Idiopathic inflammatory bowel diseases (IBDs) significantly affect the quality of life of sufferers. Improved quality of life and patient symptom management may be achieved through integrating psychological/behavioral interventions with pharmacologic treatments. Here is our experience with hypnotherapy as an adjuvant management for an 18-year-old female with Crohn's Disease (CD) in remission (patient I) and a 24-year-old female with CD in active phase (patient II). The patients participated in 12 weekly one-hour sessions of hypnotherapy. Gut-directed, ego-strengthening, and post-hypnotic suggestions and immune-directed imaginations were used. After the hypnotherapy course, symptoms, psychological state, and quality of life improved in patient I, but not patient II (according to questionnaires). After a 6 month follow-up, symptoms and quality of life were the same as at the end of hypnotherapy sessions in both patients. The patients reported the greatest benefit of hypnotherapy was in helping them to cope better with their disease and also in improving their psychological state. Hypnotherapy may improve quality of life of IBD patients in remission and help them to cope better with their disease. Well-designed controlled clinical trials are needed in this field.

Am J Clin Hypn. 2009 Jan;51(3):255-62. Emami MH, Gholamrezaei A, Daneshgar H. Department of Gastroenterology, Isfahan University of Medical Sciences, Isfahan, Iran.

Prognostic factors that predict the efficiency of autogenous training and psychopharmacotherapy were detected in 90 women with irritable bowel syndrome and constipation. A multifactor personality questionnaire, Spielberg's state-trait anxiety test, Beck's depression inventory scale, and visual analog scale were used for the purpose of psychodiagnosis. The efficiency of autogenous training was found to be higher in patients with irritable bowel syndrome and mildly or moderately compromised psychological adaptation associated with a moderately elevated level of anxiety. Psychopharmacotherapy proved to be especially efficacious in patients with hypochondriac, depressive, and manifest anxiety disorders. It was found that the pronouncedness of rigidity, tension, fixation-proneness, and the degree of depression could be used as predictors of positive effects of psychopharmacotherapy on stool patterns while hypochondriac trends served as predictors of the alleviation of pain syndrome in patients with irritable bowel syndrome and constipation.

Vopr Kurortol Fizioter Lech Fiz Kult. 2008 Sep-Oct;(5):6-8. A?vazian TA, Za?tsev VP, Pakhomova IV, Gusakova EV.

Fifteen patients with severe or very severe inflammatory bowel disease on corticosteroids but not responding to medication received 12 sessions of "gut-focused hypnotherapy" and were followed up for a mean duration of 5.4 years with disease severity being graded as remission, mild, moderate, severe, or very severe. Two patients (13.4%) failed to respond and required surgery. At follow-up for the remaining 13 patients, 4 (26.6%) were in complete remission, 8 (53.3%) had mild severity, and 1 (6.7%) was moderately severe. Quality of life became good or excellent in 12 (79.9%). Corticosteroid requirements dramatically declined with 60% of patients stopping them completely and not requiring any during follow-up. Hypnotherapy appears to be a promising adjunctive treatment for inflammatory bowel disease and has steroid sparing effects. Controlled trials to clearly define its role in this disease area are justified.

Int J Clin Exp Hypn. 2008 Jul;56(3):306-17. Miller V, Whorwell PJ. University of Manchester, United Kingdom.

Standard treatment for IBS focuses on the management or alleviation of the predominant gastrointestinal presenting symptoms, such as diarrhea or constipation, often using pharmacological therapy. For many patients, this approach is unsatisfactory, and patients frequently seek the advice of complementary and alternative medicine (CAM) practitioners in order to explore other treatment options.

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Hypnosis is a therapeutic technique that primarily involves attentive receptive concentration. Even though a small number of health professionals are trained in hypnosis and lingering myths and misconceptions associated with this method have hampered its widespread use to treat medical conditions, hypnotherapy has gained relevance as an effective treatment for irritable bowel syndrome not responsive to standard care. More recently, a few studies have addressed the potential influence of hypnosis on upper digestive function and disease. This paper reviews the efficacy of hypnosis in the modulation of upper digestive motor and secretory function. The present evidence of the effectiveness of hypnotherapy as a treatment for functional and organic diseases of the upper bowel is also summarized, coupled with a discussion of potential mechanisms of its therapeutic action.

World J Gastroenterol. 2008 Nov 7;14(41):6276-84. Chiarioni G, Palsson OS, Whitehead WE. Divisione di Riabilitazione Gastroenterologica dell'Universita di Verona, Azienda Ospedaliera di Verona, Ospedale di Valeggio sul Mincio, 37067 Valeggio sul Mincio (VR), Italy. chiarioni@tin.it.

