Providentia

Making Chatbots More User-Friendly

Emotionally-responsive chatbots are marketed as agents with which one can form emotional connections. They can also become weak ties in the outer layers of one's acquaintance network and available for social support. A recent study in Computers In Human Behavior described an experiment designed to study the acquaintance process in whgichg randomly assigned 417 participants into three conditions: face-to-face (FTF) chat with a human, online chat with a human, and online chat with a commercially-available, emotionally-responsive chatbot, Replika. After a 20-min getting-acquainted chat, participants reported their affective state and relational evaluations of the chat. Additionally, all chats were recorded and text analyzed using the Linguistic Inquiry and Word Count (LIWC) program. In all conditions, participants reported moderate levels of positive emotions and low levels of negative emotions. Those who chatted FTF with a human reported significantly more negative emotions than those who chatted with a bot. However, those who chatted with a human also reported more homophily with and liking of their chat partner and that their partner was more responsive. Meanwhile, participants had fewest conversational concerns with the chatbot. These findings have implications for future computer-mediated interaction studies: conversations with chatbots appear to have different affordances and effects on chatter enjoyment and conversational concerns in getting-acquainted contexts. These results may help designers improve reception and marketability for chatbots in consumer markets. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

For the abstract

Posttraumatic Growth and Depreciation in Chronic Pain

 Chronic pain can disrupt everyday life and shatter beliefs about the world. Shattered beliefs may be rebuilt, either positively or negatively, leading to posttraumatic growth (PTG) or posttraumatic depreciation (PTD). According to a transdiagnostic emotion regulation perspective, these phenomena are associated with coping strategies and emotions related to the body, self, others, and the world. Because PTG and PTD can coexist,  a new study published in Psychological Trauma: Theory, Research, Practice, and Policy compares different profiles of rebuilt beliefs based on emotions, emotion regulation, and psychopathology. People with chronic pain (N = 1,577) completed online self-report questionnaires evaluating PTG and PTD, trauma-related emotions, and reactions regarding pain (guilt, shame, mental defeat, injustice, feeling discounted, sensitivity to pain traumatization, sense of body–self unity), difficulties in emotion regulation, coping strategies, and psychopathological symptoms. The resulting profiles illustrate four ways to experience potentially traumatic and life-challenging circumstances: no disruption, ambivalence, growth, and distress. Differences were found regarding trauma-related emotions and reactions, levels of comorbid psychopathologies, and emotion regulation. The authors  conclude that considering trauma as a genuine dimension of chronic pain experience could provide an important framework to better address the resources and trajectories of people with chronic pain. (PsycInfo Database Record (c) 2021 APA, all rights reserved)

For the abstract

The Power of the Placebo

The Siege of Breda is one of the most graphic events of the Eighty Years War (also known as the Dutch War of Independence).   

Under the orders of Spanish general Ambrogio Spinola, the walled city of Breda in what is now the Netherlands was besieged by the Spanish army for more than eleven months.   So extreme were conditions inside the town for the 7,000 soldiers defending the town that they soldiers began dying of scurvy due to the lack of fresh fruit and vegetables.   Though curable through simple nutrition, scurvy is potentially deadly for anyone whose diet is low in Vitamin C and the Dutch soldiers were no exception.   Along with problems stemming from malnutrition, the long siege also led to a critical shortage in various medications, including medications for relieving pain (primarily opium and laudanum).     To solve this problem,  the garrison commander Justin of Nassau (a son of William of Orange), hit on a cunning plan.

Working with the city's doctors,  Justin had the doctors provide their patients with a powerful new medicine that he reportedly managed to smuggle in from the mysterious East.   The medicine was so strong that only a few drops in a gallon of water would clear up their symptoms.    The soldiers were impressed that their commander had managed to get them this medicine despite the risks and expense involved.  Except, of course, that the "medicine" in this case was nothing more than a mixture of wormwood, camomile, and camphor, carefully placed into small phials, which Justin provided to the doctors.  While available reports stated that "they took the medicine eagerly and grew well rapidly", there are likely limits to how well the power of suggestion could work in preventing the symptoms of scurvy.   Certainly men continued to die and only 3,500 Dutch soldiers were still alive by the time Justin surrendered the town.  

Though medical doctors had long observed that patient belief had a powerful effect on the body and how they responded to medical treatment, the first formal investigation into what would be called "the placebo effect" would not be until the early 19th century.   The word "placebo" is Latin for "I will please" and actually comes from a Latin translation of the Bible.   British physician John Haygarth published what would be the first treatise on the placebo effect when he investigated that medical effectiveness of a popular cure of the time known as "Perkins tractors."   Invented by American physician Elisha Perkins, these "tractors" consisted of two 3-inch metal rods made of steel and brass.  By using the tractors to "draw off the noxious electrical fluid that lay at the root of suffering", Perkins claimed to be able to cure a wide variety of illnesses, including rheumatism and arthritis. 

Even though conventional medical doctors were quick to denounce Perkins' invention as sheer quackery, many patients reported getting significant pain relief from the treatments and John Haygarth decided to investigate further.    Alarmed at the growing popularity of Perkins tractors among his patients in Bath,  Haygarth dem0nstrated that patients could get the same pain relief from rods made of virtually any substance and that they were unable to tell the difference between fake tractors and the "real" ones.   He also noted that some patients actually got worse instead of better which suggested that imagination could cause as well as cure disease.   

