Treatments

The Mind + Gut™ Clinic focuses on psychological and dietary treatments for conditions of the gastrointestinal tract. The two psychological treatments with the greatest evidence of effectiveness include gut-directed hypnotherapy and cognitive behavioural therapy. It is understood that these treatments are effective due to the bidirectional flow of information between the brain and the gut. Dietary therapies are also commonly applied.

The brain-gut axis refers to the bidirectional flow of information between the brain (central nervous system) and the gastrointestinal tract. Gastrointestinal symptoms occur as a result of information originating in the brain and/or the gut. Psychological factors such as stress, anxiety and depression have been shown to affect the gut. Similarly abnormalities in gut function (including motility and sensitivity) can contribute to gastrointestinal symptoms. Gut-directed hypnotherapy and cognitive behavioural therapy treatments aim to enhance brain-gut communication.

Gut-directed hypnotherapy is a type of hypnotherapy specifically targeted to disorders of the gastrointestinal tract. It is entirely safe and has been shown to be incredibly efficacious. Sessions are conducted while patients are in a light and relaxed subconscious state. Once in this state suggestions for the control and normalisation of gastrointestinal function are made. Metaphors for bringing about change are also used. This type of therapy differs from other forms of psychological treatment where therapy is done with the patient in a conscious state. Gut-directed hypnotherapy can be used in both adults and children.

Cognitive behavioural therapy is short-term, structured and goal orientated. It is used to help patients identify unhelpful thoughts and behaviours and to reduce physical symptoms. Cognitive behavioural therapy is also used to teach practical self-help strategies so that patients are able to evaluate and view their symptoms in ways that are more positive. Patients can expect to be taught about the nature of their condition, the effect of psychological states such as stress, anxiety and depression on their gastrointestinal symptoms and various relaxation and stress management techniques. Cognitive behavioural therapy can be used in both adults and children.

Dietary therapies are commonly applied in patients with conditions of the gastrointestinal tract. Diet may be used for disease prevention, as a primary therapy to treat disease or targeted to treat the symptoms of gastrointestinal conditions. Dietary needs and treatments will differ according to individual patients, but may include the manipulation of wheat and gluten, fructose, lactose, FODMAPs, fibre or food chemicals. Nutritional adequacy is assessed in every patient. Patients will be taught the mechanistic action of food in the gastrointestinal tract so that they are better able to identify which foods trigger their symptoms. This will generally be done through a withdrawal and reintroduction process. Our dietitian will also make longer-term dietary recommendations.

Frequently Asked Questions

The precise mechanism by which gut-directed hypnotherapy works is poorly understood. However, there is strong evidence that gut-directed hypnotherapy can influence both physiological and psychological outcomes.
Hypnotherapy, when performed by an appropriately qualified and experienced practitioner, is exceptionally safe. Two common misconceptions about hypnosis include (a) that hypnosis is a form of mind control where the hypnotised subject has no free will, and (b) that a patient can become ‘stuck’ in a state of hypnosis. It is important that these misconceptions are dispelled prior to treatment.
It is well established that people differ in their hypnotic capabilities, and despite the great majority of people being able to experience hypnosis, not everyone is equally as responsive. Despite this, hypnotic susceptibility has not been shown to correlate with the effectiveness of the therapy.

Patients will typically need 4-6 sessions. Sessions are done on a weekly basis.

Comparison of the rate of response to gut-directed hypnotherapy in patients with irritable bowel syndrome suggests that it is at least as good as some of the new and expensive pharmacological treatment options. It has also been shown to be superior to that of the low FODMAP diet. This taken together with the fact that there are no known side effects of hypnotherapy make gut-directed hypnotherapy a competitive treatment option.

The latest evidence based psychological interventions, including cognitive behavioural therapy, are applied according to individual patient needs.
To help patients reduce and manage their physiological symptoms and improve any psychological distress that may accompany their gastrointestinal upset. All psychological interventions are applied to patients in a conscious i.e. awake state.
The number of sessions needed will depend on individual patient requirements and the type of psychological intervention applied. Patients will gain a greater understanding of the number of sessions they will need during their first session with the psychologist.
Dietary needs and treatments will differ according to individual patients. Nutritional adequacy is assessed in every patient.
The number of sessions needed will depend on individual patient requirements. Patients will gain a greater understanding of the number of sessions they will need during their first session with the dietitian.
The main difference between a dietitian and a nutritionist is the level of education the practitioner has undertaken. Dietitians are tertiary qualified in food, nutrition and dietetics. They are also qualified to provide medical nutrition therapy and clinical nutrition consultations.