It was established that use of autogenous training makes possible to increase efficiency of the therapy, leading to considerable more evident improvement of somatic and psychotic state, decrease of pain syndrome. Predictors of efficiency of autogenous training were marked out. Indications for use the method in medical rehabilitation of patients with irritable colon syndrome with constipation dominance were elaborated.

Vopr Kurortol Fizioter Lech Fiz Kult. 2008 Jan-Feb;(1):24-7. Pakhomova IV, A?vazian TA, Za?tsev VP, Gusakova EV, Molina LP.

by Debra Mittler, CHt

There is an ever growing epidemic of eating disorders amongst both women and men. Some start as young as six years of age. People who develop eating disorders usually do it to cope with life circumstances. It is an unconscious reaction to develop a sense of control, escape feelings, avoid responsibility or stop the process of life. They "think" these behaviors make them feel better. They usually are not aware of, and are disconnected from the physical and emotional harm they are doing on their mind, body and spirit. These people tend to have low self-esteem and can view themselves with a lot of negativity. Some feel that nothing is ever good enough, (mostly themselves). Generally their thoughts, feelings and behaviors stem from the limiting beliefs they have about themselves and the world.

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ABSTRACT: BACKGROUND: Functional Bowel Disorders (FBD) are chronic disorders that are difficult to treat and manage. Many patients and doctors are dissatisfied with the level of improvement in symptoms that can be achieved with standard medical care which may lead them to seek alternatives for care. There are currently no data on the types of Complementary and Alternative Medicine (CAM) used for FBDs other than Irritable Bowel Syndrome (IBS), or on the economic costs of CAM treatments. The aim of this study is to determine prevalence, types and costs of CAM in IBS, functional diarrhea, functional constipation, and functional abdominal pain. METHODS: 1012 Patients with FBD were recruited through a health care maintenance organization and followed for 6 months. Questionnaires were used to ascertain: Utilization and expenditures on CAM, symptom severity (IBS-SS), quality of life (IBS-QoL), psychological distress (BSI) and perceived treatment effectiveness. Costs for conventional medical care were extracted from administrative claims. RESULTS: CAM was used by 35% of patients, at a median yearly cost of $200. The most common CAM types were ginger, massage therapy and yoga. CAM use was associated with female gender, higher education, and anxiety. Satisfaction with physician care and perceived effectiveness of prescription mediation were not associated with CAM use. Physician referral to a CAM provider was uncommon but the majority of patients receiving this recommendation followed their physician's advice. CONCLUSIONS: CAM is used by one-third of FBG patients. CAM use does not seem to be driven by dissatisfaction with conventional care. Physicians should discuss CAM use and effectiveness with their patients and refer patients if appropriate.

van Tilburg MA, Palsson OS, Levy RL, Feld AD, Turner M, Drossman DA, Whitehead WE. BMC Complement Altern Med. 2008 Jul 24;8(1):46.

INTRODUCTION: The treatment of the fibromyalgia syndrome (FMS) is not standardized and often ineffective, and the course of disease progression is unpredictable. OBJECTIVES: To highlight the efficacy of the pharmacologic and nonpharmacologic treatments administered to FMS patients. METHODS: Medline search for articles published between 1983 and 2007, using the keywords fibromyalgia, pharmacologic and nonpharmacologic treatment, and multidisciplinary modalities. RESULTS: Randomized controlled trials (RCTs) indicate that FMS has been treated by a wide range of drugs including antidepressants, opioids, nonsteroidal anti-inflammatory drugs, sedatives, muscle relaxants, and antiepileptic agents. Although the syndrome is now more widely recognized and understood, its treatment remains challenging and some physicians believe that no effective treatment exists. Only a few drugs have been shown to have clear-cut benefits in RCTs. FMS sufferers benefit from exercise and a number of the tested programs have involved more than 1 type of exercise. Two other major approaches are psychophysiologically based therapy, such as electromyography biofeedback, and interventions based on cognitive-behavioral therapy. Twelve controlled clinical studies have provided evidence supporting the efficacy of treatments administered to people with FMS by multidisciplinary teams using multicomponent strategies. CONCLUSIONS: It is difficult to draw definite conclusions concerning the most appropriate approach to managing FMS because of the methodological limitations of the available studies and the fact that the heterogeneity and nonstandardized nature of their therapeutic programs make them difficult to compare. An individually tailored multidisciplinary pharmacologic, rehabilitative, and cognitive-behavioral approach currently seems to be the most effective.

