Ls VA SN a a! Nonconscious activation of placebo and nocebo pain responses Karin B. Jensen™*<1, Ted J. Kaptchuk®, Randy L. Gollub***, Martin Ingvar*, and Jian Kong”*“ “Deparimer ving Kirsch, Jacqueline Raicek*, Kara M. Lindstrom*, Chantal Berna, Sf Paychiy, Masachusests General Hosialiarard Meskcl Snool Charlestown, MA 02129; Program in Placebo Stu, eth tae! Deaconess Meaical Centeariard Medal School, Boston, MA 02215, ‘MGHIMIT=HE Athineul A Marunes Center for Brmedial Imaging, Chalestown, MA, *cr00 of Byerelogy, Plymouth University, Pymou PU BAA, Unite Kingaor,“Depertment of Clic Neuteslence,Oshe” Center for cegratve Medicine Raroinca msetitet 17178 Stoccho, Sweden’ and ‘Dion of Pain Mesiche, Deparment of Arete, Creel Care and Pal Mdihe, Nassachusets General Hospi, Boston, MA 02108 Felted by Tomas 6. M. Hokfet, Karolinska istturet, Stockholm, Sweden, and approved August 6, 2012 (received for review February 3, 2012) ‘The dominant theories of human placebo effects rely on a notion that consciously perceptible cues, such as verbal information or distinct stimull In dassial conditioning, provide signals that activate placebo effects. However, growing evidence suggest that behavior can be triggered by stimuli presented outside of con- scious awareness. Here, we performed two experiments in which ‘the responses to thermal pain stimuli were assessed. The first ‘experiment assessed whether @ conditioning paradigm, using Clearly visible cues for high and low pain, could induce placebo land nocebo responses. he second experiment, ina separate group fof subjects, assessed whether conditioned placebo and necebo responses could be triggered in response to nonconscious (masked) ‘exposures to the same cues. A total of 40 healthy volunteers {28 female, mean age 23 y) wereinvestigatedin a laboratory setting Participants rated each pain stimulus on a numeric response scale, ranging from0 = no panto 100 = worst imaginable pain. Significant placebo and nocebo effects were found in both experiment 1 (using ‘dearly visible stimull) and experiment 2 (using nonconscious stim= Ul), indicating that the mechanizms responsible for placebo and nocebo effects can operate without conscious awareness of the tig- ‘gering cues. This isa unique experimental verification of the influ ‘ence of nonconscious conditioned stimuli on placebo/nacebo effects land the results challenge the exclusive role of awareness and con- ‘sous cognitions in placebo responses. Piste and edo ete ae xia components of meal ‘practice and clinical research. Placebo analgesia and nocebo hyperalgesia are the most robust and well studied of these elfecs. Learning is known to play an important role in placebo and nocebo effects and the dominant theories invoke classical conditioning and expectancies as explanatory tools (1). Both rely fon a notion that the conscious perceplion of sensory of social stimuli, such as the cue that triggers expectaney or the condi tioned stimulus in classical conditioning, are needed to obtain placebo responses. In some circumstances, conditioning may be fn automatic nonconscious process, but in most cases, t seems to involve the formation of expectations (2-4). However, itis not known whether conscious perception of conditioned stimulus i, needed to elicit a conditioned response There is a large literature suggesting that behavior can be motivated by stimuli that ate not consciously perceived, because they are presented at low intensities or masked from conscious awareness (5, 6), sometimes referred to as subliminal stimuli Nonconscious operations are considered a fundamental feature ‘of human cognition, for example in reward processing (7,8), fear learning (9, 10), and social behavior (11, 12). Furthermore, evi dence suggests that conditioned responses may be acquired ‘outside of conscious awareness (13-15), Neuroimaging studies of the human brain suggest that certain structures, such as the striatum and the amygdala, can process incoming stimuli before they reach conscious awareness, and thus they may mediate nonconscious effects on human cognition and behavior (16, 17). Ithas never been investigated, however, whether learned placebo and