low back pain, and that will be released in the next few months because it is certainly pain more generally, you know, depending on the type of pain. But a lot of pain conditions have been studied for with hypnotherapy, and it's shown to be very effective.


Michelle Shapiro [00:42:50]:

That's so freaking cool. The fact that we can do these things and then our brain, like listening to something and then our brain takes that information and translates it into tangible change is so cool.


Claire [00:43:03]:

It's so empowering. It's amazing that our brains have that power over our bodies and what we're experiencing. And I think it's a misconception that oftentimes when you're referred to psychological therapy, you know, you're. It feels like you're not being heard or not being listened to. And I actually think hypnotherapy is so beautiful because it's the opposite. It's actually empowering you to manage your health with your own brain and. And you can have support around that. It doesn't just have to be hypnotherapy, but when.


Claire [00:43:37]:

When it's effective and patients feel that that is so beautiful and so empowering.


Do you have to believe in hypnotherapy for it to work?

Michelle Shapiro [00:43:42]:

It's so empowering. You know how in hypnosis, like the hokey hypnosis that we would see, they say people have to believe in it for it to work. Have you noticed with hypnotherapy it's more effective if you even fake it till you make it believe it? Do you have to believe in it for it to work?


Claire [00:43:57]:

So the jury's out. In IB's, it has really been shown that it doesn't seem to matter, the patient, if patients really believe in it or not. Of course you have to believe in it to the extent that you're willing to adhere to the provider to do it. To do it. That's the big caveat. When we look at hypnotherapy for mood disorders, there definitely needs to be more of a belief around it, which is interesting, but I think the jury is still out. More research needs to be done.


Michelle Shapiro [00:44:30]:

All the research that you are about to do, I'm going to be following closely, because now I've pitched to you way too many ideas and now I'm going to have to do the follow up myself because I'm sorry about that. I'm like, what about this? You're like, we're very busy, Michelle, doing the studies we're doing already, and I'm sorry about that.


Claire [00:44:46]:

No, it's honestly, though, we have. We're in such a beautiful position with the amount of IB's patients that we have coming to us that we really take that seriously, that we want to use that data and of course, when patients consent to it, but use that data to push forward what we understand about IB's because it's historically been an area that has been underfunded and neglected in research. And so we do really take that seriously of wanting to be the Guardians, of pushing this field forward, feeling like.


Given the research you've done and the results you've seen, how hopeful are you for people with IBS?

Michelle Shapiro [00:45:20]:

The Guardians of the Galaxy, kind of because there's suffering from IB's. I'm just saying you guys are doing a fantastic job. Claire, thank you so much. I have one last question for you. Given the research you're doing, given the results you see in clients all the time, how hopeful are you for people with IB's?


Claire [00:45:37]:

I'm incredibly hopeful. When we started this just a few years ago, we'd present research at big gastroenterology conferences and we'd have a few people come and talk to us, but not that many. And the shift that we've seen in just the last few years in mainstream, in mainstream gastroenterology has been pretty incredible. Gut directed hypnotherapy is included in the treatment guidelines from the American College of Gastroenterology now and a lot of the major gastroenterology guidelines around the world. And it really is something that is thought of more seriously and the psychological component is thought of more seriously in managing IB's patients from day one of diagnosis and also educating around that. We're talking to gastroenterologists about how to educate about IB's so that patients don't leave that first appointment where they're diagnosed feeling like absolute crap about their path forward. So I feel hopeful and I'm excited about what we have in the pipeline coming up. So I think things are looking good.


Michelle Shapiro [00:46:42]:

Well, we will definitely be following. Nerva is the season podcast sponsor, one of our amazing sponsors, season for a reason. We believe in what you're doing. Our clients have had amazing success using it and we just can't wait to see what's next. And thank you so much for coming on today.


Claire [00:46:56]:

Yeah, thank you so much for having me. We'll definitely be in touch and I'll keep you posted on what we're up to.


Michelle Shapiro [00:47:02]:

It's amazing.

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