 Ooh. So quiet. I love it. Hi. How was lunch? Was it good? Welcome back. No, it's good. It's good. Welcome back. Were y'all in here? Yes, we're good. Come on in. Come on in. Come on in. All right, let's get started. Let's get started. Our next talk features Stephen Nevella, Harriet Hall. We've added some names. Paul, Ophid, Scott Lillianfield, and David Gorsky is our moderator. It's the psychology of pseudoscience in medicine. Here's the limerick. We often scoff at the painful reliance of a psychology's regretful appliance of stuff that's not true, but hey, what can you do? There's big bucks in medical pseudoscience. All right, please welcome to the stage Stephen Nevella, Harriet Hall, David Gorsky, Paul, Ophid, and Scott Lillianfield. Thank you. Oh, all right. One of the areas of pseudoscience that we see in a lot of what we call supplementary and alternative medicine has to do with psychology, and we thought to start this discussion that we would talk about perhaps the most pervasive area, because it also, some of it might not all be quackery. So let's talk about, and the slide's not coming, we're going to talk about mind-body therapies. Is it showing up? Because I can't see it on my monitor. All right, so there are two definitions that you see before you. One from the National Center for Complementary and Alternative Medicine. Is it showing? I'll just wing it here. The definitions both basically talk about interventions for the mind and body or the mind-body connection that can be either therapeutic relief symptoms or improve immune function, improve physiology, whatever. And there are a whole number of them that range from things like meditation, exercise, and even aromatherapy. So I think what we'll do is I'll just start by asking each panelist what they consider, what do they think of when they hear mind-body medicine? What does it mean? Well, in the first place, mind, to me, means an emergent phenomenon of the physical and chemical processes in the brain. And it's a handy shorthand that covers a lot of things. It doesn't cover everything the brain does, because the brain does a lot of automatic housekeeping functions. But I think of the mind as including anything that consciousness has access to, things like emotions and thoughts and memories. And when I was in medical school, our professor of psychiatry told us we could not use the word mind because he thought it led to fuzzy thinking. And when somebody tells me I can't do something, I tend to react and people who know me will understand. I rebelled and we had to write a term paper and I wrote the term paper and I used the word mind over and over and over again throughout the paper. And I got it back. It was all covered with red marks. He'd underlined every time I'd used the word mind. He'd written nasty notes in the outline in the margins. But he gave me an A-plus because I had explained what I meant by mind and I justified the way I was using it. And mind is a word that's handy in a lot of ways. How could we say things like I'll keep that in mind or I changed my mind if we didn't have a label like that? And it's kind of like a metaphor, like we say from the bottom of my heart. Well, we know that doesn't have anything to do with that little pump in your chest. But it's very useful in getting ideas across to other people. So when I hear the word mind, I don't think about anything ineffable or immaterial. And it certainly doesn't remind me of a dualistic philosophy or a vitalistic philosophy. And I think it's a good word to use as long as we understand how we're using it. But I think the idea of mind-body medicine is just stupid. Because... No, Harriet, how do you really feel about that? Because there is no division. It's all one thing. Things that happen in the mind affect what happens in the body. If you're afraid, your heart rate speeds up. And things that happen in the body affect the mind. If the body is sending pain signals to the brain, the brain interprets it as suffering. And chronic pain gets turned into depression and hopelessness and mental things. So good medicine always considers mind and body together. And there shouldn't be a separate category. Okay, before we move on to Scott, we finally have the slide up there. There are the two definitions. One from NCAM. And the other one from the NCI Office of Cancer, Complementary and Alternative Medicine, which has the most unfortunate acronym ever, ACAM. It's not on the big screen. Alright, never mind. I give up. I give up. Scott, you're next. Let me guess, it's on the screen now. Anyway, this is the list here of some of the things that fall under mind, body, medicine according to our government. And you can all see the list now. And we'll leave it up a few more seconds while the discussion continues. So I'm not sure what mind, body, medicine is, to be honest. Like Harriet, when I think of mind, I don't think of anything spooky or spiritual or non-material. I'm a non-reductive physicalist. I do think the mind is what the brain does or partly does. When I use the term mind, like Harriet, I use it to refer to an emergent property of lower-order neural elements. However, I think that when most people use the term mind, body, medicine, they're not using it that way. At least that's my impression. My impression is they're using it in a pretty dualistic way, either implicitly or explicitly. So I think one reason that is popular in many circles is this assumption that these interventions, including some of those that are listed there, I'm surprised to see cognitive behavioral therapy, which I was trained in on there. I think a lot of people who support these techniques may believe that these methods are working not through the brain, but through some kind of quasi-spiritual non-material essence. So I don't have any problem with people looking at the efficacy of meditation for anxiety or exercise. In fact, there's some pretty good evidence. I think the exercise is helpful for depression. But when I say that exercise works or cognitive behavioral therapy, which I know fairly well works, what I mean when I say that is I think what you're learning to do with cognitive behavioral therapy is you're learning to harness one part of your brain to control another part of your brain. I don't think you're harnessing the mind or some non-material essence to harness the brain, but I fear that that's often the