nocebo responses can be triggered through this cerebral circuit that bypasses conscious awareness, ‘Placebo and nacebo may be seen as the behavioral response to signals of reward and threat, respectively. Considering the neu- robiological evidence for nonconscious processing of reward and threat signals, placebo and nocebo responses would have the potential to be activated by masked stimuli. Here, we experi- ‘mentally test this hypathesis and explore the role of nonconscious ‘mental processes in placebo analgesia by investigating whether conditioned placebo and nocebo responses can be activated by ‘masked stimuli (2 = 40), Conditioning was performed with clearly visible cues and a subsequent testsequence-measured placebo dand nocebo responses to either visible (unmasked) or noncon- scious (masked) cues (see Fig, 1). Our goal was to test whether conditioned placebo and nocebo responses could be activated by both consciously and nonconsciously perceived cues. Results Experiment 1. Experiment 1 was designed to ascertain that con- sliioned placebo and nocebo pain responses could be elicited by consciously perceived stimuli, An initial conditioning sequence, in which high and low thermal pain stimuli were paired with clearly visible exposures of two male faces on a computer sereen, produced a mean rating of “high pain” at 63 (4: 221) on a me ‘meric response scale (NRS), ranging from 0 (no pain) to 100 (worst imaginable pain), and “low pain” at 24 ( 17.4) on the NRS. The test sequence, also using clearly visible stimuli, revealed significantly higher pain ratings in response to the high {ace and lower ratings forthe low face, despite identical moderate temperatures. The control condition, paited with the same ‘moderate temperature, resulted in pain ratings in between the high and low conditions; ANOVA main effec for face type (high! lowjcontzol) F(2, 36) = 24, P < 0.001, All pairwise comparisons between the highiiow (P < 0.001), highicontrol (P < 0.001) and Iov/control (P = 0.003) congitions were significant (Fig, 2) and all subjects reported that they could clearly discriminate Between the different faces during the test sequence. Correlations (Pearson's?) revealed that there was positive correlation between the dif- {erence in high minus low pain ratings during conditioning and the high minus low pain rating during the test sequence af ex- periment I; r = 0.608, P = 0.006 (Fig. 3). Analyses of alpha re- Liability (Cronbach's alpha) showed thatthe three conditions of [ks peromed eseroy RL. ang conte new teageranaiac tase 2 Ee Ck dese ted He Jac eat Ca RL FI7A av | a A CONDITIONING TESTSEQUENCE B EXPOSURE LENGHTS Experiment ik omen “I in.....7) F A) OS 3 pom at FE 0 i N + MoneRATE nest —>| Cone Faem Fig. 1. Experimental procedure and visual exposures. (2) Overview af the experimental design of experiments 1 and 2. Conditioning sequence was per formed where clearly visible images of two male acs were used as vsual ues, presented ona computer sven, Each face cue was consistently paied With 3 rapid high or low heat pain siulus on the subjects arm. After she condoning phase, there wat 8 Crt sequence n which the high eve ow cue, And {neural cnttl cue were pared with identical moderate heat simul Subjects were asted to ate the pa Intensity in response to each simul (8) periment 1 the face cues were expose fang enough for al subjects to clearly recognize them (100m) but m experiment 2, ne Tac ces were exposed for ‘nly 12 ms ana then fllwed by @ mask to preven conscious recognition. aces reprintea wth permission fom ref. 50. Copyright Karolinska Institute, Department of Clinical Neuroscience, Section of Pyehalogy,Stodkhol, Swede, the test sequence in experiment 1 (high facellow facefcontrol placebo and nocebo responses and also indicated that their face) displayed a reliability of 0.98. The pain ratings during the magnitude was predicted by the difference between high and low test sequence were not affected by the factor “time” F(2, 32) = pain ratings during the learning phase. 