# Motivation and emotion/Book/2023/Placebo effect and emotion

* Multimedia presentation (3 min)

## Overview

* Olivia's Story
* Olivia is a 35-year-old female who, for most of her life has suffered from chronic pain and fatigue while getting severe flareups when dealing with a lot of stress. However, these severe flareups usually last a few days and Olivia can go back to her usual self, while unfortunately still dealing with her chronic pain, although this is not as bad as her flareups. Recently Olivia's relatives were coming to visit Olivia and her family at home, for a few days and this frustratingly came at a stressful time as Olivia had been working long hours from home, as she was the lead in a team project and this was already taking up a lot of her time at home. Olivia was unsure of what to think and do as she knew that she was expected to provide a warm welcome for her relatives but she knew it was going to exhaust her energy. Olivia prepares the dinner and the other dishes for the upcoming days and is overwhelmed by stress and anxiety about her relatives coming to visit and stay at her home. A few days later Olivia experienced painful back cramps, where she could not move and her whole body felt inflamed. After waiting a few days and noticing that the debilitating pain was not going anywhere, Olivia goes to get a blood test done to unfortunately find out that she has an auto-immune disorder called lupus, where her immune system attacks her healthy cells thus causing severe inflammation in her body. She explains to her family what she has found out and in turn her family do everything they can to keep her spirits high.
* Olivia had noticed significant differences in the way her body felt when she was not stressed and it made her realise that her emotions and her mind are very important in helping what affects her physically. Over the next few months, Olivia is doing everything she can to create a healthy work-life balance, while her family continue to keep Olivia's mind off the pain. Over time she started to notice that her inflammation had gone down in her joints and muscles and that she was not feeling as though her whole body was in pain, Olivia was starting to feel happy.
* Although Olivia still unfortunately had lupus, she was able to manage the chronic pain much better and realised that her mental state and emotions played an important factor in why she was not able to help reduce the pain of her severe flareup for a while. She knows that stress played a significant role in the chronic pain she was experiencing and knew that moving forward it would be very crucial for her to learn how to regulate her emotions and think positively, while not taking on too much stress at once.
* Although Olivia did not take any placebo treatment, we can see that her mental state and emotions played a significant role in reducing the severity of her chronic pain and flare-ups, thus helping her focus on what she needs to do to help control her severe flare-ups and manage her chronic pain.
The placebo effect can be defined as a phenomenon formed when an inert substance is provided to the patient, similar to a normal treatment thereby improving the patient's clinical outcome (Quattrone et al., 2018). Typically a sugar pill or an inactive drug treatment is provided to individuals, that has been shown to produce actual effects in helping patients' quality of life, by relieving their symptoms and improving their overall health and well-being (Tang et al., 2022). The placebo effect has been shown to work well when the treatment in context and efficacy of the "placebo" treatment is described positively to the patients in reducing their pain and improving their symptoms (Tang et al., 2022).
The concept that pain can lead to feelings of negative emotions such as fear and anxiety can seem quite obvious specifically if the pain the individual is experiencing is chronic (Wiech & Tracey, 2009). However, there is a lot of new research highlighting how negative emotions can potentially cause pain or exacerbate it (Wiech & Tracey, 2009). It can be beneficial to understand how the placebo effect works to potentially reduce negative emotions such as fear and anxiety and induce positive emotions such as happiness, as this may lead to reducing pain, thus improving patients' overall well-being.
Ethical considerations of the placebo effect are important to discuss and understand, as there is a large concern around deception when administering the placebo treatment to the patient (Kaas et al., 2018). Another issue regarding the use of placebos is that there are concerns about using the placebo effect as an "easy fix" and potentially resulting in administrators and healthcare staff dismissing and neglecting important psychological concerns that may be related to the acute or chronic pain the patient may be experiencing, which can do more harm than good.
The nocebo effect is a notable con to the use of placebos and is the opposite of the placebo effect, which is often described as the dangerous side which induces negative emotions (Flaten, 2014). There are several ethical considerations and issues regarding the use of placebos, such as autonomy which is an important factor in health care systems. There is also the risk of dismissing any psychological issues while administering and treating the patient with a placebo treatment as an "easy fix", which can be extremely harmful to the patient (Kaas et al., 2018). However, the pros or positive outcomes of the use of placebos include the reduction in negative emotions through negative reinforcement, which can help minimise the patient's chronic or acute pain, therefore inducing positive emotions such as happiness.
* Focus Question
* Do you believe there is more to the commonly understood scope of placebos and how they induce positive emotions to help make people "feel better", in terms of the clinical significance of the use of placebos?

