No change in rectal sensitivity after gut-directed hypnotherapy in children with functional abdominal pain or irritable bowel syndrome

Non-pharmacologic approaches to treatment of pediatric functional abdominal pain disorders

Functional abdominal pain disorders (FAPDs) affect up to 25% of children in the United States. These disorders are more recently known as disorders of "brain-gut" interaction. The diagnosis is based on the ROME IV criteria, and requires the absence of an organic condition to explain the symptoms. Although these disorders are not completely understood, several factors have been involved in the pathophysiology including disordered gut motility, visceral hypersensitivity, allergies, anxiety/stress, gastrointestinal infection/inflammation, as well dysbiosis of the gut microbiome. The pharmacologic and non-pharmacologic treatments for FAPDs are directed to modifying these pathophysiologic mechanisms. This review aims to summarize the non-pharmacologic interventions used in the treatment of FAPDs including dietary modifications, manipulation of the gut microbiome (neutraceuticals, prebiotics, probiotics, synbiotics and fecal microbiota transplant) and psychological interventions that addresses the "brain" component of the brain-gut axis (cognitive behavioral therapy, hypnotherapy, breathing and relaxation techniques). In a survey conducted at a large academic pediatric gastroenterology center, 96% of patients with functional pain disorders reported using at least 1 complementary and alternative medicine treatment to ameliorate symptoms. The paucity of data supporting most of the therapies discussed in this review underscores the need for large randomized controlled trials to assess their efficacy and superiority compared to other treatments.

Clinical Hypnosis for Pediatric Gastrointestinal Disorders: A Practical Guide for Clinicians

Functional abdominal pain disorders (FAPDs) are common in the pediatric population and are associated with a significant reduction in quality of life. Bidirectional communication of the brain-gut axis plays an important role in pain generation and perception in FAPDs. There is a paucity of data on the best approach to treat this group of disorders, with no Food and Drug Administration (FDA)-approved drugs and scarce research to substantiate the use of most medications. Use of hypnosis in pediatric FAPDs is supported by evidence and has long-term benefits of up to at least 5 years beyond completion of treatment, highlighting the importance of incorporating this therapy into the care of these patients. The mechanisms by which clinical hypnosis is beneficial in the treatment of FAPDs is not completely understood, but there is growing evidence that it impacts functioning of the brain-gut axis, potentially through influence on central pain processing, visceral sensitivity, and motility. The lack of side effects or potential for significant harm and low cost makes it an attractive option compared to pharmacologic therapies. This review addresses current barriers to clinical hypnosis including misconceptions among patients and families, lack of trained clinicians, and questions around insurance reimbursement. The recent use of telemedicine and delivery of hypnosis via audio-visual modalities allow more patients to benefit from this treatment. As the evidence base for hypnosis grows, acceptance and training will likely increase as well. Further research is needed to understand how hypnosis works and to develop tools that predict who is most likely to respond to hypnosis. Studies on cost-effectiveness in comparing hypnosis to other therapies for FAPDs will increase evidence for appropriate healthcare utilization. Because hypnosis has applications beyond pain and is child-friendly with minimal to no risk, hypnosis could be an important therapeutic tool in the wider pediatric gastrointestinal population.

Future of Brain-Gut Behavior Therapies: Mediators and Moderators

With growing evidence to support their efficacy, brain-gut behavior therapies are increasingly viewed as a key component to integrated care management of disorders of gut-brain interaction. However, the types of brain-gut behavior therapies differ in how and for whom they purportedly work. We provide a conceptual review of these brain-gut behavior therapies, with an emphasis on describing how (ie, mechanisms) and for whom (ie, moderators) they work as hypothesized and/or supported by evidence. Based on evidence to date, we recommend that brain-gut behavior therapies prioritize gastrointestinal-specific targets, such as gastrointestinal-specific anxiety.

Behavioral Strategies for Irritable Bowel Syndrome: Brain-Gut or Gut-Brain?

