Effects and Components of Placebos with a Psychological Treatment Rationale - Three Randomized-Controlled Studies

Acupuncture for Combat-Related Posttraumatic Stress Disorder: A Randomized Clinical Trial

Importance

Current interventions for posttraumatic stress disorder (PTSD) are efficacious, yet effectiveness may be limited by adverse effects and high withdrawal rates. Acupuncture is an emerging intervention with positive preliminary data for PTSD.

Objective

To compare verum acupuncture with sham acupuncture (minimal needling) on clinical and physiological outcomes.

Design, Setting, and Participants

This was a 2-arm, parallel-group, prospective blinded randomized clinical trial hypothesizing superiority of verum to sham acupuncture. The study was conducted at a single outpatient-based site, the Tibor Rubin VA Medical Center in Long Beach, California, with recruitment from April 2018 to May 2022, followed by a 15-week treatment period. Following exclusion for characteristics that are known PTSD treatment confounds, might affect biological assessment, indicate past nonadherence or treatment resistance, or indicate risk of harm, 93 treatment-seeking combat veterans with PTSD aged 18 to 55 years were allocated to group by adaptive randomization and 71 participants completed the intervention protocols.

Interventions

Verum and sham were provided as 1-hour sessions, twice weekly, and participants were given 15 weeks to complete up to 24 sessions.

Main Outcomes and Measures

The primary outcome was pretreatment to posttreatment change in PTSD symptom severity on the Clinician-Administered PTSD Scale-5 (CAPS-5). The secondary outcome was pretreatment to posttreatment change in fear-conditioned extinction, assessed by fear-potentiated startle response. Outcomes were assessed at pretreatment, midtreatment, and posttreatment. General linear models comparing within- and between-group were analyzed in both intention-to-treat (ITT) and treatment-completed models.

Results

A total of 85 male and 8 female veterans (mean [SD] age, 39.2 [8.5] years) were randomized. There was a large treatment effect of verum (Cohen d, 1.17), a moderate effect of sham (d, 0.67), and a moderate between-group effect favoring verum (mean [SD] Δ, 7.1 [11.8]; t90 = 2.87, d, 0.63; P = .005) in the intention-to-treat analysis. The effect pattern was similar in the treatment-completed analysis: verum d, 1.53; sham d, 0.86; between-group mean (SD) Δ, 7.4 (11.7); t69 = 2.64; d, 0.63; P = .01). There was a significant pretreatment to posttreatment reduction of fear-potentiated startle during extinction (ie, better fear extinction) in the verum but not the sham group and a significant correlation (r = 0.31) between symptom reduction and fear extinction. Withdrawal rates were low.

Conclusions and Relevance

The acupuncture intervention used in this study was clinically efficacious and favorably affected the psychobiology of PTSD in combat veterans. These data build on extant literature and suggest that clinical implementation of acupuncture for PTSD, along with further research about comparative efficacy, durability, and mechanisms of effects, is warranted.

Trial Registration

ClinicalTrials.gov Identifier: NCT02869646.

Practitioner warmth and empathy attenuates the nocebo effect and enhances the placebo effect

Augmented patient-practitioner interactions that enhance therapeutic alliance can increase the placebo effect to sham treatment. Little is known, however, about the effect of these interactions on maladaptive health outcomes (i.e., the nocebo effect). Healthy participants (N = 84) were randomised to a 3-day course of Oxytocin nasal drops (actually, sham treatment) in conjunction with a high-warmth interaction (Oxy-HW: N = 28), a low-warmth interaction (Oxy-LW: N = 28) or to a no treatment control group (NT: N = 28). All participants were informed that the Oxytocin treatment could increase psychological well-being but was associated with several potential side effects. Treatment-related side effects, unwarned symptoms, and psychological well-being were measured at baseline and all post-treatment days. Side effect reporting was increased in the Oxy-LW condition compared to the other groups across all days. Conversely, increased psychological well-being was observed in the Oxy-HW condition, relative to the other conditions, but only on Day 1. Among those receiving treatment, positive and negative expectations, and treatment-related worry, did not vary by interaction-style, while psychological well-being and side effect reporting were inversely associated at the level of the individual. Results have important implications for practice, suggesting poorer quality interactions may not only reduce beneficial health outcomes but also exacerbate those that are maladaptive.

