Reply to comment

First, I’d like to voice a few concerns about the following statements:

“…ALL "symptoms" are in fact "in the head"... Recognizing that ALL symptoms originate in the brain seems to me a good starting point for this rethinking.”

My biggest concern with this statement is that not all symptoms originate in the brain. I’m going to talk about pain because that seems to be the general trend on the boards at this point. Most instances of pain originate peripherally, i.e. outside of the brain. The activation of nociceptors stimulates ascending mechanisms that relay information to both sensory and affect regions of the brain, and subsequent descending messages (motor or inhibitive) are relayed back to the periphery. The brain is an integral part of the process, which I believe the former message aimed to highlight. And central activities can result in the experience of pain. Nonetheless, most occasions of pain result from peripheral stimulation and I feel that the former message really detracts from the peripheral contributions to the experience.

I think it also undermines the innumerable other peripheral conditions that give rise to symptoms (physiological and psychosomatic- if you do want to classify pain as psychosomatic). For example, while most of the mechanisms underlying IBS are unknown, ongoing stress and anxiety is thought to be a key component in causing the sometimes severe physiological symptoms. Treating the stress (via removing stressors from daily life, psychotherapy, or anti-anxiety medications) or treating the physiological symptoms alone (via medication) generally will not resolve the other issues. (My understanding is that IBS is generally a lifetime condition that first arises when the person experiences a lot of stress, but that subsequently being less stressed does not make the GI tract 100% better- its like herpes, always there but not always presenting itself).

Using that example as a model for pain treatment leads me to think that treating pain as if it’s “all in one’s head” may cause a doctor to miss the source of pain elsewhere. While I do agree that pain seemingly without cause should not be so strongly stigmatized, I’m also worried that an approach to pain treatment that focuses on the treatment of pain without a search for a peripheral source would to some extent undermine the medical diagnosis practice. (Sure, there are problems with that practice, but I hope to circumnavigate that with my next example). For the longest time people (namely doctors) thought that fibromyalgia was strictly psychosomatic and in the minds of the sufferers. Had doctors stopped looking for a peripheral/biological cause on the assumption that it was a product of the mind, I don’t think the recent advances with drug development would have been made. I know two people who are using Lyrica, and both have said that the drug has really improved their quality of life and that nothing else had worked for them (which I don’t believe would be the case if their improvements were due to a placebo effect).

Sooo… now that I’ve said way too much about that, the other thing that I have some reservations about is the discussion of placebos. Like I said, I think that if my two friends were susceptible to placebos then one of the numerous drugs they tried before would have worked if for no reason other than the placebo effect. That the other drugs were so ineffective leads me to believe that the effects of Lyrica are the result of the drug’s mechanisms. I’ve done some research on placebos for other classes, and I know that only about 1/3 of people are “placebo responders,” which means that about 67% of people won’t experience the positive effects of any placebo (and placebos are more effective for pain than most other symptoms, possibly due to classical conditioning). It seems to me that most people are susceptible to the positive benefits of drugs, which leads me to believe that most drugs are more than just placebos without the consideration of placebo-controlled studies (because they do have a lot of additional problems, which have already been brought up).

My biggest concern with placebo prescription is that they’re the easy way out. Rather than having to really search for what may be a difficult to find problem, it’s a lot easier to give someone a placebo and see if they get better on their own. This for me can lead to the same problems as assuming it’s just in their heads. It’s a more time-consuming and money-consuming option to run lots and lots of tests, especially when you think there may not be an underlying physiological source to the problem. But to not do that and just prescribe a placebo instead seems negligent to me. That said, I do think that in a situation where all the resources have been exhausted and a doctor is unable to locate a physiological source of the symptoms, a placebo should be offered (obviously not as such). If nothing else has worked and that might, then it would be unethical to withhold an option that may help the patient, even if that means lying about what the drug is doing.