Psychosomatics and Phantom Limbs

Emily Alspector's picture

Welcome to the on-line forum associated with the 2008 senior seminar in Neural and Behavioral Sciences at Bryn Mawr and Haverford Colleges. Its a way to keep conversations going between course meetings, and to do so in a way that makes our conversations available to other who may in turn have interesting thoughts to contribute to them.

Thoughts this week about

and our conversation based on them ....

 

 

From Emily Alspector ...

Hey everyone! Felicia and I want to thank you all for a great discussion tonight! We went in a lot of interesting directions but there is still a lot left to discuss. Here are some things we didn't talk about:

Phantom Limbs and the Self (and/or the afterlife)

  • Cortical reorganization: why might this mechanism have evolved?
  • What do current PLP treatments (mirror therapy, virtual reality) imply about the nature of the condition? About pain in general?
  • How might media/culture affect diagnosis practices?
  • Ethical issues in treating (or not treating) a psychosomatic illness

And some things that were discussed but could possibly be further thought about:

  • Painkiller self-administration and the role of agency
  • How do we define Psychology and Physiology?
  • If side effects become more prevalent when salient, what ethical issues are involved in revealing all information to patients?
  • Are herbal remedies merely placebos?
  • What affect does self-diagnosis (WedMD) and overdiagnosis (RLS, SAD, PMS) have in terms of our individualistic society and group identification?

 

Elliot Rabinowitz's picture

I find many areas of our

I find many areas of our discussion from class last week and thoughts expressed throughout the previous posts to be quite intriguing – Professor Grobstein’s original comments at the beginning of this thread are particularly thought provoking. I agree that the intimate relationship between physiology and psychology is not as clearly recognized as maybe it deserves to be. This has huge implications for the treatment of physical and mental health. I also agree with the point made about symptoms as the brain’s understanding of the body’s state:

“ALL ‘symptoms’ are in fact ‘in the head’. Discomfort and pain are not ever simply effects of disease or other disturbance of the body outside the brain. They are ALWAYS interpretations by the brain and so may or may not have origins in the body outside the brain.”

However, I think that this statement is strikingly different than “ALL symptoms originate in the brain”. This is what Liz picked up on, suggesting numerous good points. Some diseases (at least) do seem to originate outside of the brain. Physiological differences first occur. Then, our perception of these changes follows suite, which of course requires brain power. But what truly seems important to focus on is rather that our brains are commanding tools that we can use to alter the perception of our bodies. Maybe this requires trained practice (e.g. using real-time fMRI data to help patients control cluster headache pain) or brain “trickery” (e.g. using placebos), but either way our brains/minds can generate immense changes in our body (and vice-versa). However, recognizing how powerful and effective our brains can be, I still think there are obvious limitations. Maybe it can work for some forms of pain perception, but maybe not others. Also, could it work to stop invading pathogens or cancer? Maybe the brain can, but I am skeptical as to what extent it may be successful without the aid of drugs. I do think incredible research goes into understanding the biological effects of pharmaceuticals in our bodies, and this research should not be completely denied simply because we cannot completely explain it yet. Sure, some treatment may be due to the placebo effect. But I doubt all of it is, for every symptom, for every disease, for every person.

 

On a lighter note, I found the mirror therapy for phantom limb pain to be awesome. I realize it’s still in preliminary phases, but I just think it’s so cool. It shows how being creative can truly pay off in science – a field in which research seems all too often consumed by high-tech gizmos and complicated technology. One thing I thought about in relation to our placebo discussion is whether a more expensive, designer, custom-made, platinum mirror would work better than a $10 plastic one from the local store. I obviously don’t know, but I’m sure the results would provide even more interesting data to add to this discussion.

Andrea G.'s picture

Culture and disease

I think that at this point in the discussion, I'm going to take a cue from Amelia and also address some of the issues we talked about in class that weren't related to the placebo effect.  One of the things that surprised me most about our discussion last week was my reaction to hypothetical questions about how we treat people with certain disorders.  Something about the idea of insurance companies covering multiple plastic surgeries for a person with Body Dysmorphic Disorder bothers me, while sex reassignment surgery is totally acceptable to me.  I had never considered before just how similar these situations are.  Both of these situations could be explained as cases that merit extensive psychotherapy in order to change "defective" thoughts.  They could just as easily be considered situations in which people have the right to change their physical appearance to match their mental state.  There doesn't seem to be any logic to thinking that BDD needs to be fixed "from the inside" while transgendered individuals should be allowed to get fixed in their outward appearance.  It's an interesting social construction that I'm certainly going to continue thinking about.

I've also always been interested in the idea of culture-bound syndromes, which we brought up briefly in class last week.  I'm fascinated by the idea that while people in various cultures seem to experience similar "symptoms", the label that comes along with having an actual disease makes such a big difference.  My class presentation on PMS last year that we seem to bring up a lot is a great example.  If you ask them without ever mentioning the possibility of a related disorder, women across cultures do seem to have similar experiences around the time of menstruation, but if there is no concept of PMS in their culture, they don't perceive this group of experiences as problematic.  Giving a set of previously unrelated experiences a common label seems to allow us to recognize each symptom and self-diagnose much more readily.  It's interesting to think about what diseases, other than PMS and depression, which we've mentioned, have been spread from our culture across the world due to globalization.

