Gut-Directed Hypnotherapy for IBS: A Dietitian’s Comparative Review of Nerva and Regulora Experiences
Written by: Keren Reiser, RD
Updated: April 30th, 2024
Why would a dietitian recommend Gut-Directed Hypnotherapy (GDH)? *Important: This article is an opinion piece submitted by Keren Reiser, a registered dietitian.
Irritable bowel syndrome (IBS) is a complex condition that significantly impacts the quality of life. Its symptoms, including stomach cramps, bloating, diarrhea, and constipation, can lead to stress, anxiety, and isolation.
The brain-gut connection plays a crucial role in IBS, leading to heightened “Visceral hypersensitivity.” IBS is classified as a Disorder of the Gut-Brain Interaction (DGBI), which combines the relationship between the gastrointestinal and central nervous systems. Brain-Gut Behaviour Therapies BGBT, including gut-directed hypnotherapy (GDH), provide an evidence-based approach to managing the relationship between the brain and the gut.
Gut-directed hypnotherapy for IBS was introduced in 1984 by Whorwell, Prior, and Faragher, with a significant early study that helped establish its credibility and effectiveness. In their study, they demonstrated that hypnotherapy could effectively treat IBS symptoms when other treatments had failed. The research showed improvements in overall well-being, reduction of symptoms, and, in some cases, complete remission of symptoms (10).
Further, the low FODMAP diet research was first published by Dr. Sue Shepherd and Dr. Peter Gibson, at Monash University in Melbourne, Australia, in 1999. This dietary approach was developed to reduce symptoms of IBS.
Subsequently, the diet focuses on reducing the intake of foods high in certain fermentable carbohydrates (FODMAPs), which are poorly absorbed in the small intestine and can cause digestive symptoms in some people with IBS. Since its introduction, the low FODMAP diet has been globally researched as a dietary modification strategy for IBS symptom management; however, it is only effective with 75% of IBS sufferers. For the remaining 25%, diet changes do not help, leading to more frustration and isolation.
Overview of Gut-Directed Hypnotherapy
Over the past four decades, many studies have been conducted on GDH protocols. More recently, two protocols, Manchester and North Carolina, have significantly improved physical and psychological symptoms, improved quality of life, and reduced medication use.
The 2019 Canadian Association of Gastroenterology (CAG) Clinical Practice Guideline for the Management of IBS recommends that healthcare professionals consider GDH as a potential therapy for IBS, especially for patients who haven’t seen sufficient relief from traditional approaches, including diet changes, medication, and psychological therapies. Further, GDH was recognized as effective in alleviating IBS symptoms like abdominal pain, bloating, and irregular bowel movements, based on clinical research showing notable improvements compared to standard treatments. (6)
In 2022, the Rome Working Team, a collective of international experts who specialize in DGBI, highlighted the role of BGBT in their report on treating DGBI, such as IBS.
Notably, this review emphasized that BGBTs, including cognitive-behavioural therapy (CBT), gut-directed hypnotherapy, and mindfulness-based therapies, have strong evidence supporting their effectiveness in managing symptoms of DGBI.
In particular, these therapies address the complex brain-gut interactions involved in DGBI, offering significant symptom relief and improved quality of life. The consensus was that these evidence-based psychological and behavioural interventions need to be more widely available and recognized as fundamental components of a comprehensive treatment plan for DGBI, encouraging healthcare professionals to incorporate BGBT into their clinical practice. (5)
Traditionally, GDH was offered to patients through in-person sessions with trained therapists. These sessions involved one-on-one guidance and hypnotherapy techniques tailored to manage and alleviate symptoms. However, due to the COVID-19 pandemic, the cost, and the shortage of trained therapists, access to GDH was limited, resulting in the development of digital GDH apps.
In fact, a literature review published in February 2024 by Brenner et al. looked at the evidence for using digital GDH apps to treat IBS by providing self-guided gut-directed hypnotherapy. They found that overall, digital GDH apps provided an accessible and cost-efficient method for administering supplementary BGBT treatments for IBS. The researchers recommended using digital GDH apps after a thorough patient assessment, including mental health evaluations and potential risks. (2)
Why would a dietitian recommend Gut-Directed Hypnotherapy?
