Gut-directed hypnotherapy can complement the management of disorders of brain-gut axis interaction

Ever find yourself getting off your highway exit, not remembering most of the trip?  Chances are you were in a hypnotic trance — a state of intense mental focus, reduced awareness of the environment around you and a heightened ability to receive suggestions that would normally seem unbelievable. Luckily, without the occurrence of the latter, the post-hypnotic suggestion, you probably did not find yourself a few hours later clucking like a chicken!

Hypnosis was first used in the 18th century by German physicist Franz Mesmer (think mesmerizing), who believed that many ailments could be cured through animal magnetism. While his science was ultimately debunked, doctors in the U.S. and Europe were, by the 19th century, using hypnosis as a way to anesthetize patients undergoing painful surgeries. Neuroimaging research later showed that under hypnosis, the brain can actually be manipulated into feeling or not feeling pain, with the anterior cingulate cortex and emotional arousal networks being the most affected. However, hypnotic suggestions are only therapeutic if they are directly related to the patient’s symptoms. In other words, hypnotizing a chronic pain patient to feel better about her parenting skills might improve self-esteem, but not reduce the pain.

Peter Whorwell, MD, of Manchester, England, published the first randomized, controlled trial (RCT) of gut-directed hypnotherapy (GDH) in 1984, which, using post-hypnotic suggestions around abdominal pain and slowed gut motility over 12 sessions, demonstrated substantial reductions in abdominal pain and bowel movements among patients with diarrhea-predominant refractory irritable bowel syndrome (IBS). Olafur Palsson, PsyD, of the University of North Carolina, developed a seven-session, fully scripted protocol in the mid-1990s that allowed for scalability and increased access to trained therapists. Results of Palsson’s RCTs further supported Whorwell’s, also with approximately 75 percent of patients experiencing at least around 50 percent symptom reduction. The North Carolina Protocol was later modified for a range of disorders of gut-brain interaction, swapping out post-hypnotic suggestions to mirror the specific symptom profiles for each condition. Similarly, it was adapted for alternate delivery methods including group, home audio and online in order to improve access. Meta-analysis of more than 15 RCTs shows that GDH has a number needed to treat (number of patients who improve divided by those treated) of four in IBS. Of note, GDH has been tested almost exclusively as adjunctive to medication optimization, not as a stand-alone alternative treatment.

“Hypnotic suggestions are only therapeutic if they are directly related to the patient’s symptoms.”

The most common question I get about hypnosis is how it differs from other relaxation techniques (e.g., mindfulness meditation, guided imagery, virtual reality). While several relaxation techniques activate the parasympathetic nervous system and reduce the impact of stress on the gastrointestinal (GI) tract, hypnosis is the only brain-gut therapy that addresses the subconscious, cognitive-affective components of GI pain. Think of the relaxation response itself as an IV going into a vein and the specific, gut-directed post-hypnotic suggestions as the medication. It can take four or more sessions, which I call the “loading dose,” before a patient can see benefits of GDH because, like our other brain-gut psychotherapies, hypnosis is a skill that requires routine home practice.

Another common concern about GDH is who to refer for this type of brain-gut therapy.  While 75 to 80 percent of the adult population is indeed hypnotizable, and results do not differ between patients who are hypnotizable versus not hypnotizable in any of the scientific studies, in my experience, patients must be open to the intervention and to the rationale behind their GI condition, including that brain-gut dysregulation/visceral hypersensitivity drives symptom experience. It can help to explain to patients that in the same way they do not feel a wristwatch they wear every day, hypnosis can also re-train their brain to not feel normal and uninformative gut sensations. Contrary to popular belief, hypnosis is a safe, completely voluntary state — even the people who get up and bark like dogs in a Las Vegas show might be disinhibited but are not experiencing a loss of control!

GDH is an evidence-based brain-gut therapy for a range of disorders of gut-brain interaction, with data supporting its use in IBS, heartburn, globus, non-cardiac chest pain, pediatric abdominal pain and inflammatory bowel disease (IBD) with functional overlap. The primary barrier for adoption of GDH into clinical care is access to trained professionals; this is now being addressed by the Rome Foundation through its new, freely available provider directory, which can be found at romegipsych.org.

Key takeaways:

  • GDH is one of the most robust brain-gut therapies for several disorders of gut-brain interaction, with a number-needed-to-treat of four.
  • Most patients can benefit from GDH if they are open to the rationale and willing to engage in home practice.
  • Access to GDH is improving with new delivery methods.

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