Semin Arthritis Rheum. 2008 Jun;37(6) Sarzi-Puttini P, Buskila D, Carrabba M, Doria A, Atzeni F. Clinical Research Scientist, Rheumatology Unit, L. Sacco University Hospital, Milan, Italy. sarzi@tiscali.it

Irritable bowel syndrome (IBS) is one of the most common conditions seen in primary care settings. Despite this, there is no consensus as to the pathogenesis of this disorder or a consistently effective therapeutic regimen for many patients. This has encouraged the use of various alternative therapies from behavioral or complementary medicine. This review will address the evidence for alternative therapies, including the following: cognitive behavior therapy, hypnosis, elimination diets based on food antibody testing, nutrition supplements (such as fiber, probiotics, and prebiotics), and, finally, peppermint, l-glutamine, zinc, and cromolyn sodium. The review also explores the evidence for and the therapeutic ramifications of the hypothesis that increased intestinal permeability underlies the symptoms of IBS in many patients, and how a therapeutic plan that addresses nutrition, elimination diets, and nutrition supplements may be useful in restoring the integrity of the gut immune barrier.

Wald A, Rakel D. Section of GI and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USA. axw@medicine.wisc.edu Nutr Clin Pract. 2008 Jun-Jul;23(3):284-92.

There is now good evidence that hypnotherapy benefits a substantial proportion of patients with irritable bowel syndrome and that improvement is maintained for many years. Most patients seen in secondary care with this condition also suffer from a wide range of noncolonic symptoms such as backache and lethargy, as well as a number of musculoskeletal, urological, and gynaecological problems. These features do not typically respond well to conventional medical treatment approaches, but fortunately, their intensity is often reduced by hypnosis. The mechanisms by which hypnosis mediates its benefit are not entirely clear, but there is evidence that, in addition to its psychological effects, it can modulate gastrointestinal physiology, alter the central processing of noxious stimuli, and even influence immune function.

J Psychosom Res. 2008 Jun;64(6):621-3. Epub 2008 Apr 28. Whorwell PJ. University of Manchester, Manchester, United Kingdom. peter.whorwell@manchseter.ac.uk

There is now good evidence that hypnotherapy benefits a substantial proportion of patients with irritable bowel syndrome and that improvement is maintained for many years. Most patients seen in secondary care with this condition also suffer from a wide range of noncolonic symptoms such as backache and lethargy, as well as a number of musculoskeletal, urological, and gynaecological problems. These features do not typically respond well to conventional medical treatment approaches, but fortunately, their intensity is often reduced by hypnosis. The mechanisms by which hypnosis mediates its benefit are not entirely clear, but there is evidence that, in addition to its psychological effects, it can modulate gastrointestinal physiology, alter the central processing of noxious stimuli, and even influence immune function.

J Psychosom Res. 2008 Jun;64(6):621-3. Epub 2008 Apr 28. Whorwell PJ. University of Manchester, Manchester, United Kingdom.

OBJECTIVES: Hypnotherapy is effective in several diseases with a psychosomatic component. Our aim was to study the effects of one session of hypnosis on the systemic and rectal mucosal inflammatory responses in patients with active ulcerative colitis (UC). METHODS: In total, 17 patients with active UC underwent a 50-min session of gut-focused hypnotherapy. Before and after each procedure, the systemic inflammatory response was assessed by serum interleukin (IL)-6 and IL-13 concentrations, tumor necrosis factor-alpha (TNF-alpha) and IL-6 production by lipopolysaccharide (LPS)-stimulated whole blood, leukocyte count, natural killer (NK) cell number, platelet activation, and platelet-leukocyte aggregate formation. Rectal inflammation was assessed by mucosal release of substance P (SP), histamine, IL-13 and TNF-alpha, reactive oxygen metabolite production, and mucosal blood flow. Eight patients with active UC underwent a control procedure. RESULTS: Hypnosis decreased pulse by a median 7 beats per minute (bpm) (P= 0.0008); it also reduced the median serum IL-6 concentration by 53% (P= 0.001), but had no effect on the other systemic variables assessed. Hypnosis reduced rectal mucosal release of SP by a median 81% (P= 0.001), histamine by 35% (P= 0.002) and IL-13 by 53% (P= 0.003), and also, blood flow by 18% (P= 0.0004). The control protocol had no effect on any of the variables assessed. CONCLUSIONS: Hypnosis reduced several components of the systemic and mucosal inflammatory response in active ulcerative colitis toward levels found previously in the inactive disease. Some of these effects may contribute to the anecdotally reported benefits of hypnotherapy and provide a rationale for controlled trials of hypnotherapy in UC.