As a dietitian trained on the use of a low FODMAP diet for IBS by Monash University, I have experience with patients who are challenged following the strict protocol. Even when the client follows the low FODMAP diet exactly as prescribed, only 75% will find relief, leaving 25% frustrated by its lack of symptom relief.
As a person diagnosed with ulcerative colitis over 30 years ago and a frequent sufferer of IBS symptoms, I know firsthand how the brain and gut are interrelated. I was intrigued to learn about other options beyond the low FODMAP diet that could be accessible to my clients.
In 2016, a study by Peters et al. from Monash University examined the impacts of GDH on the low FODMAP diet. The study concluded that the long-lasting effects of gut-directed hypnotherapy are comparable to the low FODMAP diet in alleviating gastrointestinal symptoms. Hypnotherapy was found to be more effective than the diet in improving psychological measures. However, no additional benefits were observed when combining both treatments. (9)
I was fascinated that these results could be achieved independently of diet changes. Since I worked entirely virtual with IBS and IBD patients during the pandemic, I was often targeted for digital ads for two applications, Nerva and Regulora. I decided to try them independently to give an honest review and explain to my patients what to expect since each follows a different format.
Overview of Gut-Directed Hypnotherapy digital therapeutics in managing IBS
Nerva
Nerva by Mindset Health was created by Dr. Simone Peters around 2019 as a gut-directed hypnotherapy app designed to help manage IBS symptoms. The app provides users access to gut-directed hypnotherapy techniques that can help manage IBS symptoms, leveraging clinical research.
Nerva Program
The Nerva program spans six weeks and offers daily activities, including a short psychoeducation reading, a 15-minute hypnotherapy session, and 5-minute guided diaphragmatic deep breathing exercises, totalling approximately 25 minutes.
In addition, the hypnotherapy sessions include metaphors, imagery, and therapeutic suggestions. The daily activities are broken into three components, providing flexibility in your time management and allowing you to complete them. You can fit in what’s manageable in one sitting and return to finish the rest later, to aim for at least 5 out of 7 hypnotherapy sessions weekly.
The weekly psychoeducation topics are:
- Gut-directed hypnotherapy and how it works
- The foundations of IBS
- The brain, the gut and the nervous system link
- The mind and the gut: breaking the symptom cycle
- The science behind gut functions
- What is normal when you have IBS
Throughout the program, participants are asked to rate their symptoms multiple times, covering overall gastrointestinal issues, abdominal bloating and pain, wind passage, stool consistency dissatisfaction, and completing an anxiety and depression questionnaire. Then, at the end of the 6 weeks, there is an additional section for ongoing IBS management to manage flare-ups and maintain results.
Research on Nerva
A retrospective evaluation of the Nerva app evaluated the effectiveness of the Nerva app’s GDH in managing symptoms of IBS, while also exploring factors that might predict a positive response to the therapy.
The study started with 3,141 self-diagnosed IBS participants who downloaded the free application, while only 2,843 started the free week trial. Only half of the participants purchased the full 42-session program after the free trial and 9% completed all 42-session sessions.
Although adherence to the app’s GDH program was low, participants who finished the program experienced significant improvements, such as greater than 30% reduction in abdominal pain symptoms. Participants aged 40 years and over, and those who had been experiencing symptoms for five years or more, showed better response on the assessments. (8)
Since there were only 7% of the initial users in the final analysis, this raised concerns about potential response bias in the findings. The researchers recommended a future randomized control trial to compare the Nerva app results to practitioner face to face session results.
Regulora
Regulora is a digital therapeutic phone app tailored for adults aged 22 and over suffering from IBS, is the first app of its kind to receive approval from both the FDA and Health Canada.
Regulora Program
The Regulora program provides a structured protocol of 7 hypnotherapy sessions over a 12-week period, each session lasting 30 minutes. Each session utilizes techniques aimed at inducing deep physical and autonomic relaxation. Moreover, it incorporates direct and indirect IBS-specific metaphors, imagery, and therapeutic suggestions, focusing on shifting attention away from symptoms and altering symptom perception.
