BRIEF REPORT Generalized Anxiety late-life GAD as a chronic disorder distinct from MDD. (Am J Geriatr Psychiatry 2005; 13:77–80) Disorder in Late Life Lifetime Course and Generalized anxiety disorder (GAD) in elderly Comorbidity With Major persons is highly prevalent1 and positively as-sociated with functional disability and healthcare Depressive Disorder utilization
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Jcn_1356 678.684G A S T R O I N T E S T I N A L N U R S I N G Effect of nurse-led gut-directed hypnotherapy upon health-relatedquality of life in patients with irritable bowel syndrome Graeme D Smith BA, PhD, RGNLecturer, School of Health in Social Science, University of Edinburgh, Old Medical School, Edinburgh, UK Submitted for publication: 29 July 2004Accepted for publication: 4 July 2005 Journal of Clinical Nursing 15, 678–684 The effect of nurse-led gut-directed hypnotherapy upon health-related quality of life in patients with irritable bowel syndrome Aims and objectives. This study quantified health-related quality of life in a group of irritable bowel syndrome patients and measures changes following a treatment programme of nurse-led gut-directed hypnotherapy.
Background. It is well recognized that health-related quality of life can be severely impaired in patients suffering form the irritable bowel syndrome. Current conven-tional treatment for irritable bowel syndrome is often unsatisfactory. In contrast ithas been shown that gut-directed hypnotherapy is an effective treatment of irritablebowel syndrome with up to three-quarters of patients reporting symptomaticimprovement.
Design/method. Seventy-five patients (55 females/20 males, median age 37Æ1 years,age range 18–64) comprised the study group. Physical symptoms of irritable bowelsyndrome were recorded using seven-day diary cards. On presentation the pre-dominant symptoms were abdominal pain (61%), altered bowel habit (32Æ5%), andabdominal distension/bloating (6Æ5%) in the patient group. An irritable bowelsyndrome quality of life questionnaire was used to define health-related quality oflife. Psychological well-being was measured using the Hospital Anxiety andDepression Scale. Data analysis was carried out using MINITAB, Release 12 forWindows.
Results. Physical symptoms statistically improved after hypnotherapy. There werealso significant statistical improvements (P < 0Æ001) in six of the eight health-related quality of life domains measured (emotional, mental health, sleep, physicalfunction, energy and social role). These improvements were most marked in femalepatients who reported abdominal pain as their predominant physical symptom.
Anxiety and depression improved following treatment.
Conclusion. Gut-directed hypnotherapy has a very positive impact on health-relatedquality of life with improvements in psychological well-being and physical symp-toms. It appears most effective in patients with abdominal pain and distension.
Relevance to clinical practice. This study demonstrates that by integrating com-plementary therapies into conventional care that gastrointestinal nurses have apotential role in the management of irritable bowel syndrome.
Key words: gut-directed hypnotherapy, health-related quality of life, irritable bowelsyndrome, nurse-led clinics, nursing These criteria state that within the preceding 12 months It has been estimated that between 10% and 15% of adults there should be at least 12 consecutive weeks of abdominaldiscomfort or pain that has two of the following three features: suffer from irritable bowel syndrome (IBS) and the physical, social and economic consequences of this illness are consid- • onset associated with a change in frequency of stool; and/or erable (Drossman et al. 1993). IBS accounts for up to 50% of • onset associated with a change in form of stool.
all referrals to out-patient gastroenterology clinics (Smith et al. 2004). It is characterized by physical symptomsincluding altered bowel habit, abdominal pain and distension Figure 1 Rome II criteria for diagnosing IBS.
(Heaton et al. 1982). Patients frequently report non-colonicsymptoms, such as lethargy, nausea and backache (Whorwell et al. 1986). In addition, anxiety and psychosocial problemsare common in IBS and have a large impact upon general The underlying cause of IBS is poorly understood because well-being (Drossman & Thompson 1992).
there are no objective or biochemical disease markers.
