A medical student tells her story about The Connection between Pelvic Pain & Childhood Trauma in this fascinating article. Pain Reprocessing Therapy (PRT) and clinical hypnosis are among the most successful approaches to reducing or eliminating such pain once serious conditions have ben excluded and one understands the links between the brain and the gut and other pelvic organs such as the bladder. Even when structural conditions such as endometriosis or polycystic ovarian syndrome are diagnosed understanding the connections between past experiences, stress, and how the nervous system processes sensations can significantly change one's perception of pain. Humans are not alone in this! Similar links between fear/stress and pelvic or bladder symptoms have been found in cats. 

Pain Reprocessing Therapy (PRT) and clinical hypnosis are among the most successful approaches to reducing or eliminating such pain once serious conditions have been excluded and one understands the links between the brain and the gut and other pelvic organs such as the bladder and reproductive organs.​ Both approaches are offered at this office. 
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The following abstracts represent just a few of the many peer-reviewed scientific journal articles on clinical hypnotherapy for IBS. Our program is based largely the research of Palsson and Whorwell, mentioned below. 

Tan, G., Hammond, D. C., & Gurrala, J. (2005). Hypnosis and Irritable Bowel Syndrome: A Review of Efficacy and Mechanism of Action. American Journal of Clinical Hypnosis, 47(3), 161–178. doi:10.1080/00029157.2005.1040 Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder characterized by abdominal pain, distension, and an altered bowel habit for which no cause can be found. Despite its prevalence, there remains a significant lack of efficacious medical treatments for IBS to date. In this paper we reviewed a total of 14 published studies (N = 644) on the efficacy of hypnosis in treating IBS (8 with no control group and 6 with a control group). We concluded that hypnosis consistently produces significant results and improves the cardinal symptoms of IBS in the majority of patients, as well as positively affecting non-colonic symptoms. When evaluated according to the efficacy guidelines of the Clinical Psychology Division of American Psychological Association, the use of hypnosis with IBS qualifies for the highest level of acceptance as being both efficacious and specific. In reviewing the research on the mechanism of action as to how hypnosis works to reduce symptoms of IBS, some evidence was found to support both physiological and psychological mechanisms of action.

Palsson, O. S., Turner, M. J., Johnson, D. A., Burnett, C. K., & Whitehead, W. E. (2002). Hypnosis Treatment for Severe Irritable Bowel Syndrome Investigation of Mechanism and Effects on Symptoms. Digestive Diseases and Sciences, 47(11), 2605–2614. doi:10.1023/a:1020545017390 Hypnosis improves irritable bowel syndrome (IBS), but the mechanism is unknown. Possible physiological and psychological mechanisms were investigated in two studies. Patients with severe irritable bowel syndrome received seven biweekly hypnosis sessions and used hypnosis audiotapes at home. Rectal pain thresholds and smooth muscle tone were measured with a barostat before and after treatment in 18 patients (study I), and treatment changes in heart rate, blood pressure, skin conductance, finger temperature, and forehead electromyographic activity were assessed in 24 patients (study II). Somatization, anxiety, and depression were also measured. All central IBS symptoms improved substantially from treatment in both studies. Rectal pain thresholds, rectal smooth muscle tone, and autonomic functioning (except sweat gland reactivity) were unaffected by hypnosis treatment. However, somatization and psychological distress showed large decreases. In conclusion, hypnosis improves IBS symptoms through reductions in psychological distress and somatization. Improvements were unrelated to changes in the physiological parameters measured.

Palsson, O. S., & Whitehead, W. E. (2002). The growing case for hypnosis as adjunctive therapy for functional gastrointestinal disorders. Gastroenterology, 123(6), 2132–2135. doi:10.1053/gast.2002.37286 The availability and affordability of this therapy would be vastly increased if the same kind of face-toface hypnosis treatment found effective for FD and IBS would also help patients when administered exclusively in a home-treatment audio format. No data have been presented to date to make it possible to conclude whether this is feasible. In conclusion, although some of the studies to date on hypnotherapy for functional GI disorders have been small and lacking in methodological rigor, and many research questions remain unanswered, the cumulative and consistent evidence for efficacy of hypnotherapy for these disorders seems to warrant serious consideration of its use as a regular adjunct in primary care and gastroenterology treatment of patients with FD and IBS.

