Psykologisk Behandling av IBS Kognitiv terapi Terapi via internett Hypnose Klinikk for psykosomatisk medisin HUS Jørn Eilert Bødtker Bergen 3.september 2014
Først modell for depresjons behandling Aaron T. Beck, A. Ellis (1960-tallet) Etter hvert ulike behandlingsmodeller for spesifikke diagnoser, både depresjonstyper og ulike angstlidelser Somatoforme lidelser, Hypokondri Vektlegger psykoedukasjon og samarbeid mellom pasient og terapeut Metakognitiv terapi A. Wells Mindfullness, Jon Kabat-Zinn
Den kognitive modell Tanker Atferd Fysiske reaksjoner Følelser
Gammel & Ny strategi Bekymringstanke,-utforske alle verste utfall. Ikke engasjere seg i den passiv tilskuer Bekymringstanke,-utforske bevis for og imot Hvis jeg er bekymret, ikke let etter for og motargumenter/bevis
Prevalences Disorder Lifetime 12-month Oslo Sogn NCS Oslo Sogn NCS Alcohol abuse/dependence 22.7 9.4 23.5 10.6 3.1 9.7 Major depression 17.8 8.3 17.1 7.3 3.3 10.3 Simple phobia 14.4 6.5 11.3 11.1 5.0 8.8 Social phobia 13.7 7.3 13.3 7.9 5.0 7.9 Dysthym disorder 10.0 6.3 6.4 3.8 1.6 2.5 Agoraphobia 6.1 3.6 5.3 3.1 1.6 2.8 Panic disorder 4.5 2.6 3.5 2.6 1.2 2.3 Generalized anxiety disorder 4.5 3.4 5.1 1.9 1.1 3.1 Somatoform disorder 3.7 3.4 2.1 2.2 Drug abuse/dependence 3.4 0.4 11.9 0.9 0.0 3.6 Eating disorder 1.8 0.5 0.7 0.1 Obsessive compulsive disorder 1.6 0.6 0.7 0.3 Bipolar disorder 1.6 0.2 1.6 0.9 0.1 1.3 Non-affective psychoses 0.4 0.4 0.7 0.2 0.3 0.5 Any axis-i disorder 52.4 30.9 48.0 32.8 16.5 28.5 Three or more axis-i disorders 14.9 5.1 14.0 7.4 2.2
Kognitiv modell for Panikk Indre/ytre hendelser Oppleves truende angst Mistolkninger Fysiske/psykiske Symptomer Unngåelse& Trygghetssøkende atferd Selektiv oppmerksomhet
Sensation Misinterpretation Safetybehaviour/ avoidance Palpitations Chest tightness Heart attack Dying Relax Slow down heart rate Unreality (dissociation) Loss of controll Madness Keep controll of mind Check memory Try to control thoughts Look for exits Breathlessness Suffocate Take deep breaths Sit by open window Suck menthol sweets Throat tightness Choking Carry a bottle of water Try to clear throat Dizzyness Fainting Collapsing Controll breathing, sit down, hold on to partner, avoid going alone
Mindfullness Gjøre Være
Hypnose tilstand indre fokus, økt mottaglighet for suggesjoner (bilder & ord) Induksjon Hypnotiserbarhet,
Indikasjoner - områder Fobier Prestasjonsangst Lavt selvbilde Psykosomatikk Smerter Lettere depresjoner Adferds kontroll, røykeslutt, forandre uvaner Post traumatic stress disorder (PTSD)
Kontraindikasjoner Psykotiske pasienter Borderline Egosvake Sensasjon Den store sannhet Dypere depresjoner Personligh.forstyrrels. DID
SOMATISERING OG STRESSS Vondt i maven - magesår Hodepine Muskelsmerter Konsentrasjon Tretthed Apati Søvnvansker Irritasjon Hukommelse
Styrke mestringsevne (redusere hjelpeløshet og håpløshet) FORSTÅ, FORUTSI, PÅVIRKE Øke fleksibilitet/ redusere unngåelsesatferd og rigiditet Styrke evnen til spenningsregulering Øke aksept for ubehag / uønsket affekt Hjelpe pasienten til å formulere (tydeliggjøre) egne mål/ verdier Gripe tak i det som vedlikeholder symptomer/ lidelse Identifisere forhold som oppleves å være til hinder for endring, autonomi og utvikling (tanker, følelser, ytre forhold)
Hypnose - prosedyre Vurdering Psykoedukasjon MED UTGANGSPUNKT I PAS KUNNSKAPER OG FORESTILLINGER Forholdet mellom kropp/ sjel (smerte; fantomsmerte mv) Kunnskapsstatus mht effekt Understøtting av psykoterapi Gir muligheter til økt kontroll Informasjon om hypnose som prosedyre og tilstand Hypnose ikke behandling, men en ramme Forberedelse - prehypnose Induksjon Testing av transe Transe - arbeid i hypnotisk tilstand Post-hypnotiske induksjoner Tilrettelegging for selv-hypnose Avslutning Oppsummering refleksjoner rundt opplevelsen
