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Thread: Placebo/Nocebo Thought Experiment.

  1. #1 Placebo/Nocebo Thought Experiment. 
    Moderator Moderator Cogito Ergo Sum's Avatar
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    Before I present my question, I provide some explanation first:

    A placebo is, in essence, a substance (a pill, an injection) that does not contain anything of medical value, but is given to reinforce a patient's expectation to get well. Placebo's are also used in many clinical trials, because they function as a control substance.

    A nocebo is the exact opposite. It does not contain anything of medical value either, but it causes harmful effects (pain, stress, etc.) in patients.
    For example, patients who take a certain medical drug, can complain about certain negative side effects by taking them. Not because there is a relationship between the drug and the observed side effects, but because the patient has read every detail of the description.


    In brief: What happens if an healthy individual receives a placebo and a nocebo at the same time?
    After all, a placebo seems to have a positive effect on human health, whilst a nocebo seems to have a negative effect. Would the opposite effects cancel each other out?

    To make it easier, I assume that the individual has an healthy condition and receives two identical looking sugar pills.
    One of the two is said to have a negative effect on his/her overall condition, whilst the other has a positive effect on his/her overall condition (e.g. attention span, resistance against pathogens, etc.). The individual does not know that it are sugar pills, but (s)he is informed about the effects of both pills.

    What do you think?


    PS: I would like to thank member DogLady for her helpful input.
    PPS: The definitions of the words are adapted from the Free Dictionary.


    Last edited by Cogito Ergo Sum; February 1st, 2014 at 04:07 PM.
    "The only safe rule is to dispute only with those of your acquaintance of whom you know that they possess sufficient intelligence and self-respect not to advance absurdities; to appeal to reason and not to authority, and to listen to reason and yield to it; and, finally, to be willing to accept reason even from an opponent, and to be just enough to bear being proved to be in the wrong."

    ~ Arthur Schopenhauer, The Art of Being Right: 38 Ways to Win an Argument (1831), Stratagem XXXVIII.
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  3. #2  
    Brassica oleracea Strange's Avatar
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    Interesting question. It might depend on whether the person is an optimist (aka "lucky") or not.

    I can imagine some people saying, "great I'm getting something that will help but I might have to put up with some side effects ... hey didn't really notice any and feeling great"
    And others saying, "well, I suppose this treatment might help but I'm not looking forward to the bad effects ... yep, they were pretty rough and I don't really feel much better".

    The interesting thing is that the placebo effect works even when you know about it(*). So if you told people that both were harmless would the two effects cancel out? Or would some people still be more influenced more by one than the other....

    It would be an interesting reseacrh project. But to make it a double blind study, wouldn't you need a placebo-placebo?

    (*) To the extent that, in general, most people find more expensive brand-name aspirin (for example) more effective than generics. Even when told this is due to the placebo effect. (I like to think I am immune to this because I studied chemistry and always read the ingredients rather than the price. But...)


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  4. #3  
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    Just to clarify: the nacebo isn't an actual poison, right? It's just something the patient has been told has a bad side effect. Chemically, it's the same as the placebo.

    I don't know how you would get the patient to take the nacebo, unless you told them it has both beneficial and adverse effects.
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  5. #4  
    ▼▼ dn ʎɐʍ sıɥʇ ▼▼ RedPanda's Avatar
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    The whole idea of nacebos makes me feel ill.
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  6. #5  
    Moderator Moderator Cogito Ergo Sum's Avatar
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    Quote Originally Posted by Harold14370 View Post
    Just to clarify: the nacebo isn't an actual poison, right? It's just something the patient has been told has a bad side effect. Chemically, it's the same as the placebo.

    Correct.
    A nocebo is e.g. a sugar pill (disguised a pill against headache) that could make a patient itchy if you tell him/her it might cause severe itch as a side effect.

    Quote Originally Posted by Strange
    The interesting thing is that the placebo effect works even when you know about it(*). So if you told people that both were harmless would the two effects cancel out? Or would some people still be more influenced more by one than the other....

    It would be an interesting reseacrh project. But to make it a double blind study, wouldn't you need a placebo-placebo?