What mattered most was the credibility of the doctor (famous doctors were more likely to get positive results than obscure ones) as well as how credulous the patients were.    The best results appeared to come from both the doctor and the patient believing in the power of the medical treatment.    He prophetically commented that: "medical practitioners of good understanding, but of various dispositions of mind, feel different degrees of skepticism in the remedies they employ. One who possesses, with discernment, the largest portion of medical faith, will be undoubtedly of greatest benefit to his patients."

As Haygarth observed in his 1800 paper Of the Imagination as a Cause and as a Cure of Disorders of the Body,  what really caused pain relief was the belief that patients were getting an apparently effective treatment.    Haygarth concluded in his paper that his results showed "to a degree which has never been suspected, what powerful influence upon diseases is produced by mere imagination".     While his research into the power of  belief would be largely overlooked by medical historians (he is mainly remembered as a pioneer in smallpox inoculation),  he is still the first physician to raise questions about the placebo effect which have haunted discussions of alternative medical treatments ever since.  

At the same time that John Haygarth was making his groundbreaking observations on the power of positive belief in relieving pain, the influence of Franz Mesmer and his disciples was also being felt across Europe and North America.   Despite attempts by skeptics such as Benjamin Franklin and Antoine Lavoisier to debunk Mesmer's work, mesmerists would ply their trade for decades afterward and physicians often had trouble understanding how they were accomplishing their apparently miraculous cures.   

Along with mesmerism, the early 19th century was also seeing a rise of interest in homeopathy.  Based on the "like cures like" doctrine of Samuel Hahnemann, homeopathic practitioners began offering their treatments for various illnesses with only anecdotal evidence from satisfied patients to prove that it even worked.    The first formal clinical trial to test the effectiveness of homeopathic medicine was carried out in Russia in 1832.   Not coincidentally, it was also the first clinical trial to use a placebo in medical research.   Tests comparing homeopathic medicine with placebo pills made of flour paste showed no real difference in medical effectiveness.     After publishing these results, the term "placebo effect" became well-known to medical researchers across Europe and North America (though homeopathic medicine seems not to have been seriously derailed by the findings).

In another informal test of the placebo effect, French physician Albert Matthieu informed many of his tuberculosis patients at the Hopital Andral in Paris of a powerful new treatment for tuberculosis that had recently been discovered in Germany.   This new treatment, which he dubbed "antiphymose" was supposed to yield wonderful results in people suffering from tuberculosis and the news quickly spread with patients demanding that the drug be tested on them.   After a time, Matthieu began conducting clinical trials which the drug he had supposedly received from Germany.   All patients receiving antiphymose injections were carefully tested on a regular basis to see if their weight and temperature changed as a result of the new treatment. 

According to the results, antiphymose had a powerful effect on tuberculosis patients receiving the injections.   Not only did the patients gain weight but their chronic fever was reduced as well.  Some gained as much as three kilograms of weight while other symptoms such as persistent coughing and insomnia improved as well.    When the antiphymose injections stopped, the old symptoms returned as well and patients quickly lost the weight they had gained before.    Only afterward did Matthieu reveal that there was no such treatment as antiphymose.   What they had received was simply sterilized water and saline.   The record fails to record how the patients responded to being deceived, even in a good cause.

While the placebo effect is an acknowledged part of modern medicine (and the driving force behind most alternative medical treatments), the power of the placebo continues to influence how many patients respond to treatment.    As patients and doctors alike believe that a treatment will work, patients tend to recover faster than they might do otherwise.   When a newer (and more expensive) drug comes out however, the drug it replaces often performs less well in research because doctors are less confident in how it will help patients.   Research has shown that simply changing the size and colour of a pill can be enough to change its apparent effectiveness. 

But how exactly does the placebo effect work?   Research into using placebos for pain  suggests that increased endorphin levels and reduced cholecystokinin production in the brain may lead to placebo-induced pain relief.    A 1978 study showed that the opioid antagonist naloxone can block endorphins and prevent the placebo effect from occurring.   These results only appear to apply to pain relief however.  

But, the power of belief can also play a role in worsening symptoms as well.   Much like the placebo effect, nocebos (coming from the Latin phrase for "I will harm") can have a powerful effect on health by making many medical conditions worse and may even play a role in "voodoo deaths" linked to curses.   Various proposed explanations for the placebo (and nocebo) effect include suggestion,  operant and classical conditioning, cognitive dissonance, the Hawthorne effect, and expectancy effects though they are all largely based on speculation.  All that we can say  for certain is that the exact mechanism for the placebo and nocebo effects are (still) unknown.

Is there such a thing as a placebo-responder personality?   While some researchers have attempted to link patient responding to placebos to suggestibility or other personality traits, the  results have been largely inconclusive.   In studies observing how subjects respond to placebos over multiple trials, no consistent pattern has been identified.   In other words,  the same subjects who respond to placebos in one trial may not respond in later trials or vice versa.    It is also difficult to decide exactly what the placebo effect can affect.   Though most research into placebo use focuses on pain relief,  some studies suggest that belief in placebos can accomplish much more, including relieving swelling and changing serum cortisol levels.     The extent to which the placebo effect can relieve symptoms can range from no effect at all to total relief in some cases.