implication. I'm often worried that that implication is almost left dangling out there because it may be appealing to some people. Paul? I guess I have a very simplistic view of this, which is I would define it as that one's emotional state influences your susceptibility to illness or your ability to recover from illness, but I completely agree with Harriet. It's all of one piece. I guess the line from Milton's Paradise Lost is the mind can make a heaven of hell and a hell of heaven. I think it's true, but there is to the degree that there's a physiological response. It is explainable. For example, you have nerve endings in your thymus and your bone marrow and your spleen. These are immunological organs. It's not surprising then that one can learn to in some ways influence one's immune system. I agree with Harriet though. I think it's certainly all of one piece. There's nothing magical about it. Steve, give us the definitive answer. I don't know either. I don't use the term mind, body, and medicine because I don't think it has a usable definition. It doesn't have what I would call an operational definition. If you have these features and have these occlusion and every feature, then that's considered mind, body, and medicine. So it's kind of like a wizard's definition, like Gandalf. It means exactly what camp opponents wanted to mean at any point in time, nothing more, nothing less. I agree with Harriet. A lot of it comes from vagaries of the term mind. We can use it as a metaphor. I just sort of sometimes just bypass it by saying, well, I'll keep that in the synaptic connections of the neurons in my neocortex. Mind tends to flow a little bit easier, so it's a useful shorthand metaphor, but when you try to use that as a scientific definition or a clinical definition, you run into trouble because it is a metaphor. It doesn't really have an operational definition. And to the extent that it has any meaning, it is just the functioning of the brain. The brain is not the mind-body. The brain is the body. It's part of the body. It's the same thing. It's just the different parts of the body connecting and working together. And so it's completely artificial, I think, when you really try to break it down to what it might mean. Okay, so among this list of therapies, are there any that you'd consider to be perhaps evidence-based? Well, evidence-based for what? Well, I mean, you can give specific indications. So, I mean, there's a lot of things on the list. This is one of the things that drives me crazy with alternative medicine claims is that they're often nonspecific. There's Tai Chi is on there. And yoga. Those are both exercise. And what the evidence shows is that they have the effects you would predict they would have for exercising and stretching and practicing balance. But saying exercise isn't as sexy as saying Tai Chi or yoga. And so there's study or meditation is another great one. There's lots of studies on meditation. I've tried to look through as much of the literature. Perhaps we should define meditation. Is there a science-based definition of meditation? So again, that's the rub is what's the operational definition of meditation? Virtually all of the studies, clinical studies looking at meditation showing it lowers your heart rate and lowers your blood pressure and reduces whatever, reduces your blood sugar and all the wonderful things that meditation does. What they never do is have a control group where you're just relaxing. So how do I know that meditation or some particular kind of meditation, transcendental meditation or whatever is any different than me just sitting on the couch and relaxing for the same amount of time? They don't do that study. I have to wonder why. The two possibilities are not to be false dichotomy, but two certainly plausible possibilities are. One is they're just terrible scientists and they're not asking the obvious question they should be asking. Or two is they don't want to know the answer to that question. They want to do the study that shows that transcendental meditation lowers your blood pressure. They don't want to show as well as sitting on the couch and doing nothing. Although if you're eating Cheetos while you're sitting on the couch it might not be. Yeah, well if you're eating Cheetos it doesn't help. So that's why they live for vague definitions. They live in the gray zone because that way it means exactly what they wanted to mean and you could never nail them down. It's like nailing Jell-O to the wall, right? You could never do it because if you have to actually define your variables it all falls apart because it's all marketing. It's not science. Some of the ambiguity Steve also that some of the proponents of these techniques are not always clear about what they mean about specific versus not specific effect. So for example one argument I hear is that if you compare meditation with a relaxation condition and a few studies have done that and as you know the results are kind of equivocal so that's how you do that and the results are kind of you know not so good. So they might say yeah but sure what you're calling a placebo effect is in part what I think is part of the technique and I'm not defending that but I just wonder part of it is just an ambiguity about what actually the active component is is that part of the problem I think is just the theoretical mechanisms are rather vague. That's the other shell game that they play is when you show that they have quote-unquote only placebo effects they go well there you go. Placebo effects are mind-body medicine. So that's one that becomes their definition of mind-body medicine because that's the placebo effect is the mind effect in the body even though it really isn't. So they just turn the whole logic of scientific research on its head by saying that only having a placebo effect is a real effect even though it's mainly nonspecific or illusory effects and it's not a real effect but it fits within their fiction that they've erected about mind-body medicine which is really what it is just a narrative. I guess if you want to really break it down. But see I think here's what I would say it's just because something doesn't work better than placebo doesn't mean the placebo doesn't work. I mean you could argue as you just did I think Steve that if you take all of this whether you call it Tai Chi or Kuigang or meditation or yoga or