Posts Tagged ‘Irving Kirsch’

Suggestible You 3

March 19, 2017

“Suggestible You” is the title of a book by Erik Vance.  The subtitle is “The Curious Science of Your Brain’s Ability to Deceive, Transform, and Heal.  This book is about the placebo response and related phenomena.   This is the third post on this book.

Irving Kirsch took up psychology out of a philosophical curiosity about the brain.  He mentored Ted Kaptchuk, a researcher who earned a Chinese doctorate in Eastern medicine and was an expert in acupuncture and other alternative therapies.  These two set up a lab at Harvard and for a long time their names have been synonymous with placebo research.  Kaptchuk’s work spans many complicated aspects of placebo research—genetic, biochemical—but Vance’s favorite study is a relatively simple one.  He handed patients pills and told them it was a placebo.  He explained that placebos had been shown to be very effective agains all manner of conditions, and so forth.  When these patients took the pill, it still worked.  Not as well as a secret placebo—but it worked, even though the people taking it knew it wasn’t real.

Tor Wager conducted research using functional magnetic resonance imaging f(MRI).  fMRI measures blood flow in the brain.  This blood flow is used to infer brain activity.  It is captured in voxels. A single voxel has about 63,000 neurons in it (and four times as much connective).  Nevertheless, fMRI has been invaluable in gaining insights regarding the brain.  Wager used fMRI to capture the placebo effect in action.  The first experiment used electric shock.  The research participants saw either a red or a blue spiral on a screen warning them hey would get either a strong or a mild shock, which would hit between 3 and 12 seconds later to keep them off guard (and build expectation).  Wager  looked two skin creams explaining that a one was designed to reduce the  pain and the other was a placebo.  Actually both skin creams were placebos, but the research participants said they felt less pain with the “active” cream.

The second experiment used a hot metal pad that seared the skin for 20 seconds.  This time the screen just read, “Get Ready,” and then the pad heated up.  As in the first experiment, the research participants received placebo and “pain killing” creams, both of which were actually placebos.  Wager surreptitiously lowered the temperature of the heat pad on the fake “active” cream, fooling the research participants into thinking that the cream was reducing the level of pain they felt.  Then, in the last phase (as Collca had with Vance’s shocks), he kept the temperature high.  Researchers carefully recorded how much pain the subjects reported feeling, and Wager also had their fMRI brain scans.  What the research participants reported about their pain tracked perfectly with the activation of several parts of the brain associated with pain, such as the anterior cingulate cortex (which plays a role in emotions, reward systems, and empathy), the thalamus (which handles sensory perception and alertness), and the insula (which is related to consciousness and perception).  Those reporting less pain from the placebo effect showed less activity in the key pain-related brain regions.  And those who felt less of the placebo effect showed more activity.  So these research participants were not imaging less pain; they were feeling it.

More importantly, Wager observed the route that the placebo response takes from anticipation to the release of drugs inside the brain.  Pain signals normally begin in the more primitive base of the brain (relaying information from wherever in the body the pain starts) and radiate outwards.  What Ager observed was backward, with the pain signals starting in the prefrontal cortex—the most advanced logic part of the brain with executive functions—and working back to the more primitive regions.  Vance noted that this seemed to suggest a sort of collision of information:  half originating in the body as pain, and half originating in the advanced part of the brain as expectation.  Whatever comes out of that collision is what we feel.

The following summary comes directly from Vance’s book,”Pain, like any sensation, starts in the body, goes up the spine, and then travels to the deeper brain structures that distribute that information to places like the prefrontal cortex, where we can contemplate it.  Placebos, on the other hand, seem to start in the prefrontal cortex (just behind the right temple) and go backward.  They work their way to parts of the brain that handle opioids and release chemicals that dull the pain.  That also seem to tamp down activity in the parts of the brain that recognize pain in the first place.  And you feel better.  All in a fraction of a second.”

How powerful these placebo effects are varies.  In some people they barely register.  However, in others the opioid dumps can be so powerful that people become physically addicted to their own internal opioids, similar, in theory, to how people become addicted to laudanum. One theory even suggests that chronic pain might be the result of a brain addicted to its inner pharmacy, in essence, looking for a fix.

More than opioids are involved.  Over the past few decades, other brain chemical have been shown to trigger the placebo effect.    Our inner pharmacy also stocks endocannabinoids—the same chemicals found in marijuana that play an important role in pain suppression—and serotonin,  which is important intestinal movements and is the primary neurotransmitter involved in feelings of happiness and well-being.

Another Discovery by Benjamin Franklin

August 18, 2013

In 1784 Benjamin Franklin along with chemist Antoine-Laurent Lavoisier simulated one of Franz Mesmer‘s sessions.1 People suffering from ailments ranging from asthma to epilepsy were asked to “hug” trees they were told were specially magnetized to “cure” them. As expected, the people swooned and shook. Then the patients were told that the trees were never magnetized. But something had induced the reactions to the trees. That unknown something was later termed the placebo effect.

In 1968 the Food and Drug Administration started using placebo treatments into their golden randomized clinical trials (RCTs), to insure that it was the drug working and not just a belief that it was the drug working. So the effect was large enough that the Food and Drug Administration believed that the placebo effect, if not accounted for, could result in incorrect interpretations of the results from clinical trials.

