What is Placebo?
A placebo is a fake treatment, which is given to the patients or the sample group. A placebo is usually given in the form of fake pills (sugar pills), fake injections, and even fake surgeries. A placebo does not consist of any active ingredients, but it may still influence the physical health of the individual if he/she may think that the placebo will improve his/her condition. The reason behind the placebo effect is generally considered a psychological phenomenon.
According to the American Society of Pain Management Nursing, Placebo is defined as the
“any sham medication or procedure to be void of any known therapeutic value”
What is Placebo Effect?
If the condition of the patient, who is getting the placebo treatment is improving, then it is said to be the placebo effect. The effectiveness of the placebo effect depends upon the methods of giving the placebo and the expectations of the patient from the treatment. For example, If a patient who is receiving the placebo treatment is given a positive and healing environment, and they are provided with the daily improvement reports of their health, the chances are high that most of the patients will show positive results. Hence, the way the health care provider’s deals with the patients and give them therapies and medical treatment also impact the health of the patient. It was shown in a Harvard research led by Ted Kaptchuck that the placebo treatment with the proper healthcare administration was more beneficial than the treatment with just placebo pills. However, Ted Kaptchuck also suggested that one can not simply think that he/she is better, the placebo treatment can not cure tumours and kill viruses. Regardless, there are numerous researches available that shows the real physiological changes due to the placebo effect such as blood pressure changes, heart rate changes, effect on pain, anxiety, depression, and even on Parkinson’s disease.
How Does the Placebo Works?
The effect of the placebo varies from person to person, and also on the type of disease. The exact working of the placebo effect is quite complex to explain, but we can try to understand the placebo mechanism through the following factors.
Classical Conditioning
It refers to a type of learning that happens on the unconscious level. In classical conditioning, the person links the naturally existing stimulus with the previously stored certain responses. Let’s understand it with the example of Pavlov’s dog. In this experiment, a Russian physiologist, Pavlov, observed an interesting phenomenon. Pavlov used to ring a bell before feeding the dog. After doing it so many times, the dog was conditioned to salivate at the time when the bell rings. Later, one day, Pavlov rang the bell but did not offer any food to the dog. It was observed that the dog was still salivating at the moment when the bell ranged, even in the absence of the food. This shows the classical conditioning, i.e., the unconditioned stimulus such as the ringing of the bell is associated with the neutral reaction such as the taste of the food or salivation. Classical conditioning directly impacts our behaviour, and thereby it influences the placebo effect too. For Example, if the person always takes a yellow pill in case of pain, he/she may start associating the yellow pill as the pain reliever. Later, if the same person receives the similar-looking yellow pill, which is a placebo pill, the classical conditioning of the person comes into play, and the person may feel relieved after consuming this placebo pill due to its association with the pain-relieving medicine.
Hormonal Response
Another factor that is also considered as an important reason behind the placebo effect is the response of the hormones such as dopamines, and endorphins. Endorphines is considered as the natural painkiller released by the brain, the structure of the endorphins is similar to the opiate painkillers. With the advancement in the technology of brain scans, the researchers have shown the activation of the opiate receptors in both the placebo group and the actual treatment group. Opioid receptors are present in the nervous system, which are responsible for the feelings of pain relief and pleasure. It was also observed that the action of the placebo pain relief decreases when the people were provided with the naloxone. Naloxone is a medication, which reverses the action of the opioid medication or blocks the release of the natural endorphins.
Expectation
The placebo effect is largely dependent upon the expectations of the person, who is undergoing the placebo treatment. The expectations of the person can influence his/her perception. This can also be understood from one of the popular sayings,
What we believe is what we experience”
A highly motivated person, who have high expectations of getting positive results from the treatment and is more likely to effectively experience the placebo effect. For example, if the person has high expectations that the particular pill (placebo pill) will cure his/her ailment, chances are high that the person may observe the positive results after taking that particular pill.
The expectations of the persons can be enhanced by using various means such as,
Verbal: If the doctor or the nurse, who is providing the placebo treatment to the patient is able to assure the patient that the treatment will improve his/her condition. It will impact the attitude of the patient and hence may enhance his/her expectations from the treatment.
Action: Actions such as taking the fake pill or receiving the fake injection directly impacts the placebo effect as one starts feeling better if he/she has done any action to improve his/her condition.
Social: Non-verbal acts, such as the body language, voice tone, and eye contact between the patient and the doctor also act as important factors to make the patient more comfortable and positive about the treatment. The enthusiasm of the person who is giving the treatment is closely related to the response of the patient to the placebo. This shows that the placebo effect comes into play even when the real pills or injections are used in the treatment.
Genetics
The impact of the placebo on the people is also dependent on the genes of the people. It is observed that some people with specific genetic materials are more responsive to the placebos than others. For example, It was shown in a study that the people with the genetically higher level of dopamine were more responsive to experience the placebo effect than those with low levels of dopamine.
