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Hypnotherapy for Esophageal Disorders

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Abstract

Hypnotherapy is an evidence based intervention for the treatment of functional bowel disorders, particularly irritable bowel syndrome. While similar in pathophysiology, less is known about the utility of hypnotherapy in the upper gastrointestinal tract. Esophageal disorders, most of which are functional in nature, cause painful and uncomfortable symptoms that impact patient quality of life and are difficult to treat from a medical perspective. After a thorough medical workup and a failed trial of proton pump inhibitor therapy, options for treatment are significantly limited. While the pathophysiology is likely multifactorial, two critical factors are believed to drive esophageal symptoms—visceral hypersensitivity and symptom hypervigilance. The goal of esophageal directed hypnotherapy is to promote a deep state of relaxation with focused attention allowing the patient to learn to modulate physiological sensations and symptoms that are not easily addressed with conventional medical intervention. Currently, the use of hypnosis is suitable for dysphagia, globus, functional chest pain/non-cardiac chest pain, dyspepsia, and functional heartburn. In this article the authors will provide a rationale for the use of hypnosis in these disorders, presenting the science whenever available, describing their approach with these patients, and sharing a case study representing a successful outcome.
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American Journal of Clinical Hypnosis
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Hypnotherapy for Esophageal Disorders
Megan E. Riehl
a
& Laurie Keefer
b
a
University of Michigan, Ann Arbor, Michigan, USA
b
Northwestern University, Chicago, Illinois, USA
Published online: 05 Jun 2015.
To cite this article: Megan E. Riehl & Laurie Keefer (2015) Hypnotherapy for Esophageal Disorders,
American Journal of Clinical Hypnosis, 58:1, 22-33, DOI: 10.1080/00029157.2015.1025355
To link to this article: http://dx.doi.org/10.1080/00029157.2015.1025355
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American Journal of Clinical Hypnosis, 58: 22–33, 2015
Copyright © American Society of Clinical Hypnosis
ISSN: 0002-9157 print / 2160-0562 online
DOI: 10.1080/00029157.2015.1025355
Hypnotherapy for Esophageal Disorders
Megan E. Riehl
University of Michigan, Ann Arbor, Michigan, USA
Laurie Keefer
Northwestern University, Chicago, Illinois, USA
Hypnotherapy is an evidence based intervention for the treatment of functional bowel disorders,
particularly irritable bowel syndrome. While similar in pathophysiology, less is known about the
utility of hypnotherapy in the upper gastrointestinal tract. Esophageal disorders, most of which
are functional in nature, cause painful and uncomfortable symptoms that impact patient quality of
life and are difficult to treat from a medical perspective. After a thorough medical workup and a
failed trial of proton pump inhibitor therapy, options for treatment are significantly limited. While
the pathophysiology is likely multifactorial, two critical factors are believed to drive esophageal
symptoms—visceral hypersensitivity and symptom hypervigilance. The goal of esophageal directed
hypnotherapy is to promote a deep state of relaxation with focused attention allowing the patient to
learn to modulate physiological sensations and symptoms that are not easily addressed with conven-
tional medical intervention. Currently, the use of hypnosis is suitable for dysphagia, globus, functional
chest pain/non-cardiac chest pain, dyspepsia, and functional heartburn. In this article the authors will
provide a rationale for the use of hypnosis in these disorders, presenting the science whenever avail-
able, describing their approach with these patients, and sharing a case study representing a successful
outcome.
Keywords: behavioral medicine, esophageal disorders, gastroesophageal reflux disease, heartburn,
hypnosis
Once a primary care doctor or gastroenterologist has ruled out esophageal cancer or
other malignant causes for a patient’s chest pain, difficulty swallowing, or heartburn, it is
probably wise to consult a health psychologist or clinical social worker for a behavioral
intervention. The authors of this article are gastrointestinal (GI) health psychologists
fully integrated within two academic GI divisions in the Midwest, that have success-
fully implemented an esophageal-directed hypnotherapy program for difficult to treat
upper GI disorders (Riehl, Kinsinger, Kahrilas, Pandolfino, & Keefer, 2014). Below they
describe their program, including its rationale, structure, and utility.
Address correspondence to Megan E. Riehl, 3912 Taubman Center, SPC 5362, Suite 3436, 1500 E. Medical Center
Drive, Ann Arbor, MI 48109. E-mail: mriehl@med.umich.edu
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HYPNOTHERAPY FOR ESOPHAGEAL DISORDERS 23
Background and Rationale for Esophageal-Directed Hypnotherapy
Much of the science behind the use of hypnotherapy (HYP) for digestive health is in
the area of irritable bowel syndrome (IBS). With a stable number needed to treat of 2.5,
meaning that for every 2.5 patients treated, 1 experiences adequate relief of symptoms
(Ford et al., 2014; Ford, Talley, Schoenfeld, Quigley, & Moayyedi, 2009), gut-directed
HYP has been shown to reduce abdominal pain, improve bowel patterns and reduce
bloating (Miller & Whorwell, 2009; Whorwell, 1990; 2008), normalize rectal sensitivity
thresholds (Lea et al., 2003; Palsson, 2010), decrease somatization and visceral anxiety
(Palsson & Whitehead, 2002), and reduce catastrophizing and unhelpful thinking about
symptoms (Gonsalkorale, Toner, & Whorwell, 2004). Further, the benefits of HYP have
been shown to last up to 5 years (Gonsalkorale, Miller, Afzal, & Whorwell, 2003)and
have demonstrated cost-effectiveness in comparison to IBS medication (Gonsalkorale,
Houghton, & Whorwell, 2002; Houghton, Heyman, & Whorwell, 1996).
