Review article: The history of hypnotherapy and its role in the irritable bowel syndrome

[Hypnotherapy for Irritable Bowel Syndrome]

Irritable bowel syndrome (IBS) is a functional disorder of the lower digestive tract. Based on the biopsychosocial model, there is a wide range of therapeutic interventions to deal with the symptoms of IBS and to improve the quality of life of those who are affected. In this context, hypnotherapy and in particular gut-directed hypnosis represents a psychotherapeutic intervention with great empirical evidence for its efficacy.

Hypnotherapy for persons with Irritable Bowel Syndrome: A three-arm randomized controlled trial

The current study sought to (1) compare the efficacies of Ericksonian hypnotherapy, traditional hypnotherapy, and educational talk in treating irritable bowel syndrome (IBS), and to (2) evaluate the impacts of hypnotic susceptibility on participants' responses to hypnotherapy. The study adopted a three-arm randomized controlled trial design and achieved an effective sample size of 144. Self-reported psychological questionnaires were used to assess participants' IBS symptom severity, health-related quality of life, and coping patterns at baseline, immediately post-intervention, and 3 months after intervention. The evaluation focused primarily on IBS symptom severity and health-related quality of life, as well as on the illness coping patterns of symptom catastrophizing and symptoms-related social hypervigilance.The findings showed that significant improvements in IBS symptom severity occurred in all three types of study groups immediately after completion of the intervention (p < .05, η_ρ² = .20). However, only the traditional hypnotherapy groups and the Ericksonian hypnotherapy groups still had a notably significant decrease in symptoms 3 months after the intervention, whereas the educational talk groups had dropped back to pre-treatment symptom levels at the 3-month follow-up. The amplitude of change of symptom catastrophizing in the traditional hypnotherapy groups was stronger than that in the Ericksonian hypnotherapy groups after completion of the intervention, and the two types of hypnotherapy groups were significantly lower in symptom catastrophizing both immediately after the intervention and also 3 months post-intervention (p < .001, η_ρ² = .17). The other coping mechanism studied, symptoms-related social hypervigilance, showed a significant decline only in the Ericksonian hypnotherapy groups (ps < .001, η_ρ² = .45). Interestingly, in the traditional hypnotherapy groups, persons with higher hypnotic susceptibility showed significant improvement in symptom severity, health-related quality of life, and coping patterns following treatment. Notably, the effects from Ericksonian hypnotherapy for IBS diverged from the effects from traditional hypnotherapy. Finally, both Ericksonian hypnotherapy and traditional hypnotherapy appeared to have greater positive effects than educational talk did, but at different levels.

Psychological Considerations and Interventions in Inflammatory Bowel Disease Patient Care

The presence of psychological comorbidities, specifically anxiety and depression, is well documented in inflammatory bowel disease (IBD). The drivers of these conditions typically reflect 4 areas of concern: disease impact, treatment concerns, intimacy, and stigma. Various demographic and disease characteristics increase risk for psychological distress. However, the risk for anxiety and depression is consistent throughout IBD course and is independent of disease activity. Early intervention before psychological distress becomes uncontrolled is ideal, but mental health often is unaddressed during patient visits. Understanding available psychological treatments and establishing referral resources is an important part of the evolution of IBD patient care.

Psychological Considerations and Interventions in Inflammatory Bowel Disease Patient Care

The presence of psychological comorbidities, specifically anxiety and depression, is well documented in inflammatory bowel disease (IBD). The drivers of these conditions typically reflect 4 areas of concern: disease impact, treatment concerns, intimacy, and stigma. Various demographic and disease characteristics increase risk for psychological distress. However, the risk for anxiety and depression is consistent throughout IBD course and is independent of disease activity. Early intervention before psychological distress becomes uncontrolled is ideal, but mental health often is unaddressed during patient visits. Understanding available psychological treatments and establishing referral resources is an important part of the evolution of IBD patient care.

The Vagus Nerve in the Neuro-Immune Axis: Implications in the Pathology of the Gastrointestinal Tract