Negative emotionality downregulation affects moral choice but not moral judgement of harm: a pharmacological study

Previous neuroscientific research has expounded on the fundamental role played by emotion during moral decision-making. Negative emotionality has been observed to exert a general inhibitory effect towards harmful behaviors against others. Nevertheless, the downregulation of negative affects at different levels of moral processing (e.g. impersonal versus personal moral dilemmas) alongside its possible interactions with other factors (e.g. perspective taking) hasn't been directly assessed; both of which can assist in predicting future moral decision-making. In the present research, we empirically test (Study 1, N = 41) whether downregulating negative emotionality through pharmacological interventions using lorazepam (a GABA receptor agonist), modulate the permissibility of harm to others -i.e. if participants find it more morally permissible to harm others when harm is unavoidable (inevitable harm moral dilemmas), than when it may be avoided (evitable harm moral dilemmas). Furthermore, using another sample (Study 2, N = 31), we assess whether lorazepam's effect is modulated by different perspective-taking conditions during a moral dilemma task -e.g. "is it morally permissible for you to […]?" (1st person perspective), relative to "is it morally permissible for [x individual] to […]?" (3rd person perspective)-, where the outcome of the different scenarios is controlled. The results of both studies converge, revealing an emotion-dependent, rather than an outcome-dependent, pharmacological modulation. Lorazepam only influenced interpersonal moral judgments when not modulated by the evitable/inevitable condition. Furthermore, there was a significant interaction between perspective-taking and drug administration, as lorazepam exerted a larger effect in modulating moral choices rather than moral judgements.

Effects of an open-label placebo intervention on reactions to social exclusion in healthy adults: a randomized controlled trial

Social exclusion, that is being left out by others, can have adverse consequences for individuals' psychological well-being. Even short-term experiences of social exclusion strongly threaten basic psychological needs and cause so-called social pain. Prior research suggests an overlap between the experience of social and physical pain that, amongst others, is reflected by the effectiveness of physical pain treatments in alleviating social pain. Drawing upon these prior findings, we here explore whether open-label placebos, which have previously been found to be effective in reducing physical pain, can alleviate social pain following social exclusion. Seventy-four healthy participants were randomly assigned to one of four conditions in a 2 × 2 between-subjects design: First, they either received an open-label placebo intervention or no treatment. Second, they either experienced inclusion or exclusion by their co-players in the interactive ball-tossing game Cyberball. We find that excluded participants in the open-label placebo condition experienced significantly less hurt feelings compared to those in the control condition (Cohen's d = 0.77). There was no effect of treatment for need threat. The findings suggest new possibilities to alleviate social pain, which is of particular interest in the context of preventing destructive and maladaptive behaviors in situations where functional coping strategies are unavailable.

Non-Deceptive Placebos Can Promote Acts of Kindness: A Randomized Controlled Trial

Placebos have often been used to reduce emotional distress but rarely to increase positive feelings. The present study investigated whether a placebo can promote acts of kindness (AoKs) that are associated with emotional well-being. A total of 160 university students were asked to perform an AoK daily for one week. They evaluated their emotional state (feelings of pleasantness, arousal, satisfaction) directly before and after the AoKs. This was monitored via a smartphone app. One group performed each AoK after taking a non-deceptive placebo; the other group received no placebo. Before and after the one-week program, the participants completed three questionnaires that assessed satisfaction with life, positive/negative affect, and flourishing. The participants reported higher pleasantness directly after engaging in an AoK and more satisfaction with life after the program. The motivation to carry out AoKs decreased strongly over the week. However, placebo receivers completed more AoKs than the no-placebo group. The results indicate that placebo treatment can promote the performance of acts of kindness.

k-Means clustering by using the calculated Z-scores from QEEG data of children with dyslexia

Learning the subtype of dyslexia may help shorten the rehabilitation process and focus more on the relevant special education or diet for children with dyslexia. For this purpose, the resting-state eyes-open 2-min QEEG measurement data were collected from 112 children with dyslexia (84 male, 28 female) between 7 and 11 years old for 96 sessions per subject on average. The z-scores are calculated for each band power and each channel, and outliers are eliminated afterward. Using the k-Means clustering method, three different clusters are identified. Cluster 1 (19% of the cases) has positive z-scores for theta, alpha, beta-1, beta-2, and gamma-band powers in all channels. Cluster 2 (76% of the cases) has negative z-scores for theta, alpha, beta-1, beta-2, and gamma-band powers in all channels. Cluster 3 (5% of the cases) has positive z-scores for theta, alpha, beta-1, beta-2, and gamma-band powers at AF3, F3, FC5, and T7 channels and mostly negative z-scores for other channels. In Cluster 3, there is temporal disruption which is a typical description of dyslexia. In Cluster 1, there is a general brain inflammation as both slow and fast waves are detected in the same channels. In Cluster 2, there is a brain maturation delay and a mild inflammation. After Auto Train Brain training, most of the cases resemble more of Cluster 2, which may mean that inflammation is reduced and brain maturation delay comes up to the surface which might be the result of inflammation. Moreover, Cluster 2 center values at the posterior parts of the brain shift toward the mean values at these channels after 60 sessions. It means, Auto Train Brain training improves the posterior parts of the brain for children with dyslexia, which were the most relevant regions to be strengthened for dyslexia.

