RESEARCH FINDINGS USING GUIDED
IMAGERY FOR
IRRITABLE
BOWEL SYNDROME
August, 2006
Definition
Irritable Bowel Syndrome (IBS),
sometimes called spastic colon, irritable colon, or nervous
stomach, is a functional disorder of the bowel. It is
marked by abdominal pain, and associated with changes in
bowel habit (either in frequency, urgency, or
characteristics). A precise cause is unknown, but faulty
interaction between the gut, brain, and central nervous
system seems to result in the bowel becoming over-reactive
(Characteristics of IBS, 2006).
Additionally, the pain receptors in many IBS patients’ guts
are unusually sensitive (Irritable Bowel Syndrome, 2006).
Stress and diet don’t cause IBS, but they can trigger
symptoms.
Many people develop IBS after a bacterial infection in the
intestinal tract (gastroenteritis). This condition is
referred to as post-infectious IBS. As many as 78% of
people with IBS have an overgrowth of intestinal bacterial
(Pimentel, Chow, and Lin, 2000).
The major symptom of IBS is a change in the patient’s bowel
function -- usually diarrhea, constipation, or alternating
between the two. Other symptoms include bloating, abdominal
fullness, flatulence, nausea, and reflux (where stomach
contents “back up”). Some people experience exhaustion or
chest pain that is not cardiac--related. Depression is
prevalent in IBS patients.
People with IBS often have a lower quality of life. IBS can
affect sleep, sexual functioning, business and personal
obligations, and social life. IBS is further complicated by
comorbidity with other conditions, such as fibromyalgia,
Chronic Fatigue Syndrome (CFIDS), and thyroid disease.
Incidence
and Costs
IBS
is more common than diabetes, asthma, heart disease, or
hypertension (Adams and Benson, 1991). It affects between
20%-22% of Americans, 60%-65% of whom are women
(Characteristics of IBS). Up to 70% of those meeting the
diagnostic criteria for IBS do not seek treatment
(Irritable Bowel Syndrome, 2002). Annual U.S. direct
medical costs are estimated at $1.35 billion annually
(Inadomi, Fennerty & Bjorkman, 2003), with 3.5 million
office visits and 2.2 million prescriptions filled
(Sandler, 1990).
Indirect costs, amounting to $205 million, include frequent
absenteeism (Inadomi, Fennerty & Bjorkman). One study
estimated that IBS patients are absent from work or school
three times more often than their non-IBS counterparts
(Drossman, Li, et al, 1993). Authors of another study
concluded that 25% of those with IBS worked fewer hours,
and 20% changed their work schedule because of the
condition (Hungin, Tack, 2002).
Diagnosis
and Medical Treatment
Since
there are no conclusive diagnostic tests, IBS is a
diagnosis of exclusion. This means that the doctors usually
rule out other possible causes of the symptoms. Medication
is geared toward reducing or relieving symptoms.
Prescriptives include antispasmodics, antidiarrhetics,
laxatives, bulking agents, and prokinetic agents (to move
food quickly through the bowel). If a patient is depressed
or has severe pain that doesn’t respond to other treatment,
two other classes of drugs (SSRIs and low-dose tricyclic
antidepressants) are used.
Complementary Treatment
Early
studies indicate that peppermint oil and Chinese herbal
medicine warrant further study (Jailwala, Imperiale, and
Kroenke, 2000), as do Slippery elm, fenugreek, devil's
claw, tormentil and wei tong ning (Langmead, Dawson, et al,
2002). The results of one well-designed trial demonstrated
that Chinese herbal medicine was significantly effective in
improving symptoms, and quality of life (Bensoussan,
Talley, et al, 1998).
Other non-pharmaceutical treatment includes patient
education, diet modification (including identification and
avoidance of food triggers), and mind-body therapies.
Mind-Body
Approaches
There
is a strong mind-body component to IBS, and emotions have
been shown to affect gut motility (Salt and Neimark, 2002;
Whorwell, Houghton, et al, 1991) and patient perception, as
illustrated in the study where hypnotically induced anger
and excitement increased the motility of the colon, while
happiness reduced motility (Houghton, Calvert, et al,
2002).
