The placebo effect / nocebo effect is psychosocial, not medical

This is a very long angry rant that I wrote today during the afternoon when I was struggling to get up out of bed and using caffeine. I haven’t been feeling well. Taking caffeine without eating any breakfast usually causes me to write long, angry rants where I am shouting at the imaginary audience, like this one. But even so, in spite of the shouting, it contains valuable content. So, here it is.

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3:16 PM 2/7/2013

I’m so angry I want to scream. I’m reading page 57 of Trick or Treatment, and they are ignoring an extremely important distinction!!!

Let me tell MY way of seeing this.

Assumption 1: Wimpy, stupid people have a tendency to go to the doctor for every tiny little ailment regardless of how trivial, unimportant, and non-life-threatening it is. Some people take cold medicine for the slightest cold, anti-diarrhea drugs for the slightest diarrhea, etc. They take unnecessary treatments for harmless and temporary ailments that will go away all by themselves with no lasting consequences regardless of treatments. I myself do not. I don’t treat any illness unless it’s obviously life-threatening and urgent. Oh no! I felt a teeny, tiny little pain in my right hand! And it lasted for five seconds! Oh no!

Instead of just ignoring it and waiting for it to go away on its own, the wimpy, stupid person assumes that they absolutely have to ‘take action’ of some kind to ‘make it go away,’ otherwise they believe it will not go away. So they ‘do something,’ and it makes no difference at all whether the thing that they do was effective or ineffective. The trivial, non-life-threatening, unimportant little pain will go away all by itself regardless of treatment. People describe this phenomenon as the placebo effect. It soothes the stupid wimpy person’s anxiety about their trivial and unimportant pains. This is a symptom of a person with an anxiety problem who doesn’t have faith that the body is usually able to just take care of itself without any treatment at all for minor, common illnesses.

Assumption 2: Stupid, wimpy people are also weak-willed, and they don’t know how to stand up for themselves socially. So whenever a doctor gives them an ineffective treatment, and their elbow is still locked (as in the example on page 57) – THIS MAKES ME *EXTREMELY ANGRY* – If a doctor gives them a treatment that doesn’t work, they are too scared of the doctor’s authority to assert themselves and say, ‘No, this didn’t work, my elbow is still locked.’ This is an issue of SOCIAL SUBMISSIVENESS. It has nothing whatsoever to do with actually curing an illness for real. The incident described in the book said that the illness was NOT CURED: they could see that the elbow was still locked.

Assumption 3: The patient is scared to be sick. They think that people won’t accept them socially if they are sick and have some kind of weakness. If a doctor treats them and fails to cure them, but is still being nice to them at the end of the ineffective treatment and telling them they’re better when they’re not, the IMPLIED MESSAGE IS: It’s okay, society will accept you even though you are still sick. IT’S OKAY TO BE SICK. IT’S OKAY TO BE WEAK. IT’S OKAY TO FAIL SOMETIMES. This is a legitimate message that everyone needs to know: there is nothing wrong with being somewhat sick and somewhat unable to function in society, as long as it isn’t life-threatening. So the patient walks away from the ineffective treatment, feeling more relaxed and soothed and self-accepting AT THE *SOCIAL* LEVEL. Society will still like me anyway even though I have a locked elbow.

That is the essence of the placebo effect.

*IT DOES NOT CURE ILLNESSES FOR REAL.*

Trivial, non-threatening, harmless illnesses can be socially tolerated and accepted. It’s okay to be a little bit sick. Society will not reject you if you are just a little bit sick or a little bit less able to function.

*I* have been saying that many people mistakenly believe that THE PLACEBO EFFECT IS ACTUALLY EFFECTIVE AT CURING ILLNESSES FOR REAL THROUGH THE POWER OF THE MIND. THIS IS WRONG. The illnesses were either trivial illnesses that would have gone away on their own in a short time if someone had waited longer and done nothing, or else they are trivial illnesses that still allow a person to (mostly) function as a member of society, which can be socially acceptable, and the person was merely anxious about whether they were ‘allowed’ to be sick or not in this society. If a society tells you you’re not allowed to be sick, then you will feel a lot of anxiety over even the most trivial and harmless of illnesses and symptoms.

