"I'm a proponent of the placebo effect" [Archive]

athon

15th April 2009, 01:38 AM

Not an MD, sorry, but I have worked in the medical field in pathology.

I tend to look at it this way - the placebo effect is a free effect. It costs nothing, arising from the sense of psychological security a patient has in being treated. A medical practitioner who demonstrates care for a patient and can make them feel as if their concerns are being looked after will be eliciting the placebo effect in a patient, as they feel as if their medical complaint is getting the best treatment possible.

In that regard, placebo treatments are useful. Indeed, it's invaluable.

I have a moral problem with selling this part of medicine on its own. Problems arise when misinformation is introduced to provide the placebo benefits;

1) The patient is denied the right to make a free choice based on accurate information.
2) People are provided with incorrect information to integrate into their world view. Transferring this information to other situations could create problems.
3) Such 'false' placebo treatments distract a patient's coping strategy away from other treatments that could work. For example, in the case of motion sickness, if a small wrist band is enough to make you think you're no longer sick, the wrist band is not necessary. The right mind-set is.

Placebos also create a market for people to exploit. If no research is required, the market is reduced to being about how well you sell your misinformation and the cost of materials. I have big problems with the exploitation of gullibility.

The placebo effect isn't a bad thing in itself, if it's couple with good medicine. It's when it's sold on the back of nonsense I see a cause for concern.

Athon

catbasket

15th April 2009, 02:21 AM

Also not an MD ... if you're interested in the placebo effect you may want to check out (Dr) Ben Goldacre's book 'Bad Science' - chapter five is twenty-plus fascinating pages all about TPE, plus plenty of further reading listed in the Notes section.

paximperium

15th April 2009, 02:46 AM

I am an MD and I agree with Athon. It is unethical to give people incorrect information even if "it is for their own good."

Rasmus

15th April 2009, 03:08 AM

Maybe I'm barking up the wrong tree, and a couple of our resident MDs here can set me straight. Over and over again, when confronting woo woo, I'm met with the rationalization that the placebo effect warrants the proliferation of woo woo. If the patient thinks it works, and it therefore works, than what's the harm?

The same patient might decide to run with the woo the next time he has something serious and expect it to work just as well.

Woo costs money. Harm is being done when I charge you a ton of money for sugar pills.

The research I have done on the topic makes me believe it is ethically wrong to rely on a placebo effect to begin with, and constitutes fraud if it's relied on to sell a modality. Am I wrong?

In a minor detail: A doctor can inform a patient (and obtain their consent) prior to administering the placebo.

And before anyone now tells me it won't work: The doctor can start out with real medication and swap to a placebo without informing the patient of the exact time that happens.

that would be the ethical thing to do.

In fact, I've seen clinical studies where the medicine was proven to be effective and the study stopped early to administer the drug to the placebo group, because to continue them on the placebo would be ethically wrong.

Interesting.

Case in point, my Google radar found a blog by a supposed MD, touting accupressure wristbands for sea sickness. His entry and response to my comment can be found here (http://www.medicineandtechnology.com/2009/04/wrist-bands-for-nausea.html).

Can any MDs here chime in?

IANADBIPOTV

Dancing David

15th April 2009, 05:25 AM

Ivor the Engineer

15th April 2009, 05:34 AM

I am an MD and I agree with Athon. It is unethical to give people incorrect information even if "it is for their own good."

...but putting a spin on what you tell them is ok?:)

paximperium

15th April 2009, 05:36 AM

...but putting a spin on what you tell them is ok?:)
As opposed to telling what is not?:rolleyes:

Ivor the Engineer

15th April 2009, 05:37 AM

<snip>

In a minor detail: A doctor can inform a patient (and obtain their consent) prior to administering the placebo.

And before anyone now tells me it won't work: The doctor can start out with real medication and swap to a placebo without informing the patient of the exact time that happens.

that would be the ethical thing to do.

<snip>

Only in a rather unique view of what constitutes ethical treatment.

ETA: On second reading it may be ethical if the patient was informed that at some point in the future her medication might be changed to placebo treatment.

Ivor the Engineer

15th April 2009, 05:41 AM

As opposed to telling what is not?:rolleyes:

:confused:

Rasmus

15th April 2009, 05:45 AM

Only in a rather unique view of what constitutes ethical treatment.

ETA: On second reading it may be ethical if the patient was informed that at some point in the future her medication might be changed to placebo treatment.

that's what I meant. You can even substitute the "might" with "will".

Holler Hoojer

15th April 2009, 06:08 AM

I think I can understand the issue. I am old enough to have acquired arthritis. I was evaluated by an older rheumatologist who concluded our visit by saying, "Yep, you have osteoarthritis. There's no cure. Would you like a prescription or would you like to buy an OTC version? There's little difference and neither one will fix the problem. Drink lots of water and get rest. You got old." I left, reasonably satisfied, knowing I had to deal with this myself.

However, many people get very unhappy when told this sort of thing. My daughter, for example, almost yells, "Well, see another doctor! Find someone who can fix this." People think doctors have magic and can fix everything. When the doctors don't, those patients often sue. So, doctors often give placebos, knowing a perceived benefit is better than no benefit at all.

That approach is wrong for me. I want honesty. Some people don't. Frankly, some people should probably be put down, but that's an option we only allow our Vets.

H3LL

15th April 2009, 06:10 AM

I always thought:

Woo-woo remedy = Placebo

Good medicine = Placebo + Tested efficacy

Surely the placebo effect is present in all properly conducted tests on medicines and promptly removed from the statistics to ascertain effect, if any.

It is rarely discussed, but IMHO woo-woo remedies profit from successfully producing a nocebo effect for conventional medicine. Anti-vac proponents, perhaps the most successful nocebo promoters.

There are no studies that I have seen, but perhaps woo-woo remedies are more successful from their nocebo effect on conventional medicine than their own placebo effect.

Just a thought.

.

Jeff Corey

15th April 2009, 06:34 AM

...There are many causes of the placebo effect. Regression to the mean is one of them.

Not technically true. A placebo effect must be shown to be produced by some sham treatment (sugar pill, sham surgery, etc,) and not from any other threat to internal validity (confound) such as statistical regression to the mean, experimenter bias, etc. This means a randomly assigned control control group would be compared to the sham treatment group, which would eliminate regression as a confounding variable.

shawmutt

15th April 2009, 06:41 AM

I searched a bit over on Science Based Medicine, and gave the Dr. in the blog the link to the AMA letter commenting on this issue. http://www.ama-assn.org/ama1/pub/upload/mm/369/ceja_recs_2i06.pdf

Skwinty

15th April 2009, 08:28 AM

Dancing David

15th April 2009, 10:17 AM

Not technically true. A placebo effect must be shown to be produced by some sham treatment (sugar pill, sham surgery, etc,) and not from any other threat to internal validity (confound) such as statistical regression to the mean, experimenter bias, etc. This means a randomly assigned control control group would be compared to the sham treatment group, which would eliminate regression as a confounding variable.

That is cool, however when the placebo effect is mentioned, it is though it is solely an effect of taking a pill.

Often it is not, but you are talking about something that is very relevant.

Often however in medical research there is a regresion to the mean when it comes to ascribing a placebo effect. But as you say, a group that does not recieve any treatment compared to sham treatment would eliminate that. (All randomly assigned.)

Dancing David

15th April 2009, 10:21 AM

I have 3 questions wrt placebo.

1. Valium (diazepam) , according to a study in 2003 (Prevention and Treatment), only works when the patient knows they are taking valium. If they do not know they are ingesting valium, the drug has no efficacy.
What gives here?:confused:

That would likely depend on teh scale being used to measure an effect, similar to Talking to Prozac.

If a finer scale is sued it will show an effect would be my guess, but if you use a gross sysmptom scale then I have to wonder. Also Valium is very sedating until tolerance is built up, so I will look at the study more.

2. Patients with post op pain are given morphine and there is pain relief. The morphine is then substituted (without the patients knowledge), for saline water, and the patient still has pain relief. Then Naloxone is added to the saline water and the pain relief stops. Naloxone has the effect of blocking the action of the morphine. But the patient isn't getting any morphine.
Once again, who is fooling who here?:confused:

3. It also appears that even if the patient knows he is getting a placebo pill, it still has the desired effect.:confused:

Mind over matter?

More citations would be good, an effect and a statistically signiificant effect are different.

I just did brief look for the Prevention and Treatment article, can you cite your source? Please. :)

Skwinty

15th April 2009, 10:34 AM

More citations would be good, an effect and a statistically signiificant effect are different.

Sorry, I should have stated that this comes from Michael Brooks "13 things that don't make sense".

There is a chapter on Placebo, but no citations wrt to the morphine/naloxone.

The placebo and knowledge of placebo (point 3) was a test he (Brooks) did with Fabrizio Benedetti at St Giovanni Hospital in Turin.

I found this book quite fascinating, and have only seen good reviews,

Skwinty

15th April 2009, 10:37 AM

The diazepam had no effect on anxiety: is referenced by Prevention and Treatment 6, no 1 (2003): v.

paximperium

15th April 2009, 10:41 AM

I have 3 questions wrt placebo.

1. Valium (diazepam) , according to a study in 2003 (Prevention and Treatment), only works when the patient knows they are taking valium. If they do not know they are ingesting valium, the drug has no efficacy.
What gives here?:confused: You need to tell the patient I almost killed with IV valium to stop pretending to stop breathing then.

2. Patients with post op pain are given morphine and there is pain relief. The morphine is then substituted (without the patients knowledge), for saline water, and the patient still has pain relief. Then Naloxone is added to the saline water and the pain relief stops. Naloxone has the effect of blocking the action of the morphine. But the patient isn't getting any morphine.
Once again, who is fooling who here?:confused:
Isn't it amazing what ENDOGENOUS opiates that your body produces for pain can do? Narcan wakes up patient with alcoholic cirrhotic coma, alcohol overdoses and many other things.

3. It also appears that even if the patient knows he is getting a placebo pill, it still has the desired effect.:confused:
Yes it does. It is well known. It even works with babies and animals. Amazing isn't it.

paximperium

15th April 2009, 10:47 AM

The diazepam had no effect on anxiety: is referenced by Prevention and Treatment 6, no 1 (2003): v.
Journal of Psychopharmacology, Vol. 21, No. 7, 774-782 (2007)
DOI: 10.1177/0269881107077355

Reviews

Review: Benzodiazepines in generalized anxiety disorder: heterogeneity of outcomes based on a systematic review and meta-analysis of clinical trials

No systematic review or meta-analysis using a hard outcome has been conducted on the role of benzodiazepines for generalized anxiety disorder (GAD). The objective of this study was to assess the effectiveness and efficacy of benzodiazepines in the treatment of GAD based on trial drop-out rates. We used a systematic review of randomized controlled trials that compared any of the three best established benzodiazepines (diazepam, Lorazepam and aLprazolam) against placebo. Our primary outcome for effectiveness was withdrawal for any reason. Our secondary outcome tapping efficacy was withdrawal due to lack of efficacy, and that tapping side effects was withdrawals due to adverse events.

We included 23 trials. Pooled analysis indicated less risk of treatment discontinuation due to lack of efficacy for benzodiazepines, compared to placebo, relative risk (RR) 0.29 (95% CI 0.18—0.45; p < 0.00001). Nevertheless, pooled analysis showed no conclusive results for risk of all-cause patient discontinuation, RR 0.78 (95% CI 0.62—1.00; p = 0.05). Meta-regression model showed that 74% of the variation in logRR across the studies was explained by year of publication (p <0.001).

This systematic review did not find convincing evidence of the short-term effectiveness of the benzodiazepines in the treatment of GAD. On the other hand, for the outcome of efficacy, this review found robust evidence in favour of benzodiazepines. Due to the heterogeneity induced by year of publication, three hypotheses are plausibLe when it comes to being able to account for the differences between efficacy and effectiveness observed in the outcomes (publication bias, quality of the trial literature and a non-differential response to the placebo effect).
http://jop.sagepub.com/cgi/content/abstract/21/7/774

Skwinty

15th April 2009, 10:50 AM

You need to tell the patient I almost killed with IV valium to stop pretending to stop breathing then.

I hope you apologised.:o
How much did you give the poor person. I hope my doctor doesn't do that to me.

Isn't it amazing what ENDOGENOUS opiates that your body produces for pain can do? Narcan wakes up patient with alcoholic cirrhotic coma, alcohol overdoses and many other things.

What is Narcan?
Incidentally I have heard of a patient who had been in a coma for months being woken up after sleeping tablets were administered. Now that's amazing:eek:

Yes it does. It is well known. It even works with babies and animals. Amazing isn't it.

How does a baby or animal know it is being given a placebo?:confused:

paximperium

15th April 2009, 10:53 AM

I hope you apologised.:o
How much did you give the poor person. I hope my doctor doesn't do that to me.
You can thank me later after I stop you uncontrolled seizures with valium.

What is Narcan?
Common trade name for Naloxone.

Incidentally I have heard of a patient who had been in a coma for months being woken up after sleeping tablets were administered. Now that's amazing:eek: Why the heck is a comatose patient being given sleeping pills?

How does a baby or animal know it is being given a placebo?:confused:
Don't know. It is one of the mysteries of the Placebo effect that is still being studied. Perhaps just the act of ingestion or receiving something has some effect.

Skwinty

15th April 2009, 10:58 AM

Why the heck is a comatose patient being given sleeping pills?

I have no idea. It was quite an issue here in South Africa a few years ago. I think it was by accident.
I remember being in hospital, and being woken up at 2am so I could take my sleeping pills! Go figure.

blutoski

15th April 2009, 11:00 AM

I'm sort of out of the norm on Skeptical community in that I always rewind the discussion about placebo effect a bit to inquire on what people mean, and whether they're trying to explain something that doesn't require explanation.

There are two meanings of the phrase "placebo effect" that are employed, and only one is proposed to be a type of 'treatment': a relationship between expectation and reported results.

There are a few one-off studies that suggest a possibly real - but sporadic - relationship between patient expectation and reported results for mild pain and mild depression.

This is just too little effect upon which to base any proposals for action.

The ethical question is not yet about whether we should reject placebo use because it may require misleading the patient - it's about whether we should reject placebo use because it does not actually appear to work.

Dancing David

15th April 2009, 11:10 AM

The diazepam had no effect on anxiety: is referenced by Prevention and Treatment 6, no 1 (2003): v.

Sorry can you get an author or something, the APA search gives zero hits.

:)

Dancing David

15th April 2009, 11:11 AM

http://jop.sagepub.com/cgi/content/abstract/21/7/774

Thanks!

Skwinty

15th April 2009, 11:13 AM

Sorry can you get an author or something, the APA search gives zero hits.

:)

Nope, sorry that's all I've got. Check Pax's post http://jop.sagepub.com/cgi/content/abstract/21/7/774

I am not medically literate so it's really greek to me.

Jeff Corey

15th April 2009, 11:48 AM

...The ethical question is not yet about whether we should reject placebo use because it may require misleading the patient - it's about whether we should reject placebo use because it does not actually appear to work.

This criticism of Beecher's work supports your contention.

J Clin Epidemiol. 1997 Dec;50(12):1311-8.
The powerful placebo effect: fact or fiction?
Kienle GS, Kiene H.

Institut für angewandte Erkenntnistheorie und medizinische Methodologie, Freiburg, Germany.

In 1955, Henry K. Beecher published the classic work entitled "The Powerful Placebo." Since that time, 40 years ago, the placebo effect has been considered a scientific fact. Beecher was the first scientist to quantify the placebo effect. He claimed that in 15 trials with different diseases, 35% of 1082 patients were satisfactorily relieved by a placebo alone. This publication is still the most frequently cited placebo reference. Recently Beecher's article was reanalyzed with surprising results: In contrast to his claim, no evidence was found of any placebo effect in any of the studies cited by him. There were many other factors that could account for the reported improvements in patients in these trials, but most likely there was no placebo effect whatsoever. False impressions of placebo effects can be produced in various ways. Spontaneous improvement, fluctuation of symptoms, regression to the mean, additional treatment, conditional switching of placebo treatment, scaling bias, irrelevant response variables, answers of politeness, experimental subordination, conditioned answers, neurotic or psychotic misjudgment, psychosomatic phenomena, misquotation, etc. These factors are still prevalent in modern placebo literature. The placebo topic seems to invite sloppy methodological thinking. Therefore awareness of Beecher's mistakes and misinterpretations is essential for an appropriate interpretation of current placebo literature.

Skwinty

15th April 2009, 11:52 AM

Why the heck is a comatose patient being given sleeping pills?

Here's the story

http://www.safpj.co.za/index.php/safpj/article/viewFile/195/195

Prometheus

15th April 2009, 11:59 AM

I have no idea. It was quite an issue here in South Africa a few years ago. I think it was by accident.
I remember being in hospital, and being woken up at 2am so I could take my sleeping pills! Go figure.

How do you get a comatose patient to swallow a pill? :confused:

Skwinty

15th April 2009, 12:03 PM

How do you get a comatose patient to swallow a pill? :confused:

Maybe you place the pill under the tongue as it should be absorbed into the blood stream quite efficiently from that location.
Just an uneducated guess:)

blutoski

15th April 2009, 01:18 PM

This criticism of Beecher's work supports your contention.

J Clin Epidemiol. 1997 Dec;50(12):1311-8.
The powerful placebo effect: fact or fiction?
Kienle GS, Kiene H.

Institut für angewandte Erkenntnistheorie und medizinische Methodologie, Freiburg, Germany.

In 1955, Henry K. Beecher published the classic work entitled "The Powerful Placebo." Since that time, 40 years ago, the placebo effect has been considered a scientific fact. Beecher was the first scientist to quantify the placebo effect. He claimed that in 15 trials with different diseases, 35% of 1082 patients were satisfactorily relieved by a placebo alone. This publication is still the most frequently cited placebo reference. Recently Beecher's article was reanalyzed with surprising results: In contrast to his claim, no evidence was found of any placebo effect in any of the studies cited by him. There were many other factors that could account for the reported improvements in patients in these trials, but most likely there was no placebo effect whatsoever. False impressions of placebo effects can be produced in various ways. Spontaneous improvement, fluctuation of symptoms, regression to the mean, additional treatment, conditional switching of placebo treatment, scaling bias, irrelevant response variables, answers of politeness, experimental subordination, conditioned answers, neurotic or psychotic misjudgment, psychosomatic phenomena, misquotation, etc. These factors are still prevalent in modern placebo literature. The placebo topic seems to invite sloppy methodological thinking. Therefore awareness of Beecher's mistakes and misinterpretations is essential for an appropriate interpretation of current placebo literature.

There's a more contemporary and comprehensive literature review available through Cochrane:

[Placebo interventions for all clinical conditions (http://www.cochrane.org/reviews/en/ab003974.html) (updated version published in 2009, but original version published in 2003)

Summary: It has been widely believed that placebo (dummy) treatments (for example sugar tablets) are associated with substantial effects on a wide range of health problems. However, this belief is not based on evidence from randomised trials that use a placebo treatment for one group of people, while another group receives no treatment. The effect of placebo treatments was studied by reviewing more than 150 such trials covering many types of healthcare problems. Placebo treatments caused no major health benefits, although they possibly had a small effect on outcomes reported by patients, for example pain.

Author's Conclusions: There was no evidence that placebo interventions in general have clinically important effects. A possible small effect on continuous patient-reported outcomes, especially pain, could not be clearly distinguished from bias.

Dancing David

15th April 2009, 02:37 PM

Nope, sorry that's all I've got. Check Pax's post http://jop.sagepub.com/cgi/content/abstract/21/7/774

I am not medically literate so it's really greek to me.

It says using the method they use that there is a difference, between Valium and placebo. I don't think it is the same article as it is from 2007.

I will try searching the APA some more later.

shawmutt

15th April 2009, 03:58 PM

...

I actually think I'm just dealing with a quack. His latest response is:

Even though the placebo effect is real, it is not ethical. OBECALP pills shouldn't be given out. I don't advocate alternative medicine purely for the placebo effect alone. I do think that complementary medicine has efficacy."

I think I made my point on his blog, and I'll just drop my bookmark and let it go.

paximperium

15th April 2009, 04:05 PM

How do you get a comatose patient to swallow a pill? :confused:
Feeding tube-through the nose or Percutenously Inserted Gastrostomy(PEG) or Jejunostomy tube.

You can't put stuff down the mouth, too high risk for aspiration and pneumonias.

paximperium

15th April 2009, 04:08 PM

Here's the story

http://www.safpj.co.za/index.php/safpj/article/viewFile/195/195
First issue is Zolpidem(Ambien in the US) is not a benzodiazepine. It is a different class of med from Valium(diazepam). I've not done stroke research in years so this is an interesting paper.

This is an interesting Case Report but it is still in the anecdotal phase at present. Very interesting. Now we have an interesting question to study.

EeneyMinnieMoe

15th April 2009, 04:32 PM

Alternative medicine once popped up in a conversation about false advertising I was having with someone.

I chose the opportunity to nota bene explain why it often seems that alternative medicine works- power of suggestion, ailments that go away by themselves by the time you decide to do something about them, etc. -and mentioned the placebo effect and fully explained it and how it works and why.

And this person, though she had a second ago been telling me about false advertising of a false cure, looked really impressed and exclaimed "Wow! It's amazing how the body can heal itself! The power of the mind over matter."

