Aug 20 2012

Nocebo Nonsense

You have probably had the experience of having a heated conversation with one or more other people and after things calm down and you are comparing notes you find that everyone has a different memory of the conversation that just happened. Of course, you are certain that your memory is the one that’s correct.

Likewise, different people can look at the same set of information and come to radically different interpretations. That’s because we all have narratives inside our head – worldviews and ways in which we model and make sense of the world.  We are very clever and creative at incorporating new information into our existing narratives.

I was reminded of this when reading a recent article by Deepak Chopra on the nocebo effect. Nocebo effects are similar to placebos effect except they are negative – unwanted side effects that are reported from taking inactive placebos. Chopra clearly has a narrative that he is working from, one that is very different from my own. He is steeped in, and in fact is partly the architect of, various “alternative medicine” narratives.

I, of course, am working from very different narratives – skeptical ones. I do think, however, that not all narratives are equivalent (that would be a post-modernist position). Some are more logically consistent and evidence-based than others. Further, the job of a journalist or intellectual is to look past existing narratives (especially their own) and ask the hard questions: what does the data actually show, how does my perspective bias the story I am telling, and are there any other points of view that deserve attention? When the topic is anything that intersects science, then a proper interpretation of the scientific evidence is what should hold sway, and should trump any existing narratives.

Chopra doesn’t do this. Rather, he dives into his existing narratives with gusto and complete disregard for the actual evidence. He begins:

For decades the placebo effect has existed basically as a nuisance, so far as the medical profession is concerned. Some people benefit from being given a sugar pill instead of an actual drug. This remarkable result cannot be marketed, however. It doesn’t fall within the ethics of medicine to prescribe fake drugs. Therefore, a doctor in practice, whose training has drummed into him that “real” medicine means drugs and surgery, will shrug off the placebo effect as psychosomatic, or “it’s all in your head.”

The alternative guru narrative is in full display: doctors only know drugs and surgery, they are concerned with what is marketable, and they are dismissive of anything psychological (spiritual). The only statement above that I would consider fair is that it is unethical to prescribe fake drugs – it is. But that doesn’t mean you cannot optimize the patient interaction to maximize non-specific therapeutic benefits (certain useful aspects of placebo effects) within the confines of ethics.

I covered placebo effects and the ethics of placebo medicine here, here, and here - so take a look for a detailed discussion. Bottom line – there are many placebo effects, most of which are just statistical effects or subjective reporting. There does not appear to be a significant biological placebo effect, and placebo effects are not dependent upon positive expectation. Any placebo effects worth having can be obtained while practicing real science-based medicine, simply through a positive interaction, and does not require deception or belief in magic. To emphasize an important point, relevant to Chopra’s  placebo narrative – placebo effects are largely subjective, without objective improvement. A recent study by Kaptchuk comparing different placebos and real treatment for asthma found just that – improvements from placebos were subjective only, without any objective improvement.

But Chopra’s narrative is that the mind is everything. It is all powerful and is the real master of health and illness. So he writes:

The placebo effect is real medicine, because it triggers the body’s healing system. One could argue that this is the best medicine, in fact, since: a. drugs do not trigger the healing system and b. the placebo effect has no side effects. Staying well means that the body is taking care of itself – and you – through a feedback loop of chemical messages.

Funny – I never learned about the “healing system” in medical school. Oh, that’s right, because I am a Western doctor who only knows about drugs and surgery. They must have edited the “healing system” out of my anatomy and physiology textbooks. Sarcasm aside, the body certainly has mechanisms for healing and repair. Bones can knit together, cuts can close back up, and we do have an immune system that vigilantly protects our bodies against infection and cleans up any dead or diseased tissue. For some reason I don’t think this is what Chopra is talking about.

Generally speaking, chronic illnesses occur because one or more of the body’s systems are failing. Perhaps there is a genetic abnormality or predisposition, or trauma or some other disease has simply overwhelmed our body’s repair and maintenance systems, or age has simply taken its toll. The “alternative medicine” narrative, however, is that the body has this mysterious, sometimes described as energy-based, “healing system” that can heal all ills. All you have to do is activate it. The healing system, therefore, can be triggered – by whatever the guru is selling.  This is a wonderfully marketable narrative.

This would be great if it were true. I wish the body had unlimited healing ability. The evidence, however, simply does not show this. Specifically, the vast literature on placebo effects does not show that they trigger any objective “healing” or physiological effect. They generally improve the reporting of subjective symptoms only.

Interestingly, Chopra says above that placebos have no side effects, but then the rest of the article is about the nocebo effect – which are side effects from placebos. D’oh. Chopra is only interested in promoting his pre-existing narrative – the mind is all-powerful. Positive thoughts cause healing, while negative thoughts cause illness. So if you are sick, it’s all your fault, due to your negative thoughts. This is standard Indian philosophy – consciousness is a real thing and the physical world is just a manifestation of consciousness.

Chopra’s article was inspired by a New York Times article by researchers into nocebo effects. The researchers, however, make very different points from Chopra. They review the scientific evidence, which is pretty clear. People will report negative side effects even when taking placebos. If they are warned about a particular side effect, they are more likely to report that one. Again – there is no reason to think this is anything other than subjective reporting. Stress is the one factor that can cause real physiological consequences, and therefore illnesses that significantly respond to stress (like heart disease) can be affected by anxiety or hopefulness. This is not true, however, of most diseases.

