WHAT IS A PLACEBO
Placebo has been defined as follows:
- Inert substances that cause symptom relief (e.g. ‘My headache went away after having a sugar pill’).
- Substances that cause changes in a symptom not directly attributable to the specific or real pharmacological action of a drug or operation (e.g. ‘After I had my hip operation I stopped getting headaches’).
- Any therapy that is deliberately used for its non-specific psychological or physiological effects (e.g. ‘I had a bath and my headache went away’).
These definitions illustrate some of the problems with understanding placebos. For example:
- What are specific/real versus non-specific/unreal effects? For example, ‘My headaches went after the operation, is this an unreal effect (it wasn’t predicted) or a real effect (it definitely happened)?’
- Why are psychological effects non-specific? (e.g. ‘I feel more relaxed after my operation – is this a non-specific effect?’).
- Are there placebo effects in psychological treatments? For example, ‘I specifically went for cognitive restructuring therapy and ended up simply feeling less tired. Is this a placebo effect or a real effect?’
The problems inherent in the distinctions between specific versus non-specific effects and physiological versus psychological effects are illustrated by examining the history of apparently medically inert treatments.
A HISTORY OF INERT TREATMENTS
For centuries, individuals (including doctors and psychologists) from many different cultural backgrounds have used (and still use) apparently inert treatments for various different conditions. For example, medicines such as wild animal feces and the blood of a gladiator were supposed to increase strength, and part of a dolphin’s penis was supposed to increase virility. These so-called ‘medicines’ have been used at different times in different cultures but have no apparent medical (active) properties. In addition, treatments such as bleeding by leeches to decrease fever or traveling to religious sites such as Lourdes in order to alleviate symptoms have also continued across the years without any obvious understanding of the processes involved. Faith healers are another example of inert treatments ranging from Jesus Christ, Buddha and Krishna. The tradition of faith healers has persisted, although our understanding of the processes involved is very poor.
Such apparently inert interventions and the traditions involved with these practices have lasted over many centuries. In addition, the people involved in these practices have become famous and have gained a degree of credibility. Furthermore, many of the treatments are still believed in. Perhaps, the maintenance of faith both in these interventions and in the people carrying out the treatments suggests that they were actually successful, giving the treatments themselves some validity. Why were they successful? It is possible that there are medically active substances in some of these traditional treatments that were not understood in the past and are still not understood now (e.g. gladiators’ blood may actually contain some still unknown active chemical). It is also possible that the effectiveness of some of these treatments can be understood in terms of modern-day placebo effects.
Recently placebos have been studied more specifically and have been found to have a multitude of effects. For example, placebos have been found to increase performance on a cognitive task (Ross and Buckalew 1983), to be effective in reducing anxiety (Downing and Rickles 1983), and Haas et al. (1959) listed a whole series of areas where
placebos have been shown to have some effect, such as allergies, asthma, cancer, diabetes, enuresis, epilepsy, multiple sclerosis, insomnia, ulcers, obesity, acne, smoking, and dementia.
Perhaps one of the most studied areas in relation to placebo effects is a pain. Beecher (1955), in an early study of the specific effects of placebos in pain reduction, suggested that 30 percent of chronic pain sufferers show relief from placebo when using both subjective (e.g. ‘I feel less pain’) and objective (e.g. ‘You are more mobile’) measures of
pain. In addition, Diamond et al. (1960) reported a sham operation for patients suffering from angina pain. They reported that half the subjects with angina pain were given a sham operation, and half of the subjects were given a real heart bypass operation. The results indicated that pain reduction in both groups was equal, and the authors
concluded that the belief that the individual had had an operation was sufficient to cause pain reduction and alleviation of angina.
Placebos – to be taken out of an understanding of health?
Since the 1940s, research into the effectiveness of drugs has used randomized controlled trials and placebos to assess the real effects of a drug versus the unreal effects. Placebos have been seen as something to take out of the health equation. However, if placebos have a multitude of effects as discussed above, perhaps, rather than being taken out they should be seen as central to health status. For this reason, it is interesting to examine how placebos work.
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