Hi everyone and welcome to our final video for module 8.

In this video, I’m going to

cover some interesting findings related to placebo effects and how characteristics of
the patient, the medical provider, and the medical setting can contribute to placebo
effects.

The Placebo Effect

LO5: What is
the Placebo
effect?
• Improvement resulting from the mere expectation of
improvement
• Can be from any type of procedure (e.g., drugs, surgery,
therapy)
• Can be very effective for reducing pain
• Endorphin release (shown with
Naloxone)
• Parkinson’s treatment
Placebo effects are effects that result from the mere expectation that effects will
happen. The term placebo effect comes from the Latin for “I will please”. There are
many examples of placebo effects from research but also many examples that we
probably come across in everyday life or see in popular media. For example, one
study looking at this idea found that people that have an allergy to certain types of
flowers would sneeze when they were presented with the flower, even if it was a
fake flower. This experiment showed that their expectation that they were going to
sneeze led to the effect of sneezing, because there was nothing about the fake flower
that should have triggered their allergy. An example from popular media comes from
Stephen King’s story IT, with the creepy clown. Spoiler alert: skip ahead to the next
page if you don’t want to hear it. In that story there is a boy, Eddie, who used an
inhaler for his asthma. He thought he had really severe asthma and that he needed
the inhaler to survive if he had an asthma attack. There were multiple instances in
the book when he would start to have an attack, use the inhaler, and then be able to
breathe fine again. Later in the book you find out that the inhaler was just water with
methol flavour added so it would taste like medicine, but it had no medicinal
ingredients in it. Just the fact that Eddie believed that the substance in the inhaler
had an effect led to positive effects on his breathing.

This idea isn’t just a far-fetched fiction book idea. This popular media example relates to
one of the examples described in your text showing that inhaling a useless drug
improved lung function in children with asthma by 33%.

Placebo effects highlight the mind-body connection we have been coming back to
throughout this course. They show that expectations really can create reality. For
example, many placebo effects are related to pain perception. Often, just the
expectation that you have taken a pain pill can cause endorphins to be released in
your body and then you actually do feel better. Expectations created the reality of
physiological pain reduction.

Any procedure, ranging from drugs to surgery to psychotherapy, can have a

placebo effect. In therapy, just having someone supportive to talk to and listen to
you can have positive effects even if they are not using any specific type of
empirically supported therapeutic intervention.

Placebo effects are often talked about as not the effect that was wanted in an
experiment, but that doesn’t mean they're necessarily bad effects. If you’re in pain
and then your pain is lessened, in a way, who cares if it was because of a drug or a
placebo – the main goal was to reduce your pain and that goal was accomplished.
We’ll see in module 9 how some pain reduction strategies actually try to harness the
placebo effect to help with pain reduction. So, placebo effects can be valuable; but,
they can get in the way of establishing whether an effect from something else, like a
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drug, is a real effect of that drug unless the placebo effect is carefully controlled for.
This is why drugs have to be tested against placebo controls, to see if giving an actual
drug is more effective than just the placebo effect. The drug could have some side
effects and be hard for the liver to metabolize, so we don’t want to give it to
someone if it’s only as effective as a sugar pill. If that’s the case, then just give
someone the sugar pill…

Because placebo effects highlight the mind-body connection, they are typically
stronger for things that have a subjective component, or a component where the
mind must interpret some information, like sensations of pain, rather than things
with a more objective biological component, like cancer or heart disease. Placebos
also often enhance hope, which can trigger the release of dopamine from the reward
centers of the brain and help to improve mood and outlook, which we’ve explored
before can be beneficial for the body, recognition and interpretation of symptoms,
and recovery processes.

I’ll give you a few examples showing the powerful effect of placebos for pain
reduction. One study showed that if a morphine drip is administered and the patient
is not aware they are receiving pain-killing meds, they subjectively experience more
pain than if they know there is morphine in the IV line. Morphine can lose as much as
25% of its effectiveness in reducing pain when patients don't know they have been
injected with a painkiller and are therefore not expecting to experience the drug’s
effects. This example already highlights simple things that medical providers can do to
help reduce patient pain, things as simple as explaining that they are now receiving
pain medication and they should expect their pain to subside shortly.

In another study, participants who were given an actual migraine medication but
labeled as a placebo reported less reduction in pain than participants who took a
placebo medication labeled as the real migraine medication, again highlighting this
idea of expectations leading to actual pain reduction. Further evidence for the
placebo effect being a real effect for reducing pain comes from research that
examines brain activity using functional magnetic resonance imaging (fMRI). This
research shows that when patients report reduced pain after taking a placebo, they
also show decreased activity in pain-sensitive regions of the brain.