The Importance of the Treatment Rationale for Pain in Animal-Assisted Interventions: A Randomized Controlled Trial in Healthy Participants

Animal-assisted interventions (AAIs) is a promising treatment approach for pain, but possible mechanisms still need to be elucidated. This study set out to investigate the analgesic effects of an animal provided with a treatment rationale in a randomized controlled trial employing a standardized experimental heat-pain paradigm. We randomly assigned 128 healthy participants to: dog treatment (DT), placebo treatment (PT), dog and placebo treatment (DPT), and no treatment (NT). Primary outcomes were heat-pain tolerance and the corresponding self-reported ratings of pain unpleasantness and intensity. Results revealed no differences in heat-pain tolerance between the conditions. However, participants in the DT condition experienced heat-pain as significantly less unpleasant at the limit of their tolerance compared to participants in the NT condition (estimate = -0.96, CI = -1.58 to 0.34, P = .010). Participants in the DT condition also showed lower ratings of pain intensity at the limit of their tolerance compared to participants in the NT condition (estimate = -0.44, CI = -0.89 to 0.02, P = .060). This study indicates that a dog has analgesic effects on pain perception when integrated into the treatment rationale. We assume that providing a treatment rationale regarding the animal is important in AAIs for pain. PERSPECTIVE: This study shows that the presence of an animal is not sufficient for animal-assisted interventions (AAIs) to have an analgesic effect on pain unless they are provided with a treatment rationale. This could imply that not only the animal but also contextual factors are important in AAIs. TRIAL REGISTRATION: Clinical Trials NCT04361968.

Imaginary pills and open-label placebos can reduce test anxiety by means of placebo mechanisms

Placebos have been shown to be beneficial for various conditions even if administered with full transparency. Hence, so-called open-label placebos (OLPs) offer a new way to harness placebo effects ethically. To take this concept one step further, this study aimed at evaluating placebo effects without the use of a physical placebo, i.e., by imagining taking a pill. Healthy students (N = 173) with self-reported test anxiety were either randomized to an imaginary pill (IP; n = 55), an OLP (n = 59) or a control group (CG; n = 59). Both intervention groups were instructed to take two pills daily for three weeks. Primary outcome was test anxiety, secondary outcomes were sleep quality, general well-being and test performance. Groups test anxiety differed at study-endpoint, F(2,169) = 11.50, p < .001. Test anxiety was lower in the intervention groups compared to the CG, t(169) = - 4.44, p < .001, d = - 0.71. The interventions did not differ significantly, i.e., both were similarly efficacious, t(169) = 0.61, p = .540, d = 0.11. The interaction between group and time in explaining test anxiety was significant, F(5,407.93) = 6.13, p < .001. OLPs and IPs reduced test anxiety in healthy participants compared to the CG. This finding opens the door for a novel and ethical method to harness placebo effects.

The alliance in mental health care: conceptualization, evidence and clinical applications

The concept of alliance reflects the collaborative relationship between a clinician and a patient, defined as consisting of three elements: a) the agreement on the goals of treatment; b) the agreement on a task or series of tasks; c) the development of a bond. Although much of the theory and research on the alliance comes from the domain of psychotherapy, the concept is applicable to any practice involving a person seeking help and a socially sanctioned healer. An extensive research evidence suggests that the alliance (typically measured at the third or fourth session) is a robust predictor of the outcomes of various forms of psychotherapy, even when prior symptom improvement and other factors are considered. Both the clinician and the patient bring to the therapy situation different capacities to form an alliance. Factors concerning the patient include, among others, the diagnosis, attachment history and style, motivation, and needs for affiliation. However, the benefits of the alliance have been found to be mostly due to the therapist's contribution, in particular his/her facilitative interpersonal skills, including verbal fluency, communication of hope and positive expectations, persuasiveness, emotional expression; warmth, acceptance and understanding; empathy, and alliance rupture-repair responsiveness. Placebo studies have allowed to experimentally manipulate aspects of the relationship between a therapist and a patient in non-psychotherapy contexts. In these settings, two components of the relationship have emerged: an emotional one (involving being cared for and understood by the clinician) and a cognitive one (including the belief in the competence of the therapist to select and administer an effective treatment). Here we propose a model that describes three pathways through which the alliance creates benefits, named CARE (caring, attentive, real and empathic), EXPECTANCY, and SPECIFIC. Although research and clinical attention have mostly focused on the alliance between a clinician and a patient in face-to-face interactions, there is preliminary evidence concerning the alliance between patients and other clinic staff, systems of care, or the program in Internet-mediated services. These new research areas clearly require further development.

