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Burke MJ, Cappon D, Perez DL, Pascual-Leone A, Santarnecchi E. Harnessing Placebo Effects for the Treatment of Functional Cognitive Disorder: A Feasibility Pilot Study. J Neuropsychiatry Clin Neurosci 2024; 36:214-219. [PMID: 38343313 DOI: 10.1176/appi.neuropsych.20230118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
OBJECTIVE Limited research has directly investigated whether and how placebo effects can be harnessed for the treatment of functional neurological disorder (FND), despite a long-standing and controversial history of interest in this area. METHODS A small exploratory study was conducted with adults with a cognitive subtype of FND recruited from a single cognitive neurology center in the United States. Participants were given the expectation of receiving cranial stimulation that could benefit their memory symptoms; however, the intervention was sham transcranial magnetic stimulation (placebo). Outcomes included measures of short-term memory testing, subjective memory rating, and state anxiety before and after stimulation. After the study, the true objective and rationale for investigating placebo effects were explained in a scripted debriefing session. Acceptability of the study design and qualitative feedback were collected. Institutional ethics approval and signed consent were obtained. RESULTS Three patients (female, N=2; male, N=1; average age=57 years) were recruited. Outcome data were analyzed descriptively at the patient level. Trends of improvement in subjective memory rating, but not objective cognitive test scores, and decreases in state anxiety were observed. After the debriefing session, all patients found the study design to be acceptable (ratings of 70%, 90%, and 100%), and two of the three patients believed that withholding mechanistic information about the intervention was needed to leverage placebo effects as treatment. CONCLUSIONS In the first study to prospectively investigate the feasibility of harnessing placebo effects for the treatment of FND, promising preliminary findings were obtained, and methods and resources for use in larger future studies are offered.
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Affiliation(s)
- Matthew J Burke
- Neuropsychiatry Program, Department of Psychiatry, and Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Center, University of Toronto, Toronto (Burke); Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto (Burke); Berenson-Allen Center for Noninvasive Brain Stimulation, Department of Neurology (Burke, Cappon, Santarnecchi) and Program in Placebo Studies (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston; Hinda and Arthur Marcus Institute for Aging Research and Deanna and Sidney Center for Memory Health, Hebrew SeniorLife, Boston (Cappon, Pascual-Leone); Department of Neurology, Harvard Medical School, Boston (Cappon, Pascual-Leone, Santarnecchi); Departments of Neurology and Psychiatry (Perez) and Precision Neuroscience and Neuromodulation Program, Gordon Center for Medical Imaging (Santarnecchi), Massachusetts General Hospital and Harvard Medical School, Boston; Guttmann Brain Health Institute, Barcelona, Spain (Pascual-Leone)
| | - Davide Cappon
- Neuropsychiatry Program, Department of Psychiatry, and Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Center, University of Toronto, Toronto (Burke); Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto (Burke); Berenson-Allen Center for Noninvasive Brain Stimulation, Department of Neurology (Burke, Cappon, Santarnecchi) and Program in Placebo Studies (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston; Hinda and Arthur Marcus Institute for Aging Research and Deanna and Sidney Center for Memory Health, Hebrew SeniorLife, Boston (Cappon, Pascual-Leone); Department of Neurology, Harvard Medical School, Boston (Cappon, Pascual-Leone, Santarnecchi); Departments of Neurology and Psychiatry (Perez) and Precision Neuroscience and Neuromodulation Program, Gordon Center for Medical Imaging (Santarnecchi), Massachusetts General Hospital and Harvard Medical School, Boston; Guttmann Brain Health Institute, Barcelona, Spain (Pascual-Leone)
| | - David L Perez
