# Panic/Anxiety and D



## Guest (Nov 20, 2001)

Hi all, I wonder if we all might discuss the coexistence of anxiety/panic with IBS-D. Does anyone out there find that this is so in their cases? There is nothing worse, for me, then being stricken with D and then being gripped by panic or strong anxiety.


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## bustaphur (May 24, 2001)

For me the two definitely coexist. If I'm having problems with my Panic Disorder, I can count on having diarrhea. Before I started on Paxil, I could count on having an IBS attack followed by anxiety. Now that I'm on the meds (my docter's and I decided that some of it was chemical after 6 years of CBT and a strong genetic factor)I will only have the anxiety following and IBS attack if my stomach feels queasy or if it comes too early in the morning.


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## DonnaP (Sep 7, 2000)

If I felt that I might have a problem and was afraid I wouldn't get to a bathroom in time, I would get extremely anxious, and that exacerbates the problem even further. Since using Mike's tapes I have had a lot of relief from anxiety---Donna


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## eric (Jul 8, 1999)

Wounded Healer, they are learning that the gut and the brain are both operative in IBS. This is a complicated process between the brain in the gut or enteric nervous system and the brain.Here is some info from one if not the most respected Dr studying IBS.The UNC is the top functional disorders research facility in the country. http://www.aboutibs.org/Publications/clinicalIssues.html Pet scan images in of the brain in IBS. http://webpotential.com/uploadpic/ They have known and been studying this now for a while.Here is one on the gut brain that explains this better. http://serendip.brynmawr.edu/biology/b103/...2/partner2.html


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## Coggie (Dec 28, 2000)

Honestly, the only panic attack I get has to do specifically with needing to go.I don't have D just because I'm having a bad day. It's almost always in reaction to suffering from D or worse, getting a D attack in my pants.If I'm starting to think about having to go and seeing nowhere to go, I'll get an attack.


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## knothappy (Jul 31, 1999)

Been there and just keep on being there- All I have to do is think about what if I have to go and there is no bathroom or it is a far distance from where I am and guarenteed I will get a big D attack. What if i #### my pants right here in the store, how will I make it out to the car-now a major panic attack take place. I know it is addictive but I have heard that Xanax taken right when this bull #### starts going through your mind can help some people. I have Xanax, but take it to sleep at night, I am afraid it would make me sleepy and then how will I drive home if I took it at a store or resturant.


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## KarenP36 (May 24, 2001)

These definitely go hand in hand for me! Actually my first panic attack was triggered by an IBS-D "accident". For months I was afraid to leave the house if I was going somewhere where I wasn't "exactly" sure where the bathroom was, even if I didn't feel like any rumbling was going on down there. I did get some counseling though. It didn't help the IBS-D part because they tried digging through my whole life to find the cause of the anxiety. Then the







clicked on, I had seen my father have panic attacks 30 years ago and didn't know what they were. Now I can partly understanding why he was an alcoholic.Anyway, sorry to drift..... I think it's a catch-22, panic triggers the IBS-D, vice versa. Maybe some day I'll try the hypno tapes myself and see if that helps. Unfortunately my first counselor tried hypnotherapy and wasn't very good at it.


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## caca (Jun 10, 2000)

YepAnxiety is my main trigger. And it doesn't have to be a panic attack to start the whole D thing. Just thinking (worrying) about the smallest thing can get me running.


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## Guest (Nov 21, 2001)

Hey wounded healer! I'm right there with you! I had a panic attack related to D once in my boyfriend's car and nearly passed out! It was awful. The main problem I have is with school...see, I'm terribly afraid of public washrooms and at school try finding a bathroom without someone in it. IT's not the cleanliness aspect of the bathroom it's the privacy. I start to panic and I'll lock myself in a stall and cry until everyone is gone. I've tried relaxation techniques, but i think a professional would be better for me to see. There's a book I'm reading out there relating to anxiety called "from panic to power". It's not IBS related, but I've found that some of the suggestions are useful. I also combine my more "positive" thinking with immodium. That seems to snuff out some of the anxiety as well. Hope some of that was helpful for you!


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## D Prone (Sep 10, 2001)

Anxiety is THE trigger for me (ok sometimes I don't even have to be anxious for a D attack to hit). God, if only butterflies in the tummy would just stay put like normal people and not take that trip down south. And I think they are right, it is a catch22, D attacks bring on panic attacks - panic attacks bring on D attacks for me anyway.


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## Guest (Nov 26, 2001)

Defintely....I have had panic disordres since I was about 8 or 9...didnt know that was what it was until I was about 30...Doc prescribed Remeron.....helps with the stomach and defintely no more panic attacks....ask your doc about this drug..also known as mirtazipine.Good Luck


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## Jeanne D (Nov 14, 2001)

wow, its amazing how many people have panic attacks that trigger D . It sure happens to me. If I know a bathroom is nearby I am usually ok, or more relaxed, but it is usually when I am far far away from the bathroom, that I get one.. and I don't know which is worse, the D or the feeling of intense panic. Anyway... it makes things a lot worse. All I need to do is have one episode of D while I am out, and the next time I go to that same place, I worry that I will have another incident, and sure enough, I get stomach pains. I know it is tied into my thoughts also.My family tells me to just " get over it".. yeah sure, easier said than done.Well good luck to all of you..Nice to know we are all out there