Therefore IBS can have a significant impact on health- Consequently, treatment options are often focused on the related quality of life (HRQoL) and several studies have relief of specific symptoms. Several proposed mechanisms to clearly shown that HRQoL is adversely affected by IBS (Houghton et al. 1996, Luscombe 2000, El-Serag et al. 2002).
This may be because of physical symptoms, psychological stress (Talley et al. 1996), sexual dysfunction (Guthrie et al.
1987) and effects upon employment, leisure, travel and diet There is clearly a close relationship between the central Given the absence of biological markers of IBS activity there nervous system and the gut, which is referred to as the brain/ has been a growing interest in the assessment of HRQoL in IBS gut axis. Gut function at the end-organ level is controlled and it is now recognized as an important outcome measure in by a very intricate nerve supply, the enteric nervous system.
IBS and several measurement tools have been developed The nerve fibres of the enteric system that line the gut (Patrick et al. 1998, Chassany et al. 1999). The objective of transmit messages of sensations and pain to higher centres in the present study was to measure the impact gut-directed the brain via the afferent arm of the autonomic nervous hypnotherapy has upon HRQoL as reported by patients.
The symptoms of IBS may be chronic or recurrent and can At present, there is no ‘gold standard treatment’ for this IBS.
vary between patients in nature and severity. Diagnosis must Little is known of the pathophysiology of IBS and, as a be based on the presence of key symptoms and IBS is consequence, medical treatment is often ineffective (Akehurst diagnosed positively on the basis of symptom criteria and the & Kaltenthaler 2001). In recent years there has been growing exclusion of organic gastrointestinal (GI) illnesses (Camilleri interest in the use of complementary therapies in gastro- & Choi 1997). Symptom-based diagnostic criteria have been used to define IBS for some time, initially the manning criteriain the 1970s followed by Rome I criteria in 1992 (Thompson et al. 1989). The most recent criteria are the Rome IIguidelines summarized in Fig. 1 (Thompson et al. 1999).
Treatment of IBS by conventional means is often disappoint-ing, with symptoms often failing to respond to traditionaltreatment. Despite the development of several new drugs drug therapies for IBS are of a limited value and have a poor There is no universal agreement about the aetiology of IBS; it evidence base (Spiller 1999). Pharmacological options tend to has been speculated that trigger factors could include stress, focus upon the predominant IBS symptom(s) and, generally, lifestyle, candida, prolonged use of antibiotics, post-gastro- treatment is empirical and patients may need to receive a enteritis, emotional trauma, or a combination of these number of different agents. The drug chosen usually depends on the patient’s presenting symptoms; constipation-predom- Ó 2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 678–684 inant IBS is treated differently from diarrhoea-predominant anxiety. Thus, anxiety may be a cause or a consequence of the disease. Pharmaceutical agents currently recommended by the British Society of Gastroenterology are summarized in Fig. 2 Phrases, such as, ‘I can’t stomach that’ or ‘gut feeling’ highlight the very significant role the gut plays as a vehicle ofsomatic expression. An understanding of role of psychosocialfactors is therefore required to optimize the nursing care of Non-pharmacological interventions: nursing role Previous research has suggested that a majority of nurses Gut-directed hypnotherapy has been shown to improve hold negative attitudes towards IBS sufferers. IBS patients physical symptoms in IBS patients. Whorwell et al. (1984, are viewed as attention seeking, unable to cope with life, 1987) reported 80% improvement in abdominal pain, bowel demanding and waste doctors’ time (Dancey & Backhouse habit and abdominal distension in a group of IBS patients 1993). However, more recently it has been clearly indicated treated by hypnotherapy. This group subsequently showed that these negative perceptions have changed dramatically that hypnotherapy had a positive effect upon a range of other and that present-day nurses fully understand the need for features of this disease and that treatment reduced the rate of specialist advice, support and reassurance for IBS patients absenteeism from work (Houghton et al. 1996). More (Nunn 2003). An understanding of the role of nurses in the recently, gut-directed hypnotherapy has been demonstrated assessment and management of patients with IBS, with to be an effective long-term treatment strategy for IBS specific regard to education, reassurance and psychological well-being, is now well established (Smith 2003).