Am J Gastroenterol. 2008 May 28. Mawdsley JE, Jenkins DG, Macey MG, Langmead L, Rampton DS. Centre for Gastroenterology, Institute of Cell and Molecular Science, Barts and the London, Queen Mary School of Medicine and Dentistry, London, United Kingdom.

A driving force in an eating disorder like anorexia nervosa has been a distorted body image. The psychobiological dynamics of eating disorders have demonstrated significant hypnotic phenomena such as forms of dissociation, hallucination, time distortion and catalepsy, and therefore, pose hypnosis as a good fit for particular parts of treatment. Presented here are four hypnotic approaches designed to inspire the establishment of a reality based body image in the eating disordered individual. Conditional prerequisites for application of these interventions are described and case examples illustrate each approach. A discussion on some of the rationale for formulating these strategies is offered.

Am J Clin Hypn. 2008 Apr;50(4):301-10. Walsh BJ. affinity@bigplanet.com

by Melissa Roth, Ph.D.

Jackie characterized her Irritable Bowel Syndrome (IBS) symptoms as a panic attack of the bowels. Sudden, explosive episodes of diarrhea had her confined to her house. She had tuned over the grocery shopping to her husband and had not been on an outing with her family in three years.

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Hypnotically assisted treatments have been used to reduce stress, improve gastrointestinal motility, strengthen immune function, and potentially reduce inflammation. Such treatments may also help reduce disease flares and improve quality of life in inflammatory bowel diseases (IBD). The authors report the results of a case series of 8 white female patients with inactive IBD. All participants initiated and completed treatment, supporting the general acceptability of hypnotically assisted treatment among IBD patients. There was a significant improvement in IBD-quality of life scores for the group posttreatment, t(7) = -3.38, p = .01, with a mean improvement in quality of life of 29 points with significant changes in all 4 subscales. No negative effects of treatment were found.

Int J Clin Exp Hypn. 2007 Oct;55(4):457-66. Keefer L, Keshavarzian A. Rush University Medical Center, Chicago, Illinois, USA. laurie.keefer@northwestern.edu

Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder of unknown aetiology. Current pharmacological treatments have limited value. Hypnotherapy has been reported to have beneficial effects for IBS symptoms. OBJECTIVES: To evaluate the efficacy of hypnotherapy for the treatment of irritable bowel syndrome. SEARCH STRATEGY: Published and unpublished randomised clinical trials and quasi-randomised clinical trials were identified through structured searches of MEDLINE (1966 to March 2006), EMBASE (1980 to March 2006), PsycINFO (1806 to March 2006), CINAHL (Cumulative Index to Nursing and Allied Health Literature, 1982 to March 2006), AMED (Allied and Complementary Medicine Database, 1985 to March 2006) and The Cochrane Central Register of Controlled trials. Conference proceedings from Digestive Disease Week (1980 to 2005) were also searched. SELECTION CRITERIA: Eligible studies included all randomised and quasi-randomised clinical studies comparing hypnotherapy for the treatment of irritable bowel syndrome with no treatment or another therapeutic intervention. DATA COLLECTION AND ANALYSIS: All studies were evaluated for eligibility for inclusion. Included studies were assessed for quality and data were extracted independently by four authors. The primary outcome measure of interest was the overall bowel symptom severity score which combines abdominal pain, diarrhoea or constipation and bloating. Secondary outcomes included abdominal pain, diarrhoea, constipation, bloating, quality of life, patient's overall assessment of well-being, psychological measures as per validated questionnaires, and adverse events. MAIN RESULTS: Four studies including a total of 147 patients met the inclusion criteria. Only one study compared hypnotherapy to an alternative therapy (psychotherapy and placebo pill), two studies compared hypnotherapy with waiting-list controls and the final study compared hypnotherapy to usual medical management. Data were not pooled for meta-analysis due to differences in outcome measures and study design. The therapeutic effect of hypnotherapy was found to be superior to that of a waiting list control or usual medical management, for abdominal pain and composite primary IBS symptoms, in the short term in patients who fail standard medical therapy. Harmful side-effects were not reported in any of the trials. However, the results of these studies should be interpreted with caution due to poor methodological quality and small size. AUTHORS' CONCLUSIONS: The quality of the included trials was inadequate to allow any conclusion about the efficacy of hypnotherapy for irritable bowel syndrome. More research with high quality trials is needed.

