Wednesday, January 4, 2012

The Placebo Effect

Originally, placebos were used in pharmaceutical trials to show whether or not a new medication was really producing the desired clinical effects. If a new compound could not do much better than a sugar pill, the reasoning went, it was not an effective agent.

But, it was not quite so clear cut. Some patients who were receiving placebos also got better. A sugar pill, coupled with the belief that they were receiving real medicine, sufficed to produce a therapeutic benefit.

The substance may have been inert, but the benefits were real.

The conclusion was inescapable. The human mind exists apart from the human brain. And it contributes to the healing process, sometimes a lot and sometimes a little.

Now science, despite itself, has demonstrated that there is more to life than the physical body. It has shown that it’s not all in the brain.

This does not, however, entail that it’s all in the mind and that the right mindset can cure whatever ails you.

Don’t throw out those antibiotics and imagine that your mind can cure your infection. And don’t do as Steve Jobs did and try to cure pancreatic cancer with brown rice and mystical chants.

Some conditions respond well to the placebo effect; others do not. Among those that respond well are depression and anxiety, along with conditions related to stress.

Now that science has identified the placebo effect, things have gotten more interesting.

If you take two individuals who have the same daily work routine and you tell one of them that his routine is giving him a good workout, his metabolism will react as though he has been having a good workout. If you fail to tell it to the other individual he will show none of the benefits that exercise confers.

Shirley Wang reports the results in The Wall Street Journal: “Hotel-room attendants who were told they were getting a good workout at their jobs showed a significant decrease in weight, blood pressure and body fat after four weeks, in a study published in Psychological Science in 2007 and conducted by Alia Crum, a Yale graduate student, and Ellen Langer, a professor in the psychology department at Harvard. Employees who did the same work but weren't told about exercise showed no change in weight. Neither group reported changes in physical activity or diet.”

These observations are compelling, but need to be questioned. Everyone is surely happy to discover that they can gain the benefits of exercise without doing any and without changing their diet.

They might conclude that they can let their gym memberships lapse, and gain the same benefit by finding a physician who will tell them that they are getting a great workout by doing their job or their chores.

And, how much should we rely on self-reporting here? What if those who are told that they are getting a good workout perform their daily tasks more energetically? What if the good news makes them more optimistic and more active and more engaged in their lives? What if the affirmation they receive from the researchers changes the way they feel about their jobs?

Given the information provided I cannot venture an answer. Still, one hopes that the study does not discourage people from going to the gym and adopting a healthier diet. Even if exercise is not all in the body, it certainly is not all in the mind.

In general terms, the placebo effect is produced when someone is tricked into thinking that he is receiving an effective treatment. If he believes that he is receiving treatment he will react as though he is receiving treatment.

Now, a new and intriguing study has suggested that a placebo will even work when the patient knows that he is taking a placebo. It would seem that patients can benefit from the placebo effect even when researchers are not trying to dupe them into believing that they are receiving the latest best treatment for what ails them.

Shirley Wang explains: “It doesn't seem to matter whether people know they are getting a placebo and not a ‘real’ treatment. One study demonstrated a strong placebo effect in subjects who were told they were getting a sugar pill with no active ingredient.”

Unfortunately, this statement is misleading.  Wang’s longer description of the study makes this clear.

In her words: “Eighty patients with irritable bowel syndrome, a chronic gastrointestinal disorder, were assigned either a placebo or no treatment. Patients in the placebo group got pills described to them as being made with an inert substance and showing in studies to improve symptoms via ‘mind-body self-healing processes.’ Participants were told they didn't have to believe in the placebo effect but should take the pills anyway, Dr. Kaptchuk says. After three weeks, placebo-group patients reported feelings of relief, significant reduction in some symptoms and some improvement in quality of life.

“Why did the placebo work—even after patients were told they weren't getting real medicine? Expectations play a role, Dr. Kaptchuk says. Even more likely is that patients were conditioned to a positive environment, and the innovative approach and daily ritual of taking the pill created an openness to change, he says.”

True enough, these patients were told that they were receiving a placebo. Yet, they were also told that the inert substance would produce positive therapeutic benefits.

One might say, as I have said myself, that some forms of psychotherapy work well for some patients because the patients believe that ingesting new ideas on a regular basis will benefit them.

In that case they do not get to take a sugar pill, but they participate in a ritual that our culture believes to be therapeutic. 
If you belong to a culture where people believe in the placebo effect you can be helped by a placebo.  

I assume that this is what Kaptchuk means by “positive environment.”  I also agree that participating in a socio-scientific ritual has a beneficial effect.

In short, we must credit the ambient culture and the social interactions  involving the placebo as much, if not more, than we credit the human mind.

For some of my earlier thoughts about placebos, see here.

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