Placebo effects

Placebo is Latin for I will please

Refers to any type of treatment that is inert
Used in research trials to objectively test
the efficacy of new treatments
One group is given the treatment, while
another group (the control group) receives
a placebo
Comparing the results from both groups
should reveal the effects of the treatment
Placebo
American Heritage Dictionary
1. A substance containing no medication and
prescribed or given to reinforce a patient's
expectation to get well
2. An inactive substance or preparation used as a
control in an experiment or test to determine
the effectiveness of a medicinal drug
3. Something of no intrinsic remedial value that is
used to appease or reassure another
Placebo effects (cont.)
Interestingly, some people get better in the
placebo group
This phenomenon is known as
the placebo effect
The placebo effect is substantial
About one third of people taking placebos for
a number of complaints will experience relief
The underlying mechanisms remain a
mystery
Sham
The term sham treatment is often used
instead of placebo
Definition:
Something false or empty that is purported to
be genuine; a spurious imitation

Placebo effects (cont.)
The placebo effect is triggered by the
patient's belief in the treatment and their
expectation of feeling better
If symptoms are relieved by taking an inert
substance or undergoing a dummy
procedure, was the original illness
imaginary?
No
Factors that influence the placebo
effect
Characteristics of the placebo
If the pill (or treatment) looks genuine, the
person taking it is more likely to believe that it
contains active ingredients
Larger sized pills suggest a stronger dose
than smaller pills, and taking two pills appears
more potent than just one
Injections have a more powerful effect than
pills
Factors that influence (cont.)
Attitude of the patient
If the person expects the treatment to work,
the chances of a placebo effect are higher
However, the placebo effect may still take
place even if the person is skeptical of
success
The power of suggestion is probably at work
here
Factors that influence (cont.)
Doctor-patient relationship
If the person trusts their health care
practitioner, they are more likely to believe
that the placebo will work
Chiropractors typically instill more trust in their
patients, consequently critics have pointed to
this as a likely explanation of our successes
Placebo effects (cont.)
Types of placebos
Pills are well-known for their placebo effect
However, a placebo can be any inert or
dummy treatment
Special diets, exercise, physical therapy or
surgery
Even chiropractic manipulation
Psychic surgery -

Is actually produced by sleight of hand
http://www.youtube.com/watch?v=roCounjrXf8&feature=related

Animal tissue and blood are used to give a realistic
appearance, while a patient's fleshy midriff helps create the
illusion that the surgeon's fingers have actually penetrated
the body

Still practiced today
in Brazil and the
Philippines
How placebos work
Self-limiting disorders
Many conditions are self-limiting (e.g.,
common cold, some back or neck pain)
They will resolve on their own with or without
treatment
Symptoms resolving is merely coincidence
How placebos work (cont.)
Remission
The symptoms of some disorders, such as
multiple sclerosis and lupus, may wax and
wane
A remission during a course of placebos may
be coincidence, and not due to the placebos
at all
How placebos work (cont.)
Changes in behavior
The placebo may increase a persons
motivation to take better care of themselves,
which may be responsible for the easing of
their symptoms
Altered perception
The persons interpretation of their symptoms
may change with the expectation of feeling
better. (e.g., a sharp pain being reinterpreted
as an uncomfortable tingling)
How placebos work (cont.)
Reduced anxiety
Taking the placebo and expecting to feel
better may soothe the autonomic nervous
system reducing levels of stress chemicals
Brain chemicals
Placebos may trigger the brain to release
endorphins, the body's own natural painkillers
How placebos work (cont.)
Altered brain state
Research has shown that the brain responds
to an imagined scene in much the same way
it responds to an actual visualized scene.
Placebos may help the brain to remember a
time before the onset of symptoms, and then
bring about physiological change
The so-called remembered wellness theory

Placebo examples
A meta-analysis of studies of depressed
individuals taking antidepressant
medications suggests that approximately:
One quarter of the drug response is due to
the administration of an active medication
One half is a placebo effect
The remaining quarter is due to other
nonspecific factors
Listening to Prozac but Hearing Placebo: A Meta-
Analysis of Antidepressant Medication. Prevention &
Treatment, Volume 1, Article 0002a, June 26, 1998
Placebo examples (cont.)
In a survey of surgery for lumbar disc
disease, although no disc herniation was
present in 346 patients (negative surgical
exploration), complete relief of sciatica
occurred in 37 percent and from back pain
in 43 percent
Placebo examples (cont.)
Moseley et al did a double-blinded,
randomized, placebo-controlled trial to
compare arthroscopic lavage and
debridement vs. a sham procedure
They found that all three treatment groups
fared equally: subjective symptomatic
relief was reported, but no objective
improvement in function in any of the
groups
Placebo examples (cont.)
Forty years ago, a young Seattle cardiologist named
Leonard Cobb conducted a unique trial of a procedure
then commonly used for angina, in which doctors made
small incisions in the chest and tied knots in two arteries
to try to increase blood flow to the heart. It was a popular
technique and 90 percent of patients reported that it
helped, but when Cobb compared it with placebo surgery
in which he made incisions but did not tie off the arteries,
the sham operations proved just as successful. The
procedure, known as internal mammary ligation, was
soon abandoned
"The Placebo Prescription" by Margaret Talbot, New York Times
Magazine, January 9, 2000
Sham v. Pill
Kaptchuk et al. Sham device v inert pill:
randomised controlled trial of two placebo
treatments. BMJ 2006;332:391-397.
Fake acupuncture and sugar pills were tested
for their effect on relieving arm pain
Both groups noticed improvements, but fake
acupuncture was significantly better
25% of acupuncture group noticed side
effects and 3 of the sugar pill group actually
withdrew because of them
Waiting list, where Hawthorne effects, natural progression of the
disease, and regression to the mean could be observed
Limited interaction that involved placebo treatment plus
minimal patient-practitioner interaction
Augmented interaction that also involved a placebo treatment,
plus a defined positive patient-practitioner relationship.
Kaptchuk T. Components of placebo effect: randomised controlled trial in patients
with irritable bowel syndrome. BMJ. 2008 May 3;336
Placebo Death?
Natural history of a disease
vs. placebo effect
The body has a natural ability to heal itself
and people heal spontaneously,
occasionally even when the illness is
serious
Hard to differentiate from placebo effect
Cases of spontaneous remission
sometimes end up being regarded as
miracles
Why is this important?
Placebo effects, disease natural history,
and regression to the mean can result in
high rates of good outcomes, which may
be falsely ascribed to specific treatment
effects
The true causes of improvements in pain
after treatment remain unknown in the
absence of independently evaluated
randomized controlled trials