whatever that you can at times at least define that you are affecting the release of stress mediators which have an effect on the immune system or have an effect on blood pressure and so that's what that is. I mean I think that there is a physiological basis to that that is effective or can be effective. It's just the part that's upsetting and I think it's upsetting to Steve too is that it's sort of sold as something mystical and greater and magical and that's I think we're in danger of lies. Yeah let's call it sorry let's just call it what it is. It's relaxation. It's exercise. It's stretching. Everything else is the ritual bullshit that surrounds the actual thing that's happening and then you end up getting these very few basic effects. Relaxation, massage, whatever. Repackaged over and over again with the different BS around it and that's that can so is confusion. Science is supposed to win away the confusion to what's actually happening. They're going in the opposite direction. They're embellishing the real effect with fake stuff. Most of the things on that list are feel good things. They're like comfort measures. They make people subjectively feel good. There are very few things on that list that have been shown to have any really significant effect on the outcome of illnesses. Some of them may have some physiologic effects but are they big enough effects to really make a difference? There's no real good evidence that there is for most of those. Yeah, I think for CBT cognitive behavioral therapy I think there is some. I think even there there's some question about whether the cognitive parts which involves restructuring the way we think about things add a lot above and beyond behavioral parts. That's a controversial issue right now. But I think there's some evidence. Pretty good evidence that CBT is efficacious for depression and also good for prophylaxis of depression. Yeah, I was actually about to ask about CBT cognitive behavioral therapy. It is used for many indications. So how does it get lumped in with mind-body medicine? I mean, Steve and I have talked about this sort of thing for a lot of other things. This is basically, and I'd like you to comment on this, this is basically a rebranding of potentially science-based therapy. Again, I wonder, I don't know, I'm sort of bewildered by it but I do wonder if again some of it reflects this implicit dualism that the cognitive part when you're changing people's thoughts you're actually, you are going through their minds but not their brains. I wonder if that's almost the assumption that is being made here. So that's what makes it a mind-body technique because you're changing their mental processes which somehow is not material. Again, all of us on the panel would agree that doesn't make any sense but intuitively I wonder if that's the way a lot of people think about it. I think they lumped in the cognitive behavioral therapies because they needed something on their list that really worked. So can there be mind-body medicine without dualism as an assumption? Does the whole category require...? I don't think it requires dualism and just to define what we're talking about. Dualism, there's different flavors of it but basically it's any philosophy of mind and Daniel Dennett is here so I'm sure he's going to talk about this. But it's any philosophy of mind that says that the mind is somehow something other than just what the brain is doing. It's something more. Cartesian dualism it means it says it's completely separate. There's this spiritual thing outside of, metaphysical thing outside of the brain but there's other types of dualism that blur the lines even further. So I think the blurring of those lines with dualism is useful for including whatever you want into the category keeping it nice and vague so we can mean whatever you want. But you can have a concept of mind-body medicine that doesn't involve dualism all you're saying is that, again like Paul said, your emotions affect your health. It's like okay, that's true in a very trivial sense and we know that it's true because the brain is your health, it is your body and it's all connected. So of course your stress hormones are released by stress and that has an effect on the physiology of your body which can affect all sorts of things. So it's true in a way that's reductionist scientific that we've known for decades that's not controversial but to the extent that it's true in that sense that it has no meaning and it's not dualistic when you go beyond what we know from biology and physiology then they start to incorporate dualism to expand their list to whatever they want like guided imagery or things that are more than just the basics of relaxation and exercise and massage and whatever. There was one study that was done in 1957 it was sort of a landmark study done by John Inboden who was a researcher at Johns Hopkins University he did this study at Fort Dietrich and what he did was it was fortuitous he went to an army barracks at Fort Dietrich, Maryland he did a sort of series of psychological profiles defining then these soldiers as being sort of more or less depressed and then the fortuitous part came that was right during the big Asian flu pandemic of 1957 which then swept across the barracks and then affected those soldiers differently and what he found that was interesting because it was really very clear that those who were more depressed were more likely to get sick that when they got sick they were more likely to develop symptoms for longer and they were more likely to shed virus for longer I think which served in some ways as a proof that mood can determine illness I don't think it's trivial but it's harnessable at some level we sort of surround it with this kind of mystical bullshit it's painful we know that it's stress, depression, emotional stress releases corticosteroids which suppress the immune system we completely reduced that access we know exactly what's happening there's no mystery there whatsoever I agree, if I could just go back to one quick point that resonates with what Paul was saying before is I think one mistake would sometimes make and I think I was guilty of a two for a while I think the question is Technique X effective or does it work and I think and also relates to what Steve's talking about as part of our role as skeptics I think it's to be clear thinkers and to sort of