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## MALI (Jul 8, 2001)

hello all, i remember well the first time i had a D attack. i was just a kid running from the bombs that where raining down on my hometown in Europe. talk about fright and flight. there is no doubt that the brain rules the gut. of course these days i get stressed out just by christmas shopping and wrestling with the turkey. take care one and all, MALI


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## Guest (Nov 30, 2001)

I'm knew here but it is so great to hear that so many people have the same thing i have. I thought it was just me. I have anxiety about public restrooms too. If anyone is in there, i just cant go, so i get anxiety about that too and it makes it worse. My mom had to get me a key to her house so i could go there when ever i just HAVE to go. Thank you guys for sharing. It makes me feel alot better.


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## orchie (Nov 30, 2001)

Just wondering -- does anyone understand why there is no scientific progress in our arena?


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## angelm0m1 (Sep 2, 2000)

You guys sound so much like me. I just can't use a public restroom. Between the 'noise' and accompanying 'odor', I am so mortified. Of course this causes me to feel panic if I get that first twinge. I also relate to the butterflies in the stomach. Why do they have to travel? Oh, to be normal!


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## Blair (Dec 15, 1998)

I get those panic / anixity attacks if I eat the wrong stuff. There is some kind of link.


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## FedUp2 (Aug 30, 2000)

It always makes me feel just a little bit better knowing I am not alone out there! In the past few years I have developed a huge anxiety to public restrooms! It's not the cleanliness either, it's the privacy! I only want to use a private restroom, where I can sit in peace and have an attack. Not worry about someone beside you listening or smelling what is going on. I actually quit my last job, because there was only one restroom with 2 stalls. I got so sick with anxiety wondering what if I went and someone came in! It makes my heart race just thinking about it. Along with that I didn't make it to my house when I got an attack once. I was five minutes from my house! Now that I know that I sometimes I just can't hold it, this leads to more anxiety. Sometimes I can't relax, because that time I really tried to talk to myself to feel okay, "It's going to be okay, relax, your going to make it" and poof I didn't. I am so scared to take prescription meds, I barely take ibuprofen. I only take imodium. So I totally understand the anxiety from having D, which will then lead to D, or vica-versa. It really is a sick cycle. I just have to add one more thing. My boyfriend and I were talking last night after watching a movie. He said when he was a wrestler in high school all the wrestlers would have D at the same time after taking laxatives to lose weight. They needed someone to talk to, since they would go for a while. I was shocked, I could never go in front of other girls! I can't even think of it. One time I got really sick, and when I was washing my hands, some girl actually looked me up and down and then continued to glare at me! Is she so perfect?


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## KSquared26 (Sep 13, 2000)

Hey hey hey!I totally know what you're talking about -- I have both of those together and it's been HELL! This fall I finally sucked it up after suffering for like 11 years and went to the counseling department at the university I go to. The counseling was worthless ("no, I do not have an eating disorder, and no I am not depressed - I HAVE PANIC ATTACKS!! Arch!!") but they sent me to a shrink who perscribed me a really freakin' low dose of Paxil and it's changed everything! I only seem to explode like every two weeks or so, when I used to get diarrhea that wouldn't go away for days. Plus, the panic attacks have virtually stopped. the stuff is a godsend -- I joke with my friends that the whole country should take this stuff and everyone would be soooooo much happier. I thought it was going to change my personality, but it hasn't at all. Talk to your Dr. about this stuff -- it's wonderful!! Yay! Hope this helps.Katie


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## jo-jo (Aug 19, 2001)

Hi allHave any of you tried St-Johns Wort? It's really good for anxiety.


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## eric (Jul 8, 1999)

orchie, there is a lot of research going on right now and theyhave found new things out.The pet scan images I posted above for one. This is important information in regards to IBS and anxiety.The signals from neurotransmitters in the gut specifically serotonin which is also use for contractions in the gut are turning up the pain and emotional/anxiety centers of the brain. It is very complicated and you don't have to feel overtly stressed for this to be happening. This is where they are at at the moment. http://www.aboutibs.org/Publications/clinicalIssues.html This is some info on serotonin and antidepressant for IBS. http://www.aboutibs.org/Publications/serotonin.html Gut directed Hypnotherapy is very effective for pain in IBS the symptoms, and especially at turning down anxiety from it. It has the highest success rate to date of any treatment for IBS.www.ibshypnosis.com


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## eric (Jul 8, 1999)

FYI here is some excellent info on relaxation and gastro disorders specifally IBS. http://www.med.unc.edu/medicine/fgidc/relax.htm http://www.med.unc.edu/medicine/fgidc/hypnosis.htm


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## eric (Jul 8, 1999)

Another fyi which is very important in all this. http://www.ahealthyme.com/article/primer/101186767


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## Guest (Dec 17, 2001)

Bump


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## Dolphinlady (Nov 5, 1999)