There are fewer studies examining the use and impact of hypnosis or other hypnoti-
cally assisted relaxation techniques for the management of disorders of the esophagus,
but of the studies published, as well as reports of clinical experience, when clin-
ically appropriate, these forms of treatment are accepted and beneficial (Palsson,
2010). Hypnotherapy has demonstrated efficacy in small trials of functional dyspepsia
(Calvert, Houghton, Cooper, Morris, & Whorwell, 2002), non-cardiac chest pain (Jones,
Cooper, Miller, Brooks, & Whorwell, 2006; Miller, Jones, & Whorwell, 2007; Palsson
& Whitehead, 2006; Whorwell, 1990) and from our own group, globus sensation
(Kiebles, Kwiatek, Pandolfino, Kahrilas, & Keefer, 2010) and functional heartburn
(Riehl, Pandolfino, Palsson, & Keefer, 2015). Prior to the availability of proton pump
inhibitors (PPIs), there were also a handful of studies that focused on hypnosis in
acid peptic disorders with modest effects in modulating gastric acid secretion (Button
et al., 1989) and gastric emptying time (Chiarioni, Vantini, De Iorio, & Benini, 2006).
Hypnosis has also been shown to modulate reflux symptoms by reducing anxiety, body
vigilance and visceral sensitivity (Scarinci, McDonald-Haile, Bradley, & Richter, 1994).
While the mechanisms of HYP in the esophagus are unknown, two related processes
are believed to underlie the majority of refractory esophageal symptoms—esophageal
hypersensitivity and esophageal hypervigilance. Interestingly, both of these are theoret-
ically amenable to HYP.
Esophageal hypersensitivity is a physiological process that occurs in certain individu-
als in response to normal esophageal stimulation (mechanical or chemical). It is readily
demonstrated among patients with functional gastrointestinal disorders (FGIDs) as
increased sensitivity during normal digestive processes and a decreased pain threshold to
balloon distention tests in the rectum or esophagus (Munakata et al., 1997; Nasr, Attaluri,
Hashmi, Gregersen, & Rao, 2010). Thus, even in cases where a patient has abnormal
levels of acid exposure treated adequately with medications, visceral hypersensitivity
might still drive symptoms (e.g., the presence of normal acid becomes painful).
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24 RIEHL AND KEEFER
Esophageal hypervigilance (EHv) on the other hand is a psychological process which
develops though operant conditioning. Consider an individual with some history of
esophageal symptoms or injury who becomes hypervigilant around early cue detec-
tion of future esophageal discomfort. This hypervigilance is out of proportion to prior
symptom experience but is nevertheless reinforced when symptoms do not occur as the
patient predicted. Instead of experiencing relief, the patient falsely attributes the lack
of symptoms to his/her careful attempt to avoid their perceived triggers. This accidental
reinforcement increases the likelihood of continued hypervigilance, which demands sus-
tained awareness of environmental (e.g., a specific food) and interoceptive (e.g., feeling
hungry, aroused) cues. Cognitively, these cues become synonymous with the esophageal
symptom itself, irrespective of pathophysiology. Hypervigilance may escalate if symp-
toms are predicted to occur in a new context. Paradoxically, context-dependent learning
increases the probability of esophageal sensations during such situations, in turn becom-
ing a “self-fulfilling prophecy” for the experience of esophageal symptoms. High EHv
can result in behavioral avoidance, increased anxiety, restricted coping or helpless-
ness, further exacerbating symptoms and social isolation. Notably, EHv is distinct from
general anxiety and other psychological disorders in that it is specific to esophageal
sensations and does not typically cross into other life domains (Keefer, Sayuk, Bratten,
Rahimi, & Jones, 2008).
Approach and Uses
Esophageal problems that commonly present in a behavioral health clinic which are
suitable for hypnosis are dyspepsia, globus sensation (lump in throat), heartburn,
non-cardiac chest pain, and dysphagia (difficulty swallowing). Visual imagery around
esophageal physiology and metaphoric imagery related to the transformation of bother-
some esophageal symptoms are readily accepted by patients (Kiebles et al., 2010;Riehl
et al., 2015). When it comes to constructing a treatment plan for patients who will likely
benefit from esophageal-directed hypnotherapy, researchers at Northwestern University
have utilized structured, scripted protocols for most of these conditions. Our protocols
have all been developed through adaptations of scripts used for IBS and inflammatory
bowel diseases which have been previously published by the author (LK) and colleagues
(Keefer et al., 2013; Palsson, 2006)(Table 1).