A key factor in finding placebo effects regards the dependent measures used to assess the effects. Placebo effects were not likely to be found in such medical measures as blood pressure. However, if the measures used reflected how patients reported they felt, then placebos were quite evident. This was especially true in conditions such as pain and nausea. Before one concludes that these measures are subjective and, hence, unimportant, one should be reminded that it is the patients’ own feelings of pain and discomfort that are the most relevant factors. The Harvard psychologist Irving Kirsch found in a meta-analysis of six of the most commonly prescribed antidepressants found that 82 percent of the improvement in mood could be duplicated by giving patients a placebo pill instead of an antidepressant. In another study Kirsch and his colleagues found that the only people in whom antidepressants worked significantly better than placebo pills were patients with the most severe cases. He concluded that unless the patient is extremely depressed, an antidepressant should not be prescribed.

Placebos also work in non-psychiatric conditions, asthma being but one example. In one study, volunteers with asthma were divided into four groups. One group was given an asthma inhaler with a drug, another group was given an inhaler with a saline placebo, a sham acupuncture placebo, or nothing. How much air the volunteers could inhale and exhale before and after each treatment. Was measured. The respiratory scores of those treated with the drug rose by 20%, whereas those in the other three groups got a 7% bump. But when the volunteers were asked to rate their respiratory discomfort on a scale of 0 to10, everyone except those who received no treatment reported a 50% improvement!

The placebo effect places the physician in an ethical dilemma. If she treats the patient with a placebo, he is likely to feel better, but she must lie to the patient. However, if she does not use a placebo, possible unnecessary suffering will not be relieved.

Sometimes the placebo procedures can be employed without deception. In a study by Kirsch, Kaptchuk and their colleagues, 40 patients with irritable bowel syndrome (IBS) pills that they described truthfully as placebo pills made of an inert substance such as sugar, that had been shown in previous clinical studies to produce significant improvements in IBS symptoms thought mind-body self-healing processes. After forty days of twice daily placebos, patients reported feeling better overall along with fewer severe symptoms that 40 patients who received no treatment.

Another way to avoid deception is to enhance the doctor-patient relationship. In a different study of patients with IBS, patients were assigned to either placebo acupuncture or a waiting list. The placebo group was further divided into acupuncture with no conversation, and acupuncture with heavy doses of attention, empathy, and interaction with the practitioner. The practitioner listened to each patient’s problem, repeated the words of the patient, expressed confidence, touched the patient, and lapsed into 20 seconds of thoughtful silence. 28% of the people on the waiting list reported that their bowel symptoms had improved, 44% of the acupuncture placebo reported improvement, and 62% of those in the placebo with the enhanced doctor-patient relationship report improvement.

It should be noted that the placebo effect has a negative counterpart, the nocebo effect, Enter “nocebo” into the search box of the healthymemory blog, to find the relevant posts.

1The facts in this blog post can be found in an article, When Pretending is the Remedy, in Scientific American Mind, March/April 2013 by Trisha Gura.

© Douglas Griffith and, 2013. Unauthorized use and/or duplication of this material without express and written permission from this blog’s author and/or owner is strictly prohibited. Excerpts and links may be used, provided that full and clear credit is given to Douglas Griffith and with appropriate and specific direction to the original content.

Self Hypnotism

October 30, 2011

It has been said that all hypnotism is actually self hypnotism. The New Scientist published an interesting article1 on hypnotism. It describe the treatment program that Peter Whorwell has developed for irritable bowel syndrome (IBS). IBS is a serious disorder that results in some sufferers contemplating suicide. Whorwell presents a tutorial to his patients on how the gut functions. Then he has his patients effectively hypnotize themselves to use visual and tactile sensations of warmth and to imagine the bowel working normally. The United Kingdom’s National Institute for Health and Clinical Excellence has recommended hypnosis as an effective treatment for IBS. Whorwell has shown that under hypnosis some IBS patients can reduce the contractions of their bowel, something that can not normally be done under conscious control2. Their bowel linings become less sensitive to pain.

The question is why this works. Irving Kirsch of the University of Kull thinks that hypnosis taps into physiological pathways that are similar to those involved in the placebo effect (See the Healthymemory Blog Post, “Placebo and Nocebo Effects”). The medical conditions that benefit from the placebo effect and hypnotism are similar. They both involve suggestion and expectation. The disappointing part is that there are individual differences in how well people respond to hypnosis.

For those who do respond well to hypnosis, the effects can be quite impressive. A common test used in studies of pain perception is called the cold presser test. The research participant is asked to keep her hand in ice water for as long as she can stand it. This does become quite painful. The research participant gives ratings of the pain as it increases as the time in the ice water increases. Eventually, the pain becomes unbearable and the participant removes the hand. People who are effectively hypnotized can keep their hand in the bucket for a long period of time. They are told when to remove their hand to prevent organic damage. They also give accurate ratings of the pain, so although they remain aware of the painful stimulus, the pain remains bearable.

1Marchant, J. (2011). Hypnotise Yourself. New Scientist, 27 August, 35.

2Journal of Psychosomatic Research, 64, p. 621.

© Douglas Griffith and, 2011. Unauthorized use and/or duplication of this material without express and written permission from this blog’s author and/or owner is strictly prohibited. Excerpts and links may be used, provided that full and clear credit is given to Douglas Griffith and with appropriate and specific direction to the original content.