Argh! :(

The placebo effect is not a cure. It is temporary. It always goes away. It doesn't "heal" anything. It is not medicine.

hcmom

15th April 2009, 05:01 PM

Jeff Corey

15th April 2009, 07:33 PM

The interesting point here is the question of whether there is a placebo effect if you remove all the other known threats to internal validity in various experimental designs. .
If you can nail a confounding variable down - this is potentially correlated with the independent variable - and show that it is plausible because of previous research, bingo.
Now conduct an experiment controlling that confound and falsify something.

shawmutt

15th April 2009, 08:02 PM

Interesting site: whatstheharm (http://whatstheharm.net)

Thanks for the link, I have been keeping an eye on that site, and it works for laypeople. However, when a supposed MD starts spouting off about how sCAM works there's not much more to discuss really. I'm "just a layman" and he has appeal to authority backing him up.

I might get into it a bit more with the guy, depending on how bored I am tonight at work.

rlr

16th April 2009, 01:14 AM

Not an MD, sorry, but I have worked in the medical field in pathology.

You can therefore be forgiven for saying:

In that regard, placebo treatments are useful. Indeed, it's invaluable.

The only place placebo has in science is in double-blind RCTs. It's necessary to give the control patient a placebo for there to be a double-blind.

There is no "placebo effect" above and beyond what is expected from chance alone, and giving someone a placebo treatment (if it were ethical or legal outside a laboratory, and it isn't) does not help them get better in any way, even psychologically.

This is a widely misunderstood concept, so I'd like to harp on it a little bit.

I was browsing the BBC the other day and came across a good example of the popular understanding of placebo. It's a quote taken randomly from a BBC "Have Your Say". Randomly aside from the fact that it illustrates my point. I didn't hunt for it.

The accusation made by many conventional medical practitioners is that complementary therapies are no more effective than a placebo, but that doesn't mean its ineffective. The placebo effect is potentially a very powerful remedy in its own right. The real problem is how to keep charlatans out of complementary medicine, force the testing of some very toxic "natural" remedies and ensure that if a patient has a serious condition that needs conventional medicine that the practitioner will recognise this and act accordingly.

John Mulholland, Glasgow

The average person does not know the difference between effective and ineffective in medicine. The average person doesn't understand that psychology plays no part in recovery from disease, and it doesn't modify the efficacy of a treatment. In fact, many physicians don't understand this either, so it's unrealistic to expect the public to, without major reform.

These people believe, to be blunt about it, that there is a magical factor in some substances that gives them healing power, and this magical factor can be enhanced by thinking happy thoughts and knocking on wood. The fact that pharmaceutical companies have recently begun to advertise on television, and offer completely pseudoscientific explanations for the mechanism of action of their drugs ("chemical imbalance" ?), certaintly does nothing to dispel the belief in magic. The impression the average consumer will get is that scientists largely don't know how any medicines work, so they could potentially do anything at any time, and the only thing that separates orthodox medicine from heterodox medicine is protocol. The two otherwise blend softly and gradually into each other, with no hard, uncrossable barrier between them. These people believe that what is called impossible today might be called miraculous and recommended tomorrow -- and in terms of what they're told by the media and by interest groups, they have every reason to believe that.

But it's not true. A placebo treatment is not useful to a patient in any way, and drugs which do actually help treat diseases do so for well-understood pharmacodynamic reasons. Acetaminophen acts on cyclooxygenase and prostaglandin receptors, and it will do this whether you know you're taking acetaminophen or not. It will do it whether you're happy or sad, and either way your fever will go down, your headache will go down, and your level of "aches and pains" will go down.

Ivor the Engineer

16th April 2009, 02:22 AM

athon

16th April 2009, 02:46 AM

You can therefore be forgiven for saying:

Arrogance like that ain't a good way to start off a criticism if you want it to be taken in good faith.

There is no "placebo effect" above and beyond what is expected from chance alone, and giving someone a placebo treatment (if it were ethical or legal outside a laboratory, and it isn't) does not help them get better in any way, even psychologically.

This is a widely misunderstood concept, so I'd like to harp on it a little bit.

So far I'm at a loss as to where you get 'widely understood' from when you state that there is no such thing as the 'placebo effect'. If anything, the opposite is true to a fault - it's 'widely understood' that the placebo effect is a very real phenomenon.

The reality seems to be that the belief in taking medication seems to ellicit an effect on the self-perception of a patient's state of health. Hence why it's useful to testing in the first place. If it didn't have this effect, it would be pointless to even bother.

So, you can see where my confusion comes from that you might say something as nonsensical as 'there is no such thing as the placebo effect'.

The accusation made by many conventional medical practitioners is that complementary therapies are no more effective than a placebo, but that doesn't mean its ineffective. The placebo effect is potentially a very powerful remedy in its own right. The real problem is how to keep charlatans out of complementary medicine, force the testing of some very toxic "natural" remedies and ensure that if a patient has a serious condition that needs conventional medicine that the practitioner will recognise this and act accordingly.

John Mulholland, Glasgow

I have no real problem with this. The psychological effect behind placebos is indeed useful. It doesn't rely on being lied to - it relies on the perception of treatment. This psychological comfort obviously has an effect on the patient's view of their health, their sense of pain and personal wellbeing. If you don't think that's important for the patient, I worry for any patient you'd potentially be seeing.

The average person does not know the difference between effective and ineffective in medicine. The average person doesn't understand that psychology plays no part in recovery from disease, and it doesn't modify the efficacy of a treatment. In fact, many physicians don't understand this either, so it's unrealistic to expect the public to, without major reform.

Saying it doesn't make it true. The psychological state of a patient definitely plays a role in patient health and wellbeing on several levels. On a basic level, patient decisions (http://www.springerlink.com/content/pg99v555178g8268/) are effected by their psychological state. Stress reduces healing (http://biology.about.com/library/weekly/aa070998.htm) and has an impact on the immunity of a patient. To say psychology plays no part in recovery from disease flies in the face of pretty basic science.

These people believe, to be blunt about it, that there is a magical factor in some substances that gives them healing power, and this magical factor can be enhanced by thinking happy thoughts and knocking on wood.

Magic? Why bring magic into it? A bit of a red herring here, methinks. Sure, some people see placebo as a magic pill that is somehow a cure within itself. It's not - however, the state of mind in a patient does have an effect on their perception of wellbeing and comfort and on their healing.

But it's not true. A placebo treatment is not useful to a patient in any way, and drugs which do actually help treat diseases do so for well-understood pharmacodynamic reasons. Acetaminophen acts on cyclooxygenase and prostaglandin receptors, and it will do this whether you know you're taking acetaminophen or not. It will do it whether you're happy or sad, and either way your fever will go down, your headache will go down, and your level of "aches and pains" will go down.

Your arguments aren't making a lot of sense, I'm afraid. The effects of placebos and the pharmacological effect of a drug aren't mutually exclusive.

Athon

rlr

16th April 2009, 02:58 AM

rlr,

While the world would be a much simpler place if your statements of fact were universally true, in the words of Ben Goldacre, it's a bit more complicated than that. The nervous system receives, processes and transmits signals which affect biological functions.

No, psychology does not affect biological functions.

But I agree that the world would be a much simpler place if a lot of people didn't talk out of their ass and were on the same page as the adults.

rlr

16th April 2009, 03:01 AM

Arrogance like that ain't a good way to start off a criticism if you want it to be taken in good faith.

You're confused. Fact isn't predicated on faith, and knowing what I'm talking about isn't a form of arrogance for the same reason that stupidity is not a form of knowing things. I challenge you to find where I said "take my word for it". Because I didn't say that. If you're not going to do your own fair share of the homework, after having been pointed in the right direction, what good are you to anyone?

paximperium

16th April 2009, 03:17 AM

No, psychology does not affect biological functions.

But I agree that the world would be a much simpler place if a lot of people didn't talk out of their ass and were on the same page as the adults.
Really? You mean the multitude of stress and disease correlation studies (and the animal model followups) are wrong?

The studies that show that anger/stress increases chance of cardiac events are also wrong?

Or the meditation studies that show how meditators can control their heart rate and autonomic responses?

athon

16th April 2009, 03:50 AM

You're confused. Fact isn't predicated on faith, and knowing what I'm talking about isn't a form of arrogance for the same reason that stupidity is not a form of knowing things. I challenge you to find where I said "take my word for it". Because I didn't say that. If you're not going to do your own fair share of the homework, after having been pointed in the right direction, what good are you to anyone?

The fact you've come in and started shooting your mouth off without anything to back up your statements than rude arrogance and rhetoric speaks volumes. You might 'know' what you're talking about. That doesn't change that it is wrong.

As pax said; you're disagreeing against a wealth of study on the relationship between stress and health and psychology and healing. That's not to say there's necessarily a direct 'mind over matter' effect. Thinking about healing a broken arm won't make it heal faster. However your blunt 'psychology does not affect biological functions' is so wrong it's silly.

Start here (http://jama.ama-assn.org/cgi/content/abstract/267/9/1244). Once you have a sound understanding of the research into the relationships between stress and various 'biological functions', we'll have a serious discussion on our hands rather than your posturing.

Athon

rlr

16th April 2009, 04:18 AM

Really? You mean the multitude of stress and disease correlation studies (and the animal model followups) are wrong?

The studies that show that anger/stress increases chance of cardiac events are also wrong?

Or the meditation studies that show how meditators can control their heart rate and autonomic responses?

You mean the multitude of stress and disease correlation studies establish a link between psychology and disease? How? Stress is not a psychological state. It is a physiological state which is actually independent of one's psychology. But please, do continue to misinterpret evidence.

As for "meditation studies", since the act of meditation has no useful definition in the first place, it's obvious that it can't be meaningfully tested. Also: cite it or you're wrong. I do not accept the burden of discrediting a merely hypothetical study on the basis that you confidently assert that it exists and is scientifically valid.

rlr

16th April 2009, 04:20 AM

The fact you've come in and started shooting your mouth off without anything to back up your statements than rude arrogance and rhetoric speaks volumes. You might 'know' what you're talking about. That doesn't change that it is wrong.

I don't need to back up a claim that there's no placebo effect. That's fact and scientific consensus. You're acting butthurt because you have no meaningful evidence for a placebo effect outside of statistical randomness. You have no evidence because there is no such effect. You're experiencing cognitive dissonance and you're lashing out at me with irrelevancies.

In short, you fail.

paximperium

16th April 2009, 04:48 AM

You mean the multitude of stress and disease correlation studies establish a link between psychology and disease? How? Stress is not a psychological state. It is a physiological state which is actually independent of one's psychology. But please, do continue to misinterpret evidence.
Ahhh, great moving goalpost you have there.

As for "meditation studies", since the act of meditation has no useful definition in the first place, it's obvious that it can't be meaningfully tested. Also: cite it or you're wrong. I do not accept the burden of discrediting a merely hypothetical study on the basis that you confidently assert that it exists and is scientifically valid. No. Your "cite or you're wrong" nonsense is not only a joke, it says alot about the type of person you are. Demanding citations is a valid burden of evidence that someone claiming a point has to meet but you are using it like a shield to defend your nonsense.

I'm not interested in educating you or arguing with an ass. You win. I withdraw my statement. You can take the podium and have fun ranting to nobody because Im pretty confident nobody will listen to you.

paximperium

16th April 2009, 04:49 AM

I don't need to back up a claim that there's no placebo effect. That's fact and scientific consensus. You're acting butthurt because you have no meaningful evidence for a placebo effect outside of statistical randomness. You have no evidence because there is no such effect. You're experiencing cognitive dissonance and you're lashing out at me with irrelevancies.

In short, you fail.Fact and scientific consensus? Citation please or are you just talk?

ponderingturtle

16th April 2009, 04:54 AM

Not an MD, sorry, but I have worked in the medical field in pathology.

I tend to look at it this way - the placebo effect is a free effect. It costs nothing,

But more expensive placebo's work better than cheaper placebo's.

link to ig nobel prize winning research (http://jama.ama-assn.org/cgi/content/full/299/9/1016)

athon

16th April 2009, 04:58 AM

I'm not interested in educating you or arguing with an ass. You win. I withdraw my statement. You can take the podium and have fun ranting to nobody because Im pretty confident nobody will listen to you.

Amen to that. There's a certain level of ignorance and pompousness that I see no point in addressing further - when somebody defines stress as not being psychological, and uses words like 'butthurt', I know I'm either dealing with a 16 year old whose playing grown-up or a troll. Neither serves much of a purpose in discussing anything with.

I might return to this thread if somebody offers something of substance to chew on.

Athon

rlr

16th April 2009, 04:58 AM

Ahhh, great moving goalpost you have there.
No. Your "cite or you're wrong" nonsense is not only a joke, it says alot about the type of person you are. Demanding citations is a valid burden of evidence that someone claiming a point has to meet but you are using it like a shield to defend your nonsense.

I'm not interested in educating you or arguing with an ass. You win. I withdraw my statement. You can take the podium and have fun ranting to nobody because Im pretty confident nobody will listen to you.

So the take-home message here is:

1. You believe that stress is a psychological effect. You contradict medical science in this belief.

2. You cannot cite the study you claim exists, and you disparage me for asking you to. You're not grown-up enough to provide evidence for your claims, probably because you know you're in a very untenable position right now.

3. You're not interested in contributing to a thread except to take ill-conceived snipes at me by willful misinterpretation of my words, which I can easily defend.

Thanks, I'm sure everyone loves you. I know I do.

Amen to that. There's a certain level of ignorance and pompousness that I see no point in addressing further - when somebody defines stress as not being psychological, and uses words like 'butthurt', I know I'm either dealing with a 16 year old whose playing grown-up or a troll. Neither serves much of a purpose in discussing anything with.

I might return to this thread if somebody offers something of substance to chew on.

Athon

Do you actually have any mode besides "ad hominem and beside the point" ? Is there a switch somewhere? You've already admitted that you don't know anything about medicine by endorsing CAM and the placebo effect, so I mean there's no real reason for me to continue engaging you in conversation, but it would personally fulfill me to know that you are a pony with at least two tricks.

athon

16th April 2009, 04:59 AM

But more expensive placebo's work better than cheaper placebo's.

link to ig nobel prize winning research (http://jama.ama-assn.org/cgi/content/full/299/9/1016)

Yeah, I found that interesting. Says a lot about our perceptions of costs and expected benefits.

Athon

paximperium

16th April 2009, 05:01 AM

But more expensive placebo's work better than cheaper placebo's.

link to ig nobel prize winning research (http://jama.ama-assn.org/cgi/content/full/299/9/1016)
That's an interesting study but frankly I don't know why it is in the ig nobel category.

rlr

16th April 2009, 05:02 AM

athon

16th April 2009, 05:07 AM

1. You believe that stress is a psychological effect. You contradict medical science in this belief.

You might want to get a wiki account (http://en.wikipedia.org/wiki/Stress_%28medicine%29) in which case. There's at least some people who disagree with you there, and few people concerned enough to modify it.

I predict, however, that the next shift in goal posts will be to give some exotic definition for 'psychological'. :rolleyes: Keep digging that hole, sunshine.

You've already admitted that you don't know anything about medicine by endorsing CAM and the placebo effect, so I mean there's no real reason for me to continue engaging you in conversation, but it would personally fulfill me to know that you are a pony with at least two tricks.

Please cite where I endorsed CAM or retract it.

Athon

ponderingturtle

16th April 2009, 05:08 AM

That's an interesting study but frankly I don't know why it is in the ig nobel category.

Real science can win an Ig Nobel prize. It just needs to be something that sounds strange and makes you laugh. The criteria is something that makes you laugh and then makes you think.

Many real serious scientific papers have won the Ig Nobel, sometimes the researcher took it as offense. Winning an Ig Nobel prize does not mean that the person is not doing good science.

Look at last years, they had several who were good science. For example they gave the prize to someone who found out that slime mold could solve mazes.

paximperium

16th April 2009, 05:09 AM

rlr

16th April 2009, 05:10 AM

You might want to get a wiki account (http://en.wikipedia.org/wiki/Stress_%28medicine%29) in which case. There's at least some people who disagree with you there, and few people concerned enough to modify it.

I predict, however, that the next shift in goal posts will be to give some exotic definition for 'psychological'. :rolleyes: Keep digging that hole, sunshine.

Please cite where I endorsed CAM or retract it.

Athon

Oh, well Wikipedia says it. I'm convinced. Because if it's on Wikipedia, you know it has to be right. Because anyone can edit it at any time for any reason, and its editors are not experts in any particular field.

Wikipedia is an acceptable substitute for going to school. Quoting Wikipedia instead of citing real peer-reviewed journal articles written by big people is a-ok, and makes you correct. If there is a Wikipedia page that agrees with you, you're in the clear.

Etc, etc. See my previous post about whether you have anything besides ad hominem and dodging the point.

ponderingturtle

16th April 2009, 05:10 AM

paximperium

16th April 2009, 05:11 AM

Real science can win an Ig Nobel prize. It just needs to be something that sounds strange and makes you laugh. The criteria is something that makes you laugh and then makes you think.

Many real serious scientific papers have won the Ig Nobel, sometimes the researcher took it as offense. Winning an Ig Nobel prize does not mean that the person is not doing good science.

Look at last years, they had several who were good science. For example they gave the prize to someone who found out that slime mold could solve mazes.
I wish my papers had won a prize.

rlr

16th April 2009, 05:11 AM

Still waiting for my citations bucko.

I'm still waiting for your citations, too. Do you expect me to read your mind and post them? Do you expect me to know what "studies" you are talking about? Because I don't. That's why I asked you for them.

Of course you know that, and are now going to pretend you provided them, and that there's a burden of proof on me to show evidence for a nonexistent effect that nobody aside from the scientifically illiterate claims exist.

athon

16th April 2009, 05:15 AM

Oh, well Wikipedia says it. I'm convinced. Because if it's on Wikipedia, you know it has to be right. Because anyone can edit it at any time for any reason, and its editors are not experts in any particular field.

Meaning what, precisely? Enough people obviously disagree with your definition of stress not being psychological. You've done nothing but virtually say 'nuh-ah' and put your fingers in your ears. Fine with me, but so far you've brought nothing to the table but ill-informed conjecture and hot-headed posturing.

Etc, etc. See my previous post about whether you have anything besides ad hominem and dodging the point.

My irony meter just broke. :( This comes from Mr. 'Butthurt' and a person who has avoided pointing out where I supported CAM.

I'll ask again in case you missed it in your enthusiasm - please cite where I support CAM or retract it.

Athon

rlr

16th April 2009, 05:16 AM

Please cite where I endorsed CAM or retract it.

The accusation made by many conventional medical practitioners is that complementary therapies are no more effective than a placebo, but that doesn't mean its ineffective. The placebo effect is potentially a very powerful remedy in its own right. The real problem is how to keep charlatans out of complementary medicine, force the testing of some very toxic "natural" remedies and ensure that if a patient has a serious condition that needs conventional medicine that the practitioner will recognise this and act accordingly.

John Mulholland, Glasgow

I have no real problem with this. The psychological effect behind placebos is indeed useful. It doesn't rely on being lied to - it relies on the perception of treatment. This psychological comfort obviously has an effect on the patient's view of their health, their sense of pain and personal wellbeing. If you don't think that's important for the patient, I worry for any patient you'd potentially be seeing.

John Mulholland is endorsing CAM. You have no real problem with John Mulholland endorsing CAM. You agree with John Mulholland. You are endorsing CAM. The belief that the placebo effect is of benefit to patients is, itself, CAM. You are endorsing CAM.

Do I need to draw it in crayon?

rlr

16th April 2009, 05:17 AM

Enough people obviously disagree with your definition of stress not being psychological.

Really? How many? What are their qualifications? What are their names?

Didn't think so. But hey, appeal to popularity is valid logical reasoning. Wait, it's not.

Dancing David

16th April 2009, 05:20 AM

No, psychology does not affect biological functions.

But I agree that the world would be a much simpler place if a lot of people didn't talk out of their ass and were on the same page as the adults.

That is kind of a silly statement, the phrase biological functions is a very broad one and yes the states of the brain do effect the biological functions of the body.

You might want to be a little more specific. For example desensitization can impact panic responses to situations, one can slow one's breating after exercise, etc...

:)

rlr

16th April 2009, 05:21 AM

rlr

16th April 2009, 05:24 AM

That is kind of a silly statement, the phrase biological functions is a very broad one and yes the states of the brain do effect the biological functions of the body.

You might want to be a little more specific. For example desensitization can impact panic responses to situations, one can slow one's breating after exercise, etc...

:)

Sorry, "states of the brain" ? You seem to be confusing psychology with neurology. The two are not actually related, and we're arguing psychology. The one with no rigorous basis in science, and which is not a form of medicine. Psychology has nothing to say about the brain. Only about the "mind", whatever that might be, which apparently but not conclusively is an artifact of the brain, but not in any real way that is amenable to objective measurement. We're talking about, essentially, the contents of the DSM-IV-TR, which is informed more by culture than by science, and which formerly listed homosexuality as a mental disorder.

So that we're on the same page.

Dancing David

16th April 2009, 05:26 AM

You mean the multitude of stress and disease correlation studies establish a link between psychology and disease? How? Stress is not a psychological state. It is a physiological state which is actually independent of one's psychology. But please, do continue to misinterpret evidence.

Excuse me, dualism is a joke. You think that psychology is not a physical state. What on earth are you thinking about? Some archaic use of the word psyche?

Perhaps you should get a clue and slow down your rude arrogant rhetoric.

Psychology is the study of the effects of the PHYSICAL systems known as the central nervous system and peripheral nervous system.

As for "meditation studies", since the act of meditation has no useful definition in the first place, it's obvious that it can't be meaningfully tested.

Um, wow, assert a lot don't you. I suppose you know a lot about meditation, don't you. I will let this rest.

The rest of your post shows such blazing ignorance, we can start with your dualist foolishness first.

Also: cite it or you're wrong.

Oh, really, like your ignorant dualist assertions?
Double standard.

