Conditioned taste aversion suppresses induction of delayed-type hypersensitivity immune reactions

Behavioral factors to modulate immunotherapy efficacy in cancer

Immune checkpoint inhibitors, including anti-PD-1 and anti-CTLA-4 therapies, are used to (re)activate the immune system to treat cancer. Despite promising results, a large group of patients does not respond to checkpoint inhibition. In the vulnerability-stress model of behavioral medicine, behavioral factors, such as stress, exercise and classical pharmacological conditioning, predict cancer incidence, recurrence and the efficacy of conventional cancer treatments. Given the important role of the immune system in these processes, certain behavior may be promising to complement immune checkpoint inhibition therapy. Here, we discuss the preliminary evidence and suitability of three behavioral mechanisms, i.e. stress modulation, exercise and classical pharmacological conditioning for the benefit of immunotherapy. It is crucial to study the potential beneficial effects of behavioral strategies that support immunotherapeutic anti-tumor effects with rigorous experimental evidence, to exploit behavioral mechanisms in improving checkpoint inhibition efficacy.

Placebo and nocebo effects for itch and itch-related immune outcomes: A systematic review of animal and human studies

Placebo and nocebo effects can influence somatic symptoms such as pain. For itch and other dermatological symptoms these effects have been far less investigated. This review systematically integrates evidence from both animal (mainly rodents) and human trials on placebo and nocebo effects in itch, itch-related symptoms and conditions of the skin and mucous membranes, and related immune outcomes (e.g., histamine). Thirty-one animal studies, and fifty-five human studies (k = 21 healthy participants, k = 34 patients) were included. Overall, studies consistently show that placebo and nocebo effects can be induced by various methods (e.g., suggestions, conditioning and social cues), despite high heterogeneity across studies. Effects of suggestions were found consistently across subjective and behavioral parameters (e.g., itch and scratching in humans), whereas conditioning was likely to impact physiological parameters under certain conditions (e.g., conditioning of histamine levels in stressed rodents). Brain areas responsible for itch processing were associated with nocebo effects. Future research may investigate how variations in methods impact placebo and nocebo effects, and whether all symptoms and conditions can be influenced equally.

Pavlovian Conditioning of Immunological and Neuroendocrine Functions

The phenomenon of behaviorally conditioned immunological and neuroendocrine functions has been investigated for the past 100 yr. The observation that associative learning processes can modify peripheral immune functions was first reported and investigated by Ivan Petrovic Pavlov and his co-workers. Their work later fell into oblivion, also because so little was known about the immune system’s function and even less about the underlying mechanisms of how learning, a central nervous system activity, could affect peripheral immune responses. With the employment of a taste-avoidance paradigm in rats, this phenomenon was rediscovered 45 yr ago as one of the most fascinating examples of the reciprocal functional interaction between behavior, the brain, and peripheral immune functions, and it established psychoneuroimmunology as a new research field. Relying on growing knowledge about efferent and afferent communication pathways between the brain, neuroendocrine system, primary and secondary immune organs, and immunocompetent cells, experimental animal studies demonstrate that cellular and humoral immune and neuroendocrine functions can be modulated via associative learning protocols. These (from the classical perspective) learned immune responses are clinically relevant, since they affect the development and progression of immune-related diseases and, more importantly, are also inducible in humans. The increased knowledge about the neuropsychological machinery steering learning and memory processes together with recent insight into the mechanisms mediating placebo responses provide fascinating perspectives to exploit these learned immune and neuroendocrine responses as supportive therapies, the aim being to reduce the amount of medication required, diminishing unwanted drug side effects while maximizing the therapeutic effect for the patient’s benefit.

Applications and limitations of behaviorally conditioned immunopharmacological responses

The importance of placebo responses for the treatment of various medical conditions has increasingly been recognized, whereas knowledge and systematic application in clinical settings are still sparse. One possible application for placebo responses in pharmacotherapy is given by learning paradigms, such as behaviorally conditioned immunosuppression, aiming at drug dose reduction while maintaining therapeutic efficacy of drug treatment. In an established learning paradigm of conditioned taste aversion/avoidance (CTA) in both, rats and humans, respectively, a novel-tasting drinking solution (conditioned stimulus, CS) is paired with an injection of the immunosuppressive drug cyclosporine A (CsA) as unconditioned stimulus (US). The conditioned response, evoked by re-presenting the CS alone at a later time, is reflected by avoidance behavior of consuming the solution (conditioned taste aversion; CTA) and a diminished interleukin (IL)-2 and interferon (IFN)-γ cytokine production as well as mRNA expression of rat splenic T cells or human peripheral T lymphocytes, closely mimicking the immunosuppressive effects of CsA. However, due to unreinforced CS-re-exposure conditioned responses progressively decreases over time (extinction), reflecting a considerable challenge for potential clinical applications of this learned immunosuppression. The present article discusses and critically reviews actual approaches, applications but also limitations of learning paradigms in immune pharmacotherapy.