Just jumping in here to let you know you're not alone. I definitely know what you're talking about. I've suffered with the co-existence of panic attacks and IBS for almost 20 years. Early on, it became so bad that I was agoraphobic for awhile. When my life became severely limited, I finally sought the help of a psychotherapist. When I was first diagnosed with panic disorder, I thought I was on the way to getting better. In addition to prescriptions, I learned some coping techniques, like proper breathing, visualization, and eventually started to reintegrate myself into situations that became scary to me. But, I soon realized that the real culprit was the IBS and it was the major trigger of my panic attacks. I've been on anti-depressants for years and take Xanas "as needed," and I hardly ever get panic attacks anymore. That may be due, however, to the fact that I avoid situations where I think I'm going to feel "trapped" and not be able to find a bathroom quickly or where there's a lot of people.The IBS is another story. I still have bad flare-ups for months on end, then it seems to subside for awhile. If I am going through a bad spell, I won't go to crowded places or ride in a car with anyone. That's when I start to panic and inevitably the "D" attack starts. I think if I could get the IBS under control, I'll be homefree.I think it's time for me to break down and try those hypnotherapy tapes from Mike . . .One good book about panic disorder is "Hope and Help for Your Nerves" by Claire Weekes. This is an older book, but I think it addresses all the major issues of panic attacks and it really helps to validate what you're experiencing. I know there are many others out there, but I haven't read them.Good luck and let us know how you're coming along. Feel free to e-mail me if you ever want to talk about it.


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## ibsjw78 (Dec 16, 2001)

I am with all of you. When I was 13, I had an "accident" at my friends house. It was obviously a very embarassing and tramatic experience for a little 7th grader. From that time on, that is when I developed IBS-D. Now that I look back, I see that this anxiety triggered my condition. Yes--I had always had a sensitive stomach and D every once in awhile--but it was never a condition that effected my life. Because this terrible experience (and others that I have had in the past 10years, I'm 23)I have a fear that I am going to have an accident, or have to go and be embarassed, that this fear is the reason I have to go so much (make sense?).Generally, I can eat whatever I want to--if I stay at home, but when I eat away from home, that is when I get nervous, which in turn makes me have to go the bathroom. Half the time, I don't even have to go, I just feel like I might have to go--which makes me have to go worse--IT IS A TERRIBLE CYCLE.And I have noticed, the times in my life that my IBS-D has "subdued" has been when I am active, and busy, and very happy...and don't have time to think about the ****s.Also--if I go out to eat, if I have a couple beers before my meal, I am normally ok. It is like the beer/slight buzz, calms me down, and then I am fine. Just thought I would through this all out for you.By the way..."Hi" I am new to the board...my 2nd post


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## tylersmommi (Dec 3, 2001)

coggie, isnt that....funny/rediculous? when you go somewhere and dont see any bathrooms, thats when you have to go. i barely leave my house anymore because i am sooooooo scared of having an accident...also i rarely use public bathrooms, and i never use them to go #2...so i get paranoid wehen i go out. is anyone else like this?


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## eric (Jul 8, 1999)

FYI for IBSwww.ibshypnosis.com http://www.ibshypnosis.com/IBSresearch.html http://www.med.unc.edu/medicine/fgidc/relax.htm http://www.med.unc.edu/medicine/fgidc/hypnosis.htm http://www.firstyearibs.com/day7learnlive2.html www.ibsaudioprogram.com


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## Lesley Taylor (Dec 22, 2001)

Sometimes worrying about needing a toilet can lead to needing the toilet! Ain't that the truth! It becomes a self-fulfilling prophecy. I try to keep to familiar places where I know where the bathrooms are (just in case) and if I feel myself getting anxious I try to slow myself down (breathing, thinking about something else). It is a total drag though to have to analyze your bowel status every time you leave the house!! Don't I know it!!! Cheers!


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## Guest (Dec 23, 2001)

It is nice to know others are struggling as well. I was so embarassed the first time I had an accident - it was close to my house and made it back to my house but how horrible.I had a holiday ball the other nite and had to get up 3 times while someone was speaking, I was embarassed there too! I have read alot of the discussion and I will follow the advice of some! This is very helpful.


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## Blueroses (Dec 23, 2001)

This is my first message. I began having panic and anxiety attacks many years ago when I first experienced chronic IBS symptoms. There is definitely a mind/intestine link! The anxiety can be overwhelming and can make one feel hopeless. Just getting through the commute to work in the morning is almost more than I can do. I make it, sometimes with stops at fast food places. I make it late, but I make it. But it takes an emotional toll. I'm taking an anti-anxiety drug, which helps, and I use Bentyl and Imodium when needed. I just began taking Caltrate today. I am trying psychotherapy. This self-help group has helped me more than I can say. Thanks to all who share.


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## sue660 (Dec 8, 2001)

I suffered my first panic attack when I was 4 years old. I am still wondering which came first, the panic attacks or the IBS.I have found that stress or panic attacks cause IBS-D for me. I have developed a phobia of D, which ofcourse makes it even worse. I am now having counselling AGAIN for panic attacks and anxiety.Like most of you, I am afraid to leave the house in case I have a D attack. As long as I have a toilet in sight, I am usually ok.