make distinctions so I think it's I've come around to the view that's not a very meaningful question if we ask does X work well what does that mean does it mean work better than doing nothing which oftentimes is not as we know a very informative comparison especially given placebo effects and a host of other non-specific factors that can account does it mean working better than a placebo does it mean working better than a rival intervention does it mean working better than treatment as usual in terms of what's typical it can mean any or all of those things and I think part of the problem with mind-body medicine is sometimes it has been vague about what that question actually means and going back to Steve's point I think the question whether something works above and beyond placebo it's often a pretty rigorous test especially in my own field of psychotherapy it's actually a controversial issue first of all it's really hard to get a good placebo control well that's actually what you've just brought up something I wanted to get to how do you test you know one of the things that CAM practitioners will say is well you can't do a randomized double-blind trial on these interventions you can't test and you know how do you how can you say they don't work so can you test these with you know what's the most rigorous way that you can test some of these we could talk about say cognitive behavioral therapy but you could pick any other one if you have if you thought how would you test it what's the control how do you control for the placebo effect like how do you make it as rigorous as possible well you definitely can't do a or it's almost impossible many people argue to do a strict double-blinded test of psychotherapy sure you can do a single blind sometimes but even there it's really hard because typically both client patient both client patient and therapist know who's in which group and they know what to expect and so on so it's impossible to do it strictly blinded on the other hand you can still use randomization and one of the old principles I always teach my students in psychology is if you can't eliminate a source of error at least try to measure it and certainly you can get closer to a blinded trial by measuring expectancies you can measure clients expectancies at the beginning throughout treatment at the end of treatment and so on and often use that as sort of statistical covariates in terms of psychotherapy what is a good control condition say for cognitive behavioral therapy boy that's a tough one that's why I asked it it is really hard what people have typically done is use what are called attention placebo control groups attention placebo control groups typical what people do is rather than actually do therapy itself they will talk to a therapist typically the same level of training expertise for the same amount of time but they will not do strict cognitive behavioral therapy they will talk about their problems use emotional support and so on usually what you find by the way when you do that when you compare a reasonably well supported therapy like cognitive behavioral therapy with an attention placebo control group you typically still get a difference but it's not as great as the difference with a say a weightless control condition where the person is getting no treatment at all so the difference often goes down by about a half or so but one of the controversies which maybe gets the question you're getting at is are you taking out too much because after all part of what works in psychotherapy is support part of what works is the ability to talk to a caring professional so that's always the question again to me and I agree fully with Steve on this to me a lot of this is what are you claiming that it's the nature of the claims you are making if you are claiming that your technique works better than just talking to somebody for a particular period of time than you better damn well have good evidence for if you're claiming that okay this is just a technique that works we don't quite know why it helps to talk to someone for a period of time then it may not be as important but the fact of the matter is almost always in my field of psychotherapy when people are proponents of a particular therapeutic technique they are claiming that that technique has some specific techniques and specific stuff in it that other therapies don't any other comments just as an example I think the one for me that I always like to go to with CBT is like the eye movement desensitization and reprocessing where you follow the finger of the therapist and moving your eyes is supposed to get you to integrate the cognitive therapy better it's based upon a completely nonsensical notion of how the brain works and again there is almost an inherent dualism in there where the mind is reprogramming the brain in some way it's all nonsense but the the researchers who claim or the proponents of that who EMDR claim there is a specific benefit to doing that that's something you can control for and you can compare it to CBT without EMDR and it may be hard to fully blind it but you can at least do some kind of controlled comparison between the two and what they don't do is they don't show that there is a specific added benefit to that isolated variable component they really just show that there is a nonspecific benefit of introducing something novel and doing the interaction between the therapist so they haven't isolated the variable and when you do you tend to isolate those variables they don't have any specific benefit so then they fall back on saying yeah but there is a nonspecific benefit and that is equivalent to working and again I agree Scott says they have a vague definition of what it means to work to the point that placebo effects will be working and so it's a win-win they can't ever possibly lose and when you can't ever prove that something doesn't work then you can't prove that it does work either in a way it becomes non-falsifiable therefore it's not science and that's what we get interested in when they're going outside the boundaries of science by essentially rendering their claims immune to falsification real quick note about that in terms of rendering claims immune to falsification there's a ad hoc hypothesis in science that does that actually concerns EMDR arm movement, desensitization, reprocessing so someone did a study if there had been a