The researchers write:

The nocebo effect can be observed even when people take real, non-placebo drugs. When medical professionals inform patients of possible side effects, the risk of experiencing those side effects can increase.

That is a perfectly reasonable point – doctors need to think about how they tell patients things. Of course, we do, but some more than others, and there is always room for improvement. The authors suggest, for example, that (within the confines of honesty and informed consent) doctors focus on the positive rather than negative aspects of a procedure. I have heard this referred to as “verbal anaesthesia.” This is, of course, one aspect of old-fashioned good bedside manner.

We can, however, get caught up in the mechanics of modern medicine and the need for informed consent. There are times I have to discuss potential negative aspects of a treatment because they are essentially mandated by the FDA. I know that doing so will increase the likelihood of my patient reporting a negative side effect (nocebo effect). It would be much easier if I could just lie to them, tell them only what they want to hear, and justify this action as maximizing the placebo effect of the procedure. But that is not the ethics of medicine (only alternative medicine practitioners can do that).

There is a nuance to communicating to patients to meet, as best as possible, these conflicting goals of informed consent with maintaining a positive outlook. That, I think, is the proper lesson to take away from this data, as the researchers themselves suggest.

Chopra, however, has a different narrative. He is selling (very successfully) the notion that consciousness is everything, and your thoughts are your destiny. Placebo and nocebo effects, regardless of what the scientific evidence actually says, are just another way to support this narrative.

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36 responses so far

36 Responses to “Nocebo Nonsense”

  1. SARAon 20 Aug 2012 at 9:27 am

    When Chopra was first emerging as a self help guru in the early 90′s I happened to be in a bookstore where he was doing a signing. He was late. He came in, yelled at 2 store employees over the circumstances that caused his lateness and then proceeded to tell his audience about the problem.

    He was understandably angry. The stress of the book tour with the calamity of circumstances made him appear to be everything he tells his audience not to be. Real life stress did not stand up to his ideas for inner peace and visualization.

  2. ConspicuousCarlon 20 Aug 2012 at 7:07 pm

    Chopra is an encyclopedia of fallacious thinking in analog format. When Dr. Novella mentioned having read Chopra’s article in this post, I first thought “Why did you do that to yourself?” But Novella probably also has a shelf full of medical books, and he isn’t going to toss those handy references just because they have descriptions of unpleasant things. That’s the whole point of them. If you want an example of pathology, you know where to find it.

  3. Mlemaon 21 Aug 2012 at 12:47 am

    If the placebo effect is caused by the caring attitude or attention of the caregiver, what is causing the nocebo effect if not the negative expectation of the patient?

    “There does not appear to be a significant biological placebo effect, and placebo effects are not dependent upon positive expectation.”

    The researchers seemed to draw different conclusions: that it is expectation that determines a positive or negative effect, not the warmth or attention of the caregiver.

    As a materialist, i think you believe that thoughts and attitudes are physical in nature, being reducible to brain activity. Why isn’t it then possible that thoughts and attitudes would affect the healing “system” (which I think Chopra believes is exactly as you describe your understanding of it to be) You only allow for stress as a cause for chronic disease, but that is a physical mechanism, and it seems to me that any emotion (which could be caused by an attitude or train of thought, both negative and positive) can affect physical disease. Digestive disease, hypertension and all the resultant diseases like kidney failure, obesity caused by overeating, resultant type 2 diabetes, long-term depression and the diseases that result from that: memory loss, shrunken hippocampus, etc etc etc – couldn’t these all be chronic diseases caused by “stress” (which is a negative attitude regarding events and circumstances – two people in the same environment can react very differently to what’s happening in that environment, depending on their attitudes and expectations)?

    Since only the physical body exists, then why is it impossible that expectation can effect the disease state for good or ill? How do you explain the “overdose” of placebo that caused a patient’s blood pressure to drop dangerously low? Or the results of the experiment with prostate medicine? Pain is often the symptom affected by placebo. This is a subjective symptom, which you suggest is the only kind affected by placebo. What does this say about the nature of pain, which must also be physical?

    I’m not criticizing what you’re saying. I’m just suggesting that you possibly misread the conclusions of the researchers, which don’t agree with your own.

    I don’t buy into Chopra, but I do believe that expectation is pivotal in health outcomes. The expectation of both the doctor and the patient effect the results of medical care, beyond just subjective outcome. And yes, it’s communication on the doctor’s side of the equation. To avoid nocebo effect for a patient, perhaps a doctor might communicate possible negative side effects by saying something like: “I’m required to inform you of these possible side effects, but I also want you to understand that i don’t expect you’ll be experiencing any of these effects yourself” Of course the physician would probably have to believe what he’s saying or the patient would probably be able to tell he was being disingenuous. This is how it works with any belief system: it’s very hard to act against what you believe, even if it would be beneficial.

  4. Steven Novellaon 21 Aug 2012 at 6:46 am

    mlema – I did not say that expectation has no effect, just that placebo effects are not dependent upon them. They can occur even without expectation.

    Expectation and suggestion do affect subjective reporting of symptoms – people are on the look out for symptoms, for example. And pain is uniquely sensitive to expectation, mood, distraction, and similar variables.

    And I specifically mentioned stress because that is a well established physical factor that is primarily determined by mental state (which yes, is physical).

