# 2005 UNC Research Day HT info



## eric (Jul 8, 1999)

2005 UNC Research Day With permission"Pelvic Floor DisordersA. Visco, continued28Hypnotic inductions can vary from dramaticto simple techniques and from lightto deep concentration (trance), dependingon the therapist and patient.Studies on the use of hypnosis for IBS dateback to an article published in Lancetin 1984 which showed that the hypnosistreatment group scored better than a controlgroup (receiving supportive psychotherapyand placebo pills) in mean scoresof weekly pain, distention, bowel habits,and general well-being. A later study in1996 showed post-hypnosis improvementin a variety of symptom scores: overall,abdominal pain, bloating, bowel dissatisfaction, incomplete evacuation, and urgency.Extra-colonic symptoms have also been shown to improve following hypnosis treatment(nausea, backache, dyspareunia, urinary symptoms, and lethargy), as well asquality of life (QoL) scores for psychic and physical wellbeing, mood, locus of control,and work. IBS patients effectively treated through hypnosis have been shown totake less time off from work, are more effective at work, and have fewer GP consultationsfor IBS and other conditions.Dr. Whorwellâ€™s program of hypnosis treatment for FGIDs at the University Hospitalof South Manchester (U.K.) includes six therapists. Using their first 250 patients assubjects, a study by Dr. Whorwell and colleagues in 2002 confirmed improvement inIBS symptom severity scores (overall, pain severity, pain frequency, bloating, bowelhabit dissatisfaction, life interference), extra-colonic features and QoL, as well asanxiety and depression.Studies are also showing the long-term benefits of hypnotherapy -- both total and individualsymptoms scores remain improved for as long as five years post-treatment.Beneficiaries are no longer taking medications for their GI symptoms or they are tak-HypnosisState-of-the-Art: Peter J. Whorwell, MDSenior Lecturer/Professor in Gastroenterology,Univ. Hospital of South Manchester, Manchester, UKHypnotherapy for functional GI disordersPeter Whorwell29Hypnosistaking medications less often, and they are consulting general practitioners less oftenabout their GI or other symptoms. Similarly promising results from hypnotherapyare being reported for functional dyspepsia (FD), as well. In 2002, Whorwellâ€™s teampublished a controlled study that showed changes in FD symptoms were highest forhypnotherapy as compared to conventional treatment and supportive treatment, asmuch as 50-60 weeks post-treatment.The mechanism of action in hypnosis treatment appears to be both psychological(non-specific cognitive change) and physiological (visceral sensitivity, central processing).In a study of cognitive changes, post-hypnosis results showed statisticallysignificant improvements in bowel performance anxiety, pain, control, self-efficacy,anger/frustration, shame, disease conviction, and social approval. Improvementscorrelated with reductions in IBS symptom score, extra colonic symptom score, andanxiety and depression scores.A 1990 study by Whorwellâ€™s team published in Gut tested visceral sensitivity before,during and after hypnotherapy for diarrhea-predominant IBS patients. Sensorythresholds for gas, stool, urgency, and discomfort were tested using fixed volumedistentions. Visceral sensitivity was reduced both during and after hypnotherapy.A more recent study by the same team, using fixed pressure distention (barostat),found that visceral thresholds of hypersensitive patients normalized after a course ofhypnotherapy. Interestingly, the thresholds of patients who were less than normallysensitive to pain in their gut tended to normalize as well (although this finding wasnot statistically significant). Furthermore, improvement in rectal hypersensitivity wascorrelated with IBS symptom improvement.Simren and colleagues have recently measured colonic sensory and motor responsesto duodenal lipid infusion. This is a model for measuring gastrocolonic responseto food. They demonstrated that hypnotherapy resulted in reduced reactivity to lipids.This may be important, because IBS symptoms are often worse after food.The ACC is an important pain processing area in the brain. Painful rectal stimulusactivates the ACC in IBS more than in controls. It has been demonstrated in brain imagingwork that hypnotic suggestion reduces suffering from but not the perceptionof a painfully hot stimulus.In sum, hypnotherapy appears to provide sustained relief of symptoms, modifies motility,modifies visceral sensitivity, improves quality of life, causes patients to haveless time off work and get back to work sooner, leads to fewer GP consultations, andreduces medication needs. It can be very effective and help with all symptoms. It istime-consuming and costly to provide, and there needs to be a back-up strategy forpatients who fail to benefit from hypnotherapy.P. Whorwell, continued30HypnosisUNC: Olafur S. Palsson, PsyDAssociate Professor of Medicine, UNC School of Medicine, Chapel Hill, NCHypnosis treatment for IBS â€" the North Carolina modelThe North Carolina model for hypnosistreatment of IBS was designed in 1994-1995at UNC-Chapel Hill. The protocol is usedverbatim regardless of peopleâ€™s differingrate of response or cognitive style, and is acombination of permissive but directive andformal/experimental style of hypnosis delivery.Elements of the standardized protocolinclude:Imagination-driven physical relaxationDeepening in classic ways with counting,combining imagery with sensoryexperiences of going deeperVivid therapeutic scene (metaphor)imagined in multiple senses that suggestsprotection from disturbance anddiscomfort, feeling comfortable insideTying each visualizing scene to GI-related changesPost-hypnotic suggestions to neutralize catastrophizing and neuroticism, changeattention focus and attention threshold, neutralize triggers, gradually diminishsymptoms, increase comfort and improve health, and changes happening automaticallywithout active effort by the patient.The course of treatment is seven biweekly sessions (about Â½ hour of hypnosis) overapproximately 12 weeks, or one session every other week. The patient receives ahome practice tape after the second treatment session and strong emphasis is placedon regular home practice. Dr. Palsson discussed three hypnosis-related studies heand his colleagues