I do not accept the burden of discrediting a merely hypothetical study on the basis that you confidently assert that it exists and is scientifically valid.

Um dude, you ignorance matches your rudeness.

Dualism is so, well, positively woo.

Do you really think that the mind is not just a stupid word for brain process?

athon

16th April 2009, 05:33 AM

John Mulholland is endorsing CAM. You have no real problem with John Mulholland endorsing CAM. You agree with John Mulholland. You are endorsing CAM. The belief that the placebo effect is of benefit to patients is, itself, CAM. You are endorsing CAM.

Do I need to draw it in crayon?

No, but your dishonesty says a lot. The context of the post is clearly about placebos. His statement regarding placebos is correct - The placebo effect is potentially a very powerful remedy in its own right. It is. Using the psychological benefits of the placebo effect is a powerful remedy on its own.

I have no problem with that statement. Nice attempt, though.

Actually, no. It was kind of lame.

Really? How many? What are their qualifications? What are their names?

Didn't think so. But hey, appeal to popularity is valid logical reasoning. Wait, it's not.

Ok, let's try a different tact. Please provide citations for the definition of 'stress' and 'psychology' that demonstrates the former is not related in any way to the latter.

Please, maestro. Show us ignorant fools how it is done.

Athon

Dancing David

16th April 2009, 05:35 AM

I don't need to back up a claim that there's no placebo effect. That's fact and scientific consensus.

Ah, I see, your personal beliefs do not need citations. What studies meet Jeff Corey's status of reporting?

Care to show some?

No, then you are a hypocrite.

You assert they are facts, show the data that says they are facts.

Duh, rude newbie.

Welcome to the JREF, your assertion that facts exist are not the same as showing the:
Data?
Evidence?

Your burden of proof that the alleged 'placebo' effect is just random chance?

You're acting butthurt because you have no meaningful evidence for a placebo effect outside of statistical randomness.

You still have shown your sources.

And BTW, this is a publically visible portion of the forum. Restraint in language is encouraged.

Your arguments through appeal to emotion are rather hollow.

You have no evidence because there is no such effect.

Wow, you are just so right!

Except you lack something, a single citation that shows your assertion is correct!

Your claim, your burden.
Data?
Evidence?

You're experiencing cognitive dissonance

Wow, now you are psychic, along with arrogant.

How many newbie errors can you put in one post?

and you're lashing out at me with irrelevancies.

In short, you fail.

In short you have not provided your evidence.

athon

16th April 2009, 05:41 AM

It's always interesting to me how many people in a forum equate "my account is new" with "I was born yesterday", and seek to measure someone's intelligence by their post count. If you really want to have a bigger internet penis than me, be my guest, but it doesn't make you right.

You're think this is about post count? Sorry, mate - it's because so far you've said nothing of real value, demonstrated ignorance in a field many of us work in or have worked in, and have done so in an insulting, pompous manner that only serves you to appear more sure of yourself than you should be.

Post count? Pft. You're digging your own grave with each post.

When it comes to making an assertion about the pharmacological effects of a drug, and whether that effect is modified by mood or expectation, cite it or it's not true. I want to see credible articles from high impact factor peer-reviewed journals, preferably NEJM, JAMA, Lancet, Ann/Arch Intern Med, etc. In that order of preference. I will not accept PLoS, as it will publish anyone who pays the publication fee, which is $1300 - $2850 depending on which title you want your article in.

How about you try wearing those boots yourself. You've not so much as posted a single link to back up any of your nonsense.

In short, I want the bare minimum for something to be considered believable in medical science.

You can want it until you're blue in the face. Bold, italics, or paint it in purple. Until you demonstrate an understanding, you've got zero credibility here.

So far the citation of studies only has you shifting goal posts faster than anybody can kick a ball. Dishonesty like that shows you're unwilling to discuss reasonably, but only want to appear like some cock-sure know-it-all. Why should anybody bother?

If you are going to claim that a study says something, then it positively behooves you to name the study. Otherwise, whether you're incidentally right or wrong, you're nevertheless talking out of your ass, and are endorsing a fundamentally Wikipedia-based method of scientific credibility.

So when you say 'it is widely accepted', your own appeal to popularity is ok?

We can add 'hypocrisy' to your list.

Athon

Ivor the Engineer

16th April 2009, 05:44 AM

http://content.onlinejacc.org/cgi/content/abstract/51/13/1237?ijkey=b3a999397c76fa7a4a9d2ee2b266d419a8caca2 9&keytype2=tf_ipsecsha

There is an enormous amount of literature on psychological stress and cardiovascular disease. This report reviews conceptual issues in defining stress and then explores the ramifications of stress in terms of the effects of acute versus long-term stressors on cardiac functioning. Examples of acute stressor studies are discussed in terms of disasters (earthquakes) and in the context of experimental stress physiology studies, which offer a more detailed perspective on underlying physiology. Studies of chronic stressors are discussed in terms of job stress, marital unhappiness, and burden of caregiving. From all of these studies there are extensive data concerning stressors’ contributions to diverse pathophysiological changes including sudden death, myocardial infarction, myocardial ischemia, and wall motion abnormalities, as well as to alterations in cardiac regulation as indexed by changes in sympathetic nervous system activity and hemostasis. Although stressors trigger events, it is less clear that stress "causes" the events. There is nonetheless overwhelming evidence both for the deleterious effects of stress on the heart and for the fact that vulnerability and resilience factors play a role in amplifying or dampening those effects. Numerous approaches are available for stress management that can decrease patients’ suffering and enhance their quality of life.

Calm down rlr. You'll give yourself a heart attack.

rlr

16th April 2009, 05:44 AM

How about you try wearing those boots yourself. You've not so much as posted a single link to back up any of your nonsense.

That would be because I haven't made a claim that something exists which does not exist, and there is no burden of proof on me to provide anything. To be sure, I could. There are literally dozens of studies confirming no placebo effect distinguishable from chance. I could take my pick of them. But why should I hold myself to a higher standard than I hold you to, and concede that you aren't required to show evidence of a placebo effect? I know you don't know how, and really all you have to do is admit you don't know how, that there is no factual basis for your belief, and leave it at that. You don't even need to apologize for saying something dumb on the internet, which is hardly a shocking occurrence.

athon

16th April 2009, 05:47 AM

You seem to be struggling, so I'll make it real simple;

Define 'stress'.

Define 'psychological'.

Explain why the former is not related to the latter.

Use citations to support your statements.

:)

Athon

Dancing David

16th April 2009, 05:47 AM

Science-based medicine demands prior plausibility in addition to all the requirements of merely evidence-based medicine. That a slew of placebo-controlled studies might suddenly demonstrate that water has a significant anti-cancer effect if you drink more than 10 glasses a day, is not itself sufficient to recommend more water to the public or to your patients. This is inherently not a plausible claim.

So when you hear someone say that "a study" (which will remain unidentified, of course) shows that "meditation" has some sort of health benefit, guess what folks? It's a ******** claim.

Ah, the newbie now uses straw to pretend that they are right.

Continue newbie.

the fact that you can't cite to defend your foolish assertions (which may have a basis, if your would show it, they are foolish because you haven't demonstrated them to be true.)

Let us see so far we have:

1. Psychology is not the study of physical systems.

2. The placebo effects is just random noise.

3. Psychic assertion that posters have cognitive dissonance.

4. Claim the Pax said there is medical benefit to meditation, which now a straw argument.

So start by showing the

Data and Evidence, to back 1, 2 then maybe you can show where there is evidence that someone on the internet has cognitive dissonance (I sense an MDC winner here!)
and then of course the post where Pax said anything like "a study" (which will remain unidentified, of course) shows that "meditation" has some sort of health benefit".

So wow, two pages and four unsupported and ignorant assertions.

Welcome to the JREF, now we can all place bets on whether you have the guts to stick around or if you will just disappear.

BTW this is your butt, this is your butt on a platter.

rlr

16th April 2009, 05:47 AM

http://content.onlinejacc.org/cgi/content/abstract/51/13/1237?ijkey=b3a999397c76fa7a4a9d2ee2b266d419a8caca2 9&keytype2=tf_ipsecsha

Calm down rlr. You'll give yourself a heart attack.

"This report reviews conceptual issues in defining stress"

later

"Although stressors trigger events, it is less clear that stress "causes" the events."

And that's just the abstract!

It helps to read the article before you cite it. Because if you actually do, it's proving my point for me. Thanks for finding it, by the way.

athon

16th April 2009, 05:50 AM

http://content.onlinejacc.org/cgi/content/abstract/51/13/1237?ijkey=b3a999397c76fa7a4a9d2ee2b266d419a8caca2 9&keytype2=tf_ipsecsha

Calm down rlr. You'll give yourself a heart attack.

He's not denying that stress isn't related to health. He's denying that stress is related to psychology and psychology is unrelated to neurology.

At least, that's the best I can make of it. It's about as bizarre as somebody saying that cheese has nothing to do with milk.

Athon

rlr

16th April 2009, 05:56 AM

1. Psychology is not the study of physical systems.

Yes. The study of the brain is called neurology. Different field. Might want to look it up. Ideas are not physical systems. Psychology actually studies behavior more than anything, which is of course due to the fact that they have no way of ascertaining "states of mind" unless they are indirectly evidenced in behavior. That's a dubious subjective form of validation for the idea of mental states, to say the least. But I digress.

2. The placebo effects is just random noise.

Yes and no. There is no placebo effect apart from random noise, meaning there is no placebo effect period.

3. Psychic assertion that posters have cognitive dissonance.

Cognitive dissonance is the uncomfortable feeling that two simultaneously-held beliefs are at odds. The most common reaction is to chuck the one that came more recently, and scorn the one who provided it.

4. Claim the Pax said there is medical benefit to meditation, which now a straw argument.

He has claimed, by pure fiat, that studies exist which show "how meditators can control their heart rate and autonomic responses". That's a quote.

Data and Evidence, to back 1, 2

What requires evidence? That psychology is not neurology? Sorry, no it doesn't. There's no reason to "provide evidence" that a stick is not a rock. They're different things. Other people arguing from ignorance doesn't place a burden on me. That there's no placebo effect? Who ever said there was? Aside from kids on the internet and scam artists? Other people arguing from ignorance or fraud doesn't place a burden on me.

then maybe you can show where there is evidence that someone on the internet has cognitive dissonance (I sense an MDC winner here!)

Recall what I said just a little while ago about how psychology tells us that states of mind are reflected in behavior. You can hardly simultaneously disagree with me about psychology being scientifically rigorous (as opposed to merely heuristically useful) and also claim I have no way of knowing other people's states of mind. That would be inconsistent, which I see a lot of on these forums.

and then of course the post where Pax said anything like "a study" (which will remain unidentified, of course) shows that "meditation" has some sort of health benefit".

That post is right in the thread for anyone to find. Take some initiative.

So wow, two pages and four unsupported and ignorant assertions.

I know, right? Maybe those two should stop making them.

Jeff Corey

16th April 2009, 05:57 AM

... We're talking about, essentially, the contents of the DSM-IV-TR, which is informed more by culture than by science, and which formerly listed homosexuality as a mental disorder...

And that defines "psychology"? Who publishes the DSM?

Ivor the Engineer

16th April 2009, 05:57 AM

"This report reviews conceptual issues in defining stress"

later

"Although stressors trigger events, it is less clear that stress "causes" the events."

And that's just the abstract!

It helps to read the article before you cite it. Because if you actually do, it's proving my point for me. Thanks for finding it, by the way.

Check out figure 4:

http://content.onlinejacc.org/cgi/content/full/51/13/1237/FIG4

There have been some intermediate approaches to studying short-term stressors that will be highlighted in this article. These approaches use telemetry to study patients’ responses in their world. Public speaking provides an excellent model for the telemetry approach. For many individuals, public speaking is a trying experience, so trying that young doctors frequently dose themselves with beta-blockers in an effort to dampen their anxiety. Using indwelling intravenous catheters, Dimsdale and Moss (7) studied young house officers who were making formal presentations at various conferences. Figure 4 presents some of these data. The dashed line reveals that, on average, epinephrine increased 3-fold. However, the outliers are worth noting. The high responder was an individual who stood up, said "first slide, please," and then had the misery of giving his totally slide-dependent talk by himself when the projector bulb blew. This sort of study reveals both the robust effect and the wide range of effects that behavioral stressors have on real-world SNS responses.

Dancing David

16th April 2009, 05:58 AM

Sorry, "states of the brain" ? You seem to be confusing psychology with neurology.

Um, wow newbie!

I am shocked, you still assert dualism.

The two are not actually related, and we're arguing psychology.

So I guess all the psych courses that I took about neuron function, cell membranes, ion channels and drug effects were imaginary.

That is extraordinary!

I will have to check my transcripts! I suppos ethe psych research I participated in regarding therm regulation , behaviors and cortical temperatures was also imaginary?
Amazing.

The one with no rigorous basis in science, and which is not a form of medicine.

Oh, my, if Jeff Corey does not school you, i am sure that Mercutio will.

Psychology has nothing to say about the brain.

My, Pollyanna, your ignorance is showing.

Only about the "mind", whatever that might be, which apparently but not conclusively is an artifact of the brain, but not in any real way that is amenable to objective measurement.

Really, have a single source for that defintion?

Should be funny, I can't wait to tell the people at the University that they aren't psychologists!

We're talking about, essentially, the contents of the DSM-IV-TR, which is informed more by culture than by science, and which formerly listed homosexuality as a mental disorder.

So that we're on the same page.

That is a whole 'nuther debate, sheesh.

rlr

16th April 2009, 05:59 AM

It's about as bizarre as somebody saying that cheese has nothing to do with milk.

Actually it's more like saying that astronomy has nothing to do with astrology. They share a common origin, but one does not prop up the other.

rlr

16th April 2009, 06:05 AM

Check out figure 4:

http://content.onlinejacc.org/cgi/content/full/51/13/1237/FIG4

There have been some intermediate approaches to studying short-term stressors that will be highlighted in this article. These approaches use telemetry to study patients’ responses in their world. Public speaking provides an excellent model for the telemetry approach. For many individuals, public speaking is a trying experience, so trying that young doctors frequently dose themselves with beta-blockers in an effort to dampen their anxiety. Using indwelling intravenous catheters, Dimsdale and Moss (7) studied young house officers who were making formal presentations at various conferences. Figure 4 presents some of these data. The dashed line reveals that, on average, epinephrine increased 3-fold. However, the outliers are worth noting. The high responder was an individual who stood up, said "first slide, please," and then had the misery of giving his totally slide-dependent talk by himself when the projector bulb blew. This sort of study reveals both the robust effect and the wide range of effects that behavioral stressors have on real-world SNS responses.

So you're actually going to try to assert here, that the statistical outliers noted in this study, which are by definition the least meaningful and least representative of anything, are in fact the most meaningful and most representative of something.

And then you're actually going to tell me that this study demonstrates in a meaningful sense a causal relationship between a psychological state and a biological effect, rather than, say, both deriving from a common cause?

Really? Is this the first journal article you've ever read? Because I do not think they mean what you think they mean. Particularly when you mine an entire study for one sentence, and hold that up as proof of something. Particularly when the rest of the study actually corroborates me in the idea that defining stress as psychological is a matter of convention at best, and has no particular basis in science. The general rule of science is to only deal in observables. Psychological states are not observable, even if one might argue they are derivable.

Seriously, guys, I am arguing from a pretty solid scientific basis here, and you're not doing a very good job with the haphazard disputatious replies.

Jeff Corey

16th April 2009, 06:07 AM

Originally Posted by rlr
"... We're talking about, essentially, the contents of the DSM-IV-TR, which is informed more by culture than by science, and which formerly listed homosexuality as a mental disorder..."
And that defines "psychology"? Who publishes the DSM?

Still waiting.

rlr

16th April 2009, 06:09 AM

Please, please, please. We're straying pretty far from what got me into this thread in the first place. Those who have attacked me have yet to actually flesh out their objections.

Chimpan A has repeatedly endorsed the idea that there is a placebo effect above and beyond what is expected from chance alone. Science says there isn't. Chimpan A has declined to provide any evidence for such a placebo effect, and has instead dwelt upon one irrelevancy after another, changed the subject by riding along on someone else's posts instead of his own, linked to Wikipedia, and generally told me how terrible a person I am for daring to question him.

Chimpan Z would have me, and others, believe that "stress and disease correlation studies" vindicate the placebo effect, which on top of being non sequitur, also misinterprets the very concept of stress, and ALSO misinterprets the very concept of correlation. He has also claimed, by pure fiat, that studies exist which show "how meditators can control their heart rate and autonomic responses". He will not provide the citation to these studies. It's apparently an ancient Chinese secret. Instead he expects me to provide documentary evidence for the nonexistence of something which the scientific community at large has never thought existed. Something which I could do, to be sure, because actually many many articles have been written on the subject. More than are strictly necessary, reflecting that it is a never-ending source of misunderstanding among the general public.

But as a matter of principle I have no burden of proof to show "no placebo effect". Rather, these chimps have a burden to show "yes placebo effect". Theirs is the extraordinary claim, and theirs is the claim with no evidence. I'm willing to bet that at least one of them is well-intentioned here, but believes these things out of pure innumeracy, and doesn't actually understand what sort of effects are to be expected by chance in a random population. That's unfortunate, but I'm not going to host a statistics class merely to set him straight.

Jeff Corey

16th April 2009, 06:11 AM

catbasket

16th April 2009, 06:18 AM

There is no "placebo effect" above and beyond what is expected from chance alone, ...

Dr Ben Goldacre, creator of badscience.net and author of the Bad Science book disagrees with. I suspect these folks also disagree with you (note I haven't read these yet ... after I've finished the book) -

Moerman DE. General medical effectiveness and human biology: placebo effects in the treatment of ulcer disease. Med Anth Quarterly (Aug 1983);14; 4: 3-16

de Craen AJ, Moerman DE, Heikerstamp SH, Tytgat GN, Tijssen JG, Kleijnen J. Placebo effect in the treatment of duodenal ulcer. Br J Clin Pharmacol (December 1999); 48 (6): 853-60

Waber et al. Commercial features of placebo and therapeutic efficacy. JAMA (2008); 299: 1016-17

Montgomery GH, Kirsch I. Mechanisms of placebo pain reduction: an empirical investigation. Psych Science (1996) 7: 174-6

Walsh BT, Seidman SN, Sysko R, Gould M. Placebo response in studies of major depression: variable, substantial, and growing. JAMA (10 April 2002); 287 (14): 1840-7

de la Fuente-Fernandez R, Ruth TJ, Sossi V, Schulzer M, Calne DB, Stoessl AJ. Expectation and dopamine release: mechanism of the placebo effect in Parkinson's disease. Science (10 August 2001); 293 (5532): 1164-6

Zubieta JK, Bueller JA, Jackson LR, Scott DJ, Xu Y, Koeppe RA, Nichols TE, Stohler CS. Placebo effects mediated by endogenous opioid activity on mu-opioid receptors. J Neur (24 August 2005); 23 (34): 7754-62

There's a quite a few more listed in the Notes section of Ben's book ...

Ivor the Engineer

16th April 2009, 06:23 AM

<snip>

Psychological states are not observable, even if one might argue they are derivable.

<snip>

I agree. Understanding what a person's state of mind might be after a particular event requires insight.

Do you think of yourself as someone with insight, or do you struggle to understand what other people are thinking/feeling?

athon

16th April 2009, 06:31 AM

Still waiting.

I suspect you'll wait a while. This is somebody who claims psychology has nothing to do with neurology and says nothing about the brain. He doesn't use the same definitions as the rest of the world, yet won't provide citations for his own bizarre versions. I mean, if he was forced to do that, he might have to admit they don't exist.

So, hotshot - got those definitions for 'stress' and 'psychology' yet? Still searching, I take it?

Athon

ponderingturtle

16th April 2009, 06:53 AM

I wish my papers had won a prize.

Then you need to publish things like

Termination of intractable hiccups with digital rectal massage. (http://www.ncbi.nlm.nih.gov/pubmed/3395000?dopt=Citation)

It also won an ig nobel prize for medicine.

Ivor the Engineer

16th April 2009, 07:05 AM

Then you need to publish things like

Termination of intractable hiccups with digital rectal massage. (http://www.ncbi.nlm.nih.gov/pubmed/3395000?dopt=Citation)

It also won an ig nobel prize for medicine.

http://www.ncbi.nlm.nih.gov/pubmed/2299306

A 60-year-old man with acute pancreatitis developed persistent hiccups after insertion of a nasogastric tube. Removal of the latter did not terminate the hiccups which had also been treated with different drugs, and several manoeuvres were attempted, but with no success. Digital rectal massage was then performed resulting in abrupt cessation of the hiccups. Recurrence of the hiccups occurred several hours later, and again, they were terminated immediately with digital rectal massage. No other recurrences were observed. This is the second reported case associating cessation of intractable hiccups with digital rectal massage. We suggest that this manoeuvre should be considered in cases of intractable hiccups before proceeding with pharmacological agents.

I've considered it. No.

paximperium

16th April 2009, 07:08 AM

Dancing David

16th April 2009, 07:09 AM

Yes. The study of the brain is called neurology. Different field. Might want to look it up. Ideas are not physical systems. Psychology actually studies behavior more than anything, which is of course due to the fact that they have no way of ascertaining "states of mind" unless they are indirectly evidenced in behavior. That's a dubious subjective form of validation for the idea of mental states, to say the least. But I digress.

And you still have yet to how that psychology does not include meurobiology , physical states as one of the areas of study.

Now have you?

Try on pathways of visual perception or how sodium depletion effects neurotransmission.

So YOU are just ASSERTINg what you think psychology is, you haven't shown
1. A defintion that is consistent with your usage.
2. That psychology does not include physical processes.

