Marc I. Oster, Psy.D., ABPH American School of Professional Psychology at Argosy University Schaumburg Campus 999 Plaza Drive, Suite 111 Schaumburg, IL (847)

The Use of Hypnosis in the Treatment of Digestion and Elimination Problems Loyola University Medical Center Maywood, IL April 24, 2009

1.To describe a model for the development of psychophysical disorders. 2.To describe how the term “success” can be used to minimize failure experiences in treatment. 3

Types of Evidence Validation Questions ________________________________________________________________________________  Experimental evidence Is the practice efficacious when examined experimentally?  Clinical (practice) evidence Is the practice effective when applied clinically?  Safety evidence Is the practice safe?  Comparative evidence Is it the best practice for the problem?  Summary evidence Is the practice known and evaluated?  Rational evidence Is the practice rational, progressing, and contributing to medical and scientific understanding?  Demand evidence Do consumers and practitioners want the practice?  Satisfaction evidence Is it meeting the expectations of patients and practitioners?  Cost evidence Is the practice inexpensive to operate and cost-effective? Is it provided by payers?  Meaning evidence Is the practice the right one for the individual? 4

1. Hypnotic ability: both high and low 2. Habitual Catastrophic Thinking 3. Habitual Neuroticism - Sympathetic Reactivity/Negative Affectivity 4. Major Life Changes and/or Daily Hassles 5. Social Support Systems and Coping Skills Wickram divides the five factors as follows: Predisposers (1-3) Triggers (4) Buffers (5)______ Hypnotic Ability Major Life Events Support Systems Catastrophizing Daily Hassles Coping Skills Sympathetic Reactivity  Wickramasekera, I. (1987). Risk factors leading to chronic stress-related symptoms. Advances. Institute for the Advancement of Health, 4(1),  Wickramasekera, I. (1998). Secrets kept from the mind but not the body or behavior: the unsolved problems of identifying and treating somatization and psychophysical disease. Advances in Mind-Body Medicine, 14,

 Symptom reduction or management  Habit alteration/change  Increase awareness  Enhance treatment compliance  Improve medication utilization  Exploration  Ego strengthening * From Weisberg & Clavel (2008) ASCH.

 Language Meaning is in the ear of the beholder

93% message is in something other than words  38% Inflection  55% Gestures  7% Words Phil & Norma Barretta

 Patient-centered  Ego-strengthening  Positive  Empathetic  Suggests change

AVOID  Burning  Stinging  Painful  Hurts  Bad  Awful  USE  Warm  Tingly  Sore  Scratchy  Soft  Gently  Easily  Quickly  Nicely

Understanding and Treating Irritable Bowel Syndrome And Encopresis

 Irritable Bowel Syndrome or IBS is a functional gastrointestinal disorder characterized by abdominal pain, bowel function abnormalities in frequency and consistency, and sometimes bloating or abdominal distention. 12

 IBS affects 9-20% of the population.  IBS is twice as common in women, representing about 75-80% of all IBS seen in practice.  IBS accounts for 3 million doctors visits a year.  IBS represents 25-50% of all visits to gastroenterologists. 13

 IBS prevalence as high as 20%  Diabetes about 3%  Asthma about 4%  Heart disease about 8%  Hypertension about 11% 14

 At lease 3 months of continuous or recurrent symptoms, and:  Abdominal pain relieved by defecation or accompanied by a change in stool frequency ( 3 x day) or consistency, and  Disturbed defecation at least 25% of the time, consisting of two or more of the following:  altered frequency of bowel movements  altered consistency of stool  altered stool passage  passage of mucus  abdominal distention 15

 Many patients with IBS who consult physicians also have depression or anxiety, perfectionism, obsessive-compulsiveness, elevated scores on tests of social desirability, and other physical complaints.  However, IBS is not a psychological disorder. It is a physical disorder that is strongly affected by one's emotional state, as well as stress and tension. 16

 The lifetime prevalence of IBS is about 20%. Although not a very serious disorder when compared to something like schizophrenia, it is a major healthcare concern.  Like many other conditions, but maybe more dramatically so, IBS suffers can be divided into two groups, those who seek treatment and those who do not seek treatment.  Studies found that of those IBS patients who do not consult a physician, 70-80% of all IBS patients, were psychologically healthy and similar to normal controls on psychological testing.  Those IBS suffers who seek medical treatment tended to also be more psychologically distressed on psychological tests. 17

