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- non-cardiac chest pain
- gastro-oesophageal reflux disease
- irritable bowel syndrome
- functional dyspepsia
Hypnosis may be an effective treatment for patients with non-cardiac chest pain that has not responded to acid inhibition
Non-cardiac chest pain (NCCP) is a condition defined by recurrent episodes of substernal chest pain suggestive of coronary artery disease in patients in whom no cardiac cause can be found after a comprehensive evaluation.1 It is aetiologically heterogeneous, and the cause in individual patients often remains unclear even after thorough investigation. Patients with NCCP are frequently not reassured by negative investigations and are persistent in their pursuit of further medical evaluations for possible cardiovascular disease. The consequent impairment in personal and occupational functioning and subjective well being can be substantial. A recent estimate places the annual cost of health care services provided in the USA to treat NCCP at 6.5 billion dollars.2
The most commonly identified cause of NCCP symptoms is gastro-oesophageal reflux disease. Consequently, a therapeutic trial of a proton pump inhibitor is often recommended to confirm the diagnosis and as the firstline treatment.3,4 However, a variety of other factors have been suggested as possible causes of NCCP in individual patients, including oesophageal dysmotility, visceral hyperalgesia, musculoskeletal problems, and psychological factors, such as anxiety and somatisation.5 When patients fail to respond to proton pump inhibitors, few treatment options remain and the results of medical management are often unsatisfactory.
In this issue of Gut, Jones and colleagues6 demonstrated in a small randomised controlled trial that hypnosis is an effective treatment for patients with NCCP that has not responded to acid inhibition (see page 1403). Following 12 sessions of individualised treatment with hypnosis, 80% of NCCP patients reported that they were “completely better” or “moderately better” compared with only 23% of patients in a control group. The controls received supportive psychotherapy and a placebo tablet to insure that the findings were not explained by expectancy or increased attention from a health care provider. The greater effectiveness of hypnotherapy was confirmed by the secondary endpoints in this study: hypnotherapy patients, when compared with control patients, showed greater reductions in pain intensity, greater improvements in quality of life, and greater reductions in medication usage. Strengths of this trial were the use of blind raters and an intent to treat analysis to evaluate efficacy.
The Manchester team that conducted this trial, headed by Dr Peter Whorwell, pioneered hypnosis treatment for functional gastrointestinal disorders more than two decades ago, and the current study is but the latest in a series of innovative contributions they have made over the years. They were the first to demonstrate that hypnosis can be of substantial help for refractory irritable bowel syndrome (IBS).7,8 They went on to demonstrate in a large patient series that it is reliably effective for IBS, benefiting more than 70% of treated patients, and that the results last for years.9,10 More recently, the Manchester group published a randomised placebo controlled trial in patients with functional dyspepsia showing that hypnotherapy is more effective than supportive therapy plus placebo medication or treatment with ranitidine.11 In this study, they also demonstrated significant reductions in overall health care visits and amount of prescribed medication taken during the year following treatment with hypnosis, showing that the greater cost of treating patients with hypnosis is offset by downstream reductions in health care utilisation. The published studies of the Manchester group have inspired other research groups to test the effectiveness of hypnosis and to independently confirm the value of this type of treatment for severe and refractory IBS cases.12 Replication of their work on functional dyspepsia is awaited.
Examining the similarities among the functional gastrointestinal disorders for which hypnosis has been found to be effective may provide insights into how hypnosis benefits these patients and how it might be adapted to further improve its efficacy. Each of these disorders is associated with a greater than expected amount of psychological symptoms,13–15 and because hypnosis is a psychological intervention, it might be anticipated that it would be more effective in psychologically distressed patients. Consistent with this hypothesis, four published studies that evaluated the efficacy of cognitive behavioural therapy (CBT) for NCCP16–19 all reported significantly greater improvement in the CBT condition compared with a control condition. However, these were uniformly small studies, and all of them compared CBT to no treatment or to standard care. Such control conditions do not elicit any anticipation of therapeutic change and therefore do not control for the placebo effect. (In this regard, the design of Jones et al’s trial is substantially stronger as its double placebo control condition is likely to have produced a considerable expectation of therapeutic effect.) However, psychological distress does not appear to be the explanation for the effectiveness of hypnosis. Unlike other psychological treatments, the benefits of hypnosis, at least in IBS where this has been tested, are no better in patients with anxiety and depression.9 Thus hypnosis does not appear to be effective because it reduces psychological distress.
A second similarity between IBS, functional dyspepsia, and NCCP which may make them more amenable to treatment with hypnosis is that all three are defined by symptoms of pain or discomfort, and large subsets of patients with all three disorders have been shown to have lower thresholds for pain induced by intraluminal distension (that is, increased pain sensitivity).20–22 While this has been interpreted by some as evidence of a biologically based difference in peripheral receptor sensitivity or spinal cord transmission of pain,23 possibly related to inflammatory processes,24 other evidence suggests that psychologically based perceptual response bias may explain the phenomenon20,25; when techniques that distinguish between biologically based pain sensitivity and perceptual response bias (that is, psychological influences on perception) are used, it has been shown for both IBS25 and NCCP26 that perceptual sensitivity is similar between patients and healthy controls but that psychologically based perceptual response bias is greater in patients and is correlated with pain thresholds. This suggests that patients with IBS and NCCP, and probably also functional dyspepsia,27 are hypervigilant in noticing pain related sensations and interpreting them as symptoms of disease. This perceptual response bias may account for the fact that these functional gastrointestinal disorders are associated with multiple comorbid complaints. Whorwell’s group have reported that hypnosis reduces pain sensitivity in IBS patients whose pain thresholds are abnormally low,28,29 and research from our laboratory30 shows that hypnosis substantially reduces somatisation in IBS patients. These findings suggest that hypnosis is perhaps uniquely able to modify hypervigilance for visceral pain sensations, and this may be one of the mechanisms that explains its effectiveness in functional gastrointestinal disorders.
