Review Article

The Effectiveness of Group and Self-help Hypnotherapy for Irritable Bowel Syndrome and the Implications for Improving Patients' Choice and Access to Treatment

Carolyn Gillan

Aliment Pharmacol Ther. 2021;54(44512):1389-1404.

Abstract and Introduction

Abstract

Background: Individual hypnotherapy (IH) is a recognised treatment for irritable bowel syndrome (IBS). However, it is not widely available to patients due to its resource-intensive nature, lack of adequately trained therapists, and scepticism about hypnosis. Non-individualised hypnotherapy approaches, such as group and self-help hypnotherapy, could maximise existing therapist resources by treating more patients at the same time, thus widening patient access to treatment without incurring additional expenditure.

Aims: To investigate the research literature for non-individualised approaches to hypnotherapy for IBS and to determine their effectiveness for reducing symptom severity and/or providing adequate relief.

Methods: A literature review of published peer-reviewed studies was conducted. Quantitative research was selected to determine the effectiveness of the interventions.

Results: Ten studies were eligible for inclusion. Three delivered group hypnotherapy, three integrated hypnosis within a group concept, and four utilised a self-help home hypnotherapy treatment using audio recordings. Both group hypnotherapy for adults and the self-help home hypnotherapy treatment for children were effective interventions that may be non-inferior to IH for patients with mild-to-moderate symptoms. Treatment benefits were long-lasting. The evidence for the integrative group concept and home treatment for adults was less compelling.

Conclusions: Group hypnotherapy for adults, and self-help hypnotherapy for children, may be cost-effective treatments that can widen access for patients with milder IBS in primary care settings.

Abstract and Introduction
Materials and Methods
Review of the Literature
Implications for Future Research, Education and Practice
Conclusion
References

