Biofeedback and the placebo effect

This article reviews the role of positive expectations, including those engendered by placebos, in symptom relief following medical and surgical procedures, and psychotherapy. Viewing biofeedback as instrument-aided psychotherapy, its procedures are considered in the light of their ability to mobilize the same healing forces as all forms of psychotherapy, with some implications for promising directions of biofeedback research.Slightly modified from an invited address to the Biofeedback Society on March 15, 1981 in Louisville, Kentucky.     

William James, faith, and the placebo effect

Long considered a fact of medicine and of clinical investigation, the placebo effect has recently been challenged. The thought of the great American psychologist and philosopher William James, particularly his understanding of the practical value of faith, helps to illuminate the nature of the placebo effect and the implications of this puzzling phenomenon for understanding healing and the practice of medicine.     

Understanding the placebo effect from an evolutionary perspective

A placebo is a treatment which is not effective through its direct action on the body, but works because of its effect on the patient's beliefs. From an evolutionary perspective, it is initially puzzling why, if people are capable of recovering, they need a placebo to do so. Based on an argument put forward by Humphrey [Great expectations: the evolutionary psychology of faith-healing and the placebo effect. In: Humphrey, N (2002). The mind made flesh. Oxford University Press, Oxford. 255–285], we present simple mathematical models of the placebo effect that involve a trade-off between the costs and benefits of allocating resources to a current problem. These models show why the effect occurs and how its magnitude and timing can depend on different factors. We identify a particular aspect of belief which may govern the effect and conclude that a deeper understanding of why the placebo effect exists may allow it to be invoked more easily in the future.     

A conditioned response model of the placebo effect

A model of the placebo response as a conditioned response(CR) is presented and predictions from this model are listed. Through association with active ingredients(UCS), neutral(CS) places, persons, procedures, and things can come to acquire the ability to reduce pain, anxiety, and depressive responses. One major counterintuitive prediction from the model is that therapists who routinely use active ingredients(UCS) or powerful drugs will get stronger placebo effects than those who routinely use inert ingredients(CS) or weak drugs. Developmentally, placebo responding appears to involve two successive conditioning stages, which may involve first the left and later the right hemisphere in right-handed subjects. The relationship between placebo responding and hypnotizability is discussed.This paper was first presented at the San Diego Biomedical Symposium (invited paper), San Diego, California, November 1977. Later it was presented at a symposium on Non-Specific Effects in Biofeedback, Biofeedback Society of America, Albuquerque, New Mexico, February 1978. It has been published in abbreviated form inProceedings of the San Diego Biomedical Symposium, New York: Academic Press, 1977. I would like to thank G. E. Schwartz for encouraging me to repackage this model for left brain (critical analytic) consumers, and particularly for his encouragement and critical comments during the review process.     

Semiotics and the Technique of Empathy

The subject of this research is one of the basic units of the psychotechnical theory of psychotherapy developed by the author, “immediate experience–empathy.” The structure of empathy is analyzed as a therapist's communicative act. This structure includes a number of elements—an operator of understanding, a mode of experiencing, a sign of experiencing, and so forth. The possibilities for modifying empathic responses and the functions of these modifications in the psychotherapeutic process are considered. Special attention is given to semiotic and expressive aspects of empathy.     

The placebo effect: how the subconscious fits in

The placebo effect is very well known, being replicated in many scientific studies. At the same time, its exact mechanisms still remain unknown. Quite a few hypothetical explanations for the placebo effect have been suggested, including faith, belief, hope, classical conditioning, conscious/subconscious expectation, endorphins, and the meaning response. This article argues that all these explanations may boil down to autosuggestion, in the sense of "communication with the subconscious." An important implication of this is that the placebo effect can in principle be used effectively without the placebo itself, through a direct use of autosuggestion. The benefits of such a strategy are clear: fewer side effects from medications, huge cost savings, no deception of patients, relief of burden on the physician's time, and healing in domains where medication or other therapies are problematic.     

Harnessing the placebo effect: the need for translational research

Laboratory research recently has greatly enhanced the understanding of placebo and nocebo effects by identifying specific neuromodulators and brain areas associated with them. However, little progress has been made in translating this knowledge into improved patient care. Here, we discuss the limitations in our knowledge about placebo (and nocebo) effects and the need for translational research with the aim of guiding physicians in maximizing placebo effects and minimizing nocebo effects in their routine clinical practice. We suggest some strategies for how, when and why interventions to promote beneficial placebo responses might be administered in the clinical setting.     