    There might be a correlation between the personality and the response (or you state, whether the individual is an optimist or not),
    but I have no idea how I could set up a double-blind clinical trial with only positive and negative placebos, given the fact that I have to compare placebos with each other.
    Last edited by Cogito Ergo Sum; January 16th, 2014 at 03:08 PM.
    "The only safe rule is to dispute only with those of your acquaintance of whom you know that they possess sufficient intelligence and self-respect not to advance absurdities; to appeal to reason and not to authority, and to listen to reason and yield to it; and, finally, to be willing to accept reason even from an opponent, and to be just enough to bear being proved to be in the wrong."

    ~ Arthur Schopenhauer, The Art of Being Right: 38 Ways to Win an Argument (1831), Stratagem XXXVIII.
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  7. #6  
    Forum Radioactive Isotope skeptic's Avatar
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    The nature of the placebo/nocebo is irrelevant. What matters is belief. Note that (according to Scientific American) only about 30% of the population responds measurably to placebo/nocebo. So, to get a result, what is needed is for the patient to be vulnerable, and to believe. There are quacks who do nothing more than wave their hands above their patient's body, and tell the patient they are now being cured. If the patient believes, and is part of the vulnerable 30%, the placebo effect will work.

    So taking a placebo and a nocebo together simply means taking two neutral substances (like a red sugar pill and a blue sugar pill) and being told one is going to help them and the other is going to harm them. Or you could turn them around. No difference, since it is the belief that matters.

    The result will, of course, depend on belief. Assuming the person who is being treated is prone to placebo/nocebo effects, then the result will depend on whether the person believes that, overall, they will benefit or be harmed.
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  8. #7  
    Moderator Moderator Cogito Ergo Sum's Avatar
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    Quote Originally Posted by skeptic View Post
    So taking a placebo and a nocebo together simply means taking two neutral substances (like a red sugar pill and a blue sugar pill) and being told one is going to help them and the other is going to harm them. Or you could turn them around. No difference, since it is the belief that matters.

    Is it possible for you to provide this article?

    Next, could it not be that the perception of the pill is a variable that also has to be taken into account?
    After all, it could be possible that those 30% you speak of, can associate size and color with placebo/nocebo effectiveness (e.g. a larger pill is more effective than a small one, a blue one seems more "friendly" than a red pill, etc.).
    "The only safe rule is to dispute only with those of your acquaintance of whom you know that they possess sufficient intelligence and self-respect not to advance absurdities; to appeal to reason and not to authority, and to listen to reason and yield to it; and, finally, to be willing to accept reason even from an opponent, and to be just enough to bear being proved to be in the wrong."

    ~ Arthur Schopenhauer, The Art of Being Right: 38 Ways to Win an Argument (1831), Stratagem XXXVIII.
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  9. #8  
    Forum Radioactive Isotope skeptic's Avatar
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    Cogito

    I no longer have the SciAm article. But your speculations are probably correct. Perception in this case could be taken as having the same result as belief. Perceiving one colour or size as healthier would then have an effect.
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  10. #9  
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    Seems to me that understanding what is going on in a biochemical/immunological sense in those that respond to placebo's would be very worthwhile. What is going on when mental states impact immune responses? And if it's just that x percentage would have got better anyway, as I've heard claimed of placebo effects, perhaps the same question is worth finding answers to; what's going on in those that get better by themselves? With or without placebos it seems like there is something to be learned.
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  11. #10  
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    Ken

    The placebo effect is real, as lots of research has shown. However, there does not seem to be a single mechanism. Some experience endorphin increase, and thus pain reduction. Some merely imagine they feel less pain. Some appear to heal faster, but I do not know why. Mostly, though, it appears to be a function of perception.
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  12. #11  
    Forum Sophomore Karsus's Avatar
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    You could do a test like this...

    Tell the subject that pill 1 is a mild poison that will cause nausea.
    Then tell them that pill 2 is the antidote to the poison and will help settle nausea.

    Get them to take pill 1, then tell them to hold off on taking pill 2 until the symptoms caused by pill 1 become bad.

    That way, you'll first weed out which subjects have been affected by the nocebo and which haven't, then you'll see which ones are "cured" by the placebo as well.
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  13. #12  
    Forum Radioactive Isotope skeptic's Avatar
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    Interesting experiment, Karsus. I doubt it would get past the ethics committee though.
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  14. #13  
    Moderator Moderator Cogito Ergo Sum's Avatar
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    Quote Originally Posted by Karsus View Post
    You could do a test like this...