Open-Label Placebo Effects on Psychological and Physical Well-Being: A Conceptual Replication Study

Background

Contrary to traditional placebos, open-label placebos (OLP) abstain from deception, i.e., participants are openly informed to receive an inert substance. Studies in clinical and healthy samples evidence the efficacy of OLPs. This study aims to conceptually replicate and expand findings of a recent OLP study in healthy participants while implementing a within-subject design and daily instead of retrospective assessments. Additionally, the effect of a brand name on the medicine container is tested and possible predictors of the OLP effects are explored.

Method

Healthy participants (N = 75) received OLP and no placebo for 5 days each (randomized sequence) and answered daily questionnaires on sleep quality, bodily symptoms, mental well-being, and psychological distress. The medicine container of half the participants had a brand name, the remaining did not. Different personality traits and situational factors were assessed.

Results

Mental and physical well-being did not differ between OLP and control phase, i.e., overall, no OLP effect emerged. Contrast analysis indicated that an OLP effect emerged for sleep quality and psychological distress when no brand name was present. Further, an OLP effect emerged in persons with higher expectations for bodily symptoms (r = .23, p = .046) and psychological distress (r = .24, p = .037).

Conclusions

Methodological differences to the original study are discussed as an explanation for the failure to induce overall OLP effects. Future studies should continue to replicate previous findings and determine the exact conditions of successful implementation of OLP effects in healthy as well as clinical samples.

Deceptive and open-label placebo effects in experimentally induced guilt: a randomized controlled trial in healthy subjects

Placebos are known to yield significant effects in many conditions. We examined deceptive and open-label placebo effects on guilt, which is important for self-regulation and a symptom of mental disorders. Following an experimental induction of guilt, healthy subjects were randomized to deceptive placebo (DP; n = 35), open-label placebo (OLP; n = 35), or no treatment (NT; n = 39). The primary outcome was guilt responses assessed in area under the curve (AUC). Secondary outcomes were shame, guilt, and affect. We hypothesized that DP and OLP would reduce guilt compared to NT. Guilt responses were higher in the NT group than in the placebo groups (estimate = 2.03, 95% CI = 0.24-3.82, d = 0.53), whereas AUC guilt did not differ significantly between the placebo groups (estimate = -0.38, 95% CI = -2.52-1.76, d = -0.09). Placebos are efficacious in reducing acute guilt responses, regardless of the placebo administration (i.e., open vs. deceptive). Furthermore, we observed narrative-specific effects with significant changes of guilt but not shame, pride, or affect. These results indicate not only that guilt is amenable to placebos but also that placebos can be administered in an ethical and potentially emotion-specific manner.

The impact of outcome expectancy on therapy outcome in adolescents with borderline personality disorder

BACKGROUND

Outcome expectancy has been found to be a significant predictor of psychotherapy outcome. However, given that severity, chronicity and comorbidity are moderators of outcome expectancy, it is important to provide evidence of whether the same holds true in clinical conditions marked by these attributes, such as in borderline personality disorder (BPD). The aim of the present study was to investigate the role of patients' outcome expectancy in adolescents undergoing early intervention for BPD using pre-post difference of psychosocial functioning as outcome.

METHODS

Forty-four adolescent BPD patients were treated with Dialectical Behavior Therapy for Adolescents (DBT-A) or Adolescent Identity Treatment (AIT). We investigated the effect of outcome expectancy on outcome with type of treatment as moderator. Based on the relevant literature, we assess the correlation between outcome expectancy and pretreatment symptomatology, namely BPD severity, personality functioning, childhood trauma and depression.

RESULTS

The results showed a significant effect of expectancy on outcome (stand. β = 0.30, p = 0.020) above autoregression. ANOVA analysis revealed no difference between the two treatments. Further, results indicate that pretreatment symptomatology, i.e., depression, childhood trauma and personality functioning dimensions self-direction and intimacy, are associated with early treatment expectancy.

CONCLUSION

Outcome expectancy as a common factor plays a key role in successful psychotherapy with adolescent BPD patients. Elevated pretreatment depression, childhood trauma and impairment in personality functioning dimensions self-direction and intimacy are risk factors associated with lower expectancy. Low outcome expectancy should be addressed in early psychotherapy to improve the therapeutical process.