couple of these studies where they have compared EMDR with the eyes wagging back and forth and then there's more of an EMDR than that like also processing the memory so they had a condition, a typical EMDR condition where the person's following the therapist's eyes and then they had a control condition which was a fixed eye movement condition they were all in a spot without the eyes and it worked just as well there was no difference at all they both worked better than a weightless control but they worked equally well so which would seem to refute at least to me or call it a strong question the theoretical mechanism underlying EMDR well, no, not so fast because the proponent of EMDR the main proponent of EMDR actually wrote on a list server I think I have this email somewhere saying no, that actually vindicates my hypothesis about EMDR because when the person is staring at a dot the eyes want to move so at some level it's still working because the eyes at some unconscious level are actually moving because the brain is simulating the eye so again it becomes possibly I guess but it becomes impossible to falsify after a while you looked like you wanted to say something I just want to say that I can see you looking over here certainly as a conventional therapist I would argue in our hospital we're certainly not above practicing placebo medicine I think we do it subtly when you come into our hospital and you see one of our doctors they have on a white coat with red stenciling not a t-shirt that says Iggy and the squirrels on the back of it we have these big machines that make fancy noises when we give medicine the machine that goes ping the machine that goes ping in the night when we give a medicine to a patient we often say I really think this is going to work for you that all matters but at some level it has an effect so it's subtle but I think it's we all do this at some level that's been studied to show that the more expensive the medicine is the more it's being good so another aspect of mind body is that it's evolving and in fact the NCAM strategic plan for the last five years is now refers to it as mind and body medicine which expanded to include things like therapeutic touch, energy medicine you know like glommed on to all of this so I guess my question here is what is it about mind body medicine whether you accept the concept or not that it attracts so much woo I mean how can we stop that I mean energy medicine is about as quackery as much quackery as you can get that's hardcore wouldn't it be wonderful if there was really such a thing as mind over matter if you could think yourself out of illness I mean that's a very seductive concept I agree I think it's a lot of things that we've been talking about it lends itself to the woo to a lot of alternative practices because it deals with vague definitions because it's essentially a rebranding of non-specific and placebo effects so it's a setup it's actually a brand that was created to create a space for things like energy medicine and things that are not scientific so it's not a surprise but let me ask this so the hospital the University of Pennsylvania which is next to our hospital I'm at Children's Hospital Philadelphia the division of oncology has a reiki master so you can go there and you know you get your healing energies manipulated now it's nonsense but you could argue that you know that in that patient who is stressed out this is decreasing stress and it's a value and it's certainly of low risk and low burden it just promotes magical thinking how about I give you my I'm going to step out of the moderator role for like 10 seconds 30 seconds my answer to that is I don't have a problem with reiki masters in the same way that I don't have a problem with chaplains because if it's mystical religious thinking they should they could be treated the same way but there is a chaplain and anyone if it's marketed that way but that's not what they do but that's not what they do that's right that's not what they do they spin it into something that's real medicine you know because I think you recently pointed this out the universities that promote reiki and I looked at Yale's website the Yale hospital does it but they were very careful in how they worded it they made no actual medical claims some people feel better when they have somebody wave their hands over them they were very vague about it which had to be deliberate they didn't make any actual claims but then other hospitals and other centers really go way over the line this is a system of medicine well Dr. Oz it'll promote healing once you start saying healing that's another vague term it doesn't mean anything like wellness it promotes your inner wellness so there's lots of ways that you could make pseudo non-scientific claims that sound good as good marketing good branding that is avoiding anything specific and then there are other sites still that actually say this will cure your cancer then they go all the way to this is going to treat your disease and that's way over the line that's where you get into the real hardcore quackery so it's a continuum the whole spectrum which is why I don't accept things like Raikey because it is on the spectrum as Paul said it promotes uncritical thinking we can't underestimate how much harm that that does because people get on that they think this is good for me to relax as an adjunct to my treatment and then the next step is I know this sounds like a slippery slope argument but this is how they do it what about acupuncture? they get you in there and say they make all the non-specific claims that they can slip past the academic goal post but when you're in the office they're like oh yeah this is going to align your chakras and cure your cancer then they really hit you it's definitely the Trojan Horse David and I have used that analogy before the soft stuff that we're like okay who cares about that it's touchy-feely, it's nice the soft stuff really is the Trojan Horse but in their heart of hearts they believe they can cure cancer with acupuncture and that's what they tell you once they have you in their office and they're not trying to sell themselves to the Dean of a medical school who isn't going to buy that so it really is a deliberate deception and we can't fall for it I think so getting to your question why is it appealing that was the question so why is it so appealing