Learned placebo responses in neuroendocrine and immune functions

The phenomenon of learned placebo responses in neuroendocrine and immune functions is a fascinating example of communication between the brain and both the endocrine and peripheral immune systems. In this chapter, we will give a short overview of afferent and efferent communication pathways, as well as the central mechanisms, which steer the behavioral conditioned immune response. Subsequently, we will focus on data that provides evidence for learned immune responses in experimental animals and learned neuroendocrine and immune placebo responses in humans. Finally, we will take a critical look at these learning protocols, to determine whether or not they can be considered a viable additional treatment option to pharmacological regimens in clinical routine. This is fundamental, since there are still a number of issues, which need to be solved, such as the potential reproducibility, predictability, and extinction of the learned neuroendocrine and immune responses. Together, these findings not only provide an excellent basis to increase our understanding of human biology but may also have far reaching clinical implications. They pave the way for the ultimate aim of employing associative learning protocols as supportive treatment strategies in pharmacological regimens. As a result, medication levels may be reduced, as well as their unwanted side effects, providing a maximized therapeutic outcome to the benefit of the patient.

The learned immune response: Pavlov and beyond

The ability to associate physiological changes with a specific flavor was most likely acquired during evolution as an adaptive strategy aimed at protecting the organism while preparing it for danger. The behaviorally conditioned or learned immune response is an exquisite example of the bidirectional communication between the central nervous system (CNS) and the peripheral immune system. How is it possible that specific immuno-modulating properties of a drug or substance (unconditioned stimulus) can be re-enlisted just by the mere re-exposure to a particular taste, odor or environment (conditioned stimulus)? To answer this key question, we review the neurobiological mechanism mediating this type of associative learning, as well as the pathways and mechanisms employed by the brain to harness the immune system during the execution of the conditioned immune response. Finally, we focus on the potential therapeutic relevance of such learned immune responses, and their re-conceptualization within the framework of "learned placebo effects".

Murine taste-immune associative learning

Taste-immune associative learning can result from contingent pairings of an immune-competent unconditioned stimulus (US) with a gustative conditioned stimulus (CS). Recalling such an association may induce a set of physiological responses affecting behavior, endocrine, and immune functions. We have established a model of behaviorally conditioned immunosuppression employing the immunosuppressant drug cyclosporine A (CsA) as the US and saccharin as the CS in rats and humans. In order to investigate the inter-species generalization of this neuro-immune interaction, we tested the feasibility of this paradigm in mice. In a single-bottle scheme, male BALB/c mice (n=5) were conditioned by conducting three association trials and a single recall trial. Control groups (n=5/group) were designed to assure associative learning, pharmacological effects of the US, and placebo effect. Results show that CsA-conditioned animals displayed significant immunosuppression in the spleen after recall, measured by in vitro T-lymphocyte proliferation, and IL-2 production. However, the same animals did not show evidence of avoidance behavior to the CS. In contrast, evoking the association of saccharin-lithium chloride (inducing gastric malaise) in another set of animals (n=4/group) resulted in significant and pronounced avoidance of the taste (CS). These animals also displayed significant suppression of splenic T-lymphocyte responsiveness after the recall phase. The present results indicate that mice seem to be capable of associating a gustative stimulus with CsA, resulting in behaviorally conditioned immunosuppression without affecting appetitive behavior.