Cochrane Database Syst Rev. 2007 Oct 17;(4):CD005110. Webb AN, Kukuruzovic RH, Catto-Smith AG, Sawyer SM. Royal Children's Hospital Melbourne, Gastroenterology, Flemington Road, Parkville Victoria 3052, Melbourne, Australia. annette.webb@rch.org.au

Functional abdominal pain (FAP) and irritable bowel syndrome (IBS) are highly prevalent in childhood. A substantial proportion of patients continues to experience long-lasting symptoms. Gut-directed hypnotherapy (HT) has been shown to be highly effective in the treatment of adult IBS patients. We undertook a randomized controlled trial and compared clinical effectiveness of HT with standard medical therapy (SMT) in children with FAP or IBS. METHODS: Fifty-three pediatric patients, age 8-18 years, with FAP (n = 31) or IBS (n = 22), were randomized to either HT or SMT. Hypnotherapy consisted of 6 sessions over a 3-month period. Patients in the SMT group received standard medical care and 6 sessions of supportive therapy. Pain intensity, pain frequency, and associated symptoms were scored in weekly standardized abdominal pain diaries at baseline, during therapy, and 6 and 12 months after therapy. RESULTS: Pain scores decreased significantly in both groups: from baseline to 1 year follow-up, pain intensity scores decreased in the HT group from 13.5 to 1.3 and in the SMT group from 14.1 to 8.0. Pain frequency scores decreased from 13.5 to 1.1 in the HT group and from 14.4 to 9.3 in the SMT group. Hypnotherapy was highly superior, with a significantly greater reduction in pain scores compared with SMT (P < .001). At 1 year follow-up, successful treatment was accomplished in 85% of the HT group and 25% of the SMT group (P < .001). CONCLUSIONS: Gut-directed HT is highly effective in the treatment of children with longstanding FAP or IBS.

Gastroenterology. 2007 Nov;133(5):1430-6. Epub 2007 Sep 2. Vlieger AM, Menko-Frankenhuis C, Wolfkamp SC, Tromp E, Benninga MA. Department of Pediatrics, St. Antonius Hospital, Nieuwegein, The Netherlands. a.vlieger@antonius.net

A case of secondary diurnal enuresis (SDE) after a car accident was treated with hypnosis by means of the Hypnotic Trauma Narrative, an instrument created by the authors for use with children who have been exposed to traumatic events and develop either classic symptoms of posttraumatic stress disorder or manifest other psychosomatic symptoms. An ABAB time-series design with multiple replications was employed to measure the relationship of the hypnotic treatment to the dependent measure: episodes of diurnal incontinence. The findings indicated a statistically significant relationship between the degree of change from phase to phase and the treatment. Hypnosis with the Hypnotic Trauma Narrative was deemed efficacious as a method for the treatment of secondary diurnal enuresis.

The patient was symptom-free at follow-up 6 months later.

Int J Clin Exp Hypn. 2008 Apr;56(2):229-40. Iglesias A, Iglesias A. Private Practice, Palm Beach Gardens, Florida, USA.

To elucidate the role of music therapy in gastrointestinal endoscopic procedures following the conflicting outcomes reported in two recent studies. The findings of our recent meta-analysis that examined this matter were discussed in the context of later studies. Our meta-analysis illustrated the beneficial effects of music therapy on patient anxiety levels when used as a single measure of relaxation and analgesia. Beneficial effects were also shown on analgesia and sedation requirements and procedure duration times when used as an adjunct to pharmacotherapy. These findings are in agreement with those of both studies excluded from analysis and those that followed it. Music therapy is an effective tool for stress relief and analgesia in patients undergoing gastrointestinal endoscopic procedures.

World J Gastroenterol. 2007 Sep 7;13(33):4533. Rudin D. King's Daughters' Hospital and Health Services, Madison, IN 47250, USA. rudind@gmail.com

Hypnotically assisted treatments have been used to reduce stress, improve gastrointestinal motility, strengthen immune function, and potentially reduce inflammation. Such treatments may also help reduce disease flares and improve quality of life in inflammatory bowel diseases (IBD). The authors report the results of a case series of 8 white female patients with inactive IBD. All participants initiated and completed treatment, supporting the general acceptability of hypnotically assisted treatment among IBD patients. There was a significant improvement in IBD-quality of life scores for the group posttreatment, t(7) = -3.38, p = .01, with a mean improvement in quality of life of 29 points with significant changes in all 4 subscales. No negative effects of treatment were found. Int J Clin Exp Hypn. 2007 Oct;55(4):457-66. Keefer L, Keshavarzian A. Rush University Medical Center, Chicago, Illinois, USA.

Hypnotically assisted treatments have been used to reduce stress, improve gastrointestinal motility, strengthen immune function, and potentially reduce inflammation. Such treatments may also help reduce disease flares and improve quality of life in inflammatory bowel diseases (IBD). The authors report the results of a case series of 8 white female patients with inactive IBD. All participants initiated and completed treatment, supporting the general acceptability of hypnotically assisted treatment among IBD patients. There was a significant improvement in IBD-quality of life scores for the group posttreatment, t(7) = -3.38, p = .01, with a mean improvement in quality of life of 29 points with significant changes in all 4 subscales. No negative effects of treatment were found.