obviously it's very appealing that if you can think yourself well, especially if you're sick I think for the same reason the chaplain's appealing there's this notion that there's something greater than you out there that can sort of reach down and make you feel better or be better, you know what I'm saying it's just that incredible need to believe there is something greater than yourself I think that's what part of the appeal I agree, I think I think two other pieces one, again this is more my psychological background I think again not too much of the dualism issue but I think it is pretty deeply embedded in the way most people think Paul Bloom has argued this that a lot of us are implicitly dualists and so developmentally we know that kids are dualists we ask preschoolers for example questions like it's interesting you ask them like what part of you can do a math problem like do add stuff together most of them will say the brain but if you ask them what part of you loves your mother they'll say the mind and Bloom and others have argued that there's a bit of this residue in all of us or is it just cultural and I think it's both I think it may be cultural I think it may also be a natural unfolding of development in terms of our understanding of the way our bodies work I think the other piece of course is that I'm the one non-MD on this panel but the one thing I always hear and I'm sure you folks have heard this too is this sort of complaint that traditional medicine is kind of cold uncaring, unfeeling harsh and I reject that view but I understand it's a widespread view and certainly there's a core of truth and obviously we're coming around to the view that some of these placebo effects that Paul talks about like being caring and having good rapport and so on are an important part of medicine it's not a dichotomy it's actually part of good medicine as being caring and being supportive but I think looking at that list that was up there before is that a lot of them are kind of feel good things a lot of them involve touch and being relaxed and mellowing out and getting in time it makes me feel good kind of thinking about it meditation, relaxing aroma therapy it's all kind of nice and I think to a lot of people it reminds them of what bothers them rightly or wrongly about traditional Western medicine which may often seem sort of cold and impersonal but has that kind of warm fuzzy feeling again to me the answer to that is to make sure that Western medicine is caring and is not cold and unfeeling rather than to resort to unscientific claims but look I can understand the temptation part of it might be due to a common understanding of something that hasn't been mentioned yet and that psychosomatic medicine you know there is a thing called somatization disorder where people's mental discomfort is expressed as physical symptoms and most people have heard about psychosomatic things I used to belong to the American Psychosomatic Association I remember reading things in my less skeptical days for instance they looked at people who had stomach ulcers and they interviewed them and they got all of them to say something to the effect that that burns me or that really makes me sick to my stomach so they thought there was something symbolic going on that caused ulcers and I don't remember the studies ever having control groups and asking lots of people the same questions and seeing how many of them said that something burned them they would say things like people with chronic back pain will say something to the effect that they'd like to run away from that problem and people who have heard that kind of thing and been indoctrinated into that kind of thinking find mind-body medicine a lot more convincing than most of us do alright I think we got about 15 minutes left and we want to have time for a fair number of questions so our MC will if we want to form a line here I'll grab the first one right there but let's form a line if you want a question just so we don't block anyone's view so feel free to come on up we got a little bit of time here here's the first one you guys take on detailing the placebo effect and people's popular conception of exactly what's going on there I seem to run into people that literally think that their mind is healing their body and that that can go towards things like outcomes in cancer how widespread is that just my anecdotal you know are there good numbers on how widespread that is you know I'll just start by saying something very quickly I think most people when they hear the term placebo effect think that you're dismissing them they think that you're saying that this is just a trivial thing it's all in your mind it's really not real and it's a dismissive I think perceived as a dismissive term that's my sense I agree or it's perceived as the mind healing the body that's the other way it's interpreted when it's like a positive thing either it's dismissive or it's exaggerated so but you're right that's not what it is I mean it's been studied enough but we know that there isn't any actual healing going on there's no physiological effect it's all the perception it's all you know illusory effects like regression to the mean etc so and again we get into the problem of the operational definition of what is actually being measured as a placebo effect versus what are the components of that go into that placebo effect it's a lot of things but it's not a mind over matter actual healing but in my personal anecdotal experience 100% of the people that I talk to thinks that's what it is and that's the opposite of the truth it's actually not what it is it's the one thing that it isn't because we know that because researchers who have tried to show that's what it is have ended up proving that there's no real healing effect going on that it really is all just transient subjective illusory effects so I had thoughts to you some of you it's my own ignorance it's been a little a while since I checked this out but I thought there was some evidence justing that placebo effect sometimes can be blocked by like the lock zone or other opiate blockers wouldn't that suggest there's some learning of endorphin release? yeah so I think you have to carve the other because that's a good point the other point is you have to see the placebo effect for what pain the problem the thing is pain is subjective and it's an experience in the brain