In identifying the different factors that can make placebos effective, researchers have identified the following:

• The nature of the intervention - the more intrusive the intervention, the more effective the placebo effect seems to be.  "Sham surgery" (skin incisions without an actual operation) seems to be at least partially effective in relieving symptoms for most patients receiving it.     Placebo injections also appear more effective than placebo pills with the more discomfort associated with the sham treatment, the better.    Treatments that are more "exotic", i.e., involving complicated technology or a radical new medical technique also seems to increase the effectiveness of the placebo.
• The credibility of the one providing the treatment -  Doctors with a high degree of status showing strong belief in their treatment are more likely to have a positive effect on their patients.   Also, therapists showing warmth and empathy to their patients will get better results on average.
• Patient expectation -  If the patient is involved in the treatment and has developed a sense of trust in the doctor and the treatment being received, the placebo effect is likely to be stronger.
• The nature of the complaint - Though most placebo research has focused on pain relief, a wide range of other symptoms appear to be affected by belief as well.   Biofeedback research suggests that many physiological functions can be consciously controlled although it is still unknown whether some complaints or disorders may be more "placebo prone" than others.
• The treatment setting -  A 1994 clinical study found that therapeutic setting was the only significant predictor for nocebo effects, i.e., patients in some clinical centres were more likely to experience adverse reactions to a placebo than patients in other centres.   This suggests that even the location where treatment is received may play a role in whether the placebo effect occurs.

It is also important to understand that simply observing patients improving after taking a placebo cannot be considered evidence for a placebo effect at work.    According to Edward Ernst and his colleagues,  evidence for a "true placebo effect" needs to rule out other factors that might be contributing to patients getting better.    This can include natural recovery from illness, regression towards the mean,  patient bias, or other time-related factors that researchers failed to take into account.    In other words, simply seeing a patient improve does not mean that a placebo effect is occurring although  this "perceived placebo effect" is often confused with the real effect.    To make medical research even more complicated, proving that a treatment is really effective means showing that the positive benefits are greater than what could be accounted for by the true and perceived placebo effects. 

In a real sense, the placebo effect is a part of all medical treatments, whether intended or not.  Many of the factors that make the placebo effect more powerful are also used by caring health professionals to reassure patients and make them more confident that the treatment will be effective.   That same confidence also plays a role in the perceived benefits that patients being treated with alternative medicine often experience and which, in turn, are taken as "proof" of their effectiveness.   Virtually every practitioner of alternative medicine can produce anecdotes provided by apparently grateful clients.   Though these glowing anecdotes can seem convincing to people desperate for a cure,  there are always limits to what can be accomplished by belief alone. 

While there are certainly colourful stories of the placebo effect at work,  relying on placebos to treat patients often invokes a critical problem in medical ethics.  Is it permissible for doctors to lie to their patients, even in a good cause?  And can practitioners of alternative medicine be considered to be providing a valuable service to patients if the placebo effect makes the treatment more effective than it might otherwise be?  

There are still too many unanswered questions about how and why placebos work despite the enormous amount of research that has been done to date.   Though the placebo effect has a long and venerable history, it remains a mystery in many ways.   And perhaps it always will be.

Florida High School Dean Fired For Medical Marijuana Use

In a unanimous vote by the Marion County School Board in Florida, a high school dean has been fired for using medical marijuana to treat chronic pain and posttraumatic stress resulting from being deployed overseas during Operation Desert Storm.  

Michael Hickman, 51, was injured after breaking up a fight between students on November 5, 2019 and, while being treated by a worker’s compensation doctor, underwent mandatory urinalysis.   The urinalysis results showing that he had tested positive for marijuana were then reported  to the Marion Country School District.   Heidi Maier, who was then Superintendent of schools filed a complaint in January seeking to fire Hickman for violating their zero tolerance policy.  

Hickman, a decorated veteran of the U.S. Marine Corps, was medevaced out of Kuwait in the spring of 1991 after suffering a 13-foot fall from an assault amphibious vehicle mid-combat.  Since his discharge from the military, he underwent two dozen surgeries which caused him to develop posttraumatic stress disorder (PTSD).   Due to problems resulting from using opioid pain relievers, he was then prescribed medical marijuana which he insists is more effective in treating his chronic pain and trauma symptoms.  

While medical marijuana is legal in Florida, the state legislature has ruled that employees are still not allowed to work when under the influence of the drug.   The School Board also insisted that marijuana use is against federal law and, as a result, failure to penalize Hickman might have led to their losing federal funding. 

They also condemned Hickman for failing to notify his supervisor about his medical marijuana use.   Though Hickman had been employed by the School Board since 2010, they made the decision to fire him after first offering to suspend him if he agreed to stop using medical marijuana.  Hickman refused, arguing that the policy was unfair given that it penalized him for use of medical marijuana to treat chronic pain but would still allow him to continue teaching under the influence of opioid pain medications.   