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## eric (Jul 8, 1999)

Why, don't the people doing therapy post to the anxiety forum there experiences to help others perhaps?This is important and partly to dolphin lady who is thinking about Mike's tapes or actually anyone for that matter.Mike's gut specific hypnotherapy addresses pain and anxiety and the symptoms of IBS and he is an expert on it.But this is important, however very complicated.Special Report: Revisiting IBS: Perspectives for the New Millennium http://www.gastroendonews.com/specreps/gen0106/0106.html "Revisiting IBS: Perspectives for the New Millennium Introduction Irritable bowel syndrome (IBS) is one of the most common gastrointestinal disorders seen in specialty and primary care practice, yet only recently has it attracted the attention of investigators and clinicians in GI and primary care. That was the message of Douglas A. Drossman, MD, professor of medicine and psychiatry, University of North Carolina (UNC) at Chapel Hill School of Medicine and co-director of the UNC Center for Functional GI and Motility Disorders. Dr. Drossman introduced 3 experts presenting the latest findings in IBS research at the 65th annual scientific meeting of the American College of Gastroenterology in New York City. These speakers discussed the following concepts: the use of brain imaging techniques to understand how patients with IBS may be more sensitive to gut stimuli; the theory that, in some cases, an acute outbreak of gastroenteritis may lead to long-term chronic IBS; and the latest treatment options clinicians can prescribe to treat IBS and the abdominal pain and discomfort that are associated with the syndrome. The following Special Report will discuss these topics. Brain Imaging: CNS Abnormalities in IBS Patients Traditionally, researchers studying the pathophysiology of IBSï¿½a condition characterized by a combination of abdominal pain and discomfort and altered bowel habitsï¿½have relied on measurement of gut function and the subjective responses of patients to given stimuli, according to Emeran A. Mayer, MD, professor of medicine and physiology at the UCLA School of Medicine and director of the UCLA/CURE Neuroenteric Disease Program, Los Angeles. However, researchers have turned to functional brain imaging techniques, including evoked potential recordings, positron emission tomography, andï¿½most recentlyï¿½functional magnetic resonance imaging, to assess activation of brain regions during visceral stimulation, in terms of increased brain activity or regional blood flow. These innovative methods have begun to demonstrate alterations in brain function in IBS patients that may help explain enhanced perception of gut stimuli. Dr. Mayer discussed the visceral hypersensitivity noted in IBS patients, including affective processing of visceral sensations, and therefore decreased discomfort thresholds/tolerance; altered arousal or hypervigilance, leading to generalized hyperresponsiveness to sensory stimuli; increased threat appraisal of and attention to visceral sensations; and stress-induced visceral hyperalgesia. The circuitry of brainï¿½gut reactions that control patients' responses to stressors is found within the "emotional motor system," said Dr. Mayer. The output of this circuitry in response to stressors or emotional experiences can be measured "in terms of autonomic, pain-modulatory, and neuroendocrine responses. Furthermore, it is modulated by a variety of factors such as belief systems, thoughts, and emotions; all play significant roles in modulating response. What is important, though, is that the output can pretty much explain the characteristic IBS symptoms." Autonomic regulation affects not only the muscle cells in the gut, but other cell types, including mast cells, enterochromaffin cells, and the intrinsic neurons of the enteric nervous system. "Therefore," Dr. Mayer explained, "the autonomic nervous system, by stimulating the release of substances from these cells, can change the sensitivity of the gut to a variety of gut stimuli or internal stressors." A recent breakthrough is the discovery that "in response to stressors, this system makes the gut more sensitive," a process referred to as stress-induced visceral hyperalgesia. "Many of you may have experienced that when you go to give a presentation, you may suddenly experience the urge to go to the toilet," Dr. Mayer explained. "It's not that you have a full bladder; it's that the anxiety over the imminent presentation causes the sensory pathways from the bladder to the brain [to be] more sensitive. What's attractive about this concept is that psychosocial stressors arising in the external environment and/or physical stressors arising from within the body, such as gut inflammation, can result in activation of the emotional motor system." Thus, hyperresponsiveness of these stress circuits in the brain might result in altered responses to the internal stresses associated with inflammation and external stressors. Dr. Mayer listed the evidence for different types of visceral hypersensitivity, including lowered discomfort threshold and decreased tolerance to balloon distention of the colon. According to Dr. Mayer, IBS patients show, along with a hyperresponsiveness to stimuli, "a tendency of increased threat appraisal of certain visceral sensations, something of an old-fashioned concept that's coming back in vogue. It's quite well known that patients with a variety of functional disorders feel more threatened by sensory experiences coming from different parts of the body." If one refers to evidence from studies that "measure the impact of intense, repetitive sigmoid colon distention [a 'visceral stressor'] on the perception of the discomfort threshold for rectal distention," Dr. Mayer said, one can see that "following this intervention, only in IBS patients was there a characteristic lowering of the rectal discomfort threshold into the range of hyperalgesia, whereas there was no threshold reduction in healthy control subjects or in those with mildly reactive ulcerative colitis." There are additional examples from other laboratories using psychosocial stressors as well. "The studies that I summarized briefly all have relied on subjective symptoms of perceptional stimuli in response to stimulation of the periphery," said Dr. Mayer. "But ultimately, this is not a very accurate way of assessing what's going on within the 'black box' of the brain. The optimum way would be to measure directly at the brain level, something that is no longer dependent on the subjective reporting of the patient." In the brain, there are "serial and parallel processing of different aspects of visceral sensory information," said Dr. Mayer. Input from the gut enters through multiple channels, and partially overlapping central circuits process the perceptual experience of gut sensations, with both autonomic pain modulatory responses. When sensory signals reach the brain, the input is measured and encoded, and includes the primary appraisal of threat and feelings of unpleasantness the individual experiences in response to the particular stimulus. In addition, parallel processing via modulatory pathways involving stress-activated systems can either up- or downregulate any of the modulatory systems. Previous experience and memory also strongly influence the perception of visceral stimulation, which again can modulate information processing. There are two different regions in the brain that encode the objective intensity of the stimuli, Dr. Mayer continued. Subjective perceptions are modulated by the attentional state of the individual, and by memories of past similar events, which influence the subjective interpretation of the unpleasantness of the experience. Dr. Mayer first explained the intensity-coding process. "The simplest aspect of this information," he said, "comes up through the spinal cord and is encoded in an area of the brain called the insula, which is the visceral sensory cortex." The insula is the part of the brain that most objectively encodes