Cleaning up the river: A metaphor for functional digestive disorders

American Journal of Clinical Hypnosis, Apr 2003 by Zimmerman, Joseph

The irritable bowel syndrome is characterized by abdominal pain, altered bowel habits and various other digestive symptoms. Emotional factors are important in some patients. I describe here a metaphor which links the altered motility of the digestive system to the emotional contents it may embody. A metaphor of a river is used to evoke both a smooth, coordinated flow through the normal digestive tract and a normal flow in the management of the patient's emotions. The possibility that some blockage has occurred in the river, resulting in perturbation of the normal flow is then suggested to the patient. This is followed by a suggestion for the patient to clear the blockage. This approach may lead patients to work on the emotional components of their symptoms, resulting in their subsequent resolution. I have used this approach with several patients and it proved very effective. This paper demonstrates the use of this metaphor in one of the patients.

Keywords: Abreaction, blockage, bowel, insight, Irritable Bowel Syndrome (IBS), hypnosis, metaphor

Introduction

Irritable bowel syndrome (IBS) is a common functional disorder of the digestive system. It is defined by abdominal pain, alterations in bowel habits and bloating in the absence of organic disease (Thompson, Longstreth, Drossman, Heaton, Irvine, & Muller-- Lissner, 1999). The course of IBS is chronic. Symptoms fluctuate over time and tend to aggravate during periods of stress. The mechanisms involved in the symptoms of this affliction are multiple. A lowered threshold for visceral pain is the biological marker of IBS (Ritchie, 1973). However, emotional, social and environmental factors contribute significantly to morbidity. Traumatic life experiences play an important role. Among these are parental loss at an early age, either through death or by divorce (Lowman, Drossman, Cramer & Mckee, 1987) and a history of sexual or physical abuse (Talley, Fett, & Zinsmeister, 1995; Drossman, Talley, Olden, Leserman, & Barreiro, 1995). It has been shown that patients with severe IBS tend to communicate psychological distress via bodily symptoms without acknowledging this association (Drossman et al., 1988; Toner, Koyama, Garfinkel, Jeejeebhoy, & Gasbarro, 1992). It is not surprising, therefore, that features such as somatization, anxiety and depression are common in these patients. However, no consistent psychopathological trait has been associated with IBS (Whitehead & Crowell, 1991; Lydiard, 1997).

The treatment of mild cases of IBS is symptomatic: Reassurance of the patient that the condition is benign; regulation of abnormal bowel habits either by bulk-forming agents in constipated patients or the use of antidiarrheal medications in those who complain of diarrhea; anti-spasmodic agents, and dietary counseling. In most cases, these measures will suffice. In the more severe cases, tranquilizers and antidepressant drugs have been reported to be of benefit. Various psychological treatments have been used in the more severe cases (Creed & Guthrie, 1989). These include psychotherapy and various forms of behavior therapy, such as relaxation and biofeedback. The use of hypnosis with severe, refractory IBS was subjected to at least two controlled trials and was demonstrated to be effective in some 75% of the patients (Whorwell, Prior, & Faragher, 1984; Harvey, Hinton, Gunary, & Barry, 1989). The beneficial effect was long-lasting and persisted for 18 months after cessation of therapy (Whorwell, Prior, & Colgan, 1987).

In view of the excellent success rate of hypnotically facilitated suggestion in the treatment of refractory patients with IBS, this modality may well be the treatment of choice for many of these patients. It is therefore disappointing that very little has been written on how to treat these patients with hypnosis. For example, in an authoritative and comprehensive text of hypnotic suggestions and metaphors (Hammond, 1990) not a single metaphor intended for use in IBS patients was cited. In this paper, I describe a metaphor that relates both to the altered motility of the digestive system as well as to the emotional content of the symptoms. I have found this metaphor useful for some patients. The following case report illustrates the use of this method.

Case History

A 50-year-old secretary in a law office consulted me for a possible treatment using hypnosis for her digestive problems. She had a one-year history of what she described as "active stomach": She felt a permanent activity in her abdomen, a need to pass diarrheic stools, and was constantly "aware of her rectum." During this period, the frequency of her evacuations increased from the usual once a day to twice daily, and she noted a decreased caliber of her stools. She also experienced a feeling of incomplete evacuation after passing a bowel movement, flatulence and bloating. She was reluctant to leave home because of her bowel problems. In addition, she complained of a chest pain that was unrelated to physical exertion. It occurred about three times a day, and she recalled a particularly severe attack when she attended a theater show. She also described occasional regurgitation after meals, as well as insomnia. She had a difficulty in falling asleep, and woke up several times at night for no apparent reason. There was no history of recurrent panic attacks or agoraphobia. The patient was unable to pinpoint the circumstances that preceded the onset of her symptoms, and she could not identify events, issues, or psychosocial interactions that were associated with their aggravation. She was unable to recall the content of the theatre scene during which she experienced the acute attack of chest pain. She conceded to a tendency to become anxious easily, and pointed out that any deviation from her usual routine would stress her. She denied any significant problems in her marital life or in her past history. However, she did mention that in the past year, owing to her symptoms, she felt depressed and hopeless. She was eager for a remedy.