Previously I mentioned that placebo effects related to pain reduction can happen
physiologically because just the expectation that pain will be reduced can cause a
release of endorphins in the body, which will actually lead to a reduction in pain. This
effect was discovered by using a drug that we talked about back in module 5 when
we discussed opioid addiction. That drug is Naloxone. This is the drug that can help
reverse an opioid overdose because it binds to opioid receptors in the body.
Endorphins also bind to opioid receptors in the body. So experiments using Naloxone
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showed that placebo effects that normally worked to reduce pain, like giving a sugar
pill and saying it is a pain-reliever, were no longer effective if the person was first
given Naloxone. Naloxone blocks opioid receptors, so even if endorphins were
released, they couldn’t bind to the appropriate receptors to have their pain-reducing
effects.

Another startling example of the placebo effect that is not related to pain is shown in
the images on the slide. These are images of the brains of people with Parkinson’s
disease. The profound physical effects of Parkinson’s, like tremors, are primarily
caused by low levels of dopamine in certain areas of the brain. In one study of 35
patients with mild to moderate Parkinson’s, brain scans showed that dopamine levels
could be returned to levels close to normal when patients were given the drug Ldopa.
But, the most surprising result was that almost identical levels of dopamine were seen
in the brain when patients were given a placebo. It's only one study, but the results do
seem to show a real physical effect from taking a pill with no active ingredients.

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 Factors that Affect the Placebo Effect

LO5: What is
• Provider attitudes
the Placebo • Warmth, confidence, competence, expectations (e.g.,
effect? chlorpromazine)
• Provider Communication
• Clarity about the treatment
• Patient characteristics
• E.g., spirituality, optimism, anxiety
• Setting characteristics
• Medical formality, pill characteristics

• NOCEBO Effect

Now that we’ve covered a bit about the placebo effect, and how strong those effects
can be for certain outcomes, let’s talk about some factors that can affect the placebo
effect, either enhancing or reducing its effectiveness.

1) The first factor is the attitude of the medical provider. The effectiveness of a
placebo can vary depending on how a provider interacts with the patient and how
much the provider seems to believe in the treatment being offered. Providers who
interact with the client in a warm way, convey confidence and competence, and
signal that they believe the treatment being offered will lead to beneficial results for
the patient, get stronger placebo effects in their patients. Basically, the provider
needs to convey belief in the treatment so that the patient believes in the treatment.
When the patient believes in the treatment, they can develop expectations that they
will improve, as the patient's expectations drive the placebo effect.

For example, I’ve included on this slide a graph from a study looking at characteristics
of doctors' personalities, expectations of the patient, and the size of a rash due to an
allergic reaction on the skin. In this study, a rash was induced on the skin of patients
that had a particular allergy. A cream was then administered for the rash by doctors
with different personality types. The important thing here is that the cream was a
placebo – it didn’t have any active ingredients. Researchers divided doctors into ones
that were high in warmth, ones that were high in competence, ones that were low in
both of those qualities, and ones that were high in both of those qualities. They also
asked the patients subjectively about their expectations that the cream would work
to reduce their rash. The Y-axis shows the size of the rash after using the placebo

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cream. You can see from the graph that the patients that received the cream from a
doctor high in warmth and that exuded competence, and that also had positive
expectations that the cream would work to reduce their rash, had a significantly
smaller rash size than any other patients. This study highlights how both the
behaviour of the medical provider and the expectations of the patient are important
for placebo effects. And the behaviour of the provider can really affect the
expectations of the patient.

Now, provider attitudes can work both ways, either enhancing or decreasing the
effectiveness of treatments through altering patient expectations. An example from
your text that highlights how provider attitude can negatively impact patient
expectations, and thus the effectiveness of treatment, is shown in a study with
chlorpromazine, a tranquilizer drug commonly used with psychiatric patients. In this
study, the drug was either given by a provider who expressed great confidence in its
effectiveness or who voiced doubt about its effectiveness. The study revealed that
when the provider expressed doubts about the effectiveness of the drug, the drug’s
actual effectiveness dropped from 77% to 10%, which is a huge drop.

2) The next factor we’ll look at is provider communication. We touched on this

topic quite a bit in the previous video. We know that it’s important for providers to
clearly communicate with their patients. One thing that can be affected by
communication is the placebo effect. Since it is based all around expectations, the
patient has to have a clear understanding of what the treatment is supposed to do,
and what they need to do, in order to develop those expectations that the treatment
will lead to improvement. Effective communication between the patient and provider
can increase the strength of placebo effects, which is another important reason to
ensure this communication is as effective as possible.