K. Smythe's picture

Placebos

            I think the part of the discussion I found most interesting this week was regarding placebos.  We define placebos as substances that are pharmacologically inert but have an effect based on “suggestion” or mental expectation of results.  It is interesting then that we consider talk therapy as a legitimate treatment and that in no class or discussion I have had has it ever been compared to or brought up in association with placebos.  These types of therapy by definition put no substance (inert or otherwise) into the body, and yet we expect them (and pay lots of money for them) to affect our physical symptoms.  If there is an affect on symptoms is it unreasonable to pay for placebos as well?  We accept CBT therapies as treatment and yet when the idea of disorders being treated with placebos was brought up there was a lot of outrage at the idea.  I suppose the tricky part is that placebos can only work if you believe they will and the word placebo implies “medically inert substance”.  The idea that Professor Grobstein brought up was interesting, but seemed to be met with much criticism.  I’m not sure I understand why we can’t treat people with placebos and simply tell them that the drug they are taking has been shown to be whatever percent affective for people with their disorder.  If a placebo, though pharmacologically inert, creates a physical change in the body for whatever reason, is it actually as placebo?  At the point where it creates a physical change in the body, it is playing some part (albeit much may be the mental effect of the person, but the actual physical placebo is a necessary part) in treatment and seems to be to be by definition not an “inert” substance.

            It is also interesting to relate the idea of placebos to the notion that many of the drugs that we dispense today for so many maladies work through pathways we do know understand or even know sometimes.  We often encourage patients to (as was said during our discussion of psychotherapy) “use what they have themselves” before using drugs to fix a problem; couldn’t placebos be just that, the first attempt at fixing a problem?  If we tried a placebo and it wasn’t having an affect, then the patient (as with any drug treatment) would simply be switched to a different drug therapy (read not a placebo).  I do believe that this could only be appropriate for some symptoms/diseases (if any), and understand that some conditions need treatment immediately, but it is still an interesting idea to throw around, even if I’m not entirely sure that I agree with it.  The mind is a very powerful thing, and even if it means in a sense “tricking” our minds/bodies, it does on some level appeal to me to use the mind first for treatment before pumping our bodies full of chemicals we don’t really understand.

Amelia's picture

PLP as memory

 

Since everyone has talked so much about placebos, I’m going to try to focus my post on some of the questions Felicia and Emily posted about Phantom Limbs and the self. In response to why might cortical reorganization have evolved, one of the theories out there is that since there are areas of the brain which are not getting stimulated anymore, since the limb from which the stimulation arises is no longer there, they want to get stimulation somehow. They do this by being taken over by surrounding brain areas, so that when someone touches their face, their arm neurons fire (which I believe was briefly talked about in class). Also, fMRI studies have shown that this seems to be the case---when someone touches the face of an amputee (I forget the actual appendage) areas of the brain that are normally activated for the arm are also activated, along with the ‘face stimulation’ areas. In individuals who are blind, it has also been found that their areas of sight are activated by hearing or touch stimuli (I, again, forget which one) and this is not seen in individuals with normal sight. It seems that this would evolve so that the brain uses its resources to the best end. There is no reason to reserve brain areas for sight stimulation if there never is any, nor to reserve areas for arm stimulation when there is no arm.

Moving on to phantom limb pain, the current treatments for PLP seem to suggest that pain is centered in the brain, and if you can ‘trick’ the brain into seeing something that isn’t there, pain can be diminished. It’s interesting to think about it in general terms of pain since we know how nociceptive pathways work to tell the brain that it’s in pain. Perhaps chronic PLP could fall under the category of pain (which I mentioned last week) that may be a memory of the pain in the cortex (see the animal research article I posted) and not actually nociceptive. (It would be interesting to see if the nerves are firing from the stump of the amputated limb). The treatments seem to suggest this. If it is simply a memory, maybe seeing the limb overpowers the brains memory of the pain. It keeps coming back because the memory is still imprinted there. Many times we want to say that something is painful because some stimulus is causing pain---but what if the noxious stimulus is the brain? However, while this explanation makes sense it terms of amputees, it is harder to explain in terms of people who are born without limbs and still have pain.

Finally, I want to briefly touch on the idea of media and culture in terms of diagnoses and illnesses (though there is much more to say). It is hard to say if a culture without media bombardment simply won’t diagnose illnesses that are really there or if they will be spared from the diagnoses of illnesses when people see an ad and say ‘oh I have that’. Someone said that many people taking abnormal psych keep diagnosing themselves—it seems that the media does that for us every day. Also, when looking at PMS, why do we consider it a disorder/illness? If we just feel moody, why is that a problem? People that previously hadn’t heard about PMS, as Emily said, might say (after they hear about it) that they have it, but if it wasn’t a problem for them, why do we need to diagnose it as one? Once something is suggested to be a problem, it seems to become one. It seems, from all of this, that while media coverage of certain disorders/illnesses (such as depression in India) may help more people seek treatment, it will always have the negative result of causing people who really have no problem to think that they do. Maybe this is ok for the good of those that are actually sick, but I would propose that it depends on the illness/disorder. If you’ve never heard of restless leg syndrome or PMS it’s probably better for you.

atuttle's picture

Responding to the Vocabulary of illness

I find that the last topic which Amelia broaches is a common theme in several posts: The idea that the extensive medical lexicon and publicity of illness leads to greater expression of these illnesses. I'm hesitant to agree with these assertions, however, given the evidence of other psychosomatic disorders in clinical populations. Although the suggestion of an illness may lead some people to believe that they have a "problem" (i.e., the PMS example that some people talk about), there are also examples of people who suffer for no reason at all.