Clinical Evaluation
Before initiating esophageal-directed hypnotherapy, a thorough evaluation should be
completed by a qualified medical provider which completely documents the medical
history and rules out other organic medical causes of the patient’s symptoms. In addi-
tion to an upper endoscopy, the medical workup may include reflux monitoring studies
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HYPNOTHERAPY FOR ESOPHAGEAL DISORDERS 25
TABLE 1
Example Hypnotherapy Metaphors by Therapeutic Target/Symptom
Dysphagia/Globus Sensation
Therapeutic Target: Peristalsis, hypervigilance around swallowing
And as you watch the panel, and move the dial from one position to the next, you can begin to feel more and more
relaxed and confident in the gentle, efficient functioning of your esophagus initiated after a swallow, more and more
confident that your esophagus is functioning just as it is supposed to, moving food and liquid gently and
rhythmically down into your stomach, gentle, rhythmic, and totally efficient. ...
Hypersensitive Esophagus/Heartburn
Therapeutic Target: Hypersensitivity to acid/normal sensations inside esophagus
Sensations that used to be uncomfortable now increasingly feel just mild and soothing and do not bother you anymore.
And even if you feel some sensation of heartburn, you will most likely notice that it is surprisingly weak, much
milder than before, as your sensitivity to pain in your esophagus is gradually and steadily fading away more and
more, leaving you more comfortable and healthy every day. Your sensitivity to pain is decreasing steadily from one
day to the next, and one week to the next, allowing you to enjoy your everyday life more and more without being
disturbed or bothered. You pay less and less attention to unpleasant feelings inside you every day, as your sensitivity
to pain and discomfort in the esophagus steadily fades away and disappears. You will probably find yourself
forgetting about the sensations in your esophagus altogether for longer and longer periods of time, sometimes even a
whole day or multiple days at a time, focusing more instead on the pleasant and enjoyable aspects of your life
experience.
(prolonged telemetry capsule pH monitoring (Bravo
TM
) and 24-h impedance pH testing)
as well as esophageal manometry (Kumar & Katz, 2013).
Psychoeducation and Engaging the Patient
Initial psychoeducation about the nature of their medical condition should always be
the first step in treatment. Our patients are told that it is very common to experi-
ence significant emotional and physical distress in association with various aspects of
their esophageal symptom presentation (pain, fear of choking, loss of control, anxiety).
Treatment goals are tailored to aid patients in developing strategies that improve cop-
ing and symptom management. Given the sensitive location of the patient’s discomfort
and symptomology, patients are often fearful that they will experience difficulty with
breathing or choking. Giving patients a thorough description of their diagnosis prior
to beginning hypnosis treatment can aid with building rapport, helping patients to feel
safe, and allows them the opportunity to gain insight into the functional aspects of their
symptoms.
The treatment provider must have adequate knowledge of the presenting
gastroesophageal complaint and provide detailed information and education about the
nature of esophageal hypersensitivity and hypervigilance and the role these play in the
patient’s symptom experience. Giving patients a brief background on the development of
the use of hypnosis for their diagnosis can begin with a description of hypnosis used for
the FGID, IBS, and how hypnosis fits within a class of effective “brain–gut” therapies.
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26 RIEHL AND KEEFER
General Str ucture
Once the patient has completed a comprehensive initial consultation with a health psy-
chologist or practitioner expert in the use of hypnosis, patients deemed appropriate for
treatment may attend five to seven weekly or bi-weekly sessions. Each hypnosis session
is about 20–25 minutes in duration. Patients have the option to sit in a comfortable chair
with the lights dimmed and minimal background distractions. Hypnosis is induced by
an eye closure, followed by progressive muscle relaxation and a deepening technique
(image of staircase, elevator, cloud, etc). Next, esophageal focused suggestions related
to the function of peristalsis, motility, and esophageal sensitivity are introduced and
repeated with corresponding images and metaphoric transformations focused on nor-
malizing the esophageal functioning. Between in-person sessions, patients are provided
a CD with a guided hypnosis exercise and instructed to listen on a daily basis as home-
work throughout the duration of the hypnosis protocol. Weekly progress can be assessed
by having patients keep symptom logs to be compared throughout the treatment and
assessed for improvement. The symptom logs can be collected weekly and discussed
with the patient in session. The symptom log can also be used to track date and time
that patients completed their home practice which can aid with treatment compliance.
Patients are given the opportunity to discuss their experience with home practice while
in-person and suggestions for improved self-hypnosis practice will be provided. The
individual is instructed to practice in a quiet, comfortable location in their home at a
time with little distraction so they can focus on the words throughout the practice. At the
conclusion of the treatment protocol, patients will no longer need to listen to the home
practice.
Condition-Specific Applications
Dyspepsia
Dyspepsia is a one of the most common GI conditions seen in an outpatient GI clinic
with variable prevalence (Tack & Talley, 2013). The symptoms of dyspepsia can signifi-
cantly impact a patient’s quality of life and include a variety of painful or uncomfortable
symptoms located throughout the epigastric region. Postprandial fullness (uncomfort-
able sensation that food sits in the stomach after a meal), early satiety (feeling full
quickly), upper abdominal bloating, epigastic pain or burning, belching, nausea, vom-
iting, or unintentional weight loss in the absence of underlying structural abnormality
would warrant a diagnosis of dyspepsia (Tack & Talley, 2013). Rome III introduced
two subgroups of functional dyspepsia which included postprandial distress syndrome
(PDS) and epigastric pain syndrome (EPS) (Drossman, 2006). PDS patients are likely to
present with postprandial fullness and early satiety while patients with EPS report symp-
tomatology inclusive of epigastric pain and/or burning (Tack & Talley, 2013). We now
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HYPNOTHERAPY FOR ESOPHAGEAL DISORDERS 27
see growing evidence highlighting the symptom overlap among patients with functional
dyspepsia, IBS, and gastroesophageal reflux disease (GERD) with one study indicating
overlap of two or all three diagnoses in 6.5% of the study population (Rasmussen et al.,
2015). Early studies in the successful use of hypnosis for dyspepsia were developed by
the Manchester group who pioneered the use of hypnosis for IBS. In a randomized con-
trol trial, hypnosis proved beneficial in improving patient quality of life and long-term
symptom management when compared to supportive therapy plus placebo medication
or medical treatment as usual (Calvert et al., 2002).
