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Resolving the Brainstem Contributions to Attentional Analgesia. J Neurosci 2017; 37:2279-2291. [PMID: 28096471 PMCID: PMC5354342 DOI: 10.1523/jneurosci.2193-16.2016] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 11/18/2016] [Accepted: 11/30/2016] [Indexed: 11/24/2022] Open
Abstract
Previous human imaging studies manipulating attention or expectancy have identified the periaqueductal gray (PAG) as a key brainstem structure implicated in endogenous analgesia. However, animal studies indicate that PAG analgesia is mediated largely via caudal brainstem structures, such as the rostral ventromedial medulla (RVM) and locus coeruleus (LC). To identify their involvement in endogenous analgesia, we used brainstem optimized, whole-brain imaging to record responses to concurrent thermal stimulation (left forearm) and visual attention tasks of titrated difficulty in 20 healthy subjects. The PAG, LC, and RVM were anatomically discriminated using a probabilistic atlas. Pain ratings disclosed the anticipated analgesic interaction between task difficulty and pain intensity (p < 0.001). Main effects of noxious thermal stimulation were observed across several brain regions, including operculoinsular, primary somatosensory, and cingulate cortices, whereas hard task difficulty was represented in anterior insular, parietal, and prefrontal cortices. Permutation testing within the brainstem nuclei revealed the following: main effects of task in dorsal PAG and right LC; and main effect of temperature in RVM and a task × temperature interaction in right LC. Intrasubject regression revealed a distributed network of supratentorial brain regions and the RVM whose activity was linearly related to pain intensity. Intersubject analgesia scores correlated to activity within a distinct region of the RVM alone. These results identify distinct roles for a brainstem triumvirate in attentional analgesia: with the PAG activated by attentional load; specific RVM regions showing pronociceptive and antinociceptive processes (in line with previous animal studies); and the LC showing lateralized activity during conflicting attentional demands. SIGNIFICANCE STATEMENT Attention modulates pain intensity, and human studies have identified roles for a network of forebrain structures plus the periaqueductal gray (PAG). Animal data indicate that the PAG acts via caudal brainstem structures to control nociception. We investigated this issue within an attentional analgesia paradigm with brainstem-optimized fMRI and analysis using a probabilistic brainstem atlas. We find pain intensity encoding in several forebrain structures, including the insula and attentional activation of the PAG. Discrete regions of the rostral ventromedial medulla bidirectionally influence pain perception, and locus coeruleus activity mirrors the interaction between attention and nociception. This approach has enabled the resolution of contributions from a hub of key brainstem structures to endogenous analgesia.
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Rief W, Shedden-Mora MC, Laferton JAC, Auer C, Petrie KJ, Salzmann S, Schedlowski M, Moosdorf R. Preoperative optimization of patient expectations improves long-term outcome in heart surgery patients: results of the randomized controlled PSY-HEART trial. BMC Med 2017; 15:4. [PMID: 28069021 PMCID: PMC5223324 DOI: 10.1186/s12916-016-0767-3] [Citation(s) in RCA: 142] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 11/17/2016] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Placebo effects contribute substantially to outcome in most fields of medicine. While clinical trials typically try to control or minimize these effects, the potential of placebo mechanisms to improve outcome is rarely used. Patient expectations about treatment efficacy and outcome are major mechanisms that contribute to these placebo effects. We aimed to optimize these expectations to improve outcome in patients undergoing coronary artery bypass graft (CABG) surgery. METHODS In a prospective three-arm randomized clinical trial with a 6 month follow-up, 124 patients scheduled for CABG surgery were randomized to either a brief psychological pre-surgery intervention to optimize outcome expectations (EXPECT); or a psychological control intervention focusing on emotional support and general advice, but not on expectations (SUPPORT); or to standard medical care (SMC). Interventions were kept brief to be feasible with a heart surgery environment; "dose" of therapy was identical for both pre-surgery interventions. Primary outcome was disability 6 months after surgery. Secondary outcomes comprised further clinical and immunological variables. RESULTS Patients in the EXPECT group showed significantly larger improvements in disability (-12.6; -17.6 to -7.5) than the SMC group (-1.9; -6.6 to +2.7); patients in the SUPPORT group (-6.7; -11.8 to 1.7) did not differ from the SMC group. Comparing follow-up scores and controlling for baseline scores of EXPECT versus SUPPORT on the variable disability only revealed a trend in favor of the EXPECT group (P = 0.09). Specific advantages for EXPECT compared to SUPPORT were found for mental quality of life and fitness for work (hours per week). Both psychological pre-surgery interventions induced less pronounced increases in pro-inflammatory cytokine concentrations reflected by decreased interleukin-8 levels post-surgery compared to changes in SMC patients and lower interleukin-6 levels in patients of the EXPECT group at follow-up. Both pre-surgery interventions were characterized by great patient acceptability and no adverse effects were attributed to them. Considering the innovative nature of this approach, replication in larger, multicenter trials is needed. CONCLUSIONS Optimizing patients' expectations pre-surgery helps to improve outcome 6 months after treatment. This implies that making use of placebo mechanisms has the potential to improve long-term outcome of highly invasive medical interventions. Further studies are warranted to generalize this approach to other fields of medicine. TRIAL REGISTRATION Ethical approval for the study was obtained from the IRB of the Medical School, University of Marburg, and the trial was registered at ( NCT01407055 ) on July 25, 2011.
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Affiliation(s)
- Winfried Rief
- Division of Clinical Psychology, University of Marburg, Gutenbergstrasse 18, Marburg, 35032, Germany.
| | - Meike C Shedden-Mora
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Johannes A C Laferton
- Division of Clinical Psychology, University of Marburg, Gutenbergstrasse 18, Marburg, 35032, Germany
| | - Charlotte Auer
- Division of Clinical Psychology, University of Marburg, Gutenbergstrasse 18, Marburg, 35032, Germany
| | - Keith J Petrie
- Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
| | - Stefan Salzmann
- Division of Clinical Psychology, University of Marburg, Gutenbergstrasse 18, Marburg, 35032, Germany
| | - Manfred Schedlowski
- Institute of Medical Psychology and Behavioral Immunobiology, University Hospital Essen, Essen, Germany
| | - Rainer Moosdorf
- Department of Cardiac and Thoracic Vessel Surgery, Heart Centre, University of Marburg, Marburg, Germany
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303
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Hayen A, Wanigasekera V, Faull OK, Campbell SF, Garry PS, Raby SJM, Robertson J, Webster R, Wise RG, Herigstad M, Pattinson KTS. Opioid suppression of conditioned anticipatory brain responses to breathlessness. Neuroimage 2017; 150:383-394. [PMID: 28062251 PMCID: PMC5391989 DOI: 10.1016/j.neuroimage.2017.01.005] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 11/27/2016] [Accepted: 01/02/2017] [Indexed: 01/20/2023] Open
Abstract
Opioid painkillers are a promising treatment for chronic breathlessness, but are associated with potentially fatal side effects. In the treatment of breathlessness, their mechanisms of action are unclear. A better understanding might help to identify safer alternatives. Learned associations between previously neutral stimuli (e.g. stairs) and repeated breathlessness induce an anticipatory threat response that may worsen breathlessness, contributing to the downward spiral of decline seen in clinical populations. As opioids are known to influence associative learning, we hypothesized that they may interfere with the brain processes underlying a conditioned anticipatory response to breathlessness in relevant brain areas, including the amygdala and the hippocampus. Healthy volunteers viewed visual cues (neutral stimuli) immediately before induction of experimental breathlessness with inspiratory resistive loading. Thus, an association was formed between the cue and breathlessness. Subsequently, this paradigm was repeated in two identical neuroimaging sessions with intravenous infusions of either low-dose remifentanil (0.7 ng/ml target-controlled infusion) or saline (randomised). During saline infusion, breathlessness anticipation activated the right anterior insula and the adjacent operculum. Breathlessness was associated with activity in a network including the insula, operculum, dorsolateral prefrontal cortex, anterior cingulate cortex and the primary sensory and motor cortices. Remifentanil reduced breathlessness unpleasantness but not breathlessness intensity. Remifentanil depressed anticipatory activity in the amygdala and the hippocampus that correlated with reductions in breathlessness unpleasantness. During breathlessness, remifentanil decreased activity in the anterior insula, anterior cingulate cortex and sensory motor cortices. Remifentanil-induced reduction in breathlessness unpleasantness was associated with increased activity in the rostral anterior cingulate cortex and nucleus accumbens, components of the endogenous opioid system known to decrease the perception of aversive stimuli. These findings suggest that in addition to effects on brainstem respiratory control, opioids palliate breathlessness through an interplay of altered associative learning mechanisms. These mechanisms provide potential targets for novel ways to develop and assess treatments for chronic breathlessness. The mechanisms of how low-dose opioids relieve breathlessness are unknown. We tested whether low-dose opioids affect conditioned anticipation and perception of breathlessness. Low-dose opioids reduced unpleasantness, but not intensity of breathlessness. Reduced breathlessness unpleasantness was associated with activation of the endogenous opioid system. Breathlessness relief was predicted by decreased anticipatory activity in amygdala/hippocampus.
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Affiliation(s)
- Anja Hayen
- Nuffield Department of Clinical Neurosciences (NDCN), University of Oxford, Oxford, UK; Department of Psychology, University of Reading, Reading, UK.
| | - Vishvarani Wanigasekera
- Nuffield Department of Clinical Neurosciences (NDCN), University of Oxford, Oxford, UK; Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Olivia K Faull
- Nuffield Department of Clinical Neurosciences (NDCN), University of Oxford, Oxford, UK
| | - Stewart F Campbell
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Payashi S Garry
- Nuffield Department of Clinical Neurosciences (NDCN), University of Oxford, Oxford, UK
| | - Simon J M Raby
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Josephine Robertson
- Nuffield Department of Clinical Neurosciences (NDCN), University of Oxford, Oxford, UK
| | - Ruth Webster
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Richard G Wise
- Cardiff University Brain Research Imaging Centre, School of Psychology, Cardiff University, Cardiff, UK
| | - Mari Herigstad
- Nuffield Department of Clinical Neurosciences (NDCN), University of Oxford, Oxford, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Kyle T S Pattinson
- Nuffield Department of Clinical Neurosciences (NDCN), University of Oxford, Oxford, UK; Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
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304
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Mertens VC, Moser A, Verbunt J, Smeets R, Goossens M. Content Validity of the Credibility and Expectancy Questionnaire in a Pain Rehabilitation Setting. Pain Pract 2016; 17:902-913. [PMID: 27911035 DOI: 10.1111/papr.12543] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 09/22/2016] [Accepted: 10/16/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Content validity, the proper reflection of the concept to be measured, is yet unknown for the Credibility and Expectancy Questionnaire (CEQ). It is frequently used in pain rehabilitation because treatment expectancy is influential on the outcome. OBJECTIVE To test and improve the content validity of the CEQ in a sample of patients with chronic pain in different phases of their treatment. METHODS A qualitative observational study design using the Three-Step Test-Interview method was used. Therein, data collection, analyses, and adaptations occur iteratively. RESULTS Seventeen patients with chronic pain in different stages of treatment participated through convenience sampling from the mother sample of a randomized controlled trial. The main study parameter is content validity, which is defined as (1) interpretations and responses of the participants and (2) the identification of response problems operationalized, and resulting in changes in the CEQ. For patients waiting for treatment, the written instruction of the CEQ allowed different interpretations. After changing the instructions, the CEQ became an easy-to-understand and content-valid questionnaire. For patients who had already undergone treatment, changes regarding time frame and recall period were necessary to overcome interpretation and response problems to the CEQ. DISCUSSION After small changes, the CEQ appeared to be a content-valid measurement instrument for patients waiting for treatment. However, for patients who had already undergone treatment, the content validity of the CEQ was less, and considerable changes were necessary.