    Tell the subject that pill 1 is a mild poison that will cause nausea.
    Then tell them that pill 2 is the antidote to the poison and will help settle nausea.

    Get them to take pill 1, then tell them to hold off on taking pill 2 until the symptoms caused by pill 1 become bad.

    That way, you'll first weed out which subjects have been affected by the nocebo and which haven't, then you'll see which ones are "cured" by the placebo as well.

    That is an interesting approach to the problem, but using the words "potion" and "antidote" does not seem very ethic.
    I am more inclined to use the notion member Harold14370 used in post #3:
    I don't know how you would get the patient to take the nacebo, unless you told them it has both beneficial and adverse effects.
    "The only safe rule is to dispute only with those of your acquaintance of whom you know that they possess sufficient intelligence and self-respect not to advance absurdities; to appeal to reason and not to authority, and to listen to reason and yield to it; and, finally, to be willing to accept reason even from an opponent, and to be just enough to bear being proved to be in the wrong."

    ~ Arthur Schopenhauer, The Art of Being Right: 38 Ways to Win an Argument (1831), Stratagem XXXVIII.
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  15. #14  
    Forum Radioactive Isotope skeptic's Avatar
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    Cogito

    If you told someone that the sugar pill intended as nocebo had both beneficial and unpleasant effects, it would not be a nocebo.

    The classic nocebo is the action taken by assorted "black magic" practitioners, intended as a curse. When a person actually believes in the power of that nasty individual to cast a curse, the curse may work, whether voodoo, aboriginal pointing stick, or medieval witch.
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  16. #15  
    Forum Sophomore Karsus's Avatar
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    Quote Originally Posted by Cogito Ergo Sum View Post
    Quote Originally Posted by Karsus View Post
    You could do a test like this...

    Tell the subject that pill 1 is a mild poison that will cause nausea.
    Then tell them that pill 2 is the antidote to the poison and will help settle nausea.

    Get them to take pill 1, then tell them to hold off on taking pill 2 until the symptoms caused by pill 1 become bad.

    That way, you'll first weed out which subjects have been affected by the nocebo and which haven't, then you'll see which ones are "cured" by the placebo as well.

    That is an interesting approach to the problem, but using the words "potion" and "antidote" does not seem very ethic.
    I am more inclined to use the notion member Harold14370 used in post #3:
    I don't know how you would get the patient to take the nacebo, unless you told them it has both beneficial and adverse effects.
    Yeah, there would be huge ethical issues in actually performing the test. You'd probably have to move into morally questionable conditions and risk your reputation to perform it.

    To get around making them take the nocebo, you could just tell them that they've been breathing in the "poison" ever since they walked into the testing room...
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  17. #16  
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    Quote Originally Posted by skeptic View Post
    Cogito

    If you told someone that the sugar pill intended as nocebo had both beneficial and unpleasant effects, it would not be a nocebo.

    The classic nocebo is the action taken by assorted "black magic" practitioners, intended as a curse. When a person actually believes in the power of that nasty individual to cast a curse, the curse may work, whether voodoo, aboriginal pointing stick, or medieval witch.

    What would your proposal be for a possible nocebo in this thought experiment?
    "The only safe rule is to dispute only with those of your acquaintance of whom you know that they possess sufficient intelligence and self-respect not to advance absurdities; to appeal to reason and not to authority, and to listen to reason and yield to it; and, finally, to be willing to accept reason even from an opponent, and to be just enough to bear being proved to be in the wrong."

    ~ Arthur Schopenhauer, The Art of Being Right: 38 Ways to Win an Argument (1831), Stratagem XXXVIII.
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  18. #17  
    Forum Radioactive Isotope skeptic's Avatar
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    My proposal?

    A sufficient number of subjects so that we can divide them into two groups. One group gets a pill called beneficial. One described as causing harm. The pill, of course, is identical in both groups. Make the results blind, in that the medico evaluating will not know if the sugar pill given is called beneficial or harmful.
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  19. #18  
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    To get them to take the nocebo, stage a fake 'medication error'. Give the patient the med, then have the "nurse" then come in and explain that it was a med given in error and that there may be negative effects and that the subject will be closly watched for 24 hours to catch and treat any negative effects.

    It would be important to have insurance coverage for malpractice and also for medical expenses the subject might incur after he left your facility in panic.
    To properly make it double blind the nurse should not know she has given a hamless med.
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