Table 1. Characteristics of included studies
Author, year, country (setting)	Design	n (age)	Population	Intervention	Control/Comparator	Primary outcome measure	Results
Berens et al,⁵² 2018, Germany (University Hospital)	Pilot RCT	34 (18–65)	IBS refractory to basic primary care treatment. Rome III with somatoform autonomic dysfunction symptom pattern⁵⁷	IG: GDH, education, psychodynamic therapy and CBT	Waitlist group receiving enhanced medical care, plus completion of online daily diary	IBS-SSS. Measure of clinical improvement was not defined	No significant improvements compared with control. IG scores improved from mean (SD) 271.18 (104.93) to 181.5 (79.09) producing a large within-group effect size d = 0.956 Control group also improved from mean (SD) 263.43 (106.05) to 231.69 (107.00) (effect size d = 0.298) ITT analysis with repeated-measures mixed ANOVA reported the main effect for the group was not significant (P = 0.370) nor was the time × group (P = 0.267). The effect size for between-group difference was moderate post-treatment (d = 0.539)
Flik et al,⁴⁹ 2019, the Netherlands (11 hospitals)	Multicentre, parallel group, long-term follow-up RCT	354 (18–65)	Rome III,⁵⁸ referred by primary and secondary care clinicians	GGDH	Educational supportive therapy (EST) & IH	ARQ "Did you have adequate relief of IBS related abdominal pain or discomfort in the past week?" Treatment response is defined as an answer of "Yes" 3 or 4 times over 4 consecutive weeks	Hypnotherapy significantly more effective than EST at 3 months P = 0.024 and 12 months P = 0.0185. ITT analysis at 3 months 40.8% of IH, 33.2% of GGDH and 16.7% of EST reported adequate relief. At 12 months 40.8% of IH, 49.5% of GGDH and 22.6% of EST reported adequate relief. Per-protocol analysis at 3 months 49.9% of IH and 42.7% of GGDH reported adequate relief. At 12 months 55.5% of IH and 51.7% of GGDH reported adequate relief. Therefore, GGDH non-inferior compared to IH at 3 months P = 0.34 and 12 months P = 0.17
Forbes et al,⁵³ 2000, UK (St Mark's Hospital—specialist bowel hospital and home-based)	Equivalence RCT	52 (19–71)	IBS diagnosis with 3 or more Manning et al⁵⁹ criteria and satisfying Rome 1⁶⁰ Symptomatic presentation for ≥6 months and refractory to fibre, antispasmodics and diet changes	HHT: Home-based autohypnosis, education and reassurance using audio recordings	IH	Daily symptom diary recording severity and frequency of pain, abdominal distension or bloating, excessive gas or wind, bowels open, stools/motions, performance at work/normal daily tasks, fatigue and tiredness. Measure of clinical improvement was not defined	Using ITT, symptom scores were reduced in 76% of IH and 59% of HHT participants with median post treatment scores of 11 and 13 respectively. The median differences of −3 (IH) and −1 (HHT) proved not to be significant. In the 45 participants who completed the symptom diary, IH median scores reduced from 14 to 8.5 and HHT median scores remained unchanged at 13 showing advantage to IH (P < 0.05). Semi-objective assessment by the assessor reported 52% improvement in both groups
Gerson et al,⁴⁸ 2013, United States (University Hospital)	Long-term follow-up, one group, pre-test, post-test	89 (20+)	Moderate to severe IBS refractory to prior medical treatment. Rome II⁶¹	GGDH		IBS-SSS. Clinical improvement is defined as ≥50 point reduction in IBS-SSS scores	ITT mean scores of IBS-SSS improved significantly from 259 to 196 (P < 0.05) Mean IBS-SSS scores of treatment completers improved significantly from 258 to 183 after 1 year (P < 0.001) Scores lower post treatment at every interval P < 0.001 45 of the 75 treatment completers (60%) achieved clinically significant improvement
Gulewitsch & Schlarb,⁵⁵ 2017, Germany (Home-based, contact via short telephone calls and emails)	RCT	45 (6–17)	Paediatric Rome III⁶²	HHT: GDH using audio recordings (GDH)	HHT: Unspecified hypnotherapy using audio recordings (UHT)	Daily symptom diary scoring number of days with pain, mean duration and intensity of pain. >80% improvement represented clinical remission. 30%-80% represented significant improvement. <30% considered unsuccessful	Reduction in number of days with pain: UHT P = 0.001, GDH P < 0.001 Reduction in pain intensity: UHT P < 0.001, GDH P = 0.171 (not significant) Reduction in pain episodes: UHT P = 0.001, GDH P < 0.005 Using ITT, significant reduction in symptoms over time for both groups [F(1,43) = 20.97–43.90, Ps < 0.001] Clinical remission (34%): UHT (n = 9), GDH (n = 2) Significant improvement (41%): UHT (n = 6), GDH (n = 7) Unsuccessful (25%): UHT (n = 3), GDH (n = 5)
Harvey et al,⁴⁷ 1989, UK (Hospital)	3 month follow up RCT	36 (19–62)	Refractory IBS is defined as abdominal pain, disordered bowel habit and abdominal distention	GGDH	IH	Daily symptom diary. Maximum weekly score of 63. Weekly score of ≤5 considered symptom free. Severe symptoms are defined as ≥35	No significant differences were reported between GGDH and IH Symptom-free (n = 11): IH (n = 5), GGDH (n = 6) Less symptoms (n = 9): IH (n = 3), GGDH (n = 6) No improvement (n = 13): IH (n = 8), GGDH (n = 5)
Moser et al,⁵¹ 2013, Austria (University Hospital)	Long-term follow-up RCT	100 (18–70)	Severe or incapacitating refractory IBS, Rome III²²	IG: GDH with supportive talks and medical treatment	Supportive talks and medical treatment (SMT)	IBS-IS. Mean score of ≤4 was defined as severe IBS. Clinical improvement is defined as an increase in an overall score of ≥1	IG was found to be superior to SMT. Significant improvements were reported within 12 weeks for IG: 28 out of 46 (60.8%) and SMT: 18 out of 44 (40.9%) [absolute difference 20%; 95% confidence interval (CI):0%-40.2%; P = 0.046] At the 12-month follow-up post-treatment, significant improvements were reported for 54.3% of IG and 25% of SMT participants (absolute difference 29.4%; 95% CI: 10.1%-48.6%; P = 0.004)
Palsson et al,⁵⁴ 2006, United States (Home-based, contact via e-mail, internet, mail)	Non-randomised comparative follow-up pilot study	25 (mean 43)	Clinical diagnosis satisfying Rome II⁶³ in an active phase of IBS	HHT: GDH treatment using audio recordings	Usual medical care	IBS-SSS. Clinical improvement is defined as >50% reduction in symptom severity	10 out of 19 participants (53%) HHT participants reported statistically significant improvements of ≥50% reduction in symptom severity in comparison to 15 out of 57 control group participants (26%) (P < 0.05).
Rutten et al,⁵⁶ 2017, Netherlands (Secondary and tertiary care centres, & home-based. Contact via visit from research nurse and two follow-up telephone calls)	Non-inferiority RCT with 1 year follow-up	260 (8–18)	Rome III⁶²	HHT: Home-based GDH treatment using audio recordings	IH	Daily symptom diary scoring pain frequency and intensity during 7 consecutive days. Treatment success is defined as ≥50% reduction in scores	HHT was reported to be significantly non-inferior to IH with 90% CI, P = 0.002 Immediately post treatment 46 (36.8%) HHT and 62 (50.1%) IH participants achieved treatment success. 12 months post treatment, 78 (62.1%) HHT and 88 (71.0%) IH participants achieved treatment success
Taylor et al,⁵⁰ 2004, England and Ireland (Hospital or community settings)	Feasibility study, one group, pre-test, post-test	190 (18–80)	Clinical diagnosis of IBS with compatible symptomatic presentation	IG: GDH with CBT		GSRS. Measure of clinical improvement was not defined	16 of 23 groups reported statistically significant improvements in gastrointestinal symptoms. When adjusted for clusters, scores significantly improved pre and post treatment from mean (SD) 40.2 (11.8) to 29.2 (9.4) (P < 0.001)

Abbreviations: ANOVA, analysis of variance; ARQ, Adequate Relief Questionnaire⁶⁴; CBT, cognitive behavioural therapy; GDH, gut-directed hypnotherapy; GGDH, group gut-directed hypnotherapy; GSRS, Gastrointestinal Symptom Rating Scale⁶⁵; HHT, Hypnotherapy Home Treatment; IBS-IS, IBS Impact Scale⁶⁶; IBS-SSS, IBS-Symptom Severity Scale²⁸; IH, Individual Hypnotherapy; ITT, Intention to Treat Analysis; RCT, Randomised Controlled Trial.