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Affiliation(s)
- Vera-Christina Mertens
- Research Unit INSIDE, Institute for Health and Behaviour, University of Luxembourg, Esch-sur-Alzette, Luxembourg.,Department of Rehabilitation Medicine, School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Albine Moser
- Department of Family Practice, School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.,Faculty of Healthcare, Research Programme Autonomy and Participation of Chronically Ill People, Zuyd University of Applied Sciences, Heerlen, The Netherlands
| | - Jeanine Verbunt
- Department of Rehabilitation Medicine, School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.,Adelante Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands.,Department of Rehabilitation Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Rob Smeets
- Department of Rehabilitation Medicine, School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.,Adelante Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands.,Libra Rehabilitation and Audiology, Eindhoven/Weert, Maastricht, The Netherlands
| | - Mariëlle Goossens
- Department of Rehabilitation Medicine, School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.,Department of Clinical Psychological Sciences, Faculty of Psychology and Neurosciences, Maastricht University, Maastricht, The Netherlands
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305
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Friedrichsdorf SJ, Giordano J, Desai Dakoji K, Warmuth A, Daughtry C, Schulz CA. Chronic Pain in Children and Adolescents: Diagnosis and Treatment of Primary Pain Disorders in Head, Abdomen, Muscles and Joints. CHILDREN (BASEL, SWITZERLAND) 2016; 3:E42. [PMID: 27973405 PMCID: PMC5184817 DOI: 10.3390/children3040042] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 11/26/2016] [Accepted: 12/01/2016] [Indexed: 12/12/2022]
Abstract
Primary pain disorders (formerly "functional pain syndromes") are common, under-diagnosed and under-treated in children and teenagers. This manuscript reviews key aspects which support understanding the development of pediatric chronic pain, points to the current pediatric chronic pain terminology, addresses effective treatment strategies, and discusses the evidence-based use of pharmacology. Common symptoms of an underlying pain vulnerability present in the three most common chronic pain disorders in pediatrics: primary headaches, centrally mediated abdominal pain syndromes, and/or chronic/recurrent musculoskeletal and joint pain. A significant number of children with repeated acute nociceptive pain episodes develop chronic pain in addition to or as a result of their underlying medical condition "chronic-on-acute pain." We provide description of the structure and process of our interdisciplinary, rehabilitative pain clinic in Minneapolis, Minnesota, USA with accompanying data in the treatment of chronic pain symptoms that persist beyond the expected time of healing. An interdisciplinary approach combining (1) rehabilitation; (2) integrative medicine/active mind-body techniques; (3) psychology; and (4) normalizing daily school attendance, sports, social life and sleep will be presented. As a result of restored function, pain improves and commonly resolves. Opioids are not indicated for primary pain disorders, and other medications, with few exceptions, are usually not first-line therapy.
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Affiliation(s)
- Stefan J Friedrichsdorf
- Children's Hospitals and Clinics of Minnesota, Minneapolis, MN 55404, USA.
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN 55455, USA.
| | - James Giordano
- Georgetown University Medical Center, Washington, DC 20057, USA.
| | | | - Andrew Warmuth
- Children's Hospitals and Clinics of Minnesota, Minneapolis, MN 55404, USA.
| | - Cyndee Daughtry
- Children's Hospitals and Clinics of Minnesota, Minneapolis, MN 55404, USA.
| | - Craig A Schulz
- Children's Hospitals and Clinics of Minnesota, Minneapolis, MN 55404, USA.
- Center for Spirituality & Healing, University of Minnesota, Minneapolis, MN 55455, USA.
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306
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Kube T, Rief W. Are placebo and drug-specific effects additive? Questioning basic assumptions of double-blinded randomized clinical trials and presenting novel study designs. Drug Discov Today 2016; 22:729-735. [PMID: 27919806 DOI: 10.1016/j.drudis.2016.11.022] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 11/17/2016] [Accepted: 11/25/2016] [Indexed: 02/07/2023]
Abstract
Double-blinded randomized clinical trials (RCTs) assume that pharmacological interventions have drug-specific and unspecific components. Traditional RCTs postulate an additivity of these two components. In this review, we provide evidence from both clinical trials and experimental studies that questions this 'additive model'. Given that the evaluation of drug treatments in RCTs is based on the assumption of additivity, its violation has far-reaching consequences. Therefore, we discuss an interactive model that, in contrast to the additive model, considers interactions between placebo and drug-specific effects. Moreover, we discuss implications for future clinical trials and present novel study designs enabling researchers to consider the complex interplay of drug-specific and unspecific effects.
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Affiliation(s)
- Tobias Kube
- Philipps-University of Marburg, Department of Clinical Psychology and Psychotherapy, Gutenbergstrabe 18, D-35032 Marburg, Germany.
| | - Winfried Rief
- Philipps-University of Marburg, Department of Clinical Psychology and Psychotherapy, Gutenbergstrabe 18, D-35032 Marburg, Germany
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307
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Abstract
OBJECTIVE On the basis of emerging research evidence, this review aims to discuss the importance of the context surrounding the doctor-patient encounter for the success of treatment. DESIGN AND SETTING Discussion paper based on placebo-nocebo and pain studies conducted in the western world. MAIN OUTCOME MEASURES Literature-based theory about impact of communication elements on seriousness of symptoms in clinical practice. RESULTS The therapeutic outcome seems to be impacted by rituals around a clinical encounter and by the doctor patient communication and relation. A warm, friendly and empathic attitude is crucial in the first contact with the practice and during the consultation as it influences the patient's perceived outcome. It is important to raise positive expectations when discussing the prognosis, conducting treatment and prescribing medications as the effect may be reduced if the physician expresses doubt about the effectiveness of the medication. Additionally, overly focus on side effects in the doctor-patient conversation about proposed treatments seems to influence the magnitude of perceived side effects in the patient. Thus, shared decision-making might be a desirable tool for ensuring better expectations in the patient and successful symptom relief. CONCLUSIONS The context of the doctor-patient interplay matters. Placebo-nocebo research provides strong evidence for this link. The therapeutic context induces biomedical processes in the patient's brain that may enhance or reduce the effects of chosen interventions. The context thus works as a drug, with real effects and side effects. KEY POINTS Increased awareness of the context drug may help GPs alleviate symptoms and better motivate patients for treatment. Treatment is affected by multiple types of context, as also confirmed by placebo-nocebo research. The therapeutic context influences the biomedical processes, which may enhance or reduce intervention effects on symptoms. The impact of context should be considered in daily general practice as it may serve as a drug, with real effects and side effects.
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Affiliation(s)
- P. Lucassen
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, the Netherlands
- CONTACT P. Lucassen Radboud University Nijmegen Medical Centre, Department of Primary and Community Care, PO Box 9101, 6500 HB Nijmegen, the Netherlands
| | - F. Olesen
- Research Unit for General Practice, Department of Public Health, Aarhus University, Aarhus C, Denmark
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308
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Wilhelm M, Winkler A, Rief W, Doering BK. Effect of placebo groups on blood pressure in hypertension: a meta-analysis of beta-blocker trials. ACTA ACUST UNITED AC 2016; 10:917-929. [DOI: 10.1016/j.jash.2016.10.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 10/18/2016] [Accepted: 10/27/2016] [Indexed: 01/02/2023]
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309
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Borsook D, Veggeberg R, Erpelding N, Borra R, Linnman C, Burstein R, Becerra L. The Insula: A "Hub of Activity" in Migraine. Neuroscientist 2016; 22:632-652. [PMID: 26290446 PMCID: PMC5723020 DOI: 10.1177/1073858415601369] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The insula, a "cortical hub" buried within the lateral sulcus, is involved in a number of processes including goal-directed cognition, conscious awareness, autonomic regulation, interoception, and somatosensation. While some of these processes are well known in the clinical presentation of migraine (i.e., autonomic and somatosensory alterations), other more complex behaviors in migraine, such as conscious awareness and error detection, are less well described. Since the insula processes and relays afferent inputs from brain areas involved in these functions to areas involved in higher cortical function such as frontal, temporal, and parietal regions, it may be implicated as a brain region that translates the signals of altered internal milieu in migraine, along with other chronic pain conditions, through the insula into complex behaviors. Here we review how the insula function and structure is altered in migraine. As a brain region of a number of brain functions, it may serve as a model to study new potential clinical perspectives for migraine treatment.
