8 - complementary theories and placebo effects

Question 1

define complementary therapies

Answer 1

a group of therapies that share a focus on, or integration of, treatment of mind and spirit as well as body

Question 2

focus of complementary therapy

Answer 2

symptom relief

prevention

Question 3

why are many people not confident with the benefits of alternative therapy

Answer 3

there is much less supporting evidence

however this does not mean it is not effective

Question 4

how might complementary therapy benefit the NHS

Answer 4

pain or discomfort relief for patients
improvement of well-being for patients
may save NHS money

Question 5

what might prevent the NHS from offering complementary therapies

Answer 5

little/no evidence to suggest that they arent harmful
NHS has limited resources
treatments must be cost-effective

Question 6

examples of complementary therapy

Answer 6

acupuncture
acupressure
aromatherapy 
herbal medicine
yoga 
reiki

Question 7

definition of placebo effects

Answer 7

treatment effects of remedies that are not understood to have any direct link to the outcome

Question 8

features of placebo effects

Answer 8

mimic drug effects
mimic drug side effects
powerful
complex interaction between psychological and physiological mechanisms

Question 9

research evidence that shows that placebos have important effects

Answer 9

van Laarhoven 2015
systematic review of 34 trials of people with chronic itch due to a skin condition e.g. psoriasis

results:
placebo arm significantly decreased itch compared with baseline (1.3 out of 10)

Question 10

psychological mechanisms of placebo effect

Answer 10

outcome expectancies

classical conditioning

Question 11

neurobiological mechanisms of placebo effect

Answer 11

opioid mechanisms

non-opioid mechanisms

Question 12

what factors influence outcome expectancies of treatment

Answer 12

manipulation via verbal cues

mode of treatment delivery (IV, oral, cream)

Question 13

how does classical conditioning work in the placebo effect

Answer 13

repeated associations between neutral stimulus and an active drug (unconditioned stimulus)

neutral stimulus elicits response characteristic of the unconditioned stimulus

Question 14

disadvantage of relying on the classical conditioning mechanism

Answer 14

its difficult to exclude any other cognitive components in human trials such as outcome expectancies

Question 15

opioid mechanisms

Answer 15

underly placebo effect
changes in brain activity can be seen using PET imaging or fMRI similar to opioid changes following placebo administration

Question 16

role of opioid antagonist naloxone

Answer 16

administered to completely or partly reverse the pain related placebo effects

Question 17

role of opioid antagonist naloxone

Answer 17

administered to completely or partly reverse the pain related placebo effects

Question 18

effect of drug type on conditioned response

Answer 18

• whilst conditioning the patient to have a response to a drug, the different drug chosen can elicit different placebo mechanisms

Question 19

non-opioid mechanisms seen as a placebo response in parkinsons patients

Answer 19

changes in dopamine release in the striatum, basal ganglia and thalamus

decrease in tremors and shaking

Question 20

non-opioid mechanisms seen as a placebo response in patients with depression

Answer 20

changes in metabolic activity in the brain seen

Question 21

example and results of research on placebos to treat headaches caused by hypoxia

Answer 21

1 aspirin tablet placebo–> effects seen via inhibition of cyclooxygenase
1 oxygen mask placebo –> effects seen by reduced ventilation and reduced blood alkalosis

result –> larger physiological effects exerted by oxygen mask placebo

evidence that placebo effect is more than psychological

Question 22

impact of types of outcome expectancies on outcome

Answer 22

conscious expectancies lead to behaviour changes and schematic processing resulting in subjective placebo effects

unconscious outcome expectancies lead to objective physiological placebo effects

Question 23

impact of placebo effect on beliefs about interventions

Answer 23

when placebo effects are large, they cast doubt on the intervention efficacy and on the proposed mechanism of action of the “real” treatment

people start to think the effect of the drug is wholly due to psychological processes

Question 24

evidence to suggest there is no difference between giving a drug and a placebo

Answer 24

howick et al 2013
systematic review of 115 studies
found no significant difference between treatment and placebo effects