Fear of a loss of social acceptance is the reason why many, or most, people are afraid of being sick. They feel a duty to provide for themselves financially, for instance.

Some people are so unrealistic and so unobservant that they simply don’t know, and don’t understand, the fact that *almost all* trivial little non-life-threatening diseases and symptoms will resolve themselves on their own after a short period of time and require no treatment at all. They have a superstitious, fallacious belief that every little symptom requires some kind of intervention to prevent it from getting worse, when in fact, just ignoring the symptom is just as ‘effective,’ because no action is needed at all. When people develop a superstitious belief, they keep on doing it, and it is not harming them, and it is also not helping them, except merely to temporarily soothe their anxiety and make them feel as though they have ‘done something’ or ‘taken action’ at the ‘appropriate time’ because they believe it is their duty to do something rather than do nothing at all.

So I believe that the ‘placebo effect’ merely influences social behavior. It influences the words that the patient says to the doctor and to other people. It influences whether the patient feels socially accepted or not. Is it okay to be sick? Am I still a socially accepted member of society, even though I still have this trivial illness that won’t go away even after I’ve been treated with an ineffective treatment? The doctor says yes, I will still be socially accepted by wealthy, powerful authority figures such as doctors. Wealthy, powerful members of society are still being nice to me even though I am sick and even though the illness didn’t go away. So it’s ‘okay’ for me to be sick, and I no longer need to feel ‘sickness anxiety’ or ‘sickness phobia.’

I have seen many people who suffer from sickness phobia. The tiniest and most trivial of symptoms, the most harmless of things, all require immediately some kind of treatment to ‘stop them from getting worse,’ when in fact they are destined to go away on their own if you merely sit there and wait it out. Like I said, I never treat any symptoms unless they are so incapacitating that I absolutely cannot function, and I’m aware of the fact that I am treating the illness because it’s interfering with my social functioning – for instance, menstrual cramps would prevent me from going to work at the beginning of my period, so I take ibuprofen. I do have sickness anxiety about my social acceptance: will I still be employed at my job if I call off sick for a day or two every single month at the beginning of my period? They probably wouldn’t like that, and I don’t want to test it and find out, so I take the pills.

But the pills are actually effective at stopping pain. If someone’s disease is severe enough that it actually interferes with their life and their functioning, then it won’t matter that the doctor told them something to the effect of ‘you’re still loved even though your elbow is locked.’ If they absolutely must use their elbow to do something, then sooner or later, the alleged ‘placebo effect’ will vanish and it will NO LONGER MATTER. A while after they go home, when they are no longer in the presence of the wealthy and powerful authority figure, the doctor, they will once again realize, in the privacy of their own home, that they are unable to bend their locked elbow. The delusion disappears whenever they leave the social environment of the doctor. If they could stay in the doctor’s company all day long, and the doctor would take care of them, then it could continue to be socially acceptable for them to have a locked elbow that wasn’t cured by an ineffective treatment.

These incidents of the ‘placebo effect’ in the book are short-lived, temporary, AND UNETHICAL. The doctor is merely using his social pressure and his authority to pressure the patient to say something, to say words, to say the words “yes, my elbow feels better now” when it actually doesn’t, only to continue to have the problem again a little while after they leave the office. The placebo effect does not last long, and sooner or later the person will be disillusioned.

However, for trivial and non-life-threatening illnesses, the placebo effect can be done again and again. It really DOESN’T MATTER if the treatment is effective or not, because the illness is so minor and so trivial THAT IT REQUIRES NO TREATMENT and the person is able to continue functioning.

In such cases, the doctor provides social assurance again and again and again. ‘It’s okay to be sick, it’s okay to fail, it’s okay to be less functional,’ again and again and again. The patient will pay money to receive this social assurance and to relieve them of their sickness anxiety and their fear that they will be socially rejected because they are less able to function. They are not paying to receive a medical treatment, they are paying to receive a psychosocial treatment.