The anti-anxiety drug lorazepam changes implicit behaviors but not explicit evaluations of sense of agency under authoritative pressure: A functional magnetic resonance imaging study

Previous research on coercion has neglected the fact that agents under authoritative pressure may also suffer from coercive power, which can trigger anxiety-like emotional negativity on its victims. Furthermore, high levels of neuroticism and/or anxiety have been found to be associated with the compliance of various forms of social pressure. In this study, we investigate the effects of the anxiolytic GABA A (gamma-Aminobutyric acid) modulator, lorazepam, on behavioral and neural responses to coercive power. Here, we applied a virtual obedience to authority paradigm alongside lorazepam administration (versus placebo), and during functional magnetic resonance imaging scanning. Our results show that lorazepam administration exerted differential effects on the reaction times (RTs) when initiating harming versus helping behaviors, with longer harming RTs compared to helping RTs, despite comparable subjective ratings regarding perceived coercion. Coercive harming significantly increased activity in the amygdala, hippocampus, orbitofrontal cortex, and dorsolateral prefrontal cortex (dlPFC). Lorazepam administration decreased amygdala and hippocampus activity, but increased dlPFC and right temporoparietal junction activations. The lower activity in the hippocampus predicted higher ratings for perceived coercion. Furthermore, lorazepam significantly decreased the functional connectivity of the hippocampus with the dlPFC during coercive harming. In conclusion, we provide evidence -by incorporating multimodal indices, including neuroimaging, neuropharmacological interventions, and behavioral assessments- to posit that the GABA A agonist, lorazepam, might aid as a possible intervention in service of coping strategies against coercion.

Possible alleviation of symptoms and side effects through clinicians' nocebo information and empathy in an experimental video vignette study

To alleviate anti-cancer treatment burden in advanced breast cancer, patient-clinician communication strategies based on nocebo-effect mechanisms are promising. We assessed distinct/combined effects on psychological outcomes (e.g. anxiety; main outcome) and side-effect expectations of (1) nocebo information about the (non)pharmacological origin of side effects, and (2) clinician-expressed empathy through reassurance of continuing support. Furthermore, we explored whether information and empathy effects on side-effect expectations were mediated by decreased anxiety. In a two-by-two experimental video-vignette design, 160 cancer patients/survivors and healthy women watched one of four videos differing in level of nocebo information (±) and empathy (±). Regression and mediation analysis were used to determine effects of information/empathy and explore anxiety's mediating role. Anxiety was not influenced by empathy or information (Stai-state: p = 0.295; p = 0.390, VAS p = 0.399; p = 0.823). Information improved (specific) side-effect coping expectations (p < 0.01). Empathy improved side-effect intensity expectations (p < 0.01 = specific; p < 0.05 = non-specific/partial) and specific side-effect probability expectations (p < 0.01), and increased satisfaction, trust, and self-efficacy (p < 0.001). No mediating effects were found of anxiety on expectations. Mainly empathy, but also nocebo information improved psychological outcomes and-mainly specific-side-effect expectations. Exploring the power of these communication elements in clinical practice is essential to diminish the anti-cancer treatment burden in advanced breast cancer.

No open-label placebo effect in insomnia? Lessons learned from an experimental trial

BACKGROUND

Open-label placebo (OLP) treatment seems to be effective in several medical conditions but has not yet been investigated in insomnia. Furthermore, it needs to be evaluated whether providing a plausible treatment rationale is essential to obtain OLP effects.

METHODS

In two consecutive nights, the sleep of patients with primary insomnia (n = 45) was assessed via subjective and objective measures. Before the second night, they received a single OLP pill that was randomly provided either with a treatment rationale (OLP+) or without (OLP-). When (M)ANOVAs did not reveal differential effects between the two OLP groups, the OLP+ group was compared post-hoc to a formerly assessed no pill control sample (NPC; n = 23).

RESULTS

Neither the MANOVAs nor the ANOVAs revealed significant interaction effects of treatment group and assessment night. The OLP+ condition was superior neither to OLP- nor to NPC in improving the patients' sleep.

DISCUSSION

Our findings do neither confirm the general efficacy of OLP in primary insomnia nor differential effects depending on the treatment rationale. Possible explanations lie in the dosing scheme (i.e., single OLP application), the provision of the OLP rationale by video and the experimental instead of therapeutic character of our investigation. Trials with larger samples and longer-term OLP treatment in insomnia are needed. Providing the rationale face-to-face and in a clinical setting might be additionally beneficial.

Improving treatment outcomes for adolescents with borderline personality disorder through a socioecological approach

BACKGROUND

There is a dearth of studies evaluating treatment efficacy for adolescents diagnosed with borderline personality disorder. The few available randomized controlled trials that have been conducted show modest results and treatments appear to have equivalent effects. The current paper draws on (a) the lessons learnt from the last 50 years of psychotherapy research in general and (b) recent advances in mentalization-based understanding of why treatment works, which together point to the importance of following a socioecological approach in the treatment of personality problems in adolescence - a developmental period that insists on a treatment approach that goes beyond the therapist-client dyad.

CASE PRESENTATION

Here, we describe such an approach, and offer a clinical case example with a young 16-year old girl diagnosed with borderline personality disorder, to illustrate what a shift toward a more socioecological approach would entail.

