Articles

The Placebo Narrative

Science journalist Sharon Begley wrote a recent piece in The Saturday Evening Post about Placebo Power. The piece, while generally better than the typical popular writing on placebos, still falls into the standard placebo narrative that is ubiquitous in the mainstream media. The article is virtually identical to a dozen other articles I have read on placebo effects in the popular press, and most significantly fails to even question that narrative.

Begley is generally one of the better science journalists, although I have had my disagreements with her – specifically over her attitude toward the relationship between skeptics and the media. She seems to have a distorted and negative view of skeptics and does not think that the media can or should help us in our “debunking crusade.” (The term itself speaks of a fundamental misunderstanding of the modern skeptical movement.)

I have also parted ways with Begley over her view of the relationship between science and medicine. She seems to have a fairly negative view of doctors, fueled in part by her imperfect grasp of medical science. This is the risk with even the best lay science journalists – science is often complex and it is difficult to master the nuances if you are not an expert and steeped in the evidence and the community. Further there is a tendency for people in general (including journalists) to go along with an appealing and available narrative. (For journalists those narratives that are appealing are the ones that make good headlines.) These shortcomings are present throughout her recent article on placebos.

I will start with what the article does well – break down several reasonably established mechanisms for certain placebo effects. These include endorphin release for pain, dopamine release which serves as both a reward signal and also may temporarily reduce certain symptoms of Parkinson’s disease, those caused by a lack of dopamine (although I consider this evidence preliminary), conditioning, and ritual. That is where she does better than most. Still, she follows the standard narrative of proclaiming in breathless terms the surprising power of “the placebo effect” without putting it into a reasonable perspective, or mentioning very high profile data that tells us what placebo effects are not. She writes:

“It is tempting to say that “mere thought” or “mere belief” caused these patients to feel and function better, just as the child’s trust in her mother made her knee feel better and our belief that little white pills will relieve a headache made the calcium tablet do so, even though it contained not a speck of headache-fighting medication. But if doctors and scientists have learned one thing about the placebo response or placebo effect, it is this: There is nothing “mere” about how thoughts, beliefs, and the power of the mind affect the body.”

And there is the standard narrative. I don’t think it is nitpicking to complain about the term “the placebo response or placebo effect” in the singular, which Begley uses throughout her piece. There are many placebo effects, which are different for different conditions. I know it’s probably hopeless at this point to expect general use to change – “the placebo effect” is likely to remain a common vernacular short hand. However, in an article entirely on placebos such distinctions should be made explicitly clear.

The only proper reference of “the placebo response” is the outcome measured in the placebo arm of a clinical trial, where use of the singular is proper because the study is measuring a net combined placebo effect. When we start talking about the placebo phenomenon, however, we have to start talking about placebo effects in the plural. One of the major conceptual problems with the placebo narrative is conflating the placebo effect that is measured in a clinical trial with all the various placebo effects that may make up that measured response.

This is where the placebo narrative almost always breaks down – popular writers like Begley talk about physiological mechanisms like endorphins and dopamine without mentioning all the other effects that are being measured in  those clinical trials they are citing as evidence for how powerful those mechanisms are. What is measured in the placebo response includes things like reporting bias, or the desire of subjects to feel better, to please their doctor or the researcher, and to justify their prior decisions (to trust the doctor, take the treatment, enter the study, etc.). Begley fails to distinguish, in other words, between the pain that patients feel and the pain that they report. In studies we never know and cannot measure how much pain patients feel, only how much pain they report. Anything that would affect that reporting will also be lumped into “the placebo response” that is measured in the placebo arm of the study.

This is not quibbling. There is good reason to believe that reporting bias may be the major component of measured placebo effects.

Begley also fails to mention non-specific responses. Anxiety reduction from the belief that one is getting treated can certainly improve one’s mood and outlook on their symptoms (and their reporting of symptoms). Being in a study also involves getting medical attention and is associated with better self-care as well. This is partly the Hawthorne effect – looking to see how patients do is likely to have an effect all by itself, improving compliance and self-care, for example.

I do have to give Begley credit for referring to “the placebo effect on pain” in one instance in her article. This is at least better than most. When discussing specific physiological mechanisms for certain placebo effects, it must be qualified what outcome is being considered. Placebo effects for pain may not be relevant at all to placebo effects for any other condition. Such articles also frequently fail to mention that placebo effects for pain tend to be much higher in magnitude than for other outcomes. In fact – placebo effects are generally restricted to subjective outcomes (ones, probably not by coincidence, that are dependent on reporting and cannot be objectively measured).

In fact Begley did not mention the now famous (or infamous, I guess, depending on your perspective) study by Kaptchuk in which he studied both objective and subjective outcomes in asthma in response to active and placebo interventions. The results – there was a measured placebo response to subjective outcomes, but none for objective outcomes. Asthma is a condition susceptible to things like anxiety and expectation – so it provided a good opportunity to demonstrate objective improvement from placebo interventions, but showed none. This study, while very telling, does not fit the placebo narrative that journalists like to tell, and so is often absent from such articles or misinterpreted when present.