Question 25

ernst et al 1995

Answer 25

says that clincial trials should always be double blind | says trials should have 3 arms not just 2 intervention, placebo and no treatment

Question 26

why is the 3rd arm (control) so important

Answer 26

controls for normal regression towards the mean over time, spontaneous remission, unknown parallel interventions or trial drop-outs makes sure we know people are only getting better due to the intervention or placebo and not due to other confounding factors

Question 27

how do you calculate results of the trial using the 3 arm method

Answer 27

treatment effect = intervention arm - placebo arm placebo effect = placebo arm - no treatment arm

Question 28

example of an intervention that it very difficult to create a placebo for

Answer 28

cognitive behavioural therapy (CBI) | patient is actively involved in the treatment

Question 29

example of a 3-arm trial

Answer 29

single-blind RCT for 262 patients with IBS | --> looked at effects of how patients are treated by the clincian

Question 30

method of 3 arm IBS trial

Answer 30

arm 1 --> validated placebo acupuncture device and supportive patient-clinician relationship (attention, warmth, confidence) arm 2 --> validated placebo acupuncture device arm 3 --> no treatment

Question 31

results of 3 arm IBS trial

Answer 31

adequate relief on validated measure for IBS patients shown by: 62% for arm 1 44% for arm 2 28% for arm 3 shows changes in expectation encouraged by the clinician can significantly effect results

Question 32

factors involved in strength of placebo effects

Answer 32

``` treatment characteristics (shape, colour, size of drug) healthcare setting (hospital works better than home) patient characteristics (beliefs, expectations, anxiety levels) HCP characteristics (gender, status, beliefs, job satisfaction) HCP-patient relations (information provision, reassurance, compassion, changing expectations) ```

Question 33

who came up with the taxonomy of placebo effects for clinical practice/research

Answer 33

bishop et al 2017

Question 34

techniques for creating placebo effects in research

Answer 34

creating positive expectancy reduce negative expectancy select patients based on treatment history sham interventions-attention only

Question 35

how does a clinician create positive expectancy in patients

Answer 35

deliberately and explicitly suggest to patients that the intervention will be negative for them

Question 36

how does a clinician reduce negative expectancy in patients

Answer 36

deliberately minimise the potentially negative or harmful procedures and characteristics of the treatment reassure the patient that the treatment is unlikely to be ineffective

Question 37

which patients would you recruit for a successful placebo study

Answer 37

patients naive to the intervention being tested (check their treatment history)

Question 38

what does bishop et al 2017 mean by sham intervention-attention only

Answer 38

patients only receive study-specific attention in terms of numbers and visits and time spent with study staff but no additional intervention

Question 39

why are the results from placebo research studies useful

Answer 39

help to create other treatments that are perhaps more cost effective provides evidence on how HCPs should interact and communicate with patients to improve patient outcome and adherence to medication

Question 40

how do HCPs provide cognitive care

Answer 40

HCPs can influence patients' beliefs and expectations through descriptions of the illness/treatment

Question 41

how do HCPs provide emotional care

Answer 41

HCPs reduce negative effects by providing empathy, warmth, reassurance and support to patient

Question 42

evidence that care from HCPs is important for patient outcomes

Answer 42

Di Blasi et al 2001 systematic review of 25 RCTs 25 manipulated cognitive care, 4 manipulated cognitive and emotional care overall found manipulation of care improved patient outcomes

Question 43

ethical issues behind placebos

Answer 43

deception of patients is wrong doing research where we dont know the outcome is risky patients consenting to placebo surgery (e.g. knee slit) that may have damaging effects

Question 44

evidence to show that placebos can work without deception

Answer 44

kaptchuk et al 2010 Harvard IBS patients tested arm 1: pills presented as placebos, patient told about benefits of the placebo effect arm 2: no treatment same patient care maintained throughout significantly higher mean IBS improvment scores in arm 1