Globus Sensation
A patient with globus may present stating, “It feels like I have a golf ball stuck in
my throat that I can’t swallow down.” As described by the Rome III diagnostic crite-
ria, globus sensation may be intermittent or persistent and a non-painful sensation of
a lump or foreign body in the throat which occurs between meals in the absence of
dysphagia, GERD, or esophageal motility disorders (Kahrilas & Smout, 2010). Given
an etiology that may originally stem from GERD, a trial of PPI medication is rec-
ommended. However, researchers investigating alternative management strategies for
patients who have not responded to PPI therapy have also found hypnosis beneficial
(Kahrilas, Boeckxstaens, & Smout, 2013; Kiebles et al., 2010). Kiebles and colleagues
(2010) implemented a 7-session scripted protocol in an open-label study to assess the
acceptability of hypnotically assisted relaxation (HAR) to decrease the globus sensation
and upper esophageal sphincter (UES) pressure. While the study was small, it spear-
headed exciting and important work in the treatment of globus that had not been done
before. Substantial improvement in the reduction of symptoms was reported, while UES
function remained unaffected suggesting that hypnosis is an acceptable treatment for this
aggravating disorder (Kiebles et al., 2010).
Gastroesophageal Reflux and Heartburn
The Rome III diagnostic criteria for functional heartburn characterizes retrosternal burn-
ing, discomfort or pain, the absence of GERD as the cause of these symptoms, and
the absence of histopathology-based motility disorders. Treatment has tended to focus
on dietary changes by the avoidance of fatty, spicy, or acidic based foods, however an
overly restrictive diet is not recommended as nutritional needs should not be disregarded
(Kumar & Katz, 2013). Without strong empirical support, but based on the pathophysiol-
ogy associated with esophageal hypersensitivity, selective serotonin reuptake inhibitors
(SSRIs) and tricyclic antidepressants (TCAs), commonly used for FGID pain modula-
tion have been prescribed (Clouse, Lustman, Eckert, Ferney, & Griffith, 1987; Viazis
et al., 2012). Esophageal hypersensitivity and its psychological counterpart, EHv influ-
ence the functional heartburn symptom experience, and may also drive symptoms in
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28 RIEHL AND KEEFER
GERD. In a small pilot study by the authors, HYP was recently established as a pre-
ferred intervention for functional heartburn (Riehl et al., 2015). As with other work in
the treatment of functional GI disorders (Palsson & Whitehead, 2013) there were consis-
tent and significant changes in heartburn symptoms, visceral anxiety and quality of life,
and a trend for improvement in catastrophizing for patients who enrolled in a 7-session
esophageal-directed HYP protocol (Riehl et al., 2015).
Functional Chest Pain/Non-Cardiac Chest Pain
In addition to the previously mentioned workup with a gastroenterologist, patients who
present with functional chest pain or non-cardiac chest pain (FCP/NCCP) require a car-
diac workup to rule out cardiac complications. Often, these patients have presented at
emergency rooms with fear of being in the midst of a heart attack or panic attack.
These patients are frequently high healthcare utilizers and a negative medical workup
may not be enough to convince them that their symptom presentation is benign. This
makes FCP/NCCP a disorder that is difficult to treat from a purely medical perspec-
tive. Commonly diagnosed with no clear etiology, patients describe a radiating pain
throughout the neck, mid-chest, and mid-back with a debilitating pressure sensation
not of burning quality (Nasr et al., 2010). Similarly to its role in functional heartburn,
esphageal hypensensitivity is likely at play in the presentation of symptoms (Miwa
et al., 2010; Nasr et al., 2010; Rao, Hayek, & Summers, 2001), therefore pain modu-
lators such as TCAs, SSRIs, SNRIs have been prescribed, but based on potential side
effects should be cautiously used (Atluri, Chandar, Fass, & Falck-Ytter, 2015; Clouse
et al., 1987). There have been promising outcomes in terms of psychological treatment
for FCP/NCCP where cognitive behavioral therapy (CBT) (Klimes, Mayou, Pearce,
Coles, & Fagg, 1990) and HYP proved superior to placebo controls in decreasing symp-
toms. Jones et al. (2006) implemented a placebo-controlled study which showed HYP
resulted in a significant reduction in pain intensity, decreased medication use, and overall
improvement in patient well-being when compared to supportive care with placebo med-
ication. Despite the limitations of generalizability due to the small sample size (n = 28;
15 in HYP), a non-medication treatment involving 12 sessions of HYP emerged as a
treatment to explore further based on these excellent preliminary findings (Jones et al.,
2006).
