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“i will please you”
By | June 6, 2009
what’s all this?
A study of arthroscopic knee surgery found that the surgery was no more successful than pretending to do the surgery.
…Sixty patients in the placebo group received skin incisions and underwent a simulated surgery without insertion of the arthroscope. Two other groups had… typical knee procedures… Results showed, “At no point did either of the intervention groups report less pain or better function than the placebo group.”
[A controlled trial of arthroscopic surgery for osteoarthritis of the knee. New England Journal of Medicine 347:2, 81-88 (2002)]
In the 1950s, a Seattle cardiologist named Leonard Cobb… demonstrated the existence of a surgical placebo effect.
…At the time, there was a popular treatment for angina – chest pain caused by decreased blood flow to the heart – that involved making two small incisions in the chest wall and tying sutures around two arteries so that some blood would be rerouted to go to the heart.
…Cobb, who with other doctors was concerned that perhaps the procedure was being overpromoted, randomized patients in his study so that half of them underwent the actual procedure, while in the other half the chest incisions were made but the arteries were not tied off… There was no difference in the relief of pain or other benefits between the two groups.
(my emphasis)
[What the Doctor Didn't Say. Jerry Menikoff, Oxford University Press, USA (2006), p.77]
[An evaluation of internal mammary artery ligation by a double-blind technique. Leonard Cobb et al., New England Journal of Medicine 260:22,1115-8 (1959)]
another recent example:
just as many people with parkinson’s disease (in finland) got a better quality of life – and their doctors noted improvement in their condition – if they had a fake surgery on their brains, as if they had the real surgery.
“One patient, for example, reported that she had not been physically active for several years before surgery, but in the year following surgery she resumed hiking and ice skating. When the double blind was lifted, she was surprised to find that she had received the sham surgery.”
[Effects of perceived treatment on quality of life and medical outcomes in a double-blind placebo surgery trial. Cynthia McCrae et al., Archives of General Psychiatry. 61:4, 412-20 (2004)]
placebo is a latin word meaning “i will please you.” one dictionary definition is “a substance having no pharmacological effect but given merely to satisfy a patient who supposes it to be a medicine.” another one is “something of no intrinsic remedial value that is used to appease or reassure another.” in popular lingo, it is used to mean “a fake.”
i think this is somewhat unfair! if the remedy actually works, then isn’t it, you know… medicine?
i’m sure you recall how the FDA banned over-the-counter cold remedies for small children, for safety, but did you know that those cold remedies also simply don’t work any better than placebo?
one study compared dextromethorphan (basically, robitussin) with diphenhydramine (basically, benadryl) and with a placebo (called “Simple Syrup” – isn’t it weird that’s a brand name?), in kids with a cough. they found that there was no difference between these groups, in how much sleep the kids – and their parents – got.
to say the least, “The desire to ease symptoms is strong for both parents and clinicians. This investigation supports the concept that upper respiratory infections are self-limited illnesses that improve with time.”
[Effect of dextromethorphan, diphenhydramine, and placebo on nocturnal cough and sleep quality for coughing children and their parents. Schroeder K. Journal of Pediatrics. 146:1,146-7 (2005)]
so last year one mom decided to put the placebo effect to work on a kid with a cold:
A nurse instructed her to give the girl a Motrin tablet. “She told me it was the most benign thing I could give,” Ms. Buettner said. “I thought, why give her any drug? Why not give her a placebo?”
…She founded a placebo company, and, without a hint of irony, named it Efficacy Brands. Its chewable, cherry-flavored dextrose tablets, Obecalp, for placebo spelled backward, goes on sale on June 1 at the Efficacy Brands Web site. Bottles of 50 tablets will sell for $5.95… As a parent, she said, “you’ll know when Obecalp is necessary.”
naturally, a storm of controversy ensued – especially among doctors, who expressed deep concern that this is ‘lying to children’ and would ‘teach children to solve everything by taking a pill.’
oh really? we seem a little selective about which placebos cause alarm. consider: the placebo effect has been quite dramatic in studies giving medicine for depression in children: lots (and lots) of studies, for almost 15 years, have shown that an average of 37-48% of kids (depending on the studies) get better when they take placebos, compared to 38-59% of kids taking antidepressants. we have not, however, been seeing storms of controversy about antidepressants for 15 years.
back in 1907, mark twain said there are three kinds of falsehood: lies, damn lies, and statistics… nowadays we might say, “and marketing.”
