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Anorectal manometry with balioon distension was performed on 28 patients with diarrhoea predominant irritable bowel syndrome, 27 patients with constipation predominant irritable bowel syndrome and 30 normal controls. In the diarrhoea predominant group balloon volumes required to perceive the sensations of gas, stool, urgency of defecation and discomfort were significantly lower than in controls or constipation predominant patients (p<0-001). Diarrhoea predominant patients also had a significantly lower rectal compliance than controls or constipation predominant patients (p<003) but showed no difference in motor activity induced by distension. When the constipation predominant patients were compared with controls the only significant difference that emerged was in the volume at which discomfort was perceived. No significant differences between constipated subjects and controls were found in the distension induced motor activity. Symptom severity and psychological parameters were also recorded and the diarrhoea predominant patients were found to be more anxious than those with constipation (p=0.04). It proved possible (by comparison with the control group) to identify three abnormal rectal subtypes in patients with irritable bowel syndrome. These were a sensitive rectum (low sensation thresholds, normal or low rectal pressure), a stiff rectum (normal or low sensation thresholds, high pressure) and an insensitive rectum (high sensation thresholds, normal or high pressure) and their distribution varied considerably depending on bowel habit. Some form of rectal abnormality was identified in 75% ofdiarrhoea predominant patients compared with 30% of constipation predominant subjects (p=0002). A sensitive rectum was a particular feature of diarrhoea predominant patients being observed in 57% of patients compared with only 7% of the constipated group (p<0001).

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In a previous controlled trial we reported that 'gut directed' hypnotherapy appeared to be highly effective in the management of patients with severe refractory irritable bowel syndrome.' A criticism of this study has been that the follow up period of three months was too short to discount a placebo response to hypnosis.2' All 15 patients treated with hypnotherapy in the original study have now been followed up for over one year and these data are reported here together with experience on an additional 35 patients treated in a similar manner. Methods PATIENTSThe 15 patients receiving hypnotherapy in the original study have been followed up at three monthly intervals with an assessment of symptom scores and an additional session of hypnotherapy at each visit. The miean follow up period was 18 months (14-21 months). Patients were asked to telephone if they experienced a relapse so that an additional session of hypnotherapy could be arranged. A further 35 patients (31 women, four men, aged 23-65 years) with intractable irritable bowel syndrome have Address for correspondence: Dr P J Whorwell, Dept of Medicine, University of South Manchester, Nell Lane, West Didsbury, Manchester M20 8LR. Received for publication 11 July 1986. also been treated by hypnotherapy and followed for at least three months. These patients were divided into three groups. Group 1: classical cases of irritable bowel syndrome exhibiting abdominal pain, abdominal distension, and an abnormal bowel habit. Group 2: atypical cases lacking one or two of the three criteria necessary for Group 1. Group 3: patients with classical irritable bowel syndrome with significant psychopathology as judged by a score in excess of 14 on the 28 question general health questionnaire.4 The original study only included patients in Group 1.Hypnotherapy was carried out 1y PJW and consisted of half hour sessions of decreasing frequency over a three month period. Patients were given a tape for daily autohypnosis after the third session. Before hypnosis the patient was given a simple account of intestinal smooth muscle physiology. Hypnosis was induced by an eye fixation and arm levitation technique followed by standard deepening procedures. After general comments about improvement of health and wellbeing, attention was directed to the control of intestinal smooth muscle. The patient was asked to place his/her hand on the abdomen, feel a sense of warmth and relate this to asserting control over gut function. All sessions were concluded with standard ego strengthening suggestions. No subject was unable to be hypnotised. Ten weekly sessions of hypnotherapy were offered before treatment was 423 on 12 May 2018 by guest. Protected by copyright.

It has been claimed that hypnotherapy may influence a number of physiological parameters not readily amenable to conscious control,"4 and it is therefore possible that its effect in the irritable bowel syndrome results from a direct action on the gut. On the other hand, it is known that patients with the irritable bowel syndrome have a high incidence of psychopathology'5"6 and it may be that improvement during hypnotherapy is secondary to its psychotherapeutic potential.It was the purpose of the present study to perform a controlled investigation into the effect of hypnotherapy on the sensory and motor functions of the rectum in patients with irritable bowel syndrome.