Psychosomatics and Phantom Limbs

I've also always been interested in the idea of culture-bound syndromes, which we brought up briefly in class last week.  I'm fascinated by the idea that while people in various cultures seem to experience similar "symptoms", the label that comes along with having an actual disease makes such a big difference.  My class presentation on PMS last year that we seem to bring up a lot is a great example.  If you ask them without ever mentioning the possibility of a related disorder, women across cultures do seem to have similar experiences around the time of menstruation, but if there is no concept of PMS in their culture, they don't perceive this group of experiences as problematic.  Giving a set of previously unrelated experiences a common label seems to allow us to recognize each symptom and self-diagnose much more readily.  It's interesting to think about what diseases, other than PMS and depression, which we've mentioned, have been spread from our culture across the world due to globalization.

Since everyone has talked so much about placebos, I’m going to try to focus my post on some of the questions Felicia and Emily posted about Phantom Limbs and the self. In response to why might cortical reorganization have evolved, one of the theories out there is that since there are areas of the brain which are not getting stimulated anymore, since the limb from which the stimulation arises is no longer there, they want to get stimulation somehow. They do this by being taken over by surrounding brain areas, so that when someone touches their face, their arm neurons fire (which I believe was briefly talked about in class). Also, fMRI studies have shown that this seems to be the case---when someone touches the face of an amputee (I forget the actual appendage) areas of the brain that are normally activated for the arm are also activated, along with the ‘face stimulation’ areas. In individuals who are blind, it has also been found that their areas of sight are activated by hearing or touch stimuli (I, again, forget which one) and this is not seen in individuals with normal sight. It seems that this would evolve so that the brain uses its resources to the best end. There is no reason to reserve brain areas for sight stimulation if there never is any, nor to reserve areas for arm stimulation when there is no arm.

Moving on to phantom limb pain, the current treatments for PLP seem to suggest that pain is centered in the brain, and if you can ‘trick’ the brain into seeing something that isn’t there, pain can be diminished. It’s interesting to think about it in general terms of pain since we know how nociceptive pathways work to tell the brain that it’s in pain. Perhaps chronic PLP could fall under the category of pain (which I mentioned last week) that may be a memory of the pain in the cortex (see the animal research article I posted) and not actually nociceptive. (It would be interesting to see if the nerves are firing from the stump of the amputated limb). The treatments seem to suggest this. If it is simply a memory, maybe seeing the limb overpowers the brains memory of the pain. It keeps coming back because the memory is still imprinted there. Many times we want to say that something is painful because some stimulus is causing pain---but what if the noxious stimulus is the brain? However, while this explanation makes sense it terms of amputees, it is harder to explain in terms of people who are born without limbs and still have pain.

Finally, I want to briefly touch on the idea of media and culture in terms of diagnoses and illnesses (though there is much more to say). It is hard to say if a culture without media bombardment simply won’t diagnose illnesses that are really there or if they will be spared from the diagnoses of illnesses when people see an ad and say ‘oh I have that’. Someone said that many people taking abnormal psych keep diagnosing themselves—it seems that the media does that for us every day. Also, when looking at PMS, why do we consider it a disorder/illness? If we just feel moody, why is that a problem? People that previously hadn’t heard about PMS, as Emily said, might say (after they hear about it) that they have it, but if it wasn’t a problem for them, why do we need to diagnose it as one? Once something is suggested to be a problem, it seems to become one. It seems, from all of this, that while media coverage of certain disorders/illnesses (such as depression in India) may help more people seek treatment, it will always have the negative result of causing people who really have no problem to think that they do. Maybe this is ok for the good of those that are actually sick, but I would propose that it depends on the illness/disorder. If you’ve never heard of restless leg syndrome or PMS it’s probably better for you.

I found the debate about placebo treatment very interesting.  On one hand I believe that if a treatment works for some people than it should be available to the public.  If that treatment happens to be a sugar pill than that isn’t much different than a traditional treatment.  In fact, if the sugar pill is tricking the mind into activating an endogenous response which causes the therapeutic effect than the sugar pill’s therapeutic effect is physiological just as the traditional therapies would are.  Since all pharmaceuticals manipulate the body’s endogenous functions to produce a therapeutic effect this provides a theoretical reason to believe that many illnesses could be treated by a placebo pill if it could trick the body into producing the same response as the active drug.  However in practice, I think the placebo would only be effective for certain problems which have an emotional component mostly because they could be more susceptible to being effected by the change in mental state which would occur when one believes he or she is receiving treatment.   I agree with the idea someone else mentioned that this process seems similar to cognitive behavioral therapy and could be a better treatment to try first because there are less likely to be side effects when there is no foreign substance entering the body. 

The issue of cost for the placebo was brought up and while I do believe that there are some problems with charging a higher price for a drug than what it actually costs to make I think there are strong arguments for why this is necessary.  If the therapeutic effect only occurs when paying more money for the drug I think it is okay to charge more because the person is not only paying for the pill but also for the therapeutic effect.  If research shows that a sugar pill is most effective when someone pays $100 for the drug I think that is similar to a study which says a certain dose of the drug is most effective.  The person is paying to get well and if paying $100 to do that helps than I think it is ultimately ok.  

One final interesting topic which the placebo discussion brought up is the question of why our society is so adamantly against believing in the placebo.  I think the news release on Vytorin was interesting because even after the study showed it had no actual effect on reducing heart disease the people who took it believed the study was flawed and it actually did help.  It seems to me that these people are trying hard to prove that they were not “fooled” by a placebo drug.  The question I have is why would it be bad if a placebo helped as long as you improved?  Our society seems much less accepting of psychosomatic illnesses and although I’m not sure why I think it is an interesting question.  