Recent research looking at Irritable Bowel Syndrome (IBS), for example, enumerates many symptoms and causes for the disorder. Among these correlational factors for the disease is a certain personality type. People who are described as having Alexithymia (the inability to assess emotional states in the self) are more likely to develop psychosomatic illnesses than those who are "in touch" with themselves. By having a working lexicon for illness, it appears that some types of disorders are alleviated.

Although it would make sense that hyping illnesses would increase the number of people who believe they are suffering, not having diagnostic definitions for illness could similarly lead to an increase in suffering. Depressed people in India are depressed whether they are branded with the name or not; by having a medical definition, these people may seek assistance to improve their lives and help them to function better in their daily lives.

 

~Alex Tuttle

Haverford '08

Jenna's picture

Placebo

I found the debate about placebo treatment very interesting.  On one hand I believe that if a treatment works for some people than it should be available to the public.  If that treatment happens to be a sugar pill than that isn’t much different than a traditional treatment.  In fact, if the sugar pill is tricking the mind into activating an endogenous response which causes the therapeutic effect than the sugar pill’s therapeutic effect is physiological just as the traditional therapies would are.  Since all pharmaceuticals manipulate the body’s endogenous functions to produce a therapeutic effect this provides a theoretical reason to believe that many illnesses could be treated by a placebo pill if it could trick the body into producing the same response as the active drug.  However in practice, I think the placebo would only be effective for certain problems which have an emotional component mostly because they could be more susceptible to being effected by the change in mental state which would occur when one believes he or she is receiving treatment.   I agree with the idea someone else mentioned that this process seems similar to cognitive behavioral therapy and could be a better treatment to try first because there are less likely to be side effects when there is no foreign substance entering the body. 

 

The issue of cost for the placebo was brought up and while I do believe that there are some problems with charging a higher price for a drug than what it actually costs to make I think there are strong arguments for why this is necessary.  If the therapeutic effect only occurs when paying more money for the drug I think it is okay to charge more because the person is not only paying for the pill but also for the therapeutic effect.  If research shows that a sugar pill is most effective when someone pays $100 for the drug I think that is similar to a study which says a certain dose of the drug is most effective.  The person is paying to get well and if paying $100 to do that helps than I think it is ultimately ok.  

 

One final interesting topic which the placebo discussion brought up is the question of why our society is so adamantly against believing in the placebo.  I think the news release on Vytorin was interesting because even after the study showed it had no actual effect on reducing heart disease the people who took it believed the study was flawed and it actually did help.  It seems to me that these people are trying hard to prove that they were not “fooled” by a placebo drug.  The question I have is why would it be bad if a placebo helped as long as you improved?  Our society seems much less accepting of psychosomatic illnesses and although I’m not sure why I think it is an interesting question.  

  
ehinchcl's picture

In reading all the above

In reading all the above comments, there are a few things that I found interesting. I wanted to briefly touch on the whole placebo thing-- simply because its gotten so much press above. I think that money is one of the biggest issues for me; otherwise, I'm really pretty okay with doing what Professor Grobstein said and prescribing something that "has been shown to work in 60% of the cases" even if it has been shown to work because of the placebo effect. I think that this whole concept of "placebo" is a little skewed, as has been mentioned above, because if it is indeed doing something then its working and therefore not a placebo as we would generally define it. I think we need to take a second to realize exactly how little we really know about the brain, and the mechanisms of action that a placebo might take. I sort of like to compare a placebo to CBT (hang on, before all you CBT supporters cut the idea down): I think that a placebo allows the brain to in a way 'confront itself.' Because the brain thinks its healing, it actually IS healing-- our brain is an incredibly powerful tool in its own ability to change its health/state. However, to go back to my original point, the issue of cost becomes a problem for me. I feel that a placebo effect will diminish if people don't feel like they have to pay too much for it (since i think payment and drugs are intimately linked in our cultural perception of diagnosis/treatment), but I can't rightfully charge people a lot for a sugar pill. dilemma...

to switch to another topic, the other thing that i want to stress, which was talked about a bit, is this idae that pain in the brain without a bodily source is just as important. We simply do not know enough about the brain to decide what pain merits diagnosis and what is "phantom"-- and why is phantom perceived as less important when it is an actually phenomenon? Since we saw a Grey's anatomy clip in class (man sawing his own foot off), the other side of the story is a different grey's anatomy episode where a drug addict manages to convince everyone of his back pain and get some serious pain killers. I think this is a big source of the dilemma over treating pain that cannot be "diagnosed"- the person might be lying to us. Yes, I admit this is a big problem and I can't really think of a good solution to it... but I think that, much like all mental states, pain is an interpretable thing and is different for everyone. Liz and I were talking in class about how, for a pain study that she had to run, some people found a hot pad against the arm much more painful than an ice bath... and visa versa. I think we need to realize that there is a spectrum for pretty much all mental experience and try to treat and diagnose accordingly.