- Neuropsychiatry Program, Department of Psychiatry, and Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Center, University of Toronto, Toronto (Burke); Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto (Burke); Berenson-Allen Center for Noninvasive Brain Stimulation, Department of Neurology (Burke, Cappon, Santarnecchi) and Program in Placebo Studies (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston; Hinda and Arthur Marcus Institute for Aging Research and Deanna and Sidney Center for Memory Health, Hebrew SeniorLife, Boston (Cappon, Pascual-Leone); Department of Neurology, Harvard Medical School, Boston (Cappon, Pascual-Leone, Santarnecchi); Departments of Neurology and Psychiatry (Perez) and Precision Neuroscience and Neuromodulation Program, Gordon Center for Medical Imaging (Santarnecchi), Massachusetts General Hospital and Harvard Medical School, Boston; Guttmann Brain Health Institute, Barcelona, Spain (Pascual-Leone)
| | - Alvaro Pascual-Leone
- Neuropsychiatry Program, Department of Psychiatry, and Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Center, University of Toronto, Toronto (Burke); Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto (Burke); Berenson-Allen Center for Noninvasive Brain Stimulation, Department of Neurology (Burke, Cappon, Santarnecchi) and Program in Placebo Studies (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston; Hinda and Arthur Marcus Institute for Aging Research and Deanna and Sidney Center for Memory Health, Hebrew SeniorLife, Boston (Cappon, Pascual-Leone); Department of Neurology, Harvard Medical School, Boston (Cappon, Pascual-Leone, Santarnecchi); Departments of Neurology and Psychiatry (Perez) and Precision Neuroscience and Neuromodulation Program, Gordon Center for Medical Imaging (Santarnecchi), Massachusetts General Hospital and Harvard Medical School, Boston; Guttmann Brain Health Institute, Barcelona, Spain (Pascual-Leone)
| | - Emiliano Santarnecchi
- Neuropsychiatry Program, Department of Psychiatry, and Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Center, University of Toronto, Toronto (Burke); Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto (Burke); Berenson-Allen Center for Noninvasive Brain Stimulation, Department of Neurology (Burke, Cappon, Santarnecchi) and Program in Placebo Studies (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston; Hinda and Arthur Marcus Institute for Aging Research and Deanna and Sidney Center for Memory Health, Hebrew SeniorLife, Boston (Cappon, Pascual-Leone); Department of Neurology, Harvard Medical School, Boston (Cappon, Pascual-Leone, Santarnecchi); Departments of Neurology and Psychiatry (Perez) and Precision Neuroscience and Neuromodulation Program, Gordon Center for Medical Imaging (Santarnecchi), Massachusetts General Hospital and Harvard Medical School, Boston; Guttmann Brain Health Institute, Barcelona, Spain (Pascual-Leone)
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Abstract
OBJECTIVE Studies have consistently shown that long-term meditation practice is associated with reduced pain, but the neural mechanisms by which long-term meditation practice reduces pain remain unclear. This study tested endogenous opioid involvement in meditation analgesia associated with long-term meditation practice. METHODS Electrical pain was induced with randomized, double-blind, cross-over administration of the opioid antagonist naloxone (0.15-mg/kg bolus dose, then 0.2-mg/kg per hour infusion dose) with 32 healthy, experienced meditation practitioners and a standardized open monitoring meditation. RESULTS Under saline, pain ratings were significantly lower during meditation (pain intensity: 6.41 ± 1.32; pain unpleasantness: 3.98 ± 2.17) than at baseline (pain intensity: 6.86 ±1.04, t(31) = 2.476, p = .019, Cohen's d = 0.46; pain unpleasantness: 4.96 ±1.75, t(31) = 3.746, p = .001, Cohen's d = 0.68), confirming the presence of meditation analgesia. Comparing saline and naloxone revealed significantly lower pain intensity (t(31) = 3.12, p = .004, d = 0.56), and pain unpleasantness (t(31) = 3.47, p = .002, d = 0.62), during meditation under naloxone (pain intensity: 5.53 ± 1.54; pain unpleasantness: 2.95 ± 1.88) than under saline (pain intensity: 6.41 ± 1.32; pain unpleasantness: 3.98 ± 2.17). Naloxone not only failed to eliminate meditation analgesia but also made meditation analgesia stronger. CONCLUSIONS Long-term meditation practice does not rely on endogenous opioids to reduce pain. Naloxone's blockade of opioid receptors enhanced meditation analgesia; pain ratings during meditation were significantly lower under naloxone than under saline. Possible biological mechanisms by which naloxone-induced opioid receptor blockade enhances meditation analgesia are discussed.
