A possible explanation of the placebo-nocebo effects and the effectiveness of hypnosis

Abstract

In the present work, it is suggested that unconscious processes may contribute to the physiological functions of the human organism regulation by preplanning and guiding them. Considering these processes as “unconscious thinking” with its own memories, codifications, beliefs, biases, and axiological standards, and not as automatic, we may explain puzzling physiological phenomena. Placebo or nocebo effects may take place when treatments physiologically ineffective influence the “decisions” of unconscious estimators concerning the physiological functions regulation. The effectiveness of hypnosis in the treatment of some illnesses may be a similar process with the special contribution of vivid imagination.

Key words: Unconscious processes, Unconscious thinking, Placebo, Nocebo, Hypnosis, Automaton

Main text.

Many regulatory factors of the physiological functions of the human organism have been well established: biochemical reactions, automatisms in the level of tissues and organs, reflexes – unconditioned and conditioned in a more systematic level, concerning autonomic, endocrinal, immune and other systems, etc. The brain processes, which guide the behavior in accordance with internally generated goals, have been considered as a responsibility of frontal lobe, and have been named “mental programming” or “executive functions”. In this article, it is suggested that, some kind of unconscious “mental programming” may also contribute to the regulation of the physiological- somatic- visceral functions. No effort for neuroanatomical localization is made in the present work, which is mainly a theoretical attempt to unveil some hidden processes.

Pre-plans Action’s Guides (PAGs) are more easily observed in musculoskeletal movements. For example, when we fall down, during walking, because we have not taken into consideration a small crack on the ground; when we fall into the door, after we have pushed it to open, because it suddenly stopped due to an unseen obstacle or when with the one hand we raise an empty can higher than another externally similar but full of sand raised on the other hand. In all these cases, although, we do no conscious calculation, a pre-plan is created and guides our actions in detail: the exact body posture and muscles tension, the exact timing etc.

On the above-mentioned examples of musculoskeletal movements, if we consider that the goals of walking or can raising are consciously posed, we should not forget that actions such as which exactly groups of muscles, on what degree and in what order they are activated, have never became conscious. Furthermore, we should also keep in mind that there is enough evidence supporting the view that even the musculoskeletal movements of which we get awareness, although we think that they are the outcome of free-willing commands, they have been pre- decided unconsciously (1), (2), (3), (4).

PAGs may preplan and guide not only the musculoskeletal movements, but also the physiological functions. However, in the later case, (a) the observation is much more difficult in comparison to the musculoskeletal movements and (b) the fact that we don’t get awareness of physiological functions (digestion, glands secretions, immune system activities etc), makes the revelation of PAGs for these functions even more difficult. Of course, many physiological functions may go on in the case of a patient in vegetative state, while the musculoskeletal movements cease. This fact indicates that the automatisms and lower order reflexes are much more sufficient for physiological functions than for musculoskeletal movements. But, this does not mean that a higher order regulation does not take place in the case of physiological functions.

A line of reasoning favoring the suggestion that PAGs may play role for physiological functions as well, is that the PAGs for the musculoskeletal movements would be inefficient if they concerned only muscle tension without any foresight for their blood supply, for example. Theoretically, this adaptation could take place by reflexes, after the initiation of movement. But the tachycardia of the runner, before starting to run, shows that a pre- estimation of action demands does exist in blood supplies and guidance to the heart to accelerate.

This tachycardia before running however could be, alternatively, explained by: a. conditioning theory or b. a fight- flight reaction due to emotional load. The classical and operant conditioning theories are very useful but inadequate for the explanation of many phenomena and cognitive components are now considered for this (5). Similarly, we should remember that a fight- flight reaction and the exact quality of emotion are posed after an estimation and decision of the situation. For example, before a danger, the reaction could be “freezing” or “fainting” instead of “fight- flight”. In addition, a general activation pattern doesn’t preclude a more specialized foresight and guidance of functions, for example, for higher blood supply on the feet in relation to the hands of the runner.

The organism of humans and many animals has the ability to discriminate and select expression of physiological functions beyond the general activation patterns. Even from the experiments of the successor of Pavlov, Bikov (6) and Miller (7), (8), many decades before, it is already known that the humans and animals can learn to express all visceral, autonomic, immunologic, endocrinal functions etc with high discriminative ability. Later intranural recordings directly showed that the degree of sympathetic differentiation is even greater than previously known; it occurs not only between different tissues but may also occur between different regions of the same tissue (9), (10). Mayer, considering the neurobiology of stress, mentions that the classical description of the autonomic nervous system to stress in the context of the “fight and flight” response by Cannon has focused only on the stereotypic and global activation of the sympathetic nervous system. Despite the integrated nature of the response to different stressors, there is a considerable variability in the specifics of the peripheral output. The context, the physiological state of the organism, memories of past stressful life events, and beliefs about the subjective meaning of the situations are all taken into account (11). And the question is: how the estimation of all these factors is made and how the physiological functions are modulated according to the estimation made?

The biggest part of the psychosomatic research is dedicated to general activation patterns, which are caused, by personality characteristics, emotions and moods. This way, serious pathological mechanisms and useful treatments are indeed be revealed. As far as the “considerable variability” the explanations resort to the undoubtedly inefficient conditioning theories.