    But – we need to put this all into perspective. The research on placebos is very clear. The effects are small, transient, and only significant for subjective symptoms or things that are directly related to stress, like the cardiovascular system.

    Kaptchuk’s asthma study is a good example – the effect of placebo on objective measures of pulmonary function was zero. The cancer literature is the same – the placebo effect for cancer survival is zero.

    My point is mainly one of magnitude. Statistical effects, illusions, and bias are the major components of placebo effects. Real physical effects from increased mood and positive expectation appear to be minor or non-existent (with pain and cardiovascular outcomes being the exception).

    The case report of the low blood pressure from taking placebos is hard to interpret – it’s basically a single anecdotal report and we don’t necessarily know all the variables.

  5. SKon 22 Aug 2012 at 4:19 am

    I wonder what is gained by persisting with the placebo concept at all.
    Researchers have spent years arguing about a definition that never overcomes a single basic problem. That is; the logical paradox of an intervention without a mechanism (a placebo) that has an effect (a placebo effect). The problem extends when you start talking about nocebos; the negative effects of placebo administration; whether an effect is negative depends on who is experiencing it.
    All this is further complicated by the questions of reporting bias, statistical issues like regression to the mean, natural history etc etc, which depending on the rigor of the researcher (or knowledge of the writer) gets either get lumped in with the placebo effect, or not.
    It seem that holding onto the magical placebo black box is completely counter-productive. If we think that manipulating patient expectations has some effect (via whatever mechanism) then we should investigate how and why they work and call them “the effects of patient expectation” or similar. The same goes for the effects of conditioning or decreasing levels of anxiety, or anything else that has been proposed as a mechanism of placebo.
    This holds at a clincal level but also for research. There is nothing to be gained by assigning the name “placebo” to a control intervention; it tells us nothing about what the intervention is actually controlling for. Nor does it help us understand what the mechanism of the index intervention might be.
    I do understand that the term is deeply entrenched in the medical literature and public understanding, but to me that is not a reason not to abandon it if we think it is unhelpful, or worse, a hindrance. It just means it might take a while.

  6. daedalus2uon 23 Aug 2012 at 2:24 pm

    SK, it is true for many interventions that the mechanism is unknown, or that the believed mechanism is shown to be wrong, even after the intervention has been shown to work quite well. For example statins are inhibitors of a step in cholesterol synthesis, but there is compensatory up-regulation of enzyme activity, so there is no reduction in enzyme activity in the step that is inhibited (it is increased). Statins do have effects on cholesterol, it is just not through the mechanism originally thought.

    If placebos do “something”, they can only do “something” if there is physiology that causes the “something” to happen.

  7. Mlemaon 23 Aug 2012 at 7:09 pm

    “Real physical effects from increased mood and positive expectation appear to be minor or non-existent…”

    I’m pretty sure I’ve read that breast cancer survivors have a better prognosis if they are part of a social support group, and have long-term goals for a continued life.
    And I think you may underestimate the role of your patients’ trust in your own intelligence, ability, and high standard of care as an accomplished neurologist, along with their faith in modern medical science.

    I guess that’s not placebo, and I guess after reading these responses I don’t really understand what’s a placebo. But I do believe consciousness, however you define it, plays a critical role in health. And I don’t see why it wouldn’t: if brain is mind and mind is brain, and brain is a powerful regulator of thought, attitude, expectation, goal-formation, and even contains the workings of the subconscious (as invisible mediator between consciousness and other physical functions: a role which is poorly understood): why not?

    I’m not saying people can “think themselves well”, just that what they do think must affect their health (no matter the cause of that thought).

  8. sonicon 23 Aug 2012 at 11:02 pm

    mlema-
    There is a problem with what you are suggesting–
    According to the reductionist model–

    Consciousness is caused by, and the effect of, particles in motion.
    Therefore, consciousness can not be the cause of particles in motion.

    Some have suggested that ‘strong emergence’ is a real phenomena. Some even suggest the notion of ‘downward causation’ — meaning that a higher level phenomena (consciousness in this case) could be causative over lower level phenomena (particles in space).

    One person to suggest the idea that consciousness could have this property was Roger Sperry- a neuroscientist and Nobel laureate.

    The idea hasn’t caught on big in the neuroscience community as of yet– and that is an understatement I believe.

    To the reductionist true cause comes from that which is irreducible.
    I don’t need to explain why the idea of consciousness being irreducible is a problem– do I?

  9. Mlemaon 24 Aug 2012 at 1:37 am

    Thanks sonic. I don’t see the problem with what I’m suggesting. i understand that under an idea like Sperry’s there would be no problem suggesting that the mind influences health. I was just trying to show that even if you think like Dr. Novella (consciousness caused by moving particles – or actually, it IS moving particles) it is still the case that as a physical part of the physical body, the mind can then, in turn, cause other physical effects.

    Dr. Novella calls consciousness a “process” -if it is, why couldn’t it in turn affect other physiological processes and physiological states? Isn’t everything physical in the body affected by and in turn effective upon everything else? If the body is simply a whole bunch of particles in motion, all effecting each other, and the consciousness is a certain “array” or “function” of some of those particles, why is it impossible that consciousness effect a physiological state, even if it didn’t ORIGINATE its own state to begin with? We don’t have a problem with Dr. Novella’s definition of consciousness, because even if consciousness is caused by the physical, there is no such thing as non-physical, therefore – no problem with consciousness affecting other physical things, right?

