There is a vast array of alternative remedies, many of which purport to treat a wide range of different illnesses. Some of these treatments are based on relaxation or meditation and only claim to reduce stress, while others make wild claims, unsubstantiated by any sort of scientific tests, that they can cure illnesses such as CFS. Even though many of these remedies have very questionable theories behind them, and could not possibly work for the reasons given by their practitioners, the fact remains that many of these remedies do in fact lead to miraculous recoveries, due to the placebo effect.
It is well known that if patients are given a pill which does not have any active ingredients, such as a sugar or chalk pill, a significant percentage of patients will sometimes improve in health over those patients not given any treatment at all, depending on the health condition being treated. In many studies the amount of improvement due to placebo alone is 50% or higher. Sometimes this placebo improvement is due to the normal resolution of symptoms that would have happened even in the absence of the placebo. However in many cases the placebo itself gives a significant improvement over no treatment at all.
The placebo effect is more effective in treating certain symptoms and illnesses than others. The greatest effect tends to be for symptoms related to abnormalities in central nervous system functioning (and symptoms over which the CNS has an influence), such as depression, anxiety, headaches, fatigue and gastrointestinal symptoms. It is also remarkably effective as a painkiller, and numerous anecdotal accounts suggest that it can positively influence the immune system to produce "miracle" cures for cancer and other illnesses.
For this reason, there is a requirement in most countries that all new drugs go through at least one double-blind placebo-controlled trial before they can be approved. One set of patients is given the drug being tested, and a second group is given a dummy pill. Both pills look and taste exactly the same (as far as is possible), and neither the patient nor the physician administering the treatment know which pill the patient has been given. The fact that the doctor does not know whether the patient is given the active treatment is important, as his body language could potentially give a clue to the patient as to which treatment is being administered.
If the real drug is not significantly better than the placebo then the drug is not allowed to be sold as a treatment. This is the case even if the drug did cause an improvement in a significant number of patients (over those not given any treatment) due to the placebo effect.
The difference between scientifically tested drugs and what might be called "quack" treatments is that, in the latter, although the treatment may work in some (or even many) cases, it is no better than a placebo.
While it might be tempting to think that the placebo effect is relatively minor, or that it only affects weak-minded or suggestible people, this is far from the truth. The published research studies on antidepressants show that placebos generally give an improvement of about 30%, whereas the figure for active treatments is usually only about 40%, not much better than placebo.
So the question arises - what is wrong with prescribing a "quack" treatment that relies completely on the placebo effect if it works in some cases? The most obvious problem is the fact that it may or may not work - it is mostly down to the psychology of the patient. If the treatment does not work, then the patient has spent time and money on something that is essentially a waste of time. Relying on a treatment that's only benefit comes from the placebo effect can also be potentially dangerous, as it prevents the patient from using more effective treatments. In the case of something minor like hay fever this is not an issue, but for more serious illnesses such as cancer, it could mean the difference between life and death.
There is also a negative placebo effect (or "nocebo"), which is the opposite of a placebo. If someone is taking a medicine and they expect to have side effects, this can sometimes be enough to cause phantom side effects such as headaches, pain and nausea. The nocebo effect is also thought to be the reason why things such as witch doctor and voodoo curses work.
The placebo effect is largely ignored or ridiculed by both the medical profession and the general public, who think that it only happens to weak-minded individuals or that it is simply due to relaxation and the reduction in stress. However research clearly shows that the placebo effect has a major effect on many types of illnesses, and has the power to enable the body to heal itself from cancer and other "incurable" diseases.
One of the most remarkable accounts of the placebo effect is that of Dr Bruno Klopfer and Mr Wright, a cancer patient who had only a few weeks to live. Dr Klopfer treated Mr Wright with an experimental cancer drug called Krebiozen. Shortly after being injected with the drug, the patient's tumour masses "melted like snowballs on a hot stove". A few months later, however, when the newspapers published the results showing that the drug was worthless, Mr Wright's tumours appeared again.
