A 1957 case study by Dr. Bruno Klopfer (who famously pioneered the Rorschach inkblot test) reports the story of Dr. Philip West and his patient Mr. Wright. Dr. West was treating Mr. Wright, who had an advanced cancer called lymphosarcoma. All treatments had failed, and time was running out. Mr. Wright’s neck, chest, abdomen, armpits, and groin were filled with tumors the size of oranges, his spleen and liver were enlarged, and his cancer was causing his chest to fill up with two quarts of milky fluid every day, which had to be drained in order for him to breathe. Dr. West didn’t expect him to last a week.
But Mr. Wright desperately wanted to live, and he hung his hope on a promising new drug called Krebiozen. He begged his doctor to treat him with the new drug, but the drug was only being offered in clinical trials to people who were believed to have at least three months left to live. Mr. Wright was too sick to qualify.
But Mr. Wright didn’t give up. Knowing the drug existed and believing the drug would be his miracle cure, he pestered his doc until Dr. West reluctantly gave in and injected him with Krebiozen. Dr. West performed the procedure on a Friday, but deep down, he didn’t believe Mr. Wright would last the weekend.
To his utter shock, the following Monday, Dr. West found his patient walking around out of bed. According to Dr. Klopfer, Mr. Wright’s “tumor masses had melted like snowballs on a hot stove” and were half their original size. Ten days after the first dose of Krebiozen, Mr. Wright left the hospital, apparently cancer-free.
Mr. Wright was rockin’ and rollin’, praising Krebiozen as a miracle drug for two months until the scientific literature began reporting that Krebiozen didn’t seem to be effective. Mr. Wright, who trusted what he read in the literature, fell into a deep depression, and his cancer came back.
This time, Dr. West, who genuinely wanted to help save his patient, decided to get sneaky. He told Mr. Wright that some of the initial supplies of the drug had deteriorated during shipping, making them less effective, but that he had scored a new batch of highly concentrated, ultra-pure Krebiozen, which he could give him. (Of course, this was a bald-faced lie.)
Dr. West then injected Mr. Wright with distilled water.
And a seemingly miraculous thing happened—again. The tumors melted away, the fluid in his chest disappeared, and Mr. Wright was feeling great again for another two months.
Then the American Medical Association blew it by announcing that a nationwide study of Krebiozen proved that the drug was utterly worthless. This time, Mr. Wright lost all faith in his treatment. His cancer came right back, and he died two days later.1
When I read this, I thought, Yeah, right. Surely, this case study couldn’t be true. How could cancerous tumors just “melt like snowballs” in response to an injection of water? If the case report was true and something so simple could make a cancer go away, why weren’t oncologists wandering through the wards, injecting stage 4 cancer patients with water? If they had nothing to lose, what was the harm?
The whole thing seemed improbable, so I kept looking. Surely, if there was any truth to such a story, there would be similar case studies reported in the literature.
Another patient reported in the Journal of Clinical Investigation suffered from severe nausea and vomiting. Instruments measured the contractions in her stomach, indicating a chaotic pattern that matched her diagnosis. Then she was offered a new, magical, extremely potent drug, which her doctors promised would undoubtedly cure her nausea.
Within a few minutes, her nausea vanished, and the instruments measured a normal pattern. But the doctors had lied. Instead of receiving a potent new drug, she had been dosed with ipecac, a substance known not to prevent nausea, but to induce it.
When this nauseated patient believed her symptoms would resolve, her nausea and abnormal stomach contractions disappeared, even when the ipecac should have made them worse.2
I sat there, scratching my head. Curious, but it didn’t prove anything.
The Healing Power of Fake Surgery
Soon after, I stumbled across an article in the New England Journal of Medicine that featured Dr. Bruce Moseley, an orthopedic surgeon renowned for the surgeries he performed on people with debilitating knee pain. To prove how effective his knee surgery was, he designed a brilliantly controlled study.
The patients in one group of the study got Dr. Moseley’s famous surgery. The other group of patients underwent an elaborately crafted sham surgery, during which the patient was sedated, three incisions were made in the same location as in the real surgery, and the patient was shown a prerecorded tape of someone else’s surgery on the video monitor. Dr. Moseley even splashed water around to mimic the sound of the lavage procedure. Then he sewed the knee back up.
As expected, one-third of the patients getting the real surgery experienced resolution of their knee pain. But what really shocked the researchers was that those getting the sham surgery had the same result! In fact, at one point in the study, those getting the sham surgery were actually having less knee pain than those getting the real surgery, probably because they hadn’t undergone the trauma of the surgery.3
What did Dr. Moseley’s patients think about the study results? As one World War II veteran who benefited from Dr. Moseley’s placebo knee surgery said, “The surgery was two years ago and the knee has never bothered me since. It’s just like my other knee now.”4This study hit me in the gut.