Det foreligger god forskning (RCTs) som klart demonstrerer at hypnose øker effekten av CBT kliniske erfaring: Et nyttig verktøy for å styrke/ støtte opp under CBT tilnærming Fleksibel bruk tilpasses den enkelte Fellesnevnere: Styrke kontroll/ mestring Styrke toleranse/ aksept Illustrerende mht forhold mellom kropp og sjel Gir raskt tilgang til å komme på innsiden av eksponering, metakognisjon mv
Anbefalt litteratur: Robert A Karlin: Hypnosis in the management of pain and stress: Mechanisms, findings and procedures. In: Lehrer, P.M.; Woolfolk, R.L. and Sime, W.E. (2007) Principles and practice of stress management. ISBN-10: 1-59385-000-X, ISBN-13:978-1-59385-000-5 Kirsch, I., Montgomery, G & SapirsteinG. (1995) Hypnosis as an adjunct to cognitive behavioral psychotherapy: AMeta analysis. Journal of Consulting aand Clinical Psychology, 63, 214-220 Scloenberger, N (2000) Research on hypnoses as an adjunct to cognitive-behavioral psychotherapy.international Journal of Clinical and Expoerimental Hypnosis, 48, 154-169 Montgomery, G.H., DuHamel,K.N. & Redd, W.H. A metaanalysis of hypnotivcally induced analgesia: How effective is hypnoses? International Hournal of Clinical and Experimental Hypnoses, 48, 138-153
IBS Bidirectional relationship between body and mind ENS ANS CNS Risk factors for IBS begins early in life, perinatal period (WJG 2014,june) PA = positiv affect (Hanbook of affect and social cognition) NA = negativ affect (Motiv Emot, 1989) Behavioral inhibition, later development of anxiety dis. (J Child Fam Stud. 2011) Serotonergic hypofunction + NA (J Clin Psychol Med 2010) Stress hormone system, Immune system Psychiatric comorbidity ved IBS > 60% (Curr Psychiatry Rep 2004)
Biopsykososial modell
Effect of Antidepressants and Psychological Therapies, Including Hypnotherapy, in IBS: Systematic Review and Meta-Analysis Am J Gastroentreol. 2014 June 17
3.788 studier funnet 92 funnet verd vurdering 46 studier ble grunnlag for metananalyse 1000 IBS pasienter behandlet med antidepressiva vs. placebo > 2,100 IBS pasienter randomisert til psykologisk behandling vs. kontrol gruppe
Eligibility criteria Randomized controlled trials. Adults (participants aged >16 years). Diagnosis of IBS based on either a clinician's opinion or meeting specific diagnostic criteria*, supplemented by negative investigations where trials deemed this necessary. Comparison of antidepressants with placebo, or psychological therapies with a control therapy, including a physician's usual management, symptom monitoring, supportive therapy, or placebo. Minimum duration of therapy 7 days. Minimum duration of follow-up 7 days. Dichotomous assessment of response to therapy in terms of effect on global IBS symptoms or abdominal pain following therapy.
Data extraction methodology Outcome of interest: Improvement in global IBS symptoms preferable; if this was not reported then improvement in abdominal pain. Reporting of outcomes: Patient-reported was preferable; if this was not available then investigatorreported. Time of assessment: Upon completion of therapy. Denominator used: True intention-to-treat analysis; if this was not available then all evaluable patients. Cutoff used for dichotomization: Any improvement in global IBS symptoms or abdominal pain for Likert-type scales, investigator-defined improvement for continuous scales; if no investigator definition was available then we used 1 s.d. decrease in symptom score from baseline to completion of therapy (we assessed if the use of any decrease in symptom score from baseline to completion of therapy altered our analysis).