Irritable bowel syndrome (IBS) is a disorder of gut-brain interaction (DGBI) that is associated with significant physical, emotional, and occupational burden. Factors such as early life stress, sleep disruption, maladaptive coping strategies, symptom hypervigilance, and visceral hypersensitivity negatively affect gut-brain communication and increase the likelihood of developing IBS or worsen IBS severity. Behavioral strategies, such as cognitive behavioral therapy, gut-directed hypnosis, and mindfulness-based treatments, have shown benefit in improving gastrointestinal (GI)-specific quality of life, as well as reducing GI symptoms. Partnering with a GI-specific mental health provider can assist gastroenterologists in providing comprehensive treatment of IBS and other DGBIs.

Paediatric functional abdominal pain disorders

Paediatric functional abdominal pain disorders, currently referred to as disorders of gut-brain interaction, comprise irritable bowel syndrome, functional dyspepsia, abdominal migraine and functional abdominal pain not otherwise specified, as defined by the Rome IV diagnostic criteria. Functional abdominal pain disorders are common disorders with a prevalence of 3-16% depending on country, age and sex. A greater understanding of aetiopathogenesis and pathophysiology is emerging and includes intestinal components (inflammation, motility and the microbiota), central factors (psychological aspects, sensitization and/or differences in connectivity or activity of certain brain regions) as well as extrinsic factors (infections). In particular, the timing of disruption of the microbiota-gut-brain axis seems to be important. Diagnosis is challenging but is primarily based on clinical symptoms and exclusion of other organic causes, with an emphasis on avoiding unnecessary invasive diagnostic procedures. The available pharmacological interventions are limited in children and, therefore, management has focused on combined approaches, including mind-targeted interventions (hypnotherapy and cognitive behavioural therapy), diet (probiotics) and percutaneous electrical nerve field stimulation. The evidence for their clinical efficacy, although limited, is favourable, with positive impacts on symptoms and overall quality of life. The coming decades hold promise for improved understanding and management of these enigmatic disorders.

Definitions of Pediatric Functional Abdominal Pain Disorders and Outcome Measures: A Systematic Review

OBJECTIVE

To systematically review definitions of functional abdominal pain orders (FAPDs) and outcome measures used in therapeutic randomized controlled trials in pediatric FAPDs adhering to the Outcome Measures in Rheumatology recommendations.

STUDY DESIGN

Cochrane, MEDLINE, Embase, and Cinahl databases were systematically searched from inception to April 2018. English-written therapeutic randomized controlled trials concerning FAPDs in children aged 4-18 years were included. Definitions of FAPDs, interventions, outcome measures, measurement instruments, and outcome assessors of each study were tabulated descriptively. Quality was assessed using the Delphi List.

RESULTS

A total of 4771 articles were found, of which 64 articles were included (n = 25, 39% of high methodologic quality). The Rome III (50%), Rome II (17%), Apley (16%), and author-defined (17%) criteria were used to define FAPDs. Fourteen studies (22%) assessed a pharmacologic, 25 (39%) a dietary, and 25 (39%) a psychosocial intervention. Forty-four studies (69%) predefined their primary outcomes. In total, 211 reported predefined outcome measures were grouped into 23 different outcome domains; the majority being patient-reported (n = 27, 61%). Of the 14 studies that evaluated a pharmacologic intervention, 12 (86%) reported on adverse events.

CONCLUSIONS

Studies on pediatric FAPDs are of limited methodologic quality and show large heterogeneity and inconsistency in defining FAPDs and outcome measures used. Development of a core outcome set is needed to make comparison between intervention studies possible.

Integration of Biomedical and Psychosocial Treatments in Pediatrics Functional Gastrointestinal Disorders

Pediatric functional gastrointestinal disorders (FGIDs) are disorders of the brain-gut axis. Pathophysiological factors include alterations in gut motility, microbiota, immune system, central nervous system, and psychosocial factors. Given the complex pathophysiology of FGIDs, many patients are in need of integrative treatment approaches that may include a combination of biomedical, nutritional, and psychological approaches. In this article, we examine goals of treatment; give a brief overview of biomedical, nutritional, and psychological approaches; and finally discuss the integrative management of pediatric FGIDs.