28, P=0073 and there was no interaction between pain ratings X time F(2, 32) = 22, P = 0.134, validating that pain habituation Experiment 2. Experiment 2 was designed to test the unique by- or sensitization did not confound the placebo'nacebo responses. pothesis that conditioned placebo and nocebo responses could Tn conclusion, the results from experiment 1 showed significant be triggered by masked, noneonscous simul. In most respects, Experiment 4 Experiment 2 e001 p<001 2°] 2 1=.008 z ee a 3 aks Low Cue Control Cue High Cue Low Cue Contrel Cue High Cue Fig. 2. Pain ratings in response to identical temperatures during the test sequence After aconivoning series of high- and low-pun temperatures (paired | previously unconditioned cue, alle the contro cue. Graph represents the average pain rating in response to identical moderate temperatures, paired with tach ofthe thee alfferens cvs. In experiment 3, the cuer dung the ter sequence were death recognizable. Experiment 2 wat perorned Ina separate (foun of subjects and he cues of the test sequence were exposed so gully tha subjects could net consciously recognize them. ror bats represen OAxpernantt Experiment? 2 ° 3 ° =o] ce i °° Blo. 3 o| 8° a = ° : ° 5 aol oe g"| co ° Test-sequencesiferenc HighiLow pai ratings (0-00 NRS) Fig.3. Corelation between conditioning and the magnitude of subsequent placebo and ing phase corelated signlartly to the maghitue ofthe placebo: and noceboliteetfecs during the est Sequence, both for ‘tings during the cord esoquencs ference HighvLow pain ratings (0-100 NRS) cebo pain rezponses. The dference between high: and low-pain ‘orscou experiment I) and nonconsious cues (experiment 2) Scalterpols represent the posive correlation between the aference in high: minus lw ‘ain ratings during condoning su andthe high minu lowpsn ratings during the tex sequence a experiment r= 0.608, P0006 experiment ?, room, P <000), the methods in experiment 2 were identical to those used in experiment 1. The only dilference was that all faces during the {est sequence were presented for 12 ms followed by a visual mask for 84°ms, resulting in comparable visual exposures for both ‘experiments (aces shown for 100 ms in experiment 1). The conditioning sequence in experiment 2 was performed with ‘early recognizable images and produced a mean rating of “high pain” at 32 (19) and “low pain” at 21 Ce 118) NRS. The test Sequence, however, was pesformed using masked images, pre venting subjects from consciously recognizing the simul. AS in experiment 1, the results ftom the te sequence revealed sig- nieanlly higher pain ratings in response to the high Lace, lower zatings forthe low face, and intermediate ratings for the contol face, despite identical moderate temperatures, ANOVA m: ‘llect for face type: FU, 18) = 11, P< 0.001. All pairwise comparisons in experiment 2 were also significant despite sub jects inability to consciously distinguish the faces Irom each other; highvlow (P = 0,002), highicomtrol (P = 0011), and low Control (P= 0.008) (Fig. 2), cortelation analysis (Pearson's) revealed postive cortelation between the dilference in high rninus low pain ratings during conditioning ané the high mainss low pain rating during the test soquence (7 = 0.822, P < 0.01), indicating. that the. magnitude of masked placcboinocedo responses could also be predicted by pan ratings during cont tioning. Analyses of alpha reliability (Chronbach's alpha) showed thatthe three conditions of the test sequence in experiment 2 (@nasked hip facelow facelconsol face) splayed a seb of (097, The pain ratings during the test sequence of experiment 2 were not allected by the factor time F(2, 38) = 08, P= 0.489 and thete was no interaction between pain ratings x time FC, 32 22, P = 0.134, validating that pain habituation oF sensitization ‘dd not confound the placeboluoeebo responses ‘All subjects in experiment 2 reported being unable to con- sciously diteiminate between the dlferent faces during the test, Sequence. To control for any potential variance due to difer fences in recognition of the Laces in experiment 2, the osteome from a subsequent masked face recognition test was used as ‘covariate in the overall ANOVA, which demonstrated non- Significance, FU, 18) = 0.69, P = 0.414, Fusther validation that the images were indeed