Stress, Pain and the Placebo Effect at the Library of Congress

This past month I had the pleasure and privilege of taking part in a symposium on the effects of stress on the mind and body, sponsored by the Kluge Foundation and held at the Library of Congress. The presentation that most captured my attention involved anxiety, pain, and the placebo effect, and was presented by Fabrizio Benedetti, Professor of Neurophysiology and Human Physiology at the University of Turin, Italy.

Most of us have heard about the so-called placebo effect – the non-specific effect that make people feel better when they receive treatment of any kind, mostly because when we go to a professional and are given a treatment, we hope to feel better. Indeed we expect to feel better. And it is this hope and expectation that is thought to be the driving force behind the placebo effect.

We mostly hear about the placebo effect as a nuisance that interferes with our ability to determine whether a drug or some other form of treatment is working because it really works, or because it simply generates the dratted placebo effect. In Benedetti’s work, however, the placebo effect itself is the focus of attention. How powerful is it? How does it work? Can we counteract or strengthen it? These are the sorts of questions Benedetti has asked, and has actually come up with some intriguing answers.

Before looking into some of this research, however, I want to introduce a second term into the discussion, “the nocebo effect,” less familiar that the placebo effect, but equally fascinating. A nocebo is an intervention that generates negative expectations in the person receiving it, and thereby results in the person feeling worse.

Most of Benedetti’s presentation focused on placebo and nocebo effects on pain. In one fascinating series of pictures, he showed how a woman suffering from post-surgical pain, when told to raise her arm as high as she could, was able to lift it no further than to a horizontal position. After being given a placebo pill, this same woman was able to raise her arm straight up into a vertical position. After receiving a nocebo, however – the very same pill with the explanation that it would make her pain worse – she was not able to lift her arm even as high as she could at baseline. In short, the placebo made the pain better; the nocebo made it worse – even though the two interventions involved the same pills!

How can placebos alleviate pain? Benedetti has shown that placebos activate the brain’s own painkillers – such as endogenous opiates and cannabinoids. These chemicals can be artificially stimulated by opiate drugs or artificial cannabinoids such as are present in marijuana. Nocebos can have the opposite effect on the same brain chemical systems. Another way in which nocebos do their dirty work is by raising anxiety – which occurs naturally when we expect the worst. Benedetti has worked out these cause-and-effect relationships by using drugs to enhance or counteract placebo and nocebo effects. For example, he found anxiety to be important in the the nocebo effect because when he pre-treated people with Valium-type drugs, called benzodiazepines, the nocebo effect disappeared.

Fascinating as the symposium was, the real star of the show was the Library of Congress. I am ashamed to say that I have lived in Washington, D.C. for over 30 years and have never set foot in this magnificent building before. It’s façade alone could rival those of many of the grand buildings in Europe are considered indispensable sights to include on a European trip.

The interior of the building is even more impressive. As I wondered down the halls, I had the sense of being inside a Venezian Palazzo of enormous dimensions. The floors are covered with mosaics, the ceilings painted, and marble abounds in the form of columns are archways. Lush and magnificent, it is unimaginable that any Congress would appropriate funds for such an edifice in these straightened times.

Here is a picture of the reading room, which looks more like the interior of some grand opera house.

And look at the central hall – too large to be captured in a single snapshot.

Since I am particularly interested in clinical depression, I was fascinated at this decorated paean to “divinest melancholy”, tucked away in a corner of the ceiling next to the service elevator. Although I admire the artistry, I can assure you, based on many years of experience, that there is nothing divine about melancholia.

Picture of divinest melancholy (directly above)

As you can see by this picture (to the right), even regular ceiling paintings are gorgeous. I could go on and on, and I wasn’t even an art major!

From the reading room specifically dedicated to the poet laureate, you have a wonderful view of the mall. Ironically, I could see a crowd standing outside the Supreme Court, where the justices were debating the constitutionality of the Health Care Bill.

While the glories of the Library of Congress were enough to make you forget all your pains and sorrows, thoughts of our health care mess might well produce the exactly opposite response – a clear demonstration of the placebo and nocebo effects in action.

Wishing you Light and Transcendence,

Norman