information from the periphery. "Currently, there's no evidence in this region of a difference between IBS patients and control patients, although the evidence is scarce and further studies are needed," noted Dr. Mayer. The second aspect of pain modulation within the brainï¿½"which may be more important in IBS," according to Dr. Mayerï¿½is the affective appraisal of the sensory information that reaches the insula, which happens at the level of the anterior cingulate cortex. In a study by Montreal researchers (Science 1997;277:968-971), the unpleasantness ratings of the stimulus were modulated by hypnotizing subjects. The subjective experience of unpleasantness was either increased or decreased in response to a given somatic stimulus. "The anterior cingulate cortex was the one region of the brain that showed a close correlation toward multiple changes of the subjective unpleasant rating," Dr. Mayer said. In other studies, this region showed decreased blood flow when subjects were treated with opioids. Given the altered affective stimulus processing for IBS patients, what is the relevance for clinical practitioners? Among the most common complaints of IBS patients, as reported by physicians, are heartburn, bloating of the lower GI tract, sensation of fullness, incomplete rectal evacuation, and abdominal pain, explained Dr. Mayer. "The amplification of the unpleasantness of these experiencesï¿½which in the healthy individual is not even consciously perceived once they reach the brainï¿½is one way to explain this range of symptoms," he said. "A more complex and higher-level interpretation of the sensory experience is a modulation based on memory and past experiences." Here, a different area of the brain comes into play; sensory association areas in the parietal cortex, which have connections to the main memory centers within the brain and also to the prefrontal cortex. "By putting together results from a large number of somatic pain studies, this conclusion was reached: This network of recalling past memories of similar events and interpreting these past memories in the cortex plays a major role in the threat appraisal that IBS patients perform on the sensory experience." According to Dr. Mayer, this altered threat appraisal in IBS patients leads them to make statements such as: "I am afraid not to be close enough to a bathroom"; "I am afraid that anything I eat may trigger my abdominal pain"; "I am afraid I will be uncomfortable all day if I don't have a bowel movement in the morning"; and "When my belly hurts, I am afraid I may have cancer." "All of these statements are based on beliefs and memory of past events that are recalled any time the patient gets into a similar situation or feels anxious," noted Dr. Mayer. "This recall is modulated by the prefrontal cortex when the sensory experience [is processed]." Another relevant modulatory factor is related to the stress response, specifically to activation of the locus caeruleus, a tiny nucleus within the brain stem that potentially threatening experiences activate. "One unique feature of that nucleus is that it projects to virtually all the regions of the brain that also receive visceral input," said Dr. Mayer. "These projections secrete norepinephrine, and a low or moderate amount of norepinephrine release would activate these regions, increasing arousal. But if norepinephrine release is excessive, it may have the opposite effect and inhibit these target areas." The enhanced arousal process regulated by the locus caeruleus is common not only in IBS, but in clinical conditions frequently overlapping with IBS, such as anxiety, panic disorder, and post-traumatic stress syndrome. Thus, "there may be a common link between these disorders, even though the symptoms are very different," he said. Arousal is reduced, as shown in animal models, by sedatives, anxiolytics, and low-dose tricyclics, Dr. Mayer continued. He suggested that this may be the reason why low-dose tricyclics, among other medications, are helpful in treating some IBS symptoms. A subgroup of patients with IBS may respond positively to relaxation therapy and exercise. The evolving knowledge of altered central nervous system (CNS) responses in IBS patients could provide a basis for more rational therapies, concluded Dr. Mayer. Altered processing of visceral sensations in brain regions such as the anterior cingulate cortex is currently the most convincing abnormality in IBS patients, he said. "By changing the visceral input to that region of the brain, it certainly would decrease the unpleasantness of the experience," he explained, "and there may be a model whereby peripherally acting compounds such as serotonin [5-HT] receptorï¿½modulating drugs may decrease some of the pain." As for the problem of altered arousal, or hypervigilance, Dr. Mayer said that possible treatments could include novel anxiolytics. He added that further research is needed to see what, if any, effect the 5-HT3 receptor antagonists or substance P antagonists would have. When considering the increased threat appraisal of visceral sensations and for inappropriate beliefs about the disorder in IBS patients, Dr. Mayer suggested the possibility of treatment, "not so much with medications, but with cognitive behavioral therapies that will change the response to situations or patient recall of inappropriate memories of similar situations." Stress-induced visceral hyperalgesia may respond well to stress management and relaxation techniques in a subset of IBS patients, but new interventions aimed at reducing altered CNS responses are clearly needed."I am re- highlighting this"According to Dr. Mayer, this altered threat appraisal in IBS patients leads them to make statements such as: "I am afraid not to be close enough to a bathroom"; "I am afraid that anything I eat may trigger my abdominal pain"; "I am afraid I will be uncomfortable all day if I don't have a bowel movement in the morning"; and "When my belly hurts, I am afraid I may have cancer." "All of these statements are based on beliefs and memory of past events that are recalled any time the patient gets into a similar situation or feels anxious," noted Dr. Mayer. "This recall is modulated by the prefrontal cortex when the sensory experience [is processed]." Another relevant modulatory factor is related to the stress response, specifically to activation of the locus caeruleus, a tiny nucleus within the brain stem that potentially threatening experiences activate. "One unique feature of that nucleus is that it projects to virtually all the regions of the brain that also receive visceral input," said Dr. Mayer. "These projections secrete norepinephrine, and a low or moderate amount of norepinephrine release would activate these regions, increasing arousal. But if norepinephrine release is excessive, it may have the opposite effect and inhibit these target areas." The enhanced arousal process regulated by the locus caeruleus is common not only in IBS, but in clinical conditions frequently overlapping with IBS, such as anxiety, panic disorder, and post-traumatic stress syndrome. Thus, "there may be a common link between these disorders, even though the symptoms are very different," he said. Arousal is reduced, as shown in animal models, by sedatives, anxiolytics, and low-dose tricyclics, Dr. Mayer continued. He suggested that this may be the reason why low-dose tricyclics, among other medications, are helpful in treating some IBS symptoms. A subgroup of patients with IBS may respond positively to relaxation therapy and exercise."This is showing how thoughts and emotions can trigger sympotms. It is a lot more commplicated then this even, but HT directly targets the same areas in the brain that IBS symptoms are generated by, in the ACC (Anterior Cingular Cortex) to the ENS (enteric Nervous system and back.It does more then that however.It is the only relaxation technique that works this way on IBS, unlike meditation, yoga, etc., which are not gut specific therapies and although they are very helpful, they work differently.


