3. Definition
• A functional bowel disorder characterized by
chronic abdominal pain, discomfort, bloating,
and alteration of bowel habits in the absence of
any detectable organic cause. In some cases,
the symptoms are relieved by bowel
movements. Diarrhoea or constipation may
predominate, or they may alternate (classified
as IBS-D, IBS-C or IBS-A, respectively). IBS
may begin after an infection (post-infectious,
IBS-PI), a stressful life event, or onset of
maturity without any other medical indicators.
• Prevalence 10.5% 6.6% men 14% women
Copyright A. Dobbin 3/12/2010
4. Co-morbidities with other
symptoms
• One of these: functional dyspepsia,
gastroesophageal reflux disease, functional
constipation, and anal incontinence in 50% of
cases (1)
• Fibromyalgia, chronic fatigue syndrome, and
chronic pelvic pain are best documented and
appear in up to 65% (1)
• Estimates of common psychiatric co-morbidities
with IBS patients range widely up to 61% have
anxiety disorder. (2)
• All studies suggest that anxiety and IBS „share
common biological factors‟ (2)
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5. Early Trauma (IBS)
• Meta analysis of studies (1) - 2007)
• Sexual Abuse all 39%, Child 24%, Adult
28%
• Physical abuse all 21% child 28% adult
22%
Other MUS Early Trauma
• Chronic Pelvic Pain SA:46% PA 43% CSA
49%
• Conversion Disorder SA:47% PA 26%
CSA 23%
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7. Common features of co-
morbidities
• Preponderance of female gender: why?
Different routes of pain suppression M:F ,
hormonal augmentation. Sociocultural
features. Increased sexual abuse/physical
abuse.
• Single symptoms can be aggravated by
stress and psychosocial burden
• Co-morbidities have a positive predictive
value for a more negative course of IBS
• A different subgroup?
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8. Cognitive Bias
• Patients with IBS as with patients with depression show a
selective attentional bias for negative words
(percieved threat) – without manifesting depression. (1)
• Faces expressing anxiety led to bilaterally increased
activity in the insular cortex and in the anterior cingulate
gyrus. This effect was disproportionately increased by
simultaneous distension stimulation of the esophagus
(over neutral faces). (2)
• Patients with functional intestinal disorders not
only show attention-dependent alterations of
central nervous system processing of intestinal
stimuli but also a generally negative emotional
tendency in their cognitive processing
strategies.(3)
Copyright A. Dobbin 3/12/2010
9. Pain Processing Pathways
increase in insular stimulation with anxious faces over
neutral causing increased pain in normal individuals
Visceral pain processing preferentially stimulates medial tract. When the
“attention loop” is highly activated, the lowest stimulus intensity would
maximally stimulate the affective-motivational pain system. Hypnosis has been
shown to increase or decrease the insular response to pain, and dissociates the
cognitive and affective components of sensation
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10. vagus
Spinal
cord
Guts
Mind Body Loop – Fear pathway (after Ledoux)
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11. IBS shows a combination of
high cortisol (present in IBS)
and amygdalar activity. Due
to dissociation there is a
focus on the attentional
channels of the visceral and
somatic channels
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12. Hypervigilance
Is whiplash a form of MUS?
Copyright A. Dobbin 3/12/2010
13. Treatment
• Review of evidence from Cochrane
Database
• Antispasmodics: evidence is weak
• Antidepressants: no evidence
• Bulking agents: no evidence
• Advised to use agents symptomatically
• No long term benefit
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14. Treatment Psychological
• CBT and interpersonal therapy and
relaxation: effective immediately after
treatment no sustained effect (2009)
• Hypnotherapy: superior to medical
management or waiting list control in
refractory IRBS (2007)
• Individual studies show lasting effect 5
years later.
