Sleep and the Placebo Effect

Placebos are used in research and may give clues to how the mind and sleep work.

A placebo is a substance or therapy that has no effective ingredient and is given in order to assess the effectiveness of a medicine or therapy or to provide benefit to a patient who believes the treatment will be helpful. The human mind is such that belief in the effectiveness of a treatment may be all that is necessary for it to produce a positive effect regardless of its true physiological impact on the body. This is known as the placebo effect.

Placebos are used in pharmacological research to test whether or not a new drug is more effective than just the belief that a substance is effective. It is often surprisingly difficult to show that new medications are actually more effective than a placebo, especially when investigating medications for conditions such as pain or depression.

Placebo conditions are used in psychological research to control for the effect of the nonspecific aspects of the treatment. For example, in a study investigating the effectiveness of a new psychological treatment for insomnia it would be necessary to eliminate factors that are not believed to contribute to a beneficial effect but could foster improvement such as attention from the researcher, being involved in an interesting project, having hope that the treatment will work and so on. It can be extremely challenging to devise a sham treatment that controls for factors such as time spent with the therapist and all the other nonspecific aspects of the psychological treatment but without the factors believed to be effective, such as instructions for changing some aspect of sleep-related behavior. A related psychological phenomenon is the Hawthorne Effect in industrial/organizational psychology in which workers seem to perform better regardless of the actual work conditions being studied just because they are responding to being in a study and the attention that goes with it.

Health care providers may use placebos intentionally or unintentionally. When used intentionally, as in giving a sugar pill for pain or prescribing oral vitamins for fatigue, an element of deception is involved. The doctor does not believe the treatment is effective for the condition but believes it will be helpful for the patient because of the patient’s belief in the doctor’s prescription. This is an ethically compromised position regardless of the possible benefit to be derived and usually is not considered acceptable practice. Unintentionally, providers often create placebo responses just by their enthusiastic endorsement of and belief in a treatment. In this case, there is no deception, as the provider genuinely believes in the treatment being provided even if in fact the treatment is later proven to be ineffective beyond the placebo effect.

Herbert Bensen, an emeritus Harvard cardiologist, was one of the first researchers to introduce research on relaxation training into western science and the public consciousness in the 1970s. Benson and Friedman published an article suggesting that the term “placebo effect” should be replaced by a new term, “remembered wellness”, in order to reduce the negative connotation of “placebo” which is often taken to mean unreal. Remembered wellness is based on three factors - the positive expectation and belief of the patient, the positive belief and expectation of the provider, and the positive relationship between the provider and the patient. These conditions allow the patient’s body to remember or reconnect with times of wellness and lead to biological changes that cause healing that is real. For more information on this important topic I recommend reading his book “Timeless Healing”.

As we know that psychological conditions such as emotional support and concern can create optimal conditions for growth and health, so negative psychological conditions can be conducive to suffering and illness. Treatments without effective components that have negative effects on the patients due to the patient’s beliefs are called nocebos. A nocebo response would occur if an ineffective treatment resulted in negative effects because of expectations for harm on the part of the patient. It can also result in negative effects to a medically effective treatment. It is easy to see how fear of dangerous side effects of a medication could result in a patient having extremely negative results from taking a prescription. We know that it is important to warn patients of possible side effects of medications before they start them both for informed consent and also so there is awareness of untoward effects that can occur. We can imagine, however, the impact on patients listening to TV commercials for medications that point out that “serious side effects including death have been reported.”

As an extreme example of the power of the nocebo effect anthropologists have noted examples of serious harm caused by the use of rituals or remedies given with malevolent intent. There are even reports of deaths caused by “witch doctors”. They curse a healthy member of the tribe who then dies, most likely due to being shunned by the community and filled with fear and convinced that the curse was effective (Flemming, 2010).

The placebo effect has been shown to affect people’s perception of their sleep and functioning. In a study that was widely reported in the popular media, research subjects were given false feedback, presumably based on physiological monitoring of their sleep, that indicated that the quality of their sleep was “above average” or “below average” regardless of the actual quality of sleep. Perception of sleep quality based on false feedback was more significant than the actual quality of sleep with regard to performance on several measures of cognitive performance. Believing you had a good night of sleep seems to help people function better during the day. Perception of effectiveness, rather than actual improvement in sleep quantity and quality, may be also be central to the popularity of sleepingmedication.

Recent research has pointed to a possible genetic basis to at least part of the placebo effect. Some people may be more prone to having a placebo response than others. There is even the possibility that future genetic testing could help reduce the number of subjects in drug trials if the potential placebo response can be determined in advance (Servick, 2014).

While the placebo effect is perhaps a problem for medical research and may make some treatments that do not have a physiological basis appear effective, it also signifies the body’s ability for self-healing. As we become increasingly aware of the genetic and biological processes activated by belief we come closer to an understanding of the mind/body. Perhaps one day soon, “Human, heal thyself” will be sensible advice to direct at those who’ve learned to make use of the mysterious placebo effect.

Author: John Cline Ph.D.

Photo: welfar.kz

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