Mawrtyr2008's picture

Thank you for your post

I think that this whole concept of "placebo" is a little skewed, as has been mentioned above, because if it is indeed doing something then its working and therefore not a placebo as we would generally define it.

I thought this was such an interesting thing you said and it deserved more discussion. I completely agree with your point here, and it brought up a whole host of questions for me.

- Why are we even using the word "placebo" when it's recognized that soemething is changing the experience of symptoms? Placebo used to mean something like "a chemically inert substance" but now it's seeming to take on the meaning of a catchall explanation for mechansisms of action other than those attributed to a specific drug's. (Marissa posed essentially this question in a different format. I liked how she brought up whether the placebo effect could work in tandem with pharmacology... that maybe it isn't a total process, but one part of a much larger process that ends in a patient's relief from a given symptom.)

- Why are we continuing to equate the example of placebo administration with "lying to a patient"? Don't we know just as little about placebo mechanisms of action as we do about SSRI mechanisms of action? If not more!

Stephanie's picture

Taking into Account the Mental & Physical

Throughout our discussion of psychosomatics, I was consistently reminded of the power of the mind/ brain.  I believe no matter what the injury, disease, or symptom (which may all be 'physical'), it is always important to account for the mind/ brain because it can influence our injury, disease, or symptom.  At some during our discussion on Tuesday night, someone mentioned "inquiring about patients' mental state and trying to instill hope & optimism."  I believe doctors should always consider a patient's mental well being when treating any injury, disease, or symptom (physical or mental in nature).  Taking a patient's mental well being into account can assist a doctor in making more appropriate treatment options for the patient.  

These ideas of 'taking into account a patient's mental well being' are displayed in the recent article I read for this upcoming week's discussion on pain- the "How Real is Your Pain? " by, Scott Haig, in TIME, Feb. 20th, 2007.  In this article two people have two drastically different self-report measures about the level of their current pain- the one man who looks like he is the most pain physically, reports feeling "1" on a 1 to 10 scale where 1 is almost no pain and 10 is the worst pain imaginable- this man has arms broken and bent at a weird angles, and he doesn't rate feeling much pain.  On the other hand, a woman with no apparent "visible" injury reports feeling the worst pain ever- 10 (she prefers to use 11 or 12 even).  Now in this specific case, I think mental well being comes into play- our mental states can determine or influence how we feel physically and our physical states can determine or influence  how we feel mentally- I think this interaction is demonstrated by these two patients.  Why would the one patient most visibly in pain report the least pain?  probably b/c his mental well being.   He may interpret this scale differently than other patients and maybe his mind is in a mental state which 'eases his pain.'  Or the woman who is in the most pain?  maybe she is in a mental state that makes her hypersensitive to pain, so any little ache or pain feels much worse because of her current mental state.  Doctors must take into account how each of their mental states is functioning in order to plan the most appropriate treatment and to comfort the patient.    

The mind, brain, and body, and the mental and the physical, cannot be distinctly separated in medicine.  The physical injuries, diseases and symptoms humans may manifest are consistently under the influence of the human mind.  Therefore, I believe we should take all of these aspects into account when treating patients.  

Marissa Patterson's picture

Placebos

I think the concept of placebos is such an interesting one. One thing I was wondering about was the interaction between (perhaps unknown) chemical reactivity of medications and the placebo effect. We mentioned in class that a large portion of the effects of many drugs may be because of a placebo effect. However, what happens when certain drugs (such as antidepressants) work for some people and not others. If someone is depressed and does not seem to have a favorable reaction to, say, Paxil, but then does to Zoloft, then how does the placebo effect fit in here? Is it possible that there is some effect of the way that the doctor introduced the medication or past research/news articles about the drug are impacting the way the person is reacting?

I located a study entitled by de Craen et al 2001 did a randomized double-blind study that gave an analgesic to study participants, with one group being told neutral information about the effects of the drug and the other being told that it is not usually a very effective pain killer. However they did not find any statistical difference between the pain management properties of the pill between the groups. (However there did seem to be increased effectiveness in both groups with the medication as compared to the placebo).

This study also mentions something that I've read before--that pill color, status of person administering drugs, and the route of administration all are factors that can influence therapeutic outcomes. People seem to react differently to medications based on the color and shape of the pills themselves. Often pills containing pseudoephedrine are red because "research has shown" that people find pills of that color to be better decongestants, and I believe this same type of research determined that viagra should be blue, but unfortunately I cannot remember where I read this. An article I found by de Craen et al (1996) does state that "available evidence suggests that green and blue may have more sedative effects and red and orange may have more stimulant effects." (I wonder what this means about viagra being blue...)

There just seem to be so many factors that play a role in how effective medication is to a person. I wonder which of these parts are officially the "placebo effect" and which function in some other capacity. It does make me wonder about the pills that I take quite a bit though, and how effective they may or may not be...

Marissa Patterson's picture

Cholesterol drug doesnt work

Also, this article was front page news on the msnbc website: http://www.msnbc.msn.com/id/23868978/ "Two popular cholesterol drugs may not work."

Apparently Vytorin was studied and "did not improve heart disease even though it worked as intended to lower three key risk factors." (lowered LDL, triglycerides and a measure of artery inflammation called CRP.) I think this brings up an interesting concept, that medications can have a measurable impact on what scientists think they should, but still do not have the impact they are anticipated to. This showcases the necessity of further research into the cause of disease as opposed to just finding drugs that "should work."

