A randomised controlled trial on hypnotherapy for irritable bowel syndrome: design and methodological challenges (the IMAGINE study)

Abdominophrenic Dyssynergia: A Narrative Review

Chronic bloating and abdominal distension are common and highly bothersome gastrointestinal symptoms. Although the differential diagnoses for bloating and distension are broad, these symptoms are frequently associated with disorders of the gut-brain interaction. Functional abdominal bloating may be a result of visceral hypersensitivity, whereas abdominal distension seems to be a somatic behavioral response associated with abdominophrenic dyssynergia, featuring diaphragmatic contraction and abdominal wall relaxation. We review the available literature regarding abdominophrenic dyssynergia and comment on its epidemiology, diagnosis, treatment, and avenues to address in the near future.

Gut-focused hypnotherapy for Functional Gastrointestinal Disorders: Evidence-base, practical aspects, and the Manchester Protocol

BACKGROUND

Despite their high prevalence and advances in the field of neurogastroenterology, there remain few effective treatment options for functional gastrointestinal disorders (FGIDs). It is recognized that approximately 25% of sufferers will have symptoms refractory to existing therapies, causing significant adverse effects on quality of life and increased healthcare utilization and morbidity. Gut-focused hypnotherapy, when delivered by trained therapists, has been shown to be highly effective in severe refractory FGIDs. However, hypnotherapy continues to be surrounded by much misunderstanding and skepticism.

PURPOSE

The purpose of this review is to provide a contemporary overview of the principles of gut-focused hypnotherapy, its effects on gut-brain interactions, and the evidence-base for its efficacy in severe FGIDs. As supplementary material, we have included a hypnotherapy protocol, providing the reader with an insight into the practical aspects of delivery, and as a guide, an example of a script of a gut-focused hypnotherapy session.

The Place of Stress and Emotions in the Irritable Bowel Syndrome

Our emotional state can have many consequences on our somatic health and well-being. Negative emotions such as anxiety play a major role in gut functioning due to the bidirectional communications between gut and brain, namely, the brain-gut axis. The irritable bowel syndrome (IBS), characterized by an unusual visceral hypersensitivity, is the most common disorder encountered by gastroenterologists. Among the main symptoms, the presence of current or recurrent abdominal pain or discomfort associated with bloating and altered bowel habits characterizes this syndrome that could strongly alter the quality of life. This chapter will present the physiopathology of IBS and explain how stress influences gastrointestinal functions (permeability, motility, microbiota, sensitivity, secretion) and how it could be predominantly involved in IBS. This chapter will also describe the role of the autonomic nervous system and the hypothalamic-pituitary axis through vagal tone and cortisol homeostasis. An analysis is made about how emotions and feelings are involved in the disruption of homeostasis, and we will see to what extent the balance between vagal tone and cortisol may reflect dysfunctions of the brain-gut homeostasis. Finally, the interest of therapeutic treatments focused on stress reduction and vagal tone enforcement is discussed.

Hypnotherapy for Inflammatory Bowel Disease Across the Lifespan

Inflammatory bowel disease (IBD) is an autoimmune disorder characterized by lifelong relapsing gastrointestinal symptoms and associated with high rates of chronic pain, depression, and anxiety. In this review the author covers the existing literature including randomized controlled studies, open trials, and case reports as well as expert opinion in evaluating how hypnotherapy can be most beneficial in adolescents and adults with IBD. Hypnotherapy evidence for functional gastrointestinal disorders (FGIDs) is also reviewed as many of the gut-focused hypnotherapy (GHT) approaches used in IBD trials were developed for this latter population. Collectively, the strongest evidence of use of hypnotherapy is its association with reduced IBD-related inflammation and improved health-related quality of life with mixed results in terms of its effects on psychological and pain outcomes in adults with IBD. Studies of hypnotherapy for FGID symptoms show consistently more positive results. Post-operative hypnotherapy may also be helpful based on findings in other surgical samples. Adolescents with IBD have not been as systematically studied but small case series support the use of hypnotherapy to improve inflammation and pain. Future studies are needed to better delineate the specific brain-gut pathways which are most influenced by hypnotherapy in the IBD population and to investigate the longer-term course of the positive short-term findings.

Genomic and clinical effects associated with a relaxation response mind-body intervention in patients with irritable bowel syndrome and inflammatory bowel disease

Introduction

Irritable Bowel Syndrome (IBS) and Inflammatory Bowel Disease (IBD) can profoundly affect quality of life and are influenced by stress and resiliency. The impact of mind-body interventions (MBIs) on IBS and IBD patients has not previously been examined.