The vagus nerve (VN) is the longest nerve of the organism and a major component of the parasympathetic nervous system which constitutes the autonomic nervous system (ANS), with the sympathetic nervous system. There is classically an equilibrium between the sympathetic and parasympathetic nervous systems which is responsible for the maintenance of homeostasis. An imbalance of the ANS is observed in various pathologic conditions. The VN, a mixed nerve with 4/5 afferent and 1/5 efferent fibers, is a key component of the neuro-immune and brain-gut axes through a bidirectional communication between the brain and the gastrointestinal (GI) tract. A dual anti-inflammatory role of the VN is observed using either vagal afferents, targeting the hypothalamic–pituitary–adrenal axis, or vagal efferents, targeting the cholinergic anti-inflammatory pathway. The sympathetic nervous system and the VN act in synergy, through the splenic nerve, to inhibit the release of tumor necrosis factor-alpha (TNFα) by macrophages of the peripheral tissues and the spleen. Because of its anti-inflammatory effect, the VN is a therapeutic target in the treatment of chronic inflammatory disorders where TNFα is a key component. In this review, we will focus on the anti-inflammatory role of the VN in inflammatory bowel diseases (IBD). The anti-inflammatory properties of the VN could be targeted pharmacologically, with enteral nutrition, by VN stimulation (VNS), with complementary medicines or by physical exercise. VNS is one of the alternative treatments for drug resistant epilepsy and depression and one might think that VNS could be used as a non-drug therapy to treat inflammatory disorders of the GI tract, such as IBD, irritable bowel syndrome, and postoperative ileus, which are all characterized by a blunted autonomic balance with a decreased vagal tone.

Psychological Interventions for Irritable Bowel Syndrome and Inflammatory Bowel Diseases

Psychological interventions have been designed and implemented effectively in a wide range of medical conditions, including Irritable Bowel Syndrome (IBS) and Inflammatory Bowel Diseases (IBD). The psychological treatments for IBS and IBD with the strongest evidence base include: cognitive behavioral therapy, hypnosis, and mindfulness-based therapies. The evidence for each of these therapies is reviewed here for both IBS and IBD. In general, there is a stronger and larger evidence base to support the use of psychological interventions in IBS compared with IBD. This is likely due to the high level of psychiatric comorbidity associated with IBS and the involvement of the stress-response in symptom presentation of IBS. Further research in psychosocial interventions for IBD is necessary. Finally, the importance of conceptualizing both IBS and IBD in a biopsychosocial model is discussed and several resources for accessing Clinical Health Psychology materials and referrals are provided.

Mind/Body psychological treatments for irritable bowel syndrome

Currently, the goal of treatment for those with irritable bowel syndrome (IBS) is to improve the quality of life through a reduction in symptoms. While the majority of treatment approaches involve the use of traditional medicine, more and more patients seek out a non-drug approach to managing their symptoms. Current forms of non-drug psychologic or mind/body treatment for IBS include hypnotherapy, cognitive behavioral therapy and brief psychodynamic psychotherapy, all of which have been proven efficacious in clinical trials. We propose that incorporating the constructs of mindfulness and acceptance into a mind/body psychologic treatment of IBS may be of added benefit due to the focus on changing awareness and acceptance of one's own state which is a strong component of traditional and Eastern healing philosophies.

Designing and delivering a hypnotherapy service for irritable bowel syndrome in primary care

Evidence-based guidelines recommend hypnotherapy as a treatment option for intractable irritable bowel syndrome (IBS). However, few National Health Service (NHS) hypnotherapy services are in place. We report the experiences and results from the only NHS-funded primary care service for IBS hypnotherapy in England (as identified by a telephone audit of 151 Primary Care Trusts (PCT) in England in February 2011). The service was delivered by a full-time nurse hypnotherapist, commissioned and funded by a PCT. In 18 months, 119 patients have been seen. Validated scoring tools showed improvement in quality of life and symptom severity scores, with improvement in all domains following therapy. This case study illustrates both the clinical effectiveness of hypnotherapy in the treatment of IBS delivered by a nurse hypnotherapist and some of the challenges faced when setting up this service. This paper summarises aspects of a model of care that could act as a template for service providers wishing to deliver hypnotherapy for IBS.

Hypnosis in pregnancy with intrauterine growth restriction and oligohydramnios: an innovative approach

The clinical application of hypnosis has been effective in obstetrics. Intrauterine growth restriction and oligohydramnios are dreaded complications of pregnancy that may result in preterm deliveries causing increased perinatal morbidity and mortality. In this longitudinal prospective study, clinical hypnosis was used in addition to the conventional medical management in such pregnancies. The perinatal outcome was compared with the control group wherein hypnosis was not used. The hypnosis group had a significantly shorter preterm delivery rate (p = .004) and fewer incidence of low birth weight babies (p = .009). Significantly reduced operative intervention in terms of lower rate of cesarean section (p = .008) was also observed in the experimental group. Hence, the use of clinical hypnosis as a viable adjunct to medical management is suggested to help to prevent neonatal morbidity and fetal loss. A multicenter randomized, controlled clinical trial is encouraged in this area.

[Predictive factors and prevention of chronic postoperative pelvic and perineal pain]

INTRODUCTION

Chronic postoperative pain has been defined as pain arising after a surgical operation, present for at least 2 months, with no organic (active cancer or chronic infection) or preexisting cause. The purpose of this article is to review the risk factors and prevention of chronic postoperative pelvic and perineal pain.

MATERIAL AND METHODS

A review of the literature was performed by searching PubMed for articles on risk factors and prevention of chronic postoperative pelvic and perineal pain.