AS SUCH, THE PLACEBO EFFECT IS *NOT EFFECTIVE* AT CURING ILLNESSES FOR REAL. And yet many people still believe that you can really use the ‘placebo effect’ to ACTUALLY MAKE THE REAL ILLNESS GO AWAY FOR REAL, rather than merely socially reassuring the patient and urging them to say (untrue) words out loud, like ‘No, my locked elbow doesn’t hurt anymore and it’s working better now,’ in a particular social context, in the physical vicinity of the doctor, when those words are actually untrue. People who misunderstand and misinterpret the placebo effect will tell you that YES, THE LOCKED ELBOW ACTUALLY UNLOCKED ITSELF *FOR REAL* AND THE PERSON WENT HOME AND WAS ABLE TO CONTINUE FUNCTIONING, FOREVER, FOR REAL, WITH AN UNLOCKED ELBOW, because of merely ‘believing’ that the elbow was going to unlock itself. That is the misunderstanding of the placebo effect that I see over and over again. People do not make any distinction between actually curing the illness versus a patient merely saying out loud the words, ‘Yes, doctor, I’m cured’ while standing next to the doctor, then going home and finding out that they still can’t use their locked elbow any better than they could yesterday, in reality. Nobody makes that distinction.

I myself, for example, suffer from chronic fatigue, which is severe enough that it greatly lowers the quality of my life. If I felt totally accepted socially, that would reduce my social anxiety, but I still would not be able to do the things I used to be able to do before I had severe chronic fatigue. Would my quality of life improve in an environment of social acceptance? *YES*, social acceptance improves overall quality of life! Social acceptance is, therefore, a beneficial and helpful treatment, BUT IT MUST BE DISTINGUISHED FROM THE SO-CALLED ‘PLACEBO EFFECT,’ and it must be called what it is!

If a treatment’s effects are so weak that you’re not sure whether or not you’re seeing the placebo effect or a real effect, then you should just assume that either 1. The condition is harmless and non-urgent and requires no treatment at all, or 2. that particular treatment does not work. If a condition is life-threatening and urgent, then you will immediately see that a particular treatment isn’t working, because you will get even sicker, or die. In that case, it’s extremely important to know whether or not a treatment actually works. But if some illness isn’t going to kill you, just don’t treat it at all! Do nothing. Just endure the illness. Or you can try to troubleshoot it on your own somehow.

Treatments in general, treatments as such, interventions, ‘actions taken,’ should only be done at all for conditions that are life-threatening, urgent, or that severely and extremely ruin the quality of someone’s life and their ability to function. If you have a trivial and minor symptom, such as a brief, fleeting, temporary flash of pain in a finger on your right hand, just ignore it and it will go away. If you catch a cold, just ignore it and it will go away.

If you get diarrhea, just ignore it and it will go away, and if your diarrhea lasts for longer than a couple days, then you have something serious and you have to go to the doctor for it, but otherwise, diarrhea will usually cure itself in a day or two. It’s usually just caused by a stomach virus or by something you ate that day. But I know people who are so anxious about the slightest temporary symptoms in their body that they will run out to the grocery store and get an over-the-counter diarrhea treatment the very instant that they first observe themselves having diarrhea. That is not only unnecessary and a waste of money, it also puts you at risk of suffering side effects from the over-the-counter drugs you’re using, which leads to new symptoms and new illnesses, which will lead this type of person to panic and start taking dozens upon dozens of new drugs one after another, each one of them leading to a dozen new side effects which will each individually need to be treated with a new drug! The best cure in this situation would be to just stop all the drugs, because the side effects of the drugs are the primary problem, and the original problem was so trivial, it didn’t need to be treated at all.

If you keep having diarrhea over and over again, you should troubleshoot what is causing it to happen instead of continually taking over-the-counter diarrhea treatments. You need to know if you’re eating something that is making you sick. If you have severe diarrhea that just won’t go away, until you’re so dehydrated and your electrolytes are so imbalanced that you almost pass out and faint, you need to go to the hospital because you have something severe like giardiasis. But hardly anyone who gets diarrhea in this country actually has anything like giardiasis. They usually just ate something or have a temporary stomach virus.