at UNC have published. The aims of the first study were to:evaluate the feasibility of delivering effective hypnosis treatment by using completelystandardized word-for-word scripts, which is highly advantageous to facilitategeneralization of the treatment across settings and therapistsassess the impact on IBS symptoms, psychological well-being and somatizationevaluate the effects on gut pain thresholds and muscle tone to elucidate themechanism of the therapeutic effectexamine whether suggestions to reduce pain sensitivity add to the effectivenessof the treatment.Eighteen adults participated in this study. All had 1+ years of IBS and had been medicallyevaluated. All except one had unsuccessfully tried multiple treatment methodsÂ»Â»Â»Â»Â»Â»Â»Â»Â»Olafur Palsson31Hypnosisrecommended or prescribed by their physicians, such as fiber and medications. Halfthe subjects were randomized to treatment with all pain-specific suggestions omitted,to examine whether this would affect benefit and pain changes. In a secondstudy, the aims were: (1) to replicate the treatment effects of the standardized protocolobserved in the first study on IBS symptoms, somatization and psychologicalwell-being, and (2) to assess the effect of hypnosis treatment on autonomic nervoussystem functioning. Twenty-four patients were enrolled using the same inclusioncriteria as in Study I and all had symptoms that had proven refractory to medicalmanagement. Patients were randomized to two groups: Group A received hypnosistreatment immediately following 2-week baseline and a laboratory test session,while Group B was a waiting-control group.Significant improvement was found after treatment in both studies for all measuredGI symptoms â€" abdominal pain, bloating and bowel consistency. More than 80% ofthe patients responded to hypnosis treatment in both studies. They also improved inscores for somatization, number of psychiatric symptoms, anxiety, and depression.Improvement was well maintained at 4 and 10-month follow-up.Based on the positive results from these studies, Dr. Palsson has concluded that thisbrief fully-standardized treatment protocol benefits about 4 of every 5 patients withmoderate and severe symptoms who are refractory to other treatments, and leads tolasting improvement in all the central symptoms of IBS. The standardized protocoltested in these studies is currently used by over 200 clinicians in the U.S. and at least6 other countries.Dr. Palssonâ€™s third study was an exploratory assessment of hypnosis home treatmentfor IBS. Nineteen IBS patients completed the 3-month hypnosis home treatment viaaudio CD recordings and were evaluated pre-and post- treatment and at 3 and 6-month follow-up. 57 patients were enrolled as controls; they were Rome II IBS patientsfrom a different study, age and gender matched and identical to the hypnosissubjects in mean IBS severity. They completed the same outcome measures as thehypnosis subjects 6 months apart but received only standard medical care. In thisstudy, 53% of the hypnosis subjects were found to be treatment responders (definedas reporting over 50% reduction in their IBS symptom severity score), whereas 26%of the control group receiving standard medical care were responders. Additionally,it was found that home-based hypnosis treatment seems to benefit non-anxious patients(75% of them) more than anxious patients (only 14%).With regard to future directions for research on hypnosis treatment for IBS, Dr. Palssonsuggested: (1) larger, controlled multi-center trial of the standardized protocol intherapist-delivered format, (2) parallel and combined tests with other IBS therapies,(3) randomized field trial of the home-hypnosis version of the protocol in normalclinical settings, and (4) creation and testing of a similar standardized and easilygeneralizable approach to treating IBS or RAP in children.O. Palsson continued32HypnosisUNC: Miranda Van Tilburg, PhDAssistant Professor of Medicine, UNC School of Medicine, Chapel Hill, NCTreating pediatric IBS with guided imageryRecurrent abdominal pain (RAP) is aprevalent condition, affecting 9-25%of school age children, of whom 2/3rdsfulfill criteria for IBS. Standard medicalcare for RAP includes acknowledgmentthat the pain is real, reassurance thatthere is no organic cause for the pain,coping advice, dietary changes, andmedications. This can be effective, butmany patients need additional therapies.Published studies of additional therapieshave shown that cognitive behaviortherapy (CBT) can be an effectivetreatment for RAP, and the combinationof guided imagery and relaxation exercisescan be particularly effective inrelieving abdominal pain in children.Therefore, psychological treatment can be of great benefit to most patients. But, theycan also be expensive, time-consuming, and require highly trained therapists. Asa consequence, they are not available to most patients. One solution is to developgroup therapies. They are cost-efficient and have been proven effective in otherdisorders, but their main drawback is that patients often lack flexibility in adheringto the schedule for group therapy sessions, causing low or diminishing attendancerates. Therefore, another alternative is to develop home-based therapies thatare inexpensive and time efficient. Dr. Olafur Palsson at UNC has developed and iscurrently testing a 3-month self-hypnosis treatment course for adults with IBS usingaudio CDs. Pilot test data have already revealed promising effectiveness.The question is whether self-hypnosis can be effective in children with RAP. The hypothesesfor Dr. Van Tilburgâ€™s on-going pilot study are: (1) self-hypnosis reduces abdominalpain, and (2) live therapies and self-hypnosis are more effective than symptommonitoring and standard medical care. For her study, she is recruiting threegroups of 10 children each, age 7-12 years, assigned as follows: 10 receive hypnosistreatment with a therapist, 10 engage in home-based self-hypnosis, and 10 receivestandard medical care followed by home-based self-hypnosis. Therapy entails threebi-weekly sessions, one booster session, and daily exercises. The outcome variablesto be studied are abdominal pain, psychological distress, functional disability, andquality of life.Miranda Van Tilburg33http://www.med.unc.edu/wrkunits/2depts/med...ay_08-18-05.pdf


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