Placebos and Psychosomatic Symptoms
Psychosomatic symptoms refer to a mind (psych) and physical body (soma) relationship. Illnesses of psychosomatic nature are caused by mental processes of the sufferer rather than physiological causes. This mind-body dialogue is powerful and is instrumental in both health and diseased states. Perhaps there is a mental aspect to every physical disease, and this possibility has important implications for the way we diagnose, treat and study sickness.
One group of psychosomatic disorders, somatoform disorders, involves symptoms that mimic disease for which there is no identifiable physical cause. Patients with somatization disorder, for example, persistently report various physical symptoms, but these symptoms have no identifiable origin. Similarly, conversion disorder involves neurological symptoms (such as numbness and paralysis) with no corresponding neurological explanation (Sharpe and Carson, 2001).
Most illnesses can be considered to be at least partially psychosomatic, as they involve the mind’s reaction to physical illness. Pain disorder, for example, is characterized by chronic and constant pain and is thought to be caused by psychological stress. Hypochondriasis, or excessive worry about having a serious illness, and body dismorphic disorder both have large psychological components. Other physical symptoms are attributed to psychosomatic illness because they have no known medical explanation, as is the case for fibromyalgia and chronic fatigue syndrome. In addition, emotional stress and anxiety may aggravate existing illness; high blood pressure and back pain are often attributed to the stresses of everyday living. It’s not hard to imagine, then, that classification of psychosomatic illness is difficult due to the wide range of illnesses, issues in diagnosis and co-morbidity, particularly with mood and anxiety disorders.
Interestingly, many diseases considered to be largely psychosomatic are also “modern” or “Western”. Premenstrual syndrome is basically unheard of in the non-developed world, but when women are made aware of this “syndrome” they often identify with the symptoms and self-diagnose themselves with the disease. Similarly, recorded rates of depression are significantly higher in Western cultures, but this could be due in large part to exposure to the disease (Simons 2001). The recent development of drugs for ailments such as chronic fatigue syndrome and restless leg syndrome imply a possible role of media and culture in the development and prevalence of some psychosomatic diseases.
The mind-body interaction demonstrated by psychosomatic illness also plays a role in healing. The placebo effect is the improvement in health not attributable to administered medication or treatment but to an “inert” substance; thus, this healing effect is attributed to psychological processes. The fact that anywhere from 35 to 75 percent of patients find relief from placebos calls into question our understanding of the mechanisms by which these drugs work (Di Blasi and Reilly 2005). Placebo effects are often overlooked or seen as nuisances, used only to prove a drugs efficacy. However, psychological symptoms and reported well-being from placebos are often accompanied by physiological improvements as well, linking the mind and body at a physiological level. While the brain, the immune system and other organ systems differ in their functions and organization, they are undoubtedly connected at a biochemical level.
Why do placebos work to the extent that they do? A psychological hypothesis insists that it’s all in the mind and that we may be able to “think ourselves well”. Going through the process of treatment – seeing a doctor, receiving care and affection – may also trigger physical healing. Perhaps we’re primed to feel better after popping a pill, or maybe the “inert” substance actually stimulates the brain’s analgesics (Talbot 2000). Maybe it’s simply the expectation of relief, the stress-relief that hope brings.
Issues with classification and diagnosis
Several definitions of many of these disorders exist, and the usage of different terms is not consistent in medical literature and practice. Diagnosis of psychosomatic disorders often involves only the exclusion of other illness. How important is it to have a biological basis for diagnosis of disease?
In a diseased state, does the physical disorder have a psychological cause or does the physical disorder cause the psychological symptom? Do all symptoms originate in the brain? In a healing state, what are the possible roles of placebos in treatment of illness? Is the placebo effect purely psychological or could the body be responding to these “chemically inert” substances? How important is it to understand the mechanism of action of drugs?
Culture and illness
How do culture and media shape the public’s understanding of illness?
Power of the prescriber
Doctors are given a lot of power. Should they prescribe medication to alleviate problems they suspect to be purely psychosomatic? What issues may arise for treating or not treating a disorder in the absence of a physiological symptom? Should the prescription of placebos be utilized? If so, what explanation should precede prescription of a placebo? Could the weakening patient-doctor relationship have an effect on the success of drugs?