## The placebo effect and emotion

Negative emotions such as fear and anxiety can increase the likelihood of pain[Why the sudden focus on pain? Explain] within our bodies and it has been hypothesised in many studies that placebos can reduce pain through reducing negative emotions (Flaten et al., 2011).[Provide more detail]

##### The theoretical background

In most cases the beneficial effects of the treatment are explained to the patient and the placebo effect starts to modulate emotions, through verbal communication of the administer describing that the pain-relieving treatment has been administered to the patient (Flaten et al., 2011).
Two main effects occur upon administering the placebo treatment:
* it may reduce negative emotions such as fear and anxiety or
* it can influence an overall positive emotional state
Research conducted by Flaten et al. (2011) proposed a model regarding the placebo effect. The model proposes that the modulation of the emotional process is involved in the placebo response which is commonly seen in many different placebo responses. The study further explains that unspecific processes are involved in the placebo response due to the general nature of the modulation of the emotional process (Flaten et al., 2011).[vague]
Lastly, Flaten et al., 2011, model proposal mentions that the model is mechanistic where the placebo response may be seen as an emotional reaction to indicators of a bad state and is being treated for. The study also mentions two new characteristics of the model which can be seen as mediators of the placebo effect. The two aspects of the proposed model are the connected neurobiological changes and emotional processes (Flaten et al., 2011).
Additionally, it can be argued that there is the involvement of operant reinforcement in the induction of positive emotions such as happiness and the depletion of negative emotions, such as anxiety and fear (Flaten et al., 2011).
The impact of the use of placebos throughout history in clinical and laboratory settings has been shown to help patients with negative emotions who are dealing with chronic or acute pain and is still being used today in the 21st century (Wager & Atlas, 2015). Most placebo clinical trials lack historical controls, thus causing many trials to not be satisfactory in evaluating placebo effects (Wager & Atlas, 2015). However, there are a small group of clinical studies with suitable historical controls, indicating causal outcomes of placebo effects on measures commonly used as primary disease endpoints, such as depression, asthma and multiple forms of chronic pain (Wager & Atlas, 2015). When compared to the effects of regular accepted drug treatments, placebo effects can be the same or even have significantly larger effects in reducing pain and improving the patient's overall well-being (Wager & Atlas, 2015).

##### The placebo effect on negative emotions

Negative emotions such as fear and anxiety can occur in individuals experiencing acute or chronic pain. The placebo effect is the outcome of the administered placebo treatment, on the patient and often when the negative emotions start to reduce, positive emotions likely occur such as happiness and contentment. The reduction in negative emotions can help reduce the pain that the individual may be experiencing, relieving their symptoms and improving their overall emotional state and well-being.
To determine if there is a causal relationship between emotions and the placebo effect, any emotion should be recorded in the absence of other symptoms and most importantly pain (Flaten, 2014). Research done by Scott et al., 2007 found that the administration of the placebo treatment lowered pain, along with negative effects and negative emotions such as fear. The decrease in fear and negative effects were examined post-placebo administration, however, it was before the pain administration (Flaten, 2014). The study observed a reduction in pain and a decrease in negative emotions in that specific order to avoid them being confounded with each other (Flaten, 2014). Therefore the placebo treatment decreased negative emotion before and independent of the following pain reduction, proposing a causal link between both of them (Flaten, 2014). The study by Scott et al., 2007 also noted induced positive emotions after the placebo was administered.

##### The placebo effect and negative reinforcement

The placebo effect can have a positive response to pain in reducing pain in patients and therefore reducing their negative emotions. Pain is mostly quite uncomfortable for humans and animals and many people try their best to avoid pain (Flaten et al., 2011). Negative reinforcement can be used to help in the reduction of pain in individuals and animals and this in itself is considered a negative reinforcer (Flaten et al., 2011). When pain presents itself, any action that has aided in the overall reduction of pain is likely to be repeated (Flaten et al., 2011).
Negative reinforcement refers to the frequency of actions or behaviours that have occurred to reduce pain in the past (Flaten et al., 2011). However is it important to note that a deep analysis of the patient's behaviour may not be able to explain the placebo effect which in this case is the reduction in pain the patient experienced (Flaten et al., 2011). The neurobiology of reinforcement has to be considered to explain the placebo effect within a patient, as the neurobiology of reinforcement takes into account positive emotions, which have been researched in reducing pain (Flaten et al., 2011).

