Clinical Question: Is hypnotherapy effective in the treatment of functional dyspepsia?

Setting: Outpatient (specialty)

Study Design: Randomized controlled trial (single-blinded)

Synopsis: Study investigators recruited patients referred for endoscopy because of dyspepsia. All had negative results on endoscopy and fulfilled the Rome I criteria for functional dyspepsia. Patients with predominant reflux symptoms, a history of peptic ulcer disease, recent gastrointestinal surgery, current Helicobacter pylori infection, or who were using nonsteroidal anti-inflammatory drugs were excluded. This left 126 patients who were randomized to receive hypnotherapy, supportive therapy plus placebo medication, or ranitidine in a dosage of 150 mg orally twice a day.

Hypnotherapy and supportive therapy took place during 12 30-minute visits during the first 16 weeks of the study. All patients also had follow-up visits at 28 and 56 weeks. Remember, ranitidine is not effective for functional dyspepsia without reflux, so this was basically an untreated control group. We are not told how randomization was performed or how allocation was concealed; analysis was by intention to treat. Outcome assessors were masked to treatment assignment, and efforts were made to maintain this blinding. Hypnotherapy involved positive imagery of symptom reduction; the supportive therapy involved a discussion of the patient's symptoms and general advice.

Quite a few patients were lost to follow-up (n = 14), did not complete treatment because they believed it was not working (n = 26), or did not receive therapy because of the time commitment (n = 8). Fewer patients in the hypnotherapy group withdrew because it was not working than did patients from the supportive or ranitidine groups (zero versus 13 and 10, respectively; P <.001).

The primary outcomes were a symptom score and quality of life. Symptoms improved more in the short term and long term for patients in the hypnotherapy group than for the other two groups. Quality of life improved significantly more for the hypnotherapy group than for the other groups in the short term, but in the long term, patients in the supportive therapy group caught up. This occurred after treatment ended and is difficult to explain, although the authors postulate that it was because five of the remaining 24 patients in that group were taking antidepressants, versus none in the other groups. Interestingly, 81.8 percent of patients in the supportive group and 89.7 percent in the medication group were taking a medication at the end of one year, compared with none in the hypnotherapy group (P <.001). These patients also had fewer consultations (one versus four; P <.001).

Bottom Line: It's all in your head! This small study found that hypnotherapy was more effective than medication (which we know does not work) and supportive therapy (which may not work) for functional, nonreflux dyspepsia. Given the number of patients lost to follow-up and the specialty setting, it would be good to see this scenario repeated in a larger study in the primary care setting. Nevertheless, for patients with chronic functional dyspepsia without reflux symptoms, intensive hypnotherapy may be worth a try. (Level of Evidence: 2b)