RESULTS

Chronic postoperative pain is frequent, disabling and represent a high cost to the community. This pain is generated by variable and complex interactions between the surgical procedure (the operated zone, perioperative management, the disease requiring the operative procedure) and the patient (age, gender, genetics, concomitant diseases, personal history). The multifactorial nature of chronic postoperative pain suggests the need for multidisciplinary management with prevention and reduction of the main risk factors. Similarly, appropriate management of acute postoperative pain has a major impact on the risk of chronic pain.

CONCLUSION

A good knowledge of the risk factors and appropriate prevention can decrease the incidence and consequences of chronic postoperative pain.

Management of stress in inflammatory bowel disease: a therapeutic option?

There is increasing evidence that psychological stress and associated mood disorders are linked with, and can adversely affect the course of, inflammatory bowel disease (IBD). Unfortunately, owing to methodological difficulties inherent in undertaking appropriately targeted and blinded trials, there are limited high-quality data regarding the effects on IBD of interventions aimed to ameliorate stress and mood disorders. Nevertheless, patients want psychological intervention as well as conventional medical strategies. Emerging trial evidence supports the suggestion that psychologically orientated therapy may ameliorate IBD-associated mood disorders, but there are no strong data as of yet to indicate that stress management has a beneficial effect on the activity or course of IBD. As yet, which, when and how interventions targeted at psychological stress and mood disturbances should be offered to individual patients with IBD is not clear.

Constructive thinking, rational intelligence and irritable bowel syndrome

AIM: To evaluate rational and experiential intelligence in irritable bowel syndrome (IBS) sufferers.

METHODS: We recruited 100 subjects with IBS as per Rome II criteria (50 consulters and 50 non-consulters) and 100 healthy controls, matched by age, sex and educational level. Cases and controls completed a clinical questionnaire (including symptom characteristics and medical consultation) and the following tests: rational-intelligence (Wechsler Adult Intelligence Scale, 3rd edition); experiential-intelligence (Constructive Thinking Inventory); personality (NEO personality inventory); psychopathology (MMPI-2), anxiety (state-trait anxiety inventory) and life events (social readjustment rating scale). Analysis of variance was used to compare the test results of IBS-sufferers and controls, and a logistic regression model was then constructed and adjusted for age, sex and educational level to evaluate any possible association with IBS.

RESULTS: No differences were found between IBS cases and controls in terms of IQ (102.0 ± 10.8 vs 102.8 ± 12.6), but IBS sufferers scored significantly lower in global constructive thinking (43.7 ± 9.4 vs 49.6 ± 9.7). In the logistic regression model, global constructive thinking score was independently linked to suffering from IBS [OR 0.92 (0.87-0.97)], without significant OR for total IQ.

CONCLUSION: IBS subjects do not show lower rational intelligence than controls, but lower experiential intelligence is nevertheless associated with IBS.

New treatments for irritable bowel syndrome in women

The estimated prevalence of irritable bowel syndrome (IBS) in Western countries is 7-15%, with a female:male ratio of 2-2.5:1 in IBS patients who seek healthcare services; however, the female predominance is lower in the general population. IBS has a significant impact on health-related quality of life and is associated with a significant healthcare and economic burden. Management of IBS is comprised of general measures and pharmacologic and nonpharmacologic treatment. However, there are ongoing efforts to find more effective therapeutic approaches. As advancements in the understanding of the pathophysiology of IBS continue to grow, new and effective treatments with novel mechanisms of action that have the potential to improve relief of IBS symptoms over current treatments are likely to be developed. This article provides an overview of current and emerging therapies for IBS and also highlights sex and gender differences in clinical trials and treatment response.

Hypnosis and upper digestive function and disease

Hypnosis is a therapeutic technique that primarily involves attentive receptive concentration. Even though a small number of health professionals are trained in hypnosis and lingering myths and misconceptions associated with this method have hampered its widespread use to treat medical conditions, hypnotherapy has gained relevance as an effective treatment for irritable bowel syndrome not responsive to standard care. More recently, a few studies have addressed the potential influence of hypnosis on upper digestive function and disease. This paper reviews the efficacy of hypnosis in the modulation of upper digestive motor and secretory function. The present evidence of the effectiveness of hypnotherapy as a treatment for functional and organic diseases of the upper bowel is also summarized, coupled with a discussion of potential mechanisms of its therapeutic action.