Regulora Research
A 2023 Randomized control study investigated the efficacy of Regulora GDH versus Regulora with a Muscle relaxation script (MR). The study compared the results of 68.5% of the Regulora GDH and 74% of Regulora MR participants that completed the full 7 sessions of both programs. Of those that completed all the sessions, 30.4% of the Regulora GDH and 27.1% of the Regulora MR group experienced a 30% reduction in abdominal pain, in the 4 weeks following treatment. These results showed no significant difference between the treatment groups. While both group results demonstrated improvements, the research findings show that the Regulora GDH program is associated with improvements in abdominal pain, stool consistency, and stool frequency across patients of all IBS subtypes. (1)
Nerva Review
Positives:
- 6 weeks
- Daily calming routine for self-care
- Short 15-minute sessions
- Commitment to completing at least 5 sessions a week was achieved without self-judgment on skipping days.
- Easily accessible and portable.
- Felt more like guided meditation than hypnotherapy
- The soothing Australian voice in the app contributed to a relaxed state, though not feeling entirely hypnotized.
- Notable benefits included feeling calmer and more energized for daily activities following each session.
- Daily education to reinforce the rationale behind the program
- Positive post-program results were noted on the IBS Symptom and Severity Scale and anxiety and depression.
- Periodic evaluations to record before and after effects on symptoms, anxiety and depression
- Ongoing management tools
- Self-prescribed
- Self-directed
- Easy access
- 179$ for 1 year
Challenges
- The app’s progression system, which continued forward even after a missed day, initially caused some anxiety, though this was mitigated by the ability to return to missed days.
Overall
- My experience with the Nerva program was positive, thanks to its ease of use, the calming effect of the sessions, and the flexibility in maintaining a routine. The ability to catch up on missed days and sessions contributed to a stress-reduced experience. The commitment to the program and the ability to integrate it into daily life were important aspects of its success for me.
Regulora Review
Positives
- Fewer sessions
- 30- minute sessions
- The bi-weekly schedule, with an optional practice session in between, was appreciated for its flexibility.
- Easily accessible and portable.
- Soothing American voice
- The hypnosis script matched expectations for a hypnotherapy session.
- After each session, I was relaxed, with noticeable calmness and increased energy for daily activities.
- Health Canada approval as a Digital Therapeutic app
- Positive post-program results were noted on the IBS Symptom and Severity Scale
Challenges
- $200 for 3 month program.
- Initial apprehension during the first session due to the immediate start with a hypnosis script, leading to concerns about being hypnotized and the potential effects.
- Maintaining a consistent schedule
- A lack of educational content regarding the rationale behind GDH and its process left feelings of confusion about how the app would help with IBS symptoms.
- The absence of follow-up after completing the program was noted as a downside.
Overall
I had a positive experience with the Regulora app and found it easily accessible and effective in reducing my IBS symptoms. Committing to less sessions was easier however several times, I was challenged with time management and had to reschedule.
The program’s structure and impact on symptoms make it a valuable tool for those who can navigate its requirements and commit to its duration. I found the higher cost, need for a prescription and lack of psychoeducation content barriers and potential areas for improvement.
Why a Dietitian would recommend Gut-Directed Hypnotherapy
Gut-Directed Hypnotherapy (GDH) is validated as an effective approach for managing IBS, supported by global standards and valued for its role in comprehensive care strategies.
In recent years. innovations have made GDH more accessible, with new formats like individualized courses, group sessions, and digital platforms.
In particular, App-based therapies like Nerva and Regulora contrast traditional, therapist-led approaches by offering wider accessibility, convenience, and affordability. These digital options provide standardized treatment protocols, making receiving care easier for more people.
However, traditional GDH, if available, allows for a more personalized therapeutic experience that can adjust to individual patient responses and foster deeper therapeutic connections.
From my personal experience, both Nerva and Regulora have been effective in offering tools to manage stress and anxiety, leading to a noticeable reduction in my IBS symptoms.
As a Registered Dietitian, I emphasize the importance of sharing evidence-based information on IBS symptom management. GDH is helpful when the low FODMAP diet isn’t the answer. I offer my patients the choice between Nerva and Regulora. My approach to recommending GDH involves a thorough initial assessment of medical, nutrition, and lifestyle histories, discussing all available treatment options, including dietary changes and stress management strategies, and carefully screening for contraindications.