Int J Clin Exp Hypn. 2007 Oct;55(4):457-66

Keefer L, Keshavarzian A. Rush University Medical Center, Chicago, Illinois, USA.

by Bunny Vreeland, Ph.D.

For years, doctors have been saying that Stress is the cause of IBS. I'm Dr. Bunny Vreeland, and while I believe and agree that Stress can and does exacerbate IBS, my personal research with my own clients shows that 100% of my clients were involved in some sort of Body Trauma prior to the onset of IBS. After researching the histories of many of my clients' over the past seven years, it is my belief and contention that IBS is caused by Body Trauma rather than stress, alone.

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Relieving abdominal pain is the principal treatment objective for patients with irritable bowel syndrome. No single drug stands out in the treatment strategy for this illness. Antispasmodics, magnesium aluminum silicates, and alverine citrate drugs all remain initial options for treatment, although their prescription is impeded by the fact that an increasing number are no longer approved for reimbursement. Increased dietary fibers often have a harmful effect on symptoms. Some patients are probably intolerant to some foods but there is no satisfactory proof on which to base a restrictive diet. Improved knowledge of the pathophysiology of irritable bowel syndrome has made it possible to diversify treatments that act first on one of the key pathophysiologic elements, visceral hypersensitivity. Antidepressants (especially tricyclics) can be used at low doses. Among the serotonergic drugs, serotonin 5-HT4 receptors agonists (tegaserod) may be available soon, but the development of 5-HT3 antagonists (alosetron, cilansetron) has been stopped for safety reasons (ischemic colitis and severe constipation). Non-drug options such as hypnosis, psychotherapy, relaxation, or yoga, may also be proposed to some patients. Probiotics are a possible treatment in the future.

Departement d'hepatogastroenterologie et de nutrition, Centre hospitalier, ADEN EA 3234 / IFRMP 23, Rouen (76). Presse Med. 2007 May 7

Comment from Tim Brunson DCH: Although this article does not specifically mention hypnosis or other mind/body modalities, I thought that it was significant since many hypnotherapists provide services with IBS. Note that relaxation and slower breathing helps the brain stem stimulate serotonin. Since activation of the parasympathetic nervous system and serotonin production are significant to GI functioning, hypnosis, guided imagery, and relaxation are significant. The article focuses on pharmacological interventions and unfortunately does not discuss the significant of hypnosis, et. al., as an adjunctive treatment.

Alternative therapies hold potential promise for the treatment of urinary incontinence in the elderly. Assessment and comparisons of the efficacies of such therapies have been hindered by a lack of standardized definitions of urinary incontinence in the study populations, lack of standardization of treatment protocols, inadequate sample sizes, and lack of blinding and appropriate controls. Biofeedback has been the most extensively studied therapy and may provide appropriate adjunctive or primary therapy for select individuals. Other potential therapies, such as acupuncture, hypnosis, and herbal therapies, have not been sufficiently examined to make definitive recommendations.

Division of Geriatrics and Gerontology, Leonard M. Miller School of Medicine, University of Miami and the Miami VA Health Care System. Correspondence address: Room 1D200, Miami VA Medical Center, 1201 NW 16 St, Miami, FL 33125 Email: evan.cherniack@med.va.gov.

Researchers from University Hospital of South Manchester in the UK review the latest research on the efficacy of hypnotherapy for irritable bowel syndrome, and conclude that the beneficial effects of hypnotherapy are long lasting, with most patients maintaining their improved status and decreasing their need for office visits and medication in the long term.

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About 20% of people in the UK have functional gastrointestinal disorders such as irritable bowel syndrome and functional dyspepsia.