The majority of class and forum discussion was centered on placebo treatments. One major barrier seems to be the stigma attached to them – that is, if a placebo alleviates the symptom, the original problem was psychosomatic, which is embarrassing for many. The hesitation of the medical community to accept placebo treatments is linked to the view of doctors as all-knowing “miracle workers”. In reality, however, we know very little about the mechanism of action of many current prescription drugs (SSRIs, for example) (Woodruff 2008). Maybe, then, we should not equate placebo administration with deception. Instead, it may be necessary to humble the scientific and medical community by recognizing the shortcomings in our understanding of drugs. This would not invalidate the effectiveness, but it may introduce more treatment options.
Just as large placebo pills tend to work better than smaller pills, expensive pills work better than cheaper ones. This leads to a payment predicament: is it ethical to charge a patient for a placebo, and how much? By charging a high price for placebos, we are ultimately denying a large portion of the population treatment. On the other hand, if a patient is paying for treatment, and the treatment that seems to work best is the placebo, cost is just another factor (be it psychosomatic or otherwise) that must be taken into account when developing treatments (Wissocki 2008) (Brown 2008).
It is interesting that in our discussions we continue to use the word placebo. In the forum discussion, many classmates brought up this contradiction. If a placebo creates a physical change in the body (no matter how), can we accurately call it a placebo? In addition, just because we don’t know the mechanism of action does not mean it is pharmacologically inert.
One trouble that arose in the discussion of psychosomatic diseases is the possibility that we are overly pathologizing the human experience. People with body dismorphic disorder and those who identify as trans-gendered feel like they need to be “fixed” so that their outward appearance aligns with their inner perception of themselves. In this disconnect between the mind and body, which should be altered, if either? Can this “problem” perceived by the transgendered individual be addressed through cognitive therapy as well as sexual reassignment surgery? More importantly, it is problematic that we assume these individuals to be broken at all; perhaps it is the societal experience that creates an issue for these individuals at all.
Some classmates saw using placebos as treatment as taking the easy way out. Instead, we should focus efforts on looking for the real problem and the real solution, even though it may be difficult to find (Bitler 2008). On the other hand, as one student simply stated, “why not?” (Smythe 2008). Perhaps placebos could be the first attempt before turning to drugs, much like psychotherapy. Similarly, both make use of what the patient already has, encouraging endogenous healing (no matter the mechanism) as opposed to (or maybe in conjunction with) exogenous substances.
The power of the mind to influence health and disease has become apparent throughout this discussion. The mental and physical are so intimately related that it is essential to take all of these factors into account with every physical symptom. Despite the degree to which a symptom is psychosomatic, all manifestations of stimuli (pain or alleviation of pain) are interpretations by the brain. No matter where these signals originate – be it inside the body, outside the body or within the brain itself – they share this instrumental passage through the brain (Grobstein 2008). Tying this into the placebo effect, it could be possible to understand the brain enough to use it without resorting to trying to trick it with placebos.
In regards to the role of culture in illness, there are advantages and disadvantages to introducing awareness of syndromes. Media coverage can no doubt lead to over diagnosis and hypersensitivity to the normal functions of the body, and with relatively minor syndromes such as PMS it may do more harm than good. In the case of depression and other more serious or chronic conditions, however, raising awareness may cause more people to seek treatment and improve quality of life. Regardless, the notion that symptoms may be at least partially an artifact of the environment is fascinating.
Despite the possible benefits of placebos, it’s important to not rule out drugs completely. It was mentioned that only a fraction of patients are “placebo responders”, implying that whatever placebo effect there may be does not actually have the potential to work on everyone (Bitler 2008). The majority of patients, however, are respondent to drugs. In addition, placebos and the therapeutic power of the brain will not likely give a substantial amount of relief for terminal illnesses such as cancer, and in the case of prescribing an antibiotic as a “placebo” for a viral infection, may even be harmful.
Many factors play a role in the efficacy of medication, and the range of response further indicates our need for a better understanding of the brain. Whether or not placebos will ultimately be used as a means of treatment, the possibility and promise of such treatment seems apparent enough to merit further study. These discussions also bring to the forefront an examination of the doctor-patient relationship and the idea of caring and affection as sufficient to start the healing process. Important, however, is more emphasis on the power of the mind and the possibility of being able to “think ourselves well” even in the absence of a large, expensive “inert” pill.
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