Mr. Wright and the lady getting ipecac were just case studies, and case studies, well known to have biases, aren’t considered the gold standard when it comes to interpreting the medical literature. The gold standard by which I was taught to investigate scientific data is the randomized, double-blind, placebo-controlled clinical trial, published in a peer-reviewed journal.
Dr. Moseley’s study, a randomized, double-blinded, placebo-controlled clinical trial—published in one of the most highly respected medical journals in the whole world—showed that a significant percentage of patients experienced resolution of their knee pain solely because they believed they got surgery.
That was the first real evidence I collected that proved to me that a belief—something that happens solely in the mind—could alleviate a real, concrete symptom in the body. Dr. Moseley’s study is what led me to research the placebo effect, the mysterious, powerful, reliably reproducible treatment effect some patients experience when given fake treatment as part of a clinical trial.
The Powerful Placebo
Like every scientist, I had long known about the placebo effect. Fake treatments, such as sugar pills, saline injections, and sham surgeries, are routinely used in modern clinical trials to determine whether a particular drug, surgery, or treatment is truly effective. The term placebo, from the Latin for “I shall please,” showed up in medical lingo ages ago to indicate inert treatments, traditionally given to neurotic patients to placate them.
For centuries, doctors prescribed treatments without any clinical data to prove that the treatments themselves actually worked. Nobody questioned the treatments the doctor prescribed, and nobody did studies to prove whether something was effective. The doctors simply mixed up tonics, dosed up their patients, and the patients got better, at least a percentage of the time. Or the doctor cut someone open, performed a surgery, and the symptoms improved, or they didn’t.
It wasn’t until late in the 19th century that the idea of using placebos in clinical research began to emerge. Then, in 1955, the Journal of the American Medical Association published a seminal article by Dr. Henry Beecher called “The Powerful Placebo,” which made the case that if you dosed people up with drugs, many got better. But if you gave them plain salt water or some other inert ingredient, about a third of them were also cured, not only in their minds, but in real, physiological ways that could be demonstrated in the body.5
Suddenly, the concept of “the placebo effect” became a mainstay of contemporary medicine and modern clinical trials were born. Now, good scientific studies bear the burden of proving that the healing effect of the drug or surgery being tested transcends the potent healing power of the placebo. If a drug or surgery demonstrates that it’s more effective than a placebo, then it is deemed “effective.” If not, the FDA probably won’t approve the drug, the surgery will fall out of favor, and the treatment will be dismissed as ineffective, as Dr. Moseley’s surgery was. Prescribing treatments that prove to be no better than a placebo is believed to violate the principles of evidence-based medicine. It’s what separates the real doctors from the quacks.
Or so I was taught.
It got me thinking. What exactly is the placebo effect? Until I began my research, I had never really stopped to think about it. We all know people in clinical trials get better when you treat them with nothing but a sugar pill. But why?
That’s when I realized I had hit the mother lode in my quest for proof that the mind can affect the body. If a percentage of people in clinical trials get better simply because they believe they’re getting a real drug or surgery, the response they are getting is triggered solely by the mind. This realization threw me into a bit of a tailspin.
Evidence That Positive Belief Can Alleviate Symptoms
Back to the medical journals I went, in search of more evidence that the mind’s belief that the body is getting a drug or surgery is enough to result in real, live symptom relief. I found that nearly half of asthma patients get symptom relief from a fake inhaler or sham acupuncture.6 Approximately 40 percent of people with headaches get relief when given a placebo.7 Half of people with colitis feel better after placebo treatment.8 More than half of patients studied for ulcer pain have resolution of their pain when given a placebo.9 Sham acupuncture cuts hot flashes almost in half (real acupuncture helps only a quarter of patients). As many as 40 percent of infertility patients get pregnant while taking placebo “fertility drugs.”10In fact, when compared to morphine, placebos are almost equally effective at treating pain.11 And multiple studies demonstrate that almost all of the happy-making responses patients experience as a result of antidepressants can be attributed to the placebo effect.12It’s not just pills and injections that work wonders when it comes to symptom relief. As proven by Dr. Moseley’s knee-surgery study, sham surgeries can be even more effective. In the past, ligation of the internal mammary artery in the chest was considered standard treatment for angina. The thought was that, if you blocked blood flow through that artery, you’d shunt more blood to the heart and relieve the symptoms people experience when they’re not getting enough coronary blood flow. Surgeons performed this procedure for decades, and almost all the patients experienced improvement in their symptoms.
But were they really responding to the ligation of the internal mammary artery? Or were their bodies responding to the belief that the surgery would be helpful?