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Affiliation(s)
- David Borsook
- Pain/Analgesia Imaging Neuroscience (P.A.I.N.) Group, Department of Anesthesia, Boston Children's Hospital, Center for Pain and the Brain, Harvard Medical School, Waltham, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
- Departments of Psychiatry and Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Rosanna Veggeberg
- Pain/Analgesia Imaging Neuroscience (P.A.I.N.) Group, Department of Anesthesia, Boston Children's Hospital, Center for Pain and the Brain, Harvard Medical School, Waltham, MA, USA
| | - Nathalie Erpelding
- Pain/Analgesia Imaging Neuroscience (P.A.I.N.) Group, Department of Anesthesia, Boston Children's Hospital, Center for Pain and the Brain, Harvard Medical School, Waltham, MA, USA
| | - Ronald Borra
- Pain/Analgesia Imaging Neuroscience (P.A.I.N.) Group, Department of Anesthesia, Boston Children's Hospital, Center for Pain and the Brain, Harvard Medical School, Waltham, MA, USA
| | - Clas Linnman
- Pain/Analgesia Imaging Neuroscience (P.A.I.N.) Group, Department of Anesthesia, Boston Children's Hospital, Center for Pain and the Brain, Harvard Medical School, Waltham, MA, USA
| | - Rami Burstein
- Department of Anesthesia, Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA, USA
| | - Lino Becerra
- Pain/Analgesia Imaging Neuroscience (P.A.I.N.) Group, Department of Anesthesia, Boston Children's Hospital, Center for Pain and the Brain, Harvard Medical School, Waltham, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
- Departments of Psychiatry and Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
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310
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Rief W, Petrie KJ. Can Psychological Expectation Models Be Adapted for Placebo Research? Front Psychol 2016; 7:1876. [PMID: 27965612 PMCID: PMC5124562 DOI: 10.3389/fpsyg.2016.01876] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 11/14/2016] [Indexed: 12/12/2022] Open
Abstract
Placebo responses contribute substantially to the effect and clinical outcome of medical treatments. Patients' expectations have been identified as one of the major mechanisms contributing to placebo effects. However, to date a general theoretical framework to better understand how patient expectations interact with features of medical treatment has not been developed. In this paper we outline an expectation model that can be used as framework for experimental studies on both placebo and nocebo mechanisms. This model is based on psychological concepts of expectation development, expectation maintenance, and expectation change within the typical paradigms used in placebo research. This theoretical framework reflects the dynamic aspects of the interaction between expectations and medical treatment, and offers a platform to combine psychological and neurophysiological research activities. Moreover, this model can be used to identify important future research questions. For example, we argue that the dynamic processes of expectation maintenance vs. expectation changes are not sufficiently addressed in current research on placebo mechanisms. Therefore, the question about how to change and optimize patients' expectations prior to treatment should be a special focus of future clinical research.
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Affiliation(s)
- Winfried Rief
- Department of Psychology, Philipps University Marburg Marburg, Germany
| | - Keith J Petrie
- Department of Psychological Medicine, University of Auckland Auckland, New Zealand
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311
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Wiech K. Deconstructing the sensation of pain: The influence of cognitive processes on pain perception. Science 2016; 354:584-587. [DOI: 10.1126/science.aaf8934] [Citation(s) in RCA: 237] [Impact Index Per Article: 29.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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312
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Kwok YH, Swift JE, Gazerani P, Rolan P. A double-blind, randomized, placebo-controlled pilot trial to determine the efficacy and safety of ibudilast, a potential glial attenuator, in chronic migraine. J Pain Res 2016; 9:899-907. [PMID: 27826212 PMCID: PMC5096778 DOI: 10.2147/jpr.s116968] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background Chronic migraine (CM) is problematic, and there are few effective treatments. Recently, it has been hypothesized that glial activation may be a contributor to migraine; therefore, this study investigated whether the potential glial inhibitor, ibudilast, could attenuate CM. Methods The study was of double-blind, randomized, placebo-controlled, two-period crossover design. Participants were randomized to receive either ibudilast (40 mg twice daily) or placebo treatment for 8 weeks. Subsequently, the participants underwent a 4-week washout period followed by a second 8-week treatment block with the alternative treatment. CM participants completed a headache diary 4 weeks before randomization throughout both treatment periods and 4 weeks after treatment. Questionnaires assessing quality of life and cutaneous allodynia were collected on eight occasions throughout the study. Results A total of 33 participants were randomized, and 14 participants completed the study. Ibudilast was generally well tolerated with mild, transient adverse events, principally nausea. Eight weeks of ibudilast treatment did not reduce the frequency of moderate to severe headache or of secondary outcome measures such as headache index, intake of symptomatic medications, quality of life or change in cutaneous allodynia. Conclusion Using the current regimen, ibudilast does not improve migraine with CM participants.
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Affiliation(s)
- Yuen H Kwok
- Discipline of Pharmacology, University of Adelaide, Level 5 Medical School North, South Australia, Australia
| | - James E Swift
- Discipline of Pharmacology, University of Adelaide, Level 5 Medical School North, South Australia, Australia
| | - Parisa Gazerani
- Department of Health Science & Technology, Aalborg University, Aalborg, Denmark
| | - Paul Rolan
- Discipline of Pharmacology, University of Adelaide, Level 5 Medical School North, South Australia, Australia
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313
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Ružić V, Ivanec D, Stanke KM. Effect of expectation on pain assessment of lower- and higher-intensity stimuli. Scand J Pain 2016; 14:9-14. [PMID: 28850443 DOI: 10.1016/j.sjpain.2016.09.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 09/18/2016] [Accepted: 09/30/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND AIMS Pain modulation via expectation is a well-documented phenomenon. So far it has been shown that expectations about effectiveness of a certain treatment enhance the effectiveness of different analgesics and of drug-free pain treatments. Also, studies demonstrate that people assess same-intensity stimuli differently, depending on the experimentally induced expectations regarding the characteristics of the stimuli. Prolonged effect of expectation on pain perception and possible symmetry in conditions of lower- and higher-intensity stimuli is yet to be studied. Aim of this study is to determine the effect of expectation on the perception of pain experimentally induced by the series of higher- and lower-intensity stimuli. METHODS 192 healthy participants were assigned to four experimental groups differing by expectations regarding the intensity of painful stimuli series. Expectations of two groups were congruent with actual stimuli; one group expected and received lower-intensity stimuli and the other expected and received higher-intensity stimuli. Expectations of the remaining two groups were not congruent with actual stimuli; one group expected higher-intensity stimuli, but actually received lower-intensity stimuli while the other group expected lower-intensity stimuli, but in fact received higher-intensity ones. Each group received a series of 24 varied-intensity electrical stimuli rated by the participants on a 30° intensity scale. RESULTS Expectation manipulation had statistically significant effect on pain intensity assessment. When expecting lower-intensity stimuli, the participants underestimated pain intensity and when expecting higher-intensity stimuli, they overestimated pain intensity. The effect size of expectations upon pain intensity assessment was equal for both lower- and higher-intensity stimuli. CONCLUSION The obtained results imply that expectation manipulation can achieve the desired effect of decreasing or increasing both slight and more severe pain for a longer period of time. Manipulation via expectation before the stimuli series was proven to be effective for pain modulation in the entire series of stimuli which lasted around 10min. The results suggest a potential benefit of manipulating expectations to alleviate emerging pain, since the obtained effects are moderate to large. IMPLICATIONS It seems that expectation effect is strong enough to "overcome" even the direct effect of stimulus intensity (at least in the low to moderate intensity range), which suggests potential benefits of verbal instructions even in rather painful stimuli.
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Affiliation(s)
- Valentina Ružić
- Naklada Slap, Centre for Education and Research, Zagreb, Croatia
| | - Dragutin Ivanec
- Department of Psychology, Faculty of Humanities and Social Sciences, University of Zagreb, Zagreb, Croatia
| | - Koraljka Modić Stanke
- Department of Psychology, Faculty of Humanities and Social Sciences, University of Zagreb, Zagreb, Croatia
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314
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Aslaksen PM, Åsli O, Øvervoll M, Bjørkedal E. Nocebo hyperalgesia and the startle response. Neuroscience 2016; 339:599-607. [PMID: 27789385 DOI: 10.1016/j.neuroscience.2016.10.040] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 10/14/2016] [Accepted: 10/17/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND The literature on the effects of nocebo on pain is sparse. The present experimental study investigated whether suggestions of nocebo hyperalgesia modified the startle response and whether increased startle contributed to the nocebo hyperalgesic effect. METHODS A design with four groups was employed; the participants were randomized into either a placebo group, a natural history group, or into two nocebo groups. The participants in the placebo and nocebo groups received suggestions of pain decrease or pain increase, together with a placebo or nocebo cream applied to the lower arm, respectively. Heat pain was induced by a PC-controlled thermode before and after the treatment. White noise was used to elicit startle responses. Startle was assessed by measuring eye blink electromyographic responses recorded from the right orbicularis oculi muscle. RESULTS The results showed that nocebo suggestions increased reports of pain and startle responses. Increased startle was significantly associated with the nocebo hyperalgesic response. CONCLUSIONS The results of the present study suggest that verbally induced expectations of increased pain engage cortical physiological defensive systems that in turn mediate the experience of increased pain.
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Affiliation(s)
- Per M Aslaksen
- Department of Psychology, Research Group for Cognitive Neuroscience, The Faculty of Health Sciences, University of Tromsø, The Arctic University of Norway, 9037 Tromsø, Norway.
| | - Ole Åsli
- Department of Psychology, Research Group for Cognitive Neuroscience, The Faculty of Health Sciences, University of Tromsø, The Arctic University of Norway, 9037 Tromsø, Norway
| | - Morten Øvervoll
- Department of Psychology, Research Group for Cognitive Neuroscience, The Faculty of Health Sciences, University of Tromsø, The Arctic University of Norway, 9037 Tromsø, Norway
| | - Espen Bjørkedal
- Department of Psychology, Research Group for Cognitive Neuroscience, The Faculty of Health Sciences, University of Tromsø, The Arctic University of Norway, 9037 Tromsø, Norway
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315
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Abstract
Over the last decade, the apparent increase in placebo responses in randomized controlled trials (RCTs) of neuropathic pain have complicated and potentially limited development and availability of new effective pain medication. Placebo analgesia and nocebo hyperalgesia effects are well described in nociceptive and idiopathic pain conditions, but less is known about the magnitude and mechanisms of placebo and nocebo effects in neuropathic pain. In neuropathic pain, placebo treatments have primarily been used as control conditions for active agents under investigation in RCTs and these placebo responses are typically not controlled for the natural history of pain and other confounding factors. Recently, mechanistic studies that control for the natural history of pain have investigated placebo and nocebo effects in neuropathic pain in their own right. Large placebo analgesia but no nocebo hyperalgesic effects have been found, and the underlying mechanisms are beginning to be elucidated. Here we review placebo and nocebo effects and the underlying mechanisms in neuropathic pain and compare them with those of nociceptive and idiopathic pain. This allows for a novel discussion on how knowledge of psychological, neurobiological, and genetic factors underlying well-controlled placebo effects may help improve the information that can be obtained from and potentially restore the utility of RCTs.