Research

We love research at Mind + Gut™ and believe that it’s pivotal to the improvement and development of new methods for treating conditions of the gastrointestinal tract. The following articles support the services we provide at our clinic and may be of interest to you, GPs and referring Specialists.

Abstract
Background
A low fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) diet is effective in treating irritable bowel syndrome (IBS).

Aim
To compare the effects of gut-directed hypnotherapy to the low FODMAP diet on gastrointestinal symptoms and psychological indices, and assess additive effects.

Method
Irritable bowel syndrome patients were randomised (computer-generated list), to receive hypnotherapy, diet or a combination. Primary end-point: change in overall gastrointestinal symptoms across the three groups from baseline to week 6. Secondary end-points: changes in psychological indices, and the durability of effects over 6 months.

Results
Of 74 participants, 25 received hypnotherapy, 24 diet and 25 combination. There were no demographic differences at baseline across groups. Improvements in over all symptoms were observed from baseline to week 6 for hypnotherapy [mean difference (95% CI): 33 ( 41 to 25)], diet [ 30 ( 42 to 19)] and combination [ 36 ( 45 to 27)] with no difference across groups (P = 0.67). This represented ≥20 mm improvement on visual analogue scale in 72%, 71% and 72%, respectively. This improvement relative to baseline symptoms was maintained 6 months post- treatment in 74%, 82% and 54%. Individual gastrointestinal symptoms similarly improved. Hypnotherapy resulted in superior improvements on psychological indices with mean change from baseline to 6 months in State Trait Personality Inventory trait anxiety of 4(95% CI 6 to 2) P < 0.0001; 1( 3 to 0.3) P = ns; and 0.3( 2 to 2) P = ns, and in trait depression of 3( 5 to 0.7) P = 0.011; 0.8( 2 to 0.2) P = ns; and 0.6( 2 to 3) P = ns, respectively. Groups improved similarly for QOL (all p ≤ 0.001).

Conclusions
Durable effects of gut-directed hypnotherapy are similar to those of the low FODMAP diet for relief of gastrointestinal symptoms. Hypnotherapy has superior efficacy to the diet on psychological indices. No additive effects were observed.

Abstract
30 patients with severe refractory irritable-bowel syndrome were randomly allocated to treatment with either hypnotherapy or psychotherapy and placebo. The psychotherapy patients showed a small but significant improvement in abdominal pain, abdominal distension, and general well-being but not in bowel habit. The hypnotherapy patients showed a dramatic improvement in all features, the difference between the two groups being highly significant. In the hypnotherapy group no relapses were recorded during the 3-month follow-up period, and no substitution symptoms were observed.

Abstract
Background
Gut-directed hypnotherapy is being increasingly applied to patients with irritable bowel syndrome (IBS) and to a lesser extent, inflammatory bowel disease (IBD). Aim: To review the technique, mechanisms of action and evidence for efficacy, and to identify gaps in the understanding of gut-directed hypnotherapy as a treatment for IBS and IBD.

Method
Gut-directed hypnotherapy is being increasingly applied to patients with irritable bowel syndrome (IBS) and to a lesser extent, inflammatory bowel disease (IBD). Aim: To review the technique, mechanisms of action and evidence for efficacy, and to identify gaps in the understanding of gut-directed hypnotherapy as a treatment for IBS and IBD.

Results
Gut-directed hypnotherapy is a clearly described technique. Its potential mechanisms of action on the brain-gut axis are multiple with evidence spanning psychological effects through to physiological gastrointestinal modifications. Six of seven randomised IBS studies reported a significant reduction (all P < 0.05) in overall gastrointestinal symptoms following treatment usually compared to supportive therapy only. Response rates amongst those who received gut-directed hypnotherapy ranged between 24% and 73%. Efficacy was maintained long-term in four of five studies. A therapeutic effect was also observed in the maintenance of clinical remission in patients with ulcerative colitis. Uncontrolled trials supported the efficacy and durability of gut-directed hypnotherapy in IBS. Gaps in understanding included to whom and when it should be applied, the paucity of adequately trained hypnotherapists, and the difficulties in designing well controlled-trials.

Conclusions
Gut-directed hypnotherapy has durable efficacy in patients with IBS and possibly ulcerative colitis. Whether it sits in the therapeutic arsenal as a primary and/or adjunctive therapy cannot be ascertained on the current evidence base. Further research into efficacy, mechanisms of action and predictors of response is required.