Psychoneuroendocrine immunology: perception of stress can alter body temperature and natural killer cell activity

Psychoimmunology has been credited with using the mind as a way to alter immunity. The problem with this concept is that many of the current psychoimmunology techniques in use are aimed at alleviating stress effects on the immune system rather than at direct augmentation of immunity by the brain. Studies in animals provide a model that permits us to approach the difficulties associated with gaining an understanding of the CNS-immune system connection. A particular advantage of using animals over humans is that psychological and social contributions play a less prominent role for animals than for human subjects, since the animals are all inbred and reared under identical controlled conditions. If the insightful information provided by animal studies is correct, then psychotherapy for the treatment of diseases might be made more effective if some aspect of this knowledge is included in the design of the treatment. We emphasize conditioning as a regimen and an acceptable way to train the brain to remember an output pathway to raise immunity. We propose that a specific drug or perception (mild stress, represented by rotation, total body heating or handling) could substitute and kindle the same output pathway without the need for conditioning. If this view is correct, then instead of using conditioning, it may be possible to use an antigen to activate desired immune cells, and substitute a drug or an external environmental sensory stimulus (perception) to energize the output pathway to these cells. Alternatively, monitoring alterations of body temperature in response to a drug or perception might allow us to follow how effectively the brain is performing in altering immunity. Studies with animals suggest that there are alternative ways to use the mind to raise natural or acquired immunity in man.

Behaviorally conditioned immunosuppression using cyclosporine A: central nervous system reduces IL-2 production via splenic innervation

Bi-directional interactions between the central nervous system (CNS) and immune system are demonstrated by the modification of immune function using behavioral conditioning. However, the mechanisms by which the CNS achieves conditioned immunomodulation are still in question. Here, we report that the immunosuppressive effects of cyclosporine A (CsA) can be behaviorally conditioned in rats using saccharin as a gustatory conditioned stimulus. The conditioned effects were compared to control groups that received CsA paired with water (sham-conditioned), CsA injection on test days (CsA-treated), and unhandled rats (untreated). In conditioned animals, the mitogen-induced lymphocyte proliferation in the spleen is significantly suppressed, and the survival time of heterotopic heart allografts prolonged. These effects are paralleled by conditioned inhibition of IL-2 and IFN-gamma synthesis by splenocytes. Furthermore, the CNS-induced immunosuppression is mediated neuronally and not via the blood, since the conditioned reduction of proliferation and cytokine production is completely abrogated after surgical denervation of the spleen. Thus, during conditioning, the CNS learns to reinstate at demand a CsA-like immunosuppression via splenic innervation. This might be used as a supportive therapy for controlling immune functions.

Conditioned taste aversion produced by cyclosporine A: concomitant reduction in lymphoid organ weight and splenocyte proliferation

The classical conditioning of immune parameters is commonly conducted within a conditioned taste aversion (CTA) paradigm. In this study, the immunosuppressive drug cyclosporine A (CsA) was investigated for its ability to produce both taste aversion to a novel stimulus and conditioned alterations in immune functioning. The paradigm comprised the pairing of a 0.2% saccharin solution (the conditioned stimulus; CS) with an intraperitoneal injection of 20 mg/kg CsA (the unconditioned stimulus; UCS). Upon saccharin re-presentation, a marked reduction in fluid consumption was observed, indicating aversion to the novel substance (=CTA). By using a single CsA/saccharin pairing the CTA lasted for one CS representation. However, by implementing three pairings, this effect could be extended for up to seven representations. No noticeable difference was recorded by adjusting the saccharin representation from every consecutive day to every second day. The most effective paradigm in creating CTA was subsequently investigated for its effectiveness in producing conditioned immune alterations. Animals were killed on the day of the third CS re-presentation, and immune functions assessed. Conditioned animals displayed a significant reduction in thymus and spleen weights. Effects on the spleen were further investigated, revealing a significantly reduced proliferative ability of isolated splenocytes to concanavalin A. These results demonstrate that the physiological effects produced by CsA are sufficiently salient to elicit CTA. Furthermore, the reduction in lymphoid organ weight and splenocyte proliferation induced by CsA are also conditionable using this paradigm.

Effects of relaxation on the delayed-type hypersensitivity (DTH) reaction to diphenylcyclopropenone (DCP)

Delayed-type hypersensitivity (DTH) reactions to the experimental allergen diphenylcyclopropenone (DCP) were measured in four groups, which either trained (+) or did not train in relaxation (-) during the sensitization and/or the challenge phase. All groups consisted of high and low hypnotic susceptible subjects. While there were no differences in erythema, the mean induration of the group which trained in relaxation in both the sensitization and the challenge phase (+/+) was significantly greater than that of the group which trained in relaxation in the challenge phase only (-/+). Significant correlations were found between induration and hypnotic susceptibility scores, and between induration and degree of perceived relaxation during challenge. High hypnotic susceptible subjects experienced a higher degree of perceived relaxation and exhibited greater indurative and erythematous DTH reactions to DCP than low hypnotic susceptible subjects in all four experimental conditions. Though the mediating mechanisms remain unclear, our results suggest that relaxation may affect the DTH reaction, and support previous findings of higher psychophysiologic reactivity of high hypnotic susceptible subjects.

