Post No.: 0213
A ‘placebo’ is something, whether a compound, procedure or other thing, that brings about a beneficial psychological (and therefore possibly physiological) effect for a patient, that cannot be attributed to the therapeutic worth of the thing itself but to the patient’s subjective judgement of his/her own symptoms based on the belief that the thing would work for him/her. Whereas a placebo brings about a perceived beneficial effect, a ‘nocebo’ brings about a perceived detrimental effect.
Placebos can work for things like pain management or helping to reduce the symptoms of anxiety where a person must self-report his/her feelings to others, but they’re not effective concerning things like curing cancer where the problem is not psychological. A person can report feeling better from a placebo while his/her physical ailments actually remain unimproved (e.g. the tumour is still present). This is not to say that pain, anxiety or anything else that’s mental isn’t real or is just a matter of choice – it’s to reveal that the psychological symptoms of problems can be improved or managed via psychological means, maybe even to the point that they’re effectively completely manageable.
Psychological thoughts, after all, ultimately involve real, physical electrochemical processes, neurotransmitters and hormones, and so these physiological effects can be somewhat affected by our own thoughts, which may in turn manifest in certain physical changes. Expectations can create physiological changes in our body, such as the expectation of food makes us start to salivate, secrete insulin and eject bile into the gastrointestinal system. Yet this doesn’t mean that we have total control of our bodies via our conscious thoughts because these effects can only go so far via thought alone and can only do so much to affect our bodies anyway (e.g. it’s a far stretch to think that salivating will cure asthma). And besides, it’s not easy for a broken or ‘broken’ mind to fix itself without external help if you’re expecting someone with a mental health disorder to just ‘get a grip’ because ‘it’s all inside your head’.
Maybe a very loose analogy is like one can summon more willpower to push harder to lift a heavy weight up but this doesn’t mean that one can therefore lift whatever weight one wishes to lift by willpower alone – we’re all still bound by physical laws and limitations. Or it’d be like naïvely believing that software problems aren’t real and expecting a smartphone with a software glitch to fix itself because it’s got sufficient battery life and it doesn’t really need any new hardware parts or any other additional external resources like that to be fixed. It changes little telling your phone, “It’s all inside the components on your motherboard”(!)
Placebos are useful if a pain is acute or a chronic pain has no cure. For problems with cures, it’s usually better to solve or cure those problems rather than merely treat the pain symptoms. The placebo effect can bring some temporary benefits to some people (typically under half of participants in experiments) when it comes to things like pain relief, reducing anxiety and maybe depression or heart break, but it has not been proven to bring any benefit for things like curing HIV or healing open wounds – hence we should remember not to over-extrapolate the findings and jump to the conclusion that ‘mind over matter’ applies to everything.
The mind is ultimately the physical output of a physical system (the brain), so ‘mind over matter’ really just ultimately means ‘matter over matter’, and that means it should be no surprise to find that the mind can affect the (rest of the) body in some way – yet matter must ultimately follow the laws of physics. We cannot break these laws with our minds (e.g. to will a virus to leave our bodies).
The placebo effect exhibits real, measurable effects on the brain during brain scans – the belief or expectation of a placebo on pain relief seems to activate a release of natural painkillers (endorphin neurotransmitters) in the brain. Reading or hearing a particularly arousing sentence on a page or spoken from a person can make you feel angry, sad, uplifted or another emotion or feeling too, but that doesn’t mean you’ve taken a drug with active chemical ingredients, yet they nevertheless had a physiological effect on you – therefore many types of stimuli affect our minds and physiology, not just drugs.
For chronic back pain sufferers who’ve found nothing else works for them, a placebo can give them the initial pain relief that allows them to believe that they can be more active, and then by being gradually more active they’ll exercise and strengthen their backs and this stronger back will thus reduce their pain, hence triggering a virtuous cycle. This contrasts with the vicious cycle that many chronic back pain sufferers follow for not wanting to move or challenge their backs because of the pain, and so their backs stay or get ever weaker, and thus they guarantee their own long-term pain. (Read Post No.: 0190 for more about chronic back pain recovery.) Again, this doesn’t mean that pain isn’t real (just about everyone who has ever lived understands that pain is real and debilitating, even though it’s all apparently inside our heads) but if the pain can be managed then one can start to make lifestyle changes to really improve one’s life.