Effect of Antidepressants and Psychological Therapies, Including Hypnotherapy, in IBS: Systematic Review and Meta-Analysis Am J Gastroentreol. 2014 June 17 N= 3,788 citations 48 RCT Dichotomous symptom data pooled to obtain RR of remaining symptomatic after therapy intervention # studies RR of IBS symp. not improving Confidence interval Psychl.vs.controll/ usual management 31 0,68 95%(0,61-0,76) Antidep/vs - placebo 16 0,67 95%(0,58-0,77) Pscychl+antidep/vs placebo 1
Efficacy of antidepressants in the treament of IBS studies intervention TCA SSRI TCA+S SRI 17 RTC Antidepr vs controll IBSC+D # patients not imprv. # patiens-control not imprv. 10 6 1 mix 260(43.9%)/592 330(65%)/508 RR of IBS not improved 0.67(95% CI = 0.58-0.77) NNT 4 (95% CI = 3-6)
Efficacy of psychological therapies IBS treatment Interv. CBT Relax. Or therapy hypnoth. Multicom.psyc. th. Internet delivered Dynamic psychoth. # RCT 6 5 5 4 2 2 1 Mindfullness therp. ++ Control arm; usual care 13, supportive care 2, placebo 1 Overall IBS-symp. did not improve 639(51,9%)/1.232 Control; IBS-symp. did not improve 839(76%)/1.102 RR of IBS symp. not improving 0.68(95% CI = 0.61 0.76) NNT 4(95% CI = 3 5)
Efficacy of CBT in IBS 9 trials compared CBT vs. control therapy i 610 patients CBT: IBS-symp. did not improve 145(41.5%)/349 Controll: IBS-symp. did not improve 166 (63.6%)/261 RR = 0.60 (95% CI = 0.44 0.83) NNT 3 (95% CI = 2 6)
Efficacy of hypnotherapy in IBS IBS-symp. did not improve i 77(54.6%)/141 Controll: IBS-symp. did not improve 106(77.4%)/137 RR not improving of IBS-symp. 0.74 (95% CI = 0.63 0.87) NNT 4 (95% CI = 3 8)
Efficacy of CBT delivered via the Internet for IBS CBT via Intern: IBS-symp. did not improve 51 (71.8%)/71 Control: IBS-symp. did not improve 68 (98.6%)9/69 RR for not improve of IBS-symp. 0.75 (95% CI = 0.48 1.17)
Efficacy of relaxation training or therapy in IBS IBS-symp. did not improve in 96(72,2%)/133 Controll: did not improve in 107(87,7%)/122 RR of IBS-symp not improving 0.77; (95% CI = 0.57 1.04) Efficacy of stress management in IBS IBS-symp. Not improving 24(40.7%)/59 Controll: 23 (59.0%)/39 RR = 0.63; (95% CI = 0.19 2.08)
How to increase effect in CBT for IBS ( Journal of Consulting and Clinical Psychology 2013, vol 81) GSA = gastrointestinal symptom-specific anxiety «the cognitive, affective, and behavioral response stemming from fear of GI sensations, symptoms, and the context in which these visceral sensations and symptoms occur» - Neagtive automatic thoughts - Worry - Ruminations - Catastrophic thoughts - Maladaptive avoidance - Maladaptive behaviors - Selective attion
How to increase effect in CBT for IBS (continue) GSA mantain & increase IBS- symptoms Reduces QOL Better effect when targeting GSA Inconsistenscies in treatment effect in psychological treatment of IBS could be explained by lack of precision Could explain why relaxation therapy dont work, possibly by strenghten safety behavior
3 råd (I) Ikke lytt til signaler fra kroppen!, jo mer du lytter dess mer vil du høre: Fokusert oppmerksomhet Sjekking av kroppen Atferdsmessige endringer Unntaket er følgende symptomer/tegn
3 råd (II) Ikke stol på følelsene!! Dersom du har angst, kan tolkningen være overdreven/katastrofetanker, følelsen er ikke tegn på/bevis at noe er farlig i verden eller galt i kroppen
3 råd (III) Ikke stol på tankene dine!!! Katastrofetanker, hvor ofte har de slått til, test dem ut Hva som helst kan dukke opp i tankene, stream of consciousness, en kan ikke kontrollere hva en tanker Metakognisjon. Tanker om tankene