Chris Altobello, an executive director with the Marion County teachers union, told media  that Hickman ‘was no more impaired than someone who took an aspirin for a headache. They implied that this is tantamount to smoking pot in the boys bathroom" and that ignoring his marijuana use would set a precedent allowing other teachers to do the same.   "‘Imagine if this employee just sat back and let the two students continue to fight without regard for their safety," Altobello added.  "We wouldn't be here right now. Or if we were, it would have been for not intervening."  In commenting on the decision,

Hickman's attorney, Mark Herdman, told media that it was " just another unfortunate decision handed down by the Marion County School Board to fire yet another good employee."   He also insisted that the School Board should should not automatically fire an employee for drug use, but that each case should be judged on its own merits, something that the board refused to consider.

Despite the zero tolerance policy for staff, the School Board passed a medical marijuana policy for students allowing parents to check their child out of school and administer the recommended dose in their car in the parking lot.  Nothing equivalent is being considered for staff members.

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Impaired cerebral blood flow regulation in chronic traumatic brain injury.

Baroreflex sensitivity (BRS) and cerebral autoregulation (CA) play an important role in maintaining constant cerebral blood flow (CBF) during systemic changes in blood pressure (BP). Impaired BRS and CA have been reported in acute traumatic brain injury (TBI) which may also contribute to secondary injury and poorer recovery after acute TBI; however, their status during chronic stages remains elusive. Thus, the goal of a new study published in the journal Brain Research is to determine whether cardiac BRS and dynamic CA (dCA) were impaired during the chronic stage in patients with single TBI and persistent neurological symptoms. Twenty-two subjects with blunt head TBI ≥ 6 months prior to the study (13 mild and 9 moderate to severe TBI) and persistent symptoms on Rivermead Post-Concussion Symptoms Questionnaire at enrollment were compared to 22 age/sex/fitness level-matched healthy control subjects. Beat-to-beat changes in heart rate, BP, and CBF velocity were measured at rest and during a repeated sit-stand maneuver. Hemodynamic variability, dCA, and cardiac BRS were calculated using spectral and transfer function analyses. We found dCA phase in low frequency (LF) range of 0.07–0.20 Hz was lower in subjects with TBI than in control subjects (0.51 ± 0.19 vs. 0.63 ± 0.26, p = 0.043) during the resting condition. Among subjects with TBI, the lower dCA phase in LF was correlated with poorer performance on measures of cognitive function (all p < 0.05). These findings suggested that subjects with chronic TBI showed impaired dCA which may contribute to persistent cognitive impairment. Cerebrovascular measures may provide a physiological measure to evaluate interventions for chronic TBI and accompanying functional deficits. (PsycInfo Database Record (c) 2020 APA, all rights reserved)

For the abstract

Canadian Company to Roll Out Drug Dispensing Machines to Help Opioid Addicts

Even as an opioid epidemic continues to grip Canada with over 15,000 overdose deaths since January, 2016, a company based in Halifax is planning to roll out automated drug dispensary machines to selected sites across the country.

Strongly resembling ATMs, the machines, which go by the name "MySafe Verified Identity Dispenser" are designed to be tamper-proof and only to allow access to users whose palm-prints are registered with the the manufacturer, Dispension Industries, Inc.  "A person can access the machine by simply scanning their palm and the machine will know that this person gets this dose (amount) and it will dispense their medication within 15 seconds," said Dispension president Corey Yantha in a recent interview.

A pilot project using the machines in Vancouver's Downtown Eastside began in December of last year and has proven to be a big success.  According to Yantha, over 4000 packets of clean opioids were dispensed to people at risk.   This allowed them to get their drugs from a safe source instead of relying on street drug vendors.    According to Dr. Mark Tyndall, a professor of medicine at the University of British Columbia's school of population and public health and a proponent of harm avoidance, the MySafe pilot project (which he spearheaded), the program will allow users to wean themselves off of street drugs and avoid overdosing.   This is a particular concern in British Columbia given that over a third of all opioid deaths have occurred there.  

"The sample size is really small obviously (only 20 people in all), but it's had a huge impact to the people's lives that are currently using it," he said in a recent interview. "We need more numbers to really show that's happening and the deployment of five more machines will give us some more evaluative power to do that."   It was the success of the pilot project that inspired MySafe to go ahead with the national program to curb the rising number of overdose death occurring in Canada.   But Dr. Tyndall also acknowledges that many physicians are actively oppose the prescribing of drugs such as as methadone and buprenorphine for opioid addicts despite their positive safety record.  

"The problem right now is getting the system engaged," Tyndall said. "Providing an actual safe supply still has a lot of barriers because, in fact, we are asking physicians to prescribe drugs where they have been told not to prescribe because they are dangerous. So getting over that hurdle is ongoing."   He views the dispensing machines as a positive step since they provide addicts with a steady supply and avoid street vendors.  "If they know that they have a secure supply of these drugs their life changes automatically," he said. "They don't have to get up in the morning and go and steal something or find money in the informal economy."

The dispensers will be leased to pharmacies and safe injection sites in Dartmouth, N.S., London, Ont., and Vancouver and Victoria, B.C.  for now but may expand to other cities in time.  Participants will require regular drug monitoring to ensure they remain compliant.  