Begley does mention the “placebo effect without deception” study. There are two main problems with citing this study the way Begley (and almost every media report about it) does, as pointed out previously here by David Gorski. The first is that the effect size is small (slight improvement), and may not even be clinically relevant. They were also barely statistically significant, and one outcome (quality of life) was not significant. These are unimpressive outcomes. Second – the placebo without deception wasn’t quite deception free as claimed. Subjects getting open-label placebo were told:

“Additionally, patients were told that “placebo pills, something like sugar pills, have been shown in rigorous clinical testing to produce significant mind-body self-healing processes.””

The bit about “rigorous clinical testing” and “significant mild-body self-healing processes” profoundly overstates and misrepresents the evidence. In other words – it’s deception. It’s just deception with plausible deniability. This hardly settles the issue about the effects of “open label placebos” without deception. But it does fit nicely into the placebo narrative, and Begley dutifully reports the standard presentation of this study without a hint of journalistic skepticism.

Conclusion

I had the pleasure of interviewing Christopher Hitchens a few years ago. He had a dim view of journalists in general, and for me one of his most memorable observations was that journalists generally accept the narratives of the day that are handed to them. Precious few do the hard work of investigative journalism to find something closer to the true story. Based on my experience I have to agree.

Unfortunately the placebo narrative that Begley regurgitates is now well-established in the media and we are likely to read some version of it over and over again. I have become a bit harsher over time on journalists for doing this because there are many articles, by experts, just a Google search away, that point out the various flaws in this narrative. Those skeptics that Begley seems to dismiss have done the hard work for her and other journalists of actually reading the original research, digging down to the salient details, and teasing out the nuances that make all the difference to a proper interpretation of a complex clinical issue.

NOTE: Orac has also weighed in on Begley’s article.

Posted in: Science and Medicine, Science and the Media

Leave a Comment (60) ↓

60 thoughts on “The Placebo Narrative

  1. windriven says:

    “This is the risk with even the best lay science journalists – science is often complex and it is difficult to master the nuances if you are not an expert and steeped in the evidence and the community.”

    So only the priesthood should write about the priesthood, only the combat veteran should report upon the war? Science is not a philosophical structure for discovering the truth, it is a community of practitioners whose pronouncements should be accepted as revealed truth because the fourth estate is too dim to interpret them and the canaille to dim to understand?

    I call BS.

    There is nothing inherently complex about the scientific method; the complexity lies much deeper at the front lines of scientific work. But those nuances aren’t the issue here; we aren’t talking about the intricacies of BRCA1 biochemistry, we’re talking about building the case for people to understand that their subjective reckoning is not necessarily an accurate perception of objective reality. That may be an uncomfortable message for many people but it is certainly not one beyond their grasp.

  2. mousethatroared says:

    I second that motion. :)

  3. Winddriven wrote:”So only the priesthood should write about the priesthood, ”

    Straw man – I never said that. I am simply pointing out a very real problem when non-scientists write about science. And it is not the scientific method that is complex – it is the details of the topic they are writing about. I documented above all the nuances that Begley missed. I explicitly made my point with numerous examples.

    I say this as a science journalist myself, who writes and talks outside my area of expertise – but always with great care, deference to the actual experts, and only after sufficient study. Even then – I make mistakes because I don’t understand the nuances of those fields. And when I am corrected – I make the appropriate corrections and update my knowledge.

    I am advocating science journalists to be more careful, to appreciate the task at hand, and not to just accept an easy narrative. I honestly think I made this all perfectly clear above – so I have to call BS back at you.

    Having said that I agree with your last statement about subjective experience vs objective reality (and have written extensively about this). These notions are not, however, mutually exclusive (therefore you are making a false dichotomy). You have to understand both critical thinking and the technical details of the subject.

  4. WilliamLawrenceUtridge says:

    You interviewed Christopher Hitchens? Linkity link link link please!!!

    So only the priesthood should write about the priesthood, only the combat veteran should report upon the war? Science is not a philosophical structure for discovering the truth, it is a community of practitioners whose pronouncements should be accepted as revealed truth because the fourth estate is too dim to interpret them and the canaille to dim to understand?

    I don’t think that’s the message, I think the message is more “if you want an adequately comprehensive and accurate view of (the priesthood, combat veterans, science) either a (priest, combat veteran, scientist) or someone who spends a large amount of time understanding and mastering the material (let’s call them a “scholar”) can master the nuances. Certainly a reporter could do this, but unlike the (priest, veteran, scientist, scholar), their day job involves more than one priority and study of more than one subject. Most reporters simply can’t spend enough time on one topic to get the same degree of understanding as a (priest, veteran, scientist, scholar). And neither reporter nor scholar will ever match the visceral experiential learning of someone who actually does the actual job.

    While the scientific method in principle is simple, as you note, the application of the scientific method is extremely complex, and often requires years of study and mastery to understand why a specific tool is used, how it works, and how it can go wrong. There’s a difference between “that needs a control group” and the actual specifications for what the control and control group should look like. The only reason I feel comfortable making pronouncements about acupuncture control groups is because their made up face medicine has no detail, no nitty-gritty substance or understanding to complicate reality. It’s magical garbage trying to wear the lab coat of a scientist.