that's it's a complicated biological experience with a lot of components and there's a lot of built in ways of modifying the pain experience at multiple levels at the peripheral level and at the central level and there's different components of pain that are modifiable by different brain mechanisms there's an emotional component to pain there's an attentional component to pain and there's a tactile they're feeling all manipulable manipulatable but with with the functioning of your brain so yes when you're in a good mood pain doesn't bother you as much when you're in a bad mood if you look at your right arm and your left arm hurts your left arm will hurt less because you're diverting your attention from the arm that hurts and I'm sure you know yes dopamine and endorphins those are that's how the brain works and so that when you measure how the brain works those are the things that are happening when your brain is modifying its own kind of all reduces down to a no kind of obviously that's the way the brain works kind of mechanism but it does mean and this is the big question we always get about placebo effects if patients feel better who cares and I agree in that if you're talking about subjective symptoms it's okay and in my opinion this is kind of come up you know already does that mean you're going to send your patients for acupuncture if they don't have my approach is that's good bedside manner you know that's something that we've been doing for hundreds of years before science-based medicine that was all we had was good bedside manner that's you know just the touchy-feely part of having a positive therapeutic interaction you know just practical ways of getting people to deal with their pain pain is a psychological experience in many ways it's all part of standard chronic pain management because yes pain is psychological but again they try to spin it into something magical something more than it is by fuzzy definitions and by really just ignoring the reductionist our reductionist understanding scientific understanding of what pain actually is I mean one other case real quickly and I'm sure you know this much better than I do but where I think of a physiological basis for placebo effect is the work on sham surgery for Parkinson's which I think is holding up pretty well so if you for example do a a sham surgery with people Parkinson's that is you actually don't do any I guess they open up the skull but don't actually do anything right what you will see is that the tremors will go down and there's actually at least a short term doesn't last very long yes but a short term relief and symptoms and it's actually a physiological improvement and some of that probably and I believe the evidence suggests it's dopaminergically mediated. Dopamine is a neurotransmitter very involved in hope so when the person feels they're getting the sham surgery they don't know which condition they're assigned to they start getting a boost in morale their dopamine starts squirting out and that actually of course Parkinson's is a dopaminergic illness it actually results in a short term improvement in the symptoms which is physiological so in a sense it's a placebo effect of course because it's an artifact of hope and morale but it's a genuine physiological effect that produces dopamine increase which in turn alleviates the symptoms of Parkinson's. Yeah I agree I reviewed that literature as well and that's my understanding as well but again so just like pain there is or like corticosteroids you know when there's an actual neurotransmitter that you know that responds to emotion then that neurotransmitter has effects or that hormone whatever's being released then yes it can have the effects that it has so again it kind of reduces down to known mechanisms but as you say it's short-lived because the emotional component is short-lived and kind of goes hand in hand with that so I still think that research is preliminary but even if we just accept that they face value it's just another thing like pain where there's a transient effect because it's directly resulting from brain function. Should we go on to the next question? This is one about the psychology of what goes on in a person's mind when they see an alternative medicine person versus a doctor the common thing in Australia is they say the doctors are greedy and they want my money and they ask and the alternative medicine doc isn't? So in Australia the situation is that the doctor cannot benefit financially from the advice they give so they cannot own a pharmacy and they cannot sell you medications and yet in my experience everybody I've spoken to who's gone to see an alternative medicine practitioner is after an examination told there's something wrong with your liver luckily I have some liver tablets that will cost you only $90 and yet they say that the doctors are in it for the money when the alternative medicine people take more over to you. It's amazing isn't it? They've completely flipped it around but it's true. The same is true in the US by the way where we're getting the next speaker up here is that the ethical sort of standard has shifted to where physicians can't own the lab that they send their patients to or the MRI scan that they send their patients to. They can't essentially do self-referrals or have a conflict of interest where they make money off of doing stuff or making specific recommendations to you. It's not an absolute rule or law but the ethics are definitely moving in that direction in the last 20 years in my experience pretty significantly. And it varies by state. Yeah, it varies by state. I'm glad you guys brought up the subject of pain because I mean that's sort of the area, the area of chronic pain is the area where as much of a skeptic as I am I like to start to look at other areas because I struggle with chronic pain people in my family have and often there's just not enough satisfaction to be gotten when you see the doctor and so you want to look like is there something anyway that I could do and I guess it's a bit off topic but I'm wondering is medical science making advances to learn more about pain? Is this something that maybe we could get more happiness out of real, bonafide medicine from in the future? I think I can go with someone else. So the short answer is yes. Pain is a very active area of research. We're learning stuff about it all the time and