Methods

Nineteen IBS and 29 IBD patients were enrolled in a 9-week relaxation response based mind-body group intervention (RR-MBI), focusing on elicitation of the RR and cognitive skill building. Symptom questionnaires and inflammatory markers were assessed pre- and post-intervention, and at short-term follow-up. Peripheral blood transcriptome analysis was performed to identify genomic correlates of the RR-MBI.

Results

Pain Catastrophizing Scale scores improved significantly post-intervention for IBD and at short-term follow-up for IBS and IBD. Trait Anxiety scores, IBS Quality of Life, IBS Symptom Severity Index, and IBD Questionnaire scores improved significantly post-intervention and at short-term follow-up for IBS and IBD, respectively. RR-MBI altered expression of more genes in IBD (1059 genes) than in IBS (119 genes). In IBD, reduced expression of RR-MBI response genes was most significantly linked to inflammatory response, cell growth, proliferation, and oxidative stress-related pathways. In IBS, cell cycle regulation and DNA damage related gene sets were significantly upregulated after RR-MBI. Interactive network analysis of RR-affected pathways identified TNF, AKT and NF-κB as top focus molecules in IBS, while in IBD kinases (e.g. MAPK, P38 MAPK), inflammation (e.g. VEGF-C, NF-κB) and cell cycle and proliferation (e.g. UBC, APP) related genes emerged as top focus molecules.

Conclusions

In this uncontrolled pilot study, participation in an RR-MBI was associated with improvements in disease-specific measures, trait anxiety, and pain catastrophizing in IBS and IBD patients. Moreover, observed gene expression changes suggest that NF-κB is a target focus molecule in both IBS and IBD—and that its regulation may contribute to counteracting the harmful effects of stress in both diseases. Larger, controlled studies are needed to confirm this preliminary finding.

Trial Registration

ClinicalTrials.Gov NCT02136745

Efficacy and cost-effectiveness: A study of different treatment approaches in a tertiary pain centre

BACKGROUND

Chronic pain is considered to be a complex phenomenon, involving an interrelation of biological, psychosocial and sociocultural factors. Currently, no single treatment or therapy can address all aspects of this pathology. In our expert tertiary pain centre, we decide to assess the effectiveness of four treatments for chronic pain classically proposed in our daily clinical work: physiotherapy; psycho-education; physiotherapy combined with psycho-education; and self-hypnosis/self-care learning.

METHODS

This study included 527 chronic pain patients, with a mean duration of pain of 10 years. Patients were allocated either to one of the four pre-cited treatment groups or to the control group. Pain intensity, quality of life, pain interference, anxiety and depression were assessed before and after treatment.

RESULTS

This study revealed a significant positive effect on pain interference and anxiety in patients included in the physiotherapy combined with psycho-education group, after 20 sessions spread over 9 months of treatment. The most prominent results were obtained for patients allocated to the self-hypnosis/self-care group, although they received only six sessions over a 9-month period. These patients showed significant benefits in the areas of pain intensity, pain interference, anxiety, depression and quality of life.

CONCLUSIONS

This clinical report demonstrates the relevance of biopsychosocial approaches in the improvement of pain and psychological factors in chronic pain patients. The study further reveals the larger impact of self-hypnosis/self-care learning treatment, in addition to a cost-effectiveness benefit of this treatment comparative to other interventions.

Treatment of abdominal pain in irritable bowel syndrome

Functional abdominal pain in the context of irritable bowel syndrome (IBS) is a challenging problem for primary care physicians, gastroenterologists and pain specialists. We review the evidence for the current and future non-pharmacological and pharmacological treatment options targeting the central nervous system and the gastrointestinal tract. Cognitive interventions such as cognitive behavioral therapy and hypnotherapy have demonstrated excellent results in IBS patients, but the limited availability and labor-intensive nature limit their routine use in daily practice. In patients who are refractory to first-line therapy, tricyclic antidepressants (TCA) and selective serotonin reuptake inhibitors are both effective to obtain symptomatic relief, but only TCAs have been shown to improve abdominal pain in meta-analyses. A diet low in fermentable carbohydrates and polyols (FODMAP) seems effective in subgroups of patients to reduce abdominal pain, bloating, and to improve the stool pattern. The evidence for fiber is limited and only isphagula may be somewhat beneficial. The efficacy of probiotics is difficult to interpret since several strains in different quantities have been used across studies. Antispasmodics, including peppermint oil, are still considered the first-line treatment for abdominal pain in IBS. Second-line therapies for diarrhea-predominant IBS include the non-absorbable antibiotic rifaximin and the 5HT3 antagonists alosetron and ramosetron, although the use of the former is restricted because of the rare risk of ischemic colitis. In laxative-resistant, constipation-predominant IBS, the chloride-secretion stimulating drugs lubiprostone and linaclotide, a guanylate cyclase C agonist that also has direct analgesic effects, reduce abdominal pain and improve the stool pattern.

