Original Research

Research: Publications in Peer Reviewed Journals

Gut-directed Hypnotherapy in a Group Format Significantly Reduces Symptoms in Refractory Irritable Bowel Syndrome: Final Report

75 patients with refractory IBS (Rome II), previously medically treated by gastroenterologists, entered a group hypnotherapy program. An established gut directed protocol has been successful in individual treatment, but there are no reports about group treatment. Primary goal was measurement of symptom reduction one year after end of the treatment period. Secondary goal was determining whether variables might predict success or failure of treatment.

METHODS
Severity of symptoms was measured with the IBS symptom severity scale (SS)* before treatment, after the last session and 3, 6 and 12 months thereafter. Predictor variables included the IBS Mind-Body scale (a measure of attribution of symptoms to emotional or physical causes) and the Quality of Relationship Inventory (QRI) with 3 stems (support, depth and conflict). 67 of the 75 subjects (89%) submitted one year SS. The other 8 were distributed from no follow-up (1), post-treatment (2), 3 months (4) and 6 months (1). Their final data points were included in the statistical analysis. Hypnotherapy sessions were 45 minutes every other week for 7 sessions, using a standard protocol, led by a clinical psychologist.

RESULTS
There was a significant decrease in SS at one year, from a mean of 258 to 183 (p<.0001). All components of the SS, abdominal pain, distension, bowel habit and interference in life also improved significantly (p<.0001). Only 14 patients (18.7%) had no improvement. Reduction of >50 points, considered to represent clinical improvement, occurred in 60% of subjects. Table 1 shows the change in clinical status* from pre-treatment to final score. There was a marked shift from severe and moderate, to mild and remission. Variables that correlated significantly with results were the mind score (attribution of symptoms to emotional cause correlated with less improvement in score) (p<.05), the mind/body ratio and the initial SS which correlated directly with improvement (p=.0008).

CONCLUSION
Group hypnotherapy significantly reduces symptom severity in refractory IBS. Reduction was sustained for one year after termination of treatment. Clinical improvement, as represented by a 50 point reduction in SS, occurred in 60% of patients. The results also suggest that the more patients attribute their symptoms to emotional causes, the less responsive they are to hypnotherapy.

TABLE 1: Number of patients in initial and final IBS severity score categories

Categories	Initial Score	Final Score
Remission (<75)	0	11
Mild (75-174)	14	27
Moderate (175-300)	36	28
Severe (>300)	25	9

*Francis CY et al. Aliment Pharmacol Ther 1997;11;395-402

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International IBS and Attachment Study (current)

Introduction & Methods

• Drs. Mary-Joan and Charles Gerson have initiated a ten country study with investigators in Mexico, Nicaragua, Germany, Italy, Israel, Iran, India, China, and Japan.
• The goal is to measure possible associations between IBS symptom severity and attachment style. Attachment, influenced by family relationships in childhood, is described as secure, avoidant or anxious, all of which can have different effects on the experience of chronic illness in adulthood.

Results

• Findings will be evaluated for all patients combined as well as between countries.
• We will also be measuring two possible medicating factors: catastrophizing and beliefs about pain.

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Irritable Bowel Syndrome: An International Study of Symptoms in Eight Countries

Introduction & Methods

• IBS symptoms were compared in eight different geographic locations around the globe: New York, Mexico City, Montreal, London, Bari (Italy), Beersheva (Israel), Kolkata (India) and Beijing (China).

Results

• Significant differences were found between locations in incidence of bloating, abdominal pain, diarrhea, and constipation.
• In Italy and Mexico, patients experienced more bloating and constipation. Patients in Italy had more abdominal pain, and patients in China had more diarrhea.
• IBS symptom differences may be explained by local diet, rural vs. urban residence, intestinal infection, access to medical care, or psycho-social and cultural differences.

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Relationship Between Pain Beliefs, Stress Perception and Symptom Severity in IBS

Introduction & Methods

• While stress is considered an important variable in IBS, little is known about the effects of perceived stress. In psychological treatment of patients with IBS it may be helpful to attempt to reshape these negative illness beliefs.
• Patient questionnaires measured the degree to which a patient viewed various life situations as stressful. Additionally, the questionnaires assessed the belief that the pain will be enduring, that the pain is not understood, and that the pain is due to self-blame.