I think the concept of placebos is such an interesting one. One thing I was wondering about was the interaction between (perhaps unknown) chemical reactivity of medications and the placebo effect. We mentioned in class that a large portion of the effects of many drugs may be because of a placebo effect. However, what happens when certain drugs (such as antidepressants) work for some people and not others. If someone is depressed and does not seem to have a favorable reaction to, say, Paxil, but then does to Zoloft, then how does the placebo effect fit in here? Is it possible that there is some effect of the way that the doctor introduced the medication or past research/news articles about the drug are impacting the way the person is reacting?

I located a study entitled by de Craen et al 2001 did a randomized double-blind study that gave an analgesic to study participants, with one group being told neutral information about the effects of the drug and the other being told that it is not usually a very effective pain killer. However they did not find any statistical difference between the pain management properties of the pill between the groups. (However there did seem to be increased effectiveness in both groups with the medication as compared to the placebo).

This study also mentions something that I've read before--that pill color, status of person administering drugs, and the route of administration all are factors that can influence therapeutic outcomes. People seem to react differently to medications based on the color and shape of the pills themselves. Often pills containing pseudoephedrine are red because "research has shown" that people find pills of that color to be better decongestants, and I believe this same type of research determined that viagra should be blue, but unfortunately I cannot remember where I read this. An article I found by de Craen et al (1996) does state that "available evidence suggests that green and blue may have more sedative effects and red and orange may have more stimulant effects." (I wonder what this means about viagra being blue...)

There just seem to be so many factors that play a role in how effective medication is to a person. I wonder which of these parts are officially the "placebo effect" and which function in some other capacity. It does make me wonder about the pills that I take quite a bit though, and how effective they may or may not be...

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.

This was such a great topic. If anything, it continually boggles my mind to realize just how much of brain function is devoted to things we aren’t even aware of most of the time. It’s incredible to me the vast amount of resources our body allocates to things like…. checking to make sure a limb is still attached… taking in as much information as possible through our senses… and constantly filtering it through to our consciousness.

I’d like to begin by addressing Emily and Felicia’s question about whether all pharmacotherapy is “merely” attributed to the placebo effect. While I disagree that all drug action across the board can be attributed to the placebo effect, I think there is a lot of merit in continuing the discussion about whether much of drug action is. I don’t think that “merely” is a useful way to characterize this process, because if so much of drug action and symptom alleviation can be attributed to this effect, it seems more “powerful” and less “mere” to me. It seems to me that for the placebo effect to be normalized enough to be an acceptable, prescribable medical tool, there really needs to be a word change or a drastic reevaluation of the connotations we place with the word “placebo”. There seems to be little controversy when one scientist comments on how little we actually know about mechanisms of action. Why, then, do we get defensive and threatened by the word placebo that concisely summarizes that lack of knowledge? I think a more useful question to ask here would be something like, “Though most people in the scientific community readily acknowledge that we have so much to learn, though many people support the idea of homeopathic healing practices, why is it so hard for us to discuss the placebo effect not just as a phenomenon, but as a tool that can be used effectively in medical practices?” A distilled version of that would be…. “What’s so scary about the placebo effect after all?”.

To comment now on why this is an important subject that merits thoughtful discussion, we need to consider the beneficial uses (which we discussed in class) and also the misuses (which we did not discuss in class) of the placebo effect. The NY Times articles gave a great explanation for the current antibiotic resistance crisis in terms of the placebo effect. The article stated that antibiotics have been used as placebos for patients with viral infections for decades. Clearly, the antibiotic won't cure the viral infection, and so in that respect, it's chemically inert and therefore acting as a placebo. However, the rammifications of physicians prescribing antibiotics for years had dangerous consequences as bacteria became resistent to the drugs. I'm convinced that placebos can have beneficial effects, but even if you're on the fence about that, isn't it enough to consider the consequences of improper use of placebos? No matter how skeptical you are, this example should motivate a discussion.

On another line of thought… I really appreciated insight regarding Body Dysmorphic Disorder as it relates to other human conditions, specifically the trans experience (body modification to align one’s perceived gender with one’s outward appearance), and even perhaps the feminist critique of the female experience (body modification to meet perceived cultural norms). Though that insight opened up a new way of perceiving culture as it relates to medicine, I think we need to be cautioned about overly pathologizing the human experience.

And we, both researchers and patients, should recognize that much suffering and pain not only originates in the brain but has no explanation other than in the workings of the brain.

This is a pretty powerful statement, especially given the insurance and payment issues your additional linked article raised. It also doesnt seem to address the reality that some people have control over their pain where others do not. How many of us have been to the dentist and are instructed to "go away" as a means of dealing with the impending pain? It works for some, I'm sure, or such statements would die out of practice, but such instructions have never had an ameliorative effect on my experience of pain. If it is all mediated by our heads, and our heads are capable of healing themselves, why is there a need for analgesics in the first place?

Further, does the rhetoric of psychology as something a biological organ "does" lessen the importance of suffering? I don't think so, but especially in your Bio 202 class the idea that "the mind" is something the brain does disturb. And not to be a broken record, but what does this do to our use of animal models of pain? The arguement has been raised that animal suffering is worse than human because we can use our "minds" to lessen the pain or at least coneptualize that it will end at some point. Non-verbal animals cannot do this, so is their experience of pain really analogous to ours? (Possibily stupid question) Is animal also mediated/created in their brains?

And I'm just going to be an ass and bring up pain as pleasure - what about the suspension crowd? Human beings seem to be the only creatures who will willingly induce pain in hopes of achieving euphoria. Not surprisingly, not all humans will engage in this behavior. Where does pain as symptom created by the brain fit into this picture?