    I think Dr. Novella did a good job of enumerating the fine hairs to be split between a naive understanding of the placebo effect, and the real, meaningful differences between the placebo group and the treatment group. It introduced me to new naunces of placebos and data measurement for clinical trials in general let alone for a specific condition. Put another way, I think Dr. Novella wasn’t talking about my first “that needs a control group” case, I think he was getting much closer to the complexities of the placebo effect as it approaches (to take your example) the “intricacies of BRCA1 biochemistry”.

  5. WilliamLawrenceUtridge says:

    Oops, “made up face medicine” should be “made up fake medicine”.

    And again – link to interview with Christopher Hitchens! It’s like watching Joss Whedon and Brian Michael Bendis discuss the intricacies of storytelling :)

    If there is a heaven, I will get to spend eternity watching Christopher Hitchens, Steve Novella, Joss Whedon and Brian Michael Bendis write a comic book about science :) :)

  6. dandover says:

    You interviewed Christopher Hitchens? Linkity link link link please!!!

    I second that motion.

  7. The entire interview is available as a pay per download here (Uncut #2) http://www.theskepticsguide.org/store.aspx

    An excerpt can be found here: http://www.theskepticsguide.org/archive/podcastinfo.aspx?mid=1&pid=82 (but you will miss the filthy limericks by Hitchens)

    While I’m at it – here is an interview with Sharon Begley: http://www.theskepticsguide.org/archive/podcastinfo.aspx?mid=1&pid=166

  8. mousethatroared says:

    The journalist is clearly mistaken in several parts of her article on…the first page. Yet you appear to spend the first three paragraphs or more of your post attempting to undermine her credibility. Why not just point out her mistakes and let your audience decide for themselves whether her information or yours is more credible? If you are really attached to your narrative theme, follow up with that. But all the credibility stuff is a distraction, at best.

  9. windriven says:

    @Dr. Novella

    “Straw man – I never said that.”

    “This is the risk with even the best lay science journalists – science is often complex and it is difficult to master the nuances if you are not an expert and steeped in the evidence and the community.”

    Hmmmmm. I’ll let your words speak for themselves.

    Placebo effects are not manifestations of arcane principles of physics or biology, they are understandable by anyone of reasonable intelligence and education. As an aside, populations that don’t understand placebo effects arguably include a subset of physicians who, one expects, are “steeped in the evidence and the community.”

    My argument with your argument is that it gives Begley and her ilk an easy out. Good science journalism is difficult. So are most enterprises worthy of human endeavor. Good reporting on any field means first getting the story right and the story of placebo effects is not that difficult to get right.

  10. weing says:

    Begley and the majority of journalists seem to equate skeptics with naysayers. This is intellectual laziness. Skeptics are those that actually read the original research, dig down to the salient details, and tease out the nuances that make all the difference to a proper interpretation of a complex clinical issue. That is hard work. I guess it’s something that Begley and her ilk don’t want to be accused of.

  11. Saying it’s difficult for non-scientists is NOT saying that non-scientist should not report on science. You incorrectly inferred that.

    I am not trying to let journalists off the hook. Read my conclusion – don’t I make that clear?

    You also contradict yourself. Yes, many physicians do not adequately understand placebo effects – because the whole concept, in all its subtle aspects, is complex. So if some physicians don’t understand it, it cannot be that easy for a non-physician to understand.

    Yes – when you break it down, like I have done, the components are not difficult to understand. What is difficult is breaking it down – understanding the difference between what is measured in clinical trials, non-specific effects, illusory effects, vs physiological effects. Also understanding the difference between statistically significant and clinically relevant. Also understanding the difference between pain experienced and pain reported.And also just knowing the literature – knowing about the asthma study and its relevance.

    Knowing to even consider these variables requires experience.

    Yet – I still criticize Begley because others (notably here) have already done the heavy lifting of breaking it down, but she apparently has not availed herself of those resources.

    Mouse – I did not call her credentials into question. I was very charitable to her. I was trying to put her attitude into perspective. It is proper to look at her current article in the context of what she has written before. The reader is still free to decide for themselves on the credibility of the information.

  12. WilliamLawrenceUtridge says:

    The journalist is clearly mistaken in several parts of her article on…the first page. Yet you appear to spend the first three paragraphs or more of your post attempting to undermine her credibility. Why not just point out her mistakes and let your audience decide for themselves whether her information or yours is more credible? If you are really attached to your narrative theme, follow up with that. But all the credibility stuff is a distraction, at best.

    I don’t see Dr. Novella’s discussions of “the” placebo effect as attacks on Begley’s credibility, I read them as pointing out nuances, wrinkles and complications in “the” placebo effect that Begley misses – perhaps because of lack of understanding, perhaps because writing a popular piece requires simplification. Pointing out that a reporter lacks the experience and expertise of a specialist, scholar or doctor isn’t undermining in my opinion. I read it as a series of “yes, but” points, or as Dr. Goldacre puts it, “I think you’ll find it’s a bit more complicated than that“. Shameless plug for Big T-shirt.