Review of the Empirical Evidence. American Journal of Clinical Hypnosis, 58(2), 134– 158. doi:10.1080/00029157.2015.1039 Hypnotherapy has been investigated for 30 years as a treatment for gastrointestinal (GI) disorders. There are presently 35 studies in the published empirical literature, including 17 randomized controlled trials (RCTs) that have assessed clinical outcomes of such treatment. This body of research is reviewed comprehensively in this article. Twenty-four of the studies have tested hypnotherapy for adult irritable bowel syndrome (IBS) and 5 have focused on IBS or abdominal pain in children. All IBS hypnotherapy studies have reported significant improvement in gastrointestinal symptoms, and 7 out of 10 RCTs in adults and all 3 RCTs in pediatric patient samples found superior outcomes for hypnosis compared to control groups. Collectively this body of research shows unequivocally that for both adults and children with IBS, hypnosis treatment is highly efficacious in reducing bowel symptoms and can offer lasting and substantial symptom relief for a large proportion of patients who do not respond adequately to usual medical treatment approaches. For other GI disorders the evidence is more limited, but preliminary indications of therapeutic potential can be seen in the single randomized controlled trials published to date on hypnotherapy for functional dyspepsia, functional chest pain, and ulcerative colitis. Further controlled hypnotherapy trials in those three disorders should be a high priority. The mechanisms underlying the impact of hypnosis on GI problems are still unclear, but findings from a number of studies suggest that they involve both modulation of gut functioning and changes in the brain’s handling of sensory signals from the GI tract.

Whitehead, W. E. (2006). Hypnosis for Irritable Bowel Syndrome:The Empirical Evidence of Therapeutic Effects. International Journal of Clinical and Experimental Hypnosis, 54(1), 7–20. doi:10.1080/00207140500328708 Abstract: Irritable bowel syndrome (IBS) is a complex and prevalent functional gastrointestinal disorder that is treated with limited effectiveness by standard medical care. Hypnosis treatment is, along with cognitive-behavioral therapy, the psychological therapy best researched as an intervention for IBS. Eleven studies, including 5 controlled studies, have assessed the therapeutic effects of hypnosis for IBS. Although this literature has significant limitations, such as small sample sizes and lack of parallel comparisons with other treatments, this body of research consistently shows hypnosis to have a substantial therapeutic impact on IBS, even for patients unresponsive to standard medical interventions. The median response rate to hypnosis treatment is 87%, bowel symptoms can generally be expected to improve by about half, psychological symptoms and life functioning improve after treatment, and therapeutic gains are well maintained for most patients for years after the end of treatment.

​Whorwell, P. J., Prior, A., & Faragher, E. B. (1984). CONTROLLED TRIAL OF HYPNOTHERAPY IN THE TREATMENT OF SEVERE REFRACTORY IRRITABLE-BOWEL SYNDROME. The Lancet, 324(8414), 1232–1234. doi:10.1016/s0140-6736(84)92793-4 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.
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This Might Hurt is a documentary describing the work of Dr Howard Schubiner. Viewers follow the moving stories of a group of chronic pain patients for whom conventional medicine had little to offer other than opiates and other drugs or potentially harmful unnecessary surgery. Most of them found significant relief using a structured program examining the underlying emotions contributing to their physical symptoms. 

This approach has been used at our office for many years. 

This Australian physiotherapist working in the UK was able to resolve her Raynaud's disease using a mind-body approach. You can read Part 1 of her story and then Part 2 here.  