For example, I have recommended over 30 patients to the Nerva program. Most report symptom improvement and value the psychoeducation modules and ongoing management tools. However, a few clients have found challenges with the program and did not achieve positive results. This is consistent with the clinical research that 60-80% of users with find improvement in their IBS symptom management.
In summary, the emergence of GDH, especially through digital platforms, offers a promising, accessible, and low-risk treatment avenue for those grappling with the challenges of IBS, including symptom management, isolation, and GI-related anxiety.
References
(1) Berry SK, Berry R, Recker D, Botbyl J, Pun L, Chey WD. A Randomized Parallel-group Study of Digital Gut-directed Hypnotherapy vs Muscle Relaxation for Irritable Bowel Syndrome. Clin Gastroenterol Hepatol. 2023 Nov;21(12):3152-3159.e2. doi: 10.1016/j.cgh.2023.06.015. Epub 2023 Jun 28. PMID: 37391055.
(2) Brenner DM, Ladewski AM, Kinsinger SW. Development and Current State of Digital Therapeutics for Irritable Bowel Syndrome. Clin Gastroenterol Hepatol. 2024 Feb;22(2):222-234. doi: 10.1016/j.cgh.2023.09.013. Epub 2023 Sep 22. PMID: 37743035.
(3) Drossman DA. Functional Gastrointestinal Disorders: History, Pathophysiology, Clinical Features, and Rome IV. Gastroenterology. 2016;150(6):1262-1279.e2. doi:10.1053/j.gastro.2016.02.032.
(4) Hasan SS, Ballou S, Keefer L, Vasant DH. Improving access to gut-directed hypnotherapy for irritable bowel syndrome in the digital therapeutics’ era: Are mobile applications a “smart” solution? Neurogastroenterol Motil. 2023 Apr;35(4):e14554. doi: 10.1111/nmo.14554. Epub 2023 Feb 27. PMID: 36847206.
(5) Keefer L, Ballou SK, Drossman DA, Ringstrom G, Elsenbruch S, Ljótsson B. A Rome Working Team Report on Brain-Gut Behavior Therapies for Disorders of Gut-Brain Interaction. Gastroenterology. 2022 Jan;162(1):300-315. doi: 10.1053/j.gastro.2021.09.015. Epub 2021 Sep 14. PMID: 34529986.
(6) Moayyedi P, Andrews CN, MacQueen G, Korownyk C, Marsiglio M, Graff L, Kvern B, Lazarescu A, Liu L, Paterson WG, Sidani S, Vanner S. Canadian Association of Gastroenterology Clinical Practice Guideline for the Management of Irritable Bowel Syndrome (IBS). J Can Assoc Gastroenterol. 2019 Apr;2(1):6-29. doi: 10.1093/jcag/gwy071. Epub 2019 Jan 17. PMID: 31294724; PMCID: PMC6507291.
(7) Moshiree B, Drossman D, Shaukat A. AGA Clinical Practice Update on Evaluation and Management of Belching, Abdominal Bloating, and Distention: Expert Review. Gastroenterology. 2023 Sep;165(3):791-800.e3. doi: 10.1053/j.gastro.2023.04.039. Epub 2023 Jul 13. PMID: 37452811.
(8) Peters SL, Gibson PR, Halmos EP. Smartphone app-delivered gut-directed hypnotherapy improves symptoms of self-reported irritable bowel syndrome: A retrospective evaluation. Neurogastroenterol Motil. 2023 Apr;35(4):e14533. doi: 10.1111/nmo.14533. Epub 2023 Jan 20. PMID: 36661117.
(9) Peters SL, Yao CK, Philpott H, Yelland GW, Muir JG, Gibson PR. Randomised clinical trial: the efficacy of gut-directed hypnotherapy is similar to that of the low FODMAP diet for the treatment of irritable bowel syndrome. Aliment Pharmacol Ther. 2016 Sep;44(5):447-59. doi: 10.1111/apt.13706. Epub 2016 Jul 11. PMID: 27397586.
(10) Whorwell PJ, Prior A, Faragher EB. Controlled trial of hypnotherapy in the treatment of severe refractory irritable-bowel syndrome. Lancet. 1984 Dec 1;2(8414):1232-4. doi: 10.1016/s0140-6736(84)92793-4. PMID: 6150275.