    Dr. Novella has also said that people get confused about the nature of consciousness because the brain is feeding information back upon itself over and over, so it’s easy to mistake self-awareness for something apart from brain function. So, if this feedback is going on in the consciousness, couldn’t that affect the entire physical body? Other brain processes do.

    “Consciousness is caused by, and the effect of, particles in motion.
    Therefore, consciousness can not be the cause of particles in motion.”

    If consciousness itself is physical (as Dr. Novella says) then there’s no reason it couldn’t effect particles in motion. So, he would not say that consciousness is CAUSED by the physical, but rather: it is A PART OF the physical – a function, or a process, as he calls it. It’s not “created” by the brain. It’s just a part, or aspect of it. If that is so, why couldn’t it be involved in the feedback that happens all the time in the body, and thereby influence the physiological state (in the same way it’s influenced by the physical state – as when alcohol, or injury, etc. influences consciousness) I’m not talking about original cause. I’m just saying: if mind and body are the same “stuff”- why can’t each cause effects upon the other? Also, I’m not even implying that we have control over our thoughts, just that that doesn’t mean they don’t affect our health. One example of consciousness effecting the physical: a spontaneous memory of (or even a dream about) a traumatic event can cause increased heartbeat, sweating, etc. fight, flight or freeze reaction in spite of absence other stimuli.

    So, if Perry is right, no problem saying that consciousness affects health. Or, if Dr. Novella is right, we still have a mechanism whereby consciousness affects health -so no problem! I’m not making an argument about the nature of consciousness, I’m just saying that no matter WHAT consciousness is, it affects the physiology of the body.

    We know that people can use biofeedback to change their brain waves, lower their blood pressure, learn to focus, etc. isn’t this an example of consciousness affecting “the rest of” the physical body? We can react to whatever we’re conscious of. Possibly, probably, we are also reacting via our subconscious. Dr. Novella has posted research showing that decisions are made subconsciously prior to becoming conscious of them.

    I believe that consciousness influences physical well-being, and I think that’s supportable whether or not you believe that consciousness is the same as, or caused by the physical; or is instead irreducible. Whether you think the chicken came first or instead the egg – the resultant relationship is the same. :)

  10. sonicon 24 Aug 2012 at 2:43 pm

    mlema-
    I’m not disagreeing with what you are saying.
    My point is that if causation goes only one way– from bottom up– then consciousness would be affected by physiology– not the other way around.

    I’m thinking that to a hardcore reductionist the notion that consciousness could effect physiology would be a bit like saying that the exhaust from your car controls the driver.
    Not that I would agree with that analogy– just saying that’s where reductionist thinking takes me.

    I know of a few possible ways around the problem of consciousness being causally effective. Here is one example–

    http://www-physics.lbl.gov/~stapp/Stapp_wfut.pdf

    Of course Stapp, like Sperry, promotes ideas that are not currently extremely popular with the mainstream.

    Go figure… :-)

  11. daedalus2uon 26 Aug 2012 at 12:03 pm

    There is nothing about causality and modeling consciousness as an emergent property of the brain that precludes consciousness affecting the physiology of the brain. From a materialist perspective it has to.

    If “thinking” is caused by “material stuff”, and thinking can affect thinking (which we know from personal experience), then thinking can affect at least the “material stuff” that causes thinking.

    Whatever “material stuff” causes thinking, it must be coupled to the rest of the “material stuff” that causes physiology. Energy comes from ATP, ATP comes from oxidative phosphorylation, oxygen comes from the lungs, glucose comes from the liver and all that “material stuff” has to work together for consciousness to happen.

    The causal chain can’t be unidirectional or the system would not be stable. There has to be feedback to the systems supplying energy from the systems consuming energy for the energy production and consumption to stay in balance.

  12. BillyJoe7on 26 Aug 2012 at 5:36 pm

    The thyroid gland produces thyroid hormones that feed back to control the thyroid output of the thyroid gland. No one is a strict reductionist. Scientist use both the bottom up and top down approach at solving problems. As long as it’s just physical interactions it’s materialism. No mbiog deal here.

  13. Mlemaon 26 Aug 2012 at 11:53 pm

    What I’m trying to point out is a contradiction in Dr. Novella’s philosophy:

    consciousness is physical, and is not “caused by” the brain/body, but is rather a function or process of the brain. He has said: the mind is what the brain DOES.

    Therefore, as daedalus2u points out, it must affect the rest of the brain/body. Dr. Novella says it doesn’t.

    How does Dr. Novella reconcile these two assertions?

  14. BillyJoe7on 27 Aug 2012 at 7:20 am

    Mlema,

    “consciousness is physical…Therefore…it must affect the rest of the brain/body. Dr. Novella says it doesn’t.”

    Here are the relevant quotes from this article:

    “you can optimize the patient interaction to maximize non-specific therapeutic benefits (certain useful aspects of placebo effects)”

    “there are many placebo effects, most of which are just statistical effects or subjective reporting. There does not appear to be a significant biological placebo effect”

    “placebo effects are largely subjective, without objective improvement”

    “the vast literature on placebo effects does not show that they trigger any objective “healing” or physiological effect. They generally improve the reporting of subjective symptoms only”

    Adding all this up, what is Steven Novella saying do you think?
    (In the last quote, I’m assuming that the word “generally” belongs to the previous sentence also)

    It seems to me that what he is saying is that the mind affects the body but only in a very limited way. Theoretically it could have had a big effect but studies show that it actually has very little effect. The mind can’t sure cancer, for example, or endocrinological diseases. However it can have some affect on cardiovascular diseases because an important underlying factor in cardiovascular diseases is anxiety and the mind certainly can play a role in modifying or exacerbating anxiety.