Just keep asserting and not demonstrating, be a hyporcrite, it is funny.

Yes and no. There is no placebo effect apart from random noise, meaning there is no placebo effect period.

Wow, i am overwhelmed by you number of citations that demonstrate your premise!

Not even one.

So you use double standards, your personal beliefs are facts, nope they are not. try showing something that says your premise is true.

Hypocrite.

Cognitive dissonance is the uncomfortable feeling that two simultaneously-held beliefs are at odds. The most common reaction is to chuck the one that came more recently, and scorn the one who provided it.

So you justa ssume that you know why posters post what they do?

Uh huh, I predict you will leave the forum, you have a lot to learn.

Why is my prediction less valid than your assertion, it isn't they are equal.

Hypocrite.

He has claimed, by pure fiat, that studies exist which show "how meditators can control their heart rate and autonomic responses". That's a quote.

So that isn't what you said in your straw man argument, now is it?

thanks for making my point.

What requires evidence? That psychology is not neurology? Sorry, no it doesn't.

Are you brain dead?
Or just ignoring?

You state psychology does not include neurology as one of it's field of study.

You are worng.

neurology and neuron function is part of psychology.

Please show that it isn't. burden on you.

There's no reason to "provide evidence" that a stick is not a rock. They're different things.

So show that psychology does not study brain function, burden on you.

Other people arguing from ignorance doesn't place a burden on me.

Nope your arguments from ignorance place the burden on you!

http://www.perceptionweb.com/perception/fulltext/p01/p010371.pdf
http://books.google.com/books?hl=en&lr=&id=Av6qWhtw0-EC&oi=fnd&pg=PP13&dq=psychology+and+neuron+function&ots=hdPIbmk1Oq&sig=-mUGRspKBCbaOCfPU7imP57eOHI
http://psychology.cua.edu/csl/PDFfiles/nACHR_and_Brain.pdf

That there's no placebo effect? Who ever said there was? Aside from kids on the internet and scam artists? Other people arguing from ignorance or fraud doesn't place a burden on me.

You say that is is just an effect of random variation, that was your statement. So that burden is on you.

Hypocrite.

Recall what I said just a little while ago about how psychology tells us that states of mind are reflected in behavior. You can hardly simultaneously disagree with me about psychology being scientifically rigorous (as opposed to merely heuristically useful) and also claim I have no way of knowing other people's states of mind. That would be inconsistent, which I see a lot of on these forums.

Wow, are you channeling karl Rove, or just a psychic woo meister. And Hurler Of Straw.

y9ousated that it was cognitive dissonance thatw as behind the nehvior , burden on you.

Wow, you are a slow learner aren't you.

You made the claim, that has nothing to do with the defintion of psychology where it sis ascience.
Overgeneralization and hypocritical.

That post is right in the thread for anyone to find. Take some initiative.

I know, right? Maybe those two should stop making them.

More later Newbie, you still haven't a clue.

The same standards apply to you, you make an assertion, you back it up!

the fact that you can't show that pax said what you claim and then ask me to prove your premise sjows you are a weak stick and likely to run from the fray.

You have political spin skills but your critical thinging has yet to be demonstrated.

paximperium

16th April 2009, 07:11 AM

I've considered it. No. Why? I have nice soothing fingers. I'll even wear a glove.

athon

16th April 2009, 07:35 AM

Why? I have nice soothing fingers. I'll even wear a glove.

It's the fact you happen to be clapping in the middle of doing the exam that has him concerned. :p

Athon

rlr

16th April 2009, 09:10 AM

No placebo effect, the Cochrane Review: <-- featured review!
http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003974/frame.html

No placebo effect:
http://content.nejm.org/cgi/content/abstract/344/21/1594

No placebo effect:
http://www.mayoclinicproceedings.com/content/77/11/1164.abstract

No placebo effect:
http://ehp.sagepub.com/cgi/content/abstract/25/4/436

No placebo effect:
http://jnci.oxfordjournals.org/cgi/content/abstract/95/1/19

No placebo effect:
http://jnci.oxfordjournals.org/cgi/content/full/95/1/2 <-- featured editorial!

No placebo effect:
http://www.bmj.com/cgi/content/full/326/7398/1083 <-- featured primer on research-oriented statistics!

No placebo effect:
http://ict.sagepub.com/cgi/content/abstract/2/2/147

No placebo effect:
http://www.theannals.com/cgi/content/abstract/37/12/1891

CAM treatments which are claimed to work merely by virtue of placebo excuses, don't work:
http://jama.ama-assn.org/cgi/content/abstract/291/5/599

No placebo effect:
http://archderm.ama-assn.org/cgi/content/abstract/140/3/338

No placebo effect:
http://ehp.sagepub.com/cgi/content/abstract/28/1/9

No placebo effect:
http://www.psychosomaticmedicine.org/cgi/content/abstract/68/3/478

No placebo effect:
http://europace.oxfordjournals.org/cgi/content/abstract/9/1/31

No placebo effect:
http://aje.oxfordjournals.org/cgi/content/full/165/10/1219

No placebo effect:
http://mh.bmj.com/cgi/content/abstract/34/2/107

No placebo effect:
http://www.bmj.com/cgi/content/abstract/338/jan27_2/a3115

Oh look, I win the internet. Thread closed.

I could have gone on listing, but at this point I just got bored.

And now you're all a bunch of re-res for demanding that I show evidence of NOTHING while you patently refuse to show any evidence of SOMETHING.

Dancing David

16th April 2009, 09:35 AM

Ivor the Engineer

16th April 2009, 09:35 AM

Um....

http://www.mayoclinicproceedings.com/content/77/11/1164.abstract

Results: Analysis of the data showed significant improvement in pain scores in both groups, but no differences were observed between the group wearing the placebo bracelet and the group wearing the ionized bracelet.

http://jnci.oxfordjournals.org/cgi/content/abstract/95/1/19

Conclusion: In randomized double-blinded, placebo-controlled trials, presumably with minimum sources of bias, placebos are sometimes associated with improved control of symptoms such as pain and appetite but rarely with positive tumor response. Substantial improvements in symptoms and quality of life are unlikely to be due to placebo effects.

http://ehp.sagepub.com/cgi/content/abstract/28/1/9

This purpose of this article is to contrast the analgesic efficacy of acupuncture following dental surgery with the analgesic effects based on the expectation of benefit in two independently conducted placebo-controlled trials evaluating acupuncture as an adjunctive therapy for dental surgery. Both trials used pain following dental surgery as the outcome variable, and both included a blinding check to ascertain patients’ beliefs regarding which treatment they were receiving. Although no statistically significant analgesic effect was observed between the acupuncture and placebo groups, participants in both experiments who believed they received real acupuncture reported significantly less pain than patients who believed that they received a placebo. Patients’ beliefs regarding the receipt of acupuncture bore a stronger relationship to pain than any specific action possessed by acupuncture. These results also support the importance of both employing credible controls for the placebo effect in clinical trials and evaluating the credibility of those controls.

I could go on, but why bother?

I think rlr sees this as a black and white issue.

rlr

16th April 2009, 09:37 AM

blutoski

16th April 2009, 09:38 AM

Hm. I can't endorse rlr's style, but I do agree with his basic claim, and I think his citations are of much better quality and certainly more on-topic than catbasket's or others'. There are a few one-offs that suggest placebos have effects, but not a lot of independent replication and oveall literature reviews are surprisingly negative.

Yet... disagreement continues. I would have thought that the Cochrane review would have settled it: given all the available evidence, there doesn't seem to be support for the claim that placebo effect has clinical benefits - and further - not a lot of support for the claim that it exists at all.

I'd like to understand why, with this type of evidence that skeptics normally say trumps one-offs and personal anecdotes, belief in the real clinical potential for "placebo effect" persists? Even within the medical community?

My guess is that it is a massive cultural inertia, and the research that refutes it is just so recent (probably about 5 years old). There is also a machine devoted to supporting the opposing story with huge budgets (CAM).

:: regarding emotional examples

Discussion about the effect of emotions are red herrings. The placebo effect we're talking about is the one that links treatment expectation with outcome. eg: neutral pill, but authority tells patient it will reduce blood pressure - it reduces blood pressure; neutral pill, but authority tells patient it will increase blood pressure - it increases blood pressure;

A placebo example using emotions would not be analogous. eg: authority tells patient that anger will lower blood pressure, so he is asked to get angry a lot to handle his blood pressure. Or: patient with depression who is obese is told that - good news - their depression will cause them to lose weight, so they remain depressed and lose weight from that point on. Does it sound like we can use emotions as placebos by inventing a story about them and causing arbitrary clinical outcomes?

Realistically, there is no way to manipulate the outcomes of emotions by inventing a treatment ritual or narrative that will do anything but what the emotions already do due to our unconscious physiology. I'm pretty sure emotions are not good analogies for placebos.

This conversation is very much like when I talk to homeopaths... they skip past the "shown not to work" stuff, and focus on the "how does it work? / how might it work? / analogies to something else that does work? / how can we use this?" discussions.

rlr

16th April 2009, 09:41 AM

Citations! Yay!

Wow, you sure get cranky just we asked for your citations. Are you okay?

This is the Jref, your mere asertion that something exists and 97 cents will buy some bad coffee.

Welcome to the Forum.

I don't think you understand the difference between claiming that something exists without evidence, and claiming that it doesn't in the absence of evidence. I also don't think you read the whole conversation in the thread very carefully. I also don't think you personally have anything to contribute, evidenced by the fact that you didn't actually contribute anything except antagonism and badgering, much like everyone else. I don't think you're personally capable of justifying your beliefs when they come under critical scrutiny, which mine just did not, because I did not have a burden to show no placebo effect, because that is not an extraordinary claim and it does not differ from scientific consensus.

But hey, that's what JREF forums are all about, right? Asking for a mile and not giving an inch, and then calling the person asking for reciprocity an ******* for not doing everything that everyone asks.

paximperium

16th April 2009, 09:42 AM

Um....

http://www.mayoclinicproceedings.com/content/77/11/1164.abstract

http://jnci.oxfordjournals.org/cgi/content/abstract/95/1/19

http://ehp.sagepub.com/cgi/content/abstract/28/1/9

I could go on, but why bother?

I think rlr sees this as a black and white issue.
It is a weird list.

Some are pretty well done studies that look specifically at placebos(and the effect is small and very subjective) and some of the studies he completely overreaches since those studies don't seem powered to look at what he is claiming.

Doesn't seem to add much to what I already considered about the placebo effect. It is there, it is subjective and it is a small effect.

blutoski

16th April 2009, 09:44 AM

Um....

http://www.mayoclinicproceedings.com/content/77/11/1164.abstract

http://jnci.oxfordjournals.org/cgi/content/abstract/95/1/19

http://ehp.sagepub.com/cgi/content/abstract/28/1/9

I could go on, but why bother?

I think rlr sees this as a black and white issue.

No, I think he sees it as a massive hole in skeptical beliefs, as do I.

If you were a homeopath, I'd accept that you found some citations (homeopaths have hundreds of one-offs).

Now, I'd ask for independent replication for these citations. eg: same clinical condition, same protocols, positive results, different team. Can you locate any?

If not - that is to say, if placebo effect is supported by one-offs or replications by the same MDs - why do we reject homeopathy? They have far more evidence supporting their claims.

The hole in skeptical beliefs to which I refer feels like an uneven burden of proof for something we already believe in.

Dancing David

16th April 2009, 09:44 AM

Actually it's more like saying that astronomy has nothing to do with astrology. They share a common origin, but one does not prop up the other.
Argument by invalid analogy:

psychology=large set
biological psychology
neurological psychology. etc...

Just because you don't like your defintion of psychology does not make your argument valid.

Some parts of what is calld psychology are science some parts are total and utter woo.

The one does not invalidate or validate the other.

There are huge areas of psychology that are exactly neurology, neurocehemistry, neurodevelopment, neuro structure, neuro function and biology.

But please let your Straw Defintion, which you haven't presented, do the arguing for you.

Ivor the Engineer

16th April 2009, 09:45 AM

<snip>

:: regarding emotional examples

Discussion about the effect of emotions are red herrings.

<snip>

I disagree. I think modulation of the sympathetic and parasympathetic nervous system are the very essence of the placebo effect.

paximperium

16th April 2009, 09:49 AM

No, I think he sees it as a massive hole in skeptical beliefs, as do I.

If you were a homeopath, I'd accept that you found some citations (homeopaths have hundreds of one-offs).

Now, I'd ask for independent replication for these citations. eg: same clinical condition, same protocols, positive results, different team. Can you locate any?

If not - that is to say, if placebo effect is supported by one-offs or replications by the same MDs - why do we reject homeopathy? They have far more evidence supporting their claims. Oh I agree. The placebo effect is mostly about natural progression of disease and regression to the mean.

However, there is a definite effect which is usually with subjective problems(pain and some psychiatric conditions) and I really doubt there is an actual biological response except for certain stress and chronic hormonal related responses.

He severely overreaches by his nonsense that psychological states cannot affect biological functions. His personality does not help either.

Dancing David

16th April 2009, 09:52 AM

I disagre, I am not like talking to a homeopath, I am like talking to a buddhist nihilist witch!

I personaly do not have much faith in the placebo effect.

Yet this is the JREF and all claims must be substantiated. I have often been in that place myself.

So now we can see what the data says, and I think if youe xamine the pro-placebo studies you will find they do not meet Jeff Corey's standard.

blutoski

16th April 2009, 09:55 AM

I disagree. I think modulation of the sympathetic and parasympathetic nervous system are the very essence of the placebo effect.

Again: what placebo effect?

This is what I'm talking about: you're trying to locate a mechanism for something that may not actually exist.

I have every confidence that emotions exist, and emotional states have very real clinical outcomes.

At the same time, I'm very doubtful that placebo treatments have shown clinical outcomes (aka: placebo effect).

If there was a placebo effect, sure. It could be related to how emotions work. Why not? I regard this as an "angels on the head of a pin" conversation.

paximperium

16th April 2009, 09:58 AM

Again: what placebo effect?

This is what I'm talking about: you're trying to locate a mechanism for something that may not actually exist.

I have every confidence that emotions exist, and emotional states have very real clinical outcomes.

At the same time, I'm very doubtful that placebo treatments have shown clinical outcomes (aka: placebo effect).

If there was a placebo effect, sure. It could be related to how emotions work. Why not? I regard this as an "angels on the head of a pin" conversation.
Ahhhh...here is the crux of the problem. We're having issues with defining what "placebo effect" really means.

I don't believe the Placebo Effect has any affect beyond subjective perception and stress response. It does not automatically make pneumonias or meningitis or heart attacks better compared to no treatment(except for subjective interpretation or stress).

Dancing David

16th April 2009, 10:00 AM

I don't think you understand the difference between claiming that something exists without evidence, and claiming that it doesn't in the absence of evidence.

Cry me a river, just because you have a personal belief does not mean that you have shown data.

Gosh, is that so hard to understand ?

You can't read or didn't read my posts or you would already know how I feel about the placebo effect.

I may have even mention 'alleged' and said something about it.

But if you act like a hypocrite and assume you should not have to substantiate a claim, well, welcome to the Forum.

Duh.

I also don't think you read the whole conversation in the thread very carefully. I also don't think you personally have anything to contribute, evidenced by the fact that you didn't actually contribute anything except antagonism and badgering, much like everyone else.

Well, excuse me, did you define psychology yet or are you just using straw arguments and appeals to cynicism?

Psychology is also the study of brain function, whether you like it or not.

Too bad, you might have something to contribute after you stop your little fussy fit and realise that you made some blatant unsupported assertions.

Maybe in whatever place you are used to posting that will stand, everyone is asked to defend the claim at the JREF.

I don't think you're personally capable of justifying your beliefs when they come under critical scrutiny, which mine just did not, because I did not have a burden to show no placebo effect, because that is not an extraordinary claim and it does not differ from scientific consensus.

Ah, more mind reading, what were my personal beliefs again?

You are getting closer and maybe you will last at the JREF.

But gee, what more can i say, you made a claim and did not provide evidence.

Duh.

But hey, that's what JREF forums are all about, right? Asking for a mile and not giving an inch, and then calling the person asking for reciprocity an ******* for not doing everything that everyone asks.

You were the one who engaged in ad hominem, I can show you the psosts, you said that placebo effect is not supported. I asked for the data, which you provided. After many requests.

If you can't show your work, well, time will tell.

You will still have to provide a defintion of psychology we can talk about.

See most (70%) of the discussion here is about defintions. But please assert that neurology is not part of psychology, it makes the neurochemists laugh very hard.

Ivor the Engineer

16th April 2009, 10:03 AM

No, I think he sees it as a massive hole in skeptical beliefs, as do I.

If you were a homeopath, I'd accept that you found some citations (homeopaths have hundreds of one-offs).

Now, I'd ask for independent replication for these citations. eg: same clinical condition, same protocols, positive results, different team. Can you locate any?

If not - that is to say, if placebo effect is supported by one-offs or replications by the same MDs - why do we reject homeopathy? They have far more evidence supporting their claims.

The hole in skeptical beliefs to which I refer feels like an uneven burden of proof for something we already believe in.

If I'm annoyed I'll do in excess of 14.25 miles on my exercise bike. If I'm fed up I'll manage less than 14.0 miles. The difference is down to the amount of exercise-induced pain I feel in the muscles of my legs.

Ivor the Engineer

16th April 2009, 10:04 AM

Ahhhh...here is the crux of the problem. We're having issues with defining what "placebo effect" really means.

I don't believe the Placebo Effect has any affect beyond subjective perception and stress response. It does not automatically make pneumonias or meningitis or heart attacks better compared to no treatment(except for subjective interpretation or stress).

(Hold onto your stethoscope Pax)

I agree.

:)

Dancing David

16th April 2009, 10:05 AM

Wow, so this is just what Jeff Corey said, now isn't it!
http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003974/frame.html

Placebo interventions are often claimed to improve patient-reported and observer-reported outcomes, but this belief is not based on evidence from randomised trials that compare placebo with no treatment.

Now that is funny, isn't it!

See RLR, maybe calling you on your claims was just standard JREF behavior.

Now as too the defintion of psychology, should we take that to another thread?

:D

It is rather Alanic, you could not even read enough of the thread to see who agreed with you before you started into your fussy fit.

:P

blutoski

16th April 2009, 10:06 AM

Oh I agree. The placebo effect is mostly about natural progression of disease and regression to the mean.

This is why I'm careful about my terminology, and deliberately defined it earlier. I'm not talking about baseline recovery rate - I'm talking about the types of experiments people have been citing to suggest that there is an opportunity to use placebos to manipulate clinical outcomes. This is the type of "placebo effect" that links suggestion to outcome.

Both definitions of "placebo effect" are abused, of course.

However, there is a definite effect which is usually with subjective problems(pain and some psychiatric conditions) and I really doubt there is an actual biological response except for certain stress and chronic hormonal related responses.

I disagree. I think at this point, the body of evidence makes this belief doubtful. The furthest I can go is to support the conclusions at Cochrane by saying that there may be limited effect in linear outcomes in pain that is unfortunately also indistinguishable from bias.

And that last part is also very important: it's not only restricted to subjective outcomes, but to outcomes that a patient would be tempted and able to exaggerate their improvement for common patient-caregiver relationship reasons.

He severely overreaches by his nonsense that psychological states cannot affect biological functions. His personality does not help either.

Agreed, but skeptics have to train ourselves to focus on the subject at hand, and try not to be distracted by red herrings such as ad hominem or theatrics.

paximperium

16th April 2009, 10:08 AM

I disagree. I think at this point, the body of evidence makes this belief doubtful. The furthest I can go is to support the conclusions at Cochrane by saying that there may be limited effect in linear outcomes in pain that is unfortunately also indistinguishable from bias.

And that last part is also very important: it's not only restricted to subjective outcomes, but to outcomes that a patient would be tempted and able to exaggerate their improvement for common patient-caregiver relationship reasons.
I'll look a bit closer at those reviews.

Agreed, but skeptics have to train ourselves to focus on the subject at hand, and try not to be distracted by red herrings such as ad hominem or theatrics.
Agreed.

Dancing David

16th April 2009, 10:09 AM

Not an MD:

The first issue is the presumtion of what the placebo effect is!

What if it has almost nothing to do with taking a pill?

There are many causes of the placebo effect. Regression to the mean is one of them.

Not technically true. A placebo effect must be shown to be produced by some sham treatment (sugar pill, sham surgery, etc,) and not from any other threat to internal validity (confound) such as statistical regression to the mean, experimenter bias, etc. This means a randomly assigned control control group would be compared to the sham treatment group, which would eliminate regression as a confounding variable.

That is cool, however when the placebo effect is mentioned, it is though it is solely an effect of taking a pill.

Often it is not, but you are talking about something that is very relevant.

Often however in medical research there is a regresion to the mean when it comes to ascribing a placebo effect. But as you say, a group that does not recieve any treatment compared to sham treatment would eliminate that. (All randomly assigned.)

RLR, did you miss these?

I am not trying to goad you, I did that already. But you seem to have missed this part of the discussion.

:)

blutoski

16th April 2009, 10:10 AM

If I'm annoyed I'll do in excess of 14.25 miles on my exercise bike. If I'm fed up I'll manage less than 14.0 miles. The difference is down to the amount of exercise-induced pain I feel in the muscles of my legs.

I believe you.

This doesn't show that placebos work.

Here's an experiment that would show if there is a clinically meaningful placebo effect, as defined in the experiments you've cited:

Get several volunteers who are using exercise bikes. Tell half of them that when they are 'annoyed' (define this as you wish) they will experience less muscle pain, and go a longer distance.

The other half will be told that the effect of being annoyed will be to increase pain (and result in a shorter distance).