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## eric (Jul 8, 1999)

With permisson from a top IBS researcher.The Effects of Hypnosis On Gastrointestinal Problems Olafur S. Palsson, Psy. D. Research Associate, UNC-CHAPEL Hill Department of Medicines Hypnosis is a treatment method, which still carries an aura of mystery,that unfortunately continues to be promoted by misrepresentations in movies and stage shows for entertainment. In reality, there is little mysterious about hypnosis anymore. It is a well-researched clinical technique which was formally accepted as a treatment method by the American Medical Association and the American psychological Association over thirty years ago. Clinical hypnosis is currently used by thousands of clinicians in the U.S. to treat both psychological and medical problems. Until recently, the possibilities of using hypnosis to treat gastrointestinal problems had received little attention. In the last 15 years, however, research has shown that hypnosis can influence gastrointestinal functioning in powerful ways, and that in particular, it is effective in helping patients with irritable bowel syndrome and to control nausea and vomiting. How Hypnosis Works: Hypnosis is a special mental state in which a person's focus of attention becomes narrow and intense like the beam of a bright flashlight in a dark room. This state is usually created with the aid of a hypnotist,who guides the person systematically to relax, focus only on one thing, and to allow things to happen by themselves. Whatever the mind focuses on while in this special mental state of hypnosis holds the entire attention. Therefore, people tend to experience things they think of, imagine or remember, more vividly and clearly than under usual circumstances. This is why people can sometimes recall things from their distant past under hypnosis even though unable to do so in the normal waking state (research has shown, however, that such hypnotically enhanced recall can be highly contaminated by the person's imagination). The narrow hyperfocus of this mental state is also why therapists using hypnosis are frequently able to help people make strong positive changes in their emotions and physical functioning. Hypnosis can work like a magnifying glass on the mind's effects on the body and emotion. Clinical hypnosis relies on suggestions, imagery, and relaxation to produce its therapeutic effects. Hypnotic suggestions are things that the hypnotist verbally suggests may happen while the person is under hypnosis. Due to the focused and receptive state of the hypnotized person, these suggestions happen almost automatically and without conscious decision or effort. If you, for example, receive the suggestion under hypnosis that your arm may be getting heavy, you will very likely feel it becoming heavy, without trying to do anything to make it happen. This "automaticity", the feeling of things happening by themselves, is by some considered the hallmark of hypnosis, and is often surprising to people experiencing hypnosis for the first time. Hypnotic imagery consists of picturing mentally events or situation or place in a way that has a desired positive physical or mental effect. For example, patients undergoing surgical or dental procedures are sometimes taught to enter a hypnotic state and go to a pleasant place in their mind. When successfully applied, the person gets completely engrossed in the vivid enjoyable imagery and is therefore happily unaware of the unpleasantness of the procedure. The hypnotic state is naturally accompanied by relaxation, and the physical relaxing effects are often deliberately strengthened further by clinicians through suggestions and relaxing imagery. Some of the benefits that come from hypnosis treatment are likely to result partly or entirely from the fact that hypnosis is a powerful relaxation method. Over decades of research and clinical experience, hypnosis has proven to have many valuable therapeutic uses. In psychotherapy, hypnotic techniques can speed the therapy process in various ways - for example by facilitating patients' self-understanding, extinguishing unfortunate habits, uncovering repressed or forgotten memories, reducing anxiety and phobias, and helping people to adopt a new and more adaptive outlook. In medicine and health psychology, hypnosis is used to reduce pain and discomfort associated with medical procedures such as childbirth, treatment of burns, and surgery where chemical anesthesia cannot be used effectively. It is also used to treat chronic pain and psychosomatic problems and counter unhealthy habits that contribute to illness. In dentistry, hypnotic analgesia is an effective needle-less alternative to topical anesthetic drugs, reduces bleeding and discomfort in oral surgery, and is used to treat teeth grinding and temporomandibular disorder. In recent years, the effects of gastrointestinal functioning and GI symptoms have been studied extensively. The Effects of Hypnosis on Gastrointestinal Functioning: The hypnotic state itself, without any particular suggestions, seems to slow down the gut, and clear-cut and specific changes in GI functioning can be induced in individuals by directing thinking or inducing specific emotional states under