The Use of Hypnotherapy in the Treatment of Functional Dyspepsia
By Hane Htut Maung, BA Hons. (Cantab)
In this article, I shall review the evidence that suggests that the æ tiology of functional dyspepsia has a significant psychological component, and the evidence that suggests that hypnotherapy is effective in its treatment, with the aim of meriting the implementation of further clinical trials and the involvement of professionals skilled in hypnosis in the management of the condition.
Dyspepsia, commonly known as ‘indigestion', is a non-specific term used to describe symptoms of abdominal discomfort that are episodic or persistent and are thought to originate from the upper gastrointestinal tract. Such symptoms may include abdominal pain, heartburn, bloating, belching, nausea, and vomiting. It is an extremely common cause of morbidity in the UK , affecting over 25% of the population each year. Of the organic causes of dyspepsia, peptic ulcer disease accounts for approximately 20% of all cases of dyspepsia, and approximately 80% of these cases are thought to be attributable to infection by Helicobacter pylori . Other organic causes of dyspepsia include reflux œsophagitis, which is responsible for approximately 10% of cases, and upper gastrointestinal malignancy, which is serious but accounts for fewer than 2% of cases. However, in up to 60% of all cases of dyspepsia, there is no evidence of organic disease on investigation. These patients are said to have functional dyspepsia.
Psychological factors in the ætiology
Although the pathogenesis of functional dyspepsia is unclear, epidemiological studies have shown the condition to be strongly associated with psychological factors. Anxiety, neuroticism, somatisation, and depression, have been found to be commoner in patients with functional dyspepsia compared to healthy controls, and in some cases of functional dyspepsia, symptoms have been known to coincide with identifiable causes of stress. 1 Abnormal illness behaviour has also been observed in sufferers of functional dyspepsia. Furthermore, studies have shown that psychological factors can produce alterations in gastrointestinal physiology. 2 This evidence suggests that psychological factors play a rôle in the ætiology of functional dyspepsia, and, as we shall see, this has implications on how it responds to different treatment methods.
In addition to psychological factors, visceral hypersensitivity, or an augmented perception of visceral pain, is thought to be a factor associated with functional dyspepsia. Studies have shown that patients with functional dyspepsia are more sensitive to gastric distension by the inflation of an intragastric balloon, and to intraduodenal acid infusion, compared to healthy controls. 3 However, this was only found in a proportion of patients with the condition, and so visceral hypersensitivity cannot be considered to be a universal feature of functional dyspepsia. Nevertheless, this too may have implications on the responsiveness of the condition to different treatment methods, particularly hypnotherapy.
The role of hypnotherapy
Over recent times, there has been a growing interest in the use of psychological interventions, such as hypnotherapy, to treat functional dyspepsia. This is, perhaps, justified, considering that psychological factors, as I have discussed, have been shown to play a rôle in the ætiology of the condition. In other words, since the underlying mechanisms of functional dyspepsia may be susceptible to modulation by the mind, there is reason to suggest that the condition might be amenable to treatment with psychological therapies that target the mind, such as hypnosis.
Hypnosis is a physical and mental state in which the body is relaxed and the mind is intensely focused and receptive. In this state, therapeutic suggestions can be made, in order to assist the patient to take control of a condition. Such a process is called hypnotherapy . Different specific protocols have been developed for different conditions, and the term clinical hypnosis is used when referring to the use of such a specific protocol in a medical framework to treat a specific condition.
Hypnotherapy has been shown to be effective in the management of another functional gastrointestinal condition, namely irritable bowel syndrome. Like functional dyspepsia, irritable bowel syndrome is not associated with any underlying organic disease, and is strongly associated with psychological factors. The results of the first formal research study on the use of hypnotherapy in the treatment of irritable bowel syndrome showed that the patients who received hypnotherapy showed marked improvements in their condition compared to the patients who received psychotherapy and placebo tablets. 4 The effectiveness of hypnotherapy in the treatment of irritable bowel syndrome begs the question of whether it may also be effective in other functional gastrointestinal disorders, such as functional dyspepsia.
The hypothesis that some patients with functional dyspepsia have an increased visceral hypersensitivity also supports the idea that functional dyspepsia may be amenable to treatment with hypnosis. Studies have shown that hypnosis can modulate the cognitive appraisal of pain, in such a way that although the patient still registers the sensation, the perception of unpleasantness is reduced. They found that the activity of the anterior cingulate cortex and prefrontal cortex, two cortical areas involved in the cognitive appraisal of pain, increases during hypnotic suggestion for the control of pain. 5 This may be one of the mechanisms that underlie the ability of hypnosis to produce analgesia in patients. Since the visceral hypersensitivity that is sometimes associated with functional dyspepsia is, in essence, an augmented sensitivity to visceral pain, it is not unreasonable to suggest that it may respond to treatment with hypnosis.
