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Mus 3

  1. 1. Copyright A. Dobbin 3/12/2010
  2. 2. Medically Unexplained Symptoms Irritable Bowel SyndromeCopyright A. Dobbin 3/12/2010
  3. 3. Definition • A functional bowel disorder characterized by chronic abdominal pain, discomfort, bloating, and alteration of bowel habits in the absence of any detectable organic cause. In some cases, the symptoms are relieved by bowel movements. Diarrhoea or constipation may predominate, or they may alternate (classified as IBS-D, IBS-C or IBS-A, respectively). IBS may begin after an infection (post-infectious, IBS-PI), a stressful life event, or onset of maturity without any other medical indicators. • Prevalence 10.5% 6.6% men 14% womenCopyright A. Dobbin 3/12/2010
  4. 4. Co-morbidities with other symptoms • One of these: functional dyspepsia, gastroesophageal reflux disease, functional constipation, and anal incontinence in 50% of cases (1) • Fibromyalgia, chronic fatigue syndrome, and chronic pelvic pain are best documented and appear in up to 65% (1) • Estimates of common psychiatric co-morbidities with IBS patients range widely up to 61% have anxiety disorder. (2) • All studies suggest that anxiety and IBS „share common biological factors‟ (2)Copyright A. Dobbin 3/12/2010
  5. 5. Early Trauma (IBS) • Meta analysis of studies (1) - 2007) • Sexual Abuse all 39%, Child 24%, Adult 28% • Physical abuse all 21% child 28% adult 22% Other MUS Early Trauma • Chronic Pelvic Pain SA:46% PA 43% CSA 49% • Conversion Disorder SA:47% PA 26% CSA 23%Copyright A. Dobbin 3/12/2010
  6. 6. Copyright A. Dobbin 3/12/2010
  7. 7. Common features of co- morbidities • Preponderance of female gender: why? Different routes of pain suppression M:F , hormonal augmentation. Sociocultural features. Increased sexual abuse/physical abuse. • Single symptoms can be aggravated by stress and psychosocial burden • Co-morbidities have a positive predictive value for a more negative course of IBS • A different subgroup?Copyright A. Dobbin 3/12/2010
  8. 8. Cognitive Bias • Patients with IBS as with patients with depression show a selective attentional bias for negative words (percieved threat) – without manifesting depression. (1) • Faces expressing anxiety led to bilaterally increased activity in the insular cortex and in the anterior cingulate gyrus. This effect was disproportionately increased by simultaneous distension stimulation of the esophagus (over neutral faces). (2) • Patients with functional intestinal disorders not only show attention-dependent alterations of central nervous system processing of intestinal stimuli but also a generally negative emotional tendency in their cognitive processing strategies.(3)Copyright A. Dobbin 3/12/2010
  9. 9. Pain Processing Pathways increase in insular stimulation with anxious faces over neutral causing increased pain in normal individuals Visceral pain processing preferentially stimulates medial tract. When the “attention loop” is highly activated, the lowest stimulus intensity would maximally stimulate the affective-motivational pain system. Hypnosis has been shown to increase or decrease the insular response to pain, and dissociates the cognitive and affective components of sensationCopyright A. Dobbin 3/12/2010
  10. 10. vagus Spinal cord Guts Mind Body Loop – Fear pathway (after Ledoux)Copyright A. Dobbin 3/12/2010
  11. 11. IBS shows a combination of high cortisol (present in IBS) and amygdalar activity. Due to dissociation there is a focus on the attentional channels of the visceral and somatic channelsCopyright A. Dobbin 3/12/2010
  12. 12. Hypervigilance Is whiplash a form of MUS?Copyright A. Dobbin 3/12/2010
  13. 13. Treatment • Review of evidence from Cochrane Database • Antispasmodics: evidence is weak • Antidepressants: no evidence • Bulking agents: no evidence • Advised to use agents symptomatically • No long term benefitCopyright A. Dobbin 3/12/2010
  14. 14. Treatment Psychological • CBT and interpersonal therapy and relaxation: effective immediately after treatment no sustained effect (2009) • Hypnotherapy: superior to medical management or waiting list control in refractory IRBS (2007) • Individual studies show lasting effect 5 years later.Copyright A. Dobbin 3/12/2010
  15. 15. Hypnotherapy (1) • reduces levels of anxiety and depression in IBS sufferers • abnormal cognitions about their disorder significantly improved (indirect spontaneous effect) • it can reduce the strength of contractions in the distal colon normalise rectal sensitivity influence gastric emptying affect gastric acid secretion, alter the gastrocolonic response to food and slow oral–caecal transit time • Reduce activation of the anterior cingulate cortex • capacity to modulate immunological responsiveness and inflammation (? Effect on depression left prefrontal cortex as immune organ) • 70% of patents helpedCopyright A. Dobbin 3/12/2010