Do you think the two groups will show different outcomes, based on what they were told the emotion was supposed to do?

Ivor the Engineer

16th April 2009, 10:19 AM

I believe you.

This doesn't show that placebos work.

Here's an experiment that would show if there is a clinically meaningful placebo effect, as defined in the experiments you've cited:

Get several volunteers who are using exercise bikes. Tell half of them that when they are 'annoyed' (define this as you wish) they will experience less muscle pain, and go a longer distance.

The other half will be told that the effect of being annoyed will be to increase pain (and result in a shorter distance).

Do you think the two groups will show different outcomes, based on what they were told the emotion was supposed to do?

I don't know, but it would be an interesting experiment. Though I don't like annoying other people, I volunteer to be the person who works the subjects into a frenzy of rage.:)

blutoski

16th April 2009, 10:20 AM

I'll look a bit closer at those reviews.

It's also a good idea to get the actual issues, because they often have an editorial and critiques of the reviews, which are good to read to ensure balance.

Hjobartsen's work is solid, but because it's new and counter-intuitive, he has lots of critics. Their concerns deserve equal attention.

Jeff Corey

16th April 2009, 11:45 AM

...But hey, that's what JREF forums are all about, right? Asking for a mile and not giving an inch, and then calling the person asking for reciprocity an ******* for not doing everything that everyone asks.

"Originally Posted by rlr
... We're talking about, essentially, the contents of the DSM-IV-TR, which is informed more by culture than by science, and which formerly listed homosexuality as a mental disorder..."

And that defines "psychology"? Who publishes the DSM?

Still waiting. It's a simple question, really.

Ivor the Engineer

16th April 2009, 11:54 AM

I think the placebo effect is closely related to suggestibility.

Whatever one thinks about hypnosis, I think most people would agree that it's purpose is to maximise the response to suggestions. There are a number of studies showing hypnosis/suggestion can significantly alter perceptions of pain and help some people who suffer from conditions with a psychological component to them. For example:

http://jnci.oxfordjournals.org/cgi/content/full/99/17/1304?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=1&author1=montgomery&andorexacttitle=and&andorexacttitleabs=and&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT

Background: Breast cancer surgery is associated with side effects, including postsurgical pain, nausea, and fatigue. We carried out a randomized clinical trial to test the hypotheses that a brief presurgery hypnosis intervention would decrease intraoperative anesthesia and analgesic use and side effects associated with breast cancer surgery and that it would be cost effective.

Methods: We randomly assigned 200 patients who were scheduled to undergo excisional breast biopsy or lumpectomy (mean age 48.5 years) to a 15-minute presurgery hypnosis session conducted by a psychologist or nondirective empathic listening (attention control). Patients were not blinded to group assignment. Intraoperative anesthesia use (i.e., of the analgesics lidocaine and fentanyl and the sedatives propofol and midazolam) was assessed. Patient-reported pain and other side effects as measured on a visual analog scale (0–100) were assessed at discharge, as was use of analgesics in the recovery room. Institutional costs and time in the operating room were assessed via chart review.

Results: Patients in the hypnosis group required less propofol (means = 64.01 versus 96.64 µg; difference = 32.63; 95% confidence interval [CI] = 3.95 to 61.30) and lidocaine (means = 24.23 versus 31.09 mL; difference = 6.86; 95% CI = 3.05 to 10.68) than patients in the control group. Patients in the hypnosis group also reported less pain intensity (means = 22.43 versus 47.83; difference = 25.40; 95% CI = 17.56 to 33.25), pain unpleasantness (means = 21.19 versus 39.05; difference = 17.86; 95% CI = 9.92 to 25.80), nausea (means = 6.57 versus 25.49; difference = 18.92; 95% CI = 12.98 to 24.87), fatigue (means = 29.47 versus 54.20; difference = 24.73; 95% CI = 16.64 to 32.83), discomfort (means = 23.01 versus 43.20; difference = 20.19; 95% CI = 12.36 to 28.02), and emotional upset (means = 8.67 versus 33.46; difference = 24.79; 95% CI = 18.56 to 31.03). No statistically significant differences were seen in the use of fentanyl, midazolam, or recovery room analgesics. Institutional costs for surgical breast cancer procedures were $8561 per patient at Mount Sinai School of Medicine. Patients in the hypnosis group cost the institution $772.71 less per patient than those in the control group (95% CI = 75.10 to 1469.89), mainly due to reduced surgical time.

Conclusions: Hypnosis was superior to attention control regarding propofol and lidocaine use; pain, nausea, fatigue, discomfort, and emotional upset at discharge; and institutional cost. Overall, the present data support the use of hypnosis with breast cancer surgery patients.

http://www.springerlink.com/content/k411272k3723167t/

Hypnosis improves irritable bowel syndrome (IBS), but the mechanism is unknown. Possible physiological and psychological mechanisms were investigated in two studies. Patients with severe irritable bowel syndrome received seven biweekly hypnosis sessions and used hypnosis audiotapes at home. Rectal pain thresholds and smooth muscle tone were measured with a barostat before and after treatment in 18 patients (study I), and treatment changes in heart rate, blood pressure, skin conductance, finger temperature, and forehead electromyographic activity were assessed in 24 patients (study II). Somatization, anxiety, and depression were also measured. All central IBS symptoms improved substantially from treatment in both studies. Rectal pain thresholds, rectal smooth muscle tone, and autonomic functioning (except sweat gland reactivity) were unaffected by hypnosis treatment. However, somatization and psychological distress showed large decreases. In conclusion, hypnosis improves IBS symptoms through reductions in psychological distress and somatization. Improvements were unrelated to changes in the physiological parameters measured.

blutoski

16th April 2009, 11:56 AM

"Originally Posted by rlr
... We're talking about, essentially, the contents of the DSM-IV-TR, which is informed more by culture than by science, and which formerly listed homosexuality as a mental disorder..."

And that defines "psychology"? Who publishes the DSM?

Still waiting. It's a simple question, really.

Mm. The DSM or ICD-10 are medicine, and the conditions described are psychiatry - not psychology. I'm pretty sure neither document really captures a definition of psychology.

blutoski

16th April 2009, 11:58 AM

I think the placebo effect is closely related to suggestibility.

Again: what placebo effect?

And again: you've provided some very thought-provoking citations. Have they been independently replicated?

Jeff Corey

16th April 2009, 12:16 PM

Mm. The DSM or ICD-10 are medicine, and the conditions described are psychiatry - not psychology. I'm pretty sure neither document really captures a definition of psychology.

Well, I knew that, you knew that and most undergraduates who have taken an intro psych course probably know that. My question was to rlr to see if she knew, because she obviously doesn't have a clear idea about what psychology is.

blutoski

16th April 2009, 12:21 PM

Ivor the Engineer

16th April 2009, 12:22 PM

Again: what placebo effect?

The point I was trying to make was that the definition of "placebo effect" being used by researchers who claim it does not exist or is of only marginal significance excludes the type of research I linked to in my previous post.

And again: you've provided some very thought-provoking citations. Have they been independently replicated?

I have no idea. There is plenty of additional research showing significant effects of suggestion, which suggests (sorry:)) there is a real underlying effect.

blutoski

16th April 2009, 01:00 PM

The point I was trying to make was that the definition of "placebo effect" being used by researchers who claim it does not exist or is of only marginal significance excludes the type of research I linked to in my previous post.

It's different, because it's actually different. It's not an oversight or error or closed-mindedness.

If you're unilaterally renaming emotions "placebos", I can see why there's confusion.

And I believe you're contradicting yourself or getting your concepts conflated. You mention earlier that suggestion is key, which I agree with. That's why I offered the example of connecting an emotion with a suggestion: can you produce the opposite effect from an emotion through suggestion (eg: can you lower blood pressure by making somebody enraged because you suggested it would work?)

I have no idea. There is plenty of additional research showing significant effects of suggestion, which suggests (sorry:)) there is a real underlying effect.

Well, it's important from a skeptic's point of view. Consider: there's lots of research showing significant effects for homeopathy - are you applying the same standard when evaluating these different claims?

I observe that people don't - even skeptics.

I think the reason people apply a different standard because of different assessments of prior plausibility. Two contributors toward higher prior plausibility:

Cultural inertia - we all grew up accepting [THE POWERFUL PLACEBO (1955) (http://en.wikipedia.org/wiki/Henry_K._Beecher)]
Conflating placebo effect with undeniable mind/body connection via emotional states

Rolfe

16th April 2009, 02:50 PM

I've always defined the "placebo effect" as a combination of spontaneous recovery/improvement and wishful thinking. I've never seen any evidence of anything else going on.

Having said that, wishful thinking, when indulged in by the actual patient, can actually make them feel quite a lot better. I'll never forget feeling physically sick when I realised how ill my pony was, then after another vet with more horse experience had taken me in hand and said firmly now this is what we're going to do and this is how often you're going to give him the kaogel and the chlorodyne, I was so relieved that someone else had taken control of the situation and was handling it for me that my own sense of physical wellbeing was remarkable. (I found out later that he'd told a friend he was pretty sure my pony was going to die, but he didn't tell me that. If he had, he'd have been wrong anyway.)

It struck me at the time that if I'd been the one who was ill, and I'd felt that much better after a session with a woo, I'd have been a convert for life. It was the whole business of someone else taking control, appearing to have the problem surrounded, and being given a set of positive things to do that made the difference. I think this is where a lot of woos score in preference to actual doctors. Doctors these days are more or less obliged to be objective and realistic. Which isn't always reassuring. Woos, on the other hand, can be as paternalistic as they like, and get all the advantage of the "handing over control" part.

There is some evidence that strictly objective measurement of clinical or physiological variables can be at least as important in finding out whether there's anything going on as having a blinded control group.

Oh yes, and wishful thinking indulged in by someone who is not the patient may make the someone feel a lot better perhaps, but it isn't going to do a damn thing for the poor bloody patient.

Rolfe.

blutoski

16th April 2009, 03:09 PM

I've always defined the "placebo effect" as a combination of spontaneous recovery/improvement and wishful thinking. I've never seen any evidence of anything else going on.

Well, lots of people have seen evidence of more effect, but my impression is that these are largely anecdotal and selective, and sometimes possibly exaggerated.

Just to clarify: when people are proposing using placebo effect as a clinical treatment, they're talking about a specific useage of the term. There are two prevailing useages, which I'll illustrate now for the purpose of making the distinction clear:

:: placebo group improvement
(E=experimental group, P=placebo group, improvement is the horizontal axis)

E: ++++++++++
P: +++++

This type of placebo-controlled trial shows that the Experimental group saw more improvement than the placebo group, which is used to bolster the claim that the experimental substance 'works'.

The confusion, though, is that there are some people who misunderstand the improvement in the Placebo group, and jump to the conclusion that the improvement is caused by the placebo, rather than this improvement representing the background rate of improvement that takes place regardless of treatment.

For the purpose of resolving this, another protocol was proposed, employing a non-treatment group (for ethical reasons, this is often a 'wait list' group).

:: placebo caused improvement
(E=experimental group, P=placebo group, N=nontreated group, improvement is the horizontal axis)

E: ++++++++++
P: +++++
N: +++++

Notice that all things being equal, with this additional information, it is not appropriate to claim that the placebo is itself causing any improvement. An untreated group is doing just as well. This is the type of protocol that Hjobartsen was collecting information about, and is really the only type of protocol that can tell us what changes are caused by the placebo itself.

This is very important, because it deflates the argument that if a treatment claims to be doing as well as a placebo, therefore it is harnessing the power of placebo, therefore it is ethical to charge for it (homeopathy, cough-cough). We have to ask why anybody would pay for something that is as good/bad as nontreatment.

The latter being... free.

Ivor the Engineer

16th April 2009, 04:12 PM

I don't think trials designed to demonstrate the effects of drugs on physiological conditions which possibly have only a small psychological component would be particularly useful for determining if suggestion, perhaps reinforced with a ritual, can be significantly more therapeutic than no treatment.

What you want to look at are trials of placebo vs. no treatment for conditions where there are plausible mechanisms to allow suggestion to have an effect.

Rolfe

16th April 2009, 05:23 PM

We're seeing with animal trials how much difference objective measurement makes. Even without proper blinding, or even without a control group, improving the objectivity of the patient assessment seems to reduce "placebo" response dramatically.

Which still doesn't mean that if the patient is human, and if the dispensing of the placebo reduces anxiety, that a useful reduction in anxiety-related symptoms can't occur.

Rolfe.

athon

16th April 2009, 05:25 PM

blutoski

16th April 2009, 05:28 PM

What you want to look at are trials of placebo vs. no treatment for conditions where there are plausible mechanisms to allow suggestion to have an effect.

That's where the trials do focus, though: almost all are about pain and mild depression.

It's important that the results for these types of trials are not compelling that there is any effect worth pursuing.

athon

16th April 2009, 05:31 PM

Which still doesn't mean that if the patient is human, and if the dispensing of the placebo reduces anxiety, that a useful reduction in anxiety-related symptoms can't occur.

That's it in one, Rolfe.

The placebo effect itself is not dependent on being misinformed or lied to. It is a free effect from patient security and patient belief in the treatment process.

The reason for medicine is to alleviate suffering. Suffering, in part, extends from the perception of ill health. Making a patient feel secure in their treatment can help them suffer less from their condition. Ergo, the placebo effect has an important role to play in conventional medicine.

It ain't rocket surgery. :p

Athon

blutoski

16th April 2009, 06:05 PM

Can I just ask, in which case, why you believe clinical trials use placebos at all, if you think they have no effect?

To ensure blinding.

By no way am I saying the placebo effect directly influences non-neurological functioning. However, obviously the psychology of the patient - including their perception of their state of health - plays an important part of the healing process.

I'm not sure I can agree with this, because the statement is pretty vague.

If you mean the patient is less stressed if we reduce stress, then I agree. If you mean the patient's medical outcomes are improved if he's less stressed, then I don't think this statement is well supported for most clinical outcomes of interest.

Jeff Corey

16th April 2009, 06:15 PM

athon

16th April 2009, 06:35 PM

To ensure blinding.

Ok, so are you suggesting it's only to blind the tester, and not the subject? What's the point of double blinding, then? An actual, physical placebo isn't needed for a blinded trial in which case - it's only an administrative issue.

I'm not sure I can agree with this, because the statement is pretty vague.

If you mean the patient is less stressed if we reduce stress, then I agree. If you mean the patient's medical outcomes are improved if he's less stressed, then I don't think this statement is well supported for most clinical outcomes of interest.

I couldn't disagree more. I think there is ample evidence on the relationship between stress and state of health. A quick look brought up this paper (http://www.psychosomaticmedicine.org/cgi/content/abstract/63/2/216) without much of a detailed search. This article also agrees that there is a link between the immune system (http://www.personalityresearch.org/papers/beaton.html) and stress. I'm certain I could find others that show a strong link between the patient's state of mind and how well they heal.

If a patient's mind is at ease, they feel better about their condition. Again, not exactly a shocking concept. Why else would a patient care to seek medical help if not to feel better?

Athon

athon

16th April 2009, 06:55 PM

I do not think you are using a technically correct definition of placebo. I use it in the sense of a control procedure. In grad school, we were testing the effects of drugs on various measures of fear in rats. The placebo control groups got injected with physiological saline to control for the effects of injection.
All the other potential confounding variables you are talking about are just that. Other confounding variables. Like regression to the mean, spontaneous combustion, maturation, experimenter bias, subject submission to demand characteristics, to name a few.

I'm not sure who you're aiming that at, but I'm not sure I agree anyway.

I think all of those things are components of the placebo effect. The effect itself isn't magic - it's a mix of factors that bias how we perceive of our state of health. This bias influences how we report our health and what we attribute the perceived changes to.

If placebos were just about the administration from the tester's side, the role of the placebo regarding the patient would be pointless. No pill or shot is necessary - the tester is simply removed from the administration part of the process is now none-the-wiser as to who received what. Single blind tests would be all that would be required.

Athon

Rolfe

16th April 2009, 06:58 PM

The placebo effect itself is not dependent on being misinformed or lied to. It is a free effect from patient security and patient belief in the treatment process.

But it's not that simple. I felt physically better after my colleague took control of my pony's illness because I believed he had everything in hand and "it was going to be all right".

I believed this because he lied to me (by omission). He didn't tell me what he told the person with whom the pony was boarding, that he thought the pony would probably die.

Actually, he was wrong about that. I've never seen such a quick and impressive recovery from a PLE in my life. But that's medicine. Sometimes you surprise even yourself.

Now I'm not saying John was wrong to keep his poor prognosis to himself in that case. Not at all. But there are other situations where a doctor simply can't, in all conscience, give the patient "security and belief in the treatment process".

If the doctor has to tell the patient that the cancer will probably recur, or that the heart failure won't go away, you're not going to get that effect. On the other hand a SCAMmer who is prepared to lie in their teeth and assure the patient that "we can help you" or "we have a cure" is going to get the full force of the benefit.

Rolfe.

Jeff Corey

16th April 2009, 08:12 PM

I'm not sure who you're aiming that at, but I'm not sure I agree anyway.

I think all of those things are components of the placebo effect. The effect itself isn't magic - it's a mix of factors that bias how we perceive of our state of health. This bias influences how we report our health and what we attribute the perceived changes to.

If placebos were just about the administration from the tester's side, the role of the placebo regarding the patient would be pointless. No pill or shot is necessary - the tester is simply removed from the administration part of the process is now none-the-wiser as to who received what. Single blind tests would be all that would be required.

Athon

Isn't it a good idea to parcel out all the different potential confounding variables that may mislead us? Confusing them makes us less competent at devising better tests to falsify our hypotheses.
I have seen people here dump all sorts of other confounds into the bag of placebo.
I don't let my students do that.

athon

16th April 2009, 08:21 PM

Rolfe

16th April 2009, 08:23 PM

Isn't it a good idea to parcel out all the different potential confounding variables that may mislead us? Confusing them makes us less competent at devising better tests to falsify our hypotheses.
I have seen people here dump all sorts of other confounds into the bag of placebo.
I don't let my students do that.

Not necessarily. The point about a placebo control is that it isolates out the drug being tested as the only variable compared to the control group. Thus it becomes easier to determine an actual effect, without having to worry about other variables which may or may not be important. The way to design an experimental control is to do exactly that - to make the thing being tested the only difference between test and control groups. Extra agonising about what sort of things you might be eliminating in this way is optional.

It's only because both test and control groups often seem to improve in drug trials that people have started to speculate about what might be going on. So then you can compare placebo and waiting list if you like. But as I said, making the patient assessments as objective as humanly possible seems to be the one that really cuts down on the size of the non-specific recovery.

Rolfe.

Jeff Corey

16th April 2009, 08:40 PM

I beg to differ. You apparently left out half of the double blind
study.
There are a few other things to control for .

paximperium

17th April 2009, 02:01 AM

I beg to differ. You apparently left out half of the double blind
study.
There are a few other things to control for .
If you want to determine the whole effect of placebo vs med vs other variables, you'd have to have:
1)Intervention group-pill/IV etc.
2)Placebo group-Placebo pill/Placebo IV etc.
3)No-intervention at all.-No intervention

Most studies are not designed to look at no intervention because it is not relevant to studying the intervention itself.

Ivor the Engineer

17th April 2009, 02:13 AM

That's where the trials do focus, though: almost all are about pain and mild depression.

It's important that the results for these types of trials are not compelling that there is any effect worth pursuing.

I don't think that's correct. What conventional trials are designed to do is see if there are effects from a drug compared to a sugar pill administered with the same standard of care. I.e. the placebo group are treated exactly the same as those receiving active medication, rather than in a way which might maximise any placebo effect. Any placebo response will be compromised from the start because the subjects are informed they might be taking sugar pills.

Let's say you're correct though, and there is no difference between being stuck on a waiting list and being treated by a doctor with placebos. What you are saying is there is zero health benefit from the therapeutic relationship. Now I've been accused of being anti-medical profession, but that is beyond what even I would postulate as reasonable.

Dancing David

17th April 2009, 06:17 AM

Well, I knew that, you knew that and most undergraduates who have taken an intro psych course probably know that. My question was to rlr to see if she knew, because she obviously doesn't have a clear idea about what psychology is.

the other issue is the wide defintion of the field of study of 'psychology' and then the public impressions as well.

From speculative kantian philosophers, through neo Freudian, to behaviorism, social network and community theory.

And then all those biologists, neurologists and biochemists.

Dancing David

17th April 2009, 06:19 AM

Wow, the last page is very good.

shawmutt

17th April 2009, 06:37 AM

Alright, so getting to the ethical part. Is it OK that something like Oscillococcinum (that's French for "sugar pill") makes tens of millions of dollars a year because people think they are taking something effective?

I mean, hell, if it is ethical I'm going to suggest to the heads of my job to toss out all that expensive to make evidence-based medicine, go kill a duck, and get to work!

fls

17th April 2009, 06:39 AM

I couldn't disagree more. I think there is ample evidence on the relationship between stress and state of health. A quick look brought up this paper (http://www.psychosomaticmedicine.org/cgi/content/abstract/63/2/216) without much of a detailed search. This article also agrees that there is a link between the immune system (http://www.personalityresearch.org/papers/beaton.html) and stress. I'm certain I could find others that show a strong link between the patient's state of mind and how well they heal.

What is the connection between that information and placebo?

Linda

athon

17th April 2009, 07:12 AM

What is the connection between that information and placebo?

Linda

I was making a connection between improved medical outcomes and reduction in stress.

Athon

fls

17th April 2009, 07:19 AM

I was making a connection between improved medical outcomes and reduction in stress.