Risk factors for refractory irritable bowel syndrome-diarrhea

AIM: To investigate the risk factors for refractory irritable bowel syndrome-diarrhea (IBS-D) to provide evidence for early prevention and treatment of IBS-D.

METHODS: One hundred and twenty-one outpatients with IBS-D were divided into a refractory group (n = 56) and a non-refractory group (n = 65). The clinical data in both groups, including sex, age, body mass index (BMI), family history, smoking status, alcohol consumption, clinical symptoms, and anxiety and depression status were assessed statistically by univariate logistic regression analysis and receiver operating characteristic (ROC) curve analysis, with an attempt to find the predictors of refractory IBS-D.

RESULTS: There were no statistically significant differences in sex, age, BMI, family history, smoking status or alcohol consumption between the two groups. The univariate logistic regression analysis showed that clinical symptoms (OR = 1.010, 95%CI: 1.005-1.015), anxiety (OR = 2.810, 95%CI: 1.888-4.180) and depression (OR = 1.637, 95%CI: 1.338-2.004) status were risk factors. Their areas under the ROC curve (AUC) were 0.757, 0.919 and 0.796, respectively, and the cut-off values were 183, 9 and 6 points, respectively.

CONCLUSION: IBS is significantly associated with clinical symptoms, anxiety and depression status, which may be used as predictors of IBS-D.

Long-term success of GUT-directed group hypnosis for patients with refractory irritable bowel syndrome: a randomized controlled trial

OBJECTIVES

Gut-directed hypnotherapy (GHT) in individual sessions is highly effective in the treatment of irritable bowel syndrome (IBS). This study aimed to assess the long-term effect of GHT in group sessions for refractory IBS.

METHODS

A total of 164 patients with IBS (Rome-III-criteria) were screened, and 100 refractory to usual treatment were randomized 1:1 either to supportive talks with medical treatment (SMT) or to SMT with GHT (10 weekly sessions within 12 weeks). The primary end point was a clinically important improvement on several dimensions of daily life (assessed by IBS impact scale) after treatment and 12-month follow-up. The secondary end point was improvement in general quality of life (QOL; Medical Outcome Study Short-Form-36), psychological status (Hospital Anxiety Depression Scale) and reduction of single IBS symptoms. Analysis was by intention to treat.

RESULTS

A total of 90 patients received allocated intervention. After treatment, 28 (60.8%) out of 46 GHT patients and 18 (40.9%) out of 44 SMTs improved (absolute difference 20.0%; 95% confidence interval (CI): 0-40.2%; P=0.046); over 15 months, 54.3% of GHT patients and 25.0% of controls improved (absolute difference 29.4%; 95% CI 10.1-48.6%; P=0.004). GHT with SMT improved physical and psychological well being significantly more than SMT alone (P<0.001). Gender, age, disease duration and IBS type did not have an influence on the long-term success of GHT.

CONCLUSIONS

GHT improves IBS-related QOL, is superior to SMT alone, and shows a long-term effect even in refractory IBS.

Psychopharmacological treatment and psychological interventions in irritable bowel syndrome

Irritable bowel syndrome (IBS) accounts for 25% of gastroenterology output practice, making it one of the most common disorders in this practice. Psychological and social factors may affect the development of this chronic disorder. Furthermore, psychiatric symptoms and psychiatric diseases are highly prevalent in this condition, but the approach to treating these is not always straightforward. As emphasized in the biopsychosocial model of IBS, with regard to the modulatory role of stress-related brain-gut interactions and association of the disease with psychological factors and emotional state, it proves useful to encourage psychopharmacological treatments and psychosocial therapies, both aiming at reducing stress perception. The aim of this paper is to analyze the effectiveness of psychopharmacological treatment and psychological interventions on irritable bowel syndrome.