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Placebo: Nice But Not Enough

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We hear a lot about the placebo effect, that remarkable ability we have to make ourselves feel better through the belief that something beneficial is happening to us. Occasionally it's sold to us as the power of positive thinking, or just looking on the bright side, being optimistic, expecting good things to happen. But how does it work? How can we kid ourselves so effectively? What is really going on?

The placebo effect is certainly very well supported by evidence. People report that they feel better when told they are being given treatment for an ailment, even when the treatment is fake. As long as they believe they are getting something, they behave as if they were actually getting it. They will report that pains have lessened, that conditions have improved, that they feel different, better.

Two questions arise from this. First, has anything changed to make them feel differently, perhaps in their brain chemistry, or in their perceptions? And secondly, has anything actually changed in the body, in the condition of the ailment itself? The first is about the brain's perception of the state of the body, and the second is about the state of the body itself. They are very different questions and both are important.

Our brains construct representations of reality that allow us to negotiate the world very effectively. Not only do we perceive the world through our senses, but being part of the world, we also perceive sensations from our own bodies. Normally, the brain suppresses many of these sensations which we would otherwise feel, because we would be inundated with signals from all parts of our bodies. That would render us unable to discriminate between the important and the mundane. 

Our brain discriminates and lets us ignore the unimportant signals from our body in favour of the significant ones that help us move around in the world. That filtering of our body sensations is one of the reasons you can't tickle yourself. Your brain desensitises your perceptions to help you focus on the important things in the external world.

But the brain also constructs our mental world. We learn to empathise by mimicking the expressions of people we see, and this in turn creates similar emotional changes to those we are observing, and hence similar changes in brain chemistry. Just the slight action of copying some facial expression that we see in others, triggers changes in our brain chemistry which produce similar feelings. This is the key to understanding the placebo effect.

Not only can physical mimicking produce these subtle brain changes, so can expectations, predictions, memories. Thinking of some frightening event can generate a change in the state of the brain, and in turn increase adrenalin. Remembering a deceased loved one can produce changes in the brain areas associated with grief. Expectation and conditioning behave in just the same way. All of these changes can be seen in brain scans such as fMRI scans, and they are very well evidenced.  Anticipation and expectation affect brain chemistry.

Now let's think about a patient presenting with a pain in the doctor's surgery. The patient has been culturally conditioned to expect that the doctor will be able to alleviate the pain, and therefore has an expectation that the pain will reduce. There will already be an effect on the opioid level in the brain, even in the absence of any treatment, so there is a likelihood that the patient will report feeling better.

Such changes in brain chemistry are also brought on by expressions of sympathy, paying attention, listening, in short any kind of consultation.

All of this is a well-established explanation for why patients report that they feel better. But are they in fact better? In other words, has there been some consequential change in the state of their bodies which cured the original ailment?

In those cases where stress or anxiety is a major factor, clearly reducing stress and anxiety addresses a primary cause. If the changes in brain chemistry brought about by the consultation, the expression of sympathy and concern, reduce stress and anxiety, then there may be a consequential improvement in the underlying condition. A cause has been addressed.  A stress-induced ulcer may well respond to the reduction in stress brought about by a sympathetic consultation.

But if the illness was caused by other factors, for example trauma, the situation is rather different. Although stress and anxiety will affect the state of the body and can impede healing, the question is whether or not the placebo effect in itself is any form of treatment.

Medical practitioners have an ethical problem with telling patients lies, even if believing them might make them less anxious, more positive, more affected by their own opioids. They are well aware that illnesses have real causes not addressed by the placebo effect. Bacterial infections, trauma, organ diseases, hormonal problems, blood disorders – the list is practically endless. In every case the placebo effect is restricted to making the patients feel better without addressing the causes.  

The placebo effect is not treatment but it is useful in making patients feel better. However, for the placebo effect to work, there has to be a lie told to the patient, and the patient has to continue believing it. That makes it a very faulty mechanism for effecting any kind of physical change. We cannot even reliably predict who will be susceptible to the placebo effect (some reports say less than 30% of us), nor in what circumstances, nor how long it might last. So it's not a basis for treatment.

Many practitioners of alternative medicine believe strongly that the cure is evidenced by people reporting that they feel better. For ailments that clear up on their own, these practitioners often cite patients' anecdotes as evidence of efficacy. But without a clear diagnosis of the evidence-based actual causes, they are not justified in claiming any kind of cure or treatment. Without being able to discount the placebo effect through controlled trials, and demonstrate the efficacy of their treatment under strict conditions, they cannot justify their claim to be offering any treatment at all.