Focus on the use of antidepressants to treat pediatric functional abdominal pain: current perspectives

Chronic abdominal pain is frequently encountered in pediatric practice. A large proportion of cases meet Rome criteria for abdominal pain-functional gastrointestinal disorders (AP-FGIDs). These disorders are costly and, in some cases, lead to impairment of daily functioning and overall quality of life. Pathophysiologic mechanisms include early stressful events, visceral hypersensitivity, dysmotility, changes in intestinal microbiota, and altered central nervous system processing. They are considered disorders of the brain-gut interaction. The diagnosis is made on clinical grounds using symptom-based criteria (Rome criteria). Anxiety and depressive symptoms are more prevalent in patients with AP-FGIDs. Therefore, attention has been directed to the use of neuromodulators as potential interventions for AP-FGIDs. Antidepressants are one type of neuromodulators, and one of the most studied drugs for the management of AP-FGIDs in adult and pediatric population. Data available in pediatric population have significant limitations including nonuniform methodology with different study designs and primary endpoints. Evidence of the efficacy of antidepressants in the management of pediatric AP-FGIDs is not consistent. There is an urgent need for well-designed randomized clinical trials using age-appropriate validated outcome measures. Careful consideration must be given to adverse effects, particularly increased suicidal ideation.

Comparison of gut-directed hypnotherapy and unspecific hypnotherapy as self-help format in children and adolescents with functional abdominal pain or irritable bowel syndrome: a randomized pilot study

OBJECTIVE

Psychosocial treatments for chronic abdominal pain in childhood or adolescence are effective, but time consuming and hardly available. In the present study, gut-directed hypnotherapy (GDHT) and unspecific hypnotherapy (UHT) were compared to evaluate the feasibility and efficacy of a hypnotherapeutic self-help intervention.

PARTICIPANTS AND METHODS

Children/adolescents between 6 and 17 years of age with chronic abdominal pain were randomized to GDHT or UHT. The treatment period was 12 weeks each. Measurements were performed before and after treatment. The primary outcome was a pain diary. Analysis was carried out as per protocol.

RESULTS

Of 45 participants included, 13 were lost to follow-up. Thirty-two participants (14 GHDT, 18 UHT) were analyzed. Dropouts had higher pain severity. Completers in both conditions showed good adherence and a similar decrease in days with pain and pain duration. Pain intensity decreased only in the UHT condition. Eleven participants (two GDHT, nine UHT) achieved clinical remission (>80% improvement) and 13 participants (seven GDHT, six UHT) improved significantly (30-80%).

CONCLUSION

Results suggest a high efficacy of standardized home-based hypnotherapy for children/adolescents with abdominal pain. Children/adolescents with high pain severity are at risk of dropping out. The UHT condition showed slight evidence of superiority, but conditions were equivalent on most outcomes. Taken together, self-help approaches based on hypnotherapy could close a treatment gap and prevent chronification.

Psychosocial interventions for recurrent abdominal pain in childhood

BACKGROUND

This review supersedes the original Cochrane review first published in 2008 (Huertas-Ceballos 2008).Between 4% and 25% of school-aged children complain of recurrent abdominal pain (RAP) severe enough to interfere with their daily activities. No organic cause for this pain can be found on physical examination or investigation for the majority of such children. Although many children are managed by reassurance and simple measures, a large range of psychosocial interventions involving cognitive and behavioural components have been recommended.

OBJECTIVES

To determine the effectiveness of psychosocial interventions for reducing pain in school-aged children with RAP.

SEARCH METHODS

In June 2016 we searched CENTRAL, MEDLINE, Embase, eight other databases, and two trials registers. We also searched the references of identified studies and relevant reviews.