Neuroimmunomodulation via limbic structures--the neuroanatomy of psychoimmunology

During the last 20 years, mutual communications between the immune, the endocrine and the nervous systems have been defined on the basis of physiological, cellular, and molecular data. Nevertheless, a major problem in the new discipline "Psychoneuroimmunology" is that controversial data and differences in the interpretation of the results make it difficult to obtain a comprehensive overview of the implications of immunoneuroendocrine interactions in the maintenance of physiological homeostasis, as well as in the initiation and the course of pathological conditions within these systems. In this article, we will first discuss the afferent pathways by which immune cells may affect CNS functions and, conversely, how neural tissues can influence the peripheral immune response. We will then review recent data, which emphasize the (patho)physiological roles of hippocampal-amygdala structures and the nucleus accumbens in neuroimmunomodulation. Neuronal activity within the hippocampal formation, the amygdaloid body, and the ventral parts of the basal ganglia has been examined most thoroughly in studies on neuroendocrine, autonomic and cognitive functions, or at the level of emotional and psychomotor behaviors. The interplay of these limbic structures with components of the immune system and vice versa, however, is still less defined. We will attempt to review and discuss this area of research taking into account recent evidences for neuroendocrine immunoregulation via limbic neuronal systems, as well as the influence of cytokines on synaptic transmission, neuronal growth and survival in these brain regions. Finally, the role of limbic structures in stress responses and conditioning of immune reactivity will be commented. Based on these data, we propose new directions of future research.

Lithium chloride and immunomodulation in taste aversion conditioning

Lithium chloride has been used in many studies of conditioning to induce taste aversion behaviour, and in some experiments investigating conditioning effects on immunity it has been used on the assumption that it is immunologically neutral. The studies reported here, however, indicate that LiCl is not immunologically neutral and when used to endow a UCS with noxious properties to enhance the behavioural response in taste aversion conditioned immunosuppression, it may antagonize the residual immunosuppression following initial UCS administration and also the conditioned immunosuppression occurring after CS reexposure. Therefore, conclusions drawn from studies of behaviourally conditioned immunomodulation where LiCl is used as part of either the CS or UCS may require reevaluation.

A behavioral augmentation of natural immunity: odor specificity supports a Pavlovian conditioning model

BALB/c mice were conditioned by pairing an odor to an injection of poly-inosinic:poly-cytidylic acid (poly I:C), a strong inducer of natural killer (NK) cell activity as the unconditioned stimulus (US). When later reexposed to the odor conditioning stimulus (CS), these mice showed a conditioned augmentation of the NK cell response to a suboptimal dose of 1 microgram poly I:C. The two stimuli used in these studies were camphor (Ca) and citronella oil (Cr) odors, two chemically-related but distinct odor stimuli. The conditioned mice demonstrated the ability to discriminate between Ca and Cr, such that the conditioned response (CR) was only elicited by the odor CS used in the formation of the conditioned association. Exposure of conditioned mice to the non-associated odor stimulus on the test day did not elicit a change in the NK cell response to the suboptimal dose of poly I:C when compared to mice in the US group that had been given the US on day 0 without pairing to either odor stimulus. This specificity of the CR for the odor CS and not the unassociated odor stimulus supports the interpretation that the elevation of NK cell activity in this paradigm is due to Pavlovian conditioning and therefore dependent on central nervous system (CNS) associative processes.

Conditioned immunosuppression of a murine delayed type hypersensitivity response: dissociation from corticosterone elevation