Despite robust evidence for myriad ailments and sound
mechanistic data, hypnosis is underused by internists. Using
hypnosis fulfills our pledge to abide by evidence-based
treatments that alleviate suffering with the least collateral
harm, but there is a discrepancy between its benefits and
physicians who offer the treatment. Although hypnosis may
appear in the medical curricula at academic powerhouses
like Baylor, Harvard, Columbia, and Stanford, hypnosis
training is rare even at these institutions. Here is why a
modern resurrection of the oldest Western form of psychotherapy
should inspire internists to get trained and offer
medical hypnosis broadly.
Hypnosis, and its myths and misconceptions, have
evolved since the 18th century when Franz Mesmer inadvertently
led hypnosis into obscurity with his theory about
manipulating a force called “animal magnetism.” These
claims were dispelled by the French Royal Academy of Sciences,
and it took nearly 100 years for Scottish physician
James Braid to first describe a mental and suggestive theory
of hypnosis as a waking physiologic state. The 2014 definition
from the American Psychological Association’s Division
30 describes hypnosis as “a state of consciousness
involving focused attention and reduced peripheral awareness
characterized by an enhanced capacity for response to
suggestion.” Long-standing empirical evidence demonstrates
that hypnosis impacts perception, symptoms, and
habits, which have recently been explained by advanced
diagnostic modalities like functional magnetic resonance
imaging (fMRI). Changes during hypnosis include reduced
activity in the dorsal portion of the anterior cingulate cortex
(a key component of the salience network) and connectivity
between the prefrontal cortex and the insula (a pathway
for mind-body control).1 Augmented by data on neurotransmitter
metabolism and genetics, the neurophysiologic
basis of hypnosis is no longer mysterious. Though our
understanding of the mechanism of action of hypnosis is
more robust than that of even acetaminophen, this has not
sufficed to enhance its use.
Skeptics describe hypnosis in 1 of 3 ways: dangerous
mind control, an ineffective farce, or placebo. It is often
viewed as a loss of control and, therefore, dangerous, when
in fact it is a powerful means of teaching patients how to
control mind and body. The ability to enter into hypnosis,
termed hypnotizability, is a stable trait possessed by most
people, which can be entered into or terminated by the
patient. It is not effective in the presence of conditions such
as stroke or schizophrenia or impaired focused attention or
language processing. Hypnosis is more powerful than placebo
(though patient expectancy is a moderating factor),
and placebo effect is blocked by administration of naloxone,
while the hypnotic analgesia is not.2
Reviews on hypnosis for internal medicine topics are
impressive,3 with demonstrated efficacy for migraine headache,
4 irritable bowel syndrome,5 and anxiety.6 Hypnosis
improves procedural pain and emotional distress and
reduces medication consumption up to 40%7--in short, if
hypnosis were a drug, it would be standard of care. Internists
should prescribe hypnosis particularly when it outperforms
the current standard of care by safety and efficacy, as
in the case of opioids and sedatives.
Patients have a strong appetite for taking charge of their
symptoms; online hypnosis videos for anxiety and insomnia
boast 15-19 million views, and medical hypnosis is quite
acceptable by patients.8 But patients cannot be expected to
differentiate between legitimate and manipulative sources
of hypnosis online any more than if they bought pills off
the street. This treatment modality falls under the purview
of medicine, and our duty is to provide safe access. To do
this, we must improve the supply.
Formal training for medical providers is offered through
national societies, such as the American Society of Clinical
Hypnosis (ASCH) and Society for Clinical and Experimental
Hypnosis (SCEH). Trainings span 4 days and include
ethics and informed consent in addition to practical skills.
Hospital credentialing for the privilege of hypnosis may be
required: If none exists, designing one to include formal
training and mentorship requirement is advised. For
ARTICLE IN PRESS
Funding: None.
Conflicts of Interest: None.
Authorship: Both authors had access to the data and a role in writing
this manuscript.
Requests for reprints should be addressed to Jessie Kittle, MD, 300
Pasteur Dr MC 5210, Stanford, CA, 94305.
E-mail address: [email protected]
0002-9343/© 2020 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.amjmed.2020.10.010
COMMENTARY

Fibromyalgia
Fibromyalgia is a common long-term condition, affecting 2-4% of the population, more commonly women than men, that causes pain all over the body along with many other symptoms.  People with fibromyalgia often have:

• Tenderness to touch or pressure affecting the skin or soft-tissues – this is the most obvious complaint and often is misdiagnosed as tendonitis, tennis elbow, or arthritis.   This tenderness is generally in a fairly symmetrical pattern over the shoulders, neck, base of the skull, upper chest, arms, legs, lower back, buttocks, hips, thighs, and lower legs - in short, all over. 
• Severe fatigue – fibromyalgia is often thought to be related to chronic fatigue syndrome – there is debate about whether they are different conditions or both on the same spectrum of illnesses
• Sleep problems (waking up unrefreshed) – called non-restorative sleep
• Problems with memory, concentration, or thinking clearly (cognitive symptoms, often referred to as “fibro-fog”)
• Depression or anxiety
• Migraine or tension headaches
• Irritable bowel syndrome (commonly called IBS) with cramps, bloating, constipation or diarrhea
• Gastroesophageal reflux disease (often referred to as GERD) or heartburn
• Irritable or overactive bladder, often labelled as interstitial cystitis
• Pelvic pain
• Temporomandibular disorder - often called TMJD that may include face or jaw pain, jaw clicking, and ringing in the ears. 

While not part of fibromyalgia itself, it is not unusual for patients to also complain of multiple chemical sensitivities. They may be told they have costochondritis because the upper chest is tender.They may also have numbness or tingling in the hands and feet suggestive of a nerve disorder. 

Books and articles often say that the causes of fibromyalgia are unknown. It may be that it is the final destination arrived at from a variety of different starting points. For some people it occurs after an illness such as influenza; for others after an accident or other traumatic event. For many it develops gradually after an overwhelming incident or as the culmination of years of accumulated stressful events, often dating back to childhood. Numerous studies have found that between 50 and 63% of patients with fibromyalgia also meet the criteria for post-traumatic stress disorder, frequently reporting adverse childhood events or subsequent physical or emotional trauma. Adverse childhood events (such as the loss of a parent, abusive or chaotic households, early hospitalizations, accidents, neglect etc), and later traumas all can prime the nervous system's fight/flight/freeze response, giving rise to a sense of being unsafe in the world, and cause the body to respond with physical symptoms. Chronically elevated stress hormones change the way our glucose metabolism and digestive function work, cause increased muscular tone (tight muscles), and affect our immune system function. 

There is a complex inter-relationship between our nervous systems, our hormones, immune systems, gastrointestinal system, and our muscular function, including how the energy powerhouses (mitochondria) in our cells function. In other words, although it is a very real physical condition, the pain is being produced in the nervous system in response to (usually prolonged and cumulative) internal (such as the demands or expectations we place on ourselves) and external sources of stress. It can also be triggered by sleep deprivation in some people.  

For this reason, it is possible to turn the pain down or even off, by means of techniques that address past trauma, anxiety, stress, beliefs and expectations, as well as by optimizing nutrition, sleep and general well-being through regular exercise (while avoiding extreme of activity).  Coming to an understanding of the condition reduces fear, which in turn can substantially reduce pain intensity.

Fibromyalgia can be best thought of as a central nervous system condition in which the brain and spinal cord are sensitized and therefore respond to sensations which are perceived as much more painful than the same sensation would be experienced by someone without fibromyalgia. It is sometimes referred to as a Central Pain Amplification Disorder. Similarly, people with irritable bowel syndrome will perceive the same degree of gaseous intestinal distension as being much more painful than someone without IBS would do. It is as though the pain ‘thermostat’ or dial has been turned up to a very high level. 

Unlike rheumatoid arthritis or lupus, fibromyalgia is not an autoimmune or inflammatory condition. It can co-exist with arthritis but it is not primarily a joint condition. It does not lead to any ilife-threatening disease.

Fibromyalgia may run in families to some extent but whether this is genetic or due to a common environment (similar stresses) or a learned response to adverse circumstances is not clear. A small subset of people with symptoms suggestive of fibromyalgia have been found on skin biopsy to have an abnormality of small nerve fibres. Genetics alone cannot explain fibromyalgia. Symptoms tend to be worse with stress, over-work, excessive exercise, or sleep deprivation. 