  16. 16. Major effect of hypnotherapy Disconnection of the affective/cognitive link in the Anterior Cingulate Cortex Removal of skin conductance (sympathetic nervous system probably due to above) Shift to right sided cerebral processingCopyright A. Dobbin 3/12/2010
  17. 17. Gruzelier, J. (1998). A working model of the neurophysiology of hypnosis: a review of the evidence. Contemporary Hypnosis, 15, 3-21 Karl Friston – Thomas BayesCopyright A. Dobbin 3/12/2010
  18. 18. BES scale • Scale of beliefs about the unacceptability of experiencing or expressing negative emotions • Directly related to symptamatology in IBS resolves with CBT • Shaun: patient with tachyarrythmiaCopyright A. Dobbin 3/12/2010
  19. 19. Emotional Regulation of Negative Emotions • There are a number of ways of „dealing with‟ unpleasant emotions. These are: • Avoidance of stress • Attentional manipulation • Suppression of emotion • Re-appraisal („Transformation‟ in Buddhism)Copyright A. Dobbin 3/12/2010
  20. 20. Copyright A. Dobbin 3/12/2010
  21. 21. Copyright A. Dobbin 3/12/2010
  22. 22. Further Work on Suppression • Subjects told to find & suppress negative autobiographical memory. • Also to record number of times negative memory intrudes in SOC exercise • Then asked to respond to emotionally valenced wordsCopyright A. Dobbin 3/12/2010
  23. 23. Basis of Rumination? Quicker response Figure 1. Mean latency in seconds (error bars are ±1 SE) to retrieve autobiographical memories to positive and negative cue words on the recall task in the dysphoric and nondysphoric groups across the suppress and no-suppress conditionsCopyright A. Dobbin 3/12/2010
  24. 24. Suppression • Increases sympathetic arousal • Decreases positive experience • Increases access to negative memories • Increases access to suppressed memory • Social consequences - increases partners stressCopyright A. Dobbin 3/12/2010
  25. 25. Common themes in therapy Mindfulness/ CBT/ Hypnotherapy/ ACT/ Therapist effect • Common link is thinking style. All these therapies encourage beneficial thinking style. • Ruminative thinking style Vs experiential: example „focus your attention‟ Vs „think about‟ • Practice noticing mind and body • Hypnotherapy diminishes the Rt posterior parietal lobe (affected in anasagnosia – a stroke with neglect of the left side) which greatly magnifies the external perspective (involuntary effects) • Regular mindfulness practice achieves the same. There is a thickening of the pre-frontal cortex signal that switches off the amygdalaCopyright A. Dobbin 3/12/2010
  26. 26. Benefits of Experiential Thinking Style • reducing overgeneral memory • improving problem solving in depression • reducing emotional vulnerability to failure • positively associated with reappraisal negatively associated with depressive rumination, experiential avoidance, and emotional suppression • Less self evaluative • “the ability to view one‟s self as not synonymous with one‟s thoughts . . . the ability to not react habitually to one‟s negative experiences” (Fresco et al., 2007, p. 236).Copyright A. Dobbin 3/12/2010
  27. 27. Reappraisal • Extinction of fear is caused by the creation of a new inhibitory pathway from the pre-frontal cortex to the amygdala. In classical extinction this is from the vmPFC, in humans however it also comes from the Dorso-lateral pre-frontal cortex, in evolution an area controlling eye movement to direct attention, it is now an area used for abstract thought, mathematics, the external perspective in experiential thinking and reappraisal.Copyright A. Dobbin 3/12/2010
  28. 28. Copyright A. Dobbin 3/12/2010
  29. 29. Reappraisal - Visualisation - Extinction – common pathway • Mechanisms of reappraisal, visualisation, and many other techniques (including placebo response) may share the same pathway as extinction - evolution has piggybacked this technique • The ref: Delgado, M.R., Nearing, K.I., Ledoux, J., Phelps, E.A. (2008). Neural circuitry underlying the regulation of conditioned fear and its relation to extinction. Neuron, 59, 829-38Copyright A. Dobbin 3/12/2010
  30. 30. Reappraisal needs to be implicit: attentional distraction hypnosis or mindfulness Gruzelier, J. (1998). A working model of the neurophysiology of hypnosis: a review of the evidence. Contemporary Hypnosis, 15, 3-21 Karl Friston – Thomas BayesCopyright A. Dobbin 3/12/2010
  31. 31. Reappraisal • You find you can never ever fail • You will learn from your mistakes • You will grow as a result of difficulties • You will see problems as solutions • You will see hindrances as challenges • You have a right to be angry/sadCopyright A. Dobbin 3/12/2010
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