Suspecting that Mr Wright's belief in the drug had caused his previous recovery, Dr Klopfer told Mr Wright that he was going to give him a double strength of a more active form of the drug, but in reality the injections simply contained distilled water. Again the tumours disappeared and Mr Wright was healthy for two more months.
Then the newspapers published a story about the worthlessness of the drug, this time without any doubt. After reading this story, Mr Wright's tumours reappeared and he died within two days.
The placebo effect is clearly psychological in nature, and it somehow involves the thought processes of the patient causing the body to heal itself. Contrary to popular opinion, it is not necessary to believe in the placebo effect for it to work. What seems to be most important is the purpose and motivation that the placebo treatment gives the patient.
It is likely that there are a number of factors that can compromise normal health and immune function. The most often cited culprit is excessive stress, which results in high levels of catecholamines and cortisol, which then act to suppress the immune system. Cortisol in high levels will suppress all parts of the immune system, while catecholamines mainly affect NK cells. In the short-term, high levels of catecholamines actually result in increased levels of NK cells (by a factor of up to 600%). However in the long-term this effect is reversed - after seven days, the same levels of increased catecholamines result in reduced NK cells. Catecholamines also appear to favour the TH2 immune response, resulting in a shift from TH1 to TH2, similar to that seen in CFS patients.
It is likely that the reason why certain personality types tend to have lower NK cells is due to them having increased levels of blood-borne catecholamines (which itself is due to greater sympathetic nervous system activity). This could explain why relaxation techniques which reduce stress (and therefore sympathetic nervous system activity) can boost the immune system and result in cures from certain illnesses. While this may explain some instances of the placebo effect, there are many other cases of the placebo effect operating where stress is not an issue.
Recent research seems to show that the HPA axis itself can have a positive influence on immune function. Although cortisol (the end product of HPA axis activation) has a suppressing effect on immunity, that is not the whole story. It is well known that during severe illness the HPA axis is chronically activated, and the adrenal cortex shifts away from DHEA and aldosterone and towards cortisol production. Clearly there must be other mechanisms operating to counteract the immunosuppressive effect of cortisol.
An experiment by the Laboratory for Experimental Internal Medicine in Amsterdam showed that food intake could modulate the immune system, resulting in a shift towards the TH1 response. They do not know the reason for this response, but they suspect that it might be because the body requires large amounts of energy in order to fight off viral infections. The actual mechanism by which this effect occurs is not known, but it is possible that it is caused by the HPA axis activation that occurs during food intake.
Another experiment that shows a clear link between HPA axis activation and immune response comes from the University of Turin. They showed that ACTH and beta-endorphin (both of which are released from the pituitary as part of the HPA axis response) reduced the inhibition of NK cell activity by cortisol. Beta-endorphin was shown to have an additional effect on the immune system in that it increased the cytotoxicity (killing ability) of NK cells. What this research shows is that different parts of the HPA axis have different effects in terms of stimulating and suppressing the immune system, and it is the combination of these different hormones that is important in determining the overall immune response.
We know that the normal functioning of the HPA axis is required for normal immune function. We also know that psychological factors can have a very profound influence over the status of the HPA axis, and in particular the response of the HPA axis to stress. It is therefore not unreasonable to postulate that the placebo response could be due to an increase or normalisation of HPA axis function, caused by a change in the patient's state of mind. The placebo effect could then be thought of as the removal of burnout, as it reverses the HPA axis abnormalities associated with burnout (and also cures the symptoms).
The release of beta-endorphin by HPA axis activation could explain the pain-reducing effect brought about by the placebo effect. Many alternative therapies claim that they increase beta-endorphin release, and this is thought to produce the healing effect. The practitioners of therapies such as acupuncture, which are known to increase levels of beta-endorphin, usually say that the therapy itself causes this increase, due to interactions with the nervous system. However there is experimental evidence showing that the placebo effect itself can result in the same increase in beta-endorphin.