On a quest to find out the answer, one study compared angina patients who got their internal mammary arteries ligated with patients who underwent a surgical procedure during which an incision was made on the chest wall, but the artery itself was not ligated.
What happened? Seventy-one percent of those subjected to the sham surgery got better, whereas only 67 percent of those who got the real surgery improved.13 Internal mammary artery ligation now exists only in medical history.
The data I was collecting was impressive, and I had to wonder if it might be even more impressive if every effort weren’t made to minimize the placebo effect in clinical trials. If researchers perceived the placebo effect as a positive phenomenon, something to embrace, perhaps we’d see even higher percentages. But that’s not the focus most researchers have. On the contrary, clinical-trial coordinators and medical researchers (who are mostly employed by pharmaceutical companies) go out of their way to diminish the placebo effect. After all, patients who get better from placebos interfere with a drug’s ability to get approved for market. To screen out those considered to have “excessive placebo responses,” many randomized, double-blinded, placebo-controlled trials of drugs are actually preceded by a “washout phase,” in which all participants take an inert pill and anyone who reacts favorably to it is eliminated from the study.
So, if the majority of researchers for new pharmaceuticals weren’t in bed with Big Pharma, we might see placebo response rates shoot even higher in clinical trials.
Does Everyone Respond to Placebos?
As I pondered the placebo effect, I found myself doubting whether I would ever respond to a placebo if I were a patient in a clinical trial. After all, I’m a doctor. I’ve been an investigator in clinical trials myself. I’m a smart cookie, and I think I’d just know whether I was getting a real treatment or not. If I suspected I was getting a placebo, clearly it wouldn’t help me, right?
It got me thinking. Are certain types of patients more susceptible to placebo responses than others? Is there any data to suggest whether there’s a classic profile for placebo responders? Are there personality traits or intelligence measures that predict who gets better when given a sugar pill? Do people with high IQs demonstrate less responsiveness to placebos? Are some people just more gullible?
Turns out scientists have studied this. Researchers originally postulated that those who responded to placebos would have lower IQs or be more “neurotic.” But what they discovered is that nearly everybody can be induced to respond to a placebo under the right conditions. We are all susceptible, even doctors and scientists. In fact, some studies suggest that those with higher IQs are even more placebo-responsive.
I took this as good news, because if it’s true that the mind’s positive beliefs can heal the body, everyone has an equal chance of benefiting from this phenomenon. It’s not just gullible people who can believe themselves well; it’s smarty-pants people like you.
Is Healing from Placebos All in Your Mind?
As my research continued, I couldn’t quite wrap my brain around what I was learning. Clearly, the evidence I was collecting looked promising. When patients—not just the gullible ones, but all patients—believe they’ll get well, a hearty percentage of them experience clinical improvement.
But this failed to fully satisfy my curiosity. I could make the argument that symptom relief really is all in your head. What is pain, after all, if not a perception in the mind? What is depression, if not a mental state? Even with more tangible diseases like asthma or colitis, maybe you just perceive that you can breathe better or think you have fewer gastrointestinal symptoms. Maybe the mental perception is changing, but the body isn’t actually responding in any measurable physiological way. Maybe you just think it is, and that’s enough to make you feel better.
If it’s true that the mind can heal the body, there must be some way to demonstrate that the body is responding, not just with symptom relief, but in physiological ways that can be studied. The next phase of my research led me in search of proof that it’s not all in your head, that the mind’s belief can actually alter the body’s physiology.
With hundreds of thousands of placebo-controlled trials published out there, finding an answer was no small feat, mostly because many of the studies I encountered evaluated symptoms such as headaches, back pain, depression, and decreased libido—which are difficult to quantify. When patients experience relief from such symptoms, it’s largely subjective. There’s no objective measurement that can prove that what they report is true.
But I did finally find proof that, at least a percentage of the time, real physiological changes happen in the body in response to placebos. When given placebos, bald men grow hair, blood pressure drops, warts disappear, ulcers heal, stomach acid levels decrease, colon inflammation decreases, cholesterol levels drop, jaw muscles relax and swelling goes down after dental procedures, brain dopamine levels increase in patients with Parkinson’s disease, white blood cell activity increases, and the brains of people who experience pain relief light up on imaging studies.14These findings convinced me. Placebos don’t just change how you feel, they change your biochemistry. This is where things really start to get interesting.
The biochemical impact of the placebo effect potentially throws our whole model of disease into question. But before I made any giant leaps, I wanted to investigate whether there might be other explanations for why people’s bodies were responding with both symptom relief and measurable physiological change when treated with placebos. Was it really just positive belief making all those changes in the body, or were there other factors influencing the patients’ outcomes? The next phase of my inquiry led me to a few theories. (...)
From Mind Over Medicine
Lissa Rankin
No comments:
Post a Comment