nonconscious was demonstrated by an analysis revealing that subjects ability to recognize the masked images, represented by the individual recognition rates, was ‘uncorrelated to the effect of high minus low pain during the test sequence (7 = ~0.253, P = 0.296), Discussion Results from the present study demonstrate that placcho and rnocebo mechanisms can be triggered by nonconscious cues, op- erating outside of conscious awareness. AS far back as 1885, Peitce and Tastrow suggested that nonconscious cues could in: fiuence somatosensory perception (18). Since then, a large liter lure as suggested thal nonconscious signals of threat and relict an be processed by suboostical (but also comical) structures in the brain and influence behavioral outcomes (8, 19). Recent theoretical analyses have also suggested the possibility that lax cebo and nocebo responses may be mediated by noaconscious ‘operations (20, 21), what Kiblstrom called the “cognitive un- conscious" (22). Previous studies (13-18) have demonstrated that fstociative learning ean be obtated by the use of noaconscious ‘Mimi ducing the acquisition of conditioned responses. Ia the present study, we extended the understanding of noaconscious opnitions by showing thal explicly conditioned placebo anal aetia and nocebo hyperagesie responses can be activated by nonconscious eves, Ou results therchy translate the investigation Sf nonconseious effects to the clinical realm, by suggesting that health-related responses can be triggered by cues that afe not consciously perceived, not only for pain which is one ofthe most common reasons for seeking healthate (23), but als for other ‘medical problems with demonstrated placebo effects, eg, asthma (G8), depression (25), and initable bowel syndrome (38). Une derstanding the role of nonconscious procesces in placebo/nocebo ‘opens unigue possiblities of enbancing clinial care by allending PRES | September 25,201 | vol 109 | no.38 | 18961av to the impact of nonconscious cues conveyed during the therse peutie encounter and improving therapeutic decisions ‘Common theories of placebos involve expectancy and classical conditioning, and both mechanisms, although they can be hard to separate, involve conscious perception of the stimulus tha ects the placebo or nocebo response (3, 4). Our study is clearly dis tinguished from previous. studies ‘because it focuses on the nonconscious activation of placebo/nocebo responses and dem “onstrates that placebo/noccho can be activated even if the con- tioned stimulus is not consciously perceived. In traditional placebo studies, conditioning is often used by pairing the ad- ‘ministration of an unconditioned stimulus (e.g, effective an gesic pill, cream, or injection) with a conditioned stimulus (€ 8. Inert placebo pill, cream, or injection), thus producing placebo responses through “associative learning” (27-30), Even if asso- ciative learning in such studies has been described in terms of {2 “nonconscious” mechanism (in which cognition may be an epiphenomenon, rather than part of a causal chain), the activa- tion of the conditioned response has always been obtained by a perceptible conditioned stimulus. Furthermore, much of the tevidence for conditioning effects in human placebo experiments demonstrates that a conscious cognitive component plays a sig- nificant role in the placebo conditioning. For example, Mont- gomery and Kirsch (31) replicated Voudouris et als (32, 33) carly conditioning placebo experiments and found that conscious awareness of the conditioning process eradicated placebo con- dlitioning. Recent work by Watson et al. (34, 35) also supports the notion that conscious expectation plays a dominant role in conditioned placebo responses. On the other hand, in one of the ‘most compelling experiments of placebo effects and condition- ing, Benedetti and colleagues (36) showed that conditioned im- ‘mune and endocrine placebo responses could stil be elicited by. saline placebo even if the subjects were given clear verbal directions not to expect any positive change. Given that subjects were aware of the injections of saline (the conditioned stimuli in this experiment, Benedetti later