GUT HYPNOTHERAPY IN DR MAY WONG FUNCTIONAL MBBS, …

GUT HYPNOTHERAPY IN FUNCTIONAL GASTROINTESTINAL DISORDERS

DR MAY WONGMBBS, MMED (CLI EPI), MRCP, FRACP, PHD

GASTROENTEROLOGIST

ROYAL NORTH SHORE HOSPITAL

WHAT WE WILL COVER

¡ Rome IV

¡ IBS and management approaches

¡ Gut focused hypnotherapy

¡ Broad principles

¡ Examples of imagery

¡ Mechanism of action

¡ Beyond the ‘gut’

¡ Trials

¡ Systematic review and network meta-analysis

¡ Closing remarks

¡ Rome IV Classification

¡ Functional gastrointestinal disorders have a reported prevalence of 35%

¡ Around ¼ will have severe, refractory symptoms

IRRITABLE BOWEL SYNDROME (ROME IV)

¡ Recurrent abdominal pain, on average, at least 1 day/week in the last 3 months, associated with two or more of the following criteria:

¡ Related to defecation

¡ Associated with a change in frequency of stool

¡ Associated with a change in form (appearance) of stool.

IBS- WHAT I TELL PATIENTS

¡ IBS is a symptom-based diagnosis—based on abdominal pain and stool habits

¡ We will do several tests to make sure IBS is the right diagnosis

¡ It can affect QoL, but it does not shorten your lifespan or cause cancer

¡ We may be unable to remove all your symptoms, but with time, we usually can find a solution that helps to take back control of your life

Chey. JAMA. 2015;313:949.

MULTIPLE FACTORS

IBS Symptom Complex

Abnormal Motility

Visceral Hypersensitivity

Genetic Predisposition

Psychosocial Factors

Gut Immune Activation

Microbiome, Bile Acids

Permeability

Diet

Chey. JAMA. 2015;313:949. Drossman. Gastroenterology. 2016;150:1262. Holtmann. Dig Dis. 2017:35:5. Radovanovic-Dinic. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2018;162:1.

WHAT CAUSES FUNCTIONAL GUT DISORDERS?

Risk factors

- Infection- Surgery

Triggers

- Genetics- Gut bacteria- Pelvic floor problems

- Psychosocial stressors- Mood

- Psychological trauma- Stress- Early life events

Changes in bowel function Symptoms

Ongoing factors

BRAIN-GUT-BACTERIA AXIS

Autonomic nervous system- Tells gut to speed up or slow down (Motility)

- Tells gut how sensitive it should/shouldn’t be

Gut Brain “Little Brain

Influence onNeurotransmittersStress/anxietyMood/behaviour

Big Brain

WHAT IS THE BRAIN–GUT AXIS? (II)

¡ Normal brain–gut communication can sometimes go wrong with prolonged disturbance (eg, stress, inadequate sleep, infection)¡ Brain may perceive gut sensations

more strongly than usual

¡ Brain may send inappropriate signals to gut that disturb intestinal functioning

Keefer. Gastroenterology. 2018;154:1249.

Gut symptoms

Thoughts

Increased focus on gut symptoms

Stress/anxiety

SOME TESTS WHICH WE RECOMMEND

1. Chey. JAMA. 2015;313:949. 2. Pimentel. PLoS ONE. 2015;10:e0126438. 3. Smalley. Gastroenterology. 2019;157:851.

§ Fecal calprotectin § Stool cultures§ When colonoscopy performed, obtain random biopsies§ Consider abdominal plain-film x-ray to assess for stool

accumulation§ Testing for celiac disease

IBS-D IBS-C

§ Age-appropriate colorectal screeningEg. In line with National Bowel Cancer Screening Program§ Medication review

All IBS Subtypes[1]

§ Abdominal plain-film Xray to assess accumulation/extent

KEY ALARM FEATURES: A PROMPT FOR ADDITIONAL TESTING

¡ Nocturnal diarrhea

¡ Symptom onset after 50 yrs of age

¡ Family history of other gastrointestinal disease

¡ Rectal bleeding or unexplained iron-deficiency anemia

¡ Unintentional, unexplained weight loss

Radovanovic-Dinic. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2018;162:1. Enck. Nat Rec Dis Primers. 2016;2:16104.

TREATMENT APPROACH BASED ON SEVERITY§ Continuing workup and care§ Psychologic treatment for known stressors§ Neuromodulators for pain§ Referral to functional GI/pain treatment center

Severe

§ Symptom monitoring and follow-up§ Pharmacotherapy§ Consider psychologic treatment for

known stressors

Moderate

§ Education about stimuli§ Reassurance§ Diet, lifestyle advice

Mild

Drossman. Gastroenterology. 2016;150:1262.