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Living the Good Life

The ‘good life’ is described by philosophers and psychologists as consisting of authentic expression of self, a sense of well-being, and active engagement in life and work. Well-being and employee engagement are outcomes of value in themselves to work organisations, but also improve performance and reduce turnover. A recent meta-analysis published in the journal Personality and Individual Differences tests the relationships between authenticity and well-being, and authenticity and engagement, investigating the impact of several moderators: age, gender, sample type, conceptual measure and individualism-collectivism. Systematic searches identified 75 studies (well-being = 65, engagement = 10) with a total N = 36,533. Analysis revealed a positive relationship between authenticity and well-being (r = 0.40) and between authenticity and engagement (r = 0.37). Individualism and type of measure were significant moderators, but age, gender and sample type were not. Specific recommendations are made for researchers choosing measures of authenticity, well-being and engagement. The study also highlights the need for further research on the interaction of culture and authenticity, as the majority of studies rely on Western / individualist conceptualisations and measures. Overall, the meta-analysis demonstrates that authenticity has positive implications for individual well-being and work engagement and could provide an important path to building healthy work organisations. (PsycINFO Database Record (c) 2019 APA, all rights reserved)

For the abstract

In Praise of Pain

Human beings have always had a love/hate relationship with pain.

Not only has pain and suffering always been viewed as something all humans had to endure (including Biblical stories such as  childbirth pain being due to the sin of Eve or Job being afflicted with suffering to test his faith),  religions often championed the notion that bearing pain stoically was a sure sign of virtuous living.  The very word “stoic” stemmed from a philosophical school that viewed pain and suffering as essential to being truly human. In St. Paul's First Letter to the Colossians, he wrote that: "I fill up that which is behind the afflictions of Christ in my flesh".     Still, while virtually every organized religion has regarded pain as a necessary evil, the use of herbal remedies to deal with pain have been a necessary part of medicine for all of recorded history (and likely long before).   While physicians and other healers often viewed pain as being an important sign of disease and that masking it with medication  interfered with treatment, they were also quick to dispense whatever pain-relieving agents that they had at their disposal for patients in agony.   That usually included the familiar standby, papaver somniferum (a.k.a., the opium poppy), which was cultivated for its analgesic properties as far back as neolithic times in most of Eurasia.

Even with the advent of anesthesia in the 19^th century, new  discoveries, including morphine, chloroform, and nitrous oxide, were greeted with mixed feelings, especially among religious leaders who viewed such innovations as somehow being a subversion of God’s plan.  Queen Victoria’s very public decision to use chloroform to ensure a painless delivery of one of her children in 1853 was greeted with alarm at first although it also helped spread the word that anesthesia was safe and effective.  Despite religious qualms, the era of painless dentistry and surgery had begun.

By the dawn of the 20^th century, anesthesia was already widely used in surgery.  While pessimistic philosophers such as Arthur Schopenhauer stressed the inescapable nature of pain in their own writings,  improvements in medicine, including the wide availability of powerful analgesics,  made pain relief universally available (at least to those who could afford it).   Even familiar remedies such as morphine continued to be superseded by better and stronger alternatives, including heroin which was available in numerous locations without a prescription.

As the dangers associated with opiate addiction became better understood, an inevitable backlash set in.  Many commercially available analgesics were eventually banned under international narcotics laws.  Prohibition became a dominant movement in the United States while, in other countries, medical doctors, theologians,  and social critics viewed the addictive properties of many popular narcotics with increasing alarm. This alarm was spurred by the thousands of wounded veterans of World War I, many of whom were left addicted to the pain medication prescribed for them.   This public alarm led to attempts at reconceptualizing how pain should be treated.  Rather than viewing pain as something to be eliminated by any means possible,  wasn't it possible that resisting pain was actually a virtue and that giving into pain by demanding medical relief was actually a form of cowardice? 

By 1935, French writer and journalist, Julien Teppe, became the leading force in what came to be known as the "dolorism" movement.  Taken from the Latin word for pain, dolorism basically exalted the value of pain, both medically and philosophically.  The two books that Teppe wrote, Apologie pour l'anormal (a.k.a. the "Dolorist manifesto") in 1935 and Dictature de la douleur in 1937 justified dolorism as a reaction against what Teppe called the "tyranny of the fit".  He viewed pain as  a way of learning about oneself (essentially arguing that "I am suffering, therefore I am").  He also wrote that, "Pain, of all the psychological states, is the one which takes over the entire being, both the flesh and the spirit, with the greatest urgency and force.  It is a disposition which sweeps away, blots out, and annihilates all the rest."   Through pain, humans learn about compassion for other human beings and inability to understand suffering was the root cause for hostility and intolerance.  Not only did Teppe argue for a better understanding of pain, he also suggested that students in all programs be required to visit hospitals and sanatoriums as part of their education. 

While not an original concept (existentialist philosophers such  as Karl Jaspers and Martin Heidegger had made  similar arguments years before), Teppe's movement quickly took root.   Along with his influential books, Teppe also launched the Revue Doloriste, an episodic journal that was meant to be the standard for the entire dolorist movement.   On its first publication in 1946, the French conservative paper, Le Figaro, a tongue-in-cheek endorsement to the new journal and to dolorism in general:  "No school ever chose its hour better than this one.  Every French citizen is an unknowing Dolorist.  And [then-premier] Monsieur Gouin, perhaps, is one".   While never the financial success that Teppe had hoped, the first issue sold 5,000 copies and eventually included original essays from such prominent writers as Andre Gide and Colette.