Dysphagia
Functional dysphagia is another esophageal diagnosis of exclusion. In the absence of
GERD or another organic medical cause, patients may describe the sensation of liquid
or solid food “sticking” in the esophageal region with swallowing or overall difficulty
with swallowing (Kahrilas & Smout, 2010). It is necessary to rule out organic medi-
cal conditions such as eosinophilic esophagitis (EoE) prior to treating the patient for
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HYPNOTHERAPY FOR ESOPHAGEAL DISORDERS 29
functional dysphagia as EoE may cause food impaction, esophageal narrowing, or stric-
tures which could explain dysphagia. One incident of dysphagia can be enough to cause
food aversion, fear of choking, and anxiety related to the experience happening again.
Behavioral modifications (i.e., chew food well, eat slowly, drink throughout meal) are
recommended as a first course of action in the treatment of dysphagia, while dila-
tion, botulin toxin injection, or smooth muscle relaxants may also provide symptom
relief (Lind, 2003). Published literature on the use of hypnosis for dysphagia is limited,
however one significant case study by Kopel and Quinn (1996) discussed their work.
A 60-year-old gentleman with cancer developed dysphagia and would require dilation
to manage esophageal strictures. It was noted that the patient was a mildly anxious man,
but no significant psychological history. Over the course of 8 HYP sessions, imagery and
suggestions centered on the experience of eating to aid with swallowing and decrease
anticipatory emotional arousal. Successful treatment allowed the patient to begin swal-
lowing liquid and saliva, eat small amounts of solid food and undergo dilation and other
medically necessary treatment (Kopel & Quinn, 1996). The authors of this article (MR
and LK) have also used esophageal-directed HYP for functional dysphagia and one such
case example will be discussed to reflect the effectiveness of this form of behavioral
treatment.
Case Example: HYP for Dysphagia
To highlight the manner in which clinical hypnosis provides treatment benefits that at
times could not be provided from a medical standpoint, a case study with a 32-year-old
gentleman is presented. A single episode food impaction while eating a steak dinner,
followed by a trip to the emergency department (ED), precipitated the onset of func-
tional dysphagia. At the ED he received a GI workup, was treated with medication,
and then prescribed PPI therapy to begin daily. His initial symptoms resolved, but he
began to feel anxious about eating and over the course of 3 months post-impaction, he
developed dysphagia for solid foods, belching, and regurgitation. At one point, EoE was
suspected and a gastroenterologist prescribed a course of steroids. The patient’s symp-
toms worsened and he began taking alprazolam as needed to aid with symptom specific
anxiety. The patient was then referred to our tertiary outpatient clinic and evaluated by
a gastroenterologist with world renowned expertise in the treatment of esophageal dis-
orders. At the conclusion of the workup (endoscopy and manometry), the patient was
disappointed that there were no surgical options for his benign condition. He was then
referred by the gastroenterologist for a behavioral medicine evaluation with the author
(MR). The patient was contemplating a trip to Mayo for a third opinion, but agreed to
wait until attempting behavioral treatment. A brief course of treatment using CBT to
address catastrophic fears of eating and esophageal-directed HYP resulted in a complete
resolution of debilitating symptoms.
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30 RIEHL AND KEEFER
The intervention took place over a 6-week period (one initial intake evaluation,
5 weeks of treatment) during which the patient was introduced to psychological treat-
ment and hypnosis for the first time. He reported no history of psychological impairment
prior to the initial food impaction. The patient was married with one young son, was
gainfully employed, and regularly exercised. Over a period of 3 months he experienced
decreased appetite initially, but then began to have difficulty swallowing solids which
lead to unintentional weight loss. He discontinued all exercise for fear of losing more
weight. He was tolerating a liquid/soft food diet of high calorie protein drinks, pudding,
and mashed potatoes. The stress of this symptom experience caused the patient to expe-
rience increased situational anxiety related to food and he began to isolate himself during
meals so that others would not distract him. The initial treatment focused on providing
the patient with psychoeducation pertaining to the nature of his functional issues, dis-
cussed the role of esophageal hypersensitivity and how this can impact the experience of
discomfort and irritation throughout his throat and esophagus. Once the medical workup
was complete, this data was sufficient in providing the patient with evidence that there
were no strictures or abnormalities that would cause him to choke and therefore that fear
began to dissipate.
The patient was instructed to slowly re-introduce solid foods into his diet despite
ongoing dysphagia symptoms of discomfort and the sensation that food remained in the
esophagus. By eating slowly and chewing thoroughly he began to improve his diet. He
kept a food log throughout treatment and also tracked his daily esophageal symptoms.
Four sessions of esophageal-directed HYP were completed focusing on relaxing imagery
and a decrease in physiological arousal. Each session centered on different images
adapted from the scripted protocols for other esophageal and gut-directed protocols (i.e.,
soothing liquid, healing light, free flowing stream). Over the course of treatment the
patient used a CD for daily home practice which he found very beneficial in terms of
self-mastery for self-hypnosis. The final session concluded with a hypnosis interven-
tion centered on maintaining the gains of treatment. The patient returned to his normal
diet and exercise regimen, re-engaged with family, and food fears and aversion were
resolved. He also planned to continue the practice of self-hypnosis and home relaxation
techniques and discontinued alprazolam. It is important to highlight that had this patient
not been referred for a behavioral medicine evaluation, he would have undergone a third,
invasive GI workup with medical providers which likely would have put him no closer to
symptom resolution. He was very pleased with the outcome and required no follow up.