again good old reductionist science which chemicals are getting released in response to trauma that increases or decreases the amount of pain being generated or being experienced exactly what are the neuro anatomical correlates of different components of pain. We actually know a lot about it and we're learning more about it. There are a lot of other benefits that are really interesting for maybe new pharmaceutical approaches and at the other end pain as a specialty which does intersect with my specialty of neurology and I do have kind of I treat migraine and I treat neuropathic pain so I do have a little bit of a clinical interest in chronic pain so there is a huge psychological component and that is part of any treatment of chronic pain. Any pain clinic all the ones that I know of personally have a psychiatrist or a psychologist with a multidisciplinary approach to pain and there's lots of studies going on looking at how can we get people. That's why I know about the fact that if you look at the other arm your pain goes down because I read a study about it a couple years ago. So there's a lot of legitimate scientific interest in pain. It's a very complicated biological and psychological phenomenon and also it's a huge there's a lot of financial incentive for pharmaceutical companies to learn about pain it's a big big big problem and while we have a lot of options we don't have enough. We absolutely need more absolutely. So you're going to see increasing options in the future. The alternative medicine people are nibbling around the edges with nonspecific effects that you will get also as part and this has also been studied you get the same placebo effects out of real medicine. You don't need to get the fake magic shit in order to get the placebo effects so why do it? Well it really isn't because if you look at it it's really not cost effective because upfront costs may be less but if you look at cost effectiveness it actually is less cost effective because it's not as efficient they're doing a lot of stuff that doesn't work and they also suck you in for a lot of recurrent treatments that are unnecessary whereas largely because it's cash on the barrel a lot of it's outside of insurance companies. Insurance companies I'm not going to defend them they have a huge pain in my ass but they do have an incentive to keep you efficient and cost effective and sometimes what their interests are the patients and medicine's best interest although I would one quick again I don't think there was a clear bright line between the alternative practitioner and the conventional practitioner I had microfactor surgery on my knee a few years ago and my University of Pennsylvania trained you know orthopedist sports medicine orthopedist recommended that for my pain I should take chondroitin sulfate and glucosamine. Now if you look at that this is actually only it's been studied I mean there's no evidence that it works any better than placebo for the pain of osteoarthritis um you know but he did that he did that because I think he is doing what many conventional practitioners are doing. They see this as something that it's a marketplace they think that there's a demand for this and there's you know and so he asked for this. Now you could argue that by taking this kind of if I had done that and not actually looked up this has been such a jerk to look up the studies to see that it actually doesn't work better than placebo if I had believed in him believed in him as a guru and that would have avoided my taking n-sids or cox-2 inhibitors that there may have been some value in that maybe I would have learned to release my own endorphins by believing this was going to work I mean I guess that's possible but it is a slippery slope I think we have time for one more yeah we should have one more along the excuse me along the same lines as pain therapy in regards to like mirror box therapy where you're trying to treat the pain experience in a phantom limb where does that fall in line in that spectrum is the mechanism understood behind that do we question whether or not that's effective therapy for treating pain in that regard you're talking about like Ramachandran's work on mirror box therapy for phantom limbs is that right yeah is anyone do you know about my understanding is it's promising but I think there's been some recent failures to replicate that but I think in principle I think what you're trying to do is you're trying to sort of harness brain plasticity you're trying to get another part of the brain which is recognizing a limb that's not there as getting it to understanding maybe I'm well I guess it's called a muriological fallacy I'm referring to part of the brain as a person but getting a part of the brain to understand that that limb is no longer there but I think some of the recent research suggests that doesn't work as well as people initially thought yeah I mean the clinical data is preliminary and ambiguous but the idea here is like a phantom limb is when you like if you have an amputation for example it's essentially a mismatch between your brain's model of your physical body and the physical body that's there the amputation of that has been described clinically you can have supernumerary phantom limbs that don't really exist you can have part of your body that you don't think is part of you or you could have a phantom limb that is no longer there which is the most common syndrome and the problem is is when your brain it's not getting that input and this is a generic phenomenon that we see when part of the brain ceases to get sensory feedback or the input that it normally has and keeping itself in homeostasis it goes off the rails sometimes so like for example if you have visual if you lose your sight you can hold your visual cortex may start hallucinating just generating its own stimulation same thing your brain says there's no limb there it's not getting the feedback so it just sort of generates its own feedback and that could be painful sometimes you could feel like your hand is clenched or something and so it's just ways of tricking the brain into not doing that into basically no longer creating these phantom experiences and it is trying to provoke plasticity which means that the brain adapting to changing sensory input and sadly we are out of time I would like to thank the panel thank you all for coming I hope you enjoyed it