    I come to SBM because I want to know what doctors and other experts (more than I anyway) think about topics. I’m less interested in hearing simple facts than I am in hearing the criticisms, and reasoning behind the criticisms. I’m keenly interested in what comes after the “but”, and I usually get it here. If that means a post spends time pointing out the difference in experience and knowledge between a doctor and a reporter, I think it’s a valid point. Credibility is important, because if done properly and responsibly (which means showing your work – saying why something is wrong, not just that it is) it speaks to the amount of trust we can and should place in someone’s work and opinion.

    Placebo effects are not manifestations of arcane principles of physics or biology, they are understandable by anyone of reasonable intelligence and education.

    Windriven, is this a quote of Dr. Novella, or your own analysis? I can’t find it in the article but it’s got a dangling quotation mark that confuses me.

    Good reporting on any field means first getting the story right and the story of placebo effects is not that difficult to get right.

    I read Dr. Novella’s original post as evidence that it is in fact not easy to get right, that “the” placebo effect is actually quite complicated for many reasons. But journalism of necessity places topics into “stories”, which means framing, background, assumptions and cultural baggage must be assumed (usually) or addressed (rarely – because most people like a simple story that doesn’t challenge their assumptions). If it’s hard for the journalist writing the story to “get it right”, I imagine it’s even harder for the editor – who doesn’t have the background of a scholar (per my original comment) or the research of the journalist, but is responsible for ensuring the newspaper sells well. Which usually means simple stories that do not challenge assumptions.

  13. mousethatroared says:

    Calling someone’s credentials into question is different that attempting to undermine their credibility. By mentioning that she seems to have a negative view of skeptics, that she doesn’t believe the media should help skeptics debunk claims, that she seems to have a negative view of doctors…these all come across, to me, as an attempt to establish her as a bias source.

    Certainly, establishing a source as bias can, in some cases, be informative, particularly when it’s difficult to tell which information is really more accurate. But I don’t think it’s needed in this case. I don’t think the accuracy of your information is in question. I don’t think that your premise is that the reporter is incorrect due to bias. Is it?

    It seems that you are saying that the thing that separates good science reporting from bad science reporting is a genuinely nuanced understanding of the issues and a willingness to abandon the “narrative” to stay faithful to that nuance. That is an excellent point. A reminder that stories that fit an expected narrative should raise a red flag is valuable.

    The question of whether a doctor or journalist is more likely to have a nuanced understanding? (doctor or laymen – Dr. Gorski or Dr. Wakefield, Sharon Begley or Brian Deer) isn’t helpful in determining whether the article meets your criteria of good scientific journalism. The question of Begley being against or for skeptics is not particularly helpful in understanding how her article either succeeds or fails to meet your criteria for good scientific journalism.

    The fact that you lead with those two points, I think, does more to distract from your premise than support it.

  14. mousethatroared says:

    WLU – I don’t think you get what I was saying.

  15. Earthman says:

    What a well written article. Superb.

  16. MTR – sounds like mostly a style issue. I generally begin with some context, whatever that is. Often I will link to other articles I think are relevant to establish a person’s attitude or biases. I don’t think it’s distracting at all.

    My first paragraph is the thesis of the blog post (so I didn’t lead with the points in question). It’s actually the second and third paragraphs that give a little background on Begley. We can disagree about its relevance, but I think pointing out what she thinks the role of science journalism is and isn’t, and her attitude toward medical science, is highly relevant. And in the third paragraph I segue into what you agree are the salient points of the article.

  17. Earthman says:

    “they are understandable by anyone of reasonable intelligence and education.”

    which begs the question whether journalists have such intelligence or education

  18. mousethatroared says:

    I would call it more a difference of opinion on strategy than style. :) It certainly is true that strategies can be a matter of personal preference. Of course, that doesn’t save you from my attempting to point out pros and cons of particular strategies. ;)

  19. mousethatroared says:

    oh, two emoticons? how perky of me. sorry about that.

  20. Quill says:

    Sharon Begley has been writing about science for years, receiving an honorary degree and lots of awards for her work. Her bio says she received a B.A. from Yale in 1977. Does anyone know what the degree was in?

    So she’s a lay writer with over three decades of experience. And I’m to understand she still doesn’t know how to write an article such as this, a topic on which she’s authored books, too, that doesn’t contain fundamental errors? How would she have done it better? Should she have started her career with at least a Master’s in Science in, say, Chemistry, or something?

    One last thing about the original article itself that seems to have been overlooked: journalists are never the final author of the articles under their byline, at least in a place like the Saturday Evening Post. Their work has almost always been picked through by an editor, read backward by a copy editor, and often many changes made. Who knows what mischief might have happened in the process, as editors, although higher on the masthead, are viewed with even greater suspicion than journalists. ;-)

  21. WilliamLawrenceUtridge says:

    WLU – I don’t think you get what I was saying.