Only if we accept the regulatory contribution of unconscious processes, as a thinking machine, with its own memory, which co- estimates, on the basis of its own criteria, a vast number of factors, we can probably, explain the remaining mysteries on physiological function regulation. For example, the repeatedly verified cure of warts (pappiloma virus), with placebo, hypnosis or even only suggestions of treatment (12), (13), (14), (15), (16), (17). Similarly, the “mental” treatment of other diseases and disorders (18), (19), (20), (21), (22), (23) cannot be explained without the consideration of the concrete intervention of unconscious processes.

          Paul Brand (24) has mentioned that a medical doctor, colleague of his, could cure warts more efficiently by making “magic tricks”, something like the spellings of my grand mother, than using authentic medicine remedies. Ιt was even more interesting that he could also cure other colleagues- doctors, although they were strictly opposite to this kind of methods, considering them ridiculous.

          This information could make us recall the well-known illusion of seeing water on the hot asphalt, in spite the knowledge that this is not real. The common element to these phenomena is that the unconscious processes, which are behind, are not enchained by conscious beliefs. These have their own criteria and “make up their own opinion”; and this opinion is in charge of what to be seen or the exact pattern of the immune system activation. The conscious thoughts, beliefs, opinions, and expectations may play a role only if the unconscious estimators- in charge of the physiological functions regulation- take them into account. How can this happen? We don’t know the whole story; and this is very important to be revealed. The main exhortation of this article could be actually that. However, there are some indications. Spanos et.al (17) have found that in treatments of warts using hypnosis, the treated subjects who lost warts reported more vivid suggested imagery than treated subjects who did not lose warts. The role of imagination or even the observation of an action in the pattern of activation of the physiological functions has been repeatedly confirmed (25), (26), (27), (28), (29). But, in the case of pappiloma virus confrontation, since there is no concrete process, which can be imagined by the patients, it seems that the decisive point is not “how” but “if” the unconscious processes can be triggered. Probably, the unconscious machine “knows” or can discover the way to lead the action of immune system. We should remember that the command for hand movement is hardly rough. The way the exact muscle fiber group is activated is a responsibility of unconscious processes. Since there is no way to give any conscious order to the immune system, if we could make it start to take care for a concrete action it might trigger the unconscious processes to specify in detail the immune system activity, behind, of course, of our awareness.

          In this point, another objection could be raised: the writing or the walking or any other movement ability is learned by repetition or exercise. The unconscious processes do not know how to order the exact group of muscle fibers in order to write or walk; it is the training that makes them know and be “automatic” i.e. without demanding of participation of the conscious mind. Learning however, may take place- and we know that this is the case- for the immune system also. The great difference is that we do not get awareness of these processes in any phase. Vivid imagery, through hypnosis or placebo tricks may activate the unconscious processes which either “know” how to activate the immune system in order to confront the virus, or trigger them to learn to do this. Both alternatives are possible and may be true in different occasions. The answer to the question “why isn’t the immune system able to confront the virus through its biochemical automatism?” may be that: the naturally short cycle of the keratinocyte circumvents the need for the virus to destroy the cell, which would trigger inflammation and immune response (30).

          Researching the palmar hyperhidrosis condition, I met enough individuals who told me the same story: in some periods of their life, from some days- up to few weeks, their hyperhidrosis was completely disappearing. They had no explanation. The habits and the other physiological functions didn’t differ. This is also a phenomenon that is difficult to be explained by conditioning or general arousal theories, since the individuals were subjected to the same stimulus, in the same context, without any other radical alteration of their physiological state except palmar sweating. In contrast, the explanation is feasible if a different PAG has been created. This may mean that PAGs are probably not only instantaneous creations but they are also regulators of physiological functions for longer periods. These may be different kinds of PAGs.

          Let’s now face the final question: is there any difference between automatic regulation of physiological functions and regulation through “unconscious thinking”? Does the notion “unconscious thinking” make any sense or is this nothing but a verbalism meaning, therefore nothing more than automatic?

          Automaton could be considered a system that has a finite number of internal states and moves between those states by following specified rules. Interacting with its environment it may change its own state, and memorize at least some of these interactions. A thinking machine may also interact with its environment and memorize, but in contrast, it may move between an infinite number of internal states by following rules in the creation of which it (the machine) has also contributed. A thinking machine has beliefs, biases, individual codifications and axiological standards that have no meaning for an automaton.

          For these reasons, if the suggestion that PAGs are made by the unconscious thinking machine contribute to the regulation of physiological functions is correct, new questions may be posed for the research, like the following:

1.    what is the extent of the regulatory role/  ability/ responsibility of the PAGs on the physiological functions?

2.    how far weird effects- like burn by hypnosis without fire, or immune reaction without antigen (24) can go? Could a cancer cured by an appropriate PAG, if it was known how to influence its creation?

3.    is the vivid imagery the “avenue”, or only one among many other ways to “lead” the unconscious thinking machine to pay, or stop paying, attention to something?

4.    which are the other ways of learning of the unconscious machine beyond conditioning? How its individual codification, axiological standards, beliefs, biases, and decisive criteria are been formulated and how could be willingly influenced?

In any case, the research for the logic, the competence and the capabilities of a strangely thinking machine is rather different from the research for the reflexes of an automaton.

 

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