Are the treatments ‘effective?’ Well, how do you define ‘effective?’ Does it *temporarily* make the *symptom* go away? Over-the-counter treatments might do this. Does it make the pain go away without actually curing the illness? Is that what you define as ‘effective?’ There are other treatments that are interested in solving the long-term illness, the cause of the problem, rather than merely making the pain go away temporarily while leaving the problem to continue again as soon as the drugs wear off.

Are drugs effective at treating depression? Yes, as long as you’re taking the drug, you will continue to have drug-like effects which are viewed as desirable. Did it actually cure the depression? No. Anything about ‘fixing a chemical imbalance in your brain’ is bullshit. You are taking a stimluant drug, a hardcore drug, and the effects that it has are DRUG effects, just like cocaine or heroin or any illegal drug. Do you desire and value drug-like effects? If so, then using drugs to treat depression is extremely effective, just as using cocaine or amphetamines to treat fatigue is effective – you’ll get lots of energy, all right.

However, if you do not value using drugs to achieve drug-like effects in the body, then no, using drugs to treat depression is not effective. The drugs do not permanently cure whatever is causing you to feel depressed or fatigued. You have an unexplained chronic health problem which is still there during and after the use of the drugs, and no, the drugs are not merely replacing natural neurotransmitters that your brain isn’t able to produce on its own and are not therefore ‘natural treatments’ or ‘real cures’ for a ‘chemical imbalance.’ Anybody can get lots of energy from taking an antidepressant or a stimulant, but this does not imply that they were depressed – it implies that the drugs induce artificial effects in the body just like cocaine and any other drugs.

In order to actually cure depression without drugs, you have to troubleshoot what’s causing the problem. You can get temporary relief from some aspects of depression by exercising, for instance, although the depression will come back again if you have some kind of chronic health problem. The effects of exercising have no resemblance whatsoever to the sensations of being on a drug. The drugs will give you AN EXTREME AND INTENSE ‘HIGH’ which has no resemblance to any ordinary physical sensation that you would ever experience from any normal, natural activity at all such as exercise. The drug effects are profoundly different from any normal experience. Do you *value* having drug effects and unusual sensations that are profoundly different from your usual everyday experiences? If so, then using drugs to treat depression is ‘effective’ for you, because you are achieving effects that you value: you *WANT* to ‘be on drugs.’ If it hadn’t been an antidepressant, then you would have gone out into the world and gotten other drugs to try for their recreational value, such as herbal hallucinogens, because you value the experience of using drugs to cause you to feel strange and abnormal physical sensations and mental states.

Are we talking about a short-term palliative that will temporarily make the discomfort go away? Are we talking about a one-shot long-term cure where you take one single pill and it permanently prevents you from ever experiencing the symptom again for the rest of your life? Are we talking about removing the cause of an ongoing problem which is happening over a long period of time? Are we talking about using a treatment over and over again, for a long period of time, to suppress or soothe a chronic illness that won’t go away? Are we talking about people who enjoy and value using any kinds of drugs at all to give themselves ‘superpowers’ and ‘super-experiences’ that are extremely, profoundly different from and perhaps ‘better than’ their normal experience of life?

‘Superpowers’ and ‘superexperiences’ and ‘supersensations’ are one of the conflicts and arguments that I have when I talk to people about the placebo effect or the nocebo effect. I assert that it is not possible to induce drug-like supersensations through a mere nocebo effect alone. The mind, and even hypnosis, is not capable of inducing such extreme, prolonged, and profoundly *different* and *abnormal* physical sensations and states merely by imagining them. It requires an addition of chemicals to produce such states, especially states that last an extremely long time, like hours or days or weeks, as drugs can do.