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15. Hypnotherapy (1)
• reduces levels of anxiety and depression in IBS sufferers
• abnormal cognitions about their disorder significantly
improved (indirect spontaneous effect)
• it can reduce the strength of contractions in the distal
colon normalise rectal sensitivity influence gastric
emptying affect gastric acid secretion, alter the
gastrocolonic response to food and slow oral–caecal
transit time
• Reduce activation of the anterior cingulate cortex
• capacity to modulate immunological responsiveness and
inflammation (? Effect on depression left prefrontal
cortex as immune organ)
• 70% of patents helped
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16. Major effect of hypnotherapy
Disconnection of the affective/cognitive
link in the Anterior Cingulate Cortex
Removal of skin conductance (sympathetic
nervous system probably due to above)
Shift to right sided cerebral processing
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17. Gruzelier, J. (1998). A working model of the neurophysiology of hypnosis: a review of
the evidence. Contemporary Hypnosis, 15, 3-21
Karl Friston – Thomas Bayes
Copyright A. Dobbin 3/12/2010
18. BES scale
• Scale of beliefs about the unacceptability
of experiencing or expressing negative
emotions
• Directly related to symptamatology in
IBS resolves with CBT
• Shaun: patient with tachyarrythmia
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19. Emotional Regulation of Negative
Emotions
• There are a number of ways of „dealing
with‟ unpleasant emotions. These are:
• Avoidance of stress
• Attentional manipulation
• Suppression of emotion
• Re-appraisal („Transformation‟ in
Buddhism)
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22. Further Work on Suppression
• Subjects told to find & suppress negative
autobiographical memory.
• Also to record number of times negative
memory intrudes in SOC exercise
• Then asked to respond to emotionally
valenced words
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23. Basis of Rumination?
Quicker
response
Figure 1. Mean latency in seconds (error bars are ±1 SE) to retrieve autobiographical memories
to positive and negative cue words on the recall task in the dysphoric and nondysphoric groups
across the suppress and no-suppress conditions
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24. Suppression
• Increases sympathetic arousal
• Decreases positive experience
• Increases access to negative memories
• Increases access to suppressed memory
• Social consequences - increases partners
stress
Copyright A. Dobbin 3/12/2010
25. Common themes in therapy
Mindfulness/ CBT/ Hypnotherapy/ ACT/ Therapist
effect
• Common link is thinking style. All these therapies
encourage beneficial thinking style.
• Ruminative thinking style Vs experiential:
example „focus your attention‟ Vs „think about‟
• Practice noticing mind and body
• Hypnotherapy diminishes the Rt posterior parietal
lobe (affected in anasagnosia – a stroke with
neglect of the left side) which greatly magnifies the
external perspective (involuntary effects)
• Regular mindfulness practice achieves the same.
There is a thickening of the pre-frontal cortex signal
that switches off the amygdala
Copyright A. Dobbin 3/12/2010
26. Benefits of Experiential Thinking Style
• reducing overgeneral memory
• improving problem solving in depression
• reducing emotional vulnerability to failure
• positively associated with reappraisal negatively
associated with depressive rumination, experiential
avoidance, and emotional suppression
• Less self evaluative
• “the ability to view one‟s self as not synonymous with
one‟s thoughts . . . the ability to not react habitually to
one‟s negative experiences” (Fresco et al., 2007, p.
236).
Copyright A. Dobbin 3/12/2010
27. Reappraisal
• Extinction of fear is caused by the creation of
a new inhibitory pathway from the pre-frontal
cortex to the amygdala. In classical extinction
this is from the vmPFC, in humans however it
also comes from the Dorso-lateral pre-frontal
cortex, in evolution an area controlling eye
movement to direct attention, it is now an
area used for abstract thought, mathematics,
the external perspective in experiential
thinking and reappraisal.
Copyright A. Dobbin 3/12/2010
29. Reappraisal - Visualisation -
Extinction – common pathway
• Mechanisms of reappraisal, visualisation,
and many other techniques (including
placebo response) may share the same
pathway as extinction - evolution has
piggybacked this technique
• The
ref: Delgado, M.R., Nearing, K.I., Ledoux, J., Phelps, E.A. (2008).
Neural circuitry underlying the regulation of conditioned fear and its
relation to extinction. Neuron, 59, 829-38
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30. Reappraisal needs to be implicit:
attentional distraction hypnosis or
mindfulness
Gruzelier, J. (1998). A working model of the neurophysiology of hypnosis: a review of
the evidence. Contemporary Hypnosis, 15, 3-21
Karl Friston – Thomas Bayes
Copyright A. Dobbin 3/12/2010
31. Reappraisal
• You find you can never ever fail
• You will learn from your mistakes
• You will grow as a result of difficulties
• You will see problems as solutions
• You will see hindrances as challenges
• You have a right to be angry/sad
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