CONCLUSIONS

The clinical impact of the socioecological approach and the potential benefits as illustrated in the current case illustration, offers a framework that justifies and allows for the expansion of service delivery for youth with borderline personality disorder beyond dyadic therapist-client work.

Lack of Effects of the Presence of a Dog on Pain Perception in Healthy Participants-A Randomized Controlled Trial

Animal-assisted interventions (AAIs) have been shown to be effective in the treatment of pain. Studies suggest that relationships with animals can have comparable qualities to relationships with humans and that this enables animals to provide social support. Further, the presence of an animal can strengthen the therapeutic alliance between patients and treatment providers. This suggests that the analgesic effects of AAI might be mediated by social support from an animal or by strengthening the alliance between the patient and the treatment provider. To test these assumptions, we examined the effects of the presence of a dog on experimentally induced pain in a pain assessment and a pain therapy context. Hundred thirty-two healthy participants were randomly assigned to the conditions “pain,” “pain + dog,” “pain + placebo,” or “pain + placebo + dog.” We collected baseline and posttreatment measurements of heat-pain tolerance and the heat-pain threshold and of the corresponding subjective ratings of heat-pain intensity and unpleasantness as well as of participants' perceptions of the study investigator. The primary outcome was heat-pain tolerance. The presence of the dog did not influence the primary outcome (“pain” vs. “pain + dog”: difference = 0.04, CI = −0.66 to 0.74, p = 0.905; “pain + placebo” vs. “pain + placebo + dog”: difference = 0.43, CI = −0.02 to 0.88, p = 0.059). Participants did also not perceive the study investigator to be more trustworthy in the presence of the dog (“pain” vs. “pain + dog”: difference = 0.10, CI = −0.67 to 0.87, p = 0.796; “pain + placebo” vs. “pain + placebo + dog”: difference = 0.11, CI = −0.43 to 0.64, p = 0.695). The results indicate that the mere presence of a dog does not contribute to pain reduction and that the analgesic effects of AAI that previous studies have found is not replicated in our study as AAI did not increase perceived social support and had no effect on the alliance between the participant and the treatment provider. We assume that the animal most likely needs to be an integrated and plausible part of the treatment rationale so that participants are able to form a treatment-response expectation toward AAI.

Clinical Trial Registration: This study was preregistered as a clinical trial on www.clinicaltrials.gov (Identifier: NCT0389814).

Makeup and Its Application Simulation Affect Women's Self-Perceptions

Appearance modification is ancient, universal and influences other and self-perceptions. It has been rarely addressed how expectation of appearance modification would affect women's self-perception. We analyzed self-assessments of women without makeup and after having makeup professionally applied at four increasing levels (light, moderate, heavy 1, and heavy 2 makeup). In the simulation phase, women were treated with colorless cosmetics. Fifty Brazilian women (M_age = 24.26 years; SD = 5.53) rated themselves on attractiveness, health, self-esteem, femininity, satisfaction with appearance, age, dominance, confidence, and competence in all experimental conditions. Women in the simulation phase considered themselves more feminine, healthier, and with higher self-esteem than without makeup. In the real makeup phases, these ratings were higher than in the simulation phase. Appearance satisfaction and attractiveness did not differ between simulation and the real makeup phases, both being higher than without makeup. Confidence increased only in real makeup phases, but there was no effect on competence. Thus, real appearance modification and/or an expectation thereof can differently affect specific domains of self-evaluation.

Lay perspectives of the open-label placebo rationale: a qualitative study of participants in an experimental trial

OBJECTIVES

To analyse participants' concepts about the open-label placebo (OLP) effect; to explore their views about the discussion points that are applied in conventional OLP trials and to examine their experiences of taking part in an OLP trial.

DESIGN

A qualitative study using thematic analysis of semistructured interviews that were nested within a randomised controlled trial investigating experimental OLP analgesia (registered at ClinicalTrials.gov: NCT02578420).

PARTICIPANTS

30 healthy adults who took part in the randomised controlled trial.

RESULTS

Participants mostly conceptualised placebo as something that is inert and requires deception in order to be effective. Interviewees used a broad definition of placebos, going beyond a conventional notion of sugar pills. In contrast to the conventional OLP rationale, participants seldom emphasised classical conditioning as a mechanism of placebo effects, stressing a variety of other well-established components through which placebos might be therapeutic, whereas the conventional OLP disclosures state that 'a positive attitude helps but is not necessary', participants in our study applied other attitudes, such as 'it's worth a try'. When asked about their experiences during the trial, the majority emphasised that the concept of OLP was completely novel to them. Participants were rather sceptical about the efficacy of the intervention.

CONCLUSION

Integrating lay perspectives into the scientific rationale of OLP treatments might enhance the plausibility and credibility of the rationale in ethical treatments.