The placebo effect works mainly on our unconscious. Placebos work better if they’re expensive, come in an orthodox medicine bottle, are accompanied with a noisy machine with flashing lights, and even a fake surgical procedure. Syringe beats a capsule, which beats a pill. It can be enhanced by peer influences, a particular colour, size, number (of pills), the packaging design, saying it’s a ‘newer version’, placing authentic-looking devices and staff in the environment, by the place of administration, how the treatment is given (the bedside manner of the person who administers the placebo), and accompanying the product with a big sell, unwavering belief and positive body language from a (pretend) doctor who’s preferably dressed in a white lab coat. Basically anything that makes it seem absolutely authentic as a drug or treatment will enhance the placebo effect. This is because our preconceptions, expectations and past experiences based on what’s associated with ‘healing’ play a huge role.
The specifics depend on the goal (e.g. two blue-and-white capsules, twice a day, has been found to be best for pain relief in some experiments). The stronger we believe that it’ll work, the stronger the placebo effect tends to be. The same placebos can work for some people and not others but everyone responds to expectation effects at least some of the time or in certain contexts. Culture is important too, for many beliefs have a cultural element to them.
Some people respond better when they receive a pseudoscientific ‘deep meaning’ reasoning, a story of higher/esoteric natural powers, and some theatre or ritual, to their treatment, as this ‘placebo explanation’ enhances the placebo effect. Such ‘placebo stories’ could even be used to enhance the effect of genuine treatments too. Woof!
More research is currently needed but early studies suggest that the dosage of a drug might be able to be amplified with the help of a placebo via operant conditioning – if a unique tasting drink (that therefore isn’t associated with anything else) becomes associated with the administration of a real drug mixed within it, then, if the amount of this drink is increased even though the dosage of that real drug remains the same, the patient may perceive that the dosage of the drug has been increased too. In some cases, even when the drug is fully removed from the drink, a patient may still perceive that the drug is present in this drink that’s associated with that drug. So by repeatedly administering a drug that genuinely does something therapeutic along with a placebo enough times, the body may associate the placebo with that therapeutic effect (and it might also therefore mean it’ll all work without any of that drug’s side-effects too?) Placebo surgery can sometimes even work on shoulder or knee operations – the surgeon makes a cut, pretends to do something but does nothing else except stitch it back up, and somehow the body ends up healing itself on its own!
Doctors who adopt a warm, fluffy, friendly and reassuring manner, and who give their clients more time, are more effective than those who keep consultations formal and/or who don’t give their clients much time during each consultation. It’s however an ethical dilemma for doctors to tell the truth, to not exaggerate or give false hope, or for pharmacies to charge a lot for placebos (since it’s generally believed that more expensive placebos, and genuine drugs, work better than cheaper ones) on the one hand, yet for doctors and other healthcare professionals to do their best to improve the well-being of their patients. From a scientific perspective, if something works then it works whether it’s a placebo or not, and if there are no side-effects then even better. From an ethical perspective though, it could be considered deception and fraud even if it does.
The same general ethical dilemma applies even when patients know that they’re just placebos – in some situations, some patients will still believe that a placebo will work, and therefore it may still actually work for them, despite being clearly told that it’s just a placebo! So even knowing that something is a placebo can still make the effect work.
Factors like not wanting to seem like a complainer, not wanting to prolong one’s stay in hospital or simply wanting desperately to feel better may also put pressures on a patient to respond positively to a treatment (a false positive error), at least for as long or as far as they can.
Another major factor to account for in the reporting of positive responses by patients is the ‘regression to the mean’ i.e. sick people tend to see their doctors when they’re at their most sick state, so they would tend to naturally get better over time without any intervention. You cannot get any lower than when you’re at your lowest so any change will be an improvement, and we may misattribute this improvement to something we personally did rather than to the mere passage of time and the body healing itself without any special help.
Placebos overlap with superstitions. And here, many people frequently pay (lots of) money in the free market for superstitions that promise them things like better luck; just like some people in certain religions offer food to practicing monks in temples in return for prayers and blessings, or like many people buy products based on hyped-up marketing that promise to make them more attractive to those they want to attract! Whether it works for them psychologically or is plain irrational behaviour exploited by fraud is debateable. An aphrodisiac is basically whatever you personally believe makes you feel more sexually in the mood.
The nocebo effect occurs when an inert substance or null treatment causes a reported negative response, as opposed to a positive response. It’s just like people can report feeling ill after being told they’ve eaten something nasty, when really it’s just a prank and what they ate was safe. Put some food in a clean and safe jar that has a label saying ‘poisonous’ on it and many people won’t eat it even when told that the jar is actually clean and safe, or put some food close to a clean and fake plastic doo-doo and many people will still think that it’s somehow contaminated.
So people don’t just believe in positive feelings and then feel more positive feelings, but can also believe in negative feelings and then feel more negative feelings. Although we shouldn’t go overboard and beyond the scientific findings – for better and worse – our beliefs and expectations are indeed powerful!