Predicting potential placebo effect in drug treated subjects

Non-specific responses to treatment (commonly known as placebo response) are pervasive when treating mental illness. Subjects treated with an active drug may respond in part due to non-specific aspects of the treatment, i.e, those not related to the chemical effect of the drug. To determine the extent a subject responds due to the chemical effect of a drug, one must disentangle the specific drug effect from the non-specific placebo effect. This paper presents a unique statistical model that allows for the separate prediction of a specific effect and non-specific effects in drug treated subjects. Data from a clinical trial comparing fluoxetine to a placebo for treating depression is used to illustrate this methodology.     

Semiotics of a Superorganism

Darwinian evolution, as it was first conceived, has two dimensions: adaptation, that is, selection based upon “apt function”, defined as the “good fit” between an organism’s metabolic and biological demands and the environment in which it is embedded; and heredity, the transmissible memory of past apt function. Modern Darwinism has come to focus almost exclusively on hereditary memory, eclipsing the—arguably still-problematic—phenomenon of adaptation. As a result, modern Darwinism retains, at its core, certain incoherencies that, as long as they remain unresolved, preclude the emergence of a fully-coherent theory of evolution. Resolving the incoherencies will involve clarifying the relationship between embodied memory and apt function. In short, adaptation is a problem of semiotics: the organism must interpret the environment to fit well into it. This is well-illustrated by the constructed environments built by colonies of social insects, such as hives or nests, and the ancillary structures that contain them, forming an organism-like system known as a superorganism. The superorganism is marked by a kind of extended physiology, in that these constructed environments often serve as adaptive interfaces between the nest and ambient environment, and are constructed to manage the matter and energy flows between environments that constitute the process of adaptation. These constructed environments are also semiotic phenomena: interpretive structures, governed by information flow between the member insects and the structures they build. I review our findings on one such example: the mounds built by the fungus-cultivating termites of the genus Macrotermes. These structures are dynamic forms that are sustained by flows of soil from deep horizons up into the mound. The form, and hence the function, of the mound is determined by several environmental cues, most notably water and wind, as well as how termites interpret these cues, and signals that flow between termites, both directly and vicariously through the structures they build.     

Molecular Semiotics toward the Emergence of Life

Molecular imprints of organisms serving as both the agents and the products of the underlying sign activities are quantum mechanical in their origins. In particular, molecules in any reaction networks constituting a biological organism are semiotic or context-dependent in the sense that their activities reside within the proper coordination of the entire networks. The origin of life could have been related to a specific aspect of molecular semiotics, especially in the transition from molecules as the physical symbols of material units to molecules as the semiotic signs having the capacity of pointing to something else other than the molecules themselves. Quantum mechanical underpinning of the molecular imprints leading to the emergence of life is in the appraisal of the material capacities of both coherent assimilation and decoherent dissociation already latent in the imprints. One empirical evidence suggesting the likelihood of both coherent assimilation and decoherent dissociation in prebiotic settings could have been found in synthetic chemical reactions running in hydrothermal circulation of seawater through hot vents in the Haedean ocean on the primitive Earth.     

Cultural variations in the placebo effect: ulcers, anxiety, and blood pressure

An analysis of the control groups in double-blind trials of medicines demonstrates broad variation--from 0 to 100 percent--in placebo effectiveness rates for the same treatment for the same condition. In two cases considered here, drug healing rates covary with placebo healing rates; placebo healing is the ultimate and inescapable "complementary medicine." Several factors can account for the dramatic variation in placebo healing rates, including cultural ones. But because variation differs by illness, large placebo effects for one condition do not necessarily anticipate large placebo effects for other conditions as well. Deeper understanding of the intimate relationship between cultural and biological processes will require close ethnographic scrutiny of the meaningfulness of medical treatment in different societies.     

The placebo effect and the autonomic nervous system: evidence for an intimate relationship

For many subjectively experienced outcomes, such as pain and depression, rather large placebo effects have been reported. However, there is increasing evidence that placebo interventions also affect end-organ functions regulated by the autonomic nervous system (ANS). After discussing three psychological models for autonomic placebo effects, this article provides an anatomical framework of the autonomic system and then critically reviews the relevant placebo studies in the field, thereby focusing on gastrointestinal, cardiovascular and pulmonary functions. The findings indicate that several autonomic organ functions can indeed be altered by verbal suggestions delivered during placebo and nocebo interventions. In addition, three experimental studies provide evidence for organ-specific effects, in agreement with the current knowledge on the central control of the ANS. It is suggested that the placebo effects on autonomic organ functions are best explained by the model of 'implicit affordance', which assumes that placebo effects are dependent on 'lived experience' rather than on the conscious representation of expected outcomes. Nevertheless, more studies will be needed to further elucidate psychological and neurobiological pathways involved in autonomic placebo effects.