Hypnotherapy in irritable bowel syndrom: a large-scale audit of a clinical service with examination of factors influencing res

HYPNOTHERAPY IN IRRITABLE BOWEL SYNDROM: A LARGE-SCALE AUDIT OF A CLINICAL SERVICE
WITH EXAMINATION OF FACTORS INFLUENCING RESPONSIVENESS
Study presented with the permission of - Dept. of Medicine, University Hospital of South Manchester OVERVIEW
Objectives: Hypnotherapy has been shown to be effective in the treatment of irritable bowel syndrome in a number of
previous research studies. This has led to the establishment of the first Unit in the UK staffed by six therapists which provides
this treatment as a clinical service. This study presents an audit on the first 250 unselected patients treated, and these large
numbers have also allowed analysis of data in terms of a variety of other factors, such as gender and bowel habit type, that
might affect outcome.
Methods: Patients underwent 12 sessions of hypnotherapy over a 3-month period and were required to practise techniques in
between sessions. At the beginning and end of the course of treatment, patients completed questionnaires to score bowel and
extra-colonic symptoms, quality of life, anxiety and depression, allowing comparisons to be made.
Results: Marked improvement was seen in all symptom measures, quality of life, anxiety and depression, in keeping with
previous studies. All subgroups of patients appeared to do equally well with the notable exception of males with diarrhoea
who improved far less than other patients. No factors, such as anxiety and depression or other pre-hypnotherapy variables
could explain this lack of improvement.
Conclusions: This study clearly demonstrates that hypnotherapy remains an extremely effective treatment for irritable bowel
syndrome which should prove more cost-effective as new, more expensive drugs come on to the market. It may be less useful
in males with diarrhoea-predominant bowel habit, a finding that may have pathophysiological implications.

INTRODUCTION

Irritable bowel syndrome (IBS) is a functional bowel disorder, characterised by abdominal pain, distension and altered bowel
habit. In addition, patients commonly complain of a variety of extra-colonic symptoms which include nausea, lethargy,
backache and urinary symptoms
This common condition is estimated to affect 15-20% of the general population at any one time and although only a small
proportion (as few as 4% of all IBS sufferers) see a hospital specialist, they account for approximately half of the
gastroenterologist’s workload. It is claimed that IBS is much more common in females, since, in the hospital clinic, women
outnumber men by as much as 4:1 although a recent survey has shown this difference is probably less marked in the general
population, being roughly twice as common in women.
In some cases, symptoms can be so severe and intrusive that they interfere with a person’s quality of life and ability to cope
with work, which can result in much time off work. Such patients are often refractory to current conventional treatment, such
that they fail to improve despite a variety of therapeutic interventions. It is not uncommon for patients to have undergone
repeated investigations and to have been referred to other specialities to seek a cause for their problem, and some may have
undergone surgery, such as cholecystectomy and hysterectomy, without symptomatic relief. Patients also tend to consult
their own general practitioner for other minor ailments more frequently than other people. Thus, for a whole variety of
reasons, IBS patients not only continue to suffer from their symptoms but can also be a significant drain on healthcare
resources.
Hypnotherapy has been shown to be extremely effective in the treatment of IBS, with up to 80% of patients showing
improvement in symptoms and overall well-being, an effect that is usually sustained. A more recent study has demonstrated
that hypnotherapy also reduces extra-colonic symptoms, improves quality of life and can help patients return to work. In
addition, the effectiveness of hypnotherapy has been confirmed by independent studies.