That dolorism became a hotly debated subject before and after World War II is perhaps not surprising given the political and economic struggle to rebuild Europe.   Theologians continued to advocate pain as a necessary evil while neurologists and physiologists weighed in on the medical aspects of pain.  Teppe's chief opponent was prominent surgeon, Rene Leriche.  Having gained his experience in treating pain associated with battlefield injuries in World War I,  Leriche's book La Chirugie de la douler (the Surgery of Pain) quickly became a classic in treating "pain disorders" after its publication in 1937.  As a militant humanist as well as a surgeon, Leriche avidly fought any attempt to glorify pain and argued against the idea that pain could be beneficial or useful in any way.    Ironically, Leriche actively spoke against the use of pain medications such as morphine and argued that surgical approaches were the ideal method for pain relief. 

Another prominent dolorism opponent, prominent neuropsychiatrist Jean L'hermitte, argued that "the first duty of medicine is to heal when it can, to relieve often, and to comfort always.  As a result, a physician's role is not only to relieve moral suffering often but also, insofar as it is possible, to alleviate pain and its repercussions on the different organs."    As an important example of pain's importance, L'hermitte described cases of syringomelia in which patients with interrupted sensory nerve fibres injure themselves due to their inability to feel pain.  He also saw analgesics such as morphine as being effective in preventing suicides among chronic pain sufferers. 

Still, the spectre of addiction to pain medication was ever present.  Even L'hermitte was quick to argue that some physicians gave out morphine "too freely" and that it should only be prescribed by physicians who were certain that their patients were genuinely suffering.  He advocated that morphine only be administered through injection and at the doctor's discretion.   While he denounced dolorism as a dangerous trend, he still advocated an extremely conservative approach to pain treatment which often meant that patients were expected to "suffer in silence" rather than admit that they were unable to bear their chronic pain "maturely".  Many religious hospitals, though recognizing the need to deal with pain, often stressed the virtue of endurance and advised doctors and nurses to train patients to resist pain rather than to plead for better analgesics.   As formal treatment shifted towards specialized hospital wards to deal with chronic pain patients, pain clinics have become an integral part of most tertiary care hospitals.

Although today's physicians are no longer expected to allow patients to "suffer for their own good", the old dolorist arguments have never completely faded away.  The reluctance to prescribe pain medications due to addiction risks, however legitimate, often masks an expectation that patients overcome pain on their own rather than rely on chemical aids.  That there is an obvious economic component to this argument (medication costs money, after all) makes it all the more appealing to rein in rising health care costs.   Many of the moral dilemmas and problems raised by Julien Teppe and his supporters remain unresolved and the stringent regulations that physicians often face in prescribing medication means that pain management remains one of the most contentious issues facing medicine today. 

And that is unlikely to change any time soon. 

Does Suicide Risk Increase with Number of Physical Ailments?

 As yet, there has been little research on the association between physical multimorbidity (the co-occurrence of two or more physical illnesses) and suicide, and results have been mixed. New research published in the Journal of Affective Disorders examined if physical multimorbidity is associated with suicidal behavior in the general population in the United States.  Data were analyzed from 15,311 adults that were obtained from the Collaborative Psychiatric Epidemiology Surveys (CPES). Information was obtained on nine self-reported physical health conditions and lifetime suicidal behavior (suicidal ideation, plan, and attempts). Logistic regression analysis was used to examine associations. Results showed an increasing number of physical health conditions was associated with higher odds for suicidal behavior. Compared to those with no physical conditions, individuals with ≥ 4 physical illnesses had 2.99, 4.82, and 4.39 times higher odds for reporting suicidal ideation, a suicide plan, and suicide attempts, respectively. An interaction analysis showed that for suicide attempts the association was stronger in younger rather than older adults.  While the data were cross-sectional and information on physical conditions and suicidal behavior was self-reported and may have been subject to reporting bias, results showed that  multimorbidity has increased in recent decades in the United States, alerting medical practitioners to the increased risk of suicidal behavior in adults who have multiple medical conditions as well as screening for suicidality in this group may be important preventive measures to help reduce suicidal behavior in the general population.

For the abstract

The Power of the Placebo

The Siege of Breda is one of the most graphic events of the Eighty Years War (also known as the Dutch War of Independence).   Under the orders of Spanish general Ambrogio Spinola, the walled city of Breda in what is now the Netherlands was besieged by the Spanish army for more than eleven months.   So extreme were conditions inside the town for the 7,000 soldiers defending the town that they soldiers began dying of scurvy due to the lack of fresh fruit and vegetables.   Though curable through simple nutrition, scurvy is potentially deadly for anyone whose diet is low in Vitamin C and the Dutch soldiers were no exception.   Along with problems stemming from malnutrition, the long siege also led to a critical shortage in various medications, including medications for relieving pain (primarily opium and laudanum).   To solve this problem,  the garrison commander Justin of Nassau (a son of William of Orange), hit on a cunning plan.