Also funny is the fact that many of the people interviewed in the article seem to be of the opinion that the drugs DO work....we just havent quite been doing the studies right and someday they will prove effective. What if they just simply don't work?

 

ebitler's picture

First, I’d like to voice

First, I’d like to voice a few concerns about the following statements:

“…ALL "symptoms" are in fact "in the head"... Recognizing that ALL symptoms originate in the brain seems to me a good starting point for this rethinking.”

My biggest concern with this statement is that not all symptoms originate in the brain. I’m going to talk about pain because that seems to be the general trend on the boards at this point. Most instances of pain originate peripherally, i.e. outside of the brain. The activation of nociceptors stimulates ascending mechanisms that relay information to both sensory and affect regions of the brain, and subsequent descending messages (motor or inhibitive) are relayed back to the periphery. The brain is an integral part of the process, which I believe the former message aimed to highlight. And central activities can result in the experience of pain. Nonetheless, most occasions of pain result from peripheral stimulation and I feel that the former message really detracts from the peripheral contributions to the experience.

I think it also undermines the innumerable other peripheral conditions that give rise to symptoms (physiological and psychosomatic- if you do want to classify pain as psychosomatic). For example, while most of the mechanisms underlying IBS are unknown, ongoing stress and anxiety is thought to be a key component in causing the sometimes severe physiological symptoms. Treating the stress (via removing stressors from daily life, psychotherapy, or anti-anxiety medications) or treating the physiological symptoms alone (via medication) generally will not resolve the other issues. (My understanding is that IBS is generally a lifetime condition that first arises when the person experiences a lot of stress, but that subsequently being less stressed does not make the GI tract 100% better- its like herpes, always there but not always presenting itself).

Using that example as a model for pain treatment leads me to think that treating pain as if it’s “all in one’s head” may cause a doctor to miss the source of pain elsewhere. While I do agree that pain seemingly without cause should not be so strongly stigmatized, I’m also worried that an approach to pain treatment that focuses on the treatment of pain without a search for a peripheral source would to some extent undermine the medical diagnosis practice. (Sure, there are problems with that practice, but I hope to circumnavigate that with my next example). For the longest time people (namely doctors) thought that fibromyalgia was strictly psychosomatic and in the minds of the sufferers. Had doctors stopped looking for a peripheral/biological cause on the assumption that it was a product of the mind, I don’t think the recent advances with drug development would have been made. I know two people who are using Lyrica, and both have said that the drug has really improved their quality of life and that nothing else had worked for them (which I don’t believe would be the case if their improvements were due to a placebo effect).

 

Sooo… now that I’ve said way too much about that, the other thing that I have some reservations about is the discussion of placebos. Like I said, I think that if my two friends were susceptible to placebos then one of the numerous drugs they tried before would have worked if for no reason other than the placebo effect. That the other drugs were so ineffective leads me to believe that the effects of Lyrica are the result of the drug’s mechanisms. I’ve done some research on placebos for other classes, and I know that only about 1/3 of people are “placebo responders,” which means that about 67% of people won’t experience the positive effects of any placebo (and placebos are more effective for pain than most other symptoms, possibly due to classical conditioning). It seems to me that most people are susceptible to the positive benefits of drugs, which leads me to believe that most drugs are more than just placebos without the consideration of placebo-controlled studies (because they do have a lot of additional problems, which have already been brought up).

My biggest concern with placebo prescription is that they’re the easy way out. Rather than having to really search for what may be a difficult to find problem, it’s a lot easier to give someone a placebo and see if they get better on their own. This for me can lead to the same problems as assuming it’s just in their heads. It’s a more time-consuming and money-consuming option to run lots and lots of tests, especially when you think there may not be an underlying physiological source to the problem. But to not do that and just prescribe a placebo instead seems negligent to me. That said, I do think that in a situation where all the resources have been exhausted and a doctor is unable to locate a physiological source of the symptoms, a placebo should be offered (obviously not as such). If nothing else has worked and that might, then it would be unethical to withhold an option that may help the patient, even if that means lying about what the drug is doing.

Paul Grobstein's picture

pains, symptoms, interpretations

I agree that "Discomfort and pain ... are ALWAYS interpretations by the brain and so may or may not have origins in the body outside the brain" is, in isolation, a better statement than "All symptoms originate in the brain". I didn't actually intend by the latter anything other than a short form of the former, and so certainly agree that looking for peripheral causes "should not be pushed by the way-side." My concern was more with current practice, and the tendency to push to the wayside those who have symptoms for which peripheral causes cannot be found. And with a broader tendency to equate internal brain states with peripheral causes.

 

Jessica Krueger's picture

Nonetheless, most occasions

Nonetheless, most occasions of pain result from peripheral stimulation and I feel that the former message really detracts from the peripheral contributions to the experience.

 

Yes, the "cause" may be elsewhere, but I think what we're trying to get at here is that the experience of the pain is constructed in the head, and without mediation by the brain there would be no pain. I guess a good example of this would be referred pain - when pain is experienced in one area of the body but the actual "cause" is elsewhere. I don't think that considering how the brain constructs pain and addressing it at the level of the experience would necessarily preclude addressing the "causal" event, but I think you have a point that in pursuing treatment of the symptoms the original "cause" should not be pushed by the way-side.