Athon

I understand that, but I thought the subject of this thread was about placebo. What connection does that have to the placebo effect (i.e. expectations)?

Linda

athon

17th April 2009, 07:49 AM

I understand that, but I thought the subject of this thread was about placebo. What connection does that have to the placebo effect (i.e. expectations)?

Linda

You disagree that expectation of treatment might reduce patient stress? I admit I don't have any studies at hand on that one, but I'd be most surprised if patient expectations and view of personal wellbeing was found to have no relationship at all to their psychological state. I know myself, the one or two times I've gotten quite sick, I was stressed until I felt I knew what was wrong. I know when an ex girlfriend of mine had a lump on her breast, she was incredibly stressed until a biopsy proved it to be benign.

Athon

fls

17th April 2009, 08:12 AM

You disagree that expectation of treatment might reduce patient stress?

I'm disagreeing with the idea of believing something when there isn't evidence to suggest it is so.

I admit I don't have any studies at hand on that one, but I'd be most surprised if patient expectations and view of personal wellbeing was found to have no relationship at all to their psychological state.

I would be surprised as well, but what has that got to do with it? Do we have any evidence to suggest that the sort of psychological state you describe has any influence on recovery, that the use of fake medicine changes that state in a way that is useful, and that change in that state is associated with a meaningful clinical outcome?

I know myself, the one or two times I've gotten quite sick, I was stressed until I felt I knew what was wrong. I know when an ex girlfriend of mine had a lump on her breast, she was incredibly stressed until a biopsy proved it to be benign.

Athon

What do either of those things have to do with placebo or with changes in clinical outcomes?

Linda

athon

17th April 2009, 08:33 AM

I'm disagreeing with the idea of believing something when there isn't evidence to suggest it is so.

Maybe I'm just tired, but I'm completely lost. You have read the whole thread, haven't you?

I'm suggesting that the placbo effect - the concept of patient perception of being treated having an influence on their psychological state - can play an indirect role in patient healing. The very fact patients are given placebos is because of this effect - if it didn't exist, there'd be no point to giving the patient anything at all. Clinical trials may as well simply be single blinded.

I would be surprised as well, but what has that got to do with it? Do we have any evidence to suggest that the sort of psychological state you describe has any influence on recovery...

It has an influence on patient decision making (http://www.springerlink.com/content/pg99v555178g8268/); stress plays a role in a range of health matters (http://jama.ama-assn.org/cgi/content/abstract/267/9/1244); stress reduces healing time (http://www.psychosomaticmedicine.org/cgi/content/full/65/5/865); link between anxiety treatment and post-operation recovery (http://www.anesthesia-analgesia.org/cgi/content/full/100/5/1394)...

All I'm saying is that patients who feel better about their state of health and perceive that they are being treated will experience less stress, which in turn takes less of a toll on their wellbeing and general health.

...that the use of fake medicine changes that state in a way that is useful, and that change in that state is associated with a meaningful clinical outcome?

I'm not sure why you feel it necessary to exemplify 'fake medicine' when from the start I've suggested that the placebo effect is merely the reporting of health improvement as a result of the psychology a patient experiences in being treated.

Again, if placebos have zero effect on the patient's psychological state and their reporting of feeling improvement, then why are trials double blinded at all?

What do either of those things have to do with placebo or with changes in clinical outcomes?

I was explaining anecdotally why I feel there is a connection between the psychology of treatment and stress.

Athon

Ivor the Engineer

17th April 2009, 08:42 AM

http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=17371590

Background
Recent reviews on placebo effects in clinical trials suggest that objective changes following placebo treatments may not exist or, at least, have been considerably overestimated. However, the possibility that yet unidentified subsets of parameters are responsive to placebo treatments has not been taken into account. Therefore, the aim of the present study is to examine the effects of placebo treatments on objectively measured outcome parameters by specifically focusing on peripheral disease processes.

Methods
An initial dataset was collected from a MEDLINE search for placebo-controlled, randomized clinical trials. Trials with stable disease conditions were identified, and the effects of placebo treatments on peripheral outcome parameters were estimated by the changes from baseline in the placebo groups. An explorative data analysis was conducted in order to identify parameter classes with differential responsiveness to placebo treatments. A subgroup meta-analysis of a second dataset was performed to test whether the preliminary classification would also apply to placebo effects derived from the comparison of placebo groups with untreated control groups.

Results
The explorative analysis of outcome parameters and strength of placebo effects yielded a classification into responsive "physical" versus non-responsive "biochemical" parameters. In total, 50% of trials measuring physical parameters showed significant placebo effects, compared with 6% of trials measuring biochemical parameters. A subgroup meta-analysis substantiated the differential response (physical parameters: n = 14, Hedges' pooled effect size g = 0.34, 95% CI 0.22 to 0.46; biochemical parameters: n = 15, g = 0.03, 95% CI -0.04 to 0.10). The subanalysis of the second dataset supported the classification and revealed a significant improvement for physical parameters (n = 20, g = 0.22, 95% CI 0.07 to 0.36) and a deterioration for biochemical parameters (n = 6, g = -0.17, 95% CI -0.31 to -0.02).

Conclusion
The results suggest that placebo interventions can improve physical disease processes of peripheral organs more easily and effectively than biochemical processes. This differential response offers a good starting point for theoretical considerations on possible mediating mechanisms, and for future investigations in this field.

http://www.ncbi.nlm.nih.gov/pubmed/17380778?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=5&log$=relatedreviews&logdbfrom=pubmed

"Placebo" is Latin for "I shall please". The placebo effect has been widely documented by randomized placebo-controlled drug studies. One of the best examples of placebo effectiveness is that have been shown in clinical trials of anti-parkinsonian drugs. The placebo effect is observable not only in drug trials but also with deep brain stimulation. Recent advances in research on the placebo effect in Parkinson's disease (PD) have suggested that motor symptoms of PD can be essentially improved by placebo. A recent study using positron emission tomography (PET) with raclopride demonstrated that release of endogeneous dopamine in the dorsal striatum occurs in placebo-responsive patients with PD. This suggests that placebo-induced expectation of clinical improvement may activate endogenous dopamine in the striatum, and that placebo effectiveness is thus achieved by endogenous dopamine supplementation. Indeed, decreased neuronal activities in the subthalamic nucleus (STN), that were recorded during surgery to implant deep brain stimulation electrodes, correlated well with placebo-induced clinical improvement in patients with PD. Although the detailed pathophysiological mechanism underlying the placebo effects remains uncertain, theoretically, the placebo effect has generally been explained by two different mechanisms: one is conditioning theory (pavlovian conditioning), and the other is cognitive theory (expectation of clinical improvement). Although both mechanisms may contribute to placebo effects, the placebo effect in PD may be attributed more to cognitive mechanisms such as expectation of improvement, because the placebo effect can be obtained in de novo PD patients. There have been accumulating findings that suggest a functional relationship between dopamine and the expectation of clinical improvement (reward). Further basic studies are required to clarify the complex link between dopamine and the reward system, but such findings will contribute to a better understanding of the pathophysiological mechanism underlying the placebo effect in PD.

athon

17th April 2009, 08:43 AM

blutoski

17th April 2009, 09:12 AM

Again, if placebos have zero effect on the patient's psychological state and their reporting of feeling improvement, then why are trials double blinded at all?

I'm pretty sure we explained that: blinding reduces bias, conscious or otherwise.

blutoski

17th April 2009, 09:14 AM

Here's an interesting study (http://pt.wkhealth.com/pt/re/bjui/abstract.00002414-199803000-00009.htm;jsessionid=JyJWcQxvnXjj5yHgLYnSxnn1Q2kSc pkN158TbDDfFjjV0JMq9QDn%211553038018%21181195628%2 18091%21-1) on the placebo effect regarding the slight improvement in patients with prostate problems.

This FDA Consumer article (http://www.fda.gov/fdac/features/2000/100_heal.html) shows if I'm completely misinformed, I'm at least not on my own.

There's a few other articles I've tracked down, but am too tired to give them too much of a deep read and post them up at this point.

Athon

I think we've accepted that there is lots of evidence to support the theory. There is also lots of evidence refuting it. This is no different than what is proferred by advocates of homeopathy.

I am trynig to understand why you believe two or three papers you selected for agreeing with your prior conclusion override a literature review of all the current research.

fls

17th April 2009, 09:18 AM

Maybe I'm just tired, but I'm completely lost. You have read the whole thread, haven't you?

Yes.

I'm suggesting that the placbo effect - the concept of patient perception of being treated having an influence on their psychological state - can play an indirect role in patient healing. The very fact patients are given placebos is because of this effect - if it didn't exist, there'd be no point to giving the patient anything at all. Clinical trials may as well simply be single blinded.

You are making unwarranted assumptions. We don't even know whether placebo changes patient perception. All we can tell is that it changes patient (and examiner) reporting (with one caveat - pain). Placebos are simply the easiest way of making sure that reporting biases are not distributed unevenly. But if reporting bias is not an issue, then placebos are not necessary. Which is why placebos are no different than no treatment when it comes to the presence or absence of an outcome (even subjective outcomes), but only show a difference when it comes to the strength of the report on a subjective outcome.

We know that some specific psychological states are associated with some specific types of healing or the risk of some diseases. But we haven't established that it is causal, and we haven't established that changing those psychological states will influence healing or risk. We certainly haven't established that placebos will influence those specific psychological states in a way that is useful, let alone that they do so in a way that is better than the myriad of other ways we have of influencing psychological states that don't involve lying.

And even if we had established all of those steps, we are still left with the problem that the evidence shows that it doesn't leave us with a meaningful clinical outcome. Does expectation count for much of anything when what we are really interested in is relief of pain, resolution of disease, prevention of disability, and avoiding death? Even if we agree that it counts for something that the patient is satisfied or that they adopt helpful behaviours, is inducing a sense of expectation with the use of a fake treatment really the best (or if not the best, at least reasonably good) way to go about achieving those results?

It has an influence on patient decision making (http://www.springerlink.com/content/pg99v555178g8268/); stress plays a role in a range of health matters (http://jama.ama-assn.org/cgi/content/abstract/267/9/1244); stress reduces healing time (http://www.psychosomaticmedicine.org/cgi/content/full/65/5/865); link between anxiety treatment and post-operation recovery (http://www.anesthesia-analgesia.org/cgi/content/full/100/5/1394)...

Again, where have you established the link between these issues and the use of placebo?

All I'm saying is that patients who feel better about their state of health and perceive that they are being treated will experience less stress, which in turn takes less of a toll on their wellbeing and general health.

How do you know? All you've given evidence for are associations between some of those characteristics without establishing a causal link or an ability to alter clinical outcomes, let alone establishing that placebo has a useful role in any of that.

I'm not sure why you feel it necessary to exemplify 'fake medicine' when from the start I've suggested that the placebo effect is merely the reporting of health improvement as a result of the psychology a patient experiences in being treated.

I have no quibble with that statement. That claim is very well supported by the evidence. My quibble is with your claim that it has an important effect on healing - assuming that when you refer to 'healing' that you are referring to actual changes in a disease state, not just changes in perception.

Again, if placebos have zero effect on the patient's psychological state and their reporting of feeling improvement, then why are trials double blinded at all?

Because we are not really interested in whether or not we can induce someone to say, "maybe I feel a little better". We are really interested in clinically relevant outcomes including meaningful changes in patient perception and behaviour.

ETA: We have good evidence that expectation induces clinically relevant changes in pain (not just the reporting of pain). Other than that, we have information showing that we can be conditioned through the use of real drugs to induce the same physiologic changes with placebo - although the response is not as strong or sustained (e.g. nitroglycerin, caffeine, bronchodilators, dopamine release with drugs for Parkinson's Disease). But it would be highly preliminary to postulate how that may be relevant to any clinical effects.

Linda

fls

17th April 2009, 09:27 AM

Here's an interesting study (http://pt.wkhealth.com/pt/re/bjui/abstract.00002414-199803000-00009.htm;jsessionid=JyJWcQxvnXjj5yHgLYnSxnn1Q2kSc pkN158TbDDfFjjV0JMq9QDn%211553038018%21181195628%2 18091%21-1) on the placebo effect regarding the slight improvement in patients with prostate problems.

The study was uncontrolled so why conclude that the changes represent the influence of placebo?

This FDA Consumer article (http://www.fda.gov/fdac/features/2000/100_heal.html) shows if I'm completely misinformed, I'm at least not on my own.

No, you are definitely not on your own. It is this pervasive misrepresentation, even among people who should know better, that is starting to annoy me. :) While you all may have chastized rlr for over-stating the case, that's what it may take to get people to notice that when they say "healing" they are really referring to meaningless changes in reporting.

Linda

blutoski

17th April 2009, 09:44 AM

http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=17371590

Summary: we get positive results if we data mine and weed out the ones that showed negative results. They're not even hiding their method.

Another concern: they pooled results from different experiments into one dataset for meta-analysis. Despite the fact that you can't actually do this.

http://www.ncbi.nlm.nih.gov/pubmed/17380778?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=5&log$=relatedreviews&logdbfrom=pubmed

I *have* read the article (there is an English translation available) and it's important to know that this was not double-blinded.

Nevertheless, it's thought-provoking and may lead to knowledge at some point: go ahead and show me a double-blinded study independently replicating these results, so we can see whether it's describing an underlying phenomenon, or just one doctor's anecdotes. Until then, this stays in the 'interesting' pile.

Again: is there a double-standard? The evidence submitted here is questionable meta-analysis and unblinded anecdotes. We routinely laugh at CAMmers who present this type of stuff.

Ivor the Engineer

17th April 2009, 09:54 AM

So you're asking for a double-blind trial of placebo vs. no treatment?

I think you may be waiting a long time.

Jeff Corey

17th April 2009, 10:21 AM

Nevermind.

blutoski

17th April 2009, 10:22 AM

So you're asking for a double-blind trial of placebo vs. no treatment?

I think you may be waiting a long time.

I'm not sure which article you're talking about...

But if it's the Parkinson's study, it wasn't even a study per se. More a collection of anecdotes, and there was no dedicated control group, much less blinding.

In general, I'd like the people evaluating the results to be blinded regarding the patients. When the author is also the evaluator, there's a concentration of incentive to misinterpret results. Blinding makes sense.

Hjobartsen's literature review consists of 150+ papers done with evaluator blinding, so the proper protocol is clearly known. It requires a bit of planning, and perhaps a little more work.

My guess: they are not really claiming to be doing anything more than forwarding anecdotes, so what's to complain about - it's very legitemate for doctors to publish recent experiences, as these often lead to experiments with resolving power.

The authors haven't done anything wrong, here: the mistake is made when somebody uses it to bolster an argument that really needs different citations.

athon

17th April 2009, 05:09 PM

I'm pretty sure we explained that: blinding reduces bias, conscious or otherwise.

Should I have bolded the word 'double'? I understand the bias on behalf of the experimenter, but if placebos have zero effect on the patient's reporting or sense of well being, then studies have no need to be double blinded. Just set the administration up so the experimenter has no idea who got something and who got nothing.

I think we've accepted that there is lots of evidence to support the theory. There is also lots of evidence refuting it. This is no different than what is proferred by advocates of homeopathy.

So you're happily comparing the evidence that is available for stress influencing state of health with evidence for homeopathy?

Blutoski, sorry to appeal to emotion here, but honestly, you're one of my favourite science posters. However to make a comparison like that is just nuts. Homeopathy has nothing to support it whatsoever. To state that stress-related illness is on par with it is just plain ludicrous.

Based on that, I think it's dismissive to ignore the studies that suggest placebos might have a small effect on patient recovery, or even improvements in their state of mind.

I have to state once again, I don't advocate lying to a patient to achieve this 'peace of mind'. I suggest this placebo effect - this bias in the mind of the patient to view their health positively - is of benefit to medicine. I just can't fathom how any medical practitioner could possibly not think it beneficial. But, hey, I have met a lot of doctors in my time who feel that way.

I am trynig to understand why you believe two or three papers you selected for agreeing with your prior conclusion override a literature review of all the current research

Because I don't agree that 'all' of the research contradicts it. I think there is enough reason to believe on what I understand and have read that patients who feel better about their state of health report better healing often do heal faster depending on the influence of stress on their condition. In the very least, their state of mind is not distinct from the 'suffering' they experience from their condition and is an important factor physicians should keep in mind during treatment.

You are making unwarranted assumptions. We don't even know whether placebo changes patient perception.

Then again, what's the point in providing patients with a placebo at all? Trials are wasting a lot of time and expense on nothing otherwise. Might as well not give them anything if there is zero evidence that placebos affect the patient's perception.

I have no quibble with that statement. That claim is very well supported by the evidence. My quibble is with your claim that it has an important effect on healing - assuming that when you refer to 'healing' that you are referring to actual changes in a disease state, not just changes in perception.

I'm referring to 'healing' in two ways, I guess. One is the alleviation of suffering, which has a psychological component. Sure, a person with cancer is in a bad state. A person with cancer who is anxious is in a worse state. Does that anxiety help them heal faster, heal slower, or have no effect at all? On that spectrum, I think there's enough evidence in my opinion that anxiety and stress can in the very least create additional problems that may interfere with healing.

Therefore the evidence that exists suggesting placebos may have a subtle effect on a patient's psychological state, and those that suggest a knock-on effect onto patient healing, may have some merit.

Athon

Rolfe

17th April 2009, 05:33 PM

Are you two guys sure you're actually arguing? You might like to map out some points of agreement here....

Rolfe.

athon

17th April 2009, 05:40 PM

Are you two guys sure you're actually arguing? You might like to map out some points of agreement here....

Rolfe.

I hope not. :( I actually like and respect these guys. The dissonance of maybe being completely wrong and yet trusting my own opinion on these things is never comfortable.

Maybe I'm just overtired. Need a holiday. Or a placebo. ;)

Athon

fls

18th April 2009, 05:23 AM

Then again, what's the point in providing patients with a placebo at all? Trials are wasting a lot of time and expense on nothing otherwise. Might as well not give them anything if there is zero evidence that placebos affect the patient's perception.

The patient is given a placebo because it is very-well established that patients will report feeling better when given something that they are told may make them feel better. It is not entirely clear whether they report they feel better because they actually perceive a variation in their subjective symptoms, or whether they report they feel better because of other biases (such as the desire to please). If you are testing a new drug (for example), you are interested in whether patients feel better because the drug has a specific effect on the underlying disease or symptom, so you need some way of measuring whether there is an effect in addition to the non-specific reporting of an effect. Which means that you need to measure the non-specific reporting of an effect for comparison.

I'm referring to 'healing' in two ways, I guess. One is the alleviation of suffering, which has a psychological component. Sure, a person with cancer is in a bad state. A person with cancer who is anxious is in a worse state. Does that anxiety help them heal faster, heal slower, or have no effect at all? On that spectrum, I think there's enough evidence in my opinion that anxiety and stress can in the very least create additional problems that may interfere with healing.

I don't think anyone is disputing that. If you recall, I asked what connection you were making between that and placebo (the expectation of receiving effective treatment), and what evidence you have for that connection. You made reference to state of mind in a very non-specific manner, but what evidence do you have that placebo alters state of mind in a way that is useful or meaningful? What evidence do you have that any intervention alters state of mind in a way that is useful or meaningful when it comes to healing?

Consider the results of this study for example:

http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1246362&blobtype=pdf

Reassurance seems to have affected state of mind and subsequently influenced soft outcomes, but placebo did not.

Or these systematic reviews where changes in state of mind do not seem to translate into changes in hard outcomes.

http://www.cochrane.org/reviews/en/ab004253.html
http://www.cochrane.org/reviews/en/ab002902.html

Therefore the evidence that exists suggesting placebos may have a subtle effect on a patient's psychological state, and those that suggest a knock-on effect onto patient healing, may have some merit.

Athon

Can you give some examples of the evidence you are referring to?

Linda

Dancing David

18th April 2009, 07:13 AM

So you're asking for a double-blind trial of placebo vs. no treatment?

I think you may be waiting a long time.

That is not the point.

To conclude that the placebo effect exists there should be a second control group, the no treatment, no sham treatment group. This is what Jeff Corey, and indirectly what RLR were talking about.

Without that control group the assumption of a 'placebo' effect is unwarranted and specious.

Jeff Corey

18th April 2009, 07:18 AM

I think Ivor knew that. He had me for a minute, too, hence the "mistake"" above.

paximperium

18th April 2009, 08:46 AM

Are you two guys sure you're actually arguing? You might like to map out some points of agreement here....

Rolfe.
One needs no good reason to argue. Keeps the relationship spicy.

Badly Shaved Monkey

19th April 2009, 05:13 AM

Coming rather late to this party and not currently in a position to support every dot comma of what I am about to say with citations, but here is my overview and understanding.

1. There is a placebo effect.
2. It requires studies with a double control for it to be measured, but these have rarely been done because most therapeutic trials are looking for a significant and clinically useful effect in their active arm.
3. The placebo effect is small, actually negligible in many clinical contexts.
4. In some clinical contexts it may not be small. These are contexts where the clinical parameter of interest is highly subjective. Here it remains hard to spot a patient who really has less pain or is presenting a falsely rosy picture for a variety of reasons. Unfortunately a waiting list control will not suffice to detect a 'real' placebo effect from a 'falsely reported' placebo effect. If the clinical parameter is entirely subjective, I cannot see how one can create a falsifiable hypothesis to distinguish these two states.
5. SCAM sits exactly in the area where a 'real' placebo effect might operate, so this is quite a big deal when discussing SCAM, but in the wider context of medicine as a whole the potential scope for this turf war is a very small piece of territory.
6. SCAMmers claim efficacy in areas of medicine far outside the range of any possible placebo effect. This seriously troubles me in any attempts to bring SCAM in from the cold, especially in my, veterinary, world.
7. I do wonder whether Ben Goldacre, since he has been named in this thread, tends to be overgenerous to the potential power of placebo because his personal professional field is psychiatry, which is bang in the centre of the patch of turf to which I have alluded.
8. Overplaying of the placebo effect has become a coded way for conventional medics to avoid appearing unsympathetic to well-intentioned but fundamentally misguided practitioners of woo.
9. The placebo effect will not cure your arthritis. It might actually make you feel a bit better, but there is a strong likelihood that you would tell your therapist that you feel more better than you actually feel.