The literature supporting mind-body therapies is
compelling. Relaxation (Blanchard, Greene, and Scharff,
1993; Keefer and Blanchard, 2001, 2002; Voirol and
Hipolito, et al, 1987) and biofeedback (Leahy,
Clayman, et al, 1998) have shown success in improving
symptoms and preventing relapse. One approach (relaxation,
therapy, and medication) was effective in two-thirds of
patients who had not responded to medication alone
(Guthrie, Creed et al, 1992).
Another combination regimen (progressive muscle relaxation,
thermal biofeedback, cognitive therapy, education) had a
50% success rate, maintained four years later (Schwarz,
Taylor, et al, 1990). Meditation was able to affect
improvements that were maintained a year later (Keefer and
Blanchard, 2002).
Confirming the power of the mind-body connection, placebo,
positive suggestion, and positive expectation were
effective in reducing both the sensory and motor components
of the gastric response in IBS patients (Simren, Ringstrom,
et al, 2004). Placebo and positive suggestion increased the
effectiveness of lidocaine in reducing pain (Vase,
Robinson, et al, 2003).
Recent reviews of the literature confirmed the efficacy of
hypnosis (Hussain and Quigley, 2006; Tan, Hammond, and
Joseph, 2005; Whitehead, 2006). Hypnosis uses relaxation,
suggestion, and imagery for its effects (Palsson, undated).
Its positive effects may be due to changes in colorectal
sensitivity and improved psychological factors (Simren,
2006).
Hypnosis has been shown to improve symptoms (Palsson,
Turner, et al, 2002), even in severe refractory cases
(Barabasz A, Barabasz M, 2006; Forbes, MacAulay, and
Chiotakakou-Faliakou, 2000; Francis and Houghton, 1996;
Galovski and Blanchard, 1998; Houghton, Heyman, and
Whorwell, 1996; Roberts, Wilson, et al, 2006), and in cases
where psychotherapy has failed (Whorwell, Prior, and
Faragher, 1984). Improvements can be sustained at long-term
(Gonsalkorale, Miller, et al, 2003; Gonsalkorale &
Whorwell, 2005).
Both the Forbes et al. and the Galovsky et al.
studies used
gut-directed suggestion, and the results showed significant
symptom improvement. Forbes specifically looked at the
effect of therapeutic suggestions on audiotape and found
them effective. The Houghton et al. study results showed
“profound” improvement in physical symptoms (pain bloating
and bowel habit). People also felt that their quality of
life was better, and that they felt more in control of
their situation. They lost less time at work and needed
fewer doctor’s office visits than the control group
(Houghton, Heyman & Whorwell).
Researchers of one review paper reported that, in 19 of 22
studies reviewed, psychotherapy was superior to medication
(Svedlund, 2002). In another study, patients receiving
therapy improved, while patients receiving medication
deteriorated (Svedlund, Sjodin, et al, 1983). A large-scale
British study (250 patients) confirmed that hypnosis
significantly improved not only symptoms, but also
depression, anxiety, and quality of life
(Gonsalkorale,
Houghton, & Whorwell, 2002).
An at-home pre-scripted hypnosis was also effective, but
not as effective as one-on-one hypnosis (Palsson, Turner,
& Whitehead, 2006). Both individual and group hypnosis
sessions proved effective (Harvey, Hinton, et al, 1989).
Mind-body techniques are effective in not only reducing
IBS’s physical symptoms, but also in lifting depression
and/or improving quality of life (Blanchard, Radnitz, et
al, 1987; Gonsasalkorale, Toner, & Whorwell, 2004;
Houghton Heyman & Whorwell, 1996; Read, 1999).
Conclusion
A
very low-cost guided imagery program can improve patients’
abilities to cope with IBS pain, reduce or eliminate its
symptoms and/or recurrences, reduce office visits,
absenteeism and, in some cases, medications. These benefits
can be long-lasting. It may improve patients’ quality of
life and symptoms, even in difficult IBS cases.
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