Complementary and alternative medicine for IBS in adults: mind-body interventions

Standard treatment for IBS focuses on the management or alleviation of the predominant gastrointestinal presenting symptoms, such as diarrhea or constipation, often using pharmacological therapy. For many patients, this approach is unsatisfactory, and patients frequently seek the advice of complementary and alternative medicine (CAM) practitioners in order to explore other treatment options. CAM practices include a broad range of modalities, and mind-body interventions hold particular promise as treatment modalities for IBS because psychological factors could have an important role in IBS symptomatology and quality of life. Psychological stressors are postulated to result in gastrointestinal symptoms through alteration of intestinal function mediated by the autonomic nervous system, hypothalamic-pituitary-adrenal axis and immune system. Hypnotherapy has the strongest supportive evidence as a beneficial mind-body intervention for IBS. Clinical studies of hypnotherapy have uniformly shown improvement of gastrointestinal symptoms, anxiety, depression and quality of life in patients with IBS. Mindfulness meditation remains unstudied for IBS, but is theoretically attractive as a stress-reduction technique. There is a suggestion that relaxation therapy or multimodal therapy (a combination of relaxation therapy, education and psychotherapy) is beneficial for IBS. The most generally accepted psychological mind-body intervention is cognitive behavioral therapy, and clinical trials support the beneficial effects of cognitive behavioral therapy in patients with IBS.

The trials and tribulations of drug development for functional gastrointestinal disorders

Functional gastrointestinal disorders (FGID) are common conditions seen in primary care and specialty practices but many affected individuals report a lack of satisfaction with available treatments. Despite the unmet need for more effective pharmacotherapy, drug development for these conditions can be challenging on many levels. This review will discuss the rationale and challenges of drug development for FGID. The reasons for engaging in drug development include that these conditions are highly prevalent, associated with a significant economic and healthcare burden, and associated with a lack of satisfaction with current therapies. The challenges include the lack of perception that FGID are legitimate disorders, the multidimensional and complex pathophysiology of FGID, the lack of a biological marker for diagnosis and treatment response, the heterogeneity of the patient population, the lack of consensus regarding the best outcome measures for clinical trials and the perceived increased risk-benefit ratio associated with drugs for FGID. Ongoing efforts are being taken to work towards a better understanding of pathophysiology, illness severity, patient-reported outcome measures, and benefit : risk assessment, and towards increasing education and communication amongst patients, clinicians, investigators, industry and regulatory agencies which will hopefully help optimize drug development strategies for FGID.

Clinical practice. Irritable bowel syndrome

A 28-year-old woman presents with a 7-month history of recurrent, crampy pain in the left lower abdominal quadrant, bloating with abdominal distention, and frequent, loose stools. She reports having had similar but milder symptoms since childhood. She spends long times in the bathroom because she is worried about uncontrollable discomfort and fecal soiling if she does not completely empty her bowels before leaving the house. She feels anxious and fatigued and is frustrated that her previous physician did not seem to take her distress seriously. Physical examination is unremarkable except for tenderness over the left lower quadrant. How should her case be evaluated and treated?

Integrative medicine in gastrointestinal disease: evaluating the evidence

Current Western therapies for many gastrointestinal diseases are suboptimal and potentially toxic. The majority of patients with digestive diseases are turning to complementary and alternative medicine for symptom relief and improved quality of life, due to dissatisfaction with conventional medical therapies. There is emerging evidence that many of these complementary and alternative medicine modalities are highly effective in modulating the immune system, disrupting the proinflammatory cascade and restoring digestive health while improving patients' quality of life. We present evidence to support the potential utility of complementary and alternative medicine modalities for irritable bowel syndrome and inflammatory bowel disease. For each condition, we detail the proposed mechanisms of action and explore the current data for the prevention and/or treatment of disease.

Irritable bowel syndrome: current approach to symptoms, evaluation, and treatment

There are frequent advances in knowledge about the clinical presentation, pathophysiology, and treatment of irritable bowel syndrome. It is important for clinicians to be aware of available therapies and the supporting evidence for those therapies to increase patient satisfaction. This is best achieved with a collaborative and long-term clinician-patient relationship and mutual commitment to modify therapy and try new modalities until the greatest relief of symptoms and improvement in health-related quality of life is achieved. This article reviews symptoms, comorbidities, gender differences, and measure of severity in irritable bowel syndrome and current and evidence-based approaches to evaluation and treatment, and the new symptom-based Rome III diagnostic criteria are reviewed and explained.

Faecal incontinence

BACKGROUND

Faecal incontinence is a life style-limiting condition with multiple aetiologies. Surgical cure is not often possible.

METHODS AND RESULTS

A review of the literature was undertaken using Medline, Cochrane database and standard textbooks. Advanced imaging techniques now inform the treatment algorithm and objectively assess success. The long-term outcome of anal surgery is uncertain. Modern approaches favour conservative measures, such as biofeedback, and less invasive surgical procedures. Stoma formation is a definitive option for some patients.

CONCLUSION

Current treatment of faecal incontinence is evolving from a sphincter-focused view to a more holistic one, recognizing the influence of the pelvic floor and psyche in maintaining continence. Modern imaging modalities direct treatment strategies.