By Mylène Gorissen
When being tense about a presentation or the coming Christmas holidays, many children experience abdominal pain as an expression of stress. Once the presentation is over or the gifts have finally been received, this belly pain has vanished. In some of these children however, the abdominal pains take the form of functional abdominal pain (FAP) or irritable bowel syndrome (IBS). Unfortunately, these types of pain can not be treated by opening a present.
Abdominal pain is common in children, with a worldwide prevalence of FAP and IBS of 13.5% [1]. These types of abdominal pain are characterised by chronic or recurrent abdominal pain without any detectable organic disorder [2]. Instead of a defect in the gut, these abdominal disorders rely on an imbalance in the brain-gut-axis. One’s psychosocial development is affected by genetics and environmental factors like exposure to infections, family influences on illness expression and major losses [3]. This has an effect on the susceptibility to life stress or psychological state and coping skills, and also on the predisposition to gut dysfunction [3]. The gut dysfunction is the result of altered mucosal immunity, abnormal motility and visceral hypersensitivity (an abnormal reaction of the gut to otherwise normal stimuli, like food ingestion). In return, these brain-gut-variables influence their expression. Via the brain-gut-axis, the interaction of psychosocial factors and altered gut physiology result in the so-called functional gastrointestinal disorders [3].
Until recently, treatment for these functional abdominal disorders consisted of pharmacological pain management and education in the origin of the functional symptoms and lifestyle (including diet and fluid intake) [1]. In the case of obstipation, laxatives can be used. A treatment that received much attention in the Netherlands recently, is hypnotherapy. This is not like the hypnosis we see on television, with a mesmerist swinging a pocket watch in front of someone’s face in order to hypnotise the person and force him to do weird things. The hypnotherapy, in this case, is a well-developed psychological therapy.
The idea behind this psychological therapy is the biopsychosocial model in which a person’s biology (for example genetics and gastrointestinal physiology), behaviours (like avoidance, eating, exercise etcetera), and higher-order cognitive processes (like coping, information processing, illness beliefs and environmental stimuli) influence IBS symptom expression in the brain-gut-axis [4]. In hypnotherapy, the aim is to address the underlying biopsychosocial processes that contribute to symptom expression [4].
Therefore, verbal cues are used for inducing a state of deep relaxation. These cues are ‘gut-directed’ and opposed to unpleasant visceral sensations [4]. For example, the patient is instructed to feel relaxed and warm muscles around his or her belly [4]. In this way, the purpose of the therapy is to change the perception, emotions, thoughts, and behaviours contributing to abdominal pain [4]. Gut-directed hypnotherapy proved very effective, with success rates varying from 49% to 100% in adults and children [1]. The significant lower pain levels remained in the long-term as well. The therapy can be provided by a certified therapist but is also effective when done in self-exercises via CD [1]. This self-directed therapy is interesting since there are patients who do not have access to the therapy due to costs, geographic location or the absence of qualified therapists [4]. Despite the recent scientific support for the efficacy of hypnosis, there are still some questions that need to be answered, for example, the mechanisms that account for the therapeutic change [4]. Also, research on the differences in effectiveness is scarce. However, some hypotheses are formed. For example, treatment response differs between men and women, which may be attributable to different neural processing of visceral stimuli [1]. It is also known that negative beliefs mediate outcomes of cognitive behavior therapy and may predict long-term outcome in children with IBS: having fewer negative beliefs about the abdominal pain resulted in better treatment response [1]. Until then, keep this option in mind for treatment when assessing a child or even an adult with functional abdominal pain.
[1] Rutten JMTM et al. Home-Based Hypnotherapy Self-exercises vs Individual Hypnotherapy With a Therapist for Treatment of Pediatric Irritable Bowel Syndrome, Functional Abdominal Pain, or Functional Abdominal Pain Syndrome: A Randomized Clinical Trial. JAMA Pediatr. 2017 May 1;171(5):470-477.
[2] Rutten JM et al. Gut-directed hypnotherapy for functional abdominal pain or irritable bowel syndrome in children: a systematic review. Arch Dis Child. 2013 Apr;98(4):252-7.
[3] Drossman DA. The functional gastrointestinal disorders and the Rome III process. Gastroenterology 2006;130:1377–90.
[4] Radziwon CD, Lackner JM. Cognitive Behavioral Therapy for IBS: How Useful, How Often, and How does it work? Curr Gastroenterol Rep. 2017 Aug 17;19(10):49