Placebo

A placebo (Latin: I shall please) is a sham or simulated medical intervention that can produce a (perceived or actual) improvement, called a placebo effect.

In medical research, placebos depend on the use of controlled and measured deception. Common placebos are inert tablets, sham surgery, and other procedures based on false information. In one common placebo procedure, a patient is given an inert pill, told that it may improve his/her condition, but not told that it is in fact inert. Such an intervention may cause the patient to believe the treatment will change his/her condition; and this belief may produce a subjective perception of a therapeutic effect, causing the patient to feel their condition has improved. This phenomenon is known as the placebo effect.

Placebos are widely used in medical research and medicine, and the placebo effect is a pervasive phenomenon; in fact, it is part of the response to any active medical intervention. The placebo effect points to the importance of perception and the brain’s role in physical health. However, when used as treatment in clinical medicine (as opposed to laboratory research), the deception involved in the use of placebos creates tension between the Hippocratic Oath and the honesty of the doctor-patient relationship. The United Kingdom Parliamentary Committee on Science and Technology has stated that: “…prescribing placebos… usually relies on some degree of patient deception” and “prescribing pure placebos is bad medicine. Their effect is unreliable and unpredictable and cannot form the sole basis of any treatment on the NHS.”

Since the publication of Henry K. Beecher’s The Powerful Placebo in 1955 the phenomenon has been considered to have clinically important effects. This view was notably challenged when in 2001 a systematic review of clinical trials concluded that there was no evidence of clinically important effects, except perhaps in the treatment of pain and continuous subjective outcomes. The article received a flurry of criticism, but the authors later published a Cochrane review with similar conclusions (updated as of 2010). Most studies have attributed the difference from baseline till the end of the trial to a placebo effect, but the reviewers examined studies which had both placebo and untreated groups in order to distinguish the placebo effect from the natural progression of the disease.

Placebos exert an “expectancy” effect whereby an inert substance which is believed to be a drug has effects similar to the actual drug. Placebos can act similarly through classical conditioning, where a placebo and an actual stimulus are used simultaneously until the placebo is associated with the effect from the actual stimulus. Both conditioning and expectations play a role in placebo effect, and make different kinds of contribution. Conditioning has a longer lasting effect, and can affect earlier stages of information processing. The expectancy effect can be enhanced through factors such as the enthusiasm of the doctor, differences in size and color of placebo pills, or the use of other inventions such as injections. In one study, the response to a placebo increased from 44% to 62% when the doctor treated them with “warmth, attention, and confidence”. Expectancy effects have been found to occur with a range of substances. Those who think a treatment will work display a stronger placebo effect than those who do not, as evidenced by a study of acupuncture.

Because the placebo effect is based upon expectations and conditioning, the effect disappears if the patient is told that their expectations are unrealistic, or that the placebo intervention is ineffective. A conditioned pain reduction can be totally removed when its existence is explained. It has also been reported of subjects given placebos in a trial of anti-depressants, that “Once the trial was over and the patients who had been given placebos were told as much, they quickly deteriorated.”

A placebo described as a muscle relaxant will cause muscle relaxation and if described as the opposite, muscle tension. A placebo presented as a stimulant will have this effect on heart rhythm, and blood pressure, but when administered as a depressant, the opposite effect. The consumption of caffeine has been reported to cause similar effects even when decaffeinated coffee is consumed, although a 2003 study found only limited support for this. Alcohol placebos can cause intoxication and sensimotor impairment. Perceived ergogenic aids can increase endurance, speed and weight-lifting ability, leading to the question of whether placebos should be allowed in sport competition. Placebos can help smokers quit. Perceived allergens which are not truly allergenic can cause allergies. Inventions such as psychotherapy can have placebo effects. The effect has been observed in the transplantation of human embryonic neurons into the brains of those with advanced Parkinson’s disease.

Because placebos are dependent upon perception and expectation, various factors which change the perception can increase the magnitude of the placebo response. For example, studies have found that the color and size of the placebo pill makes a difference, with “hot-colored” pills working better as stimulants while “cool” colored pills work better as depressants. Capsules rather than tablets seem to be more effective, and size can make a difference. One researcher has found that big pills increase the effect while another has argued that the effect is dependent upon cultural background. More pills, branding, past experience, and high price increase the effect of placebo pills. Injection and acupuncture have larger effect than pills. Proper adherence to placebos have been found to decrease mortality.

Motivation may contribute to the placebo effect. The active goals of an individual changes their somatic experience by altering the detection and interpretation of expectation-congruent symptoms, and by changing the behavioral strategies a person pursues. Motivation may link to the meaning through which people experience illness and treatment. Such meaning is derived from the culture in which they live and which informs them about the nature of illness and how it responds to treatment. Research upon the placebo treatment of gastric and duodenal ulcers shows that this varies widely with society: those in Germany having a high rate placebo effect while those in Brazil a low one. Placebo effects in treating gastric ulcers is low in Brazil, higher in northern Europe (Denmark, Netherlands) and extremely high in Germany. But the placebo effect for hypertension is lower in Germany than elsewhere. Social observation can induce a placebo effect such when a person sees another having reduced pain following what they believe is a pain reducing procedure.

The placebo effect can work selectively. If an analgesic placebo cream is applied on one hand, it will reduce pain only in that hand and not elsewhere on the body If a person is given a placebo under one name, and they respond, they will respond in the same way on a later occasion to that placebo under that name but not if under another.

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