Summary and Conclusions
In conclusion, outside of medication and conventional medical treatment, options for
patients with bothersome esophageal complaints are limited. While research focused
on the use of hypnosis for these disorders is also limited, the strong evidence-base for
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HYPNOTHERAPY FOR ESOPHAGEAL DISORDERS 31
HYP in other GI disorders (Palsson, 2010) can inform the future of research in this area.
Despite limitations of low sample sizes and inability to double blind a trial of hypnosis,
researchers should continue to pursue study in the area of esophageal concerns. In addi-
tion to an initial medical workup, HYP to manage disorders of the esophagus appears to
be a viable consideration for the treatment of appropriate candidates. It has been found
that in the treatment of FGIDs there is a 60–70% chance of substantial symptom reduc-
tion and long standing results (Miller & Whorwell, 2009). The authors find this treatment
to be of significant value in behavioral health settings and patients find the intervention
enjoyable and beneficial.
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... 153 La hipnoterapia parece modular los patrones de activación cerebral asociados al procesamiento del dolor. 154 En trastornos funcionales digestivos el objetivo es inducir un estado de relajación profunda con el fin de guiar a los pacientes en el ejercicio de algún control sobre su función digestiva. 155 En un ECA realizado en pacientes con DTNC, la hipnoterapia demostró una reducción en las puntuaciones globales de dolor en el 80% de los pacientes en comparación con un 23% de respuesta en el grupo control (p = 0,008). ...
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El dolor torácico no cardiogénico se define como la presencia de dolor retroesternal recurrente en el que la etiología cardiovascular ha sido descartada de manera objetiva. Se estima que su prevalencia global en la comunidad es del 13%. Nuestro enfoque en esta revisión se centrará en las causas esofágicas de dolor retroesternal, las cuales ocupan el primer lugar dentro de las causas no cardíacas. Las herramientas diagnósticas disponibles en la actualidad para evaluar los trastornos esofágicos relacionados con dolor torácico no cardiogénico incluyen: ensayos terapéuticos con inhibidores de bomba de protones, videoendoscopía digestiva alta, monitoreo ambulatorio de reflujo y manometría esofágica de alta resolución. El tratamiento debe estar dirigido al mecanismo fisiopatológico subyacente responsable de los síntomas. Las opciones terapéuticas incluyen fármacos (inhibidores de bomba de protones y neuromoduladores), tratamiento endoscópico, cirugía y terapias psicológicas.
... El objetivo de la hipnoterapia dirigida al esófago es promover un estado profundo de relajación, con un enfoque que permita al paciente aprender a modular las sensaciones fisiológicas y los síntomas que no pueden ser fácilmente tratados con intervenciones médicas convencionales 36 . ...
... 11 As many as 50% of patients with GERD symptoms have incomplete relief with pharmacological acid suppression, 12,13 which remains a challenge in clinical GERD management. Oesophageal neuromodulators, oesophagealdirected hypnotherapy and cognitive behavioural therapy have shown therapeutic benefits especially for proton pump inhibitor (PPI)-refractory symptoms, [14][15][16][17][18] but strategies for optimal patient selection for these therapies have not been consistently investigated. ...
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Background The pathogenesis of gastro-oesophageal reflux disease (GERD) is complex and multifactorial. The oesophageal hypervigilance and anxiety scale (EHAS) is a novel cognitive-affective evaluation of visceral sensitivity. Aims To investigate the interrelationship between EHAS and reflux symptom severity, psychological stress, acid reflux burden, phenotypes, and oesophageal mucosal integrity in patients with GERD. Methods Patients with chronic reflux symptoms and negative endoscopy underwent 24-hour impedance-pH monitoring for phenotyping, acid reflux burden, and mucosal integrity with mean nocturnal baseline impedance (MNBI) calculation. Validated scores for patient-reported outcomes, including EHAS, GERD questionnaire (GERDQ), State-Trait Anxiety Inventory score, and Taiwanese Depression Questionnaire score, were recorded. Results We enrolled 105 patients, aged 21-64 years (mean, 48.8), of whom 58.1% were female; 27 had non-erosive reflux disease, 43 had reflux hypersensitivity and 35 had functional heartburn. There were no significant differences in sex, EHAS, GERDQ, questionnaires of depression or anxiety among GERD phenotypes. EHAS was significantly correlated with GERDQ, questionnaires of depression and anxiety (P < 0.05). However, there were no significant correlations between GERDQ and questionnaires of depression or anxiety. Regarding patient-reported outcomes, GERDQ positively correlated with acid exposure time and negatively correlated with MNBI (P < 0.05). Conclusions EHAS associates with reflux symptom severity and psychological stress but not with acid reflux burden or mucosal integrity. Thus, EHAS assessment shows promise in assessment of subjective patient outcome and satisfaction with treatment, a hitherto unmet clinical need.