Danielle's picture

Treating Symptoms

      I am very interested in the idea relating the need to diagnose illness in order to treat symptoms. Sometimes, symptoms and illness are not related and if no illness or disease is diagnosed then the symptoms are dismissed and said to be a product of the brain. Do we always need to relate illness with symptoms or can symptoms be treated without a diagnosis of disease or pathology? In some cases, a significant number of our symptoms are the result of exposure to the media and its portrayal of disease. We are constantly exposed to a variety of medications that treat a diversity of diseases. Could some of our experienced symptoms be an artifact of our environmental exposure to disease? Our constant exposure to disease and treatments convinces our brain that we could be experiencing symptoms of that disease. Our constant exposure to different diseases through the media makes us concerned about our future experiences with disease. Thus, we are constantly looking for symptoms that might make us catch a disease before it progresses or before symptoms get out of our control. By being overly sensitive to our bodily functions and symptoms, we feel we are taking control over our bodies and being proactive about prolonging a healthy state of being.            

        In order to overcome our preoccupation with disease related symptoms, we take medications like Advil and Tylenol to ease our worries of possible disease and to take a proactive approach. I think that Advil and Tylenol do perform their necessary functions within the body and do change the body in a way that reduces an adverse symptom, but I think these drugs are taken with liberty even in the absence of symptoms related to physical changes within the body. I think that a good portion of the symptoms experienced are artifacts that arise from constant exposure to disease and treatments of disease. The distinction between physical and mental is quite ambiguous being that the brain itself can manifest symptoms that have no physical basis or diagnosis.  

natsu's picture

Should patients get charged for a "placebo"?

Hello all,I wanted to comment on issue of whether it would be appropriate to charge somebody even a little bit of money for a placebo pill.  I personally think that yes, it is reasonable to ask somebody to pay money for a non-drug substance (which we are calling a "placebo" at least for now), if it is true that placebos work because of the situation that the patients are receiving it in.  That is, the common hypothesis is that placebos work for some people (but not all) because they see the lab coats of the physicians and receive encouraging messages which lead patients to completely believe that they will get better.  Not everybody can create this kind of situation.  So if the placebo really works, the patients are in a way paying for the physicians' treatment (i.e. how he prescribed the pill).  It is just like when some people pay so much money to carry a prada bag.  The bags aren't even mad of leather but people feel so much more special because of that little mark on their bag, which is why they pay so much money for the designer's name. Hello all,I wanted to comment on issue of whether it would be appropriate to charge somebody even a little bit of money for a placebo pill.  I personally think that yes, it is reasonable to ask somebody to pay money for a non-drug substance (which we are calling a "placebo" at least for now), if it is true that placebos work because of the situation that the patients are receiving it in.  That is, the common hypothesis is that placebos work for some people (but not all) because they see the lab coats of the physicians and receive encouraging messages which lead patients to completely believe that they will get better.  Not everybody can create this kind of situation.  So if the placebo really works, the patients are in a way paying for the physicians' treatment (i.e. how he prescribed the pill).  It is just like when some people pay so much money to carry a prada bag.  The bags aren't even mad of leather but people feel so much more special because of that little mark on their bag, which is why they pay so much money for the designer's name. 

 

aamen's picture

Placebo Effect

I thought last week’s discussion touched on some really interesting points as well.  The placebo effect and use of placebos in general is something that’s come up in a lot of different classes I’ve taken here – in one class we were actually just discussing it a couple of weeks ago.  I don’t have the exact articles that we were looking at, but basically the idea was that placebo drugs are far more effective than we’ve tended to think in the past.  Obviously we all know that when a new drug is becoming approved it must be shown to lead to significantly greater improvement than a placebo condition.  These articles were looking at one specific drug that was approved after it was shown to be something like 60% more effective than a placebo pill.  However, in the new research, the experimenters were testing the effects of changing the appearance (color, size, etc) of the placebo pill to make it look more ‘legitimate’, and then found that the efficacy of the placebo pill increased by something like half.  They also hypothesized that people in the placebo condition might realize that they’re in this condition based on the fact that they don’t feel the expected side effects of the real drug, so they created placebo pills that would mimic the side effects of the real drug.  With these pills they found an even greater increase in efficacy, so that the effects of the real drug were no longer significant.  Of course, we talked in class about the idea that a placebo pill (even if it’s just salt) is something, and might in itself affect the body in some way.  It seems to me that whatever they were doing to the pill to make it cause side effects might have other effects on the body as well.

 

I also wanted to say in response to Kara’s question of whether placebos can work by causing the brain mimic drug action via endogenous chemicals that I know at least that placebos that have lead to pain relief have been shown to cause activation of the endogenous opioid system – so yes, in that case, the placebo does seem to be doing the same thing that a drug would, just using the brain’s own chemicals, which seems healthier to me anyways (I’m not sure why…).  If it’s the case that the brain contains the resources to fix physical problems by itself, what I’d really like to know is how we might be able to understand and use that so that we don’t have to resort to ‘tricking’ people in a sense with placebo pills.