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This study quantified health-related quality of life in a group of irritable bowel syndrome patients and measures changes following a treatment programme of nurse-led gut-directed hypnotherapy. BACKGROUND: It is well recognized that health-related quality of life can be severely impaired in patients suffering form the irritable bowel syndrome. Current conventional treatment for irritable bowel syndrome is often unsatisfactory. In contrast it has been shown that gut-directed hypnotherapy is an effective treatment of irritable bowel syndrome with up to three-quarters of patients reporting symptomatic improvement. DESIGN/METHOD: Seventy-five patients (55 females/20 males, median age 37.1 years, age range 18-64) comprised the study group. Physical symptoms of irritable bowel syndrome were recorded using seven-day diary cards. On presentation the predominant symptoms were abdominal pain (61%), altered bowel habit (32.5%), and abdominal distension/bloating (6.5%) in the patient group. An irritable bowel syndrome quality of life questionnaire was used to define health-related quality of life. Psychological well-being was measured using the Hospital Anxiety and Depression Scale. Data analysis was carried out using MINITAB, Release 12 for Windows. RESULTS: Physical symptoms statistically improved after hypnotherapy. There were also significant statistical improvements (P < 0.001) in six of the eight health-related quality of life domains measured (emotional, mental health, sleep, physical function, energy and social role). These improvements were most marked in female patients who reported abdominal pain as their predominant physical symptom. Anxiety and depression improved following treatment. CONCLUSION: Gut-directed hypnotherapy has a very positive impact on health-related quality of life with improvements in psychological well-being and physical symptoms. It appears most effective in patients with abdominal pain and distension. Relevance to clinical practice. This study demonstrates that by integrating complementary therapies into conventional care that gastrointestinal nurses have a potential role in the management of irritable bowel syndrome.

School of Health in Social Science, University of Edinburgh, Old Medical School, Edinburgh, UK. graeme.smith@ed.ac.uk

Chronic abdominal pain is a common feature of most functional gastrointestinal disorders in children, including functional abdominal pain (FAP) and irritable bowel syndrome (IBS). FAP can impair a child's life and often leads to significant school absences. Although the underlying mechanism is likely multifactorial, early pain experiences during a vulnerable period in the developing nervous system can cause long-term changes in the brain-gut axis and ultimately may result in altered pain pathways and visceral hyperalgesia. Care providers often feel uncomfortable managing patients with chronic abdominal pain, as the pathophysiology is poorly understood, and limited data exist regarding safety and efficacy of therapeutic options in children. The primary goal of therapy in FAP is to alleviate pain symptoms and to help the child return to normal daily activities. Treatment should be individualized and chosen based on the severity of symptoms, the existence of comorbid psychological disorders, and the impact the disorder has on the child's school attendance and normal functioning. Various psychological interventions, such as cognitive-behavioral therapy, hypnosis, and guided imagery, have been successfully used in children with chronic abdominal pain. Pharmacologic therapies such as H(2) blockers, proton-pump inhibitors, tricyclic antidepressants, and various serotonergic drugs have been used, but good controlled trials are lacking. More studies are clearly needed to investigate the benefits and safety of pharmacologic therapy in children. Newer pharmacologic agents that target specific receptors involved in nociception, stress, and neurogenic inflammation currently are being developed. Future targets for visceral hyperalgesia should not only be aimed at alleviating symptoms but also should include prevention, particularly in cases with a suspected sensitizing event such as neonatal pain and postinfectious IBS.

Irritable bowel syndrome (IBS) is a gastrointestinal disorder characterized by chronic abdominal pain and altered bowel habits in the absence of any organic cause. Despite its prevalence, there remains a significant lack of efficient medical treatment for IBS to date. However, according to some previous research studies, hypnosis has been shown to be effective in the treatment of IBS. AIM: To determine the definite efficacy of hypnosis in the treatment of irritable bowel syndrome. METHODS: A systematic review of the literature on hypnosis in the treatment of IBS from 1970 to 2005 was performed using MEDLINE. Full studies published in English were identified and selected for inclusion. We excluded case studies and those studies in which IBS symptoms were not in the list of outcome measures. All studies were reviewed on the basis of the Rome Working Team recommendations for design of IBS trials. RESULTS: From a total of 22 studies, seven were excluded. The results of the reviewed studies showed improved status of all major symptoms of IBS, extracolonic symptoms, quality of life, anxiety, and depression. Furthermore these improvements lasted 2-5 years. CONCLUSIONS: Although there are some methodologic inadequacies, all studies show that hypnotherapy is highly effective for patients with refractory IBS, but definite efficacy of hypnosis in the treatment of IBS remains unclear due to lack of controlled trials supporting this finding.