A third similarity between IBS, functional dyspepsia, and NCCP is that all are symptom based diagnoses for which there are no biological markers. In each case, diagnosis requires the presence of a characteristic set of symptoms but also a negative medical evaluation for other diseases that might produce these symptoms.31 Absence of objective criteria for diagnosis may increase uncertainty on the part of both the physician and the patient, with the result that anxiety and hypervigilance to symptoms on the part of either of them may play a greater role in the perpetuation of symptoms than might be the case, for example, in a fracture or an infection. One reason for the effectiveness of hypnosis intervention for functional gastrointestinal disorders could be that it focuses on reducing catastrophising cognitions and overattention to symptoms, which is likely to be particularly important in these symptom based conditions. This speculation requires testing.
This first ever study of hypnosis for NCCP has limitations which readers will need to keep in mind. Firstly, the 28 patients who were enrolled in the study were highly selected and may not be representative of all patients with NCCP: 865 patients were considered for the study, but 97% were not enrolled in treatment either because they were found to be ineligible (35%), could not be contacted (11%), listed travel related inconvenience or family and work conflicts (30%), or refused (20%). A second limitation to the study is that there was no follow up. Previous work from this group of investigators has shown that hypnosis produces improvements in IBS symptoms that are sustained for at least five years9,10 and improvements in functional dyspepsia that persist for at least a year.11 These durable treatment effects, and the reductions in health care visits and medication use that accompanied treatment for functional dyspepsia,11 are important to assess in NCCP.
IMPLICATIONS FOR TREATMENT OF NCCP WITH HYPNOSIS
Should further studies on hypnosis treatment for NCCP show equally dramatic beneficial effects of hypnosis, and especially if the long term benefits prove favourable, there is little question that hypnosis has much to offer chronic patients with this diagnosis. It must be acknowledged however that several obstacles presently prevent widespread practical application of hypnosis for gastrointestinal problems. Firstly, the number of health care providers trained in hypnosis is limited. Knowledge in a special gut directed approach to hypnosis, rather than general hypnotherapy, is required for good success in treating gastrointestinal disorders, and training in this method is hard to come by. Efforts to overcome this barrier include the development of gut focused hypnosis scripts which make it easier for health care providers to learn how to deliver effective treatment.32
A second barrier is that this approach to treatment is costly and requires multiple visits; this may deter use of this adjunctive treatment option. There are ongoing research studies to determine whether self hypnosis with the use of tape recordings may be equally effective.33
Finally, scepticism by some patients (and some physicians) due to lack of face validity of using a psychological therapy to treat a gut problem, especially a psychological method that has traditionally carried an aura of magic and mystery, may deter the treatment. However, educational efforts and growing interest due to the accumulating body of research indicative of the effectiveness of hypnosis treatment for functional gastrointestinal disorders are resulting in more and more patients and physicians becoming interested in hypnosis as a reasonable treatment alternative for refractory functional gastrointestinal symptoms, and increasing numbers of medical and mental health professionals are attending training workshops in gut directed hypnosis. For example, in the USA, several hundred clinicians nationwide now offer hypnosis treatment specifically for IBS, according to an empirically tested protocol.32
Much still remains to be done to enable patients with functional gastrointestinal disorders to benefit from hypnotherapy as a matter of course. Two changes in the way healthcare systems currently care for patients with these disorders will be important in this regard. One is the formal addition of hypnotherapy services to the scope of clinical services offered to patients seen in gastroenterology and primary care settings where functional gastrointestinal patients are treated, either through an established referral mechanism or preferably with on site delivery of hypnotherapy in medical clinics. Dr Whorwell and colleagues have convincingly demonstrated, through the example of their own clinic in Manchester,9,10 that hypnotherapy can be incorporated successfully into clinical gastroenterology. For many years, they have employed several full time hypnotherapists (non-physicians) who routinely treat those of their functional gastrointestinal patients who prove unresponsive to more conventional treatment. They report a high rate of success in patients who in many other gastrointestinal settings would be left without further treatment options. While the integration of psychological services into ambulatory care clinics would seem optimal in light of the complex biopsychosocial nature of NCCP and other functional gastrointestinal disorders, it is a rare exception in today’s healthcare delivery.
The other system change required for hypnosis to enter mainstream healthcare for gastrointestinal problems is improved coverage of the cost of hypnosis by health care systems or insurance providers. Such coverage seems reasonable in light of the accumulating evidence that hypnotherapy reduces healthcare utilisation and medication needs long term.11 As long as this expense must be borne by the patients, as is predominantly the case in the USA and in some other countries, individuals with chronic functional gastrointestinal disorders will be deprived of the potential benefit of this treatment option.
Supported in part by grants RO1 DK31369 and R24 DK67674
Hypnosis may be an effective treatment for patients with non-cardiac chest pain that has not responded to acid inhibition
Conflict of interest: None declared.
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