Mawrtyr2008's picture

Placebo Reevaluation

This was such a great topic. If anything, it continually boggles my mind to realize just how much of brain function is devoted to things we aren’t even aware of most of the time. It’s incredible to me the vast amount of resources our body allocates to things like…. checking to make sure a limb is still attached… taking in as much information as possible through our senses… and constantly filtering it through to our consciousness.

I’d like to begin by addressing Emily and Felicia’s question about whether all pharmacotherapy is “merely” attributed to the placebo effect. While I disagree that all drug action across the board can be attributed to the placebo effect, I think there is a lot of merit in continuing the discussion about whether much of drug action is. I don’t think that “merely” is a useful way to characterize this process, because if so much of drug action and symptom alleviation can be attributed to this effect, it seems more “powerful” and less “mere” to me. It seems to me that for the placebo effect to be normalized enough to be an acceptable, prescribable medical tool, there really needs to be a word change or a drastic reevaluation of the connotations we place with the word “placebo”. There seems to be little controversy when one scientist comments on how little we actually know about mechanisms of action. Why, then, do we get defensive and threatened by the word placebo that concisely summarizes that lack of knowledge? I think a more useful question to ask here would be something like, “Though most people in the scientific community readily acknowledge that we have so much to learn, though many people support the idea of homeopathic healing practices, why is it so hard for us to discuss the placebo effect not just as a phenomenon, but as a tool that can be used effectively in medical practices?” A distilled version of that would be…. “What’s so scary about the placebo effect after all?”.

To comment now on why this is an important subject that merits thoughtful discussion, we need to consider the beneficial uses (which we discussed in class) and also the misuses (which we did not discuss in class) of the placebo effect. The NY Times articles gave a great explanation for the current antibiotic resistance crisis in terms of the placebo effect. The article stated that antibiotics have been used as placebos for patients with viral infections for decades. Clearly, the antibiotic won't cure the viral infection, and so in that respect, it's chemically inert and therefore acting as a placebo. However, the rammifications of physicians prescribing antibiotics for years had dangerous consequences as bacteria became resistent to the drugs. I'm convinced that placebos can have beneficial effects, but even if you're on the fence about that, isn't it enough to consider the consequences of improper use of placebos? No matter how skeptical you are, this example should motivate a discussion.

On another line of thought… I really appreciated insight regarding Body Dysmorphic Disorder as it relates to other human conditions, specifically the trans experience (body modification to align one’s perceived gender with one’s outward appearance), and even perhaps the feminist critique of the female experience (body modification to meet perceived cultural norms). Though that insight opened up a new way of perceiving culture as it relates to medicine, I think we need to be cautioned about overly pathologizing the human experience.

kbrown's picture

Catch 22

Hi everybody,

So I thought last week's discussion brought up some really interesting topics with respect to the ethics surrounding the administration of placebo treatments. With the onset of current literature demonstrating the effectiveness, even superiority of placebo controls in drug treatment studies, scientists and researchers at least, seem to be advocating for a turn to using placebos as medically accepted drug treatments for a variety of disorders and symptoms.

However, as was mentioned in class on tuesday, the use of placebo drugs such as sugar pills as treatments has a whole slue of ethical and moral issues surrounding it which seem, at least at this point, to create a substantial barrier for the use of these types of treatments. One such barriers surrounds the stigma attached to placebo drugs; namely that if one's symptoms are helped by a placebo, the symptom itself must have been psychosomatic, a term which seems to lead people to the conclusion that they had "made up" their symptom, a cause for embarassment for most. However, I think if we are to really advocate the use of placebos, we need to better define the term "psychosomatic". Personally the barrier between psychology and physiology for me is very thin. Often a physical issue will create a psychological problem, as we have found for various types of mental disorders, and likewise, as with "psychosomatic" symptoms, the system simply seems to work in reverse, and a pyschological issue will create a physical problem. Most patients seem to be much happier knowing that a psychological problem was created by some "defect" in their physical system, perhaps because of the commonly heald belief that physical problems can be "fixed" by surgey or drug treatments. If we are to use placebos effectively in the future, without making patients feel "crazy", then the field must redefine psychosomatic for the general public as something more acceptable.

Also, I wonder whether it is possible that placebos, by altering thoughts, emotions, and the psyche of a person more generally, might be able to essentially mimick the action of drugs by using endogenous chemicals in the brain. If this were the case, it might likewise be more acceptable to explain the use of placebos to "encourage" the body to use its own resources to treat physical symptoms.

Another good point that was brought up, and one that I think goes to the crux of why it will be hard in the future to incorporate placebo drugs into regular treatment rituals, is the issues surrounding paying for these placebos. It does not seem ethical to make people pay exorbinant amounts of money for a sugar pill, especially when the amount could be excluding a socioeconomically lower portion of the population from a possibly effective treatment. However, it seems to me that the way that our society deals with medical treatments would not allow for an effective while also cheap drug treatment. Especially because the effectiveness of placebos are so dependent on the patient's belief in the drug's effectiveness, I would venture to say that if the patient felt it was "too easy" to obtain the drug (namely that it didn't put them out financially), that their belief in its effectiveness would be altered. The phrase "you don't get something for nothing" pretty aptly explains the way that most people think about science and medicine today. For one to obtain a cure, some sacrifice must be made. I also think that society's hesitency to use placebo treatments ties into the way in which doctors and scientists are revered in society today as "miracle workers" somehow above normal society. There seems to be a certain sense that treating patients with something that is readily available in any common household would undermine the pedestal on which the medical field and the people in it have been placed. I think that for placebos to work effectivly as an actual medical treatment, the entire midset of the medical science industry, as well as the way that society interacts with it, must be changed, and that is not an easy feat.

