Monday, October 30, 2023
Friday, October 27, 2023
...placebos can work even when patients know they are getting a placebo. In 2010 my colleagues and I published a provocative study showing that patients with irritable bowel syndrome who were treated with what we call open-label placebos — as in, we gave them dummy pills and told them so — reported more symptom relief compared with patients who didn’t receive placebos. (These placebos were given with transparency and informed consent.) In another blow to the concept that concealment is required for placebo effects, my team recently published a study comparing open-label placebos and double-blind placebos in irritable bowel syndrome and found no significant difference between the two. A medical myth was overthrown.
Currently, more than a dozen randomized trials demonstrate that open-placebo treatment can reduce symptoms in many illnesses with primarily self-reported symptoms such as chronic low back pain, migraine, knee pain and more. These findings suggest that patients do not have to believe, expect or have faith in placebos to elicit placebo effects. So what’s happening?
To date, the best explanation for the results of open-placebo trials suggests that for certain illnesses in which the brain amplifies symptoms, engaging in a healing drama can nudge the brain to diminish the volume or false alarm of what’s called central sensitization — when the nervous system overemphasizes or amplifies perceptions of discomfort. This mostly involves nonconscious brain processes that scientists call Bayesian brain, which describes how the brain modulates symptoms. The intensification and the relief of symptoms use the same neural pathways. Considerable evidence also shows that placebos, even when patients know they are taking them, trigger the release of neurotransmitters like endorphins and cannabinoids and engage specific regions of the brain to offer relief. Basically, the body has an internal pharmacy that relieves symptoms.
...placebos shouldn’t be a first-line treatment; patients should be given what effective medicines are available. After all, placebos rarely, if ever, change the underlying pathology or objectively measured signs of disease. I like to remind people that they don’t shrink tumors or cure infections.
Crucially, much discussion and reflection is needed among physicians and our health care system as a whole to understand why the act of treatment itself is so powerful to patients even if a pill contains no therapeutic ingredients. Medicine is not only effective drugs and procedures; it’s a human drama of charged engagement. Our team published a study in The BMJ demonstrating that placebo effects can be significantly enhanced in the context of a supportive, respectful and attentive patient-clinician relationship. Acts of human kindness in general are linked to robust placebo effects.
Wednesday, October 25, 2023
This post passes on a recent effort to put down some basic ideas in as few words as I can manage.
A Materialist’s Credo
In the beginning was the cosmos, fundamentally as incomprehensible to our human brains as quantum chemistry is to a dog’s brain.
What our human brains can understand is that our ultimate emergence from countless generations of less complex organisms can be largely explained by a simple mechanism that tests the reproductive fitness of varying replicants.
Systems that try to predict the future and dictate whether to go for it or scram - from the chemotaxis of bacteria to the predictive processing of our humans brains - have proved to be more likely to survive and propagate.
Modern neuroscience has proved that our experienced perceptions of sensing and acting are these predictions. They are fantasies, or illusions, as is our sense of having a self with agency that experiences value, purpose, and meaning. Everything we do and experience is in the service of reducing surprises by fulling these fantasies. An array of neuroendocrine mechanisms have evolved to support this process because it forms the bedrock of human culture and language.
We are as gods, who invent ourselves and our cultures through impersonal emergent processes rising from our biological substrate.
Personal and social dysfunctions can sometimes be addressed by insight into this process, as when interoceptive awareness of the settings of our autonomic nervous system's axes of arousal, valence, and agency allows us to dial them to more life sustaining values and better regulate our well-being in each instance of the present.
We can distinguish this autonomic substrate from the linguistic cultural overlay it it generates, and allow the latter to be viewed in a more objective light. This is a deconstruction that permits us to not only let awareness rest closer to the 'engine room' or 'original mind' underlying its transient reactive products, but also to derive from this open awareness the kind of succor or equanimity we once found in the imagined stability of an external world.
Hopefully the deconstruction that takes us into this metaphorical engine room makes us more able to discern and employ illusions that enhance continuation rather than termination of our personal and social evolutionary narratives.