TRIAL REGISTRATION NUMBER

NCT02578420.

Healing in a Social Context: The Importance of Clinician and Patient Relationship

When a patient presents to a health provider, the course of the disorder is composed of three effects: natural effects, specific effects, and contextual effects. Part of the contextual effect is due to the relationship between the healer and the patient. Social healing appears to be present in eusocial species and particularly well-developed in humans. Evidence for the importance of the relationship in healing is found in placebo studies, including placebo analgesics, medicine, and psychotherapy. Although the theory for how the relationship is therapeutic is not well-developed, four possible mechanisms are discussed. The implications for health care and the treatment of pain are discussed.

A mobile app that uses neurofeedback and multi-sensory learning methods improves reading abilities in dyslexia: A pilot study

Reading comprehension is difficult to improve for children with dyslexia because of the continuing demands of orthographic decoding in combination with limited working memory capacity. Children with dyslexia get special education that improves spelling, phonemic and vocabulary awareness, however the latest research indicated that special education does not improve reading comprehension. With the aim of improving reading comprehension, reading speed and all other reading abilities of children with dyslexia, Auto Train Brain that is a novel mobile app using neurofeedback and multi-sensory learning methods was developed. With a clinical study, we wanted to demonstrate the effectiveness of Auto Train Brain on reading abilities. We compared the cognitive improvements obtained with Auto Train Brain with the improvements obtained with special dyslexia training. Auto Train Brain was applied to 16 children with dyslexia 60 times for 30 minutes. The control group consisted of 14 children with dyslexia who did not have remedial training with Auto Train Brain, but who did continue special education. The TILLS test was applied to both the experimental and the control group at the beginning of the experiment and after a 6-month duration from the first TILLS test. Comparison of the pre- and post- TILLS test results indicated that applying neurofeedback and multi-sensory learning method improved reading comprehension of the experimental group more than that of the control group statistically significantly. Both Auto Train Brain and special education improved phonemic awareness and nonword spelling.

A double-blind study of empathic support and expectation as mechanisms of symptom change

Objective: A novel brief intervention was used to investigate how empathic support and expectation can induce changes in mood, anxiety, and perceived stress. Method: Seventy-six undergraduates with high negative affect were assigned to three conditions of a program involving tasks with no known therapeutic benefit. In Group 1: Expectation Only, participants were given a deceptive description of the benefits of the program to quantify the magnitude of symptom change due to expectation alone. In Group 2: Empathic Support + Expectation, participants were also instructed to write about past and current sources of distress and provided with supportive notes each week to quantify the role of empathic support plus expectation. In Group 3: Control, participants were told they were "norming" the instruments. Results: Participants in Groups 1 and 2 demonstrated decreases in depression, anxiety, and rumination, with significant medium effect reductions found in the empathic support plus expectation condition. Conclusions: Evidence suggests that empathic support and expectation cause reduction of symptoms spanning depression and anxiety.

Nonpharmacological Interventions for Pediatric Migraine: A Network Meta-analysis

CONTEXT

Migraine is a common neurologic disorder in children and adolescents. However, a comparison of multiple nonpharmacological treatments is lacking.

OBJECTIVE

To examine whether nonpharmacological treatments are more effective than waiting list and whether there are differences between interventions regarding efficacy.

DATA SOURCES

Systematic review and network meta-analysis of studies in Medline, Cochrane, Embase, and PsycINFO published through August 5, 2019.

STUDY SELECTION

Randomized controlled trials of nonpharmacological treatments in children and adolescents diagnosed with episodic migraine.

DATA EXTRACTION

Effect sizes, calculated as standardized mean differences (SMDs) for the primary outcome efficacy, were assessed in a random-effects model.

RESULTS

Twelve studies (N = 576) were included. When interventions were classified into groups on the basis of similarity of treatment components, self-administered treatments, biofeedback, relaxation, psychological treatments, and psychological placebos were significantly more effective than waiting list with effect sizes ranging between SMD = 1.14 (95% confidence interval, 0.09 to 2.19) for long-term psychological placebos to SMD = 1.44 (95% confidence interval, 0.26 to 2.62) for short-term self-administered treatments. However, when all interventions were examined individually (ie, 1 node per intervention), none were significantly more effective compared with waiting list, mainly because of lack of statistical power.

LIMITATIONS

Because of our focus on pediatric migraine, only a small number of studies could be included.

CONCLUSIONS

Our findings reveal that components of nonpharmacological interventions are effective in treating pediatric migraine. Some effects have to be interpreted carefully because they are based on small studies. Future researchers should identify factors associated with individual responses in large, multicentered studies.