Working with the city's doctors,  Justin had the doctors provide their patients with a powerful new medicine that he reportedly managed to smuggle in from the mysterious East.   The medicine was so strong that only a few drops in a gallon of water would clear up their symptoms.    The soldiers were impressed that their commander had managed to get them this medicine despite the risks and expense involved.  Except that the "medicine" in this case was nothing more than a mixture of wormwood, camomile, and camphor, carefully placed into small phials which Justin provided to the doctors.  While available reports stated that "they took the medicine eagerly and grew well rapidly", there are likely limits to how well the power of suggestion could work in preventing the symptoms of scurvy. Certainly men continued to die and only 3,500 Dutch soldiers were still alive by the time Justin surrendered the town.  

Though medical doctors had long observed that patient belief had a powerful effect on the body and how they responded to medical treatment, the first formal investigation into what would be called "the placebo effect" would not begin until the early 19th century.   The word "placebo" is Latin for "I will please" and actually comes from a Latin translation of the Bible.   British physician John Haygarth published what would be the first treatise on the placebo effect when he investigated that medical effectiveness of a popular cure of the time known as "Perkins tractors."   Invented by American physician Elisha Perkins, these "tractors" consisted of two 3-inch metal rods made of steel and brass.  By using the tractors to "draw off the noxious electrical fluid that lay at the root of suffering", Perkins claimed to be able to cure a wide variety of illnesses including rheumatism and arthritis.

Even though conventional medical doctors were quick to denounce Perkins' invention as sheer quackery, many patients reported getting significant pain relief from the treatments and John Haygarth decided to investigate further.   Alarmed at the growing popularity of Perkins tractors among his patients in Bath,  Haygarth demonstrated that patients could get the same pain relief from rods made of virtually any substance and that they were unable to tell the difference between fake tractors and the "real" ones.   He also noted that some patients actually got worse instead of better which suggested that imagination could cause as well as cure disease.    What mattered most was the reputation of the doctor (famous doctors were more likely to get positive results than obscure ones) as well as how credulous the patients were.    The best results appeared to come from both the doctor and the patient believing in the power of the medical treatment.    He prophetically commented that: "medical practitioners of good understanding, but of various dispositions of mind, feel different degrees of scepticism in the remedies they employ. One who possesses, with discernment, the largest portion of medical faith, will be undoubtedly of greatest benefit to his patients."

As Haygarth concluded in his 1800 paper Of the Imagination as a Cause and as a Cure of Disorders of the Body,  what really caused pain relief was the belief that patients were getting an apparently effective treatment.     Haygarth concluded in his paper that his results showed "to a degree which has never been suspected, what powerful influence upon diseases is produced by mere imagination".     While his research into the power of  belief would be largely overlooked by medical historians (he is mainly remembered as a pioneer in smallpox inoculation),  he is still the first physician to raise questions about the placebo effect which have haunted discussions of alternative medical treatments ever since.  

At the same time that John Haygarth was making his groundbreaking observations on the power of positive belief in relieving pain, the influence of Franz Mesmer and his disciples was also being felt across Europe and North America.   Despite attempts by skeptics such as Benjamin Franklin and Antoine Lavoisier to debunk Mesmer's work, mesmerists would ply their trade for decades afterward and physicians were slowly beginning to understand how they were accomplishing their apparently miraculous cures.   

Along with mesmerism, the early 19th century was also seeing a rise of interest in homeopathy.    Based on the "like cures like" doctrine of Samuel Hahnemann, homeopathic practitioners began offering their treatments for various illnesses with only anecdotal evidence from satisfied patients to prove that it even worked.    The first formal clinical trial to test the effectiveness of homeopathic medicine was carried out in Russia in 1832.   Not coincidentally, it was also the first clinical trial to use a placebo in medical research.   Tests comparing homeopathic medicine with placebo pills made of flour paste showed no real difference was found in medical effectiveness.     After publishing these results, the term "placebo effect" became well-known to medical researchers across Europe and North America (though homeopathic medicine seems not to have been seriously derailed by the findings).

In another informal test of the placebo effect, French physician Albert Matthieu informed many of his tuberculosis patients at the Hopital Andral in Paris of a powerful new treatment for tuberculosis that had recently been discovered in Germany.   This new treatment, which he dubbed "antiphymose" was supposed to yield wonderful results in people suffering from tuberculosis and the news quickly spread with patients demanding that the drug be tested on them.   After a time, Matthieu began conducting clinical trials which the drug he had supposedly received from Germany.   All patients receiving antiphymose injections were carefully tested on a regular basis to see if their weight and temperature changed as a result of the new treatment. 

According to the results, antiphymose had a powerful effect on tuberculosis patients receiving the injections.   Not only did the patients gain weight but their chronic fever was reduced as well.  Some gained as much as three kilogrammes of weight while other symptoms such as persistent coughing and insomnia improved as well.    When the antiphymose injections stopped, the old symptoms returned as well and patients quickly lost the weight they had gained before.    Only afterward did Matthieu reveal that there was no such treatment as antiphymose.   What they had received was simply sterilized water and saline.   The record fails to state how the patients responded to being deceived, even in a good cause.