    The whole point of his article is to warn against allowing your philosophy trump your science (a la Chopra). Science wins out in the end and any philosophy worth anything must be based in science. Science tells us that the mind does not have an effect on most illnesses and a limited effect on some ilnesses.

    The following quote seems to sum this up quite nicely:

    “People will report negative side effects even when taking placebos. If they are warned about a particular side effect, they are more likely to report that one. Again – there is no reason to think this is anything other than subjective reporting. Stress is the one factor that can cause real physiological consequences, and therefore illnesses that significantly respond to stress (like heart disease) can be affected by anxiety or hopefulness. This is not true, however, of most diseases.”

  15. Steven Novellaon 27 Aug 2012 at 9:45 am

    mlema – what BillyJoe7 said.

    I never said that thought has no affect on the body. There is a neuroendocrine system – being surprised increases temporarily the release of catecholamines in the blood which has clear physiological effects, which in turn affect how we feel and think. Our brains are part of the our bodies – they are one system that feeds back on itself in multiple complex ways.

    But this is all very general. If we are going to make specific claims then we have to ask more specific questions – in what ways and to what magnitude do cognitive processes affect other systems in the body? This has been studied to a great extent, sometimes directly, and often as an implicit part of other clinical studies (any study with a placebo group).

    The current answer is pretty clear – psychological effects do play a large role in our perception of health and symptoms, and they directly affect the cardiovascular system, but they do not contribute to any generic “healing system” and they appear to play an insignificant role in most disease processes.

    Your take: “consciousness is physical…Therefore…it must affect the rest of the brain/body. Dr. Novella says it doesn’t.” is a straw man I never said.

  16. sonicon 27 Aug 2012 at 11:53 pm

    daedalus2u-
    There are some who would say that the true causes in the universe are enumerated by the laws of physics.

    The Standard Model has 61 elementary particles and their interactions. None of the particles or interactions is called ‘consciousness’.
    Further, General Relativity is basically an equation that has motion of mass-energy on one side and curvature of space-time on the other.
    No consciousness there.

    So consciousness might be the result of the interaction of the various particles that make up the universe, but I think you are mistaken that it is a given that consciousness can exert a force on any of the objects of physics.
    Certainly there is nothing in either the Standard Model or General relativity to indicate such.

    Of course there is an interpretation of quantum mechanics that involves consciousness causing the collapse of the wave-function. But I don’t think you agree with that notion– do you?

    If you are suggesting that it is reasonable to think that emergent properties can have a downward causation– while that seems somewhat reasonable to me, let’s admit that isn’t a currently popular concept. Or am I wrong about that?

    mlema-
    If consciousness is physical– can I get an ounce? :-)
    BTW– I once produced a molecule of what I thought was ‘free-will’. Turned out to be caffeine… ;-)

  17. BillyJoe7on 28 Aug 2012 at 12:29 am

    Let’s just say that your concept of physical deviates somewhat from a physicist’s conscept of physical. Of course, you could just be kidding. ;)

  18. Mlemaon 28 Aug 2012 at 1:39 am

    Dr. N: “Stress is the one factor that can cause real physiological consequences, and therefore illnesses that significantly respond to stress (like heart disease) can be affected by anxiety or hopefulness. This is not true, however, of most diseases.”

    what are “most diseases”? Stress affects the immune system: our major disease-modulator. If there is a “generic healing system” it’s got to be the immune system.

    what is stress? For most of us it’s a negative interpretation of our experience.
    Two people in the same stressful situation can have very different physical reactions: one can experience “stress” and damage his heart, the other feels exhilarating challenge and finds pleasure in dealing with the situation – releasing endorphins . This is the mind affecting the body.

    Example:

    while trying to prepare for work, a series of mishaps causes delay. person A laughs about it and thinks “that’s the way it goes sometimes, it happens to everybody and I’ll be OK.”
    person B thinks “why does this always happen to me? This is going to hurt my reputation at work”

    person B is more likely to be unhealthy, simply due to his mental response to the situation and the effects of his thoughts on the rest of his body.

    your characterisation of these effects as “insignificant” seems contradictory to your admission that stress plays a physical role in disease. Long-term, person B is more likely to experience any number of diseases modulated by strrss, simply because he THOUGHT differently about a particular situation.

    So, if thought patterns can affect emotions and bring about anxiety and hopefulness, thus effecting “stress”,; and stress effects the cardiovascular and immune sysytems, we have a mechanism whereby the mind effects a whole host of diseases through the body’s response.

    http://www.sciencedaily.com/releases/2007/10/071009164122.htm

    http://www.sciencedaily.com/releases/2011/01/110126121452.htm

    I appreciate what you are saying here:
    “But this is all very general. If we are going to make specific claims then we have to ask more specific questions – in what ways and to what magnitude do cognitive processes affect other systems in the body? This has been studied to a great extent, sometimes directly, and often as an implicit part of other clinical studies (any study with a placebo group).”