... The treatment of reflux hypersensitivity and functional heartburn hinges on patient education, reassurance, and therapy including relaxation strategies, psychological interventions such as gut-directed hypnotherapy and cognitive behavioral therapy, and/or pharmacologic neuromodulation. [42][43][44][45] These approaches can also be valuable in patients with refractory GERD as many will exhibit a component of esophageal hypersensitivity and/or hypervigilance after suffering from chronic pathologic GERD. ...
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Objectives: Irritable bowel syndrome (IBS) is a chronic functional gastrointestinal disorder. Evidence relating to the treatment of this condition with antidepressants and psychological therapies continues to accumulate. Methods: We performed an updated systematic review and meta-analysis of randomized controlled trials (RCTs). MEDLINE, EMBASE, and the Cochrane Controlled Trials Register were searched (up to December 2013). Trials recruiting adults with IBS, which compared antidepressants with placebo, or psychological therapies with control therapy or "usual management," were eligible. Dichotomous symptom data were pooled to obtain a relative risk (RR) of remaining symptomatic after therapy, with a 95% confidence interval (CI). Results: The search strategy identified 3,788 citations. Forty-eight RCTs were eligible for inclusion: thirty-one compared psychological therapies with control therapy or "usual management," sixteen compared antidepressants with placebo, and one compared both psychological therapy and antidepressants with placebo. Ten of the trials of psychological therapies, and four of the RCTs of antidepressants, had been published since our previous meta-analysis. The RR of IBS symptom not improving with antidepressants vs. placebo was 0.67 (95% CI=0.58-0.77), with similar treatment effects for both tricyclic antidepressants and selective serotonin reuptake inhibitors. The RR of symptoms not improving with psychological therapies was 0.68 (95% CI=0.61-0.76). Cognitive behavioral therapy, hypnotherapy, multicomponent psychological therapy, and dynamic psychotherapy were all beneficial. Conclusions: Antidepressants and some psychological therapies are effective treatments for IBS. Despite the considerable number of studies published in the intervening 5 years since we last examined this issue, the overall summary estimates of treatment effect have remained remarkably stable.
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Proton pump inhibitors (PPIs) remove most of the acid from the gastroesophageal refluxate. However, PPIs do not eliminate reflux and the response of specific GERD symptoms to PPI therapy depends on the degree to which acid drives those symptoms. PPIs are progressively less effective for heartburn, regurgitation, chest pain and extra-oesophageal symptoms. Hence, with an incomplete PPI response, obtaining an accurate history, detailing which symptoms are 'refractory' and exactly what evidence exists linking these symptoms to GERD is paramount. Reflux can continue to cause symptoms despite PPI therapy because of persistent acid reflux or weakly acidic reflux. Given these possibilities, diagnostic testing (pH or pH-impedance monitoring) becomes essential. Antireflux surgery is an alternative in patients if a clear relationship is established between persistent symptoms, particularly regurgitation, and reflux. Treating visceral hypersensitivity may also benefit the subset of GERD patients whose symptoms are driven by this mechanism.
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Twenty-nine patients with esophageal symptoms and contraction abnormalities of the esophageal body completed a 6-wk, double-blind, placebocontrolled trial of trazodone (100–150 mg1day). Measures of esophageal and psychologic symptoms were completed at entry and at each follow-up visit. Esophageal manometry was repeated at the termination of the trial. Upon completion of the treatment, patients receiving trazodone (n = 15) reported a significantly greater global improvement than those receiving placebo (n =14; p=0.02). Although a variable clinical response was observed, the trazodone group had less residual distress over esophageal symptoms compared with the placebo group (59% ± 9% vs. 108% ± 19%, p=0.03). Manometric changes observed during the course of the trial were not influenced by treatment nor by clinical response. Remarkable reductions in ratings of chest pain were reported by both treatment groups, emphasizing the importace of controlled trials when studying this patient population. We conclude that low-dose trazodone therapy can be of benefit in the management of symptomatic patients with esophageal contraction abnormalities. In addition, our findings support recent observations that manometric abnormalities characterizing this patient group may not be solely responsible for symptoms.
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The evaluation of dysphagia begins with a careful history, which points to the underlying cause in up to 80% of cases. Subsequent studies depend on whether the history points to an oropharyngeal cause of dysphagia or an esophageal cause, and whether the history points to a mechanical or motor abnormality in patients with esophageal dysphagia. This article reviews the pertinent historical features and diagnostic studies that allow for an efficient evaluation of patients with dysphagia. Strategies for the evaluation and management of these patients are discussed with an emphasis on management of the functional causes of dysphagia.
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The North Carolina protocol is a seven-session hypnosis-treatment approach for irritable bowel syndrome that is unique in that the entire course of treatment is designed for verbatim delivery. The protocol has been tested in two published research studies and found to benefit more than 80% of patients. This article describes the development, content, and testing of the protocol, and how it is used in clinical practice.
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Functional heartburn (FH) is a benign but burdensome condition characterized by painful, burning epigastric sensations in the absence of acid reflux or symptom-reflux correlation. Esophageal hypersensitivity and its psychological counterpart, esophageal hypervigilance (EHv) drive symptom experience. Hypnotherapy (HYP) is an established and preferred intervention for refractory symptoms in functional gastrointestinal disorders (FGIDs) and could be applied to FH. The objective of this study was to determine the feasibility, acceptability, and clinical utility of 7 weekly sessions of esophageal-directed HYP (EHYP) on heartburn symptoms, quality of life, and EHv. Similar to other work in FGIDs and regardless of hypnotizability, there were consistent and significant changes in heartburn symptoms, visceral anxiety, and quality of life and a trend for improvement in catastrophizing. We would recommend EHYP in FH patients who are either non-responsive to medications or who would prefer a lifestyle intervention.