But some people believe that the mind can cause the body to do abnormal things which, in fact, it cannot, to that degree and extreme. For instance, perhaps an image of an unattractive woman can cause a man to feel temporarily less sexually aroused, or the image of a particular person whom he dislikes. But if a man’s body is already in a state of arousal, which is caused by chemicals, then that person is likely to continue feeling sexually aroused no matter whose image is in front of him. The brain’s power to un-arouse a man isn’t strong enough to turn him off whenever he is filled with hormones.

Yet some people claim that sexual impotence, the inability to get an erection, is merely psychological or can be induced psychologically. I claim that long-lasting impotence (lasting X number of hours, days, weeks, etc) is an extremely abnormal condition that the body is physically incapable of inducing through the mind alone. A man’s body has hormone cycles which fluctuate from day to day, and he will get a non-psychological erection after waking up from sleep in the morning, for instance, and even if he saw a photograph of an unattractive woman at the time, he still would have that non-psychological erection, and the image of the unattractive woman would not be powerful enough to get rid of that erection. If it did, the erection would come back shortly afterwards. The effect would be mild and temporary.

If the erection did not come back shortly afterwards, that merely means that it was a ‘trivial erection’ which was already doomed to fade away on its own. Do erections always require an orgasm and ejaculation? No. There are trivial, low-level, low degree states of physical arousal that will eventually just fade away on their own without release. They will fade away if you look at a photograph of an ugly woman, and they will fade away if you look at a photograph of a sexy woman, and they will fade away if you look at a photograph of a landscape, and they will fade away if you do nothing at all. Sometimes the mood is just destined to be temporary as your hormones and other chemicals fluctuate and change for no reason. Do images always, reliably produce sexual arousal, or are you *sometimes* just not in the mood even if you see an exciting image?

People claim that impotence is psychological. Prolonged impotence, lasting weeks or months. Total impotence, a total and complete lack of ability to get an erection no matter what. They are complaining that a supersymptom, an extreme, prolonged, unusual symptom, is something which the mind is capable of generating through sheer mental power alone.

People disagree about what constitutes a supersymptom or superpower or superexperience. I am well aware of what is normal and abnormal for my body and what my body is capable of generating through mental power alone, and if something strange happens that just keeps going for weeks or months, then I absolutely know it is not mental – it is a ‘supersymptom,’ an undesirable physical state which is extremely unusual and which could not be generated merely from a mental belief or a temporary bad mood or a hypnotic induction.

People who claim the placebo effect or the nocebo effect are often claiming that the mind is capable of creating supersymptoms which I assert that the body does not have the power to create. These symptoms 1. last an extremely long time, like months or years, and almost never go away during that time period, 2. are something you never experienced before in your entire life for such a long duration of time, 3. if they are positive rather than negative, they give you some kind of superpower that you wish you could have had your entire life, but never had until you took this drug, but would have wanted to create by using your mind alone if only you could, 4. are bizarre and unusual and specific and unlike any kind of normal physical sensation or sensory experience, like hallucinogens, 5. are extremely reliable, and always occur shortly after you take the drug, like the push of a button, and never fail to occur when you take that drug.

Normal physical sensations are fleeting and temporary. They do not always appear like clockwork when you do something. Sometimes you do something or go into a particular state or context, but it still does not create the desired mood or sensation or experience, even though it sometimes did in the past. That’s how real sensations and real moods behave. For instance, maybe you have a bad day, and you want to have sex, but even though you did everything to create the right mood, you just couldn’t do it that day, and you don’t know why. However, when you try again tomorrow, you succeed. The symptom is temporary and ever-changing. Sometimes it happens, sometimes it doesn’t.

A supersymptom, on the other hand, will instantly and reliably happen every time you take a drug, and it will be unchanging and long-lasting, and extreme in its degree of intensity. It will continue for extremely long periods of time, like entire days or weeks, while you are using this drug. If a drug causes impotence, it will cause extreme, severe, recurring, noticeable impotence again and again, every day, for weeks or months, while you’re on this drug. Instead of just having a rare incident that happened for one day and then went back to normal, you will have the same problem over and over again every day for *months*. That is a supersymptom. It is so extreme, so long-lasting, and so strongly correlated with the use of the drug that you know for sure that it is abnormal and the drug is causing it.