2/25/2009: The United States accused Forest Laboratories Inc. of inappropriately marketing the drugs Celexa and Lexapro for children and paying kickbacks like spa visits to pediatricians who prescribed the drugs, the Justice Department said.
don’t get me started.
to most folk, learning about the placebo effect often provokes a lot of suspicion about what doctors do – “how do i know s/he’s giving me the real medicine?” – and provokes suspicion about medicine in general – “it doesn’t work any better than a placebo, so it’s a fake.”
but you know what? whenever i think about placebos, and how they “please” us, i have to marvel at the amazing coolness of mind-over-matter – or, rather, the way placebos show us again that mind and body are one. the placebo effect isn’t a trick – it’s a skill. it’s a form of magic – or, if you don’t like magic, you could call it a form of grace – that changes our experience of life.
some folks did a placebo study on hotel maids, who, as a group, typically are kind of out of shape, and describe themselves as being out of shape and not getting any exercise, despite doing a lot of hard physical labor for long hours.
[Harvard psychologist Ellen Langer noted that] despite the fact all of the women in her study far exceeded the U.S. surgeon general’s recommendation for daily exercise, the bodies of the women did not seem to benefit from their activity. Langer and her team measured the maids’ body fat, waist-to-hip ratio, blood pressure, weight and body mass index. They found that all of these indicators matched the maids’ perceived amount of exercise, rather than their actual amount of exercise.
…She divided 84 maids into two groups. With one group, researchers carefully went through each of the tasks they did each day, explaining how many calories those tasks burned. They were informed that the activity already met the surgeon general’s definition of an active lifestyle. The other group was given no information at all.
One month later, Langer and her team returned to take physical measurements of the women and were surprised by what they found. In the group that had been educated, there was a decrease in their systolic blood pressure, weight, and waist-to-hip ratio.
[Mind-set matters: exercise and the placebo effect. Crum AJ, Langer EJ. Psychological Science 18:2, 165-71 (2007)]
what’s the opposite of the placebo effect?
it’s the nocebo effect: “i will harm you.” one version is called “nonspecific side effects”: side effects from medicine that are not caused by the medicine.
have you ever read the “patient information” folder in a package of medicine, and wondered, why all the weird side effects? for example, in a casual glance through a doctor magazine i received in the mail this morning, i see that a side effect of a new blood pressure medicine is high cholesterol; a side effect of a new asthma medicine is cataracts; a side effect of a new fibromyalgia medicine is scrotal pain… do these make sense? how can we tell if these problems were caused by the medicine, or not?
what’s a good way to study this? you guessed it: use a placebo!
Side-effect rates among those taking placebo are comparable to those reported taking an active drug, and headache in particular is more common among those taking placebo. Many commonly reported nocebo symptoms are generalized and diffuse such as drowsiness, nausea, fatigue, and insomnia… Somnolence was found in 25% of those taking placebo, fatigue in 17%, gastrointestinal complaints in 16%, difficulty concentrating in 13%, and headache in 12%.
[reference below]
what about “side effects” in people taking no medicine at all?
Reidenberg and Lowenthal ascertained the incidence of 25 commonly reported symptoms in healthy persons who were not taking any medicines. Thirty-nine percent reported fatigue, 26% difficulty concentrating, 23% drowsiness, 14% headache, and 5% dizziness; only 19% of the respondents reported experiencing no symptoms in the previous 3 days. In a more recent study, Khosla found that 73% of 236 healthy volunteers who were not taking any medications reported symptoms in the preceding 3 days. The most common were fatigue, headache, difficulty concentrating, and somnolence. (emphasis mine)
[Nonspecific medication side effects and the nocebo phenomenon. Arthur J. Barsky, MD, et al. Journal of the American Medical Association 287, 622-27 (2002)]
that article requires a subscription, but here is another article about arthur barsky’s work on nocebos.