    Quite possibly, I’m reading pretty quickly today. I’ll try to make time to re-read more carefully.

  22. windriven says:

    @WLU

    “Windriven, is this a quote of Dr. Novella, or your own analysis? I can’t find it in the article but it’s got a dangling quotation mark that confuses me.”

    My own analysis – and I’m quite comfortable with it. Placebo effects are not particularly complicated – though quantifying them in specific contexts certainly can be.

  23. ConspicuousCarl says:

    The description of the various ways placebos can affect us reminds me of those lists you sometimes see in chain emails and pulp magazines, which describe the versatility of some common substance or object. They are titled something like “15 Uses for Pineapple Juices” (I am making this up, don’t actually do this), and describe how pineapple juice can be used as everything from a solvent to a disinfectant to a lubricant. That can be interesting but they usually fail to point out that, though pineapple juice has so many different effects, they are actually mild effects and it actually doesn’t work very well for ANY of those things.

  24. pmoran says:

    I thought she did remarkably well for a journalist.

    She should have emphasized that placebos won’t help much, or probably not at all with the progress of serious illnesses (although they may help with the symptoms thereof).

    I sort of agree with your referring to the “breathless”, somewhat overblown quality to it all. OTOH we really do not have any way of being sure how strong placebo responses can be under very favorable conditions. A clinical trial cannot easily mimic those, and its conclusions average everything out. Some susceptible individuals may be displaying much stronger responses than others.

    She should have pointed out that most of the benefits from sham surgery in the knee osteoarthritis study could be from spontaneous fluctuation in symptoms, and the fact that patients will tend to get enrolled in such studies during a bad patch of symptoms and inevitably better at some later endpoints whatever you do. That study has been universally badly misrepresented.

    She also, that I can recall, failed to mention as you do the nutty problem of distinguishing placebo responses from reporting bias in those comparisons where these two are presumably the only likely major effects i.e. where placebo is compared to usual care of waiting list control — not done in the osteoarthritis study.. .

    However she did cover a lot of the research supporting the likelihood of a “real” component to the placebo and this can only be reinforced by the various non-specific beneficial influences that will usually go along with it, and are an inescapable part of more complex “treatment” methods.

    I know that it was one of the conclusions of the Hrobjartsson meta-analysis, but it is counter-intuititive to me that placebos would preferentially affect pain (or even Parkinsonism!) but not most or all other subjective symptoms. I suspect that a lot of the placebo “effect” in normal life, certainly with milder symptoms, may be simply from not focusing on symptoms so much having taken action regarding them and getting on with the normal business of life.

  25. ConspicuousCarl says:

    pmoran on 16 Jan 2013 at 4:02 pm
    I thought she did remarkably well for a
    journalist.

    “The doctor made several errors during my heart surgery, but I thought he did remarkably well for a heart surgeon.”

    Also, I would totally accept this level of accuracy if placebo effects had just been discovered recently and this was a “first draft of history” being rushed to the press. But quite a lot of information has been available for a while, and the journalist in question is not new to the subject. Furthermore, the errors are not random. They are all in line with the common misunderstanding of placebos than which we constantly lament that people will never learn better.

  26. Quill says:

    Making an analogy between journalists and heart surgeons? Sounds bad to me. If a journalist could be crossed with the heart surgeon it would improve the journalist, but it would deteriorate the surgeon.

  27. ConspicuousCarl says:

    I don’t think you understand how analogies work.

  28. Quill says:

    lol I don’t think you understand humor in this context.

  29. Peter T. Hansen says:

    Of all the news cases I’ve had first-hand knowledge about (maybe around 10), the journalists have been close to being absolutely clueless about what they reported about. From an outsiders perspective they might sound like they were reporting the facts, but as in insider it just seems like a surreal version of reality.

    I hope surgeons have a slightly better understanding of what they do ;-)

  30. mousethatroared says:

    pmoran “I thought she did remarkably well for a journalist.”

    ouch!

  31. ConspicuousCarl says:

    Good grief, my humor-detection system was most definitely experiencing trouble earlier today. I’ll have to re-install it back to nothing but chicken jokes and spend the rest of the night running updates.

  32. Quill says:

    Wow, you’re starts with chicken jokes on a clean install? I am impressed. I’ve got to go all the way back to fart jokes.

    Although in that vein, I saw a good joke today on a billboard that has chickens in it. It’s an NRA joke.

    “Which came first, the chicken or the egg?”
    Answer: “More guns!”

  33. RobLL says:

    “I have also parted ways with Begley over her view of the relationship between science and medicine. She seems to have a fairly negative view of doctors, fueled in part by her imperfect grasp of medical science.”

    Many of us have ‘fairly negative views of doctors’. In our experience we do not find ‘science based medicine’ doctors. Just in the last few/several years I have had life-threatening and other merely major serious side effects from doctors who ignored known side effects in medications the Rx’d. In my experience it is the exception, and not the usual to find doctors who do not have a ‘imperfect grasp of medical science’. I will provide details via email if you wish. The errors were egregious.