While the placebo effect is an acknowledged part of modern medicine (and the driving force behind most alternative medical treatments), the power of the placebo continues to influence how many patients respond to treatment.    As patients and doctors alike believe that a treatment will work, patients tend to recover faster than they might do otherwise.   When a newer (and more expensive) drug comes out however, the drug it replaces often performs less well in research because doctors are less confident in helping patients.   Research has shown that simply changing the size and colour of a pill can be enough to change its apparent effectiveness. 

But how exactly does the placebo effect work?   Research into using placebos for pain  suggests that increased endorphin levels and reduced cholecystokinin production in the brain may lead to placebo-induced pain relief.    A 1978 study showed that the opioid antagonist naloxone can block endorphins and prevent the placebo effect from occurring.   These results only appear to apply to pain relief however.  

Placebos have been shown to be effective in relieving a wide range of symptoms and the power of belief can also play a role in worsening symptoms as well.   Much like the placebo effect, nocebos (coming from the Latin phrase for "I will harm") can have a powerful effect on health by making many medical conditions worse and may even play a role in "voodoo deaths" linked to curses.   Various proposed explanations for the placebo (and nocebo) effect include suggestion,  operant and classical conditioning, cognitive dissonance, the Hawthorne effect, and expectancy effects though they are all largely based on speculation.  All that we can say  for certain is that the exact mechanism for the placebo effect is (still) unknown.

Is there such a thing as a placebo-responder personality?   While some researchers have attempted to link patient responding to placebos to suggestibility or other personality traits, the  results have been largely inconclusive.   In studies observing how subjects respond to placebos over multiple trials, no consistent pattern has been identified.   In other words,  the same subjects who respond to placebos in one trial may not respond in later trials or vice versa.    It is also difficult to decide exactly what the placebo effect can affect.   Though most research into placebo use focuses on pain relief,  some studies suggest that belief in placebos can accomplish much more, including relieving swelling and changing serum cortisol levels.     The extent to which the placebo effect can relieve symptoms can range from no effect at all to total relief in some cases.

In identifying the different factors that can make placebos effective, researchers have identified the following:

• The nature of the intervention - the more intrusive the intervention, the more effective the placebo effect seems to be.  "Sham surgery" (skin incisions without an actual operation) seems to be at least partially effective in relieving symptoms for most patients receiving it.     Placebo injections also appear more effective than placebo pills.   the more discomfort associated with the sham treatment, the better.    Treatments that are more "exotic", i.e., involving complicated technology or a radical new medical technique also seems to increase the effectiveness of the placebo.
• How credible the one providing the treatment seems -  Doctors with a high degree of status showing strong belief in their treatment are more likely to have a positive effect on their patients.   Also, therapists showing warmth and empathy to their patients will get better results on average.
• Patient expectation -  If the patient is involved in the treatment and has developed a sense of trust in the doctor and the treatment being received, the placebo effect is likely to be stronger.
• The nature of the complaint - Though most placebo research has focused on pain relief, a wide range of other symptoms appear to be affected by belief as well.   Biofeedback research suggests that many physiological functions can be consciously controlled although it is still unknown whether some complaints or disorders may be more "placebo prone" than others.
• The treatment setting -  A 1994 clinical study found that therapeutic setting was the only significant predictor for nocebo effects, i.e., patients in some clinical centres were more likely to experience adverse reactions to a placebo than patients in other centres.   This suggests that even the location where treatment is received may play a role in whether the placebo effect occurs.

It is also important to understand that simply observing patients improving after taking a placebo cannot be considered evidence for a placebo effect at work.    According to Edward Ernst and his colleagues,  evidence for a "true placebo effect" needs to rule out other factors that might be contributing to patients getting better.    This can include natural recovery from illness, regression towards the mean,  patient bias, or other time-related factors that researchers failed to take into account.    In other words, simply seeing a patient improve does not mean that a placebo effect is occurring although  this "perceived placebo effect" is often confused with the real effect.    To make medical research even more complicated, proving that a treatment is really effective means showing that the positive benefits are greater than what could be accounted for by the true and perceived placebo effects. 

As a result, the placebo effect is a part of all medical treatments, whether intended or not.  Many of the factors that make the placebo effect more powerful are also used by caring health professionals to reassure patients and make them more confident that the treatment will be effective.   That same confidence also plays a role in the perceived benefits that patients being treated with alternative medicine often experience and which, in turn, are taken as "proof" of their effectiveness.   Virtually every practitioner of alternative medicine can produce anecdotes provided by apparently grateful clients.   Though these glowing anecdotes can seem convincing to people desperate for a cure,  there are always limits to what can be accomplished by belief alone. 

While there are certainly colourful stories of the placebo effect at work,  relying on placebos to treat patients often invokes a critical problem in medical ethics.  Is it permissible for doctors to lie to their patients, even in a good cause?  And can practitioners of alternative medicine be considered to be providing a valuable service to patients if the placebo effect makes the treatment more effective than it might otherwise be?  

There are still too many unanswered questions about how and why placebos work despite the enormous amount of research that has been done to date.   Though the placebo effect has a long and venerable history, it remains a mystery in many ways.   And perhaps it always will be.