Cognitive change in patients undergoing hypnotherapy for irritable bowel syndrome

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Abstract

Objective

Impaired quality of life and psychological distress are common in irritable bowel syndrome (IBS) and may be associated with unhelpful cognitions. Hypnotherapy (HT) is effective in improving both symptoms and quality of life in patients with IBS, and this study was designed to determine whether this improvement is reflected in cognitive change using a validated scale recently developed for use in such patients.

Method

A total of 78 IBS patients completed a validated symptom-scoring questionnaire, the Hospital Anxiety and Depression (HAD) Scale and the Cognitive Scale for Functional Bowel Disorders (FBDs), before and after 12 sessions of gut-focused HT.

Results

HT resulted in improvement of symptoms, quality of life and scores for anxiety and depression (all P's<.001). IBS-related cognitions also improved, with reduction in the total cognitive score (TCS; P<.001) and all component themes related to bowel function (all P<.001). Cognitions were related to symptom severity because the most abnormal cognitive scores were observed in patients with the highest symptom scores (P<.001). Furthermore, a reduction in symptom score following treatment correlated with an improvement in the cognitive score (P<.001). Regression analysis confirmed that the cognitive score had independence from the other scores and did not serve solely as a proxy for symptom improvement.

Conclusion

This study shows that symptom improvement in IBS with HT is associated with cognitive change. It also represents an initial step in unravelling the many possible mechanisms by which treatments such as HT might bring about improvement.

Introduction

Irritable bowel syndrome (IBS) is a common condition that is estimated to affect around 15% of the general adult population at any one time [1] and, although the majority of individuals with symptoms do not seek medical help, those who do account for approximately half of the workload in the gastroenterology clinic [2], [3], [4]. The main symptoms of IBS are abdominal pain, distension and altered bowel habit, and these are often accompanied by a number of extracolonic symptoms, which include nausea, lethargy, backache and urinary symptoms [5].

For some individuals, symptoms can be sufficiently severe and troublesome as to impair the person's quality of life and may affect the ability to cope with work [5], [6]. The socioeconomic impact of IBS is therefore considerable, and IBS patients represent a significant drain on healthcare resources [7]. Treatment is often unsatisfactory with symptoms failing to respond to an array of currently available medications [8]. As a consequence, less conventional but often more effective approaches such as hypnotherapy (HT) [9], [10], [11], [12], [13], [14] and cognitive and/or behavioural therapies [15], [16], [17], [18], [19] have been increasingly adopted to treat this condition.

IBS is classified as a functional bowel disorder (FBD), and its cause is probably multifactorial in origin, and it has been proposed that IBS is best conceptualised within a biopsychosocial framework [20]. Psychological influences may play a complex role in that they may act as predisposing or precipitating factors which contribute to the generation or expression of symptoms and/or as perpetuating factors that exacerbate or maintain the problem [21], [22], [23], [24]. In addition, the symptoms and their consequences, real or potential, may be a source of psychological distress. For instance, symptoms may make patients feel out of control and therefore helpless, or patients may feel anxious about going out, fearing that they may not find a toilet in time.

Psychological distress is reflected in a person's stream of thoughts (automatic thoughts or cognitions), and these, in turn, may act to exacerbate symptoms. Identification and reformulation of any unhelpful or self-defeating cognitions in order to help improve the patient's condition form the basis of cognitive therapy, originally developed for the treatment of emotional disorders [25], [26] and later adapted for use with functional illnesses [27]. Studies using cognitive and/or behavioural interventions [15], [16], [17], [18], [19] have reported reduction in IBS symptoms and psychological distress. These have used measures such as the Beck Depression Inventory [28] to assess mood, and the Automatic Thoughts Questionnaire [29] for cognitions. To date, however, there has been no validated cognitive measure available to assess cognitions specific to patients with functional bowel symptoms. To address this need, therefore, a cognitive scale has recently been developed by Toner et al. [30], designed for use in this patient group, as a valid and reliable instrument to assess the cognitions of patients diagnosed with FBD and also to assess the efficacy of different forms of treatment or psychotherapeutic interventions. The scale was devised from the automatic thought diaries from FBD patients, which were formulated into statements reflecting cognitions. The authors identified several a priori themes that were relevant to people with FBD, and the scale is organised into themes relating to symptoms, such as bowel performance anxiety and pain, and to common personal themes, such as perfectionism and self-nurturance.

Gut-focused HT is a particular treatment approach, originally developed by Whorwell et al. [9], that has been found to be extremely effective in the treatment of IBS with up to 80% of patients having improvement in symptoms and overall well-being, an effect that is usually sustained [10], [11] and has been supported by independent studies [12], [13]. A further study has shown that HT improves extracolonic symptoms and quality of life, and it has also been shown to reduce HAD scores for anxiety and depression. It also helps patients return to work, and it reduces the need for medication and repeated consultation [11]. This work led to the establishment several years ago of a HT unit in the UK staffed by six therapists, which is devoted to the treatment of IBS, and a recent audit on a large number of patients receiving treatment through this service has confirmed the earlier research findings [14].

Gut-focused HT is based on the use of hypnotic techniques directed towards control and normalisation of gut function, along with ‘ego-strengthening’ interventions, but without the use of formal methods to reformulate unhelpful cognitions. Because of this, we were interested in monitoring patients' IBS-related cognitions before and after a course of HT using the Cognitive Scale for FBD to determine whether or not these cognitions change after treatment.

The aims of this study, therefore, were to establish whether patients' cognitions are related to severity of symptoms, whether these cognitions change after HT, and if so, whether this change is related to improvement in symptoms.

Section snippets

Patients

A total of 78 patients with IBS (16 male, age 17–69 years) undergoing a course of HT took part in the study. Patients had been referred from gastroenterology clinics at this hospital and other centres in the region having had symptoms of at least 2 years in duration, which were unresponsive to previous conventional treatment, i.e., laxatives, antidiarrhoeals, antispasmodics and even antidepressants, as deemed clinically appropriate. IBS was defined as the presence of abdominal pain, distension

IBS symptoms and associated features

As can be seen in Table 2, IBS symptoms before HT were at least moderately severe, as reflected in the overall IBS score and in the individual measures, namely pain severity, pain frequency, bloating, bowel habit dissatisfaction and life interference. Following HT, improvement was seen in the overall score and in all of the individual features (all P<.001).

Similarly, while the prevalence of extracolonic symptoms varied, with lethargy, excess wind, backache and bodily aches being the most common

Discussion

HT reduced both symptoms of IBS and its associated extracolonic manifestations, leading to an improvement in quality of life and psychological well-being. This is in keeping with the earlier reports from our group [9], [10], [11] as well as others [12], [13] and with a recent large-scale audit of patients treated within our Unit [14]. However, this is the first study to assess the impact of an effective treatment for IBS on patients' cognitions using a previously validated Cognitive Scale [30]

Acknowledgements

We thank the other staff of the Hypnotherapy Unit who treated some of the patients used in this study: Mrs. P. Cooper, Mrs. P. Cruickshanks, Mrs. V. Miller, Mrs. J. Randles and Mrs. V. Whelan. We also thank Mrs. Julie Morris, Head of Medical Statistics, University Hospital of South Manchester, for help with statistical analysis.

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