Use of Placebo in Clinical Trials
Placebos are generally used in clinical trials, where the patients or the control groups are given the fake treatment, and the effect of the placebo on them is observed. Placebo is also used to check the effectiveness of the newly manufactured drug on people. One group can be provided with the actual drug and the other group with the placebo. This may help the chemists to analyse the effectiveness of the new drug. A drug gets approval by the health authorities only if it shows greater efficiency than the placebo.
Real-Life Examples of Placebo Effect
Earlier, placebos were only used in the experiments as a control group for the clinical trials, but nowadays, the placebos are known to work effectively in many psychological or physical disorders. The placebo is recommended by most doctors along with the standard medical treatments due to the placebos ability to show better results. Here are some examples that show the impact of the placebo effect on various physical and psychological disorders.
1. Effect of Different Labelling of the Pills on the Patients
A study was conducted in 2014 to assess the effect of labelling of the drugs on the 66 patients suffering from the migration. In this research, the participants were told to take the assigned labelled pill for the six different episodes of migraine. During the migraine episode, the participants were given either the real migration medication (Maxalt) or the placebo pill, and throughout the research, the labelling of the pills was changed. The pills were labelled as the Maxalt, Placebo, and Neutral (either Maxalt or Placebo). The participants were informed to mark their pain intensity after half an hour into the migration episode, and then again they have to mark the pain intensity, 2.5 hours after taking the assigned labelled pill. The researchers found that even the same pills, which were labelled differently had different effects on the participants. It was observed that the real migration medication, i.e., the Maxalt was the most effective pain reliever as expected; however, the placebo pills (marked as Maxalt) provided more relief than the no medication. It was also observed in this study that the amount of relief provided by the Maxalt labelled as the placebo is almost the same as the relief provided by the placebo labelled as the Maxalt in most of the cases. In another study, it was found that the pills labelled as the treatments of specific problems such as pain, anxiety, sleep, and depression had shown improvements for that particular disorders of the participants even when all the pills had the same inactive ingredient.
2. Effect of Placebo on the Cancer-related Fatigue
A study was conducted in 2018 to analyse the effect of the placebo as compared to the standard treatment on the 74 cancer survivors having fatigue symptoms. In this study, the participants were provided with either the pill labelled as a placebo or given regular treatment for three continuous weeks. After three weeks, people who were given the placebo pills were stopped taking them, and the participants who were provided with the regular medication were given the option of taking the placebo pills for the next three weeks. On concluding the study, the researcher observed the effect of the placebo. It was found that the condition of the participants who were given the placebo treatment for the three weeks was better as compared to the participants who received only the regular treatment, and the conditions of the participants were improved even after the discontinuation of the placebo. The participants who were on regular treatment, and then later took the placebo pills were also reported to show the improvement in their symptoms of fatigue.
3. Effect of Placebo on the People Suffering from Depression.
The research was conducted in 2015 to study the effect of a placebo on the 35 participants, who were suffering from depression. The participants involved in the study were not under any other medication during the research period. In this research, each participant was provided with placebo pills. Some of the pills were labelled as the ‘fast-acting antidepressant’ and the others as the ‘placebo,’ i.e., the ‘active placebo’ and the ‘in-active placebo’ respectively. Each group was given these pills for one week. The researcher conducted PET scans of the participants who took these pills at the end of the week to measure their brain activities. Before the PET scan, the group who took the active placebo received the placebo injection, and they were told that this injection may enhance their mood, while the group who took an inactive placebo did not receive any placebo injection. After a week, both the groups switched the placebo pills, and the second PET scan was conducted at the end of the week. For the next ten weeks, all the participants received regular antidepressant treatment. After conducting the research, the researcher observed that most of the individuals have experienced the placebo effect. The PET scans of the people who took the placebo pills and placebo injection showed increased brain activity in the areas that regulate stress and emotions, i.e., depression was reported to be decreased in the people who took the active placebo.
4. Big Red Pills are More Effective
It is observed that the placebo effects act differently on the people if the size or ṭhe colour of the pills is different. A study was conducted on a group of people, who were suffering from headaches. A small-sized white coloured placebo pill was given to some of the people, while a comparatively big red placebo pill was given to the other people. It was observed that the people who took big red pills felt more relieved from the headache as compared to the ones who took small white pills. Although both the pills were neutral, i.e., both the pills did not have any active ingredient, the subconscious mind of the people expected that big red pills are more effective than the small white pills.
5. Think Healthy to Stay Healthy
There are numerous researches that show that the individual who thinks that he/she has a good health condition, live around 10 years more than the one who thinks that he/she has a bad health condition, even though the real health conditions of both the persons is same. An experiment was conducted on the cleaning workers of a hotel. Half of the workers were told that they are burning a lot of calories and they are improving their health by doing the exercises in the form of the cleaning work that they do daily, while nothing was told to the other half of the workers. After some months, it was observed that the workers who were told about their work benefits on their health had shown improvement in their cholesterol level and some had even lost their weight, while there was no such improvement in the health conditions of the other half of the workers.