SELECTION CRITERIA

Randomised controlled trials comparing psychosocial therapies with usual care, active control, or wait-list control for children and adolescents (aged 5 to 18 years) with RAP or an abdominal pain-related functional gastrointestinal disorder defined by the Rome III criteria were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Five review authors independently selected studies, assessed them for risk of bias, and extracted relevant data. We also assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

This review includes 18 randomised controlled trials (14 new to this version), reported in 26 papers, involving 928 children and adolescents with RAP between the ages of 6 and 18 years. The interventions were classified into four types of psychosocial therapy: cognitive behavioural therapy (CBT), hypnotherapy (including guided imagery), yoga, and written self-disclosure. The studies were carried out in the USA, Australia, Canada, the Netherlands, Germany, and Brazil. The majority of the studies were small and short term; only two studies included more than 100 participants, and only five studies had follow-up assessments beyond six months. Small sample sizes and the degree of assessed risk of performance and detection bias in many studies led to the overall quality of the evidence being rated as low to very low for all outcomes.For CBT compared to control, we found evidence of treatment success postintervention (odds ratio (OR) 5.67, 95% confidence interval (CI) 1.18 to 27.32; Z = 2.16; P = 0.03; 4 studies; 175 children; very low-quality evidence), but no evidence of treatment success at medium-term follow-up (OR 3.08, 95% CI 0.93 to 10.16; Z = 1.85; P = 0.06; 3 studies; 139 children; low-quality evidence) or long-term follow-up (OR 1.29, 95% CI 0.50 to 3.33; Z = 0.53; P = 0.60; 2 studies; 120 children; low-quality evidence). We found no evidence of effects of intervention on pain intensity scores measured postintervention (standardised mean difference (SMD) -0.33, 95% CI -0.74 to 0.08; 7 studies; 405 children; low-quality evidence), or at medium-term follow-up (SMD -0.32, 95% CI -0.85 to 0.20; 4 studies; 301 children; low-quality evidence).For hypnotherapy (including studies of guided imagery) compared to control, we found evidence of greater treatment success postintervention (OR 6.78, 95% CI 2.41 to 19.07; Z = 3.63; P = 0.0003; 4 studies; 146 children; low-quality evidence) as well as reductions in pain intensity (SMD -1.01, 95% CI -1.41 to -0.61; Z = 4.97; P < 0.00001; 4 studies; 146 children; low-quality evidence) and pain frequency (SMD -1.28, 95% CI -1.84 to -0.72; Z = 4.48; P < 0.00001; 4 studies; 146 children; low-quality evidence). The only study of long-term effect reported continued benefit of hypnotherapy compared to usual care after five years, with 68% reporting treatment success compared to 20% of controls (P = 0.005).For yoga therapy compared to control, we found no evidence of effectiveness on pain intensity reduction postintervention (SMD -0.31, 95% CI -0.67 to 0.05; Z = 1.69; P = 0.09; 3 studies; 122 children; low-quality evidence).The single study of written self-disclosure therapy reported no benefit for pain.There was no evidence of effect from the pooled analyses for any type of intervention on the secondary outcomes of school performance, social or psychological functioning, and quality of daily life.There were no adverse effects for any of the interventions reported.

AUTHORS' CONCLUSIONS

The data from trials to date provide some evidence for beneficial effects of CBT and hypnotherapy in reducing pain in the short term in children and adolescents presenting with RAP. There was no evidence for the effectiveness of yoga therapy or written self-disclosure therapy. There were insufficient data to explore effects of treatment by RAP subtype.Higher-quality, longer-duration trials are needed to fully investigate the effectiveness of psychosocial interventions. Identifying the active components of the interventions and establishing whether benefits are sustained in the long term are areas of priority. Future research studies would benefit from employing active control groups to help minimise potential bias from wait-list control designs and to help account for therapist and intervention time.

Complementary and Alternative Medicine Use by Children With Pain in the United States

OBJECTIVE

Chronic pain is reported by 15% to 25% of children. Growing evidence from clinical samples suggests that complementary and alternative medicine (CAM) therapies are desired by families and may benefit some children with pain conditions. The objective of this study was to provide estimates of CAM use by children with pain in the United States.