This work has led to the establishment of the first Hypnotherapy Unit within the National Health Service in the UK devoted
to the treatment of patients with IBS, which is currently staffed by a team of six (non-medical) therapists. Since its inception,
several hundred patients have already received treatment and this study represents an audit of the first 250 patients treated at
this Unit. The large number of patients evaluated in this audit allowed not only classic symptomatology to be assessed but
also, unlike in the earlier controlled trials data to be analysed in terms of factors such as age, gender, bowel habit type and psychological status that might affect or predict outcome. Patients 250 patients (aged 19-79 years, 50 male), with IBS of at least two years’ duration and refractory to previous treatment, received a course of hypnotherapy. All patients were on a waiting list for 3 months prior to this and reported that they had had no symptomatic improvement during this time. Treatment was offered to patients attending Gastroenterology Clinics at this hospital and other centres in the region whose symptoms continued to be unresponsive to conventional treatment, e.g. laxatives, antidiarrhoeals, antispasmodics or antidepressants, as was deemed appropriate. Procedure Patients were seen in consecutive order and treated by the next available therapist. At the first visit, patients completed questionnaires to measure severity of IBS symptoms. Patients then attended for 12 sessions of hypnotherapy, over a three-month period, usually at weekly intervals, after which they completed questionnaires identical to those before treatment to reflect overall symptom severity after finishing therapy. Hypnotherapy Hypnotherapy was carried out. Briefly, this involved hypnotic induction using progressive relaxation and other procedures to deepen the hypnotic state. This was followed by suggestions, imagery and other techniques appropriate to the individual, directed towards control and normalisation of gut function in addition to relevant ego-strengthening interventions. Patients were asked to practise these hypnotic skills on a daily basis with the help of an audio-tape. After the last session, all patients were asked to contact the Unit at any time for an additional session if they felt they needed further help. Questionnaires Questionnaires completed both before and at the end of the course of hypnotherapy included a validated IBS questionnaire rating IBS symptoms, extra-colonic features and quality of life measures, together with the Hospital Anxiety and Depression Scale. 232 of the 250 patients in this series completed the full course of 12 sessions of hypnotherapy. The remaining 18 discontinued before this (having from 8 to 10 sessions) because they had achieved marked improvement and felt confident that they no longer needed to attend. These patients completed the post-hypnotherapy questionnaires within two weeks of their last session and the data treated as if this was after 12 sessions. No patients discontinued before completing 12 sessions for other reasons. IBS Symptomatology
Following hypnotherapy, improvement was seen in the overall IBS score and in all individual features measured, namely pain severity, pain frequency, bloating, bowel habit dissatisfaction and life interference. Quality of Life, Anxiety and Depression
Hypnotherapy significantly improved all measures of quality of life. There was also a reduction in both anxiety and
depression. Moreover, after treatment, fewer patients were classified as clinically anxious or depressed.
Discussion
This audit is the first large scale review of hypnotherapy in IBS which not only confirms earlier findings that it is an effective
treatment for this condition but adds some important new observations. The most interesting finding in this respect was that
males with diarrhoea-predominant bowel habit did far less well with hypnotherapy than the other patient groups.
In the patients as a whole group, IBS symptoms of abdominal pain, bloating and bowel habit disturbance, together with all
extra-colonic symptoms, were significantly reduced after hypnotherapy and were considered to interfere with life far less
than before. The subjective rating of bowel habit dissatisfaction used in the symptom questionnaire to assess bowel habit
disturbance proved to be a simple yet reasonably accurate measure, since changes in dissatisfaction after treatment directly
correlated with actual changes in bowel habit. In addition, patients’ quality of life improved and ratings for anxiety and
depression were lower, with fewer patients remaining significantly anxious or depressed after treatment. Furthermore, the
improvement seen in IBS symptomatology was related to improvement both in quality of life and psychopathology (anxiety
and depression). It is reasonable to conclude that this association indicates that improvement in patients’ quality of life and
psychological well-being occurred as a consequence of reducing symptoms. However, one cannot rule out that hypnotherapy
could have had at least some partial effect by directly reducing anxiety and depression. This in itself could also help to
improve symptomatology, particularly if psychological factors played a role in triggering or exacerbating symptoms.