Considering the rôles of psychological factors and visceral hypersensitivity in the ætiology of functional dyspepsia, an appropriate clinical hypnosis protocol for use in the treatment of the condition may include suggestions of abdominal comfort and warmth, confidence, greater self-control, and an ego-strengthening script with a physical emphasis. These can aim to modulate the cognitive appraisal of pain, achieve a greater awareness and control of gastrointestinal physiology, and manage any internal stressors that may be underlying the symptoms.
The Wythenshawe trial
The first formal research study on the efficacy of hypnotherapy for functional dyspepsia was a randomised controlled trial, performed by Dr Calvert and his team in Wythenshawe Hospital , Manchester , England , in 2002. 6 The study investigators recruited patients with dyspepsia who had showed negative results on upper gastrointestinal endoscopy. Patients with symptoms of reflux œsophagitis, a past medical history of peptic ulcer disease, recent gastrointestinal surgery, current infection by Helicobacter pylori , or who were regularly using non-steroidal anti-inflammatory drugs, were excluded from the trial, to rule out anyone whose symptoms may have had an underlying organic cause. The remaining 126 patients, who fulfilled the diagnostic criteria for functional dyspepsia, were randomised to receive hypnotherapy, supportive therapy plus placebo medication, or medical treatment with ranitidine in an oral dosage of 150mg twice a day, for 16 weeks. The short-term and long-term percentage changes in symptomatology from baseline were assessed after 16 weeks and 56 weeks, respectively. Quality of Life scores were also measured as a secondary outcome. A total of 26 hypnotherapy, 24 supportive therapy, and 29 medical treatment patients completed all stages of the study.
The results showed that symptom scores improved significantly more in both the short-term and the long-term for the patients in the hypnotherapy group compared to those in the supportive therapy or medical treatment groups. The Quality of Life scores also improved more significantly in the short-term for the patients in the hypnotherapy group compared to those in the supportive therapy or medical treatment groups. In the long-term, the Quality of Life scores improved significantly more for the patients in the hypnotherapy and supportive therapy groups compared to those in the medical treatment group, but a number of the patients in the supportive therapy group commenced taking anti-depressants during the follow-up. In addition to this, no patients in the hypnotherapy group commenced medication during the follow-up compared to 82% of patients in the supportive therapy group and 90% of patients in the medical treatment group, and the patients in the hypnotherapy group made significantly fewer visits to their general practitioner or gastroenterologist compared to those in the supportive therapy or medical treatment groups.
This study makes a strong case for the use of hypnotherapy in the treatment of patients with functional dyspepsia. Not only does it show that hypnotherapy is highly effective in the short-term and long-term management of functional dyspepsia compared to supportive therapy and medical treatment, but it also suggests that medical treatment with ranitidine is no more effective than supportive therapy in the management of functional dyspepsia. This not only merits the use of hypnotherapy in the treatment of the condition, but also suggests that pharmacological intervention with ranitidine may, in fact, be inappropriate for patients with functional dyspepsia. Thus, the study suggests that it may be appropriate to favour hypnotherapy over unnecessary pharmacological intervention in the treatment of functional dyspepsia.
The study also suggests that treating functional dyspepsia with hypnotherapy reduces medication use and consultation rate in the long-term compared to treating it with supportive therapy or medical treatment. Therefore, the use of hypnotherapy for functional dyspepsia may have major economic advantages over the use of medication. This further merits the use of hypnotherapy to treat functional dyspepsia.
The Wythenshawe trial was a promising initial study on the use of hypnotherapy for the treatment of functional dyspepsia. Unfortunately, it is also, to the author's knowledge at the time of writing, the only formal research study on the use of hypnotherapy for this condition that has been published. Further similar trials are required to see if they support the findings. In these further trials, it may be helpful to assess the effectiveness of hypnotherapy compared to medical treatment with drugs other than ranitidine that are used to treat functional dyspepsia. If the results of these trials support the findings of the Wythenshawe trial, additional trials to investigate the effectiveness of hypnotherapy when combined with medical treatment may be appropriate. However, given the high prevalence of functional dyspepsia and the safety of hypnotherapy as a treatment, it seems entirely justifiable to begin involving professionals skilled in hypnosis in the care of patients with functional dyspepsia.
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