METHODS

We analyzed data from the 2012 National Health Interview Survey (NHIS) to estimate patterns, predictors, and perceived benefits of CAM use among children 4 to 17 years of age with and without painful conditions in the United States. We used chi-square tests to compare the prevalence rates of CAM use among children with pain to CAM use among children without pain. Multivariable logistic regression was used to examine factors associated with CAM use within the group of children with pain conditions.

RESULTS

Parents reported that 26.6% of children had pain conditions (eg, headache, abdominal, musculoskeletal pain) in the past year; of these children, 21.3% used CAM. In contrast, only 8.1% of children without pain conditions used CAM (χ², P < .001). CAM use among children with pain was associated with female sex (adjusted odds ratio [aOR] = 1.49, P = .005), higher income (aOR = 1.61, P = .027), and presence of 4+ comorbidities (aOR = 2.01, P = .013). Among children with pain who used CAM, the 2 most commonly used CAM modalities were biology-based therapies (47.3%) (eg, special diets and herbal supplements) and manipulative or body-based therapies (46.3%) (eg, chiropractic and massage).

CONCLUSIONS

CAM is frequently used by children with pain in the United States, and many parents report benefits for their child's symptoms.

A study of human colonic motility in healthy and constipated subjects using the wireless capsule

Constipation is a common and distressing condition that has been linked to major morbidity, burdens the health care system, and impacts patients׳ quality of life. However, there is no perfect method for diagnosing and treating constipation. The purpose of this paper is to develop an automatic algorithm to identify patients with constipation from healthy subjects. Data from 12 healthy subjects and 10 patients with constipation were analyzed. The key challenges for data processing were data filtering, feature extraction, information evaluation, and providing the reference conclusion; these were resolved by employing the phase space reconstruction (PSR), independent component analysis (ICA), dynamic feature extraction algorithm, and the Wilcoxon rank sum test. The contractile frequency (Fr), motility index per unit time (MIU), average peak of peristaltic wave (Pave) and variance (Var) were extracted as dynamic parameters and analyzed. Results between groups were compared with the Wilcoxon rank sum test. There were statistically significant differences between healthy subjects and patients with constipation for Fr and MIU (P<0.05), whereas there was no statistically difference for Var. Moreover, the Fr and MIU of patients with normal transit constipation (NTC) are significantly lower compared to healthy subjects, whereas patients with slow transit constipation (STC) did not show significant differences. The proposed algorithms were able to differentiate between healthy subjects and patients with constipation based on the colonic motility profiles.

Hypnosis Treatment of Gastrointestinal Disorders: A Comprehensive Review of the Empirical Evidence

Hypnotherapy has been investigated for 30 years as a treatment for gastrointestinal (GI) disorders. There are presently 35 studies in the published empirical literature, including 17 randomized controlled trials (RCTs) that have assessed clinical outcomes of such treatment. This body of research is reviewed comprehensively in this article. Twenty-four of the studies have tested hypnotherapy for adult irritable bowel syndrome (IBS) and 5 have focused on IBS or abdominal pain in children. All IBS hypnotherapy studies have reported significant improvement in gastrointestinal symptoms, and 7 out of 10 RCTs in adults and all 3 RCTs in pediatric patient samples found superior outcomes for hypnosis compared to control groups. Collectively this body of research shows unequivocally that for both adults and children with IBS, hypnosis treatment is highly efficacious in reducing bowel symptoms and can offer lasting and substantial symptom relief for a large proportion of patients who do not respond adequately to usual medical treatment approaches. For other GI disorders the evidence is more limited, but preliminary indications of therapeutic potential can be seen in the single randomized controlled trials published to date on hypnotherapy for functional dyspepsia, functional chest pain, and ulcerative colitis. Further controlled hypnotherapy trials in those three disorders should be a high priority. The mechanisms underlying the impact of hypnosis on GI problems are still unclear, but findings from a number of studies suggest that they involve both modulation of gut functioning and changes in the brain's handling of sensory signals from the GI tract.