AVAILABLE THERAPIES FOR IBS BASED ON PREDOMINANT SYMPTOM

Bloating/ distension

Altered bowel

function

Abdominal pain/

discomfort

Diarrhea• Antispasmodics• Gastrostop• Neuromodulators

Constipation• Fiber• Laxatives• Newer drugs• Physiotherapy

Diet (eg, FODMAP)ProbioticsRifaximin

AntispasmodicsNeuromodulators

Chang. Gastroenterology. 2014;147:1149. Weinberg. Gastroenterology. 2014;147:1146. Ford. Am J Gastroenterol. 2018;113:1.

Overall extremely challenging to treatFew medications approved for IBS

MENTAL STATE AND IBS

¡ Early research concluded that the aetiology of IBS was linked to hypochondriasis or psychogenic traits

¡ Often patients with IBS have associated mental disorders

¡ Anxiety (69%) and affective disorders (38%)

¡ Common symptoms include nervousness, rumination, panic attacks, posttraumatic stress, social phobia, somatisation and eating disorders. Less common symptoms include sleep disorders, loss of appetite and exhaustion

WHAT IS THE EVIDENCE FOR PSYCHOLOGICAL THERAPIES?

¡ Brain–gut psychotherapies target GI symptoms, not psychologic disorders

¡ Evidence-based treatments for IBS include:

¡ Cognitive behavioral therapy (CBT)

¡ Hypnotherapy

¡ Relaxation therapy/mindfulness-based stress reduction

¡ Dynamic psychotherapy

¡ Multicomponent psychologic therapy

Keefer. Gastroenterology. 2018;154:1249. 2. Ford. Am J Gastroenterol. 2018;113:1.

Treatment tailored to provide patient with skills to downregulate unpleasant GI

sensations, decrease avoidance behaviors, and

build resilience to stressors

GUT HYPNOTHERAPY

GUT HYPNOTHERAPY IN IBS

¡ Landmark paper published 1984 in Lancet

30 patients unresponsive to medical treatment were randomly assigned to receive:7 sessions of hypnosis7 Sessions of psychotherapy and placebo pills

Whorwell, Lancet 1984; 324 (8414) 1232-1234

2 PROTCOLS

12 sessions

Emphasis on gut-directed suggestions and patients’ conscious sense of control over symptoms

Manchester

7 session (biweekly)

Emphasis on symptom and threat perceptionFully standardised verbatim protocol

North Carolina

BROAD PRINCIPLES OF GUT HYPNOTHERAPY

¡ Reduced attention to bowel symptoms

¡ Altered perceptual experience of the symptoms—reducing intensity and frequency and changing the symptom qualitatively into something more pleasant

¡ Increased overall sense of health and comfort

¡ Immunity to intestinal disturbance from internal or external stimuli

¡ Normalisation of bowel functioning

BROAD PRINCIPLES OF GUT FOCUSED HYPNOTHERAPY

¡ Aims are to induce a deep state of relaxation to guide the patient to learn how to control their gut function.

• Education• AssessmentIntroductory session

• Patients are given a series of approaches to enable them to gain control of their gut function.

Subsequentsession

• Following treatment window, patients may benefit from a refresherTop up sessions

IMAGERY

¡ Use of adaptable metaphors.

¡ Imagine their gut as a river and modify its flow

¡ For abdominal pain, use of a hot water bottle over abdomen

¡ The inflated balloon being slowly deflated can be used as a metaphor to reduce abdominal bloating.

SUGGESTIONS

¡ Improvement in pain and bloating: There will be no more pain, nor more bloating and no more discomfort

¡ Improvement in bowel habits: Your bowel habits will continue to improve day by day, week by week and month by month

¡ Improvement over time: You will continue to get better and better and better

Peters;AP&T, 2015, 41:1104-1115

EXAMPLE OF A SCRIPTNow I'd like you to turn that power of your mind towards your tummy. On a count of 3put a hand on your tummy and feel a lovely warm feeling in your tummy, feel a surge of control coming over your tummy – 1,2,3.Feel a lovely soothing feeling in your tummy, as your mind takes control of your gutfeel every part of your gut being put under the control of your mind no part of your gut can resist the power, the energy of your mind as it gets stronger and stronger and strongerfeel your gut responding to the power of your mind you are taking control of your gutrather than your gut controlling youand on a count of 3 put your other hand on your tummy and double that sense of control - 1,2,3.Feel that control just getting stronger and stronger and stronger feel your gut responding to the power of your mind no pain, no bloating, no discomfortand even your bowel habit is gradually improving day by day week by week month by month

you're just going to get better and better and better failure is not on the agendayou are going to get better you are determined to get betternothing is going to stop you from getting better you are thoroughly fed up with this IBS and once and for all you are going to put it behind you so you are absolutely determined to get better nothing is going to get in your wayso that for the rest of your life you can be free of this condition and you can enjoy the rest of your lifeso no pain, no bloating, no discomfort, no trouble with your guts they just work quietly and normally and you can do what you want without it affecting your gutsyou won't need to worry about what you eat you won't have to worry about what you can and can't do you'll just be able to do whatever you want to dowithout your gut being upsetbecause you are taking control of your gut rather than your gut controlling you

Palsson, Am J of Clin Hypnosis, 2160-0562 (Suppl)

MECHANISM OF ACTION (1)