3) The third factor that can affect placebo effects is characteristics of the
patient. These characteristics can relate to both the personality traits of the patient
and also some of their typical beliefs. These characteristics then interact with other
situational variables, like the attitude of the provider, and the effectiveness of
provider-patient communication, to help either enhance or detract from the
effectiveness of placebo effects. People that rate themselves as higher on spirituality
tend to show stronger placebo effects, perhaps because spirituality may be related
to their strength of belief. We also know that optimism contributes to positive health
outcomes in many ways. This characteristic is likely also related to strength of
expectations, since one of the hallmarks of optimism is expecting more good rather
than bad things to happen to you.

An interesting patient characteristic affecting placebo effects is anxiety. People that

are higher in anxiety actually tend to show stronger placebo effects. This may be due
to the strength of the mind-body connection in people high in anxiety. Because the

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anxiety typically produces a lot of negative physical symptoms, if the highly anxious
person believes that a treatment will work for them, that can help to reduce their
anxiety, which can then reduce some of those negative physical symptoms that were
caused by the anxiety. This effect wouldn’t be as strong in someone that didn’t have
the stronger physical effects from anxiety in the first place.

4) The last factor we’ll touch on is the characteristics of the setting. A setting
that has a lot of features of a medical practice, so that things feel very official, like
medical looking machines, people in medical gowns and white coats, and medical
supplies around, will induce stronger placebo effects. This result might be related to
increasing the expectations that the treatment will work. If you feel like the setting is
professional and this is what these people do, so what they recommend must be
legitimate, that perception can increase your expectations that the treatment will
work. It’s similar to that idea of authority being attributed to people in a white coat.
We’ve been conditioned through experience and media to believe that medical
providers in white coats know what they’re doing and have a sense of medical
authority. That belief can help strengthen expectations that what the person in the
white coat in the formal medical setting tells us is true (i.e., that the treatment will be
effective).

The setting can also apply to things like the characteristics of the medicine. Studies
have shown that pills that seem more like ‘medicine’ induce stronger placebo effects.
Imagine taking a chalky white pill vs. a colourful gummy pill. You probably associate
the chalky white pill more with what a medicine is supposed to be like, so that type
of pill will have a stronger placebo effect. There is also interesting information about
the specific colour of pills. Your text describes how green and blue pills are
associated with having a sedative placebo effect, while yellow and red pills are
associated with having a stimulant placebo effect. This effect might be related to the
types of feelings we initially associate with those colours. Green and blue tend to be
more calming colours in general, while yellow and red tend to be more fiery and
energeticseeming colours. White pills are often perceived to be better at painkilling,
which may be related to our prior experience taking white pills that are meant to
reduce pain.

Before we finish our discussion of placebo effects, I wanted to touch back on a topic
that I briefly covered with one of the examples. Recall the example about a medical
provider expressing doubt in a treatment leading to less effectiveness of that
treatment, specifically the tranquilizer drug chlorpromazine for psyciatric patients.

This effect is called a nocebo effect. While placebo is Latin for ‘I will please’, nocebo is
Latin for “I will harm”. It’s important to know that these effects can go both ways.
They can really increase the effectiveness of some treatments, but they can also
really reduce the effectiveness of treatment. One startling example of a nocebo
effect was seen in a study examining the effectiveness of chemotherapy. In this

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study, a group of people received chemo and another group received saline but were
told it was chemo. In the group that received saline, 30% of the people still lost their
hair, even though they didn’t receive any chemo drugs! They lost their hair just due
to the expectation that they would lose their hair. Since this is a negative effect, it’s
called a nocebo effect. We can see from this example that expectations can have
strong effects for both the positive and the negative. It becomes very important to
consider what kind of expectations a provider may be consciously or unconsciously
contributing to in a patient with their particular communication.

And that brings us to the end of our video content for module 8. I hope that
throughout this module you’ve appreciated the impact that care settings can have on
people and their health, as well as the powerful impact that relationships and
communication with care providers can have. We’ve again seen many areas of health
that a Health Psychologist may be able to play an important role in, from studying
adherence to procedures within hospital settings, to helping both patients and
providers communicate in the most effective way possible. Now we can add to that
list studying placebo effects to try to maximize the positive benefits of placebo
effects for patient treatment.

Enjoy exploring the rest of the content from module 8! I’ll see you back here for
module 9, where we’ll revisit the topic of pain that we touched on a bit in this video
with placebo effects. I’ll see you then!