hypnosis. For example, one study(1) found that when healthy volunteers were hypnotized and simply instructed to relax, the orocaecal transit time (the time it takes material to pass through the GI tract from the mouth to the first part of the colon) was lengthened from 93 to 133 minutes. Another study(2) found that being in a hypnotic state decreases muscle movements in the stomach. The same study demonstrated that the emotional state of happiness, created under hypnosis, suppresses gastric muscle activity but anger and excitement increase muscle movement in the stomach . A pair of other studies(3) showed that when volunteers were guided to use imagery of eating a delicious meal while they were under hypnosis, gastric acid secretion was increased by 89%, and that acid production of the stomach could also be deliberately decreased during hypnosis using hypnotic instructions. Close to fifty published studies have reported on the therapeutic effects of hypnosis on nausea and vomiting problems related to chemotherapy, after surgery, and during pregnancy. Overall, this substantial body of literature indicates that hypnosis can be a powerful aid in controlling nausea and vomiting. Hypnosis may also be helpful in preventing gastrointestinal problems from recurring after they have been treated with medication: One study(4) of thirty patients with relapsing duodenal ulcers who had been successfully treated with a course of medication, found that only 53% of the patients who received preventive hypnosis treatment had a relapse within one year. In contrast everybody (100%) in a comparison group receiving no hypnosis relapsed in the same period of time. In 1984, researchers in Manchester in England published a study(5 )report in the journal Lancet, showing that hypnosis treatment dramatically improved the symptoms of IBS patients who had failed to benefit from other treatment. The researchers had randomly divided patients with severe IBS problems into two groups. Fifteen patients were treated with seven hypnosis sessions. Fifteen comparison patients were treated with seven sessions of psychotherapy, and those patients also received placebo pills (pills with no medically active ingredients) which they were told were a new research medication for IBS symptoms. Every patient in the hypnosis group improved, and that group showed substantial improvement in all central symptoms of IBS. The control group showed only very modest improvement in symptoms. Partly due to these dramatic results with treatment-refractory patients, a dozen other studies have followed, including three U.S. studies. The general conclusions from most of these studies are that hypnosis seems to improve the symptoms of 80% or more of all treated patients who have well-defined "classic" IBS problems, especially if they do not have complicating factors such as psychiatric disorders. The improvement is in many cases maintained at least for a year after the end of treatment. What is particularly remarkable is that this high rate of positive treatment response is seen even in studies where the participating patients all have failed to improve from regular medical care. The dramatic response of IBS patients to hypnosis treatment raises the question of exactly how this kind of treatment influences the symptoms in such a beneficial way. Four studies to date, two in England and two in the U.S., have tried to discover how hypnosis treatment affects the body of IBS patients. Since it is well known that many people with IBS have unusual pain sensitivity in their intestines, which is thought to be related to the clinical pain they experience, much of the focus of these studies has been on assessing the impact of this kind of treatment on intestinal pain thresholds. The two English studies both measured intestinal pain sensitivity with balloon inflation tests. The second study also measured muscle tone, to see if hypnosis relaxes the smooth muscles of the GI tract. No overall changes in pain sensitivity were detected, and gut muscle tension was also unchanged after treatment (except a subgroup of unusually pain-sensitive patients had lessened pain sensitivity in the second study(7). . In 1995-1996, during my post-doctoral fellowship in the Division of Digestive Diseases and Nutrition at UNC-Chapel Hill, we conducted the first U.S. study(8) on hypnosis for IBS under the direction of Dr. Whitehead. We evaluated the effects of a highly standardized treatment protocol, delivered verbatim following written scripts, on rectal pain thresholds and muscle tone. Seventeen out of the 18 patients we treated with hypnosis showed significant improvement in their clinical symptoms. However, we found, like the English researchers, that gut pain thresholds and muscle tension were unchanged after treatment. In a second study(9,) which I conducted with co-investigators at the Eastern Virginia Medical School, we used the same treatment protocol but this time measured autonomic nervous system functioning and blood levels of a gut hormone called vasoactive intestinal peptide. These are regulators of GI functioning in the human body, and the aim was to see if they would change due to treatment. Again, we found no changes in our physical measures after treatment (with