Legekunst Axel Munthe «The story of San Michele»
Norsk forening for kognitiv terapi www.kognitiv.no Ingvard Wilhemsen: How to treat health anxiety and somatization www.vimeo.com/19296882 Norsk forening for klinisk evidensbasert hypnose www.hypnoseforeningen.snappages.com Mindfulness, www.mindfulnessbergen.no Internett-basert terapi: Tine Nordgreen Det psykologiske fakultet UiB Institutt for klinisk psykologi Olafur S. Palsson www.ibshypnosis.com
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Historikk Gammel 2 Egypt tempeldans, trummer, gamle kulturer, ritualer Messmer, animal magnetisme, Frankrike 1734-1815 James Braid, 1785-1860, skotsk lege: The Power of The Mind over the Body James Esdaile, 1808-1859, skotsk kirurg, trene 1/2 time daglig 5 dager før OP Jean- Martin Charcot, 1825-1893, hysteriske pasienter, Salpetrier-hosp Paris Pierre Janet, 1859-1947, elev av Charcot Hypnose er en splittting av bevisste og ubevisste prosesser
Historikk II 3 Joseph Breuer, 1842-1925, katarsis. JB var venn til Sigmund Freud, JB og SF var elever til Charcote. JB var tro til Charcote, men SF utforskede seksualitet og den frie asossiasjon Nancyskolen, A.A. Liebeault intresse for Braids metoder, senere sammen med Prof. Nevr. H.M. Bernheim. Hypnose betraktet som en psykologisk tilstand. Med de riktige suggesj kan alle bli hypnotisert
Copyright 2014 Baishideng Publishing Group Inc. All rights reserved. Role of negative affects in pathophysiology and clinical expression of irritable bowel syndrome Maria Rosaria A Muscatello, Antonio Bruno, Giuseppe Scimeca, Gianluca Pandolfo and Rocco A Zoccali. World J Gastroenterol. 2014 June 28; 20(24): 7570-7586. Published online 2014 June 28. doi: 10.3748/wjg.v20.i24.7570. http://www.wjgnet.com/1007-9327/full/v20/i24/7570.htm
Next table Previous table Figures and tables index Table 5. Changes in GI symptom severity, measured with GSRS-IBS within the groups in study 2 Gut-directed hypnotherapy (n=25) GI, gastrointestinal; GSRS, Gastrointestinal Symptom Rating Scale; IBS, irritable bowel syndrome. *P<0.05, **P<0.01, ***P<0.001 vs. baseline. Control (n=23) Baseline 3 Months 1 Year Baseline 3 Months GSRS tot 4.0±0.9 3.5±1.0 * 3.4±1.1 ** 3.9±0.9 3.9±1.3 Pain 5.1±1.2 4.3±1.4 ** 3.9±1.5 ** 4.8±1.2 4.2±1.7 Bloating 4.7±1.5 3.9±1.5 *** 3.6±1.4 ** 4.4±1.5 4.5±1.5 Constipation 2.9±1.8 2.6±1.6 2.3±1.3 3.2±0.9 3.0±2.3 Diarrhoea 4.1±1.4 3.6±1.4 3.4±1.3 * 4.0±1.4 3.9±1.5 Satiety 2.5±1.6 2.9±1.6 2.3±1.2 3.0±1.5 3.3±1.6
Next table Previous table Figures and tables index Changes in GI symptom severity within the groups Gutdirected hypnother apy (n+45) Total GI symptoms Sensory symptoms Bowel habits Baseline 3 Months 1 Year Baseline 3 Months 1 Year Baseline 3 Months 1 Year GI, gastral. *P<0.05, **P<0.01, ***P<0.001 vs. baseline. 28.8±6.8 24.2±8.5 *** 24.4±8.7 ** 14.1±3.6 11.8±4.6 *** 11.6±4.7 *** 14.6±4.2 12.4±5.1 * 12.8±5.0 * Control (n+45) P<0.05 27.1±6.9 26.4±7.3 13.3±3.5 13.2±3.3 13.7±4.3 13.1±5.8
Fig. 1 The effects of cognitive behavioral therapy in female nursing students with irritable bowel syndrome: a randomized trial. Jang, Ae; Hwang, Sun-Kyung; Kim, Dong European Journal of Gastroenterology & Hepatology. 26(8):918-926, August 2014. DOI: 10.1097/MEG.0000000000000140 Fig. 1. The schematic view of the conceptual framework. CNS, central nervous system; ENS, enteric nervous system; IBS, irritable bowel syndrome; QOL, quality of life. 2014 Wolters Kluwer Health Lippincott Williams & Wilkins. Published by Lippincott Williams & Wilkins, Inc. 2