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316
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Zunhammer M, Schweizer LM, Witte V, Harris RE, Bingel U, Schmidt-Wilcke T. Combined glutamate and glutamine levels in pain-processing brain regions are associated with individual pain sensitivity. Pain 2016; 157:2248-2256. [PMID: 27649042 DOI: 10.1097/j.pain.0000000000000634] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The relationship between glutamate and γ-aminobutyric acid (GABA) levels in the living human brain and pain sensitivity is unknown. Combined glutamine/glutamate (Glx), as well as GABA levels can be measured in vivo with single-voxel proton magnetic resonance spectroscopy. In this cross-sectional study, we aimed at determining whether Glx and/or GABA levels in pain-related brain regions are associated with individual differences in pain sensitivity. Experimental heat, cold, and mechanical pain thresholds were obtained from 39 healthy, drug-free individuals (25 men) according to the quantitative sensory testing protocol and summarized into 1 composite measure of pain sensitivity. The Glx levels were measured using point-resolved spectroscopy at 3 T, within a network of pain-associated brain regions comprising the insula, the anterior cingulate cortex, the mid-cingulate cortex, the dorsolateral prefrontal cortex, and the thalamus. GABA levels were measured using GABA-edited spectroscopy (Mescher-Garwood point-resolved spectroscopy) within the insula, the anterior cingulate cortex, and the mid-cingulate cortex. Glx and/or GABA levels correlated positively across all brain regions. Gender, weekly alcohol consumption, and depressive symptoms were significantly associated with Glx and/or GABA levels. A linear regression analysis including all these factors indicated that Glx levels pooled across pain-related brain regions were positively associated with pain sensitivity, whereas no appreciable relationship with GABA was found. In sum, we show that the levels of the excitatory neurotransmitter glutamate and its precursor glutamine across pain-related brain regions are positively correlated with individual pain sensitivity. Future studies will have to determine whether our findings also apply to clinical populations.
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Affiliation(s)
| | - Lauren M Schweizer
- Abteilung für Neurologie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum, Germany
| | - Vanessa Witte
- Abteilung für Neurologie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum, Germany
| | - Richard E Harris
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Ulrike Bingel
- Klinik für Neurologie, Universitätsklinikum Essen, Essen, Germany
| | - Tobias Schmidt-Wilcke
- Abteilung für Neurologie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum, Germany
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317
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Affiliation(s)
- Jan Persson
- Pain Section , Department of Anaesthesia , Karolinska University Hospital, Huddinge , Stockholm , Sweden
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318
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Abstract
OBJECTIVES We sought to determine if negative responses to reduced nicotine content (RNC) cigarettes during open-label trials result from smokers' (negative) expectancies. We examined the effects of nicotine content description - independent of actual nicotine content - on subjective responses (craving reduction, withdrawal suppression, mood changes, and sensory ratings) and smoking behaviors (topography measures and carbon monoxide [CO] boost). METHODS Thirty-six 12-hour-abstinent daily smokers completed a 3-session crossover trial. During each session, participants smoked their preferred brand cigarette - blinded and described as containing "usual," "low," and "very low" nicotine content - through a topography device and completed CO and subjective response assessments. RESULTS Although nicotine content was identical, compared to the "usual" content cigarette, participants experienced less craving reduction after smoking the "very low" nicotine cigarette, and rated its smoke as weaker (p < .05). Participants took shallower puffs of the "low" nicotine cigarette (p < .05), and rated the "low" and "very low" nicotine cigarettes as weaker and too mild (p < .01). CONCLUSIONS Negative responses to RNC cigarettes may be due, in part, to negative expectancies about using cigarettes containing less nicotine. In this context, RNC cigarette marketing and labeling are likely important considerations if a federal nicotine reduction policy is initiated.
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319
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Luo Y, Yan C, Huang T, Fan M, Liu L, Zhao Z, Ni K, Jiang H, Huang X, Lu Z, Wu W, Zhang M, Fan X. Altered Neural Correlates of Emotion Associated Pain Processing in Persistent Somatoform Pain Disorder: An fMRI Study. Pain Pract 2016; 16:969-979. [PMID: 27641732 DOI: 10.1111/papr.12358] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 07/11/2015] [Indexed: 12/11/2022]
Abstract
Patients with persistent somatoform pain disorder (PSPD) suffer from long-term pain and emotional conflicts. Recently, accumulating evidence indicated that emotion has a significant role in pain perception of somatoform pain disorder. To further understand the association between emotion and pain-related brain activities, functional activities of patients with PSPD fulfilling ICD-10 criteria and healthy controls were assessed using functional magnetic resonance imaging technology, while participants viewed a series of positive, neutral, or negative pictures with or without pinprick pain stimulation. Results showed that patients with PSPD had altered brain activities in the parietal gyrus, temporal gyrus, posterior cingulate cortex, prefrontal cortex, and parahippocampus in response to pinprick pain stimuli during different emotions compared with the healthy control group. Moreover, patients with PSPD consistently showed hyperactivities in the prefrontal, the fusiform gyrus and the insula in response to negative stimuli under pinprick pain vs. non-pain condition. The current findings provide some insights into the underlying relationship between emotion and pain-related brain activity in patients with PSPD, which is of both theoretical and clinical importance.
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Affiliation(s)
- Yanli Luo
- Department of Psychiatry, Tongji Hospital of Tongji University, Shanghai, China
| | - Chao Yan
- Key Laboratory of Brain Functional Genomics, Ministry of Education, Shanghai Key Laboratory of Brain Functional Genomics (MOE & STCSM), East China Normal University, Shanghai, China
| | - Tianming Huang
- Mental Health Center of Changning District, Shanghai, China
| | - Mingxia Fan
- Department of Physics, East China Normal University, Shanghai, China
| | - Liang Liu
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhiyong Zhao
- Department of Physics, East China Normal University, Shanghai, China
| | - Kaiji Ni
- Department of Psychiatry, Tongji Hospital of Tongji University, Shanghai, China
| | - Hong Jiang
- Department of Medical Imaging, Tongji Hospital of Tongji University, Shanghai, China
| | - Xiao Huang
- Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zheng Lu
- Department of Psychiatry, Tongji Hospital of Tongji University, Shanghai, China
| | - Wenyuan Wu
- Department of Psychiatry, Tongji Hospital of Tongji University, Shanghai, China
| | - Mingyuan Zhang
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaoduo Fan
- Department of Psychiatry, University of Massachusetts Medical School, Massachusetts, USA
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320
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Piedimonte A, Benedetti F. Words and Drugs: Same Mechanisms of Action? JOURNAL OF CONTEMPORARY PSYCHOTHERAPY 2016. [DOI: 10.1007/s10879-015-9321-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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321
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Edwards RR, Dworkin RH, Sullivan MD, Turk DC, Wasan AD. The Role of Psychosocial Processes in the Development and Maintenance of Chronic Pain. THE JOURNAL OF PAIN 2016; 17:T70-92. [PMID: 27586832 PMCID: PMC5012303 DOI: 10.1016/j.jpain.2016.01.001] [Citation(s) in RCA: 476] [Impact Index Per Article: 59.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 12/07/2015] [Accepted: 01/05/2016] [Indexed: 12/14/2022]
Abstract
UNLABELLED The recently proposed Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION)-American Pain Society (APS) Pain Taxonomy (AAPT) provides an evidence-based, multidimensional, chronic pain classification system. Psychosocial factors play a crucial role within several dimensions of the taxonomy. In this article, we discuss the evaluation of psychosocial factors that influence the diagnosis and trajectory of chronic pain disorders. We review studies in individuals with a variety of persistent pain conditions, and describe evidence that psychosocial variables play key roles in conferring risk for the development of pain, in shaping long-term pain-related adjustment, and in modulating pain treatment outcomes. We consider "general" psychosocial variables such as negative affect, childhood trauma, and social support, as well as "pain-specific" psychosocial variables that include pain-related catastrophizing, self-efficacy for managing pain, and pain-related coping. Collectively, the complexity and profound variability in chronic pain highlights the need to better understand the multidimensional array of interacting forces that determine the trajectory of chronic pain conditions. PERSPECTIVE The AAPT is an evidence-based chronic pain classification system in which psychosocial concepts and processes are essential in understanding the development of chronic pain and its effects. In this article we review psychosocial processes that influence the onset, exacerbation, and maintenance of chronic pain disorders.
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Affiliation(s)
- Robert R Edwards
- Department of Anesthesiology, Brigham & Women's Hospital and Harvard University, Boston, Massachusetts.
| | - Robert H Dworkin
- Departments of Anesthesiology and Neurology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Mark D Sullivan
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington
| | - Dennis C Turk
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington
| | - Ajay D Wasan
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, Pennsylvania
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322
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Albu S, Meagher MW. Expectation of nocebo hyperalgesia affects EEG alpha-activity. Int J Psychophysiol 2016; 109:147-152. [PMID: 27562424 DOI: 10.1016/j.ijpsycho.2016.08.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 08/19/2016] [Accepted: 08/20/2016] [Indexed: 01/07/2023]
Abstract
Changes in EEG activity have been related to clinical and experimental pain. Expectation of a negative outcome can lead to pain enhancement (nocebo hyperalgesia) and can alter the response to therapeutic interventions. The present study characterizes EEG alteration related to pain facilitation by nocebo. Thirty healthy subjects were randomly assigned to the nocebo or control group. Five-minute EEG was recorded under: resting state, tonic innocuous heat and tonic noxious heat before and after the application of a sham inert cream to the non-dominant volar forearm combined with cognitive manipulation. The intensity and unpleasantness of heat-induced pain increased after cognitive manipulation in the nocebo group compared to control and was associated with enhanced low alpha (8-10Hz) activity. However, changes in alpha activity were predicted by catastrophizing but not by pain intensity or unpleasantness, which suggest that low alpha power might reflect brain activity related to negative cognitive-affective responses to pain.
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Affiliation(s)
- Sergiu Albu
- Department of Psychology, Texas A&M University, College Station, TX 77843-4235, United States.
| | - Mary W Meagher
- Department of Psychology, Texas A&M University, College Station, TX 77843-4235, United States
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323
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Reid MC. Expanding Targets for Intervention in Later Life Pain: What Role Can Patient Beliefs, Expectations, and Pleasant Activities Play? Clin Geriatr Med 2016; 32:797-805. [PMID: 27741971 DOI: 10.1016/j.cger.2016.06.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Clinicians are often challenged to find targets for intervention in older adults with chronic pain. This article highlights 3 targets clinicians should consider when formulating their multimodal treatment plans to include older patients' attitudes and beliefs about pain and pain treatments, expectations regarding treatment outcomes, and pleasurable activity pursuits.
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Affiliation(s)
- M Carrington Reid
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, 525 East 68th Street, #39, New York, NY 10065, USA.
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324
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Pazzaglia C, Testani E, Giordano R, Padua L, Valeriani M. Expectation to feel more pain disrupts the habituation of laser-pain rating and laser-evoked potential amplitudes. Neuroscience 2016; 333:244-51. [PMID: 27461877 DOI: 10.1016/j.neuroscience.2016.07.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 07/16/2016] [Accepted: 07/18/2016] [Indexed: 11/28/2022]
Abstract
Increased pain perception due to the expectation to feel more pain is called nocebo effect. The present study aimed at investigating whether: (1) the mere expectation to feel more pain after the administration of an inert drug can affect the laser-pain rating and the laser-evoked potential (LEP) amplitude, and (2) the learning potentiates the nocebo effect. Eighteen healthy volunteers were told that an inert cream, applied on the right hand, would increase the laser pain and LEP amplitude to right hand stimulation. They were randomly assigned to either "verbal session" or "conditioning session". In the "verbal session", LEPs to both right and left hand stimulation were recorded at the same intensity before (baseline) and after cream application. In the "conditioning session", after an initial cream application the laser stimulus intensity was increased surreptitiously to make the subjects believe that the treatment really increased the pain sensation. Then, the cream was reapplied, and LEPs were recorded at the same stimulus intensity as at the baseline. It was found that the verbal suggestion to feel more pain disrupted the physiological habituation of the laser-pain rating and LEP amplitude to treated (right) hand stimulation. Unlike previously demonstrated for the placebo effect, the learning did not potentiate the nocebo effect.