    But when you continue by limiting psychological effects to our “perception of health and symptoms”, limiting its role in numerous diseases to “insignificant”, you’re overlooking the profound inter-relationship between what a person is thinking/feeling and its effect on the rest of the physical body through all the physiological mechanisms whereby the brain always affects the rest of the body..

    You can’t have it both ways. You can assert that consciousness is physical, but then you can’t say it has little or no affect on the body. Anything that is physical affects everything that is physical. Isn’t every aspect of consciousness the determination of how our body exists in its environment? An input-output model of the brain must by necessity mean that consciousness affects the physical body. Thinking is part of consciousness. Why is it so important for you circumvent this conclusion? Our mental interpretation of our own experiences effects the rest of our physical body at each step – including disease and healing processes.

    Like I said, I’m not saying a person can “think himself well”. I’m just saying that consciousness plays a role in health and disease. It seems like you’re willing to acknowledge that, but qualify it so stringently that I can’t help but wonder what your physiological understanding of consciousness really is? If thoughts are physiological processes, why don’t they effect the state of the body, like other physiological processes?

  19. Mlemaon 28 Aug 2012 at 1:47 am

    sonic,
    “If consciousness is physical– can I get an ounce?”

    If consciousness is physical, then you should be able to get an ounce. I’m not sure how. I’m not even sure that consciousness is physical, although I sometimes feel I possess my body’s weight in consciousness. And sometimes I feel I possess a perfectly weightless consciousness. My discussion above is an attempt to point out inconsistencies in a philosophy that says: consciousness is physical and yet doesn’t affect physiology’s integrated functioning and response to disease and maintenance of health in any significant way.

    “BTW– I once produced a molecule of what I thought was ‘free-will’. Turned out to be caffeine… ”

    Caffeine is the only will of any kind that I possess :)

  20. bthomas001on 28 Aug 2012 at 6:08 am

    @Mlema:

    I detect an air of all-or-nothing thinking. Yes: consciousness is physical. Yes: it is both a result of, and source of, itself, in one way or another. However, top-down processes affecting flow of ions across the membranes of a few hundred neurons is a far cry from recruiting and coordinating an entire immune system to eradicate a tumor.

    In a system of chemical interactions as complex as an entire human body, there are bound to be some statistical ghosts. Probabilistic ensembles acting in concert toward a common “goal”. A “Game of Life,” as it were. E.g. peer-bonding leading to subjectively improved affect and objectively improved survival rates in a disease state are effects whose origins can be gleaned from the fact that we evolved as a social species. Sticking together, caring about each other, is good in that it tends to contribute to survival. Therefore, evolution has selected for that quality in that people who tend to do that tend to fare better in a number of ways.

    Thinking of consciousness as a cure-all for any ailment is, by any measure, erroneous. That is the point. This discussion goes so far as to point out that there is no good evidence that “consciousness” has a significant biological (placebo or nocebo) effect, rather those apparent effects are just that: apparent. While in tightly coupled/highly interactive systems, such as the brain/endocrine or endocrine/immune systems, thought processes might lead to measurable changes, as a general rule one would be naïve to think that good intentions can manifest in physical form.

  21. BillyJoe7on 28 Aug 2012 at 7:08 am

    Mlema,

    As I said, the mind affects the body but only in a very limited way. Theoretically it could have had a big effect but studies show that it actually has very little effect. Not only does the mind not cure cancer, it doesn’t even improve cancer survival rates. However, it can make you feel happier while you are dying of cancer. I suppose that is not nothing.

    Don’t let your philosophy rule your science. If science says your philosophy is wrong, change your philosophy. That is the message here.

  22. Mlemaon 29 Aug 2012 at 12:23 am

    I think there are logical difficulties with saying the mind effects the body in a limited way. After all, admitting the nature of consciousness prevents anyone from knowing how much anyone elses mind affects his body. (You can’t know what i’m thinking day in and day out, so how can you know if my physiology is being affected by what I’m thinking?)

    If you want to make a blanket statement that minimizes the affect of consciousness on health, you can (almost) accurately say that stress is the one case where consciousness affects health. But admitting that, how can you say the effect is “insignificant” when many, if not most of chronic disease in the U.S. is stress-mediated through exacerbation of effects on the immune system?

    Perhaps there is a failure to understand the nature of stress as we refer to it in the US today? Unless you’re a battered wife, abused child, night-shift employee, etc. stress is mental. Fear of the future, negative anticipation of failure, rejection, lack, or feelings of loneliness or uselessness contribute to patterns of thinking that “stress” the body and cause bad health. Here I must allow that I don’t know if those with whom I contend philosophically are able to understand the role of thought in stress. I’ve attempted to illustrate how that works, but if a person is unaware of his own pattern or habits of thought, beliefs, emotions, attitudes, etc., I think it’s possible that he or she mightn’t see the role these things play in their own physiological responses to their own conscious experience, and how those things affect their health. So, then it’s easy to see why those people would say: the mind only affects the body in a limited way. (for them, it SEEMS limited).