Results

• IBS patients with more severe symptoms are more likely to hold certain negative pain beliefs.
• For women, the belief that pain will endure was significantly predictive of symptom severity.
• For men, the belief that pain was due to self blame predicted symptom severity.
• In men and women, the greater perceived stress, the more severe the symptoms score. Additionally, the belief that the pain was mysterious was a modestly significant predictor of symptom severity.

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An International Study of Irritable Bowel Syndrome: Family Relationships and Mind-Body Attributions

Introduction & Methods

• Patients in eight countries (US, Mexico, Canada, United Kingdom, Italy, Israel, India and China) filled out a series of questionnaires which examined the degree to which patients attribute their illness to physical and emotional factors. Additionally, quality of family relationships (depth, support, and conflict) were recorded and compared to symptom severity scores.

Results

• The main findings were universal, suggesting that globalization and urbanization were more important variables than local cultural differences, though some geographic differences were noted.
• If patients thought their symptoms were predominantly caused by physical factors (e.g. food allergies or intestinal parasites), symptom severity was worse. If they recognized that IBS symptoms could be caused by emotional factors, symptoms were less severe.
• If family relationships were conflicted, symptom severity was high. If family relationship showed depth and support, severity was low.

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A Collaborative Family-Systemic Approach to Treating Chronic Illness: Irritable Bowel Syndrome as Exemplar

Introduction & Methods

• This study integrated family therapist, physician, family, and patient into a collaborative model to reduce physical symptoms and psychological distress.
• Patients attended a total of five small group sessions. Two focused on medical issues, two on psychological issues, and one on nutritional aspects of IBS; additionally, at-home follow-up tasks were prescribed. All meetings integrated mind and body linkages, and active participation was encouraged.

Results

• Patients often served as impressive resources for each other—sharing stories and advice, offering emotional support and understanding, and helping to relieve the sense of isolation and shame often experienced by IBS patients.
• At three months post-treatment no significant results were seen. One year-post treatment a significant delayed benefit was seen: it is hypothesized that it may take time for mind-body connections to solidify, which then reconfigure responsiveness to urgency and pain.
• A collaborative, balanced focus on psyche and soma, self and other, can result in significant experiential and empirically validated symptomatic relief in patients, as long-term outcome results indicated significant reduction in IBS symptoms.

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A Collaborative Health Care Model for the Treatment of Irritable Bowel Syndrome

Introduction & Methods

• Patients were randomly assigned to 3 treatment groups: collaborative (psychological therapy + medical treatment), medical treatment alone, and psychological therapy alone.
• Collaborative sessions focused on the following: social experience of IBS, personal life history of IBS, onset of symptoms, and current symptom pattern.
• Patients completed a daily diary and questionnaires measuring quality of life, anxiety, depression and relationships. The questionnaires were administered before treatment, after treatment, and three months post-treatment.

Results

• The collaborative treatment group: Global self-assessment improved significantly at long-term follow-up in the collaborative group. Abdominal pain, diarrhea and constipation also improved significantly.
• The psychological treatment group: 50% improvement in global score.
• The medically treated group: No significant improvement.

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Research: Other Publications

Relationships and Irritable Bowel Syndrome

Relationships affect health! When a concerned relative asks a patient if she feels ready to take a long car ride, anxiety may increase and symptoms may worsen. Because of their own frustration, family members may blame an IBS patient for his/her illness, and accuse the patient of eating the wrong foods or being too tense.
      In a research study, we showed that IBS patients with a supportive family have milder symptoms than a patient who experiences conflict in the family. Patients must communicate about problem areas, be specific about what type of support is needed, and explain that it takes time and personal research to understand what helps and hurts symptoms.

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Embodied Experience: The Psychoanalyst and Medical Illness

There exists a challenge of collaboration between psychologists and physicians, and furthermore a challenge to psychoanalysts in working with individuals with medical illness. Physicians think in terms of specific causes to syndromes, whereas psychoanalysts focus on the experience of illness. Patients ultimately want relief from suffering, and often view the psychoanalytic focus on meaning and experience as incidental. However, if psychoanalysts attend empathically to symptomatology, join their patients in curiosity about its ebb and flow, capture its essence metaphorically and locate pain and illness in relationship context, treatment can yield significant relief from distress.

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Irritable Bowel Syndrome: A Cross-Cultural Perspective in Our Research

IBS was originally described predominantly in the United States, Canada and Western Europe. There are now articles documenting the presence of IBS in most countries of the world. Many local factors may influence a mind-body illness such as IBS (e.g. cultural beliefs, psychological differences, family relationship issues, dietary habits, health care delivery systems and level of economic development).

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