the exception of reduction in sweat gland reactivity) even though 21 out of 24 treated patients were clinically improved. It should be noted, though, that in both our studies, we found clear improvement in the psychological well-being of our patients after treatment. In summary, it is clear from our work and other research that hypnosis treatment substantially improves all the central symptoms of IBS in the majority of patients who receive such treatment (see the effects of our two studies on clinical symptoms in the Figure). What happens in the body of these patients to cause such improvement, however, remains a mystery. Future prospects: In light of the many studies which have shown hypnosis treatment to be effective for such problems as IBS and nausea and vomiting, the question may be raised why this kind of treatment is not more widely available or generally offered to patients with such GI problems. One limitation is the fact that not everybody is equally hypnotizable. Research has consistently shown that at least 15% of people are practically non-hypnotizable, and even those who are able to enter a hypnotic state vary greatly in how well they respond. Interestingly, the ability to be hypnotized is a stable mental trait. In other word, if you are highly hypnotizable now, you will most likely be so also in thirty years. Fortunately, the majority of people are sufficiently hypnotizable to have a potential for enjoying at least some of the medical and psychological benefits of clinical hypnosis. Furthermore, the idea of being hypnotized does not agree with all people. Even individuals who are sufficiently hypnotizable, may not like the idea of "letting go", may have difficulty trusting a therapist to guide them in hypnosis, or may have other concerns about the hypnosis experience. Fortunately, other forms of psychological treatment for gastrointestinal problems - in the case of IBS especially cognitive-behavioral therapy -- have also been found to be effective and are good alternatives. Finally, an obstacle which has barred many patients from receiving help for gastrointestinal disorders with hypnosis is the fact that in the U.S. the technique is more commonly used by psychologists and other mental health professionals than by physicians. Many mental health professionals who use hypnosis are not accustomed to treating gastrointestinal disorders, and therefore reluctant to take on treatment of such problems. As the reliably beneficial effects of hypnosis on gastrointestinal functioning become better known both to health professionals and the general public, this benign and comfortable form of treatment will hopefully become a more popular treatment option for GI patients - especially for those who have not received much relief from standard medical management. As far as IBS is concerned, we have been making an effort in the last two years to encourage clinicians across the country who have adequate training in hypnosis to provide such treatment for IBS. We have done this by providing them, free of charge, with the complete standardized treatment protocol which has proven effective in our research. To date, more than eighty licensed health professionals, practicing in almost all states, are started using our protocol, making it a little bit easier for patients in many geographical locations to receive help with hypnosis. References 1. Beaugerie, L., Burger A.J, Cadranel J.F, Lamy, P., Gendre J.P., & Le Quintrec, F. (1991). Modulation of orocaecal transit time by hypnosis. Gut, 32, 393-394. 2. Whorwell PJ; Houghton LA; Taylor EE; Maxton DG. Physiological effects of emotion: assessment via hypnosis. (1992). Lancet, 340, 69-72 3. Klein K.B., & Spiegel, D. (1989). Modulation of gastric acid secretion by hypnosis. Gastroenterology, 96, 1383-1387. 4. Colgan, S. M. , Faragher, E. B. , & Whorwell, P. J. (1988). Controlled Trial of Hypnotherapy in Relapse Prevention of Duodenal Ulceration. The Lancet, 1(8598), 1299-300. 5. Whorwell, P.J., Prior, A., & Faragher, E.B. (1984). Controlled trial of hypnotherapy in the treatment of severe refractory irritable bowel syndrome. Lancet, 2, 1232-1234. 6. Prior A., Colgan, S.M., Whorwell P.J. (1990). Changes in rectal sensitivity after hypnotherapy in patients with irritable bowel syndrome. Gut, 31, 896-898. 7. Houghton, L.A., Larder, S., Lee, R., Gonsalkorale, W.M., Whelan, V, Randles, J., Cooper, P., Cruikshanks, P., Miller, V., & Whorwell, P.J. (1999) Gut focused hypnotherapy normalises rectal hypersensitivity in patients with irritable bowel syndrome (IBS). Gastroenterology,116: A1009. 8. Palsson, O.S., Burnett, C.K., Meyer, K., and Whitehead, W.E. (1997). Hypnosis treatment for irritable bowel syndrome. Effects on symptoms, pain threshold and muscle tone. Gastroenterology, 112, A803. 9.Palsson, O.S., Turner, M.J., & Johnson, D.A. (2000). Hypnotherapy for irritable bowel syndrome: Symptom improvement and autonomic nervous system effects. Gastroenterology, 118,(4) A174.


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## eric (Jul 8, 1999)

FYI More from top IBS researchers.Using Relaxation in Coping with Functional Gastrointestinal Disorders http://www.med.unc.edu/medicine/fgidc/relax.htm


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