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Introduction: Gastroesophageal reflux disease (GERD), functional dyspepsia (FD) and irritable bowel syndrome (IBS) are common functional gastrointestinal conditions with significant impact on the daily lives of individuals. The objective was to investigate the prevalence and overlap of the three conditions in a Western general population. Material and methods: A nationwide study of 100,000 individuals 20 years and above, randomly selected in the general population. A web-based questionnaire survey formed the basis of this study. Questions regarding FD and IBS were extracted from the ROME III adult questionnaire. Questions regarding GERD were developed based on the Montreal definition. Prevalence estimates for GERD, FD IBS were calculated in total and for each sex separately and for four age groups. A Venn diagram was constructed, illustrating the overlap between the three conditions. Results: The overall response rate was 52.2%. The prevalence of GERD, FD and IBS was 11.2%, 7.7% and 10.5%, respectively, and overlap between two or three of these conditions was seen among 6.5% of the respondents. Among individuals meeting the criteria of one or more of the conditions GERD, FD and IBS, 30.7% had overlap between two or all three conditions. Conclusion: GERD, FD and IBS are common conditions in the general population and the overlap between these conditions is also quite common. When diagnosing patients with GERD, FD and IBS, physicians should keep in mind that these patients could be suffering from more than one of these conditions.
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Background Selective serotonin reuptake inhibitors (SSRIs) are used to treat noncardiac chest pain (NCCP) symptoms, however, data regarding their efficacy remains inconclusive.AimTo conduct a meta-analysis of randomised controlled trials (RCT) comparing SSRIs to placebo in patients with NCCP, and rate the quality of evidence.Methods Electronic databases were searched using the terms ‘noncardiac chest pain’, ‘atypical chest pain’ and ‘selective serotonin reuptake inhibitors’. Data were extracted from RCTs of ≥8 weeks. Standardised mean differences (SMD), weighted mean differences (WMD) or risk ratios (RR) were used as summary statistics for pooled outcomes. GRADE methodology was used to rate the quality of evidence.ResultsFour RCTs (184 patients) met the inclusion criteria. Compared to placebo, patients on SSRIs showed a nonsignificant change in chest pain of 3½ points decrease on a 100 mm visual analogue scale (184 patients, 95% CI, −9.5 to 2.5; I2 = 0%). Change in depression scores was not significantly different between the two groups (88 patients; WMD = 0.7; 95% CI, −1.81 to 3.20; I2 = 64%). Treatment discontinuations were not significantly different between groups (154 patients, RR = 2.08; 95% CI, 0.77–5.60; I2 = 0%). The quality of evidence was rated as moderate for change in chest pain symptoms, low for change in depression scores and moderate for treatment discontinuation due to adverse events.Conclusions Selective serotonin reuptake inhibitors are not superior to placebo in improving chest pain or depression symptoms in patients with noncardiac chest pain. Larger trials with longer follow-up periods are necessary to assess the benefits and drawbacks of SSRIs for the treatment of noncardiac chest pain.
Article
Upper gastrointestinal complaints are common among patients in a gastrointestinal clinic. Outside of typical gastroesophageal reflux disease symptoms that are treated with medication, the symptom presentations of esophageal patients, particularly those with functional conditions, are often difficult to treat and account for high health-care utilization. This manuscript describes the role of a health psychologist in the treatment of esophageal disorders using behavioral medicine interventions. Observations over the course of a 1-year period indicate that the sample presents with a relatively low level of psychological distress but reports negative effects of their symptoms on health-related quality of life. Five case examples of commonly treated disorders (globus, non-cardiac chest pain, functional dysphagia, rumination syndrome, supragastric belching) are described to highlight how behavioral treatment can improve patients' symptoms, decrease health-care utilization, and improve overall quality of life in a timely and relatively simple manner. Successful treatment outcomes are associated with a collaborative working alliance between patient, health psychologist, and gastroenterologist. Results indicate the benefit of referring appropriate esophageal patients to a health psychologist with specialization in gastroenterology. © 2014 International Society for Diseases of the Esophagus.
Article
Proton pump inhibitors (PPIs) remove most of the acid from the gastroesophageal refluxate. However, PPIs do not eliminate reflux and the response of specific GERD symptoms to PPI therapy depends on the degree to which acid drives those symptoms. PPIs are progressively less effective for heartburn, regurgitation, chest pain and extra-oesophageal symptoms. Hence, with an incomplete PPI response, obtaining an accurate history, detailing which symptoms are 'refractory' and exactly what evidence exists linking these symptoms to GERD is paramount. Reflux can continue to cause symptoms despite PPI therapy because of persistent acid reflux or weakly acidic reflux. Given these possibilities, diagnostic testing (pH or pH-impedance monitoring) becomes essential. Antireflux surgery is an alternative in patients if a clear relationship is established between persistent symptoms, particularly regurgitation, and reflux. Treating visceral hypersensitivity may also benefit the subset of GERD patients whose symptoms are driven by this mechanism.