Badly Shaved Monkey

19th April 2009, 07:01 AM

10. The playing out of regression to the mean, spontaneous recovery etc. easily lead a casually sceptical observer to be rightly doubtful of the specific benefits of SCAM but unjustly generous to the placebo effect where its magnitude has not been specifically examined.

Dancing David

19th April 2009, 07:05 AM

And that is is why the mo treatment control group is useful.

Badly Shaved Monkey

19th April 2009, 07:33 AM

Question: there is much rhetoric about exploiting the placebo effect for therapeutic gain, but how would we recognise that we have succeeded? Antibiotics are a very clear example of a purely pharmaceutical drug, but their actions are greatly impaired if you do not have well-functioning defences to underpin their use. Drugs all work in a context defined by complex biological systems, I don't know how I could define a product that I'd want to market as Placebin that would somehow mark it out from other drugs in its sector.

Badly Shaved Monkey

19th April 2009, 07:38 AM

And that is is why the mo treatment control group is useful.

And the fact that such double control studies are few and far between explains why this thread has generated more heat than light in trying to define the genuine size of a 'real' placebo effect.

Jeff Corey

19th April 2009, 07:56 AM

Ivor the Engineer

19th April 2009, 08:15 AM

Does this count as placebo effect?

http://www.ncbi.nlm.nih.gov/pubmed/18978640?ordinalpos=5&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

Autogenic training to manage symptomology in women with chest pain and normal coronary arteries.

OBJECTIVES: To explore autogenic training (AT) as a treatment for psychological morbidity, symptomology, and physiological markers of stress among women with chest pain, a positive exercise test for myocardial ischemia, and normal coronary arteries (cardiac syndrome X). DESIGN: Fifty-three women with cardiac syndrome X (mean +/- SD age, 57.1 +/- 8 years) were randomized to an 8-week AT program or symptom diary control. Symptom severity and frequency, Hospital Anxiety and Depression Scale, Spielberger State-Trait Anxiety Inventory, Cardiac Anxiety Questionnaire (CAQ), and Ferrans and Powers Quality of Life Index (QLI), blood pressure, heart rate, electrocardiogram, and plasma catecholamines were measured before and after intervention and at the 8-week follow-up. RESULTS: Women who underwent AT had improved symptom frequency (8.04 +/- 10.08 vs 1.66 +/- 2.19, P < 0.001) compared with control women and reduced symtom severity (2.08 +/- 1.03 vs 1.23 +/- 1.36, P = 0.02) and frequency (6.11 +/- 3.17 vs 1.66 +/- 2.19, P < G 0.001) post-AT compared with baseline within group. Within-group improvements among women who underwent AT include QLI health functioning (17.80 +/- 5.74 vs 19.41 +/- 5.19, P = 0.04) and CAQ fear (1.53 +/- 0.61 vs 1.35 +/- 0.56, P = 0.02) post-AT and QLI health functioning (17.80 +/- 5.74 vs 20.09 +/- 5.47, P = 0.01), CAQ fear (1.53 +/- 0.61 vs 1.30 +/- 0.67, P = 0.002), CAQ total (1.42 +/- 0.54 vs 1.29 +/- 0.475, P = 0.04), Spielberger State-Trait Anxiety Inventory trait anxiety (42.95 +/- 11.19 vs 38.68 +/- 11.47, P = 0.01), and QLI quality of life (20.67 +/- 5.37 vs 21.9 +/- 4.89, P = 0.02) at follow-up. CONCLUSION: An 8-week AT program improves symptom frequency, with near-significant improvements in symptom severity in women with cardiac syndrome X.

Ivor the Engineer

19th April 2009, 08:20 AM

http://www.ncbi.nlm.nih.gov/pubmed/17635893?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=4&log$=relatedarticles&logdbfrom=pubmed

Acute emotional stress and cardiac arrhythmias.

Episodes of acute emotional stress can have significant adverse effects on the heart. Acute emotional stress can produce left ventricular contractile dysfunction, myocardial ischemia, or disturbances of cardiac rhythm. Although these abnormalities are often only transient, their consequences can be gravely damaging and sometimes fatal. Despite the many descriptions of catastrophic cardiovascular events in the setting of acute emotional stress, the anatomical substrate and physiological pathways by which emotional stress triggers cardiovascular events are only now being characterized, aided by the advent of functional neuroimaging. Recent evidence indicates that asymmetric brain activity is particularly important in making the heart more susceptible to ventricular arrhythmias. Lateralization of cerebral activity during emotional stress may stimulate the heart asymmetrically and produce areas of inhomogeneous repolarization that create electrical instability and facilitate the development of cardiac arrhythmias. Patients with ischemic heart disease who survive an episode of sudden cardiac death in the setting of acute emotional stress should receive a beta-blocker. Nonpharmacological approaches to manage emotional stress in patients with and without coronary artery disease, including social support, relaxation therapy, yoga, meditation, controlled slow breathing, and biofeedback, are also appropriate to consider and merit additional investigation in randomized trials.

Badly Shaved Monkey

19th April 2009, 09:12 AM

Blutosky's reference in post 34 found a bunch of such studies.
"this belief is not based on evidence from randomised trials that use a placebo treatment for one group of people, while another group receives no treatment. The effect of placebo treatments was studied by reviewing more than 150 such trials covering many types of healthcare problems."

Sorry, I'm not clear on your meaning. Are you saying that is a lot of studies or are you bemoaning their small number?

I think my point is that unless you have a very large number it would be hard to draw general conclusions about something monolithically called 'the' placebo effect. I am not really familiar enough with the literature base to say whether it has the necessary breadth and depth. All I can say is that, from reading secondary literature like Ben's book, I find persuasive the evidence that a real placebo effect exists at least in some circumstances and, this in contrast to homeopathy, I am happy to concede that the principle is valid but that its applicability in specific circumstances would need to be shown by good evidence. Whereas, with homeopathy, I think we can say that the principle is invalid and further study of specific applications is pointless and only serves to lend credibility to foolishness.

Deetee

19th April 2009, 09:24 AM

Does this count as placebo effect?

http://www.ncbi.nlm.nih.gov/pubmed/18978640?ordinalpos=5&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
No.

Badly Shaved Monkey

19th April 2009, 09:25 AM

Ivor the Engineer

19th April 2009, 09:29 AM

No.

Well that's settled then.:)

Badly Shaved Monkey

19th April 2009, 09:35 AM

No.

I agree, but what if the title of the paper had alluded to 'reflective self-analysis' and it had been the 'active control' arm of a trial of homeopathy where a second control arm was a matched waiting list control.

That again makes me wonder about how to accurately define a placebo effect and recognise it in action.

Deetee

19th April 2009, 10:35 AM

Well that's settled then.:)

;)
"Syndrome X" is a loose term describing features of ischaemic type chest pain in those who by angiography are found to have normal calibre coronary arteries (begging the question- why would they get symptoms suggesting constriction or narrowing of same if the artery is "normal"). The symptoms are felt to be influenced by neuro-endocrine status - stress, anxiety and other factors triggering release of chemicals with vaso-active properties (eg adrenaline) and also with the propensity to influence heart rate, blood pressure etc, changes of which could result in variation of coronary artery calibre/constriction and precipitate pain/other symptoms.

A trial of autogenics which would be anticipated to modulate these triggers is therefore not really a trial of placebo, neither would other interventions that could relieve stress/anxiety.
A trial in which wearing a tin foil hat was shown to help symptoms would make me regard tinfoil hats as placebos, however.

blutoski

19th April 2009, 11:13 AM

Should I have bolded the word 'double'? I understand the bias on behalf of the experimenter, but if placebos have zero effect on the patient's reporting or sense of well being, then studies have no need to be double blinded. Just set the administration up so the experimenter has no idea who got something and who got nothing.

I used the expression 'double' to mean that the experimenters themselves were blinded. It is impossible to blind the patient when testing for placebo effect itself, because the purpose is to establish different expectations in the patient.

As mentioned though, blinding the patients also prevents false reporting based on actual bias.

So you're happily comparing the evidence that is available for stress influencing state of health with evidence for homeopathy?

No: I'm saying stress reduction is not an example of placebo effect - it's a well-recognized and genuine effect of an emotion that I absolutely accept to be true - and that it doesn't have anything to do with placebos, and that you are somehow confusing the two.

Or perhaps your argument is that placebos relax people based on your personal anecdote, so this whisp of evidence means claims about placebos are probably true, even though objective evidence shows they aren't. A very dubious argument.

Blutoski, sorry to appeal to emotion here, but honestly, you're one of my favourite science posters. However to make a comparison like that is just nuts. Homeopathy has nothing to support it whatsoever. To state that stress-related illness is on par with it is just plain ludicrous.

The concern is because you're conflating emotion and placebo.

Based on that, I think it's dismissive to ignore the studies that suggest placebos might have a small effect on patient recovery, or even improvements in their state of mind.

Well, how much research do you want? We've been doing it for two generations, and the body of research shows it doesn't work. How many more studies can you justify?

I have to state once again, I don't advocate lying to a patient to achieve this 'peace of mind'. I suggest this placebo effect - this bias in the mind of the patient to view their health positively - is of benefit to medicine. I just can't fathom how any medical practitioner could possibly not think it beneficial. But, hey, I have met a lot of doctors in my time who feel that way.

I have never heard that definition of 'placebo effect' before, and I think your argument is flailing. At this point, I'm not sure what you're talking about at all, but it's not about placebos at this point. What you're talking about may or may not make sense, depending on what it is exactly that you propose.

Because I don't agree that 'all' of the research contradicts it. I think there is enough reason to believe on what I understand and have read that patients who feel better about their state of health report better healing often do heal faster depending on the influence of stress on their condition. In the very least, their state of mind is not distinct from the 'suffering' they experience from their condition and is an important factor physicians should keep in mind during treatment.

You're right, not 'all' the research contradicts it. *** there will always be mixed results for every experiment that is repeated, especially in different ways - there are positive and negative results for homeopathy *** what's important is to back up and look at the body of literature and see if the ones that line up on one side are of better quality &c. These results are more likely to represent the underlying situation. There are tools like funnel graphs and sometimes (rarely) we can use meta-analysis.

It's important to distinguish "well, it might be true because of x,y,z mechanism &c" from "is it *actually* true?"

The latter question should be resolved first.

What you're saying is that based on your experience and reasoning, it should work. Sure: people thought this 60 years ago, too. So experiments were done, and it turns out it doesn't work. But that doesn't stop people from insisting and doing more research.

Dr. Novella calls this 'going backwards'. The definitive studies on homeopathy were done twenty years ago. That doesn't seem to stop people from obtaining funding and going forward with fresh, new, "preliminary" studies today.

Then again, what's the point in providing patients with a placebo at all? Trials are wasting a lot of time and expense on nothing otherwise. Might as well not give them anything if there is zero evidence that placebos affect the patient's perception.

You keep asking this, and I keep answering: are you ignoring my answers?

The experimenters have a huge incentive to make their product show positive results, and blinding eliminates this by 'keeping them honest'. The bias does not have to be consciously engaged: think of Cox and his cranial volume experiments.

There are also patients who have a bias and will give a better report to their favourite modality just because they have a bone to pick with whoever.

There is also a pattern of reporting what they were supposed to report - we don't know if they really believe this or if they're just trying to make the doctor happy. *** that's very important ***

I'll give you an example: I have a coworker whose sister is a DC and deliberately enrolled in a study to falsify results because she hates Big Pharma. However, the placebo is 50% and she's stymied because she's never heard of placebo before and didn't expect it. She has since dropped out of the study.

I'm referring to 'healing' in two ways, I guess. One is the alleviation of suffering, which has a psychological component. Sure, a person with cancer is in a bad state. A person with cancer who is anxious is in a worse state. Does that anxiety help them heal faster, heal slower, or have no effect at all? On that spectrum, I think there's enough evidence in my opinion that anxiety and stress can in the very least create additional problems that may interfere with healing.

Therefore the evidence that exists suggesting placebos may have a subtle effect on a patient's psychological state, and those that suggest a knock-on effect onto patient healing, may have some merit.

That's extremely tenuous, and speculative at best. There are two unproven assumptions, and you have omitted the third: what would a 'placebo' look like in this situation, and would the whole placebo thing be better than known treatments.

For example, if you're talking about a patient who is anxious because they have been told there's no good treatment, is the placebo you suggest to lie to them and tell them they're doing fine? This is considered extremely unethical.

I didn't see anything in the examples you gave that looked like any way these hypotheses could be used, much less ethically. I'm trying to guess what you're meaning at all at this point.

blutoski

19th April 2009, 11:24 AM

And the fact that such double control studies are few and far between explains why this thread has generated more heat than light in trying to define the genuine size of a 'real' placebo effect.

This is actually my focus of interest, and I'm using the thread (sorry!) to some extent for my own purposes in attempting to develop an educational module about this.

My interest is about trying to understand why very intelligent and educated people use arguments to defend placebo's potential as a clinical treatment modality that they would not accept in other areas of discussion.

Just to give another loose analogy: psi advocates often get cornered when asked to show 'good' evidence for psi. The null hypothesis is chance - Ocham's Razor here. Skeptics are looking for independent replication. We are told by psi advocates that psi is a special exception to this threshold because of its distinctive nature. It just can't be independently replicated, but we should either accept it anyway, or maybe science has to be re-written - if science can't incorporate psi, something's wrong with science.

Now, here we are with placebo-effect-focused testing: it can't be patient-blinded, by its very nature. The null hypothesis is reporting bias - Ocham's Razor here. Yet, medicine is told that either it has to just accept these dubious results anyway or perhaps there's something wrong with Medicine and it's time for a re-write!

blutoski

19th April 2009, 11:30 AM

Rereading Blutoski's post 34, which I had rather glossed as I tried to catch up with this thread, I think we are in agreement. One must accept that such a thing as a placebo effect is real, but its effects are small and rather narrow in scope. Is that right?

I would say that the Cochrane is not even that committal. They say that the only adequat evidence for a placebo effect appears limited to the following situation:

pain
but only if measured on a gradient
not enough to be considered clinically relevant

What this means is that even within pain management, if the outcome is binary (eg: "are you feeling better, yes or no?"), there is no evidence of placebo effect, and what effect there is does not seem to improve quality of life or other factors considered important to the patient or studies' designers.

The author also points out that this is what we would expect to see from reporting bias alone (patients reporting what they think they're being expected to report, motives may vary).

blutoski

19th April 2009, 11:35 AM

Does this count as placebo effect?

http://www.ncbi.nlm.nih.gov/pubmed/18978640?ordinalpos=5&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

Absolutely not: these patients are receiving treatment in the form of what looks like a relaxation therapy. There is no placebo group. Nobody is getting placebo.

blutoski

19th April 2009, 11:39 AM

I agree, but what if the title of the paper had alluded to 'reflective self-analysis' and it had been the 'active control' arm of a trial of homeopathy where a second control arm was a matched waiting list control.

That again makes me wonder about how to accurately define a placebo effect and recognise it in action.

It's pretty well defined here in the clinical trial experiment world.

The placebo effect is the difference in outcome caused by giving placebo versus a non-treatment group. It appears to be caused by the testing authority (MD or whoever) establishing expectations in the patient.

This could be improvement, or it could actually be a worsening of symptoms (a negative-improvement in outcomes in the placebo group is sometimes called "nocebo effect").

blutoski

19th April 2009, 11:56 AM

7. I do wonder whether Ben Goldacre, since he has been named in this thread, tends to be overgenerous to the potential power of placebo because his personal professional field is psychiatry, which is bang in the centre of the patch of turf to which I have alluded.

Good question, but as a counter-anecdote, I'd like to give my wife's opinion on the morphine experiment (which was an example of operant conditioning, not an example of placebo effect):

We read it together and discussed it. She pointed out that if there's one thing you can depend on with narcotic users, it's that they notice immediately if the nurse has forgotten to put Methodone in their juice. When they miss their dose, they are perfectly aware of it. She's personally attempted to use saline injection when doing suicide rescues (eg: on bridges where the patient says if he doesn't get his morphine, he'll jump), and this has never worked, unfortunately (note: she opts not to give patients morphine when they're hanging on the edge of a bridge, because they will almost certainly let go due to the narcotic's effects).

I'm not sure what Goldacre's reasoning is. It'd be best to ask him directly at some point.

Badly Shaved Monkey

19th April 2009, 01:01 PM

I was about to post a reply, but then realised what I really need is to ask you for your definition of placebo effect- not the general definition of the patient's ability to gain healing benefit from the therapeutic interaction independen of the effect of an effective drug, but adefinition in terms of the arms of a hypothetical experiment. What minus what else yields an answer that is the naked placebo effect. I accept that you regard the size of this effect to be essentially zero, but if it existed what arithmetic would generate its estimated size.

Ivor the Engineer

19th April 2009, 01:02 PM

<snip>

A trial of autogenics which would be anticipated to modulate these triggers is therefore not really a trial of placebo, neither would other interventions that could relieve stress/anxiety.
A trial in which wearing a tin foil hat was shown to help symptoms would make me regard tinfoil hats as placebos, however.

It seems once the physiological mechanism of a treatment based on expectation is sufficiently well understood it is no longer classed as a placebo, which makes this debate somewhat one-sided.

Jeff Corey

19th April 2009, 01:26 PM

...The author also points out that this is what we would expect to see from reporting bias alone (patients reporting what they think they're being expected to report, motives may vary).

I just wanted to point out that in social psychology, reporting bias (sometimes called subject bias) is said to be a result of the "demand characteristics" of the experiment (Orne, 1959).
"Demand characteristics" refer to the totality of cues and mutual role expectations that inhere in a social context, (e.g., a psychological experiment or therapy situation), which serve to influence the behavior and/or self-reported experiences of the research participant or patient. The term was adapted by the first author (1959, Journal of Abnormal and Social Psychology, 58, 277-299)

athon

19th April 2009, 06:51 PM

I have never heard that definition of 'placebo effect' before, and I think your argument is flailing. At this point, I'm not sure what you're talking about at all, but it's not about placebos at this point. What you're talking about may or may not make sense, depending on what it is exactly that you propose.

I'll focus on this point, primarily because it might be at the core of my problem. I've always understood based on what I've read that the placebo effect is the unconscious bias a patient holds towards being treated. In itself, it's a range of psychological 'tricks' the patient plays on their self that reads improvement from a treatment that is distinct from the treatment itself.

From that, placebos are used to determine when a patient reports their health, the information that arises from this bias can be sorted from information that arises as a direct result of an actual treatment.

If this is incorrect - and I'm more than happy to be shown that - please lead me to an authoritative source that explains it better with an explanation on why that source is authoritative. If you're creating an educational resource on this, Blutoski, I'd love to be first in line to read it, especially if I have the wrong end of the stick.

Athon

blutoski

19th April 2009, 11:19 PM

blutoski

19th April 2009, 11:28 PM

It seems once the physiological mechanism of a treatment based on expectation is sufficiently well understood it is no longer classed as a placebo, which makes this debate somewhat one-sided.

No, not "once it's sufficiently well understood." The type of symptoms listed in the paper you cited are obviously aggravated by stress and have always been known to be aggravated by stress. The traditional treatment for time immemorial has been to find ways to reduce patient stress. This is 19th century stuff. The experiment you cited was exploring another way to do so, although not comparing to other known methods (likely because the authors were afraid it would not compare well).

Placebo refers to an effect caused by a treatment that would not provide benefit without suggestion, but does so in accordance to the suggestion of the experimenter.

As it is, it is not clear that the citations you provided show a placebo effect, because the patients were actually treated with a treatment that has a very credible mechanism of action that should very well be independent of placebo or suggestion. Relaxation by any means will probably reduce their symptoms. That may include drugs or other relaxation techniques. All of this is treatment, not placebo.

Again: if we are looking for a placebo effect caused by expectation, just show me the experiment where they split the patients into one group that is told one expectation, and another group that is shown another expectation, but both groups given the same actual treatment. The difference between the two is the placebo effect.

blutoski

19th April 2009, 11:33 PM

I just wanted to point out that in social psychology, reporting bias (sometimes called subject bias) is said to be a result of the "demand characteristics" of the experiment (Orne, 1959).
"Demand characteristics" refer to the totality of cues and mutual role expectations that inhere in a social context, (e.g., a psychological experiment or therapy situation), which serve to influence the behavior and/or self-reported experiences of the research participant or patient. The term was adapted by the first author (1959, Journal of Abnormal and Social Psychology, 58, 277-299)

Yes, this is one of the plausible null hypotheses for the findings that placebo results seem to be restricted to subjective linear properties.

There is also the issue of somatization, which needs to be considered seperately.

blutoski

19th April 2009, 11:44 PM

I'll focus on this point, primarily because it might be at the core of my problem. I've always understood based on what I've read that the placebo effect is the unconscious bias a patient holds towards being treated. In itself, it's a range of psychological 'tricks' the patient plays on their self that reads improvement from a treatment that is distinct from the treatment itself.

We actually don't know what causes placebo effect. That's the question. Alternative hypotheses have been presented, and they may manifest differently in different situations.

Again, please see my earlier post where I try to distinguish two common, but different, definitions for clarity.