Clinical Hypnotherapy Research Group, Medical Student Research Committee, Isfahan University of Medical Sciences (IUMS), Isfahan, Iran. gholamrezaei@edc.mui.ac.ir

In western populations irritable bowel syndrome (IBS) affects between 10% and 30% of the population and has a significant effect on quality of life. It generates a substantial workload in both primary and secondary care and has significant cost implications. Gut-directed hypnotherapy has been demonstrated to alleviate symptoms and improve quality of life but has not been assessed outside of secondary and tertiary referral centres. AIM: To assess the effectiveness of gut-directed hypnotherapy as a complementary therapy in the management of IBS. DESIGN OF STUDY: Randomised controlled trial. SETTING: Primary care patients aged 18-65 years inclusive, with a diagnosis of IBS of greater than 6 weeks' duration and having failed conventional management, located in South Staffordshire and North Birmingham, UK. METHOD: Intervention patients received five sessions of hypnotherapy in addition to their usual management. Control patients received usual management alone. Data regarding symptoms and quality of life were collected at baseline and again 3, 6, and 12 months post-randomisation. RESULTS: Both groups demonstrated a significant improvement in all symptom dimensions and quality of life over 12 months. At 3 months the intervention group had significantly greater improvements in pain, diarrhoea and overall symptom scores (P<0.05). No significant differences between groups in quality of life were identified. No differences were maintained over time. Intervention patients, however, were significantly less likely to require medication, and the majority described an improvement in their condition. CONCLUSIONS: Gut-directed hypnotherapy benefits patients via symptom reduction and reduced medication usage, although the lack of significant difference between groups beyond 3 months prohibits its general introduction without additional evidence. A large trial incorporating robust economic analysis is, therefore, urgently recommended.

Department of Primary Care and General Practice, Division of Primary Care, Public and Occupational Health, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK. robertslz@adf.bham.ac.uk

Irritable bowel syndrome (IBS) is a complex and prevalent functional gastrointestinal disorder that is treated with limited effectiveness by standard medical care. Hypnosis treatment is, along with cognitive-behavioral therapy, the psychological therapy best researched as an intervention for IBS. Eleven studies, including 5 controlled studies, have assessed the therapeutic effects of hypnosis for IBS. Although this literature has significant limitations, such as small sample sizes and lack of parallel comparisons with other treatments, this body of research consistently shows hypnosis to have a substantial therapeutic impact on IBS, even for patients unresponsive to standard medical interventions. The median response rate to hypnosis treatment is 87%, bowel symptoms can generally be expected to improve by about half, psychological symptoms and life functioning improve after treatment, and therapeutic gains are well maintained for most patients for years after the end of treatment.

University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, USA. William_Whitehead@med.unc.edu

Irritable bowel syndrome (IBS) is a very common condition in the Western part of the world, and it accounts for a large proportion of the workload of a gastroenterologist. Unfortunately, the pathogenesis and pathophysiology of the syndrome are incompletely understood, and the treatment options are limited. However, hypnotherapy is one treatment option that has proven to be very useful in IBS. The mechanisms of action explaining why hypnosis is effective for IBS are not altogether known, but recent studies have shed some light on this issue. These studies, and what can be learned from them about how hypnosis impacts IBS, are reviewed in this article. Hypnosis may affect IBS partly through changes in colorectal sensitivity and improvement in psychological factors. The effects on GI motility and the autonomic nervous system are less clear and need further evaluation.

Dept of Internal Medicine, Sahlgrenska University Hospital, Goteborg, Sweden. magnus.simren@medicine.gu.se

Hypnosis treatment often improves irritable bowel syndrome (IBS), but the costs and reliance on specialized therapists limit its availability. A 3-month home-treatment version of a scripted hypnosis protocol previously shown to improve all central IBS symptoms was completed by 19 IBS patients. Outcomes were compared to those of 57 matched IBS patients from a separate study receiving only standard medical care. Ten of the hypnosis subjects (53%) responded to treatment by 3-month follow-up (response defined as more than 50% reduction in IBS severity) vs. 15 (26%) of controls. Hypnosis subjects improved more in quality of life scores compared to controls. Anxiety predicted poor treatment response. Hypnosis responders remained improved at 6-month follow-up. Although response rate was lower than previously observed in therapist-delivered treatment, hypnosis home treatment may double the proportion of IBS patients improving significantly across 6 months.

Division of Digestive Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. opalsson@med.unc.edu

This modest clinical pilot study was intended to provide preliminary data on the effects of hypnotic inductions tailored to an irritable bowel syndrome patient at each session compared to Palsson's manualized protocol. Patients (N = 8) who had not previously responded to any form of treatment were assigned randomly to either a tailored or manualized induction condition. Other than pretesting for hypnotizability, the procedure followed for the manualized group (n = 4) was exactly as prescribed by O. Palsson (1998). The identical procedure was used for the other 4 patients except that the inductions were individualized. All 8 patients showed favorable responses to treatment immediately posttreatment and at 10-month follow-up. Only the tailored group showed no incapacitating pain at posttreatment but greater emotional stress than the manualized group. The tailored group continued to improve and showed better results than the manualized group at 10 months, and the posttreatment emotional distress was significantly attenuated.

Washington State University, Pullman, Washington 99164, USA. arreed_barabasz@wsu.edu