in our western world, where we rely – maybe too much – on a strict division of labor between body and mind, we typically interpret all this as the mind, through the power of the placebo/nocebo, controlling what the body experiences. the mind wants vitamin c to cure the cold, so vitamin c cures the cold. the doctor says the drug might cause dizziness -then the mind makes the body dizzy.
but don’t we see the body, likewise, showing the mind what is “real”?
here are two other versions of the nocebo effect:
mass hysteria. one example: the “Mattoon Gasser” occurrred down the road from a place I used to live. i first heard about it from a lady who grew up there.
The first of the 1944 gasser incidents occurred at a house on Grant Ave., Mattoon, on August 31, 1944. Urban Raef was awakened during the early hours of the morning by a strange odor. He felt nauseated and weak, and suffered from a fit of vomiting.
Suspecting that he was suffering from domestic gas poisoning, Raef’s wife tried to check the kitchen stove to see if there was a problem with the pilot light, but found that she was partially paralyzed and unable to leave her bed.
the couple believed someone (the “Mad Gasser”) was pumping poison gas into their house. word quickly spread, and more and more folks reported the same thing happening to them, over about 2 weeks.
…[A] description… of a tall man dressed in dark clothing, wearing a tight fitting cap… was reported in the local media… The FBI became involved, and the local police issued a statement calling on residents to avoid lingering in residential areas… By September 12, local police had received so many false alarms… that they reduced the priority afforded to gasser reports, and announced that the entire incident was likely the result of explainable occurrences exacerbated by public fears.
[see "Victims of Gas Prowler Now 25", "Gas Calls At Vanishing Point", and this article from Time Magazine, Sept 18, 1944.]
here’s another kind of nocebo effect:
Hex death is one that follows a ritualized pronouncement of death by a powerful authority… Case histories of two patients are presented. The first patient, a poorly educated man near death after a hex pronounced by a local voodoo priest, rapidly recovered after ingenious words and actions by his family physician. The second, who had a diagnosis of metastatic carcinoma of the esophagus, died believing he was dying of widespread cancer, as did his family and his physicians. At autopsy, only a 2 cm nodule of cancer in his liver was found.
The cases raise several intriguing questions… Is hex death only a form of human persuasion? If we can cause death by what we say or do, then what lesser behavior do we induce in our patients? Can diagnostic labels… be part of this general phenomenon?
[Hex death: voodoo magic or persuasion? Meador CK. South Med J. 1992 Mar;85(3):244-7.]
some current titles from PubMed, the national medical-research database:
Widespread hyperalgesia in irritable bowel syndrome is dynamically maintained by placebo/nocebo factors.
Drug-related information generates placebo and nocebo responses that modify the drug response.
The placebo-nocebo phenomenon: scientific evidence that values the humanization of the doctor-patient relationship.
Inter-individual variations in beliefs about the placebo effect: a study of 300 rheumatology patients and 100 nurses.
‘Just breathe normally’: word choices that trigger nocebo responses in patients.
Nocebo hyperalgesia: how anxiety is turned into pain.
“Anxiebo”, placebo, and postoperative pain.
Placebo is not always effective against nocebo bacilli. The body-mind interplay still wrapped in mystery.
…i’d say placebo/nocebo effects are social phenomena. and that makes sense. none of us exists in some intellectual-physical vacuum! so the effects of medicine, of treatment, of healing-as-a-transitive-verb, are effects of conversation, in many ways – effects of persuasion – effects of imagination, both conscious and unconscious.
the placebo/nocebo effect, until you really think about it, seems pretty threatening. but once you really think about how it works… isn’t it magical? isn’t it gracious?
Topics: Uncategorized | 1 Comment »
June 7th, 2009 at 7:39 pm
Hi Dr. Saint-Louis.
I think often that the handing of a paper prescription to a patient is the placebo in itself. Or perhaps knowing that the problem has a name (a diagnosis) or that it is self-limiting- the kind and reassuring words of the gentle physician, are enough of a cure in themselves. How often do patients not turn in the prescription, feeling better enough after the visit?