▸ Gut-directed hypnotherapy results in significant, long-term improvements in symptoms of irritable bowel syndrome.
▸ A group of clinicians in North Carolina has developed a standardized hypnotherapy protocol that physicians can obtain at no cost.
Rationale for Use
Irritable bowel syndrome (IBS) is estimated to afflict about 10%-20% of the U.S. population. In its most severe form, IBS has an impact on quality of life that rivals that of congestive heart failure or recent stroke. Treatment consists largely of advice, reassurance, and symptomatic management with antidiarrheals, antispasmodics, and laxatives–and is notoriously ineffective.
Although the precise cause of IBS remains uncertain, research has shown that a fundamental physiologic component is dysregulation of the bidirectional communication between the enteric nervous system and the brain. This brain-gut axis involves the activity of numerous neurotransmitters and related receptors, including serotonin and the 5-HT3 and 5-HT4 receptors (Med. Sci. Monit. 2004;10:RA125–31).
Moreover, many patients with the disorder also experience anxiety and other psychological symptoms along with their diarrhea, constipation, and pain, and their digestive symptoms sometimes correlate with mental and emotional states. Because of this link with psychological symptoms, researchers for the past 20 years have been investigating ways of harnessing the brain-gut axis to alleviate the condition. One of the most successful approaches has been hypnosis.
The U.K. Experience
For more than 20 years, patients with IBS referred to University Hospitals of South Manchester, England, have been treated with hypnotherapy in a program devised by gastroenterologist Peter J. Whorwell, M.D. His protocol, known as gut-directed hypnotherapy, involves hypnotic deep progressive relaxation and suggestion directed toward control of gut function. Patients are encouraged to use imagery to gain control over their gut activity. For example, a patient with diarrhea might visualize the digestive tract as a rushing river that can be slowed to a calm stream. Pain can be alleviated by applying warmth generated when the patient places a hand on his or her belly.
The Manchester protocol includes 12 sessions over a 3-month period. Patients also are given audiotapes to use at home on a daily basis.
The first small study evaluating the technique randomized 30 patients with severe, refractory IBS to hypnotherapy or psychotherapy. Both groups showed improvements in abdominal pain and distension and well-being. However, the psychotherapy group had no improvement in bowel habits, while the hypnotherapy group experienced “dramatic improvements” in all outcome measures, and no relapses were seen during 3 months of follow-up (Lancet 1984;2:1232–4). In a subsequent report, clinical improvement was maintained in all of the hypnotherapy patients for 2 years (Gut 1987;28:423–5).
The Manchester center later became the first hypnotherapy unit in the British National Health Service dedicated to IBS treatment. Investigators there have continued to follow their patients, and now have reported on long-term outcomes. Among the first 204 patients who completed a course of gut-directed hypnotherapy and responded to a subjective assessment questionnaire, 106 (52%) reported that their symptoms were “very much better” in the immediate posttreatment period, while 39 (19%) were “moderately better” and 32 (16%) were “slightly better” (Gut 2003;52:1623–9).
And the benefits persisted. Among responders who replied to the questionnaire, 81.3% reported that the initial symptomatic improvements were maintained–or even increased further–for periods up to 5 years. Extracolonic symptoms such as anxiety and depression also continued to improve.
The hypnotherapy must be gut specific, according to Dr. Whorwell. “Over the years we have found that the therapy has to be focused on the gut rather than just directed in a more general way,” he said in an interview.
The U.S. Experience
A group of therapists at the University of North Carolina at Chapel Hill has instituted a similar program with equivalent success. They also have investigated the mechanisms by which hypnosis might affect IBS symptoms. In a series of tests, they found that hypnotherapy did not alter rectal pain thresholds or smooth muscle tone, autonomic nervous system activity, or frontalis muscle EMG activity (Dig. Dis. Sci. 2002;47:2605–14). Rather, they suggested that the effects of hypnosis are mediated through reduction in somatization, “primarily by altering the patient's focus of attention and/or by changing his or her beliefs about the meaning of sensations arising from the gastrointestinal tract.”
The North Carolina clinicians also have spearheaded efforts to make hypnotherapy more widely available to patients in the United States, noting that psychological treatments are currently offered to fewer than 10% of patients with functional GI disorders seen in primary care or gastroenterology clinics. They have established a Web site with links listing hypnotherapists and other resources for patients. Clinicians can request by e-mail their protocol package, free of charge, containing verbatim scripts and other materials, at