Journal of Gastroenterology, 2002;123:2132-2147 Editorial

The Growing Case for Hypnosis as Adjunctive Therapy for Functional Gastrointestinal Disorders

In 1984, Dr. Whorwell, at al, in Manchester, England, published a small but well designed placebo-controlled trial of hypnosis as a treatment of irritable bowel syndrome (IBS). They randomized 30 patients with severe, refractory IBS to either 7 sessions of hypnotherapy or the same amount of psychotherapy plus placebo pills. The results indicated that hypnosis treatment had specific (nonplacebo) effects that substantially improved the central IBS symptoms of all the patients in that group (who showed far greater improvement than the control group). In a follow-up article, the investigators reported that clinical improvement was maintained in all the hypnotherapy patients during a two year post treatment period.

A dozen other hypnosis studies on IBS, by the same group and by other investigators in several countries have followed this initial trial. The additional studies have largely confirmed the high efficacy of hypnosis in IBS treatment, although the 100% response rate in the first study has generally not been equaled. This body of research has made hypnosis the most investigated psychological treatment of IBS. In that regard, it is rivaled only by cognitive-behavioral therapy, which also shows a high success rate and substantial impact on IBS symptoms in some trials.

Although some of these studies have been small and inadequate in design, hypnotherapy has emerged from the cumulative experience of this work not only as effective in improving the gastrointestinal (GI) symptoms that define IBS but also as a potent way to counter the quality of life impairment, disability, and excess health care costs associated with the disorder. This is most recently shown by the largest systematic assessment to date (250) consecutive patients of the therapeutic impact of this treatment, reported in 2002 by the Manchester group. Based on the more than 50% average reduction in IBS severity, substantial reduction in anxiety and depression, significantly reduced health care costs and improved quality of life noted in this report, and good maintenance of symptom improvement beyond 2 years after treatment, it might be argued that hypnotherapy is more effective than any other single treatment modality for severe IBS.

Also... the present functional dyspepsia hypnotherapy study indicating that this treatment method may be as effective for FD as it is for IBS, it is becoming increasingly hard to ignore the notion that the skills of the hypnotherapies should be made routinely available to patients with functional GI disorders. The evidence consistently argues that wide availability of hypnotherapy would make management of these disorders more effective and would add broad benefits in improved emotional well-being and functional status of these patient groups. It might also produce large savings in cost of care of health care systems because of reduction in medication use and health care visits.

These potential advantages of hypnotherapy as adjunct in the management of IBS and FD raise the question whether it would be possible to implement routine adjunctive hypnosis management in mainstream care for GI disorders. The short answer is that, although feasible, it would, at least in the United States, require overcoming substantial practical and systemic obstacles.

Psychological treatment is currently used only rarely as a therapeutic modality for functional GI patients, offered in less than 10% of all patients in primary care and gastroenterology clinics. Furthermore, this option is probably exercised mostly with patients who either present with significant psychologic symptoms or have not responded to conventional treatment. Many health maintenance organizations dissuade primary care physicians from routinely making outside referrals for psychological treatment of function GI disorders because of the higher up-front cost of such care.

Reimbursement for psychologic treatment of functional GI disorders is furthermore limited or nonexistent in many insurance plans. All of these aspects of the health care system would have to be addressed and corrected to make hypnosis for FD and IBS widely available.

Perhaps an even more serious hindrance to widespread application of hypnotherapy for functional GI disorders is the limited availability of suitably trained and experienced clinicians.. Only a very small proportion of physicians and nursing staff have the training or experience to administer hypnotherapy. Because of time pressures on physicians, such work may be impractical, especially in primary care settings, in which a series of 30 minute sessions with any one patient is likely to seem an unattainable luxury. Close collaborative ties with hypnotherapies do not exist in most medical settings. In the United States, mental health professionals, many of whom have little knowledge of functional GI disorders and therefore are often reluctant to undertake treatment of these disorders, practice much of clinical hypnosis.

Finally, popular perception of hypnosis, which even today carries an unfortunate and erroneous legacy of mystery and coercive influence over people from popular media and stage shows, may make some patients and physicians less receptive to considering this treatment option.

In light of the growing evidence of the value of hypnotherapy in enhancing care for functional GI disorders, it would seem timely to make a concerted effort to examine ways to remove these barriers and facilitate the availability of such treatment; for example, by providing systematic training to health professionals specifically in hypnotherapy for functional GI disorders, integrating hypnotherapy services, and enhancing reimbursement and referral patterns for such treatment.

The Manchester group, the pioneers in the domain of GI hypnosis, represents one model of how hypnotherapy can be effectively integrated with clinical gastroenterology. They have established a unit dedicated to medical hypnotherapy, working hand-in-hand with the gastroenterology service, and using 6 hypnotherapists who treat large numbers of functional GI patients with hypnotherapy.