Review article: gut-directed hypnotherapy in the management of irritable bowel syndrome and inflammatory bowel disease

BACKGROUND

Gut-directed hypnotherapy is being increasingly applied to patients with irritable bowel syndrome (IBS) and to a lesser extent, inflammatory bowel disease (IBD).

AIM

To review the technique, mechanisms of action and evidence for efficacy, and to identify gaps in the understanding of gut-directed hypnotherapy as a treatment for IBS and IBD.

METHODS

A review of published literature and a systematic review of clinical trials in its application to patients with IBS and IBD were performed.

RESULTS

Gut-directed hypnotherapy is a clearly described technique. Its potential mechanisms of action on the brain-gut axis are multiple with evidence spanning psychological effects through to physiological gastrointestinal modifications. Six of seven randomised IBS studies reported a significant reduction (all P < 0.05) in overall gastrointestinal symptoms following treatment usually compared to supportive therapy only. Response rates amongst those who received gut-directed hypnotherapy ranged between 24% and 73%. Efficacy was maintained long-term in four of five studies. A therapeutic effect was also observed in the maintenance of clinical remission in patients with ulcerative colitis. Uncontrolled trials supported the efficacy and durability of gut-directed hypnotherapy in IBS. Gaps in understanding included to whom and when it should be applied, the paucity of adequately trained hypnotherapists, and the difficulties in designing well controlled-trials.

CONCLUSIONS

Gut-directed hypnotherapy has durable efficacy in patients with IBS and possibly ulcerative colitis. Whether it sits in the therapeutic arsenal as a primary and/or adjunctive therapy cannot be ascertained on the current evidence base. Further research into efficacy, mechanisms of action and predictors of response is required.

The role of hypnotherapy for the treatment of inflammatory bowel diseases

Inflammatory bowel diseases (IBD) are chronic disorders of unknown aetiology which are characterized by episodes of exacerbations and remissions. There is evidence that perceived distress contributes to IBD symptom flares; anxiety and depression are frequently found in patients with the active disease. Because there is no cure, treatment has to focus on prevention of complications, induction/maintenance of remission and improvement of quality of life. Gut-directed hypnotherapy (GHT) has been used successfully in functional gastrointestinal disorders. Few experimental studies and case reports have been published for IBD; GHT increases the health-related quality of life and reduces symptoms. Additionally, GHT seems to have an immune-modulating effect and is able to augment clinical remission in patients with quiescent ulcerative colitis.

Sensitivity and specificity of hypnosis effects on gastric myoelectrical activity

Objectives

The effects of hypnosis on physiological (gastrointestinal) functions are incompletely understood, and it is unknown whether they are hypnosis-specific and gut-specific, or simply unspecific effects of relaxation.

Design

Sixty-two healthy female volunteers were randomly assigned to either a single session of hypnotic suggestion of ingesting an appetizing meal and an unappetizing meal, or to relax and concentrate on having an appetizing or unappetizing meal, while the electrogastrogram (EGG) was recorded. At the end of the session, participants drank water until they felt full, in order to detect EGG-signal changes after ingestion of a true gastric load. During both conditions participants reported their subjective well-being, hunger and disgust at several time points.

Results

Imagining eating food induced subjective feelings of hunger and disgust as well as changes in the EGG similar to, but more pronounced than those seen with a real gastric water load during both hypnosis and relaxation conditions. These effects were more pronounced when imagining an appetizing meal than with an unappetizing meal. There was no significant difference between the hypnosis and relaxation conditions.

Conclusion

Imagination with and without hypnosis exhibits similar changes in subjective and objective measures in response to imagining an appetizing and an unappetizing food, indicating high sensitivity but low specificity.