  34. pmoran says:

    CC:Also, I would totally accept this level of accuracy if placebo effects had just been discovered recently and this was a “first draft of history” being rushed to the press. But quite a lot of information has been available for a while, and the journalist in question is not new to the subject. Furthermore, the errors are not random. They are all in line with the common misunderstanding of placebos than which we constantly lament that people will never learn better.

    The most telling research is quite recent. And what do you all expect? It’s journalism. It indeed tells a story, one which has to entertain, as well as inform. More tentative, scientific approaches are long-winded and much less fun.

    And is there not a asymmetrical, parallel “narrative”within the skeptical community, which has its own reasons for not coming to grips with the implications of recent placebo research, finding it most inconvenient that it should be blurring the distinction between what “works” and what doesn’t. Medical skepticism has traditionally held that a quite clear distinction can be made, but as research piles upon research the less obviously true that has become (at the subjective end of medicine, only, I hasten to add. )

    Comments such as the one I have just made are always misinterpreted, with great hostility, as a proposal for more placebo or CAM use within the mainstream.

    This merely indicates how little skeptics have been required to think about “matters arising”.

    That does not necessarily follow at all, yet there are other very interesting ramifications. I have pointed out how the placebo concept helps people better understand and assess the worth of the CAM testimonial. It allows us to be less begrudging of the benefits that some claim from CAM, something that has always been a terrible barrier to communication. Again I say that nothing is more hostile to medical pseudoscience than that its claims are a reflection of the activity of placebo and non- specific influences (when not due to other common misinterpretations).

    Steve’s essentially non-committal approach, while not so subtlely suggesting ” a big fuss over nothing ” transmits the same “no need to bother going there (yet), folks!” message. Shelve that for another day!

    (Says Steve: This is not quibbling. There is good reason to believe that reporting bias may be the major component of measured placebo effects. I say, with the support of many others including all placebo researchers, that there are at least equally good reasons (neurotransmitter activity, morphine sparing etc) and as much plausibility for saying that symptomatic relief is a major component. This has the virtue of also being less disrespectful, alienating, confronting and dissonance-creating with the public. But it is the truth of it all that we should be seeking in the first instance.)

    I say, be brave! There is a very strong chance that we will be forced to confront all this one day, whether we like it or not, so let’s be preparing for it. The science becomes more robust by the day.

  35. ConspicuousCarl says:

    Quill on 16 Jan 2013 at 9:02 pm

    Wow, you’re starts with chicken jokes on a clean install? I am impressed. I’ve got to go all the way back to fart jokes.

    Although in that vein, I saw a good joke today on a billboard that has chickens in it. It’s an NRA joke.

    “Which came first, the chicken or the egg?”
    Answer: “More guns!”

    Steve Novella’s answer: I’m not convinced that you need an answer to that question.

  36. ConspicuousCarl says:

    pmoran on 16 Jan 2013 at 11:12 pm

    And is there not a asymmetrical, parallel “narrative”within the skeptical community,

    Irrelevant. Even if true, it wouldn’t excuse the former.

    “The skeptical community” actually has a few streaks of people who tend to give placebo effects too much credit.

    which has its own reasons for not coming to grips with the implications of recent placebo research,

    The implications of placebo research are that placebo effects are temporary, subjective, and in some cases might only be extant on paper.

    finding it most inconvenient that it should be blurring the distinction between what “works” and what doesn’t.

    See, this is where you start to sound like a new age guru.

  37. BillyJoe says:

    Michelle,

    If you had the sort of background on Steven Novella that Steven Novella gave you about Sharon Begley, you would know that providing a background on his subject part of his style, not part of his strategy.
    How’s that for irony, ;)

  38. BillyJoe says:

    windriven,

    You seem to think that the placebo question is simple to understand but, at the same time you completely misunderstand Steven Novella’s explanation of why it is not simple, which you demonstrated by unintentionally presenting the straw man.
    Seems this commentary is full of irony.

  39. mousethatroared says:

    BillyJoe – Style without strategy? Perish the thought.

  40. mousethatroared says:

    Just as aside. Arguments about whether I’m wrong or not or whether it’s SN’s style or not are pointless. I think of the comment box like a focus group*

    You put a piece (article, form, web site) in front of a focus group and they give you their impressions. They are supposed to be a representation of the average viewer. You are trying to get an idea of how the average viewer saw the piece, whether they got the information they needed or were confused, whether they were convinced by your arguments or unimpressed. The idea is, if I had those impressions, there is a good chance that other readers who do not comment and do not read comments, had the same impressions. Same goes for windriven’s concerns.

    Whether you can convince me or yourself that my impression was wrong or mistaken, doesn’t really change whether 10% (whatever) of the readers of this article will had the same impression.

    But it’s just a focus group, often a variety of responses from ‘eh, I think that’s an anomaly. I’m not doing anything’, to ‘well, I’ll consider that the next time I write on the topic’ to ‘Panic! It didn’t occur to me that the logo looked like a swastika!’** can be correct.