Information About the Optimism of a Placebo/Nocebo Provider and Placebo/Nocebo Side Effects

Background

Research has demonstrated that personality characteristics, such as optimism are associated with placebo/nocebo responding. The present study investigated whether written information about the optimism of a placebo/nocebo provider can influence the occurrence of reported placebo/nocebo side effects.

Method

We analyzed data from 201 females (mean age = 26 years) who participated in a “clinical study on a new massage oil with stone clover extract.” The oil (sunflower oil) was introduced as either eliciting a negative side effect (unpleasant itching; “nocebo oil”) or a positive side effect (pleasant tingling; “placebo oil”). The administration of the oil was combined with written information about the maker of the product. The oil maker was either portrayed as a very optimistic person or no personal information was provided (only the company name). The participants had no personal contact with the experimenter and received all materials and instructions per post.

Results

The participants reported more frequent and intense itching when they received a nocebo suggestion compared to a placebo suggestion. Positive tingling sensations were reported more frequently than itching but did not differ between the placebo/nocebo conditions. Information about the optimism of the oil maker was associated with a lower frequency of reported side effects (adverse and beneficial).

Conclusion

This study demonstrated that it is sufficient to provide participants with written information about an inert substance to elicit the suggested side effect. Information about the provider’s optimistic personality did not specifically influence reported side effects. Future studies should focus on how to adapt written information about a drug/product to minimize adverse side effects and to maximize positive side effects.

How do people feel about the possibility that a treatment might not outperform simulated and inert treatments?

BACKGROUND

Many treatments in common use are not proved better than simulated or inert treatments. While some clinicians express little concern about whether a particular treatment has a direct effect on the pathophysiology believed to be causing symptoms, we wonder if patients would agree.

QUESTIONS/PURPOSES

Are there factors independently associated with the affirmation that it is OK if a treatment is proved not to outperform simulated or inert treatment (a placebo) measured on an 11-point ordinal scale, including the risk and invasiveness of the treatment? And, are there factors independently associated with the affirmation that the clinician should inform a patient about the degree to which a given treatment is known to outperform simulated or inert treatments?

PATIENTS AND METHODS

We asked 763 English-speaking people their willingness to accept unproved treatment, depending on variations in risk, and invasiveness and their opinion regarding the importance of clinicians informing them whether a given treatment is proved to outperform simulated and inert (placebo) treatment.

RESULTS

Acceptance of the unproved treatment was quite low, more so with greater risk and invasiveness. Lower acceptance of unproved treatment was associated with older age, more education, and unemployment. People rated it quite important (mean 7.3 out of 10) that clinicians inform patients if treatments are no better than placebo, no matter the risk of the treatment.

CONCLUSIONS

People want to be informed if a treatment is not proved to outperform nonspecific effects such as the placebo effect.

LEVEL OF EVIDENCE

Not applicable.

The Other Side of the Coin: Nocebo Effects and Psychotherapy

Psychotherapy and placebo have a long history, and both have been shown to have significant and clinically meaningful effects. In the last 100 years and up to today, psychotherapy has been subject to an enduring and often heated debate about its mechanisms and its possible relationship to placebos and their effects. However, there is little awareness of the placebo effects' counterpart-nocebo effects (from Latin "I will harm")-in the context of psychotherapy. Embedded in the controversy of whether psychotherapy and placebo share some unwanted proximity in terms of effects and mechanisms, the question arises which role nocebo effects may play in relation to psychotherapy. By using two examples, this article analyzes and discusses two different kinds of possible associations between psychotherapy and nocebo effects. We close with possibilities of how to prevent the occurrence of nocebo effects in psychotherapy, including some specific recommendations for clinical practice.

Changes in Global and Nodal Networks in Patients With Unipolar Depression After 3-Week Repeated Transcranial Magnetic Stimulation Treatment

Objectives: Repeated transcranial magnetic stimulation (rTMS) therapy has been applied in depressive disorders, but its neurobiological effect has not been well understood. Changes in cortical source network after treatment need to be confirmed. The present study investigated the effect of 3-week rTMS therapy on the symptom severity and cortical source network in patients with unipolar depression. Methods: Thirty-five patients with unipolar major depressive disorder participated in the study. High-frequency (10 Hz) rTMS was applied at the left dorsolateral prefrontal cortex during 3 weeks (five consecutive weekdays every week). Clinical symptoms were examined using the Hamilton Rating Scale for Depression and Anxiety. The resting state electroencephalography was recorded with 62 scalp channels before and after rTMS treatment. Results: Clinical symptoms significantly improved after rTMS treatment in both the active (p = 0.001) and sham groups (p = 0.002). However, an increased cortical source network in global and nodal levels was observed only in the active group after a 3-week treatment. Conclusions: The present study indicates that rTMS treatment leads to improved symptoms in patients with unipolar depression. Furthermore, treatment outcome of real effect was assured in changes of cortical source network.