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Affiliation(s)
- Costanza Pazzaglia
- Department of Neurology, Don Carlo Gnocchi Onlus Foundation, Via Alfonso Capecelatro, 66, 20148 Milan, Italy.
| | - Elisa Testani
- Institute of Neurology, Catholic University of the Sacred Heart, Largo Francesco Vito, 1, 00168 Rome, Italy.
| | - Rocco Giordano
- Institute of Neurology, Catholic University of the Sacred Heart, Largo Francesco Vito, 1, 00168 Rome, Italy.
| | - Luca Padua
- Department of Neurology, Don Carlo Gnocchi Onlus Foundation, Via Alfonso Capecelatro, 66, 20148 Milan, Italy; Institute of Neurology, Catholic University of the Sacred Heart, Largo Francesco Vito, 1, 00168 Rome, Italy.
| | - Massimiliano Valeriani
- Department of Neuroscience, Pediatric Hospital Bambino Gesù, Piazza Sant'Onofrio, 4, 00146 Rome, Italy; Center for Sensory-Motor Interaction, Aalborg University, Fredrik Bajers Vej 5, 9100 Aalborg, Denmark.
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325
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Tibbs GR, Posson DJ, Goldstein PA. Voltage-Gated Ion Channels in the PNS: Novel Therapies for Neuropathic Pain? Trends Pharmacol Sci 2016; 37:522-542. [DOI: 10.1016/j.tips.2016.05.002] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 03/24/2016] [Accepted: 05/03/2016] [Indexed: 12/19/2022]
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326
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Benedetti F, Carlino E, Piedimonte A. Increasing uncertainty in CNS clinical trials: the role of placebo, nocebo, and Hawthorne effects. Lancet Neurol 2016; 15:736-747. [DOI: 10.1016/s1474-4422(16)00066-1] [Citation(s) in RCA: 104] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 02/08/2016] [Accepted: 02/11/2016] [Indexed: 12/19/2022]
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327
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Rethinking Explicit Expectations: Connecting Placebos, Social Cognition, and Contextual Perception. Trends Cogn Sci 2016; 20:469-480. [PMID: 27108268 DOI: 10.1016/j.tics.2016.04.001] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 04/01/2016] [Accepted: 04/01/2016] [Indexed: 12/19/2022]
Abstract
Expectancy effects are a widespread phenomenon, and they come with a lasting influence on cognitive operations, from basic stimulus processing to higher cognitive functions. Their impact is often profound and behaviorally significant, as evidenced by an enormous body of literature investigating the characteristics and possible processes underlying expectancy effects. The literature on this topic spans diverse fields, from clinical psychology to cognitive neuroscience, and from social psychology to behavioral biology. We present an emerging perspective on these diverse phenomena and show how this perspective stimulates new toeholds for investigation, provides insight in underlying mechanisms, improves awareness of methodological confounds, and can lead to a deeper understanding of the effects of expectations on a broad spectrum of cognitive processes.
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328
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Peterson CB, Becker CB, Treasure J, Shafran R, Bryant-Waugh R. The three-legged stool of evidence-based practice in eating disorder treatment: research, clinical, and patient perspectives. BMC Med 2016; 14:69. [PMID: 27081002 PMCID: PMC4832531 DOI: 10.1186/s12916-016-0615-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 04/08/2016] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Evidence-based practice in eating disorders incorporates three essential components: research evidence, clinical expertise, and patient values, preferences, and characteristics. Conceptualized as a 'three-legged stool' by Sackett et al. in 1996 (BMJ), all of these components of evidence-based practice are considered essential for providing optimal care in the treatment of eating disorders. However, the extent to which these individual aspects of evidence-based practice are valued among clinicians and researchers is variable, with each of these stool 'legs' being neglected at times. As a result, empirical support and patient preferences for treatment are not consistently considered in the selection and implementation of eating disorder treatment. In addition, clinicians may not have access to training to provide treatments supported by research and preferred by patients. Despite these challenges, integrating these three components of evidence-based practice is critical for the effective treatment of eating disorders. DISCUSSION Current research supports the use of several types of psychotherapies, including cognitive-behavioral, interpersonal, and family-based therapies, as well as certain types of medications for the treatment of eating disorders. However, limitations in current research, including sample heterogeneity, inconsistent efficacy, a paucity of data, the need for tailored approaches, and the use of staging models highlight the need for clinical expertise. Although preliminary data also support the importance of patient preferences, values, and perspectives for optimizing treatment, enhancing treatment outcome, and minimizing attrition among patients with eating disorders, the extent to which patient preference is consistently predictive of outcome is less clear and requires further investigation. All three components of evidence-based practice are integral for the optimal treatment of eating disorders. Integrating clinical expertise and patient perspective may also facilitate the dissemination of empirically-supported and emerging treatments as well as prevention programs. Further research is imperative to identify ways in which this three-legged approach to eating disorder treatment could be most effectively implemented.
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Affiliation(s)
- Carol B. Peterson
- />Department of Psychiatry, University of Minnesota Medical School, F282/2A West, 2450 Riverside Avenue South, Minneapolis, MN 55454 USA
- />The Emily Program, St. Paul, MN USA
| | | | - Janet Treasure
- />Department of Psychological Medicine, IOPPN, King’s College, London, UK
| | - Roz Shafran
- />Institute of Child Health, University College, London, UK
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329
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Planès S, Villier C, Mallaret M. The nocebo effect of drugs. Pharmacol Res Perspect 2016; 4:e00208. [PMID: 27069627 PMCID: PMC4804316 DOI: 10.1002/prp2.208] [Citation(s) in RCA: 113] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 11/09/2015] [Accepted: 11/20/2015] [Indexed: 12/17/2022] Open
Abstract
While the placebo effect has been studied for a long time, much less is known about its negative counterpart, named the nocebo effect. However, it may be of particular importance because of its impact on the treatment outcomes and public health. We conducted a review on the nocebo effect using PubMed and other databases up to July 2014. The nocebo effect refers by definition to the induction or the worsening of symptoms induced by sham or active therapies. Examples are numerous and concerns both clinical trials and daily practice. The underlying mechanisms are, on one hand, psychological (conditioning and negative expectations) and, on the other hand, neurobiological (role of cholecystokinin, endogenous opioids and dopamine). Nocebo effects can modulate the outcome of a given therapy in a negative way, as do placebo effects in a positive way. The verbal and nonverbal communications of physicians contain numerous unintentional negative suggestions that may trigger a nocebo response. This raises the important issue of how physicians can at the same time obtain informed consent and minimize nocebo-related risks. Every physician has to deal with this apparent contradiction between primum non nocere and to deliver truthful information about risks. Meticulous identification of patients at risk, information techniques such as positive framing, contextualized informed consent, and even noninformation, is valuable.
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Affiliation(s)
- Sara Planès
- Centre Régional de Pharmacovigilance Grenoble University Hospital Grenoble France
| | - Céline Villier
- Centre Régional de Pharmacovigilance Grenoble University Hospital Grenoble France
| | - Michel Mallaret
- Centre Régional de Pharmacovigilance Grenoble University Hospital Grenoble France
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330
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Schedlowski M, Enck P, Rief W, Bingel U. Neuro-Bio-Behavioral Mechanisms of Placebo and Nocebo Responses: Implications for Clinical Trials and Clinical Practice. Pharmacol Rev 2016; 67:697-730. [PMID: 26126649 DOI: 10.1124/pr.114.009423] [Citation(s) in RCA: 197] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The placebo effect has often been considered a nuisance in basic and particularly clinical research. This view has gradually changed in recent years due to deeper insight into the neuro-bio-behavioral mechanisms steering both the placebo and nocebo responses, the evil twin of placebo. For the neuroscientist, placebo and nocebo responses have evolved as indispensable tools to understand brain mechanisms that link cognitive and emotional factors with symptom perception as well as peripheral physiologic systems and end organ functioning. For the clinical investigator, better understanding of the mechanisms driving placebo and nocebo responses allow the control of these responses and thereby help to more precisely define the efficacy of a specific pharmacological intervention. Finally, in the clinical context, the systematic exploitation of these mechanisms will help to maximize placebo responses and minimize nocebo responses for the patient's benefit. In this review, we summarize and critically examine the neuro-bio-behavioral mechanisms underlying placebo and nocebo responses that are currently known in terms of different diseases and physiologic systems. We subsequently elaborate on the consequences of this knowledge for pharmacological treatments of patients and the implications for pharmacological research, the training of healthcare professionals, and for the health care system and future research strategies on placebo and nocebo responses.
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Affiliation(s)
- Manfred Schedlowski
- Institute of Medical Psychology and Behavioral Immunobiology (M.S.) and Department of Neurology (U.B.), University Clinic Essen, Essen, Germany; Department of Internal Medicine VI, Psychosomatic Medicine, University Hospital Tübingen, Tübingen, Germany (P.E.); and Department of Psychology, University of Marburg, Marburg, Germany (W.R.)
| | - Paul Enck
- Institute of Medical Psychology and Behavioral Immunobiology (M.S.) and Department of Neurology (U.B.), University Clinic Essen, Essen, Germany; Department of Internal Medicine VI, Psychosomatic Medicine, University Hospital Tübingen, Tübingen, Germany (P.E.); and Department of Psychology, University of Marburg, Marburg, Germany (W.R.)
| | - Winfried Rief
- Institute of Medical Psychology and Behavioral Immunobiology (M.S.) and Department of Neurology (U.B.), University Clinic Essen, Essen, Germany; Department of Internal Medicine VI, Psychosomatic Medicine, University Hospital Tübingen, Tübingen, Germany (P.E.); and Department of Psychology, University of Marburg, Marburg, Germany (W.R.)
| | - Ulrike Bingel
- Institute of Medical Psychology and Behavioral Immunobiology (M.S.) and Department of Neurology (U.B.), University Clinic Essen, Essen, Germany; Department of Internal Medicine VI, Psychosomatic Medicine, University Hospital Tübingen, Tübingen, Germany (P.E.); and Department of Psychology, University of Marburg, Marburg, Germany (W.R.)