¡ Physiology: ? normalises visceral sensation, decreases colonic motor phasic contractions

¡ Psychology: Reverses negative thoughts of IBS patients about their condition. Improves their anxiety and depression

¡ Hypnotherapy has been shown to change gastric acid secretion and change gut transit time measured using hydrogen breath test

MECHANISM OF ACTION (2)

¡ Functional brain imaging techniques

¡ Certain areas exaggerated in IBS:Anterior cingulate cortex, normally responsible for painful visceral stimuli

¡ Hypnosis shown to reduce the activation of certain areas of the brain

PATIENT SELECTION

¡ Severe symptoms refractory to 12 months of pharmacological treatment

¡ Efficacy of gut-focused hypnotherapy in children and adolescents with IBS is similar to that in adults

¡ Relative contra-indications

¡ If PTSD

¡ Fixed health beliefs

¡ Severe psychiatric disturbance (such as schizophrenia, or bipolar disorder)

Overall, gut focused hypnotherapy is a safe and well tolerated treatment in the right patients

OTHER BENEFITS

¡ Can also help with extra-intestinal manifestations eg. back pain, fatigue, urinary and gynaecological symptoms

¡ Long lasting effects

¡ High levels of patient satisfaction

HYPNOTHERAPY BEYOND THE GUT

¡ ‘Oesophagus focused hypnotherapy’

¡ Patients with normal esophageal physiology and refractory functional esophageal symptoms also have impaired QoL with high levels of psychosocial stress

¡ Similar but target oesophageal hypervigilance and hypersensitivity

¡ Other conditions: globus pharyngeus, functional dyspepsia and functional heartburn, non cardiac chest pain

LARGE TRIALS¡ IBS Symptom Severity Scores

before and after gut-focused hypnotherapy

¡ 76% had a 50-point reduction in the IBS Symptom Severity Score after 12 sessions of hypnotherapyafter 3 months

¡ 80% of women responded as opposed to 62% of men

Miller V, Aliment Pharmacol Ther 2015; 41:844–855)

SYSTEMATIC REVIEW

¡ 7 RCTs with 374 patients

Abdominal pain3 months*

1 year

Lee H, Journal of Neurogastroenterology & Motility; 2014, 20(2) 152-162

Beneficial short-term effects in improving abdominal pain in patients with IBS

Constipation3 months

1 year

Diarrhea3 months

1 year

However no short or long term benefit with constipation or diarrhea symptoms

HOW DOES HYPNOTHERAPY COMPARE WITH OTHER PSYCHOLOGICAL TREATMENTS

¡ Systematic review and network meta-analysis

Ford, Gut, 2020; 69(8) 1441-1451

Ford, Gut, 2020; 69(8) 1441-1451

HYPNOTHERAPY HAS LONG LASTING EFFECTS

¡ 250 IBS patients treated with hypnosis followed long term

¡ 71% improved after treatment

¡ 4 out of 5 of those who improved maintained improvement fully for up to 5 years

¡ Significantly fewer sick days and doctor visits after treatment

¡ Also reduced quality of life, anxiety and depression improved significantly from treatment

Gonsalkorale,Am J Gastro, 2002, 97(4) 954-61

IBS symptom severity decreased by about 50%

USED AS AN ADJUNCTIVE THERAPY

¡ Hypnotherapy should not be regarded as a standalone treatment

¡ As a patient improves during hypnotherapy, they may find that they need less of any ‘as required’ medication. For instance: antidiarrheal may be needed less often or even discontinued

¡ If they are taking an antidepressant for their IBS the patient may ask if they can stop this if they improve.

GUT DIRECTED HYPNOTHERAPY

Benefits Limitations

• Extremely safe • Highly effective even in otherwise refractory cases • Improvement in extra-intestinal symptoms • Reduced need for medication • Improves resilience and teaches self-management

skills • Improves quality of life, psychological and cognitive

function • Reduces healthcare utilization • Socioeconomic benefits including reduced

absenteeism

• Time intensive (6–12, 60-min sessions)• Needs to be practiced at home regularly, at least initially • Requirement for trained therapist• Misconceptions and negative perceptions• Relatively expensive• Limited availability outside tertiary centres• Requires highly motivated patients

FUTURE AREAS

¡ What is the efficacy of Group hypnotherapy

¡ How to explore Skype/online based/app based deliveries

¡ Is there a dose dependent response?

¡ usually somewhere between 6 and 12 weekly sessions.

¡ Interestingly, while one study has shown that response at wk6 is predictive of a response at wk12.

¡ How to identify which patients will benefit most from different psychological therapy approaches

CONCLUSIONS

¡ Gut focused hypnotherapy has a long history and is well studied

¡ Current recommendations is in refractory functional gut conditions

¡ Evidence is from 6 to 12 sessions with 2 different protocols

¡ Can help with gut symptoms and extra-intestinal symptoms

¡ Long lasting efficacy

¡ Should be used as an adjunctive therapy

¡ Gastroenterologists and GPs should work closely with hypnotherapists