Brief hypnotherapeutic-behavioral intervention for functional abdominal pain and irritable bowel syndrome in childhood: a randomized controlled trial

Functional abdominal pain and irritable bowel syndrome are two prevalent disorders in childhood which are associated with recurrent or chronic abdominal pain, disabilities in daily functioning, and reduced quality of life. This study aimed to evaluate a brief hypnotherapeutic-behavioral intervention program in a prospective randomized controlled design. Thirty-eight children, 6 to 12 years of age, and their parents were randomly assigned to a standardized hypnotherapeutic-behavioral treatment (n = 20) or to a waiting list condition (n = 18). Both groups were reassessed 3 months after beginning. Primary outcome variables were child-completed pain measures and pain-related disability. Secondary outcome variables were parent-completed measures of their children's pain and pain-related disability. Health-related quality of life from both perspectives also served as a secondary outcome. In the treatment group, 11 of 20 children (55.0%) showed clinical remission (>80% improvement), whereas only one child (5.6%) in the waiting list condition was classified as responder. Children in the treatment group reported a significantly greater reduction of pain scores and pain-related disability than children of the waiting list condition. Parental ratings also showed a greater reduction of children's abdominal pain and pain-related disability. Health-related quality of life did not increase significantly.

CONCLUSIONS

Hypnotherapeutic and behavioral interventions are effective in treating children with long-standing AP. Treatment success of this brief program should be further evaluated against active interventions with a longer follow-up.

Effect of hypnotherapy and educational intervention on brain response to visceral stimulus in the irritable bowel syndrome

BACKGROUND

Gut-directed hypnotherapy can reduce IBS symptoms, but the mechanisms underlying this therapeutic effect remain unknown.

AIM

To determine the effect of hypnotherapy and educational intervention on brain responses to cued rectal distensions in IBS patients.

METHODS

Forty-four women with moderate-to-severe IBS and 20 healthy controls (HCs) were included. Blood oxygen level dependent (BOLD) signals were measured by functional Magnetic Resonance Imaging (fMRI) during expectation and delivery of high- (45 mmHg) and low-intensity (15 mmHg) rectal distensions. Twenty-five patients were assigned to hypnotherapy (HYP) and 16 to educational intervention (EDU). Thirty-one patients completed treatments and posttreatment fMRI.

RESULTS

Similar symptom reduction was achieved in both groups. Clinically successful treatment (all responders) was associated with significant BOLD attenuation during high-intensity distension in the dorsal and ventral anterior insula (cluster size 142, P = 0.006, and cluster size 101, P = 0.005 respectively). Moreover HYP responders demonstrated a pre-post treatment BOLD attenuation in posterior insula (cluster sizes 59, P = 0.05) while EDU responders had a BOLD attenuation in prefrontal cortex (cluster size 60, P = 0.05). Pre-post differences for expectation conditions were almost exclusively seen in the HYP group. Following treatment, the brain response to distension was similar to that observed in HCs, suggesting that the treatment had a normalising effect on the central processing abnormality of visceral signals in IBS.

CONCLUSIONS

The abnormal processing and enhanced perception of visceral stimuli in IBS can be normalised by psychological interventions. Symptom improvement in the treatment groups may be mediated by different brain mechanisms.

CLINICAL TRIAL NUMBER

NCT01815164.

Functional abdominal pain in childhood: background studies and recent research trends

The present review summarizes many of the major research trends investigated in the past five years regarding pediatric functional abdominal pain, and also summarizes the primary related findings from the authors' research program. Specific areas discussed based on work within the authors' group include familial illness patterns, genetics, traits, and mechanisms or processes related to abdominal pain. Topics covered from research published in the past five years include prevalence and cost, longitudinal follow-up, overlap with other disorders, etiology and mechanisms behind functional abdominal pain and treatment studies. It is hoped that findings from this work in abdominal pain will be interpreted as a framework for understanding the processes by which other pain phenomena and, more broadly, reactions to any physical state, can be developed and maintained in children. The present article concludes with recommendations for clinical practice and research.

Effects on gastrointestinal transit and antroduodenojejunal manometry after gut-directed hypnotherapy in irritable bowel syndrome (IBS)

BACKGROUND

Gut-directed hypnotherapy is an effective treatment in irritable bowel syndrome (IBS) but little is known about the mechanisms of action. In this study we aimed to investigate the effects on gastrointestinal motility when treating IBS with gut-directed hypnotherapy.