The mechanisms involved in behavioral modulation of immunity by Pavlovian conditioning have not been delineated, although an elevation in adrenocortical steroids has been invoked as an explanation. Therefore, we investigated whether or not a 4-day, murine delayed type hypersensitivity (DTH) response could be modified by a taste aversion conditioning paradigm. Mice were conditioned by the pairing of their saccharin (0.1%) drinking water (SAC) with a cyclophosphamide (CY) injection (50 mg/kg) on Day 0. Conditioned mice that were exposed on Day 3 to SAC + CY, SAC + normal saline, or water + CY exhibited significant suppression of DTH induced paw swelling when compared to nonconditioned controls. Conditioned immunosuppression was demonstrated, since the DTH response was suppressed by SAC without a concomitant reexposure to the immunosuppressant, CY. However, when dexamethasone (3 mg/kg) was used as the conditioning agent, the SAC + vehicle group showed no reduction in paw swelling. A serum corticosterone time course study was performed to examine possible involvement of glucocorticoids in conditioned immunosuppression. On Day 3, mice were sacrificed 30, 60, 90, 120 min and 24 h after reexposure to SAC or water. No significant differences in serum corticosterone levels were detected between nonconditioned controls and any conditioned group at any time point. These results demonstrate conditioned immunosuppression of a cell-mediated immune response that is not linked to a rise in glucocorticoid levels.

Behaviorally conditioned suppression of murine T-cell dependent but not T-cell independent antibody responses

The aversive and immunosuppressive effects of cyclophosphamide (CY, 250 mg/kg IP), an unconditioned stimulus (UCS), were paired with the presentation of a novel saccharine flavored drinking solution (SAC), a conditioned stimulus (CS), in female Balb/c mice. The objective was to determine the temporal relationship between presentation of the CS (SAC) and immunization with sheep red blood cell (SRBCs), a T-cell dependent antigen, and type III pneumococcal polysaccharide (S3), a T-cell independent antigen, on subsequent antibody responses. Reexposure to the CS or UCS occurred on days -4, -2, 0, +2, or +4 relative to immunization. Primary antibody responses in each group were measured six days following immunization. A strong association between the CS and the UCS developed, producing flavor aversions as evidenced by decreased SAC consumption. CY administration by itself consistently suppressed both types of antibody responses. CS presentation (i.e., SAC) had no significant effect on anti-S3 antibody response. However, the anti-SRBC response was significantly depressed following CS exposure. Exposure to the CS only on days -4 or +2 relative to immunization resulted in statistically significant suppression of antibody response to SRBC's while exposure on days -2, 0, and +4 resulted in anti-SRBC antibody suppression that did not reach significance. These results support the hypothesis that conditioning of antibody responses is relatively specific for T-cell dependent antigens, and that the timing of CS presentation relative to immunization is important in conditioning a suppression of antibody responses.

Conditioned taste aversion induced by self-administered drugs: paradox revisited

In this paper we have reviewed the literature on Conditioned Taste Aversion (CTA) with specific attention to the "apparent paradox" in this literature. This paradox refers to the fact that drugs which are self-administered (SA) by animals and are therefore presumed to possess positive reinforcing properties are also endowed with the capacity to induce a CTA. We have argued that the CTA literature contains evidence of the existence of two qualitatively distinct types of CTA, one which is mediated by emetic agents and the other induced by SA drugs. We first provided evidence to support the notion that the traditional explanation of CTA as a function of "drug toxicity" and its resultant gastrointestinal distress does not fit the data on the nature of CTA induced by SA drugs. We proposed instead that "drug shyness" or the novelty of the drug state of these psychoactive SA drugs constitutes a better explanation of the CTA of SA drugs. We provided further evidence suggesting a functional relationship between the positive reinforcing and aversive properties of SA drugs. We have based this contention on a review of the behavioral, physiological and neurochemical data concerning the nature of CTA of SA drugs. The examination of these data reveals that the neural mechanisms underlying both the positive and aversive properties of SA drugs are the same and at the same time different from the neural mechanisms underlying the induction of CTA by emetic agents. Finally, we discussed the relevance of this interaction between the positive and aversive properties of SA drugs in the context of their abuse liability and the control they exert on drug-oriented behavior.

Behaviorally conditioned suppression of mitogen-induced lymphoproliferation and antibody production in mice

Conditioned immunosuppression was induced in C57BL/6 mice by pairing saccharin drinking (conditioned stimulus) with an i.p. injection of 250 mg/kg cyclophosphamide (unconditioned stimulus). Conditioned mice showed depressed mitogen-induced lymphoproliferation. This depression was significant for T-cell--but not for B-cell--proliferation. Mice also exhibited depressed antibody production against sheep red blood cells until 15 days after immunization. The kinetics of serum antibody levels suggest that conditioning amplifies the immunosuppressive effects of cyclophosphamide. Furthermore, we show in this report that a depression of cellular and humoral components of the immune system can be observed when conditioning is performed after immunization, the latter being not paired with the conditioned stimulus.