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331
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Psychological Placebo and Nocebo Effects on Pain Rely on Expectation and Previous Experience. THE JOURNAL OF PAIN 2016; 17:203-14. [DOI: 10.1016/j.jpain.2015.10.010] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 10/03/2015] [Accepted: 10/17/2015] [Indexed: 11/19/2022]
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332
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Monitoring heart rate variability to assess experimentally induced pain using the analgesia nociception index. Eur J Anaesthesiol 2016; 33:118-25. [DOI: 10.1097/eja.0000000000000304] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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333
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Carlino E, Benedetti F. Different contexts, different pains, different experiences. Neuroscience 2016; 338:19-26. [PMID: 26827944 DOI: 10.1016/j.neuroscience.2016.01.053] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Revised: 01/21/2016] [Accepted: 01/22/2016] [Indexed: 12/19/2022]
Abstract
Pain is an ambiguous perception: the same pain stimulation can be perceived differently in different contexts, producing different experiences, ranging from mild to unbearable pain. It can be even experienced as a rewarding sensation within the appropriate context. Overall, placebo and nocebo effects appear to be very good models to understand how the psychosocial context modulates the experience of pain. In this review, we examine the effects of different contexts on pain, with a specific focus on the neurobiological mechanisms. Positive and rewarding contexts inform the patients that an effective treatment is being delivered and are capable of producing pain relief through the activation of specific systems such as opioids, cannabinoids and dopamine. Conversely, a negative context can produce pain exacerbation and clinical worsening through the modulation of different systems, such as the activation of cholecystokinin and the deactivation of opioids and dopamine. In addition, when a therapy is delivered unbeknownst to the patient, its effects are reduced. A better understanding of the neurobiological underpinnings of the context-pain interaction is a challenge both for future pain research and for good clinical practice.
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Affiliation(s)
- E Carlino
- University of Turin Medical School, Neuroscience Department, Turin, Italy
| | - F Benedetti
- University of Turin Medical School, Neuroscience Department, Turin, Italy; Plateau Rosa Laboratories, Breuil-Cervinia, Italy, Zermatt, Switzerland.
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334
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Abstract
Expectations of pain relief drive placebo analgesia. Understanding how expectations of improvement trigger distinct biological systems to shape therapeutic analgesic outcomes has been the focus of recent pharmacologic and neuroimaging studies in the field of pain. Recent findings indicate that placebo effects can imitate the actions of real painkillers and promote the endogenous release of opioids and nonopioids in humans. Social support and observational learning also contribute to placebo analgesic effects. Distinct psychological traits can modulate expectations of analgesia, which facilitate brain pain control mechanisms involved in pain reduction. Many studies have highlighted the importance and clinical relevance of these responses. Gaining deeper understanding of these pain modulatory mechanisms has important implications for personalizing patient pain management.
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Affiliation(s)
- Zev M Medoff
- National Institute of Mental Health (NIMH), National Institutes of Health (NIH), Bethesda, MD, USA
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335
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Rief W, Glombiewski JA. Erwartungsfokussierte Psychotherapeutische Interventionen (EFPI). VERHALTENSTHERAPIE 2016. [DOI: 10.1159/000442374] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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336
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Wanigasekera V, Mezue M, Andersson J, Kong Y, Tracey I. Disambiguating Pharmacodynamic Efficacy from Behavior with Neuroimaging: Implications for Analgesic Drug Development. Anesthesiology 2016; 124:159-68. [PMID: 26669989 PMCID: PMC4684093 DOI: 10.1097/aln.0000000000000924] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Attrition rates of new analgesics during drug development are high; poor assay sensitivity with reliance on subjective outcome measures being a crucial factor. METHODS The authors assessed the utility of functional magnetic resonance imaging with capsaicin-induced central sensitization, a mechanism relevant in neuropathic pain, for obtaining mechanism-based objective outcome measures that can differentiate an effective analgesic (gabapentin) from an ineffective analgesic (ibuprofen) and both from placebo. The authors used a double-blind, randomized phase I study design (N = 24) with single oral doses. RESULTS Only gabapentin suppressed the secondary mechanical hyperalgesia-evoked neural response in a region of the brainstem's descending pain modulatory system (right nucleus cuneiformis) and left (contralateral) posterior insular cortex and secondary somatosensory cortex. Similarly, only gabapentin suppressed the resting-state functional connectivity during central sensitization between the thalamus and secondary somatosensory cortex, which was plasma gabapentin level dependent. A power analysis showed that with 12 data sets, when using neural activity from the left posterior insula and right nucleus cuneiformis, a statistically significant difference between placebo and gabapentin was detected with probability ≥ 0.8. When using subjective pain ratings, this reduced to less than or equal to 0.6. CONCLUSIONS Functional imaging with central sensitization can be used as a sensitive mechanism-based assay to guide go/no-go decisions on selecting analgesics effective in neuropathic pain in early human drug development. We also show analgesic modulation of neural activity by using resting-state functional connectivity, a less challenging paradigm that is ideally suited for patient studies because it requires no task or pain provocation.
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Affiliation(s)
- Vishvarani Wanigasekera
- Centre for Functional Magnetic Resonance Imaging of the Brain (FMRIB) & Nuffield Division of Anaesthetics, Nuffield Department of Clinical Neurosciences University of Oxford, John Radcliffe Hospital, Headington, Oxford, OX3 9DU, United Kingdom. Telephone +441865 222736
| | - Melvin Mezue
- Centre for Functional Magnetic Resonance Imaging of the Brain (FMRIB) & Nuffield Division of Anaesthetics, Nuffield Department of Clinical Neurosciences University of Oxford, John Radcliffe Hospital, Headington, Oxford, OX3 9DU, United Kingdom. Telephone +441865 222736
| | - Jesper Andersson
- Centre for Functional Magnetic Resonance Imaging of the Brain (FMRIB) & Nuffield Division of Anaesthetics, Nuffield Department of Clinical Neurosciences University of Oxford, John Radcliffe Hospital, Headington, Oxford, OX3 9DU, United Kingdom. Telephone +441865 222736
| | - Yazhuo Kong
- Centre for Functional Magnetic Resonance Imaging of the Brain (FMRIB) & Nuffield Division of Anaesthetics, Nuffield Department of Clinical Neurosciences University of Oxford, John Radcliffe Hospital, Headington, Oxford, OX3 9DU, United Kingdom. Telephone +441865 222736
| | - Irene Tracey
- Centre for Functional Magnetic Resonance Imaging of the Brain (FMRIB) & Nuffield Division of Anaesthetics, Nuffield Department of Clinical Neurosciences University of Oxford, John Radcliffe Hospital, Headington, Oxford, OX3 9DU, United Kingdom. Telephone +441865 222736
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337
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Forkmann K, Schmidt K, Schultz H, Sommer T, Bingel U. Experimental pain impairs recognition memory irrespective of pain predictability. Eur J Pain 2015; 20:977-88. [PMID: 26685005 DOI: 10.1002/ejp.822] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND Pain is hardwired to signal threat and tissue damage and therefore automatically attracts attention to initiate withdrawal or defensive behaviour. This well-known interruptive function of pain interferes with cognitive functioning and is modulated by bottom-up and top-down variables. Here, we applied predictable or unpredictable painful heat stimuli simultaneously to the presentation of neutral images to investigate (I) whether the predictability of pain modulated its effect on the encoding of images (episodic memory) and (II) whether subjects remember that certain images have been previously presented with pain (source memory). METHODS Twenty-four healthy subjects performed a categorization task in which 80 images had to be categorized into living or non-living objects. We compared the processing and encoding of these images during cued and non-cued pain trials as well as cued and non-cued pain-free trials. Effects on recognition performance and source memory for pain were immediately tested using a surprise recognition task. RESULTS Painful thermal stimulation impaired recognition accuracy (d', recollection, familiarity). This negative effect of pain was positively correlated with the individual expectation of pain interference and the attentional avoidance of pain-related words. However, the interruptive effect of pain was not modulated by the predictability of pain. Source memory for painful stimulation was at chance level, indicating that subjects did not explicitly remember that images had been paired with pain. CONCLUSIONS Targeting negative expectations and a maladaptive attentional bias for pain-related material might help reducing frequently reported pain-induced cognitive impairments.
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Affiliation(s)
- K Forkmann
- Clinic for Neurology, Essen University Hospital, Germany
| | - K Schmidt
- Clinic for Neurology, Essen University Hospital, Germany
| | - H Schultz
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Germany
| | - T Sommer
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Germany
| | - U Bingel
- Clinic for Neurology, Essen University Hospital, Germany
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338
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Colgan S, Faasse K, Martin LR, Stephens MH, Grey A, Petrie KJ. Perceptions of generic medication in the general population, doctors and pharmacists: a systematic review. BMJ Open 2015; 5:e008915. [PMID: 26671954 PMCID: PMC4679988 DOI: 10.1136/bmjopen-2015-008915] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To investigate negative perceptions about generic medicines and evaluate the proportions of lay people, doctors and pharmacists who hold these perceptions. DESIGN A systematic review of observational studies. DATA SOURCES MEDLINE, EMBASE, PsycInfo and Scopus. ELIGIBILITY CRITERIA Quantitative data from cross-sectional and prospective studies published in English after 1980, using self-report measures to evaluate perceptions about generic medicines, presented as percentages of the total sample assessed. RESULTS After screening 2737 articles, 52 articles were included in the final analysis. A high proportion of doctors, pharmacists and lay people had negative perceptions of generics. Lay people were significantly more likely to view generics as less effective than branded medication (35.6%, 95% CI 34.8% to 36.4%) compared to doctors (28.7%, 27.5% to 29.9%) and pharmacists (23.6%, 21.2% to 26.2%), p<0.0001. Pharmacists (33.4%, 31.0% to 35.9%) were significantly more likely to believe generics were of inferior quality compared to branded medication than were doctors (28.0%, 26.3% to 29.9%), p=0.0006, and lay people (25.1%, 24.2% to 26.0%), p<0.0001. Doctors believed generics caused more side effects than branded medication (24.4%, 22.2% to 26.9%), compared to pharmacists (17.6%, 15.3% to 20.1%) and lay people (18.8%, 17.8% to 19.8%), p<0.0001. Doctors (28.5%, 26.9% to 30.2%) and pharmacists (25.4%, 21.4% to 29.9%) had significantly more safety concerns about generics than did lay people (18.0%, 17.0% to 19.0%), p ≤ 0.0002. A greater proportion of lay people felt negatively about generic substitution (34.0%, 33.2% to 34.9%), compared to doctors (24.1%, 22.0% to 26.4%) and pharmacists (11.0%, 9.6% to 12.7%), p<0.0001. Rates of negative perceptions of generics do not appear to have changed substantially over time in the general population or among physician groups, p ≥ 0.431, but such negative beliefs show a decreasing trend in pharmacists over the study period, p=0.034. CONCLUSIONS A significant proportion of doctors, pharmacists and lay people hold negative perceptions of generic medicines. It is likely these attitudes present barriers to the wider use of generics.