The placebo effect is a change in brain chemistry brought about by a conditioned reflex, together with the neurochemical consequences of expectations. It affects our mental picture of our state but that may not be an accurate representation of our real state. We can feel better without actually being better. It's nice to feel better when we're sick, but it's infinitely better to be cured.

It is very lucrative to sell the placebo effect, but telling the difference between it and a real cure is essential for genuine health care. When alternative practitioners say that placebo is enough, they are misunderstanding the physical causes of illness. Selling feel-good is not selling cure.

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About Bob Lloyd

  • I think the placebo affect still has a place. Ok it doesn’t cure things, but if it can help treat symptoms removing the need for the patient to take extra drugs, surely thats a good thing

  • The question surely is what is the place for the placebo effect? Making people feel better is fine as far as it goes, but if it is not addressing the cause of the illness, it’s not offering a cure or effective treatment.

    If the illness goes away on its own, then feeling better is better than not. So having someone show sympathy when you have a cold makes you feel better while the cold is clearing up of its own accord. Clearly better than feeling bad. That placebo effect can be produced strongly simply by the patient getting sympathy, but it doesn’t do anything to address the illness.

    If the placebo effect could be reliably harnessed to reduce pain, for example, clearly that would be a good thing, but far more important is addressing the cause of the pain and actually treating it. Very many alternative practitioners pretend to be transferring energy to the patient, tapping into some mystical healing potential, and use all sorts of the mumbo jumbo when all they are actually doing is ritualising the giving of attention.

    But it’s the uncertainty and unpredictability about the placebo effect that’s the problem. We can’t tell who will be affected by it, or when, or for how long. It can disappear without warning. So telling people they’re being treated when the therapist or practitioner is only producing the placebo effect is dishonest. Such practitioners are pretending to treat conditions, when all they are really doing is exploiting the brain’s response to sympathy. Anyone showing sympathy or concern would be equally effective without the expensive consultations and the mystical talk of healing energy and the like. They’re selling illusion.

  • The question, of course, is what is the ailmint. For certain fake illnesses (CFS, I am looking at you), placeboos are just as effective. Same with people who are “allergic” to things because their eastern doctors indicated as such. Basically, real things are not treatable (save for headaches and that sort of stuff), but this fake crap is.

    That said, one of my cowriters on my site is talking about meditation fixing swine flu. He also is talking about those stupid “prayer studies” on dc. any help is appreciated

  • The case of CFS is interesting because if the cause is actually the brain chemistry associated with feeling bad, then the placebo might make people feel better without affecting the underlying aetiology. The problem of course is that the placebo effect relies on a lie, continually believed by the patient. It’s inconsistent and unreliable.

    In the case of meditation, there is some evidence that the release of serotonin creates the effect and in that case, it’s not just a placebo effect. Personally, I can’t see how meditation could address a viral infection, even if it made people more relaxed about it. It’s undoubtedly true that the vaccine manufacturers are very keen to pump up the risk and create anxiety, so perhaps meditation can calm some folks down enough for them to get it back into perspective.

    Placebo isn’t a treatment because it never addresses the underlying causes, simply masks the feeling of the symptoms. CFS doesn’t yet have identified underlying causes and maybe will be shown to be a variety of related conditions. It may or may not be a genuine syndrome but it becomes very difficult to filter out the worried well who have been talking to convincing mystics and who then report the same symptoms 🙂

  • The problem, of course, is that the placebo can actually treat some conditions. If you have migranes, even without a lie, the release of chemicals from the good feeling of, say Yoga, will help release the problems.

  • Migraine is a neurological disorder and it’s brought on by many different triggers, only one of which seems to be the stress which is reduced by yoga. In fact, there’s one theory of the cause of migraine which actually involves serotonin which is released during yoga so it’s not clear how yoga would help.

    Certainly relaxation is often recommended for migraine sufferers and there are plenty of places selling the yoga treatment, but how it actually reduces the inflammation of the trigeminal nerve (which are shown on brain scans) is debatable. I can’t find any evidence that yoga reduces this inflammation. It’s that inflammation that is directly associated with migraine attacks.

    The fact is that although feeling good about yourself makes your perception of your state better, it doesn’t necessarily affect your underlying state. If relaxing through yoga makes the individual suffer less, then that’s a great palliative but it’s not a treatment of the underlying condition. To my mind though, it’s still a valuable way of reducing the impact of the symptoms.