    Failure to recognize the extent of the influence of stress in disease, and failure to realize the role of the mind in stress, would motivate the statement that the role of consciousness in health and disease is insignificant. I don’t see that that’s where the science is. But perhaps that’s where some scientists are. It’s rather surprising to me I must admit. Whether you believe that consciousness is physical or not, it seems obvious to me that it impacts the body continually through the nerve system. Try to pay attention to what you’re thinking, and notice what you’re body is doing/feeling depending on what you’re thinking. Learn to focus your thoughts (as in meditation) and realize your body’s response. Measure what’s measurable. The body and mind are one and whether you’ve learned it or not: your mind is affecting your body as much as your body is affecting your mind. Happy realization of that when you reach it!

    BillyJoe7:
    “Not only does the mind not cure cancer, it doesn’t even improve cancer survival rates.”

    What are you basing this statement on? You have no way to know what role the mind plays in cancer survival rates. You can’t even say it plays no role in cure. Just the decision to treat is dependent upon a mental and emotional state.

    http://www.sciencedaily.com/releases/2009/09/090914110524.htm

  23. sonicon 29 Aug 2012 at 12:52 am

    Mlema-
    Some odd thoughts-

    I notice that the studies you link to seem to be over a longer time frame than the studies Dr. N. linked to. Perhaps the advantages of healthy thinking are over longer time frames. In fact, I’ll bet there would be agreement on that.

    I wonder how relevant the studies are. I haven’t read anything by Chopra, so I may be way off here, but I’m guessing that he advocates a practice– meditation or some other means of contemplation/prayer. It is possible that such a practice could improve one’s ability to produce the effects required to maintain good health. These people would not be represented in a scientific study of the general population…

    I wonder how much of the disagreement is a matter of lingo.
    For example– it seems that few actually believe that consciousness is epiphenomenal. Yet if I say “Mind over matter,” or “Consciousness can control physical objects,” this might produce a bad reaction. To say the mind and body interact in such a way that the mind can control the body sometimes might be a more acceptable way of talking.

    Finally I find it interesting that Dr. N. talks about how his ‘worldview/ narrative in his head’ can effect his perceptions and conclusions. I’m guessing Chopra would say something like “You create your own reality,” as a means of discussing this topic.

    I wonder if they would recognize they are talking about the same thing.

    Odd thoughts.

  24. Mlemaon 29 Aug 2012 at 1:29 am

    sonic, I think you are very wise.

  25. BillyJoe7on 29 Aug 2012 at 7:31 am

    sonic: “I wonder if they (Novella and Chopra) would recognize they are talking about the same thing.”
    mlema: “sonic, I think you are very wise.”

    This thread has been reduced to a comedy act.

  26. Mlemaon 30 Aug 2012 at 11:56 pm

    sonic,

    The physiology of meditation: a review. A wakeful hypometabolic integrated response.
    http://www.ncbi.nlm.nih.gov/pubmed/1528528

    Meditation is a habit of thought. I believe that it’s effects may be enhanced by certain repetitive physical movements, but I think the research may be diluted by including various meditation or relaxation techniques that aren’t really meditation. During true meditation there are measurable changes in the brain and in the physiology of the body.

    http://en.wikipedia.org/wiki/Research_on_meditation
    (talks also about the physical effects of meditation)

    I also believe (cannot show) that over time the practice also in turn affects the thinking. I think this all turns into a “positive” cycle – improving mental and physical health.

    That’s my personal opinion (the last part)
    So, of course I will say that anyone who agrees with me is above-average in intelligence :)
    (and whoever doesn’t agree just doesn’t understand what I’m talking about)

  27. sonicon 31 Aug 2012 at 5:45 pm

    Mlema,
    Thank-you for the links.
    It seems meditation has various benefits.
    As my friend says it– “Of course i think that’s right, that’s why it’s my opinion.” ;-)

  28. BillyJoe7on 02 Sep 2012 at 5:28 am

    To Sonic & Mlema from Comedy Central.

    You might care to read this blog post for a different perspective on Mind/Body Medicine:

    http://www.sciencebasedmedicine.org/index.php/questioning-whether-psychotherapy-and-support-groups-extend-the-lives-of-cancer-patients/

    There are links to previous posts, lots of references, and the promise of a couple of follow up posts. There is also the offer of a debate with anyone who has fallen for the mind/body nonsense. Maybe one of you would care to take up the offer. Or perhaps provide a little comedic relief in the commentary.

    Mind/body: It would be nice if it were true, but it’s just woo (sorry, I hate that word, but it rhymed).

  29. Mlemaon 02 Sep 2012 at 7:07 pm

    bj,
    What did you think when you read the nlm article I linked to above?

    http://www.ncbi.nlm.nih.gov/pubmed/1528528

    also interested in you comments on:

    http://en.wikipedia.org/wiki/Neuroplasticity#Meditation

    “A number of studies have linked meditation practice to differences in cortical thickness or density of gray matter. One of the most well-known studies to demonstrate this was led by Sara Lazar, from Harvard University, in 2000.[38] Richard Davidson, a neuroscientist at the University of Wisconsin, has led experiments in cooperation with the Dalai Lama on effects of meditation on the brain. His results suggest that long-term, or short-term practice of meditation results in different levels of activity in brain regions associated with such qualities as attention, anxiety, depression, fear, anger, the ability of the body to heal itself, and so on. These functional changes may be caused by changes in the physical structure of the brain.[39][40][41][42]”

    (please see the wikipedia page for references to the research)

  30. Mlemaon 02 Sep 2012 at 8:43 pm

    sorry bj I was interrupted. I wantd to comment on the blog post. It was interesting and suggested that the latest research on therapy/support groups and cancer survival that I was familiar with was actually none too recent.

