Placebos, caring and healing in rheumatology

Abstract

Chronic rheumatic diseases are complex and occur in different and changing social and cultural contexts. Linear cause and effect models may not be appropriate for their explanation or management.

The placebo response has a powerful influence on symptoms such as pain, and is responsible for the majority of the beneficial effects seen from symptomatic therapy.

Nocebos have very powerful negative effects on symptoms. Health anxiety is a key mediator of the nocebo response.

Prior expectations and conditioning are important mediators of both placebo and nocebo responses.

Placebo and nocebo administration can cause release of neurotransmitters and other changes in brain function (detected by fMRI) that may explain their actions.

Caring, compassion, empathy and validation improve symptoms and can relieve pain.

The polyvagal, nurturing (safety) response provides a neuro-regulatory theory to help explain the value of caring and relationships in health care.

Humans live in stories (narratives) and have to find ways of including illness within those narratives. Helping them achieve this can reduce distress.

Some medical narratives, (e.g. ‘you have medically unexplained symptoms’) are incompatible with the patient’s need to reduce health anxiety and make meaning of their problems.

Beneficial, profound transformational changes are sometimes observed in patients. We call this the ‘healing response’. Positive human interactions appear to be a critical way of facilitating a healing response.