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Affiliation(s)
- Sarah Colgan
- Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
| | - Kate Faasse
- Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
| | - Leslie R Martin
- Department of Psychology, La Sierra University, Riverside, California, USA
| | - Melika H Stephens
- Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
| | - Andrew Grey
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Keith J Petrie
- Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
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339
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Baber M, Bapat P, Nichol G, Koren G. The pharmacogenetics of opioid therapy in the management of postpartum pain: a systematic review. Pharmacogenomics 2015; 17:75-93. [PMID: 26652709 DOI: 10.2217/pgs.15.157] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIMS Opioids are commonly prescribed for postpartum pain. Yet, providing adequate pain relief, while ensuring that the mother and her breastfeeding infant are protected from adverse events can be challenging. The objective of this systematic review was to identify the role of opioid pharmacogenetics in analgesia and adverse events among patients being treated for postpartum pain, along with their breastfeeding infants. METHODS A comprehensive search of the literature was conducted in seven databases on June 3-4, 2015. Two reviewers independently screened studies for eligibility, extracted data and evaluated study quality using the Newcastle-Ottawa Scale. RESULTS Among the 2082 papers retrieved from the search, 17 were included in the review. These 17 papers consisted of various study designs, opioids, polymorphisms and patient outcomes. This systematic review reveals that CYP2D6, OPRM1 A118G, UGT2B7 C802T and ABCB1 G2677AT may contribute to postpartum analgesia or adverse events. CONCLUSION These findings may assist in personalizing care for patients receiving opioids during the postpartum period.
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Affiliation(s)
- Marta Baber
- Division of Clinical Pharmacology & Toxicology, Department of Pediatrics, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada.,Department of Pharmacology & Toxicology, Faculty of Medicine, University of Toronto, 1 King's College Circle, Toronto, Ontario, M5S 1A8, Canada
| | - Priya Bapat
- Division of Clinical Pharmacology & Toxicology, Department of Pediatrics, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada.,Department of Pharmacology & Toxicology, Faculty of Medicine, University of Toronto, 1 King's College Circle, Toronto, Ontario, M5S 1A8, Canada
| | - Gail Nichol
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St, Toronto, Ontario, M5S 3M2, Canada
| | - Gideon Koren
- Department of Pharmacology & Toxicology, Faculty of Medicine, University of Toronto, 1 King's College Circle, Toronto, Ontario, M5S 1A8, Canada
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340
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Petkovic G, Charlesworth JEG, Kelley J, Miller F, Roberts N, Howick J. Effects of placebos without deception compared with no treatment: protocol for a systematic review and meta-analysis. BMJ Open 2015; 5:e009428. [PMID: 26610763 PMCID: PMC4663432 DOI: 10.1136/bmjopen-2015-009428] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 09/15/2015] [Accepted: 10/07/2015] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Placebos have long provided a robust control for evaluating active pharmacological preparations, but frequently demonstrate a variable therapeutic effect when delivered in double-blinded placebo-controlled trials. Delivery of placebos as treatment alone has been considered unethical, as it has been thought that deception is essential for their effect. However, recent evidence suggests that clinical benefit can be derived from placebos delivered without deception (unblinded/open-label) manner. Here, we present a protocol for the first systematic review and meta-analysis of studies of the effects of non-deceptive placebos compared with no treatment. METHODS AND ANALYSIS This protocol will compare the effect of placebos delivered non-deceptively to no treatment. It will also assess the methods of delivery used for non-deceptive placebos. Studies will be sought through relevant database searches and will include those within disease settings and those among healthy controls. To be included, trials must include both non-deceptive (open-label) placebo and no treatment groups. All data extraction and analysis will be conducted by two independent reviewers. The analysis will evaluate any differences in outcome measures between the non-deceptive placebo and no treatment groups. Outcome measures will be the clinically-relevant outcomes detailed in the primary papers. The delivery methods, such as verbal instructions, which may provide positive expectations and outcomes, of non-deceptive placebos will also be assessed. Each study will be comprehensively assessed for bias. Subgroup analyses will identify any discrepancies among heterogeneous data. ETHICS AND DISSEMINATION This review does not require ethical approval. The completed review will be widely disseminated by publication and social media where appropriate. This protocol has been registered on PROSPERO (2015:CRD42015023347).
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Affiliation(s)
- Grace Petkovic
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - John Kelley
- Psychiatry Department, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
- Psychology Department, Endicott College, Beverly, Massachusetts, USA
| | - Franklin Miller
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Nia Roberts
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jeremy Howick
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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341
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Lee IS, Lee B, Park HJ, Olausson H, Enck P, Chae Y. A new animal model of placebo analgesia: involvement of the dopaminergic system in reward learning. Sci Rep 2015; 5:17140. [PMID: 26602173 PMCID: PMC4658539 DOI: 10.1038/srep17140] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 10/26/2015] [Indexed: 11/09/2022] Open
Abstract
We suggest a new placebo analgesia animal model and investigated the role of the dopamine and opioid systems in placebo analgesia. Before and after the conditioning, we conducted a conditioned place preference (CPP) test to measure preferences for the cues (Rooms 1 and 2), and a hot plate test (HPT) to measure the pain responses to high level-pain after the cues. In addition, we quantified the expression of tyrosine hydroxylase (TH) in the ventral tegmental area (VTA) and c-Fos in the anterior cingulate cortex (ACC) as a response to reward learning and pain response. We found an enhanced preference for the low level-pain paired cue and enhanced TH expression in the VTA of the Placebo and Placebo + Naloxone groups. Haloperidol, a dopamine antagonist, blocked these effects in the Placebo + Haloperidol group. An increased pain threshold to high-heat pain and reduced c-Fos expression in the ACC were observed in the Placebo group only. Haloperidol blocked the place preference effect, and naloxone and haloperidol blocked the placebo analgesia. Cue preference is mediated by reward learning via the dopamine system, whereas the expression of placebo analgesia is mediated by the dopamine and opioid systems.
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Affiliation(s)
- In-Seon Lee
- Acupuncture and Meridian Science Research Center, College of Korean Medicine, Kyung Hee University, Seoul, Korea.,Department of Internal Medicine: Psychosomatic Medicine and Psychotherapy, University of Tübingen, Tübingen, Germany.,Institute for Medical Psychology, fMEG Center, University of Tübingen, Tübingen, Germany.,IMPRS for Cognitive and Systems Neuroscience, University of Tübingen, Tübingen, Germany
| | - Bombi Lee
- Acupuncture and Meridian Science Research Center, College of Korean Medicine, Kyung Hee University, Seoul, Korea
| | - Hi-Joon Park
- Acupuncture and Meridian Science Research Center, College of Korean Medicine, Kyung Hee University, Seoul, Korea
| | - Håkan Olausson
- Center for Social and Affective Neuroscience, Linköping University
| | - Paul Enck
- Department of Internal Medicine: Psychosomatic Medicine and Psychotherapy, University of Tübingen, Tübingen, Germany
| | - Younbyoung Chae
- Acupuncture and Meridian Science Research Center, College of Korean Medicine, Kyung Hee University, Seoul, Korea
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342
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Napadow V, Li A, Loggia M, Kim J, Mawla I, Desbordes G, Schalock PC, Lerner EA, Tran TN, Ring J, Rosen BR, Kaptchuk TJ, Pfab F. The imagined itch: brain circuitry supporting nocebo-induced itch in atopic dermatitis patients. Allergy 2015; 70:1485-92. [PMID: 26280659 DOI: 10.1111/all.12727] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND Psychological factors are known to significantly modulate itch in patients suffering from chronic itch. Itch is also highly susceptible to both placebo and nocebo (negative placebo) effects. Brain activity likely supports nocebo-induced itch, but is currently unknown. METHODS We collected functional MRI (fMRI) data from atopic dermatitis (AD) patients, in a within-subject design, and contrast brain response to nocebo saline understood to be allergen vs open-label saline control. Exploratory analyses compared results to real allergen itch response and placebo responsiveness, evaluated in the same patients. RESULTS Nocebo saline produced greater itch than open saline control (P < 0.01). Compared to open saline, nocebo saline demonstrated greater fMRI response in caudate, dorsolateral prefrontal cortex (dlPFC), and intraparietal sulcus (iPS) - brain regions important for cognitive executive and motivational processing. Exploratory analyses found that subjects with greater dlPFC and caudate activation to nocebo-induced itch also demonstrated greater dlPFC and caudate activation, respectively, for real allergen itch. Subjects reporting greater nocebo-induced itch also demonstrated greater placebo reduction of allergen-evoked itch, suggesting increased generalized modulation of itch perception. CONCLUSIONS Our study demonstrates the capacity of nocebo saline to mimic both the sensory and neural effects of real allergens and provides an insight to the brain mechanisms supporting nocebo-induced itch in AD, thus aiding our understanding of the role that expectations and other psychological factors play in modulating itch perception in chronic itch patients.