 One's "suffering" is what determines their consultation with a physician.  In one study, 85% of a sample reported changes in their bowel habits secondary to psychological stress. Other studies found that figure to be closer to 10%.  Some studies report childhood trauma being linked to the development of IBS symptoms. Of those with functional GI disorders, 53% were sexually abused during childhood as compared to 37% of those with organic diseases. 18

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 IBS patients have been found to be twice as likely to report sexual abuse history as healthy subjects. 21

 IBS patients consistently report more stressful life events than control subjects.  More than half of IBS patients report that stressful psychological events exacerbate their symptoms or precede symptom onset. The stressful life events IBS patients report are typically commonplace events, but; loss of a parent and sexual abuse seem particularly common in the stressor history of IBS patients. 22

 Do not treat unless you're sure that a diagnosis of IBS has been made by a physician,  “Maintain good contact with their primary care physician” and encourage patients to continue to consult their physician on any changes in physical symptoms,  Use brief and time limited treatment of the kinds that have been demonstrated to be effective in research,  Make clear to the patient that progress is going to be gradual,  Use improvement in abdominal pain, bowel dysfunction, and social and work functioning as the chief criteria for improvement with emotional well being as secondary criteria. 23

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 Brief cognitive therapy  Brief dynamic therapy  Brief hypnosis treatment  Highest success rates reported for cognitive therapy, 80% and hypnosis treatment 80-95%*; these are the only treatments with replicated highly successful outcomes in controlled studies. Improvement is maintained at 14year follow-up. * VOL 57, NO 1 / JANUARY 2008 THE JOURNAL OF FAMILY PRACTICE 25

 When comparing various treatment models, treatment duration is usually short, ranging from 7-10 sessions over 8-13 weeks.  Common forms of therapy included relaxation training, cognitive, dynamic and supportive therapy as well as hypnosis. Treatment effects are generally well maintained at one-year follow-up.  When comparing insight-oriented therapy, hypnotherapy, cognitive-behavioral therapy, and biofeedback, all produce notable improvements in some symptoms with the best objective reports being with hypnotherapy showing 85% improvement in patients under age 50 at one-year follow-up, followed by cognitive-behavioral therapy alone. 26

Whorwell (classic approach) vs UNC/Palsson’s Model: min sessions maximum; improvement usually noted in 4-8 sessions; 2. hypnosis is directive, "gut-directed" and not exploratory; 3. standard eye-fixation induction and suggestions for imagery (to assess imagery capacity); 4. place hand on abdomen and feel warmth, repeat several times; 5. suggest to relate warmth to the reduction of spasm and the ability to alleviate pain and distension, bowel habits will normalize as their control gradually improves; 6. if they can visualize, they are asked to see a meandering river, then note the effect of an obstruction to the flow, such as a lock or gate. Observe the effect of the opening and closing of the gate; 7. the river is like their guts and the gate is the smooth muscle and they adjust them to a comfortable setting; 8. around the 3rd session, work on self-hypnosis, ego-strengthening and confidence –building; 9. explain that this method help them to control nor cure their problem, thus requiring regular practice. 27

age classic IBS atypical IBS  <50 yrs 93% 33%  >50 yrs 50% 50% Total 86% 38% 28

 This might be complete relief of symptoms, or it may be slight or temporary relief, or partial relief.  Sometimes, a symptom might even get a little worse. Even that is good because any change in symptoms implies movement and where there's movement, greater change can occur.  Finally, there may be minimal or no change, but you notice a sense of impending change or feel hopeful that change is coming. 29

 Beth’s IBS  Mike the pooper, or not 30

 Blanchard, E.B. (1993). Irritable Bowel Syndrome. In R.J. Gatchel & E.B. Blanchard (Eds.) Psychophysiological Disorders: Research and Clinical Applications. Washington, DC: APA.  Palsson, O.S. (Editor) (2006). Special Issue: Irritable Bowel Syndrome. IJCEH, 54:1.  Palsson, O.S. (1997). Hypnosis treatment for Irritable Bowel Syndrome. Gastroenterology, 112, A803.  Whorwell, P.J. (1987). Hypnotherapy in the irritable bowel syndrome. Stress Medicine, 3,

 Whorwell, P.J.; Prior, A. & Faragher, E.B. (December 1, 1984). Controlled trial of hypnotherapy in the treatment of severe refractory irritable bowel syndrome. The Lancet,  Wickramasekera, I. (1987). Risk factors leading to chronic stress-related symptoms. Advances, Institute for the Advancement of Health, 4(1),

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