    Howver, since psychotherapy doesn’t typically ensure its effect on the mind/brain by utilizing objective measurements of brain state, it remains the case that change in thinking over the long-run, would be likely beneficial to healing (as referenced above) You can see of course the difficulty in assessing improvements in longevity, since it’s impractical to compare one outcome with another which cannot occur, and instead rely on difference in individual participants. Minds are not comparable from one patient to another, and you can’t tell when I would die if you did or didn’t do something to me – because I only die once. Of course this is unfortunate for science, and it would be great if we could see some research which applied measurable mind/brain therapy for cancer patients/survivors.

    here’s an interesting idea about measurement of the physiological effects of meditation:
    http://www.medical-hypotheses.com/article/0306-9877%2895%2990299-6/abstract

    Ideally we would verify that participants are actually “meditating” by monitoring brain activity. It’s just not scientific enough to compare people in a support group against people who aren’t in a support group. We need to know that participating in a group causes measurably different thinking – to the point of bringing about a change in brain state as compared to not participating in a group. THEN we can compare outcomes and say something meaningful about the relationship between the mind and disease.

    right now we can only say that meditation, through its beneficial effect on physiology and the immune system, improves health.
    happy thinking BillyJoe! :)

  31. sonicon 02 Sep 2012 at 11:20 pm

    BJ7, Mlema-
    The post BJ7 referenced points out that there currently isn’t a psychotherapy that can extend a cancer patients life.
    That is basically a non-sequitur– we were discussing the possibility that meditation over a lifetime might improve one’s health.

  32. BillyJoe7on 03 Sep 2012 at 8:27 am

    Mlema,

    I don’t think I’m prepared to spend much time dissecting an abstract (your first link) or a wiki entry (your second link).

    The second paragraph of your second post seems to concede that there is (and possilby cannot be) any evidence that mind affects disease and longevity.

    “right now we can only say that meditation, through its beneficial effect on physiology and the immune system, improves health.”

    It can make you feel better but there is no evidence that it improves the outcome of disease states.
    Personally, I’d rather go for a run or a cycle.

  33. Mlemaon 03 Sep 2012 at 7:19 pm

    “I don’t think I’m prepared to spend much time dissecting an abstract (your first link) or a wiki entry (your second link).”

    that’s fine. But please refrain from critiquing my assertions if you’re not going to bother to read a few paragraphs to figure out what they are.

    “The second paragraph of your second post seems to concede that there is (and possilby cannot be) any evidence that mind affects disease and longevity.”

    the 2nd parapraph of my second post explains that: research into whether or not psychotherapy improves longevity isn’t transferable to: the question of whether or not the changes that occur in the brain during meditation improve longevity – because they’re not the same thing. I wrote about apples and you referred me to a blog page about oranges. (I was cordial enough to read and reply to your oranges link. Should I not bother to do that in future conversations?)

    “It can make you feel better but there is no evidence that it improves the outcome of disease states.”

    That’s wrong. If you care to learn why you can start with research on meditation, neuroplasticity and health.
    enjoy your run! another great way to counter-act the physiological effects of stress and benefit the health of your immune system.
    cheers

  34. Mlemaon 13 Sep 2012 at 9:33 pm

    I just read this article about Lance Armstrong, and it reminded me of this discussion. “Positive thinking” is NOT what I’m talking about when I say the mind affects health. I think I tried to note that, but anyway…

    http://www.newstatesman.com/culture/books/2012/09/voodoo-cult-positive-thinking

    I thought the article was interesting.
    It makes me think about some people I know personally – they’re “well off” and have prestigious careers. They think it’s entirely because they’ve studied harder, are smarter, and work harder than people who are busting their butts every day but weren’t lucky enough to be born into a certain kind of family and catch a certain kind of break as they went along. (I’m the one bustin’ my butt and obviously I must think I’m just as smart and work just as hard as they do – and I’ve obviously got sour grapes too…hey…I didn’t say I was FRIENDS with these people…:)

    So no, you CAN’T think yourself well, you can’t WILL away cancer, but how you think does affect your overall long-term health. Sorry if I can’t explain myself better.

  35. BillyJoe7on 14 Sep 2012 at 12:34 am

    Mlema,

    “So no, you CAN’T think yourself well, you can’t WILL away cancer, but how you think does affect your overall long-term health. Sorry if I can’t explain myself better.”

    In other words you just enjoy yourself more while you’re dying of whatever.
    Glad you agree. :|

  36. Mlemaon 14 Sep 2012 at 1:04 am

    Oh my God I think I just finally understood what the hell your misunderstanding is! No, it’s not “thinking happy thoughts so that you feel better while you’re dying” Go back and read everything. Don’t skip over the links and then complain that I’m saying something that I’m not. Remember: I read your link. If you have questions, post here and I promise I will look for them and try to answer.

    thanks for reading my comment

    Billy Joe you remind me of an Alice in Wonderland character – like someone pushing a cart down the supermarket dairy aisle wailing: why can’t someone show me cheese? I want cheese! And one by one people come alongside and point out cheddar, then Swiss, then cottage… and yet you wail: “where is the cheese?” The next person then tries to show you muenster and American, yet still you wail “I want cheese!” But don’t get me wrong, I always liked Alice in Wonderland.

    later! :)

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