Diagnosing Fibromyalgia

1. symptoms as mentioned above, present for more than 3 months with no other explanation
2. pressure at certain common soft tissue points on physical exam can be helpful to detect tenderness and to exclude other causes of muscle pain.

There is no specific blood test or X-ray that can diagnose fibromyalgia. Commonly tests will be ordered to exclude other conditions, for example, sleep apnea, an underactive thyroid, or polymyalgia rheumatica, anemia, iron-deficiency, rheumatoid arthritis or lupus. 

Treating fibromyalgia

While there is no one specific cure for fibromyalgia, approaching it from a number of different angles – certain medications, carefully structured aerobic exercise within one’s capabilities, and mind-body approaches such as relaxation, stress-reduction, Cognitive Behavioural Therapy, mindfulness, Tai Chi, and clinical hypnosis or guided imagery, can be helpful. Ensuring adequate sleep is essential. Some people have co-existent anxiety, depression, PTSD, panic disorder, all of which can also be treated.  Proper nutrition is also important. Anecdotally, some patients report a correlation between pain intensity and diet, such as refined carbohydrates, gluten, nightshades, or meat. This may be an individual response. 

A number of medications are often tried to reduce symptoms. Most of these are “off-label”. 

Low doses of an antidepressant called amitriptyline (Elavil) or related medications (such as nortriptyline or trazodone) can often be very helpful for pain, sleep, and to reduce migraines. 
A muscle relaxant such as cyclobenzaprine (Flexeril) can be helpful.  This is structurally similar to tricyclic antidepressants (TCAs) such as amitriptyline. 
A newer SNRI medication, duloxetine (Cymbalta) can sometimes help. 
Additional medications include pregabalin (Lyrica) and gabapentin (Neurontin) can be used. 
Another off-label medication is low dose naltrexone. 

Opioid narcotic medications are best avoided as they have significant side-effects, are largely ineffective, addictive and can lead to a conditions known as opiate-induced hyperalgesia, a parodoxical increase in pain the more opiates one cosumes. Of the opiates Tramadol may be better than the others but shares all the same risks as other opiates and interacts with other medications. 

Acetaminophen and anti-inflammatories (such as ibuprofen) are generally not effective for fibromyalgia but may help other co-existing pain. Sleeping tablets such as Zopiclone and benzodiazepines are not recommended. 

One small study published in December 2018 suggested that some patients with fibromyalgia may respond to treatment with a diabetes drug called metformin if their average sugar level (HBA1C) was in the high normal or elevated range. 

Gaining an understanding of fibromyalgia, engaging in self-care, ensuring good sleep, reducing stress, modifying behaviour, counselling, dietary modifications and supplements, and a judicious exercise regimen can all be helpful. 

In my own practice a combination of tender point injections, counselling, relaxation techniques, clinical hypnosis, medication and nutritional advice, and patient-education (which may include recommended reading and journalling) can lead to a significant reduction in symptoms, periods of remission, or even resolution. 

Counselling and Clinical Hypnosis
 
Supportive counselling and providing advice on matters of physical and psychological health are part and parcel of most medical visits. As pain physicians we often advise patients on general health measures, provide advice on nutrition, supplements, and ways of improving sleep as part of our holistic approach to pain-reduction and optimal health. Unfortunately, unlike other provinces, BC does not cover extended counselling, psychotherapy, or hypnosis by family physicians, so if an extended appointment is made specifically for counselling then the appointment is charged-for privately.
 
Clinical hypnosis is the use of hypnosis by a trained professional in order to assist a client or patient to make the changes they wish to make in order to relieve physical pain or emotional distress, change habits or behaviours, or improve skills or performance (generative change) or to obtain new perspectives. It can be combined with various other types of counselling such as Cognitive Behavioural Therapy or energy psychology techniques. It can also be used as a type of procedural anaesthesia to reduce discomfort during dental or medical treatments or childbirth.
 
In our office Clinical Hypnosis is used by Dr. David Bowler to reduce discomfort during procedures, to manage or eliminate chronic pain that has not responded to conventional measures, or to treat phobias or anxiety.
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