    I’m not trying tell SN what he should do with his focus group responses. I will say, if he want to convince folks of his arguments, I hope he responses strategically rather than stylistically. ;)

    *with all the drawbacks of a focus group, too, I’m sure.

    ** luckily not the case here.

  41. I love the way Steve Novella answer all the answers. He always uses reason to argument but still understand the emotional aspect of human being. You are on of the smartest person I “know”, keep the good work !

  42. BillyJoe says:

    Michelle,

    Steven Novella is not exactly a novice at this game but, you never know, an amateur like you ;) might just be able to influence him sufficiently to change his style…I’m sorry…strategy. On the other hand, have you read Orac’s article linked to at the end of Steven Novella’s post? Good luck trying to change his style.

    Jokes aside, I think the preamble/background/scene setting these authors use can be very useful. But, I have to admit, when confronted with some of Orac’s extraordinarily long articles, I sometimes scan the first few paragraphs to get to the meat of the article, especially when I’m pretty familiar with the background issues already.

    ps I haven’t patented that strategy yet, so you are free to use it if you wish. :)

  43. BillyJoe says:

    Michelle,

    (This post is on moderation so some unknown reason so I will try it again….)

    Steven Novella is not exactly a novice at this game but, you never know, an amateur like you ;) might just be able to influence him sufficiently to change his style…I’m sorry…strategy. On the other hand, have you read Orac’s article linked to at the end of Steven Novella’s post? Good luck trying to change his style.

    Jokes aside, I think the preamble/background/scene setting these authors use can be very useful. But, I have to admit, when confronted with some of Orac’s extraordinarily long articles, I sometimes scan the first few paragraphs to get to the meat of the article, especially when I’m pretty familiar with the background issues already.

    ps I haven’t patented that strategy yet, so you are free to use it if you wish. :)

  44. BillyJoe says:

    Michelle,

    (This post is in moderation for some unknown reason so I will try posting it again….)

    Steven Novella is not exactly a novice at this game but, you never know, an amateur like you ;) might just be able to influence him sufficiently to change his style…I’m sorry…strategy. On the other hand, have you read Orac’s article linked to at the end of Steven Novella’s post? Good luck trying to change his style.

    Jokes aside, I think the preamble/background/scene setting these authors use can be very useful. But, I have to admit, when confronted with some of Orac’s extraordinarily long articles, I sometimes scan the first few paragraphs to get to the meat of the article, especially when I’m pretty familiar with the background issues already.

    ps I haven’t patented that strategy yet, so you are free to use it if you wish. :)

  45. pmoran says:

    — finding it most inconvenient that it should be blurring the distinction between what “works” and what doesn’t.

    See, this is where you start to sound like a new age guru.

    Ah, but are you merely shooting one of the messengers, CC?

    Actually, knowing that beneficial placebo and non-specific responses have contributed to the evolution of the extraordinary variety of different medical cultures seriously undermines the whole idea of cultural relativism. It helps explain the very observations upon which that is based.

    We can then look at medicine as having always consisting of a sea of this basic, generic medical activity, onto which scientific medicine is now grafting itself. This in its turn helps explain CAM and the persistence of cultural medicine. This is another area where the placebo can be enlightening, as a good hypothesis should.

  46. Grant Ritchey says:

    The Placebo Response is one of the most misunderstood, over-credited, and fascinating areas of physiology. What is the most up-to-date and accurate book, website, or other reference that covers this subject?

  47. WilliamLawrenceUtridge says:

    And a bit of digging on Dr. Goldacre’s site turned up a recommendation for this book, though it’s not very new.

  48. daedalus2u says:

    Windriven:

    “Placebo effects are not manifestations of arcane principles of physics or biology, they are understandable by anyone of reasonable intelligence and education.”

    and you know this how?

    Why does an inert agent (lactose) relieve the symptoms of nausea (objective and subjective) when subjects are told it will potentiate the symptoms of nausea, yet the same substance potentiates the symptoms of nausea (objective and subjective) when subjects are told it will relieve the symptoms of nausea?

    How does the placebo effect mediate such effects on nausea? If there are no arcane principles of biology involved, there should be a simple explanation.

    The only explanation I know is fairly complicated, and is not the generally accepted mechanism behind placebo effects. That it is not the generally accepted explanation makes it arcane (in my opinion). Do you have a non-arcane explanation?

  49. pmoran says:

    Why does an inert agent (lactose) relieve the symptoms of nausea (objective and subjective) when subjects are told it will potentiate the symptoms of nausea, yet the same substance potentiates the symptoms of nausea (objective and subjective) when subjects are told it will relieve the symptoms of nausea?

    D2, those results run counter to plausibility, general experience, and the results of many clinical studies on the placebo and nocebo.

    Where did you get them? If true, there has to have been a very powerful additional psychological input, not yet revealed.

  50. daedalus2u says:

    PM, these two studies.

    https://www.ncbi.nlm.nih.gov/pubmed/16738082

    https://www.ncbi.nlm.nih.gov/pubmed/15193970

    The problem is not with these studies, the problem is with your conceptualization of what placebo and nocebo effects are such that you consider these effects to be counter-intuitive.