Abstract
Background
Recent guidelines for the treatment of irritable bowel syndrome (IBS) emphasize the need for research to facilitate home-based self-management for these patients in primary care. The aim of the current study was to test the efficacy of a manualized cognitive behavioural therapy (CBT)-based self-management programme for IBS in a pilot randomized controlled trial (RCT).

Method
Sixty-four primary-care patients meeting Rome criteria for IBS were randomized into either self-management plus treatment as usual (TAU) (n=31) or a TAU control condition (n=33). The self-management condition included a structured 7-week manualized programme that was self-administered in conjunction with a 1-hour face-to-face therapy session and two 1-hour telephone sessions. The primary outcome measures were the Subject's Global Assessment (SGA) of Relief and the Irritable Bowel Syndrome Severity Scoring System (IBS-SSS) assessed at baseline, end of treatment (2 months), and 3 and 6 months post-treatment.

Results
Analysis was by intention-to-treat. Twenty-three (76.7%) of the self-management group rated themselves as experiencing symptom relief across all three time periods compared to seven (21.2%) of the TAU controls [odds ratio (OR) 12.2, 95% confidence interval (CI) 3.72–40.1]. At 8 months, 25 (83%) of the self-management group showed a clinically significant change on the IBS-SSS compared to 16 (49%) of the control group (OR 5.3, 95% CI 1.64–17.26).

Conclusions
This study provides preliminary evidence that CBT-based self-management in the form of a structured manual and minimal therapist contact is an effective and acceptable form of treatment for primary-care IBS patients.

Abstract
Background
A diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) often is used to manage functional gastrointestinal symptoms in patients with irritable bowel syndrome (IBS), yet there is limited evidence of its efficacy, compared with a normal Western diet. We investigated the effects of a diet low in FODMAPs compared with an Australian diet, in a randomized, controlled, single-blind, cross-over trial of patients with IBS.

Method
In a study of 30 patients with IBS and 8 healthy individuals (controls, matched for demographics and diet), we collected dietary data from subjects for 1 habitual week. Participants then randomly were assigned to groups that received 21 days of either a diet low in FODMAPs or a typical Australian diet, followed by a washout period of at least 21 days, before crossing over to the alternate diet. Daily symptoms were rated using a 0- to 100-mm visual analogue scale. Almost all food was provided during the interventional diet periods, with a goal of less than 0.5 g intake of FODMAPs per meal for the low-FODMAP diet. All stools were collected from days 17–21 and assessed for frequency, weight, water content, and King's Stool Chart rating.

Results
Subjects with IBS had lower overall gastrointestinal symptom scores (22.8; 95% confidence interval, 16.7–28.8 mm) while on a diet low in FODMAPs, compared with the Australian diet (44.9; 95% confidence interval, 36.6–53.1 mm; P < .001) and the subjects' habitual diet. Bloating, pain, and passage of wind also were reduced while IBS patients were on the low-FODMAP diet. Symptoms were minimal and unaltered by either diet among controls. Patients of all IBS subtypes had greater satisfaction with stool consistency while on the low-FODMAP diet, but diarrhea-predominant IBS was the only subtype with altered fecal frequency and King's Stool Chart scores.

Conclusions
In a controlled, cross-over study of patients with IBS, a diet low in FODMAPs effectively reduced functional gastrointestinal symptoms. This high-quality evidence supports its use as a first-line therapy.

Abstract
Background
A low FODMAP (Fermentable Oligosaccharides, Disaccharides, Monosaccharides And Polyols) diet reduces symptoms of IBS, but reduction of potential prebiotic and fermentative effects might adversely affect the colonic microenvironment. The effects of a low FODMAP diet with a typical Australian diet on biomarkers of colonic health were compared in a single-blinded, randomised, cross-over trial.

Method
Twenty-seven IBS and six healthy subjects were randomly allocated one of two 21-day provided diets, differing only in FODMAP content (mean (95% CI) low 3.05 (1.86 to 4.25) g/day vs Australian 23.7 (16.9 to 30.6) g/day), and then crossed over to the other diet with ≥21-day washout period. Faeces passed over a 5-day run-in on their habitual diet and from day 17 to day 21 of the interventional diets were pooled, and pH, short-chain fatty acid concentrations and bacterial abundance and diversity were assessed.