## Ethical considerations of the placebo effect

The most common ethical argument against using placebos in clinical practices is the concern about deception (Kaas et al., 2018). In healthcare, the principle of autonomy refers to patients having the right to make informed choices regarding their care (Kaas et al., 2018). The University of Sydney has outlined key findings from a study conducted in 2019, by Associate Professor Ben Colagiuri and Dr Kate Faasse, which investigated the use of placebos among Australian general practitioners (Faasse & Colagiuri 2019). Associate Professor Colagiuri mentioned that there are no current guidelines regarding placebo use in clinical practices within Australia (Faasse & Colagiuri, 2019). In general, he discusses how Australian general practitioners are left to make their own decisions regarding placebos and the importance of developing evidence-based guidelines for placebo use, for medical professionals and patients in Australia (Faasse & Colagiuri, 2019).
In most cases, the use of placebos and the effect it can have on our emotions carries minimal risk. However, there can be some ethical arguments against the use of placebos, when treating certain disorders. The trust between the patients and the physician administering the placebo treatment is very important and if the patient discovers that they have been given a placebo treatment, the patient may lose trust in the healthcare system altogether (Kaas et al., 2018). For disorders such as functional movement disorder (FMD) patients are likely to feel quite stigmatized from the beginning within the healthcare system due to how difficult it can be to treat FMD and the overall stigmatization of any disorders concerning psychological factors (Kaas et al., 2018).
An important factor to consider is that impure placebo treatments [explain?] may do more harm than good, as they have the possibility for adverse physical effects along with larger outcomes, [grammar?] for example, a patient may develop antibiotic resistance, from the use of antibiotics to treat any viral infections, therefore resulting in impure placebos carrying more risk than pure placebos (Kaas et al., 2018).
Another issue with using placebos to improve patients' emotional and physical well-being as an "easy fix", may result in neglecting the underlying psychological concerns of the related disorder or disease, which could be extremely harmful to the patient long term (Kaas et al., 2018).

### Check your knowledge quiz
## What are the pros and cons of the placebo effect?

From the ethical considerations mentioned earlier, it is evident that there are harmful risks involved with the use of placebos. Overall placebos have shown to be quite beneficial, however, due to some issues regarding potentially neglecting underlying psychological concerns and the risk of breaking the trust between the patient and physician, placebos would be better suited as an adjunctive therapy and not replacing any form of physical therapy or psychotherapy (Kaas et al., 2018). Aside from the ethical considerations mentioned in the section above, there are two clear positive outcomes of the placebo effect and one clear negative outcome of the placebo effect. These outcomes are listed in Table 1.
Table 1.
The Pros and Cons of the Placebo Effect
| Pros of the placebo effect | Cons of the placebo effect |
| Reduction of negative emotions | The "nocebo effect" |
| Induction of positive emotions | |

##### Reduction of negative emotions and the induction of positive emotions

The placebo effect can help to induce positive emotions by eliminating negative emotions, thereby reducing chronic or acute pain in patients to ultimately improve the patient's quality of life (Flaten et al., 2011). Negative emotions can be induced by stimuli which often increases pain, while positive emotion-inducing stimuli can often decrease pain, therefore pain can be reduced through emotional mechanism, as the placebo can induce positive emotions or lower negative emotions (Flaten, 2014).[how?]
Importantly the use of placebos in clinical settings provides a way for neuroscientists to investigate how contextual information is processed by the brain systems to influence physiology and clinically significant outcomes (Wager & Atlas, 2015).

##### The "nocebo" effect

The nocebo effect is the opposite of the placebo effect and has been described as the bad side to placebo effects which can cause harmful outcomes (Geers et al., 2020). This "dark side" to placebo effects can be triggered by certain aspects of the placebo treatment context (Geers et al., 2020). An example of how the nocebo effect can be triggered is through the warning signs regarding the various side effects of the placebo treatment. The action itself of explaining the side effects can induce certain side effects from the administered placebo treatments (Flaten, 2014).
Nocebo reactions can act as positive feedback loops, where for example increased fear can lead to increased pain which in turn leads back to increased fear. This effect is the opposite of homeostatic control creating an unstable internal environment for the patient (Flaten, 2014).
* Reflection question
* If you were in a scenario where you were a patient who was being treated for pain management, would you be comfortable with your physician not telling you everything about the treatment you are going to receive as it is a placebo treatment?

## Conclusion

Earlier on in clinical trials, placebo and nocebo effects were considered nuisance variances, however, currently they are commonly recognised as important psychobiological contributors to psychological and physiological well-being (Geers et al., 2020). Further research into the placebo effect and nocebo effects can help to provide the opportunity to improve psychological well-being and physical health treatments through nonpharmacological options to improve patient well-being (Geers et al., 2020).
The use of operant reinforcement is critical as it is involved in the induction of positive emotions such as happiness and the depletion of negative emotions, such as anxiety and fear (Flaten et al., 2011). Negative reinforcement specifically can aid in the reduction of chronic and acute pain, thus the act itself is considered a negative reinforcer, as any action which has helped in reducing pain is expected to be repeated (Flaten et al., 2011). However, despite this, the neurobiology of reinforcement needs to be reviewed as it is considered positive emotions which have been significantly researched in lowering chronic and acute pain (Flaten et al., 2011). Medical practitioners in Australia need to be provided with current evidence-based guidelines, on the use of placebos in patients suffering from chronic or acute pain, as this may also help educate practitioners further on harmful side effects of a placebo treatment, such as the nocebo effect. Overall there is a causal link between placebo treatments in decreasing negative emotions and pain reduction therefore improving the patient's quality of life. (Flaten, 2014).