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Geuter S, Koban L, Wager TD. The Cognitive Neuroscience of Placebo Effects: Concepts, Predictions, and Physiology. Annu Rev Neurosci 2017; 40:167-188. [PMID: 28399689 DOI: 10.1146/annurev-neuro-072116-031132] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Placebos have been used ubiquitously throughout the history of medicine. Expectations and associative learning processes are important psychological determinants of placebo effects, but their underlying brain mechanisms are only beginning to be understood. We examine the brain systems underlying placebo effects on pain, autonomic, and immune responses. The ventromedial prefrontal cortex (vmPFC), insula, amygdala, hypothalamus, and periaqueductal gray emerge as central brain structures underlying placebo effects. We argue that the vmPFC is a core element of a network that represents structured relationships among concepts, providing a substrate for expectations and a conception of the situation-the self in context-that is crucial for placebo effects. Such situational representations enable multidimensional predictions, or priors, that are combined with incoming sensory information to construct percepts and shape motivated behavior. They influence experience and physiology via descending pathways to physiological effector systems, including the spinal cord and other peripheral organs.
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Affiliation(s)
- Stephan Geuter
- Institute of Cognitive Science, University of Colorado, Boulder, Colorado 80309; , , .,Department of Psychology and Neuroscience, University of Colorado, Boulder, Colorado 80309
| | - Leonie Koban
- Institute of Cognitive Science, University of Colorado, Boulder, Colorado 80309; , , .,Department of Psychology and Neuroscience, University of Colorado, Boulder, Colorado 80309
| | - Tor D Wager
- Institute of Cognitive Science, University of Colorado, Boulder, Colorado 80309; , , .,Department of Psychology and Neuroscience, University of Colorado, Boulder, Colorado 80309
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Carlino E, Piedimonte A, Benedetti F. Nature of the placebo and nocebo effect in relation to functional neurologic disorders. HANDBOOK OF CLINICAL NEUROLOGY 2017; 139:597-606. [PMID: 27719874 DOI: 10.1016/b978-0-12-801772-2.00048-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Placebos have long been considered a nuisance in clinical research, for they have always been used as comparators for the validation of new treatments. By contrast, today they represent an active field of research, and, due to the involvement of many mechanisms, the study of the placebo effect can actually be viewed as a melting pot of concepts and ideas for neuroscience. There is not a single placebo effect, but many, with different mechanisms across different medical conditions and therapeutic interventions. Expectation, anxiety, and reward are all involved, as well as a variety of learning phenomena and genetic variants. The most productive models to better understand the neurobiology of the placebo effect are pain and Parkinson's disease. In these medical conditions, several neurotransmitters have been identified, such as endogenous opioids, cholecystokinin, dopamine, as well as lipidic mediators, for example, endocannabinoids and prostaglandins. Since the placebo effect is basically a psychosocial context effect, these data indicate that different social stimuli, such as words and therapeutic rituals, may change the chemistry of the patient's brain, and these effects are similar to those induced by drugs.
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Affiliation(s)
- E Carlino
- Department of Neuroscience, University of Turin Medical School, Turin, Italy
| | - A Piedimonte
- Department of Neuroscience, University of Turin Medical School, Turin, Italy
| | - F Benedetti
- Department of Neuroscience, University of Turin Medical School, Turin, Italy; Plateau Rosa Labs, Breuil-Cervinia, Italy and Zermatt, Switzerland.