6. Effect of Placebo on Pain Relief
The ability of the placebo to reduce the pain of an individual is known as the placebo analgesia. It could either be due to the release of the endorphins (natural painkillers) by the brain due to the placebo or due to the change in the person’s perception of the pain.
7. Effect of Placebo on Erectile Dysfunction
In a study, the participants were divided into three groups. The researcher informed the first group that they will receive standard medical treatment for erectile dysfunction, the second group was informed that they would either receive the standard medical treatment or the placebo, and the third group was informed that they would receive the placebo. In reality, all three groups were provided with starch pills (placebo pills). At the end of the treatment, it was found that improvement in erectile dysfunction is similar in all three groups.
8. Effect of Placebo on Parkinson’s Disease
The placebo effect also works efficiently in the treatment of Parkinson’s disease. In a review of eleven clinical trials, it was found that around 16 per cent of the people suffering from Parkinson’s disease had shown long-lasting improvements. The placebo effect in this case is considered to be due to the release of dopamine in the striatum (subcortical part of the brain).
Some Interesting Findings of the Placebo Effect
- It is generally considered that for making the placebo effect effective, the person who is receiving the placebo should be tricked as that he/she is receiving a powerful medication. On the other hand, some studies have shown that the placebo effect still remains effective even if the person is aware that he/she is receiving the placebo. In research conducted on the participants with irritable bowel syndrome (IBS), it was observed that those participants that were given the ‘open placebo’ showed improvement in the irritable bowel syndrome as compared to those who did not receive any treatment.
- In contrary to the placebo effect, if the deterioration in the health of the person is observed instead of the improvement it is referred to as the Nocebo effect. This happens due to the negative expectations of the person from the treatments. The treatment could either be placebo treatment or the real treatment. The person may expect the negative effect of the treatment if he/she is told by the doctor about the side effects of that particular treatment. Let’s understand the Nocebo effect with research conducted on the people. In this research, the people were blindfolded, and they were told that their one arm was rubbed with a poisonous plant. As a consequence, all the participants started feeling the symptoms of the poisonous plants such as itching, and redness. In reality, the arms of the participants were rubbed with a harmless plant. This research strengthens the effect of nocebo. The Latin meaning of the ‘nocebo effect’ is ‘I shall harm.’
- The placebo effect not only depends upon the person who is receiving the placebo, but it also depends upon the person who is giving the placebo. It is backed by the studies that the placebo works effectively when the doctor gives the placebo with faith and confidence to the patients. In some other studies, it is found that if the patient believes that the doctor who is treating him/her shares the same values and beliefs then the patient feels lesser subjective pain after any medical surgery.
- When we talk about the placebo effect we usually think of it in terms of medical treatments such as pain relief. However, the placebo effect can also be effective in other ways, it is observed that the placebo can enhance the physical as well as the mental performance of the people. In a study, it was found that the cyclists were able to travel significantly longer distances in the given time when their clock timings have been secretly changed. In another study, the experimental group was told that if they smell the given special fragrance it may help them to enhance their score in their creative performance, while the control group was not told about the benefit of smelling that fragrance. As a result, the creativity score of the people in the experimental group was better than the people in the control group. Another study shows that the placebo can enhance the mental functioning of people too. In this study, the participants in the experimental group were told that their brains had been stimulated by gentle electric shocks, which will enhance their mental functioning, while in reality no shocks were given to the participants. However, it was found that the experimental group participants showed better and more accurate results in the given learning tasks as compared to the performance before the electric shock was provided to the group. Hence, the placebo can enhance the cognitive abilities and creativity of the person.
- Some shreds of evidence also show that the placebo effect is not only found in humans but can also be observed in animals. In fact, many of the drug trials are conducted on animals in the same manner as conducted on humans, and the animals were also responsive towards the placebo effect. It is said that the placebo effect experienced by the animal generally depends upon the way the owner or the researcher interacts with the animal.
- Some studies have shown that factors like age and gender do not impact the placebo effect, but the personality traits of the person are closely related to the placebo effect experienced by that person. This is because that the placebo effect depends upon the expectations, and beliefs of the person. It was observed that optimistic people experience better analgesic placebos than those with a Pessimistic personality.
- Some studies show that the different forms of placebos have different effects on people. The effect of the placebo will be larger if an individual imagines that the particular placebo is more powerful. For example, Some researches have shown that the people who took four placebo pills felt more relaxed than those who took two placebo pills, similarly, the participants who got placebo injection showed better improvement than the participants who were provided with the placebo pills.
- Researches have shown that the placebo effect is getting stronger than before. Research conducted in the 90s has shown that the participants who received the active medical treatment had shown 27 % more relief in the pain than the participants who received the placebo treatment. While some recent studies have shown that the number has been reduced to just 9%. The reason behind this could be the increase in the awareness or the belief of the people regarding ṭhe effectiveness of the placebo effect.