The possibility that the results of this audit are influenced at least in some way by expectations that patients had about the
outcome of treatment cannot be entirely ruled out. However, less than 10 patients had actively sought out hypnotherapy
treatment, and it is of interest that in our own Gastroenterology Clinic it is estimated that less than 2% turn down hypnotherapy when it is offered. Thus, selection bias should not be a major problem associated with this report. The results in this study represent an audit of patients undergoing hypnotherapy as part of the clinical service now offered routinely on the basis of favourable outcome in previous research studies. Since this was not a clinical trial, no control group was included here for comparison, but previous studies that have included control groups have demonstrated that hypnotherapy was superior to placebo or non-treatment. In addition, all patients in the present study had waited at least 3 months for treatment, and patients reported that no improvement in symptoms occurred during this time. The outcome of therapy was measured soon after the last therapy session and no longer term follow-up has systematically been pursued at this stage since obtaining data on such a large scale would present difficulties. However, it has been shown previously that improvement in symptoms with hypnotherapy is largely sustained, although some patients may require occasional ‘top-up’ sessions to maintain improvement. The possible effect of age on response to therapy was assessed since it had been observed in an earlier study that patients over 50 years of age improved less than younger patients . In this present study, however, the association between age and degree of symptomatic improvement was found to be very weak and reached statistical significance only because of the very large numbers of patients involved. Therefore, it seems reasonable to conclude that age is not a significant factor affecting outcome and that older patients could generally be expected to benefit as much as younger patients. Males with diarrhoea, as a group, improved far less than other patient groups with hypnotherapy, as evidenced by a much smaller degree of change in the overall IBS score. This was largely determined by the fact that ratings for bowel habit dissatisfaction and life interference remained higher after treatment, and these in turn were associated with greater continued disturbance in bowel habit, as measured by stool frequency and consistency. In addition, males with diarrhoea retained more extra-colonic symptoms and a higher score for depression than other patients after treatment. The failure of males with diarrhoea to respond as well to treatment was not obviously connected with any of the variables measured before hypnotherapy. Although males with diarrhoea were more anxious than other males, their levels of anxiety were similar to females, and no association was found between pre-hypnotherapy scores of anxiety and symptomatic improvement. Depression was found to be a significant factor in outcome only for females but not males. Furthermore, improvement of IBS symptoms was not associated with any of the other pre-hypnotherapy measures. In seeking other explanations for this lack of improvement, one possibility is that males generally have somewhat lower hypnotic or imaginative abilities than females, so that they would be not as well suited to a hypnotherapeutic approach. Alternatively, males may have been less amenable to this intervention because it was delivered by a female therapist. However, if either explanation is true, one would have expected males in the other bowel habit groups also to have done less well, which is clearly not the case. Hypnotic ability was not measured in patients in this study using formal hypnotic susceptibility testing since it is time-consuming and is generally regarded as not being necessarily predictive of how well patients respond in the clinical setting. However, hypnotic susceptibility testing was conducted in a recent controlled trial of hypnotherapy in IBS patients and no association was found between hypnotic ability and response to treatment. Another possibility to be considered is whether males with diarrhoea do in fact represent a somewhat different group of patients with regard to the pathophysiological mechanisms underlying symptoms, which may be less amenable to modification using hypnotherapy. A differential response was also observed in preliminary clinical trials with a 5-HT3 antagonist for use in non-constipated patients which showed that females responded significantly better than males. These
findings suggest that there might be pathophysiological differences between males and females with diarrhoea and therefore
one might speculate that, in some way, this could be the reason for the reduced responsiveness of males with diarrhoea to
hypnotherapy.
In conclusion, this study clearly demonstrates that hypnotherapy remains an extremely effective treatment for IBS, even in
the more challenging environment of a general service from which no referral is excluded from treatment. One new
observation emerging from the data is that hypnotherapy may be less useful in males with diarrhoea-predominant bowel
habit, a finding that warrants further study. Lastly, new, more expensive drugs are likely to come on to the market in the near
future. However, it has been shown that their beneficial effect is lost shortly after cessation of treatment which is in sharp
contrast to hypnotherapy where the symptomatic improvement is longlasting. Thus, hypnotherapy will also become a much
more cost-effective option in the treatment of irritable bowel syndrome.
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