There is evidence that nurses can integrate the principles of Although it is unlikely that psychological factors cause hypnotherapy into their clinical practice (Larkin 1999).
IBS, they appear to exert a strong influence on some Chapman (2004) has suggested that GI nurses may be the patients with the conditions. Disturbances of mood such as ideal health professional to practice hypnotherapy for anxiety and depression have also been shown to influence patients with IBS. In this study the effect of nurse-led gut- GI function and to occur commonly in IBS patients directed hypnotherapy upon physical, symptoms, psychoso- cial aspects and HRQoL was prospectively evaluated in a A clear relationship has been established between psychi- atric illness, psychosocial morbidity and IBS in patients whoseek medical help. Compared with healthy volunteers, IBS patients have higher scores for anxiety, hostile feelings,sadness, depression, and interpersonal sensitivity as well as Seventy-five IBS patients underwent gut-directed hypnother- apy. This was conducted as part of a nurse-led treatment There is, however, some difficulty interpreting the impli- programme, which also included education and support. All cations of the comorbidity between IBS and psychiatric patients fulfilled the Rome II diagnostic criteria (Thompson disorders such as anxiety and depression. For example, et al. 1999). Organic GI diseases were excluded by clinical although anxiety, via the autonomic nervous system, has evaluation and by specific radiological and endoscopic tests direct effects upon the GI tract and may lead to exacerbation as appropriate and by long-term clinical follow-up. Predom- pain, it is also reasonable to suggest that the symptom of inant symptoms, based upon analysis of weeklong diary abdominal pain in itself may lead to increased feelings of recordings are shown in Table 1. Symptom severity wasscored 0 (none), 1 (mild), 2 (moderate) and 3 (severe) and thiswas totalled for each symptom over the seven-day period of Anti-spasmodics (mebeverine, alverine citrate)Tricyclic anti-depressants (amitriptyline) Table 1 Predominant IBS symptom at presentation Ó 2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 678–684 All patients completed a standard IBS-QoL questionnaire The Wilcoxon signed test was used to compare data obtained (Hahn et al. 1997). Briefly, this validated questionnaire before and after therapy. This non-parametric procedure was comprises 30 items each with eight subscales, with responses used as it was not possible to make an assumption about the of five or six grades, each scoring 0–100.
distribution of the data in the chosen study population. Itemmeasurement theory was used to assess HRQoL results. Theresponse to each questioned was converted to a score ranging from 0 to 100 and these were combined to produce ‘scale Anxiety and depression were measured using the Hospital Anxiety and Depression questionnaire (Zigmond & Snaith1983). Gut-directed hypnotherapy was performed by the researcher in line with British Medical and Dental Hyp-notherapy guidelines (Heap & Aravind 2001). Prior to All patients were fully compliant with the study and hypnotherapy, the concept that the gut is a contractile muscular tube was introduced to the patient. Hypnotherapywas induced by eye fixation and this was followed by conventional deepening and relaxation techniques. Patientswere instructed to place their hands upon the site of maximal The mean severity, frequency and duration of physical abdominal discomfort and suggestions of warmth and symptoms significantly improved following hypnotherapy comfort in this region were made. This was followed by a (Table 2). This was most marked for abdominal pain and sequence of suggestions directed to reducing GI symptoms, distension. Altered bowel habit was more difficult to analyse based upon lessening of muscular contraction in the gut. This because this varied greatly between patients and a perception process was combined with the use of visual imagery; for of improved bowel habit was not reflected in changes of stool example the hypnotherapist encourages the patient to ima- gine the gut as a river. The constipated patient is encouragedto perceive the river as motionless; the patient then is encouraged to perceive the river flowing freely. The therapistdevelops the concept of appropriate changes in flow, the flow The results of HRQoL assessments are summarized in Table 3.
increases in the constipated patient and decrease in the It should be noted that low scores reflect good quality of life.
patient with diarrhoea. Patients are also instructed to place Prior to treatment emotional dysfunction and tiredness were their hands on the abdomen and induce feelings of comfort particularly prominent. All mean HRQoL scores significantly and warmth in this region. Treatment sessions were conclu- improved after hypnotherapy; the greatest change being in ded by standard ego strengthening exercises. This technique emotional dysfunction and insomnia. There were no clear involves the employment of direct suggestions of a highly gender differences, either at baseline or in response to therapy.
general nature, aimed at increasing the confidence andpositive well-being of the subject (Heap & Aravind 2001).