One refers to the baseline change that cannot be attributed to the treatment (placebo group improvement), and the other refers to the change caused by establishing patient expectation (placebo-caused change).

The first definition has certain plausible causes, such as natural course of illness, regression to the mean, &c.

The second definition may or may not be reporting bias, may be anything from opioids, to soup or nuts. Nobody's proposed a good protocol to resolve among the models.

From that, placebos are used to determine when a patient reports their health, the information that arises from this bias can be sorted from information that arises as a direct result of an actual treatment.

If this is incorrect - and I'm more than happy to be shown that - please lead me to an authoritative source that explains it better with an explanation on why that source is authoritative. If you're creating an educational resource on this, Blutoski, I'd love to be first in line to read it, especially if I have the wrong end of the stick.

Athon

For once, Wikipedia has a good summary description: [Placebo (http://en.wikipedia.org/wiki/Placebo)], a treatment without intrinsic therapeutic value, but administered as if it were a therapy, either in medical treatment or in clinical trials... The placebo effect can be produced by inert tablets, by sham surgery, and by false information.

The key there is 'without intrinsic value' - this is something that Ivor suggested was circular reasoning in an earlier post.

Badly Shaved Monkey

20th April 2009, 12:23 AM

I tried to touch on that in [post #134 (http://forums.randi.org/showpost.php?p=4624591&postcount=134)].

OK, using the terminology of that post;

"Placebo Effect" = P - N

But this is still a compound of a putative 'real' placebo effect (RPE) and other biases created by the difference between a situation where the patient believes themself to be under treatment and a situation where they know they are not.

P - N therefore sets an upper limit to RPE.
If P - N = 0 then RPE = 0
If P - N > 0 then RPE > 0 and RPE <= P - N, but we don't have an actual value for RPE.

Which brings me back to my previous comment, I've been convinced by the secondary literature, including Ben's book, that P - N > 0 in a restricted number of contexts. He cites various examples- Green pill stronger than Red pill, Two pills stronger than One pill.

I'll need to pull out the book to go further, but are you disputing his claim that such differentiable placebo effects occur, effects that do imply the existence of some kind of RPE?

athon

20th April 2009, 12:32 AM

We actually don't know what causes placebo effect. That's the question. Alternative hypotheses have been presented, and they may manifest differently in different situations.

I can understand that, which is why I said a 'range of psychological' tricks. Is it possible that there are non-psychological elements to the placebo effect? I agree there's a range of them, and we don't completely understand the how and why of it, let alone the contexts or particulars, but if there is no psychological component, what else do researchers hypothesise?

One refers to the baseline change that cannot be attributed to the treatment (placebo group improvement)

Ok, cool. I get that. Could this baseline change as a result of the process (since it has nothing to do with the treatment itself) be seen as positive? Sure, we don't know the precise mechanisms, but isn't the fact the patient is reporting some sort of improvement that comes from other factors independent of the actual treatment itself a potential benefit that could be exploited?

and the other refers to the change caused by establishing patient expectation (placebo-caused change).

And see above. Could this change that results from patient expectations - this bias - again be considered useful in and of itself?

The first definition has certain plausible causes, such as natural course of illness, regression to the mean, &c.

I don't see how this is placebo, in which case. If it is a natural course of illness, this would not vary with regards to the administration of a treatment.

The second definition may or may not be reporting bias, may be anything from opioids, to soup or nuts. Nobody's proposed a good protocol to resolve among the models.

This sounds more like a justification for the first cause, not the second.

The key there is 'without intrinsic value' - this is something that Ivor suggested was circular reasoning in an earlier post.

Which I tend to agree with.

Thanks for trying to help, but I'm afraid I still just don't see it. It seems to me that if there is an effect on the patient which is independent of the treatment - even a psychological one that biases their view into believing there is an improvement - there is something that is of benefit to the patient that could be of use to better understand for therapeutic reasons.

Athon

Ivor the Engineer

20th April 2009, 03:19 AM

Yoga reducing the incidence of hot flashes in menopausal women:

http://www.ncbi.nlm.nih.gov/pubmed/19214594?ordinalpos=19&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

Yoga of Awareness program for menopausal symptoms in breast cancer survivors: results from a randomized trial.

GOAL OF WORK: Breast cancer survivors have limited options for the treatment of hot flashes and related symptoms. Further, therapies widely used to prevent recurrence in survivors, such as tamoxifen, tend to induce or exacerbate menopausal symptoms. The aim of this preliminary, randomized controlled trial was to evaluate the effects of a yoga intervention on menopausal symptoms in a sample of survivors of early-stage breast cancer (stages IA-IIB). MATERIALS AND METHODS: Thirty-seven disease-free women experiencing hot flashes were randomized to the 8-week Yoga of Awareness program (gentle yoga poses, meditation, and breathing exercises) or to wait-list control. The primary outcome was daily reports of hot flashes collected at baseline, posttreatment, and 3 months after treatment via an interactive telephone system. Data were analyzed by intention to treat. MAIN RESULTS: At posttreatment, women who received the yoga program showed significantly greater improvements relative to the control condition in hot-flash frequency, severity, and total scores and in levels of joint pain, fatigue, sleep disturbance, symptom-related bother, and vigor. At 3 months follow-up, patients maintained their treatment gains in hot flashes, joint pain, fatigue, symptom-related bother, and vigor and showed additional significant gains in negative mood, relaxation, and acceptance. CONCLUSIONS: This pilot study provides promising support for the beneficial effects of a comprehensive yoga program for hot flashes and other menopausal symptoms in early-stage breast cancer survivors.

Placebo, or what would be expected from pretending to be a tree?:)

blutoski

20th April 2009, 10:18 AM

I'll need to pull out the book to go further, but are you disputing his claim that such differentiable placebo effects occur, effects that do imply the existence of some kind of RPE?

I'm saying at least three things, and I get the impression it's not been made very clear (not that it's an excuse, but I tend to compose my posts over several hours in 10-second chunks betwen meetings), so I'll state them differently than I have in previous posts:

:: verification of the phenomenon is tentative right now, acceptance is premature

I'm not saying they don't occur - I'm saying the literature does not support the claim that they occur. These experiments are unreplicated one-offs that we would not accept for other claims.

If/when the replications are consistent I will be quite happy to go from there.

This is why the analogy to psi research is interesting: for reasons that escape me, everybody wants to do a fresh new protocol or repeat research they've already done themselves - nobody seems interested in independent replication. I don't get this at all.

:: the phenomenon appears very limited in scope, at best

Even the positive results do not appear to be clinically relevant, it's not clear that there's really any potential.

Like other parasciences that linger, placebo seems to have a funnel graph characteristic that suggests it is very limited - (funnel graph => the better the study; the smaller the effect, implies that the 'real' effect is very small or probably even just statistical background noise)

:: the phenomenon is restricted to scenarios that have a null hypothesis that is well understood and long established - reporting bias.

the decision to defy ockham's razor appears to be an artefact of cultural inertia rather than through the usual scientific process of adopting a better explanation

blutoski

20th April 2009, 10:29 AM

Yoga reducing the incidence of hot flashes in menopausal women:

http://www.ncbi.nlm.nih.gov/pubmed/19214594?ordinalpos=19&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

Placebo, or what would be expected from pretending to be a tree?:)

Unknown - the experiment is not designed to ask this question. The participants in the experimental arm were not further divided and given different expectations.

Also: the study itself says it's a pilot study - this means they are not trying to show anything with the experiment anyway. Which is fine, they say this right in the abstract you quoted.

Again: I don't have a bone to pick with the authors - only people who exaggerate the quality of the resarch to support something that cannot be otherwise supported.

blutoski

20th April 2009, 11:03 AM

I can understand that, which is why I said a 'range of psychological' tricks. Is it possible that there are non-psychological elements to the placebo effect? I agree there's a range of them, and we don't completely understand the how and why of it, let alone the contexts or particulars, but if there is no psychological component, what else do researchers hypothesise?

Anything's possible. I'm discussing claims about what's proven.

Ok, cool. I get that. Could this baseline change as a result of the process (since it has nothing to do with the treatment itself) be seen as positive? Sure, we don't know the precise mechanisms, but isn't the fact the patient is reporting some sort of improvement that comes from other factors independent of the actual treatment itself a potential benefit that could be exploited?

It's been explored up the wazoo, to the tune of millions of dollars, over the last two or three generations. I'm not disputing the concept of conducting research.

What I'm saying is that knowing that exactly these types of experiments have been conducted, and since there is a body of literature to draw upon, why are new, weaker, experiments being conducted today? This is the 'going backwards' phenomenon that Dr. Novella mentions regarding, say, homeopathy.

A history of negative findings in very good quality research has not had an impact on a rich industry producing 'preliminary studies' that say more research is required.

And see above. Could this change that results from patient expectations - this bias - again be considered useful in and of itself?

What change? That's my point.

I don't see how this is placebo, in which case. If it is a natural course of illness, this would not vary with regards to the administration of a treatment.

I don't call this placebo myself, and it is not the definition of placebo used in medicine. It is, however, a use of the term 'placebo' that is in common public usage, and the most common misunderstanding passed on by media. It is also the basis for the book The Powerful Placebo.

Specifically, the claim that placebo has a 30% effectiveness is based on the fact that on average (meta-analysis - dubious anyway) the placebo group sees a 30% recovery in experiments. This is just the baseline recovery, natural course, regression to the mean, &c, and not really an effect of taking a placebo per se. This does not stop people from misrepresenting the results, and I feel it is important to discuss to clarify my meaning.

It's like when I talk to people about homeopathy, I first clarify that many people incorrectly call naturopathic remedies homeopathic, and that from this point on, I mean homeopathic in a specific way.

This sounds more like a justification for the first cause, not the second.

I don't understand.

Which I tend to agree with.

I have trouble with including treatments that have prior probability of working as placebos. Why not include pharmaceuticals, too?

Thanks for trying to help, but I'm afraid I still just don't see it. It seems to me that if there is an effect on the patient which is independent of the treatment - even a psychological one that biases their view into believing there is an improvement - there is something that is of benefit to the patient that could be of use to better understand for therapeutic reasons.

I'm not disagreeing with this. I'm saying that that's a big IF that is being glossed over in conversation. If my grandmother had wheels she might be a wagon. My impression is that there is currently insufficient evidence that such a treatment has been found, which is a long way from showing it's 'powerful' or 'amazing' &c.

We're not seeing an effect that is independent of the treatment in many of these examples - we're seeing informal and weak reports of an effect that logically follows from the treatment, and for reasons that are being unclear, people are calling it 'placebo'.

If we want to see whether the effect is independent of the treatment, an experiment must be devised to show this.

Just to clarify: Ivor seems to think that it's somehow cheating to call relaxation techniques a placebo. I'd like to know why antianxiety medications would not be considered placebos the same way relaxation techniques are, if we are not excluding things that have prior plausible mechanisms of action.

It sounds like the informal definition of 'placebo' is 'not a drug', which makes the term pretty meaningless.

Badly Shaved Monkey

20th April 2009, 11:59 AM

blutoski

20th April 2009, 01:56 PM

I think I am in agreement with you overall, except that my estimation of prior probability is, I think, higher than yours, so my resistance is lower to accepting current evidence as evidence of something real, even if small.

I agree about the need for replication and improved robustness rather than this perpetual tendency in parasciences to keep striking out in new directions when there is no firm anchor point from which to start.

I half agree: there is a firm starting point (attempt to independently replicate positive studies with larger, better protocols), but the advocates are doing something else anyway.

This is suspicious, or at least curious.

Having reached agreement, or at least agreement to disagree in one respect, I still think this point is interesting. It aligns with something I was thinking after our recent exchanges.

One must avoid defining placebo as simply "= Not Drug", because where the heck does that end? Surgery = Not Drug.

I still see no way to create a 'clean' definition of placebo beyond reporting bias.

Casually Defined Placebo Effect (CDPE) = Placebo Arm - Non-treatment Arm
But we have agreed that this is a composite = RPE + Reporting Bias etc.

We agree, if CDPE is small, then RPE cannot be large and is approximately estimated, as you have said, by the number of angels dancing on a pinhead.

But, we can only compare placeboes, but not accurately define their actual size:

e.g. RPEGreenPill= DeltaRPE + RPERedPill

i.e. the Green Pill versus Red Pill example, if replicated, would support the idea of a non-zero RPE but only estimates a "DeltaRPE" for Green versus Red, which is the minimum size of RPEGreenPill, but still yields no estimate for its upper size except that it is bounded by CDPE.

Sort of. The CDPE is the only thing we actually observe, so the rest is complete speculation, and actually the CDPE may be neither RPE or Reporting Bias nor anything we've ever thought of.

But before going there, I'm saying it's premature to speculate until we get a repeatable value for CDPE.

My other concern is that people are trying to explain CDPE for outcomes that have not only never demonstrated CDPE, but often have experiments with negative results.

You say CDPE (and RPE) is tiny, but if we start allowing wider definitions of what is placebo, then the scope of the PE widens and we have more to discuss than trivial effects on subjective reports of pain relief using homeopathic arnica.

Yes, if we include everything concievable as placebo, the effects are very large. Eg: if we include antidepressants, then placebos appear to work very well as antidepressants.

So, we have to start with prior probability of mechanism &c. Do rabbits feet have a practical mechanism for curing cancer? I can't imagine how, so it's reasonable to class as placebo. Can relaxation techniqes reduce incidence or severity of stress-related syptoms? That makes sense, so classing it as a placebo means other things that have plausible mechanisms such as drugs are placebos, and the definition has become useless.

If psychotherapy created biological changes in the brains of major depressive patients not present in waiting list controls, is that by a placebo effect? [Not saying it does, but using it to illustrate the slippery nature of the definition of placebo]

Depends on whether the biological changes are manipulated via altering expectations.

I would say that absolutely every experience during the life of a major depressive patients causes biological changes in the brain, including psychotherapy. That's how the brain works. That doesn't make everything in the universe a placebo.

blutoski

20th April 2009, 02:12 PM

blutoski

20th April 2009, 02:27 PM

So, we have to start with prior probability of mechanism &c. Do rabbits feet have a practical mechanism for curing cancer? I can't imagine how, so it's reasonable to class as placebo. Can relaxation techniqes reduce incidence or severity of stress-related syptoms? That makes sense, so classing it as a placebo means other things that have plausible mechanisms such as drugs are placebos, and the definition has become useless.

And another topical analogy: "CAM".

I was reading an article a few weeks ago with an eye-roller of a theme. I don't recall the precise title, but the paraphrase is familiar: "Alternative medicine rapidly becoming mainstream."

I read through the article, and it was a good overview of how the reporter surveyed some doctors and found that they were very willing to advise their patients eat well and exercise and make lifestyle choices such as reducing their working hours or other life stressors.

In my opinion, there was not one mention of actual CAM in the article. Everything was evidence-based medicine.

But, victory by redefinition.

Relaxation techniques to reduce stress-related symptoms is 'placebo' in the same way that reducing weight to reduce risk of diabetes is 'alternative medicine.'

Niggle

20th April 2009, 03:41 PM

athon

20th April 2009, 05:27 PM

What change? That's my point.

The change you alluded to as being the reason behind providing a placebo to the patient in the first place. :confused:

Look, as I've said before, I respect your views enough to be giving the benefit of the doubt that there's more I need to learn here. There seems to be several definitions which (from my side - not saying you're doing it on purpose or are even really doing it at all) you're flipping between, which is confusing.

Now, I must admit, I've mostly only seen reasons to think that placebos are given for a reason - that the act of treatment biases a patient's reporting on their own improvements for whatever reasons. Can you please provide me with some authoritative studies showing this does not at all happen? And do they explain the observations of this occurring?

I don't call this placebo myself, and it is not the definition of placebo used in medicine. It is, however, a use of the term 'placebo' that is in common public usage, and the most common misunderstanding passed on by media. It is also the basis for the book The Powerful Placebo.

I've long learned not to draw a hard line between 'used in science/medicine' and 'public understanding'. Sorry, as somebody who works in the 'in between' zone as a communicator, it's never as clear as either the public or scientists/doctors/researchers like to think. In other words, you'd be creating a straw man to suggest that they are mutually exclusive zones.

The term 'placebo effect' might indeed have several meanings. I've always understood that it referred to the perceived improvement in health by the patient of the patient due to a treatment. You say otherwise, which is fine. I'm asking to be educated on that. So far I just have your word on your own view of it, which unfortunately does not gel perfectly with what I've learned.

Specifically, the claim that placebo has a 30% effectiveness is based on the fact that on average (meta-analysis - dubious anyway) the placebo group sees a 30% recovery in experiments. This is just the baseline recovery, natural course, regression to the mean, &c, and not really an effect of taking a placebo per se.

So if they were not treated or seen to in any way, this is the baseline recovery? Is that what you're saying?

I know this isn't sinking in, but if that's the recovery distinct from the act of being given treatment, i.e., there's no difference between the act of treatment and no act, why use a placebo at all?

I have trouble with including treatments that have prior probability of working as placebos. Why not include pharmaceuticals, too?

I don't see what you're getting at. If you've read what I've posted, this is precisely what I've said from the beginning.

I'm not disagreeing with this. I'm saying that that's a big IF that is being glossed over in conversation. If my grandmother had wheels she might be a wagon. My impression is that there is currently insufficient evidence that such a treatment has been found, which is a long way from showing it's 'powerful' or 'amazing' &c.

If what you're saying - that there is no difference at all in the patient's perception of being treated and their receiving no treatment at all - then I guess I agree. Taking advantage of something that doesn't exist is pointless.

On the other hand, if the act of treatment does in itself make a patient feel better about their state of health, I feel this is an important thing. There are studies which show patient's self-reporting based on the colour of pills, cost of medication etc. seems to be different. This, in my view, is interesting and could demonstrate betters ways of communicating with patients or designing ways to offer treatment.

Yet, if you're correct, this studies aren't sufficient to match the wealth of data that says it's probably bunk. In which case, I'm barking up the wrong tree.

We're not seeing an effect that is independent of the treatment in many of these examples - we're seeing informal and weak reports of an effect that logically follows from the treatment, and for reasons that are being unclear, people are calling it 'placebo'.

Ok, so this does seem to be solely about the definition in which case. Don't worry, I experience these arguments all the time in my line of work. The last one I had was on how the public uses the word 'experiment'. :) Scientists get enraged, the public gets confused, and we have to find a way to marry the two.

Unfortunately I have heard and read non-lay people use the term as I understand it and am using it. Scientists, medical researchers and doctors. You can say they're wrong, but it's something of a 'no true scottsman' fallacy.

If we want to see whether the effect is independent of the treatment, an experiment must be devised to show this.

Can you clarify - do you mean 'independent of the treatment' or 'independent of the act of treatment'?

Athon

tnt666

21st April 2009, 12:12 AM

Hmm, but isn't the MD pledge to help people, not to truth itself...

Dancing David

21st April 2009, 05:56 AM

WARNING: Layman Ahead

Most of this discussion is WAY over my head, but I'm going to try a simplified definition of "placebo" to see if it helps. It sounds like a lot of people mostly agree but can't see their common ground. Feel free to disregard; IANAD.

Placebo = A treatment given (a sugar pill, saline shot, or other physical cue) that causes no physical change in a patient's condition (meaning the cancer is still cancer), but after receiving it, the patient reports feeling better. The only "effect" it can possibly have is psychological (e.g., purely subjective reporting).

Is this an acceptable definition? I can give examples to clarify if anyone wants to know what I mean.

Hi, welcome.

that is about as good as the standard usage gets.

the issue is that you can not ascribe the effect to taking the sugar pill unless you have the second control group who receives no treatment.

then you compare the three groups ; active ingredient, sham treatment and no treatment.

If the there is a statisticaly significant effect between two and three, then there is a placebo effect.

Guess which control group is usually not there?

Jeff Corey

21st April 2009, 06:12 AM

That's because most experiments are not specifically studying the placebo effect, per se.
The placebo or sham treatment control group in most experiments eliminates one potential confounding variable produced by demand characteristics, by holding them constant across groups.
Good experimental design requires this, even though the variable being controlled might, in fact, be ineffective.

Niggle

21st April 2009, 10:33 AM

Hi, welcome.

that is about as good as the standard usage gets.

the issue is that you can not ascribe the effect to taking the sugar pill unless you have the second control group who receives no treatment.

then you compare the three groups ; active ingredient, sham treatment and no treatment.

If the there is a statisticaly significant effect between two and three, then there is a placebo effect.

Guess which control group is usually not there?

Understood, and thank you. My point is that the placebo cannot be the cause of any physical difference between those groups. Therefore, if there is a difference between those groups, it must be psychologically-based, yes?

Dancing David

21st April 2009, 11:25 AM

Not really there are many possible causes.

Sample bias for one. More later.

blutoski

21st April 2009, 12:53 PM

Hmm, but isn't the MD pledge to help people, not to truth itself...

You're probably talking about the Oath, which is merely a tradition, and most do not take this oath at all (many refuse on religious grounds).

The relevant part of the oath you're thinking of is probably "First, do no harm."

Doctors are accountable to and regional law and their professional College, whose rules are based on contemporary medical ethics .

The current belief in medical ethics is that lying to the customer is a good example of "doing harm," so there is no conflict between being honest with patients and helping.

blutoski

21st April 2009, 12:57 PM

Can you clarify - do you mean 'independent of the treatment' or 'independent of the act of treatment'?

I meant 'independent of the treatment'. A clinical trial is usually designed to test a specific treatment. eg: a drug, a surgical procedure, a therapy (this includes, say, relaxation exercises or group therapy &c).

Improvement that can be attributed to a placebo would by definition be not attributed to the treatment under examination.

blutoski

21st April 2009, 01:42 PM