noted that “a [remaining] key uestion is: does unconscious conditioning exist in humans? (Gel 37, p. 53). To the best of our knowledge, our study presents lunique evidence that conditioned placebo responses can be ac- tivated by cues outside of conscious awareness. ‘Our results and proposed model, shed light on findings from two previous clinical placebo studies that investigated how pain :atings can be affected by the interaction between patients” and clinicians’ expectancies of pain relief, In one study, Gracely et al. (G8) found, in a double-blind experiment of pain relief, that the clinician's 4 priosi knowledge of the likelihood of administering fctive analgesic treatment vereus placebo was transmitted to the patient and influenced the placebo response. In another study, Levine and Gordon (39) compared the double-blind admini- {ration of morphine/placebo by either a hidden person or a hid- den machine and found that the placebo response was significantly lower in response to the machine, We speculate that in both studies, subtle cues that the clinician conveyed to the patient may have been perceived without conscious awareness ‘The outcomes from these experiments suggest that placebo and rnocebo effects in the clinical setting might not only be induced through explicit instructions and explanations, but also Uhrough rnonconscious cues. embedded inthe patient-clinician. in- teraction, Nevertheless, neither of these experiments explicitly tested the hypothesis that the findings were due to nonconscious cue mechanisns ‘The present study demonstrated successful activation of pl cebo and nocebo effects in responses to both explicit (experi. ‘ment 1) and nonconscious cues (experiment 2), sggesting that different levels of brain processing may be involved, Previous placebo and nocebo neuroimaging studies (40-44), using explicit tues to evoke placebo responses, conclude that conscious pla- cebo effects recruit a combination of cortical and subcortical brain regions to modulate pain, Brain imaging studies also sug- gest that the brain can process environmental cues even if they are not reaching constious awareness, largely through sub- Cortical regions of the brain such as the amygdala and ventral striatum (8, 10). Thus, we speculate that nonconscious cues may ‘work through the subcortical regions of the brain to produec placebo and nocebo effects. Furthermore, we speculate that rhonconscious placebo and nocebo effects may not use the commonly reported cortical regions of the brain, such a8 the rostral anterior cingulate cortex (40, 43) and the prefrontal cortex (41, 42). Conversely, they are likely to be processed in subcortical parts of the brain that rely ox @ minimal account of ‘awareness, such as the basal ganglia, Tn summaty, the present study provides an experimental demonstration of the influence of consciously nontecognized stimuli on conditioned placebo and nocebo responses. It suggests that cognitive modulation of pain can be exerted without con- cious awareness of the triggering cues. Our results point to the importance of a care process where the trajectory toward health is seen as a learning experience that is highly influenced by the activation of nonconscious environmental cues. Future studies will show whether the present findings can be translated into a clinical setting where nonconscious effects on health-related behavior and treatment outcomes can be further validated, In addition to pain responses, conditioned placebo effects are known to affect a variety of clinical symptoms (24, 45-17), sug- gesting that the present findings could be translated to other Aisciplines than pain, In addition, foture studies should establish whether conditioned placebo and nocebo responses could be obtained with the use of nonconscious stimll also during the fequistion phase of the conditioning procedure Materials and Methods In total, 4 healthy subject ware include in tht study experiment 117 = 20 Subjects, 13 women and 7 men, mean age 22 = and experiment 2-1 = 20; Ti women and 9 men, mean age 24 24) All subjects were right hended, ‘with fast mage exporoes or backward-atking experimen Subjects Were