Self-hypnosis was taught at an early stage of treatment andpatients were given audiocassettes for use at home to The results of the Hospital Anxiety and Depression Scale reinforce the effects of hypnotherapy.
(HAD) scores are summarized in Table 4. Both before and Patients received between five- and seven-and-a-half-hour after hypnotherapy anxiety was more frequent than depres- hypnotherapy sessions over a three-month period. Ethical sion although both were more common than the published approval for the study was obtained from the local researchethics committee.
Table 2 Physical symptoms before and after treatment Symptom assessment, HRQoL and psychological measure- ments were undertaken before and three months aftertreatment.
Ó 2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 678–684 Table 3 Mean HRQoL scores (SD) before and after treatment Table 4 Mean (SD) HAD scores before and after treatment normal range. The mean anxiety score significantly improved of bowel function, varying from days of constipation to after treatment in both male and female patients. In contrast, periods of loose and frequent stool, rather than consistent the mean scores for depression were similar before and after diarrhoea or constipation. Diary card analysis could not measure this variability when data were amalgamated and asa consequence changes after intervention were difficult todefine.
Anxiety was a common finding in the study group and this The patients involved in this study were typical of those seen has also been noted by other groups in IBS patients routinely in all general GI clinics. As a group they had both (Thompson et al. 1997). It contrasts with a relatively low physical and psychosocial symptoms leading to impaired incidence of depression defined by the HAD scores. The cause HRQoL. These features were quantified using diary cards and of anxiety was identified in this study although uncertainty by completion of validated questionnaires. Gut-directed about diagnosis and prognosis, severity of the physical symptoms including faecal urgency and incontinence, impact improvements in all symptoms and these findings have of the disease upon employment and underlying psychologi- directly led to the continuation of a nurse-led gut-directed cal make-up, may have been important to varying degrees in most patients. Hypnotherapy resulted in a clear improvement The majority of IBS physical symptoms are subjective and in mean anxiety scores and to a lesser improvement in mean difficult to measure. Diary cards are widely used in clinical depression scores. Others have also commented upon this trials and are most useful in assessing stool frequency. In this observation (Palsson et al. 2002). The mechanisms by which study patients subjectively graded the severity of a range of hypnotherapy alleviates anxiety are speculative and are an symptoms including abdominal pain and distension. Diary area for potential research. Improvement in HRQoL seen in card analysis showed impressive changes in mean pain scores this study may have been due to alleviation of physical and distension after hypnotherapy (although the relatively symptoms, resolution of anxiety or to other factors.
small number of subjects who recorded distension as a The impressive changes following hypnotherapy in emo- predominant problem limits the power of the latter). It was tional well-being and insomnia suggest that reduction in more difficult to show changes in bowel function because this anxiety was an effect of hypnotherapy. However, it could varied greatly between patients and with time. The problem also be argued that nursing support itself might contribute to for many patients involved in this study was unpredictability a reduction of anxiety in this patient group. Nurses in GI Ó 2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 678–684 clinics should to be aware of the ways in which patients will El-Serag HB, Olden K & Bjorkman D (2002) Health-related quality best respond and the potential benefits of nursing support.
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CURRICULUM VITAE Emmerentia Margaretha van Schalkwyk M.B.,Ch.B. (U.S.), B.Sc.Med.Sc.Hons.(Epidemiology) (U.S.), Dip. Occ. Health (U.S.) Personal details : First Language Afrikaans, Fluent in English ACADEMIC QUALIFICATIONS Matriculated, La Rochel e Girls High School, Paarl BScMedScHons(Epidemiology), University of Stel enbosch Dip. Occupational Health, University of Stel enbosc