METHODS

We randomized 90 patients with IBS, refractory to standard management to receive gut-directed hypnotherapy 1 h/week for 12 weeks or supportive treatment for the same time period. Eighty-one subjects (40 hypnotherapy, 41 controls) could be evaluated by one or more of the following investigations, both before and after the intervention: gastric emptying time, small bowel transit time, colonic transit time, and antroduodenojejunal manometry.

RESULTS

No significant differences in gastric emptying time, small bowel transit time, or colonic transit time was found when comparing the baseline and post-intervention measurements in the hypnotherapy group or in the control group. The same was true concerning the results of the antroduodenojejunal manometry. However, there was a numerical trend toward a higher number of migrating motor complexes at manometry and an accelerated gastric emptying time after hypnotherapy that did not reach statistical significance.

CONCLUSIONS

In this study, we were not able to find evidence for long-standing effects on gastrointestinal motility as a mediator of the effects on IBS when treating the condition with gut-directed hypnotherapy. Further research to understand the mechanism of action is needed.

Brain-gut axis: from basic understanding to treatment of IBS and related disorders

The present review describes advances in understanding the mechanisms and provide an update of present and promising therapy directed at the gut or the brain in the treatment of irritable bowel syndrome (IBS). The diagnosis of IBS typically is based on identification of symptoms, such as the Rome III criteria for IBS in adults and children. The criteria are similar in children and adults. The focus of the present review is the bowel dysfunction associated with IBS.

Enhanced auditory brainstem response and parental bonding style in children with gastrointestinal symptoms

BACKGROUND

The electrophysiological properties of the brain and influence of parental bonding in childhood irritable bowel syndrome (IBS) are unclear. We hypothesized that children with chronic gastrointestinal (GI) symptoms like IBS may show exaggerated brainstem auditory evoked potential (BAEP) responses and receive more inadequate parental bonding.

METHODOLOGY/PRINCIPAL FINDINGS

Children aged seven and their mothers (141 pairs) participated. BAEP was measured by summation of 1,000 waves of the electroencephalogram triggered by 75 dB click sounds. The mothers completed their Children's Somatization Inventory (CSI) and Parental Bonding Instrument (PBI). CSI results revealed 66 (42%) children without GI symptoms (controls) and 75 (58%) children with one or more GI symptoms (GI group). The III wave in the GI group (median 4.10 interquartile range [3.95-4.24] ms right, 4.04 [3.90-4.18] ms left) had a significantly shorter peak latency than controls (4.18 [4.06-4.34] ms right, p = 0.032, 4.13 [4.02-4.24] ms left, p = 0.018). The female GI group showed a significantly shorter peak latency of the III wave (4.00 [3.90-4.18] ms) than controls (4.18 [3.97-4.31] ms, p = 0.034) in the right side. BAEP in the male GI group did not significantly differ from that in controls. GI scores showed a significant correlation with the peak latency of the III wave in the left side (rho = -0.192, p = 0.025). The maternal care PBI scores in the GI group (29 [26]-[33]) were significantly lower than controls (31 [28.5-33], p = 0.010), while the maternal over-protection PBI scores were significantly higher in the GI group (16 [12]-[17]) than controls (13 [10.5-16], p = 0.024). Multiple regression analysis in females also supported these findings.

CONCLUSIONS

It is suggested that children with chronic GI symptoms have exaggerated brainstem responses to environmental stimuli and inadequate parental behaviors aggravate these symptoms.

Hypnosis for functional abdominal pain

Chronic abdominal pain is a common pediatric condition affecting 20% of the pediatric population worldwide. Most children with this disorder are found to have no specific organic etiology and are given the diagnosis of functional abdominal pain. Well-designed clinical trials have found hypnotherapy and guided imagery to be the most efficacious treatments for this condition. Hypnotic techniques used for other somatic symptoms are easily adaptable for use with functional abdominal pain. The author discusses 2 contrasting hypnotic approaches to functional abdominal pain and provides implications for further research. These approaches may provide new insights into this common and complex disorder.