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Affiliation(s)
- V. Napadow
- Martinos Center for Biomedical Imaging; Massachusetts General Hospital; Harvard Medical School; Charlestown MA USA
- Department of Radiology; Logan University; Chesterfield MO USA
| | - A. Li
- Martinos Center for Biomedical Imaging; Massachusetts General Hospital; Harvard Medical School; Charlestown MA USA
| | - M.L. Loggia
- Martinos Center for Biomedical Imaging; Massachusetts General Hospital; Harvard Medical School; Charlestown MA USA
| | - J. Kim
- Martinos Center for Biomedical Imaging; Massachusetts General Hospital; Harvard Medical School; Charlestown MA USA
| | - I. Mawla
- Martinos Center for Biomedical Imaging; Massachusetts General Hospital; Harvard Medical School; Charlestown MA USA
| | - G. Desbordes
- Martinos Center for Biomedical Imaging; Massachusetts General Hospital; Harvard Medical School; Charlestown MA USA
| | - P. C. Schalock
- Department of Dermatology; Massachusetts General Hospital; Harvard Medical School; Boston MA USA
| | - E. A. Lerner
- Department of Dermatology; Massachusetts General Hospital; Harvard Medical School; Boston MA USA
| | - T. N. Tran
- Department of Dermatology; Massachusetts General Hospital; Harvard Medical School; Boston MA USA
| | - J. Ring
- Department of Dermatology and Allergy; Technische Universität München; Munich Germany
| | - B. R. Rosen
- Martinos Center for Biomedical Imaging; Massachusetts General Hospital; Harvard Medical School; Charlestown MA USA
| | - T. J. Kaptchuk
- Program in Placebo Studies; Beth Israel Deaconess Medical Center; Harvard Medical School; Boston MA USA
| | - F. Pfab
- Martinos Center for Biomedical Imaging; Massachusetts General Hospital; Harvard Medical School; Charlestown MA USA
- Department of Dermatology and Allergy; Technische Universität München; Munich Germany
- Department of Prevention and Sports Medicine; Technische Universität München; Munich Germany
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343
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Colagiuri B, Schenk LA, Kessler MD, Dorsey SG, Colloca L. The placebo effect: From concepts to genes. Neuroscience 2015; 307:171-90. [PMID: 26272535 PMCID: PMC5367890 DOI: 10.1016/j.neuroscience.2015.08.017] [Citation(s) in RCA: 171] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 08/05/2015] [Accepted: 08/07/2015] [Indexed: 12/19/2022]
Abstract
Despite its initial treatment as a nuisance variable, the placebo effect is now recognized as a powerful determinant of health across many different diseases and encounters. This is in light of some remarkable findings ranging from demonstrations that the placebo effect significantly modulates the response to active treatments in conditions such as pain, anxiety, Parkinson's disease, and some surgical procedures. Here, we review pioneering studies and recent advances in behavioral, neurobiological, and genetic influences on the placebo effect. Consistent with recent conceptualizations, the placebo effect is presented as the product of a general expectancy learning mechanism in which verbal, conditioned, and social cues are centrally integrated to change behaviors and outcomes. Examples of the integration of verbal and conditioned cues, such as instructed reversal of placebo effects are also incorporated into this model. We discuss neuroimaging studies that have identified key brain regions and modulatory mechanisms underlying placebo effects using well-established behavioral paradigms. Finally, we present a synthesis of recent genetics studies on the placebo effect, highlighting a promising link between genetic variants in the dopamine, opioid, serotonin, and endocannabinoid pathways and placebo responsiveness. Greater understanding of the behavioral, neurobiological, and genetic influences on the placebo effect is critical for evaluating medical interventions and may allow health professionals to tailor and personalize interventions in order to maximize treatment outcomes in clinical settings.
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Affiliation(s)
- B Colagiuri
- University of Sydney, School of Psychology, Australia
| | - L A Schenk
- University Medical Center Hamburg-Eppendorf, Department of Systems Neuroscience, Hamburg, Germany
| | - M D Kessler
- University of Maryland School of Medicine, Institute For Genome Sciences, Baltimore, USA
| | - S G Dorsey
- University of Maryland School of Nursing, Department of Pain and Translational Symptom Science, Baltimore, USA; University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, USA; UM Center to Advance Chronic Pain Research, Baltimore, MD, USA
| | - L Colloca
- University of Maryland School of Nursing, Department of Pain and Translational Symptom Science, Baltimore, USA; University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, USA; UM Center to Advance Chronic Pain Research, Baltimore, MD, USA.
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344
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Nitzan U, Chalamish Y, Krieger I, Erez HB, Braw Y, Lichtenberg P. Suggestibility as a predictor of response to antidepressants: A preliminary prospective trial. J Affect Disord 2015; 185:8-11. [PMID: 26142688 DOI: 10.1016/j.jad.2015.06.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 06/16/2015] [Accepted: 06/16/2015] [Indexed: 12/28/2022]
Abstract
BACKGROUND The growing awareness that so many do not respond adequately to antidepressant (AD) pharmacotherapy has sparked research seeking to characterize those who do. While the pharmacological mechanisms of AD treatment have been extensively evaluated, much remains unknown about the placebo component of the response to medication. This study examined the association between suggestibility levels and response to ADs amongst depressed patients. METHODS Twenty unipolar depression outpatients, recruited before starting AD monotherapy, received clear, standardized instructions that the therapeutic effects of AD, though not side effects, would require 2-4 weeks. At baseline (T1), 1 week (T2), and 1 month (T3), participants were evaluated for depressive symptoms, using the Hamilton Rating Scale for Depression-17 items (HAM-D); for anxiety by the Hamilton Rating Scale for Anxiety (HAM-A); for side effects by the Antidepressant Side Effect Checklist (ASEC); and for suggestibility, using the Multidimensional Iowa Suggestibility Scale (MISS). RESULTS High levels of baseline suggestibility were associated with less improvement in depression level and more side-effects during the first week. In accordance with our hypothesis the more suggestible patients improved more between T2 and T3. No significant correlations were found between baseline suggestibility levels and change in anxiety. LIMITATIONS Small sample size and a self-report questionnaire assessing suggestibility were limitations. CONCLUSION This study offers a potentially new and clinically useful approach to understanding and predicting who will respond to AD treatment. Suggestibility seems to play a role, presumably by shaping expectation, in response to AD treatment. We hope that this avenue will be further explored.
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Affiliation(s)
- Uri Nitzan
- Shalvata Mental Health Care Center, Hod-Hasharon, Israel; Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel.
| | | | - Israel Krieger
- Shalvata Mental Health Care Center, Hod-Hasharon, Israel; Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel
| | | | - Yoram Braw
- Department of Behavioral Sciences, Ariel University, Ariel, Israel
| | - Pesach Lichtenberg
- Herzog Hospital, Jerusalem, Israel; Faculty of Medicine, Hebrew University, Jerusalem, Israel
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Colagiuri B, Quinn VF, Colloca L. Nocebo Hyperalgesia, Partial Reinforcement, and Extinction. THE JOURNAL OF PAIN 2015; 16:995-1004. [DOI: 10.1016/j.jpain.2015.06.012] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 06/12/2015] [Accepted: 06/24/2015] [Indexed: 12/19/2022]
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346
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Schmid J, Bingel U, Ritter C, Benson S, Schedlowski M, Gramsch C, Forsting M, Elsenbruch S. Neural underpinnings of nocebo hyperalgesia in visceral pain: A fMRI study in healthy volunteers. Neuroimage 2015; 120:114-22. [DOI: 10.1016/j.neuroimage.2015.06.060] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 06/17/2015] [Accepted: 06/20/2015] [Indexed: 12/16/2022] Open
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347
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Aslaksen PM, Zwarg ML, Eilertsen HIH, Gorecka MM, Bjørkedal E. Opposite effects of the same drug: reversal of topical analgesia by nocebo information. Pain 2015; 156:39-46. [PMID: 25599299 DOI: 10.1016/j.pain.0000000000000004] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Several studies have shown that psychological factors such as learning, expectation, and emotions can affect pharmacological treatment and shape both favorable and adverse effects of drugs. This study investigated whether nocebo information provided during administration of an analgesic cream could reverse topical analgesia to hyperalgesia. Furthermore, we tested whether nocebo effects were mediated by negative emotional activation. A total of 142 healthy volunteers (73 women) were randomized into 6 groups. A topical analgesic cream (Emla) was administered together with suggestions of analgesia in 1 group, whereas another group received Emla with suggestions of hyperalgesia. Two other groups received a placebo cream together with the same information as the groups receiving Emla. A fifth group received Emla with no specific information about the effect, and the sixth group received no treatment but the same pain induction as the other groups. Heat pain stimulation (48°C) was administered during a pretest and 2 posttests. Pain was continuously recorded during stimulation, and measures of subjective stress and blood pressure were obtained before the pretest, after the application of cream, and after the posttests. The results revealed that pain was significantly lower in the group receiving Emla with positive information and highest in the groups receiving suggestions of hyperalgesia, regardless of whether Emla or the placebo was administered. Mediation analyses showed that stress and blood pressure mediated hyperalgesia after nocebo suggestions. These results suggest that nocebo information can reverse topical analgesia and that emotional factors can explain a significant proportion of variance in nocebo hyperalgesia.
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Affiliation(s)
- Per Matti Aslaksen
- Department of Psychology, Faculty of Health Sciences, University of Tromsø-The Arctic University of Norway, 9037 Tromsø, Norway
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348
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The neuroscience of placebo effects: connecting context, learning and health. Nat Rev Neurosci 2015; 16:403-18. [PMID: 26087681 DOI: 10.1038/nrn3976] [Citation(s) in RCA: 438] [Impact Index Per Article: 48.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Placebo effects are beneficial effects that are attributable to the brain-mind responses to the context in which a treatment is delivered rather than to the specific actions of the drug. They are mediated by diverse processes--including learning, expectations and social cognition--and can influence various clinical and physiological outcomes related to health. Emerging neuroscience evidence implicates multiple brain systems and neurochemical mediators, including opioids and dopamine. We present an empirical review of the brain systems that are involved in placebo effects, focusing on placebo analgesia, and a conceptual framework linking these findings to the mind-brain processes that mediate them. This framework suggests that the neuropsychological processes that mediate placebo effects may be crucial for a wide array of therapeutic approaches, including many drugs.
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349
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Test–retest reliability of evoked heat stimulation BOLD fMRI. J Neurosci Methods 2015; 253:38-46. [DOI: 10.1016/j.jneumeth.2015.06.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 06/01/2015] [Accepted: 06/03/2015] [Indexed: 11/19/2022]
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350
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Raber JM, Reichelt D, Grüneberg-Oelker U, Philipp K, Stubbe-Dräger B, Husstedt IW. Capsaicin 8 % as a cutaneous patch (Qutenza™): analgesic effect on patients with peripheral neuropathic pain. Acta Neurol Belg 2015; 115:335-43. [PMID: 25421590 DOI: 10.1007/s13760-014-0395-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 11/14/2014] [Indexed: 11/28/2022]
Abstract
Evaluation of the analgesic effect after a single application of the capsaicin 8 % cutaneous patch (Qutenza™) in 37 patients suffering from painful, distal symmetric polyneuropathy (PNP) for an average of 5 years. Patients ranged from 40 to 78 years of age and 22 subjects were HIV-positive. Patients were observed 4 weeks prior to 12 weeks post administration. An evaluation of the therapeutic effect of capsaicin 8 % as a dermal patch in terms of pain reduction, change of sleeping behavior and social activities was performed and statistical analysis of data was conducted using non-parametric methods. Patients were selected according to clinical criteria. Numerical rating scale (NRS 0-10) was used to inquire pain intensity and a pain score was calculated using the painDETECT(©) questionnaire Freynhagen R (Curr Med Res Opin 22:1911-1920, [2006]). A significant reduction of pain was achieved for up to 12 weeks, with a maximum after 2-4 weeks post administration. After patient education and before application of capsaicin patch, a significant reduction of three levels on the NRS was observed. Symptoms of painful PNP decreased over the period of investigation and 8 patients reported a reduction of systemic pain medication. In patients with an HIV infection, a significant extension of sleep was achieved for 2, 4 and 8 weeks after application. Thus, the application of the capsaicin 8 % patch resulted in a significant relief of neuropathic pain, a prolongation of sleep, a reduction of oral pain medication and a resumption of social activities.
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Affiliation(s)
- Julia Marie Raber
- Department of Neurology, University Hospital of Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany,
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