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Prätzlich M, Kossowsky J, Gaab J, Krummenacher P. Impact of short-term meditation and expectation on executive brain functions. Behav Brain Res 2015; 297:268-76. [PMID: 26462570 DOI: 10.1016/j.bbr.2015.10.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Revised: 08/25/2015] [Accepted: 10/05/2015] [Indexed: 11/17/2022]
Abstract
Meditation improves executive functions such as attention and working memory processes. However, it remains unclear to what extent contextual effects contribute to these improvements, since the role of meditation-associated expectations has not been investigated so far. In a randomized, single-blind, deceptive, between-subject design we compared the impact of short-term meditation (MG) on executive functioning with an expectation (ECG) and a passive control group (CG) as well as the effect of positive and negative outcome expectations. Fifty-nine healthy meditation-naïve volunteers participated on three consecutive days (20 min/session). Five groups were examined: 2 MGs, 2 ECGs and 1 CG. While one MG and one ECG were given positive suggestions concerning the effect of meditation on attention, the other two groups were given negative suggestions. MGs practised a focused attention meditation technique; ECGs were told that they were practising meditation but were given instructions for a sham meditation. CG participants sat in silence with their eyes closed. Interference control (Stroop task), selective sustained attention (d2 task), figural and verbal fluency measures of executive functions were assessed. Results indicate that suggestions have a substantial impact on interference control and verbal fluency, with positive suggestions leading to an increase in performance, whereas negative suggestions impeded improvement. This proof of concept study demonstrates the importance of the implementation of a credible ECG to elucidate context effects in meditation processes. It also indicates that suggestions can modulate the small effect of meditation on verbal fluency.
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Affiliation(s)
- Martin Prätzlich
- Division of Clinical Psychology and Psychotherapy, Department of Psychology, University of Basel, Missionsstrasse 60/62, 4055 Basel, Switzerland; Department of Child and Adolescent Psychiatry, Psychiatric University Clinics, Schanzenstrasse 13, 4056 Basel, Switzerland
| | - Joe Kossowsky
- Division of Clinical Psychology and Psychotherapy, Department of Psychology, University of Basel, Missionsstrasse 60/62, 4055 Basel, Switzerland; Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, USA
| | - Jens Gaab
- Division of Clinical Psychology and Psychotherapy, Department of Psychology, University of Basel, Missionsstrasse 60/62, 4055 Basel, Switzerland
| | - Peter Krummenacher
- Division of Clinical Psychology and Psychotherapy, Department of Psychology, University of Basel, Missionsstrasse 60/62, 4055 Basel, Switzerland; Collegium Helveticum, Schmelzbergstrasse 25, CH-8092 Zurich, Switzerland; Brainability LLC, CH-8057 Zurich, Switzerland.
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Abstract
Today we are witnessing a new science of placebo, a complex discipline that encompasses several experimental approaches and translational implications. Modern neurobiological tools have been used to answer important questions in placebo research, such as the top-down modulation of sensory and motor systems as well as the influence of cognition, emotions, and learning on symptoms, diseases, and responses to treatments. What we have learned is that there is not one single placebo effect, but many. This review highlights the translational implications of this new knowledge, ranging from clinical trial design to medical practice to social and ethical issues.
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Affiliation(s)
- Fabrizio Benedetti
- Department of Neuroscience, University of Turin Medical School and National Institute of Neuroscience, 10125 Turin, Italy.
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Abstract
This paper is the thirty-fourth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2011 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (Section 2), and the roles of these opioid peptides and receptors in pain and analgesia (Section 3); stress and social status (Section 4); tolerance and dependence (Section 5); learning and memory (Section 6); eating and drinking (Section 7); alcohol and drugs of abuse (Section 8); sexual activity and hormones, pregnancy, development and endocrinology (Section 9); mental illness and mood (Section 10); seizures and neurologic disorders (Section 11); electrical-related activity and neurophysiology (Section 12); general activity and locomotion (Section 13); gastrointestinal, renal and hepatic functions (Section 14); cardiovascular responses (Section 15); respiration (Section 16); and immunological responses (Section 17).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY 11367, United States.
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