Psychological Treatments in Functional Gastrointestinal Disorders

A Primer for the Gastroenterologist

Olafur S. Palsson; William E. Whitehead

Disclosures

Clin Gastroenterol Hepatol. 2012;11(3):208-216. 

In This Article

Hypnosis Treatment

Clinical hypnosis is a verbal intervention that uses a special mental state of enhanced receptivity to suggestion to facilitate therapeutic psychological and physiological changes. Treatment sessions, which are generally conducted one-on-one, begin with an induction of the hypnotic state. This is accomplished in various ways that generally involve relaxation, narrowing and intensification of the focus of attention (for example, by means of eye fixation), and the patients' gradual release of deliberate control of their mental activity. Once the hypnotic state has been achieved, deepening of the altered state generally follows with the aid of counting, physical relaxation, and guided mental dissociation from the here-and-now. The hypnotherapist then conducts the clinical intervention, which is composed of targeted verbal suggestions and therapeutic imagery to encourage improvement in symptoms. In the treatment of FGIDs, imagery and suggestions commonly aim at regulating smooth muscle activity, reducing the impact of stress on gastrointestinal symptoms, reducing gut pain perception and attention to symptoms, and increasing the patient's sense of control over symptoms. Examples of imagery used in IBS hypnosis treatment are a mental image of the intestinal wall being coated with a strong protective coating that makes it immune to irritation or pain, or imagining the bowel as a river and the patient mentally slowing or speeding the flow of the river to counter diarrhea or constipation. Similar to CBT, hypnosis treatment for FGIDs usually consists of a course of 6–12 therapy sessions, and patients are commonly asked to practice hypnosis at home in between visits with the aid of audio recordings.

Hypnosis treatment has been tested for FGIDs in 11 published RCTs to date (Supplementary Table 2). Control groups have included supportive talk therapy, placebo pills, waiting lists, multicomponent (nonhypnotic) audio recordings, and usual medical care. Seven of these trials were on IBS in adults, and all except one of those RCTs found hypnosis to result in significantly greater improvement in gastrointestinal symptoms than seen in the comparison groups. Emotional symptoms and quality of life also improved significantly in studies where these parameters were measured. Improvement from hypnosis treatment generally lasts a long time. Two of the RCTs reported therapeutic gains in treatment responders to be fully maintained at 10[23] and 18[24] months after treatment, respectively. Separately, one of the investigative teams published a large case series of 204 consecutive IBS patients whose symptoms were reassessed annually for years after hypnotherapy, and they reported that 81% of patients fully maintained their treatment gains for at least 5 years.[25] Overall, the data strongly indicate that hypnosis treatment is an effective intervention for IBS.

Two controlled studies have investigated the impact of hypnosis treatment on pediatric abdominal pain, both with impressive results. Vlieger et al[26] in the Netherlands randomly assigned 53 children with functional abdominal pain to 6 sessions of either hypnotherapy or supportive therapy. The pain improved far more in the hypnosis group, and at 1-year follow-up, 85% of the hypnosis subjects and 25% of controls were treatment responders. At 5-year follow-up, the pain of a significantly higher proportion of the hypnosis subjects than of controls was in remission (68% vs 20%).[27] In the second study, which was conducted in the United States by our research team,[28] children were randomized to either guided imagery treatment (a variant of hypnosis that used hypnotic suggestions and vivid imagery without formal hypnotic induction) or usual medical care. The hypnosis intervention was self-administered by the children at home via audio recordings. At the end of treatment, pain was reduced by half or more compared with pretreatment assessment in 73.3% of the hypnosis group vs only 26.6% of the usual medical care group. Although it is desirable for more studies to be conducted on this application of hypnosis, these 2 trials indicate that hypnosis is a good option for reducing pediatric abdominal pain.

Finally, 2 initial randomized placebo-controlled investigations have found hypnosis treatment to lead to dramatically greater immediate and long-term improvement in the symptoms of noncardiac chest pain[29,30] and functional dyspepsia[31] compared with supportive talk therapy, placebo pills, and in the functional dyspepsia trial, compared with ranitidine as well. These FGIDs therefore appear to be promising new targets for hypnosis intervention, but further empirical work is needed to evaluate those applications of this therapy.

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