Jessica Krueger's picture

And we, both researchers

And we, both researchers and patients, should recognize that much suffering and pain not only originates in the brain but has no explanation other than in the workings of the brain.

 

This is a pretty powerful statement, especially given the insurance and payment issues your additional linked article raised. It also doesnt seem to address the reality that some people have control over their pain where others do not. How many of us have been to the dentist and are instructed to "go away" as a means of dealing with the impending pain? It works for some, I'm sure, or such statements would die out of practice, but such instructions have never had an ameliorative effect on my experience of pain. If it is all mediated by our heads, and our heads are capable of healing themselves, why is there a need for analgesics in the first place?

Further, does the rhetoric of psychology as something a biological organ "does" lessen the importance of suffering? I don't think so, but especially in your Bio 202 class the idea that "the mind" is something the brain does disturb. And not to be a broken record, but what does this do to our use of animal models of pain? The arguement has been raised that animal suffering is worse than human because we can use our "minds" to lessen the pain or at least coneptualize that it will end at some point. Non-verbal animals cannot do this, so is their experience of pain really analogous to ours? (Possibily stupid question) Is animal also mediated/created in their brains?

And I'm just going to be an ass and bring up pain as pleasure - what about the suspension crowd? Human beings seem to be the only creatures who will willingly induce pain in hopes of achieving euphoria. Not surprisingly, not all humans will engage in this behavior. Where does pain as symptom created by the brain fit into this picture?

Paul Grobstein's picture

pain on/in the brain

My point wasn't at all to argue that "psychology as something a biological organ does" should be understood to "lessen the importance of suffering." Very much to the contrary, my point was to argue that discomfort and pain is just as important and needing of attention ("just as real") when doctors can't trace it to an origin elsewhere in the physical body as it is when they can. Nor did I intend to be heard as saying that because pain is "in the brain" it should be possible for the brain, acting on its own, to make it go away. My point instead was that we should no more expect disturbances of the brain to fix themselves then we do disturbances of any other bodily ("physical") organ. Its interesting, no?, that I see recognizing the origin of psychology in the brain as a way to discourage people from either trivializing or overvaluing "psychological" phenomena while you see them as contributing to both. That's worth talking more about.

Yes, I think recognizing the brain dependence of pain can also help in the long run with the so far otherwise intractable problem of deciding whether and how much "non-verbal" organisms (human or otherwise) experience pain. And, for that matter, with understanding pleasure as well, and how pleasure seeking and pain avoidance interact in the behavior of humans and other organisms. All this, though, depends on a distinction between unconscious and conscious nervous system function (which we are indeed building to in Bio 202).

Paul Grobstein's picture

ALL symptoms are psychosomatic

I was particularly impressed by Sharpe, M. and Carson, A. (2001) "Unexplained" somatic symptoms, functional syndromes, and somatization: do we need a paradigm shift? Annals of Internal Medicine 134: 926-930. There is a lot to think more about here, starting with

"Patients seek help from physicians for symptoms. Physicians diagnose diseases to explain the symptoms. Symptoms are the patient's subjective experiences of changes in his or her body, whereas diseases are objectively observable abnormalities in the body. Difficulties arise when the physician can find no pathologically defined disease to explain a patient's somatic symptoms. These symptoms are referred to as poorly understood, or "unexplained," functional or somatization symptoms."

The distinction between "symptoms" and "disease" seems to me a terribly important one, and not only in cases currently labelled "psychosomatic" or "all in the head." An important generalization from contemporary work on the brain, phantom limb phenomena being one striking example, is that ALL "symptoms" are in fact "in the head". Discomfort and pain are not ever simply effects of disease or other disturbance of the body outside the brain. They are ALWAYS interpretations by the brain and so may or may not have origins in the body outside the brain.

So yes, indeed, we need a "paradigm shift," and its helpful along these lines to be reminded, as Sharpe and Carson have done, of some of the history of modern conceptions of symptoms, diseases, and the relation between them. "We need to rekindle the interest of the medical community ... in what is a substantial but neglected area of medical practice": "the psychologically augmented medical consultation".

We need as well changes in research agendas so as "to continue to explore the psychological mechanisms that produce symptoms but integrate these studies with biological investigations. The way in which psychological factors operate need not be cloaked under a mysterious process such as that suggested by 'somatization' but rather explicitly examined."

Most generally, we need to rethink presumptions we all have that create a sharp distinction between physical and mental health, and the associated research and therapeutic agendas associated with each. Recognizing that ALL symptoms originate in the brain seems to me a good starting point for this rethinking. If its all in the brain, then we should stop acting as if things "in the head" are less meaningful than things originating in the body outside the brain (see The Murky Politics of Mind-Body). All therapeutic practice should start with what's in the patient's head, moving from there to the rest of the body when it is helpful. And we, both researchers and patients, should recognize that much suffering and pain not only originates in the brain but has no explanation other than in the workings of the brain. Psychology is no longer distinct from biology, and what goes on in the brain is at least as important to human health as what goes on outside the brain.