If it is a medium degree symptom, then you might not know for sure if the drug is causing it. You might, for instance, happen to notice that you are having more frequent, but still temporary, episodes of impotence, which last longer and are slightly more difficult to overcome. But still, you can sometimes have relatively normal sex, although it is usually more difficult to do, takes longer, is less satisfying, etc. Would you know for sure if the drug was causing that? That’s the type of symptom where people, legitimately, don’t know for certain, and legitimately question if the drug might be causing it, or not. However, I’m saying that if something like that keeps happening during the entire time that you’re taking the drug, you can safely assume that the drug is very likely to be causing it, even if you are not 100% certain.

When I get into arguments with people about the placebo effect or the nocebo effect, the issue is usually about which phenomena are supersymptoms. Some people believe that the body has enormous and almost unlimited power to create supersymptoms through sheer mental power alone. In order to disprove this, I would have to do an experiment to demonstrate that the mind is *not capable* of creating experiences that have any resemblance at all to drug experiences. This would be easiest to do if I first gave a particular individual a placebo, asked them to describe their experiences, and then, later on, gave them a real hallucinogen (for instance), and asked them to describe that. They will say, ‘WHOA! That second pill you gave me was the real one!!!’ They will know right away that the experience on the real drug was totally, extremely, many orders of magnitude different from the experiences on the placebo.

You will have to account for different people’s ability to metabolize drugs. Some people just do not respond to any drugs at all unless they are at extremely high dosages, because their body is genetically able to produce huge amounts of metabolic enzymes that break down the drugs. So, you would design the experiment so that they took varying dosage levels of a drug, to find out *when* exactly their body would respond to it. The intended result of the experiment is to *successfully, reliably generate some kind of symptom.* If all that you do is give them one fixed dose of a particular drug, and see no effects from it, that means that you didn’t give them a high enough dose. But some people, on the other hand, are unable to metabolize drugs, and will get extreme and intolerable effects from low dosages that don’t bother other people. Those are the people who get accused of having the placebo effect, because some other person (in the same experiment) will say, ‘But I took TEN GALLONS OF PEYOTE CACTUS AND HAD NO EFFECTS!!!’ They think that everyone is able to metabolize drugs as easily as they themselves do, and so, if anyone else has symptoms from a lower dose, they assume that person is merely experiencing the placebo effect. Experiments are rarely, if ever, designed to account for different individuals’ differing abilities to metabolize drugs! To correctly design such an experiment, you would have to increase the dosage level for every person in the experiment until you got some kind of effect. If you deplete a particular individual’s enzymes, or use several drugs simultaneously to cause an interaction, or use a drug that specifically reduces someone’s ability to metabolize other drugs, then you can intensify the drug’s effects. So you give them ten gallons today, which depletes their enzymes, and then give them a tiny amount tomorrow, which they react to because they no longer have enough enzymes to metabolize it. Few experiments are ever designed to account for this phenomenon.

So it’s not easy to demonstrate the phenomenon of supersymptoms to everyone, because a dosage level that will trigger supersymptoms (extreme, prolonged, obvious, abnormal symptoms that are totally different from everyday life) in one person might not trigger supersymptoms in another person at that dosage, but will instead trigger the ‘Hmm, I’m not sure if this is weird or not’ level of symptoms. People who easily metabolize large doses of drugs are notorious for claiming that everything everybody else experiences are merely their imaginations, because they themselves have never experienced a supersymptom or superexperience or superpower from using a drug. They don’t know how it feels when you experience something which is several orders of magnitude beyond the usual, normal, daily sensations.

The placebo or nocebo effect or hypnotic suggestion is incapable of generating supersymptoms. It can only create mild symptoms which are temporary, unreliable, and inconsistent. It can influence the words that a person says to the doctor or to the experimenters, even if it doesn’t actually change the physical sensation that the person is experiencing inside.