Results
Faecal indices were similar in IBS and healthy subjects during habitual diets. The low FODMAP diet was associated with higher faecal pH (7.37 (7.23 to 7.51) vs. 7.16 (7.02 to 7.30); p=0.001), similar short-chain fatty acid concentrations, greater microbial diversity and reduced total bacterial abundance (9.63 (9.53 to 9.73) vs. 9.83 (9.72 to 9.93) log10 copies/g; p<0.001) compared with the Australian diet. To indicate direction of change, in comparison with the habitual diet the low FODMAP diet reduced total bacterial abundance and the typical Australian diet increased relative abundance for butyrate-producing Clostridium cluster XIVa (median ratio 6.62; p<0.001) and mucus-associated Akkermansia muciniphila (19.3; p<0.001), and reduced Ruminococcus torques.

Conclusions
Diets differing in FODMAP content have marked effects on gut microbiota composition. The implications of long-term reduction of intake of FODMAPs require elucidation.

Abstract
Background
Reduction of short-chain poorly absorbed carbohydrates (FODMAPs) in the diet reduces symptoms of irritable bowel syndrome (IBS). In the present study, we aimed to compare the patterns of breath hydrogen and methane and symptoms produced in response to diets that differed only in FODMAP content.

Method
Fifteen healthy subjects and 15 with IBS (Rome III criteria) undertook a single-blind, crossover intervention trial involving consuming provided diets that were either low (9 g/day) or high (50 g/day) in FODMAPs for 2 days. Food and gastrointestinal symptom diaries were kept and breath samples collected hourly over 14 h on day 2 of each diet.

Results
Higher levels of breath hydrogen were produced over the entire day with the high FODMAP diet for healthy volunteers (181 +/- 77 ppm.14 h vs 43 +/- 18; mean +/- SD P < 0.0001) and patients with IBS (242 +/- 79 vs 62 +/- 23; P < 0.0001), who had higher levels during each dietary period than the controls (P < 0.05). Breath methane, produced by 10 subjects within each group, was reduced with the high FODMAP intake in healthy subjects (47 +/- 29 vs 109 +/- 77; P = 0.043), but was not different in patients with IBS (126 +/- 153 vs 86 +/- 72). Gastrointestinal symptoms and lethargy were significantly induced by the high FODMAP diet in patients with IBS, while only increased flatus production was reported by healthy volunteers.

Conclusions
Dietary FODMAPs induce prolonged hydrogen production in the intestine that is greater in IBS, influence the amount of methane produced, and induce gastrointestinal and systemic symptoms experienced by patients with IBS. The results offer mechanisms underlying the efficacy of the low FODMAP diet in IBS.

Abstract
Background
Functional gut symptoms are induced by inclusion and reduced by dietary restriction of poorly absorbed short-chain carbohydrates (FODMAPs), but the mechanisms of action remain untested. Aims: To determine the effect of dietary FODMAPs on the content of water and fermentable substrates of ileal effluent.

Method
Twelve ileostomates without evidence of small intestinal disease undertook two 4-day dietary periods, comprising diets differing only in FODMAP content in a randomized, cross-over, single-blinded intervention study. Daytime (14 h) ileal effluent was collected on day four of each diet. Patients rated effluent volume and consistency on a 10-cm visual analogue scale. The FODMAP content of the diet and effluent was measured.

Results
Ingested FODMAPs of 32% (range 6-73%) was recovered in the high FODMAP diet effluent. Effluent collection weight increased by a mean of 22% (95% CI, 5-39), water content by 20% (2-38%) and dry weight by 24% (4-43%) with the high compared to low FODMAP diet arm. Output increased by 95 (28-161) mL. Volunteers perceived effluent consistency was thicker (95% CI, 0.6-1.9) with the low FODMAP diet than with the high FODMAP diet (3.5-6.1; P = 0.006).

Conclusions
These data support the hypothetical mechanism; FODMAPs increase delivery of water and fermentable substrates to the proximal colon.

Abstract
The current general interest in the use of food choice or diet in maintaining good health and in preventing and treating disease also applies to patients with IBD, who often follow poor or nutritionally challenging dietary plans. Unfortunately, dietary advice plays only a minor part in published guidelines for management of IBD, which sends a message that diet is not of great importance. However, a considerable evidence base supports a focused and serious attention to nutrition and diet in patients with IBD. In this Review, a step-wise approach in the evaluation and management of these patients is proposed. First, dietary intake and eating habits as well as current nutritional state should be documented, and corrective measures instituted. Secondly, dietary strategies as primary or adjunctive therapy for the reduction of inflammation and/or prevention of relapse of IBD should be seriously contemplated. Thirdly, use of diet to improve symptoms or lessen the effects of complications should be considered. Finally, dietary advice regarding disease prevention should be discussed when relevant. An increasing need exists for applying improved methodologies into establishing the value of current and new ways of using food choice as a therapeutic and preventive tool in IBD.