  51. pmoran says:

    PM, these two studies.
    https://www.ncbi.nlm.nih.gov/pubmed/16738082
    https://www.ncbi.nlm.nih.gov/pubmed/15193970
    The problem is not with these studies, the problem is with your conceptualization of what placebo and nocebo effects are such that you consider these effects to be counter-intuitive.

    Let’s see. The latter study came first and its findings contradict itself as well as some of the findings of the second study. Quote—

    “No significant differences were observed among expectation groups for retrospective reports of motion sickness (NP); however, significant differences in EGG responses to drum rotation were obtained. The unexpected results of a univariate analysis of variance (ANOVA) revealed significantly greater gastric tachyarrhythmia and less normal activity, an indication of motion sickness, in the low expectation for sickness conditions.
    CONCLUSION:
    These results suggest that inducing a high expectation for sickness in healthy individuals about to be exposed to provocative motion results in a protective effect from motion sickness following exposure to the stimulus,”

    So there was no statistically significant effect of expectation on symptoms under the conditions of this study, but they say their findings “suggest” this. Why? Because of the EGC findings. However the findings could equally be interpreted also as meaning that EGC findings are not well correlated with motion sickness ( just as some other researchers are saying) and the association with expectancies is due to chance or other artefact.

    The second study is a later one by the same authors and on this occasion (surprise, surprise?) the results now support the favored hypothesis.

    Now, it is possible that when told they are going to get terrible motion sickness, subjects will report very favorably if it turns out not to be so bad after all. I am prepared to accept that as real finding under the conditions that applied in this study although concerned that the researchers are after “interesting” results and have a special interest in this group. It certainly needs confirmation by other authors before being accepted as fact.

    But you also said, and this is what I found counterintuitive and “contradicting a great deal of other research”, ” — yet the same substance potentiates the symptoms of nausea (objective and subjective) when subjects are told it will relieve the symptoms of nausea”.

    The authors are not claiming that and neither can you, because there is no truly non-intervention control group. The groups given placebos may have fared better than would a group with entirely neutral expectations (assuming one could be devised) or perhaps placebo “effects” were simply dampened altogether under the conditions fo the study..

    How is the research coming along?

  52. daedalus2u says:

    PM, my research is coming along great. We have just raised funding to commercialize my “stuff”. So it is on a path to be commercialized now.

    Yes, I misremembered the paper and perhaps conflated some other stuff.

    Nausea is largely mediated by NO, because the smooth muscle of the gut is relaxed by NO, and conditions where you want the gut to empty itself (bad bacteria in the gut) are also conditions of high NO. Early pregnancy is also a high NO state and where high nausea correlates with better outcomes.

    There are few adverse symptoms characterized by high NO, so there are few things that placebos (an inert substance said to make stuff better) actually make worse. Some sickness behaviors are mediated through high NO. Low blood pressure might be another one. I will see if I can find data to that effect.

  53. daedalus2u says:

    I just found this abstract

    http://www.ncbi.nlm.nih.gov/pubmed/17484949

    Which I find quite interesting.

  54. Amalthea says:

    Then multiple chemical sensitivity would be a nocebo effect in most, if not all, cases. Correct?

  55. daedalus2u says:

    Amalthea, yes. I think the MCS is due to low NO which is acutely exacerbated by exposure to things that activate the P450 enzymes and which lower NO still more. I think the acute exposure lowers the NO level outside the compensatory range and physiology just falls apart. Placebos would make MCS better, nocebos would make it worse.

    These are just expectations based on a crude intuition of NO effects. NO effects are much more complicated and idiosyncratic. You can have high NO and low NO simultaneously in tissue compartments separated by a few microns.

    Ischemia first causes low NO as superoxide is generated, then causes high NO as the nitrite reductases are disinhibited by the lack of O2.

  56. WilliamLawrenceUtridge says:

    @daedalus2u
    Congrats on getting to the commercialization stage with your research, that’s a huge step! Awesome for you and your lab.

    @Grant Ritchey
    For some reason the first post I wrote in reply to your request for more information on the placebo effect a) never made it out of moderation and b) seems to have been deleted. Anyway, my suggestions were to look at the articles on Benedetti here on sciencebasedmedicine (plug “Benedetti” into the search box and you’ll see Dr. Hall’s two discussions of him and 3 other articles that mention them) and to search for Dr. Ben Goldacre’s “Bad Science” site, which has a “placebo” category with articles discussing the placebo effect. In addition, above you can see my reply containing a link to an amazon page with a book about the placebo effect that was recommended by Dr. Goldacre.

  57. Amalthea says:

    You guys are teaching me to find answers myself.
    In answer to the question I asked yesterday: Yes, MCS IS a nocebo responce :http://www.medterms.com/script/main/art.asp?articlekey=31482 .
    This view comes from three sources, my own experiences as an accidentally self cured multi-year sufferer of MCS, my experiences with my mother, and from having read Dr. Stephen Barrett’s A Close Look at “Multiple Chemical Sensitivity” published in 1998.

Comments are closed.