Fecrited Uwough posted fyers at several eiferent universes and a ree ermal pain stil were delivered uting the Pathway CHEPS sytem from Medex with 827mm dameter CHEPS thermede. The calibrted goa er peratures were reached witha ramp uptime 9300 ms and the duration of 3c pain stimulus was 35. An 85H, 17.neh cathode ray tue menitor NEC ‘Accuyne) was use for vsuel presentations andthe masked stimulus pre fentatons were synchronized with the refresh rae (2 ma. Screen resol ‘lon vas 1,024 x 768 pitas and the experiment was programmed in Presentation 13.0 (Neurobehaviralsjtems). The mage used in the cartent Ciperiment were taken frm The Karate Dtete!Emotonal Feces set (KOEN Ui, 2 set of imager specifically developed for wre In perception, tenon, emotion, memory, and backward masking experimen’. The Sohole set consists of 70 Inaviduals (5 mate, 35 female), mean age 25 {Tange 20-30) with seven diferent facial expresions per invigus. The Images used in the present experiment only represented men in contol epressions, Le, no emetional valence In ota 24 male faces were wed for Subjects were screened for insion and exuson crea over the tle phone and then scheduled for an experiment. Subjects wer informed that ‘the Rudy invertigated “the nflence of impli and expt esring on ain perception” but the full purpose of the study was not revealed unt the eperment was over. llsubjects gave written informed consent and the “General Hosp The experiment was cared out ina quit room at constant temperature (23-°Q, subjects were seated infront of 2 dest withthe monitor placed fraigh in front ef them: 70 cm from the subjects face. The desk faced 2 wall preventing subjects rom visual astvacions. the thetmode stimulator pain was performed by means of ascending temperatures, artng fom {80°C followed by a randomized series of maxed high anf temperatures, ‘The goa! was to find temperatures that would ek high pain at "60 of 100,Ls VA a fon 2 €-100 NRS and low pan at ~20 NAS. The aifference between the hign paifow pain coul be represented by 4946 “Cin one individual and a7 a8 Cin another. After subjective calbration ot heat pain, subjects were gten the folowing turer on the screen Each picture ix paired ith a pain smal on your arm. "Your tack to four on the sreen at liner and afer ench picture would Ike you trate ow much pain you felt on your ae, using the same 0-100 verbal ale that you wed during the clit.” To ensure that subjects Blocks of-7 min each In between the to Black rabjecs hal the chance 2 stvteh ther legs and leak away from the monitor fr about 15 min oF a5 long at they needed. In total, 30 mull were presented during the cond tioning sequence: 25 forthe highpain face and25 for the loupain face The semenrany GON wat 15 range 13-171). In Both experiment 1 and ex periment 2, the two male facer stzocated with high or low pain were ‘ounterbolanced to reduce the posi that a certain face would or Urbute to high or low pain ratings. Immediately after the conditioning se uence, ubjecs were given the flowing intrucion “You are sbout to 06 ‘the same picures onthe sreen again and each picture wil be pared wth 2 pain stmulus on you am jst ke before. The only ference tha hs lime there wil ao be pictures of new gy, hat you haven’ nee exposed te before. Your tar it to focus on the screen at all timer ana ater each Picture | woud lke you to rate how much pain you flv on your arm using {he 0-100 verbal scale.” In experiment 2. the fllwing sentence was abo taided "During thi Sequence, he pictures wil be shown to You mu ater and something that we programmed on purpose. Your only 25s to focus, fonche screen ata times and rate the pain on your arm, evenifyou can tsee the pitures" The test sequence consisted of 60 stimu 20 fo the high-paln ‘andtion 20 forthe lowepan conltion, and 20 fr the cantel conan, between, allowing Subees to maintain a high level of aareness and lesen straining f the eyes. Tw high feces and wo low faces in each ofthe three fins were paired with their original temperatures, to prevent extinction periment, the exposure time af the faces during the tert sequence 8 100 Ps. nwxperiment 2, oe exposute ime of he faces dung "ne es sequence ‘War 