Had to chime in on Jay Dixit and Dan Ariely's recent thread on placebo effect. As a psychiatrist with a practice heavy in addiction, pain management, and detox/rehab, I've grown to cringe at the loaded implications of the placebo concept. Maybe it's helpful to first toss out some definitions and etymology:
pla•ce•bo (pl -s b )
n. pl. pla•ce•bos or pla•ce•boes
1.
a. A substance containing no medication and prescribed or given to reinforce a patient's expectation to get well.
b. An inactive substance or preparation used as a control in an experiment or test to determine the effectiveness of a medicinal drug.
2. Something of no intrinsic remedial value that is used to appease or reassure another.
placebo
c.1225, name given to the rite of Vespers of the Office of the Dead, so called from the opening of the first antiphon, "I will please the Lord in the land of the living" (Psalm cxiv:9), from L. placebo "I shall please," future indic. of placere "to please" (see please). Medical sense is first recorded 1785, "a medicine given more to please than to benefit the patient."
In medicine, a clinical response to a placebo often carries the baggage or implication of ignorance, lack of insight, or self awareness. The idea that a patient would report a symptom response from "a substance containing no medication" unfortunately suggests the notion the he is easily duped, albeit unconsciously. A double extra unfortunate sequela is that many doctors prejudicially define placebo responders as not having a real disease. Many illnesses and symptom complexes (fibromyalgia, chronic fatigue syndrome, even migraines and seizure disorders) have suffered incredulity as a result.
I suggest that this is a function of the hubris of medicine. If it doesn't fit our categorical diagnosis, or if we can't explain it, it isn't a real disease. I am particularly sensitive to this for two reasons. First, in med school @ U Penn (a very crunchy, humanistic place at the time), they always drilled the difference between disease and illness into our heads. While a disease is a complex of signs and symptoms, often consistent across cases, an illness is the dialectic of that symptom complex and the person's reaction to it. Disease x Person's life/experience = illness. Using this math, we might say that: Medication x Person's life/experience = Treatment Respone (which includes a biochemically mediated effect as well as a cognitively/emotionally mediated effect, "placebo"). So, maybe the placebo effect is a complex level of endogenously mediated treatment that we just don't get quite yet.
My second annoyance with the fallout of placebo stigma is that placebo-responding patients and illnesses are often dumped onto psychiatrists. Don't get me wrong; I love the work. And now that psychiatry/neuroscience is more concretely mapping the physiological links between emotions, cognition, pain, and even the immune system with pretty pictures from functional MRI and others modalities, we have more to contribute than ever. But the dumping of these patients into a field that, sadly, still carries an it's-all-in-your-head stigma, can feel dismissive and devaluing to people who are suffering and need help and support. This leads to a plea for the integration of mind and body in medicine and psychiatry.
Lest I get too holier-than-thou, I have one final bee in my psychiatry bonnet. Placebo is the first person future tense of the latin placere, I will please. In dynamic psychiatry, the notion of pleasing or gratifying a patient's needs is often misperceived as a no-no. A placebo feeds into some unscientific, neurotic, and unconscious need. Unfortunately, bad psychiatry can miss opportunities here. The positive response to a placebo should not be read as irrational, pathological, or pejorative, but rather lead to an understanding of what brings that person or people in the aggregate relief.
The flip side of dismissing the placebo effect is using it for good. Dan Ariely and Jay Dixit both suggest the possibility of harnessing the power of placebo in treatment. Whether this is done by actively prescribing placebo medications or opting for economic, behavioral, or therapeutic structures that take advantage of psychologically mediated or ameliorated responses to treatment.
Sounds good to me with one phat caveat. Slow down. When Piaget first came to America to lecture on his studies on cognitive development in children, he was miffed to find that the big, American question was, "How can I use this to make my kid smarter faster?" His response was "Dude, back off!" There is a lot of turf between observational science and prescriptive medicine. And, just because a placebo is not an official FDA approved "medication", it can still do a lot of good or damage. GD