The placebo effect may therefore be a combination of a number of different effects that have the overall result of normalising the HPA axis and sympathetic nervous system, and therefore reversing a suppressed or abnormal immune system response that was caused by an imbalance in these hormones. It is not clear whether the short-term pain relieving placebo effect operates through the same mechanism as the long-term effects that can result in curing illnesses such as CFS. All that we can say for certain at the present time is that the placebo effect is the result of the mind interacting with the body and the immune system in order to positively influence health.
The placebo effect can be thought of as the normal functioning of the body's built-in healing power, and is almost certainly the same as the Chinese chi, or energy, which is thought to be present throughout the body and provide health and vitality. Many alternative remedies such as acupuncture are thought to normalise the body's energy and restore the natural balance. However, rather than being some mystical force, it is likely that chi is actually the body's HPA axis, and the vitality and immunity to illness provided by these remedies are the result of the normalisation of the HPA axis.
As to the actual mechanism by which the placebo effect operates, a study by the UCLA Neuropsychiatric Institute and Hospital provides some clues. They measured brain activity in patients undergoing antidepressant medication and placebo in order to see what actually happens in the brain when the placebo effect is operating. They discovered that the placebo responders had increased activity in the prefrontal cortex of the brain, in contrast to the subjects who responded to the antidepressants who tended to have reduced activity in the prefrontal cortex. The changes in brain activity in the medication responders showed up within 48 hours, but the placebo responders took two weeks to show any significant changes.
The prefrontal cortex has a number of functions such as providing selective attention and filtering out irrelevant stimulus, as well as being responsible for motivation, rewards and planning for long-term goals. It is likely that it is this long-term goal planning function that is responsible for the placebo effect, and that burnout is due to an under-activity (or imbalance) in the prefrontal cortex. As the prefrontal cortex is an important modulator of the HPA axis, an imbalance in its activity could potentially result in either a suppression of the HPA axis or an abolition of its normal circadian pattern of activation.
There have been shown to be abnormalities in prefrontal cortex function in patients with autism, schizophrenia and bipolar disorder, although it is not known whether the prefrontal cortex is the cause of these disorders or if they are the result of an underlying genetic defect that affects many parts of the brain in addition to the prefrontal cortex.
As noted earlier, higher levels of NPY in the prefrontal cortex are associated with greater stress tolerance and lower anxiety. Considering all the evidence, it therefore seems likely that the prefrontal cortex plays an important role in mind-body health, as well as in the etiology of disorders such as CFS which appear to be the result of a breakdown in this system.
It should also be noted that not all alternative treatments are purely placebo. Many herbs have medically active ingredients which have a real effect on the body. In fact many medicines, such as aspirin, are based on natural remedies. Similarly, there are many medical drugs which have little or no benefit over and above the placebo effect. On average, 75% of the effectiveness of anti-depressants is due to the placebo effect, and a number of independent studies have shown that some anti-depressants are essentially worthless as they have no benefit above placebo whatsoever.
The problem is that there is a lot of myth, pseudoscience and quackery associated with many alternative therapies. There are many myths about vitamin C helping to cure cancer and prevent cold viruses. Many well-designed studies have shown that vitamin C has no effect whatsoever in preventing colds, and recent epidemiological studies have shown that it has no effect on cancer. Some vitamins, such as vitamin E, have even been shown to increase the risk of dying.
Some therapies such as homeopathy and bioresonance, have no science behind them and no conclusive research showing their effectiveness. (For bioresonance, every single study shows that it is worthless. For homeopathy, some studies show it is effective, but a greater number show it is ineffective. For such an extraordinary theory as homeopathy, it would require very good evidence to show it's effectiveness.)
Other alternative therapies, such as acupuncture, are more likely to have some real effect, although the nature of the effect probably isn't for the reasons given by the practitioners. Acupuncture, for example, has been shown to have a larger effect when a real needle is used to puncture the skin than when a fake needle is used which doesn't puncture the skin, even though the patient does not know which is being used. Other studies have shown that there is no difference in efficacy between needles placed in the "correct" acupuncture points over those placed at random. It is likely that any effect is due to the needle puncturing the skin and masking other pains in the body, rather than due to some mysterious "energy field". More research is needed to separate reality from quackery.
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