12m (one refresh eye) and then a mase was expoved fr 84 me even Tetredh cycled, The mask condsted of an abtract image tht had the same ‘nso properties atthe faces, but war not reprerenting anything more ‘than a ramber of small squares put together. The same mask Was Sed for all Tacs in experiment 2. Duting the elbration, condoning, and test se uence, the experimental leader was placed in chal n the Bugk of the fom, icing the subject's back. The experimental leader repested exch, ‘verbal pain rating in a monotonous and contral voice before recording the rating Inehe subject's protocol the subject experienced an ncongrueney, 5 (he) wa insted to make a que correction, eg. sy “No, not 8, fe TEEN” Only in rare cases (1%), such corrections wore required. Moreover Fi Rape 7, le ened F200 Phas 4. Stenartians, Pode) 008 The pheebo eet Disehing the epee vest condorng debt. ha a 224-3 5. Canes Rhos G01 The wears it How he past f gna operates 6. Dikstemus& Aare, Sith PE (205) The power ofthe sublina On subliminal Penton and etn petenalopaestan Tre New Uneanas Sea! gre nd Ss Nearrcene (xfer Uni Prey, Hew Yor. bit do rat hange speetcercy tao. Copan 153300035 1. Posigtone Mecca 2009 Sunil true condoning demonsted nthe 9. arson ea 00 fear arte rs Manguiton of aren greater eect: Boge ela the placement of the experimental leader allowed for constant monitoring te make sre that subjects were truly facing the screen and not leaking in ther erections the exposure time ofthe cures allomea them to see eath pure propery ‘ofthe picture and dcriminate beeen the ferent face, Toverify nat the Slimllin experiment? weuld be tly nonrecognizable Wwe ist conducted forthe visual paradigm of experiment 2 and then asked to perform 3 face ‘he sreen again and I would Ike you to answer if you have seen tis face before during the exzeriment. You ean on say “yes” of "no." The pietures willbe exposed to you very quickly $0 you might rot be able to tell you Saw i before or notin any ease, you have to guess "es" o "no" Tor each ‘rporure.” The recognition test nuded "2 exposures of the prevouty wed {aces and 12 exposures of new faces and partpan's were asked‘ inaeate iether the fate hed been exposed before, oF not. Mean accuracy of entiation wat 53% (2 10) P= 0466, coniming that tne sim ware indeed nonrecognizable and thus the parameters were used i experiment vwinether they could recognize the inages propel Al subject In expe ‘masked faces. Tovey this hey were abo presented wth the face recog ‘ivon tes, wed in the methodological pilot study. The accaracy of the ‘a repeated measures ANOVA. Results validate that there was no significant tes, for any ofthe two exporures ofeach face [inet faces, ol faces ‘ith tro exposures each = 26 exposues in total Fs exposute, main effect for face type Ui, 18) = 9072, P= 099, nonsigncant second exporue rain effet for face ype A. 18) = 0397, P0538, nosignifeart] The Inesn accuracy inthe recogiton tet ster experiment ? was 58.9% (10), P0.008, onesample tte Four indiidualehad recognition rate >70%, Terult of experiment 2 war Pil significant, even i he subject wth the highest recognition accuracy were removed fom the satstal anaes recognition accuracy 52% (s8),P 0.392, onezample tte Significant main ‘tect for face type ns repested measures ANOVA wat: F,22)=725, P= 1.008 and wgnicant puiruise comparsons between the highow P< (3.008), highiconvol «0.047 and lvleotrl condition < 8013). rate Sith Counel for Working ie and Socal Researen to KB) and ‘ant REIATOOIAST National Center for Complementary and Aeinstve Medicine, NCCAM), RIBAT2183"7 (ational Iattute on rug Abuse, ROVATOOGSEA (NCCAM) JK), K2MATOOAOSS (NECAM) fo TK), OLATO0S2&0 (NCCAM (0 RL, 12. san Spencer 2am MP 200 Sabin peming td penn Suing 12, Bane Se. sens ong Pet W199 Fatt “ 14, Cl RE Mene ge UR QOD Cia condoning. awwen and bn 15, Cheer ur © bmberg Oh A (99) Norra aoc kari 16. eboun (900 Tetra San Simon & Sener, Nee Yor 17 Edn ett 20 aa eer in a ace pred ulated ucoscy proceed eles ron to 1056 14. ree svat on onal deenarnseratn oma of he Mate Soe 20, Hugi 19) Laing the aes tec Alt, ely and condoning Pr 20 2. 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