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Hypnotherapy for Functional Gastrointestinal Disorders

Hypnotherapy for Functional Gastrointestinal Disorders. PJ Whorwell. Symptoms of IBS. Abdominal pain - any site Abdominal distension Disordered bowel habit. Symptoms of IBS. Abdominal pain - any site Abdominal distension Disordered bowel habit - diarrhoea. Symptoms of IBS.

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Hypnotherapy for Functional Gastrointestinal Disorders

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  1. Hypnotherapy for Functional Gastrointestinal Disorders PJ Whorwell

  2. Symptoms of IBS Abdominal pain - any site Abdominal distension Disordered bowel habit

  3. Symptoms of IBS Abdominal pain - any site Abdominal distension Disordered bowel habit - diarrhoea

  4. Symptoms of IBS Abdominal pain - any site Abdominal distension Disordered bowel habit - diarrhoea - constipation

  5. Symptoms of IBS Abdominal pain - any site Abdominal distension Disordered bowel habit - diarrhoea - constipation - alternating

  6. Issues 1 10-15% of the population

  7. Issues 1 10-15% of the population Considered trivial (severity of pain and bowel problems)

  8. Issues 1 10-15% of the population Considered trivial (severity of pain and bowel problems) Considered psychological

  9. Issues 1 10-15% of the population Considered trivial (severity of pain and bowel problems) Considered psychological Distension

  10. Issues 2 Absenteeism

  11. Issues 2 Absenteeism Carries a stigma

  12. Issues 2 Absenteeism Carries a stigma Wind

  13. Issues 2 Absenteeism Carries a stigma Wind Sexual function

  14. Issues 2 Absenteeism Carries a stigma Wind Sexual function Quality of life

  15. Mean SF-36 Scores for Subjects With IBS Versus Subjects Without IBS or With Some Other Medical Condition Score 90 80 70 60 50 40 Role physical Body pain General health Vitality Role emotional Mental health Physical functioning Social functioning SF-36 scales IBS Heart disease Respiratory disease Renal disease Diabetes

  16. Issues 2 Absenteeism Carries a stigma Wind Sexual function Quality of life

  17. Issues 2 Absenteeism Carries a stigma Wind Sexual function Quality of life Extracolonic symptoms

  18. Extra-colonic manifestations Nausea Thigh pain Backache Lethargy Urinary symptoms Gynaecological symptoms  reassurance  diagnostically useful  inappropriate referral Gut 1986;27:37-40 BMJ 1989;299:1138-9 Gut 1991;32:784-6

  19. Pathophysiology(multifactorial) Motility Visceral sensitivity Central processing Genetic Psychological factors Inflammation Dietary factors

  20. Pathophysiology(multifactorial) Motility Visceral sensitivity Central processing Genetic Psychological factors Inflammation Dietary factors

  21. Visceral sensitivity in IBS urgency discomfort gas stool 400 240 400 240 vol 200 200 320 320 160 160 240 240 120 120 * 160 160 80 80 * * 80 80 * 40 40 0 0 0 0 p<0.05 * Gut 1990;31:458-62

  22. Pathophysiology(multifactorial) Motility Visceral sensitivity Central processing Genetic Psychological factors Inflammation Dietary factors

  23. Pathophysiology(multifactorial) Motility Visceral sensitivity Central processing Genetic Psychological factors Inflammation Dietary factors

  24. The IBS patient • Eating makes symptoms worse • Patient : blames food dietary allergy wants discussion of food diet sheet Ragnarsson et al, 1998

  25. Cereal fibre

  26. Overall symptomatic response to fibre Fibre Source Better Worse Unchanged Wheat fibre 11 (11%) 55 (55%) 33 (33%) Cornflakes 0 0 88 (100%) Rice Crispies 0 0 81 (100%) Porridge 0 9 (12%) 66 (88%) Muesli 0 21 (27%) 58 (73%) Vegetables 3 (3%) 24 (25%) 71 (72%) Fruit 5 (5%) 42 (45%) 47 (50%) Pulses 0 22 (25%) 65 (75%) Nuts 0 23 (27%) 61 (73%) Proprietary fibre 27 (39%) 15 (22%) 27 (39%) Francis et al, 1994

  27. Overall symptomatic response to fibre Fibre Source Better Worse Unchanged Wheat fibre 11 (11%) 55 (55%) 33 (33%) Cornflakes 0 0 88 (100%) Rice Crispies 0 0 81 (100%) Porridge 0 9 (12%) 66 (88%) Muesli 0 21 (27%) 58 (73%) Vegetables 3 (3%) 24 (25%) 71 (72%) Fruit 5 (5%) 42 (45%) 47 (50%) Pulses 0 22 (25%) 65 (75%) Nuts 0 23 (27%) 61 (73%) Proprietary fibre 27 (39%) 15 (22%) 27 (39%) Francis et al, 1994

  28. Overall symptomatic response to fibre Fibre Source Better Worse Unchanged Wheat fibre 11 (11%) 55 (55%) 33 (33%) Cornflakes 0 0 88 (100%) Rice Crispies 0 0 81 (100%) Porridge 0 9 (12%) 66 (88%) Muesli 0 21 (27%) 58 (73%) Vegetables 3 (3%) 24 (25%) 71 (72%) Fruit 5 (5%) 42 (45%) 47 (50%) Pulses 0 22 (25%) 65 (75%) Nuts 0 23 (27%) 61 (73%) Proprietary fibre 27 (39%) 15 (22%) 27 (39%) Francis et al, 1994

  29. Diet sheet Wheat fibre exclusion Refined wheat allowed (eg white bread) 3 month trial

  30. The over-reactive gut

  31. Cephalic response to food • Food discussion • Smell of food • Sham feeding • (chewing, tasting) Increases colonic motor activity Rogers et al, 1993 Even before swallowing - gut activation

  32. Medical treatment • Antispasmodics • Antidepressants • Antidiarrhoeals • Laxatives • Unsatisfactory

  33. Definition Yoga, TM, healing, aromatherapy, relaxation, reflexology etc Hypnosis more concentrated (trance) Subject Innate capacity Light vs Deep Depth not essential Can’t be hypnotised against will Fear of losing control Induction Dramatic vs Simple techniques

  34. Therapist Easy to learn Hard to apply Problems with Self confident application Self conscious Repetitive Challenging to ego Time consuming Therapy Focused

  35. IBS Studies

  36. 18 3 active control 2 12 mean weekly distension score mean general wellbeing score 1 6 0 0 -2 12 -2 12 1 8 1 8 -1 4 -1 4 week no. week no. 18 18 12 12 mean weekly pain score mean weekly bowel habit score 6 6 0 0 -2 12 -2 12 1 8 1 8 -1 4 -1 4 week no. week no. Lancet 1984 2 1232-1234

  37. control 100 patients post-hypnotherapy * 80 * ** 60 ** * symptom scores ** 40 20 0 abdominal pain bloating overall bowel dissatisfaction incomplete evacuation urgency Results expressed as median and interquartile range p<0.05; p<0.0001 * ** Alimentary Pharmacology and Therapeutics 1996 10 91-95

  38. Extra-colonic Symptoms control patients post-hypnotherapy 100 ** * * 80 60 * symptom scores ** 40 * 20 0 headache backache flatulence heartburn dyspar- eunia urinary symptoms thigh pain lethargy nausea early satiety Results expressed as median and interquartile range p<0.01; p0.05 * ** Alimentary Pharmacology and Therapeutics 1996 10 91-95

  39. Quality of Life control 100 patients post-hypnotherapy ** * ** *** ** 80 60 symptom scores 40 20 0 physical well-being mood psychic well-being locus of control social behaviour work *** * ** Results expressed as median and interquartile range p<0.0001; p<0.001; p<0.05 Alimentary Pharmacology and Therapeutics 1996 10 91-95

  40. Additional Advantages Back to work Less time off work More effective at work Less GP consultations - for IBS - for other conditions Alimentary Pharmacology and Therapeutics 1996 10 91-95

  41. Established NHS Service with 6 Therapists Results for first 250 treated Patients referred from GI clinic All patients treated Very severe cases included

  42. IBS Symptom Score pre-HT post-HT 400 100 p<0.001 * 300 75 * * * * * score (max 500) * score (max 100) 200 50 100 25 0 0 pain severity pain frequency overall score bloating life interference bowel habit dissatisfaction Data as median plus interquartile range Am J Gastroenterology 2002 97 954-961

  43. Extra-colonic Features 100 300 pre-HT Data as median plus interquartile range post-HT p<0.001 * * * 75 * 200 * * * score (max 500) score (max 100) 50 * 100 * * * * 25 0 0 satiety & pains aches early overall urgency vomiting urinary nausea/ score backache lethargy heartburn thigh pain headaches excess wind Am J Gastroenterology 2002 97 954-961

  44. Quality of Life Measures pre-HT 100 post-HT * * * * * * 75 score (max 100) 50 25 0 physical well-being mood psychic well-being social/ relationships work locus of control Am J Gastroenterology 2002 97 954-961

  45. Anxiety and Depression (HAD Scores) pre-HT post-HT ‘p’ value HAD ‘A’ Score 11.1 ± 0.3 7.3 ± 0.3 p<0.001 % anxious (score 9) 68.3% 34.6% p<0.001 HAD ‘D’ Score 7.2 ± 0.3 4.1 ± 0.3 p<0.001 % depressed (score 9) 36.1% 14.6% p<0.001 HAD Scores expressed as mean ± S.E.M. *post-HT v pre-HT, paired ‘t’ test Am J Gastroenterology 2002 97 954-961

  46. Males did less well Almost exclusively males with diarrhoea predominant IBS ? Reason for gender differences Am J Gastroenterology 2002 97 954-961

  47. Confirmation of Results • Harvey et al Lancet 1989; 1: 424-425 • Galovski and Blanchard Appl Psychophysiol Biofeedback 1998; 23: 219-232 • Vidakovic